成 自利者不因攻下而自泄泻也有表邪传里里虚胁热而利者有不应攻下而下之遂利者是皆胁热也又三阳合病皆
作
自利有发表攻里和解之不同（太阳阳明合病为在表故与葛根汤以汗之太阳少阳合病为在半表半里故与黄芩汤以和解之阳
明少阳合病为少阳邪气入里故与承气汤下之）且自利不渴者属太阴藏寒故也下利欲饮水者有热故也故大便溏小便自可与
夫发热后重泄色黄赤者皆为热也自利小便色白少阴病形悉具与夫恶寒脉微自利清谷者皆有寒也夫自利固多可温然肠胃
有积结与下焦客邪又非温剂所能止必也或分利之或攻泄之乃可也（经曰理中者理中焦此利在下焦宜赤石脂禹余粮汤不瘥
当利其小便是也少阴病自利清水色纯青心下必痛口干燥与夫下利三部皆平按之心下硬或脉沉而滑或不欲食而谵语或瘥
后至年月复发此数者皆肠胃有积结而须攻泄者也此则谓之通因通用）又下利虽有表证不可发汗以下利为邪气内攻走津液
而胃虚也经曰下利不可攻表汗出必胀满是也盖三阴自利居多然自利家身凉脉静为顺身热脉大为逆大抵下利脱气最为难
治盖邪盛正虚邪壅正气下脱多下利而死（经曰少阴病自利复烦躁不得卧寐者死直视谵语下利者死下利日十余行脉反实者
死下利手足厥冷无脉灸之不温脉不还者死发热下利至甚厥不止者死此数者皆邪气壅正气下脱故死）要略曰六腑气绝于外
手足寒五脏气绝于内利下不禁噫疾成而后药虽神医莫能为气已脱矣孰能为之六经俱有下利之病表里寒热治各不同学人
宜审
太阳 伤寒（汗）表不解心下有水气干呕发热而咳或渴或利或噎或小便不利少腹满或喘者小青龙汤太阳（和解）与
阳明合病必自下利葛根汤（成 伤寒有合病有并病太阳病不解并于阳明者谓之并病三经俱受邪相合病者谓之合病合病者
邪气甚也太阳阳明合病者与太阳少阳合病阳明少阳合病皆言必自下利者以邪气并于阴则阴实而阳虚邪气并于阳则阳实
而阴虚寒邪气甚客于二阳二阳方外实而不主里则里气虚故必下利与葛根汤以散经中之邪其脉必浮而长也）太阳病外证未
除而数下之遂挟热而利利不止心下痞硬表里不解者桂枝人参汤（张 或云仲景论中太阳病桂枝证医反下之利遂不止与葛
根黄连黄芩汤上条又与桂枝人参汤且二证俱系表不解而下之成利者何故用药有温凉之异夫二证俱系内虚热入协热遂利
但脉证不同故用药有殊耳经言脉促者表未解也喘而汗出者葛根黄连黄芩汤主之夫脉促为阳盛喘而汗出为里热其阳盛里
热与葛根黄连黄芩者理所宜也）太阳与少阳合病自下利者与黄芩汤若呕者黄芩加半夏生姜汤（下利而头疼胸满或口苦咽
干或往来寒热其脉或大而弦是也）
黄芩汤方
黄芩（三两） 芍药 甘草（各二两） 大枣（十二枚擘） 上四味以水一斗煮取三升去滓温服一升日再夜一服（虚
而不实者苦以坚之酸以收之黄芩芍药之苦酸以坚敛肠胃之气弱而不足者甘以补之甘草大枣之甘以补固肠胃之弱）
黄芩加半夏生姜汤
黄芩汤内加半夏半升（洗）生姜三两切
太阳少阳并病而反下之结于胸中成为结胸心下硬下利不止水浆不下其人心烦（生姜泻心汤大黄黄连泻心汤小陷胸汤
张凡合病皆下利各从外证以别焉夫太阳病头项痛腰脊强阳明病目痛鼻干不得卧少阳病胸胁痛耳聋凡遇两经阳证病齐
见而下利者曰合病也虽然但见一证便是不必悉具然仲景不言脉证止言太阳与少阳合病者以前章所论包含以上之证即此
理也况各经之证所见不一难为定论）太阳病桂枝证反下之利遂不止脉促者表未解也喘而汗出者葛根黄芩黄连汤
葛根黄芩黄连汤方
葛根（半斤） 甘草（炙） 黄芩（各二两） 黄连（三两）上四味以水八升先煮葛根减二升纳诸药煮取二升去滓
分温再服（内经曰辛甘发散为阳表未解者散以葛根甘草之甘苦以坚里气弱者坚以黄芩黄连之苦）
