巴生居近比邻，尊公秉昭翁，早子俱殇于痘。是春痘令盛行，儿多夭折，生年数龄，尚
未出
痘，翁以为忧。一夕忽发热呕吐，卧寐不安。比晓迓予，望其颊赤唇干，扪其身热指冷，烦
渴舌黄，细验周身标点，隐隐夹有紫 ，顾谓翁曰∶此布痘 闭，险逆之证也。服药 消痘
透，庶可无虞。方定羌活散 汤，加石膏灯心，午后复视，云服头渣药后，热盛闷乱，头摇
肢掣。予曰∶此欲作惊。令服复渣，薄暮烦热益甚，昏谵渴饮，舌吐唇外，掉弄不休，痘仍
不透。 反增多。其热颇剧，举家仓皇。旁议剂中石膏过凉，冰伏为害。予辞焉。秉翁坚求
拯治，因在邻居素契，且此子又从次儿受业，情难固却，复告之曰∶方书虽有痘初宜于升发
，忌用清凉，恐其冰伏之说。特此证乃心胃火毒壅遏，致成 闭，不清其火， 何由消?痘
何由透，前方清药力轻，故不胜任，于是重用石膏为君，佐以犀角、酒炒黄连、元参、升麻
、连翘、赤芍、牛蒡、紫草之属。灯心尖为引，每服另冲无比散，取其大热，利小便，亦釜
底抽薪之义。方已写就，思舌为心苗，今舌吐弄不休，内服煎药，须外用紫雪涂之，奈此物
吾乡甚罕，乞诸其邻，所与些微，亦不济事。翁云∶吾有紫雪藏之久矣。取出称有三钱，快
甚。即令蜜调涂舌，并速煎药与服，次早翁来云∶昨夕遵谕服药，涂舌至半夜，热缓 收，
泻止躁定，似有转机。再烦一看，果诸证悉平， 消痘透。予曰生矣。询其紫雪只剩三分，
余皆涂去。予笑谓翁曰∶此证虽仗药力挽回，然非如许紫雪，亦无此速效。今火势既平，药
当褪松，酌以十神解毒汤，仍稍用石膏犀角，清其余火，转用太乙保和汤，人参易沙参，加
天虫、白芷、贝母鲜鳞。浆成之后，补脾利水，清凉解毒，渐次收功。此等险证，幸在比邻
，朝夕看视，药随病转，得以保全。使病家与医居隔远，仓卒变幻，硬鞭长莫及，欲图庆成
，不亦难乎。
安波按∶方议精妙入神，读者不可忽过。
巴声茂先生住在离我家很近的地方，他的父亲秉昭老先生，早年和次子都死于天花。这一年春天，天花盛行，很多儿童夭折，巴生当时只有几岁，还没有出过痘，老先生为此十分担忧。一天夜里，他突然发热、呕吐，卧床睡眠不安稳。等到天亮时，老先生来接我诊治，我看他两颊发红、嘴唇干燥，摸他身体发热但手指发凉，烦躁口渴、舌苔黄，仔细检查全身隐约可见的痘点，发现其中夹杂有紫黑色的瘀斑。我对老先生说：“这是布痘闭陷，属于危险逆乱的证候。服药使痘毒消散并透发出来，才可能没有危险。”于是定下羌活散汤，加入石膏和灯心草。午后再次诊视，老先生说服用第一煎药后，热度更高且感到烦闷混乱，头部摇动、四肢抽搐。我说：“这是快要发生惊风了。”让他服用第二煎药。傍晚时分，烦热更加严重，神志昏沉胡言乱语、极度口渴想喝水，舌头伸出嘴唇外无法收回，不停地抖动玩耍，痘点仍然没有透发出来，反而增多了。病情非常剧烈，全家惊慌失措。旁边有人议论方剂中石膏过于寒凉，导致冰伏（寒邪凝滞）为害。我予以推辞不接受。秉翁坚决请求救治，因为我们是邻居且一向交好，况且这个孩子又跟随我的次子读书，情面上难以坚决拒绝，便又告诉他：“医书上虽然记载痘疹初期适宜升发，忌讳使用清凉药物，担心造成冰伏的说法。但是此证乃是心胃火毒壅塞遏阻，导致痘毒闭陷，不清除火热，痘毒如何能消退？痘点如何能透发？前方清热药力太轻，所以不能胜任。”于是重用石膏作为君药，辅以犀角、酒炒黄连、玄参、升麻、连翘、赤芍、牛蒡子、紫草等药物。用灯心草尖作为引经药，每次服药时另冲服无比散，取其大热之性，通利小便，这也是“釜底抽薪”的道理。处方已经写好，考虑到舌为心之苗窍，现在舌头伸出抖动不止，内服煎药的同时，必须外用紫雪丹涂抹舌头，无奈这种药在我们家乡非常罕见，向邻居求助，得到的很少，也不起作用。老先生说：“我有珍藏已久的紫雪丹。”取出来称量有三钱，非常快意。立即令他用蜂蜜调和涂抹舌头，并迅速煎药给他服用。第二天早上老先生来说：“昨晚遵照嘱咐服药，涂抹舌头到半夜，热度减退、痘点收敛，腹泻停止、躁动安定，似乎有了转机。”再请我去看，果然各种症状全部平息，痘毒消退、痘点透发。我说孩子保住了。询问紫雪丹只剩三分，其余都涂掉了。我笑着对老先生说：“这个病证虽然依靠药力挽回，但如果不是用这么多紫雪丹，也没有这么快的疗效。现在火势已经平息，药物应当减轻力度，酌情选用十神解毒汤，仍然稍微使用石膏和犀角，清除残余的火毒；转而使用太乙保和汤，将人参换成沙参，加入天虫（僵蚕）、白芷、贝母、鲜鳞（鲜石斛或类似药材，此处依原文保留‘鲜鳞’，通常指鲜品石斛或相关滋阴药，但在程杏轩医案中常指鲜石斛或鲜生地等，此处按字面翻译为鲜鳞/鲜品鳞茎类药材，结合语境多为滋阴清热之品，暂译为 fresh Lin [likely referring to a specific herb like Dendrobium or similar]）。”浆成之后，补益脾脏、利水渗湿，清凉解毒，逐渐取得成效。这类险恶证候，幸好住在隔壁，朝夕看护，药物随着病情变化而调整，得以保全性命。如果病家和医生居住相隔遥远，遇到突然的变化，即使鞭长莫及，想要谋求痊愈，不也很难吗？
安波按：方议精妙入神，读者不可忽略过去。
Mr. Ba Shengmao lived in close proximity to my residence. His father, Mr. Bingzhao, had lost both his eldest and second sons to smallpox (Xiaodou). That spring, smallpox was prevalent, causing the death of many children. Mr. Ba Shengmao was only a few years old and had not yet contracted smallpox, which caused great worry for his father. One night, he suddenly developed fever (Fare) and vomiting (Ou Tu), with restless