表。沉紧则为寒邪深入也。盖言以寒伤营之证。头痛发热。身疼腰痛。恶风无汗者而经久不治。至热邪自陷。硬结于胸
中。则
热邪内实于里矣。而脉见沉紧。足见邪结深固。所以心下不按自痛。及按之则石硬也。邪气坚结如此。非大陷胸汤何以
破
其坚结乎。
伤寒十余日。热结在里。复往来寒热者。与大柴胡汤。但结胸无大热者。此为水结在胸胁也。但
头微汗出者。大陷胸汤主之。
此亦太阳失治之结胸也。言寒伤营证而不以麻黄汤汗解。至十日之久。其邪虽未尽入。而郁热之邪。
已内结于里而为结胸。似可攻之证矣。复往来寒热如柴胡汤证。是半表之邪犹未下也。表里皆有邪。未可
以大陷胸汤攻之。以陷胸但能攻在里之热邪。而不能解散表邪也。故以大柴胡汤两解之。若但结胸而身
无大热者。其邪不在表可知。此但因热结在里。胃气不行。水饮留结于胸胁。乃可攻之候也。犹必但头汗出者。
然后知其身虽大热。而邪气不在阴经。阳邪但在上焦阳分。为结邪所隔。不得下达。水液留蓄。亦不得下走。
故以大陷胸汤主之。或曰。何以知头汗为阳邪在阳分乎。曰。少阳篇云。阴不得有汗。今头汗出。故知非少阴也。
且陷胸亦实热之药。故知阳邪在阳分耳。成氏谓但结胸无大热者。非热结也。岂知但结胸三字。即指热结在里
而言。谓但有里邪也。无大热。言不复往来寒热。谓无表邪也。有里无表。方可用大陷胸汤也。苟非热结。则
大黄芒硝。岂非热实之药。仲景肯妄用乎。尚论言后人误谓结胸之外。复有水结胸一症。又谓下文支结。乃支
饮结聚。亦另是一症。殊为可笑。愚谓若水饮必不与热邪并结。则大陷胸方中。何必有逐水利痰之甘遂乎。可谓
一言破惑。
小结胸病。正在心下。按之则痛。脉浮滑者。小陷胸汤主之。
正在心下。方氏谓不比大结胸之高而在上。不知仲景原云。若心下满而硬痛者。为结胸也。又曰心下因硬。则为结
胸。又曰结胸热实。心下痛。按之石硬。若此。则知结胸本在心下。非必心下痞而后称心下也。然则胸与心下之相去。
非甚相远也。不过鸠尾之间。上脘之分耳。若必责之胸膺。则胸骨已硬。岂能按之而知其硬且痛乎。曰正在心下者。
言止在心下一处。不若心下满而硬痛。及按之石硬。结在胸胁之甚且大也。按之则痛。亦不似膈内拒痛。及从心上
至少腹硬满而痛不可近者。至于心下痛之不按自痛也。脉之浮滑皆属阳。浮为阳邪。滑近动数。亦不比动数变迟。
及沉紧之脉。为沉陷固结之深也。故不须攻击之鸷剂。而以小陷胸汤主之也。
小陷胸汤方
黄连（一两） 半夏（半升） 栝蒌实（大者一枚）
上三味。以水六升。先煮栝蒌实取三升。去滓。内诸药煮取二升。去滓。分温三服。
此因陷入之热邪较轻。故治法亦变其制而为小陷胸汤也。然其小也。非若小承气之减其制而曰小。亦非若小青
龙之变其法而曰小也。此所谓小者。名同而药实不同。药虽不同而用意则同。用意虽同而其功用又不同也。夫邪
结虽小。同是热结。故以黄连之苦寒主之。寒以解其热。苦以开其结。非比大黄之苦寒荡涤也。邪结胸中则胃气不
行。痰饮留聚。故以半夏之辛温滑利。化痰蠲饮而散其滞结也。栝蒌实。李时珍谓其甘寒不犯胃气。能降上焦之火。
使痰气下降。盖亦取其滑润也。亦非比芒硝甘遂之咸寒逐水之峻也。然半夏栝蒌。皆取其滑者。何也。盖滑乃十剂
之一。谓滑可去着也。着者。有形之邪。留着于胸膈肠胃之中。无形之邪。留着于经络脏腑之间也。古人云。着而难去
者。以滑去之。如油之洗物也。此方之制。病小则制方亦小。即内经所云。有毒无毒。所治为主。适大小为制也。
病在阳。应以汗解之。反以冷水 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。若不瘥者。与五苓散。寒实结胸。无热证者。与三物小陷胸汤。白散亦可服。
病在阳者。盖指邪在太阳也。然仲景但言病在阳。何以知其独指太阳乎。曰。仲景阳明篇首云。身热汗自出。
不恶寒。反恶热者。为阳明外证。既云汗自出。不应再以汗解。唯邪气虽入阳明。而太阳证尚未罢者。方有用麻
黄之葛根汤及桂枝葛根汤以汗解之。此外则更无阳明发表之专药矣。是以知其非阳明也。少阳虽有半表之邪。而汗
吐下皆有禁例。又不当有应以汗解之句。故又知其非少阳也。唯太阳为最外一层。专主营卫风寒。犯之则必应以汗
解矣。此因不得汗解而烦热。非唯不以汗解。而反以冷水 之灌之。 者。喷 之也。灌者。灌洗之也。以冷水
灌之者。盖欲以寒治热。乃不知者之妄耳。遂使皮肤郁热之邪。为冷水所却。不得散去。故弥更益增其烦热也。然
烦热虽甚。其先所感之邪。本已恶寒无汗。又增 灌之水寒。外客皮肤。故肉上之寒粟耸起。意欲饮水者。烦热所
致也。反不渴者。水寒侵入也。见证如此。似当仍以汗解为是。因水寒外侵。邪热被却。已不在表。故以咸寒润下
利水之文蛤散。导水下出。若未效而不瘥者。因水寒内犯太阳之腑。膀胱受病。当与五苓散助其下焦蒸腾之用。则
气化流行而水气自除矣。即有表邪未解。服五苓散法中。更有多饮暖水。使汗出之法可去也。此条当与中风失治之
渴欲饮水。水入即吐之水逆证互看。彼因饮水所致。为内入之水寒。此因 灌所致。为外入之水寒。病情相似。故治
法亦相同也。寒实结胸无热证句。乍读之。似不宜用小陷胸之苦寒。细阅上文。因冷水 灌。其热已被却不得去。
热邪内入。所以弥更益烦。热邪遂实结于胸。乃热因寒结。故曰寒实结胸。非谓寒气实结于胸中也。若果是阴寒。
当作心下痞矣。故结胸之首条云。发于阳而反下之。热入。因作结胸谓之结胸。则知是热入而非阴寒之证矣。若非热
邪。则亦并不可谓之
结胸矣。此阴阳寒热之辨也。无热证者。谓无表热。盖指上文肉上粟起而言。非谓表里俱无热。故与三物小陷胸汤。
