素问云。寒伤形。热伤气。气伤痛。形伤肿。故先痛而后肿者。气伤形也。先肿而后痛者。
形伤气也。寒气客于脉外则脉寒。脉寒则缩蜷。缩蜷则脉绌急。脉绌急则外引小络。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。与炅气相搏则脉满。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。则血脉涩。脉涩则血虚。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。则血涩脉急。故胁肋与少腹相引痛矣。厥气客于阴股。寒气上及少腹。血涩在下相引。
故腹痛引阴股。寒气客于小肠膜原之间。络血之中。血涩不得注于大经。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。气复返则生矣。
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。
岐伯历举卒痛一十三条。属热者止一条。余皆属寒。辨之之法。当知按之痛缓者为纯寒。痛
甚不可按者为寒伏
火邪。以能闭塞阳气最甚也。
张介宾曰。后世治痛之法。有曰诸痛属实。痛无补法者。有曰通则不痛。痛则不通者。有曰
痛随利减者。互相传授。皆以为不易之定法。不知形实病实。便闭不通者。乃为相宜。或形虚脉
弱。食少便泄者。岂容混治。观王荆公解痛利二字曰。治法云。诸痛为实。痛随利减。世俗以利
为下也。假令痛在表者。实也。痛在里者。实也。痛在血气者。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。此说甚善。
已得治实之治矣。然痛证亦有虚实。治法亦有补泻。辨之不可不详。须知痛而胀闭者。多实。不
胀不闭者。多虚。扼按者。为实。可按者。为虚。喜寒者。多实。爱热者。多虚。饱则甚者。多
实。饥则甚者。多虚。脉实气粗者。多实。脉虚气少者。多虚。新病年壮者。多实。久病年衰者。
多虚。补而不效者。多实。攻而愈剧者。多虚。痛在经者。脉多弦大。痛在脏者。脉多沉微。故
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
伤也。非补中不可。下虚而痛者。肝肾败也。非温补命门不可。亦泥痛无补法。则杀人矣。
《素问》说：寒邪损伤形体，热邪损伤气机。气受伤则产生疼痛，形受伤则出现肿胀。所以先疼痛而后肿胀的，是气伤及了形；先肿胀而后疼痛的，是形伤及了气。
寒气侵入脉外，则脉管受寒。脉管受寒则收缩蜷曲，收缩蜷曲则脉道拘急紧缩，脉道拘急紧缩则向外牵引细小的络脉，因此突然发生疼痛。遇到温热则疼痛立即停止。如果再次遭受寒邪侵袭，疼痛就会持久不愈。
寒气侵入经脉之中，与体内的热气相搏结，则脉中气血充盈胀满。脉中气血充盈胀满，则疼痛剧烈且不可按压。寒气停留不去，热气随之上升，则脉道充盛扩大，血气运行紊乱，因此疼痛剧烈且不可按压。
寒气侵入肠胃之间、膜原（腹内脂膜）之下，血液不能散行，小络脉拘急牵引，所以发生疼痛。按压时血气得以疏散，所以按压后疼痛停止。
寒气侵入夹脊两侧的深部经脉，病位较深，按压无法触及，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畅，脉道不通畅则气机随之郁滞，所以喘息跳动且手按可感知。
寒气侵入背俞之脉，则血脉涩滞。血脉涩滞则血虚，血虚则疼痛。背俞之气注于心，所以相互牵引而痛。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，则血液涩滞、脉管拘急，所以胁肋与小腹部相互牵引疼痛。
厥逆之气侵入阴股（大腿内侧），寒气上行至小腹，下部血液涩滞相互牵引，所以腹痛牵引至阴股。
寒气侵入小肠的膜原之间和络脉血液中，血液涩滞不能注入大经脉，血气滞留不能运行，所以经过一段时间形成积块。
寒气侵入五脏，导致厥逆之气向上宣泄，阴气竭尽，阳气未能入里，所以突然疼痛致死、不知人事。如果气机恢复返回，就能生存。
寒气侵入小肠，小肠无法正常受纳和积聚食物，所以出现腹泻和小腹疼痛。
热气留滞于小肠，肠中疼痛，湿热炽盛导致焦渴，粪便干硬无法排出，所以疼痛且大便闭塞不通。
岐伯详细列举了十三条突发疼痛的案例，属于热的只有一条，其余都属于寒。辨别的方法，应当知道按压后疼痛缓解的是纯寒证，疼痛剧烈且不可按压的是寒邪伏藏化火（寒伏火邪），因为寒邪最能闭塞阳气。
张介宾说：后世治疗疼痛的方法，有说“各种疼痛都属实证，疼痛不能用补法”的；有说“通则不痛，痛则不通”的；有说“疼痛随着通利而减轻”的。这些说法互相传授，都被认为是不可改变的定法。却不知道形体壮实、病邪实盛、大便闭结不通的，才适合使用通下法。如果形体虚弱、脉象微弱、饮食减少、大便泄泻的，怎么可以混同治疗呢？
