之患作，而竟以告毙者，泻心之药实杀之而人竟不知也，医亦竟不悟也，可慨也！故
予谓痘已出之后，未痂之前，凡一切凉心之药如犀角、生地之类，姑禁绝不用，直
待结痂后用之解余毒可也。或曰若然则未收结之前，毒俱不可解乎？曰∶奚为皆不
可！若其血气与毒瓦斯俱盛者，脉必洪数，痘或初出即带紫黑，或既出而稠密红紫，内
证则烦闷燥渴，小便赤涩，大便秘结，此则属实热，宜速用清凉之剂以解毒。如大
便久秘者，量入酒炒大黄微利之，可也；若其毒瓦斯虽盛而血气未旺者，以解毒为主而
兼活血养气，则参 归芍之类，亦不可离也。
又曰∶近世痘方多宗黄西邱，其书自始至终，俱分顺逆险而立三图说。其为顺
者，不必服药是也，谓险者宜以保元汤加减调治，犹近理也，但谓逆者俱不可治，治
之徒劳无益，是教人袖手待毙矣！其言不仁之甚，而贻害于世不小也，此为俗医图
利计则甚便，而于救济生灵之术则甚乖也。盖医者仁术，圣人以之赞化之不及，所贵
者扶危救困，起死回生耳。若治其易治者而弃其难治者，则何以医为！惟俗医意在
图利，又恐坏名，见证有不顺者辄委弃之，彼诚恐利未必得，而徒冒不识证之名，若
仁人君子当为之死里求生，岂忍断其必死而坐视不治？故曰西邱之言，便于俗医而
非所以济世也。且其所指逆证多端，痘疮稠密者多有之，如初热而惊悸吐泻，报痘
而先发于印堂司空天庭等处，初出而根窠无晕，既出而色白灰陷，或发水泡，或痒
塌，或当行浆而不行浆，或痂未落而寒战切牙等证，皆其图所谓逆而不治者，予每
治之而得生者多矣，奈何悉谓治之无益，而戒人勿治乎！惟初出形如蚕种，既出而紫
黑干枯者，难以灌浆，多不可救耳。然宁救之而不活，不忍坐视而不救也。（折诸家之衷二条。）
痘证与他证不同，自初发以至于结痂，限日限时，救困扶危，当用之药宜及时而
用，如救焚拯溺，不可缓也。盖痘毒发自五脏，实动五脏之真气，其出痘多者，真
气发泄亦多，当此这时，人之血气几绝，岌
岌乎殆哉，如油尽之灯不速为之增油，则灯焰熄；如风中烛，不速为之蔽风，则烛
光灭也。时医则不然，轻视人命而重视财利，其愚而不知用药者，姑无论已，即稍
知用药者亦不肯及时用药，欲因祸大而显功，直待诸恶证出，然后乘人父母之惊惧，
而要重利，迟延至于血气已绝不可复续，虽有对证之药，缓不及事，因而误人性命者
多矣。嗟嗟！天地鬼神昭布森列，不可欺罔，此辈以贪利而杀人，心术不善岂无幽
责？岂无冥诛？殃必及身，必及子孙，不可逃也，此医家之害而病家不可不知也。又
时医识见浅陋，未谙妙理，执泥祖传旧方，不知通变，遇痘证之轻者，犹可动手调治，
而自以为功，一遇危险重证，便束手无策，不能救疗，甚至治一家十人，而不活者七
八人，则以为痘证原恶，而不自咎其术之拙，病家亦以为痘证本恶而不归咎医之拙。
殊不知痘疮常数，若无甚恶之证而调治得宜，十可十全，间有极恶之证，必不可救
疗者，十不过一二，今治十人而死者七八，何恶证之多也，毋亦术之不精乎！予深悯
之，故不得不为之着论立方也。（辟时医之谬。）
凡治病必先辨虚实寒热四证，望闻问切，无非辨此四者而已。四者了然于胸中，
则用药取效，其应如响，四者不能分辨，而执成方以用药，鲜有不误者，即或中病而
愈，亦幸而偶中也。至于痘疮之虚实寒热，犹为紧要，辨之不明，用药多致败事，何
以成功！奈何历代治痘之家，着论立方，互相异同，至于虚实寒热，多略而不辨，或
辨而不明，致令检方者漫无下手处，竟不知某证属虚属实，当用某方，某证属寒属
热，当用某方，则虽有千百妙方，千百妙论，无益于用也。无怪乎自古至今治痘者
之多迷途，而慈幼之术疏也。且痘疮之虚实寒热，与诸病之虚实寒热，其异同固自
有辨，诸病有虚者，元气自虚也，宜补也，痘疮有表虚，有里虚，亦元气自虚也，宜
补也，此其相同者也。诸病有实者，邪气
实也，可泻也，痘疮有表实，有里实，此则元气完固而毒瓦斯不能为害，不可泻，亦
不必泻也，此其不同者也。诸病有虚之甚者，阴有余阳不足，则寒自虚生，宜温热
之剂补之也，痘疮有虚之甚者，亦阴有余阳不足，而寒自虚生，亦宜温补之剂补之
也，此其相同者也。诸病有寒自外入者，外感是也，当其在表宜发散之，久而入里则
郁而为热，宜清解之，痘出而风寒外袭，宜温而散之，或外寒入内而为吐泻诸证，亦
宜温之而已，外不可汗，内不可清解也。诸病有虚热者，元气虚，津液竭而火从虚中
起，补之而热自除也，不必解热也，痘疮亦有虚热者，元气虚而毒瓦斯肆也，当以补
元气为主，而略兼解毒可也。三者皆同而有不同者也，诸病有实热者，血气未亏而
邪气壅盛，单用寒凉泻之可也，痘疮亦有实热者，禀气强，血气盛，而毒瓦斯亦盛，亦
单用清凉解之可也，此又其相同者也。今自发热之初，以至还元之后，俱先辨证之
虚实寒热而遂立方于其后，令人细心审证而后用药，庶不至于虚虚而实实乎！不至
于损不足而补有余乎！不至于以水益寒而以火益热乎！然痘之虚实寒热，较之他病
犹显明而易察，盖自见点以至结痂，其形其色既昭然可睹，若又听其声音，观其静
躁，视其饮食之多少，审其大小便之利涩，三岁以上者，诊其脉之迟数洪微，其辨虚
实寒热，当如黑白之分明，而用药取效易易矣。（辨虚实寒热之异。）
