【纲】仲景曰。太阳病。六七日。表症仍在。而反下之。脉微而沉。反不结胸。其人发狂者。
以热在下焦。少腹当硬满。小便自利者。下血乃愈。所以然者。以太阳随经瘀热在里故也。抵当
汤主之。
【目】成无己曰。此太阳自入腑者也。
赵嗣真曰。此亦病发于阳。误下热入之症。少腹居下焦。为膀胱之室。厥阴经脉所聚。卫任
血海所出。瘀血留结其中。故硬满。
【纲】仲景曰。太阳病。发汗。而复大下之。不大便五六日。舌上燥而渴。日晡小有潮热。从
心下至少腹硬满而痛不可近者。大陷胸汤主之。
【目】柯琴曰。此转属阳明。而尚未离乎太阳。故是下后热入水结所致。而非胃家实病。
【纲】仲景曰。病患胁下素有痞。连在脐旁。痛引小腹入阴筋者。此名脏结。死。
【目】柯琴曰。脐为立命之原。脐旁者。天枢之位。气交之际。阳明脉所合。少阳脉所出。肝
脾肾三脏之阴凝结于此。所以痛引小腹入阴筋也。少腹者。厥阴之部。两阴交尽之处。阴筋者。宗
筋也。今人多有阴筋上冲小腹而痛死者。名曰疝气。即是此类。然痛止便苏者。金匮所云。入脏
则死。入腑则愈也。治之以茴香、吴萸等味而痊。亦可明脏结之治法矣。
鳌按。从阴筋上冲小腹至胸。自下而上也。脏结从胁下痞痛引小腹入阴筋。自上而下也。柯氏
以脏结即疝气之类非是。今存其说者。正以辨脏结疝气之异也。
【纲】仲景曰。伤寒表不解。心下有水气。干呕发热而咳。或渴。或利。或噎。或小便不利少
腹满。或喘者。小青龙汤主之。
【目】柯琴曰。水气留而不行。则小便不利而少腹因满。制小青龙以两解表里之邪。其加减法。
于少腹满者。去麻黄加茯苓。以泄水也。
【纲】仲景曰。太阳病。身黄。脉沉结。少腹硬。小便不利者。为无血也。小便自利。其人如
狂者。血结症也。抵当汤主之。伤寒有热。少腹满。应小便不利。今反利者。为有血也。当下之。
不可余药。宜抵当丸。
【目】成无己曰。少腹满者。脐下满也。少腹者。下焦所治。邪气自上而下。至于下焦。结而
不利。故少腹满也。胸中满心下满。皆是气。腹满。则有由燥屎者。至于少腹满。则由邪气聚于下
焦。津液不得通。气血不得行。或溺或血。留滞下焦。是生胀满而硬痛也。若从心下至少腹皆硬满
而痛。是邪实。须大陷胸汤。若但少腹硬满而痛。小便利者。是蓄血症。小便不利者。是溺涩症。
鳌按。水结血结。俱是膀胱病。故皆少腹硬满。次条则少腹满而未硬。未发狂。只以小便自利。
预知其有蓄血。故用丸以缓之。
【纲】仲景曰。太阳病。不解。热结膀胱。其人如狂。血自下。下者愈。其外不解者。尚未可
攻。当先解外。外解已。但少腹急结者。乃可攻之。宜桃仁承气汤。
【目】张兼善曰。此少腹硬满。为物聚于下可知矣。物者。血也。渗之利之。参酌随宜。可为
上工。
鳌按。此条少腹虽急结。尚未硬满。故不用抵当。只须承气。
【纲】张仲景说：太阳病，经过六七天，表证仍然存在，反而使用了攻下法。脉象微而沉，反而没有形成结胸证。病人出现发狂的症状，这是因为热邪在下焦。少腹部应当坚硬胀满，如果小便通畅自如，那么通过泻下瘀血才能痊愈。之所以这样，是因为太阳经的邪气随经入里，导致瘀热内结的缘故。主治方剂为抵当汤。
赵嗣真说：这也是病发于阳经，误用下法导致热邪内入的病症。少腹位于下焦，是膀胱所在的部位，也是厥阴经脉汇聚之处，以及任脉、冲脉（血海）所出的地方。瘀血留滞结聚在其中，所以会出现硬满的症状。
【纲】张仲景说：太阳病，经过发汗治疗，又再次使用峻猛的下法。导致五六天不大便，舌面干燥且口渴，傍晚时分有轻微的潮热，从心窝部一直到小腹部坚硬胀满，疼痛剧烈到不能靠近触碰的，主治方剂为大陷胸汤。
【目】柯琴说：这是病邪转属阳明，但尚未完全脱离太阳经的影响，因此是由于误下后热邪内入与水饮互结所致，而不是胃家实（阳明腑实证）。
【纲】张仲景说：病患胁下向来有痞块，连接到脐旁，疼痛牵引至小腹并进入阴筋部位，这叫做脏结，预后不良，主死。
【目】柯琴说：脐部是人体生命的根本所在，脐旁是天枢穴的位置，处于气机交会的枢纽，是阳明经脉所合、少阳经脉所出的地方。肝、脾、肾三脏的阴寒凝结于此，所以疼痛会牵引至小腹并进入阴筋。少腹是厥阴经的区域，是两阴交汇尽头的地方。阴筋指的是宗筋。现在很多人有阴筋上冲小腹而疼痛致死的，名叫疝气，就是这一类情况。然而，如果疼痛停止大便通畅就能苏醒的，正如《金匮要略》所说：“病入脏则死，入腑则愈。”用茴香、吴茱萸等药物治疗可以痊愈，这也能够阐明脏结的治疗法则了。
沈金鳌按语：从阴筋上冲至小腹再到胸部，是从下往上的；脏结是从胁下的痞痛牵引至小腹并进入阴筋，是从上往下的。柯琴认为脏结就是疝气之类，这是不对的。现在保留他的说法，正是为了辨别脏结与疝气的不同之处。
【纲】张仲景说：伤寒表证未解，心下有停水之气，表现为干呕、发热且咳嗽，或者口渴，或者腹泻，或者噎塞感，或者小便不利伴少腹胀满，或者喘息的，主治方剂为小青龙汤。
【目】柯琴说：水气停留而不运行，就会导致小便不利，进而引起少腹胀满。制定小青龙汤是为了同时解除表里之邪。其加减法中，对于少腹胀满者，去掉麻黄加入茯苓，以泄除水气。
【纲】张仲景说：太阳病，病情未解，出现身黄，脉象沉涩，少腹部坚硬，如果小便不利，说明没有瘀血；如果小便通畅，病人像发狂一样，这是血结证，主治方剂为抵当汤。伤寒伴有发热，少腹胀满，本应小便不利，现在反而小便通利，说明是有瘀血，应当攻下瘀血，不可保留药渣，宜用抵当丸。
