经义
寒气客于脉外则脉寒，脉寒则缩蜷，缩蜷则脉绌急，绌急则外引小络，故卒然而痛。得炅则痛立止，因
重中于寒，则痛久矣。○寒气客于经脉之中，与炅气相薄则脉满，满则痛而不可按也。寒气稽留，炅气从上，
则脉充大而血气乱，故痛甚不可按也。○寒气客于肠胃之间，膜原之下，血不得散，小络急引，故痛；按之则
血气散，故按之痛止。○寒气客于侠脊之脉则深，按之不能及，故按之无益也。○寒气客于冲脉，冲脉起于关元，
随腹直上。寒气客则脉不通，脉不通则气因之，故喘动应手矣。○寒气客于背俞之脉则脉泣，脉泣则血虚，血
虚则痛。其俞注于心，故相引而痛。按之则热气至，热气至则痛止矣。○寒气客于厥阴之脉。厥阴之脉者，络
阴器，系于肝。寒气客于脉中则血泣脉急，故胁肋与少腹相引痛矣。○厥气客于阴股，寒气上及少腹，血泣，
上下相引，故腹痛引阴股。○寒气客于小肠膜原之间，络血之中，血泣不得注于大经，血气稽留不得行，故宿
昔而成积矣。○寒气客于五脏，厥逆上泄，阴气竭，阳气未入，故卒然痛死不知人，气复反则生矣。○寒气客于
肠胃，厥逆上出，故痛而呕也。○寒气客于小肠，小肠不得成聚，故后泄腹痛矣。○热气留于小肠，肠中痛，
瘅热焦渴，则坚干不得出，故痛而闭不通矣。（《素问》）
哲言
小肠气，绕脐耕起走注痛。膀胱气，少腹肿痛不得小便。肝气，少腹痛引两胁。疝气，少腹痛引睾丸。
肾气，少腹上冲心痛，有形即奔豚。（《医阶辨证》）
痛有虚、实。凡三焦痛证，惟食滞、寒滞、气滞者居多。其有因虫、火、痰、血者，皆能作痛。大都暴
痛多由前三证，久痛多由后四证。但虫痛、痰痛，多在中焦；火痛则三焦俱有；血痛多在下焦，妇人常有之，
男子则少也。但察其多滞、多逆者，方是实证；如无，则不得以实论也。○痛有寒热，误认为害不小。盖痛因
寒者，常居八九；因热者，十唯一二。观《内经》举痛等论可知。盖寒则凝滞，凝滞则气逆，气逆则痛胀。热
则流通，多不然也。虽热证亦常有痛，然必有明辨。如《经》言∶肠中痛，渴热焦胁，则坚干不得出。闭而不
通者，此因燥结热闭，然必有烦热等证，最易见也。若但见心腹痛，无问有无寒热，便云属火，多用寒凉，妄
亦甚矣！○痛证当辨有形、无形。无形者痛在气分。凡气为胀痛，必或胀或止，痛无常处，气聚则痛而见形，
气散则平而无迹，此无形之痛也；但顺其气，则痛自愈。有形者痛在血分，或为食积。凡血症、食积，必痛有
常所，而胀无休息，是有形之痛也。然或食、或血，察得所因而去之，此二者之所当辨也。○痛证有虚、实，
治法有补、泻，不可不详。凡痛而胀闭者多实，不胀不闭者多虚。拒按者为实，可按者为虚。喜寒者多实，爱
热者多虚。饱而甚者多实，饥而甚者多虚。脉实气粗者多实，脉虚气怯者多虚。新痛、年壮者多实，愈攻愈剧
者多虚。痛在经者，脉多弦大；痛在脏者，脉多沉微。必兼脉证而察之，则虚实自明。实者可利，虚者亦可利
乎？不当利而利之，则为害不浅。凡治表虚而痛者，阳不足也，非温经不可。里虚而痛者，阴不足也，非养营
不可。上虚而痛者，心脾受伤也，非补中不可。下虚而痛者，脱泄亡阴也，非救脾胃、温补命门不可。奈何明
似丹溪，而亦曰∶
诸痛不可补。局人意见，岂良法哉？（张景岳）
凡冲气攻痛，从背而上者，系督脉主病，治在少阴。从腹而上者，系冲、任主病，治在厥阴。○诸痛之证，
因于寒者十之七、八，因于热者十之二、三。欲辨寒热，但审其痛处，或喜寒恶热，或喜热恶寒，斯可得其情
矣。至于气血虚实之治，古人总以一通字立法。但此通字，勿误认为攻下通利讲解。所谓通其气血则不痛是也。
然必辨其在气分与血分之殊∶在气分者，但行其气，不必病轻药重，攻动其血；在血分者，则必兼乎气治，所
谓气行则血随之是也。若证之实者，气滞血凝，通其气而散其血则愈。证之虚者，气馁不能充运，血衰不能滋
荣，治当养气补血，而兼寓通于补。此乃概言其大纲耳。若夫诸痛之证，头绪甚繁。内因七情之伤，必先脏腑
而后达于肌躯；外因六气之感，必先肌躯而后入于脏腑。其十二经游行之部位，凡调治立方，必加引经之药，
佐以外治之法，如针灸、砭刺，或敷贴、熨洗，或按摩、导引，则易奏功。此外更有跌打、闪挫，阴疽、内痈，
积聚、 瘕、蛔、蛲、疝、痹、痧胀、中恶诸痛，须辨明证端，不可混治。大旨则补、泻、寒、温，惟用辛润
宣通，不用酸塞敛涩。然其独得之奇，尤在乎治络一法。盖久痛必入于络，络中气血虚实寒热，稍有留邪，皆
能致痛，此乃古人所未言及。（《临证指南》）
诸痛为实，痛随利减，世俗以利为下也。假令痛在表者，实也；在里者，实也；在气血者，亦实也。故
在表者，汗之则愈；在里者，下之则愈；在气血者，散之行之则愈。岂可以利为下乎？宜作通字训则可。（《此事难知》）
周身气血无不贯通。故古人用针通其外，由外及内，以和气血。用药通其里，由内及外，以和气血。其
理一而已矣。至于通则不痛、痛则不通，盖指本来原通而今塞者言。或在内，或在外，一通则不痛，宜十二经
络脏腑各随其处而通之。若通别处，则痛处未知，而他处反为掣动矣。（《吴医汇讲》）
【经典论述】
寒气侵入脉外，则经脉受寒；经脉受寒则收缩卷曲；收缩卷曲则经脉拘急；经脉拘急则牵引细小的络脉，因此突然发生疼痛。遇到温热之气，疼痛立即停止。如果再次受到寒邪侵袭，疼痛就会持续很久。○寒气侵入经脉之中，与热气相互搏结，则经脉充盈满实；满实则疼痛且不可按压。寒气停留不去，热气随之而上，则经脉充盛胀大，气血紊乱，所以疼痛剧烈且不可按压。○寒气侵入肠胃之间、膜原之下，血液不能散行，小络脉拘急牵引，所以发生疼痛；按压时气血得以疏散，所以按压后疼痛停止。○寒气侵入夹脊的经脉，病位较深，按压不能触及，所以按压没有益处。○寒气侵入冲脉，冲脉起于关元穴，沿腹部直上。寒气侵入则脉道不通，脉道不通则气机随之阻滞，所以呼吸时能感觉到脉搏跳动应手。○寒气侵入背俞之脉，则血脉凝涩；血脉凝涩则血虚；血虚则产生疼痛。背俞之气注于心，所以互相牵引而疼痛。按压时热气到达，热气到达则疼痛停止。○寒气侵入厥阴之脉。厥阴之脉，联络阴器，系属于肝。寒气侵入脉中则血液凝涩、经脉拘急，所以胁肋部与小腹部互相牵引疼痛。○厥逆之气侵入阴股部位，寒气上行至小腹，血液凝涩，上下互相牵引，所以腹痛牵引阴股。○寒气侵入小肠膜原之间、络脉血液中，血液凝涩不能注入大经脉，气血滞留不能运行，所以经过一段时间形成积块。○寒气侵入五脏，导致气机厥逆上泄，阴气竭绝，阳气未能入内，所以突然疼痛昏死不知人事，如果气机恢复反常（指气复返），就能生存。○寒气侵入肠胃，气机厥逆向上溢出，所以疼痛并伴有呕吐。○寒气侵入小肠，小肠不能正常聚化食物，所以出现腹泻和小腹疼痛。○热气留滞于小肠，肠中疼痛，热盛焦渴，导致大便坚硬干燥无法排出，所以疼痛且闭塞不通。（出自《素问》）
