（丙）灌浆之变化∶脓浆充足，由面部起先后作灌，痘中有饱满光荣之状，自属顺症。若（一）稠密焦
不起顶者，此血热毒盛也，当视其皮之浓薄，皮浓者，宜化毒汤加连翘、玄参，烦渴便秘犀角地黄汤。若皮
薄如水 ，必有痒塌黑陷之变，毒盛者宜辛凉合寒凉解毒之法消息之，虚者顶白，宜
参内托散加当归、芍药，使血活气行，自可转红。（二）气虚之证，用内托补剂，暂起灌浆未满，而复平
塌者，宜用大剂保元汤加川芎、当归、木香、官桂、糯米。浆色淡白，食少便溏者同。（三）头面稠密，身
上稀少，色白不能起顶灌浆者，宜参 内托散。若药力在上，先头面浆满，四肢不灌者，宜前方加糯
米、芍药，以牛膝下引至足。（四）咽中有疮，灌浆时，疮瘢新嫩，触之即痛，痂皮沾滞，痰涎缠裹，饮食
难入，或呛水呕谷者，宜甘桔汤加牛蒡子、天花粉，频频饮之。语言清亮者可治，
声哑语言不出者难治。（五）灌浆时喜笑不止者，此心包热甚也，宜保元汤加人中黄、黄连。（六）灌
浆时，忽然倒 ，或血热毒盛，不能起胀，伏陷喘胀便秘者，宜攻毒汤。（七）灌浆
时，发热自汗者，若二便不通，脉沉滑数疾，此热毒内郁，宜承气汤，酌去芒硝。若手足厥冷，自利呕吐，
脉沉细微弱，或浮大而虚，此阳气欲脱，宜理中汤加熟附子。（八）灌浆时，痛不止者，此气滞也，宜保元
汤加山楂、木香。若痘色朗绽，而两臂肿痛者，宜前方加桂枝、羌活、防风、当归、忍冬、犀角、连翘。
（九）灌浆时痒塌不止者，此血热也，宜四圣散加生地、干首乌，以凉其血。破者以白龙散敷之。（十）痘疮
抓破，其人能食，大便坚，抓破之处，复灌成浆，原无痘处，续出大小不等者可治，宜内用十全大补汤、苦参
丸间服，外以灭瘢救苦散合百花膏涂之。（十一）灌浆时干空无水者，此气虚伏陷也，宜补中益
气汤。若人事清爽，饮食如常可起，若喘胀哕，烦闷外剥者不治。（十二）痘本稠密色淡，灌浆时昏睡妄
语者，此血虚神无所根据也，宜保元汤加当归、地黄、茯神、枣仁、麦冬。（十三）灌浆
时身发壮热者、渴欲饮水者，此疮多毒盛，表里气血俱虚之故，宜加味四圣散去木香，加当归、芍药。亦有
浆半足而热甚烦渴，引饮不已者，此津液外布而肺胃枯涸也，宜大剂保元汤合生脉散频进，浆满则渴自止。
（十四）灌浆时而泄泻者，最为危候，盖病久津液已衰，脾胃已弱，再患泄泻，则仅存之气，重竭于内，
方张之毒，难化于外，必生变症，宜急用人参白术散去葛根，加木香、官桂、黄 ，不应则用不二散。（
十五）灌浆已成，并无陷伏，忽然腹痛、烦躁、喘促，此必伤食，或腹有燥屎，宜按证治之。
（丁）结 之变化∶结 之后，只须慎寒暖，慎饮食。初无重大之变化，其有剧变者∶（一）必由
灌浆后触犯秽恶，或误服药饵，如倒 黑焦，身热似灼，概宜五福化毒丹加减。（二）结
时溃烂者，此毒当发而发迟，致毒蓄肌肉，或未当发散而发散早，致毒邪暴出，故肌肉熏灼腐烂，甚至内气
并虚，滑泄自利，宜急用木香散或白术丸以治里，外以白螺散或白龙散，加麝少许
敷之。（三）痘浆清而忽然干黑，或未成痂者溃烂，已成痂者只是嫩皮，此为倒 。若当 不 ，复入于里，
元气素弱，不食自利者，宜木香散、异功散之属。如大便久秘，忽然腹胀喘呼，此毒盛薄蚀元气，复入于里，
宜急下之，用排毒汤。（四）将 之时，热不止而脉滑数者，痘未尽也，宜托里快斑汤，服后再出赠
痘，其热自除。（五）结痂干浓，忽然寒战，干呕，烦渴者，此正气将复，不能禁持之故，宜生脉散。
（六）结 太迟为虚， 黑太过为热，俱宜按证治之。
以上所述，为痘证四大时期变化之大概也。
五、痘证脉法
痘证属阳邪，故宜见阳脉，与痧疹同。凡小儿七岁以上，五至为平，七岁以下，六至为平。过则为数，
邪气实也，不及为迟，正气虚也。人迎紧者，外感为多，气口数者，内伤为多，浮而数者为表热，沉而紧者
为里热，浮而迟为气衰，沉而细元气微，惟无论沉浮，能略带洪实者终吉，弱而无力者终凶，此其纲
也。至时期之分大都自发热以迄起胀，毒从内出，其脉宜浮大而数，不宜沉细而迟。既 之后，毒从外解，
其脉宜和缓而不宜洪数，但要和平有神，切忌虚大无力。若见浮而无根，数如雀啄，细而欲散，萦萦如蛛丝，
索索无胃气，迟而欲绝，滴滴如屋漏，沉而时见如鱼跃者，皆死候也。又六部之外，有冲阳脉者，胃脉
也，太溪脉者，肾脉也，胃为后天之主，肾为先天之根，故痘证以此二脉为最关紧要。二者之中，以太溪为
尤重，倘病至六部无脉，生死难辨，宜急诊此脉，若悠悠不断不急，此元气尚在，犹
或可活。若二脉先绝，纵六脉犹存，亦为凶候。此痘证脉法之大概也。
六、痘证舌苔
痘证大都有苔，与痧疹同，大约自发热以至报点，皆为白嫩之苔，或白浓之苔，自起胀以至灌浆，皆
为黄嫩之苔，或黄
糙之苔。然有不尽然者，或一起即白苔，迄灌浆止而无甚变化。如痘证虽发热而能食，二便照常，纵白苔稍
浓，黄苔稍干，皆非重证，殊不必因苔而滥施补托，或猛用克伐也。至苔见干黄，气息粗盛，或见焦黄，其
质深绛，则气郁血热，虽欲疏达，必参辛凉，虽欲提托，必寓滋阴。又有舌忽胀大者，总由心
火胃热，舌喑者，风痰为患，舌生芒刺，急宜凉下，重舌、木舌、弄舌者，总宜视舌之红绛，一以败毒清热
为治，俱宜慎用辛温，以防劫津也。有舌缩者，宜分寒热，热者刺破舌尖，血多红紫而流利，寒者刺破舌尖，
血多紫暗而似凝，惟痘证舌缩，总以热为多。至若灰苔，或由寒湿内积，或由内伤火衰，报点以迄起
胀见此，大率热势不盛，必以补托为先，祛湿为后。若黑苔则无论发热以至结痂见此，皆为危候也。
七、治痘须知
