Zhi Shi Dao Zhi Wan (Immature Bitter Orange Stagnation-Guiding Pill) zhǐ shí dǎo zhì wán · 枳实导滞丸

Safety. Zhi Shi Dao Zhi Wan is recorded in Neiwaishang Bianhuo Lun, Li Gao's thirteenth-century treatise on telling internal damage apart from external contraction. Eight herbs, and their arrangement is the argument. Da huang and zhi shi lead, one draining downward and one moving qi. Shen qu disperses the food accumulation. Huang qin and huang lian clear the heat classical writers expected to find there. Fu ling and ze xie leach dampness out through urination. Bai zhu is present to protect the spleen while the others work. What makes this formula worth reading is that it contains a purgative and is traditionally cited for diarrhoea. This is the pattern classical texts call using a draining method for a draining symptom: the