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，导致里虚且伴有胁部郁热从而引起下利；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（此处指少阳胆经郁热或相关病机）的范畴。另外，三阳合病（太阳、阳明、少阳三经同时受邪）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，所以用葛根汤来发汗解表；太阳与少阳合病，病邪在半表半里，所以用黄芩汤来和解少阳；阳明与少阳合病，是少阳邪气入里，所以用承气汤来攻下里实。）而且，自利且不口渴的，属于太阴病，是因为脏腑有寒的缘故。下利想要喝水的，是因为有热的缘故。所以，大便稀溏、小便正常通畅的，以及发热、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（粪便中含有未消化的食物）的，都属于寒证。虽然自利多可用温法治疗，但如果肠胃中有积滞结聚，或者下焦有外来邪气，就不是单纯温补药物所能止住的。必须采用分利小便的方法，或者攻下泄热的方法才可以。（《伤寒论》经文说：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，心下部必定疼痛，口干燥；以及下利患者寸关尺三部脉象平和，但按压心下部感觉坚硬，或者脉象沉而滑，或者不想吃东西且说胡话，或者病愈后经过一段时间又复发，这几种情况都是肠胃有积滞结聚，需要攻下泄热的。这就叫做“通因通用”，即用通利的方法治疗具有通利症状的病证。）另外，下利即使有表证，也不可发汗，因为下利是邪气向内攻冲，耗伤津液，导致胃气虚弱。经文说：下利不可攻表，如果发汗导致出汗，必然会出现腹部胀满。大概三阴病自利的情况居多。然而，自利的病人身体凉爽、脉象平静，这是顺证；身体发热、脉象洪大，这是逆证。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，正气向下脱失，多因下利而死。（经文说：少阴病自利，又烦躁不安，无法躺卧睡眠的，死；眼睛直视、说胡话且下利的，死；下利一天十几次，脉象反而实大的，死；下利且手脚冰冷、没有脉搏，艾灸后不回暖、脉搏不恢复的，死；发热且下利非常严重，手脚厥冷不止的，死。这几种情况都是因为邪气壅滞，正气向下脱失，所以死亡。）《金匮要略》说：六腑之气在外衰竭，表现为手脚寒冷；五脏之气在内衰竭，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了。气已经脱失，谁能挽救它呢？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。
太阳病篇：
伤寒（汗法）：表证未解，心下有停饮，干呕，发热且咳嗽，或者口渴，或者下利，或者噎塞感，或者小便不利、小腹胀满，或者喘息的，用小青龙汤。
太阳病与阳明病合病，必定自下利，用葛根汤。（成无己注：伤寒有合病和并病两种情况。太阳病不解，并入阳明经的，称为并病；三经同时受邪，相互结合发病的，称为合病。合病意味着邪气很盛。太阳与阳明合病，以及太阳与少阳合病、阳明与少阳合病，都说“必定自下利”，这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。寒邪邪气很盛，客居于二阳经，二阳经外部充实而不主司内部，导致内部气虚，所以必定下利。用葛根汤来疏散经络中的邪气，其脉象必定浮而长。）
太阳病，外部证候尚未解除，却多次使用攻下法，于是夹杂热邪而下利，下利不止，心下部痞塞坚硬，表里证均未解除的，用桂枝人参汤。（张元素注：有人说仲景《伤寒论》中太阳病桂枝证，医生反而使用攻下法，导致下利不止，应用葛根黄连黄芩汤；上一条又说用桂枝人参汤。这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？两个证候都涉及内虚，热邪内陷协热下利，只是脉证不同，所以用药有差异。经文说脉促者，表证未解；喘息且出汗的，用葛根黄连黄芩汤主治。脉促表示阳气盛，喘息且出汗表示里有热。阳气盛、里有热，用葛根黄连黄芩汤是理所当然的。）
太阳病与少阳病合病，自下利的，用黄芩汤。如果呕吐的，用黄芩加半夏生姜汤。（下利且头痛、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，每日两次，夜间一次服用。（对于虚弱而不充实的体质，用苦味药来坚固收敛，用酸味药来收涩。黄芩、芍药的苦酸之性，可以坚固收敛肠胃之气。对于虚弱不足的肠胃，用甘味药来补益。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：
在黄芩汤基础上加入半夏半升（洗净）、生姜三两（切片）。
太阳病与少阳病并病，反而使用攻下法，邪气结聚在胸中，成为结胸证，心下部坚硬，下利不止，水浆不能入口，病人心中烦乱。（可用生姜泻心汤、大黄黄连泻心汤、小陷胸汤。张元素注：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、不得安卧；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，不必所有证候都具备。但仲景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，反而使用攻下法，下利不止，脉象急促的，表示表证未解；喘息且出汗的，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。表证未解的，用葛根、甘草的甘味来发散；里气虚弱的，用黄芩、黄连的苦味来坚固。）
太阳病，使用攻下法后，脉象急促，没有形成结胸的，是病情将要解除的表现；脉象沉滑的，是协热下利；脉象浮滑的，必定便血。用黄芩汤。
太阳病，过了两三天，不能躺卧，只想起来，心下部必定痞结，脉象微弱无力的，这是原本就有寒湿分争的情况。反而使用攻下法，如果下利停止，必定会形成结胸；如果下利不止，到了第四天再次使用攻下法，这会形成协热下利。用黄芩汤。
伤寒中风，反而使用攻下法，下利不止，食物不消化，肠中雷鸣，心下部痞硬满闷，干呕，心烦不安。医生看到他的痞证，再次使用攻下法，痞证更加严重。这不是结热，而是因为胃中空虚，客气上逆，所以导致痞硬。用甘草泻心汤。
伤寒汗解之后，胃中不和，心下部痞硬，干噫气，食物气味，胁下有停饮，肠中雷鸣，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。其人经常出汗，发作有时，头痛，心下部痞硬，牵引胁下疼痛，干呕，短气，出汗且不恶寒的，这是表证已解，里气未调和。用十枣汤。
伤寒发热，出汗后病不解，心下部痞硬，呕吐且下利的，用大柴胡汤。
伤寒十三日未解，经过传变，出现谵语的，是因为有热邪，应当用汤药攻下。如果小便通畅的，大便应当坚硬，反而下利，脉象调和的，这是俗医使用丸药攻下造成的，不是正确的治法。如果是自然下利的，脉象应当微弱厥冷，现在反而调和，这是内有实邪。用调胃承气汤。
太阳病，第二天反而烦躁，反常地用火熨背部，导致大汗出，火热之邪入胃，津液枯竭，烦躁，必定发生谵语。十多天后，如果出现振栗且自下利的，是病情将要解除的表现。
伤寒，医生使用攻下法，随后出现下利完谷不化不止，身体疼痛的，应当紧急救里，用四逆汤。身体疼痛但大小便正常的，应当紧急救表，用桂枝汤。（成无己注：伤寒使用攻下法，随后出现下利完谷不化不止，身体疼痛，应当紧急救里。因为里气不足，必须先救里。紧急给予四逆汤，等到大小便正常，知道里气已调和，然后紧急给予桂枝汤来救表。身疼是表邪。《内经》说：病发而正气不足的，先治标后治本。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，先用盐水和姜汁各半盏，用砂罐煮七沸，后加入甘草、黄连各半两，再加童便半盏，再煮七沸，停火，放置很久后捞起，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。最好选用顶圆修正的一两一枚的附子）。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，形成四逆。此汤宣发阳气，走散阴寒，温经暖肌，所以名叫四逆汤。《内经》说：寒邪淫溢于内，用甘热药治疗，驱除阴寒，扶持阳气，必须以甘味药为主，所以用甘草为君药。《内经》说：寒邪胜复，用辛热药平抑，驱逐寒邪，正气必先依靠辛热药，所以用干姜为臣药。《内经》说：辛味可以润燥，开发腠理，致津液，通气机。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：距离远的病，采用奇偶配伍，加大剂量，说的就是这种情况。
