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。
此原所以结胸与痞之故。病发于阳者。邪在阳之经。病发于阴者。邪在阴之经也。阳经受邪。
郁即成热。其气内陷。则为结胸。阴经受邪。未即成热。其气内陷。则作痞。所以然者。病邪在经。
本当发散而反下之。里气则虚。邪气因入。与饮相抟而为病也。要之阳经受邪。原有可下之例。
特以里未成实。而早行下法。故有结胸之变证。审其当下而后下之。何至是哉。仲景复申明所以
成结胸之故。而不及痞。岂非以阴经受邪。则无论迟早。俱未可言下耶。
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。心下因硬。则为结胸。大陷胸汤主之。若不结胸。但头汗出。余无汗。剂颈而还。
小便不利。身必发黄也。
脉浮动数。皆阳也。故为风为热为痛。而数则有正为邪迫。失其常度之象。故亦为虚。头痛
发热。微盗汗出。而复恶寒。为邪气在表。法当发散。而反下之。正气则虚。邪气乃陷。动数变迟
者。邪自表而入里。则脉亦去阳而之阴也。膈内拒痛者。邪欲入而正拒之。正邪相击则为痛也。
胃中空虚。客气动膈者。胃气因下而里虚。客气乘虚而动膈也。短气躁烦。心中懊 者。膈中之饮
。为邪所动。气乃不舒。而神明不宁也。
由是阳邪内陷。与饮相结。痞硬不消。而结胸之病成矣。大陷胸汤则正治阳邪内结胸中之药
也。若其不结胸者。热气散漫。既不能从汗而外泄。亦不得从溺而下出。蒸郁不解。浸淫肌体。势
必发黄也。
大陷胸汤方
大黄（六两） 芒硝（一升） 甘遂（一钱匕）
上三味。水六升。先煮大黄取二升。去滓。纳芒硝。煮一二沸。纳甘遂末。温服一升。得快利
。止后服。
按大陷胸与大承气。其用有心下与胃中之分。以愚观之。仲景所云心下者。正胃之谓。所云
胃中者。正大小肠之谓也。胃为都会。水谷并居。清浊未分。邪气入之。夹痰杂食。相结不解。则成
结胸。大小肠者。精华已去。糟粕独居。邪气入之。但与秽物结成燥粪而已。大承气专主肠中燥
粪。大陷胸并主心下水食。
燥粪在肠。必藉推逐之力。故须枳、朴。水食在胃。必兼破饮之长。故用甘遂。且大承气先煮枳、
朴。而后纳大黄。大陷胸先煮大黄。而后纳诸药。夫治上者制宜缓。治下者制宜急。而大黄生则
行速。熟则行迟。盖即一物。而其用又有不同如此。
伤寒六七日。结胸热实。脉沉而紧。心下痛。按之石硬者。大陷胸汤主之。
邪气内结。既热且实脉复沉紧有似大承气证。然结在心下而不在腹中。虽接之石硬而痛。亦是水食
互结。与阳明之燥粪不同。故宜甘遂之破饮。而不宜枳、朴之散气。如上条之说也。
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。
热结在里。而复往来寒热。是谓表里俱实。不得以十余日之久。而独治其里也。故宜大柴胡
表里两解之法。若但结胸而无大热。如口燥渴心烦等证者。此为水饮结在胸胁之间。所谓水结胸者
是也。盖邪气入里。必挟身中所有。以为根据附之地。是以在肠胃则结于糟粕。在胸膈则结于水饮。
各随其所有而为病耳。水结在胸。而但头汗出者。邪膈于上而气不下通也。故与大陷胸汤。以破饮
而散结。
太阳病。重发汗。而复下之。不大便五六日。舌上燥而渴。日晡所小有潮热。从心下至少腹。
硬满而痛不可近者。大陷胸汤主之。
汗下之后。津液重伤。邪气内结。不大便五六日。舌上燥而渴。日晡所小有潮热。皆阳明胃热之
征也。从
心下至少腹。硬满而痛不可近。则不特征诸兆。抑且显诸形矣。乃不用大承气而用大陷胸者。
亦以水食互结。且虽至少腹。而未离心下故也。不然。下证悉具。下药已行。何以不臣枳、朴而臣
甘遂哉。结胸者。项亦强。如柔 状。下之则和。宜大陷胸丸。
病之状。颈项强直。结胸之甚者。热与饮结。胸膈紧贯。上连于项。但能仰而不能俯。亦
如病之状也。曰柔而不曰刚者。以阳气内陷者。必不能外闭。而汗常自出耳。是宜下其胸中结聚
之实。则强者得和而愈。然胸中盛满之邪。固非小陷胸所能去。而水热互结之实。亦非承气汤所
可治。故与葶苈之苦。甘遂之辛。以破结饮而泄气闭。杏仁之辛。白蜜之甘。以缓下趋之势。而
去上膈之邪。其芒硝、大黄。则资其软坚荡实之能。
大陷胸丸方
大黄（半斤） 葶苈（半斤） 芒硝（半斤） 杏仁（半升去皮尖熬）
上四味。捣筛二味。纳杏仁、芒硝。合研如脂。和散。取如弹丸一枚。别捣甘遂末一钱匕。白蜜
二合。水二升。煮取一升。温顿服之。一宿乃下。如不下。更服。取下为效。禁如药法。
按汤者荡也。荡涤邪秽。欲使其净尽也。丸者缓也。和理脏腑。不欲其速下也。大陷胸丸以荡涤
