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。（结硬。玉函。作痞坚。
脉经。千金翼。不下下。有下之二字。无自利二字。及若下之必四字。）
〔程〕腹满而吐。食不下。则满为寒胀。吐与食不下。总为寒格也。阳邪亦有下利。然乍微乍甚。而痛随
利减。今下利益甚。时腹自痛。则肠虚而寒益留中也。虽曰邪之在脏。实由胃中阳乏。以致阴邪用事。升降失
职。故有此下之则胸中结硬。不顶上文吐利来。直接上太阴之为病句。如后条设当行大黄芍药者亦是也。曰胸
下。阴邪结于阴分。异于结胸之在胸。而且按痛矣。曰结硬。无阳以化气。则为坚阴。异于痞之濡而软矣。彼
皆阳从上陷而阻留。此独阴从下逆而不归。寒热大别。〔鉴〕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。
黄仲理曰。宜理中汤。阴经少有用桂枝者。如此证。若脉浮。即用桂枝汤微汗之。若恶寒甚不已者。非理
中四逆不可。
黄自利益甚四字。不允当。故姑从吴人驹之说。且脉经千金翼。文有异同。可知此条固有差错也。
伤寒蕴要曰。凡自利者。不因攻下而自泻利。俗言漏底伤寒者也。大抵泻利。小便清白不涩。完谷不化。
其色不变。有如 溏。或吐利腥秽。小便澄澈清冷。口无燥渴。其脉多沉。或细。或迟。或微。而无力。或身
虽发热。手足逆冷。
或恶寒蜷卧。此皆属寒也。凡热症。则口中燥渴。小便或赤。或黄。或涩。而不利。且所下之物。皆如垢腻之
状。或黄。或赤。所去皆热臭气。其脉多数。或浮或滑。或弦或大。或洪也。亦有邪热不杀谷。其物不消化者。
但脉数而热。口燥渴。小便赤黄。以此别之矣。
太阴中风。四肢烦疼。阳微阴涩而长者。为欲愈。
〔锡〕太阴中风者。风邪直中于太阴也。〔魏〕太阴病。而类于太阳之中风。四肢烦疼。阳脉微而热发。阴
脉涩而汗出。纯乎太阳中风矣。然腹自满。有时痛。下利益甚。吐而不能食。是非太阳之中风。宜表散也。〔钱〕
四肢烦疼者。言四肢酸疼。而烦扰无措也。盖脾为太阴之脏。而主四肢故也。（脾病四肢不得禀水谷气。见素
问阳明脉解。）阳微阴涩者。言轻取之而微。重取之而涩也。脉者。气血伏流之动处也。因邪入太阴。脾气不
能散精。肺气不得流经。营阴不利于流行。故阴脉涩也。阳微阴涩。正四肢烦疼之病脉也。长脉者。阳脉也。
以微涩两阴脉之中。而其脉来云皆长。为阴中见阳长。则阳将回。故为阴病欲愈也。
太阴病。欲解时。从亥至丑上。
〔成〕脾为阴主。王于丑亥子。向王。故为解时。〔柯〕经曰。夜半后而阴隆为重阴。又曰。合夜至鸡鸣。
天之阴。阴中之阴也。脾为阴中之至阴。故主亥子丑时。
太阴病。脉浮者。可发汗。宜桂枝汤。
〔汪〕夫曰太阴病。当见腹满等候。诊其脉不沉细。而浮。则知太阳经风邪。犹未解也。故宜桂枝汤。以
汗解之。〔鉴〕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。〔程〕条中有桂
枝汤。而无麻黄汤。桂枝胎建中之体。无碍于温也。
案舒氏云。此言太阳病。是必腹满而吐。腹痛自利矣。证属里阴。脉虽浮亦不可发汗。即令外兼太阳表证。
当以理中为主。内加桂枝。两经合治。此一定之法也。今但言太阴病。未见太阳外证。其据脉浮。即用桂枝。
专治太阳。罔顾太阴。大不合法。恐亦后人有错。此说有理。
自利不渴者。属太阴。以其脏有寒故也。当温之。宜服四逆辈。（玉函。千金翼。无服字。辈。脉经。作汤。）
〔鉴〕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。〔魏〕以其人脾脏之阳。平素不足。寒湿凝滞。
则斡运之令不行。所以胃肠水谷不分。而下泄益甚。自利二字。乃未经误下误汗吐而成者。故知其脏本有寒也。
〔舒〕口渴一证。有为实热。亦有虚寒。若为热邪伤津。而作渴者。必小便短大便硬。若自利而渴者。乃为火
衰不能熏腾津液。故口渴。法主附子。助阳温经。正所谓釜底加薪。津液上腾。而渴自止。若寒在太阴。于肾
阳无干。故不作渴。
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。（以一字。玉函。作所以然者四字。暴烦下利。千金翼。
作烦暴利。）
〔钱〕缓。为脾之本脉也。手足温者。脾主四肢也。以手足而言自温。则知不发热矣。邪在太阴。所以手
足自温。不至如少阴厥阴之四肢厥冷。故曰系在太阴。然太阴湿土之邪郁蒸。当发身黄。若小便自利者。其湿
热之气。已从下泄。故不能发黄也。如此而至七八日。虽发暴烦。乃阳气流动。
肠胃通行之征也。下利虽一日十余行。必下尽而自止。脾家之正气实。故肠胃中有形之秽腐去。秽腐去。则脾
家无形之湿热亦去故也。此条当与阳明篇中。伤寒脉浮而缓云云至八九日。大便硬者。此为转属阳明条互看。
〔喻〕暴烦下利。日十余行。其证又与少阴无别。而利尽秽腐当自止。则不似少阴之烦躁有加。下利漫无止期
也。〔汪〕成注云。下利烦躁者死。此为先利而后烦。是正气脱。而邪气扰也。兹则先烦后利。是脾家之正气
