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(Su Wen: Treatise on Reviewing Excess and Deficiency in General, Appendix: Treatment Methods for Dysentery)

The Yellow Emperor asked: What is the prognosis for Changpi (Intestinal Turbidity/Dysentery) presenting with hematochezia (blood in stool)? Qibo replied: If the body is hot, death ensues; if the body is cold (afebrile), life is preserved. (Changpi refers to "Zhi Xia" (stagnant downward flow), characterized by tenesmus or difficult defecation. Hematochezia refers to red dysentery. Body heat indicates yang excess and yin exhaustion, hence death. Afebrile condition indicates that Ying Qi (nutritive energy) remains undamaged, hence survival. The character Pi is pronounced 'pi'.)

The Yellow Emperor asked: What is the prognosis for Changpi presenting with white mucus? Qibo replied: A sinking pulse indicates survival; a floating pulse indicates death. (White mucus refers to white dysentery. When the disease is in the Yin aspect and presents with a Yin pulse, it is a favorable sign, hence survival. Presenting with a Yang pulse is an unfavorable sign, hence death.)

The Yellow Emperor asked: What is the prognosis for Changpi presenting with pus and blood? Qibo replied: A hanging and severed pulse (extreme abnormality) indicates death; a slippery and large pulse indicates survival. (Pus and blood refer to a combination of white and red dysentery. "Hanging and severed" means either excessively strong and hard/beating, or extremely weak and fading; both indicate the departure of Stomach Qi and the appearance of the True Zang pulse. With pathogenic excess and healthy deficiency, the situation is diametrically opposed, hence death. A slippery pulse indicates abundant blood; a large pulse indicates abundant Qi. Since blood and Qi are not damaged, survival is indicated.)

The Yellow Emperor asked: In cases of Changpi, if the body is not hot and the pulse is not hanging/severed, what is the prognosis? Qibo replied: A slippery and large pulse indicates survival; a hanging and choppy pulse indicates death. One can predict the time of death based on the Zang organs. (Predicting based on Zang organs means: Liver failure occurs on Geng/Xin days; Heart failure on Ren/Gui days; Lung failure on Bing/Ding days; Spleen failure on Jia/Yi days; Kidney failure on Wu/Ji days. My commentary: The syndrome of Changpi is what is now called dysentery. Since Zhang Zhongjing, it has also been called "Zhi Xia". The excretions may be red or white, purulent or bloody; there may be pain or no pain, tenesmus, vomiting, nausea, abdominal distension, inability to eat due to throat constriction ("Jin Kou"), or alternating chills and fever. Although manifestations are varied, they ultimately fall under exterior-interior and cold-heat categories, with the distinction between excess and deficiency being particularly crucial. Understanding these six aspects will prevent fatal errors. Regarding exterior-interior: As stated in chapters like "Diagnosing Disease by Observing the Forearm", wind injury in spring leads to late diarrhea and Changpi in summer. In "Chapter on the Origin of All Diseases", it says when deficient pathogens enter and remain, transmitting to the intestines and stomach, excessive cold causes borborygmus and un-digested stool, while excessive heat causes loose, mushy stools. These result from external pathogens, belonging to seasonal transmission. Any pathogen entering via the exterior must have exterior signs; resolving the exterior pathogen allows the dysentery to heal spontaneously. Without exterior signs, it must stem from dietary/internal injury. Internal injuries are common; external ones are rare. Thus, distinguishing internal from external causes is essential. Regarding cold-heat: Ancient texts held red as heat and white as cold. Liu Hejian refuted this, asking if mixed red-and-white implies both cold and heat severely affecting the intestines simultaneously. He argued white represents Lung color, green Liver, yellow Spleen, red Heart. Black is also considered heat because extreme fire mimics water transformation. Claiming green/white dysentery is cold is erroneous; true cold cannot digest grain into pus. He