痘疮作痛，有实有虚，虽曰诸痛为实，然此言亦不可执。若身有大热而大便秘结，烦躁不宁，
喘胀作渴而为痛者，此实痛也。若无大热而二便清利，脾气不健，卫气不充，营失所养而作痛者，
此虚痛也。实者宜解毒清火，当用解毒汤，或四味消毒饮之类主之。虚者宜补香血气，当用保元汤
，或六物煎之类主之。
经曰∶热甚则肿。大抵毒盛者必肿，毒微者不肿，故亦可以肿与不肿，察毒之甚与不甚也。然
痘疮应期起发，毒必以渐尽出，故头面亦必以渐浮肿，此毒火聚于三阳之分，欲化脓浆，其宜然也
。然止宜微肿，而甚肿者，大作所宜。若当起发之时，头面全然不肿，必其痘稀磊落，毒瓦斯轻浅者
然，此最吉兆也。
一、痘以渐起，面以渐肿，及灌脓收靥而肿以渐消，此常候也。如应肿不肿者，必其元气不足
；应消不消
者，必其毒瓦斯有余，须急治之。
一、有痘未起发而头面预肿，皮光色嫩，如瓠瓜之状，此恶毒上冲之候也。又有痘点已见，但隐
隐于皮肤之中，肉目肿而痘不起者决死。汪氏《理辨》曰∶痘起五六日之际，有面目先肿而光亮者
，是阳乘阴分，毒不能发也。何也？血乃气之本，气乃血之标，血有不足，则根本之力已亏，故致
虚阳动作，其气妄行肉分，区区不足之血，何能载毒而出？七日之后，传经已足，则气退毒陷，阴
阳各失其正，尚何可治之有？凡值此者，不可不预调气血，若待临期，无能为矣。
一、痘正起发头面肿胀时，正面之疮切防瘙痒，不可使之抓破，少有损伤，以致真气外泄，邪
气内蚀，则肿消毒陷，多致死矣。但得破者复灌，消者复肿，饮食二便如常，则变凶为吉矣，宜十
全大补汤，或合苦参丸治之。
一、头面肿胀而眼目咽喉痛闭者，急宜解毒，眼与咽喉相兼治之，宜消毒化斑汤去升麻，或
大连翘饮主之。
一、兼疫毒之气而头项腮颌预肿者，此必大头风及虾蟆瘟之属，宜以疫气治之，如大连翘饮，
及普济消毒饮之类主之。但兼此者亦多凶少吉也。
痘疮引起的疼痛，有实证和虚证之分。虽然常说“各种疼痛多属实证”，但这种说法不可拘泥固执。如果身体有大热且大便秘结，烦躁不安，气喘腹胀、口渴并因此产生疼痛的，这是实证疼痛。如果没有大热，大小便清利通畅，脾气虚弱不健运，卫气不足，营血失去滋养而产生疼痛的，这是虚证疼痛。实证应当解毒清热，当使用解毒汤，或者四味消毒饮之类的方剂来主治。虚证应当补益气血，当使用保元汤，或者六物煎之类的方剂来主治。
《内经》说：“热毒炽盛则会导致肿胀。”大抵毒邪旺盛的人必然会出现肿胀，毒邪轻微的人则不会肿胀，所以也可以通过观察是否肿胀来判断毒邪的轻重程度。然而，痘疮按照病程规律起发时，毒邪必定会逐渐全部透出，所以头面部也必然会逐渐浮肿，这是因为毒火聚集在太阳、阳明、少阳三阳经的分布区域，想要化生脓浆，这是正常的现象。但只适宜轻微肿胀，如果肿胀非常严重，则是治疗中需要特别关注的情况。如果在应该起发的阶段，头面部完全没有任何肿胀，那一定是因为痘疹稀疏独立，毒邪轻浅所致，这是最吉祥的征兆。
第一，痘疹逐渐起发，面部逐渐肿胀，等到灌脓收靥（结痂）时肿胀逐渐消退，这是正常的征象。如果到了该肿胀的时候却不肿胀，一定是元气不足；到了该消退的时候却不消退，一定是毒邪有余，必须紧急治疗。
第二，有的痘疹尚未起发，头面部预先就出现肿胀，皮肤光亮细嫩，像瓠瓜（葫芦）的样子，这是恶毒之气上冲的征候。又有痘点已经显现，但隐约隐藏在皮肤之中，肌肉肿胀而痘疹不起发的，必定死亡。汪氏在《理辨》中说：痘疹起发后的五六天之际，有面目先肿胀而且光亮的，这是阳气乘袭阴分，导致毒邪不能透发。为什么呢？血是气的根本，气是血的标表，血如果不足，那么根本的力量就已经亏损，所以导致虚阳妄动，气在肉分间妄行，区区不足的血液，怎么能承载毒邪排出体外呢？七天之后，传经已足，则气退毒陷，阴阳各自失去正常状态，还有什么可治的呢？凡是遇到这种情况的，不可以不预先调理气血，如果等到临期发作，就无法施为了。
第三，痘疹正在起发、头面肿胀时，正面的疮疡切忌防止瘙痒，不可让患者抓破，稍有损伤，就会导致真气外泄，邪气内蚀，从而造成肿消毒陷，大多致死。但如果破损后能重新灌浆，消退后能重新肿胀，饮食和二便如常，就能变凶为吉，适宜用十全大补汤，或者配合苦参丸来治疗。
第四，头面肿胀且眼睛、咽喉疼痛闭塞的，急需解毒，眼睛与咽喉要同时治疗，适宜用消毒化斑汤去掉升麻，或者用大连翘饮来主治。
第五，兼夹疫毒之气而导致头项腮颌预先肿胀的，这必定是大头风及虾蟆瘟（流行性腮腺炎）之类的疾病，应当以疫气的方法来治疗，如大连翘饮，以及普济消毒饮之类的方剂来主治。但是兼夹这种情况的，也多凶少吉。
Pain caused by smallpox (Variola) can be due to excess or deficiency. Although it is generally said that "all pain is an excess condition," this statement should not be adhered to rigidly. If the body has high fever, constipation, restlessness, panting, abdominal distension, thirst, and pain resulting from these, this is excess pain. If there is no high fever, urination and defecation are clear and smooth, spleen qi is weak and not vigorous, defensive qi (Wei Qi) is insufficient, and nutritive blood (Ying Blood) loses its nourishment causing pain, this is deficiency pain. For excess conditions, detoxification and clearing heat are indicated; Decoction for Detoxification (Jiedu Tang) or Four-Ingredient Decoction for Disinfecting Toxins (Siwei Xiaodu Yin) should be used as the main treatment. For deficiency conditions, tonifying qi and blood is indicated; Decoction for Preserving Origin (Baoyuan Tang) or Six-Ingredient Decoction (Liuyi Jian) should be used as the main treatment.
The Classic states: "When heat is severe, swelling occurs." Generally, where toxin is abundant, swelling must occur; where toxin is slight, there is no swelling. Therefore, one can also observe whether there is swelling to ascertain the severity of the toxin. However, when pox lesions erupt according to their expected timeline, the toxin must gradually emerge completely; thus, the head and face will inevitably swell gradually. This is because toxic fire gathers in the regions of the Three Yang meridians (Taiyang, Yangming, Shaoyang), desiring to transform into pus and plasma, which is the natural course. Nevertheless, only mild swelling is appropriate. If swelling is severe, it requires specific attention. If at the time of eruption, the head and face show absolutely no swelling, it indicates that the pox lesions are sparse and distinct, and the toxic qi is light and superficial; this is the most auspicious omen.
