丹溪治一妇。患心中如火一烧。便入小肠。急去小便。大便随时亦出。如此三年。求治
脉滑数。此相火送入小肠经。以四物加炒连、柏、小茴、木通。四帖而安。
李士材治方伯张七泽夫人饮食不进。小便不禁。李曰。六脉沉迟。水泉不藏。是无火也
投以八味丸料。兼进六君子加益智、肉桂。三剂减。数剂而安。
文学俞元倩忧忿经旬。忽然小便不禁。医皆以补脬固肾之剂投之。凡一月而转甚。李曰
六脉举之则软。按之则坚。此肾肝之阴有伏热也。用丹皮、茯苓各二钱。苦参八分。甘草
梢六分。黄连一钱。煎成。调黄鸡肠与服。六剂而安。适有医云。既愈当大补之。数日后。
仍复不禁。再来求治。曰。肝家素有郁热。得温补而转炽。遂以龙胆泻肝汤加黄鸡肠服之。
四剂即止。更以四君子加黄连、山栀。一月而痊。
震按丹溪案是相火送入小肠。此案是肝肾阴中伏热。病情微有不同。须看其用药亦微有
不同处。
张路玉治吴兴闵少江。年高体丰。不远房室。得一病。已十三年。过劳心嗔恚。或饮食
失宜。则小便频数。滴沥涩痛不已。至夜略得交睫。溺即遗出。觉则阻滞如前。凡服人参、
鹿茸、河车无算。然皆平稳无碍。触犯丹皮、白术。即胀痛不禁。张曰。此病名胞痹。因膏
粱积热于上。作强伤精于下。湿热乘虚结聚于膀胱之内胞也。用肾沥汤。颇有效。但原其不
得安寝。寝则遗溺。知肝虚火扰。而致梦魂不宁。疏泄失职。可以服牡丹疏肝之药则胀者。
不胜其气之窜以击动阴火也。服白术补脾之药亦胀者。不胜其味之浊以壅滞湿热也。服参、
茸、河车温补之药无碍者。虚能受热。但补而不切于治也。更拟加减桑螵蛸散。用羊肾汤泛
丸服。更戒以绝欲。乃安。
震按寤则淋涩。寐则溺遗。原与不禁有别。故以胞脾证治。其论药病不合处。理精义确
后来叶氏处方。最讲此旨。再观下二案。病情同而治法不同。用药俱有妙解。能细参之。
庶不犯枳、朴、归、苓。到手便撮之诮。
黄元吉年六十余。因丧明蓄外家。而患小便淋涩。春间因颠仆。昏愦遗尿。此后遂不时遗
溺。或发或止。至一阳后大剧。昼日溺涩不通。非坐于热汤则涓滴不出。交睫便遗之不禁。
张诊其脉。或时虚大。或时细数。而左关尺必显弦象。此肾气大亏而为下脱之兆也。乃与地
黄饮子数服。溺涩稍可。遗亦少间。后与八味丸除丹皮、泽泻。加鹿茸、五味、巴戟、远志
调理而痊。
陕客亢仁轩。年壮色苍。体丰善啖。患胞痹十余年。其脉软大而涩涩不调。不时蹲踞于
地。以手揉其茎囊。则溲从谷道点滴而渗。必以热汤沃之。始得少通。寐则有时而遗。其最
者中有结块如橘核之状。外裹红丝。内包黄水。杂于脂腻之中。此因恣饮不禁。酒湿乘虚袭
入髓窍。故有是患。因令坚戒烟草、火酒、湿面、椒蒜、糟醋、鸡豕、炙爆等味。与半夏、
茯苓、猪苓、泽泻、萆 、犀角、竹茹作汤。四剂。势减二三。次与肾沥汤加萆 。数服。
水道遂通。溲亦不痛。但觉食不甘美。后以补中益气加车前、木通调之而安。石顽曰。又有
胞痹二证。一因挟妓致病。用肾沥汤。加减八味丸收功。一因阴虚多火。用肾沥汤、生脉散
合六味丸收功。若萆 厘清。渗水伤精之味。咸为切禁。此人则肥盛多湿。故先与清胃豁
痰之药。然后理肾调脾。治各有宜耳。
孙东宿治南都大司马袁洪溪。冲暑理事。致发热燥渴。因食冰浸瓜梨新藕。遂成泄泻。
小水短少。医以胃苓汤加滑石、木通、车前子利之而泻止。大便又因之结燥。艰涩不堪。乃
用润肠丸。复泻不止。又进以前通利之剂。泻虽止而小水不能流通直遂。脐下胀急。立起解
之。则点滴不出。卧则流之不竭。以频取溺器。致通宵不寐。治半月余而精神削。寝食废。
诸医
俱不识。将认为癃。则立解时点滴不出。认为闭。卧则涓涓而流。谓气虚下陷。心血不足。
而补中益气与安神丸服皆无效。孙诊其脉两寸短弱。关缓大。两尺洪大。语之曰。此余暑未
解。而司马素善饮。湿热流于下部也。今已下午。恐脉未准。俟明早细察定方。司马曰。望
子久矣。姑求一剂。以邀夜间一睡。孙不得已。以益元散三钱。煎香薷汤进之。略无进退。
次早复诊。六脉如昨。思之而恍然悟曰。此证尿窍不对也。司马曰。名出何书。孙曰。内经
云。膀胱者。脬之室也。脬中湿热下坠。故立解而窍不对。小水因不得出。卧则脬不下坠而
尿渗出膀胱。亦以窍不对。虽涓涓而流。终不能通达直遂。故了而不了也。治惟提补上中二
焦元气。兼清下焦湿热。斯得矣。又有一法。今气虚下陷已久。一两剂未能取效。安得睡耶