伤寒服用汤药后，下利不止，心下部痞硬，服用泻心汤后，又用其他药攻下，下利不止。治疗用理中汤，利益更甚。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，傍晚定时发热，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。先宜用柴胡汤以解外，后用柴胡加芒硝汤。
太阳病，经过十余日，心下部温温欲吐，胸中痛，大便反而稀溏，腹部微满，郁郁微烦。先前曾经剧烈吐下过的，用调胃承气汤。
阳明病篇：
病见潮热，大便稀溏，小便尚可，胸胁满闷的，用小柴胡汤。
病患没有表证也没有典型的里证，发热七八天，虽然脉象浮数，可以攻下。攻下后脉数不解，且下利不止，必定便脓血。用黄芩汤、柏皮汤。
阳明与少阳合病，必定下利。脉象不负（即少阳脉不克伐阳明脉）的是顺证；负（即少阳脉克伐阳明脉）的是逆证。互相克贼，名为负。脉象滑而数的，是有宿食，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。下利者脉当微厥，今脉滑数，知胃有宿食，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，舌上有白苔滑腻的，难治。
太阴病篇：
太阴病，腹满而吐，食不下，自利益甚，时腹自痛。如果误用攻下法，必定胸下结硬。自利不口渴的，属于太阴，因为脏腑有寒，所以应当温补，宜服用四逆辈。（张元素注：经文说“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，老师说有用理中汤治愈的，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，是大热之剂，如果轻率使用，恐怕有过度的失误。所以仲景不为定拟。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。）太阴病，脉弱，其人持续自行便利，假设应当使用芍药、大黄的，应当减量，因为其人胃气弱，容易动利。（成无己注：腹满痛是太阴病。脉弱，其人持续自行便利，则邪气虽在里，未成大实。欲用大黄、芍药攻除满痛的，应当少量给予，因为胃气尚弱，易于动利。）伤寒，脉浮而缓，手足自温的，系在太阴。当发身黄，如果小便自利的，不发黄。到了七八天，虽然突然烦躁，下利一天十几次，必定自止，因为脾家实，腐秽当去。（可用平胃散加穿山甲）
少阴病篇：
病欲吐不吐，但想睡觉，五六日后自利且口渴的，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。（欲吐不吐、心烦，是表邪传里。如果腹满痛，则属太阴。这里但欲寐，可知属少阴。五六日是邪传少阴的时候。自利不渴，是寒在中焦，属太阴。此自利而渴，是寒在下焦，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：下利欲饮水的，因为有热，用白头翁汤主治。）少阴病，下利，咽痛，胸满，心烦的，用猪肤汤。
猪肤汤方：
猪肤（一斤）。上一味，用水一斗，煮取五升，去渣，加入白蜜一升，白粉（米粉）五合，熬香，调和，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，四肢逆冷，或者泄利下重的，用四逆散（方见前条）。
少阴病，下利，六七日，咳而呕，渴，心烦，不得眠的，用猪苓汤（方见渴条）。
少阴病，自利清水，颜色纯青，心下部必定疼痛，口干燥的，紧急攻下，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，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？”召请孙思邈到。孙思邈说：“今日不可下，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，岂不知少阴一证，自利清水，心下痛的，下之而愈？仲景的书明明白白有这样的说法。众人都钦佩信服。”
少阴病，下利，恶寒而蜷缩，手足温的，可治，用四逆汤。
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（详腹痛条）。
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，每日三次服用。如果一服痊愈，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，或者小便利，或者下利，或者呕的，用真武汤主治（详腹痛条）。
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，每日三次服用。（脾恶湿，甘先入脾。茯苓、白术的甘性可以益脾逐水。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，五味子的酸味可以收敛逆气；水寒相搏则咳，细辛、干姜的辛味可以散水寒）。如果小便利的，去茯苓（小便利，无伏水，故去茯苓）。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，加生姜足量至半斤（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，故以茯苓甘平为君，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，用通脉四逆汤主治。
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，痊愈。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。经文说：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，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，给与白通汤。利不止，厥逆无脉，干呕烦的，用白通加猪胆汁汤主治。服汤后脉暴出的，死；脉微续的，生。（少阴病下利，脉微，为寒极阴胜，给与白通汤复阳散寒。服汤后利不止，厥逆无脉，干呕烦的，寒气太甚，内为格拒，阳气逆乱，给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。服汤脉暴出的，正气因会泄而脱，故死。脉微续的，阳气渐复，故生。）
白通汤方
