心下痞结按之硬满而痛者结胸也按之硬满不痛者痞气也经曰病发于阳（发热而恶寒者）反下之热入因作结胸病发于
阴（无热而恶寒者）反下之因作痞所以成结胸者下之太早也盖表当汗反下之里之正气为下所损则表之全热乘虚入里结于
心下为结胸也里之阴分已受邪热为病是谓发于阴也或微热下证未全不任转泻而反下之则里之微热虽除而表之热邪又至
虽不结胸亦成痞也小结胸轻于大结胸而重于此也由误之大小非以痞为寒也经谓但结胸无大发热证为寒实结胸诚非寒也
但热微甚尔及夫脏结者经谓热结于脏则为病深故云难治若用凉剂而亦有生又阳结者热结于腑则微而浅也又留饮不败而
成头汗脉沉潜及附骨者积饮成水结胸也又有不因误下而成结胸与痞者此又失下及夫反汗而成者也经谓热已入里久不攻
之亦至结实名曰三死一生是失下也汗后热气传入心下而痞者是失汗也结胸固知当下或脉浮大者又不可下下之则死是犹
带表邪未全结实故也又结胸证悉具加之烦躁者亦不治也夫药所以能逐邪者必待胃气施布药力始能温汗吐下以逐其邪邪
气胜胃气绝者安可为之
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（成 动数皆阳脉也当责邪在
表睡而汗出者谓之盗汗为邪气在半里半表则不恶寒此头痛发汗微盗汗出又恶寒者表未解也当发其汗医反下之虚其胃气
表邪乘虚则陷邪在里则见阳脉邪在里则见阴脉邪气内陷动数之脉所以变迟而浮脉独不变者以邪结胸中上焦阳结脉不得
而沉也客气者外邪乘胃中空虚入里结于胸膈膈中拒痛者客气动膈也金匮要略曰短气不足以息者实也短气躁烦心中懊
皆邪热为实阳气内陷气不得通于膈壅于心下为硬满而痛成结胸也与大陷胸汤以下结热丹 谨按太阳病在表未曾解在表
而攻里可谓虚矣而况所得之脉皆浮而动数乎今得误下动数变迟矣而又曰胃中空虚又曰短气躁烦虚之甚矣借曰阳气内陷
心下因硬而可迅攻之乎岂大结胸之力缓于承气况已下者不可再下宁不畏其虚乎上文曰结胸脉浮大者不可下下者死又曰
结胸证悉具烦躁者死今曰脉浮又曰烦躁大陷胸果可用乎彼阳病实下后若胃中空虚客气动膈心中懊 者以栀子豉汤吐胸
中之邪况太阳失下后明有虚证乎）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（上文既言病发于阳而
反下之热入因作结胸则下文不必赘矣上文但言所致结胸之由至此则又发明结胸之脉与证也成注谓此不云下后而云伤寒
六七日则是传里之实热误矣 张 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
于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例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（成 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余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以小
柴胡去大枣加牡蛎汤）太阳病重发汗而复下之不大便五六日舌上燥而渴日晡时小有潮热从心下至少腹硬满而痛不可近者
大陷胸汤主之（详潮热）
大陷胸汤方
大黄（六两去皮） 芒硝（一升） 甘遂（一钱为末）上三味以水六升先煮大黄取二升去滓纳芒硝煮一二沸纳甘遂
末温服一升得快利止后服
结胸由邪在胸中处身之高分宜若何吐然所谓结者诸阳受气于胸中邪气与阳气相结不能分辨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可也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汤也
陷胸破结非苦寒直达者不能是以甘遂为君内经曰咸味涌泄为阴又曰咸以软之气坚者以咸软热胜者以寒消是以芒硝咸寒
为臣荡涤邪寇除去不平将军之功也陷胸涤热是以大黄苦寒为使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
丹 此证经曰胃中空虚曰短气躁烦曰脉浮此汤不可轻用
小结胸病正在心下按之则痛脉浮滑者小陷胸汤主之（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
按之然后作痛尔上文云至少腹是通一腹而言之此云在正心下则少腹不硬痛可知矣热微于前故云小结胸也）
小陷胸汤方
半夏（汤洗半升） 黄连（一两） 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（一服未效再微服解下黄涎便安也苦以泄之辛以散之黄连栝蒌实之苦寒以泄热半夏之辛以散结）
病在阳应以汗解之反以冷水 之若灌之其热被却不得去弥更益烦肉上粟起意欲饮水反不渴者服文蛤散若不瘥者与
五苓散寒实结胸无热证者与三物小陷胸汤白散亦可服
白散方
桔梗 贝母（各三分） 巴豆（一分去皮心熬黑研如脂）上三味为末纳巴豆更于臼中杵之以白饮和服强者半钱羸者
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假令汗出已腹中痛与芍药一两如上法上热实结胸及
寒实结胸活人不拘寒热但用陷胸汤不瘥者用枳实理中丸应手而愈结胸项亦强如柔痉状下之则和宜大陷胸丸
大陷胸丸方
大黄（半斤） 葶苈（熬） 芒硝 杏仁（去皮尖熬黑各半升）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海藏云大陷胸汤太阳
入本药也大陷胸丸阳明药也小陷胸汤少阳药也大陷胸治热实大陷胸丸兼喘小陷胸治痞（大黄芒硝之苦咸所以下热葶苈杏
仁之苦甘所以泄满甘遂取其直达白蜜取其润利皆以下泄满实物也）
心下满痛如结胸状若头下强痛眩冒者刺大椎肝俞若汗下后头项强痛发热小便不利者桂枝去桂加茯苓白术汤（方论并
见项强）
太阳病二三日不能卧但欲起心下必结脉微弱者此本有寒也反下之若利止必作结胸未止者四日复下之此作协热利也
太阳病下之脉浮者必结胸也太阳少阳并病而反下之成结胸心下硬下利不止水浆不下其人心烦结胸证悉具烦躁者亦死结
胸脉浮大不可下下之则死（张 用药如兵用知可而进知难而退此理势之必然也夫寸淫关沉乃结胸可下之脉今脉浮大心中
虽结其表邪尚多未全结也若辄下之重虚其里外邪复聚而必死矣仲景所以言此为箴戒使无踵其弊也其脉既不可攻当以候
其变而待其实假如小结胸证其脉浮滑按之则痛故知邪非深结亦不敢下无过解除心下之热耳小陷胸汤主之或又曰结胸倘
有外证大陷胸远可用否予曰结胸无外证或有微热或有小潮热仲景已明言之其余别无表证其邪亦未结实不可以结胸论也
经曰伤寒六七日若有外证发热恶寒支节烦痛微呕心下支结外证未去者柴胡加桂枝汤主之又伤寒六七日已发汗而复下胸
胁微结小便不利渴而不呕但头汗出往来寒热心烦者此未为解也柴胡桂枝干姜汤主之以上之证虽云心下支结及言胸胁满
微结二条俱有外证所以柴胡加桂及加桂姜以和解之如无外证止有胸腹结实而痛者方为结胸病也）
附
活 若误下之初未成结胸者急频与理中汤自然得解更不作结胸盖理中汤治中焦故也此古人亦说不到后人因消息
得
之若大 转损有厥证者兼与四逆汤便安胃中虽和伤寒未退者宜候日数足可下却以承气再下之盖前来下之未是故也
西晋崔功行云伤寒结胸欲绝心膈高起手不得近用大陷胸汤皆不瘥者此是下后虚逆气已不理而毒复上攻气毒相搏结
于胸者当用枳实理中丸先理其气次疗诸疾古今用之如神
枳实理中丸方
枳实（十六斤麸炒） 茯苓 人参 白术 干姜（炮） 甘草（炙以上各二两）上为末炼蜜丸如鸡子黄大每服一丸
热汤化下连进二三服胸中豁然渴者加栝蒌根一两自汗者加牡蛎二两 过下利亦加
海 增损理中丸 王朝奉云大小陷胸汤丸不愈者宜与之
人参 白术 栝蒌 牡蛎（ ） 甘草（炙各二两） 干姜（炒白半两） 枳实（麸炒二十四枚） 黄芩（去枯一
两）上为末炼蜜为丸如弹子大汤一盏煎服一丸不解复与之不过五六丸胸中豁然矣药之神速未尝见也渴者加栝蒌根自汗加
牡蛎
活 水结在胸胁间亦名结胸其证头微汗出但结胸无热者小半夏加茯苓汤小柴胡去枣加牡蛎
孙 俞伯道忽患微热心下满头有汗不能解众医以为温病用表药有谓食在膈者治之皆不愈召孙至乃用半夏茯苓汤
遂瘥众问其故曰头有汗心下满非湿证乃水结胸胁也水既去其病乃愈且如湿气心下满自当遍身汗若有食心满头岂得汗若言
是表身又不疼不恶寒表证何在故凡水结胸胁头必有汗耳
小半夏加茯苓汤（方见呕门）
穿结散 大实大满心胸高起气塞不通者为结也
蟾酥 麝香 轻粉 巴豆（另研少许）上再研过至细以乳汁为丸如黍米大每服二丸用姜汤下不时服
本 妇人伤寒血结胸膈揉而痛不可抚
海蛤散
海蛤 滑石 甘草（炙各二两） 芒硝（半两）上末每服二钱鸡子清调下
小肠通利则胸膈血散膻中血聚则小肠壅小肠壅膻中血不流行宜此方若小便血散数行更宜桂枝红花汤发其汗则愈活
人书云此方疑非仲景然其言有理姑存之
