凡泄泻水，腹不痛者是湿，宜燥渗之。饮食入胃不住，或完谷不化者是气虚，宜温
补之。腹涌肠鸣泻水，痛一阵，泻一阵是火，宜清利之。时泻时止，或多或少是痰
积，宜豁之。腹痛甚而泻，泻后痛减者是食积，宜消之。实者，宜下之。如脾泻已久，
大肠不禁者，宜涩之。下陷者，宜升提之。
河间曰∶泻而水谷变色者为热，不变色而澄澈清冷者为寒。若肛门燥涩，小便黄
赤，水谷虽不变，犹为热也。此由火性急速，食下即出，无容克化，所谓邪热不杀谷
也。然泄泻之症，虽分湿火寒虚痰食六者之殊，必以渗湿燥脾为主，湿则导之，火则清
之，寒则温之，虚则补之，痰则豁之，食则消之，是其治也。虽然六症既明，三虚不可
不察，脾虚、肾虚、肝虚是也。脾虚者，饮食所伤也。肾虚者，色欲所伤也。肝虚者，
忿怒所伤也。饮食伤脾，不能运化；色欲伤肾，不能闭藏；忿怒伤肝，木邪克土，皆令
泄泻。然肾泄、肝泄，间必有之，而脾泄恒多，盖人终日饮食，必有所伤，便致泄泻。
又尝论之，泄泻痢疟，同乎一源，多由暑月脾胃气虚，饮食伤积所致，饮食才伤便作，
则为泄泻为轻；饮食停积既久，则为疟痢为重。而疟与痢，又有分别，饮食为痰，充乎
胸胁则为疟疾，饮食为积，胶乎肠胃，则为痢疾，故有无痰不成疟，无积不成痢之论
也。
人之一身，脾胃为主，胃司纳受，脾司运化，然胃阳主气，脾阴主血，奈世之治脾
胃者，不分阴阳气血，概用辛温燥热助火消阴之剂，遂使肾火益旺，脾阴愈伤，清纯冲
和之气，变为燥热，胃脘干枯，大肠涩结，脾脏渐绝而死。独不思土虽恶湿，然亦必赖
湿润，乃得化生万物，岂可徒知偏用辛热之
剂乎？况肾脾窍于二阴，若肾气衰弱，则不能蒸腐水谷，世人但见泄物，概用参术补
之，殊不知参术乃补脾胃中州阳气之药，不能补至阴闭藏主蛰之司也。胃属土而肾属
水，肾泻而用补脾，则土愈胜，而水愈亏，一阳之火，若无二阴敛纳，何能处于釜底而
为蒸腐五谷之具耶！
胃之上口为贲门，水谷于此而入。胃下口为幽门，水谷之滓秽，自此入于小肠，小
肠十六折，水谷赖以缓行，阑门为小肠下口，水谷自此泌别，分秽为浊入大肠，分水
为清入膀胱。如水谷不分，清浊不别，则皆入大肠，而成泄泻，此其由也。然有火湿暑
风痰寒食积八症之殊，有肝虚、脾虚、肾虚三虚之别。若食入口即下，此为直肠泄难
治，下利日十余行，脉反实者，死。腹大胀，四末清，脱形泄甚，不及一时，死。下
则泄泻不止，上则吐痰不已，为上下俱脱，死。泻久而脉洪大急数，皆难治。六脏气绝
于外者，手足寒，五脏气绝于内者，利不禁，甚者，手足不仁，为难治。
脏腑泻利，其证多端，东垣先生制《脾胃论》一篇，专以补中益气汤，升提清气为
主，但未及乎肾泄也。故仲景云∶下利水止，医以理中汤与之，利益甚，理中者，理
中焦也。此利在下焦，当以理下焦法则愈矣。赵以德云∶泄泻之病，其类多端，得于
六淫五邪饮食所伤之外，复有杂合之邪，似难执法而治。先师治气，暴脱而虚，顿泻不
知人，口眼俱闭，呼吸甚微，几欲绝者，急灸气海，饮人参膏十余斤而愈。治积痰在
肺，致其所合大肠之气不固者，涌出上焦之痰，则肺气下降，而大肠之虚自复矣。治忧
思太过，脾气结而不能升举，陷入下焦，而成泄泻者，开其郁结，补其脾胃，使谷气升
发也。治阴虚而肾不能司禁固之权者，峻补其肾，而闭藏之司得职也。
肾泻看，五更时泻也。肾者，胃之关也。前阴利水，后阴利谷，肾属水，水旺于
子，肾之阳虚，不能健闭，故将交阳分则泻也。脾泻者，脾之清阳下陷，不能运化阑
门，元气不足，不能分别水谷，不痛而泻也。两症皆出于肾，命火衰，不能上生脾
土，故杨仁斋曰∶肾命之气，交通水谷，自然克化，肾司开阖，又曰∶肾开窍于二阴，
可见不但仅主小便，而大便之能开能闭者，肾操权也。肾既虚衰，则命门之火熄矣。火
熄则水独治，故令水泻不止，其泻每在五更，天将明也。盖肾属水，其位在北，于时
为亥子。正当亥子水旺之秋，故特甚也。惟八味丸（张）见去丹皮加补骨脂、菟丝子、
五味子，用山药糊丸更妙，）以补真阴真阳，则肾中之水火既济，而开阖之权得职，
命门之火旺，火能生土，而脾亦强矣。古方有椒附丸、五味子散，皆治肾泄之神方，
不可不考也。薛氏云∶脾胃虚寒下陷者，用补中益气汤，加木香、肉果、补骨脂，脾气虚
寒不禁者，用六君子汤加姜桂。命门火衰，脾土虚寒者，用八味丸。脾肾气血俱虚者，用
十全大补汤，送四神丸。大便滑利，小便闭涩，或肢体渐肿，喘咳唾痰，为脾肾亏损，宜金
匮加减肾气丸，即《难经》有五泄之分，胃泄、脾泄、大肠泄、小肠泄、大瘕泄。其大瘕泄
者，即肾泄也。里急后重，数至圊而不能便，茎中痛，世人不知此症，误为滞下治之，
祸不旋踵，此皆肾虚之症，欲去不去，似痢非痢，似虚弩而非虚弩，盖痢疾后重，
为因邪压大肠坠下，故大肠不能升举而重，治以大黄槟榔，泻其所压之邪而愈。又有久
泻，大肠虚滑，元气下陷不能自收而重，乃用涩剂，固其脱，升其坠，而愈其虚，坐弩
责，此痢后积已去尽，无便而但虚坐耳。此为亡血过多，清气下陷，倍用归芎芍药，佐
