阴邪传里者，则留于心下为痞，以心下为阴受气之分也。
程应旄曰∶泻心虽同，而证中具呕，则功专涤饮，故以半夏名汤也。曰泻心者，言
满在心下清阳之位，热邪挟饮，尚未成实，故清热涤饮，使心下之气得通，上下自无阻留，
阴阳自然交互矣。然枢机全在于胃，故复补胃家之虚，以为之斡旋，与实热入胃而泻其
蓄满者，大相径庭矣。痞虽虚邪，乃表气入里，寒成热矣。寒虽成热，而热非实，故用
苦寒以泻其热，兼佐辛甘以补其虚，不必攻痞而痞自散。所以一方之中，寒热互用，若
阴痞不关阳郁，即郁而亦未成热，泻心之法概可用也。
汪琥曰∶少阳病误下，邪在半表半里，居阴阳之间，故有痞结证。夫人身，膈以下属
阴，膈以上属阳，少阳居清道而介乎膈之间，亦为半表半里。此可征少阳病误下，邪气乘
虚入里，而结胸痞气所由分也。
半夏泻心汤方
半夏（洗，半升） 黄芩（三两） 干姜（三两） 人参（三两） 黄连（一两） 甘草（炙，三两） 大枣
（擘，十二枚）
上七味，以水一斗，煮取六升，去滓再煮，取三升，温服一升，日三服。
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。
【注】本以下之早，故成心下痞。如绑定热成实之痞，则宜大黄黄连泻心汤，寒攻之
法也；如系外寒内热之痞，则宜附子泻心汤，温攻之法也；如系虚热水气之痞，则宜生姜
泻心汤，散饮之法也；如系虚热而呕之痞，则宜半夏泻心汤，折逆之法也；如系虚热益甚
之痞，则宜甘草泻心汤，缓急之法也。今以诸泻心汤，审证与之，而痞不解，则当审其
人，若渴而口燥，心烦小便不利者，非辨证不明，药力之不及也。盖水饮内蓄，津液不
行，故痞病不解耳。宜五苓散外发内利，汗出小便利则愈，于此可类推矣。
【集注】方有执曰∶泻心汤治痞而痞不解，则非气聚之痞可知。渴而口燥、烦、小便不
利者，津液涩而不行，伏饮凝结也。五苓散利水生津，津生而渴烦止，水利而痞自除，所
以又为消痞满之一法也。
程应旄曰∶泻心诸方，开结、荡热、益虚可谓备矣。然其治法实在上、中二焦，亦
有痞在上而治在下焦者，斯又不同其法也。若痞之来路虽同，而其人口渴，躁烦，小便不
利，则知下后胃虚，以致水饮内蓄，津液不行，痞无去路，非结热也。以五苓散主之者，
使浊阴出下窃，而清阳之在上焦者，自无阻留矣。况五苓散宣通气化，兼行表里之邪，使
心邪不从心泻，而从膀胱泻，又一法也。
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。
【注】伤寒服汤药，下利不止，心中痞硬者，误下之所致也。下利痞硬，乃虚痞也，服
泻心汤已合法矣。而痞不愈，复以他药下之，痞虽去而利不止，医与理中汤温之，其利益
甚。不知理中者，理中焦也，此利在下焦，属滑脱也，故用赤石脂禹余粮汤，涩滑固脱，利
可止也。若止而复利，则当审其小便之利与不利。小便若利，当佐以温补之药以收全功；
小便不利，是水无去路，固涩日久，所以复利不止。则又当利其小便，使水道通而利自止矣。
【集注】郑重光曰∶汤者，荡也，即下药也。误下利不止，心下痞硬，服泻心汤为合
法矣。乃复以他药下之，误而又误，用理中开痞止利，原不为过，而利益甚者，以屡下
伤肾，下焦失守也。故用石脂、禹粮固肠虚而收滑脱，利仍不止，当利其小便。盖膀胱
者，肾之腑也。肾主二便，开窍于二阴，利小便者，令脏腑各司其事，庶水谷分而下利自止也。
赤石脂禹余粮汤方
赤石脂（碎，一斤） 太乙禹余粮（碎，一斤）
上二味，以水六升，煮取二升，去滓，分温三服。
【方解】柯琴曰∶甘、姜、参、术，可以补中宫元气之虚，而不足以固下焦脂膏之脱。
此利在下焦，未可以理中之剂收功也。然大肠之不固，仍责在胃；关门之不紧，仍责在
脾。此二味皆土之精气所结，能实胃而涩肠。盖急以治下焦之标者，实以培中宫之本也。要
之，此证是土虚而非火虚，故不宜于姜、附。若水不利而湿甚，复利不止者，则又当利其小便矣。
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。
【注】伤寒发汗，若吐若下，解后，设表里俱清，自然胃和思食而愈。今邪虽解，而
心下痞硬，胃虚结也。噫气不除，胃气逆也。然治痞之法，无出诸泻心汤。故于生姜泻心
汤方中，去芩、连、干姜，以病解无寒热之邪也。佐旋复代赭石者，所以补虚宣气，涤饮镇逆也。
【集注】方有执曰∶解，谓大邪己散也。心下痞硬，噫气不除者，正气未复，胃气尚
弱，而伏饮为逆也。故用旋复代赭石汤，以养正而散余邪也。
喻昌曰∶大意重在噫气不除上。既心下痞硬，更加噫气不除，则胃气上逆，全不下
行，有升无降。所谓弦绝者，其声嘶；土败者，其声哕也。故用代赭石领人参下行，以
镇安其逆气也。
