【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。
【纲】张仲景说：出现下利且排出未消化食物（清谷）的情况，不可使用发汗法解表。如果误用发汗导致出汗，必然引起腹部胀满。
如果是下利、腹部胀满，同时伴有身体疼痛的症状，应当先温补里虚，然后再攻治表证。温补里虚适宜使用四逆汤；攻治表证适宜使用桂枝汤。
伤寒病中出现呃逆（哕）并伴有腹部胀满，应观察患者前阴和后阴，看哪一部分排泄不通畅，通利该部分即可痊愈。
伤寒病经过四五日，出现腹中疼痛，如果有气向下窜动至小腹的感觉，这是即将发生下利的征兆。
【目】成无己说：呃逆并伴有腹部胀满，是气机上逆而不能下降的表现。观察前后二阴，若有不通利的情况，则通过通利的方法来降逆气。前部指小便，后部指大便。可以使用五苓散，或者使用小承气汤。
张云岐说：伤寒邪气侵入三阴经内部，导致阴阳之气不能交通，从而产生腹痛。手足各经的经脉都汇聚于腹部。如果脉象弦而腹痛，病机在于厥阴肝经和太阴肺经，可针刺太溪穴、太渊穴、太陵穴。如果脉象沉而腹痛，病机在于太阴脾经、少阴肾经和手厥阴心包经，可针刺太溪穴、太陵穴。如果脉象沉细而腹痛，病机在于太阴脾经和少阴心经，可针刺大白穴、神门穴、三阴交穴。这就是治疗腹痛的针刺方法。
魏荔彤说：上述两条条文，论述的是寒邪直中厥阴经的情况，有急需温补里阳的治疗方法，随后可以徐徐升举阳气，由厥阴经传至少阳经，进而返回到太阳经的表证层面。下利是本症，腹部胀满是阴寒内结所致，身体疼痛是寒邪拘急收敛所致。这种情况必须先使阳气回复于少阴经，然后才能徐徐谋划解决厥阴经受侵的问题。况且寒邪本源于少阴经，源头之阳气既已温暖，则灌溉于肝木的气血便如春泉般生机盎然。因此，温补肾阳即等于温养肝木。然而，如果不攻治表证，则厥阴经本经的阴寒邪气会留滞不散，所以使用桂枝汤来攻治表证。第一条中，下利且排出未消化食物，说明里寒且阳气微弱是可以确定的。如果不先温里回阳，就急于发汗，邪气虽然散去，但阳气必亡。阳气越衰微，阴寒就越盛，此时腹部胀满还算是小患，必然会导致四肢厥冷无法回暖，脉象微弱甚至断绝。这难道不是因为没有先温补里阳吗？第三条，是预防下利发生的机理。气向下窜动，无论是寒证还是热证，都有此症状。凡在伤寒病症中看到此现象，就知道这是即将自行下利。如果在阳明胃经受邪，则是邪气欲向下行的机制；如果在厥阴肝经受邪，则是邪气欲向下陷落的征候。邪气想要离去，以下利而痊愈；正气想要上升，以下利而危险。这是必然的道理。
[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.