Cheng Wuji's Commentary: Spontaneous diarrhea (Zili) refers to diarrhea that occurs on its own without the use of purgative treatment. Some cases involve exterior pathogenic factors transmitting inward, leading to interior deficiency and heat stagnation in the hypochondriac region, resulting in diarrhea; other cases occur when purgatives are incorrectly used when they should not be, causing diarrhea. These all belong to the category of hypochondriac heat (referring here to Shaoyang Gallbladder channel heat stagnation or related pathogenesis). Additionally, combined diseases of the three Yang channels (Taiyang, Yangming, and Shaoyang channels simultaneously affected by pathogens) will all present with spontaneous diarrhea, but the treatment methods differ: releasing the exterior through sweating, purging interior excess, or harmonizing the Shaoyang. (When Taiyang and Yangming combined diseases occur, the pathogen is at the exterior, so Gegen Tang is used to induce sweating and release the exterior; when Taiyang and Shaoyang combined diseases occur, the pathogen is at the half-exterior and half-interior, so Huangqin Tang is used to harmonize the Shaoyang; when Yangming and Shaoyang combined diseases occur, it is because Shaoyang pathogenic factors have entered the interior, so Chengqi Tang is used to purge interior excess.) Furthermore, spontaneous diarrhea accompanied by no thirst belongs to Taiyin disease, due to cold in the zang organs. Diarrhea accompanied by a desire to drink water is due to heat. Therefore, loose stools with normal urination, as well as fever, tenesmus (anal heaviness), and yellow-red excrement, all indicate heat syndromes. Spontaneous diarrhea with clear-white urine, presenting the complete picture of Shaoyin disease, as well as aversion to cold, faint pulse, and diarrhea with undigested food (complete grains), all indicate cold syndromes. Although spontaneous diarrhea is mostly treated with warming methods, if there are accumulations and knots in the intestines and stomach, or external pathogens in the lower jiao, simple warming tonification cannot stop it. One must employ methods to separate and drain dampness via urination, or purge and drain heat, to be effective. (The Classic states: Lizhong Tang regulates the middle jiao; this type of diarrhea is in the lower jiao and should be treated with Chishizhi Yuyuliang Tang. If it does not improve, one should promote urination. In Shaoyin disease, spontaneous diarrhea of clear water, pure green in color, with必 pain in the epigastrium and dry mouth, as well as patients with diarrhea having normal pulses in the cun, guan, and chi positions but hardness upon pressing the epigastrium, or sinking-slippery pulses, or anorexia with delirium, or recurrence after a period of recovery—these situations all indicate intestinal and gastric accumulation requiring purgation. This is called "treating obstruction with unblocking agents" (Tong Yin Tong Yong), i.e., using unblocking methods to treat diseases presenting with unblocking symptoms.) Moreover, even if diarrhea presents with exterior signs, sweating should not be induced, because diarrhea indicates pathogenic factors attacking inward, consuming body fluids, and causing stomach qi deficiency. The Classic states: Do not attack the exterior in diarrhea; if sweating induces perspiration, abdominal fullness will inevitably result. Generally, spontaneous diarrhea occurs frequently in the three Yin channels. However, in patients with spontaneous diarrhea, a cool body and calm pulse are favorable signs, while a hot body and large pulse are unfavorable signs. Generally speaking, diarrhea leading to the collapse of vital qi is the most difficult to treat. This is because pathogenic factors are abundant while healthy qi is deficient; pathogenic stagnation causes healthy qi to collapse downward, often leading to death from diarrhea. (The Classic states: In Shaoyin