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。（玉函。作其脉寸
口浮。关上自沉。时时下利云云。作时小便不利。阳脉浮。关上细沉而紧。张锡驹本。胎。作苔。）
〔汪〕此言结胸病状与脏结。虽相似而各别。夫结胸脏结。何以云太阳病。以二者皆太阳病误下所致也。
盖结胸病。始因误下。而伤其上焦之阳。阳气既伤。则风寒之邪。乘虚而入。上结于胸。按之则痛者。胸中实
也。寸浮关沉者。邪气相结。而为实之诊也。若脏结病。则不然。其始亦因误下。而伤其中焦之阴。阴血既伤。
则风寒之邪。亦乘虚而入。内结于脏。状如结胸者。以脏气不平。逆于心下故也。饮食如故者。胸无邪阻。而
胃中空也。时时下利者。脏虚邪结。不能运化。胃中之水谷。不泌别不厘清。因偏渗于大肠。而作利也。寸浮
关沉者。结胸脉也。今诊关脉。兼得小细紧者。则是脏虚。而风寒之邪内结可知。舌上白苔者。经云。丹田有
热。胸中有寒。今者苔滑。则是舌湿润而冷也。此系误下太过。而变成脏寒之证。故难治也。按结胸证。其人
本胃中挟食。下之太早。则食不能去。外邪反入。结于胸中。以故按之则痛。不能饮食。脏结证。其人胃中本
无食。下之太过。则脏虚邪入。冷积于肠。所以状如结胸。按之不痛。能饮食。时下利。舌上苔滑。此非真寒
证。乃过下之误也。〔魏〕人知仲景辨结胸非脏结为论。不知仲景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。阴
气内满。四逆汤证之对也。
金鉴曰。案此条舌上白苔滑者难治句。前人旧注。皆单指脏结而言。未见明晰。误人不少。盖舌苔白滑。
即结胸证具。亦是假实。舌苔干黄。虽脏结证具。每伏真热。脏结阴邪。白滑为顺。尚可温散。结胸阳邪。见
此为逆。不堪攻下。故为难治。由此可知。着书立论。必须躬亲体验。真知灼见。方有济于用。若徒就纸上陈
言。牵强附会。又何异案图索骥耶。○案金鉴此说。未知于经旨如何。然系于实验。故附于此。
案汪注。结胸伤上焦之阳气。脏结伤中焦之阴气。于理未允。
案胎。锡驹作苔。原于庞氏总病论。知是胎本苔字。从肉作胎。与胚胎之胎。义自别。又圣惠方。载本
经文。亦并作苔。
脏结无阳证。不往来寒热。（【原注】一云。寒而不热。）其人反静。舌上苔滑者。不可攻也。（不往
来寒热。脉经。作寒而不热。苔滑。巢源。作不胎。庞氏。胎。作苔。锡驹同。）
〔柯〕结胸。是阳邪之陷。尚有阳症见于外。故脉虽沉紧。有可下之理。脏结。是积渐凝结而为阴。五脏之
阳已竭也。外无烦躁潮热之阳。舌无黄黑芒刺之苔。虽有硬满之症。慎不可攻。理中四逆辈温之。尚有可生之义。
案脏结。补亡论。王朝奉刺关元穴。非也。汪氏云。宜用艾灸之。蕴要曰。灸气海关元穴。宜人参三白汤。
加干姜。寒甚者加附子。全生集曰。灸关元。与茱萸四逆加附子汤。以上宜撰用。准绳曰。王朝奉服小柴胡汤。
其已云不往来寒
热。何用小柴胡汤。是甚谬矣。金鉴。程知云。经于脏结白苔滑者。只言难治。未尝言不可治也。只言脏结无
热。舌苔滑者。不可攻。未尝言脏结有热。舌苔不滑者。亦不可攻也。意者。丹田有热。胸中有寒之证。必有
和解其热。温散其寒之法。俾内邪潜消。外邪渐解者。斯则良工之苦心乎。○汪氏云。脏结本无可下之证。成注
云。于法当下者。误。集注。潘氏曰。案文义。若脏结有阳证。亦属可攻。此说亦恐不必矣。○案反字。对结胸烦躁而
言。
病发于阳。而反下之。热入因作结胸。病发于阴。而反下之。（【原注】一作汗出。）因作痞也。所以
成结胸者。以下之太早故也。（成本。痞下。无也字。玉函同。病上。冠夫字。下而反下之。千金翼。作而反
汗之。痞。巢源。作否。）
〔成〕云发热恶寒者。发于阳也。而反下之。则表中阳邪入里。结于胸中。为结胸。无热恶寒者。发于阴
也。而反下之。表中之阴入里。结于心下为痞。〔钱〕发于阳者。邪在阳经之谓也。发于阴者。邪在阴经之谓
也。反下之者。不当下而下也。两反下之。其义迥别。一则以表邪未解。而曰反下。一则以始终不可下。而曰
反下也。因者。因误下之虚也。结胸则言热入者。以发热恶寒。表邪未解。误下则热邪乘虚陷入。而为结胸。
以热邪实于里。故以大小陷胸攻之。痞不言热入者。盖阴病本属无阳。一误下之。则阳气愈虚。阴邪愈盛。客
气上逆。即因之而为痞硬。如甘草半夏生姜三泻心汤证是也。末句但言下早为结胸之故。而不及痞者。以邪在
阳经而未解。邪犹在表。若早下之。则里虚而邪热陷入。致成结胸。若表邪已解而下之。自无变逆之患。故以
下早为嫌。至于邪入阴经之证。本无可下之理。阴经虽有急下之条。亦皆由热邪传里。非阴经本病也。除此以
外。其可反下之乎。
〔程〕发于阳者。从发热恶寒而来。否则热多寒少者。下则表热陷入。为膻中之阳所格。两阳相搏。是为结胸。
结胸为实邪。发于阴者。从无热恶寒而来。否亦寒多热少者。下则虚邪上逆。亦为膻中之阳所拒。阴阳互结。
是为痞。痞为虚邪。〔张〕病发于阳者。太阳表证误下。邪结于胸也。病发于阴者。皆是内挟痰饮。外感风寒。
中气先伤。所以汗下不解。而心下痞也。或言中风为阳邪。伤寒为阴邪。（方喻金鉴。皆然。）安有风伤卫气。
气受伤而反变为结胸。寒伤营血。血受伤而反成痞之理。复有误认直中阴寒之阴。下早变成痞者。则阴寒本无
实热。何得有下早之变。设阴结阴躁。而误下之。立变危逆。恐不至于成痞停日。待变而死也。
案发于阳。发于阴。成氏程氏钱氏。皆原于太阳上编第八条之义。然所谓阴。非少阴直中之谓。但是寒邪
有余。后世所谓挟阴之证。若果直中纯阴。则下之有不立毙者乎。张氏所论。虽似于经旨未明切。而验之病者。
往往有如此者。故并采而录之。张兼善驳成氏。以阴阳为表里。柯氏亦以为外内。周氏则云。发于阴者。洵是
阴证。但是阳经传入之邪。皆不可从也。
总病论曰。发热恶寒。为发于阳。误下则为结胸。无热恶寒。为发于阴。误下则为痞气。○案成注原于此。
病源候论。结胸者。谓热毒结聚于心胸也。否则。心下满也。按之自软。但气痞耳。不可复下也。又痞
者。塞也。言腑脏痞塞。不宣通也。释名曰 。痞也。气痞结也。说文。徐曰。痞。病结也。直指方曰。干上
坤下。其卦为否。阳隔阴而不降。阴为阳而不升。此否之所以痞而不通也。伤寒百问经络图曰。但满而不痛者
为痞。任人揉按。手不占护。按之且快意。
结胸者。项亦强。如柔 状。下之则和。宜大陷胸丸。（玉函。千金翼。项上。有其字 。玉函。脉经。
作痉。是。）
〔成〕结胸病项强者。为邪结胸中。胸膈结满。心下紧实。但能仰而不能俯。是项强也。〔程〕夫从胸上结
