凡治伤寒，若见吐蛔者，虽有大热，忌用凉药，犯之必死。盖胃中有寒，阳气弱极，则蛔逆而
上，此大凶之兆也。急用炮姜理中汤一服，加乌梅二个，花椒一、二十粒，服后待蛔定，然后以小
柴胡或补中益气等剂，
渐治其余。盖蛔闻酸则静，见苦则安也。仲景曰∶病患有寒，复发汗，胃中冷，必吐蛔。蛔厥证见
前三十九。
陶节庵曰∶伤寒腹痛有四，若绕脐硬痛，大便结实，烦渴者，皆属燥屎痛，急用寒药下之。因
食积而痛者，治亦同。
一、若小腹硬痛，小水自利，大便黑，身目黄者，属蓄血痛，亦用寒剂加行血药，下尽黑物自
愈。
一、凡伤寒腹中痛甚，但将凉水一盏，与病者饮而试之，若饮水后痛稍可者属热痛，当用凉药清
之。以上三条，皆实热痛也，必脉来沉实有力，方是此证，若微弱者，仍当详审，从缓治之。
一、若饮水愈加作痛，此为寒痛，当用温药和之。和之不已，而或四肢厥冷，呕吐泻利者，急
用热药救之。但须详脉之有力无力，方为良法。
凡杂证下痢，多责于寒，伤寒下痢，有寒有热。盖热邪传里，则亦有下痢之证，但寒痢最多，
热痢则仅见耳。治者当辨寒热，若误用之，则为害最大。
仲景《论》曰∶自利不渴者，属太阴，以其脏有寒故也，当温之，宜服四逆辈。少阴病二三日
，至四五日，腹痛，小便不痢，下痢不止，便脓血者，桃花汤主之。少阴病，吐痢，手足厥冷，烦
躁欲死者，吴茱萸汤主之。少阴病，下痢，白通汤主之。少阴病，二三日不已，至四五日，腹痛，
小便不痢，四肢沉重疼痛，自下痢者，此为有水气，其人或咳，或小便痢，或下痢，或呕者，真武
汤主之。少阴病，下痢清谷，里寒外热，手足厥逆，脉微欲绝，身反不恶寒，其人面色赤，或腹痛
，或干呕，或咽痛，或痢止脉不出者，四逆汤主之。大汗出，
热不去，内拘急，四肢疼，下痢厥逆而恶寒者，四逆汤主之。下痢清谷，不可攻表，汗出必胀满。
按∶此诸论，乃皆言寒痢之当温也。如所云手足厥逆，恶寒腹痛，脉微欲绝，下痢清谷之类，
此固阴寒之甚者也。其于疑似之间，则犹有真辨∶凡伤寒下痢由热邪者，必有烦躁大热，酷欲冷水
等证，亦必有洪滑强盛数实等脉，如果表里俱热，方可作火证论治。若其脉虽数而无力，外虽身
热而不恶热，内虽渴而不喜冷，此其内本不热，而病为下痢者，悉属虚寒，治宜四逆汤、理中汤、
温胃饮、胃关煎、五苓散之类，酌用可也。或表里寒邪俱甚，则当以麻桂饮相兼用之为最妥。若以
寒痢作热痢，妄用寒凉，再损胃气，则无有不死。
《论》曰∶下痢，腹胀满，身体疼痛者，先温其里，乃攻其表，温里四逆汤，攻表桂枝汤。
按∶此一条，乃言表里俱病而下痢者，虽有表证，所急在里，盖里有不实，则表邪愈陷，即欲
表之，而中气无力，亦不能散。故凡见下痢中虚者，速当先温其里，里实气强，则表邪自解，温中
可以散寒，即此谓也。
《论》曰∶热痢下重者，白头翁汤主之。下痢，脉数，欲饮水者，以有热故也，白头翁汤主之
。少阴病，下痢，六七日，咳而呕渴，心烦不得眠者，猪苓汤主之。
按∶此三条，乃言热痢之当清也。但既云脉数，又欲饮水，是诚热矣，然寒邪在表，脉无不数
，但数而有力者为阳证，数而无力者，即阴证矣。泻痢亡津，无有不渴，但渴欲饮水，愈多愈快者
为阳证，若口虽欲水，而腹不欲咽者，即非阳证矣。此外，如渴欲茶汤者，乃泻渴之当然也，不得
悉认为热证。一、凡伤寒表邪未解，脉实滑数，喜冷气壮，内外俱热而下痢者，宜柴芩煎主之。
《论》曰∶少阴病，自痢清水，色纯青，心下必痛，口干燥者，急下之，宜大承气汤。下痢，
三部脉皆平，按之心下硬者，急下之，宜大承气汤。下痢谵语者，有燥屎也，宜小承气汤。
按∶此三条，乃言下痢之当攻者也。凡伤寒下痢者，本非阳明实邪，不当谵语，今既谵语，故
知有燥屎当去也。又若少阴下痢，心下有痛有硬者，必有所积，故亦当下。
一、凡自痢家，身凉脉小者为顺，身热脉大者为逆。此以外无表证，而病之左脏者言也。下痢
，日十余行。脉反实者死。发热，下痢至甚，厥不止者死。直视谵语，下痢者死。下痢无脉，手足
厥冷，灸之不温，脉不远者死。少阴病，自痢，烦躁不得卧寐者死。大抵下痢一证，为脱气至急，
