水蛭（二十个味苦寒） 虻虫（二十五个味苦微寒） 桃仁（二十个去皮尖） 大
黄（三两）
上四味。杵、分为四丸。以水一升。煮一丸取七合。服之。 时。当下血。若不下
者。更服。太阳病。小便利者。以饮水多。必心下悸。小便少者。必苦里急也。
饮水多而小便自利者。则水不内蓄。但腹中水多。令心下悸。金匮要略曰。食少饮
多。水停心下。甚者则悸。饮水多而小便不利。则水蓄于内而不行。必苦里急也。
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。
结胸者。邪结在胸。脏结者。邪结在脏。二者皆下后邪气乘虚入里所致。下后邪
气入里。与阳相结者。为结胸。以阳受气于胸中故尔。与阴相结者。为脏结。以阴受之。
则入五脏故尔。气宜通。而塞故痛。邪结阳分。则阴气不得上通。邪结阴分。则阳气不
得下通。是二者。皆心下硬痛。寸脉浮关脉沉。知邪结在阳也。寸脉浮。关脉小细沉紧。
知邪结在阴也。阴结而阳不结。虽心下结痛。饮食亦自如故。阴气乘肠虚而下。故时时
自下利。阴得阳则解。脏结得热证多。则易治。舌上白苔滑者。邪气结。胸中亦寒。故
云难治。
王宇泰云。按本文云。如结胸状。则与结胸当有分别矣。注曰是二者。皆心下硬痛。欠
稳当。如结胸状。饮食如故。只是按之不痛耳。既结于脏。而舌白苔。又为胸寒。外证
上下俱病。故难治也。
脏结无阳证。不往来寒热。其人反静。舌上苔滑者。不可攻也。
脏结。于法当下。无阳证。为表无热。不往来寒热。为半表半里。无热。其人反静。为
里无热。经曰。舌上如苔者。以丹田有热。胸中有寒以表里皆寒。故不可攻。
病发于阳而反下之。热入。因作结胸。病发于阴而反下之。因作痞。所以成结胸者。
以下之太早故也。
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。表中阴邪入里。结于心下。为痞。
张兼善云。或谓成注无热而恶寒者。发于阴也。既无热而恶寒。为阴证。安可有下
之理。又岂止作痞而已哉。夫仲景所谓阴阳者。指表里而言也。病在表则当汗。而反下之。
因作结胸。病在里。尚未入腑。而辄下之。因作痞。所以成结胸与痞者。下之太早故也。
又云。风邪入里则结胸。寒邪入里则为痞。然此皆太阳病之所致。非阴证之所为也。
结胸者。项亦强。如柔 状。下之则和。宜大陷胸丸。
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。亦
如柔 之状也。与大陷胸丸。下结泄满。
水蛭（二十个，味苦，性寒）虻虫（二十五个，味苦，性微寒）桃仁（二十个，去皮尖）大黄（三两）
以上四味药。捣碎后分成四丸。用水一升。煮其中一丸，取汁七合服用。服药后，应当会有瘀血排出。如果没有排出，再服用。太阳病中，如果小便通畅，是因为饮水过多，必然导致心下悸动；如果小便量少，必然感到腹部急迫不适。饮水多而小便自利的，说明水液没有内停蓄积，只是腹中水多，导致心下悸动。《金匮要略》说：进食少而饮水多，水饮停滞在心下，严重的会出现心悸。饮水多而小便不利的，则水液蓄积在体内无法运行，必然感到腹部急迫不适。
问：疾病有结胸证，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，称为结胸证。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，称为脏结证。舌上苔白且滑的，难以治疗。
结胸证，是邪气结聚在胸膈；脏结证，是邪气结聚在脏腑。这两种情况都是误用下法后，邪气乘虚入里所致。误下后邪气入里，与阳气相结，就是结胸证，因为阳气受气于胸中。与阴气相结，就是脏结证，因为阴气受邪，则进入五脏。气机宜通利，因阻塞故疼痛。邪气结聚在阳分，则阴气不能向上通达；邪气结聚在阴分，则阳气不能向下通达。这两种情况，都会出现心下硬痛，寸脉浮、关脉沉，可知邪气结聚在阳分。寸脉浮，关脉小、细、沉、紧，可知邪气结聚在阴分。阴气结聚而阳气未结，虽然心下结痛，饮食也照常。阴气乘肠道空虚而下注，所以经常自行腹泻。阴证得阳气则解，脏结证若伴有热证较多，则容易治疗。舌上苔白滑的，说明邪气结聚，胸中也寒，所以说难治。
王宇泰说：按原文说“像结胸状”，那么它与结胸证应当有区别。注释中说“这两种情况，都是心下硬痛”，不够稳妥。“像结胸状，饮食如常”，只是按压时不痛罢了。既然结聚在脏，且舌苔白，又为胸寒，外证上下都有病变，所以难治。
脏结证没有阳证表现，没有往来寒热，病人反而安静，舌上苔滑的，不可攻下。
脏结证，按治法应当用下法，但没有阳证，表示表无热；没有往来寒热，表示半表半里无热；病人反而安静，表示里无热。经书说：舌上好像有苔，是因为丹田有热，胸中有寒。因为表里皆寒，所以不可攻下。
疾病发于阳证而反用下法，热邪内入，因而形成结胸证。疾病发于阴证而反用下法，因而形成痞证。之所以形成结胸证，是因为下法用得过早的缘故。
发热恶寒的，是发于阳证。如果反用下法，则表中的阳邪入里，结聚于胸中，形成结胸证。无热恶寒的，是发于阴证。如果反用下法，则表中的阴邪入里，结聚于心下，形成痞证。
