Volume Four: Hematochezia

Volume Four: Hematochezia

"The large intestine is the organ responsible for transporting and transforming substances." It is said that the large intestine receives substances transformed by the spleen and stomach, serving as the central conduit for transportation, hence its nickname 'the passage,' meaning the exit from the palace. Its meridian is closely related to the lungs; the lungs are the 'clear metal,' while the large intestine is the 'dry metal.' According to the Five Elements theory, they belong to the same family, so pulse diagnosis can be performed on the large intestine by examining the lungs. The ability of the large intestine to transport substances relies entirely on qi. Qi is primarily governed by the lungs; not only does the large intestine depend on lung qi for transportation, but urine is also processed and transported by lung qi. This is precisely the function of the lung metal in regulating the flow of qi. Furthermore, the qi of the large intestine interacts with the golden pathway, so many treatments focus on the lungs. As the large intestine is located in the lower part of the body, it is also under the jurisdiction of the kidneys. According to the 'Inner Canon,' 'the kidneys open to the two yin organs,' and 'the kidneys serve as the gatekeeper of the stomach' (1), so adequate kidney yin is essential for maintaining the health of the large intestine (2). The Jueyin liver meridian wraps around the yin organs, and the intestines and uterine cavity share the same domain, so the liver meridian and the intestines are also interconnected. Consequently, diseases of the large intestine can arise from qi deficiency and damp-heat infiltration, from residual heat transmitted from the lung meridian to the large intestine, from kidney yin deficiency preventing the intestines from being adequately moistened, or from blood heat leaking into the intestines—these are all manifestations of the interconnectedness between the large intestine and other organs. However, the root cause of the disease originates in each organ individually; once the disease has settled in the intestines, it can no longer return to its original source. Therefore, it is necessary to first treat the intestines to eliminate the symptoms, and then treat the other organs to address the root cause, ensuring that the disease is completely eradicated and does not recur.

Hematochezia occurring immediately after bleeding is referred to as 'near hematochezia,' as the blood is concentrated in the large intestine close to the anus, hence the name. There are two main types of treatment: one is treating the toxicity of the intestines, and the other is treating intestinal wind.

Intestinal toxicity manifests as anal swelling, hardness, and painful bleeding, similar to hemorrhoids and fistulas. Zhang Zhongjing recommends Chidou Danggui San, using red bean sprouts to relieve stagnation and angelica root to harmonize the blood. Red beans have diuretic properties, and their red sprouts enter the blood aspect, aiding in detoxification; angelica root lubricates and nourishes the blood, keeping the intestines from becoming constipated. Zhang Zhongjing briefly outlines the approach, emphasizing that treating intestinal toxicity requires both eliminating damp-heat and harmonizing the blood—there is no other way to treat intestinal toxicity besides these two medicines. I extend this idea: if there is severe swelling and pain, and bowel movements are blocked, Detox Soup is recommended. Use Fangfeng and Zhike to clear the qi, just as red bean sprouts do; use Dahuang and Chisha to smooth the blood, just as angelica root does. If bowel movements are unobstructed and the pain is mild, heavy doses are unnecessary; instead, use Sibu Tang supplemented with Diyu, Jingjie, Huaijiao, Danpi, Huangqin, Tufuling, Difu, Yiren, and Binglang to treat the condition. Sibu Tang embodies Zhang Zhongjing's intention to use angelica root to nourish the blood and alleviate stagnation, while the additional herbs reflect his use of red bean sprouts to dispel damp-heat and resolve blood stasis. Zhang Zhongjing only emphasized blood nourishment and stagnation relief, but now, given the difficulty of resolving damp-heat, he also incorporates cleansing agents. Those seeking to stop bleeding can also take Shihui San concurrently.

For chronic intestinal toxicity that does not heal, the liver and stomach must be treated. Blood is governed by the liver, while the intestines are the gateway to the stomach; if the stomach does not transmit damp-heat to the intestines, how can intestinal toxicity develop? Without wind-fire in the liver's blood aspect, the liver would not force the blood to congeal at the anus either. To treat the stomach, use Qingwei San supplemented with honeysuckle, Tufuling, Fangji, Huangbo, Yiren, and Cheqianzi to clear and descend the damp-heat of the Yangming channel, preventing intestinal toxicity from recurring. For the liver, use Longdan Xiegan Tang and Xiaoyao San.

Additionally, if residual heat from the lung meridian persists in the large intestine and does not heal, one will observe floating, rapid, and congested pulses, along with symptoms such as thirst, yellow urine, and coughing. In such cases, use Ginseng Qingfei Tang, incorporating Ume and Suhu acid to contract the lung qi, while other ingredients soothe the lungs, preventing residual heat from spreading to the intestines. If these two ingredients are omitted and replaced with mint and platycodon, the intention shifts toward dispersing the heat, reflecting changes in individual circumstances.