硬。而势连甚于下者。大陷胸汤。不容移易矣。若从胸上结硬。而势连甚于上者。缓急之形既殊。则汤丸之制
稍异。结胸而至项亦强。如柔痉状。如邪液布满胸中。升而上阻。更不容一毫正液。和养其筋脉矣。胸邪至此。
紧逼较甚。下之则和去邪液。即所以和正液也。改大陷胸汤。为大陷胸丸。峻治而行以缓。得建瓴之势。而复
与邪相当。是其法也。〔柯〕头不痛而项犹强。不恶寒而头汗出。故如柔痉状。
大陷胸丸方
大黄（半斤） 葶苈子（半升熬） 芒硝（半升） 杏仁（半升去皮尖熬黑）
上四味。捣筛二味。纳杏仁芒硝。合研如脂。和散。取如弹丸一枚。别捣甘遂末一钱匕。白蜜二合。水
二升。煮取一升。温顿服之。一宿乃下。如不下更服。取下为效。禁如药法。（白蜜二合。玉函。千金。并翼
外台。作一两。）
〔钱〕大黄芒硝甘遂。即大陷胸汤。白蜜一合。亦即十枣汤中之大枣十枚也。增入葶苈杏仁者。盖以胸为
肺之所处。膻中为气之海。上通于肺而为呼吸。邪结胸膈。硬满而痛。气道阻塞。则有少气躁烦。水结胸胁之
害。故用葶苈甘遂。以逐水泻肺。杏仁以利肺下气也。所用不过一弹丸。剂虽大而用实小也。和之以白蜜。药
虽峻而佐则缓也。岂如承气陷胸汤之人行十里二十里之迅速哉。
吴氏曰。凡云丸者。皆大弹丸。煮化而和滓服之也。后抵当丸理中丸同。凡云弹丸及鸡子黄者以四十梧
桐子准之。（案出本草序例。）
千金方秘涩门。本方不用甘遂。蜜丸如梧子大。服七丸。名练中丸。主宿食不消。大便难。肘后方。名
承气丸。庞氏总病论曰。虚弱家。不耐大陷胸汤。即以大陷胸丸下之。
结胸证。其脉浮大者。不可下。下之则死。
〔喻〕胸既结矣。本当下以开其结。然脉浮大。则表邪未尽。下之。是令其结而又结也。所以主死。此见一
误不堪再误也。
张兼善曰。脉浮大。心下虽结。其表邪尚多。未全结也。若辄下之。重虚其里。外邪复聚。而必死矣。
柴胡加桂枝干姜汤。以和解之。
案汪氏引补亡论。常器之云。可与增损理中丸。如未效。用黄连巴豆。捣如泥。封脐上。灼艾灸热渐效。
此盖脏结治法。恐与此条证。不相涉也。汪氏以为不可用。是矣。
案方氏钱氏程氏。以大为虚脉。恐非是也。
结胸证悉具。烦躁者亦死。（玉函。烦。作而。）
〔喻〕亦字承上。〔成〕结胸证悉具。邪结已深也。烦躁者。正气散乱也。邪气胜正。病者必死。〔程〕
此时下之则死。不下亦死。唯从前失下。至于如此。须玩一悉字。
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。（【原注】一云。头痛即眩。）胃中空虚。客气动膈。短气躁烦。
心中懊 。阳气内陷。心下因硬。则为结胸。大陷胸汤主之。若不结胸。但头汗出。余处无汗。剂颈而还。小
便不利。身必发黄。（膈内拒痛。玉函。脉经。千金翼。作头痛即眩。客气。外台。作客热。余处。玉函。脉
经。作其余。全书。脱处字。剂。脉经。千金翼。作齐。黄下。成本。有也字。袁表沈际飞本脉经。有属柴胡
栀子汤六字。金鉴云。数则为虚句。疑是衍文。是也。心下因硬。程本。作心中因硬。非也。）
〔成〕动数。皆阳脉也。当责邪在表。睡而汗出者。谓之盗汗。为邪气在半表半里。则不恶寒。此头痛发
热。微盗汗出。反恶寒者。表未解也。当发其汗。医反下之。虚其胃气。表邪乘虚则陷。邪在表则见阳脉。邪
在里则见阴脉。邪气内陷。动数之脉。所以变迟。而浮脉独不变者。以邪结胸中。上焦阳结。脉不得而沉也。
客气者。外邪乘胃中空虚入里。结于胸膈。膈中拒痛者。客气动膈也。金匮要略曰。短气不足以息者。实也。
短气躁烦。心中懊 。皆邪热为实。阳气内陷。气不得通于膈。壅于心下。为硬满而痛。成结胸也。与大陷胸
汤。以下结热。若胃中空虚。阳气内陷。不结于胸膈。下入于胃中者。遍身汗出。则为热越。不能发黄。若但
头汗出。身无汗剂颈而还。小便不利者。热不得越。必发黄也。〔方〕太阳之脉本浮。动数者。欲传也。浮则
为风四句。承上文以释其义。头痛至表未解也。言前证。然太阳本自汗。而言微盗汗。本恶寒而言反恶寒者。
稽久而然也。医反下之。至大陷胸汤主之。言误治之变。与救变之治。膈。心胸之间也。拒。格拒也。言邪气
入膈。膈气与邪气。相格拒而为痛也。空虚。言真气与食气。皆因下而致亏损也。客气。邪气也。阳气。客气
之别名也。以本外邪。故曰客气。以邪本风。故曰阳气。里虚而陷入。故曰内陷。〔汪〕夫曰膈内。曰心中。
曰心下。皆胸之分也。名曰结胸。其邪实陷于胃。胃中真气虚。斯阳邪从而陷入于胸。作结硬之形也。补亡论。
常器之云。发黄者。与茵陈蒿汤。煎茵陈浓汁。调五苓散。亦可。
钱氏云。表未解。乃桂枝汤证也。窃疑当是柴胡桂枝汤证。又云。动数之脉。变迟之后。阳邪已陷。岂尚
有浮脉乎。必无浮脉再见之理矣。
明理论曰。伤寒盗汗。非若杂病者之责其阳虚而已。是
由邪在半表半里使然也。何者。若邪气一切在表于卫。则自汗出。此则邪气侵行于里。外连于表邪。及睡则卫
气行于里。乘表中阳气不致。津液得泄。而为盗汗。亦非若自汗有为之虚者。有为之实者。其于盗汗。悉当和
表而已。
案客气。外台。作客热。知是阳气。乃阳热之邪气也。
案证治准绳。载朱震亨说云。胃中空虚。短气烦躁。虚之甚矣。岂可迅攻之乎。以栀子豉汤。吐胸中之邪
问：疾病中有结胸证，有脏结证，它们的症状表现是怎样的？
答：按压胸部疼痛，寸脉浮，关脉沉，这叫做结胸证。什么是脏结证？
答：症状像结胸证一样，但饮食如常，经常腹泻，寸脉浮，关脉小细沉紧，这叫做脏结证。舌上苔白且滑润的，难以治疗。（《玉函经》记载为“其脉寸口浮，关上自沉，时时下利”等；有的版本作“时小便不利”，阳脉浮，关上细沉而紧。张锡驹本中，“胎”字作“苔”。）
〔汪氏〕这里论述了结胸病状与脏结，虽然相似但各有不同。为什么说结胸和脏结都属于太阳病呢？因为这两种病都是由于太阳病误用攻下法导致的。
大概结胸病，起初是因为误下，损伤了上焦的阳气。阳气既已受伤，风寒之邪便乘虚而入，向上结聚于胸中。按压则痛，是因为胸中有实邪。寸脉浮、关脉沉，是邪气相结而成为实证的脉象。
至于脏结病，就不是这样了。它起初也是因为误下，损伤了中焦的阴血。阴血既已受伤，风寒之邪也乘虚而入，向内结聚于脏腑。症状像结胸，是因为脏气不平，逆乱于心下。饮食如常，是因为胸中没有邪气阻滞，胃中空虚。经常腹泻，是因为脏虚邪结，不能运化水谷，胃中的水谷不能分别清浊，因而偏渗于大肠，导致腹泻。寸脉浮、关脉沉，是结胸的脉象。现在诊察关脉，兼见小、细、紧，这说明脏气虚弱，风寒之邪内结是可以知道的。舌上白苔，经书说：“丹田有热，胸中有寒。”现在的苔滑，说明舌面湿润而冷。这是由于误下太过，变成了脏寒的证候，所以难以治疗。
