源出诸说 大便难者，由五脏不调，阴阳偏有虚实，谓三焦不和，则冷热并结故也。胃为水谷之海，
水谷之精化为荣卫，其糟粕行之于大肠以出也。五脏三焦既不调和，冷热壅涩，结在肠胃之间。其肠胃本实，
而又为冷热之气所结聚不宣，故令大便难也。（《病源论》）
又云∶邪在肾，亦令大便难，所以然者，肾脏受邪，虚而不能制小便，则小便利，津液枯燥，肠胃干涩，
故大便难。
又渴利之家大便亦难。所以尔者，为津液枯竭，致令肠胃干燥。（同上）
大便不通者，由三焦五脏不和，冷热之气不调，热气偏入肠胃，津液竭燥，故令糟粕痞结，壅塞不通也。
（同上）
大便秘滞有三∶一者，三焦五脏不和，热气小，偏入肠胃；二者，风客三焦，气弱传导不利；三者，肾虚
水少，胴肠干涩，皆令大肠秘滞。（《鸡峰》）
《素问云》∶大肠者，传导之官，变化出焉。平居之人，五脏之气贵乎平顺，阴阳二气贵乎不偏，然后津
液流通，肠胃益润，则传送如经矣。摄养乖理，三焦气涩，运掉不得，于是乎壅结于肠胃之间，遂成五秘之患。
（《济生》）
脉候 诊其左手寸口人迎以前脉，手少阴经也（按，《脉经》少作厥），脉沉为阴。阴实者，病苦闭，
大便不利，腹满四肢重，身热若胃胀。右手关上脉阴实者，脾实也。若肠中伏伏如牢状，大便难。（按∶以上
本出《脉经》。）脉紧而滑直，大便亦难。（《病源论》）
秘结，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。（《医
统》）
大便燥结，须分气血，阳数而实，阴迟而涩。（《四言举要》）
证治总说 大便秘涩，盖非一证，皆荣卫不调，阴阳之气相持也。若风气壅滞，肠胃干涩，是谓风秘。
胃蕴客热，口糜体黄，是谓热秘。下焦虚冷，窘迫后重，是谓冷秘。或因病后重亡津液，或因老弱血气不足，是
谓虚秘。或肾虚小水过多，大肠枯竭而多秘者，亡津液也。或胃实燥结，时作寒热者，中有宿食也。治法虽宜
和顺阴阳，然疏风散滞、去热
除冷、导引补虚之法，不可偏废，当审其证以治之。（《圣济》）
夫五秘者，风秘、气秘、湿秘、寒秘，热秘是也。更有发汗利小便，及妇人新产亡血，走耗津液，往往皆
令人秘结。燥则润之，涩则滑之，秘则通之，寒则温利之，此一定之法也。（《济生》）
凡脏腑之秘，不可一例治疗，有虚秘，有实秘。胃实而秘者，能饮食，小便赤，当以麻仁丸、七宣丸之类
主之（七宣丸用诃皮、柴胡、枳实、木香、桃仁、大黄、甘草）。胃虚而秘者，不能饮食，小便清利，浓朴汤
主之（用浓朴、白术、半夏、枳实、陈皮、甘草）。实秘者物也，虚秘者气也。（《保命》）
结燥之病不一，有热燥，有风燥，有阳结，有阴结，又有年老气虚津液不足而结燥者。治法云∶肾恶燥，
急食辛以润之，结者散之，如少阴不得大便，以辛润之，太阴不得大便，以苦泄之，阳结者散之，阴结者温之。
仲景云∶小便利而大便硬，不可攻下，以脾约丸润之。食伤太阴，腹满而食不化，腹响，然不能大便者，以苦
药泄之。如血燥而不能大便者，以桃仁、酒制大黄通之。风结燥而大便不行者，以麻子仁加大黄利之。如气涩而
大便不通者，以郁李仁、枳实、皂角仁润之。大抵治病必究其源，不可一概用巴豆、牵牛之类下之，损其津液，
燥结愈甚，复下复结，极则以至导引于下而不通，遂成不救，噫！可不慎哉。（《兰室》）
若气秘不通者，与三和散。若老人风秘，及产后去血过多，肠胃燥涩，便秘不通，宜以四物汤，加去白青
皮煎服。（《管见良方》）
凡通利大便，若用大黄、巴豆等药而大便不通者，阴阳关隔，水火不升降故也。有热者，来复丹夹三黄丸，
薄荷泡汤下。无热者。养正丹夹神保丸，橘皮煎汤下。（《直指》）
有风秘、冷秘、气秘、热秘。又有老人津液干燥，是名虚证。妇人分产亡血，及发汗、利小便、病后血气
未复，皆能作秘，俱宜麻仁丸。风秘之病，由风搏肺脏，传于大便，故传化难。冷秘，由冷气横于肠胃，凝阴
固结，津液不通，胃道秘塞，其人肠内气攻，喜热恶冷，宜藿香正气散（按∶《统旨》作理中汤），加官桂、
枳壳各半钱，吞半硫丸。热药多秘，惟硫黄暖而通；冷药多泄，惟黄连肥肠而止泄。气秘，则气不升降，谷气
不行，其人多噫，宜苏子降气汤加枳壳，吞养正丹，或半硫丸、来复丹。未效，佐以木香槟榔丸（用木香、枳
壳、青皮、杏仁、槟榔、郁李仁、皂角、半夏曲）。欲其速通，则枳壳生用。热秘，面赤身热，肠胃胀闷，时
欲得冷，或口舌生疮，此由大肠热结，宜四顺清凉饮，吞润肠丸，或木香槟榔丸。有气作疼，大便秘结，用通
剂而便愈不通，又有气秘、强欲通之，虽通复闭，或迫之使通，因而下血者，此惟当顺气，气顺便自通。顺气
之法，又当求温暖之剂，曾有下巴豆等药不通，进丹附却通，不可不知。宿食留滞，结而不通，腹胀气急，胸
中痞满，宜感应丸加巴豆。凡诸秘服药不通，或兼他证不受药者，用蜜皂角兑。冷秘，生姜兑亦佳。（《要诀》）
阳结阴结（肾衰证）秘结一证，在古方书有虚秘、风秘、气秘、热秘、寒秘、湿秘等说，而东垣又有
热燥风燥、阳结阴结之说，此其立名太烦，又无确据，不得其要而徒滋疑惑，不无为临证之害也。不知此证之
当辨者惟二，则曰阴结、阳结而尽之矣。盖阳结者邪有余，宜攻宜泻者也，阴结者正不足，宜补宜滋者也。知
斯二者，即知秘结之纲领矣。若或疑余之说而欲必究其详，则凡云风秘者，盖风未必秘，但风胜
则燥，而燥必由火，燥则生风，即阳结也，岂谓因风而宜散乎。有云气秘者，盖气有虚实。气实者阳有余，阳结
也；气虚者阳不足，阴结也。岂谓气结而尽宜破散乎。至若热秘、寒秘，亦不过阴阳之别名耳。再若湿秘之说，
则湿岂能秘，但湿之不化，由气之不行耳；气之不行，即虚结也，亦阴结也。总之，有火者便是阳结，无火者
便是阴结，以此辨之，岂不了然。余故曰∶凡此二者，即秘结之纲领也。（《景岳》）
阳结证，必因邪火有余，以致津液干燥，此或以饮食之火起于脾，或以酒色之火炽于肾，或以时令之火蓄于
脏，凡因暴病，或以年壮气实之人，方有此证。然必有火证火脉，内外相符者，方是阳结。治此者又当察其微
甚，邪结甚者，非攻不可，宜诸承气汤、神 丸、百顺丸之类主之；邪结微者，宜清凉饮子、元戎四物汤，或
黄龙汤、五烛散之类主之。（同上）
阴结证，但察其既无火证，又无火脉，或其人喜热恶冷，则非阳证可知。然既无邪，何以便结不通？盖此证
有二，则一以阳虚，一以阴虚也。凡下焦阳虚，则阳气不行，阳气不行，则不能传送而阴凝于下，此阳虚而阴
结也；下焦阴虚，则精血枯燥，精血枯燥，则津液不致而肠脏干槁，此阴虚而阴结也。故治阳虚而阴结者，但益
其火则阴凝自化；治阴虚而阳结者，但壮其水则泾渭自通。以上阴结一证，虽气血之分自当如此。然血虚者，
亦必气有不行；气虚者，岂曰血本无恙。大都虚而兼热者，当责其血分；虚而兼寒者，当责其气分。此要法也。
第今之世人，但知有热秘而不知有冷秘，所以《局方》有半硫丸，海藏有已寒丸之类，皆治此之良剂，所当察也。
若欲兼温兼补，似不若八味地黄丸及理阴煎之属为更妙。（同上）
少宰蒋恬 ，服五加皮酒，遂患大便秘结，四日以来，腹中胀闷，服大黄一钱，通后复结。余曰∶肾气衰少，
