心下满硬而痛者为实为结胸硬满不痛者为虚为痞气不满不硬但烦闷者为支结保命集云脾不能行气于四脏结而不散
则为痞大抵诸痞皆热也故攻痞之药皆寒剂其有一加附子者是以辛热佐其寒凉欲令开发痞之之怫郁结滞非攻寒也先发汗
或下后阳气虚故恶寒汗出太阳证云发汗后恶寒者虚也此加附子恐大黄黄连损其阳也非补虚也
痞硬 伤寒呕而发热者柴胡证具而以他药下之若心满而不痛者此为痞宜半夏泻心汤（论见结胸痞同异）
半夏泻心汤方（此方药味盖本理中人参黄芩汤方也）
半夏（半升洗） 黄芩 干姜 人参 甘草（炙以上各三两） 黄连（一两） 大枣（十二枚擘）上七味以水一升
煮取六斗去滓再煮取三升温服一升日三服（若加甘草即甘草泻心汤治痞硬吐利若加生姜即生姜泻心汤治痞硬噫气辛入肺
而散气半夏之辛以散结气苦入心而泄热黄芩黄连之苦入心痞热脾欲缓急食甘以缓之人参甘草大枣之甘以缓脾）
痞硬下利
伤寒汗出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者生姜泻心汤主之（成胃为津液之
主阳气之根大汗出后外亡津液胃中空虚客气上逆心下痞硬金匮要略曰中焦气未和不能消谷故令噫干噫食臭者胃虚而不
杀谷也胁下有水气腹中雷鸣土弱不能胜水也与泻心汤以攻痞加生姜以益胃）
生姜泻心汤方
生姜（四两切） 半夏（半升洗） 甘草（炙） 人参 黄芩（各三两） 黄连（二两） 干姜（一两） 大枣（十
二枚擘）上八味以水一斗煮取六升去滓再煎取三升温服一升日三服
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虚客气上逆故便硬也甘草泻心汤主之（成 伤寒中风是伤寒或中风也邪气在表医反下之虚其肠
胃而气内陷也下利日数十行谷不化腹中雷鸣者下后里虚胃弱也心下痞硬干呕心烦不得安者胃中空虚客气上逆也与泻心
汤以攻痞加甘草以补虚前以汗后胃虚是外伤阳气故加生姜此以下后胃虚是内损阴气故加甘草）
甘草泻心汤方
甘草（四两） 黄芩 干姜（各三两） 半夏（汤洗半升） 黄连 大枣（十二枚擘）上六味以水一斗煮取六升去
滓再煎取三升温服一升日三服
成 气结而不散壅而不通为结胸陷胸汤为直达之剂塞而不通否而不泰为痞泻心汤为分解之剂泻心者谓泻心下之
邪也痞与结胸有高下焉邪结在胸中故曰陷胸汤痞者留邪在心下故曰泻心汤内经曰苦先入心以苦泻之泻心者必以苦为主是
以黄连为君黄芩为臣以降阳而升阴也内经曰辛走气辛以散之散痞者必以辛为君故以半夏干姜为佐以分阴而行阳也阴阳
不交曰痞上下不通曰满欲通上下交阴阳必和其中所谓中者脾胃也脾不足者以甘补之故用人参甘草大枣为使以补脾而和
中中气得和上下得通阴阳得分水升火降则痞消热已而大汗解矣
痞濡
脉浮而紧而复下之紧反入里则作痞按之自濡但气痞耳（濡与硬反作痞恐当作结胸）心下痞按之濡其脉关上浮
者大黄黄连泻心汤主之（结言胸痞言心下结言按之石硬痞言按之濡结言寸脉浮关脉沉痞不言寸而但曰关上浮可以知二病
之分矣活人云结胸与痞关脉须皆沉若关脉浮而结者三黄以泻肝）
大黄黄连泻心汤
大黄（二两） 黄连（一两）上二味以麻沸汤二升渍之须臾绞去滓分温再服（内经曰火热受邪心病生焉苦入心寒除
热大黄黄连之苦寒以导泻心下之虚热但以麻沸汤渍服者取其气薄而泻虚热）
心下痞而复恶寒汗出者附子泻心汤主之（因恶寒汗出故加附子以温经固阳）
附子泻心汤方
大黄 黄连 黄芩（各一两） 附子（一枚炮去皮脐破别煮取汁）上 咀以麻沸汤二升热渍之一时久绞去滓纳附子
汁分温再服
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（活
人云大抵结胸与痞皆应下然表未解者不可攻也表证未解心下妨闷者非痞也谓之支结柴胡桂枝汤主之胸胁满微结小柴胡
加干姜牡蛎汤主之）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汤主之（成 本因下后成痞当与
泻心汤除之若服之痞不解其人渴而口燥烦小利便不者为水饮内蓄津液不行非热痞也与五苓散发汗散水则愈一方忍之一
日乃愈者不饮水者外水不入所停之水得行而痞亦愈也）
痞硬吐利
伤寒发热汗出不解心中痞硬呕吐而下利者大柴胡汤主之心下痞硬呕逆下利若表解身凉胁痛十枣汤主之
（方论并见胁痛）
活人云十枣汤大柴胡汤皆治心下痞十枣尤难用须是表证罢不恶寒身凉其人 汗出发作有时头疼心下痞满引胁下
疼干呕短气者乃可用十枣汤表未解者慎不可用也
下利表里未解
太阳病外证未除而数下之遂挟热而利利下不止心下痞硬表里不解者桂枝人参汤主之（成 外证未除
而数下之为重虚其里邪热而入里虚挟热遂利不止而心下痞若表解而下利心下痞乘虚者可与泻心汤若不下利表不解而心
下痞者可先解表而后攻痞以表里不解故与桂枝人参汤和里解表）
桂枝人参汤方
桂枝（去粗皮） 甘草（炙各四两） 白术 人参 干姜（各三两）上五味以水九升先煮四味取五升纳桂更煮取三
升温服一升日再夜一服（表未解者辛以散之里不足者甘以缓之此以里气大虚表里不解故加桂枝甘草于理中汤也）
张 或问大柴胡汤泻也桂枝人参汤补也何为皆治下利心下痞硬予曰此非里实乃下之早因作痞里虚协热而利也不
