Dysentery is the syndrome of abdominal pain, tenesmus and diarrhea with viscid red or white grains as well as pus and blood in the feces. It occurs most commonly in summer and autumn. When blood predominates it is known as “red dysentery.” When white viscid grains or pus predominates it is known as “white dysentery.” If pus and blood are comparable in quantity it is known as “red and white dysentery.”
Etiology and Pathology
The causes of dysentery as an illness are principally exogenous pathogenic evils and intemperate diet. These two often occur together and interact.
The main exogenous pathogenic evils causing dysentery are Dampness-Heat, pestilential evils and Cold-Dampness. When Dampness-Heat or a pestilential evil invades, it injures the stomach and the intestines and can cause impairment of transportation and transformation, stagnation of Qi and stasis of blood. These interact with the accumulating Heat poisons, and from this interaction arise pus and blood in the intestinal tract and the feces. When Cold-Dampness invades the stomach and the intestines, the nature of Cold is to induce gelling and that of Dampness is to impede and make viscous. The interaction between these two processes leads to Qi stagnation and blood stasis, so that the fluids in the intestinal tract become viscid and mixed with the turbid contents of chyme. This also leads to dysentery.
Intemperate diet is an important cause of dysentery. Excessive consumption of fatty, sweet or deep-fried foods, excessive drinking of alcoholic drinks, or eating of unclean foods or drinks induces internal accumulation of Dampness-Heat. Like exogenous Dampness-Heat this can lead to pus and blood in the intestinal tract and the feces. Excessive consumption of raw, cold fruits and vegetables, or unclean foods can injure the spleen and the stomach. Insufficiency of the spleen in turn leads to internal accumulation of Dampness and constraint on Yang on middle-jiao. Cold and Dampness hinder intestinal function, causing stagnation of Qi and stasis of blood. Like exogenous Cold-Dampness this also leads to dysentery.
The main pathological mechanism leading to dysentery is the interaction within the visceral organs between Dampness-Heat or Cold-Dampness with retained foods.
As a result the large intestine loses its function of transportation. Impairment of descent causes impedance of Qi and blood movement, so that the fatty membranes and blood channels of the intestines become damaged.
The illness may show a different set of symptoms depending upon whether it is due to Dampness-Heat or Cold-Dampness. In the case of Dampness-Heat, Heat may be more severe than Dampness, Dampness more severe than Heat, or Heat and Dampness equally severe. If Dampness-Heat is especially severe and is intermixed with pestilential poison, the illness is called “fulminant dysentery.” If it extends to the stomach it may become “dysentery with inability to eat.” In the latter two forms, there is danger of loss of consciousness and collapse.
Persistent dysentery may lead to deficiency of genuine Qi and lodging of the pathogenic evil. Dampness-Heat may injure Yin-blood and produce dysentery of Yin deficiency. Cold-Dampness may injure Yang-Qi and produce dysentery of Yang deficiency. If genuine Qi becomes depleted before eradication of evil Qi, dysentery may become latent, breaking out intermittently.
Clinical Manifestation
Dysentery is characterized by abdominal pain, increased frequency of defecation that is difficult and of small volumes, tenesmus and viscid grains of pus or blood. These are common to all forms of dysentery and are essential for the diagnosis of dysentery.
Dysentery may be acute or chronic, though the acute form often develops into the chronic form and the chronic form may show acute exacerbation. Care must be exercised in diagnosis. In general, acute dysentery is mainly seen in summer and autumn while chronic dysentery can be seen in all seasons. In its early stages acute dysentery presents a typical clinical picture while chronic dysentery is often atypical.