又曰∶痘疮全凭气血成功，而气血之盈亏消长，其理精微，不可不透悟也。盖
气体天而亲上，血体地而亲下，痘之出也，其高起之泡，气之位也上也，气宜充焉，其
四晕根脚，血之位也下也，血宜附焉，泡尖而色白润，是气充而居其亲上之尊也，四
围有晕而色红活，是血附而安其亲下之分也，气居其尊，血安其分，气血和顺而载
毒出外，此最吉之痘，可勿药而愈也。顶陷则气反亲下，此气亏而不能充也，法当
补气，四围根脚无红晕，此血亏而不能附也，法当补血，此其理犹易明也。其有通
顶红色成血泡者，是血反亲上也，此证最险，必不能成浆，至八九日后痒塌而死，然
此非血之独盈，乃由气亏而失居尊之常，故血得以妄行而僭居其位也。急宜大补其气，
气充则能统血，血自不得泛溢妄行而泡转白矣。世人不识此理，见其泡红则谬认为
血热而用凉血行血之剂，致令气愈亏而毙愈速也，不亦悲乎！故气血盈亏之理微妙
而难识也。至于调治痘疮气血，其气独虚者，固宜专补气而不宜补血，盖阳不能从
阴，阴愈长则阳愈消也，其有血虚者多由胃气损伤，元气不足所致，盖阴必从阳，阳
生则阴长也，黄汝言《明医杂着》乃谓血虚而用 以补气，则阳旺而阴愈消，甚矣！
其不明于阴阳消长之理，而谬立此言，为世大害矣。余每治便血之虚滑者，妇人产
后去血过多而大发热者，妇人血虚崩漏而下血不止者，俱用参 姜附为主，而佐以
血药与升提药，皆获奇效，安在血病不可补气乎！若小儿痘疮，以胃气为主，则补
血必先补气明矣，故气血消长之理，不可不深明也。（析气血盈亏消长之理。）
朱纯嘏曰∶痘之为证，始焉一点红，红者血之色也，血之为血，虽赖气以生之，究
其本则水也，天一生水，地六成之，水乃北方之坎，两肾是也，肾水充足而得木火
土金之气交相养，互相长而成气与血焉，是血之源于水，水之源于肾者明矣。虽分属
于心生血，肝藏血，脾裹血，藉令肾中水枯，则必何自而生，肝何自而藏，脾何自
而裹，合之则五脏同一太极也。阳动阴静而生水、火、木、金、土也，痘中之一点
红，血也。出齐之后，次第起长，充满于痘之中者，浆也。浆者，血气之所化也，化
毒而为浆也，浆既充足，脓成而毒解也。渐次转褐色，回水结痂之候也，痂结苍蜡色，
此一十二日之成功也。何独前此之高明，不论阴阳五行之正理，妄立名色，且曰惟肾
无候，而又实之以耳冷 冷，以明肾家无候之证佐。又曰∶痘之变黑始归肾也，此
皆不经之谈，千有余年，谁其辨之，予不得已着五脏合一论以辨之。（辨五脏合一论。）
喜泰顺曰∶痘本胎毒，号曰天疮，传染由于外感，轻重本乎内伤。初起太阳壬
水克乎丙丁，后归阳明。血水化为脓浆，势若燃眉，变如反掌，欲知表里虚实，须明
寒热温凉。初发之时，与伤寒相似，或发热烦躁，脸唇红赤，身疼头痛，乍寒乍热，
喷涕呵欠，眼目困倦，两颧之间有红纹见者，预知其为痘也。发热三日，当托里解
表使其易出；四日、五日清凉解毒，使其易长；六日、七日温补气血，使其易于灌
浆；八日、九日清利收敛，使痘易靥，此治痘之常法也。夫常者可必，而变者不可
必，安可执一以治之哉！苟痘未出而清凉，则毒得寒而凝滞，热毒未解而过补，则毒
蕴蓄而不能化浆。故治痘之法，见机生情，随时应变，至于靥后，不过慎风寒，节饮
食而已，此治痘之原论也。
又曰∶凡痘灰白不红，绽不起发，出不快，昏暗顶陷，皆表寒而虚，二便清，呕
吐泄泻，手足口气俱冷，不渴少食，唇白涕清，饮食不化，皆里寒而虚，此表里虚
寒之证。急宜温脾胃，补气血，即参 桂附，在所宜施。痘色红紫，结实高耸，顶
若尘铺，又兼火刺，内夹斑疹，此表热而实；二便秘赤，干呕吐痰，肚腹疼痛，口
冲臭气，烦渴腮红，谵语妄言，此皆热毒郁遏，皆里热而实，此表里实热之证。急
宜凉泻解毒，重加发散，芩、连、犀、柏、石膏、栀、黄，又所宜施。此表里虚实之
证显著于外，医者易明。又有表虚里实者，痘色淡白不红，绽出不快等证，是表虚也；
而兼之内证频加，肚腹 痛，烦躁热渴，白睛通红，二便秘结，此里实也。表虚里实
之证，医者先当发散，不宜苦寒发散，则毒得外泄而内热自解，苦寒则毒反冰伏，而
出愈难，或于三四朝期，斟酌下之，先清
其毒，后补气血，得以成浆，或有毒郁气虚不能充灌者，宜参连汤治之，此治表虚
里实之大略也。里虚表实者最为难治，痘疮烦红，根不松活，皮毛壮热，色赤焦紫，
此表实也，而兼之呕吐泄泻，唇白涕清，饮食不化等证，治宜活血松肌，如红花、蛇
蜕、生地、丹皮之类，在所宜施，俟色泽红润，庶可补托，不然，则痘不特不能起
发充灌，必变紫艳干枯，倒靥空疮，势如燃眉，变若反掌，医者当临证参详，不可
拘于一定。（表里虚实寒热论。）
又曰∶实热之痘，初起壮热，腮红睛赤，口渴谵语，内证固重，见点必凶，烦
红琐碎，或三五一堆，两三成群，如同蚊咬，急当发散重下，名曰双解。如蛇蜕、荆
防、葛根、石膏、大黄等剂，再用西河柳、芫荽煎汤洗浴，使毛窍通利，痘方易出，大
用清凉。如热毒不解，色泽不润，根脚不松，名为血热，仍可下之，再加连翘、犀
柏、紫草、红花、桃仁、黄连凉血之剂，再服猪尾膏、无价散等剂，方可奏效。如是