五夺之中，惟此为甚。《金匮要略》曰∶六腑气绝于外者，手足寒，五脏气绝于内者，痢下不禁，
脏气既脱，不能治也。
凡治疗伤寒，如果见到呕吐蛔虫的情况，即使体内有大热，也忌用寒凉药物，误用必定致死。这是因为胃中有寒，阳气极度虚弱，导致蛔虫上逆，这是大凶的征兆。应立即服用炮姜理中汤一剂，加入乌梅两个、花椒一二十粒，服药后等待蛔虫安定，然后再用小柴胡汤或补中益气汤等方剂，逐渐治疗其余症状。因为蛔虫闻到酸味就会安静，见到苦味就会安伏。张仲景说：患有寒证的病人，如果再次发汗，导致胃中寒冷，一定会呕吐蛔虫。蛔厥证见前文第三十九节。
陶节庵说：伤寒引起的腹痛有四种情况。如果是绕脐部硬痛，大便干结，烦躁口渴的，都属于燥屎引起的疼痛，应立即用寒下药攻下。因食积引起的疼痛，治疗方法也相同。
其一，如果是小腹部硬痛，小便通畅，大便黑色，身体和眼睛发黄，属于蓄血引起的疼痛，也用寒凉药加上活血药，排出黑色的瘀血后自然痊愈。
其二，凡是伤寒病中腹部剧烈疼痛，只给病人喝一盏凉水来试探，如果喝水后疼痛稍微缓解的，属于热痛，应当用凉药清热。以上三条，都是实热疼痛，必须脉象沉实有力，才是这种证候，如果脉象微弱，仍应当详细审察，从缓治疗。
其三，如果喝水后疼痛更加加剧，这是寒痛，应当用温药调和。调和无效，如果出现四肢厥冷、呕吐腹泻的，立即用热药急救。但必须详细辨别脉象的有力无力，这才是好方法。
凡是杂病引起的下痢，多归责于寒证；伤寒引起的下痢，则有寒证和热证之分。因为热邪传入体内，也会有下痢的症状，但寒痢最多，热痢则仅偶尔见到。治疗者应当辨别寒热，如果误用，危害最大。
张仲景《伤寒论》说：自利（不经过攻下而自行腹泻）且不口渴的，属于太阴病，因为脏腑有寒，应当温补，适宜服用四逆汤类方剂。少阴病二三天，到四五天，出现腹痛，小便不通畅，下痢不止，大便带有脓血的，用桃花汤主治。少阴病，呕吐腹泻，手足厥冷，烦躁欲死的，用吴茱萸汤主治。少阴病，下痢，用白通汤主治。少阴病，二三天未愈，到四五天，出现腹痛，小便不通畅，四肢沉重疼痛，自行下痢的，这是因为有水气，其人如果有咳嗽，或小便利，或下痢，或呕吐的，用真武汤主治。少阴病，下痢清谷（完谷不化），里寒外热，手足厥逆，脉微细欲绝，身体反而不恶寒，病人面色发红，或有腹痛，或有干呕，或有咽痛，或下痢停止但脉搏摸不到的，用四逆汤主治。大汗出，热不退，内部拘急，四肢疼痛，下痢厥逆且恶寒的，用四逆汤主治。下痢清谷，不可攻表，发汗必然导致胀满。
按语：这些论述，都是说明寒痢应当温补。如所说的手足厥冷、恶寒腹痛、脉微欲绝、下痢清谷之类，这确实是阴寒极盛的表现。在疑似之间，仍有真假辨别：凡是伤寒下痢由热邪引起的，一定伴有烦躁大热、酷爱冷水等症状，也一定有洪滑强盛数实等脉象，如果确实表里俱热，才可以作为火证论治。如果脉象虽然数但无力，外表虽然身热但不恶热，内部虽然口渴但不喜冷饮，这说明内部本来不热，而患病为下痢的，全部属于虚寒，治疗适宜选用四逆汤、理中汤、温胃饮、胃关煎、五苓散之类，酌情使用即可。如果表里寒邪都严重，则应当将麻黄桂枝类方剂配合使用最为妥当。如果把寒痢当作热痢，妄用寒凉药物，再损伤胃气，就没有不死亡的。
《伤寒论》说：下痢，腹胀满，身体疼痛的，先温其里，然后攻其表，温里用四逆汤，攻表用桂枝汤。
按语：这一条，是说明表里同病而下痢的情况，虽然有表证，但紧急的是里证，因为里气不实，表邪就会进一步内陷，即使想要解表，由于中气无力，也不能发散。所以凡是见到下痢且中气虚弱的，应当迅速先温补其里，里气充实正气强盛，表邪自然解除，温中可以散寒，说的就是这个道理。
《伤寒论》说：热痢伴有肛门重坠感的，用白头翁汤主治。下痢，脉数，想喝水的，因为有热，用白头翁汤主治。少阴病，下痢，六七天，咳嗽且呕吐口渴，心烦不得睡眠的，用猪苓汤主治。