但此不寐。非心血不足。因着心防闲小便而不敢寐也。暂将布袋衬于席上。任其流出而不
必防闲。免取便器。自然熟睡矣。方用补中益气汤加黄柏、知母。如法果愈。
震按起立则溺闭。眠卧则不禁。与张氏案又有别。尿窍不对之说。从唐与正治吴巡检案
悟来。
朱丹溪治疗一位妇人。她感觉心中像火烧一样，热感随即进入小肠，急忙去小便时，大便也会随之排出。这种情况持续了三年。求治时脉象滑数。这是相火（寄居于肝肾的命门之火）传入小肠经所致。用四物汤加入炒黄连、黄柏、小茴香、木通。服用四帖后病情安定。
李士材治疗方伯张七泽的夫人。她饮食不进，小便失禁。李士材说：六脉沉迟，水泉（指尿液）不能藏摄，这是无火（肾阳虚衰）的表现。投以八味丸的药料。同时服用六君子汤加益智仁、肉桂。服用三剂后症状减轻，数剂后病情安定。
文学俞元倩因忧愤持续多日，忽然出现小便失禁。医生们都用补膀胱、固肾脏的药剂投治。整整一个月后病情反而加重。李士材说：六脉轻取则软弱，重按则坚硬。这是肾肝之阴中有伏热（潜藏的热邪）。用牡丹皮、茯苓各二钱，苦参八分，甘草梢六分，黄连一钱，煎成后，调服黄鸡肠。服用六剂后病情安定。恰逢有医生说，既然痊愈应当大补。几天后，仍然再次出现小便失禁。再次求治时，李士材说：肝家素来有郁热，得到温补后火势更加炽盛。于是用龙胆泻肝汤加黄鸡肠服用。四剂即止住。随后用四君子汤加黄连、山栀。一个月后痊愈。
俞震按语：朱丹溪的案例是相火传入小肠，此案是肝肾阴中伏热。病情略有不同，必须看其用药也有细微的不同之处。
张路玉治疗吴兴闵少江。年高身体肥胖，房事不节制，得此病已十三年。过度劳累或发怒，或者饮食不当，就会小便频数，滴沥涩痛不止。到了夜晚稍微能入睡，睡着后尿液就会遗出，醒来则又感到阻滞如前。凡是服用人参、鹿茸、紫河车无数，然而都平稳无碍。一旦触犯牡丹皮、白术，就胀痛不禁。张路玉说：此病名为胞痹（膀胱气化不利之病），因为膏粱厚味积热于上，房劳伤精于下，湿热乘虚结聚于膀胱之内胞。用肾沥汤，颇有效。但推究其不能安寝，睡则遗尿，可知是肝虚火扰，导致梦魂不宁，疏泄失职。可以用服牡丹皮等疏肝药则胀者，是因为不胜受气机窜动而击动阴火；服白术等补脾药亦胀者，是因为不胜受药味之浊而壅滞湿热；服人参、鹿茸、紫河车等温补药无碍者，是因为虚体能受热，只是补益不对症罢了。更拟定加减桑螵蛸散，用羊肾汤泛丸服用。并告诫戒除房事，才安定下来。
俞震按语：醒时淋涩，睡时溺遗，原本与小便不禁不同。所以从胞痹、脾证论治。他对药物与病症不合处的论述，道理精微，义理确切。后来叶天士处方，最讲究这一宗旨。再看下面两个案例，病情相同而治法不同，用药都有妙解。能细细参悟，才不会犯“到手便撮”（盲目套用成方）的讥讽。
黄元吉六十多岁。因丧妻蓄养外室，而患小便淋涩。春天因跌倒昏迷，遗尿。此后便不时遗尿，有时发作有时停止。到冬至一阳生之后病情加剧。白天小便涩滞不通，如果不坐在热汤里则一滴也出不来。刚合眼睡觉就遗尿不禁。张路玉诊察他的脉象，有时虚大，有时细数，但左关尺部必显弦象。这是肾气大亏而为下脱的征兆。于是给予地黄饮子数服，小便涩滞稍可缓解，遗尿也稍见间隔。后来用八味丸去掉牡丹皮、泽泻，加鹿茸、五味子、巴戟天、远志调理而痊愈。
陕西客商亢仁轩。年轻面色青黑，身体肥胖善于饮食。患胞痹十余年。其脉软大而涩涩不调。不时蹲在地上，用手揉搓阴茎和阴囊，则尿液从肛门点滴渗出。必须用热汤浇洗，才能稍微通畅。睡觉时有时遗尿。其中最严重的部位中间有结块如橘核状，外面包裹红丝，里面包着黄水，混杂在脂腻之中。这是因为恣意饮酒不加节制，酒湿乘虚袭入髓窍，所以有此病患。因此命令坚决戒除烟草、烧酒、湿面、花椒大蒜、糟醋、鸡肉猪肉、油炸烧烤等食物。用半夏、茯苓、猪苓、泽泻、萆薢、犀角、竹茹作汤剂。服用四剂，病势减少二三成。接着用肾沥汤加萆薢。服用数剂，水道遂通，小便也不痛了。但觉得食物不甘美。后来用补中益气汤加车前子、木通调理而安定。石顽说：又有胞痹两种证候，一种是因为嫖妓致病，用肾沥汤、加减八味丸收功；一种是因为阴虚多火，用肾沥汤、生脉散合六味丸收功。若用萆薢厘清，渗水伤精的药物，都应严格禁忌。此人则肥盛多湿，所以先用清胃豁痰的药物，然后调理肾脾，治疗各有适宜之处。