津液不充，误行疏利，是助其燥矣。以六味料煎成，加人乳一钟，白蜜五钱，二剂后即通，十日而康复矣。（《必
读》）（按∶薛氏有一老儒大便不通，肚腹不胀，脉洪大而虚，此阴火内烁，用六味丸治验。）
血虚证 血虚津液枯竭而秘结者，脉必小涩，面无精光，大便虽软，努责不出，大剂四物汤加陈皮、
甘草、酒红花，导滞通幽汤，益血丹（用当归、熟地）。血少兼有热者，脉洪数口干，小便赤少，大便秘硬，
润燥汤，活血润燥丸，四物汤加酒芩、栀子、桃仁、红花。（《准绳》）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，医杀之耳。（《正传》）
蓄血证 人有大便闭结不通，手按之痛甚欲死，心中烦躁，坐卧不宁，似乎有火，然小便又复清长。
人以为有硬屎留于肠中也，谁知有蓄血不散乎。夫蓄血之症，伤寒多有之；今其人并不感风寒之邪，何亦有蓄
血之病？不知人之气血，无刻不流通于经络之中，一有拂抑，则气即郁塞不通，血即停住不散，于是遂遏于皮
肤而为痈，留于肠胃而成痛，搏结成块，阻住传化之机，隔断糟粕之路，大肠因而不通矣。治法宜通大肠，佐
之逐秽之味。然而草木之药，可通无形之结，不能通有形之结也。血乃有形之物，必得有形相制之物，始能入
其中而散其结，方用抵当汤治之，一剂而大便通，顿失痛楚矣。（《辨证录》）
肥人湿热证 肥人素多痰饮湿热结聚，因病每致大小便不通，腹满不食，气逆喘急，势盛不得不下，有
屡下不得通利者，有再三下而始通者，有下之遂利不止者。大抵湿热素盛
之人，大便不行，日数虽多，结粪甚少，所下不过溏粪垢腻，甚至骤下不可遏者。多有热去寒起，正气随脱，即
变呃逆之证。以此本属湿热，温补仍助本病，苦寒徒乏胃气，每至不可救药。若始先知其湿热痰积，用导痰汤
多加姜汁、竹沥，下滚痰丸，甚则下控涎丹，方为合法。若迟则湿热上涌势剧，胃中津液尽变浊秽，虽有合剂，
不能取效也。凡大便不通而腹中雷鸣者，下之必无结粪。盖肥人下后，多有脱泄不止之虞，瘦人汗后，每多干
热不止之患，不可不知。（《医通》）
谷瘦（见润燥方中。）
渐成膈噎 秘结日深，渐成膈噎。盖阴不可以无阳，水不可以无火，水火既济，上下相交，荣卫流行，
自然润泽。若而幽门不通则上冲，吸门不开则噎塞，故云燥结不便，气不得上下者，治在幽门。（《医统》）
治有不宜峻利 关格不通，三焦约病，责以荣卫之痞塞。乳后便难，与夫老者秘涩之病，又以津液不
足，止可滑以利之，润以滋之。苟荡以 剂，则糟粕不通，真气受弊，不可不知也。（《圣济》）
老人脏腑不可用大黄，老人津液少，所以秘涩，更服大黄以泻之，津液皆去，定须再秘甚于前，只可服宽
润大肠之药，如《养生必用方》二仁丸是也，更用槐花末煎汤淋洗亦妙。风药燥肠。又有一种风秘者，当用槟榔
七圣丸，虽有大黄，斟酌服之，勿令泻可也。又有妇人产后大便秘，须四五日、六七日不通者，出血已多，津
液少也，浓煎紫苏汤饮一两盏自通。更一日不通，服局方大麻仁丸三十丸。（《医说》引《医余》）
初虞世云∶余历观古人用通药率用降气等药，盖肺气不
下降，则大肠不能传送，以杏仁、枳壳、诃子等药是也。又老人、虚人、风人津液少，大便秘，经云涩者滑之，
故用胡麻、杏仁、麻子仁、阿胶之类是也。今人学不师古，妄意斟酌，每至大便秘燥，即以 药荡涤之，既走
津液气血，大便随手愈更秘涩，兼生他病。（《妇人良方》）
元气薄弱之人，凡患伤寒杂证病气不足等病，而有大便不行者，但察其胸腹下焦，若绝无胀实痞塞、急坠
欲解等患，此其中本无实邪，即虽十日二十日不解，亦自无妨。切不可因其不便，强为疏导。盖其胃口未开，
食饮未进，则全赖中气以为捍御之本，但俟邪气渐退，胃气渐和，则自然通达，无足虑也。若肠脏本无滞呆，而
强为通利，以泄胃气，遂至主不胜客者有之，邪因而陷者亦有之，此其害受于冥冥之中，而人多不知也，识之
慎之。（《景岳》）
秘结证，凡属老人、虚人、阴脏人，及产后、病后、多汗后，或小水过多，或亡血、失血、大吐、大泻之
后，多有病为燥结者。盖此非气血之亏，即津液之耗，凡此之类，皆须详察虚实，不可轻用芒硝、大黄、巴豆、
牵牛、芫花、大戟等药，及承气、神芎等剂，虽今日暂得通快，而重虚其虚，以致根本日竭，则明日之结必将
更甚，愈无可用之药矣。况虚弱之辈，幸得后门坚固，最是寿征，虽有涩滞，亦须缓治，但以养阴等剂渐加调
理，则无有不润。故病家医家，凡遇此类，切不可性急欲速，以自取其败，而致悔无及也。（同上）
黄蜡包丸 丹溪治一人，胃虚有滞，不通不纳，药用黄蜡包备急丸，穿一孔，令服三丸，取其不犯胃
气，故得迟化达幽门而出也。次日下结屎升许，继以调理而安。（《六要》）（按∶此出《正传》，系虞氏治
验，今引丹溪盖错，
但《正传》文繁，故从之。）
胃虚甚者，泻药性急，不能下行，反为上出，当以丸子，蜡匮而吞，不犯胃气，俾出幽门，药得施功，智
[Pathogenesis Discussion]
Difficulty in defecation arises from the dysfunction of the five Zang organs, with an imbalance of Yin and Yang, manifesting as excess or deficiency. It is said that when the San Jiao (Triple Burner) is disharmonious, cold and heat pathogens bind together. The Stomach is the sea of water and grain; the essence of water and grain transforms into Ying (Nutritive Qi) and Wei (Defensive Qi), while the dregs are transported to the Large Intestine for excretion. If the five Zang organs and the San Jiao lose harmony, cold and heat pathogens stagnate and obstruct, accumulating between the intestines and stomach. Since the intestines and stomach are inherently full, and are further bound by cold and heat pathogens without dispersion, difficulty in defecation results. (From *Zhu Bing Yuan Hou Lun*)
