中始愈，反下之则愈虚寒而愈吐矣。
寸口脉微而数，微则无气，无气则荣虚，荣虚则血不足，血不足则胸中冷。
【按】此条文义不属，必是错简。
跗阳脉浮而涩，浮则为虚，虚则伤脾。脾伤则不磨，朝食暮吐，暮食朝吐，宿谷不化，
名曰胃反。脉紧而涩，其病难治。
【按】虚则伤脾之“虚”字，当是“涩”字，是传写之讹。
【注】前条因误下而病胃反，则脉弦；此条不因误下而病胃反，则脉浮而涩也。跗阳
脉见浮而涩，浮以候胃，涩以候脾；浮而无
力为胃虚，涩而无力为伤脾；胃虚脾伤，则不能消磨水谷，故朝食暮吐，暮食朝吐，所
吐皆仍然不化之宿谷，故曰胃反也。若脉紧涩，则为邪盛正衰。故其病难治也。
【集注】徐彬曰∶紧为寒盛，涩为液竭，正不胜邪，故曰∶难治。
胃反呕吐者，大半夏汤主之。
【注】此承上条以明其治也。胃反呕吐者，谓朝食暮吐、暮食朝吐之呕吐也。主之大半
夏汤者，补脾胃、止呕吐也。
大半夏汤方
半夏（洗浣用，二升） 人参（三两） 白蜜（一升）
上三味，以水一斗二升，和蜜扬之二百四十遍，煮药取一升半，温服一升，余分再
服。
《千金方》云∶大半夏汤治胃反不受食，食入即吐。
《外台方》云∶大半夏汤治呕、心下痞硬者。
【集解】高世 曰∶朝食暮吐，宿谷不化，名曰胃反。胃反但吐不呕，然吐不离乎呕，故
曰∶胃反呕吐者。用半夏助燥气以消谷，人参补元气以安胃，白蜜入水扬之，使甘味散
于水中，水得蜜而和缓，蜜得水而淡渗，庶胃反平而呕吐愈。
李升玺曰∶呕家不宜甘味，此用白蜜何也？不知此胃反自属脾虚，经所谓甘味入脾，
归其所喜是也。况君以半夏，味辛而止呕，佐以人参温气而补中，胃反自立止矣。
胃反，吐而渴欲饮水者，茯苓泽泻汤主之。
【注】胃反吐而不渴者，寒也，渴欲饮水者，饮也，故以茯苓泽泻汤，补阳利水也。
茯苓泽泻汤方
茯苓（半斤） 泽泻（四两） 甘草（二两） 桂枝（二两） 白术（三两） 生姜（四两）
上六味，以水一斗，煮取三升，内泽泻，再煮取二升半，温服八合，日三服。
《外台方》云∶茯苓泽泻汤治消渴、胃反、脉绝。
【集解】李 曰∶吐而渴者，津液亡而胄虚燥也。饮水则水停心下，茯苓、泽泻，降
气行饮，白术补脾生津，此五苓散原方之义也。然胃反因脾气虚逆，故加生姜散逆，甘草和脾。又五苓
散治外有微热，故用桂枝。此胃反无表热，而亦用之者，桂枝非一于攻表药也，乃彻上彻下，达表里，
为通行津液、和阳散水之剂也。
尤怡曰∶茯苓泽泻汤，治吐未已，而渴欲饮水者，以吐未已，知邪未去，则宜桂枝、
甘、姜散邪气，茯苓，泽泻消水气也。
哕逆者，橘皮竹茹汤主之。
【注】哕即干呕也。因其有哕吵之声，而无他物，故不曰干呕，而曰哕逆，属气上逆
为病也。上逆之气，得出上窍，皆能作声，故肺虚气上逆，则作咳，气从喉出而有咳逆之
声，若为邪所阻，则为喘满，故无声也。胃虚气上逆，则作哕，气从咽出而有哕逆之声。
若与物凝结，则为痞痛，故无声也，是知气病也明矣。然邪气所凑，正气必虚，故用橘
皮、竹茹、生姜以清邪气，人参、甘草、大枣以补正气，则上逆之气自可顺矣。
橘皮竹茹汤方
橘皮（二斤） 竹茹（二升） 大枣（三十枚） 生姜（半斤） 甘草（五两） 人参（一两）
上六味，以水一斗，煮取三升，温服一升，日三服。
【集解】李 曰∶哕有属胃寒者，有属胃热者，此哕逆因胃中虚热，气逆所致。故用人
参、甘草、大枣补虚；橘皮、生姜散逆；竹茹甘寒，疏逆气而清胃热，因以为君。
尤怡曰∶胃虚而热乘之，则作哕逆，橘
皮、生姜和胃散逆，竹茹除热止呕哕，人参、甘草、大枣益虚安中也。
干呕哕，若手足厥者，橘皮汤主之。
【注】干呕哕，犹言干呕，即哕也。东垣以干呕为轻，哕为重，识仲景措辞之
意也。哕而手足厥，乃胃阳虚，是吴茱萸汤证也。若初病形气俱实，虽手足厥，非阳虚阴盛者比，
乃气闭不达于四肢也，故单以橘皮通气，生姜止哕也。
【集注】程林曰∶干呕哕，则气逆于胸膈间，而不行于四末，故手足为之厥。橘皮能
降逆气，生姜呕家圣药，小剂以和之也。然干呕非反胃，厥非无阳，故下咽气行即愈。
橘皮汤方
橘皮（四两） 生姜（半斤）
上二味，以水七升，煮取三升，温服一升，下咽则愈。
哕而腹满，视其前后，知何部不利，利之即愈。
【注】哕虚邪也，哕而不腹满者，为正气虚。兼有热者，以橘皮竹茹汤主之；兼有寒
者，以吴茱萸汤主之。哕而腹满者为邪气实，当视其二便，大便不利者下之，小便不利者
通之即愈也。
【集注】朱肱曰∶前部不利猪苓汤，后部不利调胃承气汤。
赵良曰∶腹满为实，实则气上逆而作哕，故必视其前后何部不利而利之，则满去而哕
止。
魏荔彤曰∶胃气上逆，冲而为哕，治法当视其前后，审大小便调不调也。前部不利
者，水邪之逆也。当利其小便而哕愈∶后部不利者，热邪实也，当利其大使而哕愈。
夫六腑气绝于外者，手足寒，上气脚缩；五脏气绝于内者，利不禁；下甚者，手足不仁。
【注】气绝非谓脱绝，乃谓虚绝也。六腑之气，阳也，阳气虚不温于外，则手足寒缩。
阳虚则阴盛上逆，故呕吐哕也。五脏之气，阴也，阴气虚不固于中，则下利不禁，利甚则
中脱形衰，故手足不仁也。此发明呕吐、下利之原委也。
下利清谷，里寒外热，汗出而厥者，通脉四逆汤主之。
【注】下利清谷，里寒也。外热汗出而厥，阳亡也。主之以通脉四逆汤，回阳胜寒，而
利自止也。
通脉四逆汤方
附子（生用，大者一枚） 干姜（三两，强人可四两） 甘草（炙，二两）
上三味，以水三升，煮取一升二合，去滓，分温再服。
下利，手足厥冷，无脉者，灸之不温；若脉不还，反微喘者，死。少阴负跗阳者，为
顺也。
【按】此条“反微喘者死”之下，有“少阴负跗阳者为顺也”一句，文义不属，其注
已详见《伤寒论·辨脉篇》内，不复释。
【注】下利手足厥冷，脉绝无者，有阴无阳之脉证也。虽用理中四逆辈，恐其缓不及
事，急灸脐下，以通其阳。若脉还手足温者生，脉不还手足不温，反微喘者，阳气上脱
也，故死。
【集注】程林曰∶下利而至于手足厥冷无脉，则独阴无阳，灸之以复其阳。而脉绝不
来，反微喘者，则正气又脱于上，孤阳无根，故死。
下利气者，当利其小便。
【注】下利气者，初利则为气郁于大肠而不外渗，水气并下，但当利其小便，输其渗
泻之窍，气宣而利止也。久利则为气陷于大肠，而不上举，又当于升补中兼利小便也。
【集注】尤怡曰∶下利气者，气随利失，即所谓气利是也。
气利，诃黎勒散主之。
【注】气利，所下之气秽臭，所利之物稠粘，则为气滞不宣，或下之、或利之皆
可也。若所利之气不臭，所下之物不粘，则谓气陷肠滑，故用诃黎勒散以固肠，或用补中益气
以举陷亦可。
诃黎勒散方
诃黎勒（煨，十枚）
上一味，为散，粥饮和顿服。
【集解】李 曰∶气利者，下利气虚，下陷而滑脱也，诃黎勒性敛涩，能温胃固肠。粥
饮和者，假谷气以助胃。顿服者，药味并下，更有力也。
尤怡曰∶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。
若下利脉数，有微热汗出，令自愈；设脉紧，为未解。
【注】下利脉数，内热利也，微热汗出，其邪衰矣，故令自愈。设脉紧者，是表未衰，
故为未解也。
【集注】程林曰∶寒则下利，脉数有微热，则里寒去，汗出则表气和。表里俱和，故令
