Application of Elimination Therapy in Warm Diseases
Warm diseases are a general term for various heat-related illnesses, including many acute traditional heat conditions, as well as infectious diseases exhibiting signs of defensive, qi, nutrient, or blood levels but not classified as acute infectious diseases, such as sepsis. Zhang Zhongjing proposed four methods for eliminating toxins in contagious heat diseases: sweating, clearing, vomiting, and purging. Liu Hejian advocated using pungent-cool therapies at the onset of heat diseases to resolve both exterior and interior conditions. Zhang Zihe believed that properly administered purgatives could act like tonics. During the Ming Dynasty, Wu Youke stated: "For epidemic fevers, expelling pathogens is urgent; removing pathogens should not be delayed even if there is no hard stool." Dai Beishan said: "For seasonal epidemics, regardless of whether exterior symptoms have resolved, once interior symptoms appear, purging should be applied immediately." The saying "early purging in warm diseases is not too early" originated from this, providing significant guidance for later physicians treating warm diseases.
1. Role and Principles of Elimination Therapy in Warm Diseases
The primary purpose of elimination therapy in warm diseases is to expel pathogenic heat and purge hardened stools, with removing accumulated stagnation being secondary. Wu Youke said: "In cases requiring purgation, if no hardened stool is present, some mistakenly believe purging is premature or inappropriate. However, they fail to realize that Cheng Qi decoctions are designed to expel pathogens, not merely to clear hardened stools. Waiting until stools become hardened may result in blood being agitated by heat, leading to multiple complications—like nurturing a tiger and leaving a danger behind, a physician’s fault. Moreover, many patients with hardened stools missed purgation may only produce extremely foul-smelling substances resembling spoiled sauce or lotus paste, and even die without forming hard stools. Once the foul matter is expelled, the pathogenic toxin disappears, symptoms and pulse return to normal. Why obsess over waiting for hardened stools? One must understand that pathogenic heat causes dryness, not the other way around... In essence, the pathogen is the root, heat is the manifestation, and hardened stools are the manifestation of the manifestation. If pathogens are removed early, why worry about dryness?" Wu Youke clearly emphasized the importance and necessity of elimination therapy in warm diseases. However, it must not be misused or abused. Timing and method must be carefully considered according to urgency and the balance between deficiency and excess to fully harness its unique therapeutic effect.
When pathogenic factors remain in the qi level without resolving externally, they inevitably accumulate internally in Yangming, where heat stagnates and easily transforms into dryness, injuring yin. Thus, early application of elimination therapy is most appropriate. Purging is not just about removing excess; it also emphasizes preserving yin and body fluids. Liu Baozhi said: "The stomach is the sea of the five zang and six fu organs, located in the central earth, best suited for receiving and accommodating. When pathogenic heat enters the stomach, it no longer spreads elsewhere. Therefore, in warm diseases with heat accumulation in the stomach, recovery through purgation occurs in about 60–70% of cases." This fully illustrates the crucial role of elimination therapy in treating warm diseases.
Elimination therapy rapidly expels pathogenic heat and toxins—a vital pathway for clearing heat and removing pathogens. Whether the pathogen resides in the exterior, interior, qi, or nutrient level, as long as the patient's constitution is robust, without signs of spleen deficiency or loose stools, or presenting indications for purgation, or exhibiting extreme heat causing wind, mania, or convulsions, one may apply purgation to eliminate foul matter, clear heat, and detoxify. Use formulas like Cheng Qi Tang or Sheng Jian San, or add Mirabilite (Mang Xiao) and Rhubarb (Da Huang) to individualized prescriptions. This is not merely boiling water to stop boiling—it is removing the fire from under the pot. It clears both intangible heat and tangible stagnation, achieving two goals at once, truly a fundamental approach. However, for pure exterior defensive stage conditions with marked chills and mild fever, or in elderly, frail individuals, pregnant women, or those menstruating, caution is advised.
2. Clinical Examples
1. Encephalitis (Japanese B Encephalitis)
Encephalitis starts abruptly and progresses rapidly. Early defensive stage symptoms are often subtle and hard to detect. By the time patients seek medical help, they usually present with combined qi and nutrient level involvement or simultaneous qi and blood burning. As long as there are no obvious exterior signs and the pathogen has already entered the interior, showing high fever, confusion, agitation, wind movement, or abdominal distension with constipation, elimination therapy should be applied urgently—"early purging to preserve yin"—to provide an exit for the pathogen. This directly affects prognosis. The goal of elimination therapy is to expel heat pathogens and preserve yin fluids. It is not limited to cases with constipation. Any sign of extreme heat resembling fire or heat-induced wind movement qualifies. After purging, temperature typically decreases, convulsions lessen, mental clarity improves, and sequelae are reduced. This preemptive, proactive strategy shortens the course and prevents cerebral edema or herniation. For example, before cerebral edema develops, early signs include mild conjunctival swelling and tongue enlargement. Immediate use of the Lowering and Eliminating Decoction can prevent progression. Professor Jiang Chunhua proposed the concept of "cutting off and reversing," while renowned physician Yan Cangshan advocated the "Three Protection Methods for Warm Diseases" (protecting the brain, protecting body fluids, protecting the intestines), emphasizing "treating the defensive stage while clearing the qi level, and clearing the qi level while guarding against blood heat to prevent transmission—this is the work of a skilled physician." Clinical practice confirms that most warm diseases can be prevented from progressing, halted in development, and redirected toward recovery.
