当观夫东垣李氏所着内外伤辨。有曰。外伤风寒客邪有余之病。当泻。不当补。内伤饮食劳
役不足之病。当补。不当泻。自此论一出。而天下后世。始知内外之伤有所别。而仲景之法
。不可例用矣。其惠也。不其大哉。虽然。夷考其言。犹或有可疑者。不敢谀佞。僭用条之
。如曰。夫饮食劳倦伤而内热者。乃阴火乘其坤土之位。故内热以及于胸中也。又曰。内经
有云。劳者温之。损者温之。惟宜温药以补元气。而泻火邪。内经曰。温能除大热。故治之
必温药乃可耳。又曰。饮者。无形之气。伤之则宜发汗。利小便。使上下分消其湿。(此饮
谓酒也)食者。有形之物。伤之则宜损其谷。其次莫如消导。若此者皆不能使人无疑者也
。
谨按素问调经论篇云。帝曰。阴虚生内热。奈何。岐伯曰。有所劳倦。形气衰少。谷气不盛
。上焦不行。下脘不通。胃气热。热气熏胸中。故内热。嗟夫。此内伤之说之原乎。请释其
义如左。夫人身之阴阳。有以表里言者。有以上下之分言者。有以气血言者。有以身前身后
言者。有以脏腑言者有以升降呼吸之气言者。余如动静。语默。起居之类甚多。不必悉举。此
所谓阴虚之阴。其所指与数者皆不同。盖劳动之过。则阳和之气。皆亢极而化为火矣。况水
谷之味又少入。是故阳愈盛。而阴愈衰也。此阴虚之阴。盖指身中之阴气。与水谷之味耳。
或以下焦阴分为言。或以肾水真阴为言。皆非也。夫有所劳役者。过动属火也。形气衰少者
。壮火食气也。谷气不盛者。劳伤元气。则少食而气衰也。上焦不行者。清阳不升也。下脘
不通者。浊阴不降也。夫胃受水谷。故清阳升。而浊阴降。以传化出入。滋荣一身也。今胃
不能纳。而谷气衰少。则清无升。而浊无降矣。故曰。上焦不行。下脘不通。然非谓绝不行
不通也。但比之平常无病时。则谓之不行不通耳。上不行下不通则郁矣。郁则少火皆成壮火
。而胃居上焦下脘两者之间。故胃气热。热则上炎。故熏胸中。而为内热也。东垣所谓劳役
形体。所谓饮食失节。而致热者。此言正与调经论篇之旨相合。固宜引此段经文。于内外伤
辩。以为之主。而乃反不引此。却谓阴火乘土位。故内热及胸中。此不能无疑者也。夫阴火
二字。素问灵枢难经未尝言。而东垣每每言之。素问止有七节之膀。中有小心二句。而刘守
真推其为命门属火不属水。引仙经心为君火。肾为相火之说。以为之证。然亦不以阴火名之
。是则名为阴火者。其东垣始欤窃意内热之作。非皆阴火也。但气有郁。则成热耳。虽曰心
为君火。君不主令。然素问所叙诸病之属热者甚众。皆君火病也。岂君火不能为病。而直欲
纯归之于阴火乎。至真要大论云。劳者温之。损者益之。夫劳则动之太过。而神不宁矣。故
温之。温也者。养也。温之者。所以调其食饮。适其起居。澄心息虑。从容以待其真气之复
常也。礼记所谓柔色以温之。此温字。正与此同。或以药扶助之。亦养也。今东垣乃以温为
温
凉之温。谓宜温药以补元气。而泻火邪。又易损者益之。为损者温之。又以温能除大热。为
内经所云。而遍考内经。并无此语。此亦不能无疑者也。然温药之补元气。泻火邪者。亦惟
气温而味甘者斯可矣。盖温能益气。甘能助脾而缓火。故元气复。而火邪熄也。夫宜用温药
。以为内伤不足之治则可。以为劳者温之之注。则不可。阴阳应象论。所谓形不足者。温之以气
。其温字亦是滋养之义。非指温药也。夫形不足。乃阳虚而不充也。气者。药之气也。药有
气浓。气薄。味浓。味薄。味浓者属阴。而滋精气。浓者属阳。而滋形。今以药之气浓
者
。滋阳不兼形乎。故曰。形不足者。温之以气。虽以药温养之。亦未尝不兼乎调食饮。适
起居。与澄心息虑也。温字固其二意然终不可视为温凉之温。苟以补之。除之。抑之。举之
。散之等语。比类而观焉。则其义自着矣。夫金木水火土。运于天地也。则无形质之可观。
其丽于地则有形质矣。金木土水者。有形有质者也。火者。有形而质不实者也。酒性虽体热
。同于水。今东垣乃谓饮者无形之气。此亦不能无疑者也。既待发汗利小便以去之。其可谓
之无形之气乎。且劳倦伤。饮食
伤二者。虽俱为内伤。然不可混而
为一。难经所谓饮食劳倦。则伤脾者。盖谓脾主饮食。而四肢亦属脾。故饮食
失节。劳役四肢。皆能伤于脾耳。非谓二者同类。而无辨也。夫劳倦伤。饮食伤。虽与风寒
