Library

The chapter on Pulse, Pathogenesis, and Symptoms of Diarrhea in the *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet): If the Yang Qi of the Six Fu Organs fails at the exterior, there will be cold hands and feet, rebellious Qi ascending, and contraction of the legs. If the Yin Qi of the Five Zang Organs fails at the interior, there will be incontinence of stool; in severe cases, the hands and feet will be insensible. In diarrhea, if the pulse is deep and wiry, there is a sensation of heaviness in the anus; if the pulse is large, the disease has not yet ceased; if the pulse is weak and rapid, it indicates that the condition is about to stop spontaneously, and death will not occur even if fever is present. In diarrhea, if the hands and feet are cold and the pulse is absent, and after moxibustion the extremities remain cold and the pulse does not return, accompanied by slight panting, this is a fatal sign. If the Shaoyin pulse is weaker than the Fuyang pulse, it is a favorable sign. In diarrhea, if there is slight fever and thirst, and the pulse is weak, recovery is expected. In diarrhea, if the pulse is rapid with slight fever and sweating, recovery is expected. If the pulse is tight, the pathogen has not been resolved. In diarrhea, if the pulse is rapid and there is thirst, recovery is expected; if it does not heal, pus and blood will appear in the stool due to heat. ("Qing" 清 is an ancient character for "Qing" 圊, meaning toilet/excretion). In diarrhea, if the pulse is unexpectedly wiry, accompanied by fever and sweating, recovery is expected. In diarrhea with excessive flatus (Qi Li), treatment should focus on promoting urination. In diarrhea, if the Cun pulse is unexpectedly floating and rapid, while the Chi pulse is choppy, pus and blood will appear in the stool. In diarrhea with undigested food (Wan Gu Hua), one must not attack the exterior; sweating will lead to abdominal fullness. In diarrhea with a deep and slow pulse, where the patient's face is slightly red, body slightly warm, and stool contains undigested food, there will likely be dizziness and confusion (Yu Mao), followed by sweating and resolution; the patient will have slightly cold extremities because the face shows "Dai Yang" (floating Yang) due to deficiency at the lower Jiao. After diarrhea stops, if the pulse disappears and hands/feet are cold, but the pulse returns and extremities become warm, life is saved; if the pulse does not return, death occurs. In diarrhea with abdominal fullness and body pain, first warm the interior, then release the exterior. For warming the interior, Si Ni Tang (Four Reversal Decoction) is indicated; for releasing the exterior, Gui Zhi Tang (Cinnamon Twig Decoction) is indicated. In diarrhea, if the pulses in all three positions are level, but palpation of the epigastrium reveals hardness, urgent purgation is required using Da Cheng Qi Tang (Major Order the Qi Decoction). In diarrhea with a slow and slippery pulse, it is an excess pattern. Since the diarrhea has not ceased, urgent purgation is required using Da Cheng Qi Tang. In diarrhea with an unexpectedly slippery pulse, there is something to be expelled; purgation leads to recovery using Da Cheng Qi Tang. If diarrhea resolves but recurs at specific years, months, days, or hours, it is because the pathogen was not fully eliminated. Purgation is required using Da Cheng Qi Tang. (Note: Regarding the repeated use of Cheng Qi Tang formulas, patients with root deficiency should be discussed separately.) In diarrhea with delirium, it is due to dry fecal masses. Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is indicated. In diarrhea with pus and blood in the stool, Tao Hua Tang (Peach Blossom Decoction) is indicated. In hot diarrhea with rectal tenesmus, Bai Tou Weng Tang (Pulsatilla Decoction) is indicated. After diarrhea, if irritability increases and the epigastrium is soft upon pressure, it is empty irritability; Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is indicated. In diarrhea with undigested food, interior cold with exterior heat, sweating, and cold extremities, Tong Mai Si Ni Tang (Pulse-Restoring Four Reversal Decoction) is indicated. In diarrhea with abdominal pain, Zi Shen Tang is indicated. In dry vomiting with diarrhea, Huang Qin Tang (Scutellaria Decoction) is indicated. The above chapter on diarrhea has been adopted as a standard by later famous physicians. What was formerly called "Xia Li" (Lower Flow/Diarrhea) is now called "Xie Xie" (Leaking Diarrhea). It includes several formulas originally used for Shang Han (Cold Damage), which Zhang Zhongjing applied to miscellaneous diseases. They are recorded here in full to show that the view that Shang Han and miscellaneous diseases have separate methods is incorrect; their therapeutic principles are unified.

