水蛭（二十个） 虻虫（二十五个） 桃仁（二十个去皮尖） 大黄（三两）
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。（ 时。周时也。）
太阳病小便利者。以饮水多。必心下悸。小便少者。必苦里急也。（太阳病小便利者。是膀胱之府无邪热也。若其人
饮水多。此热在上焦。心火亢甚。小便虽利。然渴饮水多。则水来犯火。必心下悸。若其人饮水多而小便少。此热在下
焦。为太阳邪热随经入府。水积不行。膀胱之里。必苦急也。尚论篇谓饮水多。小便少。乃邪热足以消水。故以里急二
字。为里证已急作解。大误之极。按此条论。仲景无治法。补亡论常器之云。可茯苓甘草桂姜汤。又猪苓汤。推常氏之
意。以太阳病小便利者。为表证多。里证少。故用茯苓甘草桂姜汤。小便少者。为表证少。里证多。故用猪苓汤也。）
（此系仲景原文）
问曰。病有结胸。有藏结其状何如。答曰。按之痛寸脉浮。关脉沉。名曰结胸也。何谓藏结。答曰。如结胸状。饮
食如故。时时下利。寸脉浮。关脉小细沉紧。名曰藏结。舌上白苔滑者难治。（此言结胸病状。与藏结虽相似而各别。故
仲景设为问答以辩之。夫结胸藏结。何以云。太阳病。以二者皆太阳病误下所致也。盖结胸病。始因误下。而伤其上焦
之阳。阳气既伤。则风寒之邪。乘虚而入。上结于胸。按之则痛者。胸中实也。寸浮关沉者。风与寒气相结。而为实之
诊也。若藏结病。则不然。其始亦因误下。而伤其中焦之阴。阴血既伤。则风寒之邪。亦乘虚而入。内结于藏。状如结
胸者。以藏气不平。逆于心下故也。饮食如故者。胸无邪阻而胃中空也。时时下利者。藏虚邪结。不能运化。胃中之水
谷。不泌别。不厘清。因偏渗于大肠而作利也。寸浮关沉者。结胸脉也。今诊关脉。兼得小细紧者。则是藏虚。而风寒
之邪。内结可知。舌上白苔者。经云。丹田有热。胸中有寒。今者苔滑。则是舌湿润而冷也。此系误下太过。而变成藏
寒之证。故难治也。愚按结胸证。其人本胃中挟食。下之太早。则食不能去。外邪反入。结于胸中。以故按之则痛。不
能饮食。藏结证。其人胃中本无食。下之太过。则藏虚邪入。冷积于肠。所以状如结胸。按之不痛。能饮食。时下利。
舌上苔滑。此非真寒证。乃过下之误也。结胸证。治见下。藏结证。仲景无治法。补亡论常器之云。可刺关元穴。愚以
若用刺。不若用艾灸之。）
藏结无阳证。不往来寒热。其人反静。舌上苔滑者。不可攻也。（此承上文申明藏结病。所以难治之故。夫藏结虽系
太阳病误下所致然既下之后。已无恶寒发热之证。是无太阳表热也。不往来寒热。是无少阳半表半里之热也。其人反静。
是无阳明里热也。舌上苔滑。是胸中寒。而丹田并无热也。惟其无热。故不若结胸证之可攻而难治也。愚以藏结本无可
下之证。成注云。于法当下者误。补亡论郭白云云。藏结无阳证。不可攻者。宜刺关元穴。愚以藏结病。表里皆寒。无
热可泄。若用刺法。是为认证不明。谬矣。故宜用艾灸之。）
（附例）病胁下素有痞。连在脐旁。痛引少腹。入阴筋者。此名藏结。死此条乃藏结死证。医人不可不知也。素有
痞。谓其人平素先有痞积。伏于胁下。又因新得伤寒。误行攻下。成注所云。邪气入里。与宿积相合。使藏真之气。结
而不通。致连在脐旁。痛引少腹。入阴筋。此为死证。
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。（此推原结
胸病。并及于痞病之因也。仲景云。太阳病当一二日发。太阴病当四五日发。此病发于阳。与发于阴之谓。病发于阳。
邪犹在经。为不可下。反下之。则阳经邪热。入于胸中。因作结胸。病发于阴。邪未入府。亦不可下。反下之。则阴经
邪热。入于心下。因而作痞。痞者。气塞而不通泰也。尚论篇云。二证皆由下早。皆是热入。其不言痞者。省文以见意
