文下利而言。凡少阴证中。诸阳虚阴盛之证。而至于下利及下利清谷之证。皆由寒邪太盛。非惟少阴命门。真
火衰微。且火不能生土。中焦胃脘之阳不守。故亦败泄而为下利。少阴脉虽微细欲绝。而为阴寒所胜。则为少
阴之真阳负矣。若趺阳脉尚无亏损。则是先天之阳。虽为寒邪之所郁伏。而后天胃脘之阳尚在。为真阳犹未磨
灭。所谓有胃气者生。故为顺也。若趺阳亦负。则为无胃气而死矣。
案此条未妥贴。钱注稍觉稳当。柯氏删之。盖有所见也。
下利寸脉反浮数。尺中自涩者。必清脓血。
〔成〕下利者。脉当沉而迟。反浮数者。里有热也。涩为
无血。尺中自涩者。肠胃血散也。随利下必便脓血。清与圊通。脉经曰。清者。厕也。（案脉经。引四时经注。）
〔汪〕热利而得数脉。非反也。得浮脉则为反矣。兹者寸反浮数。此在里之邪热。不少敛也。尺中涩者。阴虚
也。阳邪乘阴分之虚。则其血必瘀。而为脓血。常器之云。宜桃花汤。误矣。愚意云。宜以仲景黄芩汤代之。
案柯氏以此条。属白头翁汤部。似是。王云。黄连阿胶汤。亦得。
下利清谷。不可攻表。汗出必胀满。（表上。玉函。有其字。）
〔成〕下利者。脾胃虚也。胃为津液之主。发汗亡津液。则胃气愈虚。必胀满。〔程〕下利清谷。此为里
虚。反攻其表。则汗出而阳从外泄。浊阴得内填。胀满所由来也。汗剂所以发邪阳之在表也。表若无邪。必拔
及里阳而外泄。遂生内寒。〔汪〕郭白云云。宜通脉四逆汤。
下利脉沉弦者。下重也。脉大者为未止。脉微弱数者。为欲自止。虽发热不死。（也字。玉函无。千金
翼。作其。）
〔汪〕此辨热利之脉也。脉沉弦者。沉主里。弦主急。故为里急后重。如滞下之证也。脉大者。邪热甚
也。经云。大则病进。故为利未止也。脉微弱数者。此阳邪之热已退。真阴之气将复。故为利自止也。下利一
候。大忌发热。兹者脉微弱而带数。所存邪气有限。故虽发热。不至死耳。〔鉴〕由此可知滞下脉大。身热者
必死也。〔舒〕按厥阴下利。法当分辨阴阳。确有所据。对证用药。无不立应。但言脉者。玄渺难凭。吾不敢从。
下利脉沉而迟。其人面少赤。身有微热。下利清谷者。必郁冒汗出而解。病患必微厥。所以然者。其面戴
阳。下虚故也。
〔汪〕下利脉沉而迟。里寒也。所下者清谷。里寒甚也。面少赤。身微热。下焦虚寒。无根失守之火。
浮于上越于表也。以少赤微热之故。其人阳气虽虚。犹能与阴寒相争。必作郁冒汗出而解。郁冒者。头目之际。
郁然昏冒。乃真阳之气。能胜寒邪。里阳回而表和顺。故能解也。病患必微厥者。此指未汗出郁冒之时而言。
面戴阳系下虚。此申言面少赤之故。下虚。即下焦元气虚。按仲景。虽云汗出而解。然于未解之时。当用何药。
郭白云云。不解。宜通脉四逆汤。〔张〕太阳阳明并病。面色缘缘正赤者。为阳气怫郁。宜解其表。此下利脉
沉迟。而面见少赤。身见微热。乃阴寒格阳于外。则外微热。格阳于上。则面少赤。仲景以为下虚者。谓下无
其阳。而反在外在上。故云虚也。虚阳至于外越上出。危候已彰。或其人阳尚有根。或用温药。以胜阴助阳。
阳得复反而与阴争。瘥可恃以无恐。盖阳返虽阴不能格。然阴尚盛。亦未肯降。必郁冒少顷。然后阳胜而阴出
为汗。邪从外解。自不下利矣。
伤寒绪论云。戴阳者。面赤如微酣之状。阴证冷极。发躁面赤。脉沉细。为浮火上冲。水极似火也。凡
下元虚惫之人。阳浮于上。与在表之邪相合。则为戴阳。阳已戴于头面。而不知者。更行发散。则孤阳飞越。
危殆立至矣。大抵阳邪在表之怫郁。必面合赤色。而手足自温。若阴证。虚阳上泛而戴阳。面虽赤足胫必冷。
不可但见面赤。便以为热也。
下利脉数而渴者。今自愈。设不瘥。必清脓血。以有热故也。（玉函。千金翼。脉下。有反字。今。全
书。作令。程本魏本同。）
〔周〕下利脉数而渴。邪虽未尽。而数为热征。则亦阳气自复之候。而无利久入阴之虞。亦可自愈。而
不愈者必热势向盛。此不但利不止。而必至圊脓血耳。以此推之。则其脉
必数而有力者也〔汪〕此条。仲景无治法。补亡论。常器之云。可黄芩汤。〔王〕黄连汤。
金匮直解云。脉数而渴。则寒邪去。而利当止。经曰。若脉数不解。而下不止。必挟热而便脓血。此有热
陷于下焦。使血流腐而为脓也。
下利后脉绝。手足厥冷。 时脉还。手足温者生。脉不还者死。（玉函。脉上。有其字。无冷字。生下。
无脉字。不还下。有不温二字。千金同。）
〔成〕 时。周时也。〔钱〕寒邪下利。而六脉已绝。手足厥冷。万无更生之理。而仲景犹云周时脉还。
手足温者生。何也。夫利有新久。若久利脉绝。而至手足厥冷。则阳气以渐而虚。直至水穷山尽。阳气磨灭殆
尽。脉气方绝。岂有复还之时。惟暴注下泄。忽得之骤利。而厥冷脉绝者。则真阳未至陟绝。一时为暴寒所中。
致厥利脉伏。真阳未至陟绝。故阳气尚有还期。此条乃寒中厥阴。非久利也。故云 时脉还。手足温者生。若
脉不见还。是孤阳已绝而死也。〔柯〕此不呕不烦。不须反佐。而服白通。外灸少阴及丹田气海。或可救于万一。
伤寒下利。日十余行。脉反实者死。（千金翼。脉上。有其人二字。）
〔成〕下利者。里虚也。脉当微弱反实者。病胜脏也。故死。难经曰。脉不应病。病不应脉。是为死病。
〔钱〕所谓实者。乃阴寒下利。真阳已败。中气已伤。胃阳绝而真脏脉现也。〔印〕以上十章。论下利有表里
阴阳。寒热气血。邪正虚实。而为审辨之法。故不立方。
案汪氏以此条证。为热利之死证。恐不然也。
下利清谷。里寒外热。汗出而厥者。通脉四逆汤主之。
〔锡〕夫谷入于胃。藉中土之气。变化而黄。以成糟粕。
犹奉心化赤而为血之义也。若寒伤厥少二阴。则阴寒气甚。谷虽入胃。不能变化其精微。蒸津液而泌糟粕。清
浊不分。完谷而出。故下利清谷也。在少阴则下利清谷。里寒外热。手足厥逆。脉微欲绝。身反不恶寒。在厥
阴则下利清谷。里寒外热。汗出而厥。俱宜通脉四逆汤。启生阳之气。而通心主之脉也。〔汪〕下利清谷。为
