如发热四日至五六日后始出者，须审视曾有外感内伤否，盖伤风寒伤食之热，
久而不去，则所蕴疮痘之毒，亦能乘间而出，不可以过期论。惟无内伤外感之因，
一向热而不出，此里气虚，不能驱逐其毒，使之即出，而毒邪得以留连停伏于脏腑
肠胃之间，宜先用托里之剂，令其快出，次以和中之剂多服之，可以无伏无陷无倒
靥，托里宜托里快 汤或十宣散，和中宜四君子汤加黄 ，或保元汤合匀气散
主之。
托里快 汤
当归 黄 川芎 木香 青皮 牛蒡子 紫草 连翘 木通 防风 桂枝 蝉蜕
上锉细。加淡竹叶十片，水煎，温服，无时。
十宣散（一名十奇散，一名托里十补散）
黄 人参 当归（各二钱） 浓朴（姜制） 桔梗（各一钱） 桂心（三分） 川芎 防风
甘草 白芷（各一钱）
上为细末。每服一钱或二钱，木香汤调下。
增损八物汤
人参 黄 白术 甘草 当归 川芎 牛蒡子（炒） 赤芍药 防风 荆芥穗 连
翘桔梗 葛根
上，用水煎服。
匀气散
木香 青皮（各五钱） 山楂肉（二钱半）
上为细末。每服一钱，甘草汤调服。
痘疹之出，自有常期，如过期应出不出，有数证不同不可不辨。如内素实之人，
皮浓肉密，毒瓦斯难于发越，一旦恃其体浓，不怯风寒，又为外邪所袭，或体素弱者，
风寒易感，以致腠理闭密，气血凝涩，故应出不出也，其证头痛，四肢拘急，偎倚
盖覆，常恶风寒，此类宜发之。气强者用双解散，气弱者用参苏饮或惺惺散（俱初热）。
或内虚者，脾弱食少，宜用补脾之剂加行气发表药，四君子汤（不能食）、调元汤（即参 饮）、
（见大法）并加木香、青皮、黄 、桂枝。或脏腑自利，宜用温里之剂，黄 建中汤（腹痛）、
益黄散（脾）、并与夺命丹合进，利未止者，豆蔻丸（泄利）合进，盖里温则气不消削，气不消
削则不陷伏矣。若根据上法分治，犹不出者，此毒壅伏于三焦，不久而变生焉。
加减参苏饮
人参 紫苏叶 葛根 陈皮 前胡 白芷 桔梗 枳壳 甘草 羌活 防风
上，用竹叶为引，热服。
加减调中汤
人参 白术 黄 甘草（炙） 木香 桂枝 白茯苓 藿香 白芍药（酒炒） 陈皮
上，用生姜为引，煎服。
闻人氏 云∶是痘疹证热数日而不发见者，进退皆难，便欲大发之，惧其本稀
而成 烂，不发之，又无以出其毒瓦斯，古人立论，始以药微发之，微发不出，则加
药，加药不出，则大发之，大发之后，所出不多，气候和平无他证者，即是疮本稀，
不可更发也。以此言之，发不至太过，守不至不及，乃用药之丸活也。
愚按∶古方用发表者，升麻葛根汤轻剂也，惺惺散重剂也，谓微发，谓加
药者，或先用轻剂，后用重剂，或只用本剂先小作汤少饮之，后渐加大多饮之，
非谓于本方之外，再加辛热大发之药也。
凡痘疹过期，应出不出者，或因外感风寒，根据上发表之法，或因内虚泄泻，根据
上和中之法，如按法调治，犹不出快，热反甚，大渴腹胀满，大便硬结不通，烦躁
不安者，此毒邪壅伏于内，三黄丸、七味升麻丸（初热）择而用之，甚则三乙承气汤主
之（大便秘）。闻人氏云∶且身热脉数，大便秘而腹胀，此热毒壅遏，未见形状者，当微
下之，非微下则热不减，此是始者，热在里 未出之时也，若 点隐隐在皮肤中者，
是已发越在表，疮正发时，则不可妄下也。又有结脓窠痂 之际，脉尚洪数能食，
而大小便秘，此表已罢，里有热毒，宜微利之，大抵脏腑有热，往往利大小便者，
以其主出而不内故也。
张氏从道云∶疮痘气匀即出快，盖气匀则荣卫无滞，匀气之药，如桂枝、防风、
荆芥穗、薄荷叶，所以行在表之气，而使之无滞也，故凡发表之剂多用之。木香、
青皮、枳壳、木通，所以行在里之气，而使之无滞也，故凡和中之剂多用之。又，
疮出之时，常宜和暖如三春发生之气，则气血和畅，自然其出快，其发透，其靥齐，
若偏于太热，则壮火食气，其气反虚，而不能行，偏于太寒，则气凝涩而不得行矣。
痘疮之证，其初不免于发热者，未出毒邪在里，煎熬气血，熏蒸脏腑而然，疮
既现形，则毒泄而热解，所以疮出热退者，疮本必疏，若疮已出，热不少减，此毒
蕴于中，其势方张，其疮必密，宜急解其毒，连翘升麻汤加防风、荆芥穗、地骨皮，
或解毒防风汤（大法）加升麻，或东垣黍粘子汤（本条），兼服代天宣化丸（预防）。服药之
后，疮或不出，或再出，其热顿减者为气和也，热若不减，疮渐加多，再消详大小便
何如，大便不通七物升麻丸（初热）。小便不利连翘汤（小便不利）。小大便俱不通八正
散（小便不利）。自利
者黄芩汤（自利）加白头翁、酒黄连、调赤石脂末。里气和，毒解矣，如更加渴，烦躁