It is also stated: Pathogens invading the Kidney can also cause difficulty in defecation. This is because the Kidney, affected by pathogens, becomes deficient and unable to control urination, leading to frequent urination. Consequently, body fluids dry up, the intestines and stomach become dry and astringent, resulting in difficult defecation.
Furthermore, patients suffering from Xiao Ke (Wasting-Thirst disease, akin to diabetes) also experience difficult defecation. The reason is the depletion of body fluids, causing dryness in the intestines and stomach. (Ibid.)
Obstruction of stool is caused by the disharmony of the San Jiao and five Zang organs, where cold and heat pathogens are unregulated. Heat qi偏 enters the intestines and stomach, depleting and drying body fluids, causing dregs to become impeded and knotted, leading to obstruction. (Ibid.)
There are three main types of constipation: First, disharmony of the San Jiao and five Zang organs, with slight heat qi偏 entering the intestines and stomach; Second, Wind pathogen lodging in the San Jiao, with weak Qi failing to facilitate transmission; Third, Kidney deficiency with insufficient water, leading to dry and astringent intestines. All these result in Large Intestine constipation. (From *Ji Feng Pu Ji Fang*)
The *Su Wen* states: The Large Intestine is the official responsible for transmission, and changes occur here. In healthy individuals, the Qi of the five Zang organs must be smooth and balanced, and Yin and Yang Qi must not be偏. Only then do body fluids circulate, keeping the intestines and stomach moist, allowing normal transport. If health preservation violates natural principles, causing San Jiao Qi to become stagnant and movement to fail, knotting occurs in the intestines and stomach, leading to the five types of constipation. (From *Ji Sheng Fang*)
[Pulse Diagnosis]
Palpating the pulse before the Renying point at the Cun Kou on the left hand corresponds to the Hand Shaoyin Heart Meridian (Note: *Mai Jing* reads "Jue" instead of "Shao"). A deep pulse indicates Yin. In cases of Yin Excess, the patient suffers from closure, difficulty in defecation, abdominal fullness, heaviness of the four limbs, fever, or gastric distension. A Yin Excess pulse at the Guan position on the right hand indicates Spleen Excess. If there is a sensation of something firm and hidden within the intestines, defecation will be difficult. (Note: The above originates from *Mai Jing*). A pulse that is tight, slippery, and straight also indicates difficult defecation. (From *Zhu Bing Yuan Hou Lun*)
Pulses associated with constipation are 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. For elderly or deficient patients with constipation, a sparrow-pecking pulse (irregular and abrupt) indicates a non-treatable condition. (From *Yi Tong Zheng Zong*)
