哲言
胸痹与胸痞不同。胸痞有暴寒郁结于胸者；有火郁于中者；
有寒热互郁者；有气实填胸而痞者；有气衰而成虚痞者；有肺胃津液枯涩，因燥而痞者；有上焦湿浊弥漫而痞
者。若夫胸痹，但因胸中阳虚不运，久而成痹。《内经》未曾详言，惟《金匮》立方俱用辛滑温通，所云∶寸
口脉沉而迟，阳微阴弦，是知但有寒证而无热证矣。治法亦惟温通上焦清阳为主。莫与胸痞、结胸、噎隔、痰
食等证混治，斯得之矣。（《临证指南》）
凡遇胸痹、心痛、短气等证，以为虚而有邪在，非虚也；以为实而有邪乘，非实也。标本缓急之间，神明
者顾可缺一不讲也耶？（魏荔彤）
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。○胸痹不得卧，
心痛彻背者，栝蒌薤白半夏汤主之。○胸痹，心中痞气，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。○胸痹，胸中气塞短气，茯苓杏仁甘草汤主之；橘枳姜汤亦主之。○胸痹缓急者，薏苡仁附子
散主之。（《金匮》）
胸所蕴者，氤氲之气，此处宜空而不宜实。空者，阳气宣也；实者，阴气着也。氤氲之气，一经沸郁，而
营弗能从，则若痰、若瘀、若气、若饮，皆刺而痛之之具也。治法有升、有降、有导、有泄之不同，总不若此
之开郁顺气，能宣发诸阳而使之开也。（程郊倩）
胸中阳气，如离照当空，旷然无外，设地气一上，则窒塞有加。故知胸痹者，阴气上逆之候也。仲景微则
用薤白、白酒以通其阳；甚则用附子、干姜以消其阴。世医不知胸痹为何病，习用豆蔻、木香、诃子、三棱、
神曲、麦芽等药，坐耗其胸中之阳，亦相悬矣。（喻嘉言）
胸痹三方，皆用栝蒌、薤白，按其治法，却微分三焦。《经》言∶淫气喘息，痹聚在肺。盖谓妄行之气，
随各脏之内因所主而入为痹。然而病变不同，治亦稍异。止就胸痹喘息、咳唾、胸背痛、
短气者，君以薤白滑利通阳，臣以栝蒌润下通阴，佐以白酒熟谷之气上行药性，助其通经活络，而痹自开。若
转结中焦，而为心痛彻背者，但加半夏一味，和胃而通阴阳。若结于胸胁，更加逆气上抢于心，非但气结阳微，
而阴气并上逆矣。薤白汤无足称也，须以枳实、浓朴先破其阴气，去白酒之醇，加桂枝之辛，助薤白、枯蒌通
阳行痹。
脉候
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，以其阴弦故也。（《金匮》）
选案
文学钱尊玉，胸中不舒者年余，不能自言其状，颇以为虑。投以薤白栝蒌汤，次日云∶一年之病，一剂
而顿除，抑何神焉？不过以仲景之心法为法耳，何神之有？（喻嘉言）
哲言
胸痹与胸痞是不同的。胸痞有因暴寒郁结在胸部的；有火邪郁结在中焦的；有寒热相互郁结的；有气实充满胸部导致痞塞的；有气虚衰败而成虚性痞塞的；有肺胃津液干枯涩滞，因燥而致痞的；有上焦湿浊弥漫而导致痞塞的。至于胸痹，只是因为胸中阳气虚弱不能运化，日久形成痹阻。《内经》未曾详细论述，只有《金匮要略》中的方剂都使用辛滑温通的药物，文中说：寸口脉沉而迟，阳微阴弦，由此可知只有寒证而没有热证。治疗方法也主要以温通上焦清阳为主。不要将胸痹、结胸、噎隔、痰食等病证混淆治疗，这样才能掌握要领。（出自《临证指南》）
凡是遇到胸痹、心痛、短气等症状，认为是有虚损又有邪气停留，其实并非单纯的虚；认为是实证而有邪气乘袭，其实也并非单纯的实。在标本缓急之间，高明的医生怎能缺少对这一点的深入探讨呢？（魏荔彤）
胸痹的病证，表现为喘息咳唾，胸背疼痛，短气，寸口脉沉而迟，关上脉小紧数，用栝蒌薤白白酒汤主治。○胸痹不能平卧，心痛牵引至背部的，用栝蒌薤白半夏汤主治。○胸痹，心中痞塞感，气结在胸部，胸部胀满，胁下之气逆冲心胸，用枳实薤白桂枝汤主治；人参汤也可主治。○胸痹，胸中气塞短气，用茯苓杏仁甘草汤主治；橘枳姜汤也可主治。○胸痹发作有时缓解有时紧急的，用薏苡仁附子散主治。（出自《金匮要略》）
胸中所蕴藏的是氤氲之气，此处适宜空虚而不适宜壅实。空虚，意味着阳气宣发；壅实，意味着阴气附着。氤氲之气一旦沸腾郁结，营气就不能随之运行，那么像痰、瘀血、气滞、水饮等，都成为刺割疼痛的工具。治疗方法有升提、有降逆、有疏导、有泄下的不同，总不如开郁顺气，能够宣发诸阳使之开通。（程郊倩）
胸中的阳气，如同太阳当空照耀，广阔无外，如果地气（阴寒之气）一上升，就会更加窒塞不通。因此知道胸痹是阴气上逆的候象。张仲景病情轻时用人参、薤白、白酒来通其阳气；重时用附子、干姜来消其阴寒。世俗医生不知道胸痹是什么病，习惯性地使用豆蔻、木香、诃子、三棱、神曲、麦芽等药物，白白耗损胸中的阳气，这相差也太远了。（喻嘉言）
治疗胸痹的三个方剂，都使用了栝蒌、薤白，按其治法，却微妙地区分了上中下三焦。《内经》说：淫气喘息，痹聚在肺。这是指妄行之气，随着各脏的内因所主而入体成为痹证。然而病变不同，治疗也稍有差异。仅就胸痹出现喘息、咳唾、胸背痛、短气的情况，以薤白为君药，利用其滑利之性通阳，以栝蒌为臣药，利用其润下之性通阴，佐以白酒熟谷之气上行药性，帮助其通经活络，痹证自然解除。如果转结于中焦，而出现心痛牵引至背部的，只加半夏一味，调和胃气而通阴阳。如果结于胸胁，更加出现逆气上抢于心，不仅气结阳微，而且阴气并上逆了。此时薤白汤就不够用了，需要用枳实、厚朴先破其阴气，去掉白酒的醇厚，加入桂枝的辛味，帮助薤白、栝蒌通阳行痹。
脉候
老师说：脉象应当取太过或不及，阳微阴弦，就是胸痹且痛的原因，之所以这样，是因为正气极度虚弱。现在知道阳虚在上焦，所以出现胸痹心痛的，是因为阴弦的缘故。（出自《金匮要略》）
选案
文学钱尊玉，胸中不适一年多，不能自己描述症状，颇为忧虑。投用薤白栝蒌汤，第二天说：一年的病，一剂药就立刻除根，多么神奇啊？不过是把张仲景的心法作为准则罢了，有什么神奇的？（喻嘉言）
Zhe Yan (Philosophical Remarks)
Xiong Bi (Chest Bi Syndrome) is different from Xiong Pi (Chest Fullness). Xiong Pi may arise from sudden cold stagnating in the chest; from fire stagnating in the middle jiao (Middle Burner); from mutual stagnation of cold and heat; from excess qi filling the chest causing fullness; from deficiency of qi leading to deficient fullness; from dryness due to withered and astringent fluids of the Lung and Stomach; or from pervasive damp-turbidity in the upper jiao (Upper Burner). As for Xiong Bi, it occurs solely because of Yang deficiency in the chest failing to circulate, which over time leads to Bi obstruction. The *Neijing* (Classic of Internal