瓜蒂（熬黄）一分 赤小豆一分
右二味，各别捣筛，为散已，合治之，取一钱匕，以香豉一合，用热汤七合，煮作稀
糜，去滓，取汁和散，温顿服之。不吐者，少少加服，得快吐乃止。诸亡血虚家，不
可与瓜蒂散。
【方解】
胸中者，清阳之府。诸邪入胸府，阻遏阳气，不得宣达，以致胸满痞□，热气上冲，
燥渴心烦，嗢嗢欲吐。脉数促者，此热郁结也；胸满痞□，气上冲咽喉不得息，手足
寒冷，欲吐不能吐，脉迟紧者，此寒郁结也。凡胸中寒热与气与饮郁结为病，谅非汗
下之法所能治，必得酸苦涌泄之品，因而越之，上焦得通，阳气得复，痞□可消，胸
中可和也。瓜蒂极苦，赤豆味酸，相须相益，能疏胸中实邪，为吐剂中第一品也。而
佐香豉汁合服者，借谷气以保胃气也。服之不吐，少少加服，得快吐即止者，恐伤胸
中元气也。此方奏功之捷，胜于汗下，所谓汗、吐、下三大法也。今人不知仲景、子
和之精义，置之不用，可胜惜哉！然诸亡血虚家，胸中气液已亏，不可轻与，特为申
禁。
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。
【注】
此总释结胸与痞□之因也。中风阳邪，故曰病发于阳也。不汗而反下之，热邪乘虚陷
入，因作结胸。伤寒阴邪，故曰病发于阴也。不汗而反下之，热邪乘虚陷入，因作痞
□。所以成结胸与痞□者，以表未解而下之太早故也。病发于阴，不言热入者，省文
耳。然病发于阳而误下者，未尝无痞□；病发于阴、而误下之，亦时成结胸。良由人
之气体不同，或从实化，或从虚化也。
【集注】
张兼善曰：风邪入里则结胸，寒邪入里则为痞。然此皆太阳病之所由来，非别阴证阳
证也。
太阳病，脉浮而动数，浮则为风，数则为热，动则为痛，数则为虚，头痛发热，微盗
汗出，而反恶寒者、表未解也。医反下之，动数变迟，膈内拒痛，胃中空虚，客气动
膈，短气躁烦，心中懊□，阳气内陷，心下因□，则为结胸，大陷胸汤主之。若不结
胸，但头汗出，余处无汗，跻颈而还，小便不利，身必发黄。
【按】
「数则为虚句」，疑是衍文。
【注】
太阳病，脉浮而动数，浮则为风邪脉也，数则为热邪脉也，动则为诸痛脉也。头痛发
热，太阳证也。热蒸于阳，阳虚则自汗出，热蒸于阴，阴虚则盗汗出，阴虚当恶热，
今反恶寒，故知此非阴虚之盗汗，乃表未解之盗汗，微微而出也。表未解当解表，医
反下之，遂使动数之热脉变为寒迟，盖动数乃表邪欲传，因下而逆于膈中，故不传而
脉亦变也。表客阳邪，乘胃空虚，陷入胸膈而拒痛，短气不能布息，烦躁，心中懊□
，心下因□，迳从实化而为结胸矣。法当以大陷胸汤主之。若不从实化，不成结胸，
但头汗出至颈，余处无汗，则热不得越也。小便不利，则湿不得泻也，热湿合化，故
身必发黄也。
【集注】
成无己日：动数变迟，而浮脉独不变者，以邪结胸中，上焦阳分，脉不得而沉也。
朱震亨曰：太阳病、表未解而攻里，里已虚矣。虽见浮而动数之阳脉，一经误下，则
必变为迟阴之脉矣。胃中空虚，短气躁烦，虚之甚矣。借曰：阳气内陷，心中因□而
可迅攻之乎？大陷胸之力，不缓于承气，下而又下，宁不畏其重虚耶！即阳病实邪下
后，若胃中空虚，客气动膈，心中懊□者，亦以栀子豉汤吐胸中之邪可也。况太阳误
下后，明有虚证乎？【按】震亨所论治，以栀子豉汤吐之，亦是未成结胸，从胸虚有
热而化者宜也。若从胸虚有寒而化者，不论已成未成结胸，则又当从活人书温补法矣
，不可混施也。
方有执曰：太阳之脉本浮，动数者亦传也。太阳本自汗，而言微盗汗，本恶寒，而言
反恶寒者，稽久而然也。膈，心胸之间也。拒，格拒也。言膈气与邪气相格拒而为痛
也。客气，邪气也。短气，促气不能布息也。懊□，心为邪乱而不宁也。阳气，客气
之别名也，以本外邪，故曰客气。以邪本风，故曰阳气。以里虚因而陷入，故曰内陷
。自若不结胸句至末，以变之轻者而言也。
[Explanation of the Formula]
The chest is the residence where clear yang qi gathers. When various pathogenic factors invade the chest, they obstruct the yang qi, preventing it from circulating and dispersing freely. This leads to chest fullness and stuffiness, upward rushing of hot qi, dry mouth, thirst, irritability, and a sensation of nausea with an urge to vomit. If the pulse is rapid and frequent (shu cu), this indicates heat stagnation; if there is chest fullness and stuffiness, qi rushing upward to the throat causing dyspnea, cold hands and feet, an urge to vomit but inability to do so, and a slow and tight pulse, this indicates cold stagnation. For diseases caused by the stagnation of cold, heat, qi, or fluid retention in the chest, methods of sweating or purging are generally ineffective. One must employ sour and bitter agents that induce vomiting (yong xie) to expel pathogens upwards via emesis. This allows the upper jiao to become unobstructed, restores yang qi, eliminates stuffiness, and harmonizes the chest. Genti (Cucumis melo var. makuwa seed) is extremely bitter, and Chixiaodou (Vigna angularis) is sour; together