一、气血各有所主。凡痘之终始，无非藉赖血气，但得血气充畅，则易出易收，血气不足，则
变证百出，故治痘者，必当先顾血气。然气属阳，无形者也；血属阴，有形者也。故无形之属，皆
气主之；有形之属，皆血主之。是以气主标，血主本；气主发，血主肥；气主形，血主色；气主橐
，血主根基。故气能起胀，以主乳郭；血能灌浆，以成饱满。至其为病，则凡为白，为陷，为灰
色，为不起发，为顶有孔，为出水，为痛，为痒，为浮肿，为豆壳，为不靥不落，为饥表不固，为
肤腠不通等证，皆气之为病也。又如为紫黑，为干枯，为无血，为无脓，为黑陷黑靥，为胛痛牙疳，
为疔痈斑疹，为津液不达，为痘后余毒，皆血之为病也。此气血之分固有如是，然血无气不行，气
无血不止。气至而血不随，虽起发而灌必不周；血至而气不至，虽润浮而毒终不透。故治此者，有
不可不兼顾也。
一、察痘之要，惟在虚实二字。盖实者，邪气实也，邪实者，宜清宜泻；虚者，血气虚也，血
气虚者，宜温宜补。且痘本胎毒，非藉元气不能达，非藉元气不能收。故凡欲解毒清火，亦须凭借
元气，使元气无力，则清亦不能清，解亦不能解，设有不支，尚能堪此清解不？此痘疮之终始，皆
当斟酌元气为主。
一、痘疮表实里虚者，必易出难靥；表虚里实者，必难出易靥；若表里之气俱充实，其疮必
易出易靥。故儿自始出以至十日之外，外则浑身壮热，内则饮食二便俱如常，此即表里俱实者也，
其疮必光泽起发，且易收易靥也。
一、表里各有虚实。凡表虚者，或恶寒，成身不大热，或寒热往来，四肢厥冷，或面青色白，
多汗恶风，或怠惰嗜卧，或痘色灰白、顶陷不起、发不光泽，或色嫩皮薄痒 ，或如水泡、摸不碍
手，或根窠不红，或倒靥不能结痂，脉必浮细而弱，是皆表虚之证，治宜温补阳分。里虚者，凡
痘疮已出未出之间，有为吐泻呕恶，或喜热饮食，或为少食、不思饮食，或食亦不化，或为二便清
利，为溏泻，为不渴，为气促声微，为神昏多睡，为腹膨嗳气，为吞酸，为脉弱无力，是皆里虚之
证，治宜温补阴分。表实者，为身体壮热无汗，为面赤唇紫、头疼身痛、眼红鼻塞、皮焦肤赤、手
足热甚，为痘色红紫， 肿疼痛，为皮浓而硬，为痈肿斑疔，为脉浮洪滑大，是皆表实之证，治宜
清解表邪。里实者，为二便秘结，胸膈胀满，为唇燥咽干、口疮舌黑，为大渴咳嗽、痰涎喘粗，
为烦躁惊狂、声高谵语，为脉沉数洪滑，是皆里实之证，治宜清解里邪。
张翼之曰∶吐泻少食为里虚，陷伏倒靥灰白为表虚，二者俱见，为表里俱虚，用异功散救之，
甚至桂、附、灵砂亦可用。若能食便秘而陷伏倒靥者为里实，轻则射干鼠粘子汤，重则前胡枳壳汤。
下痢多血能食者为里实，若实其里则结痈毒。红活绽突为表实，若补其表则溃烂不结痂。
一、痘疮表里皆有寒热，热则阳证，寒则阴证，寒则血气凝涩而不章，热则血气淖泽而不敛。
然热证多
实，最忌 、术、桂、附及诸热燥之物，若元气虚弱者，即有热证，总不可执为实热。寒证多虚，
最忌芩、连、栀、檗及诸苦寒之物，虽形体强盛，但见虚脉虚证，总不可认作有余。
表寒者，不起发，不红活，根窠淡白，身凉痒 ，倒陷干枯，皆肌表无阳之证，治宜补阳温表。
里寒者，为吐泻，为呕恶，为腹胀，为腹痛，为吞酸，为不欲食，为寒战切牙，气寒喜暖，为
二便清利、完谷不化，皆脏腑无阳之证，治宜温中补阳。
表热者，为肌肤大热，根窠红紫、顶赤发斑，头面红肿，紫黑焦枯，痈肿疔毒甚，皆火在肌表
之证，治宜散邪解毒。
里执者，为烦躁狂言，口干大渴，咽肿喉痛，内热自汗，小便赤涩，大便秘结，衄血溺血，皆
火在脏腑之证，治宜清热解毒。虚实寒热等证，虽表里之分，各有如此，然表之虚实，表之寒热，
孰不由中气之所使，故惟善治中气，则未有表不和调者也，是即必求其本之道。
一、纯阴无阳之证，凡痘疮发热，手足却宜和暖，若手足厥冷，必其人曾有吐泻，脾脏气虚也。
脾主四肢所以冷为恶候，即有外证，亦不可单用发散，反损脾胃之气。此当温中兼表，宜黄 建中
汤，或六气煎、五物煎加防风、羌活、生姜、荆芥之类，以补养脾胃血气，而助痘疹之成就也。
