Blood in the Stool After a Bowel Movement? Doctor Zhang Xichun’s Baitouweng Tang (Pulsatilla Decoction) Variation for Liver Fire Stirring Blood with Heart-Spleen Deficiency
Patient search terms: blood in the stool / bleeding after a bowel movement / blood with the feces / bloody stool / a large amount of blood with the stool Medical terms: bloody stool (bian xue) · heat agitating blood and making it run wild · liver fire attacking the blood (with heart-spleen deficiency)
The opening: this disease — do not, under any circumstances, take it lightly
The illness we discuss today is one nobody should imagine is rare — it is actually extremely common. It is bloody stool (bian xue) — blood appearing in the stool when you go to the toilet.
💬 Note from Doctor Luo: With bloody stool, the first thing to do is not to rush into stopping the bleeding, but to learn how to identify what is happening. First of all, you must rule out the most frightening possibility — rectal cancer. Some people see blood in the stool and think, “I just have hemorrhoids,” and pay it no attention. By the time they finally get examined, the rectal cancer is already too far along — a truly heartbreaking situation. We have genuinely seen cases like this.
How do you tell the difference? Bloody stool from rectal cancer has its own character: it tends to be like jam — sticky, darker in color, dirty and turbid — not bright red blood. If you encounter this, you must go to the hospital for an examination; it is a simple thing to check. The second kind: the blood is not coming from the intestines but from stomach bleeding: the blood from the stomach did not go upward; it traveled down with the food. This blood is black — especially black, tarry stools; if the whole stool turns black, it is most likely stomach bleeding; bleeding from the upper part of the intestines can also look quite dark. The third kind is hemorrhoid bleeding: it usually appears after the bowel movement — an internal hemorrhoid breaks, and with every bowel movement blood accumulates in the intestine, then at the moment of defecation it gushes out all at once. It looks frightening — but actually it is blood that has pooled there, not a sudden hemorrhage. Keep these three situations in mind.
💬 Note from Doctor Luo: My family used to specialize in anorectal diseases, so I saw a great many cases of bloody stool; I have known since childhood what this illness is about. Today’s case was handled by Doctor Zhang Xichun with particular brilliance, and the formula is very well designed. Let’s go through it slowly.
Who was the patient? 45 years old, a secretary at the Hubei Governor’s Office
The patient was Du Liqi, 45 years old, in the middle of his life, from Jianqiao Town, Fucheng County. He served as a secretary at the Hubei Governor’s Office. How did he fall ill? The first factor: this man was exceptionally busy at work — his mind was overworked.
💬 Note from Doctor Luo: Notice: overworking the mind is the first factor — constant overconsumption and overexertion deplete the qi and blood, so the upright qi (zheng qi) is insufficient; especially when the mind is overworked, what is consumed is heart blood — this is what Chinese medicine calls heart-spleen dual deficiency (xin pi liang kui). That is how his foundation drained away.
He had long had a tendency to pass blood with his stool, and a dose of medicine would cure him each time. What happened this time? He had business back home in Tianjin, and it happened to coincide with excessive summer heat — the weather outside was fiercely hot; on top of that, back home he ran into some worrying matters and was busy again. That did it: the overconsumption of heart blood made his heart-spleen deficiency even worse, and the old illness flared up again. This time the trouble was — treatment after treatment failed to cure it.
How sick was he? Blood pouring down with the stool, and heat in the chest
There was nothing for it — Du Liqi came to a hospital in Tianjin. The Western doctor examined him and said: the blood appears after the bowel movement — the bleeding happens after defecation, so the cause should be internal hemorrhoids: each time he defecates, the internal hemorrhoid gets scraped and injured, and bleeding follows. But after taking the medicine, the blood still would not stop.
💬 Note from Doctor Luo: You should know that modern Western medicine has almost no drugs for anorectal disease or hemorrhoids — the main treatment is surgery. Back then the Western doctors presumably also used some hemostatic drugs, but they had no effect, so Doctor Zhang Xichun was called in.
Doctor Zhang Xichun took one look: blood comes down freely with the stool, in large quantity; the patient did not feel pain, but at the same time he felt heat in the chest and did not want to eat — no appetite. When he took the pulse: the left pulse was wiry and long (xian chang), with obvious heat signs.
