喻昌曰∶痢疾一证，难言之矣。在《灵》、《素》谓之肠 ，亦曰滞下；《金匮》以呕吐哕下利，列为一门。盖以三者，
皆足阳明胃手阳明大肠所生之病也。至其所论下利，则皆《伤寒论》中厥阴经之本证，与二阳明呕吐哕同列之义，殊不
相合。观其论中，厥与利每每并言，始先即云∶六腑气绝于外者，手足寒；五脏气绝于内者，下利不禁，是则厥而且利，
为虚寒之极。所以反能食者则死，反发热者不死。若痢证则能食者不死，发热者多死。何其相反若是耶？此必《金匮》
呕吐哕之下，脱失下痢一证，乃取伤寒厥阴下利之文，补入其中，后人屡试不验，投杼而起者多矣。夫冬月伤寒之下利，
与夏秋伤暑湿热之下痢，而可借口仲景，谩言治法哉。后人以其无师之智，各呈偏见，或得于目之所击，手之所试，分
播广传，终不可以为法，乃遂谓疟痢无正方也。医事之偷，何遂至此！昌谨以黄岐仲景之法，拟议言之∶在《内经》冬
月伤寒，已称病热，至夏秋热暑湿三气交蒸，互结之热，十倍于冬月矣！外感三气之热而成下痢，其必从外而出之，以
故下痢必从汗，先解其外，后调其内。首用辛凉以解其表，次用苦寒以清其里，一二剂愈矣。失于表者，外邪但从里出，
不死不休，故虽百日之远，仍用逆流挽舟之法，引其邪而出之于外，则死证可活，危证可安。治经千人，成效历历可纪。
按《金匮》有云∶下痢脉反弦，发热身汗者自愈。夫久痢之脉，深入阴分，沉涩微弱矣。忽然而转弦脉，浑是少阳生发
之气，非用逆挽之法，何以得此。久利邪入于阴，身必不热，间有阴虚之热，则热而不休。今因逆挽之势，逼其临时燥
热，顷之邪从表出，热自无矣。久痢阳气下陷，皮肤干涩，断然无汗。今以逆挽之法，卫外之阳领邪气同还于表，而身
有汗，是以腹中安静，而其病自愈也。昌岂敢用无师之智哉？又有骤受暑湿之毒，水谷倾囊而出，一昼夜七八十行，大
渴引水自救，百杯不止，此则肠胃为热毒所攻，顷刻腐烂。比之误食巴豆、铅粉，其烈十倍，更用逆挽之法，迂矣！远
矣！每从《内经》通因通用之法，大黄、黄连、甘草，一昼夜连进三五十杯，俟其下利、上渴之势少缓，乃始平调于内，
更不必挽之于外。盖其邪如决水转石，乘势出尽，无可挽耳。更有急开支河一法，其邪热之在里者，奔迫于大肠，必郁
结于膀胱。膀胱热结，则气不化而小溲短赤，不用顺导而用逆挽，仍非计也。清膀胱之热，令气化行而分消热势，则
甚捷也。仲景谓下利气者，当利其小便。夫气者膀胱之化也，反从大肠而出，当利其小便，非急开支河之谓乎？然而水
出高源，肺不热则小溲自行。肺与大肠为表里，大肠之热，皆因肺热所移，尤宜用辛凉之药，先清肺之化源矣。《金匮》
有下利肺痛者，紫参汤主之。气利，诃黎勒散主之。后人疑二方非仲景之方，讵知肠胃有病，其所关全在于肺，本草谓
紫参主心腹中积聚，疗肠胃中热，通九窍，利大小便，仲景取之，固通因通用之意也。诃黎勒有通有塞，通以下涎液，
消宿食，破结气；涩以固肠脱。仲景取之，亦通塞互用之意也。又可见肺气不通而痛，则急通其壅；大肠之气，坠而逼
迫，则通塞互用，而缓调其适矣。嗟乎！《内经》之法，无可下手者，求之《金匮》。《金匮》下利之法，无可下手者，求
之自心寤寐之神，转觉《金匮》之法，一如指掌。可惜少仕光阴虚掷，今老矣，不能进步矣。特揭鄙言，为后人深入之
一助。
再按∶治疟之法，当从少阳而进退其间，进而就阳，则从少阳为表法，固矣。乃痢疾之表，亦当从于少阳，盖水谷
之气，由胃入肠，疾趋而下，始焉少阳生发之气不伸，继焉少阳生发之气转陷，故泛而求之三阳，不若颛而求之少阳。
俾苍天清净之气，足以升举，水土物产之味，自然变化精微，输泄有度，而无下痢奔迫之苦矣。况两阳明经所藏之津液，
既以下泄，尤不可更发其汗。在伤寒经禁，明有阳明禁汗之条，而《金匮》复申下利发汗之禁，谓下利清谷，不可攻其
表，汗出必胀满。盖以下利一伤其津液，发汗再伤其津液。津液去，则胃气空，而下出之浊气，随汗势上入胃中，遂成
胀满。求其下利且不可得，宁非大戒乎？所以当从少阳半表之法，缓缓逆挽其下陷之清气，俾身中行春夏之令，不致于
收降耳。究竟亦是和法，全非发汗之意。津液未伤者，汗出无妨；津液既伤，皮间微微得润，其下陷之气已举矣。夫岂
太阳外感风寒，可正发汗之比乎？又岂太阳阳明合病下利，可用葛根之比乎？噫，微矣！微矣！
治痢用通因通用之法，亦有金针。盖火湿热之邪，奔迫而出，止宜用苦寒之药，如大小承气之类。方书每杂以温中
浓肠胃之药，是欲为火湿热立帜也，其孰辨之？
《内经》曰∶肠 便血，身热则死，寒则生。又曰∶肠 下白沫，脉沉则生，浮则死。肠 之候，身不热，脉不悬
绝，滑大者生，悬涩者死，以藏期之。又曰∶阴阳虚脱，肠 死，泄而夺血，脉沉微，手足逆，皆难治。
《脉经》曰∶肠 下脓血，脉沉小留连者生，数大发热者死。又肠 筋挛，脉细小安静者生，浮大坚者死。
噤口痢，乃胃中湿热之毒，熏蒸清道而上，以致胃口闭塞，而成噤口之证。亦有误服涩热之药，而邪气停于胃口者，
