大黄（六两去皮） 芒硝（一升） 甘遂（一钱）
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。
成氏明理论云。结胸由邪在胸中。处身之高分。邪结于是。宜若可汗。然所谓结者。若绑定之结。不能分解者也。
诸阳受气于胸中。邪气与阳气相结。不能分解。气不通。壅于心下。为硬为痛。是邪正固结于胸中。非虚烦膈实之所同。
是须攻下之物可理。低者举之。高者陷之。以平为止。结胸为高邪陷下以平之。故治结胸曰陷胸汤。甘遂味苦寒。苦性
泄。寒胜热。虽曰泄热。而甘遂又若夫间之遂。直达之气。陷胸破结。非直达者不能透。是以甘遂为君。芒硝味咸寒。
内经曰咸味下泄为阴。又曰咸以软之。气坚者以咸软之。热胜者。以寒消之。是以芒硝为臣。大黄味苦寒。将军也。荡
涤邪寇。除去不平。将军之功也。陷胸涤热。是以大黄为使。利药之中。此为驶剂。伤寒错恶。结胸为甚。非此汤则不
能通利。大而数少。取其迅疾。分解结邪。此奇方之制也。
琥按上成氏云。甘遂若夫间之遂。考周礼。凡治野。夫间有遂。注云。自一夫至千夫之田。为遂沟洫浍。所以通水
于川。遂者。通水之道也。广深各三尺曰遂。则是甘遂乃通水之要药。陷胸汤中以之为君。乃知结胸证。非但实热。此
系水邪结于心下故也。或问水邪从何而来。余答云。足太阳本寒水之经。其邪正盛于表。医人反误下之。邪因内陷。斯
时水气。即随经而入。况邪热郁于胸中。其上蒸之气。亦可成水。所以陷胸汤丸用甘遂葶苈。非究心医道者。不能识其
奥义也。
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。（此言结胸证。亦有不因误下而成者。如伤
寒六七日。邪热传里。填实胸中。脉沉而紧。紧固为伤寒之脉。然其脉不浮。则知紧非外来之寒矣。夫沉为在里。紧为
痛为实。今心下痛。按之其硬如石。故脉沉而紧也。成注云。与大陷胸汤以下结热。或问脉沉紧。焉知非寒实结胸。余
答云。胸中者。阳气之所聚也。邪热当胸而结。直至心下。石硬且痛。则脉道不但沉紧。甚至有伏而不见者。医人乌可
以脉沉紧为非热也。大抵辩结胸之法。但当证书。最为有准。）
（附后例）伤寒十余日。热结在里。复往来寒热者。（云云至）此为水结在胸胁也。但头微汗出者。大陷胸汤主之。
（此条系少阳证。后虽用大陷胸汤。要其人水结胸胁。胸胁者。少阳部分也。正文与注俱见后第七卷少阳篇中）
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。（日晡所句内台方议作日晡所发义甚通。重发汗。谓大发汗也。晡。日加申时也。太阳病重发汗。而复下
之。内外津液俱亡。邪热里结。以故不大便五六日。舌上燥渴。日晡潮热。少腹硬满。全是阳明府实之证。止日晡时。
所有潮热甚小。且从心胸之间。下至少腹。手不可近而痛。乃知其病为太阳结胸。兼阳明里实证。成注所云。一腹之中。
上下邪气皆盛是也。故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。（此言结胸证。有大小之分也。小结胸。结在心下。不
比大结胸之高在心间。且下至少腹也。按之则痛。比大结胸之不按亦痛较轻也。大结胸虽有浮脉。必兼沉紧。此则脉浮
而但滑。成注云。知热未深结也。故与小陷胸汤。以涤胸中结热。）
以上三味药。用水六升。先煮大黄，取药液二升。滤去药渣。加入芒硝，再煮一两沸。加入甘遂末。温服一升。若得迅速通利大便。停止后续服用。
成无己在《明理论》中说。结胸病是因为邪气停留在胸中。位置处于身体的上部。邪气结聚于此。按理似乎可以用发汗法。然而所谓的“结”，就像绑紧的绳结。无法分解一样。
诸阳经之气汇聚于胸中。邪气与阳气相互结聚。不能分离。气机不通畅。壅滞于心下。导致心下硬满疼痛。这是邪气与正气牢固结聚于胸中。不同于虚烦或膈实证。
因此必须使用攻下的药物来治疗。低陷的病证用升提法。高位的病证用陷下法。以平复为度。结胸是高位的邪气。用陷下法使其平复。所以治疗结胸称为陷胸汤。甘遂味苦性寒。苦能泄降。寒能胜热。虽然说是泄热。但甘遂又像是田间沟渠中的水道。直达气分。陷胸破结。不是直达之药不能透达。因此以甘遂为君药。芒硝味咸性寒。