也。愚以痞非太阳证。然其邪。亦由太阳而传于太阴。复因误下而作痞。故并入太阳篇中。）
结胸者。项亦强。如柔 状。下之则和。宜大陷胸丸。（此先就结胸之最剧者。议其治也。夫结胸证。至项强。则其
邪紧结于胸。胸中满实。其势常昂。有似反张之状。故云。如柔 也。下之则和者。言邪实去。则胸中和而项自舒之意。
成注云。与大陷胸丸下结泄满。愚按 有刚柔二证。皆颈项强急。今则结胸证。如其状。故曰亦也。或问项强。何以不
云如刚 。余答云。刚 无汗。柔 有汗。结胸证。既项强矣。若不云如柔 。恐医人认以为太阳经风寒之邪未解。反
疑其当用发汗之药。殊不知项虽强。表证已解。里证甚急。治法宜下。曰如柔 状者。盖言有汗而非外邪之项强也。）
水蛭（二十个） 虻虫（二十五个） 桃仁（二十个，去皮和尖） 大黄（三两）
以上四味药。捣碎后分成四丸。用水一升。煮其中一丸。取汁七合。服用。此时应当排出瘀血。如果没排出的，再服。（“时”指一周的时间。）
太阳病（太阳经受邪所致的病证）中，小便通利的，因为饮水过多，必然出现心下悸动（胃脘部跳动感）。小便少的，必然感到腹部急迫难受。（太阳病小便利者，说明膀胱腑没有邪热。如果此人饮水多，这是热在上焦，心火亢盛。虽然小便通利，但因为口渴而大量饮水，水气上犯心火，必然导致心下悸动。如果此人饮水多而小便少，这是热在下焦，是太阳经的邪热随经脉传入膀胱腑，水液积聚不行，膀胱内部必然感到急迫难受。《尚论篇》认为饮水多、小便少，是因为邪热能够消耗水液，所以将“里急”二字解释为里证已经紧急，这是极大的错误。按此条论述，张仲景没有给出治疗方法，《补亡论》常器之说：可以用茯苓甘草桂姜汤。又有猪苓汤。推测常氏的意思，以太阳病小便利者，表证多，里证少，所以用茯苓甘草桂姜汤；小便少者，表证少，里证多，所以用猪苓汤也。）
（这是张仲景的原文）
问：疾病有结胸（邪热与痰水互结于胸膈），有藏结（脏气虚衰，阴寒凝结），它们的症状是怎样的？答：按压疼痛，寸脉浮，关脉沉，叫做结胸。什么是藏结？答：症状像结胸一样，饮食如常，经常腹泻，寸脉浮，关脉小细沉紧，叫做藏结。舌上有白滑苔的，难治。（这里说结胸病的症状，与藏结虽然相似但各不相同，所以张仲景设为问答来辨析它们。结胸和藏结，为什么这么说呢？都是因为太阳病误用下法所致。大概结胸病，起初因误下，损伤了上焦的阳气。阳气既已受伤，那么风寒之邪，乘虚而入，上结于胸。按压则痛的，是胸中实邪。寸浮关沉的，是风与寒气相结，而为实证的脉象。至于藏结病，就不是这样了。它起初也因误下，损伤了中焦的阴血。阴血既已受伤，那么风寒之邪，也乘虚而入，内结于脏腑。状如结胸的，是因为脏气不平，逆乱于心下。饮食如常的，是因为胸中没有邪气阻滞，胃中空虚。经常腹泻的，是因为脏虚邪结，不能运化，胃中的水谷，不能泌别清浊，因而偏渗于大肠而变成泄泻。寸浮关沉的，是结胸的脉象。现在诊察关脉，兼见小细紧的，则是脏虚，而风寒之邪内结可知。舌上有白苔的，经云：丹田有热，胸中有寒。现在的苔滑，则是舌湿润而冷。这是由于误下太过，而变成藏寒的证候。所以难治。我按：结胸证，其人本来胃中挟有食滞，下之太早，则食滞不能去除，外邪反而入内，结于胸中，所以按压则痛，不能饮食。藏结证，其人胃中本无食滞，下之太过，则脏虚邪入，冷积于肠，所以状如结胸，按压不痛，能饮食，时下利，舌上苔滑。这并非真寒证，乃是过用下法的误治。结胸证，治法见下文。藏结证，张仲景没有给出治疗方法，《补亡论》常器之说：可以针刺关元穴。我认为如果用刺法，不如用艾灸。）