Key Points of Analysis
Characteristics of Feces. The color of the feces often varies with the changing features of the illness. In general, if the feces are white in color and are like either granulated jelly or nasal discharge, the illness is due to Cold or abnormality of Qi. This usually indicates a mild illness, though the pattern may also be seen in chronic dysentery. Slick white feces suggest an illness of deficiency-Cold. White pus suggests an illness of Heat. In general, red feces or feces with bright red blood indicates an illness of Heat, Fire or blood. This usually indicates a more severe illness. If red and white are interspersed in the feces, the illness is mainly due to Heat, with both Qi and blood affected. The illness may be mild or severe. If interspersed red and white make the feces resemble fish brain, the illness is due to Heat. But if there is more white than red it may be due to Cold. Purple feces indicate blood stasis. Dark purple and thin feces indicate Yang deficiency. If the feces are a burnt black in color and are thick and strong in stench the illness is of Fire. If they are deep yellow and foul smelling the illness is of Heat. If there is undigested food in the feces the illness is of food retention. Feces that are light and only mildly malodorous the illness is of Cold. Feces that are multi-colored indicate strong Dampness. Feces that contain much pus and blood and are difficult to pass may be due to Heat, Dryness or Yin deficiency.
Tenesmus. Tenesmus due to exogenous pathogenic evil typically lessens following defecation. If due to Cold the abdominal pain is spastic. If due to Fire or Heat it is accompanied by urgency and burning of the anus. If due to food retention it tends to be distending with a hard mass and there is guarding. Tenesmus due to deficiency illness does not lessen following defecation. If due to deficiency Cold the symptoms are more variable. Abdominal pain may be mild or vague, without tension or firmness; there may be preference for massaging pressure or warmth; or pain is not bothersome. If due to Qi deficiency or depletion tenesmus is accompanied by fecal incontinence. If due to Qi collapse, tenesmus is aggravated following defecation. If due to Qi and blood deficiency defecation is difficult requiring much straining yet sometimes unproductive.
Urgency and Severity. The assessment of urgency, or lack of urgency, depends upon the clinical picture. Observe whether evil poison is strong, whether stomach-Qi is suppressed, whether Yin-fluids are exhausted and whether Yang-Qi has collapsed. In severe illness there are pus and blood without much fecal material in the feces; in milder illness there is fecal material.
If the frequency of defecation decreases but the abdomen is distended and tense like a drum, with vomiting, anorexia, restlessness, thirst, coarse tachypnea, the illness is due to blazing of disease evil poison burning and attacking upward. In serious cases there may be mental confusion, delirium and a replete and rushed pulse.
If refusal to eat, prompt vomiting upon any eating or drinking, listless lethargy and eructation accompany dysentery, stomach-Qi is on the verge of collapse. If the feces contain viscid pus and blood and the dysentery is accompanied by restlessness, thirst, a flushed complexion with crimson lips and a rapid, swift and large pulse, Yin-fluids are on the verge of total depletion or Yin and Yang no longer interact.
If Yang-Qi is on the verge of total collapse, the symptoms may be variable and include the following. The dysentery may be persistent and uncontrollable. Abdominal pain may be absent but there is frequent expulsion of pus-containing blood. Defecation may be absent but there is lethargy, with assumption of the fetal position and cold-intolerance. The body may be cold with spontaneous sweating. The breath is short and the breathing very shallow. The pulse is either deep, threadlike and slow or indistinct and threatening to collapse.
The appearance of certain symptoms also indicates potentially serious worsening, such as the following: reduction in frequency but all other symptoms show no improvement; uncontrollable dysentery; increasing abdominal distention; agitation; increasing lethargy; worsening coldness in the hands and feet; and dissonance between the pulse and the clinical appearance.
Herbal Treatment
Regardless of the specific illness presenting with dysentery, whether deficiency or strength, there is impedance in the intestines so that Qi and blood cannot flow smoothly. Hence the basic principle in the treatment of dysentery is to remove impedance, regulate Qi and harmonize blood.
Dampness-Heat
Main Symptoms. Abdominal pain, red and white dysentery with grains of blood or pus and blood, tenesmus, burning in the anus; tightness in the chest and epigastrium; and scant urine. The tongue coating is yellow and greasy, and the pulse slippery and rapid.
Therapeutic Principle. Cool Heat, remove blockage, regulate Qi and mobilize blood.
Treatment. Shaoyao Tang.
In general, in the initial stages remove rougui and add jinyinhua (Lonicera). If there are symptoms of the exterior at onset, use Jing Fang Bai Du San (Schizonepeta-Saposhnikovia Detoxifying Powder) in addition to release the exterior.
