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Blood stasis in the large and small intestines, as well as hematochezia (blood in stool), whether due to Shanghan (Cold Damage) or Shi Yi (Epidemic Febrile Disease), is generally caused by failure to use purgatives. The pathogenic heat lingers for a long time without an outlet to vent. Blood is constrained by the heat, remains in the collaterals, decomposes into purple blood, overflows into the stomach and intestines, and rots into black blood. The stool color is like lacquer. Although defecation may seem easier because the dry feces are moistened by the blood stasis and descend, even if the dry feces pass, the vital essence (Zhen Yuan) has already been depleted, often leading to a critical condition.

Those who exhibit forgetfulness and a manic-like state have this condition because stomach heat affects the blood level. Since blood belongs to the Heart, fire retained in the blood spreads to disturb the Heart spirit, hence these symptoms. Treatment should still focus on the Stomach (clearing heat).

The syndrome of jaundice arises when excess heat in the Stomach fails to be purged, causing obstruction in both the interior and exterior, leading to stagnation and yellowing. If heat cannot vent and constrains blood to form stasis, it becomes complicated. Generally, if heat circulates in the Qi level without stagnation, jaundice does not occur; if heat does not interfere with the Blood level, blood stasis does not accumulate. Since both are affected by the same pathogen, jaundice may coexist with blood stasis, but this is not blood stasis causing jaundice. Once blood stasis is resolved, heat vents with the blood, and jaundice diminishes accordingly. I have observed patients with jaundice who originally had no blood stasis, and patients with blood stasis who originally did not have jaundice. Therefore, the cause of jaundice lies in stagnant heat in the meridians; treating only blood stasis would be a mistake.

When Stomach heat transfers to the Qi level of the Lower Jiao, resulting in difficult urination, this is heat binding the Bladder. When heat transfers to the Blood level of the Lower Jiao, it results in blood stasis in the Bladder. A hard and full sensation in the lower abdomen might suggest difficult urination, but if urination is now free and unobstructed, the cause must be attributed to blood stasis. Note that difficult urination can also be associated with blood stasis; it is not the case that only free urination indicates blood stasis.

If Stomach excess heat is not purged and fever occurs at night, this is heat remaining in the Blood level. Further failure to purge will inevitably lead to blood stasis. Initially, there is fever day and night, worsening in the late afternoon. After administering Chengqi Tang, if daytime fever subsides but night fever persists alone, it indicates that blood stasis has not yet moved. Tao Ren Chengqi Tang is indicated. After taking the decoction, if the fever disappears, the patient recovers. If the duration of fever shortens each time the medicine is taken, until the blood stasis is exhausted and the fever completely resolves. If the major pathogenic factors have passed but excessive blood loss has occurred, leaving residual heat, Xijiao Dihuang Tang is suitable to regulate the condition.

Nighttime fever can also be caused by Dan Nue (Malaria with high fever) or Re Ru Xue Shi (Heat entering the Blood Chamber). These are not blood stasis and should not be treated with purgatives; careful differentiation is required.

Tao Ren Chengqi Tang
Dahuang (Rhei Radix et Rhizoma)
Mangxiao (Natrii Sulfas)
Taoren (Persicae Semen)
Danggui (Angelicae Sinensis Radix)
Shaoyao (Paeoniae Radix Alba)
Danpi (Moutan Cortex)
Prepare and administer according to standard decoction methods.

Xijiao Dihuang Tang
Dihuang (Rehmanniae Radix Praeparata) - 1 liang
Baishao (Paeoniae Radix Alba) - 3 qian
Danpi (Moutan Cortex) - 2 qian
Xijiao (Rhino Ceratis Cornu) - 2 qian, crushed
First, moisten Dihuang with warm water until soft, slice it with a copper knife, and pound it in a stone mortar until pulpy. Add water to make a paste, squeeze out the juice, and set aside. Put the dregs back into the medicinal pot to decoct with other herbs. After decoction, remove the dregs, and mix with the previously prepared juice before administration.

Commentary: In Shanghan, if the Taiyang disease does not resolve, the pathogen transmits from the meridians to the fu organs, causing heat to bind the Bladder. The patient exhibits a manic-like state. If blood stasis discharges spontaneously, the disease heals. If blood stasis does not move, Didang Tang is indicated. However, Wenyi (Warm Epidemic) diseases begin without exterior syndromes and present primarily with Stomach excess. Therefore, blood stasis in the stomach and intestines is common, while blood stasis in the Bladder is rare. Nevertheless, Didang Tang is the most potent formula for moving stasis and expelling accumulation, applicable to both anterior (urinary) and posterior (intestinal) blood stasis. For severe cases where Tao Ren Chengqi Tang is insufficient, Didang Tang is appropriate. It is named "Didang" because only such a potent and fierce agent can withstand (di dang) such severe stasis. However, indications for Didang Tang are rare; this is included for emergency reference.

Didang Tang
Dahuang (Rhei Radix et Rhizoma) - 5 qian
Mengchong (Blaberus spp.) - 20 pieces, roasted dry, powdered
Taoren (Persicae Semen) - 5 qian, ground with wine
Shizhi (Hirudo) - Roasted dry, powdered, 5 fen
Prepare and administer according to standard decoction methods.