以开其胸中实结之邪也。白散虽峻。盖因寒实结于胸中。水寒伤肺。必有喘咳气逆。故以苦梗开之。贝母入肺。又以
巴豆之辛热有毒。斩关夺门之将。以破胸中之坚结。盖非热不足以开其水寒。非峻不足以破其实结耳。亦治实不治
虚之法也。
文蛤散方
文蛤（五两）
文蛤似蛤而背有紫斑。即今吴中所食之花蛤。俗误呼为苍蠃或昌蛾者是也。
上一味为散。以沸汤和服一钱匕。汤用五合。
三物小陷胸汤 即前小陷胸汤。
白散方
桔梗（三分味苦者） 巴豆（一分去皮心熬黑研如脂） 贝母（三分）
上三味。桔梗贝母为末。内巴豆。更于臼中杵之。以白饮和服。强人半钱。羸者减之。病在膈上必吐。在膈
下必利。不利。进热粥一杯。利过不止。进冷粥一杯。
结胸证。其脉浮大者不可下。下之则死。
大凡邪气在表。则脉必浮。结胸一证。原因太阳表邪误陷所致。然既结之后。邪已入里。则关脉当沉矣。岂容浮大
之
脉再见耶。今胸既结矣。而脉仍见浮大。则未尽陷入之表邪尚盛。且浮大之脉原属里虚。症象阳旦条云。浮则为风。
大则为虚。正气既虚而更下之。使未尽之表邪再陷。则外邪已陷复陷。胸邪已结再结。是所谓虚其虚而实其实也。
邪气重陷。正气不支。不死何待。故曰不可下。下之则死。
结胸证悉具。烦躁者亦死。
此承上文而言。更有不必再下。亦死之证也。悉具者。言凡绑定胸所犯之证。无所不具也。其证悉具。则邪气
之盛。陷入之深。不必言矣。而更见烦躁。烦为虚阳散乱。躁则阴邪上逆。剧邪坚结。上下隔绝。胃气必败。
内经热论云。营卫不行。脏腑不通则死矣。
表证。若脉象沉紧，则是寒邪深入的表现。这是说，对于因寒邪损伤营阴而导致的病证，出现头痛、发热、身体疼痛、腰痛、怕风且无汗等症状，如果长期不治疗，导致热邪自行内陷，在胸中形成硬结，那么热邪就在体内变得实盛了。此时脉象表现为沉紧，足以说明邪气结聚深固。因此，心下部位不按也会自痛，按压时则像石头一样坚硬。邪气坚结到了这种程度，不用大陷胸汤怎么能破除它的坚结呢？
伤寒病程已过十余日，热邪结聚在体内，同时又出现忽冷忽热的症状，应给予大柴胡汤。如果是结胸证，身上没有大热，这是水饮结聚在胸胁所致。只有头部微微出汗的，以大陷胸汤为主治方剂。
这也是太阳病失治导致的结胸证。意思是寒邪损伤营阴的病证，没有用麻黄汤发汗解表，直到过了十天之久，虽然邪气并未完全入里，但郁积的热邪已经在内部结聚形成了结胸，这似乎是可以用攻下法的证候了。但又出现像柴胡汤证那样的往来寒热，说明半表之邪还没有被攻下。表里都有邪气，不可以直接用大陷胸汤攻下。因为大陷胸汤只能攻逐在里的热邪，而不能解散表邪。所以用大柴胡汤来表里双解。如果只是结胸而身上没有大热，可知邪气不在表。这是因为热邪结聚在里，胃气运行不畅，水饮留滞结聚在胸胁，这才到了可以攻下的时机。而且必须见到只有头部出汗的情况，才能知道虽然身体有大热，但邪气不在阴经，阳邪只在上焦阳分，被结邪阻隔，不能下达；水液留蓄，也不能向下排泄。所以用大陷胸汤主治。有人问：怎么知道头汗是阳邪在阳分的表现呢？回答说：《伤寒论·少阳病篇》说：“阴经不得有汗”，现在头部出汗，所以知道这不是少阴病。况且大陷胸汤也是治疗实热的药物，所以知道是阳邪在阳分。成无己说“只是结胸而没有大热”，意思是不是热结。哪里知道“但结胸”这三个字，就是指热结在里而言，意思是只有里邪。“无大热”，是指不再有往来寒热，意思是无表邪。有里邪而无表邪，才可以使用大陷胸汤。如果不是热结，那么大黄、芒硝难道不是治疗热实的药物吗？张仲景怎么会胡乱使用呢？尚论派的人说后人错误地认为除了结胸之外，还有水结胸这一症，又说下文的支结，乃是支饮结聚，也是另一种症，这实在可笑。我认为如果水饮必定不与热邪并结，那么大陷胸汤方中，何必加入逐水利痰的甘遂呢？可以说是一语破除了疑惑。
小结胸病，病位正在心下，按压才会疼痛，脉象浮滑的，用小陷胸汤主治。
所谓“正在心下”，方有执认为不像大结胸那样位置高而在上。不知道张仲景原本说：“如果心下满而且硬痛，就是结胸。”又说：“心下因而变硬，就是结胸。”又说：“结胸热实，心下痛，按压像石头一样硬。”像这样，就知道结胸本来就是在心下，不一定非要心下痞塞才称为心下。然而，胸与心下的距离，并不是很远。不过是在鸠尾穴之间，上脘穴之分野罢了。如果一定要追究在胸膺部，那么胸骨已经坚硬，怎么能通过按压来知道它硬且痛呢？说“正在心下”，意思是仅仅在心下一处，不像心下满而硬痛，以及按压像石头一样硬，结聚在胸胁那样严重和广泛。按压才痛，也不像膈内拒痛，以及从心上至少腹硬满而痛得不能靠近的情况。至于心下痛不按也痛的情况。脉象浮滑都属于阳脉。浮为阳邪，滑脉接近动数脉，也不比动数脉变迟，以及沉紧脉那样沉陷固结得深。所以不需要使用猛烈攻击的药物，而用小陷胸汤主治。
小陷胸汤方
黄连（一两） 半夏（半升） 栝蒌实（大的一个）
以上三味药，用水六升，先煮栝蒌实，取三升药液，去渣，加入其他药物，煮取二升药液，去渣，分三次温服。
这是因为陷入体内的热邪较轻，所以治疗方法也改变其规模而制成小陷胸汤。然而它之所以叫“小”，不像小承气汤那样减少剂量而称“小”，也不像小青龙汤那样改变方法而称“小”。这里所说的“小”，名相同而药物实际上不同。药物虽然不同，但用意却相同。用意虽然相同，但其功效又不同。邪气结聚虽然小，同样是热结，所以用黄连的苦寒来主治。寒性可以解除热邪，苦味可以开通结聚，不像大黄那样苦寒荡涤。邪气结聚在胸中导致胃气不行，痰饮留聚，所以用半夏的辛温滑利，化痰蠲饮以消散其滞结。栝蒌实，李时珍认为它甘寒不伤胃气，能降上焦之火，使痰气下降，大概也是取其滑润的特性。也不像芒硝、甘遂那样咸寒逐水的峻烈。然而半夏、栝蒌，都取其滑利的特性，为什么呢？因为“滑”是十剂之一，意思是“滑可去着”。“着”，指有形之邪留着于胸膈肠胃之中，无形之邪留着于经络脏腑之间。古人说：附着难去的，用滑利的方法去除它，就像用油洗东西一样。这个方的制定，病轻则制方也小，正如《内经》所说：无论有毒无毒，以所治病为主，根据病情大小来制定方剂。
