Constipated, Hard Belly, Fever and Delirium? Doctor Xu Shuwei Used Da Chengqi Tang (Major Purgative Decoction)
Patient search terms: constipation / can’t pass stool / bowels not moving / no bowel movement for days / hard, bloated belly / fever with talking nonsense
Medical terms for this condition: Yangming fu-shi zheng (solid excess pattern of the Yangming bowel) · interior excess-heat pattern · constipation · intestinal endotoxemia
A word before we begin: this is a purging formula — put down your chopsticks first
Before today’s story begins, Doctor Luo Dalun has a friendly warning: if you are in the middle of a meal, please stop listening and come back when you’re finished. Why? Because today’s topic is the “downward method” (xia fa) — the purging, laxative approach to treatment. Traditional Chinese medicine has many methods for treating disease: the sweating method, the downward method, the vomiting method — all laid out in Zhang Zhongjing’s Shanghan Lun (Treatise on Cold Damage). Today we meet one specific branch of the downward method, the cold-purging method, and its star formula, Da Chengqi Tang (Major Purgative Decoction).
💬 Note from Doctor Luo: The last few stories were about the sweating method — Ma Huang Tang (Ephedra Decoction) and Gui Zhi Tang (Cinnamon Twig Decoction), the legacy of sweating treatment that the Shanghan Lun pioneered. The Huangdi Neijing (Yellow Emperor’s Classic of Internal Medicine) also mentioned the idea of sweating, but it never wrote out exactly how to induce sweat or which formulas to use. The Neijing gives guiding principles; Zhang Zhongjing in the Shanghan Lun spelled out the concrete operations — every formula represents a direction. So anyone studying Chinese medicine must get to know the Shanghan Lun — it is the root of all clinical practice.
Studying the Shanghan Lun is not easy; many people shy away, and it gets less reading than it used to. Doctor Luo says that’s fine — let’s go through it little by little, like listening to stories. And today’s story just happens to belong to the most satisfying category of Shanghan Lun case reports: one dose, and the illness was cured.
Who was the patient? In Xuanhua city, a warrior past seventy
One day, a patient arrived at Doctor Xu Shuwei’s clinic. He was a wu bian — an armed soldier — surnamed Li, working as a guard in Xuanhua (in the region of today’s Xuanhua, Hebei). He had been suffering from cold damage (shang han) for five or six days.
💬 Note from Doctor Luo: Here is a detail worth savoring: the town had no doctor. This warrior had walked a very long way into the city to find Doctor Xu Shuwei. That is how grim medical care was back then. And here’s something even more striking — guess how old this warrior was? Over seventy! The ancients said “from ancient times, few people live to seventy” — seventy was already a great age, and yet this man was still serving on the front line as a guard. It says a lot about the Song army: the fighting strength really was in decline.
Doctor Xu looked at the patient: his pulse was large, long and forceful; his bowels were blocked; his body burned with heat and he did not sweat at all. The pulse was vast and strong, the contents of the belly would not move, the body was scorching hot — and not one drop of sweat. Doctor Xu understood at once and pronounced:
“This is a Yangming pattern (yang ming zheng). It must be purged.”
The diagnostic highlight: the family blocked the purge, and Doctor Xu stood his ground
What is a “Yangming pattern”? Zhang Zhongjing divided the body’s reactions to invading external evil into six states, called the six channels (liu jing): the outermost is the Taiyang channel — the evil has just entered, and the body fights back at the surface. If the surface defense fails and the evil pushes deeper, the body mounts an even fiercer resistance — that is the second level: Yangming.
💬 Note from Doctor Luo: Yangming is the stage of the most intense struggle: all the body’s upright qi (zheng qi) mobilizes to fight the external evil. In pattern-differentiation terms: the location of the disease is in the interior (li), and its nature is heat — so this is an interior excess-heat pattern. Within this, two sub-types must be distinguished. If dry-heat evil floods the whole body and the person burns with dryness and heat, that is the Yangming channel pattern (jing zheng), treated with Bai Hu Tang (White Tiger Decoction) and similar clearing formulas. If the dry-heat evil combines with the dregs (feces) in the intestines, blocking the digestive tract and producing a severe reaction, that is the Yangming bowel pattern (fu zheng) — today’s subject, the Yangming fu-solid pattern (yangming fushi zheng).
Doctor Xu wanted to purge. But at this point, the patient’s family objected:
“The patient is over seventy. I’m afraid he cannot be purged.”
— The old man is seventy-something; how could his frame withstand laxative medicine? Doctor Xu’s answer rang out clearly:
“Heat evil and toxic qi are stored together in the Yangming channel. The Yangming channel has much qi but little blood. Whether old or young, purge.”
The heat evil and toxic qi are all pent up in the Yangming channel, and the Yangming channel is one that is rich in qi but poor in blood — at a time like this, why talk about old or young? When it should be purged, purge it. He finally laid down his condition: if you insist on not using the downward method, then I’m sorry — please find another physician, because I cannot treat this case. The family member in charge thought it over and said: Doctor Xu, if you say it can be purged, we’ll listen to you. You treat him.