Intestinal wind, on the other hand, does not cause anal swelling or pain, but rather results in bleeding. Intestinal toxicity tends to produce murky blood, while intestinal wind produces clear blood. Although Zhang Zhongjing's writings do not explicitly mention 'intestinal wind,' the 'Shanghan Lun' states: 'In cases of Taiyang disease, if fire is used to attack the illness and no sweat is produced, the patient will become restless, and if the condition does not improve, blood will inevitably appear.' (3) 'In cases of Taiyang disease, if the pulse is floating and slippery, blood will inevitably appear.' (4) Both statements indicate that external pathogenic factors of Taiyang invade the body and lead to bleeding. Furthermore, it is stated: 'In cases of Yangming disease, if the patient exhibits delirium and hallucinations due to blood entering the blood chamber, it signifies that heat has invaded the blood chamber.' (5) The 'Jueyin chapter' also mentions: 'If one experiences fainting and vomiting, along with chest and flank discomfort, blood will inevitably appear afterward.' (6) This is precisely what we now refer to as intestinal wind-induced bleeding. Since the intestines are located in the lower part of the body, where does the wind come from to attack them? On the external level, it is the Taiyang wind pathogen that invades the Yangming channel, combining with heat to cause bleeding; on the internal level, it is the Jueyin liver wood, where virtual heat generates wind, and the wind stirs up the blood. Wind is a positive pathogen; over time, it can transform into fire, and treating fire is equivalent to treating wind. Therefore, when treating intestinal wind-induced bleeding, the primary focus is always on extinguishing the fire and nourishing the blood. Once the fire is extinguished, the blood calms down, and the wind naturally subsides. The 'Shoushibao Yuan' uses Huaijiao Wan to control this phenomenon, though the rationale behind it is not explicitly stated. I believe this formula addresses the issue: Jing controls the wind pathogen invading the Taiyang-Yangming channel, Ume and Chuanxiong control the wind pathogen originating from the liver wood, while the remaining ingredients soothe the blood and quell the fire, achieving the desired effect. However, external wind combined with heat requires adherence to the spirit of Zhang Zhongjing's Ge Gen Huang Lian Huang Qin Tang, enabling the internal pathogen to rise to the surface and avoid being suppressed, thus bringing the situation to an end. The principle of treatment is: 'suppress the high, elevate the low' (7); hematemesis must suppress qi, while intestinal wind must elevate qi. Elevating qi is not merely about tonifying the middle and benefiting qi; it also involves lifting and dispersing, as exemplified by Ge Gen Huang Lian Huang Qin Tang supplemented with Jingjie, Danggui, Chaihu, Baishao, Huaihua, Diyu, and Jiegeng. If the liver wood generates wind heat internally and causes bleeding, one will observe abdominal distension, bitterness, anger, or even alternating chills and fevers; in such cases, use Xieqing Wan to treat the condition, while Xiaoyao San and Xiao Chaihu Tang can also be adjusted accordingly. It should be noted that the reason the liver wood can cause bleeding is that the liver governs blood, and the blood chamber is located between the large intestine and the bladder, so when heat enters the blood chamber, there is evidence of urinary bleeding, accumulation of blood, and even black stools. The liver blood rises to the surface, and depending on the route taken, it may result in vomiting if it follows the turbid path (8), or in epistaxis if it follows the clear path (9). The liver blood seeps downward, and if it follows the clear path, it results in urinary bleeding; if it follows the turbid path, it results in bleeding. The liver is the organ of wind wood, and it is responsible for storing blood; when wind stirs up the blood, it cannot be stored, leading to intestinal wind-induced bleeding. Several of the aforementioned formulas are capable of balancing this situation, or one can use Jisheng Ume Wan, which is excellent at using Ume to pacify the liver wind, and Jiangcan to calm the liver wind, thereby stabilizing the wind and calming the blood. However, if the liver wind stirs up the blood, it is advisable to follow the spirit of Zhang Zhongjing's Bai Tou Weng Tang, which is more powerful in extinguishing fire and dispelling wind, or to combine Sibu Tang with Bai Tou Weng Tang to supplement the blood. The key to treating wind is to treat the blood first; once the blood flows, the wind naturally disappears—this is the principle. If there is no Bai Tou Weng, choose Chaihu, Qinghao, or Bai Wei as substitutes; Sang Ji Sheng can also generate wind, making it a better alternative to Bai Tou Weng. It should also be noted that the liver meridian runs horizontally, while the lung meridian cannot flatten the wood, so the lungs and large intestine are closely related, and treating the lung meridian can also serve as a way to treat the liver meridian indirectly. For those with weak liver qi, use Ginseng Qingfei Tang; for those with strong liver qi, use Ginseng Xiegan Tang.

For intestinal wind and intestinal toxicity, if there is excessive bleeding, significant yin deficiency, and prolonged non-healing, the kidney meridian is bound to be deficient, so it is best to use Ziyin Zang Lian Wan to nourish the kidney yin and ensure it reaches the large intestine—six flavors of pills supplemented with Congrong and Huaijiao are also suitable.

Hematochezia occurring after bowel movements is referred to as 'remote hematochezia,' as the blood is located in the stomach, far from the anus, and only begins to appear after defecation. Because of this name, it is also known as 'yin-related bleeding,' and Huangtu Tang is the principal formula. The name Huangtu Tang clearly indicates that the problem arises from the failure of the central palace to maintain proper control, resulting in uncontrolled blood flow. Supplementing with Fuzi helps counteract the downward movement of yang qi, which is otherwise impossible to lift; using Huangqin is intended to address blood deficiency, which can lead to fire, so Huangqin is used to clear the blood. Zhang Zhongjing originally formulated this prescription to warm the central palace, and the Huangqin used in it serves to complement Fuzi's nature, preventing it from being too harsh and damaging the yin blood. Pu Ming Zi believes that this condition is characterized by a weak pulse, pale lips and mouth, and cold extremities, suggesting the use of Lizhong Tang supplemented with Guishao, or Guipi Tang and Shiquan Dabu Tang. Many physicians today use Zhongyi Tang to elevate qi, which aligns with the intent of Huangtu Tang. For those whose central palace cannot control blood, several formulas can be used, but Zhang Zhongjing emphasizes the use of warming and clearing agents, recognizing that the root cause of the instability lies in the presence of fire. Those with strong qi tend to rise, while those with weak qi tend to sink. Today, physicians mainly use warming and elevating agents, which can indeed treat qi deficiency, but fail to address the issue of blood disturbance. I agree with Zhang Zhongjing's view: if yin is deficient and fire is rampant, the fire consumes qi, and if the spleen is deficient while the lungs are dry, the ability to control blood is lost, then Ginseng Qingfei Tang is recommended. If the liver is angry and the lungs are depressed, resulting in blood that cannot be contained, Guipi Tang supplemented with fried Zhi, Mai Dong, A Jiao, and Wu Wei, or Dan Zhi Xiaoyao San supplemented with A Jiao, Sang Ji Sheng, and Diyu, is recommended—this reflects the use of Huangqin in Huangtu Tang. If the condition is one of severe deficiency, excessive bleeding, unstable spleen, weak kidney, sallow complexion, cold hands and feet, and six weak, floating pulses, then it is advisable to greatly strengthen the liver, spleen, and kidney—Ginseng Yangrong Tang strengthens the spleen, Jiao Ai Si Wu Tang supplemented with Ba Ji and Gan Cao strengthens the liver, and Duan Hong Wan strengthens the kidney—this reflects the use of Fuzi in Huangtu Tang. With such expansion and enrichment, countless variations are possible, far beyond what can be expressed in paper and ink (10).

