问曰。病有结胸。有脏结。其状何如。答曰。按之痛。寸脉浮。关脉沉。名曰结胸也。何谓脏结。答曰。
如结胸状。饮食如故。时时下利。寸脉浮。关脉小细沉紧。名曰脏结。舌上白苔滑者难治。
此设问以申结胸脏结之辨也。然深哉仲景之文。秘哉仲景之法。而难于推测者也。夫寸脉。气口脉也。
关脉。右关脉也。浮为阳。表脉也。沉为阴。里脉也。小细沉紧者。寒邪深入之脉也。何以知其为右寸关乎。
脉要精微论云。上附上。右外以候肺。内以候胸中故也。说见上文。邪自太阳之表。陷入上焦阳分。故寸脉浮也。
邪入胸膈。胃气不行。中焦隔绝。故关脉沉也。言热邪陷入心胸之间。按之而硬痛。寸脉浮而关脉沉者。名
曰结胸也。如结胸状者。状如结胸而已。未必如结胸之按之而硬且痛也。若如结胸之硬痛。则邪气坚结。胃脘不通。
而饮食不能如故矣。王肯堂云。谓之如结胸状。则与结胸当有分别矣。成注云。二者皆心下硬痛。尚欠稳当。
如结胸状。饮食如故。是按之不痛耳。此可谓深得仲景之意者矣。其所以谓之脏结者。邪结于脏而非结于腑也。
所谓腑者。胃也。脏者。脾也。邪结于脾脏而不犯胃腑。故饮食如故也。但所结者。太阴脾土之一脏耳。非五脏皆
结也。然则邪气何以结于脏乎。以脏结与结胸相似。虽有阴阳之分。但能食与下利不同耳。因外邪陷入。未结于
胸而入于脾之大络。名曰大包者。其络出腋下。足少阳胆经
之渊液穴下三寸是也。其脉若罗络之布于胸胁。邪气入之。故结于脾脏也。时时下利者何也。盖胃主纳而为水谷
之海。故内经以肠胃为仓廪之本。若脾则主于散精而为胃行其津液者也。盖人之便泻以时。若有以节之者。以脾
气能约束之耳。五营运大论云。地在太虚之中。大气举之也。盖岐伯以大地喻人身之脾土也。是以胃阳过强。则脾
太约而大便不易出。如阳明篇所谓趺阳脉浮则胃气强。大便则难。其脾为约者是也。寒邪结脏。则脾不能摄而水
谷不得藏。如五脏别论云。魄门亦为五脏使。水谷不得久藏是也。脉要精微论云。五脏者。中之守也。仓廪不藏者。是
门户不要也。得守者生。失守者死。今寸脉浮而邪不结于胃。所以饮食如故。关脉小细沉紧。则寒邪结于脾而时时
便泻也。其所以然者。气口主胃而关脉应脾也。脉证若此者。乃名脏结也。舌上白苔而滑者。胃中有寒也。凡胃中有
热实。则舌苔黄黑枯燥。此则脾脏已为阴邪所结。必更见阳证。乃为易治。如三阴证中之手足温及热多厥少者。方
为可治。今言舌苔白滑。则胃腑无阳。故曰难治。
脏结无阳证。不往来寒热。其人反静。舌上苔滑者。不可攻也。
此承上文。又以申明舌上白苔滑者难治之义也。言无论中风伤寒之邪。入阳经则为阳证。入阴经即为阴证。脏本
属阴。邪陷入之。已成阴结。必兼有阳证者。则尚有热邪可攻。但邪既结于阴。则太阳与阳明证在所必无。庶几三阳
之第三层。在躯壳之里层者。则少阳也。少阳与躯壳以内之脏腑。最为亲近。或尚有未尽陷入之邪。留于少阳。则当
往来寒热矣。而又曰不往来寒热。是邪气全不在阳经。故无阳症也。然邪结于里。或有躁扰不宁。而其人反静。静则
又属阴矣。其舌上所见之苔。则又滑而不燥。大凡六经见症。三阳邪热归胃。则有舌苔。其生也。自白而黄。自黄而黑。
至芒刺燥裂。种种各异凭之以验寒热虚实而温凉补泻之。真百无一失。若果能审察精当。心领神会。实万举万得。
所以舌苔从不误人。非若脉症之阴阳变幻。真假虚实之难测也。至若三阴受邪。舌苔甚少。即或有之。亦灰白湿滑
而已。此云舌上苔滑。则胃气亦寒。纯是阴邪。必当温经复阳矣。若攻之必败。庸可攻乎。故云不可攻也。成氏旁
引仲景湿证原文之丹田有热。胸中有寒解之。遂致后人因之而有丹田阴也。胸中阳也。热反在阴而寒反在阳之说。更
后而又有仍其旧者曰。丹田。阴也。反有热。胸中。阳也。反有寒。是则其病不在表里而在上下。上下之邪。相悖而不
相
入。议论若此。不知令后人作何参解。若何会悟耶。吁。我恐义理幽深。并注家亦未之或知也。
病胁下素有痞。连在脐旁。痛引少腹入阴筋者。此名脏结。死。
痞者。阴寒之积也。脐之中央。神阙也。神阙者。任脉穴也。脐旁之左右各半寸。肾经肓俞穴也。少腹。至阴之