看王安石解释“痛”和“利”二字时说：治法说“各种疼痛为实证，疼痛随着通利而减轻”。世俗之人把“利”理解为“下法”（泻下）。假如疼痛在表，是实证；疼痛在里，是实证；疼痛在血气，也是实证。所以在表的，发汗就痊愈；在里的，攻下就痊愈；在血气的，消散它、行气活血就痊愈。怎么能把“利”理解为“下法”呢？应该解释为“通”字来训释才可以。这种说法很好。这已经得到了治疗实证的方法。然而疼痛病症也有虚实之分，治疗方法也有补泻之别，辨别不可不详细。须知疼痛且伴有胀满闭塞的，多属实证；不胀满不闭塞的，多属虚证。拒绝按压的，为实证；可以按压的，为虚证。喜欢寒冷的，多属实证；喜爱温暖的，多属虚证。饱食后加重的，多属实证；饥饿时加重的，多属虚证。脉象实、气息粗壮的，多属实证；脉象虚、气息微弱的，多属虚证。新发病且年富力强的，多属实证；久病且年老体衰的，多属虚证。用补法无效，多属实证；用攻伐法病情加重，多属虚证。疼痛在经络的，脉象多弦大；疼痛在脏腑的，脉象多沉微。所以体表虚而疼痛的，是阳气不足，不用温经法不行；体内虚而疼痛的，是阴血不足，不用滋养营血不行；上部虚而疼痛的，是心脾受损，不用补益中气不行；下部虚而疼痛的，是肝肾败坏，不用温补命门不行。如果拘泥于“疼痛不能用补法”的说法，就会害死人啊。
The *Suwen* (Basic Questions) states: Cold damages the form (body structure), while Heat damages Qi. Damage to Qi results in pain, and damage to form results in swelling. Therefore, when pain precedes swelling, it indicates that Qi has damaged the form; when swelling precedes pain, it indicates that the form has damaged Qi.
When Cold pathogen lodges outside the vessels, the vessels become cold. Vessels becoming cold leads to contraction and curling. Contraction leads to vessel shortening and tension. Vessel shortening and tension then externally draw upon the small collaterals, resulting in sudden pain. Upon exposure to warmth (Jiong), the pain stops immediately. However, if subjected to repeated Cold attacks, the pain persists for a long time.
When Cold lodges within the main meridians and combats with Warmth (Heat), the vessels become full. Fullness causes severe pain that cannot be pressed. When Cold lingers and Heat rises from above, the vessels become enlarged and distended, causing chaotic flow of Blood and Qi. Thus, the pain is severe and unyielding to pressure.
When Cold lodges between the intestines and stomach, beneath the membrane source (Mo Yuan, referring to the mesentery/peritoneum), Blood cannot disperse, and the small collaterals contract and pull, causing pain. Pressing causes Blood and Qi to disperse, so pressing alleviates the pain.
When Cold lodges in the deep meridians alongside the spine, the location is deep, and pressing cannot reach it; thus, pressing is ineffective.
When Cold lodges in the Chong Mai (Penetrating Vessel), which originates at Guanyuan (CV4) and ascends straight up along the abdomen, Cold lodging causes vessel obstruction. Obstruction causes Qi stagnation, resulting in panting or pulsation palpable by hand.
