【纲】仲景曰。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。至六七日。虽暴烦。下利日十余行。必自止。以脾家实。腐秽当去故也。
【目】朱肱曰。足太阴脾之经。为三阴之首。其脉布于脾胃。络于嗌喉。故病患腹满而嗌干。
尺寸俱沉细者。知太阴经受病也。伤寒四五日。腹满咽干手足自温。或下利不渴。或腹满时痛。尺
寸脉俱沉细。此足太阴脾经受病也。伤寒手足必微冷。若手足自温者。系太阴也。自利不止。属太
阴也。腹满时痛。属太阴也。自利不渴者。脏寒也。当温之。宜四逆汤、理中汤也。腹满脉浮者。
可桂枝微发汗。腹痛者。桂枝加芍药汤。甚者。桂枝加大黄汤。
魏荔彤曰。脉浮缓。手足温。此近太阳中风。而手足不能发热。则脾脏素有湿邪。与风寒变热
之邪相溷。所以不能作大热于外。而实蓄深热于内。明其系在太阴。身当发黄。同于太阳发黄等症。
蓄热于里之义也。若小便利。湿泄而热去。故不能发黄。在阳明篇已言之。重见于此者。彼以太
阳初入阳明者言。其脾素有湿。则不能成胃实。表邪热入。止为发黄症。盖胃实本津液内竭。盛热
成实之症。既有湿邪。亦津液也。故不成胃实而成发黄。迨七八日热邪久已耗液。故复成胃实。以
大便硬为验。仲师于彼。指之为阳明病。起见与太阴病迥不同也。此条亦由太阳初入。然病终不归
阳明。故仲师指出太阴脾家实。当风寒变热传入。特以脾素湿。则邪热之投湿如烟投水。俱趋于脾
而为患也。故不能发黄。以上均于阳明所言同。但此至七八日。不惟大便不硬。却暴烦下利日十余
行者。病之初入同。病之去向分也。热胜湿。遂成胃实便硬。湿胜热。湿留而热欲去。遂成脾实下
利。此胃实脾实之分关。不出湿热二字也。湿。阴邪
凝滞。可以留。热阳邪迅捷。必欲出。小便既泄不尽。又不发黄。热从何出。必随湿下流。归于大
便。平日为泄为热所停蓄腐秽之物。无不随之而去。有不容自已之势也。此脾实系太阴。胃实属阳
明。止在湿热分关。遂为两经判然之症也。至二条俱未出方。盖阳明则胃实。宜四承气随人调剂。
太阴则脾实下利。未利前。如何除湿燥土。既利后。如何补中益脾。或兼除湿清热。又在人审量焉。
且使腐秽一泻得愈。亦可不必方治矣。
喻昌曰。太阴脉本缓。故浮缓虽类太阳中风。然手足自温。则不似太阳之发热。更不似少阴厥阴
之四逆与厥。所以系在太阴。不能发黄。以上与阳明篇中语句皆同。但彼以胃实而便硬。其症复转
阳明。此以脾实而下秽腐。其症止属太阴耳。至七八日暴烦下利。日十余行。其症又与少阴无别。
而腐秽尽。利当自止。则不似少阴之烦躁有加。下利漫无止期也。况少阴之烦而下利。手足反温。
脉紧反去者。仍为欲愈之候。若不辨析。误以四逆法治之。反增危矣。
【纲】仲景曰。伤寒下利。日十余行。脉反实者死。
【目】虞抟曰。脾气虚而邪气盛。故脉反实也。
【纲】仲景曰。太阴病。脉弱。其人续自便利。设当行大黄、芍药。宜减之。以其胃气弱。易
动故也。
【目】喻昌曰。此段叮咛。与阳明篇中互发。阳明曰不转失气。曰先硬后溏。曰未定成硬。皆
是恐伤太阴脾气。此曰脉弱便利。减用大黄、芍药。又恐伤阳明胃气也。
【纲】仲景曰。恶寒。脉微。而复利。亡血也。四逆加人参汤主之。
【目】朱肱曰。病有无热恶寒者。发于阴也。发于阴者。宜温里。脉必微。或沉细。属四逆加
人参汤、四逆汤、理中汤也。若发热微恶寒者。属柴胡桂枝汤也。
鳌按。以其恶寒未罢。故宜四逆。以其脉微为无血。故宜加人参。
【纲】仲景曰。太阴病。脉浮者。可发汗。宜桂枝汤。
【目】朱肱曰。问古人以四日太阴症发。病在胸膈。可吐而愈。何也。答曰。不然。有太阴症。
脉大胸满多痰者。可吐之。脉大而无痰症者。可汗而已。大抵在表者汗之。在里者下之。在上者
涌之。在下者泄之。瓜蒂栀豉。随症施用。不可以日数拘也。
魏荔彤曰。邪自太阳。而阳明。而少阳。递及太阴。法当还升之少阳。使由少阳之半表。透太
阳之表。亦兼在阳经之治也。太阴病而脉不沉缓。却见浮。则传入阴经之邪。复思远阳而去也。可
急发汗。俾得外越。而病可已矣。在太阳麻黄为发汗。桂枝为解肌。此言桂枝发汗。非发汗即解肌
也。盖用桂枝汤中芍药。引桂姜之辛温入阴分。而驱传入之邪。所谓阳因阴用也。且桂芍俱能走肝。
更可引太阴之邪。由少阳传入者。还回少阳而出。此桂枝汤但见太阴脉浮即可汗。未可拘风因用
桂枝。寒因用麻黄之说也。邪在太阳阳明。尚分风寒两因之来路。及由阳明而少阳。已不可复分。
更传太阴。岂能分风因寒因哉。再者。麻黄汤一概辛热。不能入阴分。即寒因可辨。亦不宜用。兼
之无隔少阳而驱入太阳之理。麻黄汤之力。但轻清上升。达于太阳。亦不能假少阳之道也。故不言
麻黄汤。非漏也。亦非举桂枝以概之也。知此则太阴邪之出路。必由少阳以返太阳。而他说俱不足以
惑之矣。
麻黄汤之走阴分。在营血则能入。以在太阳之表。入三阴之阴分。则不能入。以其升而不降也。
此亦宜知。
【纲】仲景曰。太阴中风。四肢烦疼。阳微阴涩而长者。为欲愈。
【目】方中行曰。四肢烦疼者。脾主四肢。亦风淫末疾之明验也。
魏荔彤曰。脉见长则邪自太阴欲还复少阳必矣。脾为脏里。经邪内陷。则症见腹满痛。吐不能
食等症。若经邪欲外出。则症见于四末。而不久于内陷可知矣。于是阳微阴涩。邪已有浸浸透至营
卫之势。兼以弦长。见少阳之门户辟。
