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。
阳者，指外而言，形躯是也；阴者，指内而言，胸中心下是也。此指人身之外为阳、内为阴，非指阴经之阴，
亦非指阴症之阴。发阴、发阳，俱指发热。结胸与痞，俱是热症。作痞不言热入者，热原发于里也。误下而热不得
散，因而痞硬。不可以发阴作无热解也。若作痞谓非热症，泻心汤不得用芩、连、大黄矣。若栀子豉之心中懊 ，
瓜蒂散之心中温温欲吐，与心下满而烦，黄连汤之胸中有热，皆是病发于阴。
结胸无大热，但头微汗出者，此为水结在胸胁也，大陷胸汤主之。
上条言热入是结胸之因，此条言水结是结胸之本，互相发明结胸病源。若不误下则热不入，热不入则水不结。
若胸胁无水气，则热必入胃而不结于胸胁矣。此因误下热入，太阳寒水之邪，亦随热而内陷于胸胁间。水邪、热
邪结而不散，故名曰结胸。粗工不解此义，竟另列水结胸一症，由是多歧滋惑矣。不思大陷胸汤丸，仲景用甘遂、
葶苈何为耶？无大热，指表言。未下时大热，下后无大热，可知大热乘虚入里矣。但头微汗者，热气上蒸也。余处
无汗者，水气内结也。水结于内，则热不得散；热结于内，则水不得行。故用甘遂以直攻其水，任硝、黄以大下
其热，所谓其次治六腑也，又大变乎五苓、十枣等法。太阳误下，非结胸即发黄，皆因其先失于发汗，故致湿热之
为变也。身无大热，但头汗出，与发黄症同。只以小便不利，知水气留于皮肤，尚为在表，仍当汗散。此以小便利，
知水气结于胸胁，是为在里，故宜下解。
伤寒六七日，结胸热实，脉沉紧、心下痛、按之石硬者，大陷胸汤主之。
前条言病因与外症，此条言脉与内症。又当于热实二字着眼，六七日中，详辨结胸有热实，亦有寒实。太阳病
误下，成热实结胸，外无大热，内有大热也。太阴病误下，成寒实结胸，胸中结硬，外内无热症也。沉为在里，紧
则为寒，此正水结胸胁之脉。心下满痛，按之石硬，此正水结胸胁之症。然其脉其症，不异于寒实结胸。故必审
其为病发于阳，误下热入所致，乃可用大陷胸汤，是谓治病必求其本耳。
太阳病，重发汗而复大下之，不大便五六日，舌上燥而渴，日晡小有潮热，从心下至小腹硬满而痛不可近者，
大陷胸汤主之。
此妄汗妄下，将转属阳明而尚未离乎太阳也。不大便五六日，舌上燥渴，日晡潮热，是阳明病矣。然心下者，
太阳之位，小腹者，膀胱之室也。从心下至小腹硬满而痛不可近，是下后热入水结所致，而非胃家实，故不得名
为阳明病也。若复用承气下之，水结不散，其变不可胜数矣。
大陷胸汤∶
大黄（六两） 芒硝（一升） 甘遂（一钱匕）
上三味，以水六升，先煮大黄，取二升，去滓，内芒硝，煮一二沸，内甘遂末。温服一升，得快利，止后服。
结胸者，项亦强如柔 状，下之则和，宜大陷胸丸。
头不痛而项犹强，不恶寒而头汗出，故如柔 状。此表未尽除而里症又急，丸以缓之，是以攻剂为和剂也。
此是结胸症中或有此状。若谓结胸者必如是，则不当有汤、丸之别矣。
大陷胸丸∶
大黄（八两） 芒硝 杏仁 葶苈子（各半升）
上大黄、葶苈捣筛，内杏仁、芒硝，合研如脂，和散取弹丸一枚，别捣甘遂末一钱匕，白蜜二合，水二升，
煮取一升，温顿服之。一宿乃下，如不下更服，取下为效。
硝、黄血分药也，葶、杏气分药也。病在表用气分药，病在里用血分药。此病在表里之间，故用药亦气血相
须也。且小其制而复以白蜜之甘以缓之，留一宿乃下，一以待表症之先除，一以保肠胃之无伤耳。
小结胸病正在心下，按之则痛，脉浮滑者，小陷胸汤主之。
结胸有轻重，立方分大小。从心下至小腹按之石硬而痛不可近者，为大结胸；正在心下未及胁腹，按之则痛，