血热壅遏之痘，必须清凉解毒，以至收靥之时，方可清利收敛，乃是要诀也。（实热壅遏论。）
由此引发的祸患，竟然导致患者死亡，而实际上是因为使用了泻心（清泻心火）的药物致死，人们却浑然不知，医生也未能醒悟，真是令人感慨！所以我主张，痘疮已经发出之后、尚未结痂之前，凡是犀角、生地黄等一切凉心（清泻心火）的药物，暂时禁止使用，直到结痂之后再用它们来解除余毒。有人问：如果这样，那么在未收靂结痂之前，毒素就都不能解除了吗？我说：为什么全都不可解呢！如果患者的血气与毒瓦斯（病邪之气）都旺盛的，脉象必定洪大且数急，痘疮或许刚发出就带有紫黑色，或者发出后稠密且呈红紫色，内部证候表现为烦闷燥渴，小便赤涩，大便秘结，这属于实热证，应当迅速使用清凉剂以解毒。如果大便长期秘结，可酌情加入酒炒大黄轻微通利，这是可以的；如果毒瓦斯虽然旺盛但血气尚未旺盛的，应以解毒为主并兼用活血养气之法，那么人参、当归、白芍等药物，也是不能离开的。
又说：近代治疗痘疮的方子多遵循黄西邱的观点，他的书自始至终，都分为顺证、逆证、险证而立三图说。其中所谓顺证，不需要服药是对的；所谓险证，适宜用保元汤加减调治，还比较合乎事理；但如果说逆证都不可治，治疗也是徒劳无益，这是教人袖手旁观等待死亡啊！这种言论极其不仁，贻害世间不小，这对于俗医谋取利益来说很方便，但对于救济生灵医术来说则非常违背。大概医者仁术，圣人用它来辅助教化所不及之处，可贵的是扶持危难、救助困苦、起死回生罢了。如果只治疗容易治的病而抛弃难治的病，那还要医生做什么呢！只是俗医意在谋利，又恐怕坏了名声，见到证候不顺的就往往抛弃不管，他们确实担心利益未必得到，反而白白冒上不识证候的名声。如果是仁人君子，应当为病人死里求生，怎么忍心断定其必死而坐视不治呢？所以说黄西邱的话，对俗医方便，却不是用来济世救人的。况且他所指的逆证有很多端，痘疮稠密的患者多有此情况，如初发热时惊悸吐泻，报痘（出痘初期）先发于印堂、司空、天庭等处，刚发出时根窠没有红晕，发出后颜色苍白灰陷，或者发水泡，或者瘙痒塌陷，或者该行浆时不行浆，或者痂未脱落而寒战咬牙等证，都是他图中所谓逆而不治的，我每次治疗这些患者而生还者很多，为什么全都说治疗无益，而告诫人们不要治疗呢！只有那些刚发出形如蚕种，发出后紫黑干枯的，难以灌浆，大多不可救治罢了。然而宁可努力救治而不活，也不忍心坐视不救。（折衷诸家观点之二条。）
痘证与其他病证不同，从初发到结痂，有固定的日期时辰限制，救困扶危，应当用的药宜及时使用，如同救火拯溺，不可迟缓。因为痘毒发自五脏，确实动摇了五脏的真气，发出的痘多的，真气发泄也多，在这个时候，人的血气几乎断绝，岌岌可危，就像油尽的灯如果不迅速添油，灯焰就会熄灭；像风中的蜡烛如果不迅速挡风，烛光就会熄灭。当时的医生却不是这样，轻视人命而重视财利，那些愚笨不懂用药的，暂且不提，就是稍微懂点用药的，也不肯及时用药，想要因为病情重显出自己的功劳，一直等到各种恶证出现，然后乘着患者父母惊恐害怕的时候，索要重利，拖延到血气已绝无法接续的地步，虽然有对症的药，但缓不济急，因而误人性命的很多了。唉！天地鬼神昭然列布，不可欺骗蒙蔽，这一类人因贪利而杀人，心术不善难道没有阴间的责备？难道没有冥界的诛杀？灾殃必定波及自身，波及子孙，是逃不掉的，这是医家的危害，而病患家属不可不知道。另外，当时医生见识浅陋，不通晓妙理，固执泥守祖传旧方，不知变通，遇到轻症的痘证，还可以动手调治，便自以为有功，一遇到危险重症，便束手无策，不能救疗，甚至治疗一家十人，不死七八个，就认为是痘证原本凶恶，而不责怪自己医术拙劣，病患家属也认为痘证本来凶恶而不归咎于医生医术拙劣。殊不知痘疮是常有的病，如果没有特别凶恶的证候而调治得当，十个可以治好十个，间或有极凶恶的证候，必不可救的，十个不过一两个，现在治疗十人而死七八个，为什么凶恶的证候这么多呢？莫非是医术不精吧！我深深怜悯他们，所以不得不为此著论立方的。（驳斥时医的谬误。）
大凡治病必须先辨别虚、实、寒、热四证，望闻问切，无非是辨别这四者而已。这四者在胸中了然分明，那么用药取效，反应灵敏如响，如果不能分辨这四者，而拿着成方用药，很少有不误人的，即使偶尔中病痊愈，也是侥幸偶然中的。至于痘疮的虚实寒热，尤为紧要，辨别不明，用药多会导致失败，怎么能成功呢！为什么历代治痘的人，著论立方，互相异同，对于虚实寒热，大多忽略不辨，或者辨得不明确，致使查阅方子的人漫无下手之处，竟不知道某证属虚属实，当用某方，某证属寒属热，当用某方，那么即使有千百妙方，千百妙论，对应用也没有益处。难怪自古至今治痘者多迷失方向，而慈幼（儿科/儿童护理）之术疏略了。而且痘疮的虚实寒热，与诸病的虚实寒热，其异同自然有区别，诸病有虚者，是元气自虚，宜补；痘疮有表虚，有里虚，也是元气自虚，宜补，这是相同的。诸病有实者，是邪气实，可泻；痘疮有表实，有里实，这是元气完固而毒瓦斯不能为害，不可泻，也不必泻，这是不同的。诸病有虚之甚者，阴有余阳不足，则寒自虚生，宜温热剂补之；痘疮有虚之甚者，也是阴有余阳不足，而寒自虚生，也宜温补剂补之，这是相同的。