disease, spontaneous diarrhea accompanied by irritability and inability to lie down or sleep results in death; staring straight ahead, delirium, and diarrhea result in death; diarrhea occurring more than ten times a day with a surprisingly solid pulse results in death; diarrhea with cold limbs and absent pulse, where moxibustion fails to warm the limbs and the pulse does not return, results in death; fever with severe diarrhea and persistent cold limbs results in death. All these cases result in death due to pathogenic stagnation and downward collapse of healthy qi.) The Synopsis of Golden Chamber states: When the qi of the six fu organs collapses externally, it manifests as cold hands and feet; when the qi of the five zang organs collapses internally, it manifests as uncontrollable diarrhea. Medication administered only after the disease has formed is futile, even for a divine physician. Once the qi has collapsed, who can save it? All six channels have diseases involving diarrhea, with different treatments for exterior/interior and cold/heat patterns. Students should examine these carefully.
Taiyang Chapter:
Cold Damage (Sweating Method): Exterior syndrome unresolved, fluid retention in the heart region, dry retching, fever with cough, or thirst, or diarrhea, or choking sensation, or dysuria with lower abdominal fullness, or wheezing. Treat with Xiao Qinglong Tang.
Combined disease of Taiyang and Yangming,必定 spontaneous diarrhea. Treat with Gegen Tang. (Cheng Wuji notes: Cold damage includes combined diseases (Hebing) and concurrent diseases (Bingbing). When Taiyang syndrome is unresolved and merges into the Yangming channel, it is called Bingbing; when all three channels are affected by pathogens and combine to cause disease, it is called Hebing. Hebing implies severe pathogenic factors. In Taiyang-Yangming combined disease, as well as Taiyang-Shaoyang and Yangming-Shaoyang combined diseases, all state "must have spontaneous diarrhea" because pathogens merging into Yin channels lead to Yin excess and Yang deficiency; pathogens merging into Yang channels lead to Yang excess and Yin deficiency. Severe cold pathogenic factors lodge in the two Yang channels. Since the two Yang channels are externally solid and do not govern the interior, interior qi becomes deficient, hence spontaneous diarrhea. Gegen Tang is used to disperse pathogens in the meridians; the pulse will likely be floating and long.)
Taiyang syndrome, exterior signs unresolved, yet repeatedly purged, leading to diarrhea complicated by heat, unremitting diarrhea, epigastric痞 hard/fullness, with both exterior and interior signs unresolved. Treat with Guizhi Renshen Tang. (Zhang Yuansu notes: Some say in Zhang Zhongjing's Treatise on Cold Damage, Taiyang Guizhi syndrome was incorrectly purged, causing unremitting diarrhea, which should be treated with Gegen Huanglian Huangqin Tang; the previous clause mentions Guizhi Renshen Tang. Both syndromes involve unresolved exterior and diarrhea caused by incorrect purging, yet the medications differ in temperature. Both involve interior deficiency with heat sinking and協 heat diarrhea, but the pulse and signs differ, hence the difference in medication. The Classic states: A rapid pulse indicates unresolved exterior; wheezing with sweating is treated with Gegen Huanglian Huangqin Tang. A rapid pulse indicates abundant yang; wheezing with sweating indicates interior heat. Abundant yang and interior heat warrant Gegen Huanglian Huangqin Tang.)