孙东宿治疗南京大司马袁洪溪。顶着酷暑处理公务，导致发热燥渴。因为吃了冰镇过的瓜梨和新藕，于是形成泄泻。小便短少。医生用胃苓汤加滑石、木通、车前子利水，腹泻停止。大便又因此变得干结燥硬，艰涩不堪。于是用润肠丸，反而腹泻不止。又进用以前的通利药剂，腹泻虽然停止，但小便不能流通直遂。脐下胀急，站起来解小便时，则点滴不出。躺着时则流之不竭。因为频繁取尿器，导致通宵不寐。治疗半月多，精神消瘦，寝食荒废。各位医生都不认识，将认为是癃闭（排尿困难），则站立解时点滴不出；将认为是闭（完全不通），躺着时却涓涓而流。说是气虚下陷，心血不足，而服用补中益气汤与安神丸都无效。孙东宿诊察他的脉象两寸短弱，关部缓大，两尺洪大。告诉他说：这是余暑未解，而且司马素来喜欢饮酒，湿热流注于下部。现在已经下午，恐怕脉象不准，等到明早仔细察定方剂。司马说：盼望您很久矣，姑且求一剂，以求夜间能睡一觉。孙东宿不得已，用益元散三钱，煎香薷汤进服。毫无进退变化。次早复诊，六脉如昨。思考后恍然大悟说：此证是尿窍不对（尿道口位置相对改变或功能失调）。司马问：名称出自哪本书？孙东宿说：《内经》说，膀胱者，脬之室也。脬中湿热下坠，所以站立解时窍不对，小便因此不得出。躺着时脬不下坠而尿液渗出膀胱，也是因为窍不对。虽然涓涓而流，终究不能通达直遂。所以了而不了（看似排尿实则未排净或无效）。治疗只有提补上中二焦元气，兼清下焦湿热，这样才能好。又有一法，现在气虚下陷已久，一两剂未能取效，怎么能睡着呢？但这不寐，不是心血不足，而是因为担心防闲小便而不敢睡。暂时将布袋衬在席子上，任其流出而不必防备，免去取便器，自然熟睡矣。方用补中益气汤加黄柏、知母。依法果然痊愈。
Zhu Danxi treated a woman. She felt heat in her heart as if burning, which then entered the Small Intestine channel. When she urgently went to urinate, stool would also be discharged simultaneously. This condition persisted for three years. Upon seeking treatment, her pulse was slippery and rapid. This was caused by Minister Fire (Minister Fire refers to the fire of the Mingmen residing in the Liver and Kidney) transmitting into the Small Intestine channel. He prescribed Si Wu Tang (Four Substances Decoction) added with stir-fried Huang Lian (Coptidis Rhizoma), Huang Bai (Phellodendri Cortex), Xiao Hui Xiang (Foeniculi Fructus), and Mu Tong (Akebiae Caulis). After four doses, the condition stabilized.
Li Shicai treated the wife of Fangbo Zhang Qize. She had loss of appetite and urinary incontinence. Li stated: The six pulses are deep and slow; the "Water Spring" (urine) cannot be contained, indicating a lack of Fire (Kidney Yang deficiency). He administered Ba Wei Wan (Eight-Ingredient Pill) ingredients. Concurrently, he prescribed Liu Jun Zi Tang (Six-Gentlemen Decoction) added with Yi Zhi Ren (Alpiniae Oxyphyllae Fructus) and Rou Gui (Cinnamomi Cortex). After three doses, symptoms decreased; after several doses, the condition stabilized.
