总论
气尊血分者生，毒参阳位者死（一、二日）。形圆而体天象，色润而见精华（三、四日）。血气并隆而
制毒，盈亏双治见神功（五、六日）。血气胜淫邪之毒，乾坤顺造化之情（七、八日）。血渐收而毒溢，气已
满而神凝（八、九日）。血赖天和而主命，气因毒化而成功（九、十日）。邪正明君臣道济，真元固气血成功
（十一、二日）。君道成而臣力效，神化全而毒势平（十三、四日）。脱尽淫邪之火，补全造化之功（十五、
六日）。（华佗）
痘十二朝应地支之数，在地成形，禀母质也。○痘灌满即收，月盈则蚀之象，阴之属也。○痘十二朝如围
屏十二幅，文之一面自有接续，画之一面自春景到冬景，缺不得一幅。○痘发如放烟火，故事藏在里面，药线
一着，自然根据次而出。（《橡村痘诀》）
夫痘由中以达外，用药因期而变通。以常言之，发热三日而后见标，出齐三日而后起胀，蒸长三日而后
灌脓，浆满三日而后收 。故发热三日，当托里解表，使其易出。亦有气弱而不能出者，当微补其气，气和则
出快。初不可用 ，恐腠理一密，则痘难出也。四、五、六日起发之时，以清凉解毒为主，清凉则无血热枯燥
之患，解毒则无壅滞黑陷之虞。七、八、九日灌脓之时，治法当补气血，气血流行，而成浆自易也。十至十一、
二日收 之时，宜大和气血，补脾利水，自然结 。此特语其常也。盖常者可必，而变者不可必，当随候参详。
见点之时，如痘轻少，不可过表，在后恐成斑烂；或干红紫色，急宜疏利，不然，在后必成黑陷。四、五日内，
痘出至足下为齐，苟未尽出，于解毒之中宜兼发散。若专于清凉，则痘迟滞不出。七、八日间，毒未尽解，于
温补之中又兼解毒。若偏于温燥，则毒盛不能化浆。十一、二日间，浆未满足，虽当大补气血，然须兼解余毒，
不然恐有痈毒瘟疤之患。此变通之妙，要在随时制宜。（《金镜录》）
痘期止有一十四日。自见点以至七日之内，如花之始蕾也，其气日盛；如至七日之后，则气敛而花谢矣。
故服药当于七日之前，日夜连服，毋庸姑息，借毒火之营运，而充灌成浆自易。若七日之外，治之无益矣。盖
痘毒之在血气，若糠 之在米也，惟气血充足，运转迅速，如筛米而运转不停，则糠 不混于米，腾然起聚，
自作一团。故血气充足而周流，则毒不滞于营卫之中，自然及时灌脓收 ，决不溃肌损肉，唯只将毒瓦斯收注窠
囊而已。故善治者，于见点之后即为补养气血，以助营运推出之势。奈何时医不知此理，仅以毒物攻发。嗟乎！
以毒攻毒，势难并胜，痘固出矣。若夫脓汁收 之功，又非毒物之所能致。营卫既虚，不为补益，而用毒物峻
发，戕贼中表，毒虽浮外，中内空虚，药力一缓，毒仍内陷，其可救乎！（《冯氏锦囊》）
凡痘一、二、三日欲其出快，谁不曰此当表也。然用药惟
柴、前、川芎，引清阳而达表，桔梗能发散而善开提，表药莫妙于荆、防、羌、葛。○发表，在二、三日可加
鼠粘子，此药能透肌，又能起胖。要晓羁绊之故，属在何因，则去此因之药宜为君也。荆芥能行瘀血，可加于
表药中。不用防风者，以其燥故也，亦与湿蒸之意相戾耳。其他燥药皆可例推。故猪苓、泽泻，最为痘中所恶，
恐其湿蒸之气下输，而痘浆无由生也。柴胡虽善发表，然惟身热甚者为宜，倘身非大热，又不宜轻用。○凡实
热痘证，表药中少加葛根，但不如丹参、地骨为妙，丹参治痘中游红，又能行瘀生新，丹皮亦然。痘色红紫者，
血热也，丹皮、丹参妙。地骨去气中之毒，实热证用之。连翘虽轻清散火，非芩、柏可侔，然不如前三物切于
血分。葛根惟胃热发渴所宜，他证亦不可泛用。○有逆血者，加荆芥、丹参、丹皮、荷鼻。○内热盛，痘红或
紫，可加黄芩，其丹皮、丹参尤不可缺。○大便秘加枳壳、前胡。○发表时有食碍者，以山楂为主，非但消食，
未尝不消痰不行瘀血也。○凡虚寒痘证，表药用抚芎、桔、橘为主，或加苏叶亦可，禁用鼠粘、山楂、柴胡等
药。至六日，便可加生 于前药中以催浆。次日视之，若不甚有浆，再加人参、山药、莲肉、圆眼、当归等，
令其血气俱旺，灌浆充足，收功自易。起先是毒，今化为浆，浆既充足，欲其收 。此在八、九日之期，宜以
芍药收之、防风燥之、茯苓渗之、炙 结之。此时身有大热者，恐有余毒，兼用鼠粘防之。浆足而 不结者，
多因过补，火毒未清，与清凉解毒自效。（《仁端录》）
方书未见点用升麻葛根汤，今人不用。伍氏见点忌升麻，后人谓葛根表疏亦忌，此轻扬升表套药。若
里证急，又须两解。○伍氏方，一、二日用羌防透肌汤，今人不用，恶其辛温气雄也。一、二日壮热气促，烦
渴便秘，痘粒不发，翁仲仁云∶若非风寒壅遏，定是气虚不振。愚谓∶近世布痘，每盛发于君相风木燥金司令。
盖非火不发，火郁发之，升阳散火是已。若里热甚重，煎
灼脂液，苟非苦寒下夺，佐以升表不可。（《临证指南》）
初热