Zhu Danxi stated: Causes include dampness, Qi deficiency, fire, phlegm, and food stagnation. Dai Fu'an stated: Diarrhea with water discharge and no abdominal pain is due to dampness. Food entering the stomach and immediately passing through, with undigested grains, is due to Qi deficiency. Abdominal pain with watery diarrhea, borborygmus, where pain comes in waves followed by diarrhea, is due to fire. Irregular frequency and volume of diarrhea is due to phlegm. Severe abdominal pain relieved by diarrhea is due to food stagnation. Excess dampness can lead to five types of diarrhea. Dai stated: Sun Xie (Spoon Diarrhea/Incomplete Digestion), where water and grain pass out undigested, is dampness combined with wind. Tang Xie (Loose Stool), gradually discharging dirty, sticky residue, is dampness combined with heat. Xie Xie (Clear Cold Diarrhea), discharging clear and cold fluid with clear urine, is dampness combined with cold. Ru Xie (Soft Diarrhea), with heavy body and weakness, discharging much water, is extreme dampness. Hua Xie (Slippery Diarrhea), long-term incontinence, is dampness overwhelming and Qi escaping. Damp diarrhea presents with a soft and fine pulse, indicating Taiyin Spleen Earth affected by dampness, leading to watery loose stools, heavy body, slight fullness, loss of taste, and no thirst. This often occurs during prolonged rain or when damp-earth climate factors dominate. Treatment involves Chu Shi Tang (Dampness-Removing Decoction) taken with Wu Ji Wan (Five-Abdomen Pill), assisted by Wei Ling Tang (Stomach-Cinnamon Decoction); severe cases use Shu Fu Tang (Atractylodes and Aconite Decoction).

Li Dongyuan stated: I suffered from long-term Spleen-Stomach decline, resulting in half-loss of hearing and vision. This is Yin flourishing attacking Yang, compounded by shortness of breath and insufficient spirit, caused by a wiry pulse indicating deficiency and excessive talking. All these indicate declining Yang Qi unable to extend, hiding within Yin. In the sixth and seventh months of the Gui-Mao year, continuous rainy and cold weather lasted over a month, and many people suffered from diarrhea. One day, my body felt heavy and joints painful, with frequent bowel movements and urinary retention. Recalling the *Neijing* theory of root and branch, for difficulty in both urination and defecation, regardless of root or branch, one should first promote urination. It also says: "For conditions below, draw them out and exhaust them," which also implies promoting urination first. It further states: "For various diarrheas with urinary difficulty, first separate and promote urination." And: "To treat dampness without promoting urination is not the correct method." All suggest promoting urination using bland, permeating agents. Alas, although the Sage's methods are written in books, the unwritten parts can be understood through intuition. Now, if external cold-damp pathogens invade deeply and suddenly, treating them solely with bland permeating agents might cure the disease quickly, but this is lowering again and lowering, re-enriching Yin and severely depleting Yang, causing Yang to weaken further and spirit to diminish. This strengthens Yin and weakens Yang, inadvertently assisting the pathogen. Therefore, one must use acrid-warm herbs to raise Yang to recover. Use Qiang Huo, Du Huo, Chai Hu, Sheng Ma each 1 qian, Fang Feng Gen 0.5 qian, Zhi Gan Cao 0.5 qian. Crush, decoct in two zhong of water to one zhong, strain, and drink warm. The general principle states: "When damp-cold prevails, assist with wind to pacify it." Also: "For sinking conditions, lift them; obtain Yang Qi rising to dispel [the pathogen]." Another method: "Expel the intruder"; this is straightening what is crooked. The Sage's methods can be inferred; knowing one allows knowing hundreds. Without understanding the principles of ascending/descending and floating/sinking, applying uniform treatment yields success only by luck.

