真人解毒汤（痘五二）
痘疮一证，顺者不必治，逆者不能治，所当治者，惟险证耳。何为险证？如根窠顺而部位险，
部位顺而日期险，日期顺而多寡险，多寡顺而颜色险，颜色顺而饮食险，饮食顺而杂证险，杂证顺
而治疗险，治疗顺而触秽险。然犹有最险者，则在元气与邪气，邪气虽强，元气亦强者无害，只
恐元气一馁，邪气虽微者亦危。设或犯之而不为速治，则顺者不顺，而吉变为凶矣。凡此数者，皆
痘中之要领，所当详察详辨也。故凡欲治痘，必须先识死生，辨虚实，审寒热，明此六者，则尽之
矣。
一、治痘之要，惟邪气正气二者而已。凡邪气盛而无制者杀人，正气虚而不支者杀人，及其危
也，总归元气之败耳，使元气不尽，则未必至死。凡治此者，但知补泻二字，而用之无差，则尽善
矣。故补泻难容苟且，毫厘皆有权衡，必不可使药过于病，亦不可使药不及病。是以善用攻者，必
不致伐人元气，善用补者，必不致助人邪气，务使正气无损，而邪气得释，能执中和，斯为高手。
然执中之妙，当识因人因证之辨。盖人者，本也；证者，标也。证随人见，成败所由，故当以因人
为先，因证次之。若形气本实，则始终皆可治标；若形质原虚，则开手盒饭顾本。若谓用补太早，
则补住邪气，此愚陋之见也。不知补中即能托毒，灌根即能发苗，万无补住之理。是以发源之初，
最当着力，若不有初，鲜克有终矣。此可与智者言，不可与庸人道也。
一、治痘不宜迟。凡痘疹之有不同者，无过寒热虚实四证，大都寒则虚，热则实，虚寒则宜温
补，实热则宜清解。然其挽回之力，当于三五日前治之，过此则恐无及。若七日之后，毒发于外，
外不足则外剥而死，若
毒发不尽，则又内传，内不足则内攻而死。故治痘有时，时之不可失也，有如此。倘初时不慎，则
后来之祸，从此伏矣。
一、解毒当知表里。所谓毒者，火毒也。所谓解毒者，求其所在而逐之也。盖痘疮之发，内则
本于淫火，外则成于风邪，内外相触，其毒乃发。故其发也，不甚于内则甚于外，甚于内者，以火
邪内盛而炽焰于外也；甚于外者，以寒邪外闭而郁火于内也。故但察其无汗外热而邪在表者，则当
疏之散之，使热邪从外而去，则毒亦从外而解矣。若察其多汗内热而邪在里者，则当清之利之，使
热邪从内而泄，则毒亦从内而解矣。其有内热既甚而表邪仍在者，则当表里相参，酌轻重而兼解之，
则邪必皆散矣。若邪不在表，则必不可妄兼发散，以致表气愈虚，而痘必终败，其证则身有汗而外
不甚热者是也。若毒不在里，则必不可兼用寒凉，以致中寒脾败，而瑟必反陷，其证则口不渴而二便
不秘者是也。知斯五者，则蟹毒治实之法，无余蕴矣。此外有虚邪虚火等证，则当先酌元气，次察
邪气，无使失楫中流，顾本不及，则尤为切戒。凡云痘毒者，痘必自内而达外，但得出尽，则内无
毒，但得化尽，则外无毒，既出既化，而不使复陷，则毒尽去矣。故或宜散表，或宜托送，或宜清
解，或宜固中，而治法尽之矣。
一、补虚当辨阴阳。凡痘疮血气各有所属，已见则气血条中。然痘之所主，尤惟阴分为重，何
也？盖痘从形化，本乎精血，凡其见点起胀，灌浆结痂，无非精血所为，此虽曰气为之帅，而实血
为之主。且痘以阳邪，阳盛必伤阴，所以凡治痘者，最当重在阴分，宜滋润不宜刚燥。故曰∶补脾
不若补肾，养阴所以济阳，此秘法也。然血气本自互根，原不可分为两，如参、 、白术之类，虽
云气分之药，若用从血药，则何尝不补血？归、芎、地黄之类，虽云血分之药，若用从气药，则何
尝不补气。故凡见气虚者，以保元汤为主，而佐以归、地。血虚者，以四物汤为主，而佐以参、 。
盖气血本不相离，但主辅轻重，各有所宜，而用之当不，则明拙自有差耳。
一、治痘有要方，兹表而出之，以便择用。其有未尽，当于各条求之。
凡解表诸方，乃初热时所必用者，诸家皆以升麻葛根汤为首，程氏则用苏葛汤，似为更妥，余
则常用柴归饮以兼营卫，似为尤妥，此当随宜择用。营虚表不解者，五柴胡饮。阳气虚寒表不解者，
柴葛桂枝汤。元气本壮而表不解者，疏邪饮，或加减参苏饮。寒气胜而表不解者，五积散，或麻
黄甘草汤。
凡清火解毒诸方，所以解实热也。如欲解毒清火而兼养气者，惟四味消毒饮为妙。鼠粘子汤亦
佳。热毒两盛而不化者，宜搜毒煎。烦热作渴，小水不利者，导赤散、六一散。血热赤斑，烦躁多
渴者，犀角散。热在阴分而失血者，玄参地黄汤。内热不清者，东垣凉膈散。二便供不利而火甚于
内者，通关散。热毒内蓄，小水不利，而为丹为痈者，大连翘饮。烦热多惊而神不安者，七味安神
丸。热毒内甚而狂妄者，退火丹。
凡表里兼解诸方。如内外俱有热邪者，宜柴葛煎，或柴胡麦门冬散。里邪甚而表邪微者，解毒
防风汤。表里俱有邪而元气兼虚者，实表解毒汤。表里俱实热者，双解散。
凡托里诸方，有宜专补元气者，有宜兼解毒者。如气血俱虚不起者，六物煎，或托里散。虚寒
不达，兼托兼表者，参 内托散，或十宣散。气分虚寒不透者，六气煎。气血俱虚，微热不起者，
紫草快斑汤。
凡诸补剂，皆痘中元气根本，祛邪托毒者之所必赖，但见虚邪，必当以此诸方为主。气分不足
者，调元汤。气虚宜温者，保元汤，六气煎。气虚微热宜兼凉解者，参 四圣散。血虚者，四物汤，
芎归汤。血分虚寒宜温者。五物煎。血虚血滞者，养血化斑汤。血虚血热宜兼解毒者，凉血养营煎。
气血俱虚者，六物煎、八珍汤、十全大补汤。气血虚寒，大宜温补者，无如九味异功煎、六味回阳
饮。即陈氏十一味木香散、十二味异功散，但虚寒而兼气滞者宜用之，欲赖补虚，大有不及。
凡攻下诸方，亦痘中所不可无，惟必不得已然后用之，勿得视以为常也。血虚秘结，大便不通
者，四顺清凉饮。里实多滞秘结者，前胡枳壳汤。表里俱实，大便不通者，柴胡饮子。血热便结毒
盛者，当归丸。
一、凡痘已出尽，内无不虚，盖随痘而为托送者，背元气也。使于此时，不知培补化源，则何
以灌浆？何以结痂？何以收靥？倘内虚无主，将恐毒母气复陷，无不危矣。若痘之稀疏者，气血之耗，
犹为有限，若痘之多而
甚者，其气血内亏，必更甚矣。此不可不预为之防也。
一、平顺之痘，毒原不甚，既出之后，内本无邪，此辈原不必治。无奈父母爱子之切，且不识
病之轻重，故必延医诊视。既延医至，无不用药。既已用药，无匪寒凉。在彼立意不过，曰∶但解
其毒，自亦何妨？不知无热遭寒，何从消受？生阳一拔，胃气必伤，多致中寒泄泻，犹云协热下利，
更益芩、连，最可恨也。又如痘疮初见发热，每多不审虚实，止云速当解毒，凡于十日之外，多有
泄泻而致毙者，皆此辈之杀之也。冤哉，冤哉！
余见者多矣，故笔诸此以为孟浪者戒。