观
成氏注云若表解而下利心下痞者是里实也可与泻心汤若不下利表不解而心下痞者可先解表而后攻痞此以表里不解故与
桂枝人参和里解表夫伤寒发热汗出不解心下痞硬呕吐而下利者表和而里病也以心中痞硬故为实当以大柴胡汤下之二者
心下痞硬虽同而虚实之证有别故用药有攻补之异也
痞硬噫气
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（噫气即俗所谓嗳气也活人云有旋复代赭
石证其人或咳逆气虚者先服四逆汤胃寒者先服理中丸次服旋复代赭汤为良）
旋复代赭石汤方
旋复花 甘草（各三两炙） 人参（二两） 代赭石（一两） 生姜（切五两） 半夏（汤洗半升） 大枣（十二
枚擘）上七味以水一斗煮取六升去滓再煎取三升温服一升日三服（硬则气坚咸味可以 之旋复花之咸以 痞硬虚则气浮
重剂可以镇之代赭石之重以镇虚逆辛者散也生姜半夏之辛以散虚痞甘者缓也人参甘草大枣之甘以补胃弱）
病解后心下痞硬噫气若不下利者此方旋复代赭石汤也若下利者前方生姜泻心汤也
痞硬气上冲
胸中痞硬气上冲咽不得息者瓜蒂散若心下痞硬胁痛气上冲咽眩冒者成痿（论见气上冲心）
活人云下利而心下痞服生姜泻心汤甘草泻心汤利不止者当治其下焦赤石脂禹余粮汤主之盖生姜泻心甘草泻心皆治
中焦此利在下焦若只治中焦则利益甚尔服赤石脂禹余粮利复不止当利其小便五苓散主之又云凡痞服泻心汤不愈然后可
用陷胸丸下之（不可用陷胸汤盖太猛只用陷胸丸）
发热恶寒身痛表证未解若心下支结妨闷者柴胡桂枝汤也（方见太阳病若心下痞而腹满者即前条先以桂枝汤解后用大
黄黄连泻心也）心下满似痞而手足厥冷若脉乍结乍紧心烦饥不欲食者瓜蒂散若脉细沉头汗恶寒大便硬者小柴胡汤（论见
厥）
太阳病医发汗遂发热恶寒因复下之心下痞表里俱虚阴阳并竭无阳则阴独复加烧针因胸烦面色青黄肤 者难治今色
微黄手足温易愈
脉浮而大心下反硬有热属脏者攻之不令发汗属腑者不令溲数溲数则大便硬汗多则热愈甚汗少则便难若脉迟尚未可
攻阳明痞胃实心下硬满者不可攻之（论见胃实）
附
桔梗枳壳汤 治伤寒痞气胸满欲绝
枳壳（麸炒去瓤） 桔梗（各二两）上 咀以水二盏煎至一盏去滓分二服
活 伤寒本无痞应发汗医反下之遂成痞枳实理中丸最良审知是痞先用桔梗枳壳汤尤妙缘桔梗枳壳行气下膈先用
之
无不验也
赵 活人书第七十六问中云凡痞服泻心汤不愈然后可用陷胸汤下之愚详仲景论陷胸汤无治痞之例恐太猛难用又
况
胸与心下处所不同痛与不痛阴阳邪亦异除结胸外今将痞证以传经之邪与内陷之邪分为二种而下治焉一者病发于阴身无
热而反下之医反入里则作痞其脉关上沉为阴邪内陷也先宜桔梗枳壳汤次半夏泻心诸汤随证用之服泻心汤后渴而口燥烦
小便不利者五苓散二者身有热不因下后而传邪入里亦作痞其脉关上浮为阳邪随经入里须先解表而不恶寒者宜三黄泻心
又有心下痞而汗出恶寒者以阳邪与表之正气入里故表虚汗出而恶寒因加附子以固表也既结胸证有寒实热实之殊则痞证
亦有阴阳邪不为异也外有痞而硬者或桂枝人参汤温之或大柴胡汤十枣汤下之亦自同一律也活人书又云关浮则结热三黄
以泻肝盖热结则成结胸非痞也况心下正属中焦关脉亦主中部故汤名泻心岂可援杂病脉例以左关为肝部因谓之泻肝乎
张 或谓痞证多有杂以别证而心下痞硬者必非半夏泻心之所宜也予曰证候不同宜从治疗以上诸痞皆杂别证非特
下
早而成也仲景所以各从其宜用药以治之若下早而作痞者但满而不痛别无外证与半夏泻心汤以攻痞宜也
吴 夫痞者气郁不通泰也若不因下早而为痞者或痰或食或气为之结也保命集曰治痞用泻心主之各有冷热之不同
要
在辨而治之如热实而为痞者大黄黄连泻心汤之类也或寒多而热少半夏泻心等汤之类也要之泻心非泻心火之热乃泻心下
之痞满也
心下（胃脘部）胀满坚硬且疼痛的，属于实证，称为结胸；胀满坚硬但不疼痛的，属于虚证，称为痞气；不胀满也不坚硬，只是感到烦闷的，称为支结。《保命集》说：脾不能将气输送到四肢脏腑，气机凝聚而不消散，就会形成痞证。大抵各种痞证都是由热邪引起的，所以治疗痞证的药物都是寒凉剂。其中有一种方剂加入了附子，是用辛热之药来辅助寒凉之药，目的是宣发痞证的郁结阻滞，并非为了攻逐寒邪。
先发汗或误用下法后，阳气虚弱，所以出现恶寒、汗出。太阳病篇说：“发汗后恶寒的，是虚证。”这里加入附子，是担心大黄、黄连损伤阳气，并非为了补虚。
痞硬：伤寒呕吐且发热的，柴胡证具备，但如果被其他医生误用下法，导致心下胀满但不疼痛的，这是痞证，适宜用半夏泻心汤。（相关论述见“结胸与痞证的异同”章节）
半夏泻心汤方（此方的药味大概源自理中人参黄芩汤方）：
半夏（半升，洗净）、黄芩、干姜、人参、甘草（炙，以上各三两）、黄连（一两）、大枣（十二枚，掰开）。以上七味药，用水一斗，煮取六升，去渣，再煎煮取三升，温服一升，每日三次。（如果加入甘草，即为甘草泻心汤，治疗痞硬伴吐利；如果加入生姜，即为生姜泻心汤，治疗痞硬伴嗳气。）辛味入肺而能散气，半夏的辛味可以散结气；苦味入心而能泄热，黄芩、黄连的苦味入心以清痞热；脾欲舒缓，急则食甘以缓之，人参、甘草、大枣的甘味可以缓脾。
痞硬下利：
