伤寒心下满。何以明之。心下满者。谓正当心下高起满硬者是矣。不经下后而满
者。则有吐下之殊。若下后心下满者。又有结胸痞气之别。经曰。病患手足厥冷。脉
乍紧。邪结在胸中。心中满而烦。饥不能食者。病在胸中。当须吐之。又曰。脉浮而大。
心下反硬有热。属脏者攻之。不令发汗。属腑者不令攻之。兹二者。为不经汗下而
心下满者。或吐之。或下之。看其邪气之高下。高者则因而越之。下者则因而竭之。
要在泄其邪也。至于阳明病。虽心下硬满。又未可攻。经曰。阳明病心下硬满者。不
可攻之。攻之利遂不止者死。利止者愈。是邪气自表传里。至于心下留结为实者。
则不可下。乃吐之可也。若未全为实者。则不可下。故有此戒也。又邪气在表。未应
下而强下之。邪气乘虚结于心下。实者硬满而痛为结胸。虚者满而不痛为虚痞。
经曰。呕而发热者。柴胡汤证具。而以他药下之。柴胡证仍在者。复与柴胡汤。此虽
己下之不为逆。必蒸蒸而振。却复发热。汗出而解。若心下满而硬痛者。此为结胸
也。但满而不痛者。此为虚痞。盖实邪留结。则为硬为痛。虚邪留滞。则但满而不硬
痛也。结胸热实。脉沉而紧。心下痛。按之石硬者。大陷胸汤主之。明其邪实可知矣。
脉浮而紧。而反下之。邪反入里则作痞。按之自濡。但气痞耳。明其邪虚可知矣。病
发于阳。而反下之。热入因作结胸。病发于阴。而反下之。因作痞。表邪未罢。医反下
之。胃中空虚。客气动隔。阳气内陷。心中因硬。则为结胸。须陷胸汤丸攻之可也。伤
寒中风。医反下之。心下痞硬而满。医见心下痞。谓病不尽。而复下之。其痞益甚。此
非结热。但以胃中空虚。客气上逆。故使硬也。须诸泻心汤散可也。二者俱是心下
满硬。一为虚。一为实。凡投汤者大须详审。结胸虽为实邪。众皆共知。当用陷胸汤
丸下之。或脉浮大者。则不可下。下之则死。即是犹带表邪。未全结实。下之重虚其
里。邪深结则死。设或结胸形证悉具。而加之烦躁者。又为不治之疾。药之所以能
胜邪者。必待胃气施布。药力始能温。汗吐下之。以逐其邪气。邪气胜。胃气绝者。汤
药纵下胃气不能施布。虽神丹其何能为效也。
Heart-fullness in Cold Damage. How to clarify it? Heart-fullness refers to the condition where the area just below the heart (epigastrium) is elevated, full, and hard.
For those who experience fullness without prior purgation, there are differences between emetic and purgative treatments. For those who experience fullness after purgation, there are distinctions between Chest Binding (Jie Xiong) and Pi Syndrome (Pien).
The Classics state: "When a patient has cold hands and feet, a pulse that suddenly becomes tight, pathogenic factors congealed in the chest, fullness and vexation in the heart, hunger but inability to eat, the disease is in the chest and requires emesis." It also states: "A floating and large pulse, with hardness and heat in the heart region belonging to the Zang organs should be treated by attacking downwards, not by inducing sweating; belonging to the Fu organs should not be attacked downwards." These two cases refer to heart-fullness occurring without prior sweating or purging. Depending on whether to use emesis or purgation, one observes the height of the pathogenic factor: high factors are expelled upwards ("incline and let them rise"), low factors are expelled downwards ("incline and exhaust them"). The key lies in draining the pathogen.
Regarding Yangming Disease, even if there is hardness and fullness in the heart region, purgation is not permitted. The Classics state: "In Yangming Disease, if there is hardness and fullness in the heart region, do not attack downwards. If purgation leads to unceasing diarrhea, death ensues; if diarrhea stops, recovery occurs." This is because the pathogen has transmitted from the exterior to the interior and remained/congealed in the heart region forming excess. Therefore, downward purgation is contraindicated, whereas emesis may be appropriate. If it has not fully formed an excess pattern, downward purgation is forbidden, hence this warning.
Furthermore, if the pathogen is at the exterior and purgation is forcibly applied contrary to indications, the pathogen enters the deficiency and congeals in the heart region. Excess patterns present as hardness, fullness, and pain, known as Chest Binding (Jie Xiong). Deficiency patterns present as fullness without pain, known as Empty Pi (Xu Pi).
The text states: "Vomiting accompanied by fever indicates the syndrome of Chai Hu Tang (Bupleurum Decoction). If other drugs were used for purgation, and the Chai Hu syndrome persists, administer Chai Hu Tang again. Although purgation has been performed, it is not a reversal error. The patient will inevitably experience shivering and trembling, followed by fever, and resolve through sweating." If the heart region is full, hard, and painful, this is Chest Binding (Jie Xiong). If it is merely full without pain, this is Empty Pi (Xu Pi). Solid pathogens remaining and congealing cause hardness and pain; deficient pathogens remaining and stagnating cause mere fullness without hardness or pain.
Chest Binding (Jie Xiong) involves Heat-Excess, with a deep and tight pulse, pain in the heart region, and hardness upon palpation like stone, treated primarily with Da Xian Xiong Tang (Major Inward-Expelling Chest Decoction). This clarifies that the pathogen is excess.
If the pulse is floating and tight, and purgation is wrongly applied, the pathogen turns inward causing Pi (Pien). Palpation reveals softness; this is merely Qi Pi (Qi Stagnation). This clarifies that the pathogen is deficient.
Disease originating from Yang, when wrongly purged, allows Heat to enter and form Chest Binding (Jie Xiong). Disease originating from Yin, when wrongly purged, forms Pi (Pien). If the exterior pathogen has not resolved, and the physician wrongly purges, the stomach becomes empty, hostile Qi agitates the diaphragm, Yang Qi sinks inward, causing hardness in the heart, resulting in Chest Binding (Jie Xiong), which requires treatment with Xian Xiong Tang/Wan (Inward-Expelling Chest Decoction/Pills).
In Cold Damage with Wind Strike, if the physician wrongly purges, the heart region becomes Pi-hard and full. Seeing Pi in the heart region, the physician assumes the disease is not exhausted and purges again, worsening the Pi. This is not accumulated Heat, but rather due to an empty stomach and rebellious hostile Qi rising, causing hardness. Various Xie Xin Tang (Drain the Epigastrium Decoctions) are required. Both conditions involve heart-fullness and hardness; one is deficiency, the other is excess. When administering decoctions, great care must be taken.
Although Chest Binding (Jie Xiong) is an excess pathogen known to all, requiring downward expulsion with Xian Xiong Tang/Wan, if the pulse is floating and large, purgation is contraindicated; purging leads to death. This is because the exterior pathogen remains and it is not fully consolidated; purging severely damages the interior, leading to deep congealment of the pathogen and death. Even if all signs and symptoms of Chest Binding (Jie Xiong) are present, if irritability (Fan Zao) is added, it becomes an untreatable condition.
Medicines overcome pathogens only when Wei Qi (Stomach Qi) distributes and circulates, allowing medicinal power to take effect. Sweating, vomiting, and purging methods are used to expel pathogens. If the pathogen is victorious and Wei Qi (Stomach Qi) is severed, even if decoctions enter the stomach, Wei Qi cannot distribute them. What can divine medicines achieve in such a case?