预知疮痘吉凶机，气色都于面部推，年上山根尤要紧，红光可喜黯青疑。痘疹伤寒
疑似间，古人分症可相参。莫将汗剂先轻试。发散惟图表里安。疮疹惟阳待热成，微
微发热始和平。假如大热身犹火，解毒常教小便清。始终能食最为良，平日其人脾胃
强。食少却防中气弱，淹留引日变疡疮。最宜安静号和平。表里无邪志自宁。烦扰忽来
宜察审，最嫌失志转神昏。陷伏须分实与虚，实须轻托大相宜。如逢虚冷宜温补，幽
谷春回庆有余。四时分治候须明，暑湿风寒不可轻。异气莫教相触犯，致令翻变乱其
真。痘疮脉候贵和平，胃气悠长最要清。弦数浮洪为实候，微沉短涩是须因。
夫脉为脏腑虚实之据，气血强弱之征，水火盛衰之验，故治百病必凭脉用药而无
误。痘疮尤必据脉施治而有功。盖痘疮之出，全赖正气以充，托达表也。痘疮之脓，
全赖气以嘘之。血以濡之。嘘之濡之者，不独气血为用，更有真水真火，以为气血之
根，而后嘘濡有力，克成气血之德也。痘疮之收，既赖土德化毒之功，复寓万物归藏之
理，故气血尚为标，而水火土乃其本也。且诸疮肿毒，非气血不和所致，即暴受客热而
成，并无传经定限，故可迁延岁月。或调和气血，而形肿内消，或解毒清凉，而脓血勿
溃。至于痘疮得于生身之始，根于肾，发于心，传于肝脾肺。刻期定限，十四日之中，
自头面以渐而下，见点起胀，灌浆收靥而后已。宁有内消者乎？宁有不成脓者乎？故必
调理气血，送毒出表，充打成脓，则毒化于外，还元于中。虽有客邪外犯，无足虑也。
是以治痘者，须于七日以前，如花之始蕾而发，其势日盛，气高于上之时，则助气血以
令头面灌浆。气交于中之时，则助气血以令胸背灌浆。气交于下之时，则助气血以令腿
足灌浆。借毒火之营运，而充灌成浆自易矣。有此药力，以代气血充灌之用。则脓成
之后，气血无伤，精神如故也。若不调补气血，妄行解毒，清凉延缓时日，一至七日之
后，如花之气敛而欲谢矣。其气日衰而降，复欲升提气血，以达头面行浆，不亦晚乎！
况气血日衰，而充贯自难，毒火元从消化，重则内攻脏腑，轻则变生诸症。上古婴儿天
禀有余，故古方惟为疏表清里，以图易出易解。盖因气血充足，不必为之瞻顾也。奈近
世婴孩受质嚣漓，虽名纯阳之子，孰知阴既未足，而禀阳亦虚，当此先天之症发露，而
阴阳两亏者甚多，难出难脓，若始也。徒从疏表为事，则表虚者不能约束，任其一涌而
出，则气血充贯不周，定有难浆难靥之患里虚者，中气愈馁，无力载毒成形，昧者重
用毒药迅攻，实同无米炊饭之象，非转虚而成内溃，即奔溃而如蚕种蛇皮，至于脓也
而惟图清解为事，则阳虚者水伏于中，阴虚者枯涸于表，水火不行无行之化，气血春成
有质之功。况禀薄之芽儿，不耐疾病。一经发热数日，元气已伤于中，再加疏表攻托，
气血转转潜耗。痘之少者，虽虚而无伤乎性命。痘之密者，愈损而绝其生机。故（张）
痛求至理。凡遇六脉洪大有力者，则从古法以解肌。若六脉沉微无力者，则惟为温中以
托里，使中气不馁。而气血鼓舞则逐毒有力，起胀灌浆，不谋而至也。若六脉弦数无
力者，则惟为壮水之中，仍佐补火之药，使嘘濡有力、而自出自化也。（张）壬午年在
都，值蒋总宪之令孙女令孙出痘，一险一逆，（张）以心法治之俱变为顺，盖可见痘
疮为标，气血为本。书曰∶识中标，只取本，治千人无一损，此之谓也。赘之于后，
以广识见。
蒋总宪之令孙女时年八岁，先天最薄。忽发微热，面青肢冷，腹痛吐水，项倒神
疲，六脉甚微，重按若无，余曰∶此中寒，元气内伤之候，虽防出痘，难用解肌。只可
凭脉，温以散之，即可以去疾病，复可以任痘疮，书所谓内伤多者，只须温补，正气得
力，始能推出寒邪也。乃用炙黄 二钱炒黄白术三钱酒炒当归一钱五分茯苓一钱五分炙
甘草六分甜薄桂八分煨姜胶枣为引煎服，次日神气稍爽，面青退而四肢温，脉稍起而头
项少强，身热壮而痘候现矣。照前方去黄 更进一剂，乃大热，而次日见痘，神气少
壮。但脉尚弱，而无洪体，余见痘点少屑，知必繁密，不敢HT 攻，惟照前方温补气血，
令其陆续出来。果至三四朝，来势甚稠密，幸无蛇皮蚕种之状，此温补气血，而气血送
毒出外之妙也。若以毒药攻击，则奔溃而出，如麸如 ，所不免也。乃于前方更入参
温补，痘与精神饮食日长一日而愈。未己，其兄十岁，夜半发热，次早太阳额已见
点，连片而不红。腰痛疲惫，六脉无根，余知先天阴阳两亏，脾元中气甚弱，不能制约
其毒，得以妄参阳位，然脾胃两虚，则无力送毒出经，势必沉匿而为内溃，乃用熟地八
钱当归三钱白术四钱茯苓三钱炙甘草八分肉桂一钱五分升麻六分生姜胶枣为引，煎服，
次早颧脸之间，一拥而出。如麸如 ，稠密无缝，六脉沉微，倦怠不食，幸而腰痛愈
也。余思中虚，若此而复犯，如是重痘，若不托住本元，即能一拥而出，若不能一拥而
入乎？盖正气虚极无力主宰，任毒纵横，若不乘其毒邪尽出在外之时，急为填补中气，
调益营卫，何以为充灌成脓，化毒收攻之用哉！乃照前方去升麻，另煎人参三钱浓汁冲
服，服后甚安，次日仍照前方另煎人参五钱冲服，次早神气少壮，饮食少进，顾脸之痘
少起胀而红润，天庭之痘，亦非若前之纯白色矣。余曰∶前者人参只用三钱，不过少佐
