见点三日。死生判矣。断于此时。方称高列。关窍。唯面部为吃紧。面者。诸会之首。
天庭
印堂。尤面部最紧要者。天庭为看痘把柄。何者。元神所归也。元神者。元气也。小儿出痘
。不过气血毒三字。气血又元气所统也。元气胜毒。开落应期。毒胜元气。内攻外剥。毒既
胜矣。又安望元气之复胜哉。故此处先见。先起。先贯。先靥。密而痒。惨而黯。皆死症也
。毒从虚发。信矣哉。
凡见点磊落。摸得碍手。色润泽。眼部以下先见身热渐退。吉症也。磊落碍手。稀而有
神者也。色润泽。谓有彩也。天庭后见。元气固也。反是者逆。
痘初出时。三五相连者。后必密。单见者稀。毒之浅深。于此预见矣。
形属气。色属血。两者均可验吉凶。决生死。人何专言血。而不及气。气无形难知。血
有色
易见。故见点三日。色如猪肝者死。如红米饭者死。如洗过旧红 者太重虽然面部上有数十
颗有神彩者。亦可救活。不虑形恶。虑无神。不虑色恶。虑无彩。神绽而凸。彩润而明。恶
痘中。见有一二红活可爱。虽凶亦吉。何者元气犹存也。大都自眉以上。几点悦目可爱。又
不琐屑。又不歪斜。虽遍体稠密。杂症百出。终不至于死。悦目二字。即予笔舌难尽罄。在
学人意会。
见点头焦。面色或紫者。血分毒炽也。满天秋治之。唇燥舌苔。热见愁。黄苔起者。千
里马。盖焦紫虽血热。而未必不由内热也。审之以舌。药斯当矣。
见点白如水珠者重。若稀疏不密。其人平素色黄。而兼痘起发。气至而血不至也。当与
散火
。倘神不内宁。痘日增多。头尖作 。子形。毒太甚也。恐非药可愈矣。若见点色白。不红
不
可便作虚治。白而无神。唇舌淡白。或吐或泻。虚症也。若白而起 色。唇舌赤红。非虚也
。是伏火痘也。三日后必渐变红紫。倘作虚治。其误人不浅。见点脚米冷者。不必虑。气未
下行也。
见点两日。而大便尚秘。舌上无苔。知是血燥。非毒壅也。急行清解。枳壳。玄明粉治
之。恐贯时。咽痛作泻而不起。方内归芎宜倍用。
初见时。大小不一。有色点如痱者。曰夹疹。救苦丹治之。又一等琐屑红点隐隐肉间。
曰夹
痧。治亦同前。丹症亦然。但有此症。必正痘悦目可爱。方为痧疹之夹。不然皆痘也。识者
详辨之。
又有痘出数颗。而夹疹遍身。圆净疏朗。颜色红活。现两日而尽没。众医莫不惊愕。予
曰疹
也。非痘也。痘没必闷乱烦燥。此则宁静。且正痘依然。予故知其为疹也。治以平剂。后渐
愈。未没特亦难辨焉。
点见身热。毒未尽也。但所感不同。有寒气外郁者。有热毒内郁者。两者均且散之。救
苦丹
是其治也。内郁黄苔。加千里马。其色渐焦紫。隐隐不出。而身热壮盛。或肌肤肿亮。再加
赛春雷发之。
见点自汗。有生者有死者。丹溪谓自汗无妨。指形色善者言也。若汗出而形色日变必死
。不可不辨但治症。不须以此虑。虚症也。又须看舌用药。
凡痘出不快须审时令药之。冬则寒郁。主赛春雷。夏则热郁。主满天秋。然亦有虚实之
别。唇舌滋润无苔。当从虚治。
一见点色白。不甚起发。唇舌淡白。或吐或泻。或腹膨。或自汗。肢冷神气怯弱。表里
虚也。治从虚例。
一见点。在脐。在肛门。四围成堆者。皆重症。
一出数点。即发数粒山根上者重。才出而声遂变。或焦。或哑者。尤重。
痘出数点。而面目即光亮如爪。口中气臭。勃勃冲人。其死甚速。后必发斑。吐血而死
一见点先于眉上。或两太阳出数粒。突起光亮。少顷即没。此赋痘也必死。
又有初出爱人。皮薄光亮。一两日即大长。是未至而至。疠气使然也。后必变痒塌而死
认为顺症。则医杀之诮。断乎难免。
凡患诸疮毒未愈。或疮毒新愈。而见点于此者重。此阳毒也。但疮不干红。虽重决不死
谓为于可为之时则从。为于不可为之时则凶。指险症也。至见点如蛇皮。如蚕种。蚊迹。蚤
斑。汤泡。火刺。青黑蓝斑。身如被杖。发斑。而唇肿。口臭。琐项。蒙头。断腰。无根。
色粉白如枯骨。胸高气喘。七孔流血。面斜视如橘皮。形色不正而惊狂。并腰疼
腹痛不止。可为乎。不可为乎。
凡谓断腰无根。必诸痘形色不善。如形色圆泽。即腰脚无痘何妨。
