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。以其阴弦故也。
阳微、阳不足也。阴弦、阴太过也。阳主开。阴主闭。阳虚而阴干之。即胸痹而痛。痹者闭也。
夫上焦为阳之位。而微脉为虚之甚。故曰责其极虚。以虚阳而受阴邪之击。故为心痛。
平人无寒热。短气不足以息者。实也。
平人、素无疾之人也。无寒热、无新邪也。而乃短气不足以息。当是里气暴实。或痰、或食、或
饮。碍其升降之气而然。盖短气有从素虚宿疾而来者。有从新邪暴遏而得者。二端并否。其为里实无
疑。此审因察病之法也。
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。
胸中阳也。而反痹。则阳不用矣。阳不用。则气之上下不相顺接。前后不能贯通。而喘息、咳唾、
胸背痛、短气等证见矣。更审其脉。寸口亦阳也。而沉迟。则等于微矣。关上小紧。亦阴弦之意。而
反数者。阳气失位。阴反得而主之。易所谓阴凝于阳。书所谓牝鸡之晨也。是当以通胸中之阳为主。
薤白、白酒。辛以开痹。温以行阳。栝蒌实者。以阳痹之处。必有痰浊阻其间耳。
栝蒌薤白白酒汤方
栝蒌实（一枚捣） 薤白（半升） 白酒（七升）
上三味。同煮。取二升。分温再服。
胸痹不得卧。心痛彻背者。栝蒌薤白半夏汤主之。
胸痹不得卧。是肺气上而不下也。心痛彻背。是心气塞而不和也。其痹为尤甚矣。所以然者。有
痰饮以为之援也。故于胸痹药中。加半夏以逐痰饮。
栝蒌薤白半夏汤方
栝蒌实（一枚捣） 薤白（三两） 半夏（半升） 白酒（一斗）
上四味。同煮。取四升。温服一升。日三服。
胸痹。心中痞气。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。
心中痞气。气痹而成痞也。胁下逆抢心。气逆不降。将为中之害也。是宜急通其痞结之气。否则
速复其不振之阳。盖去邪之实。即以安正。养阳之虚。即以逐阴。是在审其病之久暂。与气之虚实而
决之。
栝蒌薤白桂枝汤方
枳实（四枚） 薤白（半升） 桂枝（一两） 浓朴（四两） 栝蒌实（一枚捣）
上五味。以水五升。先煮枳实、浓朴。取二升。去滓。内诸药。煮数沸。分温三服。
人参汤方
人参 甘草 干姜 白术（各三两）
上四味。以水八升。煮取三升。温服一升。日三服。
胸痹。胸中气塞。短气。茯苓杏仁甘草汤主之。橘枳生姜汤亦主之。
此亦气闭气逆之证。视前条为稍缓矣。二方皆下气散结之剂。而有甘淡苦辛之异。亦在酌其强弱
而用之。
茯苓杏仁甘草汤方
茯苓（三两） 杏仁（五十个） 甘草（一两）
上三味。以水一斗。煮取五升。温服一升。日三服。不瘥。更服。
橘枳生姜汤方
橘皮（一斤） 枳实（三两） 生姜（半斤）
上三味。以水五升。煮取二升。分温再服。
胸痹缓急者。薏苡附子散主之。
阳气者。精则养神。柔则养筋。阳痹不用。则筋失养而或缓或急。所谓大筋软短。小筋弛长者是
也。故以薏苡仁舒筋脉。附子通阳痹。
薏苡附子散方
薏苡仁（十五两） 大附子（十枚炮）
上二味。杵为散。服方寸匕。日三服。
心中痞。诸逆。心悬痛。桂枝生姜枳实汤主之。
诸逆。该痰饮、客气而言。心悬痛。谓如悬物动摇而痛。逆气使然也。桂枝、枳实、生姜。辛以
散逆。苦以泄痞。温以祛寒也。
桂枝生姜枳实汤方
桂枝 生姜（各三两） 枳实（五两）
上三味。以水六升。煮取三升。分温三服。
心痛彻背。背痛彻心。乌头赤石脂丸主之。
心背彻痛。阴寒之气。遍满阳位。故前后牵引作痛。沈氏云。邪感心包。气应外俞。则心痛彻背。
邪袭背俞。气从内走。则背痛彻心。俞脏相通。内外之气相引。则心痛彻背。背痛彻心。即经所谓寒
气客于背俞之脉。其俞注于心。故相引而痛是也。乌、附、椒、姜。同力协济。以振阳气而逐阴邪。
取赤石脂者。所以安心气也。
乌头赤石脂丸方
乌头（一分炮） 蜀椒 干姜（各一两） 附子（半两） 赤石脂（一两）
