经曰。脉盛。皮热。腹胀。前后不通。瞀闷。此谓五实。夫脾胃气滞不能转输。加以痰饮食
积阻碍清道。大小便秘涩不快。二陈汤加升、柴、二术。数服。能令大便润而小便长。湿热痰火
结滞。脉洪盛。大小便秘赤。肢节烦疼。凉膈散、小承气汤选用。阴囊肿胀。二便不通。三白散。
大小便俱不通。小腹膨胀。乃膀胱溺满。支撑回肠。故并大便不得出。用二陈倍茯苓加泽泻、木
通先利小便。回肠得通。而大便随出矣。风闭。用烧皂肉灰为末。粥清调下。或烧汤蒸下部良。
冷闭。用连根葱一二茎。带土生姜一块。淡豆豉二十一粒。盐二匙。同研烂作饼。烘热掩脐中。
以帛扎定。良久于饼上灸之。热闭。用田螺捣烂。加麝香一分。冰片半分。入脐中。以帛束之。
如人行十里即通。
石顽曰。肥人素多痰饮湿热结聚。因病每致大小便不通。腹满不食。气逆喘急。势盛不得不下。
有屡下不得通利者。有再三下而始通者。有下之利不止者。大抵湿热素盛之人。大便不行。日数
虽多。结粪甚少。所下不过溏粪垢腻。甚至骤下不可遏者。多有热去寒起。正气随脱。即变呃逆
之证。以此本属湿热。温补仍助本病。苦寒徒乏胃气。每至不可救药。若始先知其湿热痰积。用
导痰汤多加姜汁、竹沥。下滚痰丸。甚则下控涎丹。方为合法。若迟则湿热上涌势剧。胃中津液
尽变浊秽。虽有合剂。不能取效也。凡大便不通而腹中雷鸣者。下之必无结粪。盖肥人下后。多
有脱泄不止之虞。瘦人汗后。每多干热不止之患。不可不知。
丹溪治一老人。因内伤挟外感。自误发汗。脉浮数。年高误汗。必有虚证。乃与参、术、归、
、甘草、陈皮等。自言从病不曾更衣。今虚迸痛不堪。欲用利药。朱谓非实秘。气因误汗而虚。
不得充腹。无力可努。仍用前药。间与肉汁及锁阳粥。浓煎葱椒汤浸下体。下软块五六枚。脉大
未敛。血气未复。又与前药。二日。小便不通。小腹满闷烦苦。仰卧则点滴而出。朱曰。补药未
至。倍参、术。服二日。小便通。半月而愈。
又治一妇人脾疼。后患大小便不通。此是痰隔中脘。气聚上焦。二陈加木通。初服探吐。再
服而愈。
汪石山治一妇。因忧惧劳倦。小腹胀满。大小便秘结不通。医以硝、黄三下之。随用随秘。
反增胸腹胃脘胀痛。自汗食少。汪诊之。脉皆濡细而数。曰。此劳倦忧惧伤脾也。盖脾失健运之
职。故气滞不行。前药但利血而不能利气。遂用人参二钱。归身钱半。陈皮、枳壳、黄芩各七分。
煎服而愈。
喻嘉言治一人。大小便俱不通。因新秋病疟。三五发后。用药截住。遂觉胸腹间胀满日增。
不旬日外。腹大胸高。上
气喘急。二便全无。食饮不入。能坐不能卧。能俯不能仰。屡服下药不应。商用大黄二两作一剂。
喻曰。此名何病。而敢放胆杀人耶。医曰。伤寒肠结。下而不通。惟有大下一法。何谓放胆。曰。
世间有不发热之伤寒乎。伤寒发热。津液枯槁。肠胃干结。故用下药以开其结。然有不转失气者
不可攻之戒。正恐误治太阴之腹胀也。此因腹中之气。散乱不收。津水随气横决四溢而作胀。全
是太阴脾气不能统摄所致。一散一结。相去天渊。再用大黄猛剂大散其气。若不胀死。定然腹破。
遂以理中汤少加黄连。疾势略减。次日用五苓散本方。药才入喉。病者即索秽桶。小便先去。大
便随之。腹中原是大黄推落之泄粪。其所以不出者。以膀胱胀大。腹内难容。将大肠撑紧。无隙
可出耳。石顽治杨松龄。夏月感冒。曾服发散药十余剂。大小便俱闭涩不通。更一医。用硝、黄
下之。少腹左畔遂胀起如墩。不赤不热。有时哗哗作声。复延疡医。以敷药治其外。以解毒利水
药治其内。药未进而躁扰不宁。因延石顽诊之。六脉紧细而快。此过汗津液大伤。又与苦寒攻里。
致阴邪内结。膀胱不化。溺积不通。法在不救。幸胃气有权。形神未槁。尚能稍进糜饮。姑许以
治。因与济生肾气大剂。煎成入有嘴壶。托起其项。徐徐仰灌升许。顷令转侧。以鹅翎探吐。即
时溲便如注。少腹顿平。更与十全大补调理而安。此证前后患者四五人。或小便淋沥。或遗溺不
止。或形羸气脱。皆立辞不治。
《黄帝内经》中说：脉象盛大，皮肤发热，腹部胀满，大小便不通畅，神志昏蒙烦闷，这叫做“五实”证。如果脾胃气机阻滞，不能正常转输运化，再加上痰湿、饮食积滞阻碍了清阳之道，导致大小便秘涩不畅，可用二陈汤加入升麻、柴胡、白术、苍术。服用几剂后，能使大便滋润而小便通长。若是湿热、痰火结滞，脉象洪大盛实，大小便颜色红赤，肢体关节烦痛，可选用凉膈散或小承气汤。若出现阴囊肿胀，大小便不通，可用三白散。