未曾石硬者，为小结胸。大结胸是水结在胸腹，故脉沉紧；小结胸是痰结于心下，故脉浮滑。水结宜下，故用甘
遂、葶、杏、硝、黄等下之；痰结可消，故用黄连、栝蒌、半夏以消之。水气能结而为痰，其人之阳气重可知矣。
小陷胸汤∶
黄连（一两） 半夏（半升） 大栝蒌实（一枚）
上三味，以水六升，先煮栝蒌，取三升，去滓，内诸药，煮取二升，去渣，分温三服。
结胸症，其脉浮大者，不可下，下之则死。
阳明脉浮大，心下反硬，有热属藏者，可攻之。太阳结胸热实，脉浮大者，不可下，何也？盖阳明燥化，心
下硬，是浮大为心脉矣。火就燥，故急下之以存津液，釜底抽薪法也。结胸虽因热入所致，然尚浮大，仍为表脉。
恐热未实则水未结，若下之，利不止矣。故必待沉紧，始可下之。此又凭脉不凭症之法也。
结胸症具，烦躁者亦死。
结胸是邪气实，烦躁是正气虚，故死。
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。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。”
结胸之脉沉紧者可下，浮大者不可下，此言其略耳。若按部推之，寸为阳，浮为阳，阳邪结胸而不散，必寸
部仍见浮脉。关主中焦，妄下而中气伤故沉，寒水留结于胸胁之间故紧。不及尺者，所重在关，故举关以统之也。
如结胸状而非结胸者，结胸则不能食，不下利，舌上燥而渴，按之痛，脉虽沉紧而实大，此则结在脏而不在腑，
故见症种种不同。夫硬而不通谓之结。此能食而利亦谓之结者，是结在无形之气分，五脏不通，故曰藏结。与阴结
之不能食而大便硬不同者，是阴结尚为胃病，而无间于藏也。五脏以心为主，而舌为心之外候，舌苔白而滑，是水
来克火，心火几于熄矣，故难治。
藏结无阳症，不往来寒热，其人反静，舌上苔滑者，不可攻也。
结胸是阳邪下陷，尚有阳症见于外，故脉虽沉紧，有可下之理。藏结是积渐凝结而为阴，五脏之阳已竭也。外
无烦躁潮热之阳，舌无黄黑芒刺之苔，虽有硬满之症，慎不可攻。理中、四逆辈温之，尚有可生之义。
病患胁下素有痞连在脐旁，痛引小腹入阴筋者，此名藏结，死。
藏结有如结胸者，亦有如痞状者。素有痞而在胁下，与下后而心下痞不同矣。脐为立命之原。脐旁者，天枢
之位，气交之际，阳明脉之所合，少阳脉之所出，肝脾肾三藏之阴凝结于此，所以痛引小腹入阴筋也。此阴常在，
绝不见阳。阳气先绝，阴气继绝，故死。少腹者，厥阴之部，两阴交尽之处。阴筋者，宗筋也。今人多有阴筋上
冲小腹而痛死者，名曰疝气，即是此类。然痛止便苏者，《金匮》所云“入藏则死，入府则愈”也。治之以茴香、
吴萸等味而痊者，亦可明藏结之治法矣。卢氏将种种异症，尽归藏结，亦好奇之过也。
When a disease originates in the Yang (exterior/body surface) and is mistakenly treated with purgation, heat enters and forms Jie Xiong (Chest Binding); when a disease originates in the Yin (interior) and is mistakenly treated with purgation, Pi Syndrome (Stagnant Blockage) results. The reason Jie Xiong forms is due to premature purgation.
