【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】朱肱曰。本太阳病。医反下之。因尔腹满时痛。是有表。复有里。仲景所以用桂枝加芍
药汤。甚者加大黄。桂枝加芍药。即是小建中也。仲景云。太阴脉弱自利。设当行大黄、芍药者。
宜减之。其人胃虚。阳气易动之故。下利者。先煎芍药十余沸。
腹痛有二症。有热痛。有冷痛。尺脉弦。肠鸣泄利而痛者。冷痛也。小建中汤。不瘥者。小柴
胡汤。阴症腹痛。即四逆散。四逆加芍药汤。腹痛小便不利者。真武汤。关脉实。腹满大便秘。按
之而痛者。热痛也。桂枝加大黄黄连汤、
大承气汤。
太阴大约可温。然须有积。方可下也。何谓积症。太阴腹满时痛。胸膈不快。 满闭塞。唇青。
手足冷。脉沉细。少情绪。或腹痛。此名太阴也。近人都不识阴症。才见胸膈不快。便投热药。
非其治也。大抵阴症者。由冷物伤脾胃。阴经受之也。主胸膈胀 。面色及唇。皆无色泽。手足冷。
脉沉细。少情绪。亦不因嗜欲。但内伤冷物。或损动胃气。遂成阴症。复投巴豆之类。胸膈愈不
快。或吐而利。经一二日。遂致不救。盖不知寒中太阴也。
问。万一饮食不节。寒中阴经。何法以治。曰。理中加青皮、陈皮。一二剂。胸膈即快。枳实
理中丸。五积散。太阴脾经。主胸膈满。甲乙经曰。贼风虚邪者。阳受之。饮食不节。起居不时者。
阴受之。阳受则入腑。阴受则入脏。入腑则身热不时。上为喘呼。入脏则 满闭塞。下为飧泄。
久为肠 。
腹胀满者。阴阳不和也。桔梗半夏汤最良。仲景论太阳病发汗后腹胀满者。浓朴生姜半夏甘草
人参汤。下后心烦腹满卧起不安者。栀子浓朴汤。吐后腹胀满者。调胃承气汤。
成无己曰。腹满者。俗谓之肚胀也。华佗曰。伤寒一日在皮。二日在肤。三日在肌。四日在胸。
五日在腹。六日入胃。入胃。谓入腑也。是在腹。犹未全入里也。虽腹满为里症。亦有浅深之别。
经曰。表已解而内不消。非大满犹生寒热。则病不除。是其未全入腑。若大满大实。坚有燥屎。
自可下之。虽四五日不害。谓之邪气已入腑也。伤寒邪入腹。是里症已深。故腹满乃可下。如经曰。
其热不潮。未可与承气。若腹大满不通者。可与小承气。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。大实痛者。桂枝加大黄汤。少阴症腹胀不大便者。急下之。诸如此者。
皆为里症是也。虽曰。腹满痛为实。然腹满不减则为实。可下。腹满时减则为虚。不可下。以温
药和之。盖虚气留胀。亦为之胀。但比之实者。不至坚痛也。
王肯堂曰。结胸从心下起至少腹硬满而痛。与腹满类也。然结胸按之痛。手不可近。腹满痛举
按常痛。手近不甚也。痞亦从心下起至少腹亦与腹满类也。然痞或止留心下。腹满但在腹之中也。
邪入里与正搏。则为腹痛。所以痛
有异。腹痛属里。正太阳腹不痛。少阳亦胸胁痛而无腹痛。若阳明腹满急而痛。此为里实宜下。大
柴胡、小承气。三阴下利清谷而又腹痛。里寒故也。此总论太阳经阳中之阴。四逆汤、附子理中
汤。阳气传太阴经腹满而痛。其症有二。有实痛。有虚痛。肠鸣泄利而痛者。虚痛也。此独论太阴
经阴中之阳。小建中汤。即桂枝加芍药汤。但桂有浓薄尔。不瘥。小柴胡去芩加芍如数。腹满便秘
按之痛者。实痛也。桂枝汤加大黄一钱。此虚痛实痛。乃是以阳邪渐消为虚。阳气盛大为实。
吴绶曰。凡腹痛可按可揉者。内虚也。不可按不可揉者。内实也。海藏言中脘痛者。属脾土。
脉沉迟内寒者。理中汤、附子理中丸。阳脉涩阴脉弦。小建中。若小腹痛属厥阴经分。当归四逆
汤加吴萸。厥逆者同。如大实腹满痛。绕脐刺痛。不大便。脉实。大承气。凡潮热不大便。从心下
至少腹硬满而痛。手不可近。大陷胸。若脉弦腹痛。无热无寒。芍药甘草汤。脉弦口苦。发热腹痛。
小柴胡去人参加炒白芍。若寒热交作腹痛。加肉桂、白芍。若寒多而痛。去黄芩加肉桂、白芍。
凡少阴发热手足冷腹痛。四逆散加附、桂、萸、芍。凡发热脉洪弦腹痛。芍药黄芩汤。凡蓄血。亦
令人腹痛。手不可近。腹痛欲吐利而烦躁者。多有痧毒。世俗刮刺委中穴。
柯琴曰。太阴之上。湿气主之。腹痛吐利。从湿化也。故人伤于湿。脾先受之。然寒湿入于阴
经。不能动脏。则还入于胃腑。太阴经布胃中。又发于胃。胃中寒湿。故食不纳而吐利也。太阴脉从
足入腹。寒气时上。故腹时自痛。法当温中散寒。若误下胃口受寒。故胸下结硬。
