【纲】仲景曰。伤寒发热。汗出不解。心下痞硬。呕吐而下利者。大柴胡汤主之。
【目】朱肱曰。大抵结胸与痞。皆宜下。然表未解者。不可攻也。仲景云。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。汗出表解。而胃中不和。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。利日数十行。谷不化。腹中雷鸣。心下痞硬而满。此
以医下之也。若复下之。其痞益甚。甘草泻心汤。盖此非结热。以胃中虚。客气上逆。故使硬也。
下利而心下痞。服生姜泻心汤、甘草泻心汤。利不止者。当治其下焦。赤石脂禹余粮汤。盖前二泻
心。皆治中焦。此利在下焦。只治中焦。则利益甚耳。服石脂汤仍不止。当利其小便。五苓散。若
太阳症未除而数下之。遂协热而利。利不止。心下痞硬。表里不解者。桂枝人参汤主之。如十枣汤、
大柴胡汤。皆治心下痞。此方尤难用。须是表症罢。不恶寒。身凉。其人 汗出。发作有时。
头疼。心下痞硬满。引胁下疼。干呕短气者。乃可行十枣。表未解者。慎不可用也。大柴胡治伤寒
发热。汗出不解。心下痞硬。呕吐而下利者。非大柴胡不可也。若发汗吐下后。心下痞硬。噫气不
除者。旋覆代赭汤。此是主解后心下痞硬症。
【纲】仲景曰。伤寒五六日。呕而不发热者。柴胡汤症具。而以他药下之。若心下满而硬痛者。
此为结胸也。大陷胸汤主之。但满而不痛者为痞。柴胡不中与之。宜半夏泻心汤。
【目】柯琴曰。此为柴胡坏症。故用泻心而不与柴胡。
【纲】仲景曰。少阳中风。两耳无所闻。目赤。胸中满而烦者。不可吐下。吐下则悸而惊。
【目】柯琴曰。胸中为里之表。满者。虚风所为也。
【纲】仲景曰。太阳与少阳并病。脉弦。头项强痛。或眩冒。时如结胸。心下痞硬者。当刺大
椎第一间。肺俞肝俞。慎不可发汗。发汗则谵语。若谵语不止。当刺期门。
【目】朱肱曰。心下满而不痛。此名痞也。伤寒本无痞。应身冷。医反下之。遂成痞。枳实理
中丸最良。仲景治痞气诸汤中。有生姜半夏二泻心汤。俱平和。宜用之。半夏泻心。治满而不痛之痞。
此汤盖本理中人参黄芩汤方也。
审知是痞。先用桔梗枳壳汤尤妙。缘桔枳行气下膈。先用之。无不验也。结胸与痞。关脉须皆
沉。若关脉浮者。大黄黄连黄芩泻心汤。以关浮则结热。三黄能泻肝也。若复恶寒汗出者。附子泻
心汤。病患心下痞。与泻心汤不解。发渴口燥。小便不利者。五苓散。
【纲】仲景曰。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。
太阳少阳并病。心下硬。颈项强。眩者。当刺大椎肺俞肝俞。慎勿下之。
【目】陶华曰。痞者因太阳症。当服麻黄汤。而误用承气下之。而成痞满。此因虚邪留滞。若
欲下之。必待表症罢而后可宜。小柴胡加枳桔汤。
【纲】仲景曰。伤寒八九日。下之。胸满烦惊。小便不利谵语。一身尽重。不可转侧者。柴胡
龙骨牡蛎汤主之。
【目】鳌按。此妄下。热邪内攻。以致亡阴之变也。
【纲】仲景曰。太阳病。过经十余日。反二三下之。后四五日。柴胡症仍在者。先与小柴胡汤。
呕不止。心下急。郁郁微烦者。为未解也。与大柴胡汤下之则愈。
【目】楼英曰。此屡妄下。两候之久。柴胡症仍在。因其人不虚。故枢机有主。而不致成坏病。与小柴胡汤和之。
表症虽或已罢。而内尚不解。以前此妄下之药。但去肠胃有形之物。而不能泄胸中气分之结热也。急者。满也。但满而
不痛。即是痞也。
【纲】张仲景说：伤寒发热，汗出后病证未解，胃脘部痞塞坚硬，伴有呕吐和下利的，用大柴胡汤主治。
【目】朱肱说：一般来说，结胸和痞证都适宜用攻下法。然而表证未解除时，不可攻下。张仲景说：应当先解表，表证解除后才能攻治痞证。解表适宜用桂枝汤，攻治痞证适宜用大黄黄连泻心汤。如果汗出且表证已解，但胃中不和，出现胃脘部痞塞坚硬、干呕伴有食物腐臭味、胁下有停水、肠鸣下利的，用生姜泻心汤。如果一天腹泻几十次，完谷不化，肠鸣如雷，胃脘部痞塞坚硬且胀满，这是因为医生误用攻下法所致。如果再次攻下，痞证会更加严重，此时应用甘草泻心汤。这并非实热结聚，而是因为胃气虚弱，客气上逆，所以导致痞硬。如果下利而胃脘痞硬，服用生姜泻心汤、甘草泻心汤后，下利仍不止的，应当治疗下焦，用赤石脂禹余粮汤。因为前两个泻心汤都是治疗中焦的，此处的下利源于下焦，只治中焦，则下利会更严重。如果服用赤石脂禹余粮汤后仍然不止，应当通利小便，用五苓散。如果太阳病证未除却多次攻下，导致协热下利，下利不止，胃脘痞硬，表里同病未解的，用桂枝人参汤主治。至于十枣汤、大柴胡汤，也都治疗胃脘痞证，但这方子尤其难以使用。必须是表证已罢，不恶寒，身体凉爽，病人定时出汗，头痛，胃脘部痞塞坚硬胀满，牵引胁下疼痛，干呕短气的，才可以施用十枣汤。表证未解除者，千万不可使用。大柴胡汤治疗伤寒发热，汗出病不解，胃脘痞硬，呕吐而下利的，非大柴胡汤不可。如果在发汗、催吐、攻下之后，出现胃脘痞硬，嗳气不除的，用旋覆代赭汤。这是主治解表后出现的胃脘痞硬证。
