足寒冷，欲吐不能吐，脉迟紧者，此寒郁结也。凡胸中寒热与气与饮郁结为病，谅非汗
下之法所能治，必得酸苦涌泄之品，因而越之，上焦得通，阳气得复，痞硬可消，胸中
可和也。瓜蒂极苦，赤豆味酸，相须相益，能疏胸中实邪，为吐剂中第一品也。而佐香豉
汁合服者，藉谷气以保胃气也。服之不吐，少少加服，得快吐即止者，恐伤胸中元气也。此
方奏功之捷，胜于汗下，所谓汗、吐、下三大法也。今人不知仲景、子和之精义，置之
不用，可胜惜哉！然诸亡血虚家，胸中气液已亏，不可轻与，特为申禁。
病发于阳，而反下之，热入因作结胸；病发于阴，而反下之，因作痞也。所以成结胸
者，以下之太早故也。
【注】此总释结胸与痞硬之因也。中风阳邪，故曰病发于阳也。不汗而反下之，热邪
乘虚陷入，因作结胸。伤寒阴邪，故曰病发于阴也。不汗而反下之，热邪乘虚陷入，因
作痞硬。所以成结胸与痞硬者，以表未解而下之太早故也。病发于阴，不言热入者，省
文耳。然病发于阳而误下者，未尝无痞硬；病发于阴而误下之，亦时成结胸。良由人之气
体不同，或从实化，或从虚化也。
【集注】张兼善曰∶风邪入里则结胸，寒邪入里则为痞。然此皆太阳病之所由来，非别阴证阳证也。
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，余处无汗，跻颈而还，小便不利，身必发黄。
【按】“数则为虚”句，疑是衍文。
【注】太阳病，脉浮而动数，浮则为风邪脉也，数则为热邪脉也，动则为诸痛脉也。头
痛发热，太阳证也。热蒸于阳，阳虚则自汗出，热蒸于阴，阴虚则盗汗出，阴虚当恶热，
今反恶寒，故知此非阴虚之盗汗，乃表未解之盗汗，微微而出也。表未解当解表，医反
下之，遂使动数之热脉变为寒迟。盖动数乃表邪欲传，因下而逆于膈中，故不传而脉亦
变也。表客阳邪，乘胃空虚，陷入胸膈而拒痛，短气不能布息，烦躁，心中懊 ，心下
因硬，径从实化而为结胸矣。法当以大陷胸汤主之。若不从实化，不成结胸，但头汗出
至颈，余处无汗，则热不得越也。小便不利，则湿不得泻也，热湿合化，故身必发黄也。
【集注】成无己曰∶动数变迟，而浮脉独不变者，以邪结胸中，上焦阳分，脉不得而沉也。
朱震亨曰∶太阳病、表未解而攻里，里已虚矣。虽见浮而动数之阳脉，一经误下，则
必变为迟阴之脉矣。胃中空虚，短气躁烦，虚之甚矣。借曰∶阳气内陷，心中因硬而可迅
攻之乎？大陷胸之力，不缓于承气，下而又下，宁不畏其重虚耶？即阳病实邪下后，若
胃中空虚，客气动膈，心中懊 者，亦以栀子豉汤吐胸中之邪可也。况太阳误下后，明有虚证乎！
按∶震亨所论治，以栀子豉汤吐之，亦是未成结胸，从胸虚有热而化者宜也。若从
胸虚有寒而化者，不论已成未成结胸，则又当从《活人书》温补法矣，不可混施也。
方有执曰∶太阳之脉本浮，动数者亦传也。太阳本自汗，而言微盗汗，本恶寒，而
言反恶寒者，稽久而然也。膈，心胸之间也。
拒，格拒也。言膈气与邪气相格拒而为痛也。客气，邪气也。短气，促气不能布息也。懊
，心为邪乱而不宁也。阳气，客气之别名也，以本外邪，故曰客气。以邪本风，故曰
阳气。以里虚因而陷入，故曰内陷。自“若不结胸”句至末，以变之轻者而言也。
大陷胸汤方
大黄（去皮，六两） 芒硝（一升） 甘遂（另碾，一钱）
上三味，以水六升，先煮大黄，取二升，去滓，纳芒硝，煮一两沸，内甘遂末，温服
一升，得快利，止后服。
【集解】方有执曰∶上焦有高邪，必陷下以平之，故曰陷胸汤。平邪荡寇，将军之职
也，以大黄为君；咸能软坚，以芒硝为臣；彻上彻下，破结逐水，以甘遂为佐；惟大实者，
乃为合法。如挟虚或脉浮，不可轻试。
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。
【注】此承上条互发其义，以详其证治也。太阳病，重发汗而复下之，津液伤矣。不大
便五六日，胃腑燥矣。舌上燥渴，胃中干也。日晡潮热，胃热盛也。从心下至少腹，硬满
而痛不可近者，谓胸腹之中上、下俱硬结实大痛，手不可近，故以大陷胸汤主之无疑也。
【集注】《内台方议》曰∶“日晡所”作“日晡所发”。
方有执曰∶此明结胸有阳明内实疑似之辨。晡，日加申时也。小有，微觉有也。盖
不大便，燥渴，日晡潮热，从心下至少腹硬满而痛，皆似阳明内热。惟小有潮热，不似
阳明大热之甚。所以阳明必以胃家实为主，而凡有一毫太阳证在，皆不得入阳明例者，亦以此也。
程知曰∶太阳结胸兼阳明内实，故用大陷胸汤，由胸胁以及肠胃，皆可荡涤无余。
若但下肠胃结热，而遗胸上痰饮，则非法矣。
吴人驹曰∶一腹之中，上、下邪气皆盛，证之全实者，其脉常沉伏，不可生疑畏，惟
下之，而脉自渐出也。
小结胸，病正在心下，按之则痛，脉浮滑者，小陷胸汤主之。
【注】大结胸，邪重热深，病从心下至少腹，硬满痛不可近，脉沉实，故宜大陷胸汤，
以攻其结，泻其热也。小结胸，邪浅热轻，病正在心下硬满，按之则痛，不按不痛，脉浮
滑，故用小陷胸汤以开其结，涤其热也。
【集注】程应旄曰∶按陷胸条曰∶“心下痛按之石硬”。又曰∶“心下满而硬痛”。此曰∶
“病正在心下”。则知结胸不拘在心下与胸上，只在痛不痛上分别，故痞证亦有心下硬者，但不痛耳。
张锡驹曰∶汤有大小之别，证有轻重之殊。今人多以小陷胸汤治大结胸证，皆致不
救，遂诿结胸为不可治之证。不知结胸之不可治，只一二节，余皆可治者，苟不体认经
旨，必致临时推诿，误人性命也。
魏荔彤曰∶小结胸无实热之邪，但微热而挟痰饮为患。故虽结胸而不能高踞胸巅，但
正在心下而已；不能实力作痛，惟按之痛而已；诊之不沉而深，惟浮而轻浅而已；不能
作石硬，惟虚而结阻而已。所以大陷胸汤不应用，而另设小陷胸汤。高下、坚软、轻重、
沉浮之间，病机治法昭然已。又云∶痞阴邪，结胸阳邪，然于阳邪中又有大小之分，学人
审之。于凡寒热杂合之证，无大实大热。俱宜斟酌下法，勿孟浪也。
小陷胸汤方
黄连（一两） 半夏（洗，半斤） 栝蒌实（大者，一枚）
上三味，以水六升，先煮栝蒌，取三升，去滓，纳诸药，煮取二升，去滓，分温三服。
【方解】黄连涤热，半夏导饮，栝蒌润燥下行，合之以涤胸膈痰热，开胸膈气结；攻
虽不峻，亦能突围而入，故名小陷胸汤。分温三服，乃缓以治上之法也。
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。
【注】伤寒表不解，误下成痞，此其常也。伤寒或有因误下而成结胸者，乃其变也。今
伤寒六七日，结胸不因误下而成此热实之证，若脉沉紧，里实脉也。心下痛，按之石硬，里
实证也。此为脉病皆实，故以大陷胸汤主之也。
【集注】喻昌曰∶“热实”二字，形容结胸之状甚明，见邪热填实于胸而不散漫也，浮
紧主伤寒无汗，沉紧主伤寒结胸，此与中风之阳邪结胸迥别，所以不言浮也。又曰∶阳
邪误下成结胸，阴邪误下成痞。然中风间有痞证，伤寒间有结胸证，又不可不知。
程应旄曰∶虽曰阳邪内陷，然“阴阳”二字从虚实寒热上区别，非从中风伤寒上区别，
