论
《内经》曰∶北方黑色，入通于肾，开窍于二阴，藏精于肾。夫肾主五液，故肾实则津液足而大便滋润，肾虚则津
液竭而大便结燥。原其所由，皆房劳过度，饮食失节，或恣饮酒浆，过食辛热，饮食之火起于脾胃，淫欲之火起于命门，
以致火盛水亏，津液不生，故传道失常，渐成结燥之证。是故有风燥，有热燥，有阳结，有阴结，有气滞结，又有年高
血少，津液枯涸，或因有所脱血，津液暴竭，种种不同，固难一例而推焉。经云∶肾恶燥，急食辛以润之，以苦泄之。
阳结者散之，阴结者温之。大法，治燥者润之，以大黄、当归、桃仁、麻子仁、郁李仁之类。风燥者，加以防风、羌活、
秦艽、皂荚之类，为丸以炼蜜，取其润燥以助传道之势，故结散而疏通矣。仍多服补血生津之剂，助其真阴，固其根本，
庶无再结之患。切弗以巴豆、牵牛等峻剂攻下，虽暂得通快，必致再结愈甚，反酿成病根胶固，卒难调治。或有血虚、
脉大如葱管、发热而大便结燥者，慎不可发汗，汗之则重亡津液，闭结而死，此医杀之耳。《活人书》有脾约证，谓胃强
脾弱，约束津液，不得四布，但输膀胱，故小便数而大便难，制脾约丸以下脾之结燥，使肠润结化，津流入胃而愈。丹
溪曰∶然既曰脾约，必阴血枯槁，内火燔灼，热伤元气，故肺受火邪而津竭，必窍母气以自救。夫金耗则土受木伤，脾
失转输，肺失传化，宜其大便闭而难，小便数而无藏蓄也。理宜滋养阴血，使阳火不炽，金行清化，脾土健旺，津液入
胃，大小肠润而通矣。今以此丸，用之于热甚而气实与西北人禀赋壮实者，无有不安；若用之于东南方人与热虽盛而气
血不实者，虽得暂通，将见脾愈弱而肠愈燥矣。须知在西北以开结为主，在东南以润燥为要，学人其可不知此乎。
脉法
脉多沉伏而结。阳结，脉沉实而数。阴结，脉伏而迟或结。老人虚人便结，脉雀啄者，不治。
方法
丹溪曰∶有虚有风，有湿有火，有津液不足者，有寒者，有气结者，切不可例用芒硝、大黄及巴豆、牵牛等利药。
久病，腹中有实热，大便不通，宜用润肠丸微利之，不宜用峻利之剂。
（以上丹溪方法凡二条）
脾约丸
麻仁（一两半，用生绢袋盛，百沸汤连袋泡浸，汤冷出之，垂井中，与水面差一指许，不着水，次日晒干砻之，粒
粒皆完） 枳实（麸炒黄色） 浓朴（姜制炒） 芍药（各三两） 大黄（四两，酒蒸） 杏仁（去皮尖炒，另研，一
两二钱）
上为末，炼蜜为丸，如梧桐子大，每服三十丸，温水下。
通幽汤（东垣） 治大便难，幽门不通，上冲吸门不开，噎塞不便，燥闭气不得下，治在幽门，以辛润之。
炙甘草 红花（各一分） 生地黄 熟地黄（各五分） 升麻 桃仁泥 当归身（各一钱）
上细切，作一服，水一盏半，煎至一盏，去渣，调槟榔细末五分，食前稍热服。
润燥汤（东垣）
升麻（二分） 生地黄（二分） 熟地黄 当归梢 大黄（酒湿煨） 生甘草 桃仁泥 麻仁（各一钱） 红花（五
分）
上除桃仁、麻仁另研细外，余细切，作一服，水一盏半，入桃仁、
麻仁，煎至一盏，去渣空心稍热服。
润肠丸（东垣） 治脾胃中伏火，大便闭涩，或干燥，闭塞不通，全不思食，及风结血闭皆能治之。
桃仁（汤泡去皮，略炒） 麻仁（去壳，各一两） 当归梢 大黄（酒湿煨） 羌活（各五钱）
上除桃仁、麻仁另研如泥外，其余杵为极细末，炼蜜为丸，如梧桐子大，每服三、五十丸，空心白汤下。如风湿而
大便不行，加煨皂角仁、大黄、秦艽以利之。如脉涩，觉身有气涩而大便结者，加郁李仁、大黄以除气涩燥。
麻黄白术汤（东垣） 治大便不通，五日一次，小便黄赤，浑身肿，面上及腹尤甚，其色黄，麻木，身重如山，
沉困无力，四肢痿软，不能举动，喘促不安。
青皮（去穣） 酒黄连（各二分） 黄 人参 桂枝 白术 浓朴（姜制） 柴胡 苍术 猪苓（各四分） 酒
黄柏 陈皮（去白） 甘草（半炙，半生） 升麻（各三分） 吴茱萸（去核） 白茯苓 泽泻（各五分） 白豆蔻
炒神曲（各六分） 麻黄（一钱，不去节） 杏仁（四个）
上细切，分作二服，每服水二盏，先煎麻黄令沸，掠去沫，入诸药同煎，至一盏，去渣稍热服。
升阳泻热汤（东垣） 治膈噎不通，逆气里急，大便不行。
青皮 槐子（各二分） 生地黄 熟地黄 黄柏（各三分） 当归身 甘草梢（各四分） 苍术（五分） 升麻（七
分） 黄 （一钱） 桃仁（十个，去皮尖，另研）
上细切，作一服，入桃仁泥，水二盏，煎至一盏，食前热服。
活血润燥丸（东垣） 治大便风秘血秘，常常燥结。
当归梢（五钱） 防风（三钱） 大黄（酒煨） 羌活（各一两） 皂角仁（烧存性，一两五钱） 桃仁（二两，
去皮，另研） 麻仁（二两半，去壳，另研）
上除桃仁、麻仁另研外，共为细末，炼蜜为丸，如梧桐子大，每服五十丸，白汤下。三两服后，须以麻子仁煮粥，
每日早晚食之。大便虽日久，再不结燥也。此丸药以瓷罐盛之，纸包封，毋令见风。
润肠汤（东垣） 治大便结燥不通。
生地黄 生甘草（各三分） 大黄（ ） 熟地黄 当归梢（各五分） 升麻 桃仁 麻子仁（各一钱） 红花（三
分）
上细切，作一服，水二盏，煎至一盏，去渣空心服。
润体丸（东垣） 能润血燥，治大便不通。
麻仁 当归梢 生地黄 桃仁 枳壳（各等分）
上为细末，炼蜜为丸服。
备急大黄丸（东垣） 治胃中停滞寒凉之物，大便不通，腹痛。（方见内伤门。）
枳壳丸（河间） 治三焦约，大小便不通，谷气不得下行。
枳壳（二两） 陈皮（一两） 槟榔（五钱） 木香（二钱五分） 黑丑（四两，一半生用，一半炒熟，杵头末一
两半，余不用）
上为细末，炼蜜为丸，如梧桐子大，每服五十丸，姜汤下。
枳实导滞丸（东垣） 治伤热物，大便不行，气滞胸腹作痛。（方见内伤门。）
（医案）
本邑赵德秀才之母，年五十余，身材瘦小，得大便燥结不通，饮食少进，小腹作痛，召予延医，六脉皆沉伏而结涩。
予作血虚治，用四物汤加桃仁、麻仁、煨大黄等药，数服不通，反加满闷。与东垣枳实导滞丸及备急大黄丸等药，下咽
片时即吐出，盖胃气虚而不能久留性速之药耳。遂以备急大黄丸外以黄蜡包之，又以细针穿一窍，令服三丸。盖以蜡匮