戴 热实结胸如仲景法治之又有寒实结胸虽痛而无烦躁等证此因下后虚逆寒气独结宜理中汤加枳实半钱茯苓一
钱或枳实理中汤又有水结胸无大热证头微汗出宜小半夏茯苓汤又有血结胸手不可近其人嗽水不欲咽喜忘如狂大便黑色小
便自利宜犀角地黄汤
陶 结胸之证尝见俗医不问曾下与未下但见心胸满闷便与桔梗汤便呼为结胸盖本朱奉议之说也有频频与之反成
真结胸者殊不知结胸乃下早而成未经下者非结胸也乃表邪传至胸中未入于腑证虽满闷尚为在表正属少阳部分为半表半里
之间宜用小柴胡汤加枳壳如未效则以本方对小陷胸汤一服豁然其妙如神若因下早而成者方用陷胸汤丸分浅深从缓而治
之不宜太峻上焦乃清道至高之分若过下则伤元气也故陷胸汤丸宜从缓治之尝读仲景伤寒论结胸条云病发于阳而反下之
热入因作结胸病发于阴而反下之因作痞满所以成结胸者以下太早故也及成氏注释曰发热恶寒者发于阳也无热恶寒发于
阴也再三熟玩不能不致疑于其间盖无热恶寒者寒邪直中阴经之真寒证也非阳经传至阴经之病也若误下之不死则危矣岂
可以泻心汤寒热相参之药治之而愈乎岂反轻如结胸者乎详此恐言荣卫阴阳也风属阳阳邪伤卫头痛发热微汗出反恶寒者
当服桂枝汤止汗散邪医者不达而下之胃气重伤胸中结硬经又云结胸证脉浮大者不可下下之则死结胸证悉具而烦躁者亦
死盖卫出上焦清道所伤不为不重也故用陷胸汤峻利之药以下之寒为阴阴邪伤荣当服麻黄发表误下之而成痞满宜泻心汤
以理痞盖荣出中焦黄连能泻心下痞邪下于膈不犯清道则元不伤故轻于结胸耳若阴经自中之寒以泻心汤理之而愈者未之
有也又云脉来沉实有力方为结胸急用大陷胸汤加枳桔下之
治结胸灸法
巴豆（十四个） 黄连（七寸去皮）上捣细津唾和成膏填入脐中以艾灸其上腹中有声其病去矣不拘壮数病去为度才
灸后便以温汤浸手帕拭之恐生疮也
摘 伤寒结胸先使人心蔽骨下正痛处左畔揉之以毫针刺左畔支沟穴（正坐侧臂取之二分）次刺左间使名曰双阙
次刺
左行间（卧取之针入六分此支沟行间穴下针至分数内捻针令病患五吸次外捻针三呼又次内捻针五吸吃长呼一口气出针即
左畔一壁结胸立效右畔根据上刺之慢慢呼吸停针用针获时而愈）
云 伤寒结胸痞气
胸中结痞涌泉 太溪 中冲 太陵
心中结痞隐白 太白 少冲 神门
胃中结痞少商 太涧 大敦 太冲并上下腕泻之
通玄 结胸身黄 涌泉
摘 血结胸面赤大燥口干消渴胸中疼痛不可忍
期门 太陵 关元（妊娠不得刺关元胎死不出子母俱亡慎之）
集 伤寒胸膈痛 期门 太陵
活 近世治结胸多用金针并用硫黄阳起石若寒实结胸或有瘥者而热实结胸必死也
【背景信息】
书名：证治准绳·伤寒 作者：王肯堂 朝代：明 章节：结胸 类别：伤寒
心下（胃脘部）痞塞胀满，按压时坚硬且疼痛的，称为结胸病（Jie Xiong, Chest Binding Syndrome）；按压时坚硬但不痛的，称为痞气（Pi Qi, Stagnant Qi）。经典记载：疾病发于阳证（表现为发热且恶寒），如果误用攻下法，热邪内陷，因而形成结胸病；疾病发于阴证（表现为无发热而仅恶寒），如果误用攻下法，因而形成痞证。之所以形成结胸，是因为攻下过早。本来表证应当通过发汗解表，却反而使用了攻下法，导致体内的正气被攻下药损伤，于是表证的完全热邪乘虚侵入体内，结聚于心下，形成结胸。体内的阴分已经受到邪热侵袭而发病，这叫做发于阴。或者仅有轻微发热，里实证尚未完全形成，患者不耐受泻下，却反而使用了攻下法，这样虽然体内的微热得以清除，但表里的热邪又至，即使不形成结胸，也会形成痞证。小结胸病比大结胸病轻，但比痞气重。这是由误治程度的大小决定的，并不是说痞气就是寒证。经典说“只有结胸而没有高热症状”，这是寒实结胸（Cold-Excess Jie Xiong），确实不是寒证，只是热邪轻微罢了。至于脏结（Zang Jie, Organ Binding），经典说热邪结聚在脏，则病情深重，所以说难治。如果使用凉性药剂也有治愈的可能。又有阳结（Yang Jie），热邪结聚在腑，则病情轻微且浅表。还有留饮（Liu Yin, Retained Fluids）不散，导致头部出汗、脉象沉潜以及附着于骨骼深处的积饮形成水结胸（Shui Jie Xiong, Water-Binding Chest）。又有并非因误下而形成结胸和痞气的情况，这也是因为失于攻下以及错误地发汗所致。经典说：“热邪已经入里，久不攻下，也会形成结实”，这叫作“三死一生”中的失下（Failure to purge）。发汗后热气传入心下而形成痞气，这叫作失汗（Failure to sweat properly）。结胸固然知道应当使用攻下法，但如果脉象浮大的，又不可攻下，攻下则会导致死亡，这是因为还带有表邪，尚未完全结实。另外，结胸证候全部具备，再加上烦躁不安的，也是不治之症。药物之所以能驱逐邪气，必须等待胃气分布药力，才能通过温、汗、吐、下等方法来驱逐邪气。如果邪气强盛而胃气衰竭，怎么可以治疗呢？
太阳病（Taiyang Disease）脉象浮而动数，浮脉主风，数脉主热，动脉主痛，数脉也主虚。头痛、发热、微微盗汗（Dao Han, Night Sweating during sleep）且反而恶寒的，说明表证未解。医生反而使用攻下法，原本动数的脉象变为迟脉，膈内抗拒疼痛，胃中空虚，客气（Ke Qi, Invading Pathogen）扰动膈肌，短气、烦躁、心中懊憹（Ao Nao, Restlessness and Discomfort in the Heart）阳气内陷，心下因此变硬，这就是结胸，主治以大陷胸汤（Da Xian Xiong Tang, Major Xiexion Decoction）。
[成无己注] 动数和都是阳脉，应当责求邪气在表。睡着时出汗叫做盗汗，如果是邪气在半表半里，则不应恶寒。这里头痛发热、微微盗汗又恶寒，说明表证未解，应当发汗。医生反而攻下，损伤了胃气，表邪乘虚内陷。邪气在里则见阳脉，邪气在里则见阴脉。邪气内陷，所以动数之脉变为迟脉，而浮脉独独不变，是因为邪气结聚在胸中上焦，阳气结聚，脉气不能下沉。客气是指外邪乘胃中空虚而入里，结聚于胸膈。膈中拒痛，是客气扰动膈肌。《金匮要略》说：“短气不足以息的，是实证。”短气、烦躁、心中懊憹，都是邪热为实。阳气内陷，气不能通于膈，壅滞于心下，形成硬满而痛，成为结胸，用大陷胸汤以下除结热。
[丹波元简按] 太阳病在表，未曾解除，在表而攻里，可以说是虚损了。何况所得的脉象都是浮而动数呢？现在误下之后，动数变为迟，又说胃中空虚，又说短气烦躁，虚损已经很严重了。假如说是阳气内陷，心下因此变硬，就可以迅速攻下吗？难道大结胸的力量比承气汤缓吗？况且已经攻下过，不可再下，岂不担心其虚损吗？上文说结胸脉浮大的不可攻下，攻下则死；又说结胸证候悉具且烦躁的，也是死证。现在又说脉浮，又说烦躁，大陷胸汤果真可以用吗？如果是阳病实证攻下后，若胃中空虚、客气动膈、心中懊憹的，应用栀子豉汤（Zhi Zi Chi Tang, Gardenia and Fermented Soybean Decoction）涌吐胸中之邪。何况太阳病失于攻下后，明明有虚证呢？
伤寒六七日，结胸热实，脉沉而紧，心下痛，按之像石头一样硬的，主治以大陷胸汤。
[张隐庵注] 上文既已说病发于阳而反下之，热入因而作结胸，那么下文不必赘述了。上文只说了导致结胸的原因，到这里又阐明结胸的脉与证。成无己注认为这里没写“下后”而写“伤寒六七日”，认为是传里之实热，这是错误的。张隐庵说：经典讲“所以成结胸者，以下之太早故也”。这里没写“下后”而写“伤寒六七日，结胸热实”，这也是不因下早而结胸的情况，为什么呢？下早致结胸是常理，热实结胸是变局。热实传里成为结胸，是法则中未尽涵盖的情况，所以仲景陈述其证状以附注方剂于其后。由此可见古人用心曲尽其妙。如下章讲水结胸胁，但头汗出者，用大陷胸汤主之，也在常法之外，所以条例其证状以彰显其理。或者是其人本身体虚，或者曾经呕吐攻下导致里气虚弱，外邪因而进入，所以自行为结胸。然而所入的原因不同，其证治则一理而已。
伤寒十余日，热结在里，又往来寒热（Wang Lai Han Re, Alternating Chills and Fever）的，主治与大柴胡汤（Da Chai Hu Tang, Major Bupleurum Decoction）。只有结胸而没有大热的，这是水结在胸胁。只有头部微微出汗的，主治以大陷胸汤。
[成无己注] 伤寒十余日，热结在里，是可下的证候。又往来寒热，是正邪分争，未完全敛结，用大柴胡汤下之。只有结胸而没有大热的，不是热结，是水余结于胸胁，谓之水结胸。周身汗出的是水饮外散，则会痊愈。如果只有头部微微出汗，其余地方无汗，是水饮不得外泄，停蓄而不行，用大陷胸汤以逐其水。《活人书》说：水结胸用小半夏加茯苓汤（Xiao Ban Xia Jia Fu Ling Tang, Minor Pinellia with Poria Decoction）或小柴胡去大枣加牡蛎汤（Xiao Chai Hu Qu Da Zao Jia Mu Li Tang, Minor Bupleurum without Large Jujube plus Oyster Shell Decoction）。
