痞之为证。阴阳参错。寒热分争。虚实交互。变见不测。病情至此。非唯治疗之难。而审察之尤不易也。且勿论推
求参考之难。与临证施治之难。即以仲景之圣。其立法详辩。亦甚难也。所以着书者。唯恐临证者之难晓。临证
者。每嫌着书者之不详。不知六气随时之变态不同。病者虚实之见证百出。圣贤立训之规格有限。病情变幻之伎俩无穷。
犹之五官四体虽同。绝无相同之面目。传真写像各异。岂有一定之须眉。郑子产云。人心之不同。如其面焉。此之谓也。
前人创法。唯规矩以度之。绳墨以准之。理以贯之。义以一之。变而通之。神而明之。未可按图索骥也。所以临证者。
不
知着述之艰难。着述家又不知临证之不易。然但着书而不临证。不过纸上谈兵。但
临证而不着述。每多不学无术。皆非实学也。余读仲景书。至痞结两证茫无头绪。不觉掩卷而叹。故勉为之辨。
脉浮而紧。而复下之。紧反入里。则作痞。按之自濡。乃气痞耳。（濡音软）
此以下三条。乃寒邪入里之痞也。下文阳虚阴盛之痞。则又不同矣。夫脉浮而紧。浮为在表。紧则为寒。
乃头痛发热。身疼腰痛。恶风无汗。寒邪在表之脉。麻黄汤证也。而复下之者。言不以汗解而反误下之也。紧反
入里者。言前所见紧脉之寒邪。因误下之虚。陷入于里而作心下痞满之症也。按之自濡。言证虽痞满。以手按之。
则软而不硬也。此不过因表邪未解。误下里虚。无形之邪气。陷入于里而成痞耳。其脉证不同。治法各异者。
又于下条分出。以为临证施治之用。
心下痞。按之濡。其脉关上浮者。大黄黄连泻心汤主之。
此二条。承上文言。同一误下。紧反入里而成痞。其脉症稍异。治法即殊。故示人以不可概视而妄施治疗也。
心下者。心之下。中脘之上。胃之上脘也。胃居心之下。故曰心下也。痞者。天地不交之谓也。以邪气痞塞于中。
上下不通而名之也。前所谓紧反入里者。非即寒气入里也。乃寒邪郁于营卫之间。已发热之伤寒邪气。乘误下之虚。
入里而成心下痞也。寒郁为热。即热论篇所谓人之伤于寒也则为病热之义。谓初感本是寒邪。郁于腠理。则发热矣。
按之濡。即所谓气痞也。其脉关上浮者。浮为阳邪。浮主在上。关为中焦。寸为上焦。因邪在中焦。故关上浮也。
若结胸之脉。则寸浮而关沉矣。结胸因热邪水饮并结。按之石硬。或心下至少腹皆痛不可近。故治之以大陷胸汤。
此则关上浮。按之濡。乃无形之邪热也。热虽无形。然非苦寒以泄之。不能去也。故以大黄黄连泻心汤主之。按之
濡而脉浮。未可寒下
太过。故以麻沸汤渍须臾。分服。
大黄黄连泻心汤方
大黄（二两） 黄连（一两）
上二味。以麻沸汤二升渍之。须臾。绞去滓。分温再服。
麻沸汤者。言汤沸时泛沫之多。其乱如麻也。全生集作麻黄沸汤。谬甚。
谓之泻心汤者。非用黄连以泻心脏之火也。盖以之治心下痞而名之也。大承气之治邪热归胃。以阳明中土。
万物所归。无所复传。故以大黄芒硝枳实浓朴专治胃实。大陷胸之治结胸。亦以太阳表邪误下陷入。
因热邪水饮并结。故攻热实而兼导饮。十枣汤之攻痞。以表邪已解。非热邪入里。不过水饮停蓄于胸胁之间。
故不用大黄攻热。但以大戟芫花甘遂蠲饮泄水而已。皆攻实之法也。若夫大黄黄连泻心汤者。因伤寒郁热之邪。
误下入里而痞塞于心下。虽按之濡而属无形之气痞。然终是热邪。故用大黄之苦寒泄之。以攻胃分之热邪。
黄连之苦寒开之。以除中焦之郁热。而成倾痞之功。在五等泻心汤中。独为攻热之剂也。然有是证有是脉者宜之。
设非其证者。未可概用也。麻沸汤。百沸热汤也。成氏云。但以麻沸汤渍服。取其气薄而泄虚热也。盖因按之软。
则胃中无大宿垢。关脉浮。则中气不实。故但渍而不煎。为泄虚热而非攻下之剂。成氏此言。可谓得仲景之旨矣。
心下痞。而复恶寒汗出者。附子泻心汤主之。
此又承上文言。如前应用大黄黄连泻心汤之痞。而复恶寒汗出者。则治法又不同矣。夫以心下痞而按之濡。其脉
关上浮者。即前所谓紧反入里。伤寒郁热之邪。误入而为痞。原非大实。而复见恶寒汗出者。知其命门真阳已虚。以
致卫气不密。故玄府不得紧闭而汗出。阳虚不任外气而恶寒也。人但知卫气行于皮肤。而不知乃下焦之真阳。蒸
谷气而达皮肤。乃为卫气。所以相火居于两肾之间而属少阴。卫气居于肌表而属太阳。为一根一叶。故足太阳膀
胱与足少阴肾经。相为表里而成一合也。以热邪痞于心下。则仍以大黄黄连泻之。加附子以扶真阳。助其蒸腾之
卫气。则外卫固密矣。因既有附子之加。并入黄芩以为彻热之助。而寒热并施。各司其治。而阴阳之患息。倾痞之功
又立矣。
附子泻心汤方
大黄（二两） 黄连（一两） 黄芩（一两） 附子（一枚炮去皮破另煮汁）
上四味。切三味。以麻沸汤二升。渍须臾。绞去滓。内附子汁。分温再服。
伤寒大下后。复发汗。心下痞。恶寒者。表未解也。不可攻痞。当先解表。表解。乃可攻痞。解表宜桂枝汤。攻
痞宜大黄黄连泻心汤。
伤寒。寒伤营也。以头痛发热恶寒无汗之证。法当以麻黄汤汗之。方为合法。乃先大下之。下后而表邪陷入矣。
医见未解而复发其汗。谓之复者。盖以误下之后。复用麻黄汤也。汗虽发而从前陷入之邪。已作心下痞矣。
心下已痞而仍恶寒者。犹有表邪未解也。前条同。是痞证而恶寒。以附子泻心者。因恶寒汗出。所以知其为阳虚之
恶寒也。此则恶寒而不汗出。是以知其为表未解也。故曰不可攻痞。若再攻之。必已陷再陷矣。所以必当先解其表。
俟表邪既解。
然后乃可攻痞也。但伤寒解表。不用麻黄而用桂枝者。何也。仲景以麻黄治伤寒。桂枝治中风。一定不移之法也。其
可乱乎。若其法可乱。则仲景不于桂枝汤条内。特立禁止之文曰。桂枝本为解肌。若其人脉浮紧。发热汗不出者。不
可与也。当须识此。勿令误也。此条既曰伤寒。而又以桂枝汤解表。岂立法者自相矛盾邪。盖因此证既已误下。胃中
阳气已虚。又复发汗。表间卫阳又损。若再用麻黄。必致阳气竭绝而为亡阳之败症矣。且寒邪已经陷入。其在表未
解之邪有限。故权用桂枝汤。以解表间之虚邪也。解后亦用大黄黄连泻心汤者。因此痞亦是发热恶寒之伤寒邪热。因误
下入里所致。即所谓紧反入里也。因与热入之痞同义。故治法亦同。与下文胃中不和腹中雷鸣客气上逆者。不得同论也。
伤寒中风。医反下之。其人下利日数十行。谷不化。腹中雷鸣。心下痞硬而满。干呕心烦不得安。医见心下痞。
谓病不尽。复下之。其痞益甚。此非热结。但以胃中虚。客气上逆。故使硬也。甘草泻心汤主之。
伤寒中风者。言或中风或伤寒也。谓无论伤寒中风之有表症者。但误下之。皆可致变。非后人所谓风邪入里则为
结胸。寒邪陷入则为痞也。下利日数十行者。误下伤胃。中气失守。随药势而下奔也。完谷不化。胃寒不杀谷也。腹中
雷鸣。误下则胃阳已伤。中焦虚冷。气滞不得流行。脾弱不能转运。欲通而不得。故但留滞于腹中作响而已。是以阴
气填塞于心下。硬满而为痞也。胃气受伤。阴邪上逆而干呕。阳受阴迫。虚阳上走而心烦不安也。医见心下痞满。以
