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In cases of ulcerative sores presenting with excess patterns, the differentiation involves four aspects:

First, when the patient's primordial Qi is originally strong and the fire pathogen is originally rampant, even after pus has drained, internal heat may not yet be fully eliminated. This may present with solid stools, good appetite, and a slippery pulse. In such cases, both the physical constitution and the pathogenic factor are in excess; it is still appropriate to employ clearing and draining methods, rather than warming and tonifying. Once the fire subsides, recovery will occur naturally, which is also considered a favorable prognosis.

Second, when there is an internal deficiency of True Yin, leading to water's inability to control fire, fever may intensify after pus drainage, accompanied by a rapid and restless pulse. Clearing heat would further weaken the healthy Qi, while tonifying would exacerbate the pathogenic factor. This represents a critical condition where healthy Qi cannot overcome the pathogen, constituting a state of exhaustion and failure that is incurable.

Third, in cases where the toxin is deep-seated but the ulceration is superficial, pus may have drained from the muscle layers, yet the toxin at the base remains undissipated. This is a false ulceration, not a true one. One should not hastily diagnose it as an established ulcer and indiscriminately apply methods for promoting discharge and tonifying. Misapplication would worsen the harm; thus, careful differentiation is required.

Fourth, there is another scenario where primordial Qi is extremely deficient, seemingly requiring tonification. However, if the individual has a turbid and stagnant constitution, firm and thick muscles, dark complexion, and obstructed Qi pathways, slight tonification may反而 (instead) increase stagnation and fullness. For such individuals, true deficiency cannot be tonified, and false excess cannot be attacked. These cases are difficult to manage, prone to causing resentment, and are also considered untreatable.

In summary, among ulcerative sores, only one or two out of ten present with excess patterns; thus, few ulcers require clearing methods. Conversely, among non-ulcerated swellings (swollen sores), four or five out of ten present with deficiency patterns; thus, many swollen sores require tonification. This perspective emphasizes the life-and-death risks associated with carbuncles and sores, highlighting the importance of prevention before onset. Regarding toxins located in superficial meridians, swelling inevitably leads to ulceration, and ulceration inevitably leads to healing; therefore, why insist on differentiating between tonification and purgation? Readers should examine this carefully.

A man over thirty years old developed an abdominal carbuncle. His pulse was rapid, and he preferred cold drinks. Qi Shi stated: "Swelling and hardness in sores indicate excess in carbuncles." He Jian stated: "Swelling, hardness, numbness, irritability, and craving for cold drinks indicate pathogens within." Consequently, Qingliang Yin (Cooling Drink) was used with doubled Rhubarb (Rhei Radix et Rhizoma). After three doses, symptoms slightly alleviated. Subsequently, Siwu Tang (Four Substance Decoction) was administered with added Scutellariae Radix (Huangqin), Coptidis Rhizoma (Huanglian), Gardeniae Fructus (Shanzhi), and Akebiae Caulis (Mutong). After four doses, pus drained. Then, Shixuan San (Ten Acupoints Powder) was modified by removing Ginseng Radix et Rhizoma (Renshen), [missing character], and Cinnamon Twig (Guirzhi), adding adding Honeysuckle Flower (Jinyinhua) and Trichosanthis Radix (Tianhuafen), leading to gradual recovery. The patient, desiring rapid results, self-administered warming and tonifying herbs, resulting in generalized abdominal swelling and dysuria. Treatment reverted to Qingliang Yin (Cooling Drink), resulting in the drainage of several bowls of pus. Finally, Tuoli Yao (Interior-Supporting Medicines) were used to achieve cure.

Zhao Yi Ren, over seventy years old, suffered from a temporal carbuncle that had already ulcerated. Swelling and pain were severe, she preferred cold drinks, her pulse was forceful, and she suffered from constipation. Dong Yuan stated: "Irritability, craving for cold drinks, body heat, large pulse, and mental confusion all indicate excess in the Zang-Fu organs." Thus, one dose of Qingliang Yin (Cooling Drink) was given, resolving swelling and pain completely. Subsequently, more than thirty doses of Tuoli Xiaodu Yao (Interior-Supporting and Toxin-Expelling Medicines) were administered to bring about resolution. If one were to administer tonics after ulceration in an elderly patient, it would inevitably lead to the error of reinforcing excess ("shí shí" - making the excess pattern more excessive). (Commentary by Xue Ji)