【纲】仲景曰。少阴病。脉沉者。急温之。宜四逆汤。
自利。不渴者。属太阴。以其脏有寒故也。急温之。宜四逆辈。
若膈上有寒饮者。急温之。宜四逆汤。
【目】李 曰。脉沉厥冷。膈上寒饮。干呕。或时头痛。皆寒气上攻也。急温之。三味参萸汤。
内寒已极。厥逆吐利。不渴静蜷。阳和之气欲绝。六脉若有若无。急温之。四逆汤。凡言急者。
病势已笃。将有变革。非若他病可以缓也。他如太阳汗出不止。汗后恶风。汗后烦躁心悸身痛。皆
急用附子加肉桂、白芍之类。三阳脉迟腹痛。建中汤。当先施也。但一服中病即止。伤寒之药皆然。
鳌按。脏有寒。则寒之蓄于内者甚深。脉沉为在里。亦知其内寒已甚。阳和之气欲绝。膈上寒
饮。则阴寒之气固结不散。皆用温法。所谓救急之方也。
【纲】仲景曰。病患脉阴阳俱紧。反汗出者。亡阳也。此属少阴。法当咽痛而复吐利。脉阴阳
俱紧。至于吐利。其脉独不解。紧去人安。此为欲解。少阴病。脉解。至七八日。自下利。脉暴微。
手足反温。脉紧反去者。为欲解也。虽烦下利。必自愈。
【目】朱肱曰。伤寒下利多种。须辨阴阳。勿令差误。三阳下利则身热。太阴下利则手足温。
少阴厥阴下利则身不热。以此别之。大抵下利挟太阳脉症。便不得用温药。俗医但见下利。便作阴
症。用温热药。鲜不发黄生斑而死。
大抵伤寒下利。须识脉与外症不同。下利而脉大者。虚也。脉微弱者。为自止。下利日十余行。脉
反实者逆。下利脉数而滑。有宿食也。下之愈。脉迟而滑者。实也。其利未得便止。宜更下之。下
利三部脉皆平。按其心下硬者。急下之。协热利者。脐下必实。大便赤黄色。及肠间津液垢腻。寒
毒入胃。则脐下必寒。腹胀满。大便或黄白青黑。或下利清谷。温毒瓦斯盛。则下利腹痛。大便如脓血。
如烂肉汁。更下利。欲饮水者。有热也。下利谵语。有燥屎也。寒毒入胃者。四逆汤、理中汤、白
通汤、附子四逆散。加薤白主之。协热利者。黄芩汤、白头翁汤、三黄熟艾汤、赤石脂丸。温毒下
脓血者。桃花汤、地榆散、黄连阿胶汤。虽然。自利而渴。属少阴。然三阳下利。亦有饮水者。乃有
热也。三阴下利。宜温之。然少阴自利清水。心下痛。口干燥者。却宜下之。此又不可不知也。
少阴泄利下重。不可投热药。先浓煎薤白汤。内四逆散。缘此散用枳实、芍药辈也。又寻常胃中
不和。腹痛肠鸣下利者。生姜泻心汤最妙。此二法。不特伤寒症也。若脉沉自利。而身体痛者。阴
症也。急当救里。宜四逆汤、附子汤、真武汤。大抵大便利而身体疼者。当救里。大便如常而身体
痛者。当救表。不可不知。
成无己曰。自利者。不因攻下而自泄泻也。有表邪传里。里虚协热而利者。有不因攻下而遂利者。
皆协热也。又三阳
合病。皆作自利。有攻表攻里和解之不同。何则。太阳阳明合病。为在表。故与葛根汤汗之。太阳少
阳合病。为半表里。故与黄芩汤和之。阳明少阳合病。为少阳邪气入里。故与承气下之。
下利虽有表症。不可发汗。以下利为邪气内攻。走津液而胃虚也。经曰。下利不可攻表。汗出。
必胀满是也。盖三阴自利居多。然自利家身凉脉静为顺。身热脉大为逆。大抵下利。脱气。又为难
治。盖邪盛正虚。邪壅正气下脱。多下利而死也。
【纲】仲景曰。脉阴阳俱紧者。口中气出。唇口燥干。鼻中涕出。蜷卧。足冷。舌上胎滑。勿
妄治也。到六七日以来。其人微发热。手足温者。此为欲解。或到八日以上。反大发热者。此为难
治。设使恶寒者。必欲呕也。腹内痛者。必欲利也。
【目】柯琴曰。使七八日来。不能发热。以阴阳俱紧之脉。反加恶寒。是寒甚于表。上焦应之。
必呕。反加腹痛。是寒甚于里。中焦受之。必利。
【纲】仲景曰。少阴病。吐利。手足不逆冷。反发热者。不死。脉不至者。灸少阴七壮。
少阴病。吐利。烦躁。四逆者死。
【目】庞安常曰。此由胃脘之阳将绝。故上吐而下利也。
【纲】仲景曰。少阴病。脉微涩。呕而汗出。大便数而少者。宜温其上。灸之。少阴病。脉沉
微细。但欲卧。汗出
不烦。自欲吐。至六日。自利。复烦躁。不得卧寐者死。
【目】陈士铎曰。伤寒而脉沉微细。明是阴症。况欲卧而欲动乎。汗已出矣。内无阳症可知。