太阳病下之脉促不结胸者为欲解脉沉滑者协热利脉浮滑者必下血黄芩汤太阳病二三日不能卧但欲起心下必结脉微
弱者此本有寒分也反下之若利止必作结胸未止者四日复下之此作协热利也黄芩汤伤寒中风反下之利遂不止谷不化腹中
雷鸣心下硬满干呕心烦不安医见其痞复下之痞益甚此非结热以胃中空虚客气上逆故使硬也甘草泻心汤伤寒汗解后胃中
不和心下痞硬干噫食臭胁下有水气腹中雷鸣下利者生姜泻心汤太阳中风下利呕逆表解者乃可攻之其人 汗出发作有
时头痛心下痞硬引胁下痛干呕短气汗出不恶寒者此表解里未和也十枣汤伤寒发热汗出不解心下痞硬呕吐而下利者大柴
胡汤伤寒十三日不解过经谵语者以有热也当以汤下之若小便利者大盒饭硬而反下利脉调和者俗医以丸药下之非其治也
若自下利者脉当微厥今反和者此为内实也调胃承气汤太阳病二日反躁反熨其背而大汗出火热入胃水竭躁烦必发谵语十
余日振栗自下利者为欲解也伤寒医下之续得下利清谷不止身痛者急当救里四逆汤身痛清便自调者急当救表桂枝汤（成
伤寒下之续得下利清谷不止身痛急当救里以里气不足必先救之急与四逆汤得清便自调知里气已和然后急与桂枝汤以救
表身疼者表邪也内经曰病发而不足标而本之先治其标后治其本此以寒为本也）
四逆汤方
甘草（炙二两） 干姜（一两半） 附子（一枚去皮破八片一用附子去皮脐先将盐水姜汁各半盏用砂罐煮七沸后入
甘草黄连各半两再加童便半盏再煮七沸住火良久捞起入瓷器盛贮受地气一昼夜取出晒干以备后用庶无毒害顶圆修正一
两一枚者佳）上三味 咀以水三升煮取一升二合去滓分温再服强壮人可用大附子一枚干姜三两
成 四肢者诸阳之本阳气不足阴寒加之阳气不相顺接是致手足不温而成四逆此汤申发阳气走散阴寒温经暖肌故
以
四逆名也内经曰寒淫于内治以甘热却阴扶阳必以甘为主是以甘草为君内经曰寒淫所胜平以辛热逐寒正气必先辛热是以
干姜为臣内经曰辛以润之开发腠理致津液通气也暖肌温经必凭大热是以附子为使此奇制之大剂也四逆属少阴少阴者肾
也肾肝位远非大剂不能达内经曰远而奇偶制大其服此之谓也
伤寒服汤药下利不止心下痞硬服泻心已复以他药下之利不止治以理中利益甚理中者理中焦此利在下焦赤石脂禹余
粮汤复利不止当利小便（或用猪苓汤）
赤石脂禹余粮汤方
赤石脂（一斤碎） 禹余粮（一斤碎）以上二味以水六升煮取二升去滓分三服
伤寒十三日不解胸胁满而呕日晡潮热已而微利此本柴胡证下之不利今反利者误以丸药下之也潮热者实也先宜柴胡
以解外后以柴胡加芒硝太阳病过经十余日心下温温欲吐胸中痛大便反溏腹微满郁郁微烦先时自极吐下者调胃承气汤
阳明 病潮热大便溏小便尚可胸胁满者小柴胡汤病患无表里证发热七八日虽脉浮数者可下下之脉数不解而下利不
止必便脓血也（黄芩汤柏皮汤）阳明少阳合病必下利其脉不负者顺也负者失也互相克贼名为负也脉滑而数者有宿食也当
下之宜大承气汤（成 阳明土少阳木二经合病气不相和则必下利少阳脉不胜阳明不负是不相克为顺也若少阳脉胜阳明脉
负者是鬼贼相克为正气失也脉经曰脉滑者为病食也又曰滑数则胃气实下利者脉当微厥今脉滑数知胃有宿食与大承气汤
以下除之）脏结如结胸状饮食如故时时下利寸脉浮关脉小细沉紧舌上白苔滑者难治
太阴 太阴为病腹满而吐食不下自利益甚时腹自痛若下之必胸下结硬自利不渴者属太阴以其脏有寒故也当温之宜
服四逆辈（张 经言辈字者谓药性同类惟轻重优劣不同耳凡太阴自利不渴师言有用理中而愈者甚则理中加附子而获安者
凡言辈者盖如此夫四逆汤甘辛相合乃大热之剂苟轻用之恐有过度之失所以仲景不为定拟也莫若以理中循循而用之至为
