老先生玉体清瘦。澹泊宁静以御神。病邪无从窃入。虽食饮素约。然三日始一更衣。出孔比入孔尤约。
故精神有余。足以虑周当世。而中外倚毗壮猷也。偶因大便后寒热发作有时。颇似外感。其实内伤。非感也。
缘素艰大便。努挣伤气。故便出则阴乘于阳而寒。顷之稍定。则阳复胜阴而热也。若果外感之寒
热。何必大便后始然耶。此时但宜以和平之剂治内伤。辅养元气为上。加入外感药。驱导兼行。必致内伤
转增。奈何先生方欲治肠中之燥。医家又欲除内蕴之湿。不思肠燥为相安之恒。可以不治。即治之不过润肠
生血。亦无不可。若乃见为湿热。而用滑利之药以驱导之。则误甚矣。盖瘦人身中以湿为实。有湿则
润。无湿则燥。今指燥为湿。是指火为水也。且膀胱者水道也。
大肠者谷道也。以三日一便之肠。误用滑药。转致 出无度。犹
不悔悟。每一大遗。辄矜祛湿之力。世间岂有湿从谷道而出之理哉。不过因主人暂快大肠之润。而谬饰其词
耳。讵知沧海不足以实漏卮。而元气日削乎。始之阴阳交胜者。渐至交离。而阴从泻伤。阳从汗伤。两寸脉
浮而空。阳气越于上。关尺脉微而细。阴气越于下。不相维附。势趋不返矣。然汗出尚有时。而下
痢则无时。究竟阴阳之气。两竭于下。便出急如箭。肛门热如烙。此时尚以滑石木通猪苓泽泻等。分利小
水以止泄。不知阴虚自致泉竭。小便从何得来。止令数十年大肠之积蓄尽空。仰给于胃脘。食入毋俟停留。
已挈柄而挹之下注。久久胃不能给。遂将肠中自有之垢。暗行驱下。其臭甚腥。色白如脓。垢尽而肠
气亦不留。只是周身元气至宝。坐耗于空虚之府。非不服人参大补。然药力入胃则肠空。入肠则胃空。便出
则肠胃俱空。繇是下空则上壅。胸膈不舒。喉间顽痰窒塞。口燥咽干。彻夜不寐。一
切食物。惟味薄质轻者。胃中始爱而受之。此时尚图养血安神。调脾祛痰。旷日缓治。其不达时宜也甚矣。
夫宣房瓠子之决。天子公卿。咸轻掷金马璧鸡奠之。以策群力。而襄底定。请以朝廷
破格之法。而通于医药可乎。草野罔识忌讳。或者可与图功耳。
附药议 方用人参。白术。甘草。山茱萸。五味子。宣木瓜。白芍药。升麻。赤石脂。禹余粮。人参。
白术。茯苓。甘草。为四君子汤。理脾胃之正药也。而不用茯苓者。以其淡渗。恐伤阴也。而用山茱萸以收
肝气之散。五味子以收肾气之散。宣木瓜以收胃气之散。白芍药以收脾气及脏气之散。合之参术之补。
甘草之缓。升麻之升。阴阳两和。俾元气上者下而下者上。团聚于中不散。斯脉不至上盛。腹不至雷鸣。汗
不至淋漓。肛不至火热。食饮自加。便泄自止。是收气之散。为吃紧关头。故取四味重复。藉其颛力。至于
用涩以固脱。药味多般不同。此用禹余粮石脂者。取其颛固下焦之脱也。况肠胃之空。非二味不填。肠
垢已去。非二味不复。其粘着之性。所谓下焦有病患难会。须用
余粮赤石脂者。以是故也。又况误以石之滑者伤之。必以石之涩者救之。尤有同气相求之义耶。所以必用大
剂药料。煎浓膏。调二味服下。恐药力清薄。不遂其留恋。故以啜羹之法用之。取其久停。又以饮醇之法
用之。取其缓入。非谓一饮尽剂。强以所难也。先生弗解其意。见药剂过重。谓为难用。医者见二味涩
药。又从旁破为不可用。不知十剂中涩居其一。如七曜经天。何可少一曜耶。且石脂不过土之赤者也。余
粮不过土之外刚内柔者也。中州土病而引土为治。尚谓不宜。则诸草木之根 。更无取矣。东海西海。天下
后世。有明者出焉。理自相同。光自不掩。必求行其所知。则贱者售。而病乃殆矣。谓之何哉。
先生闻名而请。极其敬重。及见议病议方。反多疑意。不才即于方末慨叹数语。飘然而别。次日先生语
戚友云。昨之论辨甚明。但石脂余粮。生平未曾服过。即娄中医者亦未曾用过。只得附未达不敢尝之义。华
天御孝廉荐治陈彦质之病。比先生更重几倍。用石脂余粮而收成功。其案具存。可复阅也。其后往郡