心中不烦。时欲呕吐。此阳邪已散。阴邪作祟。急宜祛寒为是。乃失此不温。至五六日而下利。是
上下俱乱也。此时尚不烦躁。则肾中之真阳未散。今又加烦躁不得卧寐。明是奔越而不可回之兆矣。
非死症而何。然其先原因失治而不可救。非本不可救而成此扰乱之症也。有一奇方。名转阳援绝汤。
人参、白术、枣仁各一两。茯神五钱。肉桂二钱。水煎。一帖即安。人参救绝。白术、茯神分消水
湿而止利。桂以温中去寒。枣仁安心解躁。
【纲】仲景曰。少阴病。二三日不止。至四五日。腹痛。小便不利。四肢沉重疼痛。自下利者。
此为有水气。其人或咳。或小便利。或下利。呕者。真武汤主之。
【目】吴绶曰。凡自利者。不因攻下而自泻利。俗言漏底伤寒是也。有协热。有协寒。俱宜详
辨。原病式曰。泻白为寒。泻青黄赤黑。皆为热也。大抵完谷不化。色不寒。有如 溏。或泻利腥
臭。小便澄彻清冷。口无燥渴。其脉沉细。或迟微无力。或身虽热。手足逆冷。恶寒蜷卧。此皆寒也。
凡热症。口中燥渴。小便黄赤。或涩。或所下如垢腻。其脉多数。或浮。或滑。或弦。或大。或洪。
或邪热不杀谷。其物不消化者。当以脉症别之。凡胃虚内热。烦渴泻利。脉弱者。七味人参白术
散。若发热者。参胡三白汤。去黄芩加炒黄连。若腹满小便不利者。五苓散合理中汤。若呕者。加
藿香、半夏、生姜、陈皮。如湿多而泻不止者。加二术。腹胀。加浓朴。腹疼。加白芍、肉桂、木
香。凡伤寒作利。脉浮。表未解。仲景以小青龙去麻黄加炒芫花二钱。盖散表即治水也。若小便涩。
大便水泻不止。五苓散。水甚不解。亦加芫花二钱以行水。或车前子汤。利自止也。凡下利。不
可发汗。当先治利。利止内实。正气得复。邪气得解。则汗出而愈也。盖利下由内虚。若加发汗。
则内外皆虚。变症。为难治也。
苏颂曰。为有水气。是真武汤本旨。下利亦水气为患也。后三项。乃真武汤加减法。
【纲】仲景曰。少阴病。二三日至四五日。腹痛小便不利。下利不止。便脓血者。桃花汤主之。
【目】庞安常曰。此由寒毒入胃。故腹痛而下利也。
【纲】仲景曰。大汗。若大下利。而厥冷者。四逆汤主之。
大汗出。热不去。内拘急。四肢疼。又下利。厥逆而恶寒者。四逆汤主之。自利。不渴者。属
太阴。以其脏有寒故也。当温之。宜四逆辈。
【目】柯琴曰。大汗则亡阳。大下则亡阴。阴阳俱虚。故厥冷。但利非清谷。急温之。阳回而
生可望也。二条。是治之失宜
者。虽大汗出而热不去。恶寒。表未除也。拘急下利。里寒已发。肢疼厥冷。表寒又见。可知表热
里寒者。即表寒亡阳也。
【纲】仲景曰。少阴病。下利清谷。里寒外热。手足厥逆。脉微欲绝。身反不恶寒。其人面色
赤。或腹痛。或干呕。或咽痛。或利止。脉不出者。通脉四逆汤主之。
【目】柯琴曰。咽痛利止。阳回于内也。腹痛干呕。寒热交争也。
【纲】仲景曰。少阴病。咳而下利。谵语者。被火气劫故也。小便必难。以强责少阴汗也。
【目】喻昌曰。少阴之脉。从足入腹。上循喉咙。萦绕舌根。故多咽痛之症。其支别出肺。故
间有咳症。今以火气强劫其汗。则热邪挟火力上攻。必为咳。以肺金恶火故也。下攻必为利。以火
势逼迫而走空窍故也。内攻。必谵语。以火势燔灼而乱神明故也。小便必难者。见三症皆妨小便。
若肺为火气所伤。则膀胱气化不行。大肠奔迫无度。则水谷并趋一路。心胞燔灼不已。则小肠枯
涸不至耳。少阴可强责其汗乎。
肾有热邪。其表腑之膀胱必应。小便所以不利也。咳而下利。肺大肠表里之义乎。
魏荔彤曰。此申解少阴传经热邪。入里为患。不可认为直中之寒邪误治。反强责其汗以致难治
也。少阴病。有传经热邪。有直中寒邪。固已。然热邪之传。原在经也。而肾脏可以并见。病若直
中之邪。则必分为经为脏矣。为脏者。尚单用温而不用散。为经者。方既用温而复用散。是脏病原
无散法也。况为传经入里之热邪乎。又岂可以温散之法治之乎。故热邪久而方炽。必不可用温。又
传入里而愈深。更不可用散。此在太阳入阳明之里。已忌发汗矣。再递传三阴。至少阴。下之极。
深之尽。为里中之里矣。其忌妄发强责其汗也。何待言乎。惟是少阴一经。兼直中之寒邪在内。法
有温经散寒。近于取汗之义。仲师恐人误认以之治传经之少阴。故特标出示之。正见附子麻黄细辛
