杜仲、参、附。全安。
震按此条与下慎柔案。俱非妙论奇方。然此条或补或清。独用并用。随机变换。而终之
以专补专温。丝毫不误。较之今人见补而不应。惟知有清。清又不应。不敢再补者。其智愚
相远若何。慎柔案证屡变。而方不易。亦可谓铁中铮铮者矣。
慎柔和尚云。余四弟年二十七。于甲辰闰九月。患痢。先来取药。付以芍药汤一帖。香
连丸二服。数日不止。反增心口如刀割。脐腹痛。肛门痛。声撼四邻。自分必死。因往乡视
之。昼夜不得卧。日下红血一桶。痛不可忍。发热流汗。不食。脉之六部俱豁大。浮中沉无
力。四至。虽痛虽发热。脉无力。已虚寒矣。古人云。脱血益气。此证正宜。遂用六君子一
帖。次投异功散。加升麻三分。木香五分。炒干姜五分。一剂。去后觉可。痛亦少减。至五
更。腹痛如前。予曰。此药力尽也。急煎一剂与之。比前更可。痛又减七八。即酣睡至日中
方醒。曰。不甚好过。予曰。此药止能支持一觉。再煎与之。遂安寝至晓。心腹痛止。后重
亦轻。再服前剂而愈。二日后。吃鸡肉。仍前腹痛肛肿。下秽不止。又三日。病势笃极。予
复往诊之。脉三至余。浮取无。沉按之则大。脾命脉微。与补中益气汤。不应。此虚脱之甚
加御米壳一钱。亦不应。下如洞泄。流汗发躁。尺脉渐欲收短。危甚。急于补中益气汤加
人参二钱。服之。下咽觉愦。此正气欲复。邪气欲退也。顷之。精神顿增。痢稍缓。恐再作
又一剂。下注昏愦热躁诸证渐缓。脉有神。短脉退。思古人云。久泻久痢。汤剂不如丸散
即合参苓白术散与服。觉减可。至下午复躁。予亦无奈。再诊左尺洪如火射状。此阴虚火动
之象。与加减八味丸五六十丸。精神觉爽。顷之。又下八九十丸。睡至天明。病去十七。方
信立斋谓加减八味丸治水涸之证。即令朝暮服此丸。间以参苓白术散。渐愈。复劳。觉小便
痛。想动色欲之故。服逍遥散、麦冬、五味子而平。
高果哉治丁清惠公。予告在籍。患痢。里急后重。白积兼鲜血。昼夜十余次。饮食减少
两尺脉似有似无。两寸关弦数。小便短少。众医皆以望八高龄。当凭尺脉而投温补。高独
谓禀赋素浓。宜从寸关而用清理。遂进黄芩、白芍、浓朴、槟榔、陈皮、甘草、阿胶、滑石
槐花、木香。四五剂全愈。
震按此由平素熟悉。故取舍不缪。然亦必兼有实证可据及神气不衰以断之也。
喻嘉言治周信川。年七十三岁。平素体坚。不觉其老。秋月病痢。久而不愈。至冬月成
休息痢。昼夜十余行。面目浮肿。肌肤晦黑。喻诊其脉。沉数有力。谓曰。此阳邪陷入于阴
之证也。当用逆流挽舟法。提其邪转从表出。则趋下之势止而病可愈。于是以人参败毒散本
方煎好。用浓被围椅上坐定。置火其下。更以布条卷成鹅蛋状。置椅褥上殿定肛门。使内
气不得下走。方以前药热服。良久又进前药。遂觉皮间津津微润。再溉以滚汤。教令努力忍
便。不得移身。如此约二时之久。病者心躁畏热。忍不可忍。始令连被带汗。卧于床上。是
晚止下痢二次。以后改用补中益气汤。不旬日而全愈。
朱孔阳年二十五岁。形瘦。素安逸。夏月因构讼。奔走日中。致痢。昼夜一二百次。不
能起床。但饮水而不进食。其痛甚厉。肛门如火烙。扬手掷足。躁扰无奈。喻诊其脉弦紧劲
急。不为指挠。谓曰。此证一团毒火。蕴结在肠胃之内。其势如焚。救焚须在顷刻。若二三
日外。肠胃朽腐矣。于是以大黄四两。黄连、甘草各二两。入大沙锅内煎。随滚随服。服下
人事稍宁片刻。少顷。仍前躁扰。一昼夜服至二十余次。大黄俱已煎化。黄连、甘草俱煎
至无汁。次日病者再求前药。喻又诊之。见脉势和柔。知病可愈。但用急法。不用急药。改
以生地、麦冬各四两。另研生汁。而以花粉、丹皮、赤芍、甘草各一两。煎成和汁。大碗咽
之。以其来势暴烈。一身津液从之奔竭。待下痢止。然后生津养血。则枯槁一时难回。令脉
势既减。则火邪俱退。不治痢而痢自止。岂可泥润滞之药而不急用乎。服后。痢渐止。粥饮
渐进。调理旬余。方能消谷。
陈汝明病痢。发热如蒸。昏沉不食。重不可言。至第三日。危急将绝。乃诣嘉言。其脉
数大空虚。尺脉倍加洪盛。喻曰。此两病而凑于一时之证也。内有湿热。与时令外热相合。
欲成痢症。尚不自觉。又犯房劳而为骤寒所乘。以致发热身重。不食昏沉。皆属少阴肾经外
感。少阴受邪。原要下利清白。此因肠中湿热已蒸成猪肝鱼脑之形。故色虽变而下利则同也
再用痢疾门药一剂。即刻不救矣。遂忙以麻黄附子细辛汤一剂。与之表散外邪。得汗后。
热即微减。再以附子理中汤。连进二剂。热退身轻能食。改用连理汤丸服。至旬日全安。
浦君艺病痢。初起表邪未散。误用参、术固表。病反加重。乃频进黄连、大黄。治经月
余。胃气不运。下痢一昼夜百余行。一夕呕出从前黄连药汁三五碗。呕至二三次后。胃与肠
遂打为一家。幽门兰门。洞开无阻。不但粥饮直出。即人参浓膏。才吞入喉。已 从肠奔
下。危急之至。乃以大剂四君子汤煎。调赤石脂、禹余粮二末。连连与服。服后。其下痢之