初热时只有二事，惟去邪、扶正而已。邪盛则去邪，而正气自旺；正衰则扶正，而邪热自退。正气盛而痘
自发，热为痘用，则不为害矣。邪热退，而正气不受烁，血脉充裕，则痘自泰矣。须于此时看明下手，迟则
无济于事。（吴东园）
痘初热，且与轻剂散之。若其家无痘儿，邻里无痘儿，医者不曰伤风，必曰伤食，那得知其为痘？然痘之
行，必有所自始。初用药虽与风寒无异，亦须辨之∶如头痛、腹痛、呕吐、咳逆等证，皆风寒之所有者。至于
两颧、耳后之花纹见或可凭，手足指冷或可凭，耳尻俱冷未足凭。既服表剂，则热气熏蒸，汗出热减者，表邪
也；汗出而热不减者，痘也。复表之，至二、三日，热退或未退，杂证或减或未减，抱儿于亮处，从面部头项，
及胸背手足，细细寻看。如已见点，则视儿质之虚实、火毒之微甚，打算全局，以定治法。如未见点，则究其
阻滞，斟酌用药。○痘初热，但欲其出，欲其出无过疏表。疏表之剂，天时之寒暑，别以温清；儿质之虚实，
酌以轻重。若执一定之方不为区别，第一着便瘥。（《橡村痘诀》）
或曰∶痘疮发热，何以能预识其轻重耶？曰∶凡发热乍进乍退，气色明莹，精神如常，大小便调，能食不
渴，目清唇润，此毒轻也，痘必稀疏，纵出多亦易发易 。如壮热不减，气色惨暗，精神昏闷，大便或秘或泻，
不能食，目赤唇焦，此毒甚也，痘必稠密。○或有微热，痘出反密者，其人必口渴唇焦，小便赤，大便秘，身虽
不大热，却蒸蒸然，此毒深热亦深，故表不大热，而里热也。○或有热甚，痘出反疏者，其人口必不渴，唇润，目无
赤脉，大小便调，身虽大热，但 然，此毒浅热亦浅，故表热里气和也。（万密斋）
初出一、二朝
发热一日即出痘者大重，二日出者亦重，微热三日出者为轻，四、五日身凉乃见点者尤轻。自出痘一日至
三日方齐，凡痘出至足谓之出齐。（《医鉴》）
一日便出为火证，火性急速故也。一出便尽为表虚，表虚火甚，故易出也。急与清凉，不得再表。○凡易
出之痘，防焦萎，防退缩，火甚故易焦，火甚则气血受其煎熬，故有退缩之患。清热养阴，是其治法。○有热
至五、六日而始出者，多是元气不充，步步照顾元气，方可成功。○痘出一、二点，或十数点，虽粗肥光彩，
有似稀疏，但大热未退，或呕吐腹痛，或困倦烦啼，皆为里证未平。宜羌活饮再表之，必有一番大出。○痘初
出，神先馁，即是虚证。惜得一分元气，痘子便受一分之益。发表不用羌活，通里不用硝黄，便是惜元气。○
凡痘出，鼻有涕、目有泪、口有涎、身有汗，皆吉。无者凶。○痘以参差为贵，一色大、一片细，皆凶。○痘
色重于形。颜色好，虽稠密破碎亦可成功；颜色不好，虽点粒圆稳，终须生变。○凡痘粒小者易生浆，大者难收
。阔大之痘，早须提防，尽攻发，毋清利。○初出热未退，呕吐者无妨，吐中就有发散之义。但不可见虫，
见虫者多凶。腹痛者只宜行滞，不可骤下。泄泻者或有湿热，或者夹食，只宜疏托，不必止泻。○初出渴甚，
疏托中宜重加石膏，烦热狂叫亦加石膏。○初出热未退，头痛表实者，疏痘饮加羌活；火甚者，加石膏；腰痛
者，羌活饮子加料豆。○出不快有四证∶一为表实，一为里虚，一为寒邪所迫，一为秽气所触。表实者，羌活
散郁汤；里虚者，参苏饮；寒邪所迫，非麻黄不为功；秽气所触，则焚大黄、乳香、白芷之属，药用疏托。（《橡村痘诀》）
如发热一、二日间，痘便一齐涌出者，须问其数日前曾有热
否。如数日前，曾乍热乍凉，以过期论。惟原未发热，至今才热便斑见，此表虚毒盛，腠理不密，肌肉不坚，
不能约束于外，使毒瓦斯冲击，故出太骤也。宜用实表之剂，可以无痒塌、无溃烂。○如发热至五、六日始出者，
须审其曾有外感内伤否。盖伤风、伤食之热，久而不去，则所蕴痘疮之毒，亦能乘间而出，不可以过期论。惟
无此因，一向热而不出，此里气虚，不能驱逐其毒使之即出，而留伏于脏腑之间，先用托里之剂，令其快出，
次以和中之剂多服之，可以无伏陷、无倒 。（万密斋）
周岁以内，身小元弱，常有热，一日即出，亦有顺痘者，但须看其神气静躁，热势轻重。若见点徐徐而出，
即出即长，热缓安乳，便是好证；若神气虽安，热亦不盛，痘点不多，形呆色钝，或头倾足软，或短气如喘，
或呕或泻，最多闷证。○初起必三次而出，热止即齐，其增点亦有陆续发出者，须看颜色灵活生气变化为要。
表药活血疏肌，次则凉血解毒，实热便闭者微下之，虚弱气怯者，忌进疏解寒凉。（叶天士）
闭
有热一、二日发搐，搐定又发，神气散乱，血脉不定，毒无所根据，而痘不得出者，谓之惊闭，非杀其热势，
惊不得定，痘何由出？但不得骤用苦寒，疏痘饮加石膏以镇之，惊自定，痘自出。○有热一、二日，唇口掀肿，
大热烦躁，痘点隐隐未出，遍身发出紫斑，谓之斑闭。疏痘饮加红花、紫草以活血，石膏以杀其热势，不可骤
用犀角地黄汤。便闭二、三日者可下之。热渐退，痘渐出者，可治。若斑更青紫，痘点不出，或如痱子，如火
