夫伤寒自利何以明之。自利者。有不经攻下。自然溏泻者是也。自利多种。须知冷热虚
实。消息投汤。无致失差。杂病自利。多责为寒。伤寒下利。多由协热。其与杂病有以异也。
表邪传里。里虚协热则利。不应下而便攻之。内虚协热遂利。是皆协热也。又合病家。皆作
自利。太阳与阳明合病。必自下利。葛根汤主之。太阳与少阳合病。必自下利。黄芩汤主之。
阳明与少阳合病。必自下利。大承气汤主之。三者皆合病下利。一者攻里。一者和解。所以
不同者。盖六经以太阳、阳明为表。少阳、太阴为在半表半里。少阴、厥阴为在里。太阳、
阳明合病。为在表者也。虽曰下利。必发散经中邪气而后已。故与葛根汤以汗之。太阳与少
阳合病。为在半表半里者也。虽曰下利。必和解表里之邪而后已。故与黄芩汤以散之。阳明
与少阳合病。为少阳邪气入腑者也。虽曰下利。必逐去胃中之实而后已。故与承气汤以下之。
是三者异也。下利家。何以明其寒热耶。且自利不渴。属太阴。以其脏寒故也。下利欲饮水
者。以有热也。故大便溏。小便自可者。此为有热自利。小便色白者。少阴病形悉具。此为
有寒。恶寒脉微。自利清谷。此为有寒发热。后重。泄色黄赤。此为有热。皆可理其寒热也。
凡腹中痛。转气。下趣小腹者。此欲自利也。自利家。身凉脉小为顺。身热脉大为逆。少阴
病。脉紧下利。脉暴微。手足反温。脉紧反去者。此为欲解。下利脉大者。为未止。脉微弱
数者。为欲自止。虽发热不死。是知下利脉大为逆。而脉小为顺也。自利宜若可温。理中白
通诸四逆辈。皆温脏止利之剂。又有肠胃有积结。与下焦客邪。皆温剂不能止之。必也或攻
泄之。或分利之而后已。经曰。理中者。理中焦。此利在下焦。宜赤石脂禹余粮汤。复不止。
当利其小便。是泄在下焦。渗泄而聚利者也。少阴病。自利清水。色纯青。心下必痛。口
干燥与下利。三部皆平。按之心下硬。或脉沉而滑。或不欲食而谵语。或瘥后至年月日复发。
此数者。皆肠胃有积结。而必须攻泄者也。内经有曰。大热内结。注泄不止。热宜寒疗。
结伏须除。以寒下之。结散利之。大寒凝内。久利泄溏。愈而复发。绵历岁年。以热下之。
寒去利自止。通因通用。下利虽有表证。又不可发汗。以下利为邪气内攻。走津液而胃虚
也。故经曰。下利不可攻表。其汗出必胀满者是矣。大抵下利。脱气至急。五夺之中。此为
甚者。其或邪盛正虚。邪拥正气下脱。多下利而死。何以言之。经曰。下利日十余行。脉反
实者死。发热下利至甚。厥不止者死。直视谵语。下利者死。下利手足厥冷无脉者。灸之不
温。脉不还死。少阴病自利。复烦躁。不得卧寐者死。此数者。皆邪拥正气下脱而死者也。
金匮要略曰。六腑气绝于外者。手足寒。五脏气绝于内者。利下不禁。呜呼。疾成而后药。
虽神医不可为已。气既脱矣。孰能治之。
方
白术丸 趺阳脉沉而缓。沉则胃气强。缓则大便频。沉缓相搏。小便难。其胃为
约。
白术 干姜 茯苓（各二两） 上蜜丸如桐子大。白饮服二十丸。以效为度。
诃黎勒饮 治伤寒后气不和。自利无度。
诃黎勒皮（四枚二生二煨） 草豆蔻（四棵二生二煨去皮） 上粗捣筛。每服二钱。以
浆水
一盏。煎至六分。去滓。空心温服。
燥肠丸（出济生拔萃方）治伤寒汗下后。大小便自利。肠中痛者。
附子（一个炮） 龙骨（半两） 干姜（一两） 吴茱萸（半两） 米谷（半两） 诃
黎勒皮（半
两） 上为细末。酒糊为丸。如梧桐子大。每服三十丸。温水下。利止勿服。
参附汤（出如宜方）治自利。上炎烦躁。坐卧不安。脉迟。
人参（半两） 附子（制一两） 上 咀。分作三服。姜十片。煎。食前温服。又宜既
济方。
四逆汤（出易简方）治阴证伤寒自利不渴。呕哕不止。或吐利俱作。小便或涩
或利。脉微欲绝。腹痛胀满。手足厥冷。或咳或悸。内寒外热。下利清谷。四肢沉重。
或汗出厥逆者。或汗出热不去者。并宜服之。及治一切虚冷厥。理中汤方中。亦互言
之。或伤寒病在表。医误下之。致下利不止。虽觉头疼体痛。发热恶寒。四肢拘急。表
证悉俱。未可攻表。宜先服此药。以助阳救里。次服桂枝汤。以解表证。
甘草（一两） 干姜（一两半） 熟附子（三分） 上 咀。每服四钱。水一盏半。煎
至六分
服。服此药利止而亡血者。加人参半两。面赤者。每服加葱白一茎。腹痛者。加芍药一两。
呕者。加生姜一两。咽痛者。加桔梗半两。利止脉不出。加人参一两。霍乱吐泻之后。最宜
服之。阴证伤寒。或无汗。唇青面黑。身背强痛。四肢厥冷。昏不知人。未尝服四逆汤者。
先与附子散三分。用附子、官桂、当归、白术各半两。半夏、干姜各一分。加葱白煎服。被
覆取汗。
