大黄半筋 葶苈子（熬）半升 芒硝半升 杏仁（去皮、尖，熬黑）半升
右四味，捣筛二味，内杏仁、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。
结胸证，其脉浮大者，不可下，下之则死。
【注】
结胸证，若脉大，是为胃实，知结热已实乃可下，下之则愈。今其脉浮大，是尚在表
，知热结未实，故不可下。若误下之，未尽之表邪复乘虚入里，误而又误，结而又结
，病热弥深，正气愈虚，则死矣。
【集注】
张兼善曰：结胸为可下之证，若脉浮大，心下虽结，表邪尚多，下之重虚其里，外邪
复聚则死矣。
程知曰：结胸亦有不可下者，宜审其脉以施治也。结胸为邪结上焦之分，得寸脉浮，
关脉沉或沉紧，则为在里可下也。若脉浮大，则邪犹在表，下之是令其结而又结也，
故死。
结胸证悉具，烦躁者亦死。
【注】
结胸证悉具，谓□满而痛，结在膈之上下也。悉具者，谓胸之下，少腹之上，左右两
□，无不□满而有痛也。较之大结胸为尤甚，此时宜急下之，或有生者；若复迁延，
必至邪胜正负，形气相离，烦躁不宁，下亦死，不下亦死矣。
【集注】
方有执曰：结胸证全具，已主死矣。而更加以烦躁，即不再下，亦主死也。
程应旄曰：结胸证，妄下不可，失下亦不可。总在适当其宜，则去邪即所以安正也。
魏荔彤曰：此条乃承上条脉见浮大而言。必结胸证具，脉兼见浮大，而加以烦躁，方
可卜其死。不然，烦躁亦结胸证中之一也，何遽云死耶！
问曰：病有结胸，有藏结，其状何如？答曰：按之痛，寸脉浮，关脉沉，名曰结胸也
，何谓藏结？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
藏结。舌上白胎滑者，难治。
【注】
邪结三阳，名曰结胸；邪结三阴，名曰藏结。二者皆下后邪气乘虚入里所致，而其脉
与证之状则不同。其□满而按之痛，结胸证也。寸脉浮、关脉沉，结胸脉也。寸浮主
胸主表，关沉主胃主里，是知其邪由胸表陷入胃里而结也。如结胸状，饮食如故，时
时下利，藏结证也。寸脉浮、关脉细小沉紧，藏结脉也。细小沉紧主藏结寒痛，是知
其邪由胸表陷入藏里而结也。藏结虽□满而痛，如结胸状，然结胸病，属里壅塞，必
不能饮食；藏结病，属里空虚，故饮食如故。结胸属实热，故□痛不大便而脉沉石；
藏结属虚寒，故□痛下利而脉细紧也。舌上白胎滑者，胸中无热可知：藏结阴邪，得
之为顺，尚可以理中辈温之。结胸阳邪，得之为逆，不堪攻下，故难治也。
【集注】
成无己曰：气宜通也，以塞故痛。邪结阳分，则阴气不得下通；邪结阴分，则阳气不
得上通，故知二者，皆按之痛□也。
方有执曰：此设问答以明结胸、藏结之同异。藏结之时时下利者，阴邪结于阴藏，而
寒甚也。以寒甚，故脉小细紧，此其所以不同也。盖结胸以阳邪结于阳，藏结以阴邪
结于阴故也。
汪琥曰：结胸证，其人本胃中有饮食，下之太早，则食去不尽，外邪反入，结于胸中
，以故按之则痛，不能饮食。藏结证，其人胃中本无饮食，下之太过，则藏虚，邪入
与寒结于阴分，所以状如结胸，按之不痛，能饮食，时下利也。
魏荔彤曰：人知此条为辨结胸，非指藏结而论，不知正谓藏结与痞有相类，而与结胸
实有不同。盖结胸阳邪也，痞与藏结阴邪也。痞则尚有阳浮于上，藏结则上下俱无阳
，是皆误下、误吐之过也。
【按】
此条「舌上白胎滑者难治」句，前人旧注皆单指藏结而言，未见明晰，误人不少。盖
舌胎白滑，即结胸证具，亦是假实；舌胎干黄，虽藏结证具，每伏真热。藏结阴邪，
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
按图索骥耶？
病□下素有痞，连在脐旁，痛引少腹，入阴筋者，此名藏结，死。
【注】
病藏结之人，若□下素有痞连在脐旁，新旧病合，痛引少腹，入阴筋者，其邪又进厥
阴，乃属藏结之死证也。
【集注】
程知曰：宿结之邪，与新结之邪交结而不解，痞连脐旁，脾藏结也；痛引少腹，肾藏
结也。自□入阴筋，肝藏结也；三阴之藏俱结矣，故主死。
藏结无阳证，不往来寒热，其人反静，舌上胎滑者，不可攻也。
