经义
北方黑色，入通于肾，开窍于二阴。○脉盛，身热，腹胀，前后不通，闷瞀，此谓五实。身汗得后利，
则实者活。○热气留于小肠，肠中热，瘅热焦渴，则坚干不得出，故痛而闭不通也。○阳不胜其阴，则五脏气争，
九窍不通。（《素问》）
哲言
一日一便为顺，三、四日不便为秘，一日便三、四次为利。（《医学入门》）
仲景云∶脉有阳结阴结者，何以别之？曰其脉浮而数，能食不大便者，此为实，名曰阳结。其脉沉而迟，
不能食，身体重，大便反硬，名曰阴结。实秘、热秘，即阳结也。虚秘、冷秘，即阴结也。（《证治准绳》）
实秘者，秘物也；虚秘者，秘气也。（张洁古）
秘结一证，在古方书有虚秘、风秘、气秘、热秘、寒秘、湿秘等证，东垣又有热燥、风燥、阳结、阴结
之说。立言太烦，徒滋疑惑，不知此证之当辨者惟二，则曰阴结、阳结而尽之矣。盖阳结者，邪有余也，宜攻宜
泻；阴结者，正不足也，宜补宜滋。知斯二者，即知其纲领矣。欲究其详，则凡云风秘者，盖风未必能秘，但
风胜则燥，而燥必由于火，热则生风，即阳结也。岂谓因风而宜散乎？有云气闭者，盖气有虚实，气实者，阳
有余，即阳结也；气虚者，阳不足，即阴结也。岂谓因气而宜破乎？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，气之不行，即虚秘也，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。（张景岳）
凡人大便秘结，皆由房劳过度、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，以致阴虚而血耗，火盛水亏，津液不生，故传道失职，渐成燥结之证。又有年高血少，津液枯涸；或
因有所脱血，津液暴竭；或新产之妇，气血虚耗，以致肠胃枯涩；或体虚之人，摄养乖方，三焦气涩，运化不
行，而肠胃壅滞，遂成秘结。惟当养血滋阴，滑涩润燥，不可妄用通利，恐伤元气，耗散真阴，则秘结愈甚也。
（《医学正传》）
浊气在上，则填实肺气，肺不能行降下之令，故大便闭。（周慎斋）
内伤大便不通，月余亦不欲去，饮食至多而皆化者，以五脏六腑悉皆燥火，水谷被火销烁，直待久久，脾
气渐旺，邪气渐衰，始成糟粕。须至糟粕欲去而不能，可润大肠以导之。（查了吾）
阴血外溢则为汗，阴血下润则便通。（《己任编》）
凡小便闭而大便通调者，或膀胱热结，或水源不清，湿证居多。若大便闭而小便通调者，或二肠气滞，或
津液不流，燥证居多。若二便俱闭，当先通大便，小溲自利。（《临证指南》）
补编
少阴不得大便，以辛润之；太阴不得大便，以苦泄之。阳结者清之，阴结者温之，气滞者疏导之，津少者
滋润之。大抵以养血清热为先，急攻通下为次。（《证治汇补》）
秘结之由，除阳明热结之外，则悉由乎肾。盖肾主二阴而司开阖，故大小便不禁者，其责在肾。然则不通
者，独非肾乎？故肾热者，宜凉而滋之；肾寒者，宜温而滋之；肾虚者，宜补而滋之；肾干燥者，宜润而滋之。
《经》曰∶肾苦燥，急食辛以润之。开腠理，致津液，通气也。○阳结，必因邪火有余，以致津液干燥。或以
饮食之火起于脾，酒色之火炽于肾，时令之火蓄于
脏。凡因暴病年壮气实之人，有火证火脉相符者，方是阳结，治当察其微甚。邪结甚者，非攻不可。○阴结有
二∶一以阳虚，一以阴虚也。凡下焦阳虚，则阳气不行，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，津液不致而肠脏干槁，此阴虚而阴结也。治阳虚而阴结者，但益其火，则阴凝自化；治阴虚而阴
结者，但壮其水，则泾渭自通。二者欲其速行，于前法中各加肉苁蓉二、三钱，其效尤速。（张景岳）
《经》曰∶北方黑色，入通于肾，开窍于二阴。则知大便秘结，专责少阴一经。证状虽殊，总之津液枯
干，一言以蔽之也。分而言之，则有胃实、胃虚、热秘、冷秘、风秘、气秘之分。胃实秘者，善饮食，小便赤；
胃虚秘者，不能饮食，小便清利；热秘者，面赤身热，六脉数实，肠胃胀闷，时欲得冷；冷秘者，面白或黑，
六脉沉迟，小便清白，喜热恶冷；气秘者，气不升降，谷气不行，其人多噫；风秘者，风搏肺脏，传于大肠。
更有老年津液干枯，妇人产后亡血，及发汗利小便，病后血气未复，皆能秘结。法当补养气血，使津液生则便
自通，误用硝黄，多致不救。若病虽属阴寒，而脉实微躁者，宜温药中略加苦寒以去热燥，或煎理中汤冷服；
不应，宜蜜煎导之。冷秘者，酱生姜导之；热秘者，猪胆汁导之；虚秘者，煮猪血脏汤加酥食之，血仍润血，
脏仍润脏，此妙法也。（《医宗必读》）
东垣云∶肾主五液，津液盛则大便如常。若饥饱劳役，损伤胃气，及食辛热浓味，而助火邪，伏于血中，
耗散真阴，津液亏少，故大肠结燥。又有老年气虚，津液衰少而结燥者。肾恶燥，急食辛以润之是也。予尝法
东垣之论，不用东垣之方，惟用六味丸料，兼气虚者内加参、 ，此因气虚不能推送，血虚不能濡润故耳。或
问∶何不用四物汤？曰∶四物汤特能补血耳。此是先天津液不足，故便难。《经》曰∶肾主五液。津液皆肾水
所化，与血何干？或又曰∶如干结之甚，硝黄亦可暂用否？曰∶承气汤用
硝、黄，乃为伤寒从表入里，寒变为热，热入三阴，恐肾水干枯，故用硝、黄以逐外邪，急救肾水。老人、虚
人及病后人，肾水原不足，以致干枯，若再用硝、黄下之，是虚其虚也。今日虽取一时之快，来日必愈结，再
下之，后日虽铁石亦不能通矣。（赵养葵）
肠痹，较之燥矢坚结欲便不通者稍缓，但开降上焦肺气，上窍开泄，下窍自通矣。若燥矢坚闭，则有用三
承气、润肠丸、通幽汤之类。然伤寒急下之条无几，余皆六淫之邪病后而成者为多，斯时胃气未复，元气已虚，
下药难进，莫若外用导法为稳。○按∶大便不通，有血液枯燥者，则用养血润燥；若血燥风生者，则用辛甘熄风，
或酸苦入阴，如三才、五仁、通幽等法；若血液燥而气亦滞，致气血结痹者，又当于养阴润燥剂中酌加行气活
血之品；若火腑秘结，宜苦滑重镇者，用更衣丸；老人阳衰风闭，用半硫丸；腑阳不行，则用玉壶丹；阳窒阴
凝，清浊混淆痞胀者，则用来复丹；若郁热阻气，则用苦寒泄热，辛以开郁，或用三焦通法；若湿热伤气，阻
遏经腑者，则理肺气以开降之。○大便燥结，本有承气汤、更衣丸下之，外用猪胆、蜜煎导之，可谓无遗蕴矣。
然竟有效有不效者，盖因燥粪未尝不至肛门，奈肛门如钱大，燥粪如拳大，纵使竭力努挣，终不肯出，下不得
出，则上不能食而告危矣。余友教人先以胆汁或蜜煎导之，俟粪既至肛门，令病者以中指染油，探入肛内，将
燥粪挖碎而出，竟有一次燥粪挖作百余块而出者。此法辗转救人多矣，勿嫌秽而弃之。（《临证指南》）
大便欲去不去，或着而不出，气虚；了而不了，血虚。俱宜补中。里急后重，初起皆属于热，日久作虚治
之。（周慎斋）
世人但知热秘，不知冷秘。冷秘者，冷气凝结，津液不通，如天寒地冻，水结成冰之义，治宜八味丸、半
硫丸温而通之。（张洁古）
桃、杏仁俱治大便秘，当以血气分之。昼则便难行，阳气也，宜用杏仁；夜则便难行，阴血也，宜用桃仁。
（王海藏）
古方通大便，皆用降气之剂，盖肺气不降，则大便难于传送，
用杏仁、枳壳、沉香等是也。老人、虚人、风人，津液少而秘者，宜以药滑之，用麻仁、芝麻、阿胶等是也。
若妄以峻剂逐之，则津液走，气血耗，虽暂通而复秘，更生他病矣。（朱丹溪）
有病大小便秘者，用通利药而罔效，重加升麻而反通。（《医方集解》）
古方治老人燥结，多用苁蓉，不知胃气虚者，入口即作呕吐，肥人胃多痰湿，尤非所宜。惟命门火衰，开
阖失职者，方为合剂。然须丸服，作汤亦必作吐，以其味咸气浊也。○猪胆导，非伤寒邪热不可轻试。胃气虚者
用之，往往有呃逆之虞。（《张氏医通》）
脉候
便闭脉多沉伏，阳结沉数，阴结沉迟；风燥则浮，血燥则洪。老人、虚人便秘，脉见雀啄者不治。（《脉诀》）
选案
一儒官初患小便时闭，服五苓散、八正散不效。医诊尺脉俱无，作下元虚涸，用八味丸，服之三日，大便
亦闭，渴干烦满。又用脾约丸、润肠丸，小便点滴，大便连闭十日，腹满难禁。众议承气下之，微利随闭，更
加少腹胀痛。复投舟车丸，日利数次，里急后重，粪皆赤白，如此半月，日夜呻吟，惟饮米汤盂许。余诊两寸
沉伏有力，两关洪缓无力，两尺不见。谓曰∶关尺无恙，病在膈上，此思虑气秘病也。进越鞠汤，一服嗳气连
声，再服二便若倾，所下皆沉积之物，浑身稠汗；进姜汤一盏，熟睡就榻；次早复诊，六脉和均，调理数日全
愈。一士夫问曰∶吾友病，众皆以为尺脉无根，君独以为尺脉得体；众皆曰痢疾，君独曰气秘；且便闭其病在
下，用下部药者近理，君反以上部药取效，何也？余曰∶人身之病，上下表里，虽有不同，不过一气为之流通
耳。气之通塞，又于脉辨之。今两尺皆无，众泥《经》文，谓如树之无根矣，不知今年己卯，燥金司天，君火
在泉，君火不行令，两尺当不应，若尺盛于寸，则为反矣。《经》曰∶尺寸反者死。岂
