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Diarrhea has three types: cold diarrhea, heat diarrhea, and accumulation diarrhea.

Cold diarrhea is characterized by no thirst; it should be treated primarily with Lizhong Wan (Warming the Middle Decoction).
Heat diarrhea is characterized by thirst; it should be treated primarily with Wuling San (Five-Ingredient Powder with Poria) combined with Liuyi San (Six-to-One Powder).
Accumulation diarrhea is characterized by a sallow complexion and the passage of sour, foul-smelling undigested food; it should be treated with Dingxiang Pi Ji Wan (Clove Spleen Accumulation Pill) to purge. If the accumulation is not removed, the diarrhea will not stop.
[Composition of Dingxiang Pi Ji Wan] Sanleng (Broomrape Rhizome, roasted), Ezhu (Curcuma Zedoaria Rhizome, roasted), Liangjiang (Galangal Rhizome, boiled in vinegar), Qingpi (Citrus Reticulata Pericarpium, pith removed, boiled in vinegar, each 0.5 fen), Dingxiang (Caryophylli Flos, calyx removed, 3.5 qian), Muxiang (Aucklandiae Radix).

The son of Hu Sanxi suffered from incessant diarrhea. Hu Sanxi himself, along with Gan Dayong, treated him using methods I had transmitted, but without effect. His elder brother Yuanxi said, "There is a person named Puyu here." Upon hearing this, I returned to inquire. When asked about the prescriptions used, I found they were not indicated for the condition. Observing the external signs, the patient had a sallow complexion and passed sour, foul-smelling stools; this was accumulation diarrhea, and purgation was required. Once the accumulation was removed, the diarrhea would cease. Thus, I administered Dingxiang Pi Ji Wan, and after one dose, the condition stabilized. The father asked, "I have heard that dampness often causes five types of diarrhea, but I have never heard of so-called accumulation diarrhea." I replied, "The *Nan Jing* mentions 'Da Jia Xie' (Great Mass Diarrhea), which refers to this condition. Regarding the five diarrheas caused by dampness, there are internal causes, external causes, and neither-internal-nor-external causes. For example, if caused by wind, where water and grain are not separated, it is called *Sun Xie* (Sporadic Diarrhea); if caused by heat, where water and grain rush down violently, it is called *Dong Xie* (Cavernous Diarrhea); if caused by cold, where water and grain are not digested, it is called *Tang Xie* (Pasty Diarrhea); if caused by dampness, where water and grain are thick and sticky, it is called *Ru Xie* (Moist Diarrhea). These four types belong to diseases caused by external factors, where dampness arises from outside. If caused by accumulation, with pus and blood mixed, borborygmus, abdominal pain, and foul-smelling excrement, it is called *Jia Xie* (Mass Diarrhea). 'Jia' refers to the name for retained food and stagnation, i.e., food retention syndrome. This belongs to diseases caused by internal factors, where dampness arises from within. There are also neither-internal-nor-external causes, resulting from improper use of purgatives, divided into cases with accompanying heat or cold, such as 'intestinal mucus pasty stool'." He asked again, "Pi Ji Wan is a purgative formula; how can it stop diarrhea?" I said, "The stomach is the sea of water and grain, and the intestines are the pathways through which water and grain flow. Diarrhea is a disease of the stomach and intestines. If there is no pathogen in the stomach and intestines, water and grain transform properly, and urination and defecation flow smoothly, indicating a healthy child. Now, if there is retained food that fails to digest, and stale matter accumulates in the stomach and intestines, transforming into diarrhea and dysentery, it is like spring water stagnant in the middle and flowing out externally. If one does not trace the source and expel it, the diarrhea and dysentery will never cease. Therefore, Pi Ji Wan removes the stale matter; this is the method of pulling up the root and blocking the source. According to the *Ben Cao*, Ban Dou (Croton Seed) can induce diarrhea in those who are not yet having diarrhea, and can stop diarrhea in those who already have it. In treating accumulation diarrhea with Pi Ji Wan, one must follow this ancient principle."