一、痘在肌肉，阳明主之，故自出齐以后，最不宜吐泻，与其救治于倒陷之后，孰若保脾土于
未坏之先？
故凡生果茶水之类，皆宜慎用，而寒凉之药，尤不可不慎也。
一、治痘须辨其证，大部湿多则泡，血热则斑，气不足则顶陷，血不足则浆毒不附，里实大补
则生痈毒，表实大补则不结痂。里虚不补则内攻而陷，表虚不补则外剥而枯。但使周身气血活泼无
碍，则虽密亦不难治。故惟贵得中，勿使偏胜，则寒热虚实，自无太过不及之患，斯足云尽善矣。
一、秘传治痘之法，首尾当以四物汤为主，随证加减用之。惟肚腹不实者须远当归，但将全剂
通炒微焦，则用自无碍，且复有温中暖脾之妙。
一、首尾皆忌汗下，此先哲治痘之心法。盖妄汗者，必伤阳气，阳气伤则凡起发、灌浆、收靥
之力，皆失所赖，此表虚之为害也。妄下者，必伤阴气，阴气伤则凡脏腑化源，精神锁钥，饮食仓
廪，皆为所败。此里虚之为害也。然表虚者，犹赖里气完足可以充之，里虚则根本内溃，卫气亦从
而陷，无策可施矣。故古人深以汗下为戒，诚至要之旨也。然此以常道为言，非所以应变者设。遇
外感寒邪，腠理闭密，其出不快，其发不透者，若不用辛甘发散之剂以通达肌表，则痘有壅遏之患
矣。又若有大小便秘结，而毒有留伏不达者，不与苦寒泄利之药以疏通脏腑，则有胀满烦躁，焦紫
黑陷等患矣。故当察其虚实，审其常变，当汗则汗，当下则下，中病则已，无过其制。若无汗下之
证，则必不可妄用汗下，以贼人之命也。务得其宜，然后谓之明医，而福自有归矣。
万氏曰∶解其火毒，恐郁遏而干枯；养其血气，欲流行而舒畅。按此说诚善。然所谓火毒者，
以实热为言，若火有虚实真假，则不得概认为火毒。
程氏曰∶痘疮出自六腑，先动阳分，而后归阴经，其本属阳，故多发热而阴血虚耗者多也。首
尾当滋阴补血为主，不可一毫动气，贵从缓治，所以白术、半夏之燥悍，升麻之提气上冲，皆不可
轻用也。且痘疮多有血热者，故宜用四物汤加芩、连之属，以养其阴而退其阳也。
程氏曰∶痘毒根于淫火，必因岁气传流而发，故多兼表证，则内外交攻。此时若不用轻扬之剂，
祛风散邪，淡渗解毒之药，利便退热，则外邪内火何由得解？邪既不解，则痘何由得善？此治之不
容已也。然治之之法。必须审儿形色，察儿虚实，因证用药，庶几神效。世之医者多宗钱氏清凉解
毒之论，或按陈氏辛温发敬之方，主见不同，致误多矣。殊不知痘疹色灰白，不起发，根窠不红活，
此皆虚寒，必宜陈氏方救之。荀非理明于心，无不眩惑。故必热则凉之，寒则温之，虚则补之，实
则泻之，何患乎疾之不愈耶。
程氏曰∶治痘之要，始出之前，宜开和解之门；既出之后，当塞走泄之路；落痂之后，清凉渐
进；毒去已尽，补益宜疏。
程氏曰∶凡治痘，前后须加木通，以泻热邪自小便中出，不使攻胃，令无变黑之证。七日之后，
热退者，少用之。凡痘疮前后总有危证，万勿用天灵盖、脑、麝之属攻之。盖毒出一步，财内虚一
步，血气运一日，则内耗一日，岂可夏用辛香耗气之剂，虽侥幸偶中，后必有余害也。是可见王霸
之珠，相去远矣。
程氏曰∶凡妇人有孕而出痘者，以安胎为主。气虚者，保元汤。血虚者，四物汤，或加白术、
黄芩、砂仁、陈皮，必使胎气无损为主。
程氏曰∶桂岩郑先生云∶痘者象其形而名之也。愚谓不独象形而名，而治之之法，亦犹农家之
种豆也。豆之为物，上实则难出，土瘠则难长，故实者锄扰之，瘠者灌沃之，不实不瘠，惟顺其性，
不使物害之而已，知此则可以语医矣。今人于痘初起，不察虚实寒热，或过用木香散、异功散之类，
则以火济火，致变紫黑倒陷，
痈毒吐衄者有之；或妄用芩、连、栀、檗寒凉之药，则大伤脾胃，为吐为泻，为寒战内陷者有之。
故凡治痘之法，六日之前，不宜温补，亦不宜妄用寒凉。师云∶凡解毒之内，略加温补，温补之中
，略加解毒，此不传不刻之秘诀也。若六日以后，毒已尽出于表，当温补而不温补者，脓不得壮而
痒寒战之患，必所不能兔矣。
真人解毒汤（痘五二）
痘疮这一病症，顺证的不必治疗，逆证的治疗无效，应当治疗的，只有险证罢了。什么是险证？比如根脚顺而部位险，部位顺而日期险，日期顺而出疹多少险，出疹多少顺而颜色险，颜色顺而饮食险，饮食顺而兼夹病险，兼夹病顺而治疗险，治疗顺而触秽险。然而还有最危险的，在于元气与邪气的较量。邪气虽然强盛，如果元气也强盛则无害；只怕元气一旦衰弱，即使邪气微弱也会造成危险。假如犯了这种病而不迅速治疗，那么顺证也会变得不顺，吉兆就会变为凶兆了。以上这些情况，都是痘病中的关键要点，必须详细观察和辨别。所以凡是想要治疗痘疮，必须先识别生死，辨别虚实，审察寒热，明白这六个方面，就掌握全部要领了。
一、治疗痘疮的关键，只在于邪气和正气这两者而已。凡是邪气盛而没有制约的会杀人，正气虚而不能支撑的会杀人，到了危急的时候，总归是元气的败坏。只要元气没有完全耗尽，就不一定会死。凡是治疗这种情况的人，只知道补法和泻法这两个字，并且使用得当没有差错，那就完美了。所以补法和泻法不容许马虎，毫厘之间都有权衡，绝不能让药力超过病情，也不能让药力达不到病情。因此善于攻伐的人，一定不会损伤人的元气；善于滋补的人，一定不会助长人的邪气，务必使正气不受损，而邪气得消除，能够把握中道，这才是高手。然而把握中道的奥妙，应当认识因人制宜和因证制宜的区别。人，是本；证，是标。证候随人显现，成败由此决定，所以应当以因人制宜为先，因证制宜次之。如果形体气质原本实盛，那么从头到尾都可以治标；如果体质原本虚弱，那么一开始就必须顾护根本。如果说用补法太早，会把邪气补住，这是愚昧浅陋的看法。不知道补法中就能托毒外出，灌溉树根就能发芽生长，绝无补住邪气的道理。所以在发病源头之初，最应当着力，如果不能善始，很少能善终。这个道理只能对聪明人说，不能对平庸之辈讲。
一、治疗痘疮不宜拖延。凡是痘疹的不同之处，不过是寒、热、虚、实四种证型，大体上寒证多虚，热证多实，虚寒证适宜温补，实热证适宜清解。然而挽回局势的力量，应当在发病三五天前进行治疗，过了这个时间恐怕就来不及了。如果七天之后，毒素发于体表，体表正气不足就会外剥而死；如果毒素发得不彻底，又会内传，体内正气不足就会内攻而死。所以治疗痘疮讲究时机，时机的不可错失，就像这样严重。如果在初期不慎，后来的祸患就会从此潜伏下来。
