加以升提，使邪热去而痘毒升。痘未出者，升麻葛根汤，消毒饮加大黄；热甚者，凉膈散，以其有连翘、薄荷
轻清，亦上升发也。虽痘出不快，有此里邪实热者，亦宜。痘已出或将靥，有热毒便秘者，小柴胡汤加生地；
或四顺清凉饮、犀角地黄汤，俱加大黄。寻常热轻，而无烦躁狂谵，痘未出者，只宜败毒散、连翘饮、紫草
饮、紫草木通汤；痘已出者，四物汤加芩、连、桃仁、麻仁，或麻子仁丸以润之。苟非外感邪入里深极，内伤
湿热蕴结，与毒相拒，断不敢下，惟瘥后余毒，量体下之可也。故曰痘疹下之早，则为陷伏倒靥，犹伤寒下之
早，则结胸也。又痘疮利药，忌用丸、丹及巴豆、水银、轻粉，此三味但能去脏中惊涎积热，非痘家所宜。
小便赤涩腹心膨，热微热甚有分晓；
小便赤涩，以致心腹膨满，由胃热心火不降，阴气不能升也。痘未出者，紫草饮发出其毒即愈；痘已出者，
四圣散加黄 。小便涩赤热，并大便亦秘，不敢下者，五苓散、导赤散、紫草木通汤、连翘散以渗之。如热微，
又不敢渗小便，恐损真气者，只宜独圣散、紫草饮以解其毒。古云∶大热利小便，小热和解是也。又回浆内腑
化毒，溺多则顺，稍有闭者，宜善调之。
热甚狂喘或发惊，误投惊药祸非小；
痘已出，狂叫多怒喘呼者，为热甚而无阴以敛之也，犀角地黄汤，痘毒惊搐，虽亦由于心热，肝风旺而脾
土虚，则火炎为搐，宜泻肝则风自去，利小便则热不炎。若概用惊风凉药，如银花、脑、麝、青黛、朱砂、
硝石，令心寒而毒瓦斯内伏，当出不出，已出未靥。如先惊后痘者轻，先痘后惊者逆。痘色粒分明，惊来即去者
无害。痘未出，因外感与内热相搏发惊者，惺惺散、消毒饮、加减红绵散、大青膏、紫草膏，兼服匀气散，
毒泄而心神自定，气匀而痘疮自出矣。又有暑搐昏冒者，六一散；痰盛神昏不醒者，抱龙丸；或睡中手足常缩，
将发惊搐者，急用导赤散利小便，或四圣散以解毒。痘已出，虚者保元汤加芍药最妙；热者，五福化毒丹、泻
青丸、古牛蚕散；热甚搐毒攻心，以致黑陷者，从权以凉惊丸，或猪尾膏暂服可也。抑考热证谵语妄言属心；
搐搦惊痫属肝；肿胀便秘属脾；喘渴咳嗽属肺，尽皆四脏所发。虚证可以类推。
遍身作痛毒外行，
痛乃痘之善证，或遍身痛，或只几颗痛，有外邪所搏者，初见红点时，宜参苏饮加木香；轻者，消毒饮，
或升麻葛根汤倍芍药；甚者，更加蝉蜕、山楂、羌活。有痘出身痛，肉皴痘密者，匀气散、小活血散。惟胀贯
时作痛不忌。
热痒清内虚实表。
诸痛为实，诸痒为虚，虚实于形色上分之。色不灰陷，便难而痒者为实。有因风寒者，消毒饮；有因食毒
及食盐者，四君子汤加酒芩、连，或大黄微润之。通用单蝉蜕汤，时时服之。痒甚者，水杨汤浴之，或用食盐
和百草霜，水湿略炒过，置火内烧烟熏之，其痒立止，虚痒亦效。或用蜜水调滑石末涂之，且令疮痂易落无痕。
色淡甚则倒靥，便溏而痒者为虚，宜保元汤倍加黄 实表，少加芍药活血；痒甚遍身爪破，脓血淋沥，不能坐
卧者，内托十宣散去桂，倍黄 ，加白芷止痒，当归和血，木香调气，气行血运，其痒自止，或小活血散合四君
子汤，加黄 、枳壳。有毒瓦斯陷内痒塌者，木香散加丁香攻里，官桂实表以救之。凡手足常摇动者，将发痒也。
虚证腹胀身必凉，
痘已出虚胀有二∶有因内伤生冷、凉药，与内热毒相拒，不得发越，故令腹胀，宜萝卜子、紫苏梗、陈皮
各一钱，干姜、甘草各五分，水煎服。食减者，加白术；甚者，发寒肢厥，疮白无血色，多致不救，急用木香散，
温中逐冷，甚则异功散。有毒瓦斯陷伏作胀者，宜温中解毒，人齿散、小活血散。惟腹胀目闭口臭者死。
吐泻痘出最难当；
初起吐泻无妨，痘出脾胃冷者，胃爱散。因外感者，寒月，理中汤、五积散、异功散；暑月，六和汤、胃
苓汤。因内伤者，四君子汤加砂仁、陈皮，理中汤去参，加浓朴；宿食重者，感应丸。痘出后极忌泄泻，起
胀尤忌。有泻皆属虚冷，急用保元汤加桂、芍，或木香散。泄滑者，用肉豆蔻一个，乳香一豆大，为末，米饮
下，或固肠丸。因泄顶陷者，内托十宣散、四圣散加减。如吐泻喘渴，蛔虫已出，目直便流，利肠垢者死。
自汗气弱难收靥，湿热熏蒸神术方；
痘出后，切忌汗多，以致气虚必难作浆收靥，急用保元汤止之。如初起湿热熏蒸者，用白术二钱，黄连一
钱，浮小麦煎服；若伤风自汗，量用桂枝、防风可也。惟身寒，汗缀如珠，神昏者死。
痘出寒热内虚甚，寒战火郁必发痒。
已出痘而寒热者属内虚。七日前后独热者，气血与毒俱盛之过；七日前后独寒者，气血损而毒火内郁，
难治。寒战切牙，足膝冷如冰，尻、耳反热，胀贯靥时极忌，乃气血虚极，宜保元汤加桂；甚者，异功散。
变证冷秘热吐泻，
脏腑热则便秘，脾胃冷则吐泻，常也。有呕吐不食，面青瘦者为冷秘；久不大便，而无里急后重者为虚秘，
俱宜内托十宣散。气虚者，四物汤、麻子仁丸。又有能食，结涩下如粟块者，为风秘；胸胁腰腹引痛者，为气
秘。热毒攻胃吐泻，手掌心并腋下热而 有汗，脸赤渴欲饮乳，乳满胸膈不化则吐，吐了又渴，急欲饮乳，
是热吐也；小便赤涩而渴者，热泻也，俱宜五苓散、竹叶石膏汤加陈皮。痰壅吐食者，二陈汤；湿热吐者，
葛根竹茹汤加黄连；湿热泻下臭秽者，解毒汤加白术。大吐身热腹满，二便赤涩，面赤喘闷者，当利小便，
四苓汤、导赤散，不瘥者，宣风散下之。
热甚四肢仍发厥；
凡痘证身寒不治。但其间有患热证，而忽发厥肢冷者，犹伤寒伏热深而厥亦深也，宜随证用清内解毒药，
毒出而身体自温矣。如痘未出，猪尾膏最妙。
大便不通小便血，遍身肌肉尽破裂。
初热误用热药，报痘又以胡荽、葡萄、人齿服之，虚者犹宜，实者令毒攻脏腑肢络，灌注耳、目、口、
鼻、咽喉闭塞，大便不通，小便如血，或为痈疮肌肤破裂，皆阳盛无阴也。宜猪尾膏、犀角地黄汤、解毒汤、三
黄丸。服后疮出红活者吉，倒靥者死。暑月痘烂生蛆，乃热毒盛也，内服清热之药，外以带以柳枝铺地卧
之，或水杨汤沃之亦好。
痘变倒靥与陷伏，
痘色初出淡红变白，白变黄者吉；初出鲜红变紫，紫变黑者逆。痘形陷伏倒靥，自其内伤气虚，而不
能起发而言，谓之陷伏。宜温中托里，令脾胃暖而荣卫通也，甚至硫、附亦可暂服。自其外感及秽污而言，
谓之倒靥。外感宜温散寒邪，而荣卫复行；犯秽，宜熏解之。凡当出不出，当胀不胀，当贯不贯，当靥不靥，
俱以照原为气血旺，退减均谓之倒靥陷伏。
惟有黑陷当详究；
黑，乃北方寒水之色，然火热反兼水化，色亦能黑，故变黑当究寒热。寒证变黑者，因风寒归肾，宜温
散；因为虚毒陷，宜温补。热证有毒盛火炎，宜凉心清解；有脏燥无阴，宜润