they mutually enhance each other's effect to vent solid pathogens in the chest, making them the premier emetic formula. The addition of Xiangchi (Sojae Semen Praeparatum) juice aids in preserving stomach qi through the nourishing nature of grain. If vomiting does not occur after administration, the dose should be increased slightly until rapid vomiting occurs, which serves to prevent damage to the yuan qi (original qi) of the chest. This formula acts swiftly, surpassing the efficacy of sweating and purging methods, representing one of the three major therapeutic approaches: sweating, vomiting, and purging. Today, people fail to understand the profound principles of Zhang Zhongjing and Xu Hezi, leaving these formulas unused, which is truly regrettable! However, for individuals who have suffered blood loss or are constitutionally deficient, the qi and fluids in the chest are already depleted; thus, this formula must not be given lightly. This prohibition is specifically reiterated here.
When a disease originates in the Yang (e.g., Taiyang disease) and is mistakenly treated with purgatives, heat pathogens sink inward due to deficiency, resulting in Jie Xiong (chest binding). When a disease originates in the Yin and is mistakenly treated with purgatives, Pi syndrome (stuffiness) results. The reason Jie Xiong forms is due to premature purgation.
[Annotation]
This section summarizes the causes of Jie Xiong and Pi syndrome. Wind-stroke involves Yang pathogens, hence it is said "disease originates in Yang." Failing to induce sweating first and instead using purgatives allows heat pathogens to sink inward due to deficiency, forming Jie Xiong. Cold injury involves Yin pathogens, hence it is said "disease originates in Yin." Failing to induce sweating first and instead using purgatives allows heat pathogens to sink inward due to deficiency, forming Pi syndrome. The formation of both Jie Xiong and Pi syndrome is due to the exterior pattern remaining unresolved while purgatives are used prematurely. In the phrase "disease originates in Yin," the mention of heat sinking inward is omitted for brevity. However, when diseases originating in Yang are mistakenly purged, Pi syndrome can still form; similarly, when diseases originating in Yin are mistakenly purged, Jie Xiong may occasionally result. This is primarily because human constitutions vary, leading to transformations either into excess patterns or deficiency patterns.
[Collected Annotations]
Zhang Jianshan stated: Wind pathogens entering the interior form Jie Xiong, while cold pathogens entering the interior form Pi. However, these all arise from Taiyang diseases and do not exclusively refer to distinct Yin or Yang syndromes.
