（俗名伤寒夹痢疾）
【因】痢疾古称滞下。皆由暑湿与食积胶固腑中。流行阻遏而成。或饱餐饭肉浓鲜之后。再食瓜果生冷。
令脾胃之血不行于四肢八脉。渗入胃肠而为痢。再复感表邪。如身热恶寒头痛。或染时疫成痢。或有外感
陷里而化痢。
【证】凡痢疾兼挟寒邪者。如下痢里急后重。腹有痛有不痛。恶寒头痛身热。或兼寒热恶心。舌苔浓腻。
口渴不食。变态多端。
【脉】痢脉微小滑利者吉。浮弦洪数者凶。浮大者未止。微弱者自愈。此无外感者。大旨如此。若兼表邪。初
痢身热脉浮者。先解表。初痢身热脉沉者。可攻下。久痢身热脉虚者。属正虚可治。久痢身热脉大者。属邪
盛难医。
【治】凡挟表邪之痢。与时行疫痢。皆有身热。但当先撤表邪。如恶寒头痛身热之类。因其表而行散之。表
邪解而痢亦轻矣。如仓廪汤。（人参、茯苓、甘草、柴胡、羌活、独活、枳壳、桔梗、川芎、薄荷、生姜、
陈廪米。）以解表化滞。自然身凉痢止。因于湿热者。以苦辛寒为治。苦以燥湿。寒以清热。稍加辛热佐之。
以为发散宣通之用。无不效矣。因于气者调之。因于血者和之。邵氏谓在气分、有苦辛调气。及辛甘益
气等法。在血分者、有苦辛行血。及咸柔养血诸方。治赤痢者。气分药必不可少。气行而血自止也。治
白痢者。血分药必不可兼。恐引邪入于血分。反变脓血也。此治痢者。不可不知也。
【秀按】痢疾一证。大都以赤者属热。白者属寒。然白色亦多属湿热者。如肌肉腐熟而成脓也。赤色
亦有属寒湿者。因血瘀凝涩而入肠也。不可据赤白分寒热。当以舌苔脉象辨之。大抵赤属血。自小肠来。
白属气。自大肠来。赤白相杂。气血俱病。盖心主血。肺主气。凝滞则伤气。郁热则伤血。气血既病。则
心肺亦病矣。而小肠者、心之合也。大肠者、肺之合也。二经皆出纳水谷。转输糟粕之官也。而胃又为大
小肠之总使。肺移病于大肠。则气凝涩而成白痢。心移病于小肠。则血凝涩而成赤痢。大小肠俱病。则赤
白互下。其血与气之凝结。必挟饮食痰涎。始成积滞。其饮食痰涎。皆聚于胃。故痢证亦不离乎胃。谓由心
肺而及于胃也。此辨致痢之原因也。再详证候。以定疗法。所云里急后重。其证在广肠最下之处。里急与
后重不同。里急者、急迫欲便。后重者、肛门重坠。里急有虚实之分。实为火邪有余。虚为营阴不足。里
急而不得便者火也。重者承气汤。轻者芍药汤。久病见之为气脱。里急而至圊反不能出者。气滞也。以疏
通为主。后重亦有虚实之异。实为邪实下压。虚由气虚下陷。因邪压大肠。大肠不能升上。而下坠乃后
重。宜大黄槟榔、或香连丸。泻其所压之邪而愈。若积滞已行。后重不减。脉无力。不食者。此脾气下
陷。或大肠虚滑。不能自收。治以升涩之剂。固其脱。升其坠而愈。二者何以辨之。凡邪迫而后重者。
至圊稍减。未甚复甚。（荣斋按∶未甚复甚句不大明了，或许是未
几复甚之误。）虚滑而后重者。圊后不减。而得解愈虚故也。亦由积滞已去。过服肉面生冷而后重者。运脾消
导为主。但虚坐努责。不得大便。此为无血证。倍用四物汤。加新会皮。和胃生血自安。如痢后后重不除者。
宜三奇散。（枳壳、黄 、防风。）最妙。若下痢脓血。里急后重。日夜无度。或渴者。宜导气汤。（白芍、大
黄、归尾、黄芩、黄连、木香、枳壳。）下痢赤白。里急后重。宜香连丸。或木香槟榔丸。审证用之。冷热不
调。里急后重。腹痛口渴。小便不利。宜黄连阿胶丸。（黄连、阿胶、茯苓、此方去茯苓、加黄柏、山栀、海
藏名黄连阿胶汤。）后重当调气。亦有积与气坠下者。当兼升兼消。凡用诸承气等药。攻积之后。仍后重者。
乃阳气不升。药中当加升麻升其阳。其重自去也。至于腹痛。亦有寒热虚实之不同。实痛者、非食积即火邪。
食必痛而拒按。若脉洪实有力。腹胀坚硬。为积滞作痛。若火则畏热喜寒。脉洪而数。口渴喜冷。兼见热证。
为火邪作痛。邪实于中。每多气逆。故治痛之法。皆以行气为主。食则消之。火则清之。丹溪云。初病得之亦
可用大承气、调胃承气下之。看其气病血病。然后加减用药。治痢止痛。宜如神汤。（川连、枳壳、槐花。）
或芍药甘草汤。（芍药、甘草。）热痛加芩连之类。虚寒之痛。未有不宜乎温脏也。寒在中者。宜温脾。寒在下
者。宜温肾。总以拒按喜按。好冷恶冷为辨。若守痛无补法。不知因虚而痛者。愈攻则愈虚愈痛矣。古人谓
痢而后泻。自肾传脾则易治。泻而后痢。自脾传肾则难疗。叶天士云。命门火衰。泄泻则有。若讲痢疾。断无
此理。又云。寒无上迫之理。火性急速。故下迫。脾肾气虚泄泻者有之。夏秋之痢。属湿热下迫者多。补脾补
肾之法。惟久泻而无积滞腹痛者可用。非夏秋之痢。所可用也。然又不可轻用涩药。早投兜涩。积聚不去。多
至死亡。更须慎用参 。误服则为胀满。误服升麻。即为噤口。惟气虚下陷者宜之。否则下焦湿热与积。升至
上焦。速死之道也。饮食之油腻酒面。尤宜禁戒也。凡痢时吃酒则难愈。愈后吃酒则复发。痢之最危险者。莫
如噤口。大抵初痢噤口。多属湿瘀热郁。胃气伏而不宣。脾气因而涩滞者。宜香连枳朴之类。清疏肠胃。亦有
积秽在下。浊气薰蒸。宜下之。如香连加大黄。若久痢而致噤口。是胃气虚惫。独活、理中、尚难为
力也。若脉细弱者。宜参苓白术散。（人参、茯苓、白术、扁豆、山药、米仁、桔梗、陈皮、砂仁、莲肉、
甘草、大枣。）加菖蒲末。米饮调下。沈金鳌云。石菖蒲治噤口痢。屡试屡效。古人云。胃虚有火。
