(Difficulty in defecation, hard stool, dry fecal mass)

Cheng Wuji's Commentary: Inability to defecate, difficulty in defecation, hard stool, and dry fecal mass all belong to interior syndromes (Interior Syndrome), and most are suitable for purgative treatment. However, if the exterior syndrome has not resolved and wind-dampness is struggling, it is especially appropriate to first release the exterior, and then purge the interior. This is correct practice. As stated in the classics: "In cold damage disease, if there is inability to defecate for six or seven days, accompanied by headache and fever, and the urine is clear, it indicates that the pathogen is not in the interior but remains in the exterior." Such syndromes are mostly seen in Yangming disease. Because the Stomach belongs to Earth, which is the gathering place of all things, once pathogens enter, they do not transmit further. The transmission from Taiyang and Shaoyang to Yangming is well known, but transmission from the Three Yin meridians to Yangming is rarely recognized. If one observes carefully, one will find that there are many cases of urgent purgation indications in the Three Yin meridians. Is this not Zhang Zhongjing's profound intent?

For Yangming excess with exterior signs, resolve the exterior first.

In cold damage disease (accompanied by Taiyang exterior syndrome), if there is inability to defecate for six or seven days, (if there is sweating, Guizhi Tang [Cinnamon Twig Decoction] may be used), headache, and fever, and the urine is clear, it indicates that the pathogen is not in the interior but remains in the exterior. At this time, diaphoresis (sweating method) should be employed. If the headache persists, epistaxis (nosebleed) may occur, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. (Cheng Wuji's Commentary: Inability to defecate for six or seven days, headache, and fever theoretically warrant purgation; however, if the urine is clear, it indicates no heat in the interior, so purgation is contraindicated. The classics state: "If urination is frequent, the stool must be hard; even if one does not defecate for ten days, there is no discomfort." How much more so for someone who has not defecated for six or seven days with clear urine? One cannot blame the pathogen for being in the interior; this indicates the pathogen is still in the exterior. Administer Guizhi Tang (Cinnamon Twig Decoction) to resolve the exterior pathogen. If the headache persists, it indicates the exterior pathogen has not resolved, stagnation is severe in the meridians, forcing blood to move recklessly upward, causing epistaxis.) Danbo Yuanjian notes: When exterior symptoms are unresolved, purgation is contraindicated; purging is a counter-therapeutic approach. Now, with headache and fever, one should release the exterior, yet instead administering Chengqi Tang (Bowel-Regulating Decoction) is precisely criticizing the error of reckless purgation. Therefore, the text later states that clear urine indicates no interior pathogen, and Chengqi Tang should not be used. It continues to say that diaphoresis should be employed; if headache persists, epistaxis will likely occur, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. The repeated warnings make the argument very clear, whereas the commentary directly states "therefore purgation is indicated," I suspect this is due to seeing the six or seven days of constipation. Although there is constipation, if there are no other complaints, waiting for the exterior to resolve before attacking the interior is indeed Zhang Zhongjing's method. The attention seems insufficiently lucid.) In Yangming disease (with no sweating, use Mahuang Tang [Ephedra Decoction]), if the pulse is floating, there is no sweating, and wheezing, diaphoresis leads to recovery, and Mahuang Tang (Ephedra Decoction) is appropriate. In Yangming disease (accompanied by Shaoyang syndrome), if there is hardness and fullness under the hypochondrium, difficulty in defecation, vomiting, and a white coating on the tongue, Xiaochaihu Tang (Minor Bupleurum Decoction) may be administered. Once the Upper Jiao (Upper Burner) is unblocked, fluids descend, the Stomach Qi harmonizes, and the body sweats slightly, resolving the condition. (In Yangming disease, abdominal fullness, inability to defecate, and a yellow tongue coating indicate pathogenic heat entering the Fu organs, suitable for purgation; however, if there is hardness and fullness under the hypochondrium, though unable to defecate, with vomiting and a white tongue coating, the pathogen has not entered the Fu organs but is between the exterior and interior. Administer Xiaochaihu Tang (Minor Bupleurum Decoction) to harmonize. Unblocking the Upper Jiao stops vomiting, descending fluids harmonizes Stomach Qi, and sweating resolves the condition.) Yangming Wind Strike presents with a string-taut, floating, and large pulse, shortness of breath, abdominal fullness, pain in the hypochondrium and heart region, obstruction of Qi even after prolonged pressing, dry nose, inability to sweat, drowsiness, jaundice of the whole body and face, difficulty in urination, tidal fever, occasional hiccups, and swelling around the ears. Acupuncture provides slight relief. If the exterior syndrome does not resolve and the illness lasts over ten days, and the pulse remains floating, administer Xiaochaihu Tang (Minor Bupleurum Decoction); if the pulse is only floating without other symptoms, administer Mahuang Tang (Ephedra Decoction). If there is no urination, abdominal fullness worsens, and hiccups increase, it is untreatable. (Cheng Wuji's Commentary: A floating and large pulse indicates Yang, wind in the exterior; string-taut indicates Yin, wind in the interior. Shortness of breath, abdominal fullness, and pain in the hypochondrium and heart region indicate wind-heat congesting in the abdomen and obstructing flow. If cold pathogen causes pain, pressing disperses the cold and stops the pain. Here, wind-heat internally congests, so even prolonged pressing does not relieve the obstruction. In Yangming disease, a dry nose, inability to lie down, and spontaneous sweating indicate the pathogen is in the exterior. Here, a dry nose, inability to sweat, and drowsiness indicate wind-heat attacking internally, not in the interior. Jaundice of the whole body and face, difficulty in urination, tidal fever, and hiccups indicate wind-heat attacking the Stomach. The Yangming meridian emerges from Daying, follows the cheekbone, passes the ear, and crosses Guest Master point; excessive heat causes swelling. This is wind-heat in the meridian, hence swelling around the ears; acupuncture unblocks meridian Qi, and swelling subsides slightly. In such cases, if exterior symptoms resolve, purgation may be considered; if exterior symptoms persist, even after ten days, if the pulse remains floating, the pathogen is still at the half-exterior/half-interior level, and Xiaochaihu Tang (Minor Bupleurum Decoction) is appropriate. If the pulse is only floating, not string-taut, and without interior symptoms, the pathogen is solely in the exterior, and Mahuang Tang (Ephedra Decoction) may be given. If diaphoresis is induced and results in no urination, worsening abdominal fullness, and increased hiccups, this is Guan Ge syndrome (Obstruction and Reversal), hence described as difficult to treat. The Nan Jing states: Those with Guan Ge will not live out their natural lifespan.)