八味丸所能治乎？里急后重，赤白相杂，似乎滞下，但滞下之脉，见于两关，今关脉不浮不紧不数，明非滞下，
误用承气等药，元气更伤，而病愈增也。病原由于上焦气秘，以至下窍不通。盖心肺居上，两寸当浮，今不浮
而沉，下手脉沉便知是气，气郁不行，则升降失职，譬如注水之器，闭其上窍，则下窍不通，水安从出？乃不
治上而专治下，攻之愈急，则气愈陷，二便何由而利耶？予用越鞠汤，使上窍一通，则下窍随开，里气一顺，
则表气自畅，是以周身汗出，二便俱利，所谓一通百通也。气秘者，病之本；便闭者，病之标。惟治其本，故
效速也。（易思兰）
刘泰来新秋病疟，用药截住，遂觉胸腹胀满，不旬日腹大胸高，上气喘急，二便全无，食饮不入，能坐
不能卧，能俯不能仰。医以下药不应，商用大黄二两作一剂服，余骇曰∶此名何病，而敢放胆杀人耶？！医曰∶
伤寒肠结下而不通，惟有大下一法。余曰∶世间有不发热之伤寒乎？伤寒发热，津液枯槁，肠胃干结，故用下
药以开其结。然有不转失气不可攻之戒，正恐误治太阴之腹胀也。此因腹中之气散乱不收，水津随气横决四溢
而作胀，全是太阴脾气不能统摄所致。一散一结，相去天渊，再用大黄猛剂大散其气，若不胀死，定然腹破。
遂以大剂理中汤少加黄连与服，疾势略减。次日，病者问药，予曰∶腹中原是大黄推荡之泄粪，其所以不出者，
以膀胱胀大，腹内难容，将大肠撑紧，任凭极力努挣，无隙可出。看吾以药通膀胱之气，不治大便而大便自至，
足为证验。于是用五苓散本方，药才入喉，病者即索秽桶，小便先去，大便随之，顷刻泄下半桶。观者动色，
竞称华佗再出，然亦非心服也。余恨不能分身剖心，实无居功之意也。（《寓意草》）
吴章成弟，发热闷乱，大便不通，医作外感治。予曰∶此得之伤食，因发散太过，遂成虚热。风药燥血，
故不便耳。以六味汤加肉苁蓉饮之，下黑矢十数枚，诸病悉除。（《己任编》）
江蕃仲病后便秘，医以润剂不效，改用元明粉、大黄亦不效，更服补中升提之剂，胀闷难忍。予与熟地、
元参各二两，麦冬一两，五味子一钱，火麻子二钱，煎好冲牛乳一碗服之，随手而应。此肾家真水干涸，不可
以有形之阴阳治之也。（程华仲）
一妇大便燥结，小便淋涩，半生不娠，常服疏导药则大便通利，废药则结滞。续得孕四、五月，医禁疏导，
大便为难，圊则努力，胎坠者三。又孕四月，溲溺结涩，自分胎陨，乃访戴人。诊脉滑大，以其孕不敢陡攻，
遂以食疗之，用花碱煮菠菱、葵菜、车前子苗作茹，猪、羊血作羹，食之半载，生子，燥病亦愈。（张子和）
【经义】
北方对应黑色，内通于肾，外开窍于前后二阴。○脉象盛大，身体发热，腹部胀满，大小便不通，胸闷烦乱，这称为“五实”。如果身体出汗且大小便通畅，那么实证患者就有生机。○热气停留于小肠，肠中热盛，灼热焦渴，导致大便坚硬干燥无法排出，所以出现疼痛且闭塞不通的症状。○阳气不能胜过阴气，则五脏之气相互争逆，九窍就会不通畅。（《素问》）
【哲言】
一天排便一次为正常，三、四天不排便是便秘，一天排便三、四次为泄利。（《医学入门》）
张仲景说：脉象有阳结和阴结的区别，如何辨别呢？回答说：脉象浮而数，能进食但大不便秘的，这是实证，名叫阳结。脉象沉而迟，不能进食，身体沉重，大便反而硬结的，名叫阴结。实证便秘、热证便秘，就是阳结。虚证便秘、冷证便秘，就是阴结。（《证治准绳》）
实证便秘，是指有形之邪积滞；虚证便秘，是指无形之气不足。（张洁古）
关于便秘这一病症，在古代医书中分为虚秘、风秘、气秘、热秘、寒秘、湿秘等证型，李东垣又提出了热燥、风燥、阳结、阴结的说法。立论过于繁杂，徒增疑惑，不知道此证应当辨别的只有两点，即阴结和阳结，概括无余了。所谓阳结，是邪气有余，适宜攻下泻实；阴结，是正气不足，适宜补益滋润。懂得这两点，就掌握了纲领。若要探究详情，凡是说风秘的，大概风未必直接导致便秘，只是风胜则生燥，而燥必由于火，热极生风，这就是阳结。难道认为因风而适宜发散吗？有说气闭的，气有虚实之分，气实的，是阳气有余，即阳结；气虚的，是阳气不足，即阴结。难道认为因气而适宜破气吗？至于热秘、寒秘，也不过是阴阳的别名罢了。再如湿秘之说，湿气岂能直接导致便秘，只是湿气不化，源于气机不行，气机不行，即是虚秘，也属于阴结。总之，有火的便是阳结，无火的便是阴结。以此辨别，难道不是清清楚楚吗。（张景岳）
大凡人体大便秘结，多由房事过度、饮食不节制，或者肆意饮酒浆、过食辛辣温热之物引起。饮食之火，起于脾胃；淫欲之火，起于命门，导致阴虚而血耗损，火盛水亏，津液不生，因此传导失职，逐渐形成燥结之证。又有年高之人血液稀少，津液枯涸；或者因为失血，津液突然枯竭；或者是刚生产完的妇女，气血虚耗，导致肠胃枯涩；或者是体质虚弱的人，调养不当，三焦气机涩滞，运化不行，致使肠胃壅滞，遂成便秘。只应当养血滋阴，滑涩润燥，不可妄用通利药物，恐怕损伤元气，耗散真阴，那么便秘会更加严重。（《医学正传》）
浊气停留在上部，就会填塞肺气，肺不能行使降下的命令，所以大便闭塞。（周慎斋）
内伤导致的大便不通，即使一个月也不想解手，饮食最多也只能消化一部分，这是因为五脏六腑都充满了燥火，水谷被火销烁，直待时间久了，脾气逐渐旺盛，邪气逐渐衰退，才形成糟粕。必须等到糟粕想排却排不出时，可以润大肠以引导它。（查了吾）
阴血向外溢出则为汗，阴血向下滋润则大便通畅。（《己任编》）
凡是小便闭塞而大便通调的，或是膀胱热结，或是水源不清，多为湿证。如果大便闭塞而小便通调的，或是大小肠气机阻滞，或是津液不流动，多为燥证。如果大小便都闭塞，应当先通大便，小便自然通利。（《临证指南》）
【补编】
少阴经不得大便，用辛味润燥之法；太阴经不得大便，用苦味泄下之法。阳结者清泄之，阴结者温补之，气滞者疏导之，津液少者滋润之。大抵以养血清热为先，急攻通下为次。（《证治汇补》）
便秘的原因，除了阳明热结之外，全都归因于肾。因为肾主司前后二阴并掌管开阖，所以大小便失禁的，责任在肾。那么不通畅的，难道独独不在肾吗？所以肾热的，宜凉而滋之；肾寒的，宜温而滋之；肾虚的，宜补而滋之；肾干燥的，宜润而滋之。《内经》说：肾恶燥，急食辛以润之。意思是开启腠理，输送津液，流通气机。○阳结，必定是因为邪火有余，导致津液干燥。或者因为饮食之火起于脾，酒色之火炽于肾，时令之火蓄于脏。凡是因突发疾病、年轻体壮、气实之人，有火证与火脉相符的，才是阳结，治疗应当考察其轻重。邪结严重的，非攻下不可。○阴结有两种：一是阳虚，一是阴虚。凡是下焦阳虚，则阳气不行，不能传送而阴凝于下，这是阳虚导致的阴结。下焦阴虚，则精血枯燥，津液不到而肠脏干槁，这是阴虚导致的阴结。治疗阳虚而阴结的，只需益火，则阴凝自化；治疗阴虚而阴结的，只需壮水，则泾渭自通。二者想要见效快，在前法中各加肉苁蓉二、三钱，效果尤其迅速。（张景岳）
《内经》说：北方黑色，内通于肾，外开窍于二阴。由此可知大便秘结，专门责之于少阴一经。症状虽然不同，总之是津液干枯，一言以蔽之。分而言之，则有胃实、胃虚、热秘、冷秘、风秘、气秘之分。胃实秘的，善于饮食，小便赤黄；胃虚秘的，不能饮食，小便清利；热秘的，面赤身热，六脉数实，肠胃胀闷，时常想要冷饮；冷秘的，面白或黑，六脉沉迟，小便清白，喜热恶冷；气秘的，气不升降，谷气不行，其人常打嗝；风秘的，风邪搏结肺脏，传于大肠。更有老年人津液干枯，妇人产后亡血，以及发汗利小便后，病后气血未恢复，都能导致便秘。治法应当补养气血，使津液生成则大便自然通畅，误用硝石、大黄，多导致不治。如果病虽属阴寒，但脉象实而微躁动的，宜在温药中略加苦寒以去热燥，或者煎煮理中汤冷服；无效，宜用蜜煎导法。冷秘的，用酱生姜导法；热秘的，用猪胆汁导法；虚秘的，煮猪血脏汤加酥油食用，血仍润血，脏仍润脏，这是妙法。（《医宗必读》）
李东垣说：肾主五液，津液盛则大便如常。如果饥饱劳役，损伤胃气，以及吃辛辣浓味食物，助长火邪，伏于血中，耗散真阴，津液亏少，所以大肠结燥。又有老年人气虚，津液衰少而结燥的。肾恶燥，急食辛以润之，就是这个道理。我曾经效法李东垣的理论，但不使用他的方子，只用六味丸料，兼气虚者加入人参、（此处原文缺字，推测为白术或类似补气药），这是因为气虚不能推送，血虚不能濡润的缘故。有人问：为什么不用四物汤？回答说：四物汤只能补血而已。这是先有津液不足，所以排便困难。《内经》说：肾主五液。津液都是肾水所化，与血有什么关系？又有人说：如果干结得很厉害，硝石、大黄也可以暂时使用吗？回答说：承气汤用硝、黄，是为了伤寒从表入里，寒变为热，热入三阴，恐怕肾水干枯，所以用硝、黄来驱逐外邪，急救肾水。老人、虚人及病后人，肾水原本不足，以致干枯，如果再使用硝、黄攻下，这是虚其虚。今天虽然取得一时的痛快，明天必然更加结滞，再攻下，后天即使是铁石也不能通了。（赵养葵）