表热盛实转入胃腑，则为阳明证；表热盛实不转入胃腑，而陷入于膈，则为结胸证。故
不必误下始成也。不因下而成结胸者，必其人胸有燥邪，以失汗而表邪合之，遂成里实。
观此条曰∶“伤寒六七日”，又曰∶“脉沉而紧”，则可知矣。
汪琥曰∶或问脉沉紧，焉知非寒实结胸？答曰∶胸中者，阳气之所聚也。邪热当胸而
结，直至心下，石硬且痛，则脉不但沉紧，甚至有伏而不见者，乌可以脉沉紧为非热耶？大
抵辨结胸之法，但当证书最为有准。
寒实结胸，无热证者，与三物小陷胸汤，白散亦可服。
【按】无热证之下，与三物小陷胸汤，当是“三物白散”，“小陷胸汤”四字，必是传
写之误。桔梗、贝母、巴豆三物，其色皆白，有三物白散之义，温而能攻，与寒实之理相
属∶小陷胸漏，乃栝蒌、黄连。皆性寒之品，岂可以治寒实结胸之证乎？“亦可服”三字，亦衍文也。
【注】结胸证，身无大热，口不燥渴，则为无热实证，乃寒实也，与三物白散。然此
证脉必当沉紧，若脉沉迟或证见三阴，则又非寒实结胸可比，当以枳实理中汤治之矣。
【集注】王肯堂曰∶热实结胸，及寒实结胸，《活人书》不拘寒热，但用陷胸汤，不瘥
者用枳实理中丸，即应手而愈。
方有执曰∶“寒以饮言，饮本寒也，又得水寒，两寒抟结而实于胸中，故谓无热证也。
程知曰∶结胸有大小之别，寒热之异，不得概用硝、黄也。
郑重光曰∶水寒结实在胸，则心阳被据，自非细故，用三物白散下寒而破结，皆不得已之兵也。
三物白散方
桔梗（三分） 巴豆（去皮心，熬黑，研如脂，一分） 贝母（三分）
上件二味为末，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。
【方解】是方也，治寒实水结胸证，极峻之药也。君以巴豆，极辛极烈，攻寒逐水，斩
关夺门，所到之处，无不破也；佐以贝母，开胸之结；使以桔梗，为之舟楫，载巴豆搜逐
胸邪，悉尽无余。膈上者必吐，膈下者必利。然惟知任毒以攻邪，不量强羸，鲜能善其后
也。故羸者减之，不利进热粥，利过进冷粥。盖巴豆性热，得热则行，得冷则止。不用水
而用粥者，藉谷气以保胃也。
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。
【注】伤寒十余日，热结在里，若胸胁满
硬者，此结胸也。今不满硬，复往来寒热者，乃少阳表里病，非结胸也，当与大柴胡汤两
解之。但结胸证，亦有水结者。水结胸不但表无大热，里亦无大热也。有结胸状，头微
汗出者，此水停于胸，为热气上蒸使然也。故曰水结在胸胁也。亦以大陷胸汤主之，饮热并攻也。
【集注】方有执曰∶水即饮也，以不实硬，故曰水结。胸胁亦里也，以热结不高，故曰在里。
程知曰∶此言热结于里兼少阳者，则不宜陷胸；水结于胸者，虽无大热，犹宜大陷胸也。
程应旄曰∶大柴胡与大陷胸，皆能破结。大柴胡之破结，使表分无留邪；大陷胸之破
结，使里分无留邪。
林澜曰∶此言水结胸之与热结在里不同也。十余日，邪深入腑之时，然热结在里，而
犹有半表半里之邪，作往来寒热者，必以大柴胡两解之。若但胸胁结满，初无大热，收
敛入内者，此亦不得为大柴胡证，必水结胸胁也。何以知之？水结胸者，头汗出，今但
头微汗，为水结胸明矣。与大陷胸汤。
结胸者，项亦强，如柔痉状，下之则和，宜大陷胸丸。
【注】结胸从心上至少腹，硬满痛不可近，则其势甚于下者，治下宜急攻之，以大陷胸
汤。结胸从胸上，满硬项强，如柔痉状，则其热甚于上者，治上宜缓攻之，以大陷胸丸
直攻胸肺之邪。煮服倍蜜，峻治缓行，下而和之，以其病势缓急之形既殊，汤丸之制亦
异也。故知此项强乃结胸之项强，下之则和，非柔痉之项强也。
【集注】成无己曰∶项强者，为邪结胸中，胸膈结满，但能仰而不能俯，是项强也。
程知曰∶项强如柔痉者，胸中邪气紧实，项势常昂，有似柔痉之状，然痉病身手俱张，
此但项强原非痉也，借此以验胸邪十分紧逼耳。
汪琥曰∶下之则和者，言邪实去，胸中和而项自舒之意。若不云如柔痉，恐医人认
以为太阳经风寒之邪未解，反疑其当用发汗之药。殊不知项虽强，表证已解，里证甚急，治法宜下也。
大陷胸丸方
大黄（半斤） 葶苈子（熬，半升） 芒硝（半升） 杏仁（去皮尖，熬黑，半升）
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。
结胸证，其脉浮大者，不可下，下之则死。
【注】结胸证，若脉大，是为胃实，知结热已实乃可下，下之则愈。今其脉浮大，是
尚在表，知热结未实，故不可下。若误下之，未尽之表邪复乘虚入里，误而又误，结而又
结，病热弥深，正气愈虚，则死矣。
足部发冷，想吐却吐不出来，脉象迟而紧的，这是寒邪郁结在体内。凡是胸中因寒、热、气、饮相互郁结而成的病证，想必不是发汗或攻下的方法所能治疗的，必须使用酸苦涌泄的药物，通过催吐的方法使邪气从上排出，上焦得以通畅，阳气得以恢复，痞塞硬满的症状即可消除，胸中气机得以调和。瓜蒂味道极苦，赤小豆味道酸，两者相辅相成，能够疏泄胸中的实邪，是催吐剂中的第一品药。而配合香豉汁一起服用，是借助谷气来保护胃气。服药后若不呕吐，可少量增加剂量，一旦迅速吐出就立即停药，这是担心损伤胸中的元气。此方见效之快，胜过发汗和攻下法，这就是所谓的汗、吐、下三大治法。如今的人不懂张仲景和刘河间（子和）的精妙义理，将其搁置不用，真是令人痛惜啊！然而对于各种失血或体质虚弱的人，胸中的气和液已经亏损，不可轻易给予此方，特此重申禁忌。
疾病发生在阳分（如中风），反而误用攻下法，热邪内陷因而形成结胸；疾病发生在阴分（如伤寒），反而误用攻下法，因而形成痞证。之所以形成结胸，是因为攻下太早的缘故。
【注】这是对结胸与痞硬成因的总体解释。中风属于阳邪，所以说“病发于阳”。不先发汗而反用攻下法，热邪乘虚陷入，因而形成结胸。伤寒属于阴邪，所以说“病发于阴”。不先发热而反用攻下法，热邪乘虚陷入，因而形成痞硬。之所以形成结胸与痞硬，是因为表证未解而攻下太早的缘故。疾病发生在阴分，文中没有说“热入”，是省略了文字。然而疾病发生在阳分而误用攻下法，并非不会形成痞硬；疾病发生在阴分而误用攻下法，有时也会形成结胸。这主要是由于人的体质不同，有的从实证转化，有的从虚证转化。
【集注】张兼善说：风邪入里则形成结胸，寒邪入里则形成痞证。但这都是太阳病的由来，并不是另外区分阴证和阳证。
太阳病，脉象浮而动数，浮脉主风邪，数脉主热邪，动脉主疼痛，数脉也主虚，出现头痛、发热、微微盗汗，反而恶寒的，说明表证未解。医生反而用攻下法，动数脉变为迟脉，膈内拒按疼痛，胃中空虚，客气扰动膈膜，短气、烦躁、心中懊恼，阳气内陷，心下因此硬满，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，汗止于颈部，小便不利，身体必定发黄。
【按】“数则为虚”这一句，怀疑是衍文（多余的文字）。
