瓜蒂（熬黄）一分 赤小豆一分
右二味，各别捣筛，为散已，合治之，取一钱匕，以香豉一合，用热汤七合，煮作稀
糜，去滓，取汁和散，温顿服之。不吐者，少少加服，得快吐乃止。诸亡血虚家，不
可与瓜蒂散。
【方解】
胸中者，清阳之府。诸邪入胸府，阻遏阳气，不得宣达，以致胸满痞□，热气上冲，
燥渴心烦，嗢嗢欲吐。脉数促者，此热郁结也；胸满痞□，气上冲咽喉不得息，手足
寒冷，欲吐不能吐，脉迟紧者，此寒郁结也。凡胸中寒热与气与饮郁结为病，谅非汗
下之法所能治，必得酸苦涌泄之品，因而越之，上焦得通，阳气得复，痞□可消，胸
中可和也。瓜蒂极苦，赤豆味酸，相须相益，能疏胸中实邪，为吐剂中第一品也。而
佐香豉汁合服者，借谷气以保胃气也。服之不吐，少少加服，得快吐即止者，恐伤胸
中元气也。此方奏功之捷，胜于汗下，所谓汗、吐、下三大法也。今人不知仲景、子
和之精义，置之不用，可胜惜哉！然诸亡血虚家，胸中气液已亏，不可轻与，特为申
禁。
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。
【注】
此总释结胸与痞□之因也。中风阳邪，故曰病发于阳也。不汗而反下之，热邪乘虚陷
入，因作结胸。伤寒阴邪，故曰病发于阴也。不汗而反下之，热邪乘虚陷入，因作痞
□。所以成结胸与痞□者，以表未解而下之太早故也。病发于阴，不言热入者，省文
耳。然病发于阳而误下者，未尝无痞□；病发于阴、而误下之，亦时成结胸。良由人
之气体不同，或从实化，或从虚化也。
【集注】
张兼善曰：风邪入里则结胸，寒邪入里则为痞。然此皆太阳病之所由来，非别阴证阳
证也。
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，胃中空虚，客气动
膈，短气躁烦，心中懊□，阳气内陷，心下因□，则为结胸，大陷胸汤主之。若不结
胸，但头汗出，余处无汗，跻颈而还，小便不利，身必发黄。
【按】
「数则为虚句」，疑是衍文。
【注】
太阳病，脉浮而动数，浮则为风邪脉也，数则为热邪脉也，动则为诸痛脉也。头痛发
热，太阳证也。热蒸于阳，阳虚则自汗出，热蒸于阴，阴虚则盗汗出，阴虚当恶热，
今反恶寒，故知此非阴虚之盗汗，乃表未解之盗汗，微微而出也。表未解当解表，医
反下之，遂使动数之热脉变为寒迟，盖动数乃表邪欲传，因下而逆于膈中，故不传而
脉亦变也。表客阳邪，乘胃空虚，陷入胸膈而拒痛，短气不能布息，烦躁，心中懊□
，心下因□，迳从实化而为结胸矣。法当以大陷胸汤主之。若不从实化，不成结胸，
但头汗出至颈，余处无汗，则热不得越也。小便不利，则湿不得泻也，热湿合化，故
身必发黄也。
【集注】
成无己日：动数变迟，而浮脉独不变者，以邪结胸中，上焦阳分，脉不得而沉也。
朱震亨曰：太阳病、表未解而攻里，里已虚矣。虽见浮而动数之阳脉，一经误下，则
必变为迟阴之脉矣。胃中空虚，短气躁烦，虚之甚矣。借曰：阳气内陷，心中因□而
可迅攻之乎？大陷胸之力，不缓于承气，下而又下，宁不畏其重虚耶！即阳病实邪下
后，若胃中空虚，客气动膈，心中懊□者，亦以栀子豉汤吐胸中之邪可也。况太阳误
下后，明有虚证乎？【按】震亨所论治，以栀子豉汤吐之，亦是未成结胸，从胸虚有
热而化者宜也。若从胸虚有寒而化者，不论已成未成结胸，则又当从活人书温补法矣
，不可混施也。
方有执曰：太阳之脉本浮，动数者亦传也。太阳本自汗，而言微盗汗，本恶寒，而言
反恶寒者，稽久而然也。膈，心胸之间也。拒，格拒也。言膈气与邪气相格拒而为痛
也。客气，邪气也。短气，促气不能布息也。懊□，心为邪乱而不宁也。阳气，客气
之别名也，以本外邪，故曰客气。以邪本风，故曰阳气。以里虚因而陷入，故曰内陷
。自若不结胸句至末，以变之轻者而言也。
【方解】
胸中，是清阳之气汇聚的府库。各种邪气侵入胸府，阻遏阳气，使其不能宣通发散，从而导致胸部胀满痞塞，热气上冲，出现口干舌燥、口渴、心烦意乱、恶心欲吐的症状。如果脉象数而急促，这是热邪郁结所致；如果胸部胀满痞塞，气逆上冲至咽喉导致呼吸不畅，手足寒冷，想吐却吐不出来，脉象迟而紧，这是寒邪郁结所致。凡是胸中因寒、热、气滞或痰饮郁结而成的病证，大概不是发汗或攻下的方法所能治疗的，必须使用酸苦涌泄的药物，通过催吐的方法使邪气从上排出，这样上焦得以通畅，阳气得以恢复，痞塞症状可以消除，胸中得以调和。瓜蒂味极苦，赤小豆味酸，二者相互辅助，能够疏泄胸中的实邪，是催吐剂中的第一品药。而配合香豉汁一起服用，是借助谷物的气味来保护胃气。服药后如果不吐，就少量增加剂量，直到快速吐出为止，这是为了防止损伤胸中的元气。这个方子见效迅速，胜过发汗和攻下法，这就是所谓的汗、吐、下三大治法。现在的人不了解张仲景和许叔微（字知可，号子和）的精妙义理，将其搁置不用，真是令人惋惜啊！然而，凡是失血或体质虚弱的人，胸中的气和津液已经亏损，不可轻易给予此方，特此重申禁令。
疾病发生在阳经（如太阳病），反而使用攻下法，热邪乘虚内陷因而形成结胸；疾病发生在阴经（如少阴病等），反而使用攻下法，因而形成痞证。之所以形成结胸，是因为攻下太早的缘故。
【注】
这里总括解释结胸与痞证的成因。中风属于阳邪，所以说“病发于阳”。不先发汗而反而攻下，热邪乘虚陷入，因而形成结胸。伤寒属于阴邪，所以说“病发于阴”。不先发汗而反而攻下，热邪乘虚陷入，因而形成痞证。之所以形成结胸与痞证，是因为表证未解而攻下太早的缘故。对于“病发于阴”的情况，没有提到热邪内陷，这是省略了文字。然而，病发于阳而误用攻下，并非不会形成痞证；病发于阴而误用攻下，有时也会形成结胸。这主要是因为人的体质不同，有的从实证转化，有的从虚证转化。
【集注】
张兼善说：风邪入里则形成结胸，寒邪入里则形成痞证。然而这些都属于太阳病的由来，并不是单独指阴证或阳证。
