【纲】仲景曰。病有结胸。有脏结。其状若何。答曰。按之痛。寸脉浮。关脉沉者。名曰结胸
也。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。病患胸中素有痞。连在脐旁。引入小
腹。入阴筋者。此名脏结。死。
【目】苏颂曰。病患素有痞气。再加伤寒。与宿积相合。使真脏之气。闭塞不通。亦名脏结。
切不可下。止宜小柴胡加生姜以和表。灸关元以回阳解阴结。危哉。
黄仲理曰。脏结者。脏气闭结而不流布也。一息不运机缄穷。一毫不续穹壤判。脏其可结乎。
急刺关元灸之。
李 曰。脏结与结胸相似。皆下后邪气入里。与阳相结。结在胸者。为结胸。与阴相结。结在
脏者。为脏结。惟其阴结。故脏结无阳症。不往来寒热。或但寒不热。其人反静。饮食如常。时时
下利。舌上白苔。胁肋脐腹。引入阴经俱痛者。丹田有热。胸中有寒。所以难治。
喻昌曰。胸位高。脏位卑。其脉之寸浮关沉。两俱无异。乃脏结之关脉更加小细紧者。以关脉
居上下二焦之界。外邪由此下结。积气由此上干。实往来之要冲。所以病在下。而脉反困于中也。
此症全以外受之邪定轻重。若舌上有白滑苔。则所感深重。其互结之势方炽。单表里。及两解表
里之法。俱不可用。所以难治。然温中散邪。俾阴气渐下而内消。客邪渐上而外散。两相开解。则
良工之为其所难也乎。
方中行曰。此设问答以明结胸脏结之同异。时时下利者。阴邪结于阴脏而寒甚也。以寒甚。故
脉多细小与紧。此其所以不同。盖结胸以阳邪结于阳。脏结以阴邪结于阴故也。
程郊倩曰。凡人卫气出于下焦。升阳而行其浊阴者。中焦也。宗气出于上焦。降阴而行其清阳者。中焦也。今关脉
小细沉紧。则沉寒内格。有阴无阳。阳不下入。则浊阴结而不化。是为死阴。脏结所由名。舌上白苔滑者。寒水之气。
浸浸乎透入心阳矣。故为难治。温中散邪图其急。益火之原治其缓。或亦良工之所为也。其所难乎。
魏荔彤曰。方喻程三家之注甚明。无庸再赘。独是舌上白滑之苔。断非丹田有热。即方喻二注。
于此亦不敢明言有热矣。温中散邪。喻唱之而程和之。岂有热之治乎。泻心诸方。有阴在下而阳
在上者。为治痞言也。人知仲师辨结胸非脏结为论。不知仲师正谓脏结与痞有相类。而与结胸实
不同耳。盖结胸者。阳邪也。痞与脏结。阴邪也。痞则尚有阳浮于上。脏结则上下俱无阳独阴矣。
岂无阳哉。一线之阳。无如何也。是皆误吐下汗之流毒也。可不慎欤。
阴气内满。四逆汤症之对也。客邪反散。或仍桂枝欤。然客邪岂能自散。则亦内阳生而逐邪使
散矣。
【纲】张仲景说：疾病中有结胸证，有脏结证。它们的表现是怎样的呢？回答说：按压时疼痛，寸脉浮，关脉沉的，称为结胸证。如果症状像结胸证一样，但饮食正常，经常腹泻，寸脉浮，关脉小细沉紧的，称为脏结证。舌苔白且滑润的，难以治疗。病人胸中素有痞气（指胸脘部痞塞不通的感觉），连及脐旁，牵引至小腹，甚至牵连到阴筋的，这称为脏结证，预后不良，属死证。
【目】苏颂说：病人素来有痞气，又加上伤寒病，与宿积相合，导致真脏之气闭塞不通，也称为脏结证。切不可使用攻下法，只宜用小柴胡汤加生姜以调和表里，灸关元穴以回阳解阴结。病情危急啊。
黄仲理说：脏结证，是脏气闭结而不流通。呼吸一停，生机就穷尽；毫厘之气不续，天地便判若两途。脏气怎么可以结滞呢？应紧急针刺关元穴并施灸。
李姓医家说：脏结证与结胸证相似，都是误用下法后邪气入里，与阳气相结。结在胸部的，称为结胸证；与阴气相结，结在脏器的，称为脏结证。正因为是阴结，所以脏结证没有阳证表现，如往来寒热，或者只是怕冷不发热的，病人反而安静，饮食如常，经常腹泻，舌上白苔，胁肋、脐腹牵引至阴经部位都疼痛的，这是丹田有热，胸中有寒，所以难治。
喻昌说：胸部位置高，脏器位置低。它们的脉象寸浮关沉，两者都没有异常，但脏结证的关脉更加小细紧。因为关脉位于上、下二焦的交界，外邪由此向下结聚，积气由此向上干犯，这里是气机往来的要冲，所以病位在下，而脉象反而困阻于中。此症完全以外感邪气的轻重来决定预后。如果舌上有白滑苔，说明感受邪气深重，互结之势正盛。单纯解表或表里双解的方法都不可用，所以难治。然而，通过温中散邪，使阴气逐渐下行内消，客邪逐渐上行外散，两者相互开解，这就是高明医生的做法吧。
方中行说：这里设问答是为了阐明结胸证和脏结证的异同。经常腹泻，是因为阴邪结于阴脏且寒气很重。因为寒气重，所以脉象多细小且紧。这就是两者的不同之处。大概结胸证是阳邪结于阳位，脏结证是阴邪结于阴位。