Yu Yuanqian, a scholar, suffered from worry and indignation for over a week, suddenly developing urinary incontinence. Physicians all treated him with formulas to tonify the bladder and secure the kidneys. After a full month, the condition worsened. Li stated: The six pulses are soft upon light palpation but firm upon heavy pressure. This indicates latent Heat (hidden pathogenic heat) within the Yin of the Kidney and Liver. He used Mu Dan Pi (Moutan Cortex), Fu Ling (Poria), each 2 qian; Ku Shen (Sophorae Flavescentis Radix) 8 fen; Gan Cao Gao (Glycyrrhizae Radix et Rhizoma tip) 6 fen; Huang Lian (Coptidis Rhizoma) 1 qian. Decocted and taken with Huang Ji Chang (Yellow Chicken Intestine) mixed in. After six doses, the condition stabilized. A physician remarked that since he recovered, he should undergo strong tonification. Days later, incontinence recurred. Upon re-consultation, Li said: The Liver has inherent stagnant Heat, which flared up due to warm tonification. Thus, he prescribed Long Dan Xie Gan Tang (Gentiana Decoction to Drain the Liver) added with Huang Ji Chang. After four doses, it stopped. Subsequently, he used Si Jun Zi Tang (Four Gentlemen Decoction) added with Huang Lian and Shan Zhi (Gardeniae Fructus). He recovered after one month.
Yu Zhen’s commentary: Zhu Danxi’s case involved Minister Fire entering the Small Intestine; this case involves latent Heat in the Yin of the Liver and Kidney. The pathology differs slightly, and consequently, the medication also differs slightly. One must observe these nuances.