病在阳分，应该用发汗法解表，反而用冷水喷洒或灌洗它，热气被遏制而不能散发，更加烦闷，皮肤起鸡皮疙瘩，想喝水，反而不渴的，服用文蛤散。如果不好转的，给予五苓散。寒实结胸，没有热证的，给予三物小陷胸汤。白散也可以服用。
“病在阳”，大概是指邪气在太阳经。然而张仲景只说“病在阳”，怎么知道它独指太阳经呢？回答说：张仲景在阳明篇开头说：“身热汗自出，不恶寒，反恶热”，这是阳明外证。既然已经有汗自出，就不应该再用发汗法。只有邪气虽然进入阳明，而太阳证尚未罢除的，才有使用葛根汤及桂枝加葛根汤发汗解表的适用情况。除此之外，更没有阳明经发表专用的药物。因此知道这不是阳明病。少阳经虽然有半表之邪，但汗、吐、下法都有禁忌，也不应该有“应当用发汗法解表”的说法。所以又知道这不是少阳病。只有太阳经是最外层，专门主管营卫风寒，侵犯它就必须用发汗法解表。这是因为不能发汗解表而导致烦热，不仅不以发汗解表，反而用冷水喷洒或灌洗。喷，是喷洒的意思；灌，是灌洗的意思。用冷水灌洗，大概是想要用寒凉治疗热病，这是不知医理者的妄为。于是使得皮肤郁积的热邪，被冷水遏制，不能散去，所以更加增加烦热。然而烦热虽然厉害，先前感受的邪气，本来就是恶寒无汗的，又增加了喷洒灌洗的水寒之气，客居于皮肤，所以皮肤上的寒栗耸起。想喝水，是烦热所致；反而不渴，是水寒侵入所致。见证如此，似乎仍然应该用发汗法解表才是。但因为水寒外侵，邪热被遏制，已经不在表了，所以用咸寒润下利水的文蛤散，引导水液从下排出。如果无效且不好转，是因为水寒内犯太阳之腑，膀胱受病，应当给予五苓散，帮助其下焦蒸腾的气化功能，那么气化流行而水气自然消除。即使有表邪未解，在五苓散的服法中，也有多饮暖水使其出汗的方法来祛邪。这一条应当与中风失治后渴欲饮水、水入即吐的水逆证互相参照。那个是因为饮水所致，是内入的水寒；这个是因喷洒灌洗所致，是外入的水寒。病情相似，所以治疗方法也相同。关于“寒实结胸无热证”这句话，乍读起来，似乎不适合用小陷胸汤的苦寒。仔细研读上文，因为被冷水喷洒灌洗，其热已经被遏制而不能散发，热邪内入，所以更加烦闷。热邪遂实结于胸，乃是热因寒结，所以叫作寒实结胸，并不是说寒气实结于胸中。如果真的是阴寒，应当变成心下痞了。所以在结胸证的首条中说：“发于阳而反下之，热入，因作结胸”，叫做结胸，就知道这是热入而不是阴寒的证候。如果不是热邪，也就不能称之为结胸了。这是阴阳寒热的辨别。“无热证”，是指无表热，大概是指上文提到的皮肤起鸡皮疙瘩而言，并不是说表里都没有热。所以给予三物小陷胸汤，以开通胸中实结的邪气。白散虽然药性峻猛，但因为寒实结于胸中，水寒伤肺，必然有喘咳气逆的症状，所以用桔梗开提肺气，贝母入肺，再加上巴豆的辛热有毒，作为斩关夺门的将领，以破除胸中的坚结。大概不是热不足以开通水寒，不是峻猛不足以破除实结罢了。这也是治疗实证而不治疗虚证的方法。
文蛤散方
文蛤（五两）
文蛤形状像蛤蜊但背部有紫斑，就是现在吴地人们食用的花蛤，俗误称为苍蠃或昌蛾的就是它。
以上一味药研为散，用沸水和服一钱匕，汤用量为五合。
白散方
桔梗（三分，味苦的） 巴豆（一分，去皮心，熬黑，研如脂状） 贝母（三分）
以上三味药，将桔梗、贝母研为末，加入巴豆，再在臼中捣匀，用白饮（米汤）调和服用。体质强壮的人服半钱，体弱的人减量。病位在膈上的一定会呕吐，病位在膈下的一定会腹泻。如果不腹泻，喝一杯热粥；如果腹泻不止，喝一杯冷粥。
大凡邪气在表，脉象必定浮。结胸这一证，原因是太阳表邪误治内陷所致。然而既然已经结聚，邪气已入里，关脉应当沉才对，怎么能再见浮大的脉象呢？现在胸部已经结聚，而脉象仍然浮大，说明未尽陷入的表邪仍然强盛。而且浮大的脉象原本属于里虚。症象符合阳旦条所说：“浮则为风，大则为虚”。正气既已虚弱，如果再攻下，使未尽的表邪再次内陷，那就是外邪已陷而复陷，胸邪已结而复结，这就是所谓的“虚其虚而实其实”。邪气重重内陷，正气无法支撑，不死还等什么？所以说不可攻下，攻下就会死亡。
这是承接上文来说的，更有不必再攻下，也是死证的证候。“悉具”，是说凡是绑定胸部的各种证候，无所不备。症状全部具备，那么邪气的旺盛，陷入的深度，就不用多说了。而又出现烦躁，烦是虚阳散乱，躁是阴邪上逆。剧烈邪气坚结，上下隔绝，胃气必然败绝。《内经·热论》说：“营卫不通，脏腑不通就会死亡。”