I note that this condition is no different from women's metrorrhagia; women's metrorrhagia is a condition of deficiency, and this condition is also one of deficiency. Women's metrorrhagia is characterized by cold deficiency, but also includes elements of heat; men's version of this condition is also characterized by cold deficiency, but also includes elements of heat. This is because women's blood has a menstrual cycle, and men's blood also has a menstrual cycle. Both are instances of blood escaping from the normal cycle, so the clinical presentation is similar. However, the specific points of discharge differ: metrorrhagia occurs through the front yin, so treatment often focuses on the liver to harmonize the blood chamber; hematochezia occurs through the back yin, so treatment often focuses on the lungs and kidneys to solidify the intestinal qi. The kidneys govern the lower abdomen and are responsible for raising qi; when the kidneys are strong, qi does not sink. The lungs and intestines are closely related, and when the lungs control qi, the intestines automatically solidify their qi. Physicians who understand this principle can also apply the treatment methods used for women's metrorrhagia, thereby achieving comprehensive treatment. Again, according to this principle, both hematochezia and hematemesis are blood disorders; however, one involves upward movement of qi while the other involves downward movement of qi, so the treatment principles for deficiency and excess differ slightly.

[Notes] (1) The Kidney is the Gate of the Stomach: This phrase originates from "Plain Questions · On the Water-Heat Acupoint Theory." The original text reads: "The Kidney is the gate of the Stomach; when the gate does not function properly, water accumulates and follows its nature." (2) Yu (yū): Originally meant fatty meat, later extended to mean obesity, and further to signify abundance and prosperity. (3) Article 114 of "Treatise on Cold Damage." (4) Qing (qīng), meaning toilet. (5) Article 140 of "Treatise on Cold Damage." (6) Article 216 of "Treatise on Cold Damage." (7) Article 339 of "Treatise on Cold Damage." (8) For those who fall, lift them up: This phrase comes from "Plain Questions · On the Great Principles of Supreme Truth." Here, "fall" refers to sinking, and "lift" refers to raising. For example, if middle qi sinks, one should use tonifying medicines to raise it. (9) The turbid pathway: In the upper part, it refers to the digestive tract; in the lower part, it refers to the rectum and anus. (10) The clear pathway: In the upper part, it refers to the respiratory tract; in the lower part, it refers to the urinary tract. (11) Chu (chǔ): Paper.

[Commentary] The author, drawing on the perspectives of "Treatise on Cold Damage," classifies hematochezia into two categories: proximal and distal. Proximal hematochezia occurs when bleeding precedes defecation, with the lesion located in the anus and large intestine; distal hematochezia occurs when defecation precedes bleeding, with the lesion located in the stomach. If proximal hematochezia is accompanied by anal swelling and pain, it is classified as "zang du"; if there is no anal swelling or pain, it is classified as "chang feng."

Zang du arises from the combination of damp-heat and blood stasis, and thus should be treated by clearing heat, eliminating dampness, and harmonizing the blood vessels. The use of Chixiaodou Danggui San in "Treatise on Cold Damage" to treat zang du is consistent with this therapeutic principle. Based on this, the author extends the formula to create Jiedu Tang for treating zang du, which can be seen as a development of Chixiaodou Danggui San for this condition. The formula includes Fangfeng and Zhike to regulate qi flow, embodying the essence of Chixiaodou; it also contains Dahuang and Chishao to smooth the blood circulation, reflecting the efficacy of Danggui. For long-standing zang du, treatment should also consider the Liver, Stomach, and Lung meridians. Since blood is governed by the Liver, the intestines serve as the gateway of the Stomach, and the Lung is paired with the large intestine, treatment for the Liver should involve Longdan Xiegan Tang and Xiaoyao San; treatment for the Stomach should involve Qingwei San; and treatment for the Lung should involve Renshen Qingfei Tang.

According to "Shenghui Fang": "In cases of intestinal wind causing hematochezia... cold and hot pathogenic factors collide in the large intestine, rendering it weak and causing intermittent bleeding, hence the name 'intestinal wind'." Moreover, "Treatise on Cold Damage" records "hematochezia and delirium in Yangming disease," indicating that the syndrome of intestinal wind, in addition to wind, also involves heat. Therefore, the primary therapeutic approach for intestinal wind must be clearing heat and dispelling wind. The author believes that Huaijiao Wan in "Shoushibao Yuan," with Jingjie and Fangfeng to treat solar wind, and Wumei and Chuanxiong to eliminate liver wood wind, along with the potent action of Sanhuang to clear fire, makes it an ideal prescription for treating intestinal wind. Additionally, if external wind is accompanied by heat, Ge Gen Qin Lian Tang can be used; if there is stagnation of heat in the Liver meridian, Xieqing Wan, Xiaoyao San, or Xiao Chaihu Tang may be employed. Among these formulas, ingredients such as Gegen and Chaihu have uplifting effects, embodying the principle of "lifting what has fallen." For long-standing intestinal wind, when yin deficiency occurs, Ziyin Zhanglian Wan or Liuwei Dihuang Tang can be used for treatment.