【注】
藏结无三阳证。不发热，无太阳也；不往来寒热，无少阳也；其人反静，无阳明也。
舌胎滑白，胸中有寒，故可温不可攻也。
【集注】
方有执曰：胎滑本丹田有热、胸中有寒而成。然丹田阴也。胸中阳也。热反在阴而寒
反在阳 ，所以为不可攻也。
程知曰：经于藏结白胎滑者，只言难治，未尝言不可治也。只言藏结无热舌胎滑者，
不可攻，未尝言藏结有热舌胎不滑者，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！
病在阳，应以汗解之，反以冷水潠之，若灌之，其热被却不得去，弥更益烦，肉上粟
起，意欲饮水，反不渴者，服文蛤散；若不差者，与五苓散。身热皮粟不解，欲引衣
自覆者；若水以潠之洗之，益令热被却不得出，当汗而不汗则烦。假令汗出已，腹中
痛，与芍药三两如上法。
【注】
病在阳，谓病发于阳而身热也。此应以汗解之，而反以冷水选之灌之，则身热虽被劫
而暂却，然终不得去，故热烦益甚也。水寒外束，肤热乍凝，故肉生肤粟，热入不深
，故意欲饮水反不甚渴也，故以文蛤散内疏肤热。若不差，与五苓散外解水寒；则皮
粟、身热当解矣。若不解且恶寒，引衣自覆，是尚有表也。当以桂枝汤汗解之。假令
服桂枝汤，汗已出，热粟俱解，而腹中增痛，又为表已和里未调也，宜与桂枝汤倍加
芍药，调里以和其表。若渴欲饮水而不腹痛，则不须调太阴里，而仍当调太阳府矣，
宜仍取乎五苓也。
大黄半筋，葶苈子（炒制）半升，芒硝半升，杏仁（去皮、尖，炒至黑色）半升。
以上四味药，将其中两味捣碎过筛，加入杏仁和芒硝，共同研磨如脂状，与药散混合。取如弹丸大小的一枚药团，另捣甘遂末一钱匕，白蜜二合，水二升，煎煮取一升，温服一次顿下，一夜后大便通下。如果未通下，再服用，以下便为见效。禁忌事项同一般服药法。
结胸证，若脉象浮大的，不可用攻下法，误用攻下法会导致死亡。
【注】
结胸证，若脉大，这是胃气实，知道热结已经结实才可以攻下，攻下后则痊愈。现在脉象浮大，说明病邪尚在表，知道热结尚未结实，所以不可攻下。如果误用攻下法，未尽的表邪乘虚入里，误上加误，结上加结，病热更深，正气更虚，就会死亡。
【集注】
张兼善说：结胸是可以用攻下法的证候，若脉象浮大，心下虽然结聚，但表邪尚多，攻下会严重损伤里气，外邪重新聚集就会死亡。
程知说：结胸也有不可攻下的情况，应当审察脉象来施治。结胸是邪气结在上焦部位，出现寸脉浮，关脉沉或沉紧，就是病在里可以攻下。若脉象浮大，则邪气仍在表，攻下会使邪气结而又结，所以致死。
结胸证症状全部具备，又出现烦躁的，也是死证。
【注】
结胸证症状全部具备，指心下痞满而痛，结聚在膈膜的上下。所谓“悉具”，是指胸之下，少腹之上，左右两侧，无不痞满而有疼痛。这比大结胸证更为严重，此时应当急下，或许还有生机；如果拖延，必然导致邪胜正衰，形气分离，烦躁不宁，此时攻下也死，不攻下也死。
【集注】
方有执说：结胸证完全具备，就已经主死。如果再加以烦躁，即使不再攻下，也主死。
程应旄说：结胸证，妄用攻下不可，失于攻下也不可。总在于适当其宜，那么祛除邪气也就是安护正气。
魏荔彤说：这一条是承接上一条脉见浮大而言。必须结胸证具备，脉象兼见浮大，再加上烦躁，才可以断定其死。不然，烦躁也是结胸证中的一种表现，怎么就说是死证呢！
问：病有结胸，有藏结，它们的症状如何？答：按之疼痛，寸脉浮，关脉沉，名叫结胸。什么叫藏结？答：像结胸的症状，饮食如常，时时下利，寸脉浮，关脉小细沉紧，名叫藏结。舌上苔白滑的，难治。
【注】
邪气结在三阳经，名叫结胸；邪气结在三阴经，名叫藏结。二者都是下法之后邪气乘虚入里所致，但其脉象与症状不同。心下痞满而按之疼痛，是结胸证。寸脉浮、关脉沉，是结胸脉。寸浮主胸主表，关沉主胃主里，由此知道邪气由胸表陷入胃里而结聚。像结胸的症状，饮食如常，时时下利，是藏结证。寸脉浮、关脉细小沉紧，是藏结脉。细小沉紧主藏结寒痛，由此知道邪气由胸表陷入脏里而结聚。藏结虽然痞满而痛，像结胸一样，但是结胸病，属于里部壅塞，必定不能饮食；藏结病，属于里部空虚，所以饮食如常。结胸属实热，所以痞痛不大便而脉沉石；藏结属虚寒，所以痞痛下利而脉细紧。舌上苔白滑的，可知胸中无热：藏结是阴邪，见到此苔为顺，还可以用理中汤类温补。结胸是阳邪，见到此苔为逆，不堪攻下，所以难治。