【纲】张仲景说：伤寒五六天，呕吐而不发热的，具备小柴胡汤证，如果用其他药物攻下它。如果胃脘部胀满而且坚硬疼痛的，这是结胸证，用大陷胸汤主治。只是胀满而不疼痛的是痞证，不宜用小柴胡汤，适宜用半夏泻心汤。
【目】柯琴说：这是小柴胡汤证的坏病，所以用泻心汤而不与小柴胡汤。
【纲】张仲景说：少阳中风，两耳听不见，眼睛红，胸中满闷而烦躁的，不可用吐法和下法。吐下会导致心悸和惊骇。
【纲】张仲景说：太阳病与少阳病并病，脉弦，头项强痛，有时眩晕昏冒，有时像结胸证，胃脘部痞硬的，应当针刺大椎穴第一间，以及肺俞、肝俞穴。千万不要发汗，发汗会导致谵语。如果谵语不止，应当针刺期门穴。
【目】朱肱说：胃脘部满闷而不疼痛，这叫痞证。伤寒本来没有痞证，应该身体发冷，医生反而攻下，于是形成痞证。枳实理中丸效果最好。张仲景治疗痞气的各种汤剂中，有生姜半夏两个泻心汤，药性平和，适宜使用。半夏泻心汤治疗满闷而不痛的痞证。这个汤剂大概是基于理中人参黄芩汤的方子演变而来。确切知道是痞证后，先用桔梗枳壳汤尤为奇妙。因为桔梗和枳壳能行气降膈，先用它们，没有不灵验的。结胸和痞证，关脉都必须沉。如果关脉浮，用大黄黄连黄芩泻心汤，因为关脉浮表示有结热，三黄能清泻肝火。如果又出现恶寒汗出的，用附子泻心汤。病人胃脘痞硬，服用泻心汤后不愈，出现口渴口燥、小便不利的，用五苓散。
【纲】张仲景说：太阳少阳并病，反而攻下它，形成结胸，胃脘坚硬，下利不止，水浆不能入口，病人心中烦乱。太阳少阳并病，胃脘坚硬，颈项强直，眩晕的，应当针刺大椎、肺俞、肝俞穴。千万不要攻下。
【目】陶华说：痞证是因为太阳病证，本该服用麻黄汤，而误用承气汤攻下，从而形成痞满。这是由于虚邪留滞，如果想攻下，必须等待表证解除后才适宜。可用小柴胡汤加桔梗、枳壳。
【纲】张仲景说：伤寒八九天，攻下后，胸满、惊悸、小便不利、谵语、全身沉重、不能转侧的，用柴胡龙骨牡蛎汤主治。
【纲】张仲景说：太阳病，经过十余日，反而二三度攻下，之后四五天，小柴胡汤证仍在的，先给予小柴胡汤。如果呕吐不止，胃脘拘急不适，郁郁微烦的，说明病未解，给予大柴胡汤攻下则痊愈。
【目】楼英说：这是屡次妄自攻下，经过很长时间，小柴胡汤证仍在。因为病人正气不虚，所以枢机有主，而没有发展成坏病。给予小柴胡汤和解之。虽然表证或许已经解除，但内部尚未解开，因为之前妄用的攻下药，只能去除肠胃中有形的积滞，而不能泄去胸中气分的结热。“急”的意思是胀满，只是胀满而不疼痛，就是痞证。
[General Principle] Zhang Zhongjing stated: In cold damage (Shanghan) with fever, if sweating does not resolve the condition, accompanied by epigastric fullness and hardness, vomiting, and diarrhea, Da Chai Hu Tang (Major Bupleurum Decoction) is the primary treatment.
[Detailed Discussion] Zhu Gong said: Generally speaking, both Jie Xiong (Chest Binding) and Pi Syndrome (Epigastatic Fullness) are suitable for purgative methods. However, if the exterior syndrome has not resolved, attacking internally is contraindicated. Zhang Zhongjing stated: One should first resolve the exterior; only after the exterior is resolved can one attack the Pi syndrome. To resolve the exterior, Gui Zhi Tang (Cinnamon Twig Decoction) is appropriate; to attack the Pi syndrome, Da Huang Huang Lian Xie Xin Tang (Rhubarb, Coptis, and Scutellaria Heart-Draining Decoction) is appropriate. If sweating occurs and the exterior resolves, but the stomach interior is disharmonious, presenting with epigastric fullness and hardness, dry belching with a smell of food rot, fluid retention in the hypochondrium, and rumbling diarrhea, Sheng