〔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，用来控制腠理的开阖，推动机体枢机的运转。营血是阴血，用来充盈脏腑，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、痘窠囊饱满生长的，说明气充足。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，必须责求原因并治疗，不可因循守旧而留下后悔。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。脾接纳水谷，其悍气注入肾转化为气，肾藏气于肺以形成卫气，用以温煦肌肉皮肤，充实皮毛，肥厚腠理，主管开阖。卫气虚则疮疹不起发，毒邪乘气虚侵入肺，肺受邪则导致痘疹内陷伏匿，进而归于肾。脾接纳水谷，其精气注入心转化为血，心藏血于肝以形成营血，用以流注九窍，灌注六经，汇聚百脉。营血虚则疮疹不光泽，毒邪乘血虚侵入肝，肝受邪则导致瘙痒，进而归于心。凡是治疗这类病症，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，但仍以调理脾胃为主，不可违背这一原则。
【万全】不懂得辨别虚实的人，不可以成为医生。医经说：不要使虚证更虚，不要使实证更实。虚实之分，不可不知道。医经说：必须先度量患者形体的肥瘦，来调治其气的虚实。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：邪气盛则为实证，精气亏损则为虚证。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。医经说：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。又说：五实死症，是指邪气之实；五虚死症，是指正气之虚。（凡人的诊断同理）。疮痘的病症，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汗药。又如疮痛是邪气实，应当活血以开通郁结。如果痛如刀割，烦闷混乱大叫，不要治疗。疮痒是正气虚，应当补气以燥湿，如果爬搔不定，破烂皮脱，不要治疗。灰白色是气虚，人参的功效最大。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，不超过法度，这是治疗的权衡准则。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，都是补法过度的过错。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，都是泻法过度的过错。医经说：不要招致邪气，不要丧失正气，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，亏损则阳气会不及，而痘疹圆晕的形状无法形成。血不可盈满，盈满则阴乘阳位，而痘疹倒陷的祸患立刻到来。这就是痘疹有气血虚实区别的原因。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，必须取其气血中和，不过分也不不足即可。什么是气血虚实？且如气过则水泡，血过则……气不及则顶陷不起，血不及则浆毒不附。凡是痘色淡白，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。根窠不红，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，而血自然活跃。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，又察辨气血虚实而治疗，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，则毒邪容易发出容易化解，所以善于治疗痘证的人，只是在虚弱之前保全元气，使其不至于耗散为贵罢了。然而其治疗方法是什么？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，结痂顺候了。因此禁用寒凉荡涤的药物如大黄、滑石、车前子、生地、鼠粘子、紫草、枳壳等，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鼠粘子、人牙、蝉蜕、麻黄、干葛、升麻、紫草、桔梗、羌活、防风、荆芥等，恐怕它们发散太过，导致表虚，表一虚，则元气由此外耗，塌痒外剥，性命由此丧送，是谁的过错呢？
【虚证补气不补血】虚弱痘证，精神倦怠，面青㿠白，盖因气不充则精神倦怠，血不荣则面青㿠白。现在治疗虚证，只补气不补血的原因是什么呢？气有神而无形象，补之则容易充盈，血有形而无神，补血之药，难收速效。况且气属阳而血属阴，阴从阳，血从气，这是常理，所以补气不补血，使气盛而充，则血自然跟随也盛了。况且补血之剂如当归、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、芍药等补血之剂，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、生地等活血凉血之药，并用酒炒，以折损其润下之性，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了。
【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，面青㿠白，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，闷乱切牙寒战，头温足冷，是势所必至的。所以治疗虚痘初发之际，不宜投予参苏饮、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之法为妙。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，大补汤加肉桂。塌陷灰白，腹胀泄泻，用木香散。塌痒闷乱，腹胀渴泻，喘嗽头温足冷，寒战切牙者，急进异功散救之。
【虚证变实】气虚痘证，父母能遵守禁忌，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，二便清调了。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、肉桂辛热之剂，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，重治疏利的过错，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散加木香。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。闷乱腹胀，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。呕吐似虚证，然而不知热毒在内，不得伸越，则上逆攻冲而吐，医经说：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，泄泻似虚证，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、不食之证，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之证，则邪得补而愈盛，药一入口，立见杀人，医生的过错，可不慎重吗？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、黄芩、黄连及滑泄之药，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。此热证变虚的验证，虚证既明，便从虚治，参、芪、丁、桂，也不忌讳，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、芪、白术、丁、桂、姜、附，也不忌讳，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，也不忌讳。