钱氏云∶疮疹惟用温平药治之，不可妄下，及妄攻发。《活人书》云∶小儿疮
疹与伤寒相类，头痛身热，足冷脉数，疑似之间，只与升麻汤解肌，兼治疮子，已
发未发皆可服，但不可疏转，此为大戒。伤寒身热，固不可下，疮疹发热在表，尤
不可转，世人不学，乃云初觉以药利之，宣其毒也，误矣。（海藏云，此论虽当，在经则可，若
热甚过极足冷，或内伤腹热足冷，宜以寒药如洗心、调胃，及化食药通膈之类主之，
然当求责脏腑秘与不秘，脉道何如耳。许氏云，上热下冷，伤食也， 疹初热，手足亦冷，
惟伤寒一身尽热，不与足冷相类，此伤食，非伤冷也，若伤冷不宜用。王德孚用感应丸治之。）
痘疮已出，不可疏转，出得已定，脓血太盛，却用疏利、亦非也。（海藏云，此言若在经而出
不尽者为当，若腹胃有垢腻，便时后重如痢疾，及脉滑在里者，亦当微下。）大抵疮疹首
尾皆不可下。（海藏云，脏府有凝滞者，不可拘此。）小儿身耳尻冷，咳嗽，辄用利药，即害人。
（海藏云，此言里和而少阳之气，在经热者，故用化毒犀角汤，为气出里，若气未出，里未尽，求责疏利，亦可。）
凡治疹痘，才泻则令内陷，决不可轻易转下，惟大小便多日不利，宜微微利之，及痘已靥，
尚有余热停留，或作热，或作疮痍，或成痈，宜四顺饮下之，不特消余毒，亦免生
他证，累试累验。每见疹痘者服发表麻黄药出汗，阳气尽出肤表，遂至 烂脏虚，
虚则腹痛自利，或作寒战，或作阴痫，死者多矣。凡疮疹证见及 点既生，若
无内外寒热虚实者，但安养之，任其自然，则非惟不生他证，亦易于调理，今人则才
见点，罔顾所蕴轻重，惟恐不出，用药表之，服以紫草、蝉蜕，副以人齿、猴梨，
并与酒曲芫荽，无所不试，曾不知毒瓦斯遇发，则一倍变为十倍，十疮合为一疮，名
为烂，五内七窍，至于皆有，则重者不救，轻者为声哑，为目疾，为 烂，为闭
耳塞鼻之患。又有过用表药，里无阳气以应之，为虚脱者多矣，此妄表之过也。大
抵疮疹已出，正赖胃气运其毒瓦斯，善攻其热者，热甚则利小便，盖小便利，则心火
有所导引，虽不用冷药，热亦自减矣。热轻则解其热，盖小热不解，大热必生，小
热而利其小便，则虑损气，故但当解热也。利小便之药导赤散为上，解毒之剂如玳
瑁汤、独胜散、安 散、如圣散、紫草汤、犀角饮皆可选用。昧者但言疮疹是热，
时进凉剂，致胃气转虚，令儿胸满腹胀，又且下之，内虚毒入，则杀人甚速，此不
善下之过也。若小儿鼻塞唇焦，内伏热也。脉细，面色痿黄或青色，皮肤慢，口吐
青涎者，此误下证也，或里无蕴热，亦何可下？要之，治热以温，凉而行之，未至
于冷。治寒以温，未至于热。当从其渐而已。洁古云∶大凡 疹首尾皆不可下，
恐动则生变，此谓少阳通表，宜和之也。当先安里解毒，次微发之，解毒须安五脏，
防风汤是也。如大便不秘者，须微发之，药宜钱氏方中选而用之。如大便过秘，宜
微利之，当归丸、枣变百祥丸是也。初知 疹，若使之并出，小儿难禁，是以别
生他证也。首尾不可下者，首曰上焦，尾曰下焦，若既吐利，安可下，便宜安里。
若不吐泻者，先与安里药三五服，如能食而大便秘结内实者，宜疏利之。若内虚而
利者，宜用安里药一二服，末后一服调以微发之药，要之，安里之药多，发表之药
少，秘则微疏之，令邪气勿壅并，而能作番次出，使儿易禁也。身温者顺，身凉者
逆，二者，宜多服防风汤和之。（防风汤方见大法。）海藏云∶假令五日已里，诸病与 疹
不能别辨者，不可疑作 疹，必须发之，但各从其所伤应见治之，皆不妨 出，若
强发之，其变不可胜数矣。前人言首尾俱不可下者，为 未显于表，下则邪气不得
伸越，此脉证有表而无里，故禁首不可下也。尾不可下者为 毒已显于外，内无根
蒂，大便不实，无一切里证，下之则 气逆陷，故禁尾不可下也。又言温暖盖覆，
不令通风，以 未出，或身表凉而恶寒，或天令寒而恶冷，温暖盖覆，不令通风也，
若已出，身热天暄，何必用盖覆而不使之通风乎，后人执此二句，首尾俱不敢下，
温燠不令通风，不知天令之所加，人身之所盛，致使误人多矣。大抵前人之言，随
时应变，后之人不知其变，故常执而不移也。噫、首尾俱不可下者，以其始终脏腑
元无凝滞也，若有一切里证，及大便结者，安得不下。温暖不使之通风，以其发在
冬时，故如此也，若发在夏时， 虽未出，亦不用此也。 之用药，大率以脉为主，
浮中沉之诊，平举按之，候察其虚实，定其中外，则可以万全矣。〔万〕今之治痘
者曰首尾不可汗下，听者和之，曰痘宜温补，汗下，不可也。此亦喜补恶攻之遗弊。
殊不知治痘之法，莫要于解毒，或攻或补，务使毒瓦斯得解而已，如其气血和畅，荣
卫流通，表里无邪，其出则尽，其发则透，其收则时，非但不可汗下，虽温补亦不
可用也。设使外感风寒，约束皮肤，闭密腠理，疮出不快，此当汗之，令阴阳和，
荣卫通，而疮易出，毒得解散可也，苟不汗之，则毒无从得出，留伏于内，未免闭
门留寇之祸矣。如大热不退，烦渴转增，谵妄昏沉，便溺阻塞，此毒蓄于肠胃之间，
与谷气并，宜急下之，使脏腑疏通，陈 涤去可也，苟不下之，则藏污蓄毒，
煎熬于中，宁无养虎遗患之悔乎。故大要曰∶谨守病机，各司其属，有者求之，无
者求之，盛者责之，虚者责之，必先五胜，疏其血气，令其条达，而致和平。此之谓也。
钱乙说：治疗疮疹（小儿出疹性疾病）只宜使用温和平和的药物，不可随意使用泻下药，也不可妄用攻伐或发汗的方法。《活人书》说：小儿的疮疹与伤寒症状相似，都有头痛、身体发热、脚冷、脉搏数快的表现，在难以辨别的时候，只给予升麻汤来解肌退热，同时也能治疗疮疹，无论疹子已经发出还是尚未发出都可以服用，但绝对不可以使用导致腹泻滑利的药物，这是最大的禁忌。伤寒引起的身体发热，本来就不可以使用泻下法；疮疹引起的发热如果在表证阶段，更不可以使用通利大便的方法。世人不学习医理，竟然说初起时用药通便是为了宣排毒邪，这是错误的。（张元素说：这个理论虽然正确，但如果病邪在经络层面是可以适用的；如果热势极盛导致脚冷，或者内伤饮食导致腹部发热而脚冷，应当使用寒凉药物，如洗心散、调胃承气汤，以及消食化积、通畅膈窍之类的方剂为主进行治疗，但必须审察脏腑是否有凝滞不通，脉象如何。许叔微说：上热下冷，是伤食的表现；疮疹初起发热，手足也冷，只有伤寒是一身尽热，不与脚冷相似，这是伤食，不是受寒，如果是受寒就不宜用这种治法。王德孚用感应丸来治疗。）痘疮一旦发出，就不可以再用通利大便的方法；如果痘疮已经出齐，脓血过多，却再用疏利通便的方法，也是不对的。