半由于表热而误清其里。○塌陷之患亦有二∶半由于阔大而不能充畅，半由于泄泻而中气下沉。○痒塌之证，由
渐而颓；倒 之证，突如其来。○倒 之证，既曰虚，如何黑焦？黑焦者，毒结也。元气虚，不能运化毒瓦斯，
安得不凝结而成黑焦？○塌陷如何不焦？塌陷只是虚，故不焦，不焦故可施温补。不焦者名曰陷，焦者名黑陷，
总属里虚。但白陷宜温补，黑陷宜清补。○痘本难灌，极力攻发，惟恐其不足，直追到九朝、十朝，然后清利，
故无倒 之患，但瘟疤而已。（《橡村痘诀》）
瘟疤溃烂
后瘟疤，汁气腥秽，余毒尽泄，此佳兆也。若收 时，遍身干枯而潮热者凶。○臭烂之痘，毒虽外泄，
亦能内攻，必须安卧能食，元气不败者方可。不然，犹有迁变。（《橡村痘诀》）
痘已成脓，过期不 ，溃烂脓汁淋漓，粘惹疼痛者，用败草散，或荞麦粉以绢袋盛贮扑之，更多布席上衬
卧尤佳。（《证治准绳》）
斑烂
痘疮脓熟溃烂者，常候也；若未成脓先即溃者，此名斑烂。由病当发散而不发散，则毒瓦斯闭塞；不当发
散而误发散，则热毒随阳气暴出，遍身皮肉溃烂。治宜调脾进食，安养营卫，生肌解毒。解之不至于冷，调养
不至于热，方为良法。（万密斋）
疤不落
疤不落必是疤浓，外虽结而中实溏，此因多食鲜发之物。无妨，清利收敛，自然脱矣。亦有干结着肉而
不落者，血分热也。又宜清热养阴，以润泽之。（《橡村痘诀》）
痘痂日久，当脱不脱，在于胸背手足，无妨。若面上不脱，当以百花膏润之，令其速脱，迟则干硬，
深入肌肉，遂成疤痕。然久而不脱者，脾胃虚也。治宜人参白术散，加黄 、官桂，不可 掐剥去，恐伤皮肤，
复灌作疮，反复溃烂，其后多成疥癞。（万密斋）
疤痕
痘痕赤白，各有所因，治法亦异。凡痕赤作痒者，血虚有热也，用四物加丹皮；赤而作痛者，余热也，
用四君、连翘、银花；若发热便调者，脾胃虚热也，用异功散；发热便秘者，肠胃内热也，用犀角地黄汤。○
疤痕白者，属气虚而血衰也，宜固元气为本，参兼变之证治之。服药渐转红活者可治，色不转者不治。虽经年
之后，多患泻利而死。○凡疮疤黑暗者，恐前未甚作脓，收 太急，倒 归肾也。但察其表里，如壮热大渴未除，
烦闷昏睡少食，或大便不通，或自利者，此真倒 归肾也；若身温爽快，饮食渐加，大小便调者，此疮疤本色，
无虑也。（《证治准绳》）
痘后余毒
夫痘顺证，其痘疏，其毒微，自然易出易 ，而无余毒；险证，其痘密，其毒盛，自然难出难 ，而有
余毒；逆证，或陷伏，或倒 ，幸赖脾胃强，调治早，证虽得痊，余毒未尽，发而为病，多犯疥痈目赤，痘毒
藉此消除。故凡痂落而口不渴，身无热，二便通调，腹无痛楚，精神渐壮，饮食渐加，痂疤红润者，此无余
毒也。若身热而渴，谵语惊搐，六脉浮洪，腹痛吐泻，或二便秘涩，精神昏愦，痂疤赤紫，肢倦食少者，此有
余毒也。审其表里虚实而治之。然至痘后则内外俱虚，最要避寒暑以养其表，节饮
食以养其里。倘表里失调，营卫气逆，皆可成痈成疽，未可专以毒论。毒者，阴阳偏胜所致，岂真有形恶劣之
谓欤？又不可因虚而概用温补，盖 后原宜清解余毒。但不宜太用寒凉，盖气血大虚之后，寒多真寒，热多假
热，热去而寒易起也。至于痘未 痂未落之际，尤不可过用寒凉，盖未 之痘，不藉烧疤，何自而 ？未落之
痂，不藉阳和，何自而落？（冯楚瞻）
痘疮既 之后，或发痈肿，人固知为余毒矣。不知气高而喘息作声，掀胸抬肚者，余毒之在肺也；痰涎稠
粘，切牙戛齿，泄泻口臭者，余毒之在脾胃也；盗汗出于胸前，向午热渴者，余毒之在心包也；睡中多惊，身
常发热者，余毒之在肝也，耳叶与尻常热者，余毒之在肾也；眼合不开，身肿不消，壮热不清，郁郁不乐者，
诸经皆有余毒也。（翁仲仁）
痘后三大证者∶牙疳、鬼肿、目疾是也。牙疳十救五、六；鬼肿十死二、三；目疾虽非死证，防有终身之
患，故称大证。○牙疳，一日龈黑，二日齿动，三日齿落，其来最速，故谓之走马。○牙疳有失下者，有失清者。
大便实，少腹坚，不思食者为失下；能食而便调者为失清。失下者，胃有燥矢，仍须去之；失清者，轻则竹叶
石膏汤，重则犀角地黄汤。○牙疳在门牙者唇肿，在坐牙者腮肿。洗去臭秽，吹以敷药，肿消牙不落者易愈，
牙落肿不消者不治。○牙落无血，牙床如膻猪油者，用羊毛笔洗见鲜血，然后吹药。○吹药用人中白、孩儿茶
二味，箍住牙床，不使展开，自能固齿，硼砂化瘀消肿，冰片领诸药透骨。虽名家各有秘传，总不离此四味。
○牙疳与鬼肿，或与目疾齐发，先治牙疳，莫急于牙疳也。○鬼肿者，曲池漫肿，或在手，或在足，或手足齐肿，
或左右但肿一边，与他处发肿不同。未 之前发者，一面消肿，一面攻痘，令其瘟疤，则肿可消。若发于 后，
毒无从出，安有消理？故溃者十之八、九，间有一、二消者，犹是毒结之轻也。欲行消散之法，须是身热体壮，
按之坚而无头方可，内服散结汤，
外用敷药。若体虚肿熟，即宜参、 内托，外贴膏药。○鬼肿与痈疽同，色红而痛者，虽不能消，溃亦易收敛，
色白而不痛者，最主淹缠。○溃一处者易治；溃二处者难治；手足齐溃，脓出不收，不可为矣。○书云∶毒留
于肝则为目疾。亦不尽然。有痘在目珠，擦破而成障翳者；有目开迟，闭郁而成障翳者；有失解遗热者；有胞
肿而目珠无恙者。皆宜一一分治，不必早用点药。○痘在目，其灌与 ，亦犹在肤。在肤擦破则为瘟疤，四旁红
肿，须以时日，多服解毒之药，自能 脱而愈。目中擦破，亦犹在肤，其红肿有似障翳，非障翳也，亦宜清解
剂中加羚羊角，须以时日，自能解散。点洗之品，皆非所宜。○红肿障翳，痛涩羞明，先宜荆、防、羌活，火
郁发之，不愈，然后服羚角、龙胆。○赤涩久不愈者，宜滋肝肾，盖目得血而能视也。○痘后潮热，最为可嫌。
热退人静脉平，热来脉浮弦数大，有似标邪，实非外感，惟于养阴药中兼调胃气，可望渐平。若反复变乱，胃
气益伤，阴不能复，人渐枯瘦，有类疳劳，不可治矣。○痘后便血，瘀者宜清，鲜者宜养。不急治，下多则有
暴脱之患。○痘后浮肿，与风湿同治，则余毒自散，不可早用补剂。痘后鼻痒，用黄芩、山栀以清肺；齿痒，
用犀角、石膏以清胃；痘后发落，热伤血也，宜养阴；痘后无故齿落，而非牙疳者，肾虚也，六味地黄丸主之。
○后发痈者，何也？盖痘毒之出尽归疮窠，脓化而毒解，断无发痈之理。设当脓成毒化之时，不知松肌透肌之
