痞满致病，同于结胸，均是表邪下早变症，均是表邪内陷心胸。惟以痛者为结胸，但满不痛
者为痞满。症有痛不痛之分，治有陷胸泻心轻重之别。按诸泻心汤，皆寒药以攻痞。其一加
附子者，以辛热监制寒药而攻热结，非温里寒也。另有不因误下，自己发热，胸胁满闷，非
结胸痞满，此太阳少阳两经表邪合病之支结症。仲景用柴胡桂枝汤，又有表邪传入少阳，半
表半里，心下肋胁痞满，仲景用小柴胡汤，陶氏以枳桔汤合治之。重者以小柴胡汤合小陷胸汤。
伤寒汗出解之后，胃中不和，心下痞硬，干呕噫食臭，胁下有水气，腹中雷鸣下利者，生姜
泻心汤主之。
不因汗下汗出表解后，胃中不和，心下痞硬，干呕噫食臭，此胁下有水饮，故腹中雷鸣而
下利，用生姜泻心汤。
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。
先发汗，则表邪解，今先大下后发汗，恐表未解；况心下痞满，尚有恶寒，表症仍在，未
可攻痞，先用桂枝汤解表，后用大黄黄连泻心汤。
脉浮而紧，而复下之，紧反入里，则作痞，按之自濡，但气痞耳。心下痞，按之濡，其脉关
上浮者，大黄黄连泻心汤主之。心下痞而复恶寒汗出者，附子泻心汤主之。
上章明心下痞见恶寒，乃是表邪。此章明心下痞见恶寒，因汗出，故非表邪。脉浮紧，表
症；若误下，则紧脉之寒邪入里作痞。按之濡，则内无痰饮食积，但是气痞。其脉关上
浮，属阳邪，故用大黄黄连以泄痞热。若痞而见恶寒汗出，则是邪热得寒药凝结，不得发
越而恶寒，故以泻心汤寒药中，加附子开导。
本以下之，故心下痞，与泻心汤。痞不解，其人渴而口燥烦，小便不利者，五苓散主之。
误下心下痞满，应与泻心汤。今痞不解，其人反口渴燥烦，小便不利，此太阳之邪，不特
痞结心下，复下遗而结膀胱，故用五苓散。
伤寒发热，汗出不解，心下痞硬，呕吐而下利者，大柴胡汤主之。
伤寒发热，汗出不解，太阳中风表症，汗出，心下痞硬，下利，又阳明里症。因呕吐，故
不用承气而双解表里。
伤寒发汗，若吐若下，解后，心下痞硬，噫气不除者，旋复代赭石汤主之。
未汗吐下解后，见心下痞硬，噫气不除，则痰气胃实，当用陷胸泻心汤。今汗吐下后，故
用养正涤痰扶元下坠之药。
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，汗出不恶寒者，此里未和也，宜十枣汤。
外有太阳中风，内有下利呕逆，若表邪已解，方可攻。若 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，里有痰饮结聚作痛，故用此方。
生姜泻心汤
生姜 半夏 甘草 人参 黄芩 黄连 干姜 大枣
泻心汤五方，三方皆用干姜、半夏、黄连、黄芩，两热两寒，豁痰清热。此方因汗出表
解，胃阳虚不能敷布水饮，腹中雷鸣而下利，故用生姜佐干姜和胃阳，此以痰热方中，化
出逐寒饮之法。
大黄黄连泻心汤
大黄 黄连
痞满症泻心诸方，皆用冷热各半之药。此方除去干姜、半夏辛温，惟用大黄、黄连，此以
痰热方中，化出单清里热之法。
附子泻心汤
大黄 黄连 黄芩 附子
此即前方加黄芩，以合三黄大寒之剂；加熟附子辛热，以散其凝结。此以清热方中，化出
辛温向导之法。
半夏泻心汤
半夏 黄芩 干姜 人参 甘草 黄连 大枣
泻心汤皆用半夏，而独以此方命名者，因痞满呕吐皆是痰涎作祸，故即以此汤，重加半
夏。此以泻心方中，化出重治痰涎之法。
甘草泻心汤
甘草 黄芩 干姜 半夏 黄连 大枣
此方以泻心汤，重加甘草，示明误下损中，心下痞硬，反忌甘温作胀者。细玩泻心诸方，
示后人练方治病，惟在分两上轻重加减。
大枣汤
芫花 甘遂 大戟 大枣
心下痞硬，干呕胁痛，要分表邪已解未解。全见表症者，仲景以小青龙汤，发表邪，散水
饮。邪在半表半里，则用小柴胡汤和解。若表邪尽散，里有水饮，则用十枣汤。
旋复代赭石汤
旋复花 甘草 人参 代赭石 生姜 半夏 大枣
汗吐下后，表里之邪已解，但见心下痞满，噫气无凝结作痛实象，乃是胃虚不能运化，停
痰结聚不下，故用此方。
柴胡桂枝汤
柴胡 桂枝 黄芩 芍药 甘草 大枣 半夏 生姜
支结有二条∶若少阳阳明见症，以小柴胡合小陷胸汤；太阳少阳见症，以小柴胡合桂枝
汤。一以痰热结于心胸，故合小陷胸；一以表邪内传心胸，故合桂枝、芍药。
枳桔汤
枳壳 桔梗
仲景以枳术汤，治脾虚食滞之痞；以泻心诸汤，治伤寒热病之痞，今立枳桔汤，以豁胸前
气痞，兼治胸胁支结。
痞满的致病原因，与结胸相同，都是由于表邪被过早使用下法导致的变证，都是表邪内陷于心胸部位。只是以疼痛为主的称为结胸，仅感到胀满而不疼痛的称为痞满。症状上有痛与不痛的区别，治疗上有陷胸汤与泻心汤轻重缓急的不同。考察各种泻心汤，都是用寒性药物来攻逐痞结。其中有一方加入附子，是用辛热之药来制约寒性药物从而攻逐热结，并非为了温补里寒。另有不因误用下法，而是自己发热，胸胁部胀满闷塞，这既不是结胸也不是痞满，这是太阳经和少阳经两经表邪合病所致的支结症。张仲景使用柴胡桂枝汤；又有表邪传入少阳，处于半表半里之间，导致心下及肋胁部痞满，张仲景使用小柴胡汤，陶氏则用枳桔汤合并治疗。病情重的用小柴胡汤合小陷胸汤。