张兼善说：有人说成无己的注解认为“无热而恶寒者，发于阴也”。既然无热而恶寒，属于阴证，怎么可以用下法呢？又岂止形成痞证而已呢？仲景所说的阴阳，是指表里而言。病在表则应当发汗，而反用下法，因而形成结胸证。病在里，尚未入腑，却就用下法，因而形成痞证。之所以形成结胸证和痞证，是因为下法用得过早的缘故。又说：风邪入里则形成结胸证，寒邪入里则形成痞证。然而这都是太阳病所导致的，不是阴证所为。
结胸证，项部也强直，像柔痉证的样子。用下法使邪去则和缓，宜用大陷胸丸。
结胸病出现项强的，是因为邪气结聚在胸中，胸膈结满，心下紧实，只能仰头而不能低头，这就是项强，也像柔痉证的样子。给予大陷胸丸，以泻下结滞，消除胀满。
Shuizhi (Leech, 20 individuals, bitter flavor, cold nature) Mengchong (Dragonfly larva, 25 individuals, bitter flavor, slightly cold nature) Taoren (Peach Seed, 20 individuals, remove skin and tips) Dahuang (Rhubarb Root, 3 liang).
The above four herbs. Pound them and divide into four pills. Boil one pill in one sheng of water until reduced to seven ge. Take the decoction. Stooling with blood should occur at this time. If it does not occur, administer another dose. In Taiyang disease (disease of the Taiyang channel), if urination is free, it is due to excessive drinking of water, which inevitably causes palpitations in the epigastrium; if urination is scanty, there will inevitably be distressing abdominal urgency. When water intake is high and urination is spontaneous and free, water does not accumulate internally, but merely increases in the abdomen, causing epigastric palpitations. The *Jin Gui Yao Lue* states: "When food intake is low and water intake is high, water stagnates in the epigastrium; severe cases manifest as palpitations." When water intake is high and urination is obstructed, water accumulates internally and fails to circulate, inevitably causing distressing abdominal urgency.
Question: There are diseases called Jie Xiong (Chest Binding) and Zang Jie (Organ Binding). What are their manifestations? Answer: Pain upon pressure, floating pulse at the Cun position, and sunken pulse at the Guan position is named Jie Xiong (Chest Binding). What is Zang Jie (Organ Binding)? Answer: It resembles the condition of Jie Xiong (Chest Binding), but appetite remains normal, and there is frequent diarrhea. A floating pulse at the Cun position and a small, fine, sunken, and tight pulse at the Guan position is named Zang Jie (Organ Binding). If the tongue has white and slippery coating, it is difficult to treat.