实。故不受邪。而与之争。因暴发烦热也。下利日十余行者。邪气随腐秽而去。利必自止。而病亦愈。
本太阳病。医反下之。因尔腹满时痛者。属太阴也。桂枝加芍药汤主之。大实痛者。桂枝加大黄汤主之。
（玉函。无本字。尔。全书。程本。作而。脉经。千金翼。无尔字。千金翼。作加大黄汤主之。无桂枝二字。
大实痛以下。成氏及诸本。为别条。非也。）
〔钱〕本太阳中风。医不汗解。而反下之。致里虚邪陷。遂入太阴。因尔腹满时痛。故曰属太阴也。然
终是太阳之邪未解。故仍以桂枝汤解之。加芍药者。因误下伤脾。故多用之。以收敛阴气也。〔汪〕如腹满痛
甚者。其人胃家本实。虽因太阳病误下。热邪传入太阴。然太阴之邪。已归阳明。而入于腑。此非里虚痛。乃
里实痛也。成注云。大实大满。自可下除之。故加大黄。以下里实。其仍用桂枝汤者。以太阳之邪。犹未尽故
也。〔程〕因而二字。宜玩。太阴为太阳累及耳。非传邪也。
内台方议曰。表邪未罢。若便下之。则虚其中。邪气反入里。若脉虚弱。因而腹满时痛者。乃脾虚也。
不可再下。与桂枝加芍药汤。以止其痛。若脉沉实。大实满痛。以手按之不止者。乃胃实也。宜再下。与桂枝
汤。以和表。加芍药大黄。以攻其里。
桂枝加芍药汤方（○玉函。加上。有倍字）
桂枝（三两去皮） 芍药（六两） 甘草（二两炙） 大枣（十二枚擘） 生姜（二两切）
上五味。以水七升。煮取三升。去滓。温分三服。本云桂枝汤。今加芍药。（温分。千金翼。作分温。）
桂枝加大黄汤方
桂枝（三两去皮） 大黄（二两○玉函。作三两。成本。作一两。） 芍药（六两） 生姜（三两切） 甘
草（二两炙） 大枣（十二枚擘）
上六味。以水七升。煮取三升。去滓。温服一升。日三服。
〔柯〕腹满。为太阴阳明俱有之证。然位同而职异。太阴主出。太阴病。则腐秽气凝不利。故满而时痛。
阳明主内。阳明病。则腐秽燥结不行。故大实而痛。是知大实痛。是阳明病。而非太阴病矣。仲景因表证未解。
阳邪已陷入太阴。故倍芍药。以益脾调中。而除腹满之时痛。此用阴和阳法也。若表邪未解。而阳邪陷入阳明。
则加大黄。以润胃通结。而除其大实之痛。此双解表里也。凡妄下。必伤胃之气液。胃气虚。则阳邪袭阴。故
转属太阴。胃液涸则两阳相搏。故转属阳明。属太阴。则腹满时痛。而不实。阴道虚也。属阳明。则腹满大实。
而痛。阳道实也。满而时痛。是下利之兆。大实而痛。是燥屎之征。故倍加芍药。小变建中之剂。少加大黄。
微示调胃之方也。〔汪〕案桂枝加大黄汤。仲景虽入太阴例。实则治太阳阳明之药也。与大柴胡汤。治少阳阳
明证义同。〔钱〕考汉之一两。即宋之二钱七分也。以水七升。而煮至三升。分作三次服之。止温服一升。案
李时珍云。古之一升。今之二合半。约即今之一饭瓯也。大黄不满一钱。亦可谓用之缓。而下之微矣。
案方氏云。曰桂枝加。则以本方加也。而用芍药六两。水七升。不合数。皆后人之苟用者。此说非也。
总病论曰。小建中汤。不用饴 。芍药为君。止痛复利邪故也。
圣济总录。芍药汤。治产后血气攻心腹痛。
即桂枝加芍药汤。无生姜大枣。
圣惠方。赤芍药散。治小儿初生。及一年内儿。多惊啼不休。或不得眠卧。时时肚胀。有似鬼神所为。
即桂枝加大黄汤。去姜枣。加白术五味。
太阴为病。脉弱。其人续自便利。设当行大黄芍药者。宜减之。以其人胃气弱易动故也。（【原注】下利
者。先煎芍药三沸○成本。无下利云云九字注文。）
〔程〕前条之行大黄芍药者。以其病为太阳误下之病。自有浮脉验之。非太阴为病也。若太阴自家为病。
则脉不浮。而弱矣。纵有腹满大实痛等证。其来路自是不同。中气虚寒。必无阳结之虑。目前虽不便利。续自
便利。只好静以俟之。大黄芍药之宜行者减之。况其不宜行者乎。诚恐胃阳伤动。则洞泄不止。而心下痞硬之
证成。虽复从事于温。所失良多矣。胃气弱。对脉弱言。易动。对续自便利言。太阴者。至阴也。全凭胃气鼓
动。为之生化。胃阳不衰。脾阴自无邪入。故从太阴为病。指出胃气弱来。〔锡〕曰便利。其非大实痛可知也。
曰设当行。其不当行可知也。总之伤寒无分六经。一切皆以胃气为本。〔印〕案本经凡下后。皆去芍药。盖以
芍药为苦泄也。
案锡驹云。续者。大便陆续。而利出也。汪氏云。大便必接续自利而通。盖续者。谓虽今不便利。而续必
便利之义。非自利陆续频并之谓。程注为得。
太阴病的主要表现是：腹部胀满，呕吐，饮食难以下咽，腹泻逐渐加重，时常出现腹部自发疼痛。如果误用攻下法，必然导致胸膈下方结聚硬痛。（注：《玉函经》中“结硬”写作“痞坚”。《脉经》和《千金翼方》中，“不下下”有“下”字而无“自利”二字，且没有“若下之必”这四个字。）
〔程知〕腹部胀满而呕吐，饮食难以下咽，说明胀满是寒性胀满。呕吐和饮食不下，总归是寒邪格拒所致。阳热邪气也有导致下利的情况，但通常是时轻时重，且疼痛会随着排便减轻。如今腹泻越来越严重，时常腹部自发疼痛，这是因为肠道空虚，寒邪留滞于中焦。虽然说是邪气在脏，实际上是由于胃中阳气匮乏，导致阴寒邪气盛行，升降功能失职，所以才会有误下后胸中结聚硬痛的情况。这里不承接上文的呕吐和下利，而是直接接续“太阴之为病”这一句，就像后面条文说“应当使用大黄、芍药者”一样。说“胸下”，是指阴邪结聚在阴分，不同于结胸证在胸部且按压疼痛。说“结硬”，是因为没有阳气来化气，就形成坚硬的阴凝，不同于痞证的濡软。那些（结胸、痞证）都是阳气从上陷入而阻留，唯独这个是阴气从下逆乱而不归位。寒热的区别非常大。
