郁于里。则大气不得升降。津液不得流行。而三焦之气化绝。故不尿。中气闭塞而腹满甚。胃阳败绝而加哕者。
乃必死不治之证。故无治法也。
太阳阳明者。脾约是也。
太阳阳明者。言病在太阳。无论中风伤寒。因误治失治而传入阳明。或已传阳明而太阳证犹未罢者。若发汗。若下。
若利小便。亡津液而胃中干燥。大便难者。遂为脾约也。脾约以胃中之津液言。胃无津液。脾气无以转输。
故如穷约而不能舒展也。经脉别论云。饮入于胃。游溢津气。上输于脾。脾气散精。上归于肺。通调水道。
下输膀胱。水精四布。五经并行。阳明脉解云。脾病不能为胃行其津液。四肢不得禀水谷气。气日以衰。
盖水谷入胃。脾主为胃行其津液。散精四布。以滋养灌溉夫一身内外者也。若汗吐下及利其小便。竭其
胃中之精液。使脾气无精气可散。绝上下之转输。而为屯膏之吝。故谓之约。所谓脾约者。非但下文
浮涩相搏。方谓之脾约也。历来注家。但见此条中有其脾为约句。皆指以为脾约。其余无此句者。遂
不晓矣。不知凡太阳阳明证。不论中风伤寒。因误吐误汗误下。及利其小便。致胃中津枯而大便难者。
皆谓之脾约。非独麻仁丸一条而已也。故成注云。如论中之太阳病。若吐若下若发汗后。微烦。小便数。
大便因硬者。与小承气汤。即是太阳阳明脾约病也。观此。则知正阳阳明乃热邪宿垢实满于胃。故曰胃
实而有荡涤之剂。太阳阳明因胃中津液枯燥。脾气无精可散。肠胃枯涩。故曰脾约。所以仅有和胃润燥之法。
义详下文其脾为约句下辨误中。此不多赘。但看胃实与脾约二义。一责之脾。一责之胃。命名立义。泾渭
迥殊。宁可混为一例邪。
太阳病。寸缓关浮尺弱。其人发热汗出。复恶寒。不呕。但心下痞者。此以医下之也。其不下者。病患不恶
寒而渴者。此转属阳明也。小便数者。大便必硬。不更衣十日。无所苦也。渴欲饮水。少少与之。但以法救
之。渴者宜五苓散。
缓浮弱。皆言脉之虚也。寸为气口。缓则胃气虚。关主中州。浮则无力。乃脾土弱也。尺为命门。弱则真
阳衰矣。皆误下
所致。乃下截医下之之张本也。发热汗出复恶汗者。太阳中风之表证犹未除也。不呕则邪未入少阳。且胸
为太阳之分。不呕则邪不在胸。因邪陷入里。故但心下痞也。若此者。皆以表邪未解之时。为医误下之所致也。
如其未经误下者。必无邪陷之变。病患不恶寒而渴者。此太阳之邪转属阳明也。若更小便数。则津液下渗。
故知大便必硬。然以小便数。又知其里无大热。不过因汗出小便数。以致津液枯燥而成脾约耳。里无热邪。
但有宿食。虽不更衣十日。无所苦也。若渴欲饮水。乃胃中津液少。非胃热也。当少少与之。以润其涸燥。
多则恐无热以消之也。但以法救之句。所包者广。非一法也。如坏病所谓随证治之。以法治之之意也。
若不大便。则以小承气汤和胃。若津液虚竭。则以白虎加人参汤救津液之类。皆救法也。当因时制义可也。
渴用五苓散。曰宜而不曰主之者。谓可用则宜用也。言假如既非阳明热实之证。渴欲饮水而水不能止其渴。
非胃热也。如太阳上编大汗出。胃中干。烦燥不得眠。欲得饮水者。少少与之。胃和则愈矣。若饮水不止。
当仍是太阳之邪内犯膀胱。下焦气化不行。不能蒸腾其气液。上升而为津唾。故渴也。所以宜五苓散。
阳明病。本自汗出。医更复发汗。病已瘥。尚微烦不了了者。此大便必硬故也。以亡津液。胃中干燥。
故令大便硬。当问其小便日几行。若本小便日三四行。今日再行。故知大便不久出。今为小便数少。以津液
当还入胃中。故知不久必大便也。
言脾约本因津液枯竭。非热邪燥结可比。未可轻下。更伤元气也。病在阳明。本自汗出。医更重发其汗。
病虽已瘥。尚微觉烦闷。其语言神志。若有所不了了者。此内中大便必硬故也。无他。皆以汗出过多。内无津液。
胃中干燥。遂为脾
约。故令大便硬也。然且勿轻下。当问其小便每日几行。若本小便日三四行。今日仅再行。故知大便不久出。
何也。今为小便较前日所行之数。已少其半。是下焦之气。能蒸腾上行。津液当还入胃中。能自润其枯燥。
故知不久必大便自出也。
阳明病。自汗出。若发汗小便自利者。此为津液内竭。虽硬不可攻之。当须自欲大便。宜蜜煎导而通之。
若土瓜根及与大猪胆汁。皆可为导。
言阳明病已自汗出。若又发其汗。小便又自利者。此为渗泄之极。使胃中之津液内竭。然大便虽硬。其小
便自利。则知里无热邪。不可攻之。当须自欲大便而不可得。宜用蜜煎法导而通之。若土瓜根及大猪胆汁。皆可润导。
蜜煎导法
白蜜七合。一味入铜铫中。微火煎老。试其冷则硬。勿令焦。入猪牙皂角末少许。热时手捻作梃。令头锐根凹。
长寸半者三枚。待冷硬。蘸油少许。纳谷道中。其次以锐头顶凹而入。三枚尽。以布着手指抵定。若即欲大便。勿轻去。
俟先入者已化。大便急甚。有旁流者出。方去手。随大便出。
猪胆导法
极大猪胆一枚。用芦管长三寸余。通之。磨光一头。以便插入谷道。用尖锋刀刺开胆口。以管插入胆中。用线扎定
管
口。抹油。捻入谷道。插尽芦管。外以布衬手。用力捻之。则胆汁尽入。方去之。少顷。大便即出。
阳明病。其人多汗。以津液外出。胃中燥。大便必硬。硬则谵语。小承气汤主之。若一服谵语止。更莫复
服。
此条虽无小便自利之津液下走。然汗多则津液之枯。一也。故胃中燥。大便必硬而为脾约也。至硬则谵语。
比前不同矣。前大便虽硬。皆未谵语。此独谵语者。以胃中少有热邪。导法止入谷道。不由胃中而下。不能逐热。
故以小承气汤和之。所以一服谵语止。即禁止之曰更莫复服。盖以些小实热。不须峻下。故中病即止。恐复服则