暑湿
有余之病不同。然饮食伤。又与劳倦伤不同。劳倦伤诚不足也。饮食伤尢当于不足之中。分
其有余不足也。何也。盖饥饿不饮食。与饮食太过。虽皆是失节。然必明其有两者之分。方
尽其理。节也者何。无不及无太过之中有道也。夫饥饿不饮食者。胃气空虚。此为不足。固
失节也。饮食自倍。而停滞者。胃气受伤。此不足之中兼有余。亦失节也。以受伤言。则不
足。以停滞言。则有余矣。惟其不足。故补益。惟其有余。故消导。亦有物滞气伤。必补益
消导兼行者。亦有物暂滞。而气不甚伤。宜消导独行。不须补益者。亦有既停滞。不复自化
。不须消导。但当补益。或亦不须补益者。洁古枳术丸。东垣橘皮枳术丸。木香枳术丸之类
。
虽曰消导。固有补益之意存乎其间。其他如木香分气丸。导气枳实丸。大枳壳丸之类。虽无
补益。然施之于物暂滞。气不甚伤者。岂不可哉。但不宜视为通行之药耳。且所滞之物
。非
枳术丸之力所能去者。亦安可泥于消导。而不知变乎。故备急丸。煮黄丸。感应丸。瓜蒂散
等之推逐者。洁古东垣亦未尝委之。而弗用也。故善将兵者。攻亦当。守亦当。不善者。则
宜攻而守。宜守而攻。其败也非兵之罪。用兵者之罪耳。观乎此。则知消导补益推逐之理矣
。若夫劳倦伤。则纯乎补益。固不待议。虽东垣丁宁告戒。然世人犹往往以苦寒之剂。望
除劳倦伤之热。及其不愈。而反甚。自甚而至危。但曰病势已极。药不能胜耳。医者。病者
。主病者。一委之天命。皆懵然不悟其为妄治之失也。呜呼。仁人君子。能不痛心也哉。夫
东垣先哲之出类者也。奚敢轻议。但恨其白璧微瑕。而或贻后人差毫厘谬千里之患。故不得
不逾耳。知我者其鉴之。
应当考察李东垣所著的《内外伤辨》。其中有说道：外伤风寒客邪属于有余的病证，应当泻法，不应当补法；内伤饮食劳役属于不足的病证，应当补法，不应当泻法。自从这一理论出现后，天下后世才知道内伤与外感有所区别，张仲景的治法不能一概而论地使用了。这恩惠难道不大吗？虽然如此，仔细考究他的言论，或许仍有值得怀疑的地方，不敢阿谀奉承，冒昧地逐条陈述如下。
他说：饮食劳倦损伤导致内热的，是因为阴火乘袭了坤土（脾）的位置，所以内热波及到胸中。又说：《内经》有云：“劳者温之，损者温之。”只适宜用温药来补益元气，而泻除火邪。《内经》说：“温能除大热。”所以治疗必须用温药才行。又说：酒饮，是无形的“气”，损伤它则适宜发汗、利小便，使湿邪上下分消。（这里的“饮”指酒）食物，是有形的“物”，损伤它则适宜减少谷物摄入，其次不如消食导滞。像这些说法，都让人不能不产生疑问。
谨按《素问·调经论篇》记载：黄帝问：阴虚生内热，是怎么回事？岐伯答：由于过度劳倦，形体之气衰少，谷气不盛，上焦不通畅，下脘不流通，胃气郁热，热气熏蒸于胸中，所以产生内热。唉！这大概是内伤学说的源头吧？请让我解释其含义如下。
人身上的阴阳，有从表里角度说的，有从上下的角度说的，有从气血角度说的，有从身前身后的角度说的，有从脏腑角度说的，有从升降呼吸之气的角度说的。其余如动静、语默、起居等类非常多，不必全部列举。这里所说的“阴虚”之“阴”，所指与上述几种情况都不同。大概是因为劳动过度，阳和之气亢极而化为火。况且水谷的味道摄入又少，因此阳气越盛，阴气越衰。这个“阴虚”之“阴”，大概指的是身体中的阴气与水谷的精微物质罢了。或者有人说是下焦阴分，或者说是肾水真阴，都不对。
所谓劳役，是过度运动属于火性；形气衰少，是壮火食气；谷气不盛，是劳伤元气，导致吃得少且气衰；上焦不行，是清阳不升；下脘不通，是浊阴不降。胃受纳水谷，所以清阳上升，浊阴下降，以此传化出入，滋养全身。现在胃不能受纳，谷气衰少，那么清阳无以上升，浊阴无以下降。所以说“上焦不行，下脘不通”。但这并不是说完全不行不通，只是相比平常无病时，称之为不行不通罢了。上不行、下不通就会郁结。郁结则少火皆变成壮火。而胃位于上焦和下脘两者之间，所以胃气热，热则向上炎蒸，熏灼胸中，从而形成内热。李东垣所说的劳役形体、饮食失节而导致的热，这种说法正与《调经论篇》的主旨相合。本来应该引用这段经文在《内外伤辨》中作为主旨，但他反而不引用，却说阴火乘土位，所以内热及于胸中，这是不能不让人怀疑的。
