（胸痹 痞块）
痞者，痞塞不开。满者，满闷不行也。痞满与胀满不同，胀满，内满而外胀起；
痞满，但内觉满闷，而外无胀急之形也。有在胸在腹之分，皆由中气不运。而所以
致不运者，则或寒而凝闭，或热而 胀，或食滞痰停，或气结怒郁，或脾湿不化，
或血瘀不行，皆能致之。不特外邪陷入，结塞而成，如《伤寒论》所云也。
在胸者，理同胸痹。《金匮》谓∶阳微（寸脉微也，上焦虚寒。）阴强，（尺脉弦
也，下焦寒盛。）
即胸痹而痛，（阴邪上干胸中，微阳为寒所闭，不通而痛。）责其极虚。（上焦阳虚。）
又云∶平人无寒
热，（非表邪也。）短气不足以息者，实也。（上言正虚，此言邪实。即《经》所谓∶邪之所凑，
其气必虚。
留而不去，其病为实也，实谓痰饮之类。短气不足以息，以邪阻气道，呼吸喘促不利，非真
气之短乏。）又云∶
喘息咳唾，胸背痛，短气，寸脉沉迟，（上焦内气寒也。）关脉小紧数，（小为阳虚，紧数
为寒痛，
是中焦亦受病也。寸迟关数可疑。）栝蒌薤白白酒汤。（辛温行阳开痹。）又云∶胸痹不得卧，
心痛彻
背者，（比上证更甚矣。）栝蒌薤白半夏汤。心痛彻背，背痛彻心，（犹云痛无休息，比上证又
甚矣。）乌头赤石脂丸。又云∶胸痹缓急者，（其痛或缓或急也。）薏苡附子散。（视栝蒌汤为重，乌头
丸为轻。）又云∶胸中气塞，短气，（不痛证轻。）茯苓杏仁甘草汤，或橘枳姜汤。（胸为气海，阳
邪干之则化火，火性开，不病痹也。病痹必阴邪干之，阴邪化水，水性凝，故令气塞。水盛于热，以
茯苓汤利水；
气盛于水，以橘枳汤行气。）又云∶心下痞，气结在胸，胸满，胁下逆抢心，（首条云阴弦，此云胁
下气逆，乃肝肾之邪气上逆也。）枳实薤白桂枝汤（桂以伐肝）、人参汤。（上方散邪，此方补正。）
又云∶心
中痞，诸逆，心悬痛，（上条不过冲心，此则心痛而摇动，若悬空然。）桂枝生姜枳实汤。大抵胸为
清阳之分，浊阴干之则气不行，为虚痞，甚则痰涎停聚为实痞，更甚则痛也。东垣
谓∶痞，但满不痛。视胸痹有痛，证虽不同，理则无二。兀兀欲吐者，吐之，食郁
上焦者亦然。一味栝蒌子炒熟，连皮煎，或丸，最能荡涤胸中垢腻。在腹中者，黄
补中汤加升、柴。缘天地不交为否，猪苓、泽泻降天气使下济，升麻、柴胡
升地气使上行。饮食停滞。轻者大消痞丸、枳术丸，（见伤饮食。）甚者槟榔丸（见伤饮食）下
之。酒积杂病，下之太过致痞满者，升提其胃气，加血药。（下多亡阴，故补其血。）郁者，
越鞠丸、逍遥散。（并见郁。）湿者，平胃散（见伤饮食）合五苓。（见伤湿。）气滞，四七汤。（见气。）
痰滞，导痰汤。（见痰。）脾弱不运者，四君子汤、异功散。（并见气）挟死血者，丹皮、江
西红曲、穿山甲、降香、桃仁、红花、当归、童便、韭汁之属，郁怒者加香附。（童
便制。）在腹亦有虚实之分，实而积久成形，即名痞块，于积聚门求之。
（胸痹 痞块）
痞，是指气机痞塞不通。满，是指脘腹满闷不舒。痞满与胀满不同，胀满是内部胀满且外部腹部隆起；痞满则是仅感觉内部满闷，而外部没有胀急的形态。病位有在胸部和在腹部的区别，但都是由中焦脾胃之气运行失常所致。导致气机不运的原因，有的是因寒邪凝滞闭塞，有的是因热邪导致胀满，有的是因食物停滞、痰饮内停，有的是因气机郁结或愤怒抑郁，有的是因脾虚湿盛不能运化，有的是因血瘀阻滞不行，这些都能导致痞满。不仅仅是外邪陷入体内，结聚阻塞而成，就像《伤寒论》中所说的那样。
病位在胸部的，其机理同于胸痹。《金匮要略》中说：阳微（指寸脉微弱，代表上焦虚寒），阴强（指尺脉弦硬，代表下焦寒盛），这就导致了胸痹而疼痛（阴寒之邪上犯胸中，微弱的阳气被寒邪闭阻，不通则痛），这是因为根本原因在于极度的虚损（上焦阳气虚弱）。又说：平素人无恶寒发热的表证（非外感表邪），出现短气、呼吸急促不足以息的症状，这是实证（上文讲的是正气虚，这里讲的是邪气实。即《内经》所谓：邪气聚集的地方，正气必然虚弱。邪气停留不去，疾病就表现为实证，这里的实指的是痰饮之类。短气不足以息，是因为邪气阻塞气道，导致呼吸喘促不利，并非真气真的短少匮乏）。又说：喘息、咳嗽吐唾沫，胸背疼痛，短气，寸脉沉迟（上焦内部气寒），关脉小紧数（脉小为阳气虚，紧数为寒痛，说明中焦也受病了。寸脉迟、关脉数这种情况值得怀疑）。用栝蒌薤白白酒汤治疗（辛温以通行阳气，开散痹阻）。又说：胸痹严重到不能平卧，心痛放射至背部者（比上述证候更严重），用栝蒌薤白半夏汤。如果心痛放射至背部，背痛放射至心部（意思是疼痛无休止，比上述证候又更严重），用乌头赤石脂丸。又说：胸痹疼痛时缓时急者（疼痛有时缓解有时剧烈），用薏苡附子散（此方比栝蒌汤为重，比乌头丸为轻）。又说：胸中气塞，短气（不痛的证候较轻），用茯苓杏仁甘草汤，或者橘枳姜汤（胸为气海，阳邪侵犯它则化为火，火性炎上开泄，不会导致痹证。发生痹证必然是阴邪侵犯，阴邪化为水，水性凝滞，所以导致气机堵塞。水邪盛于热邪，用茯苓汤利水；气邪盛于水邪，用橘枳汤行气）。又说：心下痞满，气结聚在胸部，胸满，胁下有气逆冲心胸（第一条说阴脉弦，这里说胁下气逆，是肝肾的邪气上逆），用枳实薤白桂枝汤（桂枝用以伐肝）、人参汤（上方用于疏散邪气，此方用于补益正气）。又说：心中痞满，各种逆气上冲，心脏悬空样疼痛（上一条不过是气冲于心，这一条则是心痛且动摇，像悬挂在空中一样），用桂枝生姜枳实汤。大抵而言，胸部是清阳分布的部位，浊阴侵犯它则气机不行，形成虚痞，严重时痰涎停聚形成实痞，再严重就会疼痛。李东垣说：痞，只是满而不痛。虽然与胸痹相比，胸痹有疼痛，证候虽不同，但道理是一样的。感到恶心欲吐的，可以通过催吐治疗，饮食郁结在上焦的情况也是如此。单味栝蒌子炒熟，连皮煎煮，或者制成丸剂，最能涤荡胸中的垢腻污浊。病位在腹部的，用黄耆补中汤加升麻、柴胡。因为天地不交即为“否”卦之象，猪苓、泽泻降天气使其下行济助下焦，升麻、柴胡升地气使其上行。如果是饮食停滞，轻症用大消痞丸、枳术丸（见伤饮食章节），重症用槟榔丸（见伤饮食章节）攻下。因酒积杂病，攻下太过导致痞满的，应升提胃气，加入补血药（下法多用会亡失阴血，所以要补其血）。气郁者，用越鞠丸、逍遥散（并见郁证章节）。湿邪者，用平胃散（见伤饮食章节）合五苓散（见伤湿章节）。气滞者，用四七汤（见气证章节）。痰滞者，用导痰汤（见痰证章节）。脾弱不能运化者，用四君子汤、异功散（并见气证章节）。挟有死血（瘀血）者，用丹皮、江西红曲、穿山甲、降香、桃仁、红花、当归、童便、韭汁这类药物，因郁怒致病者加香附（童便制）。在腹部也有虚实之分，实证且积聚日久成形，就命名为痞块，可在积聚门中查找相关论述。
