大意
痞与否同。不通泰之谓也。气血痰积。皆能成之。觉满闷痞塞。按之不痛。由脾弱勿能运化。故内经谓太阴
所至为痞膈中满。（汇补）
内因
痞由阴伏阳蓄。气血不运而成。处心下。位中央。填满痞塞。皆湿土之为病也。（心法）
外候
否与胀满不同。胀满则内胀而外亦有形。痞满则内觉满塞而外无形迹。（汇补）
痞分虚实
虚痞不食。大便利。实痞能食。大便闭。虚痞以芍药、陈皮和之。实痞以浓朴、枳实消之。（汇补）
痞满分治
有饮食痰积不运为痞者。六君子加山楂、谷芽。有湿热太甚。土来心下为痞者。分消上下。与湿同治。或黄
连泻心汤。不因误下。邪气乘虚为痞者。宜理脾胃。兼以血药调之。有阴火上炎。痞闷嗳气者。宜降火。有肝
气不伸。膈有稠痰。两寸关脉弦滑带涩者。当先吐而后舒郁。有中虚不运如饥如刺者。益气温中。有内伤
劳役。清气下陷。浊气犯上者。补中益气。兼清湿热。有悲哀多郁。痰挟痰血。结成窠囊者。宜逐瘀行气。有食
后感寒。饮食不消。或食冷物成痞者。宜温中化滞。（汇补）
痞分肥瘦
肥人心下痞。湿痰也。二陈二术。有火加芩、连。实者去白术。或滚痰丸。瘦人心下痞。乃郁热也。宜枳实、
黄连以导之。葛根、升麻以发之。（汇补）
脉法
胸痞脉滑。为有痰结。弦伏中虚。微涩气劣。沉涩血郁。（举要）
治法
大抵心下痞闷。必是脾胃受亏。浊气挟痰。不能运化为患。初宜舒郁化痰降火。二陈、越鞠、芩连之类。久之
固中气。参、术、苓、草之类。佐以他药。有痰治痰。有火清火。郁则兼化。若妄用克伐。祸不旋踵。又痞同湿治。
惟宜上下分消其气。如果有内实之症。庶可疏导。（汇补）
用药
主以二陈汤去甘草。加人参、白术、枳实、浓朴、黄芩、黄连、泽泻等。如饮食痰积。去参、术。加山楂、
麦芽、莱菔子、青皮。湿热太甚。去参术。加苍术、黄柏。中虚不运者。加山楂、麦芽助化之。肥人湿痰。
宜苍术、半夏、茯苓、滑石消之。瘦人湿热。宜枳实、黄连导之。升麻、葛根发之。若大病后。元气未复而
痞满短气。及误服利剂为虚痞者。宜补中益气汤。加陈皮、枳实。
痞满选方
浓朴温中汤 治脾胃气虚。心腹胀满。疼痛时止时作者。
浓朴 陈皮 茯苓 草豆蔻 甘草 木香 干姜 如不应。加参、术。
黄连泻心汤
黄连 浓朴 干姜（各五分） 甘草（三分） 人参 半夏 生姜（各一钱）
水煎。
东垣失笑丸 治右关脉弦。心下虚痞。恶食懒倦。开胃进食。
黄连 枳实（各五钱） 麦芽（二钱） 干姜 甘草 白术 茯苓 人参 半夏曲（各三钱） 浓朴（四钱）
蒸饼丸服。
木香顺气丸（汤） 治心腹满闷。药稍辛散。初病无火最宜。
木香 益智 陈皮 苍术 草豆蔻 浓朴 青皮 茯苓 泽泻 半夏 干姜 茱萸 当归 人参 升麻 柴胡
消痞丸 治心下痞块。或痛或黄肿。肌瘦腹大。作胀。气积食积。
苍术（四两） 浓朴（四钱） 青皮（二钱） 陈皮 山楂 枳实（各二两）
三棱 莪术 槟榔 草果 针砂（各五钱） 砂仁 木香（各七钱） 小茴 甘草 香附 乌药（各一两）
上为末。酒糊丸。如黄豆大。每服十五丸。姜汤下。
【大意】
“痞”与“否”字相通，意为不通畅、不通达。气、血、痰、食积滞，都能导致痞证。患者自觉胸脘部满闷堵塞，但按压时并不疼痛。这是由于脾脏虚弱，不能正常运化水谷精微所致。因此，《黄帝内经》中说：“太阴湿土之气所至，会出现痞塞、膈阻和胸中胀满的症状。”（引自《证治汇补》）
【内因】
痞证是由阴气潜伏、阳气蓄积，导致气血运行不畅而形成的。病位在心下（胃脘部），处于人体中央位置，表现为填满且痞塞不通，这都属于湿土之邪为患。（引自《医宗心法》）
【外候】
“痞”与“胀满”不同。胀满则是内部胀大，外部也能看到形体肿胀；而痞满则是内部感觉满塞，但外部没有明显的形迹变化。（引自《证治汇补》）
【痞分虚实】
虚性痞证表现为食欲不振，大便通畅；实性痞证表现为尚能进食，但大便闭塞不通。治疗虚性痞证，应用芍药、陈皮来调和脾胃；治疗实性痞证，应用厚朴、枳实来消导积滞。（引自《证治汇补》）
【痞满分治】
如果是饮食停滞、痰湿积聚导致运化失常而成的痞证，可用六君子汤加山楂、谷芽。如果是湿热过盛，湿邪上犯心下导致的痞证，应采用分消上下之法，按湿病同治，或者使用黄连泻心汤。如果不是因为误用攻下法，而是邪气乘虚侵入导致的痞证，应当调理脾胃，并兼用活血药物进行调治。如果有阴火上炎，导致痞闷、嗳气的，应当降火。如果有肝气郁结不舒，膈间有稠痰，且两手寸关脉象弦滑带涩的，应当先采用涌吐法祛痰，然后再疏解郁结。如果中气虚弱，运化无力，感觉像饥饿又像刺痛一样的，应当益气温中。如果是内伤劳役过度，导致清气下陷、浊气上逆犯上的，应当使用补中益气汤，兼清湿热。如果有悲哀多郁，导致痰挟瘀血，结成窠囊（顽固性病灶）的，应当逐瘀行气。如果在进食后感受寒邪，导致饮食不消化，或者吃了冷物形成痞证的，应当温中化滞。（引自《证治汇补》）
【痞分肥瘦】
肥胖之人出现心下痞，多为湿痰所致，可用二陈汤加白术、苍术治疗；如果有火热之象，加黄芩、黄连；实证则去掉白术，或者使用滚痰丸。消瘦之人出现心下痞，多为郁热所致，宜用枳实、黄连以引导泄热，葛根、升麻以发散郁热。（引自《证治汇补》）
【脉法】
胸部痞闷，脉象滑，说明有痰结；脉象弦或伏，说明中气虚弱；脉象微涩，说明气机衰弱；脉象沉涩，说明血行郁滞。（引自《脉诀举要》）
【治法】
大抵心下痞闷，必定是脾胃受损亏虚，浊气挟带痰湿，不能正常运化而产生的病变。初期适宜疏解郁结、化痰降火，可用二陈汤、越鞠丸、黄芩黄连之类。日久则需固护中气，用人参、白术、茯苓、甘草之类，佐以其他药物。有痰就治痰，有火就清火，有郁结就兼以化解。如果妄用攻伐药物，祸患很快就会到来。另外，痞证同湿证一样治疗，只适宜上下分消其气机。如果确实有里实证的症候，才可以采用疏导通下的方法。（引自《证治汇补》）
【用药】
