表虚者，则痘易出而难靥，表实者，则痘难出而易收，里实则出快而轻，里虚则发
迟而重，表实里虚，则陷伏倒靥，里实表虚，则发慢收迟，故痘灰白不红，绽不起，
发不光泽，出不快，昏暗陷顶，根窠不红者，皆表寒而虚，如二便清利，身体不凉，
手足口气俱冷不渴，少食唇白，涕清饮食不化者，皆里寒而虚。此是表里虚寒之症，宜
急温脾胃，补气血，当用参 四物木香肉桂等药，以助灌脓收靥。然表虚者，以补为
主，而补血次之，盖血之载毒于外，必由于气以拘血，苟非气之制血，则血必泛滥不附
毒、斯下陷内攻之患立至矣。里虚者，于补血之中，而兼补气，苟能补气，则脾胃乃
壮，卫气随畅，自然起发，在后必无陷伏之忧，既能补血，则气周流，送毒出尽，不致
凝滞，在后必无痒塌之患，然补气之中，更宜加以行气，则气不滞，补血之中，又宜兼
以活血，则血不瘀，盖欲血流行而不滞，必籍气以旋运也。更若红紫干滞，黑陷焦枯
者，皆表热而实，若大便秘结，小便赤涩，身热鼻干，气热唇燥，烦渴者，皆里热而
实，此表里实热之症，急宜凉血解毒，当用化毒汤，红花紫草生地蝉蜕，黄连荆芥之
类。但表热者宜清凉解表，而分利次之，里热者当重于解毒，而兼清凉，若在二三日之
前，热毒甚者，则微下之亦可，盖凉血则无红紫，解毒则免黑陷，表虚不补，即成外
剥，里虚不补，即成内攻。表实过补，则不结靥，里实过补，则发痈毒。然有似虚而
实，有似实而虚，如痘不起发，色不红活，固似虚征，若烦燥渴热二便俱难，此又当为
实治，所以痘症变迁无常，若色一转，又当变通不可拘于一定也。
夫痘疮之出，根于里而发于表，故表里之虚实寒热，不可不辨也。有虚而寒，有虚
而不寒，然未有寒而不虚者尤不可不知也，盖脾为肌肉之主，肺为皮毛之合，凡若恶
寒，或自汗恶风，寒热往来，面目青白，怠惰嗜卧，肌肉不密，手足冷而身体凉静，精
神怯弱，及疮色灰白，陷伏，倒陷，痒塌并疮不起，色不光泽，根窠不红，及身有寒惨
凌振之状，兼脉浮细而虚者，此皆脾弱肺亏，为表虚寒也。治宜温补其表。如精神怠慢，
乳食不化，饮食少进，泻泄伤渴，腹胀气促，或大便泻青，小便清白，手足厥冷，
唇面清白，欲饮不饮，身体凌振，足冷过膝，疮色灰白，寒惨不起，神思昏倦，口鼻
气冷，痘不起发，其脉沉细而迟者，此里虚寒也。宜温补其里。如身体壮热，或翕翕发
热往来不定，如扇之所复，疮色绽实，头与身背肌肉疼痛，眼黄鼻塞痘色干燥，而焦紫
不能起发，暨夫身发火热，齐涌红紫，色干燥痒，舌上有苔，面赤唇红，毛焦肤燥，手
足俱热，其脉浮数，而实大者，此肿热肺盛，为表实热也。治宜散表除热，切忌黄
实腠之药。倘若饮食如故，二便如常，精神爽快，疮色起发和顺者，此里实之得中者
也。不必施治。若蒸蒸作热，手足如烙，小便短赤，大便秘结，疮色焦紫，喜居冷处，
口气热而作渴，舌燥干而喘促。惊悸烦燥痰壅，咳嗽气粗，吐利大渴或二便不通，唇紫
而赤，谵语狂乱，胸膈饱闷，肚腹膨胀，甚或上下失血，其脉沉实，而数者，此乃里实
热之过甚者也。必致燥其阴血，治宜急与活血凉血，清热解毒，切忌参术助脾，补气之
剂。然有痘疮自始出一日，以至十日身热不退，且又精神清爽，乳食如常，大便黄稠，
小便清利，其疮光泽，起发肥满，根窠红润，易出易靥者，是表里俱实之症，虽热亦
无损伤，俱若小便赤涩者，急微利之，盖实热有余之症，惟恐蕴热发搐耳。然凡初热宜
乎表虚，则痘易出而疏朗匀净。故用苏葛以开腠理，既出之后，又宜表实，则易起宜
回，而无倒陷痒塌之变，故用参 以实肌表，然参 用于起壮之时，则 宜多而参宜
少，以补表重而补中轻也。若用之于结靥之际，则参宜多而 宜少，以补中先而补表次
也。但痘疮以头面为主，故用参 而必佐以川芎防风等品者，是欲引其上行之义耳。然
此仅言夫表里正气之虚实也。又若痘出稀疏，神安色悦，根据期起灌，诸候如常者，此
为毒之虚也，宜顺之而勿治，若齐涌稠密， 肿红紫，身发火热疼痛呼号者，此为毒之
实也。宜解毒之药因证治之。丹溪曰∶虚者益之，实者损之，寒者温之，热者清之，治
痘之大要，舍是四者，无治法矣。发热之初，急宜表散，要在表热尽退为佳，既出之
后，随证温凉，务在解热消毒，调气活血，使荣卫和畅，则无壅滞陷伏之患，又必谨避
风寒，绝戒房事，调节饮食，禁止秽气，自然获吉矣。