太阳病，脉象浮而动数，浮脉主风，数脉主热，动脉主痛，数脉也主虚（此处存疑，见下文按语）。头痛发热，微微盗汗，反而恶寒，说明表证未解。医生反而使用攻下法，导致动数之脉变为迟脉，膈内抗拒疼痛，胃中空虚，外邪扰动膈部，出现短气、烦躁、心中烦闷不安（懊憹），阳气内陷，心下因此痞硬，这就形成了结胸，用大陷胸汤主治。如果不形成结胸，只是头部出汗，身体其他部位无汗，汗止于颈部，小便不利，身体必然发黄。
【按】
“数则为虚”这一句，怀疑是衍文（多余的文字）。
【注】
太阳病，脉象浮而动数，浮脉是风邪的脉象，数脉是热邪的脉象，动脉是各种疼痛的脉象。头痛发热，是太阳病的证候。热邪蒸腾于阳分，阳虚则自汗出；热邪蒸腾于阴分，阴虚则盗汗出。阴虚应当怕热，现在反而怕冷，所以知道这不是阴虚导致的盗汗，而是表证未解导致的盗汗，微微出汗而已。表证未解应当解表，医生反而攻下，使得原本动数的热脉变为寒迟之脉。这是因为动数之脉表示表邪欲传变，因误下而逆阻于膈中，所以不传变而脉象也发生了变化。体表的阳邪，乘胃腑空虚，陷入胸膈并产生格拒疼痛，短气不能顺畅呼吸，烦躁，心中烦闷不安，心下痞硬，径直从实证转化而形成结胸了。治法应当用大陷胸汤主治。如果不从实证转化，不成结胸，只是头部出汗至颈部，其余地方无汗，那么热邪就无法向外宣泄。小便不利，湿邪就无法排泄，热与湿结合化生，所以身体必然发黄。
【集注】
成无己说：脉由动数变为迟，但浮脉唯独不变，是因为邪气结聚在胸中，位于上焦阳分，脉象不能沉下去。
朱震亨说：太阳病，表证未解而攻伐里证，里气已经虚弱了。虽然见到浮而动数的阳脉，一旦误用攻下，必定会变为迟阴之脉。胃中空虚，短气烦躁，这是极度虚弱的表现。如果说：阳气内陷，心下痞硬就可以迅速攻伐吗？大陷胸汤的力量，并不比承气汤缓弱，在下法之后又用下法，难道不怕造成严重的虚损吗？即使是阳病实邪攻下后，如果胃中空虚，外邪扰动膈部，心中烦闷不安的，也可以用栀子豉汤吐除胸中之邪。何况太阳病误下后，明明有虚证存在呢？【按】朱震亨所论述的治疗，用栀子豉汤吐之，也是适用于未形成结胸，从胸虚有热转化的情况。如果是从胸虚有寒转化的，不论是否已成结胸，就应当依据《活人书》的温补法治疗了，不可混淆施用。
方有执说：太阳病的脉本应浮，动数之脉也表示邪气在传变。太阳病本来就有汗出，却说微微盗汗；本来恶寒，却说反而恶寒，这是病程稽留久了才这样的。膈，是指心胸之间。拒，是格拒的意思。说的是膈气与邪气相互格拒而产生疼痛。客气，就是邪气。短气，是气息急促不能布散。懊憹，是心被邪气扰乱而不安宁。阳气，是客气的别名，因为本是外来邪气，所以叫客气。因为邪气本是风邪，所以叫阳气。因为里虚因而陷入，所以叫内陷。从“若不结胸”一句到最后，是说病情变化较轻的情况。
[Explanation of the Formula]
The chest is the residence where clear yang qi gathers. When various pathogenic factors invade the chest, they obstruct the yang qi, preventing it from circulating and dispersing freely. This leads to chest fullness and stuffiness, upward rushing of hot qi, dry mouth, thirst, irritability, and a sensation of nausea with an urge to vomit. If the pulse is rapid and frequent (shu cu), this indicates heat stagnation; if there is chest fullness and stuffiness, qi rushing upward to the throat causing dyspnea, cold hands and feet, an urge to vomit but inability to do so, and a slow and tight pulse, this indicates cold stagnation. For diseases caused by the stagnation of cold, heat, qi, or fluid retention in the chest, methods of sweating or purging are generally ineffective. One must employ sour and bitter agents that induce vomiting (yong xie) to expel pathogens upwards via emesis. This allows the upper jiao to become unobstructed, restores yang qi, eliminates stuffiness, and harmonizes the chest. Genti (Cucumis melo var. makuwa seed) is extremely bitter, and Chixiaodou (Vigna angularis) is sour; together they mutually enhance each other's effect to vent solid pathogens in the chest, making them the premier emetic formula. The addition of Xiangchi (Sojae Semen Praeparatum) juice aids in preserving stomach qi through the nourishing nature of