I teach my sons to treat diarrhea using three consistent methods:
Initially, administer Lizhong Wan. If it does not stop after one dose, next use Wuling San. If it does not stop after one or two doses of promoting diuresis, thirdly use Baizhu San, which is effective. If it still does not stop, regulate with Shenling Baizhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder), which is invariably effective. If it still does not stop, use Baizhu San in a ratio of two parts to Doukou (Cardamom) in one part.

[Commentary] The discussion on the five diarrheas in the *Nan Jing* is very detailed. My discussion on Large Intestine Diarrhea, Small Intestine Diarrhea, and Da Jia Diarrhea is easy to understand. My discussion on Spleen Diarrhea and Kidney Diarrhea is difficult. The dwelling of the zang-fu organs, if there is nothing received, how can there be anything discharged? The so-called Spleen Diarrhea is actually Stomach Diarrhea. It means the spleen cannot constrain the stomach, and the stomach cannot store, leading to diarrhea. Thus, some diarrheas belong to the spleen, and some to the kidney. Those coming from the stomach involve water and grain pouring down directly and in large quantities; those coming from the spleen form yellow, mushy stools, with profuse but small-volume diarrhea. Looking at Zhang Zhongjing's *Shanghan Lun*, the use of Miyue Wan (Spleen-Restraining Pill) for constipation makes the intent clear. The kidney is also a zang organ. It is called Kidney Diarrhea because the kidney opens into the two yin orifices and is the master of closure. When the kidney is deficient, it cannot govern closure, and water and grain descend spontaneously. Moreover, the lower jiao is like a ditch; what is received is discharged. However, the diarrhea differs. The *Nan Jing* states: "Diarrhea accompanied by a feeling of heaviness/tenesmus is Kidney Diarrhea." Looking at Li Dongyuan's *Pi Wei Lun*, in the Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction), when there is straining during defecation, Danggui Shenhong (Angelica Sinensis Root and Carthamus Flower) are added. Straining refers to tenesmus; Danggui and Honghua are used to moisten the blood. Since the kidney dislikes dryness, these two herbs are used to moisten it. Kidney diarrhea is similar to Da Jia diarrhea. Diarrhea and dysentery are essentially the same, being stagnant materials; thus, dysentery is called "Zhi Xia" (Stagnant Downward Flow). Furthermore, dysentery involves abdominal pain, borborygmus, tenesmus, and red-and-white discharge. In contrast, Kidney Diarrhea involves only slight difficulty during defecation, without tenesmus. Hence, it is said that dysentery involves tenesmus. Ancients formulated prescriptions for Kidney Diarrhea using Pogostemon Cablin (Gu Zhi/Bu Gu Zhi) to tonify the kidney, or Evodia Fruit (Wu Zhu Yu) to tonify the liver. These employ the method of "bitterness to firm and pungency to moisten." Now, for Spleen Diarrhea, I use only Shenling Baizhu Wan; for Kidney Diarrhea, I use Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill) plus Bu Gu Zhi, which is very effective.

Stomach Diarrhea, Large Intestine Leakage, and Small Intestine Leakage are different. Generally, those originating from the stomach involve water and grain pouring down without separation, passing as complete undigested grains; this is a cold pattern, treated primarily with Lizhong Wan. Those originating from the small intestine also involve water and grain pouring down without separation, forming dregs rather than complete grains. Since the small intestine is the palace receiving qi, water and grain reaching here have transformed but not completely. Treatment should separate water and grain, primarily using Wuling San to promote diuresis, so that diarrhea stops. Those originating from the large intestine undergo complete transformation into feces, but do not coagulate, and the excrement is sour and foul; treat with Yuyuliang Tang (Hematitum Decoction) from the *Shanghan Lun*, or Roudoukou Wan (Myristica Pill) from Chen Zhongwen's *Douzhen Fang*. This is the method of "astringency to treat slipperiness."