为热邪未尽而复下之。则胃中阳气益虚。其痞益甚。不知此非热邪所结。但以胃脘之阳伤损。真气空虚。故客气得
以上逆。客气者。非外入之邪也。乃胃阳已虚。下焦之阴气上逆。以非本经之气。故为客气。客气上逆。致成痞硬耳。
当
以甘草泻心汤主之。
甘草泻心汤方
甘草（四两） 干姜（三两） 半夏（半升） 黄芩（三两） 黄连（一两） 大枣（十二枚擘）
上六味。以水一斗。煮取六升。去滓。再煎取三升。温服一升。日三服。
此方以甘草为君。前代名家。皆疑其为甘补缓中之药。非痞满所宜。注中皆含糊抹过。而不能明言其故。
余注解素问诸篇。始知甘性虽缓。其补泻之用。于五脏各有不同。故藏气发时论云。肝苦急。急食甘以缓之。
脾欲缓。急食甘以缓之。此皆用其甘和补缓之性也。又云。心欲 。急食咸以 之。用咸补之。以甘泻之。
其以甘泻之句。人皆读而忽之。岂知圣贤垂训。语无虚发。虽一言一字。无非精微之蕴。唯仲景知之。遂
以此一句之义。立法制方。用之以治极难之证。如世之读内经而辄加删削者。又焉能得此精义哉。夫所谓
心欲 者。心乃藏神之脏。五脏六腑之大主。包络代君行令。邪不得犯。犯之则死。岂真有所 硬乎。
谓之欲 者。盖心之部分。为邪所犯。不得其平和。故 之泻之耳。仲景之泻心。亦泻心下之痞气。非泻
心脏也。故亦以甘泻之。犹素问阴阳别论所谓二阳之病发心脾。非真心脾二脏受病也。因胃病在心脾之间耳。
其义相同。当以意度之可也。故于肝则以甘缓其劲急之偏胜。于脾则以甘益其濡润之不足。于心则以甘泻
其痞满之虚邪也。然虽曰以甘泻之。而泻之之法。亦必以痞之虚实为辨。未可概用也。其热实之痞。固不必言。
然苟非胃中虚冷。脾气下陷。阴邪上逆。下利完谷。腹中雷鸣者而妄用之。未有不反增其满者也。如李东垣补
中益气汤。唯气虚而致中满者。乃为的对。倘施之于实胀。未有不殆者也。干姜守中。除里寒而止下
利。半夏利膈。神农本经言其能治伤寒寒热。心下坚硬。二者皆辛温而能散痞。故重用之以为臣。黄芩黄连。
乃苦以开之。非方氏所谓解其邪热之烦也。然仲景明言此非结热。又曷为用之。盖取至真要大论之所谓热因寒
用也。以阴邪痞塞于内。骤进辛热。恐其拒格而不受。故以寒药导之使入也。即经所云寒热温凉。反从其病。
乃反佐以取之之法。是以黄连止用干姜三倍之一也。但观厥阴条中。伤寒本自寒下。复吐下之。寒格更逆吐下。
食入口即吐。而以干姜黄连黄芩人参汤治之。理自明矣。寒热兼施。辛苦并用。中气不调。故以大枣和之。
然用甘草而不用人参者。阴邪在内。浊气留中。人参非泻剂。故不用也。旧注但云甘草坐镇中州。人但知生姜代
干姜之僭。孰知以干姜代生姜之散。但知甘草能增满。孰知甘草能去满哉。不知李东垣原云。以生姜代干姜者。
以其不僭故也。并非以生姜代干姜之僭也。本草云。干生姜。即生姜之干者。主治各有不同。而干姜又别用法
制造者也。性味主治又不同矣。且生姜散外而开发。干姜温里而守中。干姜亦岂能代生姜之散哉。而甘草所以去
满之故。终未道出。芩连之用。又未通解。窃恐未足以发明立方之义也。
伤寒五六日。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。此虽已下之不为
逆。必蒸蒸而振。却发热汗出而解。若心下满而硬痛者。此为结胸也。大陷胸汤主之。但满而不痛者。此
为痞。柴胡不中与之。宜半夏泻心汤。
此条当在少阳坏病中。因属痞症。故类附于此。
此以邪在少阳而成痞结。故不曰太阳。而但以伤寒二字冠之也。五六日。邪入渐深之候也。呕而发热。少阳之本证
也。以邪在少阳。柴胡汤证已具而不用柴胡。反以他药误下之。他药者。即承气之类。非有别药也。因此证唯柴胡为
对证之药。彼不当用者。即指为他药也。若误下之后。无他变证。而柴胡证仍在者。当复与从前对证之柴胡汤。必身
体蒸蒸而振。蒸蒸。身热汗欲出之状也。振者。振振然摇动之貌。即寒战也。言肤体蒸蒸然。却发热汗出而邪气解矣。
其所以战而后汗者。以下后正气已虚。难于胜邪。故必战而后汗也。如此。则虽有从前他药误下之失。已幸而不为
变逆矣。若误下之后。柴胡症不仍在者。则邪气必乘虚陷入矣。邪陷而心下满。按之硬痛者。此为热入之结胸也。以
大陷胸汤主之。若但满而按之不痛。其非硬结可知。已属气痞。然虽按之不痛。若如前其脉关上浮者。仍是阳邪。当
以前条大黄黄连泻心汤泄其虚邪矣。此不言关上浮。则知为下后胃中阳气空虚。身中之阴气痞塞于心下。而为虚痞也。
虽属少阳本症。今已变逆为阴痞。则柴胡汤不中与之。宜半夏泻心汤。
辨误 前注家以中风误下为结胸。伤寒误下为痞。此条以伤寒而可结可痞矣。又以阳邪入里为结胸。阴邪入里
为痞。此则邪在少阳而误下。是阳经之邪。亦能结能痞矣。以此论之。即仲景之发于阳发于阴。尚未足以尽赅其义。
后人又岂能作一定之例以范之邪。总当因时制变。因势定形。就形以定名。因变以施治耳。故岐伯曰。审察病机。无
失气宜。又曰。知其要者。一言而终。不知其要。流散无穷。此之谓也。
半夏泻心汤方
半夏（半升洗） 干姜（三两） 人参（三两） 甘草（三两炙） 黄芩（三两） 黄连（一两） 大枣（十二枚
擘）
上七味。以水一斗。煮取六升。去滓。再煮取三升。温服一升。日三服。
Pi syndrome (fullness and obstruction) is a condition characterized by the disordered intermingling of Yin and Yang, the conflicting struggle between Cold and Heat, and the interactive influence of Deficiency and Excess pathologies, leading to unpredictable variations. When the disease progresses to this stage, not only is treatment difficult, but differentiation and examination are even more challenging. Let alone the difficulties in deduction and reference, or in clinical application; even for a sage like Zhang Zhongjing, whose legislative principles were detailed and discriminative, it was extremely