从一些杂志的报道来看，很多学者将胸痹认为即是冠心病，而《千金方》、《肘后方》所谈胸痹之证见“胸中幅幅如满，噎塞习习如痒，喉中涩燥，唾沫”；“病人胸中似喘不喘，似呕不呕，似哕非哕，彻心中愦愤然无奈者”。是什么则不谈，致使胸痹证所谈的很多治疗原则得不到应有的发扬。例如：张××，女，成。感冒后突然胸满呼吸困难，头身汗出，急至某院治疗。诊为自发性气胸。因该院无空床而不能住院。又请中医治疗，医诊后颇感棘手，勉予宣肺定喘之法治之，不效。又邀余诊治。审其证见气喘而呼吸有难于接续之状，口唇、爪甲青紫，头身汗出，舌苔薄白，舌质暗，脉沉弦，胸腹满胀。综合脉证后，云：“此浊阴逆行，气壅上焦，胸阳痹阻之胸痹证也。治宜通阳泄浊。枳实薤白桂枝汤加味：瓜蒌30克，薤白10克，桂枝10克，半夏10克，厚朴10克，陈皮10克，枳壳10克，杏仁10克。昼夜兼进2剂，次日诊之，诸证俱减，乃续以上方服之，一日而安。其后该医云：若早知道这是胸痹，我也会用这法治疗。”又说：“将中医病名局限在某个西医名称之下，往往感到没有办法用中药，所以学中医还得按老师所说，按照中医观点学中医。”又如：患者郭××，女，成。腹大、乏力经治痊愈后。近半年来突见胸脘痞满，吞咽困难，气短微喘，呕吐痰涎，食欲不振，声音嘶哑。某院诊为声带麻痹，食管痉挛。先用西药、针灸治疗不效，继用中药旋覆代赭汤、四七汤等加减亦不效。邀余诊视。审其形体消瘦，神疲乏力，呼吸困难，言语低微而嘶哑，吞咽困难，面色白中透青，胃脘痞满，悸动，胁下逆抢心。综合脉证，云：此正合《金匮》“胸痹，心中痞气，气结在胸，胸满，胁下逆抢心”之枳实薤白桂枝汤证也。”因拟：枳实9克，厚朴9克，薤白9克，桂枝6克，瓜蒌15克，茯苓4克。服药4剂，诸证稍减。后因他因而转请另一医生治疗。云：痰火瘀血相结，以化痰散结，活血解毒治之。6剂后，诸证加剧。再邀余诊视，审其脉证仍为枳实薤白桂枝汤证，再拟原方服之。药进8剂，诸证大减。惟久病气血虚衰，再以原方治之恐难奏效，再审其面色已转皓白，舌苔薄白，脉弦而滑。乃拟十味温胆汤加减治少，处方：黄芪15克，当归10克，麦冬10克，五味子10克，半夏10克，枳实10克，竹茹10克，陈皮10克，茯苓10克，甘草10克，菖蒲10克，远志10克，知母10克。药进8剂，非但不效，反见加重。经验教训值得总结，因思仲景有关阳复之论，滑脉者非仅指热，指痰，指积，而且主阳气来复，阳复之脉误认阳热痰盛而以寒凉克伐，致使阳气复衰，故尔加剧，法仍宜温通阳气为治，再以枳实薤白桂枝汤方加茯苓30剂而愈。
寒疝
寒疝一证，《金匮要略》论之甚详，它说：“腹痛，脉弦而紧，弦则卫气不行，即恶寒，紧则不欲食，邪正相搏，即为寒疝。寒疝绕脐痛，若发则白汗出，手足厥冷，其脉沉紧者，大乌头煎主之。”“寒疝腹中痛，及胁痛里急者，当归生姜羊肉汤主之。”“寒疝腹中痛，逆冷，手足不仁，若身疼痛，灸刺诸药不能治，抵当乌头桂枝汤主之。”“心胸中大寒痛，呕不能食，腹中寒，上冲皮起，出见有头足，上下痛而不可触近，大建中汤主之。”“胁下偏痛，发热，其脉紧弦，此寒也，以温药下之，宜大黄附子汤。”《外台》云：“乌头汤，治寒疝腹中绞痛，贼风人攻五脏，拘急不得转侧，发作有时，使人阴缩，手足厥逆。”张景岳云：“寒疝最能作痛，多因触冒寒邪，或犯生冷所致，凡喜暖畏寒，脉弦细，鼻尖手足多冷，大小便无热之类皆是也。”可是有的医者不读经典，但读后世之论，敛寒疝之疾久久不愈。例如：患者张××，女，成。肠梗阻采用中药治疗痊愈后，8个月来，腹部经常发作性剧痛，严重时脐腹疼痛如绞，包块起伏，小者如桃，大者如拳，不敢触近，烬痛发作半小时后，即突然腹中剧烈鸣响一声而减为隐隐作痛，食纳日减，消瘦乏力，(三个月即由体重65．5千克降至42．5千克)。前医久久治之不效。邀余诊治。余初认为神疲懒言，肢厥脉弦而紧，舌苔薄白，系脾胃虚寒证，欲以附子理中汤治之，患者视后云：前医久用附子理中汤无效；余又欲以温．中散寒．活血止痛法治之，患者又示所用之剂仅有活血温中散寒之方即达25余方，然服后均寸效未见。余深思良久，再问。答云：经常数日便秘不行，腰痛不得俯仰。寻其脉见尺大而弦。乃云：脾肾俱虚，阴阳不足耳。拟方：附子10克，肉桂10克，干姜1O克，党参10克，白术10克，甘草10克，生地10克，山药]O克，肉苁蓉10克，茯苓10克，泽泻10克，丹皮10克。2剂后，腹痛大减，食纳稍增；继进4剂，疼痛消失。又服10剂而愈。又如：靳××，女，成。右胁绞痛，反复发作三个多月，某院住院检查三个月未确诊，予中、西药治疗亦不见好转。审其面容憔悴，右手捧腹，不断呻吟，食欲不振，舌苔白，舌质暗，脉弦紧。综合脉证，云：寒邪凝结于胁也，非大辛大热不能驱其寒。但寒邪壅郁者，不佐苦寒而难破阴霾，乃拟大黄附子汤合小承气汤温里攻下。处方：大黄3克，附子10克，细辛6克，枳实9克，厚朴9克。药进2剂，痛减六七，再服2剂痛苦全失。然恐再复发，乃以活血通络之膈下逐瘀汤4剂善其后。一医云：某老师说大黄非用9克以上不泻，你用3克即泻下者何也?答曰：寒证、热证不同耳，寒者虽用3克即可下，实热9克恐亦不下。
胃痛
胃脘部的疼痛是一个大题目，因为它是胃炎、溃疡病、胃神经官能症、肝炎、胆道蛔虫症、胆石症、胆囊炎、胰腺炎、肝脓肿、肾结石、心肌梗死、心绞痛以及胰、肝、胆、胃的癌痛等很多疾病的一个症状。中医又把发生在不同部位的疼痛称作不同的名称。例如：剑突下疼痛拒按者称小结胸；整个上腹部的疼痛称胃脘痛，心痛；疼痛剧烈而上冲，且伴有呕吐蛔虫者称蛔厥；胁下疼痛称胁痛。另外，又对其他症状为主，胃脘疼痛为次的称作其他名称，如呕吐为主者称呕吐，黄疸为主者称黄疸，有肿块或肝脾肿大者称癥瘕等等。这些名称繁多，统一在一个名称下进行讨论，看起来是一个非常困难的问题，但只要掌握中医的特点，掌握中医对疾病的基本分析方法，根据中医的基本理论，分清疾病所处的脏腑部位，寒热虚实阴阳，气血痰食等进行分析归纳，得出结论，然后处方治疗即可。