平稳如不得已者四逆方可为用也）太阴为病脉弱其人续自便利设当行芍药大黄者宜减之以其人胃气弱易动故也（成 腹
满痛者太阴病也脉弱其人续自便利则邪虽在里未成大实欲用大黄芍药攻除满痛者宜少与之以胃气尚弱易于动利也）伤寒
脉浮而缓手足自温者系在太阴当发身黄若小便自利者不发黄至七八日虽暴烦下利日十余行必自止以脾家实腐秽当去故
也（平胃散加穿山甲）
少阴 病欲吐不吐但欲寐五六日自利而渴者属少阴也虚故引水自救若小便色白者少阴病形悉具小便白者以下焦虚
有寒不能制水故令色白也（欲吐不吐心烦者表邪传里也若腹满痛则属太阴此但欲寐则知属少阴五六日邪传少阴之时也自
利不渴者寒在中焦属太阴此自利而渴寒在下焦属少阴按寒在下焦之说不通未闻寒在下焦而渴者小便色白下焦虚寒可知
惟其虚故藉外水以自救非热而作渴也故活人云四逆汤主之若小便不白而黄赤则不在此例故厥阴篇又曰下利欲饮水者以
有热故也白头翁汤主之）少阴病下利咽痛胸满心烦者猪肤汤
猪肤汤方
猪肤（一斤）上一味以水一斗煮取五升去滓加白蜜一升白粉五合熬香和之温分六服（猪水畜也其气先入肾少阴客热
是以猪肤解之加白蜜以润躁除烦白粉以益气断利）
少阴病四逆或泄利下重者四逆散（方见前条）少阴病下利六七日咳而呕渴心烦不得眠者猪苓汤（方见渴）少阴病自
利清水色纯青心下必痛口干燥者急下之宜大承气汤
孙 窦大郎患伤寒经十余日口燥舌干而渴心中疼自利清水众医皆知守但调理耳汗下皆所不敢窦氏亲故相谓曰伤
寒
邪气害人性命甚速安可以不决之疾投不明之医乎召孙至曰即日不可下明日正当下投小承气汤遂大便通得睡明日平复众
皆曰此证缘何下之而愈孙曰不深于书徒知有书耳不知书之奥也口燥舌干而渴岂非少阴证乎少阴证固不可下岂不知少阴
一证自利清水心下痛者下之而愈仲景之书明有是说也众皆钦服
少阴病下利恶寒而蜷手足温者可治四逆汤少阴二三日至四五日腹痛小便不利下利不止便脓血者桃花汤主之（详腹
痛）
桃花汤方
赤石脂（一斤一半全用一半节末） 干姜（一两） 粳米（一升）上三味以水七升煮米令熟去滓温服七合纳赤石脂
末方寸匕日三服若一服愈余勿服（涩可去脱赤石脂之涩以固肠胃辛以散之干姜之辛以散里寒粳米之甘以补正气）
少阴病二三日至四五日腹痛小便不利四肢沉重疼痛自下利者此为有水气其人或咳或小便利或下利或呕者真武汤主
之（详腹痛）
真武汤方
茯苓（三两） 生姜（切） 芍药（各三两） 白术（二两） 附子（一枚炮去皮破八片）上五味以水八升煮取三
升去滓温服七合日三服（脾恶湿甘先入脾茯苓白术之甘以益脾逐水寒淫所胜平以辛热湿淫所胜佐以酸平附子芍药生姜之
酸辛以温经散湿）
加减法 若咳者加五味子半升细辛干姜各一两（气逆咳者五味子之酸以收逆气水寒相搏则咳细辛干姜之辛以散水
寒）若小便利者去茯苓（小便利无伏水故去茯苓）若下利去芍药加干姜二两（芍药之酸泄气干姜之辛散寒）若呕者去附
子加生姜足前成半斤（气逆则呕附子补气生姜散气千金曰呕家多服生姜此为呕家圣药）
成 真武北方水神也水气在心下外带表而属阳必应发散故治以真武汤青龙汤主太阳病真武汤主少阴病少阴肾水
也
此汤可以和之脾恶湿腹有水气则脾不治脾欲缓急食甘以缓之渗水缓脾以甘为主故以茯苓甘平为君白术甘温为臣内经曰
湿淫所胜佐以酸辛除湿正气是用芍药酸寒生姜辛湿为佐也内经曰寒淫所胜平以辛热温经散湿是以附子辛热为使也水气
内渍散行不一故有加减之方焉咳者水寒射肺也肺气逆者以酸收之五味子酸而收也肺恶寒以辛润之细辛干姜辛而润也若