痘疹初现红点后的三天内，生死之局已定。在此时做出判断，才称得上是高明的医家。诊察的关键部位，首推面部。面部是诸阳经汇聚之首。其中，天庭和印堂这两个部位，尤为面部中最紧要之处。天庭是观察痘疹预后的关键所在，因为这里是元神（即元气）归聚的地方。元神就是元气。小儿出痘，归根结底不过是“气、血、毒”三个字在起作用，而气血又是由元气所统摄的。如果元气胜过毒邪，痘疹就能按时开落；如果毒邪胜过元气，就会向内攻伐脏腑，向外剥蚀肌肤。既然毒邪已经占了上风，又怎能指望元气重新战胜它呢？因此，如果在天庭、印堂这些要害部位先见到痘点，且先起发、先贯穿、先结痂，痘点密集且瘙痒，颜色惨暗无光，这些都是死症。毒邪从虚损之处发出，确实如此啊。
凡是痘点分布疏朗磊落，摸上去有碍手感，色泽润泽光亮，且在眼部以下先出现，伴随身体发热逐渐消退，这是吉兆。所谓“磊落碍手”，是指痘点稀疏但精神饱满。所谓“色润泽”，是指痘点有光彩。如果在天庭、印堂后见痘点，说明元气固守。反之则为逆证。
痘疹刚出来时，三五颗连在一起的，后来必然变得密集；单独出现的，则比较稀疏。毒邪的深浅，可以从这里预见。
形体属于气，颜色属于血，两者都可以用来验证吉凶，决断生死。为什么人们只专门谈论血，而不提及气呢？因为气无形体难以察觉，血有颜色容易看见。所以在见点三天内，如果痘色像猪肝一样，主死；像红米饭一样，主死；像洗过旧红布一样，颜色过重，也主死。虽然面部上有数十颗痘点，只要神采奕奕，也可以救活。不必担心形体恶劣，而要担心没有神采；不必担心颜色难看，而要担心没有光彩。神采表现为凸起鲜明，光彩表现为滋润明亮。即使在恶痘中，见到一两点红润鲜活可爱，虽然是凶险之象，但也转为吉利，这是因为元气尚存。大抵来说，只要自眉毛以上，有几颗令人悦目可爱的痘点，又不琐碎杂乱，又不歪斜，即使全身痘点稠密，并发各种杂症，最终也不会死亡。“悦目”二字，难以用笔墨完全表达清楚，需要学医者用心领会。
见点时头顶焦枯，面色发紫，这是血分毒热炽盛的表现。可用满天秋方治疗。如果嘴唇干燥，舌苔发黄，这是热象明显；若黄苔加重，可用千里马方治疗。大概焦紫色虽属血热，但未必不是由内热引起。通过审察舌象，用药才能恰当。
见点时痘色白如水珠者病情重。如果痘点稀疏不密，其人平时面色黄，兼见痘起发不畅，这是气至而血未至的表现。应当给予散火之法治疗。倘若神志不能安宁，痘点日益增多，痘头尖硬作痛，呈子形（尖锐突起），这是毒邪太甚，恐怕非药物所能治愈。如果见点色白，不红，不可便当作虚证治疗。若白色而无神采，唇舌淡白，或呕吐或腹泻，这是虚证。若白色而起发有色泽，唇舌赤红，这不是虚证，而是伏火痘。三天后必然逐渐变为红紫色。倘若当作虚证治疗，误人不浅。见点时脚底冰冷者，不必忧虑，这是气尚未下行所致。
见点两天，大便仍然秘结，舌上没有苔，知道这是血燥，而不是毒邪壅滞。应紧急进行清解治疗，用枳壳、玄明粉治疗。恐怕在贯脓期会出现咽痛、腹泻而不起发，方剂中当归、川芎宜加倍使用。
初见痘点时，大小不一，有色点如痱子样，称为夹疹，用救苦丹治疗。另一种是细小琐碎的红点隐隐出现在肌肉之间，称为夹痧，治疗方法同上。痘疹夹杂痧症也是如此，但必须有此症，且正痘必须悦目可爱，这才算是痧疹夹杂，否则都是痘疹。识者应详细辨别。
又有痘出了几颗，而全身布满疹子，圆润干净，疏朗有致，颜色红润鲜活，出现两天后就全部消退。众医生都感到惊愕，我说这是疹，不是痘。痘疹消退必然伴有闷乱烦躁，而此患者却安静，且正痘依然存在，所以我知道它是疹。用平和的药剂治疗，后来逐渐痊愈。在未消退前确实难以辨别。
见点时身体发热，说明毒邪未尽。但感受不同，有的寒气外郁，有的热毒内郁。两者都应疏散，救苦丹是其治疗方法。若内郁见黄苔，加用千里马方。若痘色逐渐焦紫，隐隐不出，而身体发热壮盛，或肌肤肿胀光亮，再加赛春雷方发散。
见点时自汗，有生的也有死的。朱丹溪说自汗无妨，是指形色良好的情况而言。如果汗出而形色日渐变坏，必死无疑，不可不辨别。但治疗病症时，不必为此担忧。若是虚证，还需看舌象用药。
