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Purgative formulas with cold property are applicable for excess internal-heat stagnation. The pathogenesis is due to the battling of accumulation of internal heat with dry stools, retention of water, qi stagnation, static blood, food stagnation, disruption of the transformative function of the gastro-intestines, and blockage of the qi dynamic. The clinical manifestations are characterized by constipation, fullness, distended or aching abdomen, and even hectic fever, yellow tongue coating and excessive pulse, etc. Purgative formulas with cold property are mainly composed of purgative medicinals with cold property, and most commonly consist of medicinals such as dà huáng (Radix et Rhizoma Rhei) and máng xiāo (Natrii Sulfas). Since the cold property can overcome heat and purgative functions can remove food accumulation, so purgative formulas with a cold property concurrently bear the efficacies of purging heat and attacking accumulations. Ke Qin stated:“ Interior symptoms are all caused by constrained heat which will not be eliminated if medicinals with bitter flavor and cold property are not applied, leaving no way out for the pathogenic qi. Thus dà huáng (Radix et Rhizoma Rhei)should be used for attacking pathogenic qi, since attacking the interior should not be done without cold medicinals ” (里证皆因郁热，下药不用苦寒，则瘀热不除，而邪无出路，所以攻邪必用大黄，攻里不远寒也), cited from the Collected Writings on Renewal of the Discussion on Cold Damage - Further Appendices to the Discussion on Cold Damage . The combinations in this field, when analyzing the set formulas from the past dynasties, are composed of several aspects as follows:
For example, zhĭ shí (Fructus Aurantii Immaturus), hòu pò (Cortex Magnoliae Officinalis), mù xiāng (木香, Radix Aucklandiae), and bīng láng (Semen Arecae). Since the six fu -organs are functional in free situations, so the smoothness of ascending and descending of the qi dynamic is usually affected by all kinds of interiorexcess stagnation such as dry stools, which will in turn further aggravate the blockage of the qi dynamic, it forms a mutual causal / pathogenic relationship. Therefore, the combinations with medicinals for promoting the flow of qi not only benefits the freeing and descending of fu qi, but also can reinforce the effect of the purgation of interior excess. Regarding this theory, Ke Qin indicated: “ All of the diseases are caused by qi, and the reason filth cannot be removed is that qi is not smooth, thus formulas for attacking accumulations must be mainly composed of medicinals with the function of promoting the flow of qi ” (夫诸病皆因于气，秽物之不去，由于气之不顺，故攻积之剂必用行气之药以主之), cited from the Collected Writings on Renewal of the Discussion on Cold Damage - Further Appendices to the Discussion on Cold Damage . It emphasizes the importance of combinations with medicinals for promoting the flow of qi in purgative formulas. For example, Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) and Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) recorded in the Discussion on Cold Damage have attained the fame of being the ancestral formulas among purgative formulas. Both formulas contain zhĭ shí (Fructus Aurantii Immaturus) and hòu pò (Cortex Magnoliae Officinalis), specified for promoting the flow of qi to reduce stagnation, and dispersing glomus and eliminating fullness. The ratio of proportions between zhĭ shí (Fructus Aurantii Immaturus), hòu pò (Cortex Magnoliae Officinalis) and dà huáng (Radix et Rhizoma Rhei) varies intentionally according to the degree of glomus and fullness. Taking hòu pò (Cortex Magnoliae Officinalis) as an example: Eight liang of it is used in Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction), which is double that of dà huáng (Radix et Rhizoma Rhei), while two liang of hòu pò (Cortex Magnoliae Officinalis) is used in Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction), which is half that of dà huáng (Radix et Rhizoma Rhei). This indicates that the degree of glomus and fullness occurring in Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) syndrome is much milder than that in Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) syndrome, thus accounting for the differences of big and small amounts of herbs in the formulas. The character“ harmonize ” (和) was mentioned several times in the original articles on the applications of Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) recorded in the Discussion on Cold Damage , which means warming and light purgation and is used to discriminate it from the “drastic purgation” (急下) and “should purge” (当下) of Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction). For example, in the 213 th clause in the “ chapter of yangming” , the following is stated: “Conditions of a big and full stomach can be treated with Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction)to lightly harmonize the stomach qi, and big purgation should be avoided” (若腹大满不通者，可与小承气汤微和胃气，勿令致大泄下);the 214 th clause states: “ fever following the onset of illness that always presents with hard but scanty feces can be harmonized by Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction); a syndrome of stagnation of qi with flatulence can also be cured by Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) ” (其后发热者，必大便复硬而少也，以小承气汤和之，不转矢气者，与小承气汤和之愈); the 253 rd clause states:“ After disease of two or three days, marked by weak pulse, anxiety and heaviness under the heart region, without the Chái Hú (Radix Bupleuri) Syndrome in the taiyang, when the disease lasts for four or five days, Xiăo Chéng Qì Tāng (Minor Qi - Coordinating Decoction) should be used in small quantity to gently harmonize ”(得病二三日，脉弱，无太阳柴胡证，烦躁，心下硬，至四五日，虽能食，以小承气汤少少与微和之). However, it is another topic of discussion regarding the reason why Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) was regarded as an “ harmonizing formula ” (和剂)by the subsequent generations.
Moreover, the Collected Writings on Renewal of the Discussion on Cold Damage by Ke Qin, Commentary on the Classic of Materia Medica ( Bĕn Jīng Shū Zhèng, 本经疏证 ) by Zou Shu and the Reference to the Categorization of Formulas from the Discussion on Cold Damage ( Shāng Hán Lùn Lèi Fāng Huì Cān , 伤寒论类方汇参) by Zuo Ji-yun all held that the dosage of hòu pò (Cortex Magnoliae Officinalis) was large particularly in Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction):“ Hòu pò (Cortex Magnoliae Officinalis) is twice that of dà huáng (Radix et Rhizoma Rhei) in dosage, the medicinal for promoting the flow of qi is used as the chief medicinal ” (厚朴倍大黄，是气药为君), while in Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) “ dà huáng(Radix et Rhizoma Rhei) is twice that of hòu pò(Cortex Magnoliae Officinalis) in dosage, the medicinal for promoting the flow of qi is used as the deputy medicinal ” (大黄倍厚朴，是气药为臣). This is related to the primary and secondary relationship between purgative medicinals and medicinals for promoting the flow of qi, and is a topic which merits discussion.
Firstly, analysis of the properties, flavors and effects of dà huáng (Radix et Rhizoma Rhei) and hòu pò (Cortex Magnoliae Officinalis)shows that the former is bitter in flavor and cold in property with the functions of purging and attacking accumulations, purging fire and removing toxicity, dispelling stasis and freeing the channels. It is thus used in Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) for attacking accumulations as well as purging heat, and prescribed for etilogical factors and excess of interior heat; the latter is bitter and pungent in flavor but warm in property with the functions of drying dampness to resolve turbidity, promoting the flow of qi and inducing stagnation, eliminating glomus and dispersing fullness, thus it is used for glomus and fullness due to qi stagnation.
