或有问于余曰∶刘河间云∶仲景治痢，多用承气，但与滞下混同立论，而无分别。考之诸方，亦未见其
有分治者，抑河间之说不足凭欤？余曰∶前人略之也，经虽无明文，然顾名思义可知矣。书曰∶夏伤于暑
，秋多疟痢。痢者，利也，通利之义，乃时症也。或从泄泻而得，或径大便脓血，盖秋令气降，腹中秽积
因时下行而痢也。彼滞下者，滞，是积滞之滞，不因时令，不由泄泻，而竟里急后重，垢腻之物频并而下
也，岂可同日语哉。故滞下之症，始得之，多用推陈致新，迎而夺之之法。至于治痢，有用补法者，有用涩
法者，有燥湿者，有升提者，有消之者，有温之者，有分利者，有下之者∶然初时不敢遽以药下之，因时
制宜，必审其胃实积固，乃敢推荡耳。余故云∶痢者，兼令气而言也∶滞下者，四时皆有之。名既别，则
治法
当有径庭矣。或曰唯。
古谓先水泻而后脓血者，为脾传肾，乃贼邪难愈；先脓血而后水泻者，为肾传脾，乃微邪易愈。
相传微贼之说，是亦以大概言之也，究竟其说，世亦有先后水泻脓血，而各有难易者。愚谓先水泻
而后脓血，此脾先虚，而积滞继至，故难愈；先脓血而后水泻，此积滞既去，已无邪矣，故易愈。高
明幸察之。
或有问于余曰∶丹溪《局方发挥》云∶翻胃，即是噎膈，噎膈乃翻胃之渐，言此盖火气炎上，熏
蒸津液成痰，切切不可用香燥之药，若服之必死。又曰∶年高者，不治。盖少年气血未虚，用药劫去痰
火，病不复作；老年气血已虚，病必不起。据曰∶翻胃即噎膈，似是一病；又曰∶噎膈乃翻胃之渐，似
又是二病。至用药，谓服香燥之剂必死。乃今时亦有用香燥而得生者何也？余曰∶噎膈、翻胃，古虽未
辩，然拟名定义，似有不同，治法亦将无同也。顾《局方发挥》一书，盖为辟温补，戒燥热，谆谆立言，
于名义亦未暇辩也。愚意谓噎、膈、翻胃，乃是三病，亘古至今，曾未有人剖析
其义者。夫饮食入于噎间，不能下噎，随即吐出，自噎而转，故曰噎。膈，是膈膜之膈，非隔截之谓也
。饮食下噎，至于膈间，不能下膈，乃徐吐出，自膈而转，故曰膈。翻胃，是饮食已入胃中，不能运化
，而下脘又燥结不通，朝食而暮吐，暮食而朝吐、明其自胃中而倒出，故曰翻胃也。均一吐病，而有上
、中、下之分。数千年间，惟洁古老人治吐，而有上、中、下之论。曰∶上焦吐者，主于气；中焦吐者
，主于积；下焦吐者，主于寒。故今人亦有用香燥而治愈者，实寒气使然也，在人体认真切尔。至于年
老之人，诚难治效，丹溪岂欺我哉。
张鸡峰曰∶膈是神思间病，惟内观自养，庶可克济。斯言亦良语也。
有人问我：“刘河间说：张仲景治疗痢疾，多用承气汤类方剂，将‘痢’与‘滞下’混同立论，没有加以区分。考察各种医方，也未见其有分别治疗的记载，难道河间的说法不可信吗？”我说：“前人对此论述简略。虽然经典中没有明文规定，但顾名思义就可以知道了。《尚书》说：‘夏季感受暑邪，秋季多发疟疾和痢疾。’‘痢’字，通‘利’，意为通利，属于时令病。有的由泄泻发展而来，有的直接出现大便脓血，这是因为秋季气候收敛下降，腹中的秽浊积滞因时令之气下行而导致的痢疾。至于‘滞下’，‘滞’是指积滞之滞，不因时令变化，也不由泄泻引起，而是表现为里急后重，污秽黏腻之物频繁并下，这怎么可以和痢疾同日而语呢？因此，治疗滞下初期，多采用推陈致新、迎而夺之的方法。而治疗痢疾，有用补法的，有用涩法的，有用燥湿法的，有用升提法的，有用消导法的，有用温里的，有用分利小便的，有用攻下的：但在初起时不敢贸然用药攻下，必须因时制宜，务必审察患者胃中实热、积滞坚固，才敢使用推荡攻下的药物。所以我常说：‘痢’是兼涉时令之气而言的；‘滞下’则是四季都可能发生的。名称既然不同，治疗方法自然应有巨大差异。”那人说：“对。”
古人说：先出现水样腹泻，随后出现脓血便的，称为脾传肾，属于贼邪（相克之邪），难以治愈；先出现脓血便，随后出现水样腹泻的，称为肾传脾，属于微邪，容易治愈。相传关于“微邪”与“贼邪”的说法，也是从大概情况来说的。究其实际，世间也有先水泻后脓血却难治，或先脓血后水泻却易治的情况。我认为：先水泻而后脓血，这是脾脏先虚，随后积滞继至，所以难愈；先脓血而后水泻，这是积滞已经去除，体内已无邪气，所以易愈。高明之士请明察。
又有人问我：“丹溪在《局方发挥》中说：翻胃，就是噎膈；噎膈是翻胃的渐进阶段。这样说大概是认为火气炎上，熏蒸津液形成痰浊，千万不可用香燥的药物，如果服用必定死亡。又说：年高者，无法治愈。因为少年气血未虚，用药劫去痰火，病不再发作；老年气血已虚，病必不能好转。据此看来：说翻胃即噎膈，似乎是一种病；又说噎膈是翻胃的渐进，似乎又是两种病。至于用药，声称服用香燥之剂必死。然而如今也有用香燥药而获救的，这是为什么呢？”我说：“噎膈、翻胃，古代虽未详细辨析，但拟定名称和定义，似乎有所不同，治疗方法恐怕也不会相同吧。不过，《局方发挥》这本书，主要是为了辟斥温补，告诫不要使用燥热药物，言辞恳切，因此无暇辨析名义上的区别。我的意见是：噎、膈、翻胃，实际上是三种病，从古至今，从未有人剖析过它们的含义。饮食进入噎部，不能通过噎门，随即吐出，食物自噎部回转，所以叫‘噎’。‘膈’，是指膈膜之膈，不是隔截的意思。饮食通过噎部，到达膈间，不能通过膈部，于是慢慢吐出，食物自膈部回转，所以叫‘膈’。翻胃，是指饮食已经进入胃中，但不能运化，且下脘干燥结塞不通，早上吃晚上吐，晚上吃早上吐，明确是从胃中倒出，所以叫‘翻胃’。同样是呕吐的病，但有上、中、下三部的区别。几千年来，只有洁古老人治疗呕吐时，提出了上、中、下的理论。他说：上焦呕吐，主要责之于气；中焦呕吐，主要责之于积；下焦呕吐，主要责之于寒。所以现在也有人用香燥药治愈的，这实际上是寒气所致，需要在人体上认真辨别。至于老年人，确实难以见效，丹溪难道会欺骗我们吗？”