Medicine) does not discuss this in detail. Only the prescriptions in the *Jinkui Yaolue* (Essential Prescriptions of the Golden Cabinet) all use acrid, slippery, warm, and unblocking herbs. It states: "The pulse at the Cun Kou (radial artery position) is deep and slow; Yang is faint, Yin is taut." From this, we know that there are only Cold patterns and no Heat patterns. The treatment method primarily focuses on warming and unblocking the clear Yang of the upper jiao. One must not confuse the treatment of Xiong Bi with Jie Xiong (Chest Binding), Ye Ge (Dysphagia), or Tan Shi (Phlegm and Food Retention) patterns. This approach ensures correct diagnosis and treatment. (From *Linzheng Zhinan*)
Whenever encountering symptoms such as Xiong Bi, Xin Tong (Heart Pain), or Duan Qi (Shortness of Breath), one might think it is deficiency with pathogenic factors present, but it is not merely deficiency; one might think it is excess with pathogenic factors invading, but it is not merely excess. In the balance between root and branch, and urgency and slackness, how can a wise physician neglect to study this? (Wei Litong)
The disease of Xiong Bi presents with panting, coughing, and expectoration, chest and back pain, shortness of breath, a deep and slow pulse at the Cun Kou, and a small, tight, and rapid pulse at the Guan position. It is primarily treated with Gualou Xiebai Baijiu Tang (Trichosanthes Fruit, Macrostemon Rhizome, and White Wine Decoction). ○ If Xiong Bi prevents lying down, and heart pain radiates to the back, it is treated with Gualou Xiebai Banxia Tang (Trichosanthes Fruit, Macrostemon Rhizome, and Pinellia Decoction). ○ If Xiong Bi involves a sensation of Qi blockage in the chest, Qi knotting in the chest, chest distension, and rebellious Qi rushing from the hypochondrium towards the heart, it is treated with Zhishi Xiebai Guizhi Tang (Immature Bitter Orange, Macrostemon Rhizome, and Cinnamon Twig Decoction); Renshen Tang (Ginseng Decoction) may also be used. ○ If Xiong Bi involves Qi blockage in the chest and shortness of breath, it is treated with Fuling Xingren Gancao Tang (Poria, Apricot Seed, and Licorice Decoction); Juzhi Jiang Tang (Tangerine Peel, Immature Bitter Orange, and Ginger Decoction) may also be used. ○ If Xiong Bi alternates between remission and acute exacerbation, it is treated with Yiyi Ren Fuzi San (Coix Seed and Aconite Powder). (From *Jinkui Yaolue*)
What accumulates in the chest is the ethereal Qi (Yinyun Zhiqi). This area should be empty rather than full. Emptiness allows for the dissemination of Yang Qi; fullness indicates the adherence of Yin Qi. Once the ethereal Qi boils and stagnates, Ying Qi (Nutritive Qi) cannot follow. Consequently, substances such as Phlegm, Blood Stasis, Qi Stagnation, and Fluid Retention become instruments of stabbing and painful obstruction. Treatment methods vary among ascending, descending, guiding, and draining. However, none are superior to opening stagnation and smoothing Qi, which can disseminate various Yangs and promote openness. (Cheng Jiaoqian)
