结胸者异日之阳明今日下早而成者也胃腑燥热汗亡其阴则成阳明胸膈湿热下陷其阳则成结胸若迟延数日湿被燥夺表
寒已解腑热既实一下而愈何至于此故太阳而见阳明之证宁迟迟而用承气勿匆匆而用陷胸盖结胸乃阳明之坏病也阳明之病
在腹结胸之病在胸承气泄下焦之燥热陷胸泄上焦之湿热高下不同燥湿亦异也
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烦躁心中懊 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剂颈而
还小便不利者身必发黄也
太阳病脉浮而兼动数浮则为表中于风数则为营郁发热动则为经气莫泄郁迫而生疼痛数从浮见尚非内实是以曰虚其证
头痛发热微盗汗出而反恶寒者表邪未解故也医不解表而反下之动数之脉变而为迟则胃气败矣阳败胃逆碍胆木降路逆冲胸
膈胆胃相拒则膈内疼痛甲木下行化相火而归癸水相火在水是为下焦主气今阳败胃虚甲木逆行以下焦主气客居膈上冲动不
已此拒痛所由来也心肺之气以下降为顺胃胆逆阻心肺莫降相火上炎助君火而刑辛金则烦躁懊 气短胸盈膈热郁发皮毛不
开经中阳气亦遂内陷经腑之热彼此壅塞心中坚凝是为结胸肺金郁遏雾气淫蒸津液淤浊化生痰涎大陷胸汤硝黄清其郁热甘
遂决其痰饮胸中邪热推荡无余矣若其不成结胸但头上汗出余处无汗剂颈而还下见小便不利者是苦寒泄其脾阳湿气内郁而
无降路身必发黄也表热传胃则为阳明证阳明有阳而无阴故病燥热表热入膈则为结胸证结胸上阳而下阴故病湿热脏气发舒
则津液流溢脏气堙塞则痰涎凝结无二理也
按大陷胸证表阳即陷而经邪未解是宜内清胸膈之热外解皮毛之邪使上郁之里热固自里散内陷之表阳还从表出仲景用
大陷胸汤但泄上焦湿热而不用表药是救急之法此处尚可变通愚意用石膏甘遂枳实麻黄双解表里得仲景法外之意矣 程氏
曰结胸证用枳实理中丸甚效欲破其结而软其坚则黄芩栝蒌牡蛎为佳
结胸证是阳明病因过早攻下而形成的变证。胃腑燥热，汗出过多导致阴液亡失，就会形成阳明病；胸膈湿热下陷，阳气随之陷入，就会形成结胸证。如果拖延数日，湿气被燥气所夺，表寒已经解除，腑热已经结实，此时使用泻下法即可痊愈，何至于发展到这种地步呢？因此，太阳病出现阳明证的迹象时，宁可迟缓地使用承气汤类方剂，也不要匆忙地使用陷胸汤类方剂。这是因为结胸证乃是阳明病的坏病（误治后的变证）。阳明病的病变部位在腹部，结胸证的病变部位在胸部。承气汤泄下的是下焦的燥热，陷胸汤泄的是上焦的湿热，高下不同，燥湿性质也有差异。
太阳病，脉象浮而动数。浮脉主风邪，数脉主热，动脉主痛，数脉在此处也提示正气虚损。患者头痛、发热，微微盗汗，反而恶寒，这是表证尚未解除的表现。医生反而使用攻下法，导致动数之脉变为迟脉。膈内拒按疼痛，胃中空虚，客气（外邪或逆乱之气）扰动膈部，出现短气、烦躁、心中懊憹（烦闷不安）。阳气内陷，心下（胃脘部）因此变得硬满，这就是结胸证，主治大陷胸汤。如果不形成结胸，仅头部出汗，身体其余部位无汗，汗止于颈部而还，小便不利的，身体一定会发黄。
太阳病脉象浮而兼见动数。浮脉表示表受风邪，数脉表示营分郁滞发热，动脉表示经气不能宣泄，郁迫而生疼痛。数脉从浮脉中显现，说明尚非内部实证，所以称为“虚”。其症状为头痛、发热、微盗汗出而反恶寒，这是表邪未解的缘故。医生不解表反而攻下，动数之脉变为迟脉，意味着胃气败坏。阳气衰败，胃气上逆，阻碍胆木下降之路，逆气冲撞胸膈，胆与胃相互抗拒，导致膈内疼痛。甲木（胆）下行化为相火而归入癸水（肾），相火在水中是下焦的主气。如今阳气衰败、胃虚，甲木逆行，以下焦主气的身份客居膈上，冲动不已，这就是拒痛产生的原因。心肺之气以向下顺降为正常，胃胆逆阻导致心肺无法下降，相火上炎助长君火而克制辛金（肺），从而出现烦躁、懊憹、气短、胸部胀满、膈热郁发。皮毛不开，经中的阳气也随之内陷，经络与脏腑的热邪彼此壅塞，心中坚凝，这就形成了结胸证。肺金被郁遏，雾气淫蒸，津液淤浊化生为痰涎，大陷胸汤用芒硝、大黄清除郁热，用甘遂决破痰饮，将胸中的邪热推荡干净。如果不形成结胸，仅头上出汗，其余部位无汗，汗止于颈部而还，且见小便不利，这是苦寒药物泄伤了脾阳，湿气内郁而没有下降出路，身体一定会发黄。表热传入胃中则形成阳明证，阳明有阳而无阴，所以病表现为燥热；表热进入膈中则形成结胸证，结胸上阳而下阴，所以病表现为湿热。脏气舒展则津液流溢，脏气壅塞则痰涎凝结，这是没有二致的道理。
按语：大陷胸证中，表阳已经内陷但经邪未解，本应内清胸膈之热，外解皮毛之邪，使上郁的里热从内部消散，内陷的表阳从体表排出。张仲景使用大陷胸汤，只泄上焦湿热而不使用解表药，这是救急的方法，此处理论上尚可变通。我个人的意见是使用石膏、甘遂、枳实、麻黄双解表里，这得到了张仲景法度之外的意蕴。程氏说：结胸证使用枳实理中丸非常有效，想要破除结聚并软化坚硬，则黄芩、瓜蒌、牡蛎为佳。
