Abstract This article summarizes the clinical experience of Professor Xiong Jibai, a master of traditional Chinese medicine, in applying the theory of ‘The Lung and Large Intestine as Interior and Exterior’. Professor Xiong believes that the essence of this theory lies in the interrelationship between the lung and large intestine, where the lung represents the interior of the large intestine, and vice versa. The pathways to realize this theory involve the mutual influence of qi dynamics, the metabolism of body fluids, the connection of meridians, and the interrelation of yin and yang within the five elements. In clinical applications, a human-centered approach should be adopted, grasping the pathogenesis and employing methods of simultaneous treatment of the lung and intestine, which have shown significant efficacy.
Keywords Lung and Large Intestine as Interior and Exterior; Clinical Application; Xiong Jibai; Master of Traditional Chinese Medicine; Xuanbai Chengqi Decoction
The theory of ‘The Lung and Large Intestine as Interior and Exterior’ is an important component of the TCM theory of organ relationships. With the deepening of multidisciplinary research in recent years, the foundation and essence of this theory have gradually been revealed, confirming the correlation between the lung and large intestine in aspects such as tissue origin, mucosal immunity, and microbial changes. Based on a profound knowledge system of traditional Chinese medicine and years of rich clinical experience, Master Xiong Jibai (hereafter referred to as Teacher Xiong) has unique insights into the theory of ‘The Lung and Large Intestine as Interior and Exterior’. The author now presents Teacher Xiong’s clinical applications of this theory for the purpose of learning and exchange with peers.
1. Historical Origins of the Theory of ‘The Lung and Large Intestine as Interior and Exterior’
The proposal of the theory of ‘The Lung and Large Intestine as Interior and Exterior’ has profound historical and academic roots. As early as in the Huangdi Neijing, there are records regarding the relationship between the lung and large intestine.
In the Ling Shu: Ben Shu, it is stated: “The lung connects with the large intestine; the large intestine is the organ of transmission.” The large intestine is responsible for the transmission of waste, hence it is referred to as the ‘organ of transmission’. Under the cooperation of the stomach’s digestion, the spleen’s transformation, and the lung’s descending function, the remnants of food and water are transmitted through the large intestine and ultimately excreted from the body.
Because the function of the large intestine’s transmission is related to the lung, the Suwen: Ke Lun mentions the cough of the lung and the cough of the large intestine: “If the lung coughs persistently, the large intestine will be affected, leading to a cough with incontinence of stool,” discussing how prolonged lung disease can affect the large intestine, causing the transmission function of the large intestine to be impaired, resulting in cough and incontinence. The Ling Shu: Si Shi Qi records: “If there is constant rumbling in the abdomen, qi rises to the chest, causing difficulty in standing; the evil resides in the large intestine,” indicating that if the evil is in the large intestine, it can also affect the lung, disrupting its function of dispersing and descending.
In the Ling Shu: Jiu Zhen Lun, it is recorded: “The hand Yangming and Taiyin are interior and exterior to each other.” In the Ling Shu: Jing Mai and Ling Shu: Jing Bie, it is also recorded that the hand Taiyin lung meridian and the hand Yangming large intestine meridian connect in the upper limbs, with specific descriptions of their interconnections through collateral pathways. Additionally, Zhang Zhongjing in his Shang Han Za Bing Lun proposed treating the lung through the intestine, applying this idea in practice, believing that if the qi dynamics of the intestinal organs are smooth, lung diseases can be cured.
Thus, it can be seen that the lung and large intestine are “interconnected organs”, and the theory of ‘The Lung and Large Intestine as Interior and Exterior’ is thus formed.
2. The Connotation of the Theory of ‘The Lung and Large Intestine as Interior and Exterior’
“Interior and exterior” refers to two opposing aspects of a single entity, which are relative to each other, indicating that they are both contradictory and unified. The theory of ‘The Lung and Large Intestine as Interior and Exterior’ illustrates the existence of an interactive and shared relationship between the two. Teacher Xiong believes that the essence of this theory lies in the lung representing the large intestine’s exterior, the large intestine representing the lung’s exterior, and both the lung and large intestine sharing the same interior and exterior.