自愈；设复紧者，知寒邪尚在，是为未解也。
下利，有微热而渴，脉弱者，令自愈。
【注】下利大热而渴，则为邪盛，脉弱则为正虚，不能愈也。今微热而渴，脉弱者，邪
正俱衰，故知自愈也。
【集注】程林曰∶下利大热而渴，则偏于阳，无热不渴，则偏于阴，皆不能愈；以微
热而渴，知阴阳和，脉弱，知邪气去，故即自愈。
下利，脉数而渴者，令自愈；设不瘥，必圊脓血，以有热故也。
【注】此承上条邪正俱衰，病当自愈而不愈之义也。设不瘥者，则必表和，热退而数
渴，仍然是里热未除也，故圊脓血。
【集注】魏荔彤曰∶下利，固以阳气有余为吉，又不可太盛，成热邪伤阴，致阳复有
偏胜之患。
下利，寸脉反浮数，尺中自涩者，必圊脓血。
【注】此承上表里已和，病当自愈而不愈之义也。下利里病，而得浮数表脉，故曰∶脉
反浮数也，但尺中自涩，则知热陷血分，必圊脓血也。
【集注】徐彬曰∶下利属寒，脉应沉迟，反浮数，其阳胜可知。而尺中自涩，涩为阳
邪入阴，此亦热多。故曰∶必圊脓血。
程林曰∶寸脉浮数，为热有余，尺脉自涩，为血不足，以热有余，则挟热而便脓血。
下利，三部脉皆平，按之心下坚者，急下之，宜大承气汤。
【注】下利之人，心下硬者，诸泻心汤证也。若寸、关、尺三部脉皆平实有力，虽下
利，宜攻坚也。
【集注】李 曰∶下利，按之心下坚者，实也。设或脉见微弱，犹未可下，今三部脉
皆平，则里气不虚可知，自宜急下之。此凭脉又证书之法也。
大承气汤方（见痉病中）
下利，脉迟而滑者，实也，利未欲止，急下之，宜大承气汤。
【注】脉迟不能兼滑，惟浮取之迟，沉取之滑，则有之矣。今下利脉迟而滑，谓浮迟而
沉滑也。浮迟则外和，沉滑则内实。欲止内实之下利，当下之，积去则止，宜大承气汤。
【集注】尤怡曰∶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
迟行。夫利因实而致者，实不去则利不止，故宜急下。
下利，脉反滑者，当有所去，下乃愈，宜大承气汤。
【注】下利脉反滑者，是病虚脉实，不相宜也。若其人形气如常，饮食如故，乃有当
去之积未去也，下之乃愈，宜大承气汤。
【集注】赵良曰∶下利虚证也，脉滑实脉也，以下利之虚证，而反见滑实之脉，故当
有所去也。
程林曰∶经云∶滑为有宿食，故当下去之，而利自止。
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。
【注】下利瘥后，至其或年、或月、或日而复发其利者，此宿食积病，攻之不尽故也。
若其人形气不衰，饮食尚强，当攻其未尽，自不复发其利也，宜大承气汤。
【集注】沈明宗曰∶此旧积之邪复病也。下利瘥后，至其年月日时复发者，是前次下
利之邪，隐僻肠间，今值脏腑司令之期，触动旧邪而复发；然隐僻之根未除，终不能愈，
故用大承气迅除之耳。
下利谵语者，有燥屎也，小承气汤主之。
【注】下利里虚证也，谵语里实证也，何以决其有燥屎也？若脉滑数，知有宿食也；其
利秽粘，知有积热也。然必脉证如此，始可知其有燥屎也，宜下之以小承气汤。于此推
之，而燥屎又不在大便硬不硬也。
【集注】李 曰∶经云∶实则谵语，故知有燥屎宜下。
小承气汤方
大黄（四两） 浓朴（炙，三两） 枳实（炙，大者三枚）
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，脉反弦，发热身汗者，自愈。
【注】下利，脾病也。弦，肝脉也，脾病不当见弦脉，故曰脉反弦也。下利里病也，发
热表证也，若发热身汗，则为表与里和，虽脉弦亦可自愈也。
下利，脉沉弦者下重，脉大者为未止，脉微弱数者为欲自止，虽发热不死。
【注】沉主里；弦主急；下重，后重也。下利脉沉弦者，故里急后重也。滞下之证，发
热脉大则邪盛为未已也，脉微弱数者则邪衰，病当自止，虽发热不死也。由此可知脉大身
热者死也。
热利下重者，白头翁汤主之。
【注】此承上条以明其治也。下利脓血，里急后重，积热已深，故以白头翁汤大苦大
寒；寒能胜热，苦能燥湿，湿热去，下重自除矣。
【集注】程林曰∶热利下重，则热迫于肠胃，非苦不足以坚下焦，非寒不足以除热，故
加一“热”字，别以上之寒利。
尤怡曰∶此证湿热下注，故用白头翁汤，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，煮取二升，去滓，温服一升，不愈更服。
下利，便脓血者，桃花汤主之。
【注】初病下利便脓血者，大承气汤或芍药汤下之。热盛者，白头翁汤清之。若日久
滑脱，则当以桃花汤养肠固脱可也。
桃花汤方
赤石脂（一半锉，一半筛末，一斤） 干姜（一两） 粳米（一升）
上三味，以水七升，煮米令熟，去滓，温七合，内赤石脂末方寸匕，日三服，若一服
愈，余勿服。
病势初愈，若误用攻下法，则会导致正气更虚、寒邪更盛，从而引发或加重呕吐。
寸口脉象微而数，脉微说明元气不足，元气不足则营气虚弱，营气虚弱则血液亏少，血液亏少则胸中寒冷。
【按语】此条文的文义不连贯，必定是竹简错乱所致。
跗阳脉象浮而涩，脉浮表示正气虚，正气虚则损伤脾脏。脾脏受损则无法运化食物，早晨吃的食物到晚上吐出来，晚上吃的食物到早上吐出来，吐出的都是未消化的隔夜食物，这叫做胃反（一种以朝食暮吐、暮食朝吐为特征的病症）。如果脉象紧而涩，说明病情难以治愈。
【按语】“虚则伤脾”中的“虚”字，应当是“涩”字，这是传抄过程中的错误。
【注解】前一条条文是因为误用攻下法导致胃反，所以脉象弦；这一条条文不是因误下导致的胃反，所以脉象浮而涩。跗阳脉出现浮而涩，浮脉用来候测胃的状态，涩脉用来候测脾的状态；浮而无力代表胃虚，涩而无力代表脾伤；胃虚脾伤，就不能消磨水谷，所以早晨吃晚上吐，晚上吃早上吐，吐出的都是未消化的隔夜食物，所以叫作胃反。如果脉象紧涩，说明邪气盛而正气衰。所以这种病难治。
【集注】徐彬说：紧脉代表寒邪盛，涩脉代表津液枯竭，正气不能战胜邪气，所以说：难治。
对于胃反呕吐的患者，主治方剂是大半夏汤。
【注解】这是承接上一条条文来说明治疗方法。所谓胃反呕吐，是指早晨吃晚上吐、晚上吃早上吐的呕吐症状。使用大半夏汤为主治方剂，是为了补益脾胃、止住呕吐。
大半夏汤方
半夏（洗净，二升） 人参（三两） 白蜜（一升）
以上三味药，用水一斗二升，加入蜂蜜并搅拌二百四十次，煎煮药物取汁一升半，温服一升，剩下的分两次服用。
《千金方》说：大半夏汤治疗胃反不能受纳饮食，吃进去就吐出来的症状。
《外台秘要》说：大半夏汤治疗呕吐、心下部痞塞硬满的症状。
【集解】高世栻说：早晨吃晚上吐，宿食不消化，这叫胃反。胃反只是吐而不呕，但吐离不开呕，所以说：胃反呕吐者。使用半夏助燥气以消化谷物，人参补元气以安顿胃，白蜜入水后扬动，使甜味散布在水中，水得到蜂蜜变得和缓，蜂蜜得到水变得淡渗，这样胃反得以平复，呕吐痊愈。
李升玺说：呕吐患者不宜用甘味药，这里为什么用白蜜呢？不知道这种胃反属于脾虚，经书所说甘味入脾，顺应其喜好是也。况且君药是半夏，味道辛能止呕，佐药是人参，温气而补中焦，胃反自然停止。
胃反，呕吐且口渴想喝水的，主治方剂是茯苓泽泻汤。
