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When sores and carbuncles have ulcerated with pus discharge, and swelling toxins are spreading and infiltrating, presenting with critical and malignant symptoms, one must distinguish between deficiency (Xu) and excess (Shi). Moreover, deficiency syndromes are difficult to tonify, while excess syndromes are easy to purge. The methods of tonification and purgation should not be used lightly; even a slight error can lead to significant harm. However, the manifestations of deficiency and excess are manifold: there are deficiencies and excesses specific to the sore itself, those of the Zang-Fu organs, those of Qi and Blood, as well as upper excess with lower deficiency, and true deficiency with false excess. These must not fail to be distinguished.

If the swelling is raised and hard, and the pus is thick, it indicates an excess syndrome of the sore or carbuncle.
If the swelling is flat and soft/slow, and the pus is thin, it indicates a deficiency syndrome of the sore or carbuncle.

Diarrhea with borborygmus, inability to take in food, frequent vomiting, cold hands and feet, weak pulse, cold skin, free urination or difficulty in urination, loose stools, loss of voice, and unclear spirit all indicate a deficiency of the Zang-Fu organs.
Hard stool, obstructed urination, normal appetite, abdominal fullness and distension, chest and diaphragm stuffiness, pain in limbs and joints, bitter taste in the mouth and dry throat, irritability with excessive thirst, fever with a large pulse, and mental confusion/obstruction all indicate an excess of the Zang-Fu organs.

If the pus and water are clear and thin, the sore opening fails to close, swelling gathers without redness, muscles are cold, spontaneous sweating occurs, and the complexion is pale/dull, this indicates a deficiency of Qi and Blood.
If the swelling is raised and red, accompanied by aversion to cold, fever, and pain, hot skin, thick and sticky pus, and heavy/dizzy head and eyes, this indicates an excess of Qi and Blood.

Headache with nasal congestion, red eyes with palpitations, pharyngeal obstruction, sores on the mouth and tongue, irritability and thirst for cold drinks, somniloquy (sleep-talking), and teeth grinding indicate Upper Excess.
Spermatorrhea/incontinence, spontaneous diarrhea, heaviness in the waist and legs, and restless sleep indicate Lower Deficiency.

Stiffness in the shoulders, neck, and nape, heaviness in the four limbs, abnormal vision, blurred eyesight, loss of taste, hoarse/broken voice, and edema of the four limbs indicate a deficiency of True Qi.
Severe swelling, unbearable pain (cannot be touched), failure to ulcerate after many days, alternating chills and fever, constipation with dry stool, dysuria resembling strangury, mental restlessness, and agitation indicate an Excess of Pathogenic Qi.

It is said: When True Qi is depleted, it is deficiency; when Pathogenic Qi is flourishing, it is excess.
It is also said: All pain belongs to excess, while itching belongs to deficiency.
It is further said: A pulse that is surging (Hong) and rapid (Shu) indicates excess; a pulse that is minute (Wei), fine (Xi), and soft indicates deficiency.
For deficiency, use tonification to harmonize Qi and support the interior; for excess, use purgation to unblock and guide the flow of Qi. The *Neijing* states: "If Blood is in excess, drain it; if Qi is deficient, draw and guide it." Yuan Rong stated: "If a person has stagnant and abundant Qi and Blood, with Ying and Wei fully filled but obstructed from flowing, leading to putrefaction and abscess formation, one should use purgation to deprive the excessive heat. If a person has reduced appetite and weakened spirit, with short and stagnant Ying and Wei, leading to cold binding and abscess formation, one should use tonification to replenish the deficient and timid Qi. This is the general principle for treating deficiency and excess."

When the pain of a sore/carbuncle ceases naturally, appetite returns, and both pulse and symptoms become mild, one treats the root. Therefore, gentle and balanced ("King's Way") medicines can be used slowly, and recovery will surely occur. If the pulse is excess and swollen, accompanied by irritability, chills, and fever, and both pulse and symptoms indicate excess, only potent agents like Shihuo (Natrii Sulfas) and Huanglian/Huangqin (often referring to Da Huang/Radix Rhizomi Rhei in purgative contexts here) can remove it; using gentle agents would be incorrect. If the sore gathers and swells without ulcerating, or ulcerates with clear/thin pus; or if there is diarrhea with borborygmus, inability to eat, frequent vomiting; or cold hands and feet—these are deficiency in both pulse and symptom. Only strong tonics can calm it; using purgatives like Shihuo and Da Huang would be incorrect. Thus, when treating such conditions, one must distinguish exterior/interior and deficiency/excess, treating according to appropriateness to ensure complete safety.