For dry and knotted stool, one must distinguish between Qi and Blood: Yang patterns present with a rapid and solid pulse, while Yin patterns present with a slow and choppy pulse. (From *Si Yan Ju Yao*)
[General Treatment Principles]
Dry and difficult defecation is not a single syndrome but results from the disharmony of Ying and Wei, with Yin and Yang Qi holding each other in balance. If Wind pathogens cause stagnation and dryness in the intestines and stomach, it is called Wind Constipation. If heat lingers in the Stomach, accompanied by oral ulcers and yellowing of the body, it is called Heat Constipation. If the Lower Jiao is deficient and cold, with urgency and tenesmus, it is called Cold Constipation. If it follows an illness with massive fluid loss, or occurs due to old age and weakness with insufficient Qi and Blood, it is called Deficiency Constipation. If Kidney deficiency leads to excessive urination, depleting the Large Intestine, it is due to fluid exhaustion. If there is Stomach excess with dry knotting and alternating chills and fever, it is due to retained food. Although treatment should harmonize Yin and Yang, methods such as dispersing Wind, resolving stagnation, clearing heat, dispelling cold, guiding flow, and tonifying deficiency must not be neglected. One must examine the specific syndrome to treat it. (From *Sheng Ji Zong Lu*)
The so-called "Five Constipations" refer to Wind, Qi, Dampness, Cold, and Heat Constipation. Additionally, sweating, diuresis, and blood loss after childbirth often consume body fluids, frequently leading to constipation. Dryness requires moistening, astringency requires lubrication, obstruction requires purging, and cold requires warming and promoting flow. This is a fixed principle. (From *Ji Sheng Fang*)
Constipation of the Zang and Fu organs cannot be treated uniformly; there are Deficiency Constipation and Excess Constipation. In Excess Constipation of the Stomach, the patient can eat, and urine is dark red; treatment should focus on Ma Ren Wan or Qi Xuan Wan (composed of He Pi, Chai Hu, Zhi Shi, Mu Xiang, Tao Ren, Da Huang, Gan Cao). In Deficiency Constipation of the Stomach, the patient cannot eat, and urine is clear; treatment should focus on Nong Po Tang (composed of Nong Po, Bai Zhu, Ban Xia, Zhi Shi, Chen Pi, Gan Cao). Excess constipation is caused by tangible obstructions, while deficiency constipation is caused by intangible Qi insufficiency. (From *Wei Sheng Bao Jian*)
Knotting and dryness vary: there is Heat Dryness, Wind Dryness, Yang Knotting, and Yin Knotting, as well as knotting due to old age, Qi deficiency, and fluid insufficiency. The treatment principle states: The Kidney dislikes dryness; urgently consume pungent foods to moisten it. Knots are dispersed. For example, if Shaoyin channel causes inability to defecate, use pungent moistening; if Taiyin channel causes inability to defecate, use bitter purgation. Yang