痘疮出齐长足。至六七日红润灌浆。九日十一日收靥为吉。盖成实之令。肺金用事。然必藉
脾胃强。则气血充实。中
陷者尽起。顶平者尽峻。饱满光荣。先长者。先作浆。次长者。次作浆。循循有序为顺。若脾胃
弱。则气衰微。不能助痘成浆为险。若脾胃损。则气血浇漓。不能灌汁。必喘胀闷乱。痒塌倒 。
呕哕泄泻为逆。其或唇上有痘先黄者。此毒攻 。当十一二日不食而危。若稠密焦紫。不起顶者。
此血热毒盛。当视其人皮之浓薄。浓者化毒汤加连翘、黑参。若皮薄如水泡者。虽灌不满。必有
痒塌黑陷之变。若头面稠密。身上稀少。色白不能起顶灌浆者。此血气虚少。参 内托散。药力
在上。先头面浆满。四肢不灌。前药加糯米、芍药。以牛膝下引至足。若五六日浆虽灌。而不稠
浓。不圆满。或陷顶者。此为气弱不能统血。保元汤合四物加观桂。若虽饱满。色见 白者。此
气盛血弱也。四物汤加木香、糯米。若六七日内灌浆不满。中有不灌者。此气血不和。必变虚寒
痒塌。保元汤加芎、归、芍药、白芷、糯米。若虽儿长满。摸则皮皱。此血虚而气不相根据。必难
收靥。参 内托散加糯米。若气虚之证。用内托补药。暂起灌浆。不满而复平塌者。更用大剂
保元汤加芎、归、木香、升、桂、糯米。痘养浆时。浆不易充。而色淡白。食少便溏。此气虚也。
保元汤加当归、肉桂。若根赤烦渴便秘者。此血热也。犀角地黄汤。误用参、 托浆而热愈甚者。
四顺清凉饮。养浆时干空无水。此气虚伏陷也。若人事清爽。饮食如常。痘无损处。补中益气汤。
若喘胀哕泻。烦闷外剥者不治。痘本稠密色淡。养浆时昏睡妄言者。此血虚神无所根据也。保元汤
加枣仁、茯神、归、地、门冬。养浆时喜笑不止者。此心包热甚也。保元汤加人中黄、黄连。养
浆时呕哕不止。而浆不充者。土败木侮。不治之证也。灌浆时痘色朗绽。而两臂肿痛如瓜者。此
手三阳气虚而毒凝滞不散也。保元汤加桂枝、羌、防、当归、忍冬、犀角、连翘。养浆时能食便
溏。诸痘俱灌。惟正面平塌无浆。此足阳明气虚也。保元汤加观桂、芍药。有灌浆时忽然倒 。
或血热毒盛。不能起长。伏陷喘胀便秘。诸药不效者。攻毒汤。有浆虽灌。而清
稀不能充满者。后来必有余毒。能食便坚者。用嫩黄雌鸡。入黄 一两煮汁。少和酒酿饮之。若
浆清顶不足。而不犯条款。自能饮食者。当发痘毒。方可收功。若有变。及不能饮食者必危。以
上诸证。年大能食者。十全五六。年小不能食者难治。浆虽灌而色太红。根脚散者。此血热未解。
九朝十一朝内必发痒。急宜化毒汤去升麻加芎、归、白芷、连翘、忍冬。勿令抓破。如破处鲜血
淋漓。则气血流通。外用陈年屋茅研细掺之。或以松花掩之。若因发痒而擦破清水无血。必无生
理。破后随灌随干。痂色青白。堆垛如鸡矢者。终必切牙寒颤。发渴作喘。二十日外必危。但抓
破处如剥光鱼皮汤火泡者不治。若八九朝灌浆之时。身发壮热。渴欲饮水者。此疮多毒盛。表里
气血俱虚之故。加味四圣散去木香加归、芍。亦有浆半足而热甚。烦渴引饮不已。此津液外布而
肺胃枯涸也。大剂保元汤合生脉散频进。浆满而渴自止也。若壮热颊渴。舌干唇裂。痘色干紫者。
血热毒盛。或重裘暖炕所致。不可误与前药。犀角地黄汤去丹皮加芩、连。若行浆时。感冒风寒
痰喘者难治。略与疏散。不效者死。痘浆充而腹满泄泻。此停食所致。保和丸消导之。若灌浆时
痛不止者。气滞也。保元汤加山楂、木香以行其滞。则痛自止。有塌痒不止者。此血热也。四圣
散加生地黄、干首乌以凉其血。其痒自止。若浆足而痒不妨。若灌浆之时。十朝之外。身体倦怠。
烦闷嗜卧。口有气息。此必胃中蕴热。喉舌生疮之故。急用黄连解毒汤。或消毒饮加防风。迟则