The exterior syndrome. If the pulse is deep and tight, it indicates that cold pathogenic factors have penetrated deeply. This statement refers to a condition caused by cold damaging the Ying (Nutrient) level, characterized by headache, fever, body ache, lower back pain, aversion to wind, and absence of sweating. If left untreated for a long time, heat pathogenic factors may sink inward spontaneously, forming hard knots in the chest. Consequently, heat becomes excess internally. The appearance of a deep and tight pulse confirms that the pathogenic factors are firmly knotted at a deep level. Therefore, there is spontaneous pain in the epigastrium even without pressure, and upon palpation, the area feels as hard as stone. Given such firm knotting of pathogenic factors, how else could Da Xianxiong Tang (Major Intrapleural Decoction) break this hardness?
After more than ten days of Shanghan (Cold Damage), with heat knotted internally and accompanied by alternating chills and fever, Da Chaihu Tang (Major Bupleurum Decoction) should be administered. However, in cases of Jie Xiong (Chest Binding Syndrome) where there is no significant fever externally, this indicates water retention knotted in the chest and hypochondrium. If only slight sweating is observed on the head, Da Xianxiong Tang (Major Intrapleural Decoction) is the primary treatment.
This is also a case of Jie Xiong (Chest Binding Syndrome) resulting from mishandling of Taiyang (Greater Yang) disease. It implies that when cold damages the Ying (Nutrient) level, if Mahuang Tang (Ephedra Decoction) is not used to induce sweating for resolution, after ten days, although the pathogen has not fully entered the interior, the stagnant heat has knotted internally to form Jie Xiong (Chest Binding Syndrome). This appears to be a pattern suitable for purgation. However, the presence of alternating chills and fever, similar to Chaihu Tang (Bupleurum Decoction) patterns, indicates that the half-exterior pathogen has not been purged. With pathogens present in both the exterior and interior, Da Xianxiong Tang (Major Intrapleural Decoction) cannot be used directly for purgation, as it can only attack internal heat but cannot resolve exterior pathogens. Therefore, Da Chaihu Tang (Major Bupleurum Decoction) is used to resolve both exterior and interior simultaneously. If there is merely Jie Xiong (Chest Binding Syndrome) without significant external fever, it is evident that the pathogen is not in the exterior. This occurs because heat is knotted internally, stomach Qi fails to circulate, and fluid retention knots