仲景曰。病发于阴。而反下之。因作痞也。庞氏曰。发热恶寒。为
发于阳。误下。则为结胸。无热恶寒。为发于阴。误下。则为痞。朱氏
曰。伤寒本无痞。因身冷。医反下之。遂成痞。枳实理中丸最良。
又曰。心下满而硬痛者。为结胸。但满而不痛。名为痞。宜半夏
泻心汤。朱氏曰。此汤药盖本理中。又参黄芩汤也。审知是痞。先用
桔梗枳壳汤尤妙。缘桔梗枳壳行气下膈。故先之。庞氏曰。设使下
后。津液入里。胃虚上逆。寒结在心下。故宜用辛甘发散之。今用半
夏以下气。用苦以去湿。兼通心气。又甘草力大。使干姜黄连不能相
恶。此用半夏泻心汤之意也。
又曰。脉浮而紧。而复下之。紧反入里。则作痞。按之自濡。但气
痞耳。常氏云。可小陷胸汤、生姜泻心汤。雍曰。宜半夏泻心汤。
又曰。心下痞。按之濡。其脉关上浮者。大黄黄连泻心汤主之。
庞氏曰。寒湿迫心气不行。欲作热也。朱氏曰。结胸与痞。关脉皆须
沉。若关浮则热结。故以三黄泻心也。
又曰。心下痞。而复恶寒汗出者。附子泻心汤主之。（大黄黄连
泻心汤内加附子）
又曰。本以下之故。心下痞。与泻心汤。痞不解。其人渴而口燥
烦。小便不利者。五苓散主之。（一云。忍之一日乃愈。）
又曰。伤寒汗出解之后。胃中不和。心下痞硬。干噫食臭。胁下
有水气。腹中雷鸣下利者。生姜泻心汤主之。庞氏云。胃中不和。为
少阳本气所制。故用生姜之辛味也。（本字当作木字）
又曰。伤寒中风。医反下之。其人下利。日数十行。谷不化。腹中
雷鸣。心下痞硬而满。干呕。心烦不得安。医见心下痞。谓病不尽。复
下之。其痞益甚。此非结热。但以胃中虚。客气上逆。故使硬也。甘草
泻心汤主之。庞氏云。胃虚。故加甘味。
又曰。伤寒服汤药。下利不止。心下痞硬。服泻心汤已。复以他
药下之。利不止。医以理中与之。利益甚。理中者。理中焦。此利在下
焦。赤石脂禹余粮汤主之。复利不止。当利其小便。庞氏云。五苓散
主之。
又曰。伤寒大下后。复发汗。心下痞。恶寒者。表未解也。不可攻
痞。当先解表。表解。乃可攻痞。解表。宜桂枝汤。攻痞。宜大黄黄连
泻心汤。庞氏曰。前加附子。是汗出多而恶寒。表将解而里结未除
也。此证是发汗无汗而恶寒。故先须解表也。朱氏曰。结胸与痞。表
未解者。不可攻也。
又曰。伤寒发热。汗出不解。心下痞硬。呕吐而下利者。大柴胡
汤主之。庞氏云。汗出呕吐下利。是胃中津液燥。里有结实。非胃虚
也。故大柴胡汤下之。
又曰。伤寒发汗。若吐。若下。解后。心下痞硬。噫气不除者。旋
覆代赭石汤主之。朱氏曰。有旋覆代赭汤证。其人或咳逆气虚。先服
四逆汤。胃寒。先服理中丸。次服此汤良。
又曰。太阳病。外证未除。而数下之。遂协热而利。利下不止。心
下痞硬。表里不解者。桂枝人参汤主之。
又曰。伤寒吐下后。发汗。虚烦。脉甚微。八九日。心下痞硬。胁
下痛。气上冲咽喉。眩冒。经脉动惕者。久而成痿。常氏云。可服茯苓
甘草白术生姜汤、振痿汤。（此汤未见方。恐是误写。）
又曰。太阳中风。下利呕逆。表解者。乃可攻之。其人 汗出。
发作有时。头痛。心下痞硬。满引胁下痛。干呕短气。汗出不恶寒者。
此表解里未和也。十枣汤主之。朱氏曰。此汤尤难用。须是表证罢。
身凉不恶寒者。乃可用。若表未解者。切不可用也。雍曰。十枣汤乃
攻里大峻药也。非和里药也。设或误用。杀人过于承气。常氏言。此
证传写之误。故朱氏亦畏而戒之。宜代用槟榔散。
又曰。太阳病。医发汗。遂发热恶寒。因复下之。心下痞。表里俱
虚。阴阳气并竭。无阳则阴独。复加烧针。因胸烦。面色青黄。肤
者。难治。今色微黄。手足温者。易愈。常氏云。痞者。可生姜泻心汤。
发热恶寒。可小柴胡汤。火逆。可桂枝去芍药加蜀漆牡蛎龙骨救逆
汤。
又曰。病如桂枝证。头不痛。项不强。寸脉微浮。胸中痞硬。气上
冲咽喉不得息者。此为胸有寒也。当吐之。宜瓜蒂散。
又曰。太阳少阳并病。心下硬。颈项强而眩者。当刺大椎肺俞肝
俞。慎勿下之。雍曰。其详见并病中。
又曰。太阳病。寸缓。关浮。尺弱。其人发热。汗出。复恶寒。不呕
吐。但心下痞者。此以医下之也。常氏云。可生姜半夏二泻心汤。雍
曰。此证汗出。发热恶寒。表证不罢。宜先服柴胡桂枝汤。次服枳实
理中丸。
又曰。太阴之为病。腹满而吐。食不下。自利益甚。时腹自痛。若
下之。必心下结硬。常氏云。可增损理中丸、桂枝加芍药汤。
