Diarrhea is abnormal defecation or the passing of abnormal feces. It may manifest as more frequent defecation or as abnormal feces that are poorly formed or water-like. It is often accompanied by abdominal distention, abdominal pain or borborygmus.
Note that diarrhea is distinct from dysentery, which usually presents with tenesmus and feces that contain blood or pus.
Etiology and Pathology
The pathogenic factors of diarrhea include attack by exogenous evils, injury by intemperate diet, unbalanced passions and weakness or insufficiency of the visceral organs. The key, however, is disturbance of the functions of the spleen and the stomach.
Among the six climatic pathogenic evils, Dampness is the most important in the pathogenesis of diarrhea. Because the spleen detests dampness and prefers dryness, exogenous Dampness can readily block the spleen (the unduly strengthened Water Element counter-restraining the Earth Element). When the spleen’s functions of transportation and transformation are impaired, the mishmash of water and food descends, leading to diarrhea. For this reason it has been said that “much Dampness is five-tenths of diarrhea” and that “without Dampness there is no diarrhea.” As for Cold and Summer Heat, they can invade the lung and the Defensive Level, transmit from the exterior to the interior and impair the functions of the spleen and the stomach. They can also injure the spleen and the stomach directly, impairing their ability to separate the pure from the turbid and causing diarrhea. Even so, they usually accompany Dampness where diarrhea is concerned.
Intemperate diet causing diarrhea means mostly excessive intake, overindulgence in raw and cold foods, overindulgence in spicy and fatty diet, or inadvertent eating of rotten or unclean foods. Any of these can impair spleen-stomach functions. Since the essences of the food and drink cannot be properly absorbed they become stagnant as Dampness and can lead to diarrhea.
Passions, especially excessive depression, rage, anxiety and brooding, can block the liver and induces stagnation of Qi. Stagnant liver-Qi then moves abnormally and attacks the spleen and the stomach.
A weak constitution, a chronic illness and convalescent weakness can all cause insufficiency of the spleen. If spleen insufficiency extends to the kidney, vital gate Fire weakens and is unable to assist the spleen in the digestion of food. This can also lead to diarrhea.
In addition, there are less common causes of diarrhea. When excessive fluid is taken in, beyond the capacity of the stomach and the intestines to absorb, the excess fluid remains in the large intestine and can lead to diarrhea. Prolonged gelling of Cold, Heat or Dampness in the sigmoid colon can affect the meridians and lead to diarrhea as well.
In general, the main pathologic change in diarrhea is in the spleen, the stomach and the intestines, but is also related to the liver and the kidney. Spleen insufficiency with ascendancy of Dampness is the key to the development of diarrhea. The exogenous causes are most intimately related to Dampness. When Dampness invades and injures the spleen and the stomach, their transportation and transformation functions are impaired. Hence Plain Questions states: “When Dampness wins, diarrhea ensues.” The endogenous causes are most intimately related to insufficiency of the spleen. An insufficient spleen fails in its functions, so that the essences of foods and drinks cannot be extracted. Endogenous Dampness and turbidity result; and the descent of the mishmash of undigested foods and turbidity descend and lead to diarrhea. In the Collected Works of Zhang Jingyue it is stated: “The basic pathology of diarrhea is no other than the spleen and the stomach.” Even diarrhea due to liver or kidney dysfunction develops primarily on the basis of impaired spleen and stomach function.
Acute diarrhea is principally due to Dampness and is an illness of strength. Chronic diarrhea is principally due to spleen insufficiency and is an illness of deficiency or mixed strength and deficiency. Strength and deficiency are interrelated also, since impairment of spleen functions leads to the ascendancy of Dampness and ascendancy of Dampness affects spleen functions.
Clinical Manifestation
Diarrhea may present as increased frequency of defecation. It may occur three times, five times, even more than a dozen times in one day. The feces may be loose (poorly formed) or watery, or may be mostly undigested foods. The main accompanying symptoms are abdominal pain and borborygmus.
If it is due to attack by Cold-Dampness, the tongue coating is white and greasy and the pulse is soft and even.
If it is due to attack by Dampness-Heat, the tongue coating is yellow and greasy and the pulse is either soft or slippery and rapid.
If it is due to injury by intemperate diet, the tongue coating is dirty or thick and greasy.