Combined disease of Taiyang and Shaoyang, with spontaneous diarrhea. Treat with Huangqin Tang. If vomiting occurs, treat with Huangqin Jia Banxia Shengjiang Tang. (Diarrhea with headache, chest fullness, bitter taste, dry throat, alternating chills and fever, with large or wiry pulses.)
Huangqin Tang Formula:
Huangqin (3 liang), Shaoyao, Gancao (each 2 liang), Dazao (12 pieces, split). The above four ingredients are boiled in 1 dou of water to obtain 3 sheng. Strain and take 1 sheng warm, twice daily and once at night. (For weak and deficient constitutions, bitter herbs solidify and astringents collect; the bitterness and sourness of Huangqin and Shaoyao solidify and collect the qi of the intestines and stomach. For weak and insufficient gastrointestinal function, sweet herbs tonify; the sweetness of Gancao and Dazao tonifies and consolidates gastrointestinal weakness.)
Huangqin Jia Banxia Shengjiang Tang:
Add Banxia (0.5 sheng, washed) and Shengjiang (3 liang, sliced) to Huangqin Tang.
Concurrent disease of Taiyang and Shaoyang, incorrectly purged, leading to pathogenic knotting in the chest, forming Jiechest (Chest Binding) syndrome, epigastric hardness, unremitting diarrhea, inability to swallow liquids, and mental restlessness. (Can use Shengjiang Xiexin Tang, Dahuang Huanglian Xiexin Tang, or Xiaoxianzhong Tang. Zhang Yuansu notes: All combined diseases involve diarrhea, distinguished by exterior signs. Taiyang disease presents with headache in the head and neck and stiffness in the waist and spine; Yangming disease presents with eye pain, nasal dryness, and insomnia; Shaoyang disease presents with hypochondriac pain and deafness. Whenever two Yang channel syndromes appear simultaneously with diarrhea, it is called combined disease. Although seeing one sign is sufficient for diagnosis, Zhang Zhongjing only mentions Taiyang and Shaoyang combined disease because the previous chapter encompasses these signs. Moreover, signs vary by channel, making fixed conclusions difficult.)
Taiyang syndrome, Guizhi syndrome, incorrectly purged, leading to unremitting diarrhea with a rapid pulse, indicating unresolved exterior; wheezing with sweating is treated with Gegen Huangqin Huanglian Tang.
Gegen Huangqin Huanglian Tang Formula:
Gegen (0.5 jin), Gancao (roasted), Huangqin (each 2 liang), Huanglian (3 liang). The above four ingredients are boiled in 8 sheng of water. First boil Gegen, reducing the water by 2 sheng, then add other herbs, boil to obtain 2 sheng. Strain and divide into two warm doses. (The Inner Canon states: Pungent and sweet disperse yang. For unresolved exterior, use the sweetness of Gegen and Gancao to disperse; for weak interior qi, use the bitterness of Huangqin and Huanglian to solidify.)
After purging Taiyang syndrome, a rapid pulse without Jiechest indicates the condition is resolving; a sinking-slippery pulse indicates協 heat diarrhea; a floating-slippery pulse indicates必定 hematochezia. Use Huangqin Tang.
Taiyang syndrome, persisting for two to three days, inability to lie down, desire to sit up, epigastric binding, weak pulse, indicates pre-existing cold-damp separation. Incorrect purging leads to either cessation of diarrhea (resulting in Jiechest) or continued diarrhea (leading to協 heat diarrhea on the fourth day if purged again). Use Huangqin Tang.
Cold damage wind-strike, incorrectly purged, leading to unremitting diarrhea, undigested food, borborygmus, epigastric hardness/fullness, dry retching, mental restlessness. The physician sees痞 and purges again, worsening the痞. This is not heat binding but empty stomach with rebellious guest qi causing hardness. Use Gancao Xiexin Tang.
After sweating resolves cold damage, stomach disharmony, epigastric痞 hard, dry belching with food odor, fluid retention in hypochondrium, borborygmus, and diarrhea. Use Shengjiang Xiexin Tang.
Taiyang wind-strike with diarrhea and vomiting/reversal. If exterior is resolved, internal attack is permissible. Frequent sweating, intermittent headaches, epigastric痞 hard, pain radiating to hypochondrium, dry retching, shortness of breath, sweating without aversion to cold. This indicates resolved exterior and unharmonized interior. Use Shizao Tang.