表虚的患者，痘疹容易发出但难以结痂愈合；表实的患者，痘疹难以发出却容易收敛。里实则痘疹发出迅速且病情较轻，里虚则痘疹发出迟缓且病情较重。若表实里虚，痘疹会出现内陷伏匿或倒靥（痘疹塌陷）的情况；若里实表虚，则痘疹发出缓慢、收敛也迟，表现为痘色灰白不红、痘粒绽开但不隆起、缺乏光泽、发出缓慢、顶部昏暗凹陷、根部周围不红润，这些都是表寒兼虚的表现。如果大小便清利通畅，身体不凉，手足和口鼻气息都冷且不口渴，食欲少、嘴唇苍白、鼻涕清稀、饮食不消化，这些都是里寒兼虚的表现。这是表里俱虚寒的证候，应当紧急温补脾胃，补益气血，应当使用人参、四物汤、木香、肉桂等药物，以助痘疹灌浆化脓和结痂愈合。然而对于表虚者，治疗以补益为主，补血为辅，因为血液承载毒邪于体表，必须依靠气的固摄作用来约束血液，如果不是气能制约血液，那么血液就会泛滥而不能附着毒邪排出，这样下陷内攻的祸患立刻就会到来。对于里虚者，在补血的同时兼补气，如果能补气，脾胃就会强壮，卫气随之畅通，痘疹自然能够起发，后续必然没有内陷伏匿的忧虑；既然能补血，气就能周流全身，将毒邪送尽，不会导致凝滞，后续必然没有因瘙痒而塌陷的祸患。然而在补气之中，更应加入行气药，使气不滞涩；在补血之中，又应兼用活血药，使血不瘀阻，因为想要血液流行而不停滞，必须借助气的运转力量。如果痘色红紫干枯滞涩，或黑陷焦枯的，都是表热而实；如果大便秘结，小便赤涩，身体发热，鼻子干燥，口气热，嘴唇燥，烦躁口渴的，都是里热而实。这是表里俱实热的证候，应当紧急凉血解毒，应当使用化毒汤，以及红花、紫草、生地、蝉蜕、黄连、荆芥之类的药物。但是表热者适宜清凉解表，分利湿热为辅；里热者应当重在解毒，兼用清凉之法。如果在发病二三日之前，热毒严重的，轻微通下也可以，因为凉血就不会出现红紫，解毒就能避免黑陷。表虚如果不补益，就会变成外剥（痘疹破溃）；里虚如果不补益，就会变成内攻。表实如果过度补益，就不能结痂；里实如果过度补益，就会引发痈毒。然而有看似虚证其实是实证，也有看似实证其实是虚证。例如痘疹不起发，颜色不红活，固然像是虚证的征象，但如果伴有烦躁、口渴、发热、大小便困难，这又应当作为实证来治疗。所以痘疹病症变化无常，如果颜色发生变化，就应当变通处理，不可拘泥于固定的法则。
痘疮的发生，根源在于里，表现于表，所以表里的虚实寒热，不可不辨别。有虚而寒的，有虚而不寒的，但没有寒而不虚的，这一点尤其不可不知道。大概脾主肌肉，肺合皮毛。凡是恶寒，或者自汗、怕风，寒热往来，面目青白，怠惰嗜卧，肌肉疏松，手足冷而身体凉静，精神怯弱，以及疮色灰白、内陷伏匿、倒陷、瘙痒塌陷并痘疹不起发、颜色无光泽、根部不红，以及身体有寒冷战栗颤抖的样子，兼见脉浮细而虚的，这都是脾弱肺亏，属于表虚寒。治疗应当温补其表。如果精神怠慢，乳汁食物不消化，进食少，腹泻伤津口渴，腹胀气促，或者大便泻青色，小便清白，手足厥冷，唇面苍白，想喝水却不怎么喝，身体战栗颤抖，脚冷过膝，疮色灰白，寒冷不起，神思昏倦，口鼻气息冷，痘疹不起发，其脉沉细而迟缓的，这是里虚寒。应当温补其里。如果身体壮热，或者翕翕发热、寒热往来不定，像扇子扇风一样忽冷忽热，疮色绽实，头与身背肌肉疼痛，眼黄鼻塞，痘色干燥而焦紫不能起发，以及身体发热如火，齐涌红紫，颜色干燥瘙痒，舌上有苔，面赤唇红，毛发焦枯皮肤干燥，手足都热，其脉浮数而实大的，这是肿热肺盛，属于表实热。治疗应当疏散表邪清除热邪，切忌使用闭塞腠理的药物。倘若饮食如常，大小便正常，精神爽快，疮色起发和顺的，这是里实之中得宜的状态，不必施治。如果蒸蒸发热，手足像烙铁一样烫，小便短赤，大便秘结，疮色焦紫，喜欢待在凉快地方，口气热而口渴，舌燥干而喘促，惊悸烦躁痰多壅塞，咳嗽气粗，呕吐腹泻大渴或者大小便不通，嘴唇紫赤，胡言乱语狂乱，胸膈饱闷，肚腹膨胀，甚至上下出血，其脉沉实而数的，这是里实热过度的表现。必然会耗伤阴血，治疗应当紧急给予活血凉血，清热解毒，切忌使用人参、白术等助脾补气的药剂。然而有痘疮从刚出一天到十天，身体发热不退，而且精神清爽，吃奶吃饭如常，大便黄稠，小便清利，其疮光泽，起发肥满，根部红润，容易发出也容易结痂的，这是表里俱实的证候，虽然有热也没有损伤。如果小便赤涩的，应当紧急轻微通利，因为实热有余的证候，只担心蕴热引发抽搐罢了。然而凡初起发热时适宜表虚，则痘疹容易发出且疏朗匀净。所以用苏叶、葛根来开泄腠理，既发出之后，又适宜表实，则容易起发和回缩，而没有倒陷瘙痒塌陷的变化，所以用人参、黄芪来充实肌表。然而人参、黄芪用于起发壮实的时候，则黄芪宜多而人参宜少，因为此时重在补表而轻于补中。如果使用在结痂之际，则人参宜多而黄芪宜少，因为此时先补中而后补表。但痘疮以头面部为主，所以用人参、黄芪而必须佐以川芎、防风等品，这是想要引导药力上行的意思。然而这仅仅说的是表里正气的虚实。另外如果痘出稀疏，神安色悦，按期起灌，诸症如常的，这是毒邪的虚，应当顺应它而不必治疗；如果齐涌稠密，肿胀红紫，身体发热疼痛呼号叫喊的，这是毒邪的实，应当用解毒药物根据症状治疗。丹溪说：虚者补益之，实者损削之，寒者温之，热者清之，治疗痘疹的大要，除了这四者，就没有治疗方法了。发热之初，紧急应当发散表邪，关键在于表热完全退去为佳，既发出之后，随证温凉，务必在解热消毒，调气活血，使营卫和畅，就没有壅滞陷伏的祸患，又必须谨慎避开风寒，绝对戒除房事，调节饮食，禁止秽气，自然能获得吉祥。