之体。为和缓之用。盖以其邪结在胸。而至如柔 状。则非峻药不能逐之。而又不可以急剂一下而
尽。故变汤为丸。煮而并渣服之。乃峻药缓用之法。峻则能胜破坚荡实之任。缓则能尽际上迄下
之邪也。
小结胸病。正在心下。按之则痛。脉浮滑者。小陷胸汤主之。
胸中结邪。视结胸较轻者。为小结胸。其证正在心下。按之则痛。不似结胸之心下至少腹硬满
。而痛不可近也。其脉浮滑。不似结胸之脉沉而紧也。是以黄连之下热。轻于大黄、半夏之破饮。
缓于甘遂、栝蒌之润利。和于芒硝。而其蠲除胸中结邪之意。则又无不同也。故曰小陷胸汤。
小陷胸汤方
黄连（一两） 半夏（半升洗） 栝蒌实（大者一枚）
上三味。以水六升。先煮栝蒌实。取三升。去滓。纳诸药。煮取二升。去滓。分温三服。
病在阳。应以汗解之。反以冷水 之。若灌之。其热被劫不得去。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。邪在表也。当以药取汗。而反以冷水 之。或灌濯之。其热得寒被劫而又不得竟去
。于是热伏水内。而弥更益烦。水居热外。而肉上粟起。而其所以为热。亦非甚深而极盛也。故意
欲饮水。而口反不渴。文蛤咸寒而性燥。能去表间水热互结之气。若服之而不瘥者。其热渐深。而
内传入本也。五苓散辛散而淡渗。能去膀胱与水相得之热。若其外不郁于皮肤。内不传于膀胱。
则水寒之气。必结于胸中。而成寒实结胸。寒实者。寒邪成实。与结胸热实者不同。审无口燥渴烦
等证见者。当与三物白散温下之剂。以散寒而除实也。本文小陷胸汤及亦可服七字。疑衍。盖未有
寒热而仍用黄连、栝蒌者。或久而
变热者。则亦可与服之耳。
文蛤散方
文蛤五两为散。以沸汤和一钱匕服。汤用五合。
三物白散方
桔梗（三分） 贝母（三分） 巴豆（一分去皮心熬黑）
上三味为末。纳巴豆。更于臼中杵之。以白饮和服。强人半钱匕。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。身热皮粟不解。欲引衣自覆者。若以
水之洗之。益令热劫不得出。当汗而不汗则烦。假令汗出已。腹中痛。与芍药三两。如上法。
太阳少阳并病。而反下之。成结胸。心下硬。下利不止。水浆不下。其人心烦。
太阳病未罢而并于少阳。法当和散。如柴胡加桂枝之例。而反下之。阳邪内陷。则成结胸。亦如
太阳及少阳误下之例也。但邪既上结。则当不复下注。乃结胸心下硬。而又下利不止者。邪气甚盛
。而淫溢上下也。于是胃气失其和。而水浆不下。邪气乱其心。而烦扰不宁。所以然者。太少二阳
之热。并而入里。充斥三焦心胃之间。故其为病。较诸结胸有独甚焉。仲景不出治法者。非以其盛
而不可制耶。
结胸证。其脉浮大者。不可下。下之则死。
结胸证。原有可下之例。如大陷胸汤及丸诸法是也。若其脉浮大者。心下虽结而表邪犹盛。
则不可迳
与下法。下之则脏气重伤。邪气复入。既不能受。又不可制。则难为生矣。故曰下之则死。
结胸证悉具。烦躁者死。下利者亦死。
伤寒邪欲入而烦躁者。正气与邪争也。邪既结而烦躁者。正气不胜。而将欲散乱也。结胸证悉具
。谓脉沉紧。心下痛。按之石硬。及不大便。舌上燥而渴。日晡所潮热。如上文所云是也。而又
烦躁不宁。则邪结甚深。而正虚欲散。或下利者。是邪气淫溢。际上极下。所谓病胜脏者也。虽
欲不死。其可得乎。
病邪在阳经受邪，反而使用下法，热邪内陷因而形成结胸。病邪在阴经受邪，反而使用下法，因而形成痞证。之所以形成结胸，是因为下法用得过早的缘故。
这是推究结胸与痞证产生的原因。病发于阳经，是指邪气在阳经；病发于阴经，是指邪气在阴经。阳经受邪，郁滞随即化热，其气内陷，就形成结胸；阴经受邪，不立即化热，其气内陷，就形成痞证。之所以这样，是因为病邪在经脉，本应当发散却反而使用下法，导致里气虚弱，邪气乘虚而入，与水饮相互搏结而致病。总之，阳经受邪，原本也有可以使用下法的例子，只是因为里实尚未完全形成，而过早使用下法，所以产生了结胸这种变证。仔细审察确当下而后用下法，怎么会到这种地步呢？张仲景又申述形成结胸的原因，而没有提及痞证，难道不是因为阴经受邪，无论早晚都不可以说使用下法吗？
太阳病，脉象浮而动数。浮脉主风邪，数脉主热，动脉主痛，数脉也主正气虚。头痛、发热，微微盗汗，反而恶寒，说明表证未解。医生反而使用下法，动数之脉变为迟脉，膈内拒按疼痛，胃中空虚，客气扰动膈间，出现短气、烦躁、心中懊憹（烦闷不安）。阳气内陷，心下因此变硬，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，身体其余部位无汗，汗水仅至颈部而止，小便不利，身体必定发黄。