迎医。用补剂稍效。然不善于补。转致夜间健食。脾气泄露无余。肛门火烙。阳气下陷。久而不升。遂成
臀痈。竟付外科治瘳。吁嗟。先生独何不身事视国也哉。
胡卣臣先生曰。萍槎司马扬历中外。清刚晓练。今之显允方叔也。从津门归。朝命再下。倚任方殷。司
马淹留抱 。竟至不起。使用嘉言之言。即以疆场死。不犹愈易箦家臣之手耶。
老先生身体清瘦。以淡泊宁静的心态来涵养精神。病邪无从趁机侵入。虽然饮食素来节制，然而三天才排便一次，排出的量比摄入的还要少。
因此精神充沛，足以思虑周全地应对世事，朝廷内外都倚重他的雄才大略。偶然因为大便后出现寒热交替、发作有时的症状，颇像外感病。其实是内伤，并非外感。
原因在于素来大便困难，用力努挣损伤了元气，所以大便排出时阴气乘虚占据阳气而发冷，过了一会儿稍微安定，则阳气重新战胜阴气而发热。如果真的是外感引起的寒热，何必一定要在大便后才这样呢？此时只应当用平和的药剂治疗内伤，以扶助滋养元气为最上策。如果加入治疗外感的药物，驱邪与导滞并行，必定导致内伤加重。奈何先生正想要治疗肠中的燥结，医生又想要清除体内蕴积的湿气。不考虑肠燥是维持安和的常态，可以不治；即使要治，也不过是润肠生血，也没什么不可以。如果认为是湿热，而使用滑利通下的药物来驱导，那就错得很厉害了。大概瘦人身体中以湿为实（指有实质性的病理产物或状态），有湿则滋润，无湿则干燥。现在把燥结指认为湿气，这就像把火指认为水一样错误。而且膀胱是水液运行的通道，大肠是食物残渣排出的通道。对于三天才排便一次的肠道，误用滑利药物，反而导致排泄无度。仍然不悔悟，每次大便失禁，就夸耀祛湿的功效。世间哪有湿气从谷道（肛门）排出的道理呢？不过是因主人暂时觉得大肠润滑舒适，而荒谬地掩饰其言辞罢了。哪里知道沧海之水不足以填满漏卮（比喻元气日益耗损），反而使元气日渐削弱。起初阴阳交替胜负的症状，逐渐发展到阴阳离决，阴气因泻下而受伤，阳气因汗出而受伤。两寸脉浮大而中空，阳气浮越于上；关尺脉微细，阴气浮越于下。上下不相维系依附，形势趋向于无法挽回。
然而汗出尚且有定时，而下痢却无时休止。终究是阴阳之气在下部双双枯竭，大便排出急如箭矢，肛门灼热如火烙。此时还用滑石、木通、猪苓、泽泻等药物，分利小便以止泄泻。不知道阴虚自然导致津液枯竭，小便从哪里得来呢？只是让几十年积蓄在肠中的糟粕全部排空，转而依赖胃脘供给。食物进入后不必停留，就已经被提挈着向下灌注。久而久之胃无法供给，于是将肠中自有的垢秽暗中驱赶下行，气味非常腥臭，颜色白如脓液。垢秽排尽后肠气也不留存了。只是全身的元气这一至宝，白白消耗在空虚的脏腑之中。不是不服用人参大补元气，然而药力进入胃则肠空，进入肠则胃空，大便排出则肠胃俱空。由此下部空虚则上部壅塞，胸膈不适，喉间顽痰阻塞，口燥咽干，彻夜不眠。一切食物，只有味道淡薄、质地轻清的，胃中才开始喜爱并受纳。此时还打算养血安神、调脾祛痰，缓慢治疗，这太不合时宜了。
当年宣房瓠子决口治理时，天子公卿都轻视金马璧鸡的祭祀，以策划群力，从而襄助平定灾祸。请以此类推，用朝廷破格任用的方法，应用于医药领域可以吗？草野之人不懂忌讳，或许可以借此建立功业。
附药议：方剂用人参、白术、甘草、山茱萸、五味子、宣木瓜、白芍药、升麻、赤石脂、禹余粮。人参、白术、茯苓、甘草组成四君子汤，这是调理脾胃的正药。但不用茯苓，是因为它淡渗利湿，恐怕损伤阴气。而用山茱萸来收敛肝气的散逸，五味子来收敛肾气的散逸，宣木瓜来收敛胃气的散逸，白芍药来收敛脾气及脏气的散逸。合用人参、白术的补益，甘草的缓和，升麻的提升，使阴阳两和，使得元气上升者下降、下降者上升，团聚于中部而不散。这样脉象不至上部盛满，腹部不至雷鸣，汗出不致淋漓，肛门不致火热，饮食自然增加，便泄自然停止。收敛散逸之气是关键环节，所以取这四味药重复使用，借其专一之力。