“阴火”这两个字，《素问》《灵枢》《难经》从未提及，而李东垣常常提到。《素问》只有“七节之膀，中有小心”两句，刘完素推测其为命门属火不属水，引用仙经“心为君火，肾为相火”的说法作为佐证，但也并不以“阴火”命名。那么名为“阴火”的，大概是李东垣开始的吧？我猜测内热的发生，并非都是阴火，只是气有郁结，就化成热罢了。虽说心为君火，君不主令，但《素问》叙述的各种属于热的病证很多，都是君火病。难道是君火不能致病，而只想纯粹归咎于阴火吗？
《至真要大论》说：“劳者温之，损者益之。”劳则动之太过，神不宁静，所以温之。“温”的意思，是养。温之，是用来调理饮食，适应起居，澄心息虑，从容等待真气恢复常态。《礼记》所谓“柔色以温之”，这个“温”字，正与此相同。或者用药扶助，也是养。现在李东垣却把“温”理解为温凉之“温”，认为适宜用温药补元气而泻火邪。又把“损者益之”改为“损者温之”，又认为“温能除大热”是《内经》的话，但遍考《内经》，并没有这句话。这也是不能不让人怀疑的。
然而，用温药补元气、泻火邪的，也只有气温而味甘的药物才可以。因为温能益气，甘能助脾而缓火，所以元气恢复，火邪熄灭。适宜用温药作为内伤不足的治疗是可以的，但作为对“劳者温之”的注解，就不可以了。《阴阳应象大论》所说“形不足者，温之以气”，这个“温”字也是滋养的意思，不是指温药。形不足，是阳虚而不充盈。气，指药的气。药有气浓、气薄、味浓、味薄。味浓者属阴，滋精气；气浓者属阳，滋形。现在用气浓的药，滋补阳的同时不也兼补形吗？所以说“形不足者，温之以气”，虽然是用药温养，也未尝不兼有调理饮食、适应起居、澄心息虑的意思。“温”字固然是两种意思，但最终不可视为温凉之“温”。如果将补、除、抑、举、散等话语类比观察，那么其中的意义自然显明。
金木水火土，运行于天地之间，是没有形质可看的。附着于大地则有形质。金木土水，是有形有质的。火，是有形而质不实的。酒的性质虽然体热，同于水。现在李东垣却说酒饮是无形的“气”，这也是不能不让人怀疑的。既然需要发汗利小便来去除它，怎么能称之为无形的“气”呢？
况且劳倦伤和饮食伤，虽然都属于内伤，但不能混为一谈。《难经》说“饮食劳倦则伤脾”，大概是说脾主饮食，而四肢也属脾，所以饮食失节、劳役四肢，都能伤脾。并不是说这两者是同类而没有区别。劳倦伤和饮食伤，虽然与风寒暑湿有余的病不同，但饮食伤又与劳倦伤不同。劳倦伤确实是不足，饮食伤尤其应当在不足之中，分辨其有余还是不足。为什么呢？饥饿不饮食，与饮食太过，虽然都是失节，但必须明确区分两者的不同，才能穷尽道理。什么是“节”？就是无不及、无太过之中有道。饥饿不饮食，胃气空虚，这是不足，固然也是失节。饮食自倍而停滞，胃气受伤，这是在不足之中兼有余，也是失节。从受伤的角度看，是不足；从停滞的角度看，是有余。正因为不足，所以补益；正因为有余，所以消导。也有物滞气伤，必须补益消导兼行的；也有物暂时停滞，而气不甚伤，适宜单独使用消导，不需要补益的；也有已经停滞，不再自行化解，不需要消导，只当补益的；或者甚至不需要补益的。洁古的枳术丸、东垣的橘皮枳术丸、木香枳术丸之类，虽说是消导，固有补益之意存乎其中。其他如木香分气丸、导气枳实丸、大枳壳丸之类，虽然没有补益，但施用于物暂滞、气不甚伤的情况，难道不可以吗？只是不宜将其视为通行的药物罢了。而且所停滞之物，不是枳术丸之力所能去除的，又怎能拘泥于消导而不知变通呢？所以备急丸、煮黄丸、感应丸、瓜蒂散等推逐攻下的方剂，洁古和东垣也未曾废弃不用。所以善于用兵的人，攻也是对的，守也是对的；不善于用兵的人，宜攻而守，宜守而攻，失败的不是军队的罪过，而是用兵者的罪过。观察这一点，就知道消导、补益、推逐的道理了。至于劳倦伤，则是纯粹的补益，本来不需要议论。虽然李东垣再三告诫，但世人往往还用苦寒的药剂，希望消除劳倦伤的热，等到病没好反而加重，从重到危，只说病势已极，药不能胜罢了。医者、患者、主治者，全都委之于天命，都懵懂不觉悟这是妄治的错误。唉！仁人君子，能不痛心吗？