脉象浮、动、数，都属于阳脉，所以表现为风、热、痛，而数脉表示正气被邪气逼迫，失去常度，所以也表现为虚。头痛、发热、微微盗汗，而又恶寒，是邪气在表，按照治法应当发散，却反而使用下法，导致正气虚弱，邪气内陷。动数脉变为迟脉，是因为邪气从表入里，脉象也由阳转阴。膈内拒按疼痛，是邪气欲入而正气抗拒，正邪相击所以产生疼痛。胃中空虚，客气扰动膈间，是因为胃气因误下而里虚，客气乘虚扰动膈间。短气、烦躁、心中懊憹，是因为膈中的水饮被邪气扰动，气机不畅，神明不宁。
由此，阳邪内陷，与水饮相结，痞硬不消，结胸的病证就形成了。大陷胸汤正是治疗阳邪内结胸中的药物。如果并不形成结胸，热气散漫，既不能通过汗液向外宣泄，也不能通过尿液向下排出，蒸郁不解，浸淫肌体，势必导致发黄。
大陷胸汤方
大黄（六两） 芒硝（一升） 甘遂（一钱匕）
以上三味药，用水六升，先煮大黄，取汁二升，去渣，加入芒硝，煮一二沸，加入甘遂末，温服一升。若得快利，停后服。
按：大陷胸汤与大承气汤的使用，有心下与胃中之区别。依我看来，张仲景所说的“心下”，正是指胃；所说的“胃中”，正是指大小肠。胃是水谷汇聚之处，清浊未分，邪气侵入，夹杂痰食，相互结聚不解，就形成结胸。大小肠中精华已去，只有糟粕独存，邪气侵入，只与秽物结成燥粪而已。大承气汤专门主治肠中的燥粪，大陷胸汤同时主治心下的水食互结。
燥粪在肠道，必须借助推逐之力，所以需要枳实、厚朴。水食在胃，必须兼有破除水饮的特长，所以使用甘遂。而且大承气汤先煮枳实、厚朴，然后纳入大黄；大陷胸汤先煮大黄，然后纳入其他药物。治疗上部的病制宜缓，治疗下部的病制宜急，而生大黄行速，熟大黄行迟。同是一味药，但用法又有不同如此。
伤寒六七日，结胸热实证，脉象沉而紧，心下疼痛，按之像石头一样硬的，用大陷胸汤主治。
邪气内结，既热且实，脉象又沉紧，似乎是大承气汤证。然而结胸在心下而不在腹中，虽然按之石硬且痛，也是水食互结，与阳明病的燥粪不同，所以适宜用甘遂破饮，而不适宜用枳实、厚朴散气，如上一条所说的那样。
伤寒十余日，热邪结在里，又出现往来寒热的，用大柴胡汤。只有结胸而无大热的，这是水邪结在胸胁。只有头部微微出汗的，用大陷胸汤主治。
热邪结在里，而又往来寒热，这叫表里俱实，不能因为病程已有十余日，就只治疗里证。所以适宜用大柴胡汤表里双解的方法。如果只是结胸而无大热，如口燥渴、心烦等症状，这是水饮结在胸胁之间，所谓的水结胸就是这种情况。邪气入里，必然挟带体内的原有物质作为依附的基础，所以在肠胃则结于糟粕，在胸膈则结于水饮，各自随着体内所有的物质而发病。水邪结在胸中，而只有头部出汗，是邪气阻隔于上，气机不能下行通畅。所以用大陷胸汤，以破除水饮而消散结聚。
太阳病，重发汗，又再次使用下法，五六天不大便，舌上干燥而口渴，傍晚时分有轻微的潮热，从心下直到小腹，硬满且疼痛不可触碰的，用大陷胸汤主治。
汗下之后，津液严重受损，邪气内结，五六天不大便，舌上干燥而口渴，傍晚轻微潮热，都是阳明胃热的征象。从心下直到小腹，硬满且疼痛不可触碰，不仅具备这些征兆，而且显现出形体症状。不用大承气汤而用大陷胸汤，也是因为水食互结，况且虽然痛至小腹，但未离开心下范围。不然的话，下证全部具备，下药已经使用，为什么不用枳实、厚朴为臣药，而用甘遂为臣药呢？结胸证，项部也强直，像柔痉的样子，用下法治疗后就会调和，适宜用大陷胸丸。
病症表现，颈项强直，是结胸较严重的情况。热与水饮互结，胸膈紧绷，向上连及项部，只能仰头而不能低头，也像柔痉的样子。说“柔”而不说“刚”，是因为阳气内陷，必然不能外闭，所以汗常自出。这适宜用下法消除胸中结聚的实邪，则强直得以缓和而痊愈。然而胸中盛满的邪气，固非小陷胸汤所能去除，而水热互结的实邪，也非承气汤所能治疗，所以给予葶苈子的苦味、甘遂的辛味，以破除结饮而泄气闭；杏仁的辛味、白蜜的甘味，以减缓下趋之势，而去上膈之邪。其中的芒硝、大黄，则是资助其软坚荡实的功效。
大陷胸丸方
大黄（半斤） 葶苈子（半斤） 芒硝（半斤） 杏仁（半升，去皮尖，炒）
以上四味药，将大黄、葶苈子捣筛成粉末，纳入杏仁、芒硝，合研如脂状，混合均匀制成散剂。取如弹丸大小的一枚，另外捣甘遂末一钱匕，白蜜二合，水二升，煮取一升，温顿服。一宿才大便通下，如果不通，再服。以下通为有效。禁忌同服药法则。
按：汤剂的作用是荡涤，荡涤邪秽，希望使其净尽。丸剂的作用是缓和，调和脏腑，不希望其速下。大陷胸丸以荡涤之体，发挥和缓之用。大概因为邪气结在胸中，而至像柔痉的样子，则非峻药不能驱逐它，但又不可以用急剂一下而尽除。所以变汤剂为丸剂，煮后连同药渣一起服用，这是峻药缓用的方法。峻猛则能胜任破坚荡实的重任，缓和则能尽除从上至下的邪气。