丹溪用人参、川连、石莲、粳米、加姜汁、细细呷之。如吐再服。或用姜炒川连、人参汤和之。叶氏半夏泻
心汤。减去大枣、甘草守中之品。又有休息痢。乃屡止屡发。经年累月。未得霍愈者也。多因兜涩太早。
湿热未清。加以调摄失宜。或因饮食不节。遂令脏腑受伤。漫无止期。用补中益气汤为最妥。有加肉果、
木香。吞驻车丸。亦有阴虚多火。不能胜任升麻、木香、白术者。只用驻车丸。加人参、乌梅之类。有积加
枳实、楂炭。积热未清。用清六丸。（滑石、甘草、红曲。）加香连。又有疟后痢。痢后疟。疟痢并作
者。既疟而后痢。非表邪内缩。即元气下陷。此似痢非痢证。若多食肉面。亦有疟后痢。宜葛根、炒麦芽、
六神曲之类化之。既痢而后疟。是邪从外达。迎其机而达之可也。初起即疟痢并作。即宜专用发散。如荆、
防、柴、葛。佐以赤苓、神曲。血痢则参加归、芎。使在腑之邪。提并于经而外解之。如不应。则辨其挟
热挟寒。表里分消之。热者去荆、防。加芩、连。寒者去柴、葛。加桂、姜。下痢兼证。亦当辨之。如痢而
呕者。胃气不和。宜加姜炒川连、竹茹、广郁金。虚则加参。因食消之。因痰化之。有痢而小便不通者。
由邪热在里。迫于大肠。必郁结于膀胱。则气不化。宜清膀胱之热。兼清肺气。喻氏有急开支河一法。令
气化行。而厘清其热势也。以小便涩痛。方是真热。轻者用六一散。凉水调服亦效。有兼大孔痛者。须辨
其新久寒热。热留于下。黄芩芍药汤清之。虚寒而痛。理中汤温之。此证宜食淡味。可用薰法。以熟艾、
黄蜡、诃子烧烟薰之。热则肛门闭。寒则肛门脱。所以兼脱肛者。虚寒多而实热少也。若久痢寒滑脱肛。
宜诃子皮散（诃子、粟壳、炮姜、橘红。）一法。以磁石末食前米饮下。外以铁锈汤洗肛门。有痢后呃
哕。为胃气虚寒。最为恶候。橘皮干姜汤。（陈皮、干姜、竹茹。）误食生冷而呃
者。理中加丁香。此秀积年经验。并参考吴云峰心得治痢法也。
【廉勘】伤寒变痢。而痢亦能化为伤寒。既夹下痢。犹当辨其下痢之色。参合外证。庶几不致误治也。
如初起里急后重。痢下色白。此为湿热凝滞。气分受邪。宜胃苓汤加香砂。兼热者、加炒黄芩、滑石。色
如豆汁者。亦属脾中湿热。燥脾分利。亦宜胃苓汤为主。或如鱼脑及鼻涕冻胶者。脾虚冷痢也。宜二术、炮
姜等味。如白脓努责而出者。气与热结也。宜木香、槟榔、黄芩之类。如屋漏水尘腐色者。皆元气虚惫也。
宜理中汤。加煨葛根、炒黄芩、茯苓。至于赤痢为血分之邪。湿热多者。以行湿清热为主。如炒黄芩、炒
银花、滑石、木香、楂炭之类。兼见紫块或稠粘。用黄芩、延胡索、桃仁、赤芍、行瘀治之。若血色鲜浓
紫浓者。则为热盛。宜用白头翁汤。或初起势盛。里急后重。脉有力者。加制大黄下之。若纯下清血。而
脉弦者。风入胃也。宜用炒枳壳、荆芥炭、煨防风。血色紫黯。屡服凉药。而血愈多者。寒湿也。宜理中
汤。加芎、归、木香。或如猪肝。如苋菜汁者。皆寒也。非炮姜不治。若血色稀淡。或如玛瑙色者。为阳
虚不能制阴而下。非温理其气。则血不清也。若辨黄黑二色。凡深黄而秽臭。热证也。浅黄色淡不甚臭。
或兼腥馊气者。寒证也。黑而焦浓浓大臭者。火证也。黑如漆光者。瘀血也。若青黑而腥薄者。肝肾腐败
之色也。又有五色痢。亦有虚有实。丹溪云脾胃有食积。及四气相并。则痢有五色之相杂。当先通利。宜
归连丸。（当归、黄连、黄柏、黄芩、阿胶、熟艾。）亦有因湿毒内盛。马元仪云。五色痢。乃五脏之气
化并伤。而治法则求之于肾。仲景所谓五液注下者是也。宜益火消阴。实脾堤水。兼分理其气。或可救
其万一。张三锡云。诸痢坏证。久下脓血。或如死猪肝色。或五色杂下。俗名刮肠痢。乃脏腑俱虚。脾气
下脱。若再投痢药则误矣。宜用真人养脏汤。大抵下痢属里证。不当更见表热。如头痛身热之类。若表
证有热。则外内俱困。故俞氏治法。以先撤表邪。冀清其痢。举其一以例其余。亦可谓扼要之论也。
【荣斋按】本节廉臣先生勘语，是指湿热痢、虚寒痢而言，不是指夹伤寒的痢。他在《名医验案类编》中，
却帮助了伤寒夹痢的治法，特录于下∶“痢疾见头痛怕冷，身热无汗者，均属有表，当从汗解。如口舌不燥
渴，胸腹不闷痛，舌或无苔，或淡白且滑，宜活人败毒散（茯苓、枳壳、桔梗、柴胡、羌活、独活、川芎各一
两，甘草五钱加薄荷少许。）每服五钱，日夜连进三五服，姜汤煎，热服取汗，汗透而痢便减。若见燥渴，
唇舌红赤，舌上黄燥或滑，面色腻滞，心烦，小便热赤者；为湿热暑湿之邪，宜胃苓汤（苍术、浓朴、陈皮、
甘草、白术、泽泻、猪苓、茯苓、官桂。）去官桂，加香薷、薄荷、连翘、滑石、淡豆豉，六神曲等；连
进三五服，得汗透而痢自止。”这治法是针对“夹痢伤寒”而设，移作补充，更见完备。
【病因】痢疾在古代被称为“滞下”。这通常是由于暑湿之邪与食物积滞胶结在肠道中，导致气机流行受阻而形成的。或者是在饱餐了米饭、肉类及浓鲜食物之后，又食用了瓜果生冷之物，致使脾胃的气血不能正常运行于四肢和全身经脉，渗入胃肠而变成痢疾。随后又感受了表邪，出现身体发热、怕冷、头痛等症状；或者是感染了时行疫气而成为痢疾；也有外感病邪内陷入里化热而成痢疾的情况。
