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For the initial appearance of smallpox lesions on the first or second day, if two or three spots with a pale red and lustrous color appear first in areas such as the philtrum (Ren Zhong), nose, cheeks, chin, or Nian Shou region, this is an omen of a favorable course (Shun). If they appear first in the Tian Ting, Si Kong, Tai Yang, Yin Tang, or Fang Guang regions, it is an omen of an unfavorable course (Ni); even if the lesions are bright, lustrous, and distinct, it remains a critical condition (Xian). Furthermore, if the lesions are round and formed but dry, red, and lacking moisture, this is another form of critical condition. A favorable course requires no specific treatment and heals spontaneously, as Qi obtains its righteousness and Blood obtains its proper form; Qi is respected and Blood stays within its domain, so the pathogenic toxin cannot act recklessly to wreak havoc. An unfavorable course may not be cured even with treatment, because Qi is stagnant and Blood flow is sluggish, and the toxin recklessly invades Yang regions, making it impossible to withstand its momentum. A critical condition is treatable and curable, generally because although the toxin attacks the upper body, Qi and Blood have not yet dispersed and still retain their supportive function. However, this is a worrying sign; one should not rush to administer treatment but must wait until Qi and Blood intersect, then treat according to the specific situation. Those who find it difficult to erupt but easy to crust over indicate Excess at the Exterior and Deficiency at the Interior. Conversely, those who erupt easily but have difficulty crusting over indicate Deficiency at the Exterior and Excess at the Interior.

On the second or third day, if the lesion base is round, Qi is full, and the Blood color is bright and clean, it is favorable. If the base lacks a halo, Qi separates from Blood, appearing withered, dead, and un-nourished, it is unfavorable. If the base is round and clear with spirit, but the apex is depressed, Blood will likely fail to gather, constituting a critical condition. Favorable cases heal spontaneously due to Qi and Blood following their proper pathways. Unfavorable cases are difficult to treat because insufficient intersection of Qi and Blood allows the toxin to invade internally during opportunities. Critical cases are treatable because weak Qi fails to control Blood; by tonifying Qi to restrain Yin, Blood can follow Qi to expel the toxin, potentially transforming into a favorable course.

By the fourth or fifth day, observing the shape and color of the lesions reveals the strength of Qi and Blood and the depth of toxin invasion. Lesions that are pointed, round, glossy, full of Qi, and rich in Blood are favorable. Those dense like silkworm eggs, or black, depressed, dry, red, purple, or blistered are unfavorable. If the base has risen but the color is not bright, the vital energy remains, classifying it as critical. Favorable cases heal spontaneously as Qi constrains and attaches Blood, each following its path, allowing the toxin to dissipate naturally. Unfavorable cases involve separation of Qi and Blood, allowing the toxin to attack internally unchecked. Critical cases involve slightly weak Qi and Blood but clear intersection; although the toxin attacks upward, using Baoyuan Decoction (Preserve the Origin Decoction) to support Wei Qi and regulate Ying Blood can successfully resolve the toxin.

Between the fifth and sixth days, when Qi meets and attaches to Blood, resulting in bright red and vivid coloration, it is favorable. If Qi is strong but Blood does not attach, presenting as gray/depressed, purple/depressed, or with blisters, itching, collapse, or dryness/density where Qi backs away and Blood separates, it is unfavorable. If Qi is strong but Blood attachment is thin, with pale/un-nourished colors or dull red/purple hues, it is critical. Favorable cases heal due to abundant Qi and Blood restraining the toxin. Unfavorable cases result from weak Qi and deficient Blood, causing toxin sinking and external peeling. Critical cases feature abundant Qi but weak Blood failing to attach; assisting Blood to attach restores balance.