(Thoracic Bi and Epigastric Mass)
Pi (Pì,痞) refers to the obstruction and stagnation of Qi. Man (Mǎn,满) refers to a sensation of fullness and oppression in the epigastrium or abdomen. Pi-Man differs from Zhang-Man (Zàng Mǎn,胀满). Zhang-Man involves internal fullness accompanied by external abdominal distension; Pi-Man is characterized solely by an internal sensation of fullness and oppression without any external signs of distension or tension. The pathology may be located in the chest or the abdomen, but both stem from the failure of Middle Jiao (Zhōng Jiāo,中焦) Qi transport. The causes for this failure include: cold pathogen causing coagulation and closure; heat pathogen causing distension; food retention and phlegm-fluid accumulation; Qi stagnation due to emotional constraint or anger; spleen deficiency with dampness failing to transform; or blood stasis obstructing flow. All these can lead to Pi-Man. It is not only caused by exterior pathogens sinking inward and knotting to form obstruction, as described in *Shanghan Lun* (Treatise on Cold Damage Diseases).
When located in the chest, the mechanism is identical to Thoracic Bi (Xiōng Bì,胸痹). *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet) states: Yang Wei (Cun pulse is faint, indicating Upper Jiao deficiency-cold), Yin Qiang (Chi pulse is wiry, indicating Lower Jiao excess-cold). This leads to Thoracic Bi with pain (Yin-cold pathogen attacks the chest, the weak Yang is closed by cold, leading to pain due to obstruction), which is attributed to extreme deficiency (Upper Jiao Yang deficiency). It further states: A healthy person without exterior cold-heat symptoms (not an exterior pathogen) who experiences shortness of breath and inability to take a deep breath has an Excess pattern (The previous statement discussed Zheng Qi deficiency; this discusses Xie Qi excess. As stated in *Neijing*: where pathogenic factors gather, Zheng Qi must be deficient. If they remain and do not depart, the disease manifests as Excess. Here, "Excess" refers to phlegm-fluids. Shortness of breath is due to pathogenic obstruction of the airway, causing panting and difficult respiration, not a true deficiency of vital Qi). It also states: Panting, coughing up saliva, chest and back pain, shortness of breath, Cun pulse deep and slow (Cold in Upper Jiao interior), Guan pulse small, tight, and rapid (Small indicates Yang deficiency; tight and rapid indicate cold-pain, suggesting Middle Jiao involvement. A