伤寒汗出表解之后，胃中不和，心下痞硬，干噫（打嗝）伴有食物腐败气味，胁下有停水，腹中雷鸣般作响并下利的，用生姜泻心汤主治。（成无己注：胃为津液之主，阳气的根本。大汗出后，体表津液亡失，胃中空虚，客气上逆，导致心下痞硬。《金匮要略》说：中焦气机未和，不能消化谷物，所以令人生噫气。干噫食臭，是胃虚不能杀谷。胁下有停水，腹中雷鸣，是土弱不能制水。给予泻心汤以攻痞，加生姜以益胃。）
生姜泻心汤方：
生姜（四两，切片）、半夏（半升，洗净）、甘草（炙）、人参、黄芩（各三两）、黄连（二两）、干姜（一两）、大枣（十二枚，掰开）。以上八味药，用水一斗，煮取六升，去渣，再煎煮取三升，温服一升，每日三次。
伤寒中风，医生反而误用下法，导致病人下利每天几十次，完谷不化，腹中雷鸣，心下痞硬且满，干呕，心烦不得安宁。医生看到心下痞，认为病邪未尽，再次误用下法，结果痞证更加严重。这并不是结热，而是因为胃中虚，客气上逆，所以导致大便硬结。用甘草泻心汤主治。（成无己注：伤寒和中风是指伤寒或中风病。邪气在表，医生反而误用下法，使肠胃虚弱，气机内陷。下利日数十行，完谷不化，腹中雷鸣，是下法后里虚胃弱。心下痞硬，干呕，心烦不得安，是胃中空虚，客气上逆。给予泻心汤以攻痞，加甘草以补虚。前文因发汗后胃虚是外伤阳气，故加生姜；此处因下法后胃虚是内损阴气，故加甘草。）
甘草泻心汤方：
甘草（四两）、黄芩、干姜（各三两）、半夏（汤洗，半升）、黄连、大枣（十二枚，掰开）。以上六味药，用水一斗，煮取六升，去渣，再煎煮取三升，温服一升，每日三次。
成无己注：气结聚而不散，壅塞而不通，称为结胸，陷胸汤是直达病所的药剂；堵塞而不通，闭塞而不通畅，称为痞，泻心汤是分解病邪的药剂。“泻心”是指泻除心下的邪气。痞与结胸有部位高下之分。邪结在胸中，所以叫陷胸汤；邪留于心下，所以叫泻心汤。《内经》说：苦味先入心，以苦味泻之。泻心必须用苦味为主，所以以黄连为君药，黄芩为臣药，以降阳升阴。《内经》说：辛味走气，辛味能散之。散痞必须用辛味为君，所以以半夏、干姜为佐药，以分阴而行阳。阴阳不交称为痞，上下不通称为满。想要上下通畅，阴阳必须调和，其中所谓“中”，指的是脾胃。脾不足者，用甘味补之，所以用人参、甘草、大枣为使药，以补脾和中。中气得和，上下得通，阴阳得分，水升火降，则痞消热退，大汗而解。
痞濡（软）：
脉浮而紧，又误用下法，紧脉反入里，则形成痞证。按之自软，只是气痞罢了。（“濡”与“硬”相反，作痞恐当作结胸。）心下痞，按之柔软，脉关上浮的，用大黄黄连泻心汤主治。（结胸言胸，痞言心下。结胸言按之石硬，痞言按之濡。结胸言寸脉浮关脉沉，痞不言寸而只说关上浮，由此可知两种病的区别。《活人书》说：结胸与痞，关脉都应当沉。若关脉浮而结，是三黄汤以泻肝。）
大黄黄连泻心汤：
大黄（二两）、黄连（一两）。以上两味药，用沸水二升浸泡片刻，绞去渣，分两次温服。（《内经》说：火热受邪，心病生焉。苦入心，寒除热。大黄、黄连的苦寒之性，以导泻心下的虚热。只用沸水浸泡服用，是取其气薄而泻虚热。）
心下痞且又恶寒汗出的，用附子泻心汤主治。（因为恶寒汗出，所以加附子以温经固阳。）
附子泻心汤方：
大黄、黄连、黄芩（各一两）、附子（一枚，炮制，去皮脐，破开，另煮取汁）。以上药材切碎，用沸水二升热浸一时许，绞去渣，纳入附子汁，分两次温服。
伤寒大下后又复发汗，心下痞，恶寒的，说明表证未解。不可攻痞，应当先解表，表解了才可以攻痞。解表宜用桂枝汤，攻痞宜用大黄黄连泻心汤。（《活人书》说：大抵结胸与痞都应下，但表未解者不可攻。表证未解，心下妨闷的，不是痞，称为支结，用柴胡桂枝汤主治。胸胁满微结，用小柴胡加干姜牡蛎汤主治。）原本因误下导致心下痞，给予泻心汤，痞不解，其人渴而口燥烦，小便不利的，用五苓散主治。（成无己注：本因下后成痞，当给泻心汤去除。若服之痞不解，其人渴而口燥烦，小便不利，是水饮内蓄，津液不行，非热痞，应与五苓散发汗散水则愈。一方说忍一天不饮水，外水不入，所停之水得行，痞亦愈。）
痞硬吐利：
伤寒发热，汗出不解，心中痞硬，呕吐而下利的，用大柴胡汤主治。心下痞硬，呕逆下利，若表解身凉，胁痛的，用十枣汤主治。（方论并见“胁痛”章节）
《活人书》说：十枣汤、大柴胡汤皆治心下痞。十枣汤尤其难用，必须是表证罢，不恶寒，身凉，其人汗出，发作有时，头疼，心下痞满，引胁下疼，干呕，短气的，才可用十枣汤。表未解者，慎不可用。
下利表里未解：
太阳病外证未除而多次误下，遂挟热而利，利下不止，心下痞硬，表里不解的，用桂枝人参汤主治。（成无己注：外证未除而多次误下，为重虚其里，邪热入里，虚挟热遂利不止而心下痞。若表解而下利心下痞，乘虚者可给泻心汤。若不下利，表不解而心下痞，可先解表而后攻痞。今以表里不解，故与桂枝人参汤和里解表。）
桂枝人参汤方：
桂枝（去粗皮）、甘草（炙，各四两）、白术、人参、干姜（各三两）。以上五味药，用水九升，先煮前四味，取五升，纳桂枝，更煮取三升，温服一升，每日两次，夜间一次。（表未解者，辛以散之；里不足者，甘以缓之。此因里气大虚，表里不解，故加桂枝、甘草于理中汤中。）