上五味。末之。蜜丸如桐子大。先食服一丸。日三服。不知稍加服。
附方
九痛丸 治九种心疼。
附子（三两炮） 生野狼牙 巴豆（去皮熬研如膏） 干姜 吴茱萸 人参（各一两）
上六味。末之。炼蜜丸如梧子大。酒下。强人初服三丸。日三服。弱者二丸。兼治卒中恶。腹胀。
口不能言。又治连年积冷。流注心胸痛。并冷冲上气。落马坠车血疾等皆主之。忌口如常法。
按、九痛者。一虫、二注、三风、四悸、五食、六饮、七冷、八热、九去来痛是也。而并以一药
治之者。岂痛虽有九。
其因于积冷结气所致者多耶。
老师说：诊脉应当区分脉象的太过与不及。脉象表现为寸部微弱、尺部弦紧，这就是胸痹并伴有疼痛的原因。之所以这样，是因为上焦阳气极度虚弱所致。如今知道是上焦阳虚，所以发生胸痹；而心痛，是因为阴寒之气弦紧的缘故。
所谓“阳微”，是指阳气不足；“阴弦”，是指阴气太过。阳气主开泄，阴气主闭藏。阳气虚弱而被阴邪侵犯，就会发生胸痹和疼痛。“痹”就是闭塞的意思。上焦是阳气所在的位置，而微脉表示虚损到了极点，所以说这是极度的虚损。以虚弱的阳气承受阴邪的攻击，因此产生心痛。
平素健康的人，没有外感寒热的症状，却出现呼吸短促、气息不足以接续的情况，这属于实证。
所谓“平人”，指平时没有疾病的人；“无寒热”，指没有新近感受的外邪。既然没有外邪，却出现呼吸短促、气息不足，这应当是体内正气突然变得壅实，或者是痰饮、食积、水饮等病理产物，阻碍了气机的升降运动所致。大概短气有从素体虚弱或宿疾而来的，也有从新邪突然遏制而得的。如果这两种情况都不存在，那么属于里实证的判断就没有疑问了。这是审查病因、考察病机的一种方法。
胸痹病的症状，包括喘息、咳嗽吐痰、胸背部疼痛、呼吸短促。诊察其脉象，寸口脉沉而迟，关脉小紧且数。治疗应以栝蒌薤白白酒汤为主。
胸中本属阳气，反而发生痹阻，说明阳气不能正常发挥作用。阳气不能发挥作用，则气机的上下就不能顺接，前后也不能贯通，于是出现喘息、咳嗽吐痰、胸背痛、短气等症状。再仔细审察脉象，寸口脉也属阳，但呈现沉迟之象，这就等同于微脉了；关脉小紧，也具有阴弦的含义，反而兼见数脉，这是阳气失位，阴气反客为主的表现。正如《易经》所说“阴凝于阳”，书中比喻为“牝鸡司晨”（母鸡打鸣，阴阳颠倒）。此时应当以通补胸中阳气为主要治法。薤白和白酒，性辛能开通痹阻，性温能运行阳气。栝蒌实的作用在于，在阳气痹阻的地方，必然有痰浊阻滞在其中。
【栝蒌薤白白酒汤方】
栝蒌实（一枚，捣碎） 薤白（半升） 白酒（七升）
以上三味药，一起煎煮，取药液二升，分两次温服。
胸痹严重到不能平卧，心痛放射至背部的，用栝蒌薤白半夏汤主治。
胸痹导致不能平卧，是肺气上逆而不能下行；心痛放射至背部，是心气闭塞而不调和。这种痹阻比前面所述更为严重。之所以这样，是因为有痰饮作为依托。所以在治疗胸痹的药物中加入半夏，以祛除痰饮。
【栝蒌薤白半夏汤方】
栝蒌实（一枚，捣碎） 薤白（三两） 半夏（半升） 白酒（一斗）
以上四味药，一起煎煮，取药液四升，每次温服一升，每日服用三次。
胸痹患者，心中感觉痞塞不通，气结聚在胸部，胸部胀满，胁下之气逆冲心胸，用枳实薤白桂枝汤主治。人参汤也可以主治。
心中痞塞，是气机痹阻而成痞证；胁下之气逆冲心胸，是气机上逆不降，将要危害中焦。此时应当紧急疏通痞结的气机，否则就要迅速恢复不振的阳气。去除邪气的实滞，就是安护正气；养护阳气的虚弱，就是驱逐阴邪。这需要审察疾病的久暂以及气机的虚实来决定选用哪一方。
【枳实薤白桂枝汤方】
枳实（四枚） 薤白（半升） 桂枝（一两） 浓朴（四两） 栝蒌实（一枚，捣碎）
以上五味药，用水五升，先煎煮枳实、浓朴，取药液二升，去渣，加入其他药物，煮沸几沸，分三次温服。
【人参汤方】
人参 甘草 干姜 白术（各三两）
以上四味药，用水八升，煎煮取药液三升，每次温服一升，每日服用三次。
