大肠者。传导之官。化物出焉。谓大肠下脾胃之化物。为中宫作传导之官。故呼为地道。乃宫中之出路也。
其经与肺相表里。肺为清金。大肠即为燥金。在五行本属一家。故诊脉者。可于肺部诊大肠焉。大肠之所
以能传送者。全赖于气。气者。肺之所主。不独大肠赖肺气之传送。即小便亦赖肺气以化行。此乃肺金制
节之能事。而大肠之气化金道又与之合。故治病者多治肺也。大肠位居下部。又系肾之所司。内经云。肾
开窍于二阴。又曰。肾为胃关。故必肾阴充足。则大肠腴润。厥阴肝脉。又绕后阴。肠与胞室。又并域而居。故
肝经与肠亦相干涉。是以大肠之病。有由中气虚陷。湿热下注者。有由肺经遗热。传于大肠者。有由肾经
阴虚。不能润肠者。有由肝经血热。渗漏入肠者。乃大肠与各脏相连之义也。但病所由来。则自各脏而生。
至病已在肠。则不能复还各脏。必先治肠以去其标。后治各脏以清其源。故病愈而永不发矣。
一先血后便为近血。谓其血即聚于大肠。去肛门近。故曰近血。此有两等证治。一为脏毒下血。一为肠风下血。
脏毒者。肛门肿硬。疼痛流血。与痔漏相似。仲景用赤豆当归散主之。取赤豆芽以疏郁。取当归以和血。赤
豆性能利湿。发芽赤色。则入血分。以为排解之用。当归润滑养血。以滋大肠。则不秘结。仲景略示其端。以
为治脏毒者。必须利湿热。和血脉也。非谓此二药外。别无治脏毒之法。吾即此药引而伸之。若大肿大痛。
大便不通者。宜解毒汤。取防风枳壳等疏理其气。即赤豆芽义也。取大黄赤芍等滑利其血。即仲景用当
归之义也。若大便不结。肿痛不甚者。不须重剂。用四物汤。加地榆荆芥槐角丹皮黄芩土茯苓地肤子苡
仁槟榔治之。四物汤。即仲景用当归养血之义。所加诸药。即仲景用赤豆芽。以疏利湿热。而解血郁也。仲
景但用养血疏郁。今恐湿热难解。故兼用清药。欲止血者。兼服锻石散。亦可。
脏毒久不愈者。必治肝胃。血者肝所司。肠者胃之关。胃若不输。湿热于肠。从何而结为脏毒哉。肝之血分
如无风火。则亦不迫结肛门矣。治胃宜清胃散。加银花土茯苓防己黄柏苡仁车前子。升清降浊。使阳明
之湿热。不再下注。则脏毒自愈。治肝者宜龙胆泻肝汤。逍遥散。
又有肺经遗热。传于大肠。而久不愈者。必见寸脉浮数洪涩。口渴溺黄。咳逆等病。方用人参清肺汤。取乌
梅粟壳酸涩之品。以收敛肺气。而余药安肺。肺自不遗热与肠矣。若去此二味。而用薄荷桔梗以代之。则
又义取解散。在人变化耳。
肠风者。肛门不肿痛。而但下血耳。脏毒下血多浊。肠风下血多清。仲景书无肠风之名。然伤寒论云。太阳
病。以火攻之。不得汗。其人必躁。到经不解。必圊血。太阳病下之。脉浮滑者。必下血。两条皆谓太阳。外邪内
陷而下血。又云阳明病。下血谵语者。为热入血室。厥阴篇云。若厥而呕。胸胁烦满者。其后必便血。此即今
所谓肠风下血之义。夫肠居下部。风从何而袭之哉。所以有风者。外则太阳风邪。传入阳明。协热而下血。
内则厥阴肝木。虚热生风。风气煽动而血下。风为阳邪。久则变火。治火即是治风。凡治肠风下血。总以清
火养血为主。火清血宁。而风自熄矣。寿世保元。用槐角丸统治之。而未明言其义。吾谓此方。荆防。治太阳
阳明传入之风。乌梅川芎。治肝木内动之风。余药宁血清火。以成厥功。宜其得效。然而外风协热。宜得仲
景葛根黄连黄芩汤之意。使内陷之邪。上升外达。不致下迫。斯止矣。治病之法。高者抑之。下者举之。吐衄
所以必降气。下血所以必升举也。升举。非第补中益气之谓。开提疏发。皆是升举。葛根黄连黄芩汤。加荆
芥当归柴胡白芍槐花地榆桔梗治之。若肝经风热内煽。而下血者。必见胁腹胀满。口苦多怒。或兼寒热。
宜泻青丸治之。逍遥散。小柴胡。均可加减出入。谨按。肝风所以能下血者何也。肝主血。血室又居大肠膀
胱之间。故热入血室。有小便下血之证。内有积血。有大便黑色之证。盖肝血上干。从浊道则吐。从清道则
衄。肝血下渗。从清道则尿血。从浊道则下血。肝为风木之脏。而主藏血。风动血不得藏。而有肠风下血之
症。上数方。力足平之。或用济生乌梅丸亦妙。以乌梅敛肝风。以僵蚕息肝风。风平火息。而血自宁矣。然肝
风动血。宜得仲景白头翁汤之意。以清火消风较有力量。或四物汤合白头翁汤。兼补其血。治风先治血。
