六气之邪，感人虽同，人受之而生病各异者，何也？盖以人之形有浓薄，气有盛衰，脏有寒热，所受之邪，
每从其人之脏气而化，故生病各异也。是以或从虚化，或从实化，或从寒化，或从热化。譬诸水火，水盛则火
灭，火盛则水耗，物盛从化，理固然也。诚知乎此，又何疑乎？阳邪传阴，变寒化热，而遂以为奇耶！自后汉
迄今，千载以来，皆谓三阴寒邪不传，且以伤寒传经阴邪，谓为直中，抑知直中乃中寒之证，非传经之邪耶！
是皆未曾熟读仲景之书，故有此误耳！如论中下利腹胀满，身体疼痛者，先温其里，乃攻其表，温里宜四逆汤，
攻表宜桂枝汤，此三阳阳邪，传入太阴，邪从阴化之寒证也。如少阴病下利，白通汤主之，此太阴寒邪，传少
阴之寒证也，如下利清谷，里寒外热，汗出而厥者，通脉四逆汤主之，此少阴寒邪传厥阴之寒证也。皆历历可
据，岂得谓伤寒阴不相传，无阳从阴化之理乎？夫太阴湿土，纯阴之脏也，故病一入太阴，则邪从阴化者多，
从阳化者少。从阴化者，如论中腹满，吐食，自利，不渴，手足自温，时腹自痛，宜服理中、四逆辈者是也。
从阳化者，如论中发汗后不解，腹满痛者，急下之，宜大承气汤；腹满大实痛者，宜桂枝加大黄汤主之者是也。
盖脾与胃同处腹中，故腹满、腹痛两皆有之。然腹满为太阴主病，心下满为阳明主病，其阳明亦有腹满者，以
阳明腹满与热同化，故必有潮热、自汗、不大便之证，而不似太阴与湿同化，有发黄、暴烦、下利秽腐之证也。
诚能更于腹之时痛，大实痛，腹满痛处，详审虚实，斟酌温下，则了无余义矣。故以此括之，自知太阴之要法也。
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。
【按】吴人驹曰∶“自利益甚”四字，当在“必胸下结硬”句之下，其说甚是。若在“吐食不下”句之下，
则是已吐食不下，而自利益甚矣。仲景复曰若下之，无所谓也。
【注】太阴，脾经也，甚脉布胃中，络于嗌。寒邪传于太阴，故腹满时腹自痛，寒邪循脉犯胃，故吐食不
下，此太阴里虚，邪从寒化之证也，当以理中、四逆辈温之。若腹满嗌干，不大便，大实痛，始为太阴里实，
邪从热化之证，当以桂枝加大黄汤下之矣。若以太阴虚寒之满痛，而误认为太阴实热之满痛而下之，则寒虚相
抟，必变为脏结痞硬，及自利益甚矣。此太阴病全篇之提纲，后凡称太阴病者，皆指此证而言也。
【集注】程应旄曰∶阳邪亦有腹满，得吐则满去而食可下者，今腹满而吐，食不下，则满为寒胀，吐为
寒格也。阳邪亦有下利腹痛，得利则痛随利减者，今下利而时腹自痛，则利为寒利，痛为寒痛也。曰胸下阴邪
结于胸下之阴分，异于阳邪结胸之在胸，且按之而痛也。曰结硬，无阳以化气则为坚阴，异于痞之濡而软也。
彼皆阳从上陷而阻留，此则阴从下逆而不归，寒热大别也。
吴人驹曰∶自利有时，而腹自痛，非若积蓄而常痛者，若以诸痛为实，从而下之，其满益甚，必令胸下
皆为结硬，而自利益甚矣。
伤寒四五日，腹中痛，若转气下趋少腹
者，此欲自利也。
【注】伤寒四五日，邪入太阴之时也。腹中痛，若不转气下趋者，属阳明也。今腹中痛，转气下趋少腹者，
乃太阴欲作自利之候也。此仲景示人不可以诸痛为实，而妄议下之意也。
【集注】方有执曰∶腹中痛转气下趋者，里虚不能守，而寒邪下迫也。
张璐曰∶腹痛亦有属火者，其痛必自下而上攻。若痛自上而下趋者，定属寒痛无疑。
魏荔彤曰∶此重在预防下利，而非辨寒热也。玩“若”字、“欲”字，可见其辨寒邪者，自有别法。
自利不渴者，属太阴，以其脏有寒故也，当温之，宜服四逆辈。
【注】凡自利而渴者，里有热，属阳也。若自利不渴，则为里有寒，属阴也。今自利不渴，知为太阴本脏
有寒也，故当温之。四逆辈者，指四逆、理中、附子等汤而言也。
【集注】程知曰∶言太阴自利为寒，宜温者也。少阴属肾水，热入而耗其水，故自利而渴。太阴属脾土，
寒入而从其湿，则不渴而利，故太阴自利当温也。
程应旄曰∶三阴同属脏寒，少阴、厥阴有渴证，太阴独无渴证者，以其寒在中焦，总与龙雷之火无涉。少
阴中有龙火，底寒甚则龙升，故自利而渴；厥阴中有雷火，故有消渴。太阳一照雷雨收声，故发热则利止，见
厥而复利也。
魏荔彤曰∶“自利”二字，乃未经误下、误汗、误吐而成者，故知其脏本有寒也。
理中丸方
人参 白术 甘草（炙） 干姜（各三两）
上四味，捣筛，蜜和为丸，如鸡子黄许大，以沸汤数合，和一丸，研碎温服之，日三四，夜二服。腹中未
热，益至三四丸，然不及汤。汤法以四物，根据两数切，用水八升，煮取三升，去滓，温服一升，日三服。
加减法∶若脐上筑者，肾气动也，去术加桂四两。吐多者，去术加生姜三两。下多者，还用术；悸者，加
茯苓二两。渴欲得水者，加术，足前成四两半。腹中痛者，加人参，足前成四两半。寒者，加干姜，足前成四
两半。腹满者，去术加附子一枚。服汤后，如食顷，饮热粥一升许，微自温，勿发揭衣被。
【集解】程应旄曰∶阳之动，始于温，温气得而谷精运，谷气升而中气赡，故名曰理中，实以燮理之功，
予中焦之阳也。盖谓阳虚即中气失守，膻中无发宣之用，六腑无洒陈之功，犹如釜薪失焰，故下至清谷，上失
滋味，五脏凌夺，诸证所由来也。参、术、炙草，所以守中州，干姜辛以温中，必假之以燃釜薪而腾阳气，是
以谷入于阴，长气于阳，上输华盖，下摄州都，五脏六腑皆受气矣，此理中之旨也。若水寒互胜，即当脾肾双
温，加之以附子，则命门益而土母温矣。白术补脾，得人参则壅气，故脐下动气，吐多腹满，皆去术也。加桂
以伐肾邪，加生姜以止呕也，加附子以消阴也。下多者，湿胜也，还用术燥湿也。渴欲饮水，饮渴也，加术使
饮化津生也。心下悸，停水也，加茯苓导水也。腹中痛，倍人参，虚痛也。寒者，加干姜，寒甚也。
伤寒，本自寒下，医复吐下之，寒格更逆吐下，若食入口即吐，干姜黄连黄芩人参汤主之。
【按】经论中并无寒下之病，亦无寒下之文。玩本条下文，寒格更逆吐下，可知寒下之“下”字，当是
“格”字，文义始相属。注家皆释胃寒下利，不但文义不属，且与芩、连之药不合。
【注】经曰∶格则吐逆。格者，吐逆之病名也。朝食暮吐，脾寒格也；食入即吐，胃热格也。本自寒格，
谓其人本自有朝食暮吐
寒格之病也。今病伤寒，医见可吐、可下之证，遂执成法，复行吐、下，是寒格更逆于吐下也，当以理中汤温
其太阴，加丁香降其寒逆可也。若食入口即吐，则非寒格乃热格也，当用干姜、人参安胃，黄连、黄芩降胃火也。
干姜黄连黄芩人参汤方
干姜 黄连 黄芩 人参（各三两）
上四味，以水六升，煮取二升，去滓，分温再服。
伤寒，医下之，续得下利清谷不止，身疼痛者，急当救里；后身疼痛，清便自调者，急当救表。救里宜四
逆汤，救表宜桂枝汤。
【注】伤寒，医不分表里、寒热、虚实而误下之，续得下利清谷不止者，寒其里也。虽有通身疼痛之表未
除，但下利清谷不止，里寒已盛，法当急救其里；俟便利自调，仍身疼痛不止，再救其表可也。救里宜四逆汤，
温中胜寒；救表宜桂枝汤，调营和卫也。
【集注】王三阳曰∶此证当照顾协热利，须审其利之色何如？与势之缓急，不可轻投四逆、桂枝也。
喻昌曰∶攻里必须先表后里，始无倒行逆施之患。惟在里之阴寒极盛，不得不急救其里，俟里证稍定，仍
救其表，盖谓救里后再行救表也。
下利清谷，不可攻表，汗出必胀满。
【注】此详上条不先救里而发其表，以明太阴、少阴同病之证也。下利清谷，太阴寒邪已传少阴，即有身
痛不可攻表。若误攻其表，即使汗出，太阳表解而太阴寒凝，必胀满矣。
下利，腹胀满，身体疼痛者，先温其里，乃攻其表，温里宜四逆汤，攻表宜桂枝汤。
【注】此承上条互发其证，以明先里后表之治也。下利腹胀满者，里寒邪也；身体疼痛者，表寒邪也。凡
表里寒邪之证同见，总以温里为急。故当先温其里，后攻其表，温里宜四逆汤，攻表宜桂枝汤。