〔赵以德〕吴人驹说：“自利益甚”这四个字，应当放在“必胸下结硬”句的下面。这种说法很正确。如果在“吐食不下”句的下面，那就是已经呕吐、饮食不下，然后腹泻加重了。张仲景又说“如果误用攻下法”，就没有什么意义了。
黄仲理说：适宜用理中汤。阴经很少用到桂枝。像这样的病症，如果脉象浮，就用桂枝汤微微发汗。如果恶寒非常严重且不缓解的，非理中汤或四逆汤不可。
我（作者）认为“自利益甚”这四个字不妥当，所以暂且采纳吴人驹的说法。而且《脉经》和《千金翼方》的文字有差异，可知这一条原文固有错误。
《伤寒蕴要》说：凡是自发性下利，不是因为攻下导致的泻利，俗称“漏底伤寒”。大抵来说，泻利时，小便清白且不涩滞，完谷不化，颜色不变，像稀溏一样；或者呕吐下利气味腥臭，小便澄澈清冷，口中没有燥渴感，脉象多沉，或细，或迟，或微而无力；或者身体虽然发热，但手足逆冷；或者恶寒蜷卧。这些都属于寒证。凡是热证，则口中燥渴，小便或赤，或黄，或涩滞而不利，而且排出的东西都像污垢腻状，或黄，或赤，排出的都有热臭气，脉象多数，或浮，或滑，或弦，或大，或洪。也有因为邪热不能消化食物，导致食物不消化的情况，但只要脉数而身热，口燥渴，小便赤黄，以此加以辨别。
太阴中风，四肢烦扰疼痛。如果脉象阳部微、阴部涩而长，这是将要痊愈的表现。
〔魏荔彤〕太阴中风，是风邪直中太阴。〔钱天来〕四肢烦疼，是说四肢酸痛，且烦扰无措。因为脾是太阴之脏，主司四肢。（脾病导致四肢得不到水谷精气的供养，见《素问·阳明脉解》。）阳微阴涩，是说轻取脉象微弱，重取脉象涩滞。脉，是气血伏流运行的动处。因为邪气侵入太阴，脾气不能散精，肺气不得流经，营阴不利于流行，所以阴脉涩滞。阳微阴涩，正是四肢烦疼的病脉。长脉，属于阳脉。在微涩两个阴脉之中，脉来都表现为长，这是阴中见到阳长，说明阳气将回复，所以是阴病将要痊愈。
太阴病，欲解的时间，是从亥时到丑时。
〔成无己〕脾属阴，旺于丑、亥、子时，趋向旺盛，所以是欲解之时。〔柯琴〕经文说：夜半以后阴气隆盛为重阴。又说：黄昏到鸡鸣，是天的阴气，阴中之阴。脾是阴中之至阴，所以主宰亥、子、丑时。
〔汪琥〕既然说是太阴病，应当见到腹满等症状。诊察脉象如果不沉细而浮，就知道太阳经的风邪还没有解除。所以适宜用桂枝汤，通过发汗来解除。〔赵以德〕即使有呕吐、下利、不食、腹满、时痛等一两个症状，只要脉象不沉而浮，就可以用桂枝汤发汗，先解除表邪。等表邪解除后，再调理里证。从这里也可以知道，论中说身痛、腹满、下利时，急先救里的情况，脉象一定是不浮的。〔程知〕条文中只有桂枝汤，而没有麻黄汤。桂枝汤具有建中的体质基础，不妨碍温补。
按语：舒氏说：这是指太阳病，必定要有腹满而吐、腹痛自利等症状。证候属于里阴，脉象虽然浮也不可以发汗。即使外兼太阳表证，也应当以理中汤为主，内加桂枝，两经合治。这是一定的法则。现在只说太阴病，未见太阳外证，仅凭脉浮就用桂枝汤，专治太阳，不顾太阴，大大不合乎法度。恐怕也是后人有的错误。这种说法有理。
自发性下利且不口渴的，属于太阴，因为内脏有寒的缘故。应当用温法，适宜服用四逆汤之类的方剂。（《玉函经》、《千金翼方》中没有“服”字。“辈”，《脉经》作“汤”。）
〔赵以德〕凡是自利而口渴的，是有里有热，属于阳证。如果自利不口渴，就是有里有寒，属于阴证。如今自利不口渴，知道是太阴本脏有寒。所以应当用温法。四逆辈，指的是四逆汤、理中汤、附子汤等而言。〔魏荔彤〕因为此人脾脏的阳气，平素不足，寒湿凝滞，那么斡旋运化的命令不行，所以胃肠水谷不分，而下泄更加严重。“自利”二字，是指未经过误下、误汗、误吐而形成的，所以知道其脏原本有寒。〔舒驰远〕口渴一症，有实热，也有虚寒。如果是热邪伤津而作渴，必定小便短少、大便干硬。如果自利而口渴，那是火衰不能熏腾津液，所以口渴，治法主要用附子，助阳温经，正所谓釜底加薪，津液上腾，而渴自然停止。如果寒在太阴，与肾阳无关，所以不作渴。
伤寒脉象浮而缓，手足自温的，系属于太阴。太阴病应当发身黄，如果小便自利的，就不能发黄。到了七八天，虽然突然烦躁，下利一天十几次，必定会自行停止，因为脾家正气恢复，腐秽之物应当排出的缘故。（“以”字，《玉函经》作“所以然者”四字。“暴烦下利”，《千金翼方》作“烦暴利”。）