用人参、石莲子等分，煎服强呷，但得一口下咽，虚热即开，更以二味为末，频频服之。
治噤口痢，多有用黄连者，此正治湿热之药，苦而且降，不能开提，况非胃虚所宜，昌故不敢取用。有用田螺捣如
泥，纳脐中，引火热下行最妙。但郁热宜一开一降，未可徒恃一法。有用丁香、砂仁之属，以火济火，则杀人之事矣。
休息痢者，乃乍作乍止，或因邪气未曾涤尽，遽止而复作者是也。或初愈恣食浓味，及妄作劳，皆能致之。
《金匮》云∶下利已瘥，至其年月日时复发者，以病不尽故也。当下之，宜大承气汤。
休息痢，止而不止，正气既虚，邪复不尽，未可言下。此证止之已久，其正已复，其积未除。故须下之。
《原病》式云∶白痢既非寒证，何故服辛热之药，亦有愈者？盖辛热之药。能开发肠胃郁结，使气液宣通，流湿润
燥，气和而已，此特其一端也。甚有先曾通泄，或因凉药太过，脉微沉细，四肢厥冷，即宜温补升阳益胃理中之属。至
云概不可用热药，亦非通变之精妙也。
《机要》云∶后重则宜下；腹痛则宜和；身重则除湿；脉弦则去风；脓血稠粘，以重剂竭之；身冷自汗，以热药温
之；风邪内结宜汗之； 溏而痢宜温之。
仲景治下痢，可下者悉用承气汤。大黄之寒，其性善走，佐以浓朴之温，善行滞气。缓以甘草之甘，饮以汤液，灌
涤肠胃，滋润轻快，积行即止。
凡先泻而后痢者逆也，复通之而不已者虚也。脉微迟，宜温补。脉弦数为逆，主死。产后痢，亦宜温补。
腹痛因肺金之气郁在大肠之间者，以苦梗发之，后用痢药。
肛门痛，热留于下也。初病身热，脉洪大，宜清之，黄芩芍药汤。病患身冷自汗，宜温之，理中汤。
下血者，宜凉血活血，当归、黄芩、桃仁之类。风邪下陷者，宜升提之。湿热伤血者，宜行湿清热。下坠异常，积
中有紫黑血，而且痛甚者，此为死血，用桃仁、滑石行之。
血痢久不愈者，属阳虚阴脱，用八珍汤加升举之药。甚有阵阵自下，手足厥冷，脉渐微缩，此为元气欲绝，急灸气
海穴，用附子理中汤，稍迟之则死。
凡下痢纯血者，如尘腐色者，如屋漏水者，大孔开而不收如竹筒，唇如朱红者，俱死。如鱼脑髓者，身热脉大者，
俱半死半生。
久痢血，脉沉弱，诸药不效，以十全大补汤，加姜枣少入蜜煎服。
【律三条】
凡治痢不分标本先后，概用苦寒者，医之罪也。以肠胃论，大肠为标，胃为本；以经脉论，手足阳明为标，少阳相
火为本。故胃受湿热，水谷从少阳之火化，变为恶浊，而传入于大肠。不治少阳，但治阳明，无益也。以少阳生发之气，
传入土中，因而下陷，不先以辛凉举之，径以苦寒夺之，痢无止期矣。
凡治痢不审病情虚实，徒执常法，自恃颛门者，医之罪也。实者邪气之实也，虚者正气之虚也。七实三虚，攻邪为
先。七虚三实，扶正为本。十分实邪，即为壮火食气，无正可扶，急去其邪，以留其正。十分虚邪，即为淹淹一息，无
实可攻，急补其正，听邪自去。故医而不知变通，徒守家传，最为误事。
凡治痢不分所受湿热多寡，辄投合成丸药误人者，医之罪也。痢由湿热内蕴，不得已用苦寒荡涤，宜煎不宜丸。丸
药不能荡涤，且多夹带巴豆、轻粉、定粉、硫黄、瑙砂、甘遂、芫花、大戟、牵牛、乌梅、粟壳之类，即使病去药存，
为害且大。况病不能去，毒烈转深，难以复救，可不慎耶！
喻昌说：痢疾这一病证，真是难以言说啊。在《灵枢》、《素问》中称为“肠澼”，也称为“滞下”；《金匮要略》将呕吐、呃逆、下利列为一门。大概因为这三者，都是足阳明胃经和手阳明大肠经所发生的疾病。至于书中论述的下利，则都是《伤寒论》中厥阴经的本证，与二阳明的呕吐、呃逆并列的意义，非常不相符合。看他的论述中，“厥”与“利”常常并提，起初就说：“六腑之气绝于外，手足寒冷；五脏之气绝于内，下利不止”，这说明厥冷并且下利，是虚寒到了极点。所以反而能进食的就会死亡，反而发热的就不会死亡。如果是痢疾证，能进食的不会死亡，发热的多数会死亡。为什么相反到这种地步呢？这一定是《金匮要略》在呕吐、呃逆之下，脱失了“下痢”这一证，于是取来《伤寒论》厥阴篇下利的文字，补入其中，后人屡次尝试不灵验，因误治而惊慌失措的人很多了。冬季伤寒引起的下利，与夏秋季节伤暑湿热引起的下痢，怎么能借口张仲景的理论，随意谈论治疗方法呢？后人凭借没有师承的智慧，各自呈现偏见，有的得自亲眼所见、亲手所试，分散传播广泛流传，最终不可以作为法则，于是就说疟疾、痢疾没有固定的方剂。医事的懈怠，怎么竟然到了这种地步！我谨慎地依据黄帝、岐伯和张仲景的方法，拟议着来说：在《内经》中，冬季伤寒，已经称为“病热”，到了夏秋季节，热、暑、湿三气交蒸，互结的热，比冬季十倍还多！外感这三种气的热邪而成下痢，其邪气必然从外表排出，因此下痢必须通过发汗，先解除表邪，然后调理内部。首先使用辛凉药物以解表，其次使用苦寒药物以清里，一两剂就能痊愈。如果失于解表，外邪只能从里出，不死不休，所以即使病程长达百日，仍然使用“逆流挽舟”的方法，引导邪气从体表排出，那么死证可以救活，危证可以转安。治疗经过千人，成效历历在目可记录。