主要使用二陈汤去掉甘草，加入人参、白术、枳实、厚朴、黄芩、黄连、泽泻等。如果是饮食痰积，去掉人参、白术，加入山楂、麦芽、莱菔子、青皮。如果是湿热太盛，去掉人参、白术，加入苍术、黄柏。如果是中虚运化无力者，加入山楂、麦芽帮助消化。肥胖之人湿痰重，宜用苍术、半夏、茯苓、滑石来消除；消瘦之人湿热重，宜用枳实、黄连引导，升麻、葛根发散。如果是大病之后，元气未恢复而出现痞满短气，以及误服利水通便药导致成为虚性痞证的，宜使用补中益气汤，加陈皮、枳实。
【痞满选方】
厚朴温中汤：治疗脾胃气虚，心腹胀满，疼痛时作时止的情况。
药材：厚朴、陈皮、茯苓、草豆蔻、甘草、木香、干姜。如果效果不明显，加入人参、白术。
黄连泻心汤
药材：黄连、厚朴、干姜（各五分）、甘草（三分）、人参、半夏、生姜（各一钱）。
用法：水煎服。
东垣失笑丸：治疗右关脉弦，心下虚痞，厌恶食物，懒倦乏力，旨在开胃进食。
药材：黄连、枳实（各五钱）、麦芽（二钱）、干姜、甘草、白术、茯苓、人参、半夏曲（各三钱）、厚朴（四钱）。
用法：蒸饼为丸服用。
木香顺气丸（或汤）：治疗心腹满闷。药性稍偏辛散，初发病且无火热之象者最为适宜。
药材：木香、益智仁、陈皮、苍术、草豆蔻、厚朴、青皮、茯苓、泽泻、半夏、干姜、吴茱萸、当归、人参、升麻、柴胡。
消痞丸：治疗心下痞块，或痛或发黄肿胀，肌肉消瘦腹部膨大，产生胀感，由气积、食积引起。
药材：苍术（四两）、厚朴（四钱）、青皮（二钱）、陈皮、山楂、枳实（各二两）、三棱、莪术、槟榔、草果、针砂（各五钱）、砂仁、木香（各七钱）、小茴香、甘草、香附、乌药（各一两）。
用法：以上药物研为细末，用酒糊制作成丸，如黄豆大小。每次服用十五丸，姜汤送下。
[General Principle]
"Pǐ" (Pǐ syndrome) is synonymous with "Pǒu" (impassable), meaning a state of obstruction and lack of smooth flow. Accumulations of Qi, Blood, Phlegm, and Food can all give rise to this condition. The patient feels fullness, stuffiness, and blockage in the chest and epigastrium, but there is no pain upon palpation. This arises because the Spleen is weak and fails to transport and transform properly. Therefore, the *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: "When Taiyin damp-earth qi prevails, it leads to Pǐ obstruction, diaphragmatic impediment, and fullness in the middle jiao." (From *Zhengzhi Huibu*)
[Etiology]
Pǐ syndrome is formed by the latent Yin and accumulated Yang, resulting in impaired circulation of Qi and Blood. It is located in the epigastrium ("heart below"), at the center of the body, presenting as filling and obstructive fullness. These are all diseases caused by Damp-Earth pathogenic factors. (From *Yizong Xinfa*)
[External Manifestations]
"Pǐ" differs from "Zhangman" (distension and fullness). In distension and fullness, there is internal swelling accompanied by external visible deformity; in Pǐ-fullness, there is an internal sensation of blockage and fullness, but no external physical signs. (From *Zhengzhi Huibu*)
[Differentiation of Deficiency and Excess in Pǐ]
Deficient Pǐ is characterized by loss of appetite and normal bowel movements. Excess Pǐ is characterized by preserved appetite but constipation. For deficient Pǐ, Shaoyao (White Peony Root) and Chenpi (Aged Tangerine Peel) are used to harmonize. For excess Pǐ, Houpo (Magnolia Bark) and Zhishi (Immature Bitter Orange) are used to dissipate stagnation. (From *Zhengzhi Huibu*)
[Treatment Based on Differentiation]