汪琥曰∶此噫气，较前生姜泻心汤之干噫不同，是虽噫而不至食臭，故知其为中气虚也。
沈明宗曰∶误下成痞，观此之发汗解后，亦可成痞。盖发汗、吐、下，皆伤内气。然
最虚之处，便是容邪之处，所以微邪从虚内陷，浊阴上逆冲心，则心下痞硬，而噫气不除也。
旋复代赭石汤方
旋复花（三两） 人参（二两） 生姜（切，五两） 代赭石（一两） 半夏（洗，半升） 甘草（炙，三两）
大枣（擘，十二枚）
上七味，以水一升，煮取六升，去滓再煎，取三升，温服一升，日三服。
【方解】罗天益曰∶汗、吐、下解后，邪虽去而胃气已亏矣。胃气既亏，三焦因之失
职，清无所归而不升，浊无所纳而不降，是以邪气留滞，伏饮为逆，故心下痞硬，噫气
不除也。方中以人参、甘草养正补虚，生姜、大枣和脾养胃，所以安定中州者至矣。更以
代赭石之重，使之敛浮镇逆；旋复花之辛，用以宣气涤饮。佐人参以归气于下，佐半夏以
蠲饮于上，浊降则痞硬可消，清升则噫气可除矣。观仲景治少阴水气上凌，用真武汤镇
之；治下焦滑脱不守，用赤石脂禹余粮汤固之；此胃虚气失升降，复用此法理之，则胸
中转否为泰。其为归元固下之法，各极其妙如此。
伤寒大吐大下之，极虚，复极汗出者，以其人外气怫郁，复与之水，以发其汗，因得
哕。所以然者，胃中寒冷故也。
【注】伤寒大吐、大下之后，津液极虚。其人面赤，表气怫郁，渴欲引饮，复与汤水，
以助发其汗，因得哕。所以然者，大吐、下已虚其中，又发其汗，阳从外亡，故曰胃中
虚冷故也。宜以吴茱萸汤，温中降逆可也。
【按】胃主纳，下通地道。若胃病失职，则不下输大小肠，不纳而反出也。物出无声，
谓之吐；声物并出，谓之呕；声出无物，谓之干呕。干呕者，即哕也，以其有哕哕之声，
故名曰哕也。论中以呕为轻，以哕为重。盖以胃中有物，物与气并逆，所伤者轻；胃中
空虚，惟气上逆，所伤者重故也。哕，与三阴证同见者，为虚为寒；与三阳证同见者，为
实为热。虚寒者，四逆、理中、吴茱萸等汤；实热者，调胃、大小承气等汤，择而用之，勿
谓哕者胃败不可下也。论中云，伤寒哕而腹满，视其前后，知何部不利，利之则愈是也。
又世有谓哕为呃逆、吃逆、噫气者，皆非也。盖哕之声气，自胃出于口，而有哕哕之声，壮
而迫急也；呃逆之声，气自脐下冲上，退场门而作格儿之声，散而不续也。夫所谓呃逆者，
即论中《平脉篇》所谓KT KT 者，气噎结有声也。观呃逆之人，与冷水实时作格，哕则
不然，自可知也。吃逆、噫气者，即今之所谓嗳气也，因饱食太急，比时作嗳，而不食
臭，故名曰吃逆也。因过食伤食，过时作嗳有食臭气，故名曰噫气也。哕KT 嗳噫，俱有
声无物，虽均属气之上逆，然不无虚实寒热、轻重新久之别也。甚至以咳逆为呃逆者，殊
不知咳逆即今之喘嗽也，兹乃与呃逆混而为一，皆不考之过，而得失利害系焉！不可以
不辨。干呕即哕，咳逆即喘嗽。详在《金匮要略》中。
【集注】程应旄曰∶哕之一证，有虚有实。虚自胃冷得之，缘大吐大下后，阴虚而阳无
所附，因见面赤，以不能得汗，而外气怫郁也。医以面赤为热气怫郁，复与水而发汗令
大出，殊不知阳从外泄而胃虚，水从内抟而
邪格，胃气虚弱矣，安得不哕！
汪琥曰∶伤寒既大吐、大下之后，已极虚矣！复极发其汗者何也？以其人外气怫郁，
面上之气，恰如外来之邪怫郁于表也。此系阳明胃腑虚极，浮热之气上升于面，医人认
以为邪热胃燥过极，不得汗，复与之水以助其汗，因而得哕。
凡是阴邪传入体内的，就会停留在心下形成痞证，因为心下是阴气受纳的部位。
程应旄说：虽然都用泻心汤，但如果症状中伴有呕吐，功效就专门在于涤除水饮，所以用半夏来命名方剂。所谓“泻心”，是指满闷位于心下清阳之气所在的位置，热邪挟带水饮，尚未结成实邪，所以用清热涤饮的方法，使心下的气机得以通畅，上下自然没有阻滞留滞，阴阳就能自然交互了。然而枢机的运转全在于胃，所以还要补益胃气的虚弱，以此来斡旋气机，这与实热入胃而泻其蓄积满实的治法，大相径庭了。痞证虽然是虚邪，但它是表气入里，寒邪转化为热邪。虽然寒已化热，但热并非实热，所以用苦寒药来泻其热，兼用辛甘药来补其虚，不必直接攻逐痞块，痞证自然会消散。因此在一方之中，寒热药物互用，如果是阴痞且不涉及阳气郁结，或者即使有郁结也未化热，泻心的方法都可以使用。
汪琥说：少阳病误用下法，邪气在半表半里，处于阴阳之间，所以会出现痞结证。人体膈以下属阴，膈以上属阳，少阳居于清道而介于膈之间，也是半表半里。这可以证明少阳病误下后，邪气乘虚入里，从而区分出结胸和痞气的成因。
半夏泻心汤方
半夏（洗，半升） 黄芩（三两） 干姜（三两） 人参（三两） 黄连（一两） 甘草（炙，三两） 大枣（掰开，十二枚）
以上七味药，用水一斗，煮取六升，去渣再煮，取三升，温服一升，每天三次服用。
