【纲】仲景曰。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。
【目】张介宾曰。按结胸一症。观伤寒论所载。凡太阳表邪未解而误下者成结胸。少阳亦然。
太阳少阳并病者亦然。此不当下而误下之。以致脏气空虚。外邪乘虚内陷。结于胸膈之间。是皆因
下而结者也。其曰伤寒六七日。结胸热实。脉沉而紧。心下痛。按之石硬者。此不因下而邪实渐深
结聚于胸者也。然则结胸一症。有因误下者。有不因下而由于本病者。近世伤寒书云。未经下者非
结胸。夫岂不谬哉。又结胸症。观仲景所言。惟太阳少阳误下者有之。而阳明一经。独无言及者。
何也。盖凡病入阳明。胃腑已实。故可下之而无害也。然又曰。阳明病心下硬满者。不可攻之。攻
之利不止者死。此岂非阳明在经表症。邪未入腑者。亦为不可下乎。不惟三阳为然。三阴之症。其
有发热恶寒。表邪未解者。切不可下也。又心下痞。是误下后里症。内外俱病。由汗下倒施。仍当
用先表后里。先汗后下之法。
鳌按。心下之痞。比清谷犹轻。
【纲】仲景曰。太阳病。外症未除而数下者。遂协热而利。利下不止。心下痞硬。表里不解者。
桂枝人参汤主之。
【目】魏荔彤曰。风邪初感在表。不治。郁而为热。故传经之热为热邪。今云数下之。其日久可
知。此因透表之风邪。变而为陷入之热邪。又屡为苦寒之剂所镇坠。由是病之热邪下于下焦。而药
之寒邪又留于心下。热入下焦。斯为协热之利不止。寒留心下。斯为协寒之痞硬。非用理中。则协
热之阳不能升。协寒之阴不能散也。
鳌按。桂枝人参汤。即理中汤加桂枝。故魏氏有非用理中云云也。
【纲】仲景曰。本以下之。故心下痞。与泻心汤。病不解。其人渴而口燥烦。小便不利者。五
苓散主之。太阳中风。下利呕逆。表解者。乃可攻之。其人 汗出。发作有时。头痛。心下痞。硬满。
引胁下痛。干呕短气。汗出不恶寒。此表解里未和也。十枣汤主之。
【目】龚信曰。痞气。通用桔梗枳壳汤。
陶华曰。痞者。因太阳症当服麻黄汤。而误用承气下之。而成痞满。此因虚邪留滞。若欲下之。
必待表症罢而后可。宜小柴胡加枳桔汤。
鳌按。此二条之痞。皆由心下水气泛溢。
【纲】仲景曰。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。所以成结胸者。以下之太早故
也。
【目】成无己曰。结胸与痞。俱是热症。作痞不言热入者。热原发于里也。
柯琴曰。热入是结胸之因。痞不言热入。见痞与结胸所以异也。
【纲】仲景曰。伤寒汗出解之后。胃中不和。心下痞硬。干呕食臭。胁下有水气。腹中雷鸣。
下利者。生姜泻心汤主之。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。此非结热。但以胃中空虚。客气上逆。故使硬也。甘草泻心汤主之。
【目】苏颂曰。胃寒。先宜理中丸。后用旋覆代赭汤。咳逆气虚。四逆汤。汗吐下后。噎气痞
硬。旋覆代赭汤。发热不解。呕吐不利。心下痞硬。大柴胡汤。下利不止。则治下焦。赤石脂禹余
粮汤。又不止。只利小便。五苓散。
柯琴曰。阳邪居胃之上口。故痞硬干呕食臭。水邪居胃之下口。故腹鸣下利。故病虽在胃而不
属阳明。仍属太阳寒水之变。上条。是汗解后水气下攻症。下条。是误下后客气上逆症。总是胃虚
而稍有分别。上条腹鸣下利。胃中犹寒热相半。故云不和。下条腹鸣而完谷不化。利日数十行。则
痞为虚痞。硬为虚硬。满为虚满明矣。上条因水气下趋。故不烦不满。下条是虚邪上逆。故心烦而满。
【纲】仲景曰。伤寒五六日。呕而发热者。柴胡汤症具。而以他药下之。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。此为痞也。柴胡不中与之。宜半夏泻心汤。
【目】许叔微曰。误下之变。结胸则其偏于半表者也。心下痞则其偏于半里者也。
【纲】仲景曰。伤寒吐下后。复发汗。虚烦。脉甚微。八九日。心下痞硬。胁下痛。气上冲咽
喉。眩冒。经脉动惕者。久而成痿。太阳病。医发汗。仍发热恶寒。复下之。心下痞。表里俱虚。
阴阳气并竭。无阳则阴独留。加烧针。因胸烦。面色青黄。肤 者。难治。今色微黄。手足温者。
易愈。
【目】柯琴曰。上条。因吐下后复汗。以致虚烦而痞。下条。因汗下后加烧针。以致虚烦而痞。
【纲】仲景曰。伤寒服汤药。下利不止。心下痞硬。服泻心汤已。复以他药下之。利不止。医
以理中与之。利益甚。理中者。理中焦。此利在下焦。赤石脂禹余粮汤主之。复利不止者。当利其
小便。
【目】柯琴曰。服汤药而利不止。是病在胃。复以他药下而利不止。是病在大肠矣。故用石脂、
余粮。
[General Principle] Zhang Zhongjing stated: After a severe purgative treatment for Taiyang disease (Taiyang Disease, a syndrome caused by pathogenic factors invading the Taiyang channel), followed by another sweating treatment, if the patient presents with fullness and stuffiness in the epigastrium (Xin Xia Pi) and aversion to cold, it indicates that the exterior syndrome has not yet been resolved. One must not attack the fullness directly; instead, one should first resolve the exterior. Once the exterior is resolved, then one may treat the fullness. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is appropriate. To treat the fullness, Dahuang Huanglian Xiexin Tang (Rhubarb, Scutellaria, and Pinellia Heart-Draining Decoction) is appropriate.