诸病有寒自外入者，是外感，当其在表宜发散，久而入里则郁而为热，宜清解；痘出而风寒外袭，宜温而散之，或外寒入内而为吐泻诸证，也宜温之而已，外不可汗，内不可清解。诸病有虚热者，元气虚，津液竭而火从虚中起，补之而热自除，不必解热；痘疮也有虚热者，元气虚而毒瓦斯肆行，当以补元气为主，而略兼解毒即可。这三者皆同而有不同。诸病有实热者，血气未亏而邪气壅盛，单用寒凉泻之即可；痘疮也有实热者，禀气强，血气盛，而毒瓦斯亦盛，也单用清凉解之即可，这又是相同的。现在从发热之初，以至还元之后，都先辨证之虚实寒热而后立方，让人细心审证而后用药，庶不至于虚其虚而实其实乎！不至于损不足而补有余乎！不至于以水益寒而以火益热乎！然而痘的虚实寒热，较之他病犹显明而易察，盖自见点以至结痂，其形其色既昭然可睹，若再听其声音，观其静躁，视其饮食之多少，审其大小便之利涩，三岁以上的，诊其脉之迟数洪微，其辨虚实寒热，应当如黑白之分明，而用药取效就容易了。（辨别虚实寒热的差异。）
又说：痘疮全凭气血成功，而气血的盈亏消长，其理精微，不可不透悟。大概气体天而亲上，血体地而亲下，痘之出也，其高起之泡，是气之位在上，气宜充焉；其四晕根脚，是血之位在下，血宜附焉。泡尖而色白润，是气充而居其亲上之尊位；四围有晕而色红活，是血附而安其亲下之分位。气居其尊，血安其分，气血和顺而载毒出外，这是最吉利的痘，可以不药而愈。顶陷则气反亲下，这是气亏而不能充，法当补气；四围根脚无红晕，这是血亏而不能附，法当补血，这个道理还容易明白。如果有通顶红色成血泡的，是血反亲上，此证最险，必不能成浆，至八九日后痒塌而死，然而这不是血独盈，乃由气亏而失居尊之常，故血得以妄行而僭居其位。急宜大补其气，气充则能统血，血自不得泛溢妄行而泡转白矣。世人不懂此理，见其泡红则谬认为血热而用凉血行血之剂，致令气愈亏而毙愈速，不也很可悲吗！所以气血盈亏之理微妙而难识。至于调治痘疮气血，其气独虚者，固宜专补气而不宜补血，盖阳不能从阴，阴愈长则阳愈消也；其有血虚者多由胃气损伤，元气不足所致，盖阴必从阳，阳生则阴长也。黄汝言《明医杂着》乃谓血虚而用以补气，则阳旺而阴愈消，甚矣！其不明于阴阳消长之理，而谬立此言，为世大害矣。我每次治疗便血的虚滑者，妇人产后去血过多而大发热者，妇人血虚崩漏而下血不止者，俱用人参、干姜、附子为主，而佐以血药与升提药，皆获奇效，安在血病不可补气乎！若小儿痘疮，以胃气为主，则补血必先补气明矣，故气血消长之理，不可不深明也。（分析气血盈亏消长之理。）
朱纯嘏说：痘之为证，始焉一点红，红者是血之色。血之为血，虽赖气以生之，究其本则水也。天一生水，地六成之，水乃北方之坎，两肾是也。肾水充足而得木火土金之气交相养，互相长而成气与血焉，是血之源于水，水之源于肾者明矣。虽分属于心生血，肝藏血，脾裹血，藉令肾中水枯，则必何自而生，肝何自而藏，脾何自而裹，合之则五脏同一太极也。阳动阴静而生水、火、木、金、土也，痘中之一点红，血也。出齐之后，次第起长，充满于痘之中者，浆也。浆者，血气之所化也，化毒而为浆也，浆既充足，脓成而毒解也。渐次转褐色，回水结痂之候也，痂结苍蜡色，此一十二日之成功也。何独前此之高明，不论阴阳五行之正理，妄立名色，且曰惟肾无候，而又实之以耳冷 冷，以明肾家无候之证佐。又曰：痘之变黑始归肾也，此皆不经之谈，千有余年，谁其辨之，予不得已着五脏合一论以辨之。（辨别五脏合一论。）
喜泰顺说：痘本胎毒，号曰天疮，传染由于外感，轻重本乎内伤。初起太阳壬水克乎丙丁，后归阳明。血水化为脓浆，势若燃眉，变如反掌，欲知表里虚实，须明寒热温凉。初发之时，与伤寒相似，或发热烦躁，脸唇红赤，身疼头痛，乍寒乍热，喷涕呵欠，眼目困倦，两颧之间有红纹见者，预知其为痘也。发热三日，当托里解表使其易出；四日、五日清凉解毒，使其易长；六日、七日温补气血，使其易于灌浆；八日、九日清利收敛，使痘易靥，此治痘之常法也。夫常者可必，而变者不可必，安可执一以治之哉！苟痘未出而清凉，则毒得寒而凝滞，热毒未解而过补，则毒蕴蓄而不能化浆。故治痘之法，见机生情，随时应变，至于靥后，不过慎风寒，节饮食而已，此治痘之原论也。
又说：凡痘灰白不红，绽不起发，出不快，昏暗顶陷，皆表寒而虚，二便清，呕吐泄泻，手足口气俱冷，不渴少食，唇白涕清，饮食不化，皆里寒而虚，此表里虚寒之证。急宜温脾胃，补气血，即人参、桂枝、附子，在所宜施。痘色红紫，结实高耸，顶若尘铺，又兼火刺，内夹斑疹，此表热而实；二便秘赤，干呕吐痰，肚腹疼痛，口冲臭气，烦渴腮红，谵语妄言，此皆热毒郁遏，皆里热而实，此表里实热之证。急宜凉泻解毒，重加发散，黄芩、黄连、犀角、黄柏、石膏、栀子、大黄，又所宜施。此表里虚实之证显著于外，医者易明。又有表虚里实者，痘色淡白不红，绽出不快等证，是表虚也；而兼之内证频加，肚腹疼痛，烦躁热渴，白睛通红，二便秘结，此里实也。表虚里实之证，医者先当发散，不宜苦寒发散，则毒得外泄而内热自解，苦寒则毒反冰伏，而出愈难，或于三四朝期，斟酌下之，先清其毒，后补气血，得以成浆，或有毒郁气虚不能充灌者，宜参连汤治之，此治表虚里实之大略也。里虚表实者最为难治，痘疮烦红，根不松活，皮毛壮热，色赤焦紫，此表实也，而兼之呕吐泄泻，唇白涕清，饮食不化等证，治宜活血松肌，如红花、蛇蜕、生地黄、牡丹皮之类，在所宜施，俟色泽红润，庶可补托，不然，则痘不特不能起发充灌，必变紫艳干枯，倒靥空疮，势如燃眉，变若反掌，医者当临证参详，不可拘于一定。（表里虚实寒热论。）
