下利气者。气随利失。即所谓气利是也。小便得利。则气行于阳。不行于阴而愈。故曰当利其小
便。喻氏所谓急开支河者是也。
下利寸脉反浮数。尺中自涩者。必圊脓血。
寸浮数者。阳邪强也。尺中涩者。阴气弱也。以强阳而加弱阴。必圊脓血。
下利清谷。不可攻其表。汗出必胀满。
清与圊同。即完谷也。是为里虚气寒。乃不温养中土。而反攻令汗出。则阳气重虚。阳虚者。气
不化。故胀满。
下利脉沉而迟。其人面少赤。身有微热。下利清谷者。必郁冒汗出而解。病患必微厥。所以然者。
其面戴阳。下虚故也。
喻氏曰。下利脉沉迟。而面少赤。身微热者。阴盛而格阳在上在外也。若其人阳尚有根。其格出
者。终必复返。阳返而阴未肯降。必郁冒少顷。然后阳胜而阴出为汗。阴出为汗。阴邪乃解。自不下
利矣。阳入阴出。俨有龙战于野。其血玄黄之象。病患能无微厥乎。
下利后脉绝。手足厥冷。 时脉还。手足温者生。脉不还者死。
下利后脉绝。手足厥冷者。阴先竭而阳后脱也。是必俟其 时经气一周。其脉当还。其手足当温。
设脉不还。其手足亦必不温。则死之事也。
下利后腹胀满。身体疼痛者。先温其里。乃攻其表。温里宜四逆汤。攻表宜桂枝汤。
下利腹胀满。里有寒也。身体疼痛。表有邪也。然必先温其里。而后攻其表。所以然者。里气不
充。则外攻无力。阳气外泄。则里寒转增。自然之势也。而四逆用生附。则寓发散于温补之中。桂枝有
甘、芍。则兼固
里于散邪之内。仲景用法之精如此。
四逆汤方（见上）
桂枝汤方
桂枝 白芍 生姜（各三两） 甘草（二两） 大枣（十二枚）
上五味。 咀。以水七升。微火煮。取三升。去滓。适寒温。服一升。服已须臾。啜稀热粥一升。
以助药力。温覆令一时许。遍身 微似有汗者益佳。不可令如水流漓。病必不除。若一服汗出病瘥。
停后服。
下利三部脉皆平。按之心下坚者。急下之。宜大承气汤。下利脉迟而滑者实也。利未欲止。急下
之。宜大承气汤。下利脉反滑者。当有所去。下乃愈。宜大承气汤。下利已瘥。至其年月日时复发者。
以病不尽故也。当下之。宜大承气汤。
下利有里虚脏脱者。亦有里实腑闭者。昔人所谓利者不利是也。按之心下坚。其证的矣。脉虽不
实大。而亦未见微弱。自宜急下。使实去则利止。通因通用之法也。脉迟为寒。然与滑俱见。则不为
寒而反为实。以中实有物。能阻其脉行之机也。夫利因实而致者。实不去则利不已。故宜急下。病已
瘥而至其时复发者。陈积在脾也。脾主信。故按期复发。是当下之。令陈积去。则病本拔而愈。
大承气汤方（见痉）
下利谵语者。有燥屎也。小承气汤主之。
谵语者。胃实之征。为有燥屎也。与心下坚脉滑者大同。然前用大承气者。以因实而致利。去之
惟恐不速也。此用小承气者。以病成而适实。攻之恐伤及其正也。
小承气汤方
大黄（四两） 枳实（三枚） 浓朴（三两炙）
上三味。以水四升。煮取一升二合。去滓。分温二服。得利则止。
下利便脓血者。桃花汤主之。
此治湿寒内淫。脏气不固。脓血不止者之法。赤石脂理血固脱。干姜温胃驱寒。粳米安中益气。崔
氏去粳米加黄连、当归。用治热利。乃桃花汤之变法也。
桃花汤方
赤石脂（一斤一半全用一半筛末） 干姜（一两） 粳米（一升）
上三味。以水七升。煮米熟去滓。温服七合。内赤石脂末方寸匕。日三服。若一服愈。余勿服。
热利下重者。白头翁汤主之。
此治湿热下注。及伤寒热邪入里作利者之法。白头翁汤苦以除湿。寒以胜热也。
白头翁汤方
白头翁 黄连 黄柏 秦皮（各三两）
上四味。以水七升。煮取三升。去滓。温服一升。不愈更服。
下利后更烦。按之心下濡者。为虚烦也。栀子豉汤主之。
下利后更烦者。热邪不从下减。而复上动也。按之心下濡。则中无阻滞可知。故曰虚烦。香豉、
栀子。能撤热而除烦。得吐则热从上出而愈。因其高而越之之意也。
栀子豉汤方
栀子（十四枚擘） 香豉（四合绵裹）
上二味。以水四升。先煮栀子。得二升半。内豉。煮取一升半。去滓。分二服。温进一服。得吐
则愈。
下利清谷。里寒外热。汗出而厥。通脉四逆汤主之。
挟热下利者。久则必伤脾阴。中寒清谷者。甚则并伤肾阳。里寒外热。汗出而厥。有阴内盛而阳
外亡之象。通脉四逆。即四逆加干姜一倍。所谓进而求阳。以收散亡之气也。
通脉四逆汤方
附子（一枚生用） 干姜（三两强人可四两） 甘草（二两炙）
上三味。以水三升。煮取一升二合。去滓。分温再服。
下利肺痛。紫参汤主之。