胸中结聚的邪气，比结胸较轻的，称为小结胸。其证正在心下，按之则痛，不像结胸那样从心下至少腹硬满且疼痛不可触碰。其脉浮滑，不像结胸那样脉沉而紧。因此黄连的清下热，轻于大黄、半夏的破饮；温和于甘遂、栝蒌的润利；平和于芒硝。而其清除胸中结邪的意思，则又没有不同。所以叫小陷胸汤。
小陷胸汤方
黄连（一两） 半夏（半升，洗） 栝蒌实（大者一枚）
以上三味药，用水六升，先煮栝蒌实，取汁三升，去渣，纳入其他药物，煮取二升，去渣，分三次温服。
病在阳经，应当用汗法解除，反而用冷水喷洒或灌洗，其热被寒气劫持不得散去，更加烦闷，皮肤起粟粒，想喝水，反而不渴的，服用文蛤散。如果不好转的，给五苓散。寒实结胸无热证的，给三物小陷胸汤（即三物白散），也可以服用。
病在阳经，邪气在表，应当用药取汗，却反而用冷水喷洒，或灌洗。其热得寒被劫持而又不能完全去除，于是热伏于水内，更加烦闷；水居热外，皮肤起粟粒。而其热势，也不是很深极盛。所以想喝水，而口反不渴。文蛤咸寒而性燥，能去除表间水热互结之气。如果服用后不好转，说明热渐深，内传入本脏。五苓散辛散而淡渗，能去除膀胱与水相得之热。如果外不郁于皮肤，内不传于膀胱，则水寒之气，必结于胸中，而成寒实结胸。寒实，是寒邪成实，与结胸热实不同。仔细审察没有口燥渴烦等证候出现的，应当给三物白散温下之剂，以散寒而除实。原文中小陷胸汤及“亦可服”七字，怀疑是衍文。大概没有寒证而仍用黄连、栝蒌的道理。或者是日久变热的，则也可以服用。
三物白散方
桔梗（三分） 贝母（三分） 巴豆（一分，去皮心，熬黑）
以上三味药研为末，纳入巴豆，再在臼中杵匀。用白饮（米汤）调服。强壮人服半钱匕，体弱者减量。病在膈上必定呕吐，病在膈下必定腹泻。如果不腹泻，进热粥一杯。如果腹泻不止，进冷粥一杯。身热、皮粟不解，想拉衣盖身的，如果用冷水洗浴，更令热邪被劫持不得外出。应当出汗而不出汗则烦闷。假如汗出后，腹中痛，给芍药三两，如上法。
太阳少阳并病，反而使用下法，形成结胸，心下硬，下利不止，水浆不下，其人烦闷。
太阳病未罢而并于少阳，按照治法应当和解发散，如柴胡加桂枝汤的例子，却反而使用下法，阳邪内陷，就形成结胸，也像太阳及少阳误下的例子。但邪气既然上结，就不应再下注。现在结胸心下硬，而又下利不止，是邪气很盛，而淫溢上下。于是胃气失其和，水浆不下；邪气乱其心，烦扰不宁。之所以这样，是因为太少二阳的热邪，并入入里，充斥三焦心胃之间，所以它的病情，比其他结胸更为严重。张仲景没有给出治法，难道不是因为它太盛而无法控制吗？
结胸证，原本有可用下法的例子，如大陷胸汤及丸剂等方法是这样的。如果脉象浮大，心下虽结聚但表邪仍然旺盛，就不能直接用下法。用下法则脏气重伤，邪气复入，既不能承受，又无法制约，就难以生存了。所以说用下法就会死亡。
结胸证全部具备，出现烦躁的死亡，下利的也死亡。
伤寒邪气欲入而烦躁的，是正气与邪气抗争。邪气既已结聚而烦躁的，是正气不胜，将要散乱。结胸证全部具备，是指脉沉紧，心下痛，按之石硬，以及不大便，舌上干燥而口渴，傍晚潮热，如上文所说的那样。而又烦躁不宁，则邪结甚深，而正气虚欲散。或者下利的，是邪气淫溢，际上极下，所谓病胜脏。虽然想不死，怎么可能呢？
When the disease originates in the Yang aspect, and purgation is wrongly applied, heat enters and forms Jie Xiong (Chest Binding). When the disease originates in the Yin aspect, and purgation is wrongly applied, Pi (Stagnation) forms. The reason for forming Jie Xiong is that purgation was used too early.