Distal hematochezia results from the collapse of the central earth, leading to an inability to control bleeding; therefore, Huangtu Tang from "Treatise on Cold Damage" should be the first choice for treatment. Huang represents the spleen and stomach, and tu also refers to the spleen and stomach, so Huangtu Tang's main purpose is to warm the center and stop bleeding. In the formula, Fuzi raises yang qi that has already collapsed, while Huangqin clears lung fire before it even emerges; the combination of these two herbs enables yang qi to rise to the middle jiao and then stop, thereby avoiding the risk of further ascent that could stir up lung fire. The author comments on how contemporary physicians use Buzhong Yiqi Tang and similar formulas to treat distal hematochezia. Although these formulas also follow the principle of Huangtu Tang in raising yang qi, they overlook the adverse factor that rising yang qi can disturb lung fire, leading to unstable bleeding. For this reason, the author believes that using Renshen Qingfei Yin to treat distal hematochezia caused by lung dryness and loss of containment, Gui Pi Tang combined with Shan Zhi and Mai Dong to treat distal hematochezia due to qi failing to control bleeding, and Danzhi Xiaoyao San with Ajiao and Sangji Sheng to treat distal hematochezia caused by liver qi restraining earth and insufficient middle qi, are all relatively ideal prescriptions. This is because these formulas all contain ingredients that balance cold and heat, which carries the same significance as the combination of Fuzi and Huangqin in Huangtu Tang from "Treatise on Cold Damage."

Pus in the Stool

This condition has two types: internal abscess and dysentery.

An internal abscess located in the upper or middle jiao will have its pus rupture and be vomited out. If it’s in the lower jiao—such as a lower abdominal abscess, small intestine abscess, flank abscess, or liver abscess—the pus and blood will both be discharged through the stool. At the onset, there will invariably be a dull, stabbing pain and distension, with a deep, slippery, and rapid pulse; in severe cases, the pain may feel like being pierced by a knife or awl. Anyone prone to this condition will inevitably feel thirsty, as blood accumulation generally leads to thirst. When an abscess first forms, the blood tends to coagulate, so thirst naturally arises. At this stage, it’s crucial to quickly drain the blood to prevent it from turning into pus and avoid the risk of ulceration. Use Danpi Tang combined with Ruxiang, Moyao, Chaihu, Jingjie, and Shan Jia to treat it. If the blood has already turned into pus, it’s better to drain it; Red Bean Coix Seed Soup, which promotes diuresis, is effective for draining pus. After rupture, the body becomes deficient, so nourishing and muscle-regenerating treatment is needed, with Bazhen Tang as the main remedy. See the section on vomiting pus for more details.

A visitor asks: How does accumulated blood turn into pus? The answer is: Blood is the substance of yin, and it moves with qi. When qi is abundant, blood is full; when qi declines, blood is depleted; when qi stagnates, blood becomes stagnant; when qi rises, blood surges. Thus, the movement of blood is driven by the movement of qi, meaning that the flow of stagnant blood is also the flow of qi. When blood stagnates between meridians and organs, it has neither the strength to move nor the way to exit, relying solely on the movement of qi to travel from the oil membrane to the gastrointestinal tract and be expelled through the stool. This shows that qi drives blood, and when qi moves, blood naturally doesn’t stay put. If qi doesn’t move but instead binds with blood, qi will be trapped by blood and cause pain, while blood will be steamed by qi and turn into pus. To illustrate with an external analogy: people with abundant qi tend to develop boils easily, whereas those with deficient qi find it hard to develop boils. Qi is like water; when qi arrives, water arrives too. Therefore, when blood transforms under the influence of qi, it takes on the form of water and turns into pus. Even a cut wound that gets wet will eventually turn into pus. Water is the essence of qi, and when blood transforms under the influence of qi, this is exactly what happens. Hence, when blood accumulates and encounters qi, it forms pus at the site of swelling; if it doesn’t encounter qi, the swelling remains just blood. From this we can see that blood is driven by qi, and qi drives blood. Therefore, anyone treating blood must regulate qi, ensuring that qi serves blood rather than becoming a source of illness for it. Only then can true healing be achieved.

As for dysentery with pus in the stool, the symptoms include tenesmus and urgency, difficulty in passing stools, and the stool may be white, red, or a mixture of both, or even muddy and foul-smelling—yet it still appears to be pus. Inside the gastrointestinal tract, apart from waste, there is only a small amount of fat and fluid. Fat belongs to the blood category, while fluid belongs to the qi category. When qi is affected, the fluid becomes white dysentery; when blood is affected, the blood becomes red dysentery; and when both qi and blood are affected, it becomes a mixture of red and white. So where does real pus come from, and why is it discharged through the stool? It comes from toxins accumulating in the gastrointestinal tract, which vaporize the fats, oils, and flesh of the gut into pus. Sometimes it leaks out like rotten melons, sometimes like a house with leaking water—this is a dangerous sign of intestinal decay and gastric ulceration, no different from the rotting of boils and sores. Ordinary methods of treating dysentery cannot handle this situation. Now, I’m using Zhang Zhongjing’s methods to prove this point, and I’ve developed a bold and insightful technique. Zhang Zhongjing said: “In Yangming disease, if the pulse is rapid and bleeding continues, it must be accompanied by heat and pus in the stool.” “In Shaoyin disease, if diarrhea is accompanied by pus in the stool, acupuncture can be used.” “In Jueyin disease, if the pulse is rapid and there is thirst, it must be accompanied by pus in the stool, because there is heat.” Although these statements don’t provide specific prescriptions, they do indicate that acupuncture can be used and that heat is involved, suggesting a method of draining dampness and clearing heat. Fangfeng Tongsheng San removes Ma Huang and Mangxiao, adding Chixiaodou and Fangji, making it a powerful formula for expelling both interior and exterior evils; Diyu San is a general formula for clearing heat. Zhang Zhongjing also said: “In Shaoyin disease, if diarrhea is accompanied by pus in the stool, Taohua Tang is the main remedy.” This soup is warm and astringent, seemingly quite different from the idea of using acupuncture to treat heat. However, over time, the heat accompanying the pus will dissipate, leaving the patient weakened. Observing that after an abscess ruptures, the body becomes deficient, we realize that prolonged pus discharge indicates a deficiency syndrome. It’s like the weather: at first it’s scorching summer, but soon a cool breeze blows, forcing those wearing summer clothes to switch to winter coats. Similarly, once the blood in the gastrointestinal tract turns into pus, it’s likely to slip away, so Taohua Tang, with its warm and astringent properties, is used to fill the gap. One dose is enough, and no further doses are needed—Zhang Zhongjing intended this as a temporary measure to address the immediate problem, with the understanding that after the acute phase, any remaining issues should be cleared, without harming the qi or drying out the yin. After all, pus and blood are diseases that harm yin, so this is only a temporary solution, with less use of dried ginger, and the intention to continue afterward. Cheng Wu Yi noted that Taohua Tang is suitable for treating yin conditions, as it reveals the inner heat of yang conditions and the inner cold of yin conditions, much like pork liver. This clearly shows that Taohua Tang is a remedy for yin conditions. However, since blood itself is divided into yin and yang, it’s difficult to determine precisely, as color alone isn’t enough evidence. For all cases of dysentery, one must carefully examine the pulse—sluggish and slow—and check for cold hands and feet, abdominal pain that eases with pressure, and pale lips and a neutral mouth—these are signs of yin conditions. Add Fuzi Lizhong Tang with Danggui, Baishao, and Muxiang, and you’ll have a supplement that Taohua Tang lacks. For thirst and heat, chest and abdominal bloating, and firm resistance to pressure—these are signs of yang conditions, so use San Yi Chengqi Tang, which fully exploits Zhang Zhongjing’s ability to treat heat with acupuncture.