按结胸证，其人本来胃中挟有食积，攻下太早，则食积不能去除，外邪反而入内，结于胸中，所以按压则痛，不能饮食。脏结证，其人胃中本来没有食积，攻下太过，则脏气虚弱，邪气入内，冷积于肠，所以症状像结胸，但按压不痛，能饮食，时常腹泻，舌上苔滑。这不是真正的寒证，而是过用攻下造成的误治。
〔魏氏〕人们只知道仲景辨析结胸不是脏结作为论断，却不知道仲景正是认为脏结与痞证有相似之处，而与结胸的实证不同罢了。大概结胸是阳邪，痞证与脏结是阴邪。痞证还有阳气浮越于上，脏结则是上下都没有阳气，只有独阴在内。阴气充满内部，这是四逆汤证的对应情况。
金鉴说：案此条“舌上白苔滑者难治”一句，前人的旧注，都单指脏结而言，未见明晰，误导了不少人。大概舌苔白滑，即使具备结胸证的症状，也是假实；舌苔干黄，即使具备脏结证的症状，往往潜伏着真热。脏结属阴邪，白滑为顺，尚可温散；结胸属阳邪，见到白滑为逆，不堪攻下，所以说难治。由此可知，著书立论，必须亲身体验，真知灼见，才对临床有用。如果仅仅依据纸上的陈词滥调，牵强附会，这与照着图画找好马有什么区别呢？○案金鉴这种说法，不知是否符合经文原旨，但因为是基于实验观察，所以附记于此。
案汪氏注释认为，结胸伤上焦之阳气，脏结伤中焦之阴气，在道理上并不妥当。
案“胎”字，锡驹作“苔”，原本出自庞氏《总病论》，知道“胎”本是“苔”字，从肉旁作“胎”，与胚胎的“胎”意义自然不同。又《圣惠方》记载本经文，也都写作“苔”。
脏结没有阳证，没有往来寒热。（【原注】一说：寒而不热。）病人反而安静，舌上苔滑的，不可攻下。（“不往来寒热”，《脉经》作“寒而不热”。“苔滑”，《病源》作“不胎”，庞氏作“胎”，锡驹同。）
〔柯氏〕结胸，是阳邪陷入，还有阳证见于外部，所以脉虽沉紧，有可以攻下的道理。脏结，是逐渐凝结而成阴证，五脏的阳气已经竭尽了。外部没有烦躁潮热等阳证，舌上没有黄黑芒刺等苔，虽然有硬满的症状，千万不可攻下。应用理中汤、四逆汤之类温补，尚且有生的希望。
案脏结，《补亡论》记载王朝奉针刺关元穴，是不对的。汪氏说，宜用艾灸。《医宗蕴要》说，灸气海、关元穴，宜用人参三白汤，加干姜，寒重的加附子。《全生集》说，灸关元，配合茱萸四逆加附子汤。以上方法适宜撰录采用。《准绳》说，王朝奉服用小柴胡汤，既然已经说了“不往来寒热”，为什么还用小柴胡汤？这是非常荒谬的。金鉴、程知说，经文对于脏结白苔滑，只说难治，从未说不可治。只说脏结无热，舌苔滑者，不可攻下，从未说脏结有热，舌苔不滑者，也不可攻下。我想，丹田有热，胸中有寒的证候，一定有和解其热、温散其寒的方法，使内邪潜消，外邪渐解，这才是高明医生的苦心吧。○汪氏说，脏结本来没有可下的证候。成无己注说，于法当下者，是错误的。集注潘氏说，按文义，如果脏结有阳证，也属于可攻，这种说法恐怕也不必。○案“反”字，是针对结胸的烦躁而言的。
病发于阳，而反用攻下法，热邪内入因而造成结胸。病发于阴，而反用攻下法，因而造成痞证。之所以形成结胸，是因为攻下太早的缘故。（成本中，“痞”字下无“也”字，《玉函》同。“病”字上冠有“夫”字。《千金翼》中“下而反下之”作“下而反汗之”。“痞”，《病源》作“否”。）
〔成无己〕说发热恶寒的，是发于阳。而反用攻下法，则表中的阳邪入里，结于胸中，成为结胸。无热恶寒的，是发于阴。而反用攻下法，表中的阴邪入里，结于心下成为痞证。
〔钱氏〕发于阳，是指邪气在阳经。发于阴，是指邪气在阴经。反用攻下法，是不应当攻下却攻下了。两个“反下”的意思截然不同。一个是表邪未解，却说反下；一个是始终不可攻下，却说反下。“因”字，是因为误下导致的正气虚弱。结胸说“热入”，是因为发热恶寒，表邪未解，误下则热邪乘虚陷入，成为结胸。因为热邪实于里，所以用大陷胸汤或小陷胸汤攻逐。痞证不说“热入”，是因为阴病本来属于无阳，一旦误下，则阳气更虚，阴邪更盛，客气上逆，就因此成为痞硬，如甘草泻心汤、半夏泻心汤、生姜泻心汤等证就是如此。末尾句只说下早是结胸的原因，而不及痞证，是因为邪在阳经而未解，邪还在表，如果早下，则里虚而邪热陷入，导致成结胸。如果表邪已解而下之，自然没有变逆的祸患，所以下早被视为禁忌。至于邪入阴经的证候，本来就没有可下的道理。阴经虽然有急下的条文，也都是由热邪传里造成的，并非阴经的本病。除此之外，还有什么可以反用攻下法的呢？
〔程知〕发于阳，是从发热恶寒而来，否则是热多寒少，攻下则表热陷入，被膻中之阳格拒，两阳相搏，这就是结胸。结胸是实邪。发于阴，是从无热恶寒而来，否则是寒多热少，攻下则虚邪上逆，也被膻中之阳所拒，阴阳互结，这就是痞。痞是虚邪。
〔张兼善〕病发于阳，是太阳表证误下，邪气结于胸中。病发于阴，都是内挟痰饮，外感风寒，中气先伤，所以汗下不解，而心下痞。有人说中风为阳邪，伤寒为阴邪（方有执、喻嘉言、金鉴都是这样认为）。哪有风伤卫气，气受伤反而变成结胸，寒伤营血，血受伤反而成痞的道理？又有误认直中阴寒之阴，下早变成痞的，则阴寒本来没有实热，怎么会有下早的变证？假设是阴结阴躁而误下之，立刻变为危逆，恐怕不至于成痞停留日久，等待变化而死。
案“发于阳”、“发于阴”，成无己、程知、钱氏都源于《伤寒论》太阳篇第八条的意义。然而所谓的“阴”，不是少阴直中的意思，只是寒邪有余，后世所谓挟阴之证。如果果真是直中纯阴，那么攻下有不立即死亡的么？张兼善的论述，虽然似乎对经文原意理解不够透彻，但验证于病人，往往有这样的情况，所以一并采录。张兼善驳斥成无己，以阴阳为表里，柯琴也认为是内外，周学海则说，发于阴者，确实是阴证，但是阳经传入的邪气，都不可从（阴经）论治。
《总病论》说：发热恶寒，是发于阳，误下则为结胸。无热恶寒，是发于阴，误下则为痞气。○案成无己的注解原本出于此。
《病源候论》说：结胸，是说热毒结聚于心胸。否则，心下满闷。按压自己感觉柔软，只是气痞而已，不可再攻下。又说痞，是塞的意思，说腑脏痞塞，不宣通。《释名》说：痞，气痞结也。《说文》徐锴曰：痞，病结也。《直指方》说：干上坤下，其卦为否。阳隔阴而不降，阴为阳而不升。这就是否卦之所以痞塞不通的原因。《伤寒百问经络图》说：但满而不痛者为痞，任人揉按，手不遮挡保护，按压并且感到舒适愉快。
