【纲】仲景曰。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。
【目】张元素曰。太阴本症。惟腹满自利而已。若邪迫于上。则吐而食不下也。邪迫于下。则
利甚而腹满也。上下相迫。必上下交乱。胃中空虚。法只可行温散之剂。其病自痊。若误下之。必
在下之邪去。而在上之邪陷。有不至于胸下结硬者哉。
魏荔彤曰。邪自外感。太阳先中之。邪自内传。太阴先受之。少阳之邪。既不能由半表而达表。
必由半里而入里。而里三阴之太阴。又为三阴之表。内经云。太阴主开是也。所以少阳之邪。传
经必先及太阴。亦不离内外表里之义而已矣。腹满而吐。食不下。自利腹痛。纯为太阴湿土。失镇
奠之令。故症全见于肠胃肚腹之间。本为三阳之邪。陷入阴经为患。法当升散其邪。复还阳分。若
以满痛为实邪而下之。则阳愈陷而下沉。阴愈凝而不散。胸下结硬。有似太阳之结胸而在下。有似
太阳之心下痞而又在上。胸下结硬。所以为太阴误下独见之症者如此。伤寒传经之邪。无论在太阳为
风因寒因。及遍历三阳。皆成热邪。复由阳而入阴。或误下误汗。又能变虚生寒。此病之变易莫测
也。惟其为热邪。所以作满而能吐。若寒邪。但胀满不食。必不能上逆为呕吐矣。自利而时腹痛。
利为挟热。时痛亦热邪。若寒邪。则痛隐隐无已时矣。所以知其确为热邪也。况凡病初得为寒。久
痛多热。亦理之常。太阳风寒之邪。传阳明时已变热矣。未有无所因而忽又变寒入三阴者。如谓入
三阴即为寒。何以有系在太阴之发黄也。发黄亦为寒邪耶。又何以三阴篇中用苦寒之剂。仲师立法。
不一而足。岂智不足耶。总由传经与直中之邪。分路不明。故见仲师立一温
散之法。便谓传经为寒邪。及见一恣用苦寒之法。便自己亦说不周全。遂含糊了事便罢。余不得不
于三阴之首条力争之。曰。直中有寒。传经悉热。（八字铁案）此二语确乎不易。再太阳结胸痞。
皆经误下而成。亦属风寒在表之邪。日久变热。遂成结聚。特风邪阳。聚于高分。寒邪阴。聚于
低分。然风因寒因。俱为已变热之邪无异也。所以陷胸泻心内。俱有苦寒之味。今此胸下结硬。又
岂能外陷胸泻心别求门路乎。或问。仲师意在温散。子言陷胸泻心。何也。曰。仲师温散。为太阴
未误下言。非为已下成胸下结硬者言也。亦如太阳未误下。用辛温。已误下。用苦寒也。三阳为表。
三阴为里。固矣。三阳有三阳之表里。三阴有三阴之表里。岂可一阳而尽表之理。一阴而尽阴之
道乎。此乃伤寒中之大关键也。
【纲】仲景曰。寒实结胸。无热症者。与三白小陷胸汤。为散亦可服。
【目】柯琴曰。太阳表热未除而反下之。热邪与寒水相结。成热实结胸。太阴腹满时痛而反下
之。寒邪与寒药相结。成寒实结胸也。无热症者。不四肢烦疼也。
【纲】张仲景说：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。如果对此误用攻下法，必然导致胸膈下方痞结坚硬。
【目】张元素说：太阴病的本证，仅仅是腹部胀满和腹泻罢了。如果邪气逼迫于上部，就会出现呕吐且饮食难进；如果邪气逼迫于下部，就会腹泻严重且腹部胀满。上下邪气相互逼迫，必然导致上下气机紊乱。此时胃中已经空虚，按照医理只应当使用温散的药物进行治疗，疾病自然痊愈。如果误用攻下法，必然导致在下的邪气虽然去了，但在上的邪气却陷入体内，难道不会导致胸膈下方痞结坚硬吗？
魏荔彤说：邪气从外感受，太阳经首先受邪；邪气从内传变，太阴经首先受邪。少阳的邪气，既然不能通过半表半里而达于体表，必然会通过半里而入于里。而在三阴经中，太阴又是三阴之表，《内经》说“太阴主开”就是这个道理。所以少阳的邪气，传经必然先波及太阴，这也不离内外表里的义理。腹部胀满、呕吐、饮食不下、腹泻腹痛，纯粹是因为太阴湿土失去了镇守奠定的功能，所以症状完全表现在肠胃肚腹之间。这原本是三阳的邪气，陷入阴经为患，治法应当升散邪气，使其复还于阳分。如果把胀满疼痛当作实邪而误用攻下，那么阳气会更加陷入并下沉，阴气更加凝滞而不散。胸膈下方痞结坚硬，看起来有点像太阳病的结胸但位置在下，又像太阳病的心下痞但位置在上。胸膈下方痞结坚硬，之所以成为太阴病误下后独有的症状，原因就在于此。伤寒传经的邪气，无论是在太阳经表现为风因还是寒因，以及遍历三阳经，都化为热邪，再由阳传入阴。或者因为误下、误汗，又能使正气变虚而生寒。这就是病情变化莫测的原因。正因为它是热邪，所以会导致胀满并能呕吐；如果是寒邪，只会胀满不食，绝不可能上逆引起呕吐。腹泻且时常腹痛，腹泻说明挟有热邪，时常疼痛也是热邪的表现；如果是寒邪，疼痛则是隐隐作痛且无休止。因此可以确知这是热邪。