小便利者去茯苓茯苓专渗泄也小便不利者去芍药以酸涩也加干姜以散寒也气上逆则呕附子补气故去之生姜散气故加之
则气顺呕（止矣）少阴病下利清谷里寒外热手足厥逆脉微欲绝身反不恶寒其人面赤色或腹痛或干呕或咽痛或利止脉不出
者通脉四逆汤主之
通脉四逆汤方（此方与四逆汤同但此倍干姜耳）
甘草（二两炙） 附子（大者一枚生用去皮破八片） 干姜（三两强者可用四两）上三味以水三升煮取一升二合去
滓分温再服其脉即出者愈面色赤者加葱九茎（葱味辛以通阳气）腹中痛者去葱加芍药二两（芍药之酸通寒利腹中痛为气
不通也）呕者加生姜二两（辛以散之呕为气不散也）咽痛者去芍药加桔梗一两（咽中如结加桔梗则能散之）利止脉不出
者去桔梗加人参二两（利止脉不出者亡血也加人参以补之经曰脉微而利亡血也四逆加人参主之脉病皆与方相应者乃可服
之）
少阴病下利白通汤主之（少阴主水少阴客寒不能制水故自利也白通汤温里散寒）少阴病下利脉微者与白通汤利不止
厥逆无脉干呕烦者白通加猪胆汁汤主之服汤后脉暴出者死微续者生（少阴病下利脉微为寒极阴胜与白通汤复阳散寒服汤
利不止厥逆无脉干呕烦者寒气太甚内为格拒阳气逆乱也与白通汤加猪胆汁汤以和之内经曰逆而从之从而逆之又曰逆者
正治从者反治此之谓也服汤脉暴出者正气因会泄而脱也故死脉微续者阳气渐复也故生）
白通汤方
成无己注：自利，是指不因攻下治疗而自行发生的泄泻。有的情况是表邪传入体内，导致里虚、胁部有热而引起下利；有的情况是不应当使用攻下法却误用了攻下法，从而导致下利。这些都属于胁热的范畴。另外，三阳合病都会出现自利的症状，但治疗方法有发汗解表、攻下里实、和解少阳的不同。（太阳与阳明合病，病邪在表，所以用葛根汤通过发汗来治疗；太阳与少阳合病，病邪在半表半里，所以用黄芩汤进行和解；阳明与少阳合病，是少阳邪气入里，所以用承气汤攻下。）而且，自利且不口渴的，属于太阴病，是因为脏腑有寒的缘故。下利且想喝水的，是因为有热的缘故。所以，大便稀溏、小便正常，或者发热、肛门重坠感、排泄物颜色黄赤的，都属于热证。自利且小便颜色清白，具备少阴病的典型症状，以及恶寒、脉微细、下利完谷不化的，都属于寒证。虽然自利多可用温法治疗，但如果肠胃有积滞结聚，或者下焦有外来邪气，就不是温补剂所能止住的，必须采用分利小便或攻下泄热的方法才能治愈。（《伤寒论》说：理中汤是调理中焦的，这种下利在下焦，应该用赤石脂禹余粮汤，如果不好转，应当通利小便。少阴病自利清水，颜色纯青，心下必定疼痛，口干燥；或者下利三部脉象都平和，但按压心下部感觉硬满，或者脉沉而滑，或者不想吃东西且说胡话，或者病愈后过了年月又复发，这几种情况都是肠胃有积滞结聚，需要攻下泄热。这就叫做“通因通用”，即用通利的方法治疗通利的病症。）另外，下利即使有表证，也不可发汗，因为下利是邪气内攻，耗伤津液，导致胃气虚弱。经书说：下利不可攻表，发汗会导致腹胀满。大概三阴经自利的情况居多，但是自利患者身体凉爽、脉象静缓的是顺证，身体发热、脉象洪大的是逆证。大致来说，下利导致元气脱失是最难治疗的，因为邪气盛而正气虚，邪气壅滞，正气下脱，多因下利而死。（经书说：少阴病自利，又烦躁不得卧寐的，死；眼睛直视、说胡话且下利的，死；下利一天十多次，脉象反而实的，死；下利手足厥冷、无脉，艾灸后不回暖、脉不还复的，死；发热下利非常严重，四肢厥冷不止的，死。这几种情况都是邪气壅盛，正气下脱，所以死亡。）《金匮要略》说：六腑之气绝于外，表现为手足寒冷；五脏之气绝于内，表现为下利不禁。疾病形成后才用药，即使是神医也无能为力，因为气已经脱失了，谁能救治呢？六经都有下利的病证，表里寒热的治法各不相同，学习的人应当仔细审察。
