【纲】仲景曰。发汗后。其人脐下悸。欲作奔豚。茯苓桂枝甘草大枣汤主之。
烧针令其汗。针处被寒。核起而赤者。必发奔豚。气从小腹上冲心者。灸其核上各一壮。与桂
枝加桂汤。阳明病。脉浮而紧。咽燥口苦。腹满而喘。发热汗出。不恶寒反恶热。身重。若下之。
则胃中空虚。客气动膈。心中懊 。舌上苔者。栀子豉汤主之。
【目】徐彬曰。首条。言君火虚极。肾邪微动。亦将凌心而发奔豚也。谓汗乃心液。发汗后则
虚可知。使非因汗时余邪侵肾。何至脐下悸。至于悸而肾邪动矣。故知欲作奔豚。乃以茯苓合桂、
甘专伐肾邪。单加大枣以安胃。似不复大顾表邪。谓发汗后表邪已少。且但欲作。则其力尚微。故
渗其湿。培其土。而阴气自衰。用甘澜水助其急下之势也。次条。
乃言太阳余邪未尽而加奔豚。兼又起核者。宜内外两治之法也。谓太阳病发汗矣。又复烧针令汗。
以太阳之邪未尽故也。奈烧针则惊。发其奔豚之气。所以气从少腹上至心。于是治其余邪。攻其冲
气。治之甚易。乃又针处被寒。核起而赤。则兼治为难。故以桂枝汤主太阳之邪。加桂以伐奔豚之
气。而赤核则另灸以从外治之法。庶为两得耳。所以然者。以无腹痛。及往来寒热。则病专在太阳
故也。
鳌按。此三条。亦动气之属也。首条脐下悸。乃肾水乘火而上克。曰欲作者。言犹未发也。当
预治之。二条。乃阳气不舒。阴气反胜。寒邪凝聚。发为赤核。是奔豚之兆。从小腹冲心。是奔豚
之象。总之。脐下悸。是水邪欲乘虚而犯心。故君伏苓以正之。奔豚自不发。小腹气冲。是木邪
挟客气以凌心。故汤中加桂以平木。而奔豚自除。一在里而未发。一在表而已发。所以治各不同
也。三条。胃中以下而空虚。邪之客上焦者。必不因下而除。故客气动于膈也。
【纲】仲景曰。动气在右。不可发汗。发汗则衄而渴。心苦烦。饮即吐水。动气在左。不可发
汗。发汗则头眩。汗不止。筋惕肉 。动气在上。不可发汗。发汗则气上冲。正在心。端。动气在
下。不可发汗。发汗则无汗。心中大烦。骨节苦疼。目运。恶寒。食则反吐。谷不得前。
【目】许叔微曰。动气筑筑然跳动于腹者是也。病患先有五积在腹中。或腹上下左右。复因伤
寒。新邪与旧邪相搏而痛。筑筑然跳动。名曰动气。大概虚者。理中汤去术加桂。热者。柴胡桂枝汤。
李 曰。五积中。惟脐下奔豚冲心最急。桂枝汤加桂一倍自效。
成无己曰。伤寒动气。何以明之。动气者。为筑然动于腹中者是矣。脏气不治。随脏所主。发
泄于脐之四旁。动跳筑筑然也。难经曰。肝内症。脐左有动气。按之牢若痛。心内症。脐上有动气。
按之牢若痛。肺内症。脐右有动气。按之牢若痛。肾内症。脐下有动气。按之牢若痛。是脏气不
治。腹中气候发动也。动气应脏。是皆真气虚。虽有表里攻发之症。即不
可攻下。且脾内症。当脐有动气。经特曰。脐之四旁动气。不可汗下。独不言脾候当脐有动气者。
以脾者中州。为胃以行津液。发汗吐下。犹先动脾。况脾家发动气者。讵可动之也。所以特不言之
也。伤寒所以看外症为当者。不在脉之可见。必待问之而得者。发汗吐下。务要审谛。举此动气。
类可知矣。
【纲】仲景曰。动气在右。不可下。下之则津液内竭。咽燥鼻干。头眩心悸也。动气在左。不
可下。下之则腹内拘急。食不下。动气更剧。虽有身热。卧则欲蜷。动气在上。不可下。下之则掌
握热烦。身上浮冷。热汗自泄。欲得水自灌。动气在下。不可下。下之则腹胀满。卒起头眩。食则
下清谷。心下痞也。
【目】李 曰。动气在右。不可发汗。先宜五苓散。后与竹叶石膏汤。不可不。宜竹叶石膏汤。
动气在左。不可汗。先宜防风白术牡蛎汤。汗。必与建中汤。不可下。先宜甘草干姜汤。后与
小建中汤。动气在上。不可汗。宜甘李根汤。不可下。宜竹叶石膏汤加减。动气在下。不可汗。先宜大橘皮汤。后与小
建中汤。不可下。宜甘草泻心汤治之也。
魏荔彤曰。成氏注。右肺左肝。上心下肾。四脏分属动气。引难经皆归之气虚。固然。然气虚
曷有动气。又必在脐之左右上下何也。脐者。先天之气所存也。气实则充而固。气虚则摇而动。
如水在瓶中。满则摇之亦不动。虚则可以摇动而有声。推之肠鸣。亦可知其象义矣。气本一。又何
属四脏乎。可见脐之气通乎脏腑。为先天之元。此气有不足。则按其部位。知所通之脏气必不治也。
不治即不至。不至即不足。无非气不能及之义。成注引难经云。按之牢。此非正气虚也。有邪居
