如发热四日至五六日后始出者，须审视曾有外感内伤否，盖伤风寒伤食之热，
久而不去，则所蕴疮痘之毒，亦能乘间而出，不可以过期论。惟无内伤外感之因，
一向热而不出，此里气虚，不能驱逐其毒，使之即出，而毒邪得以留连停伏于脏腑
肠胃之间，宜先用托里之剂，令其快出，次以和中之剂多服之，可以无伏无陷无倒
靥，托里宜托里快 汤或十宣散，和中宜四君子汤加黄 ，或保元汤合匀气散
主之。
托里快 汤
当归 黄 川芎 木香 青皮 牛蒡子 紫草 连翘 木通 防风 桂枝 蝉蜕
上锉细。加淡竹叶十片，水煎，温服，无时。
十宣散（一名十奇散，一名托里十补散）
黄 人参 当归（各二钱） 浓朴（姜制） 桔梗（各一钱） 桂心（三分） 川芎 防风
甘草 白芷（各一钱）
上为细末。每服一钱或二钱，木香汤调下。
增损八物汤
人参 黄 白术 甘草 当归 川芎 牛蒡子（炒） 赤芍药 防风 荆芥穗 连
翘桔梗 葛根
上，用水煎服。
匀气散
木香 青皮（各五钱） 山楂肉（二钱半）
上为细末。每服一钱，甘草汤调服。
痘疹之出，自有常期，如过期应出不出，有数证不同不可不辨。如内素实之人，
皮浓肉密，毒瓦斯难于发越，一旦恃其体浓，不怯风寒，又为外邪所袭，或体素弱者，
风寒易感，以致腠理闭密，气血凝涩，故应出不出也，其证头痛，四肢拘急，偎倚
盖覆，常恶风寒，此类宜发之。气强者用双解散，气弱者用参苏饮或惺惺散（俱初热）。
或内虚者，脾弱食少，宜用补脾之剂加行气发表药，四君子汤（不能食）、调元汤（即参 饮）、
（见大法）并加木香、青皮、黄 、桂枝。或脏腑自利，宜用温里之剂，黄 建中汤（腹痛）、
益黄散（脾）、并与夺命丹合进，利未止者，豆蔻丸（泄利）合进，盖里温则气不消削，气不消
削则不陷伏矣。若根据上法分治，犹不出者，此毒壅伏于三焦，不久而变生焉。
加减参苏饮
人参 紫苏叶 葛根 陈皮 前胡 白芷 桔梗 枳壳 甘草 羌活 防风
上，用竹叶为引，热服。
加减调中汤
人参 白术 黄 甘草（炙） 木香 桂枝 白茯苓 藿香 白芍药（酒炒） 陈皮
上，用生姜为引，煎服。
闻人氏 云∶是痘疹证热数日而不发见者，进退皆难，便欲大发之，惧其本稀
而成 烂，不发之，又无以出其毒瓦斯，古人立论，始以药微发之，微发不出，则加
药，加药不出，则大发之，大发之后，所出不多，气候和平无他证者，即是疮本稀，
不可更发也。以此言之，发不至太过，守不至不及，乃用药之丸活也。
愚按∶古方用发表者，升麻葛根汤轻剂也，惺惺散重剂也，谓微发，谓加
药者，或先用轻剂，后用重剂，或只用本剂先小作汤少饮之，后渐加大多饮之，
非谓于本方之外，再加辛热大发之药也。
凡痘疹过期，应出不出者，或因外感风寒，根据上发表之法，或因内虚泄泻，根据
上和中之法，如按法调治，犹不出快，热反甚，大渴腹胀满，大便硬结不通，烦躁
不安者，此毒邪壅伏于内，三黄丸、七味升麻丸（初热）择而用之，甚则三乙承气汤主
之（大便秘）。闻人氏云∶且身热脉数，大便秘而腹胀，此热毒壅遏，未见形状者，当微
下之，非微下则热不减，此是始者，热在里 未出之时也，若 点隐隐在皮肤中者，
是已发越在表，疮正发时，则不可妄下也。又有结脓窠痂 之际，脉尚洪数能食，
而大小便秘，此表已罢，里有热毒，宜微利之，大抵脏腑有热，往往利大小便者，
以其主出而不内故也。
张氏从道云∶疮痘气匀即出快，盖气匀则荣卫无滞，匀气之药，如桂枝、防风、
荆芥穗、薄荷叶，所以行在表之气，而使之无滞也，故凡发表之剂多用之。木香、
青皮、枳壳、木通，所以行在里之气，而使之无滞也，故凡和中之剂多用之。又，
疮出之时，常宜和暖如三春发生之气，则气血和畅，自然其出快，其发透，其靥齐，
若偏于太热，则壮火食气，其气反虚，而不能行，偏于太寒，则气凝涩而不得行矣。
痘疮之证，其初不免于发热者，未出毒邪在里，煎熬气血，熏蒸脏腑而然，疮
既现形，则毒泄而热解，所以疮出热退者，疮本必疏，若疮已出，热不少减，此毒
蕴于中，其势方张，其疮必密，宜急解其毒，连翘升麻汤加防风、荆芥穗、地骨皮，
或解毒防风汤（大法）加升麻，或东垣黍粘子汤（本条），兼服代天宣化丸（预防）。服药之
后，疮或不出，或再出，其热顿减者为气和也，热若不减，疮渐加多，再消详大小便
何如，大便不通七物升麻丸（初热）。小便不利连翘汤（小便不利）。小大便俱不通八正
散（小便不利）。自利