【集注】方有执曰∶里虚表实，惟其虚也，故必先之，惟其实也，故可后焉。
发汗后，腹胀满者，浓朴生姜半夏甘草人参汤主之。
【注】发汗后表已解而腹满者，太阴里虚之胀满也。故以浓朴生姜甘草半夏人参汤主之。消胀散满，补中
降逆也。
【集注】成无己曰∶吐后胀满，与下后胀满，皆为实者，言邪气乘虚入里而为实也。发汗后则外已解，腹
胀满知非里实，由太阴不足，脾气不通，故壅而为满也。与此汤和脾胃而降逆气宜矣。
汪琥曰∶此条乃汗后气虚腹胀满，其人虽作胀满而内无实形，所以用人参、炙甘草等甘温补药无疑也。
张锡驹曰∶此言发汗而伤其脾气也。脾主腹，故腹满为太阴主病。发汗后而腹胀满，则知其人脾气素虚，
今脾气愈虚，则不能转输，浊气不降，清气不升，而胀满作矣。
浓朴生姜半夏甘草人参汤方
浓朴（炙，去皮，半斤） 生姜（切，半斤） 半夏（洗，半升） 甘草（炙，二两） 人参（一两）
上五味，以水一斗，煮取三升，去滓，温服一升，日三服。
发汗不解，腹满痛者，急下之，宜大承气汤。腹满不减，减不足言，当下之，宜大承气汤。
【注】此详申上条，互发其义，以别其治也。发汗后表已解，腹满不痛者，乃腹满时减，减复如故之虚满
也，当温之，浓朴生姜半夏甘草人参汤证也。今发汗后表不解，腹满大痛者，乃腹满不减，减不足言之实满也，
当下之，宜大承气汤，盖以里急，先攻里后和表也。
【集注】喻昌曰∶“减不足言”四字，形容腹满如绘。见满至十分，即减去一二分，不足杀其势也。此所
以纵有外邪末解，而当下无疑耳！
程应旄曰∶下之而腹满如故，即减去一二分，算不得减。下之不妨再下，必当以减尽为度也。
刘宏璧曰∶太阴无可下之法也，设在经则各经已无可下之理，在脏则太阴尤无受下之处，桂枝加大黄汤安
能无疑乎？不知脾与胃相表里也，太阳误下，太阴受邪，适胃有宿食，则脾因胃之实而实，亦即因太阳之邪而
痛矣。既大满大痛，已成胃实，又非此汤之所能治，故宜大承气汤也。
太阴病，脉浮者，可发汗，宜桂枝汤。
【注】太阴经病，脉当浮缓；太阴脏病，脉当沉缓。今邪至太阴，脉浮不缓者，知太阳表邪犹未全罢也。
故即有吐利不食，腹满时痛一二证，其脉不沉而浮，便可以桂枝发汗，先解其外，俟外解已再调其内可也。于
此又可知论中，身痛腹满下利，急先救里者，脉必不浮矣。
【集注】王肯堂曰∶病在太阳脉浮无汗，宜麻黄汤。此脉浮当亦无汗，而不言者，谓阴不得有汗，不必言
也，不用麻黄汤而用桂枝汤。盖以三阴兼表病者，俱不当大发汗也，须识无汗亦有用桂枝者。
程知曰∶此言太阴宜散者也。太阴病，谓有腹痛下利证也。太阳脉，尺寸俱浮，今脉浮则邪还于表可知矣，
故宜用桂枝解散。不用麻黄者，阴病不得大发其汗也，桂枝汤有和里之意焉。
程应旄曰∶此太阴中之太阳也，虽有里病，仍从太阳表治，方不引邪入脏。
本太阳病，医反下之，因而腹满时痛者，属太阴也，桂枝加芍药汤主之。大实痛者，桂枝加大黄汤主之。
【注】本太阳中风病，医不以桂枝汤发之而反下之，因而邪陷入里，余无他证，惟腹满时痛者，此属太
阴里虚痛也，故宜桂枝加芍药汤以外解太阳之表，而内调太阴之里虚也。若大满实痛，则属太阴热化，胃实痛
也，故宜桂枝加大黄汤以外解太阳之表，而内攻太阴之里实也。
【集注】赵嗣真曰∶太阴腹满证有三∶有次第传经之邪，有直入中寒之邪，有下后内陷之邪，不可不辨。
喻昌曰∶太阳病之误下，其变皆在胸胁以上。此之误下而腹满时痛，无胸胁等证，则其邪已入阴位，所
以属在太阴也。仍用桂枝解肌之法，以升发太阳之邪，倍芍药者以调太阴之气，本方不增一药，斯为神耳！大
实、大满宜从急下，然阳分之邪初陷太阴，未可峻攻，但于桂枝汤中少加大黄，七表三里，以分杀其邪，与大
柴胡汤同其义也。
程应旄曰∶误下太阳而成腹满时痛，太阴之证见矣。然表邪内陷，留滞于太阴，非脏寒病也。仍用桂枝汤
升发阳邪，但倍芍药以调和之。倘大实而痛，于证似可急下，然阴实而非阳实，仍从桂枝例升发阳邪，但加
大黄以破结滞之物，使表里两邪各有去路，则寒随实去，不温而自温矣。然此二证虽属之太阴，实从太阳传来，
则脉必尚浮可知。
桂枝加芍药汤方
于桂枝汤方内，更加芍药三两，随前共六两，余根据桂枝汤法。
桂枝加大黄汤方
六气（风、寒、暑、湿、燥、火）的邪气，虽然感染人的途径相同，但人受邪后所患的疾病却各不相同，这是为什么呢？这是因为人的形体有肥瘦厚薄之分，正气有盛衰之别，脏腑有寒热之异，所受之邪，往往随着人体脏腑之气而发生转化，所以产生的疾病各不相同。因此，有的转化为虚证，有的转化为实证，有的转化为寒证，有的转化为热证。这就好比水火关系一样，水势强盛则火势熄灭，火势强盛则水分耗竭，事物强盛的一方会主导转化，道理本来就是这样的。如果真正明白了这个道理，还有什么可怀疑的呢？难道会因为阳邪传入阴经，由寒转热或由热转寒的变化而感到奇怪吗！
从后汉到现在，一千多年来，人们都认为是三阴经的寒邪不会传变，并且把伤寒传经过程中的阴邪，称为“直中”（病邪不经三阳经，直接侵犯三阴经）。殊不知“直中”乃是中寒的证候，并非传经之邪！这都是因为未曾熟读张仲景的著作，所以才产生这种误解！例如《伤寒论》中说：下利、腹胀满、身体疼痛的，应当先温补里虚，然后再解表邪。温里适宜用四逆汤，解表适宜用桂枝汤。这是三阳经的阳邪传入太阴，邪气随阴经属性而化为寒证的例子。又如少阴病出现下利，用白通汤主治，这是太阴的寒邪传入少阴的寒证；如果出现下利清谷（大便中有未消化的食物）、内寒外热、出汗且四肢厥冷，用通脉四逆汤主治，这是少阴的寒邪传入厥阴的寒证。这些都有据可查，怎么能说伤寒中阴经之间不互相传变，没有阳随阴化或阴随阳化的道理呢？
太阴属湿土，是纯阴的脏腑，所以病邪一旦进入太阴，随阴经属性转化的情况多，随阳经属性转化的情况少。随阴经转化的，如《伤寒论》中所说的腹满、呕吐饮食、自发性腹泻、口不渴、手足自然温暖、时常腹部自发疼痛，适宜服用理中丸、四逆汤之类的方剂。随阳经转化的，如《伤寒论》中所说的发汗后病不解，出现腹部胀满疼痛的，应当紧急攻下，适宜用大承气汤；如果腹部胀满且剧烈疼痛的，适宜用桂枝加大黄汤主治。这是因为脾与胃同处腹腔之中，所以腹满和腹痛两种症状都会出现。然而，腹满是太阴经的主要病症，心下（胃脘部）胀满是阳明经的主要病症。阳明经也有腹满的情况，是因为阳明腹满与热邪共同作用，所以必然伴有潮热、自汗、大便不通的症状，而不像太阴经与湿邪共同作用，会出现发黄、突然烦躁、排泄秽浊腐臭之物等症状。如果能进一步在腹痛、剧烈腹痛、腹满疼痛的部位，详细审察虚实，斟酌使用温法或下法，就没有什么遗漏的了。所以用这些来概括，就能掌握太阴病的要领了。
太阴病的提纲证是：腹部胀满且呕吐，饮食难以下咽，自发性腹泻日益严重，时常腹部自发疼痛。如果误用攻下法，必然导致胸膈下方痞结坚硬。
【按语】吴人驹说：“自利益甚”这四个字，应当放在“必胸下结硬”这句话的下面，他的说法非常正确。如果放在“吐食不下”这句话的下面，那就是已经呕吐、饮食难下，然后腹泻日益严重了。张仲景接着又说如果误用攻下法，那就没有什么意义了。
【注释】太阴，指脾经。其经脉布散于胃中，联络于咽喉。寒邪传入太阴，所以腹部胀满、时常腹部自发疼痛；寒邪顺着经脉侵犯胃腑，所以呕吐、饮食难下。这是太阴里虚，邪气随寒转化的证候，应当用理中丸、四逆汤之类的方剂进行温补。如果腹部胀满、咽喉干燥、大便不通、剧烈疼痛，这才是太阴里实，邪气随热转化的证候，应当用桂枝加大黄汤攻下。如果把太阴虚寒引起的胀满疼痛，误认为是太阴实热引起的胀满疼痛而使用攻下法，那么寒邪与虚损相互搏结，必然会变为脏结痞硬，以及腹泻日益严重的后果。这是太阴病全篇的提纲，后世凡是提到太阴病的，都是指这种证候而言。
