二便虽出于二肠，莫非皆肾之开窍也。有因热结大小肠，以致津液不行，热无以泄者，由此
而谵妄发狂，发黄发斑等症随焉，宜苦寒下之。有因过汗亡阴，热耗津液，以致小便秘涩，而大
便燥结者，宜润剂通之。若止小便闭者，行大便则小便通，徒利小便无益。再者，瘟疫利小水，
冀邪热由之而泄，但利之太过，反致大便燥结者有之，不可不知。
自古痢以休息名，罕闻泻而休息者也。有之，自余阅历始，此则不系之以瘟，而系之以疫矣，
盖因发时无少长皆同也。其病自长夏至秋皆有，且有自夏徂秋而不愈者，始终并无瘟疫表里等症。
有兼胀者，有不胀者，食则不减，而最恶饮水，意其为湿也。而其时甚旱，经岁不雨，不知湿从
何来。泻时日数十行，不治终不遽止。长夏炎热，烁石流金，投以健脾温补之药始痊。阅数日而
复作矣，间或痊可，再阅数日而又作矣。缠绵不已，有至数月者。询其复作之由，半因吃生冷与
饱食所致。戒以只食七八分饱，服药月余，则不复作。患此绝少不起者，然病体支离，莫可当矣。
（即泄泻）
瘟疫而见下利，病亦不轻矣。大抵属寒者三，热者七，湿则其仅见者也。而吴
又可《瘟疫论》中协热下利等说，单以热论，不亦偏乎？第瘟病下利之属寒者轻浅，自不得与冬月
感寒，与直中阴经者同日而语也。其属寒者有三。一则感原无大热之瘟病，而过用凉药，因致瘟
不除，而泻又作，此时宜舍病治药，只得先温其里，里温泻止。而瘟病不除也，再解其表。瘟病
原无汗法，斯时，仍用和解疏利，视其邪在某经，细心施治。治之而邪仍不解，必其先此下利时，
有伤元气，阴亏营枯，不能作汗，此时又宜平补滋阴。用熟地、当归、白芍、炙草，再佐以白术、
山药、莲肉，气滞者加陈皮，有寒者加煨姜，不寐者加制半夏、茯神，呕恶者加藿香，调理施治，
则自然汗解而愈矣。或见其大便不实，恐下利复作，于前药中再重用茯苓、制首乌、白扁豆等药，
消息施治，无不获效。一则因大下后而泄泻者，亦因元气亏损，气血伤败，或宜健脾，或宜补肾，
或宜补气血，或宜淡渗，或宜固涩，视其病之轻重，人之虚实，而调治之。一则有不因服凉药与
攻下，而自利者，或因岁气之偏，时气之戾，司天在泉之殊，致饥馑旱涝之触忤，感而成病，初
觉亦头痛身痛，身热发热，自汗微恶寒，继则突然泄泻，却无谵语郑声昏冒，舌苔燥渴斑黄等症。
其脉既不洪数，亦不细微，投以达原饮，而利益甚。投以元霜、素雪等丹，而利不
除。此症原无大热，乃瘟疫中之变局，问其渴，则恶饮水，视其舌，并无黄苔，知其非热利无疑，
总以健脾补肾为主，而以利水佐之。此之补肾却不用熟地，又恐其滑肠，尤忌当归，惟用大首乌、
菟丝、山药、茯苓、白术、苍术、白扁豆、人参、陈皮、炙草等药，消息施治。此时反以下利为
本，而瘟疫为标。盖泄泻不止，则元气日亏，表邪益不能解。若下利止，纵有表邪，再于补药中带
和解施治，况经此大泄，瘟邪亦不能逗留矣。再者，下利虽有表症，不可发汗，恐走津液，而胃
益虚，必成胀满，当先治利，利止内实，正气复，邪自解，得微汗而愈。盖下利为内虚，若发其
汗，则内外皆虚，变症出矣。仲景《伤寒论》三阳合病，皆能自利，有发表、和解、攻里之殊。瘟
病原无发表之说，至于攻里则用凉药。夫凉所以除热也。则试言下利之属热者。热下利必有兼症，
或有口苦咽干，唇焦舌燥，谵语烦渴，尿赤目赤，潮热等症。则或用寒凉，或用攻下，通因通用，
在在所必施。总之，下利不过寒热两端，视其兼症，皎若列眉。其因于寒者，口无燥渴，甚则恶饮水，
恶寒，小便清白，脐下多寒，身虽热，手足逆冷，（此症寒热皆有。）粪色白或淡黄，完谷不化，有如
溏，澄澈清冷，腥臭，脉不洪硬，且无力。至于蜷卧闭目，向壁卧，引衣自盖，出言微细，不欲
见明，面如刀刮等症，则系冬月严寒直中阴经之候。瘟疫下利虽寒，亦无此矣。其因于热者，发
热烦躁，欲饮水，口燥渴，小便黄赤，（寒症亦有。）更兼涩而不利，（寒症则无。）脐下热，泄出作声，
所下如垢腻奇臭，其色青黄赤，酱色，黑色，后重，得凉药则止，得热药则增。其脉则洪数浮滑弦
大盛强，以此辨寒热，万不失一。治各不同，医者宜审。
虽然二便（大小便）分别由大肠和小肠排泄，但归根结底都是肾的窍道。有的因为热邪结聚在大肠和小肠，导致津液运行不畅，热邪无法宣泄，从而出现胡言乱语、发狂、发黄、出斑等症状，应当使用苦寒性质的药物进行攻下治疗。有的因为过度发汗导致阴液亡失，热邪耗伤津液，致使小便闭塞涩痛，而大便干燥结滞，应当使用润燥的药物来通利。如果仅仅是小便闭塞，通过通畅大便则小便自然通利，单纯利尿是没有益处的。再者，瘟疫病中采用通利小便的方法，是希望邪热随之排出，但如果利尿太过，反而会导致大便干燥结滞的情况也是存在的，这一点不可不知道。