势少衰。但腹中痛不可忍。君艺曰。前此下痢虽多。尚然不痛。服此药而痛增。未可再服矣
喻曰。此正所谓通则不痛。痛则不通之说也。不痛则危。痛则安。何乐而不痛耶。仍以前
药再进。俟势已大减。才用四君子倍茯苓。十余剂全安。
震按此四案议论方法。皆古人所未有。洵足超前绝后。然较之丹溪。犹有粗豪精细之别
张路玉治春榜陈颖雍。暑月自都门归。抵家即患痢疾。半月以来。攻克不效。遂噤口。
粒米不入。且因在京久食煤火。肩背发毒。不赤不疼。陷伏不起。发呃神昏。势日濒危。内
外医科。互相推委。乃延石顽诊之。六脉弦细欲绝。面有戴阳之色。所下瘀晦如烂鱼肠脑。
证虽危殆。幸脉无旺气。气无喘促。体无躁扰。可进温补。但得补而痈肿 发。便可无虞。
遂疏保元汤。每服人参三钱。生 二钱。甘草、肉桂各一钱。伏龙肝汤代水煎服。一服粥饮
稍进。二服后重稍轻。三服痈毒贲起。另延疡科敷治其外。确守前方。又十余服而安。前后
未尝更易一味也。
震考古人治痢方案。攻补温凉。无法不备。兹选其认证明晰。用药确当者。各备数则。
此条以痢兼疡。又属一局。故录之。他如乳煎荜茇、独炼雄黄、鳖糖汤、人参樗皮散诸说。
昔日固为奇方。今时未必效验。故不采录。
又阅儒门事亲载一男子恶痢。痛不可忍。忽见水浸甜瓜。连皮食数枚。脓血皆已。而本
草却有贫人多食甜瓜。深秋下痢难治之戒。可见下痢无正形。治痢亦无正形也。刘宗浓曰。
夏月食冰水瓜果太过。致令脾胃伤冷。血不行于四肢八脉。渗入肠胃间而下痢。是诚至言。
然其咎在太过耳。若偶食之。未必为害。惟饱餐饭肉浓鲜之后。即偶食亦不可。盖凡空腹吃
井水西瓜。颇能消涤无形之暑气。使从小便出。倘胃中先有食物填实在内。而加以生冷。则
脾不营运。必成积滞矣。予少年时。赴一友人招。其家长幼俱患痢疾。窃骇之。意此岂杨子
建所谓疫毒痢耶。何独疫于其家也。及设中饭。荤腥海鲜盛备。而以冷酒偏斟。独予不饮。
反以为怪。予曰。君家之所以致痢者。由于此也。盘中诸品。正藉极热之好酒以疏通之。则
胃气方畅。乃与冷酒为伍。古语为得冷则凝。如油粘碗。虽洗难脱。滞气泣血。痢能免乎。
其家豁然省悟改焉。迄今二十余年无痢疾。又有人曰。都中土着士民。夏月饭上置冰一片。
凡鱼肉多悬井内。瓜果安放冰边。却不见其患痢。不知北方生长者。禀气刚浓。且食煤火之
食。内有蕴热。故尔相宜。若吴地人。断不可效也。
孙见心治一人秋间下痢脓血。昼夜百余次。里急后重。前医见脉歇止。谓因积滞所致。
用槟、朴、青皮、枳壳、木香等。孙诊之。脉洪弱而数。或一二至。或三四至。或五六至。
辄一止。曰。毒及少阴矣。当急顾其阳明。用生熟地各一两。归、芍、丹皮、黄连各三钱。
甘草五分。群疑阴药太重。恐饱闷增剧。然服二帖。次数尚频。急重已除。脉之洪数亦减。
至数相续。仍用前方。病去大半。又次日。去生地、黄连。加参、术、茯苓、山药。饮食大
进。午后弦脉亦减。而至数复有止状。或骇曰。病退而脉复变。防其加重。孙曰。无妨也。
歇至者。即古代结促之俗名耳。若冲气中绝。脏脉自见者危。今此证歇至。本以毒盛拥遏隧
道。阴精不承。故一二至。或三四至。或五六至而至也。经曰。数动一代者。病在阳之脉也
泄及便脓血。今予去阴药之过甚。进阳药太骤。中脏得补。则木土和而胃气安。故饮食进
而毒尚未尽者。亦随壮气而旺。故复有止状也。于方中仍加生地、黄连。即平矣。果验。
震按此条与西昌治朱孔阳案相似。而此以生地换大黄。则因脉之促止。与弦动不为指挠
者。有别也。此从炙甘草汤得之。然幸洪数而歇止。若细涩无神而歇止。断不可治。亦必其
人身不发热。尚能饮食而腹痛者。观案中云。饮食大进可见矣。总之。痢以能食为吉。腹痛
亦吉。不能食而不腹痛者大不吉。
〔附〕嘉善一妪常便血。时发时止。至五旬外。夏月便鲜血。里急后重。时或不禁。脉
软不数。用五苓建中转甚。因向宜凉血药。仍用四物加槐、榆、楂、曲。亦无效。叶天士先
生以生苍术、生浓朴、炒陈皮、炙甘草、鸡内金、砂仁壳、丁香柄丸服。全愈。又有一童子
患久痢。叶亦用此方全愈。人不解其故。震读徐春甫医统。因见此方名醉乡玉屑。治小儿食
瓜果致痢久不愈者。乃服先生之典博也。至如临证指南所载。都属古人常用方法。惟以温药
下之。乃江氏类案所未有。而附子、大黄为君。参入苓、朴及草果、益智、木香、大茴等。
谅系对证择加。总不外举散温通之义。又有用大黄、芩、连、肉桂、丹皮、归、芍者。是从
芍药汤化出。有用人参、芩、连、干姜、生姜、枳实者。是从泻心汤化出。以及二妙散加地
榆、苓、泻。白头翁汤加黄芩、白芍。亦世俗所通晓。至如附子粳米汤、脾肾双补丸、理阴
煎、四神丸、桃花汤、余粮丸。或养阴。或发表。均非创立。独有肾气丸之炒焦。及姚颐真
之用大剂苁蓉为创立。但炒焦者不过熟地炭、桂、附炭之侣。苁蓉配参、归、姜、附。即以