不已，或谵妄，或腹胀满气促，或自利不止手足厥冷，此逆证，勿治。
如果发热四至五天后才开始出痘疹的，必须仔细审视是否有外感或内伤的病史。因为伤于风寒或伤于饮食导致的发热，如果长久不愈，那么体内蕴藏的疮痘毒邪，也能趁机发作而出，不能简单地以过期未出作为判断依据。只有那些没有内伤外感诱因，一直发热却不出痘疹的，这是里气虚弱，无法驱逐毒邪使其及时发出，导致毒邪留连停伏在脏腑肠胃之间。这种情况，应当先用托里（扶助正气、托毒外出）的方剂，让痘疹迅速透出，然后再多服用调和脾胃的方剂，这样就可以避免毒邪内陷、倒靥（痘疹塌陷不起）等变证。托里宜用托里快汤或十宣散；调和脾胃宜用四君子汤加黄芪，或者保元汤合匀气散来主治。
托里快汤
当归、黄芪、川芎、木香、青皮、牛蒡子、紫草、连翘、木通、防风、桂枝、蝉蜕。
以上药物切碎。加入淡竹叶十片，加水煎煮，温服，不拘时候。
十宣散（又名十奇散，又名托里十补散）
黄芪、人参、当归（各二钱）、浓朴（姜制）、桔梗（各一钱）、桂心（三分）、川芎、防风、甘草、白芷（各一钱）。
以上药物研为细末。每次服用一钱或二钱，用木香汤调服。
增损八物汤
人参、黄芪、白术、甘草、当归、川芎、牛蒡子（炒）、赤芍药、防风、荆芥穗、连翘、桔梗、葛根。
以上药物，用水煎服。
匀气散
木香、青皮（各五钱）、山楂肉（二钱半）。
以上药物研为细末。每次服用一钱，用甘草汤调服。
痘疹的发出，自有其常规期限。如果过了期限应该发出却未发出，有不同的证候，不可不加以辨别。例如素体充实的人，皮肤厚肌肉密，毒邪难以发散透发，一旦依仗身体壮实，不怕风寒，又被外邪侵袭；或者体质素弱的人，容易感受风寒，导致腠理闭塞，气血凝滞涩阻，所以到了该发出的时候却发不出来。这类患者表现为头痛，四肢拘急挛缩，喜欢依偎覆盖衣物，经常怕冷怕风，这类情况适宜用发汗解表的方法治疗。气盛者用双解散，气虚者用参苏饮或惺惺散（均用于初热阶段）。如果是内虚者，脾弱食少，适宜用补脾的方剂加上行气发表的药物，如四君子汤（适用于不能进食者）、调元汤（即参苏饮）、以及加入木香、青皮、黄芪、桂枝。如果伴有脏腑自利（腹泻），适宜用温里的方剂，如黄芪建中汤（适用于腹痛者）、益黄散（调理脾脏），并与夺命丹配合使用；如果腹泻仍未停止，可合用豆蔻丸（止泻痢）。因为里气温暖则正气不致消损削弱，正气不削弱就不会发生内陷伏匿。如果按照上述方法分治，痘疹仍然不出，这是毒邪壅塞伏匿于三焦，不久就会发生变证。
加减参苏饮
人参、紫苏叶、葛根、陈皮、前胡、白芷、桔梗、枳壳、甘草、羌活、防风。
以上药物，用竹叶为引，热服。
加减调中汤
人参、白术、黄芪、甘草（炙）、木香、桂枝、白茯苓、藿香、白芍药（酒炒）、陈皮。
以上药物，用生姜为引，煎服。
闻人氏说：对于痘疹证发热数日而不发见的情况，进退两难。如果急于大发汗，恐怕原本稀疏的痘疹会变成糜烂；如果不发汗，又无法排出毒邪。古人确立的理论，开始是用轻微的药剂发汗，轻微发汗后若不出，则增加药量；增加药量后若仍不出，再大力发汗。大力发汗之后，如果发出的痘疹不多，且气候平和没有其他证候，这就是痘疹本身稀疏，不可再发汗了。由此而言，发汗不至太过，固守不至不及，这才是用药灵活变通的道理。
我按语：古方中使用发表药的，升麻葛根汤是轻剂，惺惺散是重剂。所谓“微发”，所谓“加药”，是指或者先用轻剂，后用重剂；或者只用本方，先少量煎汤少饮，然后逐渐增加剂量多饮，并不是指在本方之外，再加辛热的大发汗药。
凡是痘疹过期，应该发出却未发出的，或因外感风寒，根据发表的方法治疗；或因内虚泄泻，根据调和脾胃的方法治疗。如果按照法度调治，痘疹仍然不出且不快，发热反而加重，大渴，腹胀满，大便硬结不通，烦躁不安的，这是毒邪壅塞伏匿于内，可选用三黄丸、七味升麻丸（用于初热阶段）；严重的用三乙承气汤主治（针对大便秘结）。闻人氏说：而且身热脉数，大便秘结而腹胀，这是热毒壅遏，尚未见到形状的时候，应当轻微攻下。如果不轻微攻下，热势就不能减退，这是起初热在里而未出的时候。如果痘点隐隐在皮肤中，说明已经发越在表，正是痘疹发作的时候，则不可妄用攻下法。又有结成脓窠痂盖的时候，脉象尚洪数，能进食，而大小便不通，这是表证已罢，里有热毒，适宜轻微通利。大抵脏腑有热，往往通过通利大小便来治疗，因为这样有助于毒邪外出而不内陷。