血行风自灭。此之谓也。如无白头翁。则择柴胡青蒿白薇代之。桑寄生。得风气而生。代白头翁更佳。又曰
肝经之横。以肺经不能平木故也。肺与大肠又相表里。借治肺经。亦隔治之一法。虚者人参清肺汤。实者
人参泻肝汤。
凡肠风脏毒。下血过多。阴分亏损。久不愈者。肾经必虚。宜滋阴脏连丸。启肾阴以达大肠最妙。六味丸。加
苁蓉槐角皆宜。
一先便后血为远血。谓其血在胃中。去肛门远。故便后始下。因名远血。即古所谓阴结下血也。黄土汤主
之。黄土名汤。明示此症。系中宫不守。血无所摄而下也。佐以附子者。以阳气下陷。非此不能举之。使黄芩
者。以血虚则生火。故用黄芩以清之。仲景此方。原主温暖中宫。所用黄芩。乃以济附子之性。使不燥烈。免
伤阴血。普明子谓此症必脉细无力。唇淡口和。四肢清冷。用理中汤。加归芍。或归脾汤。十全大补汤。时医
多用补中益气汤。以升提之。皆黄土汤之意。凡中土不能摄血者。数方可以随用。但仲景用温药。兼用清
药。知血之所以不宁者。多是有火扰之。凡气实者。则上干。气虚者则下陷。今医但用温补升提之药。虽得
治气虚之法。而未得治血扰之法。予即仲景之意。分别言之。若阴虚火旺。壮火食气。脾阴虚而肺气燥。失
其敛摄之制者。人参清肺汤治之。若肝经怒火。肺经忧郁。以致血不藏摄者。归脾汤。加炒栀麦冬阿胶五
味。或用丹栀逍遥散。加阿胶桑寄生地榆。此即黄土汤主用黄芩之义也。若系虚损不足。下血过多。脾气
不固。肾气不强。面色萎黄。手足清厥。六脉微弱虚浮者。宜大补肝脾肾三经。人参养荣汤补脾。胶艾四物
汤。加巴戟甘草补肝。断红丸补肾。此即黄土汤主用附子之义也。能从此扩而充之。自有许多变化。岂楮
墨间所能尽者。
予按此证。与妇人崩漏无异。女子崩中属虚陷。此病亦属虚陷。女子崩中属虚寒。而亦兼有虚热者。男子
此症亦属虚寒。而亦兼有虚热者。盖女子之血有经。男子之血亦有经。同是离经之血。下泄而出。故病情
相类也。但所出之窍。各有不同。崩漏出前阴。故多治肝以和血室。便血出后阴。故兼治肺肾以固肠气。肾
主下焦。主化气上升。肾足则气不下陷。肺与肠相表里。肺气敛则肠气自固。医者能知此理。而又参用女
子崩中之法。可以尽其调治。
又按此证。与吐衄同是血病。然一则其气上行。一则其气下行。故虚实治法。略有不同。
大肠，是负责传导的器官，消化后的食物残渣由此排出。意思是说，大肠承接脾胃消化后的物质，作为中焦（脾胃）的传导之官，因此被称为“地道”，这是体内代谢物排出的通道。
大肠的经络与肺互为表里。肺属清金，大肠属燥金，在五行中本属同一家族。所以诊脉时，可以通过诊察肺部来了解大肠的情况。大肠之所以能够传送糟粕，完全依赖于气的推动。气由肺所主，不仅大肠依赖肺气的传送，小便的化生与运行也依赖肺气的作用。这是肺金制约调节的功能体现，而大肠的气化功能与肺的金行特性又相互契合。因此，治疗疾病时多从治肺入手。大肠位于身体下部，又受肾管辖。《内经》说：“肾开窍于二阴”，又说：“肾为胃之关”。所以必须肾阴充足，大肠才能滋润润滑。厥阴肝经环绕后阴，肠道与胞宫（子宫）又在同一区域相邻居住，所以肝经与肠道也有相互影响的关系。因此，大肠的疾病，有的因中气虚弱下陷、湿热下注引起；有的因肺经余热传至大肠引起；有的因肾经阴虚、不能滋润肠道引起；有的因肝经血热、渗漏入肠引起。这就是大肠与各脏腑相连的道理。但是，疾病的来源，则是从各个脏腑产生的。既然病邪已经在于肠道，就不能再返还到各脏腑去治疗，必须先治疗肠道以去除标症，然后再治疗各脏腑以清除病源。这样病愈后就不会再复发。
先出血后大便称为“近血”，意思是血液积聚在大肠，距离肛门很近，所以叫近血。这有两种证候和治疗方法：一是脏毒下血，二是肠风下血。