【注】太阳病，脉象浮而动数，浮脉是风邪的脉象，数脉是热邪的脉象，动脉是各种疼痛的脉象。头痛发热，是太阳病的证候。热气蒸腾于阳分，阳虚则自汗出；热气蒸腾于阴分，阴虚则盗汗出。阴虚应当怕热，现在反而怕冷，所以知道这不是阴虚导致的盗汗，而是表证未解导致的盗汗，微微出汗而已。表证未解应当解表，医生反而用攻下法，致使动数的热脉变为寒迟脉。大概动数是表邪欲传变的征兆，因为误下而逆乱于膈中，所以不传变而脉象也改变了。表部的阳邪，乘胃腑空虚，陷入胸膈而拒按疼痛，短气不能舒展呼吸，烦躁，心中懊恼，心下因此硬满，径直从实证化而为结胸了。治法应当用大陷胸汤主治。如果不从实证化，不形成结胸，只是头部出汗至颈部，其余部位无汗，那么热邪就不能向外发散。小便不利，湿邪就不能排泄，热与湿结合化生，所以身体必定发黄。
【集注】成无己说：动数脉变为迟脉，而浮脉唯独不变，是因为邪气结聚在胸中，位于上焦阳分，脉象不能沉下去。
朱震亨说：太阳病，表证未解而攻伐里部，里部已经虚弱了。虽然见到浮而动数的阳脉，一经误下，必然变为迟阴之脉。胃中空虚，短气烦躁，这是极度虚弱。假如说：阳气内陷，心下因硬满就可以迅速攻下吗？大陷胸汤的力量，不亚于承气汤，下而又下，难道不怕其严重损伤正气吗？即使是阳病实邪下后，如果胃中空虚，客气扰动膈膜，心中懊恼的，也可以用栀子豉汤吐除胸中之邪。何况太阳病误下后，明明有虚证存在呢！
按语：朱震亨所论述的治疗，用栀子豉汤吐之，也是适用于未形成结胸，从胸虚有热转化的情况。如果是从胸虚有寒转化的，不论是否已成结胸，又应当遵循《活人书》的温补法了，不可混淆施用。
方有执说：太阳病的脉本应浮，动数脉也是传变的征象。太阳病本来自汗，却说微盗汗，本来恶寒，却说反恶寒，这是稽留久了才这样的。膈，是心胸之间。拒，是格拒的意思。是说膈气与邪气相互格拒而疼痛。客气，就是邪气。短气，是气促不能舒展呼吸。懊恼，是心被邪气扰乱而不安宁。阳气，是客气的别名，因为本是外邪，所以叫客气。因为邪本属风，所以叫阳气。因为里虚因而陷入，所以叫内陷。从“若不结胸”一句到末尾，是讲病情较轻的变化。
大陷胸汤方
大黄（去皮，六两） 芒硝（一升） 甘遂（另研末，一钱）
以上三味药，用水六升，先煮大黄，取二升药液，去渣，加入芒硝，煮一两沸，再加入甘遂末，温服一升，得快利（大便通畅）就停服后面的药。
【集解】方有执说：上焦有高位的邪气，必须用陷下的方法来平复它，所以叫陷胸汤。平定邪气、荡涤寇贼，是将军的职责，以大黄为君药；咸味能软坚散结，以芒硝为臣药；彻上彻下，破结逐水，以甘遂为佐药；只有大实证，才是合法的。如果夹杂虚证或者脉浮，不可轻易尝试。
太阳病，重发汗后又攻下，五六天不大便，舌上干燥而渴，日晡时（下午3-5点）稍有潮热，从心下直到小腹，硬满且疼痛，手不可触碰的，用大陷胸汤主治。
【注】这是承接上一条互相发挥其义理，详细阐述其证治。太阳病，重发汗后又攻下，津液受伤了。五六天不大便，胃腑燥结了。舌上干燥口渴，胃中干枯。日晡时潮热，胃热盛了。从心下直到小腹，硬满而疼痛不可触碰，是说胸腹之中上下都硬结实大痛，手不能靠近，所以用大陷胸汤主治无疑。
【集注】《内台方议》说：“日晡所”作“日晡所发”。
方有执说：这是阐明结胸与阳明内实疑似证的鉴别。晡，是日加申时（下午3-5点）。小有，是微觉有。大概不大便、燥渴、日晡潮热、从心下至少腹硬满而痛，都像阳明内热。只是稍有潮热，不像阳明大热那么严重。所以阳明病必须以胃家实为主，而凡有一丝太阳证在，都不能归入阳明例，也是因为这个原因。
程知说：太阳结胸兼有阳明内实，所以用大陷胸汤，由胸胁以及肠胃，都可以荡涤无余。如果只是攻下肠胃结热，而遗漏胸上的痰饮，就不是合法了。
吴人驹说：一腹之中，上下邪气都盛，证候完全实的，脉象常沉伏，不可产生疑虑畏惧，只要攻下，脉象自然渐渐浮现出来。
小结胸病，病位正在心下，按压才痛，脉象浮滑的，用小陷胸汤主治。
【注】大结胸，邪重热深，病位从心下直到小腹，硬满痛不可近，脉沉实，所以宜用大陷胸汤，以攻其结，泻其热。小结胸，邪浅热轻，病位正在心下硬满，按压才痛，不按不痛，脉浮滑，所以用小陷胸汤以开其结，涤其热。
【集注】程应旄说：看陷胸条中说：“心下痛按之石硬”。又说：“心下满而硬痛”。这里说：“病正在心下”。就知道结胸不拘泥于心下或胸上，只在痛与不痛上分别，所以痞证也有心下硬的，只是不痛罢了。
张锡驹说：汤剂有大小之别，证候有轻重之殊。如今很多人用小陷胸汤治疗大结胸证，都导致不治，于是推诿结胸为不可治之证。不知道结胸不可治的只有一两节，其余都可治的，如果不体认经旨，必定导致临时推诿，误人性命。
魏荔彤说：小结胸没有实热之邪，只是微热而挟带痰饮为患。所以虽然是结胸但不能高踞胸巅，只正在心下而已；不能实力作痛，只是按压才痛而已；诊脉不沉而深，只是浮而轻浅而已；不能像石头一样硬，只是虚而结阻而已。所以大陷胸汤不适用，而另设小陷胸汤。高下、坚软、轻重、沉浮之间，病机治法昭然若揭。又说：痞证是阴邪，结胸是阳邪，然而在阳邪中又有大小之分，学人务必审察。对于凡寒热杂合之证，无大实大热的，都宜斟酌使用下法，不要鲁莽。
小陷胸汤方
黄连（一两） 半夏（洗，半斤） 栝蒌实（大的，一枚）
以上三味药，用水六升，先煮栝蒌，取三升药液，去渣，加入其他药物，煮取二升药液，去渣，分三次温服。
【方解】黄连涤除热邪，半夏引导饮邪，栝蒌润燥下行，合用以涤除胸膈痰热，开通胸膈气结；攻邪虽不峻猛，也能突围而入，所以名叫小陷胸汤。分三次温服，是缓治上焦的方法。
伤寒六七天，结胸热实证，脉沉而紧，心下痛，按之像石头一样硬的，用大陷胸汤主治。
【注】伤寒表证不解，误下形成痞证，这是常理。伤寒或者有因误下而形成结胸的，这是变局。如今伤寒六七天，结胸不因误下而形成这种热实证，如果脉沉紧，是里实的脉象。心下痛，按之石硬，是里实证。这是脉与病皆实，所以用大陷胸汤主治。
【集注】喻昌说：“热实”二字，形容结胸的状态非常明确，见邪热填实于胸而不散漫。浮紧主伤寒无汗，沉紧主伤寒结胸，这与中风之阳邪结胸截然不同，所以不说浮脉。又说：阳邪误下成结胸，阴邪误下成痞。然而中风间或有痞证，伤寒间或有结胸证，又不可不知道。
程应旄说：虽说阳邪内陷，然而“阴阳”二字是从虚实寒热上区别，不是从中风伤寒上区别，表热盛实转入胃腑，就是阳明证；表热盛实不转入胃腑，而陷入于膈，就是结胸证。所以不一定非要误下才能形成。不因误下而成结胸的，必定其人胸中有燥邪，因失汗而表邪与之结合，遂成里实。看这条说：“伤寒六七日”，又说：“脉沉而紧”，就可以知道了。
汪琥说：有人问脉沉紧，怎么知道不是寒实结胸？回答说：胸中，是阳气聚集的地方。邪热当胸而结，直至心下，石硬且痛，那么脉不但沉紧，甚至有伏而不见的，怎么能因为脉沉紧就认为不是热证呢？大抵辨别结胸的方法，但当凭据证候最为准确。
