金匮云。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。以其阴弦也。
阳微在胸中气分上看。故曰阳微知在上焦。阴弦在阴脉上看。如阴寒之脉。上于胸中气分。
则为胸痹。如阴脉上乘于心。则为心痛也。
平人无寒热。短气不足以息者。实也。
上条是言不及。此则言太过也。平人。盖言无内困虚劳。外因感冒。而患短气不足以息者。
当是胸中邪气窒塞。肾中阳气不得上通于胸中。故为实也。
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。
寸口脉沉迟者。阳气衰微也。关上小紧者。胃以上有阴寒结聚。所以胸中喘息咳唾。胸背痛
而短气。栝蒌性润。专以涤垢腻之痰。薤白臭秽。用以通秽浊之气。同气相求也。白酒熟谷之液。
色白上通于胸中。使佐药力上行极而下耳。
胸痹不得卧。心痛彻背者。栝蒌薤白半夏汤主之。
心痛彻背者。胸中痰垢积满。循脉而溢于背。背者胸之府。故于前药但加半夏。以祛痰积之痹逆也。
胸痹心中痞痛。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。
痰气结聚于胸中。胸满溢于经脉。故从胁下逆上以抢心也。二汤一以治胸中实痰外溢。用薤
白桂枝以解散之。一以治胸中虚痰内结。即用人参理中以清理之。一病二治。因人素禀而施。两
不移易之法也。
胸痹胸中气塞。短气。茯苓杏仁甘草汤主之。橘皮枳实生姜汤亦主之。
夫短气不足以息者。实也。故二方皆利气之剂。一以疏利肺气。一以疏利胃气也。
胸痹缓急者。薏苡附子散主之。
胸中为阳气所居之位。今胸中之阳。痹而不舒。其经脉所过。非缓即急。失其常度。总由阳
气不运故也。用薏苡舒其经脉。附子复其胸中之阳。则大气一转。阴浊不留。胸际旷然若太空矣。
心中痞。诸逆心悬痛。桂枝生姜枳实汤主之。
心中痞者。心气逆于上也。上气逆。则中下亦逆。气逆则经脉亦逆。故为诸逆也。上下气逆。
脉不交通。心主孤悬于上。不得营气以和之。故心悬痛也。桂枝行心气以散痞。姜、枣疏中焦以
通经也。
心痛彻背。背痛彻心。乌头赤石脂丸主之。
心痛彻背。背痛彻心。乃阴邪厥逆。而上干胸背经脉之间。牵连痛楚。乱其血气。紊其疆界。
此而用气分之药。则转益其痛。势必危殆。仲景用蜀椒、乌头一派辛辣。以温散其阴邪。然恐胸
背既乱之气难安。即于温药队中。取用干姜、赤脂之涩。以填塞厥气攻冲之经隧。俾胸之气自行
于胸。背之气自行于背。各不相犯。其患乃除。今人但知有温气补气行气散气诸法。不知有填塞
邪气攻冲之窦也。
千金治胸痹达背痛。用细辛散。胸中逆气。心痛彻背。少气不食。用前胡汤。胸中 如满。
噎塞习习如痒。喉中涩燥唾沫。服橘皮枳实生姜汤。不应。用治中汤。胸痹腹背闭满。上气喘息。
用下气汤。胸背疼痛。用熨背散。足补金匮之未逮。
病患胸中似喘不喘。似呕不呕。似哕不哕。彻心中愦愦然无奈者。生姜半夏汤主之。千金加
橘皮、吴茱萸。名通气散。治胸满短气而噎。
此即胸痹一门之证。必编者之差误。入于呕吐哕中。今并论于此。盖阳受气于胸中。以布气
息。今阴乘阳位。阻其阳气布息。呼吸往来之道。若喘若呕若哕。心舍神者也。聚饮停痰。则炎
炽不宁。彻心愦乱。无可奈何。故用半夏、生姜之辛温。以燥饮散寒。则阳得以布。气得以调。
而胸际始旷也。其用橘皮、吴茱萸。及加竹茹、人参。皆此例也。喻嘉言曰。按胸痹之证。人所
通患。金匮出十方论治。然未明言其故。盖胸中如太空。其阳气所过。如离照当空。旷然无外。
设地气一上。则窒塞有加。故知胸痹者。阳气不用。阴气在上之候也。然有微甚不同。微者但通
其上焦不足之阳。甚者必驱其下焦厥逆之气。通胸中之阳。以薤白、白酒。或栝蒌、半夏、桂枝、
枳实、浓朴、干姜、白术、人参、甘草、茯苓、杏仁、橘皮。择用对证三四味。即成一方。不但
苦寒不入。即清凉尽屏。盖以阳通阳。阴分之药。所以不得预也。甚者。则用附子、乌头、蜀椒
大辛热。以驱下焦之阴。而复上焦之阳。补天浴日。在医之手眼。奈何后世总不知胸痹为何病耳。
《金匮要略》中说：老师说，诊脉应当辨别脉象的太过与不及。阳气微弱而阴脉弦紧，这就是胸痹且伴有疼痛的原因。之所以如此，是因为（患者）极度虚弱所致。如今知道阳气虚损位于上焦，所以出现胸痹心痛的症状，是因为阴脉弦紧的缘故。
“阳微”是从胸中气分的角度来理解的，所以说“阳微”意味着病位在上焦。“阴弦”则是从阴脉的角度来看，如果是阴寒性质的脉象，上行至胸中气分，就会形成胸痹；如果阴脉上乘于心，就会形成心痛。