以升提，和之而愈。惟肾虚后重者，亦数至圊而不能便，必茎中痛，或大便不能得，而小
便先行而涩，或欲小便而大便反欲去而痛。褚氏《精血论》云∶精已耗而复竭之，
则大小便道牵痛，愈痛则愈便，愈便而愈
痛，须以补中益气汤，倍升麻，送四神丸，又以八味地黄丸料，加五味子补骨脂，多服
乃痊。此等症候，以痢药致损元气，肢体肿胀而毙者，不可枚举。肾既主大小便而司开
阖，故大小便不禁者，责之肾，然则大便不通者，独非肾乎？《金匮真言论》云∶北方
黑色，入通于肾，开窍于二阴。故肾气虚，则大小便难，宜以地黄苁蓉之属补其阴，少
佐辛药致津液而润其燥。洁古云∶脏腑之秘，不可一概治疗，有热秘，有冷秘，有实
秘，有虚秘，有风秘，有气秘，老人与产后，及发汗利小便过多，病后气血未复者，
皆能成秘，禁用硝黄、巴豆、牵牛等药。世人但知热秘，不知冷秘。冷秘者，冷气横于
肠胃，阴凝固结，津液不通，胃气闭塞，其大肠内气攻，喜热恶冷，宜以八味地黄丸
料，大剂煎之，冷冻饮料即愈。或局方半硫丸，碾生姜调乳香下之；或海藏已寒丸俱效。海
藏云∶已寒丸虽热，得芍药茴香润剂，引而下之，阴得阳而化，故大小便自通，如遇春
和之阳，冰自消矣。然不若八味丸更妙矣。东垣云∶肾主五液，津液盛则大便如常，若
饥饱劳役，损伤胃气，饮食辛热浓味，而助火邪，伏于血中，致散真阴，津液亏乏，故
大肠结燥。又有老人气虚，津液衰少而结者，肾恶燥，急食辛以润之是也，体法东垣
之论，不用润燥汤、润肠丸之类，惟六味地黄丸料煎服自愈。如热秘而又兼气虚者，以
前汤冲入人参止钱，此因气虚不能推送，阴虚不能濡润故耳。
《经》曰∶春伤于风，夏生飧世，邪气留连，乃为洞泄。又曰∶清气在下，则生飧
泄。又曰∶湿胜则濡泄。又曰∶暴注下迫，皆属于热；诸病水液澄澈清冷皆属于寒。此
《经》言，风湿寒热四气皆能为泄也。又言清气在下，则生飧泄，此明脾虚下陷之泄
也。统而论之，脾土强者，自能胜湿，无湿则不泄，故曰湿多成五泄。若土虚不能制
湿，则风寒与热皆得干之而为病，治法有九，一曰淡渗，使湿从小便而去，如农人治
涝，导其下流，虽处卑隘，不忧巨浸。《经》云∶治湿不利小便，非其治也。又云∶“在
下者，引而竭之”是也。一曰升提，气属于阳，性本上升，胃气注迫，辄尔下陷，升柴
羌葛之类，鼓舞胃气上腾，则注下自止。又如地土淖泽，风之即干。故风药多燥，且湿
为土病，风为木药，木可胜土，风可胜湿，所谓下者，举之是也。一曰清凉热淫所至，
暴注下迫，苦寒诸剂用涤燔蒸，犹当溽暑伊芳郁之时而商 疯然倏动，则炎 如失矣。所
谓热者，清之是也。一曰疏利，痰凝气滞，食积水停皆令人泻随证祛逐，勿使稽留。
《经》曰∶实者泻之；又曰∶“通因通用”是也。一曰甘缓，泻利不已，急而下趋愈趋愈
下，泄何由止？甘能缓中，善禁急速，且稼墙作甘，甘为土味，所谓急者，缓之是也。
一曰酸收，泻下日久，则气散而不收，无能统摄，注泄何时而已，酸之一味，能助收肃
之权，经云，散者，收之是也。一曰燥脾，土德无惭，水邪不滥，故泻皆成于土湿，湿
皆本于脾虚，仓禀得职，水谷善分，虚则不培，湿淫转甚，《经》云“虚者补之”是也。
一曰温肾，肾主二便，封藏之本，况虽属水，真阳寓焉。少火生气，火为土母，此火
一衰，何以营运三焦，熟腐五谷乎？故积虚者，必挟寒，脾虚者，必补母，《经》云
“寒者温之”是也。一曰固涩，注泄既久，幽门道滑，虽投温补，未克奏功，须行涩
剂，则变化不愆，揆度合节。所谓滑者，涩之是也。夫是九者，治泻之纲领，而不能出
其范围矣。刘宗浓曰∶饮食入胃，输精心肺，气必上行，然后下降。若脾胃有伤，湿
热相合，阳气日虚不能上升，脾胃之气，下流肝肾而成泄利者，法当填补中气，用轻薄
风药升之、举之，则阴不病而阳气生矣。此东垣发前人所未发也。
夫始泻而属热者，邪气胜则实也。终变为寒者，夏气奔，则为虚也。久病而热者，
内真寒而假热也。久泻虚寒者，乃夏候也。凡每早大泻一行，若止空心服热，药亦无
效，须于夜食前，再一服方妙，盖暖药虽平旦服之，至夜药力已尽，无以敌一夜阴寒之
气耳。
泄泻而属脾胃者，人固知之矣。然门户束要肝之气也。守司于下，肾之气也。若肝
肾气实，则能闭束而不泻泄，虚则闭束失职，而无禁固之权矣。且肾为胃关，故肾泻
必在子后，五更之分也。盖人生二五，妙合而成，左右两肾，肾间动气，即先天元阳之
祖气，此气自子后一阳生，生即渐渐上升，历丑寅卯辰已，而六阳已极，则入离宫，午
后一阴生，即白气变为赤液，渐渐降下至坎宫，复为白气，昼夜循环，升降不息，《经》
所谓少火生气，医家所谓真阳之火，名为相火也。道家所谓君火，乃先天祖气也。方此
火之自下而上也，行过中焦，必经脾胃，则能腐熟水谷，蒸糟粕而化精微，脾气散精，
上归于肺，通调水道，下输膀胱，是谓清升浊降，既济之象也。《经》曰∶阴平阳秘，
精气乃固，苟不慎摄生之道，则精神日损，肾之真气渐衰，而子复一阳，不以时生，不能上
升，水谷无由腐熟以传化，故寅为三阳之候，阳微既不能应候而化物，且不能胜阴