所谓脏毒，是指肛门肿胀坚硬，疼痛并流血，症状与痔疮瘘管相似。张仲景用赤豆当归散主治。取赤豆芽以疏通郁滞，取当归以调和血脉。赤豆性能利湿，发芽且呈赤色，则能入血分，起到排解瘀热的作用。当归润滑养血，以滋润大肠，使其不致秘结。张仲景仅略示其端倪，表明治疗脏毒必须利湿热、和血脉。这并不是说除了这两味药外，没有其他治疗脏毒的方法。我根据此方引申发挥：如果肿痛严重、大便不通者，宜用解毒汤。取防风、枳壳等疏理气机，即赤豆芽疏通之意；取大黄、赤芍等滑利血脉，即张仲景使用当归之意。如果大便不干燥，肿痛不严重者，不需要重剂，可用四物汤，加地榆、荆芥、槐角、丹皮、黄芩、土茯苓、地肤子、薏苡仁、槟榔治疗。四物汤，即张仲景使用当归养血的意义。所加诸药，即张仲景使用赤豆芽以疏利湿热、解除血郁的意义。张仲景仅用养血疏郁，我现在担心湿热难解，所以兼用清热药。想要止血，也可以兼服锻石散。
脏毒久治不愈者，必须治疗肝和胃。血由肝所主管，肠道是胃的关口。如果胃不输送湿热到肠道，湿热从何而在肠道结聚形成脏毒呢？如果肝的血分中没有风火扰动，也不会逼迫血液结聚于肛门。治疗胃宜用清胃散，加金银花、土茯苓、防己、黄柏、薏苡仁、车前子，以升清降浊，使阳明经的湿热不再下注，则脏毒自愈。治疗肝宜用龙胆泻肝汤或逍遥散。
又有肺经余热传于大肠，久而不愈者，必然出现寸脉浮数洪涩、口渴、小便黄、咳嗽气逆等症状。此时用人参清肺汤。取乌梅、罂粟壳等酸涩之品，以收敛肺气，其余药物安养肺脏，肺自然不再将余热遗留给肠道。如果去掉这两味药，改用薄荷、桔梗代替，则意义转为解散邪气，全凭医者灵活变通。
所谓肠风，是指肛门不肿不痛，只是单纯下血。脏毒下血多浑浊，肠风下血多清澈。张仲景的书中没有“肠风”之名，然而《伤寒论》说：“太阳病，用火攻法，不得汗出，其人必定烦躁。到了病程期限仍未解，必定出现便血。”“太阳病误用下法，脉象浮滑者，必定下血。”这两条都讲的是太阳病，外邪内陷而下血。又说：“阳明病，下血谵语的，是热入血室。”《厥阴篇》说：“如果四肢厥冷且呕吐，胸胁烦闷满胀的，其后必定便血。”这些就是现在所说的肠风下血的意义。肠道居于下部，风邪从何而来侵袭呢？之所以有风，外在则是太阳风邪传入阳明，协同热邪而下血；内在则是厥阴肝木虚热生风，风气煽动导致血液下行。风为阳邪，日久则变为火，治疗火即是治疗风。凡是治疗肠风下血，总以清火养血为主。火清血宁，风自然熄灭。《寿世保元》用槐角丸统摄治疗，但未明确说明其原理。我认为此方中，荆芥、防风，治疗太阳、阳明传入的风邪；乌梅、川芎，治疗肝木内动的风邪；其余药物宁血清火，以此成就功效，难怪有效。然而对于外风协同热邪的情况，应当借鉴张仲景葛根黄连黄芩汤的意思，使内陷的邪气上升外达，不致下迫，这样出血自止。治病的原则，高处的病势要抑制它，低处的病势要举提它。吐血衄血所以必须降气，便血所以必须升举。升举，不仅仅是指补中益气，开提疏发都属于升举。可用葛根黄连黄芩汤，加荆芥、当归、柴胡、白芍、槐花、地榆、桔梗治疗。如果是肝经风热内煽而下血，必然出现胁腹胀满、口苦易怒，或兼有寒热，宜用泻青丸治疗。逍遥散、小柴胡汤均可加减使用。谨按：肝风为什么能导致下血呢？肝主血，血室又位于大肠和膀胱之间，所以热入血室，有小便下血的证候；内有积血，有大便黑色的证候。大概肝血上逆，从浊道则呕吐，从清道则鼻衄；肝血下渗，从清道则尿血，从浊道则便血。肝为风木之脏，主藏血，风动则血不能藏，而有肠风下血的症状。上述各方，力量足以平抑此证。或者使用济生乌梅丸也很妙，以乌梅收敛肝风，以僵蚕平息肝风，风平火息，血液自然安宁。然而肝风动血，应当借鉴张仲景白头翁汤的意思，以清火消风更有力量。或者将四物汤合白头翁汤，兼补其血。“治风先治血，血行风自灭”，说的就是这个道理。如果没有白头翁，则选择柴胡、青蒿、白薇代替。桑寄生，得风气而生，代替白头翁效果更好。又说：肝经之气横逆，是因为肺经不能平抑肝木的缘故。肺与大肠又互为表里，通过治疗肺经，也是一种隔脏治疗的方法。虚证用人参清肺汤，实证用人参泻肝汤。
凡是肠风、脏毒，下血过多，导致阴分亏损，久治不愈者，肾经必然虚弱。宜用滋阴脏连丸，启补肾阴以通达大肠最为巧妙。六味地黄丸，加肉苁蓉、槐角也都适宜。