【证候】凡是痢疾兼挟寒邪的，表现为下痢伴有里急后重（腹痛窘迫，时时欲便，肛门重坠，便出不爽），腹部有的疼痛有的不痛，怕冷、头痛、身体发热，或者兼有寒热往来、恶心呕吐，舌苔厚腻，口渴但不想进食，病情变化多端。
【脉象】痢疾的脉象如果呈现微小、滑利，是吉兆；如果呈现浮弦、洪数，是凶兆。脉浮大的，说明病势未止；脉微弱的，说明正气渐复，疾病将自愈。这是指没有外感表邪的情况，大抵如此。如果兼有表邪，初起痢疾且身体发热、脉浮的，应当先解表；初起痢疾且身体发热、脉沉的，可以攻下；久痢且身体发热、脉虚的，属于正气虚弱但尚可治疗；久痢且身体发热、脉大的，属于邪气盛实，难以医治。
【治法】凡是挟带表邪的痢疾，与时行疫痢一样，都有身体发热的症状，但都应当先解除表邪，如恶寒、头痛、身热等表现。顺着表邪的性质进行发散疏散，表邪解除后，痢疾也会减轻。例如仓廪汤（人参、茯苓、甘草、柴胡、羌活、独活、枳壳、桔梗、川芎、薄荷、生姜、陈廪米），用来解表化滞，自然能身凉痢止。如果是因湿热引起的，用苦辛寒的药物来治疗，苦味以燥湿，寒性以清热，稍微加入辛热药物作为佐使，起到发散宣通的作用，没有不有效的。如果是因气分失调的，就调理气分；如果是因血分失调的，就调和血分。邵氏说，在气分的，有用苦辛调气，以及辛甘益气的等方法；在血分的，有用苦辛行血，以及咸柔养血的各种方剂。治疗赤痢的，气分药必不可少，因为气行则血自止。治疗白痢的，血分药必不可兼用，恐怕引邪进入血分，反而变成脓血。这是治疗痢疾的人不可不知道的道理。
【秀按】痢疾这一病症，大抵认为红色的属热，白色的属寒。然而白色也多属于湿热，比如肌肉腐败熟烂而成脓的样子。红色也有属于寒湿的，是因为血液瘀凝涩滞而入肠所致。不能仅根据红白来区分寒热，应当通过舌苔和脉象来辨别。大致来说，红色属血，来自小肠；白色属气，来自大肠。红白相杂，说明气血都病了。大概心主血，肺主气，凝滞会伤气，郁热会伤血。气血既已生病，那么心肺也生病了。而小肠是心的合腑，大肠是肺的合腑。这两条经络都是出纳水谷、转输糟粕的器官，而胃又是大小肠的总枢纽。肺的病传到肠，则气凝涩而成白痢；心的病传到小肠，则血凝涩而成赤痢。大小肠都病了，则红白互下。那血与气的凝结，必定挟带饮食痰涎，才形成积滞。那些饮食痰涎，都聚集在胃，所以痢疾的证候也不离开胃，说是由心肺波及到胃的。这是辨析导致痢疾的原因。再详细分析证候，以确定疗法。所说的“里急后重”，其病位在广肠（直肠）最下端。里急和后重是不同的：里急是指急迫想要排便，后重是指肛门沉重下坠。里急有虚实之分，实证是火邪有余，虚证是营阴不足。里急却排不出大便的是火邪，重的用承气汤，轻的用芍药汤。久病出现这种情况是气脱。里急到了厕所反而排不出来的，是气滞，以疏通为主。后重也有虚实之别，实证是邪气实而下压，虚证是气虚下陷。因为邪气压迫大肠，大肠不能升举而上，所以下坠就是后重，宜用大黄、槟榔，或香连丸，泻去其所压迫的邪气就好了。如果积滞已经排出，后重仍不减，脉无力，不想吃东西，这是脾气下陷，或者大肠虚滑，不能自行收敛，治疗用升提固涩的药剂，固摄其脱失，升举其下坠就好了。这两者如何辨别？凡是邪气逼迫而后重的，到了厕所稍减，不久又严重（荣斋按：这句“未甚复甚”不太明白，或许是“未几复甚”即不久又严重的误写）。虚滑而后重的，上厕所后不减，而且解完后更虚的缘故。也是因为积滞已去，过吃肉类、面食、生冷食物而后重的，以运脾消导为主。但是虚坐努责（想拉拉不出），不得大便，这是无血证，倍用四物汤，加新会皮（陈皮），和胃生血自然安宁。如果是痢疾后后重不除的，宜用三奇散（枳壳、黄柏、防风），最为奇妙。如果下痢脓血，里急后重，日夜无度，或者口渴的，宜用导气汤（白芍、大黄、归尾、黄芩、黄连、木香、枳壳）。下痢红白相间，里急后重，宜用香连丸，或木香槟榔丸，审察证候使用。冷热不调，里急后重，腹痛口渴，小便不利，宜用黄连阿胶丸（黄连、阿胶、茯苓，此方去掉茯苓，加黄柏、山栀，海藏名为黄连阿胶汤）。后重应当调气，也有积滞与气一起下坠的，应当兼用升提和消散的方法。凡是使用诸承气等药，攻下积滞之后，仍然后重的，是阳气不升，药中应当加升麻升举其阳，其重感自然去除。至于腹痛，也有寒热虚实的不同。实痛，不是食积就是火邪。食积必痛且拒按，若脉洪实有力，腹胀坚硬，为积滞作痛。若是火邪，则畏热喜寒，脉洪而数，口渴喜冷，兼见热证，为火邪作痛。邪实于中，每每多有气逆，所以治痛的方法，都以行气为主。食积则消导它，火邪则清解它。丹溪说，初病得的，也可以用大承气汤、调胃承气汤攻下。看它是气病还是血病，然后加减用药。治痢止痛，宜用如神汤（川连、枳壳、槐花），或芍药甘草汤（芍药、甘草）。热痛加黄芩、黄连之类。虚寒之痛，没有不适合温脏的。寒在中焦的，宜温脾；寒在下焦的，宜温肾。总之以拒按喜按、好冷恶冷来辨别。如果坚守痛无补法的观点，不知道因虚而痛的，越攻伐就越虚越痛。古人说痢疾而后腹泻，是自肾传脾则易治；腹泻而后痢疾，是自脾传肾则难疗。叶天士说命门火衰，只有泄泻才有，如果讲痢疾，断无此理。又说寒无上迫之理，火性急速，所以下迫。脾肾气虚泄泻的有这种情况。夏秋季节的痢疾，属湿热下迫的多。补脾补肾的方法，只有久泻而无积滞腹痛的可用，不是夏秋痢疾所能用的。然而又不可轻易使用涩药，过早投用兜涩，积聚不去，多至死亡。