详见各门
秘藏云内经曰备化之纪其病痞又曰太阴所致为积饮痞膈太阴者湿土也主壅塞乃土来心下
为痞
满也伤寒下之太早亦为痞乃因寒伤荣血心主血邪入于本故为心下痞仲景泻心汤数方皆用黄连
以泻心下之土邪至于酒积杂病下之太过亦作痞满皆血证也盖下多则亡阴亡阴者即损脾胃谓脾
胃水谷之阴亡也故胸中之气以其血虚而下陷于心之分故致心下痞上宜理脾胃以血药治之若全
用气药导之则其痞益甚而复下之气愈下降必变为中满鼓胀非其治也又有虚实之殊如实痞大便
秘浓朴枳实主之虚痞大便利芍药陈皮主之饮食所伤而为痞满者当用药消导其胸中窒塞欲吐者
则宜吐之
难知云伤寒痞者从血中来从外之内从无形杂病痞者亦从血中来从内之外从有形故无形以
苦泄之有形以辛散之
按痞之凝滞闭塞人皆知气之不运也独东垣指以血病言之谓下多则亡阴而损血此前人之未
论也世有用气药治痞而不效者盖不知此理故也
保命集云三阴三阳之标本治各不同有用寒药而为热痞大黄黄连之类也有用寒热药者阴与
阳不
和而痞大黄黄连加附子之类也有用辛热药多而寒药少者阴盛阳虚而痞半夏甘草生姜泻心三方
之类泻心汤者非泻心火之热泻心下之痞也通而论之其药阳多而阴少盖病发于阴而得之有大黄
黄连泻心汤独为阴心下痞而脉疾一证桂枝后用从太阳浮弱所变余皆阴阳杂用
详见各门类。
《秘藏》引用《内经》说：“备化之纪（土运平和之年），其病为痞。”又说：“太阴所致（太阴湿土之气异常）的病证，表现为积饮、痞膈。”太阴属于湿土，主要导致壅塞，这是土气上乘于心下，造成痞满。伤寒病如果攻下过早，也会形成痞证，这是因为寒邪损伤了营血，心主血脉，邪气侵入本脏，所以导致心下痞。张仲景的泻心汤数方中都用黄连，以清泻心下的土邪。至于酒积等杂病，如果攻下太过，也会产生痞满，这都属于血证。因为攻下过多会耗伤阴液，耗伤阴液即是损伤脾胃，指的是脾胃中水谷之阴的亡失。因此，胸中的气因为血虚而下陷，陷入心的分野，从而导致心下痞。治疗上应当调理脾胃，用血药来治疗。如果完全使用气药来疏导，那么痞满会更加严重，而且下行之气会更加下降，必然转变为中满鼓胀，这不是正确的治疗方法。又有虚实之分：如实痞，大便干结，用厚朴、枳实主治；虚痞，大便通畅，用芍药、陈皮主治。因饮食所伤而导致的痞满，应当用药消导。如果胸中窒塞感强烈且想呕吐的，则适宜采用催吐法。
《难知》说：伤寒引起的痞证，是从血中产生的，由外入内；杂病引起的痞证，也是从血中产生的，由内出外。因为是无形之邪，所以用苦味药泄降；因为有形之邪，所以用辛味药发散。
按语：对于痞证的凝滞闭塞，人们都知道是气机不运行所致。唯独李东垣指出这是血病，认为攻下过多会亡阴而损血，这是前人未曾论述过的。世上有人用气药治疗痞证而不奏效，大概是不懂这个道理的缘故。
《保命集》说：三阴三阳的标本治疗各不相同。有用寒药治疗热痞的，如大黄、黄连之类；也有用寒热药并用的，因阴阳不和而致痞，如大黄、黄连加附子之类；也有用辛热药多而寒药少的，因阴盛阳虚而致痞，如半夏、甘草、生姜泻心三方之类。所谓的“泻心汤”，并不是泻心火的火热，而是消除心下的痞满。通盘来说，这些药物中阳性药多而阴性药少。大概是因为病发于阴而形成的。有大黄黄连泻心汤这一方，专门针对阴证中心下痞且脉象急促的一种情况。桂枝汤后出现的变证，是从太阳经浮弱脉演变而来的。其余各方都是阴阳药杂用。
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*Mi Zang* cites *Nei Jing* stating: "In the era of Bei Hua (the harmonious phase of Earth), diseases manifest as Pi [Pi, a sensation of fullness and obstruction]." It also states: "Diseases caused by Tai Yin [Taiyin, one of the Six Channels characterized by dampness and earth] present as accumulated fluids, Pi, and diaphragmatic obstruction." Tai Yin belongs to damp Earth, primarily causing stagnation and blockage; this is Earth Qi overacting upon the epigastrium, resulting in Pi and fullness. If purgatives are administered too early in the course of Shang Han [Cold Damage], Pi may also result. This occurs because cold pathogenic factors damage Ying Blood [Nutritive Blood]. Since the Heart governs Blood, when pathogens invade the root organ, Pi in the epigastric region ensues. Several formulas of Xiexin Tang [Gallbladder-Draining Decoction, literally 'Heart-Draining'] from Zhang Zhongjing all contain Huanglian [Coptidis Rhizoma] to drain the Earth-pathogen in the epigastrium. Regarding Jiuzhi [Alcohol Accumulation] and other miscellaneous diseases, excessive purgation can also lead to Pi and fullness; these all belong to Blood syndromes. Excessive purgation leads to the loss of Yin [Yin fluids/substances]; losing Yin implies damaging the Spleen and Stomach, specifically referring to the depletion of the Yin derived from water and grain within the Spleen and Stomach. Consequently, Qi in the chest sinks due to Blood deficiency and descends into the domain of the Heart, causing epigastric Pi. Treatment should focus on regulating the Spleen and Stomach using Blood-invigorating