先大便后出血称为“远血”，意思是血液在胃部，距离肛门很远，所以是大便之后才出血，因此名为远血。即古代所谓的阴结下血。用黄土汤主治。名为黄土汤，明示此症系中焦脾胃失守，血液无所统摄而下溢。佐以附子，是因为阳气下陷，不用此药不能举提阳气。使用黄芩，是因为血虚则生火，故用黄芩以清火。张仲景此方，原本主要温暖中焦，所用黄芩，是为了辅助附子的药性，使其不燥烈，以免损伤阴血。普明子认为此症必然脉细无力、唇淡口润、四肢清冷，应用理中汤加当归、白芍，或归脾汤、十全大补汤。现代医生多用补中益气汤以升提，这些都是黄土汤的意思。凡是中土不能摄血者，这几方可以随证选用。但张仲景用温药兼用清药，知道血液之所以不安宁，大多是有火邪扰乱。凡气实者，则向上干犯；气虚者，则向下陷落。现在的医生只用温补升提的药物，虽然得到了治疗气虚的方法，却未得到治疗血扰的方法。我依据张仲景的意思，分别论述：如果是阴虚火旺，壮火食气，脾阴虚而肺气燥，失去敛摄功能的，用人参清肺汤治疗。如果是肝经怒火、肺经忧郁，导致血不藏摄的，用归脾汤，加炒栀子、麦冬、阿胶、五味子，或用丹栀逍遥散，加阿胶、桑寄生、地榆。这就是黄土汤主用黄芩的意义。如果是虚损不足，下血过多，脾气不固，肾气不强，面色萎黄，手足清冷，六脉微弱虚浮的，宜大补肝、脾、肾三经。人参养荣汤补脾，胶艾四物汤加巴戟天、甘草补肝，断红丸补肾。这就是黄土汤主用附子的意义。能从此扩展充实，自有许多变化，哪里是笔墨所能穷尽的呢？
我按：此证与妇人崩漏无异。女子崩中属于虚陷，此病也属于虚陷。女子崩中属于虚寒，但也兼有虚热；男子此症也属于虚寒，但也兼有虚热。大概女子的血有月经，男子的血也有常道，同样是离经之血，下泄而出，所以病情相似。只是出血的孔窍各有不同。崩漏从前阴出，所以多治肝以和血室；便血从后阴出，所以兼治肺肾以固肠气。肾主下焦，主化气上升，肾气充足则气不下陷；肺与肠相表里，肺气收敛则肠气自然固密。医者能知此理，而又参考女子崩中的治法，就可以尽其调治之道。
The Large Intestine is the official responsible for conduction, where transformed substances exit. This means that the Large Intestine receives the transformed matter from the Spleen and Stomach, acting as the conduit for the Middle Jiao (Spleen and Stomach). Therefore, it is called the "Earthly Way," which is the outlet for metabolic waste within the body.
Its meridian is exterior-interior related to the Lung. The Lung belongs to Clear Metal, while the Large Intestine belongs to Dry Metal; in the Five Elements theory, they belong to the same family. Thus, pulse diagnosis can assess the Large Intestine by examining the Lung position. The ability of the Large Intestine to transport waste relies entirely on Qi. Qi is governed by the Lung. Not only does the Large Intestine rely on Lung Qi for transportation, but the transformation and movement of urine also depend on Lung Qi. This is the function of Metal