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When the smallpox lesions are fully erupted and sufficiently developed, by the sixth or seventh day they turn ruddy and begin to fill with pus. Crusting and scabbing between the ninth and eleventh days is auspicious. This corresponds to the phase of "completion and solidity," when the Lung Metal qi is predominant. However, this process relies heavily on strong Spleen and Stomach function to ensure sufficient Qi and Blood, causing previously depressed lesions to rise completely and flat-topped lesions to become high, full, and lustrous. Lesions that appear first will fill with pus first, followed by those appearing later; a gradual and orderly progression constitutes a favorable (Shun) pattern. If the Spleen and Stomach are weak, Qi becomes deficient and fails to assist in pus formation, constituting a dangerous (Xian) pattern. If the Spleen and Stomach are damaged, Qi and Blood become depleted, failing to generate fluid/pus, inevitably leading to adverse (Ni) patterns such as panting, abdominal distension, chest oppression, restlessness, itching, collapse/inversion of lesions, vomiting, hiccups, and diarrhea.

Specifically, if lesions on the lips turn yellow first, this indicates toxin attack; inability to eat by the eleventh or twelfth day signals critical danger. If lesions are dense, scorched-purple, and fail to elevate, this indicates severe Blood Heat and toxin excess. Treatment depends on skin thickness: for thick skin, use Huadu Decoction (Toxin-Resolving Decoction) with added Lonicerae Japonicae Flos (Lianqiao, 连翘) and Panax Notoginseng Radix et Rhizoma (Heishen, 黑参). For thin skin resembling blisters, even if pus filling is incomplete, there will inevitably be changes of itching, collapse, and black inversion. If facial lesions are dense while body lesions are sparse, white in color, and fail to elevate or fill with pus, this indicates deficiency of Qi and Blood; use Shenqi Neituo San (Ginseng and Astragalus Internal-Supporting Powder). To direct medicinal action upward, initially filling the face before the limbs, add Oryzae Semen (Nuomi, 糯米) and Paeoniae Radix Alba (Shaoyao, 芍药) to the formula, and use Achyranthis Bidentatae Radix (Niuxi, 牛膝) to guide the medicine downward to the feet.

If by the fifth or sixth day pus has filled but is not dense, round, or elevated, this indicates weak Qi failing to control Blood; use Baoyuan Tang (Preserve the Origin Decoction) combined with Siwu Tang (Four Substances Decoction) plus Cinnamomi Ramulus (Guigui, 官桂). If lesions are full but pale in color, this indicates abundant Qi but weak Blood; use Siwu Tang with added Aucklandiae Radix (Muxiang, 木香) and Oryzae Semen. If by the sixth or seventh day pus filling is incomplete with gaps, this indicates disharmony of Qi and Blood, likely transforming into cold-deficiency with itching and collapse; use Baoyuan Tang with added Chuanxiong Rhizome (Chuanxiong, 川芎), Angelicae Sinensis Radix (Danggui, 当归), Paeoniae Radix Alba, Angelicae Dahuricae Radix (Baizhi, 白芷), and Oryzae Semen. If lesions are full but wrinkled to the touch, this indicates Blood deficiency with Qi lacking attachment, making crusting difficult; use Shenqi Neituo San with added Oryzae Semen. In cases of Qi deficiency where internal-supporting tonics temporarily raise the lesions but they flatten again without full filling, use a large dose of Baoyuan Tang with added Chuanxiong, Danggui, Muxiang, Cimicifugae Rhizoma (Shengma, 升麻), Cinnamon Bark (Rougui, 肉桂), and Oryzae Semen.

During the pus-nourishing stage, if pus is hard to fill and pale, with poor appetite and loose stools, this is Qi deficiency; use Baoyuan Tang with added Danggui and Rougui. If the lesion base is red, with irritability, thirst, and constipation, this is Blood Heat; use Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction). If mistaken use of Ginseng and Astragalus to support pus worsens heat, use Sishun Qingliang Yin (Four-Harmonious Cooling Decoction). During pus nourishment, if the lesion is dry and empty due to Qi deficiency sinking inward, but the patient is clear-minded, eating normally, and lesions are intact, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). If accompanied by panting, distension, hiccups, diarrhea, irritability, and external peeling of lesions, it is untreatable.

