（此痞在腹内，与心下之痞不同）
〔杨〕痞者塞也，结者实也，热气蕴于胸膈之间，留饮聚于腹胁之内，于是荣卫
不能流行，脏腑不能宣通，由胀满而致痞结，势使然耳。此热实之证也，时或发为
壮热，《圣惠》甘遂散主之。此药治小儿痞结，虽服汤药时暂得利而滞实不去，心下
坚胀，按之即啼，内有伏热，诸候并成。此疾宜疏利大便，破结散气，后宜常服进食丸。
按∶进食丸有巴豆，岂宜常服，甘遂有大毒，泻水如决江河，非十分壮实，
十分危急，十分水气，三者俱备，未可轻用，今以为痞结主方，谬矣。
〔薛〕痞癖既久，饮食减少，脾气必虚，久而不愈，必先以固胃气为主，使养正
则积自除，若欲直攻其结，不惟不能善消，抑亦损其脾土，脾土既亏，必变证百出
矣，当参各类及随见证而主治之。一小儿患痞癖，服槟榔、蓬术、枳实、黄连之
类，痞益甚。余曰此脾经血虚痞也，不可克伐。遂用六君子加当归数剂，胃气渐复，
诸证渐愈，乃朝用异功散加升麻、柴胡，夕用异功散加当归、芍药而愈。一小儿
患痞结，服克滞之药。余谓属形病俱虚，当补中气。彼不信，仍行克伐，遂致虚火
上炎，齿龈蚀烂，颔下结核。余用大芜荑汤及异功散加减，用之而安。一小儿患痞
结，久而四肢消瘦，肚腹渐大，寒热嗜卧，作渴引饮。用白术散为主，佐以四味肥
儿丸，月余诸证渐愈，又以异功散加当归，并六味地黄丸，又月余而愈。一小儿患
痞结，身热如火，病状多端，不可尽述，朝用五味异功散，夕用四味肥儿丸，月余
诸证稍愈，佐以地黄丸，自能行立，遂朝用地黄丸，夕用异功散及虾蟆丸，数服而愈。
《圣惠》前胡散 治小儿腹内痞结，壮热羸瘦多啼。
前胡 川大黄（各三分，微炒） 枳壳（炒、微黄） 赤茯苓 犀角（屑） 郁李仁（汤浸，去皮，微炒） 鳖
甲（涂醋，炙令黄，去裙 。各半两）
上件药捣，粗罗为散，每服一钱，以水一小盏，煎至五分，去滓，看儿大小分
减温服。微利为度。
《圣惠》甘遂破结散
甘遂（煨，二钱半，令黄色） 青皮（浸，去白，焙） 黄芩 川大黄（锉细，煨。各半两）
上为粗末，每服一钱，水一小盏，煎至六分，去滓，温和服。量大小加减，得
通利则止，后以冷粥补之。
进食丸 治乳食不消，心腹胀满，壮热喘粗，呕吐痰逆，腹鸣泄泻，米谷不化。或
下痢赤白，腹痛后重。及食症、乳癖、 气、痞结，并皆治之。小儿胸膈热实，
腹内有留饮，致令荣卫痞塞，脏腑之气不得宣通，其病腹内气结胀满或壮热是，
凡有此疾，当疏利大便，破结散气。
巴豆霜（一钱二分） 当归（米泔浸一宿，炒） 朱砂 代赭石（ ，醋淬七次） 枳壳（炒） 木香（各半两） 麝
香（少许）
上为末，面糊为丸，如麻子大。一岁儿一丸，温米饮下，更量虚实加减，食后
服。治食积发热，羸瘦肚大，青筋疳积，肚疼哺露。
〔汤〕户部张侍郎小娘子，患此蕴积结聚已经年矣，其候腹满壮热，大小便闭，
不食。诸医皆作虚热潮热，或作胃寒不食治，然既不食，大小便自然少，又欲作疳
热治，百药俱试，而无一中，势已窘迫，招予视之。问曰，合服何药。答曰∶当服
甘遂、大黄。张惊骇曰，前诸医者，皆用补剂，此女不进食久矣，不宜利动肠胃。
予答曰，信我者生，逆我者死。张曰，更有无甘遂而次于此药方者，可否？予令即
服大承气汤，二服而愈。次日诊之，尚有余滞积实，其证，必过数日而腹闭，须服