"Yang" here refers to the exterior, i.e., the body trunk; "Yin" refers to the interior, i.e., the chest and epigastrium. This distinguishes the external as Yang and internal as Yin, not referring to the Yin meridians nor to Yin syndromes. "Fa Yin" (onset of Yin) and "Fa Yang" (onset of Yang) both refer to fever. Both Jie Xiong and Pi are heat syndromes. The absence of "heat entering" in the description of Pi indicates that the heat originated internally. Mistaken purgation prevents heat from dispersing, leading to Pi hardness. One cannot interpret "Fa Yin" as implying no heat. If Pi were considered non-heat, Xiexin Tang (Gastroenteritis Decoction) would not contain Huangqin (Scutellaria Root), Lianhua (Coptis Rhizome), and Dahuang (Rhubarb Root). Conditions such as Zhongxin Aonao (mental restlessness in the epigastrium) in Zhizi Chitang (Gardenia and Soybean Mung Bean Decoction), Xinzhong Wenwen Yutu (warmth and urge to vomit in the epigastrium) in Goutisan (Melon Spume Powder), Xinxia Man Er Fan (epigastric fullness and irritability), and Xiongzhong You Re (heat in the chest) in Huanglian Tang (Coptis Decoction) all fall under "disease originating in Yin."
Jie Xiong presents without significant external heat, but with slight sweating on the head only; this is water binding in the chest and hypochondrium, treated with Da Xianxiong Tang (Major Sinking Chest Decoction).
The previous clause states that heat entering is the cause of Jie Xiong; this clause states that water binding is the root of Jie Xiong. Together they elucidate the etiology. Without mistaken purgation, heat does not enter; without heat entering, water does not bind. If there were no water qi in the chest and hypochondrium, heat would enter the stomach rather than bind in the chest and hypochondrium. Due to mistaken purgation allowing heat to enter, the Taiyang cold-water pathogen also sinks internally into the chest and hypochondrium along with the heat. Water and heat pathogens bind and do not disperse, hence named Jie Xiong. Incompetent physicians fail to understand this and erroneously list "water-binding Jie Xiong" as a separate condition, causing confusion. They fail to consider why Zhang Zhongjing uses Tusizi (Kansui Root) and Tinglizi (Descurainia Seed) in Da Xianxiong Tang/Wan. "No significant heat" refers to the exterior. Before purgation, there was significant heat; after purgation, it is absent, indicating heat entered due to deficiency. Head sweating occurs because heat steams upward. Lack of sweating elsewhere is due to internal water binding. Internal water binding prevents heat dispersion; internal heat binding prevents water movement. Thus, Tusizi is used to directly attack water, while Xiaoshi (Mirabilite) and Dahuang are used to vigorously purge heat. This treats the Fu organs and differs significantly from Wuling San (Five Ingredient Powder with Poria) or Shizao Tang (Ten Date Decoction). Taiyang disease mistreated with purgation results either in Jie Xiong or Jaundice, both caused by prior failure to induce sweating, leading to damp-heat transformation. Body lacking significant heat with only head sweating resembles Jaundice. However, due to difficult urination, we know water qi remains in the skin/exterior and should be dispersed via sweating. Here, because urination is free, we know water qi binds in the chest/hypochondrium (interior), so purgation is appropriate.
After six or seven days of Shanghan (Cold Damage), if Jie Xiong Heat-Shi (Excess) syndrome appears, with a deep-tight pulse, epigastric pain, and hardness like stone upon palpation, treat with Da Xianxiong Tang.
The previous clause discussed etiology and external symptoms; this clause discusses pulse and internal symptoms. Focus on the term "Heat-Shi." During the sixth/seventh day, distinguish between Heat-Shi Jie Xiong and Cold-Shi Jie Xiong. Mistaken purgation of Taiyang disease leads to Heat-Shi Jie Xiong: no significant external heat, but significant internal heat. Mistaken purgation of Taiyin disease leads to Cold-Shi Jie Xiong: chest binding and hardness, with no external or internal heat signs. Deep pulse indicates interior location; tight pulse indicates cold. This is the pulse for water binding in the chest/hypochondrium. Epigastric fullness/pain and stone-like hardness are the symptoms for water binding. Although these resemble Cold-Shi Jie Xiong, one must verify it resulted from Yang-onset disease and mistaken purgation causing heat entry before using Da Xianxiong Tang. This is treating the root cause.