更要慎用参、芪，误服则为胀满，误服升麻，即为噤口痢（不能进食）。只有气虚下陷的适宜使用，否则下焦湿热与积滞，升至上焦，是速死之道。饮食中的油腻、酒面，尤其应该禁戒。凡痢疾期间喝酒则难愈，痊愈后喝酒则复发。痢疾中最危险的，莫过于噤口痢。大抵初起噤口，多属湿瘀热郁，胃气伏而不宣，脾气因而涩滞，宜用香连枳朴之类，清疏肠胃。也有积秽在下，浊气薰蒸的，宜攻下，如香连加大黄。如果久痢导致噤口，是胃气虚惫，独活、理中汤尚难为力。如果脉细弱的，宜用人参白术散（人参、茯苓、白术、扁豆、山药、米仁、桔梗、陈皮、砂仁、莲肉、甘草、大枣），加菖蒲末，米饮调下。沈金鳌说石菖蒲治噤口痢，屡试屡效。古人说胃虚有火，丹溪用人参、川连、石莲、粳米，加姜汁，细细呷之。如果吐了再服。或用姜炒川连、人参汤和之。叶氏半夏泻心汤，减去大枣、甘草守中之品。又有休息痢，乃屡次停止屡次发作，经年累月，未能霍然痊愈的。多因兜涩太早，湿热未清，加上调养失宜，或因饮食不节，遂令脏腑受伤，漫无止期，用补中益气汤最为妥当，有加肉果、木香，吞驻车丸的。也有阴虚多火，不能胜任升麻、木香、白术的，只用驻车丸，加人参、乌梅之类。有积滞加枳实、楂炭。积热未清，用清六丸（滑石、甘草、红曲），加香连。又有疟后痢，痢后疟，疟痢并作的。既然疟疾之后得痢疾，非表邪内缩，即元气下陷，此似痢非痢证。如果多食肉面，也有疟后痢，宜葛根、炒麦芽、六神曲之类化解它。既然痢疾之后得疟疾，是邪从外达，迎其机而达之即可。初起即疟痢并作，即宜专用发散，如荆芥、防风、柴胡、葛根，佐以赤苓、神曲。血痢则参加当归、川芎，使在腑之邪，提并于经而外解之。如果不应，则辨其挟热挟寒，表里分消之。热者去荆、防，加芩、连。寒者去柴、葛，加桂、姜。下痢兼证，也应当辨别。如痢而呕吐的，胃气不和，宜加姜炒川连、竹茹、广郁金。虚则加参。因食消导它，因痰化除它。有痢而小便不通的，由邪热在里，迫于大肠，必郁结于膀胱，则气不化，宜清膀胱之热，兼清肺气。喻氏有急开支河一法，令气化行，而厘清其热势也。以小便涩痛，方是真热，轻者用六一散，凉水调服亦效。有兼大孔（肛门）痛的，须辨其新久寒热。热留于下，黄芩芍药汤清之。虚寒而痛，理中汤温之。此证宜食淡味，可用薰法，以熟艾、黄蜡、诃子烧烟薰之。热则肛门闭，寒则肛门脱。所以兼脱肛的，虚寒多而实热少也。如果久痢寒滑脱肛，宜诃子皮散（诃子、粟壳、炮姜、橘红）一法，以磁石末食前米饮下。外以铁锈汤洗肛门。有痢后呃哕（打嗝），为胃气虚寒，最为恶候，橘皮干姜汤（陈皮、干姜、竹茹）。误食生冷而呃的，理中加丁香。这是秀积年经验，并参考吴云峰心得治痢法也。
【廉勘】伤寒变为痢疾，而痢疾也能化为伤寒。既然夹带下痢，还应当辨别下痢的颜色，参合外在证候，才不至于误治。如初起里急后重，痢下色白，此为湿热凝滞，气分受邪，宜胃苓汤加香砂。兼热的，加炒黄芩、滑石。色如豆汁的，也属脾中湿热，燥脾分利，也宜胃苓汤为主。或如鱼脑及鼻涕冻胶的，脾虚冷痢也，宜二术、炮姜等味。如白脓努责而出的，气与热结也，宜木香、槟榔、黄芩之类。如屋漏水尘腐色的，皆元气虚惫也，宜理中汤，加煨葛根、炒黄芩、茯苓。至于赤痢为血分之邪，湿热多的，以行湿清热为主，如炒黄芩、炒银花、滑石、木香、楂炭之类。兼见紫块或稠粘的，用黄芩、延胡索、桃仁、赤芍，行瘀治之。若血色鲜浓紫浓的，则为热盛，宜用白头翁汤。或初起势盛，里急后重，脉有力的，加制大黄下之。若纯下清血，而脉弦的，风入胃也，宜用炒枳壳、荆芥炭、煨防风。血色紫黯，屡服凉药，而血愈多的，寒湿也，宜理中汤，加芎、归、木香。或如猪肝，如苋菜汁的，皆寒也，非炮姜不治。若血色稀淡，或如玛瑙色的，为阳虚不能制阴而下，非温理其气，则血不清也。若辨黄黑二色，凡深黄而秽臭的，热证也。浅黄色淡不甚臭，或兼腥馊气的，寒证也。黑而焦浓浓大臭的，火证也。黑如漆光的，瘀血也。若青黑而腥薄的，肝肾腐败之色也。又有五色痢，亦有虚有实。丹溪说脾胃有食积，及四气相并，则痢有五色之相杂，当先通利，宜归连丸（当归、黄连、黄柏、黄芩、阿胶、熟艾）。也有因湿毒内盛的，马元仪说五色痢，乃五脏之气化并伤，而治法则求之于肾，仲景所谓五液注下者是也。宜益火消阴，实脾堤水，兼分理其气，或可救其万一。张三锡说诸痢坏证，久下脓血，或如死猪肝色，或五色杂下，俗名刮肠痢，乃脏腑俱虚，脾气下脱，若再投痢药则误矣，宜用真人养脏汤。大抵下痢属里证，不当更见表热，如头痛身热之类。若表证有热，则外内俱困，故俞氏治法，以先撤表邪，冀清其痢，举其一以例其余，亦可谓扼要之论也。
【荣斋按】本节廉臣先生的勘语，是指湿热痢、虚寒痢而言，不是指夹伤寒的痢。他在《名医验案类编》中，却帮助了伤寒夹痢的治法，特录于下：“痢疾见头痛怕冷，身热无汗的，均属有表，当从汗解。如口舌不燥渴，胸腹不闷痛，舌或无苔，或淡白且滑，宜活人败毒散（茯苓、枳壳、桔梗、柴胡、羌活、独活、川芎各一两，甘草五钱加薄荷少许。）每服五钱，日夜连进三五服，姜汤煎，热服取汗，汗透而痢便减。若见燥渴，唇舌红赤，舌上黄燥或滑，面色腻滞，心烦，小便热赤的；为湿热暑湿之邪，宜胃苓汤（苍术、浓朴、陈皮、甘草、白术、泽泻、猪苓、茯苓、官桂。）去官桂，加香薷、薄荷、连翘、滑石、淡豆豉，六神曲等；连进三五服，得汗透而痢自止。”这治法是针对“夹痢伤寒”而设，移作补充，更见完备。”
