蓄血。与上编同义。因上冠伤寒二字。故仍置之中篇。
伤寒有热。少腹满。应小便不利。今反利者。为有血也。当下之。不可余药。宜抵当丸。
此与上编三条互相发明。非有中风伤寒之别也。言伤寒有热邪在里而少腹满者。应小便不利。何以言之。
里热则津液枯竭。少腹满则膀胱不泻。故应小便不利。今反利者。乃邪不在气分而伤血分。所以三焦膀胱之气
化流行而小便仍利。因血蓄下焦。故少腹满也。此证必当下之乃愈。不可余药者。言既无如狂喜忘。及身黄之证。
不须以桃仁承气。及抵当汤之快剂荡涤之。但宜以抵当作丸。小其制而又分其势以缓下之。庶无太过之弊。
而无伤于正气也。
抵当丸方
水蛭（二十个熬） 虻虫（二十五个去足翅熬） 桃仁（二十个去皮研） 大黄（三两酒浸）
上四味。杵分为四丸。以水一升。煮一丸。取七合服之。 时当下血。若不下者更服。
旧注咸谓风伤卫而阳邪陷入为结胸。寒伤营而阴邪陷入为痞。此诚千古之误。详究论中。中风亦有成心下
痞者。伤寒亦有成结胸者。更有中风伤寒并见而祗作心下痞者。有但伤寒而心下满硬痛者为结胸。但满而
不痛者为痞。参互交错。未便分属两篇。故另编一卷。位置于上中二卷之后。以见风寒均有此二证之意。
病发于阳而反下之。热入。因作结胸。病发于阴而反下之。因作痞。所以成结胸者。以下之太早故也。
此条义理最奥。含蓄最深。千古以来。英贤辈出。从无得其旨者。余洗心涤虑。沉默涵泳。凡五易稿
而后得其绪端。故识之以告诸同志云。
此论结胸与痞之所由作。乃痞结之纲领也。发于阳者。邪在阳经之谓也。发于阴者。邪在阴经之谓也。
反下之者。不当下而下也。两反下之。其义迥别。一则以表邪未解而曰反下。一则以始终不可下而曰反下也。
因者。因误下之虚
也。结胸则言热入者。以发热恶寒。表邪未解。误下则热邪乘虚陷入而为结胸。以热邪实于里。故以
大小陷胸攻之。痞不言热入者。盖不必言。亦难言之也。其不必言者何。阴病本属无阳。一误下之。则阳气愈虚。
阴邪愈盛。客气上逆。即因之而为痞硬。如甘草半夏生姜三泻心汤证是也。此等非唯无热而言。亦并无所入。
故不必言也。其难言者何。诸痞之中。有有表证而发热恶寒者。如解表用桂枝汤。攻里宜大黄黄连泻心汤及大柴
胡汤者是也。以杂在诸虚痞之中。难于并言。故亦不言也。其两不言者何。以在此段纲领之中。不能具言。
至后节条目中。方悉言之也。末句但言下早为结胸之故而不及痞者。以邪在阳经而未解。邪犹在表。若早下之。
则里虚而邪热陷入。致成结胸。若表邪已解而下之。自无变逆之患。故以下早为嫌。至于邪入阴经之证。
本无可下之理。阴经虽有急下之条。亦皆由热邪传里。非阴经本病也。除此以外。其可反下之乎。以无可下之理。
故不以迟早为言。即使痞症之有表证而发热恶寒者。如大柴胡汤一证。亦以伤寒发热。汗出不解。表里皆实。
故用攻解兼施之法。亦非由下早之故也。唯大黄黄连泻心汤一条。为先下后汗而致心下痞者也。然其表症犹在。
故先以桂枝解表。而后以大黄黄连攻痞。观先用桂枝。则知邪在太阳。攻之而用大黄黄连。则知热入矣。其治与结
胸之用大陷胸。彼此相为仿佛也。唯此一条。为热入之痞。其他泻心。各有区别。未可概以热入论之。所以痞结
虽皆曰反下而作。结胸因热入。故独申之以下早。痞则非尽热入。故不可言下早也。然此章义理纠棼。证治盘错。
未易明显。请更申之。夫邪在阳经。其表邪未解而反下之。则正气内虚。热邪因之而内陷。必硬结于胸中。是谓
病发于阳。言阳邪从阳经陷入于阳分。其所发之病。名曰结胸。胸者。中焦之上也。位高而属阳。以诸阳皆受气
于胸中。故膻中为气之海。上通于肺而为呼吸。阳邪陷入。必伤阳位。故结于
胸中也。邪入阴经。由传变而入者。或本经自感者。若误下之。虽无热邪陷入。而胃中阳气已伤。阴邪内盛。
必因误下之阳虚。而阴邪痞塞于心下。是谓病发于阴。言邪入阴分所发之病。名之曰痞。痞者。阴气
痞塞而不通也。心下者。腹之上。心之下。中焦之所属。胃脘之部分也。较之于胸。则位稍卑而为阴矣。
其但言因作痞而不言热入者。阴痞之证。因误下之后。阳气一虚。阴邪自盛。不必外入之邪而后成也。
阳邪必由陷入。阴邪则不必也。如日丽长空。则阳和温暖。至金乌西坠。则遍界阴寒。自然之理。何必
外来。故痞气乃阴邪内结于中。犹云雾障空。天地之气不相交通而成痞。非若热邪之陷入也。下文甘
草泻心汤条内云。此非结热。但以胃中虚。客气上逆。故使硬也。客气者。阴邪也。谓之上逆。其非
外入也明矣。又何疑焉。此为结为痞之攸分也。半夏泻心汤条内云。若心下满而硬痛者。此为结胸也。但
满而不痛者。此为痞。此尤仲景论中。彰明较着之分也。其分条论治。则于结胸之证。有大陷胸汤之
结胸。有大陷胸丸之结胸。有小陷胸汤之结胸。所以皆用攻下者。以客邪陷入。所谓热入因作结胸也。
唯支结不攻者。以外症未去。故但以柴胡桂枝汤解之也。至于心下痞之证。义各不同。未可以一端论也。
如十枣汤之痞。乃阳邪伤胃。津液不行。致水饮停蓄。此实而可攻者也。有生姜泻心汤之痞。乃中气
不和。胃寒不化。脾弱不能为胃行其津液。以致干噫食臭。胁下水气留蓄。此阳虚阴盛之痞。故可温补
宣通以开之者也。有甘草泻心汤之痞。乃下后阳虚。胃寒不化。下利清谷。腹中雷鸣。心下痞硬。干
呕心烦。又复下之。胃阳大虚。阴邪上逆之痞。此但可泻其虚气而不可攻者也。有大黄黄连泻心汤之痞。
此因先下后汗。倒行逆施。致热邪已入。表证未除。乃先解后攻。实热之痞也。有半夏泻心汤之痞。但
满而不痛。乃气痞耳。不可攻者也。有附子泻心汤之痞。因紧反入里。故亦用大黄黄连。又见恶寒汗出。知其真阳
大虚。卫气不固。又加附子以回阳固卫者也。有大柴胡汤之痞。乃伤寒发热。汗出不解。邪转入里。至
呕吐下利。此表里皆实。宜解宜攻。故用两解之法也。有旋复代赭石汤之痞。此汗吐下后。邪虽已解。
胃阳已伤。虚寒不运。痰饮留蓄。气上走而为噫。宜温补宣通。镇坠而不可攻者也。有赤石脂禹余粮
汤之痞。此伤寒误下而利不止。致成痞硬。服泻心汤而又下之。遂至利更不止。病在下焦。理中之所
不能治。故宜固下焦而涩其滑也。痞证如此之条绪繁多。虚实不一。岂可以一言蔽之乎。故曰仲景之
不言。盖难言之也。然各经初证。大约由营卫而入。营卫虽属太阳。至于成结成痞。非必皆在太阳矣。
故结胸则必以太阳病三字冠之。其所以然者。盖以结胸乃表邪未解。邪在太阳。因误下而表邪陷入故也。
至心下痞诸条。则止冠之以伤寒二字者。何也。寒邪虽必由表而入。至成痞之证。各经皆有。故不可
独称太阳也。然非但痞结条下为然也。仲景之于风伤卫诸证。无不以太阳病称之。以寒伤营诸证。唯
一二有表证者。以太阳病称之。因太阳主表故也。至误治失治传变诸证。则皆去之者。以寒邪既不在表。
于各经无所不入。入阳则为三阳里证。入阴则为三阴里证。其有各经自受者。亦概以伤寒称之。或竟
直取其病状言之而已。盖因邪既入里。或风或寒。俱不得以太阳二字加之矣。其所以不可加者。以邪
过营卫。则入里之歧路纷争。虽同入而异变矣。其或入于阳。或入于阴。皆随其虚处而中之耳。初无
定分也。后人未析其义。遂以为风邪入里则为结胸。寒邪入里则为痞证。岂知仲景本意。不论中风
伤寒之邪。在阳经者而表邪未解。误下陷入。故有下早之诫。所以有热入之结胸。并有热入之痞。实热
之痞结。皆以客邪陷入。故有攻无补。所以有大陷胸之汤丸。十枣汤之逐饮。大黄黄连之泻心。及大柴