自古以来，痢疾被称为“休息痢”（时好时坏），很少听说泄泻也有称为“休息”的。这种情况，是我亲自经历后才遇到的，这种病不归属于瘟病，而归属于疫病了，大概是因为发病时无论老少症状都相同。这种病从长夏到秋季都有发生，甚至有从夏季延续到秋季都不痊愈的，从头到尾都没有瘟疫病的表证和里证等典型症状。有的伴有腹胀，有的不胀，进食后食欲不减，但最厌恶饮水，推测其为湿邪所致。然而当时天气非常干旱，整年不下雨，不知道湿气从何而来。每天腹泻数十次，如果不治疗最终也不会突然停止。在长夏炎热、酷热难耐的时候，投以健脾温补的药物才能痊愈。过几天又复发了，偶尔痊愈，再过几天又发作了。缠绵不断，有的持续数月。询问其复发的原因，一半是因为吃生冷食物和暴饮暴食所致。告诫患者只吃七八分饱，服药一个多月，就不再复发。患此病极少不治身亡的，但病体极度虚弱，难以承受。
（即泄泻）
瘟疫病中出现下利（腹泻），病情也不轻了。大体上属于寒证的占三成，属于热证的占七成，属于湿证的只是偶尔见到。而吴又可《瘟疫论》中关于协热下利等说法，单从热证论述，难道不是偏颇吗？只是瘟疫病下利属于寒证的比较轻浅，自然不能与冬季感受寒邪，以及寒邪直中阴经的情况相提并论。属于寒证的有三种情况。一种是感染原本没有大热的瘟疫病，却过度使用凉药，导致瘟疫未除，而腹泻又发作，此时应当舍弃对原发病的治疗而针对药物副作用进行治疗，只能先温补里气，里气温和则腹泻停止。而瘟疫病仍未解除，再解其表证。瘟疫病原本没有发汗法，此时，仍用和解疏利的方法，观察邪气在哪一经，细心施治。治疗后邪气仍不解，一定是此前下利时损伤了元气，阴亏营血枯涸，不能作汗，此时又宜平补滋阴。使用熟地黄、当归、白芍、炙甘草，再佐以白术、山药、莲子肉，气滞者加陈皮，有寒者加煨姜，失眠者加制半夏、茯神，呕吐恶心者加藿香，调理施治，则自然出汗而痊愈。或者见到大便不成形，担心下利复发，在前药中再重用茯苓、制何首乌、白扁豆等药，斟酌施治，无不获效。另一种是因为大泻之后而导致的泄泻，也是因为元气亏损，气血败伤，或者宜健脾，或者宜补肾，或者宜补气血，或者宜淡渗利湿，或者宜固涩止泻，视病情的轻重、人体的虚实来调治。还有一种是不因服用凉药与攻下药，而自发下利的，可能是因为岁气偏颇，时气戾气，司天在泉之气不同，导致饥荒旱涝等外界因素触犯，感而成病，起初也觉得头痛身痛，身热发热，自汗微恶寒，随后突然泄泻，却没有胡言乱语、郑声、昏冒、舌苔燥渴、发斑发黄等症状。其脉象既不洪数，也不细微，投以达原饮，则腹泻更加严重。投以元霜、素雪等丹药，则腹泻不止。此症原本没有大热，是瘟疫中的变局，问其口渴，则厌恶饮水，看其舌苔，并没有黄苔，知道这不是热利无疑，总以健脾补肾为主，而以利水为辅。这里的补肾却不用熟地黄，又恐怕其滑肠，尤其忌讳当归，只用大何首乌、菟丝子、山药、茯苓、白术、苍术、白扁豆、人参、陈皮、炙甘草等药，斟酌施治。此时反以下利为本，而瘟疫为标。因为泄泻不止，则元气日渐亏损，表邪更不能解除。如果下利停止，纵有表邪，再于补药中带和解之法施治，况且经过这次大泄，瘟邪也不能逗留了。再者，下利虽然有表证，不可发汗，恐怕耗伤津液，使胃更虚，必然形成胀满，应当先治下利，下利停止内实，正气恢复，邪气自然解除，得到微汗而痊愈。因为下利属于内虚，如果发其汗，则内外皆虚，变症就出现了。张仲景《伤寒论》中三阳合病，都能自利，有发表、和解、攻里的区别。瘟疫病原本没有发表的说法，至于攻里则使用凉药。凉药是用来除热的。那么试说属于热证的下利。热性下利必有兼症，或者有口苦咽干、唇焦舌燥、胡言乱语烦躁口渴、尿赤目赤、潮热等症状。则或用寒凉药，或用攻下药，通因通用，在所必施。总之，下利不过寒热两端，视其兼症，清晰明了。那些因于寒证的，口中无燥渴，甚至厌恶饮水，恶寒，小便清白，脐下多寒，身体虽热，手足逆冷，（此症寒热皆有。）粪便色白或淡黄，完谷不化，有如溏泄，澄澈清冷，腥臭，脉象不洪硬，且无力。至于蜷缩卧倒闭目，面向墙壁卧，拉被子盖住自己，说话声音微弱细小，不喜欢光亮，面色如刀刮般苍白等症状，则是冬季严寒寒邪直中阴经的征候。瘟疫下利即使是寒证，也没有这些情况了。那些因于热证的，发热烦躁，想饮水，口燥渴，小便黄赤，（寒症也有。）更兼涩而不利，（寒症则无。）脐下热，泄出时发出声响，所下之物如垢腻奇臭，颜色青黄赤、酱色、黑色，有后重感，得凉药则止，得热药则加重。其脉象则洪数浮滑弦大盛强，以此辨别寒热，万无一失。治疗方法各不相同，医者应当审慎。
Although the two bowels (urine and feces) are excreted by the large intestine and small intestine respectively, they are ultimately all orifices of the Kidney. In some cases, heat pathogen binds in the large and small intestines, causing fluids to fail to circulate and heat to have no outlet, thereby leading to symptoms such as delirium, madness, jaundice, and