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(In various types of smallpox, if a single large pustule appears, either black or white, with a hard and knotted root, this is called *Dou Ding* (Smallpox Carbuncle), resembling a carbuncle, with the pathogenic factor penetrating deeply to the muscles and bones. It should be pricked open and treated with *Sisheng San* (Four Sages Powder). Among all black sunken cases, those with a tiny pointed apex resembling the fruit of the Chinese Toon tree are Ding; those without this appearance are simply called black sunken smallpox, not Ding.)

[Wan Quan's Discussion] *Dou Ding* (Smallpox Carbuncle) is formed by the accumulation of heat-toxin, leading to the corruption of Qi and Blood. Its manifestations vary, representing epidemic toxic Qi, which is the most malignant prognosis. It requires careful observation. Some present with slight muscle swelling, resembling piled millet grains without distinct particles; this indicates Qi stagnation and Blood coagulation, with toxic vapors constrained. Some begin as red spots that gradually turn black and become hard as stone; this signifies tissue decay, deficiency of middle Qi and Blood, inability to expel toxin outward, resulting in internal sinking and entrapment. Some show central black depression with surrounding elevation and pus formation; this indicates Blood following the toxin while Qi fails to control it. Some have central pus with surrounding dry, sunken, and scorched-black edges; this indicates Qi attaching to the toxin for expulsion while Blood fails to nourish. Some have heads with white pus that rupture spontaneously; this indicates insufficiency of Qi and Blood and deterioration of the skin. Some form blisters that are soft and easily broken; this indicates concurrent Fire and Dampness, with Qi deficiency failing to consolidate. Some form purple blood blisters that break easily; this indicates reckless movement of Heat in the Blood, unable to adhere to Qi. Some have puncture-like sores with spontaneous discharge of serum; this indicates failure of Defensive Qi and leakage of fluids. These several syndromes should be monitored on the fifth or sixth day after eruption. If any one symptom is observed, the condition is considered incurable.

[Xue Ji's Discussion] *Dou Ding* (Smallpox Carbuncle), also known as "Thief Pustules," may number three to five or five to seven, interspersed among other pustules. They are purple-dark in color, painful and restless, causing other symptoms to arise simultaneously, preventing suppuration, and potentially leading to death due to severe and aggregated heat-toxin. Treat with *Xianfang Huoming Yin* (Immortal Life-Preserving Decoction). If constipation and urinary difficulty occur, add *Dahuang* (Rhubarb Root) according to need. If general stiffness and spasms occur, add *Mahuang* (Ephedra Stem). Externally, the pustules must be pricked with a thread needle to release black blood, or suctioned to remove toxic blood, thereby venting the toxin, allowing other pustules to suppurate. Otherwise, the toxin cannot resolve, leading to certain death. If ineffective, urgently apply *Gesu Jiu* (Garlic-Separated Moxibustion). If toxic vapors are intense or the patient feels no pain, moxa may be applied directly to the flesh without garlic separation. If after moxibustion the sore becomes red, swollen, and hot, prick it again to release toxic blood before applying moxa, which is particularly effective. Although this method is not found in standard formularies, I have used it repeatedly with success. Relying solely on pills like *Zhibao Dan* (Precious Treasure Pill) is inadvisable. Refer to other sections on eruption management.

During the eruption phase of smallpox, if dryness and scorched-black roots are observed, immediately administer *Duoming Dan* (Life-Seizing Pill) internally and apply *Sisheng San* (Four Sages Powder) externally. If pre-existing rashes or unsuppurated sores exist, or if the skin is tender near healing, and upon eruption the local pustules cluster with black, decaying features, prick them urgently with a needle, suction out toxic blood, apply *Sisheng San* externally, and treat internally with *Jiawei Sisheng Tang* (Modified Four Sages Decoction) combined with *Wujia San* (Priceless Powder) and *Duoming Dan*. If the whole body is covered with scorched-black sores, examine the stool. If constipated, administer *Chengqi Tang* (Purgative Decoction) mixed with *Wujia San*, and use *Shuiyang Tang* (Water-Willow Decoction) bath externally. If bowel movements are normal, administer *Shiquan Dabu Tang* (Ten Ingredients Great Tonifying Decoction) mixed with *Chen's Muxiang San* (Chen's Costus Powder) combined with *Wujia San* and *Duoming Dan*, and use *Shuiyang Tang* bath externally.