further stated: Complete undigested food with unchanged color, foul vomiting/diarrhea, clear/cold excretions, clear urine without strangury, cool body without thirst, and slow/thin/fine pulse indicate cold syndrome. Digestion of grain indicates heat regardless of other signs. His treatment principle: Bitterness dries dampness, cold overcomes heat, occasionally aided by acrid-warm herbs. He prescribed Huanglian (Coptidis Rhizoma) and Huangbai (Phellodendri Cortex) as sovereign drugs for their bitter-cold nature to treat damp-heat. He also said: Moving blood heals bleeding; regulating Qi relieves tenesmus. These are Hejian's views. Zhu Danxi followed, stating red dysentery originates from the Small Intestine, white from the Large Intestine, both rooted in damp-heat. Since their words, later generations dared not deviate. Though their formularies contained warm treatments, these were mere supplements; the main theme was damp-heat. Consequently, modern physicians follow this dogma: seeing dysentery, regardless of cold/heat/excess/deficiency, they insist on clearing fire with Huangqin (Scutellariae Radix), Huanglian, Zhizi (Gardeniae Fructus), Huangbai; removing stagnation with Dahuang (Rhei Radix et Rhizoma), Mangxiao (Natrii Sulfas); moving blood with Taoren (Persicae Semen), Honghua (Carthami Flos); draining dampness with Wuling San (Five-Ingredient Powder with Poria) and Yiyuan San; regulating Qi with Muxiang (Aucklandiae Radix), Binglang (Arecae Semen), Zhishi (Aurantii Fructus Immaturus), Houpo (Magnoliae Officinalis Cortex); harmonizing/cooling blood with Danggui (Angelicae Sinensis Radix), Shengdi (Rehmanniae Radix), Shaoyao (Paeoniae Radix), Diyu (Sanguisorbae Radix). They change prescriptions frequently but achieve little, yet at the brink of death, still claim damp-heat and stagnation persist. This universal error causes immense harm. I disagree. Malaria and dysentery occur in summer/autumn due to humid heat; surely this is heat? However, if one follows heavenly climate naturally, illness does not arise. Illness comes from human behavior: seeking coolness excessively leads to pathology. External wind-cold affects meridians, causing malaria; internal cold-damage affects viscera, causing dysentery; simultaneous damage causes both. No malaria or dysentery arises without cold invasion; thus, the root is often cold, though long-standing damp-heat turns to heat, making many cases appear hot. But sudden onset from raw fruits/vegetables isn't necessarily stagnant heat. Those who guard their diet may catch dysentery from rainy season cold or conflicting foods—where is the heat here? Elderly or weak individuals are susceptible; are all cases hot? Dysentery always involves pus/blood due to damage to visceral fat and intestinal vessels; thus, both cold and heat can produce pus/blood. To say pus implies only heat denies cold dysentery exists. Waiting for undigested food, unchanged color, or clear/cold excretions to diagnose cold means Yang is already exhausted and Spleen ruined; this is a late stage. Early stages are often cold. Dampness generates from Earth. Heat transforms via Fire; Cold via Water. Wet Earth participates in all four seasons; following Fire yields Yang excess and damp-heat; following Water yields Yin deficiency and cold-damp. Ignoring cold-damp is a medical error. Differentiating cold/heat by white/red is ancient and valid. Hejian linked white to Lung (Qi) and red to Heart (Blood), which is reasonable. However, red may contain white, and white may contain red; mixed colors don't necessarily mean simultaneous cold-heat pathology, but rather varying degrees of clarity/turbidity distinguish Yin/Yang. Red dysentery can be cold (though usually more heat); white dysentery can be heat (though usually more cold). White with heat shows heat pulses/symptoms; red with cold shows cold pulses/symptoms—these are easy to distinguish. Attributing white solely to Lung ignores blood transformation; attributing red solely to Heart ignores Qi dynamics. *Ju Fang* uses warm herbs for dysentery; Hejian uses bitter-cold. Their approaches differ vastly, each biased, missing the Mean. Thus, cold-heat must be distinguished. Regarding excess-deficiency: Headache, body