Diarrhea a Dozen Times a Day with Afternoon Fever? Doctor Zhang Xichun Treats Chronic Diarrhea with Hidden True Cold (True Cold, False Heat)

Search terms this page answers: diarrhea / a dozen bowel movements a day / diarrhea with fever / afternoon fever at the same time every day / diarrhea after worry and overwork / chronic loose stools that will not stop

Medical terms: diarrhea (xie xie) · chronic diarrhea · diarrhea with burning fever · true cold, false heat (zhen han jia re) · spleen-kidney yang deficiency (pi shen yang xu) · lower-burner deficiency cold (xia jiao xu han)

Opening: diarrhea on one side, a fixed-time fever on the other — what is so strange about this illness?

Today we continue with Doctor Zhang Xichun’s stories of treating patients. What are we talking about today? Diarrhea accompanied by burning fever (xie xie jian zhuo re) — that is, the patient has diarrhea and a feverish body at the same time. And this diarrhea is not infectious — it is what we ordinarily call chronic diarrhea.

💬 Note from Doctor Luo: Today, an enormous number of people suffer from chronic diarrhea. They go to the hospital and come back with all sorts of labels — chronic colitis, ulcerative colitis, and so on. It is a very common complaint, so let us listen to how Doctor Zhang Xichun approached it.

Who was the patient? A 42-year-old Tianjin businessman, in his prime yet worn to the bone

The patient’s name was Hu Yixuan (胡奕炫). He was from Tianjin, 42 years old — middle-aged. What did he do? He was a businessman. Notice that Doctor Zhang Xichun always records his patient’s occupation at the start of every case — and he does it on purpose.

His illness began in Meng Qiu — the first month of autumn. The cause is rather sad: his brother had died of dysentery. In those days medical conditions were far worse than today, and dysentery really could kill. With his brother gone, the whole business fell on his shoulders alone — an endless burden of worry. On top of that, he had to arrange his brother’s funeral, and between grief and exhaustion, his heart and strength were spent. And so it began: his stools turned to diarrhea and his whole body started to run a fever.

💬 Note from Doctor Luo: As I have said before, many disorders of the gut are tied to a person’s emotions. This man’s diarrhea began because, after his brother’s death, his grief ran too deep.

The symptoms: fourteen or fifteen bowel movements a day, and more pain after each one

How bad was the diarrhea? Fourteen or fifteen bowel movements a day. And before each movement there was always abdominal pain first; afterwards the pain grew worse, easing only after a while. What was the diarrhea tied to? Emotion.

💬 Note from Doctor Luo: I know this from personal experience. Last year, after my own father passed away, I had diarrhea for a solid month — every single day. Why? I knew it myself: it was genuinely tied to emotion. I did not prescribe for myself at the time, and I had no desire to — my feeling was that when your body hurts somewhere, it somehow seems fitting: either your heart aches, or your belly aches. So I went on for a full month.

Besides the diarrhea, one strange complaint had appeared: every day after one o’clock in the afternoon, his whole body began to run a fever — not a severe one, but there it was. Then, at three o’clock in the middle of the night, the heat would slowly fade. A fever that comes at a fixed time every day — is that not strange? It certainly is not right, is it?

Doctor Zhang Xichun takes the pulse: all six positions weak, the chi pulses weaker still — profoundly deficient

They hurried to Doctor Zhang Xichun. He took the pulse: all six positions were weak, and the two chi pulses were weaker still — the chi positions correspond to the kidney; both kidney yin and kidney yang live there, and both chi pulses were so weak they could barely be felt.

What did Doctor Zhang Xichun judge this to be? Lower-burner deficiency cold (xia jiao xu han), with deficiency of the great qi of the chest (xiong zhong da qi xu sun).

💬 Note from Doctor Luo: A person with lower-burner deficiency cold is bound to feel cold ordinarily, and the colder it gets, the worse the diarrhea. Doctor Zhang Xichun did not write out all the symptoms in this case, but you can reason it out: this man’s yang qi was insufficient to begin with; he fell ill in autumn as the weather turned cold; and the endless diarrhea drained his yang further with every movement — so the lower-burner deficiency cold grew worse and worse.

The hardest question: if he is clearly feverish, why can’t we treat it as heat?

The single hardest point in this case is why the fever appears at all. This is something we must think through.

