【纲】仲景曰。太阳与阳明合病者。必自下利。葛根汤主之。太阳与少阳合病。自下利者。与
黄芩汤。若呕者。黄芩加半夏生姜汤主之。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。
【目】成无己曰。三者皆为合病下利。一者发表。一者攻里。一者和解。所以不同者。盖以六经
言。太阳阳明为表。少阳太阴为半表里。少阴厥阴为里。今太阳阳明合病。为在表者也。虽曰下利。
必发散经中邪气而后已。故以葛根汤汗之。太阳少阳合病。为半表里。虽曰下利。必和解表里之
邪而后已。故以黄芩汤散之。阳明与少阳合病。为少阳邪气入腑者也。虽曰下利。必逐去胃中之实
而后已。故以承气汤下之。是三者所以有异也。杂病自利。多责为虚。伤寒下利。有由协热者。表
邪传里。里虚协热。则不应下。而便攻之。内虚协热遂利。皆是协热而利之故也。
下利家。何以明其寒热耶。自利不渴。属太阴。以其脏寒故也。下利欲饮水者。以有热也。故
大便溏。小便自可者。此为有热。自利。小便色白者。少阴病形症悉具。此为有寒。恶寒脉微。自
利清谷。此为有寒。热后重泄。色黄赤。此为有热。皆可理其寒热也。凡腹中痛转气。下趋少腹者。
此欲自利也。自利家。身凉脉小为顺。身热脉大为逆。少阴病。脉紧下利。脉暴微。手足反温。
脉紧反去者。此为欲解。下利脉大者为未止。脉微弱数者为欲自止。虽发热不死。是知下利脉大为逆。
脉小为顺也。自利宜若可温。理中白通诸四逆辈。皆温脏止利之剂。其肠胃有积结。与下焦客邪。
皆温剂不能止之。必
攻泄之。或分利之。而后已。经曰。理中者。理中焦。此利在下焦。宜赤石脂禹余粮汤。复不止。
当利小便。是利在下焦而聚利者也。少阴病自利清水。色纯青。心下必痛。口干燥。与下利三部皆
平。按之心下硬或脉沉而滑。或不欲食而谵语。或瘥后至年月日复发。此数者。皆肠有积结而须攻
泄者也。内经注曰。大热内结。注泄不止。热宜寒疗。伏结须除。以寒下之。结散利止。大热凝内。
久利泄溏。愈而复发。绵历岁年。以热下之。寒去利止。谓之通因通用。
喻昌曰。下利不下利。可以辨主风主寒之不同。他条。太阳阳明合病不下利但呕者。葛根加半
夏汤主之。盖主风者。风为阳。风性上行。故合阳明胃中之水饮而上逆。此条主寒。寒为阴。阴性
下行。故合阳明胃中之水谷而下奔。然上逆则必加半夏入葛根汤。涤饮止呕。若下利。则但用葛根
以解两经之邪。不治而利自止。太阳阳明合病下利。表症为多。阳明少阳合病下利。里症为多。太阳少阳合病下利。半
表半里
之症为多。故用黄芩甘草芍药大枣为和法。
按太阳阳明合病。阳明少阳合病。俱半兼阳明。所以胃
中之水谷不安而必自下利。其不下利者。亦必水饮上越而呕。与少阳一经之症干呕者大不同。然或
利或呕。胃中之真气与津液俱伤。急须散邪。所以安其胃。更虑少阳胜而阳明负。即当急下救阳明。
其取用大承气汤正迅扫外邪。而承领元气之义也。设稍牵泥。则脉之滑数。必变为迟软。下之无
及矣。
魏荔彤曰。太阳阳明有合病。俱属二经之表。同感外邪。然又有太阳少阳二经合病。则三阳首
尾。同感阳明。岂能绝类离群。独不病乎。是太少二阳之合病。即三阳俱感之合病矣。或问三阳同
病为温症。子何混入伤寒合病内。不知温症之三阳俱病。乃冬伤于寒。春必病温。蕴蓄已久之邪也。
伤寒之合病。三阳同感。实时俱病。倏忽不时之邪也。其受病之源有不同者如此。既为三阳同感。
虽名为太少合病。其实阳明独受其邪。其少阳邪多者。则下利。风木克胃土也。其太阳邪多者。
则呕。表阳郁热而阳明气逆也。下利者。与以黄芩汤。以苦泄少阳之邪。而阳明之邪得下行。呕
者。加半夏生姜。以辛散太阳之邪。而阳明之邪不上逆。此黄芩即治挟热利之余法。此半夏生姜。
即治结胸之余法。变而用之。不过使邪或自上越。或自下泄之意耳。此又见病专受于阳明。而治之
仍从太少。盖阳明无所复传之邪。仍自太少宣泄。别无出路。与少阳阳明篇。及少阳篇所言无二也。
太少二阳合病。病必连及阳明。固已。如其人太阳病全罢。独阳明少阳合病。则又当另为审辨。
而后可出治无误。或问。太阳罢而阳明少阳病。非所谓少阳阳明乎。何为另名为合病。曰。少阳阳明。
乃自太阳已传阳明。自阳明又欲传少阳。故名曰少阳阳明。今本三阳同时俱感。而太阳表邪已罢。
阳明少阳专受其患。所以另名曰阳明少阳合病。未可即谓少阳阳明也。或又问。太阳表邪已罢。
非传经乎。曰。太阳表邪已罢。自是传经。而此合病。原系三阳同时受邪。即太阳已罢。为传经入
里。与太阳递传者。理同而名异。况阳明少阳二经。亦尚各有表邪未解。非同于太阳独受邪者。表
邪已罢。传入阳明少阳皆属里症也。表里之间。迥乎不同者如此。知之则阳阴少阳合病之下利。为
阳明合少阳在经。表邪作祟。二经同受邪。已见木动克土。肠胃虚风鼓煽作利之义。非同阳明传经。
腑里藏邪。作利明矣。是当诊以谛之。
按干刚至健之气。运于地外。而贯于地中。所以统天地而资始生者。故胃中之燥金。即干金之贯于坤土中者也。所
以生化乎万物者也。阳明燥金司秋令。万物悦于兑。战于干。二金之气。渐次
生水。为贞下起元。可以知人胃中之金气矣。
【纲】仲景曰。下利。不可攻其表。汗出必胀满。
【目】苏颂曰。下利虽有表症。又不可发汗。以下利为邪气内攻。走津液而胃虚也。
