（经曰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以下之太早故
也成注云无热恶寒发于阴误矣无热恶寒是为阴症岂有误下之理又岂止作痞而已哉仲景所谓阴阳者
指表里而言在表当汗而反下之因作结胸病虽在里尚未入腑而辄下之因作痞也结胸有大小寒热
水血食痰八者之异而痞则所传犹浅但一味气凝耳若未经下者不名结胸或痰或食或热随症治之
不按自痛。为大结胸。（大陷胸汤）按之乃痛。为小结胸。（小陷胸汤）烦渴。便闭。为热
结胸。（大陷胸汤加黄连）不热渴。小便清白。为寒结胸。（枳实理中汤）怔忡头汗。无大热。揉之
有声。为水结胸（半夏茯苓汤）胸满痛。漱水不咽。喜忘如狂。大便黑。小便利。为血结胸。
（犀角地黄汤）脉滑喘嗽为痰结胸。（黄芩半夏生姜汤加枳实）气口脉大为食结胸。（小陷胸汤
加枳实浓朴）结胸兼斑黄狂呃者最重。脉沉小者死。结胸症具。烦躁甚者死。
误下成痞。俟表症罢而后可下。（柴胡枳桔汤）恶寒。汗出痞满。（附子泻心汤）表未解。
心下满名支结。（柴胡桂枝汤）热甚而痞。（大黄黄连泻心汤）寒多热少。（半夏泻心汤）
（ 者胃经热毒也下之太早热气乘虚入胃乃致发 下之太迟热气留中不散亦令发
胃主肌肉故微微隐起实无头粒小者如芝麻大者如芡实轻者如星布重者如锦纹鲜红者为胃热易治
紫者为热甚难治黑者为胃烂必死 有六症一曰伤寒二曰时气三曰温毒四曰阳毒五曰内伤寒
六曰阴症此外惟有发疹颇类 症但诊属肺家肺主皮毛故有头粒尖起惟瘾疹亦如锦纹而无头粒尤为
难辨然疹为肺症必兼鼻塞流涕咳嗽声重为异耳疹脉多浮大 脉多洪数疹多发于病之首 多发
于病之尾自不同也独有时气发 亦是病起便见贵乎临症精思而熟察之嗟乎 症之发反掌生杀
余每深考似有独得故以下辨论最悉尔）
一曰伤寒发 。固当汗不汗。当下不下。或未当下而早下。则热蕴于胃而发 也。身温
足暖脉洪数有力者易治。脉沉足冷。挟虚者难治。 欲出未出。（升麻葛根汤发之）紫黑者。（上
方加紫草茸）脉虚者。（上方加人参） 已出。不宜再发。恐伤其气也。烦渴热盛。脉洪数者
。（犀角大青汤）谵语。便硬。（大柴胡汤加芒硝）麻黄发表。则增 烂。承气攻里。则必内陷
。故古有明禁也。大青为化 要药。如无。以大蓝叶代之。凡发 避忌香臭。与痘疮同。凡
已出未出之时。切不可投寒凉之剂。吃生冷物。恐冰凝其毒。不得发泄也。挟虚者。必先助
真气。往往拘泥而不敢补者。多致不救。
二曰时气发 。四时不正之气。人感之则寒热拘急。或呕逆。或烦闷。或头痛。鼻干。
不眠。皆 候也。鲜红稀朗者吉。紫黑稠密者凶。重者发热二三日便出。轻者发热三四日而出也
必察元气虚实。脉来有力无力为主。如虚者。（先以参胡三白汤助元气） 未透者。（升麻葛
根汤热甚加紫草）稠密咽肿。（甘草桔梗玄参知母升麻犀角黄连） 出呕逆。（陈皮半夏茯苓黄
连甘草生姜）
三曰温毒发 。或犯春令温邪而发。或犯冬令寒邪。至春始发。或冬有非时之温。皆名
温毒
。治例大抵与伤寒同法。但冬令寒而闭藏。春令温而发皇。小有分别。 将出未出。咳闷呕
吐。（葛根橘皮汤） 已出。（宜用黑膏或犀角大青汤化之）受邪于春。病发于夏。亦同此例。
四曰阳毒发 。大热狂言。目赤鼻黑。 欲出未出。须凉以解之。（干葛升麻紫草大青
陈皮甘草） 紫烦渴。（三黄石膏汤加犀角大青）阳毒发 。或成脓疮。蜜煎升麻涂之。
五曰内伤寒发 。暑月纳凉太过。食冷太多。内外皆寒。逼其暑火。浮游于外而为 。
不过数点。身无大热。脉来沉涩。（调中汤去麻黄桂枝加浓朴干姜香薷扁豆）
六曰阴症发 。状如蚊迹蚤痕。手足多而胸背少。其色淡红。稍久则为微黄。病患安静
。脉来
。熏灼肺胃。传于皮肤。（升麻藿香陈皮甘草人参熟附子生姜）得温补之剂。阳回而阴火自降
。此治本不治标也。然而此症。根本既拨。吉少凶多。惟老成炼达者。拾救四五。病家医家