〔钱天来〕缓，是脾的本脉。手足温，是脾主四肢。说手足“自温”，就知道不发热了。邪气在太阴，所以手足自温，不至于像少阴、厥阴那样四肢厥冷，所以说系在太阴。然而太阴湿土之邪郁蒸，应当发身黄。如果小便自利，其湿热之气已从下泄，所以不能发黄。如此而至七八天，虽然发作暴烦，这是阳气流动、肠胃通行的征象。下利虽然一天十几次，必定排尽而自行停止。脾家的正气实，所以肠胃中有形的秽腐去除了。秽腐去除，脾家无形的湿热也去除了。这一条应当与阳明篇中“伤寒脉浮而缓……至八九日，大便硬者，此为转属阳明”的条文互相参照。〔喻嘉言〕暴烦下利，一天十几次，其证候又与少阴没有区别，但利尽秽腐后应当自行停止，就不像少阴那样烦躁加重，下利漫无止期。〔汪琥〕成无己注解说：下利烦躁者死，这是先下利而后烦躁，是正气脱失，邪气扰乱。这里则是先烦躁后下利，是脾家的正气实，所以不受邪气干扰，而与邪气抗争，因此暴发烦热。下利一天十几次，是邪气随着腐秽而去，下利必定自行停止，病也就好了。
原本是太阳病，医生反而用了攻下法，因此导致腹满时痛的，属于太阴。用桂枝加芍药汤主治。大实痛的，用桂枝加大黄汤主治。（《玉函经》没有“本”字。“尔”，全书、程本，作“而”。《脉经》、《千金翼方》没有“尔”字。《千金翼方》作“加大黄汤主治”，没有“桂枝”二字。大实痛以下，成氏及诸本，作为别条，不对。）
〔钱天来〕原本是太阳中风，医生不汗解，反而攻下，导致里虚邪陷，遂入太阴，因此腹满时痛，所以说属太阴。然而终究是太阳的邪气未解，所以仍以桂枝汤解表。加芍药，是因为误下伤了脾，所以多用芍药，以收敛阴气。〔汪琥〕如果腹满痛严重的，其人胃家原本结实，虽然因太阳病误下，热邪传入太阴，然而太阴的邪气，已归阳明，而入于腑。这不是里虚痛，乃是里实痛。成无己注解说：大实大满，自然可以攻下除去。所以加大黄，以攻下里实。仍然用桂枝汤，是因为太阳的邪气还没有完全解除。〔程知〕“因而”二字，值得玩味。太阴是被太阳连累而已，不是传变邪气。
《内台方议》说：表邪未罢，如果就攻下，则会使其中空虚，邪气反而入里。如果脉虚弱，因而腹满时痛的，是脾虚，不可以再攻下，给予桂枝加芍药汤，以止其痛。如果脉沉实，大实满痛，用手按压疼痛不止的，是胃实，应当再攻下，给予桂枝汤以和解表邪，加芍药、大黄以攻逐里实。
桂枝加芍药汤方
桂枝（三两，去皮） 芍药（六两） 甘草（二两，炙） 大枣（十二枚，擘开） 生姜（二两，切）
以上五味药，用水七升，煮取三升，去渣滓，温服，分三次服用。原本说是桂枝汤，现在加了芍药。（“温分”，《千金翼方》作“分温”。）
桂枝加大黄汤方
桂枝（三两，去皮） 大黄（二两，《玉函经》作三两，成本作一两。） 芍药（六两） 生姜（三两，切） 甘草（二两，炙） 大枣（十二枚，擘开）
以上六味药，用水七升，煮取三升，去渣滓，温服一升，每日三次。
〔柯琴〕腹满，是太阴和阳明都有的证候。然而部位相同而职能不同。太阴主出，太阴病，则腐秽之气凝结不利，所以胀满且时痛。阳明主内，阳明病，则腐秽燥结不行，所以大实而痛。由此可知，大实痛，是阳明病，而不是太阴病。张仲景因为表证未解，阳邪已陷入太阴，所以倍用芍药，以益脾调中，而除腹满时痛。这是用阴和阳的方法。如果表邪未解，而阳邪陷入阳明，则加大黄，以润胃通结，而除其大实之痛。这是双解表里。凡是妄用攻下，必伤胃的气液。胃气虚，则阳邪袭阴，所以转属太阴。胃液枯竭则两阳相搏，所以转属阳明。属太阴，则腹满时痛，而不实，阴道虚也。属阳明，则腹满大实而痛，阳道实也。胀满而时痛，是下利的征兆；大实而痛，是燥屎的特征。所以倍加芍药，小变建中的药剂；少加大黄，微示调胃的方剂。〔汪琥〕按语：桂枝加大黄汤，张仲景虽列入太阴例，实则治疗太阳阳明病的药物。与大柴胡汤治疗少阳阳明证义相同。〔钱天来〕考证汉代的一两，即宋代的二钱七分。用水七升，煮至三升，分作三次服用，每次温服一升。按李时珍说：古之一升，相当于现在的二合半，约等于现在的一饭碗。大黄不满一钱，也可以说是用药缓和，攻下轻微。
按语：方氏说：说“桂枝加”，就是以本方加入。而用芍药六两，水七升，不合数理，都是后人苟且使用的。这种说法不对。
《总病论》说：小建中汤，不用饴糖，以芍药为君药，止痛并防止复利邪气。
《圣济总录》：芍药汤，治疗产后血气攻心腹痛。
即桂枝加芍药汤，去掉生姜、大枣。
《圣惠方》：赤芍药散，治疗小儿初生，及一年内婴儿，多惊啼不休，或不得眠卧，时时肚胀，有似鬼神所为。
即桂枝加大黄汤，去掉姜、枣，加白术、五味子。
太阴病，脉弱，其人持续自便利。假如应当使用大黄、芍药的，宜减量。因为此人胃气弱，容易动泄。（【原注】下利者，先煎芍药三沸。○成本，没有“下利云云”九字注文。）
〔程知〕前条所说的行用大黄、芍药者，是因为病是太阳误下造成的，自有浮脉验证，不是太阴自发的病。如果太阴自己发病，则脉不浮而弱。纵然有腹满大实痛等证，其来路自然是不同的。中气虚寒，必定没有阳结的顾虑。目前虽然不便利，随后自便利，只好静待。大黄、芍药宜用的也要减量，何况不宜用的呢？诚恐胃阳伤动，则洞泄不止，而心下痞硬的证候形成，即使再从事于温补，损失也很多。胃气弱，是对脉弱而言。易动，是对续自便利而言。太阴，是至阴，全凭胃气鼓动，为之生化。胃阳不衰，脾阴自然无邪入。所以从太阴为病，指出胃气弱这一点。〔魏荔彤〕说“便利”，可知不是大实痛。说“设当行”，可知不当行。总之伤寒不论分六经，一切皆以胃气为本。〔印潜〕按语：本经凡攻下后，都去掉芍药。大概因为芍药是苦泄的。