一、气与血各有其主导的功能。凡是痘疮（天花）的发生发展过程，无不依赖气血的支持，只要气血充盛通畅，痘疮就容易发出也容易收靥；若气血不足，则会出现各种变证，因此治疗痘疮的人，必须首先顾护气血。然而，气属于阳，是无形的；血属于阴，是有形的。所以无形的事物，都由气来主导；有形的事物，都由血来主导。因此，气主管表象，血主管根本；气主管发起，血主管充盈；气主管形态，血主管色泽；气主管鼓动，血主管根基。所以气能使痘疮起胀，以形成乳状的隆起；血能使痘疮灌浆，以形成饱满的状态。至于它们致病的情况，凡是表现为白色、凹陷、灰色、不起发、顶部有孔、出水、疼痛、瘙痒、浮肿、结壳、不结痂脱落、肌表不固、腠理不通等证候，都是气发生的病变。又如表现为紫黑色、干枯、无血、无脓、黑陷黑靥、肩背疼痛牙疳、疔痈斑疹、津液不能通达、痘后余毒等，都是血发生的病变。这气血的区分本来就是这样，然而血没有气就不能运行，气没有血就不能止息（指气的依附和稳定）。气到了而血不跟随，虽然能起发但灌浆必然不周全；血到了而气不到，虽然滋润浮起但毒邪终究不能透发。因此治疗这类情况，不可不兼顾两者。
二、观察痘疮的关键，只在于“虚”和“实”两个字。所谓实，是指邪气盛实，邪气盛实的，应当清热泻火；所谓虚，是指气血虚弱，气血虚弱的，应当温补。而且痘疮本是胎毒，不凭借元气就不能透达，不凭借元气就不能收束。所以凡是想要解毒清火，也必须凭借元气，如果元气无力，那么清热也不能清，解毒也不能解，假如身体已经支撑不住，还能承受这种清解之法吗？痘疮的全过程，都应当斟酌元气作为主要依据。
三、痘疮表实里虚的，一定容易发出但难收靥；表虚里实的，一定难发出但易收靥；如果表里之气都充实，痘疮就一定容易发出也容易收靥。所以小儿从开始出痘到十天之外，外部全身壮热，内部饮食和二便都正常，这就是表里俱实的表现，其痘疮一定光泽起发，且容易收束结痂。
四、表里各有虚实。凡是表虚的，有的恶寒，或全身不大热，或寒热往来，四肢厥冷，或面色青白，多汗怕风，或倦怠嗜睡，或痘色灰白、顶部凹陷不起、发出无光泽，或颜色嫩皮薄痒，或像水泡、摸起来不碍手，或根脚不红，或倒靥不能结痂，脉象一定浮细而弱，这些都是表虚的证候，治疗宜温补阳分。里虚的，凡在痘疮已出未出之间，有的出现吐泻呕恶，或喜欢热饮食，或食少、不想饮食，或吃了也不消化，或大小便清利，或溏泻，或不渴，或气促声微，或神昏多睡，或腹部膨隆嗳气，或吞酸，或脉弱无力，这些都是里虚的证候，治疗宜温补阴分。表实的，表现为身体壮热无汗，面赤唇紫、头痛身痛、眼红鼻塞、皮肤焦赤、手足很热，痘色红紫、肿胀疼痛，皮厚而硬，痈肿斑疔，脉象浮洪滑大，这些都是表实的证候，治疗宜清解表邪。里实的，表现为大小便秘结，胸膈胀满，唇燥咽干、口疮舌黑，大渴咳嗽、痰涎喘粗，烦躁惊狂、声音高亢谵语，脉象沉数洪滑，这些都是里实的证候，治疗宜清解里邪。
张翼之说：吐泻少食是里虚，陷伏倒靥灰白是表虚，两者同时出现，是表里俱虚，用异功散救治，甚至桂枝、附子、灵砂也可以使用。如果能进食但便秘且陷伏倒靥的是里实，轻症用射干鼠粘子汤，重症用前胡枳壳汤。下痢多血且能进食的是里实，如果补益其里则会结成痈毒。红活绽突是表实，如果补益其表则会溃烂不结痂。
五、痘疮表里都有寒热，热则是阳证，寒则是阴证，寒则气血凝滞而不显扬，热则气血濡润而不能收敛。然而热证多属实，最忌苍术、白术、桂枝、附子以及各种热燥的药物，如果元气虚弱者，即使有热证，也绝不能固执地认为是实热。寒证多属虚，最忌黄芩、黄连、栀子、黄柏以及各种苦寒的药物，虽然形体强盛，但只要见到虚脉虚证，就绝不能认作有余。
表寒的，不起发，不红活，根脚淡白，身凉瘙痒，倒陷干枯，都是肌表无阳的证候，治疗宜补阳温表。
里寒的，表现为吐泻，呕恶，腹胀，腹痛，吞酸，不欲食，寒战咬牙，气寒喜暖，大小便清利、完谷不化，都是脏腑无阳的证候，治疗宜温中补阳。
表热的，表现为肌肤大热，根脚红紫、顶部赤红发斑，头面红肿，紫黑焦枯，痈肿疔毒严重，都是火在肌表的证候，治疗宜散邪解毒。
里热的（原文误作“里执”，据义修正为里热），表现为烦躁狂言，口干大渴，咽肿喉痛，内热自汗，小便赤涩，大便秘结，衄血溺血，都是火在脏腑的证候，治疗宜清热解毒。虚实寒热等证候，虽然表里的区分各有如此，但是表的虚实、表的寒热，哪一个不是由中气所导致的呢？所以只有善于治理中气，就没有表不和调的了，这就是必求其本道的道理。
六、纯阴无阳的证候，凡是痘疮发热，手足却应该和暖，如果手足厥冷，一定是此人曾经有吐泻，脾脏气虚所致。脾主四肢，所以寒冷是恶候，即使有外证，也不可单用发散法，反而损伤脾胃之气。此时应当温中兼治表，宜用黄芪建中汤，或六气煎、五物煎加防风、羌活、生姜、荆芥之类，以补养脾胃气血，从而帮助痘疹的成就。
