脉浮而紧。而复下之。紧反入里。则作痞。按之自濡。但气痞耳。
此申言所以成痞之故。浮而紧者。伤寒之脉。所谓病发于阴也。紧反入里者。寒邪因下而内
陷。与热入因作结胸同意。但结胸心下硬满而痛。痞则按之濡而不硬且痛。所以然者。阳邪内陷。
止于胃中。与水谷相结。则成结胸。阴邪内陷。止于胃外。与气液相结。则为痞。是以结胸为实。
而按之硬痛。痞病为虚。而按之自濡耳。
心下痞。按之濡。其脉关上浮者。大黄黄连泻心汤主之。
按成氏云、心下硬。按之痛。关脉沉者。实热也。心下痞。按之濡。关上浮者。虚热也。
与大黄、黄连以导其虚热。成氏所谓虚热者。对燥屎而言也。非阴虚阳虚之谓。盖热邪入里。与糟
粕相结。则为实热。不与糟粕
相结。即为虚热。本方以大黄、黄连为剂。而不用枳、朴、芒硝者。盖以泄热。非以荡实也。麻沸
汤者。煮水小沸如麻子。即以煮药。不使尽药力也。
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。
心下痞。而复恶寒汗出者。附子泻心汤主之。
此即上条而引其说。谓心下痞。按之濡。关脉浮者。当与大黄黄连泻心汤泻心下之虚热。若其
人复恶寒而汗出。证兼阳虚不足者。又须加附子以复表阳之气。乃寒热并用。邪正兼治之法也。
附子泻心汤方
大黄（二两） 黄连（一两） 黄芩（一两） 附子（一枚炮去皮破别煮取汁）
上四味切。三味以麻沸汤二升渍之。须臾。绞去滓。内附子汁。分温三服。
按此证邪热有余而正阳不足。设治邪而遗正。则恶寒益甚。或补阳而遗热。则痞满愈增。此方
寒热补泻。并投互治。诚不得已之苦心。然使无法以制之。鲜不混而无功矣。方以麻沸汤渍寒药。别煮
附子取汁。合和与服。则寒热异其气。生熟异其性。药虽同行。而功则各奏。乃先圣之妙用也。
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。
结胸及痞。不特太阳误下有之。即少阳误下亦有之。柴胡汤证具者。少阳呕而发热。及脉弦
口苦等证具在也。是宜和解。而反下之。于法为逆。若柴胡证仍在者。复与柴胡汤和之即愈。此虽
已下之。不为逆也。蒸蒸而振者。气内作而与邪争胜。则发热汗出而邪解也。若无柴胡证。而心下
满而硬痛者。则为结胸。其满而不痛者。则为痞。均非柴胡所得而治之者矣。结胸宜大陷胸汤。痞
宜半夏泻心汤。各因其证而施治也。
半夏泻心汤方
黄芩（三两） 人参（三两） 甘草（三两） 黄连（一两） 半夏（半升洗） 干姜（三
两） 大枣（十二枚）
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。
按痞者。满而不实之谓。夫客邪内陷。即不可从汗泄。而满而不实。又不可从下夺。故惟半夏
、干姜之辛。能散其结。黄连、黄芩之苦。能泄其满。而其所以泄与散者。虽药之能。而实胃气
之使也。用参、草、枣者。以下后中虚。故以之益气。而助其药之能也。
伤寒汗出解之后。胃中不和。心下痞硬。干噫食臭。胁下有水气。腹中雷鸣下利者。生姜泻心
汤主之。
汗解之后。胃中不和。既不能营运真气。并不能消化饮食。于是心中痞硬。干噫食臭。金匮所谓
中焦气未和。不能消谷。故令人噫是也。噫、嗳食气也。胁下有水气。腹中雷鸣下利者。土德不及
而水邪为殃也。故以泻心消痞。加生姜以和胃。
按上条本少阳病。不宜入太阳篇中。此条汗解后病。亦不得谓之逆。而俱列于此者。所以备
诸泻心之用也。
生姜泻心汤方
生姜（四两切） 人参（三两） 半夏（半升洗） 甘草（三两炙） 黄芩（三两）
大枣（十二枚擘） 黄连（一两） 干姜（一两）
上八味。以水一斗。煮取六升。去滓。再煮取三升。温服一升。日三服。
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。但以胃中虚。客气上逆。故使硬也。
甘草泻心汤主之。
伤寒中风者。成氏所谓伤寒或中风者是也。邪盛于表而反下之。为下利谷不化。腹中雷鸣。
为心下痞硬而满。为干呕心烦不得安。是表邪内陷心间。而复上攻下注。非中气空虚。何致邪气淫
溢至此哉。医以为结热未去。而复下之。是已虚而益虚也。虚则气不得化。邪愈上逆。而痞硬有加矣
。故与泻心消痞。加甘草以益中气。
甘草泻心汤方
甘草（四两） 黄芩（三两） 干姜（三两） 黄连（一两） 半夏（半升洗） 大枣
（十二枚擘）
上六味。以水一斗。煮取六升。去滓。再煮取三升。温服一升。日三服。
按生姜泻心汤甘草泻心汤二方。虽同为治痞之剂。而生姜泻心。意在胃中不和。故主生姜
以和胃。甘草泻心。意在下利不止。与客气上逆。故不用人参之增气。而须甘草之安中也。
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。
大下复汗。正虚邪入。心下则痞。当与泻心汤如上法矣。若其人恶寒者。邪虽入里。而表犹
未罢。则不可迳攻其痞。当先以桂枝汤解其表。而后以大黄黄连泻心汤攻其痞。不然。恐痞虽解。
而表邪复入里为患也。况痞亦未必能解耶。
按伤寒下后。结胸痞满之外。又有懊 烦满下利等证。盖邪入里而未集。而其位又高。则为懊
。其已集而稍下者。则为结胸及痞。其最下而亦未结者。则为下利。结胸痞满。具如上文。凡十七
条。以下凡十一条。则备举懊 、下利诸证也。
The pulse is floating and tight. If purgation is mistakenly applied, the tightness reverses and enters the interior, resulting in Pi syndrome (epigastric fullness without hardness). Palpation reveals softness; this is merely Qi stagnation forming a Pi pattern.
