某医云：何本病前用苦辛通降、降逆止呕、芳香醒脾和胃而呕吐不减，而用理中地黄汤反愈也?答曰：本方含五苓、理中二汤，理中者理中焦者也，五苓者利水止吐之剂，此病之吐实乃水逆之吐，故以此方而愈也。且本方亦寓肾气丸意，肾气丸者治肾虚微饮之剂也，肾虚微饮之吐者，用肾气丸非但治饮，亦且能降冲，故以本方获愈也。至于前用诸方所以不效之由，我认为有三因：治标不治本一也，降胃不纳肾二也，化饮不利水三也。故以本方综肾气丸、理中汤、五苓散、苓桂术甘、茯苓泽泻汤意而温脾肾、利水湿、降冲逆、去寒水。
胃部手术后远期并发症
I．久虚之证，不知察实，久寒之证，不知察热，补实温热，其病不治
谌××，男，成。
溃疡病手术后4个多月来，胃脘剧烈疼痛虽然已经消失，但隐隐作痛却一直不减，且腹满腹胀，食欲不振日渐加重，并时时恶心，体重锐减达25千克。细审其证，面色萎黄，消瘦乏神，脘腹胀痛，按之更甚，纳呆食减，恶心欲吐，心烦易怒，头晕胀痛，口苦咽干，大便干稀不调，舌苔黄白厚腻，脉弦紧而数。综合脉证，诊为肝胃不和，寒积不化。治拟疏肝和胃，温中导滞。处方：柴胡10克，半夏10克，党参10克，黄芩10克，干姜3克，甘草6克，大枣5个，苍术15克，厚朴10克，陈皮10克，大黄3克。
服药3剂，胃脘满痛，纳呆食减，心烦易怒等证好转，大便正常。继服上方30剂，诸证全失，体重由35千克增至50千克。
某医云：何用健脾和胃而不效?答曰：寒热夹杂不可但用甘温也。又问：何用柴平汤治之亦不效?答曰：寒实之积不可不导滞也。又问：何用温中健脾而不效?答曰：病在肝胃治在脾胃，病为寒实治以温补，寒热不分，虚实不别，脏腑不明所致也。
2．病因不分，病机不明，但以健脾和胃，其病不愈
申××，男，60岁。
胃癌术后2个月来，虽然剧痛已经停止，但胃脘满痛，食欲不振，消瘦乏力一直不见改善。为此曾遍用西药和中药健脾和胃之剂进行治疗，然其效果一直不够明显。细审其证，胃脘满痛，恶心欲吐，头晕头痛，心烦不安，神疲乏力，形体瘦削，口苦咽干，面色萎黄，舌苔黄白厚腻，脉弦紧而数。综合脉证，诊为肝胃不和，寒积不化。治拟疏肝和胃，温中导滞。处方：柴胡10克，半夏10克，党参10克，黄芩10克，甘草6克，干姜3克，大枣5个，苍术10克，厚朴10克，陈皮10克，大黄3克。
服药2剂，胃脘满痛消失，心烦易怒，恶心欲吐，食欲不振好转；继服6剂，恶心消失，食欲正常，其他诸证大部消失。
某医云：健脾和胃之剂何故不效?答曰：寒热不分，脏腑不别，虚实不明所致也。寒积者不可因其有虚而不敢攻，但攻之必须恰当耳。
3．不明脏腑，不别阴阳，不分气血，久延病期
梁××，男，65岁。
食管癌手术后3个多月来，食欲一直不振，吞咽困难。医诊食管狭窄。食管扩张术后，虽然吞咽较前顺利，但却出现严重的食欲不振，胃脘持续的疼痛，胸满心烦，昼夜不能人睡。急予西药治疗1周，不但上症不减，反而出现自汗盗汗，疲乏无力，口干咽燥，体重锐减，血色素亦由14克降至9克。经输血后，病情有所稳定；但1周后，诸证又甚，乃再次输血。输血4天以后，诸证又复如初。细审其证，面色皓白无华，神疲乏力，形销骨立(体重31千克)，食纳极差，胃脘满痛，胸胁满痛，心烦失眠，按其胃脘部有明显压痛，舌质红，舌苔黄白，脉虚大弦滑。综合脉证，诊为气阴两虚为本，气滞血瘀，实滞不化为标。治拟补气养阴以培本，理气活血，消食导滞以治标。人参10克，麦冬15克，生地30克，苍术15克，白术10克，陈皮10克，青皮10克，柴胡10克，三棱10克，莪术10克，薄荷3克，夜交藤30克。
服药6剂，胃脘胀痛，食欲不振好转；继服30剂，胃脘痛消失，食欲增加，精神好转，体重增加4千克，血色素增至13克。
溃疡性结肠炎
胶于正虚，不辨气血，但予补气，久治不愈
赵××，女，48岁。
腹泻腹痛，或便脓血，里急后重3年多。医诊溃疡性结肠炎。先以西药治疗2年不效，后又以中药清热燥湿、温中导滞、补气健脾等剂治疗1年亦不见功。细审其脉沉弦细涩，面色萎黄，舌苔白，腹痛隐隐，时或剧烈，大便或见三四日不行，或见一日10～20次，呈粘液脓血或血便，里急后重。综合脉证，思之：前用诸方之所以不效者，或重于补涩，或予以导滞，或重于清热燥湿而未兼顾其寒，尤其是未顾及血分也。血分者，若便鲜红者为热，便秽暗者为寒滞血瘀。本证必寒滞血瘀之所为耳。拟温中活血。处方：小茴香10克，炮姜10克，元胡10克，灵脂10克，没药10克，川芎10克，当归10克，蒲黄10克，肉桂10克，赤芍10克。
服药6剂，腹痛大减，纳食增加，大便由15次减为2次，且脓血便消失；继服10剂，诸证消失，体重亦由40千克增至48千克。
某医云：前用资生丸、参苓白术、附子理中、理中地黄等不愈者何也?答曰：病已人血分，但治其气分也。今用少腹逐瘀汤者在于温经活血耳。又问：前曾用活血逐瘀药而不减者何也?答：寒热有别也。前用诸药大多见其便血而注意热，今见其便秽而粘辨其为寒，热证用凉，寒证用热，此自古之理也，今由凉药改温药，故愈也。
便秘
1．寒温气滞，运化不能，反用寒润，便秘更甚
孙××，女，23岁。
从幼年开始即经常便秘，有时两日1次，有时5～6天一行。在4—5岁以前，便秘严重时一用七珍丹10粒左右即可使大便通下，至7—8岁时再用七珍丹则无明显效果，于是改用西药缓泻剂，开始效果很好，至10岁时单纯西药又不见效，于是又加用了牛黄解毒丸或番泻叶，但至12岁时以上方法再不见效，又不得不改用3天一次大承气汤，每次大黄用15克、芒硝30克，但半年以后效果又不明显，又加入了肉苁蓉、生地、元参、当归、火麻仁才逐步好转。至18岁时，以上方法再无效果，因此又改用每四天灌肠1次，至今已4年。最近半年多来，每次灌肠合并服药以后近两天才有少许粪便排出。细审其证，除便秘外，并见脘腹胀满不适，舌苔薄白，脉沉弦而紧。综合脉证，思之：脉沉者气郁也，弦者肝胆三焦之脉也，紧脉者寒湿凝结也。合之于症论之：乃寒湿郁结于三焦，清气不升，浊气不降所致也。为拟理气通阳化湿。处方：木香10克，香附20克，砂仁10克，莱菔子10克，半夏10克，陈皮10克，茯苓10克，甘草6克，枳实10克，白术10克，神曲10克，苏叶3克。
服药2剂后，大便在不用泻药的情况下可以4日一行，腹脘胀满减轻，继服上药1个月，大便转为1日一行。停药后，追访一年，一直正常。
某医云：为什么久用攻下、润下而便秘不减，而改用理气之药却便秘得解?答曰：便秘一证，以热炽肠胃、血虚津亏者为多见，所以医家一见便秘即用承气汤、麻子仁丸、润肠丸进行治疗。岂知久久便秘不通者，气机郁滞者有之；阴寒内盛，寒湿不化，肠道传送无力者亦有之。此证久用苦寒、甘寒、咸寒之品，克伐脾胃肠道阳气，寒湿内生，传送不能，故再用寒凉滋润则阳气更伤，因此宜用辛温、苦温以除寒湿，行气机。
2．肝胃气郁，枢机不利，不调枢机，但予通下，其病不愈
焦××，男，58岁。
3—4年来，大便经常数日不通。医者每予西药缓泻剂进行治疗而取效，但近2年多来效果不再明显，于是改请中医以润下、番泻叶等治之，始称有效，但最近1个多月以来不再有效，尤其是近10天来，虽遍服中药大承气汤、增液承气汤、黄龙汤，以及西药灌肠法，均无明显效果。细审其证，除便秘之外，并见头晕头痛，心烦失眠，口苦咽干，脘腹时痛，舌苔白，脉沉弦紧。因思：脉沉者郁证也，弦者少阳枢机不利也，紧者寒湿凝滞不化也。综合脉证论之，乃少阳枢机不利，上热下寒，肠道传运失常之证也。治宜和解少阳，调理枢机。处方：柴胡9克，黄芩9克，党参9克，半夏9克，桂枝9克，茯苓9克，陈皮9克，大黄3克，大枣5个，甘草6克，生姜3片，龙骨15克，牡蛎15克。