If it is due to spleen insufficiency, the tongue is pale with a white and moist coating and the pulse is threadlike and feeble.
If it is due to kidney insufficiency, the tongue is pale with thin and white coating and the pulse is deep and threadlike.
Patients often have a history of eating binges or of eating unclean food or drinks. Diarrhea may occur throughout the year, but is most common in summer and autumn.
Key Points of Analysis
Acuteness and Severity. Acute or explosive diarrhea begins abruptly and has a relatively short course. It is mainly due to strong Dampness. Chronic diarrhea begins more slowly and has a longer course, often persisting for many days, and it often relapses when the patient indulges in intemperate diet or is excessively fatigued. Chronic diarrhea is mostly due to spleen insufficiency. If prolonged, there may be kidney insufficiency as well, with such symptoms as pre-dawn diarrhea and flank aches. These indicate weakness of the Fire of the vital gate and simultaneous illness of the spleen and the kidney. In mild diarrhea, appetite and diet are generally normal and the prognosis is good. If there are anorexia and emaciation and the diarrhea is unchecked, or defecation is persistent and uncontrollable, the body fluids may become depleted. This may lead to collapse of Yin or Yang.
Wind-Heat and Deficiency-Strength. If the illness is acute, with epigastric and abdominal distention, abdominal pain with guarding and relief following defecation and difficulty with urination, it is mostly one of strength. If the course is more prolonged, with mild or moderate abdominal pain that is alleviated by pressure, normal urination and absence of thirst, the illness is mostly one of deficiency. If the feces are like water and contain undigested food, with abdominal pain, cold-aversion with preference for warmth, and cold hands and feet, the illness is mostly one of Cold. If the feces are yellow-brown, with strong foul odor, burning of the anus, explosive urgency to defecate, scant urine that is red, thirst with preference for cold drinks, the illness is mostly due to Heat.
Mixed Illnesses. If cold-intolerance, spontaneous sweating, fever, headache and a floating pulse accompany the diarrhea there is Wind as well. If it comes in high summer or in especially hot weather, with fever, thirst, a heavy head, spontaneous sweating and a soft and rapid pulse, there is Summer Heat as well. If distention and pressure in the epigastrium and foul eructation accompany the diarrhea there is injury by intemperate diet as well.
Herbal Treatment
In the treatment of diarrhea, first determine whether it is acute or chronic. The treatment of acute diarrhea is based on the elimination of Dampness. Additional treatment will depend on which additional exogeneous evil has joined with Dampness. The treatment of chronic diarrhea is based on strengthening the spleen, complemented by additional treatment as needed.
For acute diarrhea, do not apply vigorous restoration or astringency, so as not to trap the exogenous evil within. For chronic diarrhea, be cautious in treatment during defervescence of fever through sweating in order to avoid aggravating depletion of Yin-fluids.
Acute Diarrhea
Cold-Dampness
Main Symptoms. Diarrhea with very loose or watery feces, abdominal pain, bor-borygmus, epigastrium discomfort, poor appetite. If there is Wind as well, aversion to cold, fever, headache, aches and pain in the body and limbs. The tongue coating is thin and white, and the pulse floating.
Therapeutic Principle. Eliminate Dampness with aromatic herbs, release the exterior and dispel Cold.
Treatment. For mild cases, Ping Wei San.
For more severe cases, Ping Wei San (Stomach-Settling Powder) combined with Wu Ling San (Five-Ingredient Poria Powder). Wu Ling San has the following composition: guizhi (Cinnamomum), baizhu (Atractylodes), fuling (Poria), zhuling (Polyporus) and zexie (Alisma).
If there is Wind in addition to Cold and Dampness, use Huoxiang Zheng Qi San. If symptoms of Cold in the exterior are severe, add jingjie (Schizonepeta) and fangfeng (Saposhnikovia) to enhance the formula’s ability to disperse Wind and dispel Cold.
Dampness-Heat
Main Symptoms. Diarrhea with abdominal pain; urgent and explosive or uncomfortable defecation; yellow brown feces with foul odor; anal burning; restlessness with thirst; and scant urine that is yellow. The tongue coating is yellow and greasy. The pulse is rapid and either slippery or soft.
Therapeutic Principle. Cool Heat and drain Dampness.