再伤津液。损坏元气。所以叮咛戒谨如此。
发汗多。若重发汗者。亡其阳。谵语脉短者死。脉自和者不死。
夫阳者。气也。汗者。营血中之阴液也。阳气鼓动。阴液外泄而为汗。阴液外泄。则阳气随之而散亡矣。此言太
阳受病之时。已多发其汗。若邪转阳明。又重发其汗。发之不已。以致阳气随汗而丧亡。故曰亡其阳。神者。阳之
灵也。阳亡则神散而不守。阴者。胃中之津液也。汗多则阴竭而胃燥。故谵语也。脉者。气之先。血之府也。脉之动。
阳气鼓之也。阳亡阴竭。故脉短促而死也。但言亡其阳而不及阴者。重阳气也。其独重阳气者。何也。盖无阳则阴无
以生也。若汗虽多而脉自和者。则真元未散。阳气犹未亡也。故曰不死。虽云不死。然亦危矣。
脉浮而芤。浮为阳。芤为阴。浮芤相搏。胃气生热。其阳则绝。
此二条。总结上文汗下。及利小便。亡津液而致脾约之见证也。浮为阳邪盛。芤为阴血虚。搏。聚也。浮芤并见。
故曰浮芤相搏。阳邪盛则胃气生热。阴血虚则津液内竭。故其阳则绝。绝者。非断绝败绝之绝。言阳邪独治。阴气
虚竭。阴阳不相为用。故阴阳阻绝而不相流通也。即生气通天论所谓阴阳离决。精气乃绝之义也。注家俱谓阳绝。乃无
阳之
互词。恐失之矣。
趺阳脉浮而涩。浮则胃气强。涩则小便数。浮涩相搏。大便则难。其脾为约。麻仁丸主之。
趺阳。足趺上动脉也。又名冲阳。胃脉也。浮为阳脉。趺阳浮。则阳邪入胃而胃中热。故曰胃气强。非胃阳之
正气强也。涩为阴脉。趺阳涩。则津液热燥而小便短数。故云小便数。非气化行而津液多之频数也。
浮涩两相搏聚。则知胃气热而津液枯矣。所以大便难而其脾为约也。所谓脾约者。胃无津液。脾气无精可散而穷约也。
脾既无精可散。胃终热燥而大便难。故当以通肠润燥为治。而以麻仁丸主之。
麻仁丸方
麻子仁（二升） 杏仁（一升） 芍药（半斤） 浓朴（一斤） 枳实（半斤） 大黄（一斤）
上六味。为末。炼蜜为丸桐子大。饮服十丸。日三服。渐加以和为度。
麻仁味甘而润。李时珍云。麻仁阿胶之属。皆润剂也。杏仁苦辛油滑。皆润燥之剂。芍药酸收。所以益阴而敛津液
也。
浓朴辛温。下气而宽中。枳实味苦。能破结利气。大黄苦寒下泄。而能荡除实热。药物虽峻。实和胃之法也。
观蜜丸则其性滞缓。分服则力小而绵。饮服则又和之矣。又云未效渐加。以和为度。则进步舒缓。此所以为和胃润燥之
剂欤。
辨误 脾约一证。成注谓俭约之约。又为约束之约。内经曰。饮入于胃。游溢精气。上输于脾。脾气散精。上归于
肺。通
调水道。下输膀胱。水精四布。五经并行。是脾主为胃行其津液者也。今胃强脾弱。约束津液。不得四布。但输膀胱。
致
小便数。大便难。愚谓胃强脾弱之说。固属误谬。而约束津液。不得四布之论。尤背经旨。何也。脾气既弱。岂反能约
束
胃中之津液邪。况津液既不得四布。岂能但输膀胱。太阴阳明论云。四肢皆禀气于胃。而不得至经。必
因于脾。乃得禀也。今脾病不能为胃行其津液。四肢不得禀水谷气。气日以衰。以此推之。则胃中之津液。
必待脾气散精。而后津液通行。若云脾弱而不能为胃行其津液则可。若云胃强脾弱而约束津液则不可。
曾不知津液本在胃中。脾气既弱。岂胃强而反自为约束乎。条辨亦云胃强则脾弱。脾弱则不能为胃行其
津液以四布。使得偏渗膀胱而为小便数。致大便干而为胃实。犹反被胃家约束而受制。故曰脾约。方论虽
与成氏无异。然偏渗膀胱之说。尤属不经。不思经文本云脾气散精。上归于肺。然后能通调水道。下输
膀胱。水精四布。既云脾弱不能为胃行其津液以四布。又云使得偏渗膀胱而为小便数。然则偏渗之路。又
何途之从。而能使小便数邪。尚论因反被胃家约束而受制之说。故设门人问云。以胃强脾弱。不能为胃行
其津液。一如懦夫受悍妻之约束乎。喻氏答云。仲景但云胃强。未说脾弱。所谓胃强。正因脾之强而强。
盖约者。省约也。脾气过强。将三五日所受之谷。省约为一二弹丸而出。是脾气过燥。故令大肠之津液日
渐干枯。所以大便为难也。岂脾弱不能约束胃中之水。反能约束胃中之谷邪。若必传会前人。而以脾约
为脾弱。将指杀妻之吴起为懦夫乎。观前人议论。大约雷同。而喻氏独能立异。似乎识见不同。然其实皆
非也。其但云胃强。未说脾弱二句。最为精当。若云胃强。正因脾之强而强。遂云脾气过强。又太过之
词也。不知仲景但云胃气强。亦未云脾气过强。但云亡津液。胃中干燥。亦未云脾气过燥。凡此之类。
悉非仲景之旨。皆过情之论也。夫脾约原非脾弱。所以仲景不责之脾。但责之胃。故独云趺阳脉浮而涩。
浮则胃气强。涩则小便数。即上文浮为阳。芤为阴。浮芤相搏。胃气生热之义也。盖趺阳。胃脉也。所谓浮者。
非邪气在表之浮也。以趺阳之胗。但主胃气。不主表邪故
也。所以浮则为胃中之阳邪有余。芤则为胃中之阴液不足。浮芤之脉。并见于趺阳一部。使阴阳偏胜偏枯。
失亢害承制之道。所以胃气生热。故曰胃气强。谓之强者。非胃阳之真气强。乃热邪在胃而强也。涩则小便数者。
胃不能藏津。脾不得散精。胃中枯燥。水精不得四布。故不能下输膀胱。故小便短促而频数也。数则胃中
之津液愈竭而阴气大亏。所以趺阳脉涩。然非因脉涩而致小便数也。小便数则脉涩矣。此仲景倒用之文。
后学惑焉。故不能解耳。惟不能解。所以止晓麻仁丸之一条。有其脾为约四字。便独认为脾约。此外更不知有
脾约矣。不思仲景云太阳阳明者。脾约是也。以一句而总该太阳阳明一篇之义。其旨甚广。岂独指浮涩相搏之
