【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】柯琴曰。腹痛吐利。从湿化也。太阴脉布胃中。又发于胃。胃中寒湿。故食不内而吐利
交作也。
【纲】仲景曰。自利不渴者。属太阴。以其脏有寒故也。当温之。宜服四逆辈。
伤寒四五日。腹中痛。若转气下趋少腹者。此欲自利也。
【目】刘完素曰。仲景大意。以自利不渴。属太阴之为病。盖太阴脾属湿土。若热邪入脾。必
蒸动其湿。湿动则不渴而
身黄又以自。利而渴。属少阴之为病。盖少阴肾属寒水。若热邪入肾。必消铄其水。水消则口渴而
烦躁。分经辨症。其所关不甚大哉。
魏荔彤曰。此言太阴病之有寒症。以见异于传经而入之热邪。另立法以别之也。太阴为脏属阴。
而太阴为经。自是阴中之表。传经之邪。本风寒而变热递传。自是热邪固已。然有太阴脏中本寒
而得病者。又当另为谛审其症而治之。不容混言热邪以贻误。盖自利未有不渴者。自利而不渴。则
非太阴之经病。而太阴之脏病也。经为里之表。脏为里之里。其人脾脏之阳素亏。寒湿凝滞。则斡
运不行。所以肠胃水谷不分。下泄益甚。此欲执升散经邪之法。必不对矣。故当温之。温之者。温
其脏也。服四逆辈。不专主一方。不出温之之义耳。凡伤寒六经之邪。皆当论其标本。以分经病脏腑
病。不然。本经即混矣。况合病并病。及递传之间。或尽传不尽传之辨。愈渺然矣。再此自利。乃
未误汗吐下者。故知其脏本寒。非药所致也。既云自利。又云脏寒。非误治。亦非传经。可谓寒邪
直中太阴矣。少阴厥阴。俱有直中。少阴直中。寒也。厥阴直中。风也。太阴直中。其此症乎。盖
太阴直中。中湿也。风寒湿虽分三邪。俱以寒邪为宗主也。
【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。以脾家实。腐秽当去故也。
【目】鳌按。前半身当发黄。是太阴寒湿伤于表。后半暴烦下利。是太阴湿热蓄于内。然寒湿
之伤于表者。因小便而出。故小便自利则身不发黄。湿热之伤于内者。必从大便而出。故下利日十
余行而自止。盖发于阴者六日愈。七八日则阳气复。因而暴烦下利。夫利至日十余行。其腐秽当尽
去。故必自止也。惟表阳仍在。故手足温。惟里阳陡发。故暴烦。此阴中有阳。与前脏寒症纯阴无
阳者迥别。
【纲】仲景曰。太阴病。脉弱。其人续自便利。设当行大黄、芍药者。宜减之。以其胃气弱。
易动故也。
【目】柯琴曰。下利为太阴本症。自利因脾实者。腐秽尽则愈。自利因脏寒者。四逆辈温之则
愈。若自利因太阳误下者。则腹满时痛。当加芍药。大实痛者。当加大黄。此下后脉弱。胃气亦弱。
故减其制而与之也。大黄泻胃。是阳明血分下药。芍药泻脾。是太阴气分下药。下利腹痛。热邪
为患。宜芍药下之。下利腹痛。为阴寒者。非芍药所宜矣。仲景于此并提。勿草草看过。
【纲】仲景曰。恶寒。脉微而复利。亡血也。四逆加人参汤主之。
【目】张兼善曰。利则止矣。以犹恶寒。仍宜四逆。以脉微无血。故加人参。
【纲】仲景曰。病在膈上必吐。在膈下者必利。
【目】柯琴曰。本症原是吐利。因胸下结硬。故不能通。因势而利导之。结硬自除矣。
【纲】仲景曰。伤寒下利。日十余行。脉反实者死。
【目】柯琴曰。脾气虚而邪气盛。故脉反实也。
【纲】张仲景说：太阴病的主要表现是腹部胀满并伴有呕吐，饮食难以下咽，腹泻症状逐渐加重，时常出现腹部自发性疼痛。如果误用攻下法治疗，必然导致胸膈下方痞结硬满。
【目】柯琴说：腹痛、呕吐和腹泻，是由于病邪从湿化所致。太阴经脉布散于胃中，且病变常发于胃。因胃中有寒湿之邪，所以食物不能正常受纳而引发呕吐和腹泻交替发作。
【纲】张仲景说：自发腹泻且不口渴的，属于太阴病，这是因为内脏有寒的缘故。应当采用温里法治疗，适宜服用四逆汤类方剂。
伤寒病程经过四五日，出现腹中疼痛，如果有气向下移动趋向少腹部的感觉，这是即将发生腹泻的征兆。
【目】刘完素说：张仲景的大意在于，以“自发腹泻且不口渴”作为判断太阴病的依据。因为太阴脾脏属湿土，如果热邪侵入脾脏，必然会蒸动湿气；湿气被蒸动则表现为不口渴且身体发黄，同时伴有腹泻。而以“腹泻且口渴”作为判断少阴病的依据。因为少阴肾脏属寒水，如果热邪侵入肾脏，必然会消烁津液；津液消烁则表现为口渴且烦躁。分经辨证，其关系非常重要啊。
魏荔彤说：这里论述的是太阴病中的寒证，以此区别于由传经传入的热邪，从而确立不同的治法加以辨别。太阴脏属阴，而太阴经则是阴中之表。传经的病邪，原本由风寒转化为热邪并依次传变，这已经是热邪了。然而，也有太阴脏本身就有寒邪而致病的，又应当仔细审察其症状进行治疗，不容许混淆说是热邪以免贻误病情。一般来说，腹泻没有不口渴的，如果腹泻而不口渴，那就不是太阴经的病，而是太阴脏的病。经位于里的表层，脏位于里的深层。如果此人脾脏阳气素来亏虚，寒湿凝滞，导致气机斡运不行，所以肠胃中水谷不分，向下泄泻的症状更加严重。此时如果执着于使用升散解除经邪的方法，必然不对症。因此应当温补，所谓温补，就是温补其脏。服用四逆汤类方剂，并非专门固定某一方，只是不出温补这一原则罢了。凡是伤寒六经的病邪，都应当讨论其标本，以区分经病和脏腑病，否则本经的病就会混淆不清。何况合病、并病以及依次传变与未完全传变的辨别，就更加渺茫难辨了。再者，这里的腹泻，是指未经过误汗、误吐、误下治疗的，所以知道其脏本寒，并非药物所致。既然说是自发腹泻，又说脏寒，既非误治，也非传经，可以说是寒邪直接中伤太阴了。少阴和厥阴都有直中情况。少阴直中是寒邪，厥阴直中是风邪，太阴直中则是湿邪。虽然风寒湿分为三种邪气，但都以寒邪为主导。
【纲】张仲景说：伤寒脉象浮而缓，手足自然温暖的，病系在太阴。太阴病通常会出现身黄，如果小便通畅自利，就不会发黄。到了七八天，虽然突然烦躁，每天腹泻十几次，这是因为脾家实（正气恢复），腐秽之物应当排出的缘故。