法，或过用寒凉，毒凝肌肉之内，或纯用温补，热遏肤腠之间，至收 时，其儿元气壮，不得内攻，聚于腠理，
结而为痈也。脓未成者散结汤，脓已成者内托散。看其部分，以加引经。（《橡村痘诀》）
痂后病目，俗谓目中出痘。果痘也？胡不见根点成脓而遂结痂？古云∶热壅于肝则病目。确论也。（《慈幼筏》）
痘后余热不除，量其轻重而治之。大热则利小便，小热则解毒。盖利其小水，使心火有所导引，而余热自
无容留矣；小热宜
解毒者，盖小热不解，恐大热渐至矣。利小水宜导赤散，解毒宜犀角地黄汤。（徐东皋）
解余毒药，全以不伤胃气为主，平淡无奇，断不败事，如三豆饮之属。若金银花一味，本草称其解毒不寒，
余见脾胃虚弱者多服即泻，伍氏用连翘饮子，亦取平和。（叶天士）
半是由于表热而误用清里法。○塌陷的祸患也有两种：一半是因为痘疮过于阔大而不能充盈畅达，一半是因为泄泻导致中气下沉。○瘙痒塌陷的证候，是逐渐发展而成的；倒靫（痘疹内陷）的证候，则是突然发生的。○倒靫的证候，既然说是虚证，为什么会出现黑焦？出现黑焦，是因为毒邪结聚。元气虚弱，不能运化毒瓦斯，怎么能不凝结而成黑焦呢？○塌陷怎么会焦枯？塌陷只是虚证，所以不焦枯，不焦枯就可以施以温补。不焦枯的称为“陷”，焦枯的称为“黑陷”，总归属于里虚。但是白陷适宜温补，黑陷适宜清补。○痘疮本来难以灌浆，极力攻发，还唯恐其不足，一直追到第九天、第十天，然后才进行清利治疗，所以没有倒靫的祸患，只是瘟疤而已。（《橡村痘诀》）
瘟疤溃烂
后出的瘟疤，脓汁气味腥秽，余毒全部排泄出来，这是佳兆。如果在收靫时，遍身干枯且伴有潮热的，预后凶险。○臭烂的痘疮，毒邪虽然向外排泄，也能向内攻伐，必须患者能安卧且能进食，元气未败才可以。否则，还会有病情迁延变化。（《橡村痘诀》）
痘疮已经成脓，过了期限还不收靫，溃烂流脓，粘惹疼痛的，使用败草散，或者用荞麦粉装在绢袋里扑撒患处，更多地在布席上铺垫让患儿躺卧更好。（《证治准绳》）
斑烂
痘疮脓熟溃烂的，是常有的现象；如果未成脓就先溃破的，这名叫“斑烂”。由于病邪应当发散而没有发散，则毒瓦斯闭塞；不应当发散而误用发散，则热毒随阳气暴出，导致遍身皮肉溃烂。治疗应当调理脾胃增进饮食，安养营卫，生肌解毒。解毒不至于过冷，调养不至于过热，这才是良法。（万密斋）
痂不落
痂皮不落必定是痂下积脓，外表虽然结痂但中间实际稀溏，这是因为多吃了鲜发之物。无妨，采用清利收敛的方法，自然会脱落。也有干燥结着肉而不落的，这是血分有热。又宜清热养阴，来润泽它。（《橡村痘诀》）
痘痂日久，应当脱落却不脱落，位于胸背手足的，无妨。如果面部不脱落，应当用百花膏润之，让它快速脱落，拖延则变干硬，深入肌肉，遂成疤痕。然而长久不脱的，是脾胃虚弱所致。治疗宜用人参白术散，加黄芪、官桂，不可用手掐剥去除，恐怕损伤皮肤，再次感染成疮，反复溃烂，其后多变成疥癞。（万密斋）
疤痕
痘痕赤白，各有原因，治法也不同。凡是痕迹赤红且作痒的，是血虚有热，用四物汤加牡丹皮；赤红且作痛的，是余热，用四君子汤、连翘、金银花；如果发热但大便调畅的，是脾胃虚热，用异功散；发热且便秘的，是肠胃内热，用犀角地黄汤。○疤痕白色的，属于气虚而血衰，宜以固护元气为本，兼看变化的证候治疗。服药后渐渐转红润活络的可治，颜色不转变的不治。即使经过多年之后，也多因患泻利而死。○凡是疮疤黑暗的，恐怕之前未充分化脓，收靫太急，倒靫归肾所致。只要察其表里，如壮热大渴未除，烦闷昏睡少食，或大便不通，或自利的，这是真正的倒靫归肾；如果身体温和爽快，饮食渐增，大小便调畅的，这是疮疤的本色，无需担忧。（《证治准绳》）
痘后余毒
痘疮顺证，痘点稀疏，毒邪轻微，自然容易发出容易收靫，而无余毒；险证，痘点密集，毒邪旺盛，自然难出难收，而有餘毒；逆证，或者陷伏，或者倒靫，幸好依赖脾胃强健，调治及时，证候虽然痊愈，余毒未尽，发作成为疾病，多犯疥疮、痈肿、目赤，痘毒借此消除。所以凡是痂落而口不渴，身体无热，二便通调，腹部无痛楚，精神渐渐强壮，饮食渐渐增加，痂疤红润的，这是无余毒。如果身热而渴，谵语惊搐，六脉浮洪，腹痛吐泻，或二便秘涩，精神昏愦，痂疤赤紫，肢倦食少的，这是有余毒。审察其表里虚实而治疗。然而到了痘后阶段，内外俱虚，最要紧的是避寒暑以养护体表，节饮食以养护体内。倘若表里失调，营卫之气逆乱，都可形成痈疽，不可专门当作毒邪论治。毒邪，是阴阳偏胜所致，难道真有有形质的恶劣之物吗？又不可因为体虚就一概使用温补，因为痘后原本应当清解余毒。但不宜太过使用寒凉，因为气血大虚之后，寒症多属真寒，热症多属假热，热去而寒易起也。至于痘未收靫、痂未落之际，尤其不可过用寒凉，因为未收靫的痘，不依靠烧疤，怎么能够收靫？未落的痂，不依靠阳和之气，怎么能够脱落？（冯楚瞻）
痘疮既已收靫之后，或者发生痈肿，人们固然知道是余毒。不知道气喘声高，掀胸抬肚的，是余毒在肺；痰涎稠粘，切牙磨牙，泄泻口臭的，是余毒在脾胃；盗汗出于胸前，午后热渴的，是余毒在心包；睡中多惊，身体常发热的，是余毒在肝；耳叶与尾骶部常发热的，是余毒在肾；眼睛闭合不开，身体浮肿不消，壮热不清，郁郁不乐的，是诸经都有余毒。（翁仲仁）
痘后三大证候：牙疳、鬼肿、眼疾是也。牙疳十人能救五、六人；鬼肿十人死二、三人；眼疾虽然不是死证，但防备有终身之患，所以称大证。○牙疳，第一天牙龈发黑，第二天牙齿松动，第三天牙齿脱落，来得最快，所以叫走马牙疳。○牙疳有失于攻下的，有失于清热的。大便实，小腹胀满坚硬，不思食的为失下；能食而大便调畅的为失清。失下的，胃中有燥屎，仍须去除；失清的，轻则用竹叶石膏汤，重则用犀角地黄汤。○牙疳长在门牙的嘴唇肿，长在臼齿的脸颊肿。洗去臭秽，吹敷药物，肿消牙不落的易愈，牙落肿不消的不治。○牙落无血，牙床像膻猪油的，用羊毛笔清洗见到鲜血，然后吹药。○吹药用牛黄、孩儿茶两味药，箍住牙床，不让展开，自然能固齿，硼砂化瘀消肿，冰片引领诸药透骨。虽然是名家各有秘传，总离不开这四味药。○牙疳与鬼肿，或与眼疾齐发，先治牙疳，没有比牙疳更紧急的了。○鬼肿，曲池穴处漫肿，或在手，或在足，或手足齐肿，或左右只肿一边，与其他地方发肿不同。在未收靫之前发的，一面消肿，一面攻痘，令其出瘟疤，则肿可消。