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 (Nutritive Qi) and Wei (Defensive Qi). Wei Qi, which is Yang Qi, controls the opening and closing of the cou li (interstices/skin pores) and drives the pivotal mechanisms of the body. Ying Blood, which is Yin Blood, fills the Zang-Fu organs and irrigates the limbs. Therefore, when Qi is deficient, the Shen (Spirit/Mental activity) 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 and, following the meridians and specific locations, directly invades Ying and Wei to emerge. Observing the eruption: if the vesicles are firm and dense, and the pustule sacs are full and long, this indicates sufficient Qi. If the roots and buds are red, vibrant, lustrous, and moist, this indicates sufficient Blood. Once Qi and Blood are sufficient, the smallpox will erupt and crust over easily, requiring no treatment, to avoid the error of "reinforcing an excess" (making an excess condition worse). 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 identify the cause and treat it, not allowing negligence to lead to regret. However, the Spleen and Stomach are the "parents" of Qi and Blood; the Heart and Kidney are the "mothers"; the Liver and Lung are the "residences." The Spleen receives water and grain; its fierce Qi enters the Kidney to transform into Qi. The Kidney stores this in the Lung to form Wei Qi, which warms the muscles and skin, fills the hair and pores, thickens the interstices, and governs opening and closing. If Wei Qi is deficient, the sores will not erupt; the toxin takes advantage of Qi deficiency to enter the Lung. If the Lung is affected, the smallpox becomes sunken and hidden, eventually returning to the Kidney. The Spleen receives water and grain; its essence Qi enters the Heart to transform into Blood. The Heart stores this in the Liver to form Ying Blood, which flows through the nine orifices, pours into the six Fu channels, and gathers in the hundred vessels. If Ying Blood is deficient, the sores lack luster; the toxin takes advantage of Blood deficiency to enter the Liver. If the Liver is affected, itching occurs, eventually returning to the Heart. In treating such cases, Qi diseases are treated by regulating Qi, Blood diseases by regulating Blood. Cold conditions are warmed, Heat conditions are cleared, Deficiency conditions are tonified, and Excess conditions are purged. Nevertheless, regulation of the Spleen and Stomach remains primary and must not be violated.
[Wan] One who does not understand the differentiation of Deficiency and Excess cannot be a physician. The Classics state: Do not make Deficiency more deficient, do not make Excess more excessive. The distinction between Deficiency and Excess must be known. The Classics state: First measure the patient's body shape (fat or thin) to regulate the Deficiency or Excess of Qi. This distinguishes Deficiency/Excess by body shape. It also states: Abundant food intake leads to abundant Qi; scant food intake leads to scant Qi. This distinguishes Deficiency/Excess by diet. It also states: An Excess pulse indicates Excess Blood; a Deficient pulse indicates Deficient Blood. This distinguishes Deficiency/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/Excess by the relationship between Pathogen and Righteous Qi. Generally, Excess refers to Pathogenic Excess, and Deficiency refers to Righteous Qi Deficiency. The Classics state: Where pathogenic factors gather, Righteous Qi must be deficient; if they remain and do not depart, the disease manifests as Excess. It is also said: Death from Five Excesses refers to Excess of Pathogenic factors; death from Five Deficiencies refers to Deficiency of Righteous Qi. (This applies to general diagnosis). In smallpox cases, if the patient is physically robust, eats well, has a洪大 (Surging) and forceful pulse in all six positions, has no prior illness, normal stool, and red/rosy lesions, this indicates both Exterior and Interior Righteous Qi are Excess; medication is unnecessary. If the patient is emaciated and weak, suffers from frequent illnesses, has reduced appetite, a faint and weak pulse in all six positions, frequent vomiting and diarrhea, and pale/tender lesions, this indicates