胡之两解也。无论中风伤寒之邪。在阴经者而误下之。其邪本不在表。不须外入。但因误下之后。胃气虚损。
阴邪痞塞。即可成痞。所以但有反下之戒。而无下早之文。邪在三阴。始终禁下。故不以迟早为言。故有甘草
泻心。半夏泻心。生姜泻心等温散开补之法。然何以阳邪必从外入。阴邪不须外陷乎。盖以三阳在躯壳
之三层。三阴已在躯壳之里矣。所以仲景但以发于阳发于阴论之。一云反下而言热入。一云反下而不言热入。
一则云下之太早。一则绝不言下早。议论无多。苞举深广。虽未显言。意在言表。曾未尝以风寒营卫定痞结也。
故方氏注云。发于阳而下之早者。未尝无痞。发于阴而下之早者。亦有结胸。疾病之机。每多不期之变。
愚谓两早字虽不应并下。于痞结则颇有圆机。余细阅论中。有心下因硬。则为结胸。又云若心下满而硬痛者。
此为结胸。是结胸亦可称心下也。有以伤寒中风并冠于首而曰心下痞者。有独称太阳中风而曰心下痞硬。
满引胁下痛者。是阳邪亦能作心下痞也。又伤寒六七日。结胸热实。脉沉紧。心下痛。按之石硬者。是阴
邪亦能作结胸者也。又太阳中风。下利呕逆。其人 汗出。发作有时。头痛心下痞硬。又太阳病。医发汗。
遂发热恶寒。因复下之。心下痞。此发于阳而亦作心下痞者也。更有太阴之为病。腹满而吐。食不下。自
利益甚。时腹自痛。若下之。必胸下结硬。又如厥阴篇中云。病患手足厥冷。脉乍紧者。邪结在胸中。此二
条虽有阴阳之分。与结胸稍异。此亦发于阴而作结胸者也。由此观之。其阴阳互见。痞结交作。参伍错综。
纵横变化。如此。则岂风寒营卫之说。可拟发于阳发于阴之义乎。尚论未悟其理。妄取条辨之说。以风为阳邪。
病发于中风。阳邪未从外解而反下之。热势乘虚陷入。必硬结于胸上。寒为阴邪。病发于伤寒。阴邪未从
外解而反下之。其热势乘虚陷入。必痞塞于心间。若作此解。则热入与不言热入之义安在哉。昔张兼善证
成氏之误曰。既以无热恶寒为发于阴。焉有可下之理。斯言之谬。亦已甚矣。不思仲景原因不可下而曰反下。
兼善岂反忘之耶。又曰
仲景所谓阴阳者。指表里而言也。病在表。当汗而反下之。因作结胸。病在里。尚未入腑而辄下之。因作痞。
此论尤为乖谬。病已在里。即攻下之。已不为逆。且病既入里。而云尚未入腑。岂所谓腑者。又在里之里乎。
又以风邪入里为结胸。寒邪入里为痞。然则太阳中风。下利呕逆。其人 汗出。而至于心下痞硬者。
非风邪入里之痞乎。伤寒六七日。结胸热实。心下痛。按之石硬者。非寒邪入里之结胸乎。及伤寒中风。
医反下之。其人下利日数十行。谷不化。腹中雷鸣。心下痞硬而满者。非或风或寒而偏作心下痞者乎。
又伤寒五六日。呕而发热。柴胡证具。而以他药下之。必蒸蒸而振。心下满而硬痛者为结胸。但满而不痛者
为痞。此又非寒邪入里而能结能痞者乎。更以此较之。则兼善之说。果合仲景发于阳发于阴之义乎。
因思方喻两家之说。得非兼善为之前导乎。是以不言热入之故。仲景确有深意。如成氏以发于阴而反下之。
谓表中阴邪入里。结于心下为痞。岂知阳气既虚。阴邪自足成痞。况尚有恶寒发热表里皆实之痞具在。则
此注已属荒唐。而方氏又谓不言热入。欲人同推也。喻氏复不察仲景之意。不辨方氏之讹。遂误信同推
之说而竟推之曰。二证皆由下早。皆是热入。省文以见意也。持论若此。不几乎淄渑不辨。菽麦不分矣。以
盲引盲之诮。可独加诸前辈耶。是故读仲景书而不能得仲景之旨。其不为盲者鲜矣。此节疑义。所以为
千古未明之案者。以仲景难言而未之详言也。然反复寻绎其文。亦既言之矣。但道无不秘。未易显言。欲令后
之学人。从妙悟中求之而已。盖以闻道之所得者犹浅。悟道之所得者弥深耳。故曰。若能寻余所集。思过半矣。
蓄血。与上编同义。因上冠伤寒二字。故仍置之中篇。
蓄血（瘀血内停），其含义与上一篇章相同。因为前面加上了“伤寒”二字，所以仍然放置在中间这一篇中。
伤寒有热。少腹满。应小便不利。今反利者。为有血也。当下之。不可余药。宜抵当丸。
患伤寒病且伴有发热，小腹部胀满，按理说应该小便不通畅。现在反而小便通畅，这是体内有瘀血的表现。应当使用攻下法治疗，不能使用其他药物，适宜用抵当丸。
此与上编三条互相发明。非有中风伤寒之别也。言伤寒有热邪在里而少腹满者。应小便不利。何以言之。
这与上一篇章中的三条内容互相印证说明，并没有中风和伤寒的区别。这里说的是患伤寒病，热邪在体内，导致小腹胀满，按理应该小便不通畅。为什么这么说呢？
里热则津液枯竭。少腹满则膀胱不泻。故应小便不利。今反利者。乃邪不在气分而伤血分。所以三焦膀胱之气化流行而小便仍利。因血蓄下焦。故少腹满也。此证必当下之乃愈。不可余药者。言既无如狂喜忘。及身黄之证。不须以桃仁承气。及抵当汤之快剂荡涤之。但宜以抵当作丸。小其制而又分其势以缓下之。庶无太过之弊。而无伤于正气也。
体内的热邪会导致津液枯竭。小腹胀满意味着膀胱排泄功能受阻。所以理应小便不通畅。现在反而通畅，是因为病邪不在气分而是损伤了血分。因此三焦和膀胱的气化功能依然流通，小便也就保持通畅。因为瘀血蓄积在下焦，所以小腹胀满。这个病症必须通过攻下法才能痊愈。“不可余药”的意思是，既然没有像发狂、健忘以及身体发黄的症状，就不需要用桃仁承气汤以及抵当汤这样峻猛的药剂来荡涤攻下。只适宜将抵当方制成丸剂，减小剂量并分散药力以缓慢攻下，这样就没有过于猛烈的弊端，也不会伤害人体的正气。
抵当丸方
水蛭（二十个熬） 虻虫（二十五个去足翅熬） 桃仁（二十个去皮研） 大黄（三两酒浸）
抵当丸处方：
水蛭（二十个，炒制）、虻虫（二十五个，去掉足和翅膀，炒制）、桃仁（二十个，去皮后研磨）、大黄（三两，用酒浸泡）。
上四味。杵分为四丸。以水一升。煮一丸。取七合服之。 时当下血。若不下者更服。
以上四味药，捣碎混合后分成四丸。用水一升，煮其中一丸，取七合药液服用。服药后当时应该会排出瘀血。如果没有排出，可以再服用。
旧注咸谓风伤卫而阳邪陷入为结胸。寒伤营而阴邪陷入为痞。此诚千古之误。详究论中。中风亦有成心下痞者。伤寒亦有成结胸者。更有中风伤寒并见而祗作心下痞者。有但伤寒而心下满硬痛者为结胸。但满而不痛者为痞。参互交错。未便分属两篇。故另编一卷。位置于上中二卷之后。以见风寒均有此二证之意。
旧的注释都声称风邪损伤卫气，阳邪陷入形成结胸；寒邪损伤营气，阴邪陷入形成痞证。这确实是千古以来的错误。详细研究《伤寒论》原文可知，中风病也有形成心下痞的，伤寒病也有形成结胸的。更有中风和伤寒症状同时出现却仅仅表现为心下痞的情况。有的仅仅是伤寒，但心下胀满、坚硬且疼痛的属于结胸；仅仅胀满而不疼痛的属于痞证。这些情况相互交错，不便分别归属于两个篇章，所以另外编写了一卷，放置在上卷和中卷之后，以表明风邪和寒邪都能导致这两种病症的意思。
病发于阳而反下之。热入。因作结胸。病发于阴而反下之。因作痞。所以成结胸者。以下之太早故也。
疾病发生在阳经，反而使用攻下法，热邪内陷，因此形成结胸。疾病发生在阴经，反而使用攻下法，因此形成痞证。之所以形成结胸，是因为攻下得太早的缘故。
此条义理最奥。含蓄最深。千古以来。英贤辈出。从无得其旨者。余洗心涤虑。沉默涵泳。凡五易稿而后得其绪端。故识之以告诸同志云。
这条内容的义理最为深奥，含蓄意蕴最深。自古以来，英才贤士层出不穷，却从未有人真正领会其中的主旨。我洗净心思，排除杂念，沉静地深入思考，前后修改了五次草稿才找到头绪。所以记录下来告诉各位同道中人。
