Diarrhea with Pus and Blood, Worse with Cold, Loose Stools at Dawn?
Patient’s search terms: diarrhea with pus and blood / diarrhea when cold / morning diarrhea / dawn diarrhea (wu geng xie) / stomach pain / restlessness and thirst / no energy
Medical terms: spleen-kidney yang deficiency diarrhea · dawn diarrhea (wu geng xie) · declining mingmen fire · true cold with false heat (deficient yang floating outward)
Opening: the cause of this official’s illness, punctured by Doctor Xue Lizhai in four characters
Today’s case is astonishingly short — the patient was frighteningly ill, yet Doctor Xue Lizhai cured him with just two doses of medicine. But for all its brevity, this case holds more lessons than it appears to.
The patient was Qu Ruwei, who held the post of Tingping — the court official responsible for writing reports and evaluating the performance of the various ministers. When he came for treatment, he was admirably candid: before the doctor even asked, he laid out the cause of his illness in full.
💬 Note from Doctor Luo: This is how it should be. Some patients come in and conceal everything, and the doctor has nothing to work with; this gentleman told the whole story plainly, and that is exactly why Doctor Xue Lizhai could see where the illness came from. The four characters of his diagnosis — spleen-kidney yang deficiency — are the key to the entire case.
Who was the patient: a middle-aged man who had long been draining his kidney qi
The physician he consulted, Doctor Xue Lizhai, was director of the Imperial Academy of Medicine — in his early years he served the emperor in Beijing, and later he moved to Nanjing. The Ming dynasty was unusual: the court kept two complete administrations, one in Beijing and one in Nanjing, and Nanjing had its own Imperial Academy of Medicine, to which the officials there all went for treatment.
Qu Ruwei told Doctor Xue Lizhai: immediately after a meal, I went to bed with my wife. The next day at noon, trouble came — his abdomen began to hurt, and hurt badly.
💬 Note from Doctor Luo: Looking back, we can tell this man was past middle age. Had he been a young man in his prime, his kidney qi would have had to be utterly exhausted to fail this way. To reach the post of Tingping, he was no longer young. He must have been a man whose kidney qi and kidney yang were already insufficient — one who had been consuming himself for years: always a bit afraid of cold, never full of spirit, unable to tolerate the slightest chill. These are all signs of kidney yang deficiency.
Symptoms: pus and blood, restlessness and thirst — the whole picture screamed “fire”
Once the symptoms are laid out, they are alarming:
- Abdominal pain, and after going to the toilet he passed stools that were “dysentery-like but not dysentery” — like dysentery yet not dysentery: painful, loose, impossible to say exactly what it was;
- The next day, pus and blood came down;
- Vexing heat and thirst — restlessness, a sense of heat, a parched mouth;
- Listlessness and drowsiness — no strength left, his head felt inadequate, he grew sleepy.
💬 Note from Doctor Luo: And here is the puzzle. Pus and blood in the stool would make most people think of heat — heat forces the blood to move, so there must be damp-heat inside causing the bleeding. Add the vexing heat and thirst — heat in the upper body, thirst — and it becomes even easier to conclude “heat.” Only “listlessness and drowsiness” is the most decisive sign: with a true heat pattern, a person should be agitated and excitable, the body still fighting the pathogen; this man had no strength left, he was weak and weary — that does not fit a heat pattern at all.
The diagnostic high point: what made Doctor Xue Lizhai dare to use warming herbs?
Doctor Xue Lizhai’s diagnosis was yang deficiency. He must have seen “listlessness and drowsiness,” first thought of insufficient upright qi, and then judged whether it was yang deficiency.
💬 Note from Doctor Luo: Here is a trick of Chinese medicine: the kidney is the gate of the stomach (shen wei wei zhi guan, from the Yellow Emperor’s Inner Canon). The kidney and the spleen-stomach are intimately connected — whether the spleen-stomach functions robustly depends to a great degree on whether the kidney qi is robust. Injure the kidney, let the kidney qi and kidney yang become insufficient, and the first place to break down is precisely the spleen-stomach. Many people with diarrhea take huang lian su (berberine) and try to clear damp-heat, and never improve; then they take Jin Gui Shen Qi Wan (Kidney Qi Pill from the Golden Cabinet) and get better at once — that is kidney qi deficiency at the root. People rarely think of this root cause; they assume they ate something bad, or that it is damp-heat, and the more they clear, the worse it gets. Why? Because it is yang deficiency — spleen-kidney yang deficiency.