2.1 The Lung Represents the Large Intestine’s Exterior
In the Suwen: Jin Kui Zhen Yan Lun, it is stated: “In the organs of the human body, yin and yang are defined; the organs are yin, and the bowels are yang.” Based on the theory of organs, the lung is yin as an organ, while the large intestine is yang as a bowel. Moreover, the lung houses the po (魄) within, as stated in the Suwen: Liu Jie Zang Xiang Lun: “The lung is the source of qi and the place of po.” The relationship between the lung and po is primarily expressed through the relationship between the lung and qi.
“Po” is synonymous with “pulp”; po governs descent, and the lung qi descends, allowing the waste to move downward to its terminal point, the exit. The exit is located at the end of the large intestine, which is connected to the lung. As Wang Bing noted, “it refers to the anal opening, which internally connects to the lung,” thus being influenced by the large intestine and connected to the exterior. The lung, being the uppermost organ, facilitates descent; when the lung qi descends smoothly, the qi of the large intestine also descends, allowing for the proper opening and closing of the exit, enabling the waste to be excreted. The lung and large intestine work together to control the opening and closing of the exit.
In terms of transmission, the lung’s qi descends to the interior, travels through the large intestine, and promotes its transformation, while the large intestine transmits waste to the exterior while also absorbing body fluids to return to the lung. As stated in the Zhong Xi Hui Tong Yi Jing Jing Yi, Tang Rongchuan said about the large intestine: “The reason the large intestine transmits is that it is the bowel of the lung; when the lung qi descends, it can transmit.”
Pathologically, if the lung qi is deficient, then qi, water, and body fluids will stagnate, and the turbid qi will not descend. If the large intestine is full, it will obstruct transmission, leading to dryness and constipation. The Xue Zheng Lun discusses: “There is always body fluid in the lung, nourishing its metal; thus, the metal is clear and the fire is suppressed. If the body fluid is harmed, then there will be thirst and wheezing, and the urine will be scant. If there is residual heat in the large intestine, then the stool will be difficult to pass,” which elucidates the interior and exterior relationship between the lung and large intestine in terms of their transmission and descent.
2.2 The Large Intestine Represents the Lung’s Exterior
In the Suwen: Liu Wei Zhi Da Lun, it states: “Above the Yangming, dryness is treated by it,” indicating that dryness is the fundamental qi of Yangming, which transforms dryness.
In the Suwen: Tian Yuan Ji Da Lun: “In the heavens, it is dry; on the earth, it is metal,” indicating that dry qi is the qi of autumn in the heavens, and metal is the quality of dry qi on earth. Both the lung and large intestine belong to the metal element in the five elements. The large intestine governs the sinking of body fluids to the interior, while the lung clears and purifies the exterior. The two share a corresponding qi, gathering essence and expelling waste, both possessing the nature of Yangming’s dry metal. Therefore, Ye Tianshi described intestinal obstruction in the Lin Zheng Zhi Nan Yi An: “White tongue, no thirst or hunger, stool not passed for a long time, skin itching, and rumbling in the abdomen,” believing that “all are due to wind, dampness, and heat, obstructing the qi, causing all meridians to close. In the past, Danxi referred to intestinal obstruction,” and the treatment should be “to open the lung qi to promote communication; when the qi is smooth, the damp heat will naturally disperse.”
In terms of the qi and body fluid generation and movement, the large intestine primarily absorbs body fluids from the interior, serving as one of the foundations for the generation of qi and body fluids, while the lung disseminates qi and body fluids to the exterior, allowing it to nourish the skin and meridians, thus enriching the pores and moistening the entire body. Therefore, in the Xue Zheng Lun, Tang Rongchuan stated: “The lung is the canopy; when there is always body fluid in the lung, the lung leaves are moist and rich, covering and descending, allowing the qi to gather and suppress, thus the qi descends, and the body fluids follow.”
Thus, the lung and large intestine are related in terms of Yangming’s dry metal and the generation and movement of qi and body fluids, with the large intestine representing the lung’s exterior.
