痞与结胸。同为硬满之症。当以痛为辨。满而硬痛为结胸。为实热。宜陷胸法治
之。满而不痛为痞满。为虚热。宜用泻心法治之。然结胸未甚。亦以泻心法治之
足矣。盖实者为结胸。虚者为痞满。两症兼参可也。
邵评∶痛者为结胸。不痛者为痞。痞属虚而无形。结胸为实而有形也。
论曰。伤寒五六日。呕而发热。柴胡症具。而以他药下之。但满而不痛。此为痞。宜半夏泻心汤。
邵评∶此少阳病误下而成痞结之症也。呕而发热。小柴胡症也。设有下症。亦宜
大柴胡。而以他药下之。误矣。
此因误下。寒反入里。阻君火之热化。而结无形气痞。故用干姜散寒。芩连泄热。
半夏散结止呕。参草补胃气。以助半夏开寒结。而痞自解。
伤寒中风。医反下之。其人下利日数行。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。此非热结。但以胃中虚。客气
上逆。故使硬也。甘草泻心汤主之。
邵评∶邪盛于表。医误下之。而下利腹鸣。完谷不化。肠胃之里虚可知矣。心下痞
硬而满。干呕而心烦不得安。是表间邪热。因误下而内陷于心间。上攻而复下
注。非中气之空虚。何致致邪气之淫溢若此。则痞为虚痞。硬为虚硬。满为虚满
也。明矣。医者不识是虚。以为结热未尽。而复误下之。是已虚而益虚也。虚则胃
不化而邪上逆。痞满更加矣。故复申明。上文之症曰。此非结热。以胃中虚。客气上逆。故使硬也。
此痞因胃虚水气上逆。火气不得下降。结而为痞。故以甘枣和胃之阴。半夏启
胃之阳。坐镇中州。不使下焦客气上逆。仍用芩连以泻已逆痞气。
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。
邵评∶大下复汗。正虚邪入而心下痞。似宜治痞。然外有恶寒之症。邪虽入里。而
表犹未解。内外俱病。不可轻攻其痞。当先以桂枝汤解其表。后用大黄黄连泻
心汤攻其痞。不然。恐痞不解。而表邪复入于里。病益增重耳。此先表而后里之
治法。至大黄泻心汤。治君火亢甚。不得下交于阴。而成痞也。
此君火亢甚。不得下交于阴而成痞。故药不煎而泡。欲其轻扬清淡以涤之。用其气。不用其味也。
心下痞。大便硬。心烦不得眠。恶寒汗出者。附子泻心汤主之。
邵评∶痞而便硬。心烦不眠。里之邪热有余也。而复恶寒汗出者。表阳虚而正不
足也。故用三黄以泻热。加附子以复其阳气也。虽然。此邪热有余。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。不得已。用寒热并投。
补泻互治之法。三黄寒而生用。附子热而煮汁。生熟异性。寒热异气。合和与服。
各奏其功。亦一片苦心也。
此热在三焦。故用三黄泄热。恶寒汗出。又虑亡阳。故即用附子彻上下以温经。
附子别煮取汁者。取三黄之气轻。取附子之力重也。
伤寒汗解之后。胃中不和。心下痞硬。干噫食臭。胁下有水气。腹中雷鸣下利。生姜泻心汤。
邵评∶汗解之后。胃中不和。既不能营运真气。又不能消化饮食。症见心下痞硬。
干呕食臭。是中焦不和。不能消谷。故令人噫嗳。胁下有水气。腹鸣下利。是土虚
不制水。而水邪为患。实则胃气不和。是太阳之余热。挟阴寒之水气。内侵而处
其中也。故以泻心开痞。主生姜散水。
胃藏津液。发汗则津液亡。故胃不和而成痞。生姜能生发胃中升腾之气。故名
汤。佐以人参、甘枣。则益胃气以生津液。干姜、半夏破阴以导阳。芩连泻阳以交
阴。通方破滞宣阳。亦泻心之义。
邵评∶观此条。可见痞症不皆由误下而成。有汗后津液干。脾胃气虚。阴阳不得
升降而成痞者。用生姜泻心汤。以开痞清湿热。兼助脾胃之气也。
伤寒发汗。若吐若下解后。心下痞硬。噫气不除者。旋复花代赭石汤主之。
邵评∶发汗吐下。火邪已去。而心下痞硬。噫气不除者。心气大虚。表寒乘虚结于
心下。心气不降而上出于口也。乃中虚胃弱而不和。痰气上逆之症。用此汤补
中和胃而止虚逆。方中旋复花味咸。咸以软坚。行水下气。代赭味苦质重而降
逆气。半夏、生姜辛温而消痰行水。参、甘、大枣甘温补中而和胃气也。
此因三法后。心气虚。不可复用泻心。故制此汤以散结消痞。
痞证与结胸证，都表现为腹部硬满的症状。应当以是否有疼痛作为鉴别要点。如果胀满且伴有硬痛，属于结胸证，是实热证，适宜用陷胸汤法治疗。如果胀满但不疼痛，属于痞满证，是虚热证，适宜用泻心汤法治疗。然而，如果结胸证病情不严重，使用泻心汤法治疗也足够了。大概而言，实证表现为结胸，虚证表现为痞满，两种病症可以相互参照判断。