凡痘出不快，须审察时令来用药。冬季则是寒邪郁闭，主用赛春雷方；夏季则是热邪郁闭，主用满天秋方。然而也有虚实之别。若唇舌滋润无苔，当从虚证治疗。
一见点色白，不甚起发，唇舌淡白，或呕吐或腹泻，或腹部膨隆，或自汗，四肢冷，神气怯弱，这是表里俱虚。治疗应从虚证例法。
一见点，长在脐部、肛门周围成堆的，都是重症。
一出数点，随即在山根（鼻根部）发数粒的，病情重。刚出来声音就改变，或焦哑，或失音的，尤其重。
痘出数点，而面目立即光亮如爪，口中气息臭秽，勃勃冲人，其死速很快，后来必然发斑，吐血而死。
一见点先于眉毛上，或两太阳穴处出数粒，突起光亮，少顷即消失，这是赋痘（先天禀赋不足之痘），必死。
又有初出时看似可爱，皮薄光亮，一两日即长得很大，这是未至而至，疠气使然。后来必然变痒塌陷而死。若认为是顺症，则难免被讥讽为医杀之罪。
凡患各种疮毒未愈，或疮毒新愈，而在此时见点的，病情重。这是阳毒。但只要疮不干红，虽然重决不会死。所谓“可为之时则从，不可为之时则凶”，指的是险症。至于见点如蛇皮、如蚕种、蚊迹、蚤斑、汤泡、火刺、青黑蓝斑，身如被杖打，发斑，而唇肿，口臭，琐项（颈部肿胀），蒙头（头部肿胀），断腰（腰部无痘），无根，色粉白如枯骨，胸高气喘，七孔流血，面斜视如橘皮，形色不正而惊狂，并腰疼腹痛不止，这些还能治吗？不能治。
Three days after the appearance of spots. Life and death are decided at this time. Making a judgment here is what qualifies one as a high-level practitioner. The key point lies in the face. The face is the head of all convergences (of Yang meridians). Among them, the Tian Ting (Forehead) and Yin Tang (Glabella) are the most critical parts of the face. The Tian Ting is the handle for observing smallpox, because it is where the Yuan Shen (Primordial Spirit, i.e., Yuan Qi/Essential Qi) returns. Yuan Shen is Yuan Qi. For children developing smallpox, it boils down to three characters: Qi (Vital Energy), Blood, and Toxin. Qi and Blood are governed by Yuan Qi. If Yuan Qi overcomes the toxin, the lesions will open and fall according to schedule; if the toxin overcomes Yuan Qi, it will attack internally and peel externally. Since the toxin has already prevailed, how can we expect Yuan Qi to regain dominance? Therefore, if spots appear first, rise first, penetrate first, and crust first in these areas, being dense and itchy, miserable and dark, they are all signs of death. The toxin emanating from deficiency is indeed true.