如果发于收靫之后，毒无从排出，哪有消散的道理？所以溃烂的占十分之八、九，间有一、二个消散的，还是毒结较轻的缘故。欲行消散之法，必须是身热体壮，按之坚硬而无头才可以，内服散结汤，外用敷药。如果体虚肿软，即宜用人参、黄芪内托，外贴膏药。○鬼肿与痈疽相同，色红而痛的，虽然不能消散，溃烂也容易收敛，色白而不痛的，最主缠绵难愈。○溃一处者易治；溃两处者难治；手足齐溃，脓出不收，不可救治了。○书云：毒留于肝则为眼疾。也不尽然。有痘长在目珠，擦破而成障翳的；有目开迟，闭郁而成障翳的；有失于解表遗留热邪的；有眼睑肿而目珠无恙的。都应当一一分治，不必早用点眼药。○痘长在目珠，其灌浆与收靫，也像在皮肤一样。在皮肤擦破则为瘟疤，四周红肿，须要时日，多服解毒的药物，自然能收靫脱落而愈。眼中擦破，也像在皮肤，其红肿有似障翳，并非障翳，也宜在清解剂中加入羚羊角，须要时日，自然能解散。点洗的药物，都不适宜。○红肿障翳，痛涩羞明，先宜用荆芥、防风、羌活，火郁发之，不愈，然后服用羚羊角、龙胆草。○赤涩久不愈的，宜滋补肝肾，因为眼睛得到血液滋养才能视物。○痘后潮热，最为可嫌。热退人脉象平和，热来脉象浮弦数大，有似标邪，实则非外感，只在养阴药中兼调胃气，可望渐渐平复。如果反复变乱，胃气益伤，阴液不能恢复，人渐渐枯瘦，有类疳劳，不可治了。○痘后便血，瘀血的宜清，鲜红的宜养。不急于治疗，下血过多则有暴脱的祸患。○痘后浮肿，与风湿同治，则余毒自散，不可早用补剂。痘后鼻痒，用黄芩、山栀以清肺；齿痒，用犀角、石膏以清胃；痘后头发脱落，是热伤血所致，宜养阴；痘后无故牙齿脱落，而非牙疳的，是肾虚，六味地黄丸主治。○后来发痈的，为什么呢？大概痘毒的排出全部归于疮窠，脓化而毒解，断无发痈的道理。假设正当脓成毒化之时，不知松肌透肌的方法，或过用寒凉，毒凝肌肉之内，或纯用温补，热遏肤腠之间，到收靫时，小儿元气壮盛，不得内攻，聚于腠理，结而为痈。脓未成的用散结汤，脓已成用的内托散。看其部位，加入引经药。（《橡村痘诀》）
痂后病目，俗谓目中出痘。果真是痘吗？何不看见根部点成脓而随即结痂？古云：热壅于肝则病目。确实是确论。（《慈幼筏》）
痘后余热不除，衡量其轻重而治疗。大热则利小便，小热则解毒。因为利其小便，使心火有所导引，而余热自然无处容留；小热宜解毒的，因为小热不解，恐怕大热渐至。利小便宜用导赤散，解毒宜用犀角地黄汤。（徐东皋）
解余毒药，全以不伤胃气为主，平淡无奇，断不会败事，如三豆饮之类。若金银花一味，本草称其解毒不寒，我见脾胃虚弱者多服即泻，伍氏用连翘饮子，也是取平和之意。（叶天士）
Partly due to exterior heat, the interior was mistakenly cleared. ○ There are two causes for collapse (sunken pustules): partly because the pustules are too broad and cannot fill out smoothly, and partly because diarrhea causes the middle Qi to sink. ○ The syndrome of itching and collapse develops gradually; the syndrome of Dao Cha (inverted scabs/pustules) occurs suddenly. ○ Regarding the syndrome of Dao Cha, if it is said to be deficiency, why does it turn black and scorched? Black and scorched indicates toxin accumulation. When Yuan Qi (original Qi) is deficient and unable to transform and transport toxins, how can it not coagulate into a black and scorched state? ○ Why would collapse not be scorched? Collapse is merely deficiency, thus it is not scorched; since it is not scorched, warm tonification can be applied. Non-scorched is called "Xian" (depression/collapse), while scorched is called "Hei Xian" (black depression); both belong to interior deficiency. However, white depression is suitable for warm tonification, while black depression is suitable for clear tonification. ○ Pustules are inherently difficult to fill with pus. By vigorously attacking and expelling, fearing insufficiency, one may pursue this until the ninth or tenth day before employing clearing and draining methods. Thus, there is no risk of Dao Cha, only epidemic pox scars. (from *Xiangcun Dou Jue*)
Epidemic Pox Scars Ulcerating
