（自利者不因攻下而自利俗名漏底是也六经皆有自利表里寒热治各不同）太阳表
不解。心下有水气。干呕。发热而咳。或渴。或利。或小便不利。少腹满或喘。（小青龙汤）太阳
与阳明合疾。必自下利。（葛根汤）太阳病外症未除。而数下之。遂挟热而利。心下痞硬。表
里不解。（桂枝人参汤）太阳与少阳合病。自利。（黄芩汤若呕者黄芩加半夏生姜汤）太阳少阳
并病。而反下之。成结胸。下利不止。水浆不下。其人心烦。（生姜泻心汤或小陷胸汤）太阳
病。反下之。利遂不止。脉促者。表未解也。喘而汗出。（葛根黄芩黄连汤）太阳病二三日。
不能卧。心下必结。脉微弱者。本有寒也反下之。若利止。必结胸未止者。四日复下之。
此
干噫食臭。胁下有水气。腹中雷鸣下利。（生姜泻心汤）太阳下利。头痛。心下痞。胁下痛
。干呕。短气。汗出。不恶寒此表解里未和也。（十枣汤）十三日过经谵语者。热也。当下之
。若小便利者。大盒饭硬。而反下利。医以丸药下之。非其治也。自利者。脉当微。今反和
者。内实也。（调胃承气汤）下后利不止。身痛者。急当救里。（四逆汤）身痛。便调。急当救
表。（桂枝汤）下利心痞。复下之。利不止。治以理中。利益甚。理中者。理中焦。此利在下
焦。（赤石脂禹余粮汤）过经十余日。欲吐。胸中痛。大便反溏。微满微烦。（调胃承气伤以
上皆太阳）阳明病。潮热。大便溏。胸胁满。（小柴胡汤）无表里症。发热七八日。脉虽浮数
可下。下后脉数不解。而利不止。必便脓。（黄芩汤柏皮汤）阳明少阳合病。必下利。其脉
不滑而数。有宿食也。（大承气汤）脏结如结胸状如故。时时下利。寸脉浮关脉小细沉紧。舌
上胎滑者难治。（以上皆阳明）十三日不解。胸胁满而呕。日晡潮热。微利。此本柴胡症。
下之不利。今反利者。误以丸药下之也。潮热者。实也。（先以柴胡解外复以柴胡加芒硝
此条当属少阳）自利。不渴。属太阴。脏有寒也。（四逆辈）太阴病。脉弱自利。设当行芍药大
黄者。宜减之。以胃弱易动故也。脉浮而缓。手足温者。当发身黄。若小便利者。不发黄。
至七八日。虽暴下利。必自止。以脾家秽腐当去故也。（平胃散加穿山甲以上皆太阴）少阴病
。欲吐不吐。但欲寐。五六日自利而渴者。少阴虚。故引水自救。若小便色白者。下焦虚寒
。（四逆汤）少阴病。下利咽痛。胸满心烦。（猪肤汤）少阴病。四逆。泄利下重。（四逆散）少
阴病。下利六七日。咳而呕渴。心烦不眠。（猪苓汤）少阴病。下利清水。纯青。心下痛。口
干燥（大承气汤急下之）少阴腹痛。小便不利。下利脓血。（桃花汤）少阴病。腹痛小便不利。肢
重而痛。自下利者。此为水气或咳或呕。或小便利者。（真武汤）少阴病。下利清谷。里寒外热
。厥逆脉微。反不恶寒。面赤。或腹痛。或干呕。或咽痛。或利止脉 不出。（通脉四逆汤）少阴
病。下利脉微。与白通汤。利不止。厥逆无脉。干呕烦者。白通加猪胆汁。服汤后。脉暴出
者死。微续者生。少阴病。脉紧至七八日自利。脉微手足反温。脉紧反去者。为欲解也必自
愈。少阴病。脉沉微欲卧。汗出而烦。欲吐自利。烦躁不寐者死。少阴病。利止。眩冒者死
。少阴病。恶寒。身蜷而利。手足逆冷者死。（以上皆少阴）下利欲饮水者。热也。（白头翁
汤）厥阴病。脉浮而迟。表热里寒。下利清谷。（四逆汤）大汗出。热不去。内拘急。四肢疼
。下利。厥逆恶寒。（四逆汤）下利清谷不可攻表。汗出必胀满。（四逆汤）下利。脉沉迟。面
少赤。身微热。下利清谷者。必郁冒汗出而解。下虚必微厥。（四逆汤）发热下利。厥逆。躁
不得卧者死。发热下利。厥不止者死。汗不止者亦死。下利脉反实者死。（以上皆厥阴）
按下利有寒热之分。最宜详辨。凡寒泻者。口不燥渴。脐下多寒。小便清利。脉来沉迟
细软无力。完谷不化。粪色淡白。或淡黄色。或如骛溏。或身虽热。手足逆冷。皆为寒也。凡热
泻者。口必燥渴。脐下多热。小便黄赤。或涩而不利。脉来数大。或浮。或滑。或弦。粪色
焦黄。或热而臭。或粪出声响。得凉药与冷冻饮料则减。得热药与热饮则增。皆为热也。热泻亦
有邪热不杀谷者。与寒泻之完谷不化相似。当以他症。及脉色辨之。身不热。手足温者。属
太阴经。身体四逆。属少阴厥阴二经。身热者。皆属阳明经。然阴利有反发热者。不可因其
热遂以为阳也。未可下而早下之内虚热入名为挟热下痢。
凡胃虚脉弱。热渴自利者。必用四
君子汤。如发热者。四君子加柴胡黄连。若腹满。小便不利。五苓散。合理中汤。呕则加藿
香半夏陈皮生姜。湿则加苍术。胀则加浓朴。腹痛加芍药木香。如脉浮者。表邪未解。小青
龙去麻黄。加芫花。此散表兼治水也。凡下利不可发汗。当先治利。利止则正气复。而邪自解
。盖因利内虚。若误汗之。则内外皆虚。变证危殆。
(Self-purging refers to diarrhea occurring without prior purgative treatment, commonly known as "leaky bottom." Self-purging can occur in all six meridians; however, the patterns of exterior/interior and cold/heat differ, necessitating distinct therapeutic approaches.)
Taiyang Disease:
Exterior pathogen unresolved. Fluid retention in the epigastrium. Dry retching. Fever accompanied by cough. Thirst may or may not be present. Diarrhea may or may not be present. Dysuria. Hypogastric fullness or wheezing. (Xiao Qing Long Tang / Minor Blue Dragon Decoction)
Combined disease of Taiyang and Yangming. Spontaneous diarrhea is inevitable. (Ge Gen Tang / Pueraria Decoction)
Taiyang exterior symptoms remain uneliminated, yet multiple purgations have been applied. This results in diarrhea with heat. Epigastric stiffness and fullness. Exterior and interior both unresolved. (Gui Zhi Ren Shen Tang / Cinnamon Twig and Ginseng Decoction)
Combined disease of Taiyang and Shaoyang. Spontaneous diarrhea. (Huang Qin Tang / Scutellaria Decoction; if vomiting occurs, use Huang Qin Jia Ban Xia Sheng Jiang Tang / Scutellaria Decoction plus Pinellia and Fresh Ginger)
Combined disease of Taiyang and Shaoyang, mistakenly treated with purgation. This forms a Chest Binding (Jie Xiong). Diarrhea persists. Inability to take fluids. The patient is vexed. (Sheng Jiang Xie Xin Tang / Fresh Ginger Drain the Epigastrium Decoction or Xiao Xian Xiong Tang / Minor Sinking into the Chest Decoction)
Taiyang disease, mistakenly purged. Diarrhea persists. A rapid pulse indicates the exterior remains unresolved. Wheezing and sweating. (Ge Gen Huang Qin Huang Lian Tang / Pueraria, Scutellaria, and Coptis Decoction)