张介宾曰。凡杂症下利。多积于寒。伤寒下利。有寒有热。盖热邪传里。则亦有下利之症。但
寒利最多。热利则仅见耳。治者当辨寒热。若误用之。则为害最大。凡伤寒下利。由热邪者。必有烦躁大热。酷欲冷水
等症。亦必有洪滑强盛数实等脉。如果表里
俱热。方可作火症论。若脉虽数而无力。虽外热而不恶热。内虽渴而不喜冷。此其内本不热。而
病为下利者。悉属虚寒。宜四逆汤、理中汤、温胃饮、胃关煎、五苓散之类。或表里寒邪俱盛。则
当以麻桂饮相兼用之为最要。若以寒利作热利。妄用寒凉。再损胃气。必死。表里俱病而下利者。虽有表症。所急在里。
盖里有不实。则表邪愈陷。即欲表之。而中气无力。
亦不能散。故凡见下利中虚者。速温其里。里实气强。则表自解。温中可以散寒也。脉数。又欲
饮水。是诚热矣。然寒邪在表。脉无不数。数而有力者为阳症。数而无力者为阴症矣。泻利亡津液。
无有不渴。但渴欲饮水。愈多愈快者为阳症。口虽欲水。而腹不欲咽。即非阳症矣。此外如渴欲
茶汤者。泻、渴之当然也。不得悉为热症。凡伤寒表邪未解。脉实滑数。喜冷气壮。内外俱热而下
利者。宜柴苓煎主之。凡伤寒下利者。本非阳明热邪。不当谵语。今谵语。故知有燥屎当去也。又
若少阴下利。心下痛。或硬。必有所积。故亦当下。
凡利家身凉脉小者为顺。身热脉大者为逆。此以外无表症。而病之在脏者言也。大抵下利一症。
惟脱气至急。五夺之中。惟此为甚。金匮曰。六脉气绝于外者。手足寒。五脏气绝于内者。利下
不禁。脏气既脱。不能治也。
陈士铎曰。伤寒发热六七日。不下利。忽变为下利。已是危症。若又汗不止。是亡阳也。有阴
无阳。死症。急以人参三两。北味一钱。救之可生。若不得参。另用白术、黄 各三两。当归一两。
白芍五钱。北味一钱。此方补气补血。以救阳气之外越。阳回则汗止。汗止则利亦止也。
【纲】仲景曰。下利。日十余行。脉反实者死。发热下利。至甚。厥不止者死。直视谵语。下利者死。下利。手足
厥冷。无脉者。灸之。不温。脉不还者死。少阴病自利。复
烦躁。不得卧寐者死。
【目】成无己曰。大抵下利。脱气至急。其或邪盛正虚。邪拥正气下脱。多下利而死。
陈士铎曰。下利日十余行。脉反实者死。何也。盖下多亡阴。宜脉之虚弱矣。今不虚而反实。
现假实之象也。（须认清）则是正气耗绝。为邪气所障。则正气消。故必死。救之必仍补其虚。
不必论脉之实与不实也。用还真汤。人参、白芍各一两。
茯苓二两。此方参固元阳。苓止脱泻。芍生真阴。阴生而阳长。利止而脱固。则正强而邪自败矣。
假象变为真虚。则死症变为真生矣。
【纲】仲景曰。问曰。病有结胸。有脏结。其状何如。答曰。按之痛。寸脉浮。关脉沉。名
曰结胸。如结胸状。饮食如故。时时下利。寸脉浮。关脉小细沉紧。名曰脏结。舌上白滑苔者。难
治。伤寒服汤药。下利不止。心下痞硬。服泻心汤已。复以他药下之。利不止。医以理中与之。利
益甚。理中者。理中焦。此利在下焦。赤石脂禹余粮汤主之。复利不止者。当利其小便。
【目】鳌按。上条。病俱重在关脉。一曰沉。虽沉而实大。是寒水留结于胸胁之间者。一曰沉
紧。是结在脏而不在腑者。故见症各不同。前贤谓能食而利。亦谓之结。结在无形之气。五脏不通。
故曰脏结是也。下条。服汤药而利不止。是病犹在胃。以他药下而利不止。则病在大肠矣。石脂
余粮汤。所以固脱。利小便。所以分消其湿。此又理下焦之二法也。
【纲】张仲景说：太阳经与阳明经同时受邪（合病）的，必然出现自发性腹泻。应当用葛根汤主治。太阳经与少阳经同时受邪的，出现自发性腹泻的，给予黄芩汤治疗。如果伴有呕吐症状的，以黄芩加半夏生姜汤主治。阳明经与少阳经同时受邪的，必然出现腹泻。脉象没有相克现象的，属于顺证；脉象相克的，属于逆证。互相克制贼害，称为“负”。脉象滑而数的，说明体内有积滞的食物，应当采用攻下法，适宜使用大承气汤。
【目】成无己说：这三种情况都是合病导致的腹泻。一种是通过发汗解表治疗，一种是攻下里实治疗，一种是和解表里治疗。之所以不同，是因为从六经辨证来看，太阳和阳明属于表证，少阳和太阴属于半表半里证，少阴和厥阴属于里证。现在太阳和阳明合病，病位在表。虽然表现为腹泻，但必须发散经络中的邪气后才会停止，所以用葛根汤发汗治疗。太阳和少阳合病，病位在半表半里。虽然表现为腹泻，但必须和解表里的邪气后才会停止，所以用黄芩汤疏散邪气。阳明与少阳合病，是少阳邪气传入腑脏的表现。虽然表现为腹泻，但必须清除胃中的实邪后才会停止，所以用承气汤攻下治疗。这就是三者治疗方法不同的原因。杂病中的自发性腹泻，多归咎于虚证；伤寒中的腹泻，有的由协热利引起。表邪传入体内，里虚兼夹热邪，则不应当攻下，如果错误地攻下，会导致内虚兼夹热邪而腹泻不止，这些都是协热利的缘故。