If the exterior is not yet cleared and Heat is already strong in the interior, use Gegen Qin Lian Tang (Pueraria-Scutellaria-Coptis Decoction) to clear the superficies and cool Heat.
If Heat is more severe than Dampness, with red dysentery, add baitouweng (Pulsatilla), chishaoyao (Paeonia), huangbai (Phellodendron) and Qinpi (Fraxinus rhynchophylla).
If Dampness is more severe than Heat, with white dysentery and tightness in the chest, remove danggui, dahuang, huangqin and jinyinhua, and add fuling (Poria), houpo (Magnolia), cangzhu (Atractylodes) and chenpi (Citrus tangerina).
If there is food retention in addition, with abdominal pain and distention and guarding, add shanzha (Crataegus), shenqu (medicated leaven), zhishi (Citrus au-rantium) and laifuzi (Raphanus).
Cold-Dampness
Main Symptoms. Spastic abdominal pain, white dysentery, tenesmus; loss of taste; epigastric discomfort and tightness; heaviness in the head and weariness; and clear urine. The tongue is pale, with white and greasy coating. The pulse is soft and even. In some patients, there may be cold-intolerance, body aches, fever without sweating and a floating pulse.
Therapeutic Principle. Warm and eliminate Cold-Dampness and mobilize Qi and blood.
Treatment. Wei Ling Tang (Stomach Ling Decoction) with added danggui (Angelica), muxiang (Aucklandia), baked ganjiang (Zingiber) and zhishi (Citrus au-rantium). Wei Ling Tang has the following composition: cangzhu (Atractylodes) 10 g, houpo (Magnolia) 10 g, chenpi (Citrus tangerina) 6g, rougui (Cinnamomum) 6g, baizhu (Atractylodes) 10 g, fuling (Poria) 15 g, zhuling (Polyporus) 10 g, and ginger-treated banxia (Pinellia) 10 g.
If there are symptoms in the exterior, add Qianghuo (Notopterygium), fangfeng (Saposhnikovia) and huoxiang (Agastache).
If Cold is especially severe, add caoguo (Amomum tsao-ko).
If there is food retention as well, add laifuzi (Raphanus), charred shanzha (Crataegus) and binglang (Areca).
If Cold-Dampness dysentery develops in the presence of Summer Heat, use Chun Yang Zheng Qi Wan (Pure Yang Qi-Regulating Pill) combined with Huoxiang Zheng Qi San.
Fulminant Dysentery
Main Symptoms. Sudden attack with severe red and white dysentery, sometimes with clots, frequent defecation, and excruciating tenesmus and abdominal pain. The tongue is red or crimson, with dry yellow coating. The pulse is slippery and rapid or swift.
This is the most severe form of dysentery, with grave prognosis. Sometimes, the dysentery itself is relatively mild but the systemic symptoms are grave, such as coma, convulsion or delirium, dysphagia, tight drum-like abdominal distention and gasping respiration. The tongue is red with dry coating, and the pulse taut and rapid or deep and swift.
Therapeutic Principle. Cool Heat, eliminate poison, cool blood and remove retention.
Treatment. Baitouweng Tang (Pulsatilla Decoction) combined with Shaoyao Tang (Paeonia Decoction). Baitouweng Tang contains the following four ingredients: baitouweng (Pulsatilla chinensis), huanglian (Coptis chinensis), huangbai (Phellodendron chinense), and Qinpi (Fraxinus rhynchophylla).
If Heat poison has entered the Nutritive and Blood Levels, with high fever and dulled sensorium, it is appropriate to add Xijiao Dihuang Tang (Rhinoceros Horn-Rehmannia Decoction) and further complement with Zi Xue Dan (Purple-Snow Pill) or Zhi Bao Dan to clear the Nutritive Level, cool blood and open orifices.
If Heat is extreme and gives rise to Wind, with loss of consciousness and convulsion, add Lingyangjiao Fen, gouteng (Uncaria) and shijueming (Haliotis) to extinguish Wind and stop convulsion.
