痘之形色初见，吉凶攸分，而寒热虚实亦已可辨，凡调摄挽回之力，惟在此时尤为紧要。且痘
出三日内，毒在半表半里之间，关系最重，故妄汗则成斑烂，妄下则成陷伏，寒凉过用必伤正气，
燥热过用则助邪气，虚寒不补则陷伏痒 ，实热不解则变黑归肾，倘有一瘥，死生立判，医者于此，
不可不为之慎。
一、痘疮见点后，身热稍退，别无内热等证，或色不甚红，顶不甚突者，便有虚象，虽在三五
日内，亦切不可用寒掠之药，恐伤脾胃，为害不小，须以保元汤，或六物煎之类为主，因证加减，
以培养之。
一、痘疮必因热而出，因热而起，若热甚则血躁血枯，其出反难。故于未见点之先，必须察其
寒热，预为调理，若有热证，勿得过用辛热气分等药，恐助火邪，致滋多变。
一、此时最畏泄泻，宜按本条急治之。
一、见点太早者，有吉凶虚实之辨。凡发热一日，或才热便见，必血热毒盛之所致，其证多凶，
但得痘稀而饮食如常，别无他证，则亦无害。若其形气本弱而痘现速者，此营热卫虚，不能约束于
外，故出现太骤，须兼实表，庶可免痒 溃烂之患，宜实表解毒汤主之。如发热一日便出而密者，
其证最凶，其毒必甚，此证最忌温补，宜搜毒煎加柴胡主之，或羌活散加牛蒡子、紫草、蝉蜕，或
调保婴丹；热甚者，调退火丹或双解散急治之，可保一二。其有痘虽出早而色不红紫，热不甚者，
此全属表虚之证，如保元汤、六物煎之类，亦所当用。
一、痘出不快者有数证，须审其有无外感内伤，而辨治其所病。如冬月严寒，或非时阴邪，外
闭寒胜而出迟者，宜五物煎加生姜、麻黄、细辛之类主之，或五积散亦佳。如夏月火热熏蒸，以致血热气虚，烦渴发躁而
出迟者，宜人参白虎汤加木通、干葛主之。有因时气不正，为风寒外邪所袭，以致皮腠闭密，发热
无汗而出迟者，其证必头痛鼻塞，四体拘急酸痛，宜疏邪饮、参苏饮、惺惺散之类主之。若本无诸
邪而出不快者，此气血内虚，不能驱毒托送，而留连于内，宜十宣散，或托里消毒散。若气分大虚
而出不快者，宜保元汤、六气煎。血分大虚者，宜五物煎，或六物煎加减主之。若内有所伤，气滞
而出不快者，宜匀气散、橘皮汤加减主之。头面出不快，当用川芎、荆芥、羌活、防风、天麻之类
为引使。胸腹出不快，当用 本、升麻、紫苏，及紫草木通汤。四肢出不快，当用桂枝、干葛、甘
草、连须、紫草、葱白，各加生姜为佐，连进二服，出自快矣。
一、痘不起发者，虽证有不同，然卒由血气内虚，不能托送者居多。此中或宜兼解散，或专补
元气，当辨而治之。凡出齐之后，或被风寒所闭，而发热头痛，陷伏不起者，宜羌活散、参苏饮，
加内托等药治之。若红点初出，暗昧干燥不起发者凶，宜四物汤加紫草、红花、丁香、蝉蜕、官桂
，或调无价散，量儿大小与之。若便实内热，隐隐肌肉间不起发者，宜紫草饮子。若血分微热而毒
不能达者，宜托里消毒散。若气虚气陷不起者，保元汤，或蝉蜕膏加黄 。若血虚不起者，芎归汤
、四物汤。若血分虚寒不起者，五物煎。若气分虚寒不起者，保元汤、六气煎。若气血俱虚不起者
，六物煎、托里散。凡以上补助气血等剂，须加好酒、人乳、糯米，更妙。凡发痘之药，用本不同
，有以毒攻毒而发痘者，如用山甲、人牙、蟾酥、蝉蜕之属是也；有解毒清毒而发痘者，如草车、
红花、牛蒡子、犀角、木通、连翘、金银花之属是也；有升提气血而发痘者，如川芎、白芷、荆芥、
升麻、蔓荆子之属是也；有解散寒邪而发痘者，如麻黄、桂枝、柴胡、干葛、防风、紫苏、葱白之
属是也；有行气行滞以通壅塞而发痘者，如丁香、木香、陈皮、浓朴、山楂、大黄之属是也；有益
火回阳、健脾止泻而发痘者，如附子、肉桂、干姜、肉豆蔻之属是也。凡此者孰非托里起痘之法，
然但可以此为佐，而必以血气为主，则在乎四君、四物、十全大补之类，庶乎随手而应，无不善矣
。
一、虚证见于报痘之时，即当速为培补，失此不治，必不能灌浆结痂，十日后必致不救。盖痘
疮实热者毒盛可畏，虚寒者内败可畏，但实热证显，虚寒证隐，人多误认，故为害反甚。且痘疮之
所赖者，惟饮食血气。
饮食之本在脾胃，血气之本在肝肾，但使脾胃气强，则滋灌有力，而无内虚陷伏之忧，气血充畅则
毒皆生化，而无表虚痒 之患。此其在气在血，或微或甚，所当早辨而治也。凡痘出灰白不红绽，
或灰黑顶陷，或身无大热，皮嫩色光，溶溶如淫湿之状，或口不渴，饮食少，腹膨溏泄，二便清凉
，皆表里虚寒证也。若气虚者，宜调元汤、四君子汤。气虚微滞者，五味异功散。气虚宜温者，保
元汤、六气煎。脾气虚寒者，养中煎、温胃饮，或理中汤。血虚者，四物汤，血虚宜温者，五物煎
。气血俱虚者，六物煎、五福饮，或八珍汤。气血俱虚而寒者，十全大补汤。脾肾血气大虚大寒者
，九味异功煎、六味回阳饮。脾胃虚寒气滞者，陈氏十二味异功散。凡痘疮色灰白不起发者，气虚