2.3 The Lung and Large Intestine Share the Same Interior
The lung and large intestine influence each other’s ascent and descent, thus they are said to share the same interior. Ye Tianshi stated: “The lung is the bellows of respiration, positioned highest, receiving the clear qi from the organs, and embodying the clear and pure body, primarily governing descent.” The lung qi descends, while the large intestine governs the transmission of waste, also functioning in descent. When the lung qi descends, it assists the large intestine’s qi in descending, allowing for smooth transmission; conversely, when the large intestine’s qi descends, it can also assist the lung qi in descending. The lung also governs dissemination; Tang Zonghai stated: “The lung governs qi, which is primarily yang, while housing the yin po. Yin arises from yang, referring to the clear and nourishing qi within the lung,” as the lung disperses the essence throughout the body, nourishing the large intestine, while the large intestine’s descent also allows for the reabsorption of body fluids to ascend to the lung.
Additionally, in terms of meridians, the lung and large intestine are interconnected; the hand Taiyin lung meridian “descends to connect with the large intestine… and ascends to connect with the lung,” while the hand Yangming large intestine meridian “connects with the lung… and belongs to the large intestine.” Furthermore, they strengthen their internal connection through collateral pathways. In the Ling Shu: Jing Mai, it states: “The hand Taiyin’s main pathway… enters and connects with the lung, dispersing to the large intestine,” while the hand Yangming’s main pathway “descends to the large intestine, belonging to the lung.” In relation to surface organs, the lung and large intestine reside within the body, and their meridians are interconnected, jointly governing the interior.
2.4 The Lung and Large Intestine Share the Same Exterior
The lung and large intestine are connected to the skin and hair, sharing the qi of heaven and earth, thus it is said that they share the same exterior. The lung is connected to the nose, which corresponds to the skin. In the Ling Shu, it states: “The upper jiao opens, dispersing the flavors of the five grains, nourishing the skin, filling the body, and moistening the hair,” indicating that when a person is affected by a deficiency of evil, it begins at the skin. If the skin is relaxed, the pores open, allowing evil to enter through the hair. The lung distributes essence to nourish the skin and also disseminates defensive qi to the skin to resist evil.
The large intestine is also related to the skin; in the Neijing, it states: “The lung connects with the large intestine; the large intestine corresponds to the skin.” The lung corresponds to the skin; if the skin is thick, the large intestine is thick; if the skin is thin, the large intestine is thin; if the skin is relaxed, the abdomen is large, the large intestine is large and long; if the skin is tense, the large intestine is short and urgent; if the skin is smooth, the large intestine is straight; if the skin and flesh are inseparable, the large intestine is constipated,” indicating that both the lung and large intestine are related to the skin. Additionally, “Heavenly qi communicates with the lung,” as the lung inhales the clear and exhales the turbid, maintaining life, while the large intestine communicates with the earthly qi through the exit, allowing for descent and transmission of waste. The lung and large intestine, residing above and below, share the qi of heaven and earth, both receiving natural qi, jointly governing the exterior.
3. Pathways to Realize the Theory of ‘The Lung and Large Intestine as Interior and Exterior’
After two thousand years of development, the theory of ‘The Lung and Large Intestine as Interior and Exterior’ has matured. Scholars throughout history have discovered that the realization of this theory occurs through multiple pathways. Teacher Xiong believes that the realization of this theory primarily involves the mutual influence of qi dynamics, the metabolism of body fluids, the connection of meridians, and the interrelation of yin and yang within the five elements.
3.1 Mutual Influence of Qi Dynamics
In the Suwen: Liu Wei Zhi Da Lun, it states: “If the entrance and exit are obstructed, the spirit’s mechanism will be extinguished; if ascent and descent cease, the qi will stand alone and precarious. Therefore, without entrance and exit, there can be no growth, aging, or decline; without ascent and descent, there can be no growth, transformation, or storage,” indicating that ascent and descent, entrance and exit, are present in all organs. The lung is the canopy, positioned highest among the organs, while the large intestine is the lowest among the six bowels, thus they are situated above and below, communicating with the exterior. The lung governs qi, while the large intestine governs transmission; the lung’s function of descending qi is the driving force for the normal transmission of the large intestine, while the smooth transmission of the large intestine is also related to the lung’s effective descent. Therefore, the mutual influence of qi dynamics between the lung and large intestine is crucial for their transmission and respiration.