里寒也。外热为身微热。兼之汗出。此真阳之气。外走而欲脱也。前条汗出为欲解。此条汗出而反厥。乃阳气
大虚也。与通脉四逆汤。以温经固表。通内外阳气。
案吴人驹云。有协热下利者。亦完谷不化。乃邪热不杀谷。其别在脉之阴阳虚实之不同。今验之。小儿此最多。
热利下重者。白头翁汤主之。
〔鉴〕热利下重。乃火郁湿蒸。秽气奔逼广肠。魄门重滞而难出。即内经所云。暴注下迫者。是也。
金匮直解云。热利下重。则热客于肠胃。非寒不足以除热。非苦不足以坚下焦。故加一热字。别以上之寒利。
白头翁汤方
白头翁（二两○金匮。全书。方。魏。钱。鉴。并作三两。） 黄柏（三两） 黄连（三两） 秦皮（三两）
上四味。以水七升。煮取二升。去滓。温服一升。不愈更服一升。
〔鉴〕白头翁。神农本经。言其能逐血止腹痛。陶弘景谓其能止毒痢。故以治厥阴热痢。黄连苦寒。能清湿
热。浓肠胃。黄柏泻下焦之火。秦皮亦属苦寒。治下痢崩带。取其收涩也。
下利腹胀满。身体疼痛者。先温其里。乃攻其表。温里宜四逆汤。攻表宜桂枝汤。（成本。脱二宜字。）
〔喻〕此与太阳中篇。下利身疼。用先里后表之法大同。彼因误下。而致下利。此因下利。而致腹胀。总以
温里为急者。见 曰消之义也。身疼痛有里有表。必清便已调。其痛仍不减。方属于表。太阳条中已悉。故此不赘。
下利欲饮水者。以有热故也。白头翁汤主之。（以。玉函。千金翼。作为。无故字。）
〔钱〕此又申上文热利之见证。以证其为果有热者。必若此治法也。夫渴与不渴。乃有热无热之大分别也。
里无热邪。口必不渴。设或口干。乃下焦无火。气液不得蒸腾。致口无津液耳。然虽渴亦不能多饮。若胃果热
燥。自当渴欲饮水。此必然之理也。宁有里无热邪。而能饮水者乎。仲景恐人之不能辨也。故又设此条。以晓
之曰。下利渴欲饮水者。以有热故也。白头翁汤主之。
下利谵语者。有燥屎也。宜小承气汤。（千金翼。利下有而字。者。作为。无也字。）
〔鉴〕下利里虚。谵语里实。若脉滑大。证兼里急。知其中必有宿食也。其下利之物。又必稠粘臭秽。知
热与宿食。合而为之也。此可决其有燥屎也。宜以小承气汤下之。于此推之。可知燥屎不在大便硬与不硬。而
在里之急与不急。便之臭与不臭也。〔汪〕下利者。肠胃之疾也。若谵语则胃家实。与厥阴无与。乃肠中有燥
屎。不得下也。治宜小承气汤者。此半利半结。只须缓以攻之也。或问。既下利矣。则热气得以下泄。何由而
致谵语有燥屎也。答曰。此系阳明腑实。大热之证。胃中糟粕。为邪所壅。留着于内。其未成硬者。或时得下。
其已成硬者。终不得出。则燥屎为下利之根。燥屎不得出。则邪热上乘于心。所以谵语。要之此证须以手按脐
腹。当必坚痛。方为有燥屎之征。
案少阴篇云。少阴病。自利清水。色纯青。心下必痛。口干燥者。急下之。宜大承气汤。辨可下编云。
下利心下硬者。急下之。宜大承气汤。下利脉迟而滑者。内实也。宜大承气汤。下利不欲食者。有宿食故也。
当下之。宜大承气汤。并与此条证同。
下利后更烦。按之心下濡者。为虚烦也。宜栀子豉汤。
〔方〕更烦。言本有烦。不为利除。而转甚也。〔柯〕虚烦。对实热而言。是空虚之虚。不是虚弱之虚。
〔鉴〕林澜曰。此利后余热之证也。曰下利后。而利止者。必非虚寒之烦。乃热遗于胸中也。按之心下濡。虽
热而非实热。故用此以清其虚烦。
呕家有痈脓者。不可治呕。脓尽自愈。
〔鉴〕心烦而呕者。内热之呕也渴而饮水呕者。停水之呕也。今呕而有脓者。此必内有痈脓。故曰不可治。
但俟呕脓尽自愈也。盖痈脓腐秽。欲去而呕。故不当治。若治其呕。反逆其机。热邪内壅。阻其出路。使无所
泄。必致他变。故不可治呕。脓尽则热随脓去。而呕自止矣。郑重光曰。邪热上逆。结为内痈。肺胃之痈是也。
呕而脉弱。小便复利。身有微热见厥者。难治。四逆汤主之。
〔成〕呕而脉弱。为邪气传里。呕则气上逆。而小盒饭不利。小便复利者。里虚也。身有微热见厥者。阴
胜阳也。为难治。与四逆汤。温里助阳。〔汪〕案诸条厥利证。皆大便利。此条以呕为主病。独小便利而见厥。
前后不能关锁。用四逆汤。以附子散寒下逆气。助命门之火。上以除呕。下以止小便。外以回厥逆也。
干呕吐涎沫。头痛者。吴茱萸汤主之。（沫下。玉函。千金翼。有
而复二字。方本。喻本。脱头痛字。）
〔张〕凡用吴茱萸汤有三证。一为阳明食谷欲呕。一为少阴吐利。手足厥冷。烦躁欲死。此则干呕吐涎
沫头痛。经络证候各殊。而治则一者。总之下焦浊阴之气。上乘于胸中清阳之界。真气反郁在下。不得安其本
位。有时欲上不能。但冲动浊气。所以干呕吐涎沫也。头痛者。厥阴之经。与督脉会于巅也。食谷欲呕者。浊
气在上也。吐利者。清气在下也。手足厥冷者。阴寒内盛也。烦躁欲死者。虚阳扰乱也。故主吴茱萸汤。以茱
萸专主开豁胸中逆气。兼人参姜枣。以助胃中之清阳。共襄祛浊之功。由是清阳得以上升。而浊阴自必下降矣。
〔锡〕成氏云。呕者。有声者也。吐者。吐出其物也。故有干呕而无干吐。今干呕吐涎沫者。涎沫随呕而吐出
也。〔钱〕涎沫者。粘饮白沫也。
案柯氏云。干呕吐涎。是二证不是并见。可谓执拘矣。舒氏云。此条多一干字。既吐涎沫。何为干呕。当
是呕吐涎沫。盖为阴邪协肝气上逆。则呕吐涎沫。此与柯说同。
金匮要略。呕而胸满者。茱萸汤主之。
呕而发热者。小柴胡汤主之。
〔成〕经曰。呕而发热者。柴胡证具。〔钱〕邪在厥阴。惟恐其厥逆下利。若见呕而发热。是厥阴与少
阳。脏腑相连。乃脏邪还腑。自阴出阳。无阴邪变逆之患矣。故当从少阳法治之。而以小柴胡汤。和解其半表
半里之邪也。
伤寒大吐大下之极虚。复极汗者。其人外气怫郁。复与之水。以发其汗。因得哕。所以然者。胃中寒冷
故也。（成本。玉函。极汗下。有出字。其人上。有以字。）
〔钱〕伤寒而大吐大下。则胃中阳气极虚矣。复极汗出者。非又汗之而极出也。因大吐大下之后。真阳已虚。
卫外之阳。
不能固密。所以复极汗出。乃阳虚而汗出也。愚医尚未达其义。以其人外气怫郁。本是虚阳外越。疑是表邪未