Breaking down the formula: da huang, mang xiao, hou pu, zhi shi — the four-character key: pi, man, zao, shi
What Doctor Xu prescribed was the famous Da Chengqi Tang (Major Purgative Decoction) — the representative formula of the cold-purging method.
Four herbs:
- Da huang (rhubarb): a cold herb that purges downward and drains heat-bound stagnation — the commanding general;
- Mang xiao (mirabilite / Glauber’s salt): works with the rhubarb to purge, drain heat and open the bowels, and it also softens hardness and moistens dryness — dissolving the hard blockages stuck inside;
- Hou pu (magnolia bark) and zhi shi (immature bitter orange): qi-regulating herbs that move qi and disperse stagnation, opening up the stuffiness and distension in the intestines.
💬 Note from Doctor Luo: This formula was used extremely often in ancient times, especially in old hospitals, where the Chengqi formulas were standard stock. Why is it used less today? First, these diseases are no longer as severe — infectious diseases aren’t as ferocious. Second, modern people react sensitively to purgatives; the purging is very uncomfortable. But when the pattern genuinely calls for it, it still must be used.
What are the characteristics of a disease treated by Da Chengqi Tang? Four characters: pi (stuffiness), man (fullness), zao (dryness), shi (solidity).
- Pi (stuffiness): the region below the heart (the stomach and digestive system) is hard and solid when pressed;
- Man (fullness): the chest, flanks and abdomen are entirely distended;
- Zao (dryness): there are “dry stools” in the intestines — desiccated, bound feces blocking the way, coming out ball by ball like sheep droppings;
- Shi (solidity): the belly is exceptionally hard, and pressing it hurts — the patient refuses pressure.
What else does the patient actually feel? No bowel movement is the chief complaint — truly nothing comes out, often for many days on end; pin zhuan shi qi — the belly keeps churning with gas and constant farting; abdominal fullness with pain on pressure — distended belly, hard and tender to the touch; tidal fever (chao re) — especially around five o’clock in the afternoon sweating begins, with the hands and feet sweating particularly noticeably; in severe cases, zhan yu — the patient starts talking nonsense, becomes confused, and rambles in delirium.
What else supports the diagnosis? Look at the tongue: the tongue coating is yellow and parched, drying in patches, sometimes even black — as if scorched, with cracks; the tongue body itself is red, and the pulse is forceful.
The treatment twist: half a day with no reaction — the family had secretly halved the dose
The formula was written, the decoction prepared, and the patient drank it. And then? Half a day. Nothing.
Doctor Xu was puzzled: I treat diseases cleanly — why no response? He took the pulse again: all the symptoms were still there. He thought for a moment, then asked the family: “Did you not give the patient the whole dose?”
The family turned red: “Yes, yes — you’re too sharp, you saw right through us.” It turned out the family knew this was a laxative, feared that a seventy-year-old man couldn’t take it, and secretly gave him only half — thinking that a lighter dose would let him survive it.
💬 Note from Doctor Luo: You can see human nature at every turn in this case record: the family meant well, afraid the old man couldn’t take it. But in treating disease with medicine, a miss by one part is a miss by one part. Doctor Xu said this won’t do — prepare another dose, and I’ll supervise personally, watching you give him the whole thing.
So the old warrior gulped down an entire dose of Da Chengqi Tang. In less than half the time — less than half of half a day — the old man lying in bed urgently called for the bedpan. And then, miraculous:
First came out several dry, bound stools (zao fen) — the desiccated feces that had been blocked inside for days. Then came a passage of foul red filth (chi se hui wu), so rank that everyone nearby held their noses and couldn’t enter the room.
💬 Note from Doctor Luo: This shows the intestines had indeed gone completely chaotic: dry stools were stuck and could not pass, and intestinal movement was abnormal. Once they came out, the blocked place opened, the qi in the belly moved freely, and blood and qi circulation returned to normal — what is this called? The “purge-then-sweat method” (xie xia chu han fa). The old man hadn’t even left the bedpan when sweat began pouring out all over his body! Once the sweat came, the evil was resolved with it.
Sure enough: sweat over the whole body; when the sweat stopped, the body cooled — the sweat came through thoroughly, the fever broke, the body cooled down, and all the suffering vanished at once (zhu ku sui chu).
Aftercare: don’t take tonics once cured — drink congee for ten days
The next day, Doctor Xu came back for a follow-up. The old warrior was full of energy and said with a smile: “I’m past seventy, and this one purge has drained me. Please prescribe some tonic medicine.” Doctor Xu shook his head:
“Once cured, tonic medicine is not suitable. Tonics would bring the heat back (bu ze re fu).”
The illness is cured — no need for tonics. Yours was a heat pattern; we used the cold-purging method to drive the heat out. If you take tonics now, the heat may come back. Just eat plain congee for about ten days, keep the diet light, and let the spleen and stomach recover slowly.
💬 Note from Doctor Luo: What shows here is Doctor Xu’s crystal-clear grasp of the disease mechanism: when to attack, when to hold, and how to wind down after the attack — not a single step out of order. The old man wanting tonics is only human nature, but the physician cannot be led by “human sentiment” — he must be led by “disease mechanism.”