苓术之力，以固中，实欲让血药先为见为功耳。所谓补血药多则补气药从之而补血也。
今色虽转娇，诚非苍固之象，浆清痒塌之候，势所必至，可不急补卫气以保之，乃用
人参六钱生黄 四钱炒干熟地五钱炒黄白术三钱酒炒当归身二钱茯苓三钱炙甘草八分肉
桂去皮一钱二分煨姜胶枣为引，早晚各进一剂。若大便一次，另煎人参浓汁单服，如是
调治，饮食渐加，精神渐长，脓浆渐浓，尚然七朝，瘙痒作而头面爬破其半，幸充浆在
前，爬破在后，痘毒化于表，药力充于里，不能为害，仍照煎方加减，直至十日之外，
痘熟而微臭。余曰∶今毒尽化于外矣。乃减人参，进以养阴退阳解毒之剂，痂落疤痕红
润，精神饮食倍于常，古人人参戒用于三日之前，今不得已始用 术姜桂，二朝便用人
参，三朝便用参 峻补，实因病情脉理危迫处方，其势不得不然耳。
信乎，医无定体，药不执方也。余治王店镇寒宗一舍侄，年七岁，平时嗜酒少食，
盖嗜酒则真阴消耗，少食则元气空虚，是以一遇痘疮发热，神昏不苏者竟日，醒则口不
能言，目不能见，医用疏表攻托，痘不甚起，而惊厥益甚。乃延余视，以其脉六部洪
数而豁大无伦，身热如火，手心如烙。余曰∶此真阴亏极，不能敛阳，神无所根据，浮
越散乱，再为疏解，愈耗其阴，再为攻托，愈乱其神，不能言者，心不能为用也。目不
见者，阴不能归明于目也。五心如烙者，脏
腑燥槁已极也。欲望其机窍滑润流通，气成其形，血华其色，排列累累于肌肉之间，焉
可得乎？况惊厥一次，则神气散乱一番，愈厥愈散，未伤性命于痘疮，先完神气于惊厥
矣。必须求源兹本，以为不治之治，乃以熟地一两、生地六钱、麦冬二钱、五味子六
分、肉桂去皮一钱二分，煎与温服，或以五味子酸敛为疑，余曰∶单使之则得为专酸敛
之能，今内有肉桂大力君主之药，一敛而辛散之势愈烈，正欲籍其敛纳，以收浮散之元
阳，随肉桂之辛温，导入坎宫之命穴，真火即归于中，阴翳之毒自显于外，神自清而言
自明，不待言也。乃服之，一一果验而愈。复治王相国之令侄孙女，而患痘亦发惊厥数
次，目盲神昏，而痘难出，身发微热，六脉沉微，重按则空，此正气虚极。小能任其毒
火之攻冲，愈厥愈虚，而出愈难。愈难愈厥，而气愈虚。前之脉洪数豁大者，则责之
真阴不足，不能敛阳，而阳无所根据，散乱于内，焉能逐毒也。兹之六脉沉微，而无根
者，乃责之真阳正气空虚，元力载毒出表也。乃以炒黄白术三钱酒炒当归身一钱二分
茯苓一钱五分炙甘草四分肉桂去皮六分煨姜胶枣为引，煎服一剂而痘出，二剂而神清，
三剂而目明，痘疮光彩而饮食精神俱倍长矣。二者之惊厥目盲同也。脉之洪数沉微有
异，则药之救阴救阳乃迥别矣。故痘初发热稍轻，至三四日痘尚不出，不可概为毒轻痘
少，若神清能食，见点光圆红润，朝暮易眼者，此真毒轻痘少也。若身热虽清，至三四
日倦怠不食，痘白无光，不宜起发者，此血气虚弱不能送毒外出也。急用温中益气，鼓
舞营卫以托之，甚者连服三四剂，始能中气旺而运毒以出，其痘必多者也。如不知此，
轻视忽略，五六日后毒瓦斯内攻，莫救矣。若见其口干舌燥，解毒清凉，益增冰伏内攻之
祸，故古人热轻而痘轻之说，可尽信乎？及六日之前勿用温补之说，可尽拘乎？故切须
分其虚实寒热，实热者宜发其壅滞，以逐毒，虚寒者补助其血气以送毒，且痘之始终
有险，救不测者二，一曰毒甚，一曰体虚，未出之时，三五日而速毙者，皆因毒盛也
治者能顺其势以导之出，勿用寒凉解毒以阻遏之。则虽盛未必毙也。及落痂之时，或因
一药一食之误，而即毙者，皆因体虚也。治者能察其虚实补养之，更防其虚而勿清解
之。则虽虚亦未必毙也。
夫医司人命，可不细心，触类旁通，以图万全挽救之策。余曰∶至外科书云，痈疽
乃破漏之病，最能走泄真气。旨哉！破漏二字，况小儿脏腑娇嫩，皮肤柔脆，神气未
全，易虚易实，一患痘疮逐处破漏，走泄真气，岂不更甚，故《心鉴》一书，谆谆以固
元气为主，况今非昔比，天禀日薄，治之者若徒宗相传浅略方论。一见发热，轻用荆防
羌独，疏散为事；则表虚者卫气愈伤，中气亦耗，初则无力逐毒达表，继则不能充灌成
实矣。轻用犀角地黄清凉为事，则里虚者荣血凝滞，脾胃虚寒，初则阻遏毒瓦斯在内，继
则冰伏不能蒸长矣。轻用穿甲牛虱以毒攻毒为事，则正虚者无力担当，奔溃而出，中气
愈虚，初则形如蚕种 窠，继则虚抬空壳或水泡清浆矣。况痘疮之发，多由于跌扑惊
恐，伤风伤食，感触所蕴之毒而发，一经病后，元气已伤，再患痘疮，气血俱耗，故贵
乎以脉消息。沉微无力者，非毒邪之内伏，乃气虚不能逐毒也，固中调元，即所谓助正
送毒，达表也。 、术、归、苓、天虫、蝉蜕、炙草、桂枝、煨姜、胶枣，皆为对症之
药。如洪数无力者，非毒药之有余，乃真水之不足也。火盛者熟地丹皮，佐以牛蒡紫草
升葛，火假者，地朱丹茯，佐以甜桂鼓舞呈形，盖必兼辛温松动之味，以助发生长养之
机，务使正气内充，荣阴外润，气血宣形，健运不息，如筛米之转运不停，则糠秕自然
起聚一堆，而不混杂于米矣。更如禾苗之长，若不仗暖日以煦之，和风以宣之，雨露