sleep. At dawn, Mr. Bingzhao came to invite me. Upon observation, I noted red cheeks (Jia Chi), dry lips (Chun Gan), body heat but cold fingers (Shen Re Zhi Leng), irritability and thirst (Fan Ke), and a yellow tongue coating (She Huang). Careful examination of the emerging rash spots revealed hidden purple-black discoloration (Zi Ban). I told Mr. Bingzhao: "This is a case of smallpox eruption obstruction (Bu Dou Bi Xian), a dangerous and adverse syndrome. Medication to dissipate the rash and promote its emergence may prevent danger." I prescribed Qianghuo San Decoction (Qianghuo San Tang) with added Gypsum Fibrosum (Shigao) and Juncus Effusus (Dengxin). In the afternoon, I visited again. Mr. Bingzhao reported that after taking the first decoction, the fever intensified, accompanied by mental restlessness and confusion, head shaking, and limb convulsions (Tou Yao Zhi Che). I said: "This indicates impending wind-stroke or convulsion (Jing Feng). Have him take the second decoction." By evening, the irritability and heat worsened significantly. He became comatose with delirious speech (Hun Chan), extremely thirsty and drinking water, with his tongue protruding outside the lips and unable to retract (She Tu Chun Wai), twitching incessantly. The rash still did not emerge and actually increased in number. The condition was severe, causing panic throughout the family. Bystanders suggested that the Gypsum in the prescription was too cooling, causing "ice-stagnation" (Bing Fu) harm. I declined this opinion. Mr. Bingzhao firmly requested treatment. Since we were neighbors with a good relationship, and since Mr. Ba Shengmao studied under my second son, I could not refuse out of courtesy. I explained: "Although medical texts state that early-stage smallpox should be treated with ascending and dispersing methods, avoiding cooling herbs to prevent ice-stagnation, this case involves excessive fire-toxin obstructing the Heart and Stomach, leading to rash obstruction. Without clearing the fire, how can the toxin dissipate? How can the rash emerge? The previous prescription's clearing power was too weak. Therefore, I will heavily use Gypsum as the sovereign herb, assisted by Rhinoceros Horn (Xijiao - *Note: Modern practice uses substitutes like Water Buffalo Horn*), wine-processed Coptis Chinensis (Jiu Chao Huanglian), Scrophularia Root (Yuanshen), Cimicifuga Rhizome (Shengma), Forsythia Fruit (Lianqiao), Red Peony Root (Chishao), Arctium Seed (Niubangzi), and Lithospermum Root (Zicao). Juncus tip serves