凡伤寒热邪正盛之时。必在阳明胃经。阳明以胃实为病。故大便不通。然火症往往下黄黑稠粘之物。
此热邪下逼大肠。非痢也。虽通仍作不通论。只用清火解毒以治阳明。其利自止。
邵评∶热结肠胃。下迫大肠而下注。治宜清化火热。
如伤寒热症。下痢纯清水或黄沫。潮热腹硬。脉沉滑有力者。此名旁流。因肠中有燥矢阻塞。水浆从
旁渗出。病在阳明。非关脾也。导去燥矢。其痢自止。
邵评∶所下皆是水沫。吃下之汤水。随热下注。肠中有燥屎内结。水从旁流也。下
其燥矢。热退则愈。盖燥矢在肠。水从旁流。非下不可。
有阳明火症。邪火不杀谷。吃汤下汤。吃水下水。此有阳明实症可据。非若脾肾俱
败者比。亦只清其火邪。其痢自止。
邵评∶胃中火盛。水谷消化不及。则谷不化。火性急速。不能停留。故一吃即利。此
火迫下注。必有实热见症。实火脉象形于外。与脾肾阳虚火衰。不能消化。下利
清谷者。大相天渊。清化胃中邪火。利可自止。
有一种外感风寒。内伤饮食。其症头疼恶寒发热。恶心
饱闷。肠胃窘迫。而泄痢者。此表里俱病。法当外散表邪。内消积滞。不在伤寒变病之例。
邵评∶表里交病。外邪内迫而下利。宜疏表和里。两解治之。如枳、桔、栀、豉加葛根、
焦鸡金。最妙。
有一种表热里寒之症。初起头痛恶寒发热。继即下痢清谷。脉浮而迟。口不渴饮。
俗名漏底伤寒是也。良由其人脾胃本虚。一感外邪。即得直入肠胃。不在太少留连。速当温中散寒。加紫苏、
桂枝、羌活、浓朴、广皮、木香、茯苓、甘草之类。甚者加冬术、干姜。
邵评∶此与上条有轻重虚实之不同。上条表有风邪。而内伤饮食。是表里俱实。此条表有热邪。而里则
虚寒。是表实里虚。中阳亏乏。表邪乘虚内入。直走肠胃而下利也。治宜温运中阳。外散表寒。与上条治法
不同。此方治脾胃中虚有寒。表邪入里而下利。的是正法。
若阳邪传里。热邪攻于肠胃。而变下利脓血者。重症也。然亦有寒热之分。盖邪至
三阴。为日已久。实者则从阳化热。虚者则从阴化寒矣。如少阴下利。用猪苓汤者。
从阳化热也。用桃花汤者。从阴化寒也。辨症之法。以脉数有力为热。脉缓无力为
寒。舌燥口渴属热。舌润不渴属寒。小便赤涩属热。清白属寒。下利肠垢属热。鸭溏
属寒。热利脐下必热。寒利脐下必寒。热利当清其肠。寒利当温其下。
邵评∶阳经热邪传于里。有化寒化热之不同。辨别精明。须熟记之。
凡伤寒疫疠。热邪传里。下利肠垢。或下鲜血。小溺赤涩。舌苔黄燥如刺。或红刺如
杨梅状。身热口渴。六脉洪数。脐腹大痛者。此热毒内攻肠胃也。不治则烂矣。急用
大黄、芩连、银花、丹皮、芍药、甘草之类。下之清之。继用鲜生地数两。代大黄与之。以
养阴解毒。若下利肠垢。其势稍缓者。宜黄芩汤加川连、银花、丹皮之属清之。血利
加丹参、槐米、川断。
邵评∶火热疫毒。盛于肠胃。急用苦寒清下治之。
如遇伤寒疫症。下利如豆汁鱼脑之色。脉象沉濡。舌白如粉。小便不利。而口不渴
者。湿毒聚于肠胃也。宜茅术、浓朴、广皮、二苓、滑石、泽泻、晚蚕砂、 本之类。渗之和之。
邵评∶此湿温症而兼疫毒也。宜清渗湿邪治之。此方颇合。
如下利杂色。六脉沉迟。舌润无苔。或紫色而光。口不渴饮。肠胃并连。直出无关闭者。此脾肾虚寒。
关闸不阖。元气下泄之证也。急投胃关煎。合桃花汤。兼从手阳明以堵截之。或桃花汤重加人参以截之。
邵评∶肾阳亏乏。虚寒下利。滑脱无度。温涩下焦为治。
如见外热内烦。舌燥口渴。脘中痞闷。或痛或呕。而利不止者。中焦湿热也。当用泻
心法。芩连、半夏、干姜、枳实、木香、赤苓、泽泻之类。
邵评∶湿热痞结中焦。脘闷呕痛。不食下利。似是噤口痢症。防其闭结。用开痞泄邪之法。却是正治。
凡下利。舌苔遍地白浓。如雪花者。脏结也。不治。
邵评∶阳虚体湿。浊阴凝结于中。苔浓如雪花者。邪结已深也。纯阴无阳。故不治。
凡三阴下利。小便不利者。津液竭也。不可妄利小便。
邵评∶阴经下利。而小便不利。阴津亏乏也。如妄利之。阴气竭绝而津涸矣。
凡是伤寒病中热邪正盛的时候，病位一定在阳明胃经。阳明经以胃腑实证为主要病变，所以出现大便不通。然而火证往往排出黄黑色、黏稠的排泄物。这是热邪向下逼迫大肠所致，并非痢疾。虽然表现为通利，但仍按不通（实热内结）来论治。只需使用清泻火热、解毒的方法治疗阳明经，其下利自然停止。
邵评：热邪结聚于肠胃，向下逼迫大肠导致下注。治疗应当清化火热。
如果是伤寒热证，下痢纯清水或黄色泡沫，伴有潮热、腹部坚硬，脉象沉滑而有力，这称为“旁流”。这是因为肠道中有燥屎阻塞，水液从旁边渗出。病位在阳明，与脾脏无关。导去燥屎，其下利自然停止。
邵评：所排出的都是水沫，是喝下去的汤水随着热邪向下注泄。肠道内有燥屎结聚，水液从旁流出。攻下燥屎，热退则病愈。因为燥屎在肠中，水从旁流，非用攻下法不可。
有的阳明火证，邪火不能腐熟水谷，吃汤就拉汤，喝水就拉水。这是有阳明实证的依据，不像脾肾俱败的情况。也只需用清泻火邪的方法，其下利自然停止。