Patient Chen, male, age 8. Admitted with Japanese B encephalitis for ten days, presenting high fever, coma, neck stiffness, convulsions, delirium, and twitching, worsening over the past four days. No bowel movement for a week, abdomen firm and distended, persistent head sweating despite fever, yellow thick greasy coating on the tongue, deep, forceful, rapid pulse. Summer heat and dampness coagulate with food stagnation, accumulating in Yangming Stomach, scorching the Pericardium and obstructing the orifices. Urgent need to purge heat and stagnation, assist in resolving dampness, dispelling turbidity, calming liver wind. Prescription: Raw Rhubarb 9g (added late), Mirabilite 6g (dissolved separately), Prepared Whole Scorpion 1.5g (ground and swallowed), Uncaria hook (added late), and Artemisia 15g each, Kudzu root, Silkworm pupa, Patchouli, and Calamus 9g each, Licorice 3g. Two doses, taken in four divided doses daily. Next morning, bowel movements occurred four times, expelling foul, dark yellow old feces. Mental clarity gradually improved, all symptoms diminished. Reduce Mirabilite and Rhubarb, continue original prescription to clear residual pathogenic factors. Three days later, condition stabilized, patient discharged voluntarily. Previously, the patient had received large doses of Bai Hu Tang and injections for anticonvulsants and fever reduction, yet condition worsened. Subsequently, elimination-focused treatment was adopted, promoting detoxification via purgation, allowing pathogenic factors to exit. This case of coma resulted from excessive Yangming heat—because the stomach meridian connects to the heart. The disease was in the qi level, not the nutrient level, thus requiring differentiation.
During the peak phase of encephalitis, phlegm obstruction often blocks qi flow, obscures the orifices, causing persistent high fever, confusion, convulsions, snoring-like sounds, thick greasy tongue coating, constipation or unproductive bowel movements. In such cases, use the Phlegm-Expelling and Convulsion-Stabilizing Powder: Prepared Whole Scorpion 30 pieces, Croton Seed Paste 0.45g, Buffalo-bezoar 0.6g, Borax 1.5g, Realgar 2g, Antelope Horn 6g, Fritillary Bulb and Tian Zhu Huang each 3g, Musk 0.3g (added late). Grind into fine powder, store in sealed bottle. After taking, patients often experience immediate relief after one purge, phlegm cleared, consciousness restored, fever subsides.
2. Typhoid and Paratyphoid
Typhoid and paratyphoid fall under the category of damp-heat diseases. Due to Wu Ju Tong’s statement: "In damp-heat diseases, purging leads to diarrhea," some later physicians believed using elimination agents risks intestinal bleeding, leading to ongoing debate on whether elimination therapy is applicable. Through reviewing literature and clinical practice, I fully agree that typhoid and paratyphoid not only can be treated with purgation but should primarily rely on elimination therapy. These diseases mainly arise from exposure to warm pathogens, often accompanied by food stagnation and dampness. Timely removal of stagnation and clearance of toxins prevent the pathogen from spreading inward to Yangming, transforming into fire, forcing downward into the intestines, thereby preventing or reducing intestinal bleeding and shortening the course. Thus, elimination therapy is an active method directly targeting the pathogen’s stronghold, expelling heat outward. It should be applied "early and promptly," without waiting for the tongue coating to turn yellow before considering purgation. Of course, typhoid and paratyphoid require "gentle, frequent purging," avoiding overly aggressive methods. Typically, Rhubarb dosage ranges from 6–15g, Mirabilite from 6–12g, and Cool Intestine Powder from 30–45g. Generally used continuously for three days, then adjusted based on constitution and severity of pathogenic heat, administered daily or every other day. I use Nie’s formulation based on Yang Lishan’s “Shengjiang San” (Raw Rhubarb, Silkworm pupa, Cicada shell, Turmeric) from “Cold and Warm Disease Differentiation,” creating “Surface-Interior Harmonizing Pills” and “Ge Ku San Huang Pills” to treat typhoid, paratyphoid, and influenza-like warm diseases. Results are excellent, with treatment duration typically 3–10 days, small doses, convenient administration, and no side effects.
