一曰内虚泄泻二曰外伤风冷三曰变黑归肾盖内虚泄泻者或因脏腑怯弱其证已逆初发以来
自然
作泄或未发之前误服凉药以致泻下凡此者其疮不发每形见红小点而白或白而微黄如水泡之状
治之当用参苓白术散南木香煎汤调下先与止泻然后以温和之剂发之外伤风冷者或因烦躁恶寒
出头露面点点方萌遽为风冷所拆或疮出如珠妄为解脱以取冷快而风冷袭之凡此者轻则其状如
螫色红而不发重则陷如石臼脚色白而不软治之当温血散寒邪用不换金正气散加川芎若恶寒隈
人更加官桂紫苏然后与发之剂或内虚泄泻或外伤风冷荏苒经日胃气虚损由是而变坏焉致令耳
反热青紫变黑此则肾证晓然矣盖肾属北方水是以其色黑其证逆治法先泻膀胱之府而后急与
温脾若其疮不黑则断非肾证谨不可下请详审之泻膀胱法先用桂枝芍药大戟等分为末每服一钱
枣汤调下次用宣风散一钱加青皮煎服若泻下恶物急与温脾汤剂继之疮痘为阴邪秽气所伤亦令
变坏可用醋炭苏合香丸解之
凡小儿痘疮已发并与紫草饮但觉身热证似伤寒若未见疮疑似未明且先与惺惺散参苏饮或
人参
羌活辈热甚则与升麻汤恐发得表虚也若初出时身热鼻尖冷呵欠咳嗽面赤方是痘出之候便宜服
升麻葛根汤加山楂大力子其疮疏稀而易愈若初出时或未见时宜以丝瓜近蒂三寸连瓜子烧灰存
性为末蜜水调服或砂糖拌干入朱砂末亦可多者可减少者可无初出时须着胸前若稠密急须消毒
饮加山楂黄芩酒洗紫草减食加人参初发热之时便以恶实子为末蜜调贴囟上免有患眼之疾若初
起时自汗不妨盖湿热熏蒸而然也
凡痘疮须分表里虚实而治若吐泻少食为里虚不吐泻欲食为里实里实而补则结痈毒陷入倒
靥为
表虚灰白者亦表虚红活绽凸为表实表实而复补则溃烂不结痂痒塌者于形色上分虚实实则脉有
力气壮虚则脉无力虚痒以实表之剂加凉血药实痒如大便不通者以大黄寒凉之药少与之下其结
粪
凡痘疮须分气虚血虚用药气虚者人参白术加解
毒药血虚者以四物汤中加解毒药痘出时多常气血不足虚则黄 生血活血剂助之略佐以风药实
则白芍药为君黄芩亦为君佐以白芷连翘续断之类黑属血热凉血为主白属气虚补气为主初出时
色白者便大补气血参术 芎升麻干葛甘草木香丁香酒洗当归白芍药若大便泻加诃子肉豆蔻黑
陷二种因气虚而毒瓦斯不能尽出者酒炒黄 紫草人参辈
出太甚者人参败毒散犀角地黄汤疏则无毒密则有毒宜凉药解之虽数帖亦不妨无害眼之患
炉灰色
白静者作寒看齐勇者 发者作热看全白色将靥时如豆壳者盖因初起时饮水多其靥不齐俗呼倒
靥不好但服实表之剂消化他大小便如大便秘通大便小便秘通小便小便赤涩者大连翘汤甘露饮
大便秘结内烦外热者小柴胡汤加枳壳取当或少少四顺清凉饮
颜色正者不须服药将欲成就却色淡者宜助血药用当归川芎酒洗芍药之类或加红花将成就
之际
却紫色者属热用凉药解其毒升麻葛根酒炒黄芩黄连及连翘之类甚者犀角大解痘毒疮干者宜退
火止用轻剂荆芥升麻葛根之类疮湿者用泻湿乃
肌表间湿宜用风药白芷防风之类咽痛者大如圣散鼠粘子汤喘满气壅者麻黄黄芩汤烦渴者甘草
散乌梅汤下痢呕吐者木香汤理中汤
钱氏曰黑陷青紫者百祥丸下之不黑者谨勿下余知其所下者泻膀胱之邪也小儿肾主虚不可
泻但
泻其膀胱以虚其腑则肾邪去矣又云下后身热气温欲饮水者可治水谷不消或寒战为逆余知其脾
强者土可以制水也泻后温脾则人参茯苓白术等分浓朴木香甘草各炒为妙盖疮发肌肉阳明主之
脾土一温胃气随畅独不可消胜已泄之肾水乎此钱氏不刊之妙旨也
大小二便不可不通其有大便自调所下黄黑则毒瓦斯已减不必多与汤剂但少用化毒汤可也大
小二腑一或闭焉则肠胃壅塞脉络凝滞毒瓦斯无从而发泄眼闭声哑肌肉黧黑不旋踵而告变矣
凡痘疮属虚寒者直可延至十数日后方死属毒盛转紫者不过七八日盖胎毒自内出外一二三
日方
出齐毒瓦斯尚在内出至六日则当尽发于表七八九日成脓而结痂矣若毒瓦斯盛不能尽出过六日毒反
入脏腑故须于六
日以前毒瓦斯该出之时急服凉血解毒之药以驱出之六日以后医无及矣故其死最急若虚弱毒瓦斯少
者只是气血不足不能贯脓成就故绵延日久而死此虚实轻重之分也若痘疮多者是毒瓦斯多便先宜
解毒然多则恐气血周贯不足故随后亦宜兼补药以助成脓血也
凡痘疮已出后而有声音者乃形病气不病也未出先声音不出者乃形不病而气病也若痘疮出