肠痹，比之燥屎坚结欲便不通的情况稍缓，只要开降上焦肺气，上窍开泄，下窍自然通畅。如果是燥屎坚闭，则有使用三承气汤、润肠丸、通幽汤之类的。然而伤寒急下的条文很少，其余多是六淫之邪病后形成的，此时胃气未复，元气已虚，下药难进，不如外用导法为稳妥。○按：大便不通，有血液枯燥的，则用养血润燥；若血燥风生的，则用辛甘熄风，或酸苦入阴，如三才、五仁、通幽等法；若血液燥而气亦滞，致气血结痹的，又应当在养阴润燥剂中酌加行气活血之品；若火腑秘结，宜用苦滑重镇的，用更衣丸；老人阳衰风闭，用半硫丸；腑阳不行，则用玉壶丹；阳窒阴凝，清浊混淆痞胀的，则用来复丹；若郁热阻气，则用苦寒泄热，辛以开郁，或用三焦通法；若湿热伤气，阻遏经腑的，则理肺气以开降之。○大便燥结，本有承气汤、更衣丸下之，外用猪胆、蜜煎导之，可谓没有遗漏了。然而竟然有效有不效的，大概因为燥粪未尝不至肛门，无奈肛门如铜钱大，燥粪如拳头大，纵使竭力努挣，终不肯出，下不得出，则上不能食而告危矣。我的朋友教人先用胆汁或蜜煎导之，等到粪已到肛门，让病人用中指沾油，探入肛内，将燥粪挖碎而出，竟有一次将一块燥粪挖作百余块而出的。此法辗转救人很多，不要嫌秽恶而抛弃它。（《临证指南》）
大便想排排不出，或者附着不出，是气虚；拉完了却没拉干净，是血虚。都适宜补中益气。里急后重，初起都属于热，日久当作虚证治疗。（周慎斋）
世人只知道热秘，不知道冷秘。冷秘的，冷气凝结，津液不通，如同天寒地冻，水结成冰的道理，治疗宜用八味丸、半硫丸温而通之。（张洁古）
桃仁、杏仁都治大便秘，应当以血气区分。白天排便困难，属阳气，宜用杏仁；晚上排便困难，属阴血，宜用桃仁。（王海藏）
古方通大便，都用降气之剂，因为肺气不降，则大便难于传送，用杏仁、枳壳、沉香等就是这类。老人、虚人、风人，津液少而便秘的，宜以药滑之，用麻仁、芝麻、阿胶等就是这类。如果妄用峻剂逐之，则津液走泄，气血耗散，虽然暂时通畅但又便秘，更生他病了。（朱丹溪）
有病人大小便秘的，用通利药无效，重加升麻反而通畅。（《医方集解》）
古方治老人燥结，多用肉苁蓉，不知道胃气虚的，入口即作呕吐，肥胖的人胃多痰湿，尤其不适合。只有命门火衰，开阖失职的，才适合服用。而且必须丸服，作汤剂也会作呕，因为其味咸气浊的缘故。○猪胆导法，非伤寒邪热不可轻试。胃气虚者使用，往往有呃逆的担忧。（《张氏医通》）
【脉候】
便秘的脉象多沉伏，阳结脉沉数，阴结脉沉迟；风燥则脉浮，血燥则脉洪。老人、虚人便秘，脉见雀啄脉的，预后不良，难以治愈。（《脉诀》）
【选案】
一位儒官起初患小便时闭，服用五苓散、八正散无效。医生诊察尺脉俱无，诊断为下元虚涸，用八味丸，服用三天后，大便也闭塞，口渴烦躁胀满。又用脾约丸、润肠丸，小便点滴，大便连续闭塞十日，腹满难忍。众人议论用承气汤攻下，轻微通便随即又闭，更加少腹胀痛。再次投予舟车丸，每天腹泻数次，里急后重，粪便皆赤白相间，如此半月，日夜呻吟，只喝少许米汤。我诊察两寸脉沉伏有力，两关脉洪缓无力，两尺脉不见。我说：关尺无恙，病在膈上，这是思虑导致的气秘病。进服越鞠汤，一服后嗳气连连，再服后二便如倾泻般通畅，所下的都是沉积之物，浑身出稠汗；进服姜汤一盏，熟睡至榻；次日早晨复诊，六脉和均，调理数日后痊愈。一位士大夫问：我的朋友生病，众人都认为尺脉无根，唯独您认为尺脉得体；众人都说是痢疾，唯独您说是气秘；而且便闭的病在下部，用下部药合乎情理，您反而用上部药取效，为什么呢？我说：人身上的病，上下表里，虽然有不同，不过是一气在流通罢了。气的通塞，又在脉象上辨别。现在两尺脉都没有，众人拘泥于《内经》经文，说像树没有根一样，不知道今年己卯年，燥金司天，君火在泉，君火不行令，两尺脉应当不应，如果尺脉盛于寸脉，则是反脉。《内经》说：尺寸反者死。难道是八味丸所能治的吗？里急后重，赤白相杂，似乎滞下（痢疾），但滞下的脉，见于两关，现在关脉不浮不紧不数，明非滞下，误用承气等药，元气更伤，而病愈加重。病原是由于上焦气秘，以至下窍不通。心肺居上，两寸脉应当浮，现在不浮而沉，下手摸到脉沉就知道是气病，气郁不行，则升降失职，譬如注水的器具，闭上上窍，则下窍不通，水从哪里出来？乃是不治上而专治下，攻之愈急，则气愈陷，二便何由而利耶？我用越鞠汤，使上窍一通，则下窍随开，里气一顺，则表气自畅，是以周身汗出，二便俱利，所谓一通百通也。气秘者，病之本；便闭者，病之标。惟治其本，故效速也。（易思兰）
刘泰来新秋患疟疾，用药截断疟疾后，遂觉胸腹胀满，不到十天腹大胸高，上气喘急，大小便全无，饮食不入，能坐不能卧，能俯不能仰。医生以下药无效，商人用大黄二两作一剂服用，我惊骇地说：这是什么病，敢放胆杀人吗！医生说：伤寒肠结下而不通，只有大下一法。我说：世间有不发热的伤寒吗？伤寒发热，津液枯槁，肠胃干结，所以用下药以开其结。然而有“不转失气不可攻”的戒律，正是怕误治太阴之腹胀。这是因为腹中之气散乱不收，水津随气横决四溢而作胀，全是太阴脾气不能统摄所致。一散一结，相去天渊，再用大黄猛剂大散其气，若不胀死，定然腹破。于是用大剂理中汤少加黄连与服，疾势略减。第二天，病人问药，我说：腹中原是大黄推荡之泄粪，之所以不出，是因为膀胱胀大，腹内难容，将大肠撑紧，任凭极力努挣，无隙可出。看我以药通膀胱之气，不治大便而大便自至，足为证验。于是用五苓散本方，药才入喉，病人即索秽桶，小便先去，大便随之，顷刻泄下半桶。旁观者动容，竞称华佗再出，然而我也并非心服居功之意。（《寓意草》）
吴章成的弟弟，发热闷乱，大便不通，医生作为外感治疗。我说：这是得之伤食，因发散太过，遂成虚热。风药燥血，所以不便。用六味汤加肉苁蓉饮之，下黑矢十数枚，诸病悉除。（《己任编》）
江蕃仲病后便秘，医生用润剂无效，改用元明粉、大黄也无效，更服补中升提之剂，胀闷难忍。我给熟地、元参各二两，麦冬一两，五味子一钱，火麻子二钱，煎好冲牛乳一碗服之，随手而应。这是肾家真水干涸，不可以有形之阴阳治之也。（程华仲）
一位妇人大便燥结，小便淋涩，半生不孕，常服疏导药则大便通利，停药则结滞。续得孕四、五月，医生禁止疏导，大便为难，上厕所用力，胎坠者三次。又孕四月，溲溺结涩，自己认为胎陨，于是访戴人。诊脉滑大，以其怀孕不敢陡攻，遂以食疗之，用花碱煮菠菜、葵菜、车前子苗作茹，猪、羊血作羹，食之半载，生子，燥病亦愈。（张子和）
[Scriptural Meaning]
The North corresponds to black, internally connects with the Kidney (Shen, 肾), and externally opens into the two yin orifices (the anus and urethra). ○ A surging pulse, body heat, abdominal distension, and obstruction of both bowel and bladder movements, accompanied by chest oppression and mental confusion, are termed "Five Excesses" (Wu Shi, 五实). If sweating occurs and bowel/bladder functions resume, the patient with excess syndrome will survive. ○ When hot pathogenic qi lingers in the Small Intestine (Xiao Chang, 小肠), causing heat within the intestines, excessive thirst and dryness lead to hard, dry stool that cannot be expelled, resulting in pain and obstipation. ○ When Yang Qi fails to overcome Yin, the Qi of the Five Zang Organs (Wu Zang, 五脏) contends with each other, leading to obstruction of the Nine Orifices (Jiu Qiao, 九窍). (Su Wen)
[Philosophical Sayings]
One bowel movement per day is normal; three to four days without a movement constitutes constipation; three to four movements per day constitute diarrhea. (Yi Xue Ru Men)