赵氏曰。大肠与肺合。大抵肠中积聚。则肺气不行。肺有所积。大肠亦不固。二害互为病。大肠
病而气塞
于肺者痛。肺有积者亦痛。痛必通用。紫参通九窍。利大小肠。气通则痛愈。积去则利自止。喻氏曰。
后人有疑此非仲景之方者。夫讵知肠胃有病。其所关全在肺气耶。程氏疑是腹痛。本草云。紫参治心
腹积聚。寒热邪气。
紫参汤方
紫参（半斤） 甘草（三两）
上二味。以水五升。先煮紫参。取二升。内甘草。煮取一升半。分温三服。
气利。诃黎勒散主之。
气利。气与屎俱失也。诃黎勒涩肠而利气。粥饮安中益肠胃。顿服者。补下治下。制以急也。
诃黎勒散方
诃黎勒（十枚煨）
上一味为散。粥饮和顿服。
附方
千金翼小承气汤 治大便不通。哕数谵语。（方见上）
外台黄芩汤 治干呕下利。
黄芩 人参 干姜（各三两） 桂枝（一两） 大枣（十二枚） 半夏（半升）
上六味。以水七升。煮取三升。温分三服。
此与前黄芩加半夏生姜汤治同。而无芍药、甘草、生姜。有人参、桂枝、干姜。则温里益气之意
居多。凡中寒气少者。可于此取法焉。其小承气汤。即前下利谵语有燥屎之法。虽不赘可也。
Diarrhea accompanied by involuntary passage of gas is known as "Qi diarrhea" (Qi Li), where Qi is lost along with the stool. If urination becomes smooth, it indicates that Yang Qi is circulating in the Yang aspect and no longer stagnating in the Yin aspect, leading to recovery. Therefore, it is said that one should promote diuresis. This is what Yu Jia Yan referred to as "urgently opening auxiliary rivers" (Ji Kai Zhi He).
In cases of diarrhea, if the Cun (inch) pulse is surprisingly floating and rapid, while the Chi (cubit) pulse is naturally choppy, pus and blood will inevitably appear in the stool.
Floating and rapid at the Cun position indicate strong Yang pathogenic factors; choppy at the Chi position indicates weak Yin Qi. When strong Yang attacks weak Yin, pus and blood in the stool are inevitable.
In cases of diarrhea with undigested food in the stool (Wan Gu), one must not attack the exterior syndrome. Sweating will inevitably lead to abdominal distension.
"Qing" here refers to excretion, specifically undigested food. This signifies deficiency in the interior and coldness, failing to warm and nourish the Middle Jiao (Spleen and Stomach). Instead of warming the Middle, attacking the exterior to induce sweating causes further depletion of Yang Qi. With deficient Yang, Qi transformation fails, resulting in distension.