【哲人言论】
小肠气痛，环绕肚脐耕起走窜作痛。膀胱气痛，少腹部肿痛且小便不通。肝气痛，少腹部疼痛牵引两胁。疝气痛，少腹部疼痛牵引睾丸。肾气痛，少腹部气机上冲至心胸部疼痛，若有形之物即为奔豚病。（出自《医阶辨证》）
疼痛有虚证和实证之分。凡是三焦部位的痛证，大多由食滞、寒滞、气滞引起。其中因虫积、火热、痰浊、瘀血引起的，都能导致疼痛。大体上，突发疼痛多由前三种证候引起，久痛多由后四种证候引起。但是虫痛、痰痛，多位于中焦；火痛则三焦都有可能出现；血痛多位于下焦，妇女常有此症，男子则较少。只有观察到多为停滞、多为逆乱的情况，才是实证；如果没有这些表现，就不能当作实证来论治。○疼痛有寒证和热证的区别，误认会造成不小危害。大概因寒致痛的占八九成，因热致痛的仅占一二成。观察《内经》关于举痛等的论述就可以知道。因为寒性凝滞，凝滞则气机逆乱，气机逆乱则疼痛胀满。热性流通，通常不会这样。虽然热证也常有疼痛，但必须有明确辨别。如《内经》所言：肠中疼痛，口渴热盛焦灼胁部，大便坚硬干燥无法排出，闭塞不通，这是因燥结热闭所致，但必然伴有烦热等症状，最容易识别。如果仅仅看到心腹痛，不问是否有寒热症状，就说是属火，多用寒凉药物，这种妄断也太严重了！○痛证应当辨别有形和无形。无形的疼痛在气分。凡是气痛表现为胀痛，必定有时胀有时止，疼痛位置不固定，气聚则疼痛显现，气散则平静无痕迹，这就是无形的疼痛；只要顺其气机，疼痛自然痊愈。有形的疼痛在血分，或者是食积。凡是血症、食积，必定疼痛位置固定，且胀满无休止，这就是有形的疼痛。然而无论是食积还是血瘀，查清病因并去除它，这两者是需要辨别的。○痛证有虚实之分，治疗方法有补法和泻法，不可不详细考察。凡是疼痛且伴有胀满闭塞的多为实证，不胀不闭的多为虚证。拒绝按压的为实证，可以按压的为虚证。喜欢寒冷的大多为实证，喜爱温暖的大多为虚证。饱食后加重的大多为实证，饥饿时加重的大多为虚证。脉象实、气息粗重的大多为实证，脉象虚、气息怯弱的大多为虚证。新近发病、年壮体强者多为实证，越攻伐病情越加重的大多为虚证。疼痛在经络的，脉象多弦大；疼痛在脏腑的，脉象多沉微。必须结合脉象和症状来考察，那么虚实自然明了。实证可以用通利之法，虚证也可以用通利之法吗？不当用通利而用了，那么危害就不浅了。凡是治疗表虚而疼痛的，是阳气不足，不用温经法不行。里虚而疼痛的，是阴血不足，不用滋养营血法不行。上虚而疼痛的，是心脾受伤，不用补中益气法不行。下虚而疼痛的，是脱泄亡阴，不用救脾胃、温补命门法不行。为什么像朱丹溪那样明理的人，也说“各种疼痛不可用补法”？这种局限的意见，难道是良法吗？（张景岳）
凡是冲气攻痛，从背部向上走的，属于督脉主病，治疗在少阴经。从腹部向上走的，属于冲脉、任脉主病，治疗在厥阴经。○各种疼痛的证候，因寒引起的占十分之七八，因热引起的占十分之二三。想要辨别寒热，只需审察疼痛部位，看患者是喜冷恶热，还是喜热恶寒，这样就可以了解病情了。至于气血虚实的治法，古人总以“通”字作为立法原则。但是这个“通”字，不要错误地理解为攻下通利。所谓通其气血则不痛就是这个意思。然而必须辨别其在气分和血分的不同：在气分的，只需行气，不必药重病轻去攻动其血；在血分的，则必须兼治气，所谓气行则血随之的道理。如果是实证，气滞血凝，通其气而散其血就能痊愈。如果是虚证，气馁不能充运，血衰不能滋荣，治疗应当养气补血，并在补益中寓含通利之意。这只是概略地说出大纲罢了。至于各种疼痛的证候，头绪非常繁杂。内因七情损伤，必先伤脏腑而后达于肌躯；外因六气感受，必先伤肌躯而后入于脏腑。其十二经游行的部位，凡调治立方，必须加入引经药，配合外治方法，如针灸、砭刺，或者敷贴、熨洗，或者按摩、导引，就容易见效。此外还有跌打、闪挫，阴疽、内痈，积聚、瘕块、蛔虫、蛲虫、疝气、痹证、痧胀、中恶等各种疼痛，必须辨明证候端绪，不可混淆治疗。大旨则是补、泻、寒、温，只宜用辛润宣通之法，不用酸涩收敛之品。然而其中独到的奇效，尤其在于治络一法。因为久痛必然入络，络中气血虚实寒热，稍有留邪，都能导致疼痛，这是古人未曾言及的。（出自《临证指南》）
各种疼痛都属于实证，疼痛随着通利而减轻，世俗之人把“利”理解为“下法”。假如疼痛在表的，是实证；在里的，是实证；在气血的，也是实证。所以在表的，发汗则愈；在里的，攻下则愈；在气血的，消散行之则愈。怎么能把“利”理解为“下”呢？应该解释为“通”字才可以。（出自《此事难知》）
周身气血无不贯通。所以古人用针通其外部，由外及内，以调和气血。用药通其内部，由内及外，以调和气血。其中的道理是一样的。至于“通则不痛，痛则不通”，大概是指本来通畅而现在堵塞的情况而言。无论是在内还是在外的，一旦通畅就不痛了，应当根据十二经络脏腑各自所在的位置而进行通治。如果通治别处，那么疼痛的部位还不知道，反而其他部位被牵动而产生疼痛了。（出自《吴医汇讲》）
[Classic Discourse]