也，候出齐，以保元汤和木通、川芎最稳。
一、火证热毒在见点之后，宜速为清解，若不早治，则日甚一日，必致不救。凡见点太赤，根
下皮色通红，此血热气有不能管束也，后必起发太骤，皮嫩易破，或痒 不可救，宜急清血分之热，
用凉血养营煎，或鼠粘子汤，或用六味消毒饮加芍药治之；或四味消毒饮、益元散俱佳。凡痘疮已
现，毒泄则热当自解，若疮已出而壮热不减，此毒蕴于内，其势方张，其疮必密，宜解其毒，用柴
葛煎、或鼠粘子汤。凡见点之后，壮热不退，或三四点相连，色红带紫，或根窠焦色，红紫成片，
或口唇热燥，烦渴喜冷，舌上有胎，或二便燥涩，此表里皆热，毒盛之重候，急须清热解毒。如表
热甚者，宜柴葛煎，里热甚者，宜搜毒煎加柴胡，或用六味消毒饮加酒芩、木通、栀子、黄连、山
楂、蝉蜕、归、芍、红花之类，或调退火丹加减用之。如热毒内甚而发惊狂谵语者，宜用紫草煎汤
磨犀角汁、调朱砂益元散，或退火丹解之。以上凡解毒之后，红紫退，二便调，能食不渴，此表里
皆清也，切勿再为解毒，须急以保元汤、四物汤、六物煎之类，调补气血以助灌浆收靥，否则恐变
痒而不能善其后矣。如痘疮内热之甚，大便硬结不通，大渴烦躁，腹胀满，脉见洪数而痘出不快
者，此热毒壅伏于内，须遍利之以祛其热毒，宜柴胡饮子，或三黄丸；甚则承气汤，或用猪胆导之。
然此惟热毒在里，痘形未见，不得已而微下之可也。若斑点隐隐见于皮肤中者，此已发越在表，乃
痘疮正发之时，切不可妄用下药。凡痘疮初出，但见红点稠密，急用缠豆藤烧存性，加制过朱砂，
连进二三服，或用薄荷、牛莠子煎汤，调退火
丹服之，另用吴茱萸为末，以水调摊足心，引下热毒，亦可解散其势。
一、痘出变黑，乃危证也。盖痘疮乃血气滋灌，血足气充，则痘自红活；若热毒熏烁，则成焦
黑；若阳气不充，则成灰黑。且黑为水色，其亏在肾，以阴犯阳，最为恶候，当辨而治之。若热毒
凝聚，大便秘结，或烦躁热渴而为焦紫黑陷者，须通其便，先以解里之急，宜柴胡饮子，或当归丸。
得利后，宜即以紫草饮，或加味四圣散以化表之毒，仍用胭脂汁以涂之。若大便不结，别无大热等
证，而痘色黯黑者，总由脾虚不能制水，故见黑色，宜速用五物煎，或保元汤加紫草、红花服之，
外点以四圣丹、胭脂汁。若渐见红活则吉，若更干黑则凶。《心鉴》云∶凡治黑痘，常用保元汤加
芎、桂补提其气，气旺则诸毒自散，黑者转黄，屡试屡验。
一、夹疹夹斑证，本非痘中吉兆，然亦有轻重之辨，宜酌而治之，外有本条，仍宜参阅。凡发
热二三日之间，痘形未见，忽然偏身发出红点一层，密如蚊蚤所咬者，决非痘也，此乃斑疹之属，
多为风寒所遏，不能发越而斑先见也，宜疏邪饮，柴葛煎、或败毒散之属，微散而解之。但得身凉
，斑必自退，再越一日，痘出必轻矣。凡痘夹斑疹齐出者，亦宜辨其寒热，若表里俱热而邪不解者
，宜柴葛煎加减主之。若热邪不甚而表邪甚者，宜疏邪饮，或柴归饮加羌活、防风、干葛之类主之
，或败毒散亦可用。若痘夹红斑如锦纹者，宜凉血化毒汤加柴胡、黄芩、玄参、犀角之属主之。若
痘出夹斑夹疹而眼红唇裂者，表热也；烦躁大渴，妄言妄见者，里热也。表里俱热，最为凶证，若
不表里兼治，何由得解？宜双解散主之。若加闷乱气喘者必不治。
一、贼痘者，于出齐之后，其中有独红独赤独大，摸之皮软而不碍手者，此贼痘也。过三日之
外，必变成水泡，甚至紫黑泡，皆危证也，急用保元汤，或六气煎加紫草、红花、蝉蜕解之，或用
灯草、木遍煎汤，调下益元散，利去心经之热，而红自退。如已成水泡，宜用保元汤，倍加四苓散
利之，此秘法也，不然则遍身擦破，臭烂而死，
一、病于未出之先，倘有湿疮脓水流注者，用附石末敷之，以防其漏气，或真正绿豆粉亦可。
痘疹的形态和色泽在初现时，便决定了吉凶预后，同时寒热虚实的证候也已可以辨别。此时，调护身体、挽回病势的力量，显得尤为紧要。况且痘疹发出后的三天内，毒邪位于半表半里之间，关系最为重大。因此，如果误用发汗法，会导致痘疮溃烂；误用泻下法，会导致痘疮内陷伏匿；过度使用寒凉药物必然损伤正气；过度使用燥热药物则会助长邪气。若是虚寒证而不进行温补，痘疮就会内陷并出现瘙痒溃烂；若是实热证而不清解，痘疮就会变黑并归入肾经（危重证候）。只要有一处处理不当，生死立见分晓，医生对此不可不谨慎对待。
一、痘疮见到红点之后，如果身体发热稍微减退，没有其他内热等证候，或者颜色不是很红，顶部不是很突出的，就显示出虚象。即使在出痘后的三到五天内，也绝对不可以使用寒凉性质的药物，恐怕损伤脾胃，带来的危害不小。应当以保元汤，或六物煎之类的方剂为主，根据具体证候加减，用来培养正气。