Bitter taste in the mouth, dry throat, floating and tight pulse, suitable for harmonization.

Yangming Wind Strike presents with bitter taste in the mouth, dry throat, abdominal fullness, slight wheezing, fever, aversion to cold, floating and tight pulse. If purgation is mistakenly used, it leads to abdominal fullness and difficulty in urination. (Fever and aversion to cold indicate the exterior is unresolved; mistaken purgation consumes Yin fluid; without Yin, Yang cannot transform, leading to abdominal fullness and difficulty in urination. Xu Xueshi says: Minor Bupleurum Decoction is appropriate.) In Yangming disease, abdominal fullness, floating and tight pulse, bitter taste, dry throat, and wheezing, if accompanied by fever, sweating, aversion to cold transforming into aversion to heat, and heaviness of the body, diaphoresis, moxibustion with burning needles, and purgation are all contraindicated. (See Self-Sweating section.) In Yangming disease, if the pulse is floating and tight, tidal fever occurs at specific times; if the pulse is only floating, night sweating will occur.

Regarding Yangming Excess (Stomach Home Excess) and inability to defecate, even a three-foot child knows purgation is indicated. However, one must not ignore Zhang Zhongjing's method: even with Yangming Excess, if the exterior is unresolved or there is a half-exterior/half-interior syndrome, one must first use Guizhi Tang (Cinnamon Twig Decoction) or Chaihu Tang (Bupleurum Decoction) to resolve the exterior, and then assess deficiency and excess before proceeding.

For Yangming Excess with resolved exterior and no specific symptoms, avoid aggressive purgation; for hard stool, use suppositories.

In Yangming disease, if there is spontaneous sweating, or if sweating was induced and urination is frequent, this indicates internal depletion of body fluids. Even if the stool is hard, it cannot be aggressively purged. One should wait until the patient feels the urge to defecate, then use Honey Suppository (Mi Jian Dao) to promote evacuation. Radish root (Tugua Gen) and human pig bile can also be used for guidance.

Honey Suppository Method:
Use seven he of honey, place in a copper vessel, and gently boil over low heat until slightly thickened like malt syrup. Stir constantly to prevent burning. When moldable, shape by hand into a cone-shaped suppository, sharp at the head, about the thickness of a finger and two cun long. While hot, insert quickly into the rectum. Press firmly with hand, and remove when the urge to defecate arises.