When cold qi invades outside the vessels, the vessels become cold; when vessels are cold, they contract and curl; when contracted and curled, the vessels become taut and urgent; when taut and urgent, they externally pull on small collaterals, thus causing sudden pain. Upon receiving warmth (Jiong), pain stops immediately. If re-inflicted by cold, pain persists for a long time. ○ When cold qi invades within the main vessels and contends with warm qi, the vessels become full; when full, there is pain that cannot be pressed. If cold qi lingers and warm qi rises from above, the vessels become distended and large, and blood and qi become chaotic, thus causing severe pain that cannot be pressed. ○ When cold qi invades between the intestines and stomach, below the membrane sources, blood cannot disperse, small collaterals become tense and pull, thus causing pain; pressing causes blood and qi to disperse, thus pain stops upon pressing. ○ When cold qi invades the vessels flanking the spine, the depth is profound, pressing cannot reach it, thus pressing is of no benefit. ○ When cold qi invades the Chong vessel, which originates at Guanyuan (CV4) and ascends straight up along the abdomen. When cold qi invades, the vessel becomes obstructed; when obstructed, qi follows suit, thus pulsation can be felt at the hand during respiration. ○ When cold qi invades the Back-Shu vessels, blood flow stagnates; when blood flow stagnates, blood deficiency occurs; when blood is deficient, pain arises. The Shu points connect to the Heart, thus mutual pulling causes pain. Pressing brings heat; when heat arrives, pain stops. ○ When cold qi invades the Jueyin vessels. The Jueyin vessels connect to the genitalia and attach to the Liver. When cold qi invades within the vessels, blood stagnates and vessels become tense, thus mutual pulling causes pain in the hypochondrium and lower abdomen. ○ Jueqi invades the medial thigh, cold qi ascends to the lower abdomen, blood stagnates, upper and lower mutually pull, thus abdominal pain radiates to the medial thigh. ○ When cold qi invades between the membrane sources of the small intestine and within the collateral blood, blood stagnates and cannot pour into the main vessels, blood and qi stagnate and cannot circulate, thus masses form after some time. ○ When cold qi invades the Zang organs, Jue reversal causes upward leakage, Yin qi is exhausted, Yang qi has not entered, thus sudden pain leads to death-like unconsciousness; if Qi returns, life is preserved. ○ When cold qi invades the intestines and stomach, Jue reversal causes upward emission, thus pain accompanied by vomiting. ○ When cold qi invades the small intestine, the small intestine cannot complete its gathering function, thus diarrhea and abdominal pain occur. ○ When hot qi remains in the small intestine, intestinal pain occurs, intense heat causes dryness and thirst, leading to hard, dry stool that cannot pass, thus pain and obstruction occur. (From *Suwen*)