温药下之。化为温药滑之耳。然同温药则可。同阴药则不可。予曾试之矣。其痢久伤肾。下
焦沉坠。刚药不效者。用人参、鹿茸、大茴、茯、菟、故纸。痢久伤阴。唇燥舌干。胃气又
弱。戒投阴腻柔药者。用人参、炙草、茯神、炒麦冬、炒白芍、炒乌梅肉。一系温柔补固。
一系酸甘化阴。仍是率由旧章也。至谓治痢大法。无过通塞二义。乃先生略举大端。比如读
云汉之诗。勿以辞害志可矣。
俞震按：这一条与下面的慎柔医案，都不是什么精妙的议论或奇特的方剂。然而这一条中，有时用补法，有时用清法，单独使用或联合使用，随机应变，但最终归结为专门的补益和温阳，丝毫不差。这与现在的人见到补法无效，就只知道用清法；清法又无效，就不敢再用补法的人相比，他们的智慧与愚笨相差多么远啊！慎柔医案中，证候多次变化，但方药没有改变，也可以说是铁骨铮铮（坚持原则）的人了。
慎柔和尚说：我的四弟二十七岁时，在甲辰年闰九月患痢疾。起初请我去取药，我给他开了芍药汤一帖，香连丸两服。几天后痢疾不止，反而增加了心口像刀割一样的疼痛，脐腹部疼痛，肛门疼痛，叫声惊动四邻。他自己认为必死无疑，于是我去乡下探望他。他昼夜无法入睡，每天排出红血一桶，疼痛难以忍受，发热出汗，不能进食。诊脉发现六部脉象都豁大，浮、中、沉三候都无力，每呼吸四次脉动一次。虽然疼痛且发热，但脉象无力，这已经是虚寒证了。古人说：“脱血者益气”，这个证候正适合此法。于是我用了六君子汤一帖，接着投异功散，加入升麻三分、木香五分、炒干姜五分，服用一剂后，患者感觉好转，疼痛也稍微减轻。到了五更天，腹痛如前。我说：“这是药效过了。”急忙煎一剂给他喝。比之前更好，疼痛又减轻了七八成，随即酣睡到中午才醒。他说：“还不太舒服。”我说：“这药只能支撑睡一觉，再煎一剂给他。”于是安稳睡到天亮。心腹疼痛停止，里急后重也减轻了。再服用前面的方剂而痊愈。两天后，吃了鸡肉，之前的腹痛和肛门肿胀再次出现，排泄污物不止。又过了三天，病势非常严重。我又去诊治，脉象每呼吸三次有余，轻取无脉，重按则脉大，脾脉和命门脉微弱。给予补中益气汤，无效。这是虚脱得很厉害，加御米壳一钱，也无效。下利像洞泄一样，流汗发躁，尺脉逐渐变得短小，情况危急。急忙在补中益气汤中加入人参二钱，服用后，咽下时感觉昏愦。这是正气将要恢复，邪气将要退却的表现。过了一会儿，精神顿时增加，痢疾稍微缓解。担心复发，又给了一剂。下注、昏愦、热躁等症状逐渐缓解，脉有神气，短脉消退。想到古人说：“久泻久痢，汤剂不如丸散”，于是合参苓白术散给他服用，感觉减轻，可以接受。到了下午又烦躁。我也无可奈何。再诊左尺脉洪大如火射状，这是阴虚火动的征象。给予加减八味丸五六十丸，精神觉得清爽。过了一会儿，又服下八九十丸，睡到天明，病好了十分之七。这才相信立斋所说加减八味丸治疗水涸（肾阴枯竭）的证候。于是让他早晚服用此丸，间以参苓白术散，逐渐痊愈。后来劳累，感觉小便痛，猜想是动了色欲的缘故。服用逍遥散、麦冬、五味子而平复。
高果哉治疗丁清惠公。我当时在家闲居。丁公患痢疾，里急后重，白脓夹杂鲜血，昼夜十余次，饮食减少。两尺脉似有似无，两寸关脉弦数，小便短少。众医生都认为他将近八十岁的高龄，应当凭尺脉而投用温补药。唯独高果哉认为他禀赋素来浓厚，应当从寸关脉而使用清理法。于是进黄芩、白芍、厚朴、槟榔、陈皮、甘草、阿胶、滑石、槐花、木香。四五剂后完全痊愈。
俞震按：这是因为平时熟悉病情，所以取舍没有错误。但也必须有实证依据以及神气不衰才能判断。
喻嘉言治疗周信川，七十三岁。平时身体坚固，不觉得老。秋天患痢疾，久而不愈，到冬天成了休息痢。昼夜十余次，面目浮肿，肌肤晦暗。喻嘉言诊其脉，沉数有力，说：“这是阳邪陷入阴分的证候。应当用逆流挽舟法，提引邪气转而向外发散，那么趋向下的势头就会停止，病就可以痊愈。”于是用人参败毒散本方煎好，用厚被子围住椅子坐定，在下面放置火炉，再用布条卷成鹅蛋形状，放在椅垫上抵住肛门，使内气不得向下走。然后用前面的药热服。过了很久又进前面的药。于是感觉皮肤间微微湿润。再浇灌滚水，教令病人努力忍住便意，不得移动身体。这样大约两个时辰之久。病人心中烦躁怕热，忍耐不可忍耐，才让连被带汗地躺在床上。当晚只下了两次痢。以后改用补中益气汤，不到十天就完全痊愈。