Jiang Xie Xin Tang (Fresh Ginger Heart-Draining Decoction) should be used. If there are dozens of bowel movements per day with undigested food, rumbling in the abdomen, and epigastric fullness, hardness, and distension, this is caused by the physician's erroneous use of purgatives. If purgatives are used again, the Pi syndrome will worsen; in such cases, Gan Cao Xie Xin Tang (Licorice Heart-Draining Decoction) should be used. This is not due to accumulated heat, but rather because of deficiency in the stomach allowing hostile Qi to rebel upward, causing hardness. If there is diarrhea with epigastric Pi, and after taking Sheng Jiang Xie Xin Tang or Gan Cao Xie Xin Tang the diarrhea persists, one should treat the Lower Jiao (Lower Burner) with Chi Shi Zhi Yu Liang Tang (Red Halloysite and Hematite Decoction). The previous two Heart-Draining Decoctions treat the Middle Jiao (Middle Burner); since this diarrhea originates from the Lower Jiao, treating only the Middle Jiao will exacerbate the diarrhea. If the Chi Shi Zhi Tang still fails to stop the diarrhea, one should promote urination using Wu Ling San (Five-Ingredient Powder with Poria). If the Tai Yang (Greater Yang) syndrome remains unresoved yet multiple purgations have been performed, leading to diarrhea with accompanying heat that does not cease, accompanied by epigastric fullness and hardness, and unresolved exterior and interior conditions, Gui Zhi Ren Shen Tang (Cinnamon Twig and Ginseng Decoction) is the main treatment. As for Shi Zao Tang (Ten Jujubes Decoction) and Da Chai Hu Tang, they also treat epigastric Pi, but this formula is particularly difficult to apply. It is indicated only when the exterior syndrome has ceased, there is no aversion to cold, the body is cool, the patient sweats at specific times, has headaches, epigastric fullness, hardness, and distension radiating pain to the hypochondrium, dry retching, and shortness of breath. Only then can Shi Zao Tang be administered. If the exterior is not resolved, it must strictly not be used. Da Chai Hu Tang treats cold damage with fever, where sweating