一、痘证起源
昔人云∶太古无痘，周末秦初乃有之。是知古时天地之气中和，人间嗜欲淡薄，故疾病稀少，并痘证
而无之也。迨后世变日亟，刀兵水旱之结果，胥足以酿时气疫疠，而人生嗜欲日增，更
足以薄元气藏内邪，两者相因，病变遂日以繁，而痘证亦其一也。考痘证之原，由于先天，盖当成胎之时，
父母欲火之遗毒，蕴藏于胎儿骨髓深处，触于岁时流行之毒，即感之而外发。是以母体受胎教者，即有
痘发，多属易治，而孕期纵欲无度者，每逢小儿出痘，最易夭亡也。然古时之痘多为并发性，盖既有内蕴之
毒，复增时气之毒，二者相合，其病必剧。是以后世发明种痘之法，其宗旨要在逗先天之毒外出，务使其不
与时行之毒并合触发。所以减轻其病，意至善也。其法系取痘苗塞入鼻中，以鼻为肺窍，使苗气内达，数
日后其气由肺传心（心主血脉），由心传脾（脾主肌肉），由脾传肝（肝主筋），由肝传肾（肾主骨髓），
至传肾后，引动先天所伏之毒，其蕴遂逐渐透露，由肾而肝而脾而心而肺，以迄于痘点发现，是为种痘，
所以别于感时气而触发之天花也。自种痘之法发明后，病者全活较多，风行甚久，咸称便利，然犹有未能满
人意者，则种痘者发痘之时，毒虽较轻而周身密布，则与天花相似也。体弱者不易起胀，或起胀后不易灌
浆，治法亦多周折，且风寒谨避，百日将息，亦觉多累，而灌浆期中，偶有不慎，仍有成面麻之患。故
此法遂又渐有淘汰之倾向，适于是时，西法牛苗传入中土，用以引痘，其出也仅发痘于
所种之处，发痘之时，绝无危险，且忌口而外，又无其他繁重之禁忌，以故人人乐用，推行世界。
至今世界天花一证，绝少发生，不可谓非牛痘苗之功也。
二、痘证病理
痘证之发，既为人身宣泄邪毒之路，故其发也，由内达外，与痧疹同，其有不同者，则痧疹之伏毒较浅，
痘症之伏毒深藏骨髓，而发动于肾也。惟其发动于肾，故恒牵涉于肾间之元阳，元阳亏者，其痘不获烘托之
力，常致痘出不快，陷为逆症，此所以有痧喜清凉，痘喜温暖之说，然邪毒炽盛，劫阴耗液，又莫此为
甚，故痘症号称难治，以其下药寒温两有不易也。且痘之出既始于肾而终于肺，则全身传遍，殆莫不有关。
于是治痘又最重时期，根据时消息，表散、清凉、温化，尤须变化于瞬息之间，方为能治
痘者。此痘证之变有如此者，故历代医家，莫不以弭痘为亟，迨近世牛痘之法发明，而弭痘之法不可谓非告
一成功矣。然或以痘为小儿大证，当天行时，人人避之，尚恐不亟，今无故而与之，庸非自
扰，不知牛痘之妙，正在于无故而与之。譬如捕盗，乘其羽翼未成而擒之，固不难也，譬如去莠，及其滋蔓
未延而除之，固甚易也。故天痘之患，正在毒发迟而祸甚，牛痘之轻，正在毒发早而祸浅也。又牛痘引种，
大都在两臂两胫，颇具至理，盖两臂乃手少阳之经脉，两胫乃足少阳之经脉，少阳主枢，引苗气内达，莫
捷于此，及其毒从内泄，引挈而出，亦莫捷乎此。故牛痘自始至终，不过旬余也。然自盛行种痘之后，
亦有已种而仍发天花者，此由伏毒泄而未尽，与未种痘而发之天花不同，且病邪出路，仍
遵向日之径，则其发泄较易，无须仗乎烘托，理至浅显，故治法要宜以少偏清凉或辛散为主，温
补在所不宜也。治痘之法，至今为之一变，此不可不知者也。
三、痘证症状
痘症之发，其初亦并无何等显著之兆，比其将出，始则微有恶寒，或身热，或身热咳呛，至是须验
其是否耳冷、鼻尖冷、尻冷、足冷，如冷者是痘候也。再验其耳后有红丝赤缕突出，脉洪
大而弦数，则痘将报点矣。痘之初起，先见红点，数日报点，初
报点时，常先于胸窝见红色粒子，或面部见红色粒子，两颧之间，现出花纹，耳尻与中指独冷，斯皆痘疮之
特征也。其他若眼目困倦有水状，或睛黄或胞赤，睡则常惊惕，小便赤，大便闭。
此皆痘疮所恒有之见证。其得之也，或以时气之感染，或由伤风，或由饮食呕吐，或由跌扑惊恐，为其诱因，
此痘证初起之大概也。痘症初起，约三四日或五六日而报点，又二三日或三四日而起胀，起胀者，颗粒次第
涌高，根脚与皮肤之界发为肿状，盖为灌浆之预备也。浆灌三日，毒已尽化，至此时期，即结靥而渐
愈，此痘证经过之大概也。然痘证有轻重，势有险顺，且随期变易，不可捉摸，往往发热时顺而报点时转险
者，或报点时顺而起胀时转险者，或起胀时顺而脓浆忽不灌因以转险者，或经过皆顺而结靥时转险者，是
在临证之随时变化焉。大凡发热之候，热而非如灼如焚，或恶寒战栗，二便如常，饮食能进，气息微粗而不
喘，腰腹不痛者，此顺症也。若壮热灼手，气逆而喘，谵语闷乱，腹胀便秘，或恶寒微热，大便溏泄，食少
神疲，此重症也。至发热而肌肤焦燥，口气秽恶，喘急音哑，或面青摇头，吐食戴眼，点来隐现，则为危症。
报点之候，点粒根窠红润，顶尖碍手，头面稀少，肢体朗布，身热而微凉，凉而又热，二便调匀，
此顺症也。若见点色淡，或红点如丹，身热如烙，或头白似 ，根窠不红，头尖皮薄，腹痛腰痛，大便泄
利者，此重症也。至点粒一齐拥出鲜红繁密，或疮色惨暗，毛焦皮燥，或多见于眼胞、
唇内、前后阴或多见于舌喉胸背者，或肌肉如被杖、昏睡不食者，则为危症。起胀之候，身热作潮，逐
渐起胀，头圆根红，光泽绽实，见此现象，易于灌浆，此顺症也。若到起胀之候，身凉
不热，隐而不易起，皮薄而亮，根脚不红，或泄泻，或微痒，此重症也。至起胀色白皮薄，光润易破，根窠
全无红色，或热甚痘色紫黑，壅而不起，或面浮肉肿，而痘不起者，则为危证，灌浆之
候，起胀之极，随即灌浆，中陷者尽起，顶平者尽峻，饱满光
荣，先胀者先作浆，次胀者次作浆，循循有序，色如黄豆，二便如常，四肢温和，此顺症也。若根窠红而
不润，灌浆不满，大便泄泻，或稠密焦紫不起顶者，或灌浆时忽作痰喘者，或烦躁不得
眠者，此重症也。至灌浆时内含清水，或干枯退缩，根窠瘀紫，或身灌而头面不灌，咳呛喘急，大便或泄
或闭，则为危证。结靥之候，痘浆灌足之后，其色渐变苍老，先从人中面部次第结靥渐至胸腹两腿，身无
大热，亦不畏寒，饮食增加，二便通调，此顺症也。若身重发热，不易结靥，或结靥如血色，或溃烂难收，
或寒战抽搐者，则为危证。此辨痘证顺逆之大概也。至于痘证愈后，元气必然亏损，允当以调补为急。而痘
期之禁忌，较痧疹尤烦，略有疏忽，变端即起，此皆不可不知，故并于后附述之焉。
近时引种之牛痘，症状颇为平淡，种后一二日，局部略见红肿，以后逐渐高胀灌浆，约至第十日左右
而脓浆灌足，此后渐次干燥收靥，至第二十日左右而痂落。在经过期中，发热有盛有不盛，然至多不过一星
期而已。小儿自第六个月至第十个月为种痘最适宜之期，以后三年一种，五年一种，均无不可。惟种痘期内
所应注意者，局部宜清洁，不可任其破溃，而忌口多日，尤为必要。盖一则免破烂成疮，二则免痘后余毒不