张氏从道说：疮痘之气均匀，则发出迅速。因为气均匀则营卫无滞涩。匀气的药物，如桂枝、防风、荆芥穗、薄荷叶，是用来运行在表的气，使之无滞涩，所以凡是发表的方剂多用这些药。木香、青皮、枳壳、木通，是用来运行在里的气，使之无滞涩，所以凡是调和脾胃的方剂多用这些药。另外，痘疹发出之时，常宜保持温暖，如同春季万物生长的气息，这样气血和畅，自然发出迅速，透发透彻，收靥整齐。如果偏于太热，则壮火食气，正气反而虚弱而不能运行；偏于太寒，则气机凝滞涩阻而不能运行。
痘疮之证，初期不免发热，是因为未出时毒邪在里，煎熬气血，熏蒸脏腑所致。疮既现形，则毒泄而热解，所以疮出热退的，疮本必然稀疏。如果疮已出，热势丝毫不减，这是毒邪蕴结于中，其势正盛，其疮必然密集，应当紧急解毒，可用连翘升麻汤加防风、荆芥穗、地骨皮，或者解毒防风汤（见大法）加升麻，或者东垣黍粘子汤（本条），兼服代天宣化丸（预防）。服药之后，痘疹或不出，或再出，热势顿时减轻的，是和气恢复的表现。如果热势不减，痘疹逐渐增多，再详细观察大小便情况如何。大便不通用七物升麻丸（初热阶段）。小便不利用连翘汤（小便不利）。大小便俱不通用八正散（小便不利）。自利（腹泻）的用黄芩汤（自利）加白头翁、酒黄连，并调服赤石脂末。里气和顺，毒邪解除。如果更加口渴，烦躁不已，或谵语妄言，或腹胀满气促，或自利不止手足厥冷，这是逆证，不要治疗。
If fever persists for four to five days before the eruption of smallpox or chickenpox appears, one must carefully examine whether there is a history of external contraction (exogenous pathogenic factors) or internal injury. Because fever caused by cold-wind injury or food stagnation, if it lingers without resolving, can cause the accumulated toxin of sores and pox to erupt opportunistically; thus, it cannot be simply judged as delayed eruption based on time alone. Only in cases where there are no causes of internal injury or external contraction, yet fever persists without eruption, is this due to deficiency of interior Qi, which fails to expel the toxin for timely release, allowing the toxic pathogen to linger and lodge between the Zang-Fu organs and intestines/stomach. In such cases, one should first use formulas that support the interior (tonify healthy Qi and push out toxins) to facilitate rapid eruption, followed by prolonged administration of harmonizing formulas for the middle Jiao (spleen and stomach). This approach prevents complications such as toxin sinking inward, collapse, or inverted crusting. For supporting the interior, Toli Kuaishang Decoction (Tuo Li Kuai Tang) or Shixuan San (Ten Acupoints Powder) may be used. For harmonizing the middle, Sijunzi Tang (Four Gentlemen Decoction) with added Huangqi (Astragalus Root), or Baoyuan Tang (Preserve Origin Decoction) combined with Yunqi San (Harmonize Qi Powder), should be administered.