疮虽收靥脱痂。延至二十日外。牙龈虫蚀出血而成牙宣。呼吸息出而成息露。或为走马硼砂狐惑
齿落唇烂。为不治矣。
痘疮发出整齐并长至饱满，到了第六七日呈现红润并开始灌浆，第九至十一日结痂脱落为吉兆。这是因为此时正值金气成实、肺金主令的时节。然而，这必须依赖脾胃强健，才能使气血充实，使原本凹陷的痘疹全部隆起，原本平坦的顶部全部高耸，显得饱满光亮。先长出的痘先化浆，后长出的痘后化浆，循序渐进为顺证。如果脾胃虚弱，则气衰微，不能助痘成浆，此为险证。如果脾胃受损，则气血枯竭，不能灌汁，必然出现喘促胀满、闷乱、瘙痒塌陷倒靥、呕吐呃逆泄泻等逆证。
如果嘴唇上的痘先变黄，这是毒邪攻冲所致，当在第十一二日因不进食而陷入危险。如果痘疹稠密且焦紫，不起顶，这是血热毒盛，应当根据患者皮肤的厚薄来辨证：皮肤厚者用化毒汤加连翘、黑参；如果皮肤薄如水泡，虽然灌浆不满，必然会有瘙痒塌陷、黑色内陷的变化。如果头面部痘疹稠密，身上稀少，颜色白而不能起顶灌浆，这是气血虚少，用参芪内托散。药力作用于上部，先使头面浆满，四肢不灌，在前药基础上加糯米、芍药，并用牛膝引药下行至足部。如果五六天浆虽已灌，但不稠浓、不圆满，或顶部凹陷，这是气弱不能统摄血液，用保元汤合四物汤加肉桂。如果虽然饱满，但颜色发白，这是气盛血弱，用四物汤加木香、糯米。如果六七日内灌浆不满，中间有未灌的部分，这是气血不和，必然变为虚寒瘙痒塌陷，用保元汤加川芎、当归、芍药、白芷、糯米。如果痘虽长满，但摸起来皮皱，这是血虚而气无所依附，必然难以收靥，用参芪内托散加糯米。如果是气虚之证，使用内托补药，暂时起浆灌浆，不满后又复平塌，更需用大剂量的保元汤加川芎、当归、木香、升麻、肉桂、糯米。痘疹养浆时，浆液不易充盈且色淡白，食少便溏，这是气虚，用保元汤加当归、肉桂。如果根部红赤、烦渴、便秘，这是血热，用犀角地黄汤。误用人参等托里药导致热势更甚者，用四顺清凉饮。养浆时干空无水，这是气虚伏陷，如果人事清爽、饮食如常、痘无破损，用补中益气汤。如果出现喘胀、呃逆、泄泻、烦闷外剥，则属不治之症。痘本稠密色淡，养浆时昏睡妄言，这是血虚神无所依，用保元汤加枣仁、茯神、当归、地黄、麦冬。养浆时喜笑不止，这是心包热甚，用保元汤加人中黄、黄连。养浆时呕哕不止且浆不充，这是土败木侮，属不治之证。灌浆时痘色朗绽，但两臂肿痛如瓜，这是手三阳气虚而毒凝滞不散，用保元汤加桂枝、羌活、防风、当归、忍冬、犀角、连翘。养浆时能食便溏，诸痘俱灌，惟正面平塌无浆，这是足阳明气虚，用保元汤加肉桂、芍药。有灌浆时忽然倒靥，或因血热毒盛不能起长，伏陷喘胀便秘，诸药不效者，用攻毒汤。有浆虽灌，但清稀不能充满者，后来必有余毒，能食便坚者，用嫩黄雌鸡一只，入黄芪一两煮汁，少许和酒酿饮之。如果浆清顶不足，但不犯上述条款，自能饮食者，当发痘毒，方可收功。如果有变化及不能饮食者必危。以上诸证，年大能食者，治愈率十之五六；年小不能食者难治。浆虽灌但色太红，根脚散漫，这是血热未解，九朝十一朝内必发痒，急宜用化毒汤去升麻加川芎、当归、白芷、连翘、忍冬，勿令抓破。如破处鲜血淋漓，则气血流通，外用陈年屋茅研细掺之，或以松花掩之。若因发痒而擦破清水无血，必无生理。破后随灌随干，痂色青白，堆垛如鸡屎者，终必切牙寒颤、发渴作喘，二十日外必危。但抓破处如剥光鱼皮或汤火泡者不治。如果八九朝灌浆之时，身发壮热，渴欲饮水，这是疮多毒盛，表里气血俱虚之故，用加味四圣散去木香加当归、芍药。