痘作脓窠之时，最要皮浓包裹完固。若脓未成，忽然疮头有孔，其水漏出，或结聚成团，堆于孔外者，或
水去囊空而干黑者，俗名漏疮，必死。若脓熟之后，囊皮亦熟，浆水沸出，因而结 者，此头额正面之间多有
之，俗谓堆屎收，不可以漏疮例论。盖漏疮脓未成，堆屎收脓过熟也。（万密斋）
涸浆
涸浆，即空壳之异名。痘形虽圆绽，而内实空虚，未几则涸极而色变矣。然此固属气血两虚，殊不知又系
火烁金枯之故。盖火炎而枭毒攻冲，则血热不能化浆矣；金燥而肾水枯竭，则气陷而成内虚矣。故一见涸机，
宜急以黄连、生地、犀角、紫草以清火毒，继以参、 、归、地培补气血，杜燥势于未萌，续真元于
未竭，乃克有济，稍一迟缓，定难疗矣。（《冯氏锦囊》）
板黄
痘脓成而色黄者，中央土之正色也。况浆之化源，由于脾胃，自宜黄润光华。故痘浆既重乎饱满，而尤贵
乎脓之黄活，此顺理也。若阴阳离其正气，枭毒肆其残虐，则囊房销铄，而脓浆之澄灌于中者，腻滞牢贴，如
物之枯萎而黄，乃气血不荣于内。是以死涩而不活动，干蜡而不明黄，以手按之，凝结板实，名为板黄，则湿
润之气全无，化源之机绝矣。（《冯氏锦囊》）
九、十朝
痘九朝色转苍蜡，渐次收 ，顺痘至此，已成功矣。若先期蹭蹬，至此内证始平，头面才灌，周身根脚不
散，或微有浆色，渐次成脓，亦可逾期而愈，不必拘守常格，执泥朝头。○痒泻内攻之证，多在九朝死。九朝
是其死期，非可救之期也。可救之处，在六、七朝，预为之计，早施温补。十二朝死期之证，九朝极力救之，
十中间有一、二得生者。（《橡村痘诀》）
痘至十日，毒解矣，脓亦转黄作苍蜡矣。元气实者，痘必循次而结。如口角与阳物先结者，正收也。身渐
轻快，肿渐消，眼渐 而欲开，饮食倍常，二便如故，从上至下，而逐渐收结，痂浓色红，大事毕矣。不
然，犹未可以为善。惟结痂时发热者不必虑，乃蒸浆作 也。凡一时痂尽落者，毒火内烁也，急解之。此证必
脓未充足。若声哑烦闷，喘促不食，死期迫矣。否则亦必发毒而解。○十日而补脾燥湿，是言证之常也。若危
险之证，至此而作脓窠者有之，何可不察而概行清凉渗湿乎？清凉渗湿，脓足毒尽之后队，施之灌脓，得无
谬乎？痘以日程限，为初学计，活法在胸，何程限可拘，当补者补，当泻者泻，不泥于书，始足以寄人司命。（程华仲）
痘至八、九、旬日，外无浆则里毒不化，必呛哑、瘙痒、痰潮、不食、眼开，危期速矣。常有忽然连串片
片之痘裂水，形如松脂
桃胶，转眼堆聚，变凶转吉。更有旬朝内外，干板涸如焦锅底状，毫无生气，忽从地角、承浆诸处裂缝，流出
臭水，渐升头额，堆肿高浓若糊脸，名曰发臭，毒泄即当补托，迟则气脱。（叶天士）
痘痒
瘙痒而作于灌脓时者，凶多吉少。须视其所发，观其所因，察其情状，以施治疗。视其所发者，或发于手
足，或发于肩背，拂之则止，禁之则听者吉；若发于正面，瘙痒不止，皮脱肉干者凶。观其所因者，或因吐泻
少食，脾胃既弱，气血不荣者，此虚痒也，治宜温补；或因秽恶之气，触动邪火者，此暴痒也，治宜熏解；或
因痘疮已熟，邪气尽解，正气渐生，气血调和，火微欲退，乃溶溶而痒者，此美疾也，不须服药。如无因自生
瘙痒者，原是恶痘，不得善成。察其情状者，如瘙痒之时，乍作乍止，精神清爽，不自抓搔，欲人抚摩者生；
若抓搔无时，神识昏沉，摇头扭项者死。（《冯氏锦囊》）
痘有灰白痒塌者，乃气血亏弱，而变为虚寒也。阳分者，气居之地也；阴分者，血居之地也。阳气弱则
陷于阴，阴血盛则乘于阳，气虚则血进，血虚则气凌，自然之理也。气虚，则为麻为痒为陷；血热，则为干为
燥为痛。痘色白者，必至于灰惨。灰惨者，必至于平伏痒塌。此皆气虚而不起胀，血虚而不华色。治法用补中
益气合四物汤，以补助气血。内有热者，加清利解毒之药，使血活气行，则白可变为红矣。苟单补气而不补血，
则气血燥热，而痒塌愈甚矣。（《金镜录》）
痘痒毕竟属虚。管HT 乃谓有气盛血热而痒，此谬说也。又有谓因血上行，血味本咸，腌螫皮肉作痒。似
为近理，然灰白之痘，不惟气虚，而血亦虚，岂能上行而腌螫皮肉？此说又恐未然。其有秽触而痒者，烧苍术、
红枣、黄柏以解之。○表虚之痘，脓浆不满，多有痒者，不能禁其手搔，须令着长袖绢衣，扎其袖口，不得爪
搔为妙。如无绢衣，用绢片裹儿手亦可。（《痘疹心法》）
痒有二证∶一则气血不足，其痒为虚，四君子汤；一则不能食淡，火生致痒，蝉蜕一物汤。（闻人 ）
爬破
木枯则折，土燥则裂。痘之囊房不甚充满，则爬破之证所自来矣。但爬破不关要处，犹可全活；若爬破要
所，如颧脸头面，是五脏精华之所聚，痘毒藉为囊房，犹人之有舍，鸟之有巢，今囊房既破，毒无栖所，况营
阴耗竭，元气外亡，焉得不乘虚而内入耶？有效女娲补天之法，用纸封固者，亦必赖夫脾胃内强而能食，气血
未残而能灌，斯有济耳。（《冯氏锦囊》）
十一、二朝
十二、三日，有形如火烧烟熏者，血不载毒而内攻也。生死看诀∶音不清，食不入，破处干枯，烦乱不寐
者，死证也；音清能食，睡卧安耽，爬破淋漓，神舒气爽者，生证也。又当分虚实治∶唇舌洁净，则补兼清解；
若唇燥舌干便秘，则单清解，继以平和，攻补两尽矣。（《慈幼筏》）
十一、二日成痂之际，极好之痘必有咳嗽，或夜暮身热。《幼科佥》云∶毒瓦斯未尽，概投苦寒，多有胃减
废食，酿成痘劳者。痘发自肾脏骨髓之中，从内之外，毒乃涣释，收疤之时，真气归里，肺合皮毛，处位高，
体清肃，从前灌胀成痂，蒸迫之气，受亏已极，气泄为咳矣。况投利湿下注之药而结痂，上焦已经转燥，若毒
仍留伏，焉能收 ？再论幼稚阳常有余，阴未充长，布痘至于结痂，一身脂液大损，阴气告匮可知，故暮夜属
阴，时为烦热者，正《内经》云∶阴虚生内热也。昔西邻吴氏女，年甫四岁，痘系顺证，浆满成痂，忽发烦躁，
夜热不寐，晨起安然，医用保元、异功，热躁益加，更医以为毒瓦斯未尽，用桑、蚕暨凉解药，热甚而添泄泻。
余视浆痂形色，询其平日起居，用六味汤一服而安。此二条人多忽而不究，故辨及之。（叶天士）
收
非难事，难于浆也。浆足则毒化，化则毒尽，毒尽则 矣。 重头面，余则轻之，浆 不及头面，是
谓气道乖和，阴阳闭塞，而失其宜。故痘 必以头面为主，而天庭尤为头面之主。盖气之上也，始在于下，则
成扶摇之势，及至中上，则滂沛横流，及顶之微末，则缓游而已。倘中上不横流，微末乌得有余劲乎？不浆
而，死无论矣。浆清而 ，与死为邻。微稠而 ，须复其斑，后必发毒，乃可得生。浆稠而 ，可决其生。
浆稠不 ，火沸不停。（《黄帝逸典》）
收 时无杂证，方为正 ；或热，或渴，或泻，或痰响，或切牙寒战，或烦躁不安，皆谓之收不回，非
正也。○螺蛳 最上；顶露松香，皮塌牵连者，名鸡矢 ，次之；浆清不成 者，急则内攻，缓则发毒。○
三、五粒中间收一、二粒，谓之打花焦，最吉。○大寒之痘，怕出不出；大暑之痘，虑收不回。暑月阳气尽泄，
体弱之儿，气血有限，尽供出长之用，至收 时无以复续，更遭酷暑，金水俱伤，忽然内陷者有之。此虽非医
罪，能于浆足之后不减参、 、归、芍，更加熟地、麦冬，庶几可保。（《橡村痘诀》）
脓后结痂，理之常也。有过期不收，遍身溃烂者，其因有六∶有因大便秘结，表里俱实，热气蒸郁，毒
气散漫，阳气太盛，无阴气以敛之而不收者，治宜清凉；有因泄泻里虚，脾胃亏弱，元气外散，表里不固，阴
气太盛，无阳气以敛之而不收者，治宜温补，有因渴饮多，以致水渍于脾，湿淫肌肉而不收者，治宜渗湿；有
因天寒失于盖覆，疮受冻冷，血凝毒滞而不收者，治宜温和；有因天热过求温暖，疮被热蒸而不收者，治宜清
凉；有因食少气虚而不收者，治宜补脾。大抵痘之成就，犹谷之秋成。盖五谷得阳气以成熟，非凉风至则不能
结实；痘之脓而不焦，犹苗之秀而不实，治须识其清凉之义可也。然亦有脓后气血虚耗，是以不 ，不可与
前同视。（《冯氏锦囊》）
痘正收 时， 而不 ，非气虚必血热也。气虚血热，唇舌之红不红辨之。亦有时令致然者，时寒用温剂
调之，时热用凉剂清之。○痘至结 ，未有不作气息者，带腥气者佳，口臭者死，全无气息，有余毒也，须解之。
（《慈幼筏》）
痘疮至成脓 ，此收功之时，手足常要和暖，过热过寒者变也；人事常要安静，烦躁闷乱者变也；六腑常
要充实，忽吐利者变也；声音常要响亮，忽喑哑者变也；饮食要渐进，忽不食反作渴者变也；色要苍蜡，形要
饱满，忽灰白平塌者变也；疮要安和，忽痒痛者变也。或触风寒，或犯禁忌，或伤食，或误服汤丸，医者当详
察其所因而治之。（《幼幼集成》）
痘至十三、四日，则 老而落矣。然犹有老而不落，名曰漆面刺肉。身体发热，眼红面赤，心烦口渴者有
矣；面虚目肿恶心者有矣；肉烂身热，口生疳蚀者有矣；发毒发疔者有矣；眼生白障，眼露白睛者有矣；痘虽
平复，祸变百出，乌得以 老而不防乎？ 脱光洁，痘若愈矣，然犹未也。 落而疤白者有矣；经月之余，犹
发寒热者有矣。或生流注，或生疥癞，或狂烦喘渴，痂落余证仍生，死生未保，又可以痂落为平安哉？（戴指南）
痘出脑后与足相应，齐起齐痂，人多未知，日久脑后不痂不 ，即恐为病耳。（倪有美）
造化之理，生于阳者阴成之，生于阴者阳成之。故痘疮收 ，头自发际以上，阳气独盛，谓之孤阳；足自
膝以下，阴气所聚，谓之寡阴。所以诸疮皆 之后，惟此二处难 ，乃造化自然之理，不可作倒 论。（《证治准绳》）
倒 塌陷
未绽一齐黑者，为黑陷，已绽而不齐黑者，为将 。（钱仲阳）
痘疹之毒，由内而外为顺；内而不出曰伏；已出复入曰陷；不能成浆谓之倒陷；不能结痂谓之倒 。曰伏、
曰陷、曰倒，皆由外而内为逆。（万密斋）
当出不出，当胀不胀，当灌不灌，当 不 ，均谓之陷伏倒 。○凡痘出胖灌 ，俱以及期为无恙；于中有
少退减者，名曰陷伏倒 ，最为恶证。或拟为寒，或拟为热，未有定论。要知本证灰白顶陷，二便清利，饮食
不进，口鼻气冷，体不甚热，脉息沉迟，渐渐痒塌者，此属虚寒，温补自愈；本证紫色顶突，小便赤，大便秘，
饮食易化，口鼻气热，身体热甚，舌刺，脉数，渐渐枯焦陷入者，此属实热，清解自愈。又在七日以前多属实
热，七日以后多属虚寒。又有因秽恶触犯者，或熏解，或补托，俱载时书，兹不赘。（《仁端录》）
