细考本汤证显属阳明，其由太阳传来者居多，不必定由误下所致。盖太阳发汗不畅，表证虽罢，而宿水积浊，留恋膈上，又加阳明之燥热，闭结于下，炎炎上熏，致湿浊凝为痰涎，欲吐不能，故胸闷特甚。细考其完全见证，厥为发热，不恶寒，但恶热，面目赤，喉中有痰声，痰粘而稠，苦咯之不出。胸闷之外，甚者微痛，不欲饮，即饮而不多，脉大而实，大便三日以上未行，苔黄腻，不咳者多，其胁或痛或不痛。故必用甘遂，方能祛膈间之浊痰，必用硝黄，方能除上炎之阳热，若但用硝黄，不用甘遂，则湿浊上据，下热得其掩护，将不肯去。否则，徒以白虎清之，则釜底之薪火未除，热无由减；徒以温胆化之，则平淡之药力嫌轻，痰无由化。若汗之，则更不合，所谓清之不愈，汗之不解，于是转为白疒咅之变，而所谓湿温之病成矣。
以上所论结胸之证，似犹为结胸之一式，若伤寒论所言结胸，其义更广。大论曰：伤寒六七日，结胸热实，脉沉而紧，心下痛，按之石鞕者，大陷胸汤主之。此结胸之以心下石鞕为主证者也。又曰：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。此结胸之以胸胁水结为主证者也。又曰：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，从心下至少腹鞕满，而痛不可近者，大陷胸汤主之。此以少腹痛为主证者也。若是诸式结胸，吾信本汤皆能疗之，与五苓散之治水，能治水之壅在下焦者，亦能治水之壅及中焦者，更能治水之壅及上焦者，实有异曲同工之妙。
大论本汤方下云：右三味，以水六升，先煮大黄，取二升，去滓，内芒硝，煮一二沸，内甘遂末，温服一升，得快利，止后服。至吾师之用本方，病者常将三药同煎，不分先后，亦不用末，服后每致呕吐痰涎，继而腹中作痛，痛甚乃大便下，于是上下之邪交去，而病可愈。窃按甘遂用末和服，其力十倍于同量煎服，吾师常用制甘遂钱半同煎，以治本证。若改为末，量当大减，切要切要。甘遂服后之反应，互详下列悬饮案。
陆渊雷按云：结胸既由误下而得，复以大陷胸汤峻下。舒驰远既疑之，铁憔先生亦谓大陷胸不可用。太炎先生云：结胸有恶涎，此有形之物，非徒无形之热也。非更以下救下，将何术哉？然江南浙西妄下者少，故结胸证不多见，而大陷胸汤之当否，亦无由目验也。吾昔在浙中，见某署携有更夫。其人河北人也，偶患中风，遽饮皮硝半盌，即大下，成结胸。有扬州医以大陷胸下之，病即良已，此绝无可疑者。按以下救误下，是犹将计就计，良工之谋，奚用疑为？故每读医书，辄佩太炎先生之伟论，非无因也。
先贤余听鸿云：泰兴太平洲王姓妇，始而发热不甚，脉来浮数，舌苔薄白，因其发热，投以二陈苏叶等，其舌即红而燥，改投川贝桑叶等，其舌又白。吾师兰泉见其舌质易变，曰：此证大有变端，使其另请高明。王姓以为病无所苦，起居如常，谅无大患。后延一屠姓医诊之，以为气止两虚，即服补中益气两三剂，愈服愈危，至六七剂，即奄奄一息，脉伏气绝。时正酷暑，已备入木。吾师日：王氏与吾世交，何忍袖手，即往视之。见病人仰卧正寝，梳头换衣，备入木矣。
吾师偕余细视，面不变色，目睛上反，唇色尚红，其形似未至死。后将薄纸一张，盖其口鼻，又不见鼓动。气息已绝，按脉亦绝。吾师左右踌躇，曰：未有面色不变，手足尚温而死者！后再按其足上太冲太溪，其脉尚存。曰：未有见足脉尚存，而手脉已绝者，必另有别情，即将其衣解开，按其膻中，石硬而板重。力按之，见病人眉间皮肉微动，似有痛若之状。吾师曰：得矣，此乃大结胸之证也！非水非痰，是补药与热邪搏结而成，医书所未载也。即书大黄一两，芒硝三钱，厚朴三钱，枳实三钱，莱菔子一两，瓜蒌皮一两，先煎枳朴莱蒌，后纳大黄滤汁，再纳芒硝滤清。将病人牙关挖开，用竹著两只，插入齿中，将药汁渐渐灌入，自午至戌，方尽一剂。至四更时，病人已有气息，至天明，稍能言语，忽觉腹中大痛。
吾师日：病至少腹矣，当再服原方半剂，腹大痛不堪，下燥矢三十余枚，而痛即止。后调以甘凉养胃。（录《诊余集》）按此乃大陷胸证之变局，大陷胸汤之活用，神而明之，竟能起九死于一生，为医者不当若是乎！吾师自治本案用大陷胸汤得效，其后屡屡用之，率奏奇功。余尝亲见，师家一房客，母女三人患病相似，师疏大陷胸汤与之，令三人合饮，次日均廖。夫以此告人，人能信之乎？
曹颖甫曰：太阳之传阳明也，上湿而下燥。燥热上熏，上膈津液悉化粘痰。
承气汤能除下燥，不能去上膈之痰。故有按之不硬之结胸，惟大陷胸汤为能彻上下而除之。原不定为误下后救逆之方治也。治病者亦观其通焉可耳。
【又按】王季寅先生作《同是泻药》篇曰：民十八四月某日，狂风大作，余因事外出，当时冒风，腹中暴疼。余夙有腹疼病，每遇发作，一吸阿芙蓉，其疼立止。不料竟不见效，服当归芍药汤加生军一剂，亦不应。时已初更，疼忽加剧，家人劝延针医。余素拒针，未允所请。至午夜，疼如刀绞，转侧床头，号痛欲绝。无何，乃饮自己小便一盅，始稍安。已而复作，状乃如前。黎明家人已延医至矣。遂针中脘，以及各穴，凡七针。行针历五小时，痛始止。据该医云，腹部坚硬如石，针虽止疼一时，而破坚开结，非药不克奏功。因拟顺气消导之方。
余不欲服，家人再三怂恿，勉进一剂，病不稍减。翌日，家人仍欲延前医。余坚辞曰：余腹坚硬如石，决非顺气化痰所能奏效，惟大承气或可见功，因自拟生军三钱，枳实二钱，厚朴三钱，芒硝五分。服后，时许，下积物甚多，胸腹稍畅。
次日，胸腹仍觉满闷硬疼，又进二剂，复下陈积数次。元气顿形不支，因改服六君子汤三剂。后元气稍复，而胸腹满疼，仍自若也。更服大承气二剂，不惟疼痛丝毫未减，腹中满硬如故，而精神衰惫，大有奄奄欲毙之势。因念攻既不任，补又不可，先攻后补，攻补兼施，其效犹复如此。生命至是，盖已绝望矣！谈次，忽忆伤寒小结胸病，正在心下，按之始痛，大结胸则从心下至少腹硬满，不待按，即痛不可近。余之初病，即胸腹坚硬如石，号痛欲绝者，得毋类是？惟大结胸以大陷胸汤为主治，此汤之药仅大黄、芒硝、甘遂三味。硝黄余已频服之矣。其结果既如上述，加少许甘遂，即能却病回生耶？兴念及此，益旁皇无以自主。既思病势至此，不服药即死，服之或可幸免，遂决计一试。方用生军二钱，芒硝五分，甘遂末一分。药既煎成，亲友群相劝阻，余力排众议，一饮而尽。服后，顿觉此药与前大不相同，盖前所服硝黄各剂，下嚥即觉药力直达少腹，以硝黄之性下行最速故也。今服此药，硝黄之力竟不下行，盘旋胸腹之间，一若寻病者然。逾时，忽下黑色如棉油者碗许，顿觉胸中豁朗，痛苦大减。四五剂后，饮食倍进，精神焕发。古人所谓用之得当，虽硝黄亦称补剂者，于斯益信。惟此汤与大承气汤，只一二味出入，其主治与效力有天渊之别，经方神妙，竟有令人不可思议者矣！嗣又守服十余剂，病已去十分之九，本可不药而愈。余狃于前服此汤，有利无弊，更服一剂，以竟全功。讵药甫下咽，顿觉心如掀，肺如捣，五藏鼎沸，痛苦不可名状。亟以潞参一两，黄耆五钱，饴糖半茶杯，连服二剂，始安。余深奇同是泻药，初服硝黄，则元气徒伤，继加甘遂，则精神反形壮旺。故详述颠末，而为之记。（录《医界春秋》）细按本篇实有无上之价值。何者？病人服医者之药，每不能详言服后之变化，惟有医者服自疏之药，乃能体察周详，言之有物。观王先生之言，今服大陷胸后，硝黄之力竟不下行，盘旋胸腹之际，一若寻病者然。可谓一言发千古之秘，胜于后世注家之书，徒以空谈为依归者！此实验之所以可贵也。
曹颖甫曰：药不由于亲试，纵凭思索理解，必有一间未达之处。予昔服生附子，一身麻痹，至于洞泄秽浊之水，不能自禁，久乃沈沈睡去，比觉，而二十余日之泄泻竟尔霍然。若夫大陷胸汤，予但知令上隔湿痰，并中下燥矢俱去耳，且甚不解下后之更用硝黄，今观王君自记，始知硝黄与甘遂同煎，硝黄之性即与甘遂化合，而为攻治上膈湿痰之用，固不当失之毫厘也！