Yang Qi in the chest is like the sun shining in the sky, vast and boundless. If Earth Qi (Yin-Cold) rises even slightly, obstruction increases. Thus, we understand that Xiong Bi is a manifestation of rebellious Yin Qi ascending. Zhang Zhongjing uses mild treatments such as Xiebai (Macrostemon Rhizome) and Baijiu (White Wine) to unblock Yang in mild cases; in severe cases, he uses Fuzi (Aconite Root) and Ganjiang (Dried Ginger) to dissipate Yin-Cold. Physicians of later generations do not understand what Xiong Bi is. They habitually use herbs such as Doukou (Black Cardamom), Muxiang (Costus Root), Hezi (Chebula Fruit), Sanleng (Sparganium Rhizome), Shenqu (Medicated Leaven), and Maiya (Malt), thereby wasting the Yang Qi in the chest. This error is significant. (Yu Jiayan)
The three formulas for treating Xiong Bi all use Gualou (Trichosanthes Fruit) and Xiebai (Macrostemon Rhizome). Their treatment methods subtly differentiate among the Upper, Middle, and Lower Jiao. The Classics state: "Rebellious Qi causes panting; Bi gathers in the Lung." This means that reckless Qi enters the body as Bi according to the internal predispositions of each Zang organ. However, since pathological changes differ, treatments also vary slightly. For Xiong Bi presenting with panting, coughing, expectoration, chest and back pain, and shortness of breath, Xiebai is used as the Sovereign herb for its slippery nature to unblock Yang; Gualou is used as the Minister herb for its moistening and downward-draining nature to unblock Yin; Baijiu is used as an Assistant herb, utilizing the ascending nature of cooked grain Qi to aid in unblocking meridians and collaterals, allowing the Bi obstruction to resolve naturally. If the pathogen shifts to knot in the Middle Jiao, causing heart pain radiating to the back, only Banxia (Pinellia Tuber) is added to harmonize the Stomach and unblock Yin-Yang. If it knots in the chest and hypochondrium, accompanied by rebellious Qi rushing to the heart, not only is Qi knotted and Yang faint, but Yin Qi also rebels upward. At this point, Xiebai Tang is insufficient. One must use Zhishi (Immature Bitter Orange) and Houpo (Magnolia Bark) to first break the Yin Qi, remove the rich nature of Baijiu, add the acridity of Guizhi (Cinnamon Twig), and assist Xiebai and Gualou in unblocking Yang and moving Bi.
Mai Hou (Pulse Diagnosis)
The Master said: "Pulses should be assessed for excess or deficiency. 'Yang faint, Yin taut' indicates Xiong Bi with pain. The reason for this is extreme deficiency. Now, knowing Yang deficiency is in the Upper Jiao, the cause of Xiong Bi and Heart Pain is the Yin tautness." (From *Jinkui Yaolue*)
Selected Cases
Literatus Qian Zunyu suffered from chest discomfort for over a year. He could not describe his condition in words and was quite worried. He was administered Xiebai Gualou Tang (Macrostemon Rhizome and Trichosanthes Fruit Decoction). The next day, he said: "A year's illness was cured instantly with one dose. How miraculous! But it is merely applying the principles of Zhang Zhongjing. What is so miraculous about it?" (Yu Jiayan)