结胸证，颈部也强硬，像柔痉的样子，攻下后则调和，宜用大陷胸丸。（《玉函》、《千金翼》中“项上”有“其”字。《玉函》、《脉经》作“痉”，是正确的。）
〔成无己〕结胸病项强的，是因为邪气结聚胸中，胸膈结满，心下紧实，只能仰头不能低头，这就是项强。
〔程知〕凡是胸上部结硬，而势态连及下部更严重的，大陷胸汤不容改变。如果胸上部结硬，而势态连及上部更严重的，缓急的形态既然不同，则汤剂与丸剂的制法稍异。结胸而至颈部也强硬，像柔痉的样子，如同邪液布满胸中，上升而上阻，更不容许一毫正气津液，和养其筋脉。胸邪到了这种地步，紧逼较甚，攻下则去邪液，也就是和正液。改大陷胸汤为大陷胸丸，峻猛治疗而行之以缓，得建瓴之势，而复与邪相当，这是它的法则。
〔柯琴〕头不痛而颈部仍然强，不恶寒而头汗出，所以像柔痉的样子。
大陷胸丸方
大黄（半斤） 葶苈子（半升，熬） 芒硝（半升） 杏仁（半升，去皮尖，熬黑）
以上四味药，捣筛两种药粉，纳入杏仁、芒硝，合研如脂状，混合散剂。取如弹丸大小一枚，另捣甘遂末一钱匕，白蜜二合，水二升，煮取一升，温服一次。一夜之后才排便。如果不排便，再服。排出大便为有效。禁忌同一般服药法。（白蜜二合，《玉函》、《千金》、《外台秘要》并作一两。）
〔钱氏〕大黄、芒硝、甘遂，即是大陷胸汤的成分。白蜜一合，也就是十枣汤中的大枣十枚。增加葶苈、杏仁，大概是因为胸是肺所在之处，膻中是气之海，上通于肺而为呼吸。邪结胸膈，硬满而痛，气道阻塞，则有少气躁烦、水结胸胁的危害。所以用葶苈、甘遂来逐水泻肺，杏仁来利肺下气。所用不过一弹丸，剂量虽然大但实际用量很小。用白蜜调和，药性虽然峻猛但佐使之力缓和。哪里像承气汤、陷胸汤那样让人行走十里二十里的迅速呢？
吴氏说：凡是说丸的，都是大弹丸，煮化后连同药渣一起服用。后面的抵当丸、理中丸同理。凡是说弹丸及鸡子黄的，以四十个梧桐子的大小为标准。（案出《本草序例》。）
《千金方》秘涩门，本方不用甘遂，蜜丸如梧桐子大，服七丸，名叫练中丸，主治宿食不消，大便难。《肘后方》名叫承气丸。庞氏《总病论》说：虚弱的人家，不耐受大陷胸汤，就用大陷胸丸攻下。
结胸证，脉象浮大的，不可攻下，攻下则死。
〔喻昌〕胸既已结聚，本来应当攻下以开其结。然而脉浮大，则表邪未尽。攻下，是令其结而又结，所以主死。这体现了一误不堪再误的道理。
张兼善说：脉浮大，心下虽然结聚，但表邪还多，未完全结聚。如果轻易攻下，重虚其里，外邪复聚，必然死亡。
柴胡加桂枝干姜汤，用以和解。
案汪氏引用《补亡论》，常器之说：可与增损理中丸，如无效，用黄连、巴豆，捣如泥，封脐上，灼艾灸热渐效。这大概是脏结的治疗方法，恐怕与此条证候不相涉。汪氏认为不可用，是对的。
案方氏、钱氏、程氏，以大为虚脉，恐怕不对。
结胸证全部具备，出现烦躁的，也死。（《玉函》中“烦”作“而”。）
〔喻昌〕“亦”字承接上文。
〔成无己〕结胸证全部具备，邪气结聚已深。烦躁，是正气散乱。邪气胜正，病人必死。
〔程知〕此时攻下则死，不攻下也死。唯有从前失于攻下，以至于如此。须玩味一个“悉”字。
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，微微盗汗出，反而恶寒的，表证未解。医生反用攻下法，动数脉变为迟脉，膈内拒痛。（【原注】一说：头痛即眩。）胃中空虚，客气动膈，短气躁烦，心中懊憹，阳气内陷，心下因硬，则为结胸，大陷胸汤主之。若不结胸，但头汗出，其余地方无汗，齐颈而还，小便不利，身体必定发黄。（“膈内拒痛”，《玉函》、《脉经》、《千金翼》作“头痛即眩”。“客气”，《外台秘要》作“客热”。“余处”，《玉函》、《脉经》作“其余”，《全书》脱“处”字。“剂”，《脉经》、《千金翼》作“齐”。“黄”下，成本有“也”字。袁表沈际飞本《脉经》有“属柴胡栀子汤”六字。金鉴说：“数则为虚”句，疑是衍文，是正确的。“心下因硬”，程本作“心中因硬”，不对。）
〔成无己〕动、数，都是阳脉。应当责求邪气在表。睡而汗出，叫做盗汗，为邪气在半表半里，则不恶寒。此头痛发热，微微盗汗出，反而恶寒的，表证未解。应当发其汗。医生反用攻下法，虚其胃气，表邪乘虚则陷。邪在表则见阳脉，邪在里则见阴脉。邪气内陷，动数之脉，所以变为迟脉，而浮脉独不变者，是因为邪结胸中，上焦阳结，脉不得而沉。
客气，是外邪乘胃中空虚入里，结于胸膈。膈中拒痛，是客气动膈。《金匮要略》说：短气不足以息者，实也。短气躁烦，心中懊憹，都是邪热为实。阳气内陷，气不得通于膈，壅于心下，为硬满而痛，成为结胸。与大陷胸汤，以攻下结热。若胃中空虚，阳气内陷，不结于胸膈，下入于胃中者，遍身汗出，则为热越，不能发黄。若但头汗出，身无汗齐颈而还，小便不利者，热不得越，必发黄。
〔方有执〕太阳的脉本浮，动数者，欲传也。浮则为风四句，承上文以解释其义。头痛至表未解也，言前证。然太阳本自汗，而言微盗汗，本恶寒而言反恶寒者，稽久而然也。医反下之，至大陷胸汤主之，言误治之变，与救变之治。膈，心胸之间也。拒，格拒也。言邪气入膈，膈气与邪气，相格拒而为痛也。空虚，言真气与食气，皆因下而致亏损也。客气，邪气也。阳气，客气之别名也。以本外邪，故曰客气，以邪本风，故曰阳气。里虚而陷入，故曰内陷。
〔汪氏〕夫曰膈内，曰心中，曰心下，皆胸之分也。名曰结胸，其邪实陷于胃，胃中真气虚，斯阳邪从而陷入于胸，作结硬之形也。《补亡论》，常器之说：发黄者，与茵陈蒿汤，煎茵陈浓汁，调五苓散，亦可。
钱氏说：表未解，乃桂枝汤证也。窃疑当是柴胡桂枝汤证。又说：动数之脉，变迟之后，阳邪已陷，岂尚有浮脉乎？必无浮脉再见之理矣。
《明理论》说：伤寒盗汗，不像杂病那样责其阳虚而已，是由邪气在半表半里使然的。为什么呢？若邪气一切在表于卫，则自汗出。此则邪气侵行于里，外连于表邪，及睡则卫气行于里，乘表中阳气不致，津液得泄，而为盗汗。也不像自汗有为之虚者，有为之实者。其于盗汗，悉当和表而已。
案“客气”，《外台秘要》作“客热”，知道是阳气，乃阳热之邪气也。
案《证治准绳》记载朱震亨说：胃中空虚，短气烦躁，虚之甚矣，岂可迅攻之乎？以栀子豉汤，吐胸中之邪。
Question: In disease, there is Jie Xiong (Chest Binding Syndrome) and Zang Jie (Organ Binding Syndrome). What are their manifestations?