restraining and regulating. The Qi transformation of the Large Intestine harmonizes with the Metal pathway. Therefore, treating diseases often involves treating the Lung. The Large Intestine is located in the lower part of the body and is also controlled by the Kidney. The *Neijing* states: "The Kidney opens into the two yin orifices" and "The Kidney is the gate of the Stomach." Thus, sufficient Kidney Yin is required for the Large Intestine to be moist and lubricated. The Jueyin Liver meridian circles the posterior orifice, and the intestines reside adjacent to the uterus (Bao Palace) in the same region, so the Liver meridian also interferes with the intestines. Consequently, diseases of the Large Intestine may arise from: deficiency and sinking of Middle Qi with damp-heat pouring downward; residual heat from the Lung meridian transmitting to the Large Intestine; Yin deficiency of the Kidney meridian failing to moisten the intestines; or Blood heat in the Liver meridian leaking into the intestines. This illustrates the connection between the Large Intestine and various Zang organs. However, since the origin of the disease lies in these organs, once the pathology is established in the intestine, it cannot simply revert to the organs for treatment. One must first treat the intestine to eliminate the branch symptoms (biao), and then treat the respective organs to clear the root source (ben). Only then will the disease heal without recurrence.
Bleeding before stool is called "Near Bleeding" (Jin Xue), meaning the blood accumulates in the Large Intestine, close to the anus. There are two types of syndromes and treatments: Zang Du bleeding and Chang Feng bleeding.