痘证之陷有四∶有白、有红、有灰、有黑。魏桂岩皆责气虚，后人遂以四者俱当用补，误矣！盖彼之论陷，
深究其源，唇舌滋润，身不壮热，惟色变迁而陷，故责之气虚。若唇燥舌苔，壮热燎人，焦紫其色，而凹陷不
起，果虚耶？抑毒耶？补益妄投，岂非按图索骥乎？予治不然，外实则解之，内实则清之、下之，内外无证则
平调之。不独治陷痘，诸痘皆然。（程华仲）
陷分五证∶一则内虚，阳气不能外达，故致出而复没，或斑点白色，或见灰黑倒陷者，其人必不乳食，或
腹胀内寒，或手足冷，或吐泻，或寒战切牙，皆内虚也。速宜温中，轻则十宣散、六气煎，甚则十二味异功散，
外用胡荽酒喷之，但得冷者暖、陷者起、黑者活，便是佳兆。○二则毒盛，内外熏灼，不能尽达于表，因而复陷
于里，乃致烦热躁扰，气喘妄言，或二便不利，渴而腹胀，皆毒陷也。轻者利小便，宜大连翘饮、通关散，或
四顺清凉饮；甚者通大便，宜承气汤，并外用水杨汤浴之，但得利后疮出则佳。○三则外感风寒，肌窍闭塞，
血脉不行，必身痛肢厥，斑点不长，或变紫黑，如瘾疹者，此倒伏也。宜温肌散表，用桂枝葛根汤，加麻黄、
蝉蜕；或紫草饮，外用胡荽酒喷之，但令温散寒邪，使热气得行，则痘自长矣。○四则或因误下，毒瓦斯入里
而黑陷者，先宜六气煎，或温胃饮，以培养胃气；如表未解者，
后宜柴葛桂枝汤，以疏散于外，甚者再加麻黄。○五则房室不洁，为秽恶所触而黑陷者，宜内服紫草饮，外用
胡荽酒喷之；或用茵陈熏法，并用辟邪丹。○服药后有三验法∶陷者复肿，渐以成脓一也；若原疮已干，别于空
处另出一层，起发成脓，渐以收 者，二也；亦有不肿不出，只变自利，下去脓血，饮食精神如故者，三也。
有者吉，无者凶。（张景岳）
倒 之证，虽曰毒甚，亦是里虚，里不虚如何倒得入？○倒 之里虚，非其里之本虚，半由于不当下而早下，
痘疮进入化脓结痂阶段时，最关键的是痘疹的皮囊要浓密包裹、完整坚固。如果脓液尚未形成，突然痘头出现孔洞，浆水漏出，或者浆水结聚成团，堆积在孔外；又或者浆水流失后痘囊空虚而变得干枯发黑，这种俗称为“漏疮”，必定导致死亡。如果脓液已经成熟，痘囊的表皮也随之成熟，浆水沸腾涌出，因而结聚堆积的，这种情况多见于额头和面部正中，俗称“堆屎收”，不能将其归类为漏疮来讨论。因为漏疮是脓未形成时的病变，而堆屎收则是脓液过熟的表现。（万密斋）
涸浆
涸浆，就是空壳的别名。痘形虽然圆润绽开，但内部实际上是空虚的，不久之后就会干涸至极并发生颜色变化。这固然属于气血两虚，但殊不知这也是火邪灼烧、肺金枯槁的缘故。因为火炎上而枭毒攻冲，导致血热而不能化为浆液；肺金燥烈而肾水枯竭，导致气陷而成内虚。所以一旦见到干涸的迹象，应当立即使用黄连、生地、犀角、紫草来清解火毒，随后用人参、白术、当归、地黄来培补气血，在未萌生燥势之前杜绝它，在未耗尽真元之前延续它，这样才能有所救治，稍有迟缓，就难以治疗了。（《冯氏锦囊》）
板黄
痘疮化脓后颜色发黄，这是中央土行的正色。况且浆液的化源来自脾胃，自然应该呈现黄色润泽、光华的状态。所以痘浆既看重饱满，尤其珍贵的是脓液要黄而灵动，这是顺理成章的事。如果阴阳背离了正气，枭毒肆意残虐，那么痘囊被销蚀，其中灌注的脓浆变得腻滞牢贴，像物体枯萎后的黄色，这是因为气血不能在内部荣养。因此痘色死涩而不活动，像干蜡一样不明亮，用手按压，凝结板实，名为“板黄”，这就意味着湿润之气全无，化源之机断绝了。（《冯氏锦囊》）
九、十朝
痘疮到了第九天，颜色转为苍老如蜡，逐渐收敛，如果是顺证痘疮到此阶段，就已经成功了。如果在前期进展不顺，到了第九天内部症状才平复，头面才开始灌浆，周身根脚不散，或者仅有微弱的浆色，逐渐化脓，也可以逾期痊愈，不必拘泥于常规格式，执着于日期的界限。○瘙痒腹泻且病邪内攻的证候，多在第九天死亡。第九天是其死期，不是可救的时期。可救的时机，在第六、七天，应预先谋划，及早施行温补。第十二天是死期证候，如果在第九天极力抢救，第十天中间有一、两个能存活的。（《橡村痘诀》）
痘疮到了第十天，毒邪已解，脓液也转为黄色，呈苍老如蜡的颜色。元气充实的人，痘疮必然按次序结痂。如果口角与生殖器先结痂的，是正常的收敛。身体逐渐轻快，肿胀逐渐消退，眼睛逐渐闭合欲开，饮食加倍，大小便正常，从上至下逐渐收结，痂皮浓密颜色红活，大事就完成了。不然，还不能算作良好。只有在结痂时发热的不必担忧，那是蒸腾浆液作痂的过程。凡是同时全部结痂脱落的，是毒火在内灼烧，必须紧急解除。此证必然脓液未充足。如果声音嘶哑、烦闷、喘促不食，死期迫近了。否则也必然会发毒而解。○十天时补脾燥湿，说的是常证。如果是危险证候，到了此时才化脓结痂的，怎么能不仔细考察而一概使用清凉渗湿之法呢？清凉渗湿是在脓足毒尽之后的步骤，如果用来灌脓，难道不会出错吗？痘疮以日程限制，是为了初学者考虑，灵活的方法要在心中，有什么日期界限可以拘泥？该补的补，该泻的泻，不拘泥于书本，才足以寄托救人的性命。（程华仲）
痘疮到了八、九、十天，外部没有浆液则内部毒邪不能化解，必然会出现呛咳声哑、瘙痒、痰多、不食、眼开等危象，死期迅速到来。常有突然成片裂开流出浆水的痘疮，形状像松脂或桃胶，转眼堆积起来，由凶转吉。更有在旬日之内，干燥板结干涸得像焦黑的锅底状，毫无生气，忽然从地角（下巴）、承浆等处裂缝，流出臭水，逐渐上升到头额，堆积肿胀高起如糊脸，名为“发臭”，毒邪泄出后就应当补托，迟了就会导致气脱。（叶天士）
痘痒
在灌浆时出现瘙痒的，凶多吉少。必须观察其发作部位，探究其原因，察看病症情状，来施治。观察其发作部位：有的发于手足，有的发于肩背，抚摸就停止，禁止抓挠就听从的，预后吉祥；如果发于正面，瘙痒不止，皮肤脱落肌肉干枯的，预后凶险。探究其原因：有的因呕吐腹泻、食欲不振，脾胃虚弱，气血不能荣养的，这是虚痒，治疗宜用温补；有的因秽恶之气触动邪火的，这是暴痒，治疗宜用熏法解表；有的因痘疮已熟，邪气完全解除，正气逐渐生成，气血调和，火气微弱欲退，从而溶溶然瘙痒的，这是美疾，不需要服药。如果没有原因自行产生的瘙痒，原本是恶痘，不能善终。察看病症情状：如瘙痒之时，忽作忽止，精神清爽，自己不抓挠，希望被人抚摸的，能存活；如果无时不抓挠，神识昏沉，摇头扭颈的，死亡。（《冯氏锦囊》）
痘疮有灰白色、瘙痒塌陷的，是气血亏弱，变为虚寒。阳分，是气居住的地方；阴分，是血居住的地方。阳气弱则陷入阴分，阴血盛则侵犯阳分，气虚则血进，血虚则气凌，这是自然的道理。气虚，则表现为麻疹样、瘙痒、塌陷；血热，则表现为干枯、燥烈、疼痛。痘色白的，必然发展到灰惨。灰惨的，必然发展到平伏瘙痒塌陷。这都是气虚而不能起胀，血虚而不能华彩。治疗方法用补中益气汤合四物汤，来补助气血。内有热的，加清利解毒的药物，使血活气行，那么白色就可以变为红色了。如果只补气而不补血，那么气血燥热，瘙痒塌陷会更加严重。（《金镜录》）
痘疮瘙痒毕竟属于虚证。管庠侯却说有气盛血热而痒的，这是谬论。又有说是因为血上行，血味本咸，腌制刺痛皮肉而作痒。似乎近于情理，然而灰白色的痘疮，不仅气虚，血也虚，怎么能上行而腌制刺痛皮肉？这种说法恐怕也不对。那些因秽浊触犯而痒的，用烧苍术、红枣、黄柏来解之。○表虚的痘疮，脓浆不满，多有瘙痒的，不能禁止手抓，必须让患儿穿着长袖绢衣，扎紧袖口，不让爪子抓挠才好。如果没有绢衣，用绢片包裹患儿的手也可以。（《痘疹心法》）
瘙痒有两种证候：一则气血不足，其痒为虚，用四君子汤；一则不能吃淡食，火生致痒，用蝉蜕一物汤。（闻人定）
爬破
树木枯槁就会折断，土壤干燥就会开裂。痘疮的囊房如果不甚充满，爬破的证候就由此而来。但是爬破如果不关紧要之处，还可以保全生命；如果爬破要害之处，如颧骨、脸颊、头面，这是五脏精华汇聚的地方，痘毒借以作为囊房，就像人有房舍，鸟有巢穴，现在囊房既已破裂，毒邪无处栖身，何况营阴耗竭，元气外亡，怎能不乘虚内入呢？有效仿女娲补天之法，用纸封固的，也必须依赖脾胃内部强健并能进食，气血未残败而能灌浆，这样才有救治的希望。（《冯氏锦囊》）
十一、二朝
十二、三天，痘形有形如火烧烟熏状的，是血不能载毒而内攻。判断生死看脉证：声音不清，不能进食，破溃处干枯，烦乱不睡的，是死证；声音清晰能进食，睡卧安稳，爬破处淋漓，神志舒畅气息爽的，是生证。又应当分虚实治疗：唇舌洁净，则补益兼清解；如果唇燥舌干便秘，则单用清解，继以平和之剂，攻补两全了。（《慈幼筏》）
十一、二天结成痂皮之际，极好的痘疮必然会有咳嗽，或者夜晚身体发热。《幼科佥书》说：毒瓦斯未尽，一概投用苦寒药，多有胃气减退废食，酿成痘劳病的。痘疮发自肾脏骨髓之中，从内向外，毒邪乃涣散释放，收疤之时，真气归里，肺合皮毛，位置高，体性清肃，从前灌浆膨胀成痂，蒸迫之气，受损已极，气泄而为咳嗽了。况且投用利湿下注的药而结痂，上焦已经转燥，如果毒邪仍留伏，怎么能收痂？再论幼稚之体阳常有余，阴未充长，布痘至于结痂，一身脂液大损，阴气告匮可知，所以暮夜属阴，时间为烦热的，正是《内经》所说：阴虚生内热也。以前西邻吴氏女，年仅四岁，痘疮属顺证，浆满成痂，忽然发烦躁，夜热不寐，晨起安然，医生用保元汤、异功散，热躁更加厉害，换医生认为毒瓦斯未尽，用桑叶、蚕砂及凉解药，热更甚而添泄泻。我视诊浆痂形色，询问其平日起居，用六味地黄丸一服而安。这两条人们多忽视而不深究，所以辨析于此。（叶天士）
收痂
不是难事，难于灌浆。浆足则毒化，化则毒尽，毒尽则收痂。重点在头面，其余则轻视，浆收不及头面，是谓气道乖和，阴阳闭塞，而失其适宜。所以痘疮收痂必须以头面为主，而天庭尤为头面的主位。盖气向上，起始在于下，则形成扶摇之势，等到中上部，则滂沛横流，到达头顶的微末之处，则缓游而已。倘若中上部不横流，微末之处怎么会有余劲呢？不灌浆而收痂，死亡不用说。浆清而收痂，与死为邻。微稠而收痂，须恢复斑纹，后来必发毒，然后可得生。浆稠而收痂，可决断其生。浆稠不收痂，火沸不停。（《黄帝逸典》）