李东垣是先哲中出类拔萃的人，怎敢轻易议论？只是遗憾他白璧微瑕，或许会遗留后人差之毫厘谬以千里的祸患，所以不得不超越常规去评论。了解我的人请鉴察。
One should examine Li Dongyuan's *Bian Nei Wai Shang* (Differentiation of Internal and External Injuries). It states: "External injuries caused by wind, cold, and pathogenic factors belong to excess conditions; they should be treated with purging methods, not tonifying methods. Internal injuries caused by diet and overwork belong to deficiency conditions; they should be treated with tonifying methods, not purging methods." Since this theory emerged, the world and future generations have come to know that internal injuries and external contractions are distinct, and Zhang Zhongjing's methods cannot be applied indiscriminately. Is this benefit not great? Nevertheless, upon careful examination of his words, there may still be points worthy of doubt. I dare not flatter him but will presumptuously list them item by item.
He says: "Internal heat resulting from injury by diet and fatigue is due to Yin Fire attacking the position of Kun Earth (Spleen), thus causing internal heat to affect the chest." He also states: "*Neijing* says, 'For exhaustion, use warmth; for loss, use warmth.' One should only use warm herbs to tonify Yuan Qi (Original Qi) and purge Fire Pathogens. *Neijing* says, 'Warmth can eliminate great heat.' Therefore, treatment must necessarily employ warm herbs." He further says: "Drinks (referring to alcohol) are formless Qi; when injured, sweating and diuresis are appropriate to disperse dampness upward and downward. Food is a tangible substance; when injured, one should reduce grain intake, or preferably use digestion-promoting methods." Such statements raise doubts.