In Taiyang disease, after excessive sweating followed by vigorous purgation, if there is constipation for five to six days, dry tongue with thirst, evening tidal fever, and hardness/fullness/pain from epigastrium to lower abdomen that is intolerable to touch, treat with Da Xianxiong Tang.
This is reckless sweating and purgation; the disease is transitioning to Yangming but has not fully left Taiyang. Constipation, dry tongue/thirst, and evening tidal fever indicate Yangming disease. However, the epigastrium is the domain of Taiyang, and the lower abdomen is the chamber of the Bladder. Hardness/fullness/pain from epigastrium to lower abdomen results from post-purgation heat entry and water binding, not Weijia Shi (Stomach House Excess), so it is not Yangming disease. Using Chengqi Tang (Gut-Purging Decoction) again would fail to resolve water binding, leading to countless complications.
Da Xianxiong Tang Formula:
Dahuang (Rhubarb Root) 6 liang, Xiaoshi (Mirabilite) 1 sheng, Tusizi (Kansui Root) 1 qianbi.
Boil the three ingredients in 6 sheng of water. First boil Dahuang to obtain 2 sheng, remove dregs, add Xiaoshi, boil for 1-2 boils, then add Tusizi powder. Take 1 sheng warm. Stop subsequent doses once rapid purgation occurs.
If Jie Xiong presents with neck stiffness resembling Rouruan (Soft Spasm), purgation will harmonize the condition; use Da Xianxiong Wan (Major Sinking Chest Pill).
Headache is absent, yet neck is stiff; aversion to cold is absent, yet head sweats, resembling Rouruan. This indicates residual exterior pathogen and urgent interior syndrome. Pills act slowly, turning an attacking formula into a harmonizing agent.
This is merely a possible presentation within Jie Xiong. If Jie Xiong always presented thus, there would be no distinction between Tang and Wan formulas.
Da Xianxiong Wan Formula:
Dahuang (Rhubarb Root) 8 liang, Xiaoshi (Mirabilite), Xingren (Apricot Kernel), Tinglizi (Descurainia Seed) each 0.5 sheng.
Pulverize Dahuang and Tinglizi. Mix with Xingren and Xiaoshi, grind into a paste. Form pills the size of a bullet. Separately prepare Tusizi powder 1 qianbi. Add Baimi (White Honey) 2 he and water 2 sheng. Boil to obtain 1 sheng. Take warm in one dose. Bowel movement may take overnight. If no movement, administer again. Movement indicates efficacy.
Xiaoshi and Dahuang enter the Blood level; Tinglizi and Xingren enter the Qi level. Exterior diseases use Qi-level herbs; interior diseases use Blood-level herbs. This disease is between exterior and interior, so herbs address both Qi and Blood. The dosage is reduced, and White Honey's sweetness moderates the action, delaying purgation until overnight. This allows time for exterior symptoms to clear first and protects the stomach/intestines.
Minor Jie Xiong disease is located precisely at the epigastrium; pain occurs only upon pressure, with a floating-slippery pulse. Treat with Xiao Xianxiong Tang (Minor Sinking Chest Decoction).
Jie Xiong varies in severity, hence Major and Minor formulas. From epigastrium to lower abdomen, stone-hard and intolerable to touch is Major Jie Xiong; located precisely at epigastrium, not extending to hypochondrium/abdomen, painful only on pressure, not stone-hard, is Minor Jie Xiong. Major Jie Xiong is water binding in chest/abdomen, hence deep-tight pulse. Minor Jie Xiong is phlegm binding at epigastrium, hence floating-slippery pulse. Water binding requires purgation (Tusizi, Tinglizi, Xingren, Xiaoshi, Dahuang); Phlegm binding requires resolution (Huanglian, Gualou, Banxia). Water can condense into phlegm, indicating strong Yang qi in the patient.
Xiao Xianxiong Tang Formula:
Huanglian (Coptis Rhizome) 1 liang, Banxia (Pinellia Tuber) 0.5 sheng, Dagualoushi (Trichosanthes Fruit) 1 piece.
Boil the three ingredients in 6 sheng of water. First boil Gualou to obtain 3 sheng, remove dregs, add other herbs, boil to obtain 2 sheng, remove dregs. Divide into three warm doses.