大陷胸汤证其二
袁茂荣六月十九日病延一月，不饥不食，小便多而黄，大便阙，但转矢气，脉形似和，藏无他病，下之当愈，上膈有湿痰，宜大陷胸汤。
生川军五钱后入制甘遂二钱先煎元明粉三钱冲
【按】有名袁茂荣者，南京人，年四十四，以卖面为业，其面摊即设上海民国路方浜桥顺泰当铺前人行道旁。体素健，今年六月间忽病，缠绵床第者达一月之久，更医已屡，迄未得效。胸闷异常，不能食，两旬不得大便，一身肌肉尽削，神疲不能起床。半月前，胯间又起跨马疽，红肿疼痛，不能转侧，至是有如千斤重量负系其间。自问病笃，无可为已。曰：有能与我竣剂剧药者，虽死，无怨也！史君惠甫与茂荣居相近，怜其遇，慨然邀师诊。师至，按脉察证，曰：此易耳。
不能食者，湿痰阻于上隔也。不大便者，燥矢结于大肠也，湿痰阻于上者，我有甘遂以逐之。燥矢结于下者，我有硝黄以扫之。一剂之后，大功可期，勿虑也。故师径用大陷胸汤如上载，但嘱服初煎一次已足。
茂荣以经营为生，性甚敏悟，虽不明医理，顾知此为剧药，必难下咽。因俟药汁稍凉，闭目凝睫，满欲一口而尽饮之。但药汁气味过烈，勉啜二口，辄不能续进，余其小半而罢。服后，呕出浓痰，且觉药力直趋腹部，振荡有声，腹痛随作，欲大便者三四次。卒无所下。至夜三鼓，腹痛更剧，乃下燥矢五六枚，随以溏粪。据云矢粪积于纸制香烟匣中，满二匣。予尝诘之曰：何不用便桶耶？曰：际此衰疲之时，尚有何能力起床耶？况家无长物，故权假烟匣作便桶耳。予为之莞尔。
翌早，茂荣一觉醒来，方入妙境。向之胸闷如窒者，今则渐趋清明，昨之腹痛如绞者，今则忽转敉平。而胯间之疽亦崩溃而脓出，重痛大除，盖内证愈而外疽无所附丽也。于是思食，能进粥一碗。喜悦之情无以复加，盖其与粥饭绝缘者，已一月有余，不意得重逢时也。后溃疽由西医调治十日，即告收功，不劳吾师之再诊矣。茂荣性情诚恳，而言语滑稽，予与惠甫崇景曾共访之，故知其病情稔。
夫大陷胸汤号称峻剂，世人罕用之，抑亦罕闻之，而吾师则能运之若反掌，抑亦何哉？曰：此乃四十年临诊之功，非骤可得而几也。苟强求之，非惟画虎不成，类犬贻讥，而人命之责实重也。予尝谓仲圣方之分类，若以其峻否别之，当作为三大类。第一类为和平方，补正而可去邪者也。姑举十方以为例：则桂枝汤、白虎汤、小柴胡汤、理中汤、小建中汤、炙甘草汤、吴茱萸汤、小青龙汤、五苓散，当归芍药散等是。若是诸汤证，遇之屡，而辨之易，故易中而无伤。第二类为次竣方，去邪而不伤正者也。并举十方以为例：则麻黄汤、大承气汤、大柴胡汤、四逆汤、麻黄附子细辛汤、大建中汤、大黄牡丹皮汤、桃核承气汤、葛根芩连汤、麻杏甘石汤等是。若是诸汤证亦遇屡而辨易，但当审慎以出之，为其不中则伤正也。第三类乃为竣方，是以救逆为急，未免伤正者也。举例以明之：则大陷胸汤、十枣汤、三物白散、瓜蒂散、乌头汤、皂夹丸、葶苈大枣泻肺汤、甘草半夏汤，甘草粉蜜汤，抵当汤等是。若是诸汤证，遇之较鲜，而辨之准确。用之而中，已有伤正之虞，不中，即有坏病之变，可不畏哉？佐景侍师数载，苦心钻研，于第一类和平方幸能施用自如，于第二类次峻方则必出之以审慎，亦每能如响斯应，独于第三类峻方，犹不敢曰能用。即遇的证，亦必请吾师重诊，方敢下药。此乃治医者必经之途径，不必讳饰。是故医士有能用第一类方，而不能用第二类，第三类方者，有能用第一类第二类方，而不能用第三类方者，未闻有能用第三类方，而不能用第一类第二类方者也。然则今有初学医者焉，毫无用方经验，见本案大陷胸汤证，惊其神而识其效，越日，偶遇一证，与本证相似，乃遽投以重剂大陷胸汤，可乎？看知其未可也。是故治医之道，法当循序而渐进，切勿躐等以求功。多下一分苦工夫，方增一分真本事。阅者能体斯旨，方为善读书者。
曹颖甫曰：世人读仲景书，但知太阳误下成结胸，乃有大陷胸汤证，而不知未经误下，实亦有结胸一证，而宜大陷胸汤者。夫伤寒六七日，热实，脉沈紧，心下痛，按之石鞕，及伤寒十余日，热结在里，无大热，此为水结在胸胁，二条皆示人以未经误下之结胸，读者自不察耳。予谓太阳传阳明之候，上湿而下燥，苟肠中燥火太重，上膈津液化为粘痰，结胸之病根已具，原不待按之石鞕，然后定为结胸证。即水结在胸胁，胸中但见痞闷，而不觉痛者，何尝非结胸证也，此方予十年来验案甚多，一时不能追忆，暇时当检出之，以供快览。
桃核承气汤证其一
仔细考察本汤证，明显属于阳明病范畴，其中由太阳病传变而来的占大多数，并不一定是因为误用下法所致。大概是因为太阳病发汗不彻底，虽然表证已解，但体内宿有的水饮和积滞的浊气留恋在膈上，再加上阳明经的燥热之气，闭结于下部，火热之气炎炎向上熏蒸，导致湿浊凝聚成痰涎，想要呕吐却吐不出来，所以胸闷特别严重。仔细考察其完整的症状表现，主要是发热，不怕冷，只怕热，面色发红，喉咙里有痰鸣声，痰液粘稠而稠厚，痛苦地咳吐却吐不出来。除了胸闷之外，严重的甚至伴有轻微疼痛，不想喝水，即使喝也喝不多，脉象大而有力，大便三天以上没有排便，舌苔黄腻，大多不咳嗽，两胁部位有时痛有时不痛。因此必须使用甘遂，才能祛除膈间浑浊的痰涎；必须使用芒硝和大黄，才能清除上炎的阳热。如果只用芒硝和大黄，而不使用甘遂，那么湿浊就会占据上部，下部的热邪得到掩护，就不会消退。否则，仅仅用白虎汤来清热，则锅底下的柴火未除，热量无从减少；仅仅用温胆汤来化解，则药力过于平淡嫌轻，痰涎无从化解。如果用发汗法，就更不合适了，这就是所谓的清热治不好，发汗解不了，于是转变为痞证的变局，从而形成了所谓的湿温病。
以上所论述的结胸证，似乎只是结胸的一种类型，若《伤寒论》中所说的结胸，其含义更广。《伤寒论》说：伤寒六七天，结胸热实证，脉象沉而紧，心下疼痛，按上去像石头一样硬的，用大陷胸汤主治。这是以心下坚硬如石为主要表现的结胸证。又说：伤寒十多天，热邪结滞在体内，又出现往来寒热的症状，给与大柴胡汤；如果是单纯的结胸，身体没有大热，这是水邪结聚在胸胁，只有头部微微出汗的，用大陷胸汤主治。这是以胸胁水结为主要表现的结胸证。又说：太阳病，重发汗后又误用下法，五六天不大便，舌面干燥且口渴，傍晚时分有轻微的潮热，从心下直到小腹硬满，并且疼痛得不能靠近，用大陷胸汤主治。这是以少腹疼痛为主要表现的结胸证。对于这些各种类型的结胸证，我相信本方（指大陷胸汤）都能治疗，就像五苓散治疗水饮病，既能治疗水饮壅滞在下焦的情况，也能治疗水饮壅滞在中焦的情况，更能治疗水饮壅滞在上焦的情况，确实有异曲同工之妙。
《伤寒论》本方方剂条文下记载：右三味药，用水六升，先煮大黄，取二升药汁，去掉药渣，加入芒硝，煮一两次沸腾，再加入甘遂末，温服一升，如果得到快速通利，就停止后服。到了我的老师使用本方时，病人通常将三味药一起煎煮，不分先后顺序，也不使用粉末，服用后往往导致呕吐出痰涎，接着腹部开始疼痛，疼痛剧烈后才排出大便，于是上下之邪气一同去除，病就可以痊愈。我私下认为甘遂研末冲服，其药效是同等剂量煎服的十倍，我的老师常用制甘遂一钱半同煎，来治疗本证。如果改为研末服用，剂量应当大幅减少，切记切记。甘遂服用后的反应，详见下列悬饮医案。