刺形，大热烦闷者，不治。○痘之最恶，莫如闭证。毒闭不出，虽有技巧，无所用其力。闭证多是腰腹痛，不
大热，见点呆而不活，或摸不碍手，或唇口掀肿，或呕吐口渴唇裂，或舌起黑苔，或舌淡如水浸精猪肉，或烦
躁啼叫、闷乱切牙，或口鼻出血，或身发紫斑，或服表药后已得汗得嚏而痘不出，或下后已利而腹痛不止，
皆闭证之最恶，十无一生者也。○治之宜早，用升麻葛根汤。羌活散郁汤。冬春之交，或肺气不通，毛窍不开
者，麻黄汤，外用水杨汤蒸之。夏令火盛，用黄土摊卧，或以雄鸡合其胸，或以大虾蟆如用雄鸡法。皆提拔闭
伏之成验也。○有一见腰腹痛，唇口裂，斑见而痘不出者，或见一、二点阔大无根者，急用升麻石膏汤加大黄、
元明粉，表里双解，痘出再言治法。若表里既通，而痘犹不碍手，胃烂也。或唇裂出血，或斑色青紫，或口吐
苋汁，不终朝而死矣。○辛卯，一秋无雨，井底见，河流断，燥气太甚，痘证大行，一时多闭伏之证，思之恍
然有得。盖痘之始出本于肾。《经》云∶雨气通于肾。无雨肾气不通，不能送毒出外，譬之种子在地，非雨露
则必不能出土。古人治痘，初出只有升提达表一法，表既开而痘不出，其咎安在？予直以升提之品，纳入滋水
药中，名曰化雨煎，所谓因时制宜也。方用生地、丹参、麦冬、料豆、柴胡、升麻、防风、荆芥、葱白为一剂，
化而裁之存乎变。此可为知者道也。○喻嘉言见痘证时行，令先服六味地黄汤，与予所见大略相似。○若因寒
气闭者，疏痘饮加麻黄、紫苏、生姜，服后暖覆片时即效。（《橡村痘诀》）
伏
痘之为毒，先天无形之火也，伏于命门，必待岁火相引而始出。岁火太过，复有疫疠之气游行其间，先天
之火自内而发，外为疫疠之气所掩，则为闭证。闭者，疫疠之气闭之也。痘之始出，升发为先，服升发之药，
表气既开，疫疠之气既散，有痘出而转顺者，此儿胎毒本轻，所谓解去时疫，痘自然顺者也。若伏证则不然，
表气既开，而毒凝然不动，与闭相似；闭自外乘，伏由内结，又当分类而治矣。○伏证有四种∶有肾命之伏，
有心经之伏，有肝胆之伏，有胃家之伏。腰痛，面青暗，无大热，毒伏在肾，一、二日死。见点无多，身无大
热，人事昏闷，咋嘴弄舌，烦躁不安，毒伏在心，亦一、二日死。或用药提拔而出，喉舌无恙，
方保性命。若喉舌壅肿，食药难进，五、六日死。痘未出，热甚惊搐，痘出惊定，谓之先惊后痘，吉；若痘见
General Discussion
Life is sustained when Qi (vital energy) respects the Blood aspect, but death ensues if pathogenic toxins invade Yang positions (Days 1-2). The shape is round, conforming to the image of Heaven; the color is lustrous, revealing essence and brilliance (Days 3-4). When Qi and Blood rise together to control the toxin, treating both deficiency and excess reveals divine efficacy (Days 5-6). When Qi and Blood overcome the toxic pathogens, following the natural order of creation (Days 7-8). As Blood gradually recedes and toxins overflow, Qi becomes full and Spirit condenses (Days 8-9). Blood relies on Heavenly Harmony to govern life, while Qi achieves success through transformation by toxins (Days 9-10). Clear distinction between Evil and Righteous follows the Way of Ruler and Minister, securing True Yuan and achieving success in Qi and Blood (Days 11-12). When the Ruler's Way is established and the Minister's power effective, spiritual transformation is complete and toxic forces are pacified (Days 13-14). Eliminating all inflammatory fire, completing the work of creation (Days 15-16). (Hua Tuo)