服药1剂，大便得通，继服6剂，他证亦愈。其后大便逐渐转为正常。
某医云：大便秘结，大黄是最好的通便药，为何前用大黄至30克而不通，而改用3克反效也?答曰：大黄苦寒为攻下之圣品，这是医家所公认之事。然本病的着重点不在腑实，而在少阳枢机不利和上热下寒，少阳枢机不利，仲景言当禁下，以防阳气过降而不升。本病前用诸方均为降药，若今再用降药则枢机更加失其斡旋之力，枢机不利则清不升，浊亦不降耳，故取少量之降，而重用升药，使其斡旋之力得以恢复。
3．寒湿郁滞，阳气不化，但用苦降，反损阳气
赵××，女，13岁。
从1岁始即经常大便秘结，少则3—4天，多则7～8天才排便1次，而且每次都得用药才能顺利排出，为了使其排便顺利，经常每天服食大量水果和蜂蜜。但最近一年多来，再用以上办法却不见效果。特别是最近3个多月以来，由于大便不通，终日感到腹胀腹痛，疲乏无力，为此不得不采用隔日灌肠法帮助排便，但还是不能正常排便。细审其证，10天来仍未排便，腹胀腹痛，纳食不能，气短懒言，面色萎黄，舌质淡暗，舌苔薄白，脉沉细弦。综其脉证，思之：沉脉者气郁也，细弦者寒湿郁滞不化也。寒湿气滞则阳气不化，清气不升则浊阴不降，腑气不通。治宜拟温阳理气，化湿和中。处方：厚朴10克，陈皮10克，甘草6克，草豆蔻10克，木香6克，干姜6克，肉桂6克，大黄1克。
药进1剂，大便即行2次；继服3剂，大便转为1日l行；其后间断服药30剂，腹痛腹满消失，食欲正常，大便正常。
某医云：本例患者余曾用大黄15克、芒硝10克，然不但大便未通，还出现恶心欲吐，而老师仅用大黄1克，却便通纳增，其故何也?答曰：如上所述本例之大便秘结在于寒湿阳气不化，所以再用大剂苦寒咸寒不但更加不通，而且纳食反减。至于大黄1克为何能通便，乃因温阳化湿佐加苦降之味耳。
4.痰湿郁滞，反与攻下、润下，痰湿反甚，运化不能
吴××，女，58岁。
大便秘结30多年。医始用西药不效，继又用中药润下、攻下等效果亦不明显。细审其证，除大便5。10日一行外，并见纳呆腹胀，舌苔白，脉沉而缓。因思脉沉者气郁也，缓者脾虚痰湿蕴郁也。综其脉证，乃痰湿郁滞也。拟用理气祛痰。又思丹溪润下丸仅用陈皮、甘草二味，汪昂《汤头歌诀》称“润下丸仅陈皮草、利气祛痰妙绝伦。”正与此法合拍。乃拟润下丸为汤。陈皮40克，甘草10克。
1剂大便行，续进1剂，追访半年，大便一直正常。
5.阳虚湿郁，反用寒下以损阳气，气虚不运，阳气不化，便秘更甚
郭××，女．40岁。
30年来经常3～5天才排便1次，为了增加排便次数和减少排便时的痛苦，每天除吃大量水果、蜂蜜外，几乎每天都服西药缓泻剂，如此这般已达20多年。但近两年以来，虽然继续采用上述办法，但仍7～8天才排便一次，而且排便之日必须在前一天服用一剂大承气汤，当天再用开塞露或灌肠。细审其证，除大便秘结之外，并见脘腹胀满，面色萎黄，舌质淡黯，舌苔薄白，脉弦大而紧。综合脉证，思之：大承气汤为峻下热结之方，其若热结便秘者往往一剂而解。吴鞠通《温病条辨》云：“此苦辛通降咸以入阴法。承气者，承胃气也。盖胃之为腑体阳而用阴，若在无病时，本系自然下降，今为邪气蟠居于中，阻其下降之气，胃虽自欲下降而不能，非药力助之不可，故承气汤通胃结，收胃阴，仍系承胃腑本来下降之气，非有一毫私智穿凿于其间也，故汤名承气。学者若真能透彻此义，则施用承气，自无弊窦。大黄荡涤热结，芒硝人阴软坚，枳实开幽门之不通，厚朴泻中宫之实满。日大承气者，合四药而观之，可谓无坚不破，无微不入，故日大也。非真正实热蔽痼，气血俱结者，不可用也。”又云：“阳明温病，下之不通，其证有五：应下失下，正虚不能运药，不运药者死，新加黄龙汤主之。喘促不宁，痰涎壅滞，右寸实大，肺气不降者，宣白承气汤主之。左尺牢坚，小便赤痛，时烦渴甚，导赤承气汤主之。邪闭心色，神昏舌短，内窍不通，饮不解渴者，牛黄承气汤主之。津液不足，无水舟停者，间服增液，再不下者，增液承气汤主之。”又思大便之不解，温病多津伤，而此为杂病，必阳气损也。脉弦大而紧者，皆阳虚寒甚之脉也，其不运药者阳气虚也，且久用苦寒咸寒甘寒又损阳气，故不愈也。治宜温补脾胃之阳气，佐以理气通便。处方：附子10克，党参10克，肉桂10克，白术10克，甘草10克，干姜10克，枳实6克，厚朴6克，大黄2克。服药1剂，次日大便竟然三行且微溏，继服6剂，追访4个月，均每日大便1次。
6．气虚湿郁，升降之功失职，反用寒降以伐生阳，运药不能，便秘不愈
独××，男，49岁
某位医生问道：为什么本病之前使用苦辛通降、降逆止呕、芳香醒脾和胃的方剂，呕吐却没有减轻，反而使用理中地黄汤治愈了呢？回答说：这个方剂包含了五苓散（Wuling San, Five-Ingredient Powder with Poria）和理中汤（Lizhong Tang, Middle-Warming Decoction）两方的意思。理中汤是调理中焦脾胃的方剂；五苓散是利水湿以停止呕吐的方剂。此病的呕吐实际上是“水逆”（Shuini, Water Reversal）类型的呕吐，所以用这个方剂而痊愈。而且，本方也蕴含了肾气丸（Shenqi Wan, Kidney Qi Pill）的意思。肾气丸是治疗肾虚导致轻微水饮内停的方剂。对于因肾虚微饮引起的呕吐，使用肾气丸不仅能治疗水饮，还能平冲降逆（Pingchong Jiangni, calm the rebellious Qi and descend counterflow），因此用本方获得了痊愈。至于之前使用的各种方剂之所以无效的原因，我认为有三点：一是治标不治本；二是只降胃气而不收纳肾气；三是化除水饮却不利尿渗湿。因此，本方综合了肾气丸、理中汤、五苓散、苓桂术甘汤（Linggui Zhugan Tang, Decoction of Poria, Cinnamon Twig, Atractodes Rhizome and Licorice）以及茯苓泽泻汤（Fuling Zexie Tang, Decoction of Poria and Alisma）的意旨，从而温补脾肾、利水渗湿、降逆平冲、祛除寒水。
胃部手术后的远期并发症
1. 久虚之证，不知察实；久寒之证，不知察热；误用补益温热之法，其病难愈
患者谌某某，男性，成年。