一证乎。若推脾约之义。胃气非必真强。脾亦何弱有。但因汗吐下。及利小便之后。胃中枯燥。已无津液。
脾虽不弱。有何精气之可散。津液之可行。故困约而不能舒展其运用。犹巧妇不能作无米之炊耳。非脾病而不
能为胃行其津液也。以胃无津液可行。如穷约之状耳。岂胃气真强。脾气真弱哉。是以太阳阳明篇首。即有太阳
入阳明之文曰。太阳病。若发汗。若下。若利小便。此亡津液。胃中干燥。因转属阳明。不更衣内实大便难者。
此名阳明病也。又云脉阳微而汗出多者为太过。阳脉实而发其汗。汗出多者亦为太过。太过为阳绝于里。亡津液。
大便因硬也。又云。太阳病。若吐若下若发汗。微烦。小便数。大便因硬者。与小承气汤和之愈。又太阳病。
寸缓关浮尺弱。其不下者。病患不恶寒而渴者。此转属阳明也。小便数者。大便必硬。不更衣十日。无所苦也。
又云其热不潮者。未可与承气汤。若腹大满不通者。可与小承气汤微和胃气。勿令大泄下。凡此诸证。皆亡津
液而大便难。无大实热之脾约证也。所谓大便难。非不大便也。盖欲出而坚涩不得出也。其他虽有不言亡津液而
[Pathogenic factors] stagnating in the interior cause the Great Qi (Zong Qi) to fail in ascending and descending, and body fluids (Jin Ye) to fail in circulating, resulting in the cessation of the Qi transformation (Qi Hua) of the San Jiao (Triple Burner). Consequently, there is no urination. The closure of the Middle Qi leads to severe abdominal fullness; if the Stomach Yang fails and is exhausted accompanied by hiccups, it is a fatal and incurable syndrome, hence there is no treatment method.
Taiyang-Yangming disease refers to Pi Yue (Spleen Constraint).
"Taiyang-Yangming disease" means the pathogen was originally in the Taiyang stage. Regardless of whether it was Wind Strike or Cold Damage, due to mis-treatment or lack of treatment, it transmitted to the Yangming stage; or it had already transmitted to Yangming, but the Taiyang symptoms had not yet resolved. If sweating-inducing methods, purgative methods, or diuretic methods were used, depleting body fluids and causing dryness in the Stomach with difficulty in defecation, this becomes Pi Yue (Spleen Constraint). "Pi Yue" is described from the perspective of body fluids in the Stomach. Without body fluids in the Stomach, the Spleen Qi cannot transport them. It is like being constrained by poverty, unable to extend freely. *Jing Mai Bie Lun* states: "When drink enters the Stomach, it overflows as Jin Qi (fluid qi), which is transported upward to the Spleen. The Spleen disperses essence, sending it upward to return to the Lung, regulating water passages, and transporting it downward to the Bladder. Water essence spreads throughout, and the five meridians proceed together." *Yang Ming Mai Jie* states: "If the Spleen is diseased and cannot transport body fluids for the Stomach, the