邵评：胃中火气旺盛，水谷消化不及，所以食物不化。火性急速，不能停留，所以一吃即泻。这是火迫急迫向下注泄，必有实热的征象。实火的脉象表现于外，与脾肾阳虚、火力衰弱、不能消化而导致的下利清谷，截然不同。清化胃中的邪火，下利可自止。
有一种因外感风寒、内伤饮食引起的病症，症状为头痛、恶寒、发热、恶心、饱闷、肠胃窘迫而下痢。这是表里同病，治法应当外散表邪，内消积滞。这不属于伤寒变病的范畴。
邵评：表里同时受病，外邪内迫导致下利。宜疏解表邪、调和里气，表里双解。如用枳壳、桔梗、栀子、豆豉，加葛根、焦鸡内金，效果最好。
有一种表热里寒的病症，初起时头痛、恶寒、发热，随即出现下利清谷，脉象浮而迟，口不渴饮。俗名“漏底伤寒”。大概是因为此人脾胃本虚，一旦感受外邪，病邪便直入肠胃，不在太阳、少阳经停留。应当迅速温中散寒，加入紫苏、桂枝、羌活、厚朴、陈皮、木香、茯苓、甘草等药。病情严重的加白术、干姜。
邵评：此条与上一条相比，有轻重虚实之不同。上一条是表有风邪，内伤饮食，属于表里俱实；此条是表有热邪，而里则虚寒，属于表实里虚。中阳亏乏，表邪乘虚内入，直走肠胃而导致下利。治疗宜温运中阳，外散表寒，与上一条的治法不同。此方治疗脾胃中虚有寒、表邪入里而下利，确实是正法。
如果阳邪传入体内，热邪攻冲肠胃，变为下利脓血，这是重症。然而也有寒热之分。邪气到达三阴经，病程已久，实证则从阳化热，虚证则从阴化寒。例如少阴下利，用猪苓汤的，是从阳化热；用桃花汤的，是从阴化寒。辨别症状的方法：脉数有力属热，脉缓无力属寒；舌燥口渴属热，舌润不渴属寒；小便赤涩属热，清白属寒；下利肠垢属热，鸭溏（稀薄如水）属寒；热利脐下必热，寒利脐下必寒；热利当清肠，寒利当温下。
邵评：阳经热邪传入体内，有化寒化热之不同。辨别必须精明，须熟记这些要点。
凡是伤寒疫病，热邪传入体内，下利肠垢，或下鲜血，小便赤涩，舌苔黄燥如刺，或红刺如杨梅状，身热口渴，六脉洪数，脐腹大痛，这是热毒内攻肠胃。如果不治疗就会腐烂死亡。急需使用大黄、黄芩、黄连、金银花、丹皮、芍药、甘草等药，攻下并清解。随后用鲜生地数两，代替大黄服用，以滋养阴液、解毒。如果下利肠垢，病情稍缓的，宜用黄芩汤加川连、金银花、丹皮等药清解。血利加丹参、槐米、川断。
如果遇到伤寒疫病，下利如豆汁、鱼脑的颜色，脉象沉濡，舌白如粉，小便不利，口不渴，这是湿毒聚于肠胃。宜用苍术、厚朴、陈皮、茯苓、猪苓、滑石、泽泻、晚蚕砂、藁本等药，渗湿和解。
如下利杂色，六脉沉迟，舌润无苔，或紫色而光亮，口不渴饮，肠胃松弛，直出无关闭之感，这是脾肾虚寒，关闸不阖，元气下泄的证候。急需投用胃关煎，合桃花汤，兼从手阳明经以堵截病势。或者在桃花汤中重加人参以截断病势。
如果见到外热内烦，舌燥口渴，脘中痞闷，或痛或呕，而下利不止，这是中焦湿热。应当使用泻心法，用黄芩、黄连、半夏、干姜、枳实、木香、赤茯苓、泽泻等药。
邵评：湿热痞结于中焦，脘闷呕痛，不食下利，看似噤口痢症。防止其闭结，用开痞泄邪的方法，却是正治。
邵评：阳虚体湿，浊阴凝结于中，苔浓如雪花，说明邪结已深。纯阴无阳，故不治。
When the pathogenic heat is at its peak in Taiyang cold damage (Taiyang Cold Damage), the disease location must be in the Yangming Stomach Meridian. The Yangming meridian manifests as excess syndrome of the stomach, resulting in constipation. However, fire syndromes often present with the discharge of yellow-black, sticky excrement. This is caused by pathogenic heat forcing downward into the Large Intestine, not dysentery. Although there is diarrhea, it should still be treated as obstruction (excess heat accumulation). One should only use methods to clear fire and detoxify to treat the Yangming meridian; the diarrhea will stop spontaneously.