💬 Note from Doctor Luo: When a person is severely deficient-cold, when the cold qi is very heavy, his yang qi is often pushed upward — this is called deficient yang floating upward (xu yang fu yue). You look and see a heat pattern; in reality it is true cold — this is true cold, false heat (zhen han jia re). When yang qi is insufficient and cold qi too strong, the deficient fire drifts outward — this happens a great deal, and it is one of the false appearances you must always watch for when warming yang.

If you look at the tongue, this kind of person’s tongue body will certainly be pale — bloodless. The coating may be thick, and the tongue surface will be wet with saliva. None of these point to a heat pattern; judging by the tongue is more reliable here.

Then why does the fever appear in the afternoon and clear by dawn? Because after noon, yin qi is at its heaviest and yang qi gradually weakens. At that time yin is heavy and yang insufficient, so the deficient fire rises; and since the great qi of the chest is also insufficient and can no longer gather and restrain it, the whole body runs hot. This heat is false.

💬 Note from Doctor Luo: The illness itself was not hard to treat — but the previous doctors saw a feverish man who ought to be warmed, and lost their nerve about using yang-warming herbs. Today many physicians of the Fire School have been summarizing: when does yin fire rise? When does yin excess repel yang (yin sheng ge yang), pushing the deficient yang outward and producing a false appearance of deficient heat? In reality it is true cold and needs yang warming. The Fire School physicians have compiled many methods for telling true cold from false heat — that is not today’s main topic; we will get to it another time.

The prescription: the iron triangle for tonifying kidney essence, plus gan jiang and fu zi to bring the yang home

Once Doctor Zhang Xichun had determined this was yang deficiency causing the diarrhea, what was his treatment strategy? He said: you must use warming tonics to gather the primal yang back and return it to its source (shou lian qi yuan yang, gui qi ben yuan) — bring the yang back home, and the diarrhea stops and the burning fever clears with it. So how did he write the formula?

• Chao bai zhu (dry-fried Atractylodes), 15 g (five qian) — tonifies the spleen; this is its specific job;
• Shu huai di huang (prepared Huai rehmannia), 30 g (one liang) — prepared rehmannia from the Huai region of Henan (Jiaozuo). A generous dose, one full liang. What does prepared rehmannia do? It tonifies kidney essence (bu shen jing);
• Sheng huai shan yao (raw Huai Chinese yam), 30 g (one liang) — dried Huai yam slices from Wen County, Jiaozuo, Henan — tonifies the spleen and nourishes the essence-qi of the spleen;
• Jing yu rou (cornel dogwood fruit), 15 g (five qian) — shan yu rou — nourishes the essence of the liver and kidney.

💬 Note from Doctor Luo: Let me tell you — “nourishing yin” is not really the most accurate way to put it. The ancients called prepared rehmannia true yin (zhen yin); my own definition is kidney essence (shen jing) — prepared rehmannia is warming in nature, and it is the single most important herb for tonifying kidney essence. These three — prepared rehmannia, Huai yam, and cornel dogwood fruit — are Doctor Zhang Xichun’s iron triangle, fixed and immovable: whenever he wants to build up a weak body, he uses exactly these three. And these three essence-tonifying herbs are precisely the three shared by Jin Gui Shen Qi Wan (Kidney Qi Pill) and Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill); add poria, and you have all four herbs common to both formulas.

Then he paired them with fu ling pian (poria) — to drain damp from the spleen, working together with the Huai yam and Atractylodes. Then gan jiang (dried ginger) and fu zi (aconite root) — gan jiang warms yang, warming and tonifying the spleen and stomach; fu zi greatly tonifies the primal yang and warms the channels and collaterals (da bu yuan yang zhi qi, wen jing tong luo) — wherever cold evil has congealed in the channels and blood vessels, anywhere in the body, fu zi can warm it and drive the cold out; and when fu zi is paired with gan jiang, the effect is even more pronounced.

Look at this: prepared rehmannia, Huai yam, cornel dogwood fruit, poria, plus fu zi — this is essentially the core of Jin Gui Shen Qi Wan, missing only cinnamon (rou gui), moutan bark (dan pi) and alisma (ze xie) — add those three and it becomes Jin Gui Shen Qi Wan (the Eight-Ingredient Kidney Qi Pill).

The formula also contains sheng bai shao (raw white peony), 9 g (three qian). Why white peony?