Zhang Luzhu treated Min Shaojiang from Wuxing. He was elderly, obese, and did not abstain from sexual activity. He suffered from this disease for thirteen years. Overexertion or anger, or improper diet, caused frequent urination with dribbling and painful dysuria. At night, when he briefly slept, urine would leak out; upon waking, obstruction returned. He had consumed countless amounts of Ren Shen (Ginseng Radix), Lu Rong (Cervi Cornu Pantotrichum), and He Che Da Xia (Placenta Humana), yet remained stable. However, touching Mu Dan Pi or Bai Zhu (Atractylodis Macrocephalae Rhizoma) caused unbearable distension and pain. Zhang said: This disease is named Bao Bi (Bladder Obstruction). It arises from accumulated Heat from rich foods above, and injury to essence from excessive sexual activity below, causing Damp-Heat to gather vacuously within the inner bladder capsule. He used Shen Li Tang (Kidney Filtration Decoction), which was quite effective. However, analyzing his inability to sleep and nocturnal enuresis, it is known that Liver deficiency with Fire disturbance causes restless dreams and failure of the Shu-Xie (dispersing and draining) function. Those who experience distension after taking Mu Dan Pi (a Liver-soothing herb) cannot tolerate the Qi movement striking the Minister Fire; those who experience distension after taking Bai Zhu (a Spleen-tonifying herb) cannot tolerate the turbid nature obstructing Damp-Heat; those who take Ren Shen, Lu Rong, and He Che Da Xia (warm tonics) without adverse effects do so because deficiency can accept heat, though the tonification does not address the root cause. He further proposed Jia Jian Sang Piao Xiao San (Modified Mulberry Mantis Egg Case Powder), made into pills using Sheep Kidney decoction. He advised strict abstinence from sex, after which he stabilized.
Yu Zhen’s commentary: Dysuria while awake and enuresis while asleep originally differ from simple incontinence. Therefore, treatment focuses on Bladder and Spleen syndromes. His discussion on the mismatch between drugs and pathology is precise in principle and accurate in meaning. Later, Ye Tianshi’s prescriptions emphasized this principle greatly. Looking at the following two cases, the pathology is the same but the treatment methods differ, and the medication choices have subtle explanations. Careful study prevents the ridicule of "grabbing any prescription that comes to hand."
Huang Yuanji, over sixty years old, suffered from painful dysuria after losing his wife and keeping a mistress. In spring, after falling and becoming unconscious, he experienced enuresis. Since then, he suffered from intermittent enuresis. After the Winter Solstice (when Yang begins to rise), the condition worsened significantly. During the day, urine was obstructed and could not flow; unless sitting in hot water, not a drop would come out. As soon as he closed his eyes to sleep, incontinence occurred. Zhang diagnosed his pulse as sometimes empty and large, sometimes fine and rapid, but the left Guan and Chi positions always showed a String-like (Xian) image. This indicated severe depletion of Kidney Qi, a sign of sinking/collapse below. He administered Di Huang Yin Zi (Rehmannia Drink) for several doses; dysuria improved slightly, and enuresis intervals lengthened. Later, he used Ba Wei Wan (Eight-Ingredient Pill) removing Mu Dan Pi and Ze Xie (Alismatis Rhizoma), adding Lu Rong, Wu Wei Zi (Schisandrae Fructus), Ba Ji Tian (Morindae Officinalis Radix), and Yuan Zhi (Polygalae Radix) for conditioning, leading to recovery.
Kang Renxuan, a merchant from Shaanxi, was young, dark-complexioned, obese, and had a hearty appetite. He suffered from Bao Bi for over ten years. His pulse was soft, large, and irregularly choppy. He would frequently squat on the ground and rub his penis and scrotum with his hands, causing urine to seep drop by drop from the anus. Only washing with hot water provided slight relief. He occasionally experienced enuresis during sleep. In the most severe cases, there were nodules in the middle resembling tangerine seeds, wrapped in red filaments externally and containing yellow fluid internally, mixed with fatty tissue. This was caused by indulging in alcohol without restraint, allowing Wine-Dampness to invade the marrow orifices vacuously. He was strictly ordered to avoid tobacco, liquor, damp noodles, pepper, garlic, pickles, chicken, pork, and fried foods. He was given a decoction of Ban Xia (Pinelliae Rhizoma), Fu Ling, Zhu Ling (Polyporus), Ze Xie, Bi Xie (Dioscoreae Hypoglaucae Rhizoma), Xi Jiao (Rhinocerotis Cornu - note: now substituted with Buffalo Horn), and Zhu Ru (Bambusae Caulis in Taenia). After four doses, the condition reduced by two or three parts. Next, Shen Li Tang added with Bi Xie was taken for several doses; the water pathway cleared, and urination became painless. However, food tasted bland. Later, Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) added with Che Qian Zi (Plantaginis Semen) and Mu Tong was used for regulation, leading to stability. Shi Wen noted: There are two types of Bao Bi. One results from visiting prostitutes, treated with Shen Li Tang and Jia Jian Ba Wei Wan. The other results from Yin deficiency with excess Fire, treated with Shen Li Tang, Sheng Mai San (Generate the Pulse Powder) combined with Liu Wei Wan (Six-Ingredient Pill). Drugs like Bi Xie that clear turbidity and drain water damaging essence are strictly prohibited. This patient was obese and damp-heavy, so clearing Stomach Heat and resolving Phlegm was done first, followed by regulating Kidney and Spleen. Treatments vary according to suitability.
