庞安时云。尺寸俱沉细者。太阴受病也。当四五日。发其经布胃中。络于嗌。故腹满而嗌干。宜大承气汤下之。(郭
河南云。此即仲景辩太阴之说也。当详证而后可下。)
琥按上条论。仲景于序例中不言汤药。庞氏以腹满嗌干。的系太阴热证。故云。宜大承气汤。郭氏云。未可遽下
者。以其脉沉细。恐胃中未结实。琥又按伤寒例云。太阴受病。脉尺寸俱沉细。少阴受病。脉尺寸俱沉。厥阴受病。脉
尺寸俱微缓。凡言脉处。大都系叔和补入。兼之传写时。不无所误。以理论之。三阴经居里。脉皆当沉。岂有太阴少阴
脉既见沉。而厥阴更居于里。其脉反不言沉之理。今校正尺寸俱微缓者。当是太阴受病。尺寸俱沉细者。当是厥阴受病。
细字。乃弦字传写之误。尺寸俱沉。是少阴受病。无烦议耳。凡三阴证。宜用承气汤者。于沉脉中。必数而有力。惟太
阴脉微带缓。此为辩证最妙之法。
又云。伤寒脉浮缓。手足自温者。系在太阴云云。以脾家实腐秽当去故也。橘皮汤主之。
橘皮(一两) 生姜(二两)
细锉。水一升半。煎七合。去滓。分二服。稍热呷。未瘥。再作服。
琥按上主疗云云。即仲景原论也。仲景云。腐秽当自去。故无方治。今庞氏用橘皮汤者。内安太阴。去秽恶。扶
助正气故也。
庞安时说道:寸脉和尺脉都呈现沉细象的,是太阴经受邪所致。通常在发病后的第四五天,病邪循经传入胃中,并联络咽喉,因此出现腹部胀满且咽喉干燥的症状。适宜使用大承气汤(大黄、芒硝、厚朴、枳实组成的泻下剂)来攻下泄热。(郭河南说:这就是张仲景关于辨治太阴病的论述。必须详细审察证候后,才能使用攻下法。)
王琥按语:在上述条文中,张仲景在《序例》里并未提及具体的汤药方剂。庞安时认为“腹满”和“咽喉干燥”确切属于太阴热证,所以说适宜用大承气汤。郭氏说不能急于攻下,是因为脉象沉细,恐怕胃中尚未形成燥屎结实。王琥又查阅《伤寒例》记载:太阴经受邪,脉象寸尺俱沉细;少阴经受邪,脉象寸尺俱沉;厥阴经受邪,脉象寸尺俱微缓。凡是提到脉象的地方,大多是由王叔和补入的,加之传抄过程中难免有误。从医理上分析,三阴经位于身体内部,脉象都应当表现为沉。难道会有太阴、少阴脉象已经见沉,而厥阴经位置更靠里,其脉象反而不说是沉的道理吗?现在校正认为,“尺寸俱微缓”应当是太阴受病的脉象;“尺寸俱沉细”应当是厥阴受病的脉象。“细”字,是“弦”字在传写时的误录;“尺寸俱沉”才是少阴受病的脉象,无需再议论了。凡属三阴证需要用到承气汤的,在沉脉之中,必定兼见数而有力的特征。只有太阴病的脉象微带缓象,这才是辨证施治的精妙之处。
庞安时又说:伤寒病脉象浮缓,手足自然温暖的,病系在太阴……这是因为脾家正气恢复,腐秽之物应当排出体外的缘故。此时应用橘皮汤(陈皮、生姜组成的理气和中剂)主治。
橘皮(一两) 生姜(二两)
切碎,用水一升半,煎煮至七合,滤去药渣,分两次温服。若稍热服用,症状未愈,可再次制作服用。
王琥按语:上述主要治疗原则……即张仲景的原论内容。张仲景说:腐秽之物应当自行排出,所以没有给出具体方治。如今庞安时使用橘皮汤,是为了内安太阴,去除秽恶之气,扶助正气。
Pang Anshi stated: When both the cun (distal) and chi (proximal) pulses are deep and fine, it indicates that the Taiyin meridian is affected. Typically, on the fourth or fifth day of illness, the pathogen spreads along the meridian into the stomach and connects with the throat; therefore, abdominal fullness and dryness of the throat occur. It is appropriate to use Dachengqi Tang (Major Order the Qi Decoction) to purge and drain heat. (Guo Henan remarked: This refers to Zhang Zhongjing’s discussion on differentiating and treating Taiyin disease. One must carefully examine the signs and symptoms before employing purgation.)
Wang Hu commented: In the aforementioned clause, Zhang Zhongjing did not mention specific decoctions in the "General Principles" (Xu Li). Pang Anshi considered "abdominal fullness" and "dryness of the throat" as definitive signs of a Taiyin heat syndrome, hence stating that Dachengqi Tang is appropriate. Guo argued against immediate purgation because the pulse is deep and fine, suggesting that the stomach may not yet have formed solidified dryness-heat accumulation. Wang Hu further consulted the "Treatise on Cold Damage" (Shanghan Li), which records: For Taiyin disease, the cun and chi pulses are both deep and fine; for Shaoyin disease, they are both deep; for Jueyin disease, they are slightly slow and moderate. Most mentions of pulse patterns were likely added by Wang Shuhe, and errors inevitably occurred during transcription. Theoretically, since the Three Yin meridians are located internally, their pulses should all be deep. How could it be that if Taiyin and Shaoyin pulses are already deep, the Jueyin meridian, being even more internal, would not also be described as having a deep pulse? Upon correction, "cun and chi both slightly slow and moderate" should correspond to Taiyin disease; "cun and chi both deep and fine" should correspond to Jueyin disease. The character "fine" (xi) is a transcription error for "wiry" (xian); "cun and chi both deep" corresponds to Shaoyin disease, requiring no further debate. In cases of Three Yin syndromes where Chengqi Tang is indicated, the deep pulse must necessarily be rapid and forceful. Only in Taiyin disease does the pulse feature a slight slowness/moderation, which represents the subtle art of differentiation and treatment.
Pang Anshi further stated: In cold damage diseases, if the pulse is floating and slow, and the hands and feet are naturally warm, the disease is associated with Taiyin... This is because the Spleen's healthy qi is recovering, and the putrid filth should be expelled. In such cases, Chupi Tang (Tangerine Peel Decoction) should be administered.
Chenpi (Citri Reticulatae Pericarpium, 1 liang) Shengjiang (Zingiberis Rhizoma Recens, 2 liang)
Finely chop, add 1.5 sheng of water, boil down to 0.7 sheng, strain off the dregs, and divide into two doses. Drink while slightly warm. If symptoms do not resolve, prepare and administer another dose.
Wang Hu commented: The aforementioned therapeutic principles... originate from Zhang Zhongjing’s original treatise. Zhang Zhongjing stated: "Putrid filth should expel itself," thus providing no specific formula. Pang Anshi’s use of Chupi Tang aims to stabilize the Taiyin, eliminate filth, and support the righteous qi.