【纲】仲景曰。太阳病。二三日不得卧。但欲起。心下必结。脉微弱者。此本有寒分也。反下
之。若利止。必作结胸。未止者。四日复下之。必作协热利。太阳病。外症未除。而数下之。遂协
热而利。利下不止。心下痞硬。表理不解者。桂枝人参汤主之。太阳病。桂枝症。医反下之。利
遂不止。脉促者。表未解也。喘而汗出。葛根黄连黄芩汤主之。
【目】张兼善曰。仲景言表症未除而误下之。因致外热未退。内复作利。故云协热下利。此一
热字。乃言表热也。非言内热也。夫协者协同之协。非挟藏之挟。即表里俱病之谓。故治此者。
止有桂枝人参汤一方。其又显然可见。即如成无己曰。表邪传里。里虚协热则利。是亦以表邪为言
也。奈何后学不明。止因协热二字。但见作利者。无论表里虚实。
即认为内热。便云协热下利。且近有不必误下。而妄用芩连治表热者。表症得寒。热愈不退。力致
下利。或脾素弱。逢寒即泄者。皆是此症。既见下利。盖云协热。其谬甚矣。独不观仲景桂枝人参
汤。岂治内热之剂乎。寒热倒施。杀人多矣。
柯琴曰。首条。论协热之因。二条。明下利之治。桂枝人参汤。双解表里也。三条。利遂不止。
所谓暴注下迫。皆属于热。盖微热在表。大热入里者。故与首条脉弱而协热下利不同。
【纲】仲景曰。太阳病。下之。其脉促。不结胸者。为欲解。脉沉滑者。协热利。脉浮滑者。
必下血。
【目】王肯堂曰。协热利。热病也。
[Outline] Zhang Zhongjing stated: In Taiyang disease (a syndrome caused by pathogenic factors affecting the Taiyang meridian), if after two or three days the patient cannot lie flat but desires to sit up, there will inevitably be a sensation of fullness and obstruction in the epigastrium. If the pulse is faint and weak, this indicates that cold-dampness was originally present within the body. If purgatives are erroneously administered, and the diarrhea stops, Jie Xiong (Chest Binding, a condition characterized by the accumulation of water-heat in the chest and diaphragm) will inevitably develop. If the diarrhea does not stop, and purgatives are administered again on the fourth day, Xie Re Li (Diarrhea accompanying exterior heat) will inevitably result.
In Taiyang disease, if the exterior symptoms have not been resolved but multiple purgative treatments are used, the exterior pathogen may penetrate inward, combining with interior heat to cause diarrhea. If the diarrhea persists incessantly, accompanied by a hard and obstructed sensation in the epigastrium, and neither the exterior nor the interior pattern is resolved, Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) should be administered.
In Taiyang disease, if Gui Zhi Tang Syndrome (Exterior deficiency syndrome characterized by wind-cold invasion) is present, but the physician erroneously uses purgatives, leading to incessant diarrhea, and the pulse is rapid (Cu), it indicates that the exterior pattern has not yet resolved. If accompanied by wheezing and sweating, Gegen Huanglian Huangqin Tang (Kudzu, Coptis, and Scutellaria Decoction) should be administered.
[Commentary] Zhang Jianshan stated: When Zhang Zhongjing mentioned that erroneous purgation while the exterior pattern remains leads to unresolved exterior heat and subsequent internal diarrhea, he termed it "Xie Re Xia Li" (Diarrhea accompanying exterior heat). The character "Re" (Heat) here refers to exterior heat, not interior heat. The character "Xie" (Coordinate/Assist) denotes coordination, not "Xia" (Clutch/Carry); it signifies that both exterior and interior are diseased. Therefore, for treating this condition, there is only one formula, Guizhi Renshen Tang, which is evident. As Cheng Wuji stated, "When exterior pathogens transmit to the interior, interior deficiency coordinates with heat to cause diarrhea." This also bases its argument on exterior pathogens. However, later scholars failed to understand this; merely because of the term "Xie Re," whenever they observed diarrhea, regardless of whether it involved exterior/interior or deficiency/excess, they assumed it was interior heat and labeled it Xie Re Xia Li. Moreover, recently some practitioners, without prior erroneous purgation, recklessly use Huang Qin (Scutellariae Radix) and Huang Lian (Coptidis Rhizoma) to treat exterior heat. When exterior patterns are treated with cold-natured herbs, the heat fails to dissipate and instead induces diarrhea. Or, in patients with inherently weak Spleen function who experience loose stools upon exposure to cold, these are all such cases. To label such diarrhea as "Xie Re" is a grave error. Have they not examined Zhang Zhongjing's Guizhi Renshen Tang? Is that not a formula for treating interior heat? Reversing cold and heat treatments has killed many people.
Ke Qin stated: The first paragraph discusses the etiology of Xie Re (accompanying heat); the second clarifies the treatment for diarrhea. Guizhi Renshen Tang resolves both the exterior and interior. The third paragraph mentions incessant diarrhea, which corresponds to the principle that "acute watery diarrhea and tenesmus belong to heat." This implies that mild heat resides in the exterior, while severe heat enters the interior. Thus, it differs from the case in the first paragraph where the pulse is weak and accompanied by Xie Re diarrhea.
[Outline] Zhang Zhongjing stated: In Taiyang disease, after purgation, if the pulse is rapid (Cu) and Jie Xiong (Chest Binding) does not form, it indicates that the condition is about to resolve. If the pulse is deep and slippery (Chen Hua), it indicates Xie Re Li (Diarrhea accompanying exterior heat). If the pulse is floating and slippery (Fu Hua), hematochezia (blood in stool) will inevitably occur.
[Commentary] Wang Kentang stated: Xie Re Li (Diarrhea accompanying exterior heat) is a type of heat disease.