分也。会阴曲骨中极关元气海等穴。任脉之所自起也。自阴股入毛中。循阴器。抵少腹者。足厥阴之脉络也。横骨大赫
四满中注等穴。足少阴之脉穴。挟任脉之两旁而行于少腹者也。阴筋者。足厥阴之络。引睾丸而结于茎者也。言病患胁
下。
平素向有阴寒之痞积。连在脐旁腹三行之阴分。而又因伤寒脏结之证。其痛下引少腹。入厥阴而控引睾丸之阴筋者。此
等脏结。以阴气过极。阳气竭绝。故曰死。
问：疾病中有结胸证，有脏结证，它们的症状表现是怎样的？
答：按压时疼痛，寸脉浮，关脉沉，这叫做结胸证。
什么叫脏结证？
答：症状像结胸证，但饮食如常，时常腹泻，寸脉浮，关脉小、细、沉、紧，这叫做脏结证。舌上苔白且滑的，难以治疗。
这是通过设问来阐明结胸与脏结的区别。然而，张仲景的文字深奥，张仲景的法度隐秘，确实难以推测。
所谓寸脉，就是气口脉。
所谓关脉，这里指右关脉。
浮脉属阳，是表证的脉象；沉脉属阴，是里证的脉象。
脉象小、细、沉、紧，是寒邪深入体内的脉象。
怎么知道这是对应右寸和右关呢？
《脉要精微论》说：“上附上，右外以候肺，内以候胸中。”所以如此解释，详见上文。
邪气从太阳经的体表，陷入上焦的阳分，所以寸脉浮。
邪气进入胸膈，胃气运行受阻，中焦隔绝不通，所以关脉沉。
如果说热邪陷入心胸之间，按压时坚硬且疼痛，寸脉浮而关脉沉的，叫做结胸证。
“像结胸状”，意思是形状类似结胸罢了，未必像结胸那样按压时坚硬且疼痛。
如果像结胸那样坚硬疼痛，那么邪气坚结，胃脘不通，饮食就不能像平常一样了。
王肯堂说：“称为‘像结胸状’，那就与结胸应当有所区别了。”
成无己注解说：“两者都是心下部位硬痛，这样解释还不够稳妥。”
“像结胸状，饮食如常”，说明是按之不痛的。这可以说是深得张仲景本意的人啊。
之所以称之为脏结，是因为邪气结聚在脏，而不是结聚在腑。
所谓的腑，指的是胃；所谓的脏，指的是脾。
邪气结聚在脾脏而不侵犯胃腑，所以饮食如常。
但是所结聚的，仅仅是太阴脾土这一脏而已，并非五脏都结聚。
既然这样，邪气为什么会在脏结聚呢？
因为脏结与结胸相似，虽然有阴阳之分，但能进食与腹泻不同罢了。
由于外邪陷入，没有结聚在胸中，而是进入了脾的大络，名叫大包穴。
该络脉出于腋下，在足少阳胆经渊液穴下方三寸处。
其脉络如同罗网一样分布于胸胁部。邪气侵入其中，所以结聚在脾脏。
为什么会时常腹泻呢？
大概胃主受纳，是水谷之海，所以《内经》将肠胃视为仓廪的根本。
至于脾，则主散精，为胃传输津液。
人的排泄是有节制的，好像有什么东西约束它一样，这是因为脾气能够约束的缘故。
《五营运大论》说：“地在太虚之中，大气举之也。”
大概岐伯是用大地来比喻人身中的脾土。
因此，如果胃阳过强，则脾约束太过，导致大便不易排出，就像阳明篇所说的：“趺阳脉浮则胃气强，大便则难，其脾为约”的情况。
如果是寒邪结聚在脏，则脾不能摄持，水谷无法藏留。
就像《五脏别论》所说：“魄门亦为五脏使，水谷不得久藏。”
《脉要精微论》说：“五脏者，中之守也。仓廪不藏者，是门户不要也。得守者生，失守者死。”
现在寸脉浮而邪气不结于胃，所以饮食如常；关脉小、细、沉、紧，则是寒邪结于脾而时常便泻。
之所以这样，是因为气口脉主要反映胃的情况，而关脉主要对应脾。
脉证如此，才叫做脏结证。
舌上苔白且滑，说明胃中有寒。
凡是胃中有热实，舌苔就会黄黑且枯燥。
这里是脾脏已经被阴邪结聚，必须再出现阳证，才是容易治疗的。
比如在三阴证中出现手足温暖，或者热多厥少的情况，才可以治疗。
现在说舌苔白滑，说明胃腑没有阳气，所以说难以治疗。
脏结证没有阳证，没有往来寒热的症状，病人反而安静，舌上苔滑的，不可使用攻下法。
这是承接上文，再次申明舌上白苔滑的难以治疗的道理。
意思是无论中风还是伤寒的邪气，进入阳经就成为阳证，进入阴经就成为阴证。
脏本来属于阴，邪气陷入其中，已经形成阴结。
如果兼有阳证，那么还有热邪可以攻下。
但是邪气既然结聚在阴，那么太阳病和阳明病的证候就一定没有。
差不多在三阳经的第三层，即在躯壳内部的那一层，就是少阳经。
