又有痰气之凝结，不在心下而在胸中者。其凝结之痰气，填
满于胸膈，至窒塞其肺中之呼吸几至停止者，此为结胸之险证，原非寻常药饵所能疗治。
《伤寒论》原文∶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。
脉浮热犹在表，原当用辛凉之药发汗以解其表，乃误认为热已入里，而以药下之，其胸中大气因下而虚，
则外表之风热即乘虚而入，与上焦痰水互相凝结于胸膺之间，以填塞其空旷之府，是以成结胸之证。不但觉
胸中满闷异常，即肺中呼吸亦觉大有滞碍。其提纲中既言其脉数则为热，而又言数则为虚者，盖人阴分不虚
者，总有外感之热，其脉未必即数，今其热犹在表，脉之至数已数，故又因其脉数，而断其为虚也。至于因
结胸而脉变为迟者，非因下后热变为凉也，盖人之脏腑中有实在瘀积，阻塞气化之流通者，其脉恒现迟象，是
以大承气汤证，其脉亦迟也。膈内拒痛者，胸中大气与痰水凝结之气，互相撑胀而作痛，按之则其痛益甚，
是以拒按也。胃中空虚，客气动膈者，因下后胃气伤损，气化不能息息下行（胃气所以传送饮食故以息息下
行为顺），而与胃相连之冲脉（冲脉之上源与胃相连），其气遂易于上干，至鼓动膈膜而转排挤呼吸之气，使
不得上升是以短气也。烦躁者，因表热内陷于胸中，扰乱其心君之火故烦躁也。
懊者，上干之气欲透膈而外越故懊 也。
【大陷胸汤方】大黄六两去皮，芒硝一升，甘遂一钱匕为末。
上三味，以水六升先煮大黄，取二升，去渣，纳芒硝煮一、两沸，纳甘遂末，温服一升，得快利、
止后服，所谓一钱匕者，俾匕首作扁方形，将药末积满其上，重可至一钱耳。
结胸之证，虽填塞于胸中异常满闷，然纯为外感之风热内陷，与胸中素蓄之水饮结成，纵有客气上干至
于动膈，然仍阻于膈而未能上达，是以若枳实、浓朴，一切开气之药皆无须用。惟重用大黄、芒硝以开痰而
清热，又虑大黄、芒硝之力虽猛，或难奏效于顷刻，故又少佐以甘遂，其性以攻决为用，异常迅速，与
大黄、芒硝化合为方，立能清肃其空旷之府使毫无障碍，制此方者乃霹雳手段也。
甘遂之性，《神农本草经》原谓其有毒。忆愚初学医时，曾遍尝诸药以求其实际，一日清晨嚼服生甘
遂一钱，阅一点钟未觉瞑眩，忽作水泻连连下行近十次，至巳时吃饭如常，饭后又泻数次，所吃之饭皆泻出，
由此悟得利痰之药，当推甘遂为第一。后以治痰迷心窍之疯狂，恒恃之成功，其极量可至一钱强，然非其
脉大实，不敢轻投，为其性至猛烈，是以大陷胸汤中所用之甘遂，折为今之分量，一次所服者只一分五厘，
而能导引大黄、芒硝直透结胸病之中坚，俾大黄、芒硝得施其药力于瞬息之顷，此
乃以之为向导，少用即可成功，原无须乎多也。
甘遂之性，原宜作丸散，若入汤剂，下咽即吐出，是以大陷胸汤方必将药煎成，而后纳甘遂之末于其中也。
甘遂之性，初服之恒可不作呕吐，如连日服即易作呕吐，若此方服初次病未尽除而需再服者，宜加
生赭石细末二钱，用此汤药送服，即可不作呕吐。
用大陷胸汤治结胸原有捷效，后世治结胸证敢用此方者，实百中无二三。一畏方中甘遂有毒，一疑
提纲论脉处，原明言数则为虚，恐不堪此猛烈之剂。夫人之畏其方不敢用者，愚实难以相
强，然其方固可通变也。《伤寒论》大陷胸汤之前，原有大陷胸丸，方系大黄半斤，葶苈半升熬，杏仁半
升去皮尖熬黑，芒硝半升。
上四味，捣筛二味，次纳杏仁、芒硝，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。
此方所主之证，与大陷胸汤同，因其兼有颈强如柔痉状，故于大陷胸汤中加葶苈、杏仁，和以白蜜，连渣