太阳病，重发汗而又复攻下，不大便五六天，舌上干燥而渴，日晡时（Ri Bu, Late Afternoon）小有潮热（Chao Re, Tidal Fever），从心下直到小腹硬满而痛，不可触碰的，主治以大陷胸汤。
[详潮热]
大陷胸汤方
大黄（六两，去皮） 芒硝（一升） 甘遂（一钱，研末）以上三味，用水六升，先煮大黄，取二升，去渣，纳芒硝，煮一二沸，纳甘遂末，温服一升，得快利止后服。
结胸是由于邪气在胸中，处于身体的上部高位，适宜用什么方法呢？应当用吐法吗？所谓“结”，是诸阳受气于胸中，邪气与阳气相结，不能分辨，气不通畅，壅滞于心下，形成硬痛。这是邪正固结于胸中，不同于虚烦膈实，所以必须攻下。低处的病用举法，高处的病用陷法，以平为正。结胸是高位的邪气，用陷法使其下降以平复它，所以叫陷胸汤。陷胸破结，非苦寒直达者不能胜任，所以以甘遂为君药。《内经》说：“咸味涌泄为阴”，又说：“咸以软之，气坚者以咸软之，热胜者以寒消之”。所以芒硝咸寒为臣药，荡涤邪寇，除去不平，发挥将军之功。陷胸涤热，是以大黄苦寒为使药。利药之中，这是峻猛的药剂。伤寒错杂恶劣，结胸最为严重，非此不能通利。剂量大而次数少，须使其迅速分解邪结。
[丹波元简按] 此证经典说“胃中空虚”、“短气烦躁”、“脉浮”，此汤不可轻用。
小结胸病（Xiao Jie Xiong, Minor Chest Binding Syndrome），病位正在心下，按压才痛，脉象浮滑的，主治以小陷胸汤（Xiao Xian Xiong Tang, Minor Xiexion Decoction）。
[注] 上文说“硬满而痛不可近”，是不待按压就痛。这里说“按之则痛”，是手按压之后才作痛。上文说“至少腹”，是通一腹而言。这里说“在正心下”，则少腹不硬痛可知。热邪轻微于前，所以叫小结胸。
小陷胸汤方
半夏（汤洗，半升） 黄连（一两） 栝蒌实（大者一枚）以上三味，用水六升，先煮栝蒌，取三升，去渣，纳诸药，煮取二升，去渣，分温三服。（一服未效，再微服，解下黄涎便安也。苦以泄之，辛以散之。黄连、栝蒌实之苦寒以泄热，半夏之辛以散结。）
病在阳证，应当以汗解之，反而用冷水浇淋或灌洗，其热被遏制不得去除，更加烦闷，皮肤起粟粒状，想要饮水反而不渴的，服用文蛤散（Wen Ge San, Soft-Shell Turtle Shell Powder）。如果不愈，给予五苓散（Wu Ling San, Five-Ingredient Powder with Poria）。寒实结胸无热证者，给予三物小陷胸汤，白散（Bai San, White Powder）也可服用。
白散方
桔梗 贝母（各三分） 巴豆（一分，去皮心，熬黑，研如脂）以上三味为末，纳巴豆更于臼中杵之，以白饮（米汤）和服。强者半钱，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。假令汗出已，腹中痛，与芍药一两，如上法。上热实结胸及寒实结胸，《活人书》不拘寒热，但用陷胸汤不愈者，用枳实理中丸（Zhi Shi Li Zhong Wan, Aurantium and Middle-Warming Pill），应手而愈。结胸项亦强，如柔痉（Rou Jing, Flaccid Spasm）状，下之则和，宜大陷胸丸（Da Xian Xiong Wan, Major Xiexion Pill）。
大陷胸丸方
大黄（半斤） 葶苈（熬） 芒硝 杏仁（去皮尖，熬黑，各半升）以上四味捣筛二味，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。
[海藏云] 大陷胸汤是太阳入本药，大陷胸丸是阳明药，小陷胸汤是少阳药。大陷胸治热实，大陷胸丸兼喘，小陷胸治痞。（大黄、芒硝之苦咸所以下热，葶苈、杏仁之苦甘所以泄满，甘遂取其直达，白蜜取其润利，皆以下泄满实物也。）
心下满痛如结胸状，若头项强痛、眩晕冒昧的，刺大椎（Dazhui, GV14）、肝俞（Ganshu, BL18）。若汗下后头项强痛、发热、小便不利的，用桂枝去桂加茯苓白术汤（Guizhi Qu Gui Jia Fuling Baizhu Tang, Cinnamon Twig Decoction without Cinnamon Twig plus Poria and Atractylodes Macrocephala Decoction）。（方论并见项强）
太阳病二三日，不能卧，但欲起，心下必结，脉微弱者，此本有寒也，反下之。若利止，必作结胸；未止者，四日复下之，此作协热利（Xie Re Li, Concurrent Heat Diarrhea）也。
太阳少阳并病（Taiyang Shaoyang Bing, Concurrent Taiyang and Shaoyang Disease）而反下之，成结胸，心下硬，下利不止，水浆不下，其人心烦。结胸证悉具，烦躁者，亦死。结胸脉浮大，不可下，下之则死。
[张隐庵注] 用药如用兵，知可而进，知难而退，此理势之必然也。夫寸脉淫溢、关脉沉，乃结胸可下之脉。今脉浮大，心中虽结，其表邪尚多，未全结也。若辄下之，重虚其里，外邪复聚而必死矣。仲景所以言此为箴戒，使无踵其弊也。其脉既不可攻，当以候其变而待其实。假如小结胸证，其脉浮滑，按之则痛，故知邪非深结，亦不敢下，无过解除心下之热耳，小陷胸汤主之。或又曰：结胸倘有外证，大陷胸远可用否？予曰：结胸无外证，或有微热，或有小潮热，仲景已明言之。其余别无表证，其邪亦未结实，不可以结胸论也。经曰：“伤寒六七日，若有外证，发热恶寒，支节烦痛，微呕，心下支结，外证未去者，柴胡加桂枝汤（Chai Hu Jia Guizhi Tang, Bupleurum plus Cinnamon Twig Decoction）主之。”又“伤寒六七日，已发汗而复下，胸胁微结，小便不利，渴而不呕，但头汗出，往来寒热，心烦者，此未为解也，柴胡桂枝干姜汤（Chai Hu Guizhi Ganjiang Tang, Bupleurum, Cinnamon Twig and Ginger Decoction）主之。”以上之证，虽云心下支结及言胸胁满微结，二条俱有外证，所以柴胡加桂及加桂姜以和解之。如无外证，止有胸腹结实而痛者，方为结胸病也。
附录
[活人书] 若误下之初未成结胸者，急频与理中汤（Li Zhong Tang, Middle-Warming Decoction），自然得解，更不作结胸。盖理中汤治中焦故也。此古人亦说不到，后人因消息得之。若大转损，有厥证（Jue Zheng, Cold Extremities Syndrome）者，兼与四逆汤（Si Ni Tang, Four-Reversal Decoction）便安。胃中虽和，伤寒未退者，宜候日数足，可下却以承气（Cheng Qi, Purging Formulas）再下之。盖前来下之未是故也。
西晋崔功行云：伤寒结胸欲绝，心膈高起，手不得近，用大陷胸汤皆不瘥者，此是下后虚逆，气已不理而毒复上攻，气毒相搏结于胸者，当用枳实理中丸，先理其气，次疗诸疾。古今用之如神。
枳实理中丸方
枳实（十六枚，麸炒） 茯苓 人参 白术 干姜（炮） 甘草（炙，以上各二两）以上为末，炼蜜丸如鸡子黄大。每服一丸，热汤化下。连进二三服。胸中豁然，渴者加栝蒌根一两。自汗者加牡蛎二两。过下利，亦加。
[海藏] 增损理中丸。王朝奉云：大小陷胸汤丸不愈者，宜与之。
人参 白术 栝蒌 牡蛎（煅） 甘草（炙，各二两） 干姜（炒白，半两） 枳实（麸炒，二十四枚） 黄芩（去枯，一两）以上为末，炼蜜为丸如弹子大。汤一盏，煎服一丸。不解，复与之。不过五六丸，胸中豁然矣。药之神速，未尝见也。渴者加栝蒌根，自汗加牡蛎。
[活人书] 水结在胸胁间，亦名结胸。其证头微汗出，但结胸无热者，小半夏加茯苓汤，小柴胡去枣加牡蛎。
[孙真人] 俞伯道忽患微热，心下满，头有汗，不能解。众医以为温病，用表药；有谓食在膈者，治之皆不愈。召孙真人至，乃用半夏茯苓汤，遂瘥。众问其故，曰：“头有汗，心下满，非湿证，乃水结胸胁也。水既去，其病乃愈。且如湿气心下满，自当遍身汗；若有食，心满头，岂得汗？若言是表，身又不疼不恶寒，表证何在？故凡水结胸胁，头必有汗耳。”
小半夏加茯苓汤（方见呕门）
穿结散
蟾酥 麝香 轻粉 巴豆（另研少许）以上再研过至细，以乳汁为丸如黍米大。每服二丸，用姜汤下，不时服。
海蛤散
海蛤 滑石 甘草（炙，各二两） 芒硝（半两）以上为末，每服二钱，鸡子清调下。
