Dai Shuang Ming Qiao Fu Qu, Wu Bin

3. Ampicillin is reserved for patients with significantly low white blood cell counts (below 3×10°/L) or those with Shanghan who do not respond to the above two medications. Because this drug has a high concentration in lymphatic fluid and is excreted via the bile duct in its active form, it exhibits intestinal-hepatic circulation, making it particularly suitable for patients with bile duct infections, pregnant women, and carriers. Administered in 3–4 intramuscular injections or intravenous infusions, with a treatment duration of 2–3 weeks.

4. Furazolidone: it has a relatively low recurrence rate and does not significantly affect the hematopoietic system. After 600–0mg daily, considering side effects, reduce the dosage by half and take 5–7 days before discontinuing the medication. However, it takes longer to reduce fever, can cause gastrointestinal irritation, and may even lead to peripheral nerve inflammation.

5. Methotrexate is the preferred medication for this disease; its structure is similar to chloramphenicol, but its antibacterial efficacy outside the body is slightly weaker than chloramphenicol, and it has limited effect on bone marrow. It is commonly used at 15–24 days, taken orally in 3–4 doses. The treatment duration is the same as chloramphenicol.

(Dai Shuang Ming Qiao Fu Qu, Wu Bin) Chapter Fifteen: Bacillary Dysentery – Overview Bacillary dysentery, often referred to as “Jin Li,” is a common intestinal infectious disease caused by Shigella bacteria. Its primary clinical manifestations include acute fever and systemic toxicity, along with abdominal pain, diarrhea, tenesmus, and bloody stools. Dysentery is an ancient infectious disease; as early as 770 BCE to 476 BCE, the “Su Wen” recorded “pus and blood in the intestines.” Nevertheless, dysentery still holds an important place among infectious diseases today, and its incidence has not decreased significantly. Dysentery is widespread across China, occurring year-round, with peak incidence in summer and autumn (accounting for approximately 80% of all annual cases). High rainfall in summer and autumn, coupled with high fly populations and frequent consumption of raw or cold fruits and vegetables, are major contributing factors to its high prevalence. Poor environmental hygiene can easily lead to outbreaks of dysentery.

The primary sources of infection are acute and chronic patients, as well as carriers; atypical cases are more likely to be missed or misdiagnosed, which is especially concerning. Infection typically occurs through hands, household contact, flies, food, and water, via oral transmission. The population is generally susceptible to this disease, with preschool children and young adults (ages 20–40) experiencing the highest peak in incidence. When immunity is low due to malnutrition or overeating and drinking, infection is more likely to occur.

Shigella bacteria are Gram-negative rods, belonging to four groups—A, B, C, and D—with 42 serotypes. They possess strong survival capabilities outside the body. The primary pathogenic factor of Shigella is endotoxin, while the Shigella group also produces exotoxins. There is no cross-protection between different groups or serotypes, making re-infection common—and one of the reasons for the high incidence of dysentery. Today, it is believed that for Shigella to cause disease, three conditions must be met: ① the presence of a smooth, polysaccharide “O” antigen; ② the ability to invade epithelial cells and multiply within them; ③ the production of toxins after invasion. After ingesting Shigella, the bacteria survive in gastric acid and are protected against digestive enzymes, but they can still cause harm when they reach the intestines.

VI. Conclusion

Traditional Chinese Medicine’s understanding of Shanghan has evolved over centuries, providing valuable insights into the pathogenesis and treatment of this disease. While the exact mechanisms behind Shanghan remain unclear, the principles of TCM have been instrumental in guiding the development of treatments that address the root causes of the disease. By focusing on the balance of qi, yin, and yang, TCM emphasizes the importance of restoring harmony within the body to alleviate symptoms and promote healing. The integration of TCM with Western medicine has led to innovative approaches in treating Shanghan, offering new perspectives and therapies that complement traditional practices. As our understanding of Shanghan continues to deepen, TCM’s role in modern medicine will undoubtedly grow, providing a unique perspective on the complex interplay between nature, health, and disease.

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Input: Under the influence of the normal gut microbiota and intestinal-specific secretory IgA, it is often eliminated. Once it enters the intestine, even a small amount of bacteria (such as those in the Shigella group—only 10 bacteria are needed) can trigger disease. Shigella primarily invades the colonic epithelial cells in the intestine and penetrates into the lamina propria through the basement membrane, causing mucosal inflammatory responses. In typical cases, the main pathological changes include diffuse purulent inflammation and ulcer formation in the colonic mucosa; however, the submucosal layer is rarely affected, and septicemia is rare. The onset of toxic dysentery may be associated with specific genetic predispositions, resulting from acute microcirculatory disorders caused by endotoxins. The primary pathologies include cerebral edema, neuronal degeneration, and, in some cases, damage to the adrenal glands and their cortex, while intestinal lesions are relatively mild.