【集注】
成无己说：气宜通畅，因堵塞故疼痛。邪结在阳分，则阴气不得下通；邪结在阴分，则阳气不得上通，所以知道二者，都是按之疼痛痞满。
方有执说：此处设问答以阐明结胸、藏结的同异。藏结之时时下利的，是阴邪结于阴脏，且寒甚。因为寒甚，所以脉小细紧，这就是它们不同的原因。大概结胸是阳邪结于阳，藏结是阴邪结于阴的缘故。
汪琥说：结胸证，其人本胃中有饮食，下法太早，则食去不尽，外邪反入，结于胸中，所以按之则痛，不能饮食。藏结证，其人胃中本无饮食，下法太过，则脏虚，邪入与寒结于阴分，所以状如结胸，按之不痛，能饮食，时时下利。
魏荔彤说：人们知道这一条是辨析结胸，并非论述藏结，不知道正是说藏结与痞证有相似之处，而与结胸确实有不同。大概结胸是阳邪，痞与藏结是阴邪。痞证则尚有阳浮于上，藏结则上下俱无阳，这都是误下、误吐造成的过错。
【按】
这一条中“舌上白胎滑者难治”一句，前人旧注都单指藏结而言，未见明晰，误导不少人。大概舌苔白滑，即使是结胸证具备，也是假实；舌苔干黄，虽然是藏结证具备，往往潜伏真热。藏结是阴邪，白滑为顺，尚可温散；结胸是阳邪，见此为逆，不堪攻下，所以为难治。由此可知，著书立论，必须亲身体验，真知灼见，才有利于应用。如果只是拘泥于纸上陈言，牵强附会，又与按图索骥有什么区别呢？
病人脐下素有痞块，连在脐旁，疼痛牵引少腹，进入阴筋的，这叫藏结，死证。
【注】
患藏结病的人，如果脐下素有痞块连在脐旁，新旧病合，疼痛牵引少腹，进入阴筋的，其邪气又进厥阴经，属于藏结的死证。
【集注】
程知说：宿结之邪，与新结之邪交结而不解，痞连脐旁，是脾脏结聚；疼痛牵引少腹，是肾脏结聚。自脐下入阴筋，是肝脏结聚；三阴之脏都结聚了，所以主死。
藏结没有阳证，不往来寒热，其人反而安静，舌上苔滑的，不可攻下。
【注】
藏结没有三阳证。不发热，就没有太阳证；不往来寒热，就没有少阳证；其人反而安静，就没有阳明证。舌苔滑白，胸中有寒，所以可温不可攻。
【集注】
方有执说：苔滑本是丹田有热、胸中有寒而成。然而丹田属阴，胸中属阳。热反在阴而寒反在阳，所以为不可攻。
程知说：经文对于藏结白苔滑者，只说难治，未曾说不可治。只说藏结无热舌苔滑者，不可攻，未曾说藏结有热舌苔不滑者，也不可攻。意思是丹田有热，胸中有寒的证候，必有和解其热，温散其寒的方法。使内邪潜消，外邪渐解，这才是良医的苦心吧！
病在阳分，应当用发汗法解除，反而用冷水喷洗，或者灌洗，其热被遏制不能去除，更加烦闷，皮肤起粟粒，想要喝水，反而不渴的，服用文蛤散；如果不愈，给予五苓散。身热皮粟不解，想要拉衣覆盖自己；如果用冷水喷洗，更加令热被遏制不能外出，应当出汗却不出汗则烦闷。假如汗出以后，腹中痛，给予芍药三两，如上法。
Da Huang (Rhei Radix et Rhizoma) half jin, Ting Li Zi (Descurainiae Semen Lepidii Semen) half sheng, Mang Xiao (Natrii Sulfas) half sheng, Xing Ren (Armeniacae Semen Amarum) (deprived of skin and tip, roasted until black) half sheng.