痘证变端，瞬息不同，较痧疹尤为复杂，上列审证之法，虽见一斑，然宜忌顺逆，犹未详尽，特再采诸
家之说，节录若干条于下∶
（一）痘证发热，体实者虑其邪盛而不易报点，体虚者虑其气弱而不易报点，然报点之后，经过有起
胀灌浆结 三时期，每期亦均有变端之可能，危症或可起于顷刻，故治痘用药，贵在随
时消息，朝夕不同，不足为异，不若痧证透后，绝少危症也。
（二）视痘吉凶，全在形色，当其报点之后，颗粒逐渐显明，尖圆坚浓者吉也，起胀之形，发荣滋长
者吉也，灌浆之形，饱满充足者吉也，结 之形，敛束完固者吉也。若初出空如蚕种，或密似针头，起胀粘
聚模糊，肌肉虚浮，灌浆形色暗晦，或清薄或干枯，结 枯朽剥蚀，或焦黑或散漫者，皆为凶也。
（三）痘证形色之辨，固为重要，然形色相较，色尤重于形，宁可有色无形，不可有形无色。盖形属
乎气，气可旺于斯须，色属乎血，补血难图速效，故察痘之色，宜以光明红活为上
乘，若形平塌而色红活，证虽剧必有可治，若色晦滞而形光圆，证虽轻必尚有可虑也。又以面部之形色言，
痘证面赤者多吉，面青者多凶也。
（四）痘证吉凶，又可验之于部位。大抵从正额及两颧先见者多顺，人中口鼻先见者多险（一说口鼻年寿
先见两三点者为顺），若未见点而口唇目胞预为浮肿者亦险。至报点起胀之时，头面渐次浮肿者，此毒瓦斯发
越，欲作脓血也，如疮尖而圆，磊落红活者，亦属顺证。又可验之于耳纹，耳纹以少为顺，条匀直上
者顺，分枝缠绕者凶，若横过发际者，多属危证。耳纹之色，以水红色者为顺，淡红色者次之，大红色者为火
甚，紫黑青色者，多属危证。
（五）痘证吉凶，又当验之于老嫩，痘证自始至终，喜老而恶嫩。苍淳者，色之老也；肥实者，形之老
也；浓浓者，浆之老也；浓坚者， 之老也。娇艳者，色之嫩也；浮虚者，形之嫩也；稀清者，浆之嫩也，
薄软者， 之嫩也。总之老者多顺而易于成功，嫩者多险而难于施治。
（六）痘证吉凶，又可辨之于疏密，密者多凶，疏者多吉，然疏者若谵妄大热，唇舌燥裂，烦躁不宁，
大小便秘，此毒壅不出，阳邪遏于里，虽疏未得为吉。密者若铺排磊落，大小匀净，
眠食皆安，二便如常，或密于手足，虽密亦未足为害也。
（七）痘证身痛者多属重证，或由热毒内作，或由血虚不能营养。大抵初发时即痛者，为血气凝滞，毒
壅而作痛也；灌浆时忽痛者，为血虚热盛，不能胜邪也。收 后忽痛者，为血液枯燥，余邪未净也。至于
痘疮上作痛，在灌浆未成之前，由毒瓦斯变化未成，郁而作痛，此其常也。毒化脓成，其痛自己，若肉如刀
割，肤如锥刺，叫号不宁者，则皮伤肉败，多属危症。
（八）痘证发热，最忌腰痛。腰痛失治，易致不能起胀，或
起胀后旋即黑陷，故腰痛较身痛尤为剧证。大抵痘未出而骤热腰
痛者，此肾脏火毒炽盛也，宜急用百祥丸或水调玄明粉以下夺其毒势。发热时腰痛者，宜羌活当归汤或人参
败毒散，斟酌进之。痘出胸腰疼痛，叫唤不宁者，宜用豆豉三两，胡椒一钱，共捣烂，又将生姜四两捣汁
调匀，炒温敷痛处，以定其痛势。至腰痛时，腰下见紫黑成片如蚤啮者，为肾坏不治之绝症。
（九）痘证腹痛，多由热毒或食积所致。然亦当分察虚实与时期，大概痘未出而腹痛者，若发热烦躁，
作渴饮冷，大便坚实者，此热毒壅滞，宜用疏利之品；若腹中有块者，此气滞也，宜用运化兼发散之品；痘
乍出乍隐而腹痛者，此伏毒也；痘未出尽，便秘而痛者，此燥屎与毒相并也，俱宜七物升麻汤。痛时身
不甚热，口不作渴，时或发寒，时或呕吐，肠鸣自利，六脉虚细，面青手足冷者，此脾胃虚寒也，宜黄 建
中汤加木香、青皮。痘已出尽而腹痛者，气已虚而血仍热，宜以紫草饮发之。至靥后发热，粪黑腹痛者，此
蓄血也，宜犀角地黄汤清利之。毒瓦斯弥漫，便血日夜无度，腹痛啼哭者，宜牛黄汤解之。如见气粗口
臭，唇舌青白，身发战动而痛者，此毒归脏腑，胃烂成脓，或发热时心腹绞痛，胀满疼痛，其痘陷伏者，
均为毒恶之气攻刺肠胃之危证，法在不治。
（十）痘证腹胀，多由毒郁肠胃。若胃中伏热，小便赤涩而胀者，宜导赤散加滑石、紫草；面黄烦躁，
小便利大便黑者，为瘀血在黑，宜犀角地黄汤加穿山甲；若痘干紫而胀，不大便者为血热毒盛，宜紫草承
气汤。至腹胀而大便利者，半属虚胀，切忌克伐。凡痘证腹胀，口中如烂肉臭者，或当起发之时，倒陷而腹
胀者，皆为不治。
（十一）痘证肠鸣失气皆属危候，盖肠鸣为胃败而中气下陷，失气为脾败而谷气下脱，痘疮见此，则生
养之气俱虑不足也，亟宜大补中气而佐以升提，或可挽救。
（十二）痘证溺血，痛者易治，不痛者难治，此证因蓄毒蕴
于心经，心失其主，血随毒激，故奔散妄驰，法当清心解毒，酌用导赤散，切忌升麻、黄 之属。若小便涩
结，血条如棉线，欲尿则号哭痛不可忍者，急用炒山栀末、青龙须草汁调服，再以木
通汤饮之自愈。若黑如豆汁者，法在不治。
（十三）痘证泄泻，常虞气陷，故恒较痧疹之泄泻为可虑。大抵痘未出而先泻者此邪并于里，肠胃热
甚而传化失常，宜清热解毒，即痘出一二日而泻者，亦为挟热，只宜疏托，不必止泻。痘已出齐而泻者，此
邪并于表，正气方逐邪气，故不能运化水谷，法宜补气。若四五朝后，泄泻数行，痘色顿减者，宜升发之。
痘起胀时，骤泻不止，危在旦夕者，宜异功散，不应急用豆蔻丸，或白术散以止之。若热毒作泻，必有热之
见证，宜加味四苓散。九十朝后，已结 而作泻者，宜解毒调中，使余毒自下传导而
出，不宜收涩，以免后患。总之痘证泄泻，仍以察形色为主，若浆色不正，根盘不化，血散不敛，此毒在内，
宜重透托；若浆色颇正，根线紧绕者，虽泻无碍，惟泻之次数，不宜过多，日泻一