又说：实热之痘，初起壮热，腮红睛赤，口渴谵语，内证固重，见点必凶，烦红琐碎，或三五一堆，两三成群，如同蚊咬，急当发散重下，名曰双解。如蛇蜕、荆芥、防风、葛根、石膏、大黄等剂，再用西河柳、芫荽煎汤洗浴，使毛窍通利，痘方易出，大用清凉。如热毒不解，色泽不润，根脚不松，名为血热，仍可下之，再加连翘、犀角、黄柏、紫草、红花、桃仁、黄连凉血之剂，再服猪尾膏、无价散等剂，方可奏效。如是血热壅遏之痘，必须清凉解毒，以至收靥之时，方可清利收敛，乃是要诀也。（实热壅遏论。）
The affliction arising from this leads to death, and in fact, it is the heart-draining (clearing Heart fire) medications that kill them, yet people remain unaware, and doctors fail to realize it; this is truly lamentable! Therefore, I assert that after the smallpox has erupted but before scabbing occurs, all cooling-heart (clearing Heart fire) medications such as rhinoceros horn (Rhinocerotis Cornu) and rehmannia root (Rehmanniae Radix) should be strictly prohibited for use. They should only be used after scabbing has formed to resolve residual toxins. Someone might ask: If so, does this mean toxins cannot be resolved at all before the scabs form? I say: Why must they all be unresolvable! If the patient's blood qi and pathogenic vapors are both vigorous, the pulse will necessarily be surging and rapid. The pustules may appear purple-black immediately upon eruption, or if erupted, they will be dense and red-purple. Internally, there will be restlessness, stifling sensation, dryness, and thirst, with dark, scanty, and difficult urination, and constipation. This constitutes a excess-heat syndrome, and one should swiftly employ cooling agents to resolve the toxin. If constipation persists for a long time, a small amount of wine-fried rheum (Rhei Radix et Rhizoma) can be added to induce mild purgation, which is acceptable. If the pathogenic vapors are vigorous but the blood qi is not yet robust, the treatment should focus on resolving toxins while simultaneously invigorating blood and nourishing qi; thus, herbs such as codonopsis (Codonopsis Radix), angelica sinensis (Angelicae Sinensis Radix), and white peony root (Paeoniae Radix Alba) should not be absent.