伤寒引起的自利该如何辨明？所谓自利，是指没有经过攻下治疗，自然出现大便溏泻的情况。自利的情况有多种，必须分辨是寒证、热证、虚证还是实证，仔细斟酌后投药，以免出现差错。杂病中的自利，多归咎于寒邪；而伤寒中的下利，多由协热引起。这与杂病是有区别的。
表邪传入体内，若里气虚弱且伴有热邪，就会导致下利；本不应使用攻下法却误用攻下，导致内虚并伴有热邪，从而引发下利，这些都属于“协热利”。此外，合病患者也常出现自利。太阳与阳明合病，必然出现自下利，用葛根汤主治。太阳与少阳合病，必然出现自下利，用黄芩汤主治。阳明与少阳合病，必然出现自下利，用大承气汤主治。这三种合病下利的情况各不相同：一种是用攻下法治里，一种是和解法，之所以不同，是因为六经中太阳、阳明属于表，少阳、太阴属于半表半里，少阴、厥阴属于里。太阳与阳明合病，病位在表。虽然表现为下利，但必须发散经络中的邪气才能痊愈，所以给予葛根汤以发汗解表。太阳与少阳合病，病位在半表半里。虽然表现为下利，但必须和解表里之邪才能痊愈，所以给予黄芩汤以疏散邪气。阳明与少阳合病，是少阳邪气传入腑中。虽然表现为下利，但必须祛除胃中的实邪才能痊愈，所以给予承气汤以下夺实邪。这就是三者的区别。
对于下利患者，如何辨别其寒热性质呢？如果自利且不口渴，属于太阴病，这是因为脏腑虚寒所致。如果下利想要喝水，说明体内有热。因此，大便溏薄而小便正常的，这是有热的自利；如果小便颜色清白，则具备少阴病的特征，这是有寒的表现。恶寒、脉微细、下利完谷不化（大便中含有未消化的食物），这是有寒且有发热的表现；如果有肛门重坠感（后重），排泄物色黄赤，这是有热的表现。这些都可以通过症状来辨析寒热。
凡是腹中疼痛，肠鸣转气，气体向下趋向小腹的，这是即将发生自利的征兆。患下利的人，如果身体凉爽、脉象细小，为顺证；如果身体发热、脉象洪大，为逆证。少阴病，脉紧而下利，如果脉搏突然变得微弱，手足反而温暖，脉紧消失，这是病情将要解除的征兆。下利脉大的，说明病势未止；脉微弱而数的，说明病情将要自行停止，即使有发热也不会死亡。由此可知，下利脉大为逆证，脉小为顺证。
自利适宜用温法治疗，理中汤、白通汤以及四逆汤类方剂，都是温补脏腑、止住下利的药剂。但是，如果肠胃中有积滞结聚，或者下焦有客邪侵袭，温补剂就不能止住下利，必须通过攻下泄浊或分利小便的方法才能痊愈。经文说：“理中汤是调理中焦的。”这种下利位于下焦，宜用赤石脂禹余粮汤。如果服用后仍不止，应当利小便。这是因为下利位于下焦，是水湿渗泄积聚导致的。
少阴病，自利清水，颜色纯青，心下部必定疼痛，口干燥。或者下利，三部脉象平和，但按压心下部感觉坚硬；或者脉沉而滑；或者不想吃东西且胡言乱语（谵语）；或者病愈后在特定的年月日复发。这几种情况，都是肠胃中有积滞结聚，必须使用攻下泄浊的方法。《内经》说：“大热内结，注泄不止，热邪宜用寒凉疗法，结伏须去除，用寒凉攻下之法。结散则利止。大寒凝滞于内，久利多见泄溏，痊愈后易复发，绵延多年，需用温热攻下之法。寒去则利自止。”这就是“通因通用”的道理。
下利虽然有表证，也不可以发汗。因为下利是邪气内攻，耗伤津液导致胃气虚弱。所以经文说：“下利不可攻表，否则出汗必致腹胀满。”大抵来说，下利会导致元气脱失，在五夺（五种极度虚损的状态）之中，这是严重的。如果邪气盛而正气虚，邪气逼迫正气下脱，会导致多次下利而死。为什么这么说呢？经文说：“下利一天十几次，脉象反而实大的，主死；发热下利非常严重，四肢厥冷不止的，主死；眼睛直视、胡言乱语且下利的，主死；下利且手足厥冷无脉的，艾灸后不回暖，脉搏不恢复的，主死；少阴病自利，又烦躁不安，不能卧睡的，主死。”这几种情况，都是因为邪气逼迫正气下脱而死亡的。《金匮要略》说：“六腑之气绝于体表，表现为手足寒冷；五脏之气绝于体内，表现为下利不禁。”唉！疾病形成后才用药，即使是神医也无法救治了。既然元气已经脱失，谁能治愈它呢？
【方剂】
白术丸：趺阳脉沉而缓。沉则胃气强，缓则大便次数多。沉与缓相搏结，导致小便困难，胃部约束失常。
组成：白术、干姜、茯苓（各二两）。上药制成蜜丸，如梧桐子大。用米汤送服二十丸，以见效为度。
诃黎勒饮：治疗伤寒后气机不和，自利无度。
组成：诃黎勒皮（四枚，二分生用，二分煨制）、草豆蔻（四颗，二分生用，二分煨制，去皮）。上药粗捣筛过。每次服用二钱，用浆水一盏，煎至六分，去渣，空腹温服。
燥肠丸（出自《济生拔萃方》）：治疗伤寒发汗或攻下后，大小便自利，肠中疼痛。