二次者，不可轻止，日泻十数次者，亦不可不虑也。
（十四）痘证痢疾，多因湿热郁于肠胃，气血受伤所致，若不速治，则外脓内痢，表里俱虚，元气易陷
，变成重症。急宜治痘为主，兼用参 补托。惟实症腹痛滞下者，则不妨微利之。
（十五）痘证发痒，其候不同，有初发时，便爬搔不停者，此邪气欲出，皮肤闭密，其火游移往来，灼
肤而痒，非恶候也，宜升发之，使皮肤纵缓，腠理开通，邪气得泄，则疮出而痒去。有痘将收敛而痒者，此时
其脓已成，邪气散而正气复，营卫和畅，致令身痒，亦非恶候，宜谨护之，勿令搔破复溃，破者以白
龙散或败草散敷之。其有起胀灌浆，血已化水，水未成脓之时，其毒未化而浑身搔痒不宁者，此为恶候，
宜急按症状施治。大抵气虚者能作痒，血热者亦能作痒，须视其痘色紫赤，饮食能进而
(C) Variations during the pustule-filling stage: When pus is sufficient, filling begins from the face and proceeds sequentially. The appearance of the pox should be full and lustrous, which belongs to a favorable course (Shun Zheng). If the following situations occur: (1) Pox are dense, scorched, and fail to elevate; this indicates excessive blood heat and toxicity. One should observe the thickness of the skin: if the skin is thick, use Huadu Tang (Toxin-Resolving Decoction) with added Lianqiao (Forsythiae Fructus) and Xuanshen (Scrophulariae Radix); if accompanied by irritability, thirst, and constipation, use Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction). If the skin is thin like water blisters, changes such as itching, collapse, and black depression will inevitably occur. For excessive toxicity, employ a method combining acrid-cool and cold-cool toxin-resolving strategies for careful application; for deficiency patterns presenting with white pustule tops, use Shen Neituo San (Ginseng Internal-Supporting Powder) with added Danggui (Angelicae Sinensis Radix) and Shaoyao (Paeoniae Radix), so that blood circulation and qi movement become smooth, naturally turning red. (2) For qi deficiency patterns, after using internal-supporting tonics, if the pox temporarily elevate but fail to fill completely and then flatten again, use a large dose of Baoyuan Tang (Preserve Origin Decoction) with added Chuanxiong (Ligustici Chuanxiong Rhizoma), Danggui, Muxiang (Aucklandiae Radix), Guangui (Cinnamomi Cortex), and Nuomi (Oryza Sativa Glutinosa Semen). If the pus color is pale white, appetite is poor, and stool is loose, apply the same formula. (3) If pox are dense on the head and face but sparse on the body, with pale colors failing to elevate or fill, use Shen Neituo San. If the medicinal force acts primarily on the upper body, causing the head and face to fill first while limbs do not, add Nuomi