【注解】胃反呕吐但不口渴的，是寒证；口渴想喝水的，是水饮内停，所以用茯苓泽泻汤，补阳气以利水湿。
茯苓泽泻汤方
茯苓（半斤） 泽泻（四两） 甘草（二两） 桂枝（二两） 白术（三两） 生姜（四两）
以上六味药，用水一斗，煎取三升，放入泽泻，再煎取二升半，温服八合，每日三次。
《外台秘要》说：茯苓泽泻汤治疗消渴、胃反、脉绝的症状。
【集解】李曰：呕吐且口渴，是津液亡失而胃虚燥热。喝水则水停在心下，茯苓、泽泻降气行水，白术补脾生津，这是五苓散原方的意思。然而胃反是因为脾气虚逆，所以加生姜散逆气，甘草调和脾胃。另外五苓散治疗外有微热，所以用桂枝。这里胃反没有表热，却也用桂枝，是因为桂枝不仅仅是攻表的药，而是贯通上下、通达表里，作为通行津液、调和阳气、消散水气的药剂。
尤怡说：茯苓泽泻汤，治疗呕吐未止，且口渴想喝水的情况，因为呕吐未止，知道邪气未去，所以宜用桂枝、甘草、生姜散邪气，茯苓、泽泻消水气。
呃逆（哕逆），主治方剂是橘皮竹茹汤。
【注解】哕就是干呕。因为它有哕吵的声音，但没有其他吐出物，所以不叫干呕，而叫哕逆，属于气机上逆为病。上逆之气，从上部窍道排出，都能发出声音，所以肺虚气上逆，就会咳嗽，气从喉咙出而有咳逆之声，如果被邪气阻滞，就会喘满，所以没有声音。胃虚气上逆，就会产生哕，气从咽部出而有哕逆之声。如果与物凝结，就会痞痛，所以没有声音，由此可知这是气病。然而邪气聚集之处，正气必然虚弱，所以用橘皮、竹茹、生姜来清泄邪气，用人参、甘草、大枣来补益正气，那么上逆之气自然可以顺降。
橘皮竹茹汤方
橘皮（二斤） 竹茹（二升） 大枣（三十枚） 生姜（半斤） 甘草（五两） 人参（一两）
以上六味药，用水一斗，煎取三升，温服一升，每日三次。
【集解】李曰：哕有属于胃寒的，有属于胃热的，此哕逆是因为胃中虚热，气逆所致。所以用人参、甘草、大枣补虚；橘皮、生姜散逆；竹茹甘寒，疏理逆气而清胃热，因此作为君药。
尤怡说：胃虚而热邪乘之，就会产生哕逆，橘皮、生姜和胃散逆，竹茹除热止呕哕，人参、甘草、大枣补虚安中。
干呕哕，如果手足厥冷的，主治方剂是橘皮汤。
【注解】干呕哕，意思是干呕，即哕。东垣认为干呕较轻，哕较重，这是识别仲景措辞的本意。哕而且手足厥冷，是胃阳虚，这是吴茱萸汤的适应证。如果是初病形气都实，虽然手足厥冷，但不是阳虚阴盛的情况，而是气机闭塞不能通达四肢，所以单用橘皮通气，生姜止哕。
【集注】程林说：干呕哕，则气逆于胸膈之间，而不能运行于四肢末端，所以手足为之厥冷。橘皮能降逆气，生姜是呕吐家的圣药，用小剂量来调和它。然而干呕不是反胃，厥冷不是无阳，所以药下咽后气行即愈。
橘皮汤方
橘皮（四两） 生姜（半斤）
以上两味药，用水七升，煎取三升，温服一升，下咽即愈。
哕而且腹部胀满，观察其前后二便，知道哪一部分不通利，通利它即可痊愈。
【注解】哕属虚邪，哕而不腹满的，是正气虚。兼有热的，用橘皮竹茹汤主治；兼有寒的，用吴茱萸汤主治。哕而且腹满的是邪气实，应当观察其二便，大便不利的攻下，小便不利的通利即可痊愈。
【集注】朱肱说：前部（小便）不利用猪苓汤，后部（大便）不利用调胃承气汤。
赵良说：腹满是实证，实证则气上逆而作哕，所以必须观察前后哪部分不利而通利它，则胀满去除而哕止。
魏荔彤说：胃气上逆，冲激而为哕，治法应当观察前后，审察大小便是否通畅。前部不利，是水邪上逆，应当利小便而哕愈；后部不利，是热邪实证，应当利大便而哕愈。
六腑之气衰竭于外的，手足寒冷，气逆脚缩；五脏之气衰竭于内的，腹泻不禁；下利严重的，手足麻木不仁。
【注解】气绝不是说脱绝，而是指虚绝。六腑之气属阳，阳气虚不能温煦于外，则手足寒冷收缩。阳虚则阴盛上逆，所以发生呕吐哕。五脏之气属阴，阴气虚不能固守于中，则下利不禁，下利严重则中气脱失形体衰败，所以手足不仁。这是阐明呕吐、下利的根本原因。
下利排出未消化的食物，里有寒外有热，出汗且手足厥冷的，主治方剂是通脉四逆汤。
【注解】下利排出未消化的食物，是里寒。外热出汗且手足厥冷，是阳气亡脱。用通脉四逆汤主治，回阳胜寒，则下利自止。
通脉四逆汤方
附子（生用，大者一枚） 干姜（三两，体质强者可用四两） 甘草（炙，二两）
以上三味药，用水三升，煎取一升二合，去渣，分两次温服。
下利，手足厥冷，无脉搏的，艾灸后仍不温暖；如果脉搏不还复，反而轻微喘息的，死。少阴脉弱于跗阳脉的，为顺证。
【按语】此条文中“反微喘者死”之下，有“少阴负跗阳者为顺也”一句，文义不连贯，其注解已详见《伤寒论·辨脉篇》内，不再解释。
【注解】下利手足厥冷，脉搏断绝的，是有阴无阳的脉证。虽然用理中汤、四逆汤之类，恐怕药力缓慢来不及救治，急灸脐下，以通其阳气。如果脉搏还复手足温暖的生，脉搏不还复手足不温，反而轻微喘息的，是阳气上脱，所以死。
【集注】程林说：下利以至于手足厥冷无脉，则是独阴无阳，艾灸以回复其阳气。而脉搏绝不来，反而轻微喘息的，则是正气又脱于上，孤阳无根，所以死。
下利伴有排气（气利）的，应当利小便。
【注解】下利伴有排气的，初起时是气郁结在大肠而不外渗，水气并走下行，只应当利小便，疏通其渗泻的窍道，气机宣通则下利停止。久利则是气陷于大肠，而不能上举，又应当在升提补益中兼以利小便。
【集注】尤怡说：下利气者，气随利失，就是所谓的气利。
气利，主治方剂是诃黎勒散。
【注解】气利，所排出的气体秽臭，所下的物质稠粘，这是气滞不宣，或者攻下、或者利小便都可以。如果所排出的气体不臭，所下的物质不粘，这叫气陷肠滑，所以用诃黎勒散以固肠，或者用补中益气汤以举陷也可以。
诃黎勒散方
诃黎勒（煨，十枚）
以上一味药，研为散，用粥饮调和一次服下。
【集解】李曰：气利，是下利气虚，下陷而滑脱，诃黎勒性收敛涩滞，能温胃固肠。用粥饮调和，是借谷气以助胃气。一次服下，是药味并下，更有力量。
尤怡说：气利，气和屎一起失禁。诃黎勒涩肠而利气，粥饮安中益肠胃。一次服下，是补下治下的制方原则，用药宜急。
如果下利脉数，有微热出汗的，会自愈；如果脉紧，说明病未解。
【注解】下利脉数，是内热利，微热出汗，邪气衰退了，所以会自愈。如果脉紧，是表邪未衰，所以病未解。
【集注】程林说：寒则下利，脉数有微热，则里寒去，汗出则表气和。表里俱和，所以会自愈；如果又变紧，知道寒邪尚在，这是病未解。
下利，有微热而口渴，脉弱的，会自愈。
【注解】下利大热而口渴，是邪气盛，脉弱是正气虚，不能自愈。现在微热而口渴，脉弱，是邪正俱衰，所以知道会自愈。
【集注】程林说：下利大热而口渴，则偏于阳，无热不渴，则偏于阴，都不能自愈；以微热而口渴，知道阴阳和，脉弱，知道邪气去，所以即自愈。
下利，脉数而口渴的，会自愈；如果不痊愈，必定排脓血，因为有热的原因。
【注解】这是承接上一条邪正俱衰，病当自愈而不愈的意思。如果不痊愈，则体表和，热退而数渴，仍然是里热未除，所以排脓血。
【集注】魏荔彤说：下利，固然以阳气有余为吉，但又不可太盛，形成热邪伤阴，导致阳气恢复后有偏胜的祸患。
下利，寸脉反浮数，尺中自涩的，必定排脓血。
