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The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: When the pulse is full, the skin is hot, the abdomen is distended, there is obstruction in both the anterior and posterior orifices (urination and defecation), and there is mental confusion and oppression, this is called the "Five Excess" syndrome. If the Qi of the Spleen and Stomach is stagnant and unable to transport and transform, compounded by phlegm-dampness and food stagnation obstructing the clear pathways, leading to constipation and difficult urination, Er Chen Tang (Two-Cured Decoction) with Sheng Ma (Cimicifugae Rhizoma), Chai Hu (Bupleuri Radix), Bai Zhu (Atractylodis Macrocephalae Rhizoma), and Cang Zhu (Atractylodis Rhizoma) can be used. After several doses, it can moisten the stool and promote urination. If damp-heat, phlegm, and fire are knotted and stagnant, with a surging and full pulse, red urine and stool, and painful joints, Liang Ge San (Cool the Upper Jiao Powder) or Xiao Cheng Qi Tang (Minor Order the Qi Decoction) can be selected. If scrotal swelling occurs with obstruction of both bowels, San Bai San (Three Whites Powder) is indicated.

When both bowel movements and urination are blocked, and the lower abdomen is distended and swollen, it is because the bladder is full of urine, pressing against and obstructing the ileum, thus preventing the passage of stool. In this case, use Er Chen Tang (Two-Cured Decoction) with doubled Fu Ling (Poria), plus Ze Xie (Alismatis Rhizoma) and Mu Tong (Akebiae Caulis) to first promote urination. Once the ileum is unblocked, the stool will follow.

For constipation caused by Wind closure, burn soap pod flesh to ash, powder it, and administer with rice gruel water. Alternatively, boil the soap pods and steam the lower part; this is effective. For Cold closure, take one or two green onions with roots, a piece of ginger with soil, twenty-one grains of Dan Dou Chi (Fermented Soybean), and two spoonfuls of salt. Pound them into a paste, make into a cake, heat it, and apply it to the umbilicus. Secure it tightly with cloth. After some time, moxibustion can be applied on top of the cake. For Heat closure, pound fresh snail meat, add one fen of She Xiang (Moschus) and half a fen of Bing Pian (Borneolum Syntheticum), place it in the umbilicus, and bind it with cloth. After walking about ten li, passage will be achieved.

Zhang Shiwen said: Obese people usually have accumulated phlegm-fluids and damp-heat. Illness often leads to obstruction of both bowels, abdominal fullness, anorexia, rebellious Qi causing wheezing and urgency. When the condition is severe, purgatives must be used. Some patients do not achieve relief even after repeated purgations; some require multiple purgations before opening; some suffer from diarrhea that does not stop after purgation. Generally, in those with inherent excess damp-heat, although no stool has passed for many days, the amount of hardened feces is small. What is discharged is merely loose, greasy, and foul-smelling stool. Even sudden, uncontrollable diarrhea may occur, where heat leaves and cold arises, causing the Righteous Qi to collapse, potentially transforming into hiccups. Since the root is damp-heat, warming tonics will aid the disease, while bitter-cold herbs will vainly deplete Stomach Qi, often leading to untreatable situations. If one initially recognizes damp-heat and phlegm accumulation, Dao Tan Tang (Guide Out Phlegm Decoction) with added Jiang Zhi (Zingiberis Rhizoma Preparatum) and Zhu Li (Bambusae Succus) should be used, followed by Gun Tan Wan (Rolling Down Phlegm Pill). In severe cases, Kong Xian Dan (Control Fluid-Ejection Pill) may be used. This is the correct method. If delayed, damp-heat surges upward violently, and Stomach fluids turn into turbid filth; even appropriate formulas will fail. Whenever there is obstruction of both bowels accompanied by borborygmus (rumbling in the abdomen), purgation will yield no hardened feces. It must be known that obese people, after purgation, risk continuous prolapse/diarrhea; thin people, after sweating, often suffer from persistent dryness and heat. These points cannot be ignored.

Zhu Danxi treated an elderly man who suffered from internal injury complicated by external contraction, and mistakenly used diaphoresis. The pulse was floating and rapid. Mistaken sweating in the elderly inevitably causes deficiency. Zhu prescribed Ren Shen (Ginseng Radix et Rhizoma), Bai Zhu (Atractylodis Macrocephalae Rhizoma), Dang Gui (Angelicae Sinensis Radix), Gan Cao (Glycyrrhizae Radix et Rhizoma), and Chen Pi (Citri Reticulatae Pericarpium). The patient stated he had not had a bowel movement since falling ill and now suffered unbearable pain from weakness and straining, desiring laxatives. Zhu reasoned this was not a solid constipation; the Qi became deficient due to mistaken sweating, failing to fill the abdomen and lacking strength to strain. He continued with the previous tonic formula, occasionally providing meat broth and Suo Yang (Cynomorii Herba) porridge, and soaking the lower body in strong decoctions of Cong Bai (Allii Fistulosi Bulbus) and Jiao Hua (Zanthoxyli Pericarpium). Several soft lumps were eventually passed. The pulse remained large and uncollected, and Blood-Qi was not yet restored, so the previous medicine was continued. Two days later, urination stopped, and the lower abdomen became full, oppressive, and distressing; only drops came out when lying supine. Zhu said, "The tonic medicine has not yet taken effect." He doubled the dosage of Ren Shen and Bai Zhu. After two days, urination resumed, and he recovered in half a month.