both Exterior and Interior Righteous Qi are Deficient; Chen's method of Warming and Tonifying may be used. If the eruption is too vigorous, with severe 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 method of Cooling and Purging may be used. If the eruption 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 lesions are pale white, fail to erupt fully, accompanied by constipation, yet the patient drinks heavily and eats greedily, this indicates Interior Excess and Exterior Deficiency; add diaphoretic/herbs promoting eruption to resolving/detoxifying 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 Righteous Qi Deficiency; tonify Qi to dry Dampness. If scratching is incessant with skin peeling and ulceration, do not treat. Gray-white color indicates Qi Deficiency; Ren Shen (Ginseng Root) is most effective. Dryness indicates Blood Deficiency; Dang Gui (Angelica Sinensis Root) and Chuan Xiong (Ligusticum Chuanxiong Rhizome) should be used generously. Deficiency requires tonification, Excess requires purging; stop when the disease is addressed, without exceeding proper limits; this is the balance of treatment. If an Excess condition is wrongly tonified, toxins become more rampant, leading to ulceration, carbuncles, eye diseases, throat sores, or hemorrhage—all due to excessive tonification. If a Deficiency condition is wrongly purged, Righteous Qi becomes further depleted, leading to vomiting, diarrhea, or cold extremities—all due to excessive purging. The Classics say: Do not invite pathogens, do not lose Righteous Qi, thereby shortening life. This is what is meant.
[Weng] Qi has the function of generating Blood, but Blood has no function of benefiting Qi. Therefore, Qi must not be deficient; if deficient, Yang energy will be insufficient, and the round outline of the smallpox vesicles will not form. Blood must not be excessive; if excessive, Yin will invade Yang positions, and the disaster of inverted/collapsed smallpox will occur immediately. Thus, smallpox presents differences in Qi and Blood Deficiency and Excess. Generally, Cold indicates Deficiency, Heat indicates Excess. Qi Deficiency requires Warming and Tonifying; Qi Excess with Heat requires Cooling; Blood Deficiency requires Tonifying Blood; Blood Heat requires Detoxifying. One must aim for the harmony of Qi and Blood, neither excessive nor insufficient. What constitutes Qi and Blood Deficiency/Excess? For instance, excess Qi leads to vesicles; excess Blood leads to [blistering/pustulation]. Insufficient Qi leads to depression and failure to rise; insufficient Blood leads to lack of pus and toxin attachment. Pale white lesions, soft tops that do not resist touch, and failure to swell indicate Qi Deficiency; Bao Yuan Tang (Preserve Origin Decoction) is highly suitable, with doubled Jiu Chao Huang Qi (Wine-fried Astragalus Root), Rou Gui (Cinnamon Bark), Chuan Xiong, Ding Xiang (Clove), Ren Ru (Human Milk), and good wine. Roots that are not red, or red but scattered, turning white upon touch, with lesions standing like goosebumps, dry and dull, indicate Blood Deficiency; Bao Yuan Tang plus Chuan Xiong, Dang Gui, Jiu Xi Hong Hua (Wine-rinsed Carthamus Flower), and Shan Zha (Hawthorn Fruit) to eliminate the stagnating effect of Ren Shen and Huang Qi, followed by Mu Xiang (Aucklandia Root) to move stagnant Qi, so Blood becomes active. Huang Qi should be used only after all smallpox have erupted. Hot herbs should be used only when toxins are completely resolved, and treatment should be adjusted according to Qi and Blood Deficiency/Excess, ensuring efficacy. For blood tonification, Di Huang (Rehmannia Root) is used at the beginning and end; Jiang Zhi (Ginger-processed) is used to prevent blood stagnation; Shao Yao (Peony Root) is avoided due to its sour-cold nature damaging Stomach Qi, or if used, must be Jiu Chao (wine-fried).