陆渊雷按语说：结胸既然因为误用下法而得病，又用大陷胸汤峻猛攻下。舒驰远对此表示怀疑，铁樵先生也说大陷胸汤不可用。太炎先生说：结胸有恶心的痰涎，这是有形之物，不仅仅是无形的热邪。如果不继续用下法来救误下之失，还有什么办法呢？然而江南浙西地区妄用下法的医生很少，所以结胸证不多见，大陷胸汤是否恰当，也没有机会亲眼验证。我以前在浙江中部，见过某官府带有一个更夫。这个人是河北人，偶然患上中风，立刻喝了半碗皮硝（芒硝），结果导致严重腹泻，形成了结胸。有一位扬州医生用大陷胸汤攻下，病情立即好转，这绝对没有什么可怀疑的。按照用下法来补救误下，这就像是将计就计，是高明医生的谋略，为什么要怀疑呢？所以我每次读医书，总是钦佩太炎先生的伟大言论，这不是没有原因的。
先贤余听鸿说：泰兴太平洲王姓妇女，起初发热不是很厉害，脉象浮数，舌苔薄白，因为她发热，投以二陈汤加紫苏叶等药物，她的舌头随即变得红而干燥，改投川贝母、桑叶等药物，她的舌头又变回白色。我的老师兰泉看到她的舌质容易变化，说：这个病症大有变端，让她另外请高明医生诊治。王姓家属认为病人没什么痛苦，起居如常，想必没有大碍。后来延请一位屠姓医生诊治，认为是气血两虚，就服用补中益气汤两三剂，越吃越危险，到六七剂时，气息奄奄，脉搏隐伏，气息断绝。当时正值酷暑，已经准备好棺材入殓。我的老师说：王氏与我家世代交好，怎么忍心袖手旁观，于是前往探视。看见病人仰卧在正厅，梳头换衣，准备入殓。
我和老师一起仔细查看，面色没有改变，眼睛向上翻，嘴唇颜色还红，形态看起来还没到死亡的地步。后来拿一张薄纸盖在口鼻上，又不见鼓动。气息已经断绝，切脉也摸不到脉搏。老师左右犹豫，说：从来没有面色不变，手脚还温暖而死的人！再切她足上的太冲穴和太溪穴，脉搏还存在。说：从来没有见到足部脉搏还在，而手部脉搏已绝的，必定另有别情，于是解开她的衣服，按压膻中穴，感觉坚硬而且板重。用力按压，看见病人眉间皮肉微动，似乎有痛苦的样子。老师说：明白了，这是大结胸证啊！不是水饮也不是痰饮，是补药与热邪搏结而成的，医书上没有记载。于是开具大黄一两，芒硝三钱，厚朴三钱，枳实三钱，莱菔子一两，瓜蒌皮一两，先煎枳实、厚朴、莱菔子、瓜蒌皮，后纳入大黄滤出汁液，再纳入芒硝滤清。将病人牙关撬开，用两根竹箸插入齿中，将药汁慢慢灌入，从中午到晚上戌时，才喝完一剂。到四更天时，病人已有呼吸，到天亮，稍微能说话，忽然觉得腹部剧烈疼痛。
老师说：病势已到少腹了，应当再服原方的一半，腹部剧烈疼痛难忍，排出干硬粪便三十多枚，疼痛随即停止。后来用甘凉药物调理养胃。（录自《诊余集》）按此乃大陷胸证的变局，大陷胸汤的灵活运用，神妙莫测，竟然能起死回生，作为医者不应当这样吗！我的老师自己治疗本案用大陷胸汤见效，之后屡屡使用，都奏效奇功。我曾经亲眼见到，老师家一个房客，母女三人患病相似，老师开具大陷胸汤给她们，让三人合在一起喝，第二天就好了。拿这个告诉别人，有人相信吗？
曹颖甫说：太阳病传变到阳明病，上面湿下面燥。燥热向上熏蒸，上膈的津液全部化为粘痰。
承气汤能除去下部的燥结，不能去除上膈的痰涎。所以有按之不硬的结胸，只有大陷胸汤能彻上下而消除它。原本不一定是误下后挽救逆证的方剂。治病的人也要观察其通达之处就可以了。
【又按】王季寅先生作《同是泻药》一文说：民国十八年四月某天，狂风大作，我因事外出，当时冒风，腹中突然剧痛。我向来有腹痛病，每次发作，吸一口阿芙蓉，疼痛立即停止。不料这次竟然无效，服用当归芍药汤加生大黄一剂，也不见效。当时已是初更，疼痛忽然加剧，家人劝请针灸医生。我向来拒绝针灸，没有答应请求。到了午夜，疼痛如刀绞，在床上辗转反侧，号哭疼痛欲绝。不久，就喝了自己的一盅小便，才稍微安定。过后又发作，状况如同之前。黎明时家人已经请来了医生。于是针刺中脘穴，以及其他穴位，共七针。行针历时五小时，疼痛才停止。据该医生说，腹部坚硬如石，针虽然暂时止痛，但要破坚开结，非药物不能奏效。于是拟定顺气消导的方剂。
我不想服用，家人再三怂恿，勉强进服一剂，病情没有丝毫减轻。第二天，家人仍想请前一位医生。我坚决推辞说：我腹部坚硬如石，绝对不是顺气化痰所能奏效的，只有大承气汤或许能见效，于是自行拟定生大黄三钱，枳实二钱，厚朴三钱，芒硝五分。服用后，一个时辰左右，排出很多积滞物，胸腹稍微通畅。
第二天，胸腹仍然觉得满闷硬疼，又进服两剂，再次排出陈旧积滞物数次。元气顿时显得支撑不住，于是改服六君子汤三剂。后来元气稍恢复，但胸腹满疼，依然如故。又服大承气汤两剂，不仅疼痛丝毫未减，腹中满硬依旧，而且精神衰惫，大有奄奄一息将要死亡的气势。心想攻既不能承受，补又不可以，先攻后补，攻补兼施，效果还是如此。生命到了这种地步，大概已经绝望了！谈话之间，忽然想起伤寒小结胸病，正在心下，按之才痛，大结胸则是从心下直到小腹硬满，不待按压，即疼痛得不能靠近。我最初的病，就是胸腹坚硬如石，号哭疼痛欲绝的，难道类似这种情况吗？惟独大结胸以大陷胸汤为主治，此方的药物仅大黄、芒硝、甘遂三味。芒硝和大黄我已经频繁服用了。其结果既然如上所述，加上少许甘遂，就能驱除疾病起死回生吗？想到这些，更加彷徨无法自主。既然想到病势到了这种地步，不服药就是死，服药或许可以侥幸免于一死，于是决定试一试。方用生大黄二钱，芒硝五分，甘遂末一分。药煎好后，亲友群起劝阻，我极力排除众议，一饮而尽。服用后，顿时觉得此药与前次大不相同，大概前所服的芒硝大黄各剂，咽下就觉得药力直达少腹，因为芒硝大黄药性下行最快。现在服用此药，芒硝大黄的力量竟然不下行，盘旋在胸腹之间，好像寻找病灶一样。过了一段时间，忽然排出黑色如棉油状的一碗左右，顿时觉得胸中豁然开朗，痛苦大减。四五剂后，饮食倍增，精神焕发。古人所谓用药得当，即使是芒硝大黄也称为补剂，于此更加相信。惟独此汤与大承气汤，只有一两味药的出入，其主治与效力有天壤之别，经方神妙，竟有令人不可思议的地方啊！随后又守方服用十余剂，病去十分之九，本来可以不药而愈。我拘泥于前次服此汤，有利无弊，又服一剂，以完成全功。岂料药刚咽下，顿时觉得心如掀翻，肺如捣碎，五脏鼎沸，痛苦不可名状。急忙用潞党参一两，黄芪五钱，饴糖半茶杯，连服两剂，才安定。我深深奇怪同样是泻药，初次服用芒硝大黄，则元气徒然受伤，继而又加甘遂，则精神反而显得壮旺。所以详细叙述始末，并为此作记。（录自《医界春秋》）仔细分析本篇实在具有极高的价值。为什么呢？病人服用医生开的药，往往不能详细讲述服用后的变化，惟有医生服用自己开的药，才能体察周详，言之有物。看王先生说的话，现在服用大陷胸汤后，芒硝大黄的力量竟然不下行，盘旋在胸腹之际，好像寻找病灶一样。可以说是一句话道出千古秘密，胜过后世注家的书籍，那些只以空谈为依据的人！这就是实验的可贵之处。
曹颖甫说：药不经过亲自尝试，纵然凭借思索理解，必有一处未能通达的地方。我以前服用生附子，全身麻痹，以至于腹泻污浊之水，不能自禁，许久才沉沉睡去，醒来后，二十多天的腹泻竟然霍然痊愈。至于大陷胸汤，我只知道它能令上膈湿痰，连同中下部的燥屎一并去除，而且很不理解下法之后还要用芒硝大黄，现在看王君自己的记录，才知道芒硝大黄与甘遂同煎，芒硝大黄的药性就与甘遂化合，成为攻治上膈湿痰的作用，确实不能失之毫厘啊！
大陷胸汤证其二
袁茂荣六月十九日发病延续一个月，没胃口不想吃东西，小便多且黄，大便不通，只是放屁，脉象看似平和，脏腑没有其他毛病，用下法应当痊愈，上膈有湿痰，宜用大陷胸汤。
生大黄五钱后下 制甘遂二钱先煎 元明粉三钱冲服
【按】有个叫袁茂荣的人，南京人，四十四岁，以卖面为业，他的面摊就设在上海民国路方浜桥顺泰当铺前的人行道旁。身体一向健康，今年六月间忽然生病，缠绵病榻长达一个月之久，更换多位医生，始终未见效。胸闷异常，不能进食，二十天没有大便，全身肌肉消瘦，神疲乏力不能起床。半个月前，胯间又长出跨马疽，红肿疼痛，不能翻身，到现在感觉像千斤重物束缚在那里。自认为病重，无可救药。说：如果有能给我峻烈药剂的，即使死了，也没有怨言！史惠甫先生与茂荣住得近，怜悯他的遭遇，慷慨邀请老师诊治。老师到达，切脉察证，说：这很容易治。