《内经》说咸味下泄属阴。又说咸能软坚。气机坚硬的用咸味来软化它。热盛的用寒凉来消除它。因此以芒硝为臣药。大黄味苦性寒。被称为将军。荡涤邪寇。除去不平。这是将军的功效。陷胸涤热。因此以大黄为使药。在泻下药中。这是峻猛的方剂。伤寒病情错杂恶劣。结胸最为严重。不用此汤就不能通利。药量大而味数少。取其迅疾。分解结聚的邪气。这是奇方的制法。
琥按：上述成无己说。甘遂像田间的沟渠水道。考察《周礼》。凡是治理田野。每夫之间有条遂。注解说。从一夫到千夫的田地。修筑遂、沟、洫、浍。用来将水通向河流。遂是通水的道路。宽深各三尺称为遂。那么甘遂就是通水的重要药物。大陷胸汤中以它为君药。就知道结胸证。不仅仅是实热。这是水邪结聚在心下所致。有人问水邪从何而来。我回答说。足太阳膀胱经本属寒水之经。其邪气正盛于体表。医生反而误用下法。邪气因此内陷。此时水气。就随经脉而入体内。况且邪热郁结在胸中。其上蒸之气。也可以化为水。所以陷胸汤和丸剂中使用甘遂、葶苈子。不是潜心研究医道的人。不能识得其奥妙义理。
伤寒病程六七天。结胸热实证。脉象沉而紧。心下疼痛。按压如石头般坚硬者。用大陷胸汤主治。（这里说的是结胸证。也有不是因误下而形成的。如伤寒六七天。邪热传入里部。填实胸中。脉象沉而紧。紧脉固然是伤寒的脉象。然而脉不浮。就知道紧脉并非外来的寒邪。沉脉主在里。紧脉主痛主实。现在心下痛。按压坚硬如石。所以脉象沉而紧。成无己注解说。用大陷胸汤来攻下结聚的热邪。有人问脉象沉紧。怎么知道不是寒实结胸。我回答说。胸中是阳气聚集的地方。邪热结聚在胸中。直至心下。坚硬且痛。那么脉道不但沉紧。甚至有伏匿不见的情况。医生怎么能因为脉沉紧就认为不是热证呢。大概辨别结胸的方法。只要依据症状。最为准确。）
（附后文例子）伤寒十余日。热邪结聚在里。又出现往来寒热的症状。（云云至）这是水邪结聚在胸胁。只有头部微微出汗者。用大陷胸汤主治。（这一条属于少阳证。后来虽用大陷胸汤。关键在于其人水邪结聚胸胁。胸胁是少阳经所主的部位。正文与注释均见于后第七卷少阳篇中）
太阳病。重发汗。又再次攻下。五六天不大便。舌上干燥而渴。傍晚时分有轻微潮热。从心下直到小腹。硬满且疼痛。不可触碰者。用大陷胸汤主治。（关于“日晡所”一句，《台方议》作“日晡所发”解释非常通达。重发汗。指大发汗。晡。是申时。太阳病重发汗。又再次攻下。内外津液都耗亡。邪热结聚在里。因此五六天不大便。舌燥口渴。傍晚潮热。少腹硬满。完全是阳明腑实证的征象。只是傍晚时的潮热很轻微。且从心胸之间。下到小腹。手不可近而痛。才知道病是太阳结胸。兼有阳明里实证。成无己注解说。一腹之中。上下邪气皆盛。因此给予大陷胸汤来攻下邪气。）
小结胸病。正在心下。按压才痛。脉象浮滑者。用小陷胸汤主治。（这里说的是结胸证。有大小之分。小结胸。结聚在心下。不像大结胸那样高位在心间。且下至少腹。按压才痛。比大结胸的不按也痛要轻。大结胸虽有浮脉。必兼沉紧。此则脉浮而仅见滑脉。成无己注解说。知道热邪未深结。因此给予小陷胸汤。来涤除胸中结聚的热邪。）
Rhubarb (Da Huang, peeled, six liang) Mirabilite (Mang Xiao, one sheng) Kansui (Gansui, one qian)
The above three herbs. Use six sheng of water. First decoct Rhubarb to obtain two sheng of liquid. Remove the dregs. Add Mirabilite and boil for one or two boils. Add powdered Kansui. Take one sheng warm. If rapid purgation occurs, stop subsequent doses.
