【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。
【纲】张仲景说：患伤寒病，经过猛烈攻下之后，又再次发汗。患者出现心下痞（胃脘部堵塞感），且伴有恶寒症状，说明表证尚未解除。此时不可直接攻治痞证，应当先解表证。待表证解除后，才可以攻治痞证。解表证，适宜使用桂枝汤；攻治痞证，适宜使用大黄黄连泻心汤。
【目】张介宾说：考察结胸这一病症，参照《伤寒论》所载，凡是太阳经表邪未解而误用攻下法，就会形成结胸。少阳病也是如此。太阳与少阳并病的情况也是如此。这是在不应当攻下的情况下误用攻下，导致脏腑之气空虚，外邪乘虚内陷，结聚在胸膈之间，这些都是因误下而导致结聚的。文中提到“伤寒六七日，结胸热实，脉沉而紧，心下痛，按之石硬”，这是不因误下，而是邪气逐渐深入，结聚于胸部的实证。然而，结胸这一病症，有因误下导致的，也有不因误下而由本病发展而来的。近代伤寒著作中说：“未经过攻下治疗的就不是结胸”，这难道不是谬误吗？另外看结胸症，参照张仲景所言，只有太阳、少阳经误下才会出现，唯独阳明经没有提及。为什么呢？大概因为凡病传入阳明，胃腑已经充实，所以可以攻下而无害。但又说：“阳明病，如果心下硬满，不可攻下。若攻下导致腹泻不止的会死亡。”这难道不是说阳明经表证，邪气未入腑者，也是不可攻下的吗？不仅三阳经是这样，三阴经的病症中，如果有发热恶寒、表邪未解的情况，也绝对不可攻下。另外，心下痞是误下后出现的里证，属于内外同病，由于汗法和下法使用颠倒，仍应当采用先解表后治里的方法，即先发汗后攻下。
【纲】张仲景说：太阳病，表证未除却多次攻下，于是导致协热下利（伴随表热的下利）。下利不止，心下痞硬，表里证均未解除的，用桂枝人参汤主治。
【目】魏荔彤说：风邪初感在体表，若不治疗，郁结而化为热，所以传经的热称为热邪。如今说多次攻下，可知病程已久。这是因为透达体表的的风邪，变为了陷入体内的热邪。又屡次被苦寒的药物镇压沉降，因此病的邪热下行至下焦，而药物的寒邪又留滞于心下。热邪进入下焦，这就是协热下利不止的原因；寒邪留留心下，这就是协寒导致的心下痞硬。如果不使用理中汤，那么协热的阳气不能升发，协寒的阴气不能消散。
沈金鳌按语：桂枝人参汤，就是理中汤加上桂枝。所以魏氏才有“非用理中”之类的说法。
【纲】张仲景说：原本因误用攻下法，导致心下痞。给予泻心汤治疗后，病未痊愈。患者口渴、口燥、心烦，小便不利的，用五苓散主治。太阳中风病，出现下利、呕吐逆气，表证已解除的，才可以攻治里证。患者汗出，发作有定时，头痛，心下痞塞坚硬胀满，牵引胁下疼痛，干呕，短气，汗出但不恶寒，这是表证已解而里气未和，用十枣汤主治。
陶华说：痞证，是因为太阳病应当服用麻黄汤，却误用承气汤攻下，从而形成痞满。这是由于虚邪留滞，如果想攻下，必须等待表证消失之后才可以。适宜用小柴胡汤加枳壳、桔梗。
【纲】张仲景说：病发于阳证（如太阳病）却反用攻下法，热邪内陷，因而形成结胸。病发于阴证（如少阴病等）却反用攻下法，因而形成痞证。之所以形成结胸，是因为攻下过早的缘故。
【目】成无己说：结胸与痞，都是热证。论述痞证时不说“热入”，是因为热邪原本就发源于体内。
柯琴说：“热入”是形成结胸的原因。论述痞证时不说“热入”，是为了显示痞证与结胸的不同之处。
【纲】张仲景说：伤寒病出汗后表证已解，但胃中不和，心下痞硬，干呕，食物气味酸腐，胁下有水气，腹中肠鸣如雷，伴有下利的，用生姜泻心汤主治。伤寒或中风病，医生反而误用攻下法。患者出现下利，每天数十次，完谷不化，腹中肠鸣如雷，心下痞硬且胀满，干呕，心烦，不得安宁。医生见心下痞，认为病邪未尽，再次攻下，结果痞证更加严重。这不是实热结聚，而是因为胃中空虚，客气（邪气）上逆，所以导致痞硬。用甘草泻心汤主治。
【目】苏颂说：胃寒，先用理中丸，后用旋覆代赭汤。咳逆气虚，用四逆汤。汗、吐、下法之后，噎气痞硬，用旋覆代赭汤。发热不解，呕吐下利，用心下痞硬，用大柴胡汤。下利不止，则治疗下焦，用赤石脂禹余粮汤。如果仍不止，只通利小便，用五苓散。
柯琴说：阳邪停留在胃的上口，所以痞硬、干呕、食臭。水邪停留在胃的下口，所以腹鸣、下利。所以病虽然发生在胃，却不属于阳明病，仍属于太阳寒水病变。上一条，是汗解后水气向下攻冲的症状。下一条，是误下后客气上逆的症状。总是因为胃虚，只是稍有区别。上一条腹鸣下利，胃中还是寒热各半，所以说“不和”。下一条腹鸣且完谷不化，下利每天数十次，那么痞是虚痞，硬是虚硬，满是虚满，这很明显了。上一条因为水气下趋，所以不烦不满。下一条是虚邪上逆，所以心烦且胀满。
【纲】张仲景说：伤寒五六天，呕吐且发热的，具备柴胡汤证。如果用其他药物攻下。如果心下胀满而且硬痛，这是结胸，用大陷胸汤主治。如果只是胀满而不痛的，这是痞证，不宜给柴胡汤，适宜用半夏泻心汤。
【目】许叔微说：误下导致的变证，结胸是偏向半表证的；心下痞是偏向半里证的。
【纲】张仲景说：伤寒病经过吐法、下法后，又再次发汗。出现虚烦，脉象非常微弱。到了第八九天，心下痞硬，胁下疼痛，气向上冲撞咽喉，头晕目眩，经脉跳动惕动不安的，时间久了会形成痿证。太阳病，医生发汗后，仍然发热恶寒，又攻下它，导致心下痞。表里俱虚，阴阳之气都衰竭。如果没有阳气，则阴气独留。再加用烧针，导致胸中烦闷，面色青黄，皮肤瞤动的，难治。现在面色微黄，手足温暖的，容易痊愈。
【目】柯琴说：上一条，因吐下后又发汗，导致虚烦而痞。下一条，因汗下后又加用烧针，导致虚烦而痞。
【纲】张仲景说：伤寒病人服用汤药后，下利不止，心下痞硬。服用泻心汤后，又以其他药物攻下，下利仍不止。医生用理中汤治疗，下利反而更严重。理中汤是调理中焦的，此处的下利在下焦，用赤石脂禹余粮汤主治。如果服后下利仍不止，应当通利小便。
[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.