解。复与之暖水。以发其汗。因而得哕。哕者。呃逆也。其所以哕者。盖因吐下后。阳气极虚。胃中寒冷。不
The text below the passage discusses diarrhea. It states that in all Shaoyin syndrome cases involving various patterns of Yang deficiency and Yin excess, which progress to diarrhea and diarrhea with undigested food (Xia Li Qing Gu), it is due to the excessive strength of cold pathogenic factors. This is not only because the True Fire of the Mingmen (Gate of Life) of the Shaoyin is weak, but also because fire fails to generate earth, causing the Yang of the middle Jiao (Stomach and Spleen) to lose its control, thus leading to collapse and discharge as diarrhea. Although the Shaoyin pulse may be faint, thin, and nearly imperceptible, being overcome by Yin-cold, this indicates that the True Yang of Shaoyin has been defeated by Yin. If the Fuyang pulse (pulse at the dorsum pedis, reflecting Stomach Qi) shows no deficit, it means that although the congenital Yang is depressed by cold pathogens, the acquired Yang of the stomach remains. The True Yang has not yet been extinguished. This is what is meant by "those with Stomach Qi survive," so it is considered a favorable prognosis. However, if the Fuyang pulse also shows signs of defeat (weakness), it indicates the absence of Stomach Qi, leading to death.
Commentary: This clause is not entirely appropriate. Qian's annotation seems more stable. Ke Qin deleted it, presumably having some insight.
If there is diarrhea with the Cun (inch) pulse appearing floating and rapid, while the Chi (cubit) pulse is naturally choppy, pus and blood will certainly appear in the stool.
Cheng Wuji's Annotation: In diarrhea, the pulse should be deep and slow. A floating and rapid pulse indicates heat in the interior. A choppy pulse signifies a lack of blood. A choppy Chi pulse indicates scattered blood in the intestines and stomach. With the diarrhea, pus and blood will inevitably be passed. "Qing" (clear) is interchangeable with "Qing" (to defecate). The *Mai Jing* (Pulse Classic) states: "Qing refers to the toilet." (Note: *Mai Jing* cites the commentary of *Si Shi Jing*).
Wang Hu's Annotation: For heat diarrhea, obtaining a rapid pulse is not abnormal; obtaining a floating pulse would be abnormal. Here, the Cun pulse is floating and rapid, indicating that the pathogenic heat in the interior is not敛 (restraining/converging). A choppy Chi pulse indicates Yin deficiency. When Yang pathogens take advantage of the deficiency of the Yin aspect, the blood must become stagnant, forming pus and blood. Chang Qizhi suggested the use of Taohua Tang, which is incorrect. I suggest substituting Zhongjing's Huangqin Tang instead.
