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In cases of watery diarrhea without abdominal pain, the etiology is dampness; treatment should focus on drying dampness and promoting diuresis. When food entering the stomach cannot be retained or digested, or when undigested food particles are passed in the stool, the cause is Qi deficiency; treatment should employ warming and tonifying methods. If there is abdominal distension with borborygmus (intestinal rumbling), where a bout of pain is followed immediately by diarrhea, the cause is Fire (Heat); treatment should involve clearing Heat and promoting dampness drainage. Intermittent diarrhea with varying severity suggests Phlegm accumulation; treatment requires resolving Phlegm. Severe abdominal pain accompanied by diarrhea that alleviates after defecation indicates Food stagnation; treatment should focus on digesting food and removing stagnation. In Excess patterns, purgative methods are appropriate. For chronic Spleen deficiency diarrhea leading to laxity of the Large Intestine, astringent methods should be used. For sinking of Qi, lifting and raising methods are indicated.

Liu Hejian stated: Diarrhea with altered color and odor of stool indicates Heat; clear, cold, and unaltered stool indicates Cold. However, if the anus feels dry and rough, and urine is yellow and red, even if the stool's color and odor remain unchanged, it still belongs to Heat. This is because the nature of Fire is rapid; food passes through quickly without sufficient time for digestion and transformation, known as "pathogenic Heat failing to transform grain." Although diarrhea can be categorized into six types—Dampness, Fire, Cold, Deficiency, Phlegm, and Food—the primary treatment principle must always be to promote dampness drainage and strengthen the Spleen. Dampness is guided out, Heat is cleared, Cold is warmed, Deficiency is tonified, Phlegm is resolved, and Food is digested. While these six patterns are clear, three types of Deficiency must not be overlooked: Spleen Deficiency, Kidney Deficiency, and Liver Deficiency. Spleen Deficiency arises from dietary injury. Kidney Deficiency results from excessive sexual activity. Liver Deficiency is caused by anger. Dietary injury impairs the Spleen's transportation and transformation; sexual excess damages the Kidney's ability to store essence; anger injures the Liver, causing Wood pathogenic factors to overact on Earth (Spleen). All lead to diarrhea. Although Kidney and Liver diarrhea occur occasionally, Spleen diarrhea is most common because constant dietary intake inevitably causes some damage, leading to diarrhea.

I have previously discussed that diarrhea, dysentery, and malaria share a common origin, often resulting from Spleen and Stomach Qi deficiency during the summer heat months, compounded by food stagnation. Acute onset after dietary injury manifests as mild diarrhea; prolonged stagnation leads to severe malaria or dysentery. Malaria and dysentery differ: when food transforms into Phlegm filling the chest and hypochondrium, it causes malaria; when food forms stagnation adhering to the intestines and stomach, it causes dysentery. Hence the saying, "No Phlegm, no malaria; no stagnation, no dysentery."

The body relies primarily on the Spleen and Stomach. The Stomach receives and accepts food, while the Spleen transports and transforms nutrients. Stomach Yang governs Qi, and Spleen Yin governs Blood. Regrettably, many physicians treat Spleen-Stomach disorders indiscriminately using acrid-warm-dry-hot herbs that assist Fire and damage Yin. This exacerbates Kidney Fire, further injuring Spleen Yin, transforming pure and harmonious Qi into dry-heat, causing dryness in the epigastrium, constipation in the Large Intestine, and eventual death due to Spleen exhaustion. One must realize that although Earth dislikes dampness, it requires moisture to generate all things; relying solely on acrid-hot herbs is misguided. Furthermore, the Kidney and Spleen open into the two lower orifices. If Kidney Qi is weak, it cannot steam and rot food and water. People often use Ginseng and Atractylodes macrocephala Rhizoma (Baizhu) for all diarrhea, unaware that these herbs tonify Middle Jiao Yang but cannot tonify the profound Yin responsible for storage and hibernation. The Stomach belongs to Earth, and the Kidney to Water. Treating Kidney diarrhea with Spleen-tonifying herbs strengthens Earth excessively, depleting Water further. Without the restraint of Yin, how can the single Yang Fire function as the heat source under the cauldron to cook grains?