macules; bitter-cold purgatives should be used for downward drainage. In other cases, excessive sweating leads to loss of Yin fluids, and heat consumes body fluids, resulting in scanty, difficult urination and dry, constipated stool; moistening agents should be used to unblock. If only urinary retention occurs, unblocking the stool will naturally facilitate urination; diuresis alone is of no benefit. Furthermore, in plague diseases, promoting urination is intended to allow heat pathogen to be excreted through it, but excessive diuresis can lead to dry, constipated stool, a fact that must not be ignored.
Since ancient times, dysentery has been called "resting dysentery" (intermittent remission and recurrence), rarely has diarrhea been described as "resting." This condition was first encountered through my own experience; it is classified not as a Wang disease (pestilence with strong epidemic potential) but as a Yi disease (epidemic disease), likely because symptoms are identical regardless of age. The disease occurs from late summer to autumn, and may persist from summer into autumn without cure, lacking typical exterior and interior signs of plague. Some patients present with abdominal distension, others without; appetite remains unchanged after eating, yet there is a strong aversion to drinking water, suggesting dampness. However, during this time, the weather was extremely dry with no rain for a year, making the source of dampness unclear. Diarrhea occurred dozens of times daily and would not stop abruptly without treatment. During the intense heat of late summer, tonifying the Spleen and warming/tonifying herbs led to recovery. However, relapse occurred after a few days; even if cured temporarily, it recurred again after several days. The course was lingering, lasting months. Inquiry revealed that recurrence was partly due to consuming raw/cold foods and overeating. Patients were advised to eat only 70-80% full, and after taking medicine for over a month, relapses ceased. Mortality was rare, but patients became extremely debilitated.