一、解毒应当知道表里之分。所谓的“毒”，就是火毒。所谓的“解毒”，就是找到它的所在并驱逐它。大概痘疮的发生，内部源于淫火，外部成于风邪，内外相互触发，其毒才发作。所以它的发作，不是在内严重就是在外严重。在内严重的，是因为火邪内盛而在外炽烈燃烧；在外严重的，是因为寒邪外闭而使火郁结在内部。所以只要观察到无汗、外热且邪气在表的，就应当疏解发散，使热邪从外表散去，那么毒也就从外表解除了。如果观察到多汗、内热且邪气在里的，就应当清利，使热邪从内部排泄，那么毒也就从内部解除了。如果有内热已经很甚而表邪仍在的，就应当表里兼顾，斟酌轻重同时解除，那么邪气必定都会消散。如果邪气不在表，就绝不可以妄加发散，以致表气更加虚弱，而痘疮必然最终败坏，其症状表现为身体有汗而外部不太热的就是这种情况。如果毒不在里，就绝不可以兼用寒凉药物，以致中寒脾败，而痘疮必然反而下陷，其症状表现为口不渴而大小便不通畅的就是这种情况。懂得这五点，那么治疗痘毒的实在方法，就没有遗漏了。此外有虚邪、虚火等证候，就应当先斟酌元气，再观察邪气，不要像船到中流失去船桨，只顾根本而不及其余，这就更是切戒了。凡是说痘毒的，痘疮一定是从内部达于外部，只要能够出尽，内部就没有毒；只要能够化尽，外部就没有毒。既然已经发出又已经化解，而不使其再次下陷，那么毒就完全去除了。所以或者适宜散表，或者适宜托送，或者适宜清解，或者适宜固护中焦，治疗方法就在这里了。
一、补虚应当辨别阴阳。凡是痘疮的血和气各有所属，已经在气血条文中见到。然而痘疮所主的，尤其以阴分为重，为什么呢？大概痘疮由形质转化而来，根本在于精血。凡是看到点状出现、起胀、灌浆、结痂，无非都是精血的作用，这虽然说是气作为统帅，但实际上血才是主体。而且痘疮属于阳邪，阳盛必然伤阴，所以凡是治疗痘疮的人，最应当重视阴分，适宜滋润而不适宜刚燥。所以说：补脾不如补肾，养阴所以济助阳气，这是秘法。然而血和气本来互相依存，原本不可分为两截，如人参、黄芪、白术之类，虽然说是气分的药，如果配合血药使用，何尝不能补血？当归、川芎、地黄之类，虽然说是血分的药，如果配合气药使用，何尝不能补气。所以凡是见到气虚的，以保元汤为主方，而佐以当归、地黄。血虚的，以四物汤为主方，而佐以人参、黄芪。大概气与血本不相离，只是主辅轻重各有适宜，而运用得当与否，高明与笨拙自然就有差别了。
一、治疗痘疮有重要方剂，现在列出以便选择使用。其中未尽的内容，应当在各条文中寻求。
凡是解表的各种方剂，是初发热时所必须使用的，各家都以升麻葛根汤为首选，程氏则使用苏葛汤，似乎更为妥当，我则常用柴归饮来兼顾营卫，似乎尤为妥当，这应当根据适宜情况选择使用。营气虚而表证不解的，用五柴胡饮。阳气虚寒而表证不解的，用柴葛桂枝汤。元气原本壮实而表证不解的，用疏邪饮，或加减参苏饮。寒气胜而表证不解的，用五积散，或麻黄甘草汤。
凡是清火解毒的各种方剂，是用来解除实热的。如果想要解毒清火而又兼补气，只有四味消毒饮奇妙。鼠粘子汤也很好。热毒两盛而不能化解的，宜用搜毒煎。烦热口渴，小便不利的，用导赤散、六一散。血热出现赤斑，烦躁多渴的，用犀角散。热在阴分而出血的，用玄参地黄汤。内热不清的，用东垣凉膈散。大小便不利而火邪盛于内部的，用通关散。热毒内蓄，小便不利，而发为丹毒或痈肿的，用大连翘饮。烦热多惊而神志不安的，用七味安神丸。热毒内盛而狂妄的，用退火丹。
凡是表里兼解的各种方剂。如果内外都有热邪的，宜用柴葛煎，或柴胡麦门冬散。里邪盛而表邪微的，用解毒防风汤。表里都有邪气而元气兼虚的，用实表解毒汤。表里俱实热的，用双解散。
凡是托里的各种方剂，有适宜专补元气的，有适宜兼解毒的。如果气血俱虚不起发的，用六物煎，或托里散。虚寒不达，兼托里兼解表的，用人参内托散，或十宣散。气分虚寒不透的，用六气煎。气血俱虚，微热不起发的，用紫草快斑汤。
凡是各种补剂，都是痘疮中元气的根本，祛邪托毒者所必须依赖的，但见到虚邪，必须以这些方剂为主。气分不足的，用调元汤。气虚适宜温补的，用保元汤，六气煎。气虚微热适宜兼凉解的，用人参四圣散。血虚的，用四物汤，芎归汤。血分虚寒适宜温补的，用五物煎。血虚血滞的，用养血化斑汤。血虚血热适宜兼解毒的，用凉血养营煎。气血俱虚的，用六物煎、八珍汤、十全大补汤。气血虚寒，大宜温补的，没有比九味异功煎、六味回阳饮更好的了。即使是陈氏的十一味木香散、十二味异功散，也只是在虚寒而兼气滞的情况下适宜使用，想要依靠它们补虚，大有不足之处。
凡是攻下的各种方剂，也是痘疮中所不可缺少的，只是必须在不得已的情况下才使用，不要把它当作常规。血虚便秘，大便不通的，用四顺清凉饮。里实多滞便秘的，用前胡枳壳汤。表里俱实，大便不通的，用柴胡饮子。血热便结毒盛的，用当归丸。
一、凡是痘疮已经出尽，内部无不虚弱，因为随着痘疮而进行托送的，都是背弃元气。如果在這個時候，不知道培补化源，那么用什么来灌浆？用什么来结痂？用什么来收靥？如果内部虚弱而无主，恐怕毒气会再次陷入，没有不危险的。如果痘疮稀疏的，气血的消耗，还算是有限；如果痘疮多而严重的，其气血内亏，必然更严重。这是不可不预先防备的。
一、平顺的痘疮，毒原不甚，既已发出之后，内部本来没有邪气，这类人原本不必治疗。无奈父母爱子心切，且不识病的轻重，所以一定要延请医生诊视。既然延请医生到了，没有不用药的。既然已经用药，没有不是用寒凉药的。在他们立意不过说：只要解除其毒，又有什么妨碍呢？不知道没有热症却遭遇寒凉，身体怎么能承受？生阳之气一旦被拔除，胃气必然受伤，多导致中寒泄泻，还说什么协热下利，更增加黄连、黄芩，最为可恨。又如痘疮初见发热，大多不审察虚实，只说应当速当解毒，凡是在十日之外，多有因泄泻而致死的，都是这些人害死的。冤枉啊，冤枉啊！
我见到的太多了，所以写在这里作为轻率者的警戒。
一、痘疮在肌肉，由阳明经主管，所以自从出齐以后，最不宜吐泻，与其在倒陷之后救治，哪里比得上在未坏之前保护脾土？
所以凡是生冷水果茶水之类，都应当慎用，而寒凉的药物，尤其不可不慎。
一、治疗痘疮必须辨别证候，大部分湿气多则水泡，血热则发斑，气不足则顶陷，血不足则浆毒不附，里实而大补则生痈毒，表实而大补则不结痂。里虚不补则内攻而陷，表虚不补则外剥而枯。只要使周身气血活泼无障碍，那么即使密集也不难治疗。所以只贵在得中，不要使偏胜，那么寒热虚实，自然没有太过不及的祸患，这才称得上尽善尽美。
一、秘传的治痘方法，从头到尾应当以四物汤为主，随证加减使用。只有肚子不实（脾胃虚弱）的必须远离当归，只要将全剂通炒至微焦，那么使用自然无碍，而且又有温中暖脾的妙处。
