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When wood is withered, it breaks; when soil is dry, it cracks. If the vesicles (pustules) of smallpox are not sufficiently filled, the condition of rupture by scratching naturally arises. However, if the rupture does not occur at critical locations, even if there is little pus and blood, life can still be preserved. If the rupture occurs at critical locations, such as the face and head, which are the gathering places of the essence of the Five Zang organs, where the smallpox toxin uses as a vesicle—just as humans have houses and objects have nests, fish become fat in water, and birds advance when they have food—now that the vesicle has broken, the toxin has no place to reside. Moreover, since Ying-Yin (nutritive Yin) is exhausted and Yuan-Qi (original Qi) escapes outward, how can the toxin not penetrate inward taking advantage of the deficiency? Even if methods similar to Nuwa mending the sky are employed, sealing the wound with paper, one must still rely on strong Spleen and Stomach function allowing for eating, and un-depleted Qi and Blood capable of suppuration and ulceration, for there to be any hope of rescue.

The song states: "Water test reveals the sac is not full, sores have holes leaking pus and fluid; gather again to seal the sore hole, draining true essence while toxins hide." When pale smallpox forms pustular sacs, it is most crucial that the skin be thick and the covering intact. If pus has not yet formed but there are holes on the sore heads, causing fluid to leak out, gather into clumps, and pile outside the holes, or if the fluid drains away leaving empty sacs that turn dry and black, this is named "Leaking Sores" (Lou Chuang), a condition that is invariably fatal. If after the heat of pus formation, the sac skin is also hot, causing the fluid to boil out and subsequently form scabs, this frequently occurs on the front of the forehead and face. This is colloquially known as "Pile-Shit Scabbing" (Dui Shi Shou) and should not be discussed as Leaking Sores. The reason is that Leaking Sores involve unformed pus, whereas Pile-Shit Scabbing results from over-mature pus.

When the stage of nourishing pus is reached and the lesions are full, it indicates that pus has formed. Turbid appearance is the shape of the pus; yellowish-white color is the hue of the pus. If, upon reaching the appropriate time, the lesions remain empty shells, this is because Qi carries the toxin while Blood fails to adhere to Qi, truly due to weak Qi and declining Blood, unable to mutually assist in transforming the toxin. Since toxin is originally formless and relies on Blood, if Blood does not arrive, the toxin remains latent within and cannot exit. Treatment should focus on tonifying Blood to support pus expulsion. If the fluid has already formed but is clear, pale, and grayish-white, lacking thickness, this indicates both Qi and Blood are deficient. Even the existing fluid is merely an initial drop of Blood now dissolved into water, not water generated after internal tide onset; treatment requires major tonification of Qi and Blood. If wind-cold is contracted just as pus is about to form, causing stagnation of fluid, treatment should involve warming and dispersing combined with interior support. If stagnation of fluid is caused by contact with foul odors, external fumigation for detoxification combined with internal attacking and supporting agents is suitable. If constipation prevents pus formation, mild purgation is indicated. If the color is grayish-white or itchy, with non-penetrating pus, warming and tonifying Qi is appropriate. If the color is purple-red or itchy, with non-penetrating pus, cooling and tonifying Blood is required; otherwise, severe cases may result in intractable itching and collapse, while mild cases leave behind residual carbuncle-toxin liabilities.

Empty shells without fluid in smallpox often occur because excessive body heat between the third and fifth days steams and dries up Qi and Blood, preventing them from circulating and transforming into fluid. Furthermore, if heat makes distension difficult and harsh purgative formulas are mistakenly used, although floating pustules may temporarily form, Qi and Blood are already exhausted and cannot sustain subsequent generation, resulting in no fluid production. The head is the meeting point of all Yang meridians; therefore, fluid must first fill here before spreading to the chest, hypochondrium, waist, and knees. In cases lasting eight or nine days, if only slight fluid appears on the upper head, turning old and waxy-yellow ready for scabbing, while the body has some fluid and the waist/knees have none, this signifies exhaustion of Qi and Blood and cessation of vital energy. Additionally, if facial swelling subsides quickly after minimal fluid appears, eyes open and close restlessly, and the tongue extends and retracts uncontrollably, these are signs of toxin entering internally, indicating imminent deterioration.