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Cheng Wuji's Commentary: Spontaneous diarrhea (Zili) refers to diarrhea that occurs without prior purgative treatment. Some cases involve exterior pathogens transmitting inward, causing interior deficiency and heat in the hypochondriac region leading to diarrhea; other cases result from inappropriate use of purgatives, also resulting in diarrhea. These all fall under the category of hypochondriac heat. Additionally, combined diseases of the three Yang meridians often present with spontaneous diarrhea, but treatments vary between releasing the exterior via sweating, purging the interior, or harmonizing the Shaoyang. (Combined disease of Taiyang and Yangming, where pathogen is in the exterior, is treated with Gegen Tang [Kudzu Decoction] to induce sweating; combined disease of Taiyang and Shaoyang, where pathogen is in half-exterior half-interior, is treated with Huangqin Tang [Scutellaria Decoction] to harmonize; combined disease of Yangming and Shaoyang, where Shaoyang pathogen has entered the interior, is treated with Chengqi Tang to purge.) Furthermore, spontaneous diarrhea accompanied by absence of thirst indicates a Taiyin syndrome due to cold in the zang organs. Diarrhea accompanied by desire to drink water indicates heat. Therefore, loose stools with normal urination, or fever with tenesmus and yellow-red excrement, are classified as heat syndromes. Spontaneous diarrhea with clear-white urine, presenting full characteristics of Shaoyin disease, or accompanied by aversion to cold, faint pulse, and undigested food in stool, are classified as cold syndromes. Although spontaneous diarrhea is generally treated with warming methods, if there are accumulations in the intestines and stomach, or external pathogens in the lower jiao, warming agents alone cannot stop it; one must employ methods to separate fluids and promote urination, or purge and drain. ("Jing" states: Lizhong Tang regulates the middle jiao; this diarrhea is in the lower jiao, so Chishizhi Yuyuliang Tang [Red Halloysite and Hematite Decoction] should be used. If ineffective, promote urination. In Shaoyin disease, spontaneous diarrhea of clear water, pure green color, with必 pain in the epigastrium and dry mouth, or where pulses in all three positions are level but the epigastrium feels hard upon palpation, or pulse is deep and slippery, or anorexia with delirium, or recurrence after remission, these indicate intestinal accumulations requiring purgation. This is called "treating obstruction with unblocking methods" [Tong Yin Tong Yong].) Moreover, even if diarrhea presents with exterior signs, sweating should not be induced, because diarrhea indicates pathogenic invasion inward, consuming body fluids and weakening stomach qi. The classics state: Do not attack the exterior in diarrhea; inducing sweat will cause abdominal distension. Generally, spontaneous diarrhea is common in the three Yin meridians. However, a cool body and quiet pulse in diarrhea patients is a favorable sign, while fever and large pulse are unfavorable. Generally, diarrhea leading to collapse of vital qi is the most difficult to treat, as excess pathogen and deficient Zheng qi lead to downward collapse of Zheng qi, often resulting in death from diarrhea. (The classics state: In Shaoyin disease, spontaneous diarrhea with irritability and inability to lie down is fatal; staring straight ahead with delirium and diarrhea is fatal; diarrhea occurring more than ten times a day with a surprisingly solid pulse is fatal; diarrhea with cold limbs and absent pulse, where moxibustion fails to warm the limbs or restore the pulse, is fatal; fever with severe diarrhea and persistent cold limbs is fatal. These cases represent excess pathogen and downward collapse of Zheng qi, hence fatal. "Jin Gui Yao Lue" states: When Qi of the six fu organs fails externally, hands and feet become cold; when Qi of the five zang organs fails internally, diarrhea becomes uncontrollable. Medication administered after disease formation, even by divine physicians, is ineffective because Qi has already collapsed. All six meridians can have diarrhea diseases, with different treatments for exterior/interior and cold/heat patterns; students must examine carefully.)