four limbs do not receive Qi from water and grain, and Qi declines daily." Generally, when food and drink enter the Stomach, the Spleen's main function is to help the Stomach transport body fluids, dispersing essence throughout to nourish and irrigate the inside and outside of the body. If sweating, vomiting, purging, and diuresis exhaust the essence and fluids in the Stomach, leaving the Spleen Qi without essence to disperse, cutting off the transmission between upper and lower, becoming stingy like hoarding fat (Tun Gao), this is called "Yue" (Constraint). The so-called "Pi Yue" does not only refer to the condition where "Floating and Choppy pulses interact" mentioned later. Historically, commentators only saw the phrase "its Spleen is constrained" in this clause and interpreted it as Pi Yue, while failing to understand other clauses lacking this phrase. They did not realize that for any Taiyang-Yangming syndrome, regardless of Wind Strike or Cold Damage, if mis-vomiting, mis-sweating, mis-purging, or diuresis causes dryness of Stomach fluids and difficulty in defecation, all are called Pi Yue, not just limited to the Ma Ren Wan clause. Therefore, Cheng Wuji's commentary says: "As in the Taiyang disease in the Treatise, after vomiting, purging, or sweating, if there is slight vexation, frequent urination, and consequently hard stool, giving Xiao Cheng Qi Tang constitutes Taiyang-Yangming Pi Yue disease." Observing this, we know that Zheng Yang Yangming involves heat pathogens and retained fecal matter filling the Stomach, hence it is called "Stomach Excess" and uses purgatives to cleanse. Taiyang-Yangming is due to dryness of Stomach fluids, inability of Spleen Qi to scatter essence, and dryness/astringency of intestines, hence it is called "Pi Yue". Thus, there are only methods to harmonize the Stomach and moisten dryness. Detailed principles are discussed under the clarification of errors regarding "its Spleen is constrained" below, so I will not elaborate here. Just look at the meanings of "Stomach Excess" and "Pi Yue": one blames the Spleen, the other blames the Stomach. Their naming and principles are distinct as clear and muddy waters; how can they be confused?