If fulminant dysentery is leading to collapse, urgently treat with Shen Fu Tang (Ginseng-Aconitum Decoction), Shen Fu Long Mu Tang (Ginseng-Aconitum-Fossil Bone-Oyster Shell Decoction) or Du Shen Tang (Lone Ginseng Decoction) in order to rescue Yang. When the patient has revived, then treat further in accordance with the clinical condition.
If Heat poison is trapped in the interior, so that the chronic dysentery is not severe but the condition of the patient is serious, treat urgently to unblock the trap and purge Heat poison. The appropriate treatment is Da Cheng Qi Tang (Potent Purgation Decoction) combined with Baitouweng Tang, with modifications as required. To further enhance the effectiveness of Heat-cooling and detoxification, kushen seed (Sophora), jinyinhua (Lonicera japonica) and other herbs may be added.
Dysentery with Inability to Eat
Main Symptoms. Pathogenic evil strength: dysentery accompanied by hiccup, chest tightness, anorexia, halitosis, a yellow greasy tongue coating, and a slippery and rapid pulse. Deficiency: dysentery accompanied by nausea, inability to eat or vomiting upon eating, emaciation, absence of taste or thirst, a pale tongue and a threadlike and feeble pulse.
Therapeutic Principle. Pathogenic evil strength: purge Heat, settle the stomach and promote smooth flow and descent with bitter and acrid herbs. Deficiency: strengthen the spleen, settle the stomach, suppress the abnormally risen and stop vomiting.
Treatment. Pathogenic evil strength: Kai Jin San (Inability-Reversing Powder), which has the following composition: huanglian (Coptis) 5 g, processed banxia (Pinellia) 10 g, chenpi (Citrus tangerina) 6g, shichangpu (Acorus) 10 g, fuling (Poria) 15 g, heye (Nelumbo nucifera) 10 g, dongguaren (Benincasa hispida) 10 g, danshen (Salvia) 10 g, ganjiang (Zingiber) 6g, and baizhu (Atractylodes) 10 g. Decoct until there is only a small volume of decoction. Administer slowly as many sips.
If dysentery persists for days so that genuine Qi gradually declines, decoct ren-shen and huanglian, and sip the decoction throughout the day.
If there is frequent vomiting, so that stomach-Yin is injured and the tongue is red or crimson and dry, remove banxia and chenpi and add xiyangshen (Panax quinquefolium), maimendong (Ophiopogon), shihu (Dendrobium nobile) and lugen (Phragmites) to support Yin and strengthen the stomach.
For vomiting upon any drinking, hold a small amount of Yu Shu Dan (Jade Pivot Pill) in the mouth and slowly swallow it with saliva. Follow with Kai Jin San.
Deficiency: Xiang Sha Liu Jun Zi Tang (Six Gentlemen Pill with Saussurea and Amomum) or Shen Ling Baizhu San (Ginseng-Poria-Atractylodes Powder) augmented with the juice of shengjiang (Zingiber).
If there is deficiency-Cold in the stomach, with incessant vomiting, add rougui (Cinnamomum), buguzhi (Psoralea) and ganjiang (Zingiber).
If dysentery is unrestrained, without oral intake and cold limbs, the illness is becoming grave. Urgently administer strong Du Shen Tang (Lone Ginseng Decoction) or Si Ni Jia Renshen Tang (Ginseng-Augmented Frigid-Extremities Decoction) to replenish Qi and rescue Yang.
Recurrent Dysentery
Main Symptoms. Dysentery that recurs intermittently and persists for many years, often precipitated by intemperate diet, improper lifestyle, exposure to exogenous pathogenic evils, excessive strain, or unbridled passions. Accompanying symptoms include fatigue with a desire to recline, abdominal distention and anorexia. During an attack, there are red and white dysentery and tenesmus. The tongue is pale red, with a greasy coating. The pulse may be threadlike and impeded, or large but depletive, or soft.
Therapeutic Principle. Strengthen the spleen, augment Qi, promote digestion and relieve food retention.