[Philosophical Statements]
Xiaochang Qi pain: pain moving around the umbilicus. Pangguang Qi pain: swelling and pain in the lower abdomen with inability to urinate. Gan Qi pain: pain in the lower abdomen radiating to both hypochondria. Shan Qi pain: pain in the lower abdomen radiating to the testicles. Shen Qi pain: Qi rushing from the lower abdomen to the heart region causing pain; if tangible, it is Ben Tun (Rushing Pig). (From *Yi Jie Bian Zheng*)
Pain is categorized as Deficiency or Excess. In cases of Sanjiao pain, most are due to Food Stagnation, Cold Stagnation, or Qi Stagnation. Those caused by parasites, Fire, Phlegm, or Blood stasis can also cause pain. Generally, acute pain is mostly due to the first three conditions, while chronic pain is mostly due to the latter four. However, parasite pain and phlegm pain are mostly in the Middle Jiao; fire pain can occur in all three Jiaos; blood pain is mostly in the Lower Jiao, common in women but rare in men. Only when observing signs of stagnation and rebellion should it be considered an Excess pattern; otherwise, it should not be treated as Excess. ○ Pain has Cold and Heat distinctions; misidentification causes significant harm. Approximately 80-90% of pains are due to Cold, while only 10-20% are due to Heat. This can be understood from the *Neijing*’s discussions on pain. Cold causes stagnation; stagnation causes Qi rebellion; Qi rebellion causes pain and distension. Heat promotes circulation, so this is less common. Although heat patterns often have pain, clear differentiation is necessary. As stated in the Classics: intestinal pain, thirst, intense heat scorching the hypochondria, hard dry stool unable to pass, and obstruction—this is due to dryness and heat closure, but must be accompanied by symptoms like irritability and heat, which are easily seen. If one merely sees heart or abdominal pain and, regardless of cold or heat signs, claims it belongs to Fire and uses many cooling herbs, such presumption is too severe! ○ Pain patterns should be differentiated as Tangible or Intangible. Intangible pain is in the Qi level. Qi pain manifests as distending pain, alternating between distension and relief, with no fixed location; when Qi gathers, pain appears; when Qi disperses, it calms without trace. This is intangible pain; soothing the Qi allows pain to heal naturally. Tangible pain is in the Blood level, or due to food accumulation. Blood stasis and food accumulation always have fixed pain locations and unrelenting distension; this is tangible pain. Whether food or blood, identifying the cause