When Cold lodges in the Back-Shu vessels, Blood flow becomes sluggish. Sluggish Blood leads to Blood deficiency, and deficiency causes pain. The Shu points connect to the Heart, causing mutual pulling pain. Pressing brings Warmth to the area; once Warmth arrives, the pain stops.
When Cold lodges in the Jueyin Meridian, which connects to the genitalia and ties to the Liver, Cold in the vessels causes Blood sluggishness and vessel tension. This results in mutual pulling pain between the hypochondrium and the lower abdomen.
If Jue Qi (Rebellious Qi) lodges in the medial thigh, and Cold ascends to the lower abdomen, sluggish Blood below pulls mutually, causing abdominal pain radiating to the medial thigh.
When Cold lodges in the membrane source and collateral blood of the small intestine, Blood becomes sluggish and cannot enter the large meridians. Stagnant Blood and Qi fail to circulate, eventually forming accumulations over time.
When Cold lodges in the Zang organs, causing rebellious upward discharge, Yin Qi is exhausted, and Yang Qi fails to enter. This causes sudden death-like pain and unconsciousness. If Qi returns, life is preserved.
When Cold lodges in the intestines and stomach, rebellious Qi erupts upward, causing pain accompanied by vomiting.
When Cold lodges in the small intestine, the intestine fails to gather and transform contents properly, resulting in diarrhea and abdominal pain.
When Heat lingers in the small intestine, intestinal pain occurs. Intense Heat causes dryness and thirst, leading to hard, dry stool that cannot pass, resulting in pain and obstipation (closure without passage).
Qibo listed thirteen cases of sudden pain. Only one belongs to Heat; the rest belong to Cold. The method of differentiation is to know that pain relieved by pressure indicates pure Cold, while severe pain unyielding to pressure indicates Cold trapped with Fire pathogen (Cold trapping Fire), as Cold most severely obstructs Yang Qi.
Zhang Jiebin stated: Later generations' methods for treating pain include assertions such as "All pains are excess patterns; pain should not be treated with tonification," "Unblocked means no pain; pain means blockage," and "Pain decreases with purgation." These are passed down and regarded as immutable laws. However, one must not forget that only when the body is solid, the disease is excess, and there is constipation/blockage is purgation appropriate. If the body is deficient, the pulse is weak, food intake is poor, and there is diarrhea, how can mixed treatment be applied?
Wang Anshi's explanation of "pain" and "Li" (benefit/purgation) notes: The saying "All pains are excess; pain decreases with Li" is often misunderstood by common people as "Li" meaning "Xia" (purgation/downward draining). If pain is in the exterior, it is excess; if in the interior, it is excess; if in Blood and Qi, it is also excess. Therefore, exterior excess is cured by sweating; interior excess is cured by purging; Blood and Qi excess is cured by dispersing and moving. How can "Li" be interpreted solely as purgation? It should be interpreted as "Tong" (unblocking/flowing). This view is excellent. It addresses the treatment of excess patterns. However, pain syndromes also have deficiency and excess distinctions, and treatments involve both tonification and sedation. Differentiation must be detailed. Know that pain with distension and closure is mostly excess; pain without distension or closure is mostly deficiency. Pain resisting pressure is excess; pain tolerating pressure is deficiency. Preference for cold indicates excess; preference for warmth indicates deficiency. Aggravation after eating indicates excess; aggravation on an empty stomach indicates deficiency. Excess pulse and coarse breath indicate excess; deficient pulse and faint breath indicate deficiency. New onset in young adults indicates excess; chronic illness in elderly/frail individuals indicates deficiency. Ineffectiveness of tonification suggests excess; worsening after attack/sedation suggests deficiency. Pain in the meridians typically presents with wiry and large pulses; pain in the Zang organs typically presents with deep and faint pulses. Therefore, exterior deficiency pain indicates insufficient Yang, requiring meridian warming. Interior deficiency pain indicates insufficient Yin, requiring nourishment of Ying (Nutrient) Qi. Upper deficiency pain indicates Heart and Spleen injury, requiring middle-Jiao tonification. Lower deficiency pain indicates Liver and Kidney failure, requiring warming and tonification of the Mingmen (Gate of Life). Adhering rigidly to "pain should not be treated with tonification" would lead to fatal errors.