尝观东垣内外篇辨曰∶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。自此议一出，而天下后世，知内伤外感之有别，而仲景之法不可例用，其惠也
不亦大哉？然夷考其说，犹或有可疑者，僭用条之如曰饮食劳倦伤而内热者，乃阴火乘其坤
土之位，故内热极乎胸中。又曰∶经云劳者温之，损者温之，惟宜温药以补元气而泻火邪。
又云∶甘温能除大热。又曰∶饮者无形之气，伤之则宜发汗利小便，使上下分消其湿；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。谨按调经论曰
∶阴虚生内热奈何？歧伯曰∶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，嗟呼？此内伤之说之源乎！请释其义如左。夫人身之阴阳，有以表
里言者，有以气血言者，有以脏腑言者。如上下前后升降呼吸之类甚多，
不必悉举。此所谓阴虚之阴，其所指数者皆
不同。盖劳动之过
，则阳和之气亢极而为火矣。况水谷之味又少入，是故阳愈甚而阴愈衰，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。夫有劳役者
，过动皆火也；形气衰少者，壮火食气也；谷气不盛者，劳伤元气，则食少而气衰也；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。今胃不纳谷，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，但比之寻常无病时，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，而胃居上焦下脘之间，故胃气热，热则上炎，故熏胸中而内热也
。东垣固宜引此段经文，以为内伤发热之本，乃反不引而谓阴火乘其土位，故内热及胸中，
此不能无疑者也。夫阴火二字，《素》、《难》未尝言，而东垣每每言之。《素问》止有七
节之旁，中有小心二句，而守真推其为命门属火不属水，引仙经心为君火，肾为相火以为证
，然亦不以阴火名之，是则名阴火者，其东垣始欤。窃谓内热之作。非皆阴火，但气郁则成
热耳。虽曰心为君不主事，然《内经》所叙诸病之属热者甚众，岂君火不能为病，而直欲纯
归之阴火乎？至真大要论曰∶劳者温之，损者益之。夫劳则动之大过，而神不宁矣。故温之
，温之者，养也，所谓调其饮食，适其起居，澄心息虑，从容以待其真气之复也。《礼记》
所谓柔色以温之，即是此义。今东垣乃以温凉之温，谓宜温药以补元气之虚而泻火邪；又易
损者益之，为损者温之；又以温能除大热为《内经》之言，而遍考《内经》并无此论，此亦
不能无疑者也。然温药之补元气，泻火邪，亦惟气温而味甘者，斯可矣。养温能益气，甘能
助脾而缓火，故元气复而火邪息也。夫宜用温药，以为内伤不足之治则可，以为劳者温之之
证则不可。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，亦未尝不兼乎调饮食，适起居，与澄心息虑者也。温字固具二义，然终不可视为温凉之
温。苟以补之除之抑之举之散之等语，比类而推焉，则其义自着矣。夫五行运于天，则无形
质可观，其丽于地，则有形质矣。金木水土，有形有质者矣。火者，有形而质不实者也，酒
性虽热，体同于水，今东垣乃谓饮者无形之气，此又不能无疑者也。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》云
∶饮食劳倦则伤脾。盖谓脾主饮食，而四肢亦属脾，故饮食失节，劳役四肢，皆能伤脾，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，然饮食伤比之劳倦
伤又不同者，诚当于不足之中，更观其有余不足也。夫饥渴不饮食者，胃气空虚，则为不足
，固失节也。以伤言则不足，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，必消补兼行者；亦有物暂滞而气不甚伤，独宜消导者；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、东垣橘皮枳实丸等，虽曰消导，固有
补益之意存乎其间。他如木香分气丸、导气枳实丸，虽无补益，然施之于物停滞气不甚伤者
，岂不可哉？但不宜视为通行之药耳。且所滞之物，非枳术之力所能去者，安可泥于消导而
不知变乎？故备急丸、感应丸之推逐者，洁古、东垣亦未尝委之而弗用也，故善将兵者，攻
亦当，守亦当；不善将兵者，宜攻而守，宜守而攻，其败也，非兵之罪，用兵者之罪耳。观
乎此，则知消导推逐补益之理矣！若夫劳役伤，则纯乎补益，自不待议，虽东垣丁宁告戒，
然世人犹以苦寒之剂，望除劳倦内伤之热，及其不愈而反甚，自甚而至危，但曰病热已极，
药不能胜耳。医者病者，一委之天命，皆不悟其妄治之失，呜呼！仁人君子，能不痛心哉？夫
东垣先哲之出类者也，奚敢轻议，但嫌白壁微瑕，或贻后人毫厘千里之谬，故不得不僭陈耳
，知我者其鉴之。
