太阴之为病。腹满而吐。食不下。自利益甚。时腹自痛。若下之。必胸下结硬。
此总叙太阴之见症。言太阴经受病。必见腹满而吐等证也。然非谓诸证皆具。方为太阴也。以后凡
称太阴病。必见此等症者。乃为太阴病也。夫太阴者。盛阴也。为东北之艮土。得先天坎中未经生化之阳
气而生者。地之纯阴象焉。以地居天之中。先天来复之阳。生于黄泉之下。透地而发生万物。盖以盛阴
为体。而以阳气为用。所以地寒则五谷不生。土暖则发生万物。故人身之太阴脾土。亦居五脏之中。具静
顺之体。而有健运之用。以胃为之腑而为水谷之
海。乃西南之坤土。为后天离火之所生。故属阳明而能腐化水谷。为坤浓载物之象。是以胃则藏五味而化
五谷。脾则行精液而运精微。周身脏腑经络。四肢筋骸。皆受其生和长养。为生气之所自出。其经脉行于任脉之
两旁。为太阴之经。故易曰坤为腹。盖腹行之脉穴也。腹行之经脉受邪。故为太阴病。所谓邪入阴经。则为
阴邪也。太阴之经。以脾为脏。以胃为腑。其经脉受邪。内通脾胃。脾胃以膜相连。寒邪在里。故腹满而吐。
即素问热论所谓太阴脉布胃中。故腹满而嗌干也。食不下者。在阳明篇中。即所谓不能食者为中寒。况太阴乎。
阴邪在中则腹满。上逆则吐。下迫则自利益甚。时常腹自痛也。当温中散寒。以解散其阴邪。如下文所谓
理中四逆辈可也。倘粗工不辨阴阳。罔知经络。以腹满而吐。食不下为停食胃实之证。而以苦寒下泄之药误下之。
必致伤败胃阳。阴邪内结而胸下结硬矣。胸下者。心胸之下。胃脘之间也。以阴寒硬结于胃脘之中。故谓之
胸下结硬。言与结胸不同也。结胸以太阳误下。阳邪陷入阳位。故结于胸。此以太阴误下。胃阳空虚。阴邪结
于胸下之胃中。故云结硬于胸下。当此而不知急救胃阳。祛除阴翳。必致胃阳败绝。至呃忒四逆之变而死矣。
辨误 成氏谓太阴为病者。阳邪传里也。其说殊谬。岂太阴无本经自受之邪乎。又云阴寒在内而为腹痛者。
则为常痛。阳邪传里。虽痛亦不常。但时时腹自痛。此论尤谬。岂反忘太阳篇首所云。病发于阳。则发热恶寒。
病发于阴。则无热恶寒邪。总之邪入阳经。则发热而为阳邪。邪入阴经。则无热而为阴邪。其旨晓然矣。成氏
既为仲景开辟功臣。岂尚懵然未辨乎。恐不若尚论所云腹满自利。为太阴之本证。为易晓也。但尚论又云。设
不知而误下之。其在下之邪可去。而在上之邪陷矣。故胸下结硬。与结胸之变颇同。愚窃谓阳邪因下之太早。
故有结胸之变。阴邪本无可下。
所以痞结总条有云。发于阳而反下之。热入。因作结胸。发于阴而反下之。因作痞。同是反下变逆。而痞症遂无
热入二字。下文但以下之太早为结胸之故。并无所以成痞之故。何也。仲景之意。盖谓太阳之邪在表。尚未解散。
误下则里虚邪陷。致成结胸。所以有下早之戒。阴邪虽亦有在经在里之分。然三阴终不在表。若误下之。必伤败
胃中之阳气。致阴邪僭逆。遂成结硬。故曰胸下结硬。前甘草泻心汤条下云。此非结热。但以胃中虚。客气上逆。
故使硬也。阴邪始终不可下。下之必致变逆。故曰反下。阴经虽多下证。在太阴必大实痛者。胃气实。然后以
桂枝大黄汤下之。少阴证中。亦必以口燥咽干。及心下必硬。口干燥者。至六七日胀满不大便。然后以大承气汤
急下之。厥阴证中。亦必以下利谵语。知有燥屎。方以小承气汤下之。皆三阴证中之邪归阳明。方可议下。此条
纯是阴邪。有何在下之邪可去。阴邪既非热入。又何在上之邪陷入乎。此论已属不经。况阳邪陷入。仲景必称结胸。
阴邪结聚。则称胸下结硬。而必不言结胸。阴邪阳邪。已自不同。陷与非陷。亦自各异。且胸与胸下之部分。更有
不同。宁可云胸下结硬。与结胸颇同之理乎。古人立法。语气不同。文法少异。则其意指绝殊矣。后人不能细绎。
其文。模糊混注。其可为后世训乎。
自利不渴者属太阴。以其脏有寒故也。当温之。宜服四逆辈。
阳经有下利。而阴经尤多下利。惟自利而不渴者方属太阴。何也。以太阴脾脏有寒邪故也。大凡邪入阳经。
则发热津枯而渴。邪入阴经。则不热而津液不耗。故不渴。即太阳篇首所谓无热恶寒发于阴之义也。阴寒在里。
故腹满痛而自利。乃太阴脾经之本证也。故当温之。宜服四逆辈者。言当用姜附辈以温之也。曰四逆辈而不曰
四逆汤者。盖示人以圆活变化之机。量其轻重以为进退。无一定可拟之法也。若胶于一法。则非圆机矣。张兼善云。
经言辈字。谓
药性同类。唯轻重优劣不同耳。四逆汤甘辛相合。乃大热之剂。苟轻用之。恐有过度之失。所以仲景不为定拟。
莫若以理中循循用之。至为稳当。夫兼善以四逆为大热而恐其过度。是最不善读书者。观仲景于三阳症中。
如误汗亡阳而以真武四逆救之。则曰四逆汤主之。又如少阴厥阴症中寒邪过盛之证。皆曰宜四逆汤。及四逆
汤主之者。皆以真阳欲绝。急温之法。不待筹画而用之无疑者也。若犹豫不决。迁延时日。则将阳气竭绝。