之也。何邪乎。寒邪也。气不足而阳虚。阴邪入而参之。参杂于其中也。愈见四脏气不至而不能开
散。即知本部寇盗不靖。知其官吏之治无术也。虚而发汗。概在所禁。况有积耶。发汗则正气益虚。
阴邪伏者必起矣。居脐之左右上下者。皆各有变症。就动气之可按可验者。可以明其禁也。
此皆由元气虚而脏气弱。所以脐之四方有动气。已示端倪。不审明而误下。其变症与误汗。大
同而小异。
【纲】张仲景说：发汗治疗后，患者感到脐下悸动，有发作奔豚病的趋势，应用茯苓桂枝甘草大枣汤主治。
用烧针强迫发汗，针刺部位受寒，出现红肿如核状者，必定会引发奔豚病。若气从小腹上冲至心脏，应在红肿处各灸一壮，并服用桂枝加桂汤。
阳明病，脉象浮而紧，咽喉干燥且口苦，腹部胀满且气喘，发热出汗，不恶寒反而恶热，身体沉重。如果误用攻下法，则胃中空虚，客气扰动膈部，心中烦闷懊恼，舌上有苔的，应用栀子豉汤主治。
【目】徐彬说：第一条，论述君火极度虚弱，肾邪轻微扰动，也将凌犯心脏而引发奔豚病。认为汗是心之液，发汗后心虚可知。如果不是因为发汗时余邪侵扰肾脏，怎么会导致脐下悸动？既然悸动说明肾邪已动，所以知道这是欲作奔豚之兆，因此用茯苓配合桂枝、甘草专门伐除肾邪，单加大枣以安和胃气，似乎不再主要顾护表邪。这是因为发汗后表邪已少，且只是“欲作”，说明病势尚微，所以通过渗湿、培土，使阴气自然衰退，并用甘澜水助其急下之势。第二条，是说太阳余邪未尽又兼发奔豚，同时伴有肿块，适宜内外同治的方法。太阳病已经发过汗，又用烧针强迫发汗，是因为太阳之邪未尽的缘故。无奈烧针引起惊恐，激发奔豚之气，所以气从少腹上冲至心。于是治疗其余邪，攻逐冲逆之气，治疗相对容易。但又因针刺处受寒，红肿起核，则兼治较为困难。所以用桂枝汤主治太阳之邪，加桂枝以伐除奔豚之气，而红肿之核则另外施灸以从外部治疗，这样才算两全其美。之所以如此，是因为没有腹痛及往来寒热等症状，说明病专在太阳经。
沈金鳌按语：这三条，也属于动气的范畴。第一条脐下悸动，是肾水乘心火而上克，说“欲作”，意思是尚未发作。应当预先治疗。第二条，是阳气不舒，阴气反胜，寒邪凝聚，发为赤色肿块，这是奔豚的先兆；从小腹上冲至心，这是奔豚的现象。总之，脐下悸动，是水邪欲乘虚侵犯心脏，故用茯苓以正之，奔豚自然不发；小腹气上冲，是木邪挟带客气凌犯心脏，故汤剂中加入桂枝以平抑肝木，而奔豚自然消除。一个在里而未发，一个在表而已发，所以治疗方法各不相同。第三条，胃中因误下而空虚，客居上焦的邪气，必然不因攻下而去除，所以客气扰动膈部。
【纲】张仲景说：动气在右侧，不可发汗。发汗则会导致鼻出血且口渴，心中烦苦，饮水即吐。动气在左侧，不可发汗。发汗则头晕目眩，汗出不止，筋肉跳动。动气在上方，不可发汗。发汗则气上冲，直抵心部。动气在下方，不可发汗。发汗则无汗，心中大烦，骨节疼痛难忍，眼花眩晕，怕冷，进食后反而呕吐，食物无法下行。
【目】许叔微说：动气是指腹部筑筑然跳动的感觉。病人腹中原本有五积，或在腹部的上下左右，又因伤寒，新邪与旧邪相搏结而疼痛，筑筑然跳动，名叫动气。大概属虚证的，用理中汤去白术加桂枝；属热证的，用柴胡桂枝汤。
李（注：原文缺名，据上下文推测可能指李东垣或泛指医家）说：五积中，只有脐下奔豚冲心最为紧急，桂枝汤加倍使用桂枝自有效验。
成无己说：伤寒中的动气，如何理解？动气，就是筑筑然动于腹中的情况。脏气失调，随其所主脏腑，发泄于脐之四旁，跳动筑筑然。《难经》说：肝内症，脐左有动气，按压坚硬且痛；心内症，脐上有动气，按压坚硬且痛；肺内症，脐右有动气，按压坚硬且痛；肾内症，脐下有动气，按压坚硬且痛。这是脏气失调，腹中气候发动所致。动气对应脏腑，这都是真气虚弱所致。虽然有表里攻发的症状，也不可以攻下。况且脾内症，当脐有动气，《内经》特别指出：脐之四旁动气，不可汗下，唯独不说脾候当脐有动气的情况，是因为脾为中州，负责引导胃行津液，发汗、吐、下法都会先伤脾。何况脾家发动气者，岂可再扰动它呢？所以特意不言。伤寒看病，外在症状重要，不仅在于脉象可见，必须询问得知。发汗、吐、下法务必审慎。举此动气一例，其他类同可知。
【纲】张仲景说：动气在右侧，不可攻下。攻下则津液内竭，咽喉干燥，鼻孔干涩，头晕心悸。动气在左侧，不可攻下。攻下则腹内拘急，饮食不下，动气更剧烈，即使身体发热，睡觉时也想要蜷缩。动气在上方，不可攻下。攻下则手掌发热烦躁，身上浮冷，热汗自出，想要喝水自我浇淋。动气在下方，不可攻下。攻下则腹胀满，突然起身头晕，进食后排泄未消化的食物，心下痞塞。