一、痘疮必定是因为热邪而出，因为热邪而起。如果热邪太盛，就会导致血液躁动、血液枯竭，反而使得痘疹难以发出。所以在未见红点之前，必须观察其寒热情况，预先进行调理。如果有热证，不要过度使用辛温香燥、走气分的药物，恐怕助长火邪，导致病情多变。
一、此时最害怕的是泄泻，应当按照本条所述的方法紧急治疗。
一、见点过早的，有吉凶虚实的区别。凡是发热一天，或者刚发热就见点的，必定是血热毒盛所致，这种证候多属凶险。但如果痘疹稀疏且饮食如常，没有其他证候，那么也就无害。如果患儿形体元气本来虚弱而痘疹出现得太快的，这是营分有热、卫分虚弱，不能约束毒邪于外，所以出现得太急促，需要兼用固表的方法，才可以避免瘙痒溃烂的祸患，适宜用实表解毒汤主治。如果发热一天就出痘而且密集的，这种证候最凶险，毒邪一定很盛。此证最忌讳温补，适宜用搜毒煎加柴胡主治，或者羌活散加牛蒡子、紫草、蝉蜕，或者调服保婴丹；如果热势严重的，调服退火丹或双解散紧急治疗，还可以保全一二成希望。那些虽然出痘早但颜色不红紫，热势不严重的，这完全属于表虚的证候，像保元汤、六物煎之类的，也是应当使用的。
一、痘出不畅快的有好几种证候，必须审察是否有外感或内伤，从而辨别治疗其所患病症。如果是冬天严寒，或非时节的阴寒邪气，导致外部闭塞、寒邪偏胜而出痘迟缓的，适宜用五物煎加生姜、麻黄、细辛之类的方剂主治，或者五积散也很好。如果是夏天火热熏蒸，导致血热气虚，烦躁口渴、发躁而出痘迟缓的，适宜用人参白虎汤加木通、干葛主治。有的因为时行不正之气，被风寒外邪侵袭，导致皮肤腠理密闭，发热无汗而出痘迟缓的，这种证候必定伴有头痛鼻塞，四肢拘急酸痛，适宜用疏邪饮、参苏饮、惺惺散之类的方剂主治。如果本来没有这些邪气而出痘不快，这是气血内部虚弱，不能驱除毒邪托送外出，而留滞在内，适宜用十宣散，或托里消毒散。如果气分大虚而出痘不快，适宜用保元汤、六气煎。血分大虚的，适宜用五物煎，或六物煎加减主治。如果内部有所损伤，气机阻滞而出痘不快，适宜用匀气散、橘皮汤加减主治。头面部出痘不快，应当用川芎、荆芥、羌活、防风、天麻之类的作为引经药。胸腹部出痘不快，应当用藁本、升麻、紫苏，以及紫草木通汤。四肢出痘不快，应当用桂枝、干葛、甘草、连须（甘草）、紫草、葱白，各加生姜作为佐使，连续服用两剂，痘疹自然出得快了。
一、痘疹不起发的，虽然证候有所不同，但大多是由于血气内部虚弱，不能托送所致。这其中有的适宜兼用解散法，有的专门补益元气，应当辨别后进行治疗。凡是痘疹出齐之后，如果被风寒所闭阻，而发热头痛，痘疹内陷伏匿不起的，适宜用羌活散、参苏饮，加入内托等药物治疗。如果红点刚出来，晦暗干燥不起发的，属凶险，适宜用四物汤加紫草、红花、丁香、蝉蜕、官桂，或者调服无价散，根据孩子的大小给予服用。如果大便干结、内部有热，隐隐在肌肉间不起发的，适宜用紫草饮子。如果血分微热而毒邪不能达出的，适宜用托里消毒散。如果气虚气陷不起的，用保元汤，或蝉蜕膏加黄芪。如果血虚不起的，用芎归汤、四物汤。如果血分虚寒不起的，用五物煎。如果气分虚寒不起的，用保元汤、六气煎。如果气血都虚不起的，用六物煎、托里散。以上所有补助气血的药剂，必须加入好酒、人乳、糯米，效果更妙。凡是用以发痘的药物，作用原理不同，有用毒攻毒来发痘的，比如用穿山甲、人牙、蟾酥、蝉蜕这一类；有解毒清毒来发痘的，比如用车前草、红花、牛蒡子、犀角、木通、连翘、金银花这一类；有升提气血来发痘的，比如用川芎、白芷、荆芥、升麻、蔓荆子这一类；有解散寒邪来发痘的，比如用麻黄、桂枝、柴胡、干葛、防风、紫苏、葱白这一类；有行气行滞以疏通壅塞来发痘的，比如用丁香、木香、陈皮、厚朴、山楂、大黄这一类；有益火回阳、健脾止泻来发痘的，比如用附子、肉桂、干姜、肉豆蔻这一类。所有这些，哪一种不是托里起痘的方法呢？然而只能把这些作为辅助，必须以血气为主，这就在于四君子汤、四物汤、十全大补汤之类的方剂，这样就能随手应验，没有不好的结果。
一、虚证出现在报痘的时候，就应当迅速进行培补，错过这个时机不治疗，必定不能灌浆结痂，十天后必定导致无法救治。大概痘疮实热的，毒邪旺盛令人畏惧；虚寒的，内部败坏令人畏惧。但是实热证候明显，虚寒证候隐蔽，人们容易误认，所以造成的危害反而更深。而且痘疮所依赖的，只有饮食和血气。饮食的根本在脾胃，血气的根本在肝肾。只要使脾胃之气强健，那么滋养灌注就有力量，而没有内部虚弱内陷的忧虑；气血充盛通畅，那么毒邪都能生化，而没有表面虚弱瘙痒的祸患。这在气在血，无论轻微还是严重，都应当尽早辨别并治疗。凡是痘出颜色灰白不红绽，或者灰黑顶部凹陷，或者身体没有大热，皮肤嫩滑光泽，像潮湿浸淫的样子，或者口不渴，饮食少，腹部膨隆溏泄，二便清凉，这些都是表里虚寒的证候。如果是气虚，适宜用调元汤、四君子汤。气虚且有轻微停滞的，用五味异功散。气虚宜温的，用保元汤、六气煎。脾气虚寒的，用养中煎、温胃饮，或理中汤。血虚的，用四物汤，血虚宜温的，用五物煎。气血都虚的，用六物煎、五福饮，或八珍汤。气血都虚且有寒的，用十全大补汤。脾肾血气大虚大寒的，用九味异功煎、六味回阳饮。脾胃虚寒气滞的，用陈氏十二味异功散。凡是痘疮颜色灰白不起发的，是气虚，等到出齐后，用保元汤配合木通、川芎最稳妥。