又曰。阳明病。心下硬满者。不可攻之。攻之。遂利不止者。死。
常氏云。可半夏泻心汤也。已攻而利者。四逆汤。
又曰。脉双弦而迟者。必心下硬。脉大而紧者。阳中有阴也。可
下之。宜大承气汤。
活人书曰。已痞。服泻心汤不愈。然后可用陷胸汤下之。
又曰。外证未解。而心下妨闷者。非痞也。谓之支结。柴胡桂枝
汤主之。胁胸满。微结。小柴胡加干姜牡蛎汤主之。
王仲弓曰。生姜泻心半夏泻心二阳和平。宜常用之。
张仲景说：疾病发于阴证，反而使用攻下法，因此形成痞证。庞安时（庞氏）说：发热恶寒，是发于阳证，误用攻下法，就会形成结胸；无热恶寒，是发于阴证，误用攻下法，就会形成痞证。朱肱（朱氏）说：伤寒病本来没有痞证，因为身体发冷，医生反而使用攻下法，于是形成痞证。枳实理中丸效果最好。
又说：心下部胀满且硬痛，称为结胸；只是胀满而不疼痛，称为痞证。适宜使用半夏泻心汤。朱氏说：这个方剂原本是基于理中汤，又参考了黄芩汤。如果确切知道是痞证，先用桔梗枳壳汤尤其巧妙。因为桔梗和枳壳能行气并引导药力下行至膈部，所以先使用它。庞氏说：假设在攻下之后，津液内入，胃气虚弱而上逆，寒气凝结在心下，所以适宜使用辛甘发散的药物。现在使用半夏来降气，使用苦味药物来祛湿，兼通心气。另外甘草力量大，能使干姜和黄莲不产生相恶作用。这就是使用半夏泻心汤的用意。
又说：脉象浮而紧，却又使用攻下法，紧脉反而进入体内，就会形成痞证。按压时感觉柔软，这只是气痞而已。常器之（常氏）说：可以使用小陷胸汤或生姜泻心汤。郭雍（雍）说：适宜使用半夏泻心汤。
又说：心下痞，按压时柔软，其脉象关部浮的，由大黄黄连泻心汤主治。庞氏说：寒湿逼迫心气运行不畅，想要化热。朱氏说：结胸与痞证，关脉都应当沉；如果关脉浮，则是热结，所以使用三黄泻心汤。
又说：心下痞，而又恶寒汗出的，由附子泻心汤主治。（在大黄黄连泻心汤中加入附子）
又说：本因攻下导致心下痞，给予泻心汤后，痞证未解，其人口渴、口燥烦躁、小便不利的，由五苓散主治。（另一种说法是：忍耐一天就会痊愈。）
又说：伤寒出汗后表证已解，但胃中不和，心下痞硬，干呕伴有食物腐败气味，胁下有水气，腹中雷鸣般作响并腹泻的，由生姜泻心汤主治。庞氏说：胃中不和，是因为受到少阳本气的制约，所以使用生姜的辛味。（原文中的“本”字当作“木”字）
又说：伤寒中风，医生反而使用攻下法，病人出现腹泻，每天几十次，完谷不化，腹中雷鸣，心下痞硬且胀满，干呕，心烦不得安宁。医生见心下痞，认为病邪未尽，再次使用攻下法，痞证更加严重。这不是结热，只是因为胃中虚损，客气上逆，所以导致痞硬。由甘草泻心汤主治。庞氏说：胃虚，所以加入甘味药物。
又说：伤寒服用汤药后，腹泻不止，心下痞硬。服用泻心汤后，又用其他药物攻下，腹泻仍不止。医生给予理中汤治疗，腹泻反而更严重。理中汤是调理中焦的，此处的腹泻在下焦，由赤石脂禹余粮汤主治。如果腹泻仍不止，应当利小便。庞氏说：由五苓散主治。
又说：伤寒经过大力攻下后，又发汗，出现心下痞，若有恶寒症状，说明表证未解。不可攻治痞证，应当先解表。表证解除后，才可以攻治痞证。解表适宜用桂枝汤，攻痞适宜用大黄黄连泻心汤。庞氏说：前面提到的加附子，是因为出汗多而恶寒，这是表将解而里结未除的情况。此证是发汗后无汗而恶寒，所以必须先解表。朱氏说：结胸与痞证，若表证未解，不可攻治。
又说：伤寒发热，出汗后表证未解，心下痞硬，呕吐并腹泻的，由大柴胡汤主治。庞氏说：出汗、呕吐、腹泻，是胃中津液干燥，里有结实，并非胃虚。所以使用大柴胡汤攻下。
又说：伤寒发汗，或用吐法，或用下法，病解后，心下痞硬，嗳气不止的，由旋覆代赭石汤主治。朱氏说：有旋覆代赭汤的适应证，其人如果有咳嗽、气逆、气虚，先服用四逆汤；如果是胃寒，先服用理中丸，再服用此汤效果良好。
又说：太阳病，外证未除，却多次使用攻下法，于是协热下利，腹泻不止，心下痞硬，表里同病的，由桂枝人参汤主治。
又说：伤寒经吐法、下法后，又发汗，出现虚烦，脉象极微，过了八九天，心下痞硬，胁下疼痛，气上冲咽喉，眩晕昏冒，经脉跳动不安的，日久会形成痿证。常氏说：可以服用茯苓甘草白术生姜汤、振痿汤。（此汤未见方剂，可能是误写。）