此论结胸与痞之所由作。乃痞结之纲领也。发于阳者。邪在阳经之谓也。发于阴者。邪在阴经之谓也。反下之者。不当下而下也。两反下之。其义迥别。一则以表邪未解而曰反下。一则以始终不可下而曰反下也。因者。因误下之虚也。结胸则言热入者。以发热恶寒。表邪未解。误下则热邪乘虚陷入而为结胸。以热邪实于里。故以大小陷胸攻之。痞不言热入者。盖不必言。亦难言之也。其不必言者何。阴病本属无阳。一误下之。则阳气愈虚。阴邪愈盛。客气上逆。即因之而为痞硬。如甘草半夏生姜三泻心汤证是也。此等非唯无热而言。亦并无所入。故不必言也。其难言者何。诸痞之中。有有表证而发热恶寒者。如解表用桂枝汤。攻里宜大黄黄连泻心汤及大柴胡汤者是也。以杂在诸虚痞之中。难于并言。故亦不言也。其两不言者何。以在此段纲领之中。不能具言。至后节条目中。方悉言之也。末句但言下早为结胸之故而不及痞者。以邪在阳经而未解。邪犹在表。若早下之。则里虚而邪热陷入。致成结胸。若表邪已解而下之。自无变逆之患。故以下早为嫌。至于邪入阴经之证。本无可下之理。阴经虽有急下之条。亦皆由热邪传里。非阴经本病也。除此以外。其可反下之乎。以无可下之理。故不以迟早为言。即使痞症之有表证而发热恶寒者。如大柴胡汤一证。亦以伤寒发热。汗出不解。表里皆实。故用攻解兼施之法。亦非由下早之故也。唯大黄黄连泻心汤一条。为先下后汗而致心下痞者也。然其表症犹在。故先以桂枝解表。而后以大黄黄连攻痞。观先用桂枝。则知邪在太阳。攻之而用大黄黄连。则知热入矣。其治与结胸之用大陷胸。彼此相为仿佛也。唯此一条。为热入之痞。其他泻心。各有区别。未可概以热入论之。所以痞结虽皆曰反下而作。结胸因热入。故独申之以下早。痞则非尽热入。故不可言下早也。然此章义理纠棼。证治盘错。未易明显。请更申之。夫邪在阳经。其表邪未解而反下之。则正气内虚。热邪因之而内陷。必硬结于胸中。是谓病发于阳。言阳邪从阳经陷入于阳分。其所发之病。名曰结胸。胸者。中焦之上也。位高而属阳。以诸阳皆受气于胸中。故膻中为气之海。上通于肺而为呼吸。阳邪陷入。必伤阳位。故结于胸中也。邪入阴经。由传变而入者。或本经自感者。若误下之。虽无热邪陷入。而胃中阳气已伤。阴邪内盛。必因误下之阳虚。而阴邪痞塞于心下。是谓病发于阴。言邪入阴分所发之病。名之曰痞。痞者。阴气痞塞而不通也。心下者。腹之上。心之下。中焦之所属。胃脘之部分也。较之于胸。则位稍卑而为阴矣。其但言因作痞而不言热入者。阴痞之证。因误下之后。阳气一虚。阴邪自盛。不必外入之邪而后成也。阳邪必由陷入。阴邪则不必也。如日丽长空。则阳和温暖。至金乌西坠。则遍界阴寒。自然之理。何必外来。故痞气乃阴邪内结于中。犹云雾障空。天地之气不相交通而成痞。非若热邪之陷入也。下文甘草泻心汤条内云。此非结热。但以胃中虚。客气上逆。故使硬也。客气者。阴邪也。谓之上逆。其非外入也明矣。又何疑焉。此为结为痞之攸分也。半夏泻心汤条内云。若心下满而硬痛者。此为结胸也。但满而不痛者。此为痞。此尤仲景论中。彰明较着之分也。其分条论治。则于结胸之证。有大陷胸汤之结胸。有大陷胸丸之结胸。有小陷胸汤之结胸。所以皆用攻下者。以客邪陷入。所谓热入因作结胸也。唯支结不攻者。以外症未去。故但以柴胡桂枝汤解之也。至于心下痞之证。义各不同。未可以一端论也。如十枣汤之痞。乃阳邪伤胃。津液不行。致水饮停蓄。此实而可攻者也。有生姜泻心汤之痞。乃中气不和。胃寒不化。脾弱不能为胃行其津液。以致干噫食臭。胁下水气留蓄。此阳虚阴盛之痞。故可温补宣通以开之者也。有甘草泻心汤之痞。乃下后阳虚。胃寒不化。下利清谷。腹中雷鸣。心下痞硬。干呕心烦。又复下之。胃阳大虚。阴邪上逆之痞。此但可泻其虚气而不可攻者也。有大黄黄连泻心汤之痞。此因先下后汗。倒行逆施。致热邪已入。表证未除。乃先解后攻。实热之痞也。有半夏泻心汤之痞。但满而不痛。乃气痞耳。不可攻者也。有附子泻心汤之痞。因紧反入里。故亦用大黄黄连。又见恶寒汗出。知其真阳大虚。卫气不固。又加附子以回阳固卫者也。有大柴胡汤之痞。乃伤寒发热。汗出不解。邪转入里。至呕吐下利。此表里皆实。宜解宜攻。故用两解之法也。有旋复代赭石汤之痞。此汗吐下后。邪虽已解。胃阳已伤。虚寒不运。痰饮留蓄。气上走而为噫。宜温补宣通。镇坠而不可攻者也。有赤石脂禹余粮汤之痞。此伤寒误下而利不止。致成痞硬。服泻心汤而又下之。遂至利更不止。病在下焦。理中之所不能治。故宜固下焦而涩其滑也。痞证如此之条绪繁多。虚实不一。岂可以一言蔽之乎。故曰仲景之不言。盖难言之也。然各经初证。大约由营卫而入。营卫虽属太阳。至于成结成痞。非必皆在太阳矣。故结胸则必以太阳病三字冠之。其所以然者。盖以结胸乃表邪未解。邪在太阳。因误下而表邪陷入故也。至心下痞诸条。则止冠之以伤寒二字者。何也。寒邪虽必由表而入。至成痞之证。各经皆有。故不可独称太阳也。然非但痞结条下为然也。仲景之于风伤卫诸证。无不以太阳病称之。以寒伤营诸证。唯一二有表证者。以太阳病称之。因太阳主表故也。至误治失治传变诸证。则皆去之者。以寒邪既不在表。于各经无所不入。入阳则为三阳里证。入阴则为三阴里证。其有各经自受者。亦概以伤寒称之。或竟直取其病状言之而已。盖因邪既入里。或风或寒。俱不得以太阳二字加之矣。其所以不可加者。以邪过营卫。则入里之歧路纷争。虽同入而异变矣。其或入于阳。或入于阴。皆随其虚处而中之耳。初无定分也。后人未析其义。遂以为风邪入里则为结胸。寒邪入里则为痞证。岂知仲景本意。不论中风伤寒之邪。在阳经者而表邪未解。误下陷入。故有下早之诫。所以有热入之结胸。并有热入之痞。实热之痞结。皆以客邪陷入。故有攻无补。所以有大陷胸之汤丸。十枣汤之逐饮。大黄黄连之泻心。及大柴胡之两解也。无论中风伤寒之邪。在阴经者而误下之。其邪本不在表。不须外入。但因误下之后。胃气虚损。阴邪痞塞。即可成痞。所以但有反下之戒。而无下早之文。邪在三阴。始终禁下。故不以迟早为言。故有甘草泻心。半夏泻心。生姜泻心等温散开补之法。然何以阳邪必从外入。阴邪不须外陷乎。盖以三阳在躯壳之三层。三阴已在躯壳之里矣。所以仲景但以发于阳发于阴论之。一云反下而言热入。一云反下而不言热入。一则云下之太早。一则绝不言下早。议论无多。苞举深广。虽未显言。意在言表。曾未尝以风寒营卫定痞结也。故方氏注云。发于阳而下之早者。未尝无痞。发于阴而下之早者。亦有结胸。疾病之机。每多不期之变。愚谓两早字虽不应并下。于痞结则颇有圆机。余细阅论中。有心下因硬。则为结胸。又云若心下满而硬痛者。此为结胸。是结胸亦可称心下也。有以伤寒中风并冠于首而曰心下痞者。有独称太阳中风而曰心下痞硬。满引胁下痛者。是阳邪亦能作心下痞也。又伤寒六七日。结胸热实。脉沉紧。心下痛。按之石硬者。是阴邪亦能作结胸者也。又太阳中风。下利呕逆。其人汗出。发作有时。头痛心下痞硬。又太阳病。医发汗。遂发热恶寒。因复下之。心下痞。此发于阳而亦作心下痞者也。更有太阴之为病。腹满而吐。食不下。自利益甚。时腹自痛。若下之。必胸下结硬。又如厥阴篇中云。病患手足厥冷。脉乍紧者。邪结在胸中。此二条虽有阴阳之分。与结胸稍异。此亦发于阴而作结胸者也。由此观之。其阴阳互见。痞结交作。参伍错综。纵横变化。如此。则岂风寒营卫之说。可拟发于阳发于阴之义乎。尚论未悟其理。妄取条辨之说。以风为阳邪。病发于中风。阳邪未从外解而反下之。热势乘虚陷入。必硬结于胸上。寒为阴邪。病发于伤寒。