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Stagnation refers to the blockage of the meridians and collaterals, where Qi and Blood either overflow or condense. Over time, they seep out of the vessels, causing chaotic Qi movement; this is Yang stagnating in Yin. All diseases arise from this, not just carbuncles and ulcers. Therefore, when a carbuncle first appears, if it is painful and swollen, it is treatable; if it is painless, non-hot, swollen yet sunken, it is untreatable.

It is also said: Wearing heavy clothes but still feeling cold indicates solitary Yin without Yang to assist; wearing thin clothes but still feeling hot indicates solitary Yang existing alone. When Yang deficiency is extreme, Yang should be tonified; when Yin fluid deficiency is extreme, the Kidney should be nourished.

It is also said: Opisthotonos (back arching) and neck stiffness are signs of disease deterioration; trismus (lockjaw), chills, and teeth grinding indicate the approach of death.

Grand Master Dou said: The occurrence of back carbuncles results from toxic accumulation in the Zang and Fu organs. When Zheng Qi (Upright Qi) is strong, the toxin lingers and progresses slowly; when Yuan Qi (Original Qi) is deficient, the condition is lighter in the morning and heavier in the evening, like drawing a bowstring—small externally but large internally. Internal support therapy leads to survival, while merely draining toxicity leads to death. The treatment method centers on Ginseng Radix et Rhizoma (Renshen, 人参); this is an unchanging principle for all generations.

Whenever a carbuncle arises on the back, spanning one chi in width and reaching one cun in depth, even if it ulcerates to the bone, as long as it does not penetrate the membrane, death will not occur. (From *Quan Shu Jing Yan*)

Sun Simiao said: At critical sites of sores, especially near deficient areas or weak/thin tissues, careful medical treatment is required.

Yu Jiayan said: Once a sore has ulcerated, treatment should focus on greatly tonifying Qi and Blood.

He also said: Pain persisting after pus discharge is due to deficiency; excessive pus with failure to heal is due to weakness.

Wang Kentang said: Medical texts describe five sources of carbuncles and ulcers: 1. Epidemic Qi (Tian Xing Shi Qi); 2. Internal emotional stagnation (Qi Qing Nei Yu); 3. Exterior contraction due to body deficiency (Ti Xu Wai Gan); 4. Body heat clashing with wind-cold (Shen Re Bo Yu Feng Leng); 5. Heat toxins from consuming roasted foods, strong wine, or Dan Shi (cinnabar/stone pills). In summary, these fall under the Three Causes (San Yin).

Regarding exterior causes related to climatic factors (Yun Qi), there are four types:
First, Fire-Heat assisting the Heart to form sores. The Classics state: "What arrives at Shaoyin manifests as sores and rashes." Also: "When Shaoyin governs the year, Heat Qi descends, Lung Qi ascends in response; severely, sores and ulcers appear." Also: "In the political phase of Shaoyin governing, during the First Qi period, Cold begins, Yang Qi stagnates, and summer heat rises, causing internal and external sores." Also: "What arrives at Shaoyang manifests as sores." Also: "When Shaoyang governs, Wind-Heat distributes mixedly, Taiyin Dampness flows horizontally, Cold arrives on time, people suffer from interior cold and exterior sores." During the First Qi climate, it is very warm, causing sores in skin and pores; during the Second Qi, Fire reverses and stagnates, causing heat stagnation above and sores in the middle; during the Third Qi, summer heat arrives, causing people to suffer from pustular sores. Also: "When Taiyang governs, during the First Qi, the air becomes very warm, causing sores in muscles and pores." These are all shallow manifestations of normal transformations. Also: "When Shaoyin governs, if Heat dominates excessively, severely sores appear." Also: "When Shaoyin governs, if invading pathogens dominate severely, sores appear." Also: "The return of Shaoyin causes fei zhen sores, jiong yong acne, and hemorrhoids." Also: "Excessive Fire is called He Xi, causing sores, ulcers, and blood flow disorders." Also: "When Fire stagnates and erupts, people suffer from sores, ulcers, and swelling." This represents severe pathological changes.

Second, Cold Evil injuring the Heart to form sores. The Classics say: "During the Third Qi of Taiyang governance, Cold is prevalent, causing people to suffer from interior cold manifesting as heat, leading to carbuncles, ulcers, and diarrhea." Also: "When Taiyang governs, if Cold dominates excessively, blood changes within, leading to sores and ulcers, with the root in the Heart." Also: "During the Fourth Qi of Yangming governance, cold rain falls, causing people to suffer from carbuncles, swelling, and sores."