【目】李（同上）说：动气在右侧，不可发汗。先宜用五苓散，后用竹叶石膏汤。不可攻下，宜用竹叶石膏汤加减。动气在左侧，不可发汗。先宜用防风白术牡蛎汤，发汗后，必用建中汤。不可攻下。先宜用甘草干姜汤，后用小建中汤。动气在上方，不可发汗。宜用甘李根汤。不可攻下。宜用竹叶石膏汤加减。动气在下方，不可发汗。先宜用大橘皮汤，后用小建中汤。不可攻下。宜用甘草泻心汤治疗。
魏荔彤说：成无己的注释，认为右肺左肝，上心下肾，四脏分属动气，引用《难经》都归结为气虚，固然正确。然而气虚怎么会有动气？又为什么一定在脐的左右上下呢？脐，是先天之气所存之处。气实则充盈稳固，气虚则摇动不安。就像水在瓶中，满了摇晃也不动，虚了就可以摇动而有声。推及肠鸣，也可知晓其象义。气本是一体，又何属四脏呢？可见脐之气通乎脏腑，为先天之元气。此气有不足，则按其部位，可知所通之脏气必然失调。失调即不至，不至即不足，无非是气不能到达的意思。成注引用《难经》说“按之牢”，这并非正气虚，而是有邪气占据。什么邪气呢？寒邪。气不足而阳虚，阴邪入而参杂其中。更加显现四脏气不至而不能开散，就知道本部寇盗不靖，知其官吏治理无方。虚而发汗，一概在禁忌之列，何况有积滞呢？发汗则正气更虚，潜伏的阴邪必起。居于脐之左右上下者，各有变症。就动气可按可验者，可以明确其禁忌。这些都是由元气虚而脏气弱，所以脐之四方有动气，已示端倪。如果不审明而误下，其变症与误汗大同而小异。
[Outline] Zhang Zhongjing said: After sweating therapy, if the patient experiences palpitations below the umbilicus and shows signs of impending Ben Tun (Rushing Pig disease), it should be treated with Fuling Guizhi Gancao Dazao Tang (Poria, Cinnamon Twig, Licorice, and Jujube Decoction).
If burning needles are used to induce sweating, and the needle site becomes cold, resulting in nodular redness, Ben Tun will inevitably occur. If Qi rushes from the lower abdomen up to the heart, moxibustion (one cone) should be applied to each nodule, and Guizhi Jia Gui Tang (Cinnamon Twig Decoction with Added Cinnamon Twig) should be administered.
In Yangming disease, if the pulse is floating and tight, accompanied by dry throat and bitter taste, abdominal fullness and wheezing, fever and sweating, aversion to cold replaced by aversion to heat, and heavy body, and if purgation is mistakenly applied, the stomach becomes empty. This allows pathogenic factors to disturb the diaphragm, causing mental restlessness and stifled sensation, with a coating on the tongue. In such cases, Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used.