and Shaoyao to the previous formula, along with Niuxi (Achyranthis Bidentatae Radix) to guide the action downward to the feet. (4) If there are sores in the throat, and during the filling stage, the new scabs are tender and painful upon touch, with sticky scabs and tangled phlegm-saliva making swallowing difficult, or causing choking on water and vomiting food, use Ganjie Tang (Licorice and Platycodon Decoction) with added Niubangzi (Arctii Fructus) and Tianhuafen (Trichosanthis Radix), administered frequently. If speech is clear, it is treatable; if hoarse or mute, it is difficult to treat. (5) Excessive laughter during the filling stage indicates severe heat in the Pericardium; use Baoyuan Tang with added Renzhonghuang (Human Feces Yellow) and Huanglian (Coptidis Rhizoma). (6) Sudden inversion (Dao Die) during filling, or failure to swell due to severe blood heat and toxicity, accompanied by depression, wheezing, abdominal distension, and constipation, requires Gongdu Tang (Attack-Toxin Decoction). (7) Fever and spontaneous sweating during filling: if urination and defecation are blocked with a deep, slippery, rapid, and frantic pulse, this indicates internal stagnation of heat-toxin; use Chengqi Tang (Downward-Pouring Decoction), omitting Mangxiao (Natrii Sulfas) as appropriate. If extremities are cold, with spontaneous diarrhea and vomiting, and a deep, fine, weak, or floating-large and empty pulse, this indicates impending collapse of yang qi; use Lizhong Tang (Regulate the Middle Decoction) with added Shu Fuzi (Prepared Aconiti Lateralis Radix). (8) Unceasing pain during filling indicates qi stagnation; use Baoyuan Tang with added Shanzha (Crataegi Fructus) and Muxiang. If pox are bright and open but arms are swollen and painful, add Guizhi (Cinnamomi Ramulus), Qianghuo (Notopterygii Rhizoma et Radix), Fangfeng (Saposhnikoviae Radix), Danggui, Rendong (Lonicerae Japonicae Flos), Xijiao, and Lianqiao to the previous formula. (9) Unceasing itching and collapse during filling indicates blood heat; use Sisheng San (Four Sages Powder) with added Shengdi (Rehmanniae Radix) and Gan Shouwu (Polygoni Multiflori Radix Praeparata) to cool the blood. Apply Bailong San (White Dragon Powder) to broken areas. (10) If pox are