伤寒经过发汗后表证已解，但胃中不和，心下痞硬，干呕并伴有食物腐臭的气味，胁下有停饮，肠鸣音亢进且腹泻的，用生姜泻心汤主治。
不是因为误用汗法或下法导致汗出表解后，出现胃中不和，心下痞硬，干呕并伴有食物腐臭气味，这是因为胁下有水饮停留，所以肠鸣音亢进而腹泻，使用生姜泻心汤。
伤寒经过剧烈攻下后，又再次发汗，出现心下痞满，并且恶寒的，说明表证尚未解除，不可攻逐痞满，应当先解除表证，表证解除后才能攻逐痞满。解除表证适宜用桂枝汤；攻逐痞满适宜用大黄黄连泻心汤。
如果先发汗，则表邪解除；现在是先剧烈攻下后再发汗，恐怕表邪未解；况且心下痞满，还有恶寒症状，表证仍在，不可攻逐痞满，先用桂枝汤解表，后用大黄黄连泻心汤。
脉象浮而紧，却又误用下法，紧脉反而入里，就会形成痞证，按之柔软，这只是气痞而已。心下痞满，按之柔软，其脉关部浮起的，用大黄黄连泻心汤主治。心下痞满而又恶寒、出汗的，用附子泻心汤主治。
上一章阐明心下痞伴见恶寒，那是表邪所致。这一章阐明心下痞伴见恶寒，是因为出汗，所以不是表邪。脉浮紧是表证；如果误用下法，则紧脉所主的寒邪入里形成痞证。按之濡软，说明内部没有痰饮、食积，只是气机阻滞形成的痞证。其脉关上浮，属于阳邪，所以用大黄、黄连来泄除痞热。如果痞证兼见恶寒、出汗，则是邪热被寒药凝结，不能发散而导致恶寒，所以在泻心汤的寒药中加入附子以开导散结。
本来因为误用下法，所以心下痞满，给予泻心汤。痞满不解，其人口渴且口燥心烦，小便不利的，用五苓散主治。
误用下法导致心下痞满，本应给予泻心汤。现在痞满不解，其人反而口渴、燥烦，小便不利，这是太阳经的邪气，不仅结聚在心下，还向下遗留结于膀胱，所以用五苓散。
伤寒发热，汗出后热不退，心下痞硬，呕吐且腹泻的，用大柴胡汤主治。
伤寒发热，汗出后热不退，这是太阳中风表证，汗出，心下痞硬，腹泻，又兼有阳明里证。因为伴有呕吐，所以不用承气汤，而是双解表里。
伤寒经过发汗，或者吐法，或者下法，病邪解除后，出现心下痞硬，嗳气不止的，用旋复代赭石汤主治。
在未进行汗、吐、下治疗前，若见心下痞硬，嗳气不止，则是痰气胃实，应当用陷胸汤或泻心汤。现在是经过汗、吐、下治疗后，所以用扶正、涤痰、助元、降逆的药物。
太阳中风，伴有腹泻、呕吐逆气，表证已解的，才可以攻逐。其人汗出，发作有定时，头痛，心下痞硬胀满，牵引胁下疼痛，干呕、短气，汗出且不恶寒的，这是里气未和，宜用十枣汤。
外有太阳中风症状，内有腹泻、呕吐逆气，如果表邪已解，方可攻逐。若见汗出，发作有时，头痛，心下痞硬胀满，牵引胁下疼痛，干呕、短气，汗出且不恶寒，这是表证已解，里有痰饮结聚作痛，所以用此方。
泻心汤的五方中，三方都使用干姜、半夏、黄连、黄芩，两热两寒，豁痰清热。此方因为汗出表解，胃阳虚不能布散水饮，腹中雷鸣而下利，所以用生姜辅助干姜调和胃阳，这是在痰热方剂中，化裁出的逐除寒饮的方法。
痞满症治疗所用的泻心诸方，都用冷热各半的药物。此方去除了干姜、半夏的辛温之性，只用大黄、黄连，这是在痰热方剂中，化裁出的单纯清泄里热的方法。
这就是前方加上黄芩，以符合三黄大寒的制剂；加上熟附子的辛热之性，以散除凝结。这是在清热方剂中，化裁出的辛温引导的方法。
泻心汤都使用半夏，唯独以此方命名，是因为痞满、呕吐都是痰涎作祟，所以就用此汤，重加半夏。这是在泻心方剂中，化裁出的重点治疗痰涎的方法。
此方在泻心汤基础上重加甘草，明示因误下损伤中气，心下痞硬，反而忌讳甘温导致胀满。仔细研读泻心诸方，是告诉后人练习方剂治病，关键在于分量的轻重加减。
心下痞硬，干呕胁痛，要分辨表邪是否已解。完全表现为表证的，张仲景用小青龙汤，发表邪，散水饮。邪在半表半里，则用小柴胡汤和解。如果表邪尽散，里有水饮，则用十枣汤。
经过汗、吐、下治疗后，表里之邪已解，只见到心下痞满，嗳气无凝结作痛的实证表现，这是胃虚不能运化，停痰结聚不下，所以用此方。
支结有两种情况：如果是少阳阳明见症，用小柴胡汤合小陷胸汤；太阳少阳见症，用小柴胡汤合桂枝汤。一是痰热结于心胸，所以合用小陷胸汤；一是表邪内传心胸，所以合用桂枝、芍药。
张仲景用枳术汤治疗脾虚食滞引起的痞满；用泻心诸汤治疗伤寒热病引起的痞满，现在创立枳桔汤，用来豁除胸前气痞，兼治胸胁支结。