我曾阅读李东垣在《内外伤辨惑论》中的论述，他说：外感风寒邪气，属于有余的实证，应当采用泻法而不宜用补法。内因饮食不节和过度劳累所致，属于不足的虚证，应当采用补法而不宜用泻法。自从这一观点提出后，天下后世的人知道了内伤与外感的区别，明白张仲景的治疗法则不能机械地套用，这带来的益处难道不大吗？然而，仔细考察他的学说，仍有一些地方令人怀疑，我冒昧地逐条陈述如下：
他说饮食劳倦损伤导致内热，是因为阴火乘袭了脾土（坤土）的位置，所以内热极度局限于胸中。他又说：《内经》记载“劳者温之，损者益之”，只适宜用温性药物来补益元气并清泻火邪。又说：甘温的药物能够清除大热。他还说：酒属于无形的“气”，损伤它应当通过发汗和利小便的方法，使湿气从上、下分消；食物属于有形的“物”，损伤它应当减少谷物摄入，其次不如使用消食导滞的方法。像这些说法，都让人无法不产生疑问。
我谨按照《素问·调经论》的说法：“阴虚生内热是怎么回事？”岐伯回答说：“由于过度劳累，形体之气衰弱减少，水谷精气不充盛，上焦的气机不通畅，下脘的传导受阻，胃气郁而化热，热气熏蒸于胸中，所以产生内热。”唉！这才是内伤学说的源头啊！请让我解释其中的含义如下：人体的阴阳，可以从表里、气血、脏腑等角度来论述，如上下的升降、前后的呼吸等等，情况很多，不必一一列举。这里所说的“阴虚”之“阴”，所指的内容各不相同。
大概是因为劳动过度，阳气亢极而化为火邪。况且水谷摄入又少，因此阳越盛而阴越衰。这个“阴虚”之“阴”，指的是人体内的阴气以及水谷的精微物质罢了。如果将其解释为下焦的阴分，或者肾水的真阴，都是不对的。凡是从事劳役的人，过度的动作都会生火；形体之气衰弱，是因为壮火（亢盛的阳气）消耗了正气；水谷精气不充盛，是因为劳倦损伤了元气，导致食欲减退、气力衰弱；上焦不通行，是指清阳之气不能上升；下脘不通畅，是指浊阴之气不能下降。
胃接受水谷，所以清阳上升、浊阴下降，以此进行传化和出入，滋养全身。现在胃不能纳谷，导致谷气衰弱，那么清气就没有升发的动力，浊气就没有下降的去路。所以说“上焦不行，下脘不通”。但这并不是说完全不行或完全不通，只是相比于平常无病时的状态而言，称之为不行不通罢了。上面不通行，下面不降通，气机就会郁结，郁结则少火（生理之火）都变成了壮火（病理之火），而胃位于上焦和下脘之间，所以胃气发热，热势向上炎蒸，熏灼胸中，从而产生内热。
李东垣本来应该引用这段经文，作为内伤发热的根本依据，但他反而不引用，却说阴火乘袭脾土位置，导致内热及于胸中，这一点确实让人难以信服。所谓“阴火”二字，《黄帝内经》和《难经》从未提及，而李东垣却常常提到。《素问》中只有“七节之旁，中有小心”两句，刘完素（守真）推测这是指命门属火不属水，引用仙经中“心为君火，肾为相火”作为证据，但也并未用“阴火”来命名它。那么，“阴火”这个名称，大概是李东垣开始使用的吧？
我个人认为，内热的产生，并不都是因为阴火，只是气机郁结才会化热。虽然常说心为君主之官而不直接主事，但《内经》中叙述的许多属于热证的疾病，难道是因为君火不能致病，而一定要全部归咎于阴火吗？《素问·至真要大论》说：“劳者温之，损者益之。”劳倦是大过度的运动，会导致神气不安宁。所以“温之”，这里的“温”是调养的意思，即所谓调理饮食，适应起居，清心寡欲，从容等待真气恢复。《礼记》中所谓的“柔色以温之”，就是这个意思。
现在李东垣却将“温凉”之“温”，理解为适宜用温性药物来补益元气的虚弱并清泻火邪；又将“损者益之”改为“损者温之”；又把“甘温能除大热”当作《内经》的话，但我遍查《内经》并没有这种论述，这也是让人难以信服的。然而，用温药补元气、泻火邪，也只限于那些气温而味甘的药物才行。温性能益气，甘味能助脾并缓和火势，所以元气恢复而火邪平息。
适宜使用温药，作为治疗内伤不足的方法是可以的，但不能将其作为“劳者温之”的证据。《素问·阴阳应象大论》说：“形不足者，温之以气。”这里的“温”字也是滋养的意思，并非指药物。所谓“形不足”，就是阳气虚弱而不充盈。这里的“气”指的是药物的气味，药物有气浓气薄、味浓味薄的区别。味浓的属于阴，能滋养精血；气浓的属于阳，能滋养形体。现在用气浓的药物来滋助阳气，难道不是同时也滋养形体吗？所以说“形不足者，温之以气”。虽然是用药物来温养，但也未尝不包括调理饮食、适应起居和清心寡欲等内容。“温”字固然包含两层含义，但最终不可将其视为寒温之“温”。如果将补、除、抑、举、散等语句类比推导，那么其中的含义自然显明。
五行在天运行，是没有有形质可见的；在地显现，就有形质了。金、木、水、土都是有形有质的。火，是有形而质不实的。酒的性质虽然热，其体状同于水，现在李东垣却说酒是“无形之气”，这又是让人难以信服的。既然需要通过发汗和利小便来祛除它，怎么能说是无形之气呢？
而且，劳倦伤和饮食伤两者虽然都属于内伤，但不能混为一谈。《难经》说：“饮食劳倦则伤脾。”意思是脾主运化饮食，而四肢也归属于脾，所以饮食失节、劳役四肢，都能损伤脾脏，这并不是说这两者是同类而没有区别的。
劳倦伤和饮食伤，虽然与风寒暑湿等有余的实证不同，但饮食伤与劳倦伤又有不同之处，确实应当在“不足”之中，进一步观察其是否有“有余”的情况。饥饿口渴不进食，导致胃气空虚，这是不足，固然是失节的表现。从损伤的角度看是不足，但从停滞的角度看则是有余。正因为不足，所以要补益；正因为有余，所以要消导。也有因为食物停滞且气机受伤，必须消补兼施的；也有食物暂时停滞但气机损伤不重，只适宜消导的；也有已经停滞，不再自行化解，不需要消导，只需补益，或者甚至不需要补益的情况。洁古的枳术丸、东垣的橘皮枳实丸等，虽然称为消导，其中固有补益的意思存在。其他如木香分气丸、导气枳实丸，虽然没有补益作用，但如果应用于食物停滞而气机损伤不重的情况，难道不可以吗？只是不宜将它们视为通用的通行药物罢了。
