Chapter Two. Accumulation syndrome and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that stimulate the intestines, promote bowel movement in order to purge accumulation, eliminate toxic substances, drain fire and cold of the body and drive out congested water. They are used to treat excess conditions and interior syndromes. These methods and strategies relieve the symptoms rather than treat the cause. However, they can stop further pathological changes caused by the accumulations.
Although accumulations can result from several pathogenic factors, such as food, phlegm, water and blood, in this chapter only accumulation of the intestines and accumulation of water are discussed. Accumulations of food, phlegm and blood are discussed in other chapters.
Obstruction of the intestines, intestinal adhesions and intussusception are acute abdominal syndromes and they have severe pathological consequences. They cause accumulation of feces, Qi, blood, heat and fire-toxin in the intestines. As well as regular western medical treatment, certain intestinal ad-hesions, intussusception and the primary stage of simple or partial intestinal obstruction can be treated with Chinese herbal medicine.
Fire-toxin, as a pathological product as well as a pathogenic factor, can accumulate in the intestines. Fire-toxin should be eliminated as soon as possible, especially before long-term accumulation and when the blood is not strongly disturbed, in order to prevent further development of disease, such as in chronic mild infections of the intestines, or at the primary stage of acute appendicitis, acute pancreatitis, acute cholecystitis, hepatitis and ulcer perforation and inflammation.
The action of downward-draining herbs can move the bowels, thus eliminating toxins from the body when Liver and Kidney functions are impaired and they fail to remove toxic substances, such as in cirrhosis of the Liver and renal failure. If a toxic substance has been ingested, the action of downward-draining herbs can assist the body in eliminating it.
When water metabolism is disturbed, water can accumulate in certain places, such as the hydrothorax and ascites, which can obstruct the Qi. In acute and excess conditions, they should be drained downwards by herbs with a cathartic effect in order to relieve symptoms.
CAUTIONS AND CONTRAINDICATIONS
1. Protect the Stomach and body fluids:
To treat severe accumulation, the purgative herbs in the formula are strong and their speed is fast, thus they easily injure Stomach-Qi and body fluids. Compared with other moist laxatives, these herbs should only be used for a short period and their dosage should be controlled carefully. Long-term usage of purgatives for constipation may lead to consumption of the body fluids in the intestines and make constipation worse. As soon as the purgative action takes effect and the symptoms are less severe, the formula should be discontinued.
2. Use only in excess conditions:
Since the actions of the strong purgative formula are harsh, they are only used for excess syndromes and for people with a strong constitution. For patients who suffer from deficiency syndromes but who also need these herbs in the treatment of acute or severe accumulation, such as in weak, elderly people and people with a chronic disease, tonifying herbs must be used as well.
3. Avoid usage in menstruation, bleeding conditions and in pregnancy:
Formulas that strongly drain downward can also drain Qi as well as blood downward, so they are not suitable for use during heavy menstruation or in bleeding conditions. They should not be used in pregnancy.
4. Unsuitable in exterior syndrome:
Formulas that drain downwards are, in principle, not suitable for patients who have an exterior syndrome. It is better to treat the exterior syndrome first and not to drain downwards, otherwise it can lead to the exogenous factors entering into a deeper region of the body.
5. Caution in special cases:
When downward-draining formulas are used to treat acute abdominal syndromes, such as acute intestinal obstruction, appendicitis, cholecystitis and pancreatitis, it is also important to remember that these herbs are only suitable for certain periods in the whole pathological process of the disease, or certain types of disorder. These formulas should only be prescribed by doctors after modern medical examination. If herbal treatment does not result in relief of symptoms, western medical treatment is usually indicated.
6. Appropriate diet:
During treatment, patients should take care of their diet. Soft, warm, light and easily digested food is recommended.
1. Accumulation syndrome due to excess heat in the intestine
Manifestations
Main symptoms in a severe case
Severe constipation, dry stool (sometimes a foul-smelling fluid is excreted instead of stool), flatulence, bowel movement once in several days, severe focal abdominal pain increased on pressure, a tense and firm abdomen. There may be tidal fever, delirious speech and profuse sweating.