The above four herbs, crush and sieve two of them, add Xing Ren and Mang Xiao, grind together until like fat, and mix with the powder. Take a pill-sized piece, separately crush Gan Sui (Kansui Radix) into powder one qian bi, Bai Mi (Mell) two he, water two sheng, boil to obtain one sheng, take warm in one dose. After one night, stool will pass. If not passed, administer again; passing stool is the sign of efficacy. Contraindications are as per general medication rules.
In Jie Xiong syndrome (Chest Binding Syndrome), if the pulse is floating and large, purgation must not be used; using it will lead to death.
[Note]
In Jie Xiong syndrome, if the pulse is large, this indicates Stomach excess; knowing that heat binding is solidified allows for purgation, after which recovery occurs. Now, since the pulse is floating and large, the pathogen remains at the exterior; knowing that heat binding is not yet solidified, purgation is contraindicated. If mistakenly purged, the remaining exterior pathogen enters the interior due to deficiency, compounding error upon error, binding upon binding, deepening the disease heat and further depleting healthy qi, leading to death.
[Collected Notes]
Zhang Jianshan said: Jie Xiong is a syndrome suitable for purgation. If the pulse is floating and large, although there is binding below the heart, there is still much exterior pathogen. Purgation severely damages the interior, and re-aggregation of external pathogens leads to death.
Cheng Zhi said: There are cases of Jie Xiong where purgation is contraindicated; one must examine the pulse to apply treatment. Jie Xiong involves pathogen binding in the upper jiao; if the cun pulse is floating and the guan pulse is sunken or sunken-tight, it is interior and suitable for purgation. If the pulse is floating and large, the pathogen is still at the exterior; purgation causes binding upon binding, hence death.