Treatment. Zi Sheng Wan (Health-Promoting Pill). It has the following composition: dangshen (Codonopsis) 15 g, baizhu (Atractylodes) 10 g, biandou (Dolichos lablab) 10 g, fuling (Poria) 15 g, yiyiren (Coix) 15 g, zhishi (Citrus aurantium) 6g, muxiang (Aucklandia) 6g, baidoukou (Amomum cardamomum) 6g, shanzha (Crataegus) 6g, shenqu (medicated leaven) 10 g, maiya (Hordeum) 10 g, huanglian (Coptis) 3 g, and fried gancao (Glycyrrhiza) 6g.
If dysentery is due to injury by brooding and anxiety, use Zi Sheng Wan together with Gui Pi Tang (Spleen-Restoring Decoction).
If it is due to pent-up passions, especially rage, use Zi Sheng Wan together with Tong Xie Yao Fang (Essential Formula for Painful Diarrhea) to suppress the liver and strengthen the spleen.
If it is due to deficiency of spleen-Yang, with unresponsive food retention, use Wen Pi Tang (Spleen-Warming Decoction) to warm the spleen and eliminate retained food.
Yin Deficiency
Main Symptoms. Protracted and refractory red and white dysentery, sometimes hematochezia; acute lower abdominal pain; inability to defecate despite frequen attempts; refusal of food; and fever with strong thirst, worst at night. The tongue is red or crimson and dry, with a coating that is greasy or with patchy exfoliation. The pulse is threadlike and rapid.
Therapeutic Principle. Stiffen Yin, purge Heat, support the genuine and stop dysentery.
Treatment. Huanglian Ejiao Tang combined with Zhu Ju Wan without ganjiang. The composition of the combined formula is as follows: huanglian (Coptis) 5 g, huangqin (Scutellaria) 10 g, danggui (Angelica) 10 g, wumei (Prunus mume) 10 g, shanyao (Dioscorea) 10 g, maimendong (Ophiopogon) 10 g, lianzi (Nelumbo nu-cifera) 10 g, and gancao (Glycyrrhiza) 6g.
If Yin deficiency is particularly severe, with strong thirst and little urine, add dried shengdihuang (Rehmannia), shihu (Dendrobium nobile) and beishashen (Glehnia).
If there is hematochezia, add danpi (Paeonia suffruticosa) and chishaoyao (Paeonia lactiflora).
Note: when attacking this illness the physician must not do so casually, in order to avoid injuring genuine Yin.
Deficiency-Cold
Main Symptoms. Protracted and unresponsive dysentery producing thin feces with white gel-like grains; impeded defecation; continual abdominal pain with preference for pressure, warmth and massage; absence of taste or thirst; diminished appetite; lassitude; and cold-aversion. The tongue is pale and its coating thin. The pulse is depletive and threadlike. If the illness worsens, there may be rectal prolapse, aches in the waist, cold-intolerance, sometimes even cold limbs and fecal incontinence.
Therapeutic Principle. Mild cases: warm the middle-jiao, dispel Cold, strengthen the spleen and dry Dampness. Severe cases: warm and strengthen the spleen and the stomach, astringe and stop leakage.
Treatment. Mild cases: Fuzi Li Zhong Wan.
Severe cases: Taohua Tang (Peach Blossom Decoction) combined with Zhen Ren Yang Zang Tang, with modification. The combined composition is as follows: dan-gshen (Codonopsis) 10 g, baizhu (Atractylodes) 10 g, rougui (Cinnamomum) 6g, ganjiang (Zingiber) 3 g, roudoukou (Myristica) 10 g, shiliu rind (Punica granatum) 10 g, chishizhi (halloysite) 10 g, kezi (Terminalia chebula) 10 g, danggui (Angelica) 10 g, baishaoyao (Paeonia) 10 g, muxiang (Aucklandia) 6g, and fried gancao (Glycyrrhiza) 6 g.
If there is relatively strong internal Cold, with cold-aversion and cold limbs, add wuyao (Lindera) and wuzhuyu (Evodia).