As for ordinary red and white cases, there’s no need for such strong formulas. If the problem lies in the water content, the diarrhea is white and turbid—this is like sporadic summer rain, with puddles forming and sweat increasing, indicating excessive moisture and damage to the qi. Examine the pulse—if it’s rapid and the person feels hot and thirsty, it’s heat and dampness, so clear and drain it; use Si Ni San combined with Zhu Ling Tang, removing Ajiao and adding Hou Pu, Huang Lian, Ku Qin, and Huang Bai. If the pulse is deep, tight, and slow, and the person doesn’t feel thirsty, with cold hands and feet, it’s cold and damp, so use Wei Ling Tang with roasted ginger; if there’s food stagnation, add malt, Shen Qu, hawthorn, and radish seeds. The reason for white diarrhea is always unclear water—water is qi, and I’ve discussed water and fire in detail before, so regulating qi means regulating water. Guiding water starts from the top, and regulating qi focuses on the lungs, as the lungs are the origin of clean water, which is the basis of regulating qi. Think about this disease occurring in autumn, when the lungs govern the metal element, and the metal element isn’t clear and pure, resulting in murky water and stagnant qi, which leads to dysentery. Understanding this principle means realizing that the lungs are responsible for purifying the air, while the metal element is responsible for collecting it. Renshen Qingfei Tang helps clear the stagnation, while Xiao Chaihu adds pollen, apricot kernels, Zhike, mulberry bark, Fu Ling, Zhi Mu, and Jie Geng to harmonize it, and Renshen Qingfei Tang completes the work. This is specifically designed for treating the lungs, providing doctors with a method to follow, so they know what to do, rather than having to rely on this formula in every case. Moreover, diseases rarely occur in isolation; there’s no such thing as lung disease without other organ involvement, so clinical practice often requires adaptation. If the problem lies in the blood category, the diarrhea will be purely red, with short periods of thirst and tenesmus. For those with a slippery pulse, use Diyu San with Jiu Jun, Zhike, Hou Pu, Coix Seed, and Ze Xie. For those with a fine, rapid pulse, there’s no need to go down, but use the original formula. If the blood is dark and the pulse is slow, with cold hands and feet, it’s a deficiency-cold condition, so treat it with Huangtu Tang. The reason for red diarrhea is always the blood category. Blood is born in the heart and stored in the liver, where the liver wood harbors the fire within. When blood is sufficient, it can feed the fire; when the fire is balanced, it can generate blood. But if the fire is too strong, it forces the blood to act recklessly, so blood-related diarrhea often feels like being stabbed by a knife—this is the pain of blood. The metal element governs the lungs in autumn, suppressing the liver wood, preventing the liver from reaching its full potential, leading to stagnation and lack of release, resulting in blockage and inability to vent. Regulating the liver allows the wood fire to be released, and the blood category to settle down. To resolve the stagnation of the wood fire, use Xiao Chaihu to remove Ban Xia and add Danggui and Baishao, or use White Headed Elderflower Soup or Four Substances Soup with Pu Huang, Wu Ling Zhi, Yan Hu Suo, Huang Bai, Long Dan Cao, Huang Qin, Chaihu, and Sang Ji Sheng. If the liver wind doesn’t blow, the fire dies out; hook vine, artemisia, white head elderflower, chaihu, and sang ji sheng are all wind-clearing agents, while silkworm pupae and cicada molts can also dispel wind. If the liver qi isn’t restrained, the blood flows freely; fragrant grass, betel nut, orange peel, green skin, agarwood, and oysters are all liver qi-dispersing agents, while Fu Ling, gall bladder herb, Qin Pi, and Ku Qin are liver fire-clearing agents, and Danggui, Sheng Di, Ajiao, and Baishao are liver blood-nourishing agents, while peach kernel, diyu, five spirit substances, and chuan xiong are liver blood-flow-promoting agents. Knowing the rules of the liver, treating blood-related diarrhea is not difficult. The liver stores blood, so all blood-related conditions ultimately boil down to liver regulation. No other book discusses this issue, but I’ve gained insight through cross-referencing various texts, starting from my own theory of yin-yang, water-fire, and blood-qi. Therefore, this theory is precise, unlike other books that merely capture shadows. A visitor asks: All diarrhea is governed by the spleen and stomach, and dysentery is also a type of diarrhea—why isn’t it governed by the spleen and stomach? The answer is: While seepage and diarrhea do belong to the spleen and stomach, the "Inner Canon" says that during the long summer, people are prone to diarrhea caused by cold, because the long summer is the spleen’s dominant qi. Dysentery, however, often occurs in autumn, and its underlying mechanisms and clinical manifestations are different from those of diarrhea, even though both involve the spleen and stomach, the focus should be on the liver and lungs, which are the root causes of the disease.

