三十九条 下利。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。
注详伤寒厥阴。
四十条 下利。三部脉皆平。按之心下坚者。急下之。宜大承气汤。
自此至四十四。凡五条。言下利之脉症。有尚宜攻下者。此条从脉平。而心下坚看出。盖谓下利。不过寒热二
因。若是上焦热。而为吹嘘奔迫之利。则当于上部见沉数之脉。若是中下寒。而为分理不清之利。则当于中
下二部见沉迟沉弦之脉。今三部脉皆平。则下利之非寒热可知。加以按之而心下坚。其因胃有积滞。而胃
气不行。以致无分别水谷之权明矣。故宜以大承下之。使胃气流行。而下利者。必自止也。
四十一条 下利。脉迟而滑者。实也。利未欲止。急下之。宜大承气汤。
此条、从脉迟而滑看出。脉字、当指右关阳明而言。盖谓病下利而右关脉迟。犹似胃寒而失分理阴阳之应。
然胃寒而利。则津伤气泄。而脉迟见涩者。常也。乃迟而兼见滑。夫滑、为宿食凝聚之诊。滑从迟见。谓非凝聚
而致气机不流行之故乎。故知其胃实也。胃实不去。则化机不醇。而利岂能愈哉。是宜主大承以通其塞矣。
此与上条两急字。恐缓则津液竭尽。而不任下。多致亡阴而死也。
四十二条 下利。脉反滑。当有所去。下乃愈。宜大承气汤。
此即上条之初候。而抽言之也。盖谓下利。脉当涩。而反见滑。便知当有所去。即宜以大承愈之。否则。坐失机
会。使滑久而胃气阻滞。致成上条迟滑之脉矣。
四十三条 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。
五行各有休囚官旺。而代谢因之。年月日时者。天地流转之五行。五脏六腑者。人身内具之五行。其生扶克
制。内外尝相应者。感通之道也。下利之病。乘时而发于脏腑。病尽固瘥。病不尽。而得运气之子气以制其鬼。
亦能瘥也。若遇所病之期。复见所病之症。则知其非新病。而为未尽之旧病。得流行之鬼气而复发也。是宜
以大承涤荡之。而毋使滋蔓矣。
四十四条 下利。谵语者。有燥屎也。小承气汤主之。
注见伤寒厥阴。
四十五条 下利。便脓血。桃花汤主之。
桃花汤方 赤石脂（一斤半锉半筛末） 干姜（一两） 粳米（一升）
上三味。以水七升。煮米令熟。去滓温七合。内赤石脂方寸匕。三服。若一服愈。余勿服。
注详伤寒少阴。方论并见。
四十六条 热利下重者。白头翁汤主之。
白头翁汤方 白头翁 黄连 黄柏 秦皮（各二两）
上四味。以水七升。煮取二升。去滓温服一升。不愈更服。
注详伤寒厥阴。方论并见。
四十七条 下利后。更烦。按之心下濡者。为虚烦也。桅子豉汤主之。
栀子豉汤方 栀子（十四枚） 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。得吐则止。（此四字系
后人所添。详别见。）
文见伤寒厥阴。有注。
四十八条 下利清谷。里寒外热。汗出而厥者。通脉四逆汤主之。
通脉四逆汤方 附子（大者一枚生用） 干姜（三两强人可四两） 甘草（一两炙）
上三味。以水三升。煮取一升二合去滓分温再服。
下利而至清谷。则里寒已甚。阴寒格阳。故外热。微阳自遁。故汗出。里寒而阳气外泄。故其气不相接而厥也。
是宜以大热之姜附为主。而佐以守中之甘草。使先温其里。则表阳从类而内附。故热汗可除。悍气得温而
外通。故厥亦可愈也。究之胃阳复而变化自神。脾气暖而水谷自别。则下利清谷。当与诸症同解矣。名之曰
通脉四逆者。以脉气行于中焦之精悍。里寒外厥者。其脉必伏。或沉迟。温中而精悍自起。则气行而脉通故
也。文见伤寒厥阴。另有注。
四十九条 下利肺痛。紫参汤主之。
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。
下利肺痛。其因有二。以利则下虚。而膈间之气。有下趋之势。肺为气之总司。而作悬痛者一也。又利则虚热
上浮。而肺管如作胀痛者。二也。紫参味苦气寒。性畅功补。用为主病之君。盖以味苦气寒者。坚其悬痛。而以
性畅功补者。除其胀痛耳。然后佐以甘浮之甘草。是欲其托之在上。而直行肺中者可见矣。
五十条 气利。诃黎勒散主之。
诃黎勒散方 诃黎勒（十枚煨）
上一味为散。粥饮和。顿服。
注见前三十四条下。
Clause 39: In cases of diarrhea (Xialì), abdominal fullness, and body pain, one should first warm the interior, and then attack the exterior. To warm the interior, Sì Nì Tāng (Four Reversals Decoction) is indicated; to attack the exterior, Guì Zhī Tāng (Cinnamon Twig Decoction) is indicated.
Note: See detailed commentary in the Jueyin Disease chapter of *Shanghan Lun*.
