大黄（六两去皮苦寒） 芒硝（一升咸寒） 甘遂（一钱苦寒）
上三味以水六升。先煮大黄、取二升。去滓。内芒硝。煮一两沸。内甘遂末。温服
一升。得快利。止后服。
大黄谓之将军。以苦荡涤。芒硝一名硝石。以其咸能 硬。夫间有遂以通水也。
甘遂若夫间之遂。其气可以直达透结。陷胸三物为允。
王宇泰云。低者举之。高者陷之。以平为正。结胸为高邪。陷下以平之。故曰陷胸。
利药之中。此驶剂也。伤寒错恶。结胸为甚。非此不能通利。剂大而数少。须其迅速。
分解邪结也。
朱丹溪云。此证经曰胃中空虚。曰短气、躁烦。曰脉浮。此汤不可轻用。
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。
病在表而下之。热入。因作结胸。此不云下后。而云伤寒六七日。则是传里之实热
也。沉为在里。紧为里实。以心下痛。按之实硬。是以为结胸。与大陷胸汤以下结热。
张兼善云。经言所以成结胸者。以下之太早故也。此不云下后。则云伤寒六七日。结
胸热实。此亦不因下早而结胸者何也。夫下早结胸。事之常。热实结胸。事之变。其热
实传里为结胸。乃法之关防不尽者。故仲景述其证以注方于其下也。此可见古人用心。曲
尽其妙。且如下章以水结胸胁。但头汗出者。以大陷胸汤主之。亦在常法之外。故条列
其证以彰其理也。亦或其人本虚。或曾吐下而
里气弱。外邪因入。故自为结胸者也。然所入之因不同。其证治则一理而已。
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。
伤寒十余日。热结在里。是可下之证。复往来寒热。为正邪分争。未全敛结。与大
柴胡汤下之。但结胸无大热者。非热结也。是水饮结于胸胁。谓之水结胸。周身汗出者。
是水饮外散则愈。若但头微汗出。余处无汗。是水饮不得外泄。停蓄而不行也。与大陷
胸汤。以逐其水。
活人云。水结胸。小半夏加茯苓汤。小柴胡去牡蛎汤。亦主之。
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。
重发汗而复下之。则内外重亡津液。而邪热内结。致不大便五六日。舌上燥而渴也。
日晡潮热者。属胃。此日晡小有潮热。非但在胃。从心下至少腹。硬满而痛。不可近者。
是一腹之中。上下邪气俱甚也。与大陷胸汤。以下其邪。
小结胸病。正在心下。按之则痛。脉浮滑者。小陷胸汤主之。
心下硬痛。手不可近者。结胸也。正在心下。按之则痛。是热气犹浅。谓之小结胸。
结胸脉沉紧。或寸浮关沉。今脉浮滑。知热未深结。与小陷胸汤。以除胸膈上结热也。
王宇泰云。上文云硬满而痛。不可近者。是不待按而亦痛也。此云按之则痛。是手
按之。然后作痛耳。上文云。至少腹是通一腹而言之。此云正在心下。则少腹不硬痛可
知矣。热微于前。故云小结胸也。
Da Huang (Rhei Radix et Rhizoma, six liang, peeled, bitter and cold) Mang Xiao (Natrii Sulfas, one sheng, salty and cold) Gan Sui (Kansui Radix, one qian, bitter and cold)
The above three herbs are boiled in six sheng of water. First, boil Da Huang to obtain two sheng of decoction. Remove the dregs. Add Mang Xiao. Boil for one or two boils. Add the powder of Gan Sui. Take one sheng warm. If rapid purgation occurs, stop taking the remaining medicine.
Da Huang is called the General. Its bitter nature can purge and cleanse. Mang Xiao, also known as Xiao Shi, has a salty nature that can soften hardness. Gan Sui acts like a dredger to unblock water flow. Its qi can reach directly through the obstruction. The three ingredients of Da Xianxiong Tang are well-matched.
Wang Yutai said: "For pathogens low down, lift them; for pathogens high up, sink them. Balance is the correct principle. Jie Xiong is a pathogen at a high level. Use sinking methods to balance it. Hence it is called Xianxiong."
Among purgative formulas, this is a harsh agent. Among the complications of Shanghan, Jie Xiong is the most severe. Without this formula, unblocking cannot be achieved. The dosage is large but taken infrequently. It must act rapidly to resolve the pathogenic accumulation.
Zhu Danxi said: Regarding this syndrome, the Classics state the stomach cavity is empty. Symptoms include shortness of breath, irritability, and a floating pulse. This formula should not be used lightly.