Zang Du refers to swelling and hardness of the anus, pain, and bleeding, resembling hemorrhoids and fistulas. Zhang Zhongjing uses Chidou Danggui San (Red Bean and Angelica Decoction) as the main formula. Red bean sprouts are used to vent stagnation, and Danggui (Angelica Sinensis) harmonizes the blood vessels. Red beans promote diuresis and resolve dampness; when sprouted and red, they enter the Blood level to help resolve stasis and heat. Danggui moistens and nourishes Blood, lubricating the Large Intestine to prevent constipation. Zhang Zhongjing merely indicates the principle that treating Zang Du requires resolving damp-heat and harmonizing the blood vessels. This does not imply that no other methods exist beyond these two herbs. Extending from this formula: if there is severe swelling, pain, and bowel obstruction, Jiedu Tang (Detoxification Decoction) should be used. Fangfeng (Saposhnikovia) and Zhike (Aurantii Fructus) regulate Qi, reflecting the action of red bean sprouts. Dahuang (Rhei Radix et Rhizoma) and Chishao (Paeoniae Radix Rubra) lubricate and move Blood, reflecting Zhang Zhongjing's use of Danggui. If stools are not dry and swelling/pain are mild, heavy doses are unnecessary. Use Siwu Tang (Four Substances Decoction) plus Diyú (Sanguisorbae Radix), Jingjie (Schizonepetae Herba), Huaijiao (Sophorae Tonkinensis Fructus), Danpi (Moutan Cortex), Huangqin (Scutellariae Radix), Tufuling (Smilacis Glabrae Rhizoma), Difuzi (Kochiae Fructus), Yiren (Coicis Semen), and Binglang (Arecae Semen). Siwu Tang reflects Zhang Zhongjing's principle of nourishing Blood with Danggui. The added herbs reflect the use of red bean sprouts to drain damp-heat and resolve Blood stagnation. While Zhang Zhongjing focused on nourishing Blood and venting stagnation, I add clearing herbs because damp-heat may be difficult to resolve alone. To stop bleeding, Duanshi San (Calcined Stone Powder) can be taken concurrently.
For chronic Zang Du that does not heal, the Liver and Stomach must be treated. Blood is governed by the Liver, and the intestines are the gate of the Stomach. If the Stomach does not transport damp-heat to the intestines, how would it accumulate to form Zang Du? If the Liver's Blood level lacks wind-fire, it would not force blood to accumulate at the anus. To treat the Stomach, use Qingwei San (Clear Stomach Powder) plus Jinyinhua (Lonicerae Japonicae Flos), Tufuling, Fangji (Stephaniae Tetrandrae Radix), Huangbo (Phellodendri Cortex), Yiren, and Cheqianzi (Plantaginis Semen) to raise the clear and descend the turbid, preventing Yangming damp-heat from pouring downward, thus healing Zang Du. To treat the Liver, use Longdan Xiegan Tang (Gentiana Decoction to Drain the Liver) or Xiaoyao San (Free and Easy Wanderer Powder).
Another type involves residual heat from the Lung meridian transmitting to the Large Intestine, persisting for a long time. Symptoms include floating, rapid, surging, and choppy pulses at the Cun position, thirst, yellow urine, cough, and counterflow qi. In such cases, Renshen Qingfei Tang (Ginseng Lung-Clearing Decoction) is used. Wumei (Mume Fructus) and Susuke (Papaveris Pericarpium) are sour and astringent to converge Lung Qi, while other herbs calm the Lung, preventing residual heat from being transmitted to the intestines. If these two are removed and replaced with Bohe (Menthae Haplocalycis Herba) and Jiegeng (Platycodonis Radix), the intent shifts to dispersing pathogens, depending on the physician's flexibility.