【注解】这是承接上一条表里已和，病当自愈而不愈的意思。下利是里病，却得到浮数表脉，所以说：脉反浮数也，但尺中自涩，则知道热陷血分，必定排脓血。
【集注】徐彬说：下利属寒，脉应沉迟，反浮数，其阳胜可知。而尺中自涩，涩为阳邪入阴，这也是热多。所以说：必排脓血。
程林说：寸脉浮数，为热有余，尺脉自涩，为血不足，以热有余，则挟热而便脓血。
下利，三部脉皆平，按压心下坚硬的，急用攻下法，宜用大承气汤。
【注解】下利的人，心下硬的，是诸泻心汤的适应证。如果寸、关、尺三部脉皆平实有力，虽下利，宜攻坚。
【集注】李曰：下利，按压心下坚硬的，是实证。如果脉见微弱，尚不可攻下，现在三部脉皆平，则里气不虚可知，自然宜急下之。这是凭脉又证病的治法。
大承气汤方（见痉病中）
下利，脉迟而滑的，是实证，下利不会停止，急用攻下法，宜用大承气汤。
【注解】脉迟不能兼滑，只有浮取之迟，沉取之滑，才有这种情况。现在下利脉迟而滑，是说浮迟而沉滑。浮迟则外和，沉滑则内实。想要停止内实之下的利，当下之，积去则止，宜用大承气汤。
【集注】尤怡说：脉迟为寒，然而与滑脉俱见，则不为寒反而为实，因为中实有物，能阻碍脉迟行。夫利因实而致者，实不去则利不止，故宜急下。
下利，脉反滑的，应当有所去（攻下积滞），下之后才痊愈，宜用大承气汤。
【注解】下利脉反滑的，是病虚脉实，不相适宜。如果其人形体气息如常，饮食如故，是有应当去除的积滞未去，下之乃愈，宜用大承气汤。
【集注】赵良说：下利是虚证，脉滑是实脉，以下利之虚证，而反见滑实之脉，故应当有所去。
程林说：经云：滑为有宿食，故当下去之，而利自止。
下利已经痊愈，到了年、月、日、时又复发的，是因为病邪未尽的缘故，应当攻下，宜用大承气汤。
【注解】下利痊愈后，到了某年、某月、某日复发其利，这是宿食积病，攻之不尽的缘故。如果其人形体气息不衰，饮食尚强，当攻其未尽，自然不复发其利，宜用大承气汤。
【集注】沈明宗说：这是旧积之邪再次发病。下利痊愈后，到了年、月、日、时复发，是前次下利的邪气，隐伏在肠间，正值脏腑司令的时期，触动旧邪而复发；然而隐伏的根未除，终究不能愈，所以用大承气汤迅速清除它。
下利说胡话（谵语）的，有燥屎，主治方剂是小承气汤。
【注解】下利是里虚证，谵语是里实证，凭什么判断有燥屎呢？如果脉滑数，知道有宿食；其利秽浊粘稠，知道有积热。然而必须脉证如此，始可知其有燥屎，宜下之以小承气汤。由此推断，燥屎又不在大便硬不硬。
【集注】李曰：经云：实则谵语，故知有燥屎宜下。
小承气汤方
大黄（四两） 浓朴（炙，三两） 枳实（炙，大者三枚）
以上三味药，用水四升，煎取一升二合，去渣，分两次温服，得利则止。
下利，脉反弦，发热身汗的，自愈。
【注解】下利，是脾病。弦，是肝脉，脾病不当见弦脉，所以说脉反弦。下利是里病，发热是表证，如果发热身汗，则为表与里和，虽脉弦亦可自愈。
下利，脉沉弦的伴肛门重坠感，脉大的为病未止，脉微弱数的为欲自止，虽有发热也不死。
【注解】沉主里；弦主急；下重，即后重。下利脉沉弦的，故里急后重。滞下之证，发热脉大则邪盛为未已也，脉微弱数者则邪衰，病当自止，虽有发热也不死。由此可知脉大身热者死。
热利伴有肛门重坠感的，主治方剂是白头翁汤。
【注解】这是承接上一条来说明治疗方法。下利脓血，里急后重，积热已深，所以用白头翁汤大苦大寒；寒能胜热，苦能燥湿，湿热去，下重自除矣。
【集注】程林说：热利下重，则热迫于肠胃，非苦不足以坚下焦，非寒不足以除热，故加一“热”字，别以上之寒利。
尤怡说：此证湿热下注，故用白头翁汤，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）
以上四味药，用水七升，煎取二升，去渣，温服一升，不愈更服。
下利，便脓血的，主治方剂是桃花汤。
【注解】初病下利便脓血的，大承气汤或芍药汤攻下。热盛的，白头翁汤清之。若日久滑脱，则当以桃花汤养肠固脱可也。
桃花汤方
赤石脂（一半锉碎，一半筛末，一斤） 干姜（一两） 粳米（一升）
以上三味药，用水七升，煮米令熟，去渣，温服七合，内赤石脂末一方寸匕，每日三次，如果一服愈，余勿服。
The disease condition initially improves, but if purgatives are mistakenly used, it will lead to further deficiency and cold, thereby worsening the vomiting.
The pulse at the Cun Kou (radial artery) is faint (Wei, indicating deficiency of Qi) and rapid (Shu). Faintness indicates a lack of Qi; lack of Qi leads to deficiency of Ying (Nutritive Qi); deficiency of Ying leads to insufficient Blood; insufficient Blood results in cold in the chest.
[Note] The meaning of this clause is incoherent; it must be due to disordered bamboo slips.
The pulse at the Fu Yang (Yangming channel point) is floating (Fu, indicating exterior or deficiency) and choppy (Se, indicating stagnation or blood deficiency). Floating indicates deficiency; deficiency injures the Spleen. When the Spleen is injured, it fails to digest food; food eaten in the morning is vomited in the evening, and food eaten in the evening is vomited in the morning; the undigested food remains unchanged. This is called Wei Fan (Stomach Reversal, characterized by delayed gastric emptying and vomiting of undigested food). If the pulse is tight (Jin) and choppy, the disease is difficult to treat.