as the guiding herb. Each dose should be taken with an additional flush of Wubi San, utilizing its hot nature to promote urination, embodying the principle of 'removing firewood from under the cauldron' (Fu Di Chou Xin)." After writing the prescription, I considered that the tongue is the sprout of the Heart. Given the persistent tongue protrusion, external application of Zi Xue Dan (Purple Snow Pill) on the tongue is necessary alongside internal decoction. However, this medicine is rare in our region. I asked neighbors for it, but the amount obtained was insufficient. Mr. Bingzhao said: "I have stored Zi Xue Dan for a long time." He took it out, weighed three qian, and felt relieved. I instructed him to mix it with honey and apply it to the tongue, and to quickly decoct and administer the medicine. The next morning, Mr. Bingzhao reported: "Last night, following your instructions, we administered the medicine and applied the tongue paste until midnight. The fever subsided, the rash receded, diarrhea stopped, and agitation settled. There seems to be a turning point." Upon re-examination, all symptoms had resolved, the toxin dissipated, and the rash emerged clearly. I said: "He has survived." Inquiry revealed only three fen of Zi Xue Dan remained, the rest having been applied. I smiled and said to Mr. Bingzhao: "Although this critical case was saved by the medication, such rapid efficacy would not have been achieved without such a large amount of Zi Xue Dan. Now that the fire energy is pacified, the medication should be relaxed. I will prescribe Shishen Jiedu Tang (Ten-God Detoxification Decoction), still using mild amounts of Gypsum and Rhinoceros Horn to clear residual fire. Then switch to Taiyi Baohe Tang, replacing Ginseng Radix (Renshen) with Glehnia Root (Shashen), adding Silkworm (Tianchong/Jiangcan), Angelica Dahurica (Baizhi), Fritillaria Bulb (Beimu), and fresh Lin (Xianlin - likely referring to fresh Dendrobium or similar yin-nourishing herb). Once the blisters form, tonify the Spleen and promote water metabolism, cool and detoxify, gradually achieving recovery. Such critical cases benefited from being neighbors, allowing daily monitoring and adjusting medications to the changing disease, thus preserving life. If the patient and doctor lived far apart, sudden changes would occur where even if one wished to help, one might be powerless. Seeking recovery would indeed be difficult."
An Bo commented: The prescription discussion is exquisite and divine; readers must not overlook it.