也有浆半足而热甚，烦渴引饮不已，这是津液外布而肺胃枯涸，用大剂量保元汤合生脉散频进，待浆满而渴自止。如果壮热颊赤，舌干唇裂，痘色干紫，这是血热毒盛，或重裘暖炕所致，不可误与前药，用犀角地黄汤去丹皮加黄芩、黄连。如果行浆时感冒风寒痰喘者难治，略予疏散，不效者死。痘浆充而腹满泄泻，这是停食所致，用保和丸消导之。如果灌浆时痛不止，是气滞，用保元汤加山楂、木香以行其滞，则痛自止。有塌痒不止者，这是血热，用四圣散加生地黄、干首乌以凉其血，其痒自止。如果浆足而痒不妨事。如果灌浆之时，十朝之外，身体倦怠，烦闷嗜卧，口有气息，这必然是胃中蕴热、喉舌生疮的缘故，急用黄连解毒汤，或消毒饮加防风，迟则疮虽收靥脱痂，延至二十日外，牙龈虫蚀出血而成牙宣，呼吸息出而成息露，或为走马硼砂、狐惑、齿落唇烂，均为不治之症。
When the smallpox lesions are fully erupted and sufficiently developed, by the sixth or seventh day they turn ruddy and begin to fill with pus. Crusting and scabbing between the ninth and eleventh days is auspicious. This corresponds to the phase of "completion and solidity," when the Lung Metal qi is predominant. However, this process relies heavily on strong Spleen and Stomach function to ensure sufficient Qi and Blood, causing previously depressed lesions to rise completely and flat-topped lesions to become high, full, and lustrous. Lesions that appear first will fill with pus first, followed by those appearing later; a gradual and orderly progression constitutes a favorable (Shun) pattern. If the Spleen and Stomach are weak, Qi becomes deficient and fails to assist in pus formation, constituting a dangerous (Xian) pattern. If the Spleen and Stomach are damaged, Qi and Blood become depleted, failing to generate fluid/pus, inevitably leading to adverse (Ni) patterns such as panting, abdominal distension, chest oppression, restlessness, itching, collapse/inversion of lesions, vomiting, hiccups, and diarrhea.