The upper opening of the Stomach is the Cardia, where food and water enter. The lower opening is the Pylorus, where waste enters the Small Intestine. The Small Intestine has sixteen curves, slowing the passage of contents. The Valvula ileocecalis (Lanmen) is the lower exit of the Small Intestine, separating clear from turbid: turbid waste goes to the Large Intestine, clear fluid to the Bladder. If this separation fails, both enter the Large Intestine, causing diarrhea. There are eight pathological factors: Fire, Dampness, Summerheat, Wind, Phlegm, Cold, and Food Stagnation, alongside three deficiencies: Liver, Spleen, and Kidney. Immediate expulsion of food after ingestion indicates Rectum diarrhea, which is difficult to treat. Profuse diarrhea (>10 times/day) with a surging pulse indicates a fatal prognosis. Abdominal distension with cold extremities, emaciation, and severe diarrhea leading to death within an hour is critical. Simultaneous persistent diarrhea and vomiting indicate collapse of both Upper and Lower Jiao, a fatal sign. Chronic diarrhea with a surging, rapid pulse is difficult to treat. Collapse of Six Fu organs externally presents with cold hands and feet; collapse of Five Zang organs internally presents with uncontrollable diarrhea. Severe cases involve numbness of extremities, also difficult to treat.

Organ-related diarrhea and dysentery present diverse symptoms. Li Dongyuan's *Treatise on the Spleen and Stomach* emphasizes lifting clear Qi using Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) but neglects Kidney diarrhea. Zhang Zhongjing noted: If diarrhea stops and the physician administers Lizhong Tang (Regulate the Middle Decoction), worsening occurs because Lizhong Tang treats the Middle Jiao, whereas this pathology lies in the Lower Jiao. Zhao Yi-de stated that diarrhea has many causes beyond the six climatic pathogens and five evils, including mixed pathogens, making fixed protocols insufficient. Our master treated sudden Qi collapse with profuse diarrhea, unconsciousness, closed eyes/mouth, and faint breathing by urgently moxa-ing Qihai (CV6) and administering large doses of Ginseng Paste. For phlegm stagnation in the Lung affecting the Large Intestine's security, inducing vomiting to remove Upper Jiao phlegm allows Lung Qi to descend and Large Intestine deficiency to resolve. For excessive worry knotting Spleen Qi, preventing its ascent into the Lower Jiao, one must resolve depression and tonify the Spleen/Stomach to raise Grain Qi. For Yin deficiency impairing Kidney retention, vigorous Kidney tonification restores storage function.

Kidney diarrhea occurs at dawn (Wugeng time). The Kidney is the gate of the Stomach. The anterior orifice excretes water; the posterior orifice excretes grain. The Kidney belongs to Water, which peaks at Zi hour. Kidney Yang deficiency fails to secure closure, causing diarrhea as Yang Qi begins to rise. Spleen diarrhea results from sinking of Spleen Clear Yang, inability to transform contents at the Valvula ileocecalis, and insufficient Yuan Qi to separate water and grain, occurring without pain. Both stem from Kidney issues: Mingmen Fire decline fails to generate Spleen Earth. Yang Renzhai stated that Kidney-Mingmen Qi facilitates digestion. The Kidney controls opening and closing via the two lower orifices, governing bowel movements. Kidney deficiency extinguishes Mingmen Fire; Water dominates unchecked, causing continuous watery diarrhea, typically at dawn. Since Kidney corresponds to Water, North, and Hai/Zi hours, symptoms peak then. The best formula is Babao Wan (Eight-Ingredient Pill) modified (removing Moutan Cortex, adding Psoralea Fructus, Cuscutae Semen, Schisandrae Fructus), pilled with Dioscoreae Rhizoma paste. This tonifies True Yin and True Yang, achieving water-fire balance, restoring Kidney control, strengthening Mingmen Fire to generate Spleen Earth. Ancient formulas like Jiaofu Wan and Wuweizi San are also effective for Kidney diarrhea. Xue Ji advised: For Spleen-Stomach deficiency-cold with sinking, use Buzhong Yiqi Tang plus Aucklandiae Radix, Myristicae Semen, and Psoralea Fructus. For Spleen Qi deficiency-cold with insecurity, use Liujunzi Tang plus Zingiberis Rhizoma Preparatum and Cinnamomi Cortex. For Mingmen Fire decline with Spleen Earth deficiency-cold, use Babao Wan. For combined Spleen-Kidney Qi-Blood deficiency, use Shiquan Dabu Tang with Sishen Wan. For slippery bowels with urinary obstruction, edema, wheezing, and phlegm, indicating Spleen-Kidney depletion, use Jin Gui Ji Jian Shenqi Wan.

