【纲】仲景曰。伤寒五六日。中风。往来寒热。胸胁苦满。默默不欲饮食。心烦喜呕。或胸中
烦而不呕。或渴。或腹中痛。或胁下痞硬。或心下悸小便不利。或不渴身有微热。或咳者。小柴胡
汤主之。
【目】王肯堂曰。邪气传里。必先自胸而胁。以次经心腹而入胃也。是以胸满多带表症。胁满
多带半表里症。如下后脉促胸满者。桂枝去芍药汤。又太阳与阳明合病。喘而胸满者。不可下。宜
麻黄汤。二者属表。须汗之。盖胸中至表尤近也。及胁则更不言发汗。但和解而已。经曰。设胸满
胁痛者。及胸胁满不去者。与夫本太阳病不解。传入少阳。胁下硬满。干呕。往来寒热。脉沉紧者。
俱宜小柴胡和解之。大抵邪初入里。尚未停留为实。但郁积生满者。和解斯可矣。若留于胸中。
聚而为实者。又非吐下之不可已。如发汗。若下之。烦热。胸中窒者。栀子豉汤。若胸中痞硬。气
上冲咽喉不得息者。此胸中有寒。瓜蒂散。二者均是吐剂。又当知栀豉吐虚烦客热。瓜蒂吐痰实宿
食也。
鳌按。此言伤寒五六日中风者。乃本伤寒病。至五六日更中风也。
【纲】仲景曰。伤寒四五日。身热恶风。颈项强。胁下满。手足温而渴者。小柴胡汤主之。
【目】陶华曰。胸满者。胸膈间气塞满闷也。非心下满。胁满者。胁肋下气填胀满也。非腹中
满。盖凡邪自表传里。必先胸至胁以至心腹入胃也。
柯琴曰。身热恶风。颈项强。桂枝症未罢。胁下满。已见柴胡一症。盒饭用小柴胡去参、夏。
加桂枝、栝蒌以两解之。不任
桂枝而主柴胡者。从枢故也。
【纲】仲景曰。阳明病。发潮热。大便溏。小便自可。胸胁满者。小柴胡汤主之。
【目】张云岐曰。此是邪从少阳而入阳明者。何以见之。潮热者。阳明症也。然阳明犹未实也。
又何以见之。曰。大便溏。小便自可。岂有胃已实而二便如此者乎。胸胁苦满。而用小柴胡和之。
使热邪仍自少阳而解。可不复入阳明也。
鳌按。前条四五日。身热恶风项强。与胁满齐见。是太阳少阳并病也。此条潮热便溏。小便自
可。与胁满齐见。是阳明少阳合病也。若云传入。则必先有太阳阳明之症。然后渐见少阳症矣。此
不可不察。
【纲】仲景曰。阳明病。胁下硬满。不大便而呕。舌上白苔者。可与小柴胡汤。上焦得通。津
液得下。胃气因和。身 然而汗出解也。
【目】王履曰。不大便。属阳明。然胁下硬满而呕也。不犹在少阳部分乎。至舌上起有白苔。
则全由痰饮溢于上焦也。
【纲】仲景曰。伤寒阳脉涩。阴脉弦。法当腹中急痛。先用小建中汤。不瘥者。小柴胡汤主之。
【目】成无己曰。胸胁满。以邪气初入里。未停留。为湿气痰积而不行。致生满也。和解可矣。
若腹中急痛。邪渐入里矣。急痛者。即满痛也。
鳌按。此条已偏于半里矣。
【纲】仲景曰。本太阳病。不解。转入少阳者。胁下硬满。干呕不能食。往来寒热。尚未吐下。
脉弦细者。与小柴胡汤。若已吐下。发汗。温针。谵语。柴胡症罢。此为坏病。知犯何逆。以法
治之。
【目】鳌按。此条坏病。尚由太阳病不解而来。已有坏之之机。故一入少阳。即患胁满干呕寒
热不食也。更兼吐下汗针。更不知变生何病矣。故必审之。知犯何逆。然后可随所犯而以法治。非
既入少阳。再加吐下汗针之后。而成坏病
也。
【纲】仲景曰。得病六七日。脉迟浮弱。恶风寒。手足温。医二三下之。不能食而胁下满痛。
面目及身黄。颈项强。小便难者。与柴胡汤后。必下重。本渴。而饮水呕。食谷哕者。柴胡不中与
也。
【目】鳌按。此太阳中风误下之坏病。非柴胡症也。故与柴胡汤而必下重。犹是误与之也。
