Diarrhea with Dull Abdominal Pain, Worse at Night, and Total Insomnia?
What people search for: dull abdominal pain / belly pain worse in the evening / lighter by day, worse at night / diarrhea that keeps you awake / can’t sleep all night / no appetite / no energy / irregular pulse
In medical terms: zhixia (dysentery-type disorder) · blood deficiency · spleen deficiency · insufficient yin aspect
Opening: Doctor Zhu Danxi treated three dysentery patients in a row — this one is the most unusual
Doctor Luo Dalun continues the story of Doctor Zhu Danxi at work. Zhixia (滞下) — the dysentery family of disorders: belly pain, diarrhea, and pain that continues even after you have emptied yourself — Doctor Zhu Danxi had treated several patients in this series, and we have covered the first two: one was his paternal uncle, whose worry had injured his heart and spleen; another was a “well-provided” official with chronic diarrhea. Today’s patient is the third — and the most special of them all.
💬 Note from Doctor Luo: How is an ordinary dysentery normally treated? When an external pathogen is present, you either clear damp-heat, or warm the yang, or purge it outward — in a word, you expel the pathogen. In the first two cases, Doctor Zhu Danxi built on Renshen (ginseng) and Baizhu (white atractylodes), adding a little of the blood-nourishing herbs from Si Wu Tang, and the patients were cured. So someone might say: isn’t all dysentery then a matter of Renshen and Baizhu? Too easy — anyone could treat it. No. Ordinary dysentery, the kind with truly severe belly pain, genuinely does require clearing the pathogen. Doctor Zhu Danxi deliberately picked out the special cases from among all those pathogen-clearing case records — this is how he teaches you to recognize exceptional situations and how to handle them.
Who was the patient: a woman surnamed Jin, nearly forty, taken ill in early autumn
The patient was a woman surnamed Jin, nearly forty years old — middle-aged by the standards of the day. She fell ill in early autumn, when the weather in the Zhejiang region was still hot. She developed zhixia: her belly ached badly, the pain continued after a bowel movement, and the discharges were often heavy.
How bad was it? Oddly, her pain was NOT severe — it was a dull, hidden ache
Dysentery pain, by the book, is fierce — truly agonizing. But this woman felt a dull ache deep in the abdomen (fu zhong yin tong) — a vague, hidden sort of pain.
And that tells you something. Doctor Luo Dalun explains: what does a dull ache mean? It means the external pathogen was no longer severe — when the pathogen is fierce, the pain is unbearable; when the pathogen is mild, this kind of pain cannot be cured by attacking the pathogen. A dull, hidden pain must be linked to internal injury — the problem is in the body itself.
💬 Note from Doctor Luo: Doctor Zhu Danxi never recorded symptoms idly. He wrote every detail down clearly, and if we analyze them in order, we can see exactly how this illness came about. A dull ache points to internal injury — that is the most crucial stroke of the whole case.
The two strangest things: worse at night, and no sleep all night long
Now look at two more symptoms. First, the pain was worse at night than by day (ye zhong yu zhou): lighter during the day, heavier at night. What does that tell you? The disease was in the yin aspect — when there is trouble in the yin, it shows itself most clearly at night.
Second, she could not sleep all night (che ye bu mian) — this was almost total insomnia; she simply could not fall asleep. Why? We will come back to that.
And there was more: her appetite had dropped. Whenever Doctor Zhu Danxi notes that a patient is eating less, you can be sure the spleen and stomach are weak. Before coming to him, she had already tried one standard stock formula for dysentery, and it had done nothing — so she came to see Doctor Zhu Danxi.
One touch of the pulse: both hands astringent and uneven — the blood was depleted
Doctor Zhu Danxi felt the pulse: both hands were astringent (se) — the pulse felt rough and hesitant, like a knife blade lightly scraping across bamboo, thread by thread; and it was uneven (bu yun) — the beats were not regular.
What does an astringent pulse mean? Blood insufficiency — yin blood is insufficient, the vessels are under-filled, and the blood moves sluggishly, which is why it feels astringent. An uneven pulse means the blood deficiency has gone so far that even the rhythm of the heart’s beating has changed — in today’s language, an irregular heartbeat. And looking at the person: her spirit was weary (shen si juan dai) — her whole mental state was exhausted; her appetite was all but gone.