Secondly, in the three types of Chéng Qì Tāng (Qi-Coordinating Decoction) created by Zhang Zhong-jing, zhĭ shí (Fructus Aurantii Immaturus) and hòu pò (Cortex Magnoliae Officinalis) are used in some cases while unused in other cases, as are máng xiāo (Natrii Sulfas)and gān căo (Radix et Rhizoma Glycyrrhizae).However, only dà huáng (Radix et Rhizoma Rhei) is used in all cases, which proves that dà huáng (Radix et Rhizoma Rhei) should be the chief medicinal in the three formulas. Otherwise, it is unreasonable that Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating Qi-Coordinating Decoction, 调胃承气汤) is still named as Chéng Qì Tāng (Qi-Coordinating Decoction) without zhĭ shí (Fructus Aurantii Immaturus) and hòu pò (Cortex Magnoliae Officinalis) in it.
Thirdly, the ingredients of Hòu Pò Sān Wù Tāng (Officinal Magnolia Bark Three Agents Decoction) recorded in the Essentials from the Golden Cabinet are the same as that of Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) and the dosage of it is the same as that of dà huáng (Radix et Rhizoma Rhei), zhĭ shí (Fructus Aurantii Immaturus) and hòu pò (Cortex Magnoliae Officinalis) in Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction).However, it is called Hòu Pò Sān Wù Tāng (Officinal Magnolia Bark Three Agents Decoction) instead of Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) with the main indication of abdominal fullness “ with pain and constipation ” (痛而闭). It is proven that formulas with the medicinals for promoting the flow of qi as the main component do not belong to the category formulas of Chéng Qì Tāng (Qi-Coordinating Decoction). Thus it can be seen that, the designation of formulas by Zhang Zhong-jing has profound meaning. To sum up, it is proven that purgative medicinals are the main component in the formulas of Chéng Qì Tāng (Qi-Coordinating Decoction), where medicinals for promoting the flow of qi act as the assistant. Combined with medicinals for promoting the flow of qi, the functions of purgative medicinals for freeing the interior and attacking the lower can be reinforced, and can resolve the interior-excess internal accumulation which causes fullness by affecting the function of transformation and transportation of the intestinal tract, thus they can complement each other. Therefore, medicinals for promoting the flow of qi are the important combinations in purgative formulas with cold property.
A homegenous design method was once carried out to analyze the compatible effects of each medicinal in Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) by observing the index of particle quantity, time, small intestinal volume and large intestinal propulsion rate. The results showed that dà huáng (Radix et Rhizoma Rhei)is the most effective in promoting defecation in mice, followed by hòu pò (Cortex Magnoliae Officinalis), while zhĭ shí (Fructus Aurantii Immaturus) was ineffective in all these aspects, and máng xiāo (Natrii Sulfas) reduced the formed defecation notably while greatly increasing the passage of watery stool (i. e. diarrhoea) in mice. The experiment also showed that over-dosage(above 12 gram per mouse) of máng xiāo (Natrii Sulfas) can cause the mouse to curl up with reducing movements till death occurs, which may be due to the anhydration of the mice from the flushing dosage of máng xiāo (Natrii Sulfas)( Pharmacology and Clinics of Chinese Materia Medica , 中药药理与临床, 1999, 5: 7).
Through the experimental study where the purgative effects of dà huáng (Radix et Rhizoma Rhei) and three types of Chéng Qì Tāng (Qi-Coordinating Decoction) are compared by observing the progression of carbo medicinalis in the small intestine and its influence on the entire intestinal tract, it is indicated that the group of medicinals in Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) has a marked efficacy in promoting the progression of carbo medicinalis in the small intestine, though all of the aforementioned formulas have a purgative effect in various degrees. Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) also has notable promotional effects on the whole intestinal tract, indicating its function of drastic purgation; the effect of Xiăo Chéng Qì Tāng (Minor Qi-Coordinating Decoction) is similar to that of dà huáng (Radix et Rhizoma Rhei); and Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating Qi-Coordinating Decoction) is inferior to dà huáng (Radix et Rhizoma Rhei)in this aspect. Thus it is indicated that dà huáng (Radix et Rhizoma Rhei) has different purgative functions when combined with different medicinals ( Chinese Journal of Experimental Traditional Medical Formulae , 中国实验方剂学杂志, 1998, 4: 37).
In addition, interior-excess will not only cause the mutual binding of excess-heat and stagnation in the stomach and intestines, each of which is the pathogenic factor of the other, but also aggravates the diseases by stagnating the qi dynamic, and inducing the mutual binding of water and qi. The difference between them is that the qi stagnation due to water retention has a much wider range of influence on the zang - fu meridians: Not only will the stomach and intestines not be freed and descended, but also the waterways will not be regulated due to the blockage of the qi dynamic in the san jiao . Therefore, formulas for dispelling water and purgative formulas with a cold property have different effects, though both of them are combined with medicinals for promoting the flow of qi. For example, Zhōu Chē Wán (Boats and Carts Pill, 舟车丸), as first mentioned in the Formulas from Benevolent Sages Compiled during the Taiping Era ( Tài Píng Shèng Huì Fāng , 太平圣惠方) cited in Pocket Prescriptions ( Xiù Zhēn Fāng , 袖珍方), is the classic formula for promoting the flow of qi and dispelling water retention. While purging the retention of body fluid with dà jĭ (Radix Euphorbiae Pekinensis), gān suì (Radix Kansui), yuán huā (Flos Genkwa), qiān niú zĭ (牵牛子, Semen Pharbitidis), and qīng fĕn (轻粉, Calomelas), the formula can also course the liver qi and break up accumulations when combined with qīng pí (Pericarpium Citri Reticulatae Viride); can promote the flow of qi in the spleen and lung for smoothing the chest and diaphragm when combined with chén pí (Pericarpium Citri Reticulatae); can course and regulate the san jiao and induce stagnation when combined with mù xiāng (Radix Aucklandiae); and descend qi to break up hardness when combined with bīng láng (Semen Arecae). In doing so, this formula“ acts as the leader for dredging and regulating various qi ” (通理诸气，为之先导), cited from Convenient Reader of Established Formulas , and the pathogenic retention of body fluid can be dispelled smoothly through the separation of urine and stool. The formula is called “ boats and carts ”, which implies the separate dispelling of urine and stool through the simultaneous treatment of water and earth. Another example is Shū Záo Yĭn Zĭ (Coursing and Piercing Drink, 疏凿饮子), recorded in Formulas to Aid the Living ( Jì Shēng Fāng , 济生方), a formula which is combined with bīng láng (Semen Arecae)and dà fù pí (大腹皮, Pericarpium Arecae)for promoting the flow of qi to induce water together with other medicinals for purging and dispelling water, and dispersing wind to resolve the exterior, make “ the force of the superior and the inferior be eliminated respectively as the rivers are dreged by Da Yu in the Xia Dynasty ”(上下分消其势，亦犹夏禹疏江河之意也), cited from the Medical Formulas Collected and Analyzed . Thus it can be seen that the medicinals for dispelling water exert a more distinct effect in drastic purging and dispelling water when they are combined with medicinals for promoting the flow of qi. Tang Zong-hai once noted that:“ Qi and water belong to one medical category, so treating qi also treats water, and treating water also means to treat qi. ” (气与水本属一家，治气即是治水，治水即是治气), cited from Discussion on Blood Patterns ( Xuè Zhèng Lùn , 血证论). This statement profoundly and ingeniously illustrates the differentiated relationship and clinical significance of this type of compatible method.