and removing it is what needs differentiation. ○ Pain patterns have Deficiency and Excess, and treatments have Tonification and Purging; these must be examined in detail. Pain with distension and obstruction is mostly Excess; without distension or obstruction is mostly Deficiency. Refusal to press indicates Excess; ability to press indicates Deficiency. Preference for cold suggests Excess; preference for warmth suggests Deficiency. Worsening after eating suggests Excess; worsening on an empty stomach suggests Deficiency. Excess pulse and coarse breath suggest Excess; Deficient pulse and timid breath suggest Defusion. Recent onset and strong constitution suggest Excess; worsening with aggressive treatment suggests Defusion. Pain in the meridians usually presents with wiry and large pulses; pain in the Zang organs usually presents with deep and faint pulses. One must examine pulse and symptoms together to clarify Deficiency and Excess. Can Excess be treated with purging? Can Deficiency be treated with purging? Using purging when inappropriate causes significant harm. For exterior Deficiency pain, Yang is insufficient; warming the meridians is essential. For interior Deficiency pain, Yin is insufficient; nourishing Ying (Nutritive) Qi is essential. For upper Deficiency pain, Heart and Spleen are injured; tonifying the Center is essential. For lower Deficiency pain, collapse and Yin loss occur; saving the Spleen and Stomach and warming the Mingmen (Gate of Vitality) is essential. How can someone as enlightened as Zhu Danxi say "All pains should not be tonified"? Such limited opinion is hardly a good method. (Zhang Jingyue)
When Chong Qi attacks causing pain, ascending from the back relates to the Du Mai (Governor Vessel) pathology, treated via Shaoyin. Ascending from the abdomen relates to Chong Mai (Penetrating Vessel) and Ren Mai (Conception Vessel) pathology, treated via Jueyin. ○ Regarding various pain patterns, 70-80% are due to Cold, 20-30% due to Heat. To differentiate Cold and Heat, examine the pain site: does the patient prefer cold and dislike heat, or prefer heat and dislike cold? This reveals the nature. Regarding treatment for Qi/Blood Deficiency/Excess, ancients generally established principles based on the character "Tong" (Unblocking/Patency). However, do not mistakenly interpret "Tong" as only purgative or draining methods. It means unblocking Qi and Blood so pain ceases. One must distinguish between Qi level and Blood level: for Qi level, simply move Qi; do not use heavy drugs to disturb Blood unnecessarily. For Blood level, must treat