有的同志可能提出问题说：“不同的疾病，例如溃疡病、胃下垂、胰腺炎等表现的证候相同，是否可用同一个方剂?”我的回答是肯定的，完全可以。反之，同一疾病表现的证候不同时应用的治疗方法就不同了。现在谈的胃脘部疼痛的辨证和治疗主要是讲不同疾病表现在胃脘痛时的辨证和治疗，至于同一疾病的辨证和治疗问题，以后再谈。
一、胃脘痛的辨证要点
胃脘疼痛大致可以从疼痛的部位，疼痛发生的时间，与冷热的关系，其他等几个方面去分析。
疼痛的部位：剑突下剧烈疼痛，憋胀，无压痛者，属寒；痛胀拒按者，属痰。胃脘剧烈疼痛，满胀而无压痛者，属寒。疼痛剧烈，无满胀，无压痛，或夜间疼痛经常发作，或气候变化时疼痛发作者，属瘀血。痞满疼痛，有压痛，饮水及饮酒后疼痛加重，阴天时闷痛加重者，属痰饮；胃脘疼痛，有明显的压痛，食后疼痛加重者，属实。胃脘部有空虚感，疲乏无力者，属脾虚。饥饿时疼痛，食后疼痛缓解者，属虚。心悸，疲之尤力，劳累后疼痛反复发作者，属气血虚：胸脘痞满，心烦，生气后疼痛发作者，属气滞。吃辛辣食物和吃热药后疼痛加重，属热。胁下疼痛属肝，其中满而隐痛者属气滞。剧烈疼痛，向上冲者，属肝寒。疼痛而满闷，有压痛者，属气滞血瘀或痰实凝结。胁下及腰部均疼痛，劳累时加重者，属肝肾虚。遇冷或吃冷饮食时疼痛者，属实。胁下持续性疼痛，无满胀者，属瘀血。
疼痛发生的时间：过去无病，突然发生剧烈疼痛者，多属寒、实。慢性、反复发作的疼痛多属虚寒、瘀血、痰积不化。慢性、反复发作，夜间疼痛者，属瘀血、阴虚。食后疼痛发作者，属食积、痰积。饥饿时疼痛发作，吃少量食物后缓解者，属虚。生气后疼痛发作者，属肝气郁结。手术或其他外伤后。持续疼痛者，属瘀血。一遇冷即发作者，属寒。
其他症状：经常腰困痛者，属肾虚。腰痛胁痛同时出现者，属肝肾虚。腹部悸动，疲乏无力，肩背沉重者，属气血俱虚。疲乏无力，下肢轻度浮肿，气短者，属气虚清阳不升。胸胁满闷，全身窜痛，心烦，头晕者，属肝气郁结。胃脘疼痛，痛则腰痛者，属脾肾阳虚。胃脘疼痛，痛则冲胁肋、肩背者，属肝寒、肝经实热。胃脘、脐部均痛者，属脾肾虚寒。胁下痛，痛彻少腹者，属肝，其中痛彻少腹睾丸，尿黄赤者，属肝、小肠、膀胱之湿热；痛彻少腹、腰者，属肝．肾虚；痛则胸满闷，气短者，属肝气、寒痰凝滞。经常夜间口干者，属阴虚、瘀血。有肿物而硬者，属瘀血；较软者，属痰积、食积．大便秘结者，属实；大便经常稀溏者，属脾虚；大便经常有粘液夹杂，属痰积；大便为黑色者，为瘀血。
面色变化：面色白如冷状者，属寒。面带愁容而紧者，属肝郁痰滞。面色萎黄，五心烦热者，属血虚。面色萎黄，而兼淡白者，多属脾虚。面如苍黄者，多属湿热。面色发青者，属瘀血。面色黑者，属肾虚。眼圈黑者，男子属肾虚，女子属血虚气滞。
舌苔舌质：舌苔薄白者，多属寒；舌苔薄黄者，多属热、上热下寒；舌苔黄腻，多属痰热、食积、湿热；舌苔黄厚干燥者，多属实热；舌苔白或黄而中心无苔者，属胃阴虚。舌苔水润者，为寒痰。舌苔黑者，属肾虚。舌质红者，属热。舌质嫩打者．属阴虚。舌紫兰或有瘀斑者，属瘀血。
脉象：常见的有沉、迟、数、虚、滑、涩、大、微、紧、缓、弦、濡、弱、细、结等。其中最常见的有沉、滑、弦、濡、迟等几种。其中沉脉主气郁。迟脉主寒。数脉主热。滑脉主瘀积、食积、脾胃湿热，实热。虚脉主气血俱虚。涩脉主寒凝气滞、血瘀。大脉主气虚，气血虚衰，气阴两虚。紧脉主寒痛：缓脉主脾湿不化、脾虚。弦脉主肝郁、诸痛、寒。若左弦而左缓者主脾虚木乘，左弦右不弦者主肝经自病。濡脉主脾虚、湿盛。弱脉主气血不足。结脉主阴盛气结，气壅痰滞。另外，尺脉大者主肾虚，尺脉甚小者亦主肾虚。寸脉沉，关脉滑者主中焦痰湿郁滞。
1．辨证分析时应注意的几个问题若遇见自述症状、面色、舌苔舌质、脉象都能统一起来，就比较容易诊断。若遇见症状、面色、舌苔舌质、脉象相反则很难措手，此时就需要结合病史去考虑。不过一般说来舌苔、舌质、面色、脉象常常反映的是本质的东西。例如：患者主诉疲乏无力，食欲不振，饥饿时胃脘疼痛，甚至有的说是胃下垂者，可是应用补中益气汤等都一直无效，这吋若能结合脸色、脉象常能查出真实情况，若面色呈忧郁状，脉弦滑，且腹有压痛，则是肝气郁结，痰实不化所致。对于症状叙述是实，而舌、面色、脉象表现虚象者，诊断的方法与上面所谈者基本相同。
2．对虚实寒热夹杂证的处理问题这也是比较难处理的问题。例如：胃脘剧烈疼痛，反复发作，食欲不振，舌苔黄，口苦，大便干等均是实热的表现，但应用攻下的方法疼痛不但小减，反而加重，这时必须结合面色、脉象，若脉弦紧者，是寒实证，而不是实热，此时应子温下法。有的叙述完全是虚寒址，而应用温补又无效，此时应多考虑实的一面。总之，辨证吋必须注意一般中的特殊和特殊中的一般，然后再进行处理。处理时一定要结合面色、舌、脉、症状的整个情况，决不可一听症状就下结论。
3．一定要亲自检查，不可一听主诉即下结论例如：有的主诉胃脘疼痛，饥饿时加重等脾胃虚寒者，但应用健脾温中的药物又不见效，此时医者必须亲自检查，胃脘有没有压痛。若有压痛即为虚中夹实，应在温补中配合消导。这种情况若不亲自检查，常常误过良机。
4．要注意情况的不断变化经常遇见这样一种情况，胃脘疼痛经过用温中健脾的药物治疗后，症状很快缓解，但应用一个阶段后，效果越来越差，后来再用此类方剂不但无效反而加重，这是由于这种疾病是由很多原因形成。开始这一个原因占据主导地位，另一原因占次要地位，经过治疗一个阶段后，主要和次要的原因发生了本质的变化，这时若还应用原来的方法，必定要碰钉子，因此我们必须要根据不断变化了的情况进行处理。
二、胃脘痛的辨证论治
胃脘痛的治疗可以从剑突下、胃脘、胁下等三部分来叙述。
1．剑突下部中医书中一般称为正在心下。常见的有三种情况：
(1)剑突下腹痛，食后不适加重，有明显的压痛，口苦口千，舌苔白或黄腻，脉滑等痰热阻滞者，化痰散结，小陷胸汤加味：瓜蒌30克，半夏9克，黄连9克(无黄连改用黄芩9克)，枳实9克．