knots are dispersed; Yin knots are warmed. Zhang Zhongjing said: If urination is free but stool is hard, do not purge aggressively; use Pi Yue Wan to moisten. If dietary injury affects Taiyin, causing abdominal fullness, indigestion, borborygmus, and inability to defecate, use bitter medicines to purge. If blood dryness prevents defecation, use Tao Ren and wine-processed Da Huang to unblock. If wind-dryness prevents defecation, use Hemp Seed and Da Huang to promote flow. If Qi astringency prevents defecation, use Yu Li Ren, Zhi Shi, and Gao Jiao Ren to moisten. Generally, treating disease requires investigating the root cause. One must not indiscriminately use Ba Dou or Qian Niu to purge, as this damages body fluids and worsens dryness. Repeated purging and knotting can lead to extreme cases where even enemas fail, resulting in death. Alas! How can one not be cautious? (From *Lan Shi Mi Cang*)
For Qi Constipation, administer San He San. For Wind Constipation in the elderly, or postpartum blood loss causing dry and astringent intestines, Si Wu Tang with Qing Pi (peel removed) is suitable. (From *Yi Xue Guan Jian Liang Fang*)
When promoting bowel movement, if Da Huang or Ba Dou fails to produce stool, it indicates a blockage of Yin and Yang, preventing the ascent and descent of Water and Fire. If there is heat, use Huan Fu Dan combined with San Huang Wan, taken with mint infusion. If there is no heat, use Yang Zheng Dan combined with Shen Bao Wan, taken with tangerine peel infusion. (From *Zhi Zhi Fang*)
There are Wind, Cold, Qi, and Heat Constipation. Elderly people with dry fluids have a Deficiency pattern. Women losing blood during childbirth, or those who have sweated, urinated excessively, or recovered from illness with unrecovered Qi and Blood, all suffer from constipation and are suitable for Ma Ren Wan. Wind Constipation arises from Wind attacking the Lung and transmitting to the Large Intestine, making digestion difficult. Cold Constipation arises from Cold Qi blocking the intestines and stomach, condensing Yin and binding, stopping fluid flow, and sealing the Stomach pathway. The patient feels gas attacking the intestines, prefers warmth, and dislikes cold. Huo Xiang Zheng Qi San (or Li Zhong Tang per *Tong Zhi*) plus Gui Xi and Zhi Qiao, swallowed with Ban Shu Wan, is indicated. Hot medicines often cause constipation, except for Su Huang which warms and unblocks; cold medicines often cause diarrhea, except for Huang Lian which fattens the intestines and stops diarrhea. Qi Constipation involves failure of Qi to ascend and descend, with Grain Qi stagnating, frequent belching. Su Zi Jiang Qi Tang plus Zhi Qiao, swallowed with Yang Zheng Dan, Ban Shu Wan, or Huan Fu Dan, is indicated. If ineffective, add Mu Xiang Bin Lang Wan. For rapid relief, use raw Zhi Qiao. Heat Constipation presents with red face, fever, abdominal