Jie Xiong (Chest Binding) is a complication of Yangming disease resulting from premature purgation. When the stomach fu organ has dry-heat and excessive sweating leads to the loss of yin fluids, Yangming disease forms; when damp-heat in the chest and diaphragm sinks downward causing yang qi to collapse inward, Jie Xiong forms. If one delays for several days, the dampness is consumed by dryness, the exterior cold is resolved, and the fu heat is solidified, purgation at this time would cure it, so why let it reach this state? Therefore, when Taiyang disease presents with signs of Yangming, it is better to delay and use Cheng Qi Tang (Gut-Preserving Decoction) rather than hastily use Xian Xiong Tang (Depress Chest Decoction). This is because Jie Xiong is a *huai bing* (complication from mis-treatment) of Yangming. The pathology of Yangming disease lies in the abdomen, while the pathology of Jie Xiong lies in the chest. Cheng Qi Tang purges dry-heat from the lower jiao, whereas Xian Xiong Tang purges damp-heat from the upper jiao; their locations differ (high vs. low), and their pathological natures differ (dry vs. damp).
In Taiyang disease, the pulse is floating, moving, and rapid. Floating indicates wind pathogen, rapid indicates heat, moving indicates pain, and rapid here also suggests deficiency of righteous qi. The patient experiences headache, fever, slight nocturnal sweating, yet paradoxically feels aversion to cold, indicating that the exterior syndrome is not yet resolved. If the physician erroneously applies purgation, the moving and rapid pulse changes to a slow one. There is resistance and pain in the diaphragm, the stomach cavity becomes empty, and "ke qi" (adverse qi) disturbs the diaphragm, leading to shortness of breath, irritability, and *ao nao* (deep restlessness). Yang qi collapses inward, causing the area below the heart (epigastrium) to become hard; this is Jie Xiong, treated primarily with Da Xian Xiong Tang (Major Depress Chest Decoction). If Jie Xiong does not form, but there is sweating only on the head and no sweat elsewhere, stopping at the neck, accompanied by difficulty in urination, the body will inevitably develop jaundice.
