中气不足，溲便为之变。阴阳盛衰，义有如此，又岂可尽以前证为实热。）诸病水液澄澈清冷，皆属于寒。（水液者，上
下所出皆是也。水体清，其气寒，故凡或吐或利，水谷不化而澄澈清冷者，皆得寒水之化，如秋冬寒冷，水必澄清也。）
诸呕吐酸，暴注下迫，皆属于热。（河间曰∶胃膈热甚则为呕，火气炎上之象也。酸者肝木之味也，由火盛制金，不能平
木，则肝木自甚，故为酸也。暴注，卒暴注泄也。肠胃热甚而传化失常，火性疾速，故如是也。下迫，后重里急迫痛也，
火性急速而能燥物故也。是皆就热为言耳。不知此云皆属于热者，言热之本也；至于阴阳盛衰，则变如冰炭，胡可偏执
为论。如举痛论曰∶寒气客于肠胃，厥逆上出，故痛而呕也。至真要等论曰，太阳司天，民病呕血善噫；太阳之复，心
胃生寒，胸中不和，唾出清水，及为哕噫；太阳之胜，寒入下焦，传为濡泄之类，是皆寒胜之为病也。又如岁木太过，
民病飧泄肠鸣，反胁痛而吐甚；发生之纪，其病吐利之类，是皆木邪乘土，脾虚病也。又如岁土不及，民病飧泄霍乱；
土郁之发，为呕吐注下；太阴所至为霍乱吐下之类，是皆湿胜为邪，脾家本病，有湿多成热者，有寒湿同气者，湿热宜
清，寒湿宜温，无失气宜，此之谓也。至于吐酸一证，在本节则明言属热，又如少阳之胜为呕酸，亦相火证也，此外别
无因寒之说；惟东垣曰∶呕吐酸水者，甚则酸水浸其心，其次则吐出酸水，令上下牙酸涩不能相对，以大辛热剂疗之必
减。酸味者收气也，西方肺金旺也，寒水乃金之子，子能令母实，故用大咸热之剂泻其子，以辛热为之佐，以泻肺之实，
若以河间病机之法作热攻之者，误矣。盖杂病酸心，浊气不降，欲为中满，寒药岂能治之乎？此东垣之说，独得前人之
未发也。又丹溪曰∶或问∶吞酸素问明以为热，东垣又以为寒何也？曰∶素问言热者，言其本也；东垣言寒者，言其末
也。但东垣不言外得风寒，而作收气立说，欲泻肺金之实；又谓寒药不可治酸，而用安胃汤、加减二陈汤，俱犯丁香，
且无治热湿郁积之法，为未合经意。余尝治吞酸，用黄连茱萸各制炒，随时令迭为佐使，苍术茯苓为辅，汤浸蒸饼为小
丸吞之，仍教以 食蔬果自养，则病亦安。此又二公之说有不一也。若以愚见评之，则吞酸虽有寒热，但属寒者多，属
热者少。故在东垣则全用温药，在丹溪虽用黄连而亦不免茱萸、苍术之类，其义可知。盖凡留饮中焦，郁久成积，湿多
生热，则木从火化，因而作酸者，酸之热也，当用丹溪之法；若客寒犯胃，顷刻成酸，本非郁热之谓，明是寒气，若用
清凉，岂其所宜？又若饮食或有失节，及无故而为吞酸嗳腐等证，此以木味为邪，肝乘脾也；脾之不化，火之衰也。得
热则行，非寒而何？欲不温中，其可得乎？故余愿为东垣之左袒而特表出之，欲人之视此者，不可谓概由乎实热。）故大
要曰∶谨守病机，各司其属，有者求之，无者求之，盛者责之，虚者责之，必先五胜，疏其血气，令其调达，而致和平。
此之谓也。（上文一十九条，即病机也。机者，要也，变也，病变所由出也。凡或有或无，皆谓之机，有者言其实，无者
言其虚。求之者，求有无之本也。譬犹寻物一般，必得其所，取之则易。如太阴雨化，施于太阳；太阳寒化，施于少阴；
少阴热化，施于阳明；阳明燥化，施于厥阴；厥阴风化，施于太阴。凡淫胜在我者，我之实也，实者真邪也。反胜在彼
者，我之虚也，虚者假邪也。此六气之虚实，即所谓有无也。然天地运气，虽分五六，而阴阳之用，水火而已。故阳胜
则阴病，阴胜则阳病。泻其盛气，责其有也。培其衰气，责其无也。求得所本而直探其赜，则排难解纷，如拾芥也。设
不明逆顺盈虚之道，立言之意，而凿执不移，所谓面东者不见西墙，面南者不睹北方，察一曲者不可与言化，察一时者
不可与言大，未免实实虚虚，遗人害矣。故余于本篇，但引经释经，冀以明夫大义耳，非谓病机之变，止于是也。夫规
矩准绳，匠氏之法，一隅三反，巧则在人，知此义者，惟王太仆乎！究其所注最妙，而人多忽者何也？余深佩之，谨附
于后。王氏曰；深乎圣人之言，理宜然也。有无求之，虚盛责之，言悉由也。夫如大寒而甚，热之不热，是无火也；热
来复去，昼见夜伏，夜发昼止，时节而动，是无火也，当助其心。又如大热而甚，寒之不寒，是无水也；热动复止，倏
忽往来，时动时止，是无水也，当助其肾。内格呕逆，食不得入，是有火也。病呕而吐，食入反出，是无火也。暴速注
下，食不及化，是无水也。溏泄而久，止发无恒，是无水也。故心盛则生热，肾盛则生寒。肾虚则寒动于中，心虚则热
收于内。又热不得寒，是无水也。寒不得热，是无火也。夫寒之不寒，责其无水。热之不热，责其无火。热之不久，责
心之虚。寒之不久，责肾之少。有者泻之，无者补之，虚者补之，盛者泻之，适其中外，疏其壅塞，令上下无碍，气血
通调，则寒热自和，阴阳调达矣。是以方有治热以寒，寒之而火食不入，攻寒以热，热之而昏躁以生，此则气不疏通，
壅而为是也。纪于水火，余气可知。故曰有者求之，无者求之，盛者责之，虚者责之，令气通调，妙之道也。五胜，谓
五行更胜也。先以五行寒暑温凉湿，酸咸甘辛苦，相胜为法也。）
中气不足，会导致小便和大便出现异常。阴阳的盛衰变化，道理正是如此，又怎么可以一概将前面的症状都归结为实热证呢。）各种病证中的水液排泄物清澈、寒冷，都属于寒证。（所谓水液，是指从身体上下各部位排出的液体。水的本性是清冷的，其气属寒，所以凡是呕吐或腹泻，食物不消化且排泄物清澈寒冷的，都是受到寒水之气的影响，就像秋冬季节天气寒冷时，水必然变得清澈一样。）各种呕吐酸水，突然剧烈腹泻伴有肛门急迫疼痛，都属于热证。（刘河间说：胃膈部位热邪严重就会发生呕吐，这是火性炎上的表现。酸味是肝木的本味，由于火气过盛克制了肺金，导致肺金不能正常制约肝木，从而使肝木之气偏亢，所以会出现酸味。暴注，指突然剧烈的泄泻。肠胃热邪严重导致传化功能失常，火性急速，所以会出现这种情况。下迫，指里急后重、腹部紧迫疼痛，这是因为火性急速且能燥伤津液所致。这些都是从热证的角度来解释的。