〔万〕人之一身，本乎荣卫，卫者阳气，所以开阖橐龠，运动枢机者也。荣者阴
血，所以充溢脏腑，灌溉肢体者也。故气虚则神机息，血虚则化源绝，二者不可偏
胜也。痘疹之毒，本于五脏之液，各随经络部位，直犯荣卫而出，气血从之，观其
裹来坚浓，窠囊充长者，气之足也。根芽红活，形色润泽者，血之足也。气血既足，
则痘易发易靥，不须施治，以蹈实实之戒。如平陷嫩薄者气之病也，干枯紫黑者血
之病也，责而治之，不可因循以贻后悔。然脾胃者，气血之父也，心肾者，气血之
母也，肝肺者，气血之舍也，脾纳水谷，其悍气注于肾而为气，肾舍于肺而为卫，
以温分肉，充皮毛，肥腠理，司开阖也，卫气虚则疮不起发，其毒乘气之虚而入于
肺，肺受之则为陷伏，而归于肾矣。脾纳水谷，其精气注于心而为血，心舍于肝而
为荣，以走九窍，注六经，朝百脉也，荣血虚则疮不光泽，其毒乘血之虚而入于肝，
肝受之则为痒 ，而归于心矣。凡治此者，气病治气，血病治血，寒则温之，热则
清之，虚则补之，实则泻之，仍以脾胃为主，不可犯之也。
〔万〕不知虚实者，不可以为工。经曰∶无虚虚，无实实。虚实之分，不可不知也。
经曰∶必先度其形之肥瘠，以调其气之虚实。此以形体别虚实也。又曰∶谷盛气盛，
谷虚气虚。此以饮食别虚实也。又曰∶脉实血实，脉虚血虚。此以脉别虚实也。又
曰∶邪气盛则实，精气夺则虚。此以邪正别虚实也。大抵实者、邪气实也，虚者、
正气虚也。经曰∶邪之所凑，其气必虚，留而不去，其病则实是也。又云∶五实死
者，谓邪气之实也。五虚死者，谓正气之虚也（凡人诊同）。疮痘之证，其人形体肥健，
饮食能多，六脉洪实，素无疾病，大便如常，疮色红润者，此表里正气俱实也，不
须服药。若形体羸怯，素多疾病，饮食减少，六脉微弱，吐利频频，疮色淡嫩者，
此表里正气俱虚也，陈氏温补之法可用。如疮势太盛， 肿痛胀，大热不退，烦渴
昏睡，大小便秘，此表里邪气俱实也，钱氏凉泻之法可用。如疮本稠密， 发红活，
吐利不食者，此表实里虚也，于补汤中加解毒药。如疮色淡白，发不透满，大小便
秘，浩饮大嚼者，此里实表虚也，于解利中加发药。又如疮痛者邪气实也，当活血
以开其郁。若痛如刀剜，闷乱大叫者，勿治。疮痒者，正气虚也，当补气以燥其湿，
如爬搔不定，破烂皮脱者，勿治。灰白者，气虚也，参 之功为大。干燥者，血虚
也，归芎之力宜多。虚则补之，实则泻之，中病即已，无过其制，此治之权衡也。
若本实而反补之，则毒瓦斯弥盛，或为溃烂，或为痈肿，或为目病，或为咽疮，或为
失血，皆补之过也。如本虚而反泻之，则正气益虚，或为吐，为利，为厥逆，皆泻
之过也。经云∶母致邪，母失正，绝人长命。其此之谓欤。
〔翁〕夫气有生血之功，血无益气之理，故气不可亏，亏则阳会不及，而痘之圆
晕之形不成。血不可盈，盈则阴乘阳位，而痘之倒陷之祸立至。是痘有气血虚实之
殊也。大抵寒为虚，热为实，气虚则宜温补，气实热则宜清凉，血虚则宜补血，血
热则宜解毒，必取其气血中和，无过不及可也。何谓气血虚实，且如气过则泡，血
过则 ，气不及顶陷不起，血不及浆毒不附，凡痘色淡白，顶不坚实，不碍指，不
起胀，皆属气虚，大宜保元，倍加酒炒黄 、肉桂、川芎、丁香、人乳、好酒同
服。根窠不红，或红而散乱，以手摸过即转白，痘上如寒毛竖起，枯涩不活者，皆
血虚也，宜保元加川芎、当归、酒洗红花，及下山楂以消参 之滞，再下木香数分
以行滞气，而血自活也。凡用黄 ，当在痘尽出之后，凡用热药，当看毒尽解之时，
又察气血虚实而治之，则药无不效矣。凡补血首尾用地黄，防滞血必用姜制，用芍
药恐酸寒伐胃气，必用酒炒。
〔虚证调护论〕痘证以元气为主，元气充实，则毒易出易化，故善治痘者，惟
保元气于虚弱之前，使不致于耗散为贵耳。然其治法惟何？一曰实腠理而固肌表，
二曰节饮食而保脾土，肌表固则外陷之患不足虑，脾土实则下陷之患不足忧，更加
以参 补益之功，则元气自然充实，而痘之出也，自然易以成浆，变证不生，而结
靥顺候矣。是以禁用寒凉荡涤之剂如大黄、滑石、车前、生地、鼠粘、紫草、枳壳、
之类，恐其荡涤润下，遂伤脾胃，脾胃伤，则元气由此而下陷，气脱内攻而死，势
所必至，是则药杀之也。禁用滑润发散之剂如鼠粘、人牙、蝉蜕、麻黄、干葛、升
麻、紫草、桔梗、羌活、防风、荆芥之类，恐其发散太过，遂致表虚，表一虚，则
元气由此而外耗，塌痒外剥，命由此丧，谁之过欤。
〔虚证补气不补血〕虚弱痘证，精神倦怠，面青 白，盖气不充则精神倦怠，
血不荣则面青 白。今治虚证，补气不补血者何也？气有神而无形，补之则易充，
血有形而无神，补血之药，难收速效，况气阳而血阴，阴从阳，血从气者理也，故
补气不补血，使气盛而充，则血自随而亦盛矣。况补血之剂如当归、生地，皆能润
燥滑下，多用恐致溏泄故耳。然虚证痘疹，亦有白陷不荣，不得已而用当归、芍药、
补血之剂，亦有虚火外浮，痘点繁红，而类于血热之证，不得已而用紫草、红花、
生地活血凉血之药，并用酒炒，以折其润下之性，借酒力而行之达表，则补血活血
之中，而有升发达表之妙，庶无润肠溏泄之患矣。
〔虚证坏势必至辨〕气虚痘证，初发身热悠悠，乍热乍凉，肌慢神倦，面青
白，饮食减少，手足时冷时热，呕吐便溏，痘点方见，隐隐不振，淡红皮薄，三四
日陆续不齐，不易长大，五六日不易成浆，少食气馁，伤食易泄，七八日塌陷，灰
白不起，自汗微渴，或腹胀喘渴，泄泻塌痒，闷乱切牙寒战，头温足冷，势所必至。
故治虚痘初发之际，不宜投参苏饮、人参败毒散、黄连解毒汤、升麻葛根汤、紫草