煮服，因其病上连颈欲药力缓缓下行也。今欲于大陷胸汤中减去甘遂，可将大陷胸丸中之葶苈及前治噫气不
除方中之赭石，各用数钱加于大陷胸汤中，则甘遂不用亦可奏效。夫赭石饶有重坠之力前已论之，至葶
苈则味苦善降，性近甘遂而无毒，药力之猛烈亦远逊于甘遂，其苦降之性，能排逐溢于肺中之痰水使之迅
速下行，故可与赭石共享以代甘遂也。
至大陷胸汤如此加减用者，若犹畏其力猛，愚又有自拟之方以代之，即医方篇之荡胸汤是也。此荡胸汤
方不但无甘遂，并无大黄，用以代大陷胸汤莫不随手奏效，故敢笔之于书以公诸医界也。
此外，还有痰气凝结的情况，其位置不在心下（胃脘部），而在胸中。这种凝结的痰气，填满了胸膈部位，甚至阻塞了肺中的呼吸功能，几乎导致呼吸停止，这是结胸证中的一种危重险证，原本不是普通的药物所能治疗的。
《伤寒论》原文记载：太阳病，脉象浮而动数。脉浮说明有风邪，脉数说明有热邪。脉动主痛，脉数也提示正气虚弱。患者出现头痛、发热，微微盗汗，反而恶寒，这说明表证尚未解除。医生反而使用攻下法治疗，导致脉象由动数变为迟脉，膈内感到抗拒性疼痛，胃中空虚，外来的邪气扰动膈膜，出现短气、烦躁不安，心中烦闷懊恼，阳气内陷，心下因此变硬，这就形成了结胸证，应当用大陷胸汤主治。
脉浮且热象仍在体表，原本应当用辛凉性质的药物发汗来解除表证，但误认为热邪已经入里，而使用泻下药，导致胸中的大气因攻下而虚弱，于是外表的风热之邪乘虚而入，与上焦原有的痰水互相凝结在胸膺之间，填塞了空旷的脏腑空间，从而形成结胸证。患者不仅感觉胸中异常满闷，就连肺中的呼吸也觉得大有滞碍。在提纲条文中，既说“脉数则为热”，又说“脉数则为虚”，这是因为如果人的阴分不虚，即使有外感的热邪，脉象未必立即表现为数脉；如今热邪尚在体表，脉率已经加快，所以又根据脉数这一现象，判断其体质为虚。至于因为结胸而导致脉象变为迟脉，并不是因为攻下后热邪变成了寒凉，而是因为人体脏腑中有实在的瘀积，阻塞了气化的流通，脉象常常呈现迟象，所以大承气汤证的脉象也是迟的。所谓“膈内拒痛”，是指胸中的大气与痰水凝结之气互相撑胀而产生疼痛，按压时疼痛更加剧烈，所以患者拒绝按压。“胃中空虚，客气动膈”，是因为攻下之后胃气受损，气化不能持续下行（胃气的功能是传送饮食，所以以持续向下运行顺遂），而与胃相连的冲脉（冲脉的上源与胃相连），其气便容易向上干犯，进而鼓动膈膜并排挤呼吸之气，使呼吸之气不得上升，从而导致短气。烦躁，是因为表热内陷于胸中，扰乱了心火所致。懊恼，是因为上干的气欲透膈而出却未能外越，故产生懊恼之感。
【大陷胸汤方】大黄六两（去皮），芒硝一升，甘遂一钱匕（研末）。
以上三味药，用水六升，先煮大黄，取二升药液，去渣，加入芒硝，再煮一至两沸，最后加入甘遂末，温服一升，若得快利（大便通畅），则停服后面的药。所谓“一钱匕”，是指用匕首形状的扁平方形工具，将药末积满其上，重量大约相当于一钱。
结胸证，虽然填塞于胸中导致异常满闷，但这纯粹是外感的风热内陷，与胸中素日蓄积的水饮相结合而成。纵然有客气上干导致动膈，但也仍然阻滞于膈部而不能上达，所以对于枳实、厚朴等一切理气开郁的药物都不需要使用。只需重用大黄、芒硝来化痰清热，又担心大黄、芒硝的力量虽然猛烈，或许难以在短时间内见效，所以又少量佐以甘遂。甘遂的性质以攻决破积为用，速度异常迅速，与大黄、芒硝配合成方，能立即清肃空旷的脏腑，使其毫无障碍，制定此方的人真是具有霹雳手段啊。