Cold damage fever, sweating without resolution, epigastric痞 hard, vomiting, and diarrhea. Use Da Chaihu Tang.
Cold damage unresolved for thirteen days, passing through stages, with delirium due to heat. Should be treated with decoction for purging. If urination is free, stool should be hard; if diarrhea occurs with a harmonious pulse, it is due to vulgar physicians using pill purgatives, which is incorrect treatment. Natural diarrhea should present with faint/cold pulse; a harmonious pulse indicates internal excess. Use Tiaowei Chengqi Tang.
Taiyang disease, second day, unexpected irritability, abnormal back fanning causing profuse sweating, fire-heat entering stomach, fluid exhaustion, irritability,必定 delirium. After ten-plus days, shaking chills and spontaneous diarrhea indicate resolution.
Cold damage, physician purges, leading to unremitting diarrhea with undigested food and body pain. Urgently rescue the interior with Sini Tang. If body pain persists but bowel/bladder functions are normal, urgently rescue the exterior with Guizhi Tang. (Cheng Wuji notes: After purging, unremitting diarrhea with undigested food and body pain requires urgent interior rescue due to interior qi deficiency. Give Sini Tang urgently. Once bowel/bladder normalize, knowing interior qi is harmonized, give Guizhi Tang urgently to rescue the exterior. Body pain is exterior pathogen. The Inner Canon states: When disease begins with deficiency, treat the branch first, then the root. Here, cold is the root.)
Sini Tang Formula:
Gancao (roasted, 2 liang), Ganjiang (1.5 liang), Fuzi (1 piece, peeled, broken into 8 pieces. Alternative method: Peel Fuzi, remove navel, boil half cup salt water and ginger juice in clay pot for seven boils, add Gancao and Huanglian (0.5 liang each), add child's urine (0.5 cup), boil seven more boils, let stand, remove, store in porcelain vessel exposed to earth qi for one day, dry for later use to avoid toxicity. Best to use round, correct 1-liang pieces). The above three ingredients are crushed, boiled in 3 sheng of water to obtain 1.2 sheng. Strain and divide into two warm doses. Robust individuals may use 1 large Fuzi and 3 liang Ganjiang.
Cheng Wuji notes: The four limbs are the root of all yang. Insufficient yang qi, exacerbated by yin-cold, leads to failure of yang qi connection, causing cold limbs (Sini). This decoction promotes yang qi, disperses yin-cold, warms meridians and muscles, hence named Sini Tang. The Inner Canon states: Treat internal cold with pungent-hot herbs, dispel yin, support yang, primarily using sweet herbs. Thus, Gancao is the sovereign herb. The Inner Canon states: To counteract winning cold, use pungent-hot herbs to drive out cold; healthy qi relies on pungent-hot herbs. Thus, Ganjiang is the minister herb. The Inner Canon states: Pungent moistens, opens pores, generates fluids, circulates qi. Warming muscles and meridians requires great heat. Thus, Fuzi is the envoy herb. This is a unique large-dose formula. Sini Tang belongs to Shaoyin disease; Shaoyin is Kidney. Liver and Kidney are distant; large doses are needed to reach them. The Inner Canon states: For distant diseases, use odd/even combinations and increase dosage.
After taking decoctions for cold damage, unremitting diarrhea and epigastric痞 hard persist despite Xiexin Tang, and further purging worsens diarrhea. Lizhong Tang treats middle jiao, but this diarrhea is in the lower jiao; use Chishizhi Yuyuliang Tang. If diarrhea continues, promote urination (or use Zhuling Tang).
Chishizhi Yuyuliang Tang Formula:
Chishizhi (1 jin, crushed), Yuyuliang (1 jin, crushed). The above two ingredients are boiled in 6 sheng of water to obtain 2 sheng. Strain and divide into three doses.
Cold damage unresolved for thirteen days, chest/hypochondriac fullness with vomiting, afternoon tidal fever, followed by mild diarrhea. This was originally a Chaihu syndrome; incorrect purging caused diarrhea. Now, relapse of diarrhea is due to incorrect use of pill purgatives. Tidal fever indicates excess. First use Chaihu Tang to resolve the exterior, then Chaihu Jia Mangxiao Tang.
Taiyang disease, over ten days past the stage, epigastric warmth with urge to vomit, chest pain, loose stool, mild abdominal fullness, slight vexation. Previous aggressive vomiting/purging warrants Tiaowei Chengqi Tang.
Yangming Chapter:
Disease with tidal fever, loose stool, normal urination, hypochondriac fullness. Use Xiaochaihu Tang.
Patient with no exterior/interior signs, fever for 7-8 days, floating-rapid pulse, can be purged. Post-purge, rapid pulse persists, unremitting diarrhea,必定 pus/blood in stool. Use Huangqin Tang, Bopi Tang.