Zhang Zhongjing said: There are Yang Jie (Yang Knotting) and Yin Jie (Yin Knotting) pulses. How to distinguish them? The answer is: A floating and rapid pulse with ability to eat but inability to defecate indicates an Excess pattern, named Yang Jie. A deep and slow pulse with inability to eat, heavy body, and conversely hard stool indicates a Deficiency/Cold pattern, named Yin Jie. Excess constipation and Heat constipation correspond to Yang Jie. Deficiency constipation and Cold constipation correspond to Yin Jie. (Zheng Zhi Zhun Sheng)
Excess constipation refers to the retention of tangible pathogens; Deficiency constipation refers to the insufficiency of Qi. (Zhang Jiegou)
Regarding constipation, ancient medical texts classify it into Deficiency, Wind, Qi, Heat, Cold, and Dampness types. Li Dongyuan further proposed Hot Dryness, Wind Dryness, Yang Jie, and Yin Jie. These theories are too verbose and cause confusion. In reality, this condition can be fully categorized into just two types: Yin Jie and Yang Jie. Yang Jie represents pathogenic excess, requiring purgation and draining. Yin Jie represents righteous deficiency, requiring tonification and moistening. Understanding these two grasps the essence. Regarding Wind Constipation, wind itself does not cause constipation; rather, wind generates dryness, which stems from Fire/Heat. Thus, Heat generating Wind is essentially Yang Jie. Is dispersal indicated for Wind? Regarding Qi Obstruction, Qi has Excess and Deficiency. Qi Excess is Yang excess, i.e., Yang Jie; Qi Deficiency is Yang insufficiency, i.e., Yin Jie. Is breaking Qi indicated? Heat and Cold constipation are merely aliases of Yin and Yang. Regarding Damp Constipation, dampness itself does not cause constipation; it results from failed transformation due to stagnant Qi. Stagnant Qi implies Deficiency, thus it is Yin Jie. In summary, presence of Fire indicates Yang Jie; absence indicates Yin Jie. This distinction is clear. (Zhang Jingyue)
Generally, fecal impaction arises from excessive sexual activity, irregular diet, indulgence in alcohol, or overconsumption of spicy and hot foods. Dietary fire originates in the Spleen and Stomach; lustful fire originates in the Mingmen (Gate of Vitality). This leads to Yin deficiency and blood consumption, excessive Fire depleting Water, failing to generate Body Fluids (Jin Ye, 津液). Consequently, transmission function fails, gradually forming dryness and impaction. Additionally, elderly people with scant blood and dried fluids; those suffering sudden blood loss; postpartum women with depleted Qi and Blood causing dry intestines; or weak individuals with improper care leading to Sanjiao (Triple Burner) Qi stagnation and poor transport, all result in constipation. Treatment should focus on nourishing Blood and Yin, lubricating dryness. One must not recklessly use purgatives, as this damages Yuan Qi (Original Qi) and consumes True Yin, worsening the condition. (Yi Xue Zheng Zhuan)
Turbid Qi residing in the upper jiao obstructs Lung Qi, preventing its descending function, thus causing fecal obstruction. (Zhou Shenzhai)
In internal injury cases of fecal obstruction where the patient does not wish to defecate for over a month, and food intake is minimal because the Five Zang and Six Fu organs are filled with dryness-fire, water and grain are scorched by fire. Only after a long time, when Spleen Qi gradually recovers and pathogenic factors decline, can feces form. When feces desire to exit but cannot, one should moisten the Large Intestine to guide them out. (Cha Liaowu)
Yin Blood overflowing outward becomes sweat; Yin Blood moistening downward allows smooth defecation. (Ji Ren Bian)