Later-appearing epidemic pox scars with foul-smelling pus indicate that residual toxins are fully discharged, which is a good omen. If during the scabbing stage, the whole body becomes dry and withered accompanied by tidal fever, the prognosis is ominous. ○ For foul and rotting pustules, although toxins are discharged externally, they can also attack internally. Treatment is permissible only if the patient can lie quietly and eat, and their Yuan Qi remains intact. Otherwise, complications may arise. (from *Xiangcun Dou Jue*)
When smallpox pustules have formed pus but fail to scab past the expected time, leading to ulceration with dripping pus and adhesive pain, use Baicao San (Decoction of Rotten Grass) or sprinkle Buckwheat Flour (*Fagopyri Tatarici Semen*) stored in a silk bag on the affected area. Lying on cloth mats covered with more material is even better. (from *Zhengzhi Zhunsheng*)
Ban Lan (Spots and Ulceration)
Pustules ripening and ulcerating is a common occurrence; however, if they ulcerate before forming pus, it is named "Ban Lan." This occurs when pathogenic factors should have been dispersed but were not, causing toxin stagnation; or when dispersion was erroneously used when inappropriate, causing heat toxins to burst forth with Yang Qi, resulting in widespread skin and flesh ulceration. Treatment should regulate the spleen and stomach to promote appetite, nourish Ying and Wei (nutritive and defensive Qi), generate flesh, and detoxify. Detoxification should not be too cold, and nourishment should not be too hot; this constitutes a good method. (Wan Mizhai)
Scabs Not Falling Off
If scabs do not fall off, there must be pus beneath them; although the surface appears crusted, the center is actually soft and loose, often caused by consuming too many fresh, stimulating foods. This is harmless; using clearing, draining, and astringent methods will allow natural shedding. In cases where scabs adhere tightly to the flesh without falling off, it is due to heat in the blood level. Clearing heat and nourishing Yin to moisten the area is appropriate. (from *Xiangcun Dou Jue*)
If smallpox scabs remain for a long time without falling off, those on the chest, back, hands, and feet are harmless. However, if facial scabs do not fall off, apply Baihua Gao (Hundred Flowers Ointment) to moisturize them for rapid shedding; delay leads to dryness and hardness, penetrating deep into muscles and leaving scars. Persistent non-shedding is due to spleen and stomach deficiency. Treatment should use Renshen Baizhu San (Ginseng and Atractylodes Macrocephala Decoction) supplemented with Huangqi (Astragalus Root) and Guigui (Cinnamon Bark). Do not pick or peel them off manually, as this may damage the skin, cause reinfection, recurrent ulceration, and eventually lead to scabies-like conditions. (Wan Mizhai)