Commentary: Ke Qin attributed this clause to the section on Baitouweng Tang, which seems plausible. Wang Ken-tang stated that Huanglian Ejiao Tang is also applicable.
In cases of diarrhea with undigested food, one must not attack the exterior. Sweating will necessarily lead to abdominal distension. (*Yu Han Jing* adds the character "Qi" before "Biao").
Cheng Wuji's Annotation: Diarrhea is due to Spleen and Stomach deficiency. The Stomach is the master of body fluids. Sweating depletes body fluids, making Stomach Qi even more deficient, inevitably leading to distension.
Cheng Zhi's Annotation: Diarrhea with undigested food indicates interior deficiency. Attacking the exterior instead leads to sweating and the leakage of Yang from the exterior. Turbid Yin then fills the interior, giving rise to distension. Sweat-inducing agents are used to disperse Yang pathogens in the exterior. If there is no pathogen in the exterior, they will draw out the interior Yang to leak outward, generating internal cold.
Wang Hu's Annotation: Guo Baiyun stated that Tongmai Sini Tang is appropriate.
In diarrhea, if the pulse is deep and wiry, there is a sensation of tenesmus (lower heaviness). If the pulse is large, the condition has not stopped. If the pulse is faint, weak, and rapid, the condition is about to stop spontaneously; even if there is fever, death will not occur. (*Ye* is absent in *Yu Han Jing*; *Qian Jin Yi Fang* uses *Qi*).
Wang Hu's Annotation: This distinguishes the pulses of heat diarrhea. A deep pulse indicates the interior; a wiry pulse indicates urgency. Thus, there is interior urgency and tenesmus, similar to dysentery. A large pulse indicates severe pathogenic heat. The Classics state: "Large means the disease is advancing," hence the diarrhea has not stopped. A faint, weak, and rapid pulse indicates that the Yang pathogenic heat has receded and the True Yin Qi is recovering, so the diarrhea will stop spontaneously. Fever is strictly contraindicated in diarrhea. Here, the pulse is faint and weak with a rapid rate, meaning the residual pathogen is limited. Therefore, even with fever, death will not ensue.