[Commentary] Xu Bin stated: The first clause discusses extreme deficiency of Ministerial Fire, where Kidney pathogenic factors slightly move and threaten the Heart, leading to Ben Tun. Sweat is the fluid of the Heart; thus, sweating leads to Heart deficiency. Unless residual pathogens invade the Kidneys during sweating, why would there be palpitations below the umbilicus? Since palpitation indicates Kidney pathogen movement, this signals impending Ben Tun. Therefore, Poria is combined with Cinnamon Twig and Licorice to specifically attack Kidney pathogens, while Jujube alone soothes the Stomach. It seems less concerned with exterior pathogens because after sweating, exterior pathogens are few, and since it is only "impending," the force is weak. Thus, by leaching out dampness and strengthening Earth, Yin Qi naturally declines, and Ganlan Shui (Water Stirred Vigorously) aids its downward movement. The second clause states that residual Taiyang pathogens remain, complicated by Ben Tun and nodules, requiring internal and external treatment. Taiyang disease was already sweated, yet burning needles were used again because Taiyang pathogens remained. However, burning needles causes fright, triggering Ben Tun Qi, so Qi rushes from the lower abdomen to the heart. Treating residual pathogens and attacking rushing Qi is relatively easy. But since the needle site is cold with red nodules, combined treatment is difficult. Thus, Guizhi Tang treats Taiyang pathogens, added Cinnamon Twig attacks Ben Tun Qi, and red nodules are treated externally with moxibustion, achieving both goals. This is because there is no abdominal pain or alternating chills and fever, indicating the disease is exclusively in the Taiyang channel.
