夫汗下二举，乃不得已之所投，如少误焉，贻害不浅。如痘症本稀，原无闭塞，表
热不快之症，而妄用重药以发之，则在后必成斑烂音哑，皮薄痒塌，或为虚脱者有矣。
如气血本和，原无便闭、热毒、紫黑之症，而妄用重药以下之，则在后必成陷伏不起，
胃弱灰白，或变虚羸腹胀者有矣。此皆妄汗妄下之过也，可不慎欤！然痘亦有当微汗微
下者，言微者恐其过也，如表热方炽，红点未见之先，影色不出，烦燥腮红，起不活动
者，则用轻扬之剂，微开腠理，使痘易出。况火郁则升之，以减其盛势也，其剂如升麻
葛根汤、参苏饮之类。若既见红点，则忌干葛，恐疏散太过，遂致成虚，根窠易塌，表
实者用亦无妨。更有当下之症，而不下之。则在后必成紫黑而壅毒热结，血枯者又为失
下之患矣。是以痘未出时，脉数洪大。小便赤涩，大便闭结，气粗腹胀，唇燥烦渴者，
此是热毒壅盛，而不得泄，宜微下之，使内元阻滞，荣卫升降，则痘出自顺矣。然痘疮
首尾无忌症，慎勿轻为汗下，恐元气一耗，则浆无自而成，后必为患矣。
夫不知虚实者，不可以为工。《经》曰∶无实实。无虚虚。故虚实不分，不可不知
也。《经》曰∶必先度其形之肥瘦，以调其气之虚实，以此形体别虚实也。又曰∶谷盛
气盛，谷虚气虚，此以饮食，别虚实也。又曰∶脉实血实，脉虚血虚，此以脉别虚实
也。又曰∶邪气盛则实，精气夺则虚，此以邪正别虚实也。大抵实者邪气实，虚者正气
虚，《经》曰∶邪之所凑，其气必虚，实而不去，其病则实是也。又云∶五实死者。谓
邪气之实也。为虚死者，谓正气之虚也。凡疮痘之症，其人形体肥健，饮食能多，六脉
洪实，素无疾病，大便如常，疮色红润者，此表里正气俱实也，不须服药。若形体羸
瘦，素多疾病，饮食减少，六脉微弱，吐利频频，疮色红润者，此表里正气俱虚也，治
宜温补之法。如疮势太盛， 肿痛胀，大热不退，烦渴昏睡，大小便秘者，此表里邪气
俱实也，治宜凉泻之法。如疮本稠密， 发红活，而吐利不食者，此表实里虚也，宜补
于中而加解毒之药。如疮色淡白，发不透满，大小便闭结，饮大嚼者，此里实表虚
也，宜于解利中而加升发之药。如诸痛为实，然疮痛者邪气实也，当活血以开其郁。
至若痛如刀剜，闷乱大叫者勿治。诸疡为虚，然疮疡者，正气虚也，当补气以燥其
湿。至若爬搔不定，破烂皮脱者勿治。灰白者，气虚也，参 之功为大，干燥者血虚
也，归芎之力宜多。虚则补之，实则泻之，中病即已，无过其治，此治之权衡也。若本
虚而反泻之，则正气益虚，或为吐利，或为厥逆，是皆泻之过也。《经》曰∶毋致邪，
毋失正，绝人长命，此之谓欤。
发汗和攻下这两种治法，是在不得已的情况下才使用的，如果稍微有误，留下的危害就不浅了。例如痘症本来稀疏，原本没有闭塞不通的情况，也没有表热不快的症状，却妄用重药来发汗，那么后来必定会形成斑烂、声音嘶哑、皮肤薄而瘙痒塌陷，或者出现虚脱的情况。如果气血本来调和，原本没有大便闭结、热毒、紫黑等病症，却妄用重药来攻下，那么后来必定会出现痘疹陷伏不起、胃气虚弱导致痘色灰白，或者变成身体消瘦、腹部胀满的情况。这些都是妄用发汗和攻下的过错，能不谨慎吗！然而痘症也有应当轻微发汗或轻微攻下的情况，说“微”是担心过度。比如表热正盛，红点尚未出现之前，痘影不出，烦躁腮红，痘起后不活动的，就用轻扬的药物，微微开通腠理（皮肤毛孔），使痘疹容易发出。况且火邪郁结应当用升散的方法，以减弱其旺盛的势头，所用的方剂如升麻葛根汤（Shengma Gegen Tang, Decoction of Cimicifugae and Puerariae）、参苏饮（Shensu Yin, Ginseng and Perillae Leaf Drink）之类。如果已经见到红点，就忌用干葛（Puerariae Radix），恐怕疏散太过，导致正气虚弱，痘根容易塌陷，如果是表实证的也可以用，无妨。更有应当攻下的病症，如果不攻下，那么后来必定形成紫黑且壅滞毒热结聚，血枯者又是失于攻下的祸患了。所以痘未发出时，脉象数而洪大，小便赤涩，大便闭结，气粗腹胀，嘴唇干燥烦渴的，这是热毒壅盛而不能宣泄，适宜轻微攻下，使内部元气阻滞解除，营卫（营养与防御之气）升降正常，那么痘疹自然顺遂而出。然而痘疮从头到尾如果没有禁忌症，千万不要轻易使用汗法和下法，恐怕元气一旦耗损，浆液就无法自然生成，后来必定成为祸患。
不懂得辨别虚实的人，不可以做医生。《内经》说：不要使实证更实，不要使虚证更虚。所以虚实不分，是不可不知的。《内经》说：必须先衡量病人的形体肥瘦，来调治其气的虚实，这是通过形体来辨别虚实。又说：饮食多则气盛，饮食少则气虚，这是通过饮食来辨别虚实。又说：脉实则血实，脉虚则血虚，这是通过脉象来辨别虚实。又说：邪气盛则表现为实证，精气亏损则表现为虚证，这是通过邪正盛衰来辨别虚实。大体上，实证是邪气盛，虚证是正气虚，《内经》说：邪气聚集的地方，正气必然虚弱；如果实证不去除，疾病就会表现为实证。又说：五实（心、肝、脾、肺、肾五脏皆见实脉证）会导致死亡，是指邪气的实。因虚而死，是指正气的虚。凡是疮痘的病症，如果病人形体肥壮健康，饮食能多，六脉洪大有力，平素没有疾病，大便正常，疮色红润的，这是表里正气都充实，不需要服药。如果形体消瘦，平素多病，饮食减少，六脉微弱，呕吐腹泻频繁，疮色红润的，这是表里正气都虚弱，治疗宜用温补的方法。如果疮势太盛，肿痛胀大，高热不退，烦躁口渴昏睡，大小便闭结的，这是表里邪气都充实，治疗宜用凉泻的方法。如果疮本稠密，发红活，但呕吐腹泻不能进食的，这是表实里虚，宜在补中的基础上加入解毒的药物。如果疮色淡白，发不透满，大小便闭结，想喝大量水吃大块食物的，这是里实表虚，宜在解利的基础上加入升发的药物。各种疼痛属于实证，然而疮痛是邪气实，应当活血以疏通郁结。至于疼痛如刀割，烦闷混乱大声叫喊的，不要治疗。各种溃疡属于虚证，然而疮疡是正气虚，应当补气以燥湿。至于抓挠不定，破烂皮脱的，不要治疗。痘色灰白的，是气虚，人参的功效很大；干燥的是血虚，当归、川芎的力量应该多用。虚证就补益它，实证就泻除它，中病即止，不要过度治疗，这是治疗的权衡标准。如果本是虚证反而泻它，那么正气更加虚弱，或者出现呕吐腹泻，或者出现四肢厥冷逆乱，这都是泻法的过错。《内经》说：不要助长邪气，不要错过扶正，断绝人的寿命，说的就是这个道理吧。