Jian's Annotation: From this, we know that in dysentery, a large pulse combined with fever indicates certain death.
Shu Chiyuan's Commentary: In Jueyin diarrhea, one must distinguish between Yin and Yang patterns based on solid evidence. Prescribing according to the pattern yields immediate results. However, relying solely on pulse diagnosis is subtle and difficult to verify; I dare not agree with this view.
In diarrhea, if the pulse is deep and slow, the person has a slightly red face and slight body heat, and suffers from diarrhea with undigested food, they will inevitably experience vertigo/dizziness (Yu Mao), sweat, and recover. The patient will likely have mild cold limbs. The reason for this is facial Dai Yang (floating Yang) due to lower deficiency.
Wang Hu's Annotation: Diarrhea with a deep and slow pulse indicates interior cold. Passing undigested food indicates severe interior cold. A slightly red face and slight body heat indicate that the rootless, uncontrolled fire of lower Jiao deficiency and cold is floating upward and dispersing to the exterior. Due to the slight redness and heat, although the person's Yang is deficient, it can still struggle against Yin-cold. This will inevitably cause Yu Mao (vertigo/dizziness) and sweating, leading to recovery. Yu Mao refers to a sudden dizziness and clouding of vision/head, occurring when True Yang energy overcomes cold pathogens, interior Yang returns, and the exterior harmonizes, allowing recovery. The mild cold limbs refer to the state before sweating and Yu Mao occur. "Dai Yang on the face" is due to lower deficiency, further explaining the slight redness. "Lower deficiency" refers to the deficiency of Yuan Qi in the lower Jiao. According to Zhongjing, although he says recovery occurs through sweating, what medicine should be used before recovery? Guo Baiyun said that if unresolved, Tongmai Sini Tang is appropriate.
Zhang Yinnan's Annotation: In Taiyang and Yangming concurrent disease, a continuous bright red face indicates obstructed Yang, requiring exterior resolution. In this case, diarrhea with a deep, slow pulse and slight facial redness and body heat indicates Yin-cold repelling Yang to the exterior (causing slight body heat) and to the upper body (causing slight facial redness). Zhongjing calls this lower deficiency because there is no Yang below, which instead floats outward and upward, hence termed "deficiency." When deficient Yang floats outward and upward, critical signs appear. If the person's Yang still has roots, using warm medicines to overcome Yin and assist Yang allows Yang to return and struggle against Yin. Recovery can be expected without fear. Although Yang returns and Yin cannot repel it, Yin is still abundant and reluctant to descend. There must be a brief period of Yu Mao, after which Yang prevails, Yin exits as sweat, and pathogens resolve from the exterior, stopping the diarrhea.
*Shanghan Xulun* states: Dai Yang refers to a face red like mild intoxication. In Yin syndromes with extreme cold, restlessness and facial redness with a deep, fine pulse indicate floating fire rushing upward, where water extreme resembles fire. In persons with depleted lower origins, Yang floats upward. Combined with exterior pathogens, this is called Dai Yang. If Yang is already Dai on the head and face, and unaware physicians use diaphoresis, isolated Yang will fly away, leading to imminent danger. Generally, Yang pathogens obstructed in the exterior cause a full red face and warm hands/feet. In Yin syndromes, floating Yang causing Dai Yang results in a red face but cold calves and feet. One must not see facial redness and assume it is heat.
In diarrhea, if the pulse is rapid and there is thirst, the condition will now heal spontaneously. If it does not heal, pus and blood will certainly appear in the stool due to heat. (*Yu Han Jing* and *Qian Jin Yi Fang* add "Fan" [reverse] after "Mai"; *Quan Shu* changes "Jin" [now] to "Ling" [order]; Cheng Ben and Wei Ben are the same).
Zhou Yangjun's Annotation: Diarrhea with a rapid pulse and thirst indicates that although pathogens are not fully exhausted, rapidity is a sign of heat, representing the self-recovery of Yang Qi, avoiding the risk of prolonged diarrhea entering Yin. It can heal spontaneously. If it does not heal, heat intensity will increase, leading not only to persistent diarrhea but also to passing pus and blood. Inferring from this, the pulse must be rapid and forceful.
Wang Hu's Annotation: Zhongjing provides no treatment method for this clause. *Bu Wang Lun* states Chang Qizhi suggested Huangqin Tang. Wang Ken-tang suggested Huanglian Tang.
*Jinkui Zhijie* states: Rapid pulse and thirst indicate the departure of cold pathogens, and diarrhea should stop. The Classics say: "If the pulse remains rapid and diarrhea does not stop, it must involve heat and passing pus and blood." This indicates heat sinking into the lower Jiao, causing blood flow to rot and form pus.