而上升，故五更或黎明而泻，其泄亦溏，俗名鸭溏，是为肾泄，亦名大瘕泄，是阳之
亡，气之脱也，则补火尤要于补气。
凡天久淫雨，湿令大行，人多腹疾，泻且痛者，胃苓汤，加炮姜、肉桂最宜。
凡是水样泄泻，腹部不疼痛的，属于湿邪所致，适宜用燥湿渗利的方法治疗。饮食进入胃中无法停留消化，或者排出未消化的食物残渣，属于气虚，适宜用温补的方法治疗。腹部胀涌、肠鸣如水声，一阵腹痛后随即腹泻，属于火邪（热邪），适宜用清热利湿的方法治疗。时好时坏、时轻时重地腹泻，属于痰积，适宜用豁痰的方法治疗。腹痛剧烈且伴随腹泻，排便后疼痛减轻的，属于食积，适宜用消食导滞的方法治疗。实证者，适宜用攻下的方法治疗。如果脾虚泄泻日久，导致大肠固摄无力，适宜用收敛固涩的方法治疗。中气下陷者，适宜用升提的方法治疗。
刘河间说：腹泻且大便颜色气味改变的是热证；大便清澈寒冷、颜色气味不变的则是寒证。如果肛门干燥涩痛，小便黄赤，虽然大便颜色气味没有改变，也仍属于热证。这是因为火性急迫，食物吃下去很快就排出来，没有足够的时间进行消化腐熟，这就是所谓的“邪热不能化谷”。然而泄泻的症状，虽然分为湿、火、寒、虚、痰、食六种不同情况，但治疗必须以渗湿健脾为主。湿邪则引导排出，火邪则清解，寒邪则温散，虚证则补益，痰积则豁除，食积则消导，这就是治疗的原则。虽然这六种症状已经明确，但三种虚证不可不仔细辨别，即脾虚、肾虚、肝虚。脾虚是由饮食损伤引起的。肾虚是由房事过度损伤引起的。肝虚是由愤怒情绪损伤引起的。饮食损伤脾胃，导致不能运化；房事损伤肾脏，导致不能闭藏精气；愤怒损伤肝脏，导致肝木邪气克制脾土，都会引起泄泻。然而肾泄和肝泄，偶尔会有，而脾泄最为常见，因为人整天都在饮食，必然会有所损伤，从而导致泄泻。
我又曾论述过，泄泻、痢疾、疟疾，根源相同，多由夏季暑月脾胃气虚，饮食停滞积滞所致。饮食刚受伤就发病，则为较轻的泄泻；饮食停积时间长久，则为较重的疟疾或痢疾。而疟疾与痢疾又有区别，饮食化为痰浊，充满胸胁部位则为疟疾；饮食化为积滞，胶结在肠胃部位，则为痢疾，所以有“无痰不成疟，无积不成痢”的说法。
人的身体，以脾胃为主，胃负责受纳食物，脾负责运化水谷。然而胃阳主司气，脾阴主司血。无奈世间治疗脾胃病的医生，不分阴阳气血，一概使用辛温燥热、助火伤阴的药物，致使肾火更加旺盛，脾阴更加受损，清纯冲和之气变为燥热，胃脘干枯，大肠涩结，脾脏逐渐衰竭而死。难道不想想，土虽然厌恶湿气，但也必须依赖湿润，才能化生万物，怎么能只知道偏用辛热药物呢？况且肾和脾的窍穴通于前后二阴，如果肾气衰弱，就不能蒸腾腐熟水谷。世人只见泄泻之物，一概用人参、白术来补益，却不知道人参、白术是补益脾胃中焦阳气的药物，不能补益至阴闭藏、主蛰伏的功能。胃属土而肾属水，如果是肾泄却用补脾的方法，那么土气更胜，水气更亏。一阳之火，如果没有二阴的敛纳，怎么能处于锅底作为蒸腐五谷的工具呢！
胃的上口叫贲门，水谷由此进入。胃的下口叫幽门，水谷的糟粕由此进入小肠。小肠有十六个弯曲，水谷依靠它缓慢通行。阑门是小肠的下口，水谷由此分别，分清浊：将秽浊部分送入大肠，将清液部分送入膀胱。如果水谷不分，清浊不别，都进入大肠，就形成泄泻，这是其成因。然而有火、湿、暑、风、痰、寒、食积八种症状的区别，以及肝虚、脾虚、肾虚三种虚证的差异。如果食物入口即下，这是直肠泄，难以治疗；下利每天十几次，脉象反而实有力的，预后不良，属死证。腹部大胀，四肢冰冷，形体脱失，泄泻严重，不到一个时辰就会死亡。下部泄泻不止，上部呕吐痰涎不停，称为上下俱脱，属死证。久泻且脉象洪大急数的，都难治。六脏之气在外衰竭的，手足寒冷；五脏之气在内衰竭的，泄泻无法控制；严重的，手足麻木不仁，为难治。
脏腑泄泻痢疾，症状多种多样。李东垣先生撰写《脾胃论》一篇，专门以补中益气汤，升提清气为主，但未涉及肾泄。所以张仲景说：下利清水停止后，医生用理中汤给他服用，腹泻反而加重。理中汤是调理中焦的。此病在下焦，应当用调理下焦的方法才能痊愈。赵以德说：泄泻的病，类别繁多，除了六淫五邪、饮食损伤之外，还有杂合之邪，似乎难以拘泥于固定法则治疗。先师治疗气机暴脱而虚，突然腹泻不知人事，口眼紧闭，呼吸微弱，几乎断气的情况，紧急灸气海穴，服用人参膏十余斤而痊愈。治疗积痰在肺，导致与其相合的大肠之气不固的情况，涌吐上焦的痰涎，肺气下降，大肠的虚弱自然恢复。治疗忧思太过，脾气郁结而不能升举，陷入下焦而成泄泻的情况，解开郁结，补益脾胃，使谷气升发。治疗阴虚而肾不能行使闭藏职权的情况，峻补肾精，使闭藏的功能恢复正常。