1. Qi and Blood each have their respective dominions. Throughout the entire process of smallpox (Dochuang), there is no reliance other than on Qi and Blood. If Qi and Blood are abundant and unobstructed, the eruption will be easy to emerge and easy to resolve; if Qi and Blood are deficient, myriad complications will arise. Therefore, those treating smallpox must first attend to Qi and Blood. However, Qi belongs to Yang and is formless; Blood belongs to Yin and is formed. Thus, formless entities are primarily governed by Qi; formed entities are primarily governed by Blood. Hence, Qi governs the superficial aspects, while Blood governs the root; Qi governs the initiation, while Blood governs the fullness; Qi governs the shape, while Blood governs the color; Qi governs the inflation, while Blood governs the foundation. Therefore, Qi enables the pustules to swell, forming the milky elevation; Blood enables the pustules to fill with pus, achieving fullness. Regarding pathological manifestations: symptoms such as white color, depression, grayish hue, failure to erupt, perforated tops, oozing fluid, pain, itching, edema, crust formation, failure to scab and fall off, unstable exterior, and blocked interstices are all diseases caused by Qi. Conversely, symptoms such as purple-black discoloration, dryness and withering, lack of blood, absence of pus, black depression and black scabs, shoulder/back pain and cancrum oris, ding carbuncles and maculopapular rashes, inability of body fluids to reach, and residual toxins after smallpox are all diseases caused by Blood. Although the distinction between Qi and Blood is indeed as described, Blood cannot circulate without Qi, and Qi cannot stabilize without Blood. If Qi arrives but Blood does not follow, although eruption may occur, filling will inevitably be incomplete; if Blood arrives but Qi does not, although moistening and floating may occur, the toxin will ultimately fail to be vented. Therefore, in treating these conditions, one must not neglect attending to both.
