痘虽光亮，全无血色，明若琉璃，略擦即破，内俱清水，而或出血，总无脓浆，此血气
不能运化毒瓦斯而然也。后必音哑而死。痘若起胀见有此等，急取其尤者而刺去其水，再用实
浆散∶人参、黄 、当归、鹿茸、白术、淮山、山楂、扁豆、白芷、炙草，加黄豆四十九粒
。或用大补元煎各方更妙。
遍身俱陷，惟尾脊骨一圈饱满润泽，其明如珠，犹之草尾露珠也。盖尾脊为肾部，此必
肾强、精髓充足，急用内托之剂，则遍身之痘旋覆起矣。
与各前篇参看施治为要。痘毒随血而出，毒盛血热亦盛，故其痘乃黑也。此必死之痘，
古方虽有数条，总以凉血解毒为主，姑载于后，以备参用。
初见黑点在皮肤之间者，用朱砂、冰片、牛黄，或用猪尾血调入牙散，好酒同服。
初出点便黑者，用紫草茸二三钱，好酒调服。
又，皮肤发青紫纹者，川紫草一钱，红花、荆芥、防风、牛蒡、生 各八分，木香、甘
草各三分，升麻五分。
又，黑痕并黑靥者，用蝉蜕五个，紫草茸一钱。
又，黑如煤炭，血不红活者，用紫草、红花、生地、牛蒡、赤芍。
又，黑而软者，气弱而血热也，用保元汤加红花、紫草、生地。
又，焦黑潮热烦躁者，用小无比散三钱，加紫草、生地、红花，磨犀角调服。
人牙散∶人牙（自落者）火 存性，入韭菜汁淬之，研为末，加麝香五厘，穿山甲二分，
用鸡冠血、葱白煎酒调服。
保元汤∶人参、黄 、当归、川芎、紫草、红花、肉桂、防风。
小无比散∶滑石六两，石膏一两（ ），寒水石（ ）、郁金（甘草水煎透，焙干）、甘
草各
Although the variola (smallpox) lesions appear bright and lustrous, they lack any blood color, resembling clear glass; they rupture upon slight friction, containing only clear fluid inside, sometimes bleeding, but never forming pus. This occurs because Qi and Blood fail to transform and eliminate toxic pathogens. The patient will inevitably die after losing their voice. If such lesions appear during the swelling stage of the variola, immediately puncture the most severe ones to drain the fluid, then administer Shijiang San (Solid Pustule Powder): Renshen (Ginseng Radix), Huangqi (Astragali Radix), Danggui (Angelicae Sinensis Radix), Lurong (Cervi Cornu Degelatinatum), Baizhu (Atractylodis Macrocephalae Rhizoma), Huaishan (Dioscoreae Rhizoma), Shanzha (Crataegi Fructus), Biandou (Lablab Semen Album), Baizhi (Angelicae Dahuricae Radix), Zhigancao (Prepared Glycyrrhizae Radix et Rhizoma), plus 49 soybeans. Alternatively, using Dabu Yuanyuan Jian (Great Tonification for Origin Decoction) is even more effective.
The lesions on the entire body are sunken, except for a ring around the coccyx which is full, moist, and lustrous, shining like pearls, similar to dewdrops on grass tips. Since the coccyx corresponds to the Kidney region, this indicates strong Kidney Qi and abundant essence. Urgently administering internal-supporting formulas will cause the lesions all over the body to rise and recover quickly.
It is essential to refer to previous chapters for treatment guidance. Variola toxins exit with the blood; when toxins are vigorous, blood heat is also vigorous, hence the lesions turn black. These are invariably fatal cases. Although ancient texts contain several prescriptions, the primary principle is always cooling blood and detoxifying. They are recorded here for reference.
For black spots initially appearing between the skin layers, use Zhusha (Cinnabar), Bingpian (Borneolum Syntheticum), and Niuhuang (Calculus Bovis), or mix Zhuwei Xue (Tail Blood of Porcus Sus Scrofa Domestica) into Renya San (Human Tooth Powder) and take with good wine.
For lesions that are black from the outset, use Zicao Rong (Arnebiae Radix et Rhizoma) 2-3 qian, mixed with good wine for oral administration.
Additionally, for blue-purple streaks on the skin, use Chuan Zicao (Lithospermi Radix) 1 qian, Honghua (Carthami Flos), Jingjie (Schizonepetae Herba), Fangfeng (Saposhnikoviae Radix), Niubangzi (Arctii Fructus), and Shengdihuang (Rehmanniae Radix Recens) each 8 fen, Muxiang (Aucklandiae Radix) and Gancao (Glycyrrhizae Radix et Rhizoma) each 3 fen, and Shengma (Cimicifugae Rhizoma) 5 fen.
For black marks and black scabs, use Chantui (Bombyx Batryticatus) 5 pieces and Zicao Rong (Arnebiae Radix et Rhizoma) 1 qian.
For lesions as black as coal with dull, non-vibrant blood, use Zicao (Lithospermi Radix), Honghua (Carthami Flos), Shengdi (Rehmanniae Radix Preparata), Niubangzi (Arctii Fructus), and Chishao (Paeoniae Radix Rubra).
For lesions that are black and soft, indicating weak Qi and blood heat, use Baoyuan Tang (Protect the Origin Decoction) added with Honghua (Carthami Flos), Zicao (Lithospermi Radix), and Shengdi (Rehmanniae Radix Preparata).
For scorched-black lesions accompanied by tidal fever and restlessness, use Xiaowubi San (Little Peerless Powder) 3 qian, added with Zicao (Lithospermi Radix), Shengdi (Rehmanniae Radix Preparata), and Honghua (Carthami Flos), mixed with ground Xijiao (Rhinocerotis Cornu) and taken with liquid.
Renya San (Human Tooth Powder): Human teeth (naturally fallen) calcined until retaining their nature, quenched in Jiucai Zhi (Juice of Allium tuberosum), ground into powder, added with Shexiang (Moschus) 5 li, Shanjia (Manis Squama) 2 fen, mixed with Jiguan Xue (Crista Galli Sanguis) and Congbai (Scallion White) decocted in wine for oral administration.
Baoyuan Tang (Protect the Origin Decoction): Renshen (Ginseng Radix), Huangqi (Astragali Radix), Danggui (Angelicae Sinensis Radix), Chuanxiong (Chuanxiong Rhizoma), Zicao (Lithospermi Radix), Honghua (Carthami Flos), Rougui (Cinnamomi Cortex), Fangfeng (Saposhnikoviae Radix).
Xiaowubi San (Little Peerless Powder): Huashi (Talcum) 6 liang, Shigao (Gypsum Fibrosum) 1 liang (calcined), Hanshuishi (Aqua Marina), Yujin (Curcumae Radix) (decocted thoroughly in Licorice water, dried), and Gancao (Glycyrrhizae Radix et Rhizoma) each appropriate amount