grain. If vomiting does not occur after administration, the dose should be increased slightly until rapid vomiting occurs, which serves to prevent damage to the yuan qi (original qi) of the chest. This formula acts swiftly, surpassing the efficacy of sweating and purging methods, representing one of the three major therapeutic approaches: sweating, vomiting, and purging. Today, people fail to understand the profound principles of Zhang Zhongjing and Xu Hezi, leaving these formulas unused, which is truly regrettable! However, for individuals who have suffered blood loss or are constitutionally deficient, the qi and fluids in the chest are already depleted; thus, this formula must not be given lightly. This prohibition is specifically reiterated here.
When a disease originates in the Yang (e.g., Taiyang disease) and is mistakenly treated with purgatives, heat pathogens sink inward due to deficiency, resulting in Jie Xiong (chest binding). When a disease originates in the Yin and is mistakenly treated with purgatives, Pi syndrome (stuffiness) results. The reason Jie Xiong forms is due to premature purgation.
[Annotation]
This section summarizes the causes of Jie Xiong and Pi syndrome. Wind-stroke involves Yang pathogens, hence it is said "disease originates in Yang." Failing to induce sweating first and instead using purgatives allows heat pathogens to sink inward due to deficiency, forming Jie Xiong. Cold injury involves Yin pathogens, hence it is said "disease originates in Yin." Failing to induce sweating first and instead using purgatives allows heat pathogens to sink inward due to deficiency, forming Pi syndrome. The formation of both Jie Xiong and Pi syndrome is due to the exterior pattern remaining unresolved while purgatives are used prematurely. In the phrase "disease originates in Yin," the mention of heat sinking inward is omitted for brevity. However, when diseases originating in Yang are mistakenly purged, Pi syndrome can still form; similarly, when diseases originating in Yin are mistakenly purged, Jie Xiong may occasionally result. This is primarily because human constitutions vary, leading to transformations either into excess patterns or deficiency patterns.
[Collected Annotations]
Zhang Jianshan stated: Wind pathogens entering the interior form Jie Xiong, while cold pathogens entering the interior form Pi. However, these all arise from Taiyang diseases and do not exclusively refer to distinct Yin or Yang syndromes.