[Discussion on Nursing Deficiency Patterns] Smallpox treatment focuses on Yuan Qi (Original Qi). If Yuan Qi is substantial, toxins are easily expelled and transformed. Therefore, skilled practitioners preserve Yuan Qi before it becomes weak, preventing depletion. The methods are: first, strengthen the cou li and consolidate the muscle surface; second, regulate diet and protect the Spleen Earth. If the exterior is solid, there is no fear of external collapse; if the Spleen Earth is solid, there is no fear of internal sinking. With the tonifying power of Ren Shen and Huang Qi, Yuan Qi naturally becomes substantial, making it easy for smallpox to form pus, preventing complications, and ensuring smooth crusting. Therefore, cold and purgative herbs like Da Huang (Rhubarb Root), Hua Shi (Talcum), Che Qian Zi (Plantago Seed), Sheng Di Huang (Rehmannia Root), Niu Bang Zi (Arctium Fruit), Zi Cao (Arnebia Root), Zhi Ke (Bitter Orange Fruit), etc., are forbidden, as their purgative and lubricating nature damages the Spleen and Stomach. Damage to Spleen/Stomach causes Yuan Qi to sink, leading to Qi collapse and internal attack, resulting in death—a certainty caused by the medicine itself. Lubricating and dispersing herbs like Niu Bang Zi, Ren Ya (Human Teeth), Chan Tui (Cicada Slough), Ma Huang (Ephedra Stem), Ge Gen (Kudzu Root), Sheng Ma (Cimicifuga Rhizome), Zi Cao, Jie Geng (Platycodon Root), Qiang Huo (Notopterygium Rhizome), Fang Feng (Saposhnikovia Root), Jing Jie (Schizonepeta Spike) are forbidden, as excessive dispersion causes Exterior Deficiency. Once the Exterior is deficient, Yuan Qi dissipates outward, leading to collapse, itching, and skin shedding, causing death. Who is to blame?
[Tonifying Qi but Not Blood in Deficiency Patterns] In weak smallpox patterns, mental fatigue and cyanotic-pale complexion occur because insufficient Qi causes fatigue, and un-nourished Blood causes cyanosis. Why treat Deficiency by tonifying Qi but not Blood? Qi has spirit but no form; tonifying it is easy to fill. Blood has form but no spirit; tonifying it yields slow results. Moreover, Qi is Yang and Blood is Yin; Yin follows Yang, Blood follows Qi. Thus, tonifying Qi makes it abundant, and Blood naturally follows and becomes abundant. Additionally, blood-tonifying agents like Dang Gui and Sheng Di Huang are moistening and laxative; excessive use may cause loose stools. However, in some deficiency smallpox cases with white, collapsed, un-nourished lesions, Dang Gui and Shao Yao may be reluctantly used. In cases of floating Deficiency Fire with numerous red spots resembling Blood Heat, Zi Cao, Hong Hua, and Sheng Di Huang may be reluctantly used for cooling and activating Blood. All should be wine-fried to counteract their laxative nature; using wine helps reach the Exterior. This achieves the subtlety of ascending and reaching the Exterior within blood tonification and activation, avoiding intestinal lubrication and diarrhea.
[Differentiating Inevitable Bad Outcomes of Deficiency Patterns] In Qi-deficient smallpox, initial symptoms include lingering fever, alternating hot and cold, flaccid skin, mental fatigue, cyanotic-pale face, reduced appetite, alternating cold/hot extremities, vomiting, loose stools. Lesions appear faintly, lacking vigor, pale red, thin-skinned. Over 3-4 days, they emerge unevenly, hard to grow. By 5-6 days, hard to form pus. Reduced food intake leads to Qi exhaustion; food stagnation leads to diarrhea. By 7-8 days, collapse, gray-white color, failure to rise, spontaneous sweating, slight thirst, or abdominal distension, wheezing, thirst, diarrhea, collapse, itching, restlessness, teeth grinding, chills, warm head/cold feet—these are inevitable outcomes. Therefore, at the onset of Qi-deficient smallpox, do not use Shen Su Yin (Ginseng and Schizonepeta Decoction), Ren Shen Bai Du San (Ginseng and Detoxifying Powder), Huang Lian Jie Du Tang (Coptis Detoxifying Decoction), Sheng Ma Ge Gen Tang (Cimicifuga and Kudzu Decoction), or Zi Cao San Dou Yin (Arnebia and Three Beans Decoction). Use Shen Qi Yin (Ginseng and Astragalus Decoction). Avoid patterns with rough breathing and dry skin lacking luster. Use Si Jun Zi Tang (Four Gentlemen Decoction) minus Ren Shen, plus small amounts of Jie Geng and Chuan Xiong, Fu Pi (Tangerine Peel), combining tonification with mild ascending methods. Once lesions are complete, heavily use Ren Shen and Huang Qi. By days 8-9, if no other ominous signs, proceed normally. If tops are depressed, gray-white, failing to rise, with clear pus, spontaneous sweating, slight thirst, add Rou Gui to major tonifying decoctions. For collapse, gray-white, abdominal distension, diarrhea, use Mu Xiang San (Aucklandia Powder). For collapse, itching, restlessness, abdominal distension, thirst, diarrhea, wheezing, warm head/cold feet, chills, teeth grinding, urgently administer Yi Gong San (Extraordinary Success Powder).