按照《金匮要略》所说：“下痢脉象反弦，发热且身体出汗的会自愈。”久痢的脉象，深入阴分，应该是沉涩微弱的。忽然转为弦脉，完全是少阳生发之气，如果不是用逆挽的方法，怎么能得到这种脉象？久痢邪气进入阴分，身体必定不发热，间或有阴虚之热，则是发热不停止。现在因为逆挽之势，逼迫临时的燥热，一会儿邪气从体表排出，热自然就没有了。久痢阳气下陷，皮肤干涩，断然没有汗。现在用逆挽的方法，卫外的阳气带领邪气一同回到体表，于是身体出汗，因此腹中安静，病就自愈了。我哪里敢用没有师承的智慧呢？又有突然遭受暑湿毒邪，水谷倾囊而出，一昼夜七八十次，大渴引水自救，喝几百杯也不止，这是肠胃被热毒攻击，顷刻腐烂。比起误食巴豆、铅粉，猛烈十倍，再用逆挽的方法，就太迂腐了！太远了！每次都遵循《内经》“通因通用”的方法，大黄、黄连、甘草，一昼夜连续服用三五十杯，等到下利、上渴的势头稍微缓和，才开始平调内部，更不必挽回于外部。因为邪气像决堤的水、滚动的石头，乘着势头排尽，没有什么可以挽回了。更有“急开支河”一法，邪热在里的，奔迫于大肠，必然郁结于膀胱。膀胱热结，则气化不行而小便短赤，不用顺导而用逆挽，仍不是好办法。清除膀胱的热，令气化运行而分消热势，那就很快捷了。张仲景说下利气滞的，应当利小便。所谓气，是膀胱的气化功能，反而从大肠排出，应当利小便，这不就是急开支河的意思吗？然而水出于高源（肺），肺不热则小便自行。肺与大肠为表里，大肠的热，都是因为肺热转移而来，尤其应该用辛凉的药物，先清肺的气化源头。《金匮要略》有下痢伴肺痛的，用紫参汤主治。气利的，用诃黎勒散主治。后人怀疑这两个方子不是张仲景的方子，怎知肠胃有病，所关联的全在于肺，本草书说紫参主治心腹中的积聚，治疗肠胃中的热，通九窍，利大小便，张仲景取用它，固然是通因通用的意思。诃黎勒既有通的作用又有涩的作用，通以向下排涎液，消化宿食，破除结气；涩以固肠脱。张仲景取用它，也是通塞互用的意思。又可见肺气不通而痛，则急需通其壅塞；大肠之气，下坠而逼迫，则通塞互用，而缓慢调节使其舒适。唉！《内经》的方法，无处下手时，求之于《金匮要略》。《金匮要略》下利的方法，无处下手时，求之于自己心中觉悟的神明，转而觉得《金匮要略》的方法，如同指掌一样清楚。可惜年轻时仕途光阴虚掷，现在老了，不能进步了。特意揭示我的浅见，作为后人深入研究的帮助。
再按：治疗疟疾的方法，应当从少阳经而在表里之间进退，进而向阳明，则从少阳作为表法，固然正确。然而痢疾的表证，也应当从少阳经入手，大概水谷之气，由胃进入肠，急速趋下，开始是少阳生发之气不能伸展，接着少阳生发之气转而陷入，所以泛泛地求之于三阳，不如专门求之于少阳。使苍天清净之气，足以升举，水土物产的味道，自然变化精微，输泄有度，而没有下痢奔迫的痛苦了。况且两阳明经所藏的津液，既然以下泄流失，尤其不可再发汗。在《伤寒论》的禁忌中，明确有阳明禁汗的条文，而《金匮要略》又重申下利发汗的禁忌，说下利清谷，不可攻其表，发汗必然导致胀满。大概因为下利已损伤津液，发汗再损伤津液。津液去除，则胃气空虚，而下出的浊气，随着汗势向上进入胃中，遂成胀满。想求得下利都不可得，难道不是大的戒律吗？所以当从少阳半表之法，缓缓逆挽其下陷的清气，使身体中行春夏的时令，不至于收降罢了。究竟也是和法，完全不是发汗的意思。津液未受伤的，出汗无妨；津液既已受伤，皮间微微湿润，其下陷之气已举起。这难道是太阳外感风寒，可以正发汗相比的吗？这难道是太阳阳明合病下利，可用葛根相比的吗？噫，微妙啊！微妙啊！
治疗痢疾使用通因通用的方法，也有金针。大概火湿热之邪，奔迫而出，只适宜用苦寒的药物，如大小承气汤之类。方书往往混杂温中浓肠胃的药物，这是想要为火湿热树立旗帜，谁能分辨呢？
《内经》说：“肠澼便血，身热则死，寒则生。”又说：“肠澼下白沫，脉沉则生，浮则死。”肠澼的候象，身不热，脉不悬绝，滑大者生，悬涩者死，以藏气期限之。又说：“阴阳虚脱，肠澼死，泄而夺血，脉沉微，手足逆冷，都难治。”
《脉经》说：“肠澼下脓血，脉沉小留连者生，数大发热者死。”又说肠澼筋挛，脉细小安静者生，浮大坚者死。
噤口痢，乃胃中湿热之毒，熏蒸清道而上，以致胃口闭塞，而成噤口之证。也有误服涩热之药，而邪气停于胃口者，用人参、石莲子等分，煎服强呷，只要得一口咽下，虚热即开，再以这两味药为末，频频服用。
治疗噤口痢，多有用黄连的，这正是治疗湿热之药，苦而且降，不能开提，况且不适合胃虚，我所以不敢取用。有用田螺捣如泥，纳入脐中，引火热下行最妙。但郁热宜一开一降，不可徒恃一法。有用丁香、砂仁之类的，以火济火，那就是杀人的事了。
休息痢，乃乍作乍止，或因邪气未曾涤尽，遽止而复作者。或初愈恣食浓味，及妄作劳，皆能致之。
《金匮要略》说：“下利已瘥，至其年月日时复发者，以病不尽故也。当下之，宜大承气汤。”
休息痢，止而不止，正气既虚，邪复不尽，未可言下。此证止之已久，其正已复，其积未除。故须下之。