邵氏点评：有疼痛的是结胸，没有疼痛的是痞证。痞证属于虚证且无形质，结胸属于实证且有形质。
《伤寒论》论述说：患伤寒病五六天，出现呕吐且发热，具备小柴胡汤证的特征，却用了其他药物进行攻下治疗，结果只感到胀满而不疼痛，这就是痞证，适宜用半夏泻心汤治疗。
邵氏点评：这是少阳病误用攻下法而形成的痞结证。呕吐且发热，是小柴胡汤证。即使有可下的症状，也应当使用大柴胡汤，却用了其他药物攻下，这是错误的。
这是因为误用攻下法，寒邪反而入里，阻遏了君火的正常气化功能，从而形成无形的气机痞塞，所以使用干姜来散寒，黄芩、黄连来泄热，半夏来散结止呕，人参、甘草来补益胃气，以辅助半夏开通寒邪凝结，那么痞证自然解除。
患伤寒或中风，医生反而使用攻下法，患者每天腹泻数次，食物不消化，肠中雷鸣般作响，胃脘部痞硬且胀满，干呕，心烦，不得安宁。医生看到胃脘部痞塞，认为病邪未除尽，再次使用攻下法，导致痞塞更加严重。这并非热邪结聚，而是因为胃中虚弱，客气上逆，所以才导致痞硬。主治方剂为甘草泻心汤。
邵氏点评：邪气盛于体表，医生误用攻下法，导致腹泻和腹中鸣响，完谷不化，可知肠胃内部已经虚弱。胃脘部痞硬且胀满，干呕且心烦不得安宁，这是表间的邪热因误用攻下法而内陷于心间，向上攻冲又向下注泄。如果不是中气空虚，怎么会致使邪气淫溢到这种程度呢？由此可见，痞是虚痞，硬是虚硬，满是虚满，这是很明显的。医生不认识这是虚证，以为结热未尽，再次误用攻下法，这是在原本已虚的基础上更加虚弱。虚则胃不能运化，邪气上逆，痞满症状更加严重。所以再次申明，前文的病症说：这不是结热，而是因为胃中虚弱，客气上逆，所以才导致痞硬。
这种痞证是因为胃虚导致水气上逆，火气不能下降，凝结而成痞证。所以使用甘草、大枣来调和胃阴，半夏来激发胃阳，坐镇中焦，防止下焦的客气上逆，仍然使用黄芩、黄连来清泄已经上逆的痞气。
患伤寒病，经过大幅度的攻下后，又发汗，出现胃脘部痞塞，伴有恶寒，说明表证尚未解除。不可直接攻治痞证，应当先解表，表证解除后才能攻治痞证。解表适宜用桂枝汤，攻治痞证适宜用大黄黄连泻心汤。
邵氏点评：大幅度的攻下后又发汗，正气虚弱，邪气入里导致心下痞塞，似乎应当治疗痞证。然而外有恶寒的症状，邪气虽然入里，但表证仍未解除。内外都有病邪，不可轻易攻治痞证。应当先用桂枝汤解除表证，后用大黄黄连泻心汤攻治痞证。否则，恐怕痞证不解，而表邪再次入里，病情会更加加重。这是先解表后治里的治疗方法。至于大黄黄连泻心汤，是治疗君火亢盛，不能下行交于阴，从而形成痞证。
这种痞证是因为君火亢盛，不能下行交于阴而形成，所以药物不煎煮而采用浸泡的方法，想要取其轻扬清淡之气来涤荡邪热，只用其气，不用其味。
胃脘部痞塞，大便干硬，心烦，不得安眠，伴有恶寒、汗出者，主治方剂为附子泻心汤。
邵氏点评：痞证且大便干硬，心烦不眠，说明里部的邪热有余。而又伴有恶寒、汗出，说明表阳虚衰，正气不足。所以使用三黄（黄芩、黄连、大黄）来泄热，加入附子来恢复阳气。虽然如此，这是邪热有余而正阳不足，如果治疗邪热而遗漏扶正，那么恶寒会更加严重；或者温补阳气而遗漏清热，那么痞满症状会增加。不得已，采用寒热并用、补泻兼施的方法。三黄性寒而生用，附子性热而另煮取汁，生熟药性不同，寒热气性各异，混合后服用，各自发挥功效，这也是医者的一片苦心。
这种热邪在三焦，所以使用三黄泄热；恶寒汗出，又担心亡阳，所以立即使用附子贯通上下以温通经脉。附子单独煮取汁液，是为了取三黄的轻清气，取附子的厚重强力。
患伤寒病，汗出病解之后，胃中不和，胃脘部痞硬，嗳气带有食物腐臭味，胁下有停水，肠中雷鸣并伴有腹泻，主治方剂为生姜泻心汤。
邵氏点评：汗出病解之后，胃中不和，既不能运行真气，又不能消化饮食，症见胃脘部痞硬，嗳气带有食臭，这是中焦不和，不能消谷，所以使人嗳气。胁下有停水，肠鸣腹泻，这是土虚不能制水，而水邪为患。实际上是胃气不和，是太阳病的余热，挟带阴寒的水气，内侵而停留其中。所以用泻心汤开痞，主用生姜来散水气。