按语：这三条，是说明热痢应当清热的。既然说脉数，又想喝水，这确实是热证，然而寒邪在表，脉象没有不数的，但数而有力的是阳证，数而无力的是阴证。泻痢导致津液流失，没有不口渴的，但如果口渴想喝水，越多越快的是阳证，如果口虽想水，但腹部不想吞咽的，就不是阳证了。此外，如想喝茶汤的，这是泻痢后的正常口渴现象，不能都认为是热证。其一，凡是伤寒表邪未解，脉象实滑数，喜欢冷气壮实，内外俱热而下痢的，宜用柴芩煎主治。
《伤寒论》说：少阴病，自行下痢清水，颜色纯青，心下部一定疼痛，口干燥的，急下之，宜用大承气汤。下痢，三部脉象都平和，按压心下部硬的，急下之，宜用大承气汤。下痢谵语的，有燥屎，宜用小承气汤。
按语：这三条，是说明下痢应当攻下的。凡是伤寒下痢，本非阳明实邪，不应当谵语，现在既然谵语，所以知道有燥屎应当去除。另外如果是少阴下痢，心下有痛有硬的，必定有积滞，所以也应当攻下。
其一，凡是自行下痢的病人，身体凉爽脉象细小的为顺证，身体发热脉象大的为逆证。这是指外部无表证，而病在左脏（此处指内脏）而言。下痢，一天十多次，脉象反而实的，死。发热，下痢非常严重，厥冷不止的，死。直视谵语，下痢的，死。下痢无脉，手足厥冷，艾灸后不温暖，脉搏久按才有的，死。少阴病，自行下痢，烦躁不得卧睡的，死。大抵下痢这一证候，是脱气至急的情况，在五夺之中，以此最为严重。《金匮要略》说：六腑之气衰竭于外的，手足寒冷；五脏之气衰竭于内的，下痢不禁，脏气既然脱失，就不能治疗了。
In the treatment of Shanghan (Cold Damage Syndrome), if vomiting of Ascaris (roundworms) is observed, even if there is severe internal heat, cold-natured medicines must be avoided; misuse will inevitably lead to death. This is because cold exists in the Stomach, and Yang Qi is extremely weak, causing Ascaris to rebel and move upward, which is an ominous sign of great danger. Immediately administer Paojiang Lizhong Tang (Baked Ginger Decoction for Regulating the Middle) one dose, adding two Wumei (Mume Fruit) and ten to twenty Huajiao (Sichuan Pepper grains). After administration, wait for the Ascaris to settle, then gradually treat the remaining symptoms with formulas such as Xiaochaihu Tang (Minor Bupleurum Decoction) or Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). This is because Ascaris becomes quiet when encountering sour flavors and settles when encountering bitter flavors. Zhang Zhongjing stated: "If a patient with cold syndrome undergoes repeated sweating, leading to coldness in the Stomach, vomiting of Ascaris is inevitable." The syndrome of Ascaris Jue (Ascaris Reversal) is described in Section 39 above.