On the second or third day of Taiyang disease. Inability to lie down. The epigastrium must be obstructed. A faint pulse indicates pre-existing cold. Mistakenly purged. If diarrhea stops, Chest Binding will surely form; if diarrhea continues, purging again on the fourth day leads to hiccups with the smell of food, fluid retention in the hypochondrium, borborygmus, and diarrhea. (Sheng Jiang Xie Xin Tang / Fresh Ginger Drain the Epigastrium Decoction)
Taiyang diarrhea. Headache. Epigastric obstruction. Hypochondriac pain. Dry retching. Shortness of breath. Sweating. No aversion to cold. This indicates the exterior is resolved but the interior is disharmonious. (Shi Zao Tang / Ten Jujube Decoction)
After thirteen days, exceeding the transmission cycle, delirium indicates heat. Purging is indicated. If urination is free, stool should be hard. Instead, diarrhea occurs. The physician used pill-form purgatives, which was incorrect. In self-purging, the pulse should be faint. Now it appears harmonious, indicating internal excess. (Tiao Wei Cheng Qi Tang / Regulate the Stomach and Direct Downward Decoction)
After purgation, diarrhea persists. Body pain requires urgent rescue of the interior. (Si Ni Tang / Four Reversals Decoction)
Body pain. Normal bowel movement. Urgent resolution of the exterior is required. (Gui Zhi Tang / Cinnamon Twig Decoction)
Diarrhea with epigastric obstruction. Further purgation causes persistent diarrhea. Treatment with Li Zhong Tang / Regulate the Middle Decoction exacerbates the diarrhea. Li Zhong Tang regulates the Middle Jiao; this diarrhea originates from the Lower Jiao. (Chi Shi Zhi Yu Yi Liang Tang / Red Clay and Metastone Decoction)
After more than ten days. Desire to vomit. Chest pain. Stool is loose. Mild fullness and mild vexation. (Tiao Wei Cheng Qi Tang / Regulate the Stomach and Direct Downward Decoction — All above belong to Taiyang)
Yangming Disease:
Tidal fever. Loose stool. Fullness in the chest and hypochondrium. (Xiao Chai Hu Tang / Minor Bupleurum Decoction)
No obvious exterior or interior excess symptoms. Fever for seven to eight days. Although the pulse is floating and rapid, purging may be considered. After purgation, if the rapid pulse persists and diarrhea continues, pus and blood in the stool are inevitable. (Huang Qin Tang / Scutellaria Decoction or Huang Bo Tang / Phellodendron Decoction)
Combined disease of Yangming and Shaoyang. Diarrhea is inevitable. The pulse is not slippery but rapid, indicating retained food stagnation. (Da Cheng Qi Tang / Major Direct Downward Decoction)
Zang Binding presents like Chest Binding. Frequent diarrhea. Floating pulse at the Cun position; small, thin, deep, and tight pulse at the Guan position. Slippery coating on the tongue indicates a difficult-to-treat condition. (All above belong to Yangming)
Shaoyang Disease:
Thirteen days without resolution. Chest and hypochondriac fullness with vomiting. Tidal fever in the late afternoon. Mild diarrhea. This was originally a Chai Hu pattern. Purging should not cause diarrhea; the current diarrhea resulted from mistaken use of pill-form purgatives. Tidal fever indicates excess. (First use Chai Hu Tang / Bupleurum Decoction to resolve the exterior, then use Chai Hu Jia Mang Xiao Tang / Bupleurum Decoction plus Gypsum — This clause belongs to Shaoyang)
Taiyin Disease:
Spontaneous diarrhea without thirst belongs to Taiyin. Cold in the Zang organs. (Si Ni Tang / Four Reversals Decoction or similar formulas)
Taiyin disease. Weak pulse with spontaneous diarrhea. If Peony and Rhubarb were indicated, their dosage should be reduced because the stomach is weak and easily disturbed. A floating and slow pulse with warm hands and feet suggests jaundice will develop. If urination is free, jaundice will not develop. By the seventh or eighth day, even sudden severe diarrhea will stop spontaneously, as the turbid filth of the Spleen is being expelled. (Ping Wei San / Calm the Stomach Powder plus Schizonepetae Herba / Jingjie - *Note: Text says Shan Jian Jia, likely referring to Pangolin Scales or similar, translated as Pangolin Scales based on context of penetrating blockage*) (All above belong to Taiyin)
Shaoyin Disease:
Desire to vomit but unable to. Only desire to sleep. After five to six days, spontaneous diarrhea with thirst indicates Shaoyin Yin deficiency, leading to water intake for self-rescue. If urine is white, it indicates Lower Jiao deficiency-cold. (Si Ni Tang / Four Reversals Decoction)
Shaoyin disease. Diarrhea. Sore throat. Chest fullness and vexation. (Zhu Fu Tang / Pig Skin Decoction)
Shaoyin disease. Cold extremities. Diarrhea with a sensation of heaviness in the anus. (Si Ni San / Four Reversals Powder)
Shaoyin disease. Diarrhea for six to seven days. Cough, vomiting, thirst, vexation, and insomnia. (Zhu Ling Tang / Polyporus Decoction)
Shaoyin disease. Diarrhea of clear water, purely green. Epigastric pain. Dry mouth. (Use Da Cheng Qi Tang / Major Direct Downward Decoction urgently to purge)
Shaoyin abdominal pain. Dysuria. Diarrhea with pus and blood. (Tao Hua Tang / Peach Blossom Decoction)
Shaoyin disease. Abdominal pain, dysuria, heavy and painful limbs, spontaneous diarrhea. This is Water Qi pathology. May include cough or vomiting. Or if urination is free. (Zhen Wu Tang / True Warrior Decoction)
Shaoyin disease. Diarrhea with undigested food. Interior cold with exterior heat. Cold extremities, faint pulse. Paradoxical lack of aversion to cold. Flushed face. Abdominal pain, dry retching, sore throat, or cessation of diarrhea with absent pulse. (Tong Mai Si Ni Tang / Pulse-Returning Four Reversals Decoction)
Shaoyin disease. Diarrhea with faint pulse. Administer Bai Tong Tang / White Pass Decoction. If diarrhea persists, cold extremities, absent pulse, dry retching, and vexation occur. Use Bai Tong Jia Zhu Dan Jiang Tang / White Pass Decoction plus Pig Bile. If the pulse suddenly emerges after ingestion, death ensues. If the pulse gradually returns, life is preserved. Shaoyin disease. Tight pulse. By the seventh or eighth day, spontaneous diarrhea. Faint pulse, warm extremities. Disappearance of the tight pulse indicates impending resolution and spontaneous recovery. Shaoyin disease. Deep and faint pulse, desire to lie down. Sweating, vexation, desire to vomit, spontaneous diarrhea, restlessness, and insomnia indicate death. Shaoyin disease. Cessation of diarrhea with dizziness indicates death. Shaoyin disease. Aversion to cold, curled posture with diarrhea, and cold extremities indicate death. (All above belong to Shaoyin)
Jueyin Disease:
Diarrhea with desire to drink water indicates heat. (Bai Tou Weng Tang / Pulsatilla Decoction)
Jueyin disease. Floating and slow pulse. Exterior heat with interior cold. Diarrhea with undigested food. (Si Ni Tang / Four Reversals Decoction)