太阳病 伤寒（发汗）：表证未解，心下有停水饮，干呕、发热且咳嗽，或者口渴，或者下利，或者噎塞，或者小便不利、小腹胀满，或者喘息的，用小青龙汤。太阳病（和解）与阳明合病，必然自下利，用葛根汤。（成无己注：伤寒有合病和并病。太阳病不解，并入阳明，称为并病；三经同时受邪，相互结合发病，称为合病。合病邪气很盛。太阳阳明合病，以及太阳少阳合病、阳明少阳合病，都说必然自下利，是因为邪气并入阴经，则阴实而阳虚；邪气并入阳经，则阳实而阴虚。寒邪气很盛，客居于二阳经，二阳经外部充实而不主里，则内部气虚，所以必然下利。用葛根汤以疏散经络中的邪气，其脉象必然浮而长。）太阳病，外部证候未除，却多次攻下，于是挟带热邪而下利，下利不止，心下痞塞坚硬，表里证都不解除的，用桂枝人参汤。（张隐庵注：有人说仲景论述中，太阳病桂枝证，医生反而攻下，下利不止，用葛根黄连黄芩汤；上一条又说用桂枝人参汤。既然两个证候都是表证未解而误下导致下利，为什么用药有温凉的区别？这两个证候都是内部虚弱，热邪内入，协热下利，只是脉证不同，所以用药有差异。经书说：脉促者，表未解；喘息且出汗者，用葛根黄连黄芩汤主治。脉促为阳气盛，喘息且出汗为里热，阳气盛且里热，用葛根黄连黄芩汤是理所当然的。）太阳与少阳合病，自下利，用黄芩汤。如果呕吐的，用黄芩加半夏生姜汤。（下利伴有头痛、胸满，或者口苦咽干，或者往来寒热，脉象或大或弦的情况。）
黄芩汤方
黄芩（三两） 芍药 甘草（各二两） 大枣（十二枚，掰开） 以上四味，用水一斗，煮取三升，去渣，温服一升，每天两次，晚上一次服用。（对于虚弱而不坚实的体质，用苦味药使其坚固，用酸味药使其收敛。黄芩、芍药的苦酸之性，可以坚固收敛肠胃之气。对于虚弱不足的体质，用甘味药补益。甘草、大枣的甘味，可以补益巩固肠胃的虚弱。）
黄芩加半夏生姜汤
在黄芩汤内加入半夏半升（洗净）、生姜三两（切片）。
太阳与少阳并病，反而攻下，邪气结于胸中，成为结胸证，心下硬满，下利不止，水浆不能入口，心中烦乱。（可用生姜泻心汤、大黄黄连泻心汤、小陷胸汤。张隐庵注：凡是合病都会下利，各自根据外部证候来辨别。太阳病头项痛、腰脊强直；阳明病目痛、鼻干、不得卧；少阳病胸胁痛、耳聋。凡是遇到两经阳证同时出现而下利的，叫作合病。虽然只要见到一个证候就可以诊断，不必全部具备。但仲景不说脉证，只说太阳与少阳合病，是因为前一章所论述的内容包含了以上的证候，就是这个道理。况且各经的证候表现不一，难以定为定论。）
太阳病桂枝证，反而攻下，下利不止，脉促者，表证未解；喘息且出汗者，用葛根黄芩黄连汤。
葛根黄芩黄连汤方
葛根（半斤） 甘草（炙） 黄芩（各二两） 黄连（三两） 以上四味，用水八升，先煮葛根，减少二升水，再加入其他药物，煮取二升，去渣，分两次温服。（《内经》说：辛甘发散为阳。表证未解，用葛根、甘草的甘味发散；里气虚弱，用黄芩、黄连的苦味使其坚固。）
太阳病，攻下后脉促，不结胸的，是病欲解的表现；脉沉滑的，是协热利；脉浮滑的，必然下血。用黄芩汤。
太阳病，二三天不能卧，只想起来，心下必定痞结，脉微弱者，这是原本就有寒湿之分，反而攻下。如果下利停止，必然变成结胸；如果下利不止，过四天再次攻下，这会变成协热利。用黄芩汤。
伤寒中风，反而攻下，下利不止，食物不消化，肠中雷鸣，心下痞硬满，干呕，心烦不安。医生见其痞满，再次攻下，痞满更加严重。这不是结热，而是因为胃中空虚，客气上逆，所以使心下硬满。用甘草泻心汤。
