痘疮成浆之时。精神倦怠。神思昏沉。不省人事。呼之不应。自语呢喃。如邪祟状。此痘出
太过。心脏空虚。神无所根据也。人参酸枣汤。气虚。大剂独参。或保元加枣仁、茯神。若烦热气
壮。痰涎涌盛者。改定清心丸。如服药后不宁。反加闷乱者死。浆清不食者。不治。
痘疮多汗。则津液外泄。或未浆。或既靥。并宜保元汤加养血药。然又有面赤发渴。汗出不
及腰者。皆胃热肾虚。四君子汤去术易麦冬。下六味丸。若面赤作渴。手足心热。大便坚者。肠
胃实热也。泻黄散。若初起发热时。自汗不妨。乃湿热熏蒸而然。切不可便用 、术之类以实腠
理。亦不可妄用升、葛之类以泄肌肉。盖自汗则痘热已轻。恐发泄太甚。则津液内耗。阴随阳散
。难以收靥。即靥后自汗。亦宜详审而治。若血虚自汗。则至夜烦热作渴。当归补血汤。气虚不
能自固而汗。则动作喘息。力微身热。四肢不温。四君子加归、 。有痘出平塌。淡白少神。身
凉而汗者。保元汤加肉桂、当归。有重帏暖炕。浓衣重衾而多汗者。宜渐减以清适之。
痘疹失血。俱为危候。若气血旺。毒火盛而失血者。乃邪从血解。不可妄投止血之剂。惟宜
清血解毒。若治之不止者凶。有气血虚而毒盛失血者。不治。有闷痘五窍流血者。不治。有痘倒
而鼻流血水者。不治。有热证误投热剂而失血者。宜清凉解毒。痘未尽出而用寒凉。毒为凉激
伤脾。不能运动其血。致逆于脏府之中。内毒搏滞于胸膈之上。积成秽血。妄行而暴吐衄昏晕。
痘色淡白陷伏者。理中汤、独参汤并加肉桂。温补为主。所谓血脱益气。阳生阴长是也。若痘尖
绽紫滞而衄者。乃毒火刑金。犀角地黄汤加炒黑山栀。有靥后余毒乘脾。脾气受伤。不能统血而
衄。小剂参
苓白术散加炒黑连、芍。若躁热闷乱。口干渴甚而衄。手足并热者。犀角地黄去丹皮加黄连、山栀
、炮姜。亦有中气虚而不时哄热。手足时冷时热而衄。此清阳之气不能上升。无根之火倏往倏来
也。补中益气加芍药、肉桂。有毒盛壅炽。肺金受制。流注大肠而便血者。四物汤换生地加芩、连
。若下血不止。昏睡不醒者危。凡痘中失血。惟从鼻出者。可治。从口中及口鼻齐出者。多不治。
亦有从痘疮出者。则为走泄。走泄多则分肉空虚。毒无定位。是皆有犯于里。为难治也。
痘疮进入化脓阶段时，患者精神疲倦乏力，神志昏沉模糊，意识不清，呼之不应，自言自语、低声呢喃，症状如同被邪祟附体一般。这是因为痘疹发出过多，导致心脏气血空虚，心神失去了依附的根本。此时应使用人参酸枣汤；若属于气虚证，则用大剂量的独参汤，或者在保元汤中加入酸枣仁、茯神。如果患者出现烦躁、发热、气息壮盛且痰涎涌盛的情况，改用定清心丸。如果在服药后不仅没有安宁，反而更加烦闷混乱，则预后不良，主死。如果痘浆清澈但患者无法进食，则属不治之症。
痘疮患者出汗较多，会导致津液从体表外泄。无论是在痘疹尚未化脓的阶段，还是已经结痂的阶段，都适宜使用保元汤加入养血药物进行治疗。然而，又有面部发红、口渴、出汗仅到达腰部以下的情况，这属于胃热肾虚，治疗应用四君子汤去掉白术，改用麦冬，并配合服用六味地黄丸。如果是面部发红且口渴，手足心发热，大便干结的，则是肠胃实热证，使用泻黄散。如果在痘疹初起发热时出现自汗，这是可以接受的，因为这是湿热熏蒸所致，切不可立即使用苍术、白术等药物来固密腠理，也不可滥用升麻、葛根等药物来发散肌肉之邪。因为自汗说明痘毒的热势已经减轻，担心发汗太过会耗伤体内津液，导致阴随阳散，难以顺利结痂。即使是结痂后的自汗，也应当仔细审察病因再进行治疗。若是血虚导致的自汗，则会在夜间出现烦热和口渴，使用当归补血汤。若是气虚不能固摄津液而导致的汗出，则表现为活动后喘息、力气微弱、身体发热、四肢不温暖，使用四君子汤加入当归、黄芪。如果有痘疹形态平塌、颜色淡白缺乏神采、身体发凉且出汗的，使用保元汤加入肉桂、当归。如果有患者在厚重的帷帐、温暖的炕上，穿着多层厚衣盖着厚被子却仍然多汗的，应当逐渐减少衣物和被褥，使其感到清爽舒适。