After diarrhea, if the pulse is absent and limbs are cold, but the pulse returns after a cycle (approx. 24 hours) and limbs become warm, life is preserved; if the pulse does not return, death occurs. (*Yu Han Jing* adds "Qi" before "Mai", omits "Leng"; omits "Mai" after "Sheng"; adds "Bu Wen" after "Bu Huan"; *Qian Jin Yi Fang* is the same).
Cheng Wuji's Annotation: " Shi" refers to a cycle (one day/night).
Qian Rang's Annotation: In cold-pathogen diarrhea, with six pulses absent and limbs cold, there is absolutely no chance of survival. Yet Zhongjing says if the pulse returns after a cycle and limbs warm, life is preserved. Why? Diarrhea has new and old forms. In chronic diarrhea with absent pulse and cold limbs, Yang gradually depletes until exhausted, and only then does the pulse cease. How could it return? Only in acute explosive diarrhea (Bao Zhu Xia Xie) with sudden onset of cold limbs and absent pulse is the True Yang not yet extinct. Struck suddenly by violent cold, causing cold limbs, diarrhea, and hidden pulse, the True Yang is not extinct, so Yang has a chance to return. This clause describes Cold invading Jueyin, not chronic diarrhea. Hence, if the pulse returns after a cycle and limbs warm, life is preserved. If the pulse does not return, isolated Yang is extinct, leading to death.
Ke Qin's Annotation: This case has no vomiting or irritability, requiring no counter-agent. Administer Baitong Tang, plus moxibustion on Shaoyin points, Dantian, and Qihai, might save one in ten thousand.
In Shanghan, diarrhea occurring more than ten times a day with a pulse that is unexpectedly Excess (Shi) indicates death. (*Qian Jin Yi Fang* adds "Qi Ren" before "Mai").
Cheng Wuji's Annotation: Diarrhea is interior deficiency. The pulse should be faint and weak. An Excess pulse means the disease defeats the Zang organs, indicating death. *Nan Jing* states: "When the pulse does not match the disease, and the disease does not match the pulse, it is a fatal disease."
Qian Rang's Annotation: The so-called Excess here refers to Yin-cold diarrhea where True Yang has failed, Middle Qi is injured, Stomach Yang is extinct, and the True Zang pulse appears.
Yin Jiguang's Annotation: The above ten chapters discuss diarrhea regarding exterior/interior, Yin/Yang, cold/heat, Qi/blood, pathogen/righteousness, and deficiency/excess, providing methods for differentiation. Therefore, no formulas are prescribed.
Commentary: Wang regarded this clause as a fatal heat-diarrhea pattern, which is likely incorrect.
In cases of diarrhea with undigested food, interior cold with exterior heat, sweating, and cold limbs, Tongmai Sini Tang is the primary treatment.
Xi Chun's Annotation: Grain enters the stomach and, aided by Middle Earth Qi, transforms into yellow and becomes waste, similar to the heart transforming blood into red. If cold damages Jueyin and Shaoyin, Yin-cold is severe. Although grain enters the stomach, it cannot transform essences, steam fluids, or separate clear from turbid. Clear and turbid mix, and undigested food passes out, causing diarrhea with undigested food. In Shaoyin, this presents as diarrhea with undigested food, interior cold/exterior heat, cold limbs, faint/near-absent pulse, and aversion to cold is absent. In Jueyin, it presents as diarrhea with undigested food, interior cold/exterior heat, sweating, and cold limbs. Both are treated with Tongmai Sini Tang to initiate Sheng Yang Qi and connect the Heart Master's pulse.
Wang Hu's Annotation: Diarrhea with undigested food indicates interior cold. Exterior heat refers to slight body heat accompanied by sweating, indicating True Yang Qi moving outward and about to escape. In the previous clause, sweating indicated impending resolution; here, sweating with cold limbs indicates severe Yang deficiency. Tongmai Sini Tang is given to warm meridians, secure the exterior, and connect interior/exterior Yang.
Commentary: Wu Renju stated that in協热 (collaborating heat) diarrhea, undigested food also passes. This is because pathogenic heat fails to "kill" the grain. The distinction lies in the difference in Yin/Yang and Deficiency/Excess of the pulse. Currently, this is most common in children.
In heat diarrhea with tenesmus (heaviness in the lower part), Baitouweng Tang is the primary treatment.
Jian's Annotation: Heat diarrhea with tenesmus is caused by fire depression and dampness steaming, forcing foul qi into the large intestine, making the anus heavy and difficult to pass. This corresponds to the *Neijing*'s description of "acute watery diarrhea with urgent straining."
*Jinkui Zhijie* states: Heat diarrhea with tenesmus means heat resides in the intestines and stomach. Only cold can remove heat; only bitter herbs can firm the lower Jiao. Hence the word "Heat" is added to distinguish it from the preceding cold diarrhea.
Formula: Baitouweng Tang
Baitouweng (2 liang ○ *Jinkui*, *Quan Shu*, Fang, Wei, Qian, Jian all list as 3 liang.) Huangbai (3 liang) Huanglian (3 liang) Qinpi (3 liang)
These four ingredients are boiled in 7 sheng of water to obtain 2 sheng. Strain. Take 1 sheng warm. If not healed, take another 1 sheng.