He Suhe stated, "Dampness abounds to cause five diarrheas," which originates from the *Neijing* theory "Excess dampness leads to moist diarrhea." The so-called five diarrheas differ from the *Nan Jing*. The *Suwen* divides five diarrheas by zang-fu, while He Suhe divides them by wind, cold, heat, dampness, and food.

If diarrhea occurs with fever and aversion to cold, and water/grain are not separated, this is a wind-damp pattern, called *Sun Xie*. The classics state: "Wind injury in spring leads to *Sun Xie* in summer." Treat primarily with Xiao Jianzhong Tang (Minor Construct the Middle Decoction) plus Fangfeng. If accompanied by pus and blood, use Weifeng Tang.

If diarrhea occurs with abdominal pain, with or without vomiting, and the excrement consists mostly of undigested grains, this is a cold-damp pattern, treated primarily with Lizhong Tang.

If diarrhea occurs with abdominal pain, sometimes painful, sometimes not, and the excrement contains undigested grains, this is due to pathogenic heat failing to cook the grain, forming dregs; all belong to heat-damp. Treat primarily with Zhuling Tang (Polyporus Decoction) from the *Shanghan Lun*. Cold-damp and heat-damp must be carefully distinguished. Cold patterns present without thirst; heat patterns present with thirst.

If diarrhea involves mixed water and grain, with scanty urine and abundant stool, this is damp diarrhea. Profuse pasty diarrhea indicates chronic dampness; both are treated primarily with Wuling San.

If diarrhea presents with abdominal pain and borborygmus, anorexia, and passage of sour/foul matter, this is due to retained food stagnating in the middle, transforming into dampness (food converting to damp). Purge it. Once the accumulation is removed, the diarrhea stops. Use Dingxiang Pi Ji Wan.

The terms "Xie" (leakage) and "Xie" (pouring) should also be distinguished. "Xie" refers to the leakage of water and grain substances. "Xie" refers to the sinking of qi in the stomach and intestines.

Zhuling Tang
Zhuling, Zexie, Ejiao, Huashi, Fuling (each 1 qian). Decoct in water.

Acquired in spring, it is named Wind Injury. Symptoms include fever, thirst, and scanty urine. Clear heat first, then tonify the spleen. Use Ru Ling Tang to clear heat, and Baizhu San to tonify the spleen.
Acquired after the Summer Solstice, diarrhea may be cold or heat. Thirst with desire to drink water indicates heat diarrhea. First take Yulu San to clear summerheat and stop thirst, then take Baizhu San to tonify the spleen.
If there is no thirst, it is cold diarrhea. First take Lizhong Wan to warm the middle and tonify the spleen, then take Wuling San to clear summerheat. This is a secret method passed down from ancestors.
Summer water diarrhea details are recorded in the section on diseases caused by the five pathogens.

Acquired in autumn, it is Dampness Injury Diarrhea. Symptoms include heavy body and loose stools, called *Ru Xie*. Promote dampness resolution, tonify the spleen, and benefit urination. Use Weiling Tang. Or Shengma Chushi Tang.

Acquired in winter, it is Cold Damage Diarrhea. Symptoms include abdominal pain and watery stools. Warmth is indicated. Use Lizhong Wan or Lizhong Tang with a small amount of Shu Fuzi. If ineffective, use Doukou Wan.

In all four seasons, there is accumulation diarrhea, characterized by sallow complexion, propensity to swelling, intermittent abdominal pain, and sour/foul excrement. First remove the accumulation, then regulate the spleen and stomach. Remove accumulation with Dingxiang Pi Ji Wan; regulate spleen/stomach with Weiling Wan.

General principles for treating diarrhea: Regardless of cold or heat, first administer Lizhong Wan. "Lizhong" means regulating the middle qi. Treating diarrhea without benefiting urination is incorrect. Then use Wuling San. If still ineffective, it is sinking of stomach qi; use Buzhong Yiqi Tang. When clear qi ascends, diarrhea ceases. If still ineffective, it is slippery diarrhea; use astringents. Use Doukou Wan. This is an ancestral secret method.