When urine is blocked but stool is regular, it is often due to Bladder Heat accumulation or unclear water source, mostly Dampness patterns. When stool is blocked but urine is regular, it is often due to Qi stagnation in the intestines or lack of fluid flow, mostly Dryness patterns. If both urine and stool are blocked, one should first unblock the stool, and urination will naturally follow. (Lin Zheng Zhi Nan)
[Supplement]
For Shaoyin channel constipation, use acrid-moistening methods; for Taiyin channel constipation, use bitter-draining methods. For Yang Jie, clear heat; for Yin Jie, warm and tonify; for Qi stagnation, promote circulation; for fluid deficiency, moisten. Generally, nourishing Blood and clearing Heat is primary; urgent purgation is secondary. (Zheng Zhi Hui Bu)
The cause of constipation, aside from Yangming Heat accumulation, lies entirely in the Kidney. The Kidney governs the two yin orifices and controls opening and closing. Therefore, incontinence is blamed on the Kidney. Is obstruction not also related to the Kidney? Thus, Kidney Heat requires cooling and moistening; Kidney Cold requires warming and moistening; Kidney Deficiency requires tonifying and moistening; Kidney Dryness requires moistening and nourishing. The Classic states: "The Kidney dislikes dryness; urgently consume acrid flavors to moisten it." This means opening the pores, distributing fluids, and promoting Qi movement. ○ Yang Jie is caused by excess pathogenic fire drying up fluids. It may stem from dietary fire in the Spleen, wine/lust fire in the Kidney, or seasonal fire in the viscera. Only in acute diseases affecting young, robust individuals with matching Fire symptoms and pulses is it truly Yang Jie. Treatment depends on severity. Severe accumulation requires purgation. ○ Yin Jie has two types: Yang Deficiency and Yin Deficiency. Lower Jiao Yang Deficiency leads to non-moving Yang Qi, failing to transport, causing Yin coagulation below—this is Yang Deficiency leading to Yin Jie. Lower Jiao Yin Deficiency leads to dry essence/blood and lack of fluids, causing dry intestines—this is Yin Deficiency leading to Yin Jie. To treat Yang Deficiency Yin Jie, benefit the Fire so Yin coagulation melts. To treat Yin Deficiency Yin Jie, strengthen the Water so channels clear. To speed up results, add Cistanche (Rou Cong Rong, 肉苁蓉) 2-3 qian to the above formulas. (Zhang Jingyue)
The Classic states: "North is black, connects to Kidney, opens to two yin orifices." Thus, fecal impaction is specifically attributed to the Shaoyin channel. Although symptoms vary, they are all summarized as fluid dryness. Specifically, there are Stomach Excess, Stomach Deficiency, Heat, Cold, Wind, and Qi constipation. Stomach Excess constipation features good appetite and dark urine; Stomach Deficiency features poor appetite and clear urine; Heat constipation features red face, body heat, rapid/solid pulse, abdominal fullness, and desire for cold drinks; Cold constipation features pale/black face, deep/slow pulse, clear urine, and preference for warmth; Qi constipation features failure of Qi ascending/descending, food stagnation, and belching; Wind constipation involves Wind attacking the Lungs and transmitting to the Large Intestine. Other causes include elderly fluid dryness, postpartum blood loss, excessive sweating/diuresis, and post-illness Qi/Blood recovery. Treatment should tonify Qi and Blood to generate fluids, ensuring natural passage. Misusing Niter (Xiao Shi, 芒硝) and Rhubarb (Da Huang, 大黄) often leads to untreatable conditions. If the disease is Cold-Yin but the pulse is solid with slight restlessness, add slight bitter-cold herbs to warm formulas to clear heat-dryness, or take Lizhong Tang cold. If ineffective, use honey suppositories. For Cold constipation, use pickled ginger suppositories; for Heat, pig bile suppositories; for Deficiency, boil pig blood/organs with butter. This is a brilliant method. (Yi Zong Bi Du)