【按】“无热证”之下，“与三物小陷胸汤”，应当是“三物白散”，“小陷胸汤”四字，必然是传写之误。桔梗、贝母、巴豆三物，其色皆白，有三物白散的含义，性温而能攻，与寒实之理相符；小陷胸汤，是栝蒌、黄连，都是性寒之品，怎么能用来治疗寒实结胸的证候呢？“亦可服”三字，也是衍文。
【注】结胸证，身无大热，口不燥渴，就是无热实证，乃寒实，给三物白散。然而此证脉必当沉紧，如果脉沉迟或者证见三阴，那就不是寒实结胸可比的了，应当用枳实理中汤治疗。
【集注】王肯堂说：热实结胸，及寒实结胸，《活人书》不拘寒热，只用陷胸汤，不愈的用枳实理中丸，即应手而愈。
方有执说：“寒”指饮而言，饮本寒也，又得水寒，两寒抟结而实于胸中，所以谓无热证。
郑重光说：水寒结实在胸，则心阳被占据，自非小事，用三物白散下寒而破结，都是不得已的兵家手段。
三物白散方
桔梗（三分） 巴豆（去皮心，熬黑，研如脂，一分） 贝母（三分）
以上两味药研为末，纳入巴豆，再在臼中杵之，用白米汤调服。强壮之人服半钱匕，瘦弱者减量，病在膈上必吐，病在膈下必利。如果不通利，进热粥一杯；如果利过不止，进冷粥一杯。
【方解】这个方子，治疗寒实水结胸证，是极峻烈的药物。以巴豆为君药，极辛极烈，攻寒逐水，斩关夺门，所到之处，无不攻破；佐以贝母，开通胸中结滞；使以桔梗，作为舟楫，载巴豆搜逐胸中邪气，悉尽无余。病在膈上者必吐，病在膈下者必利。然而只知道任用毒药攻邪，不衡量体质强弱，很少能善后的。所以瘦弱者减量，不通利进热粥，利过进冷粥。大概巴豆性热，得热则行，得冷则止。不用水而用粥，是借谷气以保胃气。
伤寒十余日，热结在里，又往来寒热的，给大柴胡汤。只是结胸无大热的，这是水结在胸胁，只是头部微微出汗的，用大陷胸汤主治。
【注】伤寒十余日，热结在里，如果胸胁满硬，这是结胸。现在不满硬，又往来寒热，这是少阳表里病，不是结胸，应当给大柴胡汤两解之。只是结胸证，也有水结的。水结胸不但表无大热，里也无大热。有结胸状，头微汗出的，这是水停于胸，为热气上蒸使然。所以说水结在胸胁。也用大陷胸汤主治，饮热并攻。
【集注】方有执说：水即饮也，以不实硬，故曰水结。胸胁亦里也，以热结不高，故曰在里。
程知说：这是说热结于里兼少阳者，则不宜陷胸；水结于胸者，虽无大热，犹宜大陷胸。
程应旄说：大柴胡与大陷胸，都能破结。大柴胡之破结，使表分无留邪；大陷胸之破结，使里分无留邪。
林澜说：这是说水结胸与热结在里不同。十余日，邪深入腑之时，然而热结在里，而犹有半表半里之邪，作往来寒热的，必以大柴胡两解之。如果只是胸胁结满，初无大热，收敛入内的，这也不得为大柴胡证，必是水结胸胁。怎么知道的？水结胸者，头汗出，现在只是头微汗，为水结胸明矣。给大陷胸汤。
【注】结胸从心上至少腹，硬满痛不可近，则其势甚于下部，治下部宜急攻之，用大陷胸汤。结胸从胸上，满硬项强，像柔痉的样子，则其热甚于上部，治上部宜缓攻之，用大陷胸丸直攻胸肺之邪。煮服倍蜜，峻治缓行，下而和之，因为其病势缓急之形既已不同，汤丸之制也各异。所以知道此项强是结胸之项强，下之则和，不是柔痉之项强。
【集注】成无己说：项强者，为邪结胸中，胸膈结满，只能仰不能俯，是项强。
程知说：项强如柔痉者，胸中邪气紧实，项势常昂，有似柔痉之状，然而痉病身手俱张，这里只是项强原非痉也，借此以验胸邪十分紧逼耳。
汪琥说：下之则和者，言邪实去，胸中和而项自舒之意。如果不说如柔痉，恐怕医人认以为太阳经风寒之邪未解，反疑其当用发汗之药。殊不知项虽强，表证已解，里证甚急，治法宜下也。
大陷胸丸方
大黄（半斤） 葶苈子（熬，半升） 芒硝（半升） 杏仁（去皮尖，熬黑，半升）
以上四味药，捣筛二味，纳入杏仁、芒硝，合研如脂，和散。取如弹丸一枚，另捣甘遂末一钱匕，白蜜二合，水二升，煮取一升，温顿服之，一宿乃下。如下不了，更服，取下为效。禁如药法。
结胸证，其脉浮大的，不可下，下之则死。
【注】结胸证，如果脉大，是为胃实，知结热已实乃可下，下之则愈。现在其脉浮大，是尚在表，知热结未实，故不可下。如果误下之，未尽之表邪复乘虚入里，误而又误，结而又结，病热弥深，正气愈虚，则死矣。
Coldness of the feet, desire to vomit but inability to do so, with a slow and tight pulse: this is cold pathogen stagnation and accumulation. For diseases caused by the stagnation and accumulation of cold, heat, qi, and fluids in the chest, it is certain that sweating or purging methods cannot treat them. One must use sour and bitter emetic agents to induce vomiting, thereby venting the pathogen upwards. Once the upper jiao becomes unobstructed and yang qi recovers, the sensation of fullness and hardness will dissipate, and the chest will harmonize. Geng Ti (Thunberg Fritillary Bulb) is extremely bitter, and Vigna angularis (Red Bean) is sour; they complement each other and can disperse solid pathogens in the chest, making them the premier emetic agent. Taking them mixed with fermented soybean juice utilizes grain qi to protect stomach qi. If vomiting does not occur after administration, increase the dose slightly; stop immediately once rapid vomiting occurs, to avoid damaging the yuan qi of the chest. The efficacy of this formula is faster than sweating or purging, representing the three major methods of sweating, vomiting, and purging. Today's physicians do not understand the profound principles of Zhang Zhongjing and Liu Wansu (Zihe), leaving these formulas unused, which is truly regrettable! However, for those who have lost blood or are constitutionally deficient, where qi and fluids in the chest are already depleted, this formula should not be given lightly; this prohibition is specifically reiterated.