For example, gān căo (Radix et Rhizoma Glycyrrhizae), dà zăo (Fructus Jujubae), bái mì (白蜜, Mel). Generally speaking, the syndrome of interior excess often affects the descending regulation of stomach qi caused by the stagnation of the fu qi or the accumulated retention of body fluids leading to the blockage of the qi dynamic. The treatment of purging excess and freeing fu organs or dispelling of the retention of body fluids to treat the root should be used for the natural restoration of stomach qi. No medicinal for regulating the middle and nourishing the stomach is needed, in order to avoid redundancy. However, the target of the purgative medicinal used in the syndrome of interior excess is the middle, and the purgative medicinals, especially those in purgative formulas with a cold property, are liable to damage the stomach qi; additionally, purgative formulas with cold property exert a drastic force and have a fast efficacy in hurrying directly along the large intestine, since the symptoms of an excess heat blockage of the yangming fu occur in the gastric cavity. Thus it is likely that the passage of medicinals along the diseased region will lead to indiscriminate extermination. Thus, combined with some medicinals for regulating the middle and nourishing the stomach, purgative formulas with cold property not only can relieve the drastic functions of the medicinals, and give them a purgative function without causing damage to the stomach qi, but also can achieve the tardy retention of the purgative force by the cold property in the middle, in order to clear heat and moisturize dryness. The example is the combination of gān căo (Radix et Rhizoma Glycyrrhizae) in Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating Qi-Coordinating Decoction), as recorded in the Discussion on Cold Damage , which has attained the comprehensive and objective commentaries by medical experts in past dynasties. For example, Xu Hong indicated: “ All the purgative formulas have rapid efficacy in purging the severe heat and excess syndrome, while gān căo(Radix et Rhizoma Glycyrrhizae) can harmonize the function of the other medicinals, so it is often deleted. It is unique among the formulas for regulating the stomach qi, thus it is used to relieve the middle ” (诸下泄方，乃下大热大实之证，速如星火，甘草能缓诸药，是以去也. 独此方中，乃调和胃气，故用甘草以缓其中也), cited from Treatise on Formulas as Golden Mirror from Discussion on Cold Damage ( Jīn Jìng Nèi Tái Fāng Yì , 金镜内台方议) . Wu Qian and others stated: “ The chief medicinals are dà huáng (Radix et Rhizoma Rhei) which is bitter and cold, and máng xiāo (Natrii Sulfas) which is salty and cold, they achieve enough force to eliminate heat and purge pathogenic fire; and gān căo (Radix et Rhizoma Glycyrrhizae) with the relieving property is used as an assistant medicinal for reconciliation between dà huáng(Radix et Rhizoma Rhei) and máng xiāo (Natrii Sulfas) in decoctions taken warm, balance can be achieved by reducing the drastic force and restraining drastic purgation ” (君大黄之苦寒，芒硝之咸寒，二味并举，攻热泻火之力备矣. 更佐甘草之缓，调停于大黄、芒硝之间，又少少温服之，使其力不峻，则不能速下而和也), cited from Golden Mirror of the Medical Tradition - Discussions of Selected Formulas from Eminent Physicians. Wang Zi-jie thought:“ Gān căo (Radix et Rhizoma Glycyrrhizae) is used to relieve the property of dà huáng (Radix et Rhizoma Rhei) and máng xiāo (Natrii Sulfas) for preservation of the middle and heat purgation, thus this is called a stomach-regulating method ”(以甘草缓大黄、芒硝，留中泄热，故曰调胃), cited from Selected Annotations to Ancient Formulas from the Garden of Crimson Snow ( Jiàng Xuĕ Yuán Gŭ Fāng Xuăn Zhù , 绛雪园古方选注). The former two statements arrive at identical medication mechanisms, though they are derived from different perspectives and opinions. Thus it can be seen that medicinals for regulating the middle and nourishing the stomach have special significance in purgative formulas with cold property.
In addition, since some purgative medicinals have drastic effects and toxicity, they should be combined with medicinals for regulating the middle and nourishing the stomach, in order to relieve the drastic properties and eliminate the toxicity, and reduce the side effects. For example, the formula, Shí Zăo Tāng (Ten Jujubes Decoction), recorded in the Discussion on Cold Damage, is combined with dà zăo (Fructus Jujubae) and named after it, because gān suì (Radix Kansui), dà jĭ (Radix Euphorbiae Pekinensis), and yuán huā (Flos Genkwa) in the formula are medicinals for drastically purging and dispelling water, and are liable to damage the right qi by attacking the spleen and stomach. Thus, ten Chinese dates should be included in the decoction, which not only invigorates the spleen and nourishes the stomach, but also relieves the drastic properties of the other medicinals and reduces toxicity, resulting in purgation without damaging the right qi. It should also be noted that gān suì (Radix Kansui), dà jĭ (Radix Euphorbiae Pekinensis), and yuán huā (Flos Genkwa) are incompatibile with gān căo (Radix et Rhizoma Glycyrrhizae), and their combination should be avoided, this is indicative of the profound meaning behind the name of the formula, “Ten Jujubes” (十枣). Ke Qin suggested in the analysis of the combination and usage of this formula: “ Toxic medicinals will certainly weaken the spleen and stomach when attacking evil, for there is no medicinal for invigorating the spleen and regulating the stomach in the master reaction, exhaustion of original qi follows that of the pathogenic qi. Thus Chinese dates, large and full, should be chosen as the chief medicinal to reinforce the weak spleen, pertaining to the earth element restraining the violent water potential, and relieve the toxicity of all medicinals, when the pathogenic qi is too violent to control and the original qi is too weak to support. This shows the perfect establishment of formulas by Zhang Zhong-jing. The inexperienced doctor is restricted to the thought that gān căo (Radix et Rhizoma Glycyrrhizae) can harmonize the middle, but fails to understand the principle behind the system of the five elements ” (毒药攻邪，脾胃必弱，使无健脾调胃之品主宰其间，邪气尽而元气亦随之尽. 故选枣之大肥者为君，预培脾土之虚，且制水势之横，又和诸药之毒，既不使邪气之盛而不制，又不使元气之虚而不支. 此仲景立法之尽善也. 昧者拘于甘能缓中之说，岂知五行承制之理乎), cited from Collected Writings on Renewal of the Discussion on Cold Damage - Further Appendices to the Discussion on Cold Damage. Obviously, it is inappropriate for Master Ke to give dà zăo (Fructus Jujubae) the status of the chief medicinal, but his statement reflects the theory of assisting restriction, which is worth contemplating.