前药，始可除根。数日后，果再闭，腹满痞结，再投此药，一服而痊。
上，疏利大便例。形气俱实者宜之。
枳术丸
白术（四两） 枳实（二两）
上为末，荷叶包煨烂饭为丸，桐子大。每服四五十丸，空心白滚汤下。
枳实理中丸
枳实（十六片，麸炒） 茯苓 人参 白术 干姜（炮） 甘草（炙。各二两）
上为末，炼蜜和丸，如龙眼大。每服一丸，热汤化下。连进二三服，胸中豁然
渴者，加栝蒌根一两。自汗者，加牡蛎二两 过。下利亦加。
快膈汤 理胸膈不快，饮食少进。亦能顺气和中，消导宿滞。
人参（去芦） 青皮（去白） 缩砂仁 乌药 良姜（制） 香附子 甘草（炙。各一两）
为细末。每一钱，温盐汤空心调服。
参术陷胸汤
人参 白术 茯苓 橘红 半夏（各一钱） 栝蒌（全用，细切，带湿三钱） 黄连 甘草（各五分）
上，用水一钟半，生姜三片，枣一个，煎七分，温服。
洁古云，饮食不进，四君子加姜枣煎。
杨氏认为：痞，是指气机阻塞；结，是指邪气结实。热气蕴积在胸膈之间，停饮聚集在腹胁之内，于是营卫之气不能正常运行，脏腑之气不能宣通，由胀满进而发展为痞结，这是病势发展的必然结果。这属于热实证的范畴，有时发作会出现高热，《太平圣惠方》中的甘遂散主治此证。该药治疗小儿痞结，虽然服用汤药后暂时得到缓解，但体内的积滞和实邪并未去除，心下部位坚硬胀满，按压时患儿会啼哭，体内有伏热，各种症状并见。此病应当疏通利导大便，破除结聚、疏散气机，之后适宜常服进食丸。
按语：进食丸中含有巴豆，岂能长期服用？甘遂有大毒，泻水之力如同决堤江河，除非患者体质十分壮实、病情十分危急、体内水湿之邪十分严重，三者兼备，否则不可轻易使用，现在将其作为痞结的主治方剂，是错误的。
薛氏认为：痞癖日久，饮食减少，脾气必然虚弱，久治不愈，应当首先以巩固胃气为主，使正气得以养护，则积滞自然消除。如果一味直接攻伐其结聚，不仅不能很好地消散积滞，反而会损伤脾土。脾土既已亏损，必定变生百种证候，应当参考各类病症及随见证候而主治。有一个小儿患痞癖，服用槟榔、蓬莪术、枳实、黄连之类的药物，痞结反而加重。我说这是脾经血虚导致的痞证，不可克伐攻逐。于是使用六君子汤加入当归，服用数剂后，胃气逐渐恢复，各种症状逐渐痊愈，接着早晨服用异功散加升麻、柴胡，晚上服用异功散加当归、芍药，最终痊愈。另一个小儿患痞结，服用消食导滞的药物。我认为属于形体与病气俱虚，应当补益中气。那家人不信，仍然进行攻伐，导致虚火上炎，牙龈溃烂，下颌出现结核。我使用大芜荑汤及异功散加减治疗，服用后病情安定。还有一个小儿患痞结，日久四肢消瘦，肚腹逐渐变大，寒热交替，嗜睡，口渴想喝水。以白术散为主方，佐以四味肥儿丸，一个月后各种症状逐渐好转，又用异功散加当归，以及六味地黄丸，再过一个月痊愈。还有一个小儿患痞结，身体发热如火，病状繁多，无法一一叙述，早晨服用五味异功散，晚上服用四味肥儿丸，一个月后各种症状稍有好转，佐以地黄丸，能够自行行走站立，随后早晨服用地黄丸，晚上服用异功散及虾蟆丸，服用几剂后痊愈。
《太平圣惠方》前胡散：治疗小儿腹内痞结，高热消瘦且多啼哭。
前胡、川大黄（各三分，微炒）、枳壳（炒至微黄）、赤茯苓、犀角（锉屑）、郁李仁（汤浸，去皮，微炒）、鳖甲（涂醋，炙令黄色，去裙襕，各半两）。