If Pǐ is caused by food retention and Phlegm-Damp accumulation leading to failed transformation, Liu Junzi Tang (Six Gentlemen Decoction) with Shanzha (Hawthorn Fruit) and Guya (Sprouted Millet) should be used. If Pǐ is caused by excessive Damp-Heat invading the epigastrium, treatment should involve dispersing Dampness through both upper and lower pathways, or Huanglian Xiexin Tang (Coptis Decoction to Drain the Heart) may be administered. If Pǐ results from pathogens taking advantage of deficiency rather than from erroneous purgative therapy, the Spleen and Stomach should be regulated, accompanied by blood-invigorating herbs. If flaming Fire from deficiency rises, causing stuffiness and belching, Fire should be descended. If Liver Qi is constrained and not free-flowing, with thick Phlegm in the diaphragm and wiry, slippery, yet slightly choppy pulses at the Cun and Guan positions, emesis should first be induced to remove Phlegm, followed by resolving depression. If Middle Jiao deficiency leads to failed transformation, causing sensations resembling hunger or stabbing pain, Qi should be tonified and the Middle warmed. If internal injury from overwork causes Clear Qi to sink and Turbid Qi to rebel upward, Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) should be used to tonify the Middle and clear Damp-Heat. If grief and depression lead to Phlegm binding with Blood stasis to form stubborn nodules, Blood stasis should be expelled and Qi moved. If cold is contracted after eating, or if cold foods cause indigestion leading to Pǐ, the Middle should be warmed and stagnation transformed. (From *Zhengzhi Huibu*)
[Differentiation by Body Constitution: Fat vs. Thin]
In obese individuals, epigastric Pǐ is due to Damp-Phlegm. Erchen Tang (Two Aged Herbs Decoction) plus Baizhu (Atractylodes Rhizome) and Cangzhu (Black Atractylodes Rhizome) is indicated; if Heat is present, add Huangqin (Scutellaria Root) and Huanglian (Coptis Rhizome); for excess patterns, remove Baizhu, or use Tuntan Wan (Rolling Phlegm Pill). In thin individuals, epigastric Pǐ is due to Depressed Heat. Zhishi (Immature Bitter Orange) and Huanglian (Coptis Rhizome) should be used to guide the heat downward, while Gegen (Kudzu Root) and Shengma (Cimicifuga Rhizome) should be used to disperse the depression. (From *Zhengzhi Huibu*)
[Pulse Diagnosis]
Chest Pǐ with a Slippery pulse indicates Phlegm knotting. Wiry or Deep-hidden pulses indicate Middle Jiao deficiency. Fine and Choppy pulses indicate Qi deficiency. Deep and Choppy pulses indicate Blood stasis. (From *Maijue Juyao*)
