Stool and Urine Both Blocked? Doctor Zhang Jingyue’s Case of Heat-Stagnation Constipation (Yang Jie) — 60 Grams of Crude Rhubarb to Hack Through a Tangled Knot
Patient search terms: constipation / can’t pass stool / no bowel movement in days / both stool and urine blocked / bloated belly / can’t poop / can’t urinate either
Medical terms for this condition: heat-stagnation constipation · yang-type constipation (yang jie) · Yangming fu excess (yang ming fu shi) · blockage of both stool and urine (er bian ju bi)
Opening: this young man had blocked up both exits
Today’s illness has to do with the intestines — constipation. And Doctor Luo warns everyone right away: if you are eating right now, come back to this later — don’t listen to this one over a meal. So how bad was this case? A young man had both of his exits completely blocked — he hadn’t had a bowel movement in days, and the urine had stopped too. He was miserable beyond words. In classical Chinese medicine this is called er bian ju bi, “blockage of both stool and urine.”
💬 Note from Doctor Luo: Don’t underestimate constipation. When it really reaches the point where both stool and urine are completely blocked, that is an emergency — handle it badly and there is real danger. This case was treated personally by the great Ming-dynasty physician Doctor Zhang Jingyue; it is known as “the case of Yang Jiexin.” Doctor Zhang Jingyue came from Shaoxing, Zhejiang, was the founding master of the warming-and-tonifying school, and wrote Jingyue Quan Shu (The Complete Works of Jingyue). His discussion of constipation is extraordinarily detailed, so today, using this case as our doorway, let us walk through his whole theory.
Who was the patient? A sturdy young man with a taste for “fire wine”
Doctor Zhang Jingyue wrote: “Yu chang zhi yi shao nian” — “I once treated a youth.” Note that “youth” here does not mean a child; it means a young man. What was this young man’s problem? Su hao huo jiu — “he had always loved fire wine.”
💬 Note from Doctor Luo: What is “fire wine”? It is distilled spirits (shao jiu). In ancient times people generally drank rice wine, which is low in alcohol and can be sipped like a beverage; later distilled spirits arrived, a much stronger drink, and many people took to it. This young man loved that strong liquor. And to make matters worse, it was summer: after drinking, his body ran hot, so he would get drunk and lie down outside to sleep under the open night air. A little night chill didn’t bother him — he thought nothing of it.
Doctor Zhang Jingyue’s comment on him: “Shi xing zhuang qi, jie you da guo ren zhe” — “in appetite, build and vigor he far surpassed other men.” This fellow was powerfully built. Most people who abused themselves the way he did would have collapsed after two such episodes; but he had a strong constitution, kept at it constantly, and still exceeded ordinary men. Yet even a body like that finally broke down. What happened? After years of this abuse, heat stagnated in the Triple Burner (san jiao), and both stool and urine closed off.
Even a strong body can’t take it forever: heat stagnating in the Triple Burner, both exits blocked
Both stool and urine gone — how do you treat that? Doctor Zhang Jingyue did not write a prescription right away. First he laid out, from beginning to end, his entire study of constipation — and this is precisely the part of Jingyue Quan Shu most worth reading.
💬 Note from Doctor Luo: Doctor Zhang Jingyue was an extremely rigorous scholar. When he wrote about constipation, he began by citing the Huangdi Neijing (Yellow Emperor’s Inner Canon) — straight away he quoted the chapter Jin Gui Zhen Yan Lun (Discussion of the Essential Subtleties of the Golden Cabinet): “The north corresponds to black, enters through the kidney, and opens at the two yin orifices.” This sentence is extremely important: it means that problems of the intestines ultimately all have to do with the kidney. The kidney opens at the two lower orifices (the anus and the urethra), so apart from Yangming fu excess caused by external invasion — where the interior is blocked up enormously — every other kind of constipation must ultimately be traced back to the kidney. That is the guidance of the Neijing.
Doctor Zhang Jingyue was a master of the Inner Canon. He devoted his life to studying it and wrote Lei Jing (The Classified Canon), a systematized commentary on the Neijing. Later, when the Qing-dynasty Imperial Medical Academy trained imperial physicians, the textbook they used for studying the Huangdi Neijing was written by none other than Doctor Zhang Jingyue. So citing the classics was second nature to him: he gathered up every relevant statement on constipation and set it out for you — so you don’t have to go dredging through the great tomes yourself.
