（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〕所谓“痞”，是指气机阻塞；所谓“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，由胀满进而导致痞结，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，《圣惠方》中的甘遂散主治此症。此药治疗小儿痞结，虽然服用汤药后暂时能通便得利，但体内的积滞实证并未去除，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。此病适宜疏通利导大便，破除结聚、疏散气机，之后应当常服进食丸。
按语：进食丸中含有巴豆，岂适合长期服用？甘遂有大毒，泻水之力犹如决堤江河，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，三者同时具备，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〕痞癖如果日久不愈，饮食减少，脾气必然虚弱，久治不愈，首先应当以固护胃气为主，使正气得以养护，则积滞自然消除。如果想要直接攻伐其结块，不仅不能很好地消散积滞，反而会损伤脾土。脾土既然亏损，必定会引发各种变证，应当参考各类病症及随证候变化而主治。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，不可用克伐攻逐之法。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，服用破滞消积的药物。我认为属于形体与病气俱虚，应当补益中气。他不听信，仍然进行攻伐，导致虚火上炎，牙龈腐蚀溃烂，下巴下方出现结核肿块。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，肚腹逐渐增大，伴有寒热往来、嗜睡、口渴想喝水的症状。以白术散为主方，佐以四味肥儿丸，一个月多月后各种症状逐渐痊愈，又用异功散加当归，以及六味地黄丸，再经过一个多月才痊愈。还有一个小儿患痞结，身体发热如火，病症表现多种多样，无法详尽叙述，早晨服用五味异功散，晚上服用四味肥儿丸，一个月多月后各种症状稍有好转，佐以地黄丸，能够自行行走站立，于是改为早晨服用地黄丸，晚上服用异功散及虾蟆丸，服用几剂后痊愈。
《圣惠方》前胡散：治疗小儿腹内痞结，高热、消瘦、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（温水浸泡，去皮，微炒）、鳖甲（涂醋，炙至黄色，去裙边）。以上各半两。
将上述药物捣碎，粗筛为散剂。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。
《圣惠方》甘遂破结散：
甘遂（煨至二钱半，呈黄色）、青皮（浸泡，去白瓤，焙干）、黄芩、川大黄（锉细，煨。以上各半两）。
以上药物制成粗末。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，得到通畅排泄后即停止，随后喝冷粥以养胃气。
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。或者下痢赤白，腹痛里急后重。以及食积、乳癖、疳气、痞结等，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，凡是有此类疾病，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（以上各半两）、麝香（少许）。
以上药物研为细末，用面糊制作成丸，如麻子大小。一岁的婴儿服用一丸，用温米汤送下，更需根据虚实情况加减剂量，饭后服用。治疗食积发热、消瘦肚大、青筋疳积、腹痛露骨。
〔汤〕户部张侍郎的小女儿，患有这种蕴积结聚的病症已经一年了，其症状是腹部胀满、高热、大小便闭塞、不能进食。各位医生都将其当作虚热或潮热，或者当作胃寒不食来治疗，然而因为不能进食，大小便自然减少，又想当作疳热来治疗，各种药物都试过了，但没有一种对症，病情已经窘迫危急，邀请我去诊治。我问：“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，都使用补剂，这个女孩很久没吃东西了，不宜使用通利肠胃的药物。”我回答说：“相信我就能活，违背我就会死。”张说：“有没有比甘遂稍微缓和一点的替代药物，可以吗？”我让他立即服用大承气汤，服用两剂后痊愈。第二天诊脉，还有余留的积滞实证，其症状显示，必须再过几天才会再次腹部闭塞，需要服用前面的药物，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，服用一剂就痊愈了。
以上，属于疏通利导大便的范例。适用于形气俱实的患者。
枳术丸：
白术（四两）、枳实（二两）。
以上药物研为细末，用荷叶包裹煨烂米饭制作成丸，如梧桐子大小。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。以上各二两）。
以上药物研为细末，用炼蜜和丸，如龙眼核大小。每次服用一丸，用热汤化开服用。连续服用二三剂，如果心中豁然开朗但仍口渴，加栝蒌根一两。自汗者，加牡蛎二两。下利者也加用。
快膈汤：调理胸膈不适，饮食少进。也能顺气和中，消导宿食积滞。
人参（去芦头）、青皮（去白瓤）、缩砂仁、乌药、良姜（制）、香附子、甘草（炙。以上各一两）。
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（以上各一钱）、栝蒌（全用，细切，带湿三钱）、黄连、甘草（以上各五分）。
以上药物，用水一钟半，生姜三片，大枣一个，煎至七分，温服。
洁古云：饮食不进，可用四君子汤加生姜、大枣煎服。
(This type of *pi* [obstruction] is located within the abdomen, differing from *pi* in the epigastrium.)