Taiyang Disease - Cold Damage (Sweating): Exterior syndrome unresolved, fluid retention in the heart region, dry heaving, fever, and cough, or thirst, or diarrhea, or dysphagia, or difficulty urinating with lower abdominal fullness, or wheezing, treated with Xiao Qinglong Tang [Minor Blue Dragon Decoction]. Taiyang (Harmonizing) combined with Yangming disease inevitably causes spontaneous diarrhea, treated with Gegen Tang. (Cheng Wuji notes: Cold damage includes combined disease [Hebing] and concurrent disease [Bingbing]. When Taiyang disease does not resolve and merges into Yangming, it is called Bingbing; when all three meridians receive pathogens simultaneously and combine, it is called Hebing. Hebing involves strong pathogens. In Taiyang-Yangming Hebing, and Taiyang-Shaoyang Hebing, Yangming-Shaoyang Hebing, spontaneous diarrhea is inevitable because pathogens merge into Yin meridians causing Yin excess and Yang deficiency, or merge into Yang meridians causing Yang excess and Yin deficiency. Severe cold pathogens affecting the two Yang meridians make the exterior solid but interior weak, leading to diarrhea. Gegen Tang disperses pathogens in the meridians; the pulse will likely be floating and long.) In Taiyang disease, if exterior signs persist but multiple purgations are applied, heat enters causing persistent diarrhea, epigastric hardness, and unresolved exterior-interior symptoms, treated with Guizhi Renshen Tang [Cinnamon Twig and Ginseng Decoction]. (Zhang Yin'an notes: Some say in Zhang Zhongjing's text, Taiyang Guizhi syndrome treated incorrectly with purgation leads to persistent diarrhea, treated with Gegen Huanglian Huangqin Tang; another case uses Guizhi Renshen Tang. Both involve unresolved exterior and purgation-induced diarrhea, yet one uses cooling herbs and the other warming ones. Both involve internal deficiency with heat entering and協 heat diarrhea, differing only in pulse/symptoms. Classics state: Rapid pulse indicates unresolved exterior; wheezing with sweating is treated with Gegen Huanglian Huangqin Tang. Rapid pulse indicates Yang excess; wheezing with sweating indicates interior heat. Thus, using Gegen Huanglian Huangqin Tang for Yang excess and interior heat is appropriate.) Combined disease of Taiyang and Shaoyang with spontaneous diarrhea is treated with Huangqin Tang. If vomiting occurs, Huangqin Jia Banxia Shengjiang Tang [Scutellaria Decoction with Added Pinellia and Ginger] is used. (Accompanied by headache, chest fullness, bitter taste, dry throat, alternating chills and fever, with large or wiry pulses.)

Huangqin Tang Formula
Huangqin (3 liang), Shaoyao (Peony Root), Gancao (Licorice Root, each 2 liang), Dazao (Jujube, 12 pieces, split). Boil four ingredients in 10 sheng of water to obtain 3 sheng, remove dregs, take 1 sheng warm, twice daily and once at night. (For weakness without firmness, use bitter herbs to strengthen and sour herbs to astringe. The bitterness and sourness of Huangqin and Shaoyao strengthen and consolidate intestinal qi. For weakness and insufficiency, use sweet herbs to tonify. The sweetness of Gancao and Dazao tonifies and consolidates weak intestinal qi.)

Huangqin Jia Banxia Shengjiang Tang
Add Banxia (Pinellia Tuber, half sheng, washed) and Shengjiang (Fresh Ginger, 3 liang, sliced) to Huangqin Tang.

In concurrent disease of Taiyang and Shaoyang, incorrect purgation causes pathogens to knot in the chest, forming Jie Xiong [Chest Binding], with epigastric hardness, persistent diarrhea, inability to swallow liquids, and mental restlessness. (Can use Shengjiang Xiexin Tang, Dahuang Huanglian Xiexin Tang, or Xiaoxianxiong Tang. Zhang Yin'an notes: All combined diseases involve diarrhea, distinguished by exterior signs. Taiyang: head/neck pain, stiff spine. Yangming: eye pain, dry nose, insomnia. Shaoyang: chest/hypochondriac pain, deafness. When two Yang meridians' signs appear together with diarrhea, it is Hebing. Seeing one sign suffices for diagnosis. Zhang Zhongjing mentions Taiyang-Shaoyang Hebing without detailing pulses/signs because previous chapters cover these signs. Each meridian's signs vary, making fixed conclusions difficult.)