The smallpox course corresponds to the twelve Earthly Branches; it takes form on earth, inheriting maternal constitution. ○ When pustules fill and begin to dry, it resembles the waning of a full moon, belonging to Yin. ○ The twelve days of smallpox are like twelve panels of a screen; the text side has its own continuity, the painting side progresses from spring to winter scenery, missing no single panel. ○ Smallpox eruption is like setting off fireworks; the pattern is hidden within, and once the fuse is lit, they emerge sequentially. (*Xiangcun Doujue*)
Smallpox originates internally and reaches externally; medication must adapt according to the stage. Generally speaking, after three days of fever, spots appear; three days after appearing fully, swelling begins; three days of steaming lead to pus formation; three days of fullness lead to drying and scabbing. Therefore, during the first three days of fever, one should support the interior and release the exterior to facilitate eruption. If Qi is weak preventing eruption, slight tonification of Qi is needed; harmonized Qi erupts quickly. Initially, harsh diaphoretic herbs must be avoided lest pores close, hindering eruption. On days four, five, and six, during the swelling phase, cooling and detoxifying methods are primary; cooling prevents blood heat and dryness, detoxifying prevents stagnation and blackening. On days seven, eight, and nine, during pus formation, treating with Qi and Blood tonics facilitates fluid generation. On days ten to twelve, during drying, harmonizing Qi and Blood, tonifying Spleen, and promoting urination naturally leads to scabbing. This describes the standard approach. Standards are predictable, variations are not; treatment must follow specific conditions.