For pediatric diarrhea, if treatment according to the above methods is ineffective, the spleen and stomach are already depleted and cannot transport medicinal properties to effect changes. Focus solely on tonifying the spleen. Once the spleen and stomach are robust, the medicine will naturally work. Use Baizhu San. Administer continuously without interruption. This was a secret transmission from my late father.

Chronic diarrhea that does not stop consumes fluids, leading to spleen/stomach collapse and loss of postnatal essence, inevitably resulting in slow convulsions. This is what is meant by "spleen deficiency leads to vomiting, diarrhea, and wind generation." Tonify the spleen and stomach before they decline significantly; use Baizhu San. If tonification is ineffective, use Tiaoyuan Tang combined with Jianzhong Tang for emergency rescue. Otherwise, once slow wind is established, even if Zhang Zhongjing were reborn, it could not be cured. (See Slow Convulsions chapter.) For pediatric diarrhea with extreme unquenchable thirst, do not give soup or water. Water intake increases thirst and worsens the disease. Generate spleen/stomach fluids; use Baizhu San.

Chronic diarrhea with fever indicates fluid deficiency and deficiency heat. Do not administer cooling medicines, as they consume fluids further. Use Baizhu San. If heat is more severe, use Huanglian Wan.

Baizhu San: Treats pediatric diarrhea with irritability and thirst.
Si Junzi Tang plus Muxiang, Huoxiang (equal parts), Gegen (doubled). Prepare a large dose, decoct in water, and take frequently as a substitute for water.

Huanglian Wan: Treats chronic diarrhea with fever (deficiency heat).
Huanglian, Ganchan (roasted, each 2 qian), Muxiang (1 qian), Shijunzi (1 qian), Lushui, Yeming Sha (each 0.7 fen). Grind into powder, mix with Shan Yao powder and water paste, make pills the size of hemp seeds. Take with rice water.

Shengma Chushi Tang: Treats wind-damp diarrhea ascending from below, drawing it out and exhausting it. For weak spleen/stomach, anorexia, borborygmus, abdominal pain, profuse diarrhea, dark/scanty urine, and limb fatigue.
Shengma, Chaihu, Fangfeng, Shenqu, Zexie, Zhuling (each 0.5 fen), Cangzhu (1 qian), Chenpi, Gancao (roasted), Maidong (each 0.3 fen). Grind into powder, decoct in water, and take hot.

Yulu San: Treats heat injury diarrhea with yellow stool. (Formula seen previously.) Mixed equally with Wuling San, named Guiling Ganlu Yin, treats heat diarrhea. This is a formula from my personal insights.

One child was ill, having diarrhea 3-4 times a day and night, alternating with cessation, lasting years without cure. This was spleen diarrhea. Treat with Weiling Wan plus Renshen.

One child was healthy during midsummer. A doctor gave him Tianshui San, claiming it could resolve summerheat toxicity. After ingestion, sudden violent diarrhea occurred. The doctor regretted it and switched to Lizhong Tang. After three doses, diarrhea turned into dysentery, day and night without limit, with pus and blood mixed. The child became increasingly exhausted, skin dry without sweat, hair clumping into tufts. I was invited to treat. I said, "Dysentery with accompanying heat implies intestinal filth. Chronic diarrhea leads to malnutrition diarrhea. This child's initial diarrhea was a seasonal epidemic disease, unrelated to Tianshui San. The doctor should have used Tianshui San adjusted with Wuling San. Instead, using the hot Lizhong Tang caused heat-accompanied intestinal filth. Dry skin and clumped hair indicate severe exterior heat; urgent dysentery indicates severe interior heat. Exterior and interior both hot, fluids depleted, critical situation." I formulated a prescription: Huanglian, Ganchan (roasted, each 1 qian), Muxiang, Qingpi, Baifuling, Danggui Shen, Hezirou (each 1.5 qian). Grind into powder, make pills with millet flour paste. Take 30 pills per dose with stir-fried old rice soup. Ten days later, small boils appeared on the head, and prickly heat like millet grains appeared on the body. Heat subsided, dysentery stopped, and the child recovered. Alas, without me, this child would not have survived.