溃疡病手术后4个多月来，虽然胃脘部的剧烈疼痛已经消失，但隐隐作痛一直未减，且伴有腹部胀满、食欲不振日渐加重，并时常感到恶心，体重锐减达25千克。仔细审查其症状，面色萎黄，形体消瘦、精神疲乏，脘腹胀痛，按压时疼痛加剧，食欲减退，恶心欲吐，心烦易怒，头晕胀痛，口苦咽干，大便干稀不调，舌苔黄白厚腻，脉象弦紧而数。综合脉象与症状，诊断为肝胃不和（Ganwei Buhe, Disharmony between Liver and Stomach），寒积不化（Hanji Buhua, Cold accumulation failing to transform）。治疗拟定疏肝和胃（Shugan Hewei, soothe the liver and harmonize the stomach），温中导滞（Wenzhong Daozhi, warm the middle and guide out stagnation）。处方：柴胡（Chaihu, Bupleuri Radix）10克，半夏（Banxia, Pinelliae Rhizoma）10克，党参（Dangshen, Codonopsis Radix）10克，黄芩（Huangqin, Scutellariae Radix）10克，干姜（Ganjiang, Zingiberis Rhizoma）3克，甘草（Gancao, Glycyrrhizae Radix et Rhizoma）6克，大枣（Dazao, Jujubae Fructus）5枚，苍术（Cangzhu, Atractodis Rhizoma）15克，厚朴（Houpo, Magnoliae Officinalis Cortex）10克，陈皮（Chenpi, Citri Reticulatae Pericarpium）10克，大黄（Dahuang, Rheum Palmati Radix et Rhizoma）3克。
服用3剂后，胃脘满痛、纳呆食减、心烦易怒等症状好转，大便恢复正常。继续服用上方30剂，所有症状全部消失，体重由35千克增至50千克。
某位医生问道：为什么使用健脾和胃的方剂却无效？回答说：寒热夹杂的病证，不可单纯使用甘温的药物。又问：为什么使用柴平汤（Chai Ping Tang, Chaihu Pingwei Decoction）治疗也不见效？回答说：寒实之积，不可不进行导滞治疗。又问：为什么使用温中健脾的方法无效？回答说：病位在肝胃，治疗却在脾胃；病性为寒实，治疗却用温补；这是由于寒热不分、虚实不辨、脏腑不明所致。
患者申某某，男性，60岁。
胃癌术后2个月来，虽然剧痛已经停止，但胃脘部满痛、食欲不振、消瘦乏力一直未见改善。为此曾广泛使用西药和中药健脾和胃的方剂进行治疗，然而效果一直不够明显。仔细审查其症状，胃脘部满痛，恶心欲吐，头晕头痛，心烦不安，神疲乏力，形体瘦削，口苦咽干，面色萎黄，舌苔黄白厚腻，脉象弦紧而数。综合脉证，诊断为肝胃不和，寒积不化。治疗拟定疏肝和胃，温中导滞。处方：柴胡10克，半夏10克，党参10克，黄芩10克，甘草6克，干姜3克，大枣5枚，苍术10克，厚朴10克，陈皮10克，大黄3克。
服用2剂后，胃脘满痛消失，心烦易怒、恶心欲吐、食欲不振好转；继续服用6剂，恶心消失，食欲正常，其他症状大部分消失。
某位医生问道：为何健脾和胃的方剂无效？回答说：这是因寒热不分、脏腑不辨、虚实不明所致。对于寒积之证，不可因其有虚象而不敢攻下，但攻下必须恰当适宜。
患者梁某某，男性，65岁。
食管癌手术后3个多月来，食欲一直不振，吞咽困难。医生诊断为食管狭窄。食管扩张术后，虽然吞咽较前顺利，但却出现严重的食欲不振，胃脘持续疼痛，胸满心烦，昼夜不能入睡。急予西药治疗1周，不但上述症状没有减轻，反而出现自汗盗汗，疲乏无力，口干咽燥，体重锐减，血色素也由14克降至9克。经输血后，病情有所稳定；但1周后，诸症又加重，于是再次输血。输血4天以后，诸症又恢复如初。仔细审查其症状，面色苍白无华，神疲乏力，形销骨立（体重31千克），饮食极差，胃脘部满痛，胸胁部满痛，心烦失眠，按压胃脘部有明显压痛，舌质红，舌苔黄白，脉象虚大弦滑。综合脉证，诊断为气阴两虚（Qiyin Liangxu, Deficiency of both Qi and Yin）为本，气滞血瘀（Qizhi Xueyu, Qi stagnation and Blood stasis）、实滞不化为标。治疗拟定补气养阴以培补根本，理气活血、消食导滞以治标。处方：人参（Renshen, Ginseng Radix）10克，麦冬（Maidong, Ophiopogonis Radix）15克，生地（Shengdi, Rehmanniae Radix）30克，苍术15克，白术（Baizhu, Atractodis Macrocephalae Rhizoma）10克，陈皮10克，青皮（Qingpi, Citri Reticulatae Pericarpium Viride）10克，柴胡10克，三棱（Sanleng, Sparganii Rhizoma）10克，莪术（Ezhu, Curcumae Rhizoma）10克，薄荷（Bohe, Menthae Haplocalycis Herba）3克，夜交藤（Yejiaoteng, Polygoni Multiflori Caulis）30克。
服用6剂后，胃脘胀痛、食欲不振好转；继续服用30剂，胃脘痛消失，食欲增加，精神好转，体重增加4千克，血色素增至13克。
胶于正虚，不辨气血，仅予补气，久治不愈
患者赵某某，女性，48岁。
腹泻腹痛，或便脓血，里急后重（Lijihouzhang, Tenesmus）3年多。医生诊断为溃疡性结肠炎。先以西药治疗2年无效，后又以中药清热燥湿（Qingre Zaoshi, clear heat and dry dampness）、温中导滞、补气健脾等方剂治疗1年亦不见效。仔细审查其脉象沉弦细涩，面色萎黄，舌苔白，腹痛隐隐，时而剧烈，大便或三四日不行，或一日10～20次，呈粘液脓血或血便，伴有里急后重。综合脉证，思考：之前使用的方剂之所以无效，或许是过于侧重补涩，或是予以导滞，或是侧重于清热燥湿而未兼顾其寒性，尤其是未顾及血分（Xuefen, Blood level/aspect）。在血分方面，若大便鲜红者为热证，大便秽暗者为寒滞血瘀。本证必然是寒滞血瘀所致。拟定温中活血（Wenzhong Huoxue, warm the middle and invigorate blood）之法。处方：小茴香（Xiaohuixiang, Foeniculi Fructus）10克，炮姜（Paojiang, Zingiberis Rhizoma Preparatum）10克，元胡（Yuanhu, Corydalis Rhizoma）10克，灵脂（Lingzhi, Typhae Pollen）10克，没药（Moyao, Myrrha）10克，川芎（Chuanxiong, Ligustici Chuanxiong Rhizoma）10克，当归（Danggui, Angelicae Sinensis Radix）10克，蒲黄（Puhuang, Typhae Pollen）10克，肉桂（Rougui, Cinnamomi Cortex）10克，赤芍（Chishao, Paeoniae Radix Rubra）10克。
服用6剂后，腹痛大减，纳食增加，大便由每日15次减为2次，且脓血便消失；继续服用10剂，所有症状消失，体重也由40千克增至48千克。