血化痰。噫！痘变不过陷伏、倒靥、黑陷、斑烂四者，黑陷最危，可不究诸？
初出黑色状如蚊，秘躁皆因瘀血蓄。
初出状如蚊咬色黑者，因毒瓦斯暴出，瘀热搏之，故血凝不行，遂成黑陷。大小便闭，腹胀喘急，烦躁，
宜山栀仁汤、人齿散、加味四圣散、单蝉蜕汤加紫草；出不快者，宣毒膏、猪尾膏。
出不能快如炭焦，表分大热还宜透；
表热如炭，焦黑陷伏，见热证者，透肌散加红花、地骨皮，或单犀角磨水服之，或独圣散、小活血散。腹
痛者，单蝉蜕汤。干枯倒陷甚者，单麻黄五钱，用蜜水拌炒，水煎去沫再煎，乘热服之，其痘复起。
青干紫黑身热微，便秘急下去陈垢；
痘出不快，已出者青干紫黑，身不大热，大小便闭，是热滞于内，毒瓦斯无由发泄，宜宣风散；气怯者，
木香槟榔丸，俱令先下黑粪，次下褐粪，后以四君子汤，加浓朴、木香、陈米和胃，良久粪黄，疮自出透。
若表大热者，不可大下。如青干紫黑、睡昏、汗出不止，烦躁热渴、腹胀啼喘，二便闭者危。
入里热极身紫黄，喜泻脓痂恶毒臭。
毒瓦斯入里，心神昏闷，或出不快，或难结痂，乃毒火燥盛，以致黑陷者，猪尾膏，凉心通窍则气和神疏，
而痂自结矣。痘出黑陷，反当结痂不结痂，便闭腹胀身黄，紫肿变黑，湿热最重者，急以单大戟丸，利去膀胱
邪水，犹伤寒木贼土败，急下之，可保五死一生。如所下水谷不消，身冷战振多汗，尻、耳热者，为水溢土崩，
必死；若下后身热气温饮水，尻、耳冷，或泻脓血，疮痂者，为毒瓦斯尽去，胃气犹强。泻后仍宜四君子汤，加
浓朴、木香温脾为妙。
脏燥至极已亡阴，痰盛发惊狂叫吼；
毒郁脏燥，无阴以守，狂叫喘呼，痰盛欲发惊风者，四齿散加蝉蜕，古牛蚕散以解毒；遂成黑陷者，犀角
地黄汤以养阴，抱龙丸以降痰。若发惊狂谵语者，砂辰六一散，用紫草、灯心煎汤，磨犀角、玳瑁汁调服，或
护心散。盖凉血则不致红紫，解毒则免黑陷。失治，不日声哑而死。
果系虚寒二便清，脾肾兼补加诃蔻；
痘出里虚，心烦恶热，以致黑陷者，八物汤去地黄，恐滞血；去芍药，恐伐胃；加木香和脾胃，大补气血。
盖脾胃畅而不致内陷，气血盛而不致痒塌。寒冷多因乳母忍饥受冷，以致芽儿寒冷归肾，痘变黑陷。寒月，木
香散、异功散发之；天温时；内托十宣散，去桂、木香，加紫草、蝉蜕。
带紫为热带白虚，黑如乌羽犹可救；
带紫者为血热，四物汤加芩、连、红花；带白者为气虚，保元汤去甘草，加紫草。通用灵砂三五粒，磨酒
服，能起黑陷。凡痘变黑如乌羽光润，不发寒而尻、耳冷者，为血活可救，紫草饮合小活血散。
外黑里白赤者轻，
凡痘外黑里白者轻，外黑里赤者微重，外白里黑者太重，疮顶陷黑，中有眼如针孔紫黑者死。
轻甚一个大黑痘。
头面上忽生三五个，或只一个高硕紫黑，俨似疔痘者，名曰飞痘。有此痘出最轻，或只此一痘，再不出痘。
是知黑痘生死轻重迥殊，可不详辨深究之乎！
遍身斑烂脓不干，
痘当发散不发散，则毒瓦斯闭塞，胸满喘促闷乱；不当发散，而强发散，则痘毒出盛，表虚难靥，以致肌肉
如烂，故曰烂斑，治宜调脾进食，令大便不秘不利，养荣卫以生肌解毒，则无目赤咽痛、口疮、吐衄等证。如大
便不通，脓水不干者，牛黄丹；斑烂脓汁不干作痛者，败草散，或干黄土为末；干糁。轻者，用猪胆汁调芒硝末敷
之，勿令动着，直候疮痂自落。疮烂成片，欲不成瘢痕者，用干牛粪火 过，取白心入乳香为末藉之，甚者，
麦麸衬卧；暑月热盛，当藉之以芭蕉叶。有因过汗内虚脏腑，自利斑烂，或因饮水多者，俱保元汤加防风、白
芷，外敷败草散。败草散∶用盖屋及墙背上远年腐草，洗净，焙或晒干为末，帛裹扑之。甚者，铺床席，令儿卧
之，甚妙。此草经霜露久，善解痘毒。
作痛有如刀刻镂；
秽污触犯而然，治见秽污。
要知痘变顶不变，阳存生意必然复。
报痘自顶上阳位起，且稠者固凶，如痘遍身变坏，独顶额上不变则吉。贯脓时变成水 无脓，皮薄如纸，
遍身擦之即破，惟额上不破者可治。若阳位与心胸先破者死速。收靥时，败证悉见，惟额上、太阳、方广、顶上
未靥如旧者可生。
疔痘头面胸背危，四肢点破毒可泄；
起胀时，有痘长大而紫黑者，名曰疔痘。疔者，钉也，把住痘疮不起，盖气血弱以致毒聚而成形。如
气血胜而毒变制，结于四肢，或小或个数少而穿筋骨者易治；结于头面、腹背，逼近于内者，势必穿脏腑，难
治，急以保元汤加牛蒡子、荆芥、芩、连，助气逐毒。外以银簪挑破疔头，令父母吮去恶血，或绵裹指甲掐去
恶血，展去亦可，盖痘破而毒瓦斯得发故也。或用珍珠五粒，铁器上炙黄色，豌豆四十九粒，头发一团，俱烧存性为
末，油胭脂调成膏，将儿在温暖处，忌风寒秽气，先用银簪挑开疔口，将药点入疔内，实时变为红白色，余疮
皆起。又有黑痘独大，顶心黑，拨之如绵筋有臭者，保元汤加芎、桂、糯米，补提其气，如变黄色者，可保。
痘痈手足先肿疼，血引毒注三阴穴；
凡痘痈，必先手足及脉络之处或有红肿，或手腕鲜红一块，或手足有硬痛处，或足痛不止，或足上痘肿
如瓜，皆发痈之兆也。因其肿痛深浅，而知其痈之大小。原因痘出，复被风寒郁其热毒，或痘出服热药、热食过多
所致。又有痘变坏，而毒并一处发者反吉，治法见后瘥证，盖痘未愈时，虽痈发亦不宜治痈。若初起胸前脑上有
一块红肿，及遍身有块者死；贯脓时，足肿青红流水，痘不好者亦死。
胀贯收靥或不齐，发疔发痈反可悦，
凡痘当胀贯不胀贯，当靥不靥，得发疔与痈者反吉。凡痈毒、疔痘生于胸前、腰肾之间至重，红小者生，
黑大者死。
阳毒凡疮每乘虚，湿润为实干枯乏。
Add lifting and raising agents to eliminate pathogenic heat and allow the smallpox toxin to rise. For smallpox that has not yet erupted, use Shengma Gegen Tang (Cinnamon Twig and Rhizoma Bupleuri Decoction) or Xiaodu Yin (Toxin-Resolving Drink) with added Radix Rheei Preparata (Dahuang, 大黄); for severe heat, use Liangge San (Cooling the Chest Powder), as it contains Qingqiao (Fructus Forsythiae, 连翘) and Bohe (Menthae Haplocalycis Herba, 薄荷), which are light and clear, also promoting upward dispersal. Even if the eruption is slow, if there is interior excess heat, this approach is also suitable. For smallpox that has already erupted or is about to scab, if there is heat-toxin and constipation, use Xiaochaihu Tang (Minor Bupleurum Decoction) with added Shengdihuang (Radix Rehmanniae Preparata, 生地黄); or Sishun Qingliang Yin (Four-Obedience Cooling Drink) and Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction), both with added Radix Rheei Preparata (Dahuang, 大黄). For ordinary mild heat without restlessness, mania, or delirium, if the smallpox has not erupted, only Bai Du San (Immunity Powder), Lianqiao Yin (Forsythia Drink), Zicao Yin (Arnebiae Root Drink), or Zicao Mutong Tang (Arnebiae Root and Akebia Decoction) should be used; if the smallpox has erupted, use Siwu Tang (Four Substances Decoction) with added Huangqin (Scutellariae Radix, 黄芩), Lianqiao (Fructus Forsythiae, 连翘), Taoren (Persicae Semen, 桃仁), and Maziren (Cannabis Seed, 麻仁), or Maziren Wan (Cannabis Seed Pill) to moisten. Unless there is external pathogen penetrating deeply into the interior, damp-heat accumulation resisting the toxin, one dare not use purgatives; only after recovery, for residual toxins, can purgatives be used according to the body's constitution. Thus it is said: purging too early in smallpox leads to sinking and inverted scabbing, just as purging too early in cold damage leads to chest binding. Furthermore, medicines for smallpox diarrhea should avoid pills, elixirs, and Ban Dou (Crotoni Fructus, 巴豆), Shuiyin (Hydrargyrum, 水银), Qingfen (Calomel, 轻粉); these three only remove phlegm-fluids and accumulated heat from the zang organs, which is not suitable for smallpox cases.
Red and scanty urine with abdominal distension distinguishes mild from severe heat:
Red and scanty urine leading to abdominal distension is due to stomach heat and failing descent of heart fire, preventing yin qi from ascending. If the smallpox has not erupted, use Zicao Yin (Arnebiae Root Drink) to release the toxin and cure; if erupted, use Sixiang San (Four Saints Powder) with added Huangqi (Astragali Radix, 黄芪). If urine is red, scanty, hot, and stool is also constipated, and purgatives are contraindicated, use Wuling San (Five-Ling Powder), Daochi San (Guiding Out Redness Powder), Zicao Mutong Tang (Arnebiae Root and Akebia Decoction), or Lianqiao San (Forsythia Powder) to promote diuresis. If heat is mild and diuresis is feared to damage true qi, only Dusheng San (Single Saint Powder) or Zicao Yin (Arnebiae Root Drink) should be used to resolve toxicity. As the ancients said: "For great heat, promote urination; for slight heat, harmonize." Additionally, during the scabbing phase, internal detoxification favors abundant urination; slight blockage requires careful regulation.
