伤寒病发于阴。下之太早。则成痞硬。病发于阳。下之太早。则成结胸。均为表邪。乘
虚入里而成。硬满。按之不痛者为痞满。属虚邪。硬满。按之大痛者为结胸。实邪也。
因热入有浅深。故结胸分大小。从心下至小腹。硬满而痛不可按者。为大结胸。其
脉沉紧。其症但头汗出。项强如痉。此由太阳失表而误下。邪入胃中。与不得化汗
之水气相结而成也。夫太阳寒水之气。结于阳明。当以大陷胸汤猛烈之剂。竟从
阳明攻陷。大黄陷热结。甘遂攻水结。佐以芒硝之咸。制二者之苦。不令直行而下。
使其引入硬满之处。软坚破积。导去热邪。
邵评∶此推原结胸与痞之故。下之太早一句。是此二症之关键。病发于阴。误下
而热不得散。则为痞硬。病发于阳。误下而热邪内陷。则为结胸。所以然者。病邪
在经。本当发散。而反下之。里气则虚。邪气因入。而与饮相搏为病也。但痞满而
按之不痛者。乃无形热结。故曰虚邪。硬满而按之大痛者。乃有形之邪热。结于
胸中。故曰实邪。若大结胸邪入深。故硬痛从心下至小腹。小结胸邪入浅。故痛只在心下。此明所以成结
胸与痞之因。结胸有大小之分。痞与结胸。有虚实之别。误下而邪内入。水邪结于胸胁。热邪入于肠胃。
为热实结胸。以致心下小腹痛不可按。脉沉为邪入里。紧为水气内结。但头汗出。是水热内结而气上蒸也。
热与水结。胸膈紧实。上连于项。但仰而不能俯。如痉状也。如此脉症。由于太阳经病失表而误下。热
入内实。与水相结。水结于内。则热不能散。热实于内。则水不能行。故用大陷胸汤。甘遂以直攻其水。硝
黄以大下其热也。
又评∶此脉症不异于寒实结胸。故审其为病发于阳。误下热入者。方可用大陷胸汤。若不误下。则热
不入。热不入。则水不结。若胸胁无水气。则邪入阳明而成胃实之症。不作结胸矣。此因误下热入。太阳之
邪随热陷入。与水相结。而成热实结胸。心下至小腹。痛满而不可按。其脉又沉紧。似是大承气症。然满痛虽至
小腹。而尚未离心下。是水热互结。与阳明之燥屎不同。故用甘遂破饮。而不宜枳朴之散气也。若误用承气。
水结不散。其变不可胜言矣。且大结胸着重在热实。外虽无热。内有大热也。太阳误下。成热实结胸。太阴误
下。成寒实结胸。所谓病发于阳。误下热入而成结胸也。
如止在心下。不及胸腹。按之知痛。不甚硬者。为小结胸。其脉浮滑。是水与热邪。凝结痰饮。留于胸膈
脉络间也。故用小陷胸汤。以陷中焦脉络之邪。使从无形之气而散。栝蒌生于蔓草。故能入络。以陷膈上
之痰。半夏成于阴月。故能通阴。以散结气。黄连以陷胸中之热。热解痰开。其结自散。
邵评∶小结胸症。其痛止在心下。不及胁腹。按之不硬者。是痰热搏结于心下。不
因妄下而成也。视大陷胸轻。故立方分大小。其脉浮滑。浮为热而滑为痰也。痰热结于中上二焦。用小陷
胸汤。黄连之清热。轻于大黄之攻下。半夏之涤痰。轻于甘遂之破水。栝蒌之润利。轻于芒硝之软坚。而其
开除胸中之结邪之意。无不同也。且小结胸痰热阻于上中二焦。乃无形之气结。水热结于中下二焦。是有形之实
结。结胸有轻重。故立方分大小。
若结胸。身有微热。头自汗出。胸中漉漉有声者。水结胸也。大陷胸丸主之。
邵评∶水结胸。身有微热。头自汗出。是水气热结于胸胁之间而上蒸也。漉漉有
声者。水与气结而气滞不利也。用硝黄以下微热。葶杏以开气。甘遂以泄水也。
且水结胸。水结因于气结。气结因于热结。以大陷胸丸破结泄水。荡涤邪热。此病在上膈。故加葶杏以开气闭。
若结胸硬满而痛。漱水不欲咽者。血结胸也。由于血瘀不能衄解。或已衄未尽。或
妇人经水适来适断。皆能成之。内实者。桃仁承气攻之。未实者。和血散结治之。（合参来苏集选注金鉴）
邵评∶此条血结胸。由瘀血邪热凝结而成。有已实未实之分。宜辨别施治。
太阴腹满时痛。误下之。成寒实结胸。无热症者。湿气与寒邪所结之痰饮也。三物
白散主之。（参来苏集）
邵评∶太阴寒邪在里而误下之。寒邪与寒药相结。成寒实结胸。与结胸实热者不同。无热症者。不四
肢烦疼也。此非阳邪。无口燥烦渴等见症。故用三物白散温下之剂。以散寒而除实也。
若饮食在胃。未当下而早下之。胸膈高起。手不可近。此食因寒凝。而成结胸。宜理
中加枳实、浓朴之类。温胃和中。不可进寒凉。（参奥旨）
邵评∶食停胃中。在中上二焦。未化糟粕。切不可下。必待其食化成屎。而滞于肠
胃之间者。方可下之。若早下之。寒药与食凝结中宫。而成食滞结胸之症。是必
用温运中阳化滞散结之剂。使中阳健运。食化而寒结自开矣。
结胸又有不因误下而成者。如论云。伤寒六七日。结胸热实。脉沉而紧。心下痛。按
之石硬者。大陷胸汤主之是也。此不云下早。但云热实。乃伤寒实邪传里。不因误下而自结聚于胸者也。治法
总当以痞满门诸法。酌其轻重。从乎缓治为当。再用外罨法。以解散胸中实邪。取效尤捷。（参景岳）
邵评∶此热实二字。最宜着眼。热邪传里。填实胸中。而内结既热且实。脉复沉紧。似是大承气症。然结