*Nan Jing* classifies five diarrheas: Stomach, Spleen, Large Intestine, Small Intestine, and Da Xia (Great Contraction) diarrhea. Da Xia diarrhea is equivalent to Kidney diarrhea. Symptoms include tenesmus, frequent urges without passage, and urethral pain. Misdiagnosing this as dysentery leads to disaster. It is a Kidney deficiency pattern: desire to pass stool but unable, resembling dysentery but distinct. Dysentery tenesmus arises from pathogenic pressure causing rectal prolapse; treated with Rheum Radix et Rhizoma and Arecae Semen to purge pathogens. Chronic diarrhea with Large Intestine laxity and sinking Qi causes heaviness; treated with astringents to secure collapse and lift sinking Qi. This differs from "empty straining" post-dysentery, where residual blood loss and sinking Qi require Angelicae Sinensis Radix, Ligusticum Chuanxiong Rhizoma, Paeoniae Radix Rubra, and lifting herbs. Kidney-related tenesmus involves urgency, pain, and urinary difficulty. Chu Shi's *Jingxue Lun* states that exhausting essence causes pain in bowel/bladder tracts, worsening with defecation. Treat with Buzhong Yiqi Tang plus heavy Shengma dosage and Sishen Wan, or Babao Wan base plus Schisandrae Fructus and Psoralea Fructus. Many die from swelling due to inappropriate dysentery treatments damaging Yuan Qi. Since the Kidney governs urination and defecation, dysfunction here implicates the Kidney. Constipation also relates to the Kidney. *Jinkui Zhenyan Lun* states: North, Black, connects to Kidney, opens to two lower orifices. Kidney Qi deficiency causes difficulty in both excretions; treat with Rehmanniae Radix and Cistanches Herba to tonify Yin, aided by acrid herbs to moisten dryness. Jiegu stated: Constipation varies (Heat, Cold, Excess, Deficiency, Wind, Qi). Elderly, postpartum women, and those with excessive sweating/diuresis suffer constipation; avoid Glauber's Salt, Rhubarb, Croton Seed, and Morning Glory Seed. People know Heat constipation but ignore Cold constipation. Cold constipation involves cold qi obstructing intestines, freezing fluids, blocking Stomach Qi, and attacking Large Intestine; patients prefer heat. Treat with strong Babao Wan decoction taken cold, or Banliu Wan with Ginger and Frankincense, or Haicang's Yihan Wan. Haicang noted Yihan Wan uses acrid-warm herbs with cooling agents (Paeoniae Radix, Fennel Fruit) to guide downward; Yin transforms with Yang, allowing free passage, like ice melting in spring. Babao Wan is superior. Li Dongyuan stated: Kidney governs five fluids; abundant fluids ensure normal stools. Injury from hunger/fatigue or spicy/greasy diet aids Fire, damaging True Yin and fluids, causing dry colon. Elderly Qi deficiency and fluid depletion also cause constipation. Kidney dislikes dryness; treat with acrid herbs to moisten. Follow Dongyuan's theory: use Liuwei Dihuang Wan instead of Runzao Tang or Runchang Wan. For Heat constipation with Qi deficiency, add Ginseng to the decoction, as Qi deficiency fails to propel and Yin deficiency fails to moisten.