甘草纯为寒邪直中少阴经而设也。寒邪直中少阴脏。且言温而不言散也。并非为少阴传经之热邪。
病及于少阴肾脏者言也。
此乃大关键处。历来无明白剖析者。不可不详辨也。如本条之上曰。少阴病。脉细沉数。病为在里。
不可发汗。而继之以本条云云。夫少阴脉本微细。今细如故。而见沉见数。盖细乃厥阴之少阴也。而
沉为少阴正脉也。今不见太阴之微。而反见阳脉之数。数者迟之对。见为微为数。皆于沉中重取辨
之也。推此则为细为弦。亦于沉之轻取辨之也。所以沉为少阴本脉也。诊其人。轻取之。沉上见细。
重取之。沉下见微。此少阴直中之寒邪也。或宜温中。或宜散寒。再徐察之。而直中少阴之脏病
经病咸得矣。若诊其人。轻取。沉上仍见细。重取之。沉中不见微而见数矣。此乃少阴传经之热邪
也。就沉中重取一诊。而分少阴寒热之二邪。此定诀也。审乎此。则知非直中之表病。而为传经之
里病也。盖在风寒初感。不论何经。总为表症。当发汗。故三阴即少阴亦可发汗。如麻黄附子细辛
甘草汤症是也。在传经愈深。不论何经。总为里症。皆不当发汗。故三阳即太阳亦不可发汗。如抵
当汤、五苓散等症是也。知乎此。方可言表里。不致以三阳定为表。三阴定为里。固执不通之论所
惑也。且明乎发汗之义。则治传里之热邪。方有随机应变之法。而亦不可执一。故仲师但言不可发
汗。并不出方。不出方者。方出之于后也。但言不可发汗者。妄发强责。则为祸不旋踵也。请试申
之。如咳而下利谵语者。此传经之热邪递及少阴也。设以火劫汗。少阴一经。气血本少。热邪又入
耗损。又火劫强责其汗。则阴愈亏短。津液内亡。小便必难也。胃亡津而小便利者。津亡于上而气
化尚行于下。此则肾阴有伤。津亡于下。而气化不行矣。强责少阴之汗。用火劫。似邪止伤其阳分
表分。而津亡气耗。为害已如是。可不慎乎。
【纲】仲景曰。伤寒六七日。大下后。寸脉沉而迟。手足厥冷。下部脉不至者。咽喉不利。吐
脓血。泄利不止者。此为难治。
【目】陶华曰。六腑气绝于外者。手足寒。五脏气绝于内者。下利不禁。此之谓也。
【纲】仲景曰。少阴病。吐利。手足厥冷。烦躁欲死者。吴茱萸汤主之。
干呕。吐涎沫。头痛者。吴茱萸汤主之。
食谷欲呕者。属阳明也。吴茱萸汤主之。得汤反剧者。属上虚也。
【目】鳌按。吐利烦躁。是阴邪入于合。而不得从阳以出乎外也。干呕者。呕而无物。胃虚也。
吐涎沫。胃寒也。食谷欲呕。谷气入于胃。即拒之而出。亦胃寒也。得汤者。即吴茱萸汤也。服之
反剧。以上焦有痰饮。俟呕尽自愈也。
【纲】仲景曰。少阴病。下利。脉微者。与白通汤。利不止。厥逆无脉。干呕烦者。白通加猪
胆汁汤主之。服汤后。脉暴出者死。微续者生。
【目】张元素曰。或谓白通汤、白通加猪胆汁汤、真武汤、通脉四逆汤。皆为少阴下利而设。
除用姜附相同。其余之药。俱各殊异。何也。盖病殊则药殊。夫少阴下利。寒气已甚。非姜附不治。
然下利之理无殊。而兼有之症不一。用药故不同耳。如白通用姜附以散寒止利。加葱白以通调阳气。
若利而干呕烦者。寒太甚。内为格拒。姜附非烦者之所宜。必呕而不纳。加人尿猪胆汁于白通汤中。
候温冷服之。二味皆咸苦性寒。是以纳而不阻。至其所。则冷体既消。热性便发。真武治少阴二三
日至四五日。腹痛小便不利四肢沉重疼痛自下利者。为有水气。故多或为之症。夫水气者。寒湿也。
肾主之。肾病不能制水。水饮停蓄。为腹痛。寒湿内甚也。肢重疼痛。寒湿外甚也。小便不利。
自下利者。湿甚而水谷不能别也。经曰。脾恶湿。甘先入脾。苓、术之甘以益脾逐水。湿所胜。平
以辛热。湿淫所胜。佐以酸辛。附子、芍药、生姜之酸辛。以温经散湿。小青龙症。亦为有水气。
[Outline] Zhang Zhongjing said: In Shaoyin disease, if the pulse is deep (Chen), urgent warming is required. Si Ni Tang (Cinnamon Twig and Prepared Aconite Decoction) is indicated.