从一些杂志的报道来看，很多学者将胸痹认为即是冠心病，而《千金方》、《肘后方》所谈胸痹之证见“胸中幅幅如满，噎塞习习如痒，喉中涩燥，唾沫”；“病人胸中似喘不喘，似呕不呕，似哕非哕，彻心中愦愤然无奈者”。是什么则不谈，致使胸痹证所谈的很多治疗原则得不到应有的发扬。
例如：张××，女，成。感冒后突然胸满呼吸困难，头身汗出，急至某院治疗。诊为自发性气胸。因该院无空床而不能住院。又请中医治疗，医诊后颇感棘手，勉予宣肺定喘之法治之，不效。又邀余诊治。审其证见气喘而呼吸有难于接续之状，口唇、爪甲青紫，头身汗出，舌苔薄白，舌质暗，脉沉弦，胸腹满胀。综合脉证后，云：“此浊阴逆行，气壅上焦，胸阳痹阻之胸痹证也。治宜通阳泄浊。枳实薤白桂枝汤加味：瓜蒌30克，薤白10克，桂枝10克，半夏10克，厚朴10克，陈皮10克，枳壳10克，杏仁10克。昼夜兼进2剂，次日诊之，诸证俱减，乃续以上方服之，一日而安。其后该医云：若早知道这是胸痹，我也会用这法治疗。”又说：“将中医病名局限在某个西医名称之下，往往感到没有办法用中药，所以学中医还得按老师所说，按照中医观点学中医。”
又如：患者郭××，女，成。腹大、乏力经治痊愈后。近半年来突见胸脘痞满，吞咽困难，气短微喘，呕吐痰涎，食欲不振，声音嘶哑。某院诊为声带麻痹，食管痉挛。先用西药、针灸治疗不效，继用中药旋覆代赭汤、四七汤等加减亦不效。邀余诊视。审其形体消瘦，神疲乏力，呼吸困难，言语低微而嘶哑，吞咽困难，面色白中透青，胃脘痞满，悸动，胁下逆抢心。综合脉证，云：此正合《金匮》“胸痹，心中痞气，气结在胸，胸满，胁下逆抢心”之枳实薤白桂枝汤证也。”因拟：枳实9克，厚朴9克，薤白9克，桂枝6克，瓜蒌15克，茯苓4克。服药4剂，诸证稍减。后因他因而转请另一医生治疗。云：痰火瘀血相结，以化痰散结，活血解毒治之。6剂后，诸证加剧。再邀余诊视，审其脉证仍为枳实薤白桂枝汤证，再拟原方服之。药进8剂，诸证大减。惟久病气血虚衰，再以原方治之恐难奏效，再审其面色已转皓白，舌苔薄白，脉弦而滑。乃拟十味温胆汤加减治少，处方：黄芪15克，当归10克，麦冬10克，五味子10克，半夏10克，枳实10克，竹茹10克，陈皮10克，茯苓10克，甘草10克，菖蒲10克，远志10克，知母10克。药进8剂，非但不效，反见加重。经验教训值得总结，因思仲景有关阳复之论，滑脉者非仅指热，指痰，指积，而且主阳气来复，阳复之脉误认阳热痰盛而以寒凉克伐，致使阳气复衰，故尔加剧，法仍宜温通阳气为治，再以枳实薤白桂枝汤方加茯苓30剂而愈。
寒疝
寒疝一证，《金匮要略》论之甚详，它说：“腹痛，脉弦而紧，弦则卫气不行，即恶寒，紧则不欲食，邪正相搏，即为寒疝。寒疝绕脐痛，若发则白汗出，手足厥冷，其脉沉紧者，大乌头煎主之。”“寒疝腹中痛，及胁痛里急者，当归生姜羊肉汤主之。”“寒疝腹中痛，逆冷，手足不仁，若身疼痛，灸刺诸药不能治，抵当乌头桂枝汤主之。”“心胸中大寒痛，呕不能食，腹中寒，上冲皮起，出见有头足，上下痛而不可触近，大建中汤主之。”“胁下偏痛，发热，其脉紧弦，此寒也，以温药下之，宜大黄附子汤。”《外台》云：“乌头汤，治寒疝腹中绞痛，贼风人攻五脏，拘急不得转侧，发作有时，使人阴缩，手足厥逆。”张景岳云：“寒疝最能作痛，多因触冒寒邪，或犯生冷所致，凡喜暖畏寒，脉弦细，鼻尖手足多冷，大小便无热之类皆是也。”可是有的医者不读经典，但读后世之论，敛寒疝之疾久久不愈。
例如：患者张××，女，成。肠梗阻采用中药治疗痊愈后，8个月来，腹部经常发作性剧痛，严重时脐腹疼痛如绞，包块起伏，小者如桃，大者如拳，不敢触近，烬痛发作半小时后，即突然腹中剧烈鸣响一声而减为隐隐作痛，食纳日减，消瘦乏力，(三个月即由体重65．5千克降至42．5千克)。前医久久治之不效。邀余诊治。余初认为神疲懒言，肢厥脉弦而紧，舌苔薄白，系脾胃虚寒证，欲以附子理中汤治之，患者视后云：前医久用附子理中汤无效；余又欲以温．中散寒．活血止痛法治之，患者又示所用之剂仅有活血温中散寒之方即达25余方，然服后均寸效未见。余深思良久，再问。答云：经常数日便秘不行，腰痛不得俯仰。寻其脉见尺大而弦。乃云：脾肾俱虚，阴阳不足耳。拟方：附子10克，肉桂10克，干姜1O克，党参10克，白术10克，甘草10克，生地10克，山药]O克，肉苁蓉10克，茯苓10克，泽泻10克，丹皮10克。2剂后，腹痛大减，食纳稍增；继进4剂，疼痛消失。又服10剂而愈。
又如：靳××，女，成。右胁绞痛，反复发作三个多月，某院住院检查三个月未确诊，予中、西药治疗亦不见好转。审其面容憔悴，右手捧腹，不断呻吟，食欲不振，舌苔白，舌质暗，脉弦紧。综合脉证，云：寒邪凝结于胁也，非大辛大热不能驱其寒。但寒邪壅郁者，不佐苦寒而难破阴霾，乃拟大黄附子汤合小承气汤温里攻下。处方：大黄3克，附子10克，细辛6克，枳实9克，厚朴9克。药进2剂，痛减六七，再服2剂痛苦全失。然恐再复发，乃以活血通络之膈下逐瘀汤4剂善其后。一医云：某老师说大黄非用9克以上不泻，你用3克即泻下者何也?答曰：寒证、热证不同耳，寒者虽用3克即可下，实热9克恐亦不下。
胃痛
胃脘部的疼痛是一个大题目，因为它是胃炎、溃疡病、胃神经官能症、肝炎、胆道蛔虫症、胆石症、胆囊炎、胰腺炎、肝脓肿、肾结石、心肌梗死、心绞痛以及胰、肝、胆、胃的癌痛等很多疾病的一个症状。中医又把发生在不同部位的疼痛称作不同的名称。例如：剑突下疼痛拒按者称小结胸；整个上腹部的疼痛称胃脘痛，心痛；疼痛剧烈而上冲，且伴有呕吐蛔虫者称蛔厥；胁下疼痛称胁痛。另外，又对其他症状为主，胃脘疼痛为次的称作其他名称，如呕吐为主者称呕吐，黄疸为主者称黄疸，有肿块或肝脾肿大者称癥瘕等等。这些名称繁多，统一在一个名称下进行讨论，看起来是一个非常困难的问题，但只要掌握中医的特点，掌握中医对疾病的基本分析方法，根据中医的基本理论，分清疾病所处的脏腑部位，寒热虚实阴阳，气血痰食等进行分析归纳，得出结论，然后处方治疗即可。