至于用涩药以固脱，药味多种多样不同。这里用禹余粮、赤石脂，是取其专门固摄下焦滑脱的功效。况且肠胃空虚，非这两味药不能填补；肠垢已去，非这两味药不能恢复。它们粘着的特性，正如所谓“下焦有病患难会，须用余粮赤石脂”，就是由于这个原因。更何况误用石质的滑利药物伤害了身体，必须用石质的涩性药物来救治，尤其符合“同气相求”的道理。所以必须用大剂量的药材，煎煮成浓膏，调和这两味药服用。恐怕药力清淡薄弱，不能使其留恋停留，所以采用喝羹汤的方法使用，取其久留体内；又采用饮醇酒的方法使用，取其缓慢吸收。不是说一次性喝完整个药剂，强人所难。先生不理解其中的用意，见药剂过重，认为难以使用。医生在旁边也破坏说这两味涩药不可用。不知道十剂中药涩居其一，如同日月五星经天运行，怎么能缺少一颗星曜呢？况且石脂不过是土中红色的部分，余粮不过是土中外刚内柔的部分。中州脾胃之土有病而引土来治疗，还说不宜，那么各种草木的根，更无需取了。东海西海，天下后世，如果有明理的人出现，道理自然是相同的，光辉自然不会掩盖。必定要求推行自己所知道的，那么低贱者就会得售其技，而病情就会危险了。这能说什么呢？
先生闻名而来请教，极其敬重。等到见到我议论病情和处方，反而多生疑虑。我不才即在方剂末尾慨叹了几句话，飘然而别。第二天先生对亲戚朋友说：“昨天的论辩很明白，但石脂、余粮生平未曾服过，即使是娄中医者也未曾用过。”只得附上“未达不敢尝”的意思。华天御孝廉推荐治疗陈彦质的病，比先生的病重几倍，用石脂、余粮而获得成功，其医案都存在，可以再去查阅。后来前往郡城迎请医生，用补剂稍有效验。然而不善于补法，反而导致夜间食欲旺盛，脾气泄露无余，肛门如火烙，阳气下陷，久而不升，最终形成臀痈，竟交给外科治疗痊愈。唉，先生为什么不亲身侍奉国家呢？
胡卣臣先生说：“萍槎司马扬历中外，清正刚直，聪慧干练，是当今显赫可靠的方叔式人物。从津门归来，朝廷命令再次下达，倚重信任正殷切。司马滞留患病，最终未能痊愈。如果使用嘉言（喻昌自称）的建议，即使战死疆场，不也比在家中病榻旁死去更好吗？”
The old gentleman's physique is lean and slender. He maintains his spirit through a life of indifference to fame and tranquility, making it impossible for pathogenic factors to intrude. Although his diet has always been moderate, he only defecates once every three days, and the volume expelled is even less than what is ingested.
Thus, his spirit is abundant, allowing him to think comprehensively about worldly affairs, and both inside and outside the court rely on his great strategic talents. Occasionally, after defecation, he experiences chills and fever that occur at regular intervals, resembling an exterior contraction. In reality, this is an interior injury, not an exterior contraction.