It is also said: In recent times, prescriptions for smallpox have largely followed Huang Xiqiu. His book consistently categorizes cases into favorable (Shun), adverse (Ni), and perilous (Xian) patterns across three diagrams. It is correct that favorable patterns do not require medication. It is reasonable that perilous patterns should be treated with modifications of Baoyuan Tang (Preserve the Origin Decoction). However, stating that adverse patterns are untreatable and that treating them is futile teaches people to stand by and wait for death! Such words are extremely inhumane and cause significant harm to the world. While convenient for quack doctors seeking profit, it severely contradicts the art of saving lives. Medicine is a benevolent art; sages utilized it to assist transformation where education fell short. What is valued is supporting the critical, rescuing the distressed, and bringing the dead back to life. If one treats only easy cases and abandons difficult ones, what is the purpose of being a doctor? Quacks seek profit and fear damage to their reputation; when encountering unfavorable patterns, they often abandon patients. They fear gaining no profit while acquiring a reputation for misdiagnosis. Benevolent gentlemen, however, should strive to save patients from the brink of death. How could one bear to declare certain deaths inevitable and watch without intervening? Thus, Huang Xiqiu’s words benefit quacks but do not serve the world. Moreover, many adverse patterns he describes occur frequently in dense smallpox cases, such as palpitations, vomiting, and diarrhea during initial fever; eruption starting at the Yintang, Sikong, or Tianting points; lack of red halos around the base upon initial eruption; pale, gray, or sunken coloration after eruption; formation of water blisters; itching and collapse; failure to fill with pus when expected; or chills and teeth grinding before scabs fall off. These are all labeled by him as adverse and untreatable, yet I have successfully treated many such cases. Why insist that treatment is useless and warn against it? Only those appearing like silkworm eggs initially, turning purple-black and dry afterward, failing to fill with pus, are mostly incurable. Nevertheless, I would rather attempt treatment and fail than sit idly by without trying. (Synthesizing views from various schools, Part 2.)
Smallpox differs from other diseases. From initial eruption to scabbing, there are fixed days and hours. To rescue the distressed and support the critical, appropriate medications must be administered promptly, akin to fighting a fire or saving someone from drowning; delay is unacceptable. Smallpox toxins originate from the five zang organs, genuinely disturbing their true qi. When many pustules erupt, much true qi is expended. At this moment, the patient’s blood qi is nearly exhausted, precarious as oil running out of a lamp—if not replenished quickly, the flame extinguishes; or like a candle in the wind—if not shielded quickly, the light goes out. Contemporary doctors are different; they value wealth over human life. Those ignorant of herbal application need not be mentioned. Even those who know some medicine hesitate to apply it timely, hoping to demonstrate merit through severe illness. They wait until various malignant symptoms appear, then exploit the parents' fear to demand heavy fees. Delay continues until blood qi is irrecoverably depleted. Although correct medications exist, they arrive too late, leading to many fatal errors. Alas! Heaven, earth, and spirits are manifest and cannot be deceived. Those who kill for greed, with corrupt intentions, surely face spiritual retribution and heavenly punishment. Misfortune will inevitably befall them and their descendants; escape is impossible. This is a danger to the medical profession, which patients’ families must understand. Furthermore, contemporary doctors have shallow insights and fail to grasp profound principles. Clinging to ancestral formulas without adaptation, they manage mild smallpox cases confidently, claiming credit. But faced with dangerous, severe cases, they are helpless. Treating ten members of one family, seven or eight may die, yet they blame the disease’s severity rather than their own incompetence. Patients’ families also blame the disease, not the doctor. Smallpox is common; with proper management and no extreme symptoms, ten cases can yield ten recoveries. Among extremely severe cases, only one or two in ten are truly incurable. Now, if seven or eight out of ten die, why are there so many severe cases? Is it not due to imprecise skills? Deeply pitying this, I feel compelled to write this treatise and prescribe formulas. (Refuting contemporary medical fallacies.)