Acute bacillary dysentery can present in five clinical forms: typical, atypical, mild, severe, and toxic. Atypical cases may be characterized by no obvious fever or bloody pus in the stool. Severe cases are more common in elderly patients, those who are frail or malnourished, with diarrhea occurring more than 30 times per day, potentially leading to the discharge of patchy pseudomembranes and causing toxic intestinal paralysis. Toxic dysentery commonly presents as shock-type, cerebral edema (respiratory failure), or mixed types. If acute bacillary dysentery persists for more than two months, it becomes chronic dysentery, which can manifest in three forms: latent, prolonged, or acute-onset, with frequent involvement of the F. flexneri group. Laboratory tests reveal white blood cell counts ranging from 10 to 20 × 10⁹/L, with elevated neutrophil counts and left shift in the nuclear morphology. Stool microscopy often shows more than 10 pus cells per high-power field, along with red blood cells and macrophages; stool cultures may yield positive results.

II. Diagnosis

(1) Diagnostic Criteria

1. Epidemiology: A history of contact with patients suffering from bacillary dysentery and poor dietary hygiene (in 2/3 of cases) is significant, and regional, seasonal, and age-related factors also play a role.
2. Clinical Manifestations: Acute onset with chills and fever, abdominal pain, diarrhea, tenesmus, and bloody, pus-filled stools (initially watery), which provide valuable diagnostic clues. Toxic dysentery is primarily characterized by high fever, altered mental status, convulsions, or collapse. Atypical cases may present with mild diarrhea, while acute bacillary dysentery often manifests mainly with symptoms of small intestinal inflammation.
3. Laboratory tests rely heavily on stool examinations and cultures to establish an accurate diagnosis; when suspecting toxic dysentery, early collection of rectal swabs or fecal samples via saline enemas should be performed. For chronic bacillary dysentery, endoscopic examination can be used to collect mucus and purulent secretions from the intestinal mucosa. In recent years, rapid pathogen detection methods have been employed, including immunofluorescence bacterial agglutination assays, enhanced latex agglutination, co-agglutination tests, and immunofluorescent staining techniques, which are reported to achieve positive rates exceeding 90%, aiding in the early diagnosis of acute bacillary dysentery.

(2) Differential Diagnosis

1. Acute Bacillary Dysentery (1) Amoebic Dysentery (Parasitic Dysentery): Often has a gradual onset without fever, abdominal pain, mild tenesmus, and fewer bowel movements, with stools that are dark red (like jam), foul-smelling, and containing numerous red blood cells under microscopic examination, along with hexagonal or rhomboid crystals. Amoebic trophozoites can be identified, and the edges of intestinal ulcers are deeply incised, with minimal bleeding from the ulcer surface. (2) Enteric Infection with Helicobacter pylori: Patients often have a history of contact with poultry or livestock, typically presenting with low to moderate fever, yellowish, watery stools, and mild abdominal pain; in some cases, abdominal pain worsens after diarrhea subsides, though there is no tenesmus. (3) Acute Necrotizing Hemorrhagic Small Intestine Inflammation: Commonly seen in adolescents, this condition is associated with severe toxemia, rapid onset of shock, and often accompanied by generalized abdominal tenderness and severe abdominal distension. Stool microscopy reveals predominantly red blood cells, while stool cultures show no growth of Shigella bacteria.
2. Chronic Bacillary Dysentery (1) Rectal and Colonic Cancer: This condition is more prevalent in middle-aged individuals, with persistent disease progression, poor response to antibiotics, and generally poor overall health, often worsening over time. Generally speaking, early rectal examination or endoscopic evaluation should be conducted for chronic patients. (2) Intestinal Tuberculosis: Patients often experience alternating diarrhea and constipation, frequently accompanied by low-grade fever in the afternoon, night sweats, weight loss, and other general symptoms of tuberculosis. Abdominal pain is often located in the right lower quadrant, with palpable masses and increased erythrocyte sedimentation rate. X-ray barium studies, endoscopic examinations, and anti-tuberculosis treatments can aid in diagnosis. (3) Non-Specific Ulcerative Colitis: This condition has a long course, with endoscopic findings showing congestion, edema, and ulcer formation in the intestinal mucosa; the mucosa is fragile and prone to bleeding, and antibiotic therapy is often ineffective. Corticosteroids and immunosuppressants are often required. Serum antibodies against lipopolysaccharides on intestinal epithelial cells are present.
3. Other Conditions Toxic dysentery must be differentiated from type B encephalitis (brain-type) and other forms of toxic shock (shock-type); patients with chronic bacillary dysentery in southern China should also be distinguished from schistosomiasis.