三豆饮，当用参 饮。气粗皮燥无润色亦忌之，只以四君子减人参、少加桔梗、川
芎、腹皮，补益之中略佐以升提之法为妙。点子出齐，重用参 ，及至八九日间，
无他凶证，用法如常。若或顶陷灰白不起，浆清自汗微渴，大补汤加桂。塌陷灰白，
腹胀泄泻，木香散。塌痒闷乱，腹胀渴泻，喘嗽头温足冷，寒战切牙者，急进异攻
散救之。
〔虚证变实〕气虚痘证，父母能守禁忌，及用药不误，调燮顺候，则元气充实，
腠理坚固，脾胃强健，饮食如常，二便清调矣。若补益太过，浆足之后，重用参 ，
容亦有腹胀喘急之患，用枳壳汤。误用五苓木通，多则有大便秘塞之患，用宽中散。
便实而渴，麦门冬汤。过用丁桂辛热之剂，则亦有咽喉肿痛，烦躁闭渴之变，滋阴
润燥汤。盖喘急腹胀，大便秘坚，烦渴咽痛，皆类实证也，然而气虚变实者，非真
实也，是病浅而用药过深之失也，只宜斟酌，不宜疏通，重治疏利之过，则方生之
气复虚，而脱证将至矣。
〔虚证似实〕气虚痘证，或为饮食生冷，调理失宜，致伤脾胃，遂成泄泻，津
液下陷，虚火上盛，必发而为渴。元气下陷，则虚阳上拥，下气不续，必发而为喘。
夫渴与喘，实证也，起于泄泻之后，则为津液暴亡而渴、气虚而喘，岂有实热而渴、
气拥而喘，生于泄泻之后哉。故治渴则用参苓白术木香散。渴泻不止，异攻散。喘
则用人参定喘汤、独参杏仁汤。喘渴而泄，木香异功散。闷乱腹胀，毒成内攻，眼
合自语，已名失志，谬认为实，医何愚哉！
〔实证似虚〕身发壮热，毛直皮燥，睡卧不宁，腮红睛赤，气粗烦渴，腹胀便
秘喘急，皆实证也，此热盛毒重，壅遏之故，而又见呕吐之证。呕吐似虚也，然未
知热毒在内，不得伸越，则上逆攻冲而吐，经云∶诸逆攻冲，皆属于火者是也。或
为寒冷所搏，或因乳食不节，致伤风冷，则使内热不得发越，冷暖相拒而吐。毒不
得伸越者，从升阳发散为最，相拒而吐者、引之使下，如猪苓、泽泻、橘皮之类。
又有泄泻之证兼见者，泄泻似虚也，然因热毒郁盛，熏炙脾胃，不得外达，则毒从
下陷，寻窍而泄，所谓热毒下注者是也，古云∶未出而泻者生，既出而泻者死，概
可见矣。治法以升提发散，引毒达表，毒得外解，则内泄自止，兼伤食而泻者，轻
则加消化之剂，重则从之。又有不思饮食，书云∶不思饮食，皆属内虚者是矣，然
不知郁热之证盖因毒瓦斯在内，不得伸越达于肌表，二便秘结，腠理阻塞，热毒壅盛，
腹胀满急，不思饮食者，必然之势也，治法以升提发散，引毒达表，则热气有所伸
越，而脏腑和平，饮食自进矣。若误用丁、桂、半夏等热药于呕吐、泄泻、不食
之证，是以热攻热，而转增烦剧，用人参、黄 、茯苓、白术等补剂于腹胀不思
饮食之证，则邪得补而愈盛，药一入口，立见杀人，医之过也，可不慎欤。他如龙
骨、豆蔻虽能止泄，神曲、麦芽、缩砂虽能助脾化食，皆不当用于壅热不食之证，
继予业者鉴之。
〔热证变虚〕血热痘证，只宜清凉发散，不宜峻用苦寒，若过投寒剂如升麻、
芩、连及滑泄之药，必致内伤脾胃，外冰肌肉，脾胃伤轻则饮食减而溏泄，重则
洞泄无度，而遂致虚寒。肌肉冰则热蒸之气不行，腠理闭涩，痘不肥大，不起发，
不行浆，而遂成伏陷。此热证变虚之验，虚证既明，便从虚治，参 丁桂，亦所不
忌，五六日后见之，则木香异攻，在所宜施，惟在审证而斟酌之也。
〔壅热变虚〕毒盛壅遏，固宜升提发散为主，而佐以清凉解毒为善，又宜得平
乃止，若发散太过，必致肌表空虚，元气耗散，内贯清浆，或虚抬空壳，或痒塌外
剥，或溃烂不收，百变皆至，见此数端，皆成表虚。表既虚，则元气从此耗泄，而
内气亦不能以自守，略伤饮食或生冷，则成泄泻，泄泻不止，遂成虚寒而气脱，烦
渴闷乱，寒战切牙，无所不至矣。既知虚证，治从虚例，参 白术丁桂姜附，亦所
不忌，六七日后见之，虽木香异攻亦宜急进，在察证而酌量之也。
〔壅热用异攻辨〕实热壅遏之证，多用寒凉，致冰伏泄泻，发散太过，或成表
虚。既成冰硬，药宜温和，姜桂之热，亦所不忌。泄泻之后，热气自散，真气自虚，
既成气虚，药宜补益。气虚必寒，虚寒既明，药宜温补。是以始出之时虽为血热壅
遏，至于三四日后，身反不热，肌肤冰冷，痘疮不长，焉得不进以温和之剂如官桂、
干姜、川芎之类，使内气一暖，则外气自和。泄泻之后，其内必虚，虽有腹胀烦
渴喘急，焉得复为实热，不过内虚伏陷，毒成内攻而然。故实热之证，七八九日曾
经泄泻，皆从虚治，有木香异功之证，便进木香异功为贵。如无冰硬之证，切勿误
投温剂，无泄泻之证，勿得误投木香异攻等，盖塌陷、倒靥、干枯、而无冰硬泄泻
之患者，多因热毒内攻而然，故宜百祥、猪尾等方以治之可也。
【万全】人的一身，根本在于营卫。卫气是阳气，负责开启和闭合腠理（皮肤毛孔），推动人体机枢运转。营血是阴血，负责充盈脏腑，灌溉肢体。所以气虚则神机停止运作，血虚则生化之源断绝，这两者不能偏废。痘疹的毒邪，源于五脏的津液，各自随着经络部位，直接侵犯营卫而发出。观察痘疹包裹坚实浓密、痘窠囊饱满长大的，说明气充足。痘根芽红润鲜活、色泽润泽的，说明血充足。气血既然充足，那么痘疹就容易发出也容易结痂，不需要施治，以免犯“实实”（使实证更实）的禁忌。如果痘疹平陷、嫩薄，这是气的病变；干枯紫黑，这是血的病变，必须责备并治疗，不可因循守旧留下后悔。然而脾胃是气血的父亲，心肾是气血的母亲，肝肺是气血的居所。脾受纳水谷，其悍气注入肾中化为气，肾藏气于肺中化为卫气，用以温煦肌肉，充实皮毛，肥厚腠理，主管开阖。卫气虚则疮疹不起发，毒邪乘气之虚侵入肺，肺受邪则导致痘疹内陷伏匿，进而归于肾。脾受纳水谷，其精气注入心中化为血，心藏血于肝中化为营血，用以流注九窍，灌注六经，朝会百脉。营血虚则疮疹不光泽，毒邪乘血之虚侵入肝，肝受邪则导致痘疹瘙痒，进而归于心。凡是治疗这种情况，气病治气，血病治血，寒证用温法，热证用清法，虚证用补法，实证用泻法，仍以调理脾胃为主，不可违背。