💬 Note from Doctor Luo: What does a wiry, long left pulse mean? We discussed this before — do you remember? A wiry pulse corresponds to the liver. A wiry pulse with obvious heat signs — there is something significant in that. Doctor Zhang Xichun’s pattern differentiation is the most brilliant stroke of this case. Let’s look closely.
What did Doctor Zhang Xichun think? The most crucial move of the whole case
Doctor Zhang Xichun’s analysis: never mind exactly where the blood comes from — the fact is the intestines are bleeding. Why does a person get this illness? First, overworking the mind generates internal heat — consuming heart blood excessively produces heat inside the body. Second, this internal heat stirs the ministerial fire (xiang huo) lodged in the liver channel — the liver channel carries ministerial fire; when you worry and get heated, that fire moves. Once the ministerial fire stirs, the liver can no longer store blood — you know that the liver stores the blood; when the liver cannot store blood, the blood runs wild in all directions. Third, on top of that, the weather outside is hot, summer-heat prevails — two kinds of heat combine: internal and external heat added together, and so blood comes down with the stool.
💬 Note from Doctor Luo: Let’s lay out the disease causes: first, this man had insufficient upright qi, heart-spleen dual deficiency, because of overwork; second, something upset him, the ministerial fire of the liver channel stirred, causing the liver to fail to store blood and the blood to run wild; third, he then met summer heat outside. Three factors combined, and the illness formed. How to regulate it? Clear the heart, cool the liver, and dispel summer heat, while at the same time tonify the heart and spleen — attacking the pathogen and supporting the upright, both lines advancing together.
The prescription: Baitouweng Tang as the foundation, but one herb swapped
At the start of the formula, Doctor Zhang Xichun prescribed: sheng huai di huang (raw rehmannia), one liang (about 30 g) — what is that for? Nourishing yin and cooling the blood. Isn’t your blood hot? Heat agitates the blood and makes it run wild, causing bleeding — so nourish the yin and cool the blood. That is the first herb. The second, bai tou weng (pulsatilla).
💬 Note from Doctor Luo: Pulsatilla is an herb that specializes in clearing damp-heat — clearing heat, resolving toxins, cooling the blood and stopping dysentery. In Zhang Zhongjing’s Jin Gui Yao Lue (Essential Prescriptions of the Golden Cabinet) there is the Baitouweng Tang (Pulsatilla Decoction) for treating dysentery. Today, when treating dysentery caused by damp-heat or heat — severe purging diagnosed as a heat pattern — doctors often add pulsatilla to the formula. One more aside here: some physicians report that pulsatilla works remarkably well for hair loss and shedding of body hair — when a person suddenly loses all their hair, even their underarm and body hair, using pulsatilla with a few other regulating herbs gives excellent results. Do remember this. I once encountered such a patient myself; at the time the treatment got halfway, some effect appeared, but we did not finish — because I travel constantly and the medicine was inconvenient, and in the end I never learned what became of that patient. Later I read other physicians’ experiences: using pulsatilla with herbs that clear the liver and gallbladder and harmonize qi and blood worked extremely well. I thought at the time: I should have used this herb! But my knowledge was too narrow; I had not seen those references, so I did not know to use it. Some herbs have specific special effects for certain diseases — this is something you must learn and read widely to grasp.
Then he added long yan rou (longan fruit) — for bloody stool, why longan fruit? This patient had heart-spleen deficiency from overwork; especially, when the spleen is deficient it can no longer command the blood — it cannot hold and secure the blood, so bleeding becomes easier; touch it with a little heat and it bleeds. Longan fruit greatly tonifies the heart and spleen — dried, its color is reddish, so it enters the heart, tonifying heart blood and settling the spirit; its taste is sweet, so it enters the spleen channel. That is why Doctor Zhang Xichun added longan fruit here.
