Application of Elimination Therapy in Warm Diseases
Warm diseases are a general term encompassing various febrile conditions, including many acute traditional infectious fevers, as well as infections exhibiting signs of defensive, qi, nutrient, or blood levels without being classified as acute communicable diseases, such as sepsis. Zhang Zhongjing proposed four methods for eliminating toxins in contagious febrile diseases: sweating, clearing heat, vomiting, and purging. Liu Hejian advocated using pungent-cool methods at the onset of febrile diseases to resolve both exterior and interior conditions. Zhang Zihe believed that proper use of purgatives could have tonic effects. Ming dynasty physician Wu Youke stated: "For epidemic fevers, expelling pathogens is urgent; removing pathogens should not be delayed even if there is no hardened stool." Dai Beishan said: "For seasonal epidemics, regardless of whether exterior symptoms persist, once interior signs appear, purgation should be applied immediately." The saying "early purgation in warm diseases is never too early" originated from this principle, providing crucial 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 eliminate dry feces, with removing accumulated stagnation being secondary. Wu Youke said: "In cases requiring purgation, even if no hardened stool is present, some mistakenly believe it's premature or inappropriate to administer purgatives. However, they fail to realize that the Cheng Qi decoction was originally intended to expel pathogens, not merely to clear hardened stools. If one waits until stool hardens, blood becomes agitated by heat, leading to multiple complications—this is akin to nurturing a tiger and leaving a hidden danger, a medical error. Moreover, many patients with hardened stool may not actually form solid feces but instead produce extremely foul-smelling substances resembling spoiled sauce or lotus paste, only forming at death. Once such foul matter is expelled, the pathogen and toxicity vanish, symptoms and pulse return to normal—why wait until stool hardens? One must understand that pathogenic heat causes dryness, not dryness causing pathogenic heat... In short, the pathogen is the root, heat is the manifestation, and hardened stool is a superficial manifestation. If pathogens are removed early, why worry about dryness?" Wu Youke clearly explained the importance and necessity of elimination therapy in warm diseases. However, it must not be misused or overused; timing and method must be carefully considered according to urgency, deficiency, or excess, so its unique role can be fully realized.
In warm diseases, when pathogenic factors remain in the qi level without resolving outwardly, 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 accumulation but especially about preserving yin and body fluids. Liu Baozhi said: "The stomach is the sea of the five zang organs, located in the central earth, naturally adept at receiving and accommodating. When pathogenic heat enters the stomach, it no longer spreads elsewhere. Therefore, in warm diseases with heat stagnating in the stomach, recovery through purgation occurs in six or seven out of ten cases." This fully demonstrates the significant role of elimination therapy in treating warm diseases.
Elimination therapy rapidly expels pathogenic heat and toxins, serving as a crucial pathway for clearing heat and eliminating pathogens. Whether the pathogen resides in the defensive or nutrient level, or between exterior and interior, as long as the patient’s constitution is robust, without signs of spleen deficiency or loose stools, or with indications for purgation, or experiencing extreme heat leading to wind, agitation, mania, or convulsions, elimination therapy can be employed to purge toxins, relieve heat, and detoxify. Formulas like Cheng Qi Tang or Sheng Jian San may be used, or rhubarb (Da Huang) and mirabilite (Mang Xiao) may be added to syndrome differentiation formulas. This approach is not merely "cooling boiling water," but rather "removing the fire from under the pot." It eliminates both invisible pathogenic heat and visible stagnation, achieving two benefits at once—a true method of treating the root cause. However, pure exterior defensive stage conditions with marked chills and mild fever, or elderly individuals, those who are physically weak, pregnant women, or women during menstruation, should use caution.
2. Clinical Examples
1. Japanese Encephalitis
Japanese encephalitis starts abruptly and progresses rapidly. Signs of the defensive stage are often subtle and difficult to detect. By the time patients seek medical attention, they typically exhibit combined qi and nutrient level involvement or simultaneous qi and blood burning. As long as there are no obvious exterior symptoms and the pathogenic factor has already entered the interior, presenting high fever, unconsciousness, agitation, wind-like movements, or abdominal distension with constipation, elimination therapy should be promptly applied—"urgent purgation to preserve yin"—to provide a pathway for pathogen expulsion. This directly affects prognosis. The goal of elimination therapy is to expel heat pathogens and preserve yin fluids. Thus, it is not limited to cases of constipation. Any condition showing extreme heat resembling fire or heat-induced wind movement can warrant its use. After purgation, body temperature usually decreases, convulsions subside, consciousness improves, and sequelae are reduced. This preemptive, proactive approach can shorten the course of illness and prevent cerebral edema or herniation. For example, before cerebral edema develops, early signs may include mild conjunctival swelling and tongue enlargement. Immediate administration of Jiao Li Tang can prevent progression. Professor Jiang Chunhua proposed the concept of "cutting off and reversing" disease progression. Famous physician Yan Cangshan advocated three protective measures for treating warm diseases (protecting the brain, protecting body fluids, protecting the intestines), emphasizing "treating both defensive and qi levels simultaneously, addressing cooling blood when in the qi level to prevent transmission—this is the mark of an excellent physician." Clinical practice confirms that most warm diseases can be prevented from progressing, halted in their development, and redirected toward recovery.