不能进食，是因为湿痰阻滞在上膈。不大便，是因为燥屎结在大肠。湿痰阻滞在上，我有甘遂来驱逐它。燥屎结在下，我有芒硝大黄来清扫它。一剂之后，大功可期，不必忧虑。所以老师直接按上述处方使用大陷胸汤，只嘱咐服用初煎一次就够了。
茂荣以经营为生，性格非常聪敏悟性高，虽然不懂医理，但知道这是峻烈药物，一定难以下咽。于是等药汁稍凉，闭上眼睛凝神，打算一口喝尽。但药汁气味过于猛烈，勉强喝了两口，就不能再继续喝，剩下小半部分就停止了。服用后，呕出浓痰，且觉得药力直趋腹部，振荡有声，腹痛随之发生，想大便三四次。最终没有排泄出来。到了半夜三更，腹痛更剧烈，才排出干硬粪便五六枚，随后是稀粪。据他说粪便积在纸质香烟盒里，满了两个盒子。我曾问他：为什么不用便桶呢？他说：在这种衰弱疲惫的时候，还有什么力气起床呢？况且家里没有多余的东西，所以暂借烟盒作便桶罢了。我为之莞尔。
第二天早上，茂荣一觉醒来，仿佛进入美妙境界。之前的胸闷如窒塞，现在逐渐趋向清明，昨天的腹痛如绞，现在忽然转为平静。而胯间的疽疮也溃破流脓，沉重疼痛大大消除，大概是内证好了，外疽就没有依附了。于是想吃东西，能吃下一碗粥。喜悦之情无以复加，大概他与粥饭绝缘，已经一个多月了，没想到能重逢。后来溃烂的疽疮由西医调治十天，就宣告治愈，不需要劳烦老师再诊治了。茂荣性情诚恳，言语滑稽，我与惠甫曾共同拜访他，所以了解他的病情很熟悉。
大陷胸汤号称峻剂，世人很少使用，也很少听说，而我的老师却能运用自如，为什么呢？回答说：这是四十年的临诊功夫，不是短时间内可以达到的。如果强行追求，不仅画虎不成反类犬被人讥笑，而且人命责任重大。我曾说仲景方剂的分类，如果以其峻烈程度来区分，应当分为三大类。第一类是和平方，补正气而能祛邪气的。姑举十方为例：桂枝汤、白虎汤、小柴胡汤、理中汤、小建中汤、炙甘草汤、吴茱萸汤、小青龙汤、五苓散、当归芍药散等是。对于这类汤证，遇到多次，辨识容易，所以容易中病而不伤正。第二类是次峻方，祛邪气而不伤正气的。并举十方为例：麻黄汤、大承气汤、大柴胡汤、四逆汤、麻黄附子细辛汤、大建中汤、大黄牡丹皮汤、桃核承气汤、葛根芩连汤、麻杏甘石汤等是。对于这类汤证也是遇到多次而辨识容易，但应当审慎使用，因为如果不中病则会伤正。第三类才是峻方，是以挽救逆证为急务，未免会伤正气。举例说明：大陷胸汤、十枣汤、三物白散、瓜蒂散、乌头汤、皂荚丸、葶苈大枣泻肺汤、甘草半夏汤、甘草粉蜜汤、抵当汤等是。对于这类汤证，遇到较少，而辨识需要准确。使用而中病，已有伤正的担忧，不中病，就有坏病的变局，能不敬畏吗？佐景侍奉老师数年，苦心钻研，对于第一类和平方幸能施用自如，对于第二类次峻方则必出于审慎，也每每能如响斯应，唯独对于第三类峻方，还不敢说能用。即使遇到确切的证候，也必须请老师重新诊察，才敢下药。这是学医者必经的途径，不必掩饰。所以医生有用第一类方，而不能用第二、第三类方的，有用第一、第二类方，而不能用第三类方的，没听说过有用第三类方，而不能用第一、第二类方的。那么现在有初学医者，毫无用方经验，看到本案大陷胸汤证，惊叹其神奇而认识其疗效，过几天，偶然遇到一个证，与本证相似，就贸然投以重剂大陷胸汤，可以吗？看来是不可以的。所以治医之道，应当循序渐进，切勿超越等级以求功效。多下一分苦工夫，才增一分真本事。读者能体会这个宗旨，才是善于读书的人。
曹颖甫说：世人读仲景书，只知道太阳病误下形成结胸，才有大陷胸汤证，而不知道未经误下，实际上也有结胸一证，而适宜用大陷胸汤的。比如伤寒六七日，热实，脉沉紧，心下痛，按之石硬，以及伤寒十多天，热结在里，无大热，这是水结在胸胁，这两条都示人以未经误下的结胸，读者自然没有察觉罢了。我认为太阳传阳明的候象，上面湿下面燥，如果肠中燥火太重，上膈津液化为粘痰，结胸的病根已经具备，原本不一定等到按之石硬，然后定为结胸证。即使是水结在胸胁，胸中只见痞闷，而不觉痛的，何尝不是结胸证呢，此方我十年来验案很多，一时不能回忆，空闲时当检出来，供快速阅览。
桃核承气汤证其一
Carefully examining this decoction's syndrome, it clearly belongs to the category of Yangming disease (Yangming disease), most of which are transmitted from Taiyang disease (Taiyang disease), and do not necessarily result from erroneous purgation. Generally speaking, because sweating for Taiyang disease was incomplete, although the exterior syndrome has resolved, the pre-existing water retention and accumulated turbid qi linger in the diaphragm region. Coupled with the dry-heat of the Yangming channel, which is closed and bound in the lower part, the blazing heat flares upward, causing damp-turbidity to condense into phlegm-saliva. The patient desires to vomit but cannot, resulting in severe chest tightness. Examining the complete manifestations, the primary symptoms are fever, aversion to cold absent but aversion to heat present, redness of the face and eyes, rattling sound of phlegm in the throat, sticky and thick sputum that is painful to expectorate. Besides chest tightness, severe cases may have slight pain, lack of desire to drink or drinking little even if they do, a pulse that is large and forceful, no bowel movement for over three days, yellow and greasy tongue coating, mostly no cough, and occasional or non-existent hypochondriac pain. Therefore, Kansui Root (Radix Kansui) must be used