痘疹出现失血症状，都属于危重证候。如果患者气血旺盛，毒火炽盛而导致的失血，这是病邪随着血液排出体外，不可随意投用止血药物，只宜采用清血解毒的方法。如果治疗无效，出血不止，则预后凶险。如果是气血虚弱而毒火炽盛导致的失血，属于不治之症。如果是闷痘（痘疹内陷）导致五官七窍流血的，属于不治之症。如果是痘疹倒靥（痘疹内陷不起）且鼻孔流出血水的，属于不治之症。如果是热证误用了温热药物而导致的失血，应当使用清凉解毒的方法。如果在痘疹尚未完全发出时就使用了寒凉药物，导致毒邪被寒凉激惹而损伤脾胃，脾胃不能运化推动血液运行，致使血液逆乱于脏腑之中，体内的毒邪搏结停滞于胸膈之上，积聚形成污秽之血，妄行而导致突然吐血、鼻衄、昏晕。对于痘色淡白、凹陷伏没的患者，使用理中汤、独参汤并加入肉桂，以温补为主要治法，这就是所谓的“血脱益气”，即通过补气使阳气生发从而促进阴血生长。如果是痘顶绽开呈紫色且滞涩不畅并伴有鼻衄的，这是毒火刑克肺金所致，使用犀角地黄汤加入炒黑山栀。如果是结痂后余毒侵袭脾脏，脾气受伤，不能统摄血液而导致的鼻衄，使用小剂量的参苓白术散加入炒黑黄连、芍药。如果是躁动烦热、烦闷混乱、口干极度口渴且鼻衄，手足均发热的，使用犀角地黄汤去掉丹皮，加入黄连、山栀、炮姜。也有因中气虚弱而不时阵发性发热，手足时而冷时而热并伴有鼻衄的，这是清阳之气不能上升，无根之火忽去忽来的表现，使用补中益气汤加入芍药、肉桂。有毒邪炽盛壅滞，制约了肺金，流注到大肠而导致便血的，使用四物汤将熟地黄换为生地黄，并加入黄芩、黄连。如果下血不止，昏睡不醒的，病情危重。凡是痘疹中的失血，只有从鼻子出来的，还可以治疗；从口中以及口鼻同时出来的，大多无法治愈。也有从痘疮本身渗出血的，这称为“走泄”。走泄严重会导致分肉之间空虚，毒邪没有固定的定位，这些都是病邪侵犯内部的表现，属于难治之症。
During the stage when smallpox pustules are filling with pus, the patient exhibits mental fatigue and lassitude, mental confusion and lethargy, loss of consciousness, unresponsiveness to calls, muttering to oneself, resembling a state of possession by evil spirits. This is due to excessive eruption of the smallpox, resulting in emptiness of the Heart, where the Shen (Spirit) lacks a foundation. Ren Shen Suan Zao Tang (Ginseng and Sour Jujube Seed Decoction) should be used. For Qi deficiency, a large dose of Du Shen Tang (Single Ginseng Decoction) or Bao Yuan Tang (Protect the Origin Decoction) added with Suan Zao Ren (Sour Jujube Seed) and Fu Shen (Poria with Hostwood) is indicated. If there is irritability, high fever, vigorous breathing, and profuse phlegm-saliva, Ding Qing Xin Wan (Fixed Clear Heart Pill) should be substituted. If after taking medicine the patient becomes restless and instead experiences increased oppression and chaos, death ensues. If the pus is clear but the patient cannot eat, it is incurable.