张元素问：大柴胡汤是泻法，桂枝人参汤是补法，为何都治下利心下痞硬？我说：这不是里实，而是下之过早因作痞，里虚协热而利。不看成氏注云：若表解而下利心下痞者是里实，可与泻心汤；若不下利，表不解而心下痞，可先解表而后攻痞。此以表里不解，故与桂枝人参和里解表。夫伤寒发热汗出不解，心下痞硬，呕吐而下利者，表和而里病也。以心中痞硬故为实，当以大柴胡汤下之。二者心下痞硬虽同，而虚实之证有别，故用药有攻补之异。
痞硬噫气：
伤寒发汗，若吐若下，解后心下痞硬，噫气不除的，用旋复代赭石汤主治。（噫气即俗所谓嗳气。《活人书》说：有旋复代赭石证，其人或咳逆气虚者，先服四逆汤；胃寒者，先服理中丸，次服旋复代赭汤为良。）
旋复代赭石汤方：
旋复花、甘草（各三两，炙）、人参（二两）、代赭石（一两）、生姜（切，五两）、半夏（汤洗，半升）、大枣（十二枚，掰开）。以上七味药，用水一斗，煮取六升，去渣，再煎取三升，温服一升，每日三次。（硬则气坚，咸味可以软之，旋复花的咸味可以软痞硬；虚则气浮，重剂可以镇之，代赭石的沉重可以镇虚逆；辛者散也，生姜、半夏的辛味可以散虚痞；甘者缓也，人参、甘草、大枣的甘味可以补胃弱。）
病解后心下痞硬，噫气，若不下利的，此方为旋复代赭石汤。若下利的，前方为生姜泻心汤。
痞硬气上冲：
胸中痞硬，气上冲咽，不得呼吸的，用瓜蒂散。若心下痞硬，胁痛，气上冲咽，眩冒的，属痿（论述见“气上冲心”章节）。
《活人书》说：下利而心下痞，服生姜泻心汤、甘草泻心汤，利不止者，当治其下焦，赤石脂禹余粮汤主治。盖生姜泻心、甘草泻心皆治中焦，此利在下焦，若只治中焦则利益甚。服赤石脂禹余粮汤，利复不止，当利其小便，五苓散主治。又云：凡痞服泻心汤不愈，然后可用陷胸丸下之（不可用陷胸汤，盖太猛，只用陷胸丸）。
发热恶寒，身痛，表证未解，若心下支结，妨闷的，用柴胡桂枝汤。（方见太阳病。若心下痞而腹满者，即前条先以桂枝汤解，后用大黄黄连泻心。）心下满似痞而手足厥冷，若脉乍结乍紧，心烦，饥不欲食的，用瓜蒂散。若脉细沉，头汗，恶寒，大便硬的，用小柴胡汤。（论述见“厥”章节）
太阳病，医生发汗，遂发热恶寒，因复下之，心下痞，表里俱虚，阴阳并竭。无阳则阴独，复加烧针，因胸烦，面色青黄，肤瞤者，难治。今色微黄，手足温，易愈。
脉浮而大，心下反硬，有热，属脏者，攻之，不令发汗；属腑者，不令溲数。溲数则大便硬，汗多则热愈甚，汗少则便难。若脉迟，尚未可攻。阳明痞，胃实心下硬满者，不可攻之。（论述见“胃实”章节）
附：桔梗枳壳汤，治伤寒痞气，胸满欲绝。
枳壳（麸炒去瓤）、桔梗（各二两）。以上药材切碎，用水二盏，煎至一盏，去渣，分二次服。
李东垣说：伤寒本无痞，应发汗，医反下之，遂成痞，枳实理中丸最良。审知是痞，先用桔梗枳壳汤尤妙，缘桔梗、枳壳行气下膈，先用之无不验也。
赵嗣真说：《活人书》第七十六问中云：凡痞服泻心汤不愈，然后可用陷胸汤下之。愚详仲景论陷胸汤无治痞之例，恐太猛难用。又况胸与心下处所不同，痛与不痛，阴阳邪亦异。除结胸外，今将痞证以传经之邪与内陷之邪分为二种而下治焉：一者病发于阴，身无热而反下之，医反入里则作痞，其脉关上沉，为阴邪内陷也，先宜桔梗枳壳汤，次半夏泻心诸汤随证用之。服泻心汤后渴而口燥烦，小便不利者，五苓散。二者身有热，不因下后而传邪入里，亦作痞，其脉关上浮，为阳邪随经入里，须先解表而不恶寒者，宜三黄泻心。又有心下痞而汗出恶寒者，以阳邪与表之正气入里，故表虚汗出而恶寒，因加附子以固表也。既结胸证有寒实热实之殊，则痞证亦有阴阳邪不为异也。外有痞而硬者，或桂枝人参汤温之，或大柴胡汤、十枣汤下之，亦自同一律也。《活人书》又云：关浮则结热，三黄以泻肝。盖热结则成结胸，非痞也。况心下正属中焦，关脉亦主中部，故汤名泻心，岂可援杂病脉例以左关为肝部，因谓之泻肝乎？
张元素说：或谓痞证多有杂以别证，而心下痞硬者，必非半夏泻心之所宜也。予曰：证候不同，宜从治疗。以上诸痞皆杂别证，非特下早而成也。仲景所以各从其宜，用药以治之。若下早而作痞者，但满而不痛，别无外证，与半夏泻心汤以攻痞宜也。
吴崑说：夫痞者，气郁不通泰也。若不因下早而为痞者，或痰或食或气为之结也。《保命集》曰：治痞用泻心主之，各有冷热之不同，要在辨而治之。如热实而为痞者，大黄黄连泻心汤之类也；或寒多而热少，半夏泻心等汤之类也。要之，泻心非泻心火之热，乃泻心下之痞满也。
The epigastrium (upper abdomen) is full, hard, and painful; this is an excess syndrome called Jie Xiong (Chest Binding). The epigastrium is full and hard but not painful; this is a deficiency syndrome called Pi Qi (Stagnant Gas/Epigastric Fullness). It is neither full nor hard, but only feels vexatious and stifled; this