【万全】不知道辨别虚实的人，不可以成为医生。经书说：不要使虚证更虚，不要使实证更实。虚实之分，不可不知。经书说：必须先衡量患者体形的肥瘦，来调节气的虚实。这是通过形体来辨别虚实。又说：饮食多则气盛，饮食少则气虚。这是通过饮食来辨别虚实。又说：脉象实则血实，脉象虚则血虚。这是通过脉象来辨别虚实。又说：邪气盛则表现为实证，精气亏损则表现为虚证。这是通过邪正关系来辨别虚实。大抵实证是邪气实，虚证是正气虚。经书说：邪气聚集的地方，正气必然虚弱，停留不去，疾病就表现为实证了。又说：五实死症，是指邪气实；五虚死症，是指正气虚（凡人诊断通用）。痘疮病症中，如果患者形体肥健，饮食能多，六脉洪大有力，素无疾病，大便正常，疮色红润，这是表里正气都实，不需要服药。如果形体瘦弱怯懦，素多疾病，饮食减少，六脉微弱，频繁呕吐腹泻，疮色淡嫩，这是表里正气都虚，陈氏的温补方法可以使用。如果疮势太盛，肿痛胀大，大热不退，烦躁口渴昏睡，大小便闭塞，这是表里邪气都实，钱氏的凉泻方法可以使用。如果疮本来稠密，发红鲜活，但出现呕吐腹泻不能进食，这是表实里虚，在补益汤剂中加入解毒药。如果疮色淡白，发不透满，大小便闭塞，大量饮水大口吃东西，这是里实表虚，在解利透疹药中加入发散药。又如疮痛，是邪气实，应当活血以开通郁结。如果痛如刀割，烦闷乱叫，不要治疗。疮痒，是正气虚，应当补气以燥湿，如果抓挠不定，破烂皮脱，不要治疗。灰白色，是气虚，人参的功效很大。干燥，是血虚，当归、川芎的力量适宜多用。虚则补之，实则泻之，中病即止，不过度，这是治疗的权衡标准。如果本实证反而用补法，则毒瓦斯更加旺盛，或者溃烂，或者痈肿，或者眼病，或者咽疮，或者失血，都是补法过度的后果。如果本虚证反而用泻法，则正气更加虚弱，或者呕吐，或者腹泻，或者四肢厥逆，都是泻法过度的后果。经书说：不要招致邪气，不要丢失正气，断送人的寿命。说的就是这个道理。
【翁仲荣】气有生血的功效，血没有益气的道理，所以气不可亏损，亏损则阳气不足，痘疹圆晕的形状无法形成。血不可过盈，过盈则阴乘阳位，痘疹倒陷的祸患立刻到来。所以痘疹有气血虚实的不同。大抵寒证属虚，热证实证，气虚则宜温补，气实热则宜清凉，血虚则宜补血，血热则宜解毒，必须取其气血中和，不过分也不不及即可。什么是气血虚实？且如气过则水泡，血过则脓疱，气不及则顶陷不起，血不及则浆毒不附。凡痘色淡白，顶部不坚实，不碍手，不起胀，都属于气虚，非常适宜保元汤，加倍加入酒炒黄芪、肉桂、川芎、丁香、人乳、好酒同服。痘根不红，或红而散乱，用手摸过即转白，痘上如寒毛竖起，枯涩不活的，都是血虚，适宜保元汤加川芎、当归、酒洗红花，以及下山楂以消除人参、黄芪的滞腻，再下木香数分以行滞气，血自然活跃。凡是使用黄芪，应当在痘疹全部发出之后；凡是使用热药，应当看毒邪完全解除之时，又察气血虚实而治疗，则药物没有不生效的。凡是补血，首尾用地黄，防止滞血必用姜制，用芍药恐怕酸寒损伤胃气，必用酒炒。
【虚证调护论】痘证以元气为主，元气充实，则毒邪容易发出容易化解，所以善于治疗痘证的人，只在虚弱之前保全元气，使其不至于耗散为贵。然而治疗方法是什么？一是实腠理而固肌表，二是节饮食而保脾土。肌表固则外陷的祸患不值得忧虑，脾土实则下陷的祸患不值得担忧，再加上人参、黄芪补益的功效，则元气自然充实，而痘疹发出时，自然容易成浆，变证不生，结痂顺候。因此禁用寒凉荡涤的药物如大黄、滑石、车前子、生地、牛蒡子、紫草、枳壳之类，恐怕它们荡涤润下，损伤脾胃，脾胃伤，则元气由此下陷，气脱内攻而死，是势所必至的，这是药物杀死了病人。禁用滑润发散的药物如牛蒡子、人牙、蝉蜕、麻黄、干葛、升麻、紫草、桔梗、羌活、防风、荆芥之类，恐怕它们发散太过，导致表虚，表一虚，则元气由此外耗，塌陷瘙痒外剥，性命由此丧失，是谁的过错呢？
【虚证补气不补血】虚弱痘证，精神倦怠，面色青白，因为气不充则精神倦怠，血不荣则面色青白。现在治疗虚证，只补气不补血的原因是什么呢？气有神而无形，补之则容易充盈，血有形而无神，补血的药物，难收速效，况且气为阳而血为阴，阴从阳，血从气，是理所当然的，所以补气不补血，使气盛而充，则血自然跟随也盛。况且补血的药剂如当归、生地，都能润燥滑下，多用恐怕导致溏泄的缘故。然而虚证痘疹，也有白陷不荣，不得已而用当归、芍药等补血药剂，也有虚火外浮，痘点繁红，而类似血热的证候，不得已而用紫草、红花、生地等活血凉血的药物，并用酒炒，以折损其润下的性质，借酒力而行达表，则在补血活血之中，而有升发达表的妙处，才没有润肠溏泄的祸患。
【虚证坏势必至辨】气虚痘证，初发时身体热势悠悠，乍热乍凉，肌肤松弛精神疲倦，面色青白，饮食减少，手足时冷时热，呕吐便溏，痘点刚见，隐隐不振，淡红皮薄，三四日陆续不齐，不易长大，五六日不易成浆，少食气馁，伤食易泄，七八日塌陷，灰白不起，自汗微渴，或腹胀喘渴，泄泻塌痒，烦闷乱咬齿寒战，头温足冷，是势所必至的。所以治疗虚痘初发之际，不宜投参苏饮、人参败毒散、黄连解毒汤、升麻葛根汤、紫草三豆饮，当用人参黄芪饮。气粗皮燥无润色的也忌讳，只用四君子汤减人参、少加桔梗、川芎、腹皮，在补益之中略佐以升提的方法为妙。点子出齐，重用参、芪，及至八九日间，无其他凶险证候，用法如常。如果或顶陷灰白不起，浆清自汗微渴，大补汤加桂枝。塌陷灰白，腹胀泄泻，用木香散。塌痒烦乱，腹胀渴泻，喘嗽头温足冷，寒战咬齿者，急进异功散救之。