者，制其不犯胃气，故得出幽门达大小肠取效也。明日，下燥屎一升许。继以四物汤加减作汤，使吞润肠丸。如此调理
月余，得大便如常，饮食进而平安。
予族侄百一通判之子，因出痘大便闭结不通。儿医云∶便实为佳兆。自病至痘疮愈后，不入厕者凡二十五日，肛门
连大肠不胜其痛，叫号声达四邻外。医及予二、三人议药调治，用皂角末及蜜煎导法，服以大小承气汤及枳实导滞丸、
备急丸皆不效，计无所出。予曰∶此痘疮余毒郁热，结滞于大小肠之间而然。以香油一大盏令饮，自朝至暮亦不效。予
画一计，令侍婢口含香油，以小竹筒一个套入肛门，以油吹入肛内。过半时许，病者自云∶其油入肠内，如蚯蚓渐渐上
行。再过片时许，下黑粪一二升止，困睡而安。
Discussion
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: "The North corresponds to the color black, internally connects with the Kidney, opens into the two yin orifices (anterior and posterior), and stores essence in the Kidney." The Kidney governs the five fluids; therefore, when Kidney qi is substantial, body fluids are sufficient and stool is moistened. When Kidney qi is deficient, body fluids are exhausted and stool becomes dry and hard. Tracing the causes, all stem from excessive sexual activity, irregular diet, indulgence in alcoholic beverages, or overconsumption of pungent and hot foods. Fire generated by diet arises in the Spleen and Stomach, while fire generated by lust arises in the Mingmen (Gate of Life). This leads to excess fire and deficient water, preventing the generation of body fluids. Consequently, the transmission function becomes abnormal, gradually forming a syndrome of dryness and constipation. Thus, there are wind-dryness, heat-dryness, Yang-constipation, Yin-constipation, and Qi-stagnation constipation. There are also cases due to advanced age with blood deficiency, exhaustion of body fluids, or sudden depletion of body fluids due to massive blood loss. These situations vary greatly and cannot be treated with a single method. The classics state: "The Kidney dislikes dryness; urgently consume acrid substances to moisten it, and bitter substances to drain it." For Yang-constipation, use dispersing methods; for Yin-constipation, use warming methods. The general principle for treating dryness is to moisten it, using herbs such as Dahuang (Rhei Radix et Rhizoma), Danggui (Angelicae Sinensis Radix), Taoren (Persicae Semen), Huomaren (Cannabis Fructus), and Yuliren (Prunus Semen). For wind-dryness, add Fangfeng (Saposhnikoviae Radix), Qianghuo (Notopterygii Rhizoma et Radix), Qinjiao (Gentianae Macrophyllae Radix), and Zaojiao (Gleditsiae Fructus), processed into honey pills. Their moistening properties assist the intestinal transmission momentum, thereby resolving the accumulation and promoting smooth defecation. Additionally, one should frequently