以上药材捣碎，粗筛为散，每次服用一钱，用水一小盏，煎至五分，去渣滓，根据患儿大小酌情减量，温服。以轻微腹泻为度。
《太平圣惠方》甘遂破结散：
甘遂（煨至二钱半，呈黄色）、青皮（浸透，去白，焙干）、黄芩、川大黄（锉细，煨，各半两）。
以上药材制成粗末，每次服用一钱，用水一小盏，煎至六分，去渣滓，温和服用。根据患儿大小加减剂量，得通利后即止，之后喝冷粥调养。
进食丸：治疗乳食不消化，心腹胀满，高热喘促粗重，呕吐痰逆，肠鸣泄泻，米谷不化。或下痢赤白，腹痛里急后重。以及食积症、乳癖、瘕气、痞结，均能治疗。小儿胸膈热实，腹内有停饮，导致营卫痞塞，脏腑之气不得宣通，其病症表现为腹内气结胀满或高热，凡有此疾，应当疏通利导大便，破除结聚、疏散气机。
巴豆霜（一钱二分）、当归（米泔水浸泡一夜，炒）、朱砂、代赭石（煅，醋淬七次）、枳壳（炒）、木香（各半两）、麝香（少许）。
以上药材研为细末，面糊为丸，如麻子大。一岁的婴儿服一丸，温米饮送下，再根据虚实情况加减，饭后服用。治疗食积发热，消瘦肚大，青筋疳积，肚痛露骨。
汤氏医案：户部张侍郎的小女儿，患有此蕴积结聚之症已经一年了，其症状为腹部胀满、高热、大小便闭塞、不能进食。各位医生都当作虚热或潮热治疗，或者当作胃寒不食治疗，然而既然不能进食，大小便自然减少，又想当作疳热治疗，各种药物都试过了，但没有一种奏效，病情已经窘迫危急，邀请我去诊治。我问她应该服用什么药。回答说：应当服用甘遂、大黄。张侍郎惊恐地说：之前的各位医生，都用补剂，这个女孩很久没吃东西了，不宜利动肠胃。我回答说：相信我者生，违背我者死。张说：有没有不用甘遂而次于此药的方子，可以吗？我让他立即服用大承气汤，服用两剂后痊愈。第二天诊察，还有余留的积滞实邪，其证候，必定过几天会导致腹部闭塞，必须服用前面的药，才能除根。几天后，果然再次闭塞，腹部胀满痞结，再次投以此药，一剂而痊愈。
以上，是疏利大便的范例。形体与气机俱实者适宜使用。
枳术丸：
白术（四两）、枳实（二两）。
以上药材研为细末，用荷叶包裹煨烂米饭为丸，如梧桐子大。每次服用四五十丸，空腹用白开水送下。
枳实理中丸：
枳实（十六片，麸炒）、茯苓、人参、白术、干姜（炮制）、甘草（炙，各二两）。
以上药材研为细末，炼蜜和丸，如龙眼大。每次服用一丸，用热汤化开服用。连续进二三服，若胸中豁然开朗但仍口渴，加栝蒌根一两。自汗者，加牡蛎二两。下利者亦加。
快膈汤：调理胸膈不适，饮食少进。也能顺气和中，消导宿滞。
人参（去芦）、青皮（去白）、缩砂仁、乌药、良姜（制）、香附子、甘草（炙，各一两）。
研为细末。每次一钱，空腹用温盐汤调服。
参术陷胸汤：
人参、白术、茯苓、橘红、半夏（各一钱）、栝蒌（全用，细切，带湿三钱）、黄连、甘草（各五分）。
以上药材，用水一钟半，生姜三片，枣一个，煎至七分，温服。
(This type of Pi [abdominal fullness and obstruction] is located within the abdomen, differing from Pi at the epigastrium.)