有的同志可能提出问题说：“不同的疾病，例如溃疡病、胃下垂、胰腺炎等表现的证候相同，是否可用同一个方剂?”我的回答是肯定的，完全可以。反之，同一疾病表现的证候不同时应用的治疗方法就不同了。现在谈的胃脘部疼痛的辨证和治疗主要是讲不同疾病表现在胃脘痛时的辨证和治疗，至于同一疾病的辨证和治疗问题，以后再谈。
一、胃脘痛的辨证要点
胃脘疼痛大致可以从疼痛的部位，疼痛发生的时间，与冷热的关系，其他等几个方面去分析。
疼痛的部位：剑突下剧烈疼痛，憋胀，无压痛者，属寒；痛胀拒按者，属痰。胃脘剧烈疼痛，满胀而无压痛者，属寒。疼痛剧烈，无满胀，无压痛，或夜间疼痛经常发作，或气候变化时疼痛发作者，属瘀血。痞满疼痛，有压痛，饮水及饮酒后疼痛加重，阴天时闷痛加重者，属痰饮；胃脘疼痛，有明显的压痛，食后疼痛加重者，属实。胃脘部有空虚感，疲乏无力者，属脾虚。饥饿时疼痛，食后疼痛缓解者，属虚。心悸，疲之尤力，劳累后疼痛反复发作者，属气血虚：胸脘痞满，心烦，生气后疼痛发作者，属气滞。吃辛辣食物和吃热药后疼痛加重，属热。胁下疼痛属肝，其中满而隐痛者属气滞。剧烈疼痛，向上冲者，属肝寒。疼痛而满闷，有压痛者，属气滞血瘀或痰实凝结。胁下及腰部均疼痛，劳累时加重者，属肝肾虚。遇冷或吃冷饮食时疼痛者，属实。胁下持续性疼痛，无满胀者，属瘀血。
疼痛发生的时间：过去无病，突然发生剧烈疼痛者，多属寒、实。慢性、反复发作的疼痛多属虚寒、瘀血、痰积不化。慢性、反复发作，夜间疼痛者，属瘀血、阴虚。食后疼痛发作者，属食积、痰积。饥饿时疼痛发作，吃少量食物后缓解者，属虚。生气后疼痛发作者，属肝气郁结。手术或其他外伤后。持续疼痛者，属瘀血。一遇冷即发作者，属寒。
其他症状：经常腰困痛者，属肾虚。腰痛胁痛同时出现者，属肝肾虚。腹部悸动，疲乏无力，肩背沉重者，属气血俱虚。疲乏无力，下肢轻度浮肿，气短者，属气虚清阳不升。胸胁满闷，全身窜痛，心烦，头晕者，属肝气郁结。胃脘疼痛，痛则腰痛者，属脾肾阳虚。胃脘疼痛，痛则冲胁肋、肩背者，属肝寒、肝经实热。胃脘、脐部均痛者，属脾肾虚寒。胁下痛，痛彻少腹者，属肝，其中痛彻少腹睾丸，尿黄赤者，属肝、小肠、膀胱之湿热；痛彻少腹、腰者，属肝．肾虚；痛则胸满闷，气短者，属肝气、寒痰凝滞。经常夜间口干者，属阴虚、瘀血。有肿物而硬者，属瘀血；较软者，属痰积、食积．大便秘结者，属实；大便经常稀溏者，属脾虚；大便经常有粘液夹杂，属痰积；大便为黑色者，为瘀血。
面色变化：面色白如冷状者，属寒。面带愁容而紧者，属肝郁痰滞。面色萎黄，五心烦热者，属血虚。面色萎黄，而兼淡白者，多属脾虚。面如苍黄者，多属湿热。面色发青者，属瘀血。面色黑者，属肾虚。眼圈黑者，男子属肾虚，女子属血虚气滞。
舌苔舌质：舌苔薄白者，多属寒；舌苔薄黄者，多属热、上热下寒；舌苔黄腻，多属痰热、食积、湿热；舌苔黄厚干燥者，多属实热；舌苔白或黄而中心无苔者，属胃阴虚。舌苔水润者，为寒痰。舌苔黑者，属肾虚。舌质红者，属热。舌质嫩打者．属阴虚。舌紫兰或有瘀斑者，属瘀血。
脉象：常见的有沉、迟、数、虚、滑、涩、大、微、紧、缓、弦、濡、弱、细、结等。其中最常见的有沉、滑、弦、濡、迟等几种。其中沉脉主气郁。迟脉主寒。数脉主热。滑脉主瘀积、食积、脾胃湿热，实热。虚脉主气血俱虚。涩脉主寒凝气滞、血瘀。大脉主气虚，气血虚衰，气阴两虚。紧脉主寒痛：缓脉主脾湿不化、脾虚。弦脉主肝郁、诸痛、寒。若左弦而左缓者主脾虚木乘，左弦右不弦者主肝经自病。濡脉主脾虚、湿盛。弱脉主气血不足。结脉主阴盛气结，气壅痰滞。另外，尺脉大者主肾虚，尺脉甚小者亦主肾虚。寸脉沉，关脉滑者主中焦痰湿郁滞。
1．辨证分析时应注意的几个问题若遇见自述症状、面色、舌苔舌质、脉象都能统一起来，就比较容易诊断。若遇见症状、面色、舌苔舌质、脉象相反则很难措手，此时就需要结合病史去考虑。不过一般说来舌苔、舌质、面色、脉象常常反映的是本质的东西。例如：患者主诉疲乏无力，食欲不振，饥饿时胃脘疼痛，甚至有的说是胃下垂者，可是应用补中益气汤等都一直无效，这吋若能结合脸色、脉象常能查出真实情况，若面色呈忧郁状，脉弦滑，且腹有压痛，则是肝气郁结，痰实不化所致。对于症状叙述是实，而舌、面色、脉象表现虚象者，诊断的方法与上面所谈者基本相同。
2．对虚实寒热夹杂证的处理问题这也是比较难处理的问题。例如：胃脘剧烈疼痛，反复发作，食欲不振，舌苔黄，口苦，大便干等均是实热的表现，但应用攻下的方法疼痛不但小减，反而加重，这时必须结合面色、脉象，若脉弦紧者，是寒实证，而不是实热，此时应子温下法。有的叙述完全是虚寒址，而应用温补又无效，此时应多考虑实的一面。总之，辨证吋必须注意一般中的特殊和特殊中的一般，然后再进行处理。处理时一定要结合面色、舌、脉、症状的整个情况，决不可一听症状就下结论。
3．一定要亲自检查，不可一听主诉即下结论例如：有的主诉胃脘疼痛，饥饿时加重等脾胃虚寒者，但应用健脾温中的药物又不见效，此时医者必须亲自检查，胃脘有没有压痛。若有压痛即为虚中夹实，应在温补中配合消导。这种情况若不亲自检查，常常误过良机。
4．要注意情况的不断变化经常遇见这样一种情况，胃脘疼痛经过用温中健脾的药物治疗后，症状很快缓解，但应用一个阶段后，效果越来越差，后来再用此类方剂不但无效反而加重，这是由于这种疾病是由很多原因形成。开始这一个原因占据主导地位，另一原因占次要地位，经过治疗一个阶段后，主要和次要的原因发生了本质的变化，这时若还应用原来的方法，必定要碰钉子，因此我们必须要根据不断变化了的情况进行处理。
二、胃脘痛的辨证论治
胃脘痛的治疗可以从剑突下、胃脘、胁下等三部分来叙述。
1．剑突下部中医书中一般称为正在心下。常见的有三种情况：
(1)剑突下腹痛，食后不适加重，有明显的压痛，口苦口千，舌苔白或黄腻，脉滑等痰热阻滞者，化痰散结，小陷胸汤加味：瓜蒌30克，半夏9克，黄连9克(无黄连改用黄芩9克)，枳实9克．