以润之，惟竭人力以揠之，而欲望其发生长
养者，吾未之见也。盖藜藿之儿，中外坚固，及禀气壮盛，六脉洪大有力，外感有余
者，暂从疏散，所谓有病则病当之，人强能任此猛剂也。
预知痘疮的吉凶征兆，气色主要从面部推断，年上部位的山根尤其关键，红光显现可喜，暗淡青色则令人怀疑。痘疹与伤寒在疑似之间，可以参考古人的分症方法。不要先用发汗剂轻率尝试，发散之法只适用于表里安和的情况。疮疹属于阳证，需待热势形成，微微发热才是平和之象。假如高热如火，常需用解毒之法使小便清利。始终能进食最为良好，说明平日脾胃强健。食量减少却要防备中气虚弱，拖延时日会变为溃疡疮疡。最宜安静称为和平之证，表里无邪志意自然安宁。烦扰忽来应当仔细审察，最忌讳神志丧失转为神昏。陷伏须分辨实证与虚证，实证适宜轻托法。如遇虚冷适宜温补，如同幽谷春回，庆幸有余。四季分时治疗必须明了，暑湿风寒不可轻视。异气不要让它们相互触犯，致使病情翻变扰乱真相。痘疮脉候贵在和平，胃气悠长最为重要且清晰。弦数浮洪为实证脉候，微沉短涩是虚证原因。
脉是脏腑虚实的确据，气血强弱的征象，水火盛衰的验证，所以治疗百病必须凭脉用药而无误。痘疮尤其必须依据脉象施治才能成功。大概痘疮发出，全赖正气以充实，托达体表。痘疮化脓，全赖气以嘘养，血以濡润。嘘养濡润的，不只是气血起作用，更有真水真火，作为气血的根本，然后嘘养濡润才有力量，成就气血的德行。痘疮结痂收口，既依赖土德化解毒邪的功效，又蕴含万物归藏的道理，所以气血尚且为标，而水火土乃是根本。况且各种疮肿毒邪，不是气血不和所致，就是暴受客热而成，并没有传经的固定期限，所以可以迁延岁月。或者调和气血，使形肿在内消散；或者解毒清凉，使脓血不溃破。至于痘疮得于出生之时，根源于肾，发源于心，传于肝脾肺。有刻期定限，十四日之中，自头面逐渐向下，见点起胀，灌浆收靥而后结束。哪里有内消的呢？哪里有不成脓的呢？所以必须调理气血，送毒出表，充打成脓，则毒化于外，还元于中。虽然有客邪外犯，也不足为虑。因此治疗痘疮的人，须在七日以前，如花之始蕾而发，其势日益旺盛，气高于上的时候，则助气血令头面灌浆。气交于中的时候，则助气血令胸背灌浆。气交于下的时候，则助气血令腿足灌浆。借毒火的营运，而充灌成浆自然容易了。有此药力，以代替气血充灌之用。则脓成之后，气血无伤，精神如故。若不调补气血，妄行解毒，清凉延缓时日，一至七日之后，如花之气收敛而欲谢矣。其气日益衰弱而降，再想升提气血，以达头面行浆，不也太晚了吗！何况气血日益衰弱，而充贯自然困难，毒火原本从消化，重则内攻脏腑，轻则变生诸症。上古婴儿天禀有余，所以古方只为疏表清里，以求易出易解。大概因为气血充足，不必为之瞻顾。无奈近世婴孩受质嚣漓，虽名纯阳之子，谁知阴既未足，而禀阳亦虚，当此先天之症发露，而阴阳两亏者甚多，难出难脓，如果起初只是徒从疏表为事，则表虚者不能约束，任其一涌而出，则气血充贯不周，定有难浆难靥之患；里虚者，中气愈馁，无力载毒成形，昧者重用毒药迅攻，实同无米炊饭之象，非转虚而成内溃，即奔溃而如蚕种蛇皮。至于脓也而惟图清解为事，则阳虚者水伏于中，阴虚者枯涸于表，水火不行无行之化，气血春成有质之功。何况禀薄之芽儿，不耐疾病。一经发热数日，元气已伤于中，再加疏表攻托，气血转转潜耗。痘之少者，虽虚而无伤乎性命。痘之密者，愈损而绝其生机。所以（张）痛求至理。凡遇六脉洪大有力者，则从古法以解肌。若六脉沉微无力者，则惟为温中以托里，使中气不馁。而气血鼓舞则逐毒有力，起胀灌浆，不谋而至也。若六脉弦数无力者，则惟为壮水之中，仍佐补火之药，使嘘濡有力、而自出自化也。（张）壬午年在都，值蒋总宪之令孙女令孙出痘，一险一逆，（张）以心法治之俱变为顺，盖可见痘疮为标，气血为本。书曰∶识中标，只取本，治千人无一损，此之谓也。赘之于后，以广识见。
蒋总宪的令孙女当时八岁，先天最薄弱。忽然发微热，面青肢冷，腹痛吐水，项倒神疲，六脉甚微，重按若无，我说：这是中寒，元气内伤的证候，虽然防出痘，难用解肌。只可凭脉，温以散之，即可以去疾病，复可以任痘疮，书所谓内伤多者，只须温补，正气得力，始能推出寒邪也。于是用炙黄芪二钱、炒黄白术三钱、酒炒当归一钱五分、茯苓一钱五分、炙甘草六分、甜薄桂八分、煨姜胶枣为引煎服，次日神气稍爽，面青退而四肢温，脉稍起而头项少强，身热壮而痘候现矣。照前方去黄芪更进一剂，乃大热，而次日见痘，神气少壮。但脉尚弱，而无洪体，我见痘点少屑，知必繁密，不敢猛攻，惟照前方温补气血，令其陆续出来。果至三四朝，来势甚稠密，幸无蛇皮蚕种之状，此温补气血，而气血送毒出外之妙也。若以毒药攻击，则奔溃而出，如麸如秕，所不免也。乃于前方更入人参温补，痘与精神饮食日长一日而愈。未几，其兄十岁，夜半发热，次早太阳额已见点，连片而不红。腰痛疲惫，六脉无根，我知先天阴阳两亏，脾元中气甚弱，不能制约其毒，得以妄参阳位，然脾胃两虚，则无力送毒出经，势必沉匿而为内溃，于是用熟地八钱、当归三钱、白术四钱、茯苓三钱、炙甘草八分、肉桂一钱五分、升麻六分、生姜胶枣为引，煎服，次早颧脸之间，一拥而出。