不知道这里所说的“皆属于热”，是指热证的本质；至于阴阳的盛衰变化，则可能变得像冰和炭那样截然相反，怎么能片面地执着于一种说法作为定论呢？比如《举痛论》中说：寒气侵犯肠胃，导致气机厥逆向上冲出，所以既疼痛又呕吐。《至真要大论》等篇章中说：太阳司天之年，百姓患病出现呕血、容易嗳气；太阳复气之时，心胃产生寒邪，胸中不适，吐出清水，以及发生呃逆嗳气；太阳胜气之时，寒气侵入下焦，传导变为濡泄之类，这些都是寒邪胜极导致的病证。又如岁运木气太过，百姓患病出现完谷不化的泄泻和肠鸣，反而胁痛且呕吐严重；发生纪年，其疾病表现为吐利之类，这都是木邪乘袭脾土，脾虚所致的病证。又如岁运土气不及，百姓患病出现完谷不化的泄泻和霍乱；土气郁结而发，表现为呕吐和下注泄泻；太阴湿土当令时出现的霍乱吐下之类，这都是湿邪胜极成为致病因素，属于脾脏的本病。其中有湿多转化为热的，有寒湿同气的，湿热适宜用清热法，寒湿适宜用温散法，不要违背气化的规律，说的就是这个道理。至于吐酸这一证候，在本节中明确说明属于热证，又如少阳相火胜气时出现呕吐酸水，也是相火证的表现，除此之外没有因寒致酸的学说；只有李东垣说：呕吐酸水的，严重时酸水浸渍心脏，其次则是吐出酸水，使得上下牙齿感到酸涩无法相对咬合，用大辛大热的药物治疗必定能减轻。酸味代表收敛之气，是西方肺金旺盛的表现，寒水是肺金之子，子能令母实，所以使用大咸热的药物来泻其子（肾水），以辛热药作为辅助，以泻肺金的实邪，如果用刘河间的病机理论将其当作热证来攻治，那就错了。因为杂病中的吞酸，是由于浊气不降，想要形成中满痞塞，寒凉药物怎么能治疗呢？这是李东垣的说法，独自发掘了前人的未发之旨。又有朱丹溪说：有人问：《素问》认为吞酸属热，李东垣又认为属寒，为什么呢？回答说：《素问》说属热，是说它的本质；李东垣说属寒，是说它的末梢表现。但是李东垣没有提及外感风寒，而是从收敛之气立论，想要泻肺金之实；又说寒凉药物不可治疗吞酸，而使用安胃汤、加减二陈汤，其中都含有丁香，并且缺乏治疗湿热郁积的方法，这与经典原意不完全符合。我曾经治疗吞酸，用黄连和吴茱萸各制炒，根据时令交替作为佐使药，苍术和茯苓作为辅药，用水浸泡蒸饼制成小丸吞服，并教导患者食用蔬菜水果来自我调养，那么病也能痊愈。这又是两位先生的说法不一致的地方。如果凭我的见解来评价，那么吞酸虽然有寒热之分，但属寒的多，属热的少。所以在李东垣那里完全使用温药，在朱丹溪那里虽然用了黄连，但也免不了使用吴茱萸、苍术之类的药物，其中的义理就可以知道了。大概凡是留饮停滞在中焦，郁结久了形成积聚，湿气多生热，则木气从火化，因而产生酸味，这是酸的热证，应当采用朱丹溪的方法；如果是客寒侵犯胃腑，顷刻间就变成酸水，本就不是郁热所致，明明是寒气，如果使用清凉药物，难道合适吗？另外，如果饮食有所失节，或者无故出现吞酸、嗳腐等证候，这是以木味为邪，肝木乘袭脾土；脾的不运化，是因为火气衰弱。得到热气才能运行，不是寒证是什么？不想温补中焦，怎么可能做到呢？所以我愿意偏向支持李东垣的观点，特别提出出来，希望人们看待这个问题时，不要一概认为是由实热引起的。）所以《大要》说：谨慎地守住病机，分别归属其相应的脏腑经络，有的症状要探究其成因，没有的症状也要探究其机理，邪气盛的要责求其盛的原因，正气虚的要责求其虚的原因，必须先明了五行胜复的关系，疏通其气血，使其调和畅达，从而达到平衡和谐的状态。说的就是这个道理。（上文列举的十九条，就是病机的内容。机，就是要领，是变化，是病变产生的根源。凡是或有或无的情况，都称为机，有是指实证，无是指虚证。求之，是探究有无的根本原因。譬如寻找物品一样，必须找到它所在的地方，取用它就容易了。比如太阴湿土的气化，施加于太阳寒水；太阳寒水的气化，施加于少阴君火；少阴君火的气化，施加于阳明燥金；阳明燥金的气化，施加于厥阴风木；厥阴风木的气化，施加于太阴湿土。凡是淫胜之气加诸于我者，是我方实邪，实即是真邪。反胜之气加诸于彼者，是我方虚邪，虚即是假邪。这六气的虚实，就是所谓的有无。然而天地运气，虽然分为五运六气，但阴阳的作用，不过水火而已。所以阳胜则阴病，阴胜则阳病。泻去其盛气，是责求其有（实）；培补其衰气，是责求其无（虚）。找到了根本并深入探究其奥妙，那么排除困难解决纷扰，就像拾取小草一样容易。如果不明白逆顺盈虚的道理，不理解立言的本意，而固执不变通，所谓面向东方看不见西墙，面向南方看不见北方，只观察局部的人不可以与他谈论气化，只关注一时的人不可以与他谈论大道，难免会导致实证实治、虚证虚治的错误，给人留下祸害。所以我在这篇中，只是引用经典来解释经典，希望阐明大义罢了，并不是说病机的变化仅限于此。规矩准绳，是工匠的法度，举一反三，巧妙在于人，懂得这个道理的，只有王冰（王太仆）啊！他研究的注解最为精妙，但人们往往忽视，为什么呢？我非常敬佩他，谨附在后面。王氏说：圣人的言语深奥，理应如此。探究有无，责求虚实，说得详尽透彻了。比如大寒且严重的，用热药治疗却不回暖，这是无火；热象往来不定，白天显现夜晚潜伏，夜间发作白天停止，随节气而动，这是无火，应当助益心阳。又如大热且严重的，用寒药治疗却不退热，这是无水；热象动止无常，忽来忽往，时而发动时而停止，这是无水，应当滋补肾阴。内格呕逆，食物无法进入，是有火。生病呕吐且进食后反出，是无火。突然快速的泄泻，食物来不及消化，是无水。溏泄日久，发作停止没有规律，是无水。所以心气盛则生热，肾气盛则生寒。肾气虚则寒邪动于中，心气虚则热邪收于内。又热证不能用寒药治愈，是无水；寒证不能用热药治愈，是无火。寒证用热药不愈，责求肾水不足；热证用寒药不愈，责求心火不足。邪气盛用泻法，正气虚无用补法，虚证用补法，实证用泻法，使内外适中，疏通壅塞，使上下无障碍，气血通畅调和，那么寒热自然平和，阴阳调达。因此有治疗热证用寒药，但寒药之后火邪未除且饮食不进；治疗寒证用热药，但热药之后昏躁丛生，这是因为气机不疏通，壅滞而导致这样的结果。记载在水火方面，其余气机可知。所以说有者求之，无者求之，盛者责之，虚者责之，使气机通畅调和，是微妙的道理。五胜，是指五行相互胜复。先以五行的寒暑温凉湿，酸咸甘辛苦，相互胜复作为法则。）