In Taiyang disease, the pulse is floating, active, and rapid (fu, dong, shu). Floating indicates wind, rapid indicates heat, active indicates pain, and rapid also indicates deficiency (see commentary below). Headache and fever, slight night sweats, and paradoxical aversion to cold indicate that the exterior pattern remains unresolved. If the physician mistakenly uses purgatives, the active and rapid pulse changes to a slow pulse. There is resistance and pain within the diaphragm, emptiness in the stomach, disturbance of the diaphragm by external pathogens, shortness of breath, irritability, and mental restlessness (ao nao). The yang qi sinks inward, causing hardness beneath the heart, resulting in Jie Xiong. Da Xianxiong Tang (Major Trap the Chest Decoction) is indicated. If Jie Xiong does not form, but only head sweating occurs (sweat stopping at the neck), with no sweat elsewhere, and urination is difficult, jaundice will inevitably develop.
[Commentary]
The phrase "rapid indicates deficiency" is suspected to be a later interpolation (derivative text).
[Annotation]
In Taiyang disease, a floating, active, and rapid pulse indicates wind (floating), heat (rapid), and pain (active). Headache and fever are Taiyang signs. Heat steaming the Yang aspect leads to spontaneous sweating due to Yang deficiency; heat steaming the Yin aspect leads to night sweats due to Yin deficiency. Yin deficiency typically presents with aversion to heat; however, the presence of aversion to cold indicates that this is not night sweats due to Yin deficiency, but rather slight night sweats due to the unresolved exterior pattern. Since the exterior is unresolved, it should be resolved via sweating. Mistaken purgation causes the active and rapid heat pulse to transform into a cold and slow pulse. The active and rapid pulse signifies that exterior pathogens were about to transmit; due to purgation, they reversed into the diaphragm, preventing transmission and altering the pulse. The exterior Yang pathogens, taking advantage of gastric emptiness, sink into the chest and diaphragm, causing resistance and pain, shortness of breath, irritability, mental restlessness, and epigastric hardness. This directly transforms into an excess pattern, forming Jie Xiong. The treatment should be Da Xianxiong Tang. If it does not transform into an excess pattern and does not form Jie Xiong, but only head sweating up to the neck occurs, heat cannot vent outward. Difficulty in urination means dampness cannot be drained. Heat and dampness combine to transform, inevitably causing jaundice.
[Collected Annotations]
Cheng Wuji stated: The pulse changes from active/rapid to slow, yet the floating pulse remains unchanged because the pathogen is bound in the chest, located in the upper jiao Yang aspect, preventing the pulse from sinking.
Zhu Zhenheng stated: In Taiyang disease, attacking the interior while the exterior is unresolved leaves the interior deficient. Although Yang pulses (floating, active, rapid) are present, mistaken purgation will inevitably cause them to transform into slow, Yin-type pulses. Gastric emptiness, shortness of breath, and irritability indicate severe deficiency. One might ask: If yang qi has sunk inward and there is epigastric hardness, can aggressive purgation be applied rapidly? The power of Da Xianxiong Tang is not milder than Chengqi Tang; applying purgation after purgation risks severe depletion. Even if excess pathogens from Yang diseases are purged, if the stomach becomes empty and external pathogens disturb the diaphragm causing mental restlessness, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) can be used to vomit out pathogens from the chest. How much more so when clear deficiency patterns exist after mistaken Taiyang purgation? [Commentary] Zhu Zhenheng’s suggestion to use Zhi Zi Chi Tang for emesis is appropriate for cases where Jie Xiong has not formed and the pathology stems from deficiency-heat in the chest. However, if the transformation stems from deficiency-cold in the chest, regardless of whether Jie Xiong has formed, one should follow the warming and tonifying methods of the *Luo Ren Shu* (Book of Vitality). These methods must not be confused.
Fang Youzhi stated: The Taiyang pulse is naturally floating; active and rapid pulses also indicate transmission. Taiyang disease naturally involves sweating, yet slight night sweats are mentioned; it naturally involves aversion to cold, yet paradoxical aversion to cold is noted, indicating the disease has lingered for some time. The diaphragm refers to the area between the heart and chest. "Ju" (resistance) refers to mutual rejection. It describes the conflict between diaphragmatic qi and pathogenic qi causing pain. "Ke qi" (guest qi) refers to pathogenic qi. "Duan qi" (shortness of breath) refers to急促 breathing unable to distribute properly. "Ao nao" refers to mental unrest caused by pathogenic disturbance. "Yang qi" is another name for guest qi; because it is an external pathogen, it is called guest qi. Because the pathogen is originally wind, it is called yang qi. Because it sinks inward due to interior deficiency, it is called internal sinking. From the phrase "if Jie Xiong does not form" to the end, the text discusses milder variations of the condition.