而声音不出者是形气俱病也当清其肺宜用八风汤并凉膈散去硝黄
第一种情况是内虚导致的泄泻，第二种是外感风冷，第三种是痘疮变黑归肾。所谓内虚泄泻，是因为脏腑虚弱，病情已经逆转。从发病初期开始自然出现腹泻，或者在出痘之前误服寒凉药物导致腹泻。凡是这种情况，痘疮往往不发，只见到红小点，颜色发白或微黄，像水泡一样。治疗时应当使用参苓白术散，用南木香煎汤调服，先止住腹泻，然后用温和的药物发散邪气。
外感风冷的情况，是因为患儿烦躁、恶寒，刚露出头脸，痘疹刚刚萌芽，突然被风冷侵袭；或者痘疮发出如珠状，为了贪图凉爽而解开衣物，导致风冷乘虚而入。凡是这种情况，轻则痘疹颜色发红但不发透，重则痘疮凹陷像石臼底，颜色发白且不柔软。治疗应当温血散寒邪，使用不换金正气散加川芎。如果恶寒严重，再加官桂、紫苏，然后给予发散药物。无论是内虚泄泻还是外感风冷，拖延日久，胃气受损，从而导致病情恶化，致使耳朵反热、青紫变黑，这就是明显的肾证了。因为肾属北方水，所以其色黑，病情逆乱。治疗方法是先泻膀胱之腑，然后紧急温补脾土。如果痘疮不黑，就断定不是肾证，切记不可攻下，请仔细审察。泻膀胱的方法：先用桂枝、芍药、大戟等分研末，每次服用一钱，用枣汤调服；接着用宣风散一钱加青皮煎服。如果泻下恶臭之物，紧接着给予温脾汤剂。痘疮被阴邪秽气所伤也会变坏，可用醋炭熏蒸和苏合香丸来解毒。
凡是小儿痘疮已经发出，都给予紫草饮。只要觉得身体发热，症状像伤寒，但如果还没看到痘疹，疑似不明，且先给予惺惺散、参苏饮或人参、羌活类药物。如果热势很盛，则给予升麻汤，恐怕会导致表虚。如果在初出时身体发热、鼻尖冷、打呵欠、咳嗽、面赤，这才是痘出的征兆，适宜服用升麻葛根汤加山楂、牛蒡子。痘疮稀疏容易痊愈。如果在初出时或未见时，适宜取丝瓜近蒂三寸，连同瓜子烧灰存性，研为细末，用蜜水调服，或者拌砂糖干服，加入朱砂末也可以。痘多者可以减少，痘少者可以不用。初出时必须保护胸前部位。如果痘疮稠密，急需服用消毒饮，加山楂、黄芩（酒洗）、紫草，减少饮食，加入人参。在初发热之时，便将恶实子研末，用蜜调匀贴敷囟门，以免发生患眼的疾病。如果初起时有自汗，不妨碍，这是湿热熏蒸所致。
凡是痘疮必须分清表里虚实来治疗。如果呕吐腹泻、食欲不振，属于里虚；如果不吐不泻、想要进食，属于里实。里实证如果误用补法，则会结成痈毒，陷入倒靥（痘疮塌陷）。如果是灰白色的，也属于表虚；如果是红活绽凸的，属于表实。表实证如果误用补法，则会溃烂不结痂。瘙痒塌陷者，要从形色上分辨虚实。实证脉象有力且壮实，虚证脉象无力。虚痒用实表剂加上凉血药；实痒如大便不通者，用大黄等寒凉药物少量给予以通结粪。
凡是痘疮必须分清气虚血虚来用药。气虚者用人参、白术加上解毒药；血虚者在四物汤中加入解毒药。痘出时大多气血不足，虚证用生血活血剂辅助，略微佐以风药。实证则以白芍药为君药，黄芩也为君药，佐以白芷、连翘、续断之类。黑色属于血热，以凉血为主；白色属于气虚，以补气为主。初出时颜色白的，便大补气血，用人参、白术、川芎、升麻、干葛、甘草、木香、丁香（酒洗）、当归、白芍药。如果大便泻，加诃子肉、肉豆蔻。黑陷两种情况，因气虚而毒瓦斯不能尽出者，用酒炒黄芪、紫草、人参之类。出得太甚者，用人参败毒散、犀角地黄汤。稀疏则无毒，稠密则有毒素，宜用凉药解之，虽然连续服用几帖也无妨。炉灰色白且安静者，视为寒证；齐整发亮者，视为热证。全白色即将收靥时，像豆壳一样的，是因为初起时饮水过多，导致收靥不齐，俗称倒靥，不好。但服用实表剂消化它。大小便方面，如大便秘结、通大便；小便秘结、通小便；小便赤涩者，用大连翘汤、甘露饮。大便秘结、内烦外热者，用小柴胡汤加枳壳，取效即可，或少量服用四顺清凉饮。
颜色正常者不需要服药。将要成就时却颜色淡者，宜助血药，用当归、川芎（酒洗）、芍药之类，或者加红花。将成就之际却呈紫色者，属于热，用凉药解其毒，用升麻、葛根、酒炒黄芩、黄连及连翘之类。严重者用犀角大解痘毒。疮干燥者宜退火，只用轻剂荆芥、升麻、葛根之类。疮湿润者用泻湿之法，那是肌表间的湿气，宜用风药白芷、防风之类。咽痛者用大如圣散、鼠粘子汤。喘满气壅者用麻黄黄芩汤。烦渴者用甘草散，乌梅汤送服。下痢呕吐者用木香汤、理中汤。