In the Zhong Xi Hui Tong Yi Jing Jing Yi, it states: “When the material in the intestine reaches this point, the essence and fluids are exhausted, transforming into waste and exiting. The reason it can exit is that the large intestine transmits it, and the reason the large intestine can transmit is that it is the bowel of the lung; when the lung qi descends, it can transmit. Therefore, regulating the large intestine’s function must involve adjusting the lung qi.” The lung qi descends harmoniously, while the large intestine functions smoothly. In terms of respiration, the lung governs breathing; when the lung qi descends clearly and smoothly, the qi of the large intestine also descends, allowing for the smooth functioning of the six bowels. Therefore, in clinical treatment, it is essential to maintain the coordination of the ascent and descent of qi between the lung and large intestine. For example, in the Shang Han Lun, the method of “opening the bowels and descending the lung” for treating wheezing states: “If there is no resolution after vomiting or purging, and no bowel movement for five or six days… slight wheezing and staring… the Da Chengqi Decoction is indicated,” which is based on the relationship of qi dynamics between the lung and intestine.
3.2 Related to the Metabolism of Body Fluids
The body’s qi, blood, and body fluids originate from the postnatal source, the spleen and stomach. The metabolism of body fluids requires the cooperation of the lung’s regulation of water and the large intestine’s governing of body fluids.
In the Suwen: Jing Mai Bie Lun, it states: “When the drink enters the stomach, it overflows with essence and qi, ascending to the spleen, where the spleen qi disperses the essence, returning to the lung, and regulating the water pathways, descending to the bladder.” The lung is the upper source of water, governing the regulation of water pathways; the large intestine is the organ of transmission, governing body fluids. Through the reabsorption of body fluids, the large intestine participates in the metabolism of body fluids. The lung and large intestine are interrelated in the metabolism of body fluids, working together to play an important role.
Modern research also indicates that body fluids are a fundamental substance that realizes and maintains the physiological relationship of ‘The Lung and Large Intestine as Interior and Exterior’. The lung governs dissemination and descent; when functioning normally, the body’s body fluids can moisten the intestines, maintaining normal water metabolism and smooth bowel function. The large intestine governs body fluids, absorbing them to nourish the intestines; when the intestines are moist, the qi dynamics descend smoothly, thus assisting the lung’s function of regulating water pathways. When the lung and large intestine function in harmony, the transmission of body fluids is orderly, and metabolism is normal.
Conversely, if one of them is impaired, such as the lung failing to regulate, leading to obstruction of the water pathways, it can affect the intestinal organs, resulting in symptoms like constipation. If the large intestine fails to govern body fluids, leading to dryness and constipation, it can also affect the lung’s descent, manifesting as cough and wheezing. Therefore, in the Jin Kui Yao Lue, it states: “If the water and qi in the intestines do not flow downward, it causes the lung qi to become stagnant above,” thus the lung and large intestine should be treated together.
3.3 Connection of Meridians
Traditional Chinese medicine posits that the organs are connected through meridians, which are the pathways for the circulation of blood and qi in the body.
In the Suwen: Xue Qi Xing Zhi, it states: “Yangming and Taiyin are interior and exterior to each other.” The hand Taiyin lung meridian and the hand Yangming large intestine meridian run along the inner and outer sides of the upper limbs, respectively, and they connect at the radial side of the index finger at the Shangyang point. The meridians that run internally are also connected to the large intestine and lung, allowing for physiological and pathological interactions, thus forming the relationship of the lung and large intestine as interior and exterior. Additionally, the lung and large intestine are further connected through collateral pathways and other relationships. It can be seen that the hand Taiyin lung meridian and the hand Yangming large intestine meridian connect through the meridians, allowing for the internal and external yin and yang to communicate, thus forming the material basis for the realization of the theory of ‘The Lung and Large Intestine as Interior and Exterior’.
Some scholars have found that there exists a multidimensional intermediary structural connection between the “lung-lung meridian” system and the “large intestine-large intestine meridian” system. These connections can promote the relationship of interior and exterior. In clinical practice, many practitioners treat lung-related diseases by selecting points on the lung meridian while also choosing points on the large intestine meridian, which elucidates the interrelatedness of the lung and large intestine in terms of meridians.