This further elaborates on the cause of Pi formation. A floating and tight pulse characterizes Cold Damage disease, referred to as "disease originating from Yin." The reversal of tightness entering the interior indicates that cold pathogenic factors have sunk inward due to purgation, consistent with the mechanism where heat pathogens sink to form Jie Xiong (chest binding). However, Jie Xiong presents with hardness and pain in the epigastrium, whereas Pi presents with softness upon palpation, lacking both hardness and pain. This is because Yang pathogens sinking into the interior remain in the Stomach, binding with water and food residue to form Jie Xiong; Yin pathogens sinking into the interior remain outside the Stomach, binding with Qi and fluids to form Pi. Thus, Jie Xiong is an Excess pattern, characterized by hardness and pain upon palpation; Pi is a Deficiency pattern, characterized by natural softness upon palpation.
When there is epigastric fullness (Pi), softness upon palpation, and a floating pulse at the Guan position, Da Huang Huang Lian Xie Xin Tang (Rhubarb and Coptis Decoction for Draining the Epigastrium) is indicated.
Cheng Wuji stated: Hardness in the epigastrium with pain upon palpation and a deep Guan pulse indicates Excess Heat; epigastric fullness with softness upon palpation and a floating Guan pulse indicates Deficient Heat. Da Huang (Rhei Radix et Rhizoma) and Huang Lian (Coptidis Rhizoma) are used to guide out this Deficient Heat. Cheng's term "Deficient Heat" refers to heat not bound with dry feces, rather than Yin or Yang Deficiency. Generally, when heat pathogens enter the interior and bind with waste matter, it is Excess Heat; when they do not bind with waste matter, it is Deficient Heat. This formula uses Da Huang and Huang Lian but excludes Zhi Shi (Aurantii Fructus), Hou Po (Magnoliae Officinalis Cortex), and Mang Xiao (Natrii Sulfas) because its purpose is to drain heat, not to purge excess accumulation. Ma Fei Tang (Sesame-Bubble Boiling Water) refers to water boiled until small bubbles appear like sesame seeds; the herbs are soaked in this hot water to prevent the full extraction of medicinal potency.
Da Huang Huang Lian Xie Xin Tang Formula
Da Huang (2 liang) Huang Lian (1 liang)
Take the above two ingredients, soak them in 2 sheng of Ma Fei Tang. After a moment, strain off the dregs. Divide into two doses and take warm.
When there is epigastric fullness accompanied by aversion to cold and sweating, Fu Zi Xie Xin Tang (Aconite Decoction for Draining the Epigastrium) is indicated.
This extends the previous clause, stating that if there is epigastric fullness, softness upon palpation, and a floating Guan pulse, Da Huang Huang Lian Xie Xin Tang should be used to drain Deficient Heat in the epigastrium. If the patient additionally exhibits aversion to cold and sweating, indicating concurrent Yang Deficiency, Fu Zi (Aconiti Lateralis Radix Praeparata) must be added to restore exterior Yang Qi. This is a method of combining cold and hot properties, treating both pathogen and righteous Qi simultaneously.
