内经传入三阴。止曰可泄而已。仲景以下字易之。立大小调胃三承气汤。
后人遵而用之。一汗之后。辄尔遽下。遗人夭殃者多矣。不知仲景分痞满
燥实坚。有上中下三焦气血水谷之别。不精求其理。则其法不可得而施
也。何以言之。上焦者。气分也。主纳而不出。病则不能主纳矣。于是为痞。在
上者因而越之。然有可吐者。有不可吐者。有吐后不减者须枳桔陈皮之
属。泄上焦之气则得矣。中焦者。主腐熟水谷者也。病则不能主腐熟矣。于
是为满。肠胃为市。无物不受。宜各随其所受而消之磨之。加以苦温等药。
是泄中焦法也。下焦者。阴分也。主出而不纳。病则不能主出矣。于是为燥
实坚积。蕴热既久。津液必亡。不能传导。须以荡涤之。剂下之。斯愈矣。由是
观之。则上中下三焦。自有浅深次第。有治上焦而中焦得快者。或治中焦
而下焦得通者。断未有不泄上中二焦。而遽用承气以下下焦之理也。观
其曰邪在中焦。不用枳实浓朴。恐伤上焦元气。以甘草和中。名曰调胃。岂
芒硝大黄。独不伤元气乎。又岂甘草一味所能调之乎。观其曰上焦受伤。
则痞而实。去芒硝。名小承气。谓不伤下焦真阴。岂枳实浓朴大黄。果不伐
其根本乎。观其又曰。三焦俱伤。痞满燥实坚俱全。用大承气汤。将谓上不
伤元气。下不伐真阴乎。又岂可一概浪投者乎。必须以手按病患。自胸至
少腹果有硬处。手不可近。不得已而施之可耳。虽然。其间有至理存焉。人
之所借以有生者命门也。其所以禀命而营运者。三焦也。命门为生气之
原。一名守邪之神。三焦者。出气以温肌肉。充皮肤。故寒邪侵犯。独赖此火
以御之。使不得深入肌肤。即发壮热。而出纳腐熟之司。则不能如平人令
矣。所以伤寒独不可食。食亦不化。正谓邪热不杀谷也。宜用甘苦温之药
助之方可。奈何反用苦寒以伐其生气哉。否则此火一衰。寒邪直犯则为
纯阴症矣。岂能发热乎。
按予一日读东垣脾胃论。其诠解黄 。谓除躁热肌热之圣药。又云温
肉分。益皮毛。实腠理。以益元气而补三焦也。似乎劳倦发热。亦本之三
焦。则余以伤寒发热。归于三焦。益非无据。然内伤不能食而可食。伤寒
独不可食。何欤。一则本气自病。利用补。一则客气来乘。利用攻也。
附时珍三焦辨
时珍曰。三焦者。元气之别使。命门者。三焦之本原。盖一原一委也。命门
指所居之府。而名为藏精系胞之物。三焦指分治之部。而名为出纳腐
热之司。盖一以体名。一以用名。其体非脂非肉。白膜裹之在七节之旁。
两肾之间。二系着脊。下通二肾。上通心肺。贯属于脑。为生命之原。相火
之主。精气之府。人物皆有之。生人生物。皆由此出。胡桃仁颇类其壮。而
外皮水汁皆青黑。能入北方。通命门。利三焦。愚按即胰脂也。联系脏腑。
充周一身。皆藉此。
谓胃承气汤
大黄（六钱酒洗） 芒硝（四钱） 甘草（一钱）
水煎。
小承气汤
大黄（四钱） 浓朴（二钱炒） 枳实（一钱炒）
水煎。
大承气汤
大黄（五钱） 浓朴（二钱炒） 枳实（一钱炒） 芒硝（四钱）
水煎。
《内经》传入三阴经时，只说可以泄下而已。张仲景以下，文字有所改变，创立了大、小、调胃三个承气汤。
后人遵循并使用这些方剂，往往在发汗之后，就急忙使用泻下法，导致许多人遭受夭折的灾祸，这太多了。这是因为不知道张仲景区分痞、满、燥、实、坚，有着上、中、下三焦气血水谷的区别。如果不精研其道理，那么治疗方法就无法施行。
为什么说这样呢？上焦，是气分所在，主要功能是受纳而不宣发。生病时就不能正常受纳了，于是出现“痞”证。病位在上方的，应当用因势利导的方法使其涌吐（因而越之）。然而有可以催吐的，有不可以催吐的，有催吐后症状不减的，需要用到枳壳、桔梗、陈皮这类药物，以宣泄上焦之气，这样才能奏效。
中焦，主要功能是腐熟水谷。生病时就不能正常腐熟了，于是出现“满”证。肠胃如同集市，没有什么是不能接受的，应该根据所受的邪气不同而分别消导磨化它。加上苦温等药物，这就是泄除中焦的方法。
