直格云伤寒里之阴分已受热邪是病发于阴也或热微下证未全误下之早则里热除去表热乘
虚入
里而作痞也故仲景攻痞多用大黄黄连黄芩寒药尔后或加附子干姜之类者是以辛热佐其寒药欲
令开发痞之怫热结滞也非攻寒耳
按前保命集论泻心汤分阴阳寒热多少而用药可谓详切矣而此论则专主于热二者似乎不同
要之
各有所当盖直格是言其受病之本保命集是论其用药之标若以为痞有阴寒之证耶则仲景泻心五
方何皆用黄芩黄连之药若以为痞无阴阳之异耶何泻心汤又有兼用干姜附子半夏生姜之类者也
一言其本一论其标而已
谨按痞之为病由阴伏阳蓄气与血不运而成处心下位中央 满痞塞皆土之病也与胀满有轻
重之
分痞则内觉痞闷而外无胀急之形胀满则外亦有形也前人所论皆指误下而致之盖误下则里气虚
故伤寒之表邪乘虚入于心下杂病则所受之邪气亦蓄于心下因致痞也亦有不因误下而得之如中
气虚弱不能运化精微为痞者有饮食痰积不能施化为痞者有湿热太甚土乘心下为痞者故古方治
痞用黄连黄芩枳实之苦以泄之浓朴生姜半夏之辛以散之人参白术之甘苦温以补之茯苓泽泻之
淡以渗之随其病之所在以调之也既痞同湿治惟宜上下分消其气如果有内实之证庶可略与疏导
世人苦于痞塞喜行利药以求速效临时通快痞若再作益以滋甚是皆不察夫所谓下多亡阴之意也
心下痞满治法
直格说：伤寒病中，如果里部的阴分已经受到热邪侵袭，这就是“病发于阴”。如果热邪轻微，下证（需要攻下的症状）尚未完全形成，此时若过早使用攻下法，会导致里热被清除，而表热乘虚进入体内，从而形成痞证。因此，张仲景在治疗痞证时，多使用大黄、黄连、黄芩等寒性药物。后来有些方剂中加入附子、干姜等辛热药物，是用辛热之药来辅助寒性药物，旨在开发痞证中的郁热结滞，并非为了攻逐寒邪。
按语：此前《保命集》在论述泻心汤时，根据阴阳、寒热的多少来用药，可以说非常详尽贴切。而这里的论述则专门侧重于热证，两者看似不同。但总之，它们各有其适用的情境。大概直格是讲述发病的根本原因，而《保命集》是论述用药的标末。如果认为痞证有阴寒的类型，那么张仲景的五首泻心汤为何都使用黄芩、黄连这些药物？如果认为痞证没有阴阳的区别，为什么泻心汤中又有兼用干姜、附子、半夏、生姜等药物的情况呢？这只是一者论述根本，一者论述标末罢了。
谨按：痞证这种病，是由于阴气潜伏、阳气蓄积，导致气与血运行不畅而形成的。病位在心下（胃脘部），处于人体中央，出现满闷痞塞的症状，这都是脾土系统的疾病。它与胀满病有轻重的区别：痞证是内部感觉痞闷，但外部没有胀急的形状；胀满病则是外部也有胀急的形状。前人所说的痞证，大多是指因误用攻下法导致的。因为误用攻下法会导致里气虚弱，所以伤寒病的表邪乘虚侵入心下；杂病中，所受的邪气也蓄积在心下，从而导致痞证。也有不是因误用攻下法而得的，如中气虚弱不能运化精微物质而形成痞证的；有饮食停滞、痰湿积聚不能施化而形成痞证的；有湿热太盛，土气上乘于心下而形成痞证的。所以古方治疗痞证，使用黄连、黄芩、枳实的苦味药物以泄降之，使用浓朴、生姜、半夏的辛味药物以散结之，使用人参、白术的甘苦温药物以补益之，使用茯苓、泽泻的淡味药物以渗利之，根据病情的所在部位进行调理。既然痞证同属湿邪为患，适宜采用上下分消气机的方法。如果有内实（腑实）的症状，才可以稍微给予疏导。世人苦于痞塞，喜欢使用利尿通导的药物以求速效，暂时虽然通畅，但痞证一旦复发，会更加严重，这些都是没有考察所谓“下法多用会亡失阴液”的道理啊。
Zhige stated: In the disease of Shanghan (Cold Damage), if the yin aspect within the interior has already been invaded by pathogenic heat, this is termed "disease originating from yin." If the heat is mild and the syndromes requiring purgation (symptoms indicating the need for downward-draining methods) are not fully formed, premature use of purgative methods will clear the interior heat. Consequently, exterior heat may enter the interior due to deficiency, resulting in Pi syndrome (a sensation of fullness and obstruction in the epigastrium). Therefore, Zhang Zhongjing often used cold-natured herbs such as Dahuang (Rhubarb Rhizome), Huanglian (Coptis Rhizome), and Huangqin (Scutellaria Root) to treat Pi syndrome. Later, some formulas added acrid-hot herbs like Fuzi (Aconite Lateral Root) and Ganjiang (Dried Ginger); these were used to assist the cold herbs with their acrid-hot nature, aiming to resolve the stagnation and constraint of heat within the Pi syndrome, rather than to attack cold.