💬 Note from Doctor Luo: Notice — in these cases of bloody stool that Doctor Zhang Xichun treated, he used longan fruit in most of them — that was his insight. He believed bloody stool frequently has a factor of spleen deficiency underneath, so he added longan fruit to tonify the spleen and hold qi and blood, making it harder for blood to escape. Then he paired sheng huai shan yao (Chinese yam), five qian (about 15 g) — longan fruit and Chinese yam together, both tonifying the spleen; when spleen qi is sufficient, the blood is secured — that is Doctor Zhang Xichun’s approach.
Then came zhi mu (anemarrhena) — zhi mu is cooling and moistening, clearing heat. The longan fruit and Chinese yam before it are both slightly warming; zhi mu restrains that warmth, working together with the first herb, the rehmannia. Then qin pi (ash bark).
💬 Note from Doctor Luo: Qin pi is the bark of the white ash tree. It clears heat, dries dampness and resolves toxins; strictly speaking it also has a bit of wind-dispelling action. In the old days we believed that bleeding or diarrhea from the intestines often involves intestinal wind (chang feng) inside, so sometimes a wind-dispelling herb is needed — for instance, the Tong Xie Yao Fang (Important Formula for Painful Diarrhea) used for diarrhea adds fang feng (siler). Qin pi is cool and cold in nature; when it meets wind stirring in the intestine caused by heat — diarrhea or bloody stool — it works.
Doctor Zhang Xichun also used huang bai (phellodendron bark) — huang bai treats damp-heat dysentery and diarrhea, clearing heat and resolving dampness, especially the damp-heat of the lower burner intestines, because it enters the kidney and bladder channels. Processed with salt, salt huang bai also has the action of nourishing yin and lowering fire — the famous Zhi Bai Di Huang Wan is Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill) plus zhi mu and huang bai, with the action of nourishing yin and clearing heat.
By now, have you noticed? In this formula Doctor Zhang Xichun used bai tou weng, qin pi, and huang bai — this is the structure of the Baitouweng Tang from the Jin Gui Yao Lue! Baitouweng Tang has four herbs in all; Doctor Zhang Xichun wrote three of them — only one is missing: huang lian (coptis) was left out.
💬 Note from Doctor Luo: Why not use coptis? Doctor Zhang Xichun judged this to be liver fire — coptis clears heart fire, which is not quite on target. What did he use to clear liver fire instead? He added long dan cao (gentian root), two qian (about 6 g). See how Doctor Zhang Xichun swapped just one herb in a classical formula and the whole positioning of the prescription became more precise: gentian root also clears damp-heat, but it clears liver-gallbladder damp-heat — exactly matching the liver-fire mechanism. The thinking is exceptionally clear. Baitouweng Tang was originally for toxic-heat dysentery; this patient also had heat inside, so choosing this formula was exactly right. Finally he added gan cao (licorice), two qian (about 6 g) to harmonize all the herbs. The whole formula — with its yin-nourishing herbs, heat-clearing herbs, liver-gallbladder fire-draining herbs, and heart-spleen tonics — is remarkably complete.
One dose, and the blood stopped — but it was not over yet
The decoction was prepared, cooled to warm, and taken. After one dose, the blood stopped — it was gone. By two doses, the patient felt the lower abdomen was slightly cool. The pulse was taken again: the wiry, long, surging and slippery heat signs of before had receded.
Doctor Zhang Xichun thought: the heat has been cleared somewhat, but not completely — keep clearing, and at the same time add some tonics, because he was already feeling slightly cool. So he wrote a second formula, this time mainly tonifying.
💬 Note from Doctor Luo: Remember this order: at the front, mainly attack the pathogen; once the blood is stopped and the heat recedes, move to half attack, half tonify; further along you should mainly tonify — this is the sequential staging (ci di) of Chinese medical treatment. Doctor Zhang Xichun handled it with complete clarity.
The second formula: tonics lead the way — Chinese yam, prepared rehmannia, cornus
How was the second formula written? Sheng huai shan yao, one liang (about 30 g) — you see, whenever he tonified, Doctor Zhang Xichun used sheng huai shan yao; it was the herb he used most skillfully in his later years — in all the cases we have discussed so far, he used it in countless numbers. Then shu di huang (prepared rehmannia), eight qian (about 24 g) — prepared rehmannia greatly tonifies kidney essence.
