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[General Principle] Zhang Zhongjing stated: In cases where the Taiyang and Yangming channels are simultaneously affected (He Bing), spontaneous diarrhea will inevitably occur. Ge Gen Tang (Kudzu Decoction) is the primary treatment. In cases where the Taiyang and Shaoyang channels are simultaneously affected, if spontaneous diarrhea occurs, Huang Qin Tang (Scutellaria Decoction) should be administered. If vomiting is present, Huang Qin Jia Ban Xia Sheng Jiang Tang (Scutellaria Decoction with Added Pinellia and Fresh Ginger) is the primary treatment. In cases where the Yangming and Shaoyang channels are simultaneously affected, diarrhea will inevitably occur. A pulse that does not show mutual overcoming indicates a favorable prognosis (Shun); a pulse showing mutual overcoming indicates an unfavorable prognosis (Fu). Mutual overcoming and damaging is termed "Fu". A slippery and rapid pulse indicates the presence of retained food (Su Shi), which requires purgation; Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate.

[Commentary] Cheng Wuji stated: These three conditions all involve diarrhea resulting from He Bing. One is treated by releasing the exterior, one by attacking the interior, and one by harmonizing the interior and exterior. The differences arise from the Six Channels differentiation: Taiyang and Yangming belong to the Exterior; Shaoyang and Taiyin belong to the Half-Exterior/Half-Interior; Shaoyin and Jueyin belong to the Interior. Currently, Taiyang and Yangming He Bing indicates the pathogen is in the Exterior. Although diarrhea occurs, it must cease only after the pathogenic qi in the meridians is dispersed via sweating; thus, Ge Gen Tang is used for diaphoresis. Taiyang and Shaoyang He Bing indicates the pathogen is in the Half-Exterior/Half-Interior. Although diarrhea occurs, it must cease only after the exterior and interior pathogens are harmonized; thus, Huang Qin Tang is used to disperse the pathogen. Yangming and Shaoyang He Bing indicates the Shaoyang pathogen has entered the Fu organs. Although diarrhea occurs, it must cease only after the excess in the stomach is driven out; thus, Cheng Qi Tang is used for purgation. These are the reasons for the different treatments among the three. Spontaneous diarrhea in miscellaneous diseases is mostly attributed to deficiency. Diarrhea in Shang Han (Cold Damage) may result from Xie Re Li (Collateral Heat Diarrhea). When exterior pathogens transmit inward, causing interior deficiency with collateral heat, purgation is contraindicated. Incorrect use of purgation leads to persistent diarrhea due to interior deficiency and collateral heat; these are all causes of Xie Re Li.

How to distinguish cold and heat in patients with diarrhea? Spontaneous diarrhea without thirst belongs to Taiyin, due to cold in the Zang organs. Diarrhea accompanied by desire to drink water indicates heat. Therefore, loose stools with normal urination indicate heat. Spontaneous diarrhea with white-colored urine presents the signs and symptoms of Shaoyin disease, indicating cold. Aversion to cold, faint pulse, and spontaneous diarrhea with undigested food indicate cold. Tenesmus with yellow-red stool indicates heat. These can all be used to differentiate cold and heat. Abdominal pain with moving gas rushing toward the lower abdomen indicates impending diarrhea. In patients with diarrhea, a cool body and small pulse are favorable (Shun); a hot body and large pulse are unfavorable (Ni). In Shaoyin disease, a tight pulse with diarrhea, if the pulse suddenly becomes faint, hands and feet become warm, and the tightness disappears, this indicates the condition is about to resolve. A large pulse in diarrhea indicates the condition has not stopped; a faint, weak, and rapid pulse indicates the condition is about to stop spontaneously. Even if fever persists, death will not occur. Thus, a large pulse in diarrhea is unfavorable, while a small pulse is favorable. Spontaneous diarrhea is suitable for warming methods; Li Zhong Tang (Regulate the Middle Decoction), Bai Tong Tang, and various Si Ni Tang (Four Counterflow Decoctions) are agents that warm the Zang organs and stop diarrhea. However, if there are accumulations in the intestines and stomach, or guest pathogens in the Lower Jiao, warming agents cannot stop the diarrhea. Purgation or separation of dampness through diuresis is required to stop it. The classic states: Li Zhong Tang regulates the Middle Jiao. This diarrhea is in the Lower Jiao; Chi Shi Zhi Yu Yu Liang Tang (Red Stone Lipstick and Hematite Decoction) is appropriate. If diarrhea persists, diuresis should be employed. This treats diarrhea caused by fluid accumulation in the Lower Jiao. In Shaoyin disease, spontaneous diarrhea of pure green water, with pain in the epigastrium and dry mouth, or when the pulses in the three positions are level but the epigastrium is hard upon palpation, or the pulse is deep and slippery, or there is anorexia with delirium, or recurrence after recovery over months or years—these cases all require purgation due to intestinal accumulations. The commentary on the Neijing states: Internal excessive heat causing persistent diarrhea should be treated with cold herbs; latent accumulations must be removed using cold purgatives. Once the accumulation disperses, diarrhea stops. Internal coagulation of excessive heat causing chronic loose stools, recurring over years, should be treated with hot purgatives; once cold dissipates, diarrhea stops. This is called "Tong Yin Tong Yong" (treating obstruction with unblocking methods).