Yang states: "Pi" refers to blockage; "Jie" refers to solidity. Heat qi accumulates between the chest and diaphragm, while retained fluid gathers within the abdomen and hypochondrium. Consequently, Ying [Nutritive] and Wei [Defensive] Qi cannot circulate freely, and the Zang-Fu organs cannot communicate smoothly. Thus, distension and fullness progress into Pi-Jie [accumulation and obstruction], which is the natural progression of the disease pattern. This belongs to a Heat-Excess syndrome. Occasionally, it manifests as high fever (Zhuang Re), for which Gan Sui San (Kansui Powder) from *Taiping Shenghui Fang* (The Holy惠民 Formulary of the Taiping Era) is indicated. This medicine treats pediatric Pi-Jie; although temporary relief may occur after taking the decoction, the stagnation and excess pathogens remain. The epigastrium feels hard and distended, and crying ensues upon palpation due to latent heat within, with various symptoms presenting simultaneously. For this disease, one should unblock and purge the bowels, break up accumulations, and dissipate Qi stagnation. Subsequently, Jin Shi Wan (Appetizing Pills) is suitable for regular use.
Commentary: Jin Shi Wan contains Ba Dou (Croton Seed Frost), which is unsuitable for long-term administration. Gan Sui (Kansui Root) possesses great toxicity; its water-draining power is like bursting a river dyke. It should not be used lightly unless three conditions are met simultaneously: the patient must be extremely robust, the condition extremely critical, and the pathogenic water-dampness extremely severe. Using it now as the primary formula for Pi-Jie is erroneous.
Xue states: When Pi-Pi [lumps or masses in the abdomen] persists for a long time, dietary intake decreases, leading inevitably to Spleen Qi deficiency. If it remains uncured for a long period, the primary treatment must focus on consolidating Stomach Qi. Nourishing the righteous Qi will cause the accumulation to resolve spontaneously. If one attempts to directly attack the accumulation, not only will it fail to dissolve effectively, but it will also damage the Spleen Earth. Once the Spleen Earth is deficient, myriad complications will arise. One should refer to various categories and treat according to the specific manifestations.
Case 1: A child suffered from Pi-Pi and took medicines such as Bing Lang (Areca Seed), Peng Zhu (Turmeric Tuber), Zhi Shi (Immature Bitter Orange), and Huang Lian (Coptis Rhizome), yet the Pi worsened. I stated that this was Pi caused by Blood deficiency in the Spleen Meridian and should not be treated with harsh purgatives. I prescribed Liu Jun Zi Tang (Six Gentlemen Decoction) added with Dang Gui (Angelica Sinensis Root). After several doses, Stomach Qi gradually recovered, and symptoms improved. Then, Yi Gong San (Benefit the Work Powder) added to Sheng Ma (Cimicifuga Rhizome) and Chai Hu (Bupleurum Root) was administered in the morning, and Yi Gong San added with Dang Gui and Shao Yao (Peony Root) in the evening, resulting in recovery.
Case 2: Another child suffered from Pi-Jie and took medicines that clear stagnation. I considered this a case of both Form and Qi being deficient, requiring tonification of Middle Qi. The family did not believe me and continued with attacking treatments, leading to deficient Fire flaming upward, erosion and ulceration of the gums, and tubercles under the jaw. I used Da Wu Yi Tang (Great Wormwood Decoction) and modified Yi Gong San, which stabilized the condition.
Case 3: A child suffered from Pi-Jie for a long time, resulting in emaciated limbs and a gradually enlarging abdomen, alternating chills and fever, lethargy, thirst, and desire to drink. Bai Zhu San (Atractylodes Macrocephala Powder) was used as the main formula, assisted by Si Wei Fei Er Wan (Four-Ingredient Child-Nourishing Pills). After more than a month, symptoms gradually improved. Then, Yi Gong San added with Dang Gui, along with Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia), were used, leading to recovery after another month.