Another Pig Bile Formula:
Use one large pig gallbladder, extract the juice, mix with a small amount of vinegar, and instill into the rectum. After the time it takes to eat a meal, the stool will pass naturally.

For hard stool without discomfort, wait.

In Taiyang disease, if the Cun position is slow, Guan is floating, and Chi is weak, and the patient has fever, sweating, recurrent aversion to cold, no vomiting, but only epigastric stuffiness, this is due to medical purgation. If not purged medically, and the patient becomes free of aversion to cold but thirsty, this indicates transformation into Yangming. Frequent urination leads to hard stool; even if one does not defecate for ten days, there is no discomfort. If thirsty for water, give small amounts frequently, and treat according to the method. For thirst, Wuling San (Five-Ingredient Powder with Poria) is appropriate. (Cheng Wuji's Commentary: In Taiyang disease, a floating Yang and weak Yin pulse indicates pathogen in the exterior. Now, slow Cun, floating Guan, and weak Chi indicate pathogen gradually transmitting inward, causing fever, sweating, and recurrent aversion to cold, meaning the exterior is unresolved. Pathogen transmitting into the interior and disrupting interior harmony usually causes vomiting. Here, no vomiting but only epigastric stuffiness indicates premature medical purgation, leaving pathogen trapped in the epigastrium. If not purged medically, aversion to cold gradually disappears and thirst appears, indicating Taiyang pathogen transforming into Yangming. After vomiting, purgation, or sweating, if urination is frequent and stool is hard, Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) should be given to harmonize. Here, without prior vomiting/purgation/sweating, frequent urination and hard stool indicate absence of fullness and excess; even without defecation for ten days, there is no discomfort. Wait for fluids to return to the Stomach; as urination decreases, stool will pass naturally. For thirst, give small amounts of water to moisten Stomach Qi. Assess pathogen location and treat accordingly; if thirst persists, use Wuling San (Five-Ingredient Powder with Poria).) Zhang Yuansu asks: The previous clause states "frequent urination leads to hard stool; not defecating for ten-plus days causes no discomfort." Yet, for those not defecating for four to seven days, purgation is often applied immediately. Why is purgation not used here for ten days? Answer: This is not heat accumulation but fluid deficiency. Even without defecation for ten days, there is no discomfort. The classics state: "In Yangming disease, originally with spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight restlessness remains, this indicates hard stool. Due to loss of fluids and dryness in the Stomach, stool becomes hard. Ask how many times the patient urinates daily. Originally three to four times, now twice, indicating stool will pass soon. Reduced urination means fluids are returning to the Stomach, so stool will pass soon." For constipation, if there are symptoms like tidal fever and delirium warranting purgation, then purge. If there is constipation without these purgative indications, it is fluid deficiency; one must be cautious and not purge simply due to prolonged duration.) In Yangming disease, originally with spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight restlessness remains, this indicates hard stool. Due to loss of fluids and dryness in the Stomach, stool becomes hard. Ask how many times the patient urinates daily. If originally three to four times daily and now twice, it is known that stool will pass soon. Now, with reduced urination, fluids are returning to the Stomach, so stool will pass soon.

For Yangming Excess with resolved exterior and existing symptoms, attack according to the syndrome.