胃藏津液，发汗则津液耗亡，所以胃不和而形成痞证。生姜能生发胃中升腾之气，所以命名为此汤。佐以人参、甘草、大枣，则是为了益胃气以生津液。干姜、半夏破除阴寒以引导阳气，黄芩、黄连清泄阳热以交通阴阳。全方破除滞涩，宣通阳气，也是泻心汤的意义所在。
邵氏点评：观察这一条，可见痞证并不都是由误用攻下法引起的。有因发汗后津液干枯，脾胃气虚，阴阳升降失常而形成痞证的，使用生姜泻心汤，以开痞清湿热，同时辅助脾胃之气。
患伤寒病，经过发汗、催吐或攻下治疗后，病邪虽解，但胃脘部痞硬，嗳气不止者，主治方剂为旋复花代赭石汤。
邵氏点评：发汗、催吐、攻下后，火邪已去，但胃脘部痞硬，嗳气不止，这是心气大虚，表寒乘虚结聚于心下，心气不降而上出于口。这是中虚胃弱而不和，痰气上逆的病症。使用此汤补中和胃，制止虚性上逆。方中旋复花味咸，咸能软坚，行水下气；代赭石味苦质重而降逆气；半夏、生姜辛温而消痰行水；人参、甘草、大枣甘温补中而调和胃气。
Pi syndrome (epigastric fullness and stuffiness) and Jie Xiong syndrome (chest binding syndrome) both present with hardness and fullness in the abdomen. The differentiation should be based on pain. Fullness accompanied by hardness and pain indicates Jie Xiong syndrome, which is a excess-heat pattern, suitable for treatment with the Xia Xiong Tang method (Decoction to Break Up the Chest). Fullness without pain indicates Pi Man syndrome (epigastric fullness), which is a deficiency-heat pattern, suitable for treatment with the Xie Xin Tang method (Decoction to Drain the Epigastrium). However, if Jie Xiong syndrome is not severe, treatment with the Xie Xin Tang method is also sufficient. Generally speaking, excess patterns manifest as Jie Xiong, while deficiency patterns manifest as Pi Man; the two syndromes can be referred to each other for judgment.
Commentary by Shao: Pain indicates Jie Xiong; absence of pain indicates Pi. Pi belongs to deficiency and is formless, whereas Jie Xiong belongs to excess and has form.
The Treatise states: After five or six days of Taiyang disease (Cold Damage), if there is vomiting and fever, indicating that the Chai Hu syndrome (Bupleurum Syndrome) criteria are met, but another medication was used to purge downwards, resulting only in fullness without pain, this is Pi syndrome. Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Epigastrium) is indicated.