(Also known as Cold Damage complicated with Dysentery)
[Etiology] Dysentery was anciently called "Zhi Xia" (Stagnant Downward Flow). It is generally caused by the entanglement of Summerheat-Dampness and food retention in the intestines, obstructing the flow of Qi. Alternatively, after a heavy meal of rice, meat, and rich/fresh foods, consuming raw or cold fruits and vegetables causes the Qi and Blood of the Spleen and Stomach to fail to circulate normally to the four limbs and all meridians, seeping into the stomach and intestines to become dysentery. Subsequently, exterior pathogens are contracted, presenting with fever, aversion to cold, and headache; or it may be contracted from seasonal epidemic pathogens becoming dysentery; or exterior pathogens may sink inward and transform into heat, resulting in dysentery.
[Signs and Symptoms] In cases where dysentery is complicated by Cold pathogens, symptoms include tenesmus (urgent desire to defecate with a feeling of incomplete evacuation), abdominal pain that may or may not be present, aversion to cold, headache, fever, or alternating chills and fever with nausea. The tongue coating is thick and greasy, there is thirst but no desire to eat, and the condition varies greatly.
[Pulse] A pulse that is fine, small, slippery, and smooth indicates a good prognosis for dysentery. A floating, wiry, surging, or rapid pulse indicates a poor prognosis. A floating and large pulse suggests the disease will not cease; a weak and thready pulse suggests spontaneous recovery. This applies to cases without exterior pathogens. Generally speaking: if dysentery is accompanied by an exterior pathogen, and in the early stage there is fever and a floating pulse, the exterior should be resolved first. If in the early stage there is fever and a deep pulse, purgation may be used. In chronic dysentery with fever and a deficient pulse, it belongs to deficiency of healthy Qi but is treatable. In chronic dysentery with fever and a large pulse, it belongs to excess of pathogenic factors and is difficult to treat.