Yu Chang stated: Whether or not diarrhea occurs helps distinguish between wind and cold dominance. In other clauses, Taiyang-Yangming He Bing without diarrhea but with vomiting is treated with Ge Gen Jia Ban Xia Tang (Kudzu Decoction with Added Pinellia). This is because wind is yang, and its nature ascends; thus, it causes water-fluids in the Yangming stomach to regurgitate upward. This clause deals with cold; cold is yin, and its nature descends; thus, it causes food and fluids in the Yangming stomach to rush downward. Upward regurgitation requires adding Ban Xia (Pinellia) to Ge Gen Tang to eliminate fluids and stop vomiting. For diarrhea, only Ge Gen is needed to resolve the pathogens of both channels; the diarrhea stops spontaneously without specific anti-diarrheal treatment. Taiyang-Yangming He Bing with diarrhea presents mostly exterior symptoms; Yangming-Shaoyang He Bing with diarrhea presents mostly interior symptoms; Taiyang-Shaoyang He Bing with diarrhea presents mostly half-exterior/half-interior symptoms. Therefore, Huang Qin, Gan Cao, Shao Yao, and Da Zao are used as a harmonizing method.

Note: Taiyang-Yangming He Bing and Yangming-Shaoyang He Bing both involve Yangming, causing instability of water and food in the stomach and leading to spontaneous diarrhea. If there is no diarrhea, there will likely be upward regurgitation of fluids and vomiting, which differs significantly from dry heaving caused by Shaoyang alone. Whether diarrhea or vomiting, the true qi and fluids of the stomach are damaged, requiring urgent dispersion of pathogens to stabilize the stomach. One must also fear Shaoyang excess overwhelming Yangming deficiency, necessitating urgent purgation to rescue Yangming. The use of Da Cheng Qi Tang aims to swiftly sweep away external pathogens and support the original qi. Hesitation would cause the slippery-rapid pulse to become slow and soft, making purgation ineffective.

Wei Litong stated: Taiyang and Yangming have He Bing, both belonging to the exterior of two channels, sharing external pathogens. However, Taiyang and Shaoyang He Bing implies the three Yang channels are connected; how could they not all be diseased? Thus, Tai-Shaoyang He Bing is essentially He Bing of all three Yang channels. Some ask: Three-Yang simultaneous disease is Wen Bing (Warm Disease); why mix it with Shang Han He Bing? It is unknown that Wen Bing's three-Yang disease results from winter cold injury manifesting as spring warmth, representing long-term accumulated pathogens. Shang Han He Bing involves three Yang channels simultaneously contracting pathogens, manifesting immediately, representing sudden, irregular pathogens. Their sources differ. Since it is three-Yang simultaneous contraction, although named Tai-Shaoyang He Bing, actually Yangming alone bears the pathogen. If Shaoyang pathogen is dominant, diarrhea occurs due to Wood overacting on Earth (Stomach). If Taiyang pathogen is dominant, vomiting occurs due to exterior yang heat stagnation causing Yangming qi rebellion. For diarrhea, Huang Qin Tang is given to bitter-drain Shaoyang pathogens, allowing Yangming pathogens to descend. For vomiting, Ban Xia and Sheng Jiang are added to acridly-disperse Taiyang pathogens, preventing Yangming qi from rebelling upward. Huang Qin Tang is a residual method for treating heat-collateral diarrhea; Ban Xia and Sheng Jiang are residual methods for treating Jie Xiong (Chest Binding). Variations merely aim to expel pathogens upward or downward. This shows the pathogen specializes in Yangming, yet treatment still addresses Taiyang and Shaoyang. Since Yangming has no further transmission pathway, pathogens are vented through Taiyang and Shaoyang, leaving no other exit, consistent with the Shaoyang-Yangming and Shaoyang chapters. Tai-Shaoyang He Bing necessarily involves Yangming. If Taiyang disease has completely resolved, leaving only Yangming-Shaoyang He Bing, careful differentiation is required before treatment. Some ask: If Taiyang resolves and Yangming-Shaoyang disease remains, isn't this Shaoyang-Yangming? Why name it He Bing? Answer: Shaoyang-Yangming refers to transmission from Taiyang to Yangming, then to Shaoyang. Here, all three Yang channels contracted pathogens simultaneously; Taiyang exterior pathogens have resolved, leaving Yangming and Shaoyang to bear the burden. Hence, it is named Yangming-Shaoyang He Bing, not Shaoyang-Yangming. Some ask: Isn't the resolution of Taiyang exterior pathogens considered transmission? Answer: Resolution of Taiyang exterior pathogens is indeed transmission. However, this He Bing originated from simultaneous three-Yang infection. Even if Taiyang resolves, viewing it as transmission inward is similar in principle but different in name compared to sequential transmission. Moreover, Yangming and Shaoyang still have unresolved exterior pathogens, unlike Taiyang alone where exterior resolution leads to interior transmission. The difference between exterior and interior is distinct. Understanding this reveals that Yangming-Shaoyang He Bing diarrhea is due to pathogens in the meridians of Yangming and Shaoyang, with exterior pathogens causing disturbance. Both channels suffer pathogens, showing Wood moving and overacting on Earth, with intestinal wind stirring to cause diarrhea. This differs clearly from Yangming transmission disease where pathogens reside in the Fu organs. Diagnosis confirms this.