【虚证变实】气虚痘证，父母能遵守禁忌，用药不误，调理顺候，则元气充实，腠理坚固，脾胃强健，饮食如常，二便清调。如果补益太过，浆足之后，重用参、芪，容亦有腹胀喘急的祸患，用枳壳汤。误用五苓散、木通，多则有大便秘塞的祸患，用宽中散。便实而渴，用麦门冬汤。过用丁香、肉桂辛热药剂，则亦有咽喉肿痛，烦躁闭渴的变证，用滋阴润燥汤。盖喘急腹胀，大便秘坚，烦渴咽痛，都类似实证，然而气虚变实者，不是真实证，是病浅而用药过深的失误，只宜斟酌，不宜疏通，重治疏利的过失，则方生之气复虚，而脱证将至了。
【虚证似实】气虚痘证，或因饮食生冷，调理失宜，致伤脾胃，遂成泄泻，津液下陷，虚火上盛，必发而为渴。元气下陷，则虚阳上拥，下气不续，必发而为喘。夫渴与喘，是实证，起于泄泻之后，则为津液暴亡而渴、气虚而喘，岂有实热而渴、气拥而喘，生于泄泻之后哉。所以治渴则用参苓白术木香散。渴泻不止，用异攻散。喘则用人参定喘汤、独参杏仁汤。喘渴而泄，用木香异功散。烦闷腹胀，毒成内攻，眼合自语，已名失志，谬认为实，医生多么愚蠢啊！
【实证似虚】身体发壮热，毛发直皮燥，睡卧不宁，腮红睛赤，气粗烦渴，腹胀便秘喘急，都是实证，这是热盛毒重，壅遏的缘故，而又见呕吐的证候。呕吐似虚，然而不知热毒在内，不得伸越，则上逆攻冲而吐，经书说：诸逆攻冲，皆属于火，就是这样的。或因寒冷所搏，或因乳食不节，致伤风冷，则使内热不得发越，冷暖相拒而吐。毒不得伸越者，从升阳发散为最，相拒而吐者，引之使下，如猪苓、泽泻、橘皮之类。又有泄泻的证候兼见的，泄泻似虚，然而因热毒郁盛，熏炙脾胃，不得外达，则毒从下陷，寻窍而泄，所谓热毒下注的是也，古书说：未出而泻者生，既出而泻者死，概可见矣。治法以升提发散，引毒达表，毒得外解，则内泄自止，兼伤食而泻者，轻则加消化药剂，重则从之。又有不思饮食，书云：不思饮食，皆属内虚的是了，然而不知郁热之证盖因毒瓦斯在内，不得伸越达于肌表，二便秘结，腠理阻塞，热毒壅盛，腹胀满急，不思饮食者，必然之势也，治法以升提发散，引毒达表，则热气有所伸越，而脏腑和平，饮食自进矣。若误用丁、桂、半夏等热药于呕吐、泄泻、不食的证候，是以热攻热，而转增烦剧，用人参、黄芪、茯苓、白术等补剂于腹胀不思饮食的证候，则邪得补而愈盛，药一入口，立见杀人，医生的过错，可不谨慎吗？其他如龙骨、豆蔻虽能止泄，神曲、麦芽、缩砂虽能助脾化食，都不当用于壅热不食的证候，继予业者鉴之。
【热证变虚】血热痘证，只宜清凉发散，不宜峻用苦寒，若过投寒剂如升麻、黄芩、黄连及滑泄药剂，必致内伤脾胃，外冰肌肉，脾胃伤轻则饮食减而溏泄，重则洞泄无度，而遂致虚寒。肌肉冰则热蒸之气不行，腠理闭涩，痘不肥大，不起发，不行浆，而遂成伏陷。此热证变虚的验证，虚证既明，便从虚治，参、芪、丁、桂，亦所不忌，五六日后见之，则木香异攻，在所宜施，惟在审证而斟酌之也。
【壅热变虚】毒盛壅遏，固宜升提发散为主，而佐以清凉解毒为善，又宜得平乃止，若发散太过，必致肌表空虚，元气耗散，内贯清浆，或虚抬空壳，或痒塌外剥，或溃烂不收，百变皆至，见此数端，皆成表虚。表既虚，则元气从此耗泄，而内气亦不能以自守，略伤饮食或生冷，则成泄泻，泄泻不止，遂成虚寒而气脱，烦渴闷乱，寒战咬齿，无所不至矣。既知虚证，治从虚例，参、芪、白术、丁、桂、姜、附，亦所不忌，六七日后见之，虽木香异攻亦宜急进，在察证而酌量之也。
【壅热用异攻辨】实热壅遏之证，多用寒凉，致冰伏泄泻，发散太过，或成表虚。既成冰硬，药宜温和，姜桂之热，亦所不忌。泄泻之后，热气自散，真气自虚，既成气虚，药宜补益。气虚必寒，虚寒既明，药宜温补。是以始出之时虽为血热壅遏，至于三四日后，身反不热，肌肤冰冷，痘疮不长，焉得不进以温和之剂如官桂、干姜、川芎之类，使内气一暖，则外气自和。泄泻之后，其内必虚，虽有腹胀烦渴喘急，焉得复为实热，不过内虚伏陷，毒成内攻而然。故实热之证，七八九日曾经泄泻，皆从虚治，有木香异功之证，便进木香异功为贵。如无冰硬之证，切勿误投温剂，无泄泻之证，勿得误投木香异攻等，盖塌陷、倒靥、干枯、而无冰硬泄泻之患者，多因热毒内攻而然，故宜百祥、猪尾等方以治之可也。
[Wan] The human body is fundamentally based on Ying (Nutrient) and Wei (Defensive) Qi. Wei Qi is Yang Qi, responsible for opening and closing the Cou Li (skin pores), and moving the physiological pivot. Ying Blood is Yin Blood, responsible for filling the Zang-Fu organs and irrigating the limbs. Therefore, when Qi is deficient, the Shen Ji (spiritual mechanism) ceases; when Blood is deficient, the source of