2. The key to observing smallpox lies solely in the concepts of Deficiency (Xu) and Excess (Shi). "Excess" refers to the excessiveness of pathogenic factors; when pathogens are excessive, clearing and purging are indicated. "Deficiency" refers to the deficiency of Qi and Blood; when Qi and Blood are deficient, warming and tonifying are indicated. Moreover, smallpox originates from fetal toxins; without Yuan Qi (Primal Qi), it cannot be vented outward, and without Yuan Qi, it cannot be resolved inward. Thus, even when seeking to detoxify and clear heat, one must rely on Yuan Qi. If Yuan Qi is weak, clearing will not work, and resolving will not work. If the body is already unable to withstand the condition, how could it endure further clearing and resolving? The entire course of smallpox should be evaluated with Yuan Qi as the primary consideration.
3. In cases where the Exterior is Excess and the Interior is Deficient, eruption will be easy but resolution difficult; where the Exterior is Deficient and the Interior is Excess, eruption will be difficult but resolution easy; if both Exterior and Interior Qi are substantial, eruption and resolution will both be easy. Thus, from the initial emergence of the rash until beyond ten days, if the exterior presents with high fever throughout the body, and the interior shows normal diet and bowel/bladder functions, this indicates Excess in both Exterior and Interior. The lesions will be lustrous and erupt easily, and will resolve and scab easily.
4. Both Exterior and Interior have states of Deficiency and Excess. Exterior Deficiency manifests as aversion to cold, or low-grade fever, alternating chills and fever, cold limbs, cyanotic or pale complexion, profuse sweating and wind-aversion, lethargy and desire to sleep, grayish-white lesions that are depressed and dull, tender skin with itching, vesicle-like appearance that feels soft to touch, non-red bases, inverted scabbing failing to form crusts, and a pulse that is floating, fine, and weak. These are all signs of Exterior Deficiency, treated by warming and tonifying the Yang aspect. Interior Deficiency occurs during the phase before or after eruption, manifesting as vomiting, diarrhea, nausea, preference for hot drinks, anorexia, indigestion, clear urine and loose stools, non-thirst, shortness of breath with faint voice, mental confusion and somnolence, abdominal distension and belching, acid regurgitation, and a weak, powerless pulse. These are signs of Interior Deficiency, treated by warming and tonifying the Yin aspect. Exterior Excess manifests as high fever without sweat, red face and purple lips, headache and body ache, red eyes and nasal congestion, scorched red skin, very hot hands and feet, red-purple lesions with swelling and pain, thick and hard skin, carbuncles and rashes, and a floating, surging, slippery, and large pulse. These are signs of Exterior Excess, treated by clearing and resolving Exterior pathogens. Interior Excess manifests as constipation of both stool and urine, chest and diaphragm fullness, dry lips and throat, mouth sores and black tongue, extreme thirst with cough and phlegm-wheezing, restlessness, mania, loud voice with delirium, and a deep, rapid, surging, and slippery pulse. These are signs of Interior Excess, treated by clearing and resolving Interior pathogens.