Cheng Wuji stated in his *Ming Lilun* (Theory of Clarification): Jie Xiong (Chest Binding Syndrome) occurs because pathogenic factors remain in the chest. The location is at the high part of the body. Pathogenic factors bind here. It might seem appropriate to use diaphoresis (sweating method). However, what is meant by "binding" is like a tied knot. It cannot be untied.
The Qi of all Yang meridians gathers in the chest. Pathogenic factors and Yang Qi bind together. They cannot separate. Qi mechanism becomes blocked. It stagnates in the epigastrium. Leading to hardness and pain in the epigastrium. This is pathogenic factors and healthy Qi firmly bound in the chest. It is not the same as empty irritability or fullness in the diaphragm.
Therefore, purgative substances must be used to treat it. For sinking conditions, lift them. For high conditions, sink them. Aim for normalization. Jie Xiong is high pathogenic factors; use sinking method to normalize it. Thus, treating Jie Xiong is called Xian Xiong Tang (Chest-Sinking Decoction). Kansui is bitter and cold. Bitterness drains downward. Cold overcomes heat. Although it is said to drain heat, Kansui is like the drainage ditch between fields. It reaches the Qi directly. To sink the chest and break binding, only direct-reaching drugs can penetrate. Therefore, Kansui is the Sovereign herb. Mirabilite is salty and cold.
The *Neijing* states that salty flavor drains downward and belongs to Yin. It also states that salt softens hardness. For rigid Qi, use salty flavor to soften it. For excess heat, use cold to eliminate it. Therefore, Mirabilite is the Minister herb. Rhubarb is bitter and cold. It is called the General. It sweeps away pathogenic invaders. Removing imbalance. This is the merit of the General. To sink the chest and drain heat, Rhubarb is the Envoy herb. Among purgative medicines, this is a potent formula. In Shang Han (Cold Damage), pathological conditions are complex and severe. Jie Xiong is the most severe. Without this decoction, unblocking cannot occur. Large dosage but few ingredients. To take advantage of swiftness. To decompose bound pathogenic factors. This is the formulation of a unique prescription.
Hu notes: Cheng Wuji said above that Kansui is like the field drainage ditch. Examining the *Zhou Li*: Whenever managing fields, there is a Su (drainage ditch) between every fu (unit of land). The commentary says: From one fu to a thousand fu of fields, Su, Gou, Xu, and Kuai are constructed to channel water into rivers. Su is the path for water flow. Width and depth of three chi constitute a Su. Thus, Kansui is an essential herb for draining water. In Da Xian Xiong Tang (Major Chest-Sinking Decoction), it is used as the Sovereign herb. It is known that Jie Xiong syndrome is not merely excess heat. This is water pathogenic factors binding in the epigastrium. One asks: Where does the water pathogenic factor come from? I answer: The Foot-Taiyang Bladder Meridian naturally belongs to cold water. Its pathogenic factors are vigorous on the exterior. Physicians mistakenly use purgation. Pathogenic factors therefore sink inward. At this time, water Qi enters along the meridian. Moreover, if pathogenic heat stagnates in the chest, its steaming Qi can also transform into water. Therefore, Gansui and Lepidium Seed (Tinglizi) are used in Xian Xiong Tang and Wan (Pills). Only those who devote themselves to medical Dao can recognize its profound meaning.
