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When the smallpox pustules are scabbing over and falling off, if the scabs are round, clean, firm, and thick like a snail shell, it is considered an excellent favorable condition. If pus oozes from the top of the pustules and piles up to form scabs resembling chicken droppings, it is of secondary quality. If the skin breaks, pus flows out, but the resulting scabs are thin as paper, it is even worse.

If the skin rots and pus溃 (ulcerates/leaks), failing to form proper scabs, and the pus has a fishy, foul odor, this is considered a poor unfavorable condition. However, if this occurs after the expected time for scabbing, it is like fruits rotting after being ripe for too long; this is a natural process and should still be viewed as a favorable progression. If it occurs before the expected time, it is termed "rotting" (Lan), which is an unfavorable sign leading to inverted scabbing (Dao Ye) and death.

During the scabbing phase, if the color of the lesions turns dark and waxy, and after one or two days, scabbing begins around the mouth and lips, then recedes from the chest and abdomen down to the legs, finally scabbing simultaneously on the dorsum of the feet and forehead before falling off with recovery, this is auspicious.

If during scabbing, the whole body emits a foul, rotting odor, like burnt cakes that is unbearable to approach, and the eyes lack spirit, death is imminent.

If during scabbing, the whole body itches intensely, and scratching reveals no pus, with the skin curling and drying like bean shells, death is imminent.

If during scabbing, there are chills, trembling of the hands and feet, teeth grinding, and lockjaw (Jin Kou), death is imminent.

If after the scabs fall off, the resulting scars are snow-white with absolutely no blood color, death is imminent; urgent supplementation of Qi and Blood and nourishment of the Spleen and Stomach may offer a chance of survival.

[Yuan] asked: On the eighth or ninth day of smallpox, when the pustules have filled with pus and begun to resolve, life should be preserved. Yet some patients die when the resolution retreats to the neck, some to the chest, some above the umbilicus, and some to the genitalia. What is the reason?

The answer is: The waxing and waning of the disease follows its own fixed destiny. If treating smallpox only focuses on the filling of pus, but the patient's congenital Yuan Qi (Original Vital Energy) was inherently weak, and the smallpox spread extensively, using toxic herbs to forcibly disperse the pathogen, followed by ascending and劫夺 (rob/capture) agents to force the Yuan Qi upward, although the pustules appear full, the exterior is solid while the interior essence is consumed and hollowed out. The Five Meridians (Wu Jing) are damaged and cannot be rescued.

The area of the neck and throat protrusion is the gatekeeper of the Lung; if Lung Qi fails first, retreat to this point leads to death due to obstruction. The chest mound is the gatekeeper of the Heart; if Heart pulse fails first, retreat to this point leads to death. The umbilicus is the gatekeeper of the Spleen; if Spleen pulse fails first, retreat to this point leads to death. The eye sockets are the gatekeepers of the Liver; if Liver pulse fails first, retreat to this point leads to death. The genitalia are the gatekeepers of the Kidney; if Kidney pulse fails first, retreat to this point leads to death. When the root is pulled, the branches wither; when the source is blocked, the stream dries up; this is the natural way.

Regarding variable conditions: if one fails to guard against Wind-Cold, allowing evil pathogens to press inward; or if one fails to regulate diet, damaging the Spleen and Stomach internally, leading to abdominal swelling and incessant phlegm-wheezing, then death occurring as the pathogen retreats to these various gatekeepers does happen. Furthermore, there is a type of aggressive smallpox that appears full of yellow pus, but causes death when retreating to the chest; this is called "Zhen Hu Dou" (True Evil Smallpox).