按语：锡驹说：“续”，是大便陆续而出。汪氏说：大便必须接续自利而通。盖“续”，是说虽然现在不便利，但随后必然便利的意思，不是自利陆续频繁的意思。程注比较得当。
Taiyin disease is characterized by abdominal fullness, vomiting, inability to eat, worsening spontaneous diarrhea, and occasional spontaneous abdominal pain. If purgatives are misapplied, it will inevitably lead to knotting and hardness below the chest. (Note: In *Yuhan Jing*, "knotting and hardness" is written as "pijian". In *Maijing* and *Qianjin Yifang*, there is a character for "xia" but no characters for "zili", and the four characters "ruo xia zhi bi" are absent.)
[Cheng Zhi] Abdominal fullness with vomiting and inability to eat indicate that the fullness is due to cold distension. Vomiting and inability to eat collectively signify cold rejection. Yang pathogens can also cause diarrhea, but it is usually intermittent in severity, and pain decreases after defecation. Now, since diarrhea worsens progressively and there is occasional spontaneous abdominal pain, it is because the intestines are empty and cold pathogens remain in the middle jiao. Although it is said that the pathogen is in the zang organs, it is actually due to a lack of yang qi in the stomach, causing yin-cold pathogens to prevail and disrupting ascending and descending functions. Thus, mistakingly using purgatives leads to knotting and hardness in the chest. This passage does not follow the previous text on vomiting and diarrhea but directly continues from the sentence "Taiyin disease is characterized by...", similar to later passages stating "those who should use Dahuang and Shaoyao". The term "below the chest" indicates that yin pathogens knot in the yin aspect, differing from Jie Xiong syndrome which is located in the chest and is painful upon pressure. The term "knotting and hardness" implies that without yang qi to transform energy, hard yin coagulation forms, differing from the soft and flaccid nature of Pi syndrome. Those (Jie Xiong, Pi) involve yang sinking from above and stagnating; here, uniquely, yin rebels from below and fails to return. The distinction between cold and heat is significant.