in the chest and hypochondrium, marking a time when purgation is appropriate. Furthermore, one must observe sweating only on the head to confirm that although the body has high fever, the pathogen is not in the Yin meridians; rather, Yang pathogens are confined to the Upper Jiao (Triple Burner) Yang division, blocked by the knotted pathogen from descending. Fluids accumulate and cannot drain downward. Thus, Da Xianxiong Tang (Major Intrapleural Decoction) is indicated. One might ask: How do we know that head sweating indicates Yang pathogens in the Yang division? The answer is: The Shaoyang (Lesser Yang) chapter states, "Yin meridians do not produce sweating." Since there is head sweating, we know it is not Shaoyin (Lesser Yin). Moreover, since Da Xianxiong Tang (Major Intrapleural Decoction) treats excess heat, we know the pathogen is Yang in the Yang division. Cheng Wuji stated that "Jie Xiong (Chest Binding Syndrome) without significant fever" means there is no heat knot. He did not realize that the phrase "merely Jie Xiong (Chest Binding Syndrome)" refers to heat knotted internally, meaning there is only interior pathology. "No significant fever" means the absence of alternating chills and fever, indicating no exterior pathogen. Only when there is interior pathology without exterior pathology can Da Xianxiong Tang (Major Intrapleural Decoction) be used. If it were not a heat knot, would Dahuang (Rhubarb Rhizome) and Mangxiao (Mirabilite) not be drugs for treating heat excess? Would Zhang Zhongjing use them recklessly? The Shanglun school erroneously claimed that besides Jie Xiong (Chest Binding Syndrome), there is another syndrome called Water Jie Xiong (Water Chest Binding), and that the subsequent mention of Zhi Jie (Branch Knot) refers to Zhi Yin (Branching Fluid) accumulation, constituting a separate syndrome. This is ridiculous. I argue that if fluid retention never combined with heat pathogens, why would Gansui (Kansui Root), a drug for draining water and resolving phlegm, be included in Da Xianxiong Tang (Major Intrapleural Decoction)? This clarifies the confusion.
Xiao Jie Xiong Bing (Minor Chest Binding Disease) is located precisely in the epigastrium. Pain occurs only upon palpation, and the pulse is floating and slippery. Xiao Xianxiong Tang (Minor Intrapleural Decoction) is the primary treatment.