Regarding dampness combined with cold diarrhea: *Neijing* says, "Excess dampness causes soft diarrhea." *Jiayi Jing* says, "Cold qi lodging in the Lower Jiao transmits as soft diarrhea." The Spleen is the ultimate Yin of the Zang organs, loathing cold-damp. When cold-damp invades the Spleen internally, it cannot assist the Stomach in rotting and ripening food, leading to confusion of clear and turbid, water entering the intestines, inability to control, resulting in profuse watery diarrhea following Qi, called Soft Diarrhea. The method is to remove dampness and promote urination, treating with Dui Jin Yin Zi. For dampness combined with heat diarrhea, use Yi Yuan San and Can Yu Wan. For dampness combined with wind, see Sun Xie section. For cold diarrhea, with deep/fine or wiry-slow pulse, cold body, no thirst, clear urine, or dull abdominal pain, use Li Zhong Tang, Fu Zi Wen Zhong Tang, or Jiang Shui San. For sudden watery diarrhea with whole-body sweating, total coldness, deep/weak pulse, scant Qi unable to speak, or vomiting, this is a critical condition; use Jiang Shui San. If Taiyang channel injury transmits to Taiyin causing diarrhea becoming loose stool, with Large Intestine inability to hold, sudden onset, hard objects in stool, urgency with incomplete evacuation, and clear urine, this is cold; warm it. Use Gui Zhi Tang in Spring/Summer, Bai Zhu Tang in Autumn/Winter. Li Zhong Tang for diarrhea, add Ju Hong and Fu Ling each 1 liang, named Bu Zhong Tang. If loose stool persists, add Fu Zi 1 liang to Bu Zhong Tang; for poor appetite and undigested food, add Sha Ren 1 liang, totaling eight ingredients. Zhang Zhongjing said: "Diarrhea unceasing, doctor gave Li Zhong Tang, diarrhea worsened." Li Zhong Tang regulates the Middle Jiao. This diarrhea is in the Lower Jiao; Chi Shi Zhi Yu Liang Tang is indicated. Using this addition regulates the Lower Jiao. Dai stated: For cold diarrhea with stabbing abdominal pain, profuse watery stool, borborygmus, undigested food, use Li Zhong Tang or Fu Zi Bu Zhong Tang, swallow Da Yi Han Wan or Fu Zi Gui Xiang Wan. For fear of eating, use Ba Wei Wan. For original cold diarrhea turning into irritability and thirst, drinking more leads to more diarrhea, use Shen Fu Tang or Lian Li Tang. If cold diarrhea drugs fail, use Mu Xiang Tang, Jiang Fu Tang, or Liu Zhu Tang, swallowing Zhen Ling Dan or Yang Qi Dan. For cold extremities, combine with Zhu Sha Dan. If medicine/food enters mouth and immediately passes, it is called "Zheng Chang" (Rectal Slippage), difficult to treat. If diarrhea stops but spirit hasn't recovered, use Shi Bu Yin. For severe cold diarrhea abdominal pain, combine with Ru Dou Wan after previous meds. If hot medicines for warming middle fail, frequent defecation of foul matter, this belongs to Lower Jiao. Use Tao Hua Wan (25 pills) or He Le Le Wan to astringe. Note: Dai's methods are often too hot; users should be cautious.