For patients with **Biao Xu (Exterior Deficiency)**, the smallpox rash is easy to erupt but difficult to crust over; for those with **Biao Shi (Exterior Excess)**, the rash is difficult to erupt but easy to resolve. If **Li Shi (Interior Excess)** is present, the eruption is rapid and the condition is mild; if **Li Xu (Interior Deficiency)** is present, the eruption is delayed and the condition is severe. If Biao Shi coexists with Li Xu, the rash may sink inward or invert (collapse); if Li Shi coexists with Biao Xu, the eruption is slow and resolution is delayed, manifesting as ashen-white, non-red rashes that spread out but do not elevate, lack luster, erupt slowly, have dark sunken tops, and red roots that are not red. These are all signs of **Biao Han (Exterior Cold)** combined with deficiency. If urination and defecation are clear and smooth, the body is not cold, hands, feet, and breath from mouth and nose are all cold without thirst, appetite is low, lips are white, nasal discharge is clear, and food is undigested, these are signs of **Li Han (Interior Cold)** combined with deficiency. This is a syndrome of **Biao Li Xu Han (Exterior and Interior Deficiency-Cold)**. One should urgently warm the Spleen and Stomach, tonify Qi and Blood, and use herbs such as Renshen (Ginseng), Siwu Tang (Four Substance Decoction), Muxiang (Aucklandia Root), and Rougui (Cinnamon Bark) to assist in pus formation and crusting. However, for Biao Xu, treatment focuses on tonification, with blood tonification secondary. Since blood carries toxins to the exterior, it must be constrained by Qi. If Qi does not control the blood, the blood will flood and fail to attach to the toxin, leading immediately to the danger of sinking inward and attacking internally. For Li Xu, while tonifying blood, one should also tonify Qi. If Qi is tonified, the Spleen and Stomach become strong, Wei Qi flows smoothly, and the rash naturally rises, eliminating the worry of sinking inward later. Since blood is tonified, Qi circulates, sending