痘疮至八九朝至十一二朝。灌浆满足。脓汁渐干。先从人中上下口鼻两边。收至项下额上。
遍身手足一齐俱收。痂浓色黑。渐渐脱落。饮食便溺如常为吉。若额上先收者。孤阳不生。脚上
先收者。独阴不长。为大逆兆。若浆不稠浓。顶未满足。面肿忽退。目闭忽开。疮脚放润。色白
干皱。痂薄如纸。此津液枯竭。血少毒存。急用四君子汤加麦冬、牛蒡、荆芥、连翘救之。今人
每见此证。认作结痂无事。致成不救者多矣。或有将靥之时。热不止而脉滑数者。痘未尽也。托
里快斑汤发之。服后复出赠痘。其热自除。有将靥时。痘内复出赠痘者吉。若浆足难靥。色转黑
者凶。亦有能食神清者可治。有收靥时。咳嗽咽喉不利者。此肺胃余火不清也。桔梗汤加牛蒡、
连翘、黑参。痘浆清而忽然干黑。谓之倒靥。若浆足而次第收靥。痂浓色苍。忽然喘急腹胀者。
此伤食所致。保和丸消导之。若收靥如期而身热喘逆者。此客冒风寒也。当随轻重以汗之。其或
当靥之时。身热闷乱不宁。哽气腹胀泄泻寒颤切牙。急用钱氏异功散加木香、当归。助其收靥。
若目开肿退。色白不收。反腹胀燥渴。闷乱哽气者。此必曾经泄泻。或过用凉药。脾胃亏损所致。
陈氏木香散。否则倒靥而危矣。薛氏云。若手足并冷。属脾胃虚寒。陈氏异功散。手足微冷。属
脾胃虚弱。钱氏异功散加木香。若手足热。大便秘。作渴引饮。属脾胃实热。四顺清凉饮。救其
阴以抑其阳。又有当靥之时。溃烂淋漓者。毒当发而发散迟。则毒蓄肌肉。未当发散而发散早。
则毒邪暴出。肌肉亏损。熏灼腐烂。甚至内气并虚。滑泄自利。闷乱呻吟而死。急用陈氏木香散。
或钱氏白术散治里。豆蔻丸以止泻。外以白螺散。或墙上败草为末掺之。或用黄牛粪烧存性。入
麝少许掺之。或蚕茧烧灰。加枯矾少许掺之。或用荞麦面、猪胆调涂烂处。并用荞麦面衬身下以
收其毒。夏月盛暑。用芒硝、猪胆汁调涂。若手臂臀胯之间。久着床席。展擦破损。急难成痂。
或破烂成片。焦干黧黑。如火烧汤泼。亦难治也。又
或当靥之时。发热恶寒。身疼面青。疮不收靥者。此必风寒侵袭。故发身疼。桂枝汤加荆、防、
淡豉。虚则参苏饮。如或夏月居处过热。热与毒相凝而痛。益元散加枳、橘、连翘、白芍。痛去
热退。疮自靥矣。倘痘疔失于挑拔。收靥时作痛。急宜挑治以泄其毒。又或顶破脓出。结聚如碎
松香者。此因多用温补之药。邪气得补。反伤正气。急磨生犀水饮之。及益元散利小便。当归丸
导大便。自然收靥。亦有浆虽灌而未得满足。不能收靥者。犀角消毒饮解散其毒。方得收靥。又
有曾用凉解之药及饮冷水。致腹中滑泄。气短体倦而不靥者。以胃苓汤和胃安脾。亦能收靥。其
或疮头有孔。脓水流出。或清水无脓。卒然自破。水出干黑。是名漏疮。不治。又有迟延日久。
溃烂淋漓。皮脱腥臭。若先曾成脓而后溃烂。能饮食。无他证者。当和脾胃。避风寒。多用干黄
土末掺之。自能平复。若先未成脓而溃烂者。不治。又有先因皮薄破损。多用补药。重复灌浆而
发热不靥者。此正气得补。驱邪为脓。然正气终为邪克。不能逼邪成痂。十全大补汤。又有虽重
灌浆。脓血浸淫面目。加味消毒饮。更加犀角多服。若元气本实可愈。如或脓血不止。变成疳蚀
难治也。又有结痂干浓。忽然战栗。干哕烦渴者。此正气将复。不能禁持之故。生脉散。又遍身
俱收。惟头与足不收者。此气血不调。四物汤去地黄加升麻、牛膝、牛蒡、红花、荆芥。陈文宿
云。痘疮收靥之后。浑身壮热。经日不除。别无他证。柴胡、麦冬、人参、甘草、黑参、胆草主
之。翁仲仁云。痘疮灌浆已满。热毒已解。至收靥时。有数日不焦者。只看痘色如初。此亦无妨。
乃表虚不能收敛之故。八珍汤加木通、牛蒡。补脾利水。痘自靥矣。朱济川曰。表虚则易出而难
靥。表实则难出而易靥。于此可见其表里虚实矣。
痘疮发展到第八九日至第十一二日，脓浆灌满，脓汁逐渐干燥。先从人中穴上下及口鼻两侧开始，收敛至颈部下方和额头上方。全身手足同时开始收敛，痂皮浓厚且颜色发黑，渐渐脱落。此时饮食、大小便如常为吉兆。如果额头先收敛，是孤阳不生之象；脚部先收敛，是独阴不长之象，均为大逆的凶兆。