At the appearance of spots, if eruptions are light and few, excessive releasing of the exterior is contraindicated to avoid later ulceration; if dry red or purple, prompt dispersing and purging is needed to prevent blackening later. Within four to five days, eruption reaching the feet signifies completion; if incomplete, dispersing should accompany detoxification. Exclusively using cooling herbs causes delayed eruption. Between days seven and eight, if toxins remain, warming and tonifying should accompany detoxification; bias towards warming/drying causes toxin excess preventing pus formation. Between days eleven and twelve, if pus is insufficient, major tonification of Qi and Blood is required, yet residual toxins must also be cleared to avoid abscesses or plague-like sores. The subtlety of variation lies in adapting to circumstances. (*Jingjian Lu*)
The smallpox period lasts only fourteen days. From spot appearance to the seventh day, like a flower bud, its energy increases daily; after the seventh day, energy contracts and the flower fades. Thus, medication should be administered continuously day and night before the seventh day without hesitation, utilizing the operation of toxic fire to facilitate pus filling. Treatment after the seventh day is futile. Toxin in Qi and Blood is like chaff in rice; only with sufficient Qi and Blood and rapid circulation, like sifting rice continuously, can chaff separate and gather into a ball. Thus, abundant circulating Qi and Blood prevent toxin stagnation in Ying and Wei, ensuring timely pus formation and drying without damaging flesh, merely confining toxic gases to the follicles. Good practitioners tonify Qi and Blood after spot appearance to aid expulsion. Regrettably, contemporary physicians ignore this, using only toxic substances to attack. Alas! Attacking toxin with toxin makes simultaneous victory difficult; although eruptions occur, the function of pus formation and drying cannot be achieved by toxic substances. With deficient Ying and Wei, failing to tonify and instead using harsh toxic emetics damages the center and exterior; though toxins float outward, the interior is empty; if medicinal force slackens, toxins sink inward again—can this be saved? (*Fengshi Jinnang*)
For days one to three, wanting rapid eruption, everyone says this requires releasing the exterior. However, herbs like Chaihu (Bupleuri Radix), Qianhu (Peucedani Radix), and Chuanxiong (Ligustici Chuanxiong Rhizoma) guide clear Yang to the exterior; Jiegeng (Platycodonis Radix) disperses and lifts. For exterior-releasing herbs, Jingjie (Schizonepetae Spica), Fangfeng (Saposhnikoviae Radix), Qianghuo (Notopterygii Rhizoma et Radix), and Gegen (Puerariae Lobatae Radix) are best. ○ For releasing the exterior, on days two and three, add Niubangzi (Arctii Fructus), which penetrates muscle and promotes swelling. One must understand the cause of obstruction; the herb removing this cause should be the sovereign. Jingjie moves blood stasis and can be added to exterior herbs. Fangfeng is omitted due to its dryness, conflicting with damp-steaming intentions. Other drying herbs are inferred similarly. Zhuling (Polyporus) and Zexie (Alismatis Rhizoma) are most detested in smallpox, fearing damp-steaming qi sinks downward, preventing pus generation. Although Chaihu releases the exterior well, it suits only high fever; if fever is not severe, it should not be used lightly. ○ For excess heat smallpox cases, adding little Gegen to exterior herbs is less effective than Danshen (Salviae Miltiorrhizae Radix) and Digupi (Lycii Cortex); Danshen treats wandering redness in smallpox, moves stasis, and generates new blood; Danpi (Moutan Cortex) acts similarly. Red-purple spots indicate blood heat; Danpi and Danshen are excellent. Digupi removes toxin from Qi, suitable for excess heat. Lianqiao (Forsythiae Fructus) clears fire lightly but cannot match Huangqin (Scutellariae Radix) and Huangbai (Phellodendri Cortex); however, the former three are more pertinent to the Blood aspect. Gegen suits Stomach heat with thirst; it should not be used generally. ○ For reversed blood, add Jingjie, Danshen, Danpi, and Henabi (Nelumbinis Plumula). ○ For intense internal heat with red or purple spots, add Huangqin; Danpi and Danshen are indispensable. ○ For constipation, add Zhike (Aurantii Fructus) and Qianhu. ○ For food stagnation during exterior release, Hawthorn (Crataegi Fructus) is primary; it not only digests food but also resolves phlegm and moves blood stasis. ○ For deficiency-cold smallpox cases, use Fuxiong (Ligustici Chuanxiong