【纲】仲景曰。下利。有微热而渴。脉弱者。令自愈。下利。脉数而渴者。令自愈。设不瘥。
必圊脓血。以有热故也。下利。脉数有微热。汗出。令自愈。设复紧。为未解。下利。寸脉反浮数。
尺中自涩者。必圊脓血。
【目】张从正曰。热邪之陷于阴中已深。因阴中有热。一时不能自止。故至便脓血也。脉反浮
数。宜其阳出于阴而愈矣。止因尺中涩。故又至便脓血也。
柯琴曰。前条是未脓血。因不瘥而预料之辞。后条在脓血后。因寸浮尺涩而揣摹之辞。
【纲】仲景曰。伤寒热少厥微。指头寒。默默不欲食。烦躁。数日。小便利。色白者。此热除
也。欲得食。其病为愈。若厥而呕。胸胁烦满者。其后必便血。
伤寒发热四日。厥反三日。复热四日。厥少热多。其病当愈。四日至七日。热不除者。必便脓
血。
伤寒厥四日。热反三日。复厥五日。其病为进。寒多热少。阳气退。故为进也。伤寒先厥。后发热
而利者。必自止。见厥。复利。伤寒先厥。后发热。下利必自止。而反汗出。咽中痛者。其喉为痹。
发热无汗而利。必自止。若不止。必便脓血。便脓血者。其喉不痹。
【目】吴绶曰。凡下血便脓血。有阴阳冷热之不同。古人云。见血无寒。又言。血得热而行。
此大概也。大抵属热者常八九。属寒者才一二。不可定为无寒也。要略曰。阳症内热。则下鲜血。
阴症内寒。则下紫黑血如猪肝也。且夫阳症脉数而有力者。为实热。苦寒之药可用。数而无力者。
为虚热。当甘温养血药中。少佐寒药可也。若阴症则脉迟而有力者。为有神。可治。无力者。难治
也。凡下利脓血。身热脉大者为难治。身热脉小者为易治也。
王肯堂曰。便脓血。热病也。其在太阳阳明者无论已。若在少阴。下利便脓血。又有至四五日
腹痛便脓血者。治以桃花汤。成氏释谓里寒非也。桃花汤虽用干姜。然分两最微。赤石脂、粳米居
多。盖调正气。涩滑脱。佐用辛以散之之义。又八九日一身尽热。必便血。又少阴下利便脓血者。
可刺。与此三条厥阴之便脓血。皆传经之热邪也。各随其轻重。或用微凉。或用疏导。无不愈者。
误用辛热。罔或得痊。世因以为难疗之疾。殊不知仲景着便脓血。别无死候。学人宜究心焉。
【纲】张仲景说：患下利（腹泻），伴有轻微发热且口渴，脉象弱小的，将会自行痊愈。患下利，脉象数而口渴的，将会自行痊愈。如果病不愈，必然出现排泄脓血的情况，这是因为体内有热邪的缘故。患下利，脉象数且有轻微发热、出汗的，将会自行痊愈。如果脉象再次变得紧实，说明病邪尚未解除。患下利，寸口脉反而浮数，尺中脉自涩的，必然出现排泄脓血的情况。
【目】张从正说：热邪深陷于阴分之中已经很深，因为阴中有热，一时不能自行停止，所以导致便脓血。脉象反而浮数，本应是阳气出于阴分而痊愈的表现，只因为尺中脉涩，所以又发展到便脓血的地步。
柯琴说：前一条是说尚未出现脓血，因病情未愈而做出的预测性论述。后一条是在出现脓血之后，因寸脉浮、尺脉涩而进行的推测性论述。
【纲】张仲景说：伤寒病热势轻微，四肢厥冷也不严重，仅指尖发凉，神情沉默不想进食，烦躁不安。过了几天，小便通畅，颜色清白，这是热邪已除的表现。想要进食，说明病将要痊愈。如果出现四肢厥冷并伴有呕吐，胸胁部烦闷胀满的，其后必然出现便血。
伤寒发热四天，四肢厥冷反而三天，随后又发热四天，厥冷时间短而发热时间长，病情应当痊愈。如果从第四天到第七天，热势不退的，必然出现便脓血。
伤寒四肢厥冷四天，发热反而三天，随后又厥冷五天，病情为进展。寒多热少，阳气衰退，所以病情加重。伤寒先出现四肢厥冷，随后发热且腹泻的，腹泻必然会自行停止；如果再出现四肢厥冷，腹泻又会复发。伤寒先出现四肢厥冷，随后发热，下利必然会自行停止；但如果反而出现出汗、咽喉疼痛的，其喉部会发生痹阻（喉痹）。发热无汗且腹泻的，腹泻必然会自行停止；如果不停止，必然出现便脓血。出现便脓血的，其喉部不会发生痹阻。
【目】吴绶说：凡是便血或便脓血，有阴阳冷热性质的不同。古人说“见血无寒”，又说“血得热而行”，这大概是一般规律。大致属于热证的占八九成，属于寒证的才占一二成，但不能绝对定为没有寒证。《金匮要略》说：阳证内热，则排出鲜红色血液；阴证内寒，则排出紫黑色如猪肝样的血液。而且阳证脉象数而有力的，属于实热，可以使用苦寒药物；脉数而无力的，属于虚热，应当在甘温养血药中，少量佐以寒药即可。如果是阴证，则脉迟而有力的，称为有神气，可以治疗；无力的，难以治疗。凡是下利脓血，身体发热且脉大的，属于难治；身体发热但脉小的，属于易治。