如果脓浆不稠浓，痘顶未饱满，面部浮肿突然消退，眼睛闭合突然睁开，疮基底部变得湿润，颜色苍白且干枯起皱，痂皮薄如纸张，这是津液枯竭、血少毒存的表现，急需使用四君子汤加入麦冬、牛蒡子、荆芥、连翘来救治。现在的人每当见到这种证候，误认为是结痂无碍，导致多因延误而不可救治。
有的患者在即将收靥时，发热不止且脉象滑数，说明痘毒未尽，需用托里快斑汤发散它。服药后再次发出赠痘（继发痘），热势自然消除。有在即将收靥时，痘内又长出赠痘的，此为吉兆。如果脓足但难以收靥，颜色转为黑色的，为凶兆。也有能进食、神志清醒的可以治疗。
在收靥时，出现咳嗽、咽喉不利的，这是肺胃余火未清的表现，用桔梗汤加入牛蒡子、连翘、玄参（黑参）。痘浆清稀而突然干黑的，称为倒靥。如果脓足且按顺序收靥，痂皮浓厚颜色苍老，突然气喘急促、腹胀的，这是伤食所致，用保和丸消导积滞。如果收靥如期进行但身体发热、气喘逆乱的，这是外感风寒所致，应当根据轻重程度用发汗法治疗。
或者在当收靥之时，身体发热、烦闷扰乱、不安宁，伴有嗳气、腹胀、泄泻、寒战、咬牙等症状，急用钱氏异功散加入木香、当归，以助其收靥。如果眼睛睁开、浮肿消退，但颜色苍白不收靥，反而腹胀、燥渴、烦闷扰乱、嗳气的，这必定是曾经泄泻，或过用凉药，导致脾胃亏损所致，用陈氏木香散，否则将发生倒靥而危及生命。
薛己说：如果手足并冷，属于脾胃虚寒，用陈氏异功散。手足微冷，属于脾胃虚弱，用钱氏异功散加木香。如果手足热，大便秘结，口渴引饮，属于脾胃实热，用四顺清凉饮，救其阴液以抑制阳气。
又有在当收靥之时，溃烂淋漓不断的，这是毒邪应当发散却发散迟缓，导致毒邪蓄积在肌肉中；尚未到发散之时却过早发散，导致毒邪暴出，肌肉亏损，熏灼腐烂，甚至内气也虚，滑泄自利，烦闷呻吟而死，急用陈氏木香散，或钱氏白术散治里，豆蔻丸以止泻。外用白螺散，或将墙上败草研末掺敷。或用黄牛粪烧存性，加入少许麝香掺敷。或用蚕茧烧灰，加少许枯矾掺敷。或用荞麦面、猪胆汁调涂溃烂处，并用荞麦面衬在身下以吸收毒邪。夏季盛暑时，用芒硝、猪胆汁调涂。
如果手臂、臀部、胯部之间，长期接触床席，摩擦破损，急难成痂，或破烂成片，焦干黧黑，如火烧汤泼一般，也难以治疗。
又在当收靥之时，发热恶寒，身体疼痛，面色青暗，疮口不收靥的，这必定是风寒侵袭，所以引起身体疼痛，用桂枝汤加入荆芥、防风、淡豆豉。体虚的用参苏饮。如果夏季居处过热，热与毒邪相凝而疼痛，用益元散加入枳壳、陈皮、连翘、白芍。疼痛去除，热势退去，疮口自然收敛。倘若痘疔失于挑破拔除，收靥时作痛，急宜挑治以泄其毒。
又或者痘顶破溃流脓，结聚如碎松香状，这是因为多用温补药物，邪气得补，反而损伤正气，急磨生犀角水饮用，以及益元散利小便，当归丸导大便，自然收靥。也有虽然灌浆但未得饱满，不能收靥的，用犀角消毒饮解散其毒，方能收靥。又有曾用凉解药物及饮用冷水，导致腹中滑泄，气短体倦而不收靥的，用胃苓汤调和胃气、安固脾气，也能收靥。
如果疮头有孔，脓水流出，或清水无脓，突然自行破裂，水流干黑，这名叫漏疮，无法治疗。又有拖延日久，溃烂淋漓，皮肤脱落散发腥臭，如果先前已经成脓而后溃烂，能进食，没有其他症状的，应当调和脾胃，避风寒，多用干黄土末掺敷，自然能平复。如果先前未成脓而溃烂的，无法治疗。
又有先前因为皮薄破损，多用补药，重复灌浆而发热不收靥的，这是正气得到补充，驱邪化为脓，然而正气终究被邪气克制，不能逼迫邪气结成痂皮，用十全大补汤。又有虽然严重灌浆，脓血浸淫面目，用加味消毒饮，更加重用犀角多服。如果元气本实可以痊愈，如果脓血不止，变成疳蚀则难治。
又有结痂干厚，突然战栗，干呕烦渴的，这是正气将要恢复，但不能禁持的缘故，用生脉散。又遍身都收敛了，只有头部和足部不收敛的，这是气血不调，用四物汤去掉地黄，加入升麻、牛膝、牛蒡子、红花、荆芥。