阴邪未从外解而反下之。其热势乘虚陷入。必痞塞于心间。若作此解。则热入与不言热入之义安在哉。昔张兼善证成氏之误曰。既以无热恶寒为发于阴。焉有可下之理。斯言之谬。亦已甚矣。不思仲景原因不可下而曰反下。兼善岂反忘之耶。又曰仲景所谓阴阳者。指表里而言也。病在表。当汗而反下之。因作结胸。病在里。尚未入腑而辄下之。因作痞。此论尤为乖谬。病已在里。即攻下之。已不为逆。且病既入里。而云尚未入腑。岂所谓腑者。又在里之里乎。又以风邪入里为结胸。寒邪入里为痞。然则太阳中风。下利呕逆。其人汗出。而至于心下痞硬者。非风邪入里之痞乎。伤寒六七日。结胸热实。心下痛。按之石硬者。非寒邪入里之结胸乎。及伤寒中风。医反下之。其人下利日数十行。谷不化。腹中雷鸣。心下痞硬而满者。非或风或寒而偏作心下痞者乎。又伤寒五六日。呕而发热。柴胡证具。而以他药下之。必蒸蒸而振。心下满而硬痛者为结胸。但满而不痛者为痞。此又非寒邪入里而能结能痞者乎。更以此较之。则兼善之说。果合仲景发于阳发于阴之义乎。因思方喻两家之说。得非兼善为之前导乎。是以不言热入之故。仲景确有深意。如成氏以发于阴而反下之。谓表中阴邪入里。结于心下为痞。岂知阳气既虚。阴邪自足成痞。况尚有恶寒发热表里皆实之痞具在。则此注已属荒唐。而方氏又谓不言热入。欲人同推也。喻氏复不察仲景之意。不辨方氏之讹。遂误信同推之说而竟推之曰。二证皆由下早。皆是热入。省文以见意也。持论若此。不几乎淄渑不辨。菽麦不分矣。以盲引盲之诮。可独加诸前辈耶。是故读仲景书而不能得仲景之旨。其不为盲者鲜矣。此节疑义。所以为千古未明之案者。以仲景难言而未之详言也。然反复寻绎其文。亦既言之矣。但道无不秘。未易显言。欲令后之学人。从妙悟中求之而已。盖以闻道之所得者犹浅。悟道之所得者弥深耳。故曰。若能寻余所集。思过半矣。
这段论述是关于结胸和痞证形成的原理，是理解痞证和结证的纲领。“发于阳”，是指病邪在阳经。“发于阴”，是指病邪在阴经。“反下之”，是指不该用攻下法的时候用了攻下法。这两个“反下之”，含义截然不同。一个是表邪未解却说“反下”，一个是始终不能用攻下法却说“反下”。“因”，是因为误用攻下法导致的正气虚弱。对于结胸提到“热入”，是因为患者发热恶寒，表邪未解，误用攻下法导致热邪乘虚内陷而形成结胸。由于热邪在体内属实证，所以用大陷胸汤或小陷胸汤来攻逐。对于痞证不提“热入”，大概是因为不必说，也难以说清楚。为什么不必说呢？阴病本来属于阳气不足（无阳），一旦误用攻下法，阳气更加虚弱，阴邪更加旺盛，客气上逆，就因此形成了痞硬，比如甘草泻心汤、半夏泻心汤、生姜泻心汤的证候就是如此。这些情况不仅没有热邪可言，也没有外邪内入的过程，所以不必说。为什么难以说清楚呢？在各种痞证中，有的伴有表证且发热恶寒，比如解表用桂枝汤，攻里宜用大黄黄连泻心汤及大柴胡汤的情况。因为这些情况混杂在各种虚性痞证之中，难以一并说明，所以也不说。为什么这两方面都不说呢？因为在这段纲领性的文字中，不能详尽说明，直到后面的具体条目中，才会全部讲清楚。最后一句只说攻下太早是导致结胸的原因而没有提及痞证，是因为病邪在阳经且未解除，邪气仍在体表，如果过早攻下，就会导致体内空虚，邪热内陷，从而形成结胸。如果表邪已经解除再攻下，自然不会有变证逆证的祸患，所以忌讳攻下太早。至于邪气进入阴经的病症，本来就没有可以攻下的道理。阴经虽然有条文提到急下法，也都是因为热邪传入体内所致，并非阴经的本病。除此之外，还有什么可以反过来攻下的呢？因为没有可以攻下的道理，所以不谈攻下早晚的问题。即使是痞证中有表证且发热恶寒的情况，比如大柴胡汤证，也是因为伤寒发热，出汗后病仍未解，表里都实证，所以采用解表和攻里相结合的方法，这也并不是因为攻下太早的缘故。只有大黄黄连泻心汤这一条，是因为先攻下后发汗，颠倒顺序，导致热邪已经内入，表证未除，于是先解表后攻里，属于实热性质的痞证。还有半夏泻心汤的痞证，只是胀满而不疼痛，属于气滞痞，不可攻下。还有附子泻心汤的痞证，因为脉象紧急反而入里，所以也用大黄和黄连，但又见到恶寒出汗，知道是真阳大虚，卫气不固，所以加上附子来恢复阳气、巩固卫气。还有大柴胡汤的痞证，是伤寒发热，出汗后病未解，邪气转入体内，发展到呕吐下利的程度，这是表里皆实证，应当解表攻里，所以用两解的方法。还有旋复代赭石汤的痞证，这是在发汗、催吐、攻下之后，邪气虽然已解，但胃阳已受伤，虚寒不能运化，痰饮停留积聚，气机上逆导致打嗝，适宜温补宣通、重镇降逆，不可攻下。还有赤石脂禹余粮汤的痞证，这是伤寒误用攻下法导致腹泻不止，进而形成痞硬，服用泻心汤后又攻下，致使腹泻更加不止。病位在下焦，理中汤这类药物无法治疗，所以适宜固摄下焦、涩肠止泻。痞证的这种情况条理繁多，虚实不一，怎么能用一句话概括呢？所以说仲景不说，大概是难以说清楚。然而各经的初始证候，大致都是由营卫侵入的。营卫虽然属于太阳，但等到形成结胸或痞证时，不一定都在太阳经了。所以结胸一定冠以“太阳病”三个字，之所以这样，大概是因为结胸是表邪未解，邪气在太阳经，因为误用攻下法导致表邪内陷的缘故。至于心下痞的各条条文，只冠以“伤寒”两个字，为什么呢？寒邪虽然必然由体表侵入，但等到形成痞证时，各经都有这种情况，所以不能单独称为太阳病。但这不仅仅是在痞证和结证的条文中如此。仲景对于风邪伤卫的各种证候，无不称之为太阳病；对于寒邪伤营的各种证候，只有一两个有表证的，称之为太阳病，因为太阳主司体表的缘故。到了误治、失治、传变等各种证候，就去掉了这个称呼，因为寒邪既然不在体表，在各经都可以侵入，进入阳经就成为三阳里的证候，进入阴经就成为三阴里的证候。那些各经直接感受邪气的，也一概称为伤寒，或者干脆直接描述病症表现罢了。大概因为邪气既然已经进入体内，无论是风邪还是寒邪，都不能再加“太阳”二字了。之所以不能加，是因为邪气经过营卫之后，进入体内的路径分歧众多，虽然都是内入但变化各异。它们或者进入阳经，或者进入阴经，都是随着人体虚弱的地方而侵袭的，起初并没有固定的界限。后人没有分析清楚其中的义理，就认为风邪入里就会形成结胸，寒邪入里就会形成痞证。哪里知道仲景的本意，不论中风还是伤寒的邪气，只要在阳经且表邪未解，误用攻下法导致内陷，所以有攻下太早的告诫，因此才有热邪内陷形成的结胸，以及热邪内陷形成的痞证。实热性质的痞结，都是因为客邪内陷，所以只用攻法不用补法，因此有大陷胸汤丸、十枣汤逐饮、大黄黄连泻心汤以及大柴胡汤的两解法。无论中风还是伤寒的邪气，如果在阴经误用攻下法，邪气本来就不在体表，不需要从外部陷入，只是因为误用攻下法之后，胃气虚损，阴邪痞塞，就可以形成痞证。所以只有反对攻下的告诫，而没有关于攻下太早的文字。邪气在三阴经，始终禁止攻下，所以不谈攻下早晚的问题。因此有甘草泻心汤、半夏泻心汤、生姜泻心汤等温散开补的方法。然而为什么阳邪必然从外部陷入，阴邪不需要外部陷入呢？大概因为三阳经在躯壳的外层三层，三阴经已经在躯壳的内层了。所以仲景只讨论发于阳和发于阴。一种说法是反对攻下并提到热邪内入，一种说法是反对攻下但不提热邪内入。一种说法是攻下太早，一种说法绝口不提攻下太早。议论虽然不多，但涵盖深远广泛。虽然没有明确说出，但意思就在言语之中。从来没有用风寒营卫来确定痞证和结胸。所以方有执的注释说：“发于阳而攻下太早的，未必没有痞证；发于阴而攻下太早的，也有结胸。