Regarding "precisely in the epigastrium," Fang Youzhi argued that it is not as high as in major Jie Xiong (Chest Binding Syndrome). However, Zhang Zhongjing originally stated: "If the epigastrium is full, hard, and painful, it is Jie Xiong (Chest Binding Syndrome)." He also said: "If the epigastrium becomes hard, it is Jie Xiong (Chest Binding Syndrome)." And again: "Jie Xiong (Chest Binding Syndrome) involves heat and excess, causing epigastric pain that feels hard as stone upon palpation." From this, we know Jie Xiong (Chest Binding Syndrome) originates in the epigastrium and does not require epigastric stuffiness to be termed so. The distance between the chest and the epigastrium is not great; it is merely between the Jiutwei (CV15) point and the Shangwan (CV13) point. If one insisted on locating it in the chest wall, the sternum itself would be hard, making it impossible to determine hardness and pain through palpation. Saying "precisely in the epigastrium" means the location is limited to one spot in the epigastrium, unlike the severe and extensive knotting in the chest and hypochondrium seen in cases of epigastric fullness, hardness, pain, and stone-hard palpation. Pain upon palpation differs from rejection pain within the diaphragm or hardness and pain extending from the heart down to the lower abdomen that makes one unable to bear touch. Regarding the epigastric pain that hurts spontaneously without pressure: A floating and slippery pulse belongs to Yang. Floating indicates Yang pathogen; slippery is close to rapid and moving pulses, but unlike the slow change from moving pulses or the deep and tight pulse indicating deep sinking and firm knotting. Therefore, violent attacking agents are unnecessary, and Xiao Xianxiong Tang (Minor Intrapleural Decoction) is used.
Formula for Xiao Xianxiong Tang (Minor Intrapleural Decoction):
Huanglian (Coptis Rhizome) - 1 liang
Banxia (Pinellia Tuber) - 0.5 sheng
Gualou Shi (Trichosanthes Fruit) - 1 large fruit
Process these three ingredients: Boil Gualou Shi (Trichosanthes Fruit) in 6 sheng of water first until reduced to 3 sheng. Remove the dregs. Add the other herbs and boil until reduced to 2 sheng. Remove the dregs. Divide into three warm doses.