陈文宿说：痘疮收靥之后，浑身壮热，经日不除，别无其他症状，用柴胡、麦冬、人参、甘草、玄参、龙胆草主治。翁仲仁说：痘疮灌浆已满，热毒已解，到了收靥时，有数日不焦痂的，只看痘色如初，这也无妨，是表虚不能收敛的缘故，用八珍汤加入木通、牛蒡子，补脾利水，痘疮自然收敛。朱济川说：表虚则容易发出而难收敛，表实则难发出而易收敛，从这里可以看出表里的虚实情况了。
By the eighth to ninth day, or eleventh to twelfth day of smallpox (Dou Chuang), the pustules are filled with pus, and the purulent fluid gradually dries. The scabbing process begins first around the Renzhong point (GV26) above and below, and on both sides of the mouth and nose, extending down to the lower neck and forehead. The entire body and limbs begin to scab simultaneously; the scabs are thick and dark in color, falling off gradually. Normal diet, urination, and defecation indicate a favorable prognosis. If scabbing starts first on the forehead, it signifies "solitary yang cannot generate," and if it starts first on the feet, it signifies "solitary yin cannot grow"; both are ominous signs of severe deviation.
If the pus is not dense, the pustule tops are not full, facial swelling suddenly subsides, eyes that were closed suddenly open, the base of the lesions becomes moist, the color turns pale and dry/wrinkled, and the scabs are thin as paper, this indicates exhaustion of body fluids and blood deficiency with retained toxins. Urgently use Sijunzi Tang (Four Gentlemen Decoction) added with Maidong (Ophiopogonis Radix), Niubangzi (Arctii Fructus), Jingjie (Schizonepetae Herba), and Lianqiao (Forsythiae Fructus) to rescue the patient. Nowadays, people often mistake this condition for simple scabbing with no danger, leading to many untreatable cases due to delay.