（张元素说：这话如果是指病邪在经且痘出不尽的情况是对的；如果腹胃中有垢腻积滞，排便时有后重感像痢疾一样，以及脉象滑而在里的情况，也应当轻微地泻下。）大抵来说，疮疹从头到尾都不可以使用泻下法。（张元素说：如果脏腑有凝滞不通的情况，则不能拘泥于这一条。）小儿出现耳朵、屁股发冷，咳嗽，就轻易使用泻利药物，就会伤害病人。（张元素说：这话指的是里气调和而少阳经气有热的情况，所以使用化毒犀角汤，因为气机向外透发；如果气机尚未完全透出，里气未尽调和，寻求疏利通便的方法，也可以考虑。）凡是治疗疹痘，只要一开始腹泻就会导致邪气内陷，决不可以轻易使用通下法，只有当大小便多日不通利时，才适宜微微地通利一下。等到痘疮已经结痂脱落，尚有余热停留，或者表现为发热，或者形成疮疡，或者变成痈肿，适宜用四顺饮来泻下，这不仅能够消除余毒，也能避免产生其他病症，多次尝试都验证有效。经常见到患疹痘的人服用发表发汗的麻黄类药物出汗，导致阳气全部耗散在体表，从而造成内脏虚损，虚弱则腹痛自利，或者发生寒战，或者发生阴痫，死亡的很多。凡是疮疹证候显现及痘点已经生成，如果没有内外寒热虚实等复杂情况，只需安心调养，顺应自然，那么不仅不会生出其他病症，也易于调理。现在的人一看到痘点，不顾体内蕴结毒邪的轻重，唯恐痘出不来，就用药物强行发散，服用紫草、蝉蜕，配合人齿、猴梨，甚至加上酒曲、芫荽，无所不用其极，却不知道毒邪遇到发散药物，会由一倍变为十倍，十个疮合为一个疮，称为“烂”，五脏七窍都会受到损害，重的无法救治，轻的会导致声音嘶哑、眼疾、皮肤溃烂、耳闭鼻塞等祸患。又有过度使用发散药物，导致体内没有阳气来呼应，造成虚脱的也很多，这是妄用发散法的过错。大抵疮疹已经发出，正依赖胃气来运解毒邪，善于清除热邪的方法是利小便，因为小便利，心火就有引导出路，即使不使用寒凉药物，热邪也会自然减退。热邪较轻时，只需解除其热，因为小热不解，大热必生，对小热如果使用利尿法，担心损伤正气，所以只应当清热。利小便的药物以导赤散为最佳，解毒的方剂如玳瑁汤、独胜散、安宫散、如圣散、紫草汤、犀角饮都可以选用。愚昧的人只说疮疹是热证，时常进服凉剂，导致胃气更加虚弱，使孩子胸满腹胀，又进而使用泻下法，导致内虚毒邪内陷，杀人非常快，这是不善于使用泻下法的过错。如果小儿鼻塞、嘴唇焦干，是内有伏热。如果脉象细，面色萎黄或青，皮肤松弛，口吐青涎，这是误用泻下法导致的证候，如果体内没有蕴结的热邪，又怎么可以使用泻下法呢？总之，治疗热证要用温药，但要凉着服用，不至于太冷。治疗寒证要用温药，但不至于太热。应当循序渐进。李东垣说：大凡疹痘从头到尾都不可以使用泻下法，恐怕一动就会产生变证，这是指少阳经气通达体表，适宜调和的方法。应当先安定里气并解毒，其次轻微地发散，解毒必须安固五脏，防风汤就是这样的方剂。如果大便不秘结，需要轻微发散，药物应当在钱乙的方剂中选择使用。如果大便过于秘结，适宜轻微通利，当归丸、枣变百祥丸就是这样的方剂。刚开始发现疹痘，如果让它们一起爆发出来，小儿难以承受，因此会产生其他病症。所谓首尾不可下，首指上焦，尾指下焦，如果已经呕吐腹泻，怎么可以再泻下，应当先安定里气。如果不呕吐腹泻，先给安定里气的药物三五服，如果能进食且大便秘结、内实者，适宜疏利通便。如果内虚而腹泻，适宜使用安定里气的药物一二服，最后一服用轻微发散的药物调服，总之，安定里气的药多，发表的药少，便秘则轻微疏通，使邪气不要壅塞聚集，能够分批透出，使小儿容易耐受。身体温暖的是顺证，身体发凉的是逆证，这两种情况，适宜多服用防风汤来调和。（防风汤方见大法篇。）张元素说：假如五天内，各种病症与疹痘无法分辨清楚，不要怀疑是疹痘，必须发散，但各自根据所受的病邪应见的症状来治疗，都不妨碍疹痘透出，如果强行发散，产生的变证不可胜数。前人说首尾都不可下，是因为疹痘未显于体表，如果泻下则邪气不得伸展越出，这是脉证有表而无里，所以禁止开头不可下。结尾不可下是因为毒邪已显于外，内部没有根基，大便不实，没有一切里证，如果泻下则痘气逆陷，所以禁止结尾不可下。又说温暖覆盖，不让通风，是因为疹痘未出，或者身体表面凉而恶寒，或者天气寒冷而恶冷，所以要温暖覆盖，不让通风。如果已经发出，身体热、天气暖，何必还要覆盖而不让通风呢？后人执着于这两句话，首尾都不敢下，温暖覆盖不让通风，不知道天时变化和人体盛衰的关系，致使误人很多。大抵前人的言论，是随时间变化而应变的，后的人不知道其中的变化，所以常常固执不变。唉！首尾都不可下，是因为始终脏腑原本没有凝滞；如果有一切里证，以及大便结者，怎么能不下呢？温暖不让通风，是因为发生在冬季，所以如此；如果发生在夏季，即使疹痘未出，也不用这种方法。治疗疹痘的用药，大体以脉象为主，通过浮中沉三部诊法，平举按之，候察其虚实，确定其中外关系，就可以万无一失了。[万全]现在的治痘者说首尾不可汗下，听的人都附和说痘宜温补，汗下是不可以的。这也是喜欢补益厌恶攻伐的遗留弊病。殊不知治疗痘疮的方法，没有比解毒更重要的，或者攻伐或者补益，务必使毒邪得以解除而已。如果气血和畅，营卫流通，表里没有邪气，那么痘疮就能出尽、发透、收适时，不仅不可汗下，就连温补也不可用。假设外感风寒，约束皮肤，闭塞腠理，痘出不快，这应当发汗，使阴阳调和，营卫通畅，而痘疮容易发出，毒邪得以解散，这是可行的。如果不发汗，则毒邪无从得出，留伏在内，难免有闭门留寇的祸患。如大热不退，烦渴加重，谵语昏沉，大小便阻塞，这是毒邪蓄积在肠胃之间，与谷气搏结，应当紧急泻下，使脏腑疏通，陈腐污秽涤除干净，这是可行的。如果不泻下，则藏污蓄毒，在中焦煎熬，难道没有养虎遗患的后悔吗？所以大意说：谨慎地守住病机，各司其职，有的求其因，无的求其源，盛的责其过，虚的责其亏，必先了解五行胜复，疏通其血气，使其条达，从而达到和平状态。说的就是这个道理。