一、火证热毒在见点之后，应当迅速清解，如果不早点治疗，就会一天比一天严重，必定导致无法救治。凡是见点太红赤，根部皮肤通红，这是血热气盛不能管束的表现，后来必定起发太急，皮肤嫩易破，或者瘙痒不可救药，适宜紧急清解血分之热，用凉血养营煎，或鼠粘子汤，或用六味消毒饮加芍药治疗；或者四味消毒饮、益元散都很好。凡是痘疮已经显现，毒邪泄出则热应当自解，如果疮已出而壮热不减，这是毒邪蕴结在内部，其势头正盛，痘疮必定密集，适宜解除其毒邪，用柴葛煎，或鼠粘子汤。凡是见点之后，壮热不退，或者三四点相连，颜色红带紫，或者根脚焦色，红紫成片，或者口唇热燥，烦躁口渴喜冷饮，舌上有苔，或者二便干燥涩滞，这是表里皆热，毒邪旺盛的重症，急需清热解毒。如果表热严重的，适宜用柴葛煎；里热严重的，适宜用搜毒煎加柴胡，或用六味消毒饮加酒炒黄芩、木通、栀子、黄连、山楂、蝉蜕、当归、芍药、红花之类，或者调服退火丹加减使用。如果热毒内部严重而出现惊狂谵语的，适宜用紫草煎汤磨犀角汁，调服朱砂益元散，或用退火丹解之。以上凡是解毒之后，红紫色消退，二便正常，能进食不口渴，这是表里都清净了，千万不要再解毒，必须紧急用保元汤、四物汤、六物煎之类的，调补气血以帮助灌浆收靥，否则恐怕会变成瘙痒而不能善终。如果痘疮内部热邪极甚，大便硬结不通，大渴烦躁，腹胀满，脉象洪数而痘出不快，这是热毒壅伏在内部，必须遍利小便以祛除热毒，适宜用柴胡饮子，或三黄丸；严重时用承气汤，或用猪胆导法。然而这只有在热毒在里，痘形尚未显现，不得已而轻微泻下的情况才可以。如果斑点隐隐见于皮肤中，这说明已经发越在表，正是痘疮正当发出来的时候，千万不可妄用下药。凡是痘疮初出，只见红点稠密，紧急用缠豆藤烧存性，加入制过的朱砂，连续服用二三剂，或者用薄荷、牛蒡子煎汤，调服退火丹，另外用吴茱萸为末，用水调匀敷在足心，引导热毒下行，也可以解散其势头。
一、痘出变黑，是危重证候。大概痘疮是靠血气滋养灌注，血足气充，则痘自然红活；如果热毒熏灼，则变成焦黑；如果阳气不充，则变成灰黑。而且黑色属水色，亏损在肾，以阴犯阳，是最为恶劣的证候，应当辨别后治疗。如果热毒凝聚，大便秘结，或者烦躁热渴而变成焦紫黑陷的，必须通大便，先用解里的急症，适宜用柴胡饮子，或当归丸。得利后，适宜立即用紫草饮，或加味四圣散以化解表部的毒邪，仍用胭脂汁涂抹它。如果大便不结，没有其他大热等证候，而痘色黯黑的，总归是脾虚不能制水，所以见到黑色，适宜速用五物煎，或保元汤加紫草、红花服用，外用四圣丹、胭脂汁点涂。如果渐渐见红活则是吉兆，如果更干黑则是凶兆。《心鉴》说：凡是治疗黑痘，常用保元汤加川芎、肉桂补提其气，气旺则诸毒自然消散，黑色的转黄，屡试屡验。
一、夹疹夹斑证，本来不是痘中的吉兆，但也有轻重的区别，应当斟酌后治疗，外部有本条内容，仍宜参阅。凡是发热二三天之间，痘形未见，忽然偏身发出一层红点，密如蚊蚤所咬的，决不是痘，这是斑疹一类，多为风寒所遏制，不能发越而斑先出现，适宜用疏邪饮，柴葛煎、或败毒散之类，微微发散而解之。只要得到身体凉爽，斑必定自退，再过一天，痘出必定轻了。凡是痘夹斑疹齐出的，也应当辨别其寒热，如果表里俱热而邪气不解的，适宜用柴葛煎加减主治。如果热邪不盛而表邪严重的，适宜用疏邪饮，或柴归饮加羌活、防风、干葛之类主治，或败毒散也可以用。如果痘夹红斑如锦纹的，适宜用凉血化毒汤加柴胡、黄芩、玄参、犀角之类主治。如果痘出夹斑夹疹而眼红唇裂的，是表热；烦躁大渴，胡言乱语看见幻象的，是里热。表里俱热，是最为凶险的证候，如果不表里兼治，怎么能得解？适宜用双解散主治。如果加上闷乱气喘的必定不治。
一、贼痘，是在出齐之后，其中有单独红、单独赤、单独大的，摸上去皮肤软而不碍手的，这就是贼痘。过了三天之外，必定变成水泡，甚至紫黑泡，都是危重证候，紧急用保元汤，或六气煎加紫草、红花、蝉蜕解之，或者用灯草、木遍煎汤，调下益元散，利去心经的热，红色自然消退。如果已成水泡，适宜用保元汤，倍加四苓散利水，这是秘法，不然则遍身擦破，臭烂而死。