[Treatment] For dysentery complicated by exterior pathogens, similar to seasonal epidemic dysentery, there is fever. However, the exterior pathogen must be resolved first, addressing symptoms like aversion to cold, headache, and fever. Following the nature of the exterior pathogen, disperse and scatter it. Once the exterior pathogen is resolved, the dysentery will also lighten. For example, Canlin Tang (Ginseng Decoction [Ren Shen, Fu Ling, Gan Cao, Chai Hu, Qiang Huo, Du Huo, Zhi Ke, Jie Geng, Chuan Xiong, Bo He, Sheng Jiang, Chen Lin Mi]) resolves the exterior and transforms stagnation, naturally leading to cooling of the body and cessation of dysentery. For cases due to Damp-Heat, treat with Bitter-Pungent-Cold herbs. Bitter herbs dry Dampness, and Cold herbs clear Heat. Add slightly Pungent-Hot herbs as assistants to facilitate dispersion and circulation. This method is invariably effective. For disorders of Qi, regulate Qi; for disorders of Blood, harmonize Blood. Mr. Shao stated that for disorders in the Qi level, use Bitter-Pungent methods to regulate Qi, and Pungent-Sweet methods to benefit Qi. For disorders in the Blood level, use Bitter-Pungent methods to move Blood, and Salty-Soft methods to nourish Blood. When treating red dysentery, Qi-regulating herbs are indispensable because moving Qi stops Blood. When treating white dysentery, Blood-harmonizing herbs must be avoided to prevent drawing pathogens into the Blood level, which could worsen pus and blood. This is crucial knowledge for treating dysentery.
[Commentary by Xiu] Dysentery is generally considered Red as Heat and White as Cold. However, White often belongs to Damp-Heat, resembling rotting flesh turning to pus. Red can also belong to Cold-Damp, due to Blood stasis and stagnation entering the intestines. One cannot distinguish Cold/Heat solely by color; one must examine the tongue coating and pulse. Generally, Red belongs to Blood and originates from the Small Intestine; White belongs to Qi and originates from the Large Intestine. Mixed Red and White indicates both Qi and Blood are diseased. Heart governs Blood, Lung governs Qi. Stagnation injures Qi, Stagnant Heat injures Blood. Once Qi and Blood are diseased, Heart and Lung are affected. The Small Intestine is the interior-exterior pair of the Heart; the Large Intestine is the interior-exterior pair of the Lung. These two meridians are officials responsible for receiving/transmitting water/grain and transporting waste. The Stomach is the general manager of the Small and Large Intestines. Disease transferring from Lung to Large Intestine causes Qi stagnation/stiffness, resulting in White Dysentery. Disease transferring from Heart to Small Intestine causes Blood stagnation/stiffness, resulting in Red Dysentery. If both intestines are diseased, Red and White pass together. The coagulation of Blood and Qi must carry dietary retention and phlegm-fluids to form stagnation. These dietary retentions and phlegm-fluids gather in the Stomach; thus, dysentery is never separate from the Stomach, implying pathology moves from Heart/Lung to Stomach. This analyzes the cause of dysentery. Further analyze signs/symptoms to determine therapy. Regarding "tenesmus," the pathology is at the lowest part of the Rectum (Guang Chang). "Li Ji" (internal urgency) and "Hou Zhong" (anal heaviness) are different. Li Ji is urgent desire to defecate; Hou Zhong is heavy bearing down sensation. Li Ji has Deficiency/Excess types: Excess is surplus Fire pathogen; Deficiency is insufficiency of Ying-Yin. Urgency without ability to defecate is Fire; severe cases use Chengqi Tang, mild cases use Shaoyao Tang. Chronic appearance indicates Qi collapse. Urgency but inability to pass stool at the toilet indicates Qi stagnation; treat primarily with unblocking. Hou Zhong also has Deficiency/Excess differences: Excess is pathogenic pressure downward; Deficiency is Qi sinking. Pathogenic pressure on Large Intestine prevents lifting, causing bearing down; use Da Huang, Bing Lang, or Xianglian Wan to purge the pressing pathogen. If stagnation has passed but Hou Zhong persists, with weak pulse and anorexia, this is Spleen Qi sinking or Large Intestine deficiency/slippage unable to contract; treat with lifting and astringent agents to secure collapse and lift sinking. How to differentiate? If Hou Zhong is due to pathogenic pressure, it lessens slightly after defecation but returns severely shortly after (Rongzhai notes: "returns severely shortly after" might be a typo for "not long after"). If Hou Zhong is due to deficiency/slippage, it does not lessen after defecation and worsens due to further depletion. Also, if Hou Zhong occurs after stagnation clears and overconsumption of meat/noodles/raw-cold foods, treat primarily with Spleen-moving and digestion-promoting methods. However, empty straining without stool indicates Blood deficiency; double the dose of Siwu Tang, add Xinhui Pi (Chen Pi), harmonize Stomach, generate Blood, and peace will return. If Hou Zhong persists after dysentery, use Sanqi San (Zhi Ke, Huang Bo, Fang Feng), which is excellent. If passing pus/blood, tenesmus, frequent day/night, or thirst, use Daoqi Tang (Bai Shao, Da Huang, Gui Wei, Huang Qin, Huang Lian, Mu Xiang, Zhi Ke). If passing mixed red/white, tenesmus, use Xianglian Wan or Muxiang Binglang Wan, selecting based on syndrome differentiation. For cold-heat imbalance, tenesmus, abdominal pain, thirst, and difficult urination, use Huanglian Ejiao Wan (Huang Lian, Ejiao, Fu Ling; remove Fu Ling, add Huang Bo, Shan Zhi; named Huanglian Ejiao Tang by Haicang). Tenesmus requires regulating Qi. If accumulation and Qi sink together, combine lifting and dispersing. After using Chengqi-type purgatives, if