[Yang] "Pi" refers to obstruction/blockage, and "jie" [knotting/mass] refers to solidity/excess. When hot qi accumulates between the chest and diaphragm, and retained fluid gathers within the abdomen and hypochondrium, the Ying [Nutritive] and Wei [Defensive] qi cannot circulate freely, and the Zang-Fu organs cannot function smoothly. Consequently, distension and fullness progress to pi-jie, which is the inevitable course of the disease. This is a syndrome of heat and excess. Occasionally, it manifests as high fever; the Gansui San (Gansui Powder) from *Shenghui Fang* is indicated for this. This medicine treats pediatric pi-jie; although temporary relief may be achieved through bowel movement after taking the decoction, the internal stagnation and excess remain. The epigastrium feels hard and distended, and crying occurs upon palpation due to latent heat inside, with various symptoms appearing simultaneously. For this disease, it is appropriate to promote bowel movements to clear stagnation, break up knots, and dissipate qi. Subsequently, Shijin Wan (Digestion-Enhancing Pill) should be taken regularly.
Commentary: Shijin Wan contains Radix Crotonis Tiglii (Badou), which is unsuitable for long-term use. Kansui Radix (Gansui) has 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 is extremely robust, the condition is extremely critical, and there is an excessive amount of water-dampness pathogen. Using it as the primary formula for pi-jie is erroneous.
[Xue] If pi-pi [masses] persist for a long time, leading to reduced appetite, the Spleen Qi must become deficient. If it remains uncured for a long time, 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 knot, 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 Areca Seed (Binglang), Turmeric Rhizome (Ezhu), Immature Bitter Orange (Zhishi), and Coptis Rhizome (Huanglian), causing the pi to worsen. I stated that this was pi due to Blood deficiency in the Spleen Meridian and advised against using harsh draining methods. I prescribed Liu Jun Zi Tang (Six Gentlemen Decoction) added with Angelicae Sinensis Radix (Danggui). After several doses, Stomach Qi gradually recovered, and symptoms improved. Then, Yi Gong San (Yi Gong Powder) added with Cimicifugae Rhizoma (Shengma) and Bupleuri Radix (Chaihu) were administered in the morning, and Yi Gong San added with Danggui and Paeoniae Radix Alba (Shaoyao) in the evening, resulting in recovery.
Case 2: Another child suffered from pi-jie and took drugs that break stagnation. I considered this a case of both Form and Qi being deficient, requiring tonification of Middle Qi. The parents did not believe me and continued with draining attacks, leading to deficient fire flaming upward, erosion and ulceration of the gums, and tubercles under the jaw. I treated with Da Wuyi Tang (Major Worm-Expelling Decoction) and modified Yi Gong San, bringing stability to the condition.
Case 3: A child suffered from pi-jie for a long time, resulting in emaciated limbs and a gradually enlarging abdomen, accompanied by alternating chills and fever, lethargy, thirst, and desire to drink. Baizhu San (Atractylodis Macrocephalae Powder) was used as the main formula, assisted by Siwei Fei'er Wan (Four-Ingredient Child-Nourishing Pill). After more than a month, symptoms gradually improved. Then, Yi Gong San added with Danggui, along with Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill), were used for another month until recovery.