疾病的机理，往往有很多意想不到的变化。”我认为这两个“早”字虽然不应该并列使用，但在解释痞证和结证时颇具圆融的智慧。我仔细查阅《伤寒论》，有心下因为坚硬，就称为结胸；又说如果心下胀满、坚硬且疼痛的，这就是结胸。可见结胸也可以称为心下。有的条文将伤寒和中风并列放在开头，然后说心下痞；有的单独称太阳中风，然后说心下痞硬，胀满牵引胁下疼痛。这说明阳邪也能导致心下痞。又有伤寒六七天，结胸热实证，脉象沉紧，心下疼痛，按压像石头一样硬的，这说明阴邪也能导致结胸。又有太阳中风，腹泻呕吐逆气，病人出汗，定时发作，头痛心下痞硬；又有太阳病，医生发汗，于是发热恶寒，接着又攻下，导致心下痞。这是发于阳但也形成心下痞的情况。更有太阴病的症状，腹部胀满呕吐，饮食不下，腹泻越来越严重，时常腹痛，如果攻下，必然胸下结硬。又如厥阴篇中说，病人手脚冰凉，脉搏突然紧张，邪气结在胸中。这两条虽然有阴阳的区别，与典型的结胸稍有不同，这也是发于阴而形成的结胸。由此可见，阴阳相互显现，痞证和结证交替出现，错综复杂，纵横变化。像这样，难道风寒营卫的说法，可以比拟发于阳和发于阴的含义吗？尚志斋没有领悟其中的道理，胡乱采纳条辨派的观点，认为风是阳邪，病发于中风，阳邪没有从外部解除反而攻下，热势乘虚内陷，必然在胸部硬结；寒是阴邪，病发于伤寒，阴邪没有从外部解除反而攻下，热势乘虚内陷，必然在心间痞塞。如果这样解释，那么“热入”和“不言热入”的含义在哪里呢？以前张兼善批评成无己的错误说：“既然把无热恶寒作为发于阴，怎么会有可以攻下的道理？”这种言论的荒谬，也太严重了。他不思考仲景正是因为不可攻下才说“反下”，张兼善难道反而忘记了吗？他又说：“仲景所说的阴阳，是指表里而言。病在表，应当发汗反而攻下，因此形成结胸；病在里，还没有进入腑就轻易攻下，因此形成痞证。”这种论述尤其荒谬。病已经在里，就攻下它，已经不算是逆治了。况且病既然已经进入里，却说还没有进入腑，难道所谓的腑，还在里的里面吗？他又认为风邪入里形成结胸，寒邪入里形成痞证。那么太阳中风，腹泻呕吐逆气，病人出汗，以至于心下痞硬的，不是风邪入里形成的痞证吗？伤寒六七天，结胸热实证，心下疼痛，按压像石头一样硬的，不是寒邪入里形成的结胸吗？以及伤寒中风，医生反而攻下，病人腹泻每天几十次，食物不消化，腹中雷鸣，心下痞硬且胀满的，不是风邪或寒邪偏重于形成心下痞证吗？又有伤寒五六天，呕吐且发热，柴胡汤证具备，却用其他药物攻下，必然战栗发抖，心下胀满且坚硬疼痛的是结胸，只是胀满而不疼痛的是痞证。这又不是寒邪入里能够形成结胸和痞证吗？拿这些来比较，张兼善的说法，果真符合仲景发于阳、发于阴的含义吗？我想到方有执和喻嘉言两家的说法，莫非是张兼善开了先河吗？仲景之所以不说“热入”，确实有深意。比如成无己认为发于阴而反用攻下，说是表中的阴邪进入体内，结聚在心下形成痞证。哪里知道阳气既然虚弱，阴邪自然足以形成痞证，况且还有恶寒发热、表里皆实的痞证存在，那么这个注释就已经很荒唐了。而方有执又说“不言热入”，是想让人类推。喻嘉言又不考察仲景的原意，不辨别方有执的错误，于是误信类推的说法竟然推断说：“两种证候都是由攻下太早引起的，都是热邪内入，省略文字来表达意思。”持有这样的论点，差不多就是不分辨淄水和渑水的味道、分不清豆类和麦子的差别了。被讥笑为“盲人引导盲人”，这种指责难道只能加在前辈身上吗？因此，阅读仲景的书却不能得到仲景的主旨，不成为盲人的很少了。这一节的疑难之处，之所以成为千古未解的公案，是因为仲景难以言说而没有详细说明。然而反复推敲它的文字，也已经说过了。只是道理没有不隐秘的，不容易明确说出，想要让后来的学习的人，从微妙的领悟中去寻求罢了。大概因为听闻道理所得到的还浅显，领悟道理所得到的就更深刻。所以说：“如果能探寻我所汇集的这些内容，思考就能达到一半以上的效果了。”
Blood Accumulation (accumulation of blood stasis) has the same meaning as in the previous section. Because it is prefixed with "Shanghan" (Cold Damage), it is still placed in this middle section.
In Shanghan with fever, if there is fullness in the lower abdomen, one should expect difficulty in urination. Now, if urination is actually free, it indicates the presence of blood stasis. It should be treated with purgation. Other medicines are not suitable; Diding Wan (Diding Pill) is appropriate.
This clarifies and complements the three clauses in the previous section. There is no distinction between Zhongfeng (Wind Strike) and Shanghan here. It states that in Shanghan, if heat pathogen is interior and causes lower abdominal fullness, urination should be difficult. Why?
Interior heat depletes body fluids. Lower abdominal fullness implies the bladder fails to excrete. Thus, difficulty in urination is expected. The fact that urination is now free means the pathogen is not in the Qi level but has injured the Blood level. Therefore, the Qi transformation and circulation of the Sanjiao (Triple Burner) and bladder continue, and urination remains free. Due to blood accumulation in the Lower Jiao (Lower Burner), there is lower abdominal fullness. This condition must be treated with purgation to heal. "Other medicines are not suitable" means that since there are no symptoms like mania, forgetfulness, or yellowing of the skin, there is no need to use potent purgatives like Taoren Chengqi Tang (Peach Kernel Decoction to Order the Qi) or Didang Tang (Diding Decoction) to scour the interior. Instead, Diding Fang (Diding Formula) should be made into pills. Reducing the dosage and dispersing the medicinal force allows for a slow purgation, avoiding excessive damage and preserving healthy Qi.