况且，所停滞的食物，不是枳术丸的力量所能去除的，怎么能拘泥于消导而不知道变通呢？所以备急丸、感应丸这类推逐积滞的药物，洁古和东垣也未曾废弃不用。所以善于带兵打仗的人，进攻得当，防守也得当；不善于带兵的人，该进攻时防守，该防守时进攻，导致失败，这不是军队的罪过，而是指挥者的罪过。从这里可以看出消导、推逐、补益的道理了！至于劳役伤，则纯粹是补益的问题，自然无需多议，虽然李东垣再三告诫，但世人仍然用苦寒的药物来期望消除劳倦内伤的热症，等到病情没有好转反而加重，从严重发展到危险，只说病热已经极盛，药物不能胜任罢了。医生和病人，都将这一切委之于天命，都不醒悟这是误治的错误，唉！仁人君子，能不痛心吗？
李东垣是先哲中出类拔萃的人物，我怎么敢轻易议论他，只是担心白璧微瑕，可能会给后人造成毫厘千里的大谬误，所以不得不冒昧陈述。了解我的人请加以鉴别。
I have read Li Dongyuan's discussion in *Nei Wai Shang Bian Huo Lun* (Differentiation of Internal Injury and External Contraction), where he states: External contraction of wind-cold pathogenic factors constitutes an excess syndrome, which should be treated with purging methods rather than tonifying methods. Internal injury caused by improper diet and overexertion constitutes a deficiency syndrome, which should be treated with tonifying methods rather than purging methods. Since this viewpoint was proposed, people in the world and subsequent generations have understood the distinction between internal injury and external contraction, realizing that Zhang Zhongjing's treatment principles cannot be mechanically applied; is not the benefit derived from this immense? However, upon careful examination of his theory, there remain points worthy of doubt. I presume to list them as follows:
He states that internal heat resulting from dietary indiscretion and fatigue is due to "Yin Fire" attacking the position of Spleen Earth (Kun Earth), thus causing extreme internal heat confined to the chest. He further says: The *Classic* records, "For exhaustion, use warmth; for loss, use warmth." It is only appropriate to use warm-natured herbs to tonify Yuan Qi (Original Qi) and drain Fire Pathogens. He also claims: Sweet and warm substances can eliminate great heat. He adds: Wine belongs to formless "Qi"; when injured, it should be treated by inducing sweating and promoting urination to disperse dampness from above and below. Food belongs to tangible matter; when injured, grain intake should be reduced, or preferably, digestion-promoting methods should be used. Such statements naturally raise doubts.