朱孔阳二十五岁，形体瘦弱，平时安逸。夏天因为打官司，在烈日下奔走，导致痢疾。昼夜一二百次，不能起床，只喝水不进食。疼痛非常剧烈，肛门像火烙一样，挥手踢脚，烦躁无奈。喻嘉言诊其脉弦紧劲急，不为手指所挠动，说：“这个证候是一团毒火，蕴结在肠胃之内，其势如火焚烧。救火必须在顷刻之间，如果过了两三天，肠胃就要腐烂了。”于是用大黄四两，黄连、甘草各二两，放入大沙锅内煎煮。随滚随服。服下后人事稍微安宁片刻。一会儿，仍然像以前那样烦躁。一昼夜服了二十多次，大黄都已煎化，黄连、甘草都煎到没有汁液。第二天病人再来求前面的药。喻嘉言又诊察，见脉势和柔，知道病可愈。但只用急法，不用急药。改用地黄、麦冬各四两，另外研取生汁，而以花粉、丹皮、赤芍、甘草各一两，煎成后混合汁液，大碗咽下。因为他发病暴烈，一身津液随之奔竭。等到下痢停止，然后生津养血，因为枯槁一时难以恢复。令脉势既减，则火邪全部退去。不直接治痢而痢自止，怎么可以拘泥于润滞的药物而不急于使用呢？服用后，痢疾逐渐停止，粥饮逐渐进服，调理十多天，才能消化食物。
陈汝明患痢疾，发热如蒸，昏沉不食，沉重得无法形容。到了第三天，危急将绝，于是去找喻嘉言。他的脉数大空虚，尺脉加倍洪盛。喻嘉言说：“这是两种病凑在一起同时发作的证候。内有湿热，与时令外热相合，想要形成痢症，自己还不察觉。又犯了房劳而被骤寒侵袭，以致发热身重，不食昏沉，都属于少阴肾经外感。少阴受邪，原本应该下利清白，这是因为肠中湿热已经蒸变成猪肝鱼脑的形状，所以颜色虽然变了，但下利的性质相同。如果再使用痢疾门的药一剂，立刻就不救了。”于是急忙用麻黄附子细辛汤一剂，与他表散外邪。得汗后，热即稍微减轻。再用附子理中汤，连续进两剂，热退身轻能食。改用连理汤丸剂服用，到十天完全安康。
浦君艺患痢疾。初起表邪未散，误用人参、白术固表，病反而加重。于是频繁进用黄连、大黄，治疗经过一个多月，胃气不运，下痢一昼夜百余行。一天晚上呕出从前黄连药汁三五碗。呕到二三次后，胃与肠遂打成一家，幽门阑门，洞开无阻。不但粥饮直出，就是人参浓膏，刚吞入喉，已经从肠奔下。危急之至，于是用大剂四君子汤煎，调赤石脂、禹余粮二种粉末，连连与服。服用后，其下痢之势稍微衰减。但腹中痛不可忍。君艺说：“此前下痢虽多，尚且不痛，服用此药而痛增，不可以再服了。”喻嘉言说：“这正是所谓通则不痛，痛则不通的说法。不痛则危，痛则安，有什么不高兴痛的呢？”仍然用前面的药再进。等势头已经大减，才用四君子汤倍加茯苓。十余剂后完全安康。
俞震按：这四个医案的议论和方法，都是古人所未有的，确实足以超前绝后。然而与丹溪相比，还有粗豪与精细的区别。
张路玉治疗春榜陈颖雍。暑月从京城回家，到家即患痢疾。半个月以来，攻下清热无效，于是噤口痢，粒米不入。而且因为在京城久食煤火之食，肩背发毒，不红不疼，陷伏不起，发呃逆神昏，形势日益濒危。内外医科互相推委，于是延请石顽诊视。六脉弦细欲绝，面有戴阳之色，所下瘀晦如烂鱼肠脑。证候虽然危殆，幸而脉无旺气，气无喘促，体无躁扰，可以进用温补。只要得补而痈肿发出，便可无忧。于是开具保元汤，每服人参三钱，生黄芪二钱，甘草、肉桂各一钱，伏龙肝汤代水煎服。一服后粥饮稍进，二服后里急后重稍轻，三服后痈毒贲起，另外延请外科敷治其外。确守前方，又十余服而安。前后未曾更换一味药。
俞震考证古人治痢的方案，攻补温凉，没有一种方法不具备。这里选取那些辨证清晰、用药确当的，各备几则。这一条因痢疾兼有疮疡，又属于同一局，所以记录下来。其他如乳煎荜茇、独炼雄黄、鳖糖汤、人参樗皮散等说法，昔日固然是奇方，今时未必有效，所以不收录。
又阅读《儒门事亲》记载一个男子患恶痢，痛不可忍，忽然看见水浸甜瓜，连皮吃了几枚，脓血皆已，而本草却有贫人多食甜瓜，深秋下痢难治的戒律。可见下痢没有固定的形态，治痢也没有固定的形态。刘宗浓说：夏天吃冰水瓜果太过，致使脾胃伤冷，血不行于四肢八脉，渗入肠胃间而下痢。这确实是至理名言。然而过错在于太过罢了。如果是偶尔吃，未必有害。只有饱餐饭肉浓鲜之后，即使偶食也不可。因为凡是空腹吃井水西瓜，颇能消涤无形的暑气，使从小便出。倘若胃中先有食物填实在内，再加上生冷，则脾不营运，必成积滞了。我年轻时，赴一位朋友邀请，其家长幼都患痢疾，我感到很惊讶。心想这难道是杨子建所说的疫毒痢吗？为什么独独感染他们家呢？等到设中饭，荤腥海鲜盛备，而以冷酒偏斟，唯独我不喝，反而以为奇怪。我说：“你们家之所以导致痢疾的原因，就在于此。盘中诸品，正藉极热的好酒来疏通它，胃气方才通畅，乃与冷酒为伍。古语说‘得冷则凝’，如油粘碗，虽洗难脱，滞气泣血，痢能免乎？”他们家豁然省悟并改正。迄今二十多年无痢疾。又有人说：都中土著士民，夏天饭上置冰一片，凡鱼肉多悬井内，瓜果安放冰边，却没见他们患痢。不知北方生长的人，禀气刚浓，且食煤火之食，内有蕴热，所以适宜。若吴地人，断不可效仿。