亡可翘足而待。岂理中汤之一味干姜可救耶。唯此太阴之邪。或有可用者。或有不必全用者。故曰宜服四逆
辈。而无一定之方也。设阴寒急证。而必以理中汤为稳当。循循用之。则小热不能治大寒。阴邪不退。真阳不
复则死矣。其谓之过度耶。抑稳当耶。所以延习至今。庸工皆以稳当为妙。至杀人而竟不自知。愚者反以
为热药之误。岂不冤哉。
辨误 尚论云。注谓自利不渴。湿胜也。故用四逆辈以燠土燥湿。此老生腐谈。非切论也。仲景大意。以
自利不渴者属太阴。以自利而渴者属少阴。分经辨证。所关甚钜。盖太阴属湿土。热邪入而蒸动其湿。则显有余。
故不渴而多发黄。少阴属肾水。热邪入而消耗其水。则显不足。故口渴而多烦躁。若不全篇体会。徒博注释之名。
其精微之蕴。不能阐发者多矣。其论如此。乍读之若顿开生面。创辟一新。陈腐皆去。特然杰出。仲景久晦之旨。
一旦为光天化日矣。既而思之。喻氏之言。即成注也。成注云。自利而渴者属少阴。为寒在下焦。自利不渴者
属太阴。为寒在中焦。与四逆等汤以温其脏。此虽三家之说。实两家言也。及推仲景原文。细绎六经之旨。方氏
固谬。而成氏之说亦非。喻氏虽痛斥方注。然其立说。更不能无误谬也。夫方注云。自利不渴为湿胜。太阴湿土。
故曰有寒。四逆辈皆能燠土燥湿。故曰温之。仲景以自利不渴为脏寒。方注偏以自利不渴为湿胜。仲景以四逆
辈为温。方注偏以四逆辈为燥湿。岂后人之
智虑过于前人。注者之识见胜于作者耶。是以谓之不能无过也。成氏以自利不渴属太阴。为寒在中焦。其论未始
不正。其自利而渴者属少阴。为寒在下焦。其义何居。试问少阴篇之渴证有几。遍阅少阴篇中。止渴证二条而已。其
一则曰五六日自利而渴者。属少阴也。虚故引水自救。小便色白者。以下焦虚有寒。不能制水。故令色白。此非真渴
也。其二则曰下利六七日。咳而呕渴。心烦不得眠。此因阴寒在下。地气不升。气液不得上腾而渴。天气不降。肺气不
得下行而壅塞咳呕。故以猪苓汤渗利下焦。上通肺气而已。初非热邪作渴也。其外四十余条。皆无渴证。岂可以自
利而渴为少阴之定旨乎。况云自利而渴者属少阴。为寒在下焦。既云寒矣。何渴之有。恐其义未通。不足为定论也。
尚论以太阴属湿土。热邪入而蒸动其湿。故不渴而多发黄。若湿热发黄。其说则可。如伤寒发汗已。身目为黄。以寒
湿在里不解故也。以为不可下。而于寒湿中求之者。岂亦热邪蒸动耶。况成注原云自利而渴者属少阴。为寒在下
焦。而喻氏遂因其说而变其词曰。少阴属肾水。热邪入而消耗其水。故口渴而多烦躁。不知下文小便色白。下焦虚
有寒。热邪何来。烦躁安在。而作此议论耶。在成氏则但阅太阴篇。有自利不渴者属太阴句。及阅少阴篇。见有五六
日自利而渴者属少阴句。并不体会全篇。通解下文。贸贸焉援笔定论。其于学术。可谓疏矣。虽不应臧否前哲。奈所
关者大所虑者深。故不能无辨耳。
伤寒脉浮而缓。手足自温者。系在太阴。太阴当发身黄。若小便自利者。不能发黄。至七八日虽暴烦。下
利日十余行。必自止。以脾家实。秽腐当去故也。
伤寒之脉浮紧。中风之脉浮缓。皆太阳证也。今以伤寒而脉见浮缓。岂风寒并感耶。若果如太阳下编大青龙汤条
下之脉浮而缓。为风寒并受。则当有表证矣。此以邪在太阴。缓为脾之本脉。因邪入阴经。故无发热等证也。
手足自温者。脾主四肢也。以手足而言自温。则知不发热矣。邪在太阴。所以手足自温。不至如少阴厥阴之四肢厥冷。
故曰系在太阴。然太阴湿土之邪郁蒸。当发身黄。若小便自利者。其湿热之气。已从下泄。故不能发黄也。
如此而至七八日。虽发暴烦。乃阳气流动。肠胃通行之征也。下利虽一日十余行。必下尽而自止。盖以湿气实于脾家。
故肠胃中有形之秽腐当去。秽腐去。则脾无形之湿热亦去故也。此条当与正阳阳明发黄篇第七十七条互看。其上节
相同而下节各异。前以小便自利而不能发黄之后。以七八日而大便硬者。乃邪归阳明。为可下之证。此以七八日而暴烦
下利。秽腐当去。为脾家实。乃邪归太阴。为利尽自止之证。一归于胃实而为阳明证。一归于脾实而成太阴证。其同
感而异变。同源而异派。若非谆谆分辨。能无多歧之惑乎。观其立法示人。谓非后学之指南。临证之冰鉴欤。
伤寒胸中有热。胃中有邪气。腹中痛。欲呕吐者。黄连汤主之。
言伤寒郁热之邪。已内入胸膈。犹未入胃。胸为太阳所属。则太阳证犹未罢。而胃中反有阴寒之邪气。故腹痛而欲
呕吐也。腹痛呕吐。皆属太阴。以胃中有邪气而见太阴证者。太阴阳明论云。脾胃以膜相连。为一表一里故也。
然胸中有热。当以寒凉为治。而腹痛欲呕。则又当以温中为急。从来治寒以热。治热以寒。乃为正治。今胸中有热。胃
中有
寒。治寒则逆其热。治热必害于寒。不得已而以黄连汤主之。所谓寒因热用。热因寒用。二者相须。素问至真要大论
云。逆之从之。逆而从之。从而逆之之法也。