In Taiyang disease with Guizhi syndrome, incorrect purgation leads to persistent diarrhea. If pulse is rapid (Cu), exterior is unresolved; if wheezing with sweating, use Gegen Huangqin Huanglian Tang [Kudzu, Scutellaria, and Coptis Decoction].

Gegen Huangqin Huanglian Tang Formula
Gegen (Pueraria Root, 8 liang), Gancao (Licorice Root, honey-fried), Huangqin (Scutellaria Root, each 2 liang), Huanglian (Coptis Rhizome, 3 liang). Boil four ingredients in 8 sheng of water, first boil Gegen reducing volume by 2 sheng, add remaining herbs, boil to 2 sheng, remove dregs, divide into two warm doses. ("Nei Jing" states: Pungent-sweet disperses Yang. For unresolved exterior, disperse with sweet Gegen and Gancao; for weak interior qi, strengthen with bitter Huangqin and Huanglian.)

After purgation in Taiyang disease, if pulse is rapid and no Jie Xiong forms, the disease is resolving; if pulse is deep and slippery, it is協 heat diarrhea; if pulse is floating and slippery, hematochezia will occur. Use Huangqin Tang.

In Taiyang disease, on days 2-3, inability to lie down, desire to rise, epigastric knotting, and weak pulse indicate pre-existing cold-dampness. Incorrect purgation may lead to Jie Xiong if diarrhea stops, or協 heat diarrhea if it persists and further purgation is applied. Use Huangqin Tang.

Cold damage with wind-strike, incorrectly purged, leading to persistent diarrhea, undigested food, borborygmus, epigastric hardness/fullness, dry heaving, and mental distress. Physician sees stagnation and purges again, worsening stagnation. This is not heat binding but empty stomach with rebellious guest qi causing hardness. Use Gancao Xiexin Tang [Licorice Heart-Purging Decoction].

After sweating resolves cold damage, stomach disharmony causes epigastric hardness, belching with food odor, fluid retention in hypochondriac region, borborygmus, and diarrhea. Use Shengjiang Xiexin Tang [Ginger Heart-Purging Decoction].

Taiyang wind-strike with diarrhea and vomiting. Once exterior is resolved, interior can be attacked. Symptoms include episodic head sweating, headache, epigastric hardness radiating to hypochondriac pain, dry heaving, shortness of breath, sweating without aversion to cold. Exterior resolved, interior unharmonized. Use Shizao Tang [Ten Jujubes Decoction].

Cold damage fever, sweating without resolution, epigastric hardness, vomiting, and diarrhea. Use Da Chaihu Tang [Major Bupleurum Decoction].

Cold damage unresolved for 13 days, passing through meridians, with delirium indicates heat; treat with decoction to purge. If urination is free, stool should be hard; if diarrhea occurs with harmonious pulse, vulgar doctors mistakenly used pill purgatives. Natural diarrhea should have faint pulse; harmonious pulse indicates interior excess. Use Tiaowei Chengqi Tang [Regulate Stomach and Guide Outward Decoction].

Taiyang disease on day 2, paradoxical irritability, back moxibustion causing heavy sweating, fire-heat entering stomach, fluid exhaustion, irritability, and delirium. After 10+ days, shaking and spontaneous diarrhea indicate resolution.

Cold damage, post-purgation, persistent diarrhea with undigested food, body ache. Urgently save the interior with Sini Tang [Four Reversals Decoction]. If body ache persists but bowels/bladder normalize, urgently save the exterior with Guizhi Tang [Cinnamon Twig Decoction]. (Cheng Wuji notes: Post-purgation diarrhea with undigested food and body ache requires saving interior first due to deficiency. Sini Tang restores interior harmony, then Guizhi Tang saves exterior. Body ache is exterior pathogen. "Nei Jing": Treat root before branch when deficiency exists. Here cold is root.)