[Wu Renju] Wu Renju stated: The four characters "worsening spontaneous diarrhea" should be placed under the sentence "inevitably leading to knotting and hardness below the chest." This view is correct. If placed under "vomiting and inability to eat," it would mean vomiting and inability to eat have already occurred, followed by worsening diarrhea. Zhang Zhongjing then saying "if purgatives are used" would be meaningless.
Huang Zhongli stated: Lizhong Tang is appropriate. Gui Zhi Tang is rarely used in yin meridians. For such cases, if the pulse is floating, Gui Zhi Tang should be used to induce slight sweating. If aversion to cold is severe and unrelenting, Lizhong Tang or Sini Tang is indispensable.
I (the author) consider the phrase "worsening spontaneous diarrhea" inappropriate and thus tentatively adopt Wu Renju's view. Moreover, textual variations in *Maijing* and *Qianjin Yifang* indicate inherent errors in this original passage.
*Shanghan Yunyao* states: Spontaneous diarrhea refers to loose stools not caused by purgation, colloquially known as "leaky bottom Shanghan." Generally, in diarrhea, urine is clear and white, non-astringent, undigested food passes through, color remains unchanged resembling thin mush, or vomiting/diarrhea has a fishy odor, urine is clear and cold, and there is no dry thirst in the mouth. The pulse is often deep, fine, slow, weak, or powerless. Or, although the body may be feverish, hands and feet are cold. Or, there is aversion to cold and curling up. These all belong to cold syndromes. In heat syndromes, there is dry thirst in the mouth, urine may be red, yellow, astringent, or difficult to pass, and excrement resembles dirty grease, either yellow or red, emitting hot foul odors. The pulse is often rapid, or floating, slippery, wiry, large, or surging. There are also cases where heat pathogens fail to digest food, resulting in undigested matter, but these are distinguished by a rapid pulse, fever, dry thirst, and red-yellow urine.
Taiyin wind-stroke presents with vexatious pain in the four limbs. If the pulse is superficially faint and deeply choppy yet long, recovery is imminent.
[Wei Litong] Taiyin wind-stroke occurs when wind pathogens strike Taiyin directly. [Qian Tianlai] Vexatious pain in the four limbs means soreness and pain accompanied by restlessness. This is because the spleen is the organ of Taiyin and governs the four limbs. (When spleen disease prevents limbs from receiving water-grain qi, see *Suwen: Yangming Maijie*.) "Yang faint, yin choppy" means the pulse is faint on light palpation and choppy on heavy palpation. The pulse is the site of qi and blood flow. Because pathogens enter Taiyin, spleen qi cannot distribute essence, lung qi cannot flow through, and ying-yin circulation is hindered, hence the yin pulse is choppy. Yang faint and yin choppy are indeed the pathological pulses for vexatious pain in the four limbs. The long pulse belongs to yang. Among the faint and choppy yin pulses, if the pulse comes appearing long, it shows yang emerging within yin, indicating yang is returning, hence it signifies impending recovery from a yin disease.
Taiyin disease tends to resolve from Hai hour to Chou hour.
[Cheng Wuji] Spleen governs yin and prospers at Chou, Hai, and Zi hours, approaching prosperity, so this is the time of resolution. [Ke Qin] The classic states: After midnight, yin flourishes into heavy yin. It also states: From dusk to rooster crow, it is heaven's yin, yin within yin. Spleen is the extreme yin within yin, thus governing Hai, Zi, and Chou hours.
In Taiyin disease, if the pulse is floating, sweating may be induced; Guizhi Tang is appropriate.
[Wang Hu] Since it is called Taiyin disease, symptoms like abdominal fullness should be present. If the pulse is not deep and fine but floating, it indicates that wind pathogens in the Taiyang meridian have not yet resolved. Therefore, Guizhi Tang is appropriate to resolve it via sweating. [Zhao Yi] Even if one or two symptoms like vomiting, diarrhea, anorexia, abdominal fullness, and periodic pain exist, if the pulse is not deep but floating, Guizhi Tang can be used to induce sweating and first resolve the exterior. Once the exterior is resolved, the interior can then be regulated. From this, we know that in cases described in the treatise requiring urgent rescue of the interior due to body ache, abdominal fullness, and diarrhea, the pulse must not be floating. [Cheng Zhi] The text mentions Guizhi Tang but not Mahuang Tang. Guizhi Tang possesses the constitution of Jianzhong and does not hinder warming.
Commentary: Shu Shi stated: This refers to Taiyang disease, which must present with abdominal fullness, vomiting, abdominal pain, and spontaneous diarrhea. The syndrome belongs to interior yin; even if the pulse is floating, sweating is contraindicated. Even if exterior Taiyang symptoms coexist, Lizhong Tang should be the primary treatment with added Guizhi, treating both meridians together. This is a fixed method. Here, only Taiyin disease is mentioned without exterior Taiyang symptoms; relying solely on a floating pulse to use Guizhi Tang exclusively for Taiyang while ignoring Taiyin is highly irregular. This may be a later error. This reasoning is sound.
Spontaneous diarrhea without thirst belongs to Taiyin, because the zang organs have cold. Warming therapy should be applied; Sini Tang category formulas are appropriate. (*Yuhan Jing* and *Qianjin Yifang* omit the character "fu". "Bei" in *Maijing* is written as "Tang".)