[Deficiency Pattern Transforming into Excess] In Qi-deficient smallpox, if parents observe taboos, medications are correct, and care is appropriate, Yuan Qi becomes substantial, cou li solid, Spleen/Stomach strong, diet normal, urination/defecation regular. However, excessive tonification, especially heavy use of Ren Shen/Huang Qi after pus formation, may cause abdominal distension and wheezing; use Zhi Ke Tang (Bitter Orange Decoction). Misuse of Wu Ling San (Five Ingredient Powder with Poria) or Tong Cao (Tetrapanax Pith) in excess may cause constipation; use Kuan Zhong San (Broad Middle Powder). Constipation with thirst: Mai Men Dong Tang (Ophiopogon Decoction). Overuse of Xin Re (Pungent-Hot) herbs like Ding Xiang and Rou Gui may cause sore throat, swelling, restlessness, and closed thirst; use Zi Yin Run Zao Tang (Nourish Yin and Moisten Dryness Decoction). Wheezing, distension, constipation, restlessness, thirst, sore throat resemble Excess, but 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 purgation. Over-purging depletes newly generated Qi, leading to collapse.
[Deficiency Pattern Resembling Excess] Qi-deficient smallpox, due to raw/cold food or improper care, damages Spleen/Stomach, causing diarrhea. Fluids sink, Deficiency Fire rises, causing thirst. Yuan Qi sinks, Deficiency Yang surges upward, lower Qi fails to continue, causing wheezing. Thirst and wheezing are Excess patterns, but arising after diarrhea, they result from sudden fluid loss (thirst) and Qi deficiency (wheezing). How could true Heat-thirst or Qi-surging-wheezing arise after diarrhea? Treat thirst with Shen Ling Bai Zhu San plus Mu Xiang. Persistent thirst and diarrhea: Yi Gong San. Wheezing: Ren Shen Ding Chuan Tang or Du Shen Xing Ren Tang. Wheezing, thirst, diarrhea: Mu Xiang Yi Gong San. Restlessness, distension, internal attacking toxin, eyes closed, talking in delirium (Shi Zhi/Loss of Will): Mistaking this for Excess is foolish.
[Excess Pattern Resembling Deficiency] High fever, straight hair, dry skin, restless sleep, red cheeks/red eyes, rough breathing, restlessness/thirst, abdominal distension, constipation, wheezing—all are Excess. This is due to severe Heat and heavy toxins causing obstruction. Vomiting may appear as Deficiency, but it is actually Heat-toxin trapped inside, unable to vent, forcing upward rebellion. The Classics state: All rebellious attacks belong to Fire. Alternatively, cold invasion or irregular diet damages Wind-Cold, trapping internal Heat, causing rejection/vomiting. For trapped toxins, ascending and dispersing is best. For rejection vomiting, guide downward using Zhu Ling (Polyporus), Ze Xie (Alisma), Ju Pi (Tangerine Peel). Diarrhea accompanying these resembles Deficiency, but is due to郁盛 (Stagnant-Abundant) Heat-Toxin baking the Spleen/Stomach, preventing external release, causing toxins to sink and exit via orifices ("Heat-Toxin pouring downward"). Ancient saying: Diarrhea before eruption indicates survival; diarrhea after eruption indicates death. Treatment: Ascend and disperse to bring toxins to the Exterior; once toxins are resolved externally, internal diarrhea stops. If combined with food stagnation, add digestive herbs (mild) or follow the path (severe). Lack of appetite resembles Internal Deficiency, but in Yu Re (Stagnant Heat) patterns, toxins are trapped internally, unable to reach the skin, causing constipation, blocked cou li, Heat-Toxin obstruction, distension, and anorexia. Treatment: Ascend and disperse to allow Heat to vent, harmonizing Zang-Fu and restoring appetite. Mistakenly using Xin Re (Pungent-Hot) herbs like Ding Xiang, Rou Gui, Ban Xia for vomiting/diarrhea/anorexia uses Heat to attack Heat, worsening symptoms. Using Bu (Tonifying) herbs like Ren Shen, Huang Qi, Fu Ling, Bai Zhu for distension/anorexia allows Pathogens to be tonified and flourish; one dose can kill. Physicians must be cautious. Long Gu (Dragon Bone), Dou Kou (Cardamom) stop diarrhea; Shen Qu, Mai Ya, Sha Ren aid digestion—but none are suitable for obstructed Heat-anorexia. Future practitioners take note.