Qian Yi stated: For treating chuangzhen (pediatric exanthematous diseases), only mild and neutral medicines should be used; one must not recklessly administer purgatives, nor indiscriminately use attacking or diaphoretic methods. The *Huoren Shu* (Book of Living People) states: Pediatric chuangzhen resembles shanghan (cold damage syndrome); symptoms include headache, body heat, cold feet, and a rapid pulse. In cases of ambiguity, only Shengma Tang (Cimicifugae Decoction) should be given to release the muscle layer and treat the rash; it can be taken whether the rash has erupted or not, but laxative or slippery-purgative drugs must absolutely be avoided. This is the greatest taboo. Body heat caused by shanghan should indeed not be treated with purgation; furthermore, fever from chuangzhen located in the exterior level especially must not be treated with bowel-regulating purgatives. Unlearned people in the world claim that using medicine to induce defecation at the onset is to promote the discharge of toxins, which is erroneous. (Zhang Yuansu stated: Although this theory is correct when applied to pathogenic factors in the meridians, if heat is extreme causing cold feet, or if internal food injury causes abdominal heat with cold feet, cold medicines such as Xixin San (Heart-Washing Powder), Tiaowei Chengqi Tang (Regulate the Stomach and Commanding Qi Decoction), and formulas for resolving food stagnation and clearing the diaphragm should be primarily used. However, one must investigate whether the zang-fu organs are stagnant and examine the pulse condition. Xu Shui stated: Upper heat and lower cold indicate food injury. Rash onset with heat and cold hands/feet differs from shanghan where the whole body is hot without cold feet; this is food injury, not cold injury, so it is not suitable for cold-injury treatments. Wang Defu treated it with Yinggan Wan (Induction Pill).) Once douchuang (smallpox) has erupted, purgatives must not be used. If the eruption is complete and pus/blood is excessive, using laxatives is also incorrect. (Zhang Yuansu stated: This statement applies correctly to pathogenic factors in the meridians with incomplete eruption; however, if there is greasy stagnation in the abdomen/stomach, tenesmus resembling dysentery during defecation, or a slippery pulse indicating interior pathology, mild purgation is appropriate.) Generally, chuangzhen should not be treated with purgatives from beginning to end. (Zhang Yuansu stated: If the zang-fu organs have stagnation, one cannot rigidly adhere to this rule.) If a child has cold ears, buttocks, and cough, and laxatives are immediately administered, it harms the patient. (Zhang Yuansu stated: This refers to a harmonious interior with heat in the Shaoyang meridian; thus, Huadu Xijiao Tang (Detoxifying Rhinoceros Horn Decoction) is