Case 4: A child suffered from Pi-Jie with body heat intense as fire and numerous complex symptoms. Morning administration of Wu Wei Yi Gong San (Five-Ingredient Benefit the Work Powder) and evening administration of Si Wei Fei Er Wan led to slight improvement after a month. Assisted by Di Huang Wan (Rehmannia Pill), the child could walk and stand independently. Subsequently, Di Huang Wan was taken in the morning, and Yi Gong San combined with Xia Wa Wan (Toad Pill) in the evening, resulting in recovery after several doses.
Qian Hu San (Peucedanum Powder) from *Taiping Shenghui Fang*: Treats pediatric abdominal Pi-Jie, high fever, emaciation, and excessive crying.
Ingredients: Qian Hu (Peucedani Radix), Chuan Da Huang (Rhei Radix et Rhizoma) (each 3 fen, slightly stir-fried), Zhi Ke (Aurantii Fructus Immaturus) (stir-fried until slightly yellow), Chi Fu Ling (Poria with Hostwood), Xi Jiao (Rhino Horn) (crushed), Yu Li Ren (Prunus Armeniaca Seed) (soaked in hot water, skin removed, slightly stir-fried), Bie Jia (Trionycis Carapax) (coated with vinegar, roasted until yellow, skirt removed) (each 0.5 liang).
Process: Crush the ingredients and sieve coarsely. Take 1 qian per dose, boil in one small cup of water until reduced to 0.5 cup, strain, and administer warm in adjusted doses according to the child's age. Stop when mild diarrhea occurs.
Gan Sui Po Jie San (Kansui Breaking Accumulation Powder) from *Taiping Shenghui Fang*:
Ingredients: Gan Sui (Kansui Radix) (roasted to 2.5 qian, yellow), Qing Pi (Citri Reticulatae Pericarpium Viride) (soaked, white pith removed, dried), Huang Qin (Scutellariae Radix), Chuan Da Huang (Rhei Radix et Rhizoma) (cut finely, roasted) (each 0.5 liang).
Process: Make into coarse powder. Take 1 qian per dose, boil in one small cup of water until reduced to 0.6 cup, strain, and take warm. Adjust dosage based on age/size. Stop when bowel movement is achieved, then replenish with cold congee.
Jin Shi Wan (Appetizing Pills): Treats indigestion of milk and food, epigastric and abdominal fullness, high fever, coarse breathing, vomiting with phlegm reversal, borborygmus with diarrhea, undigested food particles. Also treats dysentery with red and white discharge, abdominal pain with tenesmus. Additionally treats Food Accumulation Syndrome, Milk Lump, Zhi Qi [masses], and Pi-Jie. For children with Heat-Excess in the chest/diaphragm and retained fluid in the abdomen causing blockage of Ying/Wei Qi and inability of Zang-Fu Qi to circulate, manifesting as abdominal Qi knotting/distension or high fever, these pills unblock the bowels, break accumulations, and dissipate Qi.
Ingredients: Ba Dou Shuang (Crotonis Fructus Frost) (1.2 qian), Dang Gui (Angelicae Sinensis Radix) (soaked in rice wash overnight, stir-fried), Zhu Sha (Cinnabar), Dai Zhe Shi (Hematitum) (calcined, quenched in vinegar seven times), Zhi Ke (Aurantii Fructus Immaturus) (stir-fried), Mu Xiang (Aucklandiae Radix) (each 0.5 liang), She Xiang (Moschus) (a little).
Process: Grind into fine powder, bind with wheat paste into pills the size of hemp seeds. One-year-old infants take one pill, washed down with warm rice water. Adjust based on deficiency/excess. Take after meals. Treats food-stagnation fever, emaciation with large belly, Green Vein Malnutrition, abdominal pain with protruding ribs.