He also treated a woman with Spleen pain who subsequently developed obstruction of both bowels. This was due to phlegm blocking the Middle Jiao and Qi gathering in the Upper Jiao. Er Chen Tang (Two-Cured Decoction) with Mu Tong (Akebiae Caulis) was used. Induced vomiting after the first dose, and she recovered after the second dose.

Wang Shishan treated a woman whose lower abdomen was full and distended due to worry, fear, and overwork, with constipation of both bowels. A physician used Xiao Shi (Natrii Sulfas) and Da Huang (Rhei Radix et Rhizoma) three times to purge. Each time, obstruction returned immediately, worsening chest, abdominal, and epigastric distension and pain, spontaneous sweating, and poor appetite. Wang diagnosed the pulse as soggy, fine, and rapid, stating, "This is Spleen damage due to overwork, worry, and fear." Because the Spleen lost its function of healthy transportation, Qi stagnated and failed to move. The previous medicines could only benefit Blood but not Qi. He therefore used Ren Shen (Ginseng Radix et Rhizoma) 2 qian, Dang Gui Shen (Angelicae Sinensis Radix) 1.5 qian, Chen Pi (Citri Reticulatae Pericarpium), Zhi Ke (Aurantii Fructus Immaturus), and Huang Qin (Scutellariae Radix) each 0.7 fen. The patient recovered after decocting and taking this mixture.

Yu Jiayan treated a man with complete obstruction of both bowels. He had contracted malaria in early autumn. After three or five episodes, medication was used to forcibly cut off the malaria attacks. Subsequently, chest and abdominal distension increased daily. Within ten days, the abdomen became large and the chest high, with upper body wheezing and urgency. There was no urination or defecation, inability to eat or drink, ability to sit but not lie down, ability to bend forward but not backward. Multiple attempts at purgation failed. A merchant prescribed Da Huang (Rhei Radix et Rhizoma) 2 liang as a single dose. Yu asked, "What disease is this, that you dare to kill so boldly?" The doctor replied, "This is Taiyang Shaoyang transition with intestinal knotting; if purgation fails to open it, only massive purgation works. Why do you call it bold?" Yu said, "Is there such a thing as Taiyang disease without fever? In Taiyang disease with fever, body fluids are depleted, and intestines/stomach become dry and knotted, hence purgatives are used to open the knot. However, there is a warning: 'If there is no passage of flatus, do not attack.' This is precisely to avoid mistreating Taiyin abdominal distension. This case involves scattered and unrestrained Qi in the abdomen, with fluids overflowing wildly causing distension. It is entirely due to Taiyin Spleen Qi failing to control and contain. One is scattering, the other is knotting; they differ as heaven and earth. Using massive Da Huang to further scatter the Qi will either cause death by distension or bursting of the abdomen." He then used Lizhong Tang (Regulate the Middle Decoction) with a small addition of Huang Lian (Coptidis Rhizoma), slightly reducing the severity. The next day, he used Wuling San (Five-Ling Powder) in its original form. As soon as the medicine entered the throat, the patient demanded a chamber pot. Urination occurred first, followed by defecation. The feces in the abdomen were originally expelled by the Da Huang but could not exit because the bladder was distended, leaving no room in the abdomen, pinching the large intestine tight with no space for passage.

Zhang Shiwen treated Yang Songling, who caught a cold in summer and had taken more than ten doses of diaphoretic herbs. Both bowels became closed and difficult. Another physician used Xiao Shi (Natrii Sulfas) and Da Huang (Rhei Radix et Rhizoma) to purge. The left side of the lower abdomen swelled up like a mound, without redness or heat, making gurgling sounds at times. An external surgeon was consulted for topical application and internal detoxification/diuretics. Before the medicine could be taken, the patient became restless and agitated. Zhang Shiwen was then invited. The six pulses were tight, fine, and rapid. This was excessive sweating causing major fluid injury, combined with bitter-cold interior-purging herbs, leading to Yin pathogen internal knotting, bladder failure to transform, and accumulation of urine causing obstruction. The prognosis was hopeless. Fortunately, Stomach Qi still had authority, and form/spirit were not exhausted; he could still consume a little millet drink. Zhang agreed to treat him. He prescribed a large dose of Jisheng Shenqi Wan (Kidney Qi Pill for Salvation). The decoction was prepared in a spouted pot, the patient's neck was supported, and the liquid was slowly poured in while the head was tilted back, about one sheng. Shortly after, the patient was turned over, and a goose feather was used to induce vomiting. Immediately, urine and stool flowed like a torrent, and the lower abdomen flattened instantly. He was then managed with Shiquan Dabu Tang (Ten Substance Great Tonifying Decoction) until he recovered. Four or five other patients with similar conditions had been seen previously; some had dribbling urination, some had continuous enuresis, some had emaciation and Qi collapse. All were refused treatment and abandoned.