**Diding Wan Formula**
Shizhi (Leech, *Hirudo*) (20 pieces, processed); Mengchong (Dragonfly Larva, *Erythromellia*), remove feet and wings, process (25 pieces); Taoren (Peach Kernel, *Persicae Semen*), remove skin, grind (20 pieces); Dahuang (Rhubarb Root, *Rhei Radix et Rhizoma*) (3 liang, soaked in wine).
The above four ingredients are pounded and divided into four pills. Boil one pill in one sheng of water until reduced to seven he. Take this decoction orally. Blood stasis should be discharged at this time. If not discharged, take another dose.
Old commentaries all claim that Wind injures Wei (Defensive Qi) and Yang pathogen sinking inward forms Jie Xiong (Chest Binding); Cold injures Ying (Nutritive Qi) and Yin pathogen sinking inward forms Pi (Stagnant Fullness). This is indeed an error lasting for millennia. Detailed study of the Treatise reveals that Zhongfeng can also lead to Xin Xia Pi (Subcardiac Stagnant Fullness), and Shanghan can also lead to Jie Xiong. Furthermore, cases where both Zhongfeng and Shanghan signs appear may only present as Xin Xia Pi. Cases of pure Shanghan presenting with subcardiac fullness, hardness, and pain are Jie Xiong; those with only fullness without pain are Pi. These conditions interweave and cannot be conveniently separated into two chapters. Therefore, a separate volume was compiled and placed after the upper and middle volumes, to show that both Wind and Cold pathogens can cause these two syndromes.
When disease originates in Yang and is incorrectly treated with purgation, Heat enters, resulting in Jie Xiong. When disease originates in Yin and is incorrectly treated with purgation, Pi results. Jie Xiong occurs because purgation was performed too early.
The principle in this clause is profound and implicit. Since ancient times, many heroes and sages have emerged, yet none have grasped its essence. I purified my mind and thoughts, meditated deeply, and revised the draft five times before finding the thread. Thus, I record it to inform my colleagues.
This discussion on the origin of Jie Xiong and Pi is the outline for these syndromes. "Originating in Yang" refers to the pathogen being in the Yang meridians. "Originating in Yin" refers to the pathogen being in the Yin meridians. "Incorrectly using purgation" means using purgation when it is not indicated. The meaning of the two instances of "incorrectly using purgation" is vastly different. One refers to purging when exterior pathogen is unresolved; the other refers to purging when it is absolutely contraindicated throughout. "Yin" (due to) refers to the deficiency caused by erroneous purgation.