Sun Dongsu treated Yuan Hongxi, Grand Commandant of Nanjing. Working under summer heat led to fever, dryness, and thirst. Eating ice-chilled melons, pears, and fresh lotus roots caused diarrhea. Urine volume decreased. Physicians used Wei Ling Tang (Stomach Regulating Decoction) added with Hua Shi (Talcum), Mu Tong, and Che Qian Zi to promote diuresis, stopping the diarrhea. Consequently, stool became dry and hard, difficult to pass. Run Chang Wan (Moisten Intestines Pill) was used, but diarrhea continued. Previous diuretic agents were readministered; diarrhea stopped, but urine could not flow freely. Distension and urgency occurred below the umbilicus. Standing to urinate yielded no drops; lying down resulted in continuous flow. Frequent changing of urinals prevented sleep throughout the night. After more than half a month of treatment, spirit waned, and eating/sleeping ceased. All physicians failed to diagnose. Some suspected Long (difficulty urinating) because standing yielded no drops; others suspected Bi (complete retention) because lying down yielded flow. They attributed it to Qi deficiency sinking and Heart Blood insufficiency, but Bu Zhong Yi Qi Tang and An Shen Wan (Calming Spirit Pill) were ineffective. Sun diagnosed the pulse: Cun positions short and weak, Guan position slow and large, Chi positions surging and large. He said: Residual Summer-Heat has not resolved, and since the Commandant loves drinking, Damp-Heat flows to the lower part. It is now afternoon; the pulse may not be accurate. I will examine carefully tomorrow morning to finalize the prescription. The Commandant said: I have awaited you for a long time; please give me one dose just to sleep tonight. Reluctantly, Sun gave Yi Yuan San (Benefit Primordial Powder) 3 qian, decocted in Xiang Ru (Moslae Herba) soup. There was no improvement. Next morning, the six pulses were the same. Thinking deeply, he suddenly realized: This syndrome is "Urinary Orifice Misalignment." The Commandant asked: Which book mentions this? Sun said: The *Nei Jing* states, "The Bladder is the chamber of the Paopao (bladder sac)." Damp-Heat in the Paopao sinks downward, so when standing, the orifice misaligns, preventing urine exit. When lying down, the Paopao does not sink, and urine seeps out, also due to orifice misalignment. Although flowing drop by drop, it cannot reach directly, hence "finished but not finished." Treatment requires lifting and tonifying Yuan Qi of the Upper and Middle Jiao, while clearing Damp-Heat in the Lower Jiao. Another method: Qi deficiency has sunk for a long time; one or two doses won't work, so how can he sleep? This insomnia is not due to Heart Blood insufficiency, but fear of leaking urine preventing sleep. Temporarily place a cloth bag on the mat, allow leakage without worry, avoiding the need for urinals, ensuring natural sleep. The formula was Bu Zhong Yi Qi Tang added with Huang Bai and Zhi Mu (Anemarrhenae Rhizoma). Following this method, he recovered.
Yu Zhen’s commentary: Incontinence when standing and retention when sleeping differs from Zhang’s case. The concept of "Urinary Orifice Misalignment" was derived from Tang Yuzheng’s treatment of Patrol Officer Wu.