Rhizoma), Jiegeng, and Juhong (Citri Reticulatae Pericarpium Rubrum) as main exterior herbs; Suye (Perillae Folium) may be added. Niubangzi, Shanzha, and Chaihu are prohibited. By day six, add raw Huangqi (Astragali Radix) to promote pus. The next day, if pus is scant, add Ren Shen (Ginseng Radix), Shanyao (Dioscoreae Rhizoma), Lianrou (Nelumbinis Semen), Yuanyan (Longan Arillus), and Dang Gui (Angelicae Sinensis Radix) to make Qi and Blood vigorous, ensuring sufficient pus and easy recovery. Initially toxin, now transformed into pus; with sufficient pus, aiming for drying. During days eight and nine, use Shaoyao (Paeoniae Radix) to consolidate, Fangfeng to dry, Fuling (Poria) to leach, and roasted Huangqi to scab. If high fever persists, suspect residual toxin and add Niubangzi. If pus is sufficient but scabbing fails, often due to over-tonification and unclear fire-toxin, cooling and detoxifying will be effective. (*Renduan Lu*)
Medical texts rarely use Shengma Gegen Tang (Cimicifugae and Puerariae Decoction) before spot appearance; modern physicians do not use it. Wu Shi forbids Shengma at spot appearance; later generations forbid Gegen for being too dispersing; these are routine light ascending herbs. If interior symptoms are urgent, both must be resolved. ○ Wu Shi’s formula uses Qiangfang Touji Tang (Notopterygii and Saposhnikoviae Muscle-Penetrating Decoction) on days one and two; modern physicians avoid it due to pungent-warm strong qi. For days one and two with high fever, rapid breathing, irritability, thirst, constipation, and non-emerging spots, Weng Zhongren said: "If not wind-cold obstruction, it must be Qi deficiency." I believe: recent smallpox outbreaks often peak during periods governed by Wind-Wood and Dry-Metal. Fire is necessary for eruption; for constrained fire, raising Yang and scattering fire is appropriate. If interior heat is severe, burning fluids, bitter-cold purgatives assisting exterior release are indispensable. (*Linzheng Zhinan*)
Initial Fever
During initial fever, there are only two matters: eliminating evil and supporting righteousness. If evil is strong, eliminate it, and righteous Qi naturally prospers; if righteousness is weak, support it, and pathogenic heat naturally retreats. When righteous Qi is strong, smallpox erupts spontaneously; heat serves the smallpox and causes no harm. When pathogenic heat retreats, righteous Qi is not scorched, blood vessels are abundant, and smallpox becomes peaceful. Action must be taken clearly at this time; delay renders help useless. (Wu Dongyuan)
For initial smallpox fever, use mild dispersing agents. If no smallpox children exist in the family or neighborhood, physicians diagnose wind-cold or food stagnation, unaware it is smallpox. However, smallpox progression has a starting point. Initial medication resembles that for wind-cold, but differentiation is required: headache, abdominal pain, vomiting, cough are common to wind-cold. Patterns on cheeks and behind ears, or cold fingers/toes, are reliable indicators; cold ears and buttocks are not sufficient proof. After taking exterior herbs, if heat steams, sweat occurs, and heat reduces, it is exterior evil; if sweat occurs but heat remains, it is smallpox. Re-treat with exterior herbs; by days two or three, whether heat subsides or not, and miscellaneous symptoms reduce or not, hold the child in bright light, carefully examining face, head, neck, chest, back, hands, and feet. If spots appear, assess child’s constitution (deficiency/excess) and fire-toxin severity to determine treatment globally. If no spots, investigate obstruction and adjust medication. ○ For initial smallpox fever, the goal is eruption; nothing surpasses dispersing the exterior. Exterior-dispersing formulas vary in warmth/coolness based on seasonal climate, and dosage adjusts based on child’s constitution. Clinging to a fixed formula without differentiation leads to failure at the first step. (*Xiangcun Doujue*)
One might ask: How can one predict severity from smallpox fever? Answer: If fever fluctuates, complexion is bright, spirit is normal, bowels/bladder are regular, appetite is good without thirst, eyes are clear, lips moist, toxin is light; eruptions will be sparse, easy to erupt and dry even if numerous. If high fever persists, complexion is dull, spirit is confused, bowels irregular, anorexia, eyes red, lips scorched, toxin is severe; eruptions will be dense. ○ If slight fever but eruptions are dense, the person must have thirst, scorched lips, red urine, constipation; body not very hot but steaming internally indicates deep toxin and deep heat, hence external heat is low but internal heat is high. ○ If high fever but eruptions are sparse, the person does not thirst, lips are moist, eyes lack red veins, bowels/bladder regular; body very hot but relaxed indicates shallow toxin and shallow heat, hence exterior heat exists but interior Qi is harmonious. (Wan Mizhai)