Note: The vigorous energy of Qian (Heaven) operates outside the earth and penetrates within, governing heaven and earth to initiate life. Thus, the dry metal qi in the stomach is the Qian metal penetrating Kun earth, generating all things. Yangming dry metal governs autumn; all things rejoice in Dui and struggle in Qian. The qi of these two metals gradually generates water, marking the beginning of renewal (Zhen Xia Qi Yuan), allowing us to understand the metal qi in human stomachs.

[General Principle] Zhang Zhongjing stated: In diarrhea, do not attack the exterior. Sweating will inevitably cause abdominal distension.

[Commentary] Su Song stated: Although diarrhea may present with exterior symptoms, sweating is contraindicated. Diarrhea indicates internal attack by pathogens, depleting fluids and weakening the stomach.

Zhang Jiebin stated: Miscellaneous disease diarrhea is mostly due to cold accumulation. Shang Han diarrhea can be cold or heat. Heat transmitting inward can cause diarrhea, but cold diarrhea is most common, while heat diarrhea is rare. Practitioners must differentiate cold and heat; misuse causes great harm. Heat-induced Shang Han diarrhea presents with irritability, high fever, and intense craving for cold water, accompanied by surging, slippery, strong, rapid, and excess pulses. Only if both interior and exterior are hot should it be treated as a fire syndrome. If the pulse is rapid but weak, or externally hot but not aversive to heat, or internally thirsty but rejecting cold drinks, the interior is fundamentally cold. Such diarrhea belongs to deficiency-cold, treated with Si Ni Tang, Li Zhong Tang, Wen Wei Yin, Wei Guan Jian, or Wu Ling San. If exterior and interior cold are both severe, combining Ma Huang Tang and Gui Zhi Tang is crucial. Mistaking cold diarrhea for heat and using cold herbs damages stomach qi, leading to death. In simultaneous exterior-interior disease with diarrhea, the interior urgency takes precedence. Interior deficiency allows exterior pathogens to sink deeper; even if exterior release is attempted, weak middle qi prevents dispersion. Thus, for diarrhea with middle jiao deficiency, urgently warm the interior. When interior qi is solid and strong, exterior pathogens resolve naturally; warming disperses cold. A rapid pulse with thirst indicates true heat. However, exterior cold can cause rapid pulses; forceful rapidity indicates yang syndrome, while weak rapidity indicates yin syndrome. Diarrhea depletes fluids, causing thirst. Thirst with rapid drinking indicates yang syndrome; desire to drink but reluctance to swallow indicates non-yang syndrome. Craving tea or soup is a natural consequence of diarrhea and thirst, not necessarily heat. For Shang Han with unresolved exterior, excess-slippery-rapid pulse, preference for cold, and interior-exterior heat with diarrhea, Chai Ling Jian is appropriate. Shang Han diarrhea is not typically Yangming heat; delirium is uncommon. Delirium indicates dry feces requiring removal. Shaoyin diarrhea with epigastric pain or hardness indicates accumulation requiring purgation.