is called Zhi Jie (Branch Binding). *Baoming Ji* states: If the Spleen cannot transport Qi to the four viscera, and Qi condenses without dispersing, it forms Pi Zheng (Pi Syndrome). Generally, all types of Pi are caused by Heat pathogens. Therefore, medicines for treating Pi are all cold-natured agents. In one instance, Fu Zi (Prepared Aconite Root) is added; this uses acrid-hot herbs to assist cold-cool herbs, aiming to open up the stagnation and constraint of Pi, not to attack Cold.
After initial sweating or mistaken purgation, Yang Qi becomes deficient, leading to aversion to cold and sweating. The Taiyang chapter states: "Aversion to cold after sweating indicates deficiency." Adding Fu Zi here is to prevent Da Huang (Rhubarb Rhizome) and Huang Lian (Coptis Rhizome) from damaging Yang Qi, not to tonify deficiency.
Pi Hardness: In Shanghan (Cold Damage), if there is vomiting and fever, Chai Hu patterns are present. If mistakenly treated with purgatives, resulting in epigastric fullness without pain, this is Pi, suitable for Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Epigastrium). (See discussion on differences between Jie Xiong and Pi).
Ban Xia Xie Xin Tang Formula:
Ban Xia (Pinellia Tuber, half sheng, washed), Huang Qin (Scutellaria Root), Gan Jiang (Dried Ginger), Ren Shen (Ginseng Root), Gan Cao (Licorice Root, roasted, 3 liang each above), Huang Lian (Coptis Rhizome, 1 liang), Da Zao (Jujube Fruit, 12 pieces, split). Seven ingredients, boil in 10 sheng water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily. (If Gan Cao is increased, it becomes Gan Cao Xie Xin Tang, treating Pi hardness with vomiting and diarrhea; if Sheng Jiang is added, it becomes Sheng Jiang Xie Xin Tang, treating Pi hardness with belching.) Acrid flavors enter the Lung and disperse Qi; the acridity of Ban Xia disperses condensed Qi. Bitter flavors enter the Heart and drain Heat; the bitterness of Huang Qin and Huang Lian enters the Heart to clear Pi Heat. The Spleen desires relaxation; when tense, sweet foods relax it. The sweetness of Ren Shen, Gan Cao, and Da Zao relaxes the Spleen.