For example, zhī zĭ (Fructus Gardeniae), lián qiào (Fructus Forsythiae), huáng qín (Radix Scutellariae), huáng lián (Rhizoma Coptidis), shí gāo (Gypsum Fibrosum), zhī mŭ (Rhizoma Anemarrhena), and so on. Generally speaking, purgative medicinals which are bitter in flavor and cold in property have a good anti-febrile effect through removing the underlying cause of the disease, but for the symptom of heat accumulation due to fu excess of the large intestine and violent heat pathogenic qi of the stomach channel, or violent pathogenic fire of the san jiao due to interior heat expansion covering a broad diseased region, medicinals for clearing heat and purging fire should be used in combination to reinforce the effect of clearing heat. This compatible method was developed and improved by experts specializing in treating warm pathogenic diseases in their clinical practice during the Ming and Qing Dynasties. For example, Bái Hŭ Chéng Qì Tāng (White Tiger Qi-Coordinating Decoction, 白虎承气汤) recorded in the Revised Popular Guide to the Discussion on Cold Damage , is composed of Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating Qi-Coordinating Decoction) combined with Bái Hŭ Tāng (White Tiger Decoction), and is created for the treatment of clearing and purging heat accumulation in the stomach fu organ. He Xiushan stated in the postscript of this formula: “ This formula is composed of Bái Hŭ Chéng Qì Tāng(White Tiger Qi Coordinating Decoction) and Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating Qi Coordinating Decoction), one clears the dry-heat in the stomach channel and the other purges the excess pathogenic fire in the stomach fu organ, which makes it an effective formula for violent pathogenic fire of the stomach and for constipation due to fluid-dryness ” (是方白虎合调胃承气，一清胃经之燥热，一泻胃腑之实火，此为胃火炽盛，液燥便秘之良方), cited from Revised Popular Guide to the Discussion on Cold Damage. Another example is Jiĕ Dú Chéng Qì Tāng (Toxin-Resolving Qi-Coordinating Decoction, 解毒承气汤) , recorded in Systematic Differentiation of Cold Damage and Warm Epidemics ( Hán Rè Wēn Yì Tiáo Biàn, 寒热温疫条辨), for warm pathogenic disease with san jiao fire-heat and dry excess with glomus and fullness, or for the sydrome of heat retention with watery discharge. It comprised Dà Chéng Qì Tā ng (Major Qi Coordinating Decoction) to purge heat accumulations by using medicinals with cold property, combined with medicinals for clearing heat and relieving toxicity such as huáng lián (Rhizoma Coptidis), huáng qín (Radix Scutellariae), huáng băi (Cortex Phellodendri Chinensis), and zhī zĭ (Fructus Gardeniae) to not only free the fu organs by purging excess and retain yin in emergent purgation, but also clear and relieve the heat toxicity in the san jiao . Compared with the single use of Chéng Qì Tāng (Qi-Coordinating Decoctions) for removing the underlying cause of the disease, the above two formulas have the more notable effects of purging and clearing heat.
In addition, Xuān Bái Chéng Qì Tāng (White-Diffusing Qi-Coordinating Decoction)and Dăo Chì Chéng Qì Tāng (Red-Abducting Qi-Coordinating Decoction), recorded in the Systematic Differentiation of Warm Pathogen Diseases , both belong to this type of combination, though their main indications are different. The former is combined with dà huáng (Radix et Rhizoma Rhei) and shí gāo (Gypsum Fibrosum), and the latter with dà huáng (Radix et Rhizoma Rhei) , máng xiāo (Natrii Sulfas), huáng lián (Rhizoma Coptidis), huáng băi (Cortex Phellodendri Chinensis) , and shēng dì (Radix Rehmanniae) . For the same reason, some formulas for clearing heat are occasionally combined with dà huáng (Radix et Rhizoma Rhei) and máng xiāo (Natrii Sulfas), which are bitter in flavor and cold in property to free fu organs and purge heat, and strengthen the effects of clearing heat. An example is Liáng Gé Săn (Diaphragm-Cooling Powder), recorded in the Formulary of the Bureau of Medicines of the Taiping Era , which is, however, different from the combinations with medicinals for clearing heat in purgative formulas with cold property in the specific density of the degree of heat and excess, and should be compared and analyzed comprehensively in reference to the compatible method in the formulas for clearing heat. Therefore, in purgative medicinals and medicinals for clearing heat, the degree of the proportion should be balanced according to the need of diseases in clinic.
For example,
táo rén
(桃仁, Semen Persicae),
chì sháo
(Radix Paeoniae Rubra),
dān pí
(Cortex Moutan). Insect medicinals, such as
shuĭ zhì
(水蛭, Hirudo),
méng chóng
(虻虫, Tabanus), and
zhè
chóng
(
虫, Eupolyphaga seu Steleophaga)can be used for severe static blood, to break up the blood and dispel stasis. For the syndrome of stagnation of intestinal heat causing interior blockage of heat accumulation, which may affect the smoothness of the blood and qi, medicinals for invigorating the blood and dispelling stasis should be combined to dispel static blood in addition to purging and removing accumulated heat, which would improve the curative effects. For example,
Dà Huáng Mŭ Dān Tāng
(Rhubarb and Moutan Decoction, 大黄牡丹汤), recorded in the
Essentials from the Golden Cabinet,
is used for the syndrome of intestinal swelling-abscess in the early stage, constraint and fumigation of interior damp-heat, aggregation of the blood and qi and non-dispersing heat accumulation.