钱乙说：黑陷青紫者，用百祥丸攻下；不黑的切记不可攻下。我知道他所攻下的是泻除膀胱的邪气。小儿肾主虚，不可直接泻肾，但可以通过泻其膀胱使其腑气虚，从而去除肾邪。又说：攻下后身体发热、体温温和、想喝水的，可以治水谷不消；或者寒战，这是逆证。我知道这是因为脾强，土可以制水。泻后用温脾汤，则人参、茯苓、白术等分，厚朴、木香、甘草各炒过为妙。盖痘疮发于肌肉，由阳明经主司，脾土一旦温暖，胃气随之通畅，难道不能消除已经泄露的肾水吗？这是钱乙不可刊印的妙旨啊。
大小二便不可不通。如果有大便自行调和，所下为黄黑色，则毒瓦斯已减，不必多给汤剂，只需少量使用化毒汤即可。大小二腑一旦闭塞，则肠胃壅塞，脉络凝滞，毒瓦斯无从发泄，眼睛闭合、声音嘶哑、肌肉黧黑，转瞬之间就会发生变化。
凡是痘疮属于虚寒的，可以直接拖延到十几天后才死；属于毒盛转紫的，不过七八天。胎毒从内向外发，一二三天才出齐，毒瓦斯还在内部，出至第六天则应当全部发于体表，第七八九天成脓而结痂。如果毒瓦斯盛不能尽出，过了六天毒反而入脏腑，所以必须在六日以前毒瓦斯该出的时候，急服凉血解毒之药以驱出它。六日以后医生就无能为力了，所以死亡最急迫。如果虚弱、毒瓦斯少者，只是气血不足，不能贯脓成就，所以绵延日久而死。这是虚实轻重的区别。如果痘疮多，是毒瓦斯多，便先宜解毒，然而多则恐怕气血周贯不足，所以随后也宜兼用补药以助成脓血。
凡是痘疮已出后有声音的，是形病而气未病；未出前先声音不出，是形不病而气病。如果痘疮出了而声音不出，是形气俱病，当清其肺，适宜用八风汤并凉膈散去硝黄。
The first condition is diarrhea due to internal deficiency; the second is external contraction of wind and cold; the third is the eruption turning black and returning to the Kidney. Regarding diarrhea due to internal deficiency, it arises from weak Zang-Fu organs, indicating a reversal of the disease pattern. From the onset, diarrhea occurs naturally, or it results from mistakenly administering cooling medicines before the eruption appears. In such cases, the eruptions fail to emerge, presenting only as small red spots that are white or slightly yellow, resembling blisters. Treatment should employ Shen Ling Bai Zhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder), administered with Nan Mu Xiang (Southern Cyperus) decoction to stop the diarrhea first, followed by mild agents to vent the pathogen.