程郊倩说：凡人的卫气出于下焦，由中焦升发阳气并运行浊阴；宗气出于上焦，由中焦降纳阴气并运行清阳。现在关脉小细沉紧，说明沉寒内格，有阴无阳，阳气不能下入，则浊阴结聚而不化，这叫作死阴，也就是脏结证命名的由来。舌上白苔滑润，说明寒水之气渐渐透入心阳了，所以难治。急则温中散邪，缓则益火之原，或许也是高明医生的做法吧。他们所做的，正是常人认为困难的事。
魏荔彤说：方中行、喻昌、程郊倩三家的注释已经很明白了，无需再赘述。唯独关于舌上白滑苔这一点，断然不是丹田有热，即使是方中行、喻昌两位的注释，在这里也不敢明确说有热。温中散邪，是喻昌倡导、程郊倩附和的观点，难道是有热证的治法吗？泻心汤类方剂，适用于阴在下而阳在上的情况，那是治疗痞证的说法。人们只知道张仲师辨析结胸证非脏结证作为论述重点，却不知道张仲师正是指出脏结证与痞证有相似之处，而与结胸证确实不同。大概结胸证是阳邪，痞证与脏结证是阴邪。痞证还有阳气浮于上，脏结证则是上下都无阳，只有独阴罢了。难道真的无阳吗？只是一线残阳，无可奈何罢了。这都是误用吐法、下法、汗法的流毒啊。能不谨慎吗？阴气内满，对应的是四逆汤证的情况。客邪反散，或许仍用桂枝汤吗？然而客邪岂能自行消散？那也是内生阳气驱逐邪气使其消散罢了。
[General Principles] Zhang Zhongjing stated: Among diseases, there are Chengxiong (Chest Binding) and Zangjie (Visceral Binding). What are their manifestations? The answer is: When pressing causes pain, the Cun pulse is floating, and the Guan pulse is sunken, it is named Chengxiong. If the condition resembles Chengxiong, but digestion remains normal, and there is frequent diarrhea, with a Cun pulse that is floating and a Guan pulse that is small, fine, sunken, and tight, it is named Zangjie. If the tongue has a white coating that is slippery, it is difficult to treat. If the patient has had Pi syndrome (a sensation of fullness and obstruction in the chest and epigastrium) since before, extending from the umbilicus to the lower abdomen and involving the external genitalia, this is named Zangjie, which is a fatal condition.
[Commentaries] Su Song said: If a patient who already has Pi syndrome contracts Shanghan (Cold Damage), the pathogenic factors combine with accumulated pathogens, causing the Qi of the True Viscera to become blocked and unflowing; this is also called Zangjie. One must absolutely not use purgatives. Instead, one should only use Xiaochaihu Tang (Minor Bupleurum Decoction) added with Shengjiang (Fresh Ginger) to harmonize the exterior, and moxa Guanyuan (CV-4) to restore Yang and resolve Yin binding. The condition is critical.