Sini Tang Formula
Gancao (Licorice Root, honey-fried, 2 liang), Ganjiang (Dried Ginger, 1.5 liang), Fuzi (Aconite Root, 1 piece, peeled, broken into 8 slices. Alternative method: Peel Aconite, boil in salt water and ginger juice, add Licorice and Coptis, then child's urine, boil, dry in porcelain vessel exposed to earth qi for 24 hours, sun-dry to reduce toxicity. Best to use round, correct 1-liang pieces). Crush three ingredients, boil in 3 sheng water to 1.2 sheng, remove dregs, divide into two warm doses. Robust individuals may use large Aconite (1 piece) and Dried Ginger (3 liang).

Cheng Wuji notes: Limbs are the root of Yang qi. Insufficient Yang qi plus Yin-cold prevents smooth connection, causing cold limbs (Sini). This formula promotes Yang qi, scatters Yin-cold, warms meridians and muscles, hence named Sini. "Nei Jing": Treat internal cold with pungent-hot and sweet. Sweet is primary to support Yang; thus Gancao is Sovereign. "Nei Jing": Counteract winning cold with pungent-hot; thus Ganjiang is Minister. "Nei Jing": Pungent moistens, opens pores, generates fluids, moves Qi. Great heat warms muscles/meridians; thus Fuzi is Envoy. This is a potent formula for Shaoyin (Kidney) disease, distant locations requiring large doses ("Nei Jing": Distant and odd/even, make large doses).

Post-decoction diarrhea in cold damage, epigastric hardness, post-Xiexin Tang purgation worsening diarrhea. Lizhong Tang worsens it as it treats middle jiao; this is lower jiao diarrhea. Use Chishizhi Yuyuliang Tang. If persistent, promote urination (or Zhu Ling Tang).

Chishizhi Yuyuliang Tang Formula
Chishizhi (Red Halloysite, 1 jin, crushed), Yuyuliang (Hematite, 1 jin, crushed). Boil in 6 sheng water to 2 sheng, remove dregs, divide into three doses.

Cold damage unresolved for 13 days, chest/hypochondriac fullness, vomiting, evening tidal fever, slight diarrhea. Originally Chaihu syndrome, incorrectly purged. Tidal fever indicates excess. First use Chaihu Tang to release exterior, then Chaihu Jia Mangxiao Tang [Bupleurum with Gypsum Decoction].

Taiyang disease >10 days, epigastric discomfort wanting to vomit, chest pain, loose stool, mild abdominal fullness, slight vexation. History of extreme emesis/purgation. Use Tiaowei Chengqi Tang.

Yangming disease with tidal fever, loose stool, normal urination, chest/hypochondriac fullness. Use Xiao Chaihu Tang [Minor Bupleurum Decoction].

Patient with no exterior/interior signs, fever 7-8 days, floating-numerous pulse, can be purged. Post-purge, numerical pulse persists, diarrhea continues, leading to pus/blood in stool. (Use Huangqin Tang or Bopi Tang.)

Yangming-Shaoyang combined disease causes diarrhea. Non-deficient pulse is favorable; deficient pulse is unfavorable (mutual overcoming). Slippery-numerous pulse indicates retained food; purge with Da Chengqi Tang [Major Order the Qi Decoction]. (Cheng Wuji notes: Yangming Earth, Shaoyang Wood. Disharmony causes diarrhea. Shaoyang pulse not overcoming Yangming is favorable. Overcoming is pathological. Slippery-numerous pulse indicates stomach excess/retained food. Purge with Da Chengqi Tang.)

Zang Jie [Organ Knotting] resembles Jie Xiong, normal diet, frequent diarrhea, floating cun pulse, small/fine/deep-tight guan pulse, white slippery tongue coating. Difficult to treat.

Taiyin Disease: Abdominal fullness, vomiting, inability to eat, worsening spontaneous diarrhea, intermittent abdominal pain. Purgation causes epigastric knotting. Spontaneous diarrhea without thirst belongs to Taiyin due to organ cold; treat with warming, e.g., Sini Tang derivatives. (Zhang Yin'an notes: "Derivatives" means similar properties, varying strength. Taiyin diarrhea without thirst may use Lizhong Tang or Lizhong Tang with Fuzi. Sini Tang is very hot; use cautiously. Lizhong Tang is safer; use Sini Tang only if necessary.) In Taiyin disease with weak pulse and ongoing loose stools, if Shaoyao/Dahuang are indicated, reduce dosage as weak stomach qi is easily disturbed. (Cheng Wuji notes: Weak pulse and loose stools mean no severe excess. Reduce Shaoyao/Dahuang to avoid damaging weak stomach qi.) Cold damage with floating-slow pulse, warm extremities, belongs to Taiyin, likely jaundice. If urination is free, no jaundice. Day 7-8, sudden irritability, frequent diarrhea (>10 times/day) self-resolves as Spleen recovers and eliminates turbidity. (Pingwei San with Chuan Shan Jia).