【纲】仲景曰。伤寒五六日。已发汗。而复下之。胸胁满。微结。小便不利。渴而不呕。但头
汗出。往来寒热。心烦者。此为未解也。柴胡桂枝干姜汤主之。初服微烦。复服汗出。则愈。
【目】许叔微曰。本条着眼微结二字。微结者。对大结胸而言。是指心下痞。其病留着胸胁间。
故胸胁满微结五字。当作一句看。与心下痞硬。心下支结同义也。
【纲】仲景曰。伤寒胸中有热。胃中有邪气。腹中痛。欲呕吐者。黄连汤主之。
【目】陶华曰。腹满者。邪入太阴脾土也。常痛为里实。须下之。承气汤。时减者为里虚。当
温之。理中汤。若表解。内不消。非大满。犹生寒热。是邪未全入里。亦未可下。若大满大实。兼
有燥屎。是邪已入腑。虽得之四五日。亦为可下。大抵阳邪为实。则腹满而咽干。阴邪为寒。则腹
满而吐利。食不下。若已经吐下后而腹满者。治法又各不同。是又不可不知者也。有腹满痛。由脾
不胜水。水与气搏皮肉之间。腹中漉漉有声。小半夏茯苓汤加桂枝。下利腹满。身疼痛。先温其理。
四逆汤。后攻其表。桂枝汤。发汗后。腹满。当温。浓朴半夏生姜人参汤。吐后腹满。当下。少
与调胃承气汤。下后腹满。宜栀子浓朴汤。腹胀满者。阴阳不和也。桔梗半夏汤。
张介宾曰。若小腹硬痛。小水自利。大便黑。身目黄者。属蓄血痛。亦用寒剂加行血药。下尽
黑物自愈。凡伤寒腹中痛甚。但将凉水一盏与饮之。若痛稍可者。属热痛。当用凉药清之。以上皆
实热症也。必脉来沉实有力方是此症。若微
弱者。仍当审察从缓治之。若饮水愈痛。此为寒痛。急用温药和之。和之不已。而或四肢厥冷。呕
吐泻利者。急用热药救之。但须详脉之有力无力。方为良法耳。
朱 曰。有胃脘之阳不散。致腹中痛者。须知之也。
【纲】张仲景说：患伤寒病五六天，又感受风邪，出现寒热往来、胸胁部苦闷胀满、神情沉默不想吃东西、心烦且容易呕吐等症状。或者只是胸中烦闷而不呕吐；或者口渴；或者腹部疼痛；或者胁下痞塞硬满；或者心下悸动、小便不利；或者不渴但身体有轻微发热；或者咳嗽的，均用小柴胡汤主治。
【目】王肯堂说：邪气传入体内，必定先从胸部传至胁部，再依次经过心腹进入胃腑。因此，胸满多带有表证症状，如发汗后脉促、胸满者，用桂枝去芍药汤治疗；又如太阳与阳明合病，气喘且胸满者，不可用攻下法，宜用麻黄汤。这两种情况属于表证，必须用发汗法治疗，因为胸中距离体表最近。到了胁部，则不再提及发汗，只需和解即可。经书说：如果胸满胁痛，或胸胁满闷持续不去，以及原本太阳病未解，传入少阳，出现胁下硬满、干呕、寒热往来、脉沉紧等症状的，都适宜用小柴胡汤进行和解。大抵邪气初入里，尚未停留形成实证，只是郁积产生胀满，和解就可以了。如果邪气留于胸中，聚结成为实证，那就非用吐法或下法不能治愈了。如发汗或攻下后，出现烦热、胸中窒塞感的，用栀子豉汤；如果胸中痞塞硬满，气上冲咽喉导致呼吸困难的，这是胸中有寒饮，用瓜蒂散。这两者都是吐剂。另外应当知道，栀子豉汤吐出的是虚烦和客热，瓜蒂散吐出的是痰实和宿食。
沈金鳌按语：这里说的“伤寒五六日中风”，是指原本患有伤寒病，到了第五六天又再次感受风邪。
【纲】张仲景说：患伤寒病四五天，身体发热、怕风、颈项强直、胁下满闷、手足温暖且口渴的，用小柴胡汤主治。
【目】陶华说：胸满是胸膈间气机堵塞胀闷的感觉，不是心下（胃脘）的满闷；胁满是胁肋下部气机填塞胀满的感觉，不是腹中的胀满。大概凡是邪气从体表传入体内，必定先由胸传到胁，再到心腹，最后进入胃腑。