In Taiyang disease, the Cun pulse is Slow, Guan is Floating, and Chi is Weak. The patient has fever, sweating, and chills again, does not vomit, but has epigastric stuffiness. This is caused by the physician's inappropriate purgation. If not purged, and the patient is not afraid of cold but feels thirsty, this indicates transmission to Yangming. Frequent urination implies hard stool. Even if one does not defecate for ten days, there is no discomfort. If thirsty and wanting to drink, give small amounts of water. Rescue according to the appropriate method. For thirst, Wu Ling San is suitable.
Slow, Floating, and Weak all describe deficient pulses. Cun corresponds to the Qi Kou; a Slow pulse indicates deficiency of Stomach Qi. Guan governs the Middle Jiao; a Floating pulse without strength indicates weakness of Spleen Earth. Chi corresponds to the Gate of Life; a Weak pulse indicates decline of True Yang. These are all caused by inappropriate purgation, laying the groundwork for the mention of "physician purged" below. Fever, sweating, and recurrent chills indicate that the Taiyang Wind Strike exterior syndrome remains unresolved. No vomiting means the pathogen has not entered Shaoyang. Since the chest belongs to the Taiyang domain, no vomiting means the pathogen is not in the chest. Because the pathogen has sunk into the interior, there is only epigastric stuffiness. Such cases result from inappropriate purgation while the exterior pathogen was unresolved. If no inappropriate purgation occurred, there would be no variation of pathogen sinking. If the patient is not afraid of cold but feels thirsty, this is Taiyang pathogen transmitting to Yangming. If accompanied by frequent urination, body fluids seep downward, indicating hard stool. However, frequent urination also suggests no significant heat in the interior; it is merely Pi Yue caused by fluid dryness due to sweating and frequent urination. With no interior heat pathogen, only retained food, even ten days without defecation brings no discomfort. Thirst and desire to drink indicate insufficient Stomach fluids, not Stomach heat. One should give small amounts to moisten the dryness. Giving too much might overwhelm the system as there is no heat to transform it. "Rescue according to the method" encompasses a broad range of approaches, not just one. It aligns with the principle of treating Huai Bing (disordered diseases) by following the syndrome. If there is constipation, use Xiao Cheng Qi Tang to harmonize the Stomach; if fluids are exhausted, use Bai Hu Jia Ren Shen Tang to rescue fluids. All are rescue methods. Strategies should be adapted to the situation. Using Wu Ling San for thirst is described as "suitable" rather than "mainly prescribed," implying conditional usage. It implies that if it is not a Yangming heat-excess syndrome, and thirst persists despite drinking, it is not Stomach heat. As seen in the earlier Taiyang section, after heavy sweating, if the Stomach is dry, causing irritability and insomnia, and the patient desires water, giving small amounts resolves the issue when the Stomach harmonizes. If drinking does not quench thirst, it suggests Taiyang pathogen invading the Bladder internally, failure of Lower Jiao Qi transformation, inability to vaporize fluids to rise as saliva, causing thirst. Hence, Wu Ling San is suitable.
In Yangming disease, spontaneous sweating is inherent. If the physician induces further sweating, although the illness seems resolved, slight vexation and mental cloudiness persist. This is because the stool must be hard. Due to loss of body fluids and dryness in the Stomach, the stool becomes hard. One should ask how many times the patient urinates daily. If previously urinating three or four times a day, but now only twice, one knows the stool will pass soon. Now, because urine frequency has decreased, body fluids should return to the Stomach, so one knows the stool will likely pass naturally soon.