The ancients split constipation into six types; Doctor Zhang Jingyue said: two are enough
The classical formularies divided constipation very finely: deficiency constipation (xu bi) — qi too weak to push the waste through the intestines; wind constipation (feng bi) — wind evil entering and causing blockage; qi constipation (qi bi) — qi movement obstructed or qi deficient; heat constipation (re bi) — heat inside; cold constipation (han bi) — cold congealing and freezing things up; and dampness constipation (shi bi) — heavy dampness so that qi cannot circulate. Li Dongyuan also had his own scheme: “heat dryness, wind dryness, Yangming knotting, and yin knotting.”
💬 Note from Doctor Luo: Doctor Zhang Jingyue said: you have created too many categories — when you actually see a patient, all these names make you dizzy and you can’t tell which one it is. In his view, two categories suffice: yin-type knotting (yin jie) and yang-type knotting (yang jie). Yang jie means blood is in surplus and there is heat inside — you must attack, must purge. Yin jie means upright qi is insufficient — you must nourish and tonify, slowly. So where does wind constipation go? Wind arises when heat generates wind, so it goes into yang jie. Qi constipation is split: qi-excess goes into yang jie, qi-deficiency goes into yin jie. That simple. Of course, Doctor Luo adds: if you can truly perceive the finer differences among deficiency, wind, heat and so on, then by all means divide more finely — the schools can be used together.
How to treat yang jie? Wherever the fire comes from, drain it there
On treatment, Doctor Zhang Jingyue taught: yang jie means fire in surplus (huo you yu). Fire burns inside, drying up the body’s fluids and liquids, and constipation results. Where does this fire come from?
💬 Note from Doctor Luo: He named three sources of fire. First, the fire of food and drink, arising from the spleen — day after day of rich, fatty, sweet foods, barbecue and spicy dishes, piling up stagnation in the spleen. Second, the fire of wine and lust, extreme in degree — drinking strong liquor, and excessive desires on top of it. Third, the fire of the season — the weather outside is hot, and fire gathers in the body. Illness from this sort of fire usually comes on acutely. Look at the presentation — a full picture of heat: yellow tongue coating, red tongue, a full and forceful pulse. When this is the case, you treat by clearing downward and purging outward — drain the heat stagnation away. The Chengqi decoctions — Da Chengqi Tang (Major Purgative Decoction) or Xiao Chengqi Tang (Minor Purgative Decoction) — both work.
And yin jie? Yin jie is basically deficiency, and it comes in two varieties. One is yang deficiency — the whole body feels cold, yin-cold dominates internally, and there is no strength to push the waste outward. Here you must warm the yang, warm slowly and open slowly — for example Yougui Yin (Restore the Right [Kidney] Drink) or Dabuyuan Jian (Great Tonify the Origin Decoction), or send Yougui Wan or Guifu Dihuang Wan down with a decoction of ginseng, angelica and atractylodes. The other is yin deficiency — red tongue with thin coating, thin and weak pulse, hot palms and soles, night sweats while sleeping; the body’s yin fluids are insufficient, and deficiency fire has dried up the fluids as well. Here you must nourish yin — Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill) and similar yin-nourishing remedies. If you add two or three qian (about 6–9 g) of Cistanche (rou cong rong), washed in wine to remove its salty taste, and decoct it with the medicine, the effect is even better.
Constipation in the elderly and yin jie: Xu Shuwei’s bowl of hemp seed congee
Doctor Zhang Jingyue also passed along some practical experience. Some people are in no hurry at all about their bowels — they don’t go for days, even ten days — yet when they finally do go, the stool is not even dry. He said: cases like this are never heat syndromes. They are mostly caused by the seven emotions, overwork and fatigue, or excessive sexual desire — factors that wound the upright qi, so that the yang inside is depleted, unable to transform qi and unable to move the waste along. Here you must not purge; you tonify slowly: Lizhong Tang (Regulate the Center Decoction), Wenwei Yin (Warm the Stomach Drink), Wujunzi Tang (Five Gentlemen Decoction), Guipi Tang (Spleen-Restoring Decoction), Buzhong Yiqi Tang (Tonify the Center and Boost Qi Decoction) — all work. If the disease lies in the kidney, use Yougui Yin, Dabuyuan Jian, or Guifu Dihuang Wan and regulate slowly.