The pathogenesis of Pi Man (epigastric fullness and stuffiness) is the same as that of Jie Xiong (chest binding), both being complications resulting from premature purgation of exterior pathogens, where exterior pathogens sink inward into the heart and chest. The distinction lies in that pain characterizes Jie Xiong, while fullness without pain characterizes Pi Man. There is a difference in symptoms between painful and non-painful conditions, and treatments differ in severity between Xia Xiong Tang (Chest-Expelling Decoction) and Xie Xin Tang (Drain the Epigastrium Decoctions). Examining the various Xie Xin Tangs, they all use cold-natured herbs to attack the pi accumulation. One formula adds Fuzi (Prepared Aconite Root Lateralis), using acrid-hot herbs to control the cold herbs and attack heat accumulation, not to warm interior cold. Another condition arises not from mistaken purgation but from spontaneous fever, chest and hypochondriac fullness and oppression; this is neither Jie Xiong nor Pi Man, but a Zhi Jie syndrome (branch-binding syndrome) caused by the combined disease of exterior pathogens in the Taiyang (Greater Yang) and Shaoyang (Lesser Yang) meridians. Zhang Zhongjing uses Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction). When exterior pathogens transmit to Shaoyang, occupying the half-exterior half-interior region, causing epigastric and hypochondriac Pi Man, Zhang Zhongjing uses Xiao Chaihu Tang (Minor Bupleurum Decoction), while Tao Shi treats it with Zhiju Tang (Citrus Aurantium and Platycodon Decoction). For severe cases, Xiao Chaihu Tang is combined with Xiao Xianxiong Tang (Minor Chest-Binding Decoction).
After Taiyang disease resolves through sweating, if the stomach is disharmonious, presenting with hard epigastric fullness, dry retching with belching of food odor, fluid retention under the hypochondria, borborygmus, and diarrhea, Shengjiang Xiexin Tang (Fresh Ginger Drain-the-Epigastrium Decoction) is indicated.
If after sweating or purgation leads to surface resolution, one presents with stomach disharmony, hard epigastric fullness, dry retching with belching of food odor, this is due to water-fluid retention under the hypochondria, causing borborygmus and diarrhea; Shengjiang Xiexin Tang is used.