【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。至七八日。虽暴烦。下利日十余行。必自止。以脾家实。腐秽当去故也。
【目】许叔微曰。难经曰。痛为实。脾家实者。知其实必痛也。大抵痛宜下。
成无己曰。腹满。太阴症也。阳热为邪者。则腹满而咽干。阴寒为邪者。则腹满而吐。食不下。
自利益甚。时腹自痛。太阴者。脾土也。治中央。故专主腹满之候。又发汗吐下后成腹满者。皆
邪气乘虚内客为之。而所主又各不同。经曰。发汗后腹胀满者。浓朴生姜甘草半夏人参汤。伤寒吐
后腹胀满者。调胃承气汤。伤寒下后心烦腹胀满卧起不安者。栀子浓朴汤。三者有当温。有当下。有
当吐。何也。邪气不一也。且发汗则邪之在表者虽去。而汗多亡阳。致胃气虚。不能敷布。诸气壅
滞而为胀满者。是当温散。吐后邪之在胸中者。能去则安。若不能去。致胸中之邪。下传入胃而为
实。遂生胀满者。是又当下。妄下后邪气在表。未经入腑者。遂自表乘虚而入。郁于胸中。致为虚
烦。气上下不得通。腹为之胀者。是又当吐。医者要识邪气所自。知其由来。观邪气所在。知其虚
实。汗吐下之不瘥。则可矣。
鳌按。脾家实。即腐秽也。
【纲】仲景曰。伤寒四五日。腹中痛。若转气下趋少腹者。此欲自利也。
【目】柯琴曰。此自利之兆也。四五日。是太阴发病之期。
[General Principle] Zhang Zhongjing said: The main manifestations of Taiyin disease are abdominal fullness, vomiting, difficulty in swallowing food, worsening diarrhea, and spontaneous abdominal pain occurring from time to time. If purgatives are mistakenly used, it will inevitably lead to hardness and obstruction below the heart (epigastric region).
[Detailed Commentary] Zhu Gong said: Originally suffering from a Taiyang disease, if the physician erroneously uses purgation, abdominal fullness and intermittent pain result. This indicates that both exterior and interior syndromes are present. Therefore, Zhang Zhongjing uses Guizhi Jia Shaoyao Tang (Cinnamon Twig Decoction with Added Paeonia) for treatment; in severe cases, Rhubarb is added. Guizhi Jia Shaoyao Tang is essentially a variation of Xiaojianzhong Tang (Minor Construct the Middle Decoction). Zhang Zhongjing stated: In Taiyin patients with weak pulses and spontaneous diarrhea, if Da Huang (Rhubarb) and Bai Shao (White Peony Root) should be used, their dosages should be reduced. This is because the patient's stomach qi is deficient, and yang qi is prone to disturbance. For patients with diarrhea, boil Bai Shao (White Peony Root) for more than ten boils first.