Tao Jian'an stated: There are four types of abdominal pain caused by Shanghan. If there is hard and painful sensation around the umbilicus, solid stool, irritability, and thirst, these all belong to pain caused by dry feces (Zaoshi); immediately use cold purgatives to evacuate them. Pain caused by food stagnation is treated similarly.
First, if there is hard and painful sensation in the lower abdomen, free urination, black stool, and yellowing of the body and eyes, this belongs to pain caused by blood stasis (Xuxue); also use cold agents combined with blood-invigorating medicines. Evacuating the black material will result in spontaneous recovery.
Second, in cases of severe abdominal pain due to Shanghan, give the patient a cup of cool water to test. If the pain alleviates slightly after drinking, it belongs to heat pain, and cold medicines should be used to clear the heat. The above three points all refer to excess-heat pain. The pulse must be deep, firm, and forceful to confirm this syndrome; if the pulse is weak, careful examination is required, and treatment should be gradual.
Third, if drinking water exacerbates the pain, this is cold pain, and warm medicines should be used to harmonize. If harmonization fails and symptoms such as cold limbs, vomiting, and diarrhea appear, hot medicines must be used urgently for rescue. However, one must carefully distinguish whether the pulse is forceful or weak for this to be a sound method.
For miscellaneous diseases causing dysentery (Xili), the cause is mostly attributed to cold; however, dysentery caused by Shanghan can be either cold or heat. When pathogenic heat transmits inward, dysentery may occur, but cold dysentery is most common, while heat dysentery is rare. Practitioners must differentiate between cold and heat; misapplication causes the greatest harm.
Zhang Zhongjing's *Lun* states: "Spontaneous diarrhea without thirst belongs to Taiyin disease, due to cold in the Zang organs; it should be warmed, and Si Ni Tang (Frigid Extremities Decoction) type formulas are suitable." In Shaoyin disease, from day two or three to day four or five, if abdominal pain, difficulty in urination, persistent diarrhea, and pus/blood in stool occur, Taohua Tang (Peach Blossom Decoction) is indicated. In Shaoyin disease, with vomiting, diarrhea, cold limbs, and extreme irritability, Wuzhuyu Tang (Evodia Decoction) is indicated. For Shaoyin disease with diarrhea, Baitong Tang (White Onion Decoction) is indicated. In Shaoyin disease, if symptoms persist from day two or three to day four or five, presenting with abdominal pain, difficult urination, heavy/painful limbs, and spontaneous diarrhea, this indicates water retention; if accompanied by cough, frequent urination, diarrhea, or vomiting, Zhenwu Tang (True Warrior Decoction) is indicated. In Shaoyin disease, with diarrhea of undigested food, interior cold with exterior heat, cold limbs, faint pulse nearly imperceptible, absence of aversion to cold, red facial complexion, or abdominal pain, dry retching, sore throat, or cessation of diarrhea with absent pulse, Si Ni Tang is indicated. With profuse sweating, unrelenting heat, internal cramping, limb pain, diarrhea, cold limbs, and aversion to cold, Si Ni Tang is indicated. For diarrhea of undigested food, exterior release is contraindicated; sweating will inevitably cause abdominal fullness.