Whenever the spots are distinct and scattered, palpable with resistance, and lustrous and moist, appearing first below the eyes while body heat gradually subsides, it is an auspicious sign. "Distinct and scattered with resistance" means sparse yet spirited. "Lustrous and moist" refers to having color/luster. If spots appear later in the Tian Ting area, it indicates that Yuan Qi is solidified. The opposite is adverse.
When smallpox first emerges, those appearing in clusters of three or five will likely become dense later; those appearing singly will be sparse. The depth of the toxin can be anticipated from this.
Form belongs to Qi, color belongs to Blood. Both can verify auspiciousness or inauspiciousness, and decide life or death. Why do people only speak of Blood and neglect Qi? Because Qi is formless and hard to know, while Blood has color and is easy to see. Thus, within three days of spot appearance, if the color resembles pig liver, it is fatal; if it resembles red rice grains, it is fatal; if it resembles washed old red cloth, the color is too heavy [and fatal]. Although there may be dozens of spots on the face, if they have spirit and luster, the patient can still be saved. Do not worry about bad form, but worry about lack of spirit; do not worry about bad color, but worry about lack of luster. Spirit manifests as protruding and distinct; luster manifests as moist and bright. Even among severe smallpox cases, seeing one or two reddish, fresh, and lovely spots indicates that although the prognosis is ominous, it turns auspicious because Yuan Qi still exists. Generally speaking, as long as there are a few pleasing and lovely spots above the eyebrows, which are not琐碎 (trivial/cluttered) nor slanted, even if the whole body is densely covered and various complications arise, death will ultimately be avoided. The term "pleasing to the eye" is difficult to fully express with words and brushes; it must be understood intuitively by students.
If the scalp is scorched and the facial color is purple upon spot appearance, it indicates blazing toxin in the Blood aspect. Treat with Mantianqiu Decoction. Dry lips and tongue coating indicate obvious heat; if yellow coating arises, treat with Qianlima Decoction. Generally, although scorched and purple colors indicate blood heat, it may not necessarily stem from internal heat. Examine the tongue to ensure appropriate medication.
If spots appear white like water droplets, the condition is severe. If they are sparse and not dense, and the person usually has a sallow complexion accompanied by poor eruption of spots, it means Qi arrives but Blood does not. One should administer methods to scatter fire. If the spirit is not calm internally, and spots increase daily, becoming pointed and painful with a sub-form (sharp protrusion), the toxin is too excessive, and it is feared that medicine cannot cure it. If spots are white, not red, one should not immediately treat as deficiency. If white without spirit, with pale lips and tongue, or vomiting/diarrhea, it is a deficiency syndrome. If white but rising with color, and lips/tongue are crimson red, it is not deficiency; it is a hidden-fire smallpox. After three days, it will gradually turn red-purple. Treating it as deficiency would cause significant error. If the feet are cold upon spot appearance, there is no need to worry; this is because Qi has not yet descended.
Two days after spot appearance, if stool remains constipated and there is no tongue coating, it is known as dry Blood, not toxin stagnation. Urgently perform clearing and resolving treatments using Zhike (Fructus Aurantii) and Xuanmingfen (Natrii Sulfas). Fear that during the pus-formation stage, sore throat and diarrhea may occur leading to failure to erupt. In the formula, Danggui (Radix Angelicae Sinensis) and Chuanxiong (Rhizoma Chuanxiong) should be doubled.