Jian's Annotation: *Shennong Ben Cao Jing* states Baitouweng expels blood and stops abdominal pain. Tao Hongjing stated it stops toxic dysentery, hence used for Jueyin heat dysentery. Huanglian is bitter and cold, clearing damp-heat and thickening the stomach/intestines. Huangbai drains fire from the lower Jiao. Qinpi is also bitter and cold, treating dysentery and metrorrhagia/metrostaxis, utilizing its astringent properties.
In cases of diarrhea with abdominal fullness and body pain, first warm the interior, then attack the exterior. To warm the interior, use Sini Tang; to attack the exterior, use Guizhi Tang. (Cost text omits two "Yi" [should/appropriate] characters).
Yu Chang's Annotation: This is largely similar to the Taiyang chapter's method of treating diarrhea with body ache using interior-warming first, then exterior-attacking. There, misdirected purgation caused diarrhea; here, diarrhea causes abdominal fullness. In both, warming the interior is urgent, showing the principle of reduction. Body ache can be interior or exterior; only if bowel/bladder functions are regulated and pain persists does it belong to the exterior. This was detailed in the Taiyang clauses, so no repetition here.
If there is diarrhea with a desire to drink water, it is due to heat. Baitouweng Tang is the primary treatment. ("Yi" is "Wei" in *Yu Han Jing* and *Qian Jin Yi Fang*; "Gu" is omitted).
Qian Rang's Annotation: This reiterates the manifestations of heat diarrhea mentioned earlier to prove that if there is indeed heat, this treatment is required. Thirst vs. no thirst is the major distinction between heat and no heat. Without interior heat, the mouth will not be thirsty. If dry, it is due to lack of fire in the lower Jiao preventing fluid evaporation, causing dry mouth. However, even if thirsty, one cannot drink much. If the Stomach is truly hot and dry, one will naturally desire to drink water; this is inevitable. How can one have no interior heat yet desire to drink? Zhongjing feared people couldn't distinguish this, so he added this clause to clarify: Diarrhea with desire to drink water is due to heat; Baitouweng Tang is primary.
If there is diarrhea with delirium, there is dried fecal matter (Zao Shi); Xiao Chengqi Tang is appropriate. (*Qian Jin Yi Fang* adds "Er" after "Li"; "Zhe" is "Wei"; "Ye" is omitted).
Jian's Annotation: Diarrhea indicates interior deficiency; delirium indicates interior excess. If the pulse is slippery and large, with interior urgency, there must be retained food. The diarrheal material will be thick, sticky, and foul-smelling, indicating heat combined with retained food. This confirms the presence of dried fecal matter. Xiao Chengqi Tang should be used to purge it. From this, we know dried fecal matter is determined not by hardness of stool, but by interior urgency and odor.
Wang Hu's Annotation: Diarrhea is an intestinal/stomach issue. Delirium indicates Stomach excess, unrelated to Jueyin. It is dried fecal matter in the intestines unable to pass. Xiao Chengqi Tang is used because it is half-diarrhea, half-congestion, requiring gentle purging. Question: If diarrhea occurs, shouldn't heat escape downward, causing delirium and dried fecal matter? Answer: This is Yangming Fu excess, a severe heat syndrome. Stomach residue is blocked by pathogens and retained inside. Unhardened parts may pass occasionally; hardened parts never exit. Thus, dried fecal matter is the root of diarrhea. Unable to exit, pathogenic heat attacks the Heart, causing delirium. In summary, pressing the navel/abdomen will reveal hardness and pain, confirming dried fecal matter.
Commentary: The *Shaoyin Chapter* states: In Shaoyin disease, spontaneous diarrhea of pure green water, with必 (must) epigastric pain and dry mouth/throat, requires urgent purging with Da Chengqi Tang. *Bian Ke Xia Bian* states: Diarrhea with hard epigastrium requires urgent purging with Da Chengqi Tang. Diarrhea with slow and slippery pulse indicates interior excess, treat with Da Chengqi Tang. Diarrhea with aversion to food indicates retained food, requires purging with Da Chengqi Tang. These match this clause.
After diarrhea, if irritability increases, and pressing the epigastrium reveals softness, it is Empty Irritability (Xu Fan); Zhizi Chi Tang is appropriate.
Fang Youzhi's Annotation: "Geng Fan" means there was pre-existing irritability, not relieved by diarrhea, but worsened.
Ke Qin's Annotation: Empty Irritability contrasts with Excess Heat; it is emptiness, not weakness.
Jian's Annotation: Lin Lan said: This is a post-diarrhea residual heat syndrome. Since diarrhea stopped, it is not Empty-Cold irritability, but heat remaining in the chest. Pressing the epigastrium is soft; although there is heat, it is not Excess Heat. Hence this formula clears Empty Irritability.
In patients vomiting pus from an abscess, do not treat the vomiting. When the pus is exhausted, it will heal itself.