Clause 40: In cases of diarrhea, if the pulses at the cun, guan, and chi positions are all level/normal, but palpation reveals hardness in the epigastrium (xin xia), urgent purgation is required. Dà Chéng Qì Tāng (Major Order the Qi Decoction) is indicated.
From this clause to Clause 44, there are five clauses in total discussing pulse and symptom patterns of diarrhea that still warrant purgative treatment. This clause infers the condition from the combination of normal pulses and hardness in the epigastrium. It implies that diarrhea is generally caused by either cold or heat. If it is heat in the upper jiao causing a rushing, forceful type of diarrhea, the pulse should appear sun (deep) and shu (rapid) in the upper positions. If it is cold in the middle and lower jiao causing unclear differentiation of fluids and grains, the pulse should appear sun (deep) and chi (slow) or xian (wiry) in the middle and lower positions. Now, since the pulses in all three positions are normal, it is evident that the diarrhea is not caused by cold or heat. Furthermore, the hardness upon palpation of the epigastrium clearly indicates accumulation in the stomach with stagnant stomach qi, leading to a loss of the ability to differentiate fluids and grains. Therefore, Dà Chéng Qì Tāng (Major Order the Qi Decoction) should be used to purge, allowing the stomach qi to circulate freely, whereupon the diarrhea will naturally cease.
Clause 41: In cases of diarrhea, if the pulse is chi (slow) and hua (slippery), it indicates excess (shi). The diarrhea will not stop on its own; urgent purgation is required. Dà Chéng Qì Tāng (Major Order the Qi Decoction) is indicated.
This clause infers the condition from the chi (slow) and hua (slippery) pulse. The term "pulse" here refers specifically to the right guan position corresponding to the Yangming channel. It implies that although a chi (slow) pulse at the right guan during diarrhea might suggest stomach cold and a failure to regulate yin and yang, stomach cold typically leads to injury of fluids and leakage of qi, resulting in a chi (slow) and se (choppy) pulse, which is the norm. However, a chi (slow) pulse combined with hua (slippery) suggests the accumulation of retained food (su shi). The presence of hua (slipperiness) within slowness indicates that qi mechanism stagnation is caused by such accumulation. Thus, it is known to be stomach excess (wei shi). If the stomach excess is not removed, the transformative mechanism remains impure, and the diarrhea cannot heal. Therefore, Dà Chéng Qì Tāng (Major Order the Qi Decoction) should be primarily used to unblock the obstruction. The emphasis on "urgent" in these two clauses warns that delay may lead to exhaustion of body fluids, making the patient unable to tolerate purgation, often resulting in death due to collapse of yin.
Clause 42: In cases of diarrhea, if the pulse is unexpectedly hua (slippery), it indicates that there is something to be expelled; purgation will lead to recovery. Dà Chéng Qì Tāng (Major Order the Qi Decoction) is indicated.
This describes the initial presentation of the previous clause, discussed separately. It implies that while the pulse in diarrhea should typically be se (choppy), an unexpected hua (slippery) pulse indicates the presence of pathogenic retention requiring expulsion, which can be cured with Dà Chéng Qì Tāng (Major Order the Qi Decoction). Otherwise, missing this opportunity allows the slippery pulse to persist and stomach qi to become obstructed, eventually evolving into the chi-hua (slow-slippery) pulse pattern described in the previous clause.
Clause 43: If diarrhea has resolved but recurs at specific years, months, days, or hours, it is because the pathogen was not completely eliminated. Purgation is indicated. Dà Chéng Qì Tāng (Major Order the Qi Decoction) is indicated.
The Five Elements have states of rest, decline, official prosperity, and dominance, driving metabolic changes. Years, months, days, and hours represent the flowing Five Elements of heaven and earth, while the Zang and Fu organs represent the internal Five Elements of the human body. Their mutual generation, support, restriction, and control correspond internally and externally, constituting the way of resonance. Diarrhea diseases manifest in the Zang and Fu organs according to timing. If the pathogen is fully cleared, the disease resolves; if not fully cleared, the resolving child qi of the fortune cycle can suppress the "ghost" (pathogenic) qi, also leading to resolution. However, if at the time associated with the diseased organ, the original symptoms reappear, it indicates this is not a new disease but an unresolved old pathogen reactivated by the circulating "ghost" qi. Therefore, Dà Chéng Qì Tāng (Major Order the Qi Decoction) should be used to cleanse and eliminate it, preventing further spread.
Clause 44: In cases of diarrhea accompanied by delirium (shanyu), there is dry stool (zao shi). Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is indicated.
Note: See commentary in the Jueyin Disease chapter of *Shanghan Lun*.
Clause 45: In cases of diarrhea with pus and blood in the stool, Tao Hua Tang (Peach Blossom Decoction) is indicated.
Tao Hua Tang (Peach Blossom Decoction) Formula: Chi Shi Zhi (Red Halloysite, 1 jin 1.5 liang, crushed and half sifted into powder), Gan Jiang (Dried Ginger, 1 liang), Jing Mi (Rice, 1 sheng).
