痘有紫黑枯硬而独大，针拨不动，手捻有核者，是为痘疔，若不去之，则一身之痘皆不能起发
，或皆变黑色，必致死矣、其有黑大而软者，此名黑痘，慎不可作痘疔治也。
痘疔者，以热毒蓄积，气血凝败而成也。然其类亦有数种，最为恶候，宜谨察之。有初出红点
，渐变黑色，其硬如石者，此肌肉已败，气血中虚，不能化毒，反致陷伏也。有肌肉微肿，状如堆
粟，不分颗粒者，此气滞血凝，毒瓦斯结聚不散也。有中心黑陷，四畔突起戴浆者，此血随毒走，气
不能充也。有中心戴浆自破溃烂者，此
气血俱虚，皮肤败坏也。有为水泡溶溶易破者，此脾虚不能制湿，气虚不能约束也。有为血泡色紫
易破者，此血热妄行，而气虚不能完固也。有疮头针孔浆水自出者，此卫气已败，其液外脱也。以
上数证，虽与痘疔不同，而危险无异，但于五六日间候之，若见一证，多不可治。
一、凡痘疔及黑陷者，宜内服六气煎加川芎、紫草、红花、木通之类，以补血凉血而疔自退。疔
退后，宜大进六气煎，或六物煎，外用四圣丹，以胭脂汁调点之。疔若大者，用银针挑破疮口，吸
出恶血，入后药末，即转红活。大抵黑陷而疔多，或余毒不起者多死。苦痘疔挑去黑血，搽药不变
，仍是黑色者必死。
《心鉴》曰∶痘疔见于四肢，不近脏腑者易治，若穿筋骨者亦难治。但有见于头面腹背，逼近
于内者，其势必攻穿脏腑矣。如未穿者，急须治之，用飞过雄黄，以真蟾酥拌勾为丸，如麻子大，
挑疔点入，立效。又成用巴豆一粒，去皮膜，合朱砂一分，研烂点入，一时突出即愈。内服无价散
，汲井水加猪尾血三五点调下。
一、痘疮黑陷者，必气不足，血不活也，急宜托里散，或六物煎加川芍、肉桂、红花、蝉蜕，
调无价散，或独圣散，甚者宜九味异功煎，或十全大补汤，调无价散，仍外用四圣丹点之。若见焦
紫而黑，混身皆是，及身有大热，或大便秘结，内热烦渴者，此亦有火毒之证，宜四顺清凉饮，或
承气汤，合万氏夺命丹以解其毒。俟火邪略退，即宜用六气煎，调无价散以托其内，亦可望其生也
。
一、痘疮起发之时，但见干燥，其根焦黑，即当速治之。如火邪不甚，证无大热者，惟五物煎，
或六物煎为最宜也。如有火证火脉，血热毒盛而焦黑者，轻则凉血养营煎，或鼠粘子汤，甚则以万
氏夺命丹合而服之。
一、原有疮疥未愈，至痘出之时，其破处痘有攒聚，而形色黑溃者，急以银针挑破，吮去毒血，
吐于水中，其血红者可治，黑者难治，须内服加味四圣散，或万氏夺命丹，外用万氏四圣散涂之。
一、靥后痘疔溃烂成坑，内见筋骨者，宜托里消毒散，或荆防败毒散加穿山甲、蝉蜕、僵蚕，
外用神效当归膏，或太乙膏贴之，或以白龙散敷之。
痘疹中出现紫色或黑色、干枯坚硬且特别大的痘粒，用针拨动时纹丝不动，用手捻摸能感觉到有硬核的，这就是“痘疔”。如果不及时去除它，全身其他的痘疹都无法正常起发灌浆，或者全部变成黑色，必然导致死亡。那些虽然颜色黑大但质地柔软的，称为“黑痘”，千万不可当作痘疔来治疗。
痘疔的形成，是因为热毒蓄积，导致气血凝滞败坏所致。然而这类病症也有几种不同的类型，属于非常凶险的证候，应当仔细辨别。有的初出时是红点，逐渐变为黑色，质地坚硬如石头，这是肌肉已经败坏，气血中虚，不能化解毒邪，反而导致毒邪内陷伏留。有的肌肉轻微肿胀，形状像堆积的粟米，分不清颗粒，这是气机阻滞、血液凝涩，毒邪结聚不散。有的中心凹陷发黑，四周突起并带有脓浆（称为戴浆），这是血液随毒邪走窜，而气不能充盈的表现。有的中心带脓自行破裂溃烂，这是气血都虚弱，皮肤败坏所致。有的像水泡一样溶溶易破，这是脾虚不能制约湿气，气虚不能固摄约束所致。有的像血泡，颜色紫暗易破，这是血热妄行，而气虚不能固护完善所致。有的疮头像针孔，浆水自行流出，这是卫气已经败坏，体液外脱所致。以上几种证候，虽然与典型的痘疔有所不同，但危险性并无二致。通常在发病后的五六天观察，如果见到其中一种症状，大多难以治愈。
第一，凡是出现痘疔及黑陷的，适宜内服六气煎，加入川芎、紫草、红花、木通等药物，以补血凉血，痘疔自然消退。痘疔消退后，宜大量服用六气煎，或者六物煎，外用四圣丹，用胭脂汁调和后点涂患处。如果痘疔较大，可用银针挑破疮口，吸出恶血，然后敷入后面的药末，痘色就会转为红润鲜活。大抵而言，黑陷且痘疔多，或者余毒无法消除的，大多死亡。如果挑去痘疔的黑血，搽药后颜色不变，仍然是黑色的，必定死亡。
《心鉴》说：痘疔出现在四肢，不靠近脏腑部位的容易治疗；如果穿透筋骨的也难以治疗。但是如果有出现在头面、腹部和背部，逼近内部脏腑的，其病势必然会攻穿脏腑。如果尚未穿透，必须紧急治疗，使用经过飞制处理的雄黄，用真正的蟾酥拌合制成丸药，大小如麻子，挑破痘疔后点入药丸，立即见效。另外有人用巴豆一粒，去掉皮膜，配合朱砂一分，研烂后点入，一小时内痘疹突出即可痊愈。内服无价散，汲取井水加猪尾血三五滴调服。
第二，痘疮出现黑陷的，必然是气不足，血不活跃所致，急需使用托里散，或者六物煎加入川芎、肉桂、红花、蝉蜕，调服无价散，或者独圣散；病情严重的，宜用九味异功煎，或者十全大补汤，调服无价散，同时外用四圣丹点涂。如果见到焦紫而黑，遍布全身，以及身体有大热，或者大便秘结，内热烦渴的，这也是火毒的证候，适宜用四顺清凉饮，或者承气汤，合万氏夺命丹来解毒。等到火邪稍微减退，就应当用六气煎，调服无价散以托举正气于内，也可以希望存活。
第三，痘疮起发的时候，只要见到干燥，根部焦黑，就应当迅速治疗。如果火邪不严重，证候没有大热的，只有五物煎，或者六物煎最为适宜。如果有火证火脉，血热毒盛而焦黑的，轻症用凉血养营煎，或者鼠粘子汤；重症则合服万氏夺命丹。
