Library

Hematochezia (bleeding from the rectum) and Changpi (dysentery, characterized by pus and blood in stool due to diarrhea) are fundamentally different conditions. Hematochezia refers to bleeding that occurs spontaneously while the stool is generally formed; Changpi refers to the presence of pus and blood resulting from dysenteric diarrhea, which is essentially dysentery. As stated in the *Neijing* (Inner Canon): "Those who do not regulate their diet or maintain irregular daily routines will suffer Yin pathogenic invasion." When Yin is invaded, the pathogen enters the Five Zang organs. Once inside the Zang organs, it causes abdominal fullness and obstruction, manifesting downward as undigested food diarrhea (Sunxie). If prolonged, it develops into Changpi. This demonstrates that Changpi originates from diarrhea and is distinct from hematochezia, with different treatment approaches. Furthermore, hematochezia often involves chronic underlying conditions, whereas Changpi is typically caused by new external pathogens, making them relatively easy to distinguish. Many medical texts erroneously conflate these two conditions. Here, the syndrome differentiation and treatment for hematochezia are listed, while the discussion on Changpi is reserved for the Dysentery chapter. Therefore, when encountering such cases, one must carefully observe whether the stool is dry or loose to avoid misdiagnosis. However, individuals who consume excessive alcohol often suffer from loose stools and may also experience hematochezia; this should not be mistaken for Changpi simply because diarrhea is present.

1. Blood in the stool is mostly caused by Fire in the Stomach and Intestines. The Large Intestine and Small Intestine both belong to the Stomach. If blood appears before the stool, the source is near, located either in the Guangchang (lower rectum) or the anus. If blood appears after the stool, the source is distant, located either in the Small Intestine or the Stomach. Although reckless bleeding is mostly due to Fire, it is not exclusively so. Besides Fire syndromes, there are cases where Spleen and Stomach Yang deficiency fails to control the blood, cases where Qi sinking causes blood to sink with it, cases where chronic slippery diarrhea triggers bleeding, and cases where Wind pathogen knots in the Yin aspect causing hematochezia. Generally, bleeding due to Fire stems from Blood Heat, while bleeding without Fire stems from Deficiency and Slipperiness. Thus, treating bleeding requires understanding the key principles of Excess and Deficiency.

2. For bleeding caused by Fire, clearing heat is the primary method. Yueying Decoction (Yueying Jian) is the best choice, followed by Diyush San, Huaihua San, Huanglian Wan, and Huaijiao Wan. If heat resides between the Stomach, Spleen, and Small Intestine with severe Fire, Chouxin Yin or Huanglian Jiedu Tang should be used. For those with inherent intestinal Fire suffering from long-term internal toxin bleeding that does not heal, Zanglian Wan or Zhuzang Wan are indicated. For bleeding due to Wind-Heat in the Large Intestine that does not stop, Fangfeng Huangqin Wan is appropriate.

3. For bleeding caused by Wine-Toxin and Damp-Heat accumulating in the Large Intestine, Yueying Jian, Ju Jin Wan, or Huaijiao Wan should be used. For bleeding caused solely by Cold-Dampness without Fire, Erzhu Jian or Sijunzi Tang is suitable, and Gegua Jiecheng Tang is also excellent.

4. For bleeding due to Spleen and Stomach Qi Deficiency, the blood is rarely bright red; it may be purple or black, indicating Yang failure. Consequently, Heat signs are usually absent, though nausea and vomiting may occur. Since the Spleen controls blood, Spleen Qi deficiency leads to an inability to contain blood. Since the Spleen transforms blood, Spleen Qi deficiency leads to an inability to metabolize it, leaving blood without a master. This results in leakage and reckless movement. Immediate warming and tonification of the Spleen and Stomach are required, using Shoupi Jian, Lizhong Tang, Yangzhong Jian, Guipi Tang, or Shiquan Dabu Tang.

5. For bleeding due to Qi sinking and failing to rise, Buzhong Yiqi Tang, Shoupi Jian, or Guipi Tang should be used. If there is mild sinking accompanied by Fire, Dongyuan's Modified Siwu Tang is indicated. For severe Qi Deficiency with significant sinking, Juyuan Jian is appropriate.

6. For slippery, unceasing bleeding, whether due to chronic illness, aging, Qi deficiency, or misuse of attacking drugs leading to Qi sinking and slipperiness: Initially, bleeding is mostly due to Fire. Once the Fire pathogen subsides but bleeding continues, it is either Deficiency or Slipperiness. Such cases require astringency as the main approach, using Shengjin Wan or Xiangmei Wan. However, since slippery bleeding is often due to Qi deficiency, administering it with Renshen Tang is particularly effective. Alternatively, Buzhong Yiqi Tang, Guipi Tang, Juyuan Jian, or Lizhong Tang combined with Wumei, Wen Ge, and Wuweizi can be used. For extremely severe slipperiness that cannot be stopped, Yuguan Wan is the best option.

7. Jieyin Hematochezia (Knotting Yin Bleeding) is caused by Wind-Cold pathogen knotting in the Yin aspect. This differs from Shanghan (Cold Damage), as the pathogen remains lodged in the Five Zang organs without departing, termed "Jieyin." When pathogen knots internally and cannot move outward, the disease returns to the Blood aspect, causing hematochezia. The Classics state: "In Jieyin, one episode yields one sheng of blood, a second knot yields two sheng, a third knot yields three sheng," referring precisely to this condition. Treatment involves external moxibustion at Zhongwan, Qihai, and Zusanli to disperse Wind pathogen, and internally using Pingwei Diyutang or similar warming-dispersing formulas.

8. Anger injuring the Liver, causing blood to descend due to rebellious Qi, should be treated with Huagan Jian or Zhike Tang. If the rebellious Qi dissipates but slight Fire remains, Huangqin Shaoyao Tang is indicated. If Liver Pathogen invades the Stomach, causing Spleen Deficiency and blood loss, there will naturally be no irritability, heat, or rebellious Qi symptoms. In such cases, treat according to the aforementioned Spleen-Stomach Qi Deficiency protocols; do not soothe the Liver to further injure Spleen Qi.

9. Bleeding caused by fatigue, Seven Emotions, or internal injury leading to insufficiency affects either the Heart and Spleen or the Liver and Kidneys. Because the Middle Qi is injured, symptoms may include nausea, epigastric fullness, pain, diarrhea, alternating chills and fever, or loss of appetite. Contemporary physicians often fail to identify the root cause. Upon seeing these symptoms, they attribute them to Qi stagnation or Phlegm-Fire, indiscriminately using cold-natured herbs and aggressive attacks. This double injury leads to lingering and worsening conditions. Eventually, large amounts of dark purple-black spoiled blood may appear in the stool, indicating severe damage to Stomach Qi and exhaustion of Spleen Yuan, causing blood to lose its control and flow downward. Yang failure within Yin results in gray-black coloration. This is a critical condition; even immediate use of Yang-restoring agents may be insufficient. Yet, such practitioners claim, "Since bleeding is present, how can warm medicines be used? It will surely cause death." Alas, the victims are pitiable, and those who harm others are detestable.