又说：太阳中风，出现腹泻、呕吐逆气，表证解除后，才可以攻治。其人出汗，发作有时，头痛，心下痞硬，胀满牵引胁下疼痛，干呕，短气，出汗且不恶寒的，这是表证已解而里气未和，由十枣汤主治。朱氏说：此汤药很难使用，必须是表证消失，身体凉爽不恶寒的，才可以使用。如果表证未解，切不可使用。郭雍说：十枣汤是攻里的峻猛药物，不是调和里的药物。如果误用，杀人甚于承气汤。常氏说，这是传抄过程中的错误，所以朱氏也畏惧并告诫后人。适宜替代使用槟榔散。
又说：太阳病，医生发汗，于是出现发热恶寒，接着又使用攻下法，形成心下痞。此时表里俱虚，阴阳之气都已衰竭。无阳则阴独存。如果再加上烧针，会导致胸中烦闷，面色青黄，皮肤颤动的，难治。如果面色微黄，手足温暖的，容易痊愈。常氏说：痞证，可用生姜泻心汤；发热恶寒，可用小柴胡汤；火逆证，可用桂枝去芍药加蜀漆牡蛎龙骨救逆汤。
又说：病症类似桂枝汤证，但头不痛，项不强，寸脉微浮，胸中痞硬，气上冲咽喉导致呼吸困难的，这是因为胸中有寒饮。应当使用涌吐法，适宜用瓜蒂散。
又说：太阳少阳并病，心下硬，颈项强直且眩晕的，应当针刺大椎穴、肺俞穴、肝俞穴。千万不要使用攻下法。郭雍说：详细内容参见并病篇。
又说：太阳病，寸脉缓，关脉浮，尺脉弱，其人发热，出汗，又恶寒，不呕吐，只是心下痞的，这是因为医生使用了攻下法。常氏说：可使用生姜半夏二泻心汤。郭雍说：此证有出汗、发热恶寒，表证未罢，适宜先服用柴胡桂枝汤，再服用枳实理中丸。
又说：太阴病的主要表现是腹部胀满且呕吐，饮食不下，自发性腹泻日益加重，时常腹痛。如果使用攻下法，必定导致心下结硬。常氏说：可使用增损理中丸、桂枝加芍药汤。
又说：阳明病，心下硬满的，不可攻下。如果攻下，导致腹泻不止的，预后不良，致死。常氏说：可服用半夏泻心汤。已经攻下且腹泻的，服用四逆汤。
又说：脉象双弦且迟缓的，必定心下硬。脉象大而紧的，是阳中有阴，可以使用攻下法，适宜用大承气汤。
《活人书》说：已经形成痞证，服用泻心汤无效后，然后才可以使用陷胸汤攻下。
Zhang Zhongjing said: When a disease originates from a Yin syndrome, and purgation is erroneously applied, Pi (痞, glomus/fullness) results. Pang Anshi (Pang Shi) stated: Fever accompanied by aversion to cold indicates origin from Yang syndrome; erroneous purgation leads to Jie Xiong (结胸, chest binding). Absence of fever with aversion to cold indicates origin from Yin syndrome; erroneous purgation leads to Pi. Zhu Gong (Zhu Shi) stated: Taiyang Cold Damage (Shanghan) does not inherently involve Pi. Due to cold limbs, if the physician erroneously applies purgation, Pi forms. Zhishi Lizhong Wan (Aurantium Fructus and Poria Pill for Middle Jiao Regulation) is most effective.
It is further stated: Fullness in the epigastrium accompanied by hardness and pain is termed Jie Xiong. Fullness without pain is named Pi. Banxia Xiexin Tang (Pinellia Decoction for Draining the Epigastrium) is indicated. Zhu Shi stated: This decoction is based on Lizhong Tang (Regulate the Middle