某位医生问道：之前使用资生丸（Zisheng Wan, Zisheng Pill）、参苓白术散（Shenling Baizhu San, Ginseng, Poria and Atractylodes Macrocephala Powder）、附子理中汤（Fuzi Lizhong Tang, Aconite and Middle-Warming Decoction）、理中地黄汤等方剂未能治愈，是何原因？回答说：病已深入血分，但之前只治疗气分（Qifen, Qi level/aspect）。如今使用少腹逐瘀汤（Shaofu Zhuyu Tang, Lower Abdomen Blood-Stasis Expelling Decoction）在于温经活血。又问：之前曾用过活血逐瘀药却未减轻，是何原因？回答说：寒热有别。之前使用的药物大多见其便血而注意热证，如今见其大便秽浊粘腻而辨其为寒证。热证用凉药，寒证用热药，这是自古以来的道理。如今由凉药改为温药，故而痊愈。
1. 寒温气滞，运化不能，反用寒润之法，便秘更甚
患者孙某某，女性，23岁。
从幼年开始即经常便秘，有时两日1次，有时5～6天一行。在4—5岁以前，便秘严重时，一用七珍丹（Qizhen Dan, Seven-Treasure Pill）10粒左右即可使大便通下；至7—8岁时，再用七珍丹则无明显效果，于是改用西药缓泻剂，开始效果很好；至10岁时，单纯西药又不见效，于是又加用了牛黄解毒丸（Niuhuang Jiedu Wan, Calculus Bovis Detoxification Pill）或番泻叶（Fanxieye, Sennae Folium），但至12岁时，以上方法再不见效，又不得不改用每3天一次的大承气汤（Da Chengqi Tang, Major Order the Qi Decoction），每次大黄用15克、芒硝（Mangxiao, Natrii Sulfas）30克，但半年以后效果又不明显，又加入了肉苁蓉（Roucongrong, Cistanches Herba）、生地、元参（Yuanshen, Scrophulariae Radix）、当归、火麻仁（Huomaren, Cannabis Semen）才逐步好转。至18岁时，以上方法再无效果，因此又改用每四天灌肠1次，至今已4年。最近半年多来，每次灌肠合并服药以后，近两天才有少许粪便排出。仔细审查其症状，除便秘外，并见脘腹胀满不适，舌苔薄白，脉象沉弦而紧。综合脉证，思考：脉沉者，气郁也；弦者，肝胆三焦之脉也；紧脉者，寒湿凝结也。合之于症论之：乃寒湿郁结于三焦（Sanjiao, Triple Burner），清气不升，浊气不降所致也。拟理气通阳化湿（Li Qi Tong Yang Hua Shi, regulate Qi, unblock Yang, and resolve dampness）之法。处方：木香（Muxiang, Aucklandiae Radix）10克，香附（Xiangfu, Cyperi Rhizoma）20克，砂仁（Sharen, Amomi Fructus）10克，莱菔子（Laifuzi, Raphani Semen）10克，半夏10克，陈皮10克，茯苓（Fuling, Poria）10克，甘草6克，枳实（Zhishi, Aurantii Fructus Immaturus）10克，白术10克，神曲（Shenqu, Massa Medicata Fermentata）10克，苏叶（Suye, Perillae Folium）3克。
服用2剂后，大便在不用泻药的情况下可以4日一行，腹脘胀满减轻；继续服用上方1个月，大便转为1日一行。停药后，随访一年，一直正常。
某位医生问道：为什么久用攻下、润下之法而便秘不减，而改用理气之药却便秘得解？回答说：便秘一证，以热炽肠胃、血虚津亏者为多见，所以医家一见便秘即用承气汤、麻子仁丸（Mazi Ren Wan, Hemp Seed Pill）、润肠丸（Runchang Wan, Intestine-Moistening Pill）进行治疗。岂知久久便秘不通者，有气机郁滞者；有阴寒内盛，寒湿不化，肠道传送无力者亦有之。此证久用苦寒、甘寒、咸寒之品，克伐脾胃肠道阳气，寒湿内生，传送不能，故再用寒凉滋润则阳气更伤，因此宜用辛温、苦温以除寒湿，行气机。
患者焦某某，男性，58岁。
3—4年来，大便经常数日不通。医者每予西药缓泻剂进行治疗而取效，但近2年多来效果不再明显，于是改请中医以润下、番泻叶等治之，始称有效，但最近1个多月以来不再有效，尤其是近10天来，虽遍服中药大承气汤、增液承气汤（Zengye Chengqi Tang, Fluid-Increasing Order the Qi Decoction）、黄龙汤（Huanglong Tang, Yellow Dragon Decoction），以及西药灌肠法，均无明显效果。仔细审查其症状，除便秘之外，并见头晕头痛，心烦失眠，口苦咽干，脘腹时痛，舌苔白，脉象沉弦紧。因思：脉沉者，郁证也；弦者，少阳枢机（Shaoyang Shuji, Pivot of Shaoyang）不利也；紧者，寒湿凝滞不化也。综合脉证论之，乃少阳枢机不利，上热下寒，肠道传运失常之证也。治宜和解少阳（Hejie Shaoyang, harmonize the Shaoyang），调理枢机。处方：柴胡9克，黄芩9克，党参9克，半夏9克，桂枝（Guizhi, Cinnamomi Ramulus）9克，茯苓9克，陈皮9克，大黄3克，大枣5枚，甘草6克，生姜（Shengjiang, Zingiberis Rhizoma Recens）3片，龙骨（Longgu, Fosssilia Ostei Mastodi et Ossis Femoris）15克，牡蛎（Muli, Ostreae Concha）15克。
服用1剂，大便得通，继续服用6剂，他证亦愈。其后大便逐渐转为正常。
某位医生问道：大便秘结，大黄是最好的通便药，为何前用大黄至30克而不通，而改用3克反效？回答说：大黄苦寒，为攻下之圣品，这是医家所公认之事。然本病的着重点不在腑实（Fushi, Fu-organ excess），而在少阳枢机不利和上热下寒。少阳枢机不利，仲景言当禁下，以防阳气过降而不升。本病前用诸方均为降药，若今再用降药则枢机更加失其斡旋之力，枢机不利则清不升，浊亦不降耳，故取少量之降，而重用升药，使其斡旋之力得以恢复。
患者赵某某，女性，13岁。
从1岁始即经常大便秘结，少则3—4天，多则7～8天才排便1次，而且每次都得用药才能顺利排出，为了使其排便顺利，经常每天服食大量水果和蜂蜜。但最近一年多来，再用以上办法却不见效果。特别是最近3个多月以来，由于大便不通，终日感到腹胀腹痛，疲乏无力，为此不得不采用隔日灌肠法帮助排便，但还是不能正常排便。仔细审查其症状，10天来仍未排便，腹胀腹痛，纳食不能，气短懒言，面色萎黄，舌质淡暗，舌苔薄白，脉象沉细弦。综其脉证，思考：沉脉者，气郁也；细弦者，寒湿郁滞不化也。寒湿气滞则阳气不化，清气不升则浊阴不降，腑气不通。治宜拟温阳理气，化湿和中（Huashi Hezhong, resolve dampness and harmonize the middle）。处方：厚朴10克，陈皮10克，甘草6克，草豆蔻（Caodoukou, Alpiniae Katsumadai Semen）10克，木香6克，干姜6克，肉桂6克，大黄1克。