收痂时无杂证，才是正收痂；如果有热，或渴，或泻，或痰响，或切牙寒战，或烦躁不安，都叫作收不回，不是正收。○螺蛳痂最上等；顶露松香，皮塌牵连的，名鸡矢痂，次之；浆清不成痂的，急则内攻，缓则发毒。○三、五粒中间收一、二粒，谓之打花焦，最吉利。○大寒的痘疮，怕出不出；大暑的痘疮，虑收不回。暑月阳气尽泄，体弱的幼儿，气血有限，尽供出长之用，到收痂时无以复续，更遭酷暑，金水俱伤，忽然内陷的有之。这虽然不是医生的罪过，能在浆足之后不减人参、白术、当归、芍药，更加熟地、麦冬，或许可以保全。（《橡村痘诀》）
脓后结痂，是理所当然的。有过期不收，遍身溃烂的，其原因有六种：有因大便秘结，表里俱实，热气蒸郁，毒气散漫，阳气太盛，无阴气以收敛而不收的，治疗宜清凉；有因泄泻里虚，脾胃亏弱，元气外散，表里不固，阴气太盛，无阳气以收敛而不收的，治疗宜温补；有因口渴饮水多，以致水渍于脾，湿淫肌肉而不收的，治疗宜渗湿；有因天寒失于覆盖，疮受冻冷，血凝毒滞而不收的，治疗宜温和；有因天热过求温暖，疮被热蒸而不收的，治疗宜清凉；有因食少气虚而不收的，治疗宜补脾。大抵痘疮的成就，犹如谷物的秋成。五谷得阳气以成熟，非凉风至则不能结实；痘疮的脓而不焦，犹如禾苗秀而不实，治疗须认识其清凉的意义即可。然而也有脓后气血虚耗，所以不收痂，不可与前同视。（《冯氏锦囊》）
痘疮正收痂时，收而不坚，不是气虚必是血热。气虚血热，通过唇舌的红或不红来辨别。也有时令导致的，时寒用温剂调之，时热用凉剂清之。○痘疮到结痂，没有不产生气息的，带腥气的佳，口臭的死，全无气息的，有余毒，须解之。（《慈幼筏》）
痘疮到成脓收痂，这是收功之时，手足常要和暖，过热过寒的是变证；人事常要安静，烦躁闷乱的是变证；六腑常要充实，忽吐利的是变证；声音常要响亮，忽喑哑的是变证；饮食要渐进，忽不食反作渴的是变证；色要苍蜡，形要饱满，忽灰白平塌的是变证；疮要安和，忽痒痛的是变证。或触风寒，或犯禁忌，或伤食，或误服汤丸，医者当详细察其所因而治之。（《幼幼集成》）
痘疮到了十三、四天，则痂老而脱落了。然而还有老而不落的，名叫漆面刺肉。身体发热，眼红面赤，心烦口渴的有之；面虚目肿恶心的有之；肉烂身热，口生疳蚀的有之；发毒发疔的有之；眼生白障，眼露白睛的有之；痘虽平复，祸变百出，怎么能因为痂老而不防备呢？痂脱光洁，痘若愈矣，然而还未结束。痂落而疤白的有之；经月之余，犹发寒热的有之。或生流注，或生疥癞，或狂烦喘渴，痂落余证仍生，死生未保，又可以痂落为平安哉？（戴指南）
痘出脑后与足相应，齐起齐痂，人们多不知道，日久脑后不痂不收，即恐为病耳。（倪有美）
造化的道理，生于阳者阴成之，生于阴者阳成之。所以痘疮收痂，头部自发际以上，阳气独盛，谓之孤阳；足自膝以下，阴气所聚，谓之寡阴。所以诸疮皆收痂之后，惟此二处难收痂，乃是造化自然之理，不可作倒痂论。（《证治准绳》）
倒痂塌陷
未绽开一齐黑的，为黑陷，已绽开而不齐黑的，为将倒痂。（钱乙）
痘疹之毒，由内而外为顺；内而不出曰伏；已出复入曰陷；不能成浆谓之倒陷；不能结痂谓之倒痂。曰伏、曰陷、曰倒，皆由外而内为逆。（万密斋）
当出不出，当胀不胀，当灌不灌，当收痂不收痂，均谓之陷伏倒痂。○凡痘出胖灌收痂，俱以及期为无恙；其中有少退减的，名曰陷伏倒痂，最为恶证。或拟为寒，或拟为热，未有定论。要知道本证灰白顶陷，二便清利，饮食不进，口鼻气冷，体不甚热，脉息沉迟，渐渐痒塌的，此属虚寒，温补自愈；本证紫色顶突，小便赤，大便秘，饮食易化，口鼻气热，身体热甚，舌刺，脉数，渐渐枯焦陷入的，此属实热，清解自愈。又在七日以前多属实热，七日以后多属虚寒。又有因秽恶触犯的，或熏解，或补托，俱载时书，兹不赘。（《仁端录》）
痘证之陷有四：有白、有红、有灰、有黑。魏桂岩都责怪气虚，后人遂以为四者俱当用补，误矣！盖他的论陷，深究其源，唇舌滋润，身不壮热，惟色变迁而陷，故责怪气虚。如果唇燥舌苔，壮热燎人，焦紫其色，而凹陷不起，果真是虚耶？还是毒耶？补益妄投，岂不是按图索骥乎？我治疗不这样，外实则解之，内实则清之、下之，内外无证则平调之。不独治陷痘，诸痘皆然。（程华仲）
陷分五证：一则内虚，阳气不能外达，故致出而复没，或斑点白色，或见灰黑倒陷的，其人必不乳食，或腹胀内寒，或手足冷，或吐泻，或寒战切牙，皆内虚也。速宜温中，轻则十宣散、六气煎，甚则十二味异功散，外用胡荽酒喷之，但得冷者暖、陷者起、黑者活，便是佳兆。○二则毒盛，内外熏灼，不能尽达于表，因而复陷于里，乃致烦热躁扰，气喘妄言，或二便不利，渴而腹胀，皆毒陷也。轻者利小便，宜大连翘饮、通关散，或四顺清凉饮；甚者通大便，宜承气汤，并外用水杨汤浴之，但得利后疮出则佳。○三则外感风寒，肌窍闭塞，血脉不行，必身痛肢厥，斑点不长，或变紫黑，如瘾疹的，此倒伏也。宜温肌散表，用桂枝葛根汤，加麻黄、蝉蜕；或紫草饮，外用胡荽酒喷之，但令温散寒邪，使热气得行，则痘自长矣。○四则或因误下，毒瓦斯入里而黑陷的，先宜六气煎，或温胃饮，以培养胃气；如表未解的，后宜柴葛桂枝汤，以疏散于外，甚者再加麻黄。○五则房室不洁，为秽恶所触而黑陷的，宜内服紫草饮，外用胡荽酒喷之；或用茵陈熏法，并用辟邪丹。○服药后有三验法：陷者复肿，渐以成脓一也；若原疮已干，别于空处另出一层，起发成脓，渐以收痂的，二也；亦有不肿不出，只变自利，下去脓血，饮食精神如故的，三也。有者为吉，无者为凶。（张景岳）
When the smallpox pustules form and turn into pus-filled sacs, it is most crucial that the skin envelope be dense, wrapped tightly, and intact. If the pus has not yet formed and suddenly a pore appears on the head of the lesion, with fluid leaking out, or if the fluid aggregates into a mass piled outside the pore, or if the fluid drains away leaving the sac empty and dry/black, this is commonly known as "leaking sore" (Lou Chuang), which is invariably fatal. If after the pus has matured, the sac skin also matures, and the serum boils out and consequently aggregates, this often occurs between the forehead and the center of the face, commonly called "piled stool recovery" (Dui Shi Shou), and should not be discussed in the same category as leaking sores. This is because leaking sores occur when pus has not yet formed, whereas piled stool recovery occurs when the pus is overly mature. (Wan Mizhai)
Dry Serum (He Jiang)
Dry serum is another name for an empty shell. Although the smallpox lesion appears round and opened, the interior is actually empty; soon it will become extremely dry and change color. While this certainly belongs to deficiency of both Qi and Blood, one must not overlook that it is also due to Fire scorching and Lung Metal drying up. Because Fire flares upward and fierce toxins attack, Blood Heat prevents the transformation into serum; Lung Metal becomes dry and Kidney Water is exhausted, causing Qi to sink and resulting in internal deficiency. Therefore, upon seeing signs of dryness, one should immediately use Huanglian (Coptis Rhizome), Shengdi (Rehmannia Root), Xijiao (Rhinoceros Horn - *note: substitute with Buffalo Horn in modern practice*), and Zicao (Arnebia Root) to clear Fire toxins, followed by Renshen (Ginseng), Baizhu (Atractylodes Macrocephala Rhizome), Danggui (Angelica Sinensis), and Dihuang (Rehmannia Root) to nourish Qi and Blood, preventing dryness before it arises and sustaining True Yuan before it is depleted. Only then can there be hope; any delay makes treatment difficult. (Feng Shi Jin Nang)