。临斯症者。顾可忽乎哉。
（《内经》说：病发于阳证，如果误用攻下法，热邪内陷就会形成结胸；病发于阴证，如果误用攻下法，就会形成痞证。这是因为攻下太早的缘故。成无己注解说“无热恶寒是发于阴”，这是错误的。无热恶寒属于阴证，怎么会有误下的道理呢？况且又岂止形成痞证而已呢？张仲景所说的阴阳，是指表里而言。在表的应当发汗却误用攻下，因此形成结胸；病虽然在里但尚未入腑就过早攻下，因此形成痞证。）
结胸有大、小、寒、热以及水、血、食、痰八种不同情况，而痞证传变较浅，只是气机凝滞罢了。如果没有经过误下，不称为结胸；如果是痰、食或热所致，随症状治疗即可，不按之则不痛。
按之疼痛剧烈的，为大结胸。（使用大陷胸汤）
按之才痛的，为小结胸。（使用小陷胸汤）
伴有烦渴、大便闭结的，为热结胸。（在大陷胸汤中加入黄连）
不发热、口渴、小便清白的，为寒结胸。（使用枳实理中汤）
伴有心悸怔忡、头汗出、身体无明显高热、揉搓腹部有水流声的，为水结胸。（使用半夏茯苓汤）
伴有胸满痛、漱水不欲咽、健忘如狂状、大便色黑、小便通利的，为血结胸。（使用犀角地黄汤）
脉滑、气喘咳嗽的，为痰结胸。（使用黄芩半夏生姜汤加入枳实）
寸口脉大的，为食结胸。（使用小陷胸汤加入枳实、厚朴）
结胸兼见斑疹发黄、狂乱呃逆的病情最重。脉象沉小的预后不良。结胸症状具备且烦躁严重的预后不良。
因误下而形成痞证，需等待表证解除后方可攻下。（使用柴胡枳桔汤）
伴有恶寒、汗出、心下痞满的，（使用附子泻心汤）
表证未解，心下胀满称为支结。（使用柴胡桂枝汤）
热势盛而痞满的，（使用大黄黄连泻心汤）
寒多热少的，（使用半夏泻心汤）
（“发斑”是胃经的热毒。攻下太早，热气乘虚入胃，导致发斑；攻下太迟，热气留滞中焦不散，也会导致发斑。胃主肌肉，所以皮肤微微隐起，实际上没有脓头颗粒。小的如芝麻大，大的如芡实大，轻者如星点散布，重者如锦缎花纹。颜色鲜红的属胃热，容易治疗；颜色紫黑的属热毒极盛，难治；颜色黑色的属胃烂，必死无疑。发斑有六种病症：一曰伤寒发斑，二曰时气发斑，三曰温毒发斑，四曰阳毒发斑，五曰内伤寒发斑，六曰阴症发斑。此外还有发疹，颇类似发斑症状，但诊断属于肺家病变，因为肺主皮毛，所以有头粒尖起。只有瘾疹也如锦纹但没有头粒，尤为难以辨别。然而疹是肺系病症，必然兼有鼻塞流涕、咳嗽声重的症状作为区别。疹的脉象多浮大，斑的脉象多洪数。疹多发于疾病初期，斑多发于疾病后期，自然不同。唯独有时气发斑也是病起便见，贵在临证时精心思考并仔细察辨。唉！发斑症的发作，关乎生死反掌之间。我每次深入考察，似乎有独到心得，所以下面详细辨析论述。）
一曰伤寒发斑。本来应当发汗而未发汗，应当攻下而未攻下，或者未到该攻下之时而过早攻下，导致热蕴积在胃而发斑。身体温暖、足部暖和、脉象洪数有力的，容易治疗。脉象沉细、足部冰冷、夹杂虚证的，难治。斑欲出未出时，（使用升麻葛根汤透发）。颜色紫黑的，（在上述方剂中加入紫草茸）。脉虚的，（在上述方剂中加入人参）。斑已发出，不宜再次发汗，恐怕损伤正气。伴有烦渴、热势盛、脉象洪数的，（使用犀角大青汤）。出现谵语、大便硬的，（使用大柴胡汤加入芒硝）。麻黄发表，会加重斑烂；承气汤攻里，会导致邪气内陷。所以古代有明确的禁忌。大青是化解斑毒的要药，如果没有，可以用大蓝叶代替。凡是发斑期间，要避忌香臭之气，与痘疮相同。凡是在斑未出或刚出的时候，切不可投用寒凉药剂，吃生冷食物，恐怕冰凝其毒，不得发泄。夹杂虚证的，必须先扶助真气，往往因为拘泥不敢补益的，大多导致无法救治。