普通人如果没有恶寒发热的表证，却出现呼吸短促、气息不足以接续的情况，这属于实证。
上一条条文讲的是“不及”（虚证），这一条讲的是“太过”（实证）。所谓“平人”，是指没有内部虚劳困扰、也没有外部感冒侵袭的人。如果出现呼吸短促、气息不足，应当是胸中邪气壅塞，导致肾中的阳气不能上达于胸中，因此属于实证。
胸痹病的症状包括：喘息、咳嗽吐痰、胸背部疼痛、呼吸短促，寸口脉沉而迟，关脉小紧且数。治疗主方为栝蒌薤白白酒汤。
寸口脉沉迟，说明阳气衰微；关脉小紧，说明胃脘以上有阴寒结聚。因此出现胸中喘息、咳嗽吐痰、胸背疼痛及呼吸短促等症状。栝蒌性润，专门用于涤除黏腻之痰；薤白气味臭秽，用于通散秽浊之气，这是同气相求的道理。白酒是熟谷的液体，色白能上行通达胸中，协助药力上行至极点然后下行。
胸痹严重到无法平卧，心痛放射至背部的，主方为栝蒌薤白半夏汤。
心痛放射至背部，是因为胸中痰垢积满，顺着经脉溢于背部。背部是胸腑的外应部位，所以在前方基础上仅加半夏，以祛除痰积引起的痹逆。
胸痹伴心中痞塞疼痛，气结在胸中，胸部胀满，胁下有气逆冲心胸的，主方为枳实薤白桂枝汤。人参汤也可以主治。
痰气结聚于胸中，胸满溢于经脉，所以气从胁下逆上冲击心胸。这两张方剂，一张用于治疗胸中实痰外溢，用薤白、桂枝来解散它；另一张用于治疗胸中虚痰内结，用人参理中汤来清理它。同一疾病两种治法，根据患者素体禀赋不同而施治，这是不可更改的法则。
胸痹表现为胸中气塞、呼吸短促的，主方为茯苓杏仁甘草汤。橘皮枳实生姜汤也可以主治。
呼吸短促、气息不足以接续的属于实证，所以这两张方剂都是利气的药剂。一张用于疏利肺气，一张用于疏利胃气。
胸中是阳气居住的部位。如今胸中的阳气痹阻而不舒展，其经脉所经过的地方，不是舒缓就是拘急，失去了正常的节度，总归是由于阳气不运的缘故。使用薏苡仁舒缓经脉，附子恢复胸中的阳气，那么大气一转，阴浊之气不留存，胸际就会空旷得像太空一样。
心中痞塞，各种气逆导致心部悬吊样疼痛的，主方为桂枝生姜枳实汤。
心中痞塞，是心气逆乱于上。上气逆乱，则中下二焦的气也随之逆乱。气逆则经脉也逆乱，所以称为“诸逆”。上下气机逆乱，脉气不相交通，心主孤悬于上，得不到营气的调和，所以出现心悬痛。桂枝运行心气以消散痞塞，生姜、大枣疏通中焦以通达经脉。
心痛彻背，背痛彻心，这是阴邪厥逆，向上干扰胸背经脉之间，牵连致痛，扰乱血气，混淆界限。这种情况下如果使用调理气分的药物，只会加重疼痛，势必导致危殆。仲景使用蜀椒、乌头一派辛辣之品，以温散阴邪。然而担心胸背已乱之气难以安宁，便在温药队伍中，选取干姜、赤石脂的涩性，以填塞厥气攻冲的经络隧道，使得胸中之气自行于胸，背中之气自行于背，互不侵犯，病患才能消除。现在的人只知道有温气、补气、行气、散气等方法，不知道还有填塞邪气攻冲窦道的方法。
《千金方》治疗胸痹放射至背痛的，用细辛散；治疗胸中逆气、心痛彻背、少气不食的，用前胡汤；治疗胸中如胀满、噎塞感、皮肤瘙痒感、喉中涩燥唾沫多的，服用橘皮枳实生姜汤无效者，用治中汤；治疗胸痹腹背闭满、上气喘息的，用下气汤；治疗胸背疼痛的，用熨背散。这些方法弥补了《金匮要略》的不足。
病人胸中似喘非喘、似呕非呕、似呃逆非呃逆，心中烦闷无奈难受的，主方为生姜半夏汤。《千金方》加橘皮、吴茱萸，名为通气散，治疗胸满短气而噎塞。
这原本属于胸痹一门的证候，可能是编者差错，将其列入呕吐哕门中。现一并论述于此。盖因阳气受气于胸中，以布散气息。如今阴邪乘袭阳位，阻碍阳气布息，影响呼吸往来的通道，表现出似喘、似呕、似呃逆的症状。心是藏神之所，若聚饮停痰，则火热炽盛不安，导致心中烦乱无可奈何。故用半夏、生姜的辛温之性，以燥湿饮、散寒邪，使阳气得以布散，气机得以调畅，胸际始得空旷。其中使用橘皮、吴茱萸，以及加入竹茹、人参，都是此类道理。喻嘉言说：按胸痹之证，是人们普遍患有的疾病。《金匮要略》列出十方论治，但未明确说明其原因。大概胸中如同太空，阳气经过之处，如同太阳照耀天空，空旷无外。如果地气（阴邪）一旦上升，窒塞就会加重。因此可知胸痹是阳气不用、阴气在上的征候。然而病情有轻重不同。轻者只需通达上焦不足的阳气，重者必须驱除下焦厥逆之气，通达胸中之阳。选用薤白、白酒，或栝蒌、半夏、桂枝、枳实、厚朴、干姜、白术、人参、甘草、茯苓、杏仁、橘皮等，根据证候选择对证的三四味药，即成一方。不仅苦寒药物不使用，就连清凉药物也全部摒弃。这是因为以阳通阳，阴分性质的药物不得参与。重者，则使用附子、乌头、蜀椒等大辛大热之品，以驱除下焦之阴，恢复上焦之阳。补天浴日，在于医生的眼光和手段。奈何后世总是不明白胸痹是什么病。