肾泄，表现为五更时分腹泻。肾，是胃的关口。前阴排泄水液，后阴排泄谷物糟粕。肾属水，水旺于子时。肾阳虚衰，不能健固关闭，所以在阳气初生之时（五更）发生腹泻。脾泄，是脾的清阳下陷，不能运化阑门，元气不足，不能分别水谷，不痛而腹泻。这两种症候都源于肾，命门火衰，不能上生脾土。所以杨仁斋说：肾命之气，交通水谷，自然消化腐熟。肾主管开阖，又说：肾开窍于二阴，可见不仅主管小便，大便的开闭，也由肾掌握权力。肾既虚衰，命门之火就熄灭了。火熄灭则水独盛，所以导致水泻不止，其腹泻多在五更，天将亮的时候。因为肾属水，方位在北，对应时辰为亥、子。正当亥子水旺的季节（此处原文比喻时机，实指时辰），所以特别严重。只有八味丸（去掉丹皮，加补骨脂、菟丝子、五味子，用山药糊丸更好），能补真阴真阳，使肾中水火既济，开阖职权正常，命门之火旺盛，火能生土，脾也就强健了。古方有椒附丸、五味子散，都是治疗肾泄的神效方剂，不可不考察。薛己说：脾胃虚寒下陷的，用补中益气汤，加木香、肉豆蔻、补骨脂；脾气虚寒不能固摄的，用六君子汤加干姜、肉桂。命门火衰，脾土虚寒的，用八味丸。脾肾气血都虚的，用十全大补汤，送服四神丸。大便滑利，小便闭塞涩痛，或肢体逐渐肿胀，喘咳唾痰，是脾肾亏损，宜用金匮加减肾气丸。
《难经》有五泄之分：胃泄、脾泄、大肠泄、小肠泄、大瘕泄。其中大瘕泄，就是肾泄。里急后重，频繁去厕所却不能排便，尿道疼痛，世人不知道这个病症，误当作滞下（痢疾）治疗，灾祸立刻降临。这都是肾虚的病症，想拉拉不出，似痢非痢，似虚坐努责而非虚坐努责。盖因痢疾的后重，是因为邪气压迫大肠下垂，所以大肠不能升举而感到沉重，治疗用大黄、槟榔，泻下所压之邪而痊愈。又有久泻，大肠虚滑，元气下陷不能自收而感到沉重，乃用收敛固涩剂，固护脱失，升提下坠，从而治愈虚证导致的虚坐努责。此症是痢疾后积滞已去尽，无便而只是空虚用力而已。此为亡血过多，清气下陷，倍用当归、川芎、芍药，佐以升提药物，调和而痊愈。只有肾虚后重，也是频繁去厕所却不能排便，必定尿道疼痛，或大便排不出，而小便先涩痛，或想小便时大便反而想去且疼痛。褚氏《精血论》说：精已耗损又再竭尽，则大小便通道牵拉疼痛，越痛越想排便，越排便越痛，须用补中益气汤，倍加升麻，送服四神丸，又以八味地黄丸料，加五味子、补骨脂，多服才能痊愈。这类症候，因用治痢药损伤元气，导致肢体肿胀而死的，不可枚举。肾既主管大小便并司开阖，所以大小便不禁的，责任在肾，那么大便秘结不通的，难道不是肾的问题吗？《金匮真言论》说：北方黑色，内通于肾，开窍于二阴。所以肾气虚，则大小便困难，宜用地黄、肉苁蓉之类补其阴，少佐辛味药物以生津液滋润燥结。洁古说：脏腑的秘结，不可一概治疗，有热秘、冷秘、实秘、虚秘、风秘、气秘。老人、产后，以及发汗利小便过多，病后气血未恢复的人，都能形成秘结，禁用硝石、大黄、巴豆、牵牛等药。世人只知道热秘，不知道冷秘。冷秘，是冷气横亘于肠胃，阴寒凝固结聚，津液不通，胃气闭塞，大肠内气攻冲，喜热恶冷，宜用八味地黄丸料，大剂量煎煮，放凉后饮用即可痊愈。或用局方半硫丸，碾碎生姜调乳香送下；或用海藏的已寒丸都有效。海藏说：已寒丸虽然热，得到芍药、茴香等润剂引导而下，阴得阳而化，所以大小便自通，如遇春日和暖的阳光，冰自然消融。然而不如八味丸更妙。李东垣说：肾主五液，津液盛则大便如常。如果饥饱劳役，损伤胃气，饮食辛热浓味，助长火邪，伏于血中，耗散真阴，津液亏乏，所以大肠结燥。又有老人气虚，津液衰少而结燥的，肾厌恶燥，急需食用辛味以润之，这是取法东垣的论述。不用润燥汤、润肠丸之类，只用六味地黄丸料煎服自愈。如果热秘兼有气虚的，以前汤冲入人参少许，这是因为气虚不能推送，阴虚不能濡润的缘故。
《内经》说：春伤于风，夏生飧泄，邪气留连，成为洞泄。又说：清气在下，则生飧泄。又说：湿胜则濡泄。又说：暴注下迫，皆属于热；诸病水液澄澈清冷皆属于寒。这些经文说明，风、湿、寒、热四气都能导致泄泻。又说清气在下，则生飧泄，这是阐明脾虚下陷的泄泻。统而言之，脾土强盛，自然能胜湿，无湿则不泄，所以说湿多成五泄。如果土虚不能制湿，则风寒与热都能干扰它而致病。治疗方法有九种：一是淡渗，使湿邪从小便而去，如同农夫治理涝灾，疏导下游，即使身处低洼狭窄之地，也不担心大水淹没。《内经》说：治湿不利小便，不是正确的治法。又说：“在下者，引而竭之”，就是这个意思。二是升提，气属于阳，本性上升，胃气迫降，往往下陷，用升麻、柴胡、羌活、葛根之类，鼓舞胃气上腾，则下注自止。又如土地泥泞，风吹即干。所以风药多燥，且湿为土病，风为木药，木可胜土，风可胜湿，所谓“下者，举之”就是这个意思。三是清凉，热淫盛行，暴注下迫，用苦寒药剂涤荡燔蒸，就像在闷热潮湿之时忽然刮起清风，炎热便消失了。所谓热者，清之就是这个意思。四是疏利，痰凝气滞，食积水停都让人腹泻，随证祛除驱逐，不要让它们稽留。《内经》说：实者泻之；又说：“通因通用”，就是这个意思。五是甘缓，泻利不停，急迫下趋，越趋越下，泄如何能止？甘味能缓中，善于禁止急迫，且稼穑作甘，甘为土味，所谓急者，缓之就是这个意思。六是酸收，泻下日久，则气散而不收，无能统摄，注泄何时能止？酸味这一味，能辅助收肃的职权，经云：散者，收之就是这个意思。七是燥脾，土德无惭，水邪不泛滥，所以泄泻都成于土湿，湿都本于脾虚，仓廪职能正常，水谷善分，虚则不培补，湿邪转甚，《内经》云“虚者补之”就是这个意思。