伤寒汗解后，胃中不和，心下痞硬，干噫食臭（打嗝有食物腐臭味），胁下有停水饮，腹中雷鸣，下利的，用生姜泻心汤。
太阳中风，下利，呕吐逆气，表证已解的，才可以攻里。其人头部出汗，发作有时，头痛，心下痞硬，牵引胁下疼痛，干呕，短气，出汗但不恶寒的，这是表解里未和，用十枣汤。
伤寒发热，出汗后病不解，心下痞硬，呕吐且下利的，用大柴胡汤。
伤寒十三日未解，经过传变，说胡话的，是因为有热，应当用汤药攻下。如果小便通畅的，大便应当硬，反而下利，脉象调和的，俗医误用丸药攻下，这不是正确的治法。如果是自然下利的，脉应当微细，现在反而调和，这是内部实证，用调胃承气汤。
太阳病，第二天反而烦躁，反用火熨背部导致大汗出，火热入胃，津液枯竭，躁扰烦闷，必然发说胡话。十余日后，身体振栗，自下利的，是病欲解的表现。
伤寒，医生攻下后，接着出现下利完谷不化，不止，身体疼痛的，急当救里，用四逆汤。身体疼痛，大小便正常的，急当救表，用桂枝汤。（成无己注：伤寒攻下后，接着出现下利完谷不化，不止，身体疼痛，急当救里。因为里气不足，必须先救里。急予四逆汤，待大小便正常，知道里气已调和，然后急予桂枝汤以救表。身疼是表邪。《内经》说：病发而正气不足，标为本之，先治其标，后治其本。这里以寒为本。）
四逆汤方
甘草（炙二两） 干姜（一两半） 附子（一枚，去皮，破成八片。有一种用法是用附子，去皮脐，先将盐水、姜汁各半盏，用砂罐煮七沸，后入甘草、黄连各半两，再加童便半盏，再煮七沸，停火良久，捞起放入瓷器中储存，接受地气一昼夜，取出晒干，以备后用，这样就没有毒害了。最好选用顶圆修正、一两一枚的附子。）以上三味，捣碎，用水三升，煮取一升二合，去渣，分两次温服。强壮的人可以用大附子一枚，干姜三两。
成无己注：四肢是诸阳之本，阳气不足，阴寒加之，阳气不能顺接，导致手足不温而成四逆。此汤宣发阳气，走散阴寒，温经暖肌，所以名叫四逆。《内经》说：寒淫于内，治以甘热，驱除阴寒，扶助阳气，必须以甘味为主，所以用甘草为君药。《内经》说：寒淫所胜，平以辛热，驱逐寒邪，正气必先辛热，所以用干姜为臣药。《内经》说：辛以润之，开发腠理，致津液，通气也。暖肌温经，必须凭借大热之药，所以用附子为使药。这是奇制的大剂。四逆汤属于少阴病，少阴即肾。肝肾位置深远，非大剂不能到达。《内经》说：远而奇偶，制大其服，说的就是这种情况。
伤寒服用汤药后，下利不止，心下痞硬，服用泻心汤后，又以其他药攻下，下利不止。治疗用理中汤，下利更甚。理中汤是调理中焦的，这种下利在下焦，应用赤石脂禹余粮汤。如果再下利不止，应当通利小便（或用猪苓汤）。
赤石脂禹余粮汤方
赤石脂（一斤，捣碎） 禹余粮（一斤，捣碎） 以上两味，用水六升，煮取二升，去渣，分三次服用。
伤寒十三日未解，胸胁满闷且呕吐，傍晚潮热，随后轻微下利。这本是柴胡证，误用攻下法导致不利，现在反而下利，是误用丸药攻下的结果。潮热是实证。先用柴胡汤以解外，后用柴胡加芒硝汤。
太阳病，经过十余日，心下温温欲吐，胸中痛，大便反而稀溏，腹部微满，郁郁微烦。先前曾极度催吐或攻下的，用调胃承气汤。
病患没有表里证，发热七八天，虽然脉浮数，可以攻下。攻下后脉数不解，且下利不止，必然便脓血。（可用黄芩汤、柏皮汤。）