This explains the causes of Jie Xiong and Pi. "Disease originating in Yang" means the pathogen is in the Yang meridians; "disease originating in Yin" means the pathogen is in the Yin meridians. When pathogens invade the Yang meridians, stagnation quickly generates heat; if this Qi sinks inward, it forms Jie Xiong. When pathogens invade the Yin meridians, heat does not immediately form; if this Qi sinks inward, it forms Pi. The reason for this is that when pathogens are in the meridians, they should be dispersed via sweating, but purgation was wrongly applied, causing interior Qi to become deficient. Pathogens then enter and contend with fluid retention, causing disease. In summary, although there are cases where Yang meridian pathogens can be treated with purgation, because interior excess had not yet fully formed, applying purgation too early resulted in the complication of Jie Xiong. If one carefully assesses whether purgation is indicated before applying it, how could such a situation arise? Zhang Zhongjing further elucidates the cause of Jie Xiong but omits Pi. Is it not because when pathogens invade the Yin meridians, regardless of timing, purgation should never be mentioned?
In Taiyang disease, the pulse is floating, active, and rapid. Floating indicates Wind, Rapid indicates Heat, Active indicates Pain, and Rapid also indicates Deficiency. Headache, fever, slight night sweats, and aversion to cold indicate that the exterior pattern has not resolved. The physician wrongly applies purgation. The Active and Rapid pulse changes to Slow. There is resistance and pain in the diaphragm interior. The stomach becomes empty and deficient, allowing hostile Qi to disturb the diaphragm. Shortness of breath, irritability, and mental restlessness occur. Yang pathogens sink inward, causing the epigastrium to become hard, thus forming Jie Xiong. Da Xian Xiong Tang (Major Sinking Chest Decoction) is the primary treatment. If Jie Xiong does not form, but only the head sweats while the rest of the body remains dry, with sweat stopping at the neck, and urination is difficult, jaundice will inevitably develop.