In Yangming disease, with tidal fever and inability to defecate for six or seven days, suspecting dry fecal mass: To verify, give a small amount of Xiao Chengqi Tang (Minor Bowel-Regulating Decoction). If flatulence occurs, there is dry fecal mass, and purgation is possible; if no flatulence, there is no dry fecal mass, and purgation is contraindicated. (Formula discussion see Tidal Fever section.) In Yangming disease, with sweating, hard stool, and delirium, Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) is appropriate. (Formula see Delirium section.) For inability to defecate with abdominal fullness, purgation is indicated. If there is only periumbilical pain, it indicates dry fecal mass, and Chengqi Tang (Bowel-Regulating Decoction) is appropriate. If there is fullness and pain from the epigastrium to the lower abdomen, it indicates Jie Xiong (Chest Binding), and Xianxiong Tang (Sinking Chest Decoction) is appropriate. (Discussion see Abdominal Pain section.) In Yangming disease, without vomiting or purgation, but with irritability, Tiaowei Chengqi Tang (Harmonizing Stomach Bowel-Regulating Decoction) may be given. (Cheng's Note: Irritability after vomiting is called Internal Irritability; irritability after purgation is called Deficiency Irritability. Here, in Yangming disease without vomiting or purgation, irritability indicates stagnant heat in the Stomach, so Tiaowei Chengqi Tang (Harmonizing Stomach Bowel-Regulating Decoction) is used to purge stagnant heat. Analysis: Yangming syndrome is divided into Taiyang, Zhengyang, and Shaoyang levels, treated with Tiaowei, Da, and Xiao Chengqi Tangs respectively. According to Materia Medica: Rhubarb soaked in wine enters Taiyang meridian; washed in wine enters Yangming meridian. Longer soaking yields more wine qi, guiding it to higher regions. Like an object on a peak inaccessible to humans, it must be shot at. Thus, Zhang Zhongjing places Tiaowei Chengqi Tang in the Taiyang chapter, noting Rhubarb is "wine-soaked." Detailed usage: "Take small amounts, warm"; "Harmonize Stomach Qi" with Tiaowei Chengqi Tang. Symptoms include "irritability without vomiting/purgation," "persistent fever after sweating," and "abdominal fullness after vomiting." These are Taiyang-Yangming transitions, close to the exterior, with pathology above, unsuitable for strong purgation, hence requiring mild harmonizing agents. For Zhengyang Yangming, "urgent purgation" with Da Chengqi Tang (Major Bowel-Regulating Decoction) is used, noting Rhubarb is "wine-washed," which is lighter than soaking, slightly lifting its downward action to treat the middle. For Shaoyang Yangming, moving away from Zhengyang towards Taiyin, the level is lower, so Rhubarb in Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) is not wine-treated. Shaoyang is unsuitable for purgation, hence "small dose" and "slight diarrhea," avoiding massive purging. This is Zhang Zhongjing's subtle method. Dongyuan did not understand that "Stomach" in Tiaowei Chengqi Tang refers to Zhang Zhongjing placing it in the Taiyang chapter because Taiyang is unsuitable for purgation, thus adding "Stomach" to distinguish it. He followed Cheng's error, using Xiao Chengqi Tang for Taiyang Pi Yue (Spleen Restraint) and Tiaowei Chengqi Tang for Zhengyang Yangming Da Chengqi Tang syndrome. I cannot help but differentiate.) For difficulty in urination, alternating hard and soft stool, slight fever, wheezing, vertigo, and insomnia, Da Chengqi Tang (Major Bowel-Regulating Decoction) is appropriate. (Discussion see Insomnia section.) In cold damage disease for six or seven days, if vision is unclear, eyes are unresponsive, with no exterior/interior symptoms, difficulty in defecation, and slight body heat, this is Excess; urgent purgation with Da Chengqi Tang (Major Bowel-Regulating Decoction) is required. (Cheng's Commentary: All meridians connect to the eyes. In cold damage disease at six or seven days, when pathogen enters the interior, unclear vision and unresponsive eyes indicate severe internal pathogenic heat steaming upwards to the eyes. No exterior/interior symptoms and difficulty in defecation indicate interior excess. High body heat indicates exterior heat; slight body heat indicates interior heat. The Needle Classic states: "In heat disease, if vision is impaired and heat does not cease, death ensues." Unclear vision and unresponsive eyes indicate critical danger; urgent purgation with Da Chengqi Tang (Major Bowel-Regulating Decoction) is necessary.) Fuyang pulse is floating and choppy. Floating indicates strong Stomach Qi; choppy indicates frequent urination. Floating and choppy interacting leads to difficult defecation. The Spleen is restrained; Maren Wan (Hemp Seed Pill) is the primary formula. (Cheng's Commentary: Fuyang is the pulse diagnosis of Spleen and Stomach. Floating is Yang, indicating strong Stomach Qi; choppy is Yin, indicating Spleen restraint. "Restraint" implies frugality or constraint. The Inner Canon states: "Fluids enter the Stomach, essence floats up, transmits to Spleen, Spleen scatters essence to Lungs, regulates water passages, transmits to Bladder, fluids distribute four directions, five meridians run together. The Spleen governs transporting fluids for the Stomach." Now, strong Stomach and weak Spleen constrain fluids, preventing distribution, sending them only to the Bladder, causing frequent urination and difficult defecation. Administer Pi Yue Wan (Spleen Restraint Pill) to unblock intestines and moisten dryness.)

