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Purgative formulas with warm property are suitable for cold excess syndrome, namely the interior excess syndrome belonging to the cold property, whose pathomechanism is the mutual binding of cold evil and accumulated stagnation in the stomach and intestines, with the main clinical manifestations of stomachache and constipation. Purgative formulas with warm property are always mainly composed of purgative medicinals, such as dà huáng (Radix et Rhizoma Rhei) and bā dòu (巴豆, Fructus Crotonis). The compatible methods include:
For example, fù zĭ (Radix Aconiti Lateralis Praeparata), gān jiāng (Rhizoma Zingiberis) and xì xīn (Radix et Rhizoma Asari), etc. Since cold excess syndrome is caused by the mutual binding of cold evil and accumulated stagnation, it is necessary to combine applications of purgative medicinals with medicinals for warming the interior and dispelling cold when the excessive accumulation cannot be dispelled without purgation and the cold evil cannot be transformed without warming. Dà Huáng Fù Zĭ Tāng (Rhubarb and Aconite Decoction, 大黄附子汤), recorded in the Essentials from the Golden Cabinet, is the representative purgative formula with warm property, in which dà huáng (Radix et Rhizoma Rhei) is used for purging accumulated stagnation and xì xīn (Radix et Rhizoma Asari), in coordination with fù zĭ (Radix Aconiti Lateralis Praeparata), are used for warming the interior, dispelling cold and arresting pain. Together, they form a formula for dispersing cold coagulation with warm medicinals for freeing and descending, using medicinals bitter and pungent in flavor. In Sān Wù Bèi Jí Wán (Three Agents Emergency Pill, 三物备急丸), recorded in the Essentials from the Golden Cabinet , bā dòu (Fructus Crotonis) and dà huáng (Radix et Rhizoma Rhei) are combined for drastically purging cold accumulation, and gān jiāng (Rhizoma Zingiberis) is used for warming the middle, dispelling cold and arresting ache. Its main indications are sudden distention and pain in the stomach duct and abdomen, pain like the piercing with an awl, clenched jaw, and fainting; for symptoms of the upper jiao blockage and lower stomach duct blockage caused by the accumulation of food in the intestines and stomach due to intemperate eating and drinking. As these diseases cannot be cured unless this formula is applied immediately, it is thus named“pre-emergency” (备急). Vomiting or diarrhea after application can dispel evil qi and restore right qi, as was noted in the following postscript of the formula: “ The disease will be cured when vomiting or diarrhea occur and there is gurgling in the abdomen . ” (当腹中鸣，即吐下便差)As for the significance of the combination of dà huáng (Radix et Rhizoma Rhei) and bā dòu (Fructus Crotonis) in Sān Wù Bèi Jí Wán (Three Agents Emergency Pill), Wang Zi-jie stated: “ Bā dòu (Fructus Crotonis) is pungent in flavor and hot in property with strong toxicity and is incompatibile with dà huáng ( Radix et Rhizoma Rhei ) in terms of property and flavor, thus the combination of the two medicinals will counteract the purging function ” (巴豆辛热大毒，与大黄性味相畏，若同用之，泻人反缓), cited from Selected Annotations of Ancient Formulas from the Garden of Crimson Snow. Ran Xue-feng said: “ In this formula, gān jiāng(Rhizoma Zingiberis) is used for benefitting the warming function and dà huáng (Radix et Rhizoma Rhei) for increasing the purgative action ” (本方取干姜以益其温，大黄以益其泻), cited from Examples of Effective Formulas with Eight Methods ( Bā Fă Xiào Fāng Jŭ Yú, 八法效方举隅). Analyzed from the action of bā dòu (Fructus Crotonis), it originally possesses the capability of breaking a blockage with an extremely strong force of purgation. Thus dà huáng (Radix et Rhizoma Rhei) combined in Sān Wù Bèi Jí Wán (Three Agents Emergency Pill) is for restricting the drastically purgative force of bā dòu (Fructus Crotonis). Experimental studies showed that Sān Wù Bèi Jí Wán (Three Agents Emergency Pill) had a distinct effect on reinforcing the contraction of the intestinal vessels. The component of bā dòu (Fructus Crotonis) could excite the intestinal vessels, while dà huáng (Radix et Rhizoma Rhei) and gān jiāng (Rhizoma Zingiberis) exert the effect of relieving the tension in the intestinal vessels. The effects of these components usually vary with different concentrations. ( Journal of New Medicine , 新医药学杂志, 1975, 11:11)
