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Generally, sounds are produced by the mutual impact of Qi (vital energy) and body fluids. When there is more Qi, the sound is high-pitched; when there is more fluid, the sound is deep. Or, in the absence of fluid but with blockage by phlegm and food retention, when the blocked Qi suddenly unblocks, it produces a rumbling sound. Qi can be either cold or hot. Heat causes Qi to flourish, making its impact forceful. Cold causes Qi deficiency; although deficient Qi cannot inherently produce impact, after long-term stagnation, it will inevitably seek an outlet. Observing those with abdominal pain due to cold coagulation, applying fried scallion, ginger, and salt to the abdomen causes abdominal rumbling, allowing Qi to flow and pain to cease, which illustrates this principle. Therefore, when Qi is peaceful and flows smoothly, there is no rumbling; rumbling occurs only when there is heat or cold, obstruction and unblocking. The *Classic* states: "When heat pathogen prevails excessively, disease manifests as abdominal thunder-like rumbling and Qi rushing up to the chest," treated with salty-cold substances. It also states: "When Middle Qi is insufficient, the intestines rumble," referring to Spleen deficiency with abdominal fullness, intestinal rumbling, and diarrhea with undigested food (*Sun Xie*). For diarrhea and intestinal rumbling due to Stomach cold, *Sheng Yang Chu Shi Tang* (Yang-Raising Damp-Resolving Decoction, see Diarrhea) added with *Yi Zhi Ren* (Alpinia Oxyphylla Fructus), *Ban Xia* (Pinelliae Rhizoma), dates, and ginger should be used. If Fire strikes Water, *Er Chen Tang* (Two-Cured Decoction, see Phlegm) added with *Huang Qin* (Scutellariae Radix), *Lian Zi* (Coptidis Rhizoma), and *Zhi Zi* (Gardeniae Fructus) is indicated. If Water-Qi lodges in the Large Intestine, rapid movement produces a gurgling sound like water in a bag, treated with He Jian's *Ting Li Wan* (Descurainiae Semen Pill).

