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Any affliction of sores and ulcers, although caused by various factors, essentially boils down to two characters: "internal" and "external"; although the syndromes are numerous, they essentially boil down to two characters: "Yin" and "Yang". Understanding these four aspects covers everything. However, internally, pathogens may originate from the Zang organs (solid organs) or the Fu organs (hollow organs); externally, lesions may be located in the skin or in the sinews and bones; this distinguishes their depth. As for the pathology, it is invariably caused by the stagnation of Blood and Qi, and the retention of Ying and Wei (nutritive and defensive Qi).

Generally, when caused by depression, anger, worry, or excessive sexual activity and toxic heat, the pathological reversal affects the Liver, Spleen, Lung, and Kidney. These originate from the Zang organs and represent the most severe internal diseases. When caused by rich food, strong wine, and roasted or fried foods leading to obstruction, the pathology resides in the Stomach. These originate from the Fu organs and represent slightly less severe internal diseases. Furthermore, when invaded by the Six Excesses (Wind, Cold, Summer-heat, Dampness, Dryness, Fire) due to improper climate, damaging the Ying and Wei, cold-stagnating toxins arrive slowly; those arriving slowly penetrate deeply, often affecting the sinews and bones, representing deep exterior diseases. Wind-heat toxins arrive violently; those arriving violently penetrate shallowly, often affecting the skin, representing shallow exterior diseases. Why? Because pathologies in the Zang organs and bones are mostly Yin toxins, which are severe; pathologies in the Fu organs and skin are mostly Yang toxins, which are shallow.

Therefore, when examining sores and ulcers, one must distinguish between Carbuncle (a red, swollen, painful suppurative infection) and Gangrenous Ulcer (a dark, indurated, non-suppurative necrosis): Carbuncle is heat obstructing externally, belonging to Yang toxin energy. It presents with high swelling, red color, severe pain, thin and shiny skin, easy suppuration, easy healing, rapid onset, and rapid recovery. It is unrelated to the Zang organs, thus easy to treat and cure. Gangrenous ulcer is nodular and sunken internally, belonging to Yin toxin energy. It presents with low swelling, mild pain, dark/black color, or hard skin like a cow's neck, slow onset, and extreme difficulty in recovery. Some patients feel no pain or itching at all; even before the lesion appears, mental spirit may be exhausted, and the Seven Evil signs (seven critical prognostic indicators in TCM) may appear simultaneously. This indicates that the toxin is about to erupt while the internal righteous Qi has already failed, a critical danger sign. Understanding Yin, Yang, Internal, and External allows one to generalize the nature of sores and carbuncles.

However, this discussion focuses on external manifestations. Sores and ulcers can arise anywhere, in the meridians or in the Zang-Fu organs, always involving a distinction between Yin and Yang. If Yuan Qi (Original Qi) is strong, Righteous Qi overcomes Pathogenic Qi. When Righteous Qi overcomes Pathogenic Qi, the toxin remains in the Fu organs; toxins in the Fu organs are Yang toxins, thus easy to manifest, resolve, and treat. If Yuan Qi is weak, Pathogenic Qi overcomes Righteous Qi. When Pathogenic Qi overcomes Righteous Qi, the toxin remains in the Zang organs; toxins in the Zang organs are Yin toxins, thus difficult to rise, resolve, and treat. The ease or difficulty of treatment depends entirely on Deficiency and Excess. Excess is easy, Deficiency is difficult; rapid progression is easy, slow progression is difficult. Therefore, when examining carbuncles and gangrenous ulcers, one must first assess Yuan Qi to determine auspiciousness or inauspiciousness. Thus, whether it is a pre-ulcerative swelling or an open ulcer, if there is a sense of insufficient Yuan Qi, one must anticipate how to manage the outcome and prepare in advance. One must never merely treat the disease as it appears, focusing only on the present moment, lest harm ensue. Cases where Yuan Qi is inherently deficient but Pathogenic Qi is so excess that tonification cannot be tolerated are inevitably fatal adverse conditions. Cases where Pathogenic toxin is blazing and both pulse and symptoms indicate Excess should be treated by directly attacking the toxin, avoiding the error of using tonics that would aid the pathogen; this requires careful differentiation.