**Toli Kuaishang Decoction (Tuo Li Kuai Tang)**
Danggui (Angelicae Sinensis Radix), Huangqi (Astragali Membranacei Radix), Chuanxiong (Ligustici Chuanxiong Rhizoma), Muxiang (Aucklandiae Radix), Qingpi (Citri Reticulatae Pericarpium Viride), Niubangzi (Arctii Fructus), Zicao (Arnebiae Radix seu Rhizoma), Lianqiao (Forsythiae Fructus), Mutong (Akebiae Caulis), Fangfeng (Saposhnikoviae Radix), Guizhi (Cinnamomi Ramulus), Chantui (Bombyx Batryticatus).
Cut these ingredients finely. Add ten slices of Danzhuyeh (Lophatheri Herba), decoct in water, and take warm at any time.
**Shixuan San (Ten Acupoints Powder)**
(Also known as Shiqi San or Tuoli Shibu San)
Huangqi (Astragali Membranacei Radix), Renshen (Ginseng Radix et Rhizoma), Danggui (Angelicae Sinensis Radix) (each 2 qian); Nongpo (Magnoliae Officinalis Cortex, processed with ginger), Jiegeng (Platycodonis Radix) (each 1 qian); Guixin (Cinnamomi Cortex) (3 fen); Chuanxiong (Ligustici Chuanxiong Rhizoma), Fangfeng (Saposhnikoviae Radix), Gancao (Glycyrrhizae Radix et Rhizoma), Baizhi (Angelicae Dahuricae Radix) (each 1 qian).
Grind into fine powder. Take 1 or 2 qian each time, mixed with Muxiang (Aucklandiae Radix) decoction.
**Zengsun Bawu Tang (Modified Eight Substances Decoction)**
Renshen (Ginseng Radix et Rhizoma), Huangqi (Astragali Membranacei Radix), Baizhu (Atractylodis Macrocephalae Rhizoma), Gancao (Glycyrrhizae Radix et Rhizoma), Danggui (Angelicae Sinensis Radix), Chuanxiong (Ligustici Chuanxiong Rhizoma), Niubangzi (Arctii Fructus, stir-fried), Chi Shaoyao (Paeoniae Radix Rubra), Fangfeng (Saposhnikoviae Radix), Jingjiesui (Schizonepetae Spica), Lianqiao (Forsythiae Fructus), Jiegeng (Platycodonis Radix), Gegen (Puerariae Lobatae Radix).
