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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).