bubble_chart Concept

Great constipation, abbreviated as constipation, refers to the retention of feces in the intestines for too long, leading to prolonged defecation time. Typically, defecation occurs once every four to seven days or more, which is referred to as constipation.

This condition has many names in classical medical texts. In the "Cold-Damage Disease Treatise," it is called "difficult defecation," "splenic constipation," "no defecation," "no change of clothes," "yang constipation," and "yin constipation." In the Song Dynasty's "Book of Life," it is referred to as "great constipation." During the Jin and Yuan Dynasties, it was further classified into "constipation of deficiency type," "wind constipation," "qi constipation," "heat constipation," "cold constipation," "damp constipation," "heat dryness," and "wind dryness."

Although this condition and difficult defecation both primarily involve difficulty in defecation, their concepts are different. Difficult defecation refers to the difficulty and lack of smoothness during defecation, and while it may also involve defecation every other day, the defecation cycle is usually normal. This condition, however, involves the blockage of great constipation disease for several days without defecation.

In the "Cold-Damage Disease Treatise," "difficult defecation" refers to the former; while Suwen . Zhizhenyao Da Lun mentions "difficult defecation," and the "damp constipation" mentioned during the Jin and Yuan Dynasties belongs to the latter, and should be distinguished.

bubble_chart Pattern Analysis

1. Stomach and Intestine Excess Heat︰Equivalent to "heat constipation," it falls under the category of "yang constipation." Its main clinical manifestations include dry and hard stools, constipation lasting several days, abdominal distension and fullness, pain and tenderness, flushed face and body heat, worsening fever in the late afternoon, profuse sweating, dark urine, frequent desire for cold drinks, mouth and tongue ulcers, fetid mouth odor, deep and harsh voice, coarse breathing, dry tongue, thick yellow greasy or scorched yellow tongue coating with prickles, and a deep, solid or slippery, solid pulse. This indicates yangming fu-organ excess with dry stool accumulation internally. Clinically, it can be divided into three scenarios: either damage from cold pathogens transforming into heat, with pathogens entering the yangming fu-organ; or warm disease progressing to the qi aspect, with heat accumulation in the intestines and stomach; or excessive consumption of spicy foods leading to heat accumulation in the intestines and stomach. All of these can result in heat spreading through the yangming stomach fu-organ, depleting fluids and causing dryness-heat in the gastrointestinal tract, leading to severe constipation. The formation of dry stool in cold-damage disease and warm disease often occurs in high-febrile illnesses and is relatively easy to recognize clinically. To determine whether dry stool has formed, the following points must be grasped:
   1. Yangming heat pattern, with late afternoon tidal fever (late afternoon being the time when the yangming channel governs);
   2. abdominal symptoms, such as distension, fullness, pain, and tenderness (persistent distension, fullness, pain, and tenderness—if the dry stool is not expelled, the abdominal pain will not resolve);
   3. continuous sweating (excessive sweating depletes body fluids, leading to dryness in the gastrointestinal tract and hardened stools, making profuse sweating a key factor in the formation of dry stool in the intestines);
   4. or accompanied by delirious speech (yangming fu-organ excess, with the intestines blocked by dry stool, leading to qi stagnation, turbid toxins rising, and disturbing mental activity).
   The warm disease pattern of heat invading the qi aspect with intestinal and stomach excess follows the same principle, differing only in that it arises from warm pathogens, with more severe fluid damage and a more rapid and intense progression of heat. For those who habitually consume spicy and rich foods, leading to heat accumulation in the intestines and stomach, the resulting severe constipation may not stem from external contraction of cold or warm pathogens, but the mechanism of heat damaging fluids and causing dryness accumulation in the gastrointestinal tract is the same. The treatment principle in all cases is to unblock stagnation and purge excess. However, there are differences in specific applications: purgation in cold-damage disease aims to drain excess, and if interior heat has not yet solidified, purgation should not be lightly applied—hence the cautionary phrase "in cold-damage disease, purgation should not be rushed." In warm disease, purgation aims to drain heat, and since warm disease easily damages yin fluids, the saying "in warm disease, purgation should not be delayed" applies. Clinically, the Three Purgative Decoctions can be selected based on symptom severity and urgency. For cases of internal obstruction by dryness-excess with mild stuffiness and fullness, or dry stool accumulation that is not severe, use Stomach-Regulating Purgative Decoction to moisten dryness, soften hardness, harmonize the stomach, and purge excess. For constipation where dry stool is beginning to form but is not yet hardened, administer Minor Purgative Decoction to harmonize and purge. For cases with severe stuffiness, fullness, dryness, and excess, indicating a critical yangming fu-organ excess pattern, administer Major Purgative Decoction for drastic purgation. For splenic constipation with frequent urination and hard stools, use Hemp Seed Pill to moisten the intestines and relieve constipation. For qi-aspect warm disease with heat excess and fluid depletion, select from Liquid-Increasing Purgative Decoction , Newly Supplemented Yellow Dragon Decoction , Lung-Ventilating Purgative Decoction, Guide the Red Purgative Decoction, or Cow-Bezoar Purgative Decoction, among others.