After severe purgation in Taiyang disease followed by sweating, if epigastric fullness occurs accompanied by aversion to cold, the exterior is not yet resolved. One must not attack the pi; first resolve the exterior. Only after the exterior is resolved can the pi be attacked. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is suitable; to attack the pi, Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Drain-the-Epigastrium Decoction) is suitable.
If sweating is performed first, the exterior pathogen is resolved. Now, since severe purgation was done first followed by sweating, the exterior may not be resolved. Moreover, with epigastric fullness and aversion to cold, the exterior syndrome persists, so attacking the pi is contraindicated. First use Guizhi Tang to resolve the exterior, then use Dahuang Huanglian Xiexin Tang.
A pulse that is floating and tight, subjected to mistaken purgation, causes the tight quality to enter the interior, forming pi. Palpation reveals softness, indicating merely Qi pi (Qi stagnation). For epigastric fullness that is soft upon palpation, with a floating pulse at the Guan position, Dahuang Huanglian Xiexin Tang is indicated. For epigastric fullness accompanied by aversion to cold and sweating, Fuzi Xiexin Tang (Aconite Drain-the-Epigastrium Decoction) is indicated.
The previous chapter clarified that epigastric pi with aversion to cold indicates an exterior pathogen. This chapter clarifies that epigastric pi with aversion to cold, due to sweating, is not an exterior pathogen. A floating-tight pulse indicates an exterior syndrome; if mistakenly purged, the cold pathogen associated with the tight pulse enters the interior to form pi. Softness upon palpation indicates no phlegm-fluid or food retention internally, only Qi pi. A floating pulse at the Guan position belongs to Yang pathogen, so Dahuang (Rhubarb Root and Rhizome) and Huanglian (Coptis Rhizome) are used to drain pi-heat. If pi is accompanied by aversion to cold and sweating, it means the pathogenic heat has been congealed by cold herbs and cannot vent, causing aversion to cold; thus, Fuzi is added to the cold herbs of Xiexin Tang to guide and disperse.
