溃疡有余之证，其辨有四∶盖一以元气本强，火邪本盛，虽脓溃之后，而内热犹未尽
除，或大便坚实而能食，脉滑者。此其形气病气俱有余，仍宜清利，不宜温补。火退自愈，
亦善证也。一以真阴内亏，水不制火，脓既泄而热反甚，脉反躁者。欲清之则正气以虚，欲
补之则邪气愈甚，此正不胜邪，穷败之证，不可治也。一以毒深而溃浅者，其肌腠之脓已溃
，而根盘之毒未动，此乃假头，非真溃也，不得遽认为溃疡而概施托补，若误用之，则反增
其害，当详辨也。又有一种元气已虚极，似宜补，然其禀质滞浊，肌肉坚浓，色黑而气道多
壅者。略施培补，反加滞闷。若此辈者，真虚既不可补，假实又不可攻，最难调理，极易招
怨，是亦不治之证也。总之，溃疡有余者，十之一二，故溃疡宜清者少。肿疡不足者，十常
四五，故肿疡宜补者多，此亦以痈疽之危险，有关生死者为言，故贵防其未然也。至若经络
浮浅之毒，不过肿则必溃，溃则必收，又何必卷卷以补泻为辨也，观者审之。
一男子年逾三十，腹患痈肿，脉数喜冷。齐氏云∶疮疡肿起坚硬，疮疽之实也。河间
云∶肿硬木闷，烦躁饮冷，邪气在内也。遂用清凉饮倍加大黄，三剂稍缓。次以四物汤加芩
、连、山栀、木通，四剂遂溃。更以十宣散去参、 、肉桂加金银花、天花粉，渐愈。彼欲
速效，自服温补药，遂致肚腹俱肿，小便不利。仍以清凉饮治之，脓溃数碗。再以托里药而
愈。
赵宜人年逾七旬，患鬓疽已溃， 肿甚痛，喜冷脉实，大便秘涩。东垣曰∶烦躁饮冷
，身热脉大，精神昏闷者，皆脏腑之实也。遂以清凉饮一剂，肿痛悉退。更以托里消毒药三
十余剂而平。若谓年高溃后，投以补剂，实实之祸不免矣。（薛按）
溃疡病中属于实证的情况，其辨别要点有四个方面：
第一，患者元气原本强盛，火邪原本炽盛，虽然脓液已经溃破，但体内的热邪尚未完全清除，或者大便干结坚硬且食欲良好，脉象滑利。这种情况属于形体与病气均有余（实），仍然适宜采用清热通利的方法，而不宜使用温补法。待火邪退去后自然痊愈，这也属于良好的证候。
第二，患者真阴内部亏损，导致水液不能制约火邪，脓液排出后发热反而加重，脉象反而躁动不安。想要清热则正气更加虚弱，想要补益则邪气更加猖獗，这是正气不能战胜邪气的穷困败坏之证，无法治愈。
第三，毒邪深重而溃破较浅的，肌肉腠理间的脓液已经溃破，但病灶根基盘踞的毒邪尚未消散，这属于假性溃破，并非真正的溃破，不能立即认定为溃疡而一概施用托毒补益之法，如果误用，反而会增加危害，应当详细辨别。
第四，还有一种情况是元气已经极度虚弱，看似应该补益，然而其体质浊滞，肌肉坚实厚重，肤色黑且气道多壅塞不通。稍微施加培补，反而会增加滞闷感。对于这类人，真正的虚损不可补，假性的实邪又不可攻伐，最难调理，极易招致怨恨，这也是难以治疗的证候。
总之，溃疡病中属于有余（实证）的，十人中只有一二人，所以溃疡病适宜清热的较少。肿疡（未溃破的疮疡）中属于不足的（虚证），十人中有四五人，所以肿疡病适宜补益的较多。这也是从痈疽的危险性关乎生死角度而言的，因此贵在预防于未然。至于那些经络浮浅的毒邪，不过是肿胀必然溃破，溃破必然收敛愈合，又何必执着于辨析补泻呢？读者请仔细审察。
有一个男子年过三十，腹部患痈肿，脉数且喜冷饮。齐氏说：“疮疡肿起坚硬，是疮疽的实证。”河间说：“肿硬木闷，烦躁饮冷，是邪气在体内。”于是使用清凉饮倍加大黄，服用三剂后症状稍缓。接着用四物汤加黄芩、黄连、山栀、木通，服用四剂后脓液溃破。再用十宣汤去掉人参、[此处原文缺字，推测为白术或类似药]、肉桂，加入金银花、天花粉，逐渐痊愈。患者想要快速见效，自行服用温补药，导致肚腹全部肿胀，小便不利。仍然用清凉饮治疗，脓液溃出数碗。再用托里药而痊愈。
赵宜人年过七十，患鬓疽已经溃破，肿胀疼痛严重，喜冷饮，脉象实，大便秘结涩滞。东垣说：“烦躁饮冷，身热脉大，精神昏闷的，都是脏腑的实证。”于是用清凉饮一剂，肿痛全部消退。再用托里消毒药三十余剂而平复。如果说年老溃破后，投以补剂，难免造成“实实”（使实证更实）的祸害。（薛己按语）
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)