Huang Zhongli said: Zangjie refers to the closure and stagnation of Visceral Qi without circulation. If breath stops, the mechanism perishes; if even a tiny amount of Qi does not continue, heaven and earth are separated. How can Visceral Qi be bound? Urgently puncture Guanyuan (CV-4) and apply moxibustion.
Li [Name omitted] said: Zangjie resembles Chengxiong. Both result from pathogenic factors entering the interior after improper purgation, binding with Yang. When binding occurs in the chest, it is Chengxiong; when binding with Yin occurs in the Viscera, it is Zangjie. Because it is a Yin binding, Zangjie lacks Yang symptoms such as alternating chills and fever, or presents only with chills without fever. The patient appears quiet, eats normally, suffers frequent diarrhea, has a white tongue coating, and experiences pain radiating from the hypochondrium, umbilicus, and abdomen to the Yin meridians. This indicates heat in the Dantian (Lower Abdomen) and cold in the chest, making it difficult to treat.
Yu Chang said: The chest is high, while the Viscera are low. In both conditions, the Cun pulse floats and the Guan pulse sunks, showing no difference initially. However, in Zangjie, the Guan pulse becomes additionally small, fine, and tight. Since the Guan position lies at the boundary between the Upper and Lower Jiao, external pathogens bind downward here, while accumulated Qi interferes upward. This is the crucial pass for Qi movement. Thus, although the disease is located below, the pulse appears constrained in the middle. The severity depends entirely on the external pathogen. If the tongue has a white, slippery coating, the infection is deep and severe, and the binding force is strong. Neither simple exterior-releasing nor simultaneous exterior-interior resolving methods are applicable, hence it is difficult to treat. However, by warming the center and dispersing pathogens, allowing Yin Qi to gradually descend and dissipate internally, and letting the exogenous pathogen ascend and disperse externally, mutual resolution can be achieved. This is what skilled physicians do.
Fang Xingzhong said: This section uses Q&A to clarify the similarities and differences between Chengxiong and Zangjie. Frequent diarrhea indicates Yin pathogens binding in Yin Viscera with severe cold. Due to severe cold, the pulse is often small, fine, and tight. This is the key difference. Chengxiong involves Yang pathogens binding in Yang positions, whereas Zangjie involves Yin pathogens binding in Yin positions.
Cheng Jiaoqian said: Human Wei Qi originates from the Lower Jiao, and the Middle Jiao raises Yang to transport turbid Yin. Zong Qi originates from the Upper Jiao, and the Middle Jiao lowers Yin to transport clear Yang. Now, with a Guan pulse that is small, fine, sunken, and tight, deep cold blocks the interior, resulting in Yin without Yang. Since Yang cannot descend, turbid Yin binds and fails to transform, creating "Dead Yin," which gives rise to the name Zangjie. A slippery white tongue coating indicates that Cold-Water Qi is permeating into Heart Yang, making it difficult to treat. Acute cases require warming the center and dispersing pathogens; chronic cases require benefiting the source of Fire. Perhaps this is what skilled physicians accomplish—doing what others find difficult.
Wei Litong said: The commentaries by Fang, Yu, and Cheng are very clear, requiring no further elaboration. However, regarding the white slippery tongue coating, it certainly does not indicate heat in the Dantian. Even Fang and Yu did not explicitly state there was heat. Warming the center and dispersing pathogens, advocated by Yu and echoed by Cheng, cannot be a treatment for heat. Formulas like Xiexin Tangs address patterns where Yin is below and Yang is above, specifically for treating Pi syndrome. People know that Zhang Zhongjing distinguishes Chengxiong from Zangjie, but fail to realize he points out that Zangjie is similar to Pi syndrome but truly different from Chengxiong. Chengxiong is caused by Yang pathogens, while Pi and Zangjie are caused by Yin pathogens. Pi syndrome still has Yang floating above, whereas Zangjie has no Yang above or below, leaving only solitary Yin. Is there really no Yang? Only a thread of residual Yang remains, helpless. These are all consequences of erroneous emesis, purgation, and sweating therapies. Can one not be cautious? Internal fullness of Yin Qi corresponds to Sini Tang Syndrome. If exogenous pathogens disperse, perhaps Guizhi Tang is used again? However, how can exogenous pathogens disperse on their own? It is the generation of internal Yang that drives the pathogens away.