【集注】程应旄说：阳邪也会有腹满，如果是得呕吐后胀满消除且能进食的，现在的腹满伴随呕吐、饮食难下，说明胀满是寒胀，呕吐是寒格拒。阳邪也会有下利腹痛，如果是得利后疼痛随之减轻的，现在的下利伴随时常腹部自发疼痛，说明下利是寒利，疼痛是寒痛。所谓“胸下”，是指阴邪结聚在胸下的阴分，不同于阳邪结胸在胸部，而且按压时会疼痛。所谓“结硬”，是因为没有阳气来化气，所以变成坚硬的阴实，不同于痞证的濡软。那些（阳邪结胸）都是阳气从上陷入而阻留，这（阴邪结硬）则是阴气从下上逆而不能归位，寒热的区别非常大。
吴人驹说：自发性腹泻有时发生，且腹部自发疼痛，不像积蓄已久的疼痛那样持续不断。如果把各种疼痛都当作实证，从而使用攻下法，胀满会更加严重，必然导致胸下全部变成结硬，且腹泻日益严重。
伤寒病四五日，腹部疼痛，如果有肠鸣气向下趋向少腹的感觉，这是将要发生自发性腹泻的征兆。
【注释】伤寒病四五日，是邪气传入太阴的时候。腹部疼痛，如果没有肠鸣气向下趋向少腹的感觉，属于阳明病。现在腹部疼痛，且有肠鸣气向下趋向少腹，这是太阴病将要发生自发性腹泻的征候。这是张仲景提示人们不能把所有疼痛都当作实证而妄加攻下的意思。
【集注】方有执说：腹部疼痛且肠鸣气向下趋向，是里虚不能固守，寒邪向下逼迫所致。
张璐说：腹痛也有属于火（热）的，其疼痛必然是自下而上攻冲。如果疼痛是自上而下趋向的，一定属于寒痛无疑。
魏荔彤说：这一条重在预防下利，而不是辨别寒热。玩味“若”字、“欲”字，可以看出辨别寒邪自有其他方法。
自发性腹泻且不口渴的，属于太阴病，因为脏腑内有寒的缘故，应当温补，适宜服用四逆汤之类的方剂。
【注释】凡是自发性腹泻且口渴的，是有热在里，属于阳证。如果自发性腹泻且不口渴，就是有寒在里，属于阴证。现在自发性腹泻且不口渴，知道是太阴本脏有寒，所以应当温补。四逆辈，指的是四逆汤、理中丸、附子汤等方剂。
【集注】程知说：这里说的是太阴自发性腹泻属于寒证，适宜温补。少阴属肾水，热邪侵入会耗伤肾水，所以自发性腹泻且口渴。太阴属脾土，寒邪侵入会顺应湿气，所以不口渴而腹泻，因此太阴自发性腹泻应当温补。
程应旄说：三阴经都属脏寒，少阴、厥阴有口渴的证候，唯独太阴没有口渴证候，是因为寒在中焦，总与龙雷之火无关。少阴中有龙火，底寒严重时龙火上升，所以自发性腹泻且口渴；厥阴中有雷火，所以有消渴症。太阳经一照到雷雨就收声，所以发热时腹泻停止，见到四肢厥冷又腹泻。
魏荔彤说：“自发性腹泻”这几个字，是指未经过误下、误汗、误吐而形成的，所以知道其脏腑本来就有寒。
理中丸方
人参、白术、甘草（炙）、干姜（各三两）
以上四味药，捣碎过筛，用蜂蜜调和做成丸药，大小如鸡蛋黄，用沸水几合，溶化一丸，研碎后温服，每天三四次，夜间两次。如果腹中感觉不到温热，增加到每次三四丸，但这不如汤剂效果好。汤剂的用法是将这四味药，按照规定的分量切碎，用水八升，煮取三升，去渣，温服一升，每天三次。
加减法：如果脐上跳动不安的，是肾气动，去掉白术，加桂枝四两。呕吐多的，去掉白术，加生姜三两。腹泻多的，仍用白术；心悸的，加茯苓二两。想喝水的，增加白术，使总量达到四两半。腹部疼痛的，增加人参，使总量达到四两半。寒重的，增加干姜，使总量达到四两半。腹部胀满的，去掉白术，加附子一枚。服药后，大约一顿饭的时间，喝热粥一升左右，使身体微微温暖，不要掀开衣被。
【集解】程应旄说：阳气的活动，始于温暖，温暖的气机得到运行，谷精才能运化，谷气上升则中气充足，所以名叫理中，实际上是运用燮理的功效，给予中焦阳气。大概意思是阳气虚弱就是中气失守，膻中失去宣发之用，六腑失去洒陈之功，就像锅灶失去了火焰，所以下至完谷不化，上至味觉丧失，五脏受到凌夺，各种证候由此产生。人参、白术、炙甘草，用来守住中州；干姜辛热以温中，必须借助它来点燃锅灶的柴薪而腾起阳气，因此谷物进入阴分，在阳分生长气机，向上输送到华盖（肺），向下摄持州都（膀胱），五脏六腑都受到了滋养，这就是理中丸的宗旨。如果水寒互相胜负，就应当脾肾双温，加上附子，那么命门就会受益，土母（脾）就会温暖。白术补脾，得到人参就会壅滞气机，所以脐下动气、呕吐多、腹部胀满，都要去掉白术。加桂枝以伐肾邪，加生姜以止呕，加附子以消阴。腹泻多的是湿胜，仍用白术燥湿。想喝水，是饮停致渴，加白术使饮水化生津液。心下悸动，是水饮停留，加茯苓导水。腹部疼痛，倍用人参，是虚痛。寒重，加干姜，是寒甚。
伤寒病人，本来就有寒性腹泻，医生反而使用吐法或下法，导致寒邪格拒，更加逆乱出现呕吐腹泻，如果食物入口立即吐出，用干姜黄连黄芩人参汤主治。
【按语】经典论述中没有寒下这种病，也没有寒下的文字。玩味本条下文，“寒格更逆吐下”，可知寒下之“下”字，应当是“格”字，文义才连贯。注家都解释为胃寒下利，不但文义不连贯，而且与黄芩、黄连的药性不合。
【注释】经文说：格则吐逆。格，是吐逆的病名。早晨吃晚上吐，是脾寒格拒；食物入口即吐，是胃热格拒。本来就有寒格，是说这个人本来就有早晨吃晚上吐的寒格病。现在得了伤寒，医生看到可以吐、可以下的证候，就拘泥于成法，再次使用吐、下法，这使得寒格更加逆乱于吐下之中，应当用理中汤温补太阴，加丁香降逆止寒即可。如果食物入口立即吐出，那就不是寒格而是热格了，应当用干姜、人参安胃，黄连、黄芩清降胃火。
干姜黄连黄芩人参汤方
干姜、黄连、黄芩、人参（各三两）
以上四味药，用水六升，煮取二升，去渣，分两次温服。
伤寒病，医生使用下法，随后出现下利清谷不止，身体疼痛的，应当紧急救治里虚；后来身体仍然疼痛，大小便正常的，应当紧急救治表邪。救治里虚适宜用四逆汤，救治表邪适宜用桂枝汤。
【注释】伤寒病，医生不分表里、寒热、虚实而误用下法，随后出现下利清谷不止的，是里寒。虽然有全身疼痛的表证未除，但只要下利清谷不止，里寒已经盛极，依法应当急救其里；等到大小便正常，仍然身体疼痛不止，再救治其表即可。救治里虚适宜用四逆汤，温中胜寒；救治表邪适宜用桂枝汤，调和营卫。
【集注】王三阳说：这个证候应当照顾协热利，必须审查腹泻的颜色如何？以及势头的缓急，不可轻易投用四逆汤、桂枝汤。
喻昌说：攻里必须先解表后攻里，始无倒行逆施的祸患。只有在里的阴寒极盛，不得不急救其里，等到里证稍微稳定，再救治其表，这里说的是救里后再行救表。
下利清谷，不可攻表，发汗必然导致腹部胀满。
【注释】这是详细说明上一条不先救里而先发其表，以阐明太阴、少阴同病的证候。下利清谷，是太阴寒邪已传入少阴，即使有身体疼痛也不可以攻表。如果误攻其表，即使出汗，太阳表证解除而太阴寒凝，必然导致腹部胀满。
下利，腹部胀满，身体疼痛的，先温补其里，然后再解其表。温补里虚适宜用四逆汤，解表适宜用桂枝汤。
【注释】这是承接上一条互发其意，以阐明先治里后治表的治法。下利腹部胀满，是里寒邪；身体疼痛，是表寒邪。凡是表里寒邪的证候同时出现，总以温里为急务。所以应当先温补其里，后攻解其表，温补里虚适宜用四逆汤，解表适宜用桂枝汤。
【集注】方有执说：里虚表实，正因为里虚，所以必须先治里；正因为表实，所以可以后治表。
发汗后，出现腹部胀满的，用浓朴生姜半夏甘草人参汤主治。
【注释】发汗后表证已解而出现腹部胀满的，是太阴里虚的胀满。所以用浓朴生姜半夏甘草人参汤主治。作用是消胀散满，补中降逆。
【集注】成无己说：呕吐后胀满，和下法后胀满，都属于实证，是说邪气乘虚入里成为实证。发汗后则外邪已解，腹部胀满知道不是里实，是由于太阴不足，脾气不通，所以壅滞而成胀满。与此汤调和脾胃而降逆气是适宜的。
汪琥说：这一条是发汗后气虚导致的腹部胀满，其人虽然感到胀满但内部没有实形，所以用人参、炙甘草等甘温补药是毫无疑问的。