Commentary by Shao: This is a Pi Jie syndrome (binding of pi) formed due to erroneous purging in Shaoyang disease (Lesser Yang Disease). Vomiting and fever constitute the Xiao Chai Hu Tang syndrome (Minor Bupleurum Decoction Syndrome). Even if there were indications for purging, Da Chai Hu Tang (Major Bupleurum Decoction) should have been used. Using other medications to purge was an error.
This occurred because erroneous purging allowed cold pathogens to enter the interior, obstructing the normal Qi transformation of the Jun Fire (Ministerial Fire/Heart Fire), leading to the formation of formless Qi Pi (Qi stagnation/stuffiness). Therefore, Gan Jiang (Dried Ginger) is used to dispel cold, Huang Qin (Scutellaria Root) and Huang Lian (Coptis Rhizome) to drain heat, Ban Xia (Pinellia Tuber) to dissipate nodulation and stop vomiting, and Ren Shen (Ginseng Root) and Gan Cao (Licorice Root) to tonify Stomach Qi, assisting Ban Xia in opening the cold obstruction, thereby resolving the Pi.
In Taiyang disease or Wind Strike, if the physician erroneously uses purging, the patient may experience diarrhea several times a day, undigested food in stool, borborygmus (rumbling in the abdomen), epigastric hardness and fullness, dry heaving, irritability, and restlessness. Seeing the epigastric Pi, the physician assumes the pathogen is not fully eliminated and purges again, worsening the Pi. This is not due to heat accumulation, but rather Stomach deficiency causing rebellious Guest Qi (pathogenic factors invading from outside) to ascend. Gan Cao Xie Xin Tang (Licorice Decoction to Drain the Epigastrium) is the primary treatment.
Commentary by Shao: Pathogens are abundant at the exterior, but erroneous purging leads to diarrhea and abdominal rumbling with undigested food, indicating interior deficiency of the intestines and stomach. Epigastric hardness and fullness, dry heaving, irritability, and restlessness indicate that exterior pathogenic heat, due to erroneous purging, has sunk into the heart region, attacking upwards and sinking downwards. If the Middle Qi were not empty, how could pathogenic factors overflow so severely? Thus, Pi is deficient Pi, hardness is deficient hardness, and fullness is deficient fullness. It is clear. The physician, failing to recognize this deficiency, assumes residual heat binding and purges again, exacerbating the existing deficiency. Deficiency leads to the Stomach's failure to transform, causing pathogenic rebellion and worsening Pi and fullness. Hence, it reiterates: "This is not heat binding, but Stomach deficiency causing Guest Qi rebellion, leading to hardness."
This Pi arises from Stomach deficiency leading to water Qi rebellion, preventing Fire Qi from descending, resulting in condensation and Pi. Therefore, Gan Cao (Licorice Root) and Da Zao (Jujube Fruit) are used to harmonize Stomach Yin, Ban Xia (Pinellia Tuber) to stimulate Stomach Yang, anchoring the Middle Jiao to prevent lower Jiao Guest Qi from rebelling upwards. Huang Qin and Huang Lian are still used to drain the already rebellious Pi Qi.
After severe purging followed by sweating in Taiyang disease, if epigastric Pi occurs accompanied by aversion to cold, the exterior syndrome remains unresolved. One must not attack the Pi directly; instead, resolve the exterior first. Only after the exterior is resolved can the Pi be treated. Gui Zhi Tang (Cinnamon Twig Decoction) is indicated for resolving the exterior, while Da Huang Huang Lian Xie Xin Tang (Rhubarb and Coptis Decoction to Drain the Epigastrium) is indicated for treating the Pi.
Commentary by Shao: Severe purging followed by sweating causes righteous Qi deficiency and pathogen entry, leading to epigastric Pi, suggesting Pi treatment might be appropriate. However, the presence of aversion to cold indicates the exterior remains unresolved despite pathogen entry. With both interior and exterior pathology, one must not lightly attack the Pi. First, use Gui Zhi Tang to resolve the exterior, then Da Huang Huang Lian Xie Xin Tang to treat the Pi. Otherwise, the Pi may not resolve, and exterior pathogens may re-enter the interior, worsening the condition. This is the treatment principle of resolving the exterior before the interior. Regarding Da Huang Xie Xin Tang, it treats Pi caused by excessive Jun Fire unable to descend and interact with Yin.
Since this Pi results from excessive Jun Fire unable to descend and interact with Yin, the herbs are not boiled but steeped, aiming for their light, clear, and ascending properties to cleanse the pathogen, utilizing their Qi rather than their flavor.
