A Constipation-Specific Formula — “Tongyou Tang” (Opening the Mystic Decoction)
9. A Constipation-Specific Formula — “Tongyou Tang” (Opening the Mystic Decoction)
Shen Jiaji, honorary renowned TCM master of Yunnan Province. Teacher for the fourth and sixth national cohorts of renowned TCM academic experience inheritance programs.
Pathomechanism
Constipation causation involves multiple viscera: liver, spleen, stomach, and intestines. The liver governs drainage and discharge; when emotions are frustrated, liver qi stagnates; when qi mechanism is blocked, intestinal qi cannot flow. The spleen governs transport and transformation; when diet is irregular, the spleen and stomach are damaged; when transport fails, damp turbidity blocks the middle burner and descending function is impaired. Over time, qi stagnation and dampness obstruction cause intestinal accumulation and stagnation to develop internally, with waste matter停滞 (stagnating) and not passing. Shen Jiaji’s constipation treatment is based on regulating the whole body’s qi mechanism, not simply purging; he uses liver-dispersing qi-regulating, qi-moving stagnation-guiding, and dampness-resolving food-digesting simultaneously, so that when qi moves, stagnation resolves; when the viscera unblock, stools flow smoothly.
Formula Composition
Composition: Trichosanthes Peel 15g, Immature Bitter Orange (Zhishi) 15g, Magnolia Bark 30g, Bupleurum 15g, Curcuma 15g, Melia Seed 15g, Chicken Gizzard 15g, Agastache 15g, Raw Rhubarb 3g, Licorice 30g
Efficacy: Moves qi and guides stagnation, regulates qi mechanism
Primary Application: Constipation (qi stagnation dampness obstruction, viscera qi blocked pattern)
The whole formula has ten herbs: Bupleurum, Curcuma, and Melia Seed disperse the liver and regulate qi, smoothing liver-spleen qi mechanism as the guiding principle; Magnolia Bark, Zhishi, and Trichosanthes Peel move qi, open the middle, relieve distension, and guide out stagnation, directly breaking intestinal blockage; Chicken Gizzard digests food and resolves accumulation, Agastache aromatically transforms dampness and harmonizes the stomach, simultaneously supporting spleen-stomach transport; Raw Rhubarb is used at only 3g — small dose to unblock the viscera and drain heat, intent is guiding out stagnation rather than harsh purgation; Licorice is used at 30g — large dose to gently relieve urgency and stop pain, also protect stomach qi, reducing the gastrointestinal stimulation from qi-moving stagnation-guiding herbs. The whole formula emphasizes qi movement primarily, unblocking secondarily; unblocking without harsh purging, moving without damage.
| Herb Group | Herb Dosage | Function |
|---|---|---|
| Disperse Liver & Regulate Qi | Bupleurum 15g, Curcuma 15g, Melia Seed 15g | Smooth liver-spleen qi mechanism, resolve qi stagnation, restore the viscera’s descending function |
| Move Qi & Guide Out Stagnation | Magnolia Bark 30g, Zhishi 15g, Trichosanthes Peel 15g | Open the middle and descend qi, resolve distension and fullness, break intestinal blockage |
| Digest Food & Transform Dampness | Chicken Gizzard 15g, Agastache 15g | Chicken Gizzard digests food and resolves accumulation, Agastache aromatically transforms dampness and harmonizes the stomach, assisting spleen-stomach transport to normalize |
| Unblock Viscera & Drain Heat | Raw Rhubarb 3g | Small dose to drain heat and unblock bowels, guide stagnation downward; takes the unblocking intent rather than harsh attack |
| Gently Relieve & Harmonize | Licorice 30g | Large dose to gently relieve urgency and stop pain, relax intestinal spasm, also protect stomach qi, harmonize all herbs |
In this formula, Raw Rhubarb is 3g rather than the conventional 10g or more, taking the “light doses can remove excess” principle; combined with qi-moving herbs to gently unblock viscera qi, avoiding harsh purgation that damages healthy qi. Licorice at 30g is a major feature of this formula, far exceeding conventional harmonizing doses; intent is heavy use to gently relieve urgency, relax intestinal smooth muscle spasm, reduce abdominal distension and pain, forming a pairing tension of one astringing and one dispersing with Magnolia Bark and Zhishi’s qi-moving stagnation-breaking.
IV. Modifications by Pattern
| Combined Pattern | Modification Herbs | Therapeutic Intent |
|---|---|---|
| Severe abdominal distending pain | Add Corydalis 15g | Move qi and invigorate blood, enhance pain-stopping power |
| Perineal heaviness and sinking | Add Coptis 6g, increase Bupleurum to 20g | Raise and lift middle qi, raise the clear to descend the turbid |
| Poor appetite | Add Chao Hawthorn 15g, Chao Medicated Leaven 15g, Chao Malt 15g | Digest food and stimulate appetite, assist spleen-stomach transport |
| Anal fissure and hemorrhoidal bleeding | Add Aconsoe 15g, Sapona (Hua) 12g | Cool blood and stop bleeding, also address intestinal collateral damage |
| Very dry hard stools | Add Hemp Seed 15g, Apricot Kernel (Yuliren) 12g | Moist intestines and unblock bowels, enhance softening and guiding out stagnation |
| Dry mouth and bad breath | Add Trichosanthes 15g, Forsythia 12g | Clear heat and generate fluids, also resolve intestinal viscera stagnant heat |
Modifications always use qi mechanism as the guiding principle: for abdominal distending pain add Corydalis to invigorate blood and move qi, for sinking add Coptis and Bupleurum to raise and lift middle qi, all within the scope of regulating qi mechanism. When heat signs are clear, add heat-clearing herbs; when fluids are damaged, add moistening herbs; modifications follow the pattern without deviating from the Opening the Mystic therapeutic principle.