Scars
Red and white smallpox scars have different causes and require different treatments. Red scars that itch indicate blood deficiency with heat; treat with Siwu Tang (Four Substances Decoction) plus Mudanpi (Moutan Cortex). Red scars that hurt indicate residual heat; treat with Sijunzi Tang (Four Gentlemen Decoction), Lianqiao (Forsythia Fruit), and Yinhua (Honeysuckle Flower). Fever with normal bowel movements indicates spleen-stomach deficiency heat; treat with Yigong San (Extraordinary Power Powder). Fever with constipation indicates internal heat in the intestines and stomach; treat with Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction). ○ White scars indicate Qi deficiency and blood decline; the root treatment should consolidate Yuan Qi, adjusting for varying symptoms. If the color gradually turns red and vibrant after medication, it is treatable; if the color does not change, it is untreatable. Even years later, death often results from diarrhea. ○ Dark scars suggest insufficient pus formation earlier, premature scabbing, or Dao Cha returning to the Kidney. Examine the exterior and interior: if high fever, extreme thirst, restlessness, drowsiness, poor appetite, constipation, or spontaneous diarrhea persist, this is true Dao Cha returning to the Kidney. If the body is warm and comfortable, appetite increases, and excretions are regular, these are the natural colors of healing scars, requiring no worry. (from *Zhengzhi Zhunsheng*)
Residual Toxins After Smallpox
In smooth smallpox cases, sparse pustules and mild toxins allow easy eruption and resolution without residual toxins. In dangerous cases, dense pustules and strong toxins make eruption and resolution difficult, leading to residual toxins. In adverse cases, characterized by sinking or inverted scabs, recovery depends on strong spleen-stomach function and early treatment. Although the acute phase resolves, incomplete toxin clearance may manifest as sores, carbuncles, or red eyes, allowing the smallpox toxin to be eliminated. Therefore, if scabs have fallen, the mouth is not dry, the body has no fever, urination and defecation are regular, the abdomen is painless, spirit is strengthening, appetite is increasing, and scabs are red and lustrous, there are no residual toxins. Conversely, fever