[Zhou Yizhen] Spontaneous diarrhea with thirst indicates interior heat and belongs to yang. Spontaneous diarrhea without thirst indicates interior cold and belongs to yin. Now, spontaneous diarrhea without thirst indicates cold in the fundamental Taiyin zang. Thus, warming is required. "Sini category" refers to Sini Tang, Lizhong Tang, Fuzi Tang, etc. [Wei Litong] Because the person's spleen yang is chronically insufficient, cold-dampness stagnates, hindering transformation and transportation. Consequently, gastrointestinal separation of water and grain fails, leading to worsening diarrhea. The term "spontaneous diarrhea" here refers to cases not caused by mistaken purgation, sweating, or vomiting, indicating inherent cold in the zang. [Shu Chiyuan] Thirst can be due to excess heat or deficiency cold. If caused by heat damaging fluids, there must be short urine and hard stool. If spontaneous diarrhea causes thirst, it is due to fire failing to vaporize fluids; the treatment focuses on Fuzi to assist yang and warm meridians, akin to adding fuel to the furnace, allowing fluids to rise and thirst to cease. If cold is in Taiyin, it is unrelated to kidney yang, hence no thirst occurs.
In Shanghan, if the pulse is floating and slow, and hands and feet are spontaneously warm, the condition relates to Taiyin. Taiyin typically manifests with jaundice; however, if urination is spontaneous and free, jaundice will not develop. By the seventh or eighth day, even if sudden vexation occurs with diarrhea occurring more than ten times a day, it will necessarily stop spontaneously because the splei home qi is restored, and putrid filth is being expelled. ("Yi" in *Yuhan Jing* is "suoyiran zhe" four characters. "Baofan xiali" in *Qianjin Yifang* is "fanbaoli".)
[Qian Tianlai] Slow is the root pulse of the spleen. Warm hands and feet indicate spleen governs the four limbs. Saying "spontaneously warm" implies no fever. Pathogens in Taiyin cause spontaneous warmth in hands and feet, unlike the cold extremities of Shaoyin and Jueyin, hence "relates to Taiyin." However, damp-earth pathogens in Taiyin stagnating should cause jaundice. If urination is free, damp-heat escapes downward, so jaundice does not occur. By the seventh or eighth day, sudden vexation indicates flowing yang qi and patent intestinal transit. Diarrhea occurring ten-plus times daily will exhaust itself and stop. Restored spleen qi expels有形 (tangible) filth from the intestines. Once tangible filth is gone, intangible damp-heat is also removed. This passage should be cross-referenced with the Yangming chapter: "Shanghan, pulse floating and slow... by the eighth or ninth day, stool becomes hard, this is transmission to Yangming." [Yu Jiayan] Sudden vexation and diarrhea, ten-plus times daily, resemble Shaoyin, but stopping after filth expulsion differs from Shaoyin's worsening vexation and endless diarrhea. [Wang Hu] Cheng Wuji notes: Diarrhea with vexation is fatal; this is diarrhea followed by vexation, indicating qi depletion and pathogen disturbance. Here, vexation precedes diarrhea, indicating robust spleen qi resisting pathogens, causing sudden heat. Diarrhea expels pathogens with filth; it will stop, and the illness will heal.
Originally a Taiyang disease, the physician mistakenly used purgatives, resulting in abdominal fullness and periodic pain, belonging to Taiyin. Guizhi Jia Shaoyao Tang is the main formula. For severe excess pain, Guizhi Jia Dahua Tang is the main formula. (*Yuhan Jing* lacks "ben". "Er" in complete books and Cheng edition is "er". *Maijing* and *Qianjin Yifang* lack "er". *Qianjin Yifang* writes "Jia Dahua Tang Zhu Zhi", lacking "Guizhi". Cheng Shi and other editions treat "Da Shi Tong" onwards as separate clauses, which is incorrect.)
[Qian Tianlai] Originally Taiyang wind-stroke; the physician failed to sweat and instead purged, causing interior deficiency and pathogen sinking into Taiyin, resulting in abdominal fullness and periodic pain, hence "belonging to Taiyin." Ultimately, Taiyang pathogens remain unresolved, so Guizhi Tang is still used to release the exterior. Shaoyao is added because purgation injured the spleen; increased dosage收敛 (astringes) yin qi. [Wang Hu] If abdominal fullness and pain are severe, the stomach home is originally solid. Although heat pathogens transmitted to Taiyin due to mistaken purgation, the Taiyin pathogen has merged with Yangming and entered the fu organs. This is not interior deficiency pain but interior excess pain. Cheng Wuji notes: Severe excess and fullness can be purged. Hence, Dahuang is added to purge interior excess. Guizhi Tang is retained because Taiyang pathogens are not fully resolved. [Cheng Zhi] The phrase "yin er" (thereupon/because of this) warrants attention. Taiyin is implicated by Taiyang, not by transmission.
*Neitai Fangyi* states: If exterior pathogens persist and purgatives are used prematurely, the interior becomes deficient, and pathogens enter inward. If the pulse is weak and abdominal fullness/pain ensues, it is spleen deficiency; do not purge again. Give Guizhi Jia Shaoyao Tang to stop pain. If the pulse is deep and solid, with severe excess fullness/pain unrelieved by pressure, it is stomach excess; purge again. Use Guizhi Tang to harmonize the exterior, adding Shaoyao and Dahuang to attack the interior.