scratched open, the patient can eat, stool is hard, scratched areas refill with pus, and new pox of varying sizes appear where none existed before, this is treatable. Internally, alternate Shi Quan Da Bu Tang (Complete Great Tonifying Decoction) and Kushen Wan (Sophora Pill); externally, apply Miecan Jiuku San (Scar-Eliminating Bitterness-Relieving Powder) mixed with Baihua Gao (Hundred Flowers Ointment). (11) Dry emptiness without fluid during filling indicates qi deficiency and depression; use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). If consciousness is clear and diet is normal, pox may rise; if accompanied by wheezing, abdominal distension, hiccups, and restlessness with outward peeling, it is untreatable. (12) Dense, pale pox with lethargy and delirium during filling indicate blood deficiency with the spirit lacking foundation; use Baoyuan Tang with added Danggui, Dihuang (Rehmanniae Radix), Fushen (Poria Cum Radix), Zaoren (Ziziphi Spinosae Semen), and Maidong (Ophiopogonis Radix). (13) High fever and thirst for water during filling indicate abundant pox with severe toxicity and deficiency of both interior/exterior and qi/blood; use Jiawei Sisheng San (Modified Four Sages Powder), removing Muxiang and adding Danggui and Shaoyao. In cases where half-filled pus is accompanied by severe heat, irritability, and unquenchable thirst, indicating exhaustion of fluids in the lungs and stomach due to external distribution, administer large doses of Baoyuan Tang combined with Shengmai San (Generate the Pulse Powder) frequently; thirst will cease when pus is full. (14) Diarrhea during filling is a critical sign. Due to prolonged illness depleting fluids and weakening the spleen/stomach, further diarrhea exhausts remaining qi internally and prevents resolution of emerging toxins externally, leading to complications. Urgently use Renshen Baizhu San (Ginseng and Atractylodes Macrocephala Powder), remove Gegen (Puerariae Lobatae Radix), and add Muxiang, Guangui, and Huangqi (Astragali Radix). If ineffective, use Bu'er San (Two-Uniqueness Powder). (15) Once filling is complete without depression, sudden abdominal pain, irritability, and panting likely result from food stagnation or dry feces; treat according to symptoms.