Shen Jin'ao's Note: These three clauses belong to Dong Qi (Moving Qi). The first clause, palpitations below the umbilicus, is Kidney Water overcoming Heart Fire upward. "Impending" means not yet manifested. Preemptive treatment is needed. The second clause involves unsmooth Yang Qi, prevailing Yin Qi, and condensed Cold Pathogens causing red nodules, which is a sign of Ben Tun; Qi rushing from the lower abdomen to the heart is the manifestation of Ben Tun. In short, palpitations below the umbilicus indicate Water Pathogens attempting to invade the Heart via deficiency, so Poria corrects this, preventing Ben Tun. Qi rushing from the lower abdomen indicates Wood Pathogens carrying guest pathogens threatening the Heart, so adding Cinnamon Twig pacifies Wood, eliminating Ben Tun. One is interior and unmanifested; the other is exterior and manifested. Hence, treatments differ. The third clause involves an empty Stomach due to mistaken purgation. Pathogens lodging in the Upper Jiao cannot be removed by purgation, so guest pathogens disturb the Diaphragm.
[Outline] Zhang Zhongjing said: If Dong Qi is on the right, sweating is contraindicated. Sweating will cause epistaxis and thirst, severe mental distress, and vomiting water upon drinking. If Dong Qi is on the left, sweating is contraindicated. Sweating will cause dizziness, incessant sweating, and twitching of muscles and flesh. If Dong Qi is above, sweating is contraindicated. Sweating will cause Qi to rush upward, striking the heart directly. If Dong Qi is below, sweating is contraindicated. Sweating will result in inability to sweat, severe mental agitation, painful joints, vertigo, aversion to cold, vomiting after eating, and food failing to pass forward.
[Commentary] Xu Shuwei stated: Dong Qi refers to the throbbing sensation in the abdomen. Patients initially have five accumulations in the abdomen, either above, below, left, or right. Upon contracting cold damage, new pathogens clash with old ones, causing pain and throbbing, named Dong Qi. Generally, for deficiency patterns, Lizhong Tang (Regulate the Middle Decoction) with Bai Zhu removed and Gui Zhi added is used; for heat patterns, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) is used.
Li [Name Missing] stated: Among the five accumulations, only Ben Tun rushing from below the umbilicus to the heart is most urgent. Guizhi Tang with double the amount of Gui Zhi is effective.
Cheng Wuji stated: How to understand Dong Qi in cold damage? Dong Qi is the throbbing movement within the abdomen. When Zang Qi is disordered, it manifests around the four sides of the umbilicus according to its associated organ, throbbing vigorously. The Nan Jing states: Liver internal syndrome has moving Qi to the left of the umbilicus, hard and painful upon pressure; Heart internal syndrome has moving Qi above the umbilicus, hard and painful upon pressure; Lung internal syndrome has moving Qi to the right of the umbilicus, hard and painful upon pressure; Kidney internal syndrome has moving Qi below the umbilicus, hard and painful upon pressure. This is the activation of abdominal climate due to disordered Zang Qi. Dong Qi corresponds to Zang organs, all indicating true Qi deficiency. Even if there are symptoms requiring attack from exterior or interior, purgation is contraindicated. Moreover, Spleen internal syndrome has moving Qi at the umbilicus. The Classics specifically state: Moving Qi at the four sides of the umbilicus prohibits sweating and purgation. It does not mention Spleen syndrome having moving Qi at the umbilicus because the Spleen is the Central State, guiding the Stomach to distribute fluids. Sweating, vomiting, and purging all affect the Spleen first. How much more so if the Spleen itself activates Dong Qi? Therefore, it is specifically omitted. In cold damage, observing external symptoms is crucial, not just visible pulses, but obtained through inquiry. Sweating, vomiting, and purging must be examined carefully. Taking Dong Qi as an example, others can be inferred.