**Sisheng San (Four Sages Powder)**
*Mung Bean* (49 seeds), *Pea* (49 seeds): each burnt to retain its properties. *Zhenzhu* (Pearl, 1 fen). *You Toufa* (Oily Hair: burnt, 1 fen).
Grind into fine powder. Mix with *Yanzhi Shui* (Alkermes Water). First, use an hairpin to part the black sore, then apply this powder.

**Ersheng San (Two Sages Powder)**
For treating *Dou Ding*: after pricking, apply this powder.
*Xionghuang* (Realgar, 2 qian). *Zicao* (Arnebia Root, 3 qian).
Grind into powder. Mix with oil-based Alkermes.

**Application Formula**
For post-scab *Dou Ding* ulcerations exposing bone/tendon:
*Chishizhi* (Red Halloysite), *Nifen* (Calomel), *Huangbai* (Phellodendron Bark), *Hangfen* (Starch: stir-fried), *Xuexie* (Dragon's Blood), *Fulonggan* (Yellow Dragon Earth: each 1 qian). *Feidan* (Lead Monoxide: stir-fried, 8 fen). *Fahui* (Hair Ash, 5 fen).
*Ruxiang* (Frankincense), *Moyao* (Myrrh: each 3 fen). *Bingpian* (Borneol, 3 li). *Mituoseng* (Litharge: purified, 2 qian).
If foul odor exists, add *Awei* (Asafoetida, 3-4 fen).
Grind into fine powder, sieve through silk paper, and apply. Cover with plaster. Internally, take *Renshen Baidu San* (Ginseng Detoxification Powder) added with *Chuanshanjia* (Pangolin Scale), *Chantui* (Cicada Slough), and *Lianqiao* (Forsythia Fruit).

**Badu Gao (Toxin-Extracting Ointment)**
For *Dou Ding*.
*Xionghuang* (Realgar: ground).
Soak in concentrated Alkermes water, mix with *Xionghuang*, and apply to the pustule. It turns red and active immediately. This is a divine method because Realgar extracts toxins and Alkermes invigorates Blood.

**Feilong Duoming Dan (Flying Dragon Life-Seizing Pill)**
For *Dou Ding*, smallpox toxin, and carbuncles, or numbness/vomiting; in severe cases, coma and teeth-grinding.
*Zhen Chansu* (Toad Venom: dried, dissolved in wine), *Qingfen* (Calomel: each 1 qian). *Kubai Fan* (Calcined Alum), *Han Shuishi* (Halloysite), *Tonglü* (Malachite), *Ruxiang* (Frankincense), *Moyao* (Myrrh), *Shexiang* (Musk: each 2 qian).
*Zhusha* (Cinnabar, 6 qian). *Wo Niu* (Snail, 42 pieces, ground separately; optional).
Grind each into powder. Add Toad Venom and Snail, or a little wine, to make pills the size of mung beans. Take one pill per dose with warm wine or Scallion Decoction. For severe cases, use Garlic-Separated Moxibustion externally; for extreme cases, direct moxibustion.