arduous. Therefore, authors write fearing that clinicians may not understand clearly; while clinicians often complain that authors are not sufficiently detailed. They fail to realize that the six Qi (pathogenic factors) manifest differently according to seasonal changes, and patients' deficiency-excess manifestations emerge endlessly. The standards set by sages are limited, whereas the tricks of disease variation are infinite. It is akin to the five sense organs and four limbs: although they are similar in structure, no two faces are exactly alike; portraits and likenesses vary, so how can there be fixed eyebrows and beards? Zheng Zichan said, "The difference among human hearts is like their faces." This is what is meant. Predecessors established methods merely using compasses and squares to measure them, cords and ink lines to align them, reason to connect them, and meaning to unify them, varying and adapting them, and illuminating them divinely. One cannot mechanically search for a steed by following a picture. Thus, clinicians do not know the difficulty of writing, and writers do not know the difficulty of clinical practice. However, writing without clinical experience is merely armchair strategy; practicing without writing often results in ignorance and lack of skill. Neither constitutes true learning. Upon reading Zhang Zhongjing's book, when I reached the sections on Pi (obstruction) and Jie (knotty accumulation), I felt at a loss and could not help but sigh and close the book. Hence, I have reluctantly undertaken to differentiate them.
If the pulse is floating and tight, and purgation is mistakenly applied, the tightness reverses into the interior, resulting in Pi syndrome. If palpation reveals softness, it is Qi Pi (Qi-type obstruction). (Ru sounds like ruan/soft.)
The following three clauses discuss Pi caused by Cold pathogen entering the interior. The Pi due to Yang deficiency and Yin excess discussed later is different. A floating and tight pulse indicates floating as exterior and tight as Cold. This corresponds to headache, fever, body ache, lower back pain, aversion to wind, and anhidrosis—pulse signs of Cold pathogen in the exterior, constituting Ma Huang Tang syndrome. "And then purged" means instead of resolving via sweating, purgation was wrongly used. "Tightness reverses into the interior" means the Cold pathogen represented by the previously observed tight pulse, taking advantage of the deficiency caused by mistaken purgation, sinks into the interior, forming heart-down fullness and obstruction. "Soft upon palpation" means that although the syndrome presents as fullness and obstruction, manual pressure feels soft and not hard. This occurs simply because the exterior pathogen remains unresolved, mistaken purgation damages the interior, and formless pathogenic Qi sinks into the interior to form Pi. Since its pulse and symptoms differ, and treatments vary, these distinctions will be clarified in the next clause for clinical application.