[Commentary] Zhang Jiabin stated: Regarding the syndrome of Jie Xiong (Chest Binding), as recorded in Shanghan Lun (Treatise on Cold Pathogenic Diseases), whenever exterior pathogens of the Taiyang channel have not been resolved and purgatives are mistakenly used, Jie Xiong results. The same applies to Shaoyang disease (Shaoyang Disease). It also applies to concurrent Taiyang and Shaoyang diseases. This occurs because purgatives were used when they were contraindicated, leading to emptiness in the zang-fu organs, allowing external pathogens to sink inward due to deficiency and bind between the chest and diaphragm. These are all cases where binding results from mistaken purgation. The text mentions "Cold damage for six or seven days, Jie Xiong with heat excess, pulse deep and tight, pain in the epigastrium, hardness upon palpation like a stone." This is not due to purgation but rather pathogens gradually deepening and binding in the chest as an excess condition. However, Jie Xiong can result from mistaken purgation or from the progression of the primary disease without purgation. Recent Shanghan texts claim that "if no purgation was performed, it is not Jie Xiong," which is clearly erroneous. Furthermore, according to Zhang Zhongjing, Jie Xiong appears only after mistaken purgation in Taiyang and Shaoyang channels, but is never mentioned regarding the Yangming channel. Why? Because once pathogens enter Yangming, the stomach fu organ is already excess, so purgation is harmless. Yet, it is also stated: "In Yangming disease, if there is hardness and fullness in the epigastrium, do not purge. If purging leads to unceasing diarrhea, death ensues." Does this not imply that even in Yangming, if the syndrome is at the exterior level and pathogens have not entered the fu organ, purgation is contraindicated? This applies not only to the three yang channels but also to the three yin channels: if fever, aversion to cold, and unresolved exterior pathogens are present, purgation must absolutely be avoided. Additionally, Xin Xia Pi (epigastric fullness/stuffiness) is a interior syndrome resulting from mistaken purgation, involving both interior and exterior pathology due to the inversion of sweating and purging methods. Therefore, the method of treating the exterior first and the interior second, i.e., sweating first and purging later, should still be employed.
Shen Jin'ao's note: Xin Xia Pi is milder than Xia Li Qing Gu (diarrhea with undigested food).
[General Principle] Zhang Zhongjing stated: In Taiyang disease, if the exterior symptoms persist and multiple purgations are performed, it leads to Xie Re Er Li (diarrhea accompanying exterior heat). With unceasing diarrhea and hardness/fullness in the epigastrium, where neither the exterior nor the interior is resolved, Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) is the primary treatment.