Severe heat with mania, panting, or convulsions: misusing anti-convulsant drugs brings disaster:
If the smallpox has erupted and the patient screams, shows anger, and pants, it is due to excessive heat lacking yin to restrain it; use Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction). Smallpox toxin-induced convulsions, though also due to heart heat, if liver wind is hyperactive and spleen earth is deficient, fire flares causing convulsions; thus, draining the liver removes wind, and promoting urination stops heat flare. Generally using cooling anti-convulsant drugs like Jinyinhua (Lonicerae Japonicae Flos, 金银花), Nao (Borneolum Syntheticum, 冰片), Shexiang (Moschus, 麝香), Qingdai (Indigo Naturalis, 青黛), Zhusha (Cinnabar, 朱砂), Xiaoshi (Natrii Sulfas, 硝石) causes heart coldness and internal retention of toxin vapors, preventing eruption or scabbing. Convulsions before eruption are mild; eruption before convulsions is adverse. Distinct smallpox grains with immediate cessation of convulsions are harmless. Before eruption, if convulsions result from external pathogens clashing with internal heat, use Xingxing San (Xingxing Powder), Xiaodu Yin (Toxin-Resolving Drink), Ji Jian Hongmian San (Modified Red Cotton Powder), Daqing Gao (Great Green Ointment), Zicao Gao (Arnebiae Root Ointment), combined with Yunqi San (Qi-Balancing Powder); as toxins drain, the mind settles, and as qi balances, smallpox erupts. For summer convulsions with dizziness, use Liuyi San (Six-One Powder); for phlegm abundance with coma, use Baolong Wan (Dragon-Holding Pill); for curling limbs during sleep indicating impending convulsions, urgently use Daochi San (Guiding Out Redness Powder) to promote urination, or Sixiang San (Four Saints Powder) to detoxify. After eruption, deficiency cases benefit most from Baoyuan Tang (Preserve Origin Decoction) with Shaoyao (Paeoniae Radix Alba, 芍药); heat cases use Wufu Huadu Dan (Five-Fortune Toxin-Resolving Elixir), Xieqing Wan (Draining Green Pill), Gu Niucan San (Ancient Ox-Cicada Powder); for severe heat convulsions attacking the heart causing black sinking, temporarily use Liangjing Wan (Cooling Convulsion Pill) or Zhuwei Gao (Pig Tail Ointment). Heat delirium belongs to the Heart; convulsions belong to the Liver; swelling/constipation to the Spleen; panting/thirst/cough to the Lung. Deficiency cases follow similar logic.