张锡驹说：这里说的是发汗损伤了脾气。脾主腹，所以腹满是太阴的主要病症。发汗后出现腹部胀满，就知道此人脾气素来虚弱，现在脾气更加虚弱，就不能转输，浊气不降，清气不升，从而产生胀满。
浓朴生姜半夏甘草人参汤方
浓朴（炙，去皮，半斤）、生姜（切，半斤）、半夏（洗，半升）、甘草（炙，二两）、人参（一两）
以上五味药，用水一斗，煮取三升，去渣，温服一升，每天三次。
发汗后病不解，腹部胀满疼痛的，紧急攻下，适宜用大承气汤。腹部胀满不减轻，即使减轻也微不足道，应当攻下，适宜用大承气汤。
【注释】这是详细申述上一条，互发其意，以区别治法。发汗后表证已解，腹部胀满但不痛的，是腹部胀满时而减轻，减轻后又恢复原状的虚满，应当温补，是浓朴生姜半夏甘草人参汤的证候。现在发汗后表证未解，腹部胀满且剧烈疼痛的，是腹部胀满不减轻，即使减轻也微不足道的实满，应当攻下，适宜用大承气汤，这是因为里急，先攻里后和表。
【集注】喻昌说：“减不足言”这四个字，形容腹部胀满如在眼前。见胀满到了十分，即使减去一二分，也不足以削弱其势头。这就是为什么纵然有外邪未解，也应当攻下无疑的原因！
程应旄说：攻下后腹部胀满如故，即使减去一二分，也算不上减轻。攻下不妨再攻下，必须以胀满完全消除为限度。
刘宏璧说：太阴病没有可下的方法。如果在经络，各经都已经没有可下的道理；在脏腑，太阴尤其没有承受攻下的地方，桂枝加大黄汤难道不让人怀疑吗？不知道脾与胃相表里。太阳病误下，太阴受邪，恰好胃中有宿食，那么脾因胃的实证而变得实证，也就是因太阳的邪气而疼痛。既然已经大满大痛，已成胃实，又不是桂枝加大黄汤所能治疗的，所以适宜用大承气汤。
太阴病，脉浮的，可以发汗，适宜用桂枝汤。
【注释】太阴经病，脉应当浮缓；太阴脏病，脉应当沉缓。现在邪气到达太阴，脉浮而不缓，知道太阳表邪还没有完全罢休。所以即使有呕吐、腹泻、不食、腹部胀满、时常疼痛等一两个证候，只要脉不沉而浮，就可以用桂枝汤发汗，先解其外，等到外证解除后再调理其内。从这里又可以知道，《伤寒论》中说身痛、腹满、下利，紧急先救里的，脉一定不浮。
【集注】王肯堂说：病在太阳，脉浮无汗，适宜用麻黄汤。这里脉浮也应该无汗，但不说的原因，是说阴经不得有汗，不必说也，不用麻黄汤而用桂枝汤。大概因为三阴兼表病者，都不应当大发汗，须要知道无汗也有用桂枝汤的情况。
程知说：这里说的是太阴适宜疏散。太阴病，指有腹痛下利的证候。太阳脉，尺寸俱浮，现在脉浮，说明邪气还在于表，可知适宜用桂枝解散。不用麻黄的原因，是阴病不得大发其汗，桂枝汤有和里的意思在里面。
程应旄说：这是太阴中的太阳病，虽然有里病，仍然从太阳表证治疗，才不会引邪入脏。
原本太阳病，医生反而使用下法，因而出现腹部胀满、时常疼痛的，属于太阴病，用桂枝加芍药汤主治。出现大实疼痛的，用桂枝加大黄汤主治。
【注释】原本是太阳中风病，医生不用桂枝汤发汗反而使用下法，因而邪气陷入里，没有其他证候，只有腹部胀满、时常疼痛的，这属于太阴里虚痛，所以适宜用桂枝加芍药汤，外解太阳之表，内调太阴之里虚。如果大满实痛，则属于太阴热化，胃实痛，所以适宜用桂枝加大黄汤，外解太阳之表，内攻太阴之里实。
【集注】赵嗣真说：太阴腹满证有三类：有次第传经的邪气，有直入中寒的邪气，有下后内陷的邪气，不可不辨别。
喻昌说：太阳病误下，其变证都在胸胁以上。这里的误下导致腹部胀满、时常疼痛，没有胸胁等证候，说明邪气已经进入阴位，所以属于太阴。仍然用桂枝解肌的方法，以升发太阳之邪，加倍芍药是为了调顺太阴之气，原方不增加一味药，这才是神妙之处！大实、大满应当从急下，但阳分之邪初陷太阴，不可峻猛攻下，只在桂枝汤中稍加大黄，七表三里，以分杀其邪，与大柴胡汤的意义相同。
程应旄说：误下太阳而成腹部胀满、时常疼痛，太阴的证候出现了。然而表邪内陷，留滞于太阴，不是脏寒病。仍然用桂枝汤升发阳邪，只是加倍芍药以调和它。倘若大实而痛，在证候上似乎可以急下，但这是阴实而非阳实，仍然遵循桂枝例升发阳邪，只是加入大黄以破除结滞之物，使表里两邪各有去路，那么寒随实去，不温而自温了。然而这两个证候虽然属于太阴，实际上是从太阳传来，那么脉一定还浮着，这是显而易见的。
桂枝加芍药汤方
在桂枝汤方内，再加芍药三两，连同前面的共六两，其余依照桂枝汤的方法。
桂枝加大黄汤方
The pathogenic factors of the Six Qi (Wind, Cold, Summer-heat, Dampness, Dryness, Fire), although infecting people through the same pathways, cause different diseases in different individuals. Why is this? It is because people's constitutions vary in thickness and thinness, their Zheng Qi (Vital Energy) differs in strength and weakness, and their Zang-Fu organs differ in cold and heat. The pathogenic factors received often transform according to the Qi of the person's Zang-Fu organs; thus, the diseases produced are different. Therefore, some transform into deficiency patterns, some into excess patterns, some into cold patterns, and some into heat patterns. This is like the relationship between water and fire: when water is abundant, fire is extinguished; when fire is abundant, water is consumed. When one aspect is dominant, it dictates the transformation; this is the natural principle. If one truly understands this, what is there to doubt? Should one be surprised that Yang pathogens transmit to Yin meridians, transforming from cold to heat or vice versa?