本因过早使用下法，所以导致心下痞，给予泻心汤治疗。如果痞证不解除，病人出现口渴、口燥、心烦、小便不利等症状的，用五苓散主治。
【注】本因过早使用下法，所以形成心下痞。如果是像绑定热结成实邪的痞证，则适宜用大黄黄连泻心汤，这是寒攻的方法；如果是外寒内热的痞证，则适宜用附子泻心汤，这是温攻的方法；如果是虚热水气形成的痞证，则适宜用生姜泻心汤，这是散饮的方法；如果是虚热且伴有呕吐的痞证，则适宜用半夏泻心汤，这是折降逆气的方法；如果是虚热更严重的痞证，则适宜用甘草泻心汤，这是缓急的方法。现在根据各种泻心汤辨证施治，如果痞证仍不解除，就应当审察病人，如果出现口渴、口燥、心烦、小便不利，这不是辨证不明或药力不及。这是因为水饮内停，津液不行，所以痞病不解。适宜用五苓散外发汗、内利水，汗出小便通利就好了，由此可以类推其他情况。
【集注】方有执说：用泻心汤治疗痞证而痞不解，那就不是气聚成的痞证可知。口渴、口燥、心烦、小便不利，是津液涩滞而不行，伏饮凝结所致。五苓散利水生津，津液生成则口渴心烦停止，水利则痞自除，所以这也是消除痞满的一种方法。
程应旄说：各种泻心方的治疗，开结、荡热、益虚可以说很完备了。然而它们的治疗法则实在上、中二焦，也有痞在上而治在下焦的情况，这就不同于前面的治法了。如果痞证的来路相同，但病人出现口渴、躁烦、小便不利，就知道是下法后胃虚，导致水饮内停，津液不行，痞无去路，并非结热。用五苓散主治，是为了使浊阴从下窍排出，而上焦的清阳之气自然没有阻滞留滞了。况且五苓散宣通气化，兼行表里之邪，使心邪不从心经泻出，而从膀胱泻出，又是另一种方法。
伤寒病人服用汤药后，下利不止，心下痞硬，服用泻心汤后，又用其他药攻下，下利仍不止，医生用理中汤给予治疗，下利反而更严重。理中汤是调理中焦的。此下利在下焦，用赤石脂禹余粮汤主治；如果下利仍不止，应当利小便。
【注】伤寒病人服用汤药后，下利不止，心中痞硬，这是误用下法导致的。下利伴痞硬，属于虚痞，服用泻心汤已经符合治法了。但痞证未愈，又用其他药攻下，痞虽去而下利不止，医生给理中汤温中，下利反而更甚。不知道理中汤是调理中焦的，此下利在下焦，属于滑脱不禁，所以用赤石脂禹余粮汤，涩肠固脱，下利可止。如果止住后又下利，就应当审察小便的通利与否。如果小便通利，应当佐以温补药物以收全功；如果小便不利，是水无去路，固涩日久，所以复利不止。这时又应当利小便，使水道通畅而下利自止。
【集注】郑重光说：汤者，荡也，即下药。误用下法导致下利不止，心下痞硬，服用泻心汤为合法。却又用其他药攻下，误而又误，用理中汤开痞止利，原本不为过，但下利更甚，是因为屡次攻下损伤肾气，下焦失守。所以用赤石脂、禹余粮固护肠虚而收敛滑脱，如果下利仍不止，应当利小便。盖膀胱是肾的腑。肾主二便，开窍于二阴，利小便，是让脏腑各司其职，这样水谷分利而下利自止。
赤石脂禹余粮汤方
赤石脂（捣碎，一斤） 太乙禹余粮（捣碎，一斤）
以上两味药，用水六升，煮取二升，去渣，分三次温服。
【方解】柯琴说：甘、姜、参、术，可以补中宫元气的虚弱，但不足以固摄下焦脂膏的滑脱。此下利在下焦，不可以用理中剂的方子收功。但大肠的不固，责任仍在胃；关门的不紧，责任仍在脾。这两味药都是土之精气所结，能实胃而涩肠。紧急治疗下焦的标症，实际上是在培补中宫的根本。总之，此证是土虚而非火虚，所以不宜用姜、附。如果水不利而湿甚，下利仍不止，则又应当利小便了。
伤寒经过发汗，或吐或下，病解后，心下痞硬，嗳气不除的，用旋复代赭石汤主治。
【注】伤寒经过发汗，或吐或下，病解后，如果表里都清净，自然胃气和调思食而痊愈。现在邪气虽解，但心下痞硬，是胃虚结聚。嗳气不除，是胃气上逆。然而治疗痞证的方法，离不开各种泻心汤。所以在生姜泻心汤方中，去掉黄芩、黄连、干姜，因为病解后没有寒热之邪。佐以旋复代赭石，是为了补虚宣气，涤除水饮，镇降逆气。
【集注】方有执说：解，谓大邪已散。心下痞硬，嗳气不除，是正气未复，胃气尚弱，而伏饮上逆。所以用旋复代赭石汤，以扶正而散余邪。
喻昌说：大意重在“嗳气不除”上。既然心下痞硬，加上嗳气不除，那么胃气上逆，完全不下行，只有升没有降。所谓弦绝者，其声嘶；土败者，其声哕。所以用代赭石引领人参下行，以镇安其逆气。
汪琥说：此处的嗳气，与前面生姜泻心汤中的干噫不同，这里是虽然嗳气但不致于有食物臭味，所以知道是中气虚。
沈明宗说：误下成痞，看此处发汗解后，也可以成痞。盖发汗、吐、下，都损伤内气。然而最虚之处，便是容邪之处，所以微邪从虚处内陷，浊阴上逆冲心，则心下痞硬，而嗳气不除。
旋复代赭石汤方
旋复花（三两） 人参（二两） 生姜（切，五两） 代赭石（一两） 半夏（洗，半升） 甘草（炙，三两） 大枣（掰开，十二枚）
