（附心痛）
【纲】仲景曰。病心下硬满者。不可攻之。攻之利遂不止者死。利止者愈。
得病二三日。脉弱。无太阳柴胡症。烦躁。心下硬。至四五日。虽能食。以小承气汤少少与微
和之。伤寒吐下后。心下逆满。气上冲胸。起则头眩。脉沉紧。发汗则动经。身为振振摇者。茯苓
桂枝白术甘草汤。
【目】吴绶曰。凡心下满者。正在心之下。胃之上也。此自满而非下之所致。若因下早而心下
满者。此为痞气。另有条也。凡心下满者。以手按之揉之。则散而软者。此虚气也。不发热者。木
香和中汤。发热者。小柴胡汤去黄芩。减人参一半。加姜炒黄连、枳实各一钱。若按之汨汨有声者。
此有停水也。若按之硬痛者。有宿食也。若不按而痛。其人喜忘者。蓄血也。各有本条。宜详审
而治之。凡少阳脉弦口苦。发热。心下满者。小柴胡加枳实、黄连各一钱。
王肯堂曰。有不因汗下而心下满者。经曰。邪气在胸。心满而烦。饥不欲食。当吐之。又曰。
脉浮而大。心下反硬。有热属脏者。攻之。此言属脏者。宿屎在脏也。不令发汗。二者一用吐。一
用下。因其邪之高下也。又有不可下者。即首条是也。
是邪在表里之间。留于心下。未全入腑。故戒不可下也。有因汗下后。心下满而微痛者。又有下后。
心下硬满。成结胸与痞者。皆宜详考之。
【纲】仲景曰。阳明中风。脉弦浮大。短气。腹满。胁下及心痛。鼻干。无汗。嗜卧。身黄。
小便难。有潮热。时时哕者。小柴胡汤。伤寒五六日。大下之后。心中结痛者。未欲解也。栀子豉
汤主之。少阴病。自利清水。色纯青。心下必痛。口干燥者。急下之。宜大承气汤。
【目】成无己曰。伤寒五六日。邪气在里之时。若大下后。身热去。心胸空者。为欲解。若大
下后。身热去而心结痛者。结胸也。身热不去。心中结痛者。虚烦也。结胸者。热结胸中也。为实。
是热气已收敛于内。则外身热去。虚烦者。热客胸中也。未结而实。散漫为烦。是以身热不去。
六七日为欲解之时。以热为虚烦。故云未欲解也。以栀豉汤吐除之。
王肯堂曰。身热不去四字要玩。结胸而身不热。知热在表。故可用大小陷胸汤丸以逐下之。今
热仍在表。故宜越之也。成注未透。
【附：心痛】
【纲】张仲景说：凡是出现心下部位硬满症状的，不可使用攻下法。如果误用攻下法导致腹泻不止的，预后不良，可能致死；如果腹泻能够自行停止的，则病情会痊愈。
患病两三天，脉象微弱，没有太阳病或少阳病的证候，出现烦躁、心下硬满的症状。到了第四五天，虽然患者能够进食，也应少量给予小承气汤，以轻微调和胃气。
伤寒经过催吐或攻下治疗后，出现心下逆满（自觉心下有气逆胀满感），气向上冲至胸部，起身时感到头晕目眩，脉象沉紧。此时若再发汗，就会扰动经脉，导致身体震颤摇晃。这种情况应使用茯苓桂枝白术甘草汤。
【目】吴绶说：凡是心下满的，位置正处于心脏下方、胃的上方。这种满闷是自发产生的，并非因误用攻下法所致。如果是因过早攻下而导致心下满的，这属于痞气，另有专门条文论述。凡是心下满的，用手按压揉搓，如果感觉散开且变软的，这是虚气所致。如果不发热，可用木香和中汤；如果发热，可用小柴胡汤去掉黄芩，将人参用量减半，加入姜炒黄连和枳实各一钱。如果按压时听到汨汨的水声，这是有停水（水饮内停）。如果按压时感到硬痛，这是有宿食（积滞的食物）。如果不按压也痛，且患者健忘，这是蓄血（瘀血阻滞）。这些情况各有对应的条文，应当仔细审察后进行治疗。凡是少阳病见脉弦、口苦、发热、心下满的，用小柴胡汤加枳实、黄连各一钱。
王肯堂说：有不因发汗或攻下而出现心下满的情况。经书说：邪气在胸中，导致心满而烦，饥饿但不想进食，应当使用涌吐法治疗。又说：脉象浮大，心下反而硬满，且有热邪归属于脏的，应当攻下。这里所说的“属脏”，是指宿便停留在肠道内。这种情况下不令发汗。这两种情况，一种用吐法，一种用下法，是根据邪气所在部位的高低来决定的。又有不可攻下的情况，就是本条开头所述的那样。
这是因为邪气位于表里之间，停留于心下，尚未完全进入腑中，所以告诫不可攻下。还有因发汗或攻下后，心下满且微痛的；又有攻下后，心下硬满，形成结胸或痞证的，都应当详细考证。