黄连汤方
黄连（三两） 甘草（三两） 干姜（三两） 桂枝（三两） 人参（二两） 半夏（半升）
大枣（十二枚擘）
上七味。以水一斗。煮取六升。去滓。温服一升。日三服。夜二服。
热邪已入胸膈。虽未成结胸。而胸邪非若不开。热气又非寒莫治。故以黄连之苦寒为君。即黄连泻心汤之意也。甘
草缓腹中之痛。与黄连同用。能泻心下之邪。即甘草泻心汤之义也。若非干姜之温热守中。不足以疗腹中之痛。必
人参半夏之辛温扶胃。乃能止欲呕之逆。然胃有实热。则人参即为难用。此乃阴寒虚气。虽有胸中之客热。而无入
胃之热邪。仍属太阴本证。故当温补兼施也。用桂枝者。使阳气通行。兼解其未去之经邪也。加大枣者。调停其中气。
和协其药性之寒温也。黄连与干姜同用。乃寒因热用。所以治胸中有热也。干姜与黄连并行。即热因寒用。所以治
腹痛欲呕也。胸中有热而用黄连者。逆而折之之法也。复用干姜者。求其属以衰之之法也。腹痛而用干姜者。逆者
正治也。又用黄连者。从者反治也。胸既有热而腹痛欲呕。又为胃中有寒。一寒一热之邪。而以黄连干姜并驰者。从
而逆之。逆而从之也。立方之旨。精矣微矣。
太阴病的主要表现是：腹部胀满，呕吐，饮食难以下咽，腹泻逐渐加重，时常出现腹部自发性疼痛。如果误用攻下法治疗，必然导致心窝下方痞结坚硬。
这是总述太阴病的见症。意思是说，太阴经受邪，必定会出现腹满而吐等症状。但这并不意味着所有症状都必须具备，才诊断为太阴病。此后凡是称为“太阴病”的，必须见到上述这些症状，才能确认为太阴病。所谓太阴，是盛阴之经。它对应东北方的艮土，是由先天坎水中未经生化的阳气所化生，具有大地纯阴的象征。因为大地居于天之中，先天来复的阳气生于黄泉之下，穿透土地从而生长万物。可以说，太阴以盛阴为体，而以阳气为用。所以地寒则五谷不生，土暖则万物发生。人身中的太阴脾土，也居于五脏之中，具有静顺的本体，而具备健运的功能。胃作为它的腑，是水谷之海，属于西南方的坤土，由后天离火所生，因此归属于阳明而能腐熟消化水谷，体现了坤土承载万物的象意。所以，胃能藏纳五味并化生五谷；脾能运行精液并输布精微物质。全身的脏腑经络、四肢筋骨，都受其滋养和长养，它是生气产生的根源。太阴经脉行于任脉两旁，是为太阴经。所以《易经》说“坤为腹”，指的是腹部的经脉穴位。腹部的经脉受到邪气侵袭，所以形成太阴病。所谓邪气侵入阴经，就称为阴邪。太阴经以脾为脏，以胃为腑。其经脉受邪，内通脾胃。脾胃通过膜相连，寒邪在里，所以出现腹满而吐。这正是《素问·热论》所说的太阴经脉散布于胃中，所以腹满且咽喉干燥的意思。饮食不下，在阳明篇中，即所谓“不能食者为中寒”，何况是太阴病呢？阴邪在中焦则腹满，向上逆则呕吐，向下迫则腹泻加重，时常腹部自痛。应当采用温中散寒的方法，以解散阴邪，如下文所说的理中汤、四逆汤之类即可。倘若粗心的医生不辨别阴阳，不懂经络，将腹满而吐、饮食不下误认为是停食胃实的证候，而错误地使用苦寒攻下的药物，必然会导致胃阳受损败坏，阴邪在内结聚，从而造成心窝下方痞结坚硬。胸下，是指心胸之下，胃脘之间。因为阴寒硬结在胃脘之中，所以称之为胸下结硬。这是为了说明它与结胸不同。结胸是因为太阳病误下，阳邪陷入阳位，所以结于胸部；这里是太阴病误下，胃阳空虚，阴邪结于胸下的胃中，所以说结硬于胸下。在这种情况下，如果不知道急救胃阳、祛除阴寒，必然导致胃阳败绝，出现呃逆、四肢厥冷等变证而死。
【辨误】成无己认为太阴病是阳邪传入里部。这种说法非常荒谬。难道太阴没有本经直接感受的邪气吗？他又说，阴寒在内部引起的腹痛是常痛，阳邪传入里部，即使痛也不常痛，只是时常腹部自痛。这种论述更是荒谬。难道他忘记了《伤寒论》太阳篇开头所说的：“病发于阳，则发热恶寒；病发于阴，则无热恶寒”吗？总之，邪气侵入阳经，则发热而为阳邪；邪气侵入阴经，则无热而为阴邪。这道理是很清楚的。成无己既然是为张仲景著作开辟功劳的大臣，怎么会还糊涂到分辨不清呢？恐怕不如尚论所说“腹满自利”是太阴的本证，更容易让人明白。但是尚论又说，假如不知道而误用下法，在下部的邪气可以去掉，但在上部的邪气就会陷入，所以导致胸下结硬，这与结胸的变证颇为相似。我私下认为，阳邪因为下法太早，所以有结胸的变证；阴邪本来就不应该用下法。所以在痞证总条中说：“发于阳而反下之，热入，因作结胸；发于阴而反下之，因作痞。”同样是误用下法导致的变逆，但痞证的条文里没有“热入”二字。下文只说下法太早是结胸的原因，并没有说造成痞证的原因。为什么呢？张仲景的意思大概是，太阳的邪气在表，尚未解散，误用下法则里虚邪陷，导致结胸。所以有下法太早的禁忌。阴邪虽然也有在经和在里的区别，但三阴终究不在表。如果误用下法，必然损伤胃中的阳气，导致阴邪僭越逆行，遂成结硬。