（评门人吴玉纯稿）
结胸及痞二症，前贤以结胸为实，痞为虚，注释分明，可无疑矣。而于义尚有未尽者，则以陷胸之方，峻
于承气，而方名泻心，亦必别有取意，不可不深思而详辨之也。考陷胸之症曰心下硬痛，曰从心下至
少腹，硬满而痛不可近，小结胸症曰正在心下，按之痛，痞则曰心下痞，曰心下痞硬。故究其地位，实在
膈膜之中，察其病源，实系痰饮与热互结不解。痰饮者，水类也，热者，火象也，水之与火，相结于膈膜之
中，其气深，其道远，其病根牢固。且痰饮之质牵腻异常，凡汤药之轻者，非惟不能荡涤，且反与其质粘
合为患。故大陷胸汤用承气之硝黄，易枳朴以甘遂，峻烈猛厉，可以直捣水饮之巢而无抵拒。至小陷
胸症其水饮之停结较轻，然水饮为热所蒸，化而成痰。故用黄连为君，以治热盛蒸湿之源，半夏消痰
为臣，栝蒌导痰热下行，为之佐使。若夫痞症，虽属无形之气，然亦必有或湿或热。或湿热二者交阻于
膈中。故泻心汤以芩连为主，心属离火，泻心者，泻火之谓也。离卦中虚，外阳而内阴，火中有水，热能蒸
湿，且既在膈膜，固非芩连之苦寒而燥，不足以直达病所。其痰湿盛者，必佐姜半，阳气虚者，主以附子，
中气弱者，助以参甘，方法可谓备矣。然则陷胸泻心皆治膈病，而长沙不以治膈名者，何也。曰、膈内拒
痛，客气动膈，长沙亦已言之。只以膈膜之义，内难二经尚少发明，且膈者所以遮护心肺，不使浊气上
熏者也。今膈膜有病，而上焦空旷之区，悉为水饮痰热之所占踞，非急与扫荡廓清，则君主宫城，岌岌
乎有震动之险。譬如剿寇之道，必先除其暴，然后可以安其良也。推此而寒实结胸之用三物白散，
藏结之不可治，按之自濡为气痞，不在泻心例者，均可条分缕晰。其外胸痹痞气，宜用栝蒌薤白，湿温
胸痞，宜用杏朴橘半等，临症分辨，均在读书者之会通耳。
（评门人吴玉纯稿）
结胸和痞这两个病症，前代贤人认为结胸属于实证，痞属于虚证，注释十分清晰，对此不应有怀疑。但在义理上还有未尽之处，因为治疗结胸的方剂比承气汤峻烈，而方名却叫“泻心”，这必定另有深意，不可不深入思考并详细辨析。考察结胸的症状，有的表现为心下硬痛，有的表现为从心下直到少腹，硬满且疼痛剧烈到不能触碰；小结胸症表现为正在心下，按压时疼痛；痞症则表现为心下痞塞感，或心下痞硬。因此究其病位，实在膈膜之中；察其病因，实系痰饮与热邪相互结聚而不解。痰饮属于水类，热邪属于火象，水与火在膈膜之中相互结聚，病气深沉，病位遥远，病根牢固。而且痰饮的质地异常黏腻，凡是药力轻薄的汤药，不仅不能荡涤清除，反而会与痰饮质地粘合从而加重病情。所以大陷胸汤使用承气汤中的芒硝、大黄，去掉枳实、厚朴，改用甘遂，药性峻烈猛厉，可以直接直捣水饮的老巢而无阻碍。至于小陷胸症，其水饮停聚结滞较轻，但水饮被热邪蒸腾，化为痰。所以用黄连为君药，以治疗热盛蒸湿的病源；半夏消除痰饮作为臣药；栝蒌引导痰热下行，作为佐使药。至于痞症，虽然属于无形之气阻滞，但也必然伴有湿或热，或者是湿热二者交阻于膈中。所以泻心汤以黄芩、黄连为主药，心属离卦之火，所谓“泻心”，就是泻火的意思。离卦中间是虚的，外阳而内阴，火中有水，热能蒸湿，而且既然病在膈膜，确实非黄芩、黄连的苦寒燥湿之性不足以直达病所。如果痰湿盛者，必须辅以生姜、半夏；阳气虚者，主用附子；中气虚弱者，辅助用人参、甘草，治疗方法可以说非常完备了。然而，陷胸汤和泻心汤都是治疗膈部疾病的，为什么张仲景（长沙太守）不以治膈来命名呢？回答说：膈内拒痛，客气动膍，张仲景也已经说过了。只是因为“膈膜”的含义，在《内经》和《难经》中尚少阐发，而且膈是用来遮护心肺，防止浊气上熏的器官。现在膈膜有病，而上焦空旷的区域，全被水饮、痰热占据，如果不紧急进行扫荡廓清，那么君主之官（心）所在的宫城，就有岌岌可危、受到震动的危险。这就好比剿灭盗贼的道理，必须先铲除暴乱，然后才能安抚良民。推演这个道理，寒实结胸使用三物白散，藏结证不可治愈，按之柔软属于气痞，不在泻心汤治疗范围内的情况，都可以条理分明地解释清楚。至于外部的胸痹痞气，适宜使用瓜蒌薤白汤；湿温导致的胸痞，适宜使用杏仁、厚朴、橘皮、半夏等药物，临证时的分辨，都在于读书人的融会贯通罢了。
(Commentary on the manuscript by disciple Wu Yuchun)
Regarding the two syndromes of *Jie Xiong* (Chest Binding) and *Pi* (Stagnation), former sages regarded *Jie Xiong* as an Excess syndrome and *Pi* as a Deficiency syndrome, with annotations that are clear and beyond doubt. However, there is still incomplete meaning in this interpretation. Since the formulas for treating *Jie Xiong* are more峻烈 (pungent and severe) than those of Chengqi Tang (Gut-Purging Decoction), yet the formula names include "Xie Xin" (Draining the Heart), there must be another profound intention here, which requires deep reflection and detailed discrimination. Examining the symptoms of *Jie Xiong*: some present with hardness and pain below the heart; others present with hardness, fullness, and extreme pain from below the heart down to the lower abdomen, so severe that one cannot bear to be touched. The minor *Jie Xiong* syndrome presents with pain upon pressure exactly below the heart. The *Pi* syndrome presents with a sensation of blockage below the heart, or hardness and blockage below the heart. Thus, investigating its location, it truly lies within the diaphragm membrane; observing its etiology, it is indeed caused by Phlegm-Fluids and Heat binding together and refusing to resolve. Phlegm-Fluids belong to the Water category, while Heat belongs to the Fire image. When Water and Fire bind together within the diaphragm membrane, the pathogenic Qi is deep, the disease pathway is distant, and the root of the disease is firmly established. Moreover, the nature of Phlegm-Fluids is exceptionally sticky and greasy. Any decoction with mild medicinal power not only fails to scour and cleanse but also adheres to the substance of the Phlegm-Fluids, causing further harm. Therefore, Da Xianxiong Tang (Major Chest-Expelling