For those who refuse to eat, experiencing diarrhea and refusing food, it’s due to the attack of fiery, turbid energy, which damages the stomach qi and prevents it from opening. All books follow Danxi’s advice and use Shilian Tang. According to "Golden Mirror," when internal heat is severe and attacks the heart, causing nausea and refusal to eat, use Dahuang and Huang Lian, brewed with alcohol, to counteract it. The reason the gastrointestinal tract can still digest food is that the stomach produces gastric juice, which is clear, refreshing, and moist, thus stimulating appetite. Although Western medicine is often stuck in its tracks, there are still some credible points: when food enters the stomach, gastric juice is secreted, transforming the food into a mushy consistency, often stirring the gastric juice to mix everything together, and in an instant, it becomes mushy. Based on this theory, the stomach’s desire to eat is entirely due to gastric juice. Look at dogs—they salivate when they want meat, and this saliva is the very basis of their appetite. Human gastric juice works similarly. Now, the stomach is under attack by evil, fiery, turbid qi, and its originally clear, refreshing juice has been completely transformed into turbid, stagnant juice. When this juice flows into the large intestine, it becomes diarrhea; when it accumulates in the stomach, it refuses to accept food. Although Danxi’s Shilian Tang knows how to clear fire and nourish the stomach, Shilian is actually lotus seed rice with a black shell, and today’s medical community uses Shilian seeds without knowing what they are, so it’s absolutely impossible to use them. Moreover, lotus seed rice itself is somewhat astringent, and for dysentery, it’s better to use something smooth to remove stickiness; astringency is strictly forbidden, and the stomach is already filled with turbid, stagnant juice, so cleaning and transformation are essential, otherwise it won’t be a life-saving formula. Clearing heat and detoxifying drinks, bamboo leaf plaster soup, Renshen Baihu soup, and Mai Dong nourishing soup, with adjustments made as needed, can all help cleanse the stomach and transform its juices, making it easier to stimulate appetite and eat. As for the vomiting and refusal to eat, "Golden Mirror" recommends using two yellow wines to attack the reverse flow, aiming for a quick and forceful response, but this method is indeed effective in dealing with reverse flow, yet it fails to produce gastric juice, so the fundamental reason for not eating remains unresolved. I believe it’s better to use Da Chaihu Tang combined with gypsum, pollen, and Renshen, which can both attack the reverse flow and stimulate appetite, achieving both goals simultaneously, and addressing the issue of refusal to eat, which no previous theory has covered. I’ve now realized the practical truth behind this, and I’m loudly calling for it, hoping to contribute to the country through writing. Although I can’t do it myself, perhaps I can invent a method that will benefit the people a little bit.

Looking at various books, opinions on dysentery vary. Zhang Jingyue advocates warming, Zhu Danxi advocates cooling, Yu Jiayan advocates sweating and promoting water elimination, and Chen Xiuyuan advocates combining cold and heat—each has its own rationale. Jingyue argues that in summer, people tend to seek too much coolness, leading to a mix of cold and heat remedies. For example, in the case treated by Zhang Zhongjing’s Wumei Wan, there’s thirst, qi rushing to the heart, burning sensation in the chest, and lack of appetite—this is solid evidence of a heat condition. Eating leads to vomiting worms, and diarrhea doesn’t stop—this is solid evidence of a cold condition. Because there’s evidence of both heat in the stomach and cold in the intestines, Wumei Wan is used to treat both simultaneously. Another example is Zhang Zhongjing’s Ginger Heart-Soothing Soup, which treats cases like: “Hard lump in the stomach, belching with a sour smell.” This is a fire condition; “Water in the flanks, thundering in the abdomen,” this is a water condition. Because there’s evidence of fire in the stomach and water in the intestines, Ginger Heart-Soothing Soup is used to treat these conditions. Initially, the stomach feels hard, and the second half of the stool is loose—this indicates cold in the stomach and heat in the intestines, and Chen Xiuyuan suggests using Lizhong Tang with Dahuang, which provides evidence of both cold and heat. Doctors must diagnose cases with such rigor before prescribing medication, ensuring precision down to the smallest detail. These four approaches can be combined to treat dysentery without fear of being helpless.

Huang Kunzai said: “The reason human stool doesn’t lose its normal state is that the lungs are responsible for transporting it, while the intestines never stop, and the liver is responsible for releasing it, but the anus doesn’t close. It’s best to use ginseng and poria to assist lung transport, and cinnamon twig to assist liver release.” This is Huang’s statement about constipation. I’ve drawn inspiration from this statement and applied it to dysentery. I’ve learned that when the lungs push too hard, the stool rushes into the large intestine; when the liver qi is stagnant and can’t be released, the anus closes, making it difficult to pass stool, leading to bloating. This conclusion is derived from Huang’s theory, and it explains why dysentery often occurs without proper passage. However, cinnamon twig, ginseng, and poria don’t fit well with dysentery. The lungs’ urgent push is due to intense heat, so according to "Treatise on Cold Damage," when food enters the stomach, if the diarrhea is simply clear water with complete digestion, it’s because the lungs are pushing too hard and the heat is too intense, so it’s necessary to act quickly. Based on this, those who are rushing should primarily focus on clearing heat, using Renshen Qingfei and Qingfei Two Soups to treat them. The liver qi can’t be released either, because the wood is bound by fire, creating stagnation. Cinnamon twig warms the wood, which increases the fire, raising concerns about self-immolation. Looking at Zhang Zhongjing’s White Headed Elderflower Soup, which uses Qin Pi and white head elderflower to cool the wood, and Si Ni San, which adds leek to relieve stagnation, we can see that there are ways to assist liver release. Using Guizhi, Lu Hui, and Danggui to treat the liver, and using Danzhi Xiaoyao San with adjustments to treat the liver and lungs together—this kind of integrated treatment of liver and lungs has never existed before. I plan to use White Headed Elderflower Soup combined with gypsum, Zhi Mu, apricot kernels, Jie Geng, Zhike, betel nut, malt, Danggui, Baishao, and licorice to treat it. For lighter cases, use Xiao Chaihu with Danggui, Baishao, apricot kernels, Jie Geng, Zhike, betel nut, malt, and pollen to harmonize the liver and lungs, so the lungs won’t push too hard and the liver will be able to release freely. Alternatively, if the liver wants to release but the lungs don’t want to receive, and dysentery often occurs in autumn, when the metal element of the lungs is closed and the wood element of the liver is broken, leading to pain, this can also be explained from Huang’s perspective, offering another interpretation that hasn’t been recorded in any book. The appropriate remedy is Gan Ju Tang with Baishao, using Jie Geng to open the lungs and Baishao to calm the wood. With this approach, ingredients like turtle shell, dragon’s beard, green skin, Qin Pi, and aloe vera are all liver-calming drugs, while Danggui, Sheng Di, peach kernel, five spirit substances, and Yan Hu Suo are all liver-blood-treating drugs, Huang Qin, Mai Men Dong, mulberry bark, and Zhi Mu are all lung-clearing drugs, and Zhike, Beimu, apricot kernels, and Chen Pi are all lung-regulating drugs. Depending on the situation, these can be used flexibly, and there’s no dysentery that can’t be treated.