transformation is cut off. These two cannot be allowed to dominate excessively. The toxin of smallpox originates from the fluids of the five Zang organs, following the meridians and specific locations, directly invading Ying and Wei to emerge. Observing the eruption: if the vesicles are firm and dense, and the pustule bases are full and long, this indicates sufficient Qi. If the roots are red and vibrant, with lustrous color, this indicates sufficient Blood. When both Qi and Blood are sufficient, the smallpox will erupt and crust easily without requiring treatment, avoiding the error of "reinforcing excess" (making an excess condition more excessive). If the lesions are flat, depressed, tender, and thin, it is a disease of Qi; if dry, purple, and black, it is a disease of Blood. One must blame and treat these conditions, not allowing negligence that leads to regret. However, the Spleen and Stomach are the fathers of Qi and Blood; the Heart and Kidney are the mothers; the Liver and Lungs are their dwellings. The Spleen receives water and grain; its fierce Qi enters the Kidney to become Qi, which the Kidney stores in the Lung to become Wei Qi, warming the muscles, filling the skin and hair, thickening the Cou Li, and governing opening and closing. If Wei Qi is deficient, sores will not erupt; the toxin takes advantage of Qi deficiency to enter the Lung. If the Lung is affected, it leads to sinking and hiding of the rash, eventually returning to the Kidney. The Spleen receives water and grain; its essence enters the Heart to become Blood, which the Heart stores in the Liver to become Ying Blood, flowing through the nine orifices, pouring into the six Fu organs, and meeting at the hundred vessels. If Ying Blood is deficient, sores lack luster; the toxin takes advantage of Blood deficiency to enter the Liver. If the Liver is affected, it leads to itching, eventually returning to the Heart. In treating such cases, treat Qi diseases by regulating Qi, and Blood diseases by regulating Blood. For cold patterns, use warming methods; for heat patterns, use clearing methods; for deficiency patterns, use tonifying methods; for excess patterns, use purging methods. Always prioritize the Spleen and Stomach, and do not violate this principle.