In Shanghan after six or seven days, presenting with Jie Xiong heat-excess syndrome, with a deep and tight pulse, pain in the epigastrium, and hardness upon palpation like stone, Da Xianxiong Tang is indicated.
When the disease is in the exterior and purgatives are mistakenly used, heat enters inward, resulting in Jie Xiong. Here, it does not mention post-purgation, but states "Shanghan six or seven days," indicating transmitted interior excess heat.
A deep pulse indicates interior location; a tight pulse indicates interior excess. With pain in the epigastrium and hardness upon palpation, it is diagnosed as Jie Xiong. Da Xianxiong Tang is given to purge the accumulated heat.
Zhang Jianshan said: The Classics state that Jie Xiong forms because purgatives were used too early. Here, it does not mention post-purgation, but states "Shanghan six or seven days" with Jie Xiong heat-excess syndrome. Why does this form Jie Xiong without early purgation? Early purgation leading to Jie Xiong is the common occurrence; heat-excess Jie Xiong is the variation. When heat-excess transmits to the interior forming Jie Xiong, it represents a gap in standard protocol application. Thus, Zhongjing describes the syndrome to annotate the formula below. This shows the meticulous care of the ancients. For example, in the next chapter, regarding water binding in the chest and hypochondrium with only head sweating, Da Xianxiong Tang is indicated, which is also outside common protocols. Therefore, the syndromes are listed to clarify the principles. Perhaps the person was originally deficient, or had experienced vomiting/purgation weakening interior qi, allowing external pathogens to enter and form Jie Xiong independently. Although the causes of entry differ, the treatment principles remain consistent.
In Shanghan after ten-plus days, with heat bound in the interior and alternating chills and fever, Da Chaihu Tang is given. If only Jie Xiong exists without significant fever, this is water binding in the chest and hypochondrium. If only slight head sweating occurs, Da Xianxiong Tang is indicated.
In Shanghan after ten-plus days, heat bound in the interior is an indication for purgation. Alternating chills and fever indicate struggle between righteous and pathogenic qi, not yet fully consolidated. Da Chaihu Tang is used to purge. If only Jie Xiong exists without significant fever, it is not heat binding, but water-fluid binding in the chest and hypochondrium, termed Shui Jie Xiong. Whole-body sweating indicates water-fluid dispersing outward leads to recovery. If only slight head sweating occurs with no sweat elsewhere, water-fluid cannot disperse outward, stagnating and failing to move. Da Xianxiong Tang is given to drive out the water-fluid.
*Qin Ren Shu* states: For Shui Jie Xiong, Xiao Banxia Jia Fuling Tang and Xiao Chaihu Tang minus Mu Li are also indicated.
In Taiyang disease, after heavy sweating followed by purgation, constipation for five or six days, dry tongue with thirst, slight afternoon tidal fever, hardness, fullness, and pain from the epigastrium to the lower abdomen, intolerable to touch, Da Xianxiong Tang is indicated.
Heavy sweating followed by purgation causes severe loss of body fluids internally and externally, leading to internal binding of pathogenic heat, resulting in constipation for five or six days and a dry tongue with thirst.
Afternoon tidal fever belongs to the Stomach. This slight afternoon tidal fever is not solely in the Stomach. Hardness, fullness, and pain from the epigastrium to the lower abdomen, intolerable to touch, indicate severe pathogenic qi throughout the entire abdomen. Da Xianxiong Tang is given to purge the pathogen.
Xiao Jie Xiong Bing presents precisely at the epigastrium, pain upon palpation, with a floating and slippery pulse. Xiao Xianxiong Tang is indicated.
Hardness and pain in the epigastrium, intolerable to touch, is Jie Xiong. Pain precisely at the epigastrium only upon palpation indicates shallow heat, termed Xiao Jie Xiong.
Jie Xiong typically presents with a deep and tight pulse, or floating cun and deep guan. Now, with a floating and slippery pulse, it is known that heat has not deeply bound. Xiao Xianxiong Tang is given to remove the binding heat in the chest and diaphragm.
Wang Yutai said: The previous text mentions hardness, fullness, and pain, intolerable to touch, meaning it hurts even without pressing. This text mentions pain upon palpation, meaning pain arises only when pressed. The previous text mentions extending to the lower abdomen, referring to the whole abdomen. This text states precisely at the epigastrium, implying the lower abdomen is not hard or painful. The heat is milder than before, hence termed Xiao Jie Xiong.