张鸡峰说：“膈证是神志思维方面的病，只有内观自省、自我调养，才有可能克服救治。这话也是良言啊。”
Someone asked me: "Liu Hejian stated that Zhang Zhongjing, when treating dysentery (Li), often used Chengqi Tang (Cure Qi Decoction) and conflated 'Li' with 'Zhi Xia' (Dysentery with Obstruction) in his theoretical discussions without distinguishing between them. Examining various medical formulas, I see no record of separate treatments for them. Is Liu Hejian's theory unreliable?" I replied: "Predecessors have briefly addressed this. Although the classics lack explicit text, one can understand it by considering the names. The Book of Documents states: 'Summer injury by summer-heat leads to malaria and dysentery in autumn.' 'Li' (Dysentery) shares its meaning with 'Li' (to flow freely/pass), indicating a seasonal disease. It may arise from diarrhea or present directly as pus and blood in the stool. This is because in autumn, the qi descends, causing foul accumulations in the abdomen to move downward due to the seasonal influence, resulting in Li. On the other hand, 'Zhi Xia' refers to obstruction; 'Zhi' means stagnation or accumulation. It occurs regardless of season and does not stem from diarrhea. Instead, it presents with tenesmus (urgent need to defecate with little output) and frequent passage of dirty, greasy matter. How can these two be discussed as if they were the same? Therefore, in the early stage of Zhi Xia, methods such as eliminating the old to generate the new, or intercepting and seizing the pathogenic factor, are commonly used. In contrast, treating Li may involve tonification, astringency, drying dampness, lifting and raising, resolving accumulation, warming, separating clear from turbid via urination, or purging: however, at the onset, one dares not rashly use purgatives. Treatment must adapt to the time and condition; only after confirming excess heat and solid accumulation in the stomach/intestines should one dare to use pushing and荡 (purging) methods. Thus, I say: 'Li' involves seasonal qi; 'Zhi Xia' can occur in all four seasons. Since the names differ, the treatment methods must also differ significantly." The person said, "Indeed."