Doctor Xu himself later reflected that in a lifetime of treating this kind of disease, “only Da Chengqi Tang cured in one dose — nothing was ever faster” (zhi da chengqi yi fu er yu, wei you ruo ci zhi jie).
The commentator’s note: “old or young” describes the body; “cold or heat” describes the evil
At the end of the case, Doctor Xu left a very famous passage:
“Lao zhuang zhe, xing qi ye; han re zhe, bing xie ye. Zang you re du, sui shuai nian ye ke xia; zang you han xie, sui zhuang nian ye ke wen. Yao zhi yu bing, xiang yi er yi. Ruo shi ji hui, ze su bi.”
💬 Note from Doctor Luo: Translated: “Old or young” speaks of the person’s physique and qi; “cold or heat” speaks of the nature of the disease evil. If the viscera harbor heat toxin, then even in declining years one may be purged; if the viscera harbor cold evil, then even in the prime of life one should be warmed. The medicine need only match the disease — if the opportunity is missed, the patient will rapidly fall into danger. This passage is the very core spirit of pattern-based treatment in Chinese medicine: look at the person, but even more look at the disease. When boldness is called for, you must be bold.
Doctor Luo says that Doctor Xu’s case records are classics of Chinese medical history — when later physicians explain how Da Chengqi Tang should be used, the example they cite is almost always this case of Xu Shuwei’s. In medical history this belongs to the earliest documented cases applying the Shanghan Lun formulas — a small milestone: it marks when this formula should be used and how the ancients actually used it.
Extended stories: the delirious old man, the stroke patient with constipation — all connected
Why does the Yangming fu-solid pattern produce fever and delirium? Doctor Xu Shuwei’s age had no microscope, but Doctor Luo translates it for us in today’s language:
💬 Note from Doctor Luo: From the modern medical viewpoint, a serious infection has already developed in the intestines — the gut flora is severely disturbed, harmful bacteria multiply, and a great deal of toxin is produced. These toxins enter the blood, causing intestinal endotoxemia; once in the bloodstream they stimulate the brain — so the patient talks nonsense, rambles, and sinks into confusion. This is where the ancients’ wisdom lies: the stool is blocked inside; the more it blocks, the hotter it gets; the hotter it gets, the more fluid is consumed; the more fluid is consumed, the hotter it gets — a vicious cycle. What to do? The cold-purging method — use cool medicine to flush it downward, remove the fuel from under the pot (fu di chou xin).
Da Chengqi Tang’s indications go beyond this single case. For instance, re jie pang liu (“heat-bound next-flow diarrhea”) — the patient appears to pass nothing but clear water, but in fact dry stools are stuck inside and the fluid is simply flowing around them. The downward method also comes in several levels — Xiao Chengqi Tang (Minor Purgative Decoction) and Tiaowei Chengqi Tang (Regulating the Stomach and Purging the Bowels Decoction) form the Chengqi family with Da Chengqi Tang, each gentler in purging force than the last; which one to choose depends entirely on the severity of the illness. Other scenarios: external evil enters the Shaoyin channel and then returns, and during recovery comes back to the Yangming channel — this also easily forms the interior excess-heat pattern. And today, many acute abdominal conditions such as pancreatitis and biliary tract disease, when they present with an interior excess-heat pattern, can all use the Da Chengqi Tang line of thinking.
Doctor Luo especially warns about one group of people: many stroke and cerebral hemorrhage patients have been constipated for a long time. Do not underestimate constipation — when it is blocked inside, qi and blood cannot circulate smoothly, heat consumes body fluids, fluids are badly damaged, qi and blood movement is impaired, the whole body turns into a heat pattern, and in the end a cerebrovascular event is triggered. In this situation, relieving the bowels promptly is a very important measure — otherwise the body’s condition deteriorates further. Doctor Luo says he has seen many such elderly patients.
💬 Note from Doctor Luo: The sweating, vomiting and purging methods were the killer moves of many famous ancient physicians. In the Jin-Yuan period, Zhang Zihe, one of the Four Great Masters of the Jin-Yuan, carried the three methods to their extreme — every patient who came either sweated, vomited or purged, and was cured; his disciple Ma Jiuchou was also a famous physician who cured every case. That’s how they treated: attacking evil, one patient cured after another. Formulas like Da Chengqi Tang are rarely used by ordinary people, but the way of thinking should be understood — this is the charm of the classical formulas (jing fang): once the pattern matches, they turn the tide, and the effect is immediate.
The jing fang school (classical formula school, anciently called the “jin fang pai”) that Doctor Xu Shuwei founded came from mastering the Shanghan Lun: when a patient came, the problem was solved quickly — if three doses show no effect, go find another doctor. Zhang Zhongjing had already thought the pattern-differentiation method through to its depths — this is a treasure of ancient China.
Arranged from Doctor Luo Dalun’s commentary on Doctor Xu Shuwei’s case record, from the Shanghan Jiushi Lun (the Yangming kexia zheng — Yangming purgable pattern · Da Chengqi Tang).