For Jie Xiong syndrome, if the pulse is floating and large, purgation is contraindicated; purgation leads to death.
Yangming pulse is floating-large; epigastric hardness with heat belonging to Zang (organs) can be purged. For Taiyang Jie Xiong Heat-Shi, if the pulse is floating-large, purgation is contraindicated. Why? Yangming dryness transformation causes epigastric hardness; floating-large represents Heart pulse. Fire follows dryness, so rapid purgation preserves fluids (removing firewood from under the pot). Although Jie Xiong results from heat entry, a floating-large pulse still indicates exterior. Fear that heat is not yet solidified and water not yet bound; purgation would cause intractable diarrhea. Wait for deep-tight pulse before purging. This prioritizes pulse over symptoms.
If Jie Xiong syndrome is complete but accompanied by Fanzao (restlessness/irritability), it is a death sign.
Jie Xiong is excess pathogen; Fanzao is deficiency of righteous Qi. Hence, death.
Q: "There are cases of Jie Xiong and Zang Jie (Organ Binding). What are their manifestations?"
A: "Pain on pressure, Cun (inch) pulse floating, Guan (middle) pulse sinking is named Jie Xiong. Resembling Jie Xiong, but eating normally, frequent diarrhea, Cun pulse floating, Guan pulse small-fine-deep-tight, named Zang Jie. With white slippery coating on tongue, difficult to treat."
Deep-tight pulse in Jie Xiong allows purgation; floating-large prohibits it. This is a general rule. Detailed analysis: Cun is Yang, floating is Yang. Yang pathogen binding in chest without dispersing shows floating Cun. Guan governs Middle Jiao; mistaken purgation damages Middle Qi (sinking pulse); cold-water retention in chest/hypochondrium causes tight pulse. Chi (cubit) is omitted as Guan is primary.
Resembling Jie Xiong but not Jie Xiong: Cannot eat, no diarrhea, dry tongue/thirst, pain on pressure. Pulse deep-tight but solid-large. This binds in Zang, not Fu. Symptoms differ. Hardness without flow is "binding." This case eats and has diarrhea, yet called "binding," meaning binding in formless Qi level, obstruction of Five Zang. Differs from Yin Jie (constipation/inability to eat), which is Stomach disease, not Zang involvement. Heart dominates Five Zang; tongue is Heart's external indicator. White slippery coating indicates Water overcoming Fire; Heart Fire nearly extinguished. Hence difficult to treat.
Zang Jie has no Yang symptoms, no alternating chills/fever, patient is quiet, tongue coating slippery. Purging is contraindicated.
Jie Xiong is Yang pathogen sinking, showing external Yang signs; deep-tight pulse allows purging. Zang Jie is gradual Yin condensation; Five Zang Yang is exhausted. No external烦躁/tidal fever, no yellow/black prickly coating. Despite hardness/fullness, never purge. Warm with Lizhong Tang (Middle-Regulating Decoction) or Sini Tang (Frigid Extremities Decoction) offers hope.
Patient has chronic Pi (mass) under hypochondrium extending to umbilicus, pain radiating to lower abdomen and Yin sinews (genitals). Named Zang Jie, death sign.
Zang Jie may resemble Jie Xiong or Pi. Chronic Pi under hypochondrium differs from post-purgation epigastric Pi. Umbilicus is origin of life. Umbilical side is Tianshu position, Qi intersection, convergence of Yangming meridian, emergence of Shaoyang meridian. Yin qi of Liver, Spleen, Kidney binds here, causing pain radiating to lower abdomen/genitals. Yin persists, Yang is absent. Yang exhaustion precedes Yin exhaustion. Death. Lower abdomen is Jueyin region, end of two Yins. Yin sinews are Zongjin (confluence of sinews). Modern hernia pain matches this. Relief upon pain cessation aligns with Jingui Yaolue: "Entering Zang is death, entering Fu is recovery." Treatment with Huixiang (Fennel) and Wuyu (Evodia Fruit) cures, clarifying Zang Jie management. Lu's attribution of all anomalies to Zang Jie is excessive curiosity.