Patient Chen, male, 8 years old. Admitted with Japanese 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 full, persistent sweating on the head, yellow and greasy coating, deep, forceful, rapid pulse. Summer heat and dampness, combined with food stagnation, obstruct Yangming Stomach, scorching the Pericardium and causing unconsciousness and obstruction of orifices. Urgent need to purge heat and stagnation, supplemented by resolving dampness, dispelling turbidity, calming liver, and extinguishing wind to achieve bowel clearance, removal of stagnation, reduction of heat, and opening of orifices. 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 opened, expelling foul, dark brown old stool four times, consciousness gradually improved, all symptoms diminished. Reduce Mirabilite and Rhubarb, continue original prescription to eliminate residual pathogen. Three days later, condition stabilized, patient discharged spontaneously. Previously, despite large doses of Bai Hu Tang and injections for anticonvulsants and fever reduction, condition worsened. Subsequently, elimination therapy became primary, promoting toxin expulsion via bowel movement. This case of coma resulted from excessive Yangming heat—since stomach meridian connects to heart, thus the pathology lies in the qi level, not the nutrient level, requiring differentiation.
During the peak phase of Japanese encephalitis, phlegm turbidity often obstructs qi movement, obscures the orifices, leads to persistent high fever, unconsciousness, convulsions, snoring sounds, thick greasy tongue coating, constipation or unproductive bowel movements. In such cases, Use Du Tan Ding Jing San: Prepared Scorpion 30 pieces, Croton Seed 0.45g, Buffalo Horn 0.6g, Borax 1.5g, Realgar 2g, Starfish 6g, Fritillary Bulb and Tian Zhu Huang each 3g, Musk 0.3g (added late). Ground into fine powder, stored in sealed bottle. After taking, often results in immediate evacuation, phlegm dissolves, consciousness clears, fever subsides.
2. Typhoid and Paratyphoid
Both typhoid and paratyphoid belong to the category of damp-heat diseases. Due to Wu Ju Tong's statement: "In damp-heat diseases, purgation leads to diarrhea," some later physicians believed using elimination agents risks intestinal bleeding, leading to ongoing debate on whether to use elimination therapy. Through reviewing literature and clinical practice, I fully agree that "typhoid and paratyphoid not only can be purged, but should primarily rely on purgation." These diseases mainly result from exposure to warm pathogens, often accompanied by food stagnation and dampness. Thus, timely removal of stagnation and clearing of toxins is essential to prevent pathogens from spreading inward to Yangming, generating internal heat, forcing into intestinal network, thereby preventing or reducing intestinal bleeding and shortening the course of illness. Therefore, elimination therapy is an active method to reach the pathogen's stronghold and expel heat externally. It should be "early and cool purgation," not waiting for the tongue coating to turn yellow before considering purgation. Of course, typhoid and paratyphoid require "light purgation with frequent dosing," avoiding excessive intensity. Typical dosage of rhubarb in decoctions ranges from 6–15g, mirabilite 6–12g, Cool Intestine Powder 30–45g. Generally used continuously for 3 days, then adjusted based on constitution and severity of pathogen, administered daily or every other day. I use Nie's modified version of Yang Lishan's "Sheng Jian San" (Raw Rhubarb, Silkworm Pupa, Cicada Slough, Turmeric) from "Cold and Warm Disease Differentiation" to create "Exterior-Interior Harmonizing Pills" and "Ge Ku San Huang Dan" for treating typhoid, paratyphoid, and influenza-related warm diseases. These show remarkable efficacy, with treatment duration typically 3–10 days, small doses, convenient administration, and no side effects.