孙见心治疗一人秋间下痢脓血，昼夜百余次，里急后重。前医见脉歇止，认为是因积滞所致。用槟榔、厚朴、青皮、枳壳、木香等。孙见心诊之，脉洪弱而数，或一二至，或三四至，或五六至，辄一止。说：“毒及少阴了。应当急顾其阳明。”用生熟地各一两，当归、白芍、丹皮、黄连各三钱，甘草五分。众人怀疑阴药太重，恐怕饱闷增剧。然而服二帖后，次数尚频，急重已除，脉之洪数亦减，至数相续，仍用前方，病去大半。又次日，去生地、黄连，加人参、白术、茯苓、山药，饮食大进，午后弦脉亦减，而至数复有止状。有人惊恐地说：“病退而脉复变，防其加重。”孙见心说：“无妨。歇止者，即古代结促之俗名耳。若冲气中绝，脏脉自见者危。今此证歇止，本以毒盛拥遏隧道，阴精不承，故一二至，或三四至，或五六至而至也。经曰：‘数动一代者，病在阳之脉也，泄及便脓血。’今予去阴药之过甚，进阳药太骤，中脏得补，则木土和而胃气安，故饮食进而毒尚未尽者，亦随壮气而旺，故复有止状也。”于方中仍加生地、黄连，即平矣。果然应验。
俞震按：这一条与西昌治朱孔阳案相似，而此以生地换大黄，则是因脉之促止，与弦动不为指挠者有别。此从炙甘草汤得之。然而幸而洪数而歇止，若细涩无神而歇止，断不可治。也必须是其人身体不发热，尚能饮食而腹痛者，观案中云“饮食大进”可见矣。总之，痢以能食为吉，腹痛亦吉，不能食而不腹痛者大不吉。
〔附〕嘉善一老妇常便血，时发时止。至五十多岁，夏月便鲜血，里急后重，时或不禁。脉软不数。用五苓建中转甚效。因向宜凉血药，仍用四物加槐花、榆白皮、山楂、神曲。也无效。叶天士先生以生苍术、生厚朴、炒陈皮、炙甘草、鸡内金、砂仁壳、丁香柄丸服，全愈。又有一童子患久痢，叶也用此方全愈。人不解其故。俞震读徐春甫《医统》，因见此方名醉乡玉屑，治小儿食瓜果致痢久不愈者，乃是佩服先生的渊博。至于如《临证指南》所载，都属古人常用方法。惟以温药下之，乃江氏类案所未有。而附子、大黄为君，参入苓、朴及草果、益智、木香、大茴等，谅系对证择加。总不外举散温通之义。又有用大黄、芩、连、肉桂、丹皮、归、芍者，是从芍药汤化出。有用人参、芩、连、干姜、生姜、枳实者，是从泻心汤化出。以及二妙散加地榆、茯苓、泽泻，白头翁汤加黄芩、白芍，也是世俗所通晓。至如附子粳米汤、脾肾双补丸、理阴煎、四神丸、桃花汤、余粮丸，或养阴，或发表，均非创立。独有肾气丸之炒焦，及姚颐真之用大剂苁蓉为创立。但炒焦者不过熟地炭、桂、附炭之侣，苁蓉配参、归、姜、附，即以温药下之，化为温药滑之耳。然同温药则可，同阴药则不可，我曾试过。其痢久伤肾，下焦沉坠，刚药不效者，用人参、鹿茸、大茴、茯苓、菟丝子、故纸。痢久伤阴，唇燥舌干，胃气又弱，戒投阴腻柔药者，用人参、炙甘草、茯神、炒麦冬、炒白芍、炒乌梅肉。一系温柔补固，一系酸甘化阴，仍是率由旧章也。至于谓治痢大法，无过通塞二义，乃是先生略举大端，比如读《云汉》之诗，勿以辞害志可矣。
Du Zhong (Eucommiae Cortex), Renshen (Ginseng Radix et Rhizoma), Fuzi (Aconiti Lateralis Radix Praeparata). The condition was completely resolved.
Yu Zhen commented: This case and the following Shen Rou case are neither brilliant discussions nor miraculous prescriptions. However, in this case, tonification or clearing methods were used, either alone or combined, changing according to circumstances, but ultimately concluding with exclusive tonification and warming, without the slightest error. Compared to modern practitioners who, upon finding tonification ineffective, only know to use clearing methods; and when clearing fails, dare not resort to tonification again—the gap in wisdom between them is vast! In Shen Rou's case, although the symptoms changed repeatedly, the prescription remained unchanged, which can be described as steadfast and principled.