tenesmus persists, Yang Qi is not ascending; add Sheng Ma to lift Yang, and heaviness will resolve. Abdominal pain also varies by cold/heat/deficiency/excess. Excess pain is either food retention or Fire pathogen. Food retention causes pain and refusal of pressure; if pulse is surging/excessively strong with hard distension, it is stagnation pain. Fire pathogen fears heat/likes cold, pulse is surging/rapid, thirst likes cold, with heat signs; this is Fire pain. Excess pathogens in the middle often cause Qi rebellion; thus, pain treatment focuses on moving Qi. Resolve food retention, clear Fire. Danxi said early onset can use Dachengqi Tang or Tiaowei Chengqi Tang. Assess Qi vs. Blood disorder, then modify. For dysentery pain relief, use Rushen Tang (Chuan Lian, Zhi Ke, Huai Hua) or Shaoyao Gancao Tang (Bai Shao, Gan Cao). For heat pain, add Huang Qin, Huang Lian. For deficiency-cold pain, warm the viscera is suitable. Cold in Middle Jiao warms Spleen; Cold in Lower Jiao warms Kidney. Differentiate by refusal/appreciation of pressure and preference/dislike of cold. Insisting on "no tonification for pain" ignores deficiency pain; attacking more increases deficiency and pain. Ancients said dysentery followed by diarrhea (Kidney to Spleen) is easy to treat; diarrhea followed by dysentery (Spleen to Kidney) is hard to treat. Ye Tianshi said Mingmen Fire decline causes diarrhea, not dysentery. Also, Cold has no upward-pushing nature; Fire is rapid, hence downward pushing. Spleen/Kidney Qi deficiency causes diarrhea. Summer/Autumn dysentery is mostly Damp-Heat pushing downward. Tonifying Spleen/Kidney is only for chronic diarrhea without stagnation/abdominal pain, not for Summer/Autumn dysentery. Do not lightly use astringents; early astringency retains stagnation, leading to death. Use Ren Shen, Huang Qi cautiously; misuse causes distension. Misuse of Sheng Ma causes Jin Kou Li (Anorexic Dysentery). Only appropriate for Qi sinking; otherwise, Lower Jiao Damp-Heat/stagnation rises to Upper Jiao, causing rapid death. Avoid oily foods, alcohol, noodles. Alcohol during dysentery hinders cure; after cure, triggers recurrence. Most dangerous is Jin Kou Li. Early Jin Kou Li is usually Damp-Stasis-Heat depression, Stomach Qi trapped/not diffusing, Spleen Qi stagnant; use Xianglian Zhipu type to clear/disperse gut. If filth below steams turbidity, purge it, e.g., Xianglian plus Da Huang. Chronic Jin Kou Li indicates exhausted Stomach Qi; Duhuo, Lizhong Tang are insufficient. If pulse is fine/weak, use Renshen Baizhu San (Ren Shen, Fu Ling, Bai Zhu, Bian Dou, Shan Yao, Yi Yi Ren, Jie Geng, Chen Pi, Sha Ren, Lian Rou, Gan Cao, Da Zao) plus Chang Pu powder, taken with rice drink. Shen Jinao said Shi Chang Pu treats Jin Kou Li effectively. Ancients said Stomach deficiency with Fire: Danxi used Ren Shen, Chuan Lian, Shi Lian, Jing Mi, plus Ginger Juice, sipped slowly. If vomited, re-administer. Or use Ginger-fried Chuan Lian with Ren Shen decoction. Ye's Banxia Xiexin Tang, removing Da Zao/Gan Cao (middle-harmonizing items). There is also Resting Dysentery (Xiuxi Li), recurring repeatedly over years, not fully cured. Often due to early astringency, unresolved Damp-Heat, improper care, or irregular diet injuring organs, endless duration. Buyi Yiqi Tang is best, possibly adding Rou Guo, Mu Xiang, swallowing Zhuche Wan. For Yin deficiency with much Fire, unable to tolerate Sheng Ma, Mu Xiang, Bai Zhu, use only Zhuche Wan plus Ren Shen, Wu Mei. With retention, add Zhi Shi, Zha Tan. With unresolved retention-heat, use Qingliu Wan (Hua Shi, Gan Cao, Hong Qu) plus Xianglian. Post-Malaria Dysentery, Dysentery post-Malaria, or simultaneous Malaria-Dysentery. Post-Malaria dysentery implies exterior pathogen sinking or Yuan Qi sinking; this resembles dysentery but isn't true dysentery. Overeating meat/noodles can cause post-malaria dysentery; use Ge Gen, fried Mai Ya, Liu Shen Qu to transform. Post-dysentery malaria implies pathogen exiting outward; guide it out according to its mechanism. Simultaneous onset requires exclusive dispersing: Jing Jie, Fang Feng, Chai Hu, Ge Gen, assisted by Chi Fu Ling, Shen Qu. For blood dysentery, add Dang Gui, Chuan Xiong to lift pathogen from Fu organs to Jing meridians for exterior resolution. If ineffective, differentiate Cold/Heat, resolve exterior/interior separately. Heat: remove Jing/Fang, add Qin/Lian. Cold: remove Chai/Ge, add Gui/Jiang. Differentiate dysentery complications. Vomiting with dysentery indicates Stomach disharmony; add Ginger-fried Chuan Lian, Zhu Ru, Guang Yu Jin. Deficiency: add Ren Shen. Resolve food, transform phlegm. Dysentery with urinary obstruction: interior Heat pathogen presses Large Intestine, stagnates in Bladder, Qi fails to transform. Clear Bladder Heat, assist Lung Qi. Yu Shi's method of "opening side channels" promotes Qi transformation and clears Heat. True Heat presents with painful/scanty urination; mild cases use Liuyi San, taken with cool water. Anal pain: differentiate new/old, cold/heat. Heat lingering below: Huangqin Shaoyao Tang clears it. Deficiency-cold pain: Lizhong Tang warms it. Diet should be bland. Fumigation method: burn Shu Ai, Huang La, He Zi for smoke inhalation. Heat causes anal closure; Cold causes prolapse. Thus, prolapse is mostly deficiency-cold, rarely excess-heat. Chronic cold-slippage prolapse: use Hezi Pi San (He Zi, Su Qiao, Pao Jiang, Ju Hong), take Ci Shi powder with rice drink before meals. Wash anus with Iron Rust Soup. Hiccups after dysentery indicate Stomach deficiency-cold, a bad omen. Jupi Ganjiang Tang (Chen Pi, Gan Jiang, Zhu Ru). Hiccups from raw/cold food: Lizhong Tang plus Ding Xiang. This is Xiu's accumulated experience, referencing Wu Yunfeng's insights.