Dysentery is caused by Damp-Heat. It may result from consuming Damp-Heat-inducing foods or contracting summer-Dampness. (Regardless of external contraction of the Six Excesses, internal injury from the Seven Emotions, dietary irregularities, or overwork, all can lead to Damp-Heat.) Damp-Heat accumulates in the intestines and stomach. (Regardless of which Zang-Fu organs' Damp-Heat it originates from, it enters the intestines and stomach because the Stomach belongs to Central Earth, governing reception and transmission to the intestines.) Thus, Righteous Qi is obstructed by Pathogenic factors, and the transportation functions of the Spleen and Stomach become abnormal. Consequently, food and drink increasingly stagnate, transforming into foul turbidity that adheres within the intestines and stomach, further impairing the mechanism of transportation. Qi stagnation transforms into Fire, which mixes with the contracted Damp-Heat to form pathogenic factors that attack and pierce, causing pain; this is why dysentery involves abdominal pain. (Old theories attributed this to Lung Metal Qi stagnating in the Large Intestine, speaking merely from the perspective that Qi belongs to the Lung; one need not rigidly adhere to Lung Qi alone. In excess-heat patterns, the urgent nature of Fire prevents free circulation, resulting in severe pain. In deficiency-cold patterns, pain is mild because cold closure causes severe pain, while cold opening causes mild pain. Although dysentery involves stagnation and lack of smoothness, it is ultimately an opening rather than a closure; in deficiency cases, there is little Qi and less congestion, hence mild pain.) Pathogens can injure Righteous Qi. Injury to the Blood level results in bloody stools, called Red Dysentery. (This should be compared with Intestinal Wind.) Injury to the Qi level results in purulent stools, called White Dysentery. (Pus has two sources: one is the fluids of the Stomach, the other is the juices of food and drink, both boiled down by pathogenic fire into pus. Observing that spoiled food often turns into white pus makes this clear. Moreover, thickened fluids rising become phlegm, while descending become pus, which is quite evident. Zhang Jingyue claimed this was the shedding of intestinal fat. However, he did not realize that the interior of the intestines and stomach contains no fat, only saliva and mucus, as seen in pig intestines. Furthermore, the Large Intestine combines with the Lung to govern Qi, and the Small Intestine combines with the Heart to govern Blood; thus, ancient texts stated blood comes from the Small Intestine and pus from the Large Intestine, which need not be taken literally.) If both Qi and Blood are injured, red and white stools appear together. Alternatively, if Dampness is excessive and Blood deteriorates, the color resembles bean juice; if Heat is extreme, the color appears purple-black. (Black and glossy like lacquer indicates blood stasis; the same applies to stool with blood threads.) Or, in chronic dysentery where Yuan Qi is weak, damp-phlegm and foul turbidity cause the color to resemble dusty, decaying roof leak water. (In central China, roofs are made with mud, so leaked water is muddy and dark.) Or, if the pattern shifts to deficiency-cold, the color resembles fish brain, snot, or jelly. (The color is similar to white dysentery, but differs in onset severity and cold-heat nature.) Or, if Zang-Fu organs deteriorate, the complexion resembles dead pork or chicken liver. (The color is blue-dark.) These explain the various colors seen in dysentery. Since Qi is stagnant in the intestines, it cannot ascend nor descend properly. Suddenly, it forces downward. The urgent nature of Fire creates a sense of urgency, as if one cannot reach the toilet in time, yet despite trying to defecate, nothing comes out. (When Qi stagnation is not resolved, the sticky accumulation cannot exit; even today's waste is dissolved and stuck, with very little output.) Reluctant to descend but forced to descend, one must use the toilet immediately after cleaning hands. This urgency and frequency are most distressing, known as *Li Ji* (Tenesmus). Pathogens press on the anus, causing Qi and Blood to congeal and gather, leading to a sensation of heaviness and bearing down. (There are also cases of prolapse and slipping, which occur only after prolonged illness.) This is known as *Hou Zhong* (Posterior heaviness). Dysentery is fundamentally Damp-Heat. Prolonged dysentery damages Yin, transforming Damp-Heat into Dry-Heat. The anus feels like fire, and the blood in the Large Intestine dries up. Despite straining greatly, (Strain means seeking, exerting effort to expel,) the dry and rough feces cannot exit, resulting in empty straining without output, known as *Xu Zuo Nu Ze* (Empty Straining). Both diarrhea and dysentery arise from Dampness, and Dampness can be cold or hot, both capable of causing diarrhea. Dysentery, however, is due to Damp-Heat. (If it were Cold-Damp, it would present as profuse watery diarrhea, without signs of stagnation, blockage, or difficulty in expulsion.) Claiming that dysentery can be caused by Cold-Damp is erroneous. Why do some present with diarrhea and others with dysentery given the same Damp-Heat? The answer is: Diarrhea occurs because Damp-Heat surges suddenly. The urgent nature of Fire rapidly forces food and water downward before they can ferment and rot, pouring out like a rainstorm, clearing the intestines and stomach, thus leaving no sticky residue. With no accumulation, Qi flows freely, turbidity descends and clarity ascends, so there is no tenesmus or posterior heaviness. Because the disease onset is rapid, Qi and Blood are not yet injured, so there is no bloody or purulent stool. Dysentery begins with mild Damp-Heat, which gradually accumulates until it becomes excessive and then manifests. After many days, such symptoms brew forth. Some have diarrhea first, then dysentery, because there is little Dampness and much Heat. The Dampness is expelled via diarrhea, but Heat remains. Prolonged diarrhea consumes Yin, and Yin deficiency generates further Heat, turning Damp-Fire into Dry-Fire, which scrapes intestinal residue and blood downward, transforming into dysentery. (Ancient theory calls this Spleen transmitting to Kidney, as Spleen dislikes Dampness and Kidney dislikes Dryness. This pattern first injures Spleen with Dampness, then Kidney with Dryness, hence Spleen transmitting to Kidney. The disease progresses, representing a "robber pathogen.") Some have dysentery first, then diarrhea, because there is much Dampness and little Heat. After prolonged dysentery, Heat dissipates, but Dampness remains. Fire and Original Qi cannot coexist. Once pathogenic Heat is gone, Righteous Qi recovers. Righteous Qi does not tolerate pathogens, sweeping away remaining residue and Dampness. (With Heat pathogen in the middle, Lung Qi is congested. When Heat clears, Lung Qi descends, distributing fluids like timely rain, filling ditches, and washing away all residue.) Thus, it transforms into diarrhea. (This is Kidney transmitting to Spleen; the disease retreats, representing a "minor pathogen.") Pathogens contracted in Summer manifest in Autumn, as either malaria or dysentery. Though their manifestations differ, their source is the same. (Generally, in Summer, one contracts wind-cold and enjoys raw/cold foods. Wind-cold lodges in the skin and muscles, mixing with righteous Qi, while raw/cold foods stop in the intestines and stomach. Damp-Heat steams together. At this time, pores are open, not yet closed; Stomach Qi rises and is not suppressed. By Autumn, Qi converges and Fire descends. Pathogens in the skin/muscles are drawn inward and steam to become malaria; pathogens in the intestines/stomach are driven downward to become dysentery.) When malaria and dysentery occur together, if malaria stops but dysentery worsens, accompanied by abdominal pain and poor appetite, this is a deficiency-cold pattern. The cessation of malaria is not true cessation, but rather Yin prevailing while Yang dares not contend. Use *Bu Zhong Yi Qi Tang* (Tonify the Middle and Augment the Qi Decoction, see Qi) added with ginger and cinnamon. One dose cures it. If dysentery stops but malaria recurs, it means Yang has been tonified and is gradually extending, able to contend with Yin, so malaria recurs. This is an auspicious sign. Take the previous formula again to assist the weak Yang, adding five qian of *Fu Zi* (Aconiti Lateralis Radix Praeparata), curing both conditions. Note: This explanation is sound, but are there not cases where Heat sinks into the interior and does not contend with Yin? Are there not cases where Heat exceeds and Cold declines, so Yin dares not contend, causing malaria to stop and dysentery to worsen? Draw inferences about other cases from this one instance; this depends on the wisdom of the practitioner. (Note again: When malaria and dysentery occur together, treat malaria first because there is wind-cold in the exterior, requiring exterior resolution. If dysentery is treated first, it may weaken the interior, causing exterior pathogens to sink inward.)