Answer: Pain upon palpation of the chest, with a floating pulse at the Cun (inch) position and a sinking pulse at the Guan (bar) position, is called Jie Xiong (Chest Binding Syndrome). What is Zang Jie (Organ Binding Syndrome)?
Answer: The symptoms resemble those of Jie Xiong (Chest Binding Syndrome), but food intake remains normal, and there is frequent diarrhea. The pulse at the Cun (inch) position is floating, while the Guan (bar) position is small, thin, sinking, and tight; this is called Zang Jie (Organ Binding Syndrome). If the tongue has a white and slippery coating, it is difficult to treat. (*Yu Han Jing* records "pulse at Cun Kou is floating, Guan Shang is self-sinking, frequent diarrhea," etc.; some versions state "frequent difficulty in urination," Yang Mai (Yang Pulse) is floating, Guan Shang is fine, sinking, and tight. Zhang Xiju's version writes "Tai" as "Tai" [Tongue Coating].)
[Wang] This passage discusses the symptoms of Jie Xiong (Chest Binding Syndrome) and Zang Jie (Organ Binding Syndrome); although similar, they are distinct. Why are both considered Taiyang Disease (Disease of the Taiyang Channel)? Because both result from the erroneous use of purgatives in Taiyang Disease (Disease of the Taiyang Channel).
Generally, Jie Xiong (Chest Binding Syndrome) originates from an initial erroneous purgation that injures the Yang Qi (Vital Energy) of the Upper Jiao (Upper Burner). Once the Yang Qi (Vital Energy) is injured, Wind-Cold pathogenic factors enter due to deficiency and bind upward in the chest. Pain upon palpation indicates excess pathogens in the chest. A floating pulse at Cun (inch) and sinking at Guan (bar) signifies pathogenic binding resulting in excess.
As for Zang Jie (Organ Binding Syndrome), it is different. It also begins with erroneous purgation injuring the Yin Blood of the Middle Jiao (Middle Burner). Once Yin Blood is injured, Wind-Cold pathogenic factors enter due to deficiency and bind inwardly within the organs. The resemblance to Jie Xiong (Chest Binding Syndrome) arises because organ Qi is unbalanced and rebels against the epigastrium. Normal food intake indicates no pathogenic obstruction in the chest and emptiness in the Stomach. Frequent diarrhea occurs because organ deficiency and pathogenic binding impair transformation and transportation; water and grain in the Stomach fail to separate clear from turbid, instead draining into the Large Intestine, causing diarrhea. A floating pulse at Cun (inch) and sinking at Guan (bar) is typical of Jie Xiong (Chest Binding Syndrome). However, if the Guan (bar) pulse additionally presents as small, thin, and tight, it indicates organ deficiency and inward binding of Wind-Cold pathogens. A white tongue coating indicates what the Classics state: "Heat in the Dan Tian (Lower Abdomen), Cold in the Chest." A slippery coating implies the tongue is moist and cold. This results from excessive purgation transforming into a Cold syndrome of the Zang (Organs), hence it is difficult to treat.
Regarding Jie Xiong (Chest Binding Syndrome), the patient originally had food retention in the Stomach. Purging too early fails to remove the food, allowing external pathogens to enter and bind in the chest, causing pain on palpation and inability to eat. Regarding Zang Jie (Organ Binding Syndrome), the patient originally had no food retention. Excessive purgation causes organ deficiency and pathogen entry, leading to cold accumulation in the intestines. Thus, symptoms resemble Jie Xiong (Chest Binding Syndrome), but palpation yields no pain, eating is possible, diarrhea occurs frequently, and the tongue has a slippery coating. This is not a true Cold syndrome but an error caused by over-purgation.
[Wei] People know that Zhang Zhongjing distinguishes Jie Xiong (Chest Binding Syndrome) from Zang Jie (Organ Binding Syndrome), but they do not realize that he precisely means Zang Jie (Organ Binding Syndrome) resembles Pi Syndrome (Epigastric Fullness Syndrome) but differs fundamentally from the excess nature of Jie Xiong (Chest Binding Syndrome). Jie Xiong (Chest Binding Syndrome) involves Yang Pathogens (Excess Heat/Cold), whereas Pi Syndrome (Epigastric Fullness Syndrome) and Zang Jie (Organ Binding Syndrome) involve Yin Pathogens (Deficiency Cold). Pi Syndrome (Epigastric Fullness Syndrome) still has Yang Qi floating upward, while Zang Jie (Organ Binding Syndrome) lacks Yang Qi both above and below, consisting solely of Yin. Internal fullness of Yin Qi corresponds to the Si Ni Tang (Frigid Extremities Decoction) pattern.
Jin Jian states: Regarding the phrase "white slippery tongue coating indicates difficulty in treatment" in this clause, previous commentators applied it solely to Zang Jie (Organ Binding Syndrome) without clarity, misleading many. Generally, a white slippery tongue coating, even if Jie Xiong (Chest Binding Syndrome) symptoms are present, indicates false excess. A dry yellow tongue coating, even if Zang Jie (Organ Binding Syndrome) symptoms are present, often hides true heat. Zang Jie (Organ Binding Syndrome) is a Yin Pathogen (Deficiency Cold); white slipperiness is favorable and can be treated with warming dispersion. Jie Xiong (Chest Binding Syndrome) is a Yang Pathogen (Excess Heat/Cold); seeing white slipperiness is unfavorable and resists purgation, hence termed difficult to treat. This shows that writing medical texts requires personal experience and profound insight to be clinically useful. Merely relying on old textual theories and forcing interpretations is no different from searching for a horse based on a drawing. ○ Jin Jian's view may not fully align with the original intent of the Classic, but since it is based on clinical observation, it is appended here.
Note: Wang's annotation that Jie Xiong (Chest Binding Syndrome) injures Upper Jiao (Upper Burner) Yang Qi and Zang Jie (Organ Binding Syndrome) injures Middle Jiao (Middle Burner) Yin Qi is theoretically unsound.
Note: "Tai" (Fetus) written by Xiju as "Tai" (Coating) originates from Pang Shi's *Zong Bing Lun*. It is known that "Tai" was originally "Tai" (Coating), written with the meat radical, distinct in meaning from "Tai" (Fetus). Also, *Sheng Hui Fang* records this text using "Tai" (Coating).