Floating, Active, and Rapid pulses all belong to Yang, hence indicating Wind, Heat, and Pain. The Rapid pulse indicates that righteous Qi is pressured by pathogens and loses its normal rhythm, hence also indicating Deficiency. Headache, fever, slight night sweats, and aversion to cold indicate pathogens in the exterior, which should be treated with dispersing methods. Wrongly applying purgation causes righteous Qi to weaken and pathogens to sink. The change from Active/Rapid to Slow indicates pathogens moving from exterior to interior, so the pulse shifts from Yang to Yin. Resistance and pain in the diaphragm indicate pathogens attempting to enter while righteous Qi resists; the clash between righteous Qi and pathogens causes pain. Empty and deficient stomach Qi allows hostile Qi to disturb the diaphragm due to interior deficiency caused by purgation. Shortness of breath, irritability, and mental restlessness occur because fluid retention in the diaphragm is disturbed by pathogens, leading to stagnant Qi and unsettled Spirit.
Thus, Yang pathogens sink inward and bind with fluid retention. The hardness and fullness do not dissipate, and the disease of Jie Xiong is established. Da Xian Xiong Tang is the correct medicine for treating Yang pathogens binding in the chest. If Jie Xiong does not form, heat scatters diffusely. Unable to exit via sweat or urine, it steams and郁s without resolution, infiltrating the muscles and skin, inevitably leading to jaundice.
Da Xian Xiong Tang Formula
Da Huang (Rhei Radix et Rhizoma, 6 liang), Mang Xiao (Natrii Sulfas, 1 sheng), Gan Sui (Kansui Radix, 1 qian bi).
Take the above three herbs. Add 6 sheng of water. First decoct Da Huang until 2 sheng remain. Remove dregs. Add Mang Xiao. Boil for one or two boils. Add Gan Sui powder. Take 1 sheng warm. If loose stools occur rapidly, stop taking the remaining dose.
Note: There is a distinction between the use of Da Xian Xiong Tang and Da Cheng Qi Tang regarding the Epigastrium (Xin Xia) and the Stomach/Intestines (Wei Zhong). In my view, what Zhang Zhongjing calls "Epigastrium" refers to the Stomach, and what he calls "Stomach interior" refers to the Small and Large Intestines. The Stomach is the meeting place of water and grain, where clear and turbid have not yet separated. When pathogens enter, they mix with phlegm and food, binding together unresolved, forming Jie Xiong. The intestines have already eliminated essence, containing only waste. When pathogens enter, they bind only with filth to form dry feces. Da Cheng Qi Tang specifically treats dry feces in the intestines, while Da Xian Xiong Tang treats water and food binding in the epigastrium.
Dry feces in the intestines require pushing and draining forces, hence Zhi Shi (Aurantii Fructus Immaturus) and Hou Po (Magnoliae Officinalis Cortex) are needed. Water and food in the stomach require breaking fluid retention, hence Gan Sui is used. Furthermore, Da Cheng Qi Tang decocts Zhi Shi and Hou Po first, then adds Da Huang; Da Xian Xiong Tang decocts Da Huang first, then adds other herbs. Treatment for upper conditions requires a slow approach, while treatment for lower conditions requires a rapid approach. Raw Da Huang acts fast, while cooked Da Huang acts slowly. Thus, even for the same herb, usage differs significantly.
After six or seven days of Shang Han, if there is Jie Xiong with Heat and Excess, the pulse is Deep and Tight, pain is in the epigastrium, and palpation reveals hardness like stone, Da Xian Xiong Tang is the primary treatment.
Pathogens bind internally, creating Heat and Excess. The Deep and Tight pulse resembles Da Cheng Qi Tang syndrome. However, the binding is in the epigastrium, not the abdomen. Although hard as stone and painful, it is water and food binding, different from Yangming dry feces. Therefore, Gan Sui to break fluid is appropriate, while Zhi Shi and Hou Po to disperse Qi are not, as stated in the previous paragraph.
After ten-plus days of Shang Han, if heat binds in the interior and there is alternating chills and fever, Da Chai Hu Tang is given. If there is only Jie Xiong without significant heat, this is water binding in the chest and hypochondrium. If only the head sweats slightly, Da Xian Xiong Tang is the primary treatment.
Heat binding in the interior with alternating chills and fever indicates both Exterior and Interior Excess. One cannot treat only the interior despite the long duration. Hence, Da Chai Hu Tang is suitable for resolving both Exterior and Interior. If there is only Jie Xiong without significant heat, accompanied by symptoms like dry mouth/thirst and irritability, this is water-fluid binding in the chest and hypochondrium, known as "Water Binding in the Chest." When pathogens enter the interior, they attach to existing substances in the body. In the intestines, they bind with waste; in the chest/diaphragm, they bind with water-fluids. Disease manifests according to what is present. Water binding in the chest causes only head sweating because pathogens obstruct the upper part, preventing Qi from descending smoothly. Hence, Da Xian Xiong Tang is used to break fluid and dissipate binding.