Tang Case: The young daughter of Vice Minister Zhang of the Ministry of Revenue suffered from accumulated stagnation and mass formation for over a year. Symptoms included abdominal fullness, high fever, closure of stool and urine, and anorexia. Various physicians treated it as Deficient Heat or tidal fever, or as Cold-Stomach anorexia. Since she could not eat, stool and urine naturally decreased. Others tried treating it as Malnutrition Fever. All medicines failed, and the condition became critical. I was summoned. I asked what medication she should take. I answered: She should take Gan Sui and Da Huang. Mr. Zhang was horrified, saying previous doctors used tonics, and since the girl hadn't eaten for long, purging agents should not disturb the intestines. I replied: Trust me and live; defy me and die. He asked if there was a substitute without Gan Sui. I ordered immediate administration of Da Cheng Qi Tang (Major Order the Qi Decoction). After two doses, she recovered. On the next day's pulse diagnosis, residual stagnation remained. I predicted abdominal closure would recur in a few days, requiring the previous strong medicine to eradicate the root. Days later, indeed, closure recurred with abdominal fullness and Pi-Jie. Administering the strong medicine again cured her in one dose.
Above is the example of unblocking the bowels. Suitable for cases where both Form and Qi are Excess.
Zhi Zhu Wan (Immature Bitter Orange and Atractylodes Pill):
Ingredients: Bai Zhu (Atractodis Macrocephalae Rhizoma) (4 liang), Zhi Shi (Aurantii Fructus Immaturus) (2 liang).
Process: Grind into powder. Bind with steamed rice wrapped in Lotus Leaf into pills the size of tung tree seeds. Take 40-50 pills per dose, empty stomach, with plain boiling water.
Zhi Shi Li Zhong Wan (Immature Bitter Orange Regulate the Middle Pill):
Ingredients: Zhi Shi (16 slices, bran-stir-fried), Fu Ling (Poria), Ren Shen (Ginseng Radix et Rhizoma), Bai Zhu (Atractodis Macrocephalae Rhizoma), Gan Jiang (Zingiberis Rhizoma) (processed), Zhi Gan Cao (Prepared Licorice Root) (each 2 liang).
Process: Grind into powder, bind with refined honey into pills the size of longan fruits. Take one pill per dose, dissolved in hot water. Continue for 2-3 doses. If chest feels open but thirst persists, add Gua Lou Gen (Trichosanthis Radix) 1 liang. If spontaneous sweating occurs, add Mu Li (Ostrea Shell) 2 liang. Add for diarrhea as well.
Kuai Ge Tang (Quick Diaphragm Decoction): Regulates chest/diaphragm discomfort, poor appetite. Also promotes Qi flow, harmonizes the middle, and digests old stagnation.
Ingredients: Ren Shen (Ginseng Radix et Rhizoma) (rhizome removed), Qing Pi (Citri Reticulatae Pericarpium Viride) (white pith removed), Suo Sha Ren (Amomi Fructus), Wu Yao (Linderae Radix), Liang Jiang (Alpiniae Officinarum Rhizoma) (processed), Xiang Fu (Cyperi Rhizoma), Zhi Gan Cao (Prepared Licorice Root) (each 1 liang).
Process: Grind into fine powder. Take 1 qian per dose, mix with warm salted water, take empty stomach.
Shen Zhu Xian Xiong Tang (Ginseng and Atractylodes Trap-the-Chest Decoction):
Ingredients: Ren Shen (Ginseng Radix et Rhizoma), Bai Zhu (Atractodis Macrocephalae Rhizoma), Fu Ling (Poria), Ju Hong (Citri Reticulatae Pericarpium), Ban Xia (Pinelliae Rhizoma) (each 1 qian), Gua Lou (Trichosanthis Fructus) (whole, cut finely, damp weight 3 qian), Huang Lian (Coptidis Rhizoma), Zhi Gan Cao (Prepared Licorice Root) (each 0.5 qian).
Process: Use 1.5 zhong of water, 3 slices of Sheng Jiang (Zingiberis Rhizoma Recens), 1 Jujube. Decoct to 0.7 portion, take warm.
Jie Gu states: For loss of appetite, use Si Jun Zi Tang (Four Gentlemen Decoction) with Sheng Jiang and Jujube boiled together.