From reports in some journals, many scholars consider Xiongbi (Chest Bi Syndrome / Chest Obstruction) to be equivalent to Coronary Heart Disease. However, the *Qianjin Fang* and *Zhouhou Fang* describe Xiongbi symptoms as "chest feeling full and distended, choking sensation like itching, dryness and roughness in the throat, and spitting of saliva"; or "the patient feels like panting but is not panting, like vomiting but is not vomiting, like hiccuping but is not hiccuping, with a profound sense of helplessness and distress throughout the heart." The underlying pathology is often ignored, causing many treatment principles for Xiongbi syndrome discussed in classical texts to fail to receive due development.
For example: Patient Zhang XX, female, adult. After a cold, she suddenly experienced chest fullness and dyspnea, with sweating on the head and body, and rushed to a certain hospital for treatment. She was diagnosed with spontaneous pneumothorax. Due to a lack of empty beds at the hospital, she could not be hospitalized. Traditional Chinese Medicine (TCM) treatment was then sought. After diagnosis, the physician found the case quite difficult and tentatively treated it with methods to diffuse the lungs and calm wheezing, but without effect. I was invited to consult. Upon examination, her symptoms included wheezing with difficulty in continuing breaths, cyanosis of the lips and nail beds, sweating on the head and body, thin white tongue coating, dark tongue body, deep and wiry pulse, and fullness and distension of the chest and abdomen. Synthesizing the pulse and symptoms, I stated: "This is Xiongbi syndrome caused by turbid yin reversing upward, qi stagnating in the upper jiao, and obstruction of chest yang. The treatment should focus on unblocking yang and draining turbidity. Modified Zhishi Zhebai Guizhi Tang: Trichosanthis Fructus 30g, Allii Macrostemonis Bulbus 10g, Cinnamomi Ramulus 10g, Pinelliae Tuber 10g, Magnoliae Officinalis Cortex 10g, Citri Reticulatae Pericarpium 10g, Aurantii Fructus Immaturus 10g, Armeniacae Semen Amarum 10g. Administered day and night, two doses were taken. On the next day's consultation, all symptoms had decreased, so the same prescription was continued, resulting in relief within one day. Later, that physician said: 'If I had known earlier this was Xiongbi, I would have used this method.' He also added: 'Limiting TCM disease names to specific Western medical terms often leaves one unable to use Chinese herbs effectively; therefore, learning TCM must follow the teacher's advice and adhere to TCM perspectives.'"