to dispel the turbid phlegm in the diaphragm; Mangxiao and Dahuang (Rhei Radix et Rhizoma) must be used to clear the flaming Yang heat. If only Mangxiao and Dahuang are used without Kansui, the damp-turbidity will occupy the upper part, and the lower heat will be shielded, refusing to dissipate. Otherwise, merely using Baihu Decoction (White Tiger Decoction) to clear heat is like removing the firewood from under the pot without extinguishing the flame, so the heat cannot decrease; merely using Wendan Decoction (Warm Gallbladder Decoction) to resolve phlegm is too mild, and the phlegm cannot transform. Using sweating methods is even more inappropriate; this is what is meant by "clearing fails to cure, sweating fails to resolve," leading to a transformation into Pi Syndrome (Stagnation Syndrome), thereby forming the so-called Damp-Warmth disease.
The above discussion on Jie Xiong (Chest Binding) syndrome seems to describe only one type of Jie Xiong. If we consider the Jie Xiong mentioned in *Shanghan Lun* (Treatise on Cold Pathogenic Diseases), its meaning is broader. *Shanghan Lun* states: In Taiyang disease lasting six or seven days, if there is Jie Xiong with heat and excess, a deep and tight pulse, pain in the epigastrium, and hardness upon palpation like a stone, Da Xianxiong Decoction (Major Sinking the Chest Decoction) is indicated. This is the type of Jie Xiong characterized by epigastric hardness like a stone. It also states: After ten-plus days of Taiyang disease, if heat is bound internally and there is alternating chills and fever, give Chaihu Da Xiong Decoction (Bupleurum Major Purgative Decoction); if it is pure Jie Xiong without significant external heat, this indicates water binding in the chest and hypochondrium; if only the head sweats slightly, Da Xianxiong Decoction is indicated. This is the type of Jie Xiong characterized by water binding in the chest and hypochondrium. It further states: In Taiyang disease, after heavy sweating followed by erroneous purgation, if there is no bowel movement for five or six days, a dry tongue with thirst, slight afternoon tidal fever, hardness and fullness from the epigastrium down to the lower abdomen, and pain so severe it cannot be touched, Da Xianxiong Decoction is indicated. This is the type of Jie Xiong characterized by lower abdominal pain. For all these types of Jie Xiong, I believe this decoction can treat them, just as Wuling San (Five-Ingredient Powder with Poria) treats water retention, managing water accumulation in the Lower Jiao (Lower Burner), Middle Jiao (Middle Burner), and Upper Jiao (Upper Burner). There is indeed a similarity in different approaches achieving the same result.
