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When a swelling ulcer (swelling sore) reaches the stage where it should suppurate and break, pus must first be steamed and brewed within the muscle layers and interstices. In cases where the onset is most superficial, the mass stands high, with the base perimeter tightly gathered; regardless of whether the skin color is red or not, it can be known at a glance that pus has formed. Puncturing it with a needle allows the pus to drain and the pathogen to leave, achieving full recovery in three to five days. This is the easiest method to distinguish the presence or absence of pus, but these are all extremely minor and mild conditions. For example, heat boils (heat furuncles) in summer will heal spontaneously even without medical treatment and should not be discussed alongside carbuncles and ulcers.

For larger sores, the onset must be deep. The swelling is diffuse without boundaries, never standing high, and does not change color. Although pus exists internally, it remains at the bottom of the muscles. If the swelling is large and puffy, such as in obese individuals or areas with thick flesh like the thighs and buttocks, pus often forms one or two cun deep inside, while the subcutaneous tissue above appears unchanged. Ignorant practitioners fail to observe this, mistakenly believing it can still dissipate. Consequently, the internal pus grows larger with aggressive treatment, unable to reach the exterior while internal rotting deepens daily, leading to disastrous complications that become unmanageable. Such cases are frequently seen. All result from failing to detect the pus early, causing endless disaster, which is truly lamentable.

The method of differentiation: If the swelling is diffuse and unconfined, feels hard upon pressure, and pain is not severe, the pus has not yet formed. If pressing causes pain, and specifically pressing firmly with the fingertip on one spot elicits the sharpest pain, pus has definitely formed there. However, since it is deep within the flesh, immediate incision or needling is inadvisable due to abundant blood supply and intense pain. For patients with rich diets ("Gao Liang" constitution) or those who are frail, fear may arise just by looking. Therefore, external encircling medicines should be applied to bind the periphery, while internal penetrating formulas should be taken to draw the pus outward. After one or two days, the swelling becomes higher and the pus shallower; pressing again reveals softness under the fingers, indicating readiness for incision.

If the swelling is diffuse, hard, and massive, with the periphery feeling hard upon fingertip pressure but the center feeling soft and depressed, the pus has formed but remains in a shallow location. Or if the swelling spreads widely, extending up to a chi in length, feeling hard everywhere, yet when two fingers press alternately one or two cun apart, a hidden soft depression is felt beneath the hard swelling, this also indicates pus formation in a deep location.

If the swelling rises diffusely, the skin becomes tense and even shiny, this method is unnecessary. Only edema caused by Qi deficiency presents this way, which is certainly not an external sore. External sores are mostly hard, and pressing them yields no depression. If pressing causes a depression that rebounds immediately upon releasing the finger, it indicates a large amount of internal pus with a very large and shallow rupture point. This corresponds to the previously mentioned case where the skin is shiny and visible at a glance; why rely on tactile differentiation? If there is a large internal abscess but the overlying intact skin and flesh are still three or five fen thick, pressing will not cause depression nor rebound. One cannot generally assume that pus has not formed in such cases.

Some claim that hot skin indicates pus, while cool skin indicates no pus. However, small boils on the skin surface, being shallow, may feel hot even before pus forms; whereas large carbuncles deep in the muscle, despite having formed pus, may not feel hot on the surface. Another theory suggests that applying wet paper to a diffuse swelling will show drying at the spot where pus exists. These are dreams of fools, lacking personal experience and based on wild speculation (Shouyi notes: The intent behind this theory seems to be that internal pus makes the skin hot, so wet paper dries first. However, the presence of pus has nothing to do with skin temperature. It is laughable for someone to claim this without ever having seen a sore).

Only in laborers, where local swelling is not highly protruding, must one carefully press with fingertips. If a specific spot feels soft, it confirms pus formation. In the hollow, soft area of the abdomen, internal intestinal carbuncles may present with low swelling and small size. Even if pus has formed, it is difficult to distinguish by palpation. Heavy pressure naturally causes the soft abdomen to depress, which is its normal state. However, even if a hard mass exists, careful palpation with fingertips on the mass allows for accurate assessment. This requires accumulating clinical experience and insight to see through the obvious. It cannot be judged hastily by those who are careless and impetuous.

Nevertheless, for abdominal abscesses, although distinguishing pus is difficult, early differentiation is crucial. Sores on solid areas like arms and legs, if not decided upon early after pus formation (3-5 days), will lead to severe internal rotting. Misfortune strikes if they perforate the intestines or inner membranes, becoming disastrous. A physician's slight delay in judgment marks the boundary between life and death for the patient. How can one not be extremely cautious and discerning? In summary, for carbuncles and ulcers in the chest, abdomen, hypochondrium, axilla, waist, back, etc., if pus has formed, draining the toxin one day earlier reduces the risk of internal invasion by one step. Failure to decide beforehand, leading to membrane perforation and internal spread, resulting in untreatable death, is solely the fault of the doctor delaying treatment. Realizing this, one understands that the most difficult-to-differentiate diseases are the most lethal opportunities. One must not avoid them due to difficulty.

There are three major syndromes: back carbuncle, brain carbuncle, and abdominal wall abscess. Initially, a single grain-like spot appears on the skin, gradually developing a hard, swollen base. A few white necrotic spots appear on the swelling, with pus brewing from the outside. This is clearly different from other conditions where pus forms beneath the skin. Treatment focuses primarily on internal administration to support the expulsion of toxins outward, supplemented by external applications to promote pus discharge and extract toxins. Only excellent medicines can achieve success. If the pus and toxins penetrate effectively, complete cure is assured.

Additionally, carbuncles on the head and face sometimes begin with a single white granule, with pus forming from the outside. External treatments are the same as for brain and back carbuncles. Internally, heavy use of clearing and resolving herbs is required, aiming only for the necrotic tissue of the carbuncle head to liquefy and fall off, completing the great work. (Note: The treatment for abdominal wall abscess is the same as for carbuncles, focusing mainly on clearing and resolving, which is vastly different from the warming meridians and supporting toxicity expulsion method suitable for brain and back carbuncles.) This represents another scenario where pus formation occurs, but the source and destination differ significantly.