Another example: Patient Guo XX, female, adult. After successful treatment for abdominal distension and fatigue, she suddenly developed chest and epigastric stuffiness, dysphagia, shortness of breath with slight wheezing, vomiting of phlegm-saliva, loss of appetite, and hoarseness over the past half year. A certain hospital diagnosed vocal cord paralysis and esophageal spasm. Initial treatment with Western medicine and acupuncture was ineffective. Subsequent modifications of Xuansu Daizhe Tang and Siqi Tang also failed. Upon my consultation, she appeared emaciated, listless, and fatigued, with dyspnea, low-pitched and hoarse speech, dysphagia, a pale complexion with a bluish tint, epigastric stuffiness, palpitations, and rebellious qi rushing from the hypochondrium to the heart. Synthesizing the pulse and symptoms, I stated: "This perfectly matches the Zhishi Zhebai Guizhi Tang syndrome described in the *Jinkui Yaolue*: 'Xiongbi, with stifling qi in the heart, qi knotting in the chest, chest fullness, and rebellious qi rushing from the hypochondrium to the heart.'" Therefore, I prescribed: Aurantii Fructus Immaturus 9g, Magnoliae Officinalis Cortex 9g, Allii Macrostemonis Bulbus 9g, Cinnamomi Ramulus 6g, Trichosanthis Fructus 15g, Poria 4g. After four doses, symptoms slightly decreased. Due to other reasons, she transferred to another doctor who claimed the condition was a combination of phlegm-fire and blood stasis, treating it with methods to resolve phlegm, dissipate nodules, invigorate blood, and detoxify. After six doses, symptoms worsened. I was invited again; the pulse and symptoms still matched Zhishi Zhebai Guizhi Tang, so the original formula was repeated. After eight doses, symptoms significantly decreased. However, given the long-standing deficiency of qi and blood, continuing the original formula might not be effective. Re-examining her, her complexion had turned bright white, tongue coating thin white, and pulse wiry and slippery. I prescribed modified Shiwai Wendan Tang: Astragali Radix 15g, Angelicae Sinensis Radix 10g, Ophiopogonis Radix 10g, Schisandrae Fructus 10g, Pinelliae Tuber 10g, Aurantii Fructus Immaturus 10g, Bambusae Folium 10g, Citri Reticulatae Pericarpium 10g, Poria 10g, Glycyrrhizae Radix et Rhizoma 10g, Acori Tatarinowii Rhizoma 10g, Polygalae Radix 10g, Anemarrhenae Rhizoma 10g. After eight doses, there was no improvement, and symptoms worsened. This experience warrants summary. Considering Zhang Zhongjing's theory on the recovery of yang, a slippery pulse does not only indicate heat, phlegm, or accumulation, but also signifies the return of yang qi. Mistaking the pulse of yang recovery for excessive yang-heat and phlegm, and using cold-natured purgatives, led to further depletion of yang, thus worsening the condition. The method should still be to warm and unblock yang. Using Zhishi Zhebai Guizhi Tang plus Poria 30g resulted in a cure after 30 doses.
Hanshan (Cold Hernia)
The syndrome of Hanshan is discussed in detail in the *Jinkui Yaolue*, stating: "Abdominal pain, wiry and tight pulse; wiry indicates defensive qi cannot circulate, leading to aversion to cold; tight indicates desire to eat is absent; struggle between pathogen and healthy qi constitutes Hanshan. Hanshan causes periumbilical pain; if it attacks, white sweat appears, hands and feet become cold, and if the pulse is deep and tight, Da Wutou Decoction is the primary treatment." "Hanshan with abdominal pain and hypochondriac pain with internal tension, Danggui Shengyang Roushou Tang is the primary treatment." "Hanshan with abdominal pain, cold reversal, numbness of hands and feet, body pain, where moxibustion, acupuncture, and various medicines fail, Didang Wutou Guizhi Tang is the primary treatment." "Severe cold pain in the heart and chest, vomiting inability to eat, cold in the abdomen, rising up causing skin to bulge with visible heads and feet, pain above and below that cannot be touched, Dajianzhong Tang is the primary treatment." "Pain on one side of the hypochondrium, fever, tight and wiry pulse, this is cold; purge with warm medicines, Dahuang Fuzi Tang is suitable." The *Waitai Miyao* states: "Wutou Tang treats Hanshan with colicky abdominal pain, evil wind attacking the five zang organs, spasms preventing turning, occurring at times, causing penile retraction and cold reversal of hands and feet." Zhang Jingyue stated: "Hanshan causes severe pain, mostly due to exposure to cold pathogens or consumption of raw/cold foods. Those who prefer warmth and fear cold, with wiry-thin pulses, cold nose tips and extremities, and no heat in urination/defecation are examples." However, some physicians do not read classics but only later theories, leading to chronic, unresolved Hanshan.
For example: Patient Zhang XX, female, adult. After recovery from intestinal obstruction treated with TCM, for 8 months she frequently suffered paroxysmal severe abdominal pain. Severe cases involved twisting pain around the umbilicus, fluctuating masses small as peaches or large as fists, untouchable. Half an hour after pain onset, a sudden loud rumbling in the abdomen would reduce the pain to a dull ache. Appetite decreased daily, leading to emaciation and fatigue (weight dropped from 65.5 kg to 42.5 kg in three months). Previous treatments failed. Upon consultation, I initially thought listlessness, reluctance to speak, cold limbs, wiry-tight pulse, and thin white coating indicated Spleen-Stomach deficiency-cold, intending to use Fuzi Lizhong Tang. The patient showed previous prescriptions of this formula were ineffective. I then considered warming the middle, dispersing cold, and invigorating blood to stop pain. The patient indicated she had taken over 25 formulas for these purposes without effect. After deep reflection and further questioning, she answered: frequent constipation for several days, lower back pain preventing bending. Her pulse revealed a large and wiry chi position. I stated: "Both Spleen and Kidney are deficient, with insufficiency of yin and yang." Prescribed: Aconiti Lateralis Radix Praeparata 10g, Cinnamomi Cortex 10g, Zingiberis Rhizoma 10g, Codonopsis Radix 10g, Atractylodis Macrocephalae Rhizoma 10g, Glycyrrhizae Radix et Rhizoma 10g, Rehmanniae Radix 10g, Dioscoreae Rhizoma 10g, Cistanches Herba 10g, Poria 10g, Alismatis Rhizoma 10g, Moutan Cortex 10g. After two doses, abdominal pain greatly decreased, appetite slightly increased; after four more doses, pain disappeared. Another ten doses cured her.