administer formulas that tonify blood and generate fluids to support True Yin and consolidate the root, thus preventing recurrence. One must absolutely avoid using harsh purgatives such as Badou (Crotonis Fructus) and Qianni (Pharbitidis Semen). Although temporary relief may be achieved, it will inevitably lead to more severe recurrence, solidifying the pathogenic root and making treatment difficult. In cases of Blood deficiency with a pulse large like a scallion tube, fever, and dry constipation, sweating must not be induced. Sweating would cause further loss of body fluids, leading to closure and death; this constitutes medical homicide. The *Liuren Shu* describes the Pi Yue Syndrome (Splee Constriction Syndrome), stating that strong Stomach heat and weak Spleen function constrain body fluids, preventing their proper distribution throughout the body, causing them to flow only to the Bladder. This results in frequent urination and difficult defecation. The Pi Yue Wan (Spleen Constriction Pill) was formulated to resolve the Spleen's constraint and intestinal dryness, lubricating the intestines, resolving the accumulation, allowing fluids to return to the Stomach, and curing the condition. Zhu Danxi stated: "Since it is called Spleen Constriction, it implies withered Yin blood and blazing internal fire. Heat damages Yuan Qi, affecting the Lung with fire evil and exhausting its fluids. The Lung must rely on its mother organ (the Spleen) for self-rescue. When Metal (Lung) is depleted, Earth (Spleen) suffers Wood (Liver) damage. The Spleen loses its transport function, and the Lung loses its dissemination function. Hence, constipation and frequent, non-retentive urination occur." The appropriate treatment is to nourish Yin blood, suppress excessive Yang fire, allow Lung Metal to clear and transform, strengthen Spleen Earth, and enable fluids to enter the Stomach, lubricating the Large and Small Intestines for smooth passage. Using this pill for those with intense heat and robust constitution, particularly in Northwest China, yields good results. However, for people in Southeast China or those with heat but deficient Qi and Blood, although temporary relief occurs, the Spleen will become weaker and the intestines drier. It must be understood that in the Northwest, the focus is on opening obstructions, while in the Southeast, the priority is moistening dryness. Scholars must grasp this distinction.
