伤寒腹满。何以明之。腹满者。俗谓之肚胀是也。华佗曰。伤寒一日在皮。二日在肤
三日在肌。四日在胸。五日在腹。六日入胃。入胃谓入腑也。是在腹也。犹未全入里
者。虽腹满为里证。故亦有浅深之别。经曰。表已解而内不消。非大满犹生寒热。则
病不除。是其未全入腑。若大满大实。坚有燥屎。自可除下之。虽四五日不能为祸。
谓之邪气已入腑也。伤寒邪入腹。是里证已深。故腹满乃可下之者多矣。如经曰。
其热不潮。未可与承气汤。若腹大满不通者。可与小承气汤。发汗不解。腹满痛者
急下之。本太阳病。医反下之。因而腹满时痛者。属太阴也。桂枝加芍药汤主之。大
实痛者。桂枝加大黄汤主之。少阴病腹胀。不大便者。急下之。诸如此者。皆为里证
是也。虽曰腹中满痛者。此为实也。当下去之。然腹满不减者。则为实也。若腹满时减者。又为虚也。则不可下。经曰。
腹满不减。减不足言。当下之。金匮要略曰。腹满时减复如故。此虚寒从下上也。当以温药和之。盖虚气留滞。亦为之
胀。但比之实者。不至坚痛也。大抵腹满属太阴证也。阳热为邪者。则腹满而咽干。阴寒为邪者。则
腹满而吐。食不下。自利益甚。时腹自痛。太阴者脾土也。治中央。故专主腹满之候。
又发汗吐下之后。因而成腹满者。皆邪气乘虚内客为之。而所主又各不同。经曰。
发汗后腹胀满者。浓朴生姜甘草半夏人参汤主之。伤寒吐后腹胀满者。调胃承气汤主之。伤寒下后。心烦腹胀满。卧
起不安者。栀子浓朴汤主之。三者有当温者。
有当下者。有当吐者。何邪气不一也。且发汗后腹满当温之。邪气在表。因发散则
邪去。胃为津液之主。发汗亡阳。则胃气虚而不能敷布。诸气壅滞。而为胀满。是当
温散可也。吐后腹满可下之。邪气在胸者。则可吐之。吐之邪去则安。若吐后邪气
不去。加之腹胀满者。是胸中之邪。下传入胃。壅而为实。故生胀满。当须下之可也。
下后腹满可吐者。邪气在表。未传入腑。而妄下之。邪自表乘虚而入。郁于胸中。而
为虚烦。气上下不得通利者。腹为之满。故当吐之可也。凡为医者。要识邪气所起
所在。审其所起。知邪气之由来。观其所在。知邪气之虚实。发汗吐下之不瘥。温补
针艾之适当。则十全之功。自可得也。
伤寒病出现腹部胀满。如何阐明其机理？腹部胀满，就是俗称的肚子胀。华佗说：伤寒第一天邪气在皮部，第二天在肤部，第三天在肌部，第四天在胸，第五天在腹，第六天进入胃腑。所谓“入胃”，是指进入六腑。此时邪气在腹部，还算是没有完全入里。虽然腹部胀满属于里证，但仍有浅深之分。《内经》说：表证已解而内部邪气未消，如果不是大满之证，还会产生寒热，那么病就不能痊愈，这说明邪气尚未完全入腑。如果是大满大实，坚硬且有燥屎内结，自然可以使用攻下法。即使病程到了四五日，也不会造成祸害，这叫做邪气已经入腑。伤寒邪气传入腹部，说明里证已经很深，所以腹部胀满大多可以用攻下法治疗。如经文所说：如果发热不呈潮热状，不可轻易给予承气汤（Chengqi Tang, 调胃承气汤/小承气汤/大承气汤类方剂）。如果腹部显著胀满且不通畅，可以给予小承气汤（Xiao Chengqi Tang, Minor Order the Qi Decoction）。发汗后病不解，出现腹部胀满疼痛的，应当急下之。原本太阳病（Taiyang Disease, Exterior Syndrome related to Bladder and Small Intestine meridians），医生反而误用下法，导致腹部胀满、时时作痛的，属于太阴病（Taiyin Disease, Interior Cold-Deficiency Syndrome related to Spleen meridian）。以桂枝加芍药汤（Guizhi Jia Shaoyao Tang, Cinnamon Twig Decoction plus Paeonia Root）主治。如果大实痛，以桂枝加大黄汤（Guizhi Jia Dahuang Tang, Cinnamon Twig Decoction plus Rheum Rhizome）主治。少阴病（Shaoyin Disease, Interior Heat/Cold Syndrome related to Heart and Kidney meridians）出现腹胀、不大便的，应当急下之。诸如此类的情况，都属于里证。
虽然说腹中满痛，这是实证，应当用攻下法去除邪气。然而，如果腹部胀满持续不减，则为实证；如果腹部胀满时而减轻，又属于虚证，则不可使用攻下法。经文说：腹部胀满持续不减，即使有轻微减轻也不足为道，应当使用攻下法。《金匮要略》说：腹部胀满时而减轻，过后又像原来一样，这是虚寒之气从下向上逆冲所致，应当用温性药物调和。这是因为虚气留滞，也会引起胀满，只是比起实证来，不至于坚硬疼痛。大抵来说，腹部胀满属于太阴证。如果是阳热邪气致病，则腹部胀满且咽干；如果是阴寒邪气致病，则腹部胀满且呕吐，饮食不下，自利（自发腹泻）日益严重，时常腹部自痛。太阴对应脾土，治理中央，所以专门主管腹部胀满的症状。
另外，发汗、催吐、攻下之后，因而形成腹部胀满的，都是邪气乘虚侵入体内所致，但所主治的方法各不相同。经文说：发汗后出现腹胀满的，以浓朴生姜甘草半夏人参汤（Noupo Shengjiang Gancao Banxia Renshen Tang, Magnolia Bark, Fresh Ginger, Licorice, Pinellia, and Ginseng Decoction）主治。伤寒催吐后出现腹胀满的，以调胃承气汤（Tiaowei Chengqi Tang, Harmonize the Stomach Order the Qi Decoction）主治。伤寒攻下后，心烦、腹胀满、卧起不安的，以栀子浓朴汤（Zhizi Noupo Tang, Gardenia and Magnolia Bark Decoction）主治。这三种情况，有的应当温散，有的应当攻下，有的应当催吐，为什么邪气的处理方法不一样呢？