《原病式》说：“白痢既非寒证，何故服辛热之药，亦有愈者？”盖辛热之药，能开发肠胃郁结，使气液宣通，流湿润燥，气和而已，此特其一端也。甚有先曾通泄，或因凉药太过，脉微沉细，四肢厥冷，即宜温补升阳益胃理中之属。至云概不可用热药，亦非通变之精妙也。
《机要》说：“后重则宜下；腹痛则宜和；身重则除湿；脉弦则去风；脓血稠粘，以重剂竭之；身冷自汗，以热药温之；风邪内结宜汗之；溏而痢宜温之。”
张仲景治疗下痢，可下的都用承气汤。大黄之寒，其性善走，佐以厚朴之温，善行滞气。缓以甘草之甘，饮以汤液，灌涤肠胃，滋润轻快，积行即止。
凡是先泻而后痢的是逆证，复通之而不已的是虚证。脉微迟，宜温补。脉弦数为逆，主死。产后痢，也宜温补。
肛门痛，热留于下也。初病身热，脉洪大，宜清之，黄芩芍药汤。病患身冷自汗，宜温之，理中汤。
下血者，宜凉血活血，当归、黄芩、桃仁之类。风邪下陷者，宜升提之。湿热伤血者，宜行湿清热。下坠异常，积中有紫黑血，而且痛甚的，此为死血，用桃仁、滑石行之。
血痢久不愈的，属阳虚阴脱，用八珍汤加升举之药。甚有阵阵自下，手足厥冷，脉渐微缩，此为元气欲绝，急灸气海穴，用附子理中汤，稍迟之则死。
凡下痢纯血的，如尘腐色的，如屋漏水的，大孔开而不收如竹筒，唇如朱红的，都死。如鱼脑髓的，身热脉大的，都半死半生。
【律三条】
凡是治疗痢疾不分标本先后，一概用苦寒的，是医生的罪过。以肠胃论，大肠为标，胃为本；以经脉论，手足阳明为标，少阳相火为本。所以胃受湿热，水谷从少阳之火化，变为恶浊，而传入于大肠。不治少阳，但治阳明，无益也。以少阳生发之气，传入土中，因而下陷，不先以辛凉举之，径以苦寒夺之，痢无止期矣。
凡是治疗痢疾不审病情虚实，徒执常法，自恃专门的，是医生的罪过。实者邪气之实也，虚者正气之虚也。七实三虚，攻邪为先。七虚三实，扶正为本。十分实邪，即为壮火食气，无正可扶，急去其邪，以留其正。十分虚邪，即为淹淹一息，无实可攻，急补其正，听邪自去。所以医生如果不知变通，徒守家传，最为误事。
凡是治疗痢疾不分所受湿热多寡，辄投合成丸药误人的，是医生的罪过。痢由湿热内蕴，不得已用苦寒荡涤，宜煎不宜丸。丸药不能荡涤，且多夹带巴豆、轻粉、定粉、硫黄、硇砂、甘遂、芫花、大戟、牵牛、乌梅、粟壳之类，即使病去药存，为害且大。况病不能去，毒烈转深，难以复救，可不慎耶！
Yu Chang said: The syndrome of dysentery is truly difficult to describe. In the *Ling Shu* and *Su Wen*, it is called "Chang Pi" (Intestinal disorder with discharge), also known as "Zhi Xia" (Stagnant downward flow); in the *Jin Gui Yao Lue*, vomiting, hiccups, and diarrhea are listed in one chapter. This is because these three conditions are diseases generated by the Foot Yangming Stomach channel and Hand Yangming Large Intestine channel. As for the discussion of diarrhea therein, it refers to the primary syndromes of the Jueyin channel in the *Shang Han Lun*, which does not align well with the meaning of listing them together with vomiting and hiccups of the two Yangming channels. Observing his discussion, "Jue" (cold extremities) and "Li" (diarrhea/dysentery) are often mentioned together; initially, it states: "When the Qi of the six fu organs fails externally, the hands and feet become cold; when the Qi of the five zang organs fails internally, diarrhea becomes uncontrollable." Thus, Jue accompanied by Li indicates extreme