在心下。而不在腹中。虽按之石硬而痛。亦是水食互结于胸膈。与肠胃之燥粪迥别。故用大陷胸汤硝黄以
下其结热。甘遂以破其水饮也。然此为大结胸而设。若不因误下而邪入于里。或但痞结而不石硬。或按之
不痛者。此结而未实。故不用陷胸。而以痞满门泻心诸法治之。因病未甚。治亦从缓。
又评∶此结胸不由误下而成。是邪热自入于里。与内蓄水饮。及痰食互结于胸中也。
结胸与脏结。皆因下早。邪气入里而成。邪与阳结为结胸。邪与阴结为脏结。结胸
在心之分。脏结在肾之分。结胸可治。阳主生也。脏结不治。阴主杀也。（参来苏集）
Taiyang disease originating from the Yin meridians. If purgation is administered too early. it results in Pi (Glomus) hardness and fullness. Taiyang disease originating from the Yang meridians. If purgation is administered too early. it results in Jie Xiong (Chest Binding). Both conditions arise because exterior pathogens take advantage of deficiency to penetrate inward. Abdominal hardness and fullness with no pain upon palpation is termed Pi Man (Glomus Fullness). It belongs to Deficient Pathogen. Abdominal hardness and fullness with severe pain upon palpation is termed Jie Xiong (Chest Binding). It belongs to Excess Pathogen.
Because heat pathogens invade at varying depths. Jie Xiong is divided into Da Jie Xiong (Major Chest Binding) and Xiao Jie Xiong (Minor Chest Binding). From the epigastrium down to the lower abdomen. if there is hardness, fullness, and pain that cannot be tolerated by touch. it is Da Jie Xiong. The pulse is Chen Jin (Deep and Tight). The symptom is sweating only on the head. and neck stiffness resembling Jing Disease (Spasm). This occurs because Taiyang disease failed to resolve via diaphoresis and was mistakenly treated with purgation. The pathogen entered the Stomach and bound with fluid retention that could not transform into sweat. The Cold-Water Qi of Taiyang binds with Yangming. One should use Da Xian Xiong Tang (Major Decoction to Drain the Chest), a potent formula. To attack directly through Yangming. Da Huang (Rhubarb Root) drains heat accumulation. Gan Sui (Kansui Root) attacks water accumulation. Assisted by Mang Xiao (Mirabilite)'s salty nature. To moderate the bitter nature of the former two. Preventing the medicine from acting directly downward.