Under the formula instructions for this decoction in *Shanghan Lun*, it says: Take the three ingredients above, add six sheng of water, first boil Dahuang until two sheng remain, remove the dregs, add Mangxiao, boil for one or two boils, then add Kansui powder, take one sheng warm. Stop subsequent doses once rapid purgation occurs. When my teacher uses this formula, patients usually decoct all three herbs together without sequence, and do not use powder. After ingestion, vomiting of phlegm-saliva often occurs, followed by abdominal pain. Only when the pain becomes severe does stool pass, allowing pathogenic factors from above and below to be expelled, curing the disease. I privately note that Kansui taken as powder has ten times the potency of the same dose decocted. My teacher commonly uses processed Kansui (Zhi Gansui) at 1.5 qian decocted together to treat this syndrome. If changed to powder, the dosage should be significantly reduced; this is crucial. The reaction to Kansui is detailed in the following Case of Fluid Retention in the Hypochondrium (Xuan Yin).
Lu Yuanlei notes: Since Jie Xiong results from erroneous purgation, using Da Xianxiong Decoction for harsh purgation again raises doubts. Shu Chiyuan questioned this, and Tieqiao also stated Da Xianxiong Decoction should not be used. Taiyan said: Jie Xiong involves foul phlegm, a tangible substance, not just formless heat. Without using purgation to remedy the previous erroneous purgation, what other method is there? However, in Jiangnan and Western Zhejiang, erroneous purgation is rare, so Jie Xiong syndromes are uncommon, and the appropriateness of Da Xianxiong Decoction lacks clinical verification. Previously in central Zhejiang, I knew a night watchman employed by a government office. He was from Hebei and accidentally suffered from stroke-like symptoms. He immediately drank half a bowl of Pinxiao (Mangxiao), resulting in severe diarrhea and forming Jie Xiong. A doctor from Yangzhou treated him with Da Xianxiong Decoction, and he recovered immediately. This is undeniable. Using purgation to correct erroneous purgation is like playing along with the opponent's strategy, a tactic of skilled physicians; why doubt it? Thus, every time I read medical texts, I admire Taiyan's profound insights, which are well-founded.
The late expert Yu Tinghong recorded: A woman surnamed Wang from Taiping Zhou, Taixing, initially had mild fever, a floating and rapid pulse, and a thin white tongue coating. Due to her fever, she was given Erchen Tang (Two-Aged Decoction) with Zi Su Ye (Perilla Leaf). Her tongue turned red and dry. Switching to Chuan Bei Mu (Fritillaria Bulb) and Sang Ye (Mulberry Leaf) made her tongue white again. My teacher Lanquan, seeing the fluctuating tongue quality, said: This syndrome has major potential for change; advise her to seek another physician. The Wang family thought the patient suffered little discomfort and maintained normal routine, believing no serious harm would occur. Later, a doctor surnamed Tu diagnosed Qi and Blood deficiency and prescribed Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) for two or three doses. The condition worsened with each dose. By the sixth or seventh dose, she was near death, with a hidden pulse and absent breath. It was midsummer, and coffins were prepared. My teacher said: The Wang family are old friends; how could I stand idly by? I went to visit. The patient lay supine in the main hall, hair combed and clothes changed, ready for burial.