deficiency-cold. Therefore, if the patient can eat, they will die; if they have a fever, they will not die. However, in dysentery, those who can eat do not die, while those with a fever mostly die. Why is it so contrary? It must be that in the *Jin Gui Yao Lue*, under vomiting and hiccups, the syndrome of "dysentery" was lost, and text regarding Jueyin diarrhea from the *Shang Han Lun* was inserted to supplement it. Later generations tried it repeatedly without success, causing many to panic due to misprescription. How can one excuse Zhang Zhongjing's methods by citing winter Shanghan diarrhea versus summer-autumn heat-dampness dysentery? Later practitioners, relying on their untaught wisdom, each presented biased views, some derived from what they saw or tested, spreading them widely, yet ultimately unsuitable as standards, leading to the claim that malaria and dysentery have no fixed formulas. How has medical practice become so negligent! I cautiously propose discussions based on the methods of Huang Di, Qi Bo, and Zhang Zhongjing: In the *Nei Jing*, winter Shanghan is already termed "disease-heat"; by summer and autumn, the heat, summer-heat, and dampness interact and evaporate, making the accumulated heat ten times greater than in winter! External contraction of these three pathogenic heats resulting in diarrhea/dysentery implies the pathogen must exit from the exterior. Therefore, dysentery must be treated via sweating: first resolve the exterior, then regulate the interior. Initially use acrid-cool herbs to release the exterior, followed by bitter-cold herbs to clear the interior; recovery occurs in one or two doses. If the exterior is neglected, the external pathogen only exits from the interior, ceasing not until death. Thus, even after a hundred days, the method of "rowing upstream against the current" (Ni Liu Wan Zhou) should still be used to guide the pathogen out through the exterior, turning fatal cases livable and critical cases stable. Having treated thousands, the results are clearly recorded.