Because the invading heat pathogen is lighter, the treatment method changes its scale to create Xiao Xianxiong Tang (Minor Intrapleural Decoction). Its designation as "minor" does not mean reducing the dosage like Xiao Chengqi Tang (Minor Order the Qi Decoction), nor changing the method like Xiao Qinglong Tang (Minor Blue Dragon Decoction). Here, "minor" shares the name but differs in actual ingredients. Although the ingredients differ, the intent is the same. Although the intent is the same, the efficacy differs. Although the pathogen knot is small, it is still a heat knot. Therefore, Huanglian (Coptis Rhizome) is used for its bitter and cold nature. Cold resolves heat, and bitterness opens knots. This differs from the bitter-cold scouring action of Dahuang (Rhubarb Rhizome). When pathogens knot in the chest, Stomach Qi stagnates, and phlegm-fluid accumulates. Therefore, Banxia (Pinellia Tuber) is used for its acrid, warm, and slippery properties to transform phlegm, drain fluids, and dissipate stagnation. Gualou Shi (Trichosanthes Fruit), according to Li Shizhen, is sweet and cold, does not harm Stomach Qi, descends fire in the Upper Jiao (Triple Burner), and causes phlegm-Qi to descend, likely chosen for its slippery and moistening qualities. This differs from the harsh salty-cold water-draining actions of Mangxiao (Mirabilite) and Gansui (Kansui Root). However, both Banxia (Pinellia Tuber) and Gualou Shi (Trichosanthes Fruit) utilize their slippery nature. Why? Because "slippery" is one of the Ten Categories of Formulas, meaning "slipperiness removes adherence." "Adherence" refers to tangible pathogens adhering in the chest, diaphragm, and intestines, or intangible pathogens adhering in meridians and organs. Ancients said: "What adheres and is difficult to remove, remove with slipperiness," likening it to using oil to wash objects. The formulation principle here is that if the disease is minor, the formula is minor, consistent with the Neijing (Inner Canon) saying: "Whether toxic or non-toxic, treat the primary disease; adjust the size according to the condition."
When the disease is in the Yang level, it should be resolved by sweating. If instead treated by spraying or pouring cold water, the heat is suppressed and cannot escape, leading to increased irritability, goosebumps on the skin, a desire to drink water but without actual thirst. In such cases, Wenli San (Clam Shell Powder) should be administered. If there is no improvement, Wuling San (Five-Ingredient Powder with Poria) should be given. For Han Shi Jie Xiong (Cold-Excess Chest Binding Syndrome) without heat signs, Sanwu Xiao Xianxiong Tang (Three-Ingredient Minor Intrapleural Decoction) or Baisan (White Powder) may be used.
"Disease in the Yang" generally refers to pathogens in the Taiyang (Greater Yang) meridian. How do we know Zhang Zhongjing refers exclusively to Taiyang? In the opening of the Yangming (Yang Brightness) chapter, he states: "Body heat, spontaneous sweating, aversion to neither cold nor preference for heat" constitutes Yangming exterior syndrome. Since there is spontaneous sweating, sweating therapy is contraindicated. Only when pathogens enter Yangming but Taiyang symptoms persist are Gegen Tang (Kudzu Decoction) or Guizhi Jiagegen Tang (Cinnamon Twig plus Kudzu Decoction) used for sweating. There are no other specific exterior-releasing drugs for Yangming. Thus, it is not Yangming. Shaoyang (Lesser Yang) has half-exterior pathogens, but sweating, vomiting, and purging are all prohibited, so the phrase "should be resolved by sweating" does not apply. Thus, it is not Shaoyang. Only Taiyang (Greater Yang), being the outermost layer, governs Ying (Nutrient) and Wei (Defensive) and wind-cold invasion, requiring sweating for resolution. Due to the inability to sweat, irritability and heat arise. Instead of sweating, cold water is sprayed or poured. "Spraying" means misting; "pouring" means washing. Using cold water aims to treat heat with cold, which is the reckless act of the ignorant. This suppresses the郁 (stagnant) heat in the skin, preventing dispersion, thereby increasing irritability and heat. Although irritability is severe, the original pathogen involved aversion to cold and no sweating. The added cold water invades the skin, causing goosebumps. The desire to drink results from irritability; the lack of actual thirst results from cold-water invasion. Such manifestations suggest sweating might seem appropriate. However, due to external cold-water invasion suppressing heat, the pathogen is no longer in the exterior. Therefore, Wenli San (Clam Shell Powder), salty-cold and lubricating, promotes urination to guide water out. If ineffective, it indicates cold-water has invaded the Taiyang Fu organs, affecting the Bladder. Wuling San (Five-Ingredient Powder with Poria) should be given to assist lower Jiao (Triple Burner) vaporization, allowing Qi transformation to flow and water qi to dissipate. Even if exterior pathogens remain, Wuling San (Five-Ingredient Powder with Poria) includes drinking warm water to induce sweating. This clause should be read alongside the Shui Ni (Water Reversal) syndrome in Wind-Stroke mishandling, where thirst leads to immediate vomiting upon drinking. That case involves internal cold-water from drinking; this case involves external cold-water from spraying/pouring. The conditions are similar, hence similar treatments.