As for the tongue, Doctor Xue Lizhai certainly examined it — the tongue body must have been pale white. With dysentery from damp-heat, the tongue body would be red with a yellow greasy coat; this man’s was not. The tongue body must have been pale and white — the coat might have been thick, but the pale tongue body is the key.
Anatomy of the prescription: Si Shen Wan — relief in a single dose
The first formula Doctor Xue Lizhai used was Si Shen Wan (Four Spirits Pill) — he took just one dose, and every symptom immediately and markedly diminished.
💬 Note from Doctor Luo: Let me clear up a common misunderstanding while we are here. In classical texts, “one fu (一服)” means one single serving, drunk all at once — it does not mean “one prescription”. In the old days, when a decoction was made up, the patient would drink the whole thing in one go, and the physician would judge the effect of that single dose. Modern editors insist on rewriting the character “服” as “副” and saying “one fu of medicine,” meaning one course — but that is wrong. “服” here means “one swallow, one single dose.”
What is Si Shen Wan? Its story is a long one. This formula specifically treats diarrhea caused by spleen-kidney yang deficiency — and its most typical target is wu geng xie (dawn diarrhea), also called cock-crow diarrhea: in the early morning, when yang qi is just beginning to rise and yin qi is at its heaviest, people with insufficient yang are especially prone to diarrhea — as soon as the rooster crows, the purging begins. In severe cases it is not only the morning — diarrhea all day long.
💬 Note from Doctor Luo: The origin of Si Shen Wan goes back to Xu Shuwei of the Song dynasty. Xu Shuwei was one of the founders of the classical-formula (jingfang) school. Both his parents died within a hundred days of each other when he was a child; he grew up in a relative’s home, studied medicine with great diligence, and happened to live at the time when the Song emperor published the Treatise on Cold Damage (Shang Han Lun). He taught himself from it and became a master of classical formulas. He was a man of outstanding character — he gave medicine away free and rescued the suffering — and he compiled the Pu Ji Ben Shi Fang (Effective Formulas from the Collection for Universal Relief), gathering only formulas he had personally verified, of extremely high quality. Later physicians such as Ye Tianshi kept the book under their pillows and read it every day. Si Shen Wan is a combination of two formulas from the Pu Ji Ben Shi Fang: Er Shen Wan (Two Spirits Pill: rou dou kou (nutmeg) + bu gu zhi (psoralea)) plus Wu Wei Zi San (Schisandra Powder: wu wei zi (schisandra) + wu zhu yu (evodia)) — joined into the Four Spirits Pill.
How to read the formula? Bu gu zhi (psoralea) is the sovereign herb — it warms yang, replenishing the fire of mingmen and warming the earth of the spleen-stomach. Rou dou kou (nutmeg) warms the middle and the intestines, and also astringes the intestines. Wu zhu yu (evodia) enters the liver, spleen and kidney channels, warming the middle and scattering cold, dispersing cold-dampness. Wu wei zi (schisandra) is sour in taste; it tonifies the five viscera, and being sour, astringes the intestines and secures the bowel. The preparation is particular: the herbs are ground to powder, then boiled with fresh ginger and jujubes over a slow fire until the juice has completely cooked away — the medicinal power of the ginger has entirely entered the jujube flesh. The ginger slices are discarded, and the medicinal jujube flesh is mixed with the powder to form the pills. The ginger and jujube serve to harmonize the spleen-stomach.
The turning point: relief was only the first step — the root was cut with Ba Wei Wan
After one dose of Si Shen Wan, the symptoms were more than half gone — but Doctor Xue Lizhai did not stop there. Next he took the ingredients of Ba Wei Wan (Eight-Ingredient Pill — the Gui Fu Di Huang Wan, Cinnamon and Aconite Rehmannia Pill), added wu wei zi, wu zhu yu, bu gu zhi and rou dou kou, made it into a decoction, and two doses completed the cure.