Jie Xiong mentions "Heat entering" because the patient has fever and aversion to cold, indicating unresolved exterior pathogen. Erroneous purgation allows heat pathogen to sink inward due to deficiency, forming Jie Xiong. Since heat pathogen is excess in the interior, Da Xianxiong Tang (Major Intra-thoracic Decoction) or Xiao Xianxiong Tang (Minor Intra-thoracic Decoction) are used to attack it. Pi does not mention "Heat entering," either because it is unnecessary to say or difficult to explain.
Why is it unnecessary? Yin diseases inherently lack Yang. Once erroneously purged, Yang becomes more deficient, and Yin pathogen becomes more vigorous. Guest Qi rebels upward, leading to Pi and hardness, such as in Gancao Xiexin Tang (Licorice Decoction to Drain the Epigastrium), Banxia Xiexin Tang (Pinellia Decoction to Drain the Epigastrium), and Shengjiang Xiexin Tang (Fresh Ginger Decoction to Drain the Epigastrium). In these cases, not only is there no heat, but there is also no external pathogen entering. Hence, it is unnecessary to mention.
Why is it difficult to explain? Among various Pis, some have exterior signs with fever and aversion to cold, such as those treated with Guizhi Tang (Cinnamon Twig Decoction) for the exterior and Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Decoction to Drain the Epigastrium) or Dachaihu Tang (Major Bupleurum Decoction) for the interior. Because these are mixed among various deficiency Pis, they are hard to explain together, so they are omitted.
Why are both omitted? Because this outline cannot detail everything; specifics will be provided in subsequent clauses. The final sentence mentions only that early purgation causes Jie Xiong, omitting Pi. This is because when pathogen is in Yang meridians and unresolved, it is still exterior. Early purgation leads to interior deficiency and sinking of heat pathogen, causing Jie Xiong. If exterior pathogen is resolved before purgation, there is no risk of adverse changes. Thus, early purgation is cautioned against.
Regarding pathogen entering Yin meridians, there is fundamentally no rationale for purgation. Although there are clauses for urgent purgation in Yin meridians, these are due to heat pathogen transmitting inward, not the primary disease of Yin meridians. Aside from this, what could be purged? Since there is no rationale for purgation, timing (early vs. late) is not discussed. Even for Pi with exterior signs (fever/aversion to cold), such as Dachaihu Tang syndrome, it is because Shanghan fever persists despite sweating, indicating exterior and interior excess. Thus, simultaneous release and attack are used, not due to early purgation.
Only Dahuang Huanglian Xiexin Tang syndrome results from purging first then sweating, leading to Xin Xia Pi. However, exterior signs remain. Thus, Guizhi Tang is used first to release the exterior, followed by Dahuang Huanglian Xiexin Tang to attack the Pi. Using Guizhi first indicates pathogen in Taiyang. Using Dahuang and Huanglian indicates heat has entered. This treatment resembles the use of Da Xianxiong Tang for Jie Xiong. Only this case represents Pi due to heat entering. Other Xiexin variations differ and cannot generally be attributed to heat entering.
Therefore, although both Pi and Jie Xiong result from incorrect purgation, Jie Xiong is specifically linked to heat entering and thus cautioned against early purgation. Pi is not entirely due to heat entering, so early purgation is not the sole explanation. However, the principles in this chapter are tangled and complex. Let me elaborate further.
When pathogen is in Yang meridians and exterior is unresolved, erroneous purgation causes interior healthy Qi deficiency. Heat pathogen sinks inward and hardens in the chest. This is "disease originating in Yang." It means Yang pathogen sinks from Yang meridians into Yang divisions. The resulting disease is named Jie Xiong. The chest is above the Middle Jiao, high in position and belonging to Yang. All Yang meridians receive Qi in the chest; thus, Danzhong (Conception Vessel point CV17) is the Sea of Qi, connecting to the lungs for respiration. Yang pathogen sinking must injure Yang positions, hence binding in the chest.
When pathogen enters Yin meridians, either through transmission or direct infection, erroneous purgation damages Stomach Yang even without heat sinking. Yin pathogen becomes abundant internally. Due to Yang deficiency from purgation, Yin pathogen stagnates in the Xin Xia (subcardiac region). This is "disease originating in Yin." It means disease arising from pathogen entering Yin divisions is named Pi. Pi signifies Yin Qi stagnation and obstruction. Xin Xia is above the abdomen, below the heart, belonging to the Middle Jiao, specifically the stomach region. Compared to the chest, it is lower and belongs to Yin.
Pi is mentioned without "heat entering" because Yin Pi arises after purgation: once Yang is deficient, Yin pathogen naturally becomes vigorous. External pathogen entry is not required. Yang pathogen must sink inward; Yin pathogen does not need to. Like the sun shining brightly brings warmth, and sunset brings cold, this is natural law, not requiring external cause. Pi Qi is Yin pathogen knotting internally, like clouds blocking the sky, preventing Heaven and Earth Qi from communicating. It is not like heat pathogen sinking.
The next clause on Gancao Xiexin Tang states: "This is not knotted heat, but simply Stomach deficiency causing Guest Qi to rebel upward, making it hard." Guest Qi is Yin pathogen. Calling it "rebel upward" clearly shows it is not externally entering. What doubt remains? This distinguishes Jie Xiong from Pi.
Banxia Xiexin Tang clause states: "If subcardiac fullness with hardness and pain, this is Jie Xiong. If fullness without pain, this is Pi." This is a clear distinction in Zhang Zhongjing's Treatise.
Treatment differentiation for Jie Xiong includes Da Xianxiong Tang, Da Xianxiong Wan, and Xiao Xianxiong Tang. All use purgation because guest pathogen has sunk, i.e., "heat entering causes Jie Xiong." Only Zhi Jie (branch binding) is not attacked because exterior signs remain; Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) is used to resolve it.
As for Xin Xia Pi, meanings vary and cannot be generalized.
- Shi Zao Tang (Ten Date Pill) Pi: Yang pathogen injures Stomach, fluids fail to move, water retention accumulates. This is Excess and can be attacked.
- Shengjiang Xiexin Tang Pi: Middle Qi disharmony, Stomach cold failing to transform, Spleen weakness failing to transport fluids, leading to dry belching with food odor and water Qi retention under ribs. This is Yang deficiency with Yin excess Pi, treatable with warming, tonifying, and unblocking.
- Gancao Xiexin Tang Pi: Post-purgation Yang deficiency, Stomach cold, diarrhea with undigested food, borborygmus, subcardiac hardness, dry retching, irritability. Further purgation greatly damages Stomach Yang, causing Yin pathogen to rebel. This Pi can only drain deficiency Qi, not be attacked.
- Dahuang Huanglian Xiexin Tang Pi: Caused by purging first then sweating, reversing order. Heat has entered, exterior remains. Resolve exterior first, then attack. This is Excess-Heat Pi.
- Banxia Xiexin Tang Pi: Fullness without pain, Qi Pi. Cannot be attacked.
- Fuzi Xiexin Tang Pi: Pulse tight turning inward. Uses Dahuang and Huanglian. Aversion to cold and sweating indicate severe True Yang deficiency and insecure Wei Qi. Fuzi is added to restore Yang and secure Wei.
- Dachaihu Tang Pi: Shanghan fever, sweating without resolution, pathogen turns inward to vomiting and diarrhea. Exterior and Interior are both Excess. Release and attack simultaneously.
- Xuanshen Daizheshi Tang (Imperata and Hematite Decoction) Pi: After sweating, vomiting, purging, pathogen resolved but Stomach Yang injured. Deficiency-cold fails to transport, phlegm-fluid retains, Qi rebels causing belching. Warm, tonify, unblock, and anchor. Cannot be attacked.