Hua Yuanhua stated: The formation of carbuncles, gangrenous ulcers, and swellings results from the accumulation of toxins in the Five Zang and Six Fu organs that fail to circulate, not merely from the blockage of Ying and Wei. Their movement has specific locations, and their governance has specific organ affiliations. For instance, eruptions on the throat and tongue are toxins of the Heart; eruptions on the skin and hair are toxins of the Lung; eruptions on muscles are toxins of the Spleen; eruptions in bone marrow are toxins of the Kidney; eruptions on tendons and fascia are toxins of the Liver; eruptions below are toxins of the Yin; eruptions above are toxins of the Yang; eruptions outward are toxins of the Six Fu organs; eruptions inward are toxins of the Five Zang organs. Hence, internal lesions are termed "corruption," external lesions "ulceration," upper lesions "compliance" (favorable prognosis), and lower lesions "rebellion" (unfavorable prognosis). Lesions appearing above develop rapidly; those below develop slowly. Infection of the Six Fu organs is easy to treat; infection of the Five Zang organs is difficult to heal. Moreover, lesions near bones are often cold; lesions near skin are often hot. Lesions near bones that do not heal for a long time may transform into "blood worms" (necrotic tissue/biofilm). Lesions near skin that do not heal for a long time may transmit Qi and form fistulas. Formation of blood worms causes more itching than pain, or itching followed by pain. Formation of fistulas causes more pain than itching, or neither. Internal deficiency with external excess causes more pain than itching. Unstoppable bleeding leads to death. Suppuration leads to survival. Syndromes are manifold and require detailed treatment.

Wu Shi stated: There are over twenty types of carbuncle and gangrene syndromes: Fa, Gu Fa, Shi Fa, Yan Fa, Honeycomb Fa, Lotus Seed Fa, Pepper Eye Fa, Beaded Fa, Whole-body Fa, Intestinal Abscess Internal Fa, Brain and Back Fa, Eyebrow Fa, Cheek and Jaw Fa, Lung Abscess, Gourd Fa. Generally, treatment should be applied according to the depth and location of the disease without delay. Initial onset resembles Taiyang disease (Exterior syndrome), with floating and tight pulses being the characteristic signs.

He further stated: The Shu points of the Five Zang and Six Fu organs are all located on the back. Any sore condition that damages the membrane of the Zang organs often proves incurable. Fu Qi floats on the surface, so carbuncles that are floating and high are easy to treat; Zang Blood is heavy and cold, governing the interior, so gangrenous ulcers that are sunken internally are difficult to treat.

He also stated: Jie (small abscess) means joint/nodule; Yong (carbuncle) means obstruction; Ju (gangrenous ulcer) means blockage. Lesions 1 to 2 cun are Jie; 3 to 5 cun are Yong; 1 chi is Ju; 1 to 2 chi are Whole-body Ju. If the pulse is surging and rapid, it is difficult to treat; if the pulse is faint and choppy, it is easy to treat. Upon initial sensation, clear heat and extract toxin. After ulceration, drain pus and relieve pain. When pus is exhausted, promote flesh growth and apply scabs. Treatment should be adjusted based on severity and favorable/unfavorable trends.

Ma Yiqing in *Treatise on Carbuncles and Gangrene* stated: Humans have four limbs and five Zang organs, wakefulness and sleep, respiration, and the circulation of Essence and Qi, which flow to become Ying and Wei, become smooth to form complexion, and emerge as voice. Yang utilizes its form, Yin utilizes its essence; this is common to all humans. When harmony is lost, steaming generates heat, cold generates cold. Condensation forms tumors and protrusions; sinking forms carbuncles and gangrenous ulcers; stagnation forms sores and tinea; frustration forms goiter; anger forms gangrenous ulcers. Furthermore, disharmony of the Five Zang organs leads to blockage of the Nine Orifices; disharmony of the Six Qi leads to retention and condensation forming carbuncles. All result from stagnant meridians and channels, non-flowing Blood and Qi, and wind-toxin taking advantage of the situation.

Xue Lizhai stated: The production of sores and ulcers is caused by rich and greasy food, strong wine, roasted and fried foods, excessive sexual exertion, emotional stagnation transforming into fire, Yin deficiency with Yang aggregation, Essence deficiency with Qi constraint, decline of Mingmen Fire failing to generate Earth (Spleen/Stomach); weakness of Ying and Wei allowing external pathogens to invade, injuring Blood and Qi and causing disease. One must examine the meridians affected and treat according to root and branch, urgency and slackness.

Chen Liangfu stated: Externally resembling hemp seeds, internally resembling melons. He also said: Externally small as a coin, internally large enough to hold a fist.