When a disease originates from yang (e.g., wind-stroke) and is mistakenly treated with purging, heat enters and forms Jie Xiong (Chest Binding); when a disease originates from yin (e.g., cold damage) and is mistakenly treated with purging, Pi Zheng (Stagnation Syndrome) results. The reason Jie Xiong forms is due to purging too early.
[Annotation] This generally explains the causes of Jie Xiong and Pi Zheng. Wind-stroke involves yang pathogens, hence "disease originates from yang." Not sweating first but instead purging allows heat pathogens to sink into the deficiency, forming Jie Xiong. Cold damage involves yin pathogens, hence "disease originates from yin." Not sweating first but instead purging allows heat pathogens to sink into the deficiency, forming Pi Zheng. The reason for forming Jie Xiong and Pi Zheng is that the exterior syndrome was unresolved and purging was performed too early. In "disease originates from yin," "heat entering" is omitted as an ellipsis. However, when disease originates from yang and is mistakenly purged, Pi Zheng may not necessarily fail to form; when disease originates from yin and is mistakenly purged, Jie Xiong may sometimes form. This is largely because people's constitutions differ, transforming either into excess or deficiency.
[Collected Annotations] Zhang Jianshan said: Wind pathogen entering the interior forms Jie Xiong; cold pathogen entering the interior forms Pi. Yet both originate from Taiyang disease, not distinguishing separate yin or yang syndromes.
In Taiyang disease, if the pulse is floating, active, and rapid: floating indicates wind, rapid indicates heat, active indicates pain, and rapid also indicates deficiency. Headache, fever, slight nocturnal sweating, yet paradoxically aversion to cold, indicate the exterior is unresolved. If the physician mistakenly purges, the active and rapid pulse changes to slow. Rejection pain in the diaphragm, emptiness in the stomach, disturbance of the diaphragm by hostile qi, shortness of breath, irritability, and mental restlessness (Ao Na) occur as yang qi sinks inward, causing hardness below the heart, thus forming Jie Xiong, treated with Da Xian Xiong Tang (Major Decoction to Sinking Chest). If Jie Xiong does not form, but there is only sweating on the head with no sweat elsewhere, stopping at the neck, and urination is difficult, jaundice will inevitably develop.
[Comment] The phrase "rapid indicates deficiency" is suspected to be an interpolation.