清以致无效也。
四、痘证治法
痘证于初起一二日发热时，宜解表，使痘易出；三四五日清凉解毒，使痘易长；六七八九日温补气血，
使易灌浆；十及十一二日清利收敛，使痘易靥。此治痘之常法也。然亦有先期而速，或后期而迟者，不可执
一而论，先期则痘出甚速，无须藉乎狂表，后期则起胀灌浆迟迟，正有赖于透托。又痘未尽出，不可清凉，
因痘得寒将有凝滞之患；热毒未尽解，不可温补，因毒得温将有蕴蓄不能化浆之虑。大抵痘证面红者吉，
身温者吉，大便坚者吉，神志清明者吉，倘属顺症，自可不必多药。初起只须微表，点
粒即逐渐透达，疏朗分布，继则渐次起胀，只须略用清化，内毒
易解，起胀必足，迨浆灌充盈，正无须藉乎温补。若微觉低陷，则补托即起，至痘证面色不红，或青或白，
身热不扬，大便溏薄，又或面赤如火，身热如灼，大便不通，神明狂乱，皆为重症。大约面白便溏，当斟
酌于温补发散之间，面赤便难，当斟酌于攻下清血之间。此治痘之大概也。
上述痘证治法，其简易者也，至于痘证之变化独多，尤甚于痧，不可不另为条叙之。
（甲）初起之变化∶初起发热，其热乍进乍退者，身温微热者，自属顺证。若（一）骤发壮热，
闷乱狂躁，一热便见红点者，必由毒盛，大便坚者宜凉膈散下之，大便溏者宜辛凉辛温合
济之。（二）发热时肢体骨节俱痛者，此感六淫之邪也，宜表散兼透毒之剂。（三）发热时遍身作痒者，
此表虚客冒风寒，毒不能出，宜桂枝汤加黄 、防风、白芷、蝉蜕。（四）发热时恶寒身振振动摇者，
此气弱不能逼邪外出，邪正交争，故振也，宜升麻汤加人参、穿山甲、桂枝、防风。（五）发热时腹痛攻
扰，躁渴者，此毒势壅遏，热气内蒸，宜蜜调玄明粉下四五钱，或凉膈散下之，大便一利，即痛减痘发。
（六）发热时腰痛者，最为重候，盖痘证其邪由里达表为吉，此为邪逆于里也，宜急用石膏六
七钱，人参一钱，茶叶一撮煎好，入玄明粉三五钱，加生白蜜热服，或可救，或用百祥丸。若虚而腰微痛者，
不在此例。（七）发热时或吐或泻，此毒邪奔越分泄也。若精神不减为吉，吐泻即止为吉。若见点后犹吐泻
不止，宜四苓散加枳壳、橘皮、山楂。虚者宜异功散加藿香、木通。（八）发热时唇口上下紫黑，燥裂
疼痛者，此毒攻脾脏，宜急投犀角消毒饮加石膏、玄参。（九）发热时切牙窜视者，此心经热甚也，宜导
赤散加黄连、赤芍。若切牙闷瞀，为肝经风热，宜羌活汤加青皮、柴胡。（十）发热时声音变易者，宜消毒
饮加连翘、桔梗。咽喉痛者，甘桔汤加牛蒡子。（十一）发热时小便黄赤短涩者，此热毒不透，渗入膀胱
也，宜导赤散加荆芥、连翘、牛蒡子。（十二）发热时衄血者，邪从衄解也。若血不止，宜犀角地黄汤。
（十三）身不热者宜审其兼证是虚是实，热深厥冷者，宜大寒之剂，气弱邪不能透而身不热者，宜补中益
气汤、保元汤之类。（十四）发热一日，遍身即现红点，稠密如蚕种，摸过不碍手者不治。头面一片红如胭脂
者，遍身有成红块者皆不治。（十五）发热时即烦闷呕吐，舌下常流清水，或时沉默喜睡，或时躁扰不宁，
或腹痛狐疑，频频叫唤，须验其舌下青筋，或下唇有黑白细点者，此属虫，宜先与椒梅丸诱入虫口，即以紫草
承气汤下之。（十六）发热时痰喘气急，或目闭神昏，眩晕颠仆，闷乱搐搦者，此属痰，宜大黄甘草
汤，使上吐下泻，以涤其痰。
（乙）报点至起胀之变化∶点红而稀，顶尖而碍手，胀则头圆根红，光泽绽实，自属顺症。若（一）
痘初发热即报点如丹，身热如烙，渐至干焦紫黑，烦躁闷乱，唇焦口臭者，虽在冬月，亦须大剂白虎化斑汤，
石膏非数两不应。（二）身无大热，见点细如白 ，气怯无力，目闭无神，面色及口唇反鲜泽娇艳，光彩
倍常，此气虚无阳，肺胃之精华涣散于外，宜重用人参二三两，生 两许，以升麻、五味，续续灌下，或保
元汤加减。（三）痘疹腹痛，多属食积，宜透表之中佐以消积。若腹胀泄泻，不可骤止，又不可任其多泻，
只宜和之。（四）杂痘一齐涌出者，水杨柳、桃枝、槐枝各三条，同紫背浮萍，煮汤遍洗，即出痘毒，而
正痘现。（五）痘疮红紫干滞，黑陷焦枯者，此表热而实，大便秘结，小便赤涩，身热鼻干，唇燥烦渴者，
此里热而实，治宜凉血解毒，用紫草、红花、连翘、牛蒡、木通、蝉蜕、荆芥，或芩、连之属。如表热者，
则宜清凉解表而分利次之。里热者，重于解毒而兼清凉。（六）痘证见点，三四日隐于肌肤不长发者，
此气血虚也，宜快斑汤，或透肌散催之。至身面俱起，四肢不能
起发者，宜桂枝汤加防风、黄 。（七）痘虽长起，而颜色淡白
顶陷者，此气虚也，宜参 内托散加糯米。若虽不白，亦不红活而顶陷者，此血虚也，宜四物合保元汤。起
胀迟迟，浆清不满者宜独参汤。（八）色赤而兼痒，血虚有热也，宜四物汤去生地加犀角、连翘。（九）痘
顶色白连肉红肿，而痘反不肿，此毒不能灌注于痘也，宜急用化毒汤加生地、川芎调二宝散救之。（十）
色红根散不长发者，此血热而气不相根据，宜大鼠粘子汤加紫草。（十一）热证方形，虚证又现，元气本来虚
弱，而毒瓦斯猛烈，以致痘出不快，狂言乱语音，既碍用清凉之药以解毒，又恐犯温补以助火，此为最难措手之
候，可急用雄鸡一只，生剖开腹，去肠杂，以烧酒喷之，敷于脐上，其痘自出，其语亦止。若遍身疼痛
者，此毒出肾经，用黑大豆一升，煮熟擂敷腰上，即止。此外治之效方也。
一、痘证起源
古人说：远古时代没有天花，到了周末秦初才出现。由此可知，古时候天地之气和谐中和，人们欲望淡薄，所以疾病稀少，连天花这种病也不存在。等到后世情况日益恶化，战争和水旱灾害的后果，都足以酿成时行疫病，而人们的欲望日益增加，更足以损耗元气、使内脏潜伏邪气，这两者相互影响，病变于是日益繁多，天花也是其中之一。考察天花的根源，源于先天，大概是在受孕之时，父母情欲留下的毒火，蕴藏在胎儿骨髓深处，遇到岁时流行的毒气，便感应而外发。因此，母亲在孕期接受胎教的人，即使孩子出痘，多属容易治疗；而孕期纵欲无度的人，每逢小儿出痘，最容易夭亡。然而古代的天花多为并发重症，因为既有内蕴之毒，又增时气之毒，两者相合，病情必然剧烈。所以后世发明了种痘法，其宗旨在于引导先天之毒外出，务必使其不与时行之毒合并触发。这样就能减轻病情，用意非常美好。这种方法是将痘苗塞入鼻中，因为鼻为肺之窍，使痘苗之气内达，数日后其气由肺传心（心主血脉），由心传脾（脾主肌肉），由脾传肝（肝主筋），由肝传肾（肾主骨髓），传到肾后，引动先天所伏之毒，其蕴藏之毒逐渐透露，由肾而肝而脾而心而肺，直到痘点显现，这就是种痘，以此区别于感受时气而触发的天花。自从种痘法发明后，患者存活较多，流行很久，大家都称便利，然而仍有不能让人满意的地方，就是种痘者在发痘时，虽然毒性较轻但周身密布，这与天花相似。体质弱者不易起胀，或起胀后不易灌浆，治疗方法也多周折，且需谨避风寒，百日调养，也觉劳累，而在灌浆期中，偶尔不慎，仍有留下麻子的祸患。因此这种方法便渐渐有被淘汰的趋势，恰逢此时，西方牛痘苗传入中国，用来引痘，它只在接种处发痘，发痘时绝无危险，且除了忌口外，没有其他繁重的禁忌，因此人人乐于使用，推行至世界。至今世界天花这一病症，极少发生，不可不说是牛痘苗的功劳。