On the sixth or seventh day, when Qi is full and attaches to Blood, appearing bright, smooth, and plump, with toxins naturally transforming into pus, it is favorable. If Qi sinks and Blood is weak, unable to form pus, with toxins lying dormant internally, spirit departing, and color withering, it is unfavorable. If bright and lustrous with spirit, but due to insufficient Qi and Blood, or slight Cold in Ying and Wei preventing pus formation, it is critical. Favorable cases heal as Qi and Blood are balanced, resolving the toxin. Unfavorable cases involve separated Qi and Blood unable to restrain the toxin for external resolution. Critical cases involve slight deficiency in Ying and Wei or insufficient Qi and Blood to振奋 (invigorate); using Sijunzi Decoction (Four Gentlemen Decoction), Siwu Decoction (Four Substances Decoction), or Baoyuan Decoction plus Cinnamon Twig (Guizhi) and Coix Seed (Yiyiren) to assist pus formation removes worry.

By the eighth day, if toxins transform into pus, with radiant spirit, sufficient Qi, and slight Blood, it is favorable. If Qi and Blood are discordant, toxins do not transform into pus, and color is withered, dry, and purple, it is unfavorable. If Qi and Blood are not vigorous, toxins are hard to transform, and pus is incomplete, but color is bright and not withered, it is critical. Favorable cases heal due to strong Qi constraining Blood and transforming toxins. Unfavorable cases occur when Qi and Blood are insufficient to invigorate and restrain toxins; however, development of carbuncles (Ding) or abscesses (Yong) suggests survival, whereas external peeling with internal attack indicates death. Critical cases involve Qi and Blood deficiency failing to complete the process; using Baoyuan Decoction with Cinnamon Twig and Coix Seed for tonification prevents failure at the last step.

By the ninth or tenth day, if pus is sufficient, indicating strong Qi, transformed Blood, and resolved toxins without other symptoms, it is favorable. If pus is insufficient, Qi sinks and is un-nourished, and toxins cause external peeling, Qi and Blood are exhausted, indicating an unfavorable course. If Qi is calm and slightly full, with red-yellow moist color, pus does not overflow, and Blood attachment shows red lines, it is weak Qi and critical. Using Baoyuan Decoction with Ginger and Cinnamon to boost Qi and guide Blood allows natural pus formation and safety.

By the twelfth day, with exhausted Blood, resolved toxins, balanced Qi, and sufficient pus, this follows the natural law of life generation, indicating a favorable course. If Blood is pale and pus scant, or Blood coagulates and pus stagnates, showing Qi deficiency and unresolved toxins leading to extreme withering and peeling, it is unfavorable. If Blood is exhausted and pus sufficient, but moist and not contracting, it indicates Internal Deficiency; this also applies to pale Blood/scant pus and coagulated Blood/stagnant pus. If voice is clear, appetite exists, and the lesion halo remains, these are critical signs. Use Baoyuan Decoction: add Poria (Fuling) and Atractylodes Macrocephala (Baizhu) to aid contraction and scabbing; or add Ligusticum Chuanxiong (Chuanxiong), Angelica Sinensis (Danggui), and Rehmannia Glutinosa (Shudihuang) to aid pus formation and scabbing.

By the thirteenth or fourteenth day, with Qi and Blood returning to their roots, toxins largely eliminated, and old pus forming scabs, it is favorable. If scabs do not fall off and various pathogens arise simultaneously, it is unfavorable. If toxins are fully resolved but miscellaneous symptoms persist during the scabbing phase, it is critical. Treatment should follow the warming and tonifying method of Baoyuan Decoction, modified by symptoms; avoid harsh cold purgatives to prevent internal injury.

By the fifteenth to sixteenth day, Qi and Blood functions conclude. Falling scabs with clear scars and no other symptoms are signs of a favorable course. If scabs have not fallen, accompanied by chills, teeth grinding, delirium, mania, simultaneous carbuncles, and dual deficiency of Qi and Blood, it is an omen of an unfavorable course. If scabs have fallen, accompanied by tidal fever, red lips, thirst, anorexia, and mental fatigue, it is a trend toward a critical condition, requiring treatment based on the current state. For residual toxins, use detoxifying and cooling methods; for no residual toxins, use mild tonification. Even with residual toxins, after prolonged illness, knowing the pain and deficiency, one must not over-treat.