💬 Note from Doctor Luo: What are the signs of blood deficiency? Poor memory; icy cold hands and feet in winter; a weary spirit and reduced ability to think — because blood circulation is slow; pale lips, eyelids, and other mucous membranes; dark vision when you squat down for a while and stand up suddenly. And one very important one: insomnia. Blood-deficient people cannot sleep at night — this is called blood failing to nourish the heart (xue bu yang xin): the heart does not receive the nourishment of the blood, so at night it cannot rest, and insomnia follows. One more sign I mention less often: blood-deficient people experience pain in certain places — when the blood cannot nourish the whole body, areas like the joints and the abdomen do not get enough blood, and they can hurt noticeably.
The diagnostic highlight: “women are governed by blood; blood belongs to yin and is easily depleted”
Why did this woman’s belly pain have such distinctive features? Doctor Zhu Danxi said: “Women are governed by blood; blood belongs to yin and is easily depleted” (fu ren yi xue wei zhu, xue shu yin, yi yu kui qian) — women are nourished by blood. A woman’s uterus (bao gong) lies right in the abdomen, and people whose blood is depleted are especially prone to pain — abdominal pain above all.
💬 Note from Doctor Luo: Haven’t you seen this in daily life? Some young women have crippling menstrual cramps; nourish the blood and the cramps clear up. Some women get severe headaches before their period; you try dispersing wind, dispersing blood — nothing works; nourish the blood and the headache clears. When blood is depleted, certain organs — especially in women — begin to hurt. This woman’s belly pain was exactly that pattern: the pulse was astringent, so the blood was insufficient; the belly ached dully and was worse at night — the yin aspect, blood belongs to yin, and blood-deficient people have more trouble at night. So her belly pain was tied to blood deficiency.
Now the insomnia: insomnia can come from constrained liver qi, and it can come from blood depletion — lay the two side by side, and the one that matches the pulse is blood depletion. Add the loss of appetite and the insufficiency of the spleen and stomach, and Doctor Zhu Danxi saw it clearly: this looked like dysentery, but it was in fact an obvious case of blood deficiency combined with spleen deficiency. How far had the blood deficiency gone? Her spirit was weary — her vital energy was already severely depleted.
The prescription, broken down: Si Wu Tang to nourish blood, double Baizhu to strengthen the spleen, a little Chenpi to move the qi
The formula Doctor Zhu Danxi wrote could not be simpler: Si Wu Tang (Four Substances Decoction) — Shudi (prepared rehmannia), Baishao (white peony), Danggui (Chinese angelica), and Chuanxiong (ligusticum), the ancestral blood-nourishing formula; then Baizhu at double the normal dose — to strengthen the spleen; and a little Chenpi (tangerine peel) — to regulate and move the qi, helping the spleen and stomach turn.
💬 Note from Doctor Luo: Doctor Zhu Danxi was one of the earliest — and one of the most prolific — users of Si Wu Tang in history; his books deploy it constantly, and deploy it superbly. In this formula, Baishao also relaxes acute pain — it is excellent for abdominal pain. Si Wu Tang as a whole nourishes the blood and softens the liver (rou gan) — a blood-deficient person’s liver channel is bound to be in trouble, because the liver stores the blood (gan cang xue); Danggui nourishes the liver blood and the blood of the entire body. When the liver blood is sufficient, and the liver channel — which passes through the abdomen — is well nourished, abdominal pain is helped too. Si Wu Tang nourishes the blood, Baizhu strengthens the spleen, Chenpi moves the qi — a formula that simple. Yu shi shi yu tie — she took it for about ten doses, and this woman was cured.
Doctor Zhu Danxi’s closing note: “If, because of the urgency of the illness, one used drastic agents — would that not harm people?”
When the case was done, Doctor Zhu Danxi left one sentence behind that strikes like a thunderclap:
“Ruo yin qi bi po er yong jun ji, qi bu wu ren!” — “If, because the illness presses hard, one resorts to drastic purgatives, would that not be harming the patient?”
💬 Note from Doctor Luo: What does it mean? All three of these cases looked like dysentery — and dysentery hurts badly, so by the book you should use fierce attacking medicine. But in all three patients, the upright qi was already plainly insufficient. If you still attack the pathogen with large doses of violent medicine and ignore the upright qi, the body will be damaged. Doctor Zhu Danxi instead used supporting the upright qi (fu zheng) in every case — he barely attacked the pathogen at all, and yet the illness was cured. That is his warning to us: you must always weigh how much upright qi the sick person has.