组成：附子（一个，炮制）、龙骨（半两）、干姜（一两）、吴茱萸（半两）、米谷（半两）、诃黎勒皮（半两）。上药研为细末，酒糊为丸，如梧桐子大。每次服用三十丸，温水送下。利止后勿服。
参附汤（出自《如宜方》）：治疗自利，虚火上炎烦躁，坐卧不安，脉迟。
组成：人参（半两）、附子（制一两）。上药切碎，分作三次服用。加生姜十片，煎煮，饭前温服。也可参考既济方。
四逆汤（出自《易简方》）：治疗阴证伤寒自利不渴，呕吐呃逆不止，或吐利俱作，小便或涩或利，脉微欲绝，腹痛胀满，手足厥冷，或咳或悸，内寒外热，下利完谷不化，四肢沉重，或汗出厥逆，或汗出热不退者，均宜服用。也治疗一切虚冷厥证。理中汤方中也互有提及。如果伤寒病在表，医生误用攻下法，导致下利不止，虽然觉得头痛体痛、发热恶寒、四肢拘急，表证俱全，也不可攻表，宜先服用此药，以助阳救里，然后再服桂枝汤以解表证。
组成：甘草（一两）、干姜（一两半）、熟附子（三分）。上药切碎。每次服用四钱，加水一盏半，煎至六分服用。服用此药后，如果利止但出现亡血征象，加人参半两；面色发红者，每次加葱白一茎；腹痛者，加芍药一两；呕吐者，加生姜一两；咽痛者，加桔梗半两；利止但脉搏不出，加人参一两。霍乱吐泻之后，最宜服用此药。如果是阴证伤寒，无汗，唇青面黑，身背强痛，四肢厥冷，昏迷不知人，未曾服用过四逆汤的，先给予附子散三分。用附子、官桂、当归、白术各半两，半夏、干姜各一分，加葱白煎服。服药后覆盖取汗。
How should spontaneous diarrhea caused by cold damage (Shanghan) be understood? Spontaneous diarrhea refers to loose stools occurring naturally without prior purgative treatment. There are various types of spontaneous diarrhea; one must discern whether it is due to cold, heat, deficiency, or excess, carefully select the decoction accordingly, and avoid errors. In miscellaneous diseases, spontaneous diarrhea is often attributed to cold; whereas in cold damage, diarrhea is mostly caused by "collateral heat" (Xie Re). This differs from miscellaneous diseases.
When exterior pathogens transmit inward, if the interior is deficient and accompanied by heat, diarrhea ensues. If purgatives are incorrectly used when not indicated, leading to interior deficiency and collateral heat, diarrhea also results; these are all cases of collateral heat. Furthermore, patients with combined diseases often experience spontaneous diarrhea. When Taiyang and Yangming combined diseases occur, spontaneous lower diarrhea is inevitable, treated with Gegen Tang (Kudzu Decoction). When Taiyang and Shaoyang combined diseases occur, spontaneous lower diarrhea is inevitable, treated with Huangqin Tang (Scutellaria Decoction). When Yangming and Shaoyang combined