藏结没有阳证，没有往来寒热（忽冷忽热），病人反而安静，舌上有苔滑的，不可攻下。（这里承接上文申明藏结病之所以难治的原因。夫藏结虽然是太阳病误下所致，但既然下之后，已经没有恶寒发热的证候，这是没有太阳表热。没有往来寒热，这是没有少阳半表半里的热。病人反而安静，这是没有阳明里热。舌上有苔滑，是胸中有寒，而丹田并没有热。正因为无热，所以不像结胸证那样可攻而下，而是难治。我认为藏结本来没有可下的证候，成无己注云：于法当下者是错误的。《补亡论》郭白云云：藏结无阳证，不可攻者，宜刺关元穴。我认为藏结病，表里皆寒，无热可泄，如果用刺法，这是辨证不明，谬误了。所以宜用艾灸。）
（附例）病胁下素有痞块（腹内结块，固定不移），连在脐旁，疼痛牵引少腹，进入阴筋的，这名叫藏结，死。此条乃藏结死证，医生不可不知道。素有痞，谓其人平素先有痞积，伏于胁下，又因新得伤寒，误行攻下。成注所说，邪气入里，与宿积相合，使脏真之气，结而不通，致使连在脐旁，疼痛牵引少腹，进入阴筋。此为死证。
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（心下痞塞不通）。所以成为结胸的，是因为下之太早的缘故。（这里推究结胸病，并涉及痞病的成因。张仲景说：太阳病当一二日发，太阴病当四五日发。这就是病发于阳，与发于阴的说法。病发于阳，邪气还在经络，为不可下。反用下法，则阳经邪热，入于胸中，因而作结胸。病发于阴，邪气未入腑，也不可下。反用下法，则阴经邪热，入于心下，因而作痞。痞，是气塞而不通畅。《尚论篇》云：二证皆由下早，皆是热入。其不言痞者，是省略文字以见意。我认为痞不是太阳证，但其邪气，也是由太阳传于太阴，又因误下而作痞。所以并入太阳篇中。）
结胸者，项亦强，如柔痓（一种以项背强直、口噤不开甚至角弓反张为特征的病证，此处指有汗的项强）状。下之则和，宜大陷胸丸。（这里先就结胸中最严重的情况，讨论其治疗。夫结胸证，到了项强，则其邪紧结于胸，胸中满实，其势常昂，有似反张的形状。所以说：如柔痓状。下之则和的，是说邪实去，则胸中和而项自舒的意思。成注云：与大陷胸丸下结泄满。我按：痓有刚柔二证，都是颈项强急。现在则是结胸证，如其状，所以说“亦”。有人问项强，为什么不说是如刚痓？我回答说：刚痓无汗，柔痓有汗。结胸证，既然项强了，如果不说如柔痓，恐怕医生认以为太阳经风寒之邪未解，反而怀疑其应当用发汗的药。殊不知项虽强，表证已解，里证甚急，治法宜下。曰如柔痓状的，是言有汗而非外邪引起的项强。）
Leech (Shuizhi, Hirudo nipponica) (20 pieces), Bluebottle fly larva (Mengchong, Chrysomya megacephala) (25 pieces), Peach seed (Taoren, Prunus persica seed) (20 pieces, skin and tip removed), Rhubarb (Dahuang, Rheum palmatum root and rhizome) (3 liang).
The above four ingredients. Pound into powder, divide into four pills. With one sheng of water, boil one pill. Obtain seven he of liquid. Take orally. At this time, blood stasis should be discharged. If not discharged, take again. ("Shi" refers to a cycle of time.)