第四，原有疮疥未愈，到了痘出的时候，破损处的痘疹聚集在一起，颜色黑且溃烂的，急忙用银针挑破，吮去毒血，吐在水中，血色红的可以治疗，黑色的难治，需要内服加味四圣散，或者万氏夺命丹，外用万氏四圣散涂抹。
第五，痘疹结痂脱落（靥）后，痘疔溃烂成坑，里面见到筋骨暴露的，适宜用托里消毒散，或者荆防败毒散加入穿山甲、蝉蜕、僵蚕，外用神效当归膏，或者太乙膏贴敷，或者用白龙散敷撒。
Zhen (smallpox) presenting as purple or black, dry, hard, and particularly large, which cannot be moved by needle manipulation and feels nodular upon palpation, is termed "Ding Zhen" (Smallpox Carbuncle). If not removed promptly, the smallpox lesions over the entire body will fail to erupt and suppurate properly, or all turn black, inevitably leading to death. Those that are black and large but soft in texture are named "Hei Dou" (Black Smallpox); they must strictly not be treated as Ding Zhen.
Ding Zhen arises from the accumulation of heat-toxin, resulting in the coagulation and deterioration of Qi and Blood. However, this category includes several subtypes and represents a most malignant prognosis, requiring careful differentiation. Some begin as red macules that gradually turn black and become hard as stone; this indicates tissue necrosis, deficiency of middle Qi and Blood, inability to resolve toxins, and subsequent sinking/entrapment of pathogens. Some present with slight muscle swelling, resembling piled millet grains without distinct vesicles; this signifies Qi stagnation and Blood stasis, with toxin aggregation failing to disperse. Some exhibit central black depression with peripheral elevation and pus formation (termed "Dai Jiang"); this reflects Blood following the toxin while Qi fails to fill and support. Some show central pus-filled areas that spontaneously rupture and ulcerate; this indicates dual deficiency of Qi and Blood, with skin deterioration. Some resemble blisters that are easily ruptured; this stems from Spleen deficiency failing to control dampness, and Qi deficiency failing to constrain. Some appear as blood blisters, purple in color and easily broken; this results from reckless movement of Heat in Blood combined with Qi deficiency failing to consolidate. Some have pore-like openings at the lesion apex with spontaneous leakage of fluid; this denotes failure of Wei Qi and external loss of body fluids. Although these presentations differ slightly from typical Ding Zhen, their danger is equivalent. Observation during the fifth to sixth day is crucial; if any of these signs appear, the condition is often untreatable.