If lesions were originally dense and pale, and during pus nourishment the patient sleeps deeply and speaks deliriously, this is Blood deficiency with Spirit lacking attachment; use Baoyuan Tang with added Ziziphus Seed (Zaoren, 枣仁), Poria (Fushen, 茯神), Danggui, Rehmanniae Radix (Dihuang, 地), and Ophiopogonis Tuber (Mendong, 门冬). If laughing incessantly during pus nourishment, this indicates excessive Heat in the Pericardium; use Baoyuan Tang with added Human Coprolite (Renzhonghuang, 人中黄) and Coptidis Rhizome (Huanglian, 黄连). If vomiting and hiccups persist with insufficient pus, this indicates failure of Earth overacting on Wood, an untreatable condition. If lesions are bright and open during pus filling but arms are swollen and painful like melons, this indicates Qi deficiency of the Hand-Taiyang channels with stagnant toxin; use Baoyuan Tang with added Guizhi (Cinnamon Twig), Qianghuo (Notopterygii Rhizoma), Fangfeng (Saposhnikoviae Radix), Danggui, Ren Dong (Lonicerae Japonicae Caulis), Xijiao (Rhino Horn), and Lianqiao.

If the patient eats well but has loose stools, and all lesions fill except the face which is flat and empty, this indicates Qi deficiency of the Foot-Yangming channel; use Baoyuan Tang with added Guigui and Shaoyao. If sudden inversion occurs during pus filling, or if Blood Heat/toxin excess prevents elevation leading to sinking, panting, distension, and constipation unresponsive to other medicines, use Gongdu Tang (Attack-Toxin Decoction). If pus fills but is thin and watery, residual toxin will remain later; if the patient eats well and has firm stools, boil one young yellow hen with one tael of Astragali Radix (Huangqi, 黄芪) in water, mix with fermented rice wine, and drink. If pus is clear and tops are insufficient but no other contraindications exist and the patient can eat, the toxin should be vented to achieve success. If complications arise or the patient cannot eat, it is critical. Among these patterns, older patients who can eat have a 50-60% cure rate; younger patients who cannot eat are difficult to treat.

If pus fills but color is too red and the base is diffuse, Blood Heat is unresolved; itching will occur around the ninth or eleventh day. Urgently use Huadu Decoction removing Shengma and adding Chuanxiong, Danggui, Baizhi, Lianqiao, and Rendong. Do not allow scratching. If scratched and bleeding profusely, Qi and Blood flow freely; externally apply finely ground old thatch grass or cover with pine pollen. If scratched due to itching yields clear fluid without blood, survival is unlikely. If lesions dry immediately after breaking, with green-white crusts piled like chicken droppings, eventually teeth-chattering, chills, thirst, and panting will occur, leading to death after twenty days. Scratches resembling peeled fish skin or burns are untreatable.

If during the eighth or ninth day of pus filling, high fever and intense thirst for water occur, this is due to numerous lesions, heavy toxin, and deficiency of exterior-interior Qi and Blood; use Jiawei Sisheng San removing Muxiang and adding Danggui and Shaoyao. Alternatively, if half-filled pus is accompanied by severe heat, irritability, and constant thirst, this indicates fluids distributed outward leaving Lung and Stomach dry; administer large doses of Baoyuan Tang combined with Shengmai San frequently until pus fills and thirst stops. If high fever, cheek thirst, dry tongue, cracked lips, and dry-purple lesions occur, this is severe Blood Heat/toxin, possibly caused by heavy furs and heated beds; do not use previous formulas. Use Xijiao Dihuang Tang removing Moutan Cortex and adding Scutellariae Radix (Huangqin, 芩) and Huanglian.

If wind-cold contraction causes phlegm-panting during pus formation, it is difficult to treat; slight dispersal may help, otherwise death ensues. If abdomen is full and diarrhea occurs after pus fills, this is food stagnation; use Baohe Wan (Harmonize the Stomach Pill) to digest and guide out. If pain persists during pus filling, this is Qi stagnation; use Baoyuan Tang with added Hawthorn Fruit (Shanzha, 山楂) and Muxiang to move stagnation, stopping pain. If collapse and itching persist, this is Blood Heat; use Sisheng San with added Shengdihuang (Rehmanniae Radix Preparata) and Polygonum Multiflorum (Ganshouwu, 干首乌) to cool Blood, stopping itching. If pus is sufficient and itching is tolerable, it is acceptable.

If beyond the tenth day of pus filling, the body feels fatigued, with chest oppression, lethargy, and foul breath, this indicates stomach heat causing sores in throat and tongue; urgently use Huanglian Jiedu Tang (Coptis Detoxification Decoction) or Xiaodu Yin (Detoxifying Drink) with added Fangfeng. Delay leads to successful crusting but by the twentieth day outside, gum erosion with bleeding (Yaxuan, 牙宣), abnormal breathing sounds (Xilu, 息露), or rapid-progressing borax-related ulcers, Fox-Huo syndrome, tooth loss, and lip rot, which are untreatable.