💬 Note from Doctor Luo: And there is another extremely common category — constipation in the elderly. Most elderly constipation belongs to blood dryness (xue zao): blood deficiency generating dryness. The Huangdi Neijing says, “At forty, the yin qi has already declined by half” — from age forty the yin qi begins to ebb, the body ages, essence and blood are gradually consumed, and the stool slowly dries up. Elderly constipation is very common. What to do? Doctor Zhang Jingyue said the only way is xu zhe bu zhi, zao zhe run zhi — tonify the deficient, moisten the dry — mainly moistening, with just a little something to open the passage. He offered an excellent formula: Scholar Xu (Xu Shuwei, the Song-dynasty physician Xu Jichuan) treats constipation in the aged and deficient with a congee of hemp seed and perilla seed, half and half — grind them, cook them into congee; no medicine needed, and it resolves gradually.
At this point Doctor Luo cannot resist a few extra words about hemp seed (huo ma ren). Bama in Guangxi is the place with the most centenarians per capita in the world. The elderly there cook without oil: they finish a soup, grab a handful of crushed hemp seed, drop it in, and the oil comes out by itself — that’s the soup they drink. Bama hemp-seed oil: it moistens dryness and opens the bowels.
💬 Note from Doctor Luo: Hemp seed is not just a laxative. I’ve said before that Zhi Gan Cao Tang (炙甘草汤, Honey-Fried Licorice Decoction) contains hemp seed — and there it is not for moving the bowels at all. There it supplements original qi and benefits the five viscera, and it is especially good for the heart. Current research shows that hemp seed can repair damaged cardiac muscle cells and adjust the cholesterol ratio — it is very friendly to the heart. So why do the old people in longevity regions live so long? Good cardiovascular health, and smooth intestines. If you ever come across Bama hemp-seed oil, buy some — a few drops in your cooking, and you will certainly benefit. Xu Shuwei stood at the very top of Song-dynasty medicine; everyone in the field speaks of him with the deepest respect. His hemp-seed-and-perilla-seed congee is a fine way to moisten the intestines and open the bowels in the elderly.
Doctor Zhang Jingyue added a special warning: whenever the elderly, the deficient, people with a yin-type constitution, or patients after childbirth, after illness with profuse sweating, with excessive urination, with blood loss, or after violent vomiting and diarrhea develop constipation — don’t purge casually. The losses inside are already severe enough; you must moisten slowly, nourish slowly, using herbs that nourish the blood, nourish yin, and replenish the fluids — especially the oily, fatty ones — and the passage will open by itself. Lots of elderly people, for no particular reason, go out and buy rhubarb (da huang) or senna leaves (fan xie ye) to “clear themselves out” — that is wrong. It harms the body, and it should not be used that way, ever.
Back to the case: rhubarb at five to seven qian — like a stone dropped into water
With the whole theory laid out, let us return to the young man — this fellow who drank strong liquor and slept outside at night, until heat stagnated in the Triple Burner and both stool and urine closed off. Doctor Zhang Jingyue took one look: this is yang jie — heat-type knotting. How do you treat yang jie? Purge.
💬 Note from Doctor Luo: He first gave Da Chengqi Tang (Major Purgative Decoction) — Zhang Zhongjing’s formula for Yangming fu excess, containing rhubarb, bitter orange, magnolia bark and Glauber’s salt: the famous cold-natured, vigorously purging formula that breaks heat stagnation. Doctor Zhang Jingyue used rhubarb at five to seven qian — seven qian is about 21 grams. The rhubarb went in… and what happened? Like a stone dropped into water (ru shi tou shui) — not even a ripple. No response at all!
He switched formulas: Shenyou Wan (Divine Aid Pill) and the guidance method (dao fa). Shenyou Wan contains morning glory seed (qian niu — the black and white varieties) with rhubarb — also a purging formula, a strong one, though usually in modest doses. The guidance method means ways of conducting things through, for example inserting a little honey into the rectum to moisten and guide. The result? Still nothing would pass — and now both passages were closed, the urine had stopped as well.
The heavy artillery: 60 g of crude rhubarb, 9 g of Glauber’s salt, 6 g of pig-tooth gleditsia
Doctor Zhang Jingyue’s analysis stayed with Da Chengqi Tang — because the heat inside really had to be cleared out, the dose had to be large, and one must use cold-natured herbs to clear the heat; Da Chengqi Tang is a cold purgative. So what did he do? He raised the rhubarb.
