37.按之满硬不痛痞, 硬而满痛为结胸, 大结从心至少腹, 小结心下
按方疼. 热微头汗为水结, 漱水不咽血结名, 瘀衄未尽经适断, 内实
沈大审的攻, 抵当桃仁大小陷, 误攻浮大命多倾, 不实浮滑小陷证,
藏结悉具躁烦凶.
【注】伤寒下之太早则成痞硬, 中风下太早则成结胸, 均为表邪乘虚
入里. 硬满按之而痛, 为结胸实邪也. 硬满按之不痛, 为痞硬虚邪也
.大结, 谓大结胸, 从心下至少腹, 硬满而痛, 手不可近者, 宜大陷
胸汤攻之. 小结, 谓小结胸, 微结心下, 按之方痛, 不按不疼也, 宜
小陷胸汤开之. 身有微热, 头自汗出, 兼有是证者, 为水结胸也, 宜
大陷胸丸攻之. 漱水不欲咽, 兼有是证者, 为血结胸也, 血瘀不成衄
解,或衄未尽, 或妇人经来适断, 皆能成之, 宜抵当丸, 或桃仁承气
汤攻之. 内实证实可攻也, 沉大脉实可攻也, 审其的当, 则用抵当,
仁承气, 大陷胸汤丸以攻之. 审若不内实, 脉浮滑或脉浮大是未的也
,乃小陷胸证, 不可攻也, 误攻之, 定然凶也. 藏结, 谓状如结胸,
舌胎白滑, 脉浮而细也. 悉具, 谓结胸通腹, 两胁皆硬满痛也, 此证
加之烦燥, 凶死可知.
37. 腹部按之感觉胀满坚硬但不疼痛的是痞证，若硬且胀满疼痛则是结胸证。大结胸证的范围从心窝部一直延伸到小腹部，小结胸证仅在胃脘部，按压时才疼痛。热象轻微且仅有头部出汗的是水饮内结，想漱口但不愿吞咽的是血瘀内结。如果鼻衄（鼻出血）尚未排尽，或者妇女月经突然中断，都可能导致此类病证。体内邪气实盛、脉象沉而有力者，应当使用攻下法；可选用抵当汤、桃仁承气汤或大陷胸汤、小陷胸汤等方剂。如果误用于脉象浮大而无实邪的患者，会导致生命危险。若脉象浮滑且病情较轻，属于小陷胸汤的适应证；若出现藏结证并伴有躁动烦乱，则预后凶险。
【注】伤寒病过早使用泻下法会导致痞硬证，中风病过早使用泻下法会导致结胸证，这两者都是因为表邪趁虚侵入体内所致。硬满且按压疼痛的，是结胸证的实邪表现；硬满但按压不痛的，是痞硬证的虚邪表现。所谓“大结”，指的是大结胸证，病变范围从心窝部延伸至小腹部，腹部硬满且疼痛剧烈，手不能触碰，适宜用大陷胸汤进行攻逐。所谓“小结”，指的是小结胸证，病变局限在心窝部，只有按压时才疼痛，不按则不痛，适宜用小陷胸汤进行开散。身体有轻微发热，头部自然出汗，兼有此等症状的，是水结胸证，适宜用大陷胸丸进行攻逐。想漱口但不愿吞咽，兼有此等症状的，是血结胸证。血瘀未能通过鼻衄解除，或者鼻衄未止，或者是妇女月经刚来突然中断，都能形成此证，适宜用抵当丸或桃仁承气汤进行攻逐。体内邪实、证候属实是可以攻下的指征，脉象沉大有力也是可攻下的指征。仔细审察确凿无误后，才可使用抵当汤、桃仁承气汤、大陷胸汤或丸剂进行攻逐。如果审察发现体内并不实，脉象浮滑或浮大，说明并非确切的实证，而是小陷胸证，不可攻下。如果误用攻下法，必然导致凶险后果。所谓“藏结”，是指症状类似结胸，但舌苔白滑，脉象浮而细弱。所谓“悉具”，是指结胸证波及全腹，两侧胁肋部都硬满疼痛，此证如果再加之烦躁不安，可知其预后凶险致死。
37. Abdominal distension and hardness without pain upon palpation indicate Pi Syndrome (Pihardness, a syndrome of fullness and hardness due to qi stagnation). Hardness with distension and pain indicates Jie Xiong Syndrome (Chest Binding Syndrome, a syndrome characterized by binding pain in the chest/epigastrium). The Da Jie Xiong (Major Chest Binding) syndrome extends from the epigastrium to the lower abdomen. The Xiao Jie Xiong (Minor Chest Binding) syndrome is located at the epigastrium and causes pain only upon pressure. Mild heat with sweating only on the head indicates Water-Jie Xiong (Water Binding in the Chest). Desire to rinse the mouth but unwillingness to swallow indicates Blood-Jie Xiong (Blood Binding in the Chest). If nasal bleeding (Bi Xu) has not fully resolved, or if a woman's menstruation has suddenly ceased, these conditions can also lead to such syndromes. When internal excess is confirmed and the pulse is deep and forceful, purgative methods should be employed; formulas such as Didang Tang (Ephedra and Ground Beetle Decoction), Taoren Chengqi Tang (Peach Kernel and Rhubarb Decoction), Daxiexiong Tang (Major Chest Binding Decoction), or Xiaoxiexiong Tang (Minor Chest Binding Decoction) may be used. Misapplying purgatives to patients with floating and large pulses (indicating deficiency or exterior pathogen) can lead to death. If the pulse is floating and slippery and the condition is mild, it is an indication for Xiaoxiexiong Tang. If Zang Jie (Visceral Binding) presents with restlessness and irritability, the prognosis is ominous.