First One or Two Days of Eruption
Fever for one day then eruption is severe; eruption on day two is also severe; slight fever for three days then eruption is mild; eruption appearing on days four or five when body cools is especially mild. Completion means eruptions reach the feet within one to three days of onset. (*Yijian*)
Eruption on day one is Fire Syndrome, as Fire nature is rapid. Complete immediate eruption indicates Exterior Deficiency with strong Fire, hence easy eruption. Prompt cooling is needed; do not re-release the exterior. ○ For easily erupting smallpox, guard against withering and shrinking; strong Fire causes withering, and strong Fire boils Qi and Blood, causing shrinking risk. Clearing heat and nourishing Yin is the treatment. ○ Eruption delayed until days five or six usually indicates insufficient Yuan Qi; protecting Yuan Qi step-by-step ensures success. ○ One or two large, bright spots, or a dozen spots, though seemingly sparse, if high fever persists, or vomiting/abdominal pain, or fatigue/crying occur, indicate unresolved interior syndrome. Use Qianghuo Yin to re-release the exterior; a major eruption will follow. ○ At initial eruption, if spirit is depressed, it is Deficiency Syndrome. Preserving one unit of Yuan Qi benefits the spots by one unit. Not using Qianghu for exterior release, nor Xiaokuxie (Rhei Radix et Rhizoma/Nitrumsulfuratum) for interior purging, preserves Yuan Qi. ○ For smallpox eruption, nasal discharge, tears, saliva, and sweating are auspicious; absence is ominous. ○ Varied sizes are precious; uniform large or uniform fine spots are ominous. ○ Color is more important than shape. Good color allows success even if dense/broken; bad color leads to changes even if round/stable. ○ Small spots generate pus easily; large spots are hard to dry. Large spots require early vigilance; focus on attacking/emitting, not clearing/purging. ○ If heat persists at initial eruption, vomiting is acceptable as it contains dispersing meaning. Seeing worms is ominous. Abdominal pain requires moving stagnation, not sudden purging. Diarrhea may involve damp-heat or food; gentle support is needed, not stopping diarrhea. ○ For intense thirst at initial eruption, add heavy Gypsum (Gypsum Fibrosum) in supportive formulas; add Gypsum for restlessness/mania. ○ For persistent heat, headache, and exterior excess, add Qianghuo to Shudou Yin; for strong fire, add Gypsum; for lower back pain, add Doukou (Vigna umbellata) to Qianghuo Yin Zi. ○ Four signs of slow eruption: 1. Exterior Excess (Qianghuo San Yu Tang); 2. Interior Deficiency (Shensu Yin); 3. Forced by Cold Evil (Ephedrae Herba/Mahuang is essential); 4. Contact with foul air (burn Dahuang, Ruxiang, Baizhi); use supportive/dispersing herbs. (*Xiangcun Doujue*)
If eruptions surge on days one or two of fever, ask if fever occurred days prior. If fever fluctuated days prior, consider it overdue. If no prior fever, only now feverish with macules appearing, this is Exterior Deficiency with盛 Toxicity, loose pores, weak muscles unable to constrain toxins, causing sudden eruption. Use exterior-strengthening agents to prevent itching/sinking or ulceration. ○ If eruption starts on days five or six of fever, check for external contraction or internal injury. Heat from wind-cold/food stagnation lingering allows trapped smallpox toxin to emerge; do not consider it overdue. Without such causes, persistent fever without eruption indicates Interior Qi Deficiency unable to expel toxin, leaving it latent in organs. First use interior-supporting agents for rapid eruption, then harmonizing agents to prevent sinking or inverted drying. (Wan Mizhai)
Under one year old, small body, weak Yuan Qi, often febrile, erupting on day one; some are smooth cases, but observe spirit calm/restless and fever intensity. If spots emerge slowly, grow immediately, fever缓和, nursing calmly, it is a good case. If spirit is calm, fever not strong, few spots, dull appearance, or head tilting/foot weakness, shortness of breath like asthma, vomiting/diarrhea, mostly stifling cases. ○ Initial eruption must come in three waves; heat cessation marks completion; additional spots may emerge continuously; observing lively color changes is key. Exterior herbs invigorate blood and loosen muscle; next, cool blood and detoxify; for excess heat constipation, slight purging; for deficiency/cowardly Qi, avoid dispersing/cooling herbs. (Ye Tianshi)
Closure
Fever for one or two days with convulsions, recurring after settling, scattered spirit, unstable pulse, toxin without basis, preventing eruption, is called Convulsion Closure. Unless heat is suppressed, convulsions won't stop, how can eruption occur? Do not suddenly use bitter-cold herbs; use Shudou Yin plus Gypsum to settle; convulsions stop, eruption occurs. ○ Fever for one or two days, swollen lips/mouth, high fever, irritability, faint spots, purple macules all over, is called Macule Closure. Use Shudou Yin plus Honghua (Carthami Flos) and Zicao (Arnebiae Radix) to invigorate blood, Gypsum to suppress heat; do not suddenly use Xijiao Dihuang Tang (Rhino-Ceroris Cornu and Rehmanniae Decoction). Constipation for two or three days can be purged. If heat subsides and eruption proceeds, treatable. If macules turn green-purple, spots don't emerge, or resemble miliaria/fire thorns, with high fever/irritation, untreatable. ○ Worst smallpox is Closure Syndrome. Toxin closed inside, skills are useless. Closure often involves lower back/abdominal pain, low fever, dull spots, not palpable, or swollen lips/mouth, vomiting/thirst/cracked lips, black tongue coating, or pale tongue like soaked lean meat, or irritability/crying/grinding teeth, or nose/mouth bleeding, or purple macules, or sweating/sneezing after exterior herbs but no eruption, or purging with continued abdominal pain—all worst closure signs, rarely surviving. ○ Treat early with Shengma Gegen Tang or Qianghuo San Yu Tang. In winter/spring transition, or Lung Qi blockage/unopened pores, use Mahuang Tang, externally steam with Shuiyang Tang. In summer with strong Fire, lie on yellow earth, or place rooster on chest, or large toad using rooster method—all proven to lift closed/latent toxin. ○ If lower back/abdominal pain, cracked lips, macules appear but no spots, or one or two large rootless spots appear, urgently use Shengma Shigao Tang plus Dahuang and Yuanmingfen (Mirabilite) to resolve interior/exterior simultaneously; discuss treatment after eruption. If interior/exterior open but spots still not palpable, stomach rots. Or lip bleeding, green-purple macules, or mouth spitting amaranth juice—death within half a day. ○ Xinmao year, autumn without rain, wells dry, rivers cut, extreme dryness, smallpox rampant, many closure cases. Reflection yields insight: Smallpox origin is Kidney. *Classic* says: Rain Qi connects to Kidney. No rain, Kidney Qi blocked, cannot send toxin out, like seed in ground needing rain/dew to sprout. Ancients treated initial eruption only with lifting/reaching exterior method. If exterior opens but no eruption, where is the fault? I directly put lifting herbs into nourishing Water formulas, named Huayu Jian (Rain-Transforming Decoction), adapting to times. Formula: Shengdi, Danshen, Maidong, Doukou, Chaihu, Shengma, Fangfeng, Jingjie, Congbai. Adapt flexibly. This is for those who know. ○ Yu Jiayan saw epidemic smallpox, ordered Liuwei Dihuang Tang first, similar to my view. ○ If closure due to Cold Evil, use Shudou Yin plus Mahuang, Zisu, Shengjiang; warm cover briefly after ingestion for effect. (*Xiangcun Doujue*)
Latency
Smallpox toxin is innate formless Fire, latent in Mingmen, waiting for annual Fire to draw it out. If annual Fire is excessive, mixed with epidemic Qi, innate Fire erupts internally, covered by epidemic Qi externally, resulting in Closure Syndrome. Closure is blocked by epidemic Qi. Initial eruption prioritizes rising/dispersing; taking rising herbs opens exterior, epidemic Qi scatters, some eruptions become smooth; this child’s fetal toxin was light, resolving epidemic time makes smallpox naturally smooth. Latency Syndrome differs: exterior opens, but toxin remains static, similar to closure; closure is external invasion, latency is internal knotting, requiring classified treatment. ○ Four types of Latency: Kidney/Mingmen, Heart Meridian, Liver/Gallbladder, Stomach. Lower back pain, dark blue face, no high fever, toxin latent in Kidney, death in 1-2 days. Few spots, no high fever, confusion, tongue protrusion, irritability, toxin latent in Heart, death in 1-2 days. If lifting herbs bring it out, throat/tongue safe, life preserved. If throat/tongue swollen, medicine hard to take, death in 5-6 days. Before eruption, high fever with convulsions; after eruption, convulsions stop, called "Convulsion before Smallpox," auspicious; if spots appear...