Pi Yue originates from fluid exhaustion, unlike heat-pathogen dryness accumulation, so gentle purgation should not be used lightly to avoid damaging Yuan Qi. In Yangming disease, spontaneous sweating is inherent. If the physician induces heavy sweating again, although the illness appears resolved, slight vexation and unclear consciousness remain. This is due to internal hard stool. There is no other reason; excessive sweating depletes internal fluids, causing Stomach dryness and forming Pi Yue, leading to hard stool. However, do not purge lightly. Ask about daily urine frequency. If previously three or four times, now only twice, one knows stool will pass soon. Why? Urine frequency has halved compared to previous days, indicating Lower Jiao Qi can vaporize and ascend, returning fluids to the Stomach to self-moisten dryness. Thus, stool will likely pass naturally soon.
In Yangming disease, with spontaneous sweating, if sweating is induced again and urination is spontaneous and profuse, this indicates internal exhaustion of body fluids. Although the stool is hard, it cannot be attacked with purgatives. One must wait for the patient's natural urge to defecate and use Honey Suppository to guide passage. Radix Trichosanthis Kirilowii (Tu Gua Gen) or large pig bile can also serve as guides.
In Yangming disease with spontaneous sweating, if sweating is induced again and urination is profuse, this represents extreme leakage, exhausting Stomach fluids internally. Although stool is hard, profuse urination indicates no interior heat pathogen, so purgation is contraindicated. Wait for the patient's urge to defecate but inability to pass, then use Honey Suppository to guide passage. Tu Gua Gen and large pig bile can also moisten and guide.
Honey Suppository Method:
Take seven he of white honey. Place in a copper pot. Simmer gently until thickened. Test cooling hardness; do not burn. Add a small amount of powdered Gleditsia Sinensis (Zao Jiao). While hot, shape by hand into suppositories, sharpening one end and hollowing the base, each about one cun and half long. Make three. Once cooled and hardened, dip slightly in oil. Insert into the anus. Push the sharp end into the hollowed base. After inserting all three, hold in place with a cloth-wrapped finger. If the urge to defecate arises immediately, do not release easily. Wait until the first inserted suppository melts, stool becomes urgent, and liquid stool flows around, then release. Let stool exit naturally.
Pig Bile Suppository Method:
Take one large fresh pig gallbladder. Use a reed tube about three cun long, cleared and polished at one end for insertion. Puncture the gallbladder opening with a sharp knife. Insert the tube into the gallbladder and tie securely with thread. Apply oil. Insert the tube into the anus until fully inserted. Cover hand with cloth and squeeze firmly to inject all bile. Remove tool. Shortly after, stool will pass.
In Yangming disease, if the patient sweats excessively, body fluids exit externally, causing Stomach dryness and hard stool. Hard stool leads to delirium. Xiao Cheng Qi Tang is the main prescription. If delirium stops after one dose, do not administer further.
Although this clause lacks profuse urination indicating fluid loss downward, excessive sweating similarly depletes fluids. Thus, Stomach dryness and hard stool form Pi Yue. Hard stool leading to delirium differs from previous cases. Previously, hard stool did not cause delirium; here, delirium occurs due to slight heat in the Stomach. Suppositories act locally in the rectum, bypassing the Stomach, and cannot驱散 heat. Hence, Xiao Cheng Qi Tang is used to harmonize. Delirium stopping after one dose warrants discontinuation ("do not take more"). Mild excess heat does not require harsh purgation; stop upon effect. Repeated doses risk further fluid depletion and Yuan Qi damage. Hence the caution.
Excessive sweating, or repeated sweating, causes loss of Yang. Delirium with a Short pulse indicates death; a Harmonious pulse indicates survival.
Yang refers to Qi; sweat is Yin fluid within Ying Blood. Yang Qi mobilizes Yin fluid outward as sweat. Loss of Yin fluid leads to dispersion and loss of Yang Qi. This describes Taiyang disease where excessive sweating occurred. If pathogen transmits to Yangming and sweating is induced again, continuous sweating causes Yang loss with sweat, hence "loss of Yang". Spirit (Shen) is the spirit of Yang. Yang loss leads to scattered Spirit. Yin refers to Stomach fluids. Excessive sweating exhausts Yin, drying the Stomach, causing delirium. Pulse is the precursor of Qi and residence of Blood. Pulse movement is driven by Yang Qi. Yang loss and Yin exhaustion lead to short, rapid pulse and death. Mentioning only Yang loss emphasizes the importance of Yang. Why emphasize Yang? Without Yang, Yin cannot generate. If sweating is heavy but pulse is harmonious, True Yuan is intact, Yang is not lost, hence survival. Though safe, it is critical.