There are two types of abdominal pain symptoms: heat pain and cold pain. A wiry radial pulse accompanied by borborygmus, diarrhea, and pain indicates cold pain. Treat with Xiaojianzhong Tang (Minor Construct the Middle Decoction); if ineffective, switch to Xiao Chaihu Tang (Minor Bupleurum Decoction). For yin syndrome abdominal pain, use Sini San (Bupleurum Powder for Reversing Cold) or Sini Jia Shaoyao Tang (Bupleurum Powder for Reversing Cold with Added Paeonia). For abdominal pain with difficulty in urination, use Zhenwu Tang (True Warrior Decoction). A solid guan pulse, abdominal fullness, constipation, and tenderness upon palpation indicate heat pain. Treat with Guizhi Jia Dahuang Huanglian Tang (Cinnamon Twig Decoction with Added Rhubarb and Coptis) or Dachengqi Tang (Major Order the Qi Decoction).
Taiyin diseases are generally treated with warming methods. However, purgation can only be used if there is accumulation. What constitutes an accumulation syndrome? Abdominal fullness and intermittent pain characteristic of Taiyin, chest and diaphragm discomfort, stuffiness and obstruction, cyanosis of the lips, cold hands and feet, deep and fine pulse, and listlessness, or abdominal pain, are named Taiyin disease. Modern physicians often fail to recognize yin syndromes; upon seeing chest discomfort, they immediately administer hot medicines, which is incorrect treatment. Generally, yin syndromes arise from cold substances damaging the spleen and stomach, affecting the yin meridians. The primary symptoms include chest and diaphragm distension, lackluster complexion and lips, cold extremities, deep and fine pulse, and listlessness. This is not due to excessive desires but rather internal injury from cold substances or damage to stomach qi, resulting in a yin syndrome. Administering harsh drugs like Croton Seed (Badou) again will worsen the chest discomfort, potentially causing vomiting and diarrhea. After one or two days, this may lead to death, due to ignorance of cold pathogenic factors attacking the Taiyin.
Q: If dietary irregularity causes cold pathogens to invade the yin meridians, what is the treatment? A: Use Lizhong Tang (Middle Regulating Decoction) with Qingpi (Aged Tangerine Peel) and Chenpi (Tangerine Peel), taken for one or two doses, to relieve chest discomfort. Zhishi Lizhong Wan (Immature Bitter Orange Pill for Middle Regulating) or Wuji San (Five Accumulations Powder) can also be used. The Taiyin spleen meridian governs chest fullness. The *Jiayi Jing* states: External pathogens like treacherous winds and vacuous evils affect the yang meridians; irregular diet and lifestyle affect the yin meridians. Yang meridian invasion enters the fu organs, causing fever and occasional panting/calling out. Yin meridian invasion enters the zang organs, causing chest/abdominal fullness and obstruction, and lower body loose stools with undigested food (Sunxie). Over time, this develops into Chang Pi (intestinal dysentery).
Abdominal distension is a disharmony of yin and yang. Jiegeng Banxia Tang (Platycodon and Pinellia Decoction) is most effective. Zhang Zhongjing discussed abdominal fullness after sweating in Taiyang disease, prescribing Houpo Shengjiang Banxia Gancao Renshen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction); abdominal fullness and restlessness after purgation, prescribing Zhizi Houpo Tang (Gardenia and Magnolia Bark Decoction); and abdominal fullness after emesis, prescribing Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction).