况且凡是疾病初起多为寒，久痛多转为热，这也是常理。太阳的风寒邪气，传到阳明时已经变为热邪了。没有无缘无故突然又变寒进入三阴经的情况。如果说进入三阴就是寒邪，为什么会有“系在太阴”导致的发黄呢？发黄也是寒邪造成的吗？为什么在三阴篇中会使用苦寒的药剂呢？张仲景立法，多种多样，难道是他智慧不足吗？总归是因为传经与直中的邪气分路不明，所以看到张仲景设立一种温散的方法，就认为传经是寒邪；等到看到一种恣意使用苦寒的方法，自己也说不周全，于是含糊了事罢了。我不得不在三阴篇的首条力争这一点，说：直中者有寒，传经者悉为热。（这是不可更改的铁案）这两句话确实是不容置疑的。另外，太阳病的结胸和痞证，都是因为误下而成，也属于风寒在表的邪气，日久化热，遂成结聚。只是风邪属阳，聚集于高分（上部）；寒邪属阴，聚集于低分（下部）。然而，无论是风因还是寒因，都是已经变为热邪的邪气，没有什么不同。所以陷胸汤和泻心汤内部，都有苦寒的成分。现在这个胸膈下方痞结坚硬，又怎么能脱离陷胸汤和泻心汤另寻门路呢？有人问：张仲景意在温散，您却说用陷胸汤和泻心汤，为什么呢？回答说：张仲景的温散法，是针对太阴病尚未误用的情况而言的，不是针对已经误下形成胸膈下方痞结坚硬的情况而言的。这也就像太阳病未误用时用辛温药，已误用时用苦寒药一样。三阳经为表，三阴经为里，这固然正确。但三阳经有三阳经的表里，三阴经也有三阴经的表里，岂可认为一阳经尽属表，一阴经尽属阴的道理呢？这是伤寒论中的大关键所在。
【纲】张仲景说：寒实结胸，没有热象症状的，给予三白小陷胸汤。制成散剂服用也可以。
【目】柯琴说：太阳表热未除反而误用攻下，热邪与寒水相结，形成热实结胸；太阴病腹部胀满、时常腹痛反而误用攻下，寒邪与寒性药物相结，形成寒实结胸。“没有热象症状”，是指没有四肢烦疼的症状。
[Outline] Zhang Zhongjing said: The main manifestations of Taiyin disease are abdominal fullness, vomiting, difficulty in swallowing food, diarrhea that gradually worsens, and spontaneous abdominal pain occurring from time to time. If purgation is mistakenly applied, it will inevitably lead to hardness and obstruction below the chest.
[Commentary] Zhang Yuansu said: The primary symptoms of Taiyin disease are merely abdominal fullness and diarrhea. If pathogenic factors press upon the upper part, vomiting and inability to eat will occur; if they press upon the lower part, severe diarrhea and abdominal fullness will result. When pathogens in the upper and lower parts mutually oppress each other, the qi mechanism in both regions must become chaotic. At this stage, the stomach is empty. According to medical principles, only warming and dispersing agents should be used, and the disease will heal spontaneously. If purgation is mistakenly applied, the pathogens in the lower part may be expelled, but the pathogens in the upper part will sink inward. Would this not inevitably lead to hardness and obstruction below the chest?