胸痹患者，胸中气塞，呼吸短促，用茯苓杏仁甘草汤主治。橘枳生姜汤也可以主治。
这也是气机闭塞、气机上逆的证候，比前一条所述的症状稍轻。这两方都是下气散结的药剂，但在甘淡与苦辛的药性上有区别，需要根据病情的轻重强弱来斟酌使用。
【茯苓杏仁甘草汤方】
茯苓（三两） 杏仁（五十个） 甘草（一两）
以上三味药，用水一斗，煎煮取药液五升，每次温服一升，每日服用三次。如果未痊愈，继续服用。
【橘枳生姜汤方】
橘皮（一斤） 枳实（三两） 生姜（半斤）
以上三味药，用水五升，煎煮取药液二升，分两次温服。
阳气，精纯则滋养精神，柔和则滋养筋脉。阳气痹阻不能发挥作用，筋脉失去滋养，就会出现时而松弛无力、时而拘急痉挛的症状，这就是所说的“大筋软短，小筋弛长”。所以用薏苡仁舒缓筋脉，用附子通阳散痹。
【薏苡附子散方】
薏苡仁（十五两） 大附子（十枚，炮制）
以上两味药，捣碎过筛制成散剂，每次服用方寸匕，每日服用三次。
“诸逆”，包括痰饮和气逆而言。“心悬痛”，形容疼痛像悬挂物动摇一样，这是由逆气导致的。桂枝、枳实、生姜，性辛能疏散逆气，性苦能泄除痞塞，性温能祛除寒邪。
【桂枝生姜枳实汤方】
桂枝 生姜（各三两） 枳实（五两）
以上三味药，用水六升，煎煮取药液三升，分三次温服。
心背相互牵引作痛，是阴寒之气遍布充满阳气所在的部位，所以前后牵引疼痛。沈氏说：邪气侵袭心包，气应应于外部的俞穴，就会心痛放射至背部；邪气袭击背部的俞穴，气从内部向外走窜，就会背痛放射至心前区。俞穴与脏腑相通，内外的气相互牵引，就会导致心痛彻背、背痛彻心。这正是《内经》所说的寒气客居于背俞之脉，其经气注于心，所以相互牵引而疼痛。乌头、附子、花椒、干姜，合力协同，以振奋阳气而驱逐阴邪。选用赤石脂，是为了安定心气。
【乌头赤石脂丸方】
乌头（一分，炮制） 蜀椒 干姜（各一两） 附子（半两） 赤石脂（一两）
以上五味药，研成细末，用蜂蜜制成如梧桐子大小的丸药。饭前服用一丸，每日三次。如果效果不明显，适当增加剂量。
【附方】
九痛丸：治疗九种心痛。
附子（三两，炮制） 生野狼牙 巴豆（去皮熬研如膏状） 干姜 吴茱萸 人参（各一两）
以上六味药，研成细末，炼蜜制成如梧子大小的丸药。酒送服，体质强者初次服用三丸，每日三次；体质弱者服用两丸。兼治中恶邪气，腹部胀满，口不能言语。又治连年积冷，流注心胸疼痛，以及冷冲上气，落马坠车导致的血瘀等疾病，都主治。忌口遵循常规方法。
按语：所谓的“九痛”，是指虫痛、注痛、风痛、悸痛、食痛、饮痛、冷痛、热痛、往来痛。然而都用这一种药物治疗，难道疼痛虽然有九种，但大多是由于积冷结气所导致的吗？
The Master said: In pulse diagnosis, one must distinguish between excess (Tai Guo) and deficiency (Bu Ji). When the pulse presents as faint in the Yang position (Cun/Inch) and wiry in the Yin position (Chi/Cubit), this indicates Chest Bi syndrome accompanied by pain. The reason for this is attributed to extreme deficiency. It is known that Yang Qi deficiency resides in the Upper Jiao, which causes Chest Bi; the presence of heart pain is due to the Wiry nature of the Yin pathogen.