柯琴说：身热、怕风、颈项强直，说明桂枝汤证尚未解除；胁下满闷，已经出现了小柴胡汤证的一个指征。应当用小柴胡汤去掉人参、半夏，加入桂枝、栝蒌根，以同时解除两方面的病症。之所以不任用桂枝汤而主用小柴胡汤，是因为病情侧重于枢机（少阳），故从少阳论治。
【纲】张仲景说：患阳明病，出现定时发热（潮热）、大便稀溏、小便正常、胸胁满闷的，用小柴胡汤主治。
【目】张云岐说：这是邪气从少阳传入阳明的表现。怎么看出来的呢？潮热是阳明病的症状。然而阳明腑实尚未完全形成。怎么看出来的呢？回答说：大便稀溏，小便正常，难道胃气已经结实，二便会是这样吗？胸胁苦闷，用小柴胡汤和解，使热邪仍然从少阳解除，就不会再传入阳明了。
沈金鳌按语：前一条提到四五天时，身热、恶风、项强与胁满同时出现，这是太阳病和少阳病并病。这一条提到潮热、便溏、小便正常与胁满同时出现，这是阳明病和少阳病合病。如果说邪气传入，那必定先有太阳和阳明的症状，然后逐渐出现少阳的症状。这一点不可不仔细考察。
【纲】张仲景说：患阳明病，胁下硬满、不大便且呕吐、舌苔白的，可以给予小柴胡汤。上焦气机通畅，津液得以下行，胃气因而调和，身体就会自然出汗而病愈。
【目】王履说：不大便，属于阳明病范畴。但是伴有胁下硬满和呕吐，这不还在少阳的部分吗？至于舌上起白苔，则完全是由于痰饮溢于上焦所致。
【纲】张仲景说：患伤寒病，阳脉涩、阴脉弦，按照医理应当腹中急痛。先用小建中汤治疗，如果不痊愈的，再用小柴胡汤主治。
【目】成无己说：胸胁满，是因为邪气初入里，尚未停留，因湿气痰积阻滞不行，从而产生胀满。和解就可以了。如果腹中急痛，说明邪气逐渐深入里了。急痛，就是胀满疼痛的意思。
沈金鳌按语：这一条已经偏向半里证了。
【纲】张仲景说：原本患太阳病，未得解除，转入少阳的，出现胁下硬满、干呕不能进食、寒热往来，且尚未经过吐法、下法治疗，脉象弦细的，给予小柴胡汤。如果已经经过吐法、下法、发汗、温针等治疗，出现谵语，柴胡汤证已消失，这称为坏病。需要查明犯了什么错误，根据相应的法则进行治疗。
【目】沈金鳌按语：这一条所说的坏病，尚且是由太阳病未解发展而来，已经有了变坏的趋势，所以一旦转入少阳，就出现胁满、干呕、寒热、不能进食等症状。再加上误用吐、下、汗、针等法，更不知道会衍生出什么疾病了。所以必须审慎考察，弄清楚犯了什么逆乱之错，然后才能针对所犯的错误依法治疗。并不是说只要进入少阳，再加用吐、下、汗、针之后，才成为坏病。
【纲】张仲景说：患病六七天，脉象迟而浮弱，怕冷怕风，手足温暖，医生却反复多次使用攻下法，导致不能进食、胁下满痛、面目及全身发黄、颈项强直、小便困难的，如果误给柴胡汤，必然会导致排便时肛门重坠感。原本口渴，饮水却呕吐，进食则呃逆的，柴胡汤是不适用的。
【目】沈金鳌按语：这是太阳中风证误用攻下法导致的坏病，不是柴胡汤证。所以如果给予柴胡汤，必然导致下重感，这仍然是误治。
【纲】张仲景说：患伤寒病五到六天，已经发过汗，却又再次攻下，出现胸胁满闷、轻微结滞、小便不利、口渴但不呕吐、仅头部出汗、寒热往来、心烦的，这是病邪未解，用柴胡桂枝干姜汤主治。初次服用微微心烦，再次服用后汗出，病就好了。
【目】许叔微说：本条的关键在于“微结”二字。“微结”是相对于“大结胸”而言的，指的是心下痞塞。其病邪留滞在胸胁之间，所以“胸胁满微结”五个字，应当作为一句来理解，与“心下痞硬”、“心下支结”意义相同。