大小便都堵塞不通，小腹胀满膨隆，这是因为膀胱尿液充盈，支撑压迫回肠，所以大便也无法排出。此时应用二陈汤加倍茯苓用量，再加入泽泻、木通先通利小便，待回肠通畅后，大便自然随之排出。
对于风邪闭阻引起的便秘，可将烧过的皂角肉灰研成粉末，用米粥的清汁调服；或者将皂角烧汤熏洗下部，效果良好。对于冷邪闭阻，取带根的葱一二根，带土的生姜一块，淡豆豉二十一粒，盐两匙，一同捣烂做成饼状，烘热后敷在脐中，用布帛扎紧固定。过一段时间后，在药饼上施灸。对于热邪闭阻，将田螺捣烂，加入一分麝香、半分冰片，填入脐中，用布束紧。大约行走十里路的时间，大便即可通畅。
张石顽说：肥胖之人平时多痰饮湿热积聚，因病往往导致大小便不通，腹部胀满不想进食，气逆喘急，病情严重时必须使用下法。有的多次攻下仍不通利，有的经过反复攻下才通畅，有的攻下后腹泻不止。大抵湿热素来旺盛的人，虽然几天不大便，但结聚的粪便很少，排出的不过是稀溏污秽的粪便。甚至突然腹泻无法遏制时，多有热去寒生，正气随之脱失，进而变成呃逆的症状。因为此病本属湿热，温补会助长病邪，苦寒又会徒然损伤胃气，往往导致不可救药的局面。如果起初就知道是湿热痰积，应使用导痰汤多加姜汁、竹沥，再服用滚痰丸，严重时服用控涎丹，这才是合法的治疗。如果延误时机，湿热上涌，势头剧烈，胃中津液全部变为浊秽之物，即使有合适的方剂，也不能取效。凡是大小便不通且腹中肠鸣如雷的，攻下必定没有干结的粪便。大概肥胖之人攻下后，多有脱泄不止的忧虑；瘦人发汗后，每多出现干燥发热不止的祸患，这些不可不知道。
朱丹溪治疗一位老人，因内伤兼外感，自己误用发汗法，脉象浮数。年高之人误用汗法，必然出现虚证，于是给予人参、白术、当归、（此处原文缺字，推测为地黄或类似补血药）、甘草、陈皮等药物。病人自述从生病以来未曾排便，现在因虚弱迸裂般疼痛难以忍受，想用通便药。朱丹溪认为这不是实证便秘，而是因为误汗导致气虚，气虚不能充盈腹部，无力努责排便，仍然使用前面的补益药物，偶尔给予肉汤和锁阳粥，浓煎葱椒汤浸泡下肢，最终排出软块五六枚。此时脉象宏大未收敛，血气未恢复，又继续给予前面的药物。两天后，小便不通，小腹胀满烦苦，仰卧时点滴而出。朱丹溪说：“补药未到见效之时”，加倍人参、白术用量，服用两天后，小便通畅，半个月痊愈。
又治疗一位妇人脾疼，后来患大小便不通，这是痰湿阻隔中脘，气聚于上焦，用二陈汤加木通。初次服用引发呕吐，再次服用而痊愈。
汪石山治疗一位妇人，因忧惧劳倦，小腹胀满，大小便秘结不通。医生用芒硝、大黄三次攻下，随下随秘结，反而增加胸腹胃脘胀痛，自汗食少。汪石山诊察，脉象皆濡细而数，说：“这是劳倦忧惧损伤脾气。”因为脾失去健运的功能，所以气机阻滞不行，前面的药物只能利血而不能利气，于是用人参二钱，当归身一钱半，陈皮、枳壳、黄芩各七分，煎服而愈。
喻嘉言治疗一人，大小便俱不通。因初秋患疟疾，发作三五次后，用药强行截断疟疾，随即觉得胸腹间胀满日益增加，不到十天，腹部胀大胸部高耸，上气喘急，大小便全无，饮食不入，能坐不能卧，能俯不能仰。多次服用下药无效。某医生商用大黄二两作为一剂。喻嘉言说：“这是什么病，敢如此大胆杀人吗？”医生说：“这是伤寒肠结，下而不通，只有大下一法，何谓大胆？”喻嘉言说：“世间有不发热的伤寒吗？伤寒发热，津液枯槁，肠胃干结，所以用下药以开通结滞。然而有‘不转失气者不可攻’的戒律，正是担心误治太阴病的腹胀。此病是因为腹中之气散乱不收，津水随着气机横决四溢而作胀，完全是太阴脾气不能统摄所致。一散一结，相差天壤之别。再用大黄猛剂大散其气，如果不胀死，定然腹破。”于是用理中汤少加黄连，病势略微减轻。次日用五苓散原方，药刚入口，病人即索要便桶，小便先去，大便随之排出。腹中原是大黄推落之泄粪，之所以不出，是因为膀胱胀大，腹内难以容纳，将大肠撑紧，无隙可出耳。