所以说胸下结硬。在前文甘草泻心汤条下说：“这不是结热，只是因为胃中虚，客气上逆，所以使硬。”阴邪始终不可用下法，下法必然导致变逆，所以说“反下”。阴经虽然有多种可用下法的证候，但在太阴病中，必须是“大实痛”，且胃气实，然后用桂枝大黄汤攻下；少阴证中，也必须等到口燥咽干，以及心下必硬，口干燥，到了六七天腹胀满不大便，然后才用大承气汤急下；厥阴证中，也必须等到下利谵语，知道有燥屎，才用小承气汤攻下。这些都是三阴证的邪气归入阳明后，才可以讨论攻下。此条纯是阴邪，有什么在下部的邪气可去？阴邪既然不是热入，又有什么在上部的邪气会陷入呢？这种论述已经属于不经之谈。况且阳邪陷入，张仲景一定称为结胸；阴邪结聚，则称为胸下结硬，而一定不说结胸。阴邪和阳邪，自然不同；陷入和不陷入，也各自各异。而且胸部和胸下的部位，更有不同。怎么可以说胸下结硬与结胸颇同呢？古人立法，语气不同，文法稍异，其意指就截然不同了。后人不能细细推敲原文，模糊混注，怎么能成为后世的典范呢？
自利而不口渴的，属于太阴病，因为脾脏有寒的缘故。应当用温法治疗，适宜服用四逆汤类方剂。
阳经有病会有下利，而阴经的下利更多。只有自利且不口渴的，才属于太阴病。为什么呢？因为太阴脾脏有寒邪的缘故。大凡邪气侵入阳经，则发热津液枯竭而口渴；邪气侵入阴经，则不发热而津液不耗损，所以不口渴。这正是太阳篇开头所说的“无热恶寒，发于阴”的含义。阴寒在里，所以腹满痛而自利，这是太阴脾经的本证。所以应当温补，适宜服用四逆汤类方剂，意思是应当用姜附类药物来温补。说“四逆辈”而不说“四逆汤”，是向人们展示圆活变化的机枢，根据病情的轻重来决定进退，没有固定不变的法度。如果拘泥于一法，就不是圆机了。张兼善说，经文说“辈”字，是指药性同类，只是轻重优劣不同罢了。四逆汤甘辛相合，是大热之剂，如果轻率使用，恐怕有过度的失误。所以张仲景不设定固定的方剂，不如循序渐进地使用理中汤，最为稳妥。张兼善认为四逆汤是大热之剂而担心其过度，是最不善于读书的人。看张仲景在三阳症中，如误汗亡阳而用真武汤、四逆汤救治时，就说“四逆汤主之”；又如少阴、厥阴症中寒邪过盛的证候，都说“宜四逆汤”及“四逆汤主之”，这些都是因为真阳欲绝，急需温补的方法，毫不犹豫立即使用的。如果犹豫不决，拖延时日，那么阳气竭绝，死亡就在眼前，哪里是理中汤一味干姜所能救活的呢？只有这个太阴病的邪气，或许有可以用的情况，或许有不必全用的情况，所以说“宜服四逆辈”，而没有固定的方子。假设遇到阴寒急证，而一定要以理中汤为稳妥，循序渐进地使用，那么小热不能治大寒，阴邪不退，真阳不复，就会死亡。这叫做过度呢？还是稳妥呢？所以沿袭至今，庸医都以稳妥为妙，直到杀人而竟不自知，愚者反而认为是热药的误治，岂不冤枉吗？
【辨误】喻嘉言（尚论）说，注释认为自利不渴是湿胜，所以用四逆汤类方剂来暖土燥湿。这是老生常谈，不是切中要害的论述。张仲景的大意是，以自利不渴者属太阴，以自利而渴者属少阴，分经辨证，关系重大。盖太阴属湿土，热邪进入而蒸动其湿，则显得有余，所以不渴而多发黄；少阴属肾水，热邪进入而消耗其水，则显得不足，所以口渴而多烦躁。如果不通读全篇体会，仅仅博取注释的名声，其中精微的内涵，不能阐发的很多了。他的论述如此，乍读起来好像顿开生面，创辟一新，陈腐皆去，特别杰出，仿佛张仲景久晦的宗旨，一旦变成了光天化日。再仔细思考，喻氏的话，其实就是成无己的注释。成注说：“自利而渴者属少阴，为寒在下焦；自利不渴者属太阴，为寒在中焦。”给予四逆等汤以温其脏。虽然这三家的说法，实际上是两家的言论。等到推究张仲景原文，细绎六经的宗旨，方有龄固然错误，而成无己的说法也不对。喻氏虽然痛斥方注，但他立说也不能没有谬误。方注说，自利不渴为湿胜，太阴湿土，所以说有寒；四逆汤类都能暖土燥湿，所以说温之。张仲景以自利不渴为脏寒，方注偏以自利不渴为湿胜；张仲景以四逆汤类为温，方注偏以四逆汤类为燥湿。难道是后人的智虑超过前人，注释者的识见胜过作者吗？所以说是不能没有过错。成无己认为自利不渴属太阴，是寒在中焦，他的论述未始不正。他说自利而渴者属少阴，是寒在下焦，这是什么道理？试问少阴篇中的渴证有几条？遍阅少阴篇中，只有两条渴证而已。第一条说：“五六日自利而渴者，属少阴也。虚故引水自救。小便色白者，以下焦虚有寒，不能制水，故令色白。”这并不是真正的口渴。第二条说：“下利六七日，咳而呕渴，心烦不得眠。”这是因为阴寒在下，地气不升，气液不得上腾而渴；天气不降，肺气不得下行而壅塞咳呕。所以用猪苓汤渗利下焦，上通肺气而已。起初并不是热邪作渴。其余四十多条，都没有渴证。怎么可以把自利而渴作为少阴病的定旨呢？