Another example: Patient Jin XX, female, adult. Right hypochondriac colicky pain recurring for over three months. Hospitalized for three months without diagnosis; TCM and Western medicines showed no improvement. Examination revealed haggard appearance, holding right abdomen, constant groaning, loss of appetite, white tongue coating, dark tongue body, and wiry-tight pulse. Synthesizing pulse and symptoms, I stated: "Cold pathogen congealing in the hypochondrium; only great acrid-hot herbs can dispel this cold. But when cold pathogen is stagnant, without bitter-cold herbs it is hard to break the gloom." Therefore, I prescribed Dahuang Fuzi Tang combined with Xiao Chengqi Tang to warm the interior and purge downward. Rheubarb 3g, Aconiti Lateralis Radix Praeparata 10g, Asari Radix et Rhizoma 6g, Aurantii Fructus Immaturus 9g, Magnoliae Officinalis Cortex 9g. After two doses, pain reduced by 60-70%; after two more doses, pain completely vanished. To prevent recurrence, Gexia Zhuyu Tang (Blood Invigorating and Collateral Unblocking Decoction) was given for four doses to conclude treatment. One physician asked: "A certain teacher says Rheubarb must be used above 9g to cause purging; why did you use 3g and achieve purging?" I replied: "Cold and heat syndromes differ. For cold, even 3g can purge; for excess heat, even 9g might not purge."
Stomach Pain
Pain in the epigastric region is a major topic because it is a symptom of many diseases including gastritis, ulcer disease, gastric neurosis, hepatitis, biliary ascariasis, cholelithiasis, cholecystitis, pancreatitis, liver abscess, renal calculi, myocardial infarction, angina pectoris, and cancer pain of the pancreas, liver, gallbladder, and stomach. TCM also names pain occurring in different locations differently. For example: pain under the xiphoid process refusing pressure is called Xiaojietong (Minor Jie-Xiong); pain across the entire upper abdomen is called Weiwantong (Epigastric Pain) or Xintong (Heart Pain); severe upward-rushing pain accompanied by vomiting roundworms is called Huijue (Roundworm Jue); hypochondriac pain is called Xietong. Additionally, conditions where other symptoms predominate over epigastric pain have other names, such as Outu (Vomiting) if vomiting predominates, Huangdan (Jaundice) if jaundice predominates, Zhengjia (Masses) if there are masses or hepatosplenomegaly, etc. These numerous names make unified discussion seem difficult. However, by mastering TCM characteristics and basic analytical methods, applying TCM basic theory to distinguish organ location, cold/heat, deficiency/excess, yin/yang, qi/blood/phlegm/food, summarizing conclusions, and then prescribing treatment, it can be managed.
Some may ask: "Do different diseases, such as ulcer disease, gastroptosis, and pancreatitis, presenting with the same syndrome pattern, allow the use of the same formula?" My answer is affirmative, absolutely yes. Conversely, when the same disease presents with different syndrome patterns, the applied treatment methods differ. The current discussion on epigastric pain focuses on differentiation and treatment when different diseases manifest as epigastric pain; the issue of differentiation and treatment for the same disease will be discussed later.
I. Key Points in Differentiating Epigastric Pain
Epigastric pain can generally be analyzed from aspects of pain location, timing of onset, relationship with cold/heat, and other factors.
Location of Pain: Severe pain under the xiphoid process with bloating but no tenderness belongs to Cold; pain and bloathing refusing pressure belongs to Phlegm. Severe epigastric pain with fullness/distension but no tenderness belongs to Cold. Severe pain without fullness/distension or tenderness, or pain frequently occurring at night or during climate changes, belongs to Blood Stasis. Stuffiness and pain with tenderness, worsening after drinking water/alcohol, and heavy dull pain on cloudy days belong to Phlegm-Fluid; epigastric pain with obvious tenderness, worsening after eating, belongs to Excess. Empty sensation and fatigue in the epigastric region belong to Spleen Deficiency. Pain when hungry, relieved after eating, belongs to Deficiency. Palpitations, extreme fatigue, and recurrent pain after exertion belong to Qi-Blood Deficiency; chest and epigastric stuffiness, irritability, and pain triggered by anger belong to Qi Stagnation. Worsening after spicy food or hot medicines belongs to Heat. Hypochondriac pain belongs to Liver; fullness with dull pain within belongs to Qi Stagnation. Severe upward-rushing pain belongs to Liver Cold. Pain with fullness and tenderness belongs to Qi Stagnation and Blood Stasis or Phlegm-Excess Congestion. Pain in both hypochondrium and waist, worsening with exertion, belongs to Liver-Kidney Deficiency. Pain triggered by cold or cold diet belongs to Excess. Continuous hypochondriac pain without fullness belongs to Blood Stasis.
Timing of Pain: Sudden severe pain in previously healthy individuals mostly belongs to Cold or Excess. Chronic, recurrent pain mostly belongs to Deficiency-Cold, Blood Stasis, or unresolved Phlegm Accumulation. Chronic, recurrent pain occurring at night belongs to Blood Stasis or Yin Deficiency. Pain occurring after eating belongs to Food Accumulation or Phlegm Accumulation. Pain when hungry, relieved by small amounts of food, belongs to Deficiency. Pain triggered by anger belongs to Liver Qi Depression. Persistent pain after surgery or trauma belongs to Blood Stasis. Pain triggered immediately by cold belongs to Cold.
Other Symptoms: Frequent soreness/pain in the lower back belongs to Kidney Deficiency. Simultaneous lower back and hypochondriac pain belongs to Liver-Kidney Deficiency. Abdominal palpitations, fatigue, and heavy shoulders/back belong to Qi-Blood Dual Deficiency. Fatigue, mild lower limb edema, and shortness of breath belong to Qi Deficiency with failure of clear yang to ascend. Chest and hypochondriac fullness/stuffiness, wandering body pain, irritability, and dizziness belong to Liver Qi Depression. Epigastric pain with concurrent lower back pain belongs to Spleen-Kidney Yang Deficiency. Epigastric pain radiating to hypochondrium, ribs, and shoulder/back belongs to Liver Cold or Liver Meridian Excess-Heat. Pain in both epigastrium and umbilicus belongs to Spleen-Kidney Deficiency-Cold. Hypochondriac pain radiating to lower abdomen belongs to Liver; if radiating to testicles with yellow-red urine, it belongs to Damp-Heat in Liver, Small Intestine, and Bladder; if radiating to lower abdomen and waist, it belongs to Liver-Kidney Deficiency; if accompanied by chest fullness and shortness of breath, it belongs to Liver Qi and Cold-Phlegm Stagnation. Frequent nighttime dry mouth belongs to Yin Deficiency or Blood Stasis. Hard masses belong to Blood Stasis; softer masses belong to Phlegm or Food Accumulation. Constipation belongs to Excess; frequent loose stools belong to Spleen Deficiency; stools with mucus belong to Phlegm Accumulation; black stools belong to Blood Stasis.