对于腹泻患者，如何辨别寒热呢？自发性腹泻且不口渴的，属于太阴病，因为内脏寒冷所致。腹泻且想喝水的，是因为有热邪。所以大便稀溏、小便正常的，这是有热邪。自发性腹泻、小便颜色发白的，具备少阴病的形症，这是有寒邪。恶寒、脉微细、自发性腹泻排出未消化食物的，这是有寒邪。腹泻时肛门重坠感明显、粪便色黄赤的，这是有热邪。这些都可以用来辨析寒热。凡是腹中疼痛并伴有肠鸣气走、向下趋向小腹的，这是即将发生腹泻的征兆。患有腹泻的人，身体凉爽、脉象细小的为顺证；身体发热、脉象洪大的为逆证。少阴病，脉紧伴腹泻，如果脉突然变得微弱，手足反而温暖，脉紧消失的，这是病情将要解除的表现。腹泻脉象大的，表示病势未止；脉象微弱而数的，表示病情将要自行停止，即使发热也不会死亡。由此可知，腹泻脉大为逆证，脉小为顺证。自发性腹泻适宜用温法，理中汤、白通汤以及各类四逆汤等，都是温补脏腑、止泻的方剂。但是，如果肠胃中有积滞结聚，或者下焦有客邪停留，温补药剂不能止住腹泻，必须采用攻下泄浊，或者分利小便的方法，才能停止。经文说：理中汤是调理中焦的，此处的腹泻位于下焦，适宜用赤石脂禹余粮汤。如果服用后腹泻仍不止，应当通过利小便来治疗。这是针对下焦水湿聚集导致的腹泻的治疗方法。少阴病自发性腹泻排出纯青色清水，心下部必定疼痛，口干燥。或者三部脉象平和，但按压心下部感觉坚硬，或者脉象沉而滑，或者不想进食且胡言乱语，或者病愈后经过年月日又复发。这几种情况，都是因为肠道内有积滞结聚，需要攻下泄浊。《内经》注解说：大热邪气内结，导致泄泻不止，热邪应当用寒凉药物治疗，伏结的邪气必须去除，用寒下药攻下，结散则利止。大热凝滞于内，久泻泄出稀溏便，痊愈后又复发，绵延多年，应当用热下药治疗，寒去则利止。这叫做“通因通用”（即用通利的方法治疗通泄的病证）。
喻昌说：通过观察是否腹泻，可以辨别主风或主寒的不同。在其他条文中提到，太阳阳明合病，不腹泻只呕吐的，用葛根加半夏汤主治。这是因为主风者，风为阳邪，风性向上，所以合病阳明胃中的水饮而上逆。本条主寒，寒为阴邪，阴性向下，所以合病阳明胃中的水谷而下奔。然而上逆则必须在葛根汤中加入半夏，涤除饮邪以止呕。如果是腹泻，则只需使用葛根来解除两经的邪气，不用特殊治疗腹泻，腹泻自然会停止。太阳阳明合病腹泻，表证较多；阳明少阳合病腹泻，里证较多；太阳少阳合病腹泻，半表半里证较多。所以使用黄芩、甘草、芍药、大枣作为和解法。
按语：太阳阳明合病、阳明少阳合病，都兼有阳明经病变，所以胃中的水谷不安定而必然自发性腹泻。如果不腹泻，也必然是水饮上逆而呕吐。这与少阳一经病变引起的干呕大不相同。然而无论是腹泻还是呕吐，都会损伤胃中的真气与津液，急需疏散邪气，从而安和胃气。更担心少阳邪气亢盛而阳明正气受损，就应当紧急攻下以救阳明。取用大承气汤正是为了迅速扫除外邪，并承接引领元气的意义。如果稍有迟疑拘泥，那么滑数的脉象必然变为迟软，那时再攻下就来不及了。
魏荔彤说：太阳阳明有合病，都属于二经的表证，共同感受外邪。然而又有太阳少阳二经合病，那么三阳经首尾相连，共同感受邪气，难道能截然不同，唯独不生病吗？所以太阳和少阳的合病，就是三阳经共同感受邪气的合病。有人问：三阳同病是温病，为什么混入伤寒合病中？不知道温病的三阳俱病，是冬天受寒，春天必发温病，是蕴蓄已久的邪气。伤寒的合病，是三阳经同时感受邪气，即时发病，是倏忽无常的邪气。它们受病的源头有所不同，就像这样。既然已经是三阳同感，虽然名为太阳少阳合病，其实阳明独受其邪。其中少阳邪气多的，则出现腹泻，这是风木克制胃土的缘故。其中太阳邪气多的，则出现呕吐，这是表阳郁热导致阳明气逆的缘故。腹泻的，给予黄芩汤，用苦味泄降少阳的邪气，从而使阳明的邪气得以下行；呕吐的，加入半夏、生姜，用辛味发散太阳的邪气，从而使阳明的邪气不上逆。这黄芩汤即是治疗挟热利的剩余方法，这半夏生姜即是治疗结胸证的剩余方法。变化运用，不过是使邪气或从上越出，或从下排泄的意思罢了。这又显示出病邪专门受于阳明，而治疗仍然从太阳和少阳入手。因为阳明没有可以再传变的邪气，邪气仍从太阳和少阳宣泄，别无出路，这与少阳阳明篇及少阳篇所说的没有二致。太阳和少阳二经合病，病势必然连及阳明，本来就是这样。如果其人太阳病已经完全解除，只有阳明和少阳合病，则又应当另外仔细审辨，然后才能施治无误。有人问：太阳病已罢而阳明少阳病，不就是所谓的少阳阳明吗？为什么另名为合病？回答说：少阳阳明，是指病邪已从太阳传入阳明，又从阳明欲传少阳，所以名叫少阳阳明。现在是三阳经同时感受邪气，而太阳表邪已经解除，阳明和少阳专门承受病患，所以另名为阳明少阳合病。不可以立即称之为少阳阳明。又有人问：太阳表邪已罢，不是传经吗？回答说：太阳表邪已罢，自然是传经。但此合病，原本是三阳经同时受邪，即使太阳已罢，视为传经入里，与太阳依次传变相比，道理相同但名称不同。况且阳明和少阳二经，也还有各自的表邪未解，不同于太阳单独受邪，表邪已罢后传入阳明少阳都属于里证的情况。表里之间，迥然不同，就像这样。知道了这一点，就知道阳明少阳合病的腹泻，是阳明合少阳在经，表邪作祟，二经同受邪气，已经见到木动克土，肠胃虚风鼓煽导致腹泻的意义。不同于阳明传经，腑里藏邪导致的腹泻，这是明显的。所以应当诊察来确认。
按语：干刚至健之气，运行于大地之外，而贯通于大地之中，所以统摄天地而资助万物始生。因此，胃中的燥金之气，就是乾金之气贯通于坤土之中的表现。所以生化万物。阳明燥金主管秋季时令，万物在兑卦喜悦，在乾卦交战。二金之气，渐次生水，为贞下起元（冬至一阳生），可以以此推知人胃中的金气。
【目】苏颂说：腹泻虽然有表证，也不可以发汗。因为腹泻是邪气内攻，耗损津液而导致胃虚。