In Taiyang disease (disease caused by pathogenic factors invading the Taiyang channel), if urination is free, due to excessive water intake, there will inevitably be palpitations in the epigastrium (xinxia ji). If urination is scanty, there will inevitably be distressing abdominal urgency. (Free urination in Taiyang disease indicates no pathogenic heat in the Bladder Fu organ. If the person drinks much water, this indicates heat in the Upper Jiao with hyperactive Heart Fire. Although urination is free, excessive drinking due to thirst causes water to invade Fire, leading to epigastric palpitations. If the person drinks much water but urinates little, this indicates heat in the Lower Jiao, where Taiyang pathogenic heat follows the channels into the Bladder Fu, causing water accumulation and stagnation, resulting in distressing urgency in the interior of the Bladder. *Shanglun Pian* argues that excessive drinking with scanty urine means pathogenic heat consumes water, thus interpreting "abdominal urgency" as an urgent interior syndrome, which is extremely erroneous. According to this clause, Zhang Zhongjing provides no treatment method. *Buwang Lun* by Chang Qizhi states: Fuling Gancao Guijiang Tang can be used. Also Zhu Ling Tang. Inferring Chang's intent, free urination in Taiyang disease implies more exterior syndrome and less interior syndrome, hence using Fuling Gancao Guijiang Tang; scanty urination implies less exterior syndrome and more interior syndrome, hence using Zhu Ling Tang.)
(This is Zhang Zhongjing's original text.)
Question: There are diseases called Jie Xiong (Chest Binding, binding of pathogenic heat and phlegm-fluid in the chest/diaphragm) and Zang Jie (Zang Binding,凝结 of Yin-cold due to deficiency of Zang Qi). What are their manifestations? Answer: Pain upon pressure, Cun pulse floating, Guan pulse sinking, is named Jie Xiong. What is Zang Jie? Answer: Symptoms resemble Jie Xiong, diet remains normal, frequent loose stools, Cun pulse floating, Guan pulse small, fine, deep, and tight, is named Zang Jie. White slippery coating on the tongue indicates difficult-to-treat condition. (This describes Jie Xiong symptoms, which are similar yet distinct from Zang Jie, so Zhang Zhongjing uses Q&A to differentiate them. Why are they both attributed to Taiyang disease? Both result from incorrect purgation of Taiyang disease. Generally, Jie Xiong begins with incorrect purgation damaging Yang Qi of the Upper Jiao. Once damaged, Wind-Cold pathogens enter via deficiency and bind upward in the chest. Pain on pressure indicates excess in the chest. Floating Cun and Sinking Guan indicate Wind and Cold binding as an excess pattern. Zang Jie is different. It also begins with incorrect purgation damaging Yin Blood of the Middle Jiao. Once damaged, Wind-Cold pathogens enter via deficiency and bind internally in the Zang organs. Resembling Jie Xiong due to uneven Zang Qi rebelling towards the epigastrium. Normal diet indicates no pathogenic obstruction in the chest and emptiness in the Stomach. Frequent loose stools indicate Zang deficiency with pathogenic binding, inability to transform, failure to separate clear from turbid, causing water and grain to leak into the Large Intestine. Floating Cun and Sinking Guan are pulses for Jie Xiong. Now, Guan pulse being small, fine, and tight indicates Zang deficiency and internal binding of Wind-Cold. White coating on the tongue, as stated in classics: Heat in Dantian, Cold in Chest. Slippery coating indicates wet and cold tongue. This results from excessive purgation transforming into Cold of the Zang, hence difficult to treat. I note: In Jie Xiong syndrome, the person originally has food retention in the Stomach. Purging too early fails to remove food, allowing external pathogens to enter and bind in the chest, causing pain on pressure and inability to eat. In Zang Jie syndrome, the person originally has no food retention. Excessive purgation leads to Zang deficiency and pathogen entry, cold accumulation in the intestines, resembling Jie Xiong but without pain on pressure, able to eat, occasional loose stools, slippery tongue coating. This is not true Cold syndrome but error from over-purgation. Jie Xiong treatment is seen below. For Zang Jie, Zhang Zhongjing gives no treatment. *Buwang Lun* by Chang Qizhi says: Moxibustion or acupuncture at Guanyuan point can be used. I believe if using needling, moxibustion is preferable.)