In diarrhea patients, a cool body and small pulse are favorable; a hot body and large pulse are unfavorable. This refers to cases without exterior symptoms, where disease resides in the zang organs. Generally, diarrhea involving loss of qi is extremely urgent, being the most severe of the Five Depletions. The Jin Gui Yao Lue states: Six-pulse qi failing externally causes cold hands and feet; five-zang qi failing internally causes uncontrollable diarrhea. Once zang qi is lost, it cannot be treated.

Chen Shiduo stated: Shang Han fever for six or seven days without diarrhea, suddenly turning into diarrhea, is a critical condition. If accompanied by profuse sweating, it is Yang collapse (Wang Yang). Yin without Yang is a death sign. Urgently treat with 3 liang of Ren Shen (Ginseng) and 1 qian of Bei Mu Wei (Schisandra). Survival is possible. If Ren Shen is unavailable, use 3 liang each of Bai Zhu (Atractylodes) and Huang Qi (Astragalus), 1 liang of Dang Gui (Angelica), 5 qian of Bai Shao (White Peony), and 1 qian of Bei Mu Wei. This formula tonifies qi and blood to rescue outwardly floating yang. Return of yang stops sweating; cessation of sweating stops diarrhea.

[General Principle] Zhang Zhongjing stated: In diarrhea occurring ten-plus times daily, a surprisingly excess pulse indicates death. Fever with severe diarrhea and unrelenting cold limbs indicates death. Fixed gaze and delirium with diarrhea indicates death. Diarrhea with cold limbs and absent pulse: if moxibustion fails to warm the body or restore the pulse, death ensues. Shaoyin disease with spontaneous diarrhea, followed by irritability and inability to sleep, indicates death.

[Commentary] Cheng Wuji stated: Generally, diarrhea involves urgent loss of qi. If pathogens are excess and righteous qi deficient, pathogens oppress righteous qi downward, often leading to death via diarrhea.

Chen Shiduo stated: Diarrhea ten-plus times daily with a surprisingly excess pulse indicates death. Why? Excessive purging depletes yin, so the pulse should be weak. An excess pulse here indicates false excess. Righteous qi is exhausted and obstructed by pathogens, leading to death. Treatment must tonify deficiency regardless of the pulse's apparent excess. Use Huan Zhen Tang: 1 liang each of Ren Shen and Bai Shao, 2 liang of Fu Ling (Poria). Ren Shen secures original yang; Fu Ling stops depletion diarrhea; Bai Shao generates true yin. Generation of yin promotes yang; cessation of diarrhea consolidates depletion. Strong righteous qi defeats pathogens. False excess transforming into true deficiency turns a death sign into life.

[General Principle] Zhang Zhongjing asked: What are the symptoms of Jie Xiong (Chest Binding) and Zang Jie (Zang Binding)? Answer: Pain upon pressure, floating cun pulse, and sinking guan pulse constitute Jie Xiong. Symptoms resembling Jie Xiong, with normal diet but frequent diarrhea, floating cun pulse, and small, fine, deep, tight guan pulse constitute Zang Jie. A white, slippery coating on the tongue indicates a difficult-to-treat case. After taking decoctions for Shang Han, if diarrhea persists and the epigastrium feels full and hard, and subsequent use of Xie Xin Tang fails, followed by purgation causing persistent diarrhea, and the physician administers Li Zhong Tang worsening the diarrhea: Li Zhong Tang regulates the middle jiao, but this diarrhea is in the lower jiao. Chi Shi Zhi Yu Yu Liang Tang is indicated. If diarrhea persists, promote urination.

[Commentary] Shen Jin'ao noted: In the previous clause, the pathology focuses on the guan pulse. "Sinking" (even if large and solid) indicates cold-water retention between the chest and hypochondrium. "Deep and tight" indicates binding in the Zang rather than the Fu, resulting in different symptoms. Ancients stated that eating while having diarrhea is also called "Jie," referring to binding of formless qi and blockage of the five zang organs, hence "Zang Jie." In the next clause, diarrhea persisting after decoction indicates the disease is still in the stomach; diarrhea persisting after purgation indicates the disease is in the large intestine. Chi Shi Zhi Yu Yu Liang Tang secures collapse; promoting urination separates and eliminates dampness. These are two methods for treating the lower jiao.