Li Dongyuan said: The Kidney governs five fluids; abundant fluids mean normal bowels. Injury to Stomach Qi from hunger/fatigue, or consuming spicy/rich foods aiding Fire, scatters True Yin and reduces fluids, causing Large Intestine dryness. Elderly Qi deficiency also causes dryness. "Kidney dislikes dryness; consume acrid to moisten." I follow Li's theory but not his formula, using Liuwei Wan (Six-Ingredient Pill with Rehmannia) plus Ginseng for Qi deficiency, as Qi deficiency fails to push and Blood deficiency fails to moisten. Why not Siwu Tang? Siwu Tang only tonifies Blood. Here, fluid deficiency precedes difficulty. The Classic says: "Kidney governs five fluids; fluids derive from Kidney Water, unrelated to Blood." Some ask if Niter/Rhubarb can be used temporarily for severe dryness? Chengqi Tang uses them for Cold Damage transforming into Heat entering the Three Yin, fearing Kidney Water exhaustion, to expel external pathogens and save Kidney Water. For elderly/weak/post-ill patients with original Kidney Water deficiency, using Niter/Rhubarb further depletes deficiency. Temporary relief leads to worse constipation later. (Zhao Yangkui)
Chang Bi (Intestinal Impediment) is less severe than dry stool impaction. Opening the Upper Jiao Lung Qi allows the lower orifice to open. For hard dry stool, use San Chengqi Tang, Runchang Wan, or Tongyou Tang. However, urgent purgation in Cold Damage is rare; most cases arise from Six Evils post-illness when Stomach Qi is unrecovered and Yuan Qi is deficient. Purgatives are difficult to administer; external suppository methods are safer. ○ Note: For blood dryness, nourish Blood and moisten dryness. For Blood dryness generating Wind, use Acrid-Sweet to extinguish Wind or Sour-Bitter to enter Yin (e.g., Santian, Wuren, Tongyou methods). For Blood dryness with Qi stagnation causing Qi-Blood impediment, add Qi-moving and Blood-invigorating herbs to Yin-nourishing formulas. For Fire Organ blockage, use Bitter-Slip Heavy Sedatives like Gengyi Wan. For Elderly Yang Decline/Wind Closure, use Banshu Wan. For Fu Yang stagnation, use Yuhu Dan. for Yang obstruction/Yin coagulation with turbid Qi mixing, use Laifu Dan. For Depressed Heat blocking Qi, use Bitter-Cold to drain Heat and Acrid to open depression, or Sanjiao unblocking methods. For Damp-Heat injuring Qi and blocking meridians/Fu organs, regulate Lung Qi to descend. ○ While Chengqi Tang, Gengyi Wan, Pig Bile, and Honey Suppositories cover most cases, efficacy varies. Sometimes dry stool reaches the anus, but the anal opening is small while the stool mass is large. Straining fails. If stool cannot exit below, food cannot enter above, leading to danger. My friend taught using bile or honey suppositories, then inserting an oiled finger to break up the stool at the anus. Once, a single mass was broken into over a hundred pieces. This method saves many lives; do not discard it due to disgust. (Lin Zheng Zhi Nan)
Desire to defecate but unable, or stool adhering and not exiting, indicates Qi Deficiency. Feeling incomplete evacuation indicates Blood Deficiency. Both require tonifying the Middle Jiao. Tenesmus (Li Ji Hou Zhong, 里急后重) initially belongs to Heat; chronic cases should be treated as Deficiency. (Zhou Shenzhai)