[Annotation] In Taiyang disease, a floating, active, and rapid pulse: floating is the pulse of wind pathogen, rapid is the pulse of heat pathogen, and active is the pulse of various pains. Headache and fever are Taiyang signs. Heat steaming the yang leads to spontaneous sweating due to yang deficiency; heat steaming the yin leads to nocturnal sweating due to yin deficiency. Yin deficiency should involve aversion to heat; now there is aversion to cold, so we know this is not nocturnal sweating from yin deficiency, but from the unresolved exterior, occurring slightly. Since the exterior is unresolved, it should be released via sweating; the physician mistakenly purged, causing the active and rapid heat pulse to change to cold and slow. Generally, active and rapid pulses indicate exterior pathogens attempting to transmit; due to purging, they reverse into the diaphragm, so transmission does not occur, and the pulse changes. Exterior yang pathogens, taking advantage of stomach emptiness, sink into the chest and diaphragm, causing rejection pain, shortness of inability to breathe fully, irritability, mental restlessness, and hardness below the heart, directly transforming into excess and forming Jie Xiong. The method requires Da Xian Xiong Tang. If it does not transform into excess and does not form Jie Xiong, but there is only sweating on the head to the neck with no sweat elsewhere, heat cannot diffuse. Urination difficulty means dampness cannot drain; heat and dampness combine to transform, so jaundice inevitably develops.
[Collected Annotations] Cheng Wuji said: When active and rapid change to slow, but the floating pulse remains unchanged, it is because the pathogen is bound in the chest, in the upper jiao yang division, so the pulse cannot sink.
Zhu Zhenheng said: In Taiyang disease, attacking the interior while the exterior is unresolved leaves the interior deficient. Although yang pulses like floating, active, and rapid are seen, one mistake in purging will surely change them to slow yin pulses. Stomach emptiness, shortness of breath, and irritability indicate extreme deficiency. One might ask: if yang qi sinks inward and causes hardness below the heart, can it be rapidly attacked? The power of Da Xian Xiong Tang is no less than Cheng Qi Tang; purging again and again, how can one not fear severe depletion of righteousness? Even if yang disease excess pathogens are purged, if the stomach is empty and hostile qi disturbs the diaphragm causing mental restlessness, one could use Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) to vomit out chest pathogens. Moreover, after mistaken purging in Taiyang disease, there are clearly deficiency signs!
Comment: Zhu Zhenheng’s treatment using Zhi Zi Chi Tang to vomit is suitable for cases where Jie Xiong has not formed and transforms from chest deficiency with heat. If it transforms from chest deficiency with cold, regardless of whether Jie Xiong has formed, one should follow the warming and tonifying method of *Huo Ren Shu*, and not mix treatments.
Fang Youzhi said: The Taiyang pulse is naturally floating; active and rapid pulses also indicate transmission. Taiyang naturally has sweating, yet slight nocturnal sweating is mentioned; naturally aversion to cold, yet paradoxical aversion to cold is mentioned, indicating it has persisted for a long time. The diaphragm is between the heart and chest. Rejection means resistance. It means diaphragmatic qi resists pathogenic qi, causing pain. Hostile qi is pathogenic qi. Shortness of breath is急促 breathing unable to distribute air. Ao Na (mental restlessness) is the heart disturbed by pathogens and uneasy. Yang qi is another name for hostile qi; because it is originally external pathogen, it is called hostile qi. Because the pathogen is originally wind, it is called yang qi. Because it sinks inward due to interior deficiency, it is called sinking inward. From "If Jie Xiong does not form" to the end, it discusses milder transformations.
Da Xian Xiong Tang Formula
Da Huang (Rhubarb Root and Rhizome, peeled, 6 liang), Mang Xiao (Mirabilite, 1 sheng), Gan Sui (Kansui Root, ground separately, 1 qian).
These three ingredients: use 6 sheng of water, first decoct Da Huang to obtain 2 sheng, remove dregs, add Mang Xiao, boil for one or two boils, then add Gan Sui powder. Take 1 sheng warm. Stop subsequent doses once rapid bowel movement occurs.
[Collected Explanations] Fang Youzhi said: There is high pathogen in the upper jiao; it must be sunk to pacify it, hence Decoction to Sinking Chest. Pacifying pathogens and sweeping away bandits is the duty of a general; Da Huang is the sovereign herb. Salty flavor softens hardness; Mang Xiao is the minister herb. Penetrating up and down, breaking binding and driving out water; Gan Sui is the assistant herb. Only for great excess conditions is this appropriate. If accompanied by deficiency or floating pulse, do not try lightly.
In Taiyang disease, after heavy sweating and subsequent purging, if there is no bowel movement for five or six days, dry tongue with thirst, slight tidal fever in the late afternoon (You hour), hardness, fullness, and pain from below the heart to the lower abdomen, intolerable to touch: Da Xian Xiong Tang is indicated.
[Annotation] This continues the previous clause to mutually elaborate its meaning and detail the syndrome and treatment. Taiyang disease, heavy sweating followed by purging, injures body fluids. No bowel movement for five or six days indicates stomach fu dryness. Dry tongue and thirst indicate stomach dryness. Tidal fever in the late afternoon indicates abundant stomach heat. Hardness, fullness, and pain from below the heart to the lower abdomen, intolerable to touch, means the entire chest and abdomen are hard, solid, large, and painful, such that the hand cannot approach. Thus, Da Xian Xiong Tang is undoubtedly indicated.
[Collected Annotations] *Nei Tai Fang Yi* says: "You suo" should be "fa fa" (onset).
Fang Youzhi said: This clarifies the differentiation between Jie Xiong and suspected Yangming interior excess. You refers to the Shen hour (3-5 PM). "Slight" means faintly perceived. Generally, constipation, dry thirst, tidal fever in the late afternoon, and hardness/fullness/pain from below the heart to the lower abdomen all resemble Yangming interior heat. However, the slight tidal fever does not match the severe heat of Yangming. Therefore, Yangming is primarily defined by stomach house excess; any trace of Taiyang signs prevents inclusion in Yangming examples, for this very reason.
Cheng Zhi said: Taiyang Jie Xiong combined with Yangming interior excess requires Da Xian Xiong Tang, which can cleanse everything from the chest and hypochondrium to the intestines and stomach. If one only purges intestinal and stomach heat but leaves phlegm-fluids in the upper chest, it is not the correct method.
Wu Renju said: In one abdomen, if pathogenic qi is abundant above and below, and the syndrome is completely excess, the pulse is often deep and hidden. Do not hesitate; purging will cause the pulse to gradually emerge.
Xiao Jie Xiong (Minor Chest Binding): Disease is located exactly below the heart; pain upon pressure; floating and slippery pulse. Xiao Jie Xiong Tang is indicated.
[Annotation] Da Jie Xiong involves heavy pathogen and deep heat, extending from below the heart to the lower abdomen, with hardness, fullness, and pain intolerable to touch, and a deep, solid pulse. Thus, Da Xian Xiong Tang is suitable to attack the binding and purge heat. Xiao Jie Xiong involves shallow pathogen and light heat, located exactly below the heart with hardness and fullness, painful only upon pressure, and a floating, slippery pulse. Thus, Xiao Jie Xiong Tang is used to open the binding and cleanse heat.