For heat diarrhea, with rapid/hurried or surging-large pulse, dry mouth, restlessness, loud voice, sudden violent diarrhea with urgency, use Yi Yuan San plus Huang Qin, Huang Lian, Deng Xin Cao, Dan Zhu Ye. For diarrhea with fever, urinary difficulty, thirst, use Yi Yuan San and Wu Ling San. If fire is excessive, use Si Ling San plus Mu Tong, Huang Qin. For diarrhea with fatigue and difficulty, and rapid/deficient-heat pulse, use Ren Shen, Bai Zhu, Hua Shi, Fu Ling, Mu Tong. For diarrhea with slippery/firm pulse, it is excess heat; use Da Cheng Qi Tang. Dai stated: Heat diarrhea with red-yellow stool, popping sounds/pain, burning anus, hot expulsion, irritability/thirst, urinary difficulty, use Wu Ling San swallowing Xiang Lian Wan. Whenever diarrhea loses fluids, thirst occurs, and urine becomes red/astringent; do not immediately diagnose as heat. Only confirm heat diarrhea before using cold agents. Otherwise, reckless use worsens the condition. Yu Long Wan is miraculous for all latent summer-heat diarrhea. Li Zhong Tang plus Fu Ling, Huang Lian is named Lian Li Tang, often effective. In summer, if confirmed summer-heat diarrhea, use summer-heat drugs; if confirmed cold diarrhea, use hot drugs. However, in intense summer heat with internal injury from cold/raw food, Lian Li Tang is indispensable. For uncontrolled lower diarrhea, loud post-defecation sounds, hot anus, red/astringent urine, epigastric irritability/thirst, preference for cold, this drug is suitable. If originally summer-heat diarrhea, long-term deficiency of lower yuan, frequent day/night diarrhea, summer-toxin power faded but diarrhea continues, using summer-heat drugs won't work; using Ginger/Aconite seems difficult; in such doubt, this drug is best.

For Qi diarrhea, with borborygmus, Qi movement, chest/diaphragm oppression, abdominal urgency/pain, relief after defecation but returning soon, or abdominal Qi blockage without passage, this is due to Middle Jiao stagnation, Qi non-flow, and unclear separation of water/grain. Dai's method uses Da Qi Xiang Wan decocted with rice. For chronic cases, use Wu Ge Kuan Zhong San swallowing Zhen Ling Dan, assisted by rice water mixed with Xiang Fu powder. Tiao Qi San. *Jingui* He Le Le San treats Qi Li. For Qi deficiency diarrhea, use Si Jun Zi Tang plus Shen Qu, Huang Bo, Sheng Ma, Chai Hu, swallowing Er Shen Wan plus Mu Xiang. For stagnation diarrhea, abdominal discomfort before diarrhea, or abdominal fullness with hardness on pressure: shallow disease uses Shen Qu for digestion; deep/stubborn disease requires Tui Jin Cheng Qi type purgatives. For food-injury diarrhea, due to excessive food overwhelming Spleen/Stomach transport: belching smells like rotten eggs; use Zhi Zhong Tang plus Sha Ren 0.5 qian, Qu Zhi Zhu Wan. Or Qi Xiang Wan, Hong Wan Zi mixed. For food-stagnation abdominal pain and diarrhea, do not immediately use Zhi Zhong Tang to stop; first use digestive/pushing drugs. If diarrhea recurs upon re-eating the offending food due to unrecovered Spleen, use Da Jian Pi Tang (for cold patterns). Burn the offending food to ash, take 3-5 qian with water. For cold-food stagnation injuring Spleen, cold Spleen Qi failing to digest: diarrhea with undigested food appearance; use Zhi Zhong Tang plus Gan Ge, swallowing Jiu Zhu Huang Lian Wan. For long-term Spleen Qi deficiency unable to accept food: borborygmus/urgency after