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Danxi said: Someone asked, "In Hejian's discussion on 'Zhixia' (Dysentery), it seems there is no mention of conditions complicated by deficiency and cold. Is this correct?" I replied: "For diseases such as diarrhea and dysentery, food and water may or may not be digested, yet there is no sensation of straining during defecation; one only feels fatigued and weak. However, for Zhixia, this is not the case. One may pass pus, blood, a mixture of pus and blood, intestinal mucus, feces without residue, or feces mixed with residue. Although there are differences in pain—some painful, some not, some severely painful, some mildly painful—all share the symptom of tenesmus (abdominal urgency with heavy sensation in the anus and unsatisfactory passage). This feeling is oppressive and distressing, appearing to be exclusively heat excess patterns. In my recent clinical experience, however, there have been cases of severe deficiency and cold that must be known. I record these briefly for reference."

My uncle, over fifty years old, suffered from Zhixia in summer. His abdomen was slightly painful, he passed brownish stools, experienced frequent tenesmus, his appetite decreased significantly, and he occasionally had a slight fever. His pulse was wiry and choppy in both hands, resembling rapidity and slightly long, but notably not floating or large. His spirit and qi were markedly diminished. I said, "This Zhixia is caused by worry, leading to heart blood deficiency and spleen qi weakness." Therefore, I used Ginseng Radix et Rhizoma (Renshen) and Atractylodis Macrocephalae Rhizoma (Baizhu) as sovereign herbs, Angelicae Sinensis Radix (Danggui) and Citri Reticulatae Pericarpium (Chenpi) as minister herbs, Ligusticum Chuanxiong Rhizoma (Chuanxiong), fried Paeoniae Radix Alba (Shaoyao), and Poria (Fuling) as assistant and envoy herbs. Given the intense summer heat, I added a small amount of Scutellariae Radix (Huanglian). He recovered after two months.

Official Lou, in his thirties, who lived luxuriously, suffered from Zhixia in late summer and autumn. His abdomen hurt severely. Someone advised him to boil dried ginger alone and take one dose, which stopped the pain. Shortly after, the pain returned; upon giving it again, the pain ceased. Consequently, he consumed three jin of dried ginger. Eight days later, examination showed his left pulse was wiry and slightly large, resembling rapidity; his right pulse was wiry and large, slightly reduced, also resembling rapidity. Deep pressure felt tight. I said, "This must be due to excessive intake of cold foods after drinking and eating heavily. It should be treated as a deficiency-cold pattern. Since he has already taken much dried ginger, I advise using Siwu Decoction (Four Substances Decoction) minus Rehmanniae Radix Preparata (Shudihuang), adding Ginseng Radix et Rhizoma (Renshen), Atractylodis Macrocephalae Rhizoma (Baizhu), Citri Reticulatae Pericarpium (Chenpi), Safflower (Honghua) prepared with wine, Poria (Fuling), and Peach Kernel (Taoren). Decoct with fresh ginger juice. He recovered after one month."

Madam Jin, nearly forty years old, contracted Zhixia in early autumn while it was still hot. Her abdomen had only dull pain, worse at night, preventing sleep entirely. Her diet decreased slightly. She complained of dry mouth but did not desire to drink. She had already taken two doses of Lingsha (a specific formula/powder for treating dysentery). Upon observation, her pulses in both hands were choppy and irregular. Her mental state was extremely fatigued, and she ate nothing. I prescribed Siwu Decoction (Four Substances Decoction) with doubled Atractylodis Macrocephalae Rhizoma (Baizhu), assisted by Citri Reticulatae Pericarpium (Chenpi). After taking more than ten doses, she recovered. If these three cases had been treated with harsh purgatives merely because of the patient's sense of oppression, it would have been a mistake.

Note: Ancient texts often discussed Zhixia together with loose stools/diarrhea. It was not until *San Yin Fang* (Treatise on the Causes and Manifestations of All Diseases) that it was established as a separate category, as there are indeed differences. Some diseases arise from external pathogens; one must distinguish the six climatic factors. Once the exterior is injured and the intestines and stomach become stagnant, red and white dysenteric stools form. Treatment should follow the principles of warming, cooling, etc. Some arise from internal organ dysfunction affecting the intestines and stomach; one must identify the affected zang-organ and treat accordingly. Others result from dietary indiscretion; one must identify the offending food and use resolving methods. The causes of this disease in the world generally fall into these three categories. However, once ill, the intestines and stomach are obstructed, pus and blood are thick and sticky, and tenesmus occurs. Although various formulas discuss cold, heat, deficiency, and excess, Liu Hejian argued that all stem from heat. Examining the *Neijing* (Inner Canon), it seems heat is more common than cold. My teacher, Danxi, believed there are also cases complicated by deficiency and cold, deeply warning students to recognize this. Local formularies (*Jufang*) fail to differentiate the three causes and exclusively use astringent and warming drugs, which is a great error. Conversely, Hejian’s theory relies solely on bitter-cold draining drugs, which is also not entirely appropriate. Why? Because diseases have deficiency and excess, and treatment has sequence. If pathogenic qi arrives suddenly and the primal qi is strong with stubborn stagnation, purging is indicated. If the disease is prolonged, qi is depleted, and the intestines and stomach are deficient and slippery, warming and astringing are indicated. Generally, treating dysentery should follow the methods of Zhang Zhongjing and Liu Hejian: warm if suitable, purge if suitable, release the exterior, promote urination, or wait for self-healing. Liu Hejian categorized syndromes by exterior/interior, wind, heat, and cold. Later authors did not exceed these categories. However, the distinction between qi and blood was not explicitly theorized. Under Shaoyao Tang (Peony Decoction), he stated: "Moving blood makes pus discharge heal; regulating qi eliminates tenesmus." This implies that bloody pus is due to blood stasis, hence moving blood heals it; tenesmus is due to qi excess/stagnation, hence regulating qi eliminates it. This is true. However, red and white pus/blood can be distinguished by qi or blood pathology, and tenesmus can be distinguished by qi excess or blood deficiency. Students must examine this carefully. See previous discussions for details.