Tongue
Red or deep-red with a yellow or brown, dry, thick coating.
Pulse
Rapid, deep, forceful.
Main symptoms in a moderate case
Constipation or habitual constipation, dry stool, irregular bowel movement, distending pain of the abdomen.
Tongue
Slightly red or deep-red with a sticky, white or yellow coating.
Pulse
Wiry, slippery.
Secondary symptoms
Fullness in the chest and epigastria, thirst, reduced appetite and irritability.
Associated disorders in western medicine
Constipation, habitual constipation, uremia, acute intestinal obstruction, acute abdominal conditions.
Analysis of the syndrome
This syndrome is caused by accumulation in the intestines. The accumulation generates heat and this further injures the fluid of the intestines and makes the accumulation worse. The Qi is obstructed by the accumulation, which causes fullness, distension and pain in the abdomen. The conditions of the heat and body fluids are shown in the degree of constipation.
In severe cases:
• the heat is so strong that the patient may have profuse sweating, thirst and fever
• if heat disturbs the mind, patients may be irritable and speech may be delirious
• the tongue coating is very dry and the color of the coating changes from yellow to brown, indicating increasing heat. A deep-red tongue with red spots also indicates heat. A thick tongue coating and a forceful and slippery pulse are signs of the accumulation.
In a moderate case of constipation:
• the feces are dry or are difficult to defecate, and bowel movement occurs only once every 2 or 3 days. The primary cause is dryness in the intestines with heat and Qi stagnation. This is usually caused by reluctance to go to the toilet, and this develops habitual constipation, such as is seen in primary school pupils and adults with a busy life. It can be seen in people with a Yang type of constitution, or people who eat lots of fried or spicy food that produces heat. People who take too little physical exercise may have Qi stagnation that leads to constipation. Furthermore, deficiency of Qi, blood, Yin and Yang may lead to Qi stagnation and dryness in the intestines. In this case, although feces are not very dry, bowel movement is very slow and difficult.
(See Figure 2.1 on page 69.)
Treatment principle: Drain the heat in the Large Intestine and move the stool; promote Qi movement and nourish the body fluids
Note
In a severe condition, promoting bowel movement is a quick and effective way to purge accumulation, drain the heat, protect the fluid in the intestines and relieve pain and distension due to Qi stagnation. In a moderate case of constipation or in a case of chronic habitual constipation, moistening the intestines, increasing the fluid and activating the Qi are more important than clearing heat and purging the stagnation.
Herb selection principles and formula composition strategies
• In a severe case of constipation, herbs that are cold and salty or cold and bitter, and that can enter the Large Intestine meridian, purge the intestines and move stool are selected.
• In a moderate or mild case of constipation, the first priority is to select herbs that are seeds and rich in oils, can moisten the intestines and move stool.
• Herbs that are sweet and cold, and nourish the Yin and fluids of the Stomach and Large Intestine in order to moisten the intestines and soften stool are selected.
• Herbs that activate Qi movement in the Stomach, Large Intestine and Liver are selected.
• Herbs that regulate the blood, clear heat, remove phlegm, soothe the Stomach-Qi and tonify the weakness of Qi, blood, Yin or Yang can be added if these disorders are present.
• In a chronic condition, herbs that protect the Spleen and Stomach and can moderate the function of the purging herbs are selected.
• Herbs that enter the Lung and disperse the Lung-Qi so as to accelerate the Large Intestine-Qi to descend can be added.
Structure of the formula and selection of herbs
Chief: Stimulate the intestines and purge the stool in a severe case; moisten the intestines and promote bowel movement in a moderate case
Da Huang ( Rhei rhizoma)
Da Huang is a very bitter and cold herb. As it purges the intestines intensively, it can strongly drain heat and move the stool. It is the most important herb to treat excess heat accumulation in the intestines. Da Huang can be prescribed as chief in a formula in a severe case.