[Wan] One who does not know how to distinguish between deficiency and excess cannot be a physician. The Classics state: Do not make deficiency more deficient, and do not make excess more excess. The distinction between deficiency and excess must be understood. The Classics state: First measure the fatness or emaciation of the body to regulate the excess or deficiency of Qi. This distinguishes deficiency and excess by physical form. It also states: Abundant food intake leads to abundant Qi; scanty food intake leads to deficient Qi. This distinguishes deficiency and excess by diet. It also states: Excessive pulse indicates excess Blood; deficient pulse indicates deficient Blood. This distinguishes deficiency and excess by pulse. It also states: When pathogenic factors are abundant, it is excess; when essential Qi is depleted, it is deficiency. This distinguishes deficiency and excess by the relationship between pathogenic and healthy Qi. Generally, excess refers to pathogenic excess, and deficiency refers to healthy Qi deficiency. The Classics state: Where pathogenic factors gather, Healthy Qi must be deficient. If they remain and do not depart, the disease manifests as excess. It is also said: Death from the "Five Excesses" refers to pathogenic excess; death from the "Five Deficiencies" refers to healthy Qi deficiency (applicable to general diagnosis). In smallpox cases, if the patient has a robust physique, good appetite, surging and forceful pulses, no prior illness, normal stool, and red, lustrous sores, this indicates both exterior and interior Healthy Qi are excess; medication is unnecessary. If the patient is frail, prone to illness, has poor appetite, weak pulses, frequent vomiting and diarrhea, and pale, tender sores, this indicates both exterior and interior Healthy Qi are deficient; Chen's warming and tonifying method can be used. If the rash is too vigorous, with swelling, pain, distension, persistent high fever, restlessness, thirst, drowsiness, and constipation of urine and stool, this indicates both exterior and interior Pathogenic factors are excess; Qian's cooling and purging method can be used. If the rash is originally dense, red, and vibrant, but accompanied by vomiting, diarrhea, and inability to eat, this indicates exterior excess and interior deficiency; add detoxifying herbs to tonifying decoctions. If the rash is pale white, fails to fully erupt, accompanied by constipation, yet the patient drinks heavily and eats greedily, this indicates interior excess and exterior deficiency; add dispersing herbs to resolving and diffusing formulas. Furthermore, pain in sores indicates pathogenic excess; activate Blood to resolve stagnation. If pain is like knife-cutting, with extreme restlessness and screaming, do not treat. Itching indicates healthy Qi deficiency; tonify Qi to dry dampness. If scratching is uncontrollable, with broken skin and peeling, do not treat. Ashen-white color indicates Qi deficiency; the efficacy of Ginseng Radix (Renshen) is significant. Dryness indicates Blood deficiency; the power of Angelicae Sinensis Radix (Danggui) and Chuanxiong Rhizome (Chuanxiong) should be increased. Tonify deficiency, purge excess; stop when the disease is addressed, without exceeding limits; this is the balance of treatment. If an excess pattern is mistakenly treated with tonification, toxins will proliferate, leading to ulceration, carbuncles, eye diseases, throat ulcers, or hemorrhage—all due to over-tonification. If a deficiency pattern is mistakenly treated with purging, Healthy Qi will further weaken, leading to vomiting, diarrhea, or cold extremities—all due to over-purging. The Classics say: Do not invite pathogens, do not lose Healthy Qi, and do not shorten life. This is what is meant.
[Weng] Qi has the function of generating Blood, but Blood has no mechanism to benefit Qi. Therefore, Qi must not be deficient; if deficient, Yang energy will be insufficient, and the round shape of the smallpox vesicle will not form. Blood must not be excessive; if excessive, Yin will invade Yang positions, and the disaster of inverted smallpox will occur immediately. Thus, smallpox presents differences in Qi and Blood deficiency and excess. Generally, cold patterns indicate deficiency, and heat patterns indicate excess. Qi deficiency requires warming and tonification; Qi excess with heat requires cooling; Blood deficiency requires tonifying Blood; Blood heat requires detoxification. One must aim for the harmony of Qi and Blood, neither excessive nor insufficient. What constitutes Qi and Blood deficiency and excess? For instance, excessive Qi leads to vesicles; excessive Blood leads to pustules. Insufficient Qi leads to depression and failure to rise; insufficient Blood leads to lack of pus and toxin attachment. Pale white rash, non-firm tops, sensationless to touch, and failure to swell all belong to Qi deficiency. Baoyuan Decoction is highly suitable, with doubled doses of Astragali Radix (Huangqi) stir-fried with wine, Cinnamon Twig (Rougui), Chuanxiong Rhizome (Chuanxiong), Clove (Dingxiang), human milk, and fine wine taken together. Non-red roots, or red but scattered roots that turn white upon touch, with hairs standing up on the rash, appearing dry and dull, all indicate Blood deficiency. Baoyuan Decoction should be added with Chuanxiong Rhizome (Chuanxiong), Angelicae Sinensis Radix (Danggui), Safflower (Honghua) washed with wine, and Hawthorn Fruit (Shanzha) to reduce the stagnation caused by Ginseng and Astragalus. Add Aucklandiae Radix (Muxiang) in small amounts to move stagnant Qi, so that Blood becomes active. Whenever using Astragali Radix (Huangqi), it should be after the rash has fully erupted. Whenever using hot herbs, one must wait until the toxin is completely resolved, then treat according to Qi and Blood deficiency and excess, ensuring efficacy. For tonifying Blood, Rehmanniae Radix (Dihuang) is used at the beginning and end; Ginger-processed forms prevent stagnation. Paeoniae Radix (Shaoyao) is avoided due to its sour-cold nature damaging Stomach Qi, or if used, must be wine-processed.