The *Jin Gui Yao Lue* states: The Master said, "When taking the pulse, one should assess excess (Tai Guo) and deficiency (Bu Ji). Yang Wei (Yang deficiency/weakness) and Yin Xian (Yin tension/string-like pulse) indicate Chest Bi syndrome with pain. This occurs because of extreme deficiency. Now, knowing that Yang is deficient in the Upper Jiao, the reason for Chest Bi and Heart Pain is due to Yin Xian."
"We understand 'Yang Wei' from the perspective of Qi in the chest, hence 'Yang Wei indicates location in the Upper Jiao.' We understand 'Yin Xian' from the perspective of the Yin pulse. If a Yin-Cold pulse ascends to the Qi level of the chest, it results in Chest Bi; if the Yin pulse overcomes the Heart, it results in Heart Pain."
"A healthy person without exterior cold or heat symptoms who suffers from shortness of breath and inability to take a full breath has an Excess condition.
"The previous clause discussed 'Bu Ji' (Deficiency), while this one discusses 'Tai Guo' (Excess). A 'Ping Ren' (healthy person) here refers to someone without internal consumption/lao disease or external wind-cold invasion. Shortness of breath and insufficient respiration in such cases are due to pathogenic Qi obstructing the chest, preventing Kidney Yang Qi from ascending to the chest, thus constituting an Excess condition.
"The disease of Chest Bi presents with wheezing, coughing and spitting phlegm, chest and back pain, and shortness of breath. The Cun Kou (radial artery at the wrist) pulse is Chen (Deep) and Chi (Slow); the Guan pulse is Xiao Jin Shu (Small, Tight, and Rapid). It is primarily treated with Gua Lou Xie Bai Bai Jiu Tang (Trichosanthes Fruit, Macrostemon Stem, and White Wine Decoction).