According to the *Jin Gui Yao Lue*: "Diarrhea/dysentery with a wiry pulse, accompanied by fever and sweating, heals spontaneously." In chronic diarrhea/dysentery, the pulse enters the yin level, becoming deep, choppy, and weak. A sudden shift to a wiry pulse reflects the generating qi of Shaoyang. Without the method of counter-current pulling, how could such a pulse arise? In chronic diarrhea/dysentery, pathogens enter yin, and the body is typically not hot; if there is yin-deficiency heat, the fever persists. Now, due to the force of counter-current pulling, temporary dry-heat is forced out, and soon the pathogen exits the surface, eliminating the heat. Chronic diarrhea/dysentery involves sinking of yang qi, dry and rough skin, and definitely no sweat. Now, using the counter-current method, the defensive yang leads the pathogen back to the surface, resulting in sweating; thus the abdomen becomes quiet, and the disease heals spontaneously. How dare I rely on untaught wisdom? Furthermore, sudden exposure to summer-heat and dampness toxins causes water and grain to pour out, seven or eight dozen times a day, with intense thirst seeking water self-rescue, drinking hundreds of cups without relief. This means the intestines and stomach are attacked by heat toxins, rotting instantly. This is ten times more violent than ingesting croton seed or lead powder; applying the counter-current method here would be too circuitous and distant! Instead, follow the *Nei Jing* principle of "treating obstruction with unblocking agents" (Tong Yin Tong Yong): Rhubarb, Coptis, and Licorice, administered continuously over 24 hours in large quantities. Wait until the intensity of diarrhea and thirst subsides, then begin to harmonize the interior; there is no need to pull from the exterior. The pathogen is like bursting water or rolling stones, exiting completely with momentum, leaving nothing to pull. There is another method: "urgently opening branch rivers." Heat pathogens inside rush to the Large Intestine and stagnate in the Bladder. Bladder heat-stagnation prevents qi transformation, causing scanty dark urine. Using counter-current pulling instead of guiding downward is not the best plan. Clearing Bladder heat allows qi transformation to proceed and disperses heat quickly. Zhang Zhongjing stated that diarrhea with qi stagnation should be treated by promoting urination. Qi is the function of Bladder transformation; if it exits via the Large Intestine, promoting urination is indeed urgently opening branch rivers. Water originates from the high source (Lung); if the Lung is not hot, urination proceeds normally. Lung and Large Intestine are exterior-interior pairs; Large Intestine heat stems from Lung heat transfer, so acrid-cool herbs should be used first to clear the Lung's transformation source. The *Jin Gui Yao Lue* mentions dysentery with lung pain, treated with Zi Can Tang. Qi-type diarrhea is treated with He Li Le San. Later generations doubted these were not Zhang Zhongjing's formulas, failing to realize that intestinal diseases relate entirely to the Lung. Materia Medica states Zi Can treats abdominal accumulations, clears intestinal heat, opens nine orifices, and promotes urination/defecation; Zhang Zhongjing used it, embodying the principle of treating obstruction with unblocking. He Li Le has both unblocking and astringent properties: unblocking to descend phlegm, digest retained food, and break qi stagnation; astringing to secure intestinal prolapse. Zhang Zhongjing used it, embodying mutual use of unblocking and securing. This shows that when Lung qi is blocked causing pain, urgency requires unblocking congestion; when Large Intestine qi sinks and presses, mutual use of unblocking/securing provides gradual comfort. Alas! When the *Nei Jing* methods offer no entry point, seek the *Jin Gui Yao Lue*. When *Jin Gui* methods offer no entry point, seek the divine insight of one's own mind; suddenly, *Jin Gui* methods become as clear as seeing one's palm. Regrettably, my youth was wasted in official duties; now old, I cannot advance further. I reveal these humble words to assist later generations in deeper study.