Pi Hardness with Diarrhea:
After Shanghan sweating resolves the exterior, if the Stomach is disharmonious, the epigastrium is hard and full, accompanied by dry belching with food odor, fluid retention under the ribs, borborygmus (rumbling in the abdomen), and diarrhea, treat with Sheng Jiang Xie Xin Tang. (Cheng Wuji notes: The Stomach is the master of fluids and the root of Yang Qi. After profuse sweating, body fluids are lost externally, leaving the Stomach empty. Hostile Qi rebels upward, causing epigastric hardness. *Jin Gui Yao Lue* states: Disharmony of Middle Jiao Qi fails to digest grain, causing belching. Dry belching with food odor indicates Stomach deficiency failing to "kill" (digest) grain. Fluid retention under ribs and borborygmus indicate weak Earth failing to control Water. Give Xie Xin Tang to drain Pi, add Sheng Jiang to benefit the Stomach.)
Sheng Jiang Xie Xin Tang Formula:
Sheng Jiang (Fresh Ginger, 4 liang, sliced), Ban Xia (Pinellia Tuber, half sheng, washed), Gan Cao (Licorice Root, roasted), Ren Shen (Ginseng Root), Huang Qin (Scutellaria Root, 3 liang each), Huang Lian (Coptis Rhizome, 2 liang), Gan Jiang (Dried Ginger, 1 liang), Da Zao (Jujube Fruit, 12 pieces, split). Eight ingredients, boil in 10 dou water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.
In Shanghan or Zhong Feng, if the physician mistakenly uses purgatives, the patient suffers diarrhea dozens of times daily with undigested food, borborygmus, epigastric hardness and fullness, dry retching, vexation, and inability to rest. Seeing epigastric Pi, the physician assumes residual pathogen and purges again, worsening the Pi. This is not accumulated Heat, but Stomach deficiency with hostile Qi rebelling upward, causing constipation/hard stool. Treat with Gan Cao Xie Xin Tang. (Cheng Wuji notes: Shanghan and Zhong Feng refer to Cold Damage or Wind Strike. Pathogen is at the exterior; mistaken purgation weakens intestines and Stomach, causing Qi to sink inward. Diarrhea with undigested food and borborygmus indicates interior deficiency and weak Stomach post-purgation. Epigastric hardness, dry retching, and vexation indicate empty Stomach with hostile Qi rebelling. Give Xie Xin Tang to drain Pi, add Gan Cao to tonify deficiency. Previous case involved exterior injury to Yang Qi from sweating, hence adding Sheng Jiang; this case involves interior damage to Yin Qi from purgation, hence adding Gan Cao.)
Gan Cao Xie Xin Tang Formula:
Gan Cao (Licorice Root, 4 liang), Huang Qin (Scutellaria Root), Gan Jiang (Dried Ginger, 3 liang each), Ban Xia (Pinellia Tuber, washed in boiling water, half sheng), Huang Lian (Coptis Rhizome), Da Zao (Jujube Fruit, 12 pieces, split). Six ingredients, boil in 10 dou water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.
Cheng Wuji notes: Condensed Qi that does not disperse and obstructs flow is Jie Xiong; Xian Xiong Tang is a direct agent. Blocked and unsmooth is Pi; Xie Xin Tang is a resolving agent. "Draining the Heart" means draining pathogenic factors from the epigastrium. Pi and Jie Xiong differ in location. Pathogen binding in the chest is Xian Xiong Tang; pathogen lingering in the epigastrium is Xie Xin Tang. *Nei Jing* states: Bitter flavor enters the Heart first; use bitter to drain. Draining the Heart requires bitter as chief, so Huang Lian is Sovereign, Huang Qin is Minister, to descend Yang and ascend Yin. *Nei Jing* states: Acrid flavor moves Qi; use acrid to disperse. Dispersing Pi requires acrid as chief, so Ban Xia and Gan Jiang are Assistants, to divide Yin and move Yang. When Yin and Yang do not intersect, it is Pi; when upper and lower do not connect, it is Man (Fullness). To connect upper and lower, Yin and Yang must harmonize. The "Middle" refers to the Spleen and Stomach. For Spleen insufficiency, use sweet to tonify; thus Ren Shen, Gan Cao, and Da Zao are Envoys to tonify Spleen and harmonize Middle. When Middle Qi harmonizes, upper and lower connect, Yin and Yang separate, Water ascends and Fire descends, Pi dissipates, Heat clears, and profuse sweating resolves.
Pi Softness:
Pulse is floating and tight; mistaken purgation causes the tight pulse to enter the interior, forming Pi. Palpation reveals softness, indicating merely Qi Pi. ("Soft" opposes "Hard"; Pi might be a typo for Jie Xiong). Epigastric Pi, soft on palpation, with floating pulse at Guan position: Treat with Da Huang Huang Lian Xie Xin Tang. (Jie Xiong refers to chest; Pi refers to epigastrium. Jie Xiong is stone-hard on palpation; Pi is soft. Jie Xiong has floating Chi and deep Guan pulses; Pi mentions only floating Guan pulse, distinguishing the two. *Huoren Shu* states: Both Jie Xiong and Pi should have deep Guan pulses. If Guan is floating and knotted, San Huang drains Liver.)
Da Huang Huang Lian Xie Xin Tang:
Da Huang (Rhubarb Rhizome, 2 liang), Huang Lian (Coptis Rhizome, 1 liang). Two ingredients, steep in 2 sheng boiling water for a moment, squeeze out dregs, take warm in two doses. (*Nei Jing*: Fire-Heat pathogen generates Heart disease. Bitter enters Heart, Cold removes Heat. The bitter-cold of Da Huang and Huang Lian guides out deficient Heat in the epigastrium. Steeping in boiling water extracts thin Qi to drain deficient Heat.)
Epigastric Pi with aversion to cold and sweating: Treat with Fu Zi Xie Xin Tang. (Add Fu Zi due to aversion to cold and sweating to warm meridians and secure Yang.)