💬 Note from Doctor Luo: White peony softens the liver (rou gan). For abdominal pain and diarrhea triggered by emotion — essentially any such complaint — I almost always pair in white peony, and the effect is excellent; this is my own hard-won experience. Doctor Zhang Xichun also explained it himself: Zhang Zhongjing was especially skilled with yang-warming herbs, but warming yang has two modes. One is the emergency, life-saving mode when a person is at the edge of collapse; the other is exactly this situation — yang qi insufficient, kidney yang deficient, and you warm it slowly. In that case you often pair fu zi with bai shao — the white peony astringes the yang, and the warming proceeds gently, bit by bit — this is what “warming tonification” really means, and it is comparatively mild. Many of Zhang Zhongjing’s formulas — Zhen Wu Tang (True Warrior Decoction) among them — use exactly this pairing of fu zi with white peony.

Finally zhi gan cao (honey-fried licorice) to harmonize all the herbs. Decoct into one large cup and take warm.

One dose, and the fever was gone; a dozen doses, and the root was pulled out

How did the formula work?

After the first dose, the fever of the Shen hour (3 to 5 p.m.) was cured — why? Because the deficient yang had been gathered back — and with white peony in the formula, it was gathered and brought home.

By the third dose, the diarrhea was already more than half resolved, and the pulse was stronger than before. So he adjusted the original formula slightly: since there was no more fever, there was no longer any need to astringe the primal yang — out went the white peony, and in went longan fruit (long yan rou).

💬 Note from Doctor Luo: Longan fruit tonifies both the heart and the spleen, and the spleen especially. For diarrhea caused by insufficient spleen qi — even blood in the stool — it works. With longan added, the formula now tonifies both qi and blood. Everything else stayed: gan jiang, fu zi, poria, honey-fried licorice. After about ten doses of this formula, the illness was completely cured (che di hao le).

Lesson one: sort out priorities — when the body is deficient, tonify first, always

The case is told; now let us summarize what we have learned.

First: sort out priorities (fen qing qing zhong huan ji). This man’s diarrhea had emotion in it, and all sorts of other causes in it — but Doctor Zhang Xichun saw the main point at a glance: the dominant problem now was deficiency (xu). A middle-aged businessman was already tired from his trade; then he took on all the arrangements for his brother’s affairs and drained himself nearly dry — his body was profoundly weak.

💬 Note from Doctor Luo: This is the hardest judgment call: what do you regulate first for such a person? If he is already deficient to this degree, and you go regulating his emotions, soothing the liver, moving the qi — the more you soothe the liver, the more deficient he becomes (yue shu gan yue xu)! His upright qi is already insufficient — what is left to soothe? So at this point, support the upright (fu zheng) comes first — tonify the kidney, tonify the spleen, and only on the foundation of a replenished spleen and kidney do you add gan jiang and fu zi to warm the yang. Doctor Zhang Xichun never once reached directly for something to stop the diarrhea — he first replenished the kidney qi and the spleen qi. That is the key.

Lesson two: “The kidney is the gate of the stomach” — to cure diarrhea, trace the root to the kidney

Second — and this is today’s most important idea in Chinese medicine: when diarrhea goes on long enough, it injures the kidney essence; and when kidney qi is insufficient, the diarrhea becomes even more lingering and stubborn. So where do you look for the root of the illness? The Huangdi Neijing (Huangdi’s Inner Canon) has a line: “The kidney is the gate of the stomach (shen zhe wei zhi guan ye).”

💬 Note from Doctor Luo: Have you seen the film The Grandmaster? In it, the old master teaches the move “the old ape hangs the seal” — and the key point, he says, is not in the hanging of the seal, but in the turning of the head. That is a wonderful way to put it. “The kidney is the gate of the stomach” — the stomach includes the spleen and stomach, and refers especially to the spleen. If you truly want to fix a digestive problem, where is the crux? It is in the kidney. Get the kidney in order first — that is the voice of experience.

This is no empty saying; there is living proof — the famous Ming dynasty physician Zhang Jingyue (张景岳).

💬 Note from Doctor Luo: Zhang Jingyue and Zhang Xichun both share the surname Zhang, and add Zhang Zhongjing — these three men left more formulas in the TCM formulary textbooks than anyone else. The formulas we study in class today come mostly from these three — they are the three most influential men surnamed Zhang in all of Chinese medicine. Zhang Jingyue wrote the great work Jing Yue Quan Shu (Complete Works of Zhang Jingyue). In the Qing dynasty, when the Imperial Medical College trained physicians and studied the Huangdi Neijing, it used Zhang Jingyue’s guide to reading the classics. I admire that man enormously.

And Zhang Jingyue himself wrote, in Jing Yue Quan Shu: in his middle years he suffered from chronic diarrhea, and it tormented him. Now, a master of Zhang Jingyue’s caliber had extremely high medical skill — yet his own diarrhea took him several years to cure.