does not resolve the condition, accompanied by epigastric fullness and hardness, vomiting, and diarrhea; in such cases, Da Chai Hu Tang is indispensable. After sweating, emesis, or purgation, if epigastric fullness and hardness occur with persistent belching, Xuan Fu Dai Zhe Tang (Inula and Hematite Decoction) is used. This primarily treats epigastric Pi following the resolution of the exterior.
[General Principle] Zhang Zhongjing stated: In cold damage on the fifth or sixth day, if there is vomiting without fever, indicating the presence of Xiao Chai Hu Tang (Minor Bupleurum Decoction) syndrome, but other drugs were used to purge it. If the epigastrium becomes full and painful with hardness, this is Jie Xiong (Chest Binding), treated primarily with Da Xian Xiong Tang (Major Thorax-Purgating Decoction). If it is merely full without pain, it is Pi syndrome (Epigastatic Fullness); Xiao Chai Hu Tang is not indicated, and Ban Xia Xie Xin Tang (Pinellia Heart-Draining Decoction) is appropriate.
[Detailed Discussion] Ke Qin said: This is a deteriorated state of the Xiao Chai Hu Tang syndrome; therefore, a Heart-Draining decoction is used instead of Xiao Chai Hu Tang.
[General Principle] Zhang Zhongjing stated: In Shaoyang (Lesser Yang) wind strike, with hearing loss in both ears, red eyes, chest fullness, and irritability, emesis and purgation are contraindicated. Emesis and purgation will lead to palpitations and fright.
[Detailed Discussion] Ke Qin said: The chest is the exterior of the interior. Fullness is caused by deficient wind.
[General Principle] Zhang Zhongjing stated: When Tai Yang (Greater Yang) and Shaoyang (Lesser Yang) syndromes occur together, with a wiry pulse, stiffness and pain in the head and neck, occasional dizziness or vertigo, symptoms resembling Jie Xiong (Chest Binding), and epigastric fullness and hardness, one should needle the first interspace of the Dazhui (GV14) acupoint, as well as Feishu (BL13) and Ganshu (BL18). Sweating must be strictly avoided; inducing sweating will lead to delirious speech. If delirium persists, Qimen (LR14) should be needled.