二曰时气发斑。感受四时不正之气，人感染后会出现寒热拘急，或呕吐逆气，或烦闷，或头痛，鼻干，不眠，这些都是发斑的先兆。颜色鲜红稀疏明亮的为吉兆，颜色紫黑稠密的为凶兆。重症发热二三天就发出，轻症发热三四天才发出。必须察验元气虚实，以脉来有力无力为主。如属虚证，（先用参胡三白汤扶助元气）。斑未透发的，（使用升麻葛根汤，热甚加紫草）。稠密且咽喉肿痛的，（使用甘草、桔梗、玄参、知母、升麻、犀角、黄连）。斑出后出现呕吐逆气的，（使用陈皮、半夏、茯苓、黄连、甘草、生姜）。
三曰温毒发斑。或是触犯春季温邪而发，或是触犯冬季寒邪，到春季才发作，或者是冬季有不正常的温暖气候，都称为温毒。治疗原则大体与伤寒相同，但冬季寒冷而闭藏，春季温暖而发散，稍有分别。斑将出未出时，伴有咳嗽胸闷呕吐的，（使用葛根橘皮汤）。斑已发出，（宜用黑膏或犀角大青汤化解）。受邪于春季，发病于夏季，也同此例。
四曰阳毒发斑。高热狂言，目赤鼻黑，斑欲出未出，须用清凉之法解毒。（使用干葛、升麻、紫草、大青、陈皮、甘草）。斑色紫黑、烦渴的，（使用三黄石膏汤加入犀角、大青）。阳毒发斑，若形成脓疮，用蜜煎升麻涂抹。
五曰内伤寒发斑。暑月纳凉太过，食冷太多，内外皆寒，逼迫暑火浮游于外而发斑。不过几点，身体无明显高热，脉象沉涩。（使用调中汤去掉麻黄、桂枝，加入厚朴、干姜、香薷、扁豆）。
六曰阴症发斑。形状像蚊子咬的痕迹或跳蚤叮的痕印，手足多而胸背少，颜色淡红，稍久则变为微黄色。病人神志安静，脉象微弱。熏灼肺胃，传于皮肤。（使用升麻、藿香、陈皮、甘草、人参、熟附子、生姜）。得到温补药剂后，阳气回复而阴火自然下降。这是治本不治标的方法。然而这种病症，根本既已动摇，吉利少而凶险多。只有老练通达的人，能挽救四五成。病患和医生，面对这种病症，怎么能忽视呢？
(The *Neijing* states: When a disease originates from Yang, and purgation is mistakenly applied, heat enters and forms Jie Xiong (Chest Binding); when a disease originates from Yin, and purgation is mistakenly applied, Pi Syndrome (Glomus) forms. This is because the purgation was too early. Cheng Wuji's commentary stating "No fever and aversion to cold indicates origin from Yin" is incorrect. No fever and aversion to cold belong to Yin Syndromes; how could there be a rationale for mistaken purgation? Moreover, would it only result in Pi Syndrome? Zhang Zhongjing's reference to Yin and Yang here refers to Exterior and Interior. If the pathogen is in the Exterior, sweating should be induced, but purgation is mistakenly used, resulting in Jie Xiong; if the pathogen is in the Interior but has not yet entered the Fu organs, and purgation is prematurely applied, Pi Syndrome results.)