Exterior-Interior Harmonizing Pills: Suitable for initial stages of typhoid/paratyphoid and influenza-related warm diseases presenting both exterior and interior signs, or after 3–5 days of illness still having exterior signs. It can release exterior heat, clear intestinal toxins, harmonize exterior and interior, and shorten the course. After taking, often results in one evacuation, pulse calms, body cools, or noticeable improvement, continuing 2–4 times can lead to resolution. Except for those with weakened vital energy, 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 Slough, Licorice each 30g, Soapberry, Guang Jiang Huang, Charred Plum Kernel each 15g, Talc 180g. All ground into fine powder, mixed with fresh Agastache juice and fresh Mint juice each 30g, fresh Radish juice 240g, made into pills the size of green beans. Adults take 4–6g per dose, women or weak individuals reduce dosage; children around 10 years old take 2.0–2.3g, 6–8 years old 1.2–1.5g, 2–5 years old 0.5–0.75g. Once daily; if no bowel movement, repeat once. Stop once fever subsides.
Ge Ku San Huang Dan: 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, detoxification, drying dampness, and resolving turbidity. Usually effective within 5–10 days. Ingredients: Talc 600g, Raw Rhubarb 90g, Cicada Slough 15g, ground into fine powder; additionally, Sophora 150g, Kudzu Root, Scutellaria 90g each, Trichosanthes 60g, Artemisia 60g, Coptis 30g, Licorice 30g, White Cardamom 30g, Cicada Slough, Turmeric, Curcuma, Atractylodes each 15g. Boil to extract concentrated decoction. Then mix with fresh Lotus Leaf, fresh Agastache each 150g, fresh Perilla 180g, fresh Reed Rhizome 240g, raw Radish Seed 60g. Grind and press juice twice using the above decoction, add fresh Radish 90g, make into decoction juice. Mix the juice with the three powdered ingredients to form pills, weighing 6g (if fresh herbs unavailable, use half the dry herb amount, grind finely, soak in cooled decoction juice, press again with cool water to avoid loss). Take 2 pills per dose, once daily; reduce dosage for weak individuals or children. Even with loose stools, continued use is safe. Typically, expect 1–2 mild evacuations daily, fever gradually subsides and recovers.
3. Pneumonia
Using purgation in pneumonia primarily involves adding rhubarb to syndrome differentiation formulas. Ancient texts state: "When disease affects the zang organs, treat the fu organs." Clearing the intestines allows upward blockages of heat and phlegm to find an exit. Rhubarb possesses functions of clearing heat, resolving dampness, and purging blood-level excess heat. Modern pharmacological studies confirm rhubarb has mild laxative, spleen-strengthening, bile-promoting, and strong antibacterial effects, also inhibiting influenza virus. Thus, using rhubarb for measles pneumonia warrants serious attention and research. It also shows certain efficacy against viral pneumonia, demonstrating the outstanding effectiveness of elimination therapy. From personal experience, rhubarb's ability to clear heat, purge fire, and detoxify is remarkably significant; when used appropriately, it has no adverse effects.
4. Bacillary Dysentery
In the initial stage of dysentery, due to pre-existing stagnation and intense interior heat, ancient physicians noted: "No method exists to stop dysentery," "Dysentery should be treated with immediate purgation." Elimination therapy is particularly suitable for early-stage dysentery. Personally, I commonly use "Di Xie San," centered on raw and cooked rhubarb, for treating dysentery and diarrhea. It is convenient, inexpensive, highly effective, and suitable for widespread application.
Di Xie San: Raw and cooked rhubarb (roasted) each 30g, Atractylodes (soaked in rice washing water) 90g, Apricot Kernel (de-skinned, de-oiled) and Notopterygium (roasted) each 60g, Aconite (peeled, baked with bread) and Licorice (roasted) 45g. All ground into fine powder, stored in a bottle. For red-and-white dysentery, take 3–4g per dose; red dysentery should be taken with a decoction of lampwick grass 1 foot long; white dysentery with ginger 3 slices boiled; both red and white together with a decoction of lampwick grass and ginger. For diarrhea, take 2g per dose, mixed with rice broth. Children’s dosage halved; children under 4 years old take 1/4 dose, younger ones even less, twice daily. This formula has effects of purging heat, clearing stagnation, strengthening the spleen, drying dampness, warming the interior, dispelling cold, relieving pain, and calming the center. It shows significant effect on bacillary dysentery and acute/chronic diarrhea, primarily for real-heat type. Even those with deficient-cold constitution but not severely weak may use it. However, for epidemic toxic dysentery, must combine with detoxifying herbs or integrate with Western medicine for safety. Avoid use in chronic dysentery with watery bloody stools.
The above briefly illustrates the efficacy of elimination therapy in four warm diseases, demonstrating its critical role in treating warm diseases. Of course, elimination therapy is not a panacea. We must adhere to syndrome differentiation principles and apply it appropriately and timely.