The appearance and color of smallpox (Xiaozhen) at the initial stage determine good or bad prognosis, while the patterns of cold-heat and deficiency-excess can also be identified. At this time, the power of regulation and rescue is particularly crucial. Moreover, within three days after the eruption, the pathogenic toxin lies between the exterior and interior, which is of utmost importance. Therefore, improper sweating will lead to ulceration; improper purgation will cause the lesions to sink and hide; excessive use of cold-cooling herbs will inevitably damage healthy Qi; excessive use of dry-hot herbs will assist pathogenic factors. If deficiency-cold is not supplemented, the lesions will sink and itch/ulcerate; if excess-heat is not resolved, the lesions will turn black and relate to the Kidney (a critical condition). If there is even one mishandling, life and death are decided immediately. Physicians must be extremely cautious in this regard.
1. After the red spots of smallpox appear, if body heat slightly subsides without other internal heat symptoms, or if the color is not very red and the apex is not very prominent, it indicates a deficiency pattern. Even within three to five days after eruption, cold-cooling herbs must absolutely not be used, as they may damage the Spleen and Stomach, causing significant harm. The Baoyuan Tang (Preserve the Origin Decoction) or Liuwu Jian (Six-Material Decoction) should be used as the main formula, modified according to the syndrome, to nourish and support the body.
2. Smallpox erupts and rises due to heat. If heat is excessive, it causes blood agitation and blood depletion, making eruption difficult. Therefore, before the appearance of spots, one must observe cold-heat conditions and regulate in advance. If heat signs are present, do not overuse acrid-warm, qi-moving herbs, lest they aggravate fire pathogens and cause variable complications.