Complexion Changes: Pale face resembling cold state belongs to Cold. Face showing sorrowful expression and tightness belongs to Liver Depression and Phlegm Stagnation. Sallow complexion with five-center heat belongs to Blood Deficiency. Sallow complexion with pale tones mostly belongs to Spleen Deficiency. Yellowish-green complexion mostly belongs to Damp-Heat. Blue-green complexion belongs to Blood Stasis. Black complexion belongs to Kidney Deficiency. Dark eye circles: in men, Kidney Deficiency; in women, Blood Deficiency and Qi Stagnation.
Tongue Coating and Body: Thin white coating mostly belongs to Cold; thin yellow coating mostly belongs to Heat, Upper Heat/Lower Cold; yellow greasy coating mostly belongs to Phlegm-Heat, Food Accumulation, or Damp-Heat; yellow thick dry coating mostly belongs to Excess-Heat; white or yellow coating with no center coating belongs to Stomach Yin Deficiency. Moist/watery coating indicates Cold-Phlegm. Black coating belongs to Kidney Deficiency. Red tongue body belongs to Heat. Tender tongue body belongs to Yin Deficiency. Purple-blue tongue or with ecchymosis belongs to Blood Stasis.
Pulse Qualities: Common ones include Deep, Slow, Rapid, Deficient, Slippery, Choppy, Large, Micro, Tight, Moderate, Wiry, Soggy, Weak, Fine, Knotted, etc. Most common are Deep, Slippery, Wiry, Soggy, and Slow. Deep pulse governs Qi Depression. Slow pulse governs Cold. Rapid pulse governs Heat. Slippery pulse governs Blood Stasis/Accumulation, Food Accumulation, Spleen-Stomach Damp-Heat, and Excess-Heat. Deficient pulse governs Qi-Blood Dual Deficiency. Choppy pulse governs Cold Congestion with Qi Stagnation and Blood Stasis. Large pulse governs Qi Deficiency, Qi-Blood Exhaustion, and Qi-Yin Dual Deficiency. Tight pulse governs Cold Pain. Moderate pulse governs Spleen Dampness non-transformation and Spleen Deficiency. Wiry pulse governs Liver Depression, various pains, and Cold. Left wiry and left moderate indicates Spleen Deficiency with Liver Overacting; left wiry and right non-wiry indicates Liver Meridian self-disease. Soggy pulse governs Spleen Deficiency and Dampness Excess. Weak pulse governs Insufficient Qi and Blood. Knotted pulse governs Yin Excess with Qi Knotting and Qi Stagnation with Phlegm Stagnation. Additionally, large chi pulse governs Kidney Deficiency; very small chi pulse also governs Kidney Deficiency. Deep cun and slippery guan pulses govern Middle Jiao Phlegm-Damp Stagnation.
1. Issues to Note in Differentiation Analysis: If reported symptoms, complexion, tongue coating/body, and pulse all unify, diagnosis is easier. If they contradict, it is difficult to proceed, requiring consideration of medical history. Generally, tongue, complexion, and pulse reflect the essence. For example: A patient complains of fatigue, loss of appetite, and epigastric pain when hungry, possibly claiming gastroptosis, but Bu Zhong Yi Qi Tang is ineffective. Combining complexion and pulse may reveal the truth: if the face shows depression, pulse is wiry-slippery, and abdomen has tenderness, it is caused by Liver Qi Depression and unresolved Phlegm-Excess. For cases where symptoms describe Excess but tongue/complexion/pulse show Deficiency, the diagnostic method is basically the same as above.
2. Handling Mixed Deficiency-Excess and Cold-Heat Syndromes: This is also difficult. For example: Severe recurrent epigastric pain, loss of appetite, yellow coating, bitter taste, dry stool indicate Excess-Heat. However, if purgative methods reduce pain only slightly or worsen it, one must combine complexion and pulse. If the pulse is wiry-tight, it is Cold-Excess, not Excess-Heat, and Warm-Purgative method should be used. If descriptions are purely Deficiency-Cold but warm-tonifying methods fail, one should consider the Excess aspect more. In summary, differentiation must note the special within the general and the general within the special before handling. Treatment must combine the whole situation of complexion, tongue, pulse, and symptoms; never jump to conclusions based solely on symptoms.
3. Must Personally Examine, Do Not Conclude Based Solely on Chief Complaint: For example, some complain of epigastric pain worsening when hungry, indicating Spleen-Stomach Deficiency-Cold, but Spleen-fortifying and Middle-warming drugs are ineffective. The physician must personally examine if there is epigastric tenderness. If present, it is Deficiency mixed with Excess, requiring digestion-resolving methods combined with warm-tonification. Without personal examination, opportunities are often missed.
4. Pay Attention to Constant Changes: Often, epigastric pain improves quickly with Middle-warming and Spleen-fortifying drugs, but efficacy decreases over time, and later such formulas cause worsening. This is because the disease forms from multiple causes. Initially, one cause dominates, others are secondary. After treatment, the nature of primary and secondary causes changes essentially. Continuing the original method will fail. Therefore, we must handle based on changing circumstances.
II. Differentiation and Treatment of Epigastric Pain
Treatment of epigastric pain can be narrated in three parts: under the xiphoid process, epigastric region, and hypochondrium.
1. Under the Xiphoid Process: Generally referred to as "Xin Xia" (Below the Heart) in TCM books. There are three common situations:
(1) Abdominal pain under the xiphoid process, discomfort worsening after eating, obvious tenderness, bitter taste, dry mouth, white or yellow greasy tongue coating, slippery pulse, etc., indicating Phlegm-Heat obstruction: Resolve Phlegm and dissipate nodules. Modified Xiao Xianxiong Tang: Trichosanthis Fructus 30g, Pinelliae Tuber 9g, Coptidis Rhizoma 9g (use Scutellariae Radix 9g if Coptis is unavailable), Aurantii Fructus Immaturus 9g.