Heart-down Pi, soft upon palpation, with a floating pulse at the Guan position, should be treated primarily with Da Huang Huang Lian Xie Xin Tang (Rhubarb and Coptis Decoction to Drain the Heart).
These two clauses continue the previous discussion. Although both result from mistaken purgation leading to tightness reversing into the interior and forming Pi, slight differences in pulse and symptoms necessitate distinct treatments. This teaches practitioners not to treat indiscriminately.
"Heart-down" refers to the area below the heart, above Zhongwan (CV12), and at the upper epigastrium of the stomach. Since the stomach is located below the heart, it is called "heart-down." "Pi" signifies the failure of Heaven and Earth Qi to interact. It is named so because pathogenic Qi obstructs the middle jiao, preventing communication between upper and lower. The previously mentioned "tightness reversing into the interior" does not mean Cold directly enters the interior; rather, Cold pathogen stagnates between Ying and Wei levels. The Cold pathogen, which has already generated heat, takes advantage of the deficiency from mistaken purgation to enter the interior, forming heart-down Pi. Cold stagnation transforms into Heat, consistent with the meaning in the *Re Lun* chapter: "When humans are injured by Cold, they develop Heat diseases." Initially, it is Cold pathogen stagnating in the cou li (interstices), causing fever. "Soft upon palpation" refers to "Qi Pi." A floating pulse at the Guan position indicates floating represents Yang pathogen and suggests an upper location; Guan corresponds to the Middle Jiao, and Cun to the Upper Jiao. Because the pathogen is in the Middle Jiao, the pulse floats at Guan. In contrast, the pulse for Jie Xiong (Chest Binding) would be floating at Cun and sinking at Guan. Jie Xiong results from the binding of Heat pathogen and fluid retention; palpation feels stone-hard, or pain extends from the heart-down to the lower abdomen, being unbearable to touch. Thus, Da Xian Xiong Tang (Major Xiachong Decoction) is used. Here, however, the pulse floats at Guan and feels soft upon palpation, indicating formless Heat pathogen. Although formless, Heat cannot be removed without bitter-cold herbs to drain it. Therefore, Da Huang Huang Lian Xie Xin Tang is used. Given the softness upon palpation and floating pulse, excessive cold purgation is contraindicated; thus, the herbs are steeped in Ma Fei Tang (Hemp-foam boiling water) for a moment and taken in divided doses.