以上七味药，用水一升，煮取六升，去渣再煎，取三升，温服一升，每天三次服用。
【方解】罗天益说：汗、吐、下解后，邪气虽去而胃气已亏。胃气既亏，三焦因此失职，清气无所归而不升，浊气无所纳而不降，所以邪气留滞，伏饮上逆，故心下痞硬，嗳气不除。方中以人参、甘草养正补虚，生姜、大枣和脾养胃，安定中州的用意至极。再用代赭石的沉重，使之收敛浮越、镇降逆气；旋复花的辛味，用以宣气涤饮。佐人参使气归于下，佐半夏蠲除上部的饮邪，浊降则痞硬可消，清升则嗳气可除。看仲景治疗少阴水气上凌，用真武汤镇之；治疗下焦滑脱不守，用赤石脂禹余粮汤固之；此证是胃虚气失升降，复用此法调理，则胸中转否为泰。其为归元固下的方法，各极其妙如此。
伤寒经过大吐大下，极度虚弱，又极度出汗的，因为病人外表气机怫郁，又给他喝水以发汗，因而导致哕（呃逆）。之所以这样，是因为胃中寒冷。
【注】伤寒大吐、大下之后，津液极度虚弱。病人面赤，表气怫郁，渴欲饮水，又给汤水，以助发其汗，因而得哕。之所以这样，是大吐、大下已使其内部虚弱，又发其汗，阳气随汗外亡，所以说胃中虚冷。适宜用吴茱萸汤，温中降逆即可。
【按】胃主受纳，下通地道。如果胃病失职，则不下输大小肠，不纳反而吐出。物出无声，称为吐；声物并出，称为呕；声出无物，称为干呕。干呕，就是哕，因为它有哕哕的声音，所以名叫哕。论中认为呕较轻，哕较重。盖因为胃中有物，物与气并逆，所伤较轻；胃中空虚，惟气上逆，所伤较重。哕，与三阴证同见的，为虚为寒；与三阳证同见的，为实为热。虚寒者，用四逆、理中、吴茱萸等汤；实热者，用调胃、大小承气等汤，择而用之，不要认为哕是胃败不可下。论中说，伤寒哕而腹满，视其前后，知何部不利，利之则愈，就是这个意思。另外世间有人称哕为呃逆、吃逆、噫气，都不对。盖哕之声气，自胃出于口，而有哕哕之声，壮而迫急；呃逆之声，气自脐下冲上，退场门而作格儿之声，散而不续。所谓呃逆，即论中《平脉篇》所谓“吃吃”者，气噎结有声。看呃逆之人，喝冷水即时作格声，哕则不然，自然可知。吃逆、噫气，即今之所谓嗳气，因饱食太急，即时作嗳，而无食臭，故名曰吃逆。因过食伤食，过时作嗳有食臭气，故名曰噫气。哕、吃吃、嗳、噫，俱有声无物，虽均属气之上逆，然不无虚实寒热、轻重新久之别。甚至以咳逆为呃逆者，殊不知咳逆即今之喘嗽也，兹乃与呃逆混而为一，皆不考之过，而得失利害系焉！不可以不辨。干呕即哕，咳逆即喘嗽。详在《金匮要略》中。
【集注】程应旄说：哕之一证，有虚有实。虚自胃冷得之，缘大吐大下后，阴虚而阳无所附，因而见面赤，因不能得汗，而外气怫郁。医生以面赤为热气怫郁，复与水而发汗令大出，殊不知阳从外泄而胃虚，水从内抟而邪格，胃气虚弱矣，安得不哕！
汪琥说：伤寒既大吐、大下之后，已极虚矣！又极发其汗的是什么原因呢？因为病人外气怫郁，面上的气，恰如外来之邪怫郁于表。此系阳明胃腑虚极，浮热之气上升于面，医生认以为邪热胃燥过极，不得汗，复与之水以助其汗，因而得哕。
When Yin pathogens transmit inward, they remain in the epigastrium forming a *Pi* syndrome (fullness and obstruction without pain), because the epigastrium is the region where Yin Qi receives.
Cheng Yingmao stated: Although all utilize Xie Xin Tang (Drain the Epigastrium Decoction), if vomiting is present among the symptoms, the efficacy specializes in draining fluid retention; hence, Banxia is used to name the formula. The term "Xie Xin" (Draining the Heart/Epigastrium) refers to the fullness located in the position of clear Yang Qi in the epigastrium. Heat pathogens carrying fluid retention have not yet formed solid excrement. Therefore, clearing heat and draining fluid allows the Qi in the epigastrium to flow freely, eliminating