Spontaneous diarrhea with no thirst belongs to Taiyin disease, due to cold in the zang organs. Urgent warming is required; a class of formulas similar to Si Ni Tang is indicated.
If there is cold-fluid retention above the diaphragm, urgent warming is required. Si Ni Tang is indicated.
[Commentary] Li said: Deep pulse, cold extremities, cold-fluid retention above the diaphragm, dry retching, or occasional headache are all caused by cold qi attacking upwards. Urgent warming is required. San Wei Shen Yu Tang (Three-Ingredient Ginseng and Cornus Decoction) can be used.
When internal cold is extreme, presenting with cold extremities, vomiting and diarrhea, no thirst, quiet curling up, and the harmonious qi of yang about to perish, with six pulses appearing as if present or absent, urgent warming is required using Si Ni Tang. Whenever "urgent" is mentioned, it indicates that the disease progression is severe and changes are imminent, unlike other diseases that can be treated slowly. For example, in Taiyang disease, if sweating does not stop, or after sweating there is aversion to wind, restlessness, palpitations, and body pain, Fuzi (Prepared Aconite Root) added with Rougui (Cinnamon Bark) and Baishao (White Peony Root) should be used urgently. For three-yang meridians with slow pulse and abdominal pain, Jian Zhong Tang (Middle-Building Decoction) should be applied first. However, stop taking it after one dose if symptoms improve; this applies to all Shanghan medicines.
Shen Jin'ao notes: Cold in the zang organs means cold accumulates deeply internally. A deep pulse indicates the disease is interior, confirming severe internal cold and the impending loss of harmonious yang qi. Cold-fluid retention above the diaphragm signifies congealed yin-cold qi that does not dissipate. Both require warming methods, which are the so-called emergency rescue formulas.
[Outline] Zhang Zhongjing said: If a patient's pulse is tight at both cun and chi positions but sweats, this is Yang collapse (Wang Yang), belonging to Shaoyin. By law, this should present with sore throat accompanied by vomiting and diarrhea. When the pulse is tight at both cun and chi, and vomiting and diarrhea occur, if only the tightness disappears and the patient feels comfortable, this indicates the condition is resolving. In Shaoyin disease, if the pulse changes, and after seven or eight days, spontaneous diarrhea occurs, the pulse becomes suddenly faint (Wei), hands and feet become warm, and the tight pulse disappears, this indicates resolution. Although there is irritability and diarrhea, self-healing will occur.
[Commentary] Zhu Gong said: There are many types of diarrhea in Shanghan; one must distinguish between Yin and Yang to avoid errors. Diarrhea from the Three Yang meridians presents with fever; diarrhea from Taiyin presents with warm hands and feet; diarrhea from Shaoyin and Jueyin presents without fever. This distinguishes them. Generally, if diarrhea accompanies Taiyang pulse and symptoms, warming herbs must not be used. Quack doctors see only diarrhea and treat it as a Yin syndrome with warming-hot herbs, rarely resulting in death from jaundice and macules.