八是温肾，肾主二便，是封藏的根本，何况虽属水，真阳寓在其中。少火生气，火为土母，此火一衰，何以营运三焦，熟腐五谷呢？所以积虚者，必挟寒，脾虚者，必补母（肾），《内经》云“寒者温之”就是这个意思。九是固涩，注泄既久，幽门道滑，虽投温补，未能奏效，须用涩剂，则变化不失常态，揆度合乎节律。所谓滑者，涩之就是这个意思。以上这九条，是治疗泄泻的纲领，不能超出这个范围。刘宗浓说：饮食入胃，输布于心肺，气必上行，然后下降。如果脾胃受伤，湿热相合，阳气日虚不能上升，脾胃之气，下流肝肾而成泄利，治法当填补中气，用轻薄风药升提、举之，则阴不病而阳气生矣。这是李东垣发挥前人所未发的理论。
起初泄泻属于热的，是邪气盛则实。最终变为寒的，是夏气奔迫，则为虚。久病而有热的，是内真寒而外假热。久泻虚寒的，是夏令候（此处指病情演变或特定语境，结合上下文应指虚寒本质）。凡是每天早上大泻一次，如果只在空腹时服用热药，也无效，必须在夜饭前再服一次才妙，因为暖药虽然在清晨服用，到晚上药力已尽，无法抵御一夜的阴寒之气。
泄泻属于脾胃的，人们固然知道了。然而门户约束靠肝的气机。守司于下，靠肾的气机。如果肝肾气实，则能闭束而不泄泻，虚则闭束失职，而无禁固的权力了。而且肾为胃关，所以肾泄必在子时之后，五更时分。大概人生禀受天地二五之气，妙合而成，左右两肾，肾间动气，即先天元阳的祖气。此气自子时后一阳生，生后即渐渐上升，经过丑、寅、卯、辰、巳，六阳已极，则入离宫（心/火）。午后一阴生，即白气变为赤液，渐渐降下至坎宫（肾/水），复为白气，昼夜循环，升降不息。《内经》所谓少火生气，医家所谓真阳之火，名为相火。道家所谓君火，乃先天祖气也。当此火自下而上运行时，行过中焦，必经脾胃，则能腐熟水谷，蒸糟粕而化精微，脾气散精，上归于肺，通调水道，下输膀胱，这是清升浊降，水火既济的景象。《内经》说：阴平阳秘，精气乃固。如果不谨慎养生之道，则精神日损，肾之真气渐衰，而子时一阳复生，不以时生，不能上升，水谷无由腐熟以传化，所以寅时为三阳之候，阳微既不能应候而化物，且不能胜阴而上升，故五更或黎明而泻，其泄亦溏，俗名鸭溏，是为肾泄，亦名大瘕泄，这是阳之亡，气之脱也，则补火尤其重要于补气。
In cases of watery diarrhea without abdominal pain, the etiology is dampness; treatment should focus on drying dampness and promoting diuresis. When food entering the stomach cannot be retained or digested, or when undigested food particles are passed in the stool, the cause is Qi deficiency; treatment should employ warming and tonifying methods. If there is abdominal distension with borborygmus (intestinal rumbling), where a bout of pain is followed immediately by diarrhea, the cause is Fire (Heat); treatment should involve clearing Heat and promoting dampness drainage. Intermittent diarrhea with varying severity suggests Phlegm accumulation; treatment requires resolving Phlegm. Severe abdominal pain accompanied by diarrhea that alleviates after defecation indicates Food stagnation; treatment should focus on digesting food and removing stagnation. In Excess patterns, purgative methods are appropriate. For chronic Spleen deficiency diarrhea leading to laxity of the Large Intestine, astringent methods should be used. For sinking of Qi, lifting and raising methods are indicated.