💬 Note from Doctor Luo: The old physicians never hid their own illnesses; today’s physicians never admit to being sick — they all act like immortals who can cure anything, and that is a bad habit. The ancients wrote their own ailments out in the open — Xu Shuwei (许叔微) wrote about his own lower-back pain, for example. When Zhang Jingyue wrote about his own diarrhea, I was shocked when I read it in my student days: here was a man with his own illness writing it all down, never mythologizing himself.

What did Zhang Jingyue say? He said: I have read widely — I know the writings of Zhu Danxi, of Li Dongyuan, of Xue Lizhai and the other masters, and I have used their formulas too — and they simply did not work. What was he to do? He had strengthened the spleen; he had warmed the yang; he had cleared damp-heat — none of it helped. Finally he reasoned it out for himself, extracting the principle from the line “the kidney is the gate of the stomach”: the kidney must be regulated. And so he created his famous formula — Wei Guan Jian (Stomach-Gate Decoction).

💬 Note from Doctor Luo: Wei Guan Jian regulates “the gate of the stomach” — and where is that gate? In the kidney. The formula treats deficient-cold diarrhea — diarrhea from spleen-kidney yang deficiency. What does it use? The very first herb is prepared rehmannia (shu di huang), paired with Huai yam, Atractylodes, and dried ginger, plus white hyacinth bean (bai bian dou), cornel dogwood fruit (wu zhu yu) and other yang-warming herbs. Look: prepared rehmannia plus Huai yam, Atractylodes, dried ginger — is that not remarkably close to what Doctor Zhang Xichun prescribed today? Zhang Jingyue regulated himself with Wei Guan Jian and cured himself (ba zi ji gei tiao hao le). When Zhang Jingyue discussed diarrhea he placed great weight on deficiency cold, and the approach he used was the old Eight-Ingredient Pill (Kidney Qi Pill) together with Wei Guan Jian — tonifying the kidney as the centerpiece, with the theoretical basis being that line from the Neijing: “the kidney is the gate of the stomach.”

Bonus: another common kind — “mixed cold and heat” diarrhea, treated by the Wu Mei Tang method

Beyond today’s deficient-cold diarrhea, Doctor Luo Dalun also discussed a common situation — worth writing down too:

💬 Note from Doctor Luo: For chronic diarrhea of this kind, we generally regulate according to cold and heat — some need yang warming, some need clearing damp-heat, and so on. For long-term diarrhea that lingers and will not heal, I often use the Wu Mei Tang (Mume Decoction) method — the formula contains both cold and heat herbs, and the effect is excellent; diarrhea of many years’ standing can be regulated back to health with it. This kind of mixed cold-and-heat diarrhea is often connected with very deep emotional involvement — the bad mood has knotted itself deep, so deep that Chinese medicine says it has entered the jueyin channel, lurking very far down, and it can stir up gut problems. In such a formula you will find fu zi and gan jiang, plus huang lian (goldthread) and huang bai (phellodendron bark), with a little wu mei (smoked mume plum) — warming and clearing together, and the effect is excellent. And one more warning: for people who are truly deficient, long-term diarrhea empties out the upright qi; and those whose upright qi was insufficient all along will find their diarrhea even more lingering and stubborn after the bout passes.

Closing: one sentence — reading the Neijing through a case record

This case tells us — when diarrhea lingers and will not heal, do not stare only at the intestines; first sort out the priorities (xian fen qing zhu ci): if the body is deficient, tonify it first — replenish the kidney essence, replenish the kidney qi — and only then can the disease truly be cured. One line from the Neijing, plus Doctor Zhang Xichun’s practice, plus Zhang Jingyue’s personal experience — that is the wisdom Chinese medicine has handed down.

💬 Note from Doctor Luo: A line like “the kidney is the gate of the stomach” is one of the guiding statements of the Neijing. You cannot understand why the later physicians prescribed the way they did unless you read the various schools and study their case records — because those physicians felt the importance of that Neijing line in practice, guided their prescriptions by it, and finally cured their patients. To truly grasp the meaning of the Neijing, you must look at the practice of the later physicians. That is why I keep telling case records — it is for this reason: from the case records, you come to understand the thinking of the ancient sages far better.

Adapted from Doctor Luo Dalun’s commentary on Doctor Zhang Xichun’s case records, from Records of Chinese Medicine with Western Reference (《医学衷中参西录》), published serially 1918–1934.