Shen Rou, a Buddhist monk, said: My fourth brother was twenty-seven years old when he suffered from dysentery in the leap ninth month of the Jia Chen year. Initially, I prescribed one dose of Shaoyao Tang (Peony Decoction) and two doses of Xianglian Wan (Coptis and Aucklandia Pill). After several days, the dysentery did not stop; instead, it was complicated by heart pain like knife cuts, umbilical abdominal pain, and anal pain, with cries disturbing the neighbors. He believed he would surely die, so I went to visit him in the countryside. He could not sleep day or night, passing a bucket of red blood daily, unbearable pain, fever, sweating, and inability to eat. Palpation revealed all six pulse positions were large and hollow (Huo Da), weak in floating, middle, and deep levels, with four beats per respiration. Although there was pain and fever, the weak pulse indicated deficiency-cold. As the ancients said, "For hemorrhage, benefit the Qi." This case was suitable for this principle. Thus, I administered one dose of Liujunzi Tang (Six Gentlemen Decoction), followed by Yigong San (Yi Gong Powder) with Shengma (Cimicifugae Rhizoma) 3 fen, Muxiang (Aucklandiae Radix) 5 fen, and Chao Ganjiang (Stir-fried Zingiberis Rhizoma) 5 fen. After one dose, he felt better, and the pain decreased slightly. At dawn, the abdominal pain returned. I said, "The medicinal effect has worn off." I hastily decocted another dose for him. It was even more effective than before, reducing the pain by seven or eight parts, allowing him to sleep soundly until noon. He said, "I still feel uncomfortable." I replied, "This medicine only sustains one sleep; decoct another dose." He then slept peacefully until morning. The epigastric and abdominal pain stopped, and tenesmus lightened. He recovered after taking the previous prescription again. Two days later, after eating chicken, the abdominal pain and anal swelling recurred, with continuous passage of foul matter. Three days later, the condition became critical. I examined his pulse again: three beats plus remainder per respiration, non-feelable on superficial pressure, large on deep pressure, with weak Spleen and Mingmen pulses. I prescribed Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction), but it was ineffective. This indicated severe deficiency collapse. I added Yumike (Papaveris Pericarpium) 1 qian, but it was also ineffective. He had diarrhea like a hole, sweating, restlessness, and the Chi pulse gradually became short. The situation was critical. I urgently added Renshen (Ginseng Radix et Rhizoma) 2 qian to Buzhong Yiqi Tang. Upon swallowing, he felt confused/dizzy. This indicated that righteous Qi was about to recover and pathogenic factors were retreating. Soon, his spirit improved, and dysentery slowed. Fearing recurrence, I gave another dose. The symptoms of profuse discharge, confusion, heat, and restlessness gradually subsided, the pulse gained spirit, and the short pulse disappeared. Recalling the ancients' saying, "For chronic diarrhea and dysentery, pills and powders are better than decoctions," I compounded Shenling Baizhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder) for him. He felt relief and tolerated it. By afternoon, he became restless again. I was at a loss. Re-examining the left Chi position, it was surging like fire shooting, indicating Yin deficiency with hyperactive fire. I prescribed Jiajian Bawei Wan (Modified Eight-Ingredient Pill) 50-60 pills. His spirit felt refreshed. Shortly after, he took another 80-90 pills and slept until dawn, recovering seventy percent of his health. I then believed Lijiazhi's statement that Jiajian Bawei Wan treats water exhaustion (Kidney Yin depletion). I instructed him to take these pills morning and evening, interspersed with Shenling Baizhu San, leading to gradual recovery. Later, due to overwork, he experienced painful urination, likely due to sexual indulgence. He recovered after taking Xiaoyao San (Free and Easy Wanderer Powder), Maidong (Ophiopogonis Radix), and Wuweizi (Schisandrae Fructus).
Gao Guozai treated Duke Ding Qinghui. I was residing at home at the time. The Duke suffered from dysentery with tenesmus, white pus mixed with fresh blood, occurring more than ten times day and night, with reduced appetite. Both Chi pulses were faint, while the Cun and Guan pulses were wiry and rapid, with scanty urine. Most physicians argued that given his near-eighty age, treatment should rely on the Chi pulses and use warming-tonifying methods. Gao alone argued that since his constitution was robust, treatment should follow the Cun and Guan pulses using clearing methods. He prescribed Huangqin (Scutellariae Radix), Baishao (Paeoniae Radix Alba), Houpo (Magnoliae Officinalis Cortex), Binglang (Arecae Semen), Chenpi (Citri Reticulatae Pericarpium), Gancao (Glycyrrhizae Radix et Rhizoma), Ejiao (Asini Corii Colla), Huashi (Talcum), Huaihua (Sophorae Flos), and Muxiang (Aucklandiae Radix). After four to five doses, he was fully cured.
Yu Zhen commented: This success was due to familiarity with the patient's condition, ensuring correct selection. However, such judgment requires evidence of excess patterns and unexhausted Shen (Spirit).
Yu Jiayan treated Zhou Xinchuan, aged seventy-three. He was physically strong and did not feel old. He contracted dysentery in autumn, which persisted into winter, becoming chronic dysentery (Xiuxi Li). He had more than ten bowel movements daily, facial edema, and dark complexion. Yu Jiayan palpated a deep, rapid, and forceful pulse, stating, "This is Yang pathogen sinking into Yin. We must use the 'Retrieving the Boat Against the Current' method to lift the pathogen out through the exterior. Once the downward trend stops, the disease will heal." He decocted Renshen Baidu San (Ginseng and Toxin-Resolving Powder) as directed. The patient sat wrapped in thick blankets on a chair with a fire underneath. A cloth roll shaped like a goose egg was placed under the anus to prevent internal Qi from descending. The hot decoction was administered. After some time, more was given. The patient felt slight moisture on the skin. Hot water was poured over him, and he was instructed to endure the urge to defecate without moving. This lasted about two hours. The patient was irritable and afraid of heat, enduring it until finally lying down with sweat and blankets. That night, he had only two dysenteric episodes. Subsequently, Buzhong Yiqi Tang was used, and he recovered completely within ten days.