者黄芩汤（自利）加白头翁、酒黄连、调赤石脂末。里气和，毒解矣，如更加渴，烦躁
不已，或谵妄，或腹胀满气促，或自利不止手足厥冷，此逆证，勿治。
如果发热四到五天后才开始出痘疹的，必须仔细审视是否有外感或内伤的病史。因为伤于风寒或伤于饮食导致的发热，如果长久不愈，那么体内蕴藏的疮痘毒邪也能趁机发作，不能简单地以超过常规期限来论断。只有那些没有内伤外感诱因，一直发热但痘疹不出来的，这是里气虚弱，无法驱逐毒邪使其及时透出，导致毒邪留连停伏在脏腑肠胃之间。此时应当先用托里透脓的方剂，促使痘疹迅速发出，然后再多服用调和脾胃的方剂，这样就可以避免毒邪潜伏、内陷或倒靥（痘疹塌陷）的情况。托里宜用托里快汤或十宣散；调和脾胃宜用四君子汤加黄芪，或者保元汤合匀气散来主治。
托里快汤
当归、黄芪、川芎、木香、青皮、牛蒡子、紫草、连翘、木通、防风、桂枝、蝉蜕。
以上药材切碎。加入淡竹叶十片，加水煎煮，温服，不拘时候。
十宣散（又名十奇散，又名托里十补散）
黄芪、人参、当归（各二钱）、浓朴（姜制）、桔梗（各一钱）、桂心（三分）、川芎、防风、甘草、白芷（各一钱）。
以上研为细末。每次服用一钱或二钱，用木香汤调服。
增损八物汤
人参、黄芪、白术、甘草、当归、川芎、牛蒡子（炒）、赤芍药、防风、荆芥穗、连翘、桔梗、葛根。
以上用水煎服。
匀气散
木香、青皮（各五钱）、山楂肉（二钱半）。
以上研为细末。每次服用一钱，用甘草汤调服。
痘疹的发出，自有其固定的时期。如果过了期限应该发出却未发出，有多种证候不同，不可不加以辨别。例如素体实盛的人，皮肤厚肌肉密，毒邪难以发散，一旦倚仗身体壮实，不畏风寒，又被外邪侵袭；或者素体虚弱的人，容易感受风寒，导致腠理闭塞，气血凝滞涩阻，所以该出而不出。这类证候表现为头痛，四肢拘急，喜欢依偎覆盖，常常怕风怕冷，此类适宜用发汗解表的方法治疗。正气强的用双解散，正气弱的用参苏饮或惺惺散（均在初热阶段使用）。如果是内虚者，脾弱食少，适宜用补脾的方剂加上行气发表的药物，如四君子汤（用于不能进食者）、调元汤（即参苏饮，见大法），并加木香、青皮、黄芪、桂枝。如果脏腑自利（腹泻），适宜用温里的方剂，如黄芪建中汤（用于腹痛者）、益黄散（用于脾虚者），并与夺命丹配合服用；腹泻未止的，合用豆蔻丸（用于泄泻者）。因为里气温暖则气不消减耗损，气不消减则不会陷入潜伏。如果根据上述方法分别治疗，痘疹仍然不出的，这是毒邪壅塞潜伏在三焦，不久就会发生变证。
加减参苏饮
人参、紫苏叶、葛根、陈皮、前胡、白芷、桔梗、枳壳、甘草、羌活、防风。
以上，用竹叶为引，热服。
加减调中汤
人参、白术、黄芪、甘草（炙）、木香、桂枝、白茯苓、藿香、白芍药（酒炒）、陈皮。
以上，用生姜为引，煎服。
闻人氏说：对于痘疹证发热数日而不发见的情况，进退两难。如果急于大发汗，恐怕原本稀疏的痘疹会变成腐烂；如果不发汗，又无法排出毒邪。古人确立的理论，开始是用轻微的药剂发汗，轻微的发不出来，就增加药量；增加药量还发不出来，就用大剂量的药剂大发。大发之后，发出的痘疹不多，气候平和没有其他证候的，就是痘疹本来稀疏，不可以再发汗了。这样说起来，发汗不至于太过分，固守不至于不够，这就是用药的灵活之处。
我按语：古方中使用发表药的，升麻葛根汤是轻剂，惺惺散是重剂。所谓“微发”，所谓“加药”，是指或者先用轻剂，后用重剂；或者只用本方先少量煎汤少喝，后来逐渐加大多喝，并不是指在本方之外，再加辛热的大发汗药物。
凡是痘疹过期，应该发出却未发出的，或者是因为外感风寒，根据发表的方法治疗；或者是因为内虚泄泻，根据和中的方法治疗。如果按照方法调理治疗，痘疹仍然不出且快，发热反而加重，大渴，腹胀满，大便硬结不通，烦躁不安的，这是毒邪壅塞潜伏在内部，三黄丸、七味升麻丸（初热阶段）择一使用，严重的用三乙承气汤主治（大便秘结）。闻人氏说：而且身热脉数，大便秘结而腹胀，这是热毒壅遏，尚未见到形状的时候，应当轻微攻下。如果不轻微攻下，热势就不会减退，这是起初热在里而未出的时候。如果红点隐隐在皮肤中，是已经发越在表，疮正发的时候，就不可以妄用攻下法。又有结成脓窠痂皮之际，脉象尚洪数能进食，而大小便不通，这是表证已罢，里有热毒，适宜轻微通利。大抵脏腑有热，往往通过通利大小便来解决，因为它们主要作用是使毒邪外出而不内陷。