People know Heat Constipation but ignore Cold Constipation. Cold Constipation involves Cold Qi coagulation and blocked fluids, like water freezing in winter. Treat with Bawei Wan or Banshu Wan to warm and unblock. (Zhang Jiegou)
Peach Kernel (Tao Ren, 桃仁) and Apricot Kernel (Xing Ren, 杏仁) both treat constipation, distinguished by Qi/Blood. Daytime difficulty relates to Yang Qi; use Xing Ren. Nighttime difficulty relates to Yin Blood; use Tao Ren. (Wang Haizang)
Ancient formulas for constipation use Qi-descending agents because Lung Qi descent aids bowel transmission (e.g., Xing Ren, Zhi Ke, Chen Xiang). For elderly/weak/wind-patients with fluid deficiency, use slippery agents like Hemp Seed (Huo Ma Ren, 火麻仁), Sesame, and Donkey-hide Gelatin (E Jiao, 阿胶). Reckless use of harsh purgatives drains fluids and consumes Qi/Blood, causing temporary relief followed by recurrence and new diseases. (Zhu Danxi)
Cases of simultaneous urinary and fecal obstruction unresponsive to diuretics/purgatives may resolve with heavy doses of Cimicifuga (Sheng Ma, 升麻). (Yi Fang Ji Jie)
Ancient formulas for elderly dryness use Cistanche. However, it causes vomiting in Stomach Qi Deficiency and is unsuitable for phlegm-damp constitutions. It is suitable only for Mingmen Fire Decline with opening/closing failure. It must be taken as pills; decoctions cause vomiting due to salty/turbid nature. ○ Pig Bile suppositories should not be used lightly except for Cold Damage Heat. In Stomach Qi Deficiency, they risk hiccups. (Zhang Shi Yi Tong)
[Pulse Diagnosis]
Constipation pulses are often deep and hidden. Yang Jie is deep-rapid; Yin Jie is deep-slow. Wind Dryness is floating; Blood Dryness is surging. In elderly/weak patients, a Sparrow-pecking pulse indicates untreatability. (Mai Jue)
[Selected Cases]
A scholar initially suffered intermittent urinary retention. Wuling San and Bazheng San failed. The physician found no Chi (Kidney) pulse, diagnosed Lower Yuan Exhaustion, and prescribed Bawei Wan. After three days, fecal obstruction occurred, with thirst, irritability, and fullness. Pipa Wan and Runchang Wan were added, resulting in drops of urine and ten days of complete fecal obstruction with unbearable abdominal distension. The group suggested Chengqi Tang for purgation. Mild relief was followed by re-obstruction and lower abdominal pain. Zhouche Wan was administered, causing frequent diarrhea with tenesmus and bloody-white stools. After half a month of groaning and drinking only rice soup, I palpated strong, deep pulses in the Cun (Inch) positions, surging/slow weak pulses in the Guan (Bar) positions, and absent Chi pulses. I stated: Guan and Chi are safe; the disease is above the diaphragm, caused by emotional Qi stagnation. Yueju Tang was given. After one dose, continuous belching occurred; after two doses, urine and stool flowed freely, expelling accumulated matter, with profuse sweating. Ginger soup induced sleep. Next morning, pulses were harmonious; after days of regulation, he recovered. A gentleman asked why I diagnosed Qi Stagnation instead of Dysentery or Kidney Deficiency, and why treating the Upper Jiao worked for lower symptoms. I replied: Disease location varies, but Qi circulation is key. Pulse diagnosis reveals Qi status. Everyone saw absent Chi pulses and cited the Classic ("Tree without roots"), ignoring that in the Ji-Mao year, Dry Metal governed Heaven and Ministerial Fire governed Earth. With Ministerial Fire not commanding, Chi pulses should be absent. If Chi were stronger than Cun, it would be a reverse pulse ("Death"). Could Bawei Wan treat this? Tenesmus and bloody stools resembled Dysentery, but Dysentery pulses appear in Guan. Here, Guan pulses were not floating/tight/rapid, ruling out Dysentery. Misusing Chengqi Tang injured Yuan Qi. The root was Upper Jiao Qi Stagnation blocking lower orifices. Like a water vessel with the top closed, water cannot exit the bottom. Treating only the bottom worsens Qi sinking. Yueju Tang opened the Upper Jiao, allowing the Lower Jiao to open. Internal harmony led to external freedom, sweating, and free urination/defecation—"One unblocks, all unblock." Qi Stagnation is the root; constipation is the branch. Treating the root yields fast results. (Yi Silan)