Insufficiency of the Middle Qi (Middle Jiao Energy) leads to abnormalities in urination and defecation. The principles of Yin-Yang excess and deficiency are as such; how can one simply attribute all preceding symptoms to Excess-Heat? All pathological fluids that are clear, cold, and thin belong to Cold. "Fluids" refer to all discharges from the upper and lower orifices. Water is inherently clear and cold, and its nature is Cold; therefore, any vomiting or diarrhea where food is undigested and the discharge is clear and cold results from the transformation of Cold-Water, just as water becomes clear during the cold seasons of autumn and winter. Vomiting and acid regurgitation, sudden violent diarrhea with tenesmus, all belong to Heat. He-Jian Liu stated: Severe heat in the stomach and diaphragm causes vomiting, which is the manifestation of Fire flaming upward. Sourness is the flavor of Liver-Wood; when Fire is excessive and controls Lung-Metal, preventing it from balancing Wood, Liver-Wood becomes hyperactive, thus producing sourness. "Violent diarrhea" refers to sudden, severe watery stool. When intestinal and gastric heat is severe, transmission and transformation functions fail; due to the rapid nature of Fire, this occurs. "Tenesmus" refers to a feeling of urgency and pain in the rectum; the rapid and drying nature of Fire causes this. These explanations focus on Heat. However, the statement "all belong to Heat" refers to the root cause being Heat; regarding the fluctuations of Yin-Yang excess and deficiency, conditions can change drastically like ice and charcoal, so one cannot rigidly adhere to a single theory. For instance, the *Ju Tong Lun* states: When Cold pathogen invades the stomach and intestines, rebellious Qi surges upward, causing pain and vomiting. The *Zhi Yao Yao Da Lun* states: During the reign of Taiyang, people suffer from hematemesis and frequent belching; during the counter-reaction of Taiyang, Cold arises in the Heart and Stomach, causing chest discomfort, spitting of clear fluid, and hiccups/belching; during the dominance of Taiyang, Cold enters the Lower Jiao, leading to loose stools, etc. These are all diseases caused by excessive Cold. Furthermore, when Wood Qi is excessive, people suffer from incomplete digestion diarrhea and