3.4 Interrelation of Yin and Yang within the Five Elements
The theory of yin and yang is the worldview and methodology of traditional Chinese medicine for understanding the complex world. The yin and yang theory philosophically expresses the contradictory yet unified relationship; the five elements theory categorizes things based on the abstract characteristics of the five elements: wood, fire, earth, metal, and water, and summarizes the interrelationships among various phenomena based on their relationships. The yin and yang and five elements theories are the philosophical pathways for realizing the theory of ‘The Lung and Large Intestine as Interior and Exterior’.
The exterior represents yang, while the interior represents yin; thus, the “interior and exterior relationship” is also a manifestation of the yin and yang relationship. The lung and large intestine exist in a relationship of opposition and unity. Anatomically, the lung and large intestine are situated above and below; in terms of organ characteristics, the lung is full but cannot be solid, while the large intestine is solid but cannot be full; in terms of systemic relationships, the lung and large intestine cooperate physiologically and influence each other pathologically. Therefore, from the perspective of yin and yang theory, the lung and large intestine exist in a relationship of yin and yang, interior and exterior, organ and function.
From the perspective of the five elements theory, both the lung and large intestine belong to the metal element. However, the metal of the five elements is also divided into yin and yang; geng and xin both belong to metal, with geng being yang metal and xin being yin metal. Although the lung and large intestine differ in terms of the yin and yang of the five elements, their functions are complementary, seeking the same qi, thus establishing a close relationship. Therefore, the theory of ‘The Lung and Large Intestine as Interior and Exterior’ is elevated on the foundation of the yin and yang and five elements theories. Through this pathway, the physiological and pathological changes of the human body and the internal and external relationships can be analyzed, guiding clinical differentiation and treatment.
4. Clinical Applications of Professor Xiong Jibai’s Theory of ‘The Lung and Large Intestine as Interior and Exterior’
The lung governs qi; in the Lei Jing: Zang Xiang Lei, it states: “When the qi is regulated, the defensive qi and the organs are treated without exception.” The lung also governs dissemination and descent; the Yi Xue Shi Zai Yi states: “When qi communicates with the lung, all the qi of the organs and meridians is disseminated by the lung qi, which embodies the clear and empty nature, primarily governing descent, thus the clear and pure descent is smooth.” The lung plays an important regulatory role in the qi, blood, body fluids, and organ functions throughout the body.
The large intestine governs body fluids; in the Pang Wei Lun, it states: “The large intestine governs body fluids, while the small intestine governs liquids. The large and small intestines receive the nourishing qi of the stomach, thus they can transport body fluids to the upper jiao, irrigating the skin and enriching the pores.” The large intestine also governs the transmission of waste, “transmitting and transforming substances without storing them.”
The theory of ‘The Lung and Large Intestine as Interior and Exterior’ reveals the close relationship between the lung and large intestine in the occurrence, development, and outcome of diseases. Lung diseases not only affect the physiological functions of the large intestine but can also easily transmit to the large intestine, leading to “coughing with incontinence of stool, the dry metal being invaded by evil, lung disease arising and flowing into the large intestine,” ultimately resulting in simultaneous lung and large intestine diseases.
Similarly, large intestine diseases can also affect the lung’s function of dissemination and descent, easily transmitting to the lung, resulting in simultaneous lung and large intestine diseases. The Feng Shi Jin Nang Mi Lu states: “The large intestine is the bowel of the lung; if there is damp heat stagnation in the large intestine, then there must also be stagnation in the lung,” while the Xing Xuan Yi An states: “The lung and large intestine are interior and exterior; if there is heat in the intestine, it can ascend and affect the lung, causing dryness and itchiness, leading to cough. This cough is not due to wind but is actually due to dryness.”
Therefore, the lung and large intestine mutually influence each other and are closely related. In clinical treatment, based on the connotation of the theory of ‘The Lung and Large Intestine as Interior and Exterior’, Teacher Xiong often employs methods of simultaneous treatment of the lung and intestine, which often yield better results than treating the lung or intestine alone.
