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During the scabbing and falling-off stage of smallpox, if the scabs are round, clean, firm, and thick like a snail shell, this is the best outcome. If pus exudes from the head of the pustules and accumulates to form scabs resembling chicken droppings, this is of secondary quality. If the skin breaks, pus flows out, and the resulting scabs are thin as paper, this is even worse.

If the skin rots and pus ulcerates without forming complete scabs, accompanied by a fishy and foul odor in the pus, this is the worst outcome. If this occurs after the expected time for scabbing, it is akin to fruits rotting after being ripe for too long; this follows the natural order and should still be viewed as a favorable progression (Shun). However, if this occurs before the expected time, it constitutes "rotting" (Lan), which is an adverse prognosis (Ni) and leads to death due to inverted scabbing (Dao Ye).

During the scabbing process, if the body color turns pale yellow like wax, starting from the first day with scabs forming around the mouth and lips, then gradually receding from the chest and abdomen to the legs, and finally scabbing simultaneously on the dorsum of the feet and forehead, followed by healing after the scabs fall off, this is auspicious.

During the scabbing process, if the entire body emits a foul, rotting odor, unbearable like burnt flatbread, and the eyes lack spirit, this indicates death.

During the scabbing process, if the whole body itches intensely, scratching reveals no pus, and the skin curls and dries like bean shells, this indicates death.

During the scabbing process, if chills occur, hands and feet tremble, teeth are clenched, and the mouth is locked shut, this indicates death.

After the scabs fall off, if the resulting scars are snow-white with absolutely no blood color, this indicates death; urgent supplementation of Qi and Blood and nourishment of the Spleen and Stomach are required, upon which survival might be possible.

[Yuan] asked: On the eighth or ninth day of smallpox, the lesions have filled with pus and begun to recede, implying preservation of life. Yet some patients die when the recession reaches the neck, some at the chest, some above the navel, and some at the genitalia. What is the reason?

The answer is that growth and decline follow fixed laws. In assessing smallpox, one primarily looks at whether the pustules fill with pus. However, if the patient's congenital Yuan Qi (Original Vital Energy) was inherently weak, and the smallpox spread extensively, the physician mistakenly used toxic herbs to force dispersion, followed by ascending and purgative agents that exhausted the Yuan Qi. Although the pustules appear externally full, the internal essence is hollowed out and damaged, injuring the Five Meridians beyond repair.

The area above the neck near the laryngeal prominence is the gatekeeper of the Lung; if Lung Qi fails first, recession to this point causes death by obstruction. The chest mound is the gatekeeper of the Heart; if Heart vessels fail first, recession to this point causes death. The navel is the gatekeeper of the Spleen; if Spleen vessels fail first, recession to this point causes death. The eye sockets are the gatekeepers of the Liver; if Liver vessels fail first, recession to this point causes death. The genitalia are the gatekeepers of the Kidney; if Kidney vessels fail first, recession to this point causes death. When the root is pulled up, branches wither; when the source is blocked, the stream dries up—this is the natural way.

Regarding variable conditions: if wind-cold is not carefully guarded against, pathogenic factors may invade internally; if diet is not regulated, the Spleen and Stomach may be injured internally, leading to abdominal distension and incessant phlegm-wheezing. In such cases, death may occur as the lesions recede to these respective gatekeepers. There is also a type called "Xiao Dou" (Noisy Pustules), which appears to be filled with yellow pus but causes death upon recession to the chest; this is truly "Yu Dou" (Evil Pustules).