【目】成无己说：少腹胀满，是指脐下胀满。少腹是由下焦主管的区域，邪气从上往下，到达下焦，结聚而不通畅，所以导致少腹胀满。胸中的满闷和心下的满闷，都是气滞引起的；腹部的胀满，有的是由燥屎引起的；至于少腹胀满，则是由于邪气聚集在下焦，津液不得通调，气血不得运行，或者是尿液，或者是血液，留滞在下焦，从而产生胀满和硬痛。如果从心下直到小腹部都坚硬胀满且疼痛，这是邪气实盛，必须用大陷胸汤。如果只是少腹部坚硬胀满且疼痛，小便通利的，这是蓄血证；小便不利的，这是溺涩证（尿潴留）。
沈金鳌按语：水结和血结，都属于膀胱的病证，所以都会出现少腹硬满。第二条中只是少腹胀满而未变硬，也没有发狂，只凭小便自利，预先判断有蓄血，所以用丸药来缓攻。
【纲】张仲景说：太阳病，病情未解，热邪结于膀胱，病人像发狂一样，如果瘀血能自行排出，排出的就会痊愈。如果体表的证候仍未解除，还不可以攻下，应当先解表。表证解除后，如果只是少腹部急迫拘结的，才可以攻下，宜用桃仁承气汤。
【目】张兼善说：这种少腹硬满，可知是有实物积聚在下焦。这个实物就是瘀血。采用渗利或攻下的方法，斟酌适宜，可称为高明医生。
[Outline] Zhang Zhongjing stated: In Taiyang disease, after six or seven days, if the exterior syndrome persists and purgation is erroneously applied, the pulse becomes faint and deep. If there is no Jie Xiong (Chest Binding Syndrome) but the patient exhibits mania, it is because heat resides in the Lower Jiao (Lower Burner). The lower abdomen should be hard and full. If urination is normal, healing occurs only after blood stasis is purged. This happens because the Taiyang pathogen follows the meridians into the interior, causing stagnant heat to accumulate. The formula Diding Tang (Insect Pill Decoction) is indicated.
[Commentary] Cheng Wuji stated: This represents the transmission of Taiyang pathogen directly into the Fu organs.
Zhao Sizhen stated: This is also a condition resulting from a Yang-stage disease where erroneous purgation allows heat to penetrate inward. The lower abdomen is located in the Lower Jiao and is the chamber of the Bladder. It is the convergence point of the Jueyin meridian and the origin of the Ren Mai (Conception Vessel) and Chong Mai (Penetrating Vessel/Blood Sea). When blood stasis remains and knots within this area, hardness and fullness result.
[Outline] Zhang Zhongjing stated: In Taiyang disease, after sweating therapy followed by severe purgation, if constipation persists for five or six days, accompanied by a dry tongue with thirst, slight afternoon tidal fever, and hardness/fullness extending from the epigastrium down to the lower abdomen such that pain prevents touching, the formula Da Xianxiong Tang (Major Cathartic Chest Decoction) is indicated.
[Commentary] Ke Qin stated: The pathogen has transferred to Yangming but has not completely left Taiyang. Thus, this is caused by heat penetrating inward due to purgation combined with water accumulation, rather than Wei Jia Shi (Stomach House Excess/Yangming Fu Excess).