Pulse is Floating and Choppy. Floating represents Yang; Choppy represents Yin. Interaction of Floating and Choppy generates heat in Stomach Qi, leading to isolation of Yang.
These two clauses summarize the manifestations of Pi Yue caused by sweating, purging, and diuresis depleting fluids. Floating indicates excess Yang pathogen; Choppy indicates deficiency of Yin blood. "Bo" means gathering. Concurrent Floating and Choppy pulses mean "interaction". Excess Yang pathogen generates heat in Stomach Qi; Yin blood deficiency exhausts internal fluids, isolating Yang. "Isolation" does not mean absolute severance, but rather Yang pathogen dominates while Yin Qi is exhausted, preventing mutual interaction, thus blocking circulation between Yin and Yang. This aligns with *Sheng Qi Tong Tian Lun*: "When Yin and Yang separate, Jing Qi perishes." Commentators interpreting "Yang isolation" as synonymous with "no Yang" are likely mistaken.
Fu Yang pulse is Floating and Choppy. Floating indicates strong Stomach Qi; Choppy indicates frequent urination. Interaction of Floating and Choppy causes difficult defecation; its Spleen is constrained. Ma Ren Wan is the main prescription.
Fu Yang is the arterial pulse on the dorsum of the foot, also known as Chong Yang, representing the Stomach meridian. Floating is a Yang pulse. Fu Yang Floating indicates Yang pathogen entering the Stomach causing heat, hence "strong Stomach Qi", referring not to healthy Stomach Yang strength but to pathological heat. Choppy is a Yin pulse. Fu Yang Choppy indicates heat-dryness of fluids and scanty, frequent urination, hence "frequent urination", not increased volume due to normal Qi transformation.
Interaction of Floating and Choppy indicates Stomach heat and fluid exhaustion. Hence difficult defecation and Pi Yue. Pi Yue means Stomach lacks fluids, Spleen Qi has no essence to scatter, resulting in constraint. With Spleen unable to scatter essence, Stomach remains hot and dry, causing hard stool. Treatment should focus on unblocking intestines and moistening dryness using Ma Ren Wan.
Ma Ren Wan Formula:
Hemp Seed (Ma Zi Ren) - 2 Sheng
Apricot Kernel (Xing Ren) - 1 Sheng
Peony Root (Bai Shao) - 0.5 Jin
Magnolia Bark (Hou Po) - 1 Jin
Immature Bitter Orange (Zhi Shi) - 0.5 Jin
Rhubarb (Da Huang) - 1 Jin
Grind these six herbs into powder. Mix with refined honey to make pills the size of tung tree seeds. Take 10 pills with warm water, three times daily. Gradually increase dosage until bowel movements are harmonized.
Hemp Seed is sweet and moistening. Li Shizhen stated Hemp Seed and E-Jiao are moistening agents. Apricot Kernel is bitter, pungent, and oily, acting as a moistening agent. Peony is sour and astringent, benefiting Yin and conserving fluids. Magnolia Bark is acrid and warm, directing Qi downward and relaxing the middle. Immature Bitter Orange is bitter, breaking stagnation and promoting Qi flow. Rhubarb is bitter and cold, purging downward and clearing excess heat. Though potent, these drugs harmonize the Stomach. The honey pill form slows action; divided doses ensure mild, sustained effect; taking with water further harmonizes. Increasing dosage gradually until harmony is achieved ensures a gentle progression. Thus, it is a formula to harmonize Stomach and moisten dryness.
Clarification of Errors: Regarding Pi Yue, Cheng Wuji interprets "Yue" as "frugal/restrictive" and "constraint". *Nei Jing* states: "Drink enters Stomach, overflows as essence, transports to Spleen, Spleen scatters essence to Lung, regulates water passages, transports to Bladder, water essence spreads, five meridians proceed." This shows Spleen transports fluids for Stomach. Cheng argues Stomach is strong and Spleen weak, constraining fluids so they don't spread but go only to Bladder, causing frequent urination and hard stool. I consider "Stomach strong, Spleen weak" erroneous, and "constraining fluids" contrary to classics. Why? If Spleen Qi is weak, how can it constrain Stomach fluids? If fluids don't spread, how can they only go to Bladder? *Tai Yin Yang Ming Lun* states: "Four limbs receive Qi from Stomach but cannot reach meridians directly; they rely on Spleen. If Spleen is diseased and cannot transport fluids for Stomach, limbs lose nourishment, Qi declines." Thus, Stomach fluids require Spleen to scatter essence to circulate. Saying Spleen weakness prevents transport is valid; saying Stomach strength/Spleen weakness constrains fluids is invalid.