*Jing* states: Spring Wind injury leads to Summer unsifted rice diarrhea (Sunxie); lingering pathogens cause hole-like diarrhea. Clear Qi sinking causes Sunxie. Excess Dampness causes Ruoxie. Sudden violent diarrhea with urgency belongs to Heat; clear/cold fluids belong to Cold. These show Wind, Damp, Cold, and Heat all cause diarrhea. Clear Qi sinking indicates Spleen deficiency sinking. Generally, strong Spleen Earth conquers Dampness; no Dampness means no diarrhea ("Excess Damp causes five diarrheas"). Weak Spleen fails to control Dampness, allowing Wind/Cold/Heat to invade. Nine treatment principles: 1. Light leaching (Dan Shen): Drain Damp via urine, like draining floodwaters. "Treating Damp without promoting urination is incorrect." "Those below, drain them." 2. Lifting (Sheng Ti): Qi rises naturally. Stomach Qi sinking requires lifting herbs (Shengma, Chaihu, Qianghuo, Gegen) to raise Qi, stopping diarrhea. Like wind drying wet earth. Wind herbs are drying; Wood conquers Earth; Wind conquers Damp. "Sinkers, lift them." 3. Cooling (Qing Liang): For Heat-induced violent diarrhea, use bitter-cold herbs to clear blazing Heat, like wind dispelling summer heat. "Hot, clear it." 4. Purging/Draining (Shu Li): For Phlegm/Qi/Food/Water stagnation causing diarrhea, remove pathogens. "Excess, purge it." "Use unblocking to treat unblocking." 5. Sweet/Soothing (Gan Huan): For urgent, relentless diarrhea, sweet herbs soothe the middle and slow urgency. "Urgent, soothe it." 6. Sour/Astringent (Suan Shou): Chronic diarrhea scatters Qi; sour herbs aid contraction. "Scattered, gather it." 7. Drying Spleen (Zao Pi): Spleen deficiency causes Dampness. Tonify Spleen to restore function. "Deficient, tonify it." 8. Warming Kidney (Wen Shen): Kidney governs excretion and stores essence. Mingmen Fire (Mother of Earth) declines, failing to transform grains. Deficiency often involves Cold. Tonify Mother (Kidney) for Spleen deficiency. "Cold, warm it." 9. Astringing (Gu Se): Chronic diarrhea with loose pylorus requires astringents if warming/tonifying fails. "Slippery, astringe it." These nine are the guidelines for treating diarrhea.

Liu Zongnong said: Food enters Stomach, distributes to Heart/Lung, Qi ascends then descends. Spleen-Stomach injury with Damp-Heat combines, weakening Yang ascent. Spleen-Stomach Qi sinks to Liver/Kidney causing diarrhea. Treat by filling Middle Qi and lifting with light wind herbs, benefiting Yin and generating Yang. This is Dongyuan's innovation.

Initial Heat diarrhea indicates Excess (Pathogen strong). Final Cold diarrhea indicates Deficiency (Summer Qi exhausted). Chronic diarrhea with Heat indicates Internal True Cold with External False Heat. Chronic diarrhea with Cold-Deficiency is typical. Daily morning diarrhea unresponsive to empty-stomach hot medicine requires evening dosing, as morning warmth dissipates by night, failing to counter nocturnal Yin Cold.

Diarrhea involving Spleen-Stomach is well-known. Liver Qi controls sphincter closure. Kidney Qi guards the lower orifice. Strong Liver/Kidney Qi ensures closure; weakness causes leakage. Kidney is Stomach gate; Kidney diarrhea occurs post-Zi (dawn). Humans form from Heaven-Earth interaction. Kidney interstitial Qi is the ancestor of congenital Yuan Yang. This Qi rises from Zi hour (One Yang born), passing Chou-Yin-Mao-Chen-Si, reaching maximum Yang at Li Palace (Heart/Fire). Afternoon brings One Yin born (White Qi turns Red Fluid), descending to Kan Palace (Kidney/Water), returning to White Qi. Day-night cycle continues. *Jing* calls this "Minor Fire generates Qi"; physicians call it True Yang or Minister Fire. Daoists call it Lord Fire (Congenital Ancestor Qi). As this Fire ascends through Middle Jiao, it passes Spleen/Stomach, roasting food, transforming waste to essence. Spleen disperses essence to Lung, regulates waterways, sends down to Bladder. This is Clear Ascending/Turbid Descending, Water-Fire Balance. *Jing* says: "Yin balanced, Yang secret, Essence solid." Neglecting health damages Spirit, weakens Kidney True Qi. Failure of Zi-hour Yang to rise prevents food transformation. At Yin hour (Three Yang phase), weak Yang cannot respond to season or overcome Yin/ascend, causing dawn diarrhea (loose stool, "Duck Diarrhea"), known as Kidney or Da Xia diarrhea. This is Yang loss and Qi escape; tonifying Fire is more critical than tonifying Qi.

For prolonged rainy weather with excessive Dampness causing abdominal pain and diarrhea, Weiling Tang plus Prepared Zingiberis Rhizoma and Cinnamomi Cortex is most suitable.