According to the *Suwen: Tiao Jing Lun* chapter: The Yellow Emperor asked, "How does Yin deficiency generate internal heat?" Qibo replied, "Due to excessive labor and fatigue, the form and Qi decline, Gu Qi (Grain Qi) becomes insufficient, the Upper Jiao fails to function, and the Lower Wan (stomach/intestines) becomes obstructed. Stomach Qi becomes hot, and hot Qi steams the chest, thus generating internal heat." Alas! This seems to be the origin of the theory of internal injury. Let me explain its meaning as follows.
The Yin and Yang of the human body can be discussed in terms of exterior and interior, upper and lower, Qi and Blood, front and back of the body, Zang-Fu organs, and ascending-descending and respiratory Qi. There are many other categories such as movement and stillness, speaking and silence, daily activities, which need not be listed exhaustively. The "Yin" referred to in "Yin deficiency" here differs from all the aforementioned categories. Generally, excessive physical activity causes Yang and Harmonious Qi to become hyperactive and transform into Fire. Moreover, since the intake of water and food flavors is low, Yang becomes more abundant while Yin becomes more deficient. This "Yin" in "Yin deficiency" refers to the Yin Qi within the body and the essence derived from water and food. Some interpret it as the Yin division of the Lower Jiao or the True Yin of Kidney Water, both of which are incorrect.
Excessive labor belongs to Fire nature; the decline of form and Qi is because "Flaming Fire consumes Qi"; insufficient Gu Qi is due to labor injuring Yuan Qi, leading to poor appetite and Qi deficiency; failure of the Upper Jiao means Clear Yang fails to ascend; obstruction of the Lower Wan means Turbid Yin fails to descend. The stomach receives water and food, allowing Clear Yang to ascend and Turbid Yin to descend, thereby transmitting and transforming nutrients to nourish the whole body. Now, if the stomach cannot receive food and Gu Qi declines, Clear Yang has nothing to ascend, and Turbid Yin has nothing to descend. Thus, it is said, "Upper Jiao fails to function, Lower Wan is obstructed." This does not mean absolute cessation of function, but rather a state compared to normal health where function is impaired. Failure of ascent and descent leads to stagnation. Stagnation transforms Shao Huo (Lesser Fire) into Zhuang Huo (Blazing Fire). Since the stomach lies between the Upper Jiao and Lower Wan, Stomach Qi becomes hot; heat flares upward, steaming the chest, resulting in internal heat. Li Dongyuan's statement that labor and improper diet cause heat aligns perfectly with the principle of the *Tiao Jing Lun*. It would have been appropriate to cite this passage in *Bian Nei Wai Shang* as the main thesis, yet he did not. Instead, he attributed internal heat to Yin Fire attacking the Earth position, which is questionable.
The term "Yin Fire" does not appear in the *Suwen*, *Lingshu*, or *Nanjing*, yet Li Dongyuan frequently uses it. The *Suwen* only mentions "the seventh vertebra from the bottom, within lies the Small Heart." Liu Wansu inferred this referred to the Mingmen (Gate of Life) belonging to Fire rather than Water, citing the immortal classic's saying that the Heart is Jun Huo (Monarch Fire) and the Kidney is Xiang Huo (Minister Fire) as evidence, but he did not name it "Yin Fire." Thus, the naming of "Yin Fire" likely originated with Li Dongyuan. I suspect that internal heat is not always caused by Yin Fire; rather, Qi stagnation generates heat. Although the Heart is the Monarch Fire and does not actively govern pathology, the *Suwen* describes many heat-related diseases as disorders of Monarch Fire. Does this imply Monarch Fire cannot cause disease, and all heat should be solely attributed to Yin Fire?
The *Zhizhen Yao Da Lun* states: "For exhaustion, use warmth; for loss, use tonification." Exhaustion involves excessive movement, disturbing the Spirit, hence "warmth" is used. "Warmth" here means nourishment. Using warmth involves regulating diet, adapting to daily routines, calming the mind, and waiting patiently for the recovery of True Qi. As stated in the *Liji*: "Gentle demeanor warms them." This "warmth" corresponds to the same meaning. Medicinal assistance is also a form of nourishment. However, Li Dongyuan interprets "warmth" as the temperature property (warm vs. cool), suggesting warm herbs should tonify Yuan Qi and purge Fire Pathogens. He also alters "loss requires tonification" to "loss requires warmth," and claims "warmth eliminates great heat" is from the *Neijing*, yet this phrase is absent in the *Neijing*. This is also questionable.