[Note] The character "deficiency" (Xu) in "deficiency injures the Spleen" should be "choppy" (Se), which is a transcription error.
[Annotation] In the previous clause, Wei Fan was caused by mistaken purgation, so the pulse was wiry (Xian); in this clause, Wei Fan was not caused by mistaken purgation, so the pulse is floating and choppy. A floating and choppy pulse at Fu Yang: floating is used to assess the Stomach, choppy to assess the Spleen; floating without strength indicates Stomach deficiency, choppy without strength indicates Spleen injury. With Stomach deficiency and Spleen injury, water and grain cannot be digested, hence morning food is vomited in the evening and evening food in the morning; all vomited matter is undigested old food, thus called Wei Fan. If the pulse is tight and choppy, it indicates excess pathogen and deficient righteous Qi. Therefore, the disease is difficult to treat.
[Collected Notes] Xu Bin said: Tightness indicates excess cold, choppyness indicates exhaustion of fluids; righteous Qi cannot overcome the pathogen, hence it is said: difficult to treat.
For patients with Wei Fan and vomiting, Da Ban Xia Tang (Large Pinellia Decoction) is the primary formula.
[Annotation] This follows the previous clause to clarify the treatment. Wei Fan vomiting refers to the vomiting where morning food is vomited in the evening and evening food in the morning. Using Da Ban Xia Tang as the main treatment aims to tonify the Spleen and Stomach and stop vomiting.
Da Ban Xia Tang Formula
Ban Xia (Pinelliae Rhizoma, washed, 2 sheng) Ren Shen (Ginseng Radix et Rhizoma, 3 liang) Bai Mi (White Honey, 1 sheng)
Take the above three ingredients, add 12 dou of water and honey, stir two hundred and forty times, decoct to obtain 1.5 sheng of liquid. Take warm, 1 sheng per dose, divide the remainder into two doses.
Qian Jin Fang states: Da Ban Xia Tang treats Wei Fan where the patient cannot tolerate food intake and vomits immediately after eating.
Wai Tai Mi Yao states: Da Ban Xia Tang treats vomiting and epigastric fullness/stiffness.
[Collected Explanations] Gao Shishi said: Morning food vomited in the evening, undigested food, is called Wei Fan. Wei Fan involves only vomiting, not retching, but vomiting is inseparable from retching, hence "Wei Fan vomiting." Ban Xia aids dryness to digest grain; Ren Shen tonifies Yuan Qi to calm the Stomach; mixing white honey with water and stirring disperses the sweet flavor. Water becomes gentle with honey, and honey becomes light and penetrating with water, thereby calming Wei Fan and curing vomiting.
Li Shengxi said: Vomiting patients generally avoid sweet flavors; why use white honey here? One must understand that this Wei Fan belongs to Spleen deficiency. As the classics state, sweet flavor enters the Spleen, satisfying its preference. Moreover, the sovereign herb is Ban Xia, pungent to stop vomiting; the assistant is Ren Shen, warming Qi and tonifying the Middle Jiao. Thus, Wei Fan stops naturally.