Stay calm when treating: if you only think about clearing the pathogen, you have already lost
Doctor Luo Dalun spells out the principle behind all of this. There is a striking feature of clinical work: the pathogen’s manifestations are usually extremely obvious — the pain, the distension, the aches, all caused by the pathogen, are loud and clear. So people fixate on the pathogen; they hate the disease and want to flush it out fast — this is the main line of the attacking school (gong xie pai).
When the upright qi is sufficient, that approach is right: the pathogen is driven out and the upright qi recovers at once. But here is the problem — what if the person’s upright qi is extremely deficient? When upright qi is insufficient, the pathogen gets in; and precisely because the upright qi is utterly depleted, even a little pathogen shows itself loudly — the symptoms are especially obvious. At that moment it is very easy to be led around by the patient, staring at the pathogen and hammering it. Yet the upright qi cannot withstand attack: it is already weak, and the moment you go to war, the body nosedives.
💬 Note from Doctor Luo: So the doctor must be especially calm at such moments. With a chronic patient — illness dragged out long, upright qi in terrible shape, spleen and stomach weak, but a pathogen still present — when you attack, you must weigh whether the upright qi can bear it. It is a balancing act: add a tiny amount of pathogen-clearing medicine and support the upright qi as the main line; when the qi has recovered somewhat, increase the attacking medicine a little and test again; if it is not enough, reduce the attacking and add more support. Doctor Zhu Danxi was even more decisive: he used no pathogen-clearing medicine at all — he simply supported the upright qi, because he had seen through to the essence: once the upright qi is sufficient, this little bit of pathogen will certainly be cleared on its own. When the upright qi has been built up enough, one good clearing sweep and the pathogen is gone. He could dare to do that because he had truly seen through the situation.
The elderly and children need even more care: your eyes must not see only the pathogen
This principle matters especially for elderly patients. Many elderly people are already frail, with insufficient upright qi — especially in the middle and late stages of an illness. If at that point your eyes still see only the pathogen and only the textbook formulas — Xiao Qing Long Tang (Minor Blue-Green Dragon Decoction) is fine for a healthy adult, but for an elderly person whose upright qi is extremely depleted, the body cannot survive that kind of upheaval; the condition plummets, and some elderly people do not make it.
💬 Note from Doctor Luo: Some elderly patients have extremely thick tongue coating — in the terminal phase of a serious illness the coating can be astonishingly thick. You look and think: heavy phlegm-damp! Quick, resolve the phlegm-damp — and sometimes that very act is what the elderly patient cannot bear. In fact, it is because the upright qi is insufficient and the body lacks the strength to transform and transport that the phlegm-damp has piled up. Slowly supporting the upright qi is the key; do not see a thick coating and immediately pile on massive phlegm-resolving doses. This is experience: for medical students and for Chinese-medicine practitioners alike, you must see clearly what is primary and what is secondary.
Supporting the upright qi is primary; everything else is auxiliary
Doctor Luo Dalun concludes: Doctor Zhu Danxi was an absolute master of resolving phlegm, dispelling dampness, dissolving blood stasis, and releasing the exterior — in treating miscellaneous diseases, he lacked none of the attacking methods. Yet in this case, he barely used the attacking methods at all — first he supported the upright qi.
What does that tell us? Supporting the upright qi is primary; resolving phlegm, dispelling dampness, dissolving stasis, and releasing the exterior are all auxiliary techniques. For a person with insufficient upright qi, these auxiliary techniques must be used cautiously — or not at all. When a master of exterior-releasing and phlegm-resolving, a man of towering skill, encounters deficient upright qi and turns mainly to supporting it — that is the inspiration these case records of Doctor Zhu Danxi give us.
💬 Note from Doctor Luo: This series — the case records from Doctor Zhu Danxi’s two books, Ge Zhi Yu Lun (格致余论, Extra Treatises on Inquiry and Extension of Knowledge) and Ju Fang Fa Hui (局方发挥, Elaboration on the Formulas of the Pharmacy Bureau) — is now nearly complete. The cases in Danxi Xin Fa (丹溪心法, Danxi’s Mastery of Medicine) are comparatively simpler, with a great deal of miscellaneous-disease content. Next we will take up his academic thinking on treating miscellaneous diseases — how he used formulas to treat them. See you tomorrow.
Compiled from Doctor Luo Dalun’s explanations of Doctor Zhu Danxi’s case records; the cases come from the Ge Zhi Yu Lun and Ju Fang Fa Hui series.