Guiding its action to the site of hardness and fullness. Softening hardness and breaking accumulations. Guiding out the heat pathogen.
Shao's Commentary: This deduces the causes of Jie Xiong and Pi. The phrase "purgation too early" is the key to these two syndromes. When disease originates in Yin. Mistaken purgation prevents heat from dispersing. Resulting in Pi Hardness. When disease originates in Yang. Mistaken purgation causes heat to sink inward. Resulting in Jie Xiong. The reason is that when pathogens are in the meridians. They should be dispersed. But purgation is used instead. Depleting interior Qi. Allowing pathogens to enter. And binding with fluid retention to cause disease. However. Pi Fullness with no pain on palpation is an Intangible Heat Accumulation. Hence called Deficient Pathogen. Hardness and fullness with severe pain on palpation is Tangible Heat Pathogen. Bound in the chest. Hence called Excess Pathogen. In Da Jie Xiong. Pathogens penetrate deeply. So hardness and pain extend from the epigastrium to the lower abdomen. In Xiao Jie Xiong. Pathogens penetrate shallowly. So pain is confined to the epigastrium. This clarifies the causes of Jie Xiong and Pi. Jie Xiong has Major and Minor distinctions. Pi and Jie Xiong have Deficiency and Excess differences. Mistaken purgation allows pathogens to enter inward. Fluid pathogens bind in the chest and hypochondrium. Heat pathogens enter the intestines and stomach. Forming Re Shi Jie Xiong (Heat-Excess Chest Binding). Causing pain from the epigastrium to the lower abdomen that cannot be touched. A Chen (Deep) pulse indicates pathogens entering the interior. A Jin (Tight) pulse indicates internal fluid binding. Sweating only on the head is due to internal binding of water and heat causing Qi to steam upward. Heat binding with water makes the chest and diaphragm tight and solid. Connecting upward to the neck. Allowing only extension backward and preventing flexion forward. Resembling Spasm. Such pulses and symptoms result from Taiyang meridian disease failing to resolve via exterior release and being mistakenly purged. Heat enters the interior becoming excess. Binding with water. Water binding internally prevents heat from dissipating. Heat excess internally prevents water from moving. Therefore. Da Xian Xiong Tang is used. Gan Sui directly attacks water. Xiao Huang (Mang Xiao and Da Huang) vigorously purges heat.
Further Commentary: These pulses and symptoms are similar to Han Shi Jie Xiong (Cold-Excess Chest Binding). Thus. one must carefully ascertain if it is disease originating in Yang. With mistaken purgation causing heat to enter. Only then can Da Xian Xiong Tang be used. If purgation was not mistaken. Heat does not enter. If heat does not enter. Water does not bind. If there is no fluid retention in the chest and hypochondrium. Pathogens entering Yangming will form Wei Shi (Stomach Excess) syndrome. Not Jie Xiong. This is because mistaken purgation caused heat to enter. Taiyang pathogens sank inward with the heat. Binding with water. Forming Re Shi Jie Xiong. Pain and fullness from the epigastrium to the lower abdomen are untouchable. Pulses are Chen Jin. Resembling Da Cheng Qi Tang syndrome. However. although fullness and pain reach the lower abdomen. they have not moved far from the epigastrium. This is mutual binding of water and heat. Different from Yangming dry stool. Therefore. Gan Sui is used to break fluid retention. While Zhi Shi (Immature Bitter Orange) and Hou Po (Magnolia Bark) to disperse Qi are unsuitable. If Cheng Qi formulas are mistakenly used. Water binding will not dissipate. Leading to unpredictable complications. Moreover. Da Jie Xiong emphasizes Heat-Excess. Although there may be no external fever. there is intense internal heat. Mistaken purgation of Taiyang disease forms Re Shi Jie Xiong. Mistaken purgation of Taiyin disease forms Han Shi Jie Xiong. This is what is meant by "Disease originating in Yang." Mistaken purgation causing heat to enter and forming Jie Xiong.