而生发之气已动矣。更得四末之间。蠢然烦疼。汗出发热。其邪纯回太阳矣。邪不由太阳而去。乌
能自止乎。
[General Principle] Zhang Zhongjing said: In a cold damage disease, if the pulse is floating and slow, and the hands and feet are naturally warm, this indicates the pathogen is associated with the Taiyin (Greater Yin) channel. A Taiyin disease should manifest as jaundice; however, if urination is free and unobstructed, jaundice will not develop. By the sixth or seventh day, although there may be sudden irritability and diarrhea occurring more than ten times a day, the diarrhea must stop spontaneously. This is because the Spleen's healthy qi has recovered (Spleen Excess), and the rotting filth within the body is destined to be expelled.
[Commentary] Zhu Gong said: The Foot-Taiyin Spleen meridian is the head of the Three Yin channels. Its vessels distribute to the Stomach and Spleen and connect with the throat. Therefore, when a patient presents with abdominal fullness and a dry throat, and both the Cun (inch) and Chi (cubit) pulses are deep and fine, it is known that the Taiyin channel is affected by disease. Four or five days after contracting cold damage, if the patient presents with abdominal fullness, dry throat, naturally warm hands and feet, or spontaneous diarrhea without thirst, or abdominal fullness with intermittent pain, and both Cun and Chi pulses are deep and fine, this indicates the Foot-Taiyin Spleen channel is affected. In cold damage diseases, hands and feet are usually slightly cold; if they are naturally warm, the disease belongs to Taiyin. Spontaneous diarrhea that does not cease belongs to Taiyin. Abdominal fullness with intermittent pain belongs to Taiyin. Spontaneous diarrhea without thirst indicates internal cold of the zang organs. One should employ warming methods, suitable for using Sini Tang (Four Reversal Decoction) or Lizhong Tang (Regulate the Middle Decoction). If abdominal fullness is accompanied by a floating pulse, Guizhi Tang (Cinnamon Twig Decoction) can be used to induce slight sweating. If there is abdominal pain, use Guizhi Jia Shaoyao Tang (Cinnamon Twig Decoction with Added Peony). For severe cases, use Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction with Added Rhubarb).