张石顽治疗杨松龄，夏季感冒，曾服用发散药十余剂，大小便俱闭涩不通。换了一位医生，用芒硝、大黄攻下，少腹左侧遂胀起如墩，不红不热，有时哗哗作响。又延请外科医生，外用敷药，内服解毒利水药。药未进服，病人躁扰不宁。于是请张石顽诊治，六脉紧细而快，这是过汗导致津液大伤，又与苦寒攻里药，致使阴邪内结，膀胱不化，溺积不通，法在不救。幸好胃气尚存，形神未枯萎，尚能稍进糜饮，姑且答应治疗。于是给予济生肾气汤大剂，煎成后装入有嘴的壶，托起病人的颈部，徐徐仰灌约一升。片刻令其转侧，用鹅毛探吐，即时小便大便如注，少腹顿时平复。更用十全大补汤调理而安。此证前后患者四五人，有的小便淋沥，有的遗溺不止，有的形体羸弱气息脱失，都立即拒绝治疗不予救治。
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: When the pulse is full, the skin is hot, the abdomen is distended, there is obstruction in both the anterior and posterior orifices (urination and defecation), and there is mental confusion and oppression, this is called the "Five Excess" syndrome. If the Qi of the Spleen and Stomach is stagnant and unable to transport and transform, compounded by phlegm-dampness and food stagnation obstructing the clear pathways, leading to constipation and difficult urination, Er Chen Tang (Two-Cured Decoction) with Sheng Ma (Cimicifugae Rhizoma), Chai Hu (Bupleuri Radix), Bai Zhu (Atractylodis Macrocephalae Rhizoma), and Cang Zhu (Atractylodis Rhizoma) can be used. After several doses, it can moisten the stool and promote urination. If damp-heat, phlegm, and fire are knotted and stagnant, with a surging and full pulse, red urine and stool, and painful joints, Liang Ge San (Cool the Upper Jiao Powder) or Xiao Cheng Qi Tang (Minor Order the Qi Decoction) can be selected. If scrotal swelling occurs with obstruction of both bowels, San Bai San (Three Whites Powder) is indicated.
When both bowel movements and urination are blocked, and the lower abdomen is distended and swollen, it is because the bladder is full of urine, pressing against and obstructing the ileum, thus preventing the passage of stool. In this case, use Er Chen Tang (Two-Cured Decoction) with doubled Fu Ling (Poria), plus Ze Xie (Alismatis Rhizoma) and Mu Tong (Akebiae Caulis) to first promote urination. Once the ileum is unblocked, the stool will follow.