Body-wide pain indicates toxin moving outward:
Pain is a favorable sign in smallpox. Whether body-wide or localized, if caused by external pathogens, at the first appearance of red spots, use Shen Su Yin (Ginseng and Perilla Drink) with Muxiang (Aucklandiae Radix, 木香); for mild cases, Xiaodu Yin (Toxin-Resolving Drink) or Shengma Gegen Tang (Cinnamon Twig and Rhizoma Bupleuri Decoction) with doubled Shaoyao (Paeoniae Radix Alba, 芍药); for severe cases, add Chantui (Cicadae Periostracum, 蝉蜕), Shanzha (Crataegi Fructus, 山楂), and Qianghuo (Notopterygii Rhizoma et Radix, 羌活). Post-eruption body pain with wrinkled skin and dense pustules uses Yunqi San (Qi-Balancing Powder) or Xiaohuoxue San (Minor Blood-Moving Powder). Pain during the swelling/pus-filling stage is not contraindicated.
Heat and itching distinguish deficiency/excess and exterior/interior:
Pains indicate excess; itching indicates deficiency, distinguished by color and form. Non-gray, non-sunken color with difficult stool and itching indicates excess. For wind-cold, use Xiaodu Yin (Toxin-Resolving Drink); for food toxicity or salt intake, use Sijunzi Tang (Four Gentlemen Decoction) with Jiu Huangqin (Wine-fried Scutellariae Radix, 酒芩), Lianqiao (Fructus Forsythiae, 连翘), or mild Radix Rheei Preparata (Dahuang, 大黄). General use of Chan Tui Tang (Cicada Skin Decoction) frequently. For severe itching, bathe in Shuiyang Tang (Water Willow Decoction), or smoke with Yan (Salt) and Baicaoshuang (Charred Grass Ash); this stops itching instantly, even for deficiency-type itching. Alternatively, apply Huami (Honey Water) mixed with Huashi (Talcum, 滑石) powder to facilitate scab falling without scars. Pale color with inverted scabbing, loose stool, and itching indicates deficiency; use Baoyuan Tang (Preserve Origin Decoction) with doubled Huangqi (Astragali Radix, 黄芪) to secure the exterior, plus Shaoyao (Paeoniae Radix Alba, 芍药) to move blood. Severe whole-body scratching with oozing pus/blood preventing sitting/lying uses Neituo Shixuan San (Interior-Supporting Ten-Auspicious Powder) minus Rougui (Cinnamomi Cortex, 桂枝), doubled Huangqi (Astragali Radix, 黄芪), plus Baizhi (Angelicae Dahuricae Radix, 白芷) for itching, Danggui (Angelicae Sinensis Radix, 当归) to harmonize blood, Muxiang (Aucklandiae Radix, 木香) to regulate qi; or combine Xiaohuoxue San (Minor Blood-Moving Powder) with Sijunzi Tang (Four Gentlemen Decoction), adding Huangqi (Astragali Radix, 黄芪) and Zhike (Aurantii Fructus Immaturus, 枳壳). For toxin sinking causing itching/sinking, use Muxiang San (Aucklandia Powder) with Dingxiang (Caryophylli Flos, 丁香) to attack the interior, and Guirou (Cinnamomi Cortex, 官桂) to secure the exterior. Constant limb shaking indicates impending itching.
Deficiency bloating implies cold body:
Post-eruption deficiency bloating has two types: one due to internal injury from cold/raw foods or cooling meds clashing with internal heat toxin, preventing dispersion, causing bloating; use Luobozhong (Radish Seed), Zisugeng (Perillastem Stem), Chenpi (Citri Reticulatae Pericarpium, 陈皮) each 1 qian, Ganjiang (Zingiberis Rhizoma, 干姜), Gancao (Glycyrrhizae Radix et Rhizoma, 甘草) each 0.5 qian, decocted. Reduced appetite adds Baizhu (Atractylodis Macrocephalae Rhizoma, 白术); severe cases with cold limbs and pale sores require Muxiang San (Aucklandia Powder) to warm the middle and expel cold, or Yigong San (Extraordinary Work Powder) for extreme cases. Toxin sinking causing bloating uses Renchi San (Human Tooth Powder) or Xiaohuoxue San (Minor Blood-Moving Powder). Bloating with closed eyes and foul breath is fatal.