Third, Dryness Evil injuring the Liver to form sores. The Classics say: "Wood deficiency is called Wei He... branches develop carbuncles, swelling, and sores; this is evil injuring the Liver." Also: "When Yangming governs, if Dryness dominates excessively, people suffer from ulcers, acne, and sores, with the root in the Liver."

Fourth, Dampness Evil sores. The Classics say: "When Taiyin governs, Dampness transforms things; severely, sores appear on the posterior body." Also: "When Taiyin prevails, Fire Qi stagnates internally, causing sores within that spread outward." These four points refer to epidemic Qi.

In *Su Wen: Mai Yao Jing Wei Lun*, the Emperor asked: "How do various carbuncles, swelling, tendon spasms, and bone pain arise?" Qibo replied: "These are swellings caused by Cold Evil and variations of the Eight Winds." The Emperor asked: "How to treat them?" Qibo replied: "These are diseases of the four seasons; treat them using the controlling cycle to achieve cure."

*Ling Shu: Yong Ju Pian* states: Blood vessels, Ying Qi, and Wei Qi circulate ceaselessly, corresponding to stars above and numbers below. When Cold Evil lodges in the meridians, blood becomes viscous and stops flowing. Stagnation causes Wei Qi to gather there and not return, resulting in carbuncles. Cold transforms into Heat; excessive Heat rots flesh, which becomes pus. If pus is not drained, tendons rot; rotten tendons injure bones; injured bones cause marrow depletion. If not draining through bone apertures, blood dries up and empties, causing tendons, bones, muscles, and flesh to lose mutual nourishment. Meridians fail and leak, fuming into the Five Zang organs; organ injury leads to death.

*Sheng Qi Tong Tian Lun* states: Sweat from labor exposed to wind, with Cold pressing against it, forms fei hui (heat rash); stagnation leads to acne. It also states: "When Yang Qi's opening and closing functions fail, Cold enters, causing severe curvature (Da Lou)." When Ying Qi does not follow its course and rebels in the muscle tissue, carbuncles and swelling arise. This occurs because evil enters through gaps left by sweat and failed Yang Qi regulation, lingering to form carbuncles. This corresponds to body deficiency with exterior contraction, and body heat clashing with wind-cold. Treatment methods include releasing the exterior with formulas such as *Shi Xuan San*, *Wu Xiang Tang*, and Jiegu's *Cang Zhu Fu Jian San*.

Regarding internal causes, Chen Wuyue stated: Carbuncles, ulcers, and scrofula, regardless of deficiency/excess or cold/heat, all result from Qi stagnation. The Classics say: "Qi lodges in the meridians, moving sluggishly with blood, obstructing and knotting to form carbuncles and ulcers." It does not attribute them solely to Heat, but rather to emotional stagnation from anger, joy, worry, and thought. Treatment uses *Yuan Zhi Jiu* and *Du Sheng San*, incorporating the theory of the Five Emotions overcoming each other, such as Anger overcoming Thought.

Regarding non-interior/non-exterior causes, the Classics mention that dietary excesses lead to major ding sores, receiving evil as easily as holding an empty vessel. In eastern regions rich in salt, people consume salty foods, enjoying their dwellings and food, leading to interior heat and Salt overpowering Blood. Thus, their skin is dark and pores loose, prone to carbuncles and ulcers. Using Dan Shi and strong wine also falls into this category.

Li Dongyuan said: Dietary excesses also cause Ying Qi to stagnate and rebel in the muscle tissue. Ying Qi is Stomach Qi. Food entering the stomach is first transported to the Spleen, then directed to the Lungs. The Lungs direct Qi to all vessels, extending to skin and hair, proceeding via Yang pathways before returning to the Five Zang and Six Fu organs, forming the Cun position at the radial artery. Now, wealthy people lack moderation, consuming strong wine, fatty mutton, and rich flavors. Accumulated over time, these dense, pungent substances are "Yang within Yang." Instead of moving through orifices and Yang pathways, they move via Yin pathways, causing excessive Dampness. Following the generating cycle (Son strengthening Mother), Fire becomes vigorous. Excessive Heat and Dampness attack the Kidney. If sexual activity is not regulated, True Water is damaged. With insufficient Water, Dampness transforms and rises upward. Sores often appear on the back and head, constituting the most severe type of major Ding. If toxins exit via the Lungs or Spleen/Stomach regions, it is less severe; if via other channels, even less so. Wherever Heat-Damp toxins stop, ulceration occurs. Thus, the Classics say dietary excesses lead to major Ding, receiving evil like an empty vessel. To treat major Ding, one must drain Ying Qi. From the perspective of Root and Branch, the initial pathogenesis is the Root. Without bitter-cold agents as the sovereign drug, the painful suffering cannot be removed. For example, Li Dongyuan treated Yuan Haowen, and Danxi treated an old woman's brain carbuncle, both due to alcohol consumption, treating them with *San Huang Da Huang* prepared with wine. Similarly, *Pai Nong San* and *Dang Gui San* are used.