2. Liver and Spleen Disharmony︰Equivalent to "qi constipation." It is often manifested by constipation for several days, a sense of heaviness and urgency, the desire to defecate but inability to do so, mental depression, frequent belching, chest and gastric stuffiness, hypochondriac distension, or breast distension during menstruation, or vomiting and upward counterflow, cough and panting, a white and greasy tongue coating, and a deep or wiry pulse. It is an excess-pattern constipation. Qi stagnation constipation is mostly caused by sudden grief or anger, leading to blockage of qi movement; or prolonged sitting and lack of movement, resulting in impeded qi movement, as well as various factors causing stomach qi ascending counterflow and impaired lung diffusion and descent. All these can lead to depression and stagnation of qi movement, disrupting the ascending and descending functions. Suwen states: "All qi depression and stagnation are related to the lungs." Impaired lung diffusion and descent leads to large intestine qi stagnation, causing waste to accumulate internally and resulting in constipation. The key diagnostic points are constipation for several days accompanied by impaired liver dispersion (depression, sighing, chest and hypochondriac discomfort, breast distension, etc.), stomach qi ascending counterflow (belching and nausea), and impaired lung purification and descent (cough with dyspnea), among other manifestations of disrupted qi movement. If qi depression transforms into fire, heat signs may appear. Treatment involves regulating qi and relieving stagnation, descending qi to promote bowel movements. Prescriptions include Liu Mo Tang (Six Milled Ingredients Decoction) or Zhe Sui Gong Jie Tang (Red Ochre and Kansui Stagnation-Resolving Decoction); for cases where qi depression transforms into fire, use Angelica, Gentian and Aloe Pill.
3. Spleen-Lung Qi Deficiency︰It belongs to the category of "constipation of deficiency type." The stool is dry and accumulated or soft, but not passed for several days. Sometimes there is an urge to defecate, but it is difficult to pass, with straining leading to sweating and shortness of breath, or even panting. After defecation, there is extreme fatigue, weariness, reluctance to speak, a weak and timid voice, no abdominal distending pain, or possible anal prolapse. The body is cold, the face is pale, the lips and nails lack luster, the tongue is pale and tender with thin white coating, and the pulse is weak. The main cause is sinking of spleen qi; when spleen qi sinks, the large intestine lacks the strength to transport waste. Lung qi deficiency leads to the large intestine's body fluids not being distributed, and qi is also insufficient, causing waste to stagnate in the intestines. If waste remains in the intestines for a long time, it eventually forms hard masses that are difficult to expel. The clinical characteristics include having a bowel movement only once every few days, with little abdominal discomfort, but systemic malaise. During defecation, sweating, shortness of breath, and panting occur, and after defecation, there is pronounced fatigue and weakness, or even anal prolapse. The stool morphology is characterized by being large and cylindrical. Yu Tinghong described it as "huge feces like an arm" ("Essence of Medical Talks by Famous Physicians of the Qing Dynasty: Yu Tinghong's Medical Talks"), which aids in pattern identification. Treatment focuses on tonifying the spleen and lungs, supplemented with moistening the intestines. Commonly used is Middle-Tonifying Qi-Replenishing Decoction with Submature Bitter Orange and white honey.
4. Spleen-kidney Yang Deficiency︰It is equivalent to "cold constipation" and falls under the category of "yin constipation." The main manifestations include large, hard stools, accompanied by a bluish-black complexion, cold limbs and body, preference for warmth and fear of cold, normal taste sensation, clear and copious urine, frequent nighttime urination, dribbling after urination, a pale tongue with white and moist coating, and deep-slow or slightly hesitant pulses. Yang deficiency constipation presents with symptoms of yang deficiency and external cold (such as a bluish-black complexion, cold limbs and body, fear of cold, and clear, copious urine), as well as clinical manifestations of chronic cold and deep cold, primarily due to insufficient fire of the life gate caused by yang decline. This condition is commonly seen in the elderly or those with weak constitutions. The kidneys govern the two lower orifices (urination and defecation). Constipation due to kidney yang deficiency and decline, along with frequent urination, is also one of the reasons for insufficient large intestine fluids. During diagnosis and treatment, symptoms such as frequent nighttime urination and dribbling after urination should not be overlooked. Clinically, it is often observed that symptoms like frequent nighttime urination and dribbling improve first, followed by gradual relief of constipation. The treatment focuses on tonifying and replenishing the spleen and kidneys, warming and dispersing cold stagnation. The Cistanche Intestine-Moistening Pill can be used.
5. Yin Deficiency︰It belongs to the category of "constipation of deficiency type." It can be seen in the Rebing stage of convalescence, with reduced food intake, dry and difficult-to-pass stools; or postpartum; or after suffering from Yongju; or in elderly individuals with blood deficiency; or in those with chronic heat accumulation in the stomach. Symptoms include long-term dry and hardened stools, extreme difficulty in defecation (often only once every few weeks), emaciation, dry throat with little saliva, dull complexion, flusteredness and dizziness, pale lips and nails, a pale or red tongue with little moisture, and a thin or thin-rapid and weak pulse. This condition arises from a deficiency of substantial yin fluids and yin blood, leading to insufficient blood and fluids to nourish and moisten the intestines, causing stool stagnation. Clinically, it is essential to differentiate whether the disease cause is fluid depletion (e.g., after Rebing, excessive sweating, vomiting, diarrhea, diuresis, or heat accumulation in the stomach) or blood deficiency (e.g., menorrhagia and metrostaxis, blood loss). Additionally, distinguish between the clinical manifestations of fluid depletion (dry throat with little saliva, emaciation, sunken eyes, reduced skin elasticity, red tongue with scant coating and little body fluids, thin-rapid and weak pulse) and blood deficiency (dull complexion, flusteredness and dizziness, pale lips and nails, pale tongue with thin and scant coating). For blood deficiency, use the Blood-Benefiting Intestine-Moistening Pill to nourish blood and moisten the intestines. For yin deficiency, use the Left-Restoring Pill with added Fleeceflower Root and Hemp Seed to enrich yin, promote fluid production, and moisten the intestines to relieve constipation.

