（附心痛）
【纲】仲景曰。病心下硬满者。不可攻之。攻之利遂不止者死。利止者愈。
得病二三日。脉弱。无太阳柴胡症。烦躁。心下硬。至四五日。虽能食。以小承气汤少少与微
和之。伤寒吐下后。心下逆满。气上冲胸。起则头眩。脉沉紧。发汗则动经。身为振振摇者。茯苓
桂枝白术甘草汤。
【目】吴绶曰。凡心下满者。正在心之下。胃之上也。此自满而非下之所致。若因下早而心下
满者。此为痞气。另有条也。凡心下满者。以手按之揉之。则散而软者。此虚气也。不发热者。木
香和中汤。发热者。小柴胡汤去黄芩。减人参一半。加姜炒黄连、枳实各一钱。若按之汨汨有声者。
此有停水也。若按之硬痛者。有宿食也。若不按而痛。其人喜忘者。蓄血也。各有本条。宜详审
而治之。凡少阳脉弦口苦。发热。心下满者。小柴胡加枳实、黄连各一钱。
王肯堂曰。有不因汗下而心下满者。经曰。邪气在胸。心满而烦。饥不欲食。当吐之。又曰。
脉浮而大。心下反硬。有热属脏者。攻之。此言属脏者。宿屎在脏也。不令发汗。二者一用吐。一
用下。因其邪之高下也。又有不可下者。即首条是也。
是邪在表里之间。留于心下。未全入腑。故戒不可下也。有因汗下后。心下满而微痛者。又有下后。
心下硬满。成结胸与痞者。皆宜详考之。
【纲】仲景曰。阳明中风。脉弦浮大。短气。腹满。胁下及心痛。鼻干。无汗。嗜卧。身黄。
小便难。有潮热。时时哕者。小柴胡汤。伤寒五六日。大下之后。心中结痛者。未欲解也。栀子豉
汤主之。少阴病。自利清水。色纯青。心下必痛。口干燥者。急下之。宜大承气汤。
【目】成无己曰。伤寒五六日。邪气在里之时。若大下后。身热去。心胸空者。为欲解。若大
下后。身热去而心结痛者。结胸也。身热不去。心中结痛者。虚烦也。结胸者。热结胸中也。为实。
是热气已收敛于内。则外身热去。虚烦者。热客胸中也。未结而实。散漫为烦。是以身热不去。
六七日为欲解之时。以热为虚烦。故云未欲解也。以栀豉汤吐除之。
王肯堂曰。身热不去四字要玩。结胸而身不热。知热在表。故可用大小陷胸汤丸以逐下之。今
热仍在表。故宜越之也。成注未透。
[Appendix: Heart Pain]
[Gang (General Principles)] Zhang Zhongjing stated: In cases where hardness and fullness are present in the epigastrium, purgation must not be used. If purgation is mistakenly applied and diarrhea persists without stopping, the prognosis is poor and death may ensue; if the diarrhea stops spontaneously, the patient will recover.
After being ill for two or three days, with a weak pulse, absence of Taiyang (Greater Yang) or Shaoyang (Lesser Yang) syndromes, and symptoms of restlessness and epigastric hardness: by the fourth or fifth day, even if the patient can eat, Xiao Chengqi Tang (Minor Order the Qi Decoction) should be administered in small amounts to gently harmonize the stomach.
Following emesis or purgation in Cold Damage (Shanghan), if there is epigastric rebellion and fullness (a sensation of qi rebelling upward causing distension), qi rushing up to the chest, dizziness upon rising, and a deep, tight pulse: administering sweating methods at this stage will disturb the meridians, leading to tremors and shaking of the body. This condition should be treated with Fuling Guizhi Baizhu Gancao Tang (Poria, Cinnamon Twig, Atractodes Macrocephala, and Licorice Decoction).