upper and lower stagnation, allowing Yin and Yang to interact naturally. However, the pivot mechanism relies entirely on the Stomach; thus, tonifying the deficiency of the Stomach Qi serves as a mediator. This differs significantly from treating excess heat entering the Stomach by purging accumulated fullness. Pi syndrome, though a deficiency pathogen, results from exterior Qi entering the interior, transforming cold into heat. Although cold transforms into heat, this heat is not excess; therefore, bitter-cold herbs are used to drain the heat, accompanied by acrid-sweet herbs to tonify deficiency. There is no need to directly attack the Pi mass for it to dissipate spontaneously. Hence, within one formula, cold and hot herbs are used together. If it is a Yin Pi not involving Yang depression, or if there is depression but no heat formation, the method of Xie Xin can generally be applied.
Wang Hu stated: When Shaoyang disease is incorrectly treated with purgatives, the pathogen remains at the half-exterior half-interior level, situated between Yin and Yang, resulting in Pi knotting. In the human body, below the diaphragm belongs to Yin, and above the diaphragm belongs to Yang. Shaoyang resides in the clear pathways between the diaphragms, also representing the half-exterior half-interior. This confirms that after incorrect purgative treatment of Shaoyang disease, pathogens enter the interior due to deficiency, distinguishing the origins of Jie Xiong (Chest Binding) and Pi Qi.
**Banxia Xie Xin Tang (Pinellia Drain the Epigastrium Decoction) Formula**
Banxia (washed, half sheng) Huangqin (three liang) Ganjiang (dried ginger, three liang) Renshen (three liang) Huanglian (one liang) Gancao (honey-fried, three liang) Dazao (broken open, twelve pieces)
The above seven ingredients are boiled in ten dou of water to obtain six sheng. Remove the dregs and boil again to obtain three sheng. Take one sheng warm, three times daily.