甘遂的性质，《神农本草经》原来说它有毒。回忆我初学医时，曾遍尝各种药物以求了解其实效。一天清晨，我嚼服了一钱生甘遂，过了一小时没有感到头晕目眩等瞑眩反应，忽然开始连续腹泻近十次水样便，到了巳时吃饭如常，饭后又腹泻几次，吃进去的饭都泻出来了。由此我领悟到，利除痰饮的药物，当推甘遂为第一。后来用它治疗痰迷心窍导致的疯狂症，经常依靠它取得成功，其极量可用到一钱多，但如果患者的脉象不是大实之脉，我不敢轻易投用，因为它的性质极其猛烈。所以在《伤寒论》大陷胸汤中所用的甘遂，折算成现在的分量，一次服用只有一分五厘，却能引导大黄、芒硝直透结胸病的核心，使大黄、芒硝能在瞬息之间施展药力，这是把它作为向导，少用即可成功，原本不需要多用。
甘遂的性质，原本适宜做成丸剂或散剂，如果放入汤剂中，咽下后就会引起呕吐，所以大陷胸汤方必须先将其他药物煎好，然后将甘遂末纳入其中。甘遂的性质，初次服用通常不会引起呕吐，如果连日服用就容易引起呕吐。如果此方第一次服用后病未尽除需要再服，宜加入生赭石细末二钱，用此汤药送服，就可以避免呕吐。
用大陷胸汤治疗结胸本来有快捷的效果，后世治疗结胸证敢用此方的，实际上百人中不到二三人。一是畏惧方中甘遂有毒，二是怀疑提纲论述脉象的地方，明明说“脉数则为虚”，恐怕身体承受不了如此猛烈的药剂。人们畏惧这个方子不敢用，我实在难以勉强他们，但是这个方子是可以通融变化的。在《伤寒论》大陷胸汤之前，原有大陷胸丸，方子由大黄半斤，葶苈子半升（熬），杏仁半升（去皮尖，熬黑），芒硝半升组成。
以上四味药，将前两种捣筛成粉，接着加入杏仁、芒硝，研磨如脂状，混合均匀，取如弹丸大小的一枚，另外捣甘遂末一钱匕、白蜜二合，加水二升，煮取一升，温顿服下。
此方所主治的证候，与大陷胸汤相同，因为它兼有颈项强直如同柔痉的症状，所以在大陷胸汤中加入葶苈子、杏仁，并用白蜜调和，连同药渣一起煮服，是因为病势向上连及颈部，希望药力缓缓下行。现在想要在大陷胸汤中减去甘遂，可以将大陷胸丸中的葶苈子以及前面治疗噫气不除方中的赭石，各用数钱加入大陷胸汤中，那么不用甘遂也能奏效。赭石富含重坠之力，前面已经论述过；至于葶苈子，味道苦善于降泄，性质接近甘遂但没有毒性，药力的猛烈程度也远逊于甘遂，其苦降的性质，能排逐溢于肺中的痰水，使之迅速下行，所以可以与赭石共用来代替甘遂。
至于像这样加减使用大陷胸汤，如果还畏惧其力量猛烈，我又有一个自拟的方子来代替它，即医方篇中的荡胸汤。这个荡胸汤方不但没有甘遂，也没有大黄，用来代替大陷胸汤无不随手奏效，所以我敢于将其记录在书中公之于医界。
Furthermore, there are cases where phlegm and qi (vital energy) congeal not in the epigastrium but in the chest. This congealed phlegm and qi fill the chest and diaphragm to such an extent that they obstruct respiration in the lungs, nearly bringing it to a halt. This constitutes a critical and dangerous syndrome of Jie Xiong (chest binding), which originally cannot be treated by ordinary medications.