Take the above three ingredients, add 7 sheng of water, and boil until the rice is cooked. Strain the dregs. Take 7 ge of the decoction warm. Mix in Chi Shi Zhi powder equivalent to one fang cun bi (square inch spoonful). Divide into three doses. If cured after one dose, do not take the remainder.
Note: See detailed commentary in the Shaoyin Disease chapter of *Shanghan Lun*; formula discussion is included there.
Clause 46: In cases of hot diarrhea with a sensation of heaviness and tenesmus (xia zhong), Bai Tou Weng Tang (Pulsatilla Decoction) is indicated.
Bai Tou Weng Tang (Pulsatilla Decoction) Formula: Bai Tou Weng (Pulsatilla Root, 2 liang), Huang Lian (Coptis Rhizome, 2 liang), Huang Bo (Phellodendron Bark, 2 liang), Qin Pi (Ash Bark, 2 liang).
Take the above four ingredients, add 7 sheng of water, and boil to obtain 2 sheng. Strain the dregs. Take 1 sheng warm. If not cured, continue taking.
Note: See detailed commentary in the Jueyin Disease chapter of *Shanghan Lun*; formula discussion is included there.
Clause 47: After diarrhea, if irritability increases and palpation of the epigastrium reveals softness, it is deficiency irritability (xu fan). Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is indicated.
Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) Formula: Zhi Zi (Gardenia Fruit, 14 pieces), Xiang Chi (Fermented Soybean, 4 he, wrapped in silk).
Take the above two ingredients, add 4 sheng of water. First boil Zhi Zi to obtain 2.5 sheng. Add Xiang Chi and boil to obtain 1.5 sheng. Strain the dregs. Divide into two doses. Take one dose warm. If vomiting occurs, stop administration. (These four characters were added by later scholars; see elsewhere for details.)
Text appears in the Jueyin Disease chapter of *Shanghan Lun*, with notes.
Clause 48: In cases of diarrhea with undigested food (qing gu), interior cold with exterior heat, sweating, and cold extremities (jue), Tong Mai Si Ni Tang (Pulse-Returning Four Reversals Decoction) is indicated.
Tong Mai Si Ni Tang (Pulse-Returning Four Reversals Decoction) Formula: Fu Zi (Aconite Lateral Root, one large piece, raw), Gan Jiang (Dried Ginger, 3 liang; strong individuals may use 4 liang), Gan Cao (Licorice Root, 1 liang, honey-fried).
Take the above three ingredients, add 3 sheng of water, and boil to obtain 1.2 sheng. Strain the dregs. Divide into two warm doses.
Diarrhea with undigested food indicates severe interior cold. Yin-cold repelling yang causes exterior heat; weak yang escaping causes sweating. Interior cold with external leakage of yang causes disconnection of qi and thus cold extremities. Therefore, Da Re (greatly hot) Gan Jiang and Fu Zi should be used as the main herbs, assisted by Gan Cao to maintain the center. By first warming the interior, the exterior yang will follow its kind and return inward, eliminating hot sweat. Wei qi (defensive qi), warmed, will circulate outward, curing cold extremities. Ultimately, when stomach yang recovers, transformation becomes miraculous; when spleen qi warms, fluids and grains separate naturally. Thus, diarrhea with undigested food and other symptoms will resolve together. It is named Tong Mai Si Ni Tang because the pulse qi flows through the refined qi of the middle jiao. In cases of interior cold and exterior cold extremities, the pulse is likely fu (hidden) or chen chi (deep and slow). Warming the middle causes the refined qi to rise, allowing qi to flow and the pulse to open. Text appears in the Jueyin Disease chapter of *Shanghan Lun*, with additional notes.
Clause 49: In cases of diarrhea accompanied by lung pain, Zi Shen Tang (Codonopsis/Pseudostellaria Decoction - Note: Zi Shen usually refers to Codonopsis or sometimes Scutellaria Barbata depending on era/context, here treated as herb name) is indicated.
Zi Shen Tang Formula: Zi Shen (Herb name, 0.5 jin), Gan Cao (Licorice Root, 3 liang).
Take the above two ingredients, add 5 sheng of water. First boil Zi Shen to obtain 2 sheng. Add Gan Cao and boil to obtain 1.5 sheng. Divide into three warm doses.
Diarrhea with lung pain has two causes. First, diarrhea causes deficiency below, creating a downward trend for qi in the diaphragm. Since the Lung is the master of qi, this creates a hanging pain. Second, diarrhea causes deficient heat to float upward, causing distending pain in the lung passages. Zi Shen is bitter and cold, with a smooth nature and tonifying function. Used as the sovereign herb, its bitter and cold nature secures the hanging pain, while its smooth and tonifying nature removes the distending pain. Then, assisted by sweet and floating Gan Cao, the intention is to lift the action upward and direct it straight into the Lung.
Clause 50: In cases of qi diarrhea (leakage of stool with flatus), He Li Le San (Terminalia Powder) is indicated.
He Li Le San Formula: He Li Le (Terminalia Chebula, 10 pieces, roasted).
Grind the single ingredient into powder. Mix with congee broth and take in one dose.
Note: See below Clause 34.