Chang Feng (Intestinal Wind) is characterized by no swelling or pain at the anus, only bleeding. Zang Du bleeding is often turbid, while Chang Feng bleeding is often clear. Zhang Zhongjing's texts do not mention "Chang Feng." However, the *Shanghan Lun* states: "In Taiyang disease, if fire therapy is applied and sweat is not obtained, the patient becomes irritable. If the disease duration passes without resolution, bloody stool will occur." "In Taiyang disease, if purgatives are misused and the pulse is floating and slippery, bloody stool will definitely occur." Both passages describe Taiyang external pathogens sinking inward causing bleeding. It also states: "In Yangming disease, bloody stool with delirium indicates Heat entering the Blood Chamber." The *Jueyin* chapter states: "If there is cold extremities, vomiting, and fullness/irritability in the chest and hypochondrium, bloody stool will follow." These correspond to the modern concept of Chang Feng bleeding. The intestines are in the lower jiao; how does wind invade? Externally, Taiyang wind pathogens transmit to Yangming, combining with heat to cause bleeding. Internally, Jueyin Liver Wood generates wind due to deficient heat; the wind agitation causes blood to descend. Wind is a Yang pathogen that transforms into Fire over time; treating Fire is treating Wind. Generally, treating Chang Feng bleeding focuses on clearing Fire and nourishing Blood. When Fire is cleared and Blood is calmed, Wind extinguishes itself. *Shoushi Baoyuan* uses Huaijiao Wan (Sophora Pill) to treat all cases but does not explain the rationale. I propose that in this formula, Jingjie and Fangfeng treat wind transmitted from Taiyang and Yangming; Wumei and Chuanxiong treat internal wind stirring in Liver Wood; other herbs calm Blood and clear Fire, achieving efficacy. For external wind combined with heat, one should adopt the principle of Gegen Huanglian Huangqin Tang (Kudzu, Coptis, and Scutellaria Decoction) by Zhang Zhongjing, to lift and release trapped pathogens outward, preventing downward pressure, thereby stopping bleeding. The therapeutic principle is: suppress what is high, elevate what is low. Hematemesis and epistaxis require descending Qi; hematochezia requires elevating Qi. Elevation is not just Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction); lifting and dispersing are also forms of elevation. Use Gegen Huanglian Huangqin Tang plus Jingjie, Danggui, Chaihu (Bupleuri Radix), Baishao (Paeoniae Radix Alba), Huaihua (Sophorae Flos), Diyu, and Jiegeng. If Liver Wind-Heat stirs internally causing bleeding, symptoms include distension/fullness in costal and abdominal regions, bitter taste, irritability, or alternating chills and fever. Use Xieqing Wan (Drain Green Pill). Xiaoyao San and Xiao Chaihu Tang (Minor Bupleurum Decoction) can be modified. Note: Why can Liver Wind cause bleeding? The Liver governs Blood, and the Blood Chamber resides between the Large Intestine and Bladder. Thus, Heat entering the Blood Chamber presents with hematuria; internal blood stasis presents with black stool. If Liver Blood rebels upward, it vomits via the turbid orifice or nosebleeds via the clear orifice. If Liver Blood seeps downward, it causes hematuria via the clear orifice or hematochezia via the turbid orifice. The Liver is the organ of Wind-Wood, storing Blood. When Wind moves, Blood cannot be stored, resulting in Chang Feng bleeding. The aforementioned formulas have sufficient strength to pacify this. Alternatively, Jisheng Wumei Wan (Wumei Pill from the Hall of Generosity) is excellent: Wumei converges Liver Wind, Jiangcan (Bombyx Batryticatus) extinguishes Liver Wind. When Wind is calm and Fire subsides, Blood settles. However, for Liver Wind moving Blood, one should adopt the principle of Baitouweng Tang (Pulsatilla Decoction) by Zhang Zhongjing, as it is more potent in clearing Fire and eliminating Wind. Or combine Siwu Tang with Baitouweng Tang to tonify Blood simultaneously. "To treat Wind, first treat Blood; when Blood moves, Wind self-extinguishes." If Baitouweng is unavailable, substitute with Chaihu, Qinghao (Artemisiae Annuae Herba), or Baiwei (Clehemiae Radix). Sangjisheng (Taxilli Caulis), born of Wind-Qi, is an even better substitute for Baitouweng. Furthermore, Liver Qi rebellion occurs because the Lung fails to control Wood. Since Lung and Large Intestine are exterior-interior related, treating the Lung is an indirect method. Deficiency patterns use Renshen Qingfei Tang; Excess patterns use Renshen Xiegan Tang (Ginseng Liver-Draining Decoction).
Whenever Chang Feng or Zang Du causes excessive bleeding, leading to Yin deficiency and chronic non-healing, the Kidney meridian must be deficient. Use Ziyang Zanglian Wan (Nourish Yin Intestine-Lotus Pill) to activate Kidney Yin to reach the Large Intestine, which is optimal. Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill) plus Rongrong (Cynomorii Fructus) and Huaijiao is also suitable.