一、从头到尾都忌用发汗和攻下，这是先哲治疗痘疮的心法。大概妄用发汗的，必然损伤阳气，阳气损伤则凡起发、灌浆、收靥的力量，都失去依赖，这是表虚的危害。妄用攻下的，必然损伤阴气，阴气损伤则凡脏腑化源、精神锁钥、饮食仓廪，都被破坏。这是里虚的危害。然而表虚的，还赖里气完足可以充补；里虚则根本内溃，卫气也随之陷入，没有办法施行了。所以古人深深以汗法和下法为戒，确实是至关重要的宗旨。然而这是针对常道而言，不是用来应对变化的。如果遇到外感寒邪，腠理闭密，痘出不快，发不透的，如果不使用辛甘发散的药物来通达肌表，那么痘疮会有壅遏的祸患。另外如果有大小便秘结，而毒有留伏不达的，如果不使用苦寒泄利的药物来疏通脏腑，就会有胀满烦躁、焦紫黑陷等祸患。所以应当察其虚实，审其常变，应当汗则汗，应当下则下，中病即止，不要超过限度。如果没有汗下之证，就绝不可以妄用汗下，以残害人的生命。务求得其适宜，然后称之为明医，福气自然会有归宿。
万氏说：解除火毒，担心郁遏而干枯；滋养血气，希望流行而舒畅。按这种说法确实很好。然而所谓火毒，是指实热而言，如果火有虚实真假之分，就不能一概认为是火毒。
程氏说：痘疮出自六腑，先动阳分，而后归阴经，其本属阳，所以多发热而阴血虚耗的多。从头到尾应当以滋阴补血为主，不可丝毫动气，贵在从缓治疗，所以白术、半夏的燥悍，升麻的提气上冲，都不可轻用。而且痘疮多有血热的，所以适宜用四物汤加黄芩、黄连之类的，以养其阴而退其阳。
程氏说：痘毒根于淫火，必然因岁气传流而发，所以多兼表证，则内外交攻。这个时候如果不使用轻扬的药物，祛风散邪，淡渗解毒的药物，利便退热，那么外邪内火如何得以解除？邪气既然不解，那么痘疮如何能好？这是治疗不容已的情况。然而治疗的方法，必须审察孩子的形色，察辨孩子的虚实，因证用药，差不多就能神效。世上的医生多遵循钱乙的清凉解毒论，或按照陈氏的辛温发汗方，主见不同，导致误治很多。殊不知痘疹色灰白，不起发，根脚不红活，这些都是虚寒，必须适宜陈氏的方子来救急。如果不是心里明白道理，没有不迷惑的。所以热则凉之，寒则温之，虚则补之，实则泻之，何必担心疾病不愈呢。
程氏说：治疗痘疮的关键，在发出之前，适宜打开和解之门；既已发出之后，应当堵塞走泄之路；落痂之后，清凉逐渐进用；毒去已尽，补益应当疏缓。
程氏说：凡是治疗痘疮，前后须加木通，以泻热邪从小便中排出，不使其攻胃，令没有变黑的证候。七日之后，热退的，少用之。凡是痘疮前后总有危证，千万不要用天灵盖、脑、麝香之类的攻伐。大概毒出一分，内虚一分，血气运一天，则内耗一天，怎么可以用辛香耗气的药物，虽然侥幸偶中，后来必有残余危害。由此可见王道与霸道，相差远了。
程氏说：凡是妇女怀孕而出痘的，以安胎为主。气虚的，用保元汤。血虚的，用四物汤，或加白术、黄芩、砂仁、陈皮，必须使胎气无损为主。
程氏说：桂岩郑先生说：痘是根据其形状命名的。我认为不仅象形命名，而且治疗的方法，也像农家种豆一样。豆这种东西，上面实了难出，土壤贫瘠难长，所以实的要锄松扰动，瘠的要浇灌肥沃，不实不瘠的，只顺应其本性，不让事物伤害它而已，懂得这个就可以谈论医学了。现在的人在痘初起时，不察虚实寒热，或过用木香散、异功散之类，则是以火济火，导致变紫黑倒陷，生痈毒、吐血衄血的有之；或妄用黄芩、黄连、栀子、黄柏等寒凉药物，则大伤脾胃，导致呕吐泄泻、寒战内陷的有之。所以凡是治疗痘疮的方法，六日之前，不宜温补，也不宜妄用寒凉。老师说：凡是解毒之内，略加温补，温补之中，略加解毒，这是不传的秘诀。如果六日以后，毒已经完全出于体表，应当温补而不温补的，脓不得壮而痒寒战的祸患，必然不能避免。
Zhenren Jiedu Tang (Real Person's Detoxification Decoction) [Disease 52]
Regarding the disease of smallpox, favorable cases do not require treatment, and unfavorable cases cannot be cured; what requires treatment are only the critical/dangerous cases. What constitutes a critical case? For instance, when the base is favorable but the location is dangerous; when the location is favorable but the timing is dangerous; when the timing is favorable but the quantity is dangerous; when the quantity is favorable but the color is dangerous; when the color is favorable but the dietary intake is dangerous; when dietary intake is favorable but the accompanying symptoms are dangerous; when accompanying symptoms are favorable but the treatment approach is dangerous; when the treatment approach is favorable but exposure to filth is dangerous. However, there is an even more dangerous factor: the struggle between Yuan Qi (Primary Qi/Vital Energy) and pathogenic factors. Even if pathogenic factors are strong, if Yuan Qi is also strong, there is no harm; the fear lies in Yuan Qi becoming weak, in which case even mild pathogenic factors become