distension, desire for cold drinks, or mouth ulcers, due to Large Intestine Heat Knotting. Si Shun Qing Liang Yin, swallowed with Run Chang Wan or Mu Xiang Bin Lang Wan, is indicated. If pain accompanies constipation and purgatives fail, or if forced evacuation causes bleeding, one must only regulate Qi. Once Qi flows smoothly, stool passes naturally. Regulation requires warm formulas. There are cases where Ba Dou failed but Dan Fu (Aconite formulas) succeeded. For retained food causing knotting, abdominal distension, urgency, and chest fullness, Gan Ying Wan plus Ba Dou is indicated. For any constipation unresponsive to medication or complicated by other conditions preventing intake, use Honey-soaked Gao Jiao suppository. For Cold Constipation, Ginger suppository is also good. (From *Shi Yi De Xiao Fang*)
[Differentiation of Yang and Yin Knotting]
Regarding constipation, ancient texts mention Deficiency, Wind, Qi, Heat, Cold, and Damp Constipation. Li Dongyuan added Heat Dryness, Wind Dryness, Yang Knotting, and Yin Knotting. These names are too complex and lack solid basis, causing confusion and harming clinical practice. The key differentiation lies in only two categories: Yin Knotting and Yang Knotting. Yang Knotting is excess of pathogenic factors, requiring attack and purgation. Yin Knotting is deficiency of healthy Qi, requiring tonification and nourishment. Understanding these two grasps the essence of constipation. Regarding Wind Constipation, Wind itself does not necessarily cause constipation; rather, Wind dominance leads to Dryness, which stems from Fire. Dryness generates Wind, which is essentially Yang Knotting, not requiring dispersal. Regarding Qi Constipation, Qi has excess and deficiency. Qi Excess is Yang Excess (Yang Knotting); Qi Deficiency is Yang Insufficiency (Yin Knotting). It is not appropriate to disperse all Qi knots. Heat and Cold Constipation are merely aliases for Yin and Yang. Regarding Damp Constipation, Dampness itself does not cause constipation; it is the failure of Qi transformation. Failure of Qi movement is Deficiency Knotting, i.e., Yin Knotting. In summary, presence of Fire indicates Yang Knotting; absence of Fire indicates Yin Knotting. Thus, these two are the guidelines. (From *Jing Yue Quan Shu*)
Yang Knotting syndrome is caused by excess Evil Fire drying up body fluids. This may arise from dietary fire in the Spleen, sexual excess fire in the Kidney, or seasonal fire stored in the Zang organs. It typically occurs in acute illnesses or robust, strong individuals. There must be Fire symptoms and pulses matching internally and externally. Treatment depends on severity. Severe knotting requires aggressive purgation, using Cheng Qi Decoctions, Shen Xiong Wan, or Bai Shun Wan. Mild knotting uses Qing Liang Yin Zi, Yuan Rong Si Wu Tang, Huang Long Tang, or Wu Ling San. (Ibid.)