In Taiyang disease, the pulse is floating, active, and rapid (fu, dong, shu). Floating indicates wind, rapid indicates heat, active indicates pain, and rapid also indicates deficiency (see commentary below). Headache and fever, slight night sweats, and paradoxical aversion to cold indicate that the exterior pattern remains unresolved. If the physician mistakenly uses purgatives, the active and rapid pulse changes to a slow pulse. There is resistance and pain within the diaphragm, emptiness in the stomach, disturbance of the diaphragm by external pathogens, shortness of breath, irritability, and mental restlessness (ao nao). The yang qi sinks inward, causing hardness beneath the heart, resulting in Jie Xiong. Da Xianxiong Tang (Major Trap the Chest Decoction) is indicated. If Jie Xiong does not form, but only head sweating occurs (sweat stopping at the neck), with no sweat elsewhere, and urination is difficult, jaundice will inevitably develop.
[Commentary]
The phrase "rapid indicates deficiency" is suspected to be a later interpolation (derivative text).
[Annotation]
In Taiyang disease, a floating, active, and rapid pulse indicates wind (floating), heat (rapid), and pain (active). Headache and fever are Taiyang signs. Heat steaming the Yang aspect leads to spontaneous sweating due to Yang deficiency; heat steaming the Yin aspect leads to night sweats due to Yin deficiency. Yin deficiency typically presents with aversion to heat; however, the presence of aversion to cold indicates that this is not night sweats due to Yin deficiency, but rather slight night sweats due to the unresolved exterior pattern. Since the exterior is unresolved, it should be resolved via sweating. Mistaken purgation causes the active and rapid heat pulse to transform into a cold and slow pulse. The active and rapid pulse signifies that exterior pathogens were about to transmit; due to purgation, they reversed into the diaphragm, preventing transmission and altering the pulse. The exterior Yang pathogens, taking advantage of gastric emptiness, sink into the chest and diaphragm, causing resistance and pain, shortness of breath, irritability, mental restlessness, and epigastric hardness. This directly transforms into an excess pattern, forming Jie Xiong. The treatment should be Da Xianxiong Tang. If it does not transform into an excess pattern and does not form Jie Xiong, but only head sweating up to the neck occurs, heat cannot vent outward. Difficulty in urination means dampness cannot be drained. Heat and dampness combine to transform, inevitably causing jaundice.
[Collected Annotations]
Cheng Wuji stated: The pulse changes from active/rapid to slow, yet the floating pulse remains unchanged because the pathogen is bound in the chest, located in the upper jiao Yang aspect, preventing the pulse from sinking.
Zhu Zhenheng stated: In Taiyang disease, attacking the interior while the exterior is unresolved leaves the interior deficient. Although Yang pulses (floating, active, rapid) are present, mistaken purgation will inevitably cause them to transform into slow, Yin-type pulses. Gastric emptiness, shortness of breath, and irritability indicate severe deficiency. One might ask: If yang qi has sunk inward and there is epigastric hardness, can aggressive purgation be applied rapidly? The power of Da Xianxiong Tang is not milder than Chengqi Tang; applying purgation after purgation risks severe depletion. Even if excess pathogens from Yang diseases are purged, if the stomach becomes empty and external pathogens disturb the diaphragm causing mental restlessness, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) can be used to vomit out pathogens from the chest. How much more so when clear deficiency patterns exist after mistaken Taiyang purgation? [Commentary] Zhu Zhenheng’s suggestion to use Zhi Zi Chi Tang for emesis is appropriate for cases where Jie Xiong has not formed and the pathology stems from deficiency-heat in the chest. However, if the transformation stems from deficiency-cold in the chest, regardless of whether Jie Xiong has formed, one should follow the warming and tonifying methods of the *Luo Ren Shu* (Book of Vitality). These methods must not be confused.
Fang Youzhi stated: The Taiyang pulse is naturally floating; active and rapid pulses also indicate transmission. Taiyang disease naturally involves sweating, yet slight night sweats are mentioned; it naturally involves aversion to cold, yet paradoxical aversion to cold is noted, indicating the disease has lingered for some time. The diaphragm refers to the area between the heart and chest. "Ju" (resistance) refers to mutual rejection. It describes the conflict between diaphragmatic qi and pathogenic qi causing pain. "Ke qi" (guest qi) refers to pathogenic qi. "Duan qi" (shortness of breath) refers to急促 breathing unable to distribute properly. "Ao nao" refers to mental unrest caused by pathogenic disturbance. "Yang qi" is another name for guest qi; because it is an external pathogen, it is called guest qi. Because the pathogen is originally wind, it is called yang qi. Because it sinks inward due to interior deficiency, it is called internal sinking. From the phrase "if Jie Xiong does not form" to the end, the text discusses milder variations of the condition.