[Outline] Zhang Zhongjing said: If Dong Qi is on the right, purgation is contraindicated. Purgation will deplete internal fluids, causing dry throat and nose, dizziness, and palpitations. If Dong Qi is on the left, purgation is contraindicated. Purgation will cause abdominal cramping, inability to eat, worsened Dong Qi, and even if there is body heat, the patient desires to curl up when lying down. If Dong Qi is above, purgation is contraindicated. Purgation will cause hot palms and agitation, floating coldness on the body, spontaneous sweating of hot sweat, desire to pour water on oneself. If Dong Qi is below, purgation is contraindicated. Purgation will cause abdominal fullness, dizziness upon sudden rising, passage of undigested food after eating, and epigastric痞 (fullness/stuffiness).
[Commentary] Li [Name Missing] stated: For Dong Qi on the right, sweating is contraindicated. Initially use Wuling San (Five-Ingredient Powder with Poria), then Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction). Purgation is contraindicated; use modified Zhuye Shigao Tang. For Dong Qi on the left, sweating is contraindicated. Initially use Fangfeng Baizhu Muli Tang (Saposhnikovia, Atractylodes, and Oyster Shell Decoction); after sweating, use Jianzhong Tang (Establish the Middle Decoction). Purgation is contraindicated. Initially use Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction), then Xiaojianzhong Tang (Minor Establish the Middle Decoction). For Dong Qi above, sweating is contraindicated. Use Ganligengen Tang (Tamarisk Root Decoction). Purgation is contraindicated; use modified Zhuye Shigao Tang. For Dong Qi below, sweating is contraindicated. Initially use Dajupi Tang (Large Tangerine Peel Decoction), then Xiaojianzhong Tang. Purgation is contraindicated; treat with Gancaoxie Xin Tang (Licorice and Heart-Purging Decoction).
Wei Litong stated: Cheng Wuji’s commentary attributes Right Lung, Left Liver, Upper Heart, Lower Kidney to Dong Qi, citing Nan Jing to attribute them all to Qi deficiency. This is correct. However, how can Qi deficiency produce movement? And why specifically at the four directions of the umbilicus? The umbilicus stores congenital Qi. When Qi is sufficient, it is firm and stable; when deficient, it shakes and moves. Like water in a bottle: full, it doesn't shake; empty, it shakes and makes noise. Similarly, intestinal borborygmus illustrates this principle. Qi is one, so why attributed to four Zang organs? This shows Qi at the umbilicus connects to Zang organs as congenital Yuan Qi. Deficiency here indicates dysfunction in the corresponding Zang Qi based on location. Dysfunction means absence, absence means insufficiency—simply Qi failing to reach. Cheng’s note cites Nan Jing saying "hard upon pressure," implying not just deficiency but pathogenic occupation. What pathogen? Cold Pathogen. Qi insufficiency and Yang deficiency allow Yin pathogens to intrude and mix. This further shows four Zang Qi failing to open and scatter, indicating rebellion in the local area and incompetence of the "officials" (Zang Qi). Sweating in deficiency is strictly prohibited, especially with accumulations. Sweating increases deficiency, causing latent Yin pathogens to rise. Each direction (left, right, upper, lower) has specific complications. Observable Dong Qi clarifies these prohibitions. All stem from congenital Qi deficiency and weak Zang Qi, showing Dong Qi at the four sides of the umbilicus as an early sign. Mistaken purgation without clear diagnosis leads to complications similar to, yet slightly different from, those of mistaken sweating.