张介宾说：凡杂病腹泻，多积聚于寒邪；伤寒腹泻，有寒有热。大概热邪传入体内，也会有腹泻的症状。但是寒利多见，热利仅偶尔见到。治疗者应当辨别寒热，如果误用，危害最大。凡伤寒腹泻，由热邪引起的，必然有烦躁、大热、极度想喝冷水等症状，也必然有洪大、滑利、强盛、数实等脉象。如果确实表里俱热，才可以作为火症论治。如果脉象虽数但无力，虽然外表发热但不怕热，内部虽然口渴但不喜欢冷饮。这说明内部本来不热，而患病为腹泻的，全部属于虚寒，适宜用四逆汤、理中汤、温胃饮、胃关煎、五苓散之类。或者表里寒邪都旺盛，则应当将麻黄汤和桂枝汤配合使用最为重要。如果把寒利当作热利，妄用寒凉药物，再次损伤胃气，必然致死。表里都患病而腹泻的，虽然有表证，所急迫的是里证。因为里气不实，则表邪更加陷入，即使想要解表，由于中气无力，也不能散发。所以凡是见到腹泻中气虚弱的，迅速温补里气。里气充实、正气强盛，则表邪自然解除，温补中可以散寒。脉数，又想喝水，这确实是热症。然而寒邪在表，脉象没有不数的。数而有力的是阳症，数而无力的是阴症。泻利亡失津液，没有不口渴的。但是渴欲饮水，越多越快的是阳症；口虽想喝水，但腹部不想吞咽，即非阳症。此外如渴欲喝茶汤的，是泻利、口渴的当然反应，不得全都认为是热症。凡伤寒表邪未解，脉象实滑数，喜欢冷气壮盛，内外俱热而腹泻的，适宜用柴苓煎主治。凡伤寒腹泻的，本来不是阳明热邪，不应当谵语。现在出现谵语，所以知道有燥屎应当去除。又如少阴腹泻，心下部疼痛，或者坚硬，必然有所积滞，所以也应当攻下。
凡是腹泻患者，身体凉爽、脉象细小的为顺证；身体发热、脉象洪大的为逆证。这是指外部无表证，而病在脏腑的情况。大概腹泻一症，唯有脱气最为急迫，在五夺之中，以此为甚。《金匮要略》说：六脉之气绝于外的，手足寒冷；五脏之气绝于内的，泻下不禁。脏气既已脱失，就不能治疗了。
陈士铎说：伤寒发热六七日，原本不腹泻，忽然变为腹泻，已经是危重症。如果又出汗不止，这是亡阳。有阴无阳，是死症。紧急用人参三两，北五味子一钱，救治可以存活。如果得不到人参，另外用白术、黄芪各三两，当归一两，白芍五钱，北五味子一钱。此方补气补血，以挽救外越的阳气。阳气回复则汗止，汗止则腹泻也停止。
【纲】张仲景说：腹泻，一天十几次，脉象反而实大的，预后不良（死）。发热腹泻，非常严重，四肢厥冷不止的，预后不良（死）。眼睛直视、胡言乱语、腹泻的，预后不良（死）。腹泻，手足厥冷，无脉的，艾灸治疗后，如果不温暖，脉象不恢复的，预后不良（死）。少阴病自发性腹泻，又出现烦躁，不能卧睡的，预后不良（死）。
【目】成无己说：大概腹泻，脱气至为急迫。或者邪气盛而正气虚，邪气拥逼正气下脱，多因腹泻而死。
陈士铎说：腹泻一天十几次，脉象反而实大的，预后不良（死）。为什么呢？大概下利过多会亡失阴液，脉象应当虚弱。现在不虚反而实，呈现假实的象。（必须认清）则是正气耗竭，被邪气阻滞，正气消亡，所以必然死亡。救治时必须仍然补其虚，不必论脉象的实与不实。用还真汤，人参、白芍各一两，茯苓二两。此方用人参固护元阳，茯苓止住脱泻，白芍生养真阴，阴生则阳长，利止则脱固，则正气强盛而邪气自然败退。假象变为真虚，则死症变为真生。
【纲】张仲景说：问：病有结胸，有脏结，它们的症状如何？答：按压疼痛，寸脉浮，关脉沉，名叫结胸。像结胸的样子，饮食正常，时常腹泻，寸脉浮，关脉小细沉紧，名叫脏结。舌上有白滑苔的，难治。伤寒服用汤药后，腹泻不止，心下部痞塞坚硬，服用泻心汤后，又用其他药物攻下，腹泻不止。医生用理中汤与之，腹泻更加严重。理中汤是调理中焦的，此处的腹泻在下焦，应当用赤石脂禹余粮汤主治。如果腹泻仍不止，应当利小便。
【目】沈金鳌按：上一条，病证重点都在关脉。一个说是沉，虽然是沉但实大，是寒水留结在胸胁之间；一个是沉紧，是结在脏而不在腑。所以见到的症状各不相同。前贤谓能食而腹泻，也称为结。结在无形之气，五脏不通，所以叫脏结。下一条，服用汤药而腹泻不止，是病还在胃；用其他药物攻下而腹泻不止，则病在大肠。赤石脂禹余粮汤，是用来固脱的；利小便，是用来分消湿气的。这是治疗下焦的两种方法。
[General Principle] Zhang Zhongjing stated: In cases where the Taiyang and Yangming channels are simultaneously affected (He Bing), spontaneous diarrhea will inevitably occur. Ge Gen Tang (Kudzu Decoction) is the primary treatment. In cases where the Taiyang and Shaoyang channels are simultaneously affected, if spontaneous diarrhea occurs, Huang Qin Tang (Scutellaria Decoction) should be administered. If vomiting is present, Huang Qin Jia Ban Xia Sheng Jiang Tang (Scutellaria Decoction with Added Pinellia