I respectfully refer to the *Suwen·Tiao Jing Lun* (Treatise on Regulating the Meridians): "How does Yin deficiency generate internal heat?" Qibo answers: "Due to excessive labor, the physical energy declines, and Gu Qi (Grain Qi) becomes insufficient. The Upper Jiao fails to circulate, and the Lower Wan (stomach outlet) fails to conduct. Stomach Qi stagnates and generates heat, which steams upward into the chest, thus generating internal heat." Alas! This is the source of the theory of internal injury! Let me explain its meaning as follows: The Yin and Yang of the human body can be discussed from perspectives of exterior-interior, Qi-Blood, and Zang-Fu organs, such as ascending-descending and respiration, which are numerous and need not be listed exhaustively. The "Yin" referred to here as "Yin deficiency" varies in its specific reference.
Generally, excessive labor causes Yang Qi to hyperactive and transform into Fire. Moreover, since the intake of water and food is scant, Yang becomes more excessive while Yin becomes more deficient. This "Yin" in "Yin deficiency" refers to the body's Yin Qi and the essence of water and food. Interpreting it as the Yin division of the Lower Jiao or the True Yin of Kidney Water is incorrect. Those engaged in labor exert themselves excessively, generating fire; the decline of physical energy occurs because vigorous Fire consumes Qi; insufficiency of Grain Qi results from labor injuring Yuan Qi, leading to poor appetite and weakness; failure of the Upper Jiao to circulate means Clear Yang fails to ascend; obstruction of the Lower Wan means Turbid Yin fails to descend.
The Stomach receives food and drink, allowing Clear Yang to ascend and Turbid Yin to descend, facilitating transformation and transportation to nourish the whole body. Now, if the Stomach fails to receive food and Gu Qi declines, there is no ascent of Clear Qi and no descent of Turbid Qi. Hence, it is said, "The Upper Jiao fails to circulate, and the Lower Wan fails to conduct." This does not mean absolute cessation, but rather a state compared to normal health, described as non-circulation and non-conduction. When the upper part does not circulate and the lower part does not descend, Qi stagnates. Stagnation transforms Shao Huo (Physiological Fire) into Zhuang Huo (Pathological Fire). Since the Stomach lies between the Upper Jiao and Lower Wan, Stomach Qi becomes hot, flares upward, steams the chest, and generates internal heat.
Li Dongyuan should have cited this passage as the root of internal injury fever, yet he did not. Instead, he claimed Yin Fire attacks the Spleen Earth position, causing internal heat in the chest, which is indeed doubtful. The term "Yin Fire" never appears in the *Huangdi Neijing* or *Nan Jing*, yet Li Dongyuan uses it frequently. The *Suwen* contains only the phrase "Beside the seventh vertebra, there is the Small Heart," which Liu Wansu (Shouzhen) interpreted as referring to the Mingmen (Gate of Life) belonging to Fire rather than Water, citing ancient texts stating "Heart is Sovereign Fire, Kidney is Ministerial Fire" as evidence, yet he did not name it "Yin Fire." Thus, the term "Yin Fire" likely originated with Li Dongyuan.