used because qi is moving outward. If qi has not fully emerged and the interior is not yet harmonized, seeking mild purgation may also be considered.) When treating rashes and smallpox, any initial diarrhea causes pathogenic factors to sink inward; one must never lightly use purgatives. Only when urination and defecation have been blocked for many days should mild promotion of flow be used. After smallpox pustules have crusted, if residual heat remains, manifesting as fever, sores, or abscesses, Sishun Yin (Four Compliance Drink) should be used to purge. This not only eliminates residual toxins but also prevents other syndromes; repeated trials have verified its efficacy. I often see patients taking Mahuang (Ephedra) to induce sweating for rash/smallpox treatment; this exhausts yang qi to the surface, leading to visceral deficiency. Deficiency causes abdominal pain and spontaneous diarrhea, chills, or yin epilepsy, resulting in many deaths. When chuangzhen signs appear and spots form, if there are no exterior-interior, cold-heat, or deficiency-excess patterns, one should simply nurture the patient and allow nature to take its course. This prevents other syndromes and facilitates regulation. Modern practitioners, upon seeing spots, ignore the severity of internal toxin accumulation and fear non-eruption; they use drugs to force eruption, administering Zicao (Arnebiae Radix et Rhizoma), Chantui (Cicadae Periostracum), human teeth, monkey pears, wine qu, and Yuanxu (Coriandri Fructus), trying everything. They fail to realize that when toxins encounter eruptive drugs, potency increases tenfold; multiple sores merge into one called "lan" (rotting), affecting the five viscera and seven orifices. Severe cases are incurable; mild cases result in hoarseness, eye diseases, skin ulceration, ear blockage, and nasal obstruction. Overuse of diaphoretics often leads to collapse due to lack of interior yang support; this is the fault of reckless diaphoresis. Generally, once chuangzhen erupts, stomach qi is needed to transport and resolve toxins. The best method to clear heat is promoting urination; clear urine allows heart fire to drain, reducing heat even without cold medicines. For mild heat, simply resolve the heat; unresolved mild heat generates severe heat. Since diuresis may damage qi, one should only clear heat. Daoshi San (Guide Out Red Powder) is superior for promoting urination. Detoxifying agents like Dai Mao Tang (Trionyx Decoction), Dusheng San (Sole Victory Powder), Angong San (Peace Palace Powder), Rusheng San (Like Sage Powder), Zicao Tang (Arnebia Decoction), and Xijiao Yin (Rhinoceros