Generally, in Shanghan diarrhea, one must recognize differences between pulse and external symptoms. Diarrhea with a large pulse indicates deficiency; a faint pulse indicates diarrhea will stop spontaneously. Diarrhea occurring more than ten times a day with a surprisingly solid pulse is an adverse sign. Diarrhea with a rapid and slippery pulse indicates retained food; purgation will cure it. A slow and slippery pulse indicates excess; diarrhea will not stop immediately, and further purgation is appropriate. If the pulse at all three positions is level but pressing on the epigastrium reveals hardness, urgent purgation is needed. For heat-collusion diarrhea (Xie Re Li), there is fullness below the navel, reddish-yellow stool, and greasy intestinal fluids. If cold poison enters the stomach, there is cold below the navel, abdominal distension, and stools of various colors or undigested food. If warm-toxin qi is abundant, there is painful diarrhea with pus and blood resembling rotten meat juice. If thirst follows, there is heat. Delirium with diarrhea indicates dry feces. For cold poison entering the stomach, use Si Ni Tang, Li Zhong Tang, Bai Tong Tang, or Fu Zi Si Ni San plus Xiebai (Allium macrostemon Bulb). For heat-collusion diarrhea, use Huang Qin Tang, Bai Tou Weng Tang, San Huang Shu Ai Tang, or Chi Shi Zhi Wan. For warm-toxin causing pus and blood in stool, use Tao Hua Tang, Di Yu San, or Huang Lian E Jiao Tang. Although spontaneous diarrhea with thirst belongs to Shaoyin, Three Yang diarrhea may also involve thirst due to heat. Three Yin diarrhea requires warming. However, for Shaoyin clear-water diarrhea with epigastric pain and dry mouth, purgation is indicated. This must be known.
For Shaoyin diarrhea with a feeling of heaviness in the anus, hot herbs must not be given. First, decoct Xiebai (Allium macrostemon Bulb) tea thickly, then add Si Ni San (Bupleurum Decoction). This formula uses Zhi Shi (Immature Bitter Orange) and Shaoyao (Peony Root). For ordinary stomach disharmony with abdominal pain, borborygmus, and diarrhea, Sheng Jiang Xie Xin Tang (Ginger Decoction for Draining the Epigastrium) is best. These two methods apply not only to Shanghan. If the pulse is deep with spontaneous diarrhea and body pain, it is a Yin syndrome; urgent rescue of the interior is needed with Si Ni Tang, Fu Zi Tang, or Zhen Wu Tang. Generally, if stool is normal but body hurts, rescue the interior; if stool is normal but body hurts, rescue the exterior. This must be known.
Cheng Wuji said: Spontaneous diarrhea refers to loose stools without prior purgation. It can be due to exterior pathogen transmitting inward with interior deficiency and heat-collusion, or direct spontaneous diarrhea, both involving heat-collusion. Also, combined diseases of the Three Yang cause spontaneous diarrhea, treated by attacking the exterior, interior, or harmonizing. Why? Taiyang-Yangming combined disease is exterior, so Ge Gen Tang (Kudzu Decoction) is used to sweat. Taiyang-Shaoyang combined disease is half-exterior half-interior, so Huang Qin Tang is used to harmonize. Yangming-Shaoyang combined disease involves Shaoyang pathogen entering the interior, so Cheng Qi Tang (Order the Qi Decoction) is used to purge.
Even if diarrhea has exterior symptoms, do not sweat, because diarrhea indicates pathogen attacking inward, depleting fluids and weakening the stomach. The Classic states: Do not attack the exterior in diarrhea; sweating will cause abdominal fullness. Mostly, Three Yin spontaneous diarrhea occurs. However, cool body and quiet pulse in diarrhea is favorable; fever and large pulse is adverse. Generally, diarrhea with Qi depletion is difficult to treat because strong pathogen and deficient Zheng Qi lead to downward collapse of Qi, often resulting in death from diarrhea.
[Outline] Zhang Zhongjing said: If the pulse is tight at both cun and chi, with breath exiting the mouth, dry lips and mouth, runny nose, curling up to sleep, and cold feet, with a slippery tongue coating, do not treat rashly. After six or seven days, if the patient has slight fever and warm hands and feet, this indicates resolution. Or, if after eight days there is sudden high fever, this is difficult to treat. If there is aversion to cold, vomiting will likely occur; if there is abdominal pain, diarrhea will likely occur.
[Commentary] Ke Qin said: If after seven or eight days there is no fever, and with a tight pulse, aversion to cold worsens, cold is severe in the exterior affecting the Upper Jiao, leading to vomiting. If abdominal pain worsens, cold is severe in the interior affecting the Middle Jiao, leading to diarrhea.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with vomiting and diarrhea, if hands and feet are not cold but instead feverish, death will not occur. If the pulse is unobtainable, moxa seven burns on Shaoyin points.
In Shaoyin disease, with vomiting, diarrhea, irritability, and cold extremities, death occurs.