From the Later Han Dynasty to the present day, spanning a thousand years, people have claimed that Cold pathogens of the Three Yin meridians do not transmit. Furthermore, they refer to Yin pathogens transmitting via the meridian sequence in Shanghan (Cold Damage) as "Direct Invasion" (Zhizhong, where pathogens bypass the Three Yang meridians and directly invade the Three Yin meridians). Little do they know that "Direct Invasion" refers to the syndrome of Cold Strike, not transmission via meridians! These errors arise from a failure to thoroughly study the works of Zhang Zhongjing. For instance, in the Treatise, it states: for symptoms of diarrhea, abdominal fullness, and body pain, one should first warm the interior, then attack the exterior. Warming the interior is suitable with Sini Tang (Frigid Extremities Decoction), and attacking the exterior is suitable with Guizhi Tang (Cinnamon Twig Decoction). This is an example of Yang pathogens from the Three Yang meridians transmitting to Taiyin, where the pathogen transforms into a cold pattern following the nature of the Yin meridian. Again, for Shaoyin disease presenting with diarrhea, Baicong Tang (Scallion Decoction) is the primary treatment; this is a cold pattern where Taiyin cold pathogens transmit to Shaoyin. If there is diarrhea with undigested food, interior cold with exterior heat, sweating, and cold extremities, Tongmai Sini Tang (Pulse-Recovering Frigid Extremities Decoction) is the primary treatment; this is a cold pattern where Shaoyin cold pathogens transmit to Jueyin. All these are well-documented. How can one claim that Yin meridians do not transmit to each other in Shanghan, denying the principles of Yang transforming into Yin or Yin transforming into Yang?
Taiyin belongs to Wet Earth and is a purely Yin organ. Therefore, once a pathogen enters Taiyin, transformations following the Yin nature are common, while those following the Yang nature are rare. Transformations following the Yin nature include, as stated in the Treatise: abdominal fullness, vomiting of food, spontaneous diarrhea, lack of thirst, naturally warm hands and feet, and occasional spontaneous abdominal pain. These are suitable for treatment with Lizhong Wan (Regulate the Middle Pill) or Sini Tang. Transformations following the Yang nature include, as stated in the Treatise: after sweating, if the disease persists with abdominal fullness and pain, urgent purgation is required, suitable for Dachengqi Tang (Major Order the Qi Decoction); if there is significant abdominal fullness and severe pain, Guizhi Jiadahuang Tang (Cinnamon Twig Decoction with Added Rhubarb) is the primary treatment. This is because the Spleen and Stomach reside together in the abdomen, so both abdominal fullness and pain occur. However, abdominal fullness is the principal disease of Taiyin, while subcostal/fullness in the heart region (epigastrium) is the principal disease of Yangming. Although Yangming also presents with abdominal fullness, it transforms with Heat; thus, it must be accompanied by tidal fever, spontaneous sweating, and constipation. This differs from Taiyin, which transforms with Dampness, presenting with jaundice, sudden irritability, and diarrhea of foul-smelling waste. If one carefully examines the deficiency and excess at the sites of abdominal pain, severe pain, and fullness, and judiciously applies warming or purging methods, nothing will be left unaddressed. Thus, summarizing these points allows one to grasp the essential methods of Taiyin disease.