Wei Litong said: A floating and slow pulse with warm hands and feet resembles Taiyang Wind Strike, but since the hands and feet cannot become hot, it indicates that the Spleen organ inherently possesses damp-evil, which mixes with the wind-cold transforming into heat evil. Thus, significant heat cannot manifest on the exterior, but profound heat is actually accumulated in the interior. Clarifying that the disease is tied to Taiyin, the body should develop jaundice, similar to jaundice symptoms in Taiyang disease, signifying the accumulation of heat in the interior. If urination is smooth, dampness is drained and heat departs, so jaundice does not occur. This was discussed in the Yangming chapter; its repetition here serves to contrast with the previous context where Taiyang initially entered Yangming. If the Spleen inherently has dampness, it cannot form a Stomach Excess condition. When exterior heat enters, it only results in jaundice. Stomach Excess is originally caused by the depletion of fluids internally, where intense heat creates excess. Since dampness exists, and dampness is also a form of fluid, it does not form Stomach Excess but rather jaundice. By the seventh or eighth day, prolonged heat consumes fluids, thus re-forming Stomach Excess, verified by hard stool. Zhang Zhongjing identified this as Yangming disease, which differs fundamentally from Taiyin disease in origin. This case also begins with initial entry from Taiyang, but the disease ultimately does not enter Yangming. Hence, Zhang Zhongjing points out this as Taiyin Spleen Excess. When wind-cold transforms into heat and transmits inward, specifically because the Spleen inherently has dampness, the heat evil投s into the dampness like smoke into water, all tending toward the Spleen to cause pathology. Thus, jaundice does not occur. The above points align with those in the Yangming chapter. However, at seven or eight days, not only is the stool not hard, but there is sudden irritability and diarrhea more than ten times a day. The initial entry is the same, but the progression diverges. Heat overcoming dampness leads to Stomach Excess and hard stool; dampness overcoming heat, with dampness lingering and heat seeking exit, leads to Spleen Excess and diarrhea. This distinction between Stomach Excess and Spleen Excess hinges on the concepts of dampness and heat. Dampness is a yin evil, stagnant, capable of lingering; heat is a yang evil, swift, demanding exit. Since urination does not fully drain the heat and jaundice does not appear, where does the heat go? It must flow downward with the dampness into the large intestine. Rotting filth previously retained by heat during diarrhea will inevitably be expelled along with it, driven by an uncontrollable force. This Spleen Excess belongs to Taiyin, while Stomach Excess belongs to Yangming; the distinction lies solely in dampness versus heat, creating clearly different syndromes for the two channels. Regarding these two clauses lacking prescriptions: for Yangming Stomach Excess, one should adjust among the four Chengqi Decoctions according to the individual; for Taiyin Spleen Excess with diarrhea, before diarrhea starts, how to drain dampness and dry the earth? After diarrhea starts, how to tonify the middle and benefit the Spleen? Or simultaneously drain dampness and clear heat? These require the physician's judgment. Moreover, if expelling the filth cures the patient, medication might not even be necessary.
Yu Chang said: The Taiyin pulse is naturally slow. Although floating and slow resembles Taiyang Wind Strike, naturally warm hands and feet differ from Taiyang fever, and certainly differ from the cold limbs and reversal cold of Shaoyin and Jueyin. Thus, the disease ties to Taiyin. The inability to develop jaundice aligns with statements in the Yangming chapter. However, in Yangming, hard stool due to Stomach Excess causes symptoms to revert to Yangming; here, foul expulsion due to Spleen Excess keeps symptoms within Taiyin. By the seventh or eighth day, sudden irritability and diarrhea more than ten times a day resemble Shaoyin disease. Yet, once the filth is exhausted, diarrhea stops spontaneously, unlike Shaoyin where irritability worsens and diarrhea has no end. Furthermore, in Shaoyin, if irritability and diarrhea are accompanied by warming hands and feet and the disappearance of a tight pulse, it indicates impending recovery. Failure to distinguish this and mistakenly treating with Sini Tang would increase danger.
[General Principle] Zhang Zhongjing said: In cold damage disease with diarrhea occurring more than ten times a day, if the pulse is unexpectedly excessive and forceful, death ensues.
[Commentary] Yu Tun said: When Spleen qi is deficient and pathogenic qi is abundant, the pulse becomes unexpectedly excessive.
[General Principle] Zhang Zhongjing said: In Taiyin disease, if the pulse is weak and the person continues to have loose stools, if Da Huang (Rhubarb Root and Rhizome) or Shao Yao (Peony Root) were indicated, their dosage should be reduced. This is because the Stomach qi is weak and easily disturbed.
[Commentary] Yu Chang said: This admonition complements the discussion in the Yangming chapter. Yangming warns against non-passing of flatus, hard stool followed by loose stool, and uncertain hardness, fearing injury to Taiyin Spleen qi. Here, weak pulse and loose stools warn against reducing Da Huang and Shao Yao to avoid injuring Yangming Stomach qi.
[General Principle] Zhang Zhongjing said: Chills, a faint pulse, and recurrent diarrhea indicate loss of blood. Treat with Sini Jia Renshen Tang (Four Reversal Decoction plus Ginseng).