In some cases, during the impending scabbing phase, fever persists and the pulse is slippery and rapid, indicating that the toxin has not been fully expelled. Use Tuoli Kuaiban Tang (Support Interior and Rapidly Expel Rash Decoction) to disperse it. After administration, secondary pustules (Zeng Dou) will erupt, and the fever will naturally subside. If secondary pustules appear within existing lesions just before scabbing, this is auspicious. However, if there is sufficient pus but difficulty in scabbing, and the color turns black, this is inauspicious. Cases where the patient can eat and remains clear-minded are treatable.
During scabbing, if cough and throat obstruction occur, this is due to residual fire in the Lung and Stomach not being cleared. Use Jiegeng Tang (Platycodon Decoction) added with Niubangzi, Lianqiao, and Heishen (Scrophulariae Radix). If the clear pus suddenly dries and turns black, it is called Daoye (Reverse Scabbing). If there is sufficient pus and scabbing proceeds sequentially, with thick, mature-colored scabs, but sudden shortness of breath and abdominal distension occur, this is caused by food stagnation. Use Baohe Wan (Preserve Harmony Pill) to digest and guide out stagnation. If scabbing occurs on schedule but the body is hot with panting and rebellious qi, this is due to external invasion of wind-cold. Treat according to severity with diaphoresis (sweating method).
Alternatively, during the scabbing period, if the body is hot, restless, irritable, accompanied by belching, abdominal distension, diarrhea, chills, and teeth grinding, urgently use Qian's Yigong San (Qian Yi's Five Gentlemen Powder) added with Muxiang (Aucklandiae Radix) and Danggui (Angelicae Sinensis Radix) to assist scabbing. If the eyes open, swelling subsides, but the color is pale and scabbing does not proceed, accompanied by abdominal distension, dry mouth/thirst, irritability, and belching, this is likely due to prior diarrhea or overuse of cooling medicines, resulting in Spleen-Stomach deficiency. Use Chen's Muxiang San (Chen's Aucklandia Powder); otherwise, Daoye may occur, endangering life.
Xue Ji stated: If hands and feet are cold, it belongs to Spleen-Stomach deficiency-cold; use Chen's Yigong San. If hands and feet are slightly cold, it belongs to Spleen-Stomach weakness; use Qian's Yigong San added with Muxiang. If hands and feet are hot, constipation, thirst with desire to drink, it belongs to Spleen-Stomach excess-heat; use Sishun Qingliang Yin (Four-Obedience Cooling Decoction) to nourish yin and suppress yang.
In cases where lesions ulcerate and weep profusely during scabbing, it is because the toxin should have been dispersed but was delayed, causing toxin accumulation in muscles; or if dispersed too early before the proper time, causing toxin to burst forth, damaging muscles, leading to burning and rotting, potentially causing internal qi deficiency, slippery diarrhea, irritability, groaning, and death. Urgently use Chen's Muxiang San or Qian's Baizhu San (Qian's Atractylodes Macrocephala Powder) to treat the interior, and Doukou Wan (Cardamom Pill) to stop diarrhea. Externally apply Bailuo San (White Conch Powder) or powder from decaying grass found on walls. Alternatively, burn yellow cow dung until charred but retaining its nature, add a little Shexiang (Musk), and apply. Or burn silkworm cocoons to ash, add a little Kunfan (Alumen), and apply. Alternatively, mix Tartary Buckwheat Flour (Qiaomai Mian) with Pig Bile to apply to ulcers, and place Tartary Buckwheat Flour under the body to absorb toxins. In midsummer heat, use Mangxiao (Natrii Sulfas) and Pig Bile mixed for application.
If arms, buttocks, or groin areas, which are in long contact with bedding, become abraded and difficult to scab, or break into large patches, becoming scorched, dry, and dark like burns or scalds, these are also difficult to treat.