(D) Variations during the scabbing stage: After scabbing, one must only guard against cold/heat extremes and regulate diet. Initially, there are no major changes; severe variations include: (1) Caused by exposure to filth after filling or erroneous medication, leading to inverted black scorching and burning fever; generally use Wufu Huadu Dan (Five Blessings Toxin-Resolving Pill) with modifications. (2) Ulceration during scabbing indicates delayed eruption of toxins accumulating in muscles, or premature dispersal causing violent toxin emergence, leading to muscle burning and rotting, potentially with internal qi deficiency, sliding diarrhea, and spontaneous purging. Urgently use Muxiang San (Aucklandia Powder) or Baizhu Wan (Atractylodes Pill) to treat the interior, and apply Bailuo San (White Snail Powder) or Bailong San with a little Shexiang (Moschus) externally. (3) Clear pus suddenly drying black, or non-scabbed areas ulcerating, or fresh scabs remaining tender, indicates inverted scabbing. If scabbing fails and toxins re-enter the interior in patients with inherent weak yuan qi, anorexia, and spontaneous diarrhea, use Muxiang San or Yigong San (Extraordinary Skill Powder). If chronic constipation leads to sudden abdominal distension and panting, indicating severe toxins eroding yuan qi and re-entering the interior, urgently purge using Paidu Tang (Eliminate-Toxin Decoction). (4) During impending scabbing, persistent heat with a slippery-rapid pulse indicates incomplete eruption; use Tuoli Kuaiban Tang (Support-Interior Accelerate-Macule Decoction). After administration, if additional pox erupt, the heat will subside. (5) Dry, thick scabs followed by sudden chills, dry retching, and irritability/thirst indicate recovering zheng qi unable to sustain itself; use Shengmai San. (6) Late scabbing indicates deficiency; excessively dark scabbing indicates heat; treat according to symptoms.
The above describes the general variations of the four major stages of smallpox/variolous diseases.
V. Pulse Diagnosis for Smallpox
Smallpox involves yang pathogens, so yang pulses are appropriate, similar to measles/rash diseases. For children over seven years old, five beats per respiration is normal; under seven years old, six beats per respiration is normal. Exceeding this is rapid (Shu), indicating excess pathogen; falling short is slow (Chi), indicating deficient righteous qi. Tight Renying (neck artery) pulses suggest exterior contraction; rapid Qikou (radial artery) pulses suggest interior injury; floating-rapid indicates exterior heat; deep-tight indicates interior heat; floating-slow indicates qi decline; deep-fine indicates微弱 yuan qi. Regardless of floating or deep, a slight Hong-Shi (surging-solid) quality is ultimately auspicious; weak and powerless is ultimately ominous. This is the general principle. Regarding specific periods: From fever until swelling, toxins emerge from within; pulses should be floating-large and rapid, not deep-fine and slow. After scabbing, toxins resolve from outside; pulses should be harmonious and moderate, not surging-rapid, but must possess spirit and peace, avoiding floating-large and powerless. Floating without root, rapid like a sparrow pecking, fine and dissipating, lingering like spider silk, trembling without stomach qi, slow and nearly absent, dripping like a leaking roof, or deep with occasional jumps like fish leaping—all are death omens. Beyond the six positions, Chongyang (Stomach meridian) and Taixi (Kidney meridian) pulses are crucial. The Stomach is the master of post-heaven; the Kidney is the root of pre-heaven. Among these, Taixi is especially important. If all six positions lack pulse, life/death is hard to distinguish; urgently check Taixi. If steady and uninterrupted, yuan qi remains, and survival is possible. If both pulses vanish first, even if six positions remain, it is ominous. This is the general overview of smallpox pulse diagnosis.
VI. Tongue Coating in Smallpox
Smallpox usually presents with coating, similar to rashes. Generally, from fever until macule appearance, the coating is white-tender or white-thick; from swelling until filling, it is yellow-tender or yellow-rough. However, exceptions exist: some present with white coating immediately, persisting unchanged until filling. If fever exists but eating and excretion are normal, even slightly thick white or dry yellow coatings are not severe conditions; avoid indiscriminate tonification or harsh purging. Dry-yellow coating with coarse breathing, or scorched-yellow coating with deep crimson tongue substance, indicates qi stagnation and blood heat; although dispersing is desired, acrid-cool herbs must be included; although lifting/supporting is desired, yin-nourishing herbs must be incorporated. Sudden tongue enlargement stems from heart fire and stomach heat; aphasia results from wind-phlegm; prickles require urgent cooling-purging; double tongue, wooden tongue, and playing tongue treatments depend on redness/crimsonness, universally using toxin-resolving and heat-clearing methods, strictly avoiding acrid-warm herbs to prevent fluid depletion. Retracted tongue requires differentiation of cold/heat: heat yields bright red/purple flowing blood upon pricking; cold yields dark purple congealed blood. Smallpox retracted tongue is mostly heat-related. Gray coating arises from internal cold-dampness or internal injury with fire decline; appearing from macules to swelling, it suggests mild heat, requiring tonification/support first, dampness-resolving later. Black coating at any stage from fever to scabbing is critical.