Yin Knotting syndrome is identified by the absence of Fire symptoms and pulses, or preference for warmth and aversion to cold. If there is no external pathogen, why is there constipation? There are two subtypes: Yang Deficiency and Yin Deficiency. Lower Jiao Yang Deficiency leads to failure of Yang Qi movement, causing Yin to congeal below (Yang Deficiency Yin Knotting). Lower Jiao Yin Deficiency leads to dryness of Essence and Blood, causing intestinal dryness (Yin Deficiency Yin Knotting). Treating Yang Deficiency Yin Knotting requires tonifying Fire to melt the Yin congealment. Treating Yin Deficiency Yin Knotting requires strengthening Water to clear the channels. Although Blood and Qi deficiencies differ, Blood deficiency implies Qi stagnation, and Qi deficiency implies Blood involvement. Generally, Deficiency with Heat concerns the Blood aspect; Deficiency with Cold concerns the Qi aspect. This is a crucial method. Modern practitioners often know only Heat Constipation, ignoring Cold Constipation. Formulas like Ban Shu Wan (*Ju Fang*) and Yi Han Wan (Hai Zang) are excellent for this. For combined warming and tonifying, Ba Wei Di Huang Wan or Li Yin Jian are superior. (Ibid.)
[Case Study]
Jiang Tian, Vice Minister, drank Wu Jia Pi Wine and developed severe constipation. After four days of abdominal distension, he took one qian of Da Huang. After passing stool, it rebounded. I said: Kidney Qi is declining, fluids are insufficient. Misusing purgatives exacerbated the dryness. I prescribed Liu Wei Di Huang decoction with one cup of human milk and five qian of white honey. After two doses, stool passed, and he recovered in ten days. (From *Bi Du*) (Note: Xue Ji treated an old scholar with constipation but no abdominal distension, with a large and empty pulse, indicating internal Yin Fire. Liu Wei Wan was effective.)
[Blood Deficiency Syndrome]
Constipation due to Blood deficiency and fluid exhaustion presents with a small, choppy pulse, dull complexion, soft stool that is difficult to expel despite straining. Use large doses of Si Wu Tang plus Chen Pi, Gan Cao, and wine-processed Hong Hua, Dao Zhi Tong You Tang, or Yi Xue Dan (Dang Gui, Shu Di). If Blood deficiency with Heat presents with rapid pulse, dry mouth, scanty dark urine, and hard stool, use Run Zao Tang, Huo Xue Run Zao Wan, or Si Wu Tang plus Jiu Qin, Zhi Zi, Tao Ren, and Hong Hua. (From *Yi Xue Zhun Sheng*) If Blood deficiency presents with a pulse large like a scallion tube, fever, and dry constipation, absolutely do not induce sweating, as this severely depletes fluids, leading to fatal closure. This would be medical homicide. (From *Ge Zhi Yu Lun*)
[Blood Stasis Syndrome]
Patients with closed and obstructed stool, severe pain upon palpation, restlessness, and apparent heat signs, yet with clear and long urination, are often mistaken for having hard feces. However, this is due to accumulated Blood stasis. While common in Shang Han (Cold Damage), it can occur without external pathogens. Qi and Blood normally circulate freely; obstruction causes Qi stagnation and Blood stasis. This can form masses in the skin (abscesses) or intestines, blocking transmission and causing Large Intestine obstruction. Treatment should unblock the Large Intestine and assist with blood-dispersing herbs. Plant-based medicines can resolve intangible knots but not tangible ones. Blood is tangible; thus, tangible-resolving agents are needed. Dang Gui Tang is used, often resulting in immediate relief after one dose. (From *Bian Zheng Lu*)
[Damp-Heat in Obese Individuals]
Obese individuals often have phlegm-damp-heat accumulation. Illness can lead to urinary and fecal obstruction, abdominal fullness, anorexia, and wheezing. Aggressive purgation is sometimes necessary. Responses vary: some remain obstructed despite purging, some pass after repeated purging, some suffer continuous diarrhea. In damp-heat dominant patients, few hard stools form over many days; what passes is loose, greasy stool, sometimes uncontrollable. Heat clearance may lead to Cold onset and collapse of Healthy Qi, resulting in hiccups. Since the root is damp-heat, warming tonics exacerbate the disease, and bitter-cold herbs damage Stomach Qi, leading to untreatable conditions. Early recognition of damp-heat-phlegm accumulation warrants Dao Tan Tang with ginger juice and bamboo sap, followed by Gun Tan Wan, or Kong Xian Dan in severe cases. Delay allows damp-heat to surge upward, turning stomach fluids turbid, rendering treatments ineffective. Abdominal borborygmus with constipation indicates no hard stool. Obese patients risk collapse after purging; thin patients risk dry heat after sweating. (From *Yi Zong Bi Du*)