with thirst, delirium, convulsions, floating and surging pulses, abdominal pain, vomiting/diarrhea, constipation or difficult urination/defecation, mental confusion, purple-red scabs, limb fatigue, and poor appetite indicate residual toxins. Treat based on exterior/interior and deficiency/excess. Since both interior and exterior are depleted post-smallpox, avoiding cold and heat to nourish the exterior, and moderating diet to nourish the interior are paramount. Imbalance of exterior/interior and reversal of Ying and Wei Qi can lead to carbuncles and ulcers; do not attribute everything solely to toxins. Toxins result from Yin-Yang imbalance, not necessarily tangible evil substances. Do not indiscriminately use warm tonics due to deficiency; rather, clear residual toxins appropriately. Avoid excessive cold herbs, as post-deficiency states often feature true cold and false heat; clearing heat may trigger cold. During the pre-scabbing and pre-scab-falling stages, avoid excessive cold herbs, as un-resolved pustules need scabbing to heal, and un-fallen scabs need Yang warmth to shed. (Feng Chuzhan)
After smallpox scabs form, carbuncles may appear, known as residual toxins. High-pitched breathing with audible wheezing and chest/abdominal distension indicates lung involvement. Thick sticky phlegm, teeth grinding, diarrhea, and bad breath indicate spleen-stomach involvement. Night sweats on the chest and afternoon fever/thirst indicate pericardium involvement. Frequent startles during sleep and constant low-grade fever indicate liver involvement. Heat in the ears and sacrum indicates kidney involvement. Closed eyes, persistent edema, unremitting high fever, and melancholy indicate residual toxins in all meridians. (Weng Zhongren)
The three major post-smallpox syndromes are Gangrene of the Gums (Yagan), Ghost Swelling (Guizhong), and Eye Diseases. Yagan has a 50-60% survival rate; Guizhong has an 80-90% mortality rate; eye diseases, though not usually fatal, carry lifelong risks, hence termed "major syndromes." ○ Yagan progresses rapidly: black gums on day one, loose teeth on day two, tooth loss on day three, hence called "Running Horse" gangrene. ○ Yagan results from missed purgation or missed clearing. Constipation, lower abdominal hardness, and anorexia indicate missed purgation; eating well with normal stools indicates missed clearing. Missed purgation requires removing dry feces; missed clearing requires Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction) for mild cases or Xijiao Dihuang Tang for severe cases. ○ Yagan on incisors causes lip swelling; on molars, cheek swelling. Clean foul matter, apply medicated powder. If swelling subsides but teeth remain, it heals easily; if teeth fall and swelling persists, it is incurable. ○ If teeth fall without bleeding and gums resemble mutton fat, clean with a sheep-hair brush until fresh blood appears, then apply powder. ○ Medications include Renzhongbai (Calcinis Os Humanum) and Haiercha (Camellia Seed Tea) to bind the gums, Pengsha (Borax) to resolve stasis and reduce swelling, and Bingpian (Borneolum Syntheticum) to guide drugs into bones. These four ingredients are central to all expert prescriptions. ○ If Yagan, Guizhong, and eye disease occur together, treat Yagan first as it is most urgent. ○ Guizhong presents as diffuse swelling at Quchi (LI11), affecting hands, feet, or one side. If appearing before scabbing, simultaneous swelling reduction and smallpox promotion can resolve it. If appearing after scabbing, toxins have no exit, making resolution unlikely; 80-90% ulcerate, 10-20% resolve if toxin accumulation is light. For resolution therapy, the patient must have fever, strength, and firm swelling without a head; use Sanjie Tang (Dispersal Knot Decoction) internally and external applications. For weak patients with soft swelling, use Renshen (Ginseng) and Huangqi (Astragalus) for internal support and external plasters. ○ Like carbuncles, red painful Guizhong ulcerates and heals easily; white painless Guizhong is chronic. ○ Single-site ulceration is easy to treat; double-site is difficult; multi-site with non-healing discharge is incurable. ○ Texts state toxins in the Liver cause eye disease, but this is not absolute. Corneal abrasions from scratching cause opacities; delayed eye opening causes closure-related opacities; unresolved heat causes issues; eyelid swelling without globe involvement is distinct. Treat each separately; avoid early eye drops. ○ Smallpox on the eyeball follows similar filling/scabbing rules as skin. Scratching causes scar-like redness; treat with prolonged detoxification. Eyeball scratches mimic opacities but are not; add Lingyangjiao (Saiga Antelope Horn) to clearing formulas. Prolonged treatment allows resolution; washes/drops are unsuitable. ○ For red/swollen opacities with pain/light sensitivity, use Jingjie (Schizonepeta), Fangfeng (Saposhnikovia), and Qianghuo (Notopterygium) to vent fire; if ineffective, use Lingyangjiao and Longdancao (Gentiana Root). ○ Chronic redness/astringency requires nourishing Liver/Kidney, as vision depends