Decoction), incorporating elements of Huangqin Tang (Scutellaria Decoction). If Pi is confirmed, using Jiegeng Zhike Tang (Platycodon and Aurantium Decoction) first is particularly excellent, as these herbs promote Qi movement and direct it downward across the diaphragm. Pang Shi explained: After purgation, body fluids may enter the interior, causing Stomach deficiency and rebellious Qi. Cold congeals in the epigastrium; thus, acrid-sweet dispersing methods are appropriate. Here, Banxia (Pinelliae Rhizoma) descends Qi, bitter herbs drain dampness, and together they unblock Heart Qi. Gancao (Glycyrrhizae Radix et Rhizoma) is potent enough to prevent the mutual antagonism between Ganjiang (Zingiberis Rhizoma) and Huanglian (Coptidis Rhizoma). This explains the rationale behind Banxia Xiexin Tang.
It is further stated: A pulse that is floating and tight, followed by erroneous purgation, causes the tightness to sink into the interior, resulting in Pi. Palpation reveals softness; this is merely Qi Pi (Qi-type glomus). Chang Qizi (Chang Shi) suggested Xiaoxianxiong Tang (Minor Chest-Binding Decoction) or Shengjiang Xiexin Tang (Fresh Ginger Decoction for Draining the Epigastrium). Guo Yong (Yong) stated: Banxia Xiexin Tang is indicated.
It is further stated: For Pi in the epigastrium where palpation is soft and the Guan pulse position is floating, Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Decoction for Draining the Epigastrium) is the primary treatment. Pang Shi stated: Cold-dampness constrains Heart Qi, leading to potential heat transformation. Zhu Shi stated: In both Jie Xiong and Pi, the Guan pulse should be deep; if floating, it indicates heat accumulation, hence the use of Sanhuang Xiexin Tang (Three-Yellow Decoction for Draining the Epigastrium).