[Commentary] Pang Anchang said: This is due to the impending extinction of Yang qi in the stomach and duodenum, causing upper vomiting and lower diarrhea.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with a faint and choppy pulse, vomiting and sweating, frequent but scanty bowel movements, warm the upper part and apply moxibustion. In Shaoyin disease, with a deep, faint, and fine pulse, desire to sleep, sweating, no irritability, and desire to vomit, if on the sixth day spontaneous diarrhea occurs, followed by irritability and inability to sleep, death occurs.
[Commentary] Chen Shiduo said: Shanghan with deep, faint, and fine pulse is clearly a Yin syndrome. Moreover, desiring to sleep yet wanting to move? Sweat has occurred, indicating no interior Yang syndrome. No irritability in the heart, frequent desire to vomit, shows Yang pathogen has dispersed and Yin pathogen is acting. Urgent removal of cold is correct. Losing this chance not to warm leads to diarrhea on the fifth or sixth day, meaning chaos in both upper and lower. If not irritable then, true Yang in Kidney is not scattered. Now adding irritability and insomnia indicates irreversible scattering of Yuan Qi. Is this not a death case? However, the cause was missed treatment, not incurable disease becoming chaotic. There is a miraculous formula called Zhuan Yang Yuan Jue Tang (Turning Yang to Rescue Extinction Decoction): Ren Shen (Ginseng Root), Bai Zhu (Atractylodes Rhizome), Suan Zao Ren (Ziziphus Seed) each 1 liang, Fu Shen (Poria with Hostwood) 5 qian, Rou Gui (Cinnamon Bark) 2 qian. Decoct in water; one dose brings relief. Ren Shen rescues extinction; Bai Zhu and Fu Shen drain dampness and stop diarrhea; Gui warms middle and removes cold; Suan Zao Ren calms mind and relieves restlessness.
[Outline] Zhang Zhongjing said: In Shaoyin disease, persisting from two to three days to four to five days, with abdominal pain, difficulty urinating, heavy and painful limbs, and spontaneous diarrhea, this is Water Qi (fluid retention). The patient may cough, have free urination, have diarrhea, or vomit. Zhen Wu Tang (True Warrior Decoction) governs.
[Commentary] Wu Shou said: Spontaneous diarrhea refers to loose stools without purgation, commonly called "leaky bottom Shanghan." There is heat-collusion and cold-collusion, requiring detailed differentiation. *Yuan Bing Shi* states: White discharge is cold; green, yellow, red, black are heat. Generally, undigested food, non-cold color, like mush, or foul-smelling diarrhea, clear cold urine, no dry mouth/thirst, deep/fine or slow/faint/weak pulse, or fever with cold limbs, aversion to cold, curling up, are all cold syndromes. Heat syndromes feature dry mouth/thirst, yellow/red or obstructive urine, greasy discharge, and numerous/rapid/slippery/wiry/large/hyperactive pulses, or heat failing to digest food. Differentiate by pulse and symptoms. For stomach deficiency with internal heat, irritability, thirst, diarrhea, and weak pulse, use Qi Wei Ren Shen Bai Zhu San (Seven-Ingredient Ginseng and Atractylodes Powder). If feverish, use Shen Hu San Bai Tang (Ginseng, Bupleurum, and Three Whites Decoction), remove Huang Qin, add fried Huang Lian. If abdominal fullness and difficulty urinating, use Wu Ling San (Five-Ingredient Poria Powder) combined with Li Zhong Tang. If vomiting, add Huo Xiang (Patchouli), Ban Xia (Pinellia Tuber), Sheng Jiang (Fresh Ginger), Chen Pi (Tangerine Peel). If dampness causes persistent diarrhea, add Bai Zhu and Cang Zhu (Atractylodes). If abdominal distension, add Hou Po (Magnolia Bark). If abdominal pain, add Bai Shao and Rou Gui, Mu Xiang (Aucklandia Root). For Shanghan diarrhea with floating pulse and unresolved exterior, Zhang Zhongjing uses Xiao Qing Long Tang (Minor Green Dragon Decoction) removing Ma Huang and adding fried Yuan Hua (Genkwa Flower) 2 qian. Dispersing exterior treats water. If obstructive urination and watery diarrhea, use Wu Ling San. If severe water retention unresolved, add Yuan Hua 2 qian or Che Qian Zi (Plantago Seed) soup to stop diarrhea. Generally, do not sweat in diarrhea; treat diarrhea first. Once stopped, interior solidifies, Zheng Qi recovers, pathogen resolves, then sweating cures. Diarrhea stems from interior deficiency; sweating makes both interior and exterior deficient, causing difficult-to-treat complications.
Su Song said: "Water Qi" is the original intent of Zhen Wu Tang. Diarrhea is also caused by Water Qi. The latter three items are modifications of Zhen Wu Tang.
[Outline] Zhang Zhongjing said: In Shaoyin disease, from two to three days to four to five days, with abdominal pain, difficulty urinating, persistent diarrhea, and bloody/purulent stool, Tao Hua Tang (Peach Kernel Decoction) governs.