The original text of *Shanghan Lun* (Treatise on Cold Pathogenic Diseases) states: In Taiyang disease (disease of the Taiyang channel), the pulse is floating and rapid-numerous. Floating indicates wind; rapid-numerous indicates heat. Agitated indicates pain; rapid-numerous also indicates deficiency. The patient presents with headache, fever, slight night sweating, and conversely, aversion to cold, indicating that the exterior syndrome has not yet resolved. If the physician erroneously applies purgation, the agitated-rapid pulse changes to a slow one. There is resistance and pain within the diaphragm, the stomach is empty and deficient, pathogenic qi disturbs the diaphragm, leading to shortness of breath, irritability, and inner restlessness. Yang qi sinks inward, causing the epigastrium to become hard, thus forming Jie Xiong (chest binding). Da Xian Xiong Tang (Major Decoction for Draining the Chest) should be administered.
When the pulse is floating and heat remains at the exterior, one should originally use acrid-cool herbs to induce sweating and resolve the exterior. However, mistakenly believing the heat has entered the interior, the physician uses purgatives. This causes the Great Qi (Zong Qi) in the chest to become deficient due to downward draining. Consequently, external wind-heat enters through this deficiency and congeals with existing phlegm-fluids in the upper jiao between the chest and shoulders, filling the hollow organs and resulting in Jie Xiong. The patient feels extreme fullness and oppression in the chest, and even respiration in the lungs feels significantly obstructed. The guideline mentions both "rapid-numerous indicates heat" and "rapid-numerous indicates deficiency." This is because if a person's yin aspect is not deficient, even with external heat, the pulse may not necessarily be rapid-numerous. Now, since the heat is still at the exterior but the pulse rate is already rapid, the rapidity is interpreted as a sign of underlying deficiency. Regarding the pulse becoming slow due to Jie Xiong, it is not because the heat turns cold after purgation. Rather, when there is substantial stasis or accumulation in the viscera and bowels blocking the flow of qi transformation, the pulse often appears slow. Thus, in the syndrome of Da Cheng Qi Tang (Major Order the Qi Decoction), the pulse is also slow. "Resistance and pain within the diaphragm" refers to the mutual distension and pain caused by the Great Qi in the chest clashing with the congealed qi of phlegm-fluids; pressing exacerbates the pain, hence the rejection of pressure. "Empty stomach and pathogenic qi disturbing the diaphragm" occurs because purgation damages stomach qi, preventing qi transformation from descending continuously (stomach qi transmits food and drink, so continuous downward movement is favorable). The Chong Mai (Penetrating Vessel), whose upper source connects with the stomach, allows its qi to easily ascend and harass the diaphragm. It then drums against the diaphragm and compresses respiratory qi, preventing it from ascending, thereby causing shortness of breath. Irritability arises because exterior heat sinks into the chest, disturbing the fire of the Heart Mind. Restlessness (Ao Nao) occurs because the harassing qi attempts to penetrate the diaphragm and escape outward but fails, causing internal frustration.
[Da Xian Xiong Tang Formula]
Da Huang (Rhubarb Root and Rhizome) 6 liang (peeled), Mang Xiao (Mirabilite) 1 sheng, Gan Sui (Kansui Root) 1 qian bi (powdered).
Take these three ingredients. Add 6 sheng of water, first decoct Da Huang until 2 sheng remain, remove the dregs, add Mang Xiao, boil for one or two boils, then add the Gan Sui powder. Take 1 sheng warm. If loose stools occur rapidly, stop taking the remaining medicine. "1 qian bi" refers to accumulating powder on a flat, dagger-shaped scoop, weighing approximately 1 qian.
In Jie Xiong syndrome, although the chest is filled with extreme fullness and oppression, it is purely due to external wind-heat sinking inward and combining with pre-existing fluid retention in the chest. Even if pathogenic qi harasses upward affecting the diaphragm, it remains blocked at the diaphragm and does not reach higher levels. Therefore, qi-regulating herbs like Zhi Shi (Immature Bitter Orange) and Hou Po (Magnolia Bark) are unnecessary. One should heavily use Da Huang and Mang Xiao to resolve phlegm and clear heat. Anticipating that although Da Huang and Mang Xiao are potent, they might not act instantly, a small amount of Gan Sui is added as an assistant. Gan Sui acts by breaking down accumulations and is extremely rapid. Combined with Da Huang and Mang Xiao, it immediately clears the hollow organs without obstruction. The creator of this formula employed thunderbolt-like measures.