4.1 Lung Disease and Intestine: Simultaneous Treatment of Lung and Intestine
In the Suwen: Ling Wei Yun, it states: “The lung and large intestine share the same qi; when the lung qi transforms essence, it nourishes the large intestine, making it smooth and easy to pass.” The lung and large intestine influence each other’s ascent and descent; the large intestine receives the essence and body fluids transmitted by the lung. If the lung qi is insufficient in transforming essence, the regulation of body fluids is disrupted, and the large intestine’s function is affected. The two are related in transmission; if the lung qi is weak and the descent is insufficient, the large intestine’s transmission will be obstructed, ultimately leading to simultaneous lung and large intestine diseases.
Thus, when symptoms of lung disease such as cough and wheezing are accompanied by symptoms of intestinal disease such as constipation or diarrhea, the treatment should focus on disseminating and nourishing the lung while also promoting downward movement of qi, employing simultaneous treatment of the lung and intestine.
Case Example: A 73-year-old male patient was first diagnosed on May 11, 2021.
Chief complaint: Recurrent shortness of breath and chest tightness for half a month.
Current medical history: Half a month ago, the patient was admitted to Xiangya Hospital due to shortness of breath and chest tightness, diagnosed with respiratory failure and coronary heart disease, and was treated with Western medicine before being discharged. He still experiences difficulty breathing, shortness of breath, wheezing, cough with a significant amount of yellow phlegm, chest tightness, and dry mouth without bitterness. He has not had a bowel movement for a week, with a red tongue, yellow greasy coating, and a wiry slippery pulse.
Diagnosis: Lung qi not descending, bowel qi not smooth. Treatment: Clear heat, disseminate the lung, descend qi, and open the bowels, prescribed Xuanbai Chengqi Decoction with modifications.
Prescription: Apricot kernel 10g, stir-fried melon shell 8g, raw gypsum 15g, rhubarb 3g, magnolia bark 15g, mulberry bark 15g, Fritillaria 8g, stir-fried radish seed 15g. Total 14 doses, 1 dose/day, decocted in water, taken warm in two doses.
Second diagnosis: May 25, 2021. The patient reports similar symptoms, still experiencing wheezing and excessive phlegm, with constipation and difficulty passing stool, red tongue, yellow greasy coating, and wiry slippery pulse. Continue with Xuanbai Chengqi Decoction with modifications, combined with Sangbei Xiaoxianxiong Decoction and Tingli Dazao Xie Lung Decoction.
Prescription: Mulberry bark 20g, Fritillaria 8g, Coptis 5g, stir-fried melon shell 8g, half summer 10g, apricot kernel 10g, rhubarb 3g, raw gypsum 15g, Tingli seed 10g, jujube 6g. Total 14 doses, 1 dose/day, decocted in water, taken warm in two doses.
Third diagnosis: June 8, 2021. The patient reports slight reduction in symptoms, still experiencing shortness of breath upon exertion, more pronounced when lying down, constipation 3-4 days per occurrence, stool is dry, red tongue, yellow greasy coating, and wiry slippery pulse. Continue with the previous prescription for 20 doses, 1 dose/day, decocted in water, taken warm in two doses. Follow-up shows further improvement in symptoms.
Commentary:
Respiratory failure in traditional Chinese medicine falls under the categories of “lung distension” and “suspended fluid disease.” The lung governs qi and respiration; when evil qi invades the lung, the patient’s lung qi is inherently deficient and also harmed by external evil, leading to stagnation in the lung pathway, causing cough; when qi is retained in the lung, the lung becomes distended, unable to descend, resulting in lung distension; when distension is severe, the qi reverses, causing obstruction in the lung system, leading to shortness of breath and wheezing; the lung and large intestine are interior and exterior, influencing each other’s ascent and descent, and when the lung qi does not descend, the intestinal organs are not smooth, leading to weakness in governing body fluids and obstruction in the transmission of waste, resulting in difficulty in passing stool.