and Fresh Ginger) is the primary treatment. In cases where the Yangming and Shaoyang channels are simultaneously affected, diarrhea will inevitably occur. A pulse that does not show mutual overcoming indicates a favorable prognosis (Shun); a pulse showing mutual overcoming indicates an unfavorable prognosis (Fu). Mutual overcoming and damaging is termed "Fu". A slippery and rapid pulse indicates the presence of retained food (Su Shi), which requires purgation; Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate.
[Commentary] Cheng Wuji stated: These three conditions all involve diarrhea resulting from He Bing. One is treated by releasing the exterior, one by attacking the interior, and one by harmonizing the interior and exterior. The differences arise from the Six Channels differentiation: Taiyang and Yangming belong to the Exterior; Shaoyang and Taiyin belong to the Half-Exterior/Half-Interior; Shaoyin and Jueyin belong to the Interior. Currently, Taiyang and Yangming He Bing indicates the pathogen is in the Exterior. Although diarrhea occurs, it must cease only after the pathogenic qi in the meridians is dispersed via sweating; thus, Ge Gen Tang is used for diaphoresis. Taiyang and Shaoyang He Bing indicates the pathogen is in the Half-Exterior/Half-Interior. Although diarrhea occurs, it must cease only after the exterior and interior pathogens are harmonized; thus, Huang Qin Tang is used to disperse the pathogen. Yangming and Shaoyang He Bing indicates the Shaoyang pathogen has entered the Fu organs. Although diarrhea occurs, it must cease only after the excess in the stomach is driven out; thus, Cheng Qi Tang is used for purgation. These are the reasons for the different treatments among the three. Spontaneous diarrhea in miscellaneous diseases is mostly attributed to deficiency. Diarrhea in Shang Han (Cold Damage) may result from Xie Re Li (Collateral Heat Diarrhea). When exterior pathogens transmit inward, causing interior deficiency with collateral heat, purgation is contraindicated. Incorrect use of purgation leads to persistent diarrhea due to interior deficiency and collateral heat; these are all causes of Xie Re Li.