💬 Note from Doctor Luo: Why keep tonifying after the warmth has arrived? Dear friends, Si Shen Wan warmed the spleen-stomach and stopped the diarrhea, but it only solved the immediate problem. You warmed it up and changed the situation — but why was it cold in the first place? Because the kidney qi was insufficient — the original driving force was lacking. Stop the medicine, and after a while it will leak again. So Doctor Xue Lizhai’s strategy is excellent: on one hand, use Si Shen Wan to scatter the cold and stop the diarrhea at once; on the other hand, use Ba Wei Wan to tonify kidney essence and warm kidney yang — treating the root. If you want to try it yourself with patent medicines, that works too: as long as the pattern is spleen-kidney yang deficiency — diarrhea the moment you touch anything cold — rest assured, it can be regulated.
Note from the commentator: yang deficiency can also bleed!
The hardest pass in this case was the combination of pus and blood in the stool plus vexing heat and thirst — it looked exactly like a heat pattern, easy to misdiagnose as dysentery from damp-heat. Doctor Xue Lizhai, using tongue diagnosis and other signs, determined that this was yang deficiency.
💬 Note from Doctor Luo: Everyone must remember: blood disorders are not only heat disorders. “Heat forcing the blood to move” is just one pattern. When yang is deficient, the whole body’s function declines, the intestines and spleen-stomach operate at low capacity, the system “collapses” — and bleeding is one result of that collapse. In the past there were far too many such cases: a person vomits blood and looks like a heat pattern, but is in fact all cold — warm the yang with fu zi (aconite) and gan jiang (dried ginger), and the bleeding stops at once. Blood in the stool is the same; much of it comes from spleen-kidney yang deficiency. So the moment you see blood and cry “fire,” you are wrong — cold can also cause bleeding.
What about the “vexing heat and thirst”? That is deficient yang floating outward (xu yang wai yue): when the lower burner is cold, it pushes deficiency heat upward — the colder below, the more disordered the function, the harder the body tries to adjust, and the more chaotic it becomes, until heat can no longer circulate through the body. The result is the feeling of “cold below, heat above.” There really are patients who, when cold reaches an extreme, become intensely restless, want to drink water, and feel terribly hot — while the lower body is profoundly cold.
💬 Note from Doctor Luo: Read through Doctor Xue Lizhai’s case records, and you will find true cold with false heat on nearly every other page — it is the single most common pattern in his cases. For today, just fix this impression in your mind: many people who look a little “hot” are in fact yang deficient. We will talk about this gradually over time, and soon you will recognize it.
Bonus: Doctor Luo’s diarrhea experience and a self-test for dawn diarrhea
To close, two practical ways to tell.
First, Doctor Luo Dalun has said it himself: don’t rush to clear damp-heat when you have diarrhea. He wrote about it once on Weibo — a patient’s diarrhea would not improve no matter how much huang lian su (berberine) he took; the root turned out to be insufficient kidney qi, and Jin Gui Shen Qi Wan worked immediately. So if diarrhea drags on, and you are cold-intolerant and purge whenever you touch anything cold, stop thinking about clearing heat — think spleen-kidney yang deficiency.
Second, the self-test for dawn diarrhea: when autumn arrives and the weather turns cold, people in the north start getting diarrhea; the first thing in the morning is a rush to the toilet, purging until dawn; touch anything cold and you purge — then you are eight or nine times out of ten spleen-kidney yang deficient. Si Shen Wan is available as a patent medicine in pharmacies today; the Tongrentang version is called Rou Kou Si Shen Wan, and its effect is excellent.
💬 Note from Doctor Luo: The character of this illness is “cold” — warm the middle, warm the yang, astringe and secure. Get the direction right, and results come extremely fast. Qu Ruwei’s case — one dose brought immediate relief, two doses completed the cure — is the best example. For friends with spleen-kidney yang deficiency who purge at the slightest chill, Si Shen Wan is a fine medicine well worth knowing.
Compiled from Doctor Luo Dalun’s lectures on Doctor Xue Lizhai’s cases; the case is from Xue’s Case Records (《薛氏医案》).