[Detailed Discussion] Zhu Gong said: Epigastric fullness without pain is named Pi syndrome (Epigastatic Fullness). Cold damage inherently does not present with Pi; the body should be cold. If the physician erroneously purges, Pi forms. Zhi Shi Li Zhong Wan (Immature Bitter Orange and Spleen-Nourishing Pill) is most effective. Among Zhang Zhongjing’s various decoctions for Pi Qi (Pi Syndrome), the two Heart-Draining Decoctions involving Sheng Jiang (Fresh Ginger) and Ban Xia (Pinellia) are mild and gentle, making them suitable for use. Ban Xia Xie Xin Tang treats Pi characterized by fullness without pain. This decoction is likely derived from the Li Zhong Ren Shen Huang Qin Tang (Spleen-Nourishing, Ginseng, and Scutellaria Decoction). Once Pi is confirmed, using Jie Geng Zhi Ke Tang (Platycodon and Aurantium Decoction) first is excellent, as these herbs move Qi and descend through the diaphragm; their prior use is invariably effective. For both Jie Xiong and Pi, the Guan (Cun) pulse must be deep. If the Guan pulse is floating, Da Huang Huang Lian Huang Qin Xie Xin Tang (Rhubarb, Coptis, and Scutellaria Heart-Draining Decoction) is used, because a floating Guan pulse indicates accumulated heat, and the three yellows can clear Liver fire. If there is additionally aversion to cold and sweating, Fu Zi Xie Xin Tang (Aconite Heart-Draining Decoction) is used. If the patient has epigastric Pi that does not resolve with Heart-Draining Decoctions, accompanied by thirst, dry mouth, and dysuria, Wu Ling San (Five-Ingredient Powder with Poria) is indicated.
[General Principle] Zhang Zhongjing stated: In Tai Yang-Shaoyang combined syndrome, if purgation is erroneously applied, resulting in Jie Xiong (Chest Binding), epigastric hardness, incessant diarrhea, inability to take fluids, and mental restlessness. In Tai Yang-Shaoyang combined syndrome, with epigastric hardness, neck stiffness, and dizziness, one should needle Dazhui (GV14), Feishu (BL13), and Ganshu (BL18). Purging must strictly be avoided.
[Detailed Discussion] Tao Hua said: Pi syndrome arises from Tai Yang syndrome, where Ma Huang Tang (Ephedra Decoction) should have been taken, but Cheng Qi Tang (Ordering the Qi Decoction) was mistakenly used for purgation, leading to Pi and fullness. This is due to the stagnation of deficient pathogenic factors. If purgation is desired, one must wait until the exterior syndrome has resolved before proceeding. Xiao Chai Hu Tang (Minor Bupleurum Decoction) added with Jie Geng (Platycodon) and Zhi Ke (Aurantium) is appropriate.
[General Principle] Zhang Zhongjing stated: In cold damage lasting eight or nine days, after purgation, if there is chest fullness, fright, dysuria, delirium, heaviness of the entire body, and inability to turn over, Chai Hu Long Gu Mu Li Tang (Bupleurum, Dragon Bone, and Oyster Shell Decoction) is the main treatment.
[Detailed Discussion] Shen Jin'ao noted: This results from reckless purgation, causing heat pathogens to invade inward, leading to a transformation of Yin exhaustion.
[General Principle] Zhang Zhongjing stated: In Tai Yang disease, after passing beyond the meridian for more than ten days, if purgation is erroneously applied two or three times, and four or five days later the Xiao Chai Hu Tang (Minor Bupleurum Decoction) syndrome persists, administer Xiao Chai Hu Tang (Minor Bupleurum Decoction) first. If vomiting persists, there is epigastric urgency, and slight depression with vexation, the condition has not resolved; administer Da Chai Hu Tang (Major Bupleurum Decoction) to purge, and the patient will recover.
[Detailed Discussion] Lou Ying said: This is due to repeated reckless purgation over a long period, yet the Xiao Chai Hu Tang syndrome persists. Because the patient's healthy Qi is not deficient, the pivot mechanism remains intact, preventing the formation of a deteriorated disease. Administering Xiao Chai Hu Tang harmonizes the condition. Although the exterior syndrome may have resolved, the interior remains unrelieved. The previously used purgatives could only remove tangible accumulations in the intestines and stomach but failed to drain the accumulated heat in the Qi aspect of the chest. "Urgency" refers to fullness; mere fullness without pain constitutes Pi syndrome (Epigastatic Fullness).