diseases occur, spontaneous lower diarrhea is inevitable, treated with Dachengqi Tang (Major Order the Qi Decoction). These three types of combined disease diarrhea differ: one involves purging the interior, another involves harmonizing. The difference lies in the Six Meridians: Taiyang and Yangming are considered exterior, Shaoyang and Taiyin are semi-exterior/semi-interior, and Shaoyin and Jueyin are interior. Taiyang and Yangming combined diseases are located in the exterior. Although presenting as diarrhea, the pathogenic qi in the meridians must be dispersed through sweating to resolve. Hence, Gegen Tang is given to induce sweating. Taiyang and Shaoyang combined diseases are located in the semi-exterior/semi-interior. Although presenting as diarrhea, the pathogenic qi in both exterior and interior must be harmonized to resolve. Hence, Huangqin Tang is given to disperse the pathogen. Yangming and Shaoyang combined diseases involve Shaoyang pathogenic qi entering the fu organs. Although presenting as diarrhea, the excess in the stomach must be driven out to resolve. Hence, Chengqi Tang is given to purge the excess. These are the differences among the three.
How can one distinguish between cold and heat in patients with diarrhea? If spontaneous diarrhea occurs without thirst, it belongs to Taiyin, due to cold in the zang organs. If diarrhea is accompanied by a desire to drink water, it indicates heat. Therefore, loose stools with normal urination indicate heat-type spontaneous diarrhea. If urine is clear and white, it exhibits the signs of Shaoyin disease, indicating cold. Aversion to cold, faint pulse, and diarrhea with undigested food (Qing Gu) indicate cold. Diarrhea accompanied by fever and tenesmus (Hou Zhong), with yellow-red excrement, indicates heat. These symptoms allow for the differentiation of cold and heat.