小肠通利则胸膈血散，膻中血聚则小肠壅。小肠壅，膻中血不流行，宜此方。若小便血散，数行更宜桂枝红花汤（Guizhi Honghua Tang, Cinnamon Twig and Safflower Decoction）发其汗则愈。《活人书》云：此方疑非仲景，然其言有理，姑存之。
[戴原礼] 热实结胸，如仲景法治之。又有寒实结胸，虽痛而无烦躁等证，此因下后虚逆，寒气独结，宜理中汤加枳实半钱、茯苓一钱，或枳实理中汤。又有水结胸，无大热证，头微汗出，宜小半夏茯苓汤。又有血结胸，手不可近，其人嗽水不欲咽，喜忘如狂，大便黑色，小便自利，宜犀角地黄汤（Xi Jiao Di Huang Tang, Rhinoceros Horn and Rehmannia Decoction）。
[陶华] 结胸之证，尝见俗医不问曾下与未下，但见心胸满闷，便与桔梗汤，便呼为结胸。盖本朱奉议之说也。有频频与之，反成真结胸者。殊不知结胸乃下早而成，未经下者，非结胸也。乃表邪传至胸中，未入于腑，证虽满闷，尚为在表，正属少阳部分，为半表半里之间，宜用小柴胡汤加枳壳。如未效，则以本方对小陷胸汤，一服豁然，其妙如神。若因下早而成者，方用陷胸汤丸，分浅深从缓而治之，不宜太峻。上焦乃清道，至高之分，若过下则伤元气也。故陷胸汤丸宜从缓治之。尝读仲景《伤寒论》结胸条云：“病发于阳而反下之，热入因作结胸；病发于阴而反下之，因作痞满。所以成结胸者，以下太早故也。”及成氏注释曰：“发热恶寒者，发于阳也；无热恶寒，发于阴也。”再三熟玩，不能不致疑于其间。盖无热恶寒者，寒邪直中阴经之真寒证也，非阳经传至阴经之病也。若误下之，不死则危矣，岂可以泻心汤（Xie Xin Tang, Drain the Epigastrium Decoction）寒热相参之药治之而愈乎？岂反轻如结胸者乎？详此，恐言荣卫阴阳也。风属阳，阳邪伤卫，头痛发热，微汗出，反恶寒者，当服桂枝汤止汗散邪。医者不达而下之，胃气重伤，胸中结硬。经又云：“结胸证，脉浮大者，不可下，下之则死；结胸证悉具而烦躁者，亦死。”盖卫出上焦，清道所伤，不为不重也。故用陷胸汤峻利之药以下之。寒为阴，阴邪伤荣，当服麻黄发表。误下之而成痞满，宜泻心汤以理痞。盖荣出中焦，黄连能泻心下痞，邪下于膈，不犯清道，则元不伤，故轻于结胸耳。若阴经自中之寒，以泻心汤理之而愈者，未之有也。又云：“脉来沉实有力，方为结胸，急用大陷胸汤加枳桔下之。”
治结胸灸法
巴豆（十四个） 黄连（七寸，去皮）以上捣细，津唾和成膏，填入脐中，以艾灸其上。腹中有声，其病去矣。不拘壮数，病去为度。才灸后便以温汤浸手帕拭之，恐生疮也。
[摘玄] 伤寒结胸，先使人心蔽骨下正痛处左畔揉之，以毫针刺左畔支沟穴（正坐侧臂取之，二分）。次刺左间使（Jianshi, PC7）。名曰双阙。次刺左行间（Hang Jian, LR2）（卧取之，针入六分。此支沟、行间穴下针至分数内，捻针令病患五吸，次外捻针三呼，又次内捻针五吸，吃长呼一口气，出针。即左畔一壁结胸立效。右畔根据上刺之。慢慢呼吸，停针，用针获时而愈。）
[云岐子] 伤寒结胸痞气：胸中结痞，涌泉（Yongquan, KI1）、太溪（Taixi, KI3）、中冲（Zhongchong, PC9）、太陵（Tailing, PC7）。心中结痞，隐白（Yinbai, SP1）、太白（Taibai, SP3）、少冲（Shaochong, HT8）、神门（Shenmen, HT7）。胃中结痞，少商（Shaoshang, LU11）、太涧（应为太渊 Taiyuan, LU9）、大敦（Dadun, LR1）、太冲（Taichong, LR3），并上下腕泻之。
[摘玄] 血结胸，面赤大燥，口干消渴，胸中疼痛不可忍。期门（Qimen, LR14）、太陵、关元（Guanyuan, CV4）（妊娠不得刺关元，胎死不出，子母俱亡，慎之）。
[Background Information]
Book: Zhengzhi Zhunsheng · Shanghan (Standardized Treatment of Cold Damage)
Author: Wang Kentang
Dynasty: Ming
Chapter: Jie Xiong (Chest Binding)
Category: Shanghan (Cold Damage)
If there is a sensation of fullness and obstruction in the epigastrium (Xia Xin), which feels hard upon palpation and is painful, it is called Jie Xiong (Chest Binding Syndrome). If it feels hard upon palpation but is not painful, it is called Pi Qi (Stagnant Qi). The Classics state: When a disease originates from a Yang syndrome (characterized by fever and aversion to cold), if purgatives are mistakenly used, heat enters internally and consequently forms Jie Xiong. When a disease originates from a Yin syndrome (characterized by absence of fever and only aversion to cold), if purgatives are mistakenly used, it consequently forms Pi syndrome. The reason for forming Jie Xiong is that purgation was performed too early. Originally, the exterior syndrome should have been resolved through sweating, but instead, purgation was used. This damaged the righteous qi inside, allowing the complete heat of the exterior to enter the interior vacuously and bind at the epigastrium, forming Jie Xiong. When the yin portion inside has already been affected by pathogenic heat and become ill, this is called originating from Yin. Or, if there is only slight fever, the interior excess syndrome is not yet fully formed, and the patient cannot tolerate catharsis, yet purgation is mistakenly used; although the slight heat inside may be cleared, the heat pathogen from the exterior and interior arrives again. Even if Jie Xiong does not form, Pi syndrome will result. Xiao Jie Xiong (Minor Chest Binding) is lighter than Da Xie Xiong (Major Chest Binding) but heavier than Pi. This depends on the magnitude of the error, not because Pi is considered a cold syndrome. The Classics say, "Only Jie Xiong exists without significant fever," referring to Han Shi Jie Xiong (Cold-Excess Chest Binding), which indeed is not a cold syndrome, but merely mild heat. As for Zang Jie (Organ Binding), the Classics state that when heat binds in the zang organs, the disease is deep, hence it is said to be difficult to treat. Using cooling agents can also lead to survival. There is also Yang Jie (Yang Binding), where heat binds in the fu organs, resulting in a mild and superficial condition. Additionally, Liu Yin (Retained Fluids) that do not dissipate can cause head sweating, submerged pulse, and accumulation of fluids binding to the bones, forming Shui Jie Xiong (Water-Binding Chest). There are also cases of Jie Xiong and Pi not caused by mistaken purgation; these arise from failure to purge and erroneous sweating. The Classics state: "Heat has entered the interior; if not purged for a long time, it will also form firmness." This is referred to as "three deaths and one life" due to failure to purge. After sweating, if heat transmits to the epigastrium forming Pi, this is called failure to sweat properly. It is known that Jie Xiong must be treated with purgation; however, if the pulse is floating and large, purgation must not be used, otherwise death ensues, because the exterior pathogen remains and the condition is not yet fully bound. Furthermore, if all symptoms of Jie Xiong are present and accompanied by irritability, it is also incurable. Medicines can drive out pathogens only after the stomach qi distributes the medicinal power, enabling warming, sweating, vomiting, or purging to expel the pathogen. If the pathogen is strong and the stomach qi is exhausted, treatment is impossible.
In Taiyang Disease (Taiyang Disease), the pulse is floating, active, and rapid. Floating indicates wind, rapid indicates heat, active indicates pain, and rapid also indicates deficiency. Headache, fever, slight night sweating (Dao Han), and aversion to cold indicate that the exterior syndrome is unresolved. If the physician mistakenly uses purgation, the previously active and rapid pulse changes to slow. There is resistance and pain in the diaphragm, emptiness in the stomach, Ke Qi (Invading Pathogen) agitates the diaphragm, shortness of breath, irritability, and Ao Nao (Restlessness and Discomfort in the Heart). Yang qi sinks internally, causing hardness in the epigastrium, forming Jie Xiong. The primary formula is Da Xian Xiong Tang (Major Xiexion Decoction).
[Cheng Wuji's Commentary] Active and rapid pulses are yang pulses; one should attribute the pathogen to the exterior. Sweating during sleep is called Dao Han. If the pathogen were in the half-exterior half-interior, there would be no aversion to cold. Here, headache, fever, slight night sweating, and aversion to cold indicate the exterior is unresolved; sweating should be induced. Mistaken purgation damages the stomach qi, allowing exterior pathogens to sink internally. Pathogens in the interior manifest as yang pulses; pathogens in the interior manifest as yin pulses. Internal sinking of pathogens causes the active/rapid pulse to become slow, while the floating pulse remains unchanged because the pathogen binds in the upper jiao chest, where yang qi binds, preventing the pulse from sinking. Ke Qi refers to external pathogens entering the interior due to stomach emptiness and binding in the chest-diaphragm. Resistance and pain in the diaphragm indicate Ke Qi agitating the diaphragm. *Jingui Yaolue* states: "Shortness of breath with inability to breathe fully is an excess syndrome." Shortness of breath, irritability, and Ao Nao are all due to pathogenic heat being excess. Internal sinking of yang qi prevents flow to the diaphragm, causing congestion in the epigastrium, leading to hardness, fullness, and pain, forming Jie Xiong. Da Xian Xiong Tang is used to purge the binding heat.