Originally, premature use of purgatives caused epigastric Pi. Xie Xin Tang was administered. If the Pi does not resolve, and the patient presents with thirst, dry mouth, irritability, and dysuria, Wuling San (Five-Ingredient Powder with Poria) should be used as the primary treatment.
[Note] Premature purgative treatment led to epigastric Pi. If the Pi resembles binding heat forming solid excrement, Dahuang Huanglian Xie Xin Tang (Rhubarb and Coptis Drain the Epigastrium Decoction) is appropriate, employing a cold purgative method. If the Pi involves exterior cold and interior heat, Fuzi Xie Xin Tang (Aconite Drain the Epigastrium Decoction) is appropriate, employing a warm purgative method. If the Pi involves deficiency-heat and fluid-water, Shengjiang Xie Xin Tang (Fresh Ginger Drain the Epigastrium Decoction) is appropriate, employing a method to disperse fluid retention. If the Pi involves deficiency-heat with vomiting, Banxia Xie Xin Tang is appropriate, employing a method to subvert rebellious Qi. If the Pi involves severe deficiency-heat, Gancao Xie Xin Tang (Licorice Drain the Epigastrium Decoction) is appropriate, employing a method to relieve urgency. Now, having examined the various Xie Xin Tang formulas based on syndrome differentiation, if the Pi does not resolve, one must examine the patient. If there is thirst, dry mouth, irritability, and dysuria, this is not due to unclear syndrome differentiation or insufficient medicinal power. Rather, internal accumulation of fluid-water and non-flowing Jin-Ye (body fluids) cause the Pi to persist. Wuling San should be used to induce sweating externally and promote urination internally. Recovery occurs when sweat appears and urination becomes smooth; other cases can be inferred similarly.
[Collected Notes] Fang Youzhi stated: If Xie Xin Tang fails to resolve Pi, it indicates the Pi is not formed by Qi aggregation. Thirst, dry mouth, irritability, and dysuria indicate stagnant and non-flowing Jin-Ye with condensed hidden fluid retention. Wuling San promotes urination and generates Jin-Ye; once Jin-Ye is generated, thirst and irritability cease; once urination flows, Pi dissipates. Thus, this is another method for eliminating Pi fullness.
Cheng Yingmao stated: Various Xie Xin formulas adequately address opening knots, sweeping heat, and tonifying deficiency. However, their therapeutic methods focus on the Upper and Middle Jiao. There are cases where Pi is in the upper part but treated via the Lower Jiao, which differs from previous methods. If the origin of Pi is similar, but the patient exhibits thirst, restlessness, and dysuria, it indicates that post-purgative Stomach deficiency led to internal fluid-water accumulation and non-flowing Jin-Ye, leaving Pi with no exit route; this is not clustered heat. Using Wuling San causes turbid Yin to exit from the lower orifices, allowing clear Yang in the Upper Jiao to flow without obstruction. Moreover, Wuling San promotes Qi transformation and expels pathogens from both exterior and interior, causing Heart pathogens to drain via the Bladder rather than the Heart channel, representing yet another method.
In Shanghan (Cold Damage), after taking herbal decoctions, persistent diarrhea and hard epigastric Pi occur. After taking Xie Xin Tang, if other purgatives are administered and diarrhea persists, and the physician prescribes Lizhong Tang (Regulate the Middle Decoction), the diarrhea worsens. Lizhong Tang regulates the Middle Jiao. This diarrhea is in the Lower Jiao; Chishizhi Yuyuliang Tang (Red Halloysite and Hematitum Decoction) should be used. If diarrhea persists despite this, promoting urination is indicated.
[Note] In Shanghan, taking herbal decoctions leading to persistent diarrhea and epigastric hardness is caused by incorrect purgative treatment. Diarrhea with Pi hardness constitutes deficiency Pi; taking Xie Xin Tang was correct. However, if Pi does not heal and further purgatives are used, although Pi may resolve, diarrhea persists. If the physician administers Lizhong Tang for warmth, diarrhea worsens. One must understand that Lizhong Tang regulates the Middle Jiao; this diarrhea is in the Lower Jiao, belonging to sliding collapse (incontinence). Therefore, Chishizhi Yuyuliang Tang is used to astringe intestines and secure collapse, stopping diarrhea. If diarrhea stops and recurs, one must assess urination. If urination is smooth, tonifying and warming herbs should be added to complete the cure. If urination is unsmooth, it indicates water has no exit route; prolonged astringency causes recurrent diarrhea. In this case, promoting urination is necessary so that the water pathway opens and diarrhea stops spontaneously.