王肯堂说：便脓血属于热病。发生在太阳经和阳明经的就不用说了，如果发生在少阴经，下利便脓血，又有到了四五日腹痛便脓血的，用桃花汤治疗。成无己解释说是里寒，这是不对的。桃花汤虽然用了干姜，但是分量最轻，赤石脂、粳米占据多数，大概是调和正气、固涩滑脱的意思，辅以辛味药以散之的道理。又有八九日全身都发热的，必然便血。还有少阴经下利便脓血的，可以针刺。这三条关于厥阴经便脓血的记载，都是传经的热邪所致。根据病情的轻重，或用微凉之法，或用疏导之法，没有不痊愈的。误用辛热药物，几乎没有能治愈的。世人因此认为这是难以治疗的疾病，殊不知张仲景在论述便脓血时，并没有提到死亡的征兆，学习的人应该深入研究。
[General Principles] Zhang Zhongjing stated: In cases of diarrhea (Xia Li), if there is slight fever and thirst, and the pulse is weak, the disease will resolve spontaneously. In cases of diarrhea, if the pulse is rapid and there is thirst, the disease will resolve spontaneously. If the condition does not improve, pus and blood will inevitably appear in the stool, due to the presence of heat pathogen. In cases of diarrhea, if the pulse is rapid with slight fever and sweating, the disease will resolve spontaneously. If the pulse becomes tight again, it indicates that the pathogen has not yet been resolved. In cases of diarrhea, if the Cun (inch) position of the pulse is floating and rapid, while the Chi (cubit) position is naturally choppy (Se), pus and blood will inevitably appear in the stool.
[Commentaries] Zhang Congzheng said: When heat pathogen sinks deeply into the Yin aspect, and because there is heat within the Yin, it cannot stop by itself for a time, leading to pus and blood in the stool. A floating and rapid pulse should indicate that Yang Qi emerges from Yin and the patient recovers; however, because the Chi position is choppy, the condition progresses to pus and blood in the stool.
Ke Qin said: The previous clause refers to a predictive statement made before pus and blood appeared, due to the non-resolution of the disease. The latter clause is a speculative statement made after pus and blood appeared, based on the floating Cun and choppy Chi pulses.