Fu Zi Xie Xin Tang Formula
Da Huang (2 liang) Huang Lian (1 liang) Huang Qin (Scutellariae Radix, 1 liang) Fu Zi (1 piece, processed, skin removed, broken, decocted separately for juice)
Cut the above four ingredients. Soak three of them (Da Huang, Huang Lian, Huang Qin) in 2 sheng of Ma Fei Tang. After a moment, strain off the dregs, and add the Fu Zi juice. Divide into three doses and take warm.
Regarding this pattern, there is an excess of pathogenic heat but a deficiency of righteous Yang. If one treats the pathogen while neglecting the righteous Qi, aversion to cold will worsen; if one tonifies Yang while neglecting heat, epigastric fullness will increase. This formula administers cold, hot, tonifying, and purging agents simultaneously for mutual treatment, which is indeed a painstaking measure of necessity. However, without proper methods to control them, few would achieve efficacy without confusion. By soaking the cold-natured herbs in Ma Fei Tang and separately decocting Fu Zi for juice, then mixing them for administration, the cold and hot properties remain distinct, and raw versus cooked natures differ. Although administered together, their effects act independently. This is the profound application of the ancient sages.
After five or six days of Cold Damage, if vomiting and fever are present, Chai Hu Tang (Bupleurum Decoction) patterns are established. If other drugs are mistakenly used for purgation, and Chai Hu patterns persist, Chai Hu Tang should be re-administered. Although purgation has been performed, this is not considered a counter-indication (Ni).
There will likely be a sensation of steaming heat followed by chills, after which fever and sweating occur, leading to resolution. If the epigastrium is full, hard, and painful, this is Jie Xiong (Chest Binding), treated with Da Xian Xiong Tang (Major Blue-Green Pill for Draining the Chest). If it is merely full without pain, this is Pi (Epigastric Fullness); Chai Hu Tang is contraindicated, and Ban Xia Xie Xin Tang (Pinellia Decoction for Draining the Epigastrium) is appropriate.
Both Jie Xiong and Pi can result from mistaken purgation in Taiyang (Greater Yang) disorders, as well as Shaoyang (Lesser Yang) disorders. "Chai Hu Tang patterns established" implies that Shaoyang symptoms such as vomiting, fever, wiry pulse, and bitter taste are all present. Harmonization is indicated, but purgation was wrongly applied, constituting a counter-indication. If Chai Hu patterns persist, re-administering Chai Hu Tang for harmonization leads to recovery; despite prior purgation, this is not a counter-indication. Steaming heat and chills indicate internal righteous Qi rising to contend with the pathogen, followed by fever, sweating, and pathogen resolution. Without Chai Hu patterns, epigastric fullness with hardness and pain indicates Jie Xiong; fullness without pain indicates Pi. Neither is treatable by Chai Hu Tang. Jie Xiong requires Da Xian Xiong Tang; Pi requires Ban Xia Xie Xin Tang. Treatment varies according to the specific pattern.
Ban Xia Xie Xin Tang Formula
Huang Qin (3 liang) Ren Shen (Ginseng Radix, 3 liang) Gan Cao (Licorice Root, 3 liang) Huang Lian (1 liang) Ban Xia (Pinelliae Tuber, half sheng, washed) Gan Jiang (Zingiberis Rhizoma, 3 liang) Da Zao (Jujubae Fructus, 12 pieces)
Take the above seven ingredients, decoct in 10 dou of water to obtain 6 sheng. Strain, then decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.
Pi is defined as fullness without solidity. When external pathogens sink inward, diaphoresis (sweating) is contraindicated; since the fullness is not solid, purgation is also contraindicated. Therefore, only the acridity of Ban Xia and Gan Jiang can disperse the knot, and the bitterness of Huang Lian and Huang Qin can drain the fullness. While these actions are functions of the herbs, they rely fundamentally on the Stomach Qi. Ren Shen, Gan Cao, and Da Zao are used because purgation causes Middle Jiao Deficiency; they tonify Qi and assist the efficacy of the other herbs.
After Cold Damage resolves via sweating, if the Stomach becomes disharmonious, presenting with epigastric stiffness/fullness, dry belching with food odor, fluid retention under the costal region, borborygmus, and diarrhea, Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction for Draining the Epigastrium) is indicated.