1. When pox lesions gradually erupt, the face gradually swells, and during the stage of suppuration and scabbing, the swelling gradually subsides, this is a normal presentation. If swelling does not occur when it should, it must be due to insufficiency of primal qi (Yuan Qi); if swelling does not subside when it should, it must be due to surplus of toxic qi, requiring urgent treatment.
2. In some cases, before the pox lesions erupt, the head and face are pre-swollen, with skin that is smooth and tender, resembling a bottle gourd (Hu Gua). This is a sign of malignant toxin rushing upward. In another scenario, pox spots have appeared but remain faintly hidden within the skin, with flesh swelling while the pox fails to rise; this invariably leads to death. Wang Shi, in *Li Bian*, stated: At five or six days after the onset of pox, if the face and eyes swell first and appear shiny, this is yang invading the yin aspect, preventing the toxin from venting. Why? Blood is the root of qi, and qi is the branch of blood. If blood is deficient, the strength of the root is already compromised, leading to hyperactive deficient yang and erratic movement of qi within the flesh. How can such insufficient blood carry the toxin out? After seven days, when the transmission through the meridians is complete, qi retreats and toxin sinks; yin and yang each lose their proper state, leaving little hope for treatment. In all such cases, one must not fail to regulate qi and blood in advance; if one waits until the crisis, it will be too late to act.
3. When pox lesions are erupting and the head and face are swollen, one must strictly prevent scratching of the sores on the front of the face. Do not allow them to be scratched open. Even minor injury can cause primal qi to leak outward and pathogenic qi to erode inward, leading to the disappearance of swelling and sinking of toxin, often resulting in death. However, if broken lesions refill with pus and subsided lesions swell again, and diet and excretion remain normal, misfortune can turn to fortune. Full-Tonifying Great Supplement Decoction (Shiquan Dabu Tang) or combined with Sophora Root Pill (Kushen Wan) is suitable for treatment.
4. When head and face are swollen accompanied by pain and obstruction in the eyes and throat, urgent detoxification is required, treating both eyes and throat simultaneously. Decoction for Disinfecting Toxins and Resolving Macules (Xiaodu Huaban Tang) with Ephedrae Herba (Shengma, 升麻) removed, or Large Lonicera Decoction (Dalianqiao Yin), is indicated.
5. When pre-swelling of the head, neck, cheeks, and jaw occurs due to concurrent epidemic toxic qi, this belongs to conditions such as Big Head Wind (Datou Feng) or Mumps (Hamawen). It should be treated as an epidemic disease using formulas like Large Lonicera Decoction (Dalianqiao Yin) or Universal Benefit Decoction for Detoxification (Puji Xiaodu Yin). However, cases with such complications are mostly ominous with few favorable outcomes.