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After the smallpox pustules have filled with pus, they are plump, lustrous, and firm. Upon palpation, the pustule heads are hard and slightly scorched, indicating that scabbing (jieye) is about to occur. If the scabbing process is clean, without protrusions, depressions, excessive exudate, or rupture, and the color is waxy grayish-green, the skin is thick and dense, bright on the outside but dark inside, with sharp points that irritate the finger, this is considered normal scabbing (zhengye). However, if the pustules appear dry but the crusts are thin as paper, or if internal pathogenic factors remain unresolved, this represents an extremely critical stage of smallpox. Immediate regulation and tonification are necessary to prevent harm.

1. From the onset until the tenth, eleventh, or twelfth day, the smallpox lesions should gradually resolve and scab starting from the lips, head, and face. Resolution proceeding from top to bottom is a favorable progression (shun), while resolution proceeding from bottom to top is unfavorable (ni). If other symptoms are observed, they must be treated promptly.

2. During the impending scabbing phase, if the body temperature, which was previously normal, suddenly rises, it is termed "dry paste" (ganjiang), which is also a common occurrence. At this time, diaphoretic or purgative therapies should not be used lightly. Only in cases of external contraction of wind-cold or dietary injury should treatment be administered according to the specific syndrome.

3. Delayed scabbing or failure to scab when expected presents several syndromes that require detailed differentiation and treatment. Most cases of delayed scabbing are due to weak spleen-stomach function and deficiency of middle qi. Since middle qi deficiency fails to nourish muscles to make them solid, it may also lead to ulceration. If no other symptoms are present and the complexion, form, and qi-blood are all deficient, Shiquan Dabu Tang (Complete Great Tonifying Decoction) should be taken internally, and Baicao San (Decayed Grass Powder) applied externally as a lining. If scabbing fails to occur accompanied by slight fever and a large pulse without other symptoms, this indicates insufficiency of the yin aspect; Siwu Tang (Four Substances Decoction) with increased amounts of Shaoyao (Paeoniae Radix) and Heshouwu (Polygoni Multiflori Radix) is indicated. If blood deficiency and heat-toxin are unclarified, Siwu Tang added with Niubangzi (Arctii Fructus), Mutong (Akebiae Caulis), and Shanzha (Crataegi Fructus) is appropriate. If failure to scab results from poor appetite and spleen-stomach qi deficiency, Liuqi Jian (Six Qi Decoction) or Liuwu Jian (Six Substances Decoction) with modifications is indicated. If frequent diarrhea occurs alongside weak spleen-stomach, vacuous muscles, abdominal distension, and vexatious thirst preventing scabbing, Chen's Shi'erwei Yigong San (Twelve-Ingredient Extraordinary Merit Powder) or Muxiang San (Costus Root Powder) should be used, with Baicao San applied externally. If, during the scabbing period, the head and face become warm while the toes are cold, the body is not hot, or diarrhea, abdominal distension, shortness of breath, and vexatious thirst appear, Chen's Shi'erwei Yigong San or Jiawei Yigong Jian (Nine-Ingredient Extraordinary Merit Decoction) must be administered immediately; delay renders the condition incurable. Smallpox cases presenting diarrhea, vexatious thirst, abdominal distension, and teeth grinding during the impending scabbing phase are often incurable. Administration of honey water or raw/cold foods will inevitably lead to aggravated restlessness and death. Cases caused by excessive water intake or exposure to dampness, leading to dampness inundating the spleen-stomach and muscles and preventing scabbing, should be treated with Wuling San (Five-Ingredient Powder with Poria) or Siling San (Four-Ingredient Powder with Poria) added with Shanzha to promote diuresis. Cases where heat-toxin has not subsided, causing stagnation and steaming in the skin and pores, preventing yin from consolidating and thus hindering scabbing, require rapid resolution; otherwise, toxin will attack inward causing significant harm. Xijiao San (Rhinoceros Horn Powder) added with Shaoyao and Niubangzi is indicated. In cases of internal and external heat, scattered yang-toxin, constipation, and blocked yin qi preventing scabbing, Sishun Qingliang Yin (Four-Obedience Cooling Clearing Decoction) or Sanhuang Wan (Three-Yellow Pill) should be taken internally to unblock bowels, while Baicao San and pig gallbladder enema methods are used externally. If cold weather leads to lack of covering, causing cold coagulation in the sores and preventing scabbing, Wuji San (Five Accumulations Powder) is indicated, with Rushxiang (Frankincense) or Yunxiang (Dill Fruit) smoked within bedding externally. If excessive heat from warm weather causes steaming of the pustules preventing scabbing, Renshen Baihu Tang (Ginseng White Tiger Decoction) or Wuling San/Siling San should be taken internally to drain damp-heat, and Tianshui San (Heavenly Water Powder) applied externally. If touched by evil filth and yin-cold, damaging yuan qi and preventing scabbing, Baoyuan Tang (Preserve Origin Decoction) or Shi'erwei Yigong San is indicated, with Pixie Dan (Evil-Repelling Pill) smoked externally and Zhuisui Gao (Pig Marrow Ointment) applied.