[Discussion on Nursing Deficiency Patterns] Smallpox treatment prioritizes Yuan Qi (Original Qi). When Yuan Qi is sufficient, toxins are easily expelled and transformed. Therefore, skilled physicians preserve Yuan Qi before it becomes weak, preventing depletion. What are the treatment methods? First, strengthen the Cou Li and secure the muscle surface; second, regulate diet and protect the Spleen Earth. If the exterior is secure, there is no worry about external sinking; if the Spleen Earth is solid, there is no worry about internal sinking. With the tonifying effects of Ginseng and Astragalus, Yuan Qi naturally becomes sufficient, making it easy for the rash to form pus, preventing complications, and ensuring smooth crusting. Therefore, cold and purging agents such as Rheum Radix et Rhizoma (Dahuang), Talcum (Huashi), Plantaginis Semen (Cheqianzi), Rehmanniae Radix (Shengdi), Arctii Fructus (Niubangzi), Leonuri Herba (Zicao), and Aurantii Fructus (Zhike) are prohibited, lest they purge and moisten downward, damaging the Spleen and Stomach. Damage to the Spleen and Stomach causes Yuan Qi to sink, leading to Qi collapse and internal attack, resulting in death—a certainty caused by the medicine itself. Slippery and dispersing agents such as Arctii Fructus (Niubangzi), Human Teeth (Renya), Bombyx Batryticatus (Chantui), Ephedrae Herba (Mahuang), Puerariae Radix (Gegen), Cimicifugae Rhizoma (Shengma), Leonuri Herba (Zicao), Platycodonis Radix (Jiegeng), Notopterygii Rhizoma et Radix (Qianghuo), Saposhnikoviae Radix (Fangfeng), and Schizonepetae Spica (Jingjie) are prohibited, lest they disperse too much, causing exterior deficiency. Exterior deficiency leads to external consumption of Yuan Qi, resulting in collapse, itching, and exfoliation, causing death. Whose fault is this?
[Supplementing Qi without Supplementing Blood in Deficiency Patterns] In weak smallpox cases, mental fatigue and blue-white complexion occur because insufficient Qi causes fatigue, and un-nourished Blood causes the complexion. Why treat deficiency by supplementing Qi but not Blood? Qi has spirit but no form; tonifying it is easy to fill. Blood has form but no spirit; tonifying blood yields slow results. Moreover, Qi is Yang and Blood is Yin; Yin follows Yang, and Blood follows Qi, which is logical. Thus, tonifying Qi makes it abundant, and Blood naturally follows to become abundant. Additionally, blood-tonifying agents like Angelicae Sinensis Radix (Danggui) and Rehmanniae Radix (Shengdi) moisten and slide downward; excessive use may cause loose stools. However, in some deficiency smallpox cases with white, sunken, un-nourished lesions, Danggui and Paeoniae Radix (Shaoyao) are reluctantly used. In cases of floating deficiency fire with numerous red spots resembling Blood heat, Leonuri Herba (Zicao), Safflower (Honghua), and Rehmanniae Radix (Shengdi) are reluctantly used for activating Blood and clearing Heat. All are wine-processed to counteract their sliding nature, using wine to reach the exterior. This achieves the subtlety of ascending and reaching the exterior within blood-tonifying and activating methods, avoiding intestinal lubrication and loose stools.
[Distinguishing Inevitable Deterioration in Deficiency Patterns] In Qi-deficient smallpox, initial symptoms include lingering low-grade fever, alternating hot and cold, relaxed skin, mental fatigue, blue-white complexion, reduced appetite, cold and hot extremities, vomiting, loose stools, faint and weak rash appearance, pale red thin skin, irregular eruption over 3-4 days, difficulty in growth, difficulty forming pus by day 5-6, shortness of breath with little food, diarrhea with food injury, collapse by day 7-8, ashen-white non-rising lesions, spontaneous sweating, slight thirst, abdominal distension, wheezing, thirst, diarrhea, collapse with itching, restlessness, grinding teeth, chills, warm head and cold feet. These are inevitable. Therefore, at the onset of Qi-deficient smallpox, Shensu Decoction, Renshen Baidu San, Huanglian Jiedu Tang, Shengma Gegen Tang, and Zicao Sandou Yin are inappropriate. Instead, use Renshen Huangqi Yin. Formulas causing rough breathing and dry skin are also contraindicated. Use Sizijunzi Decoction minus Ginseng, plus少量 Platycodonis Radix (Jiegeng) and Chuanxiong Rhizome (Chuanxiong), and Pericarpium Citri Reticulatae (Fupi). Adding mild ascending methods to tonification is excellent. Once spots are complete, heavily use Ginseng and Astragalus. By days 8-9, if no other ominous signs, proceed normally. If tops are depressed and ashen-white, not rising, with clear pus, spontaneous sweating, and slight thirst, add Cinnamon Twig (Guizhi) to major tonifying decoctions. For collapse, ashen-white, abdominal distension, and diarrhea, use Muxiang San. For collapse, itching, restlessness, abdominal distension, thirst, diarrhea, wheezing, warm head/cold feet, chills, and teeth grinding, urgently administer Yigong San.
[Deficiency Pattern Transforming into Excess] In Qi-deficient smallpox, if parents observe taboos, use correct medications, and manage care properly, Yuan Qi becomes sufficient, Cou Li solid, Spleen and Stomach strong, diet normal, and excretions regulated. However, excessive tonification, especially heavy use of Ginseng and Astragalus after pus formation, may cause abdominal distension and wheezing; use Zhike Tang. Mistaken use of Wuling San or Akebia Caulis (Mutong) in excess may cause constipation; use Kuanzhong San. Constipation with thirst calls for Ophiopogonis Decoction (Maimendong Tang). Overuse of Acorus Tatarinowii Rhizoma (Ding) and Cinnamon Bark (Gui) may cause sore throat, swelling, restlessness, and closed thirst; use Ziyin Runzao Tang. Wheezing, abdominal distension, hard constipation, restless thirst, and sore throat resemble excess patterns. However, Qi deficiency transforming into excess is not true excess; it is a mistake of shallow disease treated with deep/heavy medication. Careful adjustment is needed, not purging. Heavy purging will deplete newly generated Qi, leading to collapse.