Zang Jie (Organ Binding Syndrome) has no Yang signs, nor does it feature alternating chills and fever. ([Original Note] One version says: Chills without fever.) The patient appears calm. If the tongue has a slippery coating, purgation is contraindicated. ("Alternating chills and fever," *Mai Jing* reads "Chills without fever." "Slippery coating," *Bing Yuan* reads "No Tai," Pang Shi reads "Tai," Xiju agrees.)
[Ke] Jie Xiong (Chest Binding Syndrome) is the sinking of Yang Pathogens (Excess Heat/Cold), with Yang signs still visible externally. Thus, although the pulse is sinking and tight, purgation may be indicated. Zang Jie (Organ Binding Syndrome) is gradual condensation into a Yin condition, where the Yang Qi (Vital Energy) of the Five Zang Organs is exhausted. There are no external Yang signs like irritability or tidal fever, nor a tongue coating with yellow/black prickles. Despite hardness and fullness, purgation must be strictly avoided. Warming treatments such as Li Zhong Tang (Central Restore Decoction) or Si Ni Tang (Frigid Extremities Decoction) offer hope for survival.
Note: In *Bu Wang Lun*, Wang Chaofeng punctured the Guan Yuan (CV-4) acupoint for Zang Jie (Organ Binding Syndrome), which is incorrect. Wang suggests moxibustion is appropriate. *Yi Zong Yun Yao* recommends moxibustion on Qi Hai (CV-6) and Guan Yuan (CV-4), combined with Ren Shen San Bai Tang (Ginseng Three Whites Decoction) plus Gan Jiang (Dried Ginger), adding Fu Zi (Aconite Root) for severe cold. *Quan Sheng Ji* recommends moxibustion on Guan Yuan (CV-4) with Zhu Yu Si Ni Tang Plus Aconite (Nutmeg Frigid Extremities Decoction Plus Aconite). These methods should be adopted. *Zhun Sheng* states Wang Chaofeng used Xiao Chai Hu Tang (Minor Bupleurum Decoction), despite stating "no alternating chills and fever," which is absurd. Jin Jian and Cheng Zhi note that the Classic only says "difficult to treat" for Zang Jie (Organ Binding Syndrome) with white slippery coating, never "untreatable." It only says purgation is contraindicated when there is no heat and the coating is slippery, not that purgation is contraindicated if there is heat and the coating is not slippery. I surmise that for patterns of "Heat in Dan Tian, Cold in Chest," there must be methods to harmonize the heat and warm-disperse the cold, allowing internal pathogens to dissipate and external pathogens to resolve. This reflects the careful intention of skilled physicians. ○ Wang states Zang Jie (Organ Binding Syndrome) inherently lacks indications for purgation. Cheng Wuji notes that claiming it should be purged according to method is wrong. Pan in the Collected Notes argues that if Zang Jie (Organ Binding Syndrome) has Yang signs, purgation might be applicable, but this seems unnecessary. ○ The character "Fan" (Reverse/Instead) contrasts with the irritability seen in Jie Xiong (Chest Binding Syndrome).
When disease originates from Yang, and purgation is erroneously used, heat enters and forms Jie Xiong (Chest Binding Syndrome). When disease originates from Yin, and purgation is erroneously used, Pi Syndrome (Epigastric Fullness Syndrome) forms. The reason Jie Xiong (Chest Binding Syndrome) develops is due to purgation being too early. (In *Cheng Ben*, the word "Ye" follows "Pi"; *Yu Han* agrees. The character "Fu" precedes "Bing." *Qian Jin Yi* reads "Fan Han Zhi" instead of "Fan Xia Zhi." *Bing Yuan* writes "Pi" as "Pou".)
[Cheng Wuji] States that fever and aversion to cold indicate origin from Yang. Erroneous purgation causes exterior Yang Pathogens (Excess Heat/Cold) to enter the interior and bind in the chest, forming Jie Xiong (Chest Binding Syndrome). Absence of fever with aversion to cold indicates origin from Yin. Erroneous purgation causes interior Yin pathogens to enter and bind in the epigastrium, forming Pi Syndrome (Epigastric Fullness Syndrome).
[Qian] Originating from Yang means the pathogen is in the Yang Channels. Originating from Yin means the pathogen is in the Yin Channels. Erroneous purgation means purging when one should not. The two instances of "erroneous purgation" have distinct meanings. One refers to purging when the exterior pathogen is unresolved; the other refers to purging when it is absolutely contraindicated. "Yin" (Because/Due to) refers to the deficiency caused by erroneous purgation. Jie Xiong (Chest Binding Syndrome) mentions "heat entering" because fever and aversion to cold indicate unresolved exterior pathogen; erroneous purgation allows heat pathogens to sink into deficiency, forming Jie Xiong (Chest Binding Syndrome). Since heat pathogens are excess in the interior, Da Xian Xiong Tang (Major Sinking Chest Decoction) or Xiao Xian Xiong Tang (Minor Sinking Chest Decoction) are used. Pi Syndrome (Epigastric Fullness Syndrome) does not mention "heat entering" because Yin diseases inherently lack Yang. One erroneous purgation further depletes Yang Qi and exacerbates Yin pathogens. Guest Qi (External Pathogens) rebels upward, forming Pi Syndrome (Epigastric Fullness Syndrome), as seen in Gan Cao Xie Xin Tang (Licorice Drain the Epigastrium Decoction), Ban Xia Xie Xin Tang (Pinellia Drain the Epigastrium Decoction), and Sheng Jiang Xie Xin Tang (Fresh Ginger Drain the Epigastrium Decoction). The final sentence only cites early purgation as the cause of Jie Xiong (Chest Binding Syndrome), omitting Pi Syndrome (Epigastric Fullness Syndrome), because if the pathogen is in the Yang Channels and unresolved, it remains in the exterior. Early purgation causes interior deficiency and heat pathogen sinking, leading to Jie Xiong (Chest Binding Syndrome). If the exterior pathogen resolves before purgation, no adverse changes occur; thus, early purgation is cautioned against. For pathogen entering Yin Channels, there is inherently no indication for purgation. Although Yin Channels have clauses for urgent purgation, these arise from heat pathogens transmitting to the interior, not from the primary disease of Yin Channels. Aside from this, what else warrants erroneous purgation?
[Cheng Zhi] Originating from Yang stems from fever and aversion to cold, or alternatively, more heat than cold. Purgation causes exterior heat to sink and be rejected by the Yang of the Dan Zhong (Pericardium). Two Yangs contend, forming Jie Xiong (Chest Binding Syndrome), which is an Excess Pathogen. Originating from Yin stems from absence of fever with aversion to cold, or alternatively, more cold than heat. Purgation causes deficient pathogens to rebel upward and be rejected by the Yang of the Dan Zhong (Pericardium). Yin and Yang bind mutually, forming Pi Syndrome (Epigastric Fullness Syndrome), which is a Deficient Pathogen.
[Zhang Jianshan] Disease originating from Yang is Taiyang Exterior Syndrome treated erroneously with purgation, causing pathogen binding in the chest. Disease originating from Yin involves internal phlegm-fluid retention combined with external Wind-Cold, damaging Middle Qi first. Hence, sweating and purgation fail to resolve it, resulting in epigastric Pi Syndrome (Epigastric Fullness Syndrome). Some argue Wind Strike is Yang Pathogen and Cold Damage is Yin Pathogen (Fang Youzhi, Yu Jiayan, Jin Jian agree). How could Wind damaging Wei Qi lead to Jie Xiong (Chest Binding Syndrome), or Cold damaging Ying Blood lead to Pi Syndrome (Epigastric Fullness Syndrome)? Others mistakenly identify direct transmission to Yin Cold as Yin, attributing Pi Syndrome (Epigastric Fullness Syndrome) to early purgation. However, Yin Cold lacks excess heat, so how could early purgation cause change? Assuming Yin Binding and Yin Restlessness treated with erroneous purgation would immediately become critical, unlikely to linger as Pi Syndrome (Epigastric Fullness Syndrome) until death.