Zhu Kongyang, aged twenty-five, was thin and accustomed to comfort. In summer, due to litigation and running in the sun, he developed dysentery, occurring 100-200 times daily. He could not get out of bed, drank only water, and ate nothing. The pain was severe, the anus felt like burning, and he kicked and waved in distress. Yu Jiayan palpated a wiry, tight, and urgent pulse that resisted finger pressure, saying, "This is a mass of toxic fire accumulating in the intestines and stomach, burning fiercely. Saving from fire requires immediate action; otherwise, the intestines and stomach will rot in two or three days." He prescribed Dahuang (Rhei Radix et Rhizoma) 4 liang, Huanglian (Coptidis Rhizoma) and Gancao (Glycyrrhizae Radix et Rhizoma) 2 liang each, decocted in a large clay pot. The patient drank it as it boiled. After ingestion, he rested briefly, but soon resumed restlessness. Over twenty doses were taken in a day and night, with the herbs fully decocted. The next day, the patient requested the same medicine. Yu re-palpated the pulse, finding it soft and gentle, indicating recovery was possible. However, he used an urgent method without urgent drugs. He switched to Shengdi (Rehmanniae Radix) and Maidong (Ophiopogonis Radix) 4 liang each, crushed for raw juice, mixed with Huafen (Trichosanthis Radix), Danpi (Moutan Cortex), Chishao (Paeoniae Radix Rubra), and Gancao (Glycyrrhizae Radix et Rhizoma) 1 liang each, decocted and mixed with the juice, drunk in large bowls. Because the onset was violent, body fluids were exhausted. Once dysentery stopped, nourishing fluids and blood was necessary, as dryness takes time to restore. With the pulse softened, fire pathogens retreated. Dysentery stopped spontaneously without direct anti-dysentery drugs, proving that sticking to cloying/stagnating remedies was wrong. Dysentery gradually ceased, porridge and drinks were accepted, and digestion recovered after ten days of regulation.
Chen Ruming suffered from dysentery with steaming fever, coma, inability to eat, and extreme heaviness. On the third day, he was critical. He sought Yu Jiayan. His pulse was rapid, large, and empty, with the Chi pulse significantly surging. Yu said, "This is two diseases combining simultaneously. Internal damp-heat combines with seasonal external heat, forming dysentery unconsciously. Additionally, sexual exertion exposed him to sudden cold, causing fever, heaviness, anorexia, and coma—all attributable to Shaoyin Kidney channel external contraction. Shaoyin contraction typically causes clear-white diarrhea. Here, intestinal damp-heat has steamed into shapes resembling pig liver or fish brain, changing color but retaining the nature of diarrhea. If standard dysentery medicines were used, death would be immediate." He urgently prescribed Mahuang Fuzi Xixin Tang (Ephedra, Prepared Aconite, and Asarum Decoction) to release the exterior. After sweating, fever subsided slightly. Then, Fuzi Lizhong Tang (Prepared Aconite and Centipede Decoction) was given for two doses, resolving fever, restoring lightness, and appetite. Finally, Lianli Tang/Wan (Coptis and Licorice Decoction/Pill) was used, and he recovered completely in ten days.
Pu Junyi suffered from dysentery. Initially, exterior pathogens were present, but Ren Shen and Baizhu were mistakenly used to consolidate the exterior, worsening the condition. Subsequently, Huanglian and Dahuang were frequently administered for over a month, damaging Stomach Qi. He had over a hundred bowel movements daily. One night, he vomited three to five bowls of previous Huanglian decoction. After vomiting two or three times, the Stomach and Intestines merged, the pylorus and ileocecal valve opened unrestrictedly. Porridge and drinks flowed directly out, and even concentrated Ginseng paste passed immediately into the intestines. The situation was critical. A large dose of Sijunzi Tang (Four Gentlemen Decoction) was decocted, mixed with Chishizhi (Halloysitum Rubrum) and Yuyuliang (Ilmenitum), and administered continuously. The dysentery decreased slightly, but abdominal pain became unbearable. Junyi said, "Previously, frequent dysentery caused no pain; now pain increases after this medicine; do not continue." Yu said, "This illustrates 'Unblocked means no pain; pain means blockage.' No pain indicates danger; pain indicates safety. Why not welcome pain?" The previous prescription was continued. Once the severity greatly reduced, Sijunzi Tang with doubled Fuling (Poria) was used. After ten-plus doses, he recovered.
Yu Zhen commented: These four cases demonstrate methods unprecedented by ancients, surpassing posterity. Yet compared to Danxi, there is a distinction between rough and refined approaches.
Zhang Luzhu treated Chen Yingyong, a successful candidate. Returning home in summer, he contracted dysentery. For half a month, purgative and cooling treatments failed, leading to Jin Kou Li (Closed Mouth Dysentery) where he could not eat. Having consumed coal-heated food in the capital, he developed a boil on his shoulder/back, non-red, non-painful, sunken, accompanied by hiccups, coma, and imminent death. Physicians shifted blame. Zhang Shiwang palpated wiry, fine, nearly absent pulses, with a Dai Yang (floating Yang) facial appearance, and passage of dark, bloody stool resembling rotten fish intestines. Despite the critical condition, the pulse lacked vigorous energy, breathing was not panting, and there was no restlessness, indicating suitability for warming-tonification. If the boil erupted after tonification, there would be no danger. He prescribed Baoyuan Tang (Preserve the Origin Decoction): Renshen 3 qian, Huangqi (Astragali Radix) 2 qian, Gancao 1 qian, Rougui (Cinnamomi Cortex) 1 qian, decocted in Fulonggan (Dragon's House Earth) water. After one dose, intake improved; after two, tenesmus lightened; after three, the boil rose. An external surgeon treated the boil externally. Adhering strictly to the formula, he recovered after ten more doses, never changing a single herb.
Yu Zhen researched ancient dysentery cases, noting comprehensive use of attacking, tonifying, warming, and cooling methods. I selected those with clear differentiation and appropriate medication. This case involves dysentery with a boil, so it is recorded. Other methods like milk-boiled Bibo, refined realgar, turtle sugar soup, and Ginseng Camptotheca bark powder were once considered miraculous but may not be effective today, so they are excluded.