eating, relief only after expelling food; known as "Lu Shi Xie" (Recorded Food Diarrhea), chronic; use Kuai Pi Wan. For alcohol-injury morning diarrhea, use Li Zhong Tang plus Gan Ge, swallowing Jiu Zhu Huang Lian Wan. Or Ge Hua Jie Ying Tang. For noodle/wheat-injury diarrhea, use Yang Wei Tang plus Chao Yan Lu Zi 1 qian; if painful, add Mu Xiang 0.5 fen; if severe diarrhea, remove Huo Xiang, add Pao Jiang equally. For phlegm diarrhea, use Er Chen Tang, Hai Shi, Qing Dai, Huang Qin, Shen Qu, Jiang Zhi, Zhu Li made into pills. Take 30-50 pills. Mild cases require emesis. A man with nocturnal frequent urination was taught to use 1 liang ginger, washed Ban Xia, 30 dates, decocted in 1 sheng water in a porcelain bottle; sip slowly, cured in days. Daily predawn diarrhea may be due to wine accumulation, cold accumulation, food accumulation, or Kidney deficiency,俗称 Pi Shen Xie. Some must have a large bowel movement every morning, with or without pain, ineffective hot meds on empty stomach. Someone advised taking hot meds before night meal, then continuing daily, curing it. Warm meds taken at dawn lose potency by night, unable to counteract night Yin. Some have loose stool at predawn; some call this Kidney Xie, cured by Wu Wei Zi San. Chronic diarrhea, morning 1-2 movements, relief after, slippery/weak pulse: first Nong Hou He Zhong Wan 50 pills, after purgation, use Bai Zhu as sovereign, Zhi Ke, Ban Xia, Fu Ling as ministers, Nong Hou, Zhi Gan Cao, Qin, Lian, Chuan Xiong, Hua Shi as assistants, Wu Zhu Yu ~10 grains as envoy, decocted with ginger, cured in >10 doses. Dai stated: Predawn profuse diarrhea unresponsive to anti-diarrheals, Wu Wei Wan with rice water, or pure Bei Wu Wei decoction. Despite diet control, symptoms cease until near predawn recurrence. Disease is in Kidney division. Er Shen Wan, Jiao Po Wan, or Ping Wei San with Xiao Hui Xiang Wan. Er Shen Wan + Wu Wei Zi San = Si Shen Wan, excellent for diarrhea.

For diarrhea with urinary difficulty: if fluids leak to Large Intestine causing diarrhea and scant urine, use Wei Ling San to separate. If Yin/Yang separated but urine short, it is Spleen/Lung Qi deficiency failing to generate water; use Bu Zhong Yi Qi Tang plus Mai Men Dong, Wu Wei Zi. If Yin fire flares with red/scant urine, Lung Qi injured failing to generate water; use Liu Wei Di Huang Wan plus Mai Men Dong, Wu Wei Zi. If Kidney Yin deficiency, Yang has no source, short urine; use Zi Shen Wan, Shen Qi Wan. If Kidney Yang deficiency, Yin has no transformation, short urine; use Yi Qi Tang, Liu Wei Wan. Misusing permeating/separating drugs damages Yang, Yin has no source, urine becomes harder, leading to edema and critical illness. For diarrhea treated with Li Zhong Tang, urinary difficulty, worsening diarrhea, ignoring Qi transformation: originally Lung fails to transmit/transform, treating with pure hot drugs causes worsening diarrhea; small dose ineffective, large dose increases heat, so no separation. Using Qing Pi, Chen Pi works. Classic says: Bladder is the official of storage, stores fluids, transforms via Qi to excrete. Diarrhea with thirst/drinking indicates internal fluid loss; use Qian Shi Bai Zhu San or Bu Zhong Yi Qi Tang. For Kidney Water deficiency with diarrhea, or thirst from overusing separating drugs, use Jia Jian Ba Wei Wan. Untreated, it becomes urinary difficulty, edema, critical. Water soaking Stomach, named