- Chishizhi Yuyuliang Tang (Red Halloysite and Metaltail Decoction) Pi: Shanghan erroneous purgation leads to incessant diarrhea, forming Pi/hardness. Taking Xiexin Tang and purging again worsens diarrhea. Pathogen in Lower Jiao, beyond Lizhong Tang's scope. Secure Lower Jiao and astringe leakage.
Pi syndromes are numerous and varied in deficiency/excess. How can they be summarized in one word? Thus, Zhang Zhongjing's silence is due to difficulty in explanation.
Initial signs of each meridian generally enter via Ying and Wei. Although Ying/Wei belong to Taiyang, formation of Jie Xiong/Pi is not necessarily in Taiyang. Hence, Jie Xiong is prefixed with "Taiyang Bing" (Taiyang Disease) because it involves unresolved exterior pathogen in Taiyang sinking due to error. Xin Xia Pi clauses are prefixed only with "Shanghan" because while Cold enters from exterior, Pi can occur in any meridian, not just Taiyang.
Zhang Zhongjing calls Wind-injuring-Wei signs "Taiyang Bing." For Cold-injuring-Ying signs, only those with exterior signs are called "Taiyang Bing" because Taiyang governs the exterior. For misdiagnosis/mistreatment/transmission signs, the prefix is dropped because pathogen is no longer exterior but has entered various meridians. Entering Yang becomes Three Yang Interior signs; entering Yin becomes Three Yin Interior signs. Direct infections are called Shanghan or described by symptoms. Once inside, Wind/Cold cannot be labeled Taiyang. Pathogen diverges after passing Ying/Wei, entering Yang or Yin based on deficiency. No fixed division exists.
Later scholars failed to analyze this, assuming Wind-sinking causes Jie Xiong and Cold-sinking causes Pi. They missed Zhang Zhongjing's intent: regardless of Wind/Cold, if in Yang meridians with unresolved exterior, erroneous purgation causes sinking, hence the warning against early purgation and "heat entering" Jie Xiong/Pi. Excess-Heat Pi/Jie Xiong results from guest pathogen sinking, treated with attack only (Da Xianxiong, Shi Zao Tang, Dahuang Huanglian Xiexin Tang, Dachaihu Tang).
If pathogen is in Yin meridians and purged erroneously, it is not exterior and does not need to sink. Stomach Qi deficiency and Yin stagnation cause Pi. Hence, warning against incorrect purgation, but no warning against "early" purgation. Three Yin meridians strictly forbid purgation. Thus, warming/dispersing/tonifying methods (Gancao/Banxia/Shengjiang Xiexin Tangs) are used.
Why must Yang pathogen enter from outside, while Yin does not? Because Three Yang are in the outer layers of the body, while Three Yin are already internal. Zhang Zhongjing discusses "originating in Yang/Yin." One mentions "heat entering" after incorrect purgation; the other does not. One warns of "too early" purgation; the other never does. The discourse is concise but comprehensive. Though not explicitly stated, the meaning is clear. He never defined Pi/Jie Xiong solely by Wind/Cold or Ying/Wei.
Fang Youzhi noted: "Early purgation in Yang-originating cases may still cause Pi; early purgation in Yin-originating cases may still cause Jie Xiong. Disease mechanisms often have unexpected changes." I believe while "early" shouldn't be applied uniformly, it offers flexibility in understanding Pi/Jie Xiong.
Reviewing the Treatise: Subcardiac hardness is Jie Xiong; subcardiac fullness, hardness, pain is Jie Xiong. Thus, Jie Xiong can be called Xin Xia. Some clauses combine Shanghan/Zhongfeng to describe Xin Xia Pi. Some specify Taiyang Zhongfeng with Xin Xia Pi/hardness radiating to hypochondrium. This shows Yang pathogen can cause Xin Xia Pi.
Shanghan day 6-7, Jie Xiong Heat-Excess, pulse deep/tight, subcardiac pain, stone-hard palpation: Yin pathogen can cause Jie Xiong.
Taiyang Zhongfeng with diarrhea/vomiting, sweating, periodic headache, subcardiac Pi/hardness: Originating in Yang but causing Xin Xia Pi.
Taiyin disease: Abdominal fullness/vomiting, inability to eat, worsening diarrhea, spontaneous abdominal pain. Purging causes lower chest binding.
Jueyin chapter: Cold limbs, sudden tight pulse, pathogen knotting in chest. These differ slightly from typical Jie Xiong but represent Yin-originating Jie Xiong.
Thus, Yin/Yang intermix, Pi/Jie Xiong alternate, intricately varying. Can Wind/Cold/Ying/Wei theories match "originating in Yang/Yin"?
Shanglun failed to grasp this, adopting Tiaobian school views: Wind is Yang pathogen; Zhongfear onset, Yang pathogen unresolved, purged, heat sinks to chest -> Jie Xiong. Cold is Yin pathogen; Shanghan onset, Yin pathogen unresolved, purged, heat sinks to heart -> Pi. If interpreted this way, where is the meaning of "heat entering" vs. "not mentioning heat entering"?
Zhang Jianshan criticized Cheng Wuji: "If 'no heat, aversion to cold' is originating in Yin, how can purgation be indicated?" This error is severe. Zhang ignored that Zhongjing said "incorrectly purged" precisely because it was contraindicated.
Zhang also said: "Zhongjing's Yin/Yang refer to Exterior/Interior. Exterior disease purged wrongly -> Jie Xiong. Interior disease not yet in Fu organs purged -> Pi." This is absurd. If in Interior, purging is not adverse. If in Interior, saying "not yet in Fu" implies Fu is deeper than Interior?
He claimed Wind-sinking -> Jie Xiong, Cold-sinking -> Pi. Then:
- Taiyang Zhongfeng with diarrhea/vomiting/sweating/Xin Xia Pi: Is this not Wind-sinking Pi?
- Shanghan day 6-7 Jie Xiong Heat-Excess: Is this not Cold-sinking Jie Xiong?
- Shanghan/Zhongfeng purged wrongly, diarrhea/borborygmus/Xin Xia Pi: Is this not Wind/Cold biasing toward Pi?
- Shanghan day 5-6, vomiting/fever, Chaihu signs present, purged wrongly, chills/shivering, subcardiac fullness/pain (Jie Xiong) or fullness only (Pi): Is this not Cold-sinking causing both?
Comparing these, does Zhang Jianshan's view align with Zhongjing's "Originating in Yang/Yin"? Perhaps Fang and Yu were led by Zhang?
Zhongjing's omission of "heat entering" has deep meaning. Cheng Wuji claimed Yin-originating incorrect purgation means exterior Yin pathogen sinking to Xin Xia causing Pi. But if Yang is deficient, Yin pathogen alone suffices to cause Pi. Moreover, Pi with aversion to cold/fever and Exterior/Interior excess exists. Cheng's note is absurd. Fang Youzhi claimed "omitting heat entering" invites inference. Yu Jiayou failed to check Zhongjing's intent or Fang's error, believing inference: "Both syndromes due to early purgation, both heat entering, text omits for brevity." Such argument confuses similar things (Zi/Mian waters, beans/wheat). To blame predecessors for "blind leading blind" is unfair.
Reading Zhongjing without grasping his intent makes one blind. This ambiguity persists because Zhongjing found it hard to explain fully. Yet, repeated analysis reveals the meaning. Principles are subtle and not easily explicit, inviting later students to seek insight. Hearing the Dao yields shallow knowledge; realizing the Dao yields deep knowledge. Thus: "If you explore my collected works, your understanding will be more than half complete."