"Yang faint" refers to insufficient Yang Qi; "Yin wiry" refers to excessive Yin. Yang governs opening, while Yin governs closing. When Yang is deficient and invaded by Yin, Chest Bi and pain occur. "Bi" means obstruction. The Upper Jiao is the domain of Yang, and a Faint pulse indicates severe deficiency; thus, it is termed extreme deficiency. With weak Yang suffering the attack of Yin pathogens, heart pain ensues.
In a healthy person without chills or fever, shortness of breath and inability to take a full breath indicate an Excess condition.
A "healthy person" refers to one who has no prior disease; "no chills or fever" indicates no recent external pathogenic invasion. If such a person suffers from shortness of breath and insufficient respiration, it should be due to a sudden excess of internal Qi, or obstruction caused by phlegm, food retention, or fluid retention, hindering the ascending and descending movement of Qi. Generally, shortness of breath may arise from constitutional deficiency or chronic illness, or from acute obstruction by new pathogens. If neither of these two causes applies, it is undoubtedly an interior Excess condition. This is a method of investigating etiology and pathology.
The symptoms of Chest Bi include wheezing, coughing with expectoration, chest and back pain, and shortness of breath. Pulse examination reveals a Deep and Slow pulse at the Cun (Inch) position, and a Small, Tight, and Rapid pulse at the Guan (Bar) position. The primary treatment is Gualou Xiebai Baijiu Tang (Trichosanthes Fruit, Macrostemon Rhizome, and White Wine Decoction).
The chest belongs to Yang, but when Bi occurs, Yang fails to function. When Yang does not function, the ascending and descending of Qi are not connected, and the front and back cannot communicate smoothly, leading to symptoms such as wheezing, coughing with expectoration, chest and back pain, and shortness of breath. Further pulse analysis shows that although the Cun position corresponds to Yang, a Deep and Slow pulse equates to a Faint pulse. A Small and Tight Guan pulse carries the meaning of Wiry Yin, and the accompanying Rapid rate indicates that Yang has lost its position, allowing Yin to dominate. As stated in the I Ching, "Yin condenses upon Yang," analogous to a hen crowing at dawn (a reversal of natural order). Treatment should focus on unblocking and tonifying the Yang of the chest. Xiebai (Macrostemon Rhizome) and Baijiu (White Wine) are acrid to open obstructions and warm to promote Yang circulation. Gualou Shi (Trichosanthes Fruit) is used because where Yang is obstructed, turbid phlegm inevitably blocks the area.
[Gualou Xiebai Baijiu Tang Formula]
Gualou Shi (Trichosanthes fruit, one piece, crushed)
Xiebai (Macrostemon rhizome, half sheng)
Baijiu (White wine, seven sheng)
Boil the above three ingredients together until two sheng remains. Divide into two doses and take warm.
