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Having passed these four days since the eruption of smallpox, the pustules should gradually become distended. Those that erupted first will distend first, and those that erupted later will distend later. By the fifth or sixth day, the pathogenic toxins are fully expressed and stabilized. If the base of the pustules is red and vibrant, plump, lustrous, and clear, no medication is required. If other syndromes are present, treat according to the following discussions.

For cases where the pustules do not distend, appearing grayish-white with depressed tops, this indicates a deficiency of Qi and Blood, constituting a Deficient-Cold syndrome. It is appropriate to administer Neituo San (Internal Support Powder) with added Dingxiang (Clove), or to take Zicao Gao (Arnebia Ointment) mixed with wine. For cases presenting as gray-black and sunken, use Wujia San (Priceless Powder) mixed with wine, or decoct Neituo San with a little wine and take it together with Wujia San, which yields excellent results.

For cases presenting as purple-red but failing to distend, this indicates Excess Fire and Heat in the Blood. It is appropriate to administer Neituo San, removing Guanzi Gui (Chinese Cinnamon Bark), and adding Zicao (Arnebia Root) and Honghua (Safflower). If Heat is severe, add Huangqin (Scutellaria Root). For cases presenting as purple-black and sunken, mix Dusheng San (Unique Holy Powder), which consists of Chuan Shan Jia (Pangolin Scales), with liquid. For cases of extreme Heat leading to black depression with Phlegm, first administer Baolong Wan (Embrace Dragon Pill) to descend Phlegm, then decoct Zicao Tang (Arnebia Decoction) to mix with Wujia San, or add a small amount of Chan Tui powder (Cicada Slough). Since "Yi Zheng" (abnormal manifestations) belongs to the Kidney, and the "Four Teeth" also belong to the Kidney, they can stimulate Kidney toxins. The internal presence of Mao Ya (Cat Tooth) provides detoxification, making it suitable for Heat syndromes as well. In the absence of these, Wujia San and Zhibao Dan (Treasure of Life Pill) are essential medicines for treating Heat-Toxin causing purple-black scorching depression; choose and use them accordingly.

When the pustules are distending, the toxins are entirely at the exterior. One must rely on sufficient Righteous Qi to avoid danger. If there is even slight diarrhea, the interior Qi becomes deficient and collapses, allowing toxins to counter-attack due to deficiency, resulting in sunken pustules. For Heat Diarrhea, where stools are yellow, black, or reddish, accompanied by burning pain in the anus like fire, severe foul odor and stagnation, strong Qi, good appetite, or yellow, red, scanty, and painful urination, it is appropriate to decoct and take Siling San (Four-Poria Powder) with added Muxiang (Aucklandia Root), Che Qian Zi (Plantago Seed), Chi Shao (Red Peony Root), and Wu Mei (Mume Fruit). If the stools are white or pale white, accompanied by weak Qi, inability to eat, or clear and profuse urination, this is Deficiency Diarrhea, and it is appropriate to take Guzhen Tang (Solidify True Decoction). For diarrhea with abdominal distension, thirst, rapid breathing, and grayish-white pustules, one may take Muxiang San (Aucklandia Powder) to deliver Roudoukou Wan (Nutmeg Pill). If abdominal distension worsens, take Renya San (Human Tooth Powder) mixed with wine.

For itching caused by insufficient Qi and Blood, mild cases require modified Baoyuan Tang (Support Origin Decoction); severe cases require Neituo San without Guizhi (Cinnamon Twig), doubling the dosage of Baizhi (Angelica Dahurica), Huangqi (Astragalus Root), Renshen (Ginseng Root), Danggui (Angelica Sinensis), and Muxiang. For cases involving both itching and collapse, use Muxiang San with added Dingxiang (Clove) to attack the interior and Guizhi (Cinnamon Twig) to treat the exterior; when both interior and exterior are sufficient, recovery is easy.

Cases involving both itching and collapse occur because Blood moves upward into the Qi level. Since Blood has a salty taste, it irritates and stings the skin and flesh, causing itching. However, the more deficient the Qi, the more severe the itching, inevitably leading to Qi sinking and toxin collapse. Use Baoyuan Tang with doubled Huangqi (Astragalus Root) to support the exterior, and add a small amount of Shaoyao (Peony Root) to restrain Blood, thereby stopping the toxicity.

During the distension phase, if there are large, black pustules in the center, they are named Dou Ding (Smallpox Carbuncle). If untreated, the entire body will transform, leading to death. If there are few carbuncles and the bases are red and vibrant, treatment is possible: puncture the carbuncle opening with a root needle, suck out the dark purple malignant blood, apply Sisheng San (Four-Saints Powder) into the sore, which will immediately turn red and vibrant. Continue administering Lianxue Jiedu Yao (Blood-Cooling and Toxin-Resolving Medicines) for one or two doses. If there are many carbuncles, the basal blood is not vibrant, or they are numerous on the back and chest, the condition is untreatable.

For cases of excessive Heat obstruction with fullness and distension, and constipation that cannot be relieved, it is appropriate to use Mizao Wan (Honey and Soap Pill) to guide evacuation.

Six days after the onset of smallpox, if the pustules remain red and purple covering the tops, the condition is untreatable. If the head and face are swollen but the pustules do not distend, the condition is untreatable.