“Regulating blood will naturally cure pus in the stool, and regulating qi will naturally eliminate tenesmus,” these two phrases have been the standard method for treating dysentery for thousands of years, and they’re also the conventional approach passed down through generations. However, if we talk about regulating blood in general, Danggui, Baishao, and Diyu are exhausted without effect; if we talk about regulating qi in general, Chen Pi and Muxiang are taken repeatedly without success. People don’t realize that Muxiang and Chen Pi are actually medicines for regulating spleen qi, and although dysentery is a spleen disease, the real culprit behind the rush is the liver and lungs (20). Knowing how to regulate the liver and lungs means knowing how to regulate qi effectively. Blood is managed by the Blood Sea, which resides in the large intestine, so patients with extreme pain below the navel due to dysentery will definitely have pus in their stool, while those with milder pain won’t have pus, because the Blood Sea below the navel is painful. Understanding the Blood Sea means understanding how to treat blood effectively.

Pumingzi (21) believes that dysentery often comes with food stagnation, so it’s best to use Zhike, Hou Pu, and Dahuang; for milder cases, use hawthorn, Shen Qu, radish seeds, and malt. This view is the most basic yet most accurate.

If dysentery persists for a long time, the lung qi will leak downward, dragging the soul along with it, and when the soul leaves, death follows. The lungs store the soul, so treatment should focus on replenishing lung qi, using Renshen Qingfei Tang to strengthen it. For those with cold and slippery conditions, Taohua Tang is used. Zhang Zhongjing’s He Li Le San is also a formula for strengthening the lungs and preventing soul loss. Four Gods Pill and Wumei Wan both carry the meaning of Taohua Tang. There are many formulas, but they all require balancing cold and heat, and there’s no mistake in doing so.

For those who recover from dysentery only to relapse, it’s because the astringent treatment was applied too early, leaving the pathogen inside, which causes repeated outbreaks. Treatment should follow the above methods for treating dysentery, choosing the appropriate medicine based on which meridian is affected, to eliminate the pathogen. Once the pathogen is gone, it won’t reappear. For example, using sheep fat, white honey, and powdered Dahuang is only to make things slippery and remove stickiness, with the intention of clearing heat. It’s even better to choose medicines based on the specific symptoms of the pathogen, which is more targeted.

Another supplementary comment: for all cases of “closed-mouth dysentery” (22)—those with upper closure and lower diarrhea—the treatment should focus on balancing the middle. This is evident when compared with cholera. Cholera involves vomiting and diarrhea, and it’s cured by balancing the middle, so we know that closed-mouth dysentery, with upper closure and lower diarrhea, should also be cured by balancing the middle. However, cholera is caused by cold in the middle, resulting in both upper and lower parts being empty, so the main treatment is Lizhong Tang to warm it up. Closed-mouth dysentery, on the other hand, has heat in the middle, with heat concentrated in the middle and both upper and lower parts blocked, so the treatment should reverse the effects of Lizhong Tang by using cold medicines, such as Ginger Heart-Soothing Soup without dried ginger, and Renshen Baihu Soup is also good.

[Notes] (1) Oil membrane: refers to the greater omentum. (2) Grease: the dissolved product of fat, here referring to the viscous substance in the intestines. (3) Article 258 of "Treatise on Cold Damage." (4) Article 308 of "Treatise on Cold Damage." (5) Article 367 of "Treatise on Cold Damage." (6) Article 306 of "Treatise on Cold Damage." (7) Vastly different: “Jing” means path, “Ting” means courtyard. Used metaphorically to describe a huge difference. (8) Scorching summer melts gold: describes extremely intense summer heat that seems capable of melting even metal. (9) Cool breeze shakes leaves: refers to the autumn wind blowing and shaking leaves. “Biao” means strong wind or storm; “Zhen” means shaking or vibrating. (10) Summer cloth: fabric woven from kudzu stem fibers, lightweight and cool, suitable for summer wear. (11) Winter coat: fur clothing worn in winter. (12) Puddles swell with sweat: “Xinglao” refers to standing water by the roadside after rain. “Han” means dirty; “Han zhang” means the dirt keeps growing. (13) Wet diarrhea: also known as damp diarrhea. According to "Plain Questions · On the Great Principle of Yin-Yang Correspondence," "When dampness prevails, wet diarrhea occurs." (14) Stagnant in traces: “Stagnant” means stuck or rigid; “Yu” means similar to. “Traces” refers to surface phenomena. (15) Method of pulling the boat against the current: when dysentery first breaks out, use methods to dispel the surface symptoms, as advocated by Yu Jiayan with “Renshen Bai Du San” and modifications. (16) Article 157 of "Treatise on Cold Damage." (17) Zhu: an ancient unit of weight. One Zhu equals one twenty-fourth of a tael at the time. (18) Huang Kunzai: a famous physician from the Qing Dynasty. Author of "Treatise on Cold Damage Suspended Explanation," "Golden Treasury Suspended Explanation," "Difficult Classic Suspended Explanation," among others. (19) Ji: means to restrain or collect. (20) Gu: means fault or negligence. (21) Pumingzi: also known as Cheng Zhongling. Physician from the Qing Dynasty. Author of "Medical Insight." (22) Closed-mouth dysentery: refers to dysentery accompanied by refusal to eat or inability to vomit.