Note: "Originating from Yang/Yin" by Cheng, Cheng Zhi, and Qian derives from Article 8 of the Taiyang Chapter. However, "Yin" here does not refer to Shaoyin Direct Transmission, but rather excess Cold, later termed "Cold-Clasping" syndrome. If it were pure Yin Direct Transmission, purgation would cause immediate death. Zhang Jianshan's discussion, while seemingly unclear on the Classic's intent, matches clinical observations, so it is recorded. Zhang Jianshan refutes Cheng Wuji, interpreting Yin/Yang as Interior/Exterior. Ke Qin also views them as Exterior/Interior. Zhou Xuehai states that originating from Yin is indeed a Yin Syndrome, but pathogens transmitted from Yang Channels cannot be treated via Yin Channels.
*Zong Bing Lun* states: Fever and aversion to cold indicate origin from Yang; erroneous purgation leads to Jie Xiong (Chest Binding Syndrome). Absence of fever with aversion to cold indicates origin from Yin; erroneous purgation leads to Pi Qi (Epigastric Fullness Qi). ○ Cheng Wuji's commentary originates here.
*Bing Yuan Hou Lun* states: Jie Xiong (Chest Binding Syndrome) refers to heat-toxin binding in the chest and epigastrium. Otherwise, epigastric fullness exists. Palpation feels soft; it is merely Qi Pi (Qi Fullness), not suitable for further purgation. It also states Pi means blockage, referring to fu-organ blockage without free flow. *Shi Ming* states: Pi is Qi binding. Xu Kai in *Shuo Wen* states: Pi is pathological binding. *Zhi Zhi Fang* states: Heaven above, Earth below, the hexagram is Pi (Obstruction). Yang separates Yin and does not descend; Yin is blocked by Yang and does not ascend. This is why Pi (Obstruction) is blocked and不通. *Shang Han Bai Wen Jing Luo Tu* states: Fullness without pain is Pi (Epigastric Fullness); patients allow palpation without guarding, finding relief.
In Jie Xiong (Chest Binding Syndrome), the neck is also stiff, resembling Rou Jing (Soft Spasm). Purging brings harmony; Da Xian Xiong Wan (Major Sinking Chest Pill) is indicated. (*Yu Han*, *Qian Jin Yi* add "Qi" after "Xiang Shang." *Yu Han*, *Mai Jing* read "Jing," which is correct.)
[Cheng Wuji] Neck stiffness in Jie Xiong (Chest Binding Syndrome) occurs because pathogens bind in the chest, filling the chest-diaphragm, making the epigastrium tight and solid. The patient can look up but not down, constituting neck stiffness.
[Cheng Zhi] When hardness binds from the upper chest extending downward more severely, Da Xian Xiong Tang (Major Sinking Chest Decoction) is immutable. When hardness binds from the upper chest extending upward more severely, the urgency differs, requiring slight modifications between decoction and pill. Jie Xiong (Chest Binding Syndrome) with neck stiffness resembling Rou Jing (Soft Spasm) suggests fluid pathogens filling the chest, rising and obstructing, leaving no healthy fluids to nourish tendons. The chest pathology is tightly pressing; purging removes pathogenic fluids, thereby harmonizing healthy fluids. Changing Da Xian Xiong Tang to Da Xian Xiong Wan employs harsh treatment with slow action, utilizing gravity-like momentum to match the pathogens. This is its method.
[Ke Qin] Head is not painful, yet the neck is stiff; there is no aversion to cold, but head sweating occurs, resembling Rou Jing (Soft Spasm).
Da Xian Xiong Wan (Major Sinking Chest Pill) Formula
Da Huang (Rhubarb Root and Rhizome) - Half Jin
Ting Li Zi (Descurainiae Semen) - Half Sheng, roasted
Mang Xiao (Mirabilite) - Half Sheng
Xing Ren (Apricot Seed) - Half Sheng, skin and tips removed, roasted until black
Crush and sieve two ingredients. Add Xing Ren (Apricot Seed) and Mang Xiao (Mirabilite), grind together until pasty. Mix with powder. Take one pill the size of a bullet. Separately crush Gan Sui (Kansui Root) to one qian bi. Add Bai Mi (White Honey) two he, water two sheng. Boil to obtain one sheng. Warm and drink in one dose. Bowel movement occurs after one night. If no movement, administer again. Passage of stool indicates efficacy. Follow general medication precautions. (Bai Mi (White Honey) two he, *Yu Han*, *Qian Jin*, *Wai Tai* record as one liang.)
[Qian] Da Huang (Rhubarb Root and Rhizome), Mang Xiao (Mirabilite), and Gan Sui (Kansui Root) constitute Da Xian Xiong Tang (Major Sinking Chest Decoction). Bai Mi (White Honey) one he corresponds to ten Da Zao (Jujube Fruit) in Shi Zao Tang (Ten Jujubes Decoction). Adding Ting Li Zi (Descurainiae Semen) and Xing Ren (Apricot Seed) is because the chest is the residence of the Lung, and Dan Zhong (Pericardium) is the Sea of Qi, connecting to the Lung for respiration. Pathogen binding in the chest-diaphragm causes hardness, fullness, and pain, blocking the Qi pathway, leading to shortness of breath, irritability, and harm of water binding in the chest-hypochondrium. Thus, Ting Li Zi (Descurainiae Semen) and Gan Sui (Kansui Root) are used to drain water and purge the Lung, while Xing Ren (Apricot Seed) benefits the Lung and directs Qi downward. The dose is but one bullet-sized pill; though large in quantity, the actual medicinal amount is small. Harmonized with Bai Mi (White Honey), the harsh medicine is moderated. It is not as rapid as Cheng Qi Tang (Order the Qi Decoction) or Xian Xiong Tang (Sinking Chest Decoction), which act within ten to twenty li.
Wu states: All pills mentioned are large bullets, boiled down, and taken with the dregs. This applies to Di Dang Wan (Blood-Thirst Pill) and Li Zhong Wan (Restore the Center Pill). All mentions of bullet-sized or chicken-egg-yolk-sized pills are standardized to forty wutongzi-sized pills (see *Ben Cao Xu Li*).
*Qian Jin Fang* Mi Se Men uses this formula without Gan Sui (Kansui Root), formed into honey pills wutongzi-sized, seven pills per dose, named Lian Zhong Wan, treating retained food and difficult defecation. *Zhou Hou Fang* names it Cheng Qi Wan (Order the Qi Pill). Pang Shi's *Zong Bing Lun* states: For weak patients intolerant to Da Xian Xiong Tang (Major Sinking Chest Decoction), use Da Xian Xiong Wan (Major Sinking Chest Pill) to purge.
In Jie Xiong (Chest Binding Syndrome), if the pulse is floating and large, purgation is contraindicated; purgation leads to death.
[Yu Chang] The chest is already bound; purgation should open the binding. However, a floating-large pulse indicates unresolved exterior pathogens. Purgation causes binding upon binding, leading to death. This illustrates that one error cannot be repeated.
Zhang Jianshan states: Floating-large pulse indicates that although the epigastrium is bound, exterior pathogens remain abundant and not fully bound. Premature purgation heavily depletes the interior, allowing external pathogens to re-aggregate, causing certain death.
Chai Hu Jia Gui Zhi Gan Jiang Tang (Bupleurum Plus Cinnamon Twig and Dried Ginger Decoction) is used to harmonize.