One child had diarrhea with extreme unquenchable thirst. Doctors used Wuling San and Yulu San without effect; the condition worsened, with red cheeks and lips. I observed and said, "Do not drain further. Extreme thirst in diarrhea is due to fluid loss and insufficient grain/fluids. The method is to use Baizhu San to replenish fluids. But he took Wuling San and Yulu San, diuretic agents, severely depleting fluids and weakening the spleen/stomach. The aphorism says: 'Extreme thirst that returns after stopping is fatal; diarrhea that continues with good spirit is fatal.' Parents did not believe, and three days later, the child died from convulsions."

Wan Binlan, top scholar in the Renzi year, was the eldest son of Stone Spring's uncle. Stone Spring had a son late, loving Binlan like pearl and jade. At one year old, he got water diarrhea, over ten times daily. Stone Spring, skilled in medicine, made Lizhong Tang with Hezirou and Roudoukou for him, without effect. He urgently summoned me. I recounted the ineffectiveness of previous meds. I said, "The *Zhengli Lun* states: Lizhong regulates middle qi. Treating diarrhea without benefiting urination is incorrect." So I used Wuling San minus Guizhi plus Gancao. One dose stopped the diarrhea. Three days later, red spots appeared all over the body. Stone Spring feared. I said, "No harm. The *Huoren Shu* states: Early purgation in cold damage allows heat qi to enter the stomach causing spots. In summer heat, chronic diarrhea leaves the interior empty, allowing heat qi to enter. Plus, excessive use of Lizhong's pungent-sweet agents left heat in the stomach. Now red spots appear as heat exits the interior to the exterior. Use Huaban Tang, and recovery will be easy." Stone Spring said, "Shigao is cold, unsuitable for diarrhea." I said, "With the disease, administer the medicine. Even in summer, Baihu Tang is appropriate." One dose cleared the spots and reduced heat.

County Magistrate Zhu Yunge's son had diarrhea for ten days. Various doctors used Lizhong, Wuling, Yi Yuan, Baizhu San, etc., all ineffective. Diarrhea was severe. The magistrate urgently summoned me. Observing external signs, I advised, "Extreme thirst requires stopping thirst first." The magistrate said, "Stop diarrhea first." I said, "The root is damp-heat, water/grain not separated. Drinking more water damages spleen/stomach, accumulating water in intestines. The expelled water is the ingested water. Thus, stop thirst first; when thirst stops, diarrhea stops." Magistrate asked, "Which formula?" I said, "Baizhu San." Magistrate said, "Already taken too much." I said, "The usage differs." Magistrate asked, "Is there another method?" I said, "The method lies in frequent administration. 'Frequent' is the method. Baizhu San is the divine formula for diarrhea with thirst. There are two methods: Renshen, Baizhu, Fuling, Gancao, Huoxiang, Muxiang (each 1 qian), Gegen doubled (2 qian) is for chronic diarrhea where stomach fluids sink. Gegen is doubled to raise stomach fluids. This is one method. People today don't know to double Gegen, using equal parts, hence less efficacy. Children with thirst need constant water; people don't know to use medicine as water. Though the formula is correct, the method is wrong. Small medicine dose with large water volume is like saving a burning cart of firewood with a cup of water; water cannot overcome fire, so no effect. Make a large decoction to replace water. Drink only this formula for thirst, forbid all other water. Then stomach qi ascends, fluids generate, thirst and diarrhea stop." The magistrate agreed, and indeed one dose cured it. Regardless of diarrhea or dysentery, this is suitable, the more the better. Not only stops diarrhea, but prevents spleen deficiency wind. Truly a miraculous formula. I detail it herein. The young master had weak spleen/stomach since childhood, prone to food retention. A doctor used Zhizhu Wan and Baohe Wan, intending to use Zhizhu Wan to tonify spleen and Baohe Wan for food retention, but ineffective. The magistrate asked me. I said, "This method is good, but exclusive use of Zhizhu Wan lacks guiding/digesting herbs, unable to control food injury initially. Exclusive use of Baohe Wan, given spleen deficiency, cannot handle digestion, damaging neutral qi. Establish a formula: 70% tonification, 30% digestion, strengthening spleen/stomach so they cannot be injured again." Magistrate said, "Very good. Show me a formula." I formulated Renshen, Baizhu, Qingpi, Chenpi, Gancao, Muxiang, Suosharen, Shan Yao, Lianrou, Shijunzi, Shenqu, Maiya as powder, steamed lotus leaf with rice mashed into pills, taken with rice drink, named Yangpi Xiaoshi Fei'er Wan. After taking, vitality changed instantly, diet caused no injury. The magistrate was delighted, recorded the formula for long-term use, inscribed "Confucian Physician" on a plaque, and bestowed it upon me.