Jian's Annotation: Irritability with vomiting indicates internal heat vomiting. Thirst with drinking leading to vomiting indicates water retention. Vomiting pus indicates an internal abscess. Hence, do not treat the vomiting; wait for pus exhaustion for self-healing. Abscess pus is foul and wants to exit, causing vomiting. Treating vomiting opposes this mechanism, trapping heat internally and blocking exit, leading to complications. Do not treat vomiting. When pus exhausts, heat leaves with it, and vomiting stops. Zheng Zhongguang said: Pathogenic heat reverses upward, forming internal abscesses, such as Lung or Stomach abscesses.
If there is vomiting with a weak pulse, frequent urination, slight body heat, and cold limbs, it is difficult to treat; Sini Tang is primary.
Cheng Wuji's Annotation: Vomiting with weak pulse indicates pathogen transmitting inward. Vomiting causes Qi rebellion. Urination should be difficult; frequent urination indicates interior deficiency. Slight heat with cold limbs indicates Yin overcoming Yang, making it difficult to treat. Sini Tang warms the interior and assists Yang.
Wang Hu's Annotation: In other Jue/Li clauses, there is profuse diarrhea. Here, vomiting is the main symptom, with frequent urination and cold limbs, indicating failure of front/back closure. Sini Tang uses Fuzi to scatter cold and direct rebellious Qi downward, assisting Mingmen fire, stopping vomiting above, stopping urine below, and reversing cold limbs outside.
Dry retching with salivation and headache is treated with Wuzhuyu Tang. (*Mo* is followed by "Er Fu Er" in *Yu Han Jing* and *Qian Jin Yi Fang*. Fang Ben and Yu Ben omit "Tou Tong").
Zhang Yinnan's Annotation: There are three indications for Wuzhuyu Tang: 1. Yangming desire to vomit after eating; 2. Shaoyin vomiting/diarrhea with cold limbs and irritability wanting to die. This case involves dry retching, salivation, and headache. Although meridians and symptoms differ, the treatment is the same: Lower Jiao turbid Yin Qi ascends to the Upper Jiao clear Yang realm. True Qi is depressed below, unable to stay in its position. Sometimes trying to ascend but failing, it only stirs turbid Qi, causing dry retching and salivation. Headache occurs because Jueyin meridian meets Du meridian at the vertex. Desire to vomit after eating indicates turbid Qi above. Vomiting/diarrhea indicates clear Qi below. Cold limbs indicate internal Yin-cold excess. Irritability indicates disturbed deficient Yang. Wuzhuyu Tang uses Wuzhuyu to open rebellious Qi in the chest, plus Renshen, Jiang, Zao to assist Stomach clear Yang, jointly dispelling turbidity. Clear Yang rises, turbid Yin descends.
Xi Chun's Annotation: Cheng stated: Ou (vomiting) has sound; Tu (spitting up) expels matter. Hence there is Gan Ou (dry retching) but no Gan Tu. Here, dry retching expels salivation.
Qian Rang's Annotation: Xian Mo refers to sticky white foam.
Commentary: Ke Qin said dry retching and spitting saliva are two separate conditions, not simultaneous, which is too rigid. Shu Chiyuan said the character "Gan" is superfluous; since saliva is spat, why dry retch? It should be "Tu Xian Mo" (spitting saliva). This is due to Yin evil collaborating with Liver Qi rebelling upward, causing spitting of saliva. This aligns with Ke's view.
*Jinkui Yaolue*: Vomiting with chest fullness is treated with Zhuyu Tang.
Vomiting with fever is treated with Xiao Chaihu Tang.
Cheng Wuji's Annotation: The Classics state: Vomiting with fever indicates Chaihu syndrome is present.
Qian Rang's Annotation: Pathogen in Jueyin fears cold limbs and diarrhea. Seeing vomiting and fever indicates Jueyin and Shaoyang organs are connected; pathogen returns from Zang to Fu, exiting Yin to Yang, avoiding Yin pathogenic reversal. Thus, treat according to Shaoyang method with Xiao Chaihu Tang to harmonize half-exterior/half-interior pathogens.
In Shanghan, after extreme purging/vomiting causing extreme deficiency, followed by extreme sweating, if the person has exterior oppression (Fu Yu), and water is given to induce sweating, resulting in hiccup (Yue), it is due to cold in the Stomach. (Cost/Yu Han add "Chu" after "Ji Han Xia"; add "Yi" before "Qi Ren").
Qian Rang's Annotation: Extreme purging/vomiting in Shanghan makes Stomach Yang extremely deficient. Extreme sweating afterwards is not from inducing sweat, but because after extreme purging/vomiting, True Yang is deficient, and defensive Yang cannot secure the exterior, leading to extreme sweating due to Yang deficiency. Ignorant doctors misunderstand this. Seeing exterior oppression, which is actually deficient Yang floating outward, they suspect unresolved exterior pathogen and give warm water to induce sweating, causing hiccup. Yue is hiccup. The cause is extreme Yang deficiency and Stomach cold after purging/vomiting, not...