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Madam Wang, over eighty years old, had a carbuncle on the head that had already ulcerated, followed by the emergence of a back carbuncle; the pustules were as small as millet seeds, and the pulse was large but powerless. This was caused by damp-heat in the Bladder Meridian (Taiyang Bladder Channel), yet a large and powerless pulse indicates a decline in Blood and Qi. Consequently, she took Tuo Li Xiao Du San (Support Interior and Eliminate Toxin Decoction) for several doses, with slight improvement. The dosage of Ren Shen (Ginseng Radix et Rhizoma) was then increased. Although the sore raised up, thirst ensued, indicating extreme deficiency of Blood and Qi. A prescription containing one liang each of Ren Shen (Ginseng Radix et Rhizoma) and Huang Qi (Astragali Radix), five qian each of Dang Gui (Angelicae Sinensis Radix) and Shu Di Huang (Rehmanniae Radix Preparata), and one qian each of Mai Dong (Ophiopogonis Radix) and Wu Wei Zi (Schisandrae Chinensis Fructus) was administered for several doses, after which the thirst ceased and she recovered. If the Zang-Fu organs could speak and Blood and Qi could report their condition, how could one not realize this? Patients often attribute their death to fate, which is deeply lamentable. There was another patient who was constitutionally robust or had phlegm-dampness and refused tonifying agents. However, they did not realize that after internal ulceration of pus and blood, both Blood and Qi become deficient; should they not be tonified? In my frequent treatment of sores, I used Yin-tonifying formulas with heavy doses of Ren Shen (Ginseng Radix et Rhizoma) and Huang Qi (Astragali Radix), while labeling them with names implying detoxification, and patients took them without experiencing abdominal fullness, and the sores responded promptly. In cases of severe deficiency, I even added Gan Jiang (Zingiberis Rhizoma) and Rou Gui (Cinnamomi Cortex), or even Fu Zi (Aconiti Lateralis Radix Preparata), and there was never a case where it failed. (Commentary by Xue Ji)

Xue Lizhai said: When pus has matured but does not ulcerate, it is due to deficiency of Yang Qi, and tonification is indicated. When stagnant blood does not putrefy, one should greatly tonify Yang Qi and apply moxibustion with mulberry wood. When pus is clear and does not heal, it indicates deficiency of both Blood and Qi, requiring great tonification. After pus discharge, if appetite is poor and sleep is absent, or fever occurs, it is deficiency, and tonification is indicated. If fatigue, reluctance to speak, poor appetite, and insomnia are present, it is deficiency, and tonification is indicated. If cold pathogen invades the sore opening, preventing healing or causing sinking without healing, warm tonification is indicated. If the pulse is large and powerless, or choppy and minute, it indicates deficiency of both Blood and Qi, requiring vigorous tonification. If bleeding or excessive pus discharge occurs with irritability and insomnia, it indicates collapse of Yang, requiring urgent tonification.
Generally, when pus discharges and is clear, or the sore opening fails to close, or swelling gathers without redness, muscles are cold, flesh is cold, spontaneous sweating occurs, and complexion is pale, all indicate deficiency of both Blood and Qi, and tonification is indispensable.
When much pus and blood have been lost, even if the sore opening has closed, tonification is still crucial. One must ensure the restoration of Blood and Qi; otherwise, other syndromes may arise, making treatment difficult.
He also said: Generally, when pus and blood are heavily discharged, replenishing Blood and Qi should be the priority. Even if other syndromes exist, they should be left untreated for the time being. For major ulceration of carbuncles and sores, fever and aversion to cold belong to extreme deficiency of Blood and Qi. If the Left Hand pulse is insufficient, Blood-tonifying herbs should outweigh Qi-tonifying herbs; if the Right Hand pulse is insufficient, Qi-tonifying herbs should outweigh Blood-tonifying herbs. One must absolutely avoid releasing the exterior (diaphoresis).
Generally, carbuncles and sores rely entirely on Blood and Qi as the foundation. If the lesion fails to rise, or ulcerates without puttingrefying, or fails to heal, or if pus is scant or clear, all indicate deficiency of Blood and Qi, and great tonification is appropriate. Formulas that attack and drain are most contraindicated. There are cases where pus increases instead, which is due to deficiency of Blood and Qi failing to contain it. It is common to see that individuals with substantial Blood and Qi who suffer from sores will have high, swollen, red lesions that easily putrefy and ulcerate, producing thick pus, and heal readily. Weak individuals often fail to rise, do not putrefy, and find healing difficult. If one fails to examine carefully and recklessly administers attacking formulas, the disaster of "deficiency inducing further deficiency" is unavoidable. Post-illness, nourishment and regulation are essential. For conditions such as scrofula (Luo Li) and flowing abscesses (Liu Zhu), tonification is especially important. Otherwise, other syndromes may arise, making management difficult. Be cautious.
He also said: If an ulcer belongs to deficiency of both Blood and Qi, tonification is certainly indicated. If a pre-ulcerative sore (swelling) presents with weak Blood and Qi, preventive tonification is especially advisable. Otherwise, even if it ulcerates, it will not heal. Furthermore, after serious illness, when Blood and Qi have not recovered, recurrence is common. Without regulation and tonification, it will surely transform into other critical syndromes. Or, mistaking recurrence for toxic flare-up and administering attacking formulas, one accelerates the failure to recover; this is a profound warning.
He also said: If the sore swelling and pain are severe, accompanied by irritability and a large pulse, then acrid-hot formulas are contraindicated, not only for pre-ulcerative sores but also for ulcers.
The *Taiping Shenghui Fang* states: After pus has discharged from a carbuncle or sore, if the pulse is faint, choppy, slow, and delayed, it indicates that the pathogenic factor has departed and the True Qi is recovering, signifying easy recovery. If the pulse comes deep, fine, and straight, it indicates interior deficiency and impending transformation of the syndrome. Once pus and blood have gone, the pulse should be calm, the body cool, swelling reduced, and pain ceased, similar to the resolution of a Taiyang Exterior Syndrome after sweating. If, conversely, fever and thirst occur with a flooding and rapid pulse, this indicates deficiency of True Qi and excess of pathogenic factors, and death is certain.