[Mu (Detailed Analysis)] Wu Shou said: Fullness in the epigastrium is located precisely below the heart and above the stomach. This fullness arises spontaneously and is not caused by premature purgation. If epigastric fullness results from early purgation, it constitutes Pi Syndrome (Stagnation Syndrome), which is covered in separate clauses. For epigastric fullness, if pressing and rubbing causes the sensation to dissipate and feel soft, it is due to deficient qi. If there is no fever, Muxiang Hezhong Tang (Costus Harmonizing the Middle Decoction) is indicated. If there is fever, Xiaochaihu Tang (Minor Bupleurum Decoction) is used, with Huangqin (Scutellaria Root) removed, Ren Shen (Ginseng) reduced by half, and Jiang Chao Huanglian (Ginger-fried Coptis Rhizome) and Zhishi (Immature Bitter Orange) added, one qian each. If pressing elicits a gurgling sound, this indicates retained water (fluid retention). If pressing elicits hardness and pain, this indicates retained food (food stagnation). If pain occurs without pressing and the patient suffers from forgetfulness, this indicates accumulated blood (blood stasis). Each has its own specific clause and requires careful examination before treatment. For Shaoyang syndrome presenting with a wiry pulse, bitter taste in the mouth, fever, and epigastric fullness, Xiaochaihu Tang (Minor Bupleurum Decoction) is used with Zhishi (Immature Bitter Orange) and Huanglian (Coptis Rhizome) added, one qian each.
Wang Kentang said: There are cases of epigastric fullness not caused by sweating or purgation. The Classics state: When pathogenic factors are in the chest, causing fullness and irritability, hunger but lack of desire to eat, vomiting (emesis) should be employed. It also states: With a floating and large pulse, and contrary hardness in the epigastrium accompanied by heat belonging to the Zang organs, purgation should be used. "Belonging to the Zang" here refers to fecal matter retained in the intestines. In such cases, sweating is contraindicated. These two scenarios—one using emesis and the other purgation—are determined by the high or low location of the pathogen. There are also cases where purgation is contraindicated, as mentioned in the first clause.
This is because the pathogen is between the exterior and interior, lingering in the epigastrium, and has not fully entered the Fu organs; thus, purgation is prohibited. Furthermore, after sweating or purgation, there may be epigastric fullness with slight pain; or after purgation, epigastric hardness and fullness may develop into Jie Xiong (Chest Binding) or Pi (Stagnation). All these must be carefully examined.
[Gang (General Principles)] Zhang Zhongjing stated: In Yangming Wind Strike, with a wiry, floating, and large pulse, shortness of breath, abdominal fullness, pain in the hypochondrium and heart region, dry nose, absence of sweat, lethargy, jaundice, difficult urination, tidal fever, and frequent hiccups, Xiao Chaihu Tang (Minor Bupleurum Decoction) is indicated.
In Cold Damage, after five or six days, if severe purgation was performed and the patient experiences knotted pain in the heart/chest, the disease has not yet resolved; Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered.
In Shaoyin disease, if there is spontaneous purging of clear water, pure green in color, inevitable pain in the epigastrium, and dryness of the mouth, urgent purgation is required, and Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Mu (Detailed Analysis)] Cheng Wuji said: On the fifth or sixth day of Cold Damage, when pathogens are in the interior, if severe purgation leads to the disappearance of body heat and an empty feeling in the chest and heart, the disease is about to resolve. If severe purgation leads to the disappearance of body heat but knotted pain in the heart remains, this is Jie Xiong (Chest Binding). If body heat persists and knotted pain in the heart remains, this is Xu Fan (Deficiency Irritability). Jie Xiong is heat binding in the chest, representing an excess pattern, where heat has converged internally, causing external body heat to subside. Xu Fan is heat lodging in the chest without forming a solid mass, scattering to cause irritability, hence body heat persists. Although the fifth to seventh day is typically when resolution is expected, because the heat manifests as deficiency irritability, it is stated that the disease has not yet resolved. Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used to induce vomiting and eliminate the pathogenic heat.
Wang Kentang commented: The phrase "body heat does not subside" warrants careful consideration. In Jie Xiong (Chest Binding) where there is no body heat, the heat is known to be in the exterior, so Da Xie Xiong Tang (Major Draining Chest Decoction) or Xiao Xie Xiong Tang (Minor Draining Chest Decoction) can be used to purge it downward. Since the heat is still in the exterior in this case, it is appropriate to disperse it via emesis. Cheng's annotation is not sufficiently thorough.