药进1剂，大便即行2次；继续服用3剂，大便转为1日1行；其后间断服药30剂，腹痛腹满消失，食欲正常，大便正常。
某位医生问道：本例患者余曾用大黄15克、芒硝10克，然不但大便未通，还出现恶心欲吐，而老师仅用大黄1克，却便通纳增，其故何也？回答说：如上所述，本例之大便秘结在于寒湿阳气不化，所以再用大剂苦寒咸寒不但更加不通，而且纳食反减。至于大黄1克为何能通便，乃因温阳化湿佐加苦降之味耳。
4. 痰湿郁滞，反与攻下、润下，痰湿反甚，运化不能
患者吴某某，女性，58岁。
大便秘结30多年。医始用西药不效，继又用中药润下、攻下等效果亦不明显。仔细审查其症状，除大便5—10日一行外，并见纳呆腹胀，舌苔白，脉象沉而缓。因思脉沉者，气郁也；缓者，脾虚痰湿蕴郁也。综其脉证，乃痰湿郁滞也。拟用理气祛痰（Li Qi Qutan, regulate Qi and resolve phlegm）。又思丹溪润下丸仅用陈皮、甘草二味，汪昂《汤头歌诀》称“润下丸仅陈皮草、利气祛痰妙绝伦。”正与此法合拍。乃拟润下丸为汤。陈皮40克，甘草10克。
1剂大便行，续进1剂，随访半年，大便一直正常。
5. 阳虚湿郁，反用寒下以损阳气，气虚不运，阳气不化，便秘更甚
患者郭某某，女性，40岁。
30年来经常3～5天才排便1次，为了增加排便次数和减少排便时的痛苦，每天除吃大量水果、蜂蜜外，几乎每天都服西药缓泻剂，如此这般已达20多年。但近两年以来，虽然继续采用上述办法，但仍7～8天才排便一次，而且排便之日必须在前一天服用一剂大承气汤，当天再用开塞露或灌肠。仔细审查其症状，除大便秘结之外，并见脘腹胀满，面色萎黄，舌质淡黯，舌苔薄白，脉象弦大而紧。综合脉证，思考：大承气汤为峻下热结之方，其若热结便秘者往往一剂而解。吴鞠通《温病条辨》云：“此苦辛通降咸以入阴法。承气者，承胃气也。盖胃之为腑体阳而用阴，若在无病时，本系自然下降，今为邪气蟠居于中，阻其下降之气，胃虽自欲下降而不能，非药力助之不可，故承气汤通胃结，收胃阴，仍系承胃腑本来下降之气，非有一毫私智穿凿于其间也，故汤名承气。学者若真能透彻此义，则施用承气，自无弊窦。大黄荡涤热结，芒硝人阴软坚，枳实开幽门之不通，厚朴泻中宫之实满。日大承气者，合四药而观之，可谓无坚不破，无微不入，故日大也。非真正实热蔽痼，气血俱结者，不可用也。”又云：“阳明温病，下之不通，其证有五：应下失下，正虚不能运药，不运药者死，新加黄龙汤主之。喘促不宁，痰涎壅滞，右寸实大，肺气不降者，宣白承气汤主之。左尺牢坚，小便赤痛，时烦渴甚，导赤承气汤主之。邪闭心色，神昏舌短，内窍不通，饮不解渴者，牛黄承气汤主之。津液不足，无水舟停者，间服增液，再不下者，增液承气汤主之。”又思大便之不解，温病多津伤，而此为杂病，必阳气损也。脉弦大而紧者，皆阳虚寒甚之脉也，其不运药者阳气虚也，且久用苦寒咸寒甘寒又损阳气，故不愈也。治宜温补脾胃之阳气，佐以理气通便。处方：附子（Fuzi, Aconiti Lateralis Radix Praeparata）10克，党参10克，肉桂10克，白术10克，甘草10克，干姜10克，枳实6克，厚朴6克，大黄2克。
服药1剂，次日大便竟然三行且微溏，继续服用6剂，随访4个月，均每日大便1次。
6. 气虚湿郁，升降之功失职，反用寒降以伐生阳，运药不能，便秘不愈
患者独某某，男性，49岁。
A physician asked: Why did the vomiting persist despite the prior use of formulas employing bitter-pungent descending and unblocking, anti-emetic, and aromatic spleen-strengthening and stomach-harmonizing methods, yet was cured by Lizhong Dihuang Tang (Lizhong Dihuang Decoction)? The answer is: This formula incorporates the principles of Wuling San (Five-Ingredient Powder with Poria) and Lizhong Tang (Middle-Warming Decoction). Lizhong Tang regulates the Middle Jiao (Middle Burner); Wuling San promotes diuresis to stop vomiting. The vomiting in this case is actually "Water Reversal" (Shuini), hence the cure with this formula. Furthermore, this formula also embodies the intent of Shenqi Wan (Kidney Qi Pill), which treats mild fluid retention due to Kidney deficiency. For vomiting caused by mild fluid retention from Kidney deficiency, using Shenqi Wan not only treats the fluid retention but also calms rebellious Qi and descends counterflow. Thus, the cure was achieved with this formula. As for why the previously used formulas were ineffective, I believe there are three reasons: first, treating the branch without addressing the root; second, descending Stomach Qi without receiving Kidney Qi; third, transforming fluids without promoting diuresis. Therefore, this formula synthesizes the principles of Shenqi Wan, Lizhong Tang, Wuling San, Linggui Zhugan Tang (Decoction of Poria, Cinnamon Twig, Atractodes Rhizome and Licorice), and Fuling Zexie Tang (Decoction of Poria and Alisma) to warm the Spleen and Kidney, promote water metabolism, descend rebellious Qi, and eliminate cold-water retention.