[Annotation] If Han Bing (Cold Damage) is treated too early with purgatives, Pi Syndrome (Pihardness) results; if Feng Zhong (Wind Strike) is treated too early with purgatives, Jie Xiong Syndrome results. Both occur because exterior pathogens enter the interior due to deficiency. Hardness and fullness with pain upon palpation indicate the excess pathogen of Jie Xiong Syndrome. Hardness and fullness without pain upon palpation indicate the deficient pathogen of Pi Syndrome. "Da Jie" refers to Major Chest Binding Syndrome, where hardness, fullness, and severe pain extend from the epigastrium to the lower abdomen, making the area intolerable to touch; Daxiexiong Tang should be used to purge it. "Xiao Jie" refers to Minor Chest Binding Syndrome, where slight binding occurs at the epigastrium, causing pain only upon pressure, not otherwise; Xiaoxiexiong Tang should be used to open and scatter it. Slight body heat with spontaneous sweating on the head, accompanied by these signs, indicates Water-Jie Xiong; Daxiexiong Wan (Major Chest Binding Pill) should be used to purge it. Desire to rinse the mouth but unwillingness to swallow, accompanied by these signs, indicates Blood-Jie Xiong. If blood stasis does not resolve through nasal bleeding, or if nasal bleeding is incomplete, or if a woman's menstruation has just stopped, these can all form this syndrome; Didang Wan (Ground Beetle Pill) or Taoren Chengqi Tang should be used to purge it. Internal excess and solid symptoms are indications for purging; a deep and large pulse is also an indication for purging. After careful verification, Didang Tang, Taoren Chengqi Tang, Daxiexiong Tang, or Wan may be used for purging. If internal excess is absent and the pulse is floating and slippery or floating and large, it is not a definite excess pattern but rather a Xiaoxiexiong pattern; purging is contraindicated. Misapplication of purgatives will certainly lead to fatal consequences. "Zang Jie" refers to a condition resembling Jie Xiong, but with a white and slippery tongue coating and a floating, thin pulse. "Xi Ju" means that the Jie Xiong symptoms involve the entire abdomen, with hardness, fullness, and pain in both hypochondriac regions. If this condition is accompanied by irritability and restlessness, death is inevitable.