【纲】张仲景说：患伤寒病，胸中有热，胃中有邪气，腹中疼痛，想要呕吐的，用黄连汤主治。
【目】陶华说：腹满，是邪气侵入太阴脾土的表现。经常疼痛属于里实证，必须用攻下法，如承气汤；时轻时重的属于里虚证，应当用温补法，如理中汤。如果表证已解，内部仍有积滞但未到大满的程度，依然会有寒热，说明邪气未完全入里，也不可攻下。如果大满大实，兼有燥屎，说明邪气已进入腑，即使患病四五天，也可以攻下。大抵阳邪致实证，则腹满且咽干；阴邪致寒证，则腹满且吐利、饮食不下。如果已经经过吐下治疗后出现腹满，治疗方法又各不相同，这也是不可不知道的。如果有腹满痛，是由于脾不胜水湿，水气与脾气搏结在皮肉之间，腹中漉漉有声的，用小半夏茯苓汤加桂枝。下利伴腹满、身体疼痛的，先温里，用四逆汤；后解表，用桂枝汤。发汗后出现腹满的，应当温补，用厚朴半夏生姜人参汤。呕吐后出现腹满的，应当攻下，少量给予调胃承气汤。攻下后出现腹满的，宜用栀子厚朴汤。腹胀满的，是阴阳不和，用桔梗半夏汤。
张介宾说：如果小腹硬痛，小便自利，大便色黑，身目发黄的，属于蓄血痛，也用寒凉药加上活血药，排出黑色瘀物后自愈。凡是伤寒腹痛剧烈的，只给一盏凉水饮用，如果疼痛稍减的，属于热痛，应当用凉药清解。以上都属于实热证。必须脉象沉实有力才是此证。如果脉微弱，仍当审察，从容治疗。如果饮水后疼痛加剧，这是寒痛，急用温药调和。调和无效，且出现四肢厥冷、呕吐泻利的，急用热药救治。但必须详细诊察脉象的有力无力，这才是良法。
[Outline] Zhang Zhongjing said: In the course of a Shanghan (Cold Damage) disease, after five or six days, if Wind pathogen is contracted, presenting with alternating chills and fever (Wanglai Hanre), bitter fullness in the chest and hypochondrium (Xiong Xie Ku Man), silent desire not to eat (Mo Mo Bu Yu Yin Shi), mental irritability (Xin Fan), and frequent vomiting (Xi Ou). Or alternatively, mental irritability in the chest without vomiting; or thirst; or abdominal pain; or stuffiness and hardness under the hypochondrium (Xia Xia Pi Ying); or palpitation in the epigastrium with urination difficulty; or no thirst but slight body heat; or coughing. In all these cases, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be administered as the primary treatment.