How to distinguish cold and heat in patients with diarrhea? Spontaneous diarrhea without thirst belongs to Taiyin, due to cold in the Zang organs. Diarrhea accompanied by desire to drink water indicates heat. Therefore, loose stools with normal urination indicate heat. Spontaneous diarrhea with white-colored urine presents the signs and symptoms of Shaoyin disease, indicating cold. Aversion to cold, faint pulse, and spontaneous diarrhea with undigested food indicate cold. Tenesmus with yellow-red stool indicates heat. These can all be used to differentiate cold and heat. Abdominal pain with moving gas rushing toward the lower abdomen indicates impending diarrhea. In patients with diarrhea, a cool body and small pulse are favorable (Shun); a hot body and large pulse are unfavorable (Ni). In Shaoyin disease, a tight pulse with diarrhea, if the pulse suddenly becomes faint, hands and feet become warm, and the tightness disappears, this indicates the condition is about to resolve. A large pulse in diarrhea indicates the condition has not stopped; a faint, weak, and rapid pulse indicates the condition is about to stop spontaneously. Even if fever persists, death will not occur. Thus, a large pulse in diarrhea is unfavorable, while a small pulse is favorable. Spontaneous diarrhea is suitable for warming methods; Li Zhong Tang (Regulate the Middle Decoction), Bai Tong Tang, and various Si Ni Tang (Four Counterflow Decoctions) are agents that warm the Zang organs and stop diarrhea. However, if there are accumulations in the intestines and stomach, or guest pathogens in the Lower Jiao, warming agents cannot stop the diarrhea. Purgation or separation of dampness through diuresis is required to stop it. The classic states: Li Zhong Tang regulates the Middle Jiao. This diarrhea is in the Lower Jiao; Chi Shi Zhi Yu Yu Liang Tang (Red Stone Lipstick and Hematite Decoction) is appropriate. If diarrhea persists, diuresis should be employed. This treats diarrhea caused by fluid accumulation in the Lower Jiao. In Shaoyin disease, spontaneous diarrhea of pure green water, with pain in the epigastrium and dry mouth, or when the pulses in the three positions are level but the epigastrium is hard upon palpation, or the pulse is deep and slippery, or there is anorexia with delirium, or recurrence after recovery over months or years—these cases all require purgation due to intestinal accumulations. The commentary on the Neijing states: Internal excessive heat causing persistent diarrhea should be treated with cold herbs; latent accumulations must be removed using cold purgatives. Once the accumulation disperses, diarrhea stops. Internal coagulation of excessive heat causing chronic loose stools, recurring over years, should be treated with hot purgatives; once cold dissipates, diarrhea stops. This is called "Tong Yin Tong Yong" (treating obstruction with unblocking methods).
Yu Chang stated: Whether or not diarrhea occurs helps distinguish between wind and cold dominance. In other clauses, Taiyang-Yangming He Bing without diarrhea but with vomiting is treated with Ge Gen Jia Ban Xia Tang (Kudzu Decoction with Added Pinellia). This is because wind is yang, and its nature ascends; thus, it causes water-fluids in the Yangming stomach to regurgitate upward. This clause deals with cold; cold is yin, and its nature descends; thus, it causes food and fluids in the Yangming stomach to rush downward. Upward regurgitation requires adding Ban Xia (Pinellia) to Ge Gen Tang to eliminate fluids and stop vomiting. For diarrhea, only Ge Gen is needed to resolve the pathogens of both channels; the diarrhea stops spontaneously without specific anti-diarrheal treatment. Taiyang-Yangming He Bing with diarrhea presents mostly exterior symptoms; Yangming-Shaoyang He Bing with diarrhea presents mostly interior symptoms; Taiyang-Shaoyang He Bing with diarrhea presents mostly half-exterior/half-interior symptoms. Therefore, Huang Qin, Gan Cao, Shao Yao, and Da Zao are used as a harmonizing method.
Note: Taiyang-Yangming He Bing and Yangming-Shaoyang He Bing both involve Yangming, causing instability of water and food in the stomach and leading to spontaneous diarrhea. If there is no diarrhea, there will likely be upward regurgitation of fluids and vomiting, which differs significantly from dry heaving caused by Shaoyang alone. Whether diarrhea or vomiting, the true qi and fluids of the stomach are damaged, requiring urgent dispersion of pathogens to stabilize the stomach. One must also fear Shaoyang excess overwhelming Yangming deficiency, necessitating urgent purgation to rescue Yangming. The use of Da Cheng Qi Tang aims to swiftly sweep away external pathogens and support the original qi. Hesitation would cause the slippery-rapid pulse to become slow and soft, making purgation ineffective.