If the pulse in diarrhea is deep and slow, the patient has a slightly red face and slight body heat, and passes undigested food, they will inevitably experience dizziness and vertigo (Yu Mao), followed by sweating and resolution of the disease. The patient will likely have mild coldness in the extremities. This occurs because the facial redness is "Dai Yang" (floating Yang due to lower deficiency), caused by deficiency-cold in the lower Jiao.
Yu Jia Yan stated: In diarrhea with a deep, slow pulse, slight facial redness, and mild body heat, it is extreme Yin cold repelling Yang to the upper and exterior aspects. If the patient's Yang still has a root, the repelled Yang will eventually return. As Yang returns but Yin does not descend, there will be brief dizziness and vertigo, after which Yang overcomes Yin, and Yin transforms into sweat. As Yin exits via sweat, the pathogen resolves, and diarrhea stops naturally. Yang enters, Yin exits, resembling a battle between dragons in the wild, presenting an image of dark yellow blood. How could the patient not experience mild extremity coldness?
After diarrhea, if the pulse disappears and the hands and feet are cold, but the pulse returns and hands and feet become warm after a period, the prognosis is good; if the pulse does not return, the prognosis is fatal.
Disappearance of the pulse and cold extremities after diarrhea indicate exhaustion of Yin first and subsequent collapse of Yang. One must wait for the circulation of Jing Qi for one cycle; the pulse should then return, and extremities should warm.
If the pulse does not return and extremities remain cold, death is certain.
After diarrhea, if abdominal distension and body pain occur, one should first warm the interior and then release the exterior. Si Ni Tang (Four Counterflow Decoction) is suitable for warming the interior, and Gui Zhi Tang (Cinnamon Twig Decoction) is suitable for releasing the exterior.
Abdominal distension with diarrhea indicates interior cold; body pain indicates exterior pathogens. However, interior must be warmed first, then exterior released. This is because without sufficient interior Qi, external attack is ineffective; if Yang Qi leaks outward, interior cold increases. This is the natural trend. Si Ni Tang uses raw Fu Zi (Aconite Lateralis Radix Preparata) to embed dispersal within warming and tonification; Gui Zhi Tang contains Gan Cao (Licorice Root) and Bai Shao (White Peony Root) to secure the interior while dispelling pathogens. Zhang Zhong Jing's precision in prescription lies here.
Si Ni Tang (See above)
Gui Zhi Tang (Cinnamon Twig Decoction)
Gui Zhi (Ramulus Cinnamomi) 3 liang, Bai Shao (Radix Paeoniae Alba) 3 liang, Sheng Jiang (Rhizoma Zingiberis Recens) 3 liang, Gan Cao (Radix Glycyrrhizae) 2 liang, Da Zao (Fructus Jujubae) 12 pieces.
Crush the five ingredients, boil in 7 sheng of water, simmer to obtain 3 sheng, strain. Take 1 sheng at a comfortable temperature. Shortly after taking, drink 1 sheng of hot thin porridge to assist medicinal power. Cover with blankets for about the time it takes to cook a meal until a slight general perspiration occurs, which is best. Do not allow profuse sweating like flowing water, or the disease will not be cured. If symptoms resolve after one dose, stop taking the remaining medicine.
If all three pulses (Cun, Guan, Chi) in diarrhea are level/normal, but pressing the epigastrium feels hard, urgent purgation is required using Da Cheng Qi Tang (Major Order the Qi Decoction).
If the pulse in diarrhea is slow and slippery, it indicates excess. Diarrhea will not cease; urgent purgation is required using Da Cheng Qi Tang.
If the pulse in diarrhea is surprisingly slippery, it indicates retention requiring evacuation; diarrhea will cease after evacuation. Use Da Cheng Qi Tang.
If diarrhea improves but recurs at specific years, months, days, or hours, it is because the pathogen is not fully cleared; purgation is required using Da Cheng Qi Tang.