When Chest Bi is severe enough to prevent lying down, and heart pain radiates to the back, Gualou Xiebai Banxia Tang (Trichosanthes Fruit, Macrostemon Rhizome, and Pinellia Decoction) is indicated.
Inability to lie down due to Chest Bi indicates Lung Qi rebelling upward instead of descending. Heart pain radiating to the back indicates Heart Qi obstruction and disharmony. This obstruction is more severe than previously described. The reason is the support provided by Phlegm-Fluids. Therefore, Banxia (Pinellia Tuber) is added to the Chest Bi formula to expel Phlegm-Fluids.
[Gualou Xiebai Banxia Tang Formula]
Gualou Shi (Trichosanthes fruit, one piece, crushed)
Xiebai (Macrostemon rhizome, three liang)
Banxia (Pinellia tuber, half sheng)
Baijiu (White wine, one dou)
Boil the above four ingredients together until four sheng remains. Take one sheng warm, three times daily.
In Chest Bi, if there is a sensation of epigastric distension and stuffiness, Qi knotting in the chest, chest fullness, and rebellious Qi rushing from the hypochondrium toward the heart, Zhishi Xiebai Guizhi Tang (Immature Bitter Orange, Macrostemon Rhizome, and Cinnamon Twig Decoction) is indicated. Renshen Tang (Ginseng Decoction) is also indicated.
Epigastric stuffiness results from Qi obstruction forming a Pi syndrome. Rebellious Qi rushing from the hypochondrium toward the heart indicates failing descent, threatening the Middle Jiao. Urgent unblocking of the stagnant Qi is required; otherwise, rapid restoration of the depressed Yang is necessary. Removing the Excess of pathogens secures the Righteous Qi; nourishing the deficiency of Yang drives away Yin. The choice depends on assessing the duration of the disease and the deficiency or excess of Qi.
[Zhishi Xiebai Guizhi Tang Formula]
Zhishi (Immature bitter orange, four pieces)
Xiebai (Macrostemon rhizome, half sheng)
Guizhi (Cinnamon twig, one liang)
Nongpo (Magnolia bark, four liang)
Gualou Shi (Trichosanthes fruit, one piece, crushed)
Add five sheng of water to the above five ingredients. First boil Zhishi and Nongpo until two sheng remains, discard the dregs, then add the remaining herbs. Boil briefly. Divide into three doses and take warm.
[Renshen Tang Formula]
Renshen (Ginseng root)
Gancao (Licorice root)
Ganjiang (Dried ginger)
Baizhu (Atractylodes macrocephala rhizome) (Each three liang)
Add eight sheng of water to the above four ingredients. Boil until three sheng remains. Take one sheng warm, three times daily.
In Chest Bi, if there is a sensation of Qi blockage in the chest and shortness of breath, Fuling Xingren Gancao Tang (Poria, Apricot Seed, and Licorice Decoction) is indicated. Ju Zhi Shengjiang Tang (Tangerine Peel, Immature Bitter Orange, and Fresh Ginger Decoction) is also indicated.
This is also a pattern of Qi blockage and rebellion, though slightly milder than the previous case. Both formulas are agents for descending Qi and dissipating knots, differing in their sweet-bland versus bitter-acrid properties. Selection should be based on the strength of the condition.
[Fuling Xingren Gancao Tang Formula]
Fuling (Poria sclerotium, three liang)
Xingren (Apricot seed, fifty pieces)
Gancao (Licorice root, one liang)
Add one dou of water to the above three ingredients. Boil until five sheng remains. Take one sheng warm, three times daily. If not cured, continue administration.
[Ju Zhi Shengjiang Tang Formula]
Jupi (Tangerine peel, one jin)
Zhishi (Immature bitter orange, three liang)
Shengjiang (Fresh ginger, half jin)
Add five sheng of water to the above three ingredients. Boil until two sheng remains. Divide into two doses and take warm.
For Chest Bi with alternating severity (relaxation and spasm), Yiyi Fuzi San (Coix Seed and Aconite Powder) is indicated.
Yang Qi nourishes the spirit when refined and pure, and nourishes the sinews when soft and flexible. When Yang is obstructed and non-functional, sinews lose nourishment, resulting in either flaccidity or spasm, described as "large sinews becoming soft and short, small sinews becoming lax and long." Therefore, Yiyiren (Coix seed) is used to relax the sinews and meridians, and Fuzi (Prepared aconite lateral root) is used to unblock Yang obstruction.