[Collected Annotations] Cheng Yingmao said: Looking at the Jie Xiong clauses: "Pain below the heart, stone-hard upon pressure" and "Fullness and hardness below the heart with pain." Here it says: "Disease is exactly below the heart." We know Jie Xiong is not limited to below the heart or upper chest; differentiation lies only in pain or no pain. Thus, Pi syndrome also has hardness below the heart, but without pain.
Zhang Xiju said: Decoctions have size differences; syndromes have severity differences. Many today use Xiao Jie Xiong Tang to treat Da Jie Xiong syndromes, leading to untreatable outcomes, and then claim Jie Xiong is incurable. They do not know that only one or two sections of Jie Xiong are incurable; the rest are treatable. If one does not comprehend the classic principles, one will shift blame at the critical moment, costing lives.
Wei Litong said: Xiao Jie Xiong lacks solid heat pathogens; it is merely slight heat combined with phlegm-fluids causing harm. Thus, although it is Jie Xiong, it cannot occupy the peak of the chest, but is located exactly below the heart; it cannot cause solid pain, only pain upon pressure; the pulse is not deep but floating and superficial; it is not stone-hard, but void and obstructed. Therefore, Da Xian Xiong Tang is not applicable, and Xiao Jie Xiong Tang is specially designed. Between height/depth, hardness/softness, severity/lightness, and floating/sinking, the pathology and treatment methods are clear. He also said: Pi is yin pathogen, Jie Xiong is yang pathogen. However, within yang pathogens, there are size distinctions; students must examine carefully. For all syndromes of mixed cold and heat without great excess or heat, one should cautiously consider purging methods, avoiding rashness.
Xiao Jie Xiong Tang Formula
Huang Lian (Coptis Rhizome, 1 liang), Ban Xia (Pinellia Tuber, washed, 8 jin), Gua Lou Shi (Trichosanthes Fruit, large, 1 piece).
These three ingredients: use 6 sheng of water, first decoct Gua Lou to obtain 3 sheng, remove dregs, add other herbs, decoct to obtain 2 sheng, remove dregs. Divide into three warm doses.
[Formula Explanation] Huang Lian cleanses heat; Ban Xia guides fluids; Gua Lou moistens dryness and descends. Combined, they cleanse phlegm-heat in the chest and diaphragm and open chest qi binding. Although the attack is not harsh, it can break through, hence named Minor Decoction to Sinking Chest. Dividing into three warm doses is the method of treating the upper jiao slowly.
After cold damage for six or seven days, if Jie Xiong heat-excess presents with a deep and tight pulse, pain below the heart, and stone-hardness upon pressure: Da Xian Xiong Tang is indicated.
[Annotation] In cold damage, if the exterior is unresolved and mistaken purging forms Pi, this is the norm. However, cold damage may occasionally form Jie Xiong due to mistaken purging; this is the variation. Now, after six or seven days of cold damage, Jie Xiong forms as this heat-excess syndrome without mistaken purging. If the pulse is deep and tight, it is a pulse of interior excess. Pain below the heart, stone-hard upon pressure, is an interior excess syndrome. Since both pulse and disease are excess, Da Xian Xiong Tang is indicated.
[Collected Annotations] Yu Chang said: The two characters "Heat Excess" describe the state of Jie Xiong very clearly, showing pathogenic heat filling the chest without scattering. Floating-tight indicates cold damage without sweat; deep-tight indicates cold damage Jie Xiong. This is distinctly different from wind-stroke yang pathogen Jie Xiong, hence floating is not mentioned. He also said: Yang pathogen mistaken purging forms Jie Xiong; yin pathogen mistaken purging forms Pi. However, wind-stroke occasionally has Pi syndromes, and cold damage occasionally has Jie Xiong syndromes; this must be known.
Cheng Yingmao said: Although it is said yang pathogen sinks inward, the terms "yin" and "yang" are distinguished by excess/deficiency and cold/heat, not by wind-stroke/cold damage. If exterior heat excess transfers to the stomach fu, it becomes Yangming syndrome; if exterior heat excess does not transfer to the stomach fu but sinks into the diaphragm, it becomes Jie Xiong syndrome. Thus, it does not require mistaken purging to form. Jie Xiong forming without purging implies the person has dry pathogen in the chest; losing sweat allows exterior pathogen to combine with it, forming interior excess. Seeing "cold damage six or seven days" and "deep and tight pulse" confirms this.
Wang Hu said: One asks: How do we know deep-tight pulse is not cold-excess Jie Xiong? Answer: The chest is the gathering place of yang qi. If pathogenic heat binds in the chest, reaching down to the heart, becoming stone-hard and painful, the pulse is not only deep-tight, but even hidden and invisible. How can one say deep-tight pulse is not heat? Generally, the method to differentiate Jie Xiong relies most accurately on symptoms.
For cold-excess Jie Xiong with no heat signs, San Wu Xiao Jie Xiong Tang (Three-Ingredient Minor Chest Binding Decoction) is given; Bai San (White Powder) may also be taken.
[Comment] Under "no heat signs," "San Wu Xiao Jie Xiong Tang" should be "San Wu Bai San." The four characters "Xiao Jie Xiong Tang" are likely transcription errors. Jie Geng, Bei Mu, and Ba Dou are all white, fitting the meaning of San Wu Bai San. It is warm and attacking, consistent with cold-excess theory. Xiao Jie Xiong Tang consists of Gua Lou and Huang Lian, both cold-natured herbs; how can they treat cold-excess Jie Xiong? The three characters "may also be taken" are also interpolations.
[Annotation] For Jie Xiong syndrome, if there is no significant fever and no dry mouth/thirst, it is a non-heat excess syndrome, i.e., cold-excess. Give San Wu Bai San. However, in this syndrome, the pulse must be deep and tight. If the pulse is deep-slow or three-yin signs appear, it is not comparable to cold-excess Jie Xiong; Zhi Shi Li Zhong Tang (Immature Bitter Orange and Atractylodes Macrocephala Decoction to Regulate the Middle) should be used.
[Collected Annotations] Wang Kentang said: For heat-excess Jie Xiong and cold-excess Jie Xiong, *Huo Ren Shu* uses Xian Xiong Tang regardless of cold or heat. If ineffective, use Zhi Shi Li Zhong Wan, and recovery is immediate.
Fang Youzhi said: "Cold" refers to fluids; fluids are originally cold. Combining with water-cold, two colds bind and become solid in the chest, hence "no heat signs."
Cheng Zhi said: Jie Xiong has distinctions of size and differences of cold/heat; one cannot indiscriminately use Mang Xiao and Da Huang.
Zheng Zhongguang said: Water-cold binding solidly in the chest occupies heart yang, which is no small matter. Using San Wu Bai San to purge cold and break binding is a不得已 (last resort) military action.