For Wei Fan with vomiting, thirst, and desire to drink water, Fu Ling Ze Xie Tang (Poria and Alisma Decoction) is the primary formula.
[Annotation] Wei Fan vomiting without thirst indicates cold; thirst and desire to drink indicate fluid retention. Therefore, Fu Ling Ze Xie Tang is used to tonify Yang and promote diuresis.
Fu Ling Ze Xie Tang Formula
Fu Ling (Poria, 8 liang) Ze Xie (Alismatis Rhizoma, 4 liang) Gan Cao (Licorice Root, 2 liang) Gui Zhi (Cinnamon Twig, 2 liang) Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 liang) Sheng Jiang (Fresh Ginger, 4 liang)
Take the above six ingredients, add 10 dou of water, decoct to obtain 3 sheng. Add Ze Xie, decoct again to obtain 2.5 sheng. Take warm, 0.8 sheng per dose, three times daily.
Wai Tai Mi Yao states: Fu Ling Ze Xie Tang treats Xiao Ke (Wasting-Thirst), Wei Fan, and absent pulse.
[Collected Explanations] Li said: Vomiting with thirst indicates loss of body fluids and Stomach deficiency-dryness. Drinking water causes fluid retention in the heart/lower chest area. Fu Ling and Ze Xie descend Qi and move fluids; Bai Zhu tonifies the Spleen and generates fluids. This reflects the principle of Wu Ling San (Five-Ingredient Powder with Poria). However, Wei Fan is due to Spleen Qi deficiency and rebellion, so Sheng Jiang is added to scatter rebellion, and Gan Cao harmonizes the Spleen. Wu Ling San uses Gui Zhi for external slight heat. Here, there is no external heat, yet Gui Zhi is used because Gui Zhi is not solely an exterior-releasing drug; it penetrates upper and lower, reaches interior and exterior, and serves as an agent to circulate body fluids, harmonize Yang, and dissipate water.
You Yi said: Fu Ling Ze Xie Tang treats cases where vomiting has not ceased and there is thirst/desire to drink. Since vomiting persists, the pathogen remains; thus, Gui Zhi, Gan Cao, and Sheng Jiang are used to scatter pathogenic Qi, while Fu Ling and Ze Xie eliminate fluid accumulation.
For hiccups/reverse qi (Yue Ni), Ju Pi Zhu Ru Tang (Tangerine Peel and Bamboo Shavings Decoction) is the primary formula.
[Annotation] Yue refers to dry heaves/hiccups. Because there is a sound but no other matter expelled, it is called Yue Ni rather than dry heaves; it belongs to rebellious ascending Qi. Ascending Qi exiting through upper orifices produces sound. Lung deficiency with ascending Qi causes coughing (sound from throat); if obstructed by pathogen, it causes wheezing/fullness without sound. Stomach deficiency with ascending Qi causes Yue (sound from pharynx). If凝 with matter, it causes palpitations/pain without sound. Thus, it is clearly a Qi disorder. Where pathogens gather, righteous Qi is necessarily deficient. Therefore, Ju Pi, Zhu Ru, and Sheng Jiang are used to clear pathogenic Qi, while Ren Shen, Gan Cao, and Da Zao tonify righteous Qi, allowing rebellious Qi to descend smoothly.
Ju Pi Zhu Ru Tang Formula
Ju Pi (Citri Reticulatae Pericarpium, 2 jin) Zhu Ru (Bambusae Caulis in Taenia, 2 sheng) Da Zao (Ziziphi Jujubae Fructus, 30 pieces) Sheng Jiang (Fresh Ginger, 0.5 jin) Gan Cao (Licorice Root, 5 liang) Ren Shen (Ginseng Radix et Rhizoma, 1 liang)
Take the above six ingredients, add 10 dou of water, decoct to obtain 3 sheng. Take warm, 1 sheng per dose, three times daily.
[Collected Explanations] Li said: Yue can belong to Stomach cold or Stomach heat. This Yue Ni is caused by deficiency-heat in the Stomach and rebellious Qi. Thus, Ren Shen, Gan Cao, and Da Zao tonify deficiency; Ju Pi and Sheng Jiang scatter rebellion; Zhu Ru is sweet and cold, soothing rebellious Qi and clearing Stomach heat, serving as the sovereign herb.
You Yi said: Stomach deficiency allows heat to invade, causing Yue Ni. Ju Pi and Sheng Jiang harmonize the Stomach and scatter rebellion; Zhu Ru eliminates heat and stops vomiting/Yue; Ren Shen, Gan Cao, and Da Zao tonify deficiency and stabilize the Middle Jiao.
For dry heaves/Yue with cold extremities, Ju Pi Tang (Tangerine Peel Decoction) is the primary formula.
[Annotation] Dry heaves/Yue implies dry heaves, i.e., Yue. Dong Yuan considered dry heaves mild and Yue severe, recognizing Zhongjing's wording intent. Yue with cold extremities indicates Stomach Yang deficiency, which is the indication for Wu Zhu Yu Tang. If the initial illness presents with both form and Qi being excess, even with cold extremities, it is not comparable to Yang deficiency and Yin excess; rather, it is Qi closure failing to reach the four limbs. Thus, Ju Pi alone is used to unblock Qi, and Sheng Jiang to stop Yue.
[Collected Notes] Cheng Lin said: Dry heaves/Yue means Qi rebels in the chest/diaphragm and does not reach the extremities, causing cold hands/feet. Ju Pi descends rebellious Qi; Sheng Jiang is the holy medicine for vomiting. A small dose harmonizes them. However, dry heaves are not Wei Fan, and cold extremities do not mean absence of Yang; thus, upon ingestion, Qi moves and health returns.
Ju Pi Tang Formula
Ju Pi (Citri Reticulatae Pericarpium, 4 liang) Sheng Jiang (Fresh Ginger, 0.5 jin)
Take the above two ingredients, add 7 sheng of water, decoct to obtain 3 sheng. Take warm, 1 sheng per dose; health returns upon swallowing.
For Yue with abdominal fullness, observe the anterior (urination) and posterior (defecation) orifices. Knowing which part is obstructed, unblocking it will cure the condition.
[Annotation] Yue belongs to deficiency-pathogen. Yue without abdominal fullness indicates righteous Qi deficiency. With heat, Ju Pi Zhu Ru Tang is used; with cold, Wu Zhu Yu Tang is used. Yue with abdominal fullness indicates excess pathogen. One must examine bowel and bladder movements: if defecation is obstructed, purge it; if urination is obstructed, promote diuresis. This will cure the condition.
[Collected Notes] Zhu Gong said: Anterior obstruction (urinary) treated with Zhu Ling Tang; posterior obstruction (fecal) treated with Tiao Wei Cheng Qi Tang.
Zhao Liang said: Abdominal fullness indicates excess; excess causes Qi to rebel upward producing Yue. Thus, one must observe which orifice is obstructed and unblock it; then fullness resolves and Yue stops.
Wei Litong said: Stomach Qi rebels upward, rushing to produce Yue. Treatment requires observing the anterior and posterior orifices to check bowel/bladder regulation. Anterior obstruction indicates water-pathogen rebellion; promote diuresis to cure Yue. Posterior obstruction indicates heat-excess; promote defecation to cure Yue.