Fu Zi Xie Xin Tang Formula:
Da Huang (Rhubarb Rhizome), Huang Lian (Coptis Rhizome), Huang Qin (Scutellaria Root, 1 liang each), Fu Zi (Prepared Aconite Root, 1 piece, processed, skin and umbilicus removed, broken, decocted separately for juice). Chop herbs, steep in 2 sheng hot water for one hour, squeeze out dregs, mix with Fu Zi juice, take warm in two doses.
After severe purgation and subsequent sweating in Shanghan, if epigastric Pi and aversion to cold persist, the exterior is unresolved. Do not attack Pi; resolve exterior first. Resolve exterior with Gui Zhi Tang (Cinnamon Twig Decoction); attack Pi with Da Huang Huang Lian Xie Xin Tang. (*Huoren Shu*: Generally, Jie Xiong and Pi require purgation, but not if exterior is unresolved. If exterior unresolved with epigastric oppression, it is Zhi Jie, treat with Chai Hu Gui Zhi Tang. Chest/flank fullness with slight knotting: Xiao Chai Hu Tang plus Gan Jiang and Mu Li. Originally caused by mistaken purgation leading to Pi; if Xie Xin Tang fails, and patient has thirst, dry mouth, vexation, and scanty urine, use Wu Ling San (Poria Pill). Cheng Wuji notes: Post-purgation Pi should be treated with Xie Xin Tang. If ineffective, and symptoms include thirst, dry mouth, vexation, and urinary difficulty, it is internal fluid retention blocking Jin Ye, not Heat Pi. Use Wu Ling San to induce sweating and dissipate water. Alternatively, abstain from drinking for a day; external water does not enter, retained water moves, Pi resolves.)
Pi Hardness with Vomiting and Diarrhea:
Shanghan fever, sweating without resolution, epigastric hardness, vomiting, and diarrhea: Treat with Da Chai Hu Tang. Epigastric hardness, retching, diarrhea, if exterior resolved and body cool with flank pain: Treat with Shi Zao Tang. (*Huoren Shu*: Shi Zao Tang and Da Chai Hu Tang both treat epigastric Pi. Shi Zao Tang is difficult to use; indicated only when exterior signs cease, no aversion to cold, body cool, sweating, paroxysmal headache, epigastric fullness radiating to flanks, dry retching, shortness of breath. Contraindicated if exterior unresolved.)
Diarrhea with Unresolved Exterior and Interior:
Taiyang exterior signs persist despite multiple purgations, leading to heat-carrying diarrhea, continuous diarrhea, epigastric hardness, and unresolved exterior-interior: Treat with Gui Zhi Ren Shen Tang. (Cheng Wuji notes: Multiple purgations while exterior persists severely weaken interior, allowing heat pathogen to enter, causing deficiency-with-heat diarrhea and Pi. If exterior resolved with Pi and diarrhea, use Xie Xin Tang. If no diarrhea, unresolved exterior with Pi, resolve exterior first then attack Pi. Here, unresolved exterior-interior requires Gui Zhi Ren Shen Tang to harmonize interior and resolve exterior.)
Gui Zhi Ren Shen Tang Formula:
Gui Zhi (Cinnamon Twig, bark removed), Gan Cao (Licorice Root, roasted, 4 liang each), Bai Zhu (Atractylodes Macrocephala Rhizome), Ren Shen (Ginseng Root), Gan Jiang (Dried Ginger, 3 liang each). Five ingredients, boil in 9 sheng water, decoct first four to 5 sheng, add Gui Zhi, decoct to 3 sheng. Take 1 sheng warm, twice daily, once at night. (Acrid disperses unresolved exterior; sweet moderates interior insufficiency. Due to severe interior deficiency and unresolved exterior, Gui Zhi and Gan Cao are added to Li Zhong Tang.)
Zhang Yuansu asked: Da Chai Hu Tang is purgative; Gui Zhi Ren Shen Tang is tonic. Why both treat diarrhea and epigastric hardness? I reply: This is not interior excess, but premature purgation causing Pi, interior deficiency with heat-carrying diarrhea. Cheng Wuji notes: If exterior resolved with Pi and diarrhea, it is interior excess, use Xie Xin Tang. If no diarrhea, unresolved exterior with Pi, resolve exterior first. Here, unresolved exterior-interior requires Gui Zhi Ren Shen Tang. Fever and sweating without resolution, epigastric hardness, vomiting, diarrhea: Exterior is harmonized, interior is diseased. Epigastric hardness indicates excess, requiring Da Chai Hu Tang. Though both present epigastric hardness, one is excess, one deficiency; thus treatments differ (purgation vs. tonification).
Pi Hardness with Belching:
After Shanghan sweating, vomiting, or purgation resolves, if epigastric hardness and persistent belching remain: Treat with Xuan Fu Dai Zhe Shi Tang. (Belching is common belching. *Huoren Shu*: If coughing, rebellious Qi, or deficiency, take Si Ni Tang first; if Stomach Cold, take Li Zhong Wan first, then Xuan Fu Dai Zhe Shi Tang.)
Xuan Fu Dai Zhe Shi Tang Formula:
Xuan Fu Hua (Inula Flower), Gan Cao (Licorice Root, roasted, 3 liang each), Ren Shen (Ginseng Root, 2 liang), Dai Zhe Shi (Hematite, 1 liang), Sheng Jiang (Fresh Ginger, sliced, 5 liang), Ban Xia (Pinellia Tuber, washed in boiling water, half sheng), Da Zao (Jujube Fruit, 12 pieces, split). Seven ingredients, boil in 10 dou water to 6 sheng, remove dregs, decoct again to 3 sheng. Take 1 sheng warm, three times daily. (Hardness implies firm Qi; salty flavor softens. Xuan Fu Hua's saltiness softens Pi hardness. Deficiency implies floating Qi; heavy agents anchor. Dai Zhe Shi's heaviness anchors rebellious Qi. Acrid disperses; Sheng Jiang and Ban Xia's acridity disperses deficient Pi. Sweet moderates; Ren Shen, Gan Cao, and Da Zao's sweetness tonifies weak Stomach.)