Summary
Tongyou Tang establishes its principle with liver-dispersing qi-regulating and qi-moving stagnation-guiding, with dampness-transforming food-digesting and viscera-unblocking urgency-relieving as assistants; ten herbs with clear layering. Raw Rhubarb only 3g takes the gentle unblocking intent, heavy Licorice 30g gently relieves urgency and protects healthy qi; unblocking without harsh purging, moving without damage. Suitable for qi stagnation dampness obstruction type constipation, especially for those with longer disease course who have not responded to simple unblocking.
References:
[1] Shen Jiaji. Shen Jiaji Clinical Experience Collection [M]. Kunming: Yunnan Academy of TCM and Pharmacology.
[2] National Administration of TCM Terminology and Product Development and Standardization Project. Shen Jiaji [DB/OL]. Mass Medicine Network.
[3] Yunnan TCM Administration. Dian Nan Medical Inheritance Record · Renowned Master Shen Jiaji [EB/OL]. 2023.
9. 一張便秘專用方「通幽湯」
沈家驥雲南省榮譽名中醫。全國第四批、第六批名老中醫藥專家學術經驗繼承工作指導老師。
病機
便秘的成因涉及肝、脾、胃、腸多個臟腑。肝主疏洩，情志不遂則肝氣鬱滯，氣機不行則腑氣不通；脾主運化，飲食不節則脾胃受損，運化失職則溼濁中阻，通降無權；氣滯溼阻日久，腸腑積滯內生，糟粕停滯不去。沈家驥治便秘立足調暢全身氣機，非單純攻下，以疏肝理氣、行氣導滯、化溼消食並舉，使氣行則滯消，腑通則便暢。
方藥組成
組成：瓜蔞殼 15g、枳實 15g、厚朴 30g、柴胡 15g、鬱金 15g、川楝子 15g、雞內金 15g、藿香 15g、生大黃 3g、甘草 30g
功效：行氣導滯，調暢氣機
主治：便秘（氣滯溼阻、腑氣不通證）
全方十味藥，以柴胡、鬱金、川楝子疏肝理氣，調暢肝脾氣機為立法先導；厚朴、枳實、瓜蔞殼行氣寬中、消脹導滯，直折腸腑壅塞；雞內金消食化積，藿香芳香化溼和胃，兼顧脾胃運化；生大黃僅用3g，小劑量通腑瀉熱，意在導滯而非峻下；甘草用至30g，大劑量緩急止痛，兼護胃氣，減輕行氣導滯藥對胃腸的刺激。全方以行氣為主，通下為輔，通而不瀉，行而不傷。
| 藥組 | 藥物劑量 | 功用 |
|---|---|---|
| 疏肝理氣 | 柴胡 15g、鬱金 15g、川楝子 15g | 調暢肝脾氣機，解除氣機鬱滯，恢復腑氣通降之職 |
| 行氣導滯 | 厚朴 30g、枳實 15g、瓜蔞殼 15g | 寬中下氣，消脹除滿，破除腸腑壅滯 |
| 消食化溼 | 雞內金 15g、藿香 15g | 雞內金消食化積，藿香芳香化溼和胃，助脾胃運化復常 |
| 通腑瀉熱 | 生大黃 3g | 小劑量瀉熱通便，導滯下行，取其通下之意而非峻攻 |
| 緩急調和 | 甘草 30g | 大劑量緩急止痛，緩解腸腑痙攣，兼護胃氣，調和諸藥 |
方中生大黃用3g而非常規10g以上，取”輕可去實”之意，配合行氣藥以微通腑氣，避免峻下傷正。甘草30g為本方一大特點，遠超常規調和用量，意在重用緩急，鬆弛腸道平滑肌痙攣，減輕腹脹腹痛，與厚朴、枳實的行氣破滯形成一收一散的配伍張力。
四、隨證加減
| 兼證 | 加減藥物 | 立法用意 |
|---|---|---|
| 腹脹痛甚 | 加延胡索 15g | 行氣活血，增強止痛之力 |
| 會陰下墜 | 加升麻 6g，柴胡加至 20g | 升提中氣，升清以降濁 |
| 食慾不振 | 加焦山楂 15g、焦神曲 15g、焦麥芽 15g | 消食開胃，助脾胃運化 |
| 肛裂痔血 | 加地榆 15g、槐花 12g | 涼血止血，兼顧腸道絡損 |
| 大便乾結甚 | 加火麻仁 15g、郁李仁 12g | 潤腸通便，增強軟堅導滯之力 |
| 口乾口臭 | 加天花粉 15g、連翹 12g | 清熱生津，兼解腸腑鬱熱 |
加減總以氣機為綱，腹脹痛加延胡索活血行氣，下墜加升麻柴胡升提中氣，均不離調暢氣機之旨。熱象明顯者佐清熱藥，津傷者佐潤腸藥，隨證出入而不失通幽立法。
小結
通幽湯以疏肝理氣、行氣導滯立法，佐以化溼消食、通腑緩急，十味藥配伍層次分明。生大黃僅用3g取輕通之意，甘草重用30g緩急護正，通而不瀉、行而不傷，適用於氣滯溼阻型便秘，尤宜病程較長、單純通下乏效者。
參考文獻：
[1] 沈家驥. 沈家驥臨床經驗集[M]. 昆明:雲南省中醫中藥研究院.
[2] 國家中醫藥管理局名詞術語成果轉化與規範推廣項目. 沈家驥[DB/OL]. 大眾醫學網.
[3] 雲南省中醫藥管理局. 滇南醫學傳承錄·名醫沈家驥[EB/OL]. 2023.