[Commentary] This condition appears in both abscesses with pus and dysentery. Abscesses with pus in the lower jiao may lead to pus in the stool after rupture, but this accounts for only a small fraction of all cases of pus in the stool; the vast majority of cases of pus in the stool occur in dysentery. This article discusses the mechanisms and treatments for various types of pus in the stool associated with dysentery, presenting concise and to-the-point explanations, apt metaphors, and meticulous reasoning, making it truly clinically instructive in terms of understanding and treating dysentery. The author believes that "when qi is stagnated by blood, pain arises," and "when blood is steamed by qi, it transforms into pus." Consequently, dysentery manifests as two main symptoms: tenesmus and purulent-bloody stools. Among these, when pus predominates, it is called white dysentery; when blood predominates, it is called red dysentery. White dysentery indicates a disorder in the water aspect of the body, i.e., excessive dampness causing disease; red dysentery indicates a disorder in the blood aspect, i.e., blood heat leading to illness. Within white dysentery, there are distinctions between damp-heat and cold-damp types: for damp-heat, one should clear heat and drain dampness using Si Ni San combined with Zhu Ling Tang, omitting E Jiao and adding Huang Qin and Lian Zi; for cold-damp, one should warm and disperse cold-damp using Wei Ling Tang with roasted ginger. Since white dysentery is fundamentally a water-related disorder, treatment must also address water. Based on the view that "qi is essentially water," the author proposes that regulating lung qi is an effective method to "clear the source of water," and uses Ren Shen Qing Fei Tang to treat white dysentery, achieving good clinical results. Most cases of red dysentery are due to blood heat, but some are due to deficiency-cold; the former are treated with Di Yu San plus wine, coix seed, etc., while the latter use Huang Tu Tang with modifications. Red dysentery is a disorder of the blood aspect, closely related to the liver—partly because the liver governs "phase fire," and partly because the liver stores blood. Therefore, treatment should focus on regulating the liver: clinically, Xiao Chai Hu Tang, Si Wu Tang, and Bai Tou Weng Tang are used to regulate liver qi; Gou Teng, Sang Ji Sheng, Jiang Can, and Chan Yi are employed to dispel liver wind; Xiang Fu, Qing Pi, and Bin Lang are used to relieve liver depression; Dan Cao and Huang Qin are used to clear liver heat; and Tao Ren, Di Yu, and Wu Ling Zhi are used to invigorate the liver and promote blood circulation. The author states: "Once one understands how to regulate the liver, treating blood dysentery becomes easy." This demonstrates the importance of liver regulation in treating blood dysentery. This viewpoint is original to the author and constitutes one of the important theories in traditional Chinese medicine for treating dysentery, representing a significant contribution to the field.

In dysentery, if toxins accumulate in the intestines and stomach, or if fat, flesh, and blood are transformed into pus, resulting in stools resembling rotten melons or leaking like a roof, this signifies a critical condition of intestinal decay and gastric ulceration, which cannot be cured by ordinary dysentery treatments. The author employs Fang Feng Tong Sheng San, omitting Mang Xiao and Ma Huang, adding Chi Dou and Fang Ji, to achieve dual exterior-exterior treatment. For cases where pus formation leads to deficiency, the author uses Peach Blossom Decoction from the Treatise on Cold Damage to treat them. Dysentery characterized by refusal to eat is called "silent dysentery," often caused by damp-heat ascending to damage the stomach qi. The author adopts a combined Chinese-Western perspective, believing that at such times, the gastric juices are saturated with damp-heat, becoming "completely turbid and stagnant" and unable to perform normal digestive functions. Treatment for this condition should combine clearing heat and draining dampness with nourishing the gastric juices. Therefore, the author points out that Zhu Dan Xi's Shi Lian Tang, due to its astringent and stagnant nature, is ineffective in removing turbidity from the stomach; and the Da Huang Huang Lian compound from the Golden Mirror only clears heat and drains dampness without nourishing the gastric juices, making both unsuitable for this condition. Instead, the author advocates using Da Chai Hu Tang with gypsum, flower pollen, and ginseng to attack the root cause and generate fluids, addressing both aspects simultaneously. The author emphasizes that the introduction of this formula was motivated by the idea of "contributing to the country through scholarship."

Tang also believes that all other theories on treating dysentery fall within the scope of the principles outlined in the Treatise on Cold Damage. Zhang Jing Yue advocates warming medicines for dysentery, using Zuo Guan Jian, which incorporates the ideas of Si Ni Tang and Peach Blossom Decoction; Zhu Dan Xi advocates clearing heat and draining dampness, using Huang Lian Jie Du Tang, which incorporates the ideas of Bai Tou Weng Tang; Yu Jia Yan advocates reversing the flow of water to rescue the boat, using Ren Shen Bai Du San, which incorporates the ideas of Ge Gen Qin Lian Tang; Yu further advocates rapidly opening up the river to allow damp-heat to be expelled through urination, aligning with the principle in the Treatise on Cold Damage that "if diarrhea does not stop, one should promote urination"; Chen Xiu Yuan advocates using both cooling and warming methods, employing Li Zhong Tang with rhubarb and applying the same principles as various heart-clearing decoctions and Wu Mei Wan from the Treatise on Cold Damage. The author agrees with Huang Kun Zai's view that "the lungs are responsible for transmission while the intestines do not stop, and the liver is responsible for dispersal while the anus does not close," thus the symptoms of dysentery arise from "excessive lung qi, sudden overflow into the large intestine, and stagnation of liver qi, leading to closure of the anus." Therefore, the author proposes a treatment principle of simultaneous liver-lung regulation for dysentery, formulating Bai Tou Weng Tang with gypsum, zhi mu, apricot kernel, platycodon, betel nut, bupleurum, malt, angelica, white peony, and licorice—a method that balances lung regulation and liver relaxation—and achieving good clinical results. This represents another creative experience of the author in treating dysentery.