borborygmus, accompanied by hypochondriac pain and severe vomiting; in the Year of Fa Sheng, diseases manifest as vomiting and diarrhea, all caused by Wood pathogen attacking Earth and Spleen deficiency. When Earth Qi is insufficient, people suffer from incomplete digestion diarrhea and cholera-like syndromes; when Earth Qi is stagnant and erupts, it manifests as vomiting and profuse diarrhea; during the influence of Taiyin, cholera and vomiting/diarrhea occur, all caused by excessive Dampness affecting the Spleen. Some dampness transforms into Heat, while some shares the nature of Cold-Damp; Heat-Damp should be cleared with cooling methods, while Cold-Damp should be treated with warming methods, without violating the laws of Qi transformation. Regarding acid regurgitation, this section explicitly states it belongs to Heat; similarly, when Shaoyang wins, vomiting acid occurs, which is also a Minister-Fire syndrome, with no other theory attributing it to Cold. Only Li Dongyuan stated: In cases of vomiting acid water, if severe, the acid soaks the Heart; if mild, the acid is vomited out, causing the teeth to feel sour and astringent, unable to meet. Treating with major acrid-hot agents will reduce symptoms. Sourness represents the Qi of gathering, associated with the prosperity of West Lung-Metal. Cold-Water is the child of Metal; the child can make the mother full. Therefore, using major salty-hot agents to drain the child (Kidney-Water), assisted by acrid-hot agents to drain the excess of Lung-Metal, is correct. Using Liu Hejian's method to attack it as Heat would be an error. In miscellaneous diseases, acid regurgitation is due to turbid Qi failing to descend, intending to form middle-fullness; how can cold medicines treat this? Li Dongyuan's insight uniquely uncovered what predecessors had not expressed. Zhu Danxi asked: The *Su Wen* says acid regurgitation is Heat, but Dongyuan says it is Cold. Why? I replied: The *Su Wen* speaks of the root (Heat); Dongyuan speaks of the branch (Cold). However, Dongyuan did not mention external Wind-Cold but based his theory on gathering Qi to drain Lung-Metal excess; he claimed cold medicines cannot treat acid regurgitation, using An Wei Tang or Modified Er Chen Tang containing Ding Xiang (Clove), lacking methods for treating Damp-Heat stagnation, which does not fully align with classic intent. I once treated acid regurgitation using prepared Huang