Another cause is excessive sexual activity leading to Essence deficiency and Qi exhaustion, belonging to non-interior/non-exterior causes. Treatment should focus on tonifying deficiency and internal support. Avoid *Wu Xiang* drugs that consume True Yin and aid pathogenic Heat. Medicines include *Nei Gu Huang Tang* and *Shen Xiao Tuo Li San*.

The Classics state: "Stagnant Heat in the Five Zang causes sores in the Six Fu organs." Also: "Disorder in the Six Fu organs leads to retention and knotting, forming sores." Also: "All pain, itching, and sores belong to the Heart." "Lung overcoming Liver causes sores; Kidney transferring Cold to Liver causes swelling and shortness of breath; Spleen transferring Cold to Liver causes swelling and tendon spasms." These are all Zang-Fu transformations belonging to internal causes.

Li Dongyuan cited *Sheng Qi Tong Tian Lun*: "Ying Qi not following its course, rebelling in muscle tissue, causes carbuncles." And "Dietary excesses lead to major Ding." And *Yin Yang Ying Xiang Lun*: "Earth's Dampness, when contracted, harms skin, flesh, tendons, and vessels." This means external Dampness impedes Ying Qi. Ying and Wei Qi are managed by Ying Qi. Ying Qi is Stomach Qi and transport Qi. Ying Qi is the Root. If the Root rebels and fails to move, damaged by Dampness, sores arise. Dietary excesses also cause Ying Qi to reverse and congeal in meridians, forming sores. This evil is neither in the exterior nor the interior, but in the middle of the meridians. All statements in *Nei Jing* attribute this to reversed Ying Qi. Reviewing various discussions on sores, some mention two heats clashing transforming into pus; some mention only Heat transforming into pus; some mention Dampness generating sores and Cold transforming into Heat to form pus. These are all sources of carbuncles and ulcers. One should use channel-guiding herbs for the affected area and distinguish Yin/Yang patterns. Draining Ying Qi is the primary treatment. If rebellion aids Fire, combining with Heat-Damp to destroy muscle into pus-blood, this is secondary treatment. Consider nature: Summer is the hottest, yet things do not rot then; rotting occurs when Autumn Dampness prevails. Considering the body: Heat diseases show heat but do not destroy muscle. This logic is clear. If Root and Branch do not match, evil will not subdue. One who knows one thing and understands a hundred can be a superior physician. (From *Yang Yi Zhun Sheng*)

It is also said: *Ling Shu Jing* states: "When Ying and Wei Qi linger in the meridians, blood becomes viscous and stops flowing. Stagnation causes Wei Qi to gather and obstruct, generating Heat. Persistent high Heat wins over flesh, rotting it into pus. However, if it cannot sink into muscles, scorch marrow, or injure the Five Zang, it is named 'Yong' (Carbuncle). If Heat Qi is pure and abundant, sinking into muscles, drying tendons and marrow, connecting internally to the Five Zang, exhausting Qi and Blood, destroying tendons, bones, and good flesh beneath the carbuncle, it is named 'Ju' (Ulcer/Gangrene). On Ju, the skin is dull and hard, resembling ox neck skin. On Yong, the skin is thin and glossy. These are their signs."

*Gui Yi Fang* states: Carbuncle pain is only on the skin surface. Its eruption is like burning thatch, starting like a millet grain, growing to palm size in 2-3 days, and bowl size in 5-7 days; thus easy to treat. If cold swelling, thirst, and rebellious Qi occur, it is difficult to cure. Ulcers may start like small boils; touching causes heart-piercing pain, edges slightly raised like orange peel, pore color red but incomplete, pus not much. By day 7-8, pain, oppression, and rapid breathing persist. If initially swollen and high, suddenly flattening by day 5-7, this is a sign of internal attack.