First, for cases of Ding Zhen and black depression, internal administration of Liuqi Decoction (Six-Qi Decoction) supplemented with Chuanxiong Rhizoma (Chuanxiong), Arnebiae Radix seu Lithospermi Radix (Zicao), Carthami Flos (Honghua), and Akebiae Caulis (Mutong) is indicated to nourish Blood, cool Blood, and allow the Ding to recede. After the Ding subsides, substantial doses of Liuqi Decoction or Liuwu Decoction (Six-Ingredient Decoction) should be continued, externally applying Six-Sheng Powder (Sisheng Dan) mixed with juice from Rubia Cordifolia Root (Yanzhi). For larger Ding, puncture the lesion with a silver needle, evacuate the foul blood, and apply the subsequent powder; the lesion will then turn red and vibrant. Generally, extensive black depression with numerous Ding, or persistent residual toxins preventing recovery, leads to mortality. If, after evacuating black blood from the Ding, topical medication fails to change the color back to red, remaining black, death is certain.
*Xin Jian* states: Ding Zhen appearing on the limbs, distant from the Zang-Fu organs, is easier to treat; however, if it penetrates sinews and bones, it is difficult to manage. Lesions appearing on the head, face, abdomen, or back, approaching the interior, pose a risk of penetrating the Zang-Fu organs. If penetration has not yet occurred, urgent treatment is required using refined Realgar (Xionghuang) mixed with true Toad Venom (Chansu) to form pills the size of hemp seeds. Puncture the Ding and insert the pill for immediate effect. Alternatively, one seed of Croton Tiglium Seed (Badou), peeled, mixed with Cinnabar (Zhusha), ground into a paste and applied, can lead to eruption and cure within an hour. Internally administer Wujia San (Priceless Powder) dissolved well-water with 3–5 drops of pig tail blood.
Second, smallpox presenting with black depression indicates insufficiency of Qi and inactive Blood. Urgent treatment involves Tuoli San (Support-the-Interior Powder) or Liuwu Decoction added with Chuanxiong Rhizoma (Chuanxiong), Cinnamon Twig (Rougui), Carthami Flos (Honghua), and Bombyx Batryticatus (Chantui), taken with Wujia San or Dusheng San (Single-Saint Powder). In severe cases, Jiwei Yigong Jian (Nine-Ingredient Yi-Gong Decoction) or Shiquan Dabu Tang (Ten-Ingredient Great Tonifying Decoction) taken with Wujia San is indicated, along with external application of Sisheng Dan. If lesions are scorched purple-black, covering the whole body, accompanied by high fever, constipation, internal heat, irritability, and thirst, this constitutes a Fire-Toxin syndrome. Treat with Sishun Qingliang Yin (Four-Compliance Cooling Drink) or Chengqi Tang (Chengqi Decoction) combined with Wan's Duoming Dan (Wan's Life-Seizing Pill) to resolve toxins. Once the Fire pathogen subsides slightly, resume Liuqi Decoction with Wujia San to tonify the interior, offering hope for survival.
Third, during the eruption phase of smallpox, if lesions appear dry with scorched-black bases, immediate treatment is necessary. If Fire pathogen is mild and fever is absent, Wuwu Decoction (Five-Material Decoction) or Liuwu Decoction is most appropriate. If signs of Fire and rapid pulse indicate severe Blood Heat and toxin accumulation causing scorching and blackening, mild cases use Liangxue Yangying Jian (Cool-Blood Nourish-Nutrition Decoction) or Niuzangzi Tang (Arctii Decoction); severe cases require concurrent administration of Wan's Duoming Dan.
Fourth, if pre-existing sores have not healed when smallpox erupts, and lesions cluster at broken sites appearing black and ulcerated, puncture immediately with a silver needle, suck out toxic blood, and spit into water. Red blood indicates treatability; black blood indicates difficulty. Internally administer Jiawei Sisheng San (Modified Six-Sheng Powder) or Wan's Duoming Dan, and externally apply Wan's Sisheng San.
Fifth, after the crusting stage (Ye), if Ding Zhen ulcerates into pits exposing sinews and bones, use Tuoli Xiaodu San (Support-Interior Detoxify-Pus Powder) or Jingfang Baidu San (Aucklandia and Saposhnikovia Decoction to Overcome Toxicity) added with Manis Squama (Chuanshanjia), Bombyx Batryticatus (Chantui), and Bombyx Morsio (Jiangcan). Externally apply Shenxiao Danggui Gao (Miraculous Angelica Ointment), Taiyi Gao (Supreme One Ointment), or Baisheng San (White Dragon Powder).