critical. If such a condition occurs and is not treated promptly, favorable conditions will turn unfavorable, and auspicious signs will turn into ominous ones. All these points are key essentials in smallpox and must be carefully observed and distinguished. Therefore, anyone wishing to treat smallpox must first distinguish life from death, differentiate deficiency from excess, examine cold from heat. Understanding these six aspects covers everything.
1. The essence of treating smallpox lies solely in the two factors of pathogenic factors and Zheng Qi (Upright Qi/Healthy Energy). When pathogenic factors are abundant and uncontrolled, they kill; when Zheng Qi is deficient and unable to sustain, they kill. In critical situations, it always boils down to the collapse of Yuan Qi. As long as Yuan Qi is not completely exhausted, death is not inevitable. Those who treat this condition should understand only the concepts of tonification (Bu) and purgation (Xie), applying them without error for perfection. Tonification and purgation allow no negligence; every minute detail requires balance. One must never let the medicinal force exceed the pathology, nor fall short of it. Thus, those skilled in attacking pathogens do not damage the patient's Yuan Qi; those skilled in tonification do not assist pathogenic factors. The goal is to ensure Zheng Qi remains undamaged while pathogenic factors are resolved, maintaining the Middle Way (Zhong He). This is the mark of a master physician. However, the subtlety of maintaining the Middle Way requires distinguishing between treating based on the individual (Yin Ren) and treating based on the syndrome (Yin Zheng). The person is the root; the syndrome is the branch. Syndromes manifest according to the person, determining success or failure. Therefore, treating based on the individual takes precedence, followed by treating based on the syndrome. If the constitution is originally robust, one may treat the branch throughout; if the constitution is originally deficient, one must attend to the root from the outset. To claim that early tonification "traps" pathogenic factors is a view held by the ignorant and shallow. One fails to realize that tonification can help expel toxins, just as watering roots promotes sprouting; there is no logic in "trapping" with tonification. Therefore, effort is most crucial at the onset. Without a good beginning, few achieve a good end. This can be discussed with the wise, but not with the mediocre.
