【纲】仲景曰。伤寒中风。医反下之。其人下利日十数行。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。
【目】黄仲理曰。下利完谷。腹鸣呕烦。皆误下而胃中空虚之互词。设不知此义。以为结热而复
下之。其痞必益甚。故重以胃中虚客气上逆。昭揭病因。
楼英曰。客气者。乍来之气。非本有之气也。伤寒伤风者。原无此阴邪之气格于心下。乃庸医
不治表而误下使然也。痞硬而满腹鸣下利者。阴沉于下也。干呕心烦不安者。阳浮于上也。仍用泻
心法而异其术。
【纲】仲景曰。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。
【目】成无己曰。腹中雷鸣有二症。坏病也。一主甘草泻心者。以误下损阴气也。一主生姜
泻心者。以误汗损阳气也。用此二汤。以复阴阳之气耳。
魏荔彤曰。本条诸症。皆凝聚停蓄之象。即雷鸣下利。亦是中气营运不健之故。鸣则为虚。利
则为热。痞硬少气而虚。干噫食臭为热。虚热二字。合成此症。此生姜泻心以苦治热。以甘补虚。
以辛散痞。为对症之剂也。
【纲】张仲景说：患伤寒或中风病，医生反而使用泻下法治疗。患者出现每天腹泻十几次，食物不消化，肠中鸣响如雷，胃脘部痞塞坚硬且胀满，干呕，心烦意乱不得安宁。医生看到胃脘部痞塞，认为病邪未尽，再次使用泻下法，导致痞塞症状更加严重。这并非实热结聚，而是因为胃气虚弱，客气（指外来的邪气）上逆，所以才导致痞硬。应当用甘草泻心汤主治。
【目】黄仲理说：腹泻完谷不化、腹中鸣响、呕吐、心烦，都是误用泻下法导致胃中空虚的不同表述。如果不知道这个道理，认为是实热结聚而再次泻下，痞塞症状必然更加严重。因此特别强调“胃中虚，客气上逆”，以明确病因。
楼英说：所谓客气，是突然到来的气，并非人体本有的气。伤寒或伤风原本没有这种阴邪之气阻隔在心下，这是庸医不先解表而误用下法造成的。痞硬、胀满、腹中鸣响、腹泻，是因为阴邪下沉于下；干呕、心烦、不安，是因为阳气浮越于上。仍然使用泻心汤的方法，但调整了具体用药。
【纲】张仲景说：伤寒通过发汗后表证已解，但胃中不和，胃脘部痞塞坚硬，嗳气带有食物腐臭味，胁下有停水之气，肠中鸣响如雷，伴有腹泻的，应当用生姜泻心汤主治。
【目】成无己说：腹中鸣响有两种病症表现，都属于坏病（变证）。一种主治用甘草泻心汤，是因为误下损伤了阴气；一种主治用生姜泻心汤，是因为误汗损伤了阳气。使用这两首方剂，是为了恢复阴阳二气。
魏荔彤说：本条所述的各种症状，都是气机凝聚停滞的表现。即使是肠鸣腹泻，也是中焦脾胃之气运化功能不健的缘故。鸣响说明是虚证，腹泻说明有热象，痞硬、少气说明是虚证，嗳气带食臭说明有热象。“虚”和“热”两个字合起来构成了这个病症。生姜泻心汤用苦味药清热，用甘味药补虚，用辛味药散结消痞，是对症的方剂。
[General Principle] Zhang Zhongjing stated: In cases of Taiyang disease (Cold Damage) or Wind-stroke, if the physician erroneously employs purgation, the patient may suffer from diarrhea occurring ten to several times a day, with undigested food in the stool, borborygmus (rumbling in the abdomen), epigastric fullness and hardness, dry retching, and irritability with restlessness. If the physician observes the epigastric fullness and assumes the pathogenic factor is not exhausted, and administers purgation again, the fullness will become even more severe. This is not due to accumulated heat, but rather to deficiency in the Stomach and the counterflow of "guest qi" (pathogenic factors invading due to deficiency), which causes the hardness. Gancao Xiexin Tang (Licorice Decoction for Draining the Epigastrium) should be administered.
[Commentary] Huang Zhongli stated: Diarrhea with undigested food, abdominal borborygmus, vomiting, and irritability are all different expressions of the same underlying condition: emptiness and deficiency in the Stomach caused by erroneous purgation. If one fails to understand this principle and mistakenly treats it as accumulated heat, administering purgation again will inevitably exacerbate the epigastric fullness. Therefore, the text emphasizes "Stomach deficiency and counterflow of guest qi" to clarify the etiology.
Lou Ying stated: "Guest qi" refers to pathogenic qi that arrives suddenly, distinct from the body's inherent qi. In Cold Damage or Wind-stroke, there is originally no such Yin pathogenic qi obstructing the epigastrium; this results from incompetent physicians failing to resolve the exterior first and erroneously using purgation. Epigastric fullness, hardness, distension, borborygmus, and diarrhea indicate Yin pathogens sinking downward; dry retching, irritability, and restlessness indicate Yang floating upward. The treatment still utilizes the method of Xiexin Tang (Draining the Epigastrium Decoction), but with modified ingredients.
[General Principle] Zhang Zhongjing stated: After Taiyang disease has been resolved through sweating, if there is disharmony in the Stomach, characterized by epigastric fullness and hardness, belching with a smell of fermented food, fluid retention under the hypochondrium, borborygmus, and diarrhea, Shengjiang Xiexin Tang (Fresh Ginger Decoction for Draining the Epigastrium) should be administered.
[Commentary] Cheng Wuji stated: There are two presentations of borborygmus, both belonging to "bad diseases" (complications/malpractices). One is treated with Gancao Xiexin Tang because erroneous purgation damaged Yin Qi; the other is treated with Shengjiang Xiexin Tang because erroneous sweating damaged Yang Qi. These two formulas are used to restore the balance of Yin and Yang Qi.
Wei Litong stated: All symptoms described in this clause represent stagnation and accumulation. Even borborygmus and diarrhea result from impaired transportation and transformation of Middle Jiao Qi. Borborygmus indicates deficiency; diarrhea indicates heat. Epigastric hardness and shortness of breath indicate deficiency; belching with food odor indicates heat. The combination of "deficiency" and "heat" constitutes this syndrome. Shengjiang Xiexin Tang uses bitter herbs to clear heat, sweet herbs to tonify deficiency, and acrid herbs to dissipate stagnation, making it an appropriate formula for this condition.