Cheng Wuji said: Abdominal fullness is commonly called belly bloating. Hua Tuo stated: On the first day of Shanghan, the pathogen is in the skin; on the second day, in the flesh; on the third day, in the muscles; on the fourth day, in the chest; on the fifth day, in the abdomen; on the sixth day, it enters the stomach. Entering the stomach means entering the fu organs. At this stage, being in the abdomen does not mean fully entering the interior. Although abdominal fullness is an interior syndrome, there are degrees of depth. The classic states: If the exterior is resolved but internal stagnation remains, and it is not a major fullness, chills and fever may persist, indicating the disease is not cured. This implies the pathogen has not fully entered the fu organs. If there is major fullness and excess, with hard dry feces, purgation is appropriate even after four or five days, indicating the pathogen has entered the fu organs. When Shanghan pathogens enter the abdomen, the interior syndrome is deep, so abdominal fullness warrants purgation. As the classic says: If the fever is not tidal, do not give Chengqi formulas. If the abdomen is largely full and obstructed, give Xiao Chengqi Tang (Minor Order the Qi Decoction). Originally having Taiyang disease, erroneous purgation leading to abdominal fullness and intermittent pain belongs to Taiyin, treated with Guizhi Jia Shaoyao Tang. For severe excess pain, use Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction with Added Rhubarb). For Shaoyin syndrome with abdominal fullness and constipation, urgent purgation is required. These are all interior syndromes. Although abdominal fullness and pain are often excess, persistent fullness without relief indicates excess and warrants purgation. Intermittent fullness that relieves itself indicates deficiency and contraindicates purgation; instead, use warm medicines to harmonize. Deficient qi retention also causes bloating, but unlike excess, it is not hard or severely painful.
Wang Kentang said: Jie Xiong (Chest Binding) starts from below the heart down to the small abdomen with hardness, fullness, and pain, resembling abdominal fullness. However, Jie Xiong is extremely tender to touch, preventing proximity; abdominal fullness pain is tender upon lifting and pressing, but not intolerable to proximity. Pi (Stagnation) also starts from below the heart to the small abdomen, resembling abdominal fullness. However, Pi may remain confined to the epigastrium, whereas abdominal fullness is centered in the abdomen. When pathogens enter the interior and contend with healthy qi, abdominal pain occurs, hence the variations in pain. Abdominal pain belongs to interior syndromes. Taiyang disease does not involve abdominal pain; Shaoyang involves chest and hypochondriac pain without abdominal pain. Yangming disease involves urgent abdominal fullness and pain, indicating interior excess suitable for purgation, using Da Chaihu Tang (Major Bupleurum Decoction) or Xiao Chengqi Tang. Three Yin syndromes with clear undigested stool diarrhea and abdominal pain are due to interior cold. This summarizes the yin aspect within the Taiyang meridian, treated with Sini Tang (Bupleurum Decoction for Reversing Cold) or Fuzi Lizhong Tang (Aconite Decoction for Middle Regulating). When yang qi transmits to the Taiyin meridian causing abdominal fullness and pain, there are two types: excess pain and deficiency pain. Pain with borborygmus and diarrhea is deficiency pain. This specifically discusses the yang aspect within the Taiyin meridian, treated with Xiaojianzhong Tang, which is Guizhi Jia Shaoyao Tang, differing only in the dosage of Cinnamon Twig. If ineffective, use Xiao Chaihu Tang removing Scutellaria and adding Paeonia in equal amounts. Abdominal fullness, constipation, and tenderness upon pressure indicate excess pain, treated with Guizhi Tang adding one qian of Rhubarb. This distinction between deficiency and excess pain is based on the gradual dissipation of yang pathogens (deficiency) versus the abundance of yang qi (excess).
Wu Shou said: Abdominal pain that can be pressed or rubbed indicates interior deficiency; pain that cannot be pressed or rubbed indicates interior excess. Haizang stated that pain at the Zhongwan point belongs to the spleen earth. With a deep, slow pulse indicating interior cold, use Lizhong Tang or Fuzi Lizhong Wan. With a superficial choppy pulse and deep wiry pulse, use Xiaojianzhong Tang. Small abdominal pain belonging to the Jueyin meridian is treated with Danggui Sini Tang (Angelica Decoction for Reversing Cold) plus Evodia Fruit. For reversal cold, the same formula applies. For major excess abdominal fullness and pain, stabbing pain around the umbilicus, constipation, and a solid pulse, use Dachengqi Tang. For tidal fever, constipation, hardness/fullness/pain from the epigastrium to the small abdomen, and extreme tenderness, use Daxiexiong Tang (Major Chest-Binding Decoction). For wiry pulse abdominal pain without heat or cold, use Shaoyao Gancao Tang (Paeonia and Licorice Decoction). For wiry pulse, bitter taste, fever, and abdominal pain, use Xiao Chaihu Tang removing Ginseng and adding stir-fried Paeonia. For alternating chills and fever with abdominal pain, add Cinnamon Bark and Paeonia. For predominant cold with pain, remove Scutellaria and add Cinnamon Bark and Paeonia. For Shaoyin fever, cold extremities, and abdominal pain, use Sini San plus Aconite, Cinnamon, Evodia, and Paeonia. For fever, surging/wiry pulse, and abdominal pain, use Shaoyao Huangqin Tang (Paeonia and Scutellaria Decoction). Blood stasis also causes abdominal pain, extreme tenderness. Abdominal pain with urge to vomit/diarrhea and irritability often indicates sha toxin. Secular practice involves scraping the Weizhong acupoint.