【目】沈金鳌按语：前半段提到应当发黄，是太阴寒湿伤于体表；后半段突然烦躁并腹泻，是太阴湿热蓄积于体内。然而，伤于体表的寒湿，会因小便排出，所以小便自利则身体不发黄。伤于体内的湿热，必然从大便排出，所以每天腹泻十几次后自然会停止。一般来说，病发于阴经的，六日可愈，到七八天时阳气回复，因而出现突然烦躁和腹泻。腹泻达到每天十几次，说明体内的腐秽之物应当已经排尽，所以腹泻必定会自行停止。只有表阳仍在，所以手足温暖；只有里阳突然发动，所以突然烦躁。这是阴中带有阳气，与前文脏寒证纯阴无阳的情况截然不同。
【纲】张仲景说：太阴病，脉象虚弱，病人持续大便通利。假设应当使用大黄、芍药的，应当减少剂量。因为病人胃气虚弱，容易受到药性影响而动荡不安。
【目】柯琴说：腹泻是太阴的本症。如果是因脾实导致的腹泻，腐秽排尽就会痊愈；如果是因脏寒导致的腹泻，服用四逆汤类方剂温补就会痊愈。如果是因太阳病误用下法导致的腹泻，则会出现腹部胀满、时痛，应当加用芍药；如果是大实痛，应当加用大黄。此处是因为下法之后脉象虚弱，胃气也弱，所以减少药量给予服用。大黄泻胃，是阳明血分的下药；芍药泻脾，是太阴气分的下药。如果是热邪引起的腹泻腹痛，适宜用芍药下之；如果是阴寒引起的腹泻腹痛，就不适宜用芍药了。张仲景在此处并列提及，不要草率看过。
【纲】张仲景说：恶寒，脉微细并且伴有腹泻，这是亡血的表现，主方用四逆加人参汤。
【目】张兼善说：腹泻本应停止，但因为仍然恶寒，所以仍宜用四逆汤；因为脉微显示无血，所以加入人参。
【目】柯琴说：本症原本是呕吐和腹泻，因为胸下痞结硬满，导致气机不通。顺应病势进行疏导，痞结硬满自然消除。
[General Principle] Zhang Zhongjing stated: The primary manifestations of Taiyin disease include abdominal fullness accompanied by vomiting, difficulty in accepting food, progressively worsening diarrhea, and spontaneous abdominal pain occurring at times. If purgative methods are mistakenly applied, it will inevitably lead to stagnation and hardness below the chest and diaphragm.
[Commentary] Ke Qin stated: Abdominal pain, vomiting, and diarrhea arise from the transformation into dampness. The Taiyin meridian distributes within the stomach, and pathology often originates there. Due to cold-dampness in the stomach, food cannot be properly received, leading to alternating episodes of vomiting and diarrhea.
[General Principle] Zhang Zhongjing stated: Spontaneous diarrhea without thirst indicates involvement of the Taiyin, due to cold in the internal organs. Treatment should employ warming methods, preferably using formulas similar to Sini Tang (Four Reversal Decoction).
In the course of Shanghan (Cold Damage) lasting four or five days, if abdominal pain occurs with a sensation of gas moving downward toward the lower abdomen, this is a sign that diarrhea is impending.
[Commentary] Liu Wansu stated: Zhang Zhongjing’s main point is that "spontaneous diarrhea without thirst" serves as the criterion for Taiyin disease. This is because the Taiyin spleen belongs to wet earth; if heat pathogens enter the spleen, they will steam and mobilize the dampness. Mobilized dampness results in non-thirsty yellowing of the body accompanied by diarrhea. Conversely, "diarrhea with thirst" serves as the criterion for Shaoyin disease. This is because the Shaoyin kidney belongs to cold water; if heat pathogens enter the kidney, they will consume and melt the fluids. Consumed fluids result in thirst and restlessness. Differentiating meridians and syndromes is of great significance.