For constipation caused by Wind closure, burn soap pod flesh to ash, powder it, and administer with rice gruel water. Alternatively, boil the soap pods and steam the lower part; this is effective. For Cold closure, take one or two green onions with roots, a piece of ginger with soil, twenty-one grains of Dan Dou Chi (Fermented Soybean), and two spoonfuls of salt. Pound them into a paste, make into a cake, heat it, and apply it to the umbilicus. Secure it tightly with cloth. After some time, moxibustion can be applied on top of the cake. For Heat closure, pound fresh snail meat, add one fen of She Xiang (Moschus) and half a fen of Bing Pian (Borneolum Syntheticum), place it in the umbilicus, and bind it with cloth. After walking about ten li, passage will be achieved.
Zhang Shiwen said: Obese people usually have accumulated phlegm-fluids and damp-heat. Illness often leads to obstruction of both bowels, abdominal fullness, anorexia, rebellious Qi causing wheezing and urgency. When the condition is severe, purgatives must be used. Some patients do not achieve relief even after repeated purgations; some require multiple purgations before opening; some suffer from diarrhea that does not stop after purgation. Generally, in those with inherent excess damp-heat, although no stool has passed for many days, the amount of hardened feces is small. What is discharged is merely loose, greasy, and foul-smelling stool. Even sudden, uncontrollable diarrhea may occur, where heat leaves and cold arises, causing the Righteous Qi to collapse, potentially transforming into hiccups. Since the root is damp-heat, warming tonics will aid the disease, while bitter-cold herbs will vainly deplete Stomach Qi, often leading to untreatable situations. If one initially recognizes damp-heat and phlegm accumulation, Dao Tan Tang (Guide Out Phlegm Decoction) with added Jiang Zhi (Zingiberis Rhizoma Preparatum) and Zhu Li (Bambusae Succus) should be used, followed by Gun Tan Wan (Rolling Down Phlegm Pill). In severe cases, Kong Xian Dan (Control Fluid-Ejection Pill) may be used. This is the correct method. If delayed, damp-heat surges upward violently, and Stomach fluids turn into turbid filth; even appropriate formulas will fail. Whenever there is obstruction of both bowels accompanied by borborygmus (rumbling in the abdomen), purgation will yield no hardened feces. It must be known that obese people, after purgation, risk continuous prolapse/diarrhea; thin people, after sweating, often suffer from persistent dryness and heat. These points cannot be ignored.
Zhu Danxi treated an elderly man who suffered from internal injury complicated by external contraction, and mistakenly used diaphoresis. The pulse was floating and rapid. Mistaken sweating in the elderly inevitably causes deficiency. Zhu prescribed Ren Shen (Ginseng Radix et Rhizoma), Bai Zhu (Atractylodis Macrocephalae Rhizoma), Dang Gui (Angelicae Sinensis Radix), Gan Cao (Glycyrrhizae Radix et Rhizoma), and Chen Pi (Citri Reticulatae Pericarpium). The patient stated he had not had a bowel movement since falling ill and now suffered unbearable pain from weakness and straining, desiring laxatives. Zhu reasoned this was not a solid constipation; the Qi became deficient due to mistaken sweating, failing to fill the abdomen and lacking strength to strain. He continued with the previous tonic formula, occasionally providing meat broth and Suo Yang (Cynomorii Herba) porridge, and soaking the lower body in strong decoctions of Cong Bai (Allii Fistulosi Bulbus) and Jiao Hua (Zanthoxyli Pericarpium). Several soft lumps were eventually passed. The pulse remained large and uncollected, and Blood-Qi was not yet restored, so the previous medicine was continued. Two days later, urination stopped, and the lower abdomen became full, oppressive, and distressing; only drops came out when lying supine. Zhu said, "The tonic medicine has not yet taken effect." He doubled the dosage of Ren Shen and Bai Zhu. After two days, urination resumed, and he recovered in half a month.
He also treated a woman with Spleen pain who subsequently developed obstruction of both bowels. This was due to phlegm blocking the Middle Jiao and Qi gathering in the Upper Jiao. Er Chen Tang (Two-Cured Decoction) with Mu Tong (Akebiae Caulis) was used. Induced vomiting after the first dose, and she recovered after the second dose.