The outline syndrome of Taiyin disease is: abdominal fullness with vomiting, inability to eat, worsening spontaneous diarrhea, and occasional spontaneous abdominal pain. If treated with purgation, it will inevitably lead to hardness and knotting below the chest.
[Commentary] Wu Renju said: The phrase "worsening spontaneous diarrhea" should follow the sentence "inevitably leads to hardness and knotting below the chest." His view is correct. If placed after "vomiting and inability to eat," it implies that vomiting and inability to eat have already occurred, followed by worsening diarrhea. Then Zhang Zhongjing adds, "if treated with purgation," which would be meaningless.
[Annotation] Taiyin refers to the Spleen Meridian. Its vessels spread through the stomach and connect to the throat. When Cold pathogens transmit to Taiyin, abdominal fullness and occasional spontaneous abdominal pain occur. When Cold pathogens follow the vessels to invade the Stomach, vomiting and inability to eat occur. This is a syndrome of Taiyin interior deficiency with pathogen transforming into cold, suitable for warming with Lizhong Wan or Sini Tang. If there is abdominal fullness, dry throat, constipation, and severe pain, this is a syndrome of Taiyin interior excess with pathogen transforming into heat, suitable for purging with Guizhi Jiadahuang Tang. If one mistakes the fullness and pain of Taiyin deficiency-cold for excess-heat and uses purgation, Cold and Deficiency will contend, leading to Zang-Jie (organ knotting) and痞硬 (stiff palpitations/knotting), as well as worsening spontaneous diarrhea. This is the outline for the entire chapter on Taiyin disease; subsequent mentions of Taiyin disease refer to this syndrome.
[Collected Annotations] Cheng Yingmao said: Yang pathogens can also cause abdominal fullness. If vomiting relieves the fullness and allows eating, that is one case. Now, with abdominal fullness, vomiting, and inability to eat, the fullness is due to Cold distension, and vomiting is due to Cold rejection. Yang pathogens can also cause diarrhea and abdominal pain. If pain decreases after defecation, that is one case. Now, with diarrhea and occasional spontaneous abdominal pain, the diarrhea is due to Cold, and the pain is due to Cold. "Below the chest" refers to Yin pathogens knotting in the Yin portion below the chest, distinct from Yang pathogens knotting in the chest, and painful upon pressure. "Knotting and hardness" occurs because without Yang to transform Qi, it becomes hard Yin, distinct from Pi (glutinous softness) which is soft. Those (Yang knotting) involve Yang sinking from above and stagnating; this involves Yin rising from below and failing to return. The distinction between Cold and Heat is great.
Wu Renju said: Spontaneous diarrhea occurring at times with spontaneous abdominal pain is not like accumulated constant pain. If one treats all pain as excess and uses purgation, the fullness will worsen, inevitably causing the area below the chest to become knotted and hard, and the spontaneous diarrhea will worsen.
In Shanghan disease, on the fourth or fifth day, if there is abdominal pain and gas moving downward toward the lower abdomen, this indicates impending spontaneous diarrhea.
[Annotation] On the fourth or fifth day of Shanghan disease, the pathogen enters Taiyin. Abdominal pain without gas moving downward toward the lower abdomen belongs to Yangming. Now, with abdominal pain and gas moving downward toward the lower abdomen, this is a sign that Taiyin is about to produce spontaneous diarrhea. This is Zhang Zhongjing indicating that one should not treat all pain as excess and recklessly use purgation.
[Collected Annotations] Fang Youzhi said: Abdominal pain with gas moving downward indicates interior deficiency unable to hold, with Cold pathogens pressing downward.
Zhang Lu said: Abdominal pain can also belong to Fire (Heat), in which case the pain attacks upward from below. If the pain trends downward from above, it is undoubtedly Cold pain.
Wei Litong said: This clause focuses on preventing diarrhea, rather than distinguishing Cold from Heat. Examining the words "if" and "impending" reveals that distinguishing Cold pathogens has its own methods.
Spontaneous diarrhea without thirst belongs to Taiyin, because the Zang organs have Cold. It should be warmed, and Sini Tang-type decoctions are suitable.
[Annotation] Generally, spontaneous diarrhea with thirst indicates Heat in the interior and belongs to Yang. Spontaneous diarrhea without thirst indicates Cold in the interior and belongs to Yin. Now, spontaneous diarrhea without thirst indicates Cold in the original Taiyin Zang, so it should be warmed. "Sini Tang-type" refers to Sini Tang, Lizhong Wan, Fuzi Tang, etc.
[Collected Annotations] Cheng Zhi said: This states that Taiyin spontaneous diarrhea is Cold and suitable for warming. Shaoyin belongs to Kidney Water; Heat invading consumes Water, causing spontaneous diarrhea with thirst. Taiyin belongs to Spleen Earth; Cold invading follows Dampness, causing no thirst but diarrhea. Thus, Taiyin spontaneous diarrhea requires warming.
Cheng Yingmao said: The Three Yin meridians all belong to Zang Cold. Shaoyin and Jueyin have thirst syndromes, but Taiyin alone does not, because the Cold is in the Middle Jiao and is unrelated to Dragon-Liver Fire. Shaoyin contains Dragon Fire; when interior Cold is severe, Dragon Fire rises, causing spontaneous diarrhea with thirst. Jueyin contains Thunder Fire, hence polydipsia. In Taiyang, thunder stops when sunlight appears; thus, fever stops diarrhea, but cold extremenss brings back diarrhea.
Wei Litong said: The term "spontaneous diarrhea" refers to cases formed without prior mistaken purgation, sweating, or vomiting, indicating that the Zang originally had Cold.
Lizhong Wan Formula
Renshen (Ginseng Radix et Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Gancao (Licorice Root, honey-fried), Ganjiang (Dried Ginger Rhizome) (each 3 liang).
Crush and sieve the four ingredients. Mix with honey to form pills the size of chicken egg yolks. Dissolve one pill in a few he of boiling water, crush, and take warm. Take 3-4 times daily and 2 times at night. If warmth is not felt in the abdomen, increase to 3-4 pills per dose. However, this is less effective than the decoction. For the decoction method, cut the four ingredients according to the specified weights. Use 8 sheng of water, boil to obtain 3 sheng, remove dregs, and take 1 sheng warm, three times daily.
Modifications: If there is throbbing above the navel, it indicates Kidney Qi movement; remove Baizhu and add Guizhi (Cinnamon Twig) 4 liang. If vomiting is excessive, remove Baizhu and add Shengjiang (Fresh Ginger Rhizome) 3 liang. If diarrhea is excessive, retain Baizhu; if palpitations occur, add Fuling (Poria) 2 liang. If there is desire to drink water, increase Baizhu to total 4.5 liang. If there is abdominal pain, increase Renshen to total 4.5 liang. If Cold is severe, increase Ganjiang to total 4.5 liang. If there is abdominal fullness, remove Baizhu and add Fuzi (Aconite Lateralis Radix Praeparata) 1 piece. After taking the medicine, approximately the time it takes to eat a meal, drink about 1 sheng of hot porridge to induce slight warmth. Do not uncover clothes or blankets.