Da Huang Huang Lian Xie Xin Tang Formula
Da Huang (Rhei Radix et Rhizoma) (2 liang)
Huang Lian (Coptidis Rhizoma) (1 liang)
Take the above two ingredients, steep them in 2 sheng of Ma Fei Tang. After a moment, strain off the dregs. Take warm in two divided doses.
Ma Fei Tang refers to boiling water where the foam is abundant and chaotic like hemp. *Quan Sheng Ji* writes it as "Ma Huang Fei Tang," which is highly erroneous.
It is called Xie Xin Tang not because Huang Lian drains Heart Fire, but because it treats heart-down Pi. Da Cheng Qi Tang treats邪热 (evil heat) returning to the Stomach because the Yangming Central Earth is where all things return and no further transmission occurs; thus, it uses Da Huang, Mang Xiao, Zhi Shi, and Hou Po specifically to treat Stomach Excess. Da Xian Xiong Tang treats Jie Xiong because Taiyang exterior pathogen, after mistaken purgation, sinks inward, binding with Heat and fluid retention; thus, it attacks Heat Excess while guiding out fluids. Shi Zao Tang attacks Pi because the exterior pathogen has resolved, and it is not Heat entering the interior, but merely fluid retention between the chest and hypochondrium; thus, Da Huang is not used to attack Heat, but Da Ji, Yuan Hua, and Gan Sui are used to eliminate fluid and drain water. These are all methods of attacking Excess. As for Da Huang Huang Lian Xie Xin Tang, it is because the stagnant Heat pathogen of Shang Han, after mistaken purgation, enters the interior and obstructs the heart-down area. Although it feels soft upon palpation and belongs to formless Qi Pi, it is ultimately Heat pathogen. Therefore, Da Huang's bitter-cold nature is used to drain it, attacking Heat in the Stomach branch; Huang Lian's bitter-cold nature is used to open it, clearing stagnant Heat in the Middle Jiao, thereby achieving the effect of overturning Pi. Among the five grades of Xie Xin Tangs, it is uniquely a formula for attacking Heat. However, it is suitable only when specific symptoms and pulses exist. If the syndrome does not match, it should not be used indiscriminately. Ma Fei Tang is boiling hot water. Cheng Shi said: "Steeping and taking with Ma Fei Tang aims to utilize its thin qi to drain deficient Heat." Because it is soft upon palpation, there is no major accumulated fecal matter in the Stomach; because the Guan pulse is floating, the Middle Qi is not solid. Thus, steeping without decocting serves to drain deficient Heat rather than act as a purgative. Cheng Shi's words truly capture Zhongjing's intent.
Heart-down Pi accompanied by aversion to cold and sweating should be treated primarily with Fu Zi Xie Xin Tang (Aconite Decoction to Drain the Heart).
This continues the previous discussion. For Pi that previously required Da Huang Huang Lian Xie Xin Tang, if accompanied by aversion to cold and sweating, the treatment differs. For heart-down Pi, soft upon palpation, with a floating pulse at Guan, representing the tightness reversing into the interior where stagnant Heat pathogen of Shang Han enters mistakenly to form Pi (originally not severe Excess), the appearance of aversion to cold and sweating indicates that the True Yang of the Mingmen (Gate of Life) is deficient. This leads to insecure Wei Qi (Defensive Qi), causing the xu fu (pores) to fail to close tightly, resulting in sweating. Yang deficiency fails to resist external Qi, causing aversion to cold. People know Wei Qi circulates in the skin but forget it originates from the True Yang of the Lower Jiao steaming Gu Qi (Grain Qi) to reach the skin. Thus, Xiang Huo (Ministerial Fire) resides between the two kidneys belonging to Shaoyin, while Wei Qi resides on the muscular surface belonging to Taiyang. They share one root and one leaf. Therefore, the Foot-Taiyang Bladder Meridian and Foot-Shaoyin Kidney Meridian are interior-exterior partners forming a union. Since Heat pathogen obstructs the heart-down, Da Huang and Huang Lian are still used to drain Heat. Fuzi is added to support True Yang and assist the steaming Wei Qi, securing the exterior defense. With the addition of Fuzi, Huang Qin is included to assist in thoroughly clearing Heat. Cold and Heat are administered together, each performing its function,平息 (calming) the Yin-Yang disorder, and establishing the effect of overturning Pi.