[Commentary] Wei Litong stated: When wind pathogens initially affect the exterior, if untreated, they stagnate and transform into heat; thus, heat transmitted through channels is called heat-pathogen. Here, multiple purgations indicate a prolonged duration. The wind pathogen intended to exit the exterior transforms into a heat-pathogen sinking inward. Furthermore, repeated use of bitter-cold agents suppresses and sinks the condition. Consequently, the pathological heat sinks to the Lower Jiao (Lower Burner), while the cold nature of the drugs remains in the epigastrium. Heat entering the Lower Jiao causes unceasing diarrhea accompanying heat; cold lingering in the epigastrium causes hardness and fullness accompanying cold. Without using Lizhong Tang (Regulate the Middle Decoction), the yang qi accompanying heat cannot ascend, and the yin qi accompanying cold cannot dissipate.
Shen Jin'ao's note: Guizhi Renshen Tang is essentially Lizhong Tang plus Guizhi (Cinnamon Twig). Hence, Mr. Wei’s comment about "not using Lizhong" makes sense.
[General Principle] Zhang Zhongjing stated: Originally, mistaken purgation led to Xin Xia Pi. After administering Xiexin Tang (Heart-Draining Decoction), the disease did not resolve. If the patient experiences thirst, dry mouth, irritability, and difficulty urinating, Wuling San (Five-Ingredient Powder with Poria) is the primary treatment. In Taiyang Wind Strike, if there is diarrhea and vomiting/retching, and the exterior syndrome has resolved, one may then attack the interior. If the patient sweats, with attacks occurring at specific times, headache, epigastric fullness and hardness, pain radiating to the hypochondrium, dry retching, shortness of breath, sweating without aversion to cold, this indicates the exterior is resolved but the interior is disharmonious. Shizao Tang (Ten Date Decoction) is the primary treatment.
[Commentary] Gong Xin stated: For Pi Qi (Fullness-Stuffiness Syndrome), Jiegeng Zhike Tang (Platycodon and Aurantium Decoction) is commonly used.
Tao Hua stated: Pi syndrome arises when Taiyang syndrome requires Mahuang Tang (Ephedra Decoction), but Chengqi Tang (Stomach-Clearing Decoction) is mistakenly used for purgation, resulting in fullness and stuffiness. This is due to deficient pathogens lingering. If purgation is desired, one must wait until the exterior symptoms cease. Xiaochaihu Tang Plus Zhike and Jiegeng (Minor Bupleurum Decoction plus Aurantium and Platycodon) is appropriate.
Shen Jin'ao's note: The Pi syndromes in these two clauses are both caused by the overflow of water-qis in the epigastrium.
[General Principle] Zhang Zhongjing stated: When a disease begins with a Yang syndrome (such as Taiyang) and is mistakenly purged, heat enters, resulting in Jie Xiong. When a disease begins with a Yin syndrome and is mistakenly purged, it results in Pi. The reason Jie Xiong forms is that purgation was performed too early.
[Commentary] Cheng Wuji stated: Both Jie Xiong and Pi are heat syndromes. Pi is described without "heat entering" because the heat originates internally.
Ke Qin stated: "Heat entering" is the cause of Jie Xiong. Pi does not mention "heat entering" to highlight the difference between Pi and Jie Xiong.
[General Principle] Zhang Zhongjing stated: After cold damage resolves via sweating, if the stomach is disharmonious, presenting with hardness/fullness in the epigastrium, dry retching, foul breath from food, water-qis in the hypochondrium, borborygmus (rumbling in the abdomen), and diarrhea, Shengjiang Xiexin Tang (Fresh Ginger Heart-Draining Decoction) is the primary treatment. In cold damage or wind strike, if the physician mistakenly purges, the patient suffers diarrhea dozens of times a day, with undigested food, borborygmus, hardness/fullness in the epigastrium, dry retching, irritability, and inability to rest. Seeing the epigastric fullness, the physician assumes residual pathogens and purges again, worsening the fullness. This is not heat accumulation, but rather emptiness in the stomach causing rebellious counterflow of pathogenic qi, leading to hardness. Gancao Xiexin Tang (Licorice Heart-Draining Decoction) is the primary treatment.