Liu Hejian stated: Diarrhea with altered color and odor of stool indicates Heat; clear, cold, and unaltered stool indicates Cold. However, if the anus feels dry and rough, and urine is yellow and red, even if the stool's color and odor remain unchanged, it still belongs to Heat. This is because the nature of Fire is rapid; food passes through quickly without sufficient time for digestion and transformation, known as "pathogenic Heat failing to transform grain." Although diarrhea can be categorized into six types—Dampness, Fire, Cold, Deficiency, Phlegm, and Food—the primary treatment principle must always be to promote dampness drainage and strengthen the Spleen. Dampness is guided out, Heat is cleared, Cold is warmed, Deficiency is tonified, Phlegm is resolved, and Food is digested. While these six patterns are clear, three types of Deficiency must not be overlooked: Spleen Deficiency, Kidney Deficiency, and Liver Deficiency. Spleen Deficiency arises from dietary injury. Kidney Deficiency results from excessive sexual activity. Liver Deficiency is caused by anger. Dietary injury impairs the Spleen's transportation and transformation; sexual excess damages the Kidney's ability to store essence; anger injures the Liver, causing Wood pathogenic factors to overact on Earth (Spleen). All lead to diarrhea. Although Kidney and Liver diarrhea occur occasionally, Spleen diarrhea is most common because constant dietary intake inevitably causes some damage, leading to diarrhea.
I have previously discussed that diarrhea, dysentery, and malaria share a common origin, often resulting from Spleen and Stomach Qi deficiency during the summer heat months, compounded by food stagnation. Acute onset after dietary injury manifests as mild diarrhea; prolonged stagnation leads to severe malaria or dysentery. Malaria and dysentery differ: when food transforms into Phlegm filling the chest and hypochondrium, it causes malaria; when food forms stagnation adhering to the intestines and stomach, it causes dysentery. Hence the saying, "No Phlegm, no malaria; no stagnation, no dysentery."
The body relies primarily on the Spleen and Stomach. The Stomach receives and accepts food, while the Spleen transports and transforms nutrients. Stomach Yang governs Qi, and Spleen Yin governs Blood. Regrettably, many physicians treat Spleen-Stomach disorders indiscriminately using acrid-warm-dry-hot herbs that assist Fire and damage Yin. This exacerbates Kidney Fire, further injuring Spleen Yin, transforming pure and harmonious Qi into dry-heat, causing dryness in the epigastrium, constipation in the Large Intestine, and eventual death due to Spleen exhaustion. One must realize that although Earth dislikes dampness, it requires moisture to generate all things; relying solely on acrid-hot herbs is misguided. Furthermore, the Kidney and Spleen open into the two lower orifices. If Kidney Qi is weak, it cannot steam and rot food and water. People often use Ginseng and Atractylodes macrocephala Rhizoma (Baizhu) for all diarrhea, unaware that these herbs tonify Middle Jiao Yang but cannot tonify the profound Yin responsible for storage and hibernation. The Stomach belongs to Earth, and the Kidney to Water. Treating Kidney diarrhea with Spleen-tonifying herbs strengthens Earth excessively, depleting Water further. Without the restraint of Yin, how can the single Yang Fire function as the heat source under the cauldron to cook grains?
The upper opening of the Stomach is the Cardia, where food and water enter. The lower opening is the Pylorus, where waste enters the Small Intestine. The Small Intestine has sixteen curves, slowing the passage of contents. The Valvula ileocecalis (Lanmen) is the lower exit of the Small Intestine, separating clear from turbid: turbid waste goes to the Large Intestine, clear fluid to the Bladder. If this separation fails, both enter the Large Intestine, causing diarrhea. There are eight pathological factors: Fire, Dampness, Summerheat, Wind, Phlegm, Cold, and Food Stagnation, alongside three deficiencies: Liver, Spleen, and Kidney. Immediate expulsion of food after ingestion indicates Rectum diarrhea, which is difficult to treat. Profuse diarrhea (>10 times/day) with a surging pulse indicates a fatal prognosis. Abdominal distension with cold extremities, emaciation, and severe diarrhea leading to death within an hour is critical. Simultaneous persistent diarrhea and vomiting indicate collapse of both Upper and Lower Jiao, a fatal sign. Chronic diarrhea with a surging, rapid pulse is difficult to treat. Collapse of Six Fu organs externally presents with cold hands and feet; collapse of Five Zang organs internally presents with uncontrollable diarrhea. Severe cases involve numbness of extremities, also difficult to treat.