[Commentary] Pang Anchang said: This is due to cold poison entering the stomach, causing abdominal pain and diarrhea.
[Outline] Zhang Zhongjing said: Profuse sweating or severe diarrhea with cold extremities: Si Ni Tang governs.
Profuse sweating with persistent fever, internal cramping, limb pain, plus diarrhea, cold extremities, and aversion to cold: Si Ni Tang governs. Spontaneous diarrhea with no thirst belongs to Taiyin due to cold in zang organs; warm it with Si Ni Tang class.
[Commentary] Ke Qin said: Profuse sweating causes Yang collapse; severe diarrhea causes Yin collapse. Both Yin and Yang are deficient, hence cold extremities. But diarrhea is not undigested food; urgent warming allows Yang return and hope of life. These two cases result from improper treatment. Although profuse sweating persists with fever, aversion to cold indicates unresolved exterior. Cramping and diarrhea indicate developed interior cold. Limb pain and cold extremities show exterior cold again. Thus, exterior heat with interior cold is actually exterior cold with Yang collapse.
[Outline] Zhang Zhongjing said: In Shaoyin disease, diarrhea with undigested food, interior cold with exterior heat, cold extremities, faint pulse nearly imperceptible, body not averse to cold, flushed face, or abdominal pain, dry retching, sore throat, or cessation of diarrhea with unobtainable pulse: Tong Mai Si Ni Tang (Pulse-Returning Cinnamon and Aconite Decoction) governs.
[Commentary] Ke Qin said: Sore throat and cessation of diarrhea indicate Yang returning internally. Abdominal pain and dry retching indicate struggle between cold and heat.
[Outline] Zhang Zhongjing said: In Shaoyin disease, cough with diarrhea and delirium results from fire therapy forcing sweat. Urination will certainly be difficult due to forcibly demanding sweat from Shaoyin.
[Commentary] Yu Chang said: The Shaoyin meridian enters the abdomen from the foot, ascends along the throat, and surrounds the tongue root, hence frequent sore throats. Its branch emerges from the Lung, hence occasional coughs. Forcing sweat with fire causes heat pathogen to attack upward with fire power, causing cough (Lung Metal dislikes fire). Downward attack causes diarrhea (fire forces exit through orifices). Internal attack causes delirium (fire scorers and confuses Shen). Difficulty urinating occurs because these three symptoms obstruct urination. If Lung is injured by fire, Bladder Qi transformation fails; if Large Intestine rushes excessively, water and grain follow one path; if Pericardium scorers endlessly, Small Intestine dries up. Can Shaoyin be forcibly sweated?
Kidney heat affects its exterior organ, the Bladder, causing difficult urination. Cough and diarrhea reflect the exterior-interior relationship of Lung and Large Intestine.
Wei Litong said: This explains Shaoyin transmitted heat pathogen causing interior harm, not mistaken for direct cold pathogen. Forcibly sweating makes it difficult. Shaoyin disease has transmitted heat and direct cold. Heat transmission starts in the meridian but involves Kidney. Direct cold divides into meridian and zang. Zang uses only warming, not dispersing; meridian uses warming and dispersing. Zang pathology has no dispersing method. How much less for transmitted interior heat? Thus, prolonged intense heat cannot be warmed; deep interior heat cannot be dispersed. This applies to Taiyang transmitting to Yangming interior where sweating is contraindicated. Further transmitting to Three Yin, reaching Shaoyin (extreme depth, interior of interiors), forbidding forced sweating is obvious. Only Shaoyin includes direct cold, treated by warming meridians and dispersing cold, akin to sweating. Zhang Zhongjing warns against using this for transmitted Shaoyin heat, specifically marking Fu Zi, Ma Huang, Xi Xin, Gan Cao for direct cold Shaoyin meridian. Direct cold Shaoyin zang mentions only warming, not dispersing. It is not for transmitted heat affecting Kidney zang.