Wang Shishan treated a woman whose lower abdomen was full and distended due to worry, fear, and overwork, with constipation of both bowels. A physician used Xiao Shi (Natrii Sulfas) and Da Huang (Rhei Radix et Rhizoma) three times to purge. Each time, obstruction returned immediately, worsening chest, abdominal, and epigastric distension and pain, spontaneous sweating, and poor appetite. Wang diagnosed the pulse as soggy, fine, and rapid, stating, "This is Spleen damage due to overwork, worry, and fear." Because the Spleen lost its function of healthy transportation, Qi stagnated and failed to move. The previous medicines could only benefit Blood but not Qi. He therefore used Ren Shen (Ginseng Radix et Rhizoma) 2 qian, Dang Gui Shen (Angelicae Sinensis Radix) 1.5 qian, Chen Pi (Citri Reticulatae Pericarpium), Zhi Ke (Aurantii Fructus Immaturus), and Huang Qin (Scutellariae Radix) each 0.7 fen. The patient recovered after decocting and taking this mixture.
Yu Jiayan treated a man with complete obstruction of both bowels. He had contracted malaria in early autumn. After three or five episodes, medication was used to forcibly cut off the malaria attacks. Subsequently, chest and abdominal distension increased daily. Within ten days, the abdomen became large and the chest high, with upper body wheezing and urgency. There was no urination or defecation, inability to eat or drink, ability to sit but not lie down, ability to bend forward but not backward. Multiple attempts at purgation failed. A merchant prescribed Da Huang (Rhei Radix et Rhizoma) 2 liang as a single dose. Yu asked, "What disease is this, that you dare to kill so boldly?" The doctor replied, "This is Taiyang Shaoyang transition with intestinal knotting; if purgation fails to open it, only massive purgation works. Why do you call it bold?" Yu said, "Is there such a thing as Taiyang disease without fever? In Taiyang disease with fever, body fluids are depleted, and intestines/stomach become dry and knotted, hence purgatives are used to open the knot. However, there is a warning: 'If there is no passage of flatus, do not attack.' This is precisely to avoid mistreating Taiyin abdominal distension. This case involves scattered and unrestrained Qi in the abdomen, with fluids overflowing wildly causing distension. It is entirely due to Taiyin Spleen Qi failing to control and contain. One is scattering, the other is knotting; they differ as heaven and earth. Using massive Da Huang to further scatter the Qi will either cause death by distension or bursting of the abdomen." He then used Lizhong Tang (Regulate the Middle Decoction) with a small addition of Huang Lian (Coptidis Rhizoma), slightly reducing the severity. The next day, he used Wuling San (Five-Ling Powder) in its original form. As soon as the medicine entered the throat, the patient demanded a chamber pot. Urination occurred first, followed by defecation. The feces in the abdomen were originally expelled by the Da Huang but could not exit because the bladder was distended, leaving no room in the abdomen, pinching the large intestine tight with no space for passage.
Zhang Shiwen treated Yang Songling, who caught a cold in summer and had taken more than ten doses of diaphoretic herbs. Both bowels became closed and difficult. Another physician used Xiao Shi (Natrii Sulfas) and Da Huang (Rhei Radix et Rhizoma) to purge. The left side of the lower abdomen swelled up like a mound, without redness or heat, making gurgling sounds at times. An external surgeon was consulted for topical application and internal detoxification/diuretics. Before the medicine could be taken, the patient became restless and agitated. Zhang Shiwen was then invited. The six pulses were tight, fine, and rapid. This was excessive sweating causing major fluid injury, combined with bitter-cold interior-purging herbs, leading to Yin pathogen internal knotting, bladder failure to transform, and accumulation of urine causing obstruction. The prognosis was hopeless. Fortunately, Stomach Qi still had authority, and form/spirit were not exhausted; he could still consume a little millet drink. Zhang agreed to treat him. He prescribed a large dose of Jisheng Shenqi Wan (Kidney Qi Pill for Salvation). The decoction was prepared in a spouted pot, the patient's neck was supported, and the liquid was slowly poured in while the head was tilted back, about one sheng. Shortly after, the patient was turned over, and a goose feather was used to induce vomiting. Immediately, urine and stool flowed like a torrent, and the lower abdomen flattened instantly. He was then managed with Shiquan Dabu Tang (Ten Substance Great Tonifying Decoction) until he recovered. Four or five other patients with similar conditions had been seen previously; some had dribbling urination, some had continuous enuresis, some had emaciation and Qi collapse. All were refused treatment and abandoned.