Ancient texts state: If watery diarrhea precedes pus and blood in the stool, it is Spleen transmitting to Kidney, representing a destructive pathogen (Zei Xie) that is difficult to cure; if pus and blood precede watery diarrhea, it is Kidney transmitting to Spleen, representing a mild pathogen (Wei Xie) that is easy to cure. The traditional distinction between mild and destructive pathogens is a generalization. In reality, there are cases where watery diarrhea precedes pus/blood yet is hard to cure, or vice versa. I believe: Watery diarrhea preceding pus/blood indicates initial Spleen deficiency followed by accumulation, hence difficult to cure; pus/blood preceding watery diarrhea indicates that the accumulation has been cleared and no pathogen remains, hence easy to cure. Wise practitioners should observe this carefully.
Another person asked me: "In *Ju Fang Fa Hui*, Danxi states: Fan Wei (Revolving Stomach/Regurgitation) is identical to Ye Ge (Choking and Diaphragm Obstruction); Ye Ge is merely the gradual progression of Fan Wei. This view implies that fire qi flares upward, steaming body fluids into phlegm. One must absolutely avoid aromatic-drying herbs; taking them will lead to death. He also states: Elderly patients cannot be cured. This is because youth possesses un-depleted qi and blood; medication can seize and eliminate phlegm-fire, preventing recurrence. In old age, qi and blood are already deficient, so the illness will not improve. Based on this: saying Fan Wei is Ye Ge suggests one disease; saying Ye Ge is the precursor to Fan Wei suggests two diseases. Regarding medication, he claims aromatic-dosing agents cause death. Yet today, some recover using aromatic-drying herbs. Why?" I replied: "Although ancient texts did not distinguish Ye Ge and Fan Wei, their named definitions seem different, and thus their treatment methods likely differ as well. However, *Ju Fang Fa Hui* was written primarily to refute warm-tonifying practices and warn against dry-heat herbs, with earnest admonitions, leaving no room for semantic辨析 (analysis). My opinion is that Ye, Ge, and Fan Wei are three distinct diseases. Throughout history, no one has analyzed their meanings. 'Ye' (Choking): Food enters the Ye region but cannot pass through, immediately regurgitating, turning back from the Ye. Hence 'Ye'. 'Ge' (Diaphragm): Refers to the diaphragm membrane, not separation/blockage. Food passes the Ye but reaches the Ge region, cannot descend further, slowly regurgitates, turning back from the Ge. Hence 'Ge'. 'Fan Wei' (Revolving Stomach): Food has entered the Stomach but fails to transform/digest, and the lower writhing is dry and obstructed. Morning food vomited in evening, evening food vomited in morning, clearly pouring out from the Stomach. Hence 'Fan Wei'. All are vomiting disorders, but divided into Upper, Middle, and Lower Jiao. For thousands of years, only Jieguc Laoren (Elder Jiegu) discussed vomiting with an Upper/Middle/Lower framework. He stated: Vomiting from the Upper Jiao is governed by Qi; Middle Jiao by Accumulation; Lower Jiao by Cold. Therefore, some are cured today using aromatic-drying herbs, actually due to Cold pathogen. One must discern this in the human body. As for the elderly, indeed efficacy is difficult to achieve; would Danxi deceive us?"
Zhang Jifeng said: "Ge syndrome is a disorder of the mind/spirit. Only through introspection and self-nourishment can it be overcome. These are also good words."