4. If internal heat in smallpox remains and toxin is not fully transformed, resulting in too rapid scabbing, eye diseases, carbuncles/toxins, and various strange syndromes will likely follow later. Liangxue Yangying Jian (Cool Blood Nourish Ying Decoction) should be used to slightly clear the fire. If stools are excessively dry and bound, mild purgation is needed to resolve toxin, using Danggui Wan (Angelica Sinensis Pill).

5. Smallpox with pus formation and subsequent scabbing is auspicious; scabbing without pus is ominous. Treatment cannot be delayed. If pustules have formed pus but fail to scab, instead becoming ulcerated or detaching with the skin, this is called "reverse scabbing" (daoye), indicating toxin entering the interior. Urgent major tonification of middle qi to support the interior is required, using Liuqi Jian with doubled Shaoyao, plus Zicao (Lithospermi Radix), Fangfeng (Saposhnikoviae Radix), and Baizhi (Angelicae Dahuricae Radix). If damp-heat is concurrent, Liuqi Jian added with Shaoyao combined with Siling San is indicated. If facial sores break and, after taking tonic medicines, swell and refill again, or if a new layer erupts on areas without sores, this is called "filling empty spaces" (bukong). Although prolonged, if diet remains unchanged, it is not a major harm. If, after medication, there is no rise, filling, or replenishment, the toxin has penetrated deeply, representing the most ominous prognosis.

6. Regardless of whether sores have ulcerated, if scabbing occurs after the twelfth day, it is a good omen. If crusts do not form, reverse scabbing will result. If resolution is incomplete, or if the whole body has scabbed except for a few spots, itching and scratching may eventually cause rupture, making survival uncertain. Prompt treatment is essential.

7. If the color during scabbing is white like plum blossom petals, this is "false return" (jiahui). Death will occur after twelve days; this is an untreatable syndrome. If there is no diarrhea, Liuqi Jian or Liuwu Jian combined with Erxian San (Two Immortals Powder) should be administered vigorously for rescue.

8. For smallpox that fails to scab after pus formation, leading to ulceration, dripping pus, sticking pain, and inability to lie on mats, use Baicao San or Qiaomai San (Buckwheat Powder) contained in silk bags for application. Laying more cloth on the mat for lying is even better. The secret tea prescription is also effective. To prevent facial scarring, Jiuku Mieban San (Save Life Remove Scar Powder) mixed with honey water should be applied.

9. Ulceration of smallpox starting on the face is an ominous sign. If there is no obstruction to eating/drinking, bowel/bladder functions are normal, and no other symptoms exist, Shiquan Dabu Tang is indicated internally. If toxin is severe with internal heat, Jiedu Fangfeng Tang (Detoxify Wind-Barrier Decoction) added with Danggui and Chantui (Cicada Slough) should be taken alternately, with Jiuku Mieban San applied externally.

10. Before pus formation, or if a sore becomes broken/ulcerated due to injury, or if other sores scab while this one does not, with non-drying pus and increased pain, failure to treat urgently will lead to gan erosion, damage to sinews and bones, and premature death. Shiquan Dabu Tang should be taken, with Jiuku Mieban San or Bailing San (White Dragon Powder) applied externally.

11. If smallpox is scratched open, skin removed, but blood and fluid remain, Liuqi Jian or Liuwu Jian should be used urgently, with Bailing San applied externally.

12. Odor in smallpox: During scabbing, a smell that is foul yet fishy indicates mature smallpox qi, with evil qi exiting from within; this is auspicious. A smell like rotting meat, turbid and repulsive, suggests apparent but false scabbing; urgent clearing of heat and nourishing of blood is required, using Liangxue Yangying Jian or Jiedu Fangfeng Tang. If odor appears during the "nourishing paste" phase, it indicates toxic fire steaming, accumulating in the center and manifesting externally; this is highly ominous, requiring rapid heat-clearing to resolve toxin. If smallpox is ulcerated, does not scab, and emits unbearable stench, it is named "rotten smallpox" (landou). Some cases resolve without issue. As long as stomach qi is not exhausted, diet is normal, and there is no vexation/restlessness, it is treatable. Bazhen Tang (Eight-Treasure Decoction) or Simiao Xiaodu Yin (Four-Ingredient Detoxifying Decoction) is indicated, with Baicao San applied externally.

13. If smallpox develops new sores and ulcers forming pits after scabbing, Tuoli Xiaodu San (Support Interior Detoxify Powder) or Jiedu Neituo San (Detoxify Support Interior Powder) should be used. If qi and blood are both deficient and unable to converge, Shiquan Dabu Tang is mandatory. If the entire body has numerous deep ulcers lacking qi and blood, death is inevitable.