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How should spontaneous diarrhea caused by cold damage (Shanghan) be understood? Spontaneous diarrhea refers to loose stools occurring naturally without prior purgative treatment. There are various types of spontaneous diarrhea; one must discern whether it is due to cold, heat, deficiency, or excess, carefully select the decoction accordingly, and avoid errors. In miscellaneous diseases, spontaneous diarrhea is often attributed to cold; whereas in cold damage, diarrhea is mostly caused by "collateral heat" (Xie Re). This differs from miscellaneous diseases.

When exterior pathogens transmit inward, if the interior is deficient and accompanied by heat, diarrhea ensues. If purgatives are incorrectly used when not indicated, leading to interior deficiency and collateral heat, diarrhea also results; these are all cases of collateral heat. Furthermore, patients with combined diseases often experience spontaneous diarrhea. When Taiyang and Yangming combined diseases occur, spontaneous lower diarrhea is inevitable, treated with Gegen Tang (Kudzu Decoction). When Taiyang and Shaoyang combined diseases occur, spontaneous lower diarrhea is inevitable, treated with Huangqin Tang (Scutellaria Decoction). When Yangming and Shaoyang combined diseases occur, spontaneous lower diarrhea is inevitable, treated with Dachengqi Tang (Major Order the Qi Decoction). These three types of combined disease diarrhea differ: one involves purging the interior, another involves harmonizing. The difference lies in the Six Meridians: Taiyang and Yangming are considered exterior, Shaoyang and Taiyin are semi-exterior/semi-interior, and Shaoyin and Jueyin are interior. Taiyang and Yangming combined diseases are located in the exterior. Although presenting as diarrhea, the pathogenic qi in the meridians must be dispersed through sweating to resolve. Hence, Gegen Tang is given to induce sweating. Taiyang and Shaoyang combined diseases are located in the semi-exterior/semi-interior. Although presenting as diarrhea, the pathogenic qi in both exterior and interior must be harmonized to resolve. Hence, Huangqin Tang is given to disperse the pathogen. Yangming and Shaoyang combined diseases involve Shaoyang pathogenic qi entering the fu organs. Although presenting as diarrhea, the excess in the stomach must be driven out to resolve. Hence, Chengqi Tang is given to purge the excess. These are the differences among the three.

How can one distinguish between cold and heat in patients with diarrhea? If spontaneous diarrhea occurs without thirst, it belongs to Taiyin, due to cold in the zang organs. If diarrhea is accompanied by a desire to drink water, it indicates heat. Therefore, loose stools with normal urination indicate heat-type spontaneous diarrhea. If urine is clear and white, it exhibits the signs of Shaoyin disease, indicating cold. Aversion to cold, faint pulse, and diarrhea with undigested food (Qing Gu) indicate cold. Diarrhea accompanied by fever and tenesmus (Hou Zhong), with yellow-red excrement, indicates heat. These symptoms allow for the differentiation of cold and heat.

Abdominal pain, borborygmus (Zhuan Qi), and gas moving downward toward the lower abdomen indicate impending spontaneous 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, if the pulse is tight with diarrhea, but suddenly becomes weak, hands and feet become warm, and the tightness disappears, this indicates impending resolution. A large pulse in diarrhea indicates the condition has not stopped; a weak, fine, and rapid pulse indicates the condition will stop spontaneously. Even with fever, death is unlikely. Thus, a large pulse in diarrhea is unfavorable, while a small pulse is favorable.

Spontaneous diarrhea is suitable for warming treatments. Lizhong Tang (Regulate the Middle Decoction), Baitong Tang, and Sini Tang (Frigid Extremities Decoction) and similar formulas are agents that warm the viscera and stop diarrhea. However, if there are accumulations and knots in the intestines and stomach, or external pathogens in the lower jiao, warming agents cannot stop the diarrhea. One must use purgatives to drain or diuretics to separate fluids to resolve it. The classics state: "Lizhong regulates the middle jiao." For diarrhea located in the lower jiao, Chishizhi Yuyuli Tang (Red Halloysite and Hematite Decoction) is appropriate. If it does not stop, promote urination. This is because the diarrhea is in the lower jiao, caused by infiltration and accumulation of dampness.

In Shaoyin disease, spontaneous diarrhea of clear water, purely green in color, with pain in the epigastrium and dry mouth, requires attention. Or, in diarrhea where the pulses at the three positions are level, but palpation reveals hardness in the epigastrium; or a deep and slippery pulse; or anorexia with delirium; or recurrence after recovery on specific dates—these conditions all indicate intestinal and gastric accumulations requiring purgation. The *Neijing* states: "Severe internal heat with unceasing diarrhea: heat should be treated with cold methods; accumulated heat must be removed with cold purgatives. Once the accumulation disperses, the diarrhea stops. Severe internal cold with chronic loose stools, recurring over years: treat with warm purgatives. Once the cold is gone, the diarrhea stops." This illustrates the principle of "treating obstruction with unblocking methods" (Tong Yin Tong Yong).