When the Qi of the Six Fu organs fails externally, there is cold extremities, upward rushing Qi, and retracted legs; when the Qi of the Five Zang organs fails internally, there is uncontrollable diarrhea; if severe, there is numbness of extremities.
[Annotation] "Qi failure" here does not mean total collapse, but extreme deficiency. The Qi of the Six Fu organs is Yang; Yang deficiency fails to warm the exterior, causing cold and retraction of extremities. Yang deficiency leads to Yin excess rebelling upward, causing vomiting and Yue. The Qi of the Five Zang organs is Yin; Yin deficiency fails to secure the interior, causing uncontrollable diarrhea. Severe diarrhea leads to central collapse and physical decline, causing numbness of extremities. This elucidates the origins of vomiting and diarrhea.
For diarrhea with undigested food, internal cold with external heat, sweating, and cold extremities, Tong Mai Si Ni Tang (Pulse-Restoring Four-Reversal Decoction) is the primary formula.
[Annotation] Diarrhea with undigested food indicates internal cold. External heat, sweating, and cold extremities indicate Yang collapse. Tong Mai Si Ni Tang is used to restore Yang and overcome cold, stopping diarrhea.
Tong Mai Si Ni Tang Formula
Fu Zi (Aconiti Lateralis Radix Praeparata, raw, large piece, 1) Gan Jiang (Zingiberis Rhizoma, 3 liang, 4 liang for strong constitutions) Gan Cao (Licorice Root, prepared, 2 liang)
Take the above three ingredients, add 3 sheng of water, decoct to obtain 1.2 sheng. Remove dregs, divide into two warm doses.
For diarrhea with cold extremities and absent pulse, moxibustion fails to warm; if the pulse does not return and slight panting occurs, death ensues. If Shao Yin (Kidney) pulse is weaker than Fu Yang (Yangming) pulse, it is a favorable sign.
[Note] The phrase "If Shao Yin is weaker than Fu Yang, it is favorable" following "slight panting indicates death" is incoherent; its explanation is detailed in Shang Han Lun · Bian Mai Pian, so it is not repeated here.
[Annotation] Diarrhea with cold extremities and absent pulse represents a syndrome of Yin without Yang. Although Li Zhong Wan or Si Ni Tang might be used, their action may be too slow. Urgent moxibustion below the umbilicus is needed to unblock Yang. If the pulse returns and extremities warm, survival is expected. If the pulse does not return, extremities remain cold, and slight panting occurs, it indicates Yang collapsing upward, leading to death.
[Collected Notes] Cheng Lin said: Diarrhea progressing to cold extremities and absent pulse indicates solitary Yin without Yang. Moxibustion restores Yang. If pulse remains absent and slight panting occurs, righteous Qi collapses upward, leaving solitary Yang without root, leading to death.
For diarrhea accompanied by flatus (Qi Li), promoting diuresis is indicated.
[Annotation] Diarrhea with flatus: initially, Qi is stagnant in the Large Intestine and does not diffuse outward, with water-Qi moving downward together. Promoting diuresis opens the drainage pathways; once Qi circulates, diarrhea stops. In chronic cases, Qi sinks in the Large Intestine and fails to rise; treatment should combine lifting/tonifying with promoting diuresis.
[Collected Notes] You Yi said: Diarrhea with flatus means Qi is lost with the stool, known as Qi Li.
For Qi Li, He Li Le San (Terminalia Powder) is the primary formula.
[Annotation] Qi Li: if the expelled gas is foul-smelling and the stool is thick/sticky, it indicates Qi stagnation and lack of circulation; purging or promoting diuresis may be used. If the gas is odorless and stool non-sticky, it indicates Qi sinking and intestinal sliding; He Li Le San is used to secure the intestine, or Bu Zhong Yi Qi Tang to lift the sinking.
He Li Le San Formula
He Li Le (Terminalia Chebulae Fructus, roasted, 10 pieces)
Grind the single ingredient into powder. Mix with rice gruel and take in one dose.
[Collected Explanations] Li said: Qi Li is diarrhea due to Qi deficiency, sinking, and sliding. He Li Le is astringent and warming, securing the Stomach and intestine. Mixing with rice gruel borrows grain Qi to assist the Stomach. Taking in one dose ensures maximum efficacy.
You Yi said: Qi Li involves simultaneous loss of Qi and stool. He Li Le secures the intestine and regulates Qi; rice gruel calms the Middle and benefits intestines/stomach. Taking in one dose follows the principle of urgent treatment for lower-joint diseases.
If diarrhea presents with a rapid pulse, slight fever, and sweating, recovery is expected. If the pulse is tight, the disease is unresolved.
[Annotation] Rapid pulse in diarrhea indicates internal heat. Slight fever and sweating indicate pathogen decline, hence spontaneous recovery. If the pulse is tight, the exterior pathogen has not declined, so the disease is unresolved.
[Collected Notes] Cheng Lin said: Cold causes diarrhea. Rapid pulse with slight fever indicates resolution of internal cold; sweating indicates harmony of the exterior. With exterior and interior harmonized, recovery is expected. If the pulse becomes tight again, cold pathogen remains, indicating unresolved disease.
For diarrhea with slight fever, thirst, and weak pulse, recovery is expected.
[Annotation] High fever and thirst in diarrhea indicate excess pathogen; weak pulse indicates deficient righteous Qi; recovery is unlikely. Here, slight fever/thirst and weak pulse indicate both pathogen and righteous Qi are declining, hence recovery is expected.
[Collected Notes] Cheng Lin said: High fever/thickness leans toward Yang; no fever/no thirst leans toward Yin; neither recovers easily. Slight fever/thirst indicates Yin-Yang harmony; weak pulse indicates pathogen departure, hence spontaneous recovery.
For diarrhea with a rapid pulse and thirst, recovery is expected. If it does not improve, pus and blood will appear in the stool due to heat.
[Annotation] This continues the previous clause regarding unresolved disease despite declining pathogen/righteous Qi. If it does not improve, the exterior is harmonized, heat subsides, but persistent thirst/rapid pulse indicates lingering internal heat, leading to pus/blood in stool.
[Collected Notes] Wei Litong said: In diarrhea, surplus Yang is auspicious, but excessive heat damages Yin, causing Yang restoration to become excessive.
For diarrhea, if the Cun pulse is unexpectedly floating and rapid, and Chi pulse is inherently choppy, pus and blood will appear in the stool.
[Annotation] This continues the theme of unresolved disease despite apparent harmony. Diarrhea is an interior disease, yet a floating/rapid exterior pulse appears, hence "unexpectedly floating/rapid." However, the inherently choppy Chi pulse indicates heat trapped in the Blood level, leading to pus/blood in stool.
[Collected Notes] Xu Bin said: Diarrhea belongs to cold, pulse should be deep/slow. Unexpectedly floating/rapid indicates Yang excess. Choppy Chi pulse indicates Yang pathogen entering Yin; this also indicates excess heat. Hence, pus/blood in stool is certain.
Cheng Lin said: Floating/rapid Cun pulse indicates heat excess; inherently choppy Chi pulse indicates Blood deficiency. Heat excess combined with Blood deficiency leads to pus/blood in stool.