Generally, treating any disease requires first distinguishing deficiency (Xu), excess (Shi), cold (Han), and heat (Re). Observation, listening/smelling, inquiry, and palpation aim solely at distinguishing these four. If these four are clear in mind, medication yields immediate results. Failure to distinguish them leads to frequent errors, even if occasional recovery occurs, it is merely luck. Distinguishing deficiency/excess and cold/heat in smallpox is particularly crucial. Unclear distinction leads to treatment failure. Why do历代 (past generations) of smallpox experts differ in theories and prescriptions, often neglecting or vaguely defining deficiency/excess and cold/heat? This leaves practitioners confused about which formula suits which pattern. Thus, hundreds of excellent formulas and theories become useless. No wonder smallpox treatment has been misguided since ancient times, and pediatric care neglected. The deficiency/excess and cold/heat of smallpox differ from other diseases in specific ways. Other diseases with deficiency involve intrinsic yuan qi deficiency, requiring tonification. Smallpox involves exterior deficiency and interior deficiency, also involving intrinsic yuan qi deficiency, requiring tonification—this is similar. Other diseases with excess involve pathogenic excess, requiring purgation. Smallpox involves exterior excess and interior excess, where yuan qi is solid and pathogens cannot harm; purgation is neither necessary nor appropriate—this is different. Severe deficiency in other diseases involves yin excess and yang insufficiency, generating internal cold, requiring warm-tonifying agents. Smallpox severe deficiency similarly involves yin excess and yang insufficiency with internal cold, requiring warm-tonifying agents—this is similar. External cold invading other diseases (exterior contraction) requires dispersal when at the exterior; if lingering internally, it transforms into heat, requiring clearing/resolving. For smallpox, external wind-cold invasion requires warming and dispersing; if external cold enters internally causing vomiting/diarrhea, warming is sufficient. Sweating externally or clearing internally is inappropriate. Deficient heat in other diseases arises from yuan qi deficiency and fluid depletion, with fire rising from deficiency; tonification removes heat without needing heat-clearing. Smallpox deficient heat involves yuan qi deficiency and rampant pathogens; primary treatment is tonifying yuan qi with slight toxin resolution. These three aspects are similar yet distinct. Excess heat in other diseases involves intact blood qi but overwhelming pathogens, treatable with cold/purgative agents alone. Smallpox excess heat involves strong constitution, abundant blood qi, and vigorous pathogens, also treatable with cooling/resolving agents alone—this is similar. From initial fever to post-recovery, one must always differentiate deficiency/excess and cold/heat before prescribing. Careful pattern differentiation ensures medication avoids exacerbating deficiency or excess, avoiding damaging the insufficient or supplementing the excessive, or adding cold to cold and heat to heat. However, smallpox deficiency/excess and cold/heat are more obvious and easier to observe than other diseases. From spotting to scabbing, shape and color are visible. Listening to voice, observing agitation/calmness, checking diet intake, and examining bowel/bladder function provide further clues. For children over three, pulse diagnosis (slow/fast, surging/faint) clarifies patterns distinctly like black and white, making effective treatment easy. (Differentiating differences in deficiency/excess and cold/heat.)
It is also said: Smallpox success relies entirely on blood and qi. The principles of their fluctuation are subtle and must be thoroughly understood. Qi belongs to heaven and tends upward; blood belongs to earth and tends downward. The elevated vesicles of smallpox represent the position of qi (upper); qi should be充盈 (abundant). The red halos and bases represent the position of blood (lower); blood should adhere. Vesicle tips that are white and moist indicate abundant qi occupying its superior position. Red, vibrant halos around the periphery indicate blood adhering to its subordinate position. When qi occupies its尊贵 (honorable) place and blood remains in its proper division, harmonious blood and qi carry toxins outward. This is the most auspicious smallpox, healable without medication. Sunken tops indicate qi sinking downward, signifying qi deficiency unable to fill; treatment requires tonifying qi. Lack of red halos at the base indicates blood deficiency unable to adhere; treatment requires tonifying blood. This principle is relatively easy to understand. If the entire vesicle turns red and becomes a blood blister, blood is rising upward—an extremely dangerous pattern. Pus formation will fail, leading to death from itching and collapse around day eight or nine. This is not due to blood excess, but qi deficiency losing its governing role, allowing blood to act recklessly and usurp positions. Urgent large-scale qi tonification is needed. Once qi is abundant, it governs blood, preventing reckless overflow, and vesicles turn white. People misunderstanding this see red vesicles, mistakenly diagnose blood heat, and use blood-cooling/moving agents, worsening qi deficiency and accelerating death. Tragic! Thus, the principles of blood/qi fluctuation are subtle and hard to grasp. For smallpox treatment, isolated qi deficiency requires exclusive qi tonification, not blood tonification, because yang cannot follow yin; increasing yin depletes yang. Blood deficiency often stems from stomach qi injury and insufficient yuan qi; yin follows yang, and yang generation promotes yin growth. Huang Ruyan’s *Ming Yi Za Zhuo* claims tonifying qi for blood deficiency causes yang excess and yin depletion. This demonstrates ignorance of yin/yang fluctuation principles and creates great harm. I successfully treat bloody stool with deficiency-slippage, postpartum women with massive blood loss and high fever, and women with uterine bleeding due to blood deficiency, using primarily ginseng (Ren Shen), dried ginger (Gan Jiang), and aconite (Fu Zi), assisted by blood-invigorating and ascending herbs, achieving remarkable results. Who says blood disorders cannot be treated by tonifying qi? For pediatric smallpox, prioritizing stomach qi makes it clear that tonifying blood must begin with tonifying qi. Thus, the principles of blood/qi fluctuation must be deeply understood. (Analyzing principles of blood/qi fluctuation.)