Guizhi Jia Shaoyao Tang Formula
Guizhi (3 liang, peeled) Shaoyao (6 liang) Gancao (2 liang, honey-fried) Dazao (12 pieces, split) Shengjiang (2 liang, sliced)
These five herbs are boiled in 7 sheng of water to yield 3 sheng. Remove dregs. Take warm, divided into three doses. Originally called Guizhi Tang, now with added Shaoyao. ("Wen fen" in *Qianjin Yifang* is "fen wen".)
Guizhi Jia Dahua Tang Formula
Guizhi (3 liang, peeled) Dahua (2 liang; *Yuhan Jing* 3 liang, Cheng edition 1 liang) Shaoyao (6 liang) Shengjiang (3 liang, sliced) Gancao (2 liang, honey-fried) Dazao (12 pieces, split)
These six herbs are boiled in 7 sheng of water to yield 3 sheng. Remove dregs. Take 1 sheng warm, three times daily.
[Ke Qin] Abdominal fullness is a symptom shared by Taiyin and Yangming. Though location is same, function differs. Taiyin governs output; in Taiyin disease, putrid qi stagnates, causing fullness and periodic pain. Yangming governs intake; in Yangming disease, putrid dryness obstructs, causing severe excess and pain. Thus, severe excess pain is Yangming disease, not Taiyin. Zhang Zhongjing, because exterior symptoms persist and yang pathogens sink into Taiyin, doubles Shaoyao to benefit spleen and regulate middle, relieving fullness and periodic pain. This is using yin to harmonize yang. If exterior persists and yang pathogens sink into Yangming, Dahuang is added to moisten stomach and unblock obstruction, relieving severe excess pain. This resolves both exterior and interior. Mistaken purgation damages stomach qi and fluids. Deficient stomach qi allows yang pathogens to invade yin, transmitting to Taiyin. Depleted stomach fluids cause two yangs to clash, transmitting to Yangming. Taiyin transmission brings fullness/periodic pain without solidity (yin channel deficiency). Yangming transmission brings fullness/severe excess/pain (yang channel excess). Fullness with periodic pain signals diarrhea; severe excess pain signals dry feces. Hence, doubling Shaoyao slightly modifies Jianzhong formula; adding little Dahuang subtly indicates Tiaowei formula. [Wang Hu] Commentary: Guizhi Jia Dahua Tang, though listed under Taiyin examples by Zhang Zhongjing, actually treats Taiyang-Yangming syndromes, analogous to Xiaochaihu Tang treating Shaoyang-Yangming. [Qian Tianlai] Examining Han dynasty measurements: 1 liang equals Song dynasty 2 qian 7 fen. Boiling 7 sheng down to 3 sheng, divided into three doses, taking 1 sheng warm per dose. Li Shizhen noted: Ancient 1 sheng equals modern 2 he 5 cun, approx. one rice bowl. Dahuang less than 1 qian indicates mild usage and gentle purgation.
Commentary: Fang Shi stated: "Guizhi Jia" implies addition to base formula. Using 6 liang Shaoyao with 7 sheng water is numerically inconsistent, suggesting later careless alterations. This view is incorrect.
*Zongbing Lun* states: Xiao Jianzhong Tang omits Yitang, using Shaoyao as sovereign herb to stop pain and prevent recurrence of diarrhea pathogens.
*Shengji Zonglu*: Shaoyao Tang treats postpartum blood/qi attacking heart causing abdominal pain.
This is Guizhi Jia Shaoyao Tang minus Shengjiang and Dazao.
*Shenghui Fang*: Chi Shaoyao San treats newborns and infants under one year old with frequent startle crying, insomnia, and periodic abdominal distension, resembling ghost possession.
This is Guizhi Jia Dahua Tang minus Jiang and Zao, plus Baizhu and Wuweizi.
In Taiyin disease, if the pulse is weak and the patient continuously has loose stools, even if Dahuang and Shaoyao were indicated, their dosage should be reduced. This is because the person's stomach qi is weak and prone to movement. ([Original Note: In cases of diarrhea, decoct Shaoyao for three boils first. ○ Cheng edition lacks the nine characters "zai xiali..."].)
[Cheng Zhi] The previous mention of using Dahuang and Shaoyao referred to Taiyang disease caused by mistaken purgation, verified by a floating pulse, not spontaneous Taiyin disease. If Taiyin disease occurs spontaneously, the pulse is not floating but weak. Even with symptoms like severe abdominal fullness/excess pain, the origin differs. Middle qi deficiency and cold preclude yang knotting concerns. Although currently not having loose stools, they will continue spontaneously; one should wait quietly. Indicated Dahuang and Shaoyao should be reduced, let alone those contraindicated. Fear that damaging stomach yang will cause relentless diarrhea and epigastric knotting/hardness, making subsequent warming therapy ineffective. "Stomach qi weak" corresponds to "pulse weak". "Prone to movement" corresponds to "continuously loose stools". Taiyin is extreme yin, relying entirely on stomach qi for transformation. If stomach yang is robust, spleen yin excludes pathogens. Thus, pointing out "stomach qi weak" in Taiyin disease is crucial. [Wei Litong] "Loose stools" indicates it is not severe excess pain. "If one should use" indicates it should not be used. In summary, Shanghan regardless of six meridians, everything depends on stomach qi as the foundation. [Yin Qian] Commentary: In this classic, after purgation, Shaoyao is always removed because Shaoyao is bitter and draining.
Commentary: Xi Ju stated: "Xu" means stool comes out successively. Wang Shi stated: Stool must continuously loosen and pass. "Xu" means although currently not loose, it will subsequently become loose, not referring to frequent successive diarrhea. Cheng's annotation is accurate.