Jie Xiong presents with variations of Large/Small, Cold/Heat, and Water, Blood, Food, and Phlegm types. Pi Syndrome involves shallower transmission, characterized merely by Qi stagnation. If no purgation has been performed, it is not termed Jie Xiong; if caused by Phlegm, Food, or Heat, treatment follows symptoms, and there is no pain upon palpation.
Severe pain upon deep palpation indicates Large Jie Xiong. (*Da Xian Xiong Tang*)
Pain only upon light palpation indicates Small Jie Xiong. (*Xiao Xian Xiong Tang*)
Accompanied by irritability, thirst, and constipation indicates Heat Jie Xiong. (*Da Xian Xiong Tang* plus *Huang Lian*)
Absence of fever/thirst and clear, copious urine indicates Cold Jie Xiong. (*Zhi Shi Li Zhong Tang*)
Palpitations, sweating on the head, absence of high fever, and gurgling sounds upon abdominal rubbing indicate Water Jie Xiong. (*Ban Xia Fu Ling Tang*)
Chest fullness and pain, rinsing mouth without swallowing, forgetfulness resembling mania, black stools, and free urination indicate Blood Jie Xiong. (*Xi Jiao Di Huang Tang*)
Slippery pulse, asthma, and cough indicate Phlegm Jie Xiong. (*Huang Qin Ban Xia Sheng Jiang Tang* plus *Zhi Shi*)
Large pulse at the Qi Kou (Cun Kou) position indicates Food Jie Xiong. (*Xiao Xian Xiong Tang* plus *Zhi Shi* and *Hou Po*)
Jie Xiong accompanied by macules, jaundice, mania, and hiccups is the most severe. A sunken, small pulse indicates death. Jie Xiong symptoms present with severe restlessness indicates death.
Pi Syndrome resulting from mistaken purgation requires waiting for Exterior symptoms to resolve before applying purgation. (*Chai Hu Zhi Jie Tang*)
Aversion to cold, sweating, and epigastric fullness indicate Pi with Cold-Excess. (*Fu Zi Xie Xin Tang*)
Unresolved Exterior symptoms with epigastric fullness constitute Zhi Jie (Branch Binding). (*Chai Hu Gui Zhi Tang*)
High heat with Pi indicates Heat Pi. (*Da Huang Huang Lian Xie Xin Tang*)
More cold than heat indicates Cold-Heat Complex Pi. (*Ban Xia Xie Xin Tang*)
(Fa Ban [Eruption of Macules] is due to heat-toxin in the Stomach Meridian. Purgation too early allows heat to enter the Stomach vacuity, causing Fa Ban; purgation too late leaves heat stagnant in the Middle, also causing Fa Ban. The Stomach governs muscles/skin, so eruptions rise slightly under the skin without distinct pustules. Small ones are sesame-sized, large ones are like Euryale seeds. Mild cases resemble scattered stars; severe cases resemble brocade patterns. Bright red indicates Stomach Heat, easy to treat; purple-black indicates extreme Heat, difficult to treat; black indicates Rotting Stomach, invariably fatal. There are six types of Fa Ban: 1. Shang Han Fa Ban, 2. Shi Qi Fa Ban, 3. Wen Du Fa Ban, 4. Yang Du Fa Ban, 5. Nei Shang Han Fa Ban, 6. Yin Zheng Fa Ban. Additionally, Zhen [Rash] resembles Ban but belongs to the Lung system, as the Lung governs skin/hair, presenting with pointed papules. Only Yin Zhen resembles brocade patterns without papules, making it hard to distinguish. However, Zhen is a Lung disorder, necessarily accompanied by nasal congestion, runny nose, cough, and heavy voice. Zhen pulses are typically floating and large; Ban pulses are typically surging and rapid. Zhen often appears at the beginning of illness; Ban often appears at the end. They differ naturally. Occasionally, Shi Qi causes Fa Ban from onset, requiring careful clinical observation. Alas, the eruption of Ban determines life or death instantly. I have studied this deeply and claim unique insights, hence the detailed discussion below.)