如麸如秕，稠密无缝，六脉沉微，倦怠不食，幸而腰痛愈也。我思中虚，若此而复犯，如是重痘，若不托住本元，即能一拥而出，若不能一拥而入乎？盖正气虚极无力主宰，任毒纵横，若不乘其毒邪尽出在外之时，急为填补中气，调益营卫，何以为充灌成脓，化毒收攻之用哉！于是照前方去升麻，另煎人参三钱浓汁冲服，服后甚安，次日仍照前方另煎人参五钱冲服，次早神气少壮，饮食少进，顾脸之痘少起胀而红润，天庭之痘，亦非若前之纯白色矣。我说：前者人参只用三钱，不过少佐苓术之力，以固中，实欲让血药先为见为功耳。所谓补血药多则补气药从之而补血也。今色虽转娇，诚非苍固之象，浆清痒塌之候，势所必至，可不急补卫气以保之，于是用人参六钱、生黄芪四钱、炒干熟地五钱、炒黄白术三钱、酒炒当归身二钱、茯苓三钱、炙甘草八分、肉桂去皮一钱二分、煨姜胶枣为引，早晚各进一剂。若大便一次，另煎人参浓汁单服，如是调治，饮食渐加，精神渐长，脓浆渐浓，尚然七朝，瘙痒作而头面爬破其半，幸充浆在前，爬破在后，痘毒化于表，药力充于里，不能为害，仍照煎方加减，直至十日之外，痘熟而微臭。我说：今毒尽化于外矣。乃减人参，进以养阴退阳解毒之剂，痂落疤痕红润，精神饮食倍于常，古人人参戒用于三日之前，今不得已始用术姜桂，二朝便用人参，三朝便用参芪峻补，实因病情脉理危迫处方，其势不得不然耳。
确实如此，医无定体，药不执方也。我治王店镇寒宗一舍侄，年七岁，平时嗜酒少食，大概嗜酒则真阴消耗，少食则元气空虚，是以一遇痘疮发热，神昏不苏者竟日，醒则口不能言，目不能见，医用疏表攻托，痘不甚起，而惊厥益甚。于是延我视，以其脉六部洪数而豁大无伦，身热如火，手心如烙。我说：这是真阴亏极，不能敛阳，神无所根据，浮越散乱，再为疏解，愈耗其阴，再为攻托，愈乱其神，不能言者，心不能为用也。目不见者，阴不能归明于目也。五心如烙者，脏腑燥槁已极也。欲望其机窍滑润流通，气成其形，血华其色，排列累累于肌肉之间，焉可得乎？况惊厥一次，则神气散乱一番，愈厥愈散，未伤性命于痘疮，先完神气于惊厥矣。必须求源兹本，以为不治之治，于是以熟地一两、生地六钱、麦冬二钱、五味子六分、肉桂去皮一钱二分，煎与温服，或以五味子酸敛为疑，我说：单使之则得为专酸敛之能，今内有肉桂大力君主之药，一敛而辛散之势愈烈，正欲籍其敛纳，以收浮散之元阳，随肉桂之辛温，导入坎宫之命穴，真火即归于中，阴翳之毒自显于外，神自清而言自明，不待言也。于是服之，一一果验而愈。复治王相国之令侄孙女，而患痘亦发惊厥数次，目盲神昏，而痘难出，身发微热，六脉沉微，重按则空，这是正气虚极。小能任其毒火之攻冲，愈厥愈虚，而出愈难。愈难愈厥，而气愈虚。前之脉洪数豁大者，则责之真阴不足，不能敛阳，而阳无所根据，散乱于内，焉能逐毒也。兹之六脉沉微，而无根者，乃责之真阳正气空虚，元力载毒出表也。于是以炒黄白术三钱、酒炒当归身一钱二分、茯苓一钱五分、炙甘草四分、肉桂去皮六分、煨姜胶枣为引，煎服一剂而痘出，二剂而神清，三剂而目明，痘疮光彩而饮食精神俱倍长矣。二者之惊厥目盲同也。脉之洪数沉微有异，则药之救阴救阳乃迥别矣。故痘初发热稍轻，至三四日痘尚不出，不可概为毒轻痘少，若神清能食，见点光圆红润，朝暮易眼者，此真毒轻痘少也。若身热虽清，至三四日倦怠不食，痘白无光，不宜起发者，此血气虚弱不能送毒外出也。急用温中益气，鼓舞营卫以托之，甚者连服三四剂，始能中气旺而运毒以出，其痘必多者也。如不知此，轻视忽略，五六日后毒瓦斯内攻，莫救矣。若见其口干舌燥，解毒清凉，益增冰伏内攻之祸，故古人热轻而痘轻之说，可尽信乎？及六日之前勿用温补之说，可尽拘乎？故切须分其虚实寒热，实热者宜发其壅滞，以逐毒，虚寒者补助其血气以送毒，且痘之始终有险，救不测者二，一曰毒甚，一曰体虚，未出之时，三五日而速毙者，皆因毒盛也治者能顺其势以导之出，勿用寒凉解毒以阻遏之。则虽盛未必毙也。及落痂之时，或因一药一食之误，而即毙者，皆因体虚也。治者能察其虚实补养之，更防其虚而勿清解之。则虽虚亦未必毙也。
大概医生司掌人命，可不细心，触类旁通，以图万全挽救之策。我说：至于外科书云，痈疽乃破漏之病，最能走泄真气。旨哉！破漏二字，况小儿脏腑娇嫩，皮肤柔脆，神气未全，易虚易实，一患痘疮逐处破漏，走泄真气，岂不更甚，所以《心鉴》一书，谆谆以固元气为主，况今非昔比，天禀日薄，治之者若徒宗相传浅略方论。一见发热，轻用荆防羌独，疏散为事；则表虚者卫气愈伤，中气亦耗，初则无力逐毒达表，继则不能充灌成实矣。轻用犀角地黄清凉为事，则里虚者荣血凝滞，脾胃虚寒，初则阻遏毒瓦斯在内，继则冰伏不能蒸长矣。轻用穿甲牛虱以毒攻毒为事，则正虚者无力担当，奔溃而出，中气愈虚，初则形如蚕种窠，继则虚抬空壳或水泡清浆矣。况痘疮之发，多由于跌扑惊恐，伤风伤食，感触所蕴之毒而发，一经病后，元气已伤，再患痘疮，气血俱耗，故贵乎以脉消息。沉微无力者，非毒邪之内伏，乃气虚不能逐毒也，固中调元，即所谓助正送毒，达表也。芪、术、归、苓、天虫、蝉蜕、炙草、桂枝、煨姜、胶枣，皆为对症之药。如洪数无力者，非毒药之有余，乃真水之不足也。火盛者熟地丹皮，佐以牛蒡紫草升葛，火假者，地朱丹茯，佐以甜桂鼓舞呈形，盖必兼辛温松动之味，以助发生长养之机，务使正气内充，荣阴外润，气血宣形，健运不息，如筛米之转运不停，则糠秕自然起聚一堆，而不混杂于米矣。更如禾苗之长，若不仗暖日以煦之，和风以宣之，雨露以润之，惟竭人力以揠之，而欲望其发生长养者，吾未之见也。盖藜藿之儿，中外坚固，及禀气壮盛，六脉洪大有力，外感有余者，暂从疏散，所谓有病则病当之，人强能任此猛剂也。