Jie Xiong (Chest Binding) refers to pathogenic factors binding in the chest; Zang Jie (Organ Binding) refers to pathogenic factors binding in the Zang organs. Both conditions result from pathogenic factors entering the interior due to deficiency after improper purgation. After purgation, pathogenic factors enter the interior and bind with Yang Qi, forming Jie Xiong (Chest Binding), because Yang Qi receives its qi in the chest. Binding with Yin Qi forms Zang Jie (Organ Binding), because Yin Qi receives the pathogen and enters the Five Zang Organs. Qi should flow freely; obstruction causes pain. When pathogenic factors bind in the Yang aspect, Yin Qi cannot ascend; when they bind in the Yin aspect, Yang Qi cannot descend. Both conditions present with hardness and pain in the epigastrium, with a floating pulse at the Cun position and a sunken pulse at the Guan position, indicating pathogenic binding in the Yang aspect. A floating pulse at the Cun position and a small, fine, sunken, and tight pulse at the Guan position indicates pathogenic binding in the Yin aspect. With Yin binding and no Yang binding, although there is binding and pain in the epigastrium, diet remains normal. Yin Qi descends into the intestines due to intestinal emptiness, causing frequent spontaneous diarrhea. Yin conditions resolve with Yang; if Zang Jie (Organ Binding) presents with many heat syndromes, it is easier to treat. White and slippery tongue coating indicates pathogenic binding and cold in the chest, hence described as difficult to treat.
Wang Yutai stated: According to the text, "resembling Jie Xiong," there must be a distinction between it and Jie Xiong. The annotation stating "both conditions involve hardness and pain in the epigastrium" is imprecise. "Resembling Jie Xiong, with normal diet" implies only that there is no pain upon pressure. Since it binds in the Zang organs, and the tongue shows white coating indicating chest cold, with exterior symptoms affecting both upper and lower aspects, it is difficult to treat.
Zang Jie (Organ Binding) lacks Yang syndrome manifestations, such as alternating chills and fever. The patient appears unusually quiet. If the tongue has slippery coating, purgation is contraindicated.
For Zang Jie (Organ Binding), purgation is indicated by principle, but without Yang syndrome, indicating no heat in the exterior. Absence of alternating chills and fever indicates no heat in the half-exterior/half-interior. The patient's unusual quietness indicates no heat in the interior. The Classics state: "Tongue coating resembling moss indicates heat in the Dantian and cold in the chest." Because both exterior and interior are cold, purgation is contraindicated.
If a disease originates from Yang syndrome and is incorrectly treated with purgation, heat enters inward, resulting in Jie Xiong (Chest Binding). If a disease originates from Yin syndrome and is incorrectly treated with purgation, it results in Pi Syndrome (Glomus). The reason Jie Xiong (Chest Binding) occurs is due to premature purgation.
Fever with aversion to cold indicates origin from Yang syndrome. Incorrect purgation causes exterior Yang pathogenic factors to enter the interior and bind in the chest, forming Jie Xiong (Chest Binding). Absence of fever with aversion to cold indicates origin from Yin syndrome. Incorrect purgation causes exterior Yin pathogenic factors to enter the interior and bind in the epigastrium, forming Pi Syndrome (Glomus).
Zhang Jianshan stated: Some argue that Cheng Wuji's annotation claims "absence of fever with aversion to cold indicates origin from Yin syndrome." If there is no fever and only aversion to cold, it is a Yin syndrome; how can purgation be applicable? Moreover, would it not result in more than just Pi Syndrome (Glomus)? The Yin and Yang mentioned by Zhang Zhongjing refer to the Exterior and Interior. Disease in the Exterior requires diaphoresis; incorrect purgation leads to Jie Xiong (Chest Binding). Disease in the Interior, not yet entering the Fu organs, subjected to premature purgation, leads to Pi Syndrome (Glomus). The cause of both Jie Xiong (Chest Binding) and Pi Syndrome (Glomus) is premature purgation. He further stated: Wind pathogen entering the interior forms Jie Xiong (Chest Binding); Cold pathogen entering the interior forms Pi Syndrome (Glomus). However, these are caused by Taiyang disease (disease of the Taiyang channel), not by Yin syndromes.
Jie Xiong (Chest Binding) may also present with stiffness of the neck, resembling Rou Ji (Soft Spasm). Purgation harmonizes the condition; Da Xian Xiong Wan (Major Chest-Draining Pill) is appropriate.
In Jie Xiong (Chest Binding) disease, neck stiffness occurs because pathogenic factors bind in the chest, causing fullness and binding in the chest and diaphragm, and tightness in the epigastrium. The patient can only extend the head backward but cannot flex forward, constituting neck stiffness, similar to the presentation of Rou Ji (Soft Spasm). Administer Da Xian Xiong Wan (Major Chest-Draining Pill) to purge binding and relieve fullness.