This condition did not develop overnight; treatment should emphasize the urgency of addressing both the symptoms and the root cause. Therefore, Teacher Xiong first used Xuanbai Chengqi Decoction to relieve constipation and stabilize breathing, employing simultaneous treatment of the lung and intestine, and then focused on draining the lung and promoting water. Xuanbai Chengqi Decoction originates from the Wen Bing Tiao Bian, where Wu Tang states: “For wheezing and shortness of breath, with phlegm and fluid stagnation, the right cun pulse is full; if the lung qi does not descend, Xuanbai Chengqi Decoction is indicated.” Xuanbai refers to the dissemination of lung qi, while Chengqi refers to the smooth functioning of bowel qi; thus, Xuanbai Chengqi combines the dissemination of lung qi with the smooth functioning of bowel qi, treating the condition of lung qi not descending and heat in the bowel.
The original formula of gypsum, rhubarb, apricot kernel, and melon shell disseminates lung qi and transforms phlegm, draining heat and promoting descent, allowing the bowel qi to open, thus the organ qi descends. Teacher Xiong added magnolia bark to enhance its ability to descend qi and relieve fullness, while stir-fried radish seed, being neutral, reduces distension, both descending qi and moistening the intestines. Fritillaria moistens the lung and stops cough, while mulberry bark drains the lung and promotes water, achieving the effects of Sangbei San. Although the number of herbs is few, both the lung and intestine are addressed, with the herbs matching the symptoms, treating both the upper and lower organs simultaneously.
4.2 Intestinal Disease and Lung: Simultaneous Treatment of Intestine and Lung
In the Huangdi Neijing Suwen Jizhu, it states: “The large intestine is the bowel of the lung and governs defecation; if evil obstructs the large intestine, it can lead to shortness of breath… Therefore, large intestine diseases can also reverse and affect the lung,” indicating that the lung and large intestine are interior and exterior, and they are related in terms of the transmission and descent of organs, as well as the generation and movement of qi and body fluids. When evil obstructs the large intestine, the earthly qi does not flow, and the turbid qi rises, causing the lung to lose its function of dissemination, leading to simultaneous lung and large intestine diseases. Therefore, when there is constipation accompanied by symptoms of shortness of breath, cough, and difficulty breathing, the treatment should focus on promoting downward movement and moistening the intestines, while also disseminating the lung and regulating qi, employing simultaneous treatment of the intestine and lung.
Case Example: A 67-year-old female patient was first diagnosed on August 12, 2021.
Chief complaint: Difficulty in defecation for six months. Current medical history: The patient reports difficulty in defecation for nearly six months, sometimes requiring the use of a laxative to pass stool, with prolonged defecation time. The stool is dry and pellet-like, with easy abdominal distension and dry mouth, accompanied by cough with little phlegm, fatigue, and occasional dizziness. The patient has a history of hypertension, with a pale yellow complexion, red tongue, thin yellow coating, and thin pulse.
Diagnosis: Intestinal heat dryness, lung metal losing moisture. Treatment: Moisten the intestines and promote defecation, clear heat and transform phlegm, prescribed a modified version of the Renmazi Ren Wan combined with the Fritillaria Melon Shell Powder.
Prescription: American ginseng 8g, hemp seed 30g, white peony 10g, apricot kernel 10g, peach kernel 10g, bitter orange peel 10g, magnolia bark 10g, rhubarb 2g, Zhejiang fritillaria 30g, stir-fried melon shell 10g, angelica 10g, gastrodia 10g. Total 20 doses, 1 dose/day, decocted in water, taken warm in two doses.
Second diagnosis: September 2, 2021. The patient reports improvement in defecation, with significantly reduced defecation time, and alleviation of cough and fatigue symptoms. The stool is still somewhat dry and hard, with occasional cough and phlegm, and recent dizziness, with a pale red tongue, thin yellow coating, and thin slippery pulse.
Prescribe the previous formula with modifications: American ginseng 8g, hemp seed 30g, white peony 10g, apricot kernel 10g, magnolia bark 10g, rhubarb 2g, kudzu root 30g, gastrodia 20g, Zhejiang fritillaria 30g, stir-fried melon shell 10g, half summer 10g, platycodon 10g, licorice 6g. Total 20 doses, 1 dose/day, decocted in water, taken warm in two doses. Follow-up shows that defecation has returned to normal, with 1-2 days per occurrence, and stool quality is good, with no significant cough.