[Commentary] Wang Kentang stated: When pathogenic factors transmit inward, they must first move from the chest to the hypochondrium, then sequentially through the heart/abdomen into the stomach. Therefore, chest fullness often carries exterior syndrome characteristics. For instance, if pulse is rapid and there is chest fullness after purgation, Gui Zhi Qu Shao Yao Tang (Cinnamon Twig Decoction without Paeonia) is used. Similarly, in combined Taiyang and Yangming syndromes with wheezing and chest fullness, purgation is contraindicated; Ma Huang Tang (Ephedra Decoction) is appropriate. Both belong to exterior syndromes and require diaphoresis (sweating method), as the chest is closest to the exterior. However, when the pathogen reaches the hypochondrium, sweating is no longer mentioned; only harmonization is indicated. The classics state: If there is chest fullness and hypochondriac pain, or persistent chest-hypochondriac fullness, or if an initial Taiyang syndrome fails to resolve and transmits to Shaoyang, presenting with hardness/fullness under the hypochondrium, dry retching, alternating chills and fever, and a deep-tight pulse, Xiao Chai Hu Tang should be used for harmonization. Generally, when pathogenic factors initially enter the interior but have not yet stagnated to form excess, causing fullness merely through depression and accumulation, harmonization suffices. If they remain in the chest and gather into excess, neither emesis nor purgation will suffice. For example, after sweating or purging, if irritability and heat with chest oppression occur, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is used. If there is chest stuffiness and hardness with qi rushing to the throat causing breathing difficulty, this indicates cold-phlegm in the chest, treated with Gua Di San (Melon Seed Powder). Both are emetic agents. Furthermore, one must understand that Zhi Zi Chi Tang expels deficiency-irritability and guest-heat, while Gua Di San expels phlegm-excess and retained food.
Shen Jin'ao's Note: The phrase "Shanghan five or six days, Wind contraction" here refers to a patient who originally had Shanghan, and upon reaching the fifth or sixth day, contracted Wind again.
[Outline] Zhang Zhongjing said: In Shanghan disease lasting four or five days, presenting with body heat, aversion to wind, stiffness of the neck and nape, fullness under the hypochondrium, warm hands and feet, and thirst, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be administered.
[Commentary] Tao Hua stated: Chest fullness refers to Qi blockage and distension in the chest and diaphragm, not fullness in the epigastrium (Xin Xia). Hypochondriac fullness refers to Qi filling and distension under the ribs, not fullness in the abdomen. Generally, when pathogens transmit from the exterior to the interior, they proceed from the chest to the hypochondrium, then to the heart/abdomen, and finally enter the stomach.
Ke Qin stated: Body heat, aversion to wind, and neck stiffness indicate that the Gui Zhi Tang (Cinnamon Twig Decoction) syndrome has not yet resolved. Fullness under the hypochondrium indicates the appearance of one symptom of the Xiao Chai Hu Tang syndrome. One should use Xiao Chai Hu Tang, removing Ren Shen (Ginseng Radix) and Ban Xia (Pinelliae Rhizoma), and adding Gui Zhi (Cinnamomi Ramulus) and Gua Lou Gen (Trichosanthis Radix) to address both conditions simultaneously. The reason for prioritizing Xiao Chai Hu Tang over Gui Zhi Tang is due to the focus on the pivot mechanism (Shaoyang).
[Outline] Zhang Zhongjing said: In Yangming disease, presenting with tidal fever (Chao Re), loose stools, normal urination, and chest-hypochondriac fullness, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be administered.
[Commentary] Zhang Yunqi stated: This represents pathogens entering Yangming from Shaoyang. How do we know? Tidal fever is a Yangming symptom. However, Yangming excess has not yet fully formed. How do we know? Loose stools and normal urination suggest that the Stomach Qi is not yet solidified; would the bowel and bladder movements be like this if the Stomach were truly excess? With chest-hypochondriac fullness, Xiao Chai Hu Tang is used to harmonize, allowing the heat pathogen to resolve via Shaoyang, preventing further transmission to Yangming.