The application of diaphoresis (sweating method) and purgation are measures taken only when no other options remain. Even a slight error can cause significant harm. For instance, if the variola (smallpox) lesions are originally sparse, with no obstruction, and without symptoms of unrelieved exterior heat, but heavy medicines are recklessly used to induce sweating, it will inevitably lead later to ulcerated lesions, hoarseness, thin and itchy collapsing skin, or even collapse due to deficiency. If the Qi and Blood are originally harmonious, with no constipation, toxic heat, or purple-black discoloration, but heavy medicines are recklessly used to purge, it will inevitably result in the lesions sinking and failing to rise, weak stomach function leading to grayish-white lesions, or transformation into emaciation and abdominal distension. All these are faults of reckless diaphoresis and purgation; how can one not be cautious! However, there are cases where mild diaphoresis or mild purgation is indicated for variola. The term "mild" warns against excess. For example, if exterior heat is intense, before red spots appear, the shadow of the lesions does not emerge, accompanied by irritability, red cheeks, and lesions that do not rise actively, light and ascending agents should be used to slightly open the Couli (skin pores), facilitating the eruption of the lesions. Moreover, since fire stagnation requires ascending methods to reduce its excessive momentum, formulas such as Shengma Gegen Tang (Decoction of Cimicifugae and Puerariae) and Shensu Yin (Ginseng and Perillae Leaf Drink) may be employed. Once red spots have appeared, Puerariae Radix (Gegen) should be avoided, lest excessive dispersion leads to deficiency and easy collapse of the lesion bases; however, if the exterior is solid, its use is permissible. Furthermore, there are conditions requiring purgation; if purgation is neglected, it will later result in purple-black discoloration with stagnant toxic heat accumulation, and blood depletion becomes a consequence of missed purgation. Therefore, before the eruption of variola, if the pulse is rapid and surging, urine is scanty and dark, stool is constipated, breathing is coarse with abdominal distension, lips are dry with irritability and thirst, this indicates abundant toxic heat that cannot vent. Mild purgation is appropriate to resolve internal stagnation, allowing the Ying (Nutritive) and Wei (Defensive) Qi to ascend and descend normally, so that the lesions erupt smoothly. However, if there are no contraindications throughout the course of variola, one must not lightly employ diaphoresis or purgation, lest the Yuan Qi (Original Qi) be depleted, preventing the formation of pus, which will inevitably cause trouble later.