[Therapeutic Principles]
Generally, epigastric stuffiness implies damage to the Spleen and Stomach, where Turbid Qi carries Phlegm, failing to transform and causing pathology. Initially, one should soothe depression, resolve Phlegm, and descend Fire, using formulas like Erchen Tang (Two Aged Herbs Decoction), Yueju Wan (Solve Depression Pill), or Huangqin-Huanglian combinations. Over time, one must consolidate Middle Qi using Renshen (Ginseng Root), Baizhu (Atractylodes Rhizome), Fuling (Poria), and Gancao (Licorice Root), supplemented by other herbs. Treat Phlegm if present, clear Fire if present, and resolve depression if present. Reckless use of harsh purgatives will bring swift disaster. Furthermore, Pǐ is treated similarly to Dampness; it is best to disperse Qi through both upper and lower pathways. Only if there are definite interior-excess symptoms should guiding and draining methods be employed. (From *Zhengzhi Huibu*)
[Medication Selection]
The primary formula is Erchen Tang (Two Aged Herbs Decoction) without Gancao (Licorice Root), added with Renshen (Ginseng Root), Baizhu (Atractylodes Rhizome), Zhishi (Immature Bitter Orange), Houpo (Magnolia Bark), Huangqin (Scutellaria Root), Huanglian (Coptis Rhizome), and Zexie (Alisma Rhizome). For food and Phlegm accumulation, remove Renshen and Baizhu; add Shanzha (Hawthorn Fruit), Maiya (Sprouted Barley Seed), Laifuzi (Radish Seed), and Qingpi (Green Tangerine Peel). For excessive Damp-Heat, remove Renshen and Baizhu; add Cangzhu (Black Atractylodes Rhizome) and Huangbai (Phellodendron Bark). For Middle deficiency with failed transformation, add Shanzha (Hawthorn Fruit) and Maiya (Sprouted Barley Seed) to aid digestion. For obese patients with Damp-Phlegm, use Cangzhu (Black Atractylodes Rhizome), Banxia (Pinellia Tuber), Fuling (Poria), and Huashi (Talcum) to eliminate it. For thin patients with Damp-Heat, use Zhishi (Immature Bitter Orange) and Huanglian (Coptis Rhizome) to guide, and Shengma (Cimicifuga Rhizome) and Gegen (Kudzu Root) to disperse. After severe illness, if Yuanqi (Original Qi) has not recovered and Pǐ-fullness with shortness of breath occurs, or if erroneous use of purgatives has led to deficient Pǐ, Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with Chenpi (Aged Tangerine Peel) and Zhishi (Immature Bitter Orange) is indicated.