张氏从道说：疮痘气息均匀就能出得快，因为气均匀则营卫无阻滞。匀气的药物，如桂枝、防风、荆芥穗、薄荷叶，是用来运行在表的气，使之无阻滞，所以凡是发表的方剂多用这些药。木香、青皮、枳壳、木通，是用来运行在里的气，使之无阻滞，所以凡是和中的方剂多用这些药。另外，疮发出的时候，常宜保持温暖如春天生发之气的环境，这样气血和畅，自然出得快，发得透，收靥整齐。如果偏于太热，则壮火食气，气反而虚弱而不能运行；偏于太寒，则气凝滞涩阻而不能运行。
痘疮之证，起初不免于发热，是因为未出时毒邪在里，煎熬气血，熏蒸脏腑所致。疮既现形，则毒泄而热解，所以疮出热退的，疮本必稀疏。如果疮已出，热势不少减，这是毒蕴于中，其势正盛，其疮必密集，应当紧急解毒，可用连翘升麻汤加防风、荆芥穗、地骨皮，或者解毒防风汤（见大法）加升麻，或者东垣黍粘子汤（本条），兼服代天宣化丸（预防）。服药之后，疮或者不出，或者再出，热势顿减的是气和的表现。如果热势不减，疮渐增多，再详细查看大小便情况如何。大便不通用七物升麻丸（初热阶段）。小便不利用连翘汤（小便不利）。小大便俱不通用八正散（小便不利）。自利的用黄芩汤（自利）加白头翁、酒黄连、调赤石脂末。里气和顺，毒邪解除。如果更加口渴，烦躁不已，或者谵妄，或者腹胀满气促，或者自利不止手足厥冷，这是逆证，不要治疗。
If fever persists for four to five days before the eruption of smallpox or measles begins, one must carefully examine whether there is a history of external contraction (Wai Gan) or internal injury (Nei Shang). This is because heat caused by injury from wind-cold or food stagnation, if lingering for a long time without resolving, can cause the accumulated toxin of sores and pox to erupt opportunistically; it cannot simply be judged as exceeding the normal timeframe. Only in cases where there are no causes of internal injury or external contraction, yet fever persists without eruption, is this due to deficiency of Qi in the interior, failing to drive out the toxin for timely release, allowing the pathogenic toxin to linger and lodge between the Zang-Fu organs and intestines. In such cases, one should first use formulas that support the interior (Tuo Li) to promote rapid eruption, followed by prolonged administration of formulas that harmonize the middle Jiao (He Zhong), thereby preventing the toxin from lurking, sinking inward, or collapsing during crusting (Dao Ye). For supporting the interior, Tuo Li Kuai Tang or Shi Xuan San may be used; for harmonizing the middle, Si Jun Zi Tang added with Huang Qi, or Bao Yuan Tang combined with Yun Qi San, may be prescribed.