This is because he has long suffered from difficult defecation; straining injures the Qi. Therefore, when stool is expelled, Yin takes advantage of Yang, causing chills; after a moment, when things settle slightly, Yang reasserts dominance over Yin, causing fever. If it were truly chills and fever caused by an exterior contraction, why would they necessarily occur only after defecation? At this time, one should only use mild agents to treat the interior injury, with supporting and nourishing the Yuan Qi (Primal Qi) as the highest priority. Adding medicines for exterior contraction, which drive out pathogens and guide stagnation simultaneously, will inevitably worsen the interior injury. Why does the gentleman wish to treat the dryness in the intestines, while the physician wishes to eliminate the dampness retained within? They fail to consider that intestinal dryness is a constant state of peace and can be left untreated; even if treated, moistening the intestines and generating blood is acceptable. However, regarding it as Damp-Heat and using slippery, purgative drugs to drain it is a grave error. Generally, in lean individuals, the presence of Dampness constitutes "fullness" (substantial pathological state); with Dampness, there is moisture; without Dampness, there is dryness. To identify dryness as Dampness now is like identifying Fire as Water. Furthermore, the Bladder is the pathway for water fluids, and the Large Intestine is the pathway for grain residues. For an intestine that defecates only once every three days, mistakenly using slippery drugs leads to uncontrolled discharge. Yet, still refusing to realize the mistake, each time there is fecal incontinence, he boasts of the power of removing Dampness. Is there any logic in the world where Dampness exits through the Grain Pathway (anus)? It is merely that because the master temporarily feels relief from intestinal lubrication, the words are absurdly embellished. How could the waters of the vast ocean fill a leaking cup, instead causing the Yuan Qi to be depleted day by day? Initially, the alternating victory of Yin and Yang gradually develops into their separation; Yin is injured by diarrhea, and Yang is injured by sweating. The pulses at both Cun (inch) positions are floating and empty, indicating Yang Qi floating upward; the pulses at Guan (bar) and Chi (cubit) positions are minute and fine, indicating Yin Qi floating downward. They no longer support each other, and the situation trends toward irreversibility.
Although sweating occurs at times, dysentery/diarrhea occurs without pause. Ultimately, both Yin and Yang Qi are exhausted below. Stool is expelled urgently like an arrow, and the anus feels hot as if branded. At this point, using Slippery Stone (Hua Shi), Akebia Caulis (Mu Tong), Polyporus (Zhu Ling), and Poria (Ze Xie) to separate and promote urination to stop diarrhea ignores the fact that Yin deficiency naturally leads to the exhaustion of spring-like fluids; from where can urine come? This merely empties decades of accumulated waste in the intestines, forcing reliance on the stomach and epigastrium for supply. Food enters and, without needing to stay, is already drawn down. Over time, the stomach cannot provide enough, so it secretly drives down its own inherent filth. The odor is extremely fishy, the color white like pus. Once the filth is gone, the Qi of the intestines also disappears. Only the precious Yuan Qi of the whole body is wasted in these empty organs. Even if Ginseng Radix et Rhizoma (Renshen) is taken for major tonification, when the medicinal power enters the stomach, the intestines are empty; when it enters the intestines, the stomach is empty; when stool is expelled, both stomach and intestines are empty. Consequently, lower emptiness leads to upper congestion, chest and diaphragm discomfort, stubborn phlegm obstructing the throat, dry mouth and throat, and sleeplessness all night. All food must be light in flavor and texture for the stomach to accept it. At this stage, planning to nourish blood, calm the mind, regulate the Spleen, and dispel phlegm through slow treatment is extremely untimely.
When the levee at Xuanfang was breached, emperors and ministers lightly discarded gold horses, jade, and chickens for sacrifice, strategizing collective efforts to assist in pacification. May we apply the method of extraordinary appointment by the court to medicine? A commoner unaware of taboos might perhaps achieve success this way.