combination of slow Cun and rapid Guan warrants suspicion). Treat with Gualou Xiebai Baijiu Tang (Gourd Fruit, Macrostemon, and White Wine Decoction) (Acrid-warm to promote Yang circulation and open obstruction). It further states: For Thoracic Bi severe enough to prevent lying down, with heart pain radiating to the back (more severe than the above), use Gualou Xiebai Banxia Tang (Gourd Fruit, Macrostemon, and Pinellia Decoction). If heart pain radiates to the back and back pain radiates to the heart (meaning pain is ceaseless, even more severe than above), use Wutou Chishizhi Wan (Aconite and Red Stone Pill). It further states: For Thoracic Bi with alternating severity of pain (pain fluctuates between mild and severe), use Yiyi Fuzi San (Coix Seed and Prepared Aconite Powder) (Heavier than Gualou Tang, lighter than Wutou Wan). It further states: For Qi blockage in the chest and shortness of breath (a milder condition without pain), use Fuling Xingren Gancao Tang (Poria, Apricot Seed, and Licorice Decoction), or Juzhi Jiang Tang (Citrus Peel, Immature Tangerine Peel, and Ginger Decoction) (The chest is the Sea of Qi. If Yang pathogen invades, it transforms into fire; fire nature is ascending and dispersing, so it does not cause Bi. Bi is caused by Yin pathogen, which transforms into water; water nature is coagulating, thus blocking Qi. If water exceeds heat, use Poria Decoction to drain water; if Qi exceeds water, use Citrus Peel and Immature Tangerine Peel Decoction to move Qi). It further states: Fullness below the heart, Qi knotted in the chest, chest oppression, and rebellious Qi from the hypochondrium rushing to the heart (The first clause mentions wiry Yin pulse; here, rebellious Qi from the hypochondrium indicates Liver-Kidney pathogenic Qi rebelling upward). Use Zhishi Xiebai Guizhi Tang (Immature Bitter Orange, Macrostemon, and Cinnamon Twig Decoction) (Cinnamon twig to subdue Liver) and Renshen Tang (Ginseng Decoction) (The former formulas disperse pathogen; this formula tonifies Zheng Qi). It further states: Fullness in the heart region, various rebellious Qi movements, and hanging pain in the heart (The previous clause involved Qi rushing to the heart; this involves heart pain with trembling, as if suspended in empty space). Use Guizhi Shengjiang Zhishi Tang (Cinnamon Twig, Ginger, and Immature Bitter Orange Decoction). Generally, the chest is the domain of Clear Yang. When Turbid Yin invades, Qi fails to circulate, resulting in Deficiency Pi. Severe cases involve phlegm-drool accumulation forming Excess Pi. Even more severe cases involve