Late-term complications after gastric surgery
1. In cases of prolonged deficiency, failing to detect excess; in cases of prolonged cold, failing to detect heat; applying tonifying and warming methods erroneously leads to untreatable disease.
Patient Chen XX, male, adult.
Over four months post-ulcer surgery, although severe epigastric pain had subsided, dull pain persisted. Abdominal fullness and distension increased, appetite worsened, and nausea occurred frequently. Body weight dropped sharply by 25 kg. Careful examination revealed sallow complexion, emaciation, lack of spirit, epigastric and abdominal distension and pain exacerbated by pressure, poor appetite, nausea, irritability, dizziness and distending headache, bitter taste in the mouth and dry throat, alternating constipation and diarrhea, yellow-white thick greasy tongue coating, and a wiry-tight-rapid pulse. Synthesizing pulse and symptoms, the diagnosis was Liver-Stomach Disharmony (Ganwei Buhe) and Cold Accumulation failing to transform. Treatment aimed to soothe the Liver and harmonize the Stomach, and warm the Middle to guide out stagnation. Prescription: Chaihu (Bupleuri Radix) 10g, Banxia (Pinelliae Rhizoma) 10g, Dangshen (Codonopsis Radix) 10g, Huangqin (Scutellariae Radix) 10g, Ganjiang (Zingiberis Rhizoma) 3g, Gancao (Glycyrrhizae Radix et Rhizoma) 6g, Dazao (Jujubae Fructus) 5 pieces, Cangzhu (Atractodis Rhizoma) 15g, Houpo (Magnoliae Officinalis Cortex) 10g, Chenpi (Citri Reticulatae Pericarpium) 10g, Dahuang (Rhei Radix et Rhizoma) 3g.
After 3 doses, epigastric fullness/pain, poor appetite, and irritability improved, and bowel movements normalized. After continuing the same prescription for 30 doses, all symptoms disappeared, and body weight increased from 35 kg to 50 kg.
A physician asked: Why was the Spleen-strengthening and Stomach-harmonizing method ineffective? The answer is: In mixed cold-heat patterns, one cannot rely solely on sweet-warm herbs. Another question: Why was Chaiping Tang (Chaihu-Pingwei Decoction) ineffective? The answer is: In cases of cold-excess accumulation, guiding out stagnation is indispensable. Another question: Why was warming the Middle and strengthening the Spleen ineffective? The answer is: The pathology lies in the Liver and Stomach, but treatment focused on the Spleen and Stomach; the nature is cold-excess, yet warming-tonification was used. This resulted from failing to distinguish cold from heat, excess from deficiency, and organs.
2. Failure to distinguish etiology and pathogenesis, relying solely on Spleen-strengthening and Stomach-harmonizing results in non-cure.
Patient Shen XX, male, 60 years old.
Two months post-gastric cancer surgery, although severe pain ceased, epigastric fullness/pain, poor appetite, emaciation, and fatigue persisted without improvement. Extensive use of Western medicines and Chinese herbal formulas for Spleen-strengthening and Stomach-harmonizing yielded insignificant results. Careful examination revealed epigastric fullness/pain, nausea, dizziness/headache, restlessness, fatigue, emaciation, bitter taste/dry throat, sallow complexion, yellow-white thick greasy tongue coating, and wiry-tight-rapid pulse. Diagnosis: Liver-Stomach Disharmony, Cold Accumulation failing to transform. Treatment: Soothe Liver, harmonize Stomach, warm Middle, guide out stagnation. Prescription: Chaihu 10g, Banxia 10g, Dangshen 10g, Huangqin 10g, Gancao 6g, Ganjiang 3g, Dazao 5 pieces, Cangzhu 10g, Houpo 10g, Chenpi 10g, Dahuang 3g.
After 2 doses, epigastric fullness/pain resolved; irritability, nausea, and poor appetite improved. After 6 more doses, nausea ceased, appetite normalized, and most other symptoms disappeared.
A physician asked: Why were Spleen-strengthening and Stomach-harmonizing formulas ineffective? The answer is: Due to failure to distinguish cold/heat, organs, and excess/deficiency. In cold-accumulation patterns, one must not hesitate to purge due to signs of deficiency, but purging must be appropriate.
3. Failure to understand organs, distinguish Yin/Yang, and differentiate Qi/Blood leads to prolonged disease course.
Patient Liang XX, male, 65 years old.