Dà huáng
(Radix et Rhizoma Rhei) and
máng xiāo
(Natrii Sulfas) are used for expelling pathogenic heat and freeing the stool, softening hardness and dispersing accumulation;
dōng guā rén
(冬瓜仁, Semen Benincasae) is used for clearing heat and expelling dampness, discharging purulence to treat boils, and is combined with
táo rén
(Semen Persicae) and
dān pí
(Cortex Moutan)for invigorating the blood and dispelling stasis. Experimental research has shown that the main effect of this formula is to reinforce the peristalsis of the appendix for promoting the flow of the blood. (
Briefing of Scientific Research and Technological Innovation by Xi’an Medical University
, 西安医学院科学研究技术革新辑要, 1959, 1: 185). According to the introduction of the
Treatment of Acute Abdominal Disease by Integration of Traditional Chinese and Western Medicine
(
Zhōng Xī Yī Jié Hé Zhì Liáo Jí Fù Zhèng,
中西医结合治疗急腹症) by Tianjin Nankai Hospital, when formulas such as
Lán Wĕi Huà Yū Tāng
(Appendix Stasis-Transforming Decoction, 阑尾化瘀汤),
Lán Wĕi Qīng Huà Tāng
(Appendix-Clearing and Resolving Decoction) and
Lán Wĕi Qīng Jiĕ Tāng
(Appendix-Clearing and Resolving Decoction)which are formulated by modifying
Dà Huáng Mŭ Dān Tāng
(Rhubarb and Moutan Decoction)are used in the various phases and types of appendicitis, faster treatment effects can be attained with clinical experience. The medicinals for invigorating the blood and dispelling stasis, promoting the flow of qi and arresting ache such as
dān pí
(Cortex Moutan),
táo rén
(Semen Persicae),
chì sháo
(Radix Paeoniae Rubra) and
yán hú suŏ
(延胡索, Rhizoma Corydalis), are combined in the three formulas respectively, thus strengthening the direction of the disease treatment.
Moreover, due to the intimate relationship between qi and blood, blood flow follows qi flow, while blood stasis follows qi stagnation. Therefore, whenever heat binds in the yangming channels of the stomach and intestines and the qi of the fu -organs stagnates, the flow of blood will certainly be affected, causing stagnation of interior excess combined with static blood in various degrees. This possible pathogenesis of static blood may be inferred by the qi-blood theory of traditional Chinese medicine, though it is more likely to be confirmed by clinical diagnosis of the acute severe symptoms of heat binding due to fu excess. Modern research on physiological pathology has shown that intestinal linings are rich in micro-circulation and store a large amount of blood, and have the blood-bank like function of blood volume regulation. In abdominal distention found in fu excess syndrome, there is compression in the veins of the intestinal linings, causing blood stasis and reducing the regulation of blood volume due to the large amount of stagnated blood. Accordingly, both traditional Chinese medicine and biomedicine share the common recognition of the pathogenesis of static blood due to fu excess. In comparison, the modern pharmacology of formulas of traditional Chinese medicine has had breakthroughs in compatibilities of combining medicinals for invigorating the blood and dispelling stasis with cold purgative formulas. For example, Fù Fāng Dà Chéng Qì Tāng (Compound Formula Major Qi-Coordinating Decoction) , recorded in the Treatment of Acute Abdominal Disease by Integration of Traditional Chinese and Western Medicine, is used for simple intestinal obstruction, in which máng xiāo (Natrii Sulfas)and fān xiè yè (番泻叶, Folium Sennae) are used for purging excess to free fu organs, hòu pò (Cortex Magnoliae Officinalis) , mù xiāng (Radix Aucklandiae) , wū yào (Radix Linderae), lái fú zĭ (莱菔子, Semen Raphani) are used for regulating qi and inducing stagnation, and táo rén (Semen Persicae) , and chì sháo (Radix Paeoniae Rubra) are used for invigorating the blood and dispelling stasis. This combination represents the aforementioned compatible characteristics.
This type of compatible method is thought of highly in modern formulas studies, so the selections of medicinals for purging and invigorating the blood and dispelling stasis should be made not only according to their pharmacological actions but also according to the characteristics of the traditional Chinese medicinals. The selection of purgative medicinals should be focused on cold purgative medicinals which can be enhanced with the additional effects of invigorating the blood and dispelling stasis. Dà huáng (Radix et Rhizoma Rhei) has the double function of purging heat to free the stools, and invigorating the blood to dispel stasis, thus it is used as the first choice. For the selection of medicinals for invigorating the blood and dispelling stasis, one should first choose medicinals with the functions of invigorating the blood, dispelling stasis and the concurrent function of freeing the stools and moistening the intestines such as táo rén (Semen Persicae), which is “ bitter in flavor for purging blood heat, and moist in texture for nourishing intestinal dryness; …can cool and regulate the blood with its immersing moistening property to break nodes and free stagnation ” (味苦能泻血热，体润能滋肠燥，……以其濡润凉血和血，有开结通滞之力), cited from Transforming the Significance of Medicinal Substances ( Yào Pĭn Huà Yì , 药品化义); secondly, one should choose medicinals with a cold property, namely medicinals that can cool and invigorate the blood such as dān pí (Cortex Moutan), chì sháo (Radix Paeoniae Rubra) and dān shēn (丹参, Radix et Rhizoma Salviae Miltiorrhizae), and so on, in order to pay attention to both the function of invigorating the blood and dispelling stasis, and the function of clearing heat and cooling the blood.
Clinically, discrimination should be used to identify whether the main symptoms are characterized by accumulations and stagnation, or static heat. For the former, purgative medicinals should be used as the main component combined with the proper medicinals for invigorating the blood and dispelling stasis; if the latter is the case, medicinals for invigorating the blood and dispelling stasis should be used accordingly, as the main component combined with purgative medicinals. The relationship of priority and the importance between medicinal and dosage should be distinguished.