1. Treating smallpox should not be delayed. The differences in rash diseases generally fall into four categories: Cold, Heat, Deficiency, and Excess. Generally, Cold implies Deficiency, and Heat implies Excess. Deficient-Cold syndromes suit Warm Tonification (Wen Bu), while Excess-Heat syndromes suit Clearing and Resolving (Qing Jie). However, the power to reverse the situation must be applied within three to five days before onset; after this, it may be too late. If after seven days, the toxin manifests externally, insufficient external Zheng Qi leads to external peeling and death; if the toxin does not fully emerge, it transmits internally, and insufficient internal Zheng Qi leads to internal attack and death. Thus, timing is crucial in treating smallpox. Negligence in the early stage sows the seeds for later disaster.
1. Detoxification requires understanding Exterior (Biao) and Interior (Li). The so-called "toxin" is Fire Toxin (Huo Du). "Detoxification" means locating the toxin and driving it out. Smallpox originates internally from excessive Fire and externally from Wind Pathogens. Their interaction triggers the toxin. Manifestations are either severe internally or externally. Severe internal cases involve excessive internal Fire blazing outward; severe external cases involve external Cold closing pores, trapping Fire inside. If observing no sweat, external heat, and exterior pathogens, one should disperse and scatter, allowing Heat Pathogens to exit via the exterior, thus resolving the toxin externally. If observing profuse sweating, internal heat, and interior pathogens, one should clear and drain, allowing Heat Pathogens to excrete internally, thus resolving the toxin internally. If internal heat is severe but exterior pathogens remain, one must address both Interior and Exterior simultaneously, weighing severity. If pathogens are not in the Exterior, one must not recklessly use dispersing methods, which would further weaken Exterior Qi and cause the rash to fail (symptoms: sweating but little external heat). If the toxin is not in the Interior, one must not combine cooling/cold-natured herbs, which would damage Spleen Yang and cause the rash to sink (symptoms: no thirst, normal bowel/bladder function). Mastering these five points leaves no gaps in treating real/excess toxin. For other cases like Deficient Pathogens or Deficient Fire, one must first assess Yuan Qi, then pathogenic factors, avoiding losing control mid-stream. Smallpox toxins move from Interior to Exterior; if fully expelled, the Interior is toxin-free; if fully transformed, the Exterior is toxin-free. Once emerged and transformed without sinking, the toxin is gone. Treatments include dispersing the Exterior, supporting expulsion, clearing/resolving, or securing the Middle Jiao.