[Commentary] Zhu Gong said: Diseases presenting with chills without fever originate from the Yin channels. Originating from Yin requires warming the interior. The pulse will be faint, or deep and fine, indicating suitability for Sini Jia Renshen Tang, Sini Tang, or Lizhong Tang. If there is fever with slight chills, it belongs to Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction).
Shen Jin'ao notes: Since chills have not ceased, Sini Tang is appropriate. Since the faint pulse indicates lack of blood, adding Renshen (Ginseng Root) is appropriate.
[General Principle] Zhang Zhongjing said: In Taiyin disease, if the pulse is floating, sweating may be induced. Use Guizhi Tang (Cinnamon Twig Decoction).
[Commentary] Zhu Gong said: Questioning ancients regarding Taiyin syndrome appearing on the fourth day with pathology in the chest and diaphragm, curable by emesis. Answer: Incorrect. For Taiyin syndrome with a large pulse, chest fullness, and much phlegm, emesis is applicable. For a large pulse without phlegm symptoms, sweating is sufficient. Generally, treat exterior conditions with sweating, interior conditions with purging, upper conditions with vomiting, and lower conditions with draining. Genti San (Thistle Powder) and Zhizi Chichi Tang (Gardenia and Soybean Decoction) are applied according to symptoms; one should not be bound by the number of days.
Wei Litong said: Pathogens transmit from Taiyang to Yangming, then to Shaoyang, and finally to Taiyin. The method should aim to raise the pathogen back to Shaoyang, allowing it to exit via the half-exterior of Shaoyang to the exterior of Taiyang, combining treatments for Yang channels. In Taiyin disease, if the pulse is not deep and slow but floating, the pathogen entering the Yin channels seeks to depart from Yang and exit outward. Urgent sweating should be induced to allow the pathogen to escape outward, curing the disease. In Taiyang, Mahuang Tang (Ephedra Decoction) induces sweating, while Guizhi Tang releases the muscle layer. Saying Guizhi Tang induces sweating here does not equate sweating with releasing the muscle layer. It utilizes Shaoyao (Peony) in Guizhi Tang to guide the acrid-warm nature of Guizhi (Cinnamon Twig) and Shengjiang (Fresh Ginger) into the Yin aspect to drive out the transmitted pathogen, known as "Yang utilizing Yin." Furthermore, both Guizhi and Shaoyao enter the Liver channel, guiding Taiyin pathogens transmitted from Shaoyang back through Shaoyang to exit. Thus, Guizhi Tang can induce sweating whenever a Taiyin floating pulse is seen, without adhering to the rule that wind uses Guizhi and cold uses Mahuang. When pathogens are in Taiyang and Yangming, one distinguishes wind vs. cold origins. Once transmitting from Yangming to Shaoyang, distinction is impossible; further transmission to Taiyin makes such distinction irrelevant. Additionally, Mahuang Tang is entirely acrid-hot and cannot enter the Yin aspect; even if cold is identified, it is unsuitable. There is no mechanism to drive pathogens directly from Shaoyang to Taiyang without passing through intermediate stages. Mahuang Tang's power rises lightly and clears, reaching only Taiyang, unable to borrow the Shaoyang pathway. Thus, Mahuang Tang is not mentioned, not due to omission, nor to generalize Guizhi Tang. Understanding this, the exit route for Taiyin pathogens must return from Shaoyang to Taiyang; other theories are insufficient to confuse this principle.
Mahuang Tang entering the Yin aspect works in Ying and Blood levels because it is at the Taiyang exterior; entering the Yin aspect of the Three Yin channels fails because it ascends without descending. This too must be understood.
[General Principle] Zhang Zhongjing said: In Taiyin Wind Strike, with painful and uncomfortable limbs, if the pulse is faint externally, choppy internally, yet long, recovery is imminent.
[Commentary] Fang Zhongxing said: Painful and uncomfortable limbs confirm that the Spleen governs the limbs and validates the concept of wind invading the extremities.
Wei Litong said: A long pulse indicates the pathogen is likely returning from Taiyin to Shaoyang. The Spleen is an interior zang organ; if channel pathogens sink inward, symptoms include abdominal fullness, pain, vomiting, and inability to eat. If channel pathogens seek to exit outward, symptoms manifest in the extremities, proving they do not remain sunk inward. Thus, a faint external pulse and choppy internal pulse show the pathogen gradually penetrating to the Ying and Wei levels. Combined with a string-like and long quality, it shows the Shaoyang gate opening and generating qi activating. Coupled with restless pain in the extremities, sweating, and fever, the pathogen purely returns to Taiyang. If the pathogen does not exit via Taiyang, how can it cease spontaneously?