[Collected Explanations] Cheng Yingmao said: The movement of Yang begins with warmth. When warm Qi functions, grain essence is transported; when grain Qi rises, Middle Qi is sufficient. Hence it is called "Regulate the Middle," actually bestowing regulating power to give Yang Qi to the Middle Jiao. Yang deficiency means Middle Qi fails to hold; Danzhong loses its dispersing function, and the Six Fu organs lose their sprinkling and arranging function. It is like a stove losing its flame, leading to undigested stool below and loss of taste above, with the Five Zang organs plundering each other, giving rise to various syndromes. Renshen, Baizhu, and honey-fried Gancao guard the Central State. Ganjiang is pungent and warms the middle; it must be used to ignite the stove fuel and raise Yang Qi. Thus, grain enters Yin, grows Qi in Yang, transports upward to the Huagai (Lungs), and controls the Zhoudou (Bladder), nourishing all Five Zang and Six Fu organs. This is the essence of Lizhong. If Water and Cold compete, Spleen and Kidney should be warmed simultaneously; adding Fuzi benefits the Mingmen (Gate of Life) and warms the Mother of Earth (Spleen). Baizhu tonifies Spleen but causes Qi stagnation when combined with Renshen; thus, it is removed for umbilical throbbing, excessive vomiting, and abdominal fullness. Add Guizhi to suppress Kidney pathogens, Shengjiang to stop vomiting, and Fuzi to eliminate Yin. Excessive diarrhea indicates Dampness excess; retain Baizhu to dry Dampness. Desire to drink water indicates fluid retention causing thirst; add Baizhu to transform fluids and generate Jin-Ye. Palpitations below the heart indicate water retention; add Fuling to guide out water. Abdominal pain requires doubling Renshen for deficiency pain. Severe Cold requires increasing Ganjiang.
In Shanghan disease, if the patient originally had Cold-type diarrhea, and the physician mistakenly used emesis or purgation, Cold rejection may cause further reversal of vomiting and diarrhea. If food is vomited immediately upon entering the mouth, Ganjiang Huanglian Huangqin Renshen Tang (Dried Ginger, Coptis, Scutellaria, and Ginseng Decoction) is the primary treatment.
[Commentary] The classic texts do not mention "Cold-type diarrhea" as a disease or text. Examining the following text, "Cold rejection causes further reversal of vomiting and diarrhea," it is clear that the character "Xia" (down/purgation) in "Han Xia" should be "Ge" (rejection). Only then does the meaning connect. Commentators interpret it as Stomach Cold causing diarrhea, which disconnects the text and contradicts the properties of Huangqin and Huanglian.
[Annotation] The Classic states: "Rejection leads to vomiting and reversal." Ge (Rejection) is the name of the vomiting-reversal disease. Vomiting food eaten in the morning until evening indicates Spleen Cold rejection; vomiting food immediately upon entry indicates Stomach Heat rejection. "Originally having Cold Rejection" means the person inherently suffers from morning-eating-evening-vomiting Cold Rejection. Now, contracting Shanghan, the physician sees indications for emesis or purgation and rigidly applies these methods, causing Cold Rejection to reverse further due to emesis/purgation. One should warm Taiyin with Lizhong Tang and add Dingxiang (Clove) to descend Cold reversal. If food is vomited immediately upon entry, it is not Cold Rejection but Heat Rejection. One should use Ganjiang and Renshen to calm the Stomach, and Huanglian and Huangqin to descend Stomach Fire.
Ganjiang Huanglian Huangqin Renshen Tang Formula
Ganjiang (Dried Ginger Rhizome), Huanglian (Coptis Rhizome), Huangqin (Scutellaria Root), Renshen (Ginseng Radix et Rhizoma) (each 3 liang).
Boil the four ingredients in 6 sheng of water to obtain 2 sheng. Remove dregs and divide into two warm doses.
In Shanghan disease, if the physician uses purgation, leading to continuous diarrhea with undigested food and body pain, urgent rescue of the interior is required. Later, if body pain persists but bowel movements normalize, urgent rescue of the exterior is required. Rescuing the interior is suitable with Sini Tang; rescuing the exterior is suitable with Guizhi Tang.
[Annotation] In Shanghan disease, if the physician fails to distinguish exterior/interior, cold/heat, deficiency/excess and mistakenly uses purgation, leading to continuous diarrhea with undigested food, this indicates Interior Cold. Although exterior body pain remains, continuous diarrhea with undigested food indicates severe Interior Cold. According to the law, one must urgently rescue the interior. Wait until bowel movements normalize and body pain persists, then rescue the exterior. Rescuing the interior uses Sini Tang to warm the middle and overcome Cold; rescuing the exterior uses Guizhi Tang to harmonize Ying and Wei.
[Collected Annotations] Wang Sanyang said: This syndrome should consider Xiere Li (Diarrhea with协同 Heat). One must examine the color of the diarrhea and the urgency of the condition; do not lightly administer Sini Tang or Guizhi Tang.
Yu Chang said: Attacking the interior usually requires resolving the exterior first to avoid reverse actions. Only when Interior Yin Cold is extremely severe is it necessary to urgently rescue the interior. Once the interior syndrome stabilizes, rescue the exterior again. This means rescuing the interior before rescuing the exterior.
Diarrhea with undigested food prohibits attacking the exterior; sweating will inevitably cause abdominal fullness.
[Annotation] This elaborates on the previous clause regarding not rescuing the interior first but attacking the exterior, clarifying the syndrome of simultaneous Taiyin and Shaoyin disease. Diarrhea with undigested food indicates Taiyin Cold pathogens have transmitted to Shaoyin. Even with body pain, one must not attack the exterior. If one mistakenly attacks the exterior, causing sweating, Taiyang exterior resolves but Taiyin Cold congeals, inevitably leading to abdominal fullness.
For diarrhea, abdominal fullness, and body pain, first warm the interior, then attack the exterior. Warming the interior is suitable with Sini Tang; attacking the exterior is suitable with Guizhi Tang.
[Annotation] This expands on the previous clause to clarify the treatment of treating interior first, then exterior. Diarrhea and abdominal fullness indicate Interior Cold pathogens; body pain indicates Exterior Cold pathogens. Whenever Exterior and Interior Cold pathogens present simultaneously, warming the interior is urgent. Thus, one must first warm the interior, then attack the exterior. Warming the interior uses Sini Tang; attacking the exterior uses Guizhi Tang.
[Collected Annotations] Fang Youzhi said: Interior deficiency and Exterior excess. Because of deficiency, one must treat it first; because of excess, one can treat it later.
After sweating, if abdominal fullness occurs, Nongpo Shengjiang Banxia Gancao Renshen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) is the primary treatment.
[Annotation] After sweating, if the exterior is resolved but abdominal fullness remains, this is Taiyin interior deficiency distension. Therefore, Nongpo Shengjiang Banxia Gancao Renshen Tang is used to dissipate distension, relieve fullness, tonify the middle, and descend rebellion.
[Collected Annotations] Cheng Wuji said: Fullness after vomiting and fullness after purgation are both excess, indicating pathogens entering the interior due to deficiency to become excess. After sweating, the exterior is resolved; abdominal fullness is known not to be interior excess. It arises from Taiyin insufficiency and Spleen Qi blockage, leading to stagnation and fullness. This decoction harmonizes Spleen and Stomach and descends rebellious Qi appropriately.