阳明与少阳合病，必然下利。脉象不负者为顺证，负者为失证。互相克贼，名为负。脉滑而数的，有宿食，应当攻下，宜用大承气汤。（成无己注：阳明属土，少阳属木，二经合病，气不相和则必下利。少阳脉不胜阳明，不负，是不相克，为顺证。若少阳脉胜阳明脉，负，是鬼贼相克，为正气失。《脉经》说：脉滑者为病食。又说：滑数则胃气实。下利者脉应当微细，现在脉滑数，知道胃有宿食，与大承气汤以下除之。）
脏结，症状像结胸，饮食如故，时时下利，寸脉浮，关脉小细沉紧，舌上白苔滑的，难治。
太阴病：太阴为病，腹满而吐，食不下，自利益甚，时腹自痛。如果攻下，必然胸下结硬。自利不渴的，属于太阴，因为脏腑有寒，所以应当温之，宜服用四逆辈。（张隐庵注：经书中说“辈”字，意思是药性同类，只有轻重优劣不同。凡是太阴自利不渴，老师说有用理中汤痊愈的，严重的用理中汤加附子而获安的。凡说“辈”的，大概就是这样。四逆汤甘辛相合，乃是大热之剂，如果轻率使用，恐怕有过度的失误。所以仲景不定为定拟。不如以理中汤循序渐进地使用，最为平稳。如果不得已，四逆方可用。）太阴为病，脉弱，其人继续自行便利，假设应当使用芍药、大黄的，宜减量，因为其人胃气弱，容易动利。（成无己注：腹满痛是太阴病。脉弱，其人继续自行便利，则邪虽在里，未成大实。想要用大黄、芍药攻除满痛的，宜少量给予，因为胃气尚弱，易于引起下利。）伤寒，脉浮而缓，手足自温的，系在太阴，应当发身黄。如果小便自利的，不发黄。到七八天，虽然突然烦躁，下利一天十多次，必然自止，因为脾家实，腐秽当去。（可用平胃散加穿山甲。）
少阴病：想吐又吐不出来，只想睡觉，五六天后自利且口渴的，属于少阴。因为虚，所以引水自救。如果小便颜色白的，少阴病的形证全部具备。小便白，是因为下焦虚寒，不能制约水液，所以令颜色白。（想吐又吐不出来，心烦，是表邪传里。如果腹满痛，则属太阴。这里但欲寐，则知属少阴。五六日是邪传少阴的时候。自利不渴，寒在中焦，属太阴。这里自利而渴，寒在下焦，属少阴。按寒在下焦的说法不通，没听说过寒在下焦而渴的。小便色白，可知下焦虚寒。正因为虚，所以借外水以自救，并非热而作渴。所以《活人书》说用四逆汤主治。如果小便不白而黄赤，则不在此例，所以厥阴篇又说：下利想喝水的，因为有热，用白头翁汤主治。）
猪肤汤方
猪肤（一斤） 以上一味，用水一斗，煮取五升，去渣，加白蜜一升，白粉五合，熬香，混合均匀，温分六次服用。（猪是水畜，其气先入肾。少阴客热，所以用猪肤解之。加白蜜以润燥除烦，加白粉以益气断利。）
少阴病，下利六七天，咳嗽，呕吐，口渴，心烦，不得眠的，用猪苓汤（方见渴）。
少阴病，自利清水，颜色纯青，心下必定疼痛，口干燥的，急下之，宜用大承气汤。
孙思邈医案：窦大郎患伤寒，经过十余日，口燥舌干而渴，心中疼痛，自利清水。众医都知道保守调理，不敢用汗法和下法。窦氏亲戚朋友互相说：伤寒邪气害人性命很快，怎么能不把确定的疾病交给不明智的医生呢？召请孙思邈来。孙思邈说：当日不可下，明日正当下。投以小承气汤，于是大便通，得以睡眠。第二天平复。众人都说：这个证候为什么下之而愈？孙思邈说：不深究书籍，只知道书本表面，不知道书的奥妙。口燥舌干而渴，难道不是少阴证吗？少阴证固然不可下，难道不知道少阴一证，自利清水，心下痛的，下之而愈吗？仲景的书明明白白有这样的说法。众人都钦佩信服。
少阴病，二三日到四五日，腹痛，小便不利，下利不止，便脓血的，用桃花汤主治（详见腹痛）。
桃花汤方
赤石脂（一斤，一半全用，一半研末） 干姜（一两） 粳米（一升） 以上三味，用水七升，煮米令熟，去渣，温服七合，纳入赤石脂末一方寸匕，每天三次服用。如果一服就好了，剩下的不要服。（涩可去脱，赤石脂的涩性可以固护肠胃；辛以散之，干姜的辛性可以散里寒；粳米的甘性可以补正气。）