If pain is limited only to the epigastrium. not extending to the chest or abdomen. and is painful but not very hard upon palpation. it is Xiao Jie Xiong. The pulse is Fu Hua (Floating and Slippery). This is water and heat pathogens condensing into Tan Yin (Phlegm-Fluid Retention). Remaining in the chest and diaphragm collaterals. Therefore. Xiao Xian Xiong Tang (Minor Decoction to Drain the Chest) is used. To drain pathogens in the Middle Jiao collaterals. Allowing them to dissipate with intangible Qi. Gua Lou (Trichosanthes Fruit) grows on vines. Thus entering collaterals. To drain phlegm above the diaphragm. Ban Xia (Pinellia Tuber) matures in Yin months. Thus penetrating Yin. To scatter binding Qi. Huang Lian (Coptis Rhizome) drains heat in the chest. Once heat resolves and phlegm opens. The binding naturally dissipates.
Shao's Commentary: Xiao Jie Xiong syndrome. Pain is limited to the epigastrium. Not extending to the hypochondrium or abdomen. Not hard on palpation. This is Phlegm-Heat binding in the epigastrium. Not caused by reckless purgation. It is milder than Da Xian Xiong Tang syndrome. Hence formulas are divided into Major and Minor. The pulse is Fu Hua. Floating indicates Heat. Slippery indicates Phlegm. Phlegm-Heat binds in the Upper and Middle Jiao. Using Xiao Xian Xiong Tang. Huang Lian's heat-clearing power is lighter than Da Huang's purgative power. Ban Xia's phlegm-resolving power is lighter than Gan Sui's water-breaking power. Gua Lou's moistening and draining power is lighter than Mang Xiao's softening-hardness power. Yet their intent to eliminate chest binding pathogens is identical. Moreover. Xiao Jie Xiong Phlegm-Heat obstructs the Upper and Middle Jiao. Being Intangible Qi Binding. Water-Heat binds in the Lower and Middle Jiao. Being Tangible Excess Binding. Jie Xiong has severity levels. Hence formulas are divided into Major and Minor.
If Jie Xiong presents with slight body heat. spontaneous head sweating. and gurgling sounds in the chest. it is Shui Jie Xiong (Water Chest Binding). Da Xian Xiong Wan (Major Pill to Drain the Chest) is the primary treatment.
Shao's Commentary: Shui Jie Xiong. Slight body heat and spontaneous head sweating indicate Water-Qi and Heat binding in the chest and hypochondrium steaming upward. Gurgling sounds indicate Water and Qi binding with stagnant and unfavorable Qi flow. Using Xiao Huang to purge slight heat. Ting Li Zi (Descurainia Seed) and Xing Ren (Apricot Seed) to open Qi. Gan Sui to drain water.
Furthermore. Shui Jie Xiong arises from Qi binding. Qi binding arises from Heat binding. Da Xian Xiong Wan breaks binding. drains water. and sweeps away heat pathogens. Since this pathology is in the Upper Diaphragm. Ting Li Zi and Xing Ren are added to open Qi closure.
If Jie Xiong presents with hardness, fullness, pain. and rinsing the mouth without desire to swallow. it is Xue Jie Xiong (Blood Chest Binding). Due to blood stasis unable to resolve via nosebleed. Or nosebleed occurred but was incomplete. Or women's menstruation just started or ended. All can cause this. If interior excess is present. Tao Ren Cheng Qi Tang (Peach Kernel Decoction to Directly Downward) attacks it. If not yet excess. Harmonize blood and scatter binding is the treatment. (Refer to *Lai Su Ji* commentary on *Jin Jian*)
Shao's Commentary: This Xue Jie Xiong is formed by congealing of blood stasis and heat pathogens. Divided into Excess and Non-Excess states. Treatment should be differentiated accordingly.