Surface-Interior Harmonizing Pills: Suitable for initial stages of typhoid, paratyphoid, and influenza-like warm diseases presenting both surface and interior symptoms, or cases still having surface symptoms after three to five days. It helps release exterior heat, clear interior toxins, harmonize surface and interior, and shorten the course. After taking, patients often experience one purge followed by calm pulse and cool body, or noticeable improvement. Continue for 2–4 doses to achieve full effect. Except for those with weakened constitution, spleen deficiency with loose stools, or very mild fever with prominent chills, adults and children can take. Ingredients: Raw Rhubarb 135g, Fried Silkworm pupa 45g, Cicada shell and Licorice each 30g, Soapberry, Fresh Turmeric, Charred Prunus 15g, Talc 180g. Grind into fine powder. Mix with fresh Honeysuckle juice, fresh Mint juice each 30g, fresh Radish juice 240g, form pills the size of green beans. Adults: 4–6g per dose; women or weak individuals reduce dosage; children aged 10: 2.0–2.3g; 6–8 years: 1.2–1.5g; 2–5 years: 0.5–0.75g. One dose daily. If no bowel movement, repeat once. Stop when fever subsides.
Ge Ku San Huang Pills: For damp-heat and other warm diseases, if fever persists after three days of the above pill, continue with this formula. It combines elimination, clearing heat, detoxifying, drying dampness, and resolving turbidity. Usually effective after continuous use for 5–10 days. Ingredients: Talc 600g, Raw Rhubarb 90g, Cicada shell 15g, ground finely; additionally, Sophora root 150g, Kudzu root, Scutellaria root each 90g, Trichosanthes root, Yinchen, Artemisia 60g each, Coptis, Licorice, White Cardamom each 30g, Cicada shell, Turmeric, Curcuma, Atractylodes each 15g. Boil to extract concentrated decoction. Then grind fresh Lotus leaf, fresh Honeysuckle each 150g, fresh Perilla 180g, fresh Reed rhizome 240g, raw radish seeds 60g, mix with the above decoction, squeeze twice. Add fresh radish 90g, prepare decoction. Mix the decoction with the three powdered ingredients to form pills, weighing 6g (if fresh herbs unavailable, use half the dried herb amount, grind finely, soak in cooled decoction, squeeze again to avoid loss). Take 2 pills per dose, once daily. Reduce dosage for weak individuals or children. Even with loose stools, it can be safely taken. Typically, patients experience mild diarrhea 1–2 times daily, fever gradually decreasing and improving.
3. Pneumonia
Using purgation in pneumonia mainly involves adding Rhubarb to syndrome differentiation-based prescriptions. Ancient texts state: "If illness affects the zang organs, treat the fu organs." Clearing the intestines allows upper-jiao stagnated heat and phlegm to find an outlet. Rhubarb clears heat, resolves dampness, and purges blood-level excess heat. Modern pharmacological studies confirm Rhubarb has mild laxative, spleen-strengthening, bile-promoting, strong antibacterial properties, and inhibits influenza virus. Thus, using Rhubarb for measles pneumonia is worth serious attention and research. It also shows efficacy against viral pneumonia, demonstrating the outstanding effectiveness of elimination therapy. From personal experience, Rhubarb’s ability to clear heat, purge fire, detoxify, and combat bacteria is remarkable. When used appropriately, it has no side effects.
4. Bacillary Dysentery
In the early stage of dysentery, due to pre-existing stagnation and intense interior heat, ancient physicians long held the view: "There is no fixed method to stop dysentery" and "Dysentery should be treated with immediate purging." Elimination therapy is especially suitable for early-stage dysentery. Personally, I commonly use the "Dysentery-Purging Powder" centered on raw and cooked Rhubarb to treat dysentery and diarrhea. It is convenient, inexpensive, highly effective, and suitable for widespread application.
Dysentery-Purging Powder: Raw Rhubarb, Cooked Rhubarb (roasted) each 30g, Atractylodes (soaked in rice wash water) 90g, Apricot kernel (skin and oil removed) 60g, Qianghuo (roasted) 60g, Sichuan Aconite (peeled, baked in bread) 45g, Licorice (roasted) 45g. Grind into extremely fine powder, store in a bottle. For red-and-white dysentery, take 3–4g per dose; for red dysentery, mix with a 1-foot-long lampwick grass decoction; for white dysentery, mix with ginger slices decoction; for mixed red-and-white, mix with both decoctions. For diarrhea, take 2g per dose, mixed with rice broth. Children’s dosage halved; under 4 years: 1/4 dose; younger children further reduced; twice daily. This formula clears heat and eliminates stagnation, strengthens the spleen, dries dampness, warms the interior, disperses cold, relieves pain, and stabilizes the center. It is highly effective for bacillary dysentery and acute/chronic diarrhea, primarily used for real-heat type dysentery and diarrhea. Even those with mild deficiency-cold constitution may use it cautiously. However, for epidemic toxic dysentery, combination with intestinal detoxifying herbs or integrated Western and Chinese medicine is necessary. Avoid use in chronic dysentery with watery bloody stools.
These examples briefly illustrate the efficacy of elimination therapy in treating four types of warm diseases, underscoring its crucial role in warm disease management. Nevertheless, elimination therapy is not a panacea. We must adhere to syndrome differentiation principles and apply it timely and appropriately.