Tuo Li Kuai Tang
Dang Gui, Huang Qi, Chuan Xiong, Mu Xiang, Qing Pi, Niu Bang Zi, Zi Cao, Lian Qiao, Mu Tong, Fang Feng, Gui Zhi, Chan Tui.
Crush these ingredients finely. Add ten slices of Dan Zhu Ye, decoct in water, and take warm at any time.
Shi Xuan San (Also known as Shi Qi San, or Tuo Li Shi Bu San)
Huang Qi, Ren Shen, Dang Gui (each 2 qian), Hou Po (processed with ginger), Jie Geng (each 1 qian), Gui Xin (3 fen), Chuan Xiong, Fang Feng, Gan Cao, Bai Zhi (each 1 qian).
Grind into a fine powder. Take 1 or 2 qian each time, mixed with Mu Xiang decoction.
Zeng Sun Ba Wu Tang
Ren Shen, Huang Qi, Bai Zhu, Gan Cao, Dang Gui, Chuan Xiong, Niu Bang Zi (stir-fried), Chi Shao Yao, Fang Feng, Jing Jie Sui, Lian Qiao, Jie Geng, Ge Gen.
Decoct in water and take orally.
Yun Qi San
Mu Xiang, Qing Pi (each 5 qian), Shan Zha Rou (2.5 qian).
Grind into a fine powder. Take 1 qian each time, mixed with Gan Cao decoction.
The eruption of smallpox or measles follows its own regular schedule. If the eruption fails to occur after the expected time, there are several different patterns that must be distinguished. For instance, individuals who are constitutionally excess, with thick skin and dense flesh, find it difficult to disperse toxins. If they rely on their robust physique, disregard wind-cold, and are subsequently attacked by external pathogens, or if constitutionally weak individuals easily contract wind-cold, leading to closed pores and stagnant, sluggish Qi and Blood, the eruption will fail to occur despite being due. These cases present with headache, stiffness and tension of the four limbs, a desire to huddle under covers, and aversion to wind and cold. Such cases are suitable for treatment via diaphoresis (Fa Zhi). For those with strong Qi, Shuang Jie San may be used; for those with weak Qi, Shen Su Yin or Xing Xing San may be used (both applicable during the initial fever stage). For those with internal deficiency, characterized by weak Spleen and poor appetite, formulas that tonify the Spleen combined with herbs that move Qi and release the exterior should be used, such as Si Jun Zi Tang (for inability to eat), Diao Yuan Tang (which is Shen Su Yin, see Da Fa), added with Mu Xiang, Qing Pi, Huang Qi, and Gui Zhi. If there is spontaneous diarrhea due to internal cold, warming interior formulas such as Huang Qi Jian Zhong Tang (for abdominal pain) or Yi Huang San (for Spleen deficiency) should be used, combined with Duo Ming Dan. If diarrhea persists, Dou Kou Wan (for diarrhea) should be added. Because when the interior is warm, Qi does not dissipate; if Qi does not dissipate, it will not sink or lurk. If, according to the above methods, the eruption still does not occur, this indicates toxin congestion and lurking in the San Jiao, which will lead to complications shortly.
Jia Jian Shen Su Yin
Ren Shen, Zi Su Ye, Ge Gen, Chen Pi, Qian Hu, Bai Zhi, Jie Geng, Zhi Ke, Gan Cao, Qiang Huo, Fang Feng.
Use Zhu Ye (Bamboo Leaf) as a guide, take hot.
Jia Jian Tiao Zhong Tang
Ren Shen, Bai Zhu, Huang Qi, Gan Cao (honey-fried), Mu Xiang, Gui Zhi, Fu Ling, Huo Xiang, Bai Shao Yao (wine-fried), Chen Pi.
Use Sheng Jiang (Fresh Ginger) as a guide, decoct and take.