Horn Drink) are all selectable. Ignorant people claim chuangzhen is heat and frequently administer cooling agents, worsening stomach qi deficiency, causing chest fullness and abdominal distension, then resort to purgation. Internal deficiency allows toxins to enter, killing rapidly; this is the fault of improper purgation. Nasal congestion and dry lips indicate latent internal heat. Fine pulse, sallow or green complexion, flaccid skin, and spitting of blue saliva indicate misdiagnosis from prior purgation. If there is no internal heat accumulation, how can purgation be justified? In summary, treat heat with warm medicines taken coolly, avoiding excessive cold. Treat cold with warm medicines, avoiding excessive heat. Proceed gradually. Li Dongyuan stated: Generally, chuangzhen should not be purged from start to finish, lest movement cause complications. This refers to Shaoyang meridian patency favoring harmonization. First, stabilize the interior and detoxify; second, mildly erupt. Detoxification requires stabilizing the five viscera; Fangfeng Tang (Saposhnikoviae Decoction) serves this purpose. If stool is not constipated, mild eruption is needed, selecting from Qian Yi's formulas. If stool is severely constipated, mild purgation is indicated; Danggui Wan (Angelica Pill) and Zaobian Baixiang Wan (Date-Transformed Baixiang Pill) are appropriate. At early rash/smallpox onset, forcing simultaneous eruption overwhelms the child, causing other syndromes. "Start and end no purgation": Start refers to Upper Jiao, End to Lower Jiao. If vomiting/diarrhea occur, do not purge; stabilize the interior first. If no vomiting/diarrhea, give interior-stabilizing medicine 3-5 doses. If appetite is good but stool is constipated and interior excess exists, mild purgation is suitable. If interior deficiency with diarrhea exists, use interior-stabilizing medicine 1-2 doses, finishing with a mild eruptive agent. Generally, more interior-stabilizing than exterior-releasing medicine; mild unblocking prevents pathogenic congestion, allowing sequential eruption for better tolerance. Warm body indicates favorable prognosis; cold body indicates unfavorable. Both benefit from frequent Fangfeng Tang administration. (Fangfeng Tang formula seen in General Principles chapter.) Zhang Yuansu stated: If within five days, various symptoms and rash cannot be distinguished, do not doubt it is rash; eruption is necessary, but treat according to specific pathogenic injuries. Allowing natural eruption avoids complications; forced eruption yields countless variations. Predecessors said "start and end no purgation" because