【纲】仲景曰。病发于阳而反下之。热入。因作结胸。若不结胸。但头汗出。余无汗。至颈而
还。小便不利。身必发黄也。
【目】陈士铎曰。伤寒变为结胸者。以伤寒火邪正炽。急与饮食。胃中得食。茹而不出。他脏
因胃中有食。群起而争。其势猖狂。必当以变法治之。急用栝蒌一枚。槌碎。入甘草一钱。同煎服。
夫栝萎乃陷胸之胜物。平人服之。必至心如遗落。然惟食结在胸。非硝、黄、枳、朴、槟榔等可
祛。必得栝蒌始能陷之。尤恐其过于下也。可加甘草留之。使不至十分推荡。此变症而用变法。真
胜于用正也。
张云岐曰。不发汗而反下之。热反内陷。寒气随热而入。入于胸必结。瘀热在里故也。
【纲】仲景曰。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。
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。结胸者。项亦强。如
柔痉状。下之则和。宜大陷胸丸。
【目】成无己曰。结胸虽为实邪。人皆知用陷胸汤丸下之。或脉浮大者。不可下。下则死。是
犹带表邪未全结实。下之重虚其里。邪深结则死。设或结胸形症悉具。而加烦躁者。尤为不治之疾。
【纲】仲景曰。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。所以成结胸
者。以下之太早故也。
【目】赵嗣真曰。不经下后而心下满者。则有吐下之殊。如病患手足厥冷。脉乍紧。邪结在胸
中。心中满而烦。饥不能食者。病在胸中。当须吐之。又脉浮而大。心下反硬。有热属脏者。攻之。
不令发汗。属腑者。不令溲数。此二条是也。或吐或攻。要在泄其邪气。若下后心下满者。又有
结胸痞之别。如阳明病。虽心下硬。又未可攻。经曰。阳明病心下硬满者。不可攻之。攻之利遂不
止者死。利止者愈。是邪气自表传里。至于心下。留结为实者。不可下。乃吐之可也。若未全为实
者。则不可下。故有此戒。又邪气在表。未应下而强下之。邪气乘虚结于心下。实者硬满而痛。
为结胸。虚者满而不痛。为痞。盖实邪留结。则为硬为痛。虚邪留滞。则但满而不硬痛也。
柯琴曰。阳指形躯。阴指胸中心下。非指阴经阴症。发阳发阴。俱指发热。结胸与痞。俱是热
症。作痞不言热入。热原发于里也。误下热不散。因而痞硬。不可以发阴作无热解也。若谓非热症。
泻心汤不得用黄芩、大黄矣。
【纲】仲景曰。小结胸病。正在心下。按之则痛。脉浮滑者。小陷胸汤主之。
【目】张兼善曰。从心下至少腹。石硬而痛不可近者。大结胸也。正在心下。未及腹胁。按之痛。未至石硬。小结
胸也。形症之分如此。盖大结胸者。是水结在胸腹。故其脉沉紧。小结胸者。是痰结于心下。故其脉浮滑。水结宜下。
故用甘遂、葶、杏、硝、黄等。痰结宜消。故用栝蒌、半夏等。
【纲】仲景曰。结胸症。其脉浮大者。不可下。下之则死。结胸症具。烦躁者亦死。
【目】陈士铎曰。言不可下。见下之必死也。夫结胸而加烦躁。此胃气将绝也。胃气欲绝。即
不能生津液而养心。故为死症。虽然。津液之竭。非五脏自绝。亦因结胸之故耳。是必攻其中坚。
使结胸症愈。而津液自生。死症可望更苏也。药用化结汤。
柯琴曰。阳明脉浮大。心下反硬。有热属脏者。可攻之。太阳结胸热实。脉浮大者。不可下。
盖太阳浮大。仍为表脉。恐热未实。则水未结。故不可下也。结胸是实邪。烦躁是正气虚。故亦死。
【纲】仲景曰。伤寒五六日。呕而发热者。柴胡汤症具。而以他药下之。若心下满而硬痛者。
此为结胸也。大陷胸汤主之。但满而不痛者。此为痞也。柴胡不中与之。宜半夏泻心汤。
【目】程郊倩曰。误下后有二症者。少阳为半表半里之经。不全发阳。不全发阴。故误下之变。
亦因偏于半表者。成结胸。偏于半里者。心下痞耳。此条本为半夏泻心汤而发。故只以痛不痛分
结胸痞。不及他症。
陶华曰。结胸乃下早而成。未曾下者。非结胸也。乃表邪传至于胸中。未入于腑。症虽满闷。
尚为在表。正属少阳部分。为半表半里之间。只消小柴胡加枳壳以治。不效。则以本方对小陷胸汤。
一服如神。若因下早而成者。方用陷胸汤丸。分浅深从纵治之。不宜太峻。上焦乃清道至高之分。
过下则伤元气。慎之。热实结胸。懊 烦渴心下痛。少与大陷胸汤。寒实结胸无热症。三物白
散、枳实理中丸。
[General Principle] Zhang Zhongjing stated: When a disease originates from a Yang syndrome and purgation is inappropriately applied, heat pathogens penetrate inward, resulting in Jie Xiong (Chest Binding). If Jie Xiong does not form, but only sweating on the head occurs with no sweat elsewhere on the body, stopping at the neck, accompanied by dysuria, jaundice will inevitably develop.