况且发汗后腹部胀满应当温散。因为邪气在表，通过发散则邪气去，胃是津液的主宰，发汗导致阳气亡失，则胃气虚弱而不能敷布运行，各种气机壅滞，从而形成胀满，所以应当用温散法。催吐后腹部胀满可以攻下。因为邪气在胸部的，可以用催吐法，吐后邪气去则安。如果催吐后邪气不去，加上腹部胀满，这是胸中的邪气向下传入胃中，壅塞而成实证，所以产生胀满，应当用攻下法。攻下后腹部胀满可以用催吐法。因为邪气在表，未传入腑，却妄用攻下法，邪气从体表乘虚而入，郁结于胸部，形成虚烦，气机上下不得通利，腹部因此胀满，所以应当用催吐法。
凡是做医生的，必须识别邪气产生的原因和所在部位。审察其产生的原因，了解邪气的由来；观察其所在的部位，了解邪气的虚实。发汗、催吐、攻下如果不愈，温补、针灸艾灸得当，那么十全十美的疗效，自然可以获得。
Abdominal fullness in Shanghan (Cold Damage) disease. How can this be elucidated? Abdominal fullness is commonly referred to as abdominal distension. Hua Tuo stated: On the first day of Shanghan, the pathogen is in the skin; on the second day, in the flesh; on the third day, in the muscles; on the fourth day, in the chest; on the fifth day, in the abdomen; on the sixth day, it enters the stomach. "Entering the stomach" refers to entering the fu organs (Hollow Organs). At this stage, although the pathogen is in the abdomen, it has not yet fully entered the interior. Although abdominal fullness is a sign of an interior syndrome, there are still distinctions between shallow and deep levels. The Classics state: If the exterior is resolved but the interior accumulation remains, unless it is a case of severe fullness, chills and fever will persist, and the disease will not be cured. This indicates that the pathogen has not fully entered the fu organs. However, if there is severe fullness and excess, with hardness and dry feces, purgation (downward draining) can naturally be applied. Even if the disease has lasted four or five days, it will not cause harm; this is called the pathogen having entered the fu organs. When the Shanghan pathogen enters the abdomen, the interior syndrome is already deep-seated; therefore, abdominal fullness is often treated with purgation. As the Classics state: If there is no tidal fever, one should not administer Chengqi Tang (Order the Qi Decoctions) prematurely. If the abdomen is significantly full and obstructed, Xiao Chengqi Tang (Minor Order the Qi Decoction) may be given. If sweating fails to resolve the condition and abdominal fullness and pain occur, urgent purgation is required. In a Taiyang Disease (Exterior Syndrome), if the physician erroneously applies purgation, leading to abdominal fullness and intermittent pain, it belongs to Taiyin Disease (Interior Cold-Deficiency Syndrome). It should be treated with Guizhi Jia Shaoyao Tang (Cinnamon Twig Decoction plus Paeonia Root). In cases of severe excess pain, Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction plus Rheum Rhizome) is indicated. In Shaoyin Disease (Interior Heat/Cold Syndrome), if abdominal distension and constipation occur, urgent purgation is required. All such cases belong to interior syndromes.