To predict the auspicious or ominous signs of smallpox, one should deduce the qi and color primarily from the face; the Shangen (山根, root of the nose) at the "Nian Shang" area is particularly critical. A radiant red hue is auspicious, while a dull cyan suggests suspicion. Between smallpox/rash (Chuangzhen, 痘疹) and Cold Damage (Shanghan, 伤寒), which may appear similar, one can refer to the symptom differentiation methods of the ancients. Do not rashly try diaphoretic agents first; dispersing methods are only suitable when the exterior and interior are harmonious. Rashes belong to Yang patterns and require heat to mature; slight fever indicates a peaceful state. If the fever is high like fire, detoxification should be employed to clear the urine. The ability to eat throughout the course is excellent, indicating strong Spleen and Stomach function in daily life. Reduced appetite warns of weak Middle Qi; prolongation may lead to ulceration. Quietness signifies a peaceful pattern where there is no pathogen in the exterior or interior, and the mind is naturally calm. Sudden restlessness requires careful examination; loss of spirit turning into coma is most feared. Sunken lesions must be differentiated into Excess and Deficiency; Excess patterns suit mild support (Tuo, 托). For Deficiency-Cold, warming and tonifying are appropriate, likened to spring returning to a secluded valley, bringing relief. Seasonal treatments must be distinguished clearly; summer-heat, dampness, wind-cold, and pathogenic qi must not be neglected, as they can cause chaotic transformations. The pulse in smallpox should be peaceful, with a long and clear Stomach Qi being paramount. Wiry, rapid, floating, or full pulses indicate Excess; faint, deep, short, or choppy pulses indicate Deficiency causes.