toxins out completely without stagnation, eliminating the worry of itching and collapse later. However, within Qi tonification, Qi-moving herbs should be added to prevent Qi stagnation; within Blood tonification, Blood-activating herbs should be added to prevent Blood stasis, because for Blood to flow without stagnation, it relies on the movement of Qi. If the rash is red-purple, dry, and stagnant, or black-sunken and scorched, these are signs of **Biao Re (Exterior Heat)** and Excess. If there is constipation, dark and scanty urine, fever, dry nose, hot breath, dry lips, irritability, and thirst, these are signs of **Li Re (Interior Heat)** and Excess. This is a syndrome of **Biao Li Shi Re (Exterior and Interior Excess-Heat)**. One should urgently cool the Blood and resolve toxicity, using Huadu Tang (Toxin Resolving Decoction) and herbs like Honghua (Safflower), Zicao (Arnebia Root), Shengdi (Rehmannia Root), Chantui (Cicada Slough), Huanglian (Coptis Rhizome), and Jingjie (Schizonepeta). For Biao Re, cooling and releasing the exterior is primary, with promoting diuresis secondary. For Li Re, resolving toxicity is primary, with cooling secondary. If before the second or third day, heat-toxin is severe, mild purgation is acceptable. Cooling Blood prevents redness and purple discoloration; resolving toxicity prevents blackening and sinking. If Biao Xu is not tonified, it becomes external peeling; if Li Xu is not tonified, it becomes internal attack. Over-tonification of Biao Shi prevents crusting; over-tonification of Li Shi causes carbuncles and sores. However, there are cases that appear deficient but are actually excess, and vice versa. For example, if the rash does not rise and color is not red and vibrant, it appears deficient; but if accompanied by irritability, thirst, fever, and difficulty in urination and defecation, it should be treated as excess. Thus, smallpox symptoms change unpredictably; if the color changes, treatment must adapt and not be rigid.