[Outline] Zhang Zhongjing stated: If a patient has a chronic Pi Mass (Focal Distention) under the hypochondrium extending to beside the umbilicus, with pain radiating to the lower abdomen and entering the Yin Jin (Genital Tendons), this is named Zang Jie (Zang Organ Knotting), which is fatal.
[Commentary] Ke Qin stated: The umbilicus is the root of life. Beside the umbilicus lies Tianshu (ST25), a hub of Qi interaction where the Yangming and Shaoyang meridians converge and diverge. Yin condensation of the Liver, Spleen, and Kidney accumulates here, causing pain to radiate to the lower abdomen and enter the Yin Jin. The lower abdomen is the domain of Jueyin, the place where two Yins meet and end. Yin Jin refers to the Zong Jin (Major Tendons/Genitals). Many people today die from pain caused by Yin Jin rushing up to the lower abdomen, a condition called Shan Qi (Hernia), which belongs to this category. However, those who recover when pain ceases and stool passes align with the statement in *Jin Gui Yao Lue*: "Disease entering the Zang leads to death; entering the Fu leads to recovery." Treatment with Huixiang (Fennel Fruit) and Wuyu (Evodia Fruit) can cure it, clarifying the treatment principles for Zang Jie.
Shen Jin'ao's Note: The upward rush from Yin Jin to the lower abdomen and chest moves from bottom to top. Zang Jie involves pain radiating from hypochondriac Pi Mass to the lower abdomen and Yin Jin, moving from top to bottom. Ke Qin’s view that Zang Jie is similar to Hernia is incorrect. His theory is preserved here to distinguish between Zang Jie and Hernia.
[Outline] Zhang Zhongjing stated: In Shanghan (Cold Damage) with unresolved exterior syndrome and Water Qi (Fluid Retention) in the Heart Below (Epigastrium), symptoms include dry heaving, fever, and cough. There may also be thirst, diarrhea, dysphagia sensation, oliguria with lower abdominal fullness, or wheezing. The formula Xiao Qinglong Tang (Minor Blue Dragon Decoction) is indicated.
[Commentary] Ke Qin stated: Stagnant Water Qi fails to circulate, leading to oliguria and consequent lower abdominal fullness. Xiao Qinglong Tang resolves both exterior and interior pathogens. In its modifications, for cases with lower abdominal fullness, Ephedrae Herba (Mahuang) is removed and Poria (Fuling) is added to drain water.
[Outline] Zhang Zhongjing stated: In Taiyang disease, if the condition remains unresolved, presenting with jaundice, a deep and knotted pulse, and a hard lower abdomen: if urination is difficult, there is no blood stasis; if urination is free and the patient appears manic, this is Blood Knotting Syndrome, treated with Diding Tang. In Shanghan with fever and lower abdominal fullness, one would expect oliguria; if urination is actually free, it indicates blood stasis. Purging is required without retaining dregs; Diding Wan (Insect Pill) is appropriate.
[Commentary] Cheng Wuji stated: Lower abdominal fullness refers to distension below the umbilicus. The lower abdomen is governed by the Lower Jiao. Pathogens descending from above accumulate in the Lower Jiao, blocking flow, causing fullness. Fullness in the chest or epigastrium is due to Qi stagnation. Abdominal fullness may be due to dry feces. Lower abdominal fullness specifically arises from pathogens gathering in the Lower Jiao, preventing the circulation of fluids and Qi/Blood, leading to retention of urine or blood, generating distension, hardness, and pain. If hardness/fullness/pain extends from the epigastrium to the lower abdomen, it is Excess Pathogen requiring Da Xianxiong Tang. If only the lower abdomen is hard/full/painful with free urination, it is Blood Accumulation Syndrome. If urination is difficult, it is Urinary Obstruction Syndrome.
Shen Jin'ao's Note: Both Water Knotting and Blood Knotting are diseases of the Bladder, hence both present with lower abdominal hardness/fullness. In the second case, there is fullness without hardness and no mania; merely by observing free urination, one anticipates Blood Accumulation, hence using a pill for slow action.
[Outline] Zhang Zhongjing stated: In Taiyang disease, if unresolved, heat knots in the Bladder, causing mania. If blood self-discharges, the patient recovers. If the exterior remains unresolved, attack is contraindicated; resolve the exterior first. Once the exterior is resolved, if only the lower abdomen feels urgent and knotted, then attack is permissible, using Tao Ren Cheng Qi Tang (Peach Kernel Cathartic Decoction).
[Commentary] Zhang Jianshan stated: This lower abdominal hardness/fullness indicates an accumulation of material in the Lower Jiao. That material is blood. Employing permeating or draining methods, adapted appropriately, constitutes the skill of a superior physician.
Shen Jin'ao's Note: In this case, although the lower abdomen is urgent and knotted, it is not yet hard and full; thus, Diding Tang is not used, and Cheng Qi Tang suffices.