Again, during scabbing, if there is fever, aversion to cold, body pain, cyanotic complexion, and lesions fail to scab, this is due to wind-cold invasion causing body pain. Use Guizhi Tang (Cinnamon Twig Decoction) added with Jingjie, Fangfeng (Saposhnikoviae Radix), and Danshi (Fermented Soybean). For deficiency patterns, use Rensu Yin (Ginseng and Perilla Drink). If summer living quarters are too hot, causing heat and toxin to congeal and cause pain, use Yiyuan San (Benefit Origin Powder) added with Zhike (Aurantii Fructus), Chenpi (Citri Reticulatae Pericarpium), Lianqiao, and Baishao (Paeoniae Radix Alba). Once pain ceases and heat subsides, lesions will naturally scab. If Dou Ding (Smallpox Carbuncle) is neglected and not picked/drained, causing pain during scabbing, urgently pick and drain to release toxin.
Or if the pustule top breaks, pus flows out, and forms clumps resembling broken rosin, this is due to excessive use of warming and tonifying herbs, where pathogenic qi benefits from tonification and damages healthy qi. Urgently grind fresh Xijiao (Rhinocerotis Cornu) for water intake, use Yiyuan San to promote urination, and Danggui Wan (Angelica Pill) to guide bowel movements; scabbing will occur naturally. There are cases where pus is insufficient despite filling, preventing scabbing; use Xijiao Xiaodu Yin (Rhino Horn Detoxification Drink) to resolve toxin, allowing scabbing. There are also cases where cooling/detoxifying herbs and cold water consumption caused intestinal slipping, shortness of breath, fatigue, and failure to scab; use Weiling Tang (Gastrointestinal Regulation Decoction) to harmonize stomach and stabilize spleen, enabling scabbing.
If lesion heads have holes with pus or clear fluid leaking, or suddenly rupture with clear fluid turning black, this is named Lou Chuang (Leaking Ulcer), which is untreatable. If delayed for a long time, ulcerating and weeping, with skin shedding and foul odor: if pus formed first then ulcerated, and the patient can eat without other symptoms, harmonize spleen and stomach, avoid wind-cold, and frequently apply dried Huangtu (Yellow Earth) powder; recovery will occur naturally. If ulceration occurs without prior pus formation, it is untreatable.
If skin was initially thin and damaged, and excessive tonics were used, causing repeated pus formation with fever and failure to scab, this is because healthy qi was boosted to expel evil as pus, yet healthy qi is ultimately overcome by pathogen and cannot force scabbing. Use Shiquan Dabu Tang (Ten Complete Great Tonifying Decoction). In cases of heavy pus formation with pus/blood soaking face and eyes, use Jiawei Xiaodu Yin (Modified Detoxification Drink) with increased Xijiao taken frequently. If original qi is solid, cure is possible; if pus/blood continues and transforms into Gan Shi (Gangrenous Erosion), it is difficult to treat.
If scabs are dry and thick, but sudden shivering, dry retching, and irritability/thirst occur, this is because healthy qi is recovering but cannot sustain itself; use Shengmai San (Generate Pulse Powder). If the whole body scabs except head and feet, this is disharmony of qi and blood; use Siwu Tang (Four Substances Decoction) removing Dihuang, adding Shengma (Cimicifugae Rhizoma), Niuxi (Achyranthis Bidentatae Radix), Niubangzi, Honghua (Carthami Flos), and Jingjie.
Chen Wensu stated: After smallpox scabbing, if high fever persists all over the body for days without other symptoms, use Chaihu (Bupleuri Radix), Maidong, Renshen (Ginseng Radix), Gancao (Glycyrrhizae Radix), Heishen, and Dancao (Gentianae Radix). Weng Zhongren stated: When smallpox pus is full and heat-toxin resolved, but scabbing is delayed for several days, if the lesion color remains normal, this is harmless; it is due to exterior deficiency failing to consolidate. Use Bazhen Tang (Eight Treasures Decoction) added with Mutong (Akebiae Caulis) and Niubangzi to tonify spleen and promote water metabolism; scabbing will occur naturally. Zhu Jichuan said: Exterior deficiency makes eruption easy but scabbing difficult; exterior excess makes eruption difficult but scabbing easy. From this, one can discern the excess/deficiency of the exterior and interior.