少阴病，二三日到四五日，腹痛，小便不利，四肢沉重疼痛，自下利的，这是有水气。其人或者咳，或者小便自利，或者下利，或者呕的，用真武汤主治（详见腹痛）。
真武汤方
茯苓（三两） 生姜（切片） 芍药（各三两） 白术（二两） 附子（一枚，炮，去皮，破成八片） 以上五味，用水八升，煮取三升，去渣，温服七合，每天三次服用。（脾恶湿，甘先入脾。茯苓、白术的甘味可以益脾逐水。寒淫所胜，平以辛热。湿淫所胜，佐以酸平。附子、芍药、生姜的酸辛之性，可以温经散湿。）
加减法：如果咳的，加五味子半升、细辛、干姜各一两（气逆咳者，五味子的酸味以收敛逆气；水寒相搏则咳，细辛、干姜的辛味以散水寒）。如果小便自利的，去茯苓（小便自利，无伏水，所以去茯苓）。如果下利的，去芍药，加干姜二两（芍药的酸泄气，干姜的辛散寒）。如果呕的，去附子，加生姜足前成半斤（气逆则呕，附子补气，生姜散气。《千金方》说：呕家多服生姜，此为呕家圣药）。
成无己注：真武是北方水神。水气在心下，外带表而属阳，必然应发散，所以治以真武汤。青龙汤主太阳病，真武汤主少阴病。少阴肾水也。此汤可以和之。脾恶湿，腹有水气则脾不治。脾欲缓，急食甘以缓之。渗水缓脾，以甘为主，所以用茯苓甘平为君，白术甘温为臣。《内经》说：湿淫所胜，佐以酸辛。除湿正气，是用芍药酸寒、生姜辛湿为佐。《内经》说：寒淫所胜，平以辛热。温经散湿，是以附子辛热为使。水气内渍，散行不一，故有加减之方焉。咳者，水寒射肺也。肺气逆者，以酸收之，五味子酸而收也。肺恶寒，以辛润之，细辛、干姜辛而润也。若小便自利的，去茯苓，茯苓专渗泄也。小便不利的，去芍药，以酸涩也。加干姜以散寒也。气上逆则呕，附子补气，故去之；生姜散气，故加之，则气顺呕止矣。
少阴病，下利清谷，里寒外热，手足厥逆，脉微欲绝，身反不恶寒，其人面色赤，或者腹痛，或者干呕，或者咽痛，或者利止脉不出者，用通脉四逆汤主治。
通脉四逆汤方（此方与四逆汤相同，只是此方倍用干姜罢了）
甘草（二两，炙） 附子（大者一枚，生用，去皮，破成八片） 干姜（三两，强者可用四两） 以上三味，用水三升，煮取一升二合，去渣，分两次温服。其脉即出的，病愈。面色赤的，加葱九茎（葱味辛，以通阳气）。腹中痛的，去葱，加芍药二两（芍药的酸味，通寒利，腹中痛为气不通也）。呕的，加生姜二两（辛以散之，呕为气不散也）。咽痛的，去芍药，加桔梗一两（咽中如结，加桔梗则能散之）。利止脉不出者，去桔梗，加人参二两（利止脉不出者，亡血也。加人参以补之。经书说：脉微而利，亡血也。四逆加人参主之。脉病皆与方相应者，乃可服之）。
少阴病，下利，用白通汤主治（少阴主水，少阴客寒，不能制水，故自利也。白通汤温里散寒）。
少阴病，下利，脉微的，与白通汤。如果利不止，厥逆无脉，干呕，心烦的，用白通加猪胆汁汤主治。服药后脉暴出的，死；脉微续的，生。（少阴病下利，脉微，为寒极阴胜，与白通汤复阳散寒。服药后利不止，厥逆无脉，干呕，心烦的，是寒气太甚，内为格拒，阳气逆乱。与白通汤加猪胆汁汤以和之。《内经》说：逆而从之，从而逆之。又说：逆者正治，从者反治，说的就是这种情况。服药后脉暴出的，是正气因会泄而脱，故死。脉微续的，是阳气渐复，故生。）
白通汤方
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