💬 Note from Doctor Luo: When it comes to herbs that tonify kidney essence, among all Chinese medicines, apart from prepared rehmannia, no second herb dares to speak up — prepared rehmannia’s power is simply too strong. Where is it produced? Wen County, Jiaozuo, Henan — from the same land as the huai shan yao. You can see from this how highly Doctor Zhang Xichun regarded these two herbs.
Then shan yu rou (cornus fruit), five qian (about 15 g) — Chinese yam, prepared rehmannia and cornus fruit: these three, you are familiar with them, right? We discussed them last time. They are the herbs Doctor Zhang Xichun used most for supporting the upright, for nourishing the essence of the five organs. These three lead the charge, followed by longan fruit to greatly tonify the heart and spleen — if you thoroughly understand these few herbs that Doctor Zhang Xichun used constantly, you will be eight or nine tenths of the way there in tonification.
💬 Note from Doctor Luo: The tonics are assembled — tonify at the front, clear at the back: bai tou weng, five qian (about 15 g), to clear damp-heat, with qin pi working alongside it; then sheng hang shao (white peony), three qian (about 9 g): white peony nourishes the blood, softens the liver and eases pain, and can restrain yin and check sweating. White peony paired with the last herb, licorice, forms Zhang Zhongjing’s Shao Yao Gan Cao Tang (Peony and Licorice Decoction) — sour and sweet transforming into yin: white peony is sour in nature, licorice is sweet; sour and sweet combined can transform into yin, converting the body’s fluids toward the yin — a special function used to nourish and supplement yin.
Then di gu pi (wolfberry bark), three qian (about 9 g) — what is di gu pi? It is the bark of the wolfberry tree. It clears heat and cools the blood; it is generally used to treat tidal fever and night sweats from yin deficiency, and especially blood disorders from yin deficiency: yin deficiency produces deficiency heat, and deficiency heat breaks the blood and makes it run wild, so yin deficiency can cause bleeding. Once di gu pi removes the heat, the bleeding stops — for this reason it is also commonly used to treat bloody stool, blood in the urine, nosebleeds and the like caused by yin deficiency with internal heat.
The appetite suddenly opened, and the belly stopped hurting
This formula was decocted and given to the patient. After one dose: the appetite suddenly opened — he had not wanted to eat before, and now his appetite returned; why? Because the upright qi was sufficient, able to transport and transform food, so the appetite opened; the belly no longer hurt either.
💬 Note from Doctor Luo: There is a small detail here: at the start Doctor Zhang Xichun wrote that the patient “did not feel pain,” and later wrote that after treatment “the belly no longer hurts” — so did the belly hurt or not? Actually, in patients like this, the bearing-down, dragging pain is not obvious; but with bloody stool from damp-heat, there should still have been some pain in the belly — it was simply not written clearly earlier. By now, the belly no longer hurt. Doctor Zhang Xichun then told the patient: take a few more doses and the illness will slowly recover. The case record ends there.
Note from the commentator: bloody stool is mostly a heat pattern
What do we learn from this case? Bloody stool — no matter which part of the intestine the blood comes from, most cases are heat patterns — heat breaks the blood and drives it to run. What is the root cause? Imbalance inside the body — for example insufficient upright qi, plus heat generated by various circumstances — in this case, heat from liver fire.
💬 Note from Doctor Luo: In this case, Doctor Zhang Xichun showed us: how to nourish yin, how to clear heat, how to clear damp-heat, how to clear liver fire, and then add a measure of supporting the upright — how to regulate this kind of condition — a complete train of thought, perfectly clear. Are there other kinds of bloody stool? Yes — bloody stool caused by cold. That situation is also fairly common. Today we discussed the heat-caused kind; tomorrow we will talk about how Doctor Zhang Xichun treated bloody stool caused by cold — see you tomorrow!
Based on the lectures of Doctor Luo Dalun (PhD in TCM diagnostics, Beijing University of Chinese Medicine) explaining the medical cases of Doctor Zhang Xichun; the case is from Yi Xue Zhong Zhong Can Xi Lu (Records of Integrating Chinese and Western Medicine).