Over three months post-esophageal cancer surgery, appetite remained poor with dysphagia. Diagnosed with esophageal stenosis. Post-esophageal dilation, swallowing improved slightly, but severe anorexia, persistent epigastric pain, chest fullness, and irritability developed, causing insomnia day and night. One week of Western medicine failed to alleviate symptoms, instead inducing spontaneous/night sweats, fatigue, dry mouth/throat, sharp weight loss, and hemoglobin drop from 14 g/dL to 9 g/dL. Transfusion stabilized the condition temporarily, but symptoms worsened after one week, requiring another transfusion. Four days post-transfusion, symptoms returned to baseline. Careful examination showed pale lusterless complexion, fatigue, extreme emaciation (31 kg), very poor intake, epigastric/chest fullness/pain, irritability/insomnia, tenderness on epigastric palpation, red tongue body, yellow-white coating, and deficient-large-wiry-slippery pulse. Diagnosis: Root is Qi-Yin Deficiency (Qiyin Liangxu); Branch is Qi Stagnation and Blood Stasis (Qizhi Xueyu) with solid stagnation failing to transform. Treatment: Tonify Qi and nourish Yin to support the root; regulate Qi, invigorate blood, digest food, and guide out stagnation to treat the branch. Prescription: Renshen (Ginseng Radix) 10g, Maidong (Ophiopogonis Radix) 15g, Shengdi (Rehmanniae Radix) 30g, Cangzhu 15g, Baizhu (Atractodis Macrocephalae Rhizoma) 10g, Chenpi 10g, Qingpi (Citri Reticulatae Pericarpium Viride) 10g, Chaihu 10g, Sanleng (Sparganii Rhizoma) 10g, Ezhu (Curcumae Rhizoma) 10g, Bohe (Menthae Haplocalycis Herba) 3g, Yejiaoteng (Polygoni Multiflori Caulis) 30g.
After 6 doses, epigastric distending pain and anorelia improved. After 30 more doses, epigastric pain vanished, appetite increased, spirit improved, weight gained 4 kg, and hemoglobin rose to 13 g/dL.
Ulcerative Colitis
Sticking to righteous deficiency, failing to differentiate Qi/Blood, administering only Qi-tonics leads to chronic non-cure.
Patient Zhao XX, female, 48 years old.
Diarrhea, abdominal pain, or pus/blood in stool, with tenesmus (Lijihouzhang) for over 3 years. Diagnosed with ulcerative colitis. Two years of Western medicine failed. One year of Chinese medicine (clearing heat/drying dampness, warming Middle/guiding stagnation, tonifying Qi/strengthening Spleen) also failed. Pulse was deep-wiry-thin-choppy; complexion sallow; tongue coating white; abdominal pain dull yet occasionally severe; bowel movements irregular (every 3-4 days or 10-20 times/day), presenting as mucopurulent bloody stools with tenesmus. Analysis: Previous failures were due to excessive astringency/tonification, inappropriate guiding of stagnation, or focusing on clearing heat/drying dampness without addressing cold, especially neglecting the Blood level (Xuefen). In the Blood level, bright red blood indicates heat; dark/foul blood indicates cold-stagnation and blood stasis. This case is due to cold-stagnation and blood stasis. Treatment: Warm the Middle and invigorate blood. Prescription: Xiaohuixiang (Foeniculi Fructus) 10g, Paojiang (Zingiberis Rhizoma Preparatum) 10g, Yuanhu (Corydalis Rhizoma) 10g, Lingzhi (Typhae Pollen) 10g, Moyao (Myrrha) 10g, Chuanxiong (Ligustici Chuanxiong Rhizoma) 10g, Danggui (Angelicae Sinensis Radix) 10g, Puhuang (Typhae Pollen) 10g, Rougui (Cinnamomi Cortex) 10g, Chishao (Paeoniae Radix Rubra) 10g.
After 6 doses, abdominal pain decreased significantly, appetite increased, bowel movements reduced from 15 to 2 per day, and pus/blood stools disappeared. After 10 more doses, all symptoms resolved, and weight increased from 40 kg to 48 kg.
A physician asked: Why did Zisheng Wan (Zisheng Pill), Shenling Baizhu San (Ginseng, Poria and Atractylodes Macrocephala Powder), Fuzi Lizhong Tang (Aconite and Middle-Warming Decoction), and Lizhong Dihuang Tang fail? The answer is: The disease had entered the Blood level, but treatment addressed only the Qi level (Qifen). Shaofu Zhuyu Tang (Lower Abdomen Blood-Stasis Expelling Decoction) is used now to warm meridians and invigorate blood. Another question: Why did previous blood-invigorating/stasis-expelling herbs fail? The answer is: Distinction between cold and heat. Previous prescriptions focused on heat due to bloody stools; this case presents foul/sticky stools indicating cold. Heat requires cooling herbs; cold requires warming herbs. Switching from cooling to warming led to recovery.
Constipation
1. Cold-warmth Qi stagnation impairs transformation; using cold-moistening methods exacerbates constipation.
Patient Sun XX, female, 23 years old.
Chronic constipation since childhood. Before age 4-5, Qizhen Dan (Seven-Treasure Pill) worked well. By age 7-8, it became ineffective. Western laxatives worked initially but failed by age 10. Niuhuang Jiedu Wan (Calculus Bovis Detoxification Pill) or Fanxieye (Sennae Folium) were added but failed by age 12. Da Chengqi Tang (Major Order the Qi Decoction) with Dahuang 15g and Mangxiao (Natrii Sulfas) 30g every 3 days was tried but lost efficacy after 6 months. Adding Roucongrong (Cistanches Herba), Shengdi, Yuanshen (Scrophulariae Radix), Danggui, and Huomaren (Cannabis Semen) helped gradually. By age 18, these methods failed, leading to enemas every 4 days for 4 years. Recently, even with enemas and medication, minimal stool passage occurs after nearly two days. Examination: Epigastric/abdominal fullness/discomfort, thin-white tongue coating, deep-wiry-tight pulse. Analysis: Deep pulse indicates Qi depression; wiry indicates Liver/Gallbladder/Sanjiao (Triple Burner) involvement; tight indicates cold-damp coagulation. Pathogenesis: Cold-damp stagnation in the Sanjiao, preventing ascending of clear Qi and descending of turbid Qi. Treatment: Regulate Qi, unblock Yang, resolve dampness. Prescription: Muxiang (Aucklandiae Radix) 10g, Xiangfu (Cyperi Rhizoma) 20g, Sharen (Amomi Fructus) 10g, Laifuzi (Raphani Semen) 10g, Banxia 10g, Chenpi 10g, Fuling (Poria) 10g, Gancao 6g, Zhishi (Aurantii Fructus Immaturus) 10g, Baizhu 10g, Shenqu (Massa Medicata Fermentata) 10g, Suye (Perillae Folium) 3g.
After 2 doses, bowel movements occurred every 4 days without laxatives, and abdominal fullness decreased. After 1 month of continued use, bowel movements normalized to once daily. Follow-up for one year showed normal function.
A physician asked: Why did long-term purging/moistening fail while Qi-regulating herbs succeeded? The answer is: Constipation is often due to intestinal heat or blood/fluid deficiency, leading physicians to use Chengqi Tangs or Runchang Wan (Intestine-Moistening Pill). However, chronic constipation can stem from Qi stagnation or internal Yin-cold/cold-damp impairing intestinal motility. Long-term use of bitter-cold/sweet-cold/salty-cold herbs damages Spleen/Stomach/Intestinal Yang, generating internal cold-damp. Further use of cold-moistening herbs further injures Yang. Thus, pungent-warm/bitter-warm herbs are needed to remove cold-damp and move Qi.
2. Liver-Stomach Qi stagnation and pivot dysfunction; failing to regulate the pivot and relying solely on purging leads to non-cure.