Pulse Diagnosis
The pulse is often deep, hidden, and knotted. In Yang-constipation, the pulse is deep, solid, and rapid. In Yin-constipation, the pulse is hidden, slow, or knotted. In elderly or deficient patients with constipation, if the pulse exhibits the Sparrow-pecking quality (Que Zhuo Mai), it is incurable.
Methods
Zhu Danxi stated: Constipation can arise from deficiency, wind, dampness, fire, insufficient body fluids, cold, or Qi stagnation. One must never indiscriminately use Mangxiao (Natrii Sulfas), Dahuang, Badou, or Qianni. For chronic illness with real heat in the abdomen and constipation, Run Chang Wan (Intestine-Moistening Pill) should be used for mild purgation, avoiding harsh purgatives.
(The above two methods are from Zhu Danxi.)
Pi Yue Wan (Spleen Constriction Pill)
Huomaren (Cannabis Fructus, 1 liang 5 qian, placed in a raw silk bag, soaked in boiling water with the bag, removed when cool, suspended in a well water so it does not touch the surface, dried the next day, husked ensuring grains remain intact) Zhishi (Immature Bitter Orange Fruit, stir-fried with bran until yellow) Houpo (Magnolia Bark, processed with ginger juice and stir-fried) Shaoyao (Peony Root, 3 liang each) Dahuang (Rhubarb Root, 4 liang, steamed with wine) Xingren (Apricot Seed, peeled, de-husked, stir-fried, ground separately, 1 liang 2 qian)
Grind all ingredients into fine powder, mix with refined honey to form pills the size of Sophora seeds. Take 30 pills per dose with warm water.
Tong You Tang (Unblocking the Nethermost Decoction - Li Dongyuan)
Treats difficulty in defecation, obstruction of the Youmen (Lower Gate), rebellious Qi rushing up to the Ximen (Upper Gate), causing dysphagia and inability to pass stool, dryness blocking Qi descent. Treatment focuses on the Youmen, using acrid-moistening methods.
Zhi Gancao (Prepared Licorice Root), Honghua (Carthamus Flower, 1 fen each) Sheng Dihuang (Fresh Rehmannia Root), Shu Dihuang (Prepared Rehmannia Root, 5 fen each) Shengma (Cimicifugae Rhizoma), Taoren Ni (Peach Kernel Paste), Danggui Shen (Dong Quai Root Stem, 1 qian each)
Cut finely, prepare as one dose. Add 1.5 cups of water, decoct to 1 cup. Strain, mix with 5 fen of fine Binglang (Areca Seed) powder. Take slightly warm before meals.
Run Zao Tang (Moistening Dryness Decoction - Li Dongyuan)
Shengma (1 fen) Sheng Dihuang (1 fen) Shu Dihuang, Danggui Shao (Dong Quai Root Tip), Dahuang (moistened with wine and baked), Sheng Gancao (Raw Licorice Root), Taoren Ni, Huomaren (1 qian each) Honghua (5 fen)
Except for Taoren and Huomaren which are ground separately, cut other ingredients finely. Prepare as one dose. Add 1.5 cups of water, include Taoren and Huomaren, decoct to 1 cup. Strain and take slightly warm on an empty stomach.
Run Chang Wan (Intestine-Moistening Pill - Li Dongyuan)
Treats latent fire in Spleen and Stomach, constipation, dryness, complete blockage, loss of appetite, as well as Wind-constipation and Blood-constipation.