or Blood-nourishing herbs. If only Qi-moving herbs are used for guidance, the Pi will worsen, and the descending Qi will fall further, inevitably transforming into abdominal distension and drum-like bloating. This is not the correct treatment. There are also distinctions between excess and deficiency: For Excess Pi with constipation, Houpo [Magnoliae Officinalis Cortex] and Zhishi [Aurantii Fructus Immaturus] are indicated. For Deficiency Pi with loose stools, Shaoyao [Paeoniae Radix Alba] and Chenpi [Citri Reticulatae Pericarpium] are indicated. For Pi and fullness caused by dietary injury, digestive and resolving herbs should be used. If there is severe oppression in the chest accompanied by the urge to vomit, emesis [inducing vomiting] is appropriate.
*Nan Zhi* states: Pi caused by Shang Han arises from Blood, moving from the exterior to the interior. Pi caused by miscellaneous diseases also arises from Blood, moving from the interior to the exterior. Because the former involves formless pathogens, bitter-draining methods are used; because the latter involves formed pathogens, acrid-dispersing methods are used.
Commentary: Regarding the stagnation and obstruction of Pi, it is commonly known that it results from the failure of Qi movement. Only Li Dongyuan pointed out that this is a Blood disease, arguing that excessive purgation leads to Yin loss and Blood damage—a point previously unaddressed by earlier physicians. The reason why some people fail to treat Pi with Qi-moving herbs is likely due to ignorance of this principle.
*Bao Ming Ji* states: The treatment of the root and branch of the Three Yin and Three Yang channels varies. Cold herbs may be used to treat Heat Pi, such as Dahuang [Rhei Radix et Rhizoma] and Huanglian [Coptidis Rhizoma]. Both cold and hot herbs may be used when Pi results from disharmony between Yin and Yang, such as Dahuang [Rhei Radix et Rhizoma] and Huanglian [Coptidis Rhizoma] combined with Fuzi [Aconiti Lateralis Radix Praeparata]. Acrid-hot herbs may predominate over cold herbs when Pi results from Yin excess and Yang deficiency, such as Banxia Xiexin Tang [Pinellia Decoction Draining the Epigastrium], Gancao Xiexin Tang [Licorice Decoction Draining the Epigastrium], and Shengjiang Xiexin Tang [Fresh Ginger Decoction Draining the Epigastrium]. The term "Xiexin Tang" does not refer to draining Heart Fire heat, but rather eliminating Pi in the epigastrium. Generally speaking, these formulas contain more Yang-tonifying/warming herbs than Yin-nourishing/cooling herbs. This is generally because the pathology originates from Yin. However, Dahuang Huanglian Xiexin Tang [Rhei and Coptis Decoction Draining the Epigastrium] is unique in treating a specific syndrome of Yin-origin Pi with rapid pulse. The variations occurring after the use of Guizhi Tang [Cinnamon Twig Decoction] stem from changes originating from the floating and weak pulse of the Taiyang [Greater Yang] channel. The remaining formulas utilize a mixture of Yin and Yang herbs.