Shaoyin Disease: Desire to vomit but cannot, somnolence, day 5-6 spontaneous diarrhea with thirst belongs to Shaoyin due to deficiency seeking water. White urine indicates complete Shaoyin syndrome; lower jiao deficiency-cold cannot control water. (Vomiting/somnolence/vexation indicates interior transmission. Abdominal pain would be Taiyin. Somnolence indicates Shaoyin. Day 5-6 is transmission time. Thirsty diarrhea is lower jiao cold; non-thirsty is middle jiao cold. Lower jiao cold causing thirst is debated; white urine confirms lower jiao deficiency-cold. Huo Ren Shu suggests Sini Tang. Yellow/red urine excludes this, suggesting heat treated with Baitouweng Tang.)

Shaoyin disease with diarrhea, sore throat, chest fullness, vexation. Use Zhufu Tang [Pig Skin Decoction].

Zhufu Tang Formula
Zhufu (Pig Skin, 1 jin). Boil in 10 sheng water to 5 sheng, remove dregs, add Baimi (White Honey, 1 sheng) and Baifen (Rice Flour, 5 he), cook until fragrant, mix, divide into six warm doses. (Pig is water animal, enters Kidney. Zhufu clears Shaoyin guest heat. Baimi moistens/dries vexation; Baifen tonifies/stops diarrhea.)

Shaoyin disease with cold limbs or heaviness in diarrhea. Use Sini San [Four Reversals Powder] (See previous entry).

Shaoyin disease, diarrhea 6-7 days, cough, vomiting, thirst, vexation, insomnia. Use Zhuling Tang [Polyporus Decoction] (See Thirst entry).

Shaoyin disease, spontaneous diarrhea of clear green water, epigastric pain, dry mouth. Urgently purge with Da Chengqi Tang.

Sun Simiao Case: Dou Dalang had cold damage >10 days, dry mouth/tongue/thirst, heart pain, clear water diarrhea. Physicians advised conservative care, fearing sweat/purge. Relatives summoned Sun. Sun said: Do not purge today, purge tomorrow. Gave Xiao Chengqi Tang. Bowels opened, slept well, recovered next day. Asked why purge worked? Sun said: Superficial knowledge misses depth. Dry mouth/thirst is Shaoyin. Though Shaoyin usually avoids purgation, "clear water diarrhea with epigastric pain" is an indication for purgation per Zhang Zhongjing. Crowd admired him.

Shaoyin disease, diarrhea, aversion to cold, curling up, warm extremities. Treatable with Sini Tang.

Shaoyin disease, days 2-4, abdominal pain, difficulty urinating, persistent diarrhea with pus/blood. Use Taohua Tang [Peach Blossom Decoction] (See Abdominal Pain).

Taohua Tang Formula
Chishizhi (Red Halloysite, 1 jin, half whole/half powder), Ganjiang (Dried Ginger, 1 liang), Jingmi (Glutinous Rice, 1 sheng). Boil in 7 sheng water until rice cooks, remove dregs, take 7 he warm, mix in 1 cubic-inch spoon of Chishizhi powder, three times daily. Stop if cured. (Astringency stops leakage; Chishizhi consolidates intestines. Pungency disperses cold; Ganjiang disperses interior cold. Sweet tonifies; Jingmi tonifies righteous Qi.)

Shaoyin disease, days 2-4, abdominal pain, difficulty urinating, heavy/cold limbs, spontaneous diarrhea, indicates water qi. Variants: cough, free urination, diarrhea, vomiting. Use Zhenwu Tang [True Warrior Decoction] (See Abdominal Pain).