VII. Essentials for Treating Smallpox
Smallpox variations change instantly, more complex than rashes. Although the above diagnostic methods provide insight, they do not fully detail contraindications, favorables, and unfavorables. Therefore, excerpts from various masters are recorded below:
(1) Fever in smallpox: Constitutionally strong patients risk excessive pathogen hindering macule appearance; constitutionally weak patients risk insufficient qi hindering macule appearance. After macule appearance, passing through swelling, filling, and scabbing stages, each has potential variations, and critical conditions can arise suddenly. Thus, medication must be adjusted constantly, differing day and night, unlike rashes where critical conditions are rare after eruption.
(2) Auspiciousness/misfortune depends entirely on form and color. After macule appearance, distinct, sharp, round, firm, and thick pox are auspicious; flourishing growth during swelling is auspicious; full and sufficient filling is auspicious; tight and secure scabbing is auspicious. Empty like silkworm eggs, dense like needle heads, sticky/vague swelling, floating flesh, dark/thin/dry filling, rotten/scattered/black scabbing are all ominous.
(3) Color is more important than form. Better to have color without perfect form than form without color. Form relates to qi (which can fluctuate quickly); color relates to blood (tonifying blood takes time). Bright, red, and lively color is superior. Flat form with red/lively color is treatable despite severity; dull color with round form still carries concern despite mildness. On the face, redness is mostly auspicious; blueness is mostly ominous.
(4) Location also indicates prognosis. Forehead and cheeks appearing first are mostly favorable; Renzhong and nose appearing first are mostly dangerous (some say 2-3 spots on nose/year area are favorable). Swollen lips/eyelids before macule appearance is dangerous. Gradual facial swelling during macule/swelling stages indicates toxin expansion into pus/blood; round, bright red pox are favorable. Ear veins: few are favorable; straight/upward are favorable; branched/tangled are ominous; crossing hairline is critical. Water-red ear veins are favorable; pale red secondary; bright red indicates severe fire; purple-black/blue-green are critical.
(5) Age/Maturity: Prefer "old" (mature) over "young" (immature). Dark/rich color is mature color; plump/solid form is mature form; thick pus is mature pus; thick/firm scab is mature scab. Delicate/colorful is immature color; floating/empty is immature form; thin/clear pus is immature pus; thin/soft scab is immature scab. Mature is mostly favorable/easy to cure; immature is mostly dangerous/hard to treat.
(6) Density: Dense is mostly ominous; sparse is mostly auspicious. However, sparse pox with delirium, high fever, dry lips/tongue, irritability, and constipation indicate trapped toxin/yang pathogen in interior—still not auspicious. Dense pox arranged neatly, uniform size, normal sleep/eating/excretion, or dense only on hands/feet are not necessarily harmful.
(7) Body pain often indicates severe condition, from internal heat-toxin or blood deficiency failing to nourish. Pain at onset indicates qi/blood stagnation and toxin obstruction; sudden pain during filling indicates blood deficiency with excess heat failing to overcome pathogen; pain after scabbing indicates dry blood and residual pathogen. Pain before filling completion is normal due to toxin transformation stagnation. Pain ceases when pus forms. Severe cutting/stinging pain with crying indicates skin/flesh damage and critical condition.
(8) Lower back pain during fever is most taboo. Untreated lower back pain leads to failed swelling or immediate black depression, making it worse than body pain. Sudden fever/back pain before eruption indicates kidney fire-toxin; urgently use Baixiang Wan or Xuanmingfen (Mirabilite) water mixture to drain toxin. Fever with back pain: use Qianghuo Danggui Tang or Renshen Baidu San cautiously. Chest/waist pain with crying: apply paste of Douchi (Soja Preparata), Hujiao (Piperis Longi Fructus), and Shengjiang (Zingiberis Rhizoma Recens) juice to the area. Purple-black patches like flea bites below waist indicate kidney failure and untreatable terminal condition.