【纲】张仲景说：阳明中风，脉象弦、浮、大，短气，腹部胀满，胁下及心部疼痛，鼻干，无汗，嗜睡，身体发黄，小便困难，有潮热，时常呃逆的，用小柴胡汤。
伤寒五六天，经过猛烈攻下之后，心中结聚疼痛的，说明病邪尚未解除，应用栀子豉汤主治。
少阴病，自利清水，颜色纯青，心下必然疼痛，口干燥的，应当急下，宜用大承气汤。
【目】成无己说：伤寒五六天，是邪气在里的时期。如果经过猛烈攻下后，身热退去，心胸空虚无物，这是病欲解的表现。如果猛烈攻下后，身热退去但心中结聚疼痛的，这是结胸证。如果身热不退，心中结聚疼痛的，这是虚烦证。结胸证，是热邪结聚在胸中，属于实证，说明热气已经收敛于内，所以体表的热象退去。虚烦证，是热邪客居在胸中，未结成实邪，而是散漫引起烦闷，所以身热不退。第六七天本是病欲解的时候，但因为热邪表现为虚烦，所以说病未欲解。应用栀豉汤通过涌吐的方法去除邪热。
王肯堂说：“身热不去”这四个字值得玩味。如果是结胸证而身不热，说明热邪在表，所以可以用大陷胸汤丸或小陷胸汤丸来逐下热邪。现在热邪仍在表，所以适宜用涌吐法发散它。成无己的注释不够透彻。
[Appendix: Heart Pain]
[Gang (General Principles)] Zhang Zhongjing stated: In cases where hardness and fullness are present in the epigastrium, purgation must not be used. If purgation is mistakenly applied and diarrhea persists without stopping, the prognosis is poor and death may ensue; if the diarrhea stops spontaneously, the patient will recover.
After being ill for two or three days, with a weak pulse, absence of Taiyang (Greater Yang) or Shaoyang (Lesser Yang) syndromes, and symptoms of restlessness and epigastric hardness: by the fourth or fifth day, even if the patient can eat, Xiao Chengqi Tang (Minor Order the Qi Decoction) should be administered in small amounts to gently harmonize the stomach.
Following emesis or purgation in Cold Damage (Shanghan), if there is epigastric rebellion and fullness (a sensation of qi rebelling upward causing distension), qi rushing up to the chest, dizziness upon rising, and a deep, tight pulse: administering sweating methods at this stage will disturb the meridians, leading to tremors and shaking of the body. This condition should be treated with Fuling Guizhi Baizhu Gancao Tang (Poria, Cinnamon Twig, Atractodes Macrocephala, and Licorice Decoction).