Combined disease of Yangming and Shaoyang,必定 diarrhea. Non-defeating pulse (Shaoyang pulse does not overcome Yangming) is favorable; defeating pulse is unfavorable. Mutual overcoming is called defeating. Slippery-rapid pulse indicates retained food, should be purged with Dachengqi Tang. (Cheng Wuji notes: Yangming is Earth, Shaoyang is Wood. Combined disease, qi disharmony leads to diarrhea. Shaoyang pulse not overcoming Yangming is non-overcoming/favorable. Shaoyang overcoming Yangming is defeating/unfavorable. Pulse Classic states: Slippery pulse indicates food disease. Slippery-rapid indicates strong stomach qi. Diarrhea should have faint/cold pulse; slippery-rapid indicates retained food. Give Dachengqi Tang to purge.)
Zangjie (Organ Binding) resembles Jiechest, normal diet, frequent diarrhea, floating cun pulse, small-fine-sinking-tight guan pulse, white slippery tongue coating. Difficult to treat.
Taiyin Chapter:
Taiyin disease, abdominal fullness with vomiting, inability to eat, worsening spontaneous diarrhea, periodic abdominal pain. Incorrect purging leads to epigastric binding. Spontaneous diarrhea without thirst belongs to Taiyin due to organ cold; treat with warming, suitable for Si Ni Bei (Zhang Yuansu notes: "Bei" means similar properties, varying in strength/quality. Taiyin spontaneous diarrhea without thirst is treated with Lizhong Tang, or Lizhong Tang plus Fuzi for severe cases. Si Ni Tang is very hot; cautious use is advised. Lizhong Tang is safer. Si Ni Tang is for desperate cases.). Taiyin disease, weak pulse, continuous loose stools. If Shaoyao/Dahuang were indicated, reduce dosage due to weak stomach qi prone to moving stool. (Cheng Wuji notes: Abdominal fullness/pain is Taiyin. Weak pulse and continuous loose stools mean pathogen is interior but not severe excess. If using Dahuang/Shaoyao to purge, use small amounts as stomach qi is weak and prone to diarrhea.) Cold damage, floating-slow pulse, warm hands/feet, relates to Taiyin. Jaundice expected; if urination is free, no jaundice. By day 7-8, sudden irritability and >10 diarrheas will self-resolve as spleen qi recovers and rotting filth is expelled. (Use Pingwei San plus Chuan Shan Jia).
Shaoyin Chapter:
Desire to vomit without vomiting, drowsiness, spontaneous diarrhea with thirst after 5-6 days belongs to Shaoyin. Deficiency draws water for self-rescue. White urine indicates complete Shaoyin syndrome; white urine is due to lower jiao deficiency-cold failing to control water. (Desire to vomit/vexation is exterior transmitting inward. Abdominal pain/fullness is Taiyin. Drowsiness indicates Shaoyin. Day 5-6 is transmission time. Diarrhea without thirst is middle jiao cold/Taiyin. Diarrhea with thirst is lower jiao cold/Shaoyin. Note: "Cold in lower jiao causing thirst" is logically flawed; cold doesn't cause thirst. White urine confirms lower jiao deficiency-cold. Water is drawn externally due to deficiency, not heat. Huoren Shu says treat with Sini Tang. If urine is yellow-red, see Jueyin chapter: Diarrhea with desire to drink water is heat, treat with Baitouweng Tang.) Shaoyin disease, diarrhea, sore throat, chest fullness, vexation. Use Zhufu Tang.
Zhufu Tang Formula:
Zhufu (1 jin). Boil in 1 dou of water to obtain 5 sheng. Strain, add Baimi (1 sheng) and Baifen/Rice Flour (0.5 he), cook until fragrant, mix, divide into six warm doses. (Pig is water animal, qi enters Kidney. Shaoyin guest heat is resolved by Zhufu. Baimi moistens/dispels vexation; Baifen boosts qi/stops diarrhea.)
Shaoyin disease, cold limbs or heavy diarrhea. Use Sini San (see previous).
Shaoyin disease, diarrhea for 6-7 days, cough, vomiting, thirst, vexation, insomnia. Use Zhuling Tang (see thirst section).
Shaoyin disease, spontaneous clear green water diarrhea, epigastric pain, dry mouth. Urgently purge with Dachengqi Tang.
Sun Simiao Case: Dou Dalang had cold damage for 10+ days, dry mouth/tongue/thirst, heart pain, clear green water diarrhea. Physicians advised conservative care, fearing sweating/purging. Relatives summoned Sun Simiao. Sun said: "Cannot purge today, must purge tomorrow." Gave Xiao Chengqi Tang. Bowels opened, patient slept. Recovered next day. Asked why purging worked, Sun said: "Superficial knowledge misses the essence. Dry mouth/thirst is Shaoyin syndrome. Though Shaoyin usually forbids purging, Zhang Zhongjing explicitly states Shaoyin clear water diarrhea with heart pain is cured by purging." All admired.