Dysentery following malaria is due to residual pathogens lurking internally or Spleen Qi deficiency sinking, termed "pseudo-dysentery." Malaria following dysentery is due to dual deficiency of Qi and Blood. Qi deficiency causes aversion to cold; Blood deficiency causes fever. Thus, alternating chills and fever occur, termed "pseudo-malaria." Both are treated as deficiency patterns using *Bu Zhong Yi Qi Tang*.

In all dysentery cases, those with fever are serious. If accompanied by external contraction (external wind-cold constrained transforming into Damp-Heat causing dysentery), this is not discussed here. If not externally contracted, initial fever indicates abundant toxins in the interior reaching the exterior. Fever in chronic dysentery indicates Yin deficiency with Yang floating outward; thus, both are serious patterns.

Vomiting and belching indicate Fire pathogen rushing upward; seeing this symptom warns against impending "Jin Kou" (closed-mouth) dysentery.

"Jin Kou" dysentery (anorexia/nausea preventing intake) arises from: accumulation blocking stagnation; retained food not digesting; toxic heat rushing upward; retained fluids reversing upward; premature use of astringents causing pathogens to rise; or excessive use of cold medicines damaging Stomach Qi, rendering both food and medicine intolerable, leading to immediate vomiting upon ingestion—a critical condition. If Stomach fatigue and Qi sinking result in complete loss of appetite, it is incurable.

Dysentery that repeatedly stops and recurs, lasting years, is named "Resting Dysentery." It is often caused by premature astringency leaving accumulated heat uncleared, or excessive use of cold herbs causing Yuan Qi to sink and Kidney deficiency failing to secure.

Epidemic dysentery occurring in specific seasons should be treated according to the seasonal Qi. There must be identical symptoms among patients, indicating the specific pathogenic Qi. (For example, if everyone presents with edema, it indicates seasonal Dampness.)

All initial dysentery cases lack cold patterns. However, if a person is constitutionally Yang-deficient with weak Yuan Qi and consumes excessive raw/cold foods, Fire constraint steams to create Damp-Heat. Although the branch is heat, the root is cold; treatment must address the root. Conversely, prolonged illness with Qi deficiency or excessive use of cooling agents may transform into cold patterns, which are common and require careful differentiation. Initial signs include irritability, thirst with desire for cold drinks, aversion to cold, red/scanty urine, yellow-red complexion, warm extremities, and rapid/full pulse. Over time, irritability ceases, thirst disappears (or desire for hot drinks emerges), urine changes from red to yellow to white, complexion turns blue-white, extremities become cool/cold, and pulse becomes weak/deficient. The pattern undoubtedly shifts to deficiency-cold. Differentiate between deficiency and excess. Abdominal pain that rejects pressure indicates excess; pain relieved by pressure indicates deficiency. Thick, sticky pus and blood with frequent trips to the toilet unable to pass indicates excess; involuntary leakage without wiping indicates deficiency. Posterior heaviness before evacuation indicates excess; posterior heaviness persisting after evacuation indicates deficiency. In excess-type heaviness, stool output slightly relieves the sensation (called "pre-stool bearing-down"), but heaviness returns shortly after (pathogen not exhausted). In deficiency-slippery heaviness, stool output worsens the sensation (called "post-stool bearing-down"), but it relaxes slightly after a moment (Qi rises again). All symptoms in dysentery, such as irritability/thirst, dry throat, black tongue, and swelling, have deficiency/excess distinctions. Do not generally label them all as excess; differentiate carefully.