Specifically, if lesions on the lips turn yellow first, this indicates toxin attack; inability to eat by the eleventh or twelfth day signals critical danger. If lesions are dense, scorched-purple, and fail to elevate, this indicates severe Blood Heat and toxin excess. Treatment depends on skin thickness: for thick skin, use Huadu Decoction (Toxin-Resolving Decoction) with added Lonicerae Japonicae Flos (Lianqiao, 连翘) and Panax Notoginseng Radix et Rhizoma (Heishen, 黑参). For thin skin resembling blisters, even if pus filling is incomplete, there will inevitably be changes of itching, collapse, and black inversion. If facial lesions are dense while body lesions are sparse, white in color, and fail to elevate or fill with pus, this indicates deficiency of Qi and Blood; use Shenqi Neituo San (Ginseng and Astragalus Internal-Supporting Powder). To direct medicinal action upward, initially filling the face before the limbs, add Oryzae Semen (Nuomi, 糯米) and Paeoniae Radix Alba (Shaoyao, 芍药) to the formula, and use Achyranthis Bidentatae Radix (Niuxi, 牛膝) to guide the medicine downward to the feet.
If by the fifth or sixth day pus has filled but is not dense, round, or elevated, this indicates weak Qi failing to control Blood; use Baoyuan Tang (Preserve the Origin Decoction) combined with Siwu Tang (Four Substances Decoction) plus Cinnamomi Ramulus (Guigui, 官桂). If lesions are full but pale in color, this indicates abundant Qi but weak Blood; use Siwu Tang with added Aucklandiae Radix (Muxiang, 木香) and Oryzae Semen. If by the sixth or seventh day pus filling is incomplete with gaps, this indicates disharmony of Qi and Blood, likely transforming into cold-deficiency with itching and collapse; use Baoyuan Tang with added Chuanxiong Rhizome (Chuanxiong, 川芎), Angelicae Sinensis Radix (Danggui, 当归), Paeoniae Radix Alba, Angelicae Dahuricae Radix (Baizhi, 白芷), and Oryzae Semen. If lesions are full but wrinkled to the touch, this indicates Blood deficiency with Qi lacking attachment, making crusting difficult; use Shenqi Neituo San with added Oryzae Semen. In cases of Qi deficiency where internal-supporting tonics temporarily raise the lesions but they flatten again without full filling, use a large dose of Baoyuan Tang with added Chuanxiong, Danggui, Muxiang, Cimicifugae Rhizoma (Shengma, 升麻), Cinnamon Bark (Rougui, 肉桂), and Oryzae Semen.
During the pus-nourishing stage, if pus is hard to fill and pale, with poor appetite and loose stools, this is Qi deficiency; use Baoyuan Tang with added Danggui and Rougui. If the lesion base is red, with irritability, thirst, and constipation, this is Blood Heat; use Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction). If mistaken use of Ginseng and Astragalus to support pus worsens heat, use Sishun Qingliang Yin (Four-Harmonious Cooling Decoction). During pus nourishment, if the lesion is dry and empty due to Qi deficiency sinking inward, but the patient is clear-minded, eating normally, and lesions are intact, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). If accompanied by panting, distension, hiccups, diarrhea, irritability, and external peeling of lesions, it is untreatable.
If lesions were originally dense and pale, and during pus nourishment the patient sleeps deeply and speaks deliriously, this is Blood deficiency with Spirit lacking attachment; use Baoyuan Tang with added Ziziphus Seed (Zaoren, 枣仁), Poria (Fushen, 茯神), Danggui, Rehmanniae Radix (Dihuang, 地), and Ophiopogonis Tuber (Mendong, 门冬). If laughing incessantly during pus nourishment, this indicates excessive Heat in the Pericardium; use Baoyuan Tang with added Human Coprolite (Renzhonghuang, 人中黄) and Coptidis Rhizome (Huanglian, 黄连). If vomiting and hiccups persist with insufficient pus, this indicates failure of Earth overacting on Wood, an untreatable condition. If lesions are bright and open during pus filling but arms are swollen and painful like melons, this indicates Qi deficiency of the Hand-Taiyang channels with stagnant toxin; use Baoyuan Tang with added Guizhi (Cinnamon Twig), Qianghuo (Notopterygii Rhizoma), Fangfeng (Saposhnikoviae Radix), Danggui, Ren Dong (Lonicerae Japonicae Caulis), Xijiao (Rhino Horn), and Lianqiao.