Mr. Wenren stated: In cases where smallpox or measles fever persists for several days without eruption, both advancing and retreating are difficult. One fears that aggressive diaphoresis will turn sparse eruptions into rotting sores, while failing to diaphorese prevents the expulsion of toxins. The ancient theory proposes starting with mild diaphoretic agents; if mild agents fail, increase the dosage; if increased dosage fails, use strong diaphoretic agents. After strong diaphoresis, if few eruptions appear and the climate is peaceful with no other symptoms, it indicates the eruption was originally sparse, and further diaphoresis is contraindicated. Thus, diaphoresis should not be excessive, and retention should not be insufficient; this represents flexibility in medication.
My commentary: Ancient formulas for releasing the exterior include Sheng Ma Ge Gen Tang as a light agent and Xing Xing San as a heavy agent. "Mild diaphoresis" and "adding medicine" refer to either using a light agent first followed by a heavy one, or using the base formula initially in small amounts with little liquid, gradually increasing the dose and volume later. It does not mean adding pungent and hot strong diaphoretic drugs outside the base formula.
For smallpox or measles that fail to erupt past the expected time, if due to external wind-cold, treat according to exterior-releasing methods; if due to internal deficiency and diarrhea, treat according to middle-harmonizing methods. If following these methods yields no rapid improvement, and fever worsens with intense thirst, abdominal distension and fullness, hard and unpassable stool, and restlessness, this indicates toxin congestion and lurking in the interior. Choose between San Huang Wan or Qi Wei Sheng Ma Wan (initial fever stage); for severe cases, San Yi Cheng Qi Tang is indicated (constipation). Mr. Wenren stated: Fever, rapid pulse, constipation, and abdominal distension indicate heat-toxin congestion before the rash appears. Mild purgation is required; otherwise, heat will not subside. This occurs when heat is in the interior prior to eruption. If red spots are faintly visible under the skin, the toxin has moved to the exterior, and the rash is emerging; in this phase, reckless purgation is contraindicated. When pustules form scabs, if the pulse remains surging and rapid, appetite is preserved, but bowel and bladder movements are blocked, the exterior syndrome has resolved, and there is heat-toxin in the interior. Mild purgation is appropriate. Generally, heat in the Zang-Fu is often treated by promoting urination and defecation, as this facilitates the exit of toxins rather than their re-entry.
Zhang Congdao stated: Even distribution of Qi leads to rapid eruption because even Qi ensures no stagnation in Ying and Wei. Herbs that regulate Qi, such as Gui Zhi, Fang Feng, Jing Jie Sui, and Bo He Ye, move Qi in the exterior to prevent stagnation, hence they are commonly used in exterior-releasing formulas. Mu Xiang, Qing Pi, Zhi Ke, and Mu Tong move Qi in the interior to prevent stagnation, hence they are commonly used in middle-harmonizing formulas. Furthermore, during eruption, warmth similar to the spring season is beneficial, ensuring smooth Qi and Blood flow, leading to rapid eruption, thorough development, and uniform crusting. Excessive heat consumes Qi (Zhuang Huo Shi Qi), causing Qi deficiency and stagnation; excessive cold causes Qi coagulation and stagnation.
Smallpox invariably involves fever at the onset because, prior to eruption, the toxin resides in the interior, boiling Qi and Blood and steaming the Zang-Fu. Once the rash appears, the toxin is released and fever subsides. Therefore, fever subsiding with eruption indicates sparse rash. If fever persists after eruption, it indicates toxin accumulation in the interior with vigorous pathogenic force, resulting in dense rash. Urgent detoxification is required. Use Lian Qiao Sheng Ma Tang added with Fang Feng, Jing Jie Sui, and Di Gu Pi; or Jie Du Fang Feng Tang (see Da Fa) added with Sheng Ma; or Dong Yuan Shu Nian Zi Tang (this section), combined with Dai Tian Xuan Hua Wan (prevention). After medication, if the rash does not appear or reappears and fever suddenly decreases, this indicates harmonious Qi. If fever persists and the rash increases, carefully observe bowel and bladder functions. Constipation: Qi Wu Sheng Ma Wan (initial fever). Dysuria: Lian Qiao Tang (dysuria). Both constipation and dysuria: Ba Zheng San (dysuria). Spontaneous diarrhea: Huang Qin Tang (diarrhea) added with Bai Tou Weng, Jiu Huang Lian, and Chi Shi Zhi powder. When interior Qi harmonizes and toxin resolves, if thirst intensifies, restlessness persists, delirium occurs, abdominal distension and shortness of breath arise, or uncontrollable diarrhea with cold extremities develops, these are adverse signs (Ni Zheng) and should not be treated.