In addition, according to a study on the discrepancy of the effects between the combined formulas of dà huáng (Radix et Rhizoma Rhei)and bā dòu (Fructus Crotonis) in different proportions (1:1, 1:2, 2:1) and each of the single medicinals, there is no obvious difference in the purgative effects and the inhibition of swelling of the auricles in mice caused by xylene; the effect of prevention of albumin-like voix pedis swelling is not obvious until two hours later; and there is a shortening effect on the blood-clotting time in mice (using the glass method). This indicates that the effective intensity of a single medicinal and the combined medicinals vary according to the different surveying indexes. ( Journal of Yunnan College of Traditional Chinese Medicine , 云南中医学院学报, 1997, 1: 1)
For example, rén shēn (Radix et Rhizoma Ginseng), dăng shēn (Radix Codonopsis) and fù zĭ (Radix Aconiti Lateralis Praeparata), etc. For the syndrome of cold accumulation due to spleen yang insufficiency, yang qi deficiency and cold coagulation, marked by abdominal ache and constipation, or that of the spleen yang damage due to long-term dysentery; simply invigorating the spleen yang with medicinals warm in property is not effective for dispelling accumulated stagnation; while the application of dredging therapy will lead to further injury to the middle yang. Therefore, simultaneous purging cold accumulation and tonifying the spleen yang with medicinals warm in property should be used. Wēn Pí Tāng (Spleen-Warming Decoction, 温脾汤), recorded in Important Formulas Worth a Thousand Gold Pieces [for Any Emergency] , where fù zĭ (Radix Aconiti Lateralis Praeparata), rén shēn (Radix et Rhizoma Ginseng), gān jiāng (Rhizoma Zingiberis) and gān căo (Radix et Rhizoma Glycyrrhizae) are used for tonifying the spleen yang, with medicinals warm in property, and for dispelling congealed cold; and dà huáng (Radix et Rhizoma Rhei) (four liang in dosage)for flushing and purging accumulated stagnation, is prepared as a formula for simultaneous application of warm tonification and purgation. Xu Shu-wei changed the formula in Formulas of Universal Benefit [from My Practice] ( Pŭ Jì Bĕn Shì Fāng , 普济本事方) by decreasing the dosage of dà huáng (Radix et Rhizoma Rhei) to four qian, and adding hòu pò (Cortex Magnoliae Officinalis), substituting rén shēn (Radix et Rhizoma Ginseng) with guì xīn (桂心, Cinnamomi Cortex Rasus). He explained that:“ For obstinate cold in the stomach-intestines with years of aches and diarrhea, in which various medicinals hot in property have been ineffective, it is proper to purge first, and then to regulate the deficiency, rather than fostering the disease due to worry over the deficiency . ” (治痼冷在肠胃间，连年腹痛泄泻，休作无时，服诸热药不效，宜先取去，然后调治易差，不可畏虚以养病也). This indicates that the dosage proportion of purgative medicinals and medicinals with warm property should be considered cautiously. Yu Chang thought: “ This formula prepared by Xu Shu-wei is in accordance with the method of purgation with medicinals warm in property by Zhong-jing, with four qian of dà huáng (Radix et Rhizoma Rhei), which is more reasonable. For obstinate cold in the stomach-intestine with efflux diarrhea, dà huáng (Radix et Rhizoma Rhei) should not be used heavily, as it is quite strong in force among medicinals with warm property. The dosage of dà huáng (Radix et Rhizoma Rhei) is thus decreased to one fifth, reflecting the profound understanding of Shu-wei on Zhang Zhong-jing’s theory. Zhang Zhong-jing said that: ‘Zhī Zĭ Tāng (Gardenia Decoction, 栀子汤 ) is forbidden for patients with preexsiting slight coagulation. ’ He added that: ‘The greater yin disease with weak pulse and smooth feces should be treated with dà huáng (Radix et Rhizoma Rhei) and sháo yào (Radix Paeoniae)but decrease their dosage, for the weak stomach qi is liable to be damaged. According to this, dà huáng (Radix et Rhizoma Rhei) cannot be used casually for treating efflux diarrhea due to obstinate cold of the stomach and intestine. Purgation will be achieved by medicinals warm in property without the application of dà huáng(Radix et Rhizoma Rhei), however long-term use will lead to chronic retention of uneliminated evils; yet purgation may not be controlled when medicinals warm in property are used heavily, as it will cancel or increase the purgative force. Appropriate application of this formula is the authentic method ” (许叔微制此方，深合仲景以温药下之之法，其大黄止用四钱，更为有见. 夫痼冷在肠胃而滑泄矣，即温药中宁敢多用大黄之猛重困之乎？减而用其五之一，乃知叔微之得于仲景者深也. 仲景云：病人旧微溏者，栀子汤不可与服. 又云：太阴病脉弱便利，设当行大黄、芍药者宜减之，以其人胃气弱，易动故也. 即是观之，肠胃痼冷之滑泄，而可恣用大黄耶？不用则温药必不能下，而久留之邪非攻不去；多用则温药恐不能制，而洞下之势或至转增. 裁酌用之，真足法矣), cited from Precepts for Physicians ( Yī Mén Fă Lǜ, 医门法律). His analysis has deep insight for enlightenment.