If all symptoms of Jie Xiong syndrome are present and restlessness (Fan Zao) appears, it is also a fatal condition.
[Note]
"All symptoms present" refers to epigastric fullness and pain, binding above and below the diaphragm. "Fully present" means from below the chest to above the lower abdomen, on both left and right sides, there is fullness and pain. This is more severe than Da Jie Xiong (Major Chest Binding). At this time, urgent purgation should be applied; survival is possible. If delayed, evil will overcome righteousness, form and qi will separate, causing restless agitation; purging leads to death, not purging also leads to death.
[Collected Notes]
Fang Youzhi said: When all symptoms of Jie Xiong are fully present, death is indicated. Adding restlessness confirms death even without purgation.
Cheng Yingmao said: In Jie Xiong syndrome, reckless purgation is inadvisable, but failing to purge when necessary is also inadvisable. The key lies in appropriateness; eliminating evil thereby protects righteous qi.
Wei Litong said: This clause follows the previous discussion on floating-large pulses. Death can only be predicted if Jie Xiong symptoms are complete, the pulse is floating-large, AND restlessness is present. Otherwise, restlessness is merely one symptom of Jie Xiong; why declare it fatal?
Q: There are Jie Xiong and Zang Jie (Viscera Binding); what are their manifestations? A: Tenderness on pressure, cun pulse floating, guan pulse sunken is named Jie Xiong. What is Zang Jie? A: Similar to Jie Xiong, but food intake is normal, frequent loose stools occur, cun pulse floating, guan pulse small-fine-sunken-tight is named Zang Jie. White slippery coating on the tongue indicates difficult treatment.
[Note]
Pathogen binding in the Three Yang meridians is named Jie Xiong; binding in the Three Yin meridians is named Zang Jie. Both result from pathogen entering the interior due to deficiency after improper purgation, but their pulses and symptoms differ. Epigastric fullness with tenderness on pressure is Jie Xiong syndrome. Floating cun and sunken guan pulses are Jie Xiong pulses. Floating cun indicates chest/exterior; sunken guan indicates Stomach/interior; thus, pathogen moves from chest exterior to Stomach interior. Similar appearance but normal diet and frequent loose stools indicate Zang Jie syndrome. Floating cun and small-fine-sunken-tight guan pulses are Zang Jie pulses. Small-fine-sunken-tight indicates Zang Jie cold-pain; thus, pathogen moves from chest exterior to Viscera interior. Although Zang Jie has fullness and pain like Jie Xiong, Jie Xiong belongs to interior obstruction and prevents eating; Zang Jie belongs to interior emptiness, so eating remains normal. Jie Xiong is excess-heat, causing pain and constipation with stone-like sinking pulse; Zang Jie is deficiency-cold, causing pain and diarrhea with fine-tight pulse. White slippery tongue coating indicates no heat in the chest: Zang Jie is yin-pathogen, seeing this coating is favorable, treatable with warming formulas like Lizhong Tang. Jie Xiong is yang-pathogen, seeing this coating is unfavorable, resistant to purgation, hence difficult to treat.
[Collected Notes]
Cheng Wuji said: Qi should flow freely; blockage causes pain. Pathogen binding in Yang divisions blocks Yin qi from descending; binding in Yin divisions blocks Yang qi from ascending. Thus, both present with tenderness and fullness on pressure.
Fang Youzhi said: This Q&A clarifies similarities and differences between Jie Xiong and Zang Jie. Frequent loose stools in Zang Jie indicate Yin pathogen binding in Yin viscera with severe cold. Due to severe cold, the pulse is small-fine-tight, which distinguishes it. Generally, Jie Xiong is Yang pathogen binding in Yang; Zang Jie is Yin pathogen binding in Yin.
Wang Hu said: In Jie Xiong, the patient originally had food in the Stomach; premature purgation leaves undigested food, allowing external pathogen to enter and bind in the chest, causing tenderness and inability to eat. In Zang Jie, the patient originally had no food in the Stomach; excessive purgation causes Viscera deficiency, allowing pathogen to enter and bind with cold in Yin divisions. Thus, it resembles Jie Xiong but lacks tenderness on pressure, allows eating, and features frequent loose stools.