[Dannbo Yuanjian's Note] Taiyang disease is in the exterior and unresolved; attacking the interior while in the exterior is considered deficient. Moreover, the obtained pulses are all floating, active, and rapid. Now, after mistaken purgation, the active/rapid pulse becomes slow, and it is stated that the stomach is empty, shortness of breath occurs, and there is irritability; the deficiency is severe. If one claims yang qi has sunk and the epigastrium is hard, can aggressive purgation be applied immediately? Is Da Xie Xiong milder than Chengqi formulas? Since purgation has already been used, it should not be repeated; how can we not fear further deficiency? Earlier it was stated that if the Jie Xiong pulse is floating and large, purgation is contraindicated, and purging leads to death. It was also stated that if all Jie Xiong symptoms are present with irritability, it is fatal. Now, with a floating pulse and irritability, can Da Xian Xiong Tang truly be used? If yang disease excess is purged, and subsequently the stomach is empty, Ke Qi agitates the diaphragm, and there is Ao Nao, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used to induce vomiting of pathogens from the chest. Especially since Taiyang disease, having failed to purge, clearly presents deficiency signs.
After six or seven days of Shanghan, if there is Jie Xiong with heat-excess, a submerged and tight pulse, pain in the epigastrium, and hardness like stone upon palpation, Da Xian Xiong Tang is indicated.
[Zhang Yinan's Commentary] The earlier text already explained that when disease originates from yang and is mistakenly purged, heat enters and forms Jie Xiong, so the following text need not repeat this. The earlier text only explained the cause of Jie Xiong; here, the pulse and symptoms are elucidated. Cheng Wuji's note suggests that mentioning "six or seven days of Shanghan" instead of "after purgation" implies transmitted interior excess heat, which is incorrect. Zhang Yinan states: The Classics say, "The reason for Jie Xiong is premature purgation." Here, mentioning "six or seven days of Shanghan, heat-excess Jie Xiong" without mentioning purgation indicates Jie Xiong occurring without premature purgation. Why? Premature purgation causing Jie Xiong is the norm; heat-excess Jie Xiong is the variation. Heat-excess transmitting to the interior to form Jie Xiong is a gap in standard rules, so Zhang Zhongjing described the symptoms to annotate the formula. This shows the meticulous care of ancients. Similarly, in the next chapter regarding water-binding in the chest-hypochondrium with only head sweating, Da Xian Xiong Tang is used, which is outside standard rules, so symptoms are detailed to clarify principles. Alternatively, if the person is inherently deficient or has undergone vomiting/purgation weakening interior qi, external pathogens enter spontaneously, forming Jie Xiong. Although the causes differ, the treatment principle remains the same.
After ten-plus days of Shanghan, if heat binds in the interior and there is alternating chills and fever (Wang Lai Han Re), Da Chai Hu Tang (Major Bupleurum Decoction) is indicated. If there is only Jie Xiong without significant fever, this is water binding in the chest-hypochondrium. If there is only slight head sweating, Da Xian Xiong Tang is indicated.
[Cheng Wuji's Commentary] After ten-plus days of Shanghan, heat binding in the interior is a purgation indication. Alternating chills and fever indicate struggle between righteous and pathogenic qi, not yet fully condensed; Da Chai Hu Tang is used to purge. If there is only Jie Xiong without significant fever, it is not heat binding but residual water binding in the chest-hypochondrium, called Water Jie Xiong. Generalized sweating indicates water fluids dispersing externally, leading to recovery. If only slight head sweating occurs with no other sweating, water fluids cannot disperse externally, stagnating and stopping; Da Xian Xiong Tang is used to expel water. *Huoren Shu* states: For Water Jie Xiong, use Xiao Ban Xia Jia Fu Ling Tang (Minor Pinellia with Poria Decoction) or Xiao Chai Hu Qu Da Zao Jia Mu Li Tang (Minor Bupleurum without Large Jujube plus Oyster Shell Decoction).
In Taiyang disease, after heavy sweating and subsequent purgation, if there is constipation for five to six days, dry tongue with thirst, slight tidal fever (Chao Re) in the late afternoon (Ri Bu), hardness and fullness from the epigastrium to the lower abdomen that is painful and intolerable to touch, Da Xian Xiong Tang is indicated.
[See Tidal Fever]
Da Xian Xiong Tang Formula
Da Huang (6 liang, peeled), Mang Xiao (1 sheng), Gan Sui (1 qian, powdered). Boil the first three ingredients in 6 sheng of water, first decocting 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 brisk purgation occurs.
Jie Xiong arises from pathogens in the chest, located at the high position of the body. What method is suitable? Should emesis be used? The term "Jie" (binding) refers to yang qi receiving energy in the chest; pathogenic qi binds with yang qi, becoming indistinguishable, blocking qi flow, causing congestion in the epigastrium, leading to hardness and pain. This is pathogenic and righteous qi firmly bound in the chest, distinct from deficiency vexation or diaphragmatic excess, thus requiring purgation. Low diseases are lifted; high diseases are descended, aiming for balance. Jie Xiong is a high pathogen; descending it brings balance, hence the name "Xian Xiong Tang" (Descending Chest Decoction). Descending chest and breaking binding requires bitter-cold herbs reaching directly; thus, Gan Sui is the sovereign herb. *Neijing* states: "Salty flavors induce vomiting and purging, belonging to yin," and "Salty softens; firm qi is softened by salty; heat dominance is eliminated by cold." Thus, Mang Xiao, salty and cold, is the minister herb, sweeping away pathogens and removing imbalance, acting as the general. To descend chest and cleanse heat, Da Huang, bitter and cold, is the envoy herb. Among purgative medicines, this is a potent agent. In complex and severe Shanghan, Jie Xiong is the most severe; only this can unblock. The dosage is large but frequency low, ensuring rapid decomposition of pathogenic binding.
[Dannbo Yuanjian's Note] The Classics mention "stomach emptiness," "shortness of breath and irritability," and "floating pulse"; this decoction must not be used lightly.
Xiao Jie Xiong (Minor Chest Binding Syndrome) occurs precisely at the epigastrium; pain arises only upon palpation, and the pulse is floating and slippery. Xiao Xian Xiong Tang (Minor Xiexion Decoction) is indicated.
[Note] The earlier text mentioned "hardness, fullness, and pain intolerable to touch," indicating pain without palpation. Here, "pain upon palpation" means pain only after manual pressure. The earlier text mentioned extending to the lower abdomen, implying the whole abdomen. Here, "precisely at the epigastrium" implies the lower abdomen is not hard or painful. Heat is milder than before, hence "Minor" Jie Xiong.
Xiao Xian Xiong Tang Formula
Ban Xia (half sheng, washed in hot water), Huang Lian (1 liang), Gua Lou Shi (one large fruit). Boil the first three ingredients in 6 sheng of water, first decocting Gua Lou to obtain 3 sheng, remove dregs, add other herbs, decoct to obtain 2 sheng, remove dregs. Divide into three warm doses. (If one dose is ineffective, take a small additional dose; passing yellow phlegm brings relief. Bitterness drains heat; pungency disperses binding. Bitter-cold Huang Lian and Gua Lou Shi drain heat; pungent Ban Xia disperses binding.)