San Wu Bai San Formula
Jie Geng (Platycodon Root, 3 fen), Ba Dou (Croton Seed, peeled and heart removed, roasted black, ground to paste, 1 fen), Bei Mu (Fritillaria Thunbergii Bulb, 3 fen).
Grind the first two ingredients into powder, add Ba Dou, and pound further in a mortar. Mix with white rice drink for administration. Strong persons take half a qian bi; weak persons reduce the dose. If the disease is above the diaphragm, vomiting will occur; if below the diaphragm, purging will occur. If no purging, give one cup of hot porridge; if purging continues excessively, give one cup of cold porridge.
[Formula Explanation] This formula treats cold-excess water-binding in the chest; it is an extremely harsh medicine. Ba Dou is the sovereign herb, extremely pungent and fierce, attacking cold and driving out water, breaking gates and seizing doors, destroying everything it reaches. Bei Mu is the assistant, opening chest binding. Jie Geng is the envoy, acting as a boat to carry Ba Dou to search and eliminate chest pathogens completely. Above the diaphragm, vomiting occurs; below the diaphragm, purging occurs. However, those who rely solely on toxic herbs to attack pathogens without assessing strength/weakness rarely achieve good outcomes. Hence, reduce dose for weak persons; give hot porridge if no purging, cold porridge if excessive purging. Ba dou is hot in nature; it moves with heat and stops with cold. Using porridge instead of water utilizes grain qi to protect the stomach.
After cold damage for ten-plus days, if heat binds in the interior and there is alternating chills and fever: Da Chai Hu Tang (Major Bupleurum Decoction) is given. If it is merely Jie Xiong without significant heat, this is water-binding in the chest and hypochondrium; if there is only slight sweating on the head: Da Xian Xiong Tang is indicated.
[Annotation] After cold damage for ten-plus days, heat binds in the interior. If there is chest/hypochondrium fullness and hardness, this is Jie Xiong. Now, if there is no fullness/hardness, but alternating chills and fever, this is Shaoyang exterior-interior disease, not Jie Xiong; Da Chai Hu Tang should be given to resolve both. However, Jie Xiong syndromes can also involve water-binding. Water-binding in the chest has no significant heat in the exterior or interior. With Jie Xiong appearance and slight head sweating, this is water stopping in the chest, caused by heat steaming upward. Hence, "water-binding in the chest and hypochondrium." Da Xian Xiong Tang is also used to attack both fluid and heat.
[Collected Annotations] Fang Youzhi said: Water is fluid; since it is not solid/hard, it is called water-binding. Chest and hypochondrium are also interior; since heat binding is not high, it is called "in the interior."
Cheng Zhi said: This states that if heat binds in the interior combined with Shaoyang, Xian Xiong is inappropriate; if water binds in the chest, even without significant heat, Da Xian Xiong Tang is still appropriate.
Cheng Yingmao said: Both Da Chai Hu Tang and Da Xian Xiong Tang can break binding. Da Chai Hu Tang breaks binding to prevent lingering pathogens in the exterior division; Da Xian Xiong Tang breaks binding to prevent lingering pathogens in the interior division.
Lin Lan said: This distinguishes water-binding in the chest from heat-binding in the interior. At ten-plus days, pathogens deeply enter the fu organs. However, if heat binds in the interior while half-exterior/half-interior pathogens remain, causing alternating chills and fever, Da Chai Hu Tang must be used to resolve both. If there is merely chest/hypochondrium binding/fullness with no initial significant heat, contracting inward, this is not a Da Chai Hu Tang syndrome, but water-binding in the chest and hypochondrium. How do we know? Water-binding in the chest causes head sweating; now there is only slight head sweating, clearly indicating water-binding in the chest. Give Da Xian Xiong Tang.
In Jie Xiong, if the neck is also stiff, resembling Rou Ji (Soft Spasm): purging brings harmony; Da Xian Xiong Wan (Major Decoction to Sinking Chest Pill) is suitable.
[Annotation] If Jie Xiong extends from above the heart to the lower abdomen with hardness, fullness, and pain intolerable to touch, the momentum is heavier downwards; treating the lower requires rapid attack with Da Xian Xiong Tang. If Jie Xiong is from the upper chest, with fullness, stiffness, and neck rigidity resembling Rou Ji, the heat is heavier upwards; treating the upper requires slow attack with Da Xian Xiong Wan to directly attack chest-lung pathogens. Boiling with double honey allows harsh treatment to act slowly, purging to bring harmony. Because the shape of the disease momentum (fast/slow) differs, the preparation of decoction vs. pill also differs. Thus, we know this neck stiffness is Jie Xiong neck stiffness; purging brings harmony, unlike Rou Ji neck stiffness.
[Collected Annotations] Cheng Wuji said: Neck stiffness is due to pathogen binding in the chest; chest-diaphragm binding/fullness allows looking up but not bending down; this is neck stiffness.
Cheng Zhi said: Neck stiffness resembling Rou Ji means chest pathogen qi is tight and solid, causing the neck to constantly tilt back, resembling Rou Ji. However, spasm involves stretching of hands and body; here, only neck stiffness exists, originally not spasm. This borrows the term to verify that chest pathogen is extremely pressing.
Wang Hu said: "Purging brings harmony" means that when excess pathogen is removed, the chest harmonizes and the neck relaxes naturally. If it did not say "resembling Rou Ji," physicians might mistake it for unresolved Taiyang wind-cold pathogen and suspect sweating herbs are needed. Little do they know, although the neck is stiff, the exterior syndrome is resolved, and the interior syndrome is urgent; the treatment method should be purging.
Da Xian Xiong Wan Formula
Da Huang (Rhubarb Root and Rhizome, 8 liang), Ting Li Zi (Periploca Seed, roasted, 1/2 sheng), Mang Xiao (Mirabilite, 1/2 sheng), Xing Ren (Apricot Kernel, peeled and tips removed, roasted black, 1/2 sheng).
Grind two ingredients, add Xing Ren and Mang Xiao, grind together until pasty, and mix. Take one pill-sized amount. Separately grind Gan Sui powder (1 qian bi), mix with 2 he of white honey and 2 sheng of water. Decoct to obtain 1 sheng. Take warm in one dose. Bowel movement occurs overnight. If no movement, take again. Movement is the effect. Follow medication prohibitions.
In Jie Xiong syndrome, if the pulse is floating and large: do not purge. Purging leads to death.
[Annotation] In Jie Xiong syndrome, if the pulse is large, it indicates stomach excess; knowing the binding heat is solid allows purging, leading to cure. Now, if the pulse is floating and large, it indicates the pathogen is still in the exterior; knowing the heat binding is not solid, purging is contraindicated. If mistakenly purged, remaining exterior pathogens re-enter the interior taking advantage of deficiency. Mistake upon mistake, binding upon binding, disease heat deepens, righteous qi depletes, leading to death.