况且说自利而渴者属少阴，是寒在下焦。既然说是寒，为什么会有渴呢？恐怕其义不通，不足以作为定论。尚论认为太阴属湿土，热邪进入而蒸动其湿，所以不渴而多发黄。如果是湿热发黄，这种说法还可以。如《伤寒论》说发汗后，身目为黄，是因为寒湿在里不解的缘故，认为不可下，而在寒湿中求治，这难道是热邪蒸动吗？况且成注原本说自利而渴者属少阴，是寒在下焦，而喻氏就顺着他的说法改变措辞说：“少阴属肾水，热邪进入而消耗其水，所以口渴而多烦躁。”不知道下文说小便色白，下焦虚有寒，热邪从哪里来？烦躁在哪里？而作出这样的议论呢？在成氏那里，只是阅读太阴篇，有“自利不渴者属太阴”一句，及阅读少阴篇，见到“五六日自利而渴者属少阴”一句，并不体会全篇，通解下文，贸贸然提笔定论，对于学术，可以说是疏漏了。虽然不应该妄评前哲，但所关者大，所虑者深，所以不能不进行辨析。
伤寒脉浮而缓，手足自温的，系在太阴。太阴病应当发身黄，如果小便自利的，就不能发黄。到了七八天，虽然突然烦躁，一天腹泻十几次，必定会自行停止，因为脾家实，秽腐当去去的缘故。
伤寒的脉象浮紧，中风的脉象浮缓，都是太阳证。现在以伤寒而脉见浮缓，难道是风寒并感吗？如果果真像太阳篇下编大青龙汤条下的脉浮而缓，为风寒并受，那么应当有表证了。这里是因为邪气在太阴，缓是脾的本脉，因为邪气侵入阴经，所以没有发热等症状。手足自温，是因为脾主四肢。从手足而言自温，就知道不发热了。邪气在太阴，所以手足自温，不至于像少阴、厥阴那样四肢厥冷。所以说系在太阴。然而太阴湿土之邪郁蒸，应当发身黄。如果小便自利，其湿热之气已从下泄，所以不能发黄。像这样到了七八天，虽然发暴烦，这是阳气流动，肠胃通行的征象。下利虽然一日十余行，必定下尽而自行停止。这是因为湿气实于脾家，所以肠胃中有形的秽腐应当去除。秽腐去，则脾无形之湿热也去除了。这一条应当与正阳阳明发黄篇第七十七条互看。其上节相同而下节各异。前一条是以小便自利而不能发黄之后，以七八天而大便硬的，是邪归阳明，为可下的证候；这一条是以七八天而暴烦下利，秽腐当去，为脾家实，是邪归太阴，为利尽自止的证候。一个归于胃实而为阳明证，一个归于脾实而成太阴证。同感而异变，同源而异派，如果不是谆谆分辨，怎能没有多歧之惑呢？观其立法示人，谓不是后学的指南，临证的冰鉴吗？
意思是说伤寒郁热之邪，已内入胸膈，犹未入胃。胸为太阳所属，则太阳证犹未罢，而胃中反有阴寒之邪气，所以腹痛而想呕吐。腹痛呕吐，都属于太阴。因为胃中有邪气而出现太阴证，《太阴阳明论》说：脾胃通过膜相连，为一表一里的关系。然而胸中有热，应当用寒凉药治疗；而腹痛欲呕，又应当以温中为急。从来治寒以热，治热以寒，才是正治。现在胸中有热，胃中有寒，治寒则违背其热，治热必伤害其寒。不得已而用黄连汤主治。这就是所谓的“寒因热用，热因寒用”，二者相辅相成。《素问·至真要大论》说：“逆之从之，逆而从之，从而逆之”的方法。
黄连汤方
黄连（三两） 甘草（三两） 干姜（三两） 桂枝（三两） 人参（二两） 半夏（半升）
大枣（十二枚，掰开）
以上七味药，用水一斗，煮取六升，去滓，温服一升，日三服，夜二服。
热邪已入胸膈，虽未成结胸，但胸邪非不开散。热气又非寒药莫治，所以用黄连的苦寒为君药，即黄连泻心汤的意思。甘草缓腹中之痛，与黄连同用，能泻心下之邪，即甘草泻心汤的意义。如果不是干姜的温热守中，不足以治疗腹中之痛；必须用人参、半夏的辛温扶胃，才能止住欲呕之逆。然而胃有实热，则人参即为难用。此处是阴寒虚气，虽有胸中之客热，而无入胃之热邪，仍属太阴本证，所以应当温补兼施。用桂枝，是为了使阳气通行，兼解其未去之经邪。加大枣，是为了调停其中气，和协其药性的寒温。黄连与干姜同用，乃寒因热用，所以治胸中有热。干姜与黄连并行，即热因寒用，所以治腹痛欲呕。胸中有热而用黄连，是逆而折之的方法。复用干姜，是求其属以衰之的方法。腹痛而用干姜，是逆者正治。又用黄连，是从者反治。胸既有热而腹痛欲呕，又为胃中有寒，一寒一热之邪，而以黄连、干姜并用，是从而逆之，逆而从之。立方之意，精微极了。
Taiyin disease is characterized by abdominal fullness and vomiting, inability to eat, worsening spontaneous diarrhea, and occasional spontaneous abdominal pain. If purgation is applied, it will inevitably lead to hardness and obstruction below the chest.