3. Diarrhea is most feared at this stage and should be treated urgently according to the relevant section.
4. Early appearance of spots has distinctions of good/bad and deficiency/excess. If fever lasts only one day, or spots appear as soon as fever starts, it is caused by blood heat and abundant toxin, usually indicating a ominous prognosis. However, if the spots are sparse and appetite remains normal without other symptoms, it is harmless. If the patient's constitution is originally weak but spots appear rapidly, this is Ying-heat with Wei-deficiency, unable to constrain pathogens externally, leading to sudden eruption. It requires simultaneous exterior-strengthening to avoid itching and ulceration. Shibiao Jiedu Tang (Exterior-Solidifying and Toxin-Resolving Decoction) is indicated. If spots appear densely after one day of fever, the prognosis is worst and toxin is severe. This pattern strictly forbids warm-tonification. Sousong Decoction (Search-toxin Decoction) plus Chaihu (Bupleuri Radix) is indicated, or Qianghuo San (Notopterygii Rhizoma et Radix Powder) plus Niubangzi (Arctii Fructus), Zicao (Arnebiae Radix seu Rubra), and Chantui (Cicadae Periostracum), or Bao Ying Dan (Infant-Preserving Pill). For severe heat, Tuihuo Dan (Fire-Removing Pill) or Shuangjie San (Double-Resolving Powder) should be used urgently for a slight chance of survival. If spots appear early but are not red-purple and heat is mild, it belongs entirely to exterior deficiency. Baoyuan Tang or Liuwu Jian are appropriate.
5. Slow eruption has several patterns; one must examine for exterior invasion or internal injury to treat accordingly. In winter severe cold, or non-seasonal Yin-cold pathogens closing the exterior, causing slow eruption due to excess cold, Wuwu Jian (Five-Material Decoction) plus Shengjiang (Zingiberis Rhizoma Recens), Mahuang (Ephedrae Herba), and Xixin (Asari Radix) is indicated, or Wuji San (Five-accumulations Powder) is also good. In summer, heat steaming causes blood heat and Qi deficiency, restlessness, thirst, and agitation with slow eruption; Renshen Baihu Tang (Ginseng White Tiger Decoction) plus Mutong (Akebiae Caulis) and Gange (Puerariae Radix) is indicated. If affected by abnormal seasonal Qi, invaded by Wind-Cold exterior pathogens, causing closed pores, fever, no sweat, and slow eruption, accompanied by headache, nasal congestion, and limb stiffness/pain, Shuxie Yin (Dispersing Pathogens Infusion), Shen Su Yin (Ginseng and Perilla Infusion), or Xingxing San (Awakening Powder) are indicated. If there are no such pathogens but eruption is slow, it is due to internal Qi and Blood deficiency failing to drive out toxin, leaving it stagnant internally. Shixuan San (Ten-Accumulations Powder) or Tuoli Xiaodu San (Interior-Supporting and Toxin-Resolving Powder) are indicated. For severe Qi deficiency slowing eruption, Baoyuan Tang or Liuqi Jian (Six-Qi Decoction) are used. For severe Blood deficiency, Wuwu Jian or Liuwu Jian are used. For internal injury causing Qi stagnation and slow eruption, Yunqi San (Harmonizing Qi Powder) or Jupi Tang (Tangerine Peel Decoction) are used. For slow eruption on the head and face, Chuanxiong (Ligustici Chuanxiong Rhizoma), Jingjie (Schizonepetae Herba), Qianghuo (Notopterygii Rhizoma et Radix), Fangfeng (Saposhnikoviae Radix), and Tianma (Gastrodiae Rhizoma) are used as guiding herbs. For chest and abdomen, Gaoben (Ligustici Wallichii Rhizoma), Shengma (Cimicifugae Rhizoma), Zisu (Perillae Folium), and Zicao Mutong Tang (Arnebia and Akebia Decoction) are used. For limbs, Guizhi (Cinnamomi Ramulus), Gange, Gancao (Glycyrrhizae Radix et Rhizoma), Lianxu (Gancao with roots), Zicao, and Congbai (Allii Fistulosi Bulbus) plus Shengjiang as assistants are used; two doses will ensure rapid eruption.