Wang Hu said: This clause describes abdominal fullness due to Qi deficiency after sweating. Although the patient feels full, there is no internal excess form. Thus, using Renshen and honey-fried Gancao, sweet-warm tonics, is unquestionable.
Zhang Xiqiu said: This describes damaging Spleen Qi through sweating. The Spleen governs the abdomen, so abdominal fullness is the principal disease of Taiyin. After sweating, abdominal fullness indicates the person's Spleen Qi was originally deficient. Now, with further Spleen Qi deficiency, transport fails, turbid Qi does not descend, clear Qi does not ascend, resulting in fullness.
Nongpo Shengjiang Banxia Gancao Renshen Tang Formula
Nongpo (Magnolia Bark, honey-fried, skin removed, half jin), Shengjiang (Fresh Ginger Rhizome, sliced, half jin), Banxia (Pinellia Tuber, washed, half sheng), Gancao (Licorice Root, honey-fried, 2 liang), Renshen (Ginseng Radix et Rhizoma, 1 liang).
Boil the five ingredients in 1 dou of water to obtain 3 sheng. Remove dregs and take 1 sheng warm, three times daily.
If sweating fails to resolve the disease, and abdominal fullness and pain occur, urgent purgation is required, suitable for Dachengqi Tang. If abdominal fullness does not decrease, or decreases insignificantly, purgation is required, suitable for Dachengqi Tang.
[Annotation] This elaborates on the previous clause to distinguish treatments. After sweating, if the exterior is resolved and there is abdominal fullness without pain, it is "fullness that occasionally decreases and returns," a deficiency fullness, suitable for warming with Nongpo Shengjiang Banxia Gancao Renshen Tang. Now, after sweating, if the exterior is unresolved and there is significant abdominal fullness and severe pain, it is "fullness that does not decrease, or decreases insignificantly," an excess fullness, requiring purgation with Dachengqi Tang. This is because of interior urgency; attack the interior first, then harmonize the exterior.
[Collected Annotations] Yu Chang said: The phrase "decreases insignificantly" vividly describes abdominal fullness. Seeing fullness reach ten parts, reducing it by one or two parts is insufficient to curb its momentum. This is why, despite unresolved exterior pathogens, purgation is undoubtedly indicated!
Cheng Yingmao said: If purgation leaves abdominal fullness unchanged, even reducing it by one or two parts does not count as reduction. Purgation may be repeated until fullness is completely eliminated.
Liu Hongbi said: There is no method for purgation in Taiyin disease. If in the meridians, no meridian has a basis for purgation; in the Zang organs, Taiyin especially cannot accept purgation. Is Guizhi Jiadahuang Tang not doubtful? One must understand that Spleen and Stomach are exterior-interior partners. Taiyang mistaken purgation harms Taiyin. If the Stomach has retained food, the Spleen becomes excess due to the Stomach's excess, and pain arises from Taiyang pathogens. Since there is major fullness and severe pain, forming Stomach excess, this decoction cannot treat it; thus, Dachengqi Tang is suitable.
In Taiyin disease, if the pulse is floating, sweating may be used, suitable with Guizhi Tang.
[Annotation] In Taiyin Meridian disease, the pulse should be floating and slow; in Taiyin Zang disease, the pulse should be deep and slow. Now, with pathogens reaching Taiyin, the pulse is floating but not slow, indicating Taiyang exterior pathogens have not fully subsided. Thus, even with one or two symptoms like vomiting, diarrhea, anorexia, abdominal fullness, and occasional pain, if the pulse is floating rather than deep, one can use Guizhi Tang to sweat and resolve the exterior first. Wait for exterior resolution before regulating the interior. From this, we know that in the Treatise, cases of body pain, abdominal fullness, and diarrhea requiring urgent interior rescue have pulses that are definitely not floating.
[Collected Annotations] Wang Kentang said: In Taiyang disease with floating pulse and no sweating, Mahuang Tang is suitable. Here, with floating pulse, there should also be no sweating, but it is not mentioned because Yin meridians do not typically sweat, so it need not be said. Guizhi Tang is used instead of Mahuang Tang. Generally, for Three Yin diseases with exterior involvement, heavy sweating is inappropriate. Note that Guizhi Tang can be used even without sweating.
Cheng Zhi said: This discusses dispersing in Taiyin. Taiyin disease refers to syndromes with abdominal pain and diarrhea. Taiyang pulse is floating at both Cun and Chi positions. Now, with floating pulse, pathogens returning to the exterior are evident, so Guizhi is suitable for dispersion. Mahuang is not used because Yin diseases should not be heavily sweated; Guizhi Tang contains the intent of harmonizing the interior.
Cheng Yingmao said: This is Taiyang within Taiyin. Although there is interior disease, treating it from the Taiyang exterior prevents drawing pathogens into the Zang.
Originally Taiyang disease, if the physician mistakenly uses purgation, leading to abdominal fullness and occasional pain, it belongs to Taiyin. Guizhi Jiashaoyao Tang (Cinnamon Twig Decoction with Added Peony) is the primary treatment. For severe excess pain, Guizhi Jiadahuang Tang (Cinnamon Twig Decoction with Added Rhubarb) is the primary treatment.
[Annotation] Originally Taiyang Wind Strike disease, if the physician fails to use Guizhi Tang to sweat and mistakenly uses purgation, pathogens sink into the interior. With no other symptoms except abdominal fullness and occasional pain, this belongs to Taiyin interior deficiency pain. Thus, Guizhi Jiashaoyao Tang is suitable to externally resolve Taiyang exterior and internally regulate Taiyin interior deficiency. If there is major fullness and excess pain, it belongs to Taiyin heat transformation and Stomach excess pain. Thus, Guizhi Jiadahuang Tang is suitable to externally resolve Taiyang exterior and internally attack Taiyin interior excess.
[Collected Annotations] Zhao Sizhen said: There are three types of Taiyin abdominal fullness: pathogens transmitting sequentially via meridians, Cold pathogens directly entering the middle, and pathogens sinking inward after purgation. These must be distinguished.
Yu Chang said: Mistaken purgation in Taiyang disease results in changes above the chest and hypochondrium. Here, mistaken purgation leads to abdominal fullness and occasional pain without chest/hypochondrium symptoms, indicating pathogens have entered Yin positions, thus belonging to Taiyin. Still using Guizhi to resolve muscle layer raises Taiyang pathogens; doubling Shaoyao regulates Taiyin Qi. Not adding any new herbs to the base formula is divine! Major excess and fullness require urgent purgation, but since Yang pathogens initially sink into Taiyin, harsh purgation is inadvisable. Adding a little Rhubarb to Guizhi Tang divides and reduces pathogens (7 parts exterior, 3 parts interior), similar to the meaning of Xiaochaihu Tang.
Cheng Yingmao said: Mistaken purgation of Taiyang leading to abdominal fullness and occasional pain reveals Taiyin syndromes. However, exterior pathogens sinking and stagnating in Taiyin is not a Zang Cold disease. Still use Guizhi Tang to raise Yang pathogens, but double Shaoyao to harmonize. If major excess and pain seem suitable for urgent purgation, it is Yin excess, not Yang excess. Still follow Guizhi example to raise Yang pathogens, but add Rhubarb to break stagnation, giving both exterior and interior pathogens an exit. Cold goes with excess, warming itself without added heat. Although these two syndromes belong to Taiyin, they originate from Taiyang transmission, so the pulse must still be floating.
Guizhi Jiashaoyao Tang Formula
In the Guizhi Tang formula, add Shaoyao (Peony Root) 3 liang, totaling 6 liang with the previous amount. Follow the rest of the Guizhi Tang method.
Guizhi Jiadahuang Tang Formula