before eruption, purgation traps pathogens; this is exterior pattern without interior involvement, forbidding early purgation. Late purgation is forbidden because toxins are external with no root, stool is loose, and no interior signs exist; purgation causes qi reversal and sinking. Also, warming covers and preventing drafts apply when rash is un-erupted, or body is cool/chills present, or weather is cold. If erupted, body hot, weather warm, why cover and prevent ventilation? Later generations rigidly applied these two rules, fearing purgation and enforcing warmth/no-ventilation, ignoring seasonal and physiological changes, causing much harm. Predecessors' words adapted to times; later generations failed to adapt, remaining rigid. Alas! "Start and end no purgation" assumes no initial visceral stagnation; if interior signs or constipation exist, purgation is necessary. Warming/no-ventilation applies to winter eruptions; summer eruptions do not require this. Rash/smallpox medication primarily relies on pulse diagnosis: floating, middle, deep palpation to assess deficiency/excess and determine interior-exterior status ensures safety. [Wan Quan] Current smallpox practitioners say "start and end no sweating or purging," and followers agree "smallpox favors warming tonification, sweating/purging are contraindicated." This is the legacy of preferring tonification over attack. Little do they know that resolving toxins is paramount in smallpox treatment; whether attacking or tonifying, the goal is toxin resolution. If qi-blood is harmonious, ying-wei circulates freely, and no exterior-interior pathogens exist, eruption will be complete, development thorough, and recovery timely; neither sweating/purging nor warming tonification is needed. If external wind-cold constrains skin and closes pores, slowing eruption, sweating is required to harmonize yin-yang and ying-wei, facilitating eruption and toxin release. Without sweating, toxins remain trapped internally, akin to locking the door and keeping the thief inside. If high fever persists, thirst worsens, delirium/coma occurs, and urination/defecation are blocked, toxins accumulate in intestines/stomach mixing with grain qi; urgent purgation is needed to clear viscera and remove filth. Without purgation, toxins ferment internally, inviting disaster. Thus, the essence is: Carefully observe disease mechanisms, assign responsibilities, seek causes for existing signs, investigate origins of absent signs, address excess and deficiency, understand five-element interactions, unblock blood-qii, ensure smooth flow, and achieve harmony. This is the principle.