【纲】仲景曰。下利清谷。不可发表。汗出必腹满。
下利。腹胀满。身体疼痛者。先温其里。乃攻其表。温里宜四逆汤。攻表宜桂枝汤。伤寒哕而
腹满。视其前后。何部不利。利之则愈。伤寒四五日。腹中痛。若转气下趣少腹者。此欲下利也。
【目】成无己曰。哕而腹满。气上而不下也。视其前后部。有不利者。则利之以降其气。前部。
小便也。后部。大便也。或用五苓散。或用小承气汤。
张云岐曰。伤寒邪在三阴内。不得交通。故为腹痛。手足之经。皆会于腹。如脉弦而腹痛。过
在厥阴肝。太阴肺。刺太溪太渊太陵。脉沉而腹痛。过在太阴脾。少阴肾。手厥阴心包。刺太溪太
陵。脉沉细而腹痛。过在太阴脾。少阴心。刺大白
神门三阴交。此刺腹痛之法也。
魏荔彤曰。二条。乃言直中厥阴之寒邪。有急行温里之法。徐可升举其阳。由厥阴而少阳。以
返于太阳之表也。下利本症也。腹满痛。阴寒内结也。身体疼痛。寒邪拘急也。此必先使阳回于少
阴。而后厥阴之侵及者可徐图之。且寒邪本自少阴发源。源头之阳水既温。则灌溉于肝木者皆春泉
矣。是温肾即以温肝也。然不攻其表。则厥阴本经之阴寒。留滞不散。于是用桂枝攻表也。首条。
下利清谷。则里寒阳微可审。不先温里回阳。遽发其汗。邪即散。阳必亡。阳愈衰。阴愈盛。腹满
犹小患也。必至厥冷不还。脉微至绝矣。岂非失于温里乎。三条。乃预防下利之因也。转气下趣。
为寒为热。俱有此症。凡伤寒症中见此。则知其为欲自利。然在阳明胃邪。则为欲下行之机。在厥
阴肝邪。则为欲下陷之候。邪欲其去。以下利而痊。正欲上升。以下利而危。必然之理也。
[General Principle] Zhang Zhongjing stated: In cases of diarrhea with undigested food (Qinggu), exterior-releasing methods should not be used. If sweating occurs due to improper treatment, abdominal fullness will inevitably result.
In cases of diarrhea accompanied by abdominal fullness and body pain, the interior deficiency should first be warmed, followed by the treatment of the exterior syndrome. To warm the interior, Sini Tang (Four Reversal Decoction) is appropriate; to treat the exterior, Guizhi Tang (Cinnamon Twig Decoction) is appropriate.
In Shaoyang disease presenting with hiccups (Yue) and abdominal fullness, observe the anterior and posterior orifices to determine which part is obstructed; unblocking the obstruction leads to recovery.
After four or five days of Taiyang disease, if abdominal pain occurs along with a sensation of Qi moving downward toward the lower abdomen, this indicates an impending onset of diarrhea.
[Detailed Commentary] Cheng Wuji stated: Hiccups accompanied by abdominal fullness indicate rebellious Qi failing to descend. By observing the anterior (urination) and posterior (defecation) orifices, if there is obstruction, promoting flow helps to subdue the rebellious Qi. The anterior refers to urine, and the posterior refers to stool. Wuling San (Five-Ingredient Powder with Poria) or Xiaochengqi Tang (Minor Order the Yang Decoction) may be used.
Zhang Yunqi stated: When pathogenic factors of cold invade the interior of the Three Yin meridians, causing a lack of communication between Yin and Yang, abdominal pain results. The meridians of the hands and feet all converge in the abdomen. If the pulse is wiry (Xian) with abdominal pain, the pathology lies in the Jueyin Liver meridian and the Taiyin Lung meridian; acupuncture points Taixi (KI3), Taiyuan (LU9), and Tailing (PC7) may be needled. If the pulse is deep (Chen) with abdominal pain, the pathology lies in the Taiyin Spleen meridian, Shaoyin Kidney meridian, and Hand Jueyin Pericardium meridian; acupuncture points Taixi (KI3) and Tailing (PC7) may be needled. If the pulse is deep and fine (Xi) with abdominal pain, the pathology lies in the Taiyin Spleen meridian and Shaoyin Heart meridian; acupuncture points Dabai (LI14), Shenmen (HT7), and Sanyinjiao (SP6) may be needled. These are the acupuncture methods for treating abdominal pain.
Wei Litong stated: The aforementioned two clauses discuss cold pathogenic factors directly invading the Jueyin meridian, requiring urgent warming of the interior Yang. Subsequently, Yang Qi can be gradually lifted from Jueyin to Shaoyang, returning to the exterior of Taiyang. Diarrhea is the primary symptom; abdominal fullness indicates internal binding of Yin-cold; body pain indicates contraction caused by cold pathogens. In such cases, Yang must first return to the Shaoyin meridian before the invasion of Jueyin can be gradually addressed. Since cold pathogens originate from Shaoyin, once the source of Yang water is warmed, the Qi irrigating the Liver Wood becomes like spring water. Thus, warming the Kidney is equivalent to warming the Liver. However, if the exterior is not attacked, the Yin-cold of the Jueyin meridian itself will remain stagnant; therefore, Guizhi Tang is used to attack the exterior. In the first clause, diarrhea with undigested food indicates that interior cold and deficient Yang are evident. If one does not first warm the interior to restore Yang but rashly induces sweating, although the pathogen may scatter, Yang will perish. As Yang declines further, Yin becomes more abundant. Abdominal fullness would then be a minor affliction, inevitably leading to cold extremities that do not recover and a faint or imperceptible pulse. Is this not due to the failure to warm the interior first? The third clause addresses the etiology of impending diarrhea. The sensation of Qi moving downward occurs in both cold and heat syndromes. Seeing this in Taiyang disease indicates impending spontaneous diarrhea. If the pathogen is in the Yangming Stomach, it represents a mechanism for the pathogen to move downward; if in the Jueyin Liver, it represents a sign of the pathogen sinking downward. If the pathogen wishes to exit, recovery comes through diarrhea; if the Healthy Qi wishes to ascend, danger arises from diarrhea. This is an inevitable principle.