If the patient eats well but has loose stools, and all lesions fill except the face which is flat and empty, this indicates Qi deficiency of the Foot-Yangming channel; use Baoyuan Tang with added Guigui and Shaoyao. If sudden inversion occurs during pus filling, or if Blood Heat/toxin excess prevents elevation leading to sinking, panting, distension, and constipation unresponsive to other medicines, use Gongdu Tang (Attack-Toxin Decoction). If pus fills but is thin and watery, residual toxin will remain later; if the patient eats well and has firm stools, boil one young yellow hen with one tael of Astragali Radix (Huangqi, 黄芪) in water, mix with fermented rice wine, and drink. If pus is clear and tops are insufficient but no other contraindications exist and the patient can eat, the toxin should be vented to achieve success. If complications arise or the patient cannot eat, it is critical. Among these patterns, older patients who can eat have a 50-60% cure rate; younger patients who cannot eat are difficult to treat.
If pus fills but color is too red and the base is diffuse, Blood Heat is unresolved; itching will occur around the ninth or eleventh day. Urgently use Huadu Decoction removing Shengma and adding Chuanxiong, Danggui, Baizhi, Lianqiao, and Rendong. Do not allow scratching. If scratched and bleeding profusely, Qi and Blood flow freely; externally apply finely ground old thatch grass or cover with pine pollen. If scratched due to itching yields clear fluid without blood, survival is unlikely. If lesions dry immediately after breaking, with green-white crusts piled like chicken droppings, eventually teeth-chattering, chills, thirst, and panting will occur, leading to death after twenty days. Scratches resembling peeled fish skin or burns are untreatable.
If during the eighth or ninth day of pus filling, high fever and intense thirst for water occur, this is due to numerous lesions, heavy toxin, and deficiency of exterior-interior Qi and Blood; use Jiawei Sisheng San removing Muxiang and adding Danggui and Shaoyao. Alternatively, if half-filled pus is accompanied by severe heat, irritability, and constant thirst, this indicates fluids distributed outward leaving Lung and Stomach dry; administer large doses of Baoyuan Tang combined with Shengmai San frequently until pus fills and thirst stops. If high fever, cheek thirst, dry tongue, cracked lips, and dry-purple lesions occur, this is severe Blood Heat/toxin, possibly caused by heavy furs and heated beds; do not use previous formulas. Use Xijiao Dihuang Tang removing Moutan Cortex and adding Scutellariae Radix (Huangqin, 芩) and Huanglian.
If wind-cold contraction causes phlegm-panting during pus formation, it is difficult to treat; slight dispersal may help, otherwise death ensues. If abdomen is full and diarrhea occurs after pus fills, this is food stagnation; use Baohe Wan (Harmonize the Stomach Pill) to digest and guide out. If pain persists during pus filling, this is Qi stagnation; use Baoyuan Tang with added Hawthorn Fruit (Shanzha, 山楂) and Muxiang to move stagnation, stopping pain. If collapse and itching persist, this is Blood Heat; use Sisheng San with added Shengdihuang (Rehmanniae Radix Preparata) and Polygonum Multiflorum (Ganshouwu, 干首乌) to cool Blood, stopping itching. If pus is sufficient and itching is tolerable, it is acceptable.
If beyond the tenth day of pus filling, the body feels fatigued, with chest oppression, lethargy, and foul breath, this indicates stomach heat causing sores in throat and tongue; urgently use Huanglian Jiedu Tang (Coptis Detoxification Decoction) or Xiaodu Yin (Detoxifying Drink) with added Fangfeng. Delay leads to successful crusting but by the twentieth day outside, gum erosion with bleeding (Yaxuan, 牙宣), abnormal breathing sounds (Xilu, 息露), or rapid-progressing borax-related ulcers, Fox-Huo syndrome, tooth loss, and lip rot, which are untreatable.