病机云里急后重脉大而洪实为里热甚而闭是有物结坠也若脉浮大甚不宜下虽里急后重
而脉
沉细弱者谓寒在内而气散也可温养自愈里急后重闭者大肠经气不宣通也宜加槟榔木香宣通其
气原病式云下迫后重里急窘迫急痛也火性急速而能燥物故也
按里急者窘迫急痛是也后重者大肠坠重而下也夫里急后重其证不一有因火热者所谓火性
急速
而能燥物是也有因气滞此大肠经气壅而不宣通也有因积滞壅盛者是有物结坠也有气虚者此大
肠气降而不能升也有血虚者所谓虚坐努责是也治法火热者寒之清之气滞者调之积滞者去之气
虚而降者升之举之血虚者补之各察其所因也切观前论未为详尽
病机云如痢或泄而呕者胃中气不和也上焦不和治以生姜橘皮中焦不和治以芍药当归桂茯
苓下焦不和而寒治以轻热甚以重热药
按此云泄痢而呕谓胃气不和所致盖亦有胃中火逆冲上而呕者有胃虚而呕者有积滞毒瓦斯上
攻而呕者有阴虚而呕者岂可一于胃气之不和而不他及耶
机要云腹痛者和之如发热恶寒腹不痛药加黄芩为主腹痛甚者加当归倍芍药
按泄痢腹痛其证甚多皆因内气郁结不行所致理宜行气散郁为先然亦有挟寒有挟火热者有
因积
滞者有血虚者又宜随证处治为当也今机要云和之一字总言之耳盖加当归倍芍药之法惟血虚可
用
《病机》中说：里急后重，脉象大而洪实，是里热极盛且伴有便秘，这是有实物结聚下坠所致；如果脉象浮大，就不宜使用攻下法。虽然出现里急后重，但若脉象沉细弱，说明寒邪在体内且气机涣散，可以通过温养使其自然痊愈。里急后重伴便秘，是大肠经气机不能宣通所致，适宜加入槟榔、木香来宣通气机。《原病式》说：下迫后重、里急窘迫急痛，是因为火性急速且能燥物的缘故。
按语：所谓“里急”，是指腹部窘迫急痛；所谓“后重”，是指大肠坠胀沉重感。里急后重的证候有多种情况：有的因火热引起，即所谓火性急速且能燥物；有的因气滞，即大肠经气机壅塞而不宣通；有的因积滞壅盛，即有实物结聚下坠；有的因气虚，即大肠之气只降不升；有的因血虚，即所谓“虚坐努责”（想排便但无物排出，用力努责）。治疗方法：火热者用寒凉药清之；气滞者调畅气机；积滞者祛除积滞；气虚而下陷者升举阳气；血虚者补益血液。需仔细考察其病因。我看前面的论述还不够详尽。
《病机》中说：如痢疾或泄泻同时伴有呕吐，是胃中气机不和所致。上焦不和，用生姜、橘皮治疗；中焦不和，用芍药、当归、桂枝、茯苓治疗；下焦不和且偏寒，用轻度的热药；热甚，用重度的热药。
按语：这里所说的泄痢而呕，认为是由胃气不和引起的。其实也有因胃中火逆冲上而致呕的，有因胃虚而致呕的，有因积滞毒瓦斯上攻而致呕的，有因阴虚而致呕的。怎么能一概归结为胃气不和而不考虑其他原因呢？
《机要》中说：腹痛者，调和之。如果伴有发热恶寒，以黄芩为主药；腹痛剧烈者，加入当归，加倍使用芍药。
按语：泄痢腹痛的证候很多，都是因为内气郁结不通所致，理应以行气散郁为先。然而也有挟寒、挟火热、因积滞、因血虚等情况，应当随证治疗才恰当。现在《机要》用一个“和”字总括而言。至于加入当归、加倍使用芍药的方法，仅适用于血虚的情况。
The *Bingji* (Pathogenesis) states: Tenesmus and heaviness in the rectum with a pulse that is large, surging, and solid indicates excessive heat in the interior accompanied by constipation, caused by the accumulation of tangible pathogenic factors causing a dragging sensation. If the pulse is floating and large, purgation should not be used. Although tenesmus and heaviness are present, if the pulse is deep, fine, and weak, it indicates cold in the interior and dispersion of qi; self-healing can be achieved through warming and nourishing. Tenesmus and heaviness with constipation result from the failure of the Large Intestine meridian qi to circulate freely; it is appropriate to add Areca Seed (Binglang, 槟榔) and Costus Root (Muxiang, 木香) to promote qi circulation. The *Yuanbing Shi* (Treatise on Original Pathogenesis) states: The urgency to defecate, tenesmus, and severe abdominal pain are due to the nature of fire being rapid and drying.
Commentary: "Li ji" (tenesmus/urgency) refers to abdominal distress and acute pain. "Hou zhong" (heaviness in the rectum) refers to the sensation of heaviness and dragging in the Large Intestine. The syndrome of tenesmus and heaviness varies in etiology: some are caused by fire-heat, as described by the rapid and drying nature of fire; some are caused by qi stagnation, where the qi of the Large Intestine meridian is obstructed and fails to circulate; some are caused by excessive accumulation of stagnant products, resulting in tangible obstruction; some are caused by qi deficiency, where the qi of the Large Intestine descends but fails to ascend; some are caused by blood deficiency, known as "xu zuo nu ze" (straining during empty defecation attempts). Treatment methods: for fire-heat, use cold herbs to clear it; for qi stagnation, regulate the qi; for accumulated stagnation, remove the stagnation; for qi deficiency with sinking, lift and raise the qi; for blood deficiency, tonify the blood. One must carefully examine the underlying cause. I observe that the preceding discussion is not sufficiently comprehensive.
The *Bingji* states: In cases of dysentery or diarrhea accompanied by vomiting, it is due to disharmony of qi in the stomach. For disharmony in the Upper Jiao, treat with Fresh Ginger (Shengjiang, 生姜) and Tangerine Peel (Chenpi, 橘皮); for disharmony in the Middle Jiao, treat with White Peony Root (Shaoyao, 芍药), Angelica Sinensis (Danggui, 当归), Cinnamon Twig (Guizhi, 桂枝), and Poria (Fuling, 茯苓); for disharmony in the Lower Jiao with cold, use mild hot herbs; for severe heat, use potent hot herbs.
Commentary: The mention of vomiting accompanying diarrhea and dysentery here attributes it to stomach qi disharmony. However, vomiting can also result from rebellious stomach fire rushing upward, stomach deficiency, toxic stagnant products attacking upward, or yin deficiency. How can one solely attribute it to stomach qi disharmony while ignoring other causes?
The *Jiyao* (Essentials) states: For abdominal pain, harmonize it. If accompanied by fever and aversion to cold, use Scutellaria Root (Huangqin, 黄芩) as the principal herb; for severe abdominal pain, add Angelica Sinensis and double the dosage of White Peony Root.
Commentary: Abdominal pain accompanying diarrhea and dysentery presents many syndromes, all caused by the internal stagnation and blockage of qi. It is appropriate to prioritize promoting qi circulation and dissipating stagnation. However, there are also cases involving cold, fire-heat, accumulated stagnation, and blood deficiency, so treatment should be tailored to the specific syndrome. The term "harmonize" in the *Jiyao* serves as a general summary. The method of adding Angelica Sinensis and doubling White Peony Root is applicable only to cases of blood deficiency.