Patient Jiao XX, male, 58 years old.
For 3-4 years, infrequent bowel movements. Western laxatives worked initially but failed over the past 2 years. Chinese moistening/laxative herbs provided temporary relief but failed recently. Over the last 10 days, Da Chengqi Tang, Zengye Chengqi Tang (Fluid-Increasing Order the Qi Decoction), Huanglong Tang (Yellow Dragon Decoction), and enemas were ineffective. Examination: Dizziness/headache, irritability/insomnia, bitter taste/dry throat, intermittent abdominal pain, white tongue coating, deep-wiry-tight pulse. Analysis: Deep pulse indicates depression; wiry indicates Shaoyang (Lesser Yang) pivot dysfunction; tight indicates cold-damp stagnation. Diagnosis: Shaoyang pivot dysfunction, upper heat/lower cold, impaired intestinal transport. Treatment: Harmonize Shaoyang, regulate the pivot. Prescription: Chaihu 9g, Huangqin 9g, Dangshen 9g, Banxia 9g, Guizhi (Cinnamomi Ramulus) 9g, Fuling 9g, Chenpi 9g, Dahuang 3g, Dazao 5 pieces, Gancao 6g, Shengjiang (Zingiberis Rhizoma Recens) 3 slices, Longgu (Fosssilia Ostei Mastodi et Ossis Femoris) 15g, Muli (Ostreae Concha) 15g.
After 1 dose, bowel movement occurred; after 6 doses, other symptoms resolved. Bowel movements gradually normalized.
A physician asked: Dahuang is the best laxative; why did 30g fail while 3g succeeded? The answer is: Dahuang is indeed a potent purgative. However, this case's focus is not Fu-organ excess (Fushi) but Shaoyang pivot dysfunction and upper heat/lower cold. When Shaoyang pivot is dysfunctional, Zhang Zhongjing advises against purging to prevent excessive descent of Yang Qi. Previous formulas were descending; adding more descending herbs would further impair the pivot's rotating power, preventing clear Qi from ascending and turbid Qi from descending. Using a small amount of descending herb alongside ascending herbs restores the pivot's rotation.
3. Cold-damp stagnation and Yang Qi failure to transform; using bitter-descending methods damages Yang Qi.
Patient Zhao XX, female, 13 years old.
Chronic constipation since age 1. Bowel movements every 3-8 days, requiring medication. High intake of fruits/honey was used but became ineffective over the past year. For the last 3+ months, daily abdominal distension/pain, fatigue necessitated alternate-day enemas, yet normal defecation remained impossible. Examination: No bowel movement for 10 days, abdominal distension/pain, inability to eat, shortness of breath/reluctance to speak, sallow complexion, pale-dark tongue body, thin-white coating, deep-thin-wiry pulse. Analysis: Deep pulse indicates Qi stagnation; thin-wiry indicates cold-damp stagnation. Cold-damp-Qi stagnation prevents Yang transformation; failure to ascend clear Qi prevents descending of turbid Yin, blocking Fu Qi. Treatment: Warm Yang, regulate Qi, resolve dampness, harmonize Middle. Prescription: Houpo 10g, Chenpi 10g, Gancao 6g, Caodoukou (Alpiniae Katsumadai Semen) 10g, Muxiang 6g, Ganjiang 6g, Rougui 6g, Dahuang 1g.
After 1 dose, two bowel movements occurred; after 3 doses, normalization to once daily. After intermittent use of 30 doses, pain/fullness resolved, appetite and bowel movements normalized.
A physician asked: Why did Dahuang 15g and Mangxiao 10g cause nausea and no relief, while Dahuang 1g succeeded? The answer is: As stated, constipation here is due to cold-damp and Yang failure. Large doses of bitter-cold/salty-cold worsen obstruction and reduce appetite. Dahuang 1g works because it assists the warming/damp-resolving formula with a slight descending action.
4. Phlegm-damp stagnation; using purging/moistening worsens phlegm-damp and impairs transformation.
Patient Wu XX, female, 58 years old.
Chronic constipation for 30+ years. Western and Chinese moistening/purging treatments were ineffective. Examination: Bowel movements every 5-10 days, anorexia/abdominal distension, white tongue coating, deep-slow pulse. Analysis: Deep pulse indicates Qi stagnation; slow pulse indicates Spleen deficiency with phlegm-damp accumulation. Diagnosis: Phlegm-damp stagnation. Treatment: Regulate Qi, resolve phlegm. Reference: Danxi's Runxia Wan uses only Chenpi and Gancao. Wang Ang's *Tangtou Gejue* praises it for regulating Qi and resolving phlegm. Formula prepared as decoction: Chenpi 40g, Gancao 10g.
After 1 dose, bowel movement occurred; after 1 more dose, follow-up for half a year showed normal bowel movements.
5. Yang deficiency with damp stagnation; using cold purging damages Yang; Qi deficiency fails to move; Yang failure persists, worsening constipation.
Patient Guo XX, female, 40 years old.
For 30 years, bowel movements every 3-5 days. To manage frequency and pain, high fruit/honey intake and daily Western laxatives were used for 20+ years. Recently, frequency dropped to every 7-8 days, requiring Da Chengqi Tang the day before and enemas/opening suppositories on the day of defecation. Examination: Constipation, epigastric/abdominal distension, sallow complexion, pale-dark tongue body, thin-white coating, large-wiry-tight pulse. Analysis: Da Chengqi Tang is for severe heat accumulation. Wu Jutong's *Wenbing Tiaobian* states: "Chengqi inherits Stomach Qi... Dahuang clears heat knots, Mangxiao softens hardness, Zhishi opens the pylorus, Houpo empties the center. It is called 'Great' because it breaks all resistance. It should not be used unless there is true excess-heat binding with Qi/Blood clotting." Also, "If purging fails in Yangming Warm Disease, five patterns exist... New Huanglong Tang for deficiency unable to move medicine... Xuanbai Chengqi Tang for lung Qi failing to descend... Daochi Chengqi Tang for lower jiao heat... Niuhuang Chengqi Tang for heart orifice blockage... Zengye Chengqi Tang for fluid insufficiency." Here, unlike Warm Diseases involving fluid damage, this chronic disease involves Yang damage. Large-wiry-tight pulses indicate severe Yang deficiency/cold. Inability to move medicine is due to Yang deficiency, exacerbated by long-term cold herbs. Treatment: Warm-tonify Spleen/Stomach Yang, assist with Qi-regulating and bowel-moving herbs. Prescription: Fuzi (Aconiti Lateralis Radix Praeparata) 10g, Dangshen 10g, Rougui 10g, Baizhu 10g, Gancao 10g, Ganjiang 10g, Zhishi 6g, Houpo 6g, Dahuang 2g.
After 1 dose, three loose bowel movements occurred next day; after 6 doses, follow-up for 4 months showed daily normal bowel movements.
6. Qi deficiency with damp stagnation, failure of ascending/descending functions; using cold-descending methods destroys generating Yang, preventing medicine movement, leading to chronic constipation.
Patient Du XX, male, 49 years old.