The eruption of smallpox originates in the Interior and manifests in the Exterior, so the Excess/Deficiency and Cold/Heat of the Exterior and Interior must be distinguished. There is Deficiency with Cold, and Deficiency without Cold, but never Cold without Deficiency, which is crucial to know. The Spleen governs muscles, and the Lung governs skin and hair. Symptoms such as aversion to cold, spontaneous sweating, aversion to wind, alternating chills and fever, blue-white face, lethargy, desire to sleep, loose muscles, cold hands and feet, cool and quiet body, weak spirit, gray-white rash, sinking/inversion, itching/collapse, failure to rise, lack of luster, non-red roots, and body trembling with cold, combined with a floating, fine, and deficient pulse, indicate Spleen weakness and Lung deficiency, constituting Biao Xu Han (Exterior Deficiency-Cold). Treatment should warm and tonify the Exterior. If spirit is sluggish, milk/food indigestion, poor appetite, diarrhea causing thirst, abdominal distension and shortness of breath, green stool, clear urine, cold extremities, pale lips/face, desire to drink but little intake, body trembling, cold feet above knees, gray-white cold rash, mental fatigue, cold breath, rash failing to rise, and a deep, fine, slow pulse, this is Li Xu Han (Interior Deficiency-Cold). Treatment should warm and tonify the Interior. If there is high fever, intermittent fever like fan-blowing, firm rash, pain in head/back muscles, yellow eyes, nasal congestion, dry/scorched-purple rash unable to rise, body burning with red-purple surge, dry/itchy rash, tongue coating, red face/lips, scorched hair/dry skin, hot extremities, and a floating, rapid, large, and excess pulse, this is swelling-heat and Lung excess, constituting Biao Shi Re (Exterior Excess-Heat). Treatment should disperse the Exterior and remove heat; strictly avoid herbs that close the pores. If diet is normal, excretion is normal, spirit is bright, and rash rises harmoniously, this is a balanced state of Interior Excess, requiring no treatment. If there is steaming fever, scalding hands/feet, short dark urine, constipation, scorched-purple rash, preference for cool places, hot breath/thirst, dry tongue with panting, palpitations, irritability, phlegm obstruction, cough with rough breathing, vomiting/diarrhea with extreme thirst, urinary/fecal retention, purple-red lips, delirium, chest fullness, abdominal distension, even bleeding from upper/lower orifices, and a deep, solid, rapid pulse, this is excessive Interior Excess-Heat. It will consume Yin-Blood. Treatment should urgently activate and cool Blood, resolve heat, and detoxify; strictly avoid tonifying herbs like Renshen (Ginseng) and Baizhu (Atractylodes Macrocephala Rhizome) that aid the Spleen and tonify Qi. However, if from day one to ten of eruption, fever persists but spirit is clear, diet is normal, stool is yellow/thick, urine is clear, rash is lustrous, plump, with red roots, easy to erupt and crust, this is Biao Li Shi Re (Exterior and Interior Excess-Heat). Although there is heat, it causes no damage. If urine is dark/scanty, mild purgation is urgent, as excess heat-toxin risks triggering convulsions. Initially, Biao Xu allows easy, neat eruption; thus, Su Ye (Perilla Leaf) and Gegen (Pueraria Root) open the pores. After eruption, Biao Shi facilitates rising and resolving, preventing inversion/collapse; thus, Renshen (Ginseng) and Huangqi (Astragalus Root) fortify the muscle-exterior. During the rising phase, Huangqi should be more than Renshen to prioritize exterior tonification over middle jiao. During crusting, Renshen should be more than Huangqi to prioritize middle jiao over exterior. Since the face/head is primary, adding Chuanxiong (Ligusticum Rhizome) and Fangfeng (Saposhnikovia Root) guides the medicine upward. This discusses only the Excess/Deficiency of righteous Qi. If rash is sparse, spirit calm, color pleasant, rising/crusting on schedule, symptoms normal, this is Deficiency of Toxin; follow nature without treating. If rash is dense, swollen red-purple, body burning/painful/wailing, this is Excess of Toxin; treat with detoxifying herbs according to symptoms. Danxi said: Tonify the deficient, reduce the excess, warm the cold, clear the heat. These four are the essentials of smallpox treatment. At initial fever, urgent dispersal is needed until exterior heat subsides. After eruption, adjust warmth/coolness, resolve heat/toxin, regulate Qi/Blood, harmonize Ying and Wei, avoid wind-cold, abstain from sex, regulate diet, avoid foul odors, and auspicious results will follow.