下焦，是阴分所在，主要功能是排出而不受纳。生病时就不能正常排出了，于是出现燥、实、坚积滞。蕴结的热邪时间久了，津液必然耗亡，不能传导糟粕，需要用荡涤攻下的药剂来治疗，这样才能痊愈。
由此看来，上、中、下三焦，自然有浅深次第之分。有治疗上焦而中焦得以快通的，或者有治疗中焦而下焦得以通畅的。断然没有不先泄除上、中二焦，就急忙用承气汤来泻下焦的道理。
看他说：邪气在中焦，不用枳实、厚朴，恐怕会损伤上焦元气，所以用甘草调和胃气，名叫调胃承气汤。难道芒硝、大黄就不伤元气吗？又难道仅靠一味甘草就能调理好吗？
看他说：上焦受伤，则痞而且实，去掉芒硝，名叫小承气汤，说是为了不损伤下焦真阴。难道枳实、厚朴、大黄果真不伐害根本吗？
看他又说：三焦都受伤，痞、满、燥、实、坚全都具备，使用大承气汤。难道是说上不伤元气，下不伐真阴吗？又难道可以一概乱投吗？必须用手按压病人，从胸部到小腹确实有硬块，手不敢靠近，不得已的情况下才能施用。
虽然如此，其中蕴含着至深的道理。人赖以生存的是命门。禀受生命并营运全身的是三焦。命门是生气的源头，又名守邪之神。三焦的作用是出气以温暖肌肉，充实皮肤。所以寒邪侵犯时，唯独依赖此火来抵御它，使寒邪不得深入肌肤，就会发生壮热。而出纳、腐熟的功能，就不能像正常人那样了。所以伤寒病独独不可进食，吃了也不消化，正是所说的邪热不能杀谷（消化食物）。适宜用甘、苦、温的药物来辅助它才可以。为什么反而用苦寒药来伐害生气呢？否则，如果此火一衰，寒邪直接侵犯就成为纯阴证了，怎么能发热呢？
按语：我有一天读李东垣的《脾胃论》，其中解释黄芩，说是清除躁热、肌热的圣药。又说温暖肉分，益皮毛，实腠理，以补益元气而补三焦。似乎劳倦发热，也本源于三焦，那么我将伤寒发热归于三焦，更加不是没有依据的。然而内伤不能吃饭却可以吃饭，伤寒独独不可吃饭，为什么呢？一个是本气自病，利用补法；一个是客气来乘，利用攻法。
附李时珍关于三焦的辨析
李时珍说：三焦，是元气的别使（使者）；命门，是三焦的本原。大概是一个源头和一个分支的关系。命门指其所居住的府，命名为藏精系胞之物；三焦指分管治疗的部位，命名为出纳、腐熟之司。大概一个以形体命名，一个以功能命名。它的形体既不是脂肪也不是肌肉，是白色的膜包裹着，位于第七节脊椎旁边，两肾之间，两条系带连着脊柱，下通两肾，上通心肺，贯通属于脑，是生命的源头，相火的主宰，精气的府库。人和动物都有它，生育人类和生物，都由此而出。胡桃仁很类似它的形状，而外皮和水汁都是青黑色的，能入北方，通命门，利三焦。我按察认为那就是胰脂。联系脏腑，周流一身，都借助于此。
谓胃承气汤
大黄（六钱，酒洗） 芒硝（四钱） 甘草（一钱）
用水煎煮。
When the *Neijing* (Classic of Internal Medicine) was transmitted to the Three Yin meridians, it only stated that purgation could be used. From Zhang Zhongjing onwards, the terminology changed, establishing the Da Chengqi Tang (Major Order the Stomach Decoction), Xiao Chengqi Tang (Minor Order the Stomach Decoction), and Tiaowei Chengqi Tang (Regulate the Stomach Order the Stomach Decoction).