Commentary: The previous work *Baoming Ji* discussed Xixin Tang (Gastrodia and Uncaria Decoction? No, Heart-Draining Decoction variants), prescribing medication based on the degrees of yin/yang and cold/heat, which can be considered detailed and appropriate. However, this discussion focuses exclusively on heat syndromes. Although they appear different, each has its specific application. Generally, Zhige discusses the root cause of the disease, while *Baoming Ji* discusses the symptomatic treatment. If one argues that Pi syndrome includes yin-cold types, why do all five Xixin Tang variants by Zhang Zhongjing use Huangqin and Huanglian? If one argues that Pi syndrome has no distinction between yin and yang, why do some Xixin Tang variants include Ganjiang, Fuzi, Banxia (Pinellia Tuber), and Shengjiang (Fresh Ginger)? This merely reflects one discussing the root and the other discussing the branch.
Respectfully noted: Pi syndrome arises from the latent yin and accumulated yang, causing dysfunction in the movement of Qi and Blood. The location is at the Xin Xia (epigastric region), situated in the center of the body; the symptoms of fullness and obstruction belong to disorders of the Earth element (Spleen/Stomach). There is a distinction in severity between Pi syndrome and Zhangman (distension and fullness): Pi syndrome involves an internal sensation of oppression without external signs of distension, whereas Zhangman presents with both internal and external distension. Previous discussions on Pi syndrome mostly refer to cases caused by erroneous purgation. Erroneous purgation leads to deficiency of interior Qi, allowing exterior pathogenic factors from Shanghan to invade the Xin Xia due to weakness; in miscellaneous diseases, pathogenic factors also accumulate in the Xin Xia, leading to Pi syndrome. There are also cases not caused by erroneous purgation, such as those arising from deficiency of Middle Qi failing to transform and transport essential nutrients; those caused by food retention and phlegm accumulation failing to be metabolized; and those where excessive damp-heat causes Earth qi to overact upon the Xin Xia. Therefore, ancient formulas for treating Pi syndrome employ bitter herbs like Huanglian, Huangqin, and Zhishi (Immature Bitter Orange) to drain downward; acrid herbs like Houpo (Magnolia Bark), Shengjiang, and Banxia to disperse stagnation; sweet, bitter, and warm herbs like Renshen (Ginseng Root) and Baizhu (Atractylodes Macrocephala Rhizome) to tonify; and bland herbs like Fuling (Poria) and Zexie (Alisma Rhizome) to leach out dampness, adjusting according to the location of the pathology. Since Pi syndrome is treated similarly to dampness disorders, it is appropriate to dissipate Qi through upper and lower channels. If there are signs of interior excess (Fu organ excess), slight guidance/drainage may be applied. People suffering from Pi obstruction often prefer using diuretic or purgative drugs for quick relief. Although temporary relief occurs, recurrence worsens the condition. These individuals fail to examine the principle that excessive purgation leads to the loss of Yin fluids.
Treatment methods for Xin Xia Pi Man (Epigastric Fullness and Obstruction)