For example, gān suì (Radix Kansui), dà jĭ (Radix Euphorbiae Pekinensis), yuán huā (Flos Genkwa), qiān niú zĭ (Semen Pharbitidis), etc. The evil-heat and retention of body fluid mutually binding in the chest and abdomen belongs to a heat and excess syndrome, and cannot be cured by simply purging heat accumulation. Thus, medicinals for dispelling water and retention of body fluid can be combined in purgative formulas with cold property to quickly purge the pathogenic waterheat through the urine and stool, thus achieving a quick recovery, a shortened course of disease and improved curative effects. For example, Dà Xiàn Xiōng Tāng (Major Chest Bind Decoction, 大陷胸汤) and Dà Xiàn Xiōng Wán (Major Chest Bind Pill, 大陷胸丸), recorded in the Discussion on Cold Damage, are both formulas for Thoracic Accumulation Syndrome due to mutual binding of water and heat in the chest and hypochondrium. The two formulas combine dà huáng (Radix et Rhizoma Rhei) and máng xiāo (Natrii Sulfas) with gān suì (Radix Kansui) for the effects of purging heat and dispelling water. The difference is that the former is used to purge excess by drastic purgation for symptoms of muscular hardness and fullness from beneath the heart to the lower abdomen with pain worsened by touch and constipation; the latter is used for muscular hardness and fullness with pain in the chest, and neck stiffness. Additionally, tíng lì zĭ (葶苈子, Semen Lepidii) and xìng rén (Semen Armeniacae) are added to purge the lung qi, and bái mì (Mel) , which is sweet and moderate, is made into pills for consumption. Thus it is more appropriate compared to Dà Xiàn Xiōng Tāng (Major Chest Bind Decoction). This type of combination is set mainly according to the etilogical factors and diseased regions of water-heat mutually binding, which is different from that of Dà Chéng Qì Tāng (Major Qi-Coordinating Decoction) which is used for excess heat stagnation with concurrent qi stagnation. As You Yi stated: “ The syndrome of interior accumulation of pathogenic qi is hot and excessive, with the symptom of a stagnated and tight pulse, as in the syndrome of Dà Chéng Qì Tāng (Major Qi Coordinating Decoction), but here the accumulation is below the heart instead of in the abdomen; though hardness is absent, there is pain on palpation, along with mutual binding of water and food, which are different from the dry stools found in the yangming syndrome. Thus, gān suì (Radix Kansui) is recommended for breaking up retention instead of zhĭ shí (Fructus Aurantii Immaturus) and hòu pò(Cortex Magnoliae Officinalis) for dispersing qi ”(邪气内结，既热且实，脉复沉紧，有似大承气证，然结在心下，而不在腹中，虽按之不硬而痛，亦是水食互结，与阳明之燥粪不同，故宜甘遂之破饮，而不宜枳、朴以散气), cited from String of Pearls from the [Discussion on] Cold Damage ( Shāng Hán Guàn Zhū Jí, 伤寒贯珠集). Moreover, for severe intestinal obstruction with much fluid accumulation in the intestinal cavity, the combination of medicinals for dispelling water and retention in purgative formulas with cold property can attain good curative effects. In Gān Suì Tōng Jié Tāng (Kansui Bind-Freeing Decoction, 甘遂通结汤), recorded in the Treatment of Acute Abdominal Disease with Integration of Traditional Chinese and Western Medicine , gān suì (Radix Kansui) and dà huáng (Radix et Rhizoma Rhei) are combined for purging to dispel retention, táo rén (Semen Persicae) , chì sháo (Radix Paeoniae Rubra) and niú xī (牛膝, Radix Achyranthis Bidentatae)for invigorating the blood and dispelling stasis, and hòu pò (Cortex Magnoliae Officinalis) and mù xiāng (Radix Aucklandiae) for promoting the flow of qi and inducing stagnation. This formula has achieved further development in terms of combination when compared with that of Dà Xiàn Xiōng Tāng ( Wán ) (Major Chest Bind Decoction/Pill).
As for excess syndromes of the pleural fluid and abdominal dropsy due to fluid retention accumulated in the chest and the stomach, medicinals for purging water and fluid retention should be applied in large dosages, or medicinals for dispelling water can be applied merely for drastically purging and dispelling water and retention. The former is illustrated by Zhōu Chē Wán (Boats and Carts Pill), cited in Pocket Prescriptions , from Formulas from Benevolent Sages Compiled during the Taiping Era, where a large group of medicinals for purging water and fluid retention such as gān suì (Radix Kansui) , dà jĭ (Radix Euphorbiae Pekinensis), yuán huā (Flos Genkwa), qiān niú zĭ (Semen Pharbitidis), bīng láng (Semen Arecae) and qīng fĕn (Calomelas), are combined to reinforce the effects of drastic purging and dispelling water, while dà huáng (Radix et Rhizoma Rhei) is applied for clearing the stomach and the intestines, and freeing the stools to purge heat; the latter is exemplified by Shí Zăo Tāng (Wán) (Ten Jujubes Decoction/Pill)and Kòng Xián Dān (Drool-Controlling Elixir, 控涎丹), which have achieved wondrous effects with the use of simple medicinals for dispelling water. Although it is called Shí Zăo Tāng (Ten Jujubes Decoction), this formula is actually given in powder form, because its active components such as gān suì (Radix Kansui) and dà jĭ (Radix Euphorbiae Pekinensis), are insoluble in water and unfit for decoction. In addition, according to clinical studies, powder formulas are considered more effective compared to decoction and pill formulas ( Medical Journal of Chinese People’s Liberation Army , 解放军医学杂志, 1965, 2:150).An overview of formulas for drastically purging and dispelling water used in successive generations reveals that powder or pill formulas have been the most utilized, and these are conclusions of practical significance derived from practical experience of long-term clinical prescriptions as well as modern pharmacological studies.
For example, qián hú (Radix Peucedani), jié gĕng (Radix Platycodonis), xìng rén (Semen Armeniacae). Due to the internal and external communication between the lung and the large intestine, the diffusion and descent of the lung qi benefits from the function of the large intestine for channel defecation, and the freeing and descent of the qi of the large intestine likewise benefit from the diffusion and descent of the lung qi. The two organs complement each other physiologically and influence each other pathologically. The obstruction of the large intestine caused by excess heat binding of the yangming fu -organs can lead to the disordered diffusion and descent of the lung qi, or, combined with symptoms of cough and stagnation of sputum saliva; on the contrary, a deficiency of the diffusion and descent of the lung qi can aggravate heat binding due to fu excess of the large intestine. Therefore, there are two situations in which medicinals for opening and diffusing the lung qi are combined in purgative formulas with cold property. The first is heat binding due to fu excess of the large intestine, which affects the diffusion and descent force of the lung qi. Based on the theory of treating the upper in the lower diseases, medicinals for opening and diffusing the lung qi should be combined in sufficient amounts, in the purgative formulas to act as the assistant medicinals to assist the freeing and descent of the large intestine fu qi, thus reinforcing the purgative effect. This is illustrated by Zēng Sŭn Chéng Qì Tāng (Modified Qi-Coordinating Decoction, 增损承气汤) , recorded in the Arcane Essentials from the Imperial Library, in which qián hú (Radix Peucedani) is combined; and Huáng Lóng Tāng (Yellow Dragon Decoction, 黄龙汤), recorded in the Six Texts on Cold Damage, in which jié gĕng (Radix Platycodonis) is combined. The second situation is concurrent diseases of the lung and the large intestine caused by nondescent of the lung qi combined with interior excess, marked by tidal fever and constipation, sputum stagnation, restless dyspnea, greasy or glossy yellow muscus, excess and heavy right cun kou pulse. The combined treatment of opening the lung and freeing the intestine should be taken based on the combined treating method of fu and zang organs. As was recorded in Systematic Differentiation of Warm Pathogen Diseases , the formula Xuān Bái Chéng Qì Tāng (White-Diffusing Qi-Coordinating Decoction)is composed of “ shí gāo (Gypsum Fibrosum), for clearing heat and diffusing the lung; xìng rén (Semen Armeniacae), for descending the lung qi; guā lóu pí ( 瓜蒌皮 , Pericarpium Trichosanthis), for clearing and transforming the phlegm heat. The combination of the three medicinals can diffuse and descend the lung qi to pacify the counterflow of the lung qi. Combined with dà huáng (Radix et Rhizoma Rhei), which can purge heat accumulation, the combination of the four medicinals can open the lung and free the intestine through their interactions. Purging the excess in the lung benefits the freeing of the large intestine, and attacking heat accumulation helps to descend the lung qi, thus the combined treatment of fu and zang organs can complement each other ” (石膏清热宣肺；杏仁肃降肺气，更有润肠之功；瓜蒌皮清化痰热. 三药相配，宣降肺气，以平肺气之逆. 大黄攻下热结. 四药配伍，开肺通肠，相互为用. 泄肺实则有助于通大肠，攻热结亦有助于降肺气，脏腑合治，相辅相成), cited from the Comprehensive Discussion of Warm Diseases ( Wēn Bìng Zòng Héng, 温病纵横).