Furthermore: Treating malaria should involve advancing and retreating within the Shaoyang channel. Advancing toward Yang implies using Shaoyang as an exterior-releasing method, which is correct. However, the exterior aspect of dysentery should also be sought in Shaoyang. Roughly, water and grain qi moves from Stomach to Intestine, rushing downward. Initially, Shaoyang generating qi fails to extend; subsequently, it sinks. Thus, broadly seeking among the Three Yang channels is inferior to specifically seeking Shaoyang. This allows the pure qi of Heaven to rise sufficiently, and the flavors of earth and water transform into essence and subtlety, with regulated transmission and excretion, avoiding the suffering of urgent dysentery. Moreover, the fluids stored in the two Yangming channels are already lost through downward discharge; one must not induce sweating again. The *Shang Han Lun* explicitly forbids sweating in Yangming, and the *Jin Gui Yao Lue* reiterates the prohibition of sweating in diarrhea, stating that diarrhea with undigested food precludes attacking the exterior; sweating will cause abdominal fullness. Since diarrhea damages fluids, sweating damages them again. Loss of fluids empties Stomach qi, allowing turbid qi from below to ascend into the Stomach with the sweating momentum, forming fullness. Seeking even diarrhea becomes impossible; is this not a major warning? Therefore, one should use the half-exterior method of Shaoyang to slowly counter-currently pull the sinking clear qi, ensuring the body maintains spring-summer functions without descending/retracting. Ultimately, this is a harmonizing method, not a sweating intent. If fluids are undamaged, sweating is harmless; if fluids are damaged, slight moisture on the skin indicates the sinking qi has been raised. How is this comparable to Taiyang exterior wind-cold requiring direct sweating? Or Taiyang-Yangming combined disease diarrhea using Kudzu Root? Ah, subtle! Subtle!
Treating dysentery with the principle of "treating obstruction with unblocking agents" also has golden needles. Fire, heat, and dampness pathogens rush out; only bitter-cold herbs like Da Cheng Qi Tang or Xiao Cheng Qi Tang are suitable. Formulary books often mix in warm-middle and thickening-intestine herbs, effectively setting up banners for fire-heat-dampness; who can distinguish this?
The *Nei Jing* says: "Chang Pi with blood stool, fever indicates death, cold indicates survival." Also: "Chang Pi with white mucus, deep pulse indicates survival, floating pulse indicates death." Signs of Chang Pi: body not hot, pulse not suspended/extreme; slippery-large pulse indicates survival, suspended-choppy pulse indicates death, judged by zang organ timing. Also: "Yin-yang deficiency collapse, Chang Pi, death; diarrhea with blood loss, deep-micro pulse, cold extremities, all difficult to treat."
The *Mai Jing* says: "Chang Pi with pus and blood, deep-small lingering pulse indicates survival, rapid-large with fever indicates death." Also Chang Pi with muscle cramps: fine-small quiet pulse indicates survival, floating-large firm pulse indicates death.
Jin Kou Li (Dysentery with inability to swallow/open mouth) is caused by heat-dampness toxin in the Stomach steaming upward along the clear pathways, blocking the gastric opening. It can also result from mistakenly taking astringent-hot herbs, trapping pathogens at the gastric opening. Use equal parts Ginseng and Stone Lotus Seed, decocted and forcibly swallowed; once a mouthful goes down, deficient-heat opens. Then take these two herbs as powder frequently.
Treating Jin Kou Li often uses Coptis, which treats heat-dampness, is bitter and descending, unable to lift; moreover, it is unsuitable for Stomach deficiency, so I dare not use it. Using crushed river snail applied to the umbilicus to draw fire-heat downward is excellent. But stagnant heat requires both opening and descending; relying on one method alone is insufficient. Using Clove and Amomum, adding fire to fire, is a killing act.
Xiu Xi Li (Intermittent Dysentery) comes and goes intermittently, either because pathogens were not fully cleared and stopped abruptly before recurring, or due to indulging in rich foods or excessive labor immediately after initial recovery.
The *Jin Gui Yao Lue* states: "If diarrhea recurs at the same time/year/day after recovery, it is because the disease was not exhausted. It should be purged; Da Cheng Qi Tang is appropriate."
In Xiu Xi Li, if it stops but recurs, Zheng qi is deficient, and pathogens remain; purging cannot be discussed yet. If this syndrome has stopped for a long time, Zheng qi has recovered, but accumulation remains; thus purging is necessary.