[Collected Notes] Zheng Zhongguang stated: "Tang" (decoction) implies sweeping, i.e., purgatives. Incorrect purgative treatment caused persistent diarrhea and hard epigastric Pi; taking Xie Xin Tang was correct. Yet, using other purgatives compounded the error. Using Lizhong Tang to open Pi and stop diarrhea was not wrong, but worsening diarrhea occurred because repeated purgation damaged Kidney Qi, causing Lower Jiao instability. Thus, Chishizhi and Yuyuliang are used to secure intestinal deficiency and arrest sliding collapse. If diarrhea persists, promoting urination is required. The Bladder is the Fu organ of the Kidney. The Kidney governs the two lower orifices and opens into them. Promoting urination allows Zang-Fu organs to perform their functions, separating water and grain so diarrhea stops.
**Chishizhi Yuyuliang Tang (Red Halloysite and Hematitum Decoction) Formula**
Chishizhi (crushed, one jin) Taiyi Yuyuliang (crushed, one jin)
The above two ingredients are boiled in six sheng of water to obtain two sheng. Remove dregs and take warm in three doses.
[Formula Analysis] Ke Qin stated: Gan, Jiang, Renshen, and Zhu can tonify the deficiency of Yuan Qi in the Middle Palace but cannot secure the sliding collapse of lipid essence in the Lower Jiao. Since this diarrhea is in the Lower Jiao, Lizhong agents cannot achieve the cure. However, large intestine insecurity is attributed to the Stomach; loose closure is attributed to the Spleen. These two ingredients are結 (condensed) essences of Earth, capable of firming the Stomach and astringing intestines. Urgently treating the branch symptom in the Lower Jiao actually cultivates the root in the Middle Palace. Essentially, this syndrome involves Earth deficiency, not Fire deficiency; thus, Jiang (Ginger) and Fu (Aconite) are unsuitable. If water is unsmooth and dampness is severe, causing persistent diarrhea, promoting urination is again indicated.
After Shanghan is treated with sweating, vomiting, or purgation, and resolves, if epigastric hardness and persistent belching remain, Xuanshu Daizhe Shi Tang (Inula and Hematitum Decoction) should be used.
[Note] After Shanghan is treated with sweating, vomiting, or purgation, if exterior and interior are cleared, natural recovery follows with harmonized Stomach Qi and appetite. Now, although pathogens are resolved, epigastric hardness indicates Stomach deficiency with knotting. Persistent belching indicates rebellious Stomach Qi. Methods for treating Pi do not exceed various Xie Xin Tangs. Therefore, in the Shengjiang Xie Xin Tang formula, Huangqin, Huanglian, and Ganjiang are removed because, post-resolution, there are no cold or heat pathogens. Xuanshu and Daizhe Shi are added to tonify deficiency, circulate Qi, drain fluid, and suppress rebellion.
[Collected Notes] Fang Youzhi stated: Resolution means major pathogens have dispersed. Epigastric hardness and persistent belching indicate unrecovered righteous Qi, weak Stomach Qi, and rebellious hidden fluid retention. Thus, Xuanshu Daizhe Shi Tang is used to nourish righteousness and scatter residual pathogens.
Yu Chang stated: The emphasis lies on "persistent belching." With epigastric hardness and persistent belching, Stomach Qi rebels upward, failing to descend, rising only without descending. As the saying goes: when strings break, the sound is hoarse; when Earth fails, the sound is hiccups. Thus, Daizhe Shi leads Renshen downward to calm rebellious Qi.
Wang Hu stated: This belching differs from the dry belching in Shengjiang Xie Xin Tang; here, belching occurs without food odor, indicating Middle Qi deficiency.
Shen Mingzong stated: Incorrect purgation causes Pi; observing this case, resolution after sweating can also cause Pi. Sweating, vomiting, and purgation all damage internal Qi. Wherever there is greatest deficiency, pathogens reside. Thus, minor pathogens sink inward through deficiency, turbid Yin rebels upward striking the Heart, causing epigastric hardness and persistent belching.
**Xuanshu Daizhe Shi Tang (Inula and Hematitum Decoction) Formula**
Xuanfuhua (three liang) Renshen (two liang) Shengjiang (cut, five liang) Daizhe Shi (one liang) Banxia (washed, half sheng) Gancao (honey-fried, three liang) Dazao (broken open, twelve pieces)
The above seven ingredients are boiled in one sheng of water to obtain six sheng. Remove dregs and simmer again to obtain three sheng. Take one sheng warm, three times daily.