Regarding external contraction of wind and cold, it occurs when the child is restless and aversive to cold, exposing their head and face while the papules are just emerging, suddenly being attacked by wind and cold; or when the eruptions appear like beads, and for the sake of cooling comfort, clothing is loosened, allowing wind and cold to invade. In mild cases, the lesions are red but do not fully erupt; in severe cases, they sink like the bottom of a stone mortar, appearing white and soft. Treatment requires warming the blood and dispersing cold pathogens using Bu Huan Jin Zheng Qi San (Golden Exchange Harmonizing the Upright Qi Decoction) plus Chuan Xiong (Ligusticum). If aversion to cold is severe, add Guan Gui (Cinnamon Bark) and Zi Su (Perilla Leaf), then administer venting agents. Whether due to internal deficiency diarrhea or external wind-cold contraction, if prolonged, the Stomach Qi becomes damaged, leading to deterioration. The ears may become hot, cyanotic, and black, clearly indicating a Kidney syndrome. Since the Kidney belongs to Water in the North, its color is black, and the prognosis is adverse. The treatment method is to first drain the Bladder Fu organ, then urgently warm the Spleen. If the eruptions are not black, it is definitely not a Kidney syndrome; caution against purgation is essential. To drain the Bladder: first, use equal parts of Gui Zhi (Cinnamon Twig), Shao Yao (White Peony Root), and Da Ji (Euphorbia Lathyris) powdered, taking one qian per dose with Jujube decoction; subsequently, take Xuan Feng San (Promoting Wind Powder) one qian with Qing Pi (Tangerine Peel) decocted. If foul matter is discharged, follow immediately with Wen Pi Tang (Warming the Spleen Decoction). Eruptions damaged by Yin pathogens and turbid qi can also deteriorate; vinegar-charred fumes and Su He Xiang Wan (Styrax Pill) can be used to resolve toxicity.