When the disease is in the yang stage, it should be resolved by sweating. If mistakenly cooled with cold water splashing or pouring, the heat is suppressed and cannot leave, causing greater烦闷 (vexation), skin gooseflesh, desire to drink but no thirst. Wen Ge San (Soft-Shell Turtle Shell Powder) is administered. If ineffective, Wu Ling San (Five-Ingredient Powder with Poria) is given. For Han Shi Jie Xiong (Cold-Excess Chest Binding) without heat signs, San Wu Xiao Xian Xiong Tang or Bai San (White Powder) may be used.
Bai San Formula
Jie Geng, Bei Mu (each 3 fen), Ba Dou (1 fen, peeled, heart removed, roasted black, ground to paste). Grind the first three into powder, mix with Ba Dou, pound in mortar. Mix with Bai Yin (rice gruel) for administration. Strong patients take half qian; weak patients reduce dose. Pathogens above the diaphragm cause vomiting; below, diarrhea. If no diarrhea, give one cup of hot porridge; if diarrhea persists excessively, give one cup of cold porridge. If sweating occurs and abdominal pain follows, administer Shao Yao (1 liang) as above. For Re Shi Jie Xiong (Heat-Excess Chest Binding) and Han Shi Jie Xiong, *Huoren Shu* advises using Xie Xiong Tang regardless of cold/heat; if ineffective, use Zhi Shi Li Zhong Wan (Aurantium and Middle-Warming Pill) for immediate relief. If Jie Xiong involves neck stiffness resembling Rou Jing (Flaccid Spasm), purgation harmonizes; Da Xian Xiong Wan (Major Xiexion Pill) is indicated.
Da Xian Xiong Wan Formula
Da Huang (half jin), Ting Li (roasted), Mang Xiao, Xing Ren (peeled, pointed removed, roasted black, each half sheng). Pound and sieve two ingredients, mix with Xing Ren and Mang Xiao until paste-like. Form pill size of a bullet. Separately pound Gan Sui end to 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; stool passes overnight. If no stool, take another dose; effectiveness is marked by stool passage. Follow medication restrictions.
[Hai Zang says] Da Xian Xiong Tang is the primary formula for Taiyang entering the interior; Da Xian Xiong Wan is for Yangming; Xiao Xian Xiong Tang is for Shaoyang. Da Xie Xiong treats heat-excess; Da Xie Xiong Wan treats heat-excess with wheezing; Xiao Xie Xiong treats Pi. (Bitter-salty Da Huang and Mang Xiao descend heat; bitter-sweet Ting Li and Xing Ren drain fullness; Gan Sui reaches directly; white honey moistens and lubricates; all act to descend and drain full/excess substances.)
If the epigastrium is full and painful resembling Jie Xiong, accompanied by neck stiffness, headache, and dizziness, needle Dazhui (GV14) and Ganshu (BL18). If after sweating/purgation there is neck stiffness, headache, fever, and dysuria, use Guizhi Qu Gui Jia Fuling Baizhu Tang (Cinnamon Twig Decoction without Cinnamon Twig plus Poria and Atractylodes Macrocephala Decoction). [Formula discussion see Neck Stiffness].
In Taiyang disease, after two to three days, if the patient cannot lie down but wants to sit up, the epigastrium is likely bound. If the pulse is weak and fine, this indicates pre-existing cold. Mistaken purgation follows. If diarrhea stops, Jie Xiong will form; if it continues, and purgation is repeated on the fourth day, this becomes Xie Re Li (Concurrent Heat Diarrhea).
In Taiyang disease, if purgation is used and the pulse remains floating, Jie Xiong will definitely form.
In concurrent Taiyang and Shaoyang disease (Taiyang Shaoyang Bing), mistaken purgation forms Jie Xiong. The epigastrium is hard, diarrhea is incessant, food and fluids cannot be taken, and the patient is irritable. If all Jie Xiong symptoms are present with irritability, it is fatal. If the Jie Xiong pulse is floating and large, purgation is contraindicated; purging leads to death.
[Zhang Yinan's Commentary] Medication is like warfare: advance when possible, retreat when difficult; this is inevitable logic. Floating pulse at cun and submerged at guan indicate Jie Xiong amenable to purgation. Now, with a floating and large pulse, although there is internal binding, exterior pathogens are still numerous and not fully bound. Immediate purgation severely weakens the interior, allowing external pathogens to re-aggregate, leading to death. Zhang Zhongjing warns against this to prevent repeating errors. Since the pulse is not attackable, wait for changes and confirmation of excess. For example, in Xiao Jie Xiong, the pulse is floating and slippery, painful on palpation, indicating shallow binding; do not purge, only clear epigastric heat with Xiao Xian Xiong Tang. Some ask: If Jie Xiong has exterior signs, can Da Xie Xiong be used? I say: Jie Xiong has no exterior signs, or only slight fever or minor tidal fever, as clarified by Zhang Zhongjing. Other than this, there are no exterior signs, and the pathogen is not firmly bound, so it cannot be classified as Jie Xiong. The Classics state: "After six or seven days of Shanghan, if there are exterior signs such as fever, aversion to cold, limb pain, slight vomiting, and subcostal binding, with exterior signs unresolved, Chai Hu Jia Guizhi Tang (Bupleurum plus Cinnamon Twig Decoction) is indicated." Also: "After six or seven days of Shanghan, after sweating and purgation, if there is slight chest-hypochondriac binding, dysuria, thirst, no vomiting, only head sweating, alternating chills and fever, and irritability, the disease is not resolved; Chai Hu Guizhi Ganjiang Tang (Bupleurum, Cinnamon Twig and Ginger Decoction) is indicated." These cases, though mentioning subcostal binding or slight chest-hypochondriac fullness, both have exterior signs, so Chai Hu formulas harmonize them. Without exterior signs, only firm chest/abdominal binding with pain constitutes Jie Xiong disease.
Appendix
[Huoren Shu] If mistaken purgation initially fails to form Jie Xiong, urgently and frequently administer Li Zhong Tang (Middle-Warming Decoction); it will naturally resolve without forming Jie Xiong, as Li Zhong Tang treats the middle jiao. This point was overlooked by ancients but discovered by later generations through reflection. If there is severe damage with Jue Zheng (Cold Extremities Syndrome), combine with Si Ni Tang (Four-Reversal Decoction) for comfort. Although the stomach harmonizes, if Shanghan remains, wait for sufficient days before using Cheng Qi (Purging Formulas) again, as previous purgation was inappropriate.
Cui Gongxing of Western Jin stated: In severe Shanghan Jie Xiong, the epigastrium rises high, hands cannot approach, and Da Xian Xiong Tang fails. This is due to post-purgation deficiency and rebellious qi, where toxins attack upward, binding with qi in the chest. Use Zhi Shi Li Zhong Wan to regulate qi first, then treat other diseases. Used effectively since ancient times.
Zhi Shi Li Zhong Wan Formula
Zhi Shi (16 pieces, bran-fried), Fu Ling, Ren Shen, Bai Zhu, Gan Jiang (roasted), Zhi Gan Cao (honey-fried, each 2 liang). Grind into powder, refine honey into pills size of chicken egg yolk. Take one pill dissolved in hot water. Continue 2-3 doses. If chest opens and thirst occurs, add Gua Lou Gen (1 liang). If spontaneous sweating occurs, add Mu Li (2 liang). If excessive diarrhea occurs, add as well.
[Hai Zang] Zeng Sun Li Zhong Wan. Wang Chaofeng stated: If Da/Xiao Xie Xiong Tang/Wan fail, use this.
Ren Shen, Bai Zhu, Gua Lou, Mu Li (calcined), Zhi Gan Cao (each 2 liang), Chao Bai Gan Jiang (0.5 liang), Zhi Shi (bran-fried, 24 pieces), Huang Qin (remove rotten part, 1 liang). Grind into powder, refine honey into pill size of a bullet. Decoct one bowl of water, take one pill. If unresolved, repeat. Within 5-6 pills, the chest opens. The speed is miraculous. Add Gua Lou Gen for thirst, Mu Li for sweating.