6. Failure of eruption varies but is mostly due to internal Qi and Blood deficiency failing to push outward. Some require simultaneous dispersal, others require tonifying Yuan Qi exclusively. After full eruption, if blocked by Wind-Cold with fever, headache, and sinking lesions, Qianghuo San or Shen Su Yin plus interior-supporting herbs are used. If red spots are dark, dry, and fail to rise, it is ominous; Siwu Tang (Four-Substance Decoction) plus Zicao, Honghua (Carthami Flos), Dingxiang (Syzygii Flos), Chantui, and Guanzi Gui (Cinnamomi Cortex) or Wu Jia San (Priceless Powder) adjusted for age is used. If constipation and internal heat cause hidden failure to rise, Zicao Yin (Arnebia Infusion) is used. For slight Blood heat preventing toxin release, Tuoli Xiaodu San is used. For Qi deficiency and sinking, Baoyuan Tang or Chantui Gao (Cicada Paste) plus Huangqi (Astragali Radix) is used. For Blood deficiency, Xionggui Tang (Angelica and Ligusticum Decoction) or Siwu Tang is used. For Blood deficiency-cold, Wuwu Jian is used. For Qi deficiency-cold, Baoyuan Tang or Liuqi Jian is used. For both Qi and Blood deficiency, Liuwu Jian or Tuoli San is used. These Qi-Blood tonics work best with good wine, human milk, and glutinous rice. Eruptive herbs differ: some attack toxin with toxin (Shanjia [Manis Squama], Renya [Hominis Dentium Os], Chansu [Toad Venom], Chantui); some clear toxin (Cheqiancao [Plantaginis Herba], Honghua, Niubangzi, Xijiao [Rhinocerotis Cornu - note: substitute with Buffalo Horn in modern practice], Mutong, Lianqiao (Schizonepetae Herba? No, Forsythiae Fructus), Jinyinhua (Lonicerae Japonicae Flos)); some lift Qi and Blood (Chuanxiong, Baizhi (Angelicae Dahuricae Radix), Jingjie, Shengma, Manjingzi (Viticis Semen)); some disperse Cold (Mahuang, Guizhi, Chaihu (Bupleuri Radix), Gange, Fangfeng, Zisu, Congbai); some move Qi to unblock obstruction (Dingxiang, Muxiang (Aucklandiae Radix), Chenpi (Citri Reticulatae Pericarpium), Houpo (Magnoliae Officinalis Cortex), Shanzha (Crataegi Fructus), Dahuang (Rhei Radix et Rhizoma)); some warm Fire and restore Yang to stop diarrhea (Fuzi [Aconiti Lateralis Radix Praeparata], Rougui [Cinnamomi Cortex], Ganjiang (Zingiberis Rhizoma), Roudoukou (Myristicae Semen)). All these support the interior to promote eruption, but must be auxiliaries to the main treatment of Qi and Blood via Sijunzi Tang (Four-Gentlemen Decoction), Siwu Tang, or Shiquan Dabu Tang (Comprehensive Great Tonifying Decoction) for success.
7. Deficiency patterns during the reporting phase require immediate tonification; otherwise, pustule formation and scabbing will fail, leading to death after ten days. Excess-heat smallpox fears abundant toxin; deficiency-cold fears internal collapse. Excess-heat is obvious; deficiency-cold is hidden, often misdiagnosed, causing greater harm. Smallpox relies on diet and Qi/Blood. Diet root is Spleen/Stomach; Qi/Blood root is Liver/Kidney. Strong Spleen/Stomach Qi ensures nourishment without internal sinking; sufficient Qi/Blood transforms toxin without exterior itching. Differentiate early. Gray-white non-red spots, gray-black sunken tops, no high fever, tender shiny skin like dampness, no thirst, poor appetite, distended abdomen, loose stools, cool urine/stool indicate exterior-interior deficiency-cold. For Qi deficiency, Diaoyuan Tang (Regulate Origin Decoction) or Sijunzi Tang. For Qi deficiency with slight stagnation, Wuwei Yigong San (Five-Ingredient Extra-Effort Powder). For Qi deficiency needing warmth, Baoyuan Tang or Liuqi Jian. For Spleen Qi deficiency-cold, Yangzhong Jian (Nourish Middle Decoction), Wenwei Yin (Warm Stomach Infusion), or Lizhong Tang (Regulate Middle Decoction). For Blood deficiency, Siwu Tang; for Blood deficiency needing warmth, Wuwu Jian. For both Qi/Blood deficiency, Liuwu Jian, Wufu Yin (Five-Fortune Infusion), or Bazhen Tang (Eight-Treasure Decoction). For both deficient and cold, Shiquan Dabu Tang. For severe Spleen/Kidney Qi/Blood deficiency-cold, Jiwei Yigong Jian (Nine-Ingredient Extra-Effort Decoction) or Liuwei Huiyang Yin (Six-Ingredient Restore-Yang Infusion). For Spleen/Stomach deficiency-cold with Qi stagnation, Chen's Twelve-Ingredient Extra-Effort Powder. For gray-white non-rising spots (Qi deficiency), after full eruption, Baoyuan Tang with Mutong and Chuanxiong is safest.