"A Chen Chi pulse at Cun Kou indicates decline and weakness of Yang Qi. A Xiao Jin pulse at the Guan position indicates accumulation of Yin-Cold above the Stomach. Hence, there is wheezing, coughing, spitting phlegm, chest/back pain, and shortness of breath in the chest. Gua Lou is moistening and specifically clears sticky phlegm. Xie Bai has a strong odor and is used to diffuse turbid Qi, following the principle of similar Qi attracting each other. Bai Jiu (white wine) is the liquid of cooked grains; its white color allows it to ascend to the chest, assisting medicinal power to reach the upper extremity before descending.
"When Chest Bi is severe enough to prevent lying down, and Heart Pain radiates through to the back, Gua Lou Xie Bai Ban Xia Tang (Trichosanthes Fruit, Macrostemon Stem, and Pinellia Tuber Decoction) is primarily indicated.
"Heart Pain radiating through to the back occurs because phlegm and filth accumulate fully in the chest, overflowing along the meridians to the back. The back is the mansion of the chest. Therefore, only Ban Xia is added to the previous formula to dispel the obstruction caused by phlegm accumulation.
"When Chest Bi involves epigastric fullness and pain, Qi knotting in the chest, chest distension, and rebellious Qi rushing upward from the hypochondrium to strike the heart, Zhi Shi Xie Bai Gui Zhi Tang (Immature Bitter Orange, Macrostemon Stem, and Cinnamon Twig Decoction) is primarily indicated. Ren Shen Tang (Ginseng Decoction) can also be used.
"Phlegm and Qi knot in the chest, causing chest distension that overflows into the meridians, leading Qi to rush upward from the hypochondrium to strike the heart. These two formulas differ in application: one treats excess phlegm overflowing from the chest, using Xie Bai and Gui Zhi to disperse it; the other treats interior-knotted deficiency phlegm in the chest, using Ren Shen Li Zhong Tang (Ginseng and Middle-Warming Decoction) to clear it. One disease, two treatments, applied according to the patient's constitution, is an unchangeable method.
"When Chest Bi presents with Qi stagnation in the chest and shortness of breath, Fu Ling Xing Ren Gan Cao Tang (Poria, Apricot Seed, and Licorice Decoction) is primarily indicated. Ju Pi Zhi Shi Sheng Jiang Tang (Tangerine Peel, Immature Bitter Orange, and Fresh Ginger Decoction) can also be used.
"Since shortness of breath and insufficient respiration constitute an Excess condition, both formulas are agents that promote Qi movement. One disperses Lung Qi, and the other disperses Stomach Qi.
"When Chest Bi symptoms alternate between relaxation and urgency/spasm, Yi Yi Fu Zi San (Coix Seed and Aconite Powder) is primarily indicated.
"The chest is the residence of Yang Qi. Currently, Yang Qi in the chest is obstructed and not free-flowing. Wherever its meridians pass, the state is either relaxed or spasmodic, losing its normal rhythm, all due to the failure of Yang Qi to circulate. Yi Yi Ren (Coix Seed) soothes the meridians, and Fu Zi (Aconite Root) restores Yang Qi in the chest. Thus, the Great Qi turns, Yin-Turbidity remains no longer, and the chest becomes vast and clear like the empty sky.
"When there is epigastric fullness, various rebellious Qi causing a hanging pain in the heart region, Gui Zhi Sheng Jiang Zhi Shi Tang (Cinnamon Twig, Fresh Ginger, and Immature Bitter Orange Decoction) is primarily indicated.
"Epigastric fullness arises from Heart Qi rebelling upward. When Upper Qi rebels, Middle and Lower Qi also rebel. Qi rebellion causes meridian rebellion, hence termed 'various rebellions.' With Upper and Lower Qi rebelling and pulses failing to communicate, the Heart Master hangs isolated above, unable to receive Ying (Nutritive) Qi to harmonize it, resulting in hanging heart pain. Gui Zhi moves Heart Qi to dissipate fullness; Sheng Jiang (Fresh Ginger) and Da Zao (Jujube) smooth the Middle Jiao to unblock the meridians.
"When Heart Pain radiates through to the back, and back pain radiates through to the heart, Wu Tou Chi Shi Zhi Wan (Kochia Seed, Aconite, and Red Stone Lipid Pill) is primarily indicated.