Decoct in water and take orally.
**Yunqi San (Harmonize Qi Powder)**
Muxiang (Aucklandiae Radix), Qingpi (Citri Reticulatae Pericarpium Viride) (each 5 qian); Shan楂rou (Crataegi Fructus) (2.5 qian).
Grind into fine powder. Take 1 qian each time, mixed with Gancao (Glycyrrhizae Radix et Rhizoma) decoction.
The eruption of sores and pox follows its natural schedule. If the scheduled time passes without eruption, different syndromes may present, requiring careful differentiation. For instance, individuals with robust constitutions have thick skin and dense flesh, making it difficult for toxins to vent outward. If they rely on their physical strength, neglect protection against wind-cold, and are subsequently attacked by exogenous pathogens, or if weak individuals easily contract wind-cold, causing pore closure and stagnation of Qi and blood, eruption will be delayed. Symptoms include headache, stiffness and spasm of the four limbs, a desire to huddle under covers, and aversion to wind and cold. Such cases require diaphoresis (sweating methods). For those with strong Qi, Shuangjie San (Double Resolution Powder) is used; for those with weak Qi, Shen Su Yin (Ginseng and Perilla Drink) or Xingxing San (Xingxing Powder) (both for initial heat stage) are used. For those with interior deficiency, characterized by weak spleen and poor appetite, tonifying spleen formulas combined with Qi-moving and exterior-releasing herbs should be used, such as Sijunzi Tang (for inability to eat), Tianyuan Tang (which is Shen Su Yin), plus Muxiang, Qingpi, Huangqi, and Guizhi. If accompanied by spontaneous diarrhea from internal cold, warming interior formulas like Huangqi Jianzhong Tang (for abdominal pain) or Yihuang San (for spleen dysfunction), combined with Xueming Dan (Life-Extending Pill), should be used. If diarrhea persists, Doukou Wan (Cardamom Pill) should be added. Warming the interior preserves Qi from depletion; preserved Qi prevents sinking and lodging. If, after following these treatments, eruption still does not occur, the toxin is obstructed and lodged in the Triple Burner (San Jiao), and complications will arise shortly.
**Jiajian Shen Su Yin (Modified Ginseng and Perilla Drink)**
Renshen (Ginseng Radix et Rhizoma), Zisuye (Perillae Folium), Gegen (Puerariae Lobatae Radix), Chenpi (Citri Reticulatae Pericarpium), Qianhu (Peucedani Radix), Baizhi (Angelicae Dahuricae Radix), Jiegeng (Platycodonis Radix), Zhike (Aurantii Fructus Immaturus), Gancao (Glycyrrhizae Radix et Rhizoma), Qianghuo (Notopterygii Rhizoma et Radix), Fangfeng (Saposhnikoviae Radix).
Use Zhuyeh (Bambusae Folium) as a guide, take hot.
**Jiajian Tiaozhong Tang (Modified Harmonizing Middle Decoction)**
Renshen (Ginseng Radix et Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Huangqi (Astragali Membranacei Radix), Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried), Muxiang (Aucklandiae Radix), Guizhi (Cinnamomi Ramulus), Baifuling (Poria), Huoxiang (Agastaches Herba), Baishaoyao (Paeoniae Radix Alba, wine-fried), Chenpi (Citri Reticulatae Pericarpium).
Use Shengjiang (Zingiberis Rhizoma Recens) as a guide, decoct and take.
Wenren Shi stated: When sores and pox show fever for several days without eruption, both advancing and retreating are difficult. Rushing to induce heavy sweating risks turning sparse eruptions into ulceration; failing to sweat prevents toxin expulsion. The ancients established a strategy: start with mild diaphoretic herbs. If mild sweating fails to produce eruption, increase the dosage. If increased dosage fails, then induce heavy sweating. After heavy sweating, if few eruptions appear and the climate/pulse is peaceful without other symptoms, it indicates naturally sparse eruptions, and further sweating is contraindicated. Thus, sweating should not be excessive, and retention should not be insufficient; this represents flexible medication usage.