Wei Litong stated: This passage discusses cold syndromes within Taiyin disease, distinguishing them from heat pathogens transmitted via meridians, thereby establishing distinct treatment principles. The Taiyin zang organ is Yin, while the Taiyin meridian is the exterior of Yin. Pathogens transmitted through meridians typically transform from wind-cold into heat and transmit sequentially, constituting heat pathogens. However, some cases involve inherent cold in the Taiyin zang organ causing disease, which requires careful symptom assessment and treatment, avoiding confusion with heat pathogens to prevent mismanagement. Generally, diarrhea is accompanied by thirst; if diarrhea occurs without thirst, it is not a disease of the Taiyin meridian but of the Taiyin zang organ. The meridian is the superficial layer of the interior, while the zang organ is the deep interior. If a person has deficient spleen yang and stagnant cold-dampness, obstructing the dynamic movement of Qi, water and grain fail to separate in the intestines and stomach, leading to severe downward discharge. Applying ascending and dispersing methods for meridian pathogens would be inappropriate. Therefore, warming is required. Warming refers to warming the zang organ. Using Sini Tang (Four Reversal Decoction) does not imply a single fixed formula but adheres to the principle of warming. For pathogens in the six meridians of Shanghan, one must analyze the root and branch to distinguish between meridian diseases and zang-fu diseases; otherwise, the specific meridian involvement becomes confused. This is especially true when considering combined diseases, concurrent diseases, and distinctions in sequential transmission. Furthermore, this diarrhea refers to cases where no erroneous sweating, vomiting, or purging has occurred, indicating inherent cold in the zang rather than drug-induced injury. Since it is spontaneous diarrhea and involves cold zang, neither caused by mis-treatment nor by transmission, it can be described as direct invasion of cold pathogen into Taiyin. Both Shaoyin and Jueyin have direct invasions: Shaoyin direct invasion is cold, Jueyin direct invasion is wind, and Taiyin direct invasion is dampness. Although wind, cold, and damp are three distinct pathogens, cold is predominant.