[Mu (Detailed Analysis)] Wu Shou said: Fullness in the epigastrium is located precisely below the heart and above the stomach. This fullness arises spontaneously and is not caused by premature purgation. If epigastric fullness results from early purgation, it constitutes Pi Syndrome (Stagnation Syndrome), which is covered in separate clauses. For epigastric fullness, if pressing and rubbing causes the sensation to dissipate and feel soft, it is due to deficient qi. If there is no fever, Muxiang Hezhong Tang (Costus Harmonizing the Middle Decoction) is indicated. If there is fever, Xiaochaihu Tang (Minor Bupleurum Decoction) is used, with Huangqin (Scutellaria Root) removed, Ren Shen (Ginseng) reduced by half, and Jiang Chao Huanglian (Ginger-fried Coptis Rhizome) and Zhishi (Immature Bitter Orange) added, one qian each. If pressing elicits a gurgling sound, this indicates retained water (fluid retention). If pressing elicits hardness and pain, this indicates retained food (food stagnation). If pain occurs without pressing and the patient suffers from forgetfulness, this indicates accumulated blood (blood stasis). Each has its own specific clause and requires careful examination before treatment. For Shaoyang syndrome presenting with a wiry pulse, bitter taste in the mouth, fever, and epigastric fullness, Xiaochaihu Tang (Minor Bupleurum Decoction) is used with Zhishi (Immature Bitter Orange) and Huanglian (Coptis Rhizome) added, one qian each.
Wang Kentang said: There are cases of epigastric fullness not caused by sweating or purgation. The Classics state: When pathogenic factors are in the chest, causing fullness and irritability, hunger but lack of desire to eat, vomiting (emesis) should be employed. It also states: With a floating and large pulse, and contrary hardness in the epigastrium accompanied by heat belonging to the Zang organs, purgation should be used. "Belonging to the Zang" here refers to fecal matter retained in the intestines. In such cases, sweating is contraindicated. These two scenarios—one using emesis and the other purgation—are determined by the high or low location of the pathogen. There are also cases where purgation is contraindicated, as mentioned in the first clause.
This is because the pathogen is between the exterior and interior, lingering in the epigastrium, and has not fully entered the Fu organs; thus, purgation is prohibited. Furthermore, after sweating or purgation, there may be epigastric fullness with slight pain; or after purgation, epigastric hardness and fullness may develop into Jie Xiong (Chest Binding) or Pi (Stagnation). All these must be carefully examined.
[Gang (General Principles)] Zhang Zhongjing stated: In Yangming Wind Strike, with a wiry, floating, and large pulse, shortness of breath, abdominal fullness, pain in the hypochondrium and heart region, dry nose, absence of sweat, lethargy, jaundice, difficult urination, tidal fever, and frequent hiccups, Xiao Chaihu Tang (Minor Bupleurum Decoction) is indicated.
In Cold Damage, after five or six days, if severe purgation was performed and the patient experiences knotted pain in the heart/chest, the disease has not yet resolved; Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered.
In Shaoyin disease, if there is spontaneous purging of clear water, pure green in color, inevitable pain in the epigastrium, and dryness of the mouth, urgent purgation is required, and Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Mu (Detailed Analysis)] Cheng Wuji said: On the fifth or sixth day of Cold Damage, when pathogens are in the interior, if severe purgation leads to the disappearance of body heat and an empty feeling in the chest and heart, the disease is about to resolve. If severe purgation leads to the disappearance of body heat but knotted pain in the heart remains, this is Jie Xiong (Chest Binding). If body heat persists and knotted pain in the heart remains, this is Xu Fan (Deficiency Irritability). Jie Xiong is heat binding in the chest, representing an excess pattern, where heat has converged internally, causing external body heat to subside. Xu Fan is heat lodging in the chest without forming a solid mass, scattering to cause irritability, hence body heat persists. Although the fifth to seventh day is typically when resolution is expected, because the heat manifests as deficiency irritability, it is stated that the disease has not yet resolved. Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used to induce vomiting and eliminate the pathogenic heat.
Wang Kentang commented: The phrase "body heat does not subside" warrants careful consideration. In Jie Xiong (Chest Binding) where there is no body heat, the heat is known to be in the exterior, so Da Xie Xiong Tang (Major Draining Chest Decoction) or Xiao Xie Xiong Tang (Minor Draining Chest Decoction) can be used to purge it downward. Since the heat is still in the exterior in this case, it is appropriate to disperse it via emesis. Cheng's annotation is not sufficiently thorough.