In Shang Han disease, after six or seven days, Jie Xiong Heat-Excess syndrome presents with deep and tight pulse. Pain in the epigastrium, hard as stone upon palpation. Da Xian Xiong Tang is indicated. (This refers to Jie Xiong syndrome. There are cases not caused by mistaken purgation. For example, after six or seven days of Shang Han, pathogenic heat transmits to the interior, filling the chest. Pulse is deep and tight. Tight pulse is indeed characteristic of Shang Han. However, since the pulse is not floating, it is known that the tightness is not external cold. Deep indicates interior. Tight indicates pain and excess. Now, epigastric pain, hard as stone upon pressure, hence the pulse is deep and tight. Cheng's commentary says: Use Da Xian Xiong Tang to purge bound heat. One asks: How do we know deep and tight pulse is not Cold-Excess Jie Xiong? I answer: The chest is where Yang Qi gathers. Pathogenic heat binds in the chest, reaching down to the epigastrium. Hardness and pain mean the pulse vessel may not only be deep and tight, but even hidden and invisible. How can physicians consider deep and tight pulse as non-heat? Generally, the method for distinguishing Jie Xiong is to rely on symptoms, which is most accurate.)
(Attached later example): Shang Han for more than ten days. Heat binds in the interior. Recurrent alternating chills and fever occur. (etc.) This is water binding in the chest and hypochondrium. Only slight sweating on the head. Da Xian Xiong Tang is indicated. (This clause belongs to Shaoyang syndrome. Although Da Xian Xiong Tang is used later, the key is water binding in the chest and hypochondrium. Chest and hypochondrium are the domains of Shaoyang. The main text and commentary are found in Volume Seven, Shaoyang Chapter.)
Taiyang disease. After heavy sweating, followed by purgation. No bowel movement for five or six days. Dry tongue with thirst. Slight tidal fever in the late afternoon. From the epigastrium to the lower abdomen, hardness, fullness, and pain. Intolerable to touch. Da Xian Xiong Tang is indicated. (Regarding the phrase "late afternoon", *Taifang Yi* interprets it as "onset in the late afternoon," which is very logical. Heavy sweating means massive sweating. Bu refers to Shen hour (3-5 PM). Taiyang disease with heavy sweating and subsequent purgation causes loss of fluids inside and out. Pathogenic heat binds in the interior. Hence no bowel movement for five or six days, dry tongue and thirst, late afternoon tidal fever, lower abdominal hardness and fullness. These are entirely signs of Yangming Fu Excess syndrome. Only the tidal fever in the late afternoon is slight. And from the heart/chest area down to the lower abdomen, pain intolerable to touch. It is known that the disease is Taiyang Jie Xiong combined with Yangming Interior Excess syndrome. Cheng's commentary says: In one abdomen, pathogenic factors are abundant both above and below. Therefore, give Da Xian Xiong Tang to purge the pathogenic factors.)
Xiao Jie Xiong Bing (Minor Chest Binding Disease). Located exactly in the epigastrium. Pain only upon palpation. Floating and slippery pulse. Xiao Jie Xiong Tang (Minor Chest-Sinking Decoction) is indicated. (This refers to Jie Xiong syndrome having major and minor distinctions. Minor Jie Xiong binds in the epigastrium. Unlike Major Jie Xiong which is high in the chest and extends to the lower abdomen. Pain only upon palpation is milder than Major Jie Xiong where pain exists without palpation. Major Jie Xiong may have floating pulse, but must combine with deep and tight. Here, the pulse is floating and merely slippery. Cheng's commentary says: Knowing heat has not deeply bound. Therefore, give Xiao Jie Xiong Tang to cleanse bound heat in the chest.)