Shen Jin'ao's Note: In the previous clause, body heat, aversion to wind, neck stiffness, and hypochondriac fullness appearing together indicate concurrent Taiyang and Shaoyang syndromes. In this clause, tidal fever, loose stools, normal urination, and hypochondriac fullness appearing together indicate combined Yangming and Shaoyang syndromes. If describing transmission, there must first be Taiyang and Yangming symptoms before Shaoyang symptoms gradually appear. This requires careful observation.
[Outline] Zhang Zhongjing said: In Yangming disease, presenting with hardness/fullness under the hypochondrium, constipation, vomiting, and a white coating on the tongue, Xiao Chai Hu Tang may be given. Once the Upper Jiao (Upper Burner) becomes unobstructed, body fluids descend, Stomach Qi harmonizes, and the body naturally sweats, resolving the condition.
[Commentary] Wang Lu stated: Constipation belongs to Yangming. However, with hardness/fullness under the hypochondrium and vomiting, is it not still within the Shaoyang domain? The presence of a white coating on the tongue indicates that turbid phlegm-fluids are overflowing into the Upper Jiao.
[Outline] Zhang Zhongjing said: In Shanghan disease, if the Yang pulse is choppy (Se) and the Yin pulse is string-like (Xian), according to medical principles, there should be acute abdominal pain. First, use Xiao Jian Zhong Tang (Minor Construct the Middle Decoction). If it does not improve, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be administered.
[Commentary] Cheng Wuji stated: Chest-hypochondriac fullness occurs because pathogenic factors have just entered the interior and have not yet stagnated; dampness and phlegm accumulate and fail to circulate, causing fullness. Harmonization is sufficient. If there is acute abdominal pain, the pathogen is gradually entering the interior. Acute pain implies pain associated with fullness.
Shen Jin'ao's Note: This clause leans towards a semi-interior syndrome.
[Outline] Zhang Zhongjing said: If an initial Taiyang syndrome fails to resolve and transmits to Shaoyang, presenting with hardness/fullness under the hypochondrium, dry retching, inability to eat, alternating chills and fever, and without prior emesis or purgation, with a string-thin pulse, Xiao Chai Hu Tang should be given. If emesis, purgation, sweating, or moxibustion/warm needle therapy have already been performed, leading to delirium (Chan Yu) and the cessation of the Xiao Chai Hu syndrome, this is termed a "Hua Bing" (Ruined/Malformed Disease). One must determine what error was committed and treat according to the appropriate method.
[Commentary] Shen Jin'ao's Note: The "Hua Bing" in this clause originates from the unresolved Taiyang syndrome, showing signs of deterioration. Thus, upon entering Shaoyang, symptoms such as hypochondriac fullness, dry retching, chills/fever, and anorexia arise. Compounded by erroneous emesis, purgation, sweating, and needling, it is unknown what new pathology has emerged. Therefore, one must carefully examine to identify the specific deviation before treating accordingly based on the error. It is not simply that entering Shaoyang followed by further errors creates a Hua Bing.
[Outline] Zhang Zhongjing said: After six or seven days of illness, if the pulse is slow, floating, and weak, with aversion to cold and wind, and warm hands and feet, but the physician repeatedly applies purgatives, leading to inability to eat, painful fullness under the hypochondrium, yellowing of the face/eyes and body, neck stiffness, and difficult urination: if Chai Hu Tang is mistakenly administered, it will inevitably cause a sensation of heaviness in the rectum (Xia Zhong). If the patient was thirsty but vomits after drinking water, or experiences hiccups after eating, Chai Hu Tang is contraindicated.
[Commentary] Shen Jin'ao's Note: This is a Hua Bing resulting from erroneous purgation in a Taiyang Wind-strike syndrome, not a Chai Hu syndrome. Therefore, administering Chai Hu Tang causes rectal heaviness, which is itself a mismanagement.