Shao's Commentary: Heat accumulation in the intestines and stomach forces downward into the Large Intestine, causing diarrhea. Treatment should focus on clearing and transforming the pathogenic heat.
In cases of cold damage heat syndrome, if there is diarrhea of pure clear water or yellow foam, accompanied by tidal fever, abdominal hardness, and a deep, slippery, and forceful pulse, this is named "Pangliu" (Side Flow). This occurs because dry fecal matter obstructs the intestine, allowing fluids to seep out from the sides. The disease is in the Yangming meridian and has nothing to do with the Spleen. Once the dry fecal matter is guided out, the diarrhea stops spontaneously.
Shao's Commentary: What is discharged are all water and foam; the consumed soups and waters flow downward with the heat. Dry fecal matter is internally bound in the intestine, and water flows from the sides. Purging the dry fecal matter allows the heat to retreat and the illness to heal. Because dry fecal matter is in the intestine and water flows from the sides, purgation is indispensable.
In some Yangming fire syndromes, pathogenic fire fails to digest food and drink ("not killing grain"). Whatever soup is eaten is passed as soup, whatever water is drunk is passed as water. This indicates evidence of Yangming excess syndrome, unlike cases where both the Spleen and Kidney are exhausted. Only clearing the pathogenic fire is needed, and the diarrhea will stop spontaneously.
Shao's Commentary: Excessive fire in the stomach prevents the digestion of food and drink, hence undigested grains appear. Fire nature is rapid and does not stay, so ingestion leads immediately to diarrhea. This is fire forcing downward rapidly, necessarily presenting with signs of excess heat. The pulse of excess fire manifests externally, which is vastly different from diarrhea of undigested food due to Spleen-Kidney Yang deficiency and weak fire failing to digest. Clearing and transforming the pathogenic fire in the stomach can stop the diarrhea.