1. Shang Han Fa Ban. Indicated sweating but not done, indicated purgation but not done, or premature purgation leads to heat accumulation in the Stomach and Fa Ban. Warm body, warm feet, surging-rapid-forceful pulse indicates easy treatment. Sunken pulse, cold feet, deficiency-complex indicates difficult treatment. Before eruption, use *Sheng Ma Ge Gen Tang* to vent. Purple-black color, add *Zi Cao Rong*. Deficient pulse, add *Ren Shen*. After eruption, do not re-sweat to avoid damaging Qi. Irritability, thirst, intense heat, surging-rapid pulse, use *Xi Jiao Da Qing Tang*. Delirium, hard stool, use *Da Chai Hu Tang* plus *Mang Xiao*. *Ma Huang* promotes sweating and worsens macule rot; *Cheng Qi* formulas purge interior and cause internal collapse. Thus, ancient texts strictly forbid them. *Da Qing* is essential for resolving macules; substitute with *Da Lan Ye* if unavailable. Avoid fragrant/foul odors during eruption, similar to smallpox. Do not use cold-cooling agents or eat raw/cold food during pre-eruption or eruption phases to prevent freezing toxins and hindering venting. For deficiency-complex, tonify True Qi first; failure to tonify due to rigidity often leads to untreatable conditions.
2. Shi Qi Fa Ban. Caused by irregular Qi of four seasons, leading to chills, fever, stiffness, vomiting, irritability, headache, dry nose, insomnia—these are prodromal signs of Fa Ban. Bright red and sparse is auspicious; purple-black and dense is ominous. Severe cases erupt after 2-3 days of fever; mild cases after 3-4 days. Assess Yuan Qi deficiency/excess via pulse strength. For deficiency, first use *Shen Hu San Bai Tang* to support Yuan Qi. For non-penetrating eruption, use *Sheng Ma Ge Gen Tang*; add *Zi Cao* for high heat. For dense eruption with sore throat, use *Gan Cao*, *Jie Geng*, *Xuan Shen*, *Zhi Mu*, *Sheng Ma*, *Xi Jiao*, *Huang Lian*. For post-eruption vomiting, use *Chen Pi*, *Ban Xia*, *Fu Ling*, *Huang Lian*, *Gan Cao*, *Sheng Jiang*.
3. Wen Du Fa Ban. Caused by Spring Warmth pathogens, or Winter Cold pathogens manifesting in Spring, or abnormal warmth in Winter. Treatment principles largely mirror Shang Han, though Winter Cold implies closure while Spring Warmth implies dispersal, showing slight differences. Pre-eruption with cough, chest oppression, vomiting: *Ge Gen Ju Pi Tang*. Post-eruption: Use *Hei Gao* or dissolve *Xi Jiao Da Qing Tang*. Pathogens contracted in Spring, manifesting in Summer follow this pattern.
4. Yang Du Fa Ban. High fever, delirium, red eyes, black nose, pre-eruption macules. Cool to resolve. (*Ge Gen*, *Sheng Ma*, *Zi Cao*, *Da Qing*, *Chen Pi*, *Gan Cao*). Purple-black, irritability, thirst: *San Huang Shi Gao Tang* plus *Xi Jiao*, *Da Qing*. Yang Du Fa Ban forming abscesses: Apply honey-fried *Sheng Ma*.
5. Nei Shang Han Fa Ban. Excessive cooling and cold food intake in summer causes internal/external cold, forcing Summer Heat Fire to float outward, causing Fa Ban. Few spots, no high fever, sunken-sluggish pulse. (*Tiao Zhong Tang* minus *Ma Huang*, *Gui Zhi*; plus *Hou Po*, *Gan Jiang*, *Xiang Ru*, *Bian Dou*).
6. Yin Zheng Fa Ban. Resembles mosquito bites or flea marks, more on limbs than trunk/back, pale red turning slightly yellow over time. Patient is quiet, pulse is weak. Heat torments Lung/Stomach, transmitting to skin. (*Sheng Ma*, *Huo Xiang*, *Chen Pi*, *Gan Cao*, *Ren Shen*, *Shu Fu Zi*, *Sheng Jiang*). Warming and tonifying agents restore Yang, causing Yin Fire to subside. This treats the root, not the branch. However, once the foundation is shaken, prognosis is poor. Only experienced physicians can save 40-50%. Physicians and families must not neglect this condition.