Shaoyin disease, diarrhea, aversion to cold, curling up, warm hands/feet. Treatable with Sini Tang.
Shaoyin disease, days 2-4, abdominal pain, dysuria, unremitting bloody/pus diarrhea. Treat with Taohua Tang (see abdominal pain).
Taohua Tang Formula:
Chishizhi (1 jin, half whole, half powder), Ganjiang (1 liang), Jingmi (1 sheng). Boil in 7 sheng water until rice is cooked. Strain, take 0.7 sheng warm, add 1 cubic inch of Chishizhi powder, three times daily. Stop if cured. (Astringency removes collapse; Chishizhi secures intestines. Pungency disperses; Ganjiang disperses interior cold. Sweetness tonifies; Jingmi supports healthy qi.)
Shaoyin disease, days 2-4, abdominal pain, dysuria, heavy limbs, diarrhea, indicates water qi. Cough, free urination, diarrhea, or vomiting variants. Treat with Zhenwu Tang (see abdominal pain).
Zhenwu Tang Formula:
Fuling (3 liang), Shengjiang (sliced), Shaoyao (each 3 liang), Baizhu (2 liang), Fuzi (1 piece, roasted, peeled, broken). Boil in 8 sheng water to obtain 3 sheng. Strain, take 0.7 sheng warm, three times daily. (Spleen dislikes dampness; sweet enters spleen. Fuling/Baizhu tonify spleen/drive water. Cold/wind dampness treated with pungent-hot/sour-flat. Fuzo/Shao Yao/Sheng Jiang warm meridians/disperse damp.)
Modifications: If cough, add Wuweizi (0.5 sheng), Xixin, Ganjiang (each 1 liang) to astringe lung qi and disperse cold-water. If urination free, remove Fuling (no retained water). If diarrhea, remove Shaoyao, add Ganjiang (2 liang) as Shaoyao drains qi and Ganjiang disperses cold. If vomiting, remove Fuzi, add Shengjiang (to 0.5 jin) as Fuzi tonifies qi (bad for rebellion) and Shengjiang disperses qi (stops vomiting).
Cheng Wuji notes: Zhenwu is Northern Water God. Water qi in heart region/exterior yang requires dispersion, hence Zhenwu Tang for Shaoyin (Kidney Water). Spleen dislikes dampness; water in abdomen impairs spleen. Spleen desires relaxation, sweet foods relax. Sweet herbs (Fuling/Baizhu) drain water/relax spleen. Sour-flat (Shaoyao/Sheng Jiang) assist in draining damp. Pungent-hot (Fuzi) warms meridians. Variations exist due to water qi distribution. Cough is cold-water attacking lung; astringe with Wuweizi. Lung dislikes cold; moisten with Xixin/Ganjiang. Free urination removes Fuling. Dysuria removes Shaoyao (astringent) adds Ganjiang (disperses cold). Vomiting removes Fuzi (tonifies) adds Shengjiang (disperses).
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 retching, sore throat, or cessation of diarrhea with absent pulse. Treat with Tongmai Sini Tang.
Tongmai Sini Tang Formula (Same as Sini Tang but double Ganjiang):
Gancao (roasted, 2 liang), Fuzi (1 large, raw, peeled, broken), Ganjiang (3 liang, 4 liang for robust). Boil in 3 sheng water to obtain 1.2 sheng. Strain, divide into two warm doses. Pulse returning indicates cure. Red face: add Congbai (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 (1 liang) to scatter knot. Cessation of diarrhea/absent pulse: remove Jiegeng, add Renshen (2 liang) to tonify blood/qi. (Classic: Faint pulse with diarrhea indicates blood loss; Sini Jia Renshen Tang treats this. Match pulse/symptoms to formula.)
Shaoyin disease, diarrhea. Baitong Tang treats (Shaoyin governs water; guest cold fails to control water, causing diarrhea. Baitong Tang warms interior/disperses cold).
Shaoyin disease, diarrhea, faint pulse, given Baitong Tang. If diarrhea continues, cold limbs, absent pulse, dry retching, vexation. Baotong Jia Zhu Danji Tang treats. Post-medication, sudden pulse emergence indicates death; gradual pulse return indicates life. (Faint pulse indicates extreme cold/yin excess. Baitong Tang restores yang. Continued symptoms indicate severe cold rejection/rebellion. Baotong Jia Zhu Danji Tang harmonizes. Inner Canon: Reverse treatment vs. Follow treatment. Sudden pulse is healthy qi collapsing; death. Gradual pulse is yang recovering; life.)
Baitong Tang Formula