(9) Abdominal pain is caused by heat-toxin or food accumulation. Differentiate deficiency/excess and stage. Before eruption: fever/irritability/thirst/hard stool indicates heat-toxin stagnation (use draining/promoting agents); abdominal mass indicates qi stagnation (use transforming/dispersing agents); intermittent appearance indicates hidden toxin; incomplete eruption with constipation/pain indicates dry feces/toxin combination (use Qi Wu Shengma Tang). Low-grade fever/no thirst/chills/vomiting/bowel sounds/diarrhea/weak pulse/cold extremities indicates spleen/stomach deficiency-cold; use Huangqi Jianzhong Tang with Muxiang and Qingpi. After full eruption: qi deficient, blood still hot; use Zicao Yin (Solomon's Seal Drink). Post-scab fever, black stool, abdominal pain indicates blood stasis; use Xijiao Dihuang Tang. Diffuse toxin, continuous bloody stool, crying pain: use Niuhuang Tang (Calculus Bovis Decoction). Rough breathing, foul odor, blue-white lips/tongue, tremors/pain indicate toxin entering organs, stomach rotting/pus formation, or severe heart/abdominal pain with depressed pox—these are critical attacks by evil qi on intestines/stomach, considered untreatable.
(10) Abdominal distension is mostly due to toxin stagnation in intestines/stomach. Stomach latent heat, red/scanty urine/distension: use Daochi San with Huashi (Talcum) and Zicao (Arnebiae Radix). Yellow face, irritability, clear urine/black stool indicates blood stasis in lower jiao; use Xijiao Dihuang Tang with Chuanshanjia (Manis Squama). Dry purple pox with distension/constipation indicates blood heat/toxin excess; use Zicao Chengqi Tang. Distension with free stool is half-deficiency distension; avoid harsh purging. Foul smell like rotting meat, or inversion with distension during swelling, are untreatable.
(11) Bowel sounds and flatus are critical signs. Bowel sounds indicate stomach failure and sinking middle qi; flatus indicates spleen failure and grain qi leakage. Both suggest insufficient nurturing qi; urgently tonify middle qi with ascending agents to possibly save.
(12) Hematuria: painful is easy to treat; painless is difficult. Caused by accumulated toxin in Heart Meridian, losing control, blood agitated by toxin. Treat by clearing heart/resolving toxin, using Daochi San cautiously; avoid Shengma (Cimicifugae Rhizoma) and Huangqi. Urinary retention with thread-like blood clots and unbearable pain: urgently use fried Zhizi (Gardeniae Fructus) powder and Qinglongxu Cao (Equiseti Herba) juice, followed by Mutong Tang (Akebia Decoction). Black like bean dregs is untreatable.
(13) Diarrhea risks qi sinking, more concerning than rash diarrhea. Diarrhea before eruption indicates pathogen merging in interior with intense intestinal/thermal heat; clear heat/resolve toxin. Diarrhea 1-2 days after eruption indicates accompanying heat; only support/disperse, do not stop diarrhea. Diarrhea after full eruption indicates pathogen moving to exterior, righteous qi chasing pathogen, failing to transform fluids; tonify qi. Diarrhea after 4-5 days with sudden reduction in pox color: promote rising. Sudden unceasing diarrhea during swelling is critical; use Yigong San, do not urgently use Doukou Wan (Cardamom Pill) or Baizhu San to stop. Heat-toxin diarrhea requires heat signs; use Jiawei Siling San (Modified Four Ling Powder). Post-scab diarrhea (90+ days): resolve toxin/regulate middle, allow residual toxin to exit via bowels; avoid astringents to prevent future issues. Overall, prioritize observing form/color. Abnormal pus color/unresolved base/scattered blood indicates internal toxin; heavily support/disperse. Normal pus color/tight base allows diarrhea; limit frequency. 1-2 times/day need not be stopped; 10+ times/day requires caution.
(14) Dysentery is caused by damp-heat stagnation in intestines/stomens damaging qi/blood. Without prompt treatment, external pus and internal dysentery lead to exterior/interior deficiency and yuan qi collapse, becoming severe. Prioritize treating smallpox with Ginseng/Astragalus support. For excess pattern with abdominal pain and tenesmus, mild purging is acceptable.
(15) Itching varies. Early scratching indicates pathogen wanting to exit, closed skin, wandering fire burning skin—not ominous; promote eruption to open pores and release pathogen. Itching during convergence indicates formed pus, dispersed pathogen, recovered righteous qi, harmonious Ying/Wei—not ominous; protect carefully to prevent breaking. Use Bailong San or Baicao San on broken areas. Itching during swelling/filling when blood turns to water but not yet pus, with untransformed toxin causing whole-body restlessness, is ominous; treat urgently based on symptoms. Qi deficiency causes itching; blood heat causes itching. Observe purple-red pox and ability to eat...