金匮云。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。以其阴弦也。
阳微在胸中气分上看。故曰阳微知在上焦。阴弦在阴脉上看。如阴寒之脉。上于胸中气分。
则为胸痹。如阴脉上乘于心。则为心痛也。
平人无寒热。短气不足以息者。实也。
上条是言不及。此则言太过也。平人。盖言无内困虚劳。外因感冒。而患短气不足以息者。
当是胸中邪气窒塞。肾中阳气不得上通于胸中。故为实也。
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。
寸口脉沉迟者。阳气衰微也。关上小紧者。胃以上有阴寒结聚。所以胸中喘息咳唾。胸背痛
而短气。栝蒌性润。专以涤垢腻之痰。薤白臭秽。用以通秽浊之气。同气相求也。白酒熟谷之液。
色白上通于胸中。使佐药力上行极而下耳。
胸痹不得卧。心痛彻背者。栝蒌薤白半夏汤主之。
心痛彻背者。胸中痰垢积满。循脉而溢于背。背者胸之府。故于前药但加半夏。以祛痰积之痹逆也。
胸痹心中痞痛。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。
痰气结聚于胸中。胸满溢于经脉。故从胁下逆上以抢心也。二汤一以治胸中实痰外溢。用薤
白桂枝以解散之。一以治胸中虚痰内结。即用人参理中以清理之。一病二治。因人素禀而施。两
不移易之法也。
胸痹胸中气塞。短气。茯苓杏仁甘草汤主之。橘皮枳实生姜汤亦主之。
夫短气不足以息者。实也。故二方皆利气之剂。一以疏利肺气。一以疏利胃气也。
胸痹缓急者。薏苡附子散主之。
胸中为阳气所居之位。今胸中之阳。痹而不舒。其经脉所过。非缓即急。失其常度。总由阳
气不运故也。用薏苡舒其经脉。附子复其胸中之阳。则大气一转。阴浊不留。胸际旷然若太空矣。
心中痞。诸逆心悬痛。桂枝生姜枳实汤主之。
心中痞者。心气逆于上也。上气逆。则中下亦逆。气逆则经脉亦逆。故为诸逆也。上下气逆。
脉不交通。心主孤悬于上。不得营气以和之。故心悬痛也。桂枝行心气以散痞。姜、枣疏中焦以
通经也。
心痛彻背。背痛彻心。乌头赤石脂丸主之。
心痛彻背。背痛彻心。乃阴邪厥逆。而上干胸背经脉之间。牵连痛楚。乱其血气。紊其疆界。
此而用气分之药。则转益其痛。势必危殆。仲景用蜀椒、乌头一派辛辣。以温散其阴邪。然恐胸
背既乱之气难安。即于温药队中。取用干姜、赤脂之涩。以填塞厥气攻冲之经隧。俾胸之气自行
于胸。背之气自行于背。各不相犯。其患乃除。今人但知有温气补气行气散气诸法。不知有填塞
邪气攻冲之窦也。
千金治胸痹达背痛。用细辛散。胸中逆气。心痛彻背。少气不食。用前胡汤。胸中 如满。
噎塞习习如痒。喉中涩燥唾沫。服橘皮枳实生姜汤。不应。用治中汤。胸痹腹背闭满。上气喘息。
用下气汤。胸背疼痛。用熨背散。足补金匮之未逮。
病患胸中似喘不喘。似呕不呕。似哕不哕。彻心中愦愦然无奈者。生姜半夏汤主之。千金加
橘皮、吴茱萸。名通气散。治胸满短气而噎。
此即胸痹一门之证。必编者之差误。入于呕吐哕中。今并论于此。盖阳受气于胸中。以布气
息。今阴乘阳位。阻其阳气布息。呼吸往来之道。若喘若呕若哕。心舍神者也。聚饮停痰。则炎
炽不宁。彻心愦乱。无可奈何。故用半夏、生姜之辛温。以燥饮散寒。则阳得以布。气得以调。
而胸际始旷也。其用橘皮、吴茱萸。及加竹茹、人参。皆此例也。喻嘉言曰。按胸痹之证。人所
通患。金匮出十方论治。然未明言其故。盖胸中如太空。其阳气所过。如离照当空。旷然无外。
设地气一上。则窒塞有加。故知胸痹者。阳气不用。阴气在上之候也。然有微甚不同。微者但通
其上焦不足之阳。甚者必驱其下焦厥逆之气。通胸中之阳。以薤白、白酒。或栝蒌、半夏、桂枝、
枳实、浓朴、干姜、白术、人参、甘草、茯苓、杏仁、橘皮。择用对证三四味。即成一方。不但
苦寒不入。即清凉尽屏。盖以阳通阳。阴分之药。所以不得预也。甚者。则用附子、乌头、蜀椒
大辛热。以驱下焦之阴。而复上焦之阳。补天浴日。在医之手眼。奈何后世总不知胸痹为何病耳。
The *Jin Gui Yao Lue* states: The Master said, "When taking the pulse, one should assess excess (Tai Guo) and deficiency (Bu Ji). Yang Wei (Yang deficiency/weakness) and Yin Xian (Yin tension/string-like pulse) indicate Chest Bi syndrome with pain. This occurs because of extreme deficiency. Now, knowing that Yang is deficient in the Upper Jiao, the reason for Chest Bi and Heart Pain is due to Yin Xian."