For pediatric smallpox/chickenpox that has already erupted, Zi Cao Yin (Arnebiae Decoction) is generally given. If fever is present with symptoms resembling Taiyang disease (Exterior Syndrome), but eruptions are not yet visible and diagnosis is uncertain, initially administer Xing Xing San (Wonderful Powder), Shen Su Yin (Ginseng and Perilla Decoction), or Ren Shen (Ginseng) and Qiang Huo (Notopterygium). If heat is intense, use Sheng Ma Tang (Ephedra Decoction), fearing exterior deficiency. If at the initial stage there is fever, a cold nose tip, yawning, coughing, and facial redness, these are signs of eruption; Sheng Ma Ge Gen Tang (Ephedra and Kudzu Decoction) added with Shan Zha (Hawthorn) and Niu Bang Zi (Arctii Fructus) is appropriate. Sparse eruptions heal easily. At the initial or pre-eruption stage, take three cun of Si Gua (Luffa Fruit) near the stem, including seeds, burn to ash preserving nature, powder it, and mix with honey water, or mix with sugar and Cinnabar powder. For numerous eruptions, reduce dosage; for few, omit. Protect the chest during initial eruption. If dense, urgently use Xiao Du Yin (Detoxification Decoction) added with Shan Zha, Huang Qin (Scutellaria root washed with wine), Zi Cao, reduce diet, and add Ren Shen. At the onset of fever, apply Orealis seed powder mixed with honey to the anterior fontanelle to prevent eye complications. Spontaneous sweating at the onset is acceptable, caused by damp-heat steaming.
Treatment of eruptions must distinguish between Exterior/Interior and Deficiency/Excess. Vomiting, diarrhea, and poor appetite indicate Interior Deficiency; no vomiting/diarrhea and desire to eat indicate Interior Excess. Tonifying Interior Excess leads to carbuncles and inverted crusts (inverted scabbing). Ash-white color indicates Exterior Deficiency; red, vibrant, and convex color indicates Exterior Excess. Tonifying Exterior Excess leads to ulceration without scabbing. Itching and collapsing require differentiation by form and color. Excess presents with strong, robust pulse; Deficiency with weak pulse. Deficient itching is treated with exterior-firming agents plus blood-cooling herbs; excess itching with constipation is treated with minor doses of Da Huang (Rhubarb) and other cooling purgatives to unblock stool.
Medication must distinguish Qi Deficiency and Blood Deficiency. Qi Deficiency uses Ren Shen and Bai Zhu with detoxifying herbs; Blood Deficiency uses Si Wu Tang (Four Substances Decoction) with detoxifying herbs. Most eruptions involve Qi and Blood insufficiency; deficiency is aided by blood-generating and activating agents with slight wind-dispersing herbs. Excess uses Bai Shao (White Peony Root) as the sovereign herb, Huang Qin as minister, assisted by Bai Zhi (Angelica Dahurica), Lian Qiao (Forsythia), and Xu Duan (Dipsacus). Black color indicates Blood Heat, prioritizing blood cooling; white color indicates Qi Deficiency, prioritizing Qi tonification. Initial white color warrants major Qi and Blood tonification: Ren Shen, Bai Zhu, Chuan Xiong, Sheng Ma, Gan Jiang, Gan Cao, Mu Xiang, Ding Xiang (wine-washed), Dang Gui, Bai Shao. Add He Zi Rou (Terminalia Chebula pulp) and Dou Kou (Cardamom) for diarrhea. Two types of black sinking due to Qi deficiency preventing toxin expulsion are treated with wine-fried Huang Qi (Astragalus), Zi Cao, and Ren Shen. Severe over-emergence uses Ren Shen Bai Du San (Ginseng Detoxification Powder) and Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction). Sparse eruptions lack toxicity; dense ones have toxicity, requiring cooling resolution; multiple doses are safe. Gray-white and quiet eruptions indicate Cold; bright and uniform eruptions indicate Heat. All-white eruptions resembling bean shells during crusting result from excessive water intake early on, causing uneven scabbing (inverted scabbing). Treat with exterior-firming agents. For bowel/bladder issues: constipation requires promoting bowel movement; urinary retention requires promoting urination; red, scanty urine uses Da Lian Qiao Tang (Large Forsythia Decoction) or Gan Lu Yin (Sweet Dew Decoction). Constipation with internal restlessness and external heat uses Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Zhi Ke (Bitter Orange), or Si Shun Qing Liang Yin (Four Compliance Cooling Drink).