Taoren (Peach Kernel, soaked in hot water, peeled, lightly stir-fried) Huomaren (Cannabis Fructus, shelled, 1 liang each) Danggui Shao, Dahuang (wine-moistened and baked), Qianghuo (5 qian each)
Except for Taoren and Huomaren ground into paste, grind remaining ingredients into extremely fine powder. Mix with refined honey to form pills the size of Sophora seeds. Take 30-50 pills on an empty stomach with plain boiled water. If constipation is due to Wind-Damp, add Wei Zaojiao Ren (Baked Gleditsia Seed), Dahuang, and Qinjiao to promote bowel movement. If the pulse is choppy and there is a sensation of Qi stagnation with dry stool, add Yuliren (Bush Cherry Seed) and Dahuang to remove Qi stagnation and dryness.
Mahuang Baizhu Tang (Ephedra and Atractylodes Macrocephala Decoction - Li Dongyuan)
Treats constipation occurring once every five days, yellow-red urine, generalized edema (worse on face and abdomen), yellowish complexion, numbness, heavy body feeling like lead, weakness, flaccid limbs unable to move, panting and restlessness.
Qingpi (Green Tangerine Peel, pith removed), Jiu Huanglian (Coptis Rhizome, wine-treated), Huangqi (Astragalus Root), Renshen (Ginseng Root), Guizhi (Cinnamon Twig), Baizhu (Atractylodes Macrocephala Rhizoma), Houpo (Magnolia Bark, ginger-processed), Chaihu (Bupleuri Radix), Cangzhu (Atractylodis Rhizoma), Zhuling (Polyporus, 4 fen each) Jiu Huangbai (Phellodendri Cortex, wine-treated), Chenpi (Aged Tangerine Peel, white pith removed), Gancao (Licorice Root, half roasted, half raw), Shengma (Cimicifugae Rhizoma, 3 fen each) Wuzhuyu (Evodia Fruit, core removed), Bai Fuling (Poria), Zexie (Alisma Rhizoma, 5 fen each) Baixiudoukou (White Cardamom), Chao Shenqu (Stir-fried Medicated Leaven, 6 fen each) Mahuang (Ephedra Herb, 1 qian, nodes unremoved) Xingren (Apricot Seed, 4 pieces)
Cut finely, divide into two doses. For each dose, add 2 cups of water. First boil Mahuang until bubbling, skim off foam, add other herbs, decoct to 1 cup. Strain and take slightly warm.
Sheng Yang Xie Re Tang (Raise Yang and Drain Heat Decoction - Li Dongyuan)
Treats esophageal obstruction, rebellious Qi with urgency, and constipation.
Qingpi, Huaizi (Sophora Seed, 2 fen each) Sheng Dihuang, Shu Dihuang, Huangbai (Phellodendri Cortex, 3 fen each) Danggui Shen, Gancao Shao (Licorice Root Tip, 4 fen each) Cangzhu (5 fen) Shengma (7 fen) Huangqi (1 qian) Taoren (10 Apricot Kernels, peeled, de-husked, ground separately)
Cut finely, prepare as one dose. Add Taoren paste, 2 cups of water, decoct to 1 cup. Take hot before meals.
Huo Xue Run Zao Wan (Invigorate Blood and Moisten Dryness Pill - Li Dongyuan)
Treats Wind-constipation and Blood-constipation, characterized by frequent dryness and accumulation.
Danggui Shao (5 qian) Fangfeng (3 qian) Dahuang (wine-baked), Qianghuo (1 liang each) Zaojiao Ren (Gleditsia Seed, burned to retain character, 1 liang 5 qian) Taoren (2 liang, peeled, ground separately) Huomaren (2.5 liang, shelled, ground separately)
Except for Taoren and Huomaren ground separately, grind all together into fine powder. Mix with refined honey to form pills the size of Sophora seeds. Take 50 pills with plain boiled water. After taking three doses, cook Huomaren porridge and eat it morning and night. Even if constipation has persisted for a long time, it will not recur. Store these pills in porcelain jars, wrapped in paper, sealed to prevent exposure to wind.
Run Chang Tang (Intestine-Moistening Decoction - Li Dongyuan)
Treats dry, hard, and obstructed stool.