This section generally describes the manifestations of Taiyin disease, stating that when the Taiyin meridian is affected, symptoms such as abdominal fullness and vomiting must appear. However, this does not mean that all these symptoms must be present for a diagnosis of Taiyin disease. Henceforth, whenever "Taiyin disease" is mentioned, it refers specifically to cases presenting with these aforementioned symptoms. Taiyin represents abundant Yin. It corresponds to Gen Earth in the northeast, generated from the Yang Qi within Kan Water (Kidney) that has not yet undergone transformation, symbolizing pure Yin like the earth. Since the earth resides in the center of heaven, the returning Yang Qi from the pre-heaven state arises from beneath the yellow springs, penetrating the soil to generate all things. Thus, Taiyin takes abundant Yin as its substance and utilizes Yang Qi as its function. Therefore, cold earth fails to produce grains, while warm earth generates all things. Similarly, the Taiyin Spleen Earth in the human body resides among the five zang organs, possessing a quiet and compliant nature but exhibiting vigorous transportation functions. The Stomach serves as its fu organ, acting as the sea of water and grain. It belongs to Kun Earth in the southwest, generated by the post-heaven Li Fire (Heart), thus associating with Yangming to rot and ripen food and drink, embodying the image of Kun Earth bearing all things. Consequently, the Stomach stores the five flavors and transforms the five grains, while the Spleen circulates essence fluids and transports refined nutrients. All internal organs, meridians, limbs, and bones throughout the body receive nourishment and growth from it; it is the source of vital Qi. The Taiyin meridian runs alongside the Ren Mai (Conception Vessel) and is designated as the Taiyin Meridian. Hence, the *I Ching* states "Kun represents the abdomen," referring to the meridians and acupoints of the abdomen. When the abdominal meridian is invaded by pathogenic factors, Taiyin disease ensues. Pathogens entering Yin meridians are termed Yin pathogens. The Taiyin meridian comprises the Spleen as the zang organ and the Stomach as the fu organ. Upon invasion, the pathogen affects the meridians internally connecting to the Spleen and Stomach. Connected by membranes, when Cold pathogens reside in the interior, abdominal fullness and vomiting occur. This aligns with the *Su Wen: Re Lun*, which states that the Taiyin meridian spreads into the stomach, causing abdominal fullness and dry throat. Inability to eat, as mentioned in the Yangming chapter, implies "inability to eat indicates Middle Jiao Cold"; how much more so for Taiyin? Yin pathogens in the middle jiao cause abdominal fullness; reversing upward causes vomiting; pressing downward worsens spontaneous diarrhea; and occasional spontaneous abdominal pain occurs. Treatment should involve warming the middle and dispersing Cold to resolve Yin pathogens, such as Lizhong Tang (Center-Regulating Decoction) or Sini Tang (Frigid Extremities Decoction) as described later. If incompetent physicians fail to distinguish Yin and Yang and do not understand the meridians, mistaking abdominal fullness, vomiting, and inability to eat for food stagnation and Stomach excess, and erroneously applying bitter-cold purgatives, they will inevitably damage the Stomach's Yang Qi. Yin pathogens will knot internally, resulting in hardness and obstruction below the chest. "Below the chest" refers to the area between the heart/chest and the epigastrium. Because Yin-Cold knots hard in the epigastrium, it is called "hardness below the chest." This distinguishes it from Chest Binding (Jie Xiong). Chest Binding results from premature purgation in Taiyang disease, where Yang pathogens sink into Yang positions and bind in the chest. Here, premature purgation in Taiyin disease leaves Stomach Yang empty, allowing Yin pathogens to knot in the stomach below the chest, hence "hardness below the chest." In such cases, failing to urgently rescue Stomach Yang and dispel Yin shadows will lead to the exhaustion of Stomach Yang, resulting in death due to hiccups and cold extremities.