"Heart Pain radiating through to the back, and back pain radiating through to the heart, indicates Yin Pathogen rebellion interfering with the meridians between the chest and back, causing connected pain, disturbing Blood and Qi, and confusing boundaries. Using Qi-regulating medicines here would only increase pain and lead to danger. Zhang Zhongjing uses Shu Jiao (Sichuan Pepper) and Wu Tou (Aconite), a batch of pungent-hot herbs, to warm and disperse Yin Pathogens. However, fearing the chaotic Qi in the chest and back cannot be settled, he adds Gan Jiang (Dried Ginger) and Chi Shi Zhi (Red Halloysite) within the warming formula group. Their astringent nature fills the tunnels where rebellious Qi attacks, allowing Chest Qi to remain in the chest and Back Qi to remain in the back, without interfering with each other, thereby curing the ailment. Modern practitioners only know methods of warming, tonifying, moving, and dispersing Qi, but do not know the method of filling the orifices where pathogenic Qi attacks.
"The *Qian Jin Fang* treats Chest Bi radiating to the back with Xi Xin San (Asarum Powder); treats rebellious Qi in the chest, heart pain radiating to the back, shortness of breath, and loss of appetite with Qian Hu Tang (Peucedanum Decoction); treats chest fullness, choking sensation, itching skin, dry throat, and profuse saliva/phlegm—if Ju Pi Zhi Shi Sheng Jiang Tang fails—with Zhi Zhong Tang (Middle-Regulating Decoction); treats Chest Bi with abdominal and back closure/fullness and rebellious Qi wheezing with Xia Qi Tang (Qi-Descending Decoction); and treats chest/back pain with Yi Bei San (Back-Irrigating Powder). These supplement what the *Jin Gui* omitted.
"When a patient feels as if panting but not actually panting, as if vomiting but not actually vomiting, as if hiccuping but not actually hiccuping, and feels profound mental distress and helplessness in the heart region, Sheng Jiang Ban Xia Tang (Fresh Ginger and Pinellia Decoction) is primarily indicated. The *Qian Jin Fang* adds Ju Pi (Tangerine Peel) and Wu Zhu Yu (Evodia Fruit), naming it Tong Qi San (Unblocking Qi Powder), treating chest fullness, shortness of breath, and choking.
"This belongs to the category of Chest Bi syndromes, likely misplaced by editors into the Vomiting/Hiccup section. I discuss it here together. Yang receives Qi in the chest to distribute breath. Now, Yin invades the Yang position, blocking the distribution of Yang Qi and the pathway of respiration, manifesting as panting, vomiting, or hiccuping. The Heart houses the Spirit. Accumulated fluids and retained phlegm cause fiery agitation, leading to profound mental confusion and helplessness. Therefore, the pungent-warm properties of Ban Xia and Sheng Jiang are used to dry fluid retention and disperse cold, allowing Yang to distribute and Qi to regulate, making the chest vast again. The use of Ju Pi, Wu Zhu Yu, and additions of Zhu Ru (Bamboo Shavings) and Ren Shen (Ginseng) follow this example. Yu Jiayan stated: Regarding Chest Bi, it is a common affliction. The *Jin Gui* presents ten formulas for treatment but does not explicitly explain the cause. The chest is like the empty sky; where Yang Qi passes, it is like the sun shining in the sky, vast and boundless. If Earth Qi (Yin Pathogen) rises, obstruction increases. Thus, Chest Bi is a sign of Yang Qi failing to function and Yin Qi occupying the upper positions. However, severity varies. Mild cases require only unblocking the insufficient Yang of the Upper Jiao; severe cases require driving out rebellious Qi from the Lower Jiao and unblocking Yang in the chest. Select three or four appropriate herbs from Xie Bai, Bai Jiu, Gua Lou, Ban Xia, Gui Zhi, Zhi Shi, Hou Po, Gan Jiang, Bai Zhu, Ren Shen, Gan Cao, Fu Ling, Xing Ren, or Ju Pi to form a prescription. Bitter-cold herbs are excluded, and even cooling herbs are discarded. This is because Yang is unblocked by Yang; Yin-category medicines have no place. In severe cases, Fu Zi, Wu Tou, and Shu Jiao—greatly pungent and hot—are used to drive out Yin from the Lower Jiao and restore Yang in the Upper Jiao. Restoring Heaven and bathing the Sun depend on the physician's insight. Alas, later generations fail to understand what Chest Bi truly is."