[General Principles] Zhang Zhongjing stated: In Shanghan (Cold Damage) disease, if the heat is slight and cold extremities are mild, only the fingertips are cold, the patient is silent and lacks appetite, and feels irritable. After several days, if urination is smooth and the urine color is clear/white, this indicates that the heat has been eliminated. If the patient desires food, the disease is about to heal. If, however, cold extremities occur accompanied by vomiting, and there is irritability and fullness in the chest and hypochondrium, blood in the stool will inevitably follow later.
In Shanghan, if there is fever for four days, followed by cold extremities for three days, and then fever for another four days, meaning the duration of cold extremities is shorter than the duration of fever, the disease should heal. However, if from the fourth day to the seventh day the heat persists without abating, pus and blood will inevitably appear in the stool.
In Shanghan, if there are four days of cold extremities, followed by three days of fever, and then five more days of cold extremities, the disease is progressing. There is more cold and less heat, indicating the retreat of Yang Qi, hence the progression of the disease. In Shanghan, if cold extremities appear first, followed by fever and diarrhea, the diarrhea will likely stop spontaneously; if cold extremities reappear, the diarrhea will recur. In Shanghan, if cold extremities appear first, followed by fever, the lower diarrhea will likely stop spontaneously; but if sweating occurs instead, along with throat pain, Bi syndrome (obstruction) of the throat will develop. If there is fever, no sweating, and diarrhea, the diarrhea will likely stop spontaneously; if it does not stop, pus and blood will inevitably appear in the stool. In cases where pus and blood appear in the stool, Bi syndrome of the throat will not develop.
[Commentaries] Wu Shou said: Regarding hematochezia or pus and blood in the stool, there are differences in Yin/Yang and Cold/Heat natures. Ancient texts state "bleeding implies no cold" and "blood moves with heat," which is generally true. Mostly, these cases belong to Heat (80-90%), while only a few belong to Cold (10-20%). However, one cannot absolutely rule out Cold patterns. *Jin Gui Yao Lue* states: In Yang patterns with internal heat, fresh red blood is discharged; in Yin patterns with internal cold, purple-black blood resembling pig liver is discharged. Furthermore, in Yang patterns, if the pulse is rapid and forceful, it indicates Excess Heat, and bitter-cold herbs can be used. If the pulse is rapid but weak, it indicates Deficiency Heat, and cold herbs should be slightly added to sweet-warm blood-nourishing formulas. In Yin patterns, if the pulse is slow and forceful, it indicates the presence of Shen Qi (vital spirit/energy) and is treatable; if weak, it is difficult to treat. Generally, for diarrhea with pus and blood, if the body is hot and the pulse is large, it is difficult to treat; if the body is hot but the pulse is small, it is easy to treat.
Wang Kentang said: Pus and blood in the stool is a heat disease. Cases involving the Taiyang and Yangming meridians need not be discussed separately. If it involves the Shaoyin meridian, with diarrhea and pus/blood in the stool, and abdominal pain leading to pus/blood after four or five days, it is treated with Taohua Decoction (Peach Kernel Decoction). Cheng Wuji interpreted this as Interior Cold, which is incorrect. Although Taohua Decoction uses Ganjiang (Dried Ginger), its dosage is minimal, while Chishizhi (Halloysitum Rubrum) and Jingmi (Rice) constitute the majority. This formula aims to harmonize Zheng Qi (Upright Qi) and astringe slippage, using acrid herbs to disperse. Additionally, if after eight or nine days the whole body is hot, bleeding will inevitably occur. For Shaoyin diarrhea with pus and blood, acupuncture can be used. These three clauses regarding Jueyin diarrhea with pus and blood all involve heat pathogens transmitted through the meridians. Depending on the severity, either mild cooling methods or draining/dredging methods can be used, and recovery is assured. Misuse of acrid-hot herbs rarely leads to cure. The world considers this a difficult-to-treat disease, unaware that Zhang Zhongjing did not describe any fatal prognoses for pus and blood in the stool. Students should investigate this carefully.