Da Huang is a very good purgative agent compared with such agents in western medicine. It stimulates the intestines and purges the bowels without severe cramp. The purgative effect appears 6–8 hours after oral consumption of this herb; as an enema, it has a much quicker onset of action.
Da Huang can be used raw or processed. Raw Da Huang has a stronger function of purging the accumulations in the intestines than baked Da Huang. Raw Da Huang should not be cooked for too long, otherwise the purgative action becomes weaker.
Mang Xiao ( Natrii sulfas)
Mang Xiao is another commonly used purgative substance. It is salty and cold, can moisten the intestines, soften the feces and therefore promote bowel movement. It is particularly suitable for constipation when the feces are very dry.
The main constituent of Mang Xiao is sodium sulfate. As the intestines cannot absorb sulfate, it stays in the intestines and increases osmotic pressure to accumulate water in the intestines, stimulate them and soften the feces.
Several products of Mang Xiao can be selected. The commonly used version is called Mang Xiao. Another version, called Pu Xiao, contains salt, calcium sulfate and magnesium sulfate as well as sodium sulfate. Its ability to promote bowel movement is stronger.
Da Huang and Mang Xiao are often used together to treat constipation and excess heat in the intestines. Because Da Huang can purge the bowels and Mang Xiao can soften the feces, their therapeutic actions are accentuated.
Lu Hui ( Aloe folii extractus)
Lu Hui is very bitter and cold, and enters the Liver, Heart, Stomach and Large Intestine meridians. It is a very strong herb to purge the bowels and reduce excess heat. It directly drains Liver-fire and Heart-fire. It is selected when the heat of Heart and Liver affects the Stomach and Large Intestine.
Fan Xie Ye ( Sennae folium)
Fan Xie Ye is sweet, bitter and cold, and enters the Large Intestine meridian. It has a moistening nature and is able to moisten dryness in the intestines, clear heat and promote bowel movement. Its function of moving the bowels is stronger than that of Da Huang. If a small dosage of Fan Xie Ye is applied, it can also promote digestion and is used for constipation caused by improper diet.
Huo Ma Ren ( Cannabis semen) and Yu Li Ren ( Pruni semen)
These two types of seed contain oils and can moisten the intestines. In addition, they have a descending ability and can promote Qi movement. Thus they are often selected in formulas to treat mild or chronic constipation. They are often used for habitual constipation.
Huo Ma Ren is a sweet and neutral herb, and it can either promote bowel movement or tonify the Qi and blood. It is particularly suitable for treating constipation after surgical operations or delivery of a baby, and in patients who suffer from chronic diseases or have a weak constitution. It can also be used to treat hemorrhoids and habitual constipation.
Yu Li Ren is pungent, bitter, sweet and neutral, and enters the Spleen, Small Intestine and Large Intestine meridians. It is moist in nature and has a descending tendency of action. It is able to descend the Qi, promote bowel movement and urination and is usually used in excess syndromes.
These two herbs are often used together to treat chronic constipation as this accentuates their therapeutic actions.
Deputy: Nourish the Yin and moisten the Stomach and Large Intestine
Mai Men Dong ( Ophiopogonis radix), Xuan Shen ( Scrophulariae radix) and Sheng Di Huang ( Rehmanniae radix)
These herbs are cold in temperature and all three can nourish the Yin and clear heat in the intestines. As such, they are often used as deputies in a formula to treat constipation due to dryness and heat in the intestines. They can be used together or separately according to the degree of dryness and heat in the Large Intestine.
Zhi Shi ( Aurantii fructus immaturus) and Hou Po ( Magnoliae cortex)
These two herbs are often used as assistants to promote Qi movement and descend the Qi in the Large Intestine so as to assist the chief herb to move the stool.
Zhi Shi is bitter and cold, and can strongly direct the Qi downwards in the Large Intestine. It is an important herb to break up the stasis of Qi, phlegm and food.