Board-like Yellow (Ban Huang)
When smallpox pus forms and turns yellow, this is the correct color of Central Earth. Moreover, since the source of serum transformation lies in the Spleen and Stomach, it naturally should appear yellow, moist, and lustrous. Thus, while smallpox serum values fullness, it especially values pus that is yellow and lively; this follows natural principles. If Yin and Yang deviate from righteous Qi, and fierce toxins act cruelly, the sac chambers are corroded, and the clarified serum within becomes greasy, sticky, and firmly attached, resembling the yellow of a withered object. This indicates that Qi and Blood fail to nourish internally. Consequently, the color is dead and stiff without vitality, like dry wax rather than bright yellow. Pressing with the hand reveals a hard, board-like solidity. Named "Board-like Yellow," this signifies the complete absence of moistening Qi and the extinction of the transformative source. (Feng Shi Jin Nang)
Ninth and Tenth Days
On the ninth day, if the smallpox color turns dark-yellow like wax and gradually recovers, for a favorable case, success has been achieved at this stage. If progress was hindered earlier, but internal symptoms stabilize by the ninth day, the head and face begin to fill with serum, the roots of the lesions all over the body do not scatter, or there is only slight serum color gradually turning to pus, recovery can still occur beyond the usual timeline. One should not rigidly adhere to standard formats or fixate on specific days. ○ Itching accompanied by diarrhea and internal attack of pathogens usually leads to death on the ninth day. The ninth day is its death period, not a time for rescue. The window for rescue is the sixth and seventh days; plans should be made in advance to apply warming and tonifying methods early. For cases destined to die on the twelfth day, vigorous rescue efforts on the ninth day may result in one or two survivors by the tenth day. (Xiang Cun Dou Jue)
By the tenth day, the toxin is resolved, and the pus turns yellow, appearing dark-yellow like wax. In individuals with solid Yuan Qi, the lesions will crust over in sequence. If the corners of the mouth and the genitalia crust over first, this is normal recovery. The body feels progressively lighter, swelling subsides, eyes gradually close and wish to open, appetite doubles, and bowel/bladder functions remain normal. Recovery proceeds from top to bottom, gradually crusting over with thick, red-colored scabs, marking the completion of the major events. Otherwise, it cannot be considered good. Fever during crusting need not be worried about, as it is the process of steaming serum to form scabs. If all scabs fall off simultaneously, it indicates internal scorching by toxin-fire, requiring urgent resolution. This condition implies insufficient pus. If hoarseness, restlessness, panting, and anorexia occur, death is imminent. Otherwise, the toxin will likely erupt and resolve. ○ Tonifying the Spleen and drying dampness on the tenth day refers to the normal course. However, in critical cases where pustules form only at this stage, one must not indiscriminately use cooling and diuretic methods. Using cooling and diuretics at the stage of filling pustules, after pus is sufficient and toxins are exhausted, would surely be erroneous. Smallpox timelines are set for beginners; flexible methods must be kept in mind. What constraints do timelines impose? Tonify when necessary, purge when necessary, do not be bound by books, and you will be worthy of entrusting lives. (Cheng Huazhong)
By the eighth, ninth, or tenth day, if there is no external serum, internal toxins cannot transform, leading to choking, hoarseness, itching, excessive phlegm, anorexia, and open eyes, signaling a rapid approach to the critical period. Sometimes, lesions suddenly crack in strips, oozing fluid, resembling pine resin or peach gum, accumulating rapidly, changing from ominous to auspicious. More rarely, within ten days, the lesions become dry, hard, and desiccated like a scorched pot bottom, devoid of vitality. Suddenly, cracks appear at the chin (Di Jiao) and Chengjiang point, oozing foul-smelling fluid that rises to the forehead, swelling high and thick like paste applied to the face. Named "Fa Chou" (Emitting Stench), once the toxin is excreted, tonification and support must be administered; delay will lead to Qi collapse. (Ye Tianshi)