Vomiting/diarrhea with eruption is hardest to manage:
Initial vomiting/diarrhea is acceptable. For post-eruption spleen/stomach cold, use Weiai San (Stomach-Warmth Powder). For external pathogens: winter uses Lizhong Tang (Regulate the Middle Decoction), Wuji San (Five Accumulations Powder), Yigong San (Extraordinary Work Powder); summer uses Liuhe Tang (Six-Harmonies Decoction), Weiling Tang (Stomach and Five-Ling Decoction). For internal injury: Sijunzi Tang (Four Gentlemen Decoction) with Sharen (Amomi Fructus, 砂仁), Chenpi (Citri Reticulatae Pericarpium, 陈皮); Lizhong Tang (Regulate the Middle Decoction) minus Renshen (Ginseng Radix, 人参), plus Houpo (Magnoliae Officinalis Cortex, 厚朴); heavy food stagnation uses Yinggan Wan (Responsive Pill). Post-eruption diarrhea is strictly forbidden, especially during swelling. Diarrhea indicates deficiency-cold; urgently use Baoyuan Tang (Preserve Origin Decoction) with Guizhi (Cinnamomi Ramulus, 桂枝), Shaoyao (Paeoniae Radix Alba, 芍药), or Muxiang San (Aucklandia Powder). Slippery diarrhea uses Rou Doukou (Myristicae Semen, 肉豆蔻) and Rushi (Frankincense, 乳香) powder with rice water, or Guchang Wan (Intestine-Solidifying Pill). Diarrhea causing sunken papulas uses Neituo Shixuan San (Interior-Supporting Ten-Auspicious Powder) or Sixiang San (Four Saints Powder) modified. Vomiting/diarrhea with panting/thirst, expelled roundworms, fixed gaze, liquid stool, and intestinal mucus is fatal.
Spontaneous sweating and weak qi hinder scabbing; damp-heat steaming uses Shenzhu Fang:
Post-eruption, excessive sweating depletes qi, hindering pus formation and scabbing; urgently use Baoyuan Tang (Preserve Origin Decoction) to stop sweating. Initial damp-heat steaming uses Baizhu (Atractylodis Macrocephalae Rhizoma, 白术) 2 qian, Huanglian (Coptidis Rhizoma, 黄连) 1 qian, Xiaomai (Tritici Fructus, 浮小麦) decocted. Wind-cold spontaneous sweating uses Guizhi (Cinnamomi Ramulus, 桂枝) and Fangfeng (Saposhnikoviae Radix, 防风) appropriately. Cold body with bead-like sweat and coma is fatal.
Eruption with chills/fever indicates severe interior deficiency; cold-fire depression causes itching:
Chills/fever post-eruption indicate interior deficiency. Isolated heat around day seven indicates excess qi/blood/toxin; isolated cold indicates damaged qi/blood with depressed toxin-fire, difficult to treat. Rigors, clenched teeth, ice-cold knees, hot buttocks/ears are extremely contraindicated during swelling/scabbing, indicating extreme qi/blood deficiency; use Baoyuan Tang (Preserve Origin Decoction) with Guizhi (Cinnamomi Ramulus, 桂枝); severe cases use Yigong San (Extraordinary Work Powder).
Variations: cold constipation vs. heat vomiting/diarrhea:
Organ heat causes constipation; spleen/stomach cold causes vomiting/diarrhea. Vomiting/anorexia with blue face/emaciation indicates cold constipation; long-term constipation without tenesmus indicates deficiency constipation; both use Neituo Shixuan San (Interior-Supporting Ten-Auspicious Powder). Qi deficiency uses Siwu Tang (Four Substances Decoction) or Maziren Wan (Cannabis Seed Pill). Eating well but hard, millet-like stools indicate wind constipation; chest/flank/back/abdominal pulling pain indicates qi constipation. Heat-toxin attacking stomach causes vomiting/diarrhea; hot palms/armpits with sweat, red face, thirst for milk, undigested milk causing vomiting, then thirst again indicates heat vomiting; red/scanty urine with thirst indicates heat diarrhea; both use Wuling San (Five-Ling Powder) or Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) with Chenpi (Citri Reticulatae Pericarpium, 陈皮). Phlegm obstruction vomiting uses Erchen Tang (Two-Chen Decoction); damp-heat vomiting uses Gegen Zhuru Tang (Rhizoma Bupleuri and Bamboo Sap Decoction) with Huanglian (Coptidis Rhizoma, 黄连); damp-heat foul diarrhea uses Jiedu Tang (Toxin-Resolving Decoction) with Baizhu (Atractylodis Macrocephalae Rhizoma, 白术). Massive vomiting, fever, abdominal fullness, red/scanty excretions, red face, panting require promoting urination with Siling Tang (Four-Ling Decoction) or Daochi San (Guiding Out Redness Powder); if ineffective, use Xuanfeng San (Dispersing Wind Powder) to purge.
Severe heat with cold extremities:
Cold body in smallpox is untreatable. However, heat cases with sudden cold extremities resemble deep latent heat in cold damage; use interior-cooling detoxifiers; as toxins exit, warmth returns. Pre-eruption, Zhuwei Gao (Pig Tail Ointment) is best.
Constipation, bloody urine, ruptured muscles:
Early heat mistreated with warming meds, or post-eruption use of Huyan (Coriandri Fructus, 胡荽), Putao (Vitis Vinifera, 葡萄), Renchi (Human Teeth, 人齿粉) in excess cases causes toxin to attack organs/limbs, blocking orifices, constipation, bloody urine, abscesses, or skin rupture, all due to yang excess without yin. Use Zhuwei Gao (Pig Tail Ointment), Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction), Jiedu Tang (Toxin-Resolving Decoction), Sanhuang Wan (Three-Yellow Pill). Red/vibrant eruption after medication is auspicious; inverted scabbing is fatal. Summer rotting maggots indicate severe heat-toxin; internal cooling herbs, external willow branch bedding or Shuiyang Tang (Water Willow Decoction) wash.
Inverted scabbing and sinking:
Pale red turning white/yellow is auspicious; bright red turning purple/black is adverse. Sinking refers to qi deficiency failing to raise; invert scabbing refers to external pathogens/filth. Sinking requires warming middle/supporting interior to warm spleen/stomach and unblock defensive/defensive qi; sulfur/aconite may be used temporarily. Invert scabbing requires warming/dispersing cold or fumigation for filth. Failure to erupt/swell/fill/scab due to qi/blood weakness is sinking/inversion.