[Huoren Shu] Water binding in the chest-hypochondrium is also named Jie Xiong. Symptoms include slight head sweating, only Jie Xiong without heat. Use Xiao Ban Xia Jia Fu Ling Tang or Xiao Chai Hu Qu Zao Jia Mu Li Tang.
[Sun Simiao] Yu Bodao suddenly suffered slight fever, epigastric fullness, and head sweating, unresolved. Physicians treated as Warm Disease with exterior-resolving drugs, or as food stagnation in the diaphragm; all failed. Sun Simiao used Ban Xia Fu Ling Tang, and the patient recovered. Asked why, he said: "Head sweating and epigastric fullness indicate not dampness, but water binding in the chest-hypochondrium. Once water leaves, the disease resolves. If it were dampness causing epigastric fullness, there would be generalized sweating. If food stagnation, would there be head sweating? If it were exterior, there would be body ache and aversion to cold. Where is the exterior sign? Therefore, water binding in the chest-hypochondrium always presents with head sweating."
Xiao Ban Xia Jia Fu Ling Tang [See Vomiting Section]
Chuan Jie San
Chan Su, She Xiang, Qing Fen, Ba Dou (separately ground slightly). Grind finely, form pills size of millet seeds with milk. Take 2 pills with ginger soup as needed.
[Bencao] Women with Shanghan suffering from Blood Jie Xiong in the chest-diaphragm experience pain upon rubbing, intolerable to touch.
Hai Ge San
Hai Ge, Hua Shi, Zhi Gan Cao (each 2 liang), Mang Xiao (0.5 liang). Grind into powder. Take 2 qian mixed with egg white.
If the Small Intestine is unobstructed, blood in the chest-diaphragm disperses. If blood gathers in Dan Zhong, the Small Intestine becomes obstructed. If the Small Intestine is obstructed, blood in Dan Zhong does not flow. Use this formula. If urine contains blood, taking it multiple times is beneficial. Alternatively, Guizhi Honghua Tang (Cinnamon Twig and Safflower Decoction) to induce sweating leads to recovery. *Huoren Shu* notes: This formula is suspected not to be by Zhang Zhongjing, but the reasoning is sound; retain it.
[Dai Yuanli] Treat Heat-Excess Jie Xiong according to Zhang Zhongjing's methods. There is also Cold-Excess Jie Xiong, painful but without irritability, caused by post-purgation deficiency and cold binding alone. Use Li Zhong Tang plus 0.5 qian Zhi Shi and 1 qian Fu Ling, or Zhi Shi Li Zhong Tang. There is Water Jie Xiong without significant heat, with slight head sweating; use Xiao Ban Xia Fu Ling Tang. There is Blood Jie Xiong, intolerable to touch, with coughing but not swallowing water, forgetfulness resembling mania, black stool, and free urination; use Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction).
[Tao Hua] Regarding Jie Xiong, common physicians often prescribe Jie Geng Tang whenever chest/epigastric fullness is seen, calling it Jie Xiong, based on Zhu Fengyi's theory. Frequent use can transform it into true Jie Xiong. They do not know that Jie Xiong is caused by premature purgation; those not purged do not have Jie Xiong. It is exterior pathogens transmitting to the chest, not entering the fu organs. Although full, it remains in the exterior, belonging to the Shaoyang sector, the half-exterior half-interior. Use Xiao Chai Hu Tang plus Zhi Qiao. If ineffective, combine with Xiao Xian Xiong Tang for immediate relief. Only if caused by premature purgation should Xie Xiong Tang/Wan be used, treating gradually based on depth, not too aggressively. The upper jiao is the clear pathway, the highest division; excessive purgation damages yuan qi. Thus, Xie Xiong Tang/Wan should be treated cautiously. Reading Zhang Zhongjing's *Shanghan Lun* Jie Xiong section: "Disease originating from yang, mistakenly purged, heat enters forming Jie Xiong; disease originating from yin, mistakenly purged, forms Pi fullness. The reason for Jie Xiong is premature purgation." Cheng Shi's commentary says: "Fever and aversion to cold originate from yang; no fever and aversion to cold originate from yin." Repeated study raises doubts. No fever and aversion to cold indicate true cold directly invading yin meridians, not transmission from yang to yin. Mistaken purgation would be fatal or critical; how could Xie Xin Tang (Drain the Epigastrium Decoction) with mixed cold/hot herbs cure it? How could it be milder than Jie Xiong? This likely refers to Ying and Wei yin-yang. Wind belongs to yang; yang pathogens injure Wei, causing headache, fever, slight sweating, and aversion to cold; Guizhi Tang should stop sweating and scatter pathogens. Physicians failing to understand this purge, damaging stomach qi and causing chest binding. The Classics state: "Jie Xiong with floating/large pulse cannot be purged, purging leads to death; Jie Xiong with all symptoms and irritability is fatal." Wei originates from the upper jiao; injury to the clear pathway is serious. Thus, potent Xie Xiong Tang is used to purge. Cold is yin; yin pathogens injure Ying, requiring Ma Huang to release the exterior. Mistaken purgation forms Pi; use Xie Xin Tang to regulate Pi. Ying originates from the middle jiao; Huang Lian drains epigastric Pi. Pathogens descend to the diaphragm, not harming the clear pathway, so yuan qi is undamaged, making it milder than Jie Xiong. If cold directly invading yin meridians were cured by Xie Xin Tang, it has never been observed. Also: "Submerged, solid, and forceful pulse indicates Jie Xiong; urgently use Da Xian Xiong Tang plus Jie Geng and Jie Ke to purge."
Moxibustion Method for Treating Jie Xiong
Ba Dou (14 pieces), Huang Lian (7 cun, peeled). Pound finely, mix with saliva into paste, fill into the navel. Moxa above. Sound in the abdomen indicates disease removal. Number of moxa cones is not fixed; stop when disease is gone. Immediately wipe with warm wet towel after moxibustion to prevent sores.
[Zhaixuan] For Shanghan Jie Xiong, massage the left side of the sternum's painful point. Needle Zhi Gou (SJ6) on the left side (sit upright, arm sideways, depth 2 fen). Then needle Jianshi (PC7) on the left, named Shuang Que. Then needle Hang Jian (LR2) on the left (lie down, depth 6 fen. While needling Zhi Gou/Hang Jian to specified depth, rotate needle letting patient inhale five times, then exhale three times rotating outward, then inhale five times rotating inward. Exhale long, withdraw needle. Left-side Jie Xiong resolves immediately. Right side follows same method. Breathe slowly, retain needle, withdraw at appropriate time for recovery.)
[Yun Qizi] Shanghan Jie Xiong and Pi Qi:
Chest binding: Yongquan (KI1), Taixi (KI3), Zhongchong (PC9), Tailing (PC7).
Heart binding: Yinbai (SP1), Taibai (SP3), Shaochong (HT8), Shenmen (HT7).
Stomach binding: Shaoshang (LU11), Taiyuan (LU9), Dadun (LR1), Taichong (LR3), plus draining upper/lower wrist points.
[Tongxuan Zhiyao Fu] Jie Xiong with jaundice: Yongquan.
[Zhaixuan] Blood Jie Xiong: flushed face, severe dryness, dry mouth, polydipsia, unbearable chest pain. Qimen (LR14), Tailing, Guanyuan (CV4) (Do not needle Guanyuan in pregnancy; if fetus dies and cannot be expelled, mother and child both perish; be cautious).
[Jicheng] Shanghan chest-diaphragm pain: Qimen, Tailing.
[Huoren Shu] Recent treatments for Jie Xiong often use gold needles and sulfur/Yang Qi Shi. If Cold-Excess Jie Xiong may recover, Heat-Excess Jie Xiong will definitely be fatal.