Fluids reside in Stomach. If Spleen is weak, how can strong Stomach constrain itself? *Tiao Bian* also says Stomach strong/Spleen weak prevents fluid distribution, causing leakage to Bladder (frequent urination) and dry stool (Stomach excess), ironically being constrained by Stomach, hence "Pi Yue". Fang Lun agrees with Cheng, but "leakage to Bladder" is unfounded. Classics state Spleen scatters essence to Lung, then regulates water passages to Bladder. If Spleen weak prevents spreading, how does leakage occur? From what pathway?
*Shang Lun* asks: "Does Stomach strong/Spleen weak resemble a weak husband controlled by a fierce wife?" Yu Jia Yan answers: "Zhongjing said Stomach strong, not Spleen weak. 'Stomach strong' actually means Spleen is strong. 'Yue' means economizing. Excessively strong Spleen economy reduces days' worth of grain to tiny pellets, causing Spleen dryness, drying Large Intestine fluids, leading to hard stool. How can weak Spleen constrain water but constrain grain?" Criticizing predecessors for equating Pi Yue with Spleen weakness is like calling Wu Qi a coward. Yu's view seems unique but is also incorrect. The phrase "Only said Stomach strong, did not say Spleen weak" is most accurate. Saying "Stomach strong because Spleen is strong" and "Spleen excessively strong" is excessive. Zhongjing said "Stomach Qi strong", not "Spleen Qi excessively strong". Said "Fluid loss, Stomach dry", not "Spleen excessively dry". These are over-interpreted.
Pi Yue is originally not Spleen weakness. Zhongjing blames Stomach, not Spleen, citing only Fu Yang pulse Floating and Choppy. Floating = Stomach Qi strong; Choppy = frequent urination. This matches "Floating Yang, Choppy Yin, interaction generates Stomach heat". Fu Yang is Stomach pulse. Floating here is not exterior pathogen floating, but Stomach Qi dominance. Floating indicates excess Yang pathogen in Stomach; Choppy indicates insufficient Yin fluids in Stomach. Both appearing at Fu Yang indicate Yin-Yang imbalance, losing regulatory balance, generating Stomach heat ("Stomach Qi strong"). "Strong" refers to pathological heat, not healthy Yang. Choppy/frequent urition means Stomach cannot store fluids, Spleen cannot scatter essence, Stomach dry, water essence doesn't spread, cannot transport to Bladder, causing scanty, frequent urination. Frequent urition exhausts fluids, increasing Yin deficiency, causing Choppy pulse. Not vice versa. Zhongjing uses inverted syntax, confusing students. Only understanding Ma Ren Wan clause with "Spleen constrained" limits knowledge of Pi Yue.
Zhongjing's "Taiyang-Yangming is Pi Yue" broadly covers the chapter. Pi Yue meaning: Stomach Qi isn't truly strong, Spleen isn't truly weak. After sweating/vomiting/purging/diuresis, Stomach is dry, fluids exhausted. Even if Spleen isn't weak, it has no essence/fluids to scatter/transport. Thus, it is constrained and cannot function, like a clever woman unable to cook without rice. It is not Spleen disease failing to transport fluids, but Stomach lacking fluids to transport, resembling poverty constraint. Is Stomach truly strong and Spleen truly weak?
At the start of Taiyang-Yangming chapter: "Taiyang disease, if sweating, purging, or diuresis depletes fluids, causing Stomach dryness and transmission to Yangming, infrequent defecation, internal excess, hard stool, is named Yangming disease." Also: "Weak Yang pulse with heavy sweating is excess. Solid Yang pulse with induced sweating causing heavy sweating is also excess. Excess leads to Yang isolation in interior, fluid loss, hard stool." Also: "Taiyang disease, after vomiting/purging/sweating, slight vexation, frequent urination, hard stool, treat with Xiao Cheng Qi Tang to harmonize." Also: "Taiyang disease, Cun Slow, Guan Floating, Chi Weak. If not purged, no chills but thirst indicates transmission to Yangming. Frequent urination implies hard stool. Ten days without defecation, no discomfort." Also: "If fever is not tidal, do not give Cheng Qi Tang. If abdominal fullness/blockage, give Xiao Cheng Qi Tang to mildly harmonize Stomach Qi, do not cause severe purging." All these syndromes involve fluid depletion and hard stool without major heat-excess, constituting Pi Yue. "Hard stool" does not mean no stool, but stool is hard and difficult to pass. Other cases mentioning fluid loss...