In Taiyang disease, after excessive sweating followed by purgation, if there is no bowel movement for five to six days, dry tongue with thirst, slight afternoon tidal fever, and hardness/fullness/pain from the epigastrium to the lower abdomen that cannot be touched, Da Xian Xiong Tang is the primary treatment.
After sweating and purgation, body fluids are severely damaged, and pathogens bind internally. No bowel movement for five to six days, dry tongue with thirst, and slight afternoon tidal fever are signs of Yangming Stomach Heat. Hardness, fullness, and untouchable pain from the epigastrium to the lower abdomen manifest these signs physically. Da Xian Xiong Tang is used instead of Da Cheng Qi Tang because water and food are mutually bound. Although pain extends to the lower abdomen, it has not left the epigastrium. Otherwise, with all purgative indications present and purgatives administered, why would Zhi Shi and Hou Po not be used as ministers, but Gan Sui instead? In Jie Xiong, the neck may also be stiff, resembling Rou Ji (Soft Spasm). Purging harmonizes the condition; Da Xian Xiong Wan (Major Sinking Chest Pill) is appropriate.
The symptom is neck stiffness, a severe form of Jie Xiong. Heat and fluid bind, tightening the chest and diaphragm, extending upward to the neck. The patient can only extend the head backward, unable to bend forward, resembling Rou Ji. It is called "Soft" rather than "Stiff" because sinking Yang Qi prevents external closure, causing spontaneous sweating. Purging the solid accumulation in the chest will harmonize and cure the stiffness. However, the abundant evil in the chest cannot be removed by Xiao Xian Xiong Tang, nor can the solid water-heat binding be treated by Cheng Qi Tang. Therefore, Ting Li Zi (Perillae Semen) bitterness and Gan Sui pungency are used to break fluid binding and vent Qi obstruction. Xing Ren (Armeniacae Semen Amarum) pungency and Bai Mi (Honey) sweetness slow the downward rush and remove upper diaphragm pathogens. Mang Xiao and Da Huang provide softening and purging power.
Da Xian Xiong Wan Formula
Da Huang (Rhei Radix et Rhizoma, 0.5 jin), Ting Li Zi (Perillae Semen, 0.5 jin), Mang Xiao (Natrii Sulfas, 0.5 jin), Xing Ren (Armeniacae Semen Amarum, 0.5 sheng, peeled and crushed).
Pound and sieve the first two herbs. Mix with Xing Ren and Mang Xiao, grinding into a paste-like consistency. Form pills the size of a bullet. Separately pound Gan Sui powder (1 qian bi). Mix with 2 he of Honey and 2 sheng of Water. Decoct to obtain 1 sheng. Take warm in one dose. Bowel movement occurs after one night. If no movement, take again. Movement indicates efficacy. Follow standard medication prohibitions.
Note: Tang (Decoction) implies sweeping away filth completely. Wan (Pill) implies harmonizing organs gently, avoiding rapid purging. Da Xian Xiong Wan uses a sweeping nature for a gentle effect. Because pathogens bind in the chest causing neck stiffness, strong medicines are needed to drive them out, but a single rapid purge cannot eliminate everything. Thus, changing Decoction to Pill, decocting and consuming the dregs, represents using strong medicine gently. Strong enough to break firmness and purge excess; gentle enough to clear pathogens from top to bottom.
In Xiao Jie Xiong (Minor Chest Binding) disease, the binding is exactly in the epigastrium, painful upon pressure, with a Floating and Slippery pulse. Xiao Xian Xiong Tang is the primary treatment.
Binding pathogens in the chest lighter than Jie Xiong are called Minor Chest Binding. The symptom is exactly in the epigastrium, painful on pressure, unlike Jie Xiong which involves hardness/fullness/pain from epigastrium to lower abdomen. The pulse is Floating and Slippery, unlike Jie Xiong's Deep and Tight pulse. Therefore, Huang Lian (Coptidis Rhizoma) clearing heat is milder than Da Huang and Ban Xia breaking fluid; it is gentler than Gan Sui and Gua Lou moistening and draining; and milder than Mang Xiao. Its intent to clear chest binding pathogens is the same. Hence, it is called Xiao Xian Xiong Tang.
Xiao Xian Xiong Tang Formula
Huang Lian (Coptidis Rhizoma, 1 liang), Ban Xia (Pinelliae Rhizoma, 0.5 sheng, washed), Gua Lou Shi (Trichosanthis Fructus, one large fruit).
Add 6 sheng of water. First decoct Gua Lou Shi until 3 sheng remain. Remove dregs. Add other herbs. Decoct to obtain 2 sheng. Remove dregs. Divide into three warm doses.