The pulse is the evidence of Zang-Fu excess or deficiency, the sign of Qi and Blood strength, and the verification of Water and Fire balance. Therefore, treating all diseases requires relying on the pulse for medication to avoid error. Smallpox treatment especially depends on pulse diagnosis for success. Generally, the eruption of smallpox relies entirely on Righteous Qi (Zhengqi, 正气) to fill and support it to the surface. The suppuration of smallpox relies on Qi to nourish and Blood to moisten. This nourishing and moistening is not solely due to Qi and Blood but also involves True Water and True Fire as their roots, enabling effective nourishment and completing the virtue of Qi and Blood. The scabbing phase relies on the Earth element's ability to transform toxins and embodies the principle of things returning to storage. Thus, Qi and Blood are the branch, while Water, Fire, and Earth are the root. Moreover, various sores and toxic swellings result either from disharmony of Qi and Blood or sudden exposure to external heat, without fixed transmission stages, allowing them to linger. One may harmonize Qi and Blood to resolve swelling internally, or use cooling and detoxification to prevent suppuration. Smallpox originates at birth, rooted in the Kidney, manifesting in the Heart, and transmitting to the Liver, Spleen, and Lungs. It follows a specific timeline: within fourteen days, it progresses from the head and face downward, showing spots, swelling, suppuration, and scabbing. Internal resolution or failure to suppurate is impossible. Therefore, one must regulate Qi and Blood, send toxins out via the exterior, and complete suppuration, transforming toxins externally and restoring origin internally. Even if external pathogens attack, there is little to fear. Thus, treating smallpox before the seventh day, when the momentum is rising like a budding flower and Qi is high, supports Qi and Blood to fill the head and face with fluid. When Qi transitions to the middle, it supports filling the chest and back. When Qi transitions to the lower body, it supports filling the legs and feet. Borrowing the operation of toxin-fire makes filling easy. With this medicinal power replacing the function of Qi and Blood, after suppuration, Qi and Blood remain unharmed, and spirit remains intact. If one fails to tonify Qi and Blood and recklessly uses cooling/detoxifying methods, delaying time, after seven days, like fading flowers, Qi declines. Trying to raise Qi and Blood to the head later is too late! As Qi and Blood decline, filling becomes difficult; severe cases involve internal organ attack, mild cases generate other symptoms. Ancient infants had abundant innate endowment, so ancient formulas focused on releasing the exterior and clearing the interior for easy eruption and resolution, assuming sufficient Qi and Blood. However, modern infants have weak constitutions; though called "Pure Yang," Yin is insufficient and Yang is also deficient. Many suffer dual deficiency of Yin and Yang during congenital manifestations, making eruption and suppuration difficult. If initially treated only by releasing the exterior, those with Exterior Deficiency cannot contain the eruption, leading to uneven Qi and Blood distribution and difficulty in filling/scabbing. Those with Interior Deficiency have weakened Middle Qi, unable to carry toxins to form shape; ignorant practitioners using harsh toxic drugs is like cooking rice without grain, leading to internal collapse or溃烂 (ulceration) resembling silkworm cocoons or snake skins. If focusing only on cooling/detoxification for pus, Yang Deficiency leads to water stagnation internally, Yin Deficiency leads to dryness externally, hindering Water/Fire transformation and Qi/Blood formation. Infants with thin constitutions cannot tolerate disease; fever damages Middle Yuan Qi. Adding exterior-releasing and supporting methods further depletes Qi and Blood. Fewer spots, even if deficient, may not endanger life; dense spots, if damaged, destroy vitality. Therefore, Zhang sought profound principles. If the six pulses are full, rapid, and forceful, follow ancient methods to release muscle layer. If six pulses are faint, deep, and weak, warm the middle and support the interior to prevent Middle Qi weakness. Encouraged Qi and Blood will drive out toxins, causing swelling and suppuration spontaneously. If six pulses are wiry, rapid, and weak, nourish Water while assisting Fire to ensure effective nourishment and spontaneous transformation. In the Renwu year in the capital, treating the granddaughter of Censor Jiang, who had dangerous and adverse smallpox, Zhang used mental/heart method to turn both favorable, showing that smallpox is the branch, Qi and Blood are the root. As the book says: "Recognize the branch, treat the root; treat thousands without loss." I add this to broaden understanding.