[Progression to Ge Ye (Regurgitation)]
Chronic constipation can gradually develop into Ge Ye (Regurgitation/Obstruction). Yin requires Yang; Water requires Fire. When Water and Fire interact, Upper and Lower Jiao connect, Ying and Wei circulate, and natural moisture is maintained. If the幽门 (Pylorus/Hou Men) is blocked, Qi rushes upward; if the 吸门 (Xi Men) fails to open, choking occurs. Thus, dry constipation with impaired Qi movement is treated by addressing the Hou Men. (From *Yi Tong Zheng Zong*)
[Caution Against Harsh Purgatives]
Guan Ge (Obstruction) and San Jiao constraint stem from Ying and Wei blockage. Difficulty in defecation after breastfeeding or in the elderly, due to fluid insufficiency, should be treated with lubrication and moistening. Using harsh purgatives blocks dregs and damages True Qi. (From *Sheng Ji Zong Lu*)
Elderly people should avoid Da Huang. Their fluids are low, causing constipation; purging further depletes fluids, worsening constipation. Use intestinal-moistening drugs like Er Ren Wan (*Yang Sheng Bi Yong Fang*) or wash with Sophora flower decoction. Wind medicines dry the intestines. For Wind Constipation, Bing Lang Qi Sheng Wan can be used cautiously with Da Huang, avoiding diarrhea. Postpartum constipation in women, lasting 4-7 days due to blood loss and fluid deficiency, can be resolved by drinking strong Perilla decoction. If unresolved, take Ju Fang Da Ma Ren Wan. (From *Yi Shuo* citing *Yi Yu*)
Chu Yushi observed that ancients used Qi-descending herbs (Xing Ren, Zhi Qiao, He Zi) because Lung Qi descending facilitates Large Intestine transmission. For elderly, deficient, or Wind-affected patients with low fluids, "astringency requires lubrication," hence using Hu Ma, Xing Ren, Ma Zi Ren, and E Jiao. Modern practitioners, ignoring antiquity, recklessly use harsh purgatives, depleting fluids and Qi, worsening constipation and causing other diseases. (From *Fu Ren Da Quan Liang Fang*)
In individuals with weak Yuan Qi and deficiency syndromes, if there is no abdominal distension, fullness, or urgent need to defecate, there is no Excess pathogen. Even if constipation lasts 10-20 days, it is harmless. Do not forcibly promote evacuation. With poor appetite, Middle Qi is vital for defense. Wait for pathogen decline and Stomach Qi harmony for natural passage. Forcing purgation in non-stagnant intestines damages Stomach Qi, leading to Host overcoming Guest or pathogen sinking. These harms are subtle and often unnoticed. Be vigilant. (From *Jing Yue Quan Shu*)
Constipation in the elderly, deficient, Yin-constitution individuals, postpartum, post-illness, post-sweating, or after excessive urination/blood loss/vomiting/diarrhea, is usually due to Qi/Blood deficiency or fluid exhaustion. Carefully differentiate deficiency and excess. Avoid harsh purgatives like Mang Xiao, Da Huang, Ba Dou, Qian Niu, Yuan Hua, Da Ji, or Cheng Qi/Shen Xiong formulas. Temporary relief leads to deeper deficiency and worse future constipation. For the weak, stable bowel function is a sign of longevity. Treat slowly with Yin-nourishing agents. Do not rush, lest you cause failure and regret. (Ibid.)
[Honey Wax Pill]
Zhu Danxi treated a patient with Stomach deficiency and stagnation, unable to tolerate medication. He used Bei Ji Wan wrapped in beeswax, pierced with a hole, administering three pills. This avoided irritating the Stomach, allowing slow digestion and release at the Hou Men. The next day, a significant amount of hard stool passed, and the patient recovered with subsequent regulation. (From *Ben Cao Hui Yan*) (Note: Originally from *Ge Zhi Yu Lun*, attributed to Chu Yushi, mistakenly cited here as Danxi. Text condensed.)
For severe Stomach deficiency, harsh purgatives act too quickly and may be vomited up. Pills wrapped in wax ensure they reach the Hou Men without irritating the Stomach, allowing the medicine to work effectively...