少阳经与躯壳以内的脏腑最为亲近。
或许还有未完全陷入的邪气，停留在少阳经，就会出现往来寒热的症状。
但又说不往来寒热，这说明邪气完全不在阳经，所以没有阳证。
然而邪气结聚在里，可能会有躁动不安，但病人反而安静，安静又属于阴了。
舌上所见的苔，又是滑而不燥的。
大凡六经出现的症状，三阳经的邪热归并于胃，就会产生舌苔。
它的生成过程，是从白变黄，从黄变黑，直到出现芒刺、干燥、裂纹等种种不同的表现。
凭借这些来验证寒热虚实，从而决定温凉补泻的治疗，真是百无一失。
如果能审慎察验，精准得当，心领神会，确实是万举万得。
所以舌苔从来不会误导人，不像脉症那样阴阳变幻，真假虚实难以测度。
至于三阴经受邪，舌苔很少，即使有，也是灰白湿滑而已。
这里说舌上苔滑，说明胃气也寒，纯粹是阴邪，必须当用温经复阳的方法。
如果使用攻下法必定失败，怎么可以攻下呢？
所以说不可攻下。
成无己旁征博引张仲景关于湿证的原文，“丹田有热，胸中有寒”来解释，致使后人因此产生了“丹田属阴，胸中属阳，热反在阴而寒反在阳”的说法。
更后来又有沿袭旧说的人认为：“丹田，属阴，反而有热；胸中，属阳，反而有寒。”
这样的话，病就不在表里而在上下了。上下的邪气，相互违背而不相入。
议论如此，不知道让后人如何参悟理解呢？
唉，我恐怕义理幽深，连注释家也未必知晓啊。
病人胁下平素有痞块，连接在脐旁，疼痛牵引少腹并进入阴筋的，这叫做脏结，预后不良（死）。
痞块，是阴寒积聚而成的。
脐的中央，是神阙穴。神阙穴，是任脉的穴位。
脐旁左右各半寸处，是肾经的肓俞穴。
少腹，是至阴的分野。
会阴、曲骨、中极、关元、气海等穴位，是任脉起始的地方。
从阴股进入毛际，沿着阴器，抵达到少腹的，是足厥阴肝经的脉络。
横骨、大赫、四满、中注等穴位，是足少阴肾经的脉穴，挟持任脉两旁而行于少腹部的。
阴筋，是指足厥阴肝经的络脉，牵引睾丸结聚于阴茎。
意思是病患胁下，平素就有阴寒性质的痞积，连接在脐旁腹部三行的阴分部位。
而又因为伤寒脏结的病证，疼痛向下牵引少腹，进入厥阴经而控引睾丸的阴筋。
这种脏结，因为阴气过极，阳气竭绝，所以说预后不良（死）。
Question: In diseases, there are "Jie Xiong" (Chest Binding) and "Zang Jie" (Organ Binding). What are their clinical manifestations?
Answer: Pain upon palpation, with a floating pulse at the Cun position and a deep pulse at the Guan position. This is called Jie Xiong (Chest Binding).
What is meant by Zang Jie (Organ Binding)?
Answer: The presentation resembles that of Jie Xiong (Chest Binding), yet appetite remains normal, and there is frequent diarrhea. The pulse at the Cun position is floating, while the pulse at the Guan position is small, fine, deep, and tight. This is called Zang Jie (Organ Binding). If the tongue coating is white and slippery, it is difficult to treat.