After resolution via sweating, Stomach disharmony prevents the circulation of True Qi and the digestion of food. This results in epigastric fullness and stiffness, and dry belching with food odor, as described in the *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet): "Middle Jiao Qi is unharmonized, unable to digest grain, thus causing belching." Belching here refers to expelling food odor. Fluid retention under the costal region, borborygmus, and diarrhea indicate insufficient Earth virtue allowing Water pathogenic factors to cause harm. Thus, Xie Xin Tang is used to drain the epigastrium, and Sheng Jiang (Zingiberis Rhizoma Recens) is added to harmonize the Stomach.
Note: The previous clause pertains to Shaoyang disease and should not ideally be in the Taiyang chapter. This clause concerns post-sweat resolution and is not a counter-indication. Both are listed here to illustrate the various applications of Xie Xin Tang formulas.
Sheng Jiang Xie Xin Tang Formula
Sheng Jiang (4 liang, sliced) Ren Shen (3 liang) Ban Xia (half sheng, washed) Gan Cao (3 liang, honey-fried) Huang Qin (3 liang)
Da Zao (12 pieces, split) Huang Lian (1 liang) Gan Jiang (1 liang)
Take the above eight ingredients, decoct in 10 dou of water to obtain 6 sheng. Strain, then decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.
In Cold Damage or Wind Strike, if the physician mistakenly applies purgation, the patient may experience diarrhea dozens of times daily, undigested food, borborygmus, epigastric fullness/stiffness, dry vomiting, irritability, and restlessness. Seeing epigastric fullness, the physician might assume residual pathogen and purge again, worsening the fullness. This is not accumulated heat, but rather Stomach Deficiency with rebellious Qi ascending, causing hardness. Gan Cao Xie Xin Tang (Licorice Decoction for Draining the Epigastrium) is indicated.
"Cold Damage or Wind Strike" refers to Cheng Wuji's description. Pathogens are abundant at the exterior, yet purgation is wrongly applied, leading to diarrhea with undigested food, borborygmus, epigastric fullness/stiffness, dry vomiting, and irritability. This indicates exterior pathogens sinking into the Heart/Epigastrium and attacking upward and downward. Unless the Middle Qi is profoundly deficient, how could pathogens overflow to this extent? The physician mistook this for lingering accumulated heat and purged again, exacerbating the existing Deficiency. Deficiency prevents Qi transformation, causing further rebellious Qi and worsening fullness. Therefore, Xie Xin Tang is used to drain the epigastrium, and Gan Cao is added to tonify Middle Qi.
Gan Cao Xie Xin Tang Formula
Gan Cao (4 liang) Huang Qin (3 liang) Gan Jiang (3 liang) Huang Lian (1 liang) Ban Xia (half sheng, washed) Da Zao (12 pieces, split)
Take the above six ingredients, decoct in 10 dou of water to obtain 6 sheng. Strain, then decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.
Note: Although both Sheng Jiang Xie Xin Tang and Gan Cao Xie Xin Tang treat Pi, Sheng Jiang Xie Xin Tang targets Stomach disharmony, using Sheng Jiang to harmonize the Stomach. Gan Cao Xie Xin Tang targets persistent diarrhea and rebellious Qi; therefore, Ren Shen is omitted to avoid increasing Qi, and Gan Cao is used to calm the Middle.
After severe purgation followed by sweating in Cold Damage, if epigastric fullness and aversion to cold occur, the exterior pattern remains unresolved. One must not attack the Pi directly; the exterior must be resolved first. Only after the exterior is resolved can the Pi be treated.
For resolving the exterior, Gui Zhi Tang (Cinnamon Twig Decoction) is indicated. For treating the Pi, Da Huang Huang Lian Xie Xin Tang is indicated.
Severe purgation followed by sweating depletes righteous Qi and allows pathogens to enter, forming Pi. Typically, Xie Xin Tang would be used as above. However, if aversion to cold persists, although pathogens have entered the interior, the exterior pattern has not ceased. One must not directly attack the Pi. First, use Gui Zhi Tang to resolve the exterior, then use Da Huang Huang Lian Xie Xin Tang to treat the Pi. Otherwise, although the Pi might resolve, the exterior pathogens could re-enter the interior and cause complications. Moreover, the Pi might not resolve anyway.
Note: After mistaken purgation in Cold Damage, besides Jie Xiong and Pi, there are also Ao Nan (restlessness/oppression), fullness, and diarrhea patterns. Generally, if pathogens enter the interior but have not coalesced, and the location is high, it forms Ao Nan; if they have coalesced and are slightly lower, it forms Jie Xiong and Pi; if they are lowest and have not coalesced, it forms diarrhea. Jie Xiong and Pi are detailed above. These constitute seventeen clauses. The following eleven clauses detail various patterns of Ao Nan and diarrhea.