Case 4: A child suffered from pi-jie with body heat like fire and numerous complex symptoms. Morning administration of Wuwei Yigong San (Five-Ingredient Yi Gong Powder) and evening administration of Siwei Fei'er Wan led to slight improvement after over a month. Assisted by Dihuang Wan, the child could walk and stand independently. Subsequently, Dihuang Wan was given in the morning, and Yi Gong San combined with Xama Wan (Toad Pill) in the evening. After several doses, recovery occurred.
Qianhu San (Peucedani Radix Powder) from *Shenghui Fang*: Treats pediatric abdominal pi-jie, high fever, emaciation, and excessive crying.
Peucedani Radix (Qianhu), Rhubarb (Chuan Dahuang) (each 3 fen, slightly stir-fried), Aurantium Fructus Immaturus (Zhike) (stir-fried until slightly yellow), Red Poria (Chi Fuling), Rhinoceros Horn (Xijiao) (crushed), Prunus Armeniaca Semen (Yuliren) (soaked in water, skin removed, slightly stir-fried), Turtle Shell (Biejia) (coated with vinegar, roasted until yellow, skirt removed) (each half liang).
Crush the above ingredients and sieve coarsely. Take 1 qian per dose, boil in one small cup of water until reduced to five parts, strain, and administer warm in divided doses according to the child's age/size. Stop when mild diarrhea occurs.
Gansui Po Jie San (Gansui Breaking-Knot Powder) from *Shenghui Fang*:
Kansui Radix (Gansui) (roasted, 2.5 qian, until yellow), Citri Reticulatae Pericarpium Viride (Qingpi) (soaked, white pith removed, dried), Scutellariae Radix (Huangqin), Rhubarb (Chuan Dahuang) (cut finely, roasted) (each half liang).
Make into coarse powder. Take 1 qian per dose, boil in one small cup of water until reduced to six parts, strain, and take warm. Adjust dosage based on size. Stop when bowel movement is achieved, then feed cold congee to support the stomach.
Shijin Wan (Digestion-Enhancing Pill): Treats indigestion of milk and food, epigastric and abdominal distension/fullness, high fever, coarse breathing, vomiting with phlegm-reversal, borborygmus with diarrhea, undigested food in stool. Also treats dysentery with red and white mucus, abdominal pain with tenesmus. Additionally treats food accumulation, milk masses, Gan Qi [Childhood Malnutrition Syndrome], and pi-jie. For children with heat-excess in the chest/diaphragm and retained fluid in the abdomen, causing obstruction of Ying/Wei qi and blockage of Zang-Fu qi, manifesting as abdominal qi-knotting, distension, or high fever, the treatment principle is to promote bowel movements, break knots, and dissipate qi.
Crotonis Fructus Frost (Badoushuang) (1.2 qian), Angelicae Sinensis Radix (Danggui) (soaked overnight in rice wash water, stir-fried), Cinnabar (Zhusha), Hematitum (Daizheshi) (calcined, quenched in vinegar seven times), Aurantium Fructus Immaturus (Zhike) (stir-fried), Aucklandiae Radix (Muxiang) (each half liang), Moschus (Shexiang) (a small amount).
Grind into fine powder, mix with wheat paste to make pills the size of hemp seeds. One pill for a one-year-old, taken with warm rice broth. Adjust dosage based on deficiency/excess. Take after meals. Treats heat from food accumulation, emaciation with large abdomen, Qingjin Ganji [Green-Vein Childhood Malnutrition], abdominal pain with protruding ribs.