For diarrhea, if all three pulses (Cun, Guan, Chi) are normal, but pressure on the epigastrium reveals hardness, urgent purging is required using Da Cheng Qi Tang (Major Order the Qi Decoction).
[Annotation] Patients with diarrhea having epigastric hardness usually indicate Xie Xin Tang patterns. However, if all three pulses are normal and forceful, despite diarrhea, aggressive purging is indicated.
[Collected Explanations] Li said: Diarrhea with epigastric hardness indicates excess. If the pulse were weak, purging would be contraindicated. Now, with normal pulses throughout, interior deficiency is ruled out, warranting urgent purging. This is a method of diagnosing based on pulse and symptoms.
Da Cheng Qi Tang Formula (See Jing Bing section)
For diarrhea, if the pulse is slow and slippery, it indicates excess; diarrhea will not cease until purged. Use Da Cheng Qi Tang urgently.
[Annotation] A pulse cannot be both slow and slippery simultaneously. It refers to superficial slowness and deep slipperiness. Superficial slowness indicates exterior harmony; deep slipperiness indicates interior excess. To stop diarrhea caused by interior excess, purging is required; once accumulation is removed, diarrhea stops. Use Da Cheng Qi Tang.
[Collected Notes] You Yi said: Slow pulse indicates cold, but combined with slipperiness, it indicates excess, not cold. Interior accumulation obstructs pulse flow, causing slowness. Diarrhea caused by excess will not stop until excess is removed; thus, urgent purging is indicated.
For diarrhea, if the pulse is unexpectedly slippery, there is likely accumulation to be removed. Purging will cure it. Use Da Cheng Qi Tang.
[Annotation] An unexpectedly slippery pulse in diarrhea indicates a mismatch between deficiency disease and excess pulse. If the patient's constitution and appetite remain normal, it suggests retained accumulation that needs removal. Purging will cure it. Use Da Cheng Qi Tang.
[Collected Notes] Zhao Liang said: Diarrhea is a deficiency syndrome; slippery pulse is an excess pulse. Seeing an excess pulse in a deficiency syndrome indicates something must be removed.
Cheng Lin said: The classics state: slipperiness indicates retained food. Thus, purging is required, and diarrhea will stop.
If diarrhea has healed but recurs at specific years, months, days, or hours, it is because the disease root remains. Purging is indicated using Da Cheng Qi Tang.
[Annotation] Recurrence of diarrhea after healing, at specific time cycles, is due to incomplete removal of retained food/accumulation. If the patient's constitution and appetite remain strong, attacking the remaining accumulation prevents recurrence. Use Da Cheng Qi Tang.
[Collected Notes] Shen Mingzong said: This is the recurrence of old accumulated pathogen. After healing, recurrence at specific times indicates residual pathogen hidden in the intestines, triggered by organ command periods. Since the hidden root remains, complete cure is impossible without removing it; thus, Da Cheng Qi Tang is used to swiftly eliminate it.
For diarrhea with delirium, there is dry fecal impaction. Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is the primary formula.
[Annotation] Diarrhea is an interior deficiency syndrome; delirium is an interior excess syndrome. How to determine dry fecal impaction? Slippery/rapid pulse indicates retained food; foul/sticky stool indicates accumulated heat. Only with such pulse-symptom correspondence can dry fecal impaction be confirmed. Purge with Xiao Cheng Qi Tang. From this, we infer that dry fecal impaction is not defined merely by hard stool.
[Collected Notes] Li said: The classics state: excess causes delirium. Thus, dry fecal impaction warrants purging.
Xiao Cheng Qi Tang Formula
Da Huang (Rhei Radix et Rhizoma, 4 liang) Hou Po (Magnoliae Officinalis Cortex, prepared, 3 liang) Zhi Shi (Immature Bitter Orange, prepared, 3 large pieces)
Take the above three ingredients, add 4 sheng of water, decoct to obtain 1.2 sheng. Remove dregs, divide into two warm doses. Stop when bowel movement occurs.
For diarrhea, if the pulse is unexpectedly wiry, with fever and sweating, recovery is expected.
[Annotation] Diarrhea is a Spleen disease. Wiry pulse is a Liver pulse; Spleen disease should not present with wiry pulse, hence "unexpectedly wiry." Diarrhea is an interior disease; fever is an exterior symptom. Fever with sweating indicates exterior-interior harmony; even with a wiry pulse, recovery is expected.
For diarrhea, a deep-wiry pulse indicates tenesmus; a large pulse indicates the disease has not stopped; a weak-rapid pulse indicates impending cessation. Even with fever, death is not imminent.
[Annotation] Deep indicates interior; wiry indicates urgency. Tenesmus (heavy sensation in rectum). Deep-wiry pulse in diarrhea indicates interior urgency and tenesmus. In dysentery, fever with large pulse indicates excess pathogen and ongoing disease. Weak-rapid pulse indicates declining pathogen and impending cessation; even with fever, death is avoided. From this, we know that large pulse with high fever indicates death.
For heat-diarrhea with tenesmus, Bai Tou Weng Tang (Pulsatilla Decoction) is the primary formula.
[Annotation] This follows the previous clause to clarify treatment. Pus/blood in stool, tenesmus, and deep accumulated heat require Bai Tou Weng Tang, which is bitter and cold. Cold overcomes heat; bitterness dries dampness. Once damp-heat is eliminated, tenesmus resolves.
[Collected Notes] Cheng Lin said: Heat-diarrhea with tenesmus indicates heat forcing the intestines/stomach. Bitterness is needed to firm the Lower Jiao; coldness is needed to remove heat. The addition of "heat" distinguishes it from the previous cold-diarrhea.
You Yi said: This syndrome involves damp-heat pouring downward. Bai Tou Weng Tang is used: bitterness to drain dampness, coldness to overcome heat.
Bai Tou Weng Tang Formula
Bai Tou Weng (Pulsatillae Radix) Huang Lian (Coptidis Rhizoma) Huang Bo (Phellodendri Cortex) Qin Pi (Fraxini Cortex) (each 3 liang)
Take the above four ingredients, add 7 sheng of water, decoct to obtain 2 sheng. Remove dregs. Take warm, 1 sheng per dose. If not cured, take again.
For diarrhea with pus/blood in stool, Tao Hua Tang (Peach Blossom Decoction) is the primary formula.
[Annotation] For acute diarrhea with pus/blood, Da Cheng Qi Tang or Shao Yao Tang may be used to purge. For excess heat, Bai Tou Weng Tang clears it. For chronic cases with sliding/incontinence, Tao Hua Tang nourishes the intestine and secures leakage.
Tao Hua Tang Formula
Chi Shi Zhi (Halloysit Rubra, half crushed, half powdered, 1 jin) Gan Jiang (Zingiberis Rhizoma, 1 liang) Jing Mi (Oryza Sativa, 1 sheng)
Take the above three ingredients, add 7 sheng of water, cook rice until soft. Remove dregs. Take warm, 0.7 sheng per dose. Add 1 cubic inch of Chi Shi Zhi powder. Three times daily. If cured after one dose, do not take the rest.