Wei Litong said: Pathogens acquired externally first affect the Taiyang channel; pathogens transmitted internally first affect the Taiyin channel. Shaoyang pathogens, since they cannot reach the exterior via the half-exterior/half-interior level, must enter the interior via the half-interior. Among the three Yin channels, Taiyin serves as the exterior of the three Yin. As stated in the *Neijing* (Inner Canon), "Taiyin governs opening." Therefore, Shaoyang pathogens transmitting through the channels must first involve Taiyin, which aligns with the principles of interior/exterior and surface/depth. Abdominal fullness, vomiting, inability to eat, diarrhea, and abdominal pain are purely due to the failure of Taiyin damp-earth to maintain its stabilizing function. Thus, symptoms manifest entirely in the intestines, stomach, and abdomen. This originates from pathogens of the three Yang channels sinking into the Yin channels to cause pathology. The treatment method should be to ascend and disperse the pathogens, restoring them to the Yang level. If fullness and pain are mistaken for excess pathogens and treated with purgation, Yang qi will sink further, and Yin qi will become more stagnant and undispersed. Hardness and obstruction below the chest resemble the chest binding of Taiyang disease but located lower, and resemble the epigastric stuffiness of Taiyang disease but located higher. This is why hardness and obstruction below the chest is a unique symptom appearing after mistaken purgation in Taiyin disease. Regarding pathogens transmitted through the channels in cold damage diseases, whether presenting as wind or cold at the Taiyang stage, or traversing the three Yang channels, they all transform into heat pathogens. They then transmit from Yang to Yin. Alternatively, mistaken purgation or sweating can cause deficiency and generate cold. This unpredictability characterizes the changes in disease. Precisely because it is a heat pathogen, it causes fullness and vomiting. If it were a cold pathogen, there would only be distension and anorexia, absolutely no upward reversal causing vomiting. Diarrhea accompanied by intermittent abdominal pain indicates diarrhea with heat; intermittent pain also indicates heat pathogens. If it were a cold pathogen, the pain would be dull, lingering, and ceaseless. Therefore, we can confirm it is a heat pathogen. Moreover, it is a common principle that diseases initially present as cold, but prolonged pain often transforms into heat. When wind-cold pathogens of Taiyang transmit to Yangming, they have already transformed into heat. There is no case where pathogens suddenly transform into cold and enter the three Yin channels without cause. If entering the three Yin always meant cold, why does "lingering in Taiyin" cause jaundice? Is jaundice caused by cold pathogens? Why are bitter-cold formulas used in the chapter on the three Yin channels? Zhang Zhongjing established various methods; was his wisdom insufficient? It is simply because the distinction between transmitted pathogens and directly invading pathogens was unclear. Upon seeing Zhang Zhongjing establish a warming and dispersing method, one might wrongly conclude that transmitted pathogens are cold. Upon seeing a liberal use of bitter-cold methods, one might find oneself unable to explain fully and thus gloss over it ambiguously. I could not help but vigorously argue at the beginning of the three Yin chapter, stating: Direct invasion involves cold; transmission involves heat. (This is an unchangeable iron-clad case.) These two statements are indeed indisputable. Furthermore, chest binding and epigastric stuffiness in Taiyang disease are all caused by mistaken purgation. They belong to wind-cold pathogens in the exterior that transform into heat over time, leading to aggregation. Wind pathogens are Yang and aggregate in high positions (upper); cold pathogens are Yin and aggregate in low positions (lower). However, whether originating from wind or cold, they are essentially heat-transformed pathogens with no difference. Therefore, Xiaoxin Tang (Minor Chest-Draining Decoction) and Xixin Tang (Epigastric-Purgating Decoction) contain bitter-cold ingredients. Now, regarding this hardness and obstruction below the chest, how could it possibly deviate from Xiaoxin Tang and Xixin Tang to seek another approach? Someone asked: Zhang Zhongjing intended warming and dispersing, yet you speak of Xiaoxin Tang and Xixin Tang. Why? I replied: Zhang Zhongjing's warming and dispersing method applies to Taiyin disease before mistaken purgation, not to cases where hardness and obstruction below the chest have already formed due to purgation. This is analogous to using acrid-warm herbs for Taiyang disease before mistaken purgation, and bitter-cold herbs after mistaken purgation. It is true that the three Yang channels are exterior and the three Yin channels are interior. However, the three Yang channels have their own interior/exterior distinctions, and the three Yin channels have their own interior/exterior distinctions. How can one claim that a single Yang channel is entirely exterior, or a single Yin channel is entirely interior? This is a critical point in the study of cold damage diseases.
[Outline] Zhang Zhongjing said: For cold-excess chest binding characterized by the absence of heat symptoms, Sanbai Xiaoxin Tang (Three-White Minor Chest-Draining Decoction) should be administered. It may also be taken as a powder.
[Commentary] Ke Qin said: If the exterior heat of Taiyang is not resolved and purgation is mistakenly applied, heat pathogens bind with cold water, forming heat-excess chest binding. If abdominal fullness and intermittent pain of Taiyin are not addressed correctly and purgation is mistakenly applied, cold pathogens bind with cold-natured drugs, forming cold-excess chest binding. "Absence of heat symptoms" refers to the lack of vexatious pain in the four limbs.