Later generations followed and used these formulas. Often, after administering a sweating treatment, they would hastily proceed to purgation, causing many people to suffer premature death. This is because they did not understand that Zhang Zhongjing distinguished between pi (glomus/fullness), man (distension), zao (dryness), shi (excess), and jian (hardness), noting the differences among the Upper, Middle, and Lower Jiao regarding qi, blood, fluids, and food residues. Without meticulously seeking the underlying principles, the methods cannot be applied.
Why is this so? The Upper Jiao is the realm of qi. Its primary function is reception without discharge. When diseased, it loses its ability to receive properly, leading to pi (glomus sensation). For pathogens located in the upper region, one should use the method of "causing them to ascend and vomit" (yin er yue zhi). However, there are cases suitable for emesis and those unsuitable. In cases where symptoms persist after vomiting, herbs such as Zhi Ke (Aurantii Fructus), Jie Geng (Platycodonis Radix), and Chen Pi (Citri Reticulatae Pericarpium) are required to vent the qi of the Upper Jiao, which will achieve the desired effect.
The Middle Jiao is primarily responsible for the rotting and ripening of food and drink. When diseased, it loses this function, leading to man (distension). The intestines and stomach are like a market, accepting all things; treatment should vary according to the specific pathogen received, using methods to dissolve and grind away the stagnation. Combined with bitter-warm herbs, this constitutes the method for draining the Middle Jiao.
The Lower Jiao belongs to the yin aspect. Its primary function is discharge without reception. When diseased, it fails to discharge properly, resulting in zao (dryness), shi (excess), and jian (hardness) accumulations. After prolonged retention of heat, body fluids must be depleted, and the transmission of waste is impaired. One must use drastic purgative agents to cleanse and purge, thereby achieving recovery.
From this perspective, the Upper, Middle, and Lower Jiao naturally have a sequence of depth. There are instances where treating the Upper Jiao leads to rapid resolution in the Middle Jiao, or treating the Middle Jiao leads to unblocking the Lower Jiao. It is inconceivable that one would skip draining the Upper and Middle Jiao and hastily use Chengqi formulas to purge the Lower Jiao.
Consider his statement: "When pathogenic factors are in the Middle Jiao, if Zhi Shi (Immature Bitter Orange) and Hou Po (Magnolia Bark) are not used, it is feared that the yuan qi (original qi) of the Upper Jiao will be damaged; therefore, Gan Cao (Licorice Root) is used to harmonize the stomach, hence the name Tiaowei Chengqi Tang." Do Mang Xiao (Natrii Sulfas) and Da Huang (Rhei Radix et Rhizoma) not damage the yuan qi? Can a single herb of Gan Cao truly regulate it?
Consider his statement: "If the Upper Jiao is injured, pi becomes solid; Mang Xiao is removed, naming it Xiao Chengqi Tang," claiming this avoids damaging the true yin of the Lower Jiao. Do Zhi Shi, Hou Po, and Da Huang truly fail to undermine the root?