Note: These discussions all address the warming treatment for cold dysentery. Symptoms such as cold limbs, aversion to cold, abdominal pain, faint pulse, and diarrhea of undigested food indicate extreme Yin-cold. Differentiation is crucial: Dysentery caused by heat pathogens in Shanghan must present with irritability, high fever, craving for cold water, and pulses that are surging, slippery, strong, rapid, and excess. Only when both interior and exterior are clearly hot should it be treated as a Fire syndrome. If the pulse is rapid but weak, or if there is external heat without aversion to heat, or internal thirst without preference for cold drinks, the interior is fundamentally not hot. Such dysentery belongs to deficiency-cold and should be treated with Si Ni Tang, Lizhong Tang, Wenwei Yin (Warm the Stomach Drink), Weiguan Jian (Stomach Gate Frying/Decoction), or Wuling San (Five-Ingredient Powder with Poria), selected according to circumstances. If exterior and interior cold pathogens are both severe, combining Mahuang Guizhi Yin (Ephedra and Cinnamon Twig Drink) is most appropriate. Mistaking cold dysentery for heat dysentery and recklessly using cold-cooling medicines will damage Stomach Qi further, leading inevitably to death.
The *Lun* states: "With dysentery, abdominal fullness, and body pain, first warm the interior, then attack the exterior. Warm the interior with Si Ni Tang, attack the exterior with Guizhi Tang (Cinnamon Twig Decoction)."
Note: This passage addresses dysentery with simultaneous exterior and interior involvement. Although exterior signs exist, the interior urgency takes precedence. If the interior is deficient, exterior pathogens sink deeper; even attempting exterior release fails due to weak Middle Qi. Therefore, for dysentery with Middle Qi deficiency, one must urgently warm the interior first. Once the interior is solid and Qi is strong, exterior pathogens resolve spontaneously. Warming the middle dispels cold, which is the principle here.
The *Lun* states: "For heat dysentery with a feeling of heaviness/restriction in the anus, Baitouweng Tang (Pulsatilla Decoction) is indicated. For dysentery with a rapid pulse and desire to drink water, indicating heat, Baitouweng Tang is indicated. In Shaoyin disease, with dysentery lasting six or seven days, accompanied by cough, vomiting, thirst, irritability, and insomnia, Zhuling Tang (Polyporus Decoction) is indicated."
Note: These three passages address the clearing treatment for heat dysentery. A rapid pulse and desire to drink indeed indicate heat. However, cold pathogens in the exterior also cause rapid pulses; a rapid pulse with force indicates Yang syndrome, while a rapid pulse without force indicates Yin syndrome. Diarrhea/dysentery depletes fluids, causing thirst. Thirst with a strong desire to drink large amounts quickly indicates Yang syndrome; thirst with no desire to swallow indicates non-Yang syndrome. Additionally, a desire for tea or soup is a normal consequence of fluid loss from diarrhea and should not be universally considered a heat syndrome. First, for Shanghan where exterior pathogens remain unresolved, with excess/slippery/rapid pulse, robust constitution, interior/exterior heat, and dysentery, Chaiqin Jian (Bupleurum and Scutellaria Frying/Decoction) is indicated.
The *Lun* states: "In Shaoyin disease, spontaneous discharge of clear water, pure green color,必 (must) have heart epigastrium pain, and dry mouth; urgent evacuation is required, Da Chengqi Tang (Major Order the Qi Decoction) is indicated. For dysentery where all three pulse positions are level, but palpation reveals hardness in the heart epigastrium; urgent evacuation is required, Da Chengqi Tang is indicated. For dysentery with delirious speech, there are dry feces; Xiao Chengqi Tang (Minor Order the Qi Decoction) is indicated."
Note: These three passages address the purgative treatment for dysentery. Shanghan dysentery is typically not Yangming excess pathology and should not involve delirium; the presence of delirium indicates dry feces that must be removed. Similarly, Shaoyin dysentery with pain and hardness in the epigastrium indicates accumulation requiring purgation.
First, for patients with spontaneous dysentery, a cool body and fine pulse indicate a favorable prognosis (Shun), while a hot body and large pulse indicate an unfavorable prognosis (Ni). This refers to cases without exterior syndromes, affecting the internal organs. Dysentery occurring more than ten times a day with a surprisingly excess pulse indicates death. Fever with severe dysentery and unrelenting cold limbs indicates death. Fixed gaze, delirium, and dysentery indicate death. Dysentery with absent pulse, cold limbs, unwarmed by moxibustion, and pulse only felt after prolonged pressure indicates death. Shaoyin disease with spontaneous dysentery, irritability, and inability to lie down indicates death. Generally, dysentery represents a critical depletion of Qi; among the Five Depletions (Wu Duo), this is the most severe. *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, dysentery is uncontrollable. Once organ Qi has collapsed, it cannot be treated."