[Review by Lian] Cold Damage transforming into dysentery, and dysentery transforming into Cold Damage. Since it involves lower dysentery, one must distinguish the color of the discharge and correlate with external signs to avoid misdiagnosis. Early stage tenesmus, white discharge: Damp-Heat stagnation, Qi level pathogen. Use Weiling Tang plus Xiang Sha. With Heat: add fried Huang Qin, Hua Shi. Color like bean juice: Spleen Damp-Heat, dry Spleen, separate fluids; Weiling Tang is primary. Like fish brain or mucus jelly: Spleen deficiency Cold Dysentery. Use Er Zhu, Pao Jiang, etc. White pus with straining: Qi and Heat knot. Use Mu Xiang, Bing Lang, Huang Qin. Like roof leak water or dust/rot color: Vital Qi exhaustion. Use Lizhong Tang, add Wei Ge Gen, fried Huang Qin, Fu Ling. Red dysentery is Blood level pathogen. Mostly Damp-Heat: move Dampness, clear Heat. Fried Huang Qin, fried Jin Yin Hua, Hua Shi, Mu Xiang, Zha Tan. With purple clots or sticky texture: Huang Qin, Yan Hu Suo, Tao Ren, Chi Shao, move stasis. Bright fresh/purple-concentrated blood: Excess Heat. Use Baitouweng Tang. Early severe stage, tenesmus, strong pulse: add processed Da Huang to purge. Pure clear blood, wiry pulse: Wind entering Stomach. Use fried Zhi Ke, Jing Jie Tan, Wei Fang Feng. Purple-dark blood, worsening with cold meds: Cold-Damp. Use Lizhong Tang, add Chuan Xiong, Dang Gui, Mu Xiang. Like pig liver or amaranth juice: Cold. Requires Pao Jiang. Pale/thin blood or agate color: Yang deficiency failing to control Yin. Must warm/regulate Qi to clear Blood. Yellow/Black colors: Deep yellow foul odor: Heat. Light yellow pale slight odor or fishy/sour: Cold. Black scorched thick strong odor: Fire. Black shiny lacquer-like: Blood stasis. Blue-black thin fishy: Liver/Kidney corruption. Five-color dysentery has deficiency/excess. Danxi said food retention in Spleen/Stomach plus four Qi merging causes five-color mixing. First purge/unblock, use Guilian Wan (Dang Gui, Huang Lian, Huang Bo, Huang Qin, Ejiao, Shu Ai). Some due to internal Damp-Toxin excess. Ma Yuanyi said five-color dysentery injures Qi transformation of five Zang organs; treatment seeks Kidney, as Zhang Zhongjing described "five fluids pouring down." Benefit Fire, eliminate Yin, solidify Spleen, dam Water, regulate Qi separately, perhaps save one in ten thousand. Zhang Sanxi said bad syndromes of various dysenteries, chronic pus/blood, or dead pig liver color, or mixed five colors, vulgarly "scraping intestine dysentery," indicates total organ deficiency, Spleen Qi collapse. Further dysentery drugs are errors; use Zhenren Yangzang Tang. Generally, dysentery is Interior syndrome, do not expect Exterior Heat like headache/fever. If exterior heat exists, interior/exterior are both distressed. Thus Yu's method prioritizes resolving exterior pathogen to clear dysentery, exemplifying key points.
[Rongzhai Note] Mr. Lianchen's review here refers to Damp-Heat Dysentery and Deficiency-Cold Dysentery, not Cold Damage complicated with dysentery. In "Mingyi Yan Lei Bian," he aids the treatment of Cold Damage complicated with dysentery, recorded below: "Dysentery with headache, aversion to cold, fever, no sweating: all indicate exterior pathogen, resolve via sweating. If mouth/tongue not dry/thirsty, chest/abdomen not stuffy/painful, tongue no coating or pale/white/slippery: use Huoren Baidu San (Fu Ling, Zhi Ke, Jie Geng, Chai Hu, Qiang Huo, Du Huo, Chuan Xiong 1 liang each, Gan Cao 5 qian, plus little Bo He). Take 5 qian per dose, 3-5 doses day/night, decoct with Ginger Water, take hot to induce sweat. Sweat penetrates, dysentery reduces. If dry/thirsty, red lips/tongue, yellow/dry or slippery coating, greasy complexion, vexation, hot/red urine: Damp-Heat/Summerheat pathogen. Use Weiling Tang (Cang Zhu, Hou Po, Chen Pi, Gan Cao, Bai Zhu, Ze Xie, Zhu Ling, Fu Ling, Guan Gui). Remove Guan Gui, add Xiang Ru, Bo He, Lian Qiao, Hua Shi, Dan Dou Chi, Liu Shen Qu. Take 3-5 doses continuously. Sweat penetrates, dysentery stops." This treatment targets "Cold Damage complicated with Dysentery," added as supplement, making it more complete."