Decoction) uses Rhubarb (Rhei Radix et Rhizoma) and Mirabilite (Natrii Sulfas) from Chengqi Tang, replaces Zhi Shi (Aurantii Fructus Immaturus) and Hou Po (Magnoliae Officinalis Cortex) with Kansui (Kansui Radix). Its pungency and severity are fierce, allowing it to directly strike the nest of the Phlegm-Fluids without resistance. As for the minor *Jie Xiong* syndrome, the retention and binding of Phlegm-Fluids are lighter, yet the Phlegm-Fluids steamed by Heat transform into Phlegm. Hence, Huanglian (Coptidis Rhizoma) is used as the Sovereign herb to treat the source of Heat steaming Dampness; Banxia (Pinelliae Rhizoma) eliminates Phlegm as the Minister herb; Gualou (Trichosanthis Fructus) guides Phlegm-Heat downward as the Assistant and Envoy herbs. Regarding the *Pi* syndrome, although it belongs to the obstruction of formless Qi, it must inevitably involve either Dampness or Heat, or both Dampness and Heat obstructing each other in the diaphragm. Therefore, Xiexin Tang (Heart-Draining Decoction) relies primarily on Huangqin (Scutellariae Radix) and Huanglian. The Heart belongs to the Fire of the Li Trigram; "Draining the Heart" means draining Fire. The Li Trigram is hollow in the middle, Yang on the outside and Yin on the inside, containing Water within Fire. Heat steams Dampness, and since the disease is located in the diaphragm, it is indeed insufficient to reach the disease site unless one utilizes the bitter-cold and drying properties of Huangqin and Huanglian. If Phlegm-Dampness is abundant, Shengjiang (Zingiberis Rhizoma Recens) and Banxia must be assisted; if Yang Qi is deficient, Fuzi (Aconiti Lateralis Radix Praeparata) is the main agent; if Middle Qi is weak, Renshen (Ginseng Radix) and Gancao (Glycyrrhizae Radix) assist. The methods can be said to be comprehensive. Then why do both Xianxiong Tang and Xiexin Tang treat diseases of the diaphragm, yet Zhang Zhongjing (the Grand Administrator of Changsha) does not name them by treating the diaphragm? The answer is: "Rejection pain within the diaphragm, hostile Qi agitating the diaphragm," Zhang Zhongjing has already stated this. It is merely because the concept of the "diaphragm membrane" was rarely elucidated in the *Neijing* (Inner Canon) and *Nanjing* (Classic of Difficult Issues). Furthermore, the diaphragm serves to shield the Heart and Lungs, preventing turbid Qi from ascending and fuming upwards. Now that the diaphragm membrane is diseased, the empty and vast region of the Upper Jiao is entirely occupied by Phlegm-Fluids, Phlegm, and Heat. If one does not urgently sweep and clear them away, the Palace City of the Sovereign Organ (the Heart) faces the danger of being shaken and endangered. This is like the way of suppressing bandits: one must first eliminate the violent rebels before one can pacify the good people. Extending this logic, the use of Sanwu Baisan (Three-Material White Powder) for Cold-Excess *Jie Xiong*, the untreatability of Zangjie (Visceral Binding), the fact that softness upon pressure indicates Qi *Pi* which is not within the scope of Xiexin Tang, can all be clarified item by item. As for external Chest Bi (Obstruction) and Pi Qi (Stagnation Qi), Gualou Xiebai Tang (Trichosanthes and Macrostemon Decoction) is suitable; for Chest Pi caused by Damp-Warmth, Xingren (Armeniacae Semen Amarum), Houpo, Jupe (Citri Reticulatae Pericarpium), and Banxia are suitable. Differentiation during clinical practice depends entirely on the reader's ability to integrate and understand comprehensively.