Post-illness epigastric hardness and belching without diarrhea: Xuan Fu Dai Zhe Shi Tang. With diarrhea: Sheng Jiang Xie Xin Tang.
Pi Hardness with Qi Rushing Upward:
Chest Pi hardness, Qi rushing to throat, inability to breathe: Gua Di San (Melon Seed Powder). Epigastric hardness, flank pain, Qi rushing to throat, vertigo: Wei pattern. (*Huoren Shu*: Diarrhea with Pi, if Sheng Jiang Xie Xin Tang and Gan Cao Xie Xin Tang fail, treat Lower Jiao with Chi Shi Zhi Yu Liang Tang. These Xie Xin Tangs treat Middle Jiao; this diarrhea is Lower Jiao. Treating only Middle worsens diarrhea. If Chi Shi Zhi Yu Liang Tang fails, promote urination with Wu Ling San. Also: If Pi unresponsive to Xie Xin Tang, use Xian Xiong Wan (not Xian Xiong Tang, which is too strong).)
Fever, aversion to cold, body ache, unresolved exterior, with branch-binding oppression in epigastrium: Chai Hu Gui Zhi Tang. Epigastric fullness resembling Pi with cold limbs, intermittent knotted/tight pulse, vexation, hunger but no desire to eat: Gua Di San. Fine, deep pulse, head sweating, aversion to cold, hard stool: Xiao Chai Hu Tang.
Taiyang disease, after sweating and purgation, leads to fever, aversion to cold, epigastric Pi, simultaneous exterior-interior deficiency, exhaustion of Yin and Yang. Without Yang, Yin stands alone. Adding moxibustion causes chest vexation, bluish-yellow complexion, muscle twitching: Difficult to treat. Mild yellow complexion and warm hands/feet: Easy to cure.
Floating and large pulse, epigastric hardness contrary to expectation, presence of Heat: If belonging to Zang, purge, do not sweat. If belonging to Fu, do not cause frequent urination. Frequent urination hardens stool; excessive sweating increases Heat; scanty sweating causes difficulty defecating. If pulse is slow, purgation is not yet appropriate. Yangming Pi with full Stomach and epigastric hardness/fullness: Do not purge.
Appendix: Jie Geng Zhi Ke Tang treats Shanghan Pi with chest fullness nearing death.
Zhi Ke (Bitter Orange, bran-fried, pith removed), Jie Geng (Platycodon Root, 2 liang each). Chop, boil in 2 cups water to 1 cup, remove dregs, take in two doses.
Li Dongyuan says: Shanghan originally has no Pi; should sweat, but mistaken purgation causes Pi. Zhi Shi Li Zhong Wan is best. Confirming Pi, use Jie Geng Zhi Ke Tang first to move Qi downward through diaphragm; always effective.
Zhao Sizhen says: *Huoren Shu* Q76 states: If Pi unresponsive to Xie Xin Tang, use Xian Xiong Tang. I examine Zhang Zhongjing's texts; Xian Xiong Tang has no example for Pi, likely too strong. Chest and epigastrium differ; pain vs. non-pain differs in Yin/Yang pathology. Excluding Jie Xiong, classify Pi into transmitted pathogen and sinking pathogen. 1. Originating in Yin, no fever, mistaken purgation sinks pathogen inward, Guan pulse deep (Yin sinking): First Jie Geng Zhi Ke Tang, then Ban Xia Xie Xin Tang variants. If thirsty, dry mouth, vexation, scanty urine after Xie Xin Tang: Wu Ling San. 2. Fever, pathogen transmits inward without purgation, Guan pulse floating (Yang entering): Resolve exterior first if no aversion to cold, use San Huang Xie Xin Tang. If Pi with sweating and aversion to cold, Yang pathogen enters with exterior Zheng Qi, causing exterior deficiency sweating/aversion: Add Fu Zi to secure exterior. Since Jie Xiong has Cold/Excess and Heat/Excess, Pi also has Yin/Yang distinctions. External Pi hardness may be warmed by Gui Zhi Ren Shen Tang or purged by Da Chai Hu Tang/Shi Zao Tang. *Huoren Shu* claims floating Guan indicates Heat knotting, San Huang drains Liver. But Heat knotting forms Jie Xiong, not Pi. Epigastrium is Middle Jiao, Guan pulse governs Middle. Hence "Xie Xin" (Drain Heart/Epigastrium), not "Drain Liver" based on left Guan Liver association.
Zhang Yuansu says: Some argue Pi with mixed symptoms and epigastric hardness is unsuitable for Ban Xia Xie Xin Tang. I reply: Patterns differ, treatment follows. All aforementioned PIs involve mixed symptoms, not just premature purgation. Zhang Zhongjing treats according to suitability. Premature purgation Pi, full but painless, no other exterior signs: Ban Xia Xie Xin Tang is appropriate to drain Pi.
Wu Kun says: Pi is Qi stagnation and lack of smoothness. If not from premature purgation, it may be Phlegm, Food, or Qi knotting. *Baoming Ji* states: Treat Pi with Xie Xin formulas, distinguishing Cold/Heat. Heat-excess Pi: Da Huang Huang Lian Xie Xin Tang. Cold-excess/Heat-deficient: Ban Xia Xie Xin Tang variants. Ultimately, "Xie Xin" does not drain Heart Fire Heat, but drains epigastric Pi fullness.