Liu Tailai contracted malaria in early autumn. Medication stopped the fever, but chest/abdominal distension developed. Within ten days, abdomen enlarged, chest rose, asthma became urgent, and both urine/stool ceased. Food intake stopped; could sit but not lie down, bend forward but not backward. Physicians failed with purgatives. A merchant gave 2 liang of Rhubarb in one dose. I exclaimed: What disease dares such killing? The physician argued: Cold Damage intestinal blockage requires purgation. I countered: Are there non-febrile Cold Damages? Febrile Cold Damage dries fluids and hardens intestines, justifying purgation. However, "Do not purge if flatus does not pass," fearing misdiagnosis of Taiyin abdominal distension. This case involved scattered abdominal Qi and overflowing fluids due to Spleen Qi failure to control. Scattering vs. Coagulation are worlds apart. Using strong Rhubarb would scatter Qi further, risking rupture. I prescribed Lizhong Tang with slight Coptis (Huang Lian, 黄连). Symptoms slightly improved. The next day, I explained that the abdomen contained Rhubarb-induced waste trapped by a distended bladder compressing the Large Intestine. By treating the Bladder Qi, not the stool directly, success would prove the point. I used Wuling San. Upon swallowing, the patient demanded a chamber pot. Urine passed first, then stool followed, emptying half a bucket instantly. Observers marveled, calling me Hua Tuo reborn, though I felt no pride. (Yu Yi Cao)
Wu Zhangcheng’s brother had fever, mental confusion, and constipation. The doctor treated it as External Contraction. I said: This is Food Retention exacerbated by excessive diaphoresis, leading to Deficient Heat. Wind medicines dry Blood, causing constipation. I prescribed Liuwei Tang plus Cistanche. He passed several black stools, and all symptoms resolved. (Ji Ren Bian)
Jiang Fanzhong suffered post-illness constipation. Moistening agents failed. Yuanning Fen (Mirabilite) and Rhubarb failed. Tonifying/Lifting agents caused unbearable distension. I prescribed 2 liang each of Prepared Rehmannia (Shu Di, 熟地) and Scrophularia (Yuan Shen, 玄参), 1 liang Ophiopogon (Mai Dong, 麦冬), 1 qian Schisandra (Wu Wei Zi, 五味子), and 2 qian Hemp Seed (Huo Ma Ren, 火麻仁), decocted with 1 bowl of cow milk. Relief was immediate. This was Kidney True Water exhaustion, unmanageable by tangible Yin/Yang tonics. (Cheng Huazhong)
A woman had dry constipation and dribbling urine, remaining childless for half her life. She relied on draining herbs for regularity; stopping caused blockage. During her fourth/fifth month pregnancy, doctors forbade draining herbs. Defecation became difficult; straining caused three miscarriages. In her fourth month of another pregnancy, urinary blockage returned, and she feared fetal loss. She sought Dai Ren. Pulses were slippery and large. Due to pregnancy, he avoided aggressive attack and used food therapy: Spinach boiled with alkali, Malva vegetables, Plantago seed shoots, and pork/mutton blood soups. After six months of this diet, she delivered a healthy baby, and the dryness disease cured. (Zhang Zihe)