[Commentary] Chen Shiduo stated: When Shang Han (Cold Damage) transforms into Jie Xiong (Chest Binding), it is because the fire pathogen of Shang Han is intense. If food is consumed hastily, food remains in the stomach without being expelled. Other organs contend due to the food accumulation in the stomach, leading to rampant pathology. It must be treated with modified methods. Urgently use one Gualou Fructus (Trichosanthis Fructus), crushed, mixed with one qian of Gancao Radix et Rhizoma (Licorice Root), decocted together for oral administration. Gualou is an excellent herb for resolving chest binding. Even healthy people taking it may feel a sensation of emptiness in the heart. However, only when food retention binds in the chest can Mangxiao Natrii Sulfas (Glauber's Salt), Dahuang Radix et Rhizoma (Rhubarb Root), Zhishi Immature Bitter Orange Fruit, Houpo Magnolia Bark, and Binglang Areca Seed effectively dispel it; Gualou is required to sink it. One must fear its overly strong purgative effect; therefore, Gancao can be added to moderate it, preventing excessive pushing and draining. This is using modified methods for modified syndromes, which truly surpasses using standard methods.
Zhang Yunqi stated: Failure to induce sweating followed by inappropriate purgation causes heat pathogens to sink inward. Cold pathogens follow the heat inward; upon entering the chest, they bind. This is due to blood stasis and heat accumulating internally.
[General Principle] Zhang Zhongjing stated: In Jie Xiong (Chest Binding) without significant fever, but with slight sweating on the head, this indicates water retention binding in the chest and hypochondrium, primarily treated with Da Xianxiong Tang (Major Decoction to Drain the Chest).
In Shang Han (Cold Damage) lasting six or seven days, presenting as Jie Xiong heat excess syndrome with a deep and tight pulse, pain in the epigastrium, and hardness upon palpation like stone, Da Xianxiong Tang (Major Decoction to Drain the Chest) is indicated. For patients with Jie Xiong (Chest Binding) who also exhibit stiffness in the neck resembling Rou Jing (Soft Spasm), purgation harmonizes the condition; Da Xianxiong Wan (Major Pill to Drain the Chest) is appropriate.
[Commentary] Cheng Wuji stated: Although Jie Xiong (Chest Binding) involves excess pathogens, everyone knows to use Xianxiong Tang/Wan to purge it. However, if the pulse is floating and large, purgation is contraindicated; applying it leads to death. This is because exterior pathogens have not fully consolidated; purgation severely depletes the interior, and deep pathogen binding results in death. If all signs and symptoms of Jie Xiong are present, compounded by irritability (Fan Zao), it becomes an untreatable condition.
[General Principle] Zhang Zhongjing stated: When a disease originates from Yang and is inappropriately purged, heat penetrates inward, forming Jie Xiong (Chest Binding); when a disease originates from Yin and is inappropriately purged, Pi Syndrome (Epigastric Fullness/Blockage) forms. The reason Jie Xiong forms is that purgation was applied too early.
[Commentary] Zhao Sizhen stated: Epigastric fullness occurring without prior purgation distinguishes between emesis and purgation indications. For instance, if a patient has cold extremities, a suddenly tight pulse, pathogen binding in the chest, epigastric fullness with irritability, hunger but inability to eat, the pathology is in the chest and requires emesis. Conversely, if the pulse is floating and large, the epigastrium is unexpectedly hard, and heat belongs to the Zang organs, purgation is indicated without inducing sweating; if heat belongs to the Fu organs, frequent urination should be avoided. These two cases illustrate the principle. Whether using emesis or purgation, the goal is to drain the pathogen. If epigastric fullness occurs after purgation, it differentiates between Jie Xiong and Pi. For example, in Yang Ming disease, even if the epigastrium is hard, purgation is not yet indicated. The Classics state: In Yang Ming disease with epigastric hardness and fullness, do not purge. If purgation leads to unceasing diarrhea, death ensues; if diarrhea stops, recovery occurs. This describes pathogens transmitting from exterior to interior, lodging in the epigastrium and becoming excess; such cases cannot be purged, though emesis might be considered. If the condition is not fully excess, purgation is contraindicated, hence this warning. Furthermore, if pathogens are in the exterior and purgation is forced unnecessarily, pathogens enter the deficiency and bind in the epigastrium. Excess manifests as hardness, fullness, and pain, termed Jie Xiong; deficiency manifests as fullness without pain, termed Pi. Generally, excess pathogen retention causes hardness and pain, while deficient pathogen stagnation causes only fullness without hardness or pain.
Ke Qin stated: "Yang" refers to the physical body, and "Yin" refers to the chest and epigastrium, not Yin meridians or Yin syndromes. "Originating from Yang/Yin" both refer to fever. Both Jie Xiong and Pi are heat syndromes. Pi formation is described without mentioning heat penetration because the heat originates internally. Inappropriate purgation fails to dissipate heat, leading to Pi hardness; thus, "originating from Yin" cannot be interpreted as absence of heat. If it were not a heat syndrome, Xiexin Tang (Decoction to Drain the Epigastrium) would not contain Huangqin Radix (Scutellaria Root) and Dahuang.