Zhenwu Tang Formula
Fuling (Poria, 3 liang), Shengjiang (Fresh Ginger, sliced), Shaoyao (Peony Root, 3 liang), Baizhu (Atractylodes Macrocephala, 2 liang), Fuzi (Aconite Root, 1 piece, roasted, peeled, broken). Boil five ingredients in 8 sheng water to 3 sheng, remove dregs, take 7 he warm, three times daily. (Spleen dislikes dampness; sweet enters Spleen. Fuling/Baizhu tonify Spleen/drive water. Cold/dampness treated with pungent-hot/sour-flat. Fuzao/Shao Yao/Sheng Jiang warm meridians/disperse damp.)

Modifications: Cough: Add Wuweizi (Schisandra, half sheng), Xixin (Asarum, 1 liang), Ganjiang (1 liang). Sour collects rebellious Qi; pungent disperses water-cold. Free urination: Remove Fuling (no retained water). Diarrhea: Remove Shaoyao, add Ganjiang (2 liang). Shaoyao drains Qi; Ganjiang disperses cold. Vomiting: Remove Fuzao, add Shengjiang (to total half jin). Fuzao tonifies Qi; Shengjiang disperses Qi.

Cheng Wuji notes: Zhenwu is Northern Water God. Water qi in heart/exterior-Yang requires dispersion. Qinglong Tang treats Taiyang; Zhenwu Tang treats Shaoyin (Kidney Water). Harmonizes spleen which dislikes dampness. Sweet slows spleen; Fuling (Sovereign), Baizhu (Minister) tonify spleen/drain water. Sour-flat assistants (Shaoyao, Sheng Jiang) disperse damp. Pungent-hot envoy (Fuzao) warms meridians. Variations address specific manifestations: Cough (water-cold attacking lung) uses sour Wuweizi and pungent Xixin/Ganjiang. Free urination removes Fuling. Difficulty urinating removes Shaoyao (astringent), adds Ganjiang. Vomiting removes Fuzao (tonifying), adds Shengjiang (dispersing).

Shaoyin disease, diarrhea with undigested food, interior cold/exterior heat, cold limbs, faint/almost absent pulse, no aversion to cold, red face, abdominal pain, dry heaving, sore throat, or cessation of diarrhea with absent pulse. Use Tongmai Sini Tang [Pulse-Recovering Four Reversals Decoction].

Tongmai Sini Tang Formula (Same as Sini Tang but double Ganjiang)
Gancao (Licorice, fried, 2 liang), Fuzao (Large Aconite, raw, peeled, broken, 1 piece), Ganjiang (Dried Ginger, 3 liang, 4 liang for robust). Boil in 3 sheng water to 1.2 sheng, remove dregs, divide into two warm doses. Pulse return indicates cure. Red face: Add Congbai (Green Onion White, 9 stems) to unblock Yang. Abdominal pain: Remove Congbai, add Shaoyao (2 liang) to unblock Qi. Vomiting: Add Shengjiang (2 liang) to disperse Qi. Sore throat: Remove Shaoyao, add Jiegeng (Platycodon, 1 liang) to scatter knot. Cessation of diarrhea/absent pulse: Remove Jiegeng, add Renshen (Ginseng, 2 liang) to tonify blood/Qi. ("Mai Bing" states: Faint pulse with diarrhea indicates blood loss; Sini Jia Renshen Tang treats this. Match pulse/symptoms to formula.")

Shaoyin disease, diarrhea. Use Baitong Tang [White Pass Decoction] (Warms interior/scatters cold).

Shaoyin disease, diarrhea, faint pulse, given Baitong Tang. If diarrhea persists, cold limbs, absent pulse, dry heaving, vexation, use Baitong Jia Zhuchidan Tang [White Pass with Pig Gallbladder Bile Decoction]. Violent pulse return after dosing is fatal; gradual return is survival. (Faint pulse indicates extreme cold/Yin excess. Baitong restores Yang. Persistent symptoms indicate severe cold rejection/rebellion. Pig bile harmonizes. "Nei Jing": Reverse treatment vs. Conforming treatment. Violent pulse return indicates Zheng qi collapse; gradual return indicates Yang recovery.)

Baitong Tang Formula