Organ-related diarrhea and dysentery present diverse symptoms. Li Dongyuan's *Treatise on the Spleen and Stomach* emphasizes lifting clear Qi using Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) but neglects Kidney diarrhea. Zhang Zhongjing noted: If diarrhea stops and the physician administers Lizhong Tang (Regulate the Middle Decoction), worsening occurs because Lizhong Tang treats the Middle Jiao, whereas this pathology lies in the Lower Jiao. Zhao Yi-de stated that diarrhea has many causes beyond the six climatic pathogens and five evils, including mixed pathogens, making fixed protocols insufficient. Our master treated sudden Qi collapse with profuse diarrhea, unconsciousness, closed eyes/mouth, and faint breathing by urgently moxa-ing Qihai (CV6) and administering large doses of Ginseng Paste. For phlegm stagnation in the Lung affecting the Large Intestine's security, inducing vomiting to remove Upper Jiao phlegm allows Lung Qi to descend and Large Intestine deficiency to resolve. For excessive worry knotting Spleen Qi, preventing its ascent into the Lower Jiao, one must resolve depression and tonify the Spleen/Stomach to raise Grain Qi. For Yin deficiency impairing Kidney retention, vigorous Kidney tonification restores storage function.
Kidney diarrhea occurs at dawn (Wugeng time). The Kidney is the gate of the Stomach. The anterior orifice excretes water; the posterior orifice excretes grain. The Kidney belongs to Water, which peaks at Zi hour. Kidney Yang deficiency fails to secure closure, causing diarrhea as Yang Qi begins to rise. Spleen diarrhea results from sinking of Spleen Clear Yang, inability to transform contents at the Valvula ileocecalis, and insufficient Yuan Qi to separate water and grain, occurring without pain. Both stem from Kidney issues: Mingmen Fire decline fails to generate Spleen Earth. Yang Renzhai stated that Kidney-Mingmen Qi facilitates digestion. The Kidney controls opening and closing via the two lower orifices, governing bowel movements. Kidney deficiency extinguishes Mingmen Fire; Water dominates unchecked, causing continuous watery diarrhea, typically at dawn. Since Kidney corresponds to Water, North, and Hai/Zi hours, symptoms peak then. The best formula is Babao Wan (Eight-Ingredient Pill) modified (removing Moutan Cortex, adding Psoralea Fructus, Cuscutae Semen, Schisandrae Fructus), pilled with Dioscoreae Rhizoma paste. This tonifies True Yin and True Yang, achieving water-fire balance, restoring Kidney control, strengthening Mingmen Fire to generate Spleen Earth. Ancient formulas like Jiaofu Wan and Wuweizi San are also effective for Kidney diarrhea. Xue Ji advised: For Spleen-Stomach deficiency-cold with sinking, use Buzhong Yiqi Tang plus Aucklandiae Radix, Myristicae Semen, and Psoralea Fructus. For Spleen Qi deficiency-cold with insecurity, use Liujunzi Tang plus Zingiberis Rhizoma Preparatum and Cinnamomi Cortex. For Mingmen Fire decline with Spleen Earth deficiency-cold, use Babao Wan. For combined Spleen-Kidney Qi-Blood deficiency, use Shiquan Dabu Tang with Sishen Wan. For slippery bowels with urinary obstruction, edema, wheezing, and phlegm, indicating Spleen-Kidney depletion, use Jin Gui Ji Jian Shenqi Wan.
*Nan Jing* classifies five diarrheas: Stomach, Spleen, Large Intestine, Small Intestine, and Da Xia (Great Contraction) diarrhea. Da Xia diarrhea is equivalent to Kidney diarrhea. Symptoms include tenesmus, frequent urges without passage, and urethral pain. Misdiagnosing this as dysentery leads to disaster. It is a Kidney deficiency pattern: desire to pass stool but unable, resembling dysentery but distinct. Dysentery tenesmus arises from pathogenic pressure causing rectal prolapse; treated with Rheum Radix et Rhizoma and Arecae Semen to purge pathogens. Chronic diarrhea with Large Intestine laxity and sinking Qi causes heaviness; treated with astringents to secure collapse and lift sinking Qi. This differs from "empty straining" post-dysentery, where residual blood loss and sinking Qi require Angelicae Sinensis Radix, Ligusticum Chuanxiong Rhizoma, Paeoniae Radix Rubra, and lifting herbs. Kidney-related tenesmus involves urgency, pain, and urinary difficulty. Chu Shi's *Jingxue Lun* states that exhausting essence causes pain in bowel/bladder tracts, worsening with defecation. Treat with Buzhong Yiqi Tang plus heavy Shengma dosage and Sishen Wan, or Babao Wan base plus Schisandrae Fructus and Psoralea Fructus. Many die from swelling due to inappropriate dysentery treatments damaging Yuan Qi. Since the Kidney governs urination and defecation, dysfunction here implicates the Kidney. Constipation also relates to the Kidney. *Jinkui Zhenyan Lun* states: North, Black, connects to Kidney, opens to two lower orifices. Kidney Qi deficiency causes difficulty in both excretions; treat with Rehmanniae Radix and Cistanches Herba to tonify Yin, aided by acrid herbs to moisten dryness. Jiegu stated: Constipation varies (Heat, Cold, Excess, Deficiency, Wind, Qi). Elderly, postpartum women, and those with excessive sweating/diuresis suffer constipation; avoid Glauber's Salt, Rhubarb, Croton Seed, and Morning Glory Seed. People know Heat constipation but ignore Cold constipation. Cold constipation involves cold qi obstructing intestines, freezing fluids, blocking Stomach Qi, and attacking Large Intestine; patients prefer heat. Treat with strong Babao Wan decoction taken cold, or Banliu Wan with Ginger and Frankincense, or Haicang's Yihan Wan. Haicang noted Yihan Wan uses acrid-warm herbs with cooling agents (Paeoniae Radix, Fennel Fruit) to guide downward; Yin transforms with Yang, allowing free passage, like ice melting in spring. Babao Wan is superior. Li Dongyuan stated: Kidney governs five fluids; abundant fluids ensure normal stools. Injury from hunger/fatigue or spicy/greasy diet aids Fire, damaging True Yin and fluids, causing dry colon. Elderly Qi deficiency and fluid depletion also cause constipation. Kidney dislikes dryness; treat with acrid herbs to moisten. Follow Dongyuan's theory: use Liuwei Dihuang Wan instead of Runzao Tang or Runchang Wan. For Heat constipation with Qi deficiency, add Ginseng to the decoction, as Qi deficiency fails to propel and Yin deficiency fails to moisten.
