哲言
胸痹与胸痞不同。胸痞有暴寒郁结于胸者；有火郁于中者；
有寒热互郁者；有气实填胸而痞者；有气衰而成虚痞者；有肺胃津液枯涩，因燥而痞者；有上焦湿浊弥漫而痞
者。若夫胸痹，但因胸中阳虚不运，久而成痹。《内经》未曾详言，惟《金匮》立方俱用辛滑温通，所云∶寸
口脉沉而迟，阳微阴弦，是知但有寒证而无热证矣。治法亦惟温通上焦清阳为主。莫与胸痞、结胸、噎隔、痰
食等证混治，斯得之矣。（《临证指南》）
凡遇胸痹、心痛、短气等证，以为虚而有邪在，非虚也；以为实而有邪乘，非实也。标本缓急之间，神明
者顾可缺一不讲也耶？（魏荔彤）
胸痹之病，喘息咳唾，胸背痛，短气，寸口脉沉而迟，关上小紧数，栝蒌薤白白酒汤主之。○胸痹不得卧，
心痛彻背者，栝蒌薤白半夏汤主之。○胸痹，心中痞气，气结在胸，胸满，胁下逆抢心，枳实薤白桂枝汤主之；
人参汤亦主之。○胸痹，胸中气塞短气，茯苓杏仁甘草汤主之；橘枳姜汤亦主之。○胸痹缓急者，薏苡仁附子
散主之。（《金匮》）
胸所蕴者，氤氲之气，此处宜空而不宜实。空者，阳气宣也；实者，阴气着也。氤氲之气，一经沸郁，而
营弗能从，则若痰、若瘀、若气、若饮，皆刺而痛之之具也。治法有升、有降、有导、有泄之不同，总不若此
之开郁顺气，能宣发诸阳而使之开也。（程郊倩）
胸中阳气，如离照当空，旷然无外，设地气一上，则窒塞有加。故知胸痹者，阴气上逆之候也。仲景微则
用薤白、白酒以通其阳；甚则用附子、干姜以消其阴。世医不知胸痹为何病，习用豆蔻、木香、诃子、三棱、
神曲、麦芽等药，坐耗其胸中之阳，亦相悬矣。（喻嘉言）
胸痹三方，皆用栝蒌、薤白，按其治法，却微分三焦。《经》言∶淫气喘息，痹聚在肺。盖谓妄行之气，
随各脏之内因所主而入为痹。然而病变不同，治亦稍异。止就胸痹喘息、咳唾、胸背痛、
短气者，君以薤白滑利通阳，臣以栝蒌润下通阴，佐以白酒熟谷之气上行药性，助其通经活络，而痹自开。若
转结中焦，而为心痛彻背者，但加半夏一味，和胃而通阴阳。若结于胸胁，更加逆气上抢于心，非但气结阳微，
而阴气并上逆矣。薤白汤无足称也，须以枳实、浓朴先破其阴气，去白酒之醇，加桂枝之辛，助薤白、枯蒌通
阳行痹。
脉候
师曰∶夫脉当取太过不及，阳微阴弦，即胸痹而痛，所以然者，责其极虚也。今阳虚知在上焦，所以胸痹
心痛者，以其阴弦故也。（《金匮》）
选案
文学钱尊玉，胸中不舒者年余，不能自言其状，颇以为虑。投以薤白栝蒌汤，次日云∶一年之病，一剂
而顿除，抑何神焉？不过以仲景之心法为法耳，何神之有？（喻嘉言）
Zhe Yan (Philosophical Remarks)
Xiong Bi (Chest Bi Syndrome) is different from Xiong Pi (Chest Fullness). Xiong Pi may arise from sudden cold stagnating in the chest; from fire stagnating in the middle jiao (Middle Burner); from mutual stagnation of cold and heat; from excess qi filling the chest causing fullness; from deficiency of qi leading to deficient fullness; from dryness due to withered and astringent fluids of the Lung and Stomach; or from pervasive damp-turbidity in the upper jiao (Upper Burner). As for Xiong Bi, it occurs solely because of Yang deficiency in the chest failing to circulate, which over time leads to Bi obstruction. The *Neijing* (Classic of Internal Medicine) does not discuss this in detail. Only the prescriptions in the *Jinkui Yaolue* (Essential Prescriptions of the Golden Cabinet) all use acrid, slippery, warm, and unblocking herbs. It states: "The pulse at the Cun Kou (radial artery position) is deep and slow; Yang is faint, Yin is taut." From this, we know that there are only Cold patterns and no Heat patterns. The treatment method primarily focuses on warming and unblocking the clear Yang of the upper jiao. One must not confuse the treatment of Xiong Bi with Jie Xiong (Chest Binding), Ye Ge (Dysphagia), or Tan Shi (Phlegm and Food Retention) patterns. This approach ensures correct diagnosis and treatment. (From *Linzheng Zhinan*)
Whenever encountering symptoms such as Xiong Bi, Xin Tong (Heart Pain), or Duan Qi (Shortness of Breath), one might think it is deficiency with pathogenic factors present, but it is not merely deficiency; one might think it is excess with pathogenic factors invading, but it is not merely excess. In the balance between root and branch, and urgency and slackness, how can a wise physician neglect to study this? (Wei Litong)
The disease of Xiong Bi presents with panting, coughing, and expectoration, chest and back pain, shortness of breath, a deep and slow pulse at the Cun Kou, and a small, tight, and rapid pulse at the Guan position. It is primarily treated with Gualou Xiebai Baijiu Tang (Trichosanthes Fruit, Macrostemon Rhizome, and White Wine Decoction). ○ If Xiong Bi prevents lying down, and heart pain radiates to the back, it is treated with Gualou Xiebai Banxia Tang (Trichosanthes Fruit, Macrostemon Rhizome, and Pinellia Decoction). ○ If Xiong Bi involves a sensation of Qi blockage in the chest, Qi knotting in the chest, chest distension, and rebellious Qi rushing from the hypochondrium towards the heart, it is treated with Zhishi Xiebai Guizhi Tang (Immature Bitter Orange, Macrostemon Rhizome, and Cinnamon Twig Decoction); Renshen Tang (Ginseng Decoction) may also be used. ○ If Xiong Bi involves Qi blockage in the chest and shortness of breath, it is treated with Fuling Xingren Gancao Tang (Poria, Apricot Seed, and Licorice Decoction); Juzhi Jiang Tang (Tangerine Peel, Immature Bitter Orange, and Ginger Decoction) may also be used. ○ If Xiong Bi alternates between remission and acute exacerbation, it is treated with Yiyi Ren Fuzi San (Coix Seed and Aconite Powder). (From *Jinkui Yaolue*)