"We understand 'Yang Wei' from the perspective of Qi in the chest, hence 'Yang Wei indicates location in the Upper Jiao.' We understand 'Yin Xian' from the perspective of the Yin pulse. If a Yin-Cold pulse ascends to the Qi level of the chest, it results in Chest Bi; if the Yin pulse overcomes the Heart, it results in Heart Pain."
"A healthy person without exterior cold or heat symptoms who suffers from shortness of breath and inability to take a full breath has an Excess condition.
"The previous clause discussed 'Bu Ji' (Deficiency), while this one discusses 'Tai Guo' (Excess). A 'Ping Ren' (healthy person) here refers to someone without internal consumption/lao disease or external wind-cold invasion. Shortness of breath and insufficient respiration in such cases are due to pathogenic Qi obstructing the chest, preventing Kidney Yang Qi from ascending to the chest, thus constituting an Excess condition.
"The disease of Chest Bi presents with wheezing, coughing and spitting phlegm, chest and back pain, and shortness of breath. The Cun Kou (radial artery at the wrist) pulse is Chen (Deep) and Chi (Slow); the Guan pulse is Xiao Jin Shu (Small, Tight, and Rapid). It is primarily treated with Gua Lou Xie Bai Bai Jiu Tang (Trichosanthes Fruit, Macrostemon Stem, and White Wine Decoction).
"A Chen Chi pulse at Cun Kou indicates decline and weakness of Yang Qi. A Xiao Jin pulse at the Guan position indicates accumulation of Yin-Cold above the Stomach. Hence, there is wheezing, coughing, spitting phlegm, chest/back pain, and shortness of breath in the chest. Gua Lou is moistening and specifically clears sticky phlegm. Xie Bai has a strong odor and is used to diffuse turbid Qi, following the principle of similar Qi attracting each other. Bai Jiu (white wine) is the liquid of cooked grains; its white color allows it to ascend to the chest, assisting medicinal power to reach the upper extremity before descending.
"When Chest Bi is severe enough to prevent lying down, and Heart Pain radiates through to the back, Gua Lou Xie Bai Ban Xia Tang (Trichosanthes Fruit, Macrostemon Stem, and Pinellia Tuber Decoction) is primarily indicated.
"Heart Pain radiating through to the back occurs because phlegm and filth accumulate fully in the chest, overflowing along the meridians to the back. The back is the mansion of the chest. Therefore, only Ban Xia is added to the previous formula to dispel the obstruction caused by phlegm accumulation.
"When Chest Bi involves epigastric fullness and pain, Qi knotting in the chest, chest distension, and rebellious Qi rushing upward from the hypochondrium to strike the heart, Zhi Shi Xie Bai Gui Zhi Tang (Immature Bitter Orange, Macrostemon Stem, and Cinnamon Twig Decoction) is primarily indicated. Ren Shen Tang (Ginseng Decoction) can also be used.
"Phlegm and Qi knot in the chest, causing chest distension that overflows into the meridians, leading Qi to rush upward from the hypochondrium to strike the heart. These two formulas differ in application: one treats excess phlegm overflowing from the chest, using Xie Bai and Gui Zhi to disperse it; the other treats interior-knotted deficiency phlegm in the chest, using Ren Shen Li Zhong Tang (Ginseng and Middle-Warming Decoction) to clear it. One disease, two treatments, applied according to the patient's constitution, is an unchangeable method.
"When Chest Bi presents with Qi stagnation in the chest and shortness of breath, Fu Ling Xing Ren Gan Cao Tang (Poria, Apricot Seed, and Licorice Decoction) is primarily indicated. Ju Pi Zhi Shi Sheng Jiang Tang (Tangerine Peel, Immature Bitter Orange, and Fresh Ginger Decoction) can also be used.
"Since shortness of breath and insufficient respiration constitute an Excess condition, both formulas are agents that promote Qi movement. One disperses Lung Qi, and the other disperses Stomach Qi.
"When Chest Bi symptoms alternate between relaxation and urgency/spasm, Yi Yi Fu Zi San (Coix Seed and Aconite Powder) is primarily indicated.
"The chest is the residence of Yang Qi. Currently, Yang Qi in the chest is obstructed and not free-flowing. Wherever its meridians pass, the state is either relaxed or spasmodic, losing its normal rhythm, all due to the failure of Yang Qi to circulate. Yi Yi Ren (Coix Seed) soothes the meridians, and Fu Zi (Aconite Root) restores Yang Qi in the chest. Thus, the Great Qi turns, Yin-Turbidity remains no longer, and the chest becomes vast and clear like the empty sky.
"When there is epigastric fullness, various rebellious Qi causing a hanging pain in the heart region, Gui Zhi Sheng Jiang Zhi Shi Tang (Cinnamon Twig, Fresh Ginger, and Immature Bitter Orange Decoction) is primarily indicated.