Originally due to mistaken purgation, epigastric pi occurred, and Xie Xin Tang was given. If the pi does not resolve, and the patient presents with thirst, dry mouth, irritability, and difficult urination, Wuling San (Five-Ingredient Powder with Poria) is indicated.
Mistaken purgation leading to epigastric fullness should have been treated with Xie Xin Tang. Now, if the pi does not resolve, and the patient instead presents with thirst, dryness, irritability, and difficult urination, this indicates that the Taiyang pathogen has not only bound in the epigastrium but also descended to bind in the Bladder; thus, Wuling San is used.
In Taiyang disease, if fever persists despite sweating, accompanied by hard epigastric fullness, vomiting, and diarrhea, Da Chaihu Tang (Major Bupleurum Decoction) is indicated.
In Taiyang disease, if fever persists despite sweating, this represents a Taiyang Wind-strike exterior syndrome with sweating, hard epigastric fullness, and diarrhea, combined with Yangming interior syndrome. Due to vomiting, Chengqi Tang formulas are avoided; instead, both exterior and interior are resolved simultaneously.
After Taiyang disease is treated with sweating, emesis, or purgation, and the pathogen is resolved, if hard epigastric fullness and persistent belching occur, Xuanshen Dahezeshi Tang (Imperata and Hematitum Decoction) is indicated.
Before sweating, emesis, or purgation, if hard epigastric fullness and persistent belching are seen, this indicates phlegm-Qi and Stomach excess, requiring Xiaoxiong Tang or Xiexin Tang. After these treatments, however, tonifying healthy Qi, eliminating phlegm, supporting Yuan Qi, and descending rebellious Qi are required.
In Taiyang Wind-strike, if diarrhea and vomiting are present, treatment to attack can proceed only after the exterior is resolved. If the patient sweats, with periodic attacks, headache, hard epigastric fullness and distension, pain radiating to the hypochondria, dry retching, shortness of breath, sweating without aversion to cold, this indicates interior disharmony; Shizao Tang (Ten-Date Decoction) is appropriate.
With external Taiyang Wind-strike symptoms and internal diarrhea and vomiting, if the exterior pathogen is resolved, attack can proceed. If sweating occurs periodically, with headache, hard epigastric fullness and distension, pain radiating to the hypochondria, dry retching, shortness of breath, sweating without aversion to cold, this indicates the exterior is resolved, and there is phlegm-fluid accumulation internally causing pain; thus, this formula is used.
Shengjiang Xiexin Tang: Shengjiang (Fresh Ginger Rhizome), Banxia (Pinellia Tuber), Gancao (Licorice Root), Renshen (Ginseng Root), Huangqin (Scutellaria Root), Huanglian (Coptis Rhizome), Jiangjiang (Dried Ginger Rhizome), Dazao (Jujube Fruit).
Among the five Xiexin Tangs, three use Jiangjiang, Banxia, Huanglian, and Huangqin, combining two hot and two cold herbs to resolve phlegm and clear heat. This formula, because sweating has resolved the exterior and Stomach Yang deficiency fails to distribute fluids, causing borborygmus and diarrhea, uses Shengjiang to assist Jiangjiang in harmonizing Stomach Yang. This derives a method for expelling cold-fluid from a phlegm-heat formula.
Dahuang Huanglian Xiexin Tang: Dahuang (Rhubarb Root and Rhizome), Huanglian (Coptis Rhizome).
The Xiexin formulas for Pi Man all use half hot and half cold herbs. This formula removes the acrid-warm Jiangjiang and Banxia, using only Dahuang and Huanglian. This derives a method for purely clearing interior heat from a phlegm-heat formula.
Fuzi Xiexin Tang: Dahuang (Rhubarb Root and Rhizome), Huanglian (Coptis Rhizome), Huangqin (Scutellaria Root), Fuzi (Prepared Aconite Root Lateralis).