Excessive sweating in smallpox leads to the external leakage of Body Fluids. Whether before the pustules form or after they have crusted over, Bao Yuan Tang (Protect the Origin Decoction) added with Blood-nourishing herbs is appropriate. However, if there is facial flushing, thirst, and sweating only reaching below the waist, this indicates Stomach Heat and Kidney Deficiency. Si Jun Zi Tang (Four Gentlemen Decoction) with Bai Zhu (Atractylodis Rhizoma) removed and replaced by Mai Dong (Ophiopogonis Radix), combined with Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill), should be administered. If there is facial flushing, thirst, heat in the palms and soles, and hard stool, this is Excess Heat in the Intestines and Stomach; Xie Huang San (Drain Yellow Powder) is indicated. If spontaneous sweating occurs during the initial fever at the onset of the disease, it is acceptable, as it results from Damp-Heat steaming. One must not hastily use Cang Zhu (Atractylodis Rhizoma) or Bai Zhu (Atractylodis Rhizoma) to consolidate the Cou Li (interstitial spaces), nor recklessly use Sheng Ma (Cimicifugae Rhizoma) or Ge Gen (Puerariae Lobatae Radix) to disperse muscle-layer pathogens. Since spontaneous sweating indicates that the smallpox heat has already subsided, one must fear that excessive sweating will consume internal Body Fluids, causing Yin to dissipate with Yang, making it difficult for the lesions to crust over. Even spontaneous sweating after crusting requires careful examination and treatment. If spontaneous sweating is due to Blood deficiency, there will be night-time irritability and thirst; Dang Gui Bu Xue Tang (Angelica Sinensis and Astragalus Decoction) is indicated. If sweating is due to Qi deficiency failing to secure the exterior, symptoms include panting upon movement, weak strength, body heat, and cold limbs; Si Jun Zi Tang (Four Gentlemen Decoction) added with Dang Gui (Angelicae Sinensis Radix) and Huang Qi (Astragali Radix) is used. If the eruptions are flat, pale, lacking spirit, with a cool body and sweating, Bao Yuan Tang (Protect the Origin Decoction) added with Rou Gui (Cinnamomi Cortex) and Dang Gui (Angelicae Sinensis Radix) is indicated. If a patient sweats excessively despite being in heavy curtains, on a warm kang, wearing thick clothes and heavy quilts, the bedding and clothing should be gradually reduced to achieve comfort and clarity.
Hemorrhage in smallpox/rash diseases is always a critical condition. If hemorrhage occurs due to robust Qi and Blood and intense toxic fire, it signifies that the pathogen is resolving through the blood; hemostatic agents should not be used blindly. Instead, clearing the blood and detoxifying is appropriate. If treatment fails to stop the bleeding, the prognosis is ominous. If hemorrhage occurs due to deficient Qi and Blood combined with intense toxicity, it is incurable. If "stifling smallpox" (internalized eruptions) causes bleeding from the five orifices, it is incurable. If inverted smallpox causes bloody fluid to flow from the nose, it is incurable. If hemorrhage results from misapplying hot formulas to a Heat syndrome, cooling and detoxifying methods should be used. If cold-natured drugs were used while the eruptions had not fully emerged, the toxin was shocked by the cold, damaging the Spleen and Stomach, preventing them from moving the blood. This causes blood to rebel within the Zang-Fu organs, with internal toxins stagnating in the chest and diaphragm, accumulating into foul blood that flows recklessly, causing sudden hematemesis, epistaxis, and syncope. For pale, white, depressed, and sunken eruptions, Li Zhong Tang (Regulate the Middle Decoction) and Du Shen Tang (Single Ginseng Decoction) added with Rou Gui (Cinnamomi Cortex) are used, focusing on warming and tonifying. This illustrates the principle of "tonifying Qi in cases of Blood depletion," where Yang generation promotes Yin growth. If the tips of the eruptions open showing purple stagnation accompanied by epistaxis, this is Toxic Fire punishing Metal (Lung); Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) added with stir-fried black Shan Zhi (Gardeniae Fructus) is indicated. If residual toxins attack the Spleen after crusting, injuring Spleen Qi and impairing its ability to control blood, causing epistaxis, a small dose of Shen Ling Bai Zhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder) added with stir-fried black Lian (Coptidis Rhizome) and Shao Yao (Paeoniae Radix) is used. If there is restlessness, heat, oppression, chaos, severe dry mouth and thirst, epistaxis, and heat in both hands and feet, Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) with Dan Pi (Moutan Cortex) removed, and added with Huang Lian (Coptidis Rhizome), Shan Zhi (Gardeniae Fructus), and Pao Jiang (Zingiberis Rhizoma Preparatum) is indicated. There are also cases of mid-Qi deficiency causing intermittent paroxysmal heat, alternating cold and heat in the extremities, and epistaxis; this indicates that Clear Yang Qi fails to ascend, and rootless fire comes and goes suddenly. Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) added with Shao Yao (Paeoniae Radix) and Rou Gui (Cinnamomi Cortex) is used. If intense toxicity causes obstruction and stifling, constraining Lung Metal, leading to flow into the Large Intestine and causing hematochezia, Si Wu Tang (Four Substances Decoction) with Shu Di Huang (Rehmanniae Radix Preparata) replaced by Sheng Di Huang (Rehmanniae Radix), and added with Huang Qin (Scutellariae Radix) and Huang Lian (Coptidis Rhizome) is indicated. If lower bleeding continues without stopping and the patient falls into a deep sleep from which they cannot be awakened, the condition is critical. Among all hemorrhages in smallpox, only those originating from the nose are treatable; those from the mouth or both mouth and nose simultaneously are mostly incurable. Some bleed directly from the pusticles, termed "Zou Xie" (leaking pathogen). Severe leaking leads to emptiness in the intermuscular spaces, leaving the toxin without a fixed location. These are all invasions of the interior and are difficult to treat.