**Juanlian Ding (Rolling-Curtain Carbuncle) [Yuan's Discussion]**
On the sixth or seventh day of smallpox, the tongue rolls upward, throat locks, with severe thirst and pain, making eating difficult. Ignorant practitioners may cut the blue veins under the tongue, causing sudden death. One must realize the toxin is rooted at the base of the tongue; severe cases resemble black beans, mild ones grapes. Use a silver hook to pierce the affected area, drain all evil blood, rinse mouth with bitter tea to spit out toxic blood, then administer the following formula. Verse: *Buxian*’s miraculous Long Palace Pill, mixed with Borneol, Borax, and Indigo; Stir-fry Mint, Schizonepeta, and Silkworm; Seek processed Coptis, grind finely, blow slowly into the throat to unroll the curtain. Note: This carbuncle is unknown to many, killing children. Since it affects the Heart, clear and resolve urgently; tonics are contraindicated. Using Clam Juice and Yulu Drop is also acceptable.

**Yanwo Ding (Swallow’s Nest Carbuncle)**
On days five or six, hardness and swelling appear in the armpit, arms hang limp and immobile, with restlessness, delirium, greenish eyes, red face, extreme thirst, and foaming. Ignorant people mistake this for an abscess. In fact, smallpox toxin gathers in the armpit, named Yanwo Ding. Urgently pierce the root with a silver needle, drain evil blood, wash with clarified Swallow’s Nest water, apply Pearl Powder mixed with Oil Alkermes externally, and take *Xiaodu Yin* (Detoxification Decoction) internally. Verse: To cure Yanwo Ding, use Swallow’s Nest; pierce and clarify mud; wash away toxic blood; mix Oil Alkermes with Rice Pearl; apply constantly until toxin leaves. Also: *Xiaodu Yin* starts with Burdock, Licorice, Akebia, Poria, Rehmannia complete; add Safflower, Rhinoceros Horn, Peony, Forsythia; boil Rush grass strongly to eliminate toxin. Detailed observation shows: left armpit involvement causes right-sided pustules to sink and lose color; right armpit involvement causes left-sided pustules to rebel and lose vitality. This is the rule. Saying left Ding ruins left pustules is wrong. Using Slug and Walnut meat orally gives temporary relief but ultimately fails.

**Huozhu Ding (Fire Pearl Carbuncle)**
On days six or seven, nasal passages are blocked with fire-like sensation, breathing is difficult, with extreme thirst, restlessness, red face/eyes, tight phlegm, anorexia, and burning heat. Named Huozhu Ding. Externally, hook/pierce it, apply medicine to the eye corners, then take *Xiejing Tang* (Draining Metal Decoction) for cure. Verse: Nasal blockage with Fire Pearl Ding; quickly hook up towards the eye; Apply Coptis Ointment and Plum Blossom Borneol; drip into both sides; take two doses of Draining Metal Decoction, toxin clears naturally. *Xiejing Tang* Verse: Black Rhinoceros, Platycodon, Burdock move; Peony, Licorice, Licorice Root, Cooling Green settle fire; Rehmannia, Safflower, Akebia, Arnebia combine; decoct together, toxin dissolves. Note: This occurs in children; mistaken for polyps, lack of piercing leads to death. Practitioners should check for eye rolling, rapid breathing, and limb flailing. Using Snail water is not ideal.

**Wangji Ding (Forgotten Drawing Carbuncle)**
On days six or seven, eyelids suddenly swell and knot; toxin seals like a clam, causing extreme heat, purple face, thirst. Treat like nasal Ding: prick and apply mashed Tile Onion (*Wacong*) immediately, as hooks cannot penetrate here. Verse: Ding on eyelid blinds the eye; use immortal method; mash Tile Onion firmly, do not wait for Wind Owl to cause evil. Formerly, Mu Xiu treated this with Mountain Garlic (*Shancigu*) and Dung Beetle meat mashed and applied to extract the root; also effective.