This passage employs a question-and-answer format to clarify the distinction between Jie Xiong (Chest Binding) and Zang Jie (Organ Binding). However, the writings of Zhang Zhongjing are profound, and his therapeutic principles are subtle, making them indeed difficult to speculate upon.
The term "Cun pulse" refers to the Qi Kou pulse (radial artery pulse at the wrist).
The term "Guan pulse" here refers to the Right Guan pulse.
A floating pulse belongs to Yang and indicates a exterior syndrome; a deep pulse belongs to Yin and indicates an interior syndrome.
A pulse that is small, fine, deep, and tight indicates that cold pathogenic factors have penetrated deeply into the interior.
How do we know this corresponds to the Right Cun and Right Guan positions?
The *Ling Shu: Mai Yao Jing Wei Lun* (Treatise on the Essentials of Pulse Diagnosis) states: "At the upper level, the right side externally corresponds to the Lung and internally corresponds to the Chest Middle." Hence this explanation, as detailed in the preceding text.
Pathogenic factors from the exterior of the Taiyang channel sink into the Yang aspect of the Upper Jiao, resulting in a floating pulse at the Cun position.
When pathogens enter the chest and diaphragm, the Stomach Qi fails to circulate, causing obstruction in the Middle Jiao, resulting in a deep pulse at the Guan position.
If heat pathogens sink into the heart and chest region, causing hardness and pain upon palpation, accompanied by a floating Cun pulse and a deep Guan pulse, it is termed Jie Xiong (Chest Binding).
"Resembling Jie Xiong" implies that the presentation is similar to Jie Xiong (Chest Binding), but not necessarily characterized by the hardness and pain upon palpation seen in true Jie Xiong.