[General Principle] Zhang Zhongjing stated: 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 and abundant, jaundice will not develop. By the seventh or eighth day, although sudden irritability may occur with frequent diarrhea (more than ten times a day), this is due to the restoration of Spleen Qi (Splei Jia Shi), expelling putrid and foul matter.
[Commentary] Shen Jin'ao noted: The initial mention of potential jaundice indicates Taiyin cold-dampness affecting the exterior; the subsequent sudden irritability and diarrhea indicate Taiyin damp-heat accumulating internally. Cold-dampness affecting the exterior is expelled via urine; thus, free urination prevents jaundice. Damp-heat affecting the interior is expelled via stool; thus, frequent diarrhea eventually stops spontaneously. Typically, diseases originating in Yin meridians resolve in six days; by the seventh or eighth day, Yang Qi recovers, causing sudden irritability and diarrhea. When diarrhea reaches more than ten times a day, it indicates that putrid matter is being expelled, so it must stop spontaneously. The hands and feet remain warm because exterior Yang persists; sudden irritability occurs because interior Yang suddenly activates. This represents Yang within Yin, distinctly different from the pure Yin-without-Yang condition of previous cold-zang syndromes.
[General Principle] Zhang Zhongjing stated: In Taiyin disease, if the pulse is weak and the patient continues to have loose stools, if Da Huang (Rhubarb Rhizome) or Bai Shao (White Peony Root) were indicated, their dosages should be reduced. This is because the Stomach Qi is weak and easily disturbed by strong medications.
[Commentary] Ke Qin stated: Diarrhea is a primary symptom of Taiyin. If diarrhea is due to Spleen excess (accumulation), it resolves once putrid matter is expelled. If due to cold zang, it resolves with warming formulas like Sini Tang (Four Reversal Decoction). If caused by erroneous purgation in Taiyang disease, resulting in abdominal fullness and intermittent pain, Bai Shao (White Peony Root) should be added; for severe pain, Da Huang (Rhubarb Rhizome) should be added. In the current case, post-purgation weak pulse indicates weak Stomach Qi, hence reducing the dosage. Da Huang (Rhubarb Rhizome) drains the Stomach and acts on the Blood level of Yangming; Bai Shao (White Peony Root) drains the Spleen and acts on the Qi level of Taiyin. For diarrhea and abdominal pain caused by heat pathogens, Bai Shao (White Peony Root) is suitable for purging; for those caused by yin-cold, it is unsuitable. Zhang Zhongjing mentions both here; do not overlook this.
[General Principle] Zhang Zhongjing stated: Aversion to cold, a faint pulse, and continued diarrhea indicate loss of blood. The principal formula is Sini Jia Renshen Tang (Four Reversal Decoction plus Ginseng).
[Commentary] Zhang Jianshan stated: Diarrhea should cease, but since aversion to cold persists, Sini Tang (Four Reversal Decoction) is still appropriate. Because the faint pulse indicates blood deficiency, Ren Shen (Ginseng Root) is added.
[General Principle] Zhang Zhongjing stated: If the pathogen is above the diaphragm, vomiting will necessarily occur; if below the diaphragm, diarrhea will necessarily occur.
[Commentary] Ke Qin stated: The original symptoms were vomiting and diarrhea. Due to stagnation and hardness below the chest, Qi flow was blocked. Guiding the pathogen according to its tendency eliminates the stagnation and hardness.
[General Principle] Zhang Zhongjing stated: In Shanghan with diarrhea, if the pulse is excessively forceful (excess pulse) despite frequent stools (more than ten times a day), the prognosis is fatal.
[Commentary] Ke Qin stated: Spleen Qi is deficient while pathogenic factors are excessive, resulting in an apparent excess pulse.