💬 Note from Doctor Luo: Here is a piece of materia medica knowledge: rhubarb is usually used in its processed form (shu da huang, e.g. wine-processed rhubarb) — milder in action, with a clear heat-clearing effect. Crude rhubarb (sheng da huang), by contrast, has a pronounced purging effect. This time Doctor Zhang Jingyue used crude rhubarb at two liang — 60 grams — plus Glauber’s salt at three qian (9 g), and added six grams of pig-tooth gleditsia fruit (zhu ya zao). Gleditsia resolves phlegm, opens the orifices, and disperses stagnation and swelling. In the old folk medicine for acute intestinal obstruction there was a method: burn the gleditsia fruit over a gentle flame and let the smoke fumigate the anus — the patient sits over it for ten or twenty minutes, the intestines begin to gurgle, and most people get relief. Intestinal obstruction is agonizing, and mishandled it can threaten life, so the gleditsia fruit’s power to open the orifices and break up obstruction is worth remembering.
The medicine was taken at dusk — and by the fourth watch of the night it moved. Once the stool passed, the urine gradually came through as well.
Medicine at dusk, bowel movement at the fourth watch: why did the urine open up with the stool?
Why does the urine open up the moment the stool passes?
💬 Note from Doctor Luo: It was because everything was blocked inside — the qi movement was all imprisoned within, and the function of both passages was deranged, so nothing could be expelled. The moment the stool passed, the urine came through with a whoosh. From the Western-medicine perspective, when you are severely constipated the bowel can press on the urethra and interfere with urination; but in Chinese medicine, the main explanation is the stagnation of qi movement — the whole function had gone wrong. Similar cases appear in other ancient physicians too: doctors like Miao Xiyong recorded cases of both passages closed, and there are various formulas for opening the gates and unblocking the blockages.
Doctor Zhang Jingyue himself commented on this case with a famous line: “Ci suo wei pan gen cuo jie, you fei fu jin bu ke zhe” — “This is what is meant by tangled roots and knotted branches; nothing but an axe will do.” The heat evil inside had grown into a tangled, knotted mess; you simply had to bring down a big axe. Earlier, rhubarb at five to seven qian had done nothing — two liang was what it took. In a situation like this, if the physician hesitates and wavers, the patient may be lost.
Bonus: how to use rhubarb safely — Master Zhao Shaoqin’s method
Taking this case as his cue, Doctor Luo would like to share one more way of using rhubarb, from Master Zhao Shaoqin — the great master of warm-disease medicine at Beijing University of Chinese Medicine.
💬 Note from Doctor Luo: Master Zhao Shaoqin was famous for treating kidney disease. In chronic nephritis and kidney failure, the heat evil often hides deep in the kidney channel, and the treatment is to cool the blood and invigorate the blood. Warm-disease theory speaks of wei, qi, ying, blood — the four levels. Heat evil travels from the defense level (wei) all the way to qi, nutritive (ying) and blood levels, and if it goes even deeper, down to the marrow level, you get blood-system diseases like chronic nephritis and leukemia. Such patients have heat inside, and many of them are constipated — kidney-failure and chronic-nephritis patients very often are. In that situation you add rhubarb — and the rhubarb must be packaged separately (dan bao), with clear instructions to the patient, because everyone’s tolerance differs: some people don’t purge even with one or two liang, others purge at the slightest touch. So start with two grams of crude rhubarb, and if you want it to purge, it must be added late (hou xia) — dropped in during the last ten or twenty minutes of decocting, then left to steep a while. The shorter the cooking time, the stronger the purging effect. Did it move? No? Then next time add three or four grams; still nothing, add more, step by step. When it finally moves at ten or twenty grams, cut back the dose — keep the bowels moving smoothly: not constipated, but not pouring out like water either — and hold it right there. You see, Chinese medicine is very scientific: everyone reacts differently. Some people move with the tiniest amount; others, with heat too heavy, must build up a large dose before it works. This young man, for instance, needed 60 grams of crude rhubarb — only when the dose was basically right did the purge come.
Finally, Doctor Zhang Jingyue sums up the diagnostic essentials of heat-type knotting once more: the patient’s face will certainly be red; the tongue coating yellow, the tongue body red, the edges red; the coating yellow and greasy — in severe cases dry, parched, even black; the pulse bounces “thump, thump” — forceful, fast; and when you feel the abdomen, it is hot all over. That is heat-type knotting. Heat-type knotting is usually an acute condition — it comes on suddenly, and once you purge it away, it is done. Yin-type knotting, by contrast, tends to be chronic — many elderly people have been constipated for years. The cases of yin-type knotting, Doctor Luo says, we will take up tomorrow.
*Compiled from Doctor Luo Dalun’s explanation of Doctor Zhang Jingyue’s case records; the case comes from Jingyue Quan Shu (The Complete Works of Jingyue).