Commentary:
Constipation can have multiple causes; although the disease is located in the large intestine, it is related to the spleen, stomach, lung, and kidney.
In the Yi Zong Bi Du: Da Bian Bu Tong, it states: “Moreover, elderly patients may experience dryness of body fluids… leading to constipation,” indicating that the patient, being elderly and weak, has a deficiency of yin and blood, leading to dryness and intestinal stagnation, thus causing difficulty in passing stool and abdominal distension. The lung and large intestine are interior and exterior; when the earthly qi does not flow, the bowel qi does not descend, leading to qi rising and causing shortness of breath. The deficiency of qi and body fluids leads to fatigue and dizziness.
The patient initially presented with intestinal heat dryness and insufficient body fluids, leading to dryness in the lung, thus Teacher Xiong prescribed a modified version of the Renmazi Ren Wan combined with the Fritillaria Melon Shell Powder to clear and moisten the intestines and lungs, promote defecation, drain heat, regulate qi, and achieve simultaneous treatment of the intestine and lung.
The Renmazi Ren Wan, as stated in the Shang Han Lun, treats the “spleen deficiency syndrome” characterized by weak spleen and stomach. The hemp seed is neutral and moistening, primarily promoting bowel movement, while the apricot kernel disperses lung qi. Teacher Xiong also added peach kernel to enhance the moistening effect on both the lung and intestine. Bitter orange peel, magnolia bark, and rhubarb are included to represent the intention of the small Chengqi Decoction, lightly purging heat accumulation and alleviating intestinal heat dryness. “When the lung is dry, it should be moistened with Fritillaria Melon Shell Powder” (from Yi Xue Xin Wu), as this case primarily involves intestinal disease, but also affects the lung, thus Teacher Xiong included Zhejiang fritillaria and stir-fried melon shell to stop cough and transform phlegm, while white peony and angelica nourish yin and blood. American ginseng is added to clear heat and tonify qi, while gastrodia is used to dispel dampness and calm wind to alleviate dizziness. The combination of these herbs ensures that both the lung and intestine are moistened, allowing for smooth bowel function and descent of lung qi, thus achieving relief from cough.
5. Conclusion
In summary, the theory of ‘The Lung and Large Intestine as Interior and Exterior’ has a long history, rich connotation, and broad pathways for realization. In the clinical application of this theory, Teacher Xiong emphasizes the fundamentals, does not forget the whole, pays attention to the etiology and pathogenesis, and values differentiation and treatment. The theory of ‘The Lung and Large Intestine as Interior and Exterior’ has high guiding value and broad research prospects in clinical practice, warranting continuous exploration and in-depth study. Teacher Xiong often says that the life of traditional Chinese medicine lies in clinical practice, and the foundation of clinical practice lies in the classics. “Medicine values precision, learning values breadth, knowledge values excellence, and the heart values emptiness.” Great physicians are sincere, and learning has no limits.
Source: Journal of Yunnan University of Traditional Chinese Medicine, Volume 46, Issue 5
Authors: Sun Haoxian, Hunan University of Traditional Chinese Medicine, First Affiliated Hospital of Hunan University of Traditional Chinese Medicine; Xiao Zixuan, Hunan University of Traditional Chinese Medicine; Liu Shan, Hunan University of Traditional Chinese Medicine; Sun Jiaqiqi, Hunan University of Traditional Chinese Medicine; Sun Guixiang, Hunan University of Traditional Chinese Medicine, Inheritance Studio of Master Xiong Jibai
Funding Projects: National Administration of Traditional Chinese Medicine Youth Qihuang Scholar Project (Guo Zhong Yi Yao Ren Jiao Fa [2020] No. 7); Fund Project of Inheritance Studio of Master Xiong Jibai, First Affiliated Hospital of Hunan University of Traditional Chinese Medicine (XJB202208); Clinical Medical Technology Innovation Guidance Project of Hunan Provincial Science and Technology Department (2021SK51406); Graduate Innovation Project of Hunan University of Traditional Chinese Medicine (2022CX35)
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