Smallpox Itching
Itching during the serum-filling stage is more often ominous than auspicious. Treatment must be based on observing the site of onset, investigating the cause, and examining the clinical presentation. Observing the site: If itching occurs on hands/feet or shoulders/back, stops upon stroking, and obeys commands to stop scratching, it is auspicious; if it occurs on the front of the face, persists incessantly, with skin peeling and muscle drying, it is ominous. Investigating the cause: If caused by vomiting, diarrhea, and poor appetite leading to weak Spleen/Stomach and lack of Qi/Blood nourishment, this is Deficiency Itching, treated with warming and tonifying. If caused by foul odors triggering pathogenic Fire, this is Acute Itching, treated with fumigation and resolution. If the smallpox is mature, pathogens are fully resolved, righteous Qi is generating, Qi/Blood are harmonious, and mild Fire is retreating, causing a gentle itching, this is a beautiful disease, requiring no medication. Spontaneous itching without cause indicates malignant smallpox that will not heal well. Examining the presentation: If itching comes and goes, spirit is clear, the patient does not scratch themselves but desires to be stroked, they will survive; if scratching is constant, consciousness is clouded, and the head/neck twist, they will die. (Feng Shi Jin Nang)
Smallpox lesions that are gray-white, itchy, and collapsed indicate Qi and Blood deficiency transforming into Cold-Deficiency. The Yang aspect is where Qi resides; the Yin aspect is where Blood resides. Weak Yang sinks into Yin; abundant Yin invades Yang. Qi deficiency allows Blood to advance; Blood deficiency allows Qi to oppress. This is natural law. Qi deficiency manifests as macular rash, itching, and collapse; Blood Heat manifests as dryness, aridity, and pain. Gray-white lesions inevitably become gray and miserable. Gray and miserable lesions inevitably become flat, itchy, and collapsed. All these result from Qi deficiency failing to raise the lesions and Blood deficiency failing to provide luster. Treatment uses Buzhong Yiqi Tang combined with Siwu Tang to supplement Qi and Blood. If there is internal heat, add clearing and detoxifying herbs to activate Blood and move Qi, turning white to red. If only Qi is supplemented without Blood, Qi and Blood become dry and hot, worsening the itching and collapse. (Jing Jian Lu)
Smallpox itching ultimately belongs to deficiency. Guan Hanghou claimed there is itching due to excess Qi and Blood Heat, which is erroneous. Others suggested that because Blood moves upward and blood tastes salty, it腌s (pickles/irritates) the skin and flesh causing itching. This seems plausible, but gray-white lesions involve both Qi and Blood deficiency; how can Blood move upward to irritate the skin? This theory is likely incorrect. For itching caused by foul contact, burn Cangzhu (Atractylodes Rhizome), Hongzao (Red Date), and Huangbai (Phellodendron Bark) to resolve it. ○ For exterior-deficient smallpox with incomplete serum, itching is common. Patients cannot resist scratching; having them wear long-sleeved silk garments with tied cuffs to prevent clawing is ideal. If silk is unavailable, wrapping the infant's hands in silk pieces works too. (Dou Zhen Xin Fa)
There are two types of itching: First, Qi and Blood insufficiency causes deficiency itching, treated with Sijunzi Tang. Second, inability to eat bland food generates Fire causing itching, treated with Chan Tui Yi Wu Tang. (Wenren Ding)
Scratching Breakage