Normal color requires no medicine. Pale color nearing completion requires blood-assisting herbs: Dang Gui, Chuan Xiong (wine-washed), Bai Shao, possibly Hong Hua (Safflower). Purple color nearing completion indicates Heat, resolved with cooling herbs: Sheng Ma, Ge Gen, wine-fried Huang Qin, Huang Lian, Lian Qiao. Severe cases use Xi Jiao (Rhinoceros Horn) for major detoxification. Dry eruptions require fire-clearing with light agents: Jing Jie (Schizonepeta), Sheng Ma, Ge Gen. Wet eruptions require damp-draining using wind herbs like Bai Zhi and Fang Feng (Saposhnikovia) for surface dampness. Sore throat uses Da Ru Sheng San and Niu Bang Zi Tang (Arctii Decoction). Wheezing and distension use Ma Huang Huang Qin Tang (Ephedra and Scutellaria Decoction). Restlessness and thirst use Gan Cao San (Licorice Powder) taken with Wu Mei Tang (Mume Decoction). Dysentery and vomiting use Mu Xiang Tang and Li Zhong Tang (Regulate the Middle Decoction).
Qian Yi stated: Black sinking with cyanosis is treated with Baixiang Wan (Hundred Perfected Pills) for purgation; non-black cases must not be purged. I understand this purges Bladder pathogens. The Child's Kidney is inherently deficient and should not be purged directly; instead, draining the Bladder empties the Fu organ, removing Kidney pathogens. Post-purgation fever, warmth, and thirst indicate water accumulation or indigestion; chills indicate reversal. This implies strong Spleen Earth controls Water. Post-purgation Wen Pi Tang uses equal parts Ren Shen, Fu Ling, Bai Zhu, plus fried Hou Po, Mu Xiang, and Gan Cao. Eruptions manifest in muscles governed by Yangming; warming Spleen Earth smooths Stomach Qi, eliminating leaked Kidney Water. This is Qian’s profound insight.
Urination and defecation must remain unobstructed. If stools are normal and yellow/black, toxins are reduced; minimal Hua Du Tang (Toxin Resolution Decoction) suffices. Closure of bowels/bladders causes intestinal congestion, meridian stagnation, and toxin retention, leading to closed eyes, hoarseness, dark skin, and rapid deterioration.
Cold-deficiency eruptions may persist ten days before death; toxin-excess purple eruptions die within seven to eight days. Fetal toxins emerge outwardly over one to three days; toxins remain internal until day six when they fully manifest externally, suppurating and scabbing by days seven to nine. If toxins are excessive and cannot exit, entering organs after day six necessitates urgent blood-cooling and detoxifying drugs before day six. After day six, treatment fails, causing rapid death. Weakness with low toxins results in delayed death due to insufficient Qi/Blood for suppuration. This distinguishes deficiency/excess severity. Numerous eruptions imply high toxins, requiring initial detoxification, followed by tonics to support pus formation due to potential Qi/Blood insufficiency.
Post-eruption voice indicates body pathology without Qi pathology; pre-eruption voice loss indicates Qi pathology without body pathology. Voice loss post-eruption indicates both body and Qi pathology, requiring Lung clearing with Ba Feng Tang (Eight Winds Decoction) and Liang Ge San (Cooling Diaphragm Powder) minus Xiao Shi and Da Huang.