[Outline] Zhang Zhongjing said: In Shanghan disease, after five or six days, if sweating has been induced but purgation is subsequently applied, presenting with chest-hypochondriac fullness, slight knotting/congestion (Wei Jie), urination difficulty, thirst without vomiting, sweating only on the head, alternating chills and fever, and mental irritability, this indicates the pathogen has not resolved. Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction) should be administered. Mild irritability upon the first dose, and sweating upon subsequent doses, leads to recovery.
[Commentary] Xu Shuwei stated: The key to this clause lies in the term "slight knotting" (Wei Jie). "Slight knotting" contrasts with "Great Knotting" (Da Jie Xiong) and refers to epigastric stuffiness. The pathology lingers in the chest-hypochondriac region. Therefore, "chest-hypochondriac fullness and slight knotting" should be read as a single phrase, synonymous with "epigastric stuffiness and hardness" or "epigastric branch-knotting."
[Outline] Zhang Zhongjing said: In Shanghan disease, if there is heat in the chest and pathogenic factors in the Stomach, accompanied by abdominal pain and a desire to vomit, Huang Lian Tang (Coptis Decoction) should be administered.
[Commentary] Tao Hua stated: Abdominal fullness indicates pathogen invasion of the Taiyin Spleen Earth. Constant pain indicates interior excess, requiring purgation (e.g., Cheng Qi Tang). Intermittent reduction indicates interior deficiency, requiring warming (e.g., Li Zhong Tang). If the exterior is resolved but internal stagnation remains without being a "great fullness," and chills/fever persist, the pathogen has not fully entered the interior, so purgation is contraindicated. If there is great fullness and excess with dry feces, the pathogen has entered the Fu organs, and purgation is permissible even after four or five days. Generally, Yang pathogens causing excess lead to abdominal fullness and dry throat; Yin pathogens causing cold lead to abdominal fullness, vomiting, diarrhea, and inability to eat. If abdominal fullness occurs after emesis/purgation, treatment methods differ, which must be known. For abdominal fullness/pain due to Spleen failing to control Water, with water-Qi battling in the flesh causing gurgling sounds, Xiao Ban Xia Fu Ling Tang (Minor Pinellia, Poria Decoction) plus Gui Zhi is used. For diarrhea with abdominal fullness and body pain, warm the interior first with Si Ni Tang (Frigid Extremities Decoction), then release the exterior with Gui Zhi Tang. For abdominal fullness after sweating, warm with Hou Po Ban Xia Sheng Jiang Ren Shen Tang (Magnolia Bark, Pinellia, Fresh Ginger, and Ginseng Decoction). For abdominal fullness after vomiting, purge slightly with Tiao Wei Cheng Qi Tang (Regulate the Weight and Establish the Qi Decoction). For abdominal fullness after purgation, use Zhi Zi Hou Po Tang (Gardenia and Magnolia Bark Decoction). Abdominal distension-fullness indicates disharmony of Yin and Yang, treated with Jie Geng Ban Xia Tang (Platycodon and Pinellia Decoction).
Zhang Jiebin stated: If there is hardness and pain in the lower abdomen, free urination, black stools, and jaundice of the body and eyes, this belongs to Blood Stasis pain. Cold-natured herbs combined with blood-invigorating herbs should be used; clearing out black material leads to self-healing. For severe abdominal pain in Shanghan, offering a cup of cool water can help diagnose: if pain decreases slightly, it is Heat pain, treated with cooling herbs (Excess-Heat syndrome). The pulse must be deep, solid, and forceful. If the pulse is weak, observe cautiously and treat gently. If pain worsens with water intake, it is Cold pain, treated urgently with warming herbs. If warming fails and cold limbs, vomiting, or diarrhea occur, urgent hot herbs are needed. Carefully assessing pulse forcefulness is essential.
Zhu Danxi stated: Abdominal pain caused by the failure of Stomach-Yang Qi to disperse should be recognized.