[Correction of Errors] Cheng Wuji stated that Taiyin disease involves Yang pathogens transmitting to the interior. This view is profoundly erroneous. Does Taiyin not have pathogens directly affecting its own meridian? He further claimed that abdominal pain caused by internal Yin-Cold is constant pain, whereas pain from Yang pathogens transmitting to the interior is intermittent, occurring only occasionally. This argument is even more absurd. Has he forgotten the opening of the Taiyang chapter: "Diseases originating from Yang manifest with fever and aversion to cold; diseases originating from Yin manifest without fever but with aversion to cold"? In summary, pathogens entering Yang meridians cause fever and become Yang pathogens; pathogens entering Yin meridians cause no fever and become Yin pathogens. The principle is clear. Cheng Wuji, despite being a pioneer in interpreting Zhang Zhongjing's work, remains ignorant of this basic distinction. It would be clearer to follow Shanglun's assertion that "abdominal fullness and spontaneous diarrhea" are the fundamental signs of Taiyin disease. However, Shanglun also claims that if misdiagnosed and treated with purgation, pathogens in the lower part may be expelled, but those in the upper part will sink, causing hardness below the chest, similar to Chest Binding. I privately believe that Chest Binding arises because Yang pathogens were purged too early. Yin pathogens inherently require no purgation. As stated in the general rules for Pi Syndrome (Glomus): "Originating from Yang, if purged in error, heat enters, leading to Chest Binding; originating from Yin, if purged in error, Pi Syndrome results." Both are adverse reactions to erroneous purgation, yet Pi Syndrome lacks the phrase "heat enters." The text below attributes Chest Binding solely to premature purgation but offers no explanation for Pi Syndrome. Why? Zhang Zhongjing's intent was likely that Taiyang pathogens remain in the exterior and have not been resolved; erroneous purgation leads to interior deficiency and pathogen sinking, causing Chest Binding. Hence the warning against premature purgation. Although Yin pathogens can be in the meridian or interior, the Three Yin meridians are never in the exterior. Erroneous purgation inevitably damages Stomach Yang, causing Yin pathogens to rebel and ascend, leading to hardness. Thus, "hardness below the chest." Regarding the Gancao Xiexin Tang clause earlier: "This is not heat binding, but rather stomach deficiency causing hostile Qi to reverse upward, resulting in hardness." Yin pathogens should never be purged; doing so causes adverse reactions, hence "erroneous purgation." While many Yin meridian conditions allow for purgation, in Taiyin disease, one must see "severe abdominal pain" and confirm Stomach Qi excess before using Guizhi Dahuang Tang (Cinnamon Twig and Rhubarb Decoction). In Shaoyin disease, purgation with Dachengqi Tang (Major Order the Qi Decoction) is reserved for cases with dry mouth/throat, hardness under the heart, and constipation after six to seven days. In Jueyin disease, Xiaochengqi Tang (Minor Order the Qi Decoction) is used only when diarrhea accompanied by delirium indicates dry feces. These instances involve pathogens transferring to Yangming before purgation is considered. This specific case involves purely Yin pathogens; what lower-pathogen exists to purge? Since Yin pathogens are not heat entering, what upper-pathogen could sink? This argument is untenable. Moreover, Zhang Zhongjing uses "Chest Binding" for sinking Yang pathogens and "hardness below the chest" for knotting Yin pathogens, never conflating them. Yin and Yang pathogens differ fundamentally; sinking versus non-sinking differs equally. Furthermore, the anatomical regions of the chest and below the chest are distinct. How can one claim similarity between hardness below the chest and Chest Binding? Ancient medical legislation varies in tone and syntax, leading to vastly different meanings. Later commentators who fail to analyze the text carefully and provide vague annotations cannot serve as models for posterity.
Spontaneous diarrhea without thirst belongs to Taiyin disease because the zang organs harbor Cold. Treatment requires warming methods, preferably using Sini Tang (Frigid Extremities Decoction) category formulas.
Yang meridian diseases involve diarrhea, but Yin meridian diseases feature it more frequently. Only spontaneous diarrhea accompanied by lack of thirst belongs to Taiyin. Why? Because the Taiyin Spleen harbors Cold pathogens. Generally, pathogens entering Yang meridians cause fever, fluid depletion, and thirst. Pathogens entering Yin meridians cause no fever and preserve fluids, hence no thirst. This aligns with the Taiyang chapter's principle: "No fever and aversion to cold indicate origin from Yin." Internal Yin-Cold causes abdominal fullness, pain, and spontaneous diarrhea, which are fundamental signs of the Taiyin Spleen meridian. Therefore, warming is indicated. "Sini Tang category" implies using ginger and aconite-based formulas to warm. Specifying "category" rather than a fixed formula demonstrates flexibility, adjusting dosage based on severity without rigid adherence. Adhering strictly to one method lacks adaptability. Zhang Jianshan noted that "category" implies drugs with similar properties but varying potency. Sini Tang is a highly heating formula; careless use risks overdose. Thus, Zhang Zhongjing did not fixate on it, preferring the steady application of Lizhong Tang. Zhang Jianshan’s fear that Sini Tang is too hot reveals poor reading comprehension. Zhang Zhongjing prescribed Sini Tang unhesitatingly for Yang collapse due to excessive sweating (using Zhenwu Tang or Sini Tang) and for severe Cold in Shaoyin/Jueyin. These represent urgent warming for impending Yang exhaustion. Hesitation leads to certain death, which Lizhong Tang alone cannot prevent. For Taiyin disease, however, Sini Tang may be partially used or modified, hence "suitable to take Sini Tang category." In acute Yin-Cold emergencies, relying solely on the "steady" Lizhong Tang might result in small heat failing to treat great Cold, leading to death. Is this "overdose" or "steadiness"? Modern quacks favor "steadiness" to avoid blame, killing patients unknowingly while blaming "hot medicines." How unjust!
[Correction of Errors] Shanglun (Yu Jia Yan) criticized the annotation claiming "spontaneous diarrhea without thirst indicates dampness excess, treated by warming earth and drying dampness with Sini Tang category," calling it stale and irrelevant. Zhang Zhongjing’s main point is distinguishing Taiyin (diarrhea without thirst) from Shaoyin (diarrhea with thirst) for accurate meridian differentiation. Taiyin is Wet Earth; heat steams dampness, causing jaundice without thirst. Shaoyin is Kidney Water; heat consumes water, causing thirst and irritability. Failing to read the whole text misses subtle nuances. Yu’s critique seems novel but essentially repeats Cheng Wuji’s note: "Diarrhea with thirst belongs to Shaoyin (Cold in Lower Jiao); diarrhea without thirst belongs to Taiyin (Cold in Middle Jiao), treated with warming formulas." Fang Youling’s interpretation is wrong, and Cheng’s is also flawed. Yu’s criticism of Fang contains errors himself. Fang interpreted "without thirst" as dampness excess and "warming" as drying dampness. Zhang Zhongjing interpreted "without thirst" as zang Cold and "warming" as general warming. Did later commentators surpass ancient authors? Cheng Wuji correctly identified Middle Jiao Cold for Taiyin but incorrectly attributed Lower Jiao Cold to Shaoyin thirst. How many thirst cases exist in Shaoyin? Only two. One involves "five to six days of diarrhea with thirst... urine white... lower jiao deficiency cold." This is not true thirst. The other involves "six to seven days of diarrhea, cough, vomiting, thirst, insomnia," treated with Zhuling Tang to drain dampness, not due to heat-thirst. Over forty other clauses lack thirst. Can "thirst" define Shaoyin? If it is Cold, why thirst? The logic is flawed. Shanglun argued Taiyin heat steams dampness causing jaundice. While valid for damp-heat jaundice, it contradicts cold-damp jaundice treatments. Cheng Wuji cited Lower Jiao Cold for Shaoyin thirst, but Yu changed it to "heat consuming water." Yet the text mentions "urine white, lower jiao deficiency cold." Where is the heat? Cheng Wuji merely cited isolated sentences without analyzing the entire context, showing scholarly negligence. Though respecting predecessors is important, the stakes are high, necessitating correction.