Yi Yin Slippery Diarrhea, thirsty for water, drinks then diarrhea, extreme thirst: no drug indication, moxa Da Zhui (depression below 1st thoracic vertebra). Slippery diarrhea: Li Dongyuan said: Middle Jiao Qi weak, Spleen/Stomach cold, slippery stool, borborygmus, or mis-purgation leading to cold center, plus seasonal cold, cold extremities, heart/stomach colic, cold sweat: Kidney-Spleen-Stomach deficiency. Treat with Chen Xiang Wen Wei Wan. Xue said: If Spleen/Stomach deficiency-cold sinking, use Bu Zhong Yi Qi Tang plus Mu Xiang, Rou Dou Kou, Gu Po Zi. If Spleen Qi deficiency-cold incontinence, use Liu Jun Zi Tang plus Pao Jiang, Rou Gui. If Ming Men fire decline, Spleen Earth cold, use Ba Wei Wan. If Spleen/Kidney Qi/Blood dual deficiency, use Shi Quan Da Bu Tang sending Si Shen Wan. If slippery stool, closed urine, limb swelling, cough/phlegm: Spleen/Kidney Qi/Blood dual deficiency; Shi Quan Da Bu Tang sending Si Shen Wan. If slippery stool, closed urine, swelling, cough/phlegm: Spleen/Stomach damage; *Jingui* Jia Jian Shen Qi Wan. *Bao Ming Ji* said: Chronic slippery diarrhea transforming into dysentery, Taiyin transmitting to Shaoyin is "Ghost Evil"; first use Nong Hou Zhi Shi Tang to prevent transmission. Note: This method suits excess; deficiency is better treated with Si Shen Wan solidifying Kidney. Astringents: Gu Chang Wan, He Zi San treat heat slip. Fu Pi Wan, Tao Hua Wan, He Zi Wan, Chi Shi Zhi Yu Liang Tang treat cold slip. Diarrhea cured but recurs next year same time: due to accumulation. Spleen governs trust/timing, hence recurrence. Heat accumulation: Da Cheng Qi Tang. Cold accumulation: Gan Ying Wan. Deficiency: Bao He Wan plus San Leng, Peng Ze.

Zhao Yi-de said: I heard masters say diarrhea has many types, beyond six evils, five pathogens, diet injury, including mixed pathogens, hard to treat uniformly. I saw a master treat sudden Qi collapse and deficiency, acute diarrhea, unconsciousness, closed eyes/mouth, faint breathing, near death: urgently moxa Qi Hai, drink Ren Shen Gao over 10 jin, cured. Treat Yin deficiency with Kidney failing to control: strongly tonify Kidney. Treat phlegm accumulation in Lung causing Large Intestine insecurity: induce vomit upper Jiao phlegm, Lung Qi descends, Large Intestine deficiency restores. Treat excessive worry/sorrow knotting Spleen Qi, sinking to Lower Jiao causing diarrhea: open depression, tonify Spleen/Stomach, raise Grain Qi. These cannot be enumerated. Asked why the master is so divine, he said: No secret, flexible methods are in *Neijing*; study it well and you will know.

[Sun Xie] Undigested water and grain passing out completely. *Shiji - Cang Gong Zhuan* Wind refers to this. Classic says: Clear Qi sinking generates Sun Xie. Also: Long-standing Wind entering middle becomes Chang Feng Sun Xie. Spleen/Stomach is Earth, harmonious Qi transforms food. Now Clear Qi sinks instead of rising, Wind pathogen harasses Stomach long-term, Wood attacks Earth, harmonious Qi fails to transform, food passes undigested, called Sun Xie. Or excessive diet injuring intestines/stomach, causing undigested grains, commonly called Water-Grain Li. Method: Lift the sinking and digest/remove, using Jia Jian Mu Xiang San. Li Dongyuan said: Clear Qi sinking is due to Spleen/Stomach Qi decline, unable to raise Yang Qi; thus use Sheng Ma, Chai Hu, aiding sweet-acrid flavors to guide Yuan Qi upward.