*Jing* states: Spring Wind injury leads to Summer unsifted rice diarrhea (Sunxie); lingering pathogens cause hole-like diarrhea. Clear Qi sinking causes Sunxie. Excess Dampness causes Ruoxie. Sudden violent diarrhea with urgency belongs to Heat; clear/cold fluids belong to Cold. These show Wind, Damp, Cold, and Heat all cause diarrhea. Clear Qi sinking indicates Spleen deficiency sinking. Generally, strong Spleen Earth conquers Dampness; no Dampness means no diarrhea ("Excess Damp causes five diarrheas"). Weak Spleen fails to control Dampness, allowing Wind/Cold/Heat to invade. Nine treatment principles: 1. Light leaching (Dan Shen): Drain Damp via urine, like draining floodwaters. "Treating Damp without promoting urination is incorrect." "Those below, drain them." 2. Lifting (Sheng Ti): Qi rises naturally. Stomach Qi sinking requires lifting herbs (Shengma, Chaihu, Qianghuo, Gegen) to raise Qi, stopping diarrhea. Like wind drying wet earth. Wind herbs are drying; Wood conquers Earth; Wind conquers Damp. "Sinkers, lift them." 3. Cooling (Qing Liang): For Heat-induced violent diarrhea, use bitter-cold herbs to clear blazing Heat, like wind dispelling summer heat. "Hot, clear it." 4. Purging/Draining (Shu Li): For Phlegm/Qi/Food/Water stagnation causing diarrhea, remove pathogens. "Excess, purge it." "Use unblocking to treat unblocking." 5. Sweet/Soothing (Gan Huan): For urgent, relentless diarrhea, sweet herbs soothe the middle and slow urgency. "Urgent, soothe it." 6. Sour/Astringent (Suan Shou): Chronic diarrhea scatters Qi; sour herbs aid contraction. "Scattered, gather it." 7. Drying Spleen (Zao Pi): Spleen deficiency causes Dampness. Tonify Spleen to restore function. "Deficient, tonify it." 8. Warming Kidney (Wen Shen): Kidney governs excretion and stores essence. Mingmen Fire (Mother of Earth) declines, failing to transform grains. Deficiency often involves Cold. Tonify Mother (Kidney) for Spleen deficiency. "Cold, warm it." 9. Astringing (Gu Se): Chronic diarrhea with loose pylorus requires astringents if warming/tonifying fails. "Slippery, astringe it." These nine are the guidelines for treating diarrhea.
Liu Zongnong said: Food enters Stomach, distributes to Heart/Lung, Qi ascends then descends. Spleen-Stomach injury with Damp-Heat combines, weakening Yang ascent. Spleen-Stomach Qi sinks to Liver/Kidney causing diarrhea. Treat by filling Middle Qi and lifting with light wind herbs, benefiting Yin and generating Yang. This is Dongyuan's innovation.
Initial Heat diarrhea indicates Excess (Pathogen strong). Final Cold diarrhea indicates Deficiency (Summer Qi exhausted). Chronic diarrhea with Heat indicates Internal True Cold with External False Heat. Chronic diarrhea with Cold-Deficiency is typical. Daily morning diarrhea unresponsive to empty-stomach hot medicine requires evening dosing, as morning warmth dissipates by night, failing to counter nocturnal Yin Cold.
Diarrhea involving Spleen-Stomach is well-known. Liver Qi controls sphincter closure. Kidney Qi guards the lower orifice. Strong Liver/Kidney Qi ensures closure; weakness causes leakage. Kidney is Stomach gate; Kidney diarrhea occurs post-Zi (dawn). Humans form from Heaven-Earth interaction. Kidney interstitial Qi is the ancestor of congenital Yuan Yang. This Qi rises from Zi hour (One Yang born), passing Chou-Yin-Mao-Chen-Si, reaching maximum Yang at Li Palace (Heart/Fire). Afternoon brings One Yin born (White Qi turns Red Fluid), descending to Kan Palace (Kidney/Water), returning to White Qi. Day-night cycle continues. *Jing* calls this "Minor Fire generates Qi"; physicians call it True Yang or Minister Fire. Daoists call it Lord Fire (Congenital Ancestor Qi). As this Fire ascends through Middle Jiao, it passes Spleen/Stomach, roasting food, transforming waste to essence. Spleen disperses essence to Lung, regulates waterways, sends down to Bladder. This is Clear Ascending/Turbid Descending, Water-Fire Balance. *Jing* says: "Yin balanced, Yang secret, Essence solid." Neglecting health damages Spirit, weakens Kidney True Qi. Failure of Zi-hour Yang to rise prevents food transformation. At Yin hour (Three Yang phase), weak Yang cannot respond to season or overcome Yin/ascend, causing dawn diarrhea (loose stool, "Duck Diarrhea"), known as Kidney or Da Xia diarrhea. This is Yang loss and Qi escape; tonifying Fire is more critical than tonifying Qi.
For prolonged rainy weather with excessive Dampness causing abdominal pain and diarrhea, Weiling Tang plus Prepared Zingiberis Rhizoma and Cinnamomi Cortex is most suitable.