My teacher and I examined her closely. Her complexion was unchanged, eyes rolled up, lips still red; she did not appear dead. We placed a thin paper over her mouth and nose, observing no movement. Breath and pulse were undetectable. My teacher hesitated, saying: I have never seen someone die with an unchanged complexion and warm extremities! Checking the Taichong and Taixi pulses on the feet, pulses were still present. He said: I have never seen foot pulses present while hand pulses are absent; there must be another explanation. Unbuttoning her clothes, he pressed the Danzhong point (CV17), finding it hard and rigid. Upon firm pressure, he saw slight movement in her brow muscles, indicating pain. He said: I understand now. This is a Great Jie Xiong syndrome! It is neither fluid nor phlegm, but a binding of tonic herbs and heat pathogens, unrecorded in medical books. He prescribed Dahuang (Rhei Radix et Rhizoma) 1 liang, Mangxiao (Natrii Sulfas) 3 qian, Houpo (Magnolia Bark) 3 qian, Zhishi (Immature Bitter Orange) 3 qian, Laifuzi (Radish Seed) 1 liang, and Gualou Pi (Trichosanthes Peel) 1 liang. First decoct Zhishi, Houpo, Laifuzi, and Gualou Pi, then add Dahuang and filter the juice, finally add Mangxiao and filter clear. Pry open the patient's jaw, insert two bamboo chopsticks between the teeth, and slowly pour in the medicine. From noon to Xu hour (7-9 PM), one dose was consumed. By the fourth watch (1-3 AM), the patient breathed; by dawn, she could speak slightly, then suddenly experienced severe abdominal pain.
My teacher said: The pathogen has moved to the lower abdomen. Administer half a dose of the original formula. Severe abdominal pain ensued, followed by the passage of over thirty hard fecal pellets, after which the pain ceased. Subsequently, nourish the stomach with sweet-cool herbs. (Recorded in *Zhenyu Ji*) Note: This is a variant of the Da Xianxiong syndrome. The flexible application of Da Xianxiong Decoction is miraculous, rescuing life from the brink of death. Should not physicians strive for such efficacy? My teacher achieved success with Da Xianxiong Decoction in this case and used it repeatedly with remarkable results. I personally witnessed his tenant, a mother and daughter, suffering similar illnesses. He prescribed Da Xianxiong Decoction for them to share. They recovered the next day. Would people believe this if told?
Cao Yingfu stated: When Taiyang transmits to Yangming, dampness is above and dryness below. Dry-heat flares upward, transforming fluids in the upper diaphragm into sticky phlegm. Chengqi Decoctions can remove lower dryness but cannot eliminate upper diaphragmatic phlegm. Therefore, for Jie Xiong where palpation reveals no hardness, only Da Xianxiong Decoction can thoroughly resolve both upper and lower aspects. It is not solely a rescue formula for post-purgation complications. Physicians must observe the overall pattern.
[Additional Note] Mr. Wang Jiyin wrote "Both Are Purgatives": On a certain day in April of the 18th year of the Republic, strong winds blew. I went out for business, exposed to wind, and suffered sudden severe abdominal pain. I had a chronic abdominal pain condition; usually, inhaling opium stopped the pain instantly. This time it failed. One dose of Danggui Shaoyao Tang (Angelica and Peony Decoction) plus raw Dahuang also failed. By the first watch, pain intensified. Family urged acupuncture, but I refused. By midnight, pain felt like knife-twisting; I rolled on the bed, crying in agony. Soon, I drank a cup of my own urine, providing slight relief. Pain returned later. At dawn, a doctor arrived. Seven needles were applied to Zhongwan (CV12) and other points. Needling lasted five hours before pain ceased. The doctor reported the abdomen was hard as stone; while needles provided temporary relief, breaking hardness required medication. A Qi-regulating and digestion-promoting formula was prescribed.
I refused to take it. Persuaded by family, I took one dose with no improvement. The next day, family wanted the same doctor. I declined firmly, stating my abdomen was hard as stone; only Dachengqi Tang (Major Order the Qi Decoction) might work. I self-prescribed raw Dahuang 3 qian, Zhishi 2 qian, Houpo 3 qian, and Mangxiao 0.5 fen. After one shichen (2 hours), much stagnation was expelled, and chest/abdomen felt slightly freer.
The next day, chest/abdomen remained full, hard, and painful. Two more doses were taken, expelling old accumulations several times. Vital energy weakened significantly, so I switched to Liujunzi Tang (Six-Gentlemen Decoction) for three doses. Vital energy recovered slightly, but chest/abdominal fullness and pain persisted. Two more doses of Dachengqi Tang were taken. Pain remained unchanged, abdomen remained hard and full, and spirit became exhausted, nearing death. Thinking that attacking was intolerable and tonifying impossible, and that sequential or combined attack-tonification failed, I despaired. Suddenly recalling that minor Jie Xiong is at the epigastrium and hurts only on pressure, while major Jie Xiong extends from epigastrium to lower abdomen with hardness and untouchable pain, I realized my initial symptoms matched major Jie Xiong. Da Xianxiong Decoction is the treatment, containing only Dahuang, Mangxiao, and Kansui. I had already taken Mangxiao and Dahuang with poor results. Would adding a little Kansui cure me? Hesitant, yet realizing death awaited without medicine, I decided to try. Formula: Raw Dahuang 2 qian, Mangxiao 0.5 fen, Kansui powder 0.1 fen. Relatives advised against it, but I drank it. Immediately, the effect differed greatly from previous doses. Previously, Mangxiao/Dahuang acted quickly on the lower abdomen. Now, their power stayed in the chest/abdomen, searching for the pathology. After some time, about a bowl of black, cotton-oil-like material was passed. Chest felt clear, pain greatly reduced. After four or five doses, appetite doubled, spirit revived. The ancients' claim that proper use makes Mangxiao/Dahuang tonic-like is confirmed here. Though differing from Dachengqi Tang by only one or two herbs, the effects are vastly different. The mystery of classical formulas is inconceivable! I continued for over ten doses, curing 90%. Believing it harmless due to prior success, I took one more dose to finish. Immediately upon swallowing, heart churned, lungs pounded, five zang boiled with indescribable pain. I urgently took Ludongshen (Codonopsis) 1 liang, Huangqi (Astragalus) 5 qian, and Yitang (Maltose) half a teacup for two doses to stabilize. I marveled that both are purgatives: initial Mangxiao/Dahuang damaged vital energy, but adding Kansui strengthened spirit. I record this fully. (Recorded in *Yijie Chunqiu*) This article has immense value. Patients cannot detail post-medication changes, but physicians taking their own prescriptions can observe meticulously. Mr. Wang's observation that Mangxiao/Dahuang power stays in the chest/abdomen searching for pathology reveals ancient secrets, surpassing empty commentaries. This is the value of experimentation.