pain. Li Dongyuan stated: Pi is merely fullness without pain. Although different from Thoracic Bi which involves pain, the underlying principle is the same. For those feeling nauseous and wanting to vomit, induce vomiting. This applies similarly to food stagnation in the Upper Jiao. Single herb Gualouzi (Trichosanthes Seed), stir-fried and decocted with peel, or made into pills, is most effective at cleansing turbidity and grease from the chest.
For pathology located in the abdomen, use Huangqi Buzhong Tang (Astragalus Spleen-Boosting Decoction) plus Shengma (Cimicifugae Rhizoma) and Chaihu (Bupleuri Radix). This is because when Heaven and Earth do not interact, it forms the hexagram Pi (Obstruction). Zhenling (Polyporus) and Zexie (Alisma) descend Heavenly Qi to nourish the lower; Shengma and Chaihu ascend Earthly Qi to rise upward. For food stagnation, mild cases use Daxiaopi Wan (Great Elimination of Fullness Pill) or Zhizhu Wan (Immature Bitter Orange and Atractylodes Macrocephala Pill) (see Food Stagnation section); severe cases use Binglang Wan (Betel Nut Pill) (see Food Stagnation section) to purge downward. For Pi-Man caused by excessive purgative treatment of wine accumulation or miscellaneous diseases, elevate Stomach Qi and add Blood-invigorating herbs (Excessive purging loses Yin/Blood, hence tonify Blood). For Qi depression, use Yueju Wan (Six Depression Pill) or Xiaoyao San (Free and Easy Wanderer Powder) (see Depression section). For Dampness, use Pingwei San (Stomach-Pacifying Powder) (see Food Stagnation section) combined with Wuling San (Five-Ingredient Powder with Poria) (see Dampness section). For Qi stagnation, use Siqi Tang (Seven-Character Decoction) (see Qi section). For Phlegm stagnation, use Daotan Tang (Phlegm-Guiding Decoction) (see Phlegm section). For Spleen weakness failing to transport, use Sijunzi Tang (Four Gentlemen Decoction) or Yigong San (Extraordinary Skill Powder) (see Qi section). For cases complicated by fixed blood stasis, use Mudanpi (Moutan Cortex), Jiangxi Hongqu (Red Yeast Rice), Chuanshanjia (Pangolin Scale), Jiangxiang (Dalbergiae Odoriferae Lignum), Taoren (Persicae Semen), Honghua (Carthami Flos), Danggui (Angelicae Sinensis Radix), Tongbian (Child's Urine), and Jiu Zhi (Chinese Chive Juice). For cases due to depression and anger, add Xiangfu (Cyperi Rhizoma) processed with Tongbian. In the abdomen, there are also Deficiency and Excess distinctions. Excess patterns that accumulate over time and form masses are named Pi-Kuai (Epigastric Mass); refer to the Accumulation and Mass section for details.