When wood is dry, it breaks; when soil is dry, it cracks. If smallpox sac chambers are not sufficiently filled, scratching breakage ensues. If scratched areas are not vital, life can still be saved; if vital areas like cheeks, face, or head are scratched, disaster strikes. These areas gather the essence of the Five Zang organs. The smallpox toxin uses the sac as a shelter, like a bird's nest. Once the sac breaks, the toxin has no dwelling place. With Ying-Yin exhausted and Yuan Qi escaping externally, how can the toxin not enter internally through the deficiency? Effective methods mimic Nuwa mending the sky, sealing with paper. However, salvation depends on strong internal Spleen/Stomach function enabling eating, and residual Qi/Blood enabling serum filling. (Feng Shi Jin Nang)
Eleventh and Twelfth Days
On the twelfth or thirteenth day, lesions looking like fire-scars or smoke-stains indicate Blood failing to carry toxins, leading to internal attack. Life/death prognosis: Unclear voice, inability to eat, dry cracked lesions, restlessness, and insomnia are death signs; clear voice, ability to eat, peaceful sleep, dripping scratched lesions, comfortable spirit, and fresh breath are survival signs. Differentiate deficiency/excess: Clean lips/tongue require tonification combined with clearing; dry lips/tongue and constipation require pure clearing, followed by balanced formulas, achieving both attacking and tonifying. (Ci You Fa)
During the eleventh and twelfth days, when scabs form, excellent smallpox cases often feature cough or evening fever. *You Ke Qian* states: If toxins are not fully cleared, administering bitter-cold herbs indiscriminately often damages Stomach Qi, causing anorexia and酿ning smallpox consumption. Smallpox originates in the Kidney marrow and emerges outward; toxins disperse. During scar formation, True Qi returns inward. The Lung governs skin/hair, sits high, and is pure/descending. The steaming pressure from previous serum filling damages Qi significantly; Qi leakage causes cough. Furthermore, using draining-dampness herbs to form scabs dries the Upper Jiao. If toxins remain latent, how can scabs form? Infants have excess Yang and undeveloped Yin. By the crusting stage, bodily fluids are greatly depleted, indicating Yin exhaustion. Night is Yin; evening fever corresponds to *Neijing*: "Yin deficiency generates internal heat." Formerly, a four-year-old girl from the West neighbor Wu family had a favorable case. After serum filled and scabs formed, she suddenly became irritable, feverish at night, unable to sleep, but fine in the morning. Doctors used Baoyuan Tang and Yigong San, worsening the heat/restlessness. Another doctor attributed it to lingering toxins, using Mulberry leaf and Silkworm, plus cooling/resolving herbs, worsening heat and adding diarrhea. I examined the serum/scab appearance and daily habits, prescribing Liuwei Dihuang Wan once, bringing peace. These two points are often ignored, hence this clarification. (Ye Tianshi)
Scab Formation
Not difficult; the difficulty lies in serum filling. Sufficient serum transforms toxins; transformed toxins are eliminated; eliminated toxins allow scabbing. Focus is on the head and face; other areas are secondary. If serum fails to reach the head and face, it indicates disharmony of Qi pathways, closure of Yin/Yang, and loss of appropriateness. Thus, scabbing prioritizes the head and face, with the Tian Ting (forehead) being paramount. Qi rises; starting low, it gains momentum (Fuyao); reaching middle/upper levels, it flows abundantly; at the crown's tip, it slows. If middle/upper levels don't flow abundantly, how can the tip have strength? No serum means no scabbing, leading to death. Clear serum with scabbing is near death. Slightly thick serum with scabbing requires restoration of spots; later eruption of toxins may allow survival. Thick serum with scabbing predicts survival. Thick serum without scabbing indicates unceasing boiling Fire. (Huangdi Yidian)
