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Although the pustules are full, if fresh blood suddenly appears, it indicates that the toxin has returned to the Large Intestine (Da Chang). Since the Large Intestine is the exterior counterpart of the Lung (Fei), the condition will be critical within fifteen days. If palpitations and fright occur suddenly when the lesions are about to scab over (Shou Ye), it indicates that the toxin is stagnant in the Heart (Xin) and consuming the True Yuan (Zhen Yuan); the condition will be critical within fourteen days. If hoarseness occurs suddenly just as the lesions are about to scab over, it indicates that the toxin has returned to the Lung; the condition will be critical within thirteen days. If hard, purple-black swellings appear suddenly just as the lesions are about to scab over and gradually worsen, the condition will be critical within sixteen days. If the lesions fail to scab over when they should, accompanied by diarrhea without thirst, chills, and teeth grinding, this belongs to Deficiency-Cold (Xu Han). Yi Gong San (Yigong Powder) should be administered urgently to rescue the patient. However, among various critical conditions, there are those that seem similar but are actually different; one must consider all symptoms together for judgment.

(Sui Jin Chapter)

When the scabs of smallpox lesions descend from the head downwards, it is a favorable progression (Shun). When they ascend from the feet up to the waist and above, it is an unfavorable progression (Ni), which inevitably returns to the heart pit leading to death. If the Primordial Qi (Yuan Qi) can be lifted early on, allowing the pus to return and the scabbing process to resume its downward direction, this is optimal. Only when the scabbing begins first at the genitalia is this considered an excellent sign, falling outside the category of unfavorable downward progression. From the emergence of the first lesion until the blood transforms and the toxin resolves, with pus resembling the color of pale wax, the scabbing starts from both sides of the mouth and nose, above and below the philtrum, and the face, gradually extending down to the chest and abdomen, then to both legs, finally with the forehead and dorsum of the feet scabbing over simultaneously. With no internal symptoms remaining, normal diet, refreshing spirit, and light body, this is auspicious. Scabbing first at the palms/soles or fingertips, or at the genitals, is also auspicious. If a single lesion is pale wax-colored with slight heat, it is a sign of scar formation; there is no need to worry or treat. If a single lesion scorches first on the nasal bridge, although ominous, it will not lead to death. When lesions recede to the neck, one must strictly avoid overusing Astragali Radix (Huangqi) to support the eruption. Forcing support while the lesions wish to recede causes unstable ascending and descending movements, leading the toxin to attack internally and cause death. After scabbing, pungent spices (Wu Xin: garlic, onion, leek, chives, Chinese chive) are forbidden to prevent heat-toxin from steaming the Liver and Diaphragm, causing eye opacities. Heart-pox is a critical condition characterized by severe deficiency of Qi and Blood. Taking many tonics leads to pus formation and impending scabbing; even if heat signs exist, cooling herbs should be added to the tonic formula. If one assumes that because scabbing is imminent, tonics should be used but instead gives cooling herbs, or uses purgatives to force rapid scabbing, this hastens death. Because the deficient becomes more deficient, the toxin counter-attacks internally leading to death; this is an inevitable principle and a verified experience.