二、痘证病理
天花的发生，既然是人体宣泄邪毒的途径，所以它的发作是由内达外，与痧疹相同，不同的是，痧疹潜伏的毒较浅，天花潜伏的毒深藏骨髓，且发动于肾。正因为发动于肾，所以常牵涉到肾间的元阳，元阳亏虚的，其痘得不到烘托之力，常导致痘出不快，陷入逆症，这就是所谓“痧喜清凉，痘喜温暖”的说法。然而邪毒炽盛，劫耗阴液，没有比这更严重的了，所以天花号称难治，因为其用药寒温两难把握。而且痘的发出既始于肾而终于肺，则全身传遍，几乎没有不相关的。于是治痘最重时期，根据时令消息，表散、清凉、温化，尤其须在瞬息之间变化，才是能治痘的人。这就是痘证的变化如此之多，所以历代医家，无不以消除天花为急务，等到近代牛痘法发明，消除天花的方法可以说告一段落了。然而有人以为天花是小儿的大病，在当时行时疫的时候，人人都躲避它还怕来不及，现在无故去接种它，难道不是自找麻烦吗？不知道牛痘的妙处，正在于无故而与之。譬如捕盗，趁其羽翼未成而擒获，固然不难；譬如除草，趁其滋蔓未延而除去，固然很容易。所以天痘的祸患，正在毒发迟而祸患大，牛痘的轻缓，正在毒发早而祸患浅。另外牛痘引种，大多在两臂两胫，颇具至理，盖两臂乃手少阳经脉，两胫乃足少阳经脉，少阳主枢机，引苗气内达，没有比这更便捷的，及其毒从内泄，引挈而出，也没有比这更便捷的。所以牛痘自始至终，不过旬余时间。然而自盛行种痘之后，也有已种痘仍发天花的，这是由伏毒泄而未尽，与未种痘而发的天花不同，且病邪出路，仍遵循旧日的路径，则其发泄较易，无须仗赖烘托，道理至为浅显，所以治法主要宜以稍偏清凉或辛散为主，温补在所不宜。治痘的方法，至今为之大变，这是不可不知道的。
天花发作，起初并没有何等显著的征兆，等到将要发出时，开始微有恶寒，或身热，或身热咳呛，到这时须查验是否耳冷、鼻尖冷、尻冷、足冷，如果冷的，就是痘候。再查验耳后有红丝赤缕突出，脉洪大而弦数，那么痘即将报点（出疹）。痘之初起，先见红点，数日报点，初报点时，常先在胸窝见红色粒子，或面部见红色粒子，两颧之间，现出花纹，耳尻与中指独冷，这些都是痘疮的特征。其他如眼目困倦有水状，或睛黄或胞赤，睡则常惊惕，小便赤，大便闭。这些都是痘疮所恒有的见证。得此病的原因，有时气感染，或由伤风，或由饮食呕吐，或由跌扑惊恐，作为诱因，这是痘证初起的大概。痘症初起，约三四日或五六日而报点，又二三日或三四日而起胀，起胀者，颗粒次第涌高，根脚与皮肤之界发为肿状，盖是为灌浆做准备。浆灌三日，毒已尽化，至此时期，即结痂而渐愈，这是痘证经过的大概。然而痘证有轻重，势有险顺，且随期变易，不可捉摸，往往发热时顺而报点时转险者，或报点时顺而起胀时转险者，或起胀时顺而脓浆忽不灌因以转险者，或经过皆顺而结痂时转险者，这是在临证时随时变化的。大凡发热之候，热而非如灼如焚，或恶寒战栗，二便如常，饮食能进，气息微粗而不喘，腰腹不痛者，此为顺症。若壮热灼手，气逆而喘，谵语闷乱，腹胀便秘，或恶寒微热，大便溏泄，食少神疲，此为重症。至发热而肌肤焦燥，口气秽恶，喘急音哑，或面青摇头，吐食戴眼（两眼上翻），点来隐现，则为危症。报点之候，点粒根窠红润，顶尖碍手，头面稀少，肢体朗布，身热而微凉，凉而又热，二便调匀，此为顺症。若见点色淡，或红点如丹，身热如烙，或头白似粟米，根窠不红，头尖皮薄，腹痛腰痛，大便泄利者，此为重症。至点粒一齐拥出鲜红繁密，或疮色惨暗，毛焦皮燥，或多见于眼胞、唇内、前后阴或多见于舌喉胸背者，或肌肉如被杖、昏睡不食者，则为危症。起胀之候，身热作潮，逐渐起胀，头圆根红，光泽绽实，见此现象，易于灌浆，此为顺症。若到起胀之候，身凉不热，隐而不易起，皮薄而亮，根脚不红，或泄泻，或微痒，此为重症。至起胀色白皮薄，光润易破，根窠全无红色，或热甚痘色紫黑，壅而不起，或面浮肉肿，而痘不起者，则为危证。灌浆之候，起胀之极，随即灌浆，中陷者尽起，顶平者尽峻，饱满光荣，先胀者先作浆，次胀者次作浆，循循有序，色如黄豆，二便如常，四肢温和，此为顺症。若根窠红而不润，灌浆不满，大便泄泻，或稠密焦紫不起顶者，或灌浆时忽作痰喘者，或烦躁不得眠者，此为重症。至灌浆时内含清水，或干枯退缩，根窠瘀紫，或身灌而头面不灌，咳呛喘急，大便或泄或闭，则为危证。结痂之候，痘浆灌足之后，其色渐变苍老，先从人中面部次第结痂渐至胸腹两腿，身无大热，亦不畏寒，饮食增加，二便通调，此为顺症。若身重发热，不易结痂，或结痂如血色，或溃烂难收，或寒战抽搐者，则为危证。这是辨痘证顺逆的大概。至于痘证愈后，元气必然亏损，应当以调补为急。而痘期的禁忌，较痧疹尤烦，略有疏忽，变端即起，这些不可不知，故并于后附述之焉。
近时引种的牛痘，症状颇为平淡，种后一二日，局部略见红肿，以后逐渐高胀灌浆，约至第十日左右而脓浆灌足，此后渐次干燥收痂，至第二十日左右而痂落。在经过期中，发热有盛有不盛，然至多不过一个星期而已。小儿自第六个月至第十个月为种痘最适宜之期，以后三年一种，五年一种，均无不可。惟种痘期内所应注意者，局部宜清洁，不可任其破溃，而忌口多日，尤为必要。盖一则免破烂成疮，二则免痘后余毒不清以致无效也。
四、痘证治法
痘证于初起一二日发热时，宜解表，使痘易出；三四五日清凉解毒，使痘易长；六七八九日温补气血，使易灌浆；十及十一二日清利收敛，使痘易靥。这是治痘的常法。然而也有先期而速，或后期而迟者，不可执一而论，先期则痘出甚速，无须藉乎狂表（强力发汗解表），后期则起胀灌浆迟迟，正有赖于透托。又痘未尽出，不可清凉，因痘得寒将有凝滞之患；热毒未尽解，不可温补，因毒得温将有蕴蓄不能化浆之虑。大抵痘证面红者吉，身温者吉，大便坚者吉，神志清明者吉，倘属顺症，自可不必多药。初起只须微表，点粒即逐渐透达，疏朗分布，继则渐次起胀，只须略用清化，内毒易解，起胀必足，迨浆灌充盈，正无须藉乎温补。若微觉低陷，则补托即起，至痘证面色不红，或青或白，身热不扬，大便溏薄，又或面赤如火，身热如灼，大便不通，神明狂乱，皆为重症。大约面白便溏，当斟酌于温补发散之间，面赤便难，当斟酌于攻下清血之间。这是治痘的大概。
上述痘证治法，其简易者也，至于痘证之变化独多，尤甚于痧，不可不另为条叙之。