Scabbing without mixed symptoms is proper scabbing; fever, thirst, diarrhea, rattling phlegm, teeth-chattering chills, or restlessness indicate failure to scab properly. ○ Snail-shell scabs are best; scabs exposing pine-resin-like centers with sagging skin connections are Chicken-Dung scabs (secondary); clear serum failing to form scabs leads to internal attack if acute, or toxin eruption if chronic. ○ Scabbing 1-2 lesions among 3-5 is called "Flower-Beating Scorched," most auspicious. ○ Severe Cold smallpox fears non-emergence; Severe Heat smallpox fears failure to scab. In summer, Yang Qi exhausts; weak infants have limited Qi/Blood, used entirely for emergence/growth. By scabbing time, resources are depleted. Combined with intense heat damaging Metal/Water, internal collapse can occur. Though not the doctor's fault, maintaining Renshen, Baizhu, Danggui, Shaoyao after serum sufficiency, adding Shudi and Maidong, can ensure safety. (Xiang Cun Dou Jue)
Pus-to-scab transition is normal. Delayed scabbing with widespread ulceration has six causes: 1. Constipation, excess in interior/exterior, steaming heat, scattered toxins, excessive Yang without Yin to restrain → treat with cooling. 2. Diarrhea, interior deficiency, weak Spleen/Stomach, scattered Yuan Qi, insecure exterior/interior, excessive Yin without Yang to restrain → treat with warming/tonifying. 3. Excessive drinking, water soaking Spleen, dampness invading muscles → treat with damp-draining. 4. Cold weather, lack of covering, cold injury to sores, congealed Blood/stagnant toxins → treat with warming/mildness. 5. Hot weather, excessive warmth-seeking, heat steaming sores → treat with cooling. 6. Poor appetite, Qi deficiency → treat with Spleen-tonifying. Generally, smallpox achievement resembles autumn harvest. Grains ripen via Yang Qi but need cool wind to fruit; pus without scabbing is like grain flowering without fruiting; treatment requires understanding cooling principles. However, post-pus Qi/Blood depletion causing non-scabbing differs from the above. (Feng Shi Jin Nang)
During proper scabbing, loose/unfirm scabs indicate either Qi deficiency or Blood Heat. Differentiate Qi/Blood status by lip/tongue redness. Seasonal factors also play a role: cold seasons use warming agents; hot seasons use cooling agents. ○ At crusting, breath odor is expected. Fishy smell is good; bad breath indicates death; no odor indicates residual toxins requiring resolution. (Ci You Fa)
At the pus-to-scab stage, this is the conclusion. Hands/feet should be warm; too hot/cold is aberrant. Behavior should be calm; restlessness/confusion is aberrant. Six Fu organs should be full; sudden vomiting/diarrhea is aberrant. Voice should be loud; sudden hoarseness is aberrant. Diet should increase gradually; sudden anorexia/thirst is aberrant. Color should be dark-yellow/wax-like, shape full; sudden gray-white/flat is aberrant. Sores should be peaceful; sudden itching/pain is aberrant. Whether triggered by wind-cold, taboos, food injury, or mistaken medication, doctors must investigate the cause and treat accordingly. (You You Ji Cheng)
By the thirteenth/fourteenth day, scabs age and fall. However, some old scabs do not fall, named "Lacquer-Face Piercing Flesh." Cases exist with fever, red eyes/face, irritability, thirst; facial puffiness, eye swelling, nausea; rotting flesh, fever, mouth ulcers; toxin eruption/carbuncles; white films over eyes, exposed sclera. Even if smallpox flattens, myriad disasters arise. How can one ignore precautions just because scabs age? Smooth, clean scab shedding suggests cure, but not necessarily. White scars after scab fall exist; fever/chills persisting months later exist. Abscesses, scabies, mania/panting/thirst may arise. Residual symptoms persist after scab fall; life/death uncertain. Can scab fall guarantee peace? (Dai Zhinan)
Smallpox emerging at the back of the head corresponds to the feet, rising and crusting together. People often ignore this; if the back of the head fails to crust/recover after many days, disease is feared. (Ni Youmei)
The principle of creation: Born of Yang, completed by Yin; born of Yin, completed by Yang. Thus, during smallpox scabbing, the area above the hairline has exclusive Yang, called "Solitary Yang"; the area below the knees gathers Yin, called "Lonely Yin." Therefore, while all sores scab, these two areas are hardest to scab, following natural creation laws, not to be classified as inverted scabbing. (Zheng Zhi Zhun Sheng)