1. Tonifying Deficiency requires distinguishing Yin and Yang. Blood and Qi have their respective domains in smallpox, as detailed in the Blood and Qi sections. However, the Yin aspect is particularly important. Why? Smallpox transforms from form, rooted in Essence and Blood. From spotting to swelling, pus formation, and scabbing, all rely on Essence and Blood. Although Qi commands, Blood is the substance. Since smallpox involves Yang pathogens, excessive Yang injures Yin. Therefore, treatment must prioritize the Yin aspect, favoring moistening/nourishing over drying/astringent methods. It is said: "Tonifying the Spleen is inferior to tonifying the Kidney; nourishing Yin aids Yang." This is a secret method. However, Blood and Qi are mutually rooted. Herbs like Ginseng Radix (Renshen), Astragali Radix (Huangqi), and Atractylodis Macrocephalae Rhizoma (Baizhu) are Qi-tonics but can nourish Blood when combined with Blood herbs. Herbs like Angelicae Sinensis Radix (Danggui), Ligustici Chuanxiong Rhizoma (Chuanxiong), and Rehmanniae Radix (Dihuang) are Blood-tonics but can benefit Qi when combined with Qi herbs. For Qi deficiency, Baoyuan Tang is primary, supplemented by Danggui and Dihuang. For Blood deficiency, Siwu Tang is primary, supplemented by Renshen and Huangqi. Qi and Blood are inseparable; the key lies in appropriate主次 (primary/secondary) ratios. Skill determines efficacy.
1. Important formulas for treating smallpox are listed below for selection. Unlisted details can be found in specific sections.
For Exterior-resolving formulas used in early fever: Shengma Gegen Tang is standard; Cheng uses Sugge Tang (more appropriate); I often use Chaigui Yin to harmonize Ying and Wei (most appropriate). Choose based on suitability.
- Ying deficiency with unresolved Exterior: Wucha Hu Yin.
- Yang deficiency/Cold with unresolved Exterior: Chaige Guizhi Tang.
- Robust Yuan Qi with unresolved Exterior: Shuxie Yin or Jiajian Renshen Su Yin.
- Excessive Cold with unresolved Exterior: Wuji San or Mahuang Gancao Tang.
For Fire-clearing and detoxifying formulas for Excess Heat:
- To detoxify, clear fire, and tonify Qi: Siwei Xiaodu Yin is excellent. Shuniuzi Tang is also good.
- Severe Heat-Toxin stagnation: Saudu Jian.
- Restlessness, thirst, difficult urination: Daochi San or Liuyi San.
- Blood heat with red spots, restlessness, thirst: Xijiao San.
- Heat in Yin aspect with bleeding: Xuanshen Dihuang Tang.
- Persistent internal heat: Dongyuan Liangge San.
- Bowel/bladder obstruction with intense internal fire: Tongguan San.
- Internal Heat-Toxin stagnation, difficult urination, carbuncles/rashes: Dalianqiao Yin.
- Restlessness,惊悸 (palpitations/fright), restless spirit: Qiwei Anshen Wan.
- Severe internal Heat-Toxin with delirium: Tuohuo Dan.
For simultaneous Interior-Exterior resolution:
- Heat in both Interior and Exterior: Chaige Jian or Chaihu Maidong San.
- Severe Interior pathogen, mild Exterior: Jiedu Fangfeng Tang.
- Pathogens in both Interior and Exterior with Yuan Qi deficiency: Shibiao Jiedu Tang.
- Excess Heat in both: Shuangjie San.
For Interior-supporting formulas:
- Qi and Blood deficiency with failure to erupt: Liuwu Jian or Tuoli San.
- Deficient-Cold failing to reach surface, requiring support and exterior release: Renshen Neituo San or Shixuan San.
- Qi deficiency/Cold failing to penetrate: Liuqi Jian.
- Qi and Blood deficiency with slight heat and failure to erupt: Zicao Kuaiban Tang.
Various tonics are essential for Yuan Qi in smallpox. Use these primarily for deficiency-pathogen patterns:
- Qi insufficiency: Tiaoyuan Tang.
- Qi deficiency needing warmth: Baoyuan Tang, Liuqi Jian.
- Qi deficiency with slight heat needing cooling: Renshen Sisheng San.
- Blood deficiency: Siwu Tang, Xiong Gui Tang.
- Blood deficiency/Cold needing warmth: Wuwu Jian.
- Blood deficiency/stagnation: Yangxue Huanban Tang.
- Blood deficiency/Heat needing detoxification: Liangxue Yangying Jian.
- Qi and Blood deficiency: Liuwu Jian, Bazhen Tang, Shiquan Dabu Tang.
- Qi and Blood deficiency/Cold needing strong warming: Jiuwei Yigong Jian, Liumei Huiyang Yin.
- Chen's Shi Yi Wei Muxiang San or Shi Er Wei Yigong San are suitable only for Deficient-Cold with Qi stagnation; they are insufficient for pure deficiency.
For Purgative formulas (use only when absolutely necessary):
- Blood deficiency constipation: Sishun Qingliang Yin.
- Interior excess with stagnation/constipation: Qianhu Zhike Tang.
- Exterior-Interior excess with constipation: Chaihu Yinzi.
- Blood heat, constipation, severe toxin: Danggui Wan.