Attached Medical Discussion: The prescription uses Ren Shen (Ginseng), Bai Zhu (Atractylodes Macrocephala), Gan Cao (Licorice), Shan Zhu Yu (Cornus), Wu Wei Zi (Schisandra), Xuan Mu Gua (Chaenomelis Fructus), Bai Shao Yao (White Peony Root), Sheng Ma (Cimicifugae Rhizoma), Chi Shi Zhi (Red Halloysite), and Yu Liang (Haematitum). Ren Shen, Bai Zhu, Fu Ling (Poria), and Gan Cao form Si Jun Zi Tang (Four Gentlemen Decoction), the correct medicine for regulating the Spleen and Stomach. However, Fu Ling is omitted because its bland and draining nature may injure Yin. Instead, Shan Zhu Yu is used to gather the scattering Liver Qi, Wu Wei Zi to gather the scattering Kidney Qi, Xuan Mu Gua to gather the scattering Stomach Qi, and Bai Shao Yao to gather the scattering Spleen Qi and Zang Qi. Combined with the tonifying effects of Ren Shen and Bai Zhu, the moderating effect of Gan Cao, and the ascending effect of Sheng Ma, Yin and Yang are harmonized, causing Yuan Qi that rises to descend and that which descends to rise, gathering in the center without scattering. Thus, the pulse will not be excessive above, the abdomen will not rumble, sweating will not be profuse, and the anus will not feel hot. Diet and drink will naturally increase, and diarrhea will stop. Gathering scattered Qi is the critical juncture, hence these four ingredients are repeated to leverage their specific strength. Regarding the use of astringents to secure collapse, various drugs differ. Here, Yu Liang and Chi Shi Zhi are used for their specific ability to secure lower Jiao collapse. Moreover, the emptiness of the intestines and stomach cannot be filled except by these two substances; the intestinal filth having gone cannot be restored except by them. Their adhesive nature aligns with the saying, "When diseases of the lower Jiao are difficult to resolve, Haematitum and Red Halloysite must be used," for this very reason. Furthermore, since the smooth nature of stone damaged the body, the astringent nature of stone must be used to rescue it, further adhering to the principle of "similar energies seeking each other." Therefore, large doses of medicinal materials must be decocted into a thick paste, mixed with these two substances and taken orally. It is feared that if the medicinal power is too thin, it will not linger; thus, the method of drinking soup is used to ensure prolonged retention, and the method of drinking strong wine is used to ensure slow absorption. It is not meant to force the patient to consume the entire dose at once. The gentleman did not understand this intention; seeing the heavy dosage, he considered it difficult to use. Physicians nearby also argued against the use of these two astringent substances, unaware that among the Ten Categories of Medicinals, astringents constitute one category, just as the Seven Luminaries traverse the sky—how can one be missing? Moreover, Chi Shi Zhi is merely the red part of Earth, and Yu Liang is the hard exterior and soft interior of Earth. If treating Spleen/Stomach (Central Earth) disease by drawing upon Earth is deemed unsuitable, then the roots of herbs are certainly not worth considering. From the East Sea to the West Sea, in the world and future generations, if enlightened ones emerge, the principles will naturally be the same, and the light will not be obscured. If one insists on practicing only what one knows, lowly practitioners will succeed, and the illness will become dangerous. What can be said?
Upon hearing my name, the gentleman invited me with extreme respect. But upon seeing my discussion of the disease and prescription, he harbored many doubts. I, though unworthy, sighed briefly at the end of the prescription and departed gracefully. The next day, the gentleman told relatives and friends, "Yesterday's debate was very clear, but I have never taken Chi Shi Zhi or Yu Liang in my life, nor have eminent physicians like Lou Zhongyi ever used them." He attached the meaning of "not daring to taste what I do not understand." Hua Tianyu Xiaolian recommended treating Chen Yanzhi's illness, which was several times heavier than the gentleman's condition. Using Chi Shi Zhi and Yu Liang achieved success; the case record exists and can be reviewed. Later, when doctors were invited to the prefecture, tonic formulas provided slight relief. However, improper tonification led to increased appetite at night, complete leakage of Spleen Qi, a burning anus, sinking of Yang Qi that failed to ascend over time, eventually resulting in a gluteal abscess, which was finally cured by surgical treatment. Alas, why did the gentleman not serve the country personally?
Mr. Hu Youchen stated: "Sima Pingcha has served both internally and externally, possessing integrity, uprightness, wisdom, and practical experience; he is the Fangshu (reliable minister) of our time. Returning from Jinmen, imperial orders were issued again, and his reliance was intense. Sima remained ill and ultimately passed away. Had he followed Jiayan's (Yu Chang's self-reference) advice, even dying on the battlefield would have been better than dying in bed at home."