It is further stated: For Pi accompanied by aversion to cold and sweating, Fuzi Xiexin Tang (Aconite Decoction for Draining the Epigastrium) is indicated (formed by adding Fuzi (Aconiti Lateralis Radix Praeparata) to Dahuang Huanglian Xiexin Tang).
It is further stated: If Pi resulted from prior purgation and persists despite Banxia Xiexin Tang, accompanied by thirst, dry mouth, irritability, and dysuria, Wuling San (Five-Ingredient Powder with Poria) is indicated. (Another version states: Enduring it for one day will lead to recovery.)
It is further stated: After Taiyang Cold Damage resolves via sweating, if the Stomach becomes disharmonious, presenting with epigastric fullness and hardness, belching with food odor, water retention under the flanks, borborygmus, and diarrhea, Shengjiang Xiexin Tang is indicated. Pang Shi noted: Stomach disharmony here is constrained by Shaoyang constitutional Qi, justifying the use of Shengjiang's acrid flavor. (Note: The character "Ben" should likely be "Mu".)
It is further stated: In Taiyang Cold Damage or Wind Strike, if the physician erroneously purges, causing frequent diarrhea (dozens of times daily), undigested food, borborygmus, severe epigastric fullness and hardness, dry retching, and irritability, and subsequent purgation worsens the Pi, this is not heat accumulation but Stomach deficiency with rebellious pathogenic Qi. Gancao Xiexin Tang (Licorice Decoction for Draining the Epigastrium) is indicated. Pang Shi noted: Sweet flavors are added to address Stomach deficiency.
It is further stated: If purgative decoctions cause persistent diarrhea and epigastric hardness, and subsequent use of Xiexin Tangs fails, followed by further purgation worsening the diarrhea, Lizhong Tang is ineffective because it regulates the Middle Jiao while the pathology lies in the Lower Jiao. Chishizhi Yuyuliang Tang (Red Stone Lipid and Hematite Decoction) is indicated. If diarrhea persists, promoting urination is required. Pang Shi suggested Wuling San.
It is further stated: After severe purgation and subsequent sweating in Taiyang Cold Damage, if Pi appears with aversion to cold, the exterior remains unresolved. One must not attack the Pi directly but resolve the exterior first. Guizhi Tang (Cinnamon Twig Decoction) is used for the exterior; Dahuang Huanglian Xiexin Tang is used for the Pi. Pang Shi clarified: The previous mention of adding Fuzi applied to cases with profuse sweating and aversion to cold (exterior resolving, interior binding remaining). This case involves no sweat and aversion to cold post-sweating, necessitating exterior resolution first. Zhu Shi emphasized: Exterior unresolved patterns of Jie Xiong or Pi cannot be attacked internally.
It is further stated: In Taiyang Cold Damage with fever, unresolved sweating, epigastric fullness/hardness, vomiting, and diarrhea, Da Chaihu Tang (Major Bupleurum Decoction) is indicated. Pang Shi stated: Sweating, vomiting, and diarrhea indicate dried Stomach fluids and interior excess, not deficiency; thus, Da Chaihu Tang is used to purge.
It is further stated: After Taiyang Cold Damage treated with sweating, emesis, or purgation, if Pi hardness and persistent belching remain, Xuansu Daizhe Shi Tang (Inula and Magnetite Decoction) is indicated. Zhu Shi noted: For patients with cough, rebellious Qi, or deficiency, Sini Tang (Frigid Extremities Decoction) should be taken first; for Stomach cold, Lizhong Wan should precede this decoction.
It is further stated: In Taiyang disease, if external symptoms persist and multiple purgations are applied, leading to heat-collateral diarrhea, persistent diarrhea, and epigastric hardness with simultaneous exterior-interior involvement, Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) is indicated.
It is further stated: Following emesis, purgation, and sweating in Taiyang Cold Damage, if vexation, a very faint pulse, and after eight to nine days, epigastric hardness, hypochondriac pain, Qi rushing to the throat, vertigo, and muscle twitching occur, chronic weakness (Wei syndrome) may develop. Chang Shi suggested Fuling Gancao Baizhu Shengjiang Tang (Poria, Licorice, Atractylodes, and Fresh Ginger Decoction) or Zhenwei Tang (Stabilize Weakness Decoction - formula missing).
