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。）
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.)