However, among warm herbs that tonify Yuan Qi and purge Fire Pathogens, those that are warm in nature and sweet in flavor are suitable. Warmth benefits Qi, and sweetness strengthens the Spleen and moderates Fire, thereby restoring Yuan Qi and extinguishing Fire Pathogens. Using warm herbs to treat internal deficiency is acceptable, but using them to annotate "for exhaustion, use warmth" is incorrect. In the *Yinyang Yingxiang Da Lun*, "For deficiency of form, warm with Qi," the word "warm" also implies nourishment, not specifically warm-temperature herbs. Deficiency of form indicates Yang deficiency and lack of fullness. "Qi" here refers to the Qi of herbs. Herbs vary in strength of Qi and Flavor. Strong flavor belongs to Yin and nourishes Essence; strong Qi belongs to Yang and nourishes Form. Using herbs with strong Qi to tonify Yang also nourishes Form. Thus, "warming with Qi" implies not only medicinal nourishment but also dietary regulation, routine adaptation, and mental calmness. Although "warmth" has dual meanings, it should not be reduced merely to temperature properties. By comparing terms like tonify, purge, suppress, lift, and disperse, the true meaning becomes clear.
Metal, Wood, Water, and Earth possess form and substance when attached to the earth, whereas Fire has form but lacks substantial density. Alcohol, though hot in nature, shares characteristics with fluids. Li Dongyuan describes alcohol as "formless Qi," which is doubtful. If it requires sweating and diuresis for elimination, how can it be called "formless Qi"?
Although both fatigue injury and dietary injury are internal injuries, they should not be conflated. The *Nanjing* states "dietary irregularities and fatigue injure the Spleen" because the Spleen governs digestion and limbs; thus, improper diet and limb overwork injure the Spleen. They are not identical. While both differ from excess conditions like Wind-Cold-Damp-Heat, dietary injury differs from fatigue injury. Fatigue injury is purely deficiency; dietary injury requires distinguishing between deficiency and excess within the context of injury. Hunger and starvation represent deficiency (empty Stomach Qi), which is a deviation from moderation. Overeating causing stagnation represents injury to Stomach Qi, combining deficiency with excess. From the perspective of injury, it is deficiency; from the perspective of stagnation, it is excess. Due to deficiency, tonification is needed; due to excess, resolution/promotion of digestion is needed. Some cases require both tonification and resolution; some require only resolution if Qi is not severely damaged; some require only tonification if stagnation persists without self-resolution. Formulas like Ji Gu's Zhizhu Wan, Dongyuan's Jupi Zhizhu Wan, and Muxiang Zhizhu Wan, though promoting digestion, contain tonifying intent. Others like Muxiang Fenqi Wan, Daoqi Zhishi Wan, and Dazhiqiao Wan, lacking tonifying effects, are suitable for temporary stagnation with mild Qi damage, though they should not be used indiscriminately. For severe stagnation beyond the capacity of these formulas, one must adapt. Even Ji Gu and Dongyuan did not discard drastic purgatives like Beijji Wan, Zhu Huang Wan, Ganying Wan, or Gouti San. A skilled general knows when to attack and when to defend; failure lies in the commander's error, not the army's. Understanding this clarifies the principles of resolution, tonification, and purgation.
Fatigue injury requires pure tonification, a point not needing debate. Despite Dongyuan's warnings, people often use bitter-cold agents to treat heat from fatigue, worsening the condition until it becomes critical, blaming fate rather than recognizing erroneous treatment. Alas! Would not benevolent gentlemen feel heartbroken?
Li Dongyuan was an outstanding sage. How dare I lightly criticize him? I regret his minor flaws, which might lead future generations astray by a hair's breadth, resulting in errors of thousands of miles. Hence, I must transcend conventional commentary. May those who understand me judge accordingly.