Censor Jiang's granddaughter was eight years old with the weakest innate constitution. She suddenly developed slight fever, cyan face, cold limbs, abdominal pain vomiting water, neck stiffness, fatigue, very faint pulses (barely felt on heavy pressure). I said: This is Middle Cold and internal injury to Yuan Qi. Although preventing smallpox eruption, releasing muscle layer is difficult. Rely on pulse, warm to disperse; this removes disease and allows handling smallpox. The book states: "Many internal injuries require only warming and tonifying; once Righteous Qi is strong, it expels cold pathogens." Prescribed: Roasted Astragali Radix (Huangqi, 黄芪) 2 qian, Stir-fried Atractylodis Macrocephalae Rhizoma (Baizhu, 白术) 3 qian, Wine-fried Angelicae Sinensis Radix (Danggui, 当归) 1.5 qian, Poria (Fuling, 茯苓) 1.5 qian, Roasted Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) 0.6 qian, Sweet Cinnamon Bark (Rougui, 肉桂) 0.8 qian, with baked ginger and jujube as guides. Next day, spirit improved, cyan faded, limbs warmed, pulse rose slightly, neck less stiff, fever intensified, smallpox signs appeared. Following formula minus Huangqi, next day high fever, then spots appeared, spirit strengthened slightly. Pulse still weak without fullness. Seeing few spots, I knew density would increase, dared not attack fiercely, continued warming/tonifying Qi and Blood for gradual eruption. By day 3-4, eruption was dense, fortunately without silkworm/snake-skin appearance, demonstrating the wonder of warming/tonifying Qi and Blood to send toxins out. Toxic attacks would cause溃烂 (ulceration) like chaff. Added Ginseng to formula for warming/tonifying; smallpox, spirit, and diet improved daily. Soon after, her ten-year-old brother developed fever at midnight, spots on forehead/temples next morning, confluent but not red. Lower back pain, fatigue, rootless pulses. I knew dual Yin-Yang deficiency and weak Spleen/Stomach Middle Qi, unable to control toxins, allowing them to invade Yang positions. Spleen/Stomach deficiency meant inability to send toxins out meridians, risking internal collapse. Prescribed: Rehmanniae Radix Preparata (Shudi, 熟地) 8 qian, Danggui 3 qian, Baizhu 4 qian, Fuling 3 qian, Gancao 0.8 qian, Rougui 1.5 qian, Cimicifugae Rhizoma (Shengma, 升麻) 0.6 qian, fresh ginger and jujube. Next morning, spots erupted on cheeks like chaff, dense seamless, pulses faint/deep, fatigue/anorexia, fortunately back pain resolved. I thought: With such Middle Deficiency, if not supporting Root Yuan, how could toxins exit? Since Righteous Qi is extremely weak to govern, allowing toxins to spread wildly, one must urgently replenish Middle Qi and regulate Ying-Wei when toxins are fully outside, to enable filling/suppuration and toxin transformation. Removed Shengma from previous formula, decocted separately 3 qian Ginseng, took concentrated juice. Patient comfortable. Next day, 5 qian Ginseng taken. Next morning, spirit strengthened, diet slightly improved, cheek spots swelled reddish, forehead spots no longer pure white. I said: Previous 3 qian Ginseng assisted Fuling/Baizhu to secure Middle, letting blood tonics act first. More blood tonics attract Qi tonics to tonify blood. Current color is tender, not firm; clear fluid/itching/collapse is inevitable. Must urgently tonify Wei Qi. Prescribed: Ginseng 6 qian, Raw Astragali Radix (Huangqi, 黄芪) 4 qian, Stir-fried Dried Rehmanniae Radix (Shudi, 熟地) 5 qian, Stir-fried Baizhu 3 qian, Wine-fried Danggui Shen 2 qian, Fuling 3 qian, Gancao 0.8 qian, Peeled Rougui 1.2 qian, baked ginger/jujube. One dose morning/evening. If bowel movement occurs, take separate Ginseng juice. Treatment increased diet/spirit, thickened pus. On day 7, itching caused half-face scratching. Fortunately, filling occurred before scratching; toxins transformed externally, medicine filled internally, causing no harm. Continued adjustments until day 10+, spots ripe with slight odor. I said: Toxins fully transformed externally. Reduced Ginseng, added Yin-nourishing/Yang-retreating/detoxifying agents. Scabs fell, scars red/rosy, spirit/diet doubled. Ancients avoided Ginseng before day 3; here, forced by condition/pulse, used Baizhu/Ginger/Cinnamon early, Ginseng on day 2, strong tonification on day 3. Truly necessary due to critical condition.