Ke Qin said: Above Taiyin, dampness prevails. Abdominal pain, vomiting, and diarrhea transform from dampness. Thus, when humans are injured by dampness, the spleen is affected first. However, if cold-dampness invades the yin meridians without disturbing the zang organs, it returns to the stomach fu. The Taiyin meridian spreads through the stomach and manifests there. Cold-dampness in the stomach prevents food intake, causing vomiting and diarrhea. The Taiyin meridian enters the abdomen from the foot; cold qi ascends intermittently, causing spontaneous abdominal pain. The method should be to warm the middle and dispel cold. Erroneous purgation causes cold to injure the stomach opening, leading to hardness below the heart.
[General Principle] Zhang Zhongjing said: In Shanghan, if the pulse is floating and slow, and the hands and feet are naturally warm, the disease is associated with Taiyin. Taiyin disease typically presents with jaundice. However, if urination is free, jaundice will not develop. By the seventh or eighth day, although sudden irritability occurs and diarrhea happens more than ten times a day, it will necessarily stop spontaneously. This is because the spleen qi becomes sufficient (Shi), and the putrid filth is expelled.
[Detailed Commentary] Xu Shuwēi said: The *Nan Jing* states: Pain indicates excess. "Spleen excess" implies that true excess must involve pain. Generally, pain syndromes are suitable for purgation.
Cheng Wuji said: Abdominal fullness is a Taiyin syndrome. When yang-heat acts as the pathogen, there is abdominal fullness with a dry throat. When yin-cold acts as the pathogen, there is abdominal fullness, vomiting, inability to eat, worsening diarrhea, and spontaneous abdominal pain. Taiyin corresponds to spleen earth, which governs the center, thus primarily manifesting as abdominal fullness. Furthermore, abdominal fullness resulting from sweating, emesis, or purgation is caused by pathogens invading the interior due to deficiency, but the treatments differ. The classic states: Abdominal fullness after sweating is treated with Houpo Shengjiang Gancao Banxia Renshen Tang. Abdominal fullness after emesis in Shanghan is treated with Tiaowei Chengqi Tang. Abdominal fullness, restlessness, and irritability after purgation in Shanghan is treated with Zhizi Houpo Tang. These three require warming, purgation, or emesis respectively. Why? Because the pathogens differ. Sweating removes exterior pathogens, but excessive sweating depletes yang, causing stomach qi deficiency and failure to distribute, leading to qi stagnation and bloating; this requires warming and dispersing. Emesis removes pathogens from the chest; if successful, peace is restored. If unsuccessful, chest pathogens descend to the stomach becoming excess, causing bloating; this requires purgation. Erroneous purgation leaves exterior pathogens unentered into fu organs, which then invade the interior via deficiency, stagnating in the chest, causing empty irritability and blocked qi flow leading to abdominal bloating; this requires emesis. Physicians must identify the origin and nature of the pathogen, observe its location, and determine deficiency or excess, so that sweating, emesis, and purgation therapies will be effective.
Shen Jin'ao notes: "Spleen excess" refers to the expulsion of putrid filth.
[General Principle] Zhang Zhongjing said: In Shanghan, on the fourth or fifth day, if there is abdominal pain and gas moving downward toward the small abdomen, this is a sign of impending spontaneous diarrhea.
[Detailed Commentary] Ke Qin said: This is a precursor to spontaneous diarrhea. The fourth or fifth day is the period for Taiyin disease onset.