It also says: There are three grades of carbuncles and ulcers. Superficial toxins belong to Fu organs; deep toxins belong to Zang organs; fierce toxins travel through meridians, varying in depth, affecting all Zang and Fu. These are difficult to regulate. Urgently treat carbuncles appearing on the skin, regardless of deficiency/excess, high swelling, brightness, or pain, provided they are superficial, hot, distended, or itchy/painful without malignant signs. Initially use warm herbs to calm Qi, then use pus-draining and acupoint-opening methods. (Calming Qi for carbuncles involves *Xi Jiao Yin* using Rhino Horn, Forsythia, Agrimonia, Licorice, Angelica, and Cinnamon Twig—all releasing exterior herbs. Opening acupoints involves thorns, using Gleditsia Spine as sovereign, Licorice, Ligusticum, and Frankincense as assistants—also supporting interior herbs, though Jiegu and Li Dongyuan's releasing/supporting formulas are more stable.)

It also says: Ulcers arising anywhere, regardless of size, especially on the back spanning 1-3 chi, with thick purple-black skin, irregular high swelling, internal stabbing pain, chest oppression, heavy limb pain, and anterior chest pain. Eruptions elsewhere are tolerable, but those in deficient areas or near tendons/bones, if pus-toxin has not ulcerated, will damage tendons and bones. Muscle loss defines Ju, belonging to deep Zang toxins. Qi lies hidden, hard and firm; slowness is inadvisable. Treatment must solidify the Five Zang internally and penetrate the skin externally, making it soft and even, allowing pus to emerge. Use internal support herbs to solidify Zang Qi and harmonize Qi to drain pus. This differs from superficial carbuncle toxins; do not treat them identically.

It also says: For all swellings, if initially high and swollen but suddenly flattening by day 5-7, this is a sign of internal attack. Urgently use *Nei Tuo San* and internal tonifying decoctions to fill and solidify the Zang and Fu organs. Penetrating the membrane is most feared; once penetrated, ten cases yield no survivors.

Lou Quanshan said: Carbuncle evil is shallow, lingering and obstructing only in the meridians, attacking exclusively outward. Thus, upon onset, fever appears from the exterior, and the site swells high like a bowl or basin, painful. Even if tending to sink, upright Qi secures the interior, refusing acceptance, causing constipation, thirst, or rebellious Qi to resist. Thus, marrow never scorches, and Zang organs remain uninjured. Ulcer evil is deep, lingering and obstructing, connecting internally to the Five Zang, not attacking exclusively outward. Thus, the body has no fever, the site may not be painful or swollen; severely, hoarseness, Qi collapse, black/small eyes, and black swollen fingers occur, often leading to death. Treatment for early carbuncles follows Jiegu's method: release the exterior to scatter, purge the interior to descend, moxa to burn, apply herbs to cover. Unformed pus must resolve; formed pus must quickly rupture. Early ulcer treatment follows *Gui Yi Fang*: fill and solidify Zang and Fu, prevent sinking evil from spreading, moxa externally to draw evil out, providing a pathway for expulsion, turning death to life and disaster to auspiciousness. Modern surgeons fail to distinguish carbuncles from ulcers, uniformly clearing heat and extracting toxins, depleting Qi with external *Wu Xiang*, and exhausting Blood with internal Rhubarb. They never realize their error; what a pity!

Jiegu said: Sores and ulcers belong to Fire and must be distinguished internally and externally. If the pulse is deep and solid, first dredge the interior to cut off the source. If the pulse is floating and large, first support the interior to fear evil entering inward. For those in between, evil is extreme, blocking meridians, causing carbuncles. The Classics state: "Ying Qi not following its course, rebelling in muscle tissue, causes carbuncles." This results from failing to support the interior, failing to dredge, and failing to harmonize Ying and Wei. The key to treating sores requires understanding three methods: Supporting Interior, Dredging, and Moving Ying-Wei. Supporting Interior treats exterior-to-interior; Dredging treats interior-to-exterior; Moving Ying-Wei treats the middle. Interior-to-exterior presents with deep-solid pulse, fever, irritability, no severe exterior redness/pain, indicating deep interior evil. Thus, first dredge Zang-Fu to cut the source (*Nei Shu Huang Lian Tang*). Exterior-to-interior presents with floating-rapid pulse, swelling outside, obvious exterior signs, fearing extreme evil moving inward. Thus, first support interior to prevent invasion (*Nei Tuo Fu Jian San*). Middle-of-interior-and-exterior presents with no malignant exterior Qi and smooth interior Zang-Fu, knowing the evil is in the meridians, requiring harmonizing Ying-Wei (*Dang Gui Huang Qi Tang*). After using these three methods, even if not cured, complications will not arise, and evil will diminish significantly for easier recovery.