I believe internal heat is not always caused by Yin Fire; rather, it arises from Qi stagnation transforming into heat. Although it is said the Heart, as the Sovereign, does not directly govern pathology, the *Neijing* describes many heat-related diseases. Does this imply Sovereign Fire cannot cause disease, forcing all attribution to Yin Fire? The *Zhizhen Yao Da Lun* (Major Requirements of the Most Genuine) states: "For exhaustion, use warmth; for loss, use benefit." Exhaustion involves excessive movement, disturbing Shen (Spirit). Therefore, "warmth" here implies nourishment and regulation—adjusting diet, adapting to daily life, calming the mind, and waiting patiently for the recovery of True Qi. This aligns with the meaning of "gentle demeanor to warm" in the *Liji* (Book of Rites).
However, Li Dongyuan interprets "warmth" in the context of cold-warm properties as using warm herbs to tonify deficient Yuan Qi and drain Fire Pathogens. He alters "loss, use benefit" to "loss, use warmth" and attributes "sweet and warm eliminates great heat" to the *Neijing*, which is absent upon thorough review. This is also questionable. Nevertheless, using warm herbs to tonify Yuan Qi and drain Fire is valid only for herbs that are warm in nature and sweet in flavor. Warmth benefits Qi; sweetness strengthens the Spleen and moderates Fire, allowing Yuan Qi to recover and Fire Pathogens to subside.
Using warm herbs as a treatment for internal injury deficiency is acceptable, but using it as proof for "for exhaustion, use warmth" is incorrect. The *Yinyang Yingxiang Dalun* states: "For deficiency of form, warm with Qi." Here, "warm" means nourishing, not referring to drugs. "Deficiency of form" indicates Yang deficiency and lack of fullness. "Qi" here refers to the energetic quality of herbs, which vary in intensity. Strong flavors belong to Yin and nourish Essence; strong aromas/energies belong to Yang and nourish Form. Using strong aromatic herbs to tonify Yang inherently nourishes form as well. Thus, "warm with Qi" implies using drug energy to warm and nourish, which also encompasses adjusting diet, lifestyle, and mental calmness. Although "warm" has dual meanings, it should not be equated merely with thermal temperature. By analogizing terms like tonify, purge, suppress, lift, and disperse, the true meaning becomes clear.
The Five Elements operate invisibly in Heaven but manifest materially on Earth. Metal, Wood, Water, and Earth have material substance. Fire has form but lacks solid substance. Wine is hot in nature but liquid in form. Li Dongyuan classifies wine as "formless Qi," which is dubious. If it requires diaphoresis and diuresis for elimination, how can it be considered formless?
Although both fatigue injury and dietary injury are internal injuries, they must not be conflated. The *Nan Jing* states: "Dietary indiscretion and fatigue injure the Spleen." This means the Spleen governs digestion and controls the limbs; thus, irregular eating and physical overwork both damage the Spleen, indicating they are distinct categories. While differing from excess syndromes like Wind-Cold-Damp-Heat, dietary injury differs from fatigue injury. One must observe excess within deficiency. Starvation leads to empty Stomach Qi, representing deficiency due to irregularity. Viewed as injury, it is deficiency; viewed as retention, it is excess. Due to deficiency, tonification is needed; due to excess, resolution is required. Some cases require both resolving and tonifying due to food stagnation and Qi injury; some require only resolving due to temporary stagnation with mild Qi injury; some require only tonifying due to persistent stagnation without self-resolution, or even neither. Ji Gu's Zhizhu Wan and Dongyuan's Jupi Zhishi Wan, though termed resolving agents, contain tonifying intent. Other formulas like Muxiang Fenqi Wan and Daoqi Zhishi Wan, lacking tonifying effects, are suitable for mild stagnation with minimal Qi injury, provided they are not used indiscriminately. If stagnation exceeds the capacity of Zhizhu Wan, one must adapt. Thus, Beiji Wan and Ganying Wan, which purge accumulation, were also utilized by Ji Gu and Dongyuan. A skilled general knows when to attack and defend; a poor general fails due to misapplication, not the army itself. This illustrates the principles of resolving, purging, and tonifying.
Fatigue injury, conversely, purely requires tonification, requiring little debate. Despite Dongyuan's warnings, people still use bitter-cold herbs to treat internal heat from fatigue. When conditions worsen to critical stages, attributing it to "heat too severe for medicine" reflects ignorance of iatrogenic error. Physicians and patients surrender to fate, unaware of their mistakes. Alas! Would not benevolent scholars grieve?
Li Dongyuan is a distinguished sage. How dare I lightly critique him? I fear minor flaws may lead to significant errors for posterity, hence my presumption. May those who understand me judge accordingly.