[Tang] The young daughter of Vice Minister Zhang of the Ministry of Revenue suffered from accumulated stagnation and knotting for a year. Her symptoms included abdominal fullness, high fever, closure of both upper and lower orifices (constipation and urinary retention), and inability to eat. Various physicians treated her as deficiency-heat or tidal fever, or as Stomach-cold causing anorexia. However, since she could not eat, her bowel and bladder movements naturally decreased. Others tried treating her as Gan-heat. All medicines failed to hit the mark, and her condition became desperate. I was invited to examine her. I asked what medicine she should take. I answered: "She should take Gansui and Dahuang." Zhang was shocked and said, "Previous doctors all used tonics. This girl hasn't eaten for a long time; it is inappropriate to use purgatives to move the intestines and stomach." I replied, "Trust me and she lives; defy me and she dies." Zhang asked, "Is there a substitute for Gansui that is slightly milder?" I ordered him to immediately give Dachengqi Tang (Major Order the Qi Decoction). After two doses, she recovered. On the next day, pulse diagnosis revealed residual stagnation and excess. The prognosis indicated that abdominal closure would recur in a few days, requiring the previous strong medicine to eradicate the root. Indeed, after a few days, recurrence occurred with abdominal fullness and pi-jie. Re-administering the medicine cured her in one dose.
Above is an example of promoting bowel movements. Suitable for cases where both Form and Qi are excess.
Zhizhu Wan (Aurantium and Atractylodes Pill):
Atractylodis Macrocephalae Rhizoma (Baizhu) (4 liang), Aurantium Fructus Immaturus (Zhishi) (2 liang).
Grind into powder. Wrap in Lotus Leaf and roast with cooked rice until soft, then make pills the size of Torreya Seeds. Take 40-50 pills per dose, fasting, with plain boiling water.
Zhishi Lizhong Wan (Aurantium Regulating Middle Pill):
Aurantium Fructus Immaturus (Zhishi) (16 slices, bran-stir-fried), Poria (Fuling), Ginseng Radix et Rhizoma (Renshen), Atractylodis Macrocephalae Rhizoma (Baizhu), Zingiberis Rhizoma Recens (Ganjiang) (processed), Glycyrrhizae Radix et Rhizoma (Gancao) (roasted) (each 2 liang).
Grind into powder, mix with refined honey to make pills the size of Longan seeds. Take one pill per dose, dissolved in hot water. Continue for 2-3 doses. If the chest feels open but thirst persists, add Trichosanthis Radix (Gualougen) 1 liang. If spontaneous sweating occurs, add Oyster Shell (Muli) 2 liang. Also add if diarrhea is present.
Kuaise Tang (Quick Diaphragm Decoction): Regulates discomfort in the chest and diaphragm, poor appetite. Also promotes smooth Qi flow, harmonizes the middle, and resolves old stagnation.
Ginseng Radix et Rhizoma (Renshen) (rhizome removed), Citri Reticulatae Pericarpium Viride (Qingpi) (white pith removed), Amomi Fructus (Suosharen), Linderae Radix (Wuyao), Alpiniae Officinarum Rhizoma (Liangjiang), Cyperi Rhizoma (Xiangfu), Glycyrrhizae Radix et Rhizoma (Gancao) (roasted) (each 1 liang).
Grind into fine powder. Take 1 qian per dose, fasting, mixed with warm salted water.
Shenzhu Xiantang (Ginseng and Atractylodes Chest-Trap Decoction):
Ginseng Radix et Rhizoma (Renshen), Atractylodis Macrocephalae Rhizoma (Baizhu), Poria (Fuling), Tangerine Peel (Juhong), Pinelliae Rhizoma (Banxia) (each 1 qian), Trichosanthis Fructus (Gualou) (whole, cut finely, moist, 3 qian), Coptidis Rhizoma (Huanglian), Glycyrrhizae Radix et Rhizoma (Gancao) (each 5 fen).
Boil the above with 1.5 cups of water, 3 slices of Ginger, and 1 Jujube until reduced to 0.7 parts. Take warm.
Jiegugu stated: For loss of appetite, use Sijunzi Tang (Four Gentlemen Decoction) added with Ginger and Jujube, boiled and taken.