If it were hard and painful like Jie Xiong, the pathogenic factors would be firmly bound, obstructing the stomach and epigastrium, thereby preventing normal eating.
Wang Kentang stated: "To call it 'resembling Jie Xiong' implies a distinction from actual Jie Xiong."
Cheng Wuji's commentary states: "Both involve hardness and pain below the heart; this interpretation is insufficiently accurate."
"Resembling Jie Xiong, yet eating normally" indicates that there is no pain upon palpation. This understanding truly captures the intent of Zhang Zhongjing.
It is called Zang Jie (Organ Binding) because the pathogenic factors bind within the Zang organs rather than the Fu organs.
The Fu organ referred to is the Stomach; the Zang organ referred to is the Spleen.
Since the pathogenic factors bind in the Spleen without invading the Stomach, appetite remains normal.
However, the binding occurs only in the Taiyin Spleen Earth, not in all five Zang organs.
Then why do pathogenic factors bind in the Zang organs?
Because Zang Jie resembles Jie Xiong, differing primarily in the ability to eat versus the presence of diarrhea, despite the yin-yang distinction.
Due to the sinking of external pathogens, instead of binding in the chest, they enter the large collateral of the Spleen, known as the Da Bao point.
This collateral emerges from under the axilla, three cun below the Yuan Ye point of the Foot-Shaoyang Gallbladder Channel.
Its vessels spread across the chest and hypochondrium like a net. When pathogens invade, they bind in the Spleen.
Why is there frequent diarrhea?
Generally, the Stomach governs reception and is the sea of water and grain; thus, the *Nei Jing* regards the intestines and stomach as the foundation of the granary.
The Spleen, however, governs the dispersion of essence and transports fluids for the Stomach.
Human defecation is regulated, as if constrained by something, due to the Spleen Qi's restraining function.
The *Su Wen: Wu Yun Yun Da Lun* (Great Treatise on the Five Movements and Six Qi) states: "The earth floats in the great void, upheld by the great qi."
Qibo used the earth to metaphorically represent the Spleen Earth in the human body.
Therefore, if Stomach Yang is excessive, the Spleen's constraint becomes too strong, leading to difficult defecation, as described in the Yangming chapter: "A floating Douyang pulse indicates strong Stomach Qi, leading to difficult stools, a condition where the Spleen is constrained."
If cold pathogens bind in the Zang organs, the Spleen cannot retain, and water and grain cannot be stored.
As stated in the *Wu Zang Bie Lun*: "The anal opening serves the five Zang organs; water and grain cannot be stored long."
The *Mai Yao Jing Lun* states: "The five Zang organs are the guardians within. If the granary cannot store, the gates are not secured. Those who retain security live; those who lose it die."
Currently, the Cun pulse is floating, and pathogens do not bind in the Stomach, hence appetite is normal; the Guan pulse is small, fine, deep, and tight, indicating cold pathogens binding in the Spleen, causing frequent diarrhea.
This is because the Qi Kou pulse primarily reflects the Stomach, while the Guan pulse corresponds to the Spleen.
With such pulse and symptom patterns, it is named Zang Jie (Organ Binding).
A white and slippery tongue coating indicates cold in the Stomach.
Whenever there is heat and excess in the Stomach, the tongue coating becomes yellow or black and dry.
Here, the Spleen has been bound by yin pathogens. It would be easier to treat if yang symptoms were present.
For instance, in Shaoyin or Taiyin syndromes, if the hands and feet are warm, or if heat predominates over cold limbs, treatment is feasible.
Now, since the tongue coating is white and slippery, it indicates a lack of yang in the Stomach-Fu, hence it is said to be difficult to treat.
In Zang Jie (Organ Binding), there are no yang symptoms, no alternating chills and fever, the patient appears calm, and the tongue coating is slippery; purgative methods must not be used.
This follows the previous text to reiterate the difficulty of treating cases with a white, slippery tongue coating.