The *Yuan Bing Shi* asks: "White dysentery is not a cold syndrome; why do acrid-hot herbs sometimes cure it?" Acrid-hot herbs can open gastrointestinal stagnation, promote qi-fluid circulation, moisten dryness, and harmonize qi; this is just one aspect. In cases where purgatives were previously used excessively or cold herbs were overused, resulting in micro-deep-fine pulse and cold limbs, warming-tonifying, raising yang, benefiting Stomach, and Li Zhong Tang category herbs are appropriate. To say heat herbs are generally unusable is not the essence of flexibility.
The *Ji Yao* states: "Tenesmus requires purging; abdominal pain requires harmonizing; heavy body requires removing dampness; wiry pulse requires expelling wind; thick sticky pus/blood requires heavy dosage to exhaust; cold body with spontaneous sweating requires warming with hot herbs; internal wind-pathogen binding requires sweating; loose stool with dysentery requires warming."
Zhang Zhongjing treated diarrhea/dysentery suitable for purging with Cheng Qi Tang. Rhubarb's cold nature moves well; assisted by Magnolia Bark's warmth, it moves stagnant qi gently. Licorice's sweetness moderates it; taken as decoction, it irrigates and cleanses intestines/stomach, moisturizes and lightens, stopping once accumulation moves.
Preceding diarrhea followed by dysentery is adverse; continuing purgation without cessation indicates deficiency. Micro-slow pulse requires warming-tonifying. Wiry-rapid pulse is adverse, indicating death. Postpartum dysentery also requires warming-tonifying.
Abdominal pain due to Metal-of-Lung qi stagnating in the Large Intestine should be treated with Platycodon to disperse, followed by dysentery herbs.
Anal pain indicates heat lingering below. Initial illness with fever and large pulse requires clearing; Huang Qin Shao Yao Tang. Patient with cold body and spontaneous sweating requires warming; Li Zhong Tang.
Hematochezia requires cooling-blood and activating-blood herbs like Angelica Sinensis, Scutellaria, and Peach Kernel. Sunken wind-pathogen requires lifting. Damp-heat damaging blood requires moving-dampness and clearing-heat. Abnormal bearing-down sensation with purple-black blood in stool and severe pain indicates dead blood; use Peach Kernel and Talc to move it.
Chronic bloody dysentery not healing belongs to yang-deficiency and yin-collapse; use Ba Zhen Tang with lifting herbs. Cases with periodic defecation, cold extremities, and gradually shrinking micro-pulse indicate yuan qi about to perish; urgently moxa Qihai acupoint, use Fu Zi Li Zhong Tang; delay slightly and death ensues.
Pure blood in dysentery, color like dust/rot, like roof-leak water, anus open and unretracting like a bamboo tube, lips vermilion-red, all indicate death. Color like fish brain matter, fever, large pulse, indicate half-death half-life.
Chronic bloody dysentery with deep-weak pulse, unresponsive to other herbs: use Shi Quan Da Bu Tang with ginger, jujube, and a little honey decocted and taken.
[Three Laws]
1. Any physician who treats dysentery indiscriminately with bitter-cold herbs without distinguishing root/branch or sequence commits a medical error. Regarding the gastrointestinal tract, Large Intestine is branch, Stomach is root; regarding channels, Hand/Foot Yangming are branch, Shaoyang Ministerial Fire is root. Thus, Stomach receives heat-dampness, water/grain transforms via Shaoyang fire into foul turbidity, transmitting to Large Intestine. Treating only Yangming without addressing Shaoyang is useless. If Shaoyang generating qi transmits to Earth and sinks, failing to first lift with acrid-cool herbs and directly draining with bitter-cold herbs ensures dysentery never ceases.
2. Any physician who treats dysentery without assessing deficiency/excess, clinging to standard methods and relying on specialized knowledge alone commits a medical error. Excess refers to pathogen excess; deficiency refers to Zheng qi deficiency. Seven parts excess, three parts deficiency: attack pathogen first. Seven parts deficiency, three parts excess: support Zheng qi as root. Ten parts excess pathogen consumes Zheng qi via fierce fire; no Zheng qi to support, urgently remove pathogen to preserve Zheng qi. Ten parts deficiency pathogen leaves barely a breath; no excess to attack, urgently tonify Zheng qi, letting pathogen depart naturally. Thus, physicians who do not know flexibility and cling to family traditions cause greatest harm.
3. Any physician who prescribes compounded pill medicines for dysentery regardless of heat-dampness quantity, misleading patients, commits a medical error. Dysentery stems from internal heat-dampness accumulation; bitter-cold purgation is不得已 (unavoidable). Decoctions are preferred over pills. Pills cannot purge effectively and often contain Croton Seed, Calomel, Lead Powder, Sulfur, Ammonium Chloride, Kansui, Genkwa, Euphorbia, Pharbitis Seed, Chinese Plum, Poppy Shell, etc. Even if the disease resolves but medicine remains, harm is great. Worse, if disease persists, toxicity deepens, making rescue difficult. Must one not be cautious?