This is a critical point lacking clear analysis. Above this clause: "Shaoyin disease, fine/deep/rapid pulse, disease is interior, do not sweat." Followed by this clause. Shaoyin pulse is normally faint/fine; now fine remains, showing deep/rapid. Fine relates to Jueyin-Shaoyin; deep is proper Shaoyin pulse. Absence of Taiyin faintness but presence of Yang rapid pulse (opposite of slow) requires heavy pressing in deep position to distinguish. Similarly, fine/wiry pulses require light pressing in deep position. Thus, deep is Shaoyin root pulse. Light pressing shows fine above deep; heavy pressing shows faint below deep: this is direct cold Shaoyin. Warm middle or disperse cold accordingly. Light pressing shows fine above deep; heavy pressing shows rapid instead of faint in deep: this is transmitted heat Shaoyin. One pulse in deep position distinguishes Shaoyin cold/heat. Knowing this clarifies it is not direct exterior disease but transmitted interior disease. Initial wind-cold is always exterior, requiring sweating (even Shaoyin, e.g., Ma Huang Fu Zi Xi Xin Gan Cao Tang). Deep transmission is always interior, prohibiting sweating (even Taiyang, e.g., Di Dang Tang, Wu Ling San). Understanding this avoids rigid exterior/interior definitions. Knowing sweating principles allows flexible treatment of interior heat. Zhang Zhongjing says "do not sweat" without prescribing because the formula follows later. He warns against forced sweating to prevent immediate disaster. Consider cough/diarrhea/delirium: transmitted heat reaching Shaoyin. Fire forcing sweat depletes Shaoyin Qi/Blood and Yin fluids, causing difficult urination. Stomach fluid loss with free urination means fluid loss above with lower Qi transformation intact. Here, Kidney Yin is damaged, fluid loss below stops Qi transformation. Forcing Shaoyin sweat with fire seems to injure only Yang/exterior, but fluid/Qi loss is severe. Be cautious!
[Outline] Zhang Zhongjing said: After six or seven days of Shanghan, following severe purgation, if cun pulse is deep and slow, hands/feet are cold, lower pulses are unobtainable, throat is obstructed, expectoration of pus/blood occurs, and diarrhea is uncontrollable, this is difficult to treat.
[Commentary] Tao Hua said: Six-Fu Qi perishing externally causes cold hands/feet; Five-Zang Qi perishing internally causes uncontrollable diarrhea. This is what is meant.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with vomiting, diarrhea, cold extremities, and severe irritability, Wu Zhu Yu Tang (Evodia Decoction) governs.
Dry retching, spitting saliva/phlegm, headache: Wu Zhu Yu Tang governs.
Desire to vomit after eating belongs to Yangming; Wu Zhu Yu Tang governs. If symptoms worsen after taking the decoction, it belongs to Upper Jiao deficiency.
[Commentary] Shen Jin'ao notes: Vomiting, diarrhea, irritability indicate Yin pathogen entering the He-sea points, unable to exit via Yang. Dry retching (vomiting without matter) indicates stomach deficiency. Spitting saliva/phlegm indicates stomach cold. Desire to vomit after eating, where grain is rejected, also indicates stomach cold. "Taking the decoction" refers to Wu Zhu Yu Tang. Worsening after ingestion is due to phlegm-fluid in Upper Jiao; self-healing occurs after vomiting clears it.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with diarrhea and faint pulse, give Bai Tong Tang. If diarrhea persists, with cold extremities, unobtainable pulse, dry retching, and irritability, Bai Tong Jia Zhu Dan Ye Tang (Bai Tong Decoction with Pig Bile) governs. After taking the decoction, if pulse suddenly appears, death; if pulse gradually returns, survival.
[Commentary] Zhang Yuansu said: Some say Bai Tong Tang, Bai Tong Jia Zhu Dan Ye Tang, Zhen Wu Tang, and Tong Mai Si Ni Tang are all for Shaoyin diarrhea. Except for Ginger and Aconite, other herbs differ. Why? Different diseases require different drugs. Shaoyin diarrhea involves severe cold, requiring Ginger and Aconite. However, while diarrhea mechanism is similar, accompanying symptoms vary, hence different prescriptions. Bai Tong uses Ginger/Aconite to disperse cold and stop diarrhea, adds Cong Bai (Scallion White) to regulate Yang Qi. If diarrhea with dry retching/irritability, cold is too severe with internal rejection; Ginger/Aconite are unsuitable for irritability, causing vomiting/refusal. Adding Ren Nao (Human Urine) and Zhu Dan Ye (Pig Bile) to Bai Tong Tang, taken warm/cold. These two are salty/bitter/cold, allowing intake without rejection. Upon reaching the site, cold nature dissipates, hot nature activates. Zhen Wu Tang treats Shaoyin days 2-4 with abdominal pain, difficulty urinating, heavy/painful limbs, spontaneous diarrhea due to Water Qi. Water Qi is cold-dampness, governed by Kidney. Kidney failure to control water leads to stagnation, causing abdominal pain (internal cold-damp), heavy/painful limbs (external cold-damp), difficulty urinating, and spontaneous diarrhea (dampness preventing separation of water/grain). Classic states: Spleen dislikes dampness; sweet enters Spleen first. Licorice/Poria sweetness tonifies Spleen and drains water. To balance dampness excess, use pungent-hot. To assist dampness excess, use sour-pungent. Aconite, Shaoyao, Sheng Jiang are sour-pungent to warm meridians and disperse dampness. Xiao Qing Long Tang also addresses Water Qi.