Xue Xinpu said: The occurrence of sores and ulcers results from rich and greasy foods, strong wine, roasted/fried foods, excessive sexual activity, emotional stagnation transforming into fire, Yin deficiency with Yang gathering, essence and Qi depletion, decline of Mingmen Fire failing to generate Earth, weakness of Ying and Wei allowing external pathogens to invade, and injury to Qi and Blood. One must examine the meridians affected and treat based on the priority of root and branch. If the disease is acute but Yuan Qi is sufficient, treat the branch first; if the disease is chronic but Yuan Qi is deficient, treat the root first; if the disease is acute and Yuan Qi is also deficient, prioritize treating the root while simultaneously addressing the branch. Generally, if the swelling is high and painful with thick/sticky pus, Yuan Qi is undamaged, and treatment is easy. If the swelling is diffuse with slight pain and thin pus, Yuan Qi is weak, and treatment is difficult. If there is no swelling or pain, or if the swelling is diffuse, dark/black, and non-ulcerating, Yuan Qi is severely deficient, and treatment is particularly difficult.

Regarding treatment methods: For high swelling and pain, first use Xianfang Huoming Yin (Immortal Life Elixir) to resolve, followed by Tuoli Xiaodu San (Support Interior and Detoxify Powder). For diffuse swelling with slight pain, use Tuoli San (Support Interior Powder). If ineffective, add Shengjiang (Fresh Ginger) and Rougui (Cinnamon Bark). If pain persists after pus discharge, it is Qi and Blood deficiency; use Bazhen Tang (Eight Treasures Decoction). If pus does not form and tissue does not necrose/slough, it is Yang Qi deficiency; use Sijunzi Tang (Four Gentlemen Decoction) plus Danggui (Angelicae Sinensis Radix), Huangqi (Astragali Radix), and Rougui. If granulation tissue does not grow and the wound does not contract, it is Spleen Qi deficiency; use Sijunzi Tang plus Shaoyao (Paeoniae Radix) and Muxiang (Aucklandiae Radix). If aversion to cold/chills occur, it is Yang Qi deficiency; use Shiquan Dabu Tang (Ten Significant Tonifying Decoction) plus Shengjiang and Rougui. Afternoon fever and internal heat indicate Yin Blood deficiency; use Siwu Tang (Four Substances Decoction) plus Renshen (Ginseng Radix) and Baizhu (Atractylodis Macrocephalae Rhizoma). Nausea and vomiting indicate Stomach Qi deficiency; use Liujunzi Tang (Six Gentlemen Decoction) plus Paojiang (Prepared Ginger). Spontaneous and night sweats indicate Five Zang deficiency; use Liuwei Wan (Six-Ingredient Pill) formula plus Wuweizi (Schisandrae Fructus). Poor appetite and fatigue indicate Spleen Qi deficiency; use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) plus Fuling (Poria) and Banxia (Pinelliae Rhizoma). Panting and coughing indicate Spleen and Lung deficiency; use the previous decoction plus Maidong (Ophiopogonis Radix) and Wuweizi. Nausea and poor appetite indicate Spleen and Stomach deficiency; use Renshen Lizhong Tang (Ginseng Regulate the Middle Decoction). Abdominal pain and diarrhea indicate Spleen and Stomach deficiency-cold; use Fuzi Lizhong Tang (Aconite Regulate the Middle Decoction). Lower abdominal fullness and leg/shin edema indicate Spleen and Kidney deficiency; use Shiquan Dabu Tang plus Shanzhuyu (Corni Fructus), Shanyao (Dioscoreae Rhizoma), and Rougui. Diarrhea with cold feet indicate Spleen and Kidney deficiency-cold; use the previous medicine plus Rougui and Fuzi (Aconiti Lateralis Radix Praeparata). Heat, thirst, strangury, and urinary retention indicate Kidney deficiency with Yin fire; use Jiaban Bawei Wan (Modified Eight-Ingredient Pill). Panting, coughing, strangury, and retention indicate Lung and Kidney deficiency with false fire; use Buzhong Yiqi Tang and Jiaban Bawei Wan.

Generally, for frail individuals, whether swollen or ulcerated, one should first tonify Stomach Qi. Some suspect that Renshen and Huangqi fill the middle jiao; occasionally used, combined with dispersing and detoxifying herbs, the tonification may not compensate for the damage. Others, adhering to their constitution being naturally robust or having phlegm, refuse tonics, often leading to errors. They do not realize that sores arise from Yin-Yang depletion; once pus is discharged, Qi and Blood become even more deficient. How could tonification be inappropriate? Danxi先生 said: "Whenever swelling and pain are seen, if the pulse and symptoms indicate deficiency, administer tonification. If Qi and Blood are not depleted, ultimate auspiciousness can be preserved." One must also set aside seasonal considerations in favor of the syndrome. For example, red swelling, irritability, fever craving cold, constipation with thirst, and a surging/rapid/excess pulse constitute the "Five Excesses." Even in severe cold, one must use major bitter-cold agents to purge Yin and save Yin. Conversely, a fine pulse, cold skin, diarrhea with borborygmus, inability to eat, frequent vomiting, and inverted cold of hands/feet constitute the "Five Deficiencies." Even in peak summer heat, one must use major pungent-hot agents to disperse Yin and restore Yang. The *Neijing* states: "Use cold remedies avoiding cold seasons; use hot remedies avoiding hot seasons." However, if there are false appearances, reverse this rule. Although violating the season, one must follow the syndrome. Adhering rigidly to standard rules leads to error.