There is a condition caused by external contraction of wind-cold and internal injury from diet. Symptoms include headache, aversion to cold, fever, nausea, fullness, intestinal distress, and diarrhea. This is a simultaneous exterior and interior disease. The method should be to disperse exterior pathogens externally and eliminate stagnation internally. This does not fall under the category of complications of cold damage.
Shao's Commentary: Exterior and interior are simultaneously diseased; external pathogens force inward causing diarrhea. It is appropriate to soothe the exterior and harmonize the interior, treating both. For example, using Zhi Qiao (Fructus Aurantii), Jie Geng (Radix Platycodonis), Zhi Zi (Fructus Gardeniae), Chi Dou (Semen Sojae Praeparatum) plus Ge Gen (Radix Puerariae) and Jiao Ji Jin (Endothelium Corneum Gigeriae Galli) is excellent.
There is a syndrome of exterior heat and interior cold. Initially, there is headache, aversion to cold, and fever, followed immediately by diarrhea of undigested food. The pulse is floating and slow, and there is no thirst for drinking. This is commonly known as "Lou Di Shang Han" (Leaky Bottom Cold Damage). This is likely because the person's Spleen and Stomach are originally deficient; upon contracting external pathogens, the pathogen enters the intestines and stomach directly without lingering in the Taiyang or Shaoyang meridians. One should quickly warm the middle and dispel cold, adding Zi Su Ye (Folium Perillae), Gui Zhi (Ramulus Cinnamomi), Qiang Huo (Rhizoma Notopterygii), Hou Po (Cortex Magnoliae Officinalis), Chen Pi (Pericarpium Citri Reticulatae), Mu Xiang (Radix Aucklandiae), Fu Ling (Poria), and Gan Cao (Radix Glycyrrhizae). In severe cases, add Bai Zhu (Rhizoma Atractylodis Macrocephalae) and Gan Jiang (Rhizoma Zingiberis).
Shao's Commentary: This differs from the previous clause in terms of severity, deficiency, and excess. The previous clause had wind pathogens on the exterior and dietary injury inside, representing both exterior and interior excess. This clause has heat pathogens on the exterior but deficiency-cold inside, representing exterior excess and interior deficiency. Middle Yang is deficient, allowing exterior pathogens to enter inward through the deficiency, going straight to the intestines and stomach causing diarrhea. Treatment should warm and transport Middle Yang and disperse exterior cold, differing from the treatment of the previous clause. This formula correctly treats diarrhea caused by cold in the Spleen-Stomach deficiency entering the interior.
If Yang pathogens transmit to the interior, and heat pathogens attack the intestines and stomach, changing into diarrhea with pus and blood, this is a severe condition. However, there is also a distinction between cold and heat. When pathogens reach the Three Yin meridians, after many days, excess conditions transform into heat from Yang, while deficiency conditions transform into cold from Yin. For example, in Shaoyin diarrhea, using Zhu Ling Tang (Polyporus Decoction) indicates transformation into heat from Yang; using Tao Hua Tang (Peach Blossom Decoction) indicates transformation into cold from Yin. The method for distinguishing symptoms is: rapid and forceful pulse indicates heat; slow and weak pulse indicates cold; dry tongue and thirst indicate heat; moist tongue and no thirst indicate cold; red and astringent urine indicates heat; clear and white urine indicates cold; diarrhea with intestinal mucus indicates heat; duck-like loose stool indicates cold; heat diarrhea implies heat below the umbilicus; cold diarrhea implies cold below the umbilicus. Heat diarrhea should be cleared in the intestines; cold diarrhea should be warmed below.
Shao's Commentary: Heat pathogens from Yang meridians transmitting to the interior may transform into cold or heat. Distinction must be precise; these points must be memorized thoroughly.