Sheng Dihuang, Sheng Gancao (3 fen each) Dahuang ( ) Shu Dihuang, Danggui Shao (5 fen each) Shengma, Taoren, Maziren (Cannabis Fructus, 1 qian each) Honghua (3 fen)
Cut finely, prepare as one dose. Add 2 cups of water, decoct to 1 cup. Strain and take on an empty stomach.
Run Ti Wan (Body-Moistening Pill - Li Dongyuan)
Moistens Blood dryness, treats constipation.
Huomaren, Danggui Shao, Sheng Dihuang, Taoren, Zhike (Bitter Orange Fruit, equal parts)
Grind into fine powder, mix with refined honey to form pills.
Bei Ji Da Huang Wan (Emergency Dahuang Pill - Li Dongyuan)
Treats retention of cold-cool substances in the Stomach, constipation, and abdominal pain. (Formula see Internal Injury Section.)
Zhike Wan (Bitter Orange Fruit Pill - Liu Hejian)
Treats Sanjiao (Triple Burner) constriction, obstruction of both upper and lower orifices, inability of grain Qi to descend downward.
Zhike (2 liang) Chenpi (1 liang) Binglang (Areca Seed, 5 qian) Muxiang (Vladimiria Root, 2 qian 5 fen) Heiqiu (Pharbitidis Semen, 4 liang, half raw, half stir-fried, pounded into coarse powder 1.5 liang, remainder unused)
Grind into fine powder, mix with refined honey to form pills the size of Sophora seeds. Take 50 pills with Ginger Decoction.
Zhishi Dao Zhi Wan (Immature Bitter Orange and Detoxification Pill - Li Dongyuan)
Treats injury from hot foods, constipation, Qi stagnation causing chest and abdominal pain. (Formula see Internal Injury Section.)
Medical Case 1
The mother of Scholar Zhao De in our county, over fifty years old, slender and small in stature, suffered from dry, hard, and obstructed stool, reduced food intake, and lower abdominal pain. I was summoned to treat her. All six pulses were deep, hidden, knotted, and choppy. I treated it as Blood deficiency using Siwu Tang (Four Substances Decoction) plus Taoren, Huomaren, and Wei Dahuang (baked Rhubarb). After several doses, there was no relief, and distension worsened. I administered Li Dongyuan’s Zhishi Dao Zhi Wan and Bei Ji Da Huang Wan. Upon swallowing, they were vomited immediately because the Stomach Qi was too weak to retain fast-acting drugs. Therefore, I coated Bei Ji Da Huang Wan in beeswax externally and pierced a small hole with a needle, instructing the patient to take three pills. The wax coating prevented direct irritation of Stomach Qi, allowing the medicine to pass through the Youmen and reach the Large and Small Intestines effectively. The next day, approximately one sheng (unit of volume) of dry feces was passed. Subsequently, I prescribed a modified Siwu Tang decoction to be taken alongside Run Chang Wan. After over a month of such regulation, her bowel movements normalized, food intake increased, and she recovered safely.
Medical Case 2
My clan nephew Bailong Tongpan’s son suffered from complete constipation due to smallpox. Pediatricians claimed that firm stool was a favorable sign. From onset until smallpox resolution, he had not defecated for twenty-five days. The pain in the anus extending to the Large Intestine was unbearable, his cries reaching neighboring houses. Two physicians and I discussed treatments. We used Zaojiao powder (Gleditsia Powder) and Honey Suppository methods, administered Da Cheng Qi Tang (Major Order the Qi Decoction), Xiao Cheng Qi Tang (Minor Order the Qi Decoction), Zhishi Dao Zhi Wan, and Bei Ji Wan, all without effect. At a loss, I said: "This is residual toxin and stagnant heat from smallpox lodged between the Large and Small Intestines." We gave him one large cup of Sesame Oil to drink, but it failed from morning to evening. I devised a plan: have a maid hold sesame oil in her mouth, insert a small bamboo tube into the anus, and blow the oil into the rectum. After about half an hour, the patient reported that the oil moved upward in the intestine like an earthworm. After another short while, one or two sheng of black stool were passed, and the patient fell into a peaceful sleep.