Diarrhea can involve interior deficiency with organ collapse, or interior excess with fu-organ obstruction. This is what ancients called "treating diarrhea with purgatives" (Tong Yin Tong Yong). Pressing the epigastrium hardness confirms excess. Although the pulse is not large/excess nor weak/faint, urgent purgation is appropriate to remove excess and stop diarrhea. This is the method of "using unblocking to treat unblocking." Slow pulse usually indicates cold, but when combined with slippery, it indicates excess rather than cold, as internal matter obstructs pulse flow. For diarrhea caused by excess, if excess is not removed, diarrhea persists; thus, urgent purgation is needed. Recurrence at specific times indicates chronic accumulation in the Spleen. Since the Spleen governs punctuality, recurrence happens on schedule; purgation removes accumulation, curing the root.
Da Cheng Qi Tang (See Spasm Chapter)
Diarrhea with delirium indicates dry feces in the intestines; Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is the main treatment.
Delirium is a sign of Stomach excess due to dry feces. This is similar to epigastric hardness and slippery pulse. However, Da Cheng Qi Tang was used previously because diarrhea was caused by excess, requiring rapid removal. Xiao Cheng Qi Tang is used here because the condition has formed excess, and harsh purgation might damage healthy Qi.
Xiao Cheng Qi Tang (Minor Order the Qi Decoction)
Da Huang (Radix et Rhizoma Rhei) 4 liang, Zhi Shi (Fructus Aurantii Immaturus) 3 pieces, Hou Po (Cortex Magnoliae Officinalis) 3 liang (stir-fried).
Boil the three ingredients in 4 sheng of water to obtain 1.2 sheng, strain. Divide into two warm doses. Stop upon defecation.
Diarrhea with pus and blood in the stool is treated with Tao Hua Tang (Peach Blossom Decoction).
This treats damp-cold invading internally, unstable organ Qi, and persistent pus/blood. Chi Shi Zhi (Hematitum) stabilizes blood and secures collapse; Gan Jiang (Rhizoma Zingiberis) warms the Stomach and drives out cold; Jing Mi (Oryza Sativa) calms the middle and benefits Qi. Cui Shi removed Jing Mi, adding Huang Lian (Rhizoma Coptidis) and Dang Gui (Radix Angelicae Sinensis) to treat heat-type diarrhea, a variation of Tao Hua Tang.
Tao Hua Tang (Peach Blossom Decoction)
Chi Shi Zhi (Hematitum) 1 jin (half whole, half powdered), Gan Jiang (Rhizoma Zingiberis) 1 liang, Jing Mi (Oryza Sativa) 1 sheng.
Boil the three ingredients in 7 sheng of water until rice is cooked, strain. Take 0.7 sheng warm, mixing in 1 fang cun bi of Chi Shi Zhi powder. Take three times daily. If cured after one dose, do not take the rest.
Heat-type diarrhea with tenesmus (feeling of incomplete evacuation/heaviness) is treated with Bai Tou Weng Tang (Pulsatilla Decoction).
This treats damp-heat pouring downward and heat pathogens entering the interior causing diarrhea. Bai Tou Weng Tang is bitter to drain dampness and cold to overcome heat.
Bai Tou Weng Tang (Pulsatilla Decoction)
Bai Tou Weng (Herba Pulsatellae) 3 liang, Huang Lian (Rhizoma Coptidis) 3 liang, Huang Bo (Cortex Phellodendri) 3 liang, Qin Pi (Cortex Fraxini) 3 liang.
Boil the four ingredients in 7 sheng of water to obtain 3 sheng, strain. Take 1 sheng warm. If not improved, take again.
After diarrhea, if irritability worsens and pressing the epigastrium feels soft, it is "empty irritability" (Xu Fan); Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the main treatment.
Worsening irritability after diarrhea indicates heat pathogens did not decrease downward but moved upward. Soft epigastrium indicates no obstruction in the middle. Hence, "empty irritability." Xiang Chi (Fermen Sojae Glandulum) and Zhi Zi (Fructus Gardeniae) clear heat and relieve irritability. Vomiting allows heat to exit from above, resolving the condition. This follows the principle of "evoking emesis for pathogens high up."
Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction)
Zhi Zi (Fructus Gardeniae) 14 pieces (broken), Xiang Chi (Fermen Sojae Glandulum) 4 he (wrapped in silk).