Reading *Ru Men Shi Qin*, a man with severe dysentery ate water-soaked melons with skin, curing the pus and blood. However, materia medica warns that poor people eating too many melons in late autumn face difficult-to-treat dysentery. This shows dysentery has no fixed form, nor does its treatment. Liu Zongnong stated: Excessive consumption of ice water and fruits in summer damages Spleen-Stomach cold, preventing blood circulation in limbs and meridians, seeping into intestines causing dysentery. This is true, but the fault lies in excess. Occasional consumption is harmless. However, after heavy meals of meat and rich foods, even occasional cold items are forbidden. Eating well-water watermelon on an empty stomach clears formless summer heat via urine. But if the stomach is full of food, adding cold/raw items causes Spleen stagnation and accumulation. In my youth, visiting a friend whose family all had dysentery, I wondered if it was Yang Zijian's epidemic toxic dysentery. At lunch, rich seafood was served with cold wine. I refused to drink, explaining that the rich foods needed hot wine to circulate Stomach Qi. Cold wine causes coagulation ("cold congeals"), like oil on a bowl, hard to wash off, leading to stagnant Qi and bleeding dysentery. They realized their mistake and abstained, remaining dysentery-free for twenty years. Others noted Beijing residents eat ice and store food in wells without dysentery because Northern constitutions are robust and coal-food generates internal heat, making it suitable. Southern people should not imitate this.
Sun Jianxin treated a man with autumn dysentery, passing pus and blood over a hundred times daily with tenesmus. Previous doctors saw intermittent pulses and attributed it to accumulation, using Binglang, Houpo, Qingpi, Zhike, and Muxiang. Sun palpated a large, weak, rapid pulse with intermittent beats (one to six beats then a pause). He said, "Toxicity has reached Shaoyin. Urgently support Yangming." He used Sheng Di and Shu Di 1 liang each, Dang Gui, Baishao, Danpi, Huanglian 3 qian each, Gancao 5 fen. Skeptics feared excessive Yin-nourishing herbs would cause bloating. After two doses, frequency remained high, but urgency resolved, and pulse rapidity decreased. The pulse rhythm continued, so the same formula was used, removing half the illness. The next day, Sheng Di and Huanglian were removed, and Renshen, Baizhu, Fuling, and Shanyao added. Appetite improved, and wiry pulse subsided, though intermittency returned. Some feared worsening. Sun explained, "Intermittency is ancient 'Jie Cu' pulse. If Yuan Qi interrupts, it is critical. Here, toxicity blocks channels, Yin essence fails to support, causing irregular beats. The Classic says: 'Rapid and intermittent pulses indicate Yang disease, diarrhea with pus/blood.' I removed Yin herbs excessively and added Yang herbs too quickly. Now Zang organs are tonified, Wood and Earth harmonize, Stomach Qi stabilizes, appetite returns. Remaining toxins surge with strong Qi, causing intermittent pulses again." He added Sheng Di and Huanglian back, and the pulse normalized. It worked.
Yu Zhen commented: This resembles Zhu Kongyang's case, but uses Sheng Di instead of Dahuang due to pulse intermittency vs. wiry/unyielding nature. It derives from Zhigancao Tang. Fortunately, the pulse was large/rapid with intermittency; if fine/choppy/spiritless with intermittency, it is untreatable. Also, the patient must not have fever, must be able to eat, and have abdominal pain—evidenced by "appetite improved." Generally, ability to eat is auspicious in dysentery; abdominal pain is also auspicious. Inability to eat without pain is very inauspicious.
[Appendix] A woman from Jiashen had intermittent hematochezia. In her fifties, she passed fresh blood in summer with tenesmus and incontinence. Pulse was soft, not rapid. Wuling Jianzhong Tang was very effective. Cooling-blood herbs (Siyu San plus Huaihua, Yupibai, Shanzha, Shenqu) were ineffective. Ye Tianshi cured her with Sheng Cangzhu, Sheng Houpo, Chao Chenpi, Zhi Gancao, Jineijin, Sharen Qiao, and Dingxiang Bang made into pills. A boy with chronic dysentery was also cured by this formula. People didn't understand why. Yu read Xu Chunfu's *YiTong* and found this formula named *Zui Xiang Yu Xie*, treating chronic dysentery in children from fruit/melon consumption, appreciating Ye's erudition. *Lin Zheng Zhi Nan* records similar common methods. Using warm herbs to purge is unique to Jiang's cases, using Fuzi and Dahuang as sovereigns, combined with Fuling, Houpo, Caoguo, Yizhi, Muxiang, Dahuixiang, presumably symptom-specific additions, embodying dispersing and warming-unblocking principles. Others used Dahuang, Huangqin, Huanglian, Rougui, Danpi, Dang Gui, Baishao (derived from Shaoyao Tang); Renshen, Huangqin, Huanglian, Ganjiang, Shengjiang, Zhishi (derived from Xiexin Tang); Ermiao San plus Diyue, Fuling, Zexie; Bai Tou Weng Tang plus Huangqin, Baishao—all common knowledge. Fu Zi Jing Mi Tang, Shipen Shuangbu Wan, Liyin Jian, Sishen Wan, Taohua Tang, Yuliang Wan—either nourish Yin or release exterior, none are original creations. Only charred Shenqi Wan and Yao Yizhen's large-dose Congrong (Cynomorii Fructus) are innovations. Charred versions are merely charred Shudi, Rougui, Fuzi partners. Congrong paired with Renshen, Dang Gui, Ganjiang, Fuzi transforms "warm purging" into "warm lubricating." Warm herbs work; Yin-nourishing herbs do not, as I have tested. For long-term dysentery injuring Kidney with lower Jiao heaviness, unresponsive to harsh herbs: Renshen, Lurong (Cervicornium), Dahuixiang, Fuling, Tusizi, Guboli. For long-term dysentery injuring Yin with dry lips/tongue and weak Stomach Qi, avoiding cloying Yin herbs: Renshen, Zhi Gancao, Fushen, Chao Maidong, Chao Baishao, Chao Wumei Rou. One is gentle-warm tonification; the other is sour-sweet generating Yin. Both follow traditional principles. Regarding the general principle of treating dysentery via "unblocking" and "stopping," Mr. Ye only outlined the main points. Like reading the poem *Yun Han*, do not let words obscure the intent.