Inverted Scab Collapse
Lesions blackening uniformly before opening are Black Collapse; lesions opening but not uniformly blackening are impending inverted scabbing. (Qian Zhongyang)
Smallpox/rash toxins moving outward from inside are favorable; staying inside without emerging is "Fu" (Hidden); emerging then re-entering is "Xian" (Collapse); failing to form serum is "Dao Xian" (Inverted Collapse); failing to crust is "Dao Jie" (Inverted Scab). Fu, Xian, Dao all represent unfavorable movement from outside to inside. (Wan Mizhai)
Failure to emerge when it should, fail to swell when it should, fail to fill serum when it should, fail to scab when it should, are all termed Collapse/Hidden/Inverted Scab. ○ Normal emergence, filling, and scabbing occurring on schedule is safe; slight regression is termed Collapse/Hidden/Inverted Scab, the worst syndrome. Etiology varies (Cold/Heat). Identify: Gray-white, depressed tops, clear urine/stool, anorexia, cold breath/nose, mild fever, slow/deep pulse, gradual itching/collapse → Deficiency-Cold, self-heals with warming/tonifying. Purple-red, protruding tops, red urine, constipation, easy digestion, hot breath/nose, high fever, prickly tongue, rapid pulse, gradual drying/collapse → Excess-Heat, self-heals with clearing/resolving. Pre-day 7 mostly Excess-Heat; post-day 7 mostly Deficiency-Cold. Contact with foul odors requires fumigation or tonification/support, as recorded in contemporary texts. (Ren Duan Lu)
Four types of collapse: White, Red, Gray, Black. Wei Guiyan blamed Qi deficiency for all; later doctors wrongly used tonification for all. Wei analyzed deeply: moist lips/tongue, no high fever, only color change/collapse → blame Qi deficiency. But dry lips/tongue coating, blazing fever, scorched-purple color, sunken/non-raising lesions—are they truly deficient or toxic? Blind tonification is like hunting by map. My treatment: Exterior excess → resolve; Interior excess → clear/purge; No excess → balance. Applies to all smallpox, not just collapse. (Cheng Huazhong)
Five types of collapse: 1. Internal deficiency, Yang fails to reach exterior, emerging then sinking, white/gray-black inverted lesions, refusal to nurse/eat, abdominal distension/internal cold, cold limbs, vomiting/diarrhea, chills/teeth-chattering → Internal Deficiency. Urgently warm the middle. Mild: Shixuan San, Liuqi Jian; Severe: Shi'erwei Yigong San. External: Huisu wine spray. Signs of improvement: Cold warms, collapse raises, black livens. 2. Toxin excess, internal/external scorching, failure to reach surface, sinking internally, restlessness, panting, delirium, urinary/fecal obstruction, thirst/abdominal distension → Toxin Collapse. Mild: Promote urination, Dalianqiao Yin, Tongguan San, Sishun Qingliang Yin; Severe: Promote defecation, Chengqi Tang. External: Shuiyang Tang bath. Improvement: Lesions emerge after purgation. 3. External wind-cold, blocked pores, stagnant blood, body pain/cold limbs, stalled spots, purple-black hives → Inverted Hidden. Warm muscles/release exterior: Guizhi Gegen Tang + Mahuang, Chan Tui; or Zicao Yin. External: Huisu wine spray. Goal: Warm-dispel cold, allow heat to move, lesions grow. 4. Mistaken purgation, toxins enter interior, black collapse. First: Liuqi Jian or Wenwei Yin to nurture Stomach Qi. If exterior unresolved: Chai Ge Guizhi Tang to release exterior; severe cases add Mahuang. 5. Unclean bedroom, foul contact, black collapse. Internal: Zicao Yin; External: Huisu wine spray; or Yinchen fumigation, Pixie Dan. Three verification signs after medication: 1. Collapsed lesions swell, gradually form pus. 2. Original dry lesions produce a new layer in empty spaces, rise/form pus, gradually scab. 3. No swelling/emergence, only spontaneous diarrhea passing pus/blood, diet/spirit normal. Presence is auspicious, absence ominous. (Zhang Jingyue)
Inverted scabbing, though toxin-heavy, involves interior deficiency. Without interior deficiency, how could inversion occur? ○ Interior deficiency in inverted scabbing is not original deficiency, but half due to premature purgation when not indicated,