Constipation is generally considered one of the representative symptoms of interior syndromes. If constipation is accompanied by an exterior pattern, it belongs to a disease involving both the exterior and interior. During pattern identification, the focus is on whether the external pathogen is cold or heat. For cases of exterior cold with interior excess, the treatment should aim to release exterior cold while also addressing interior excess, using Saposhnikovia Sage-Inspired Powder as the main remedy. For cases of external contraction of wind-heat accompanied by interior excess, the treatment should focus on clearing heat with pungent-cool medicinals while also addressing interior excess, using Powder for Ascending and Descending with modifications. Additionally, symptoms such as alternating chills and fever, chest tightness, nausea, epigastric stuffiness, mild irritability, and a wiry and forceful pulse may also indicate a disease involving both the exterior and interior, but the condition is located in the Shaoyang and Yangming meridians. The treatment should aim to harmonize and purge, with Major Bupleurum Decoction as the main remedy.

Comparison:

• Constipation due to gastrointestinal excess heat is caused by the depletion of intestinal fluids due to the presence of Yangming excess heat in the intestines, which consumes body fluids and leads to dryness in the intestines. This condition is often acute and occurs during the course of cold-damage disease or warm disease, with prominent abdominal symptoms. It is distinct from constipation due to blood deficiency and yin deficiency, which develops slowly and has a prolonged course. Clinically, constipation due to gastrointestinal excess heat presents with a range of symptoms indicating excessive interior heat, belonging to an interior excess heat pattern. In contrast, constipation due to blood deficiency and yin deficiency presents with symptoms of insufficient yin and blood, representing a deficiency pattern. These two conditions, one excess and one deficiency, should not be confused. They can also be distinguished from constipation due to qi deficiency or yang deficiency by considering the accompanying symptoms.
• The commonality between spleen-lung qi deficiency and spleen-kidney yang deficiency is that both are deficiency pattern, one being yang deficiency and the other qi deficiency. Sometimes, these two conditions can coexist, or qi sinking may progress to yang decline.

bubble_chart Documentation

1. Danxi Xinfa．Dryness Accumulation: "When the intestines and stomach are affected by wind, leading to dryness and constipation, this condition is caused by the accumulation of wind qi."
2. Jingyue Quanshu．Constipation: "For individuals with weak original qi, who suffer from cold-damage disease, miscellaneous syndromes, or insufficient pestilent qi, and experience difficulty in bowel movement, if there is no abdominal distension, fullness syndrome of excess type, or urgency to defecate, it indicates the absence of excess pathogen. Even if there is no bowel movement for ten or twenty days, it is not a concern. One must not force bowel movement due to inconvenience. Since the appetite has not returned and food intake has not resumed, the body relies entirely on middle qi for defense. As pathogenic qi gradually recedes and stomach qi gradually harmonizes, natural bowel movement will occur without worry. If the intestines are not obstructed but bowel movement is forced, it may lead to the loss of stomach qi, causing the body to be overwhelmed or allowing pathogens to invade. This harm occurs subtly and is often unnoticed. Be cautious and aware."
3. Zhangshi Yitong．Large and Small Intestines: "There is a type of constipation where the abdomen is distended and uncomfortable, with frequent unsuccessful attempts to defecate, excessive straining, and the descent of weak qi to the anus, causing tenesmus that is unbearable at times. Qi counterflow leads to nausea and vomiting, thirst and desire for water, inability to eat, and continuous moaning. Attempting to promote bowel movement may cause qi to descend and collapse, while attempting to lift qi may cause it to ascend and reverse, leading to unbearable nausea. Decoction of Ginseng, Submature Bitter Orange, and Chinese Angelica, with the addition of aged citron fruit peel, is particularly effective."