Indeed, medicine has no fixed form, medicines no fixed prescription. I treated a nephew of Han Zong in Wangdian Town, age 7, addicted to alcohol, eating little. Alcohol consumes True Yin; lack of food empties Yuan Qi. Upon smallpox fever, he was comatose all day, mute/blind upon waking. Doctors used exterior-releasing/supporting methods; spots didn't rise, convulsions worsened. I examined him: six pulses full/rapid/huge, body hot like fire, palms burning. I said: Extreme True Yin deficiency fails to constrain Yang; Spirit has no basis, floats/scatters. Further releasing consumes Yin; further supporting confuses Spirit. Muteness means Heart cannot function; blindness means Yin cannot brighten eyes. Burning five hearts mean extreme organ dryness. How can organs flow smoothly, Qi form shape, Blood colorize, and spots arrange on muscles? Each convulsion scatters Spirit more; convulsions damage Spirit before smallpox damages life. Must seek root for non-treatment treatment. Prescribed: Rehmanniae Radix (Dihuang, 地黄) 1 liang, Raw Rehmanniae Radix (Shengdi, 生地) 6 qian, Ophiopogonis Tuber (Maidong, 麦冬) 2 qian, Schisandrae Fructus (Wuweizi, 五味子) 0.6 qian, Peeled Cinnamomi Ramulus (Rougui, 肉桂) 1.2 qian. Some doubted Wuweizi's sour astringency. I said: Alone it astrings; with powerful Rougui, astringency intensifies pungent dispersion, capturing floating Yuan Yang, guiding it via Rougui's warmth to Kan Palace Life Gate. True Fire returns to center, Yin-shadow toxins show externally, Spirit clears, speech returns. It worked. Also treated niece of Chancellor Wang, age ?, with smallpox convulsions, blindness/coma, difficult eruption, slight fever, faint/rootless pulses. Extreme Righteous Qi deficiency cannot bear toxin-fire attack; convulsions weaken Qi, making eruption harder. Previous case (full/rapid pulses) blamed True Yin deficiency failing to constrain Yang. This case (faint pulses) blames True Yang/Qi deficiency failing to carry toxins out. Prescribed: Stir-fried Baizhu 3 qian, Wine-fried Danggui 1.2 qian, Fuling 1.5 qian, Gancao 0.4 qian, Peeled Rougui 0.6 qian, baked ginger/jujube. One dose: eruption; two doses: clarity; three doses: vision, spots bright, diet/spirit doubled. Both had convulsions/blindness, but pulses differed (full/rapid vs. faint/deep), so treatments differed (Yin vs. Yang rescue). Thus, early mild fever with no spots by day 3-4 isn't always mild toxin/few spots. If spirit clear, eating, spots round/red, changing quickly, it is mild. If fever clears but fatigue/anorexia by day 3-4, spots pale/no shine, unable to rise, it is Qi/Blood weakness failing to send toxins out. Urgently warm middle/boost Qi, encourage Ying-Wei to support. Severe cases need 3-4 doses to strengthen Middle Qi to transport toxins; many spots will emerge. Ignoring this leads to internal toxin attack by day 5-6, incurable. Dry mouth/tongue treated with cooling/detox increases internal ice/toxin risk. Can we fully believe ancients' "mild fever = mild smallpox"? Can we rigidly follow "no warming/tonifying before day 6"? Must distinguish Excess/Deficiency/Cold/Heat. Excess-Heat: release stagnation to drive toxins. Deficiency-Cold: tonify Qi/Blood to send toxins. Smallpox has dangers: severe toxin or weak body. Early death (3-5 days) due to severe toxin; guide顺势 (following trend) out, don't block with cold/detox. Late death (scabbing) due to weak body; check deficiency, tonify, don't cool/detox. Then even weak bodies survive.
Doctors hold human lives; must be careful, generalize to find comprehensive rescue strategies. Surgical texts say carbuncles/furuncles are leaking diseases that drain True Qi profoundly. Indeed, "leaking" is key. Children have delicate Zang-Fu, fragile skin, incomplete spirit, prone to Deficiency/Excess changes. Smallpox leaks everywhere, draining True Qi severely. *Xin Jian* emphasizes securing Yuan Qi. Modern constitutions are weaker than past; relying on shallow transmitted formulas, lightly using Jingjie/Fangfeng/Qianghuo/Duohuo for dispersal upon fever injures Wei Qi and Middle Qi, initially failing to drive toxins out, later failing to fill/mature. Lightly using Xijiao Dihuang Tang for cooling stagnates Ying Blood, causes Spleen/Stomach cold, blocks toxins internally, then freezes growth. Lightly using Chuanjia/Niu Shi (toxic drugs attacking toxins) overburdens Deficient Zheng, causing溃烂 (ulceration), empty shells, or clear blisters. Smallpox often arises from falls/fright, wind-cold/food stagnation, touching accumulated toxins. Post-illness, Yuan Qi is injured; smallpox consumes Qi/Blood. Pulse diagnosis is crucial. Faint/weak pulses aren't internal toxin retention but Qi deficiency failing to drive toxins; secure Middle/regulate Yuan (assist Zheng to send toxins out). Huangqi, Baizhu, Danggui, Fuling, Tianchong, Chanui, Gancao, Guizhi, Baked Ginger, Jujube are appropriate. Full/rapid/weak pulses aren't excess toxin but True Water deficiency. Excess Fire: Shudi, Danpi, assisted by Niubangzi, Zicao, Shengma, Gegen. Fake Fire: Shudi, Zhuru, Dan, Fuling, assisted by sweet Rougui to encourage shape. Must include pungent/warm/loosening flavors to aid growth, ensuring internal Zheng Qi, external Ying Yin, smooth Qi/Blood circulation, like sifting rice separating bran. Like seedlings needing sun/wind/rain, not pulling stalks to force growth. Commoners' children with strong constitutions and full/forceful pulses/excess external pathogens may temporarily use dispersal ("when sick, the drug bears the burden").