Fu Zi Xie Xin Tang Formula
Da Huang (Rhei Radix et Rhizoma) (2 liang)
Huang Lian (Coptidis Rhizoma) (1 liang)
Huang Qin (Scutellariae Radix) (1 liang)
Fu Zi (Aconiti Lateralis Radix Praeparata) (one piece, processed, peeled, broken, decocted separately for juice)
Cut the first three ingredients. Steep them in 2 sheng of Ma Fei Tang for a moment, strain off the dregs. Add the Fuzi juice. Take warm in two divided doses.
After severe purgation in Shang Han, followed by repeated sweating, if heart-down Pi and aversion to cold occur, the exterior is unresolved. Do not attack Pi; resolve the exterior first. Once the exterior is resolved, then attack Pi. To resolve the exterior, Gui Zhi Tang (Cinnamon Twig Decoction) is appropriate; to attack Pi, Da Huang Huang Lian Xie Xin Tang is appropriate.
Shang Han involves Cold injuring the Ying level. With symptoms of headache, fever, aversion to cold, and anhidrosis, the legal method is to sweat with Ma Huang Tang. Instead, severe purgation was performed first, causing the exterior pathogen to sink inward. Seeing the unresolved state, the physician sweated again. "Repeated" implies using Ma Huang Tang again after mistaken purgation. Although sweat was induced, the pathogen that had sunk previously has already formed heart-down Pi.
Heart-down Pi persists with continued aversion to cold, indicating unresolved exterior pathogen. Similar to the previous clause. In this Pi syndrome with aversion to cold, Fu Zi Xie Xin Tang is used because aversion to cold is accompanied by sweating, indicating Yang deficiency. Here, aversion to cold exists without sweating, indicating unresolved exterior. Thus, it says do not attack Pi. Attacking again would cause further sinking of the pathogen. Therefore, the exterior must be resolved first. Only after the exterior pathogen resolves can Pi be attacked. Why use Gui Zhi Tang instead of Ma Huang Tang to resolve the exterior in Shang Han? Zhongjing's rule is firm: Ma Huang treats Shang Han, Gui Zhi treats Feng Zhong (Wind Strike). How can this be confused? If his rules were mutable, Zhongjing would not have explicitly prohibited in the Gui Zhi Tang section: "Gui Zhi Tang is originally for releasing the muscle layer. If the pulse is floating-tight, with fever and no sweat, do not give it. You must understand this and avoid error." Since this clause states Shang Han yet uses Gui Zhi Tang for the exterior, is the legislator contradictory? Because this syndrome has undergone mistaken purgation, Stomach Yang Qi is already deficient. Repeated sweating damages the Wei Yang on the surface. Using Ma Huang again would exhaust Yang Qi, leading to fatal Yang collapse. Moreover, since the Cold pathogen has already sunk, the remaining unresolved exterior pathogen is limited. Thus, Gui Zhi Tang is tentatively used to resolve the deficient exterior pathogen. After resolution, Da Huang Huang Lian Xie Xin Tang is also used because this Pi is also caused by Heat pathogen from feverish Shang Han entering the interior due to mistaken purgation, i.e., "tightness reversing into the interior." It shares the same meaning as Pi from Heat entry, hence the same treatment. It cannot be discussed together with the following case of Stomach disharmony, borborygmus, and rebellious guest Qi.
In Shang Han or Feng Zhong, if the physician mistakenly applies purgation, the patient suffers diarrhea dozens of times daily, undigested food, borborygmus in the abdomen, hard and full heart-down Pi, dry heaving, irritability, and restlessness. The physician sees heart-down Pi, assumes incomplete pathogen elimination, and purges again, worsening the Pi. This is not Heat knotting, but Stomach deficiency with rebellious Guest Qi causing hardness. Gan Cao Xie Xin Tang (Licorice Decoction to Drain the Heart) should be used.
"Shang Han or Feng Zhong" means either Wind Strike or Cold Damage. Regardless of whether there are exterior symptoms, mistaken purgation can lead to complications. It is not the later theory that Wind pathogen entering the interior forms Jie Xiong and Cold pathogen sinking forms Pi. Diarrhea dozens of times daily results from mistaken purgation damaging the Stomach, losing Middle Qi control, and collapsing downward with the medicine's force. Undigested food indicates Cold Stomach failing to digest. Borborygmus occurs because mistaken purgation injures Stomach Yang, causing Middle Jiao deficiency and Cold, blocking Qi flow. Spleen weakness fails to transport; wanting to flow but unable, Qi stagnates in the abdomen making noise. Consequently, Yin Qi fills the heart-down, causing hardness and fullness Pi. Stomach Qi is injured, Yin pathogen rebels upward causing dry heaving; Yang is pressured by Yin, deficient Yang floats upward causing irritability and restlessness. The physician sees heart-down fullness, assumes residual Heat, and purges again, further depleting Stomach Yang and worsening Pi. They do not realize this is not Heat knotting, but damage to Stomach Yang Qi and emptiness of True Qi, allowing Guest Qi to rebel upward. "Guest Qi" is not an external pathogen but Yin Qi from the Lower Jiao rebelling upward due to deficient Stomach Yang. Since it is not the original meridian Qi, it is called Guest Qi. Guest Qi rebellion causes Pi and hardness. Gan Cao Xie Xin Tang should be used.