In Shanghan (Cold Damage), if the pulse is floating and slow, and hands and feet are naturally warm, the condition relates to Taiyin. Taiyin typically manifests with jaundice; however, if urination is free, jaundice will not develop. By the seventh or eighth day, although sudden irritability and frequent diarrhea (more than ten times daily) occur, it will stop spontaneously because the Spleen Qi becomes sufficient (Shi), expelling foul residues.
Taiyang Shanghan presents with a floating-tight pulse; Fengshang (Wind Strike) presents with a floating-slow pulse. A floating-slow pulse in Shanghan suggests concurrent Wind-Cold? If so, exterior symptoms should exist. Here, the pathogen is in Taiyin; "slow" is the Spleen’s native pulse. Pathogen entry into Yin meridians eliminates fever symptoms. Hands and feet warmth reflects Spleen’s dominion over the four limbs, indicating absence of fever. Unlike Shaoyin/Jueyin cold extremities, Taiyin pathology keeps extremities warm. Thus, "relates to Taiyin." Taiyin Wet-Earth pathogen stagnation usually causes jaundice. Free urination allows damp-heat to drain downward, preventing jaundice. By day seven or eight, sudden irritability signals Yang Qi movement and intestinal passage. Frequent diarrhea clears有形 (solid) filth accumulated due to Spleen dampness excess. Once filth is gone, formless damp-heat dissipates. Compare this with Clause 77 (Yangming Jaundice). The first half is identical; the second half differs. In Yangming, free urination followed by hard stool indicates pathogen transfer to Yangming (purgative indication). Here, irritability and diarrhea indicate pathogen transfer to Taiyin (self-limiting diarrhea due to Spleen Shi). One resolves to Stomach Excess (Yangming); the other to Spleen Excess (Taiyin). Same origin, divergent outcomes. Clear distinction prevents confusion. This serves as a guide for students and clinicians.
In Shanghan, if there is heat in the chest, pathogenic Qi in the stomach, abdominal pain, and desire to vomit, Huanglian Tang (Coptis Decoction) is indicated.
Heat pathogens have entered the chest/diaphragm but not the Stomach. The chest belongs to Taiyang, so Taiyang symptoms persist, while Cold pathogens reside in the Stomach, causing abdominal pain and nausea. Abdominal pain and vomiting relate to Taiyin. The *Taiyin Yangming Lun* states Spleen and Stomach are connected by membranes, forming an interior-exterior pair. Chest heat requires cold/cool herbs; abdominal pain/nausea requires warming the middle. Standard treatment opposes pathogen nature (cold for heat, hot for cold). Here, chest heat and Stomach Cold create conflict. Warming harms heat; cooling harms Cold. Huanglian Tang addresses this via "treating heat with cold principles, treating Cold with heat principles," mutually supporting each other, as per *Su Wen: Zhi Zhen Yao Da Lun*.
Huanglian Tang Formula
Huanglian (3 liang), Gancao (3 liang), Ganjiang (3 liang), Guizhi (3 liang), Renshen (2 liang), Banxia (0.5 sheng), Dazao (12 pieces, split).
Seven ingredients. Boil in 10 dou of water, reduce to 6 sheng. Strain. Warm dose: 1 sheng, three times daily, twice at night.
Heat in the chest/diaphragm, though not Chest Binding, requires resolution. Heat demands cold treatment. Huanglian (bitter/cold) acts as Sovereign, echoing Huanglian Xiexin Tang. Gancao relieves abdominal pain and assists Huanglian in draining Heart/Stomach evil, echoing Gancao Xiexin Tang. Ganjiang (warm/hot) stabilizes the middle to treat abdominal pain. Renshen and Banxia (acrid/warm) support Stomach Qi to stop vomiting. Renshen is difficult to use in Stomach Excess-Heat; here, it treats Yin-Cold deficiency Qi. Despite chest guest-heat, there is no Stomach heat; it remains a Taiyin fundamental pattern requiring simultaneous warming and tonification. Guizhi promotes Yang Qi circulation and resolves lingering exterior pathogens. Dazao harmonizes middle Qi and balances herb temperatures. Huanglian + Ganjiang = "Treating heat with cold" for chest heat. Ganjiang + Huanglian = "Treating Cold with heat" for abdominal pain/nausea. Using Huanglian for chest heat is "opposing/reducing." Reusing Ganjiang is "seeking the root to decline." Using Ganjiang for pain is "opposing standard treatment." Adding Huanglian is "following counter-treatment." Combining cold/hot pathogens with Huanglian/Ganjiang exemplifies "following then opposing, opposing then following." The prescription’s intent is exquisite and subtle.