It is further stated: In Taiyang Wind Strike with diarrhea and vomiting, once the exterior is resolved, internal treatment may proceed. Symptoms include paroxysmal sweating, headache, epigastric hardness, fullness radiating to the hypochondrium, dry retching, shortness of breath, and non-aversion to cold. This indicates resolved exterior and unharmonized interior. Shizao Tang (Ten Dates Decoction) is indicated. Zhu Shi warned: This is a harsh formula; use only when exterior signs are gone and the patient is cool without aversion to cold. Guo Yong emphasized: Shizao Tang is a harsh interior-purgative, not a harmonizer; misuse can be fatal, worse than Chengqi Tangs. Chang Shi attributed warnings to textual errors; Binglang San (Areca Seed Powder) is a safer alternative.
It is further stated: In Taiyang disease, if sweating leads to fever and aversion to cold, followed by purgation causing Pi, both exterior and interior are deficient, and Yin and Yang Qi are exhausted. "No Yang means Yin stands alone." If moxibustion (burning needle) is added, causing chest烦 (vexation), cyan-yellow complexion, and skin twitching, prognosis is poor. A slightly yellow complexion and warm hands/feet indicate easy recovery. Chang Shi suggested: Pi -> Shengjiang Xiexin Tang; Fever/Aversion to Cold -> Xiao Chaihu Tang (Minor Bupleurum Decoction); Fire Reversal -> Guizhi Qu Shaoyao Jia Shujimu Li Longgu Jiuni Tang (Cinnamon Twig Decoction Removing Peony plus Coix Seed, Oyster Shell, and Dragon Bone to Rescue Reversal).
It is further stated: Symptoms resembling Guizhi Tang pattern but without headache or neck stiffness, with a slightly floating Cun pulse, epigastric fullness/hardness, and Qi rushing to the throat causing breathing difficulty, indicates Cold Fluid (Han) in the Chest. Emesis is indicated; Gouti San (Melon Seed Powder) is used.
It is further stated: In concurrent Taiyang and Shaoyang disease with epigastric hardness, neck stiffness, and vertigo, acupuncture at Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) is indicated. Purging is forbidden. Guo Yong referred readers to the section on Concurrent Diseases.
It is further stated: In Taiyang disease with slow Cun pulse, floating Guan pulse, weak Chi pulse, fever, sweating, aversion to cold, no vomiting, but only epigastric Pi, the cause is erroneous purgation. Chang Shi suggested Shengjiang Banxia Er Xiexin Tang. Guo Yong stated: With exterior signs present, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) should be taken first, followed by Zhishi Lizhong Wan.
It is further stated: Taiyin disease presents with abdominal fullness, vomiting, inability to eat, worsening spontaneous diarrhea, and intermittent abdominal pain. Purging will cause epigastric knotting and hardness. Chang Shi suggested Zengsun Lizhong Wan (Modified Regulate Middle Pill) or Guizhi Jia Shaoyao Tang (Cinnamon Twig Decoction Added Peony).
It is further stated: In Yangming disease, epigastric hardness/fullness contraindicates purging. If purged and diarrhea ensues, death may result. Chang Shi suggested Banxia Xiexin Tang for the Pi; Sini Tang for post-purge diarrhea.
It is further stated: A double-string-like and slow pulse indicates epigastric hardness. A large and tight pulse indicates Yang containing Yin; purging is permissible. Dachengqi Tang (Major Order the Qi Decoction) is indicated.
The *Ren Shu* (Book of Human Life) stated: If Pi persists despite Xiexin Tangs, Xiaoxianxiong Tang may then be used.
It is further stated: If external symptoms are unresolved and epigastric oppression occurs, it is not Pi but Zhijie (Branch Binding). Chaihu Guizhi Tang is indicated. For hypochondriac/chest fullness and slight binding, Xiao Chaihu Jia Ganjiang Muli Tang (Minor Bupleurum Plus Dried Ginger and Oyster Shell Decoction) is indicated.
Wang Zhonggong stated: Shengjiang Xiexin Tang and Banxia Xiexin Tang are balanced and mild, suitable for regular use.