Treatment. Gegen Qin Lian Tang (Pueraria-Scutellaria-Coptis Decoction). It has the following composition: gegen (Pueraria) 15 g, huangqin (Scutellaria) 10 g, huanglian (Coptis) 6g, yiyiren (Coix) 20 g, houpo (Magnolia) 10 g, jinyinhua (Lonicera) 10 g, muxiang (Aucklandia) 6g, fuling (Poria) 15 g, pugongying (Taraxacum) 20 g, and gancao (Glycyrrhiza) 6g.
If accompanied by food retention, add shenqu (medicated leaven), shanzha (Crataegus) and maiya (Hordeum).
If there are symptoms of Wind-Heat in the exterior, such as fever, headache and a floating pulse, add lianqiao (Forsythia) and bohe (Mentha).
If diarrhea occurs in high summer, with such symptoms as fever, heaviness in the head, strong thirst, spontaneous sweating, scant urine and a soft and rapid pulse, it is an illness of Summer Heat and Dampness affecting the interior and the exterior simultaneously. Treat with Xin Jia Xiangru Yin combined with Liu Yi San to dissipate Dampness and stop diarrhea.
Intemperate Diet
Main Symptoms. Diarrhea with abdominal pain, borborygmus, feces that smells like rotten egg; abdominal pain reduced following defecation; epigastric and abdominal distention; foul and fetid eructation; and anorexia. The tongue coating is dirty or thick and greasy. The pulse is slippery.
Therapeutic Principle. Relieve food retention.
Treatment. Bao He Wan.
If food retention is especially severe, with epigastric and abdominal distention and discomfort during defecation, add zhishi (Citrus aurantium) and binglang (Areca).
For food retention transforming into Heat, add huanglian (Coptis).
For vomiting, add baidoukou (Amomum cardamomum).
Chronic Diarrhea
Spleen Insufficiency
Main Symptoms. Feces sometimes loose, sometimes watery, sometimes containing undigested food; postprandial epigastric distress; even small amounts of greasy foods followed by increased frequency of defecation; sallow complexion; and lassitude. The tongue is pale, with white coating. The pulse is threadlike and feeble.
Therapeutic Principle. Strengthen the spleen and augment Qi.
Treatment. Shen Ling Baizhu San (Ginseng-Poria-Atractylodes Powder). It has the following composition: renshen (Panax) 10 g, baizhu (Atractylodes) 10 g, fuling (Poria) 15 g, shanyao (Dioscorea) 10 g, biandou (Dolichos lablab) 10 g, yiyiren (Coix) 20 g, lianzi (Nelumbo) 10 g, chenpi (Citrus tangerina) 6 g, sharen (Amomum) 5 g, jiegeng (Platycodon) 6 g, and fried gancao (Glycyrrhiza) 6 g.
If spleen-Yang is deficient, conducing to hyperactivity of Yin-Cold, add processed fuzi (Aconitum), rougui (Cinnamomum) and ganjiang (Zingiber).
For persistent unrelenting diarrhea, so that middle-jiao-Qi sinks and the rectum prolapses, add huangqi (Astragalus), shengma (Cimicifuga) and chaihu (Bupleurum).
For anorexia, add maiya (Hordeum) and shenqu (medicated leaven).
Kidney Insufficiency
Main Symptoms. Predawn peri-umbilical pain, borborygmus followed promptly by diarrhea, the abdominal symptoms being relieved by defecation; cold body and limbs; and aching pain in the waist and knees. The tongue is pale, with white coating. The pulse is deep and threadlike.
Therapeutic Principle. Warm and strengthen the spleen and the kidney, astringe the leaking and stop diarrhea.
Treatment. Li Zhong Tang (Middle-Regulating Decoction) combined with Si Shen Wan. Their combined composition is as follows: wuzhuyu (Evodia) 6 g, buguzhi (Psoralea) 10 g, wuweizi (Schisandra) 5 g, roudoukou (Myristica) 10 g, processed fuzi (Aconitum) 10 g, dangshen (Codonopsis) 15 g, baizhu (Atractylodes) 10 g, ganjiang (Zingiber) 6g, and fried gancao (Glycyrrhiza) 6g.
If diarrhea is unrelenting, leading to the sinking of middle-jiao Qi, add herbs to augment Qi, raise Yang and astringe, such as huangqi (Astragalus), kezi fruit (Terminalia chebula), chishizhi (halloysite) and yuyuliang (limonite).