Cao Yingfu stated: Without personal trial, understanding remains incomplete. I once took raw Fuzi (Aconite Lateralis Radix Preparata), causing whole-body numbness and uncontrollable diarrhea of foul water, followed by deep sleep. Upon waking, my twenty-day diarrhea vanished. Regarding Da Xianxiong Decoction, I only knew it removes upper diaphragmatic damp-phlegm and middle/lower dry feces. I did not understand why Mangxiao/Dahuang were used after purgation. Reading Mr. Wang's account, I learned that decocting Mangxiao/Dahuang with Kansui combines their properties to target upper diaphragmatic damp-phlegm. Precision is essential!
Da Xianxiong Decoction Syndrome II
Yuan Maorong fell ill on June 19th, continuing for a month. No hunger, no eating, frequent yellow urine, constipation, only passing gas. Pulse seemed harmonious, internal organs otherwise healthy. Purging should cure. Upper diaphragm has damp-phlegm; Da Xianxiong Decoction is suitable.
Raw Dahuang 5 qian added later; Processed Kansui 2 qian decocted first; Yuan Ming Fen (Mangxiao) 3 qian dissolved in liquid.
[Note] Yuan Maorong, 44, from Nanjing, sold noodles. His stall was on the sidewalk in front of Shuntai Pawnshop, Fangbang Bridge, Min Guo Road, Shanghai. He was usually healthy but fell ill in June, bedridden for a month despite multiple doctors. Severe chest tightness, inability to eat, no bowel movement for 20 days, emaciated, weak, unable to rise. Half a month ago, a carbuncle appeared in the groin, red, swollen, painful, limiting movement, feeling like a thousand-pound weight. Feeling hopeless, he said: Whoever gives me a strong medicine, I accept death without complaint. Shi Huifu, living nearby, pitied him and invited my teacher. Teacher examined pulse and signs, saying: Easy to treat.
Inability to eat is due to damp-phlegm blocking the upper diaphragm. Constipation is due to dry feces bound in the large intestine. For damp-phlegm above, I have Kansui to drive it out. For dry feces below, I have Mangxiao and Dahuang to sweep them away. One dose promises great success; do not worry. So, the teacher prescribed Da Xianxiong Decoction as listed, instructing only the first decoction be taken.
Maorong, being sharp-witted though unversed in medicine, knew this was a strong medicine and difficult to swallow. Waiting for the liquid to cool, he closed his eyes and intended to drink it in one gulp. But the odor was too pungent; after two sips, he could not continue, leaving half unfinished. After ingestion, he vomited thick phlegm, felt the medicine rush to the abdomen with gurgling sounds, and abdominal pain started. He tried to defecate three or four times but failed. By the third watch (11 PM - 1 AM), pain worsened, then he passed five or six hard stools followed by loose stool. He claimed the feces filled two cigarette boxes. I asked: Why not use a chamber pot? He replied: In this weak state, how could I get up? And we have no spare items, so I borrowed cigarette boxes. I smiled.
Next morning, Maorong woke up feeling wonderful. The previous chest oppression cleared; the previous twisting pain subsided. The groin carbuncle ruptured and drained pus, relieving heavy pain, as internal healing allowed external sores to resolve. He desired food and ate a bowl of porridge, overjoyed after a month of fasting. The carbuncle healed after ten days of Western medical care, requiring no further attention from my teacher. Maorong was sincere and humorous. Shi Huifu and I visited him, knowing his condition well.
Da Xianxiong Decoction is known as a harsh agent, rarely used or heard of by the public, yet my teacher uses it effortlessly. Why? This is forty years of clinical experience, not achievable overnight. Forcing it leads to failure and ridicule, endangering lives. I classify Zhongjing's formulas into three categories based on harshness. Category 1: Harmonizing formulas (e.g., Guizhi Tang, Baihu Tang, Xiaochaihu Tang, Lizhong Tang, Xiao Jianzhong Tang, Zhi Gancao Tang, Wuzhuyu Tang, Xiao Qinglong Tang, Wuling San, Danggui Shaoyao San). These are easy to identify and safe. Category 2: Moderately harsh formulas (e.g., Mahuang Tang, Dachengqi Tang, Chaihu Daxiong Tang, Sini Tang, Mahuang Fuzi Xixin Tang, Da Jianzhong Tang, Dahuang Mudanpi Tang, Taohe Chengqi Tang, Gegen Qinlian Tang, Maxing Gan Shi Tang). These require caution to avoid damaging healthy Qi. Category 3: Harsh formulas (e.g., Da Xianxiong Tang, Shizao Tang, Sanwu Baisan, Gouti San, Wutou Tang, Zaojia Wan, Tingli Dazao Xiefei Tang, Gancao Banxia Tang, Gancao Fenmi Tang, Didang Tang). These are for emergency rescue, risking damage to healthy Qi. Encounters are rare, diagnosis must be precise. Correct use risks damage; incorrect use causes deterioration. One must fear these. Having studied under my teacher for years, I master Category 1, apply Category 2 cautiously, but dare not claim mastery of Category 3. Even with accurate diagnosis, I consult my teacher before prescribing. This is the necessary path for physicians. Some can use Category 1 but not 2 or 3; some can use 1 and 2 but not 3; none can use 3 without mastering 1 and 2. Therefore, a novice seeing this case and imitating it with a rash prescription of Da Xianxiong Tang is inadvisable. Medicine requires gradual progress. Hard work builds true skill. Readers who grasp this are good students.
Cao Yingfu stated: People reading Zhongjing only know Taiyang erroneous purgation causes Jie Xiong treated by Da Xianxiong Tang, ignoring that Jie Xiong exists without erroneous purgation. The passages regarding Taiyang disease with heat/excess/deep-tight pulse/epigastric pain/hardness, and Taiyang disease with internal heat/water binding, show Jie Xiong without prior error. Readers overlook this. I posit that in Taiyang transmitting to Yangming, upper dampness and lower dryness create sticky phlegm from excessive intestinal dry-heat. The root of Jie Xiong is established without needing epigastric hardness. Even chest fullness without pain can be Jie Xiong. I have many verified cases over ten years, which I will publish later.
Taohé Chengqi Tang Syndrome I