Epigastric Pi, hard stools, irritability, insomnia, aversion to cold, and sweating are treated with Fu Zi Xie Xin Tang (Aconite Decoction to Drain the Epigastrium).
Commentary by Shao: Pi with hard stools and irritability/insomnia indicates excess heat in the interior. Aversion to cold and sweating indicate deficiency of Exterior Yang and insufficient righteous Qi. Therefore, San Huang (Three Yellows: Huang Qin, Huang Lian, Da Huang) are used to drain heat, and Fu Zi (Prepared Aconite Root) is added to restore Yang Qi. Although there is excess heat and insufficient righteous Yang, treating the pathogen while neglecting righteousness would worsen aversion to cold; tonifying Yang while neglecting heat would increase Pi and fullness. Reluctantly, a method of combining cold and hot, tonification and purgation, is employed. San Huang are cold and used raw; Fu Zi is hot and decocted separately. Raw and cooked herbs differ in nature and Qi. Mixed and taken together, they each achieve their effect, reflecting the physician's painstaking effort.
Heat in the Three Jiao (Triple Burner) is treated with San Huang to drain heat. Aversion to cold and sweating raise concern for loss of Yang, hence Fu Zi is immediately used to penetrate upper and lower levels to warm the channels. Fu Zi is decocted separately to extract its potent force, while San Huang provide their light Qi.
After Taiyang disease resolves via sweating, if Stomach disharmony occurs with epigastric hardness, belching with a smell of fermented food, water Qi under the hypochondrium, borborygmus, and diarrhea, Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction to Drain the Epigastrium) is indicated.
Commentary by Shao: After resolution via sweating, Stomach disharmony implies an inability to circulate True Qi and digest food. Symptoms include epigastric hardness and belching with food odor, indicating Middle Jiao disharmony and failure to digest grains, causing belching. Water Qi under the hypochondrium, borborygmus, and diarrhea indicate Spleen deficiency failing to control Water, leading to Water pathogen pathology. Essentially, this is Stomach Qi disharmony, where residual heat from Taiyang disease combines with Yin-cold water Qi, invading and residing within. Thus, Xie Xin Tang opens the Pi, primarily using Sheng Jiang (Fresh Ginger) to disperse water Qi.
The Stomach stores Jin Ye (Body Fluids); sweating depletes these fluids, leading to Stomach disharmony and Pi. Sheng Jiang generates the ascending Qi of the Stomach, giving the decoction its name. Assisted by Ren Shen, Gan Cao, and Da Zao, it benefits Stomach Qi to generate fluids. Gan Jiang (Dried Ginger) and Ban Xia break Yin to guide Yang, while Huang Qin and Huang Lian drain Yang to communicate with Yin. The formula breaks stagnation and promotes Yang, embodying the principle of Xie Xin Tang.
Commentary by Shao: This clause shows that Pi syndrome is not always caused by erroneous purging. Some cases arise from fluid dryness after sweating, Spleen-Stomach Qi deficiency, and impaired ascending/descending of Yin and Yang. Sheng Jiang Xie Xin Tang is used to open Pi, clear damp-heat, and assist Spleen-Stomach Qi.
After Taiyang disease resolves via sweating, vomiting, or purging, if epigastric hardness persists with unrelenting belching, Xuan Fu Dai Zhe Tang (Inula and Hematite Decoction) is indicated.
Commentary by Shao: After sweating, vomiting, and purging, Fire pathogens are gone, yet epigastric hardness and unrelenting belching persist, indicating significant Heart Qi deficiency. Exterior cold exploits this deficiency to bind in the epigastrium, and Heart Qi fails to descend, rising out through the mouth. This is a pattern of Middle deficiency, weak Stomach, disharmony, and Phlegm-Qi rebellion. This formula tonifies the Middle, harmonizes the Stomach, and stops rebellious Qi. In the formula, Xuan Fu Hua (Inula Flower) is salty, softening hardness and moving water/Qi downward; Dai Zhe Shi (Hematite) is bitter and heavy, directing rebellious Qi downward; Ban Xia and Sheng Jiang are acrid-warm, resolving phlegm and moving water; Ren Shen, Gan Cao, and Da Zao are sweet-warm, tonifying the Middle and harmonizing Stomach Qi.
Following the three methods (sweating, vomiting, purging), Heart Qi is deficient, making further use of Xie Xin Tang inappropriate. Thus, this formula is formulated to dissipate nodulation and resolve Pi.