Wei Litong stated: Taiyang and Yangming have He Bing, both belonging to the exterior of two channels, sharing external pathogens. However, Taiyang and Shaoyang He Bing implies the three Yang channels are connected; how could they not all be diseased? Thus, Tai-Shaoyang He Bing is essentially He Bing of all three Yang channels. Some ask: Three-Yang simultaneous disease is Wen Bing (Warm Disease); why mix it with Shang Han He Bing? It is unknown that Wen Bing's three-Yang disease results from winter cold injury manifesting as spring warmth, representing long-term accumulated pathogens. Shang Han He Bing involves three Yang channels simultaneously contracting pathogens, manifesting immediately, representing sudden, irregular pathogens. Their sources differ. Since it is three-Yang simultaneous contraction, although named Tai-Shaoyang He Bing, actually Yangming alone bears the pathogen. If Shaoyang pathogen is dominant, diarrhea occurs due to Wood overacting on Earth (Stomach). If Taiyang pathogen is dominant, vomiting occurs due to exterior yang heat stagnation causing Yangming qi rebellion. For diarrhea, Huang Qin Tang is given to bitter-drain Shaoyang pathogens, allowing Yangming pathogens to descend. For vomiting, Ban Xia and Sheng Jiang are added to acridly-disperse Taiyang pathogens, preventing Yangming qi from rebelling upward. Huang Qin Tang is a residual method for treating heat-collateral diarrhea; Ban Xia and Sheng Jiang are residual methods for treating Jie Xiong (Chest Binding). Variations merely aim to expel pathogens upward or downward. This shows the pathogen specializes in Yangming, yet treatment still addresses Taiyang and Shaoyang. Since Yangming has no further transmission pathway, pathogens are vented through Taiyang and Shaoyang, leaving no other exit, consistent with the Shaoyang-Yangming and Shaoyang chapters. Tai-Shaoyang He Bing necessarily involves Yangming. If Taiyang disease has completely resolved, leaving only Yangming-Shaoyang He Bing, careful differentiation is required before treatment. Some ask: If Taiyang resolves and Yangming-Shaoyang disease remains, isn't this Shaoyang-Yangming? Why name it He Bing? Answer: Shaoyang-Yangming refers to transmission from Taiyang to Yangming, then to Shaoyang. Here, all three Yang channels contracted pathogens simultaneously; Taiyang exterior pathogens have resolved, leaving Yangming and Shaoyang to bear the burden. Hence, it is named Yangming-Shaoyang He Bing, not Shaoyang-Yangming. Some ask: Isn't the resolution of Taiyang exterior pathogens considered transmission? Answer: Resolution of Taiyang exterior pathogens is indeed transmission. However, this He Bing originated from simultaneous three-Yang infection. Even if Taiyang resolves, viewing it as transmission inward is similar in principle but different in name compared to sequential transmission. Moreover, Yangming and Shaoyang still have unresolved exterior pathogens, unlike Taiyang alone where exterior resolution leads to interior transmission. The difference between exterior and interior is distinct. Understanding this reveals that Yangming-Shaoyang He Bing diarrhea is due to pathogens in the meridians of Yangming and Shaoyang, with exterior pathogens causing disturbance. Both channels suffer pathogens, showing Wood moving and overacting on Earth, with intestinal wind stirring to cause diarrhea. This differs clearly from Yangming transmission disease where pathogens reside in the Fu organs. Diagnosis confirms this.
Note: The vigorous energy of Qian (Heaven) operates outside the earth and penetrates within, governing heaven and earth to initiate life. Thus, the dry metal qi in the stomach is the Qian metal penetrating Kun earth, generating all things. Yangming dry metal governs autumn; all things rejoice in Dui and struggle in Qian. The qi of these two metals gradually generates water, marking the beginning of renewal (Zhen Xia Qi Yuan), allowing us to understand the metal qi in human stomachs.
[General Principle] Zhang Zhongjing stated: In diarrhea, do not attack the exterior. Sweating will inevitably cause abdominal distension.
[Commentary] Su Song stated: Although diarrhea may present with exterior symptoms, sweating is contraindicated. Diarrhea indicates internal attack by pathogens, depleting fluids and weakening the stomach.
Zhang Jiebin stated: Miscellaneous disease diarrhea is mostly due to cold accumulation. Shang Han diarrhea can be cold or heat. Heat transmitting inward can cause diarrhea, but cold diarrhea is most common, while heat diarrhea is rare. Practitioners must differentiate cold and heat; misuse causes great harm. Heat-induced Shang Han diarrhea presents with irritability, high fever, and intense craving for cold water, accompanied by surging, slippery, strong, rapid, and excess pulses. Only if both interior and exterior are hot should it be treated as a fire syndrome. If the pulse is rapid but weak, or externally hot but not aversive to heat, or internally thirsty but rejecting cold drinks, the interior is fundamentally cold. Such diarrhea belongs to deficiency-cold, treated with Si Ni Tang, Li Zhong Tang, Wen Wei Yin, Wei Guan Jian, or Wu Ling San. If exterior and interior cold are both severe, combining Ma Huang Tang and Gui Zhi Tang is crucial. Mistaking cold diarrhea for heat and using cold herbs damages stomach qi, leading to death. In simultaneous exterior-interior disease with diarrhea, the interior urgency takes precedence. Interior deficiency allows exterior pathogens to sink deeper; even if exterior release is attempted, weak middle qi prevents dispersion. Thus, for diarrhea with middle jiao deficiency, urgently warm the interior. When interior qi is solid and strong, exterior pathogens resolve naturally; warming disperses cold. A rapid pulse with thirst indicates true heat. However, exterior cold can cause rapid pulses; forceful rapidity indicates yang syndrome, while weak rapidity indicates yin syndrome. Diarrhea depletes fluids, causing thirst. Thirst with rapid drinking indicates yang syndrome; desire to drink but reluctance to swallow indicates non-yang syndrome. Craving tea or soup is a natural consequence of diarrhea and thirst, not necessarily heat. For Shang Han with unresolved exterior, excess-slippery-rapid pulse, preference for cold, and interior-exterior heat with diarrhea, Chai Ling Jian is appropriate. Shang Han diarrhea is not typically Yangming heat; delirium is uncommon. Delirium indicates dry feces requiring removal. Shaoyin diarrhea with epigastric pain or hardness indicates accumulation requiring purgation.