[Commentary] Su Song stated: For stomach cold, start with Lizhong Wan (Regulate the Middle Pill), then use Xuanfu Daizhe Tang (Inula and Hematite Decoction). For coughing/wheezing with qi deficiency, use Sini Tang (Counterflow Decoction). After sweating, vomiting, or purging, if there is choking sensation and epigastric fullness/hardness, use Xuanfu Daizhe Tang. If fever persists with vomiting and diarrhea, and epigastric fullness/hardness, use Dachaihu Tang (Major Bupleurum Decoction). If diarrhea is unceasing, treat the Lower Jiao with Chishizhi Yuyuliang Tang (Red Halloysite and Hematite Decoction). If still unceasing, promote urination with Wuling San.
Ke Qin stated: Yang pathogens residing at the upper opening of the stomach cause fullness/hardness, dry retching, and foul breath. Water pathogens residing at the lower opening of the stomach cause borborygmus and diarrhea. Thus, although the disease is in the stomach, it does not belong to Yangming but is a variation of Taiyang cold-water pathology. The previous clause describes water-qis attacking downward after resolution via sweating. The next clause describes rebellious counterflow of pathogenic qi after mistaken purgation. Both stem from stomach deficiency, with slight differences. In the first clause, borborygmus and diarrhea indicate half-cold and half-heat in the stomach, hence "disharmony." In the second clause, borborygmus with undigested food and frequent diarrhea indicate that the fullness is deficient fullness, hardness is deficient hardness, and distension is deficient distension. The first clause involves water-qis moving downward, so there is no irritability or fullness. The second clause involves rebellious deficient pathogens, causing irritability and fullness.
[General Principle] Zhang Zhongjing stated: In cold damage for five or six days, if there is vomiting and fever, indicating Chaihu Tang (Bupleurum Decoction) syndrome, and other medicines are mistakenly used for purgation: if the epigastrium becomes full, hard, and painful, this is Jie Xiong, treated with Da Xiexiong Tang (Major Chest-Breaking Decoction). If it is merely full without pain, this is Pi, and Chaihu Tang is not indicated; Banxia Xiexin Tang (Pinellia Heart-Draining Decoction) is appropriate.
[Commentary] Xu Shuwēi stated: Variations from mistaken purgation: Jie Xiong leans toward the half-exterior; Xin Xia Pi leans toward the half-interior.
[General Principle] Zhang Zhongjing stated: After cold damage is treated with vomiting and purging, followed by sweating, if there is deficiency irritability and a very faint pulse, and on the eighth or ninth day, the patient presents with hardness/fullness in the epigastrium, pain in the hypochondrium, qi rushing up to the throat, dizziness, and twitching/trembling of the meridians, prolonged illness will lead to Wei Syndrome (flaccidity syndrome). In Taiyang disease, if the physician sweats the patient, and fever and aversion to cold persist, followed by purgation, leading to epigastric fullness, both exterior and interior are depleted, and both yin and yang qi are exhausted. Without yang, yin remains alone. Adding moxibustion (burning needle) causes chest irritability. If the complexion is greenish-yellow and the skin twitches, it is difficult to treat. If the complexion is slightly yellow and hands/feet are warm, recovery is easy.
[Commentary] Ke Qin stated: The first clause results from vomiting/purging followed by sweating, leading to deficiency irritability and Pi. The second clause results from sweating/purging followed by burning needle therapy, leading to deficiency irritability and Pi.
[General Principle] Zhang Zhongjing stated: After taking herbal decoctions for cold damage, if diarrhea is unceasing and the epigastrium is hard/full, and after taking Xiexin Tang, if other medicines are used for purgation and diarrhea continues, and the physician uses Lizhong Tang, the diarrhea worsens. Lizhong Tang regulates the Middle Jiao, but this diarrhea is in the Lower Jiao. Chishizhi Yuyuliang Tang (Red Halloysite and Hematite Decoction) is the primary treatment. If diarrhea remains unceasing, one should promote urination.
[Commentary] Ke Qin stated: Diarrhea unceasing after taking decoctions indicates the disease is in the stomach. Diarrhea unceasing after further purgation indicates the disease is in the large intestine. Hence, Red Halloysite and Hematite are used.