What accumulates in the chest is the ethereal Qi (Yinyun Zhiqi). This area should be empty rather than full. Emptiness allows for the dissemination of Yang Qi; fullness indicates the adherence of Yin Qi. Once the ethereal Qi boils and stagnates, Ying Qi (Nutritive Qi) cannot follow. Consequently, substances such as Phlegm, Blood Stasis, Qi Stagnation, and Fluid Retention become instruments of stabbing and painful obstruction. Treatment methods vary among ascending, descending, guiding, and draining. However, none are superior to opening stagnation and smoothing Qi, which can disseminate various Yangs and promote openness. (Cheng Jiaoqian)
Yang Qi in the chest is like the sun shining in the sky, vast and boundless. If Earth Qi (Yin-Cold) rises even slightly, obstruction increases. Thus, we understand that Xiong Bi is a manifestation of rebellious Yin Qi ascending. Zhang Zhongjing uses mild treatments such as Xiebai (Macrostemon Rhizome) and Baijiu (White Wine) to unblock Yang in mild cases; in severe cases, he uses Fuzi (Aconite Root) and Ganjiang (Dried Ginger) to dissipate Yin-Cold. Physicians of later generations do not understand what Xiong Bi is. They habitually use herbs such as Doukou (Black Cardamom), Muxiang (Costus Root), Hezi (Chebula Fruit), Sanleng (Sparganium Rhizome), Shenqu (Medicated Leaven), and Maiya (Malt), thereby wasting the Yang Qi in the chest. This error is significant. (Yu Jiayan)
The three formulas for treating Xiong Bi all use Gualou (Trichosanthes Fruit) and Xiebai (Macrostemon Rhizome). Their treatment methods subtly differentiate among the Upper, Middle, and Lower Jiao. The Classics state: "Rebellious Qi causes panting; Bi gathers in the Lung." This means that reckless Qi enters the body as Bi according to the internal predispositions of each Zang organ. However, since pathological changes differ, treatments also vary slightly. For Xiong Bi presenting with panting, coughing, expectoration, chest and back pain, and shortness of breath, Xiebai is used as the Sovereign herb for its slippery nature to unblock Yang; Gualou is used as the Minister herb for its moistening and downward-draining nature to unblock Yin; Baijiu is used as an Assistant herb, utilizing the ascending nature of cooked grain Qi to aid in unblocking meridians and collaterals, allowing the Bi obstruction to resolve naturally. If the pathogen shifts to knot in the Middle Jiao, causing heart pain radiating to the back, only Banxia (Pinellia Tuber) is added to harmonize the Stomach and unblock Yin-Yang. If it knots in the chest and hypochondrium, accompanied by rebellious Qi rushing to the heart, not only is Qi knotted and Yang faint, but Yin Qi also rebels upward. At this point, Xiebai Tang is insufficient. One must use Zhishi (Immature Bitter Orange) and Houpo (Magnolia Bark) to first break the Yin Qi, remove the rich nature of Baijiu, add the acridity of Guizhi (Cinnamon Twig), and assist Xiebai and Gualou in unblocking Yang and moving Bi.
Mai Hou (Pulse Diagnosis)
The Master said: "Pulses should be assessed for excess or deficiency. 'Yang faint, Yin taut' indicates Xiong Bi with pain. The reason for this is extreme deficiency. Now, knowing Yang deficiency is in the Upper Jiao, the cause of Xiong Bi and Heart Pain is the Yin tautness." (From *Jinkui Yaolue*)
Selected Cases
Literatus Qian Zunyu suffered from chest discomfort for over a year. He could not describe his condition in words and was quite worried. He was administered Xiebai Gualou Tang (Macrostemon Rhizome and Trichosanthes Fruit Decoction). The next day, he said: "A year's illness was cured instantly with one dose. How miraculous! But it is merely applying the principles of Zhang Zhongjing. What is so miraculous about it?" (Yu Jiayan)