This is the previous formula plus Huangqin to form a major-cold preparation of the "Three Yellows"; plus Shu Fuzi (Prepared Aconite Root Lateralis) for its acrid-hot nature to disperse congealment. This derives an acrid-warm guiding method from a heat-clearing formula.
Banxia Xiexin Tang: Banxia (Pinellia Tuber), Huangqin (Scutellaria Root), Jiangjiang (Dried Ginger Rhizome), Renshen (Ginseng Root), Gancao (Licorice Root), Huanglian (Coptis Rhizome), Dazao (Jujube Fruit).
All Xiexin Tangs use Banxia, but this one is named specifically because Pi Man and vomiting are caused by phlegm-saliva; thus, Banxia is heavily increased in this decoction. This derives a method for heavily treating phlegm-saliva from the Xiexin formulas.
Gancao Xiexin Tang: Gancao (Licorice Root), Huangqin (Scutellaria Root), Jiangjiang (Dried Ginger Rhizome), Banxia (Pinellia Tuber), Huanglian (Coptis Rhizome), Dazao (Jujube Fruit).
This formula heavily increases Gancao in the Xiexin Tang to clarify that mistaken purgation damages the Middle, causing hard epigastric pi, where sweet-warm herbs that cause distension are contraindicated. Carefully studying the Xiexin formulas shows that mastering formulas for treating diseases relies on adjusting dosages.
Shizao Tang (Ten-Date Decoction): Yuanhua (Genkwa Flower), Gansui (Kansui Root), Daji (Euphorbia Root), Dazao (Jujube Fruit).
For hard epigastric fullness, dry retching, and hypochondriac pain, one must distinguish whether the exterior pathogen is resolved. If fully exterior symptoms are present, Zhang Zhongjing uses Xiao Qinglong Tang (Minor Blue-Green Dragon Decoction) to release the exterior and scatter fluid-retention. If the pathogen is in the half-exterior half-interior, Xiao Chaihu Tang is used for harmonization. If the exterior pathogen is completely dispersed and there is fluid-retention internally, Shizao Tang is used.
Xuanshen Dahezeshi Tang: Xuanshenhua (Stemona Flower), Gancao (Licorice Root), Renshen (Ginseng Root), Dahezeshi (Hematitum), Shengjiang (Fresh Ginger Rhizome), Banxia (Pinellia Tuber), Dazao (Jujube Fruit).
After sweating, emesis, and purgation, when exterior and interior pathogens are resolved, but hard epigastric fullness and belching persist without signs of congealment or pain-excess, this indicates Stomach deficiency failing to transform and transport, with retained phlegm accumulating and failing to descend; thus, this formula is used.
Chaihu Guizhi Tang: Chaihu (Bupleurum Root), Guizhi (Cinnamon Twig), Huangqin (Scutellaria Root), Shaoyao (Peony Root), Gancao (Licorice Root), Dazao (Jujube Fruit), Banxia (Pinellia Tuber), Shengjiang (Fresh Ginger Rhizome).
There are two types of Zhi Jie: If Shaoyang-Yangming symptoms appear, combine Xiao Chaihu Tang with Xiao Xianxiong Tang; if Taiyang-Shaoyang symptoms appear, combine Xiao Chaihu Tang with Guizhi Tang. One addresses phlegm-heat binding in the heart and chest, hence combining with Xiao Xianxiong Tang; the other addresses exterior pathogens transmitting inward to the heart and chest, hence combining with Guizhi and Shaoyao.
Zhiju Tang: Zhike (Citrus Aurantium Peel), Jiegeng (Platycodon Root).
Zhang Zhongjing used Zhizhu Tang (Citrus and Atractylodes Decoction) to treat pi from Spleen deficiency and food stagnation; and used various Xiexin Tangs to treat pi from Taiyang heat diseases. Now, Zhiju Tang is established to resolve anterior chest Qi pi and concurrently treat chest-hypochondriac branch-binding.