Gan Sui is stated to be toxic in *Shennong Bencao Jing*. I recall when I first studied medicine, I tasted various herbs to understand their practical effects. One morning, I chewed and swallowed 1 qian of raw Gan Sui. After an hour, without experiencing dizzying reactions, I suddenly had watery diarrhea nearly ten times. By Si hour (9–11 AM), I ate normally. After the meal, I had several more episodes of diarrhea, expelling all the food eaten. From this, I realized that among herbs that drain phlegm-fluids, Gan Sui is supreme. Later, using it to treat madness caused by phlegm confusing the heart orifices, it consistently succeeded. Its maximum dose can exceed 1 qian, but I dare not administer it lightly unless the pulse indicates substantial excess, due to its extreme potency. In Da Xian Xiong Tang, the dosage of Gan Sui is折算 (converted) to modern units: only 1.5 fen per dose. Yet, it guides Da Huang and Mang Xiao directly to the core of the Jie Xiong pathology, allowing them to exert their power instantly. It serves as a guide; a small amount suffices, and large doses are unnecessary.
Gan Sui is originally suitable for pills or powders. If added to a decoction, it often induces vomiting upon swallowing. Therefore, in Da Xian Xiong Tang, other herbs are decocted first, and Gan Sui powder is added subsequently. Initially, Gan Sui may not cause vomiting, but with consecutive days of use, vomiting becomes likely. If a second dose is needed because the first did not fully resolve the illness, adding 2 qian of fine powder of Sheng Zhe Shi (Hematite) to be taken with the decoction will prevent vomiting.
Using Da Xian Xiong Tang to treat Jie Xiong originally yields swift results, yet later physicians who dared to use this formula accounted for less than two out of a hundred. Some feared the toxicity of Gan Sui; others doubted the pulse discussion in the guidelines, specifically the statement "rapid-numerous indicates deficiency," fearing the body could not withstand such a fierce preparation. While I cannot force those who fear the formula to use it, the formula itself allows for modification. Before Da Xian Xiong Tang in *Shanghan Lun*, there exists Da Xian Xiong Wan (Major Pill for Draining the Chest), composed of Da Huang 8 liang, Ting Li Zi (Periploca Seed) 0.5 sheng (roasted), Xing Ren (Apricot Seed) 0.5 sheng (skin and tip removed, roasted until black), and Mang Xiao 0.5 sheng.
Take these four ingredients. Pound and sieve two of them, then add Xing Ren and Mang Xiao, grind into a paste-like consistency, mix well. Take one pill-sized portion. Separately, pound Gan Sui powder 1 qian bi and Bai Mi (White Honey) 2 he. Add 2 sheng of water, decoct to obtain 1 sheng, take warm in one dose.
This formula treats the same syndrome as Da Xian Xiong Tang. Because it is accompanied by neck stiffness resembling Rou Ji (soft tetanus), Ting Li Zi and Xing Ren are added to Da Xian Xiong Tang, mixed with white honey, and decocted with dregs. This is because the pathology extends upward to the neck, requiring the medicinal power to descend slowly. To substitute for Gan Sui in Da Xian Xiong Tang, one can add several qian each of Ting Li Zi from Da Xian Xiong Wan and Zhe Shi from the previous formula for persistent belching to Da Xian Xiong Tang. This achieves efficacy without Gan Sui. As previously discussed, Zhe Shi possesses heavy-sinking properties. Ting Li Zi is bitter and excellent at descending, similar in nature to Gan Sui but non-toxic, and far less potent. Its bitter-descending nature can expel phlegm-fluids overflowing into the lungs, driving them down rapidly. Thus, it can share the role with Zhe Shi to replace Gan Sui.
If one still fears the potency of such modified Da Xian Xiong Tang, I have another self-formulated replacement: Dang Xiong Tang (Chest-Sweeping Decoction) found in the Medical Formulas section. This Dang Xiong Tang contains neither Gan Sui nor Da Huang. Used to replace Da Xian Xiong Tang, it invariably produces immediate results. Therefore, I dare to record it in this book for the medical community.