Zhu Chengu states: Smallpox begins with a red spot; red is the color of blood. Blood relies on qi for generation, but fundamentally originates from water. "Heaven generates one water, Earth completes six." Water corresponds to Kan (North), represented by the two kidneys. Sufficient kidney water interacts with wood, fire, earth, and metal qi to mutually nourish and grow, forming qi and blood. Thus, blood originates from water, and water from kidneys is clear. Although heart generates blood, liver stores blood, and spleen envelops blood, if kidney water dries up, how can they generate/store/envelop? Together, the five zang organs constitute one Taiji. Yang movement and yin stillness generate water, fire, wood, metal, and earth. The initial red spot in smallpox is blood. After complete eruption, sequential growth fills the pustules with pus. Pus is transformed from blood and qi, converting toxins into pus. Once pus is sufficient, suppuration occurs and toxins resolve. Gradually turning brown, returning to water, scabs form. Scabs become waxy-gray, completing the process in twelve days. Why did past experts ignore the orthodox principles of yin/yang and five elements, inventing names, claiming only the kidney has no signs, and citing cold ears to prove kidney absence? Also claiming blackening returns to the kidney? These are unfounded tales for over a thousand years, unchallenged. I was forced to write the "Theory of Five Zang Unity" to refute them. (Differentiating the Theory of Five Zang Unity.)
Xi Taishun states: Smallpox is fetal toxin, called Heavenly Cramps. Transmission depends on external contraction; severity depends on internal injury. Initially, Taiyang Ren Water controls Bing Ding (Fire), later returning to Yangming. Blood and water transform into pus and plasma, urgent as burning eyebrows, changing like flipping a hand. To know exterior/interior and deficiency/excess, one must understand cold/heat/warm/cool. Initial eruption resembles Cold Damage (Shanghan): fever, irritability, red face/lips, body/head pain, alternating chills/fever, sneezing/yawning, sleepy eyes, red lines between cheekbones predict smallpox. On fever day three, support interior and release exterior to facilitate eruption. Days four-five: cool and resolve toxins to facilitate growth. Days six-seven: warm and tonify blood/qi to facilitate pus filling. Days eight-nine: clear, drain, and astringe to facilitate scabbing. This is the standard method. Standards are predictable, variations are not; how can one stick rigidly to one approach? Cooling before eruption stagnates toxins with cold; over-tonifying unresolved heat toxins prevents pus formation. Thus, smallpox treatment requires adaptability. Post-scabbing, merely avoid wind/cold and regulate diet. This is the original theory of smallpox treatment.
It is also said: Ashen-white, non-red, non-elevated, slow eruption, dull/sunken tops indicate exterior cold-deficiency. Clear urine/stool, vomiting/diarrhea, cold limbs/breath, no thirst, poor appetite, white lips/clear mucus, indigestion indicate interior cold-deficiency. This is exterior-interior cold-deficiency syndrome. Urgently warm spleen/stomach, tonify blood/qi; ginseng, cinnamon twig (Guizhi), and aconite are appropriate. Red-purple, firm/high, dusty tops, fire thorns, accompanied by macules/rashes indicate exterior heat-excess. Constipation with dark urine, dry retching/phlegm, abdominal pain, foul breath, irritability/thirst, red cheeks, delirium indicate heat-toxin suppression, interior heat-excess. This is exterior-interior heat-excess syndrome. Urgently cool, purge, resolve toxins, heavily disperse; scutellaria (Huang Qin), coptis (Huang Lian), rhinoceros horn, phellodendron (Huang Bai), gypsum (Shi Gao), gardenia (Zhi Zi), and rheum are appropriate. Exterior-interior deficiency/excess patterns are obvious externally, easy for doctors to identify. Exterior deficiency-interior excess: pale/non-red, slow eruption indicates exterior deficiency; accompanied by frequent internal symptoms, abdominal pain, irritability/thirst, white sclera redness, constipation indicates interior excess. For exterior deficiency-interior excess, doctors should first disperse. Bitter-cold dispersal is inappropriate; otherwise, toxins escape externally but internal heat resolves. Bitter-cold causes toxin freezing, making eruption harder. Around days three-four, consider purgation to clear toxins first, then tonify blood/qi for pus formation. For toxin-stagnation with qi-deficiency unable to fill, Shelian Tang (Ginseng and Coptis Decoction) is suitable. This outlines treating exterior deficiency-interior excess. Interior deficiency-exterior excess is hardest to treat. Irritated red smallpox, tight bases, hot skin, red-dry-purple color indicates exterior excess; accompanied by vomiting/diarrhea, white lips/clear mucus, indigestion. Treatment should invigorate blood and loosen muscle using safflower (Hong Hua), snake molt (She Tui), rehmannia root, and moutan cortex (Mu Dan Pi). Wait for red/vibrant color before supporting/tonifying. Otherwise, pustules fail to elevate/fill, turning purple-dry, inverted scabs, empty sores, urgent as burning eyebrows, changing rapidly. Doctors must examine clinically, not rigidly. (Theory of Exterior/Interior Deficiency/Excess/Cold/Heat.)
It is also said: Excess-heat smallpox begins with high fever, red cheeks/red eyes, thirst, delirium. Internal symptoms are severe; spotting is ominous. Irritated red, fragmented, clustered like mosquito bites. Urgently disperse and purge heavily, named "Double Resolution." Herbs like snake molt, schizonepeta (Jing Jie), saposhnikovia (Fang Feng), pueraria (Ge Gen), gypsum, and rheum are used. Bathing with tamarisk (Xi He Liu) and coriander (Yan Xu) decoctions opens pores, facilitating eruption with heavy cooling. If heat-toxin unresolved, luster dull, bases tight, named blood heat, purgation continues. Add forsythia (Lian Qiao), rhinoceros horn, phellodendron, arnebia/lithospermum (Zi Cao), safflower, peach kernel (Tao Ren), and coptis for blood cooling. Administer pig tail paste (Zhu Wei Gao) and Priceless Powder (Wu Jia San) for effect. For blood-heat stagnation, cooling/resolving is mandatory until scabbing, then clearing/draining/astringing is the key. (Theory of Excess-Heat Stagnation.)