If there is food retention, with abdominal pain, guarding and uncomfortable defecation, remove roudoukou, kezi, shiliupi and chishizhi and add raw dahuang (Rheum palmatum), zhiqiao (Poncirus trifoliata) and shanzha (Crataegus).
If dysentery is protracted and leads to rectal prolapse, add Bu Zhong Yi Qi Tang to raise the sunken Qi.
If dysentery is unrestrained and leads to fainting, use Shen Fu Long Mu Tang (Ginseng-Aconitum-Fossil Bone-Oyster Shell Decocion) with Taohua Tang to astringe and rescue Yang.
Acupuncture Treatment
Select Hegu (LI-4), Tianshu (ST-25) and Shangjuxu (ST-37) as the principal acupoints. Shangjuxu may be replaced by Zusanli (ST-36). Use filiform needles and apply the reducing method.
If there is Cold, add moxibustion.
For dysentery due to Dampness-Heat, add Quchi (LI-11) and Neiting (ST-44). For dysentery due to Cold-Dampness, add Zhongwan (CV-12) and Qihai (CV-6). For dysentery with inability to eat, add Zhongwan (CV-12) and Neiting (ST-44). For recurrent dysentery, add Pishu (BL-20), Weishu (BL-21), Guanyuan (CV-4) and Shenshu (BL-23).
If there is rectal prolapse, add ChangQiang (GV-1) and apply moxibustion to Baihui (GV 20).
If tenesmus is severe, add Zhonglushu (BL-29).
Case Study
The patient was a 36-year old male with a history of dysentery. For 2 days he had chills and fever, distending headache, body aches and abdominal pain. Thereafter he had red and white dysentery, tenesmus and rectal prolapse. The feces were more red than white, with color resembling that of hog liver. He defecated over 20 times in one day. The feces soon changed to more white than red. He also had chest tightness, dryness of the mouth without thirst, a pale tongue with thin white coating, and a small slippery and rapid pulse. His body temperature was 38.8°C (101.8°F).
Therapeutic Principle. Release the exterior, unblock the intestines and eliminate retention.
Treatment and Course. The composition of the prescribed formula is as follows: huoxiang (Agastache) 10 g, peilan (Eupatorium) 10 g, parched cangzhu (Atractylodes lancea) 10 g, processed banxia (Pinellia) 10 g, binglang (Areca) 10 g, charred shanzha (Crataegus) 10 g, charred shenqu (medicated leaven) 10 g, houpo (Magnolia) 5 g, muxiang (Aucklandia) 5g, zhishi (Citrus aurantium) 10 g, chenpi (Citrus tangerina) 10 g, and dandouchi (Glycine max).
Following administration of this formula, the patient sweated slightly. Chills and fever subsided, but he still had white gel-like dysentery over ten times in one day. Following defecation the anus felt heavy and unrelieved. He had no thirst. The tongue coating was white at the bottom with yellow overlay. The tongue was pale.
At this stage, the diagnosis was Cold-Dampness accumulating and lodging in the interior and causing blockage. The therapeutic principle was now to warm, relieve blockage and conduct downward.
The new formula had the following composition: huanglian (Coptis) 1.5 g, wuzhuyu (Evodia) 1.5 g, ganjiang (Zingiber) 2g, rougui (Cinnamomum) 2g, dahuang (Rheum palmatum) 10 g, parched cangzhu (Atractylodes) 10 g, parched zhishi (Citrus aurantium) 10 g, binglang (Areca) 10 g, parched laifuzi (Raphanus) 10 g, houpo (Magnolia) 5g, muxiang (Aucklandia) 5g, chishaoyao (Paeonia) 6g, and baishaoyao (Paeonia) 6 g.
After two days, the frequency of defecation was unchanged. Huanglian was removed, and the modified formula was continued for four more days. The frequency of defecation decreased to four times a day and the feces became loose and yellow. Rectal prolapse also improved. Dahuang was removed and the formula was continued. After six more days, the frequency of defecation decreased further to twice a day and the feces became soft normal. The only symptom still present was left abdominal pain. Danggui (Angelica) 10 g was added to harmonize blood. After several days, the patient was completely cured.