8. Fire-pattern toxin after spot appearance requires rapid clearing. Delay leads to worsening and death. Very red spots with red base skin indicate Blood heat/Qi excess failing to constrain, leading to rapid, fragile eruption prone to fatal itching. Urgently clear Blood heat using Liangxue Yangying Jian (Cool Blood Nourish Ying Decoction), Shi Niu Zi Tang (Arctii Decoction), or Liuwei Xiaodu Yin (Six-Ingredient Toxin-Resolving Infusion) plus Shaoyao (Paeoniae Radix); or Siwei Xiaodu Yin (Four-Ingredient Toxin-Resolving Infusion), Yi Yuan San (Benefit-Origin Powder). If toxin clears but fever persists, toxin is trapped internally with dense spots; resolve toxin with Chaige Jian (Bupleuri and Pueraria Decoction) or Shi Niu Zi Tang. Persistent high fever, connected red-purple spots, scorched bases, red-purple patches, dry hot lips, thirst for cold, tongue coating, dry stool/urine indicate severe interior-exterior heat/toxin. Clear heat/toxin urgently. Severe exterior heat: Chaige Jian. Severe interior heat: Sousong Decoction plus Chaihu, or Liuwei Xiaodu Yin plus Jiuhuangqin (Wine-fried Scutellariae Radix), Mutong, Zhizi (Gardeniae Fructus), Huanglian (Coptidis Rhizoma), Shanzha, Chantui, Danggui (Angelicae Sinensis Radix), Shaoyao, Honghua; or Tuihuo Dan. If heat-toxin causes惊狂 (startled madness) and delirium, Zicao Jian (Arnebia Decoction) ground with Xijiao (Rhinocerotis Cornu) juice, mixed with Zhusha Yi Yuan San (Cinnabar Benefit-Origin Powder) or Tuihuo Dan. After detoxification, if redness fades, bowels normalize, appetite returns, stop detoxification. Immediately tonify Qi/Blood with Baoyuan Tang, Siwu Tang, Liuwu Jian to aid pustulation/scabbing, lest itching occur. If severe internal heat causes hard constipation, extreme thirst, irritability, abdominal fullness, surging-rapid pulse, and slow eruption, heat-toxin is trapped internally. Promote urination to remove heat-toxin using Chaihu Yinzi (Bupleuri Infusion) or Sanhuang Wan (Three-Yellow Pill); severely, Chengqi Tang (Chengqi Decoction) or Pig Gallbladder enema. This is only for internal heat-toxin before visible spots, used mildly if necessary. If spots are faintly visible on skin, they are emerging externally; do not use purgatives. For dense red spots initially, burn Chandouteng (Entadae Phaseoloides Caulis) to charcoal, add processed Zhusha (Cinnabar), take 2-3 doses; or Bohe (Menthae Haplocalycis Herba), Niuxiangzi (Arctii Fructus) decoction with Tuihuo Dan. Apply Wuzhuyu (Evodiae Fructus) powder mixed with water to soles to guide heat down.
9. Black smallpox is critical. Healthy blood/Qi makes spots red/vibrant; heat-toxin scorching makes them black; insufficient Yang makes them gray-black. Black relates to Water/Kidney, Yin attacking Yang, a dire sign. Differentiate and treat. If heat-toxin aggregates with constipation, irritability, thirst, turning black/depressed, unblock bowels first with Chaihu Yinzi or Danggui Wan (Angelica Pill). After evacuation, use Zicao Yin or Jiawei Sisheng San (Modified Four-Sages Powder) to resolve exterior toxin, apply Yanzhi Zhi (Red Lac Juice). If no constipation/heavy heat but dark/black spots, it is Spleen deficiency failing to control Water. Use Wuwu Jian or Baoyuan Tang plus Zicao, Honghua orally; apply Sisheng Dan, Yanzhi Zhi externally. Red/vibrant return is good; dry/black is bad. *Xinjian* states: Treat black spots with Baoyuan Tang plus Chuanxiong, Rougui to boost Qi; strong Qi disperses toxins, black turns yellow.
10. Smallpox with rash/macules is not auspicious but has severity levels. Between 2-3 days of fever, if red spots appear suddenly all over like mosquito bites before smallpox shape, it is macules/rash, not smallpox, caused by Wind-Cold blocking eruption. Use Shuxie Yin, Chaige Jian, or Baidu San (Resolve-Toxin Powder) to gently disperse. Once cool, macules fade, and subsequent smallpox will be mild. For simultaneous smallpox and macules/rash, differentiate cold/heat. Interior-exterior heat with unresolved pathogen: Chaige Jian modified. Mild heat, severe exterior pathogen: Shuxie Yin or Chai Gui Yin (Bupleuri and Angelica Infusion) plus Qianghuo, Fangfeng, Gange; or Baidu San. Red macules like brocade: Liangxue Huadu Tang (Cool Blood Transform-Toxin Decoction) plus Chaihu, Huangqin (Scutellariae Radix), Xuanshen (Scrophulariae Radix), Xijiao. Eye redness/lip cracking indicates exterior heat; irritability/thirst/delusions indicate interior heat. Both are dire; treat both with Shuangjie San. Dyspnea/confusion is untreatable.
11. "Thief Smallpox" appears after full eruption: single red/huge spots, soft to touch. After 3 days, they become blisters, even purple-black, critical. Urgently use Baoyuan Tang or Liuqi Jian plus Zicao, Honghua, Chantui; or Dengcao (Junci Medulla), Mubian decoction with Yi Yuan San to drain Heart heat, fading redness. If blisters form, Baoyuan Tang plus Sibing San (Four-Drain Powder) to diurese; this is a secret method, else whole body breaks down and rots.
12. Before eruption, if wet sores with pus flow, apply Fusshi Mo (Adhering Stone Powder) to prevent Qi leakage, or true Mouton Fen (Mung Bean Starch) works too.