Black sinking requires detailed investigation:
Black is water color, but fire can mimic it; investigate cold vs. heat. Cold blackening (wind-cold to Kidney) needs warming/dispersing; deficiency-toxin sinking needs warming/nourishing. Heat blackening (excess fire) needs cooling heart/resolving; dry organ/no-yin needs moistening blood/phlegm-resolving. Black sinking is the most critical variation.
Black like mosquito bites, constipation/restlessness from blood stasis:
Black like mosquito bites indicates violent toxin eruption clashing with stasis-heat, coagulating blood. Constipation, abdominal distension, panting, restlessness use Shanzhiren Tang (Gardenia Seed Decoction), Renchi San (Human Tooth Powder), Ji Jian Sixiang San (Modified Four Saints Powder), Chan Tui Tang (Cicada Skin Decoction) with Zicao (Arnebiae Radix, 紫草); slow eruption uses Xuandu Gao (Dispersing Toxin Ointment) or Zhuwei Gao (Pig Tail Ointment).
Slow eruption like charred coal, exterior heat needs releasing:
Exterior heat like charcoal, black sinking with heat signs uses Touji San (Releasing Muscle Powder) with Honghua (Carthami Flos, 红花), Digupi (Lycei Cortex, 地骨皮), or ground Xijiao (Rhinoceros Hornis Cornu, 犀角) water, Dusheng San (Single Saint Powder), or Xiaohuoxue San (Minor Blood-Moving Powder). Abdominal pain uses Chan Tui Tang (Cicada Skin Decoction). Dry/severe sinking uses Mahuang (Ephedrae Herba, 麻黄) 5 qian, honey-fried, decocted, drunk hot to revive eruptions.
Blue-dry/purple-black with mild heat, constipation needs purging:
Slow eruption, blue-dry/purple-black, mild heat, constipation indicates interior heat stagnation; use Xuanfeng San (Dispersing Wind Powder); weak qi uses Muxiang Binglang Wan (Aucklandia and Areca Nut Pill) to pass black/brown stool, then Sijunzi Tang (Four Gentimens Decoction) with Houpo (Magnoliae Officinalis Cortex, 厚朴), Muxiang (Aucklandiae Radix, 木香), aged rice to harmonize stomach; yellow stool indicates eruption. Exterior heat prohibits strong purging. Blue-dry/purple-black with coma, sweating, restlessness, abdominal distension, closed excretions is critical.
Interior heat extreme, purple/yellow body, preferring pus/scabs over foul odor:
Toxin entering interior, mental cloudiness, slow eruption/hard scabbing due to dry heat-toxin causing black sinking uses Zhuwei Gao (Pig Tail Ointment); cooling heart/unblocking orifices harmonizes qi/spirit for scabbing. Black sinking failing to scab, constipation, yellow body, purple swelling uses Dan Daji Wan (Single Euphorbia Pill) to drain bladder water; like cold damage earth failure, urgent purging saves one in five. Post-purge cold/shivering/hot buttocks/ears indicates water overflow/earth collapse (fatal); post-purge warmth/drinking/cold buttocks/ears or pus/blood discharge indicates toxin removal/stomach strength; follow with Sijunzi Tang (Four Gentlemen Decoction) + Houpo/Muxiang to warm spleen.
Extreme organ dryness, yin loss, phlegm convulsions:
Depressed toxin/dry organs, no yin restraint, screaming/panting/phlegm-convulsions use Sichi San (Four-Tooth Powder) + Chan Tui (Cicadae Periostracum, 蝉蜕), Gu Niucan San (Ancient Ox-Cicada Powder) to detoxify; black sinking uses Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) to nourish yin, Baolong Wan (Dragon-Holding Pill) to descend phlegm. Mania/delirium uses Shachen Liuyi San (Realgar and Six-One Powder) with Zicao (Arnebiae Radix, 紫草), Dengxincao (Junci Medulla, 灯心) decoction, ground Xijiao (Rhinoceros Hornis Cornu, 犀角)/Daimao (Trionycis Carapax, 玳瑁) juice, or Huxin San (Heart-Protecting Powder). Cooling blood prevents purple/red; resolving toxin prevents black sinking. Untreated leads to hoarseness/death.
True deficiency-cold, clear excretions, spleen/kidney tonification with Hezi/Kudou:
Interior deficiency, irritability/hatred of heat causing black sinking uses Bawu Tang (Eight-Substance Decoction) minus Dihuang (Rehmanniae Radix, 地黄) to avoid blood stasis, minus Shaoyao (Paeoniae Radix Alba, 芍药) to avoid stomach damage, plus Muxiang (Aucklandiae Radix, 木香) to harmonize spleen/stomach, greatly tonifying qi/blood. Smooth spleen/stomach prevents sinking; abundant qi/blood prevents itching/sinking. Cold often from nursing mother fasting/cold, causing infant cold to Kidneys, black sinking. Winter: Muxiang San (Aucklandia Powder), Yigong San (Extraordinary Work Powder); warm weather: Neituo Shixuan San (Interior-Supporting Ten-Auspicious Powder) minus Guizhi/Muxiang, plus Zicao (Arnebiae Radix, 紫草), Chan Tui (Cicadae Periostracum, 蝉蜕).