"Epigastric fullness arises from Heart Qi rebelling upward. When Upper Qi rebels, Middle and Lower Qi also rebel. Qi rebellion causes meridian rebellion, hence termed 'various rebellions.' With Upper and Lower Qi rebelling and pulses failing to communicate, the Heart Master hangs isolated above, unable to receive Ying (Nutritive) Qi to harmonize it, resulting in hanging heart pain. Gui Zhi moves Heart Qi to dissipate fullness; Sheng Jiang (Fresh Ginger) and Da Zao (Jujube) smooth the Middle Jiao to unblock the meridians.
"When Heart Pain radiates through to the back, and back pain radiates through to the heart, Wu Tou Chi Shi Zhi Wan (Kochia Seed, Aconite, and Red Stone Lipid Pill) is primarily indicated.
"Heart Pain radiating through to the back, and back pain radiating through to the heart, indicates Yin Pathogen rebellion interfering with the meridians between the chest and back, causing connected pain, disturbing Blood and Qi, and confusing boundaries. Using Qi-regulating medicines here would only increase pain and lead to danger. Zhang Zhongjing uses Shu Jiao (Sichuan Pepper) and Wu Tou (Aconite), a batch of pungent-hot herbs, to warm and disperse Yin Pathogens. However, fearing the chaotic Qi in the chest and back cannot be settled, he adds Gan Jiang (Dried Ginger) and Chi Shi Zhi (Red Halloysite) within the warming formula group. Their astringent nature fills the tunnels where rebellious Qi attacks, allowing Chest Qi to remain in the chest and Back Qi to remain in the back, without interfering with each other, thereby curing the ailment. Modern practitioners only know methods of warming, tonifying, moving, and dispersing Qi, but do not know the method of filling the orifices where pathogenic Qi attacks.
"The *Qian Jin Fang* treats Chest Bi radiating to the back with Xi Xin San (Asarum Powder); treats rebellious Qi in the chest, heart pain radiating to the back, shortness of breath, and loss of appetite with Qian Hu Tang (Peucedanum Decoction); treats chest fullness, choking sensation, itching skin, dry throat, and profuse saliva/phlegm—if Ju Pi Zhi Shi Sheng Jiang Tang fails—with Zhi Zhong Tang (Middle-Regulating Decoction); treats Chest Bi with abdominal and back closure/fullness and rebellious Qi wheezing with Xia Qi Tang (Qi-Descending Decoction); and treats chest/back pain with Yi Bei San (Back-Irrigating Powder). These supplement what the *Jin Gui* omitted.
"When a patient feels as if panting but not actually panting, as if vomiting but not actually vomiting, as if hiccuping but not actually hiccuping, and feels profound mental distress and helplessness in the heart region, Sheng Jiang Ban Xia Tang (Fresh Ginger and Pinellia Decoction) is primarily indicated. The *Qian Jin Fang* adds Ju Pi (Tangerine Peel) and Wu Zhu Yu (Evodia Fruit), naming it Tong Qi San (Unblocking Qi Powder), treating chest fullness, shortness of breath, and choking.
"This belongs to the category of Chest Bi syndromes, likely misplaced by editors into the Vomiting/Hiccup section. I discuss it here together. Yang receives Qi in the chest to distribute breath. Now, Yin invades the Yang position, blocking the distribution of Yang Qi and the pathway of respiration, manifesting as panting, vomiting, or hiccuping. The Heart houses the Spirit. Accumulated fluids and retained phlegm cause fiery agitation, leading to profound mental confusion and helplessness. Therefore, the pungent-warm properties of Ban Xia and Sheng Jiang are used to dry fluid retention and disperse cold, allowing Yang to distribute and Qi to regulate, making the chest vast again. The use of Ju Pi, Wu Zhu Yu, and additions of Zhu Ru (Bamboo Shavings) and Ren Shen (Ginseng) follow this example. Yu Jiayan stated: Regarding Chest Bi, it is a common affliction. The *Jin Gui* presents ten formulas for treatment but does not explicitly explain the cause. The chest is like the empty sky; where Yang Qi passes, it is like the sun shining in the sky, vast and boundless. If Earth Qi (Yin Pathogen) rises, obstruction increases. Thus, Chest Bi is a sign of Yang Qi failing to function and Yin Qi occupying the upper positions. However, severity varies. Mild cases require only unblocking the insufficient Yang of the Upper Jiao; severe cases require driving out rebellious Qi from the Lower Jiao and unblocking Yang in the chest. Select three or four appropriate herbs from Xie Bai, Bai Jiu, Gua Lou, Ban Xia, Gui Zhi, Zhi Shi, Hou Po, Gan Jiang, Bai Zhu, Ren Shen, Gan Cao, Fu Ling, Xing Ren, or Ju Pi to form a prescription. Bitter-cold herbs are excluded, and even cooling herbs are discarded. This is because Yang is unblocked by Yang; Yin-category medicines have no place. In severe cases, Fu Zi, Wu Tou, and Shu Jiao—greatly pungent and hot—are used to drive out Yin from the Lower Jiao and restore Yang in the Upper Jiao. Restoring Heaven and bathing the Sun depend on the physician's insight. Alas, later generations fail to understand what Chest Bi truly is."