Maren Wan (Hemp Seed Pill) Formula:
Hemp Seed (Ma Zi Ren) (2 sheng), Peony Root (Shao Yao) (0.5 jin), Immature Bitter Orange (Zhi Shi) (0.5 jin, stir-fried), Rhubarb (Da Huang) (1 jin, peeled), Magnolia Bark (Hou Po) (1 chi, coarse bark removed, stir-baked), Apricot Kernel (Xing Ren) (1 jin, skin and tip removed, separately cooked into paste). Grind the above six herbs into powder, refine honey, and make pills the size of tung seeds. Take 10 pills with water, three times daily. Gradually increase dosage until cure is achieved. (Cheng's Commentary: The Inner Canon states: "The Spleen desires relaxation; urgently feed sweet foods to relax it." Sweetness of Hemp Seed and Apricot Kernel relaxes Spleen and moistens dryness. Fluid deficiency requires sour astringency; Sourness of Peony Root astringes fluids. Intestinal dryness and Stomach excess require bitter purgation; Bitterness of Immature Bitter Orange, Magnolia Bark, and Rhubarb descends dryness and purges Stomach excess.)

In Yangming syndrome, if the patient is forgetful, there must be accumulated blood. The reason is pre-existing old blood stasis, causing forgetfulness. Although stool is hard, defecation is surprisingly easy, and the color is necessarily black. Didang Tang (Di Dang Decoction) is the primary formula. (Formula see Accumulated Blood section.) With no exterior/interior symptoms, if after purgation the rapid pulse persists, digestion increases, hunger returns, and there is inability to defecate for six or seven days, there is blood stasis; Didang Tang (Di Dang Decoction) is appropriate.

Xu Shumi had two scholars from the same family ill for ten days. One had body heat, no sweating, inability to defecate,涩 (astringent/difficult) urination, confusion, and sleepiness. Pulse was large, long, and solid. I used Chengqi Tang (Bowel-Regulating Decoction) to purge, and he recovered. The other had Yangming spontaneous sweating, inability to defecate, free urination, little body fluids, dry mouth, and a large but deficient pulse. I administered Honey Suppositories three times, expelled dry feces, and he recovered through loose stools. The family asked: Both have constipation, why different treatments? I replied: Though similar, spontaneous sweating and free urination indicate inability to scour the Five Zang organs due to lack of fluids. Thus, although major cold damage syndromes are similar, slight differences require careful deliberation. Just as in destiny reading, even with identical year, month, day, and hour, nobility or poverty differs due to subtle depths within the same time. Thus, caution is essential.

Stool initially hard, later loose.

In Zhang Zhongjing's discussions, there are four syndromes. Two do not mention urination; one mentions difficulty in urination; one mentions little urination. Of the two not mentioning urination: In Yangming disease with tidal fever and inability to defecate for six or seven days, if after giving Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) there is no flatulence, this is only initial hardness, followed by looseness; do not purge. This indicates pathogenic heat in the Stomach has not formed excess. Also, in Taiyang disease after purgation, if there is vexation and abdominal fullness, stool is initially hard then loose; this is deficiency vexation with heat above, and no dry fecal mass in the Stomach. Regarding the syndrome with difficulty in urination: In Yangming disease with Cold pathogen, inability to eat, difficulty in urination, and continuous sweating on hands and feet, this suggests impending chronic mass formation, and stool will be initially hard then loose. The reason is indistinguishable food and water in the Stomach. Regarding the syndrome with little urination: After taking one sheng of Chengqi Tang, if there is still no defecation after six or seven days and urination is scanty, even if unable to eat, stool is initially hard then loose, not yet definitely hardened. Purging will cause looseness. Only when urination is free and stool is definitely hard can purgation be performed. Thus, Zhang Zhongjing's method for assessing stool relies on observing urination. Clear urine indicates pathogen not in interior; if diarrhea persists, benefit urination; if urination is less, fluids return to Stomach, and stool passes—all verifiable. However, even with free urination and definitely hard stool suitable for purgation, there are cases of free urination with hard stool where purgation is contraindicated. Why? In Yangming disease with spontaneous sweating or induced sweating, if urination is free, this indicates internal depletion of fluids; even if hard, do not purge. Wait for the urge to defecate and use Honey Suppository. This is not interior excess, hence purgation is contraindicated. Another Taiyang syndrome states: After vomiting, purgation, or sweating, if there is slight vexation, frequent urination, and hard stool, give Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) to harmonize. In these two cases, post-sweating hard stool and free urination are the same, but treatments differ. The latter has transmitting pathogen, hence slight vexation; after sweating/vomiting/purgation, frequent urition depletes internal fluids, hardening stool due to heat entering interior, so Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) is used to drain. In the former case, free urination indicates no transmitting pathogen, hence no vexation; although stool is hard, it is not interior heat, but merely dryness at the rectal entrance, making Honey Suppository appropriate. Readers of Zhang Zhongjing's works should investigate this in detail.