（甲）初起之变化：初起发热，其热乍进乍退者，身温微热者，自属顺证。若（一）骤发壮热，闷乱狂躁，一热便见红点者，必由毒盛，大便坚者宜凉膈散下之，大便溏者宜辛凉辛温合济之。（二）发热时肢体骨节俱痛者，此感六淫之邪也，宜表散兼透毒之剂。（三）发热时遍身作痒者，此表虚客冒风寒，毒不能出，宜桂枝汤加黄芪、防风、白芷、蝉蜕。（四）发热时恶寒身振振动摇者，此气弱不能逼邪外出，邪正交争，故振也，宜升麻汤加人参、穿山甲、桂枝、防风。（五）发热时腹痛攻扰，躁渴者，此毒势壅遏，热气内蒸，宜蜜调玄明粉下四五钱，或凉膈散下之，大便一利，即痛减痘发。（六）发热时腰痛者，最为重候，盖痘证其邪由里达表为吉，此为邪逆于里也，宜急用石膏六七钱，人参一钱，茶叶一撮煎好，入玄明粉三五钱，加生白蜜热服，或可救，或用百祥丸。若虚而腰微痛者，不在此例。（七）发热时或吐或泻，此毒邪奔越分泄也。若精神不减为吉，吐泻即止为吉。若见点后犹吐泻不止，宜四苓散加枳壳、橘皮、山楂。虚者宜异功散加藿香、木通。（八）发热时唇口上下紫黑，燥裂疼痛者，此毒攻脾脏，宜急投犀角消毒饮加石膏、玄参。（九）发热时切牙窜视者，此心经热甚也，宜导赤散加黄连、赤芍。若切牙闷瞀，为肝经风热，宜羌活汤加青皮、柴胡。（十）发热时声音变易者，宜消毒饮加连翘、桔梗。咽喉痛者，甘桔汤加牛蒡子。（十一）发热时小便黄赤短涩者，此热毒不透，渗入膀胱也，宜导赤散加荆芥、连翘、牛蒡子。（十二）发热时衄血者，邪从衄解也。若血不止，宜犀角地黄汤。（十三）身不热者宜审其兼证是虚是实，热深厥冷者，宜大寒之剂，气弱邪不能透而身不热者，宜补中益气汤、保元汤之类。（十四）发热一日，遍身即现红点，稠密如蚕种，摸过不碍手者不治。头面一片红如胭脂者，遍身有成红块者皆不治。（十五）发热时即烦闷呕吐，舌下常流清水，或时沉默喜睡，或时躁扰不宁，或腹痛狐疑，频频叫唤，须验其舌下青筋，或下唇有黑白细点者，此属虫，宜先与椒梅丸诱入虫口，即以紫草承气汤下之。（十六）发热时痰喘气急，或目闭神昏，眩晕颠仆，闷乱搐搦者，此属痰，宜大黄甘草汤，使上吐下泻，以涤其痰。
（乙）报点至起胀之变化：点红而稀，顶尖而碍手，胀则头圆根红，光泽绽实，自属顺症。若（一）痘初发热即报点如丹，身热如烙，渐至干焦紫黑，烦躁闷乱，唇焦口臭者，虽在冬月，亦须大剂白虎化斑汤，石膏非数两不应。（二）身无大热，见点细如粟米，气怯无力，目闭无神，面色及口唇反鲜泽娇艳，光彩倍常，此气虚无阳，肺胃之精华涣散于外，宜重用人参二三两，生黄芪两许，以升麻、五味，续续灌下，或保元汤加减。（三）痘疹腹痛，多属食积，宜透表之中佐以消积。若腹胀泄泻，不可骤止，又不可任其多泻，只宜和之。（四）杂痘一齐涌出者，水杨柳、桃枝、槐枝各三条，同紫背浮萍，煮汤遍洗，即出痘毒，而正痘现。（五）痘疮红紫干滞，黑陷焦枯者，此表热而实，大便秘结，小便赤涩，身热鼻干，唇燥烦渴者，此里热而实，治宜凉血解毒，用紫草、红花、连翘、牛蒡、木通、蝉蜕、荆芥，或芩、连之属。如表热者，则宜清凉解表而分利次之。里热者，重于解毒而兼清凉。（六）痘证见点，三四日隐于肌肤不长发者，此气血虚也，宜快斑汤，或透肌散催之。至身面俱起，四肢不能起发者，宜桂枝汤加防风、黄芪。（七）痘虽长起，而颜色淡白顶陷者，此气虚也，宜参芪内托散加糯米。若虽不白，亦不红活而顶陷者，此血虚也，宜四物合保元汤。起胀迟迟，浆清不满者宜独参汤。（八）色赤而兼痒，血虚有热也，宜四物汤去生地加犀角、连翘。（九）痘顶色白连肉红肿，而痘反不肿，此毒不能灌注于痘也，宜急用化毒汤加生地、川芎调二宝散救之。（十）色红根散不长发者，此血热而气不相根据，宜大鼠粘子汤加紫草。（十一）热证方形，虚证又现，元气本来虚弱，而毒瓦斯猛烈，以致痘出不快，狂言乱语音，既碍用清凉之药以解毒，又恐犯温补以助火，此为最难措手之候，可急用雄鸡一只，生剖开腹，去肠杂，以烧酒喷之，敷于脐上，其痘自出，其语亦止。若遍身疼痛者，此毒出肾经，用黑大豆一升，煮熟擂敷腰上，即止。此外治之效方也。
I. Origin of Smallpox (Disease)
The ancients said: In ancient times, there was no smallpox; it only appeared around the end of the Zhou Dynasty and the beginning of the Qin Dynasty. This indicates that in ancient times, the Qi of heaven and earth was harmonious and balanced, people's desires were simple and light, so diseases were rare, and even smallpox did not exist. As times changed and deteriorated, the consequences of warfare, floods, and droughts were sufficient to breed epidemic pathogens, while human desires increased daily, further depleting Yuan Qi (Original Vital Energy) and allowing latent pathogenic factors to accumulate within the Zang-Fu organs. These two factors interacting caused diseases to become increasingly complex, with smallpox being one of them. Investigating the origin of smallpox, it stems from congenital factors. Generally, at the time of conception, the residual toxic fire from parental sexual desire is stored deep within the fetus's bone marrow. When triggered by the epidemic toxins circulating in the seasons, it