In Taiyang disease, the pulse is floating and combined with moving and rapid qualities. Floating indicates wind attacking the exterior, rapid indicates stagnation of the Ying (nutritive) level causing fever, moving indicates the inability of Jing (channel) qi to vent, leading to pain due to stagnation and pressure. Since the rapid quality appears alongside floating, it indicates that interior excess has not yet formed, hence it is termed "deficiency." The symptoms are headache, fever, slight nocturnal sweating, and paradoxical aversion to cold, which signifies that exterior pathogens remain unresolved. When the physician fails to resolve the exterior and instead purges, the moving and rapid pulse becomes slow, indicating the failure of Stomach qi. Yang qi fails, Stomach qi rebels upward, obstructing the descent of Gallbladder Wood; the rebellious qi rushes into the chest and diaphragm, causing mutual rejection between Gallbladder and Stomach, resulting in pain within the diaphragm. Jia Wood (Gallbladder) normally descends to transform into Ministerial Fire and return to Gui Water (Kidney); Ministerial Fire in water is the ruling qi of the Lower Jiao. Now, with Yang failure and Stomach deficiency, Jia Wood rebels, occupying the Upper Diaphragm as an intruder with the identity of Lower Jiao ruling qi, causing continuous agitation; this is the origin of the resistance pain. Lung and Heart qi should descend smoothly; obstruction by rebellious Stomach and Gallbladder prevents this descent. Ministerial Fire flares upward, assisting Sovereign Fire to attack Xin Metal (Lung), causing irritability, *ao nao*, shortness of breath, chest fullness, and diaphragmatic heat stagnation. With pores closed, Yang qi in the channels collapses inward. Heat in the channels and fu organs blocks each other, condensing firmly in the heart region, forming Jie Xiong. Lung Metal is suppressed, misty dampness steams, turbid fluids transform into phlegm-saliva. Da Xian Xiong Tang uses Mang Xiao (Mirabilite) and Da Huang (Rhubarb) to clear stagnant heat, and Gan Sui (Euphorbia kansui) to drain phlegm-fluids, sweeping away all evil heat from the chest. If Jie Xiong does not form, but there is sweating only on the head, stopping at the neck, and urinary difficulty, this is due to bitter-cold medicines damaging Spleen Yang, causing dampness to stagnate internally without a descending pathway, leading inevitably to jaundice. Exterior heat transmitting to the Stomach forms Yangming syndrome; Yangming has Yang but lacks Yin, so the pathology is dry-heat. Exterior heat entering the diaphragm forms Jie Xiong syndrome; Jie Xiong is Yang above and Yin below, so the pathology is damp-heat. When Zang qi is free, fluids flow freely; when Zang qi is blocked, phlegm-saliva coagulates; there is no difference in principle.
Note: In Da Xian Xiong syndrome, exterior Yang has collapsed inward, yet channel pathogens remain unresolved. Ideally, one should clear interior heat in the chest/diaphragm internally and release exterior pathogens from the skin/hair externally, allowing upper-stagnant interior heat to dissipate from within and collapsed exterior Yang to exit via the surface. Zhang Zhongjing used Da Xian Xiong Tang to purge upper jiao damp-heat without using exterior-releasing herbs; this is a method for emergency rescue, though theoretically adaptable here. My opinion is to use Shi Gao (Gypsum), Gan Sui, Zhi Shi (Immature Bitter Orange), and Ma Huang (Ephedra) to simultaneously resolve both exterior and interior, capturing the meaning beyond Zhang Zhongjing's explicit methods. Mr. Cheng stated: For Jie Xiong syndrome, using Zhi Shi Li Zhong Wan (Immature Bitter Orange and Gastrodia Pill) is very effective. To break the binding and soften hardness, Huang Qin (Scutellaria), Gua Lou (Trichosanthes fruit), and Mu Li (Oyster shell) are excellent choices.