Moreover, since the lung is the upper source of water, it can regulate the waterways for the transportion down to the bladder in order to maintain the smoothness of urine and normal body fluid metabolism. Therefore, medicinals for diffusing and descending the lung qi can be combined in purgative formulas to reinforce the effects of dispelling water for the syndrome of unregulated waterways caused by accumulation of water retention and stagnation of the lung qi. For example, Jĭ Jiāo Lì Huáng Wán (Fangji, Zanthoxylum, Lepidium/Descurainiae, and Rhubarb Pill, 己椒苈黄丸), recorded in the Essentials from the Golden Cabinet, is used for interior accumulation of water-retention in the chest and abdomen with the symptoms of abdominal fullness and constipation, intestinal gurgling, difficult micturation, dryness in the mouth and tongue and taut pulse. Fáng jĭ (Radix Stephaniae Tetrandrae) and jiāo mù (椒目, Semen Zanthoxyli)are used for inducing diuresis to alleviate edema and for purging fluid retention; dà huáng (Radix et Rhizoma Rhei) is used for purging heat and for freeing the stools; and tíng lì zĭ (Semen Lepidii)is combined for descending the lung qi to regulate the waterways, and respectively dispel pathogenic water retention through the urine and stool. Like Shū Záo Yĭn Zĭ (Coursing and Piercing Drink), recorded in the Formulas to Aid the Living, it is a formula for purging and dispelling water, calming wind and relieving the exterior syndrome, and respectively eliminating the interior and exterior. The formula combines qiāng huó (Rhizoma et Radix Notopterygii) , qín jiāo (Radix Gentianae Macrophyllae) and shēng jiāng (Rhizoma Zingiberis Recens), which are good at traveling along the skin to calm wind and relieve exterior syndromes. Though they are not medicinals for diffusing the lung qi, they still hold this function, since the lung is connected with the skin and hair, and releasing the exterior leads to the diffusion of the lung qi. According to the above, either purgative formulas with cold property or formulas for dispelling water can be reinforced in their functions of freeing the stool or diuresis when they are combined with the proper medicinals for opening and diffusing the lung qi, which reflects thoroughly the compatible mechanism of treatment for “ treating the upper to relieve purgative disease ” (下病治上).
For example, rén shēn (Radix et Rhizoma Ginseng), dăng shēn (Radix Codonopsis), dāng guī (Radix Angelicae Sinensis) and bái sháo (Radix Paeoniae Alba), etc. In interior excess syndromes with deficiency of the right qi, the right qi cannot find support when pathogenic qi is attacking, and excess pathogenic qi will accumulate more when the right qi is supported. Thus purgation and tonification should be combined, namely the simultaneous application of purging and tonifying therapy, where purging the pathogen is the main objective, combined with supporting the right qi to achieve a double effect. Meanwhile, for those with constitutions deficient in right qi, the application of strict drastic purgative medicinals will lead to the stagnation of dry stools due to weaker right qi, the consumption of qi and blood, and possibly the danger of purging healthy qi along with pathogenic qi. Therefore, the combined application of purgation and tonification is the comprehensive method for treating the interior and regulating deficiency. The formula, Huáng Lóng Tāng (Yellow Dragon Decoction), recorded in the Six Texts on Cold Damage, uses máng xiāo (Natrii Sulfas) , dà huáng (Radix et Rhizoma Rhei) , zhĭ shí (Fructus Aurantii Immaturus) , and hòu pò (Cortex Magnoliae Officinalis)( Dà Chéng Qì Tāng , Major Qi-Coordinating Decoction) for purging excessive accumulation. It is also combined with rén shēn (Radix et Rhizoma Ginseng), dāng guī (Radix Angelicae Sinensis), and gān căo (Radix et Rhizoma Glycyrrhizae) for benefitting qi and tonifying the blood, thus being taken as the typical formula for the simultaneous application of purging and tonifying therapy. Wu You-xing indicated in his statement on Huáng Lóng Tāng (Yellow Dragon Decoction): “ Deficiency will not be cured until severe deficiency is tonified, and pathogenic qi will not be eliminated until severe excess is purged. Rén shēn (Radix et Rhizoma Ginseng)and dāng guī (Radix Angelicae Sinensis) are recommended for tonifying deficiency and Chéng Qì Tāng (Qi-Coordinating Decoctions)for dispelling excess; the combination of both of these is the simultaneous therapy of purging and tonifying ” (大虚不补，虚何由以回，大实不泻，邪何由以去，勉用参、归以补虚，承气以逐实，此补泻兼施之法也), cited from Discussion on Warm Epidemics. Wang Tai-lin thought: “ For patients with the syndrome of stomach excess in the yangming caused by weak constitution and deficiency of qi and blood, or those with non-eliminated dry stools due to deficiency caused by mistreatment, obstructed excess of pathogenic qi will lead to death if no purgation is performed, yet purgation can possibly lead to the exhaustion of the weakened right qi. This formula recognizes the simultaneous application of the purging-tonifying theory, so that the calamity of weakening the existing deficiency will not occur. The reason for the formula’s name, “Yellow Dragon” is that the assistance of rén shēn (Radix et Rhizoma Ginseng) can wondrously reinforce the effect of dà huáng(Radix et Rhizoma Rhei), just as the dragon assisted by clouds can rise up and down with unexpected changes ” (体质气血虚人，而得阳明胃实之证，或因病误治致虚，而燥屎犹未去者，不下则邪气壅实而死，下之又恐正气益虚而即脱. 此方攻补兼施，庶几不犯虚虚之祸. 曰黄龙者，大黄得人参为佐，则能神其功用，如龙得云助，升腾上下，莫能测其变化也), cited from Six Types of Medical Books by Wang Xu - gao - Annotation of Categorized Formulas from the Collection after Retiring ( Wáng Xù - gāo Yī Shū Liù Zhŏng - Tuì Sī Jí Lèi Fāng Gē Zhù , 王旭高医书六种·退思集类方歌注). In addition to the combination of purgation and tonification in the simultaneous application of purgingtonifying theory, the method of purging followed by tonifying or tonifying followed by purging can also be applied in order to eliminate the pathogen and cure the disease. Therefore, Cheng Guo-peng stated that: “ For patients with a weak pulse and constitution, tonification should be applied in advance of purgation, or temporary purgation followed by tonification should be used, such as taking Sān Huáng Zhĭ Zhú Wán(Three Yellow Unripe Bitter Orange and White Atractylodes Pill, 三黄枳术丸 ) along with Rén Shēn Tāng (Ginseng Decoction, 人参汤 ) or rén shēn (Radix et Rhizoma Ginseng), guā lóu ( 瓜蒌 , Fructus Trichosanthis) and zhĭ shí (Fructus Aurantii Immaturus) applied for simultaneous purging and tonifying without causing contrary efficacy. Whenever drastic formulas are applied, rén shēn (Radix et Rhizoma Ginseng), bái zhú(Rhizoma Atractylodis Macrocephalae), dāng guī(Radix Angelicae Sinensis) and bái sháo (Radix Paeoniae Alba) should be used for maintenance and regulation, achieving latent elimination of pathogenic qi and steady firmness of healthy qi, which is a method worthy of the fame of a monarch ” (更有脉虚体弱不能胜任者，则先补之而后攻之，或暂攻之而随补之，或以人参汤送下三黄枳术丸，又或以人参、瓜蒌、枳实攻补并行而不相悖. 盖峻剂一投，即以参、术、归、芍维持调护于其中，俾邪气潜消而正气安固，不愧为王者之师也), cited from Medical Revelations .