[Selected Formulas for Pǐ-Fullness]
Houpo Wenzhong Tang (Magnolia Bark Decoction to Warm the Middle): Treats Spleen-Stomach Qi deficiency, abdominal distension and fullness, with intermittent pain.
Ingredients: Houpo (Magnolia Bark), Chenpi (Aged Tangerine Peel), Fuling (Poria), Caodoukou (Cardamom Seed), Gancao (Licorice Root), Muxiang (Aucklandia Root), Ganjiang (Dried Ginger). If ineffective, add Renshen (Ginseng Root) and Baizhu (Atractylodes Rhizome).
Huanglian Xiexin Tang (Coptis Decoction to Drain the Heart)
Ingredients: Huanglian (Coptis Rhizome), Houpo (Magnolia Bark), Ganjiang (Dried Ginger) [each 5 fen]; Gancao (Licorice Root) [3 fen]; Renshen (Ginseng Root), Banxia (Pinellia Tuber), Shengjiang (Fresh Ginger) [each 1 qian].
Preparation: Decoct in water.
Dongyuan Shixiao Wan (Dongyuan's Make-You-Cry Pill): Treats wiry pulse at the right Guan position, empty Pǐ in the epigastrium, aversion to food, lethargy, aiming to open the stomach and promote intake.
Ingredients: Huanglian (Coptis Rhizome), Zhishi (Immature Bitter Orange) [each 5 qian]; Maiya (Sprouted Barley Seed) [2 qian]; Ganjiang (Dried Ginger), Gancao (Licorice Root), Baizhu (Atractylodes Rhizome), Fuling (Poria), Renshen (Ginseng Root), Banxiaqu (Fermented Pinellia) [each 3 qian]; Houpo (Magnolia Bark) [4 qian].
Preparation: Form pills with steamed dough.
Muxiang Shunqi Wan (Aucklandia Pill to Smooth Qi) (or Decoction): Treats heart and abdominal fullness and stuffiness. The formula is slightly acrid and dispersing, most suitable for early-stage disease without Fire.
Ingredients: Muxiang (Aucklandia Root), Yizhi (Alpinia Oxyphylla Fruit), Chenpi (Aged Tangerine Peel), Cangzhu (Black Atractylodes Rhizome), Caodoukou (Cardamom Seed), Houpo (Magnolia Bark), Qingpi (Green Tangerine Peel), Fuling (Poria), Zexie (Alisma Rhizome), Banxia (Pinellia Tuber), Ganjiang (Dried Ginger), Zhuyu (Evodia Fruit), Danggui (Angelica Sinensis Root), Renshen (Ginseng Root), Shengma (Cimicifuga Rhizome), Chaihu (Bupleurum Root).
Xiaopi Wan (Eliminate Pǐ Pill): Treats epigastric Pǐ masses, which may be painful or associated with yellow swelling, muscle emaciation with abdominal enlargement, and distension caused by Qi and Food accumulation.
Ingredients: Cangzhu (Black Atractylodes Rhizome) [4 liang]; Houpo (Magnolia Bark) [4 qian]; Qingpi (Green Tangerine Peel) [2 qian]; Chenpi (Aged Tangerine Peel), Shanzha (Hawthorn Fruit), Zhishi (Immature Bitter Orange) [each 2 liang]; Sanleng (Sparganium Rhizome), Ezhu (Curcuma Rhizome), Binglang (Areca Seed), Caoguo (Tsaoko Cardamom Fruit), Zhensha (Needle Sand/Iron Filings) [each 5 qian]; Sharen (Amomum Fruit), Muxiang (Aucklandia Root) [each 7 qian]; Xiaohui (Fennel Fruit), Gancao (Licorice Root), Xiangfu (Cyperus Rhizome), Wuyao (Lindera Root) [each 1 liang].
Preparation: Grind into powder, make pills with wine paste, size of soybeans. Take 15 pills per dose, washed down with Ginger Decoction.