Abdominal pain, borborygmus (Zhuan Qi), and gas moving downward toward the lower abdomen indicate impending spontaneous diarrhea. In patients with diarrhea, a cool body and small pulse are favorable (Shun); a hot body and large pulse are unfavorable (Ni). In Shaoyin disease, if the pulse is tight with diarrhea, but suddenly becomes weak, hands and feet become warm, and the tightness disappears, this indicates impending resolution. A large pulse in diarrhea indicates the condition has not stopped; a weak, fine, and rapid pulse indicates the condition will stop spontaneously. Even with fever, death is unlikely. Thus, a large pulse in diarrhea is unfavorable, while a small pulse is favorable.
Spontaneous diarrhea is suitable for warming treatments. Lizhong Tang (Regulate the Middle Decoction), Baitong Tang, and Sini Tang (Frigid Extremities Decoction) and similar formulas are agents that warm the viscera and stop diarrhea. However, if there are accumulations and knots in the intestines and stomach, or external pathogens in the lower jiao, warming agents cannot stop the diarrhea. One must use purgatives to drain or diuretics to separate fluids to resolve it. The classics state: "Lizhong regulates the middle jiao." For diarrhea located in the lower jiao, Chishizhi Yuyuli Tang (Red Halloysite and Hematite Decoction) is appropriate. If it does not stop, promote urination. This is because the diarrhea is in the lower jiao, caused by infiltration and accumulation of dampness.
In Shaoyin disease, spontaneous diarrhea of clear water, purely green in color, with pain in the epigastrium and dry mouth, requires attention. Or, in diarrhea where the pulses at the three positions are level, but palpation reveals hardness in the epigastrium; or a deep and slippery pulse; or anorexia with delirium; or recurrence after recovery on specific dates—these conditions all indicate intestinal and gastric accumulations requiring purgation. The *Neijing* states: "Severe internal heat with unceasing diarrhea: heat should be treated with cold methods; accumulated heat must be removed with cold purgatives. Once the accumulation disperses, the diarrhea stops. Severe internal cold with chronic loose stools, recurring over years: treat with warm purgatives. Once the cold is gone, the diarrhea stops." This illustrates the principle of "treating obstruction with unblocking methods" (Tong Yin Tong Yong).
Even if diarrhea presents with exterior signs, sweating should not be induced. Diarrhea indicates pathogenic qi attacking internally, consuming fluids and weakening the stomach. Thus, the classics state: "Diarrhea should not be treated by attacking the exterior; inducing sweat will lead to abdominal distension." Generally, diarrhea leads to the loss of vital qi; among the Five Deprivations (Wu Duo), this is severe. If pathogens are strong and righteous qi is weak, forcing righteous qi to collapse downward leads to death from frequent diarrhea. Why? The classics state: "Diarrhea more than ten times a day with a paradoxically strong pulse indicates death; severe fever and diarrhea with unrelenting cold limbs indicate death; fixed gaze, delirium, and diarrhea indicate death; diarrhea with cold limbs and absent pulse, unresponsive to moxibustion and pulse return, indicates death. Shaoyin disease with spontaneous diarrhea, restlessness, and inability to sleep indicates death." These cases all result from pathogens forcing righteous qi to collapse downward. The *Jingui Yaolue* states: "When qi of the six fu organs fails externally, hands and feet are cold; when qi of the five zang organs fails internally, diarrhea is uncontrollable." Alas! Medicating only after disease formation, even a divine physician cannot cure it. Once qi has collapsed, who can treat it?
[Formulas]
Baizhu Wan (Atractylodes Macrocephala Pill): Fuyang pulse is deep and slow. Deep indicates strong stomach qi; slow indicates frequent bowel movements. The combination of deep and slow leads to difficult urination and constrained stomach function.
Ingredients: Baizhu (Atractodis Macrocephalae Rhizoma), Ganjiang (Zingiberis Rhizoma), Fuling (Poria) (each 2 liang). Process into honey pills the size of paulownia seeds. Take 20 pills with rice water, adjusting dosage until effective.
Helile Yin (Galangal Drink): Treats post-cold damage disharmony of qi and endless spontaneous diarrhea.