1. Once smallpox has fully erupted, the Interior is invariably deficient. Supporting the eruption consumes Yuan Qi. If one fails to cultivate the Source of Transformation (Hua Yuan) at this stage, how can pus form, scabs appear, or crusts heal? Internal deficiency without support risks toxin sinking, leading to danger. Sparse eruptions consume less Qi and Blood; severe eruptions deplete them significantly. Prevention is essential.
1. Favorable smallpox has mild toxins and no internal pathogens post-eruption; technically, no treatment is needed. However, anxious parents seek doctors regardless of severity. Doctors prescribe medication, almost always cold-natured, under the guise of "detoxification." Ignoring that cold damages Yang and Spleen Stomach Qi, this often causes cold-dysentery. Adding Scutellariae Radix (Huangqin) and Coptidis Rhizoma (Huanglian) exacerbates this. Early fever misdiagnosed as needing rapid detoxification often leads to fatal diarrhea after ten days. This is murder.
I have seen too many such cases, writing this to warn the reckless.
1. Smallpox resides in muscles, governed by the Yangming channel. After full eruption, vomiting and diarrhea are strictly contraindicated. Protecting Spleen Earth before damage is better than treating collapse afterward. Avoid raw fruits, tea, and water. Be extremely cautious with cold-natured medicines.
1. Differentiate syndromes: Dampness causes blisters; Blood Heat causes macules; Qi deficiency causes sunken tops; Blood deficiency causes poor pus adherence; Excess Interior with heavy tonification causes abscesses; Excess Exterior with heavy tonification prevents scabbing. Interior deficiency without tonification leads to internal collapse; Exterior deficiency without tonification leads to external peeling. If Qi and Blood flow freely, dense eruptions are manageable. Balance is key to avoid excess or deficiency.
1. Secret method: Use Siwu Tang throughout, modifying by syndrome. If the abdomen is not firm (Spleen/Stomach weakness), avoid Danggui. Frying the entire formula slightly scorches it, removing hazards and adding warming/Spleen-nourishing properties.
1. Sweating and purging are taboo throughout, per ancient masters. Reckless sweating damages Yang Qi, ruining eruption/pus/scabbing forces (Exterior deficiency harm). Reckless purging damages Yin Qi, destroying organ sources and digestion (Interior deficiency harm). Exterior deficiency can be supported by sufficient Interior Qi; Interior deficiency collapses the root, trapping Wei Qi, with no remedy. Hence, ancients warned against sweating/purging. However, this applies to routine cases. For external Cold blocking pores with slow eruption, pungent-sweet dispersants are needed. For constipation with trapped toxin, bitter-cold draining agents are needed. Assess deficiency/excess and routine/change. Sweat if needed, purge if needed. Stop when illness is addressed. Do not abuse sweating/purging if not indicated. This defines a wise physician.
Wan says: "Clear fire-toxin to prevent dryness/stagnation; nourish Qi/Blood for smooth flow." This is sound. However, "fire-toxin" refers to Excess Heat. One must distinguish true/false and excess/deficient fire.
Cheng says: Smallpox originates in Six Fu organs, moving from Yang to Yin channels. Rooted in Yang, it causes fever and Yin-Blood depletion. Treatment should focus on nourishing Yin/Blood, avoiding Qi-moving herbs. Bai Zhu and Ban Xia are too drying; Sheng Ma is too ascending. Use Siwu Tang plus Huang Qin and Huang Lian to nourish Yin and subdue Yang.
Cheng says: Toxin stems from excessive Fire, triggered by seasonal Qi, often involving Exterior syndromes. Light, ascending herbs dispel Wind; bland-draining herbs resolve toxin and reduce heat. Without this, Exterior Cold and Interior Fire persist. Treatment is urgent. Assess child's appearance and deficiency/excess. Many doctors follow Qian Yi's cooling methods or Chen's warming methods, causing errors. Gray-white, non-erupting rashes indicate Deficient-Cold, requiring Chen's formulas. One must cool heat, warm cold, tonify deficiency, purge excess.
Cheng says: Before eruption, open the door of Harmonization (He Jie); after eruption, block leakage paths; after scabbing, gradually introduce cooling; once toxin is gone, tonify gently.
Cheng says: Add Tong Cao throughout to drain Heat via urine, preventing stomach attack and blackening. Reduce dose after day seven if heat subsides. Never use Tian Ling Gai (Human Skull), Nao Bing (Camphor), or She Xiang (Musk) for critical cases. Each step of toxin emergence increases internal deficiency. Pungent-aromatic herbs consume Qi; although sometimes effective, they leave residual harm. The difference between Kingly Way and Hegemonic Way is vast.
Cheng says: Pregnant women with smallpox should prioritize fetal safety. Qi deficiency: Baoyuan Tang. Blood deficiency: Siwu Tang, or add Bai Zhu, Huang Qin, Sha Ren, Chen Pi. Ensure fetal Qi is undisturbed.
Cheng says: Mr. Zheng of Guiyan stated: Smallpox is named for its shape. Treatment resembles farming beans. Beans need loose soil to emerge and fertile soil to grow. Loosen compacted soil, fertilize barren soil, and follow nature for average soil. Understanding this allows one to discuss medicine. Modern practitioners misuse Muxiang San or Yigong San (warming) or Huang Qin/Huang Lian/Zhi Zi/Huang Bo (cooling) in early stages, causing purple-black sinking or Spleen/Stomach damage. Before day six, avoid heavy warming or reckless cooling. The secret is: in detoxification, add slight warming; in warming, add slight detoxification. After day six, when toxin is fully exterior, failure to warm results in itching/chills due to weak pus.