Qi simultaneously, as "when Qi moves, Blood follows." For Excess patterns where Qi stagnates and Blood coagulates, unblock Qi and dissipate Blood to cure. For Deficiency patterns where Qi energy fails to circulate and Blood decline fails to nourish, treatment should tonify Qi and Blood, incorporating unblocking within tonification. This is a general outline. However, pain patterns are complex. Internal injuries from Seven Emotions first damage Zang-Fu then reach muscles/skin; external injuries from Six Evils first affect muscles/skin then enter Zang-Fu. For the pathways of the Twelve Meridians, prescriptions must include guiding herbs and combine with external therapies like acupuncture, cupping, application, moxibustion, massage, or Qigong for better efficacy. Additionally, differentiate traumas, sprains, yin abscesses, internal carbuncles, accumulations, masses, roundworms, pinworms, hernias, bi-syndromes, sand-swelling, and evil invasion pains. Do not mix treatments. The general principle is Tonification, Purging, Cold, and Warmth, using acrid-moistening and diffusing-unblocking methods, avoiding sour-astringent and consolidating methods. The unique brilliance lies especially in treating Collaterals. Chronic pain inevitably enters collaterals; any slight pathogenic retention in the collaterals' Qi/Blood Deficiency/Excess/Cold/Heat can cause pain. This was not mentioned by ancients. (From *Lin Zheng Zhi Nan*)
All pains are Excess; pain decreases with "Li" (benefit/unblocking). Secular people interpret "Li" as "Xia" (Purgation). Suppose pain is in the Exterior, it is Excess; in the Interior, it is Excess; in Qi/Blood, it is Excess. Therefore, exterior pain cures with sweating; interior pain cures with purging; Qi/Blood pain cures with dispersing and promoting movement. How can "Li" be interpreted as "Xia"? It should be interpreted as "Tong" (Unblocking). (From *Ci Shi Nan Zhi*)
Qi and Blood throughout the body must be patent. Thus, ancients used needles to unblock externally, from outside to inside, to harmonize Qi and Blood. Used medicine to unblock internally, from inside to outside, to harmonize Qi and Blood. The principle is the same. "Patency prevents pain, pain indicates blockage" refers to situations that were originally patent but are now blocked. Whether internal or external, once patent, pain ceases. One should unblock according to the specific locations of the Twelve Meridians, Collaterals, and Zang-Fu organs. If one unblocks other areas, the pain site remains unknown, and other areas may be pulled/disturbed instead. (From *Wu Yi Hui Jiang*)