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The afflictions of external sores are most commonly manifested by swelling and pain. However, the conditions of swelling vary, and the origins and developments of pain are not uniform. Therefore, in general terms, the occurrence of external sores is nothing but the stagnation of Qi and Blood; the ancient saying "pain indicates obstruction, freedom from pain indicates flow" captures the main principle. But upon detailed differentiation, various situations have their own causes. Thus, there are cases where swelling precedes pain, and cases where pain precedes swelling; cases with only pain but no swelling, and cases with only swelling but no pain; cases where swelling gradually becomes hard and large while pain gradually appears, and cases where swelling remains soft with little pain; cases where pain begins as pus forms internally, and cases where pus has already formed internally yet there is no pain; cases where pain erupts in multiple places simultaneously, and cases of wandering pain without a fixed location that cannot be pinpointed; cases where pain is located between muscles, and cases where pain is deep within sinews and bones; cases of severe pain that does not cease for a moment, and cases of mild pain that intensifies intermittently; cases of dull pain that feels pleasant when rubbed with the palm, and cases of frequent pain that feels like knife stabbing when pressed by fingers; cases where swelling has spread extensively but pain is localized to one spot, and cases where swelling is diffuse and widespread with severe pain throughout the swollen area; cases of long-standing lumps that are not very prominent, hard and immobile, sore to touch but not severely painful, and cases of long-standing hard lumps that initially do not swell but suddenly flare up with occasional pulling pain that persists even after easing; cases where pain does not decrease despite poor drainage of pus after ulceration, and cases where pain continues unabated while necrotic flesh has not yet detached; cases where pain intensifies due to excessive discharge of pus and blood, and cases of severe ulceration that never causes significant pain; cases where ulceration progresses over time and pain suddenly ceases. The clinical manifestations are indeed diverse, leading to vastly different prognoses. Some are favorable (Shun), some are unfavorable (Ni); some gradually improve, while others fall into danger. Some appear critical superficially but are actually easy to treat; some seem harmless but are actually difficult to cure. Hence, there are cases where intense pain is successfully treated promptly, and cases where mild pain ultimately proves incurable. This is because disease sources vary in depth, and clinical presentations differ in severity. A fundamentally severe disease may still be turned around if treated correctly; conversely, a seemingly mild disease with a deep root may prove completely unresponsive. Unless one has accurate understanding, detailed differentiation skills, extensive experience, and profound practical knowledge, how can one perceive the subtle signs, comprehend the origin and evolution, prevent issues beforehand, and decisively judge fatal outcomes?

Let us analyze the different manifestations of swelling and pain. All have logical basis and traceable origins, not mere speculation. Cases of swelling preceding pain indicate shallow disease. This is the normal state of external sores and represents a mild condition. Pain preceding swelling indicates deep disease. It is either a major syndrome attached to bone and joints (such as penetrating bone, penetrating ankle, or alveolar osteitis, including Osteomyelitis [Fugu Ju] and Hip Joint Abscess [Huantiao Ju]), or it belongs to categories like Wandering Phlegm [Liutan], Flowing Injection [Liuzhu], or internal carbuncles (such as abdominal abscess or intestinal abscess). Flesh rotting into pus naturally causes pain. Internal pus formation without pain is an atypical variation of sores; nerve death makes rescue difficult. Pain erupting in several places simultaneously, or succeeding each other in succession, indicates the spreading of seasonal pathogens [Shixie]; wandering pain that shifts locations unpredictably indicates Wind-dominant Bi-syndrome [Xingbi]. Pain located between muscles indicates shallow disease; even if severe, major changes are unlikely. Pain located deep within sinews and bones indicates deep affliction; delayed treatment will likely lead to many complications. Severe, unremitting pain indicates that pus has formed. Mild, intermittent pain indicates that pus has not yet gathered. Dull pain relieved by rubbing indicates that although the disease is not severe and pus is not formed, the pathology originates from Yin, is deeply concealed, and certainly should not be ignored as a minor ailment. Frequent, unceasing pain intolerable to touch indicates internal pus formation, suitable for puncture to induce ulceration. When swelling spreads widely but pain is localized, the pus-toxin is contained; although the shape is large, aggregation without dispersion can be expected. If swelling is diffuse and painful everywhere, the toxin is dispersing in all directions with strong momentum; unless treatment is appropriate, toxic spreading is inevitable. Long-standing lumps that are not prominent, hard, immobile, and sore but not painful belong to scrofula [Luoli], phlegm nodules, or stagnant accumulations; they have deep roots and cannot be abruptly eliminated. If a hard lump, existing for a long time, suddenly swells and experiences pulling pain, it indicates conditions like Breast Cancer [Ruyan], Stone Carbuncle [Shiju], or Loss of Prosperity [Shirong]; prolonged stagnation threatens rupture. If pain decreases after ulceration and pus discharge, it is auspicious; absence of pain is ominous. This is the critical juncture of life and death. Ignorant people mistakenly consider absence of pain as safety, which is erroneous. When swelling localizes but pain intensifies, the toxin has matured and moved from deep to shallow, signaling gathered internal pus. Laypeople often fear severe pain, which is a misconception. After ulceration, if pain eases with pus discharge, it is the normal course: toxin has reached its peak and waned, indicating calmness and recovery. If pain persists after ulceration and pus discharge, it is a variation: either surgical technique was imprecise causing poor drainage, or residual toxin is vigorous, reigniting inflammation. If pain does not subside after ulceration while toxin remains, it means evil toxin has not detached and new tissue is not growing.

For heavy toxins, detoxification is prioritized. For deficient Zheng-Qi (Upright Qi), tonification is urgent. If pain intensifies after excessive pus discharge post-ulceration, it is because the wound is large and recovery takes time; if residual toxin remains, clearing it is necessary. If Zheng-Qi is weak, support is essential. Ulcerations that are extensive but cause little pain are characteristic of Damp Sores [Shiyang]. Skin diseases with heavy dampness and light heat, such as Oozing Sores [Jinyin Chuang], should be treated with drying and clearing. In cases of Brain and Back Carbuncles [Naobei Ju] with declining Yuan-Qi (Primal Qi), warm tonification and pushing out toxin are required, otherwise failure is likely. If ulceration enlarges and pain stops after initially being present, proper management leads to cleaning of necrotic tissue, indicating retreat of pathogenic factors and replenishment of Zheng-Qi, a favorable trend. However, if necrotic tissue remains, new tissue has not grown, and sudden numbness/loss of pain sensation occurs, it indicates internal sinking of the pathogen, approaching danger. Pain that seems harmless but resides in vital areas constitutes stubborn diseases difficult to cure. Breast Cancer [Ruyan] and Stone Carbuncle [Shiju] are among the most severe sores, along with Osteomyelitis [Fugu] and Wandering Phlegm [Liutan]. Improper timing, rough surgery, or inappropriate topical medications constitute physician negligence causing harm. Natural bad outcomes are relatively few. Those wielding the power of life and death must distinguish clearly and act firmly to avoid causing premature death or cutting short longevity.