Gan Cao Xie Xin Tang Formula
Gan Cao (Glycyrrhizae Radix et Rhizoma) (4 liang)
Gan Jiang (Zingiberis Rhizoma) (3 liang)
Ban Xia (Pinelliae Tuber) (0.5 sheng)
Huang Qin (Scutellariae Radix) (3 liang)
Huang Lian (Coptidis Rhizoma) (1 liang)
Da Zao (Jujubae Fructus) (12 pieces, split)
Take the above six ingredients, boil in 1 dou of water to obtain 6 sheng. Strain. Decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.
This formula uses Gan Cao as the Sovereign herb. Previous masters doubted it was a sweet,緩 (slow/gentle), and tonifying Middle herb, unsuitable for Pi fullness. Annotations glossed over it without clear explanation.
Only after annotating various chapters of *Su Wen* did I realize that although Gan nature is slow, its tonifying and draining effects differ among the Five Zang. Thus, *Zang Qi Fa Shi Lun* states: "Liver suffers from tension, urgently eat Sweet to relax it." "Spleen desires relaxation, urgently eat Sweet to relax it." These utilize its Sweet harmony and tonifying-slowness. It also states: "Heart desires softness, urgently eat Salty to soften it. Use Salty to tonify, use Sweet to drain." The phrase "use Sweet to drain" is often read but ignored. Did people not know that sage teachings are never empty? Even one word contains profound essence. Only Zhang Zhongjing understood this, legislating formulas based on this principle to treat extremely difficult syndromes. Those who delete from *Nei Jing* cannot grasp such essence. "Heart desires softness": The Heart is the organ storing Spirit, the great master of the Five Zang and Six Fu. Pericardium acts on behalf of the Sovereign; pathogens cannot invade, or death ensues. How can there truly be "hardness"? "Desires softness" means the Heart region is invaded by pathogens, losing peace, so Softening/Dredging is used to drain it. Zhongjing's "Draining Heart" also refers to draining heart-down Pi Qi, not Heart organ fire. Thus, Sweet is used to drain it. Similarly, *Yin Yang Bie Lun* mentions "Diseases of Er Yang (Stomach and Large Intestine) originate in Heart and Spleen," not that Heart and Spleen organs are diseased, but because Stomach disease affects the area between Heart and Spleen. The meaning is identical; infer by mind. Thus, for Liver, Sweet relieves tension; for Spleen, Sweet supplements moisture deficiency; for Heart, Sweet drains Pi fullness of deficient Evil. However, although called "draining with Sweet," the method must distinguish Pi deficiency/excess; it cannot be used generally. Heat-Excess Pi certainly does not apply. But if used recklessly in cases of Stomach Cold-Deficiency, Spleen Qi sinking, Yin pathogen rebellion, undigested diarrhea, and borborygmus, fullness will surely increase. Li Dongyuan's Bu Zhong Yi Qi Tang is precise only for Qi deficiency causing Middle Fullness; applying it to Excess distension is dangerous. Gan Jiang guards the Middle, removes interior Cold, stops diarrhea. Ban Xia benefits the diaphragm; *Shennong Ben Cao Jing* says it treats Shang Han chills/fever and heart-down hardness. Both are Pungent-Warm and can dissipate Pi, so they are heavily used as Ministers. Huang Qin and Huang Lian use Bitter to open; not Fang Shi's claim of resolving Heat-Fire vexation. Yet Zhongjing explicitly says this is not Heat knotting; why use them? Likely drawing from *Zhi Zhen Yao Da Lun*: "Treat Heat with Cold." Because Yin pathogen obstructs internally, sudden administration of Pungent-Warm might be rejected; thus, Cold herbs guide entry. This is the classic method of counter-assistance (fan zuo), following the disease's nature with opposite temperatures. Hence, Huang Lian is used at one-third the dose of Gan Jiang. Observe the Jue Yin clause: "Shang Han originally had Cold diarrhea, repeated vomiting/purgation, Cold rejection causing reverse vomiting/diarrhea, food vomited immediately upon entry," treated with Gan Jiang Huang Lian Huang Qin Ren Shen Tang. The logic is clear. Cold and Heat combined, Bitter and Pungent used together, Middle Qi discordant, so Da Zao harmonizes. Gan Cao is used instead of Ren Shen because Yin pathogen is internal, turbid Qi stays in the Middle, and Ren Shen is not a draining agent. Old annotations only say Gan Cao stabilizes the Central Province. People know Ginger replaces Dried Ginger to avoid hyperactivity, but who knows Dried Ginger replaces Fresh Ginger to prevent dispersion? People know Gan Cao increases fullness, but who knows it removes fullness? Li Dongyuan originally stated replacing Dried Ginger with Fresh Ginger because Fresh Ginger is not hyperactive, not replacing Dried Ginger's hyperactivity. *Ben Cao* states: Dried Ginger is dried Fresh Ginger. Indications differ, and Dried Ginger has special processing. Properties and indications differ. Fresh Ginger disperses externally and opens; Dried Ginger warms internally and guards the Middle. Can Dried Ginger replace Fresh Ginger's dispersion? The reason Gan Cao removes fullness remains unexplained. The use of Qin and Lian is not fully understood. I fear this is insufficient to elucidate the formula's intent.