Bleeding after stool is called "Far Bleeding" (Yuan Xue), meaning the blood originates in the Stomach, far from the anus, hence appearing after stool. This is the ancient "Yin Knot Bleeding." It is treated with Huangtu Tang (Yellow Earth Decoction). The name "Yellow Earth Decoction" explicitly indicates that this syndrome results from the Middle Jiao failing to secure Blood, causing it to pour downward. Fuzi (Aconiti Lateralis Radix Praeparata) is added because Yang Qi has sunk and requires this herb to lift it. Huangqin is used because Blood deficiency generates Fire, which Huangqin clears. Zhang Zhongjing's original intent was to warm the Middle Jiao; the Huangqin serves to moderate the drying and hot nature of Fuzi, preventing damage to Yin Blood. Pumingzi states this syndrome presents with fine, weak pulses, pale lips, neutral mouth sensation, and cold limbs, recommending Lizhong Tang (Middle-Regulating Decoction) plus Danggui and Baishao, or Guipi Tang (Restore the Spleen Decoction), Shiquan Dabu Tang (Ten Significant Tonifying Decoction). Modern physicians often use Buzhong Yiqi Tang to lift Qi, following the logic of Huangtu Tang. For any case where the Earth element fails to control Blood, these formulas can be selected. However, Zhang Zhongjing used warming herbs alongside clearing herbs, recognizing that Blood instability is often caused by Fire disturbance. Excess Qi rebels upward; Deficient Qi sinks downward. Current physicians use only warming, tonifying, and lifting herbs, addressing Qi deficiency but ignoring Blood disturbance. Expanding on Zhang Zhongjing's principles: If Yin deficiency with Hyperactive Fire consumes Qi, Spleen Yin deficiency, and Lung Qi dryness lead to loss of astringency, use Renshen Qingfei Tang. If Liver Fire and Lung Depression cause failure to store Blood, use Guipi Tang plus Chao Zhizi (Fried Gardenia), Maidong (Ophiopogonis Radix), Ejiao (Asini Corii Colla), and Wuweizi (Schisandrae Fructus), or Danshi Xiaoyao San plus Ejiao, Sangjisheng, and Diyu. This reflects the rationale for using Huangqin in Huangtu Tang. If deficiency exhaustion leads to excessive bleeding, Spleen Qi insecurity, Kidney Qi weakness, sallow complexion, cold extremities, and faint, floating pulses, greatly tonify the Liver, Spleen, and Kidney meridians. Renshen Yangrong Tang tonifies the Spleen; Jiao'ai Siwu Tang plus Bajitian (Morindae Officinalis Radix) and Gancao (Glycyrrhizae Radix) tonifies the Liver; Duanhong Wan (Stop Red Pill) tonifies the Kidney. This reflects the rationale for using Fuzi in Huangtu Tang. Expanding upon this yields many variations beyond mere textual description.
Note: This syndrome is identical to metrorrhagia and metrostaxis in women. Female metrorrhagia belongs to deficiency-sinking; this male condition also belongs to deficiency-sinking. Female metrorrhagia is primarily deficiency-cold but may involve deficiency-heat; this male condition is also deficiency-cold with potential deficiency-heat. Women have menstrual cycles; men have their own blood pathways. Both involve blood leaving its normal vessel and flowing downward, hence the similar pathology. However, the orifices differ. Metrorrhagia exits the anterior orifice, so treatment focuses on the Liver to harmonize the Blood Chamber. Hematochezia exits the posterior orifice, so treatment combines Lung and Kidney regulation to secure Intestinal Qi. The Kidney governs the Lower Jiao and transforms Qi to ascend; sufficient Kidney Qi prevents sinking. The Lung and Intestine are exterior-interior related; Lung Qi convergence secures Intestinal Qi. Understanding this and applying female metrorrhagia methods allows for comprehensive management.
Furthermore: This syndrome and hematemesis/epistaxis are both Blood disorders. However, one involves ascending Qi, the other descending Qi, so the treatment principles for excess and deficiency differ slightly.