If the disease is in the Yang (Exterior), it should be resolved by sweating. Wrongly spraying or pouring cold water on the patient traps the heat, making it more irritable. Skin raises goosebumps. The patient desires water but feels no thirst. Wen Ge San (Clam Shell Powder) is taken. If not cured, Wu Ling San (Five-Ingredient Powder with Poria) is given. For Cold-Excess Jie Xiong without Heat signs, San Wu Xiao Xian Xiong Tang (Three-Ingredient Minor Chest Binding Tang, i.e., San Wu Bai San) is given, which can also be taken.
Disease in Yang means pathogens are in the exterior. Sweating should be induced medicinally. Wrongly spraying or washing with cold water traps heat within water, increasing irritability. Water sits outside heat, raising goosebumps. The heat is not deep or extreme. Hence, desire for water but no thirst. Wen Ge is salty, cold, and drying, removing exterior water-heat binding. If ineffective, heat deepens and transmits inward. Wu Ling San is pungent and diuretic, removing heat associated with water in the Bladder. If pathogens do not郁 in skin or transmit to Bladder, cold-water Qi binds in the chest, forming Cold-Excess Jie Xiong. Cold-Excess differs from Heat-Excess Jie Xiong. If oral dryness/thirst and irritability are absent, San Wu Bai San (Three-Ingredient White Powder) is given as a warming purgative to dispel cold and remove excess. The characters "Xiao Xian Xiong Tang" and "ke yi fu" (can also be taken) in the text are suspected interpolations. There is no logic in using Huang Lian and Gua Lou for cold patterns. Perhaps if the condition transforms into heat over time, they can be taken.
Wen Ge San Formula
Wen Ge (Veneris Concha, 5 liang), powdered. Mix 1 qian bi with boiling water (5 he) and take.
San Wu Bai San Formula
Jie Geng (Platycodonis Radix, 3 fen), Bei Mu (Fritillariae Bulbus, 3 fen), Ba Dou (Crotonis Fructus, 1 fen, peeled, heart removed, roasted black).
Powder the three herbs. Mix with Ba Dou. Pound in a mortar. Mix with white drink (rice water) and administer. Robust persons take half a qian bi; frail persons reduce dose. Pathogens above the diaphragm cause vomiting; below, diarrhea. If no diarrhea, drink a cup of hot porridge. If diarrhea persists, drink a cup of cold porridge. If fever and goosebumps persist, and the patient pulls clothes to cover themselves, washing with water traps heat further. Sweating should occur; if not, irritability arises. If sweating occurs and abdominal pain follows, give Shao Yao (Paeoniae Radix Alba, 3 liang) as above.
In concurrent Taiyang and Shaoyang disease, wrongly applying purgation forms Jie Xiong. Epigastric hardness, continuous diarrhea, inability to swallow liquids, and mental irritability occur.
Taiyang disease unresolving merges with Shaoyang. The method should be harmonizing and dispersing, e.g., Chai Hu Jia Gui Zhi Tang. Wrongly applying purgation causes Yang pathogens to sink inward, forming Jie Xiong, similar to erroneous purgation in Taiyang/Shaoyang. Since pathogens bind upward, they should not flow downward. Yet, epigastric hardness with continuous diarrhea indicates excessive pathogens overflowing up and down. Stomach Qi loses harmony, preventing liquid intake. Pathogens disturb the Heart, causing irritability. This is because Heat from Taiyang and Shaoyang merges into the interior, filling the San Jiao, Heart, and Stomach. The pathology is more severe than ordinary Jie Xiong. Zhang Zhongjing provides no treatment method, likely because the excess is uncontrollable.
In Jie X Zheng (Chest Binding Syndrome), if the pulse is Floating and Large, purgation is contraindicated. Purgation leads to death.
Jie Xiong has indications for purgation, such as Da Xian Xiong Tang and Pills. If the pulse is Floating and Large, although binding exists in the epigastrium, exterior pathogens are still vigorous. Direct purgation is forbidden. Purgation injures Zang Qi deeply, allowing pathogens to re-enter. Unable to withstand or control the pathogens, survival is unlikely. Hence, purgation leads to death.
If all Jie Xiong symptoms are present and Irritability occurs, death results. Diarrhea also results in death.
In Shang Han, irritability as pathogens attempt to enter indicates righteous Qi fighting pathogens. Irritability after pathogens have bound indicates righteous Qi failing and scattering. "All Jie Xiong symptoms present" refers to Deep/Tight pulse, epigastric pain, stone-hard palpation, no bowel movement, dry tongue/thirst, and afternoon tidal fever, as described previously. With persistent irritability, pathogens bind deeply while righteous Qi is deficient and scattering. If diarrhea occurs, pathogens overflow from top to bottom, meaning the disease conquers the Zang. Death is inevitable.