Zhang Yizhi stated: Vomiting, diarrhea, and poor appetite indicate Interior Deficiency; depression, inversion, and grayish-white lesions indicate Exterior Deficiency. When both are present, it is Deficiency in both Exterior and Interior, treated with Yigong San (Extra Efficacy Powder); even Guizhi Tang (Cinnamon Twig Decoction), Fuzi (Prepared Aconite Root), and Lingsha (Cinnabar) may be used. Ability to eat with constipation and inverted lesions indicates Interior Excess; mild cases use Shegan Nu Bazhen Zi Tang (Belamcanda and Burdock Seed Decoction), severe cases use Qianhu Zhiqiao Tang (Peucedanum and Aurantium Decoction). Dysentery with much blood and ability to eat indicates Interior Excess; tonifying the Interior here would lead to carbuncle-toxin formation. Red, vibrant, and protruding lesions indicate Exterior Excess; tonifying the Exterior here would lead to ulceration and failure to scab.
5. Smallpox can present with Cold or Heat in both Exterior and Interior. Heat indicates Yang syndromes; Cold indicates Yin syndromes. Cold causes Qi and Blood to become stagnant and obscure; Heat causes Qi and Blood to become too moist and fail to consolidate. Heat syndromes are mostly Excess, strictly contraindicating Cangzhu (Atractylodes Rhizome), Baizhu (White Atractylodes Rhizome), Guizhi (Cinnamon Twig), Fuzi (Prepared Aconite Root), and other hot/dry substances. If Yuan Qi is weak, even if Heat signs appear, one must not rigidly diagnose them as Excess-Heat. Cold syndromes are mostly Deficiency, strictly contraindicating Huangqin (Scutellaria Root), Huanglian (Coptis Rhizome), Zhizi (Gardenia Fruit), Huangbai (Phellodendron Bark), and other bitter-cold substances. Even if the physique is robust, if Deficient pulses and signs are seen, one must not mistake them for Excess.
Exterior Cold manifests as failure to erupt, lack of redness/vitality, pale bases, cool body with itching, inverted/depressed/withered lesions; these are signs of Yang deficiency in the muscle-surface, treated by tonifying Yang and warming the Exterior.
Interior Cold manifests as vomiting/diarrhea, nausea, abdominal distension/pain, acid regurgitation, anorexia, chattering teeth, aversion to cold/love for warmth, clear urine and undigested food in stool; these are signs of Yang deficiency in the Zang-Fu organs, treated by warming the Middle and tonifying Yang.
Exterior Heat manifests as intense skin heat, red-purple bases, red tops with macules, swollen/red head and face, purple-black scorched/withered areas, severe carbuncles and ding toxins; these are signs of Fire in the muscle-surface, treated by dispersing pathogens and resolving toxicity.
Interior Heat manifests as restlessness, mania, dry mouth with extreme thirst, swollen throat/sore throat, internal heat with spontaneous sweating, dark/scanty urine, constipation, epistaxis, hematuria; these are signs of Fire in the Zang-Fu organs, treated by clearing Heat and resolving toxicity.
Although Deficiency/Excess and Cold/Heat differ by Exterior/Interior, the Deficiency/Excess and Cold/Heat of the Exterior are all driven by the Middle Qi. Therefore, only by skillfully regulating the Middle Qi can the Exterior be harmonized; this is the way of seeking the root cause.
6. In pure Yin without Yang syndromes, although smallpox fever is present, the hands and feet should be warm. If the hands and feet are cold, it indicates prior vomiting/diarrhea and Spleen Qi deficiency. Since the Spleen governs the four limbs, coldness is a bad omen. Even if exterior symptoms exist, one must not use dispersing methods alone, as this damages Spleen and Stomach Qi. Instead, one should warm the Interior while addressing the Exterior, using Huangqi Jianzhong Tang (Astragalus Decoction for Building the Middle), Liuqi Jian (Six Qi Decoction), or Wuwu Jian (Five Substance Decoction) added with Fangfeng (Saposhnikovia Root), Qianghuo (Notopterygium Rhizome), Shengjiang (Fresh Ginger), and Jingjie (Schizonepeta Spike), to nourish Spleen and Stomach Qi and Blood, thereby assisting the maturation of the smallpox eruption.