Although abdominal fullness and pain generally indicate excess patterns requiring downward elimination, persistent abdominal fullness without relief signifies excess, whereas abdominal fullness that intermittently relieves itself indicates deficiency, for which purgation is contraindicated. The Classics state: Abdominal fullness that does not relieve itself, even slightly, requires purgation. *Jingui Yaolue* states: Abdominal fullness that intermittently relieves itself only to return to its previous state is caused by deficiency-cold rising from below; it should be harmonized with warm herbs. This is because stagnant deficient qi also causes distension, though it is not as hard and painful as in excess patterns. Generally, abdominal fullness belongs to Taiyin patterns. If yang-heat pathogens cause the condition, there is abdominal fullness accompanied by a dry throat. If yin-cold pathogens cause it, there is abdominal fullness accompanied by vomiting, inability to eat, worsening spontaneous diarrhea, and frequent spontaneous abdominal pain. Taiyin corresponds to the spleen earth, which governs the center; thus, it specifically manifests as abdominal fullness.
Furthermore, abdominal fullness arising after sweating, vomiting, or purging is caused by pathogens invading due to deficiency, yet the treatments differ. The Classics state: For abdominal fullness after sweating, Noupо Shengjiang Gancao Banxia Renshen Tang (Magnolia Bark, Fresh Ginger, Licorice, Pinellia, and Ginseng Decoction) is indicated. For abdominal fullness after vomiting in Shanghan, Tiaowei Chengqi Tang (Harmonize the Stomach Order the Qi Decoction) is indicated. For restlessness, abdominal fullness, and inability to lie down comfortably after purging in Shanghan, Zhizi Noupо Tang (Gardenia and Magnolia Bark Decoction) is indicated. These three cases require warming, purging, or inducing vomiting respectively. Why do the treatments for pathogens differ?
For instance, abdominal fullness after sweating should be treated with warming dispersion. Since the pathogen was in the exterior, dispersing removes it. The stomach is the master of fluids and electrolytes; excessive sweating depletes yang qi, causing stomach qi deficiency and failure to distribute qi, leading to stagnation and distension. Thus, warming dispersion is appropriate. Abdominal fullness after vomiting may be treated with purging. If the pathogen was in the chest, vomiting removes it. If vomiting fails to remove the pathogen and abdominal fullness ensues, it means the chest pathogen has descended into the stomach, causing obstruction and excess, resulting in distension; thus, purging is required. Abdominal fullness after erroneous purging may be treated with inducing vomiting. If the pathogen was in the exterior and had not entered the fu organs, but purging was wrongly applied, the pathogen enters via the deficiency, stagnates in the chest, causing empty irritability, and blocks the free flow of qi up and down, leading to abdominal fullness; thus, inducing vomiting is appropriate.
Physicians must identify the origin and location of the pathogen. By examining its origin, one understands its source; by observing its location, one discerns its excess or deficiency nature. If sweating, vomiting, or purging fails to cure, and warming, tonifying, acupuncture, and moxibustion are applied appropriately, perfect healing can be achieved.