One who does not understand Excess and Deficiency cannot be a physician. The *Classic* states: Do not reinforce an Excess condition, nor deplete a Deficiency condition. Thus, failing to distinguish between Excess and Deficiency is unacceptable. The *Classic* states: One must first assess the fatness or thinness of the body to regulate the Excess or Deficiency of Qi; this distinguishes Excess and Deficiency through physical form. It also states: Abundant food intake correlates with abundant Qi, while deficient food intake correlates with deficient Qi; this distinguishes Excess and Deficiency through diet. It further states: A solid pulse indicates solid Blood, while a deficient pulse indicates deficient Blood; this distinguishes Excess and Deficiency through the pulse. Additionally, it states: When pathogenic factors are abundant, it is Excess; when essential Qi is depleted, it is Deficiency; this distinguishes Excess and Deficiency through the struggle between pathogens and healthy Qi. Generally, Excess refers to the abundance of pathogenic factors, while Deficiency refers to the weakness of healthy Qi. The *Classic* says: Where pathogenic factors gather, healthy Qi must be deficient; if Excess persists without being resolved, the disease manifests as Excess. It is also said that death from "Five Excesses" refers to the Excess of pathogenic factors, while death from Deficiency refers to the Deficiency of healthy Qi. In all cases of sores and variola, if the patient has a robust physique, eats well, has a surging and solid pulse in all six positions, has no prior illnesses, normal bowel movements, and red, lustrous lesions, this indicates that both Exterior and Interior Healthy Qi are solid, and medication is unnecessary. Conversely, if the patient is emaciated, prone to illness, has reduced appetite, a weak and thready pulse in all six positions, frequent vomiting and diarrhea, yet the lesions are red and lustrous, this indicates that both Exterior and Interior Healthy Qi are deficient; treatment should employ warming and tonifying methods. If the sores are too vigorous, with swelling, pain, distension, persistent high fever, irritability, thirst, drowsiness, and constipation of both urine and stool, this indicates that both Exterior and Interior Pathogenic Factors are solid; treatment should employ cooling and purging methods. If the lesions are dense, red, and active, but accompanied by vomiting, diarrhea, and inability to eat, this indicates Exterior Solidity and Interior Deficiency; treatment should tonify the Middle Jiao while adding detoxifying herbs. If the lesions are pale white, fail to erupt fully, accompanied by constipation of urine and stool, and a desire for large amounts of water and substantial food, this indicates Interior Solidity and Exterior Deficiency; treatment should resolve the exterior while adding ascending and dispersing herbs. Generally, pain indicates Excess; thus, sore pain is due to solid pathogenic factors, requiring blood-invigorating methods to relieve stagnation. However, if the pain is like knife-wounding, accompanied by confusion and loud crying, do not treat. Generally, ulcers indicate Deficiency; thus, sore-ulcers are due to deficient healthy Qi, requiring Qi-tonifying methods to dry dampness. However, if there is restless scratching, ulceration, and skin peeling, do not treat. Grayish-white lesions indicate Qi Deficiency, where the efficacy of Ginseng Radix et Rhizoma (Renshen) is paramount; dryness indicates Blood Deficiency, where the power of Angelicae Sinensis Radix (Danggui) and Chuanxiong Rhizoma (Chuanxiong) should be emphasized. Treat Deficiency by tonifying, and Excess by purging; stop when the disease is addressed, avoiding over-treatment; this is the balance of treatment. If a fundamentally Deficient condition is treated with purgation, Healthy Qi becomes further depleted, potentially leading to vomiting, diarrhea, or cold extremities; these are all consequences of excessive purgation. The *Classic* states: Do not exacerbate the pathogen, do not neglect the healthy Qi, thereby cutting short human life—this is what is meant.