Purple tint indicates heat, white tint indicates deficiency, black like raven feather is salvageable:
Purple tint indicates blood heat: Siwu Tang (Four Substances Decoction) + Huangqin (Scutellariae Radix, 黄芩), Lianqiao (Fructus Forsythiae, 连翘), Honghua (Carthami Flos, 红花). White tint indicates qi deficiency: Baoyuan Tang (Preserve Origin Decoction) minus Gancao (Glycyrrhizae Radix et Rhizoma, 甘草), plus Zicao (Arnebiae Radix, 紫草). Lingsha (Spirit Sand) 3-5 pills ground in wine revives black sinking. Black like raven feather, smooth, no chills, cold buttocks/ears indicates active blood/salvageable: Zicao Yin (Arnebiae Root Drink) + Xiaohuoxue San (Minor Blood-Moving Powder).
Outer black inner white/red is mild:
Outer black/inner white is mild; outer black/inner red is slightly severe; outer white/inner black is very severe; sunken black top with needle-hole purple center is fatal.
One large black pimple is mild:
Sudden 3-5 or one large purple-black pimple on head/face resembling a carbuncle is Fei Dou (Flying Pimple). This indicates mildest eruption, possibly solitary. Black pimple severity varies greatly; careful differentiation is essential.
Whole-body rotting, pus not drying:
Failure to disperse causes toxin blockage, chest fullness, panting. Forced dispersion causes excessive eruption, exterior deficiency, hard scabbing, muscle rot ("Rotting Spots"). Treatment: harmonize spleen/appetite, normalize bowels, nourish defensive/defensive qi to generate flesh/resolve toxin, preventing eye/throat inflammation, mouth sores, bleeding. Constipation/non-drying pus uses Niuhuang Dan (Cow Bezoar Elixir); rotting/painful pus uses Baicao San (Decayed Grass Powder) or Gan Huangtu (Dry Yellow Earth) powder. Mild cases: Pig bile + Mangxiao (Natrii Sulfas, 芒硝) paste. Large ulcers preventing scars: Calcined Cow Dung + Rushi (Frankincense, 乳香) powder; severe: Wheat bran bedding; summer: Banana leaf bedding. Sweating-induced deficiency/diarrhea/rotting or excessive drinking uses Baoyuan Tang (Preserve Origin Decoction) + Fangfeng (Saposhnikoviae Radix, 防风), Baizhi (Angelicae Dahuricae Radix, 白芷), external Baicao San (Decayed Grass Powder). Baicao San: Old roof/wall grass, cleaned, dried, powdered, applied via cloth. Severe: Bedding. Long-exposed grass resolves smallpox toxin effectively.
Knife-like pain:
Caused by filth contact; treatment for filth.
Know that if the crown remains unchanged despite other changes, yang life persists and recovery is certain:
Smallpox rises from the crown (yang position). Dense is ominous; if body rots but crown/forehead remains unchanged, it is auspicious. Pus-filling stage: water blisters without pus, thin skin breaking easily, except forehead which remains intact is treatable. Forehead/chest breaking first is rapidly fatal. Scabbing stage: if败证 (failure signs) appear everywhere except forehead/Siyang/Fangguang/Crown remaining normal, survival is possible.
Carbuncles on head/chest/back are dangerous; limb pricking drains toxin:
Swelling stage: large purple-black pimples are Ding Dou (Carbuncle Pimples). "Ding" means nail, holding eruption down due to weak qi/blood allowing toxin aggregation. If qi/blood overcome toxin, clustering on limbs (small/few/piercing sinews/bones) is easy to treat; clustering on head/chest/back (approaching interior) pierces organs, difficult to treat. Urgently use Baoyuan Tang (Preserve Origin Decoction) + Niubangzi (Arctii Fructus, 牛蒡子), Jingjie (Schizonepetae Spica, 荆芥), Huangqin (Scutellariae Radix, 黄芩), Lianqiao (Fructus Forsythiae, 连翘) to boost qi/expel toxin. Externally, silver needle pierces carbuncle head, parents suck bad blood, or cotton-wrapped fingernail pinches blood out. Pearl (5 grains), iron-heated yellow, Peas (49 grains), Hair (1 ball), burnt to ash, powder, oil-red dye paste. Warm place, avoid wind/cold/filth. Pierce head, apply medicine, turns red/white, other eruptions rise. Large black pimple, black crown, soft smelly core: Baoyuan Tang + Xiong (Ligustici Chuanxiong Rhizoma, 川芎), Guizhi (Cinnamomi Ramulus, 桂枝), Nuomi (Oryza Sativa Glutinosa, 糯米) to boost qi; turning yellow is safe.
Smallpox abscess starts with swollen/painful hands/feet, toxin注入三阴穴:
Abscesses start with red/swollen hands/feet/meridians, red wrist patch, hard painful feet, or melon-like swelling on feet. Depth indicates size. Caused by wind-cold depressing heat-toxin, or excessive hot meds/food. Bad eruption toxin clustering is auspicious; treatment see recovery phase. Do not treat abscess while smallpox is unresolved. Chest/brain red swelling or whole-body lumps is fatal; pus-stage green/red flowing foot swelling with bad smallpox is fatal.
Uneven swelling/scabbing, carbuncles/abscesses are auspicious:
Failure to swell/fill/scab, developing carbuncles/abscesses is auspicious. Carbuncles/carbuncle pimples on chest/lower back are severe; red/small live, black/large die.
Yang-toxin sores exploit deficiency; moisture indicates excess, dryness indicates deficiency.