III. Traditional Chinese Medicine’s Understanding and Treatment of Bacillary Dysentery

(1) Medical Classics’ Discussions on Similar Conditions to Bacillary Dysentery

As early as 2,000 years ago, traditional Chinese medicine recorded “pus and blood in the intestinal cavity,” also known as “chiwo.” The Neijing also provided comparisons and distinctions between the large and small intestines, as well as between three types of diarrhea: “dysentery” and “diarrhea.” In the Jin Gui, both dysentery and diarrhea were collectively referred to as “xia li.” It was during the Eastern Jin Dynasty, under the leadership of Ge Hong, that the term “li” first became widely used to describe this condition. The Zhi Wu Yuan Hou Lun (written by Chao Yuanfang during the Sui Dynasty) provided a detailed classification of this disease, categorizing it into “twenty types of dysentery conditions,” which were further divided into two categories: acute and chronic. The book also distinguished between red and white diarrhea based on heat and cold, identifying factors such as seasonal imbalances in cold and heat, wind, cold, heat toxins, physical labor, and dietary habits as contributing causes. It emphasized integrating the physiological and pathological aspects of the spleen, stomach, large intestine, qi and blood, as well as body fluids, to analyze the underlying mechanisms of disease. In Qi Jiang Yin, the Tang Dynasty physician Sun Simiao described this condition as “stagnant diarrhea” (which is also referred to abroad as “special constipation”), proposing four theories regarding dysentery: cold, coldness, dampness due to childhood malnutrition, and pediatric dysentery. The Dan Xi Xin Fa also introduced the concept of “epidemic dysentery”: “When an epidemic occurs, dysentery spreads within a single household, with similar transmission patterns across families.”

In terms of treatment, the Shang Han Lun stated: “For heat-induced diarrhea with heavy defecation, the Bai Tou Weng Tang is effective,” and also mentioned the Taohua Tang. These formulas aimed to clear the intestines, detoxify, warm the interior, and promote bowel movements. The He Qian Liu Shen, in his work “Stagnant Diarrhea,” proposed: “When there is tenesmus, one should induce defecation; when there is abdominal pain, one should soothe the abdomen; when the body feels heavy, one should eliminate dampness; when the pulse is wiry, one should dispel wind.” “When blood flows smoothly, pus and blood will heal on their own; when qi is regulated, tenesmus will naturally disappear.” These principles remain fundamental to treating dysentery to this day. The text also highlighted valuable experiences such as “When treating all types of dysentery, Huang Lian and Huang Bai serve as the principal herbs, with their bitter and cold properties effectively addressing damp-heat conditions.” Later, during the Ming and Qing Dynasties, understanding of dysentery deepened further. Ye Tian Shi believed that “the fundamental principle of treating dysentery lies in the dual concepts of clearing and blocking,” while Yu Chang proposed the “reverse-flow boat” method. Gu Songyuan outlined four key prohibitions when treating dysentery: warming and tonifying, excessive laxative use, sweating, and excessive urination (from the medical text “Yi Jing,” Volume 8, Chapter on Dysentery). Many other works on dysentery were subsequently published.

(2) TCM’s Understanding of the Pathogenesis of Bacillary Dysentery Regarding the causes of dysentery, as noted in the Dan Xi Xin Fa: “All conditions stem from damp-heat.” The Lei Zheng Zhi Cai also stated: “Dysentery arises in summer and autumn… the condition originates from dampness and heat accumulating in the stomach, causing qi and blood to become congested, with waste products stagnating and being transported into the large and small intestines, leading to the accumulation of intestinal fluid and the subsequent formation of pus and blood. Because these pathways are blocked and not properly cleared, this leads to stagnant diarrhea.” Based on ancient and modern understandings, TCM believes that the onset of this disease is related to exposure to external pathogens, dietary injuries, emotional distress, weakness of the spleen and stomach, and other factors. Although the disease primarily affects the large intestine, it can ascend to the spleen and stomach, extend to the liver and kidneys, and even lead to pathogenic factors infiltrating the pericardium and harming the heart’s spirit. The core mechanism of this disease is the obstruction of the Yangming intestinal tract by damp-heat or cold-dampness, resulting in impaired intestinal motility, poor descending and ascending functions, qi and blood congestion, and damage to the intestinal membranes and blood vessels.

The disease progresses to a state of damp-heat or cold-dampness, where food stagnation obstructs the Yangming intestinal tract, leading to impaired intestinal function, reduced descending and ascending movement, qi and blood congestion, and damage to the intestinal membranes and blood vessels. Patients with damp-heat syndrome may exhibit heat dominating dampness, dampness dominating heat, or both heat and dampness together. For instance, if internal cold-dampness damages the middle burner, or if damp-heat causes diarrhea, but heat is removed while dampness remains, and the spleen’s yang is harmed, then cold-dampness may develop. When damp-heat or toxic agents penetrate deeply, or when the body’s righteous qi cannot resist the pathogenic forces, the disease may spread to the blood vessels, infiltrate the pericardium, and trigger liver wind, resulting in high fever, altered mental status, convulsions, and even life-threatening conditions like internal obstruction and external depletion. If damp-heat or toxic agents surge upward and attack the stomach, they may cause “closed-mouth dysentery.” If the body’s defenses are too weak, and the bowels are closed too early, with dietary irregularities and undigested waste remaining, then the body’s righteous qi may already be weakened, leading to intermittent episodes of restful dysentery (chronic bacillary dysentery).

(3) TCM Differentiation and Classification of Dysentery Types and Herbal Formulas