**Huanhu Ding (Taming Tiger Carbuncle)**
During the suppuration/crusting phase, toxin forms in the ear canal. The Kidney region should be free of smallpox toxin; its presence here indicates fierce inflammation and depletion of Kidney Essence. Urgently pierce with an awl, then blow extremely fine powder of *EGuanguan Shi* (Tube Stone), *Nüzhenzi* (Eucommia Seed), and *Bohe* (Mint) into the site. Wash *Malan Gen* (Kalimeris Root), cut into inches, and insert into the ear. Verse: Taming Tiger originates in both ears; Shaoyang syndrome managed with blowing tube; Tube Stone, Eucommia Seed, Mint attack together; Wash Kalimeris Root, cut and insert; no need to hesitate, miracle works within the Ding. Note: *EGuanguan Shi* should be changed to *Xuanjing Shi* (Mysterious Essence Stone); copying errors exist regarding *Nüzhenzi*.

**Zhuming Ding (Life-Directing Carbuncle)**
On the soles of the feet during the disease period, toxin gathers into a Ding, hard, swollen, painful, resembling a coin, large black bean, or peppercorn. Purple veins extend to the thigh/knee. Toxicity is severe. Quickly dig out the root, drain all blood, apply Ice Borneol mixed with Snail water three times, mash soaked Caulophyllum (*Shenhuaocao*) and Mung Beans, apply locally, and take *Huadu Dan* (Toxin-Resolving Pill) internally. Verse: If Zhuming Ding arises in smallpox, the flower fence is not light; silver needle drains toxin; find snail spitting clear water; mix Borneol and Alkermes; seek true Dragon Scale Grass (aka Fire Dan Grass); soak peeled Mung Beans, mash together, apply layer; take Huadu Dan internally, fear not the sole Ding. Laypeople ignore foot Ding, not knowing it connects upwards to Spleen and Heart meridians; it cannot be delayed, hence "Life-Directing."

**Lihan Ding (Black Snake Containing Carbuncle)**
On days five or six, body feverish and restless, delirious, eyes rolling, abdomen distended, urine blocked, painful crying. Toxin gathers in Bladder, forming poison in the urethral orifice. Named Lihan Ding. Saying: Ding here means death soon. Urgently mix *Yinzhu* (Silver Cinnabar), Borneol, Toad Venom, Cow Bezoar, Musk into fine powder. Boil Coptis and strong Tea, cool, take half spoon to mix medicine. Dip soft Rice Straw Heart in medicine, insert into orifice, massage shaft with Rapeseed Oil, take *Mutong Baidu San* (Akebia Detoxification Powder) internally. Verse: Lihan Ding like a knife; nine out of ten do not survive; Monk’s divine method saves life later; Cow Bezoar, Borneol, Toad Venom, Musk, mixed with Silver Cinnabar; boil Tea/Coptis strong, cool; dip Rice Straw Heart in paste; follow method, fear not night/day cries. Formerly, a monk from Yunjian used thin silver wire to clear orifice, rinsed with water, sucked out toxic blood; externally using Pearl and Borneol was also effective.

**Touchang Ding (Penetrating Intestine Carbuncle)**
Within days six or seven, abdominal fullness, unbearable colic, constipation, thirst. Toxin gathers beside the anus, hard, purple, conical. Named Touchang Ding, toxin penetrates Yangming. Quickly needle/pierce toxin. Boil large amounts of *Jinyinhua* (Honeysuckle Flower) and *Fangfeng* (Saposhnikovia Root), cool, clean, then apply Calomel, Pearl, Borneol, *Bailian* (White Tulip Bulb) powder dipped on Rush Grass. Take *Huanglian Jiedu Tang* (Coptis Detoxification Decoction) internally. Verse: Touchang Ding toxin threatens life; if cured, fistula may form; who knows this miracle? Only *Buxian* treasures it; Borneol, Pearl, Calomel, equal weights; first grind Bailian, sift dry, then mix; when toxin recovers and yellows, it dries; when ulcerating, it is repulsive. After picking, mashed Ramie Root or Mulberry Twig with Musk is effective, but wild Mung Bean powder mixed with Safflower powder, dry-applied, is best.