Stagnation of Liver-Qi
Main Symptoms. Chronic chest and flank distention and pain; eructation, anorexia; abdominal pain and diarrhea precipitated by passions or emotional stress and borborygmus. The tongue is pale red and the pulse taut.
Therapeutic Principle. Suppress the liver, strengthen the spleen and harmonize the middle-jiao to stop diarrhea.
Treatment. Tong Xie Yao Fang (Essential Formula for Painful Diarrhea).
If the diarrhea persists for a long time, add sour and astringent herbs such as wumei (Prunus mume), shiliu rind (Punica granatum) and kezi (Terminalia chebula).
If there is also spleen insufficiency, with decreased appetite and lassitude, add dangshen (Codonopsis), shanyao (Dioscorea), Qianshi (Euryale ferox) and biandou (Dolichos lablab) to strengthen the spleen.
If constipation and diarrhea alternate, add muxiang (Aucklandia) and sharen (Amomum) to regulate Qi and settle the spleen and the stomach.
If Qi stagnation is especially prominent, with subcostal pain, abdominal distention, pain promptly inducing diarrhea and not relieved by it, add zhishi (Citrus aurantium), xiangfu (Cyperus), gancao (Glycyrrhiza) and similar herbs to unblock the liver, regulate Qi and settle the middle-jiao.
Acupuncture Treatment
Violent Diarrhea
For Cold-Dampness attacking the spleen, the approach is to warm the middle-jiao and dry Dampness. Select the acupoints Zhongwan (CV-12), Tianshu (ST-25) and Zusanli (ST-36). The acupoints Zhangmen (LR-13) and Pishu (BL-20) are reserve. Apply the reducing method and moxibustion.
For Dampness-Heat injuring the middle-jiao, the approach is to cool Heat and dry Dampness. Select the acupoints Zhongwan (CV-12), Tianshu (ST-25), Shangjuxu (ST-37) and Yinlingquan (SP-9). Apply the reducing method. Do not apply moxibustion.
For food retention, the approach is to promote digestion and relieve retention. Select the acupoints Jianli (CV-11), Qihai (CV-6), Tianshu (ST-25), Zhangmen (LR-13), Pishu (BL-20) and Zusanli (ST-36). Apply the reducing method.
Chronic Diarrhea
For spleen and stomach insufficiency, the approach is to strengthen the spleen and invigorate the middle-jiao. Select the acupoints Zhongwan (CV-12), Zhangmen (LR-13), Qihai (CV-6), Tianshu (ST-25), Pishu (BL-20) and Sanyinjiao (SP-6). Apply the reinforcing method and moxibustion.
For suppressed vital gate Fire, the approach is to warm and augment kidney-Yang. Select the acupoints Mingmen (GV-4), Shenshu (BL-23), Shenque (CV-8), Qihai (CV-6), Guanyuan (CV-4) and Sanyinjiao (SP-6). Apply moxibustion to all the acupoints.
Case Study
The patient was an adult female who the day before had acute onset fever and chills. By evening she began having diarrhea of thin yellow feces. The diarrhea had recurred seven or eight times by the time of consultation. Each bout was preceded by abdominal pain, epigastric distress and nausea. Her urine was scant. Her tongue was red, with thin and white coating, and the pulse was soft and rapid. Her body temperature was 39.3°C (102.7°F). Stool analysis showed zero to two white blood cells and zero to two red blood cells.
Diagnosis. Diarrhea due to Summer Heat and Dampness disturbing the interior and aggravated by new exogenous evils in the exterior, leading to disharmony of the spleen and the stomach.
Therapeutic Principle. Release both the interior and the exterior.
Treatment and Course. The prescribed formula had the following composition: dandouchi (Glycine max) 12 g, Ji Su San 12 g, gegen (Pueraria) 10 g, huoxiang stalk (Agastache) 10 g, fuling (Poria) 10 g, zexie (Alisma) 10 g, processed banxia (Pinellia) 6 g, parched zhiqiao (Poncirus trifoliata) 6 g, huangqin (Scutellaria) 6 g, muxiang (Aucklandia) 3 g, and huanglian (Coptis) 1.5 g.
After the first dose, sweating stopped and fever subsided. The following day diarrhea also stopped. After two more doses the patient recovered completely.