[Yiyi Fuzi San Formula]
Yiyiren (Coix seed, fifteen liang)
Da Fuzi (Large prepared aconite lateral root, ten pieces, processed)
Grind the above two ingredients into a powder. Take one fangcun bi (square-inch spoonful) per dose, three times daily.
With epigastric stuffiness, various rebellious Qi patterns, and hanging pain in the heart region, Guizhi Shengjiang Zhishi Tang (Cinnamon Twig, Fresh Ginger, and Immature Bitter Orange Decoction) is indicated.
"Various rebellions" refer to Phlegm-Fluids and hostile Qi. "Hanging pain in the heart" describes pain resembling a swinging object, caused by rebellious Qi. Guizhi (Cinnamon twig), Zhishi (Immature bitter orange), and Shengjiang (Fresh ginger) are acrid to disperse rebellion, bitter to drain stuffiness, and warm to dispel cold.
[Guizhi Shengjiang Zhishi Tang Formula]
Guizhi (Cinnamon twig)
Shengjiang (Fresh ginger) (Each three liang)
Zhishi (Immature bitter orange, five liang)
Add six sheng of water to the above three ingredients. Boil until three sheng remains. Divide into three doses and take warm.
When heart pain radiates to the back and back pain radiates to the heart, Wutou Chishizhi Wan (Aconite and Halloysit Rubra Pill) is indicated.
Mutual radiation of pain between heart and back indicates Yin-Cold Qi filling the Yang positions, causing traction pain between the front and back. Shen's commentary states: When pathogens invade the Pericardium, Qi responds to the exterior Shu points, causing heart pain radiating to the back. When pathogens attack the Back Shu points, Qi moves from inside to outside, causing back pain radiating to the heart. Since Shu points connect with Zang organs, internal and external Qi attract each other, resulting in mutual radiation of pain. This aligns with the Classic stating that when Cold Qi lodges in the vessels of the Back Shu points, and their Qi flows into the Heart, they attract each other causing pain. Wutou (Aconite root), Fuzi (Prepared aconite lateral root), Shujiao (Sichuan pepper), and Ganjiang (Dried ginger) work synergistically to invigorate Yang and expel Yin pathogens. Chishizhi (Halloysit rubra) is included to calm the Heart Qi.
[Wutou Chishizhi Wan Formula]
Wutou (Aconite root, one fen, processed)
Shujiao (Sichuan pepper)
Ganjiang (Dried ginger) (Each one liang)
Fuzi (Prepared aconite lateral root, half liang)
Chishizhi (Halloysit rubra, one liang)
Grind the above five ingredients into powder. Make pills using honey, sized like tung seeds. Take one pill before meals, three times daily. If ineffective, slightly increase the dosage.
[Supplementary Formulas]
Jiu Tong Wan (Nine Pain Pill): Treats nine types of heartache.
Fuzi (Prepared aconite lateral root, three liang, processed)
Sheng Ye Langya (Raw wolf's tooth herb)
Badou (Croton seed, skin removed, roasted, ground into paste)
Ganjiang (Dried ginger)
Wuzhuyu (Evodia fruit)
Renshen (Ginseng root) (Each one liang)
Grind the above six ingredients into powder. Make pills using refined honey, sized like wu zi (wu berry). Administer with wine. Strong individuals take three pills initially, three times daily; weak individuals take two pills. Also treats sudden onset of evil qi, abdominal distension, and inability to speak. Treats chronic accumulated cold flowing into the chest and heart causing pain, cold rising Qi, blood disorders from falls or carriage accidents, etc. Observe usual dietary restrictions.
Note: The "Nine Pains" refer to: 1. Worm pain, 2. Invasion pain, 3. Wind pain, 4. Palpitation pain, 5. Food pain, 6. Drink pain, 7. Cold pain, 8. Heat pain, 9. Migratory pain. Using a single formula for all suggests that although pains vary, most are caused by accumulated cold and stagnant Qi.