[General Principle] Zhang Zhongjing stated: In Xiao Jie Xiong (Minor Chest Binding), the location is precisely in the epigastrium, pain occurs only upon pressure, and the pulse is floating and slippery; this is primarily treated with Xiao Xianxiong Tang (Minor Decoction to Drain the Chest).
[Commentary] Zhang Jianshan stated: Hardness like stone extending from the epigastrium to the lower abdomen, with pain so severe it cannot be touched, is Da Jie Xiong (Major Chest Binding). Location strictly in the epigastrium, not involving the abdomen or hypochondrium, with pain upon pressure but not reaching stone-like hardness, is Xiao Jie Xiong (Minor Chest Binding). The distinction in signs and symptoms is as follows. Da Jie Xiong involves water binding in the chest and abdomen, hence the deep and tight pulse; Xiao Jie Xiong involves phlegm binding in the epigastrium, hence the floating and slippery pulse. Water binding requires purgation, utilizing Gansui Radix (Kansui Root), Tinglizi Semen (Descurainia Seed), Xingren Semen (Apricot Seed), Mangxiao, and Dahuang; phlegm binding requires resolution/dissipation, utilizing Gualou and Banxia Rhizoma (Pinellia Tuber).
[General Principle] Zhang Zhongjing stated: In Jie Xiong syndromes, if the pulse is floating and large, purgation is contraindicated; applying it leads to death. If Jie Xiong symptoms are complete and accompanied by irritability, death also ensues.
[Commentary] Chen Shiduo stated: Stating "do not purge" implies that purging guarantees death. Jie Xiong combined with irritability indicates impending exhaustion of Wei Qi (Stomach Qi). When Wei Qi is about to fail, it cannot generate fluids to nourish the Heart, resulting in a fatal prognosis. Nevertheless, fluid depletion is not due to the independent failure of the Five Zang organs, but rather a consequence of Jie Xiong. One must attack the central hardness; once the Jie Xiong resolves, fluids will naturally regenerate, offering hope for revival in these fatal cases. Use Huajie Tang (Decoction to Resolve Binding).
Ke Qin stated: In Yang Ming, a floating and large pulse with unexpected epigastric hardness and internal heat belonging to Zang organs allows for purgation. However, in Taiyang Jie Xiong heat excess, a floating and large pulse contraindicates purgation. A Taiyang floating and large pulse still indicates an exterior pattern; fearing the heat is not yet consolidated and water has not bound, purgation is forbidden. Jie Xiong represents excess pathogens, while irritability represents deficiency of righteous Qi; hence, it is fatal.
[General Principle] Zhang Zhongjing stated: In Shang Han (Cold Damage) lasting five or six days, vomiting and fever indicate Chaihu Tang (Bupleurum Decoction) syndrome. If other drugs are used to purge inappropriately, and the epigastrium becomes full, hard, and painful, this is Jie Xiong, primarily treated with Da Xianxiong Tang (Major Decoction to Drain the Chest). If there is fullness without pain, this is Pi Syndrome; Chaihu Tang is not indicated. Instead, Banxia Xiexin Tang (Pinellia Decoction to Drain the Epigastrium) is appropriate.
[Commentary] Cheng Jiaoqian stated: After inappropriate purgation, two syndromes may appear. Shaoyang is the half-exterior, half-interior meridian; it does not fully manifest Yang nor fully manifest Yin. Therefore, changes following inappropriate purgation depend on whether the pathogen leans toward the half-exterior, forming Jie Xiong, or the half-interior, forming epigastric Pi. This clause originally pertains to Banxia Xiexin Tang; thus, it distinguishes Jie Xiong from Pi solely based on the presence or absence of pain, omitting other symptoms.
Tao Hua stated: Jie Xiong results from premature purgation. Cases not subjected to purgation are not Jie Xiong. They represent exterior pathogens transmitting to the chest without entering the Fu organs. Although symptoms include fullness and oppression, the pathology remains in the exterior, specifically belonging to the Shaoyang portion, situated between the half-exterior and half-interior. Treatment requires Xiaochaihu Tang (Minor Bupleurum Decoction) plus Zhike (Aurantii Fructus Immaturus). If ineffective, combine the base formula with Xiao Xianxiong Tang; one dose yields miraculous results. Only if Jie Xiong is caused by premature purgation should Xianxiong Tang/Wan be used, treating according to depth and vertical progression, avoiding overly harsh methods. The Upper Jiao is the highest clear pathway; excessive purgation damages Yuan Qi (Primal Qi); caution is essential. For Heat-Excess Jie Xiong with restlessness, thirst, and epigastric pain, administer a small dose of Da Xianxiong Tang. For Cold-Excess Jie Xiong without heat symptoms, use Sanwu Baisan (Three-Ingredient White Powder) or Zhishi Lizhong Wan (Immature Bitter Orange and Middle-Warming Pill).