Wei Litong said: People know this clause differentiates Jie Xiong, not discussing Zang Jie, but it actually states that Zang Jie resembles Pi (Glomus) syndrome but differs significantly from Jie Xiong. Jie Xiong is Yang pathogen; Pi and Zang Jie are Yin pathogens. Pi has some Yang floating upward; Zang Jie has no Yang above or below. These are errors from mistaken purgation or vomiting.
[Commentary]
The phrase "White slippery tongue coating indicates difficult treatment" in this clause was previously interpreted by commentators as referring solely to Zang Jie, lacking clarity and misleading many. Actually, white slippery coating, even if Jie Xiong symptoms are present, indicates false excess; dry yellow coating, even if Zang Jie symptoms are present, often hides true heat. Zang Jie is Yin pathogen; white slippery is favorable, treatable with warming dispersal. Jie Xiong is Yang pathogen; seeing this is unfavorable, resistant to purgation, hence difficult. Thus, writing medical theories requires personal experience and profound insight for practical utility. Merely relying on old texts and forcing interpretations is akin to following a map to find a horse—what difference is there?
If a patient has long-standing Pi (Glomus) below the umbilicus, connected to the side of the umbilicus, pain radiating to the lower abdomen and entering the genital tendons, this is named Zang Jie, a fatal condition.
[Note]
In patients with Zang Jie, if there is long-standing Pi below the umbilicus connected to the side, combining new and old diseases, with pain radiating to the lower abdomen and entering the genital tendons, the pathogen has advanced to the Jueyin meridian, constituting a fatal stage of Zang Jie.
[Collected Notes]
Cheng Zhi said: Old binding pathogen and new binding pathogen intertwine unresolved. Pi connected to the umbilicus indicates Spleen Viscera binding; pain radiating to the lower abdomen indicates Kidney Viscera binding. From the umbilicus entering genital tendons indicates Liver Viscera binding; with all Three Yin Viscera bound, death is indicated.
Zang Jie presents without Yang syndromes: no alternating chills and fever, the person is instead quiet, and the tongue coating is slippery; attack/purgation is contraindicated.
[Note]
Zang Jie lacks Three Yang syndromes. No fever means no Taiyang syndrome; no alternating chills and fever means no Shaoyang syndrome; the person is quiet, meaning no Yangming syndrome. Slippery white coating indicates Cold in the chest; therefore, warming is indicated, not attacking/purging.
[Collected Notes]
Fang Youzhi said: Slippy coating results from Heat in the Dantian and Cold in the chest. However, Dantian is Yin, and chest is Yang. Heat being in Yin and Cold in Yang makes it unsuitable for purgation.
Cheng Zhi said: The Classic states regarding Zang Jie with white slippery coating that it is difficult to treat, never saying untreatable. It states regarding Zang Jie without heat and slippery coating that purgation is contraindicated, never saying that Zang Jie with heat and non-slippery coating is also contraindicated. The implication is that conditions with Heat in Dantian and Cold in chest require methods to harmonize heat and warm-disperse cold, allowing internal evil to dissipate and external evil to resolve gradually. This is the painstaking effort of a skilled physician!
When the disease is in the Yang level, sweating should be used to resolve it. Instead, cold water is sprayed or poured on the body. The heat is suppressed but cannot escape, increasing irritability, causing gooseflesh on the skin, desire to drink water but lack of thirst. Administer Wen Ge San (Clam Shell Powder); if ineffective, administer Wu Ling San (Five-Ingredient Powder with Poria). If body heat and skin gooseflesh persist, and the patient desires to cover themselves with clothes; spraying/washing with water further suppresses heat preventing its exit, leading to frustration when sweat should occur but does not. If sweating occurs subsequently and abdominal pain arises, administer Shao Yao (Paeoniae Radix) three liang, as per the above method.