Zang Jie has no Yang syndromes, no alternating chills and fever (wanglai hanre), the person is instead quiet, white slippery coating on the tongue, cannot use attack/purgation methods. (This continues the previous text to explain why Zang Jie is difficult to treat. Although Zang Jie results from incorrect purgation of Taiyang disease, after purgation, there are no aversion to cold or fever, meaning no Taiyang exterior heat. No alternating chills and fever means no Shaoyang half-exterior half-interior heat. The person is quiet, meaning no Yangming interior heat. White slippery coating on the tongue means Cold in the chest and no heat in Dantian. Precisely because there is no heat, it is not like Jie Xiong which can be attacked/purged, making it difficult to treat. I believe Zang Jie originally has no indications for purgation. Cheng Wuji's commentary says: claiming it should be purged according to method is wrong. *Buwang Lun* by Guo Baiyun says: Zang Jie has no Yang syndromes, cannot be attacked, suitable for acupuncture at Guanyuan. I believe Zang Jie involves Cold in both exterior and interior, no heat to drain. Using acupuncture here indicates unclear differentiation, which is erroneous. Thus, moxibustion is suitable.)
(Attached Example) Disease with pre-existing mass (Pi, fixed abdominal mass) under the hypochondrium, connected to beside the navel, pain radiating to the lower abdomen and entering the genital tendons, this is named Zang Jie, death. This clause is about fatal Zang Jie, physicians must know. Pre-existing Pi means the person had Pi accumulation under the hypochondrium normally. Due to new contraction of Cold Damage, incorrect purgation was performed. Cheng's commentary states: Pathogen enters interior, combines with old accumulation, causing True Zang Qi to bind and not flow, connecting beside the navel, pain radiating to lower abdomen and genital tendons. This is a fatal syndrome.
Disease originating from Yang, incorrectly purged, heat enters thereby forming Jie Xiong. Disease originating from Yin, incorrectly purged, thereby forming Pi (Epigastric Fullness/Obstruction). The reason for becoming Jie Xiong is purging too early. (This traces the origin of Jie Xiong and mentions the cause of Pi. Zhang Zhongjing says: Taiyang disease manifests in 1-2 days, Taiyin disease manifests in 4-5 days. This refers to disease originating from Yang and Yin. Disease originating from Yang, pathogen is still in channels, purgation is contraindicated. Incorrect purgation causes Yang channel pathogenic heat to enter the chest, forming Jie Xiong. Disease originating from Yin, pathogen has not entered Fu organs, purgation is also contraindicated. Incorrect purgation causes Yin channel pathogenic heat to enter the epigastrium, forming Pi. Pi means Qi blockage and lack of smoothness. *Shanglun Pian* says: Both syndromes result from early purgation, both involve heat entering. Omission of Pi in some contexts is ellipsis to imply meaning. I believe Pi is not a Taiyang syndrome, but its pathogen transmits from Taiyang to Taiyin, and forms Pi due to incorrect purgation. Hence included in Taiyang chapter.)
Jie Xiong, neck stiffness also, resembling Rou Ji (soft spasm with sweating) state. Purging brings harmony, Da Xian Xiong Wan is suitable. (This discusses treatment for the most severe Jie Xiong. When Jie Xiong reaches neck stiffness, the pathogen tightly binds in the chest, chest is full and solid, posture often erect, resembling opisthotonos. Hence said: resembling Rou Ji. "Purging brings harmony" means removing pathogenic excess harmonizes the chest and relaxes the neck. Cheng's commentary says: Da Xian Xiong Wan purges binding and drains fullness. I note: Ji has Gang (hard/no sweat) and Rou (soft/sweat) types, both involving neck stiffness. Now Jie Xiong resembles this, hence "also". Question: Why not say resembling Gang Ji? Answer: Gang Ji has no sweat, Rou Ji has sweat. In Jie Xiong with neck stiffness, if not specified as Rou Ji, physicians might mistake it for unresolved Taiyang Wind-Cold and suspect need for diaphoresis. Unknowingly, although neck is stiff, exterior syndrome is resolved, interior syndrome is urgent, treatment should be purgation. Saying "resembling Rou Ji" indicates sweating, distinguishing it from neck stiffness caused by external pathogens.)