Xiangsheng Hu Yiquan, eldest son of East Suburb Old Man, had water diarrhea at one year old. First consulted doctor Gan Dayong, ineffective. Then consulted me. Muscles wasted, face pale, midsummer, sweat congealed not moistening, skin dry, hair erect, frequent stools with slight tenesmus. This was qi and blood deficiency. Regulated according to treatment: tonify middle qi, benefit urination, raise yang, astringe slipperiness, step-by-step regulation, with no effect. Someone asked, "What now?" I said, "Methods exhausted, only one method remains." Treated as malnutrition diarrhea, using Renshen, Baizhu, Baifuling, Gancao, Chenpi, Shan Yao, Danggui, Lianrou, Sharen, Hezirou, Roudoukou, Huanglian, Muxiang, Ganchan as powder, Shenqu paste pills, taken with Si Junzi Tang decoction. Within two days, skin moist with slight sweat; next day red sores appeared on head; urine gradually increased; diarrhea stopped in five days. Later, Shenling Baizhu Wan was taken for regulation and recovery.

Wang Wangfeng's eldest son, Chengnan, had a son raised by his sister's husband, Nanhe Hu. Nanhe told others, "Old Master Wan excels in pediatrics. Now acting clever, telling people to ask Brother Zhang for medical help. He was personally taught by the master. I also gather herbs with others, not sticking to fixed formulas, saving many lives. Let me cite a few verified cases." Chengnan's son had diarrhea for over ten days. Always treated by Zhang, using one pill of Weiling Wan, all ineffective. Summoned me. Wangfeng knew the reason, fearing I wouldn't try hard, offered two taels of silver as a gift. I sighed, "It's not about the gift, but trust. My treatments, though appearing clever, rely on ancestors' old formulas, just used differently. Treat major illnesses with heavy doses, minor with light ones. How can one pill of Weiling Wan treat this severe illness?" I took fifty Doukou Wan and fifty Weiling Wan, taken with Chen Cang Mi (aged rice) decoction. Told Nanhe, "One dose will stop it, no more needed." Nanhe initially didn't listen. Diarrhea stopped, he realized, "True masters do not show their simplicity, truly so?"

Miss Sun, Right Commissioner of Huguang, had diarrhea starting in May, continuing to July. All doctors failed. Sent for me. Upon arrival... [text missing], knowing fluid deficiency. Without stopping thirst, diarrhea won't stop, nor will heat. The lord asked, "How many days to recover?" I said, "Thirst stops in three days, diarrhea in five, heat gone in ten. Recover in eighteen days." Lord said, "Illness is long, recovering in a month is fortunate." Then administered Baizhu San in a large... [text ends]