Taiyin abdominal fullness and intermittent pain. Mistaken purgation leads to Han Shi Jie Xiong (Cold-Excess Chest Binding). Without heat symptoms. This is Phlegm-Fluid Retention bound by dampness and cold pathogens. San Wu Bai San (Three-Material White Powder) is the primary treatment. (Refer to *Lai Su Ji*)
Shao's Commentary: Taiyin Cold pathogens in the interior. Mistaken purgation causes Cold pathogens to bind with Cold medicines. Forming Han Shi Jie Xiong. Different from Re Shi Jie Xiong. Absence of heat symptoms means no limb restlessness or pain. This is not Yang pathogens. Lacking oral dryness and thirst. Therefore. San Wu Bai San. a Warm Purgative formula. is used to dispel cold and remove excess.
If food stagnates in the Stomach. Purging before the appropriate time causes the chest and diaphragm to bulge high. Untouchable by hand. This is food binding due to cold. Forming Jie Xiong. Li Zhong Tang (Regulate the Middle Decoction) plus Zhi Shi and Hou Po is suitable. To warm the Stomach and harmonize the Middle. Cold-cooling agents must not be used. (Refer to *Ao Zhi*)
Shao's Commentary: Food stagnating in the Stomach. Located in the Upper and Middle Jiao. Not yet transformed into feces. Must absolutely not be purged. Must wait until food transforms into stool. And stagnates between the intestines and stomach. Before purging. If purged too early. Cold medicines and food bind in the Middle Palace. Forming Food Stagnation Jie Xiong. Must use formulas that Warm and Move Middle Yang. Resolve stagnation and scatter binding. Making Middle Yang robust. Food digests and Cold binding naturally opens.
Jie Xiong also exists cases not caused by mistaken purgation. As stated in the Treatise: "After six or seven days of Taiyang disease. Jie Xiong Heat-Excess. Pulse Deep and Tight. Epigastric pain. Stone-hard upon palpation. Da Xian Xiong Tang is the primary treatment." This is such a case. Here. "purging too early" is not mentioned. Only "Heat-Excess". This is Taiyang Excess Pathogen transmitting inward. Self-binding in the chest without mistaken purgation. Treatment methods should generally refer to those in the Pi Fullness chapter. Assessing severity. Adopting slow treatment is appropriate. Combined with external compress therapy. To dissipate interior excess in the chest. Efficacy is particularly rapid. (Refer to Zhang Jingyue)
Shao's Commentary: The term "Heat-Excess" is crucial. Heat pathogens transmit inward. Filling and solidifying the chest. Internal binding is both Hot and Excess. Pulse is Deep and Tight. Resembling Da Cheng Qi Tang syndrome. However. binding is in the epigastrium. Not the abdomen. Although stone-hard and painful. It is mutual binding of water and food in the chest and diaphragm. Distinct from dry feces in the intestines and stomach. Therefore. Da Xian Xiong Tang is used. Xiao Huang to purge binding heat. Gan Sui to break water retention. However. this is designed for Da Jie Xiong. If pathogens enter the interior not due to mistaken purgation. Or only Pi binding without stone-hardness. Or no pain on palpation. This is Binding but not Excess. Therefore. Xian Xiong formulas are not used. Instead. Heart-draining methods from the Pi Fullness chapter are employed. Because the disease is not severe. Treatment adopts a slow approach.
Further Commentary: This Jie Xiong is not caused by mistaken purgation. Heat pathogens enter the interior themselves. Binding with internal retained fluids. And mutually binding with Phlegm and Food in the chest.
Jie Xiong and Zang Jie (Organ Binding) both result from premature purgation allowing pathogens to enter the interior. Pathogens binding with Yang meridians form Jie Xiong. Pathogens binding with Yin meridians form Zang Jie. Jie Xiong locates in the Heart region. Zang Jie locates in the Kidney region. Jie Xiong is treatable. Yang governs life. Zang Jie is untreatable. Yin governs death. (Refer to *Lai Su Ji*)