[Formula Analysis] Luo Tianyi stated: After resolution via sweating, vomiting, or purgation, pathogens are gone but Stomach Qi is depleted. Depleted Stomach Qi causes San Jiao dysfunction: clear Qi has no return and fails to ascend; turbid Qi has no reception and fails to descend. Thus, pathogens linger, hidden fluid rebels, causing epigastric hardness and persistent belching. In the formula, Renshen and Gancao nourish righteousness and tonify deficiency; Shengjiang and Dazao harmonize Spleen and nourish Stomach, stabilizing the Middle Region profoundly. Daizhe Shi's heaviness gathers floating Qi and suppresses rebellion; Xuanfuhua's acridity circulates Qi and drains fluid. Assisted by Renshen, Qi returns downward; assisted by Banxia, fluid is eliminated upward. Turbidity descends, resolving hardness; clarity ascends, removing belching. Observe Zhang Zhongjing treating Shaoyin fluid-water flooding upward with Zhenwu Tang to suppress it; treating Lower Jiao sliding collapse with Chishizhi Yuyuliang Tang to secure it; here, Stomach deficiency with disrupted Qi ascent/descent uses this method to regulate, turning obstruction into harmony. Their methods of returning to the root and securing the lower are each exquisitely effective.
After excessive vomiting and purgation in Shanghan, extreme deficiency occurs. If excessive sweating follows, because the patient's exterior Qi is constrained (Fu Yu), and water is given to induce sweating, hiccups (Yue) result. The reason is cold in the Stomach.
[Note] After excessive vomiting and purgation in Shanghan, Jin-Ye is extremely deficient. The patient has a red face, exterior Qi is constrained, desires to drink, and is given soup/water to aid sweating, resulting in hiccups. The reason is that excessive vomiting/purgation weakened the interior, and sweating caused Yang to escape outward, hence "Stomach deficiency and cold." Wu Zhu Yu Tang (Evodia Decoction) should be used to warm the middle and subvert rebellion.
[Commentary] The Stomach governs reception, connecting downward to the earthy pathway. If Stomach disease causes dysfunction, contents do not transmit to the large and small intestines; instead of receiving, they vomit. Ejection of matter without sound is called Tu (vomiting); ejection of matter and sound is called Ou (retching); sound without matter is called Gan Ou (dry retching). Gan Ou is Yue (hiccups/belching), named for its "Yue Yue" sound. The Treatise considers Ou mild and Yue severe. Because Stomach contains matter, matter and Qi rebel together, causing lighter injury; empty Stomach, only Qi rebels, causing heavier injury. Yue accompanying Three Yin syndromes indicates deficiency and cold; Yue accompanying Three Yang syndromes indicates excess and heat. For deficiency-cold, use Sini Tang, Lizhong Tang, Wu Zhu Yu Tang, etc.; for excess-heat, use Tiaowei Chengqi Tang, Dachengqi Tang, etc. Choose appropriately; do not assume Yue indicates Stomach failure precluding purgation. The Treatise states: "In Shanghan, Yue with abdominal fullness, observe anterior and posterior orifices, identify which is obstructed, unblock it, and it heals." Also, worldly terms calling Yue "E Ni" (hiccup), "Chi Ni," or "Yi Qi" are incorrect. Yue's sound/Qi comes from Stomach to mouth, loud and urgent. E Ni's sound arises from below the navel rushing up, making "ge" sounds at the anus, scattered and discontinuous. "E Ni" corresponds to "Chi Chi" in the Ping Mai Pian chapter, meaning Qi blockage with sound. Observing E Ni patients, drinking cold water immediately triggers "ge" sounds, unlike Yue. Chi Ni and Yi Qi refer to modern "belching." Chi Ni occurs immediately after eating too fast, without food odor. Yi Qi occurs later after overeating, with food odor. Yue, Chi Chi, Ai, and Yi all involve sound without matter, all being upward Qi rebellion, yet differing in deficiency/excess, cold/heat, severity, and duration. Confusing Ke Ni (coughing against) with E Ni is erroneous; Ke Ni is modern asthma/cough. Mixing them is an investigative failure with significant consequences. Distinction is crucial. Gan Ou is Yue; Ke Ni is asthma/cough. Detailed in *Jingui Yaolue*.
[Collected Notes] Cheng Yingmao stated: Yue syndrome has deficiency and excess types. Deficiency arises from Stomach cold, following excessive vomiting/purgation where Yin deficiency leaves Yang unattached, causing red face and constrained exterior Qi due to inability to sweat. Physicians mistaking red face for heat constraint give water to induce heavy sweating, unaware that Yang escapes outward weakening Stomach, and water attacks internally blocking pathogens, weakening Stomach Qi, inevitably causing Yue!
Wang Hu stated: After excessive vomiting/purgation in Shanghan, extreme deficiency exists! Why induce excessive sweating? Because the patient's exterior Qi is constrained; facial Qi resembles external pathogens constrained at the exterior. This is extreme deficiency of the Yangming Stomach Fu, with floating heat rising to the face. Physicians mistake this for extreme Stomach heat/dryness preventing sweating, giving water to aid sweating, resulting in Yue.