heat, bone/joint ache indicate exterior excess. Distension, fullness, aversion to pressure, acute pain indicate interior excess. Restlessness, thirst, preference for cold, fear of heat indicate Yang excess. Slippery/rapid, forceful pulses indicate pulse excess. Dominance of Fire/Earth elements indicates seasonal excess. Outside these, most are deficiency. Some mistake thirst for excess-heat, forgetting dysentery loses fluids; lower loss causes upper dryness/thirst. Distinguish by preference for hot/cold drinks. Some mistake abdominal pain for excess, forgetting dysentery damages intestines; pus/blood cutting flesh causes pain. Distinguish by pain severity, tenderness, Zang/Yang status, and abdominal distension. Some mistake dark/scanty urine for excess-heat, forgetting fluid loss via dysentery reduces urine volume and changes color. Distinguish by stool temperature and fluid hydration. Some mistake tenesmus for excess-heat, attributing it only to damp-heat obstruction in Large Intestine. Actually, Qi sinking prevents storage; Yin loss prevents closure. Distinguish by disease duration and constitution strength. Confusing pathogen and healthy Qi leads to rapid disaster; thus, excess-deficiency must be distinguished. Regarding treatment: Seek the pathogen and affected Zang to identify the root; other symptoms are branches. Remove damp-heat if caused by damp-heat; remove stagnation if caused by stagnation. Regulate Qi for Qi issues; harmonize Blood for Blood issues. New/excess cases may use "treat obstruction with purgatives" (Tong Yin Yong Tong); old/deficient cases use "treat obstruction with tonification" (Sai Yin Sai Sai). These are standard. However, modern dysentery patients are 60-70% deficient, yet doctors rarely use tonification. If Qi is sunk, moving Qi worsens tenesmus. If Middle is deficient, attacking stagnation exhausts Yuan Qi. Damp-heat damaging Blood requires blood harmonization; overusing purgatives harms Blood further. Fluid loss causing thirst requires stopping diarrhea; overusing diuretics depletes fluids further. Waiting for blood purification and pain cessation before tonifying is too late. This stems from confusing root and branch, focusing on visible disease while ignoring invisible Yuan Qi. Once Yuan Qi is deficient, how else to restore it? Tonification indications are clear: Weak pulse indicates non-excess, so tonify. Emaciation indicates inability to withstand attack, so tonify. Dietary caution suggests no accumulation, so tonify. Comfortable chest/diaphragm suggests no retention, so tonify. Post-illness infection indicates injured Qi, so tonify. Worsening after attack indicates inappropriate attack, so tonify. Tenesmus amenable to tonification: Sink it, lift and tonify; Heat it, cool and tonify. Abdominal pain amenable to tonification: Loose stool, astringe and tonify; Deficient-cold, warm and tonify. Yang excess leading to Yin deficiency requires sweet-cool agents to nourish Zang Qi. Yin excess leading to Yang deficiency requires acrid-sweet-warm agents to restore Yuan Yang. These are tonification methods. Crucially, focus on Spleen and Kidney. *Weisheng Baojian* states Taiyin governs diarrhea, transmitting to Shaoyin as dysentery, referring to Spleen/Kidney. Diarrhea from Spleen is shallow; progression to Kidney as dysentery is severe. Kidney is the Gate of Stomach, opening to two yin orifices. Long-term dysentery inevitably depletes Yin; Yin depletion inevitably weakens Kidney. Treating dysentery without treating Kidney Yin is incorrect. Formulas like Sijunzi Tang (Four-Gentlemen Decoction), Guipi Tang (Restore the Spleen Decoction), Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction), and Shiquan Dabu Tang (Ten-Increment Great Tonic Decoction) treat Spleen deficiency and are good; however, if the disease originates in the Source (Kidney) and is critical, merely tonifying Spleen is insufficient. One must greatly tonify Mingmen (Gate of Life) to restore Kidney Yang, strengthening the Mother of Spleen Earth. Otherwise, how can True Yin recover? How can the gate be secured? If the source is not filled, the leak cannot be stopped. Only Xue Lizhai grasped this principle; consult his case records for reference.)