For example, shēng dì (Radix Rehmanniae), xuán shēn (玄参, Radix Scrophulariae), mài dōng (Radix Ophiopogonis). The warm disease of the yangming with yin deficiency due to heat binding can cause the blockage of dry stools and constipation, which is similar to a“ boat stopping due to the lack of water ” (无水舟停), and “ fluid should be supplemented before dredging ” (若欲通之，必先充之). The method of “ increasing body fluid for curing constipation ”(增水行舟) should be used to replenish yin fluid, purge heat accumulation, free and descend the stomach and the intestines, thus eliminating pathogenic qi and recovering right qi for curing the disease. Zēng Yè Chéng Qì Tāng (Humor-Increasing Qi-Coordinating Decoction) and Xīn Jiā Huáng Lóng Tāng (Newly Supplemented Yellow Dragon Decoction, 新加黄龙汤) , recorded in the Systematic Differentiation of Warm Pathogen Diseases, are composed of the combination of dà huáng (Radix et Rhizoma Rhei) and máng xiāo (Natrii Sulfas) along with medicinals for nourishing yin and increasing body fluid, such as shēng dì (Radix Rehmanniae) , xuán shēn (Radix Scrophulariae) and mài dōng (Radix Ophiopogonis). Wu Tang suggested:“ Warm disease of the yangming without upper jiao symptoms but with constipation lasting for several days should be treated by purgation. For the patient who always has yin deficiency and thus cannot be treated with Chéng Qì Tāng(Qi-Coordinating Decoctions), they may be treated with Zēng Yè Tāng (Humor-Increasing Decoction, 增液汤 ). Observe the symptoms for twelve hours after taking Zēng Yè Tāng(Humor-Increasing Decoction). If stools are still not purged, Tiáo Wèi Chéng Qì Tāng (Stomach-RegulatingQi-Coordinating Decoction) should be combined for mild action ” (阳明温病，无上焦证者，数日不大便，当下之，若其人阴素虚，不可行承气者，增液汤主之. 服增液汤已，周十二时观之，若大便不下者，合调胃承气汤微和之). Additionally, he said: “ For warm disease of the yangming with stagnation … leading to constipation due to deficiency of body fluid, Zēng Yè Tāng (Humor-Increasing Decoction)should be taken in intervals, and Zēng Yè Chéng Qì Tāng (Humor-Increasing Qi-Coordinating Decoction) should be used if constipation is still not purged ” (阳明温病，下之不通，……津液不足，无水舟停者，间服增液，再不下者，增液承气汤主之), cited from Systematic Differentiation of Warm Pathogen Diseases. It is indicated that purgative formulas should be used with caution for treating yin deficiency and heat accumulation with stagnation of dry stools.
Moreover, for the syndrome of dry stools caused by deficiency of the stomach-intestinal fluid, it is appropriate to use a combination of medicinals for moistening the intestines and freeing the stool, and medicinals for nourishing yin and tonifying the blood; for kidney deficiency with weak qi causing difficulty in urination or feebleness after consumptive disease causing asthenia of intestinal transmissional function with dry stools, medicinals for warming and moistening the bowels and freeing the stool are appropriate for treatment. Má Zĭ Rén Wán (Cannabis Fruit Pill), recorded in the Discussion on Cold Damage and Wŭ Rén Wán (Five Kernels Pill, 五仁丸), recorded in Effective Formula From a Family Tradition ( Shì Yī Dé Xiào Fāng, 世医得效方), are both common formulas for constipation due to fluid-consuming accumulation in the stomach-intestines. Jì Chuān Jiān (Ferry Brew, 济川煎), recorded in Collected Treatises of[Zhang] Jing-yue , is comprised of medicinals for warming and moistening the bowels, tonifying the blood and simultaneously ascending the clear and descending the turbid, making it an effective formula for constipation caused by deficiency of the kidney qi. Cheng Guo-peng stated: “ The treatment methods for constipation in complicated symptoms can be combined with each other. For constipation of the elderly, longterm patients and new parturients, Zhu Dan-xi adopted Sì Wù Tāng (Four Agents Decoction), and Li Dong-yuan used Tōng Yōu Tāng (Dark-Gate-Freeing Decoction, 通幽汤 ), I once considered them carefully and added cōng róng ( 苁蓉 , Herba Cistanches), gŏu qĭ ( 枸杞 , Fructus Lycii), băi zĭ rén ( 柏子仁 , Semen Platycladi), zhī ma ( 芝麻 , Semen Sesami), sōng zĭ rén ( 松子仁 , Semen Pini), rén rŭ ( 人乳 , Hominis Lac), lí zhī( 梨汁 , Fructus Succus Pyri) and fēng mì (Mel);effects were attained instantly. The combination of Sì Wù Tāng (Four Agents Decoction) with shēng má (Rhizoma Cimicifugae) and the above medicinals for warming and moistening has shown effects in treating depleted blood causing fluid insufficiency and constipation in the elderly. All the above belong to the method of indirect elimination ” (杂症中，大便不通，其用药之法可相参者. 如老人、久病人、新产妇人，每多大便闭结之症，丹溪用四物汤，东垣用通幽汤，予尝合而酌之，而加以苁蓉、枸杞、柏子仁、芝麻、松子仁、人乳、梨汁、蜂蜜之类，随手取效. 又尝于四物加升麻及前滋润药，治老人血枯，数至圊而不能便者，往往有验，此皆委曲疏通之法), cited from Medical Revelations .