At initial appearance, if spots vary in size, with colored dots resembling prickly heat, it is called "Jia Zhen" (Smallpox complicated by Rash). Treat with Jiuku Dan. Another type consists of tiny,琐碎 (trivial) red dots faintly appearing between muscles, called "Jia Sha" (Smallpox complicated by Sand-pox). Treatment is the same as above. This applies to smallpox cases as well, but such complications must present with positive smallpox spots that are pleasing and lovely; otherwise, they are just smallpox. Experts should distinguish carefully.
There are cases where a few smallpox spots emerge, but rashes cover the whole body, round and clean, sparse and clear, with fresh red color, disappearing completely after two days. All physicians were astonished. I said it is rash, not smallpox. Smallpox disappearance must involve confusion and irritability, whereas this case was quiet, and the main smallpox spots remained. Hence I knew it was rash. Treated with a mild agent, it gradually healed. It was difficult to distinguish before disappearance.
Body heat upon spot appearance indicates toxin is not exhausted. However, the pathogen differs: some have external constriction by cold, others have internal depression of heat-toxin. Both require dispersal; Jiuku Dan is the treatment. If internal depression presents with yellow coating, add Qianlima Decoction. If color gradually becomes scorched purple, spots remain hidden, and body heat is intense, or skin is swollen and shiny, add Saichunlei Decoction to vent.
Spontaneous sweating upon spot appearance can lead to survival or death. Zhu Danxi stated that spontaneous sweating is harmless, referring to cases with good form and color. If sweating occurs and form/color deteriorate daily, death is certain; this must be distinguished. However, when treating symptoms, do not worry about this. If it is a deficiency syndrome, observe the tongue for medication.
Whenever smallpox fails to erupt quickly, one must consider the season for treatment. In winter, cold constrains; use Saichunlei Decoction. In summer, heat constrains; use Mantianqiu Decoction. However, there are also differences between deficiency and excess. If lips and tongue are moist with no coating, treat as deficiency.
One type: Spots are white, poorly erupted, lips and tongue are pale, with vomiting/diarrhea, abdominal distension, spontaneous sweating, cold limbs, and timid spirit. This is exterior-interior deficiency. Treat according to deficiency principles.
Another type: Spots appear on the navel or around the anus in clusters. These are all severe conditions.
Erupting a few spots followed by several on the Shan Gen (root of nose) is severe. Voice changing immediately upon eruption, becoming hoarse or aphonic, is especially severe.
Erupting a few spots, then face and eyes becoming bright like claws, with foul breath rushing out, leads to rapid death. Later, macules will appear, leading to death from hematemesis.
Spots appearing first above the eyebrows or on both temples, protruding brightly, then disappearing shortly after, is "Fu Dou" (Endowed Smallpox), which is fatal.
Another type appears lovely initially, with thin, bright skin, growing large in one or two days. This is "Wei Zhi Er Zhi" (Arriving before its time), caused by epidemic qi. Later, itching and collapse will occur, leading to death. Mistaking this for a favorable course invites the accusation of medical homicide.
For patients with unresolved sores/toxins, or newly healed sores, who develop smallpox spots now, the condition is severe. This is Yang Toxin. But if the sores are not dry and red, although severe, it will not be fatal. "Treatable when possible, fatal when impossible" refers to dangerous syndromes. As for spots resembling snake skin, silkworm eggs, mosquito bites, flea marks, scalds, burns, blue-black macules, body feeling like beaten, macules, swollen lips, foul odor, neck swelling, head swelling, waist gap (no spots on waist), rootlessness, powder-white color like dead bones, chest fullness with panting, bleeding from seven orifices, oblique gaze like orange peel, abnormal form/color with convulsions/raving, and unceasing lower back/abdominal pain—can these be treated? No.
Regarding "waist gap" and rootlessness: it must be that the form and color of all spots are poor. If the form and color are round and lustrous, what harm is there if there are no spots on the waist and legs?