Consider his further statement: "When all three Jiao are injured, and pi, man, zao, shi, and jian are all present, Da Chengqi Tang is used." Does this imply no damage to the yuan qi above and no undermining of true yin below? Can such formulas be indiscriminately administered? One must palpate the patient; only if there is indeed hardness from the chest to the lower abdomen, which is intolerable to touch, should these be used reluctantly.
Nevertheless, profound principles exist within. What humans rely on for life is the Mingmen (Gate of Life). What receives destiny and operates throughout the body is the Sanjiao (Triple Burner). Mingmen is the source of generating qi, also known as the Spirit that Guards against Pathogens. The Sanjiao emits qi to warm the muscles and fill the skin. Therefore, when cold pathogens invade, one relies solely on this fire to resist them, preventing deep penetration into the flesh and skin; if they penetrate, high fever ensues. The functions of reception/discharge and rotting/ripening then cannot function as in a healthy person. Thus, in Shanghan (Cold Damage), one strictly should not eat, and even if one does, digestion fails; this refers to the concept that pathogenic heat cannot "kill grain" (digest food). It is appropriate to use sweet, bitter, and warm herbs to assist this fire. Why instead use bitter-cold herbs to attack the generating qi? Otherwise, if this fire declines, cold pathogens directly invade, resulting in a Pure Yin syndrome, from which fever cannot arise.
Note: One day I read Li Dongyuan's *Pi Wei Lun* (Treatise on the Spleen and Stomach). His explanation of Huang Qin (Scutellariae Radix) states it is a holy medicine for removing irritability, heat, and muscle heat. It also says it warms the muscular layer, benefits the skin and hair, consolidates the cou li (pores), thereby benefiting yuan qi and tonifying the Sanjiao. It seems that fatigue-induced fever also originates from the Sanjiao. Thus, attributing Shanghan fever to the Sanjiao is well-founded. However, why can internal injury patients who cannot eat eventually eat, while Shanghan patients strictly cannot eat? One is a disease of the proper qi itself, requiring tonification; the other is an invasion by exogenous pathogens, requiring purgation.
Appendix: Li Shizhen's Differentiation of the Sanjiao
Li Shizhen said: The Sanjiao is the envoy of Yuan Qi; the Mingmen is the origin of the Sanjiao. They share one origin and one branch. The Mingmen refers to the residence, named as the organ storing essence and connecting to the uterus. The Sanjiao refers to the regions of governance, named as the department of reception/discharge and rotting/ripening. One is named by form, the other by function. Its form is neither fat nor flesh, but a white membrane wrapping around, located beside the seventh thoracic vertebra, between the two kidneys. Two ligaments attach to the spine, connecting downward to the two kidneys, upward to the heart and lungs, and penetrating to the brain. It is the origin of life, the master of Ministerial Fire, and the mansion of essence and qi. All humans and animals possess it; human birth and biological generation all emerge from here. Walnut kernels resemble it significantly; their outer skin and juice are dark green-black, entering the North, communicating with the Mingmen, and benefiting the Sanjiao. I observe that this is actually pancreatic fat. It connects the zang-fu organs and circulates throughout the body, relying on this substance.
Prescriptions
Wei Chengqi Tang (Stomach-Ordering Purgative Decoction)
Da Huang (6 qian, washed with wine), Mang Xiao (4 qian), Gan Cao (1 qian).
Decoct in water.
Xiao Chengqi Tang (Minor Order the Stomach Decoction)
Da Huang (4 qian), Hou Po (2 qian, stir-fried), Zhi Shi (1 qian, stir-fried).
Decoct in water.
Da Chengqi Tang (Major Order the Stomach Decoction)
Da Huang (5 qian), Hou Po (2 qian, stir-fried), Zhi Shi (1 qian, stir-fried), Mang Xiao (4 qian).
Decoct in water.