*San Yin Fang Lun* states: Carbuncles, ulcers, and scrofula, regardless of deficiency/excess or cold/heat, all result from Qi stagnation. The Classics say: "Qi lodges in meridians, moving sluggishly with blood, obstructing and knotting to form carbuncles and ulcers." It does not attribute them solely to Heat, but to emotional stagnation from anger, joy, worry, and thought. *Jing Yao* states: People frustrated and unfulfilled in desires often suffer from carbuncles and ulcers.

Zhang Jingyue said: Although causes of sores are many, the essence lies in Interior and Exterior. Although symptoms are many, the essence lies in Yin and Yang. Knowing these four covers everything. Internally, some arise from Zang, some from Fu. Externally, some are in skin, some in tendons/bones; this distinguishes depth. Pathologically, all result from Qi-Blood obstruction and Ying-Wei lingering. Emotional anger/worry or lust/Dan Du rebellion affects Liver, Spleen, Lung, Kidney—originating from Zang, being the most severe internal disease. Dietary rich flavors, strong wine, and roasted meats obstruct the Stomach—originating from Fu, being slightly less severe internal disease. External invasion of Six Qi, imbalance of Cold/Heat, penetrating meridians and harming Ying-Wei: Cold stagnation comes slowly, entering deeply, often affecting tendons/bones (deep exterior disease). Wind-Heat comes violently, entering shallowly, often affecting skin/flesh (shallow exterior disease). Why? Zang/Bone involve mostly Yin-Toxin (severe); Fu/Skin involve mostly Yang-Toxin (shallow). Thus, examining sores requires distinguishing carbuncles from ulcers. Carbuncles: Heat obstructed externally, Yang-Toxin Qi. Swelling is high, color red, pain severe, skin thin and glossy, pus easy to liquefy, wound easy to close, onset fast, healing fast. Unrelated to Zang-Fu, thus easy to treat and heal. Ulcers: Knotting and sinking internally, Yin-Toxin Qi. Swelling not high, pain not severe, color dark/black, skin like ox neck, onset not sudden, healing hardest. May feel no pain/itching; even before toxin forms, spirit is exhausted, Seven Evils appear. This indicates toxin emerging while interior fails first—a critical danger. Knowing Yin/Yang and Interior/Exterior allows categorizing sores. Speaking of external manifestations, sores have no fixed location, possibly in meridians or Zang-Fu, all having Yin/Yang distinction. If Original Qi is strong, Upright defeats Evil; Evil in Fu is Yang-Toxin, easy to emit, collect, and treat. If Original Qi is weak, Evil defeats Upright; Evil in Zang is Yin-Toxin, hard to rise, collect, and treat. Difficulty depends on Deficiency/Excess: Excess is easy, Deficiency is hard; Fast is easy, Slow is hard. Thus, examining carbuncles/ulcers requires assessing Original Qi to judge fortune/misfortune. Regardless of pre-ulcer or post-ulcer stages, if Original Qi feels insufficient, one must anticipate the outcome and prepare in advance. Treating disease only when seen, focusing only on the present, rarely avoids harm. If Original Qi is fundamentally deficient but Evil is too strong to tolerate tonification, it is a rebellious/destructive pattern. If Evil-Toxin is blazing and pulse/symptoms are full, directly attack the toxin, avoiding mistakenly aiding Evil with tonification. Careful differentiation is required. (From *Quan Shu*)

Ma Yiqing's *Yong Ju Lun* states: Humans have four limbs and five Zang organs, waking and sleeping, breathing and exchanging Qi, Jing-Qi flowing as Ying-Wei, flourishing as Qi-color, emitting as voice. Yang uses Form, Yin uses Essence; this is the constant shared by humans. When deviation occurs, steaming generates Heat, cooling generates Cold. Knotting forms tumors/lumps, sinking forms carbuncles and ulcers.