[Deficiency Pattern Resembling Excess] In Qi-deficient smallpox, improper diet or care may damage the Spleen and Stomach, causing diarrhea. Fluids sink, deficiency fire rises, causing thirst. Yuan Qi sinks, deficiency Yang rushes upward, lower Qi fails to continue, causing wheezing. Thirst and wheezing are excess symptoms, but arising after diarrhea, they result from sudden fluid loss (thirst) and Qi deficiency (wheezing). Can real heat cause thirst and Qi rushing cause wheezing after diarrhea? No. Treat thirst with Shenling Baizhu San plus Muxiang. Persistent thirst and diarrhea call for Yigong San. Wheezing calls for Renshen Dingchuan Tang or Dushen Renxing Tang. Wheezing, thirst, and diarrhea call for Muxiang Yigong San. Restlessness, abdominal distension, internal attack of toxin, eyes closed, talking in delirium—this is loss of spirit. Mistaking this for excess shows great foolishness.
[Excess Pattern Resembling Deficiency] High fever, straight hair, dry skin, restless sleep, red cheeks, red eyes, rough breathing, restless thirst, abdominal distension, constipation, and wheezing are all excess patterns, caused by severe heat and heavy toxin obstruction. Vomiting may appear. Vomiting resembles deficiency, but if heat-toxin is internal and cannot expand, it rebels upward causing vomiting. The Classics state: All rebellious attacks belong to Fire. Cold invasion or irregular diet may damage Wind-Cold, preventing internal heat from expanding, causing rejection and vomiting. For toxin obstruction, ascending and dispersing is best. For rejection vomiting, guide downward using Polyporus (Zuling), Alisma Rhizoma (Zexie), and Tangerine Peel (Chenpi). Diarrhea may accompany these. Diarrhea resembles deficiency, but if caused by郁盛 heat-toxin roasting the Spleen and Stomach, preventing external release, toxin sinks and exits via orifices—this is heat-toxin pouring downward. Ancient texts say: Diarrhea before eruption indicates survival; diarrhea after eruption indicates death. Treatment involves ascending and dispersing to guide toxin to the exterior. Once toxin is resolved externally, internal leakage stops. If accompanied by food stagnation, add digestive agents; if severe, follow the pathogen. Lack of appetite is often considered internal deficiency, but郁热 patterns where toxin is trapped internally, blocking Cou Li, causing heat-toxin accumulation, abdominal distension, and lack of appetite are inevitable. Treatment involves ascending and dispersing to allow heat to expand, harmonizing Zang-Fu and restoring appetite. Mistakenly using hot herbs like Acorus, Cinnamon, and Pinellia for vomiting, diarrhea, or anorexia attacks heat with heat, worsening symptoms. Using tonics like Ginseng, Astragalus, Poria, and Atractylodes for abdominal distension and anorexia strengthens the pathogen, potentially killing the patient. This is the doctor's fault. Be cautious! Dragon Bone (Longgu) and Cardamom (Doukou) stop diarrhea; Medicated Leaven (Shenqu) and Hordeolum Vulgare (Maiya) aid digestion, but none are suitable for heat-toxin obstruction with anorexia. Future practitioners should note this.
[Heat Pattern Transforming into Deficiency] Blood-heat smallpox requires cooling and dispersing, not harsh bitter-cold agents. Overuse of cold agents like Cimicifugae Rhizoma (Shengma), Scutellariae Radix (Huangqin), and Coptidis Rhizoma (Huanglian), or slippery agents, damages the Spleen and Stomach internally and freezes muscles externally. Mild damage reduces appetite and causes loose stools; severe damage causes profuse watery diarrhea, leading to deficiency-cold. Frozen muscles prevent heat vaporization, close the Cou Li, prevent rash growth and pus formation, leading to hidden sinking. This is heat transforming into deficiency. Once deficiency is clear, treat as deficiency. Ginseng, Astragalus, Clove, and Cinnamon are not taboo. After 5-6 days, Muxiang Yigong San is appropriate. Judgment depends on careful examination.
[Obstructing Heat Transforming into Deficiency] Severe toxin obstruction requires ascending and dispersing as primary, assisted by cooling and detoxifying. Stop when balanced. Excessive dispersing empties the exterior, depletes Yuan Qi, leading to clear pus penetration, empty shells, itching/collapse/exfoliation, or non-healing ulcers. These indicate exterior deficiency. Exterior deficiency leads to Yuan Qi leakage and internal instability. Minor dietary errors cause diarrhea, leading to deficiency-cold and Qi collapse, with restlessness, thirst, chills, and teeth grinding. Once deficiency is known, treat as deficiency. Ginseng, Astragalus, Atractylodes Macrocephala Rhizome (Baizhu), Clove, Cinnamon, Ginger, and Aconite Root (Fuzi) are not taboo. After 6-7 days, even Muxiang Yigong San should be administered urgently. Adjust based on examination.
[Distinguishing Use of Yigong San for Obstructing Heat] Real heat obstruction often uses cold agents, causing ice-like fixation and diarrhea, or excessive dispersing causing exterior deficiency. Once ice-hard, use mild medicines; Ginger and Cinnamon heat are not taboo. After diarrhea, heat dissipates, True Qi becomes deficient. Deficiency requires tonification. Qi deficiency implies cold; clear deficiency-cold requires warming and tonification. Thus, although initial blood-heat obstruction exists, by days 3-4, if the body is cool and skin cold, and rash does not grow, mild agents like Official Cinnamon (Guigui), Dried Ginger (Ganjiang), and Chuanxiong Rhizome (Chuanxiong) are necessary to warm internal Qi, harmonizing external Qi. After diarrhea, the interior is definitely deficient. Even with abdominal distension, restlessness, thirst, and wheezing, it is not real heat, but internal deficiency with hidden sinking and internal toxin attack. Therefore, real heat cases with diarrhea on days 7-9 are treated as deficiency. If Muxiang Yigong indications exist, use Muxiang Yigong. Without ice-hard signs, do not mistakenly use warming agents. Without diarrhea, do not mistakenly use Muxiang Yigong. Collapse, inverted crusting, dryness without ice-hardness or diarrhea are usually due to internal heat-toxin attack; thus, Baixiang or Zhuwei formulas are appropriate.