My commentary: Ancient formulas for releasing the exterior include Shengma Gegen Tang (Kudzu and Cimicifuga Decoction) as a light agent, and Xingxing San as a heavy agent. "Mild sweating" and "adding medicine" refer to either using a light agent first then a heavy one, or using the base formula initially in small amounts and gradually increasing the dose. It does not mean adding pungent-hot heavy sweating drugs outside the base formula.
For overdue eruptions due to external wind-cold, follow exterior-releasing methods. For overdue eruptions due to interior deficiency and diarrhea, follow middle-harmonizing methods. If treatment according to these laws fails to produce rapid eruption, and fever worsens with severe thirst, abdominal distension, hard constipation, and restlessness, this indicates toxin obstruction and lodging in the interior. Choose Sanhuang Wan (Three Yellows Pill) or Qiwei Shengma Wan (Seven-Ingredient Cimicifuga Pill) (for initial heat). Severe cases require Yi Yi Chengqi Tang (Modified Yi Yi Da Chengqi Decoction) (for severe constipation). Wenren Shi said: Fever, rapid pulse, constipation, and abdominal distension indicate heat-toxin obstruction before visible eruption; mild purgation is required. Without mild purgation, heat will not subside. This applies when heat is in the interior prior to eruption. If spots are faintly visible under the skin, the toxin has vented to the exterior, and eruption is underway; reckless purgation is forbidden. During the stage of pus formation and scabbing, if the pulse is surging and rapid, the patient can eat, but bowels/bladder are blocked, the exterior syndrome has resolved, and interior heat-toxin remains; mild purgation is appropriate. Generally, clearing interior heat involves regulating bowel and bladder movements to facilitate toxin exit rather than re-entry.
Zhang Congdao stated: Uniform Qi flow leads to rapid eruption because uniform Qi ensures unobstructed Ying and Wei (Nutritive and Defensive) flows. Qi-harmonizing herbs like Guizhi, Fangfeng, Jingjiesui, and Boheye (Menthae Haplocalycis Herba) move exterior Qi to prevent stagnation, hence used in exterior-releasing formulas. Muxiang, Qingpi, Zhike, and Mutong move interior Qi to prevent stagnation, hence used in middle-harmonizing formulas. Furthermore, during eruption, warmth similar to spring’s generative energy is ideal for smooth Qi and blood flow, ensuring rapid, thorough eruption and even crusting. Excessive heat consumes Qi via "flaming fire," leading to weakness and stagnation; excessive cold causes Qi condensation and stagnation.
Initial fever in smallpox/chickenpox occurs because pre-eruption toxins in the interior boil Qi and blood and steam the Zang-Fu. Once eruptions appear, toxins vent and heat resolves; thus, fever subsiding with eruption indicates naturally sparse eruptions. If eruptions appear but fever persists, toxins are concentrated internally with vigorous pathogenic force, indicating dense eruptions. Urgent detoxification is needed using Lianqiao Shengma Tang (Forsythia and Cimicifuga Decoction) plus Fangfeng, Jingjiesui, Digupi (Phellodendri Cortex); or Jiedu Fangfeng Tang (Detoxify Wind-Dispelling Decoction) plus Shengma; or Dongyuan Shunianzi Tang (Barley Seed Decoction), combined with Daitian Xuanhua Wan (Heavenly Proclamation Transformation Pill) for prevention. After medication, if eruptions appear or reappear and fever drops suddenly, Qi harmony is restored. If fever persists and eruptions multiply, observe bowel and bladder function. Constipation requires Qi Wu Shengma Wan (Seven-Ingredient Cimicifuga Pill). Dysuria requires Lianqiao Tang (Forsythia Decoction). Total blockage of bowel and bladder requires Bazheng San (Eight Correctness Powder). Spontaneous diarrhea requires Huangqin Tang (Scutellaria Decoction) plus Bitouweng (Polygoni Multiflori Caulis), Jiuhuanglian (Coptidis Rhizoma processed with wine), and Chishizhi (Halloysitum Rubrum) powder. When interior Qi harmonizes and toxins resolve, the condition improves. If thirst increases, restlessness persists, delirium occurs, abdominal distension and shortness of breath develop, or uncontrollable diarrhea with cold extremities ensues, these are adverse signs (Ni Zheng); do not treat.