Lian (Coptis Rhizome) and Zhu Yu (Evodia Fruit) as佐使 (assistant-guiding herbs) according to seasons, with Cang Zhu (Atractylodes Rhizome) and Fu Ling (Poria) as assistants, formed into small pills with steamed dough, and advised patients to nourish themselves with vegetables and fruits, resulting in recovery. Thus, the two masters' views differ. In my opinion, although acid regurgitation has both Cold and Heat types, Cold is more common than Heat. Hence, Dongyuan used entirely warming medicines; Danxi, though using Huang Lian, also employed Zhu Yu and Cang Zhu, revealing the underlying logic. Generally, retained fluids in the Middle Jiao, stagnating for long periods, generate accumulation; dampness often generates Heat, causing Wood to transform via Fire, resulting in sourness—this is Heat-type acid regurgitation, treated per Danxi's method. If external Cold attacks the Stomach, turning sour instantly, it is not stagnation-Heat but clearly Cold; using cooling agents would be inappropriate. Also, irregular diet or spontaneous acid regurgitation and belching of rotten food indicate Wood flavor acting as pathogen, with Liver overacting on Spleen; Spleen's failure to transform is due to deficient Fire. Heat promotes movement; thus, it must be Cold. How can one avoid warming the Middle? Therefore, I side with Dongyuan and highlight this view, urging others not to assume all cases are due to Excess-Heat. Thus, the *Da Yao* states: Carefully observe the Pathogenesis (Bing Ji), assign each to its corresponding category; investigate the presence of symptoms, investigate their absence; address excess by examining its source, address deficiency by examining its origin; first understand the Five Phases' overcoming cycles, unblock Blood and Qi, ensure smooth flow, and achieve harmony. This is the principle. (The previous nineteen clauses constitute the Pathogenesis. "Ji" means essential point, change, and the origin of disease variation. Presence indicates Excess, absence indicates Deficiency. "Investigating" means seeking the root of presence/absence. Like searching for an object, finding its location makes retrieval easy. For example, Taiyin's humidity applies to Taiyang; Taiyang's cold applies to Shaoyin; Shaoyin's heat applies to Yangming; Yangming's dryness applies to Jueyin; Jueyin's wind applies to Taiyin. What overwhelms me is my Excess (True Pathogen); what overwhelms others is my Deficiency (False Pathogen). These six Qi's excess/deficiency correspond to presence/absence. Heaven and Earth's luck divides into Five Movements and Six Qi, but Yin-Yang function lies in Water and Fire. Thus, Yang excess harms Yin, Yin excess harms Yang. Draining excess addresses "presence"; tonifying decline addresses "absence". Finding the root and exploring deeply resolves difficulties easily. Without understanding reversal,順逆, fullness, and emptiness, and clinging rigidly, one is like facing East missing the West wall; partial observers cannot discuss transformation, time-bound observers cannot discuss greatness, leading to reinforcing Excess and draining Deficiency, harming patients. I cite classics to explain classics here to clarify major principles, not to limit Pathogenesis variations. Rules and compasses are craftsmen's tools; ingenuity lies in application. Wang Taipu (Wang Bing) understood this best; his annotations are exquisite yet overlooked. I admire him greatly and append them below. Wang said: Sage words are profound. Investigating presence/absence, addressing excess/deficiency covers all. For severe Cold unresponsive to heat therapy, it indicates Kidney-Fire deficiency; for intermittent Heat, it indicates Kidney-Water deficiency. Internal obstruction with vomiting prevents food intake, indicating Heart-Fire excess. Vomiting after eating indicates Heart-Fire deficiency. Sudden profuse diarrhea indicates Kidney-Water deficiency. Chronic loose stools indicate Kidney-Water deficiency. Heart excess generates Heat; Kidney excess generates Cold. Kidney deficiency causes internal Cold; Heart deficiency causes internal Heat. Heat unresponsive to cold indicates Water deficiency; Cold unresponsive to heat indicates Fire deficiency. Short-lived heat response indicates Heart deficiency; short-lived cold response indicates Kidney deficiency. Drain excess, tonify deficiency. Balance interior/exterior, unblock congestion, ensure smooth Qi and Blood flow, harmonizing Cold/Heat and Yin/Yang. If heat treatment with cold fails, or cold treatment with heat causes agitation, it is due to Qi stagnation. Water/Fire principles apply to all Qi. Thus, investigating presence/absence and addressing excess/deficiency to ensure smooth Qi flow is the subtle way. "Five Overcoming" refers to the mutual overcoming of Five Phases, using Cold/Hot/Warm/Cool/Damp and Sour/Sweet/Bitter/Pungent/Salty as governing laws.)