In diarrhea patients, a cool body and small pulse are favorable; a hot body and large pulse are unfavorable. This refers to cases without exterior symptoms, where disease resides in the zang organs. Generally, diarrhea involving loss of qi is extremely urgent, being the most severe of the Five Depletions. The Jin Gui Yao Lue states: Six-pulse qi failing externally causes cold hands and feet; five-zang qi failing internally causes uncontrollable diarrhea. Once zang qi is lost, it cannot be treated.
Chen Shiduo stated: Shang Han fever for six or seven days without diarrhea, suddenly turning into diarrhea, is a critical condition. If accompanied by profuse sweating, it is Yang collapse (Wang Yang). Yin without Yang is a death sign. Urgently treat with 3 liang of Ren Shen (Ginseng) and 1 qian of Bei Mu Wei (Schisandra). Survival is possible. If Ren Shen is unavailable, use 3 liang each of Bai Zhu (Atractylodes) and Huang Qi (Astragalus), 1 liang of Dang Gui (Angelica), 5 qian of Bai Shao (White Peony), and 1 qian of Bei Mu Wei. This formula tonifies qi and blood to rescue outwardly floating yang. Return of yang stops sweating; cessation of sweating stops diarrhea.
[General Principle] Zhang Zhongjing stated: In diarrhea occurring ten-plus times daily, a surprisingly excess pulse indicates death. Fever with severe diarrhea and unrelenting cold limbs indicates death. Fixed gaze and delirium with diarrhea indicates death. Diarrhea with cold limbs and absent pulse: if moxibustion fails to warm the body or restore the pulse, death ensues. Shaoyin disease with spontaneous diarrhea, followed by irritability and inability to sleep, indicates death.
[Commentary] Cheng Wuji stated: Generally, diarrhea involves urgent loss of qi. If pathogens are excess and righteous qi deficient, pathogens oppress righteous qi downward, often leading to death via diarrhea.
Chen Shiduo stated: Diarrhea ten-plus times daily with a surprisingly excess pulse indicates death. Why? Excessive purging depletes yin, so the pulse should be weak. An excess pulse here indicates false excess. Righteous qi is exhausted and obstructed by pathogens, leading to death. Treatment must tonify deficiency regardless of the pulse's apparent excess. Use Huan Zhen Tang: 1 liang each of Ren Shen and Bai Shao, 2 liang of Fu Ling (Poria). Ren Shen secures original yang; Fu Ling stops depletion diarrhea; Bai Shao generates true yin. Generation of yin promotes yang; cessation of diarrhea consolidates depletion. Strong righteous qi defeats pathogens. False excess transforming into true deficiency turns a death sign into life.
[General Principle] Zhang Zhongjing asked: What are the symptoms of Jie Xiong (Chest Binding) and Zang Jie (Zang Binding)? Answer: Pain upon pressure, floating cun pulse, and sinking guan pulse constitute Jie Xiong. Symptoms resembling Jie Xiong, with normal diet but frequent diarrhea, floating cun pulse, and small, fine, deep, tight guan pulse constitute Zang Jie. A white, slippery coating on the tongue indicates a difficult-to-treat case. After taking decoctions for Shang Han, if diarrhea persists and the epigastrium feels full and hard, and subsequent use of Xie Xin Tang fails, followed by purgation causing persistent diarrhea, and the physician administers Li Zhong Tang worsening the diarrhea: Li Zhong Tang regulates the middle jiao, but this diarrhea is in the lower jiao. Chi Shi Zhi Yu Yu Liang Tang is indicated. If diarrhea persists, promote urination.
[Commentary] Shen Jin'ao noted: In the previous clause, the pathology focuses on the guan pulse. "Sinking" (even if large and solid) indicates cold-water retention between the chest and hypochondrium. "Deep and tight" indicates binding in the Zang rather than the Fu, resulting in different symptoms. Ancients stated that eating while having diarrhea is also called "Jie," referring to binding of formless qi and blockage of the five zang organs, hence "Zang Jie." In the next clause, diarrhea persisting after decoction indicates the disease is still in the stomach; diarrhea persisting after purgation indicates the disease is in the large intestine. Chi Shi Zhi Yu Yu Liang Tang secures collapse; promoting urination separates and eliminates dampness. These are two methods for treating the lower jiao.