Even if diarrhea presents with exterior signs, sweating should not be induced. Diarrhea indicates pathogenic qi attacking internally, consuming fluids and weakening the stomach. Thus, the classics state: "Diarrhea should not be treated by attacking the exterior; inducing sweat will lead to abdominal distension." Generally, diarrhea leads to the loss of vital qi; among the Five Deprivations (Wu Duo), this is severe. If pathogens are strong and righteous qi is weak, forcing righteous qi to collapse downward leads to death from frequent diarrhea. Why? The classics state: "Diarrhea more than ten times a day with a paradoxically strong pulse indicates death; severe fever and diarrhea with unrelenting cold limbs indicate death; fixed gaze, delirium, and diarrhea indicate death; diarrhea with cold limbs and absent pulse, unresponsive to moxibustion and pulse return, indicates death. Shaoyin disease with spontaneous diarrhea, restlessness, and inability to sleep indicates death." These cases all result from pathogens forcing righteous qi to collapse downward. The *Jingui Yaolue* states: "When qi of the six fu organs fails externally, hands and feet are cold; when qi of the five zang organs fails internally, diarrhea is uncontrollable." Alas! Medicating only after disease formation, even a divine physician cannot cure it. Once qi has collapsed, who can treat it?

[Formulas]

Baizhu Wan (Atractylodes Macrocephala Pill): Fuyang pulse is deep and slow. Deep indicates strong stomach qi; slow indicates frequent bowel movements. The combination of deep and slow leads to difficult urination and constrained stomach function.
Ingredients: Baizhu (Atractodis Macrocephalae Rhizoma), Ganjiang (Zingiberis Rhizoma), Fuling (Poria) (each 2 liang). Process into honey pills the size of paulownia seeds. Take 20 pills with rice water, adjusting dosage until effective.

Helile Yin (Galangal Drink): Treats post-cold damage disharmony of qi and endless spontaneous diarrhea.
Ingredients: Helile Pi (Myristicae Pericarpium) (4 pieces, half raw, half roasted), Caodoukou (Alpiniae Katsumadai Semen) (4 pods, half raw, half roasted, peeled). Coarsely grind and sieve. Take 2 qian per dose. Decoct with Jiangshui (fermented rice water) one cup until reduced to 60%. Strain and take warm on an empty stomach.

Zaochang Wan (Dry Intestine Pill) (from *Jisheng Babie Fang*): Treats spontaneous diarrhea of both bowels and bladder after cold damage sweating or purging, with intestinal pain.
Ingredients: Fuzi (Aconiti Lateralis Radix Praeparata) (1 piece, processed), Longgu (Fossilia Ossis Mastodi et Scapulae) (0.5 liang), Ganjiang (Zingiberis Rhizoma) (1 liang), Wuzhuyu (Evodiae Fructus) (0.5 liang), Miguj (Rice and Grain residue) (0.5 liang), Helile Pi (Myristicae Pericarpium) (0.5 liang). Grind into fine powder, bind with wine paste into pills the size of paulownia seeds. Take 30 pills with warm water. Stop taking once diarrhea ceases.

Shenfu Tang (Ginseng and Aconite Decoction) (from *Ruyi Fang*): Treats spontaneous diarrhea with floating false fire causing irritability, restlessness, and slow pulse.
Ingredients: Renshen (Ginseng Radix) (0.5 liang), Fuzi (Aconiti Lateralis Radix Praeparata) (processed, 1 liang). Cut into pieces, divide into three doses. Add 10 slices of Shengjiang (Zingiberis Rhizoma Recens), decoct, and take warm before meals. Also refer to Ji Ji Fang.

Sini Tang (Frigid Extremities Decoction) (from *Yijian Fang*): Treats yin-pattern cold damage with spontaneous diarrhea and no thirst, continuous vomiting and hiccups, simultaneous vomiting and diarrhea, dysuria or polyuria, faint pulse nearly imperceptible, abdominal pain and distension, cold limbs, cough or palpitations, internal cold with external heat, diarrhea with undigested food, heavy limbs, sweating with cold limbs, or sweating with persistent heat. Also treats all deficiency-cold syncope. Mentioned interchangeably with Lizhong Tang. If cold damage is in the exterior and mistakenly purged by a physician, causing unceasing diarrhea, even if headache, body ache, fever, aversion to cold, and limb stiffness (exterior signs) are present, do not attack the exterior. First administer this medicine to support yang and rescue the interior, then administer Guizhi Tang (Cinnamon Twig Decoction) to resolve the exterior.
Ingredients: Gancao (Glycyrrhizae Radix et Rhizoma) (1 liang), Ganjiang (Zingiberis Rhizoma) (1.5 liang), Shu Fuzi (Prepared Aconiti Lateralis Radix) (0.3 fen). Cut into pieces. Take 4 qian per dose. Decoct with 1.5 cups of water until reduced to 60%. If diarrhea stops but blood loss occurs, add Renshen (Ginseng Radix) 0.5 liang. If face is red, add Congbai (Allii Tuberosi Bulbus) one stalk per dose. If abdominal pain, add Shaoyao (Paeoniae Radix Alba) 1 liang. If vomiting, add Shengjiang (Zingiberis Rhizoma Recens) 1 liang. If sore throat, add Jiegeng (Platycodonis Radix) 0.5 liang. If diarrhea stops but pulse does not emerge, add Renshen (Ginseng Radix) 1 liang. Most suitable after cholera-like vomiting and diarrhea. For yin-pattern cold damage with no sweat, blue lips, black face, back stiffness and pain, cold limbs, coma, and no prior Sini Tang usage, first give Fuzi San (Aconite Powder) 0.3 fen. Use Fuzi (Aconiti Lateralis Radix Praeparata), Guigui (Cinnamomi Ramulus), Danggui (Angelicae Sinensis Radix), Baizhu (Atractodis Macrocephalae Rhizoma) each 0.5 liang, Banxia (Pinelliae Rhizoma), Ganjiang (Zingiberis Rhizoma) each 0.1 fen, plus Congbai (Allii Tuberosi Bulbus). Decoct and take. Cover to induce sweat.