In all cases of cold damage epidemics, when heat pathogens transmit to the interior, presenting with diarrhea of intestinal mucus or fresh blood, red and astringent urine, yellow and dry tongue coating like thorns, or red prickles like a strawberry, body heat, thirst, surging and rapid pulses in all six positions, and severe pain in the navel and abdomen, this is heat-toxin attacking the intestines and stomach internally. If untreated, rotting will occur. Urgently use Da Huang (Radix et Rhizoma Rhei), Huang Qin (Radix Scutellariae), Lian Qiao (Fructus Forsythiae - *Note: Text says Huang Lian, usually Rhizoma Coptidis*), Yin Hua (Flos Lonicerae), Dan Pi (Cortex Moutan), Shao Yao (Radix Paeoniae Rubra/Alba), and Gan Cao (Radix Glycyrrhizae) to purge and clear. Subsequently, use several liang of fresh Sheng Di Huang (Radix Rehmanniae Preparata) instead of Da Huang to nourish Yin and detoxify. If diarrhea of intestinal mucus is slightly less severe, use Huang Qin Tang (Scutellaria Decoction) added with Chuan Lian (Rhizoma Coptidis), Yin Hua, and Dan Pi to clear. For bloody diarrhea, add Dan Shen (Radix Salviae Miltiorrhizae), Huai Mi (Flos Sophorae), and Chuan Duan (Radix Dipsaci).
Shao's Commentary: Fiery heat and epidemic toxins are abundant in the intestines and stomach; urgently treat with bitter-cold purgatives.
When encountering cold damage epidemic syndromes, if diarrhea resembles the color of bean curd dregs or fish brains, with a deep and soggy pulse, white tongue coating like powder, difficult urination, and no thirst, this is damp-toxin accumulating in the intestines and stomach. Use Cang Zhu (Rhizoma Atractylodis), Hou Po, Chen Pi, Er Ling (Fu Ling and Zhu Ling), Hua Shi (Talcum), Ze Xie (Rhizoma Alismatis), Wan Can Sha (Semen Bombycis Batryticatum), and Ben Cao (Radix Ligustici Chuanxiong - *Note: Text says 'Ben', likely Gu Ben or Chuan Ben*) to渗 (percolate/drain) and harmonize.
Shao's Commentary: This is a damp-warmth syndrome complicated by epidemic toxin. It is appropriate to clear and percolate dampness. This formula fits well.
If diarrhea presents mixed colors, with deep and slow pulses in all six positions, a moist tongue without coating, or purple and shiny tongue, no thirst for drinking, lax intestines and stomach, and uncontrolled expulsion without closure sensation, this is Spleen-Kidney deficiency-cold, failure of the gate to close, and leakage of Yuan Qi downward. Urgently administer Wei Guan Jian (Stomach Gate Decoction) combined with Tao Hua Tang (Peach Blossom Decoction), and additionally block the path via the Hand-Yangming meridian. Or, heavily add Ren Shen (Radix Ginseng) to Tao Hua Tang to intercept the pathogen.
Shao's Commentary: Kidney Yang deficiency causes deficiency-cold diarrhea with uncontrolled slipping. Treatment should warm and astringe the Lower Jiao.
If external heat and internal restlessness are seen, with dry tongue, thirst, epigastric stuffiness, pain or vomiting, and continuous diarrhea, this is damp-heat in the Middle Jiao. One should use the Xie Xin Fa (Drain the Epigastrium Method), using Huang Qin, Huang Lian, Ban Xia (Rhizoma Pinelliae), Gan Jiang, Zhi Shi (Fructus Aurantii Immaturus), Mu Xiang, Chi Ling (Poria cum Radix Pini), and Ze Xie.
Shao's Commentary: Damp-heat stagnation in the Middle Jiao causes epigastric stuffiness, vomiting, pain, anorexia, and diarrhea, resembling Jin Kou Li (Silent Dysentery). To prevent closure, using methods to open stagnation and drain pathogens is indeed the correct treatment.
In all cases of diarrhea, if the tongue coating is thick and white everywhere, like snowflakes, this is Zang Jie (Organ Binding), which is untreatable.
Shao's Commentary: Yang deficiency with damp constitution causes turbid yin to condense in the middle. Thick tongue coating like snowflakes indicates deep pathogen binding. Pure yin without yang, thus untreatable.
In all Three Yin diarrhea cases, if urination is difficult, it indicates exhaustion of body fluids. Do not recklessly use diuretics.
Shao's Commentary: In Three Yin diarrhea, difficulty in urination indicates deficiency of Yin fluids. Reckless diuresis would exhaust Yin Qi and dry up fluids.