Note: Wang cites *Bu Wang Lun*, Chang Qizhi suggests Zeng Sun Li Zhong Wan (Modified Restore the Center Pill); if ineffective, apply Huang Lian (Coptis Rhizome) and Ba Dou (Croton Seed) paste to the umbilicus with moxibustion. This is likely a treatment for Zang Jie (Organ Binding Syndrome), unrelated to this clause. Wang correctly deems it inapplicable.
Note: Fang, Qian, and Cheng interpret "large" as a deficiency pulse, which is likely incorrect.
If all Jie Xiong (Chest Binding Syndrome) symptoms are present and irritability occurs, death ensues. (*Yu Han* reads "Fan" as "Er".)
[Yu Chang] "Er" (Also) connects to the previous context.
[Cheng Wuji] All Jie Xiong (Chest Binding Syndrome) symptoms present indicate deep pathogen binding. Irritability indicates scattered Zheng Qi (Upright Qi). Pathogen overcoming Zheng Qi guarantees death.
[Cheng Zhi] Purging now leads to death; not purging also leads to death. This results from prior failure to purge. One must ponder the character "Xi" (All/Completely).
Taiyang Disease (Disease of the Taiyang Channel) presents with a floating, moving, and rapid pulse. Floating indicates Wind, Rapid indicates Heat, Moving indicates Pain, Rapid indicates Deficiency. Headache, fever, slight nocturnal sweating, and reverse aversion to cold indicate the exterior is unresolved. The physician erroneously uses purgation. The moving-rapid pulse becomes slow. Rejection pain in the diaphragm. ([Original Note] One version: Headache equates to vertigo.) The Stomach is empty; Guest Qi (External Pathogens) agitates the diaphragm. Shortness of breath, irritability, mental restlessness (Ao Nao), Yang Qi sinks inward. The epigastrium becomes hard, forming Jie Xiong (Chest Binding Syndrome). Da Xian Xiong Tang (Major Sinking Chest Decoction) governs. If Jie Xiong (Chest Binding Syndrome) does not form, but only head sweating occurs, with no sweat elsewhere, stopping at the neck, and urination is difficult, jaundice will surely develop. ("Rejection pain in the diaphragm," *Yu Han*, *Mai Jing*, *Qian Jin Yi* read "Headache equates to vertigo." "Guest Qi," *Wai Tai* reads "Ke Re" (Guest Heat). "Yu Chu," *Yu Han*, *Mai Jing* read "Qi Yu," *Quan Shu* omits "Chu." "Ji," *Mai Jing*, *Qian Jin Yi* read "Qi." After "Huang," *Cheng Ben* adds "Ye." Yuan edition/Shen Jifei *Mai Jing* includes "Shu Chai Hu Zhi Zi Tang" six characters. Jin Jian states the clause "Rapid indicates Deficiency" is likely an interpolation, which is correct. "Xin Xia Yin Ying," Cheng Ben reads "Xin Zhong Yin Ying," which is incorrect.)
[Cheng Wuji] Moving and Rapid are both Yang pulses. Pathogen should be sought in the exterior. Sweating during sleep is called Dao Han (Night Sweat), indicating pathogen in half-exterior half-interior, hence no aversion to cold. Here, headache, fever, slight nocturnal sweating, and reverse aversion to cold indicate unresolved exterior. Sweating should be induced. Erroneous purgation depletes Stomach Qi, allowing exterior pathogens to sink into deficiency. Exterior pathogen shows Yang pulses; interior pathogen shows Yin pulses. Pathogen sinking inward changes the moving-rapid pulse to slow. The floating pulse alone remains unchanged because pathogen binds in the chest, Yang binds in the Upper Jiao (Upper Burner), preventing the pulse from sinking.
Guest Qi refers to external pathogens entering the interior due to Stomach emptiness, binding in the chest-diaphragm. Diaphragmatic rejection pain is Guest Qi agitating the diaphragm. *Jin Gui Yao Lue* states: Shortness of breath with insufficient respiration indicates Excess. Shortness of breath, irritability, and mental restlessness (Ao Nao) indicate Excess Heat Pathogen. Yang Qi sinks inward, Qi fails to pass through the diaphragm, congests in the epigastrium, causing hardness, fullness, and pain, forming Jie Xiong (Chest Binding Syndrome). Da Xian Xiong Tang (Major Sinking Chest Decoction) is given to purge binding heat. If Stomach is empty, Yang Qi sinks inward, does not bind in chest-diaphragm, but descends into the Stomach, whole-body sweating occurs, representing Heat venting, preventing jaundice. If only head sweats, body has no sweat stopping at the neck, and urination is difficult, Heat cannot vent, and jaundice will surely develop.
[Fang Youzhi] Taiyang pulse is naturally floating. Moving-Rapid indicates impending transmission. The four clauses "Floating indicates Wind..." explain the preceding text. From headache to "exterior unresolved" describes prior symptoms. Taiyang naturally sweats; mentioning slight nocturnal sweat, and naturally having aversion to cold; mentioning reverse aversion to cold, implies prolonged duration. Physician erroneously purges, leading to Da Xian Xiong Tang (Major Sinking Chest Decoction) governing, describing mis-treatment changes and rescue treatments. Diaphragm is between heart and chest. Ju (Reject) means repulsion. Pathogen enters diaphragm, Diaphragm Qi repels pathogen, causing pain. Kong Xu (Empty/Void) means True Qi and Food Qi are depleted by purgation. Ke Qi (Guest Qi) is pathogen. Yang Qi is another name for Guest Qi. Because it is external pathogen, it is called Guest Qi; because pathogen is Wind, it is called Yang Qi. Interior deficiency causes sinking, hence "Internal Sink."
[Wang] Terms "Ge Nei" (Inside Diaphragm), "Xin Zhong" (In Heart), "Xin Xia" (Below Heart) all refer to the chest region. Named Jie Xiong (Chest Binding Syndrome), the pathogen excessively sinks into the Stomach, Stomach True Qi is deficient, allowing Yang Pathogen to sink into the chest, forming hardness. *Bu Wang Lun*, Chang Qizhi states: For jaundice, use Yin Chen Hao Tang (Artemisiae Scopariae Decoction), brew strong Yin Chen juice, mix with Wu Ling San (Five-Ling Powder), which is also acceptable.
Qian states: Unresolved exterior is Gui Zhi Tang (Cinnamon Twig Decoction) pattern. I suspect it should be Chai Hu Gui Zhi Tang (Bupleurum Plus Cinnamon Twig Decoction) pattern. Also, after the moving-rapid pulse changes to slow, Yang pathogen has sunk; how can a floating pulse remain? It is impossible for a floating pulse to reappear.
*Ming Li Lun* states: Shang Han (Cold Damage) nocturnal sweating is not merely attributed to Yang deficiency as in miscellaneous diseases, but results from pathogen in half-exterior half-interior. If pathogen is entirely in the exterior on the Wei level, spontaneous sweating occurs. Here, pathogen invades the interior, connecting externally to exterior pathogen. During sleep, Wei Qi travels inward. Taking advantage of insufficient Yang Qi in the middle-exterior, fluids leak out, causing nocturnal sweating. Unlike spontaneous sweating which can be deficiency or excess, nocturnal sweating generally requires harmonizing the exterior.
Note: "Ke Qi" (Guest Qi) in *Wai Tai* is "Ke Re" (Guest Heat), indicating Yang Qi, specifically Yang-Heat Pathogen.
Note: *Zheng Zhi Zhun Sheng* records Zhu Zhenheng saying: Empty Stomach, shortness of breath, irritability indicate extreme deficiency. How can one rapidly attack? Use Zhi Zi Chi Tang (Gardenia and Soybean Decoction) to vomit pathogen from the chest.