[Heat Pattern Transforming into Deficiency] Blood-Heat smallpox requires Cooling and Dispersing, not harsh Bitter-Cold. Overuse of Cold agents like Sheng Ma, Huang Qin, Huang Lian, and laxatives damages Spleen/Stomach internally and freezes muscles externally. Mild damage reduces appetite and causes loose stools; severe damage causes profuse watery diarrhea, leading to Cold-Deficiency. Frozen muscles prevent Heat vaporization, close cou li, prevent smallpox from swelling, erupting, or forming pus, leading to hidden collapse. This is Heat transforming into Deficiency. Once Deficiency is identified, treat as Deficiency. Ren Shen, Huang Qi, Ding Xiang, Rou Gui are not contraindicated. After day 5-6, Mu Xiang Yi Gong San is appropriate. Judgment depends on careful syndrome differentiation.
[Obstructed Heat Transforming into Deficiency] Severe toxin obstruction requires ascending/dispersing as primary, aided by Cooling/Detoxifying. Stop when balanced. Excessive dispersion empties the Exterior, depletes Yuan Qi, leading to clear fluid penetration, empty shells, itching/collapse/shedding, or non-healing ulcers. These signs indicate Exterior Deficiency. Once Exterior is deficient, Yuan Qi leaks, internal Qi cannot guard itself. Minor dietary errors (cold/raw food) cause diarrhea; persistent diarrhea leads to Cold-Deficiency, Qi collapse, restlessness, chills, etc. Once Deficiency is known, treat as Deficiency. Ren Shen, Huang Qi, Bai Zhu, Ding Xiang, Rou Gui, Gan Jiang, Fu Zi are not contraindicated. After day 6-7, even Mu Xiang Yi Gong San should be administered urgently. Adjust based on observation.
[Differentiating Use of Yi Gong San for Obstructed Heat] Excess-Heat obstruction often uses Cold herbs, causing frozen diarrhea, or excessive dispersion, causing Exterior Deficiency. If frozen/hard, use mild herbs; Ginger/Cinnamon heat is acceptable. After diarrhea, Heat dissipates, True Qi becomes deficient; use tonics. Qi Deficiency implies Cold; if Cold-Deficiency is clear, use Warming-Tonics. Thus, although initial eruption shows Blood-Heat obstruction, by days 3-4, if the body is no longer hot and skin is cold, and lesions do not grow, mild warming agents like Guan Gui (Cinnamon), Gan Jiang, Chuan Xiong are necessary to warm internal Qi, harmonizing external Qi. After diarrhea, the interior is definitely deficient. Even with distension, restlessness, thirst, wheezing, it is not Excess-Heat, but Internal Deficiency with hidden collapse and internal attacking toxins. Therefore, Excess-Heat cases with diarrhea on days 7-8-9 are treated as Deficiency. If Mu Xiang Yi Gong indications exist, prioritize this formula. Without frozen/hard signs, do not mistakenly use warming agents. Without diarrhea, do not mistakenly use Mu Xiang Yi Gong San. Collapse, inverted crusting, dryness without freezing/diarrhea are usually due to internal attacking Heat-Toxin; treat with Bai Xiang Dan or Zhu Wei Dan.