Five or six days into Shang Han, with vomiting and fever, Chai Hu Tang syndrome is complete. If purged with other drugs, and Chai Hu syndrome persists, administer Chai Hu Tang again. Although purged, this is not adverse. There will be vigorous shaking and trembling, followed by fever and sweating for resolution. If heart-down is full and hard-painful, this is Jie Xiong, treated with Da Xian Xiong Tang. If only full without pain, this is Pi. Chai Hu Tang is not indicated; Ban Xia Xie Xin Tang is appropriate.
This clause belongs in Shaoyang complicated diseases but is attached here due to Pi syndrome.
This describes Pi formation from pathogen in Shaoyang, hence titled "Shang Han" rather than Taiyang. Five or six days indicate deepening pathogen. Vomiting and fever are Shaoyang primary symptoms. Pathogen in Shaoyang, Chai Hu Tang syndrome present, yet Chai Hu is not used; instead, other drugs are mistakenly used for purgation. "Other drugs" refers to Cheng Qi types, not literally different drugs. Since only Chai Hu is correct for this syndrome, inappropriate drugs are termed "other." If after mistaken purgation, no other complications arise and Chai Hu syndrome persists, re-administer the correct Chai Hu Tang. The body will shake vigorously (zheng zheng), indicating heat rising and sweat欲 (desiring) to come; "zhen" means trembling/shaking, i.e., chills. The body shakes, then fever and sweating resolve the pathogen. Shaking before sweating occurs because post-purgation Righteous Qi is deficient and struggles against pathogen. Thus,虽有 (although) the error of mistaken purgation, fortunately, no adverse transformation occurs. If Chai Hu syndrome disappears after purgation, pathogen sinks due to deficiency. Pathogen sinking causes heart-down fullness, hard and painful upon palpation: this is Heat-entry Jie Xiong, treated with Da Xian Xiong Tang. If only full and not painful upon palpation, it is not hard-knotted. It belongs to Qi Pi. Although not painful, if the pulse floats at Guan as before, it is still Yang pathogen, and Da Huang Huang Lian Xie Xin Tang should drain the deficient pathogen. Here, Guan floating is not mentioned, indicating post-purgation Stomach Yang emptiness, with internal Yin Qi obstructing heart-down, forming Deficient Pi. Although originating from Shaoyang primary syndrome, it has transformed into Yin Pi; thus, Chai Hu Tang is not suitable. Ban Xia Xie Xin Tang is appropriate.
Differentiation of Errors: Previous commentators believed Wind Strike mistaken purgation leads to Jie Xiong, while Shang Han mistaken purgation leads to Pi. This clause shows Shang Han can lead to both Jie Xiong and Pi. They claimed Yang pathogen entering interior forms Jie Xiong, Yin pathogen entering interior forms Pi. Here, Shaoyang pathogen mistaken purgation shows Yang meridian pathogen can also form knots or Pi. Thus, even Zhongjing's "manifesting from Yang/Yin" is insufficient to cover all meanings. How can later generations set rigid examples? One must adapt to time, determine form by trend, name by shape, and treat by change. As Qibo said: "Examine the pathogenesis, do not lose the Qi suitability." And: "He who knows the essentials ends in one word; he who does not, scatters infinitely." This is the meaning.
Ban Xia Xie Xin Tang Formula
Ban Xia (Pinelliae Tuber) (0.5 sheng, washed)
Gan Jiang (Zingiberis Rhizoma) (3 liang)
Ren Shen (Ginseng Radix) (3 liang)
Gan Cao (Glycyrrhizae Radix et Rhizoma) (3 liang, honey-fried)
Huang Qin (Scutellariae Radix) (3 liang)
Huang Lian (Coptidis Rhizoma) (1 liang)
Da Zao (Jujubae Fructus) (12 pieces, split)
Take the above seven ingredients, boil in 1 dou of water to obtain 6 sheng. Strain. Decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.