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。
第三十九条：出现下利（腹泻）、腹部胀满、身体疼痛的症状。应当先温补里虚，然后再解表邪。温补里虚适宜使用四逆汤，解除表邪适宜使用桂枝汤。
注释详见《伤寒论》厥阴病篇。
第四十条：出现下利，寸、关、尺三部脉象都平和，但按压心下部感觉坚硬者，应当紧急攻下。适宜使用大承气汤。
从本条至第四十四条，共有五条，论述的是下利的脉症中，仍有适宜采用攻下法的情况。这一条是从脉象平和而心下部坚硬这一现象推断出来的。大概意思是说，下利不过是由寒或热两种病因引起。如果是上焦有热，导致气息吹嘘奔迫的下利，那么脉象应当在上部表现为沉数脉；如果是中下焦有寒，导致分理不清的下利，那么脉象应当在中、下两部表现为沉迟或沉弦脉。如今三部脉象都平和，那么可知下利并非由寒热引起。再加上按压时心下部坚硬，这显然是因为胃中有积滞，导致胃气运行不畅，从而失去了分别水谷的功能，这是很明显的。所以适宜用大承气汤攻下，使胃气得以流行，而下利自然就会停止。
第四十一条：出现下利，脉象迟缓而滑的，属于实证。下利不会自行停止，应当紧急攻下。适宜使用大承气汤。
这一条是从脉象迟缓而滑推断出来的。“脉”字，应当是指右手关部阳明经的脉象。大概意思是说，患下利而右关脉迟缓，似乎像是胃寒而失去分辨阴阳功能的反应。然而，胃寒导致的下利，会导致津液损伤、气机泄脱，脉象迟缓且兼见涩象，这是常理。现在脉象迟缓却兼见滑象，滑脉是宿食凝聚的诊断指征。滑脉出现在迟缓之中，难道不是由于凝聚导致气机不能正常运行吗？因此知道这是胃实（胃肠实热积滞）。如果胃实的病邪不去除，那么化生机制就不纯正，下利怎么能痊愈呢？所以适宜主用大承气汤来通导闭塞。这两条中的“急”字，恐怕是因为如果拖延，津液会枯竭耗尽，身体将无法承受攻下，多会导致亡阴而死。
第四十二条：出现下利，脉象反而滑的，说明体内有积滞需要排出，通过攻下才能痊愈。适宜使用大承气汤。
这就是上一条所述的初期症状，单独抽取出来论述。大概意思是说，下利时脉象应当涩，现在反而见滑脉，便知道应当有积滞需要去除，即适宜用大承气汤治愈。否则，坐失良机，使滑脉日久且胃气阻滞，就会形成上一条所述的迟滑脉象。
第四十三条：下利已经痊愈，到了特定的年、月、日、时又复发，是因为病邪未除尽的缘故。应当采用攻下法。适宜使用大承气汤。
五行各有休囚旺相的状态，代谢随之发生。年、月、日、时代表天地流转的五行，五脏六腑代表人体内部具备的五行。它们的生扶克制，内外常常相应，这是感通的道理。下利之病，乘时而发于脏腑，如果病邪尽去则痊愈；若病邪未尽，得到运气中子气的制约以抑制其鬼贼之气，也能痊愈。如果遇到所患病邪的时期，再次出现所患病的症状，就知道这不是新病，而是未尽的旧病，得到了流行之鬼气的影响而复发。因此适宜用大承气汤涤荡清除，不要使其滋长蔓延。
第四十四条：出现下利并伴有谵语（胡言乱语）的，是有燥屎内结。用小承气汤主治。
注释参见《伤寒论》厥阴病篇。
第四十五条：出现下利并伴有便脓血的，用桃花汤主治。
桃花汤方：赤石脂（一斤半，锉碎后过一半筛成末），干姜（一两），粳米（一升）。
以上三味药，用水七升，煮米至熟，滤去药渣，取温服七合。将赤石脂方寸匕大小的药末纳入药液中，分三次服用。如果一次服药后痊愈，剩下的药不要服用。
注释详见《伤寒论》少阴病篇，方剂论述一并参见。
第四十六条：热性下利且伴有肛门重坠感的，用白头翁汤主治。
白头翁汤方：白头翁、黄连、黄柏、秦皮（各二两）。
以上四味药，用水七升，煮取二升，滤去药渣，温服一升。如果不愈，继续服用。
注释详见《伤寒论》厥阴病篇，方剂论述一并参见。
第四十七条：下利之后，更加烦躁，按压心下部柔软的，属于虚烦。用栀子豉汤主治。
栀子豉汤方：栀子（十四枚），香豉（四合，用绵布包裹）。
以上两味药，用水四升，先煮栀子取得二升半，加入香豉，再煮取一升半，滤去药渣，分两次服用，温服一次。如果服药后呕吐，则停止服用。（这四个字是后人添加的，详见别处。）
文字见于《伤寒论》厥阴病篇，有注释。
第四十八条：出现下利清谷（泻下未消化的食物）、里寒外热、出汗且四肢厥冷的，用通脉四逆汤主治。
通脉四逆汤方：附子（大者一枚，生用），干姜（三两，体壮者可增至四两），甘草（一两，炙）。
以上三味药，用水三升，煮取一升二合，滤去药渣，分两次温服。
下利而至泻下未消化食物，说明里寒已经很严重。阴寒格拒阳气，所以外表发热；微弱的阳气自行遁逃，所以出汗。里寒而阳气外泄，所以气不相接续而出现厥冷。因此适宜以大热的干姜、附子为主药，辅以守中的甘草，使先温补里虚，则表阳会顺从其类而内附，所以热汗可以消除；卫气得到温暖而向外通达，所以厥冷也可以痊愈。究其根本，胃阳恢复则变化自然神妙，脾气温暖则水谷自然分别，那么下利清谷等症状，应当与其他症状一同解除。命名为通脉四逆汤，是因为脉气运行于中焦的精悍之气，对于里寒外厥的患者，其脉必伏，或呈沉迟脉。温中则精悍之气自起，气行则脉通，所以如此命名。文字见于《伤寒论》厥阴病篇，另有注释。
第四十九条：下利伴有肺痛的，用紫参汤主治。
紫参汤方：紫参（半斤），甘草（三两）。
以上两味药，用水五升，先煮紫参取得二升，加入甘草，再煮取一升半，分三次温服。
下利伴有肺痛，其原因有两个：一是因为下利导致下虚，膈间之气有向下趋行的趋势，肺为气的总司，因而产生悬吊样的疼痛，这是一方面；二是因为下利导致虚热上浮，肺管如同胀痛一样，这是另一方面。紫参味苦气寒，性质通畅功效补益，作为治疗主病的君药。大概是用味苦气寒的特性来坚固其悬吊样的疼痛，用性质通畅功效补益的特性来消除其胀痛。然后辅以甘浮的甘草，是想让它托举药力在上，直接作用于肺中，这是显而易见的。
第五十条：气利（放屁伴随大便失禁）的，用诃黎勒散主治。
诃黎勒散方：诃黎勒（十枚，煨制）。
以上一味药研成散剂，用粥饮调和，一次性顿服。
注释见前三十四条之下。
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.