(Referring to Diarrhea)
The appearance of diarrhea in plague indicates a serious condition. Generally, three parts are cold-type, seven parts are heat-type, and damp-type is merely occasional. Wu Keyou's *Treatise on Plague* discusses "collateral heat diarrhea," focusing solely on heat, which is biased. Cold-type diarrhea in plague is mild and cannot be compared to winter cold invasion or direct transmission to Yin meridians. There are three types of cold-type diarrhea: First, contracting a plague without significant heat but using too many cooling medicines causes the plague to persist while diarrhea starts. At this stage, treat the iatrogenic cause first by warming the interior; once the interior is warm, diarrhea stops, then resolve the exterior. Since plague does not typically use sweating methods, use harmonizing and draining methods at this time, treating based on the affected meridian. If pathogens remain unresolved, it is likely due to Qi damage and Yin/Blood depletion from prior diarrhea preventing sweating; thus, gentle tonification and Yin nourishment are needed. Use Shu Di Huang (Prepared Rehmannia Root), Dang Gui (Angelica Sinensis), Bai Shao (White Peony Root), Zhi Gan Cao (Honey-fried Licorice), supplemented by Bai Zhu (Atractylodes Macrocephala), Shan Yao (Chinese Yam), Lian Rou (Lotus Seed Flesh). Add Chen Pi (Tangerine Peel) for Qi stagnation, Wei Jiang (Baked Ginger) for cold, Zhi Ban Xia (Processed Pinellia) and Fu Shen (Poria with Hostwood) for insomnia, Huo Xiang (Patchouli) for vomiting. With proper regulation, sweating will occur naturally, leading to recovery. If loose stools suggest impending relapse, heavily use Fu Ling (Poria), Zhi He Shou Wu (Prepared Fleeceflower Root), and Bai Bian Dou (White Hyacinth Bean) in previous formulas, adjusting as needed for efficacy. Second, diarrhea following severe purging results from Qi deficiency and Blood/Qi damage; treatment may involve tonifying Spleen, tonifying Kidney, tonifying Qi/Blood, mild diuresis, or astringency, depending on severity and constitution. Third, spontaneous diarrhea without prior cooling/purgative use may result from climatic abnormalities, pestilential Qi, or environmental factors like drought/floods. Initial symptoms include headache, body pain, fever, spontaneous sweating, and slight aversion to cold, followed suddenly by diarrhea without delirium, coma, dry tongue coating, thirst, or jaundice. Pulse is neither surging-rapid nor fine-small. Using Da Yuan Yin (Reach the Origin Powder) worsens diarrhea; using Yuan Shuang or Su Xue pills fails to stop it. This case lacks significant heat, representing a variation in plague. Thirst is absent with aversion to drinking; tongue lacks yellow coating, confirming non-heat type. Main treatment focuses on tonifying Spleen and Kidney, assisted by diuresis. For Kidney tonification, avoid Shu Di Huang (slippery to intestines) and Dang Gui (strictly contraindicated); instead use Da He Shou Wu (Polygonum Multiflorum), Tu Si Zi (Cuscuta Seed), Shan Yao, Fu Ling, Bai Zhu, Cang Zhu (Atractylodes Lancea), Bai Bian Dou, Ren Shen (Ginseng), Chen Pi, Zhi Gan Cao. Here, diarrhea is the root, plague is the branch. Unstopping diarrhea depletes Qi daily, preventing exterior resolution. Once diarrhea stops, even if exterior pathogens remain, harmonize within tonics. After severe diarrhea, plague pathogens cannot linger. Although exterior signs exist with diarrhea, do not induce sweating to avoid fluid loss and gastric deficiency leading to distension. Treat diarrhea first; when stopped and interior solidified, Zheng Qi recovers, pathogens resolve via mild sweating. Diarrhea indicates internal deficiency; sweating causes both internal and external deficiency, leading to complications. Zhang Zhongjing's *Treatise on Cold Damage* states San Yang combined disease can cause self-diarrhea, distinguishable by exterior-releasing, harmonizing, or interior-purging methods. Plague theory rejects exterior-releasing; interior-purging uses cooling medicines to remove heat. Now discuss heat-type diarrhea. Heat diarrhea presents with accompanying symptoms: bitter taste, dry throat, cracked lips, dry tongue, delirium, irritability, thirst, red urine, red eyes, tidal fever. Treat with cold-cooling or purgative methods, applying "treat obstruction with unblocking" (Tong Yin Tong Yong). Ultimately, diarrhea falls into cold or heat categories, clearly distinguished by accompanying signs. Cold-type: no dry mouth/thirst, aversion to drinking/cold, clear urine, cold below umbilicus, hot body but cold extremities, white or pale yellow stool, undigested food, watery/clear/cold/fishy-smelling stool, pulse not surging-hard but weak. Symptoms like curling up, facing wall, covering with clothes, whispering, avoiding light, pale face belong to winter cold directly invading Yin meridians, absent in plague cold-diarrhea. Heat-type: fever, irritability, desire to drink, dry mouth/thirst, yellow-red urine (also seen in cold but accompanied by difficulty/dysuria, absent in cold), heat below umbilicus, noisy defecation, foul/greasy stool in colors green/yellow/red/brown/black, tenesmus, relief with cooling meds, worsening with heating meds. Pulse is surging-rapid-floating-slippery-string-tense-strong. Distinguishing cold/heat by these signs is infallible. Treatments differ; physicians must examine carefully.