Hou Po is bitter and warm, and can effectively descend the Qi in the Lung, Stomach and intestines to reduce fullness, dry dampness and eliminate phlegm.
These two herbs are often used together to treat severe cases and chronic moderate cases of constipation as this can accentuate their therapeutic actions.
Bing Lang ( Arecae semen), Mu Xiang ( Aucklandiae radix)**, Lai Fu Zi ( Raphani semen) and Gua Lou Ren ( Trichosanthis semen)
These four herbs all enter the Large Intestine meridian. In formulas for promoting bowel movement, they can effectively promote Qi movement so as to assist the purgative function of the chief herbs. They can be selected separately or in groups.
Bing Lang is pungent, bitter and warm, and is good at promoting Qi movement and reducing the accumulation of food. It is only used in severe distension of the abdomen due to accumulation of food and dampness.
Mu Xiang is aromatic, pungent, bitter and warm, and has a drying nature. It can effectively move the Qi and reduce pain due to Qi stagnation. As it also enters the Liver meridian, it is particularly suitable for use in conditions where the Liver-Qi attacks the Spleen, Stomach and Large Intestine.
Lai Fu Zi is pungent, sweet and neutral, and enters the Spleen and Stomach meridians. Its function in the formula is to promote digestion and reduce fullness.
Gua Lou Ren is sweet and cold, and enters the Lung, Stomach and Large Intestine meridians. As a seed, it can directly moisten the intestines and move the stool. Since it enters the Lung meridian, it can eliminate phlegm and descend the Qi, which can accelerate the downward movement of the Qi in the intestines and promote bowel movement. It is usually used in cases of chronic constipation.
Xing Ren is a seed and has the function of moistening the Large Intestine and promoting bowel movement. It enters the Lung meridian, which is externally/internally related to the Large Intestine meridian, and is used especially to treat disturbance of the dispersing and descending function of the Lung-Qi that influences the intestines and causes constipation. It can also be used as a strategic assistant to disperse the Lung-Qi so as to activate the Qi in the intestines.
Jie Geng is a strategic assistant in the formula. As it enters the Lung meridian and has an ascending property, it ascends the Qi in the Lung in order to accelerate the Qi descending in the Large Intestine. In this way, it assists herbs that purge and drain downwards and herbs that descend Qi in the intestines. For applying this strategy, Jie Geng should be used in small dosage.
Lian Qiao ( Forsythiae fructus) and Shi Gao ( Gypsum)
In the condition of constipation due to excess heat in the intestines, it is important to reduce the heat without delay because heat consumes fluid in the intestines and leads to constipation.
Lian Qiao is aromatic, bitter and cold, and has a dispersing and opening-up ability. It can disperse and clear heat from accumulation in the intestines.
Shi Gao is pungent, sweet and cold. It can effectively clear heat from Yang Ming meridians. As it is sweet and cold, and can generate the body fluids, it is particularly suitable for conditions where the body fluids are being constantly injured by heat.
Huang Jing ( Polygonati rhizoma), Dang Gui ( Angelicae sinensis radix) and Rou Cong Rong ( Cistanchis herba)**
These herbs can tonify the Qi, blood and Yang respectively. They are all moist in nature. They can be applied in chronic constipation that is caused by deficiency of Qi, blood and Yang respectively.
Assistant and envoy: Protect the Stomach and Spleen, and moderate the function of the purging herbs
Zhi Gan Cao ( Glycyrrhizae radix preparata) and Feng Mi ( Mel)
Zhi Gan Cao is sweet and enters the Spleen meridian. In formulas that drain downwards, it is often used as corrective assistant and envoy to protect the Stomach from harsh herbs such as Da Huang and Lu Hui. It can also moderate the function of the herbs in the formulas and make the purgative action lasting and stable.
Feng Mi has a similar function to Zhi Gan Cao in protecting the Spleen and Stomach and in moderating the speed of harsh herbs. Furthermore, it is moistening in nature, can tonify the Spleen, moisten the intestines and promote bowel movement.
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