Ingredients: Helile Pi (Myristicae Pericarpium) (4 pieces, half raw, half roasted), Caodoukou (Alpiniae Katsumadai Semen) (4 pods, half raw, half roasted, peeled). Coarsely grind and sieve. Take 2 qian per dose. Decoct with Jiangshui (fermented rice water) one cup until reduced to 60%. Strain and take warm on an empty stomach.
Zaochang Wan (Dry Intestine Pill) (from *Jisheng Babie Fang*): Treats spontaneous diarrhea of both bowels and bladder after cold damage sweating or purging, with intestinal pain.
Ingredients: Fuzi (Aconiti Lateralis Radix Praeparata) (1 piece, processed), Longgu (Fossilia Ossis Mastodi et Scapulae) (0.5 liang), Ganjiang (Zingiberis Rhizoma) (1 liang), Wuzhuyu (Evodiae Fructus) (0.5 liang), Miguj (Rice and Grain residue) (0.5 liang), Helile Pi (Myristicae Pericarpium) (0.5 liang). Grind into fine powder, bind with wine paste into pills the size of paulownia seeds. Take 30 pills with warm water. Stop taking once diarrhea ceases.
Shenfu Tang (Ginseng and Aconite Decoction) (from *Ruyi Fang*): Treats spontaneous diarrhea with floating false fire causing irritability, restlessness, and slow pulse.
Ingredients: Renshen (Ginseng Radix) (0.5 liang), Fuzi (Aconiti Lateralis Radix Praeparata) (processed, 1 liang). Cut into pieces, divide into three doses. Add 10 slices of Shengjiang (Zingiberis Rhizoma Recens), decoct, and take warm before meals. Also refer to Ji Ji Fang.
Sini Tang (Frigid Extremities Decoction) (from *Yijian Fang*): Treats yin-pattern cold damage with spontaneous diarrhea and no thirst, continuous vomiting and hiccups, simultaneous vomiting and diarrhea, dysuria or polyuria, faint pulse nearly imperceptible, abdominal pain and distension, cold limbs, cough or palpitations, internal cold with external heat, diarrhea with undigested food, heavy limbs, sweating with cold limbs, or sweating with persistent heat. Also treats all deficiency-cold syncope. Mentioned interchangeably with Lizhong Tang. If cold damage is in the exterior and mistakenly purged by a physician, causing unceasing diarrhea, even if headache, body ache, fever, aversion to cold, and limb stiffness (exterior signs) are present, do not attack the exterior. First administer this medicine to support yang and rescue the interior, then administer Guizhi Tang (Cinnamon Twig Decoction) to resolve the exterior.
Ingredients: Gancao (Glycyrrhizae Radix et Rhizoma) (1 liang), Ganjiang (Zingiberis Rhizoma) (1.5 liang), Shu Fuzi (Prepared Aconiti Lateralis Radix) (0.3 fen). Cut into pieces. Take 4 qian per dose. Decoct with 1.5 cups of water until reduced to 60%. If diarrhea stops but blood loss occurs, add Renshen (Ginseng Radix) 0.5 liang. If face is red, add Congbai (Allii Tuberosi Bulbus) one stalk per dose. If abdominal pain, add Shaoyao (Paeoniae Radix Alba) 1 liang. If vomiting, add Shengjiang (Zingiberis Rhizoma Recens) 1 liang. If sore throat, add Jiegeng (Platycodonis Radix) 0.5 liang. If diarrhea stops but pulse does not emerge, add Renshen (Ginseng Radix) 1 liang. Most suitable after cholera-like vomiting and diarrhea. For yin-pattern cold damage with no sweat, blue lips, black face, back stiffness and pain, cold limbs, coma, and no prior Sini Tang usage, first give Fuzi San (Aconite Powder) 0.3 fen. Use Fuzi (Aconiti Lateralis Radix Praeparata), Guigui (Cinnamomi Ramulus), Danggui (Angelicae Sinensis Radix), Baizhu (Atractodis Macrocephalae Rhizoma) each 0.5 liang, Banxia (Pinelliae Rhizoma), Ganjiang (Zingiberis Rhizoma) each 0.1 fen, plus Congbai (Allii Tuberosi Bulbus). Decoct and take. Cover to induce sweat.