It means that regardless of whether wind-cold or cold-damp pathogens enter the yang channels becoming yang syndromes, or enter the yin channels becoming yin syndromes, the Zang organs inherently belong to yin. Once pathogens sink in, they form a yin binding.
If yang symptoms are present, there may still be heat pathogens amenable to purgation.
However, since pathogens have bound in the yin, Taiyang and Yangming syndromes will certainly be absent.
Approximating the third layer of the three yang channels, which lies inside the shell of the body, is the Shaoyang channel.
Shaoyang is closest to the internal zang-fu organs.
Perhaps some pathogens remain un-sunk in the Shaoyang, which would manifest as alternating chills and fever.
But since there is no alternating chills and fever, it indicates pathogens are entirely outside the yang channels, hence no yang symptoms.
Furthermore, although pathogens binding in the interior might cause restlessness, the patient is actually calm; calmness also belongs to yin.
The tongue coating observed is slippery and not dry.
Generally, in the six channels, when heat from the three yang channels converges in the Stomach, a tongue coating forms.
It develops from white to yellow, then to black, eventually showing prickles, dryness, and cracks.
These variations allow one to verify cold, heat, deficiency, and excess, guiding warm, cool, tonifying, or draining treatments with high accuracy.
If examined precisely and understood intuitively, success is nearly guaranteed.
Thus, tongue diagnosis rarely misleads, unlike pulse and symptom differentiation, where yin-yang transformations and true/false patterns are hard to discern.
In shaoyin or taiyin syndromes, tongue coatings are scarce; if present, they are gray-white and wet/slippery.
A slippery tongue coating here indicates cold Stomach Qi and purely yin pathogens, requiring warming of the channels and restoration of yang.
Purgation would fail; therefore, it must not be used.
Hence, it is stated that purgation is contraindicated.
Cheng Wuji cited Zhang Zhongjing’s text on dampness, "Heat in the Dantian, Cold in the Chest," leading later scholars to argue that "Dantian is yin but has heat; Chest is yang but has cold."
Later adherents maintained: "Dantian is yin, yet has heat; Chest is yang, yet has cold."
This suggests the pathology is neither exterior-interior nor simply vertical, but that upper and lower pathogens contradict each other without merging.
Such discussions leave later practitioners confused about how to interpret them.
Alas, I fear the principles are so profound that even commentators may not understand them.
If a patient has had a mass (Pi) in the hypochondrium since before, extending to beside the umbilicus, with pain radiating to the lower abdomen and into the yin sinews, this is called Zang Jie (Organ Binding), and the prognosis is fatal.
Pi (mass) refers to accumulation caused by yin-cold.
The center of the umbilicus is the Shenque point, an acupoint of the Ren Mai (Conception Vessel).
Half a cun lateral to the umbilicus on both sides are the Huangshu points of the Kidney Channel.
The lower abdomen is the domain of extreme yin.
Points such as Huiyin, Qugu, Zhongji, Guanyuan, and Qihai are where the Ren Mai originates.
From the inner thigh entering the pubic hair, following the genitalia to the lower abdomen runs the Foot-Jueyin Liver Channel.
Points such as Henggu, Dahe, Siman, and Zhongzhu are acupoints of the Foot-Shaoyin Kidney Channel, running alongside the Ren Mai in the lower abdomen.
Yin sinews refer to the collaterals of the Foot-Jueyin Liver Channel, which connect the testicles to the penis.
This describes a patient who has chronically had a yin-cold mass in the hypochondrium, extending to the yin aspect of the abdominal rows beside the umbilicus.
Complicated by the syndrome of Shanghan Zang Jie (Organ Binding), the pain radiates downward to the lower abdomen, enters the Jueyin channel, and draws the testicular yin sinews.
In such cases of Zang Jie, yin qi is extremely excessive, and yang qi is exhausted; hence, the prognosis is fatal.