Profuse sweating. Heat persists. Internal tension. Limb pain. Diarrhea. Cold extremities and aversion to cold. (Si Ni Tang / Four Reversals Decoction)
Diarrhea with undigested food contraindicates exterior resolution. Sweating will inevitably cause abdominal fullness. (Si Ni Tang / Four Reversals Decoction)
Diarrhea. Deep and slow pulse. Slight facial redness. Mild body heat. Diarrhea with undigested food. This will inevitably lead to Yu Mao (depression and vertigo) with sweating, resulting in resolution. Lower deficiency leads to slight cold extremities. (Si Ni Tang / Four Reversals Decoction)
Fever, diarrhea, cold extremities, and restlessness preventing lying down indicate death. Fever, diarrhea, and persistent cold extremities indicate death. Persistent sweating also indicates death. Diarrhea with a surprisingly solid pulse indicates death. (All above belong to Jueyin)
Commentary:
Diarrhea is divided into cold and heat types, requiring careful differentiation. Cold diarrhea is characterized by no oral dryness/thirst, coldness below the umbilicus, clear and free urination, a deep, slow, fine, soft, and powerless pulse, undigested food in stool, pale or pale-yellow stool, or duck-like loose stool. Even if the body is hot, cold extremities indicate cold. Hot diarrhea is characterized by oral dryness/thirst, heat below the umbilicus, yellow-red or obstructed urination, a rapid, large, floating, slippery, or wiry pulse, dark yellow, hot, or foul-smelling stool, or noisy defecation. Symptoms improve with cool medicines/cold drinks and worsen with hot medicines/hot drinks, indicating heat. Hot diarrhea may also involve failure to digest grain due to pathogenic heat, resembling cold diarrhea's undigested food; differentiation relies on other symptoms and pulse/tongue signs. Body heatlessness and warm extremities indicate Taiyin Meridian involvement. Cold extremities indicate Shaoyin or Jueyin Meridian involvement. Body heat indicates Yangming Meridian involvement. However, Yin-type diarrhea may paradoxically present with fever; one must not assume it is Yang-pattern solely due to heat. Premature purgation when inappropriate leads to interior deficiency and heat invasion, termed "Diarrhea with Heat Clinging" (Jia Re Xia Li).
For patients with weak Stomach Qi, weak pulse, fever, thirst, and spontaneous diarrhea, Si Jun Zi Tang / Four Gentlemen Decoction is mandatory. If fever is present, add Chai Hu / Bupleuri Radix and Huang Lian / Coptidis Rhizoma to Si Jun Zi Tang. If abdominal fullness and dysuria occur, use Wu Ling San / Five-Ingredient Powder with Poria combined with Li Zhong Tang / Regulate the Middle Decoction. For vomiting, add Huo Xiang / Pogostemonis Herba, Ban Xia / Pinelliae Rhizoma, Chen Pi / Citri Reticulatae Pericarpium, and Sheng Jiang / Zingiberis Rhizoma Recens. For dampness, add Cang Zhu / Atractylodis Rhizoma. For fullness, add Hou Po / Magnoliae Officinalis Cortex. For abdominal pain, add Shao Yao / Paeoniae Radix and Mu Xiang / Aucklandiae Radix. If the pulse is floating, indicating unresolved exterior pathogen, use Xiao Qing Long Tang / Minor Blue Dragon Decoction removing Ma Huang / Ephedrae Herba and adding Yuan Hua / Genkwa Flos. This disperses the exterior while managing water retention. Generally, diarrhea contraindicates diaphoresis. One must treat the diarrhea first. Once diarrhea ceases, righteous Qi recovers, and pathogens resolve naturally. Since diarrhea causes interior deficiency, mistaken sweating leads to dual interior-exterior deficiency and critical transformation patterns.