The phrase "Han Shi Jie Xiong (Cold-Excess Chest Binding Syndrome) without heat signs" initially seems incompatible with the bitter-cold Xiao Xianxiong Tang (Minor Intrapleural Decoction). However, reviewing the text above, cold water suppression prevented heat dissipation, causing heat to sink inward and increase irritability. Heat thus knotted excessively in the chest due to cold constraint, termed "Cold-Excess Chest Binding," not implying cold excess knotted in the chest. If it were truly Yin-cold, it would manifest as Epigastric Stuffiness (Pi). The first clause of Jie Xiong (Chest Binding Syndrome) states: "Originating in Yang, if wrongly purged, heat enters, resulting in Jie Xiong (Chest Binding Syndrome)." This confirms heat entry, not Yin-cold. Without heat, it cannot be called Jie Xiong (Chest Binding Syndrome). This distinguishes Yin/Yang and Cold/Heat. "Without heat signs" refers to the absence of exterior heat, citing the earlier mention of goosebumps, not the absence of heat in both interior and exterior. Therefore, Sanwu Xiao Xianxiong Tang (Three-Ingredient Minor Intrapleural Decoction) is used to open chest excess knots. Although Baisan (White Powder) is harsh, it addresses cold-excess knotted in the chest where cold-water injures the Lung, causing wheezing, coughing, and rebellious Qi. Jiegeng (Platycodon Root) opens Lung Qi; Beimu (Fritillaria Bulb) enters the Lung; and Badou (Croton Seed), acrid, hot, and toxic, acts as a general breaking through gates to destroy chest knots. Heat is insufficient to open cold-water; harshness is insufficient to break excess knots. This is a method for treating excess, not deficiency.
Formula for Wenli San (Clam Shell Powder):
Wenli (Clam Shell) - 5 liang
Wenli resembles clams but has purple spots on the back; it is the flower clam eaten in Wu regions today, mistakenly called Cangluo or Chang'e.
Grind this single ingredient into powder. Mix with boiling water and take one qianbi dose. Use five he of water.
Sanwu Xiao Xianxiong Tang (Three-Ingredient Minor Intrapleural Decoction) is the aforementioned Xiao Xianxiong Tang (Minor Intrapleural Decoction).
Formula for Baisan (White Powder):
Jiegeng (Platycodon Root) - 3 fen (choose bitter ones)
Badou (Croton Seed) - 1 fen (remove skin and heart, roast black, grind into paste)
Beimu (Fritillaria Bulb) - 3 fen
Grind Jiegeng (Platycodon Root) and Beimu (Fritillaria Bulb) into powder. Add Badou (Croton Seed). Pound further in a mortar. Mix with Baiyin (rice water) for administration. Strong individuals take half a qian; weak individuals reduce the dose. If the disease is above the diaphragm, vomiting will occur; if below, diarrhea will occur. If no diarrhea, drink one cup of hot porridge soup. If diarrhea persists uncontrollably, drink one cup of cold porridge soup.
In Jie Xiong (Chest Binding Syndrome), if the pulse is floating and large, purging is contraindicated; purging leads to death.
Generally, when pathogens are in the exterior, the pulse floats. Jie Xiong (Chest Binding Syndrome) arises from mistaken inward sinking of Taiyang (Greater Yang) exterior pathogens. Once knotted, pathogens enter the interior, and the Guan (Gate) pulse should be deep. How can a floating and large pulse reappear? Now that the chest is knotted, yet the pulse remains floating and large, the remaining exterior pathogens are still strong. Moreover, floating and large pulses originally indicate interior deficiency. As stated in the Yangdan clause: "Floating indicates wind; large indicates deficiency." With deficient Zheng Qi (Upright Qi), further purging causes remaining exterior pathogens to sink again. This results in exterior pathogens sinking twice and chest pathogens knotting twice, described as "deficiencyizing the deficient and excessizing the excess." Heavy sinking of pathogens overwhelms Zheng Qi (Upright Qi); death is inevitable. Hence, purging is contraindicated; purging leads to death.
In Jie Xiong (Chest Binding Syndrome), if all symptoms are present and restlessness (Fan Zao) appears, it is also a death sign.
This follows the previous discussion, presenting cases that lead to death even without purging. "All symptoms present" means all syndromes binding the chest are fully manifested. With all symptoms present, the severity of pathogens and depth of sinking are evident. The appearance of Fan Zao (restlessness) indicates Fan (irritability) as scattered deficient Yang and Zao (agitation) as rebellious Yin pathogens. Severe pathogen knotting isolates upper and lower parts, leading to failure of Stomach Qi. The Neijing (Inner Canon) Heat Theory states: "If Ying (Nutrient) and Wei (Defensive) do not circulate, and Zang-Fu organs do not communicate, death ensues."