夫出痘历此四日，当渐起胀，先出者先起，后出者后起，至五
六日，毒瓦斯尽出已定，若根窠红活，肥满光泽明净者，不须服药。若有他证，照后论治。
凡痘不起胀，灰白顶陷者，气血不足，虚寒证也，宜服内托散
加丁香，或酒调紫草膏；若灰黑陷伏，酒调无价散，或就加酒少许，煎内托散调下无价散，最妙。
凡紫红不起胀者，火盛血热，宜服内托散，去官桂，加紫草、红花，热盛加黄芩；若紫黑陷伏，调独
圣散，即穿山甲；热极黑陷有痰者，先服抱龙丸降痰，后煎紫草汤调无价散，或少加蝉蜕末。盖异证属肾，四
牙亦属肾，故能发肾毒，内有猫牙解毒，故热证亦宜，如无此，无价散、至宝丹皆治热毒紫
黑焦陷之要药也，可选而用之。
凡痘起胀时，毒尽在表，须赖乘实则无虞，苟略有泻，则内气虚脱，毒乘虚反攻，而疮陷伏矣。热泻所
下黄黑赤色便时，肛门热痛如火下者，臭滞殊甚，气强盛而能食，或小便黄赤涩痛，宜四苓散加木香、车
前子、赤芍、乌梅煎服；若所下白色，或淡白色，气怯弱而不能食，或兼小便清滑，此虚泻也，宜服固真汤；
若泄泻腹胀，口渴气促，痘色灰白者，可服木香散送下肉豆蔻丸；腹胀愈作者，酒调人牙散。
凡血气不足发痒者，轻则保元汤加减，重则内托散去桂，倍
白芷、黄 、人参、当归、木香。痒塌者，木香散加丁香攻里、官桂治表，表里皆实则易愈。
凡痒塌者，皆因血上行气分，血味本咸，腌螫皮肉作痒，然气
愈虚，而痒愈甚，必气陷而毒倒塌矣，以保元汤倍黄 而助表，少
加芍药以制血，其毒即止。
凡起胀时，中有痘大而黑者，名曰痘疔。失治则遍身皆变而死。若疔少根窠红活者，可治，用根簪
挑破疔口，吮去紫黑恶血，将四圣散点入疮内，即变红活，仍服凉血解毒药一二帖。若疔多根血不
活，背心前多者，不治。
凡有热壅盛胀满，便闭不可通利者，宜蜜皂丸导之。
自出痘至此六日，仍前红紫满顶者，不治；头面虽肿，痘不起胀者，不治。
出痘经过这四天，应当逐渐起胀，先发出的痘先起胀，后发出的痘后起胀。到了第五六天，毒气完全透出并稳定下来。如果痘的根部红活、饱满光泽且明净，就不需要服药。如果有其他证候，按照后面的论述进行治疗。
凡是痘不起胀，颜色灰白、顶部凹陷的，是气血不足，属于虚寒证，适宜服用内托散加丁香，或者用酒调服紫草膏；如果是灰黑色且陷伏的，用酒调服无价散，或者在内托散中加少许酒煎煮，送服无价散，效果最好。
凡是呈紫红色但不起胀的，是火盛血热，适宜服用内托散，去掉官桂，加入紫草、红花，热势盛者加黄芩；如果是紫黑色且陷伏的，调服独圣散（即穿山甲）；热极黑陷且有痰的，先服用抱龙丸以降痰，然后再煎紫草汤调服无价散，或者少加蝉蜕末。因为异证属肾，四牙也属肾，所以能发肾毒，内有猫牙解毒，所以热证也适宜使用，如果没有这些，无价散、至宝丹都是治疗热毒紫黑焦陷的重要药物，可以选择使用。
凡是痘在起胀时，毒气全在体表，必须依靠正气充实才能无忧，如果稍有腹泻，则内气虚脱，毒气乘虚反攻，导致疮疡陷伏。热泻所下的粪便呈黄黑赤色，肛门灼热疼痛如火烧，气味臭秽停滞严重，气盛且能进食，或者小便黄赤涩痛，适宜服用四苓散加木香、车前子、赤芍、乌梅煎服；如果所下粪便为白色或淡白色，气怯弱且不能进食，或者兼有小便清长滑利，这是虚泻，适宜服用固真汤；如果泄泻伴腹胀、口渴、气促，痘色灰白，可服用木香散送下肉豆蔻丸；如果腹胀加重，用酒调服人牙散。
凡是因血气不足而发痒的，轻症则保元汤加减，重症则内托散去官桂，加倍白芷、黄芪、人参、当归、木香。如果又痒又塌陷，用木香散加丁香攻里、官桂治表，表里皆实则容易痊愈。
凡是又痒又塌陷的，都是因为血上行入气分，血味本咸，腌渍刺扰皮肉而作痒，然而气越虚，痒越厉害，必然气陷而毒倒塌，用保元汤加倍黄芪以助表，少加芍药以制约血，其毒即止。
凡是在起胀时，中间有痘大而黑的，名叫痘疔。失治则全身都会变化而死。如果疔少且根部红活的，可以治疗，用根簪挑破疔口，吮去紫黑恶血，将四圣散点入疮内，立即变红活，仍服用凉血解毒药一二帖。如果疔多且根部血液不活，背心前方多的，无法治疗。
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.