on blood. ○ Post-smallpox tidal fever is problematic. Pulse normalizes when fever breaks; when fever returns, pulse is floating/wiry/rapid/large, mimicking exterior pathogens but being internal. Nourish Yin and regulate Stomach Qi for gradual recovery. Recurrent chaos damages Stomach Qi and Yin, leading to emaciation resembling consumption, which is incurable. ○ Post-smallpox hematochezia: clear stasis for dark blood, nourish for bright red blood. Untreated heavy bleeding risks sudden collapse. ○ Post-smallpox edema treats like wind-dampness to disperse toxins; avoid early tonics. Post-smallpox nasal itch clears Lung with Huangqin (Scutellaria Root) and Shanzhi (Gardenia Fruit); tooth itch clears Stomach with Xijiao (Rhinoceros Horn - substitute with water buffalo horn clinically) and Shigao (Gypsum); hair loss indicates heat damaging blood, requiring Yin nourishment;无故 tooth loss (non-gangrene) indicates Kidney deficiency, treated with Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia). ○ Carbuncles post-smallpox occur when toxins concentrate in pustules. If pus forms and toxins resolve, no carbuncles should appear. If mistaking timing, using excessive cold (trapping toxins in muscle) or pure warm tonics (trapping heat in pores), and the child's strong Qi prevents internal attack, toxins accumulate in interstices forming carbuncles. Pre-pus: Sanjie Tang; Post-pus: Neituo San (Internal Support Powder). Add meridian-guiding herbs based on location. (from *Xiangcun Dou Jue*)
Eye disease after scabbing is colloquially called "smallpox in the eye." Is it truly smallpox? One should observe roots forming pus and scabbing. Ancient texts state: "Heat congesting the Liver causes eye disease," which is accurate. (from *Ciyou Fa*)
For lingering residual heat post-smallpox, treat based on severity. High fever requires promoting urination; low fever requires detoxification. Promoting urination guides Heart Fire away, eliminating residual heat. Low fever requires detoxification to prevent progression to high fever. Use Daochi San (Guide Out the Red Powder) for urination and Xijiao Dihuang Tang for detoxification. (Xu Donggao)
Formulas for clearing residual toxins must prioritize protecting Stomach Qi. Mild, unremarkable formulas like Sandou Yin (Three Beans Decoction) are safe. Jinnyinhua (Honeysuckle Flower) is described in Materia Medica as non-cold, but I have observed it causing diarrhea in patients with weak spleen/stomach. Wu Shi's Lianqiao Yin Zi (Forsythia Drink) is also chosen for its mild nature. (Ye Tianshi)