Boil Zhi Zi in 4 sheng of water to obtain 2.5 sheng, add Xiang Chi, boil to obtain 1.5 sheng, strain. Divide into two doses. Take one warm dose. Cure upon vomiting.
Diarrhea with undigested food, interior cold with exterior heat, sweating, and cold extremities is treated with Tong Mai Si Ni Tang (Pulse-Recovering Four Counterflow Decoction).
Heat-type diarrhea damages Spleen Yin; cold-type diarrhea with undigested food damages Kidney Yang. Interior cold, exterior heat, sweating, and cold extremities indicate extreme Yin inside and escaping Yang outside. Tong Mai Si Ni Tang is Si Ni Tang with double the amount of Gan Jiang, advancing to seek Yang and gather scattered Qi.
Tong Mai Si Ni Tang (Pulse-Recovering Four Counterflow Decoction)
Fu Zi (Aconiti Lateralis Radix Preparata, raw) 1 piece, Gan Jiang (Rhizoma Zingiberis) 3 liang (4 liang for robust persons), Gan Cao (Radix Glycyrrhizae, stir-fried) 2 liang.
Boil the three ingredients in 3 sheng of water to obtain 1.2 sheng, strain. Divide into two warm doses.
Diarrhea with lung pain is treated with Zi Shen Tang (Periploca Decoction).
Zhao stated: Large Intestine and Lung are exterior-interior related. Accumulation in the intestines blocks Lung Qi; accumulation in the Lung affects Large Intestine stability. They harm each other. Large Intestine disease blocking Qi in the Lung causes pain; Lung accumulation also causes pain. Zi Shen (Radix Periplocae) opens the nine orifices and benefits both intestines. Unblocking Qi relieves pain; removing accumulation stops diarrhea. Yu stated: Some doubt this is not Zhang Zhong Jing's formula. But how could one know that intestinal disease relates entirely to Lung Qi? Cheng suspected abdominal pain; Materia Medica states Zi Shen treats heart/abdominal accumulations and cold-heat pathogens.
Zi Shen Tang (Periploca Decoction)
Zi Shen (Radix Periplocae) 0.5 jin, Gan Cao (Radix Glycyrrhizae) 3 liang.
Boil Zi Shen in 5 sheng of water to obtain 2 sheng, add Gan Cao, boil to obtain 1.5 sheng. Divide into three warm doses.
Qi diarrhea (involuntary gas passage) is treated with He Li Le San (Chebula Powder).
Qi diarrhea involves simultaneous loss of gas and stool. He Li Le (Fructus Chebulae) astringes intestines and regulates Qi; porridge drink calms the middle and benefits intestines/stomach. Taking it in one dose ("dun fu") reflects urgent treatment for lower jiao conditions.
He Li Le San (Chebula Powder)
He Li Le (Fructus Chebulae, roasted) 10 pieces.
Grind into powder, mix with porridge drink, take in one dose.
Attached Formulas
Qian Jin Yi Xiao Cheng Qi Tang (Minor Order the Qi Decoction from Qian Jin Yi) Treats constipation, frequent hiccups, and delirium. (Formula seen above)
Wai Tai Huang Qin Tang (Scutellaria Decoction from Wai Tai) Treats dry retching and diarrhea.
Huang Qin (Radix Scutellariae) 3 liang, Ren Shen (Radix Ginseng) 3 liang, Gan Jiang (Rhizoma Zingiberis) 3 liang, Gui Zhi (Ramulus Cinnamomi) 1 liang, Da Zao (Fructus Jujubae) 12 pieces, Ban Xia (Rhizoma Pinelliae Preparata) 0.5 sheng.
Boil the six ingredients in 7 sheng of water to obtain 3 sheng. Divide into three warm doses.
This matches the previous Huang Qin plus Ban Xia and Sheng Jiang Tang in indication but lacks Bai Shao, Gan Cao, and Sheng Jiang, instead containing Ren Shen, Gui Zhi, and Gan Jiang, emphasizing warming the interior and benefiting Qi. It serves as a model for interior cold with Qi deficiency. The Xiao Cheng Qi Tang mentioned corresponds to the previous method for diarrhea with delirium and dry feces; no repetition is needed.