manifests externally. Therefore, if the mother observed prenatal education during pregnancy, even if the child develops smallpox, it is generally easy to treat. Conversely, if the mother indulged excessively in sexual activity during pregnancy, the child is most likely to die when developing smallpox. However, ancient smallpox cases were often severe and concurrent because, having both internal latent toxins and external epidemic toxins, their combination made the illness necessarily severe. Thus, the later invention of variolation aimed to guide the congenital toxin outwards, ensuring it did not merge and trigger simultaneously with the epidemic toxin. This approach effectively reduced the severity of the disease, which was a benevolent intention. The method involved inserting smallpox material into the nose. Since the nose is the orifice of the Lung, the Qi of the material enters internally. After a few days, its Qi transmits from the Lung to the Heart (Heart governs Blood vessels), from the Heart to the Spleen (Spleen governs muscles), from the Spleen to the Liver (Liver governs sinews/tendons), and from the Liver to the Kidney (Kidney governs bone marrow). Upon reaching the Kidney, it stirs the latent congenital toxin, which gradually reveals itself, transmitting from the Kidney to the Liver, then Spleen, Heart, and Lung, until the pustules appear. This is variolation, distinguishing it from natural smallpox triggered by epidemic pathogens. Since the invention of variolation, more patients have survived, and it has been widely practiced for a long time, praised for its convenience. However, there were still shortcomings: although the toxicity was lighter, the pustules were densely distributed all over the body, resembling natural smallpox. Weak individuals had difficulty raising the pustules (Qi Zhang) or filling them with pus (Jiang Guang). Treatment was often complicated, requiring strict avoidance of wind and cold and hundred-day recuperation, which was burdensome. During the pus-filling stage, even slight negligence could result in scarring (facial pockmarks). Consequently, this method faced gradual obsolescence. Coincidentally, Western cowpox vaccine was introduced to China. Used to induce immunity, it only causes pustules at the inoculation site, posing no danger during eruption. Besides dietary restrictions, there are no other heavy taboos, making it popular worldwide. Today, natural smallpox is rarely seen, undoubtedly due to the merit of the cowpox vaccine.
II. Pathology of Smallpox
The eruption of smallpox serves as a pathway for the body to excrete pathogenic toxins. Thus, its eruption moves from the interior to the exterior, similar to measles (Sha Zhen). The difference lies in the depth of the latent toxin: the toxin in measles is shallow, whereas the toxin in smallpox is deeply hidden in the bone marrow and originates from the Kidney. Because it originates from the Kidney, it often involves the Yuan Yang (Primary Fire) within the Kidney. If Yuan Yang is deficient, the pustules lack the supportive force to erupt properly, often leading to unfavorable outcomes (Ni Zheng). This explains the saying "Measles prefers cooling, while smallpox prefers warmth." However, when pathogenic toxins are vigorous, consuming Yin fluids, nothing is more severe than this. Hence, smallpox is known as difficult to treat because balancing cold and warm medications is challenging. Furthermore, since smallpox begins in the Kidney and ends in the Lung, affecting the whole body, almost every aspect is relevant. Therefore, treating smallpox emphasizes timing. Based on seasonal changes, methods such as releasing the exterior, clearing heat, and transforming dampness must be adjusted instantly to be effective. This complexity is why physicians throughout history prioritized eradicating smallpox. With the modern invention of cowpox vaccination, the goal of eliminating smallpox can be considered achieved. Some argue that since smallpox is a major childhood disease, people should avoid it during epidemics, and voluntarily contracting it via vaccination seems unnecessary. They fail to understand that the brilliance of cowpox lies precisely in voluntary administration before exposure. It is like catching a thief before they gain support, or removing weeds before they spread. Natural smallpox is dangerous because the toxin erupts late with severe consequences; cowpox is mild because the toxin erupts early with shallow consequences. Additionally, cowpox inoculation is typically done on the arms and legs, which is scientifically sound. The arms contain the Hand-Shaoyang meridians, and the legs contain the Foot-Shaoyang meridians. Shaoyang governs the pivot mechanism, facilitating the internal transmission of the vaccine Qi efficiently. Similarly, the expulsion of toxins is most efficient here. Thus, the entire cowpox process takes about ten days. However, after widespread vaccination, some vaccinated individuals still contracted natural smallpox. This occurs because the latent toxin was not fully cleared, differing from unvaccinated cases. Since the pathogen exits via the traditional pathway, elimination is easier, requiring less supportive warming. The treatment principle should lean slightly towards cooling or acrid-dispersing methods, avoiding warming tonification. Treatment methods for smallpox have thus undergone significant changes, which must be understood.
III. Symptoms of Smallpox
At the onset of smallpox, there are no obvious signs initially. As it is about to erupt, there may be slight aversion to cold, fever, or fever with cough. At this stage, one must check if the ears, nose tip, buttocks (Kao), and feet are cold. Coldness in these areas indicates smallpox. Checking for red threads protruding behind the ears and a pulse that is large, stringy, and rapid suggests the rash is about to appear (Bao Dian - reporting spots). Initially, small red spots appear. Within a few days, spots report. Early spots often appear first in the chest hollow or on the face, with patterns appearing between the cheekbones. Coldness specifically in the ears, buttocks, and middle finger are characteristic features of smallpox. Other common signs include tired eyes with watery discharge, yellow sclera or red eyelids, frequent startle during sleep, dark urine, and constipation. Causes include epidemic infection, wind-cold injury, dietary indigestion/vomiting, or fright/falls. This covers the general onset of smallpox. Onset usually reports spots after 3-5 days, followed by raising (Qi Zhang) after another 2-3 days. Raising means particles rise sequentially, with swelling at the base and skin boundary, preparing for pus formation. After three days of pus filling, toxins are transformed, leading to scabbing and recovery. This outlines the progression. However, severity varies (favorable vs. critical), changing unpredictably. A case may be favorable during fever but critical during spot reporting, or favorable during reporting but critical during raising, etc. Clinical judgment is essential. Generally, during fever, if heat is not burning, or there is aversion to cold/chills, normal bowel/bladder function, ability to eat, slight rough breathing without wheezing, and no abdominal pain, it is a favorable syndrome. If high fever burns to touch, wheezing with rebellious Qi, delirium/restlessness, abdominal distension/constipation, or slight aversion to cold with loose stools, fatigue, and poor appetite, it is a severe syndrome. If fever accompanies scorched skin, foul breath,急促 breathing/hoarseness, blue face/head shaking, vomiting/upward staring eyes, or intermittent spots, it is a critical syndrome. During spot reporting, if bases are red and round, tips are raised and rough to touch, sparse on head/face but distributed on limbs, with alternating mild heat and coolness, and regular bowel/bladder function, it is favorable. If spots are pale or bright red like cinnabar, fever is burning, or tips are white like millet grains with non-red bases, thin skin, abdominal/lower back pain, and diarrhea, it is severe. If spots erupt densely and brightly red, or are dark/dull, dry hair/skin, or appear on eyelids, lips, genitals, tongue, throat, chest, or back, or if muscles feel bruised with coma/anorexia, it is critical. During raising, if fever comes in waves, raising gradually, with round heads, red bases, and lustrous firmness, facilitating pus filling, it is favorable. If body is cool/not hot, raising is hidden/difficult, skin is thin/shiny, bases are not red, or accompanied by diarrhea/mild itching, it is severe. If raising shows white color/thin skin, easily broken, no redness at base, or high fever with purple/black pustules that do not rise, or facial edema preventing rising, it is critical. During pus filling, following maximum raising, pits fill, flat tops become elevated, full and lustrous, sequential filling, yellow bean-like color, normal bowels/bladder, and warm limbs indicate favorability. If bases are red but not moist, incomplete filling, diarrhea, dense/purple/non-elevating spots, sudden phlegm-wheezing during filling, or irritability/insomnia, it is severe. If pus contains clear water, shrinks/dries up, bases are purple/stagnant, body fills but head does not, or cough/wheezing/irregular bowels occur, it is critical. During scabbing, after full pus filling, color becomes mature/aged, starting from philtrum/face, moving to chest/abdomen/legs. No high fever, no aversion to cold, increased appetite, and regulated bowels/bladder indicate favorability. If body is heavy/feverish, difficult scabbing, blood-colored scabs, ulceration/difficulty healing, or chattering convulsions, it is critical. This summarizes favorable vs. critical differentiation. Post-recovery, Yuan Qi is depleted, requiring immediate regulation and tonification. Taboos during smallpox are stricter than measles; negligence leads to complications. These are noted below.
Modern cowpox symptoms are mild. One to two days post-inoculation, local redness/swelling appears, gradually raising and filling with pus. By day 10, pus is full, drying and scabbing by day 20. Fever may vary but lasts no more than a week. The best age for vaccination is 6-10 months, with boosters every 3-5 years. Care includes keeping the site clean, preventing rupture, and dietary restrictions to prevent secondary infection and ensure efficacy.
IV. Treatment Methods for Smallpox
For the first 1-2 days of fever, release the exterior to facilitate eruption. Days 3-5: clear heat and detoxify to promote growth. Days 6-9: warm and tonify Qi and Blood to aid pus filling. Days 10-12: clear, drain, and astringe to promote scabbing. This is the standard method. However, timing varies; early eruptions need no strong exterior-releasing, while late eruptions rely on penetrating and supporting. Do not use cooling herbs before all spots appear, as cold causes stagnation. Do not use warming tonics before heat-toxin is resolved, as warmth may cause accumulation and failure to form pus. Generally, red face, warm body, firm stool, and clear mind are auspicious. For favorable cases, minimal medication is needed. Mild exterior release initially allows spots to emerge sparsely. Then, slight clearing transforms internal toxins, ensuring proper raising. Once pus fills, warming tonics are unnecessary unless sinking occurs, requiring supportive tonification. Unred/blue/white face, subdued fever, loose stool, or fiery red face, burning fever, constipation, and delirium are severe. For pale face/loose stool, balance warming/tonifying with dispersing. For red face/constipation, balance purging/clearing blood. This is the general approach.
Variations in early stages:
(1) Sudden high fever, restlessness, spots appearing immediately upon fever indicates excess toxin. If stool is hard, use Liang Ge San to purge. If loose, combine acrid-cool and acrid-warm formulas.
(2) Joint/bone pain during fever indicates Six Evils invasion; use exterior-releasing and penetrating agents.
(3) Generalized itching indicates deficient exterior exposed to wind-cold, blocking toxin exit; use Gui Zhi Tang plus Huang Qi, Fang Feng, Bai Zhi, Chan Tui.
(4) Shivering/aversion to cold indicates weak Qi failing to expel pathogens; use Sheng Ma Tang plus Ren Shen, Shan Jia, Gui Zhi, Fang Feng.
(5) Abdominal pain/thirst indicates blocked toxin and steaming heat; use Xuan Ming Fen mixed with honey or Liang Ge San. Relief follows bowel movement.
(6) Lower back pain is critical, indicating pathogen reversing inward. Use Shi Gao, Ren Shen, tea, Xuan Ming Fen, and honey, or Baixiang Wan. Mild pain in deficiency is excluded.
(7) Vomiting/diarrhea indicates toxin dispersing. If spirit remains good and symptoms stop quickly, it is auspicious. Persistent vomiting/diarrhea after spots: Si Ling San plus Zhi Ke, Ju Pi, Shan Zha. For deficiency: Yi Gong San plus Huo Xiang, Mu Tong.
(8) Purple-black cracked lips/mouth indicates toxin attacking Spleen; use Xi Jiao Xiao Du Yin plus Shi Gao, Xuan Shen.
(9) Grinding teeth/wandering eyes indicates excessive Heart heat; use Dao Chi San plus Huang Lian, Chi Shao. If grinding/coma indicates Liver wind-heat; use Qiang Huo Tang plus Qing Pi, Chai Hu.
(10) Voice changes: use Xiao Du Yin plus Lian Qiao, Jie Geng. Sore throat: Gan Jie Tang plus Niu Bang Zi.
(11) Dark scanty urine indicates heat-toxin entering Bladder; use Dao Chi San plus Jing Jie, Lian Qiao, Niu Bang Zi.
(12) Epistaxis indicates pathogen exiting via nose. If bleeding persists, use Xi Jiao Di Huang Tang.
(13) No fever: assess deficiency/excess. Deep heat with cold extremities requires cold herbs. Weak Qi failing to penetrate requires Bu Zhong Yi Qi Tang or Bao Yuan Tang.
(14) Spots appearing densely like silkworm eggs on day 1, not rough to touch, or face like rouge/red patches everywhere are untreatable.
(15) Restlessness/vomiting, clear fluid under tongue, silence/sleepiness or agitation, abdominal pain/crying: check for worm signs (blue veins under tongue/black-white spots on lower lip). Use Jiao Mei Wan to lure worms, then Zi Cao Cheng Qi Tang to purge.
(16) Phlegm-wheezing, closed eyes/coma, dizziness/falling, convulsions indicate phlegm. Use Da Huang Gan Cao Tang to induce vomiting/diarrhea to clear phlegm.
Variations from spot reporting to raising:
(1) Spots like cinnabar, burning fever, turning dry/purple-black, restlessness, dry lips/bad breath: despite winter, use large dose Bai Hu Hua Ban Tang with massive Shi Gao.
(2) No high fever, spots fine like millet, weak spirit, closed eyes, overly rosy face/lips indicates Qi/Yang deficiency with scattering essence. Use heavy Ren Shen, Sheng Huang Qi, Sheng Ma, Wu Wei Zi, or modified Bao Yuan Tang.
(3) Abdominal pain indicates food stagnation; add digestion-promoting herbs to exterior-releasing formula. For distension/diarrhea, harmonize rather than abruptly stop or allow excessive loss.
(4) Mixed eruptions: wash with decoction of Willow Peach Branch, Locust Branch, and Zi Bei Fu Ping to eliminate mixed toxins and reveal true smallpox.
(5) Red/purple/dry/black depressed spots with constipation/dark urine/hot nose/dry mouth indicate interior/excess heat. Use Zi Cao, Hong Hua, Lian Qiao, Niu Bang, Mu Tong, Chan Tui, Jing Jie, or Huang Qin/Huang Lian. Exterior heat: clear exterior and separate turbidity. Interior heat: focus on detoxifying and clearing.
(6) Spots hidden for 3-4 days indicate Qi/Blood deficiency. Use Kuai Ban Tang or Tou Ji San. If limbs fail to raise, use Gui Zhi Tang plus Fang Feng, Huang Qi.
(7) Pale/depressed spots indicate Qi deficiency; use Shen Qi Nei Tuo San plus Nuomi. Non-red/depressed spots indicate Blood deficiency; use Si Wu Tang combined with Bao Yuan Tang. Delayed raising/clear pus: use Du Shen Tang.
(8) Red/itchy spots indicate Blood deficiency with heat; use Si Wu Tang minus Sheng Di plus Xi Jiao, Lian Qiao.
(9) White top with swollen flesh but non-swollen pustule indicates toxin failing to fill; use Hua Du Tang plus Sheng Di, Chuan Xiong, mixed with Er Bao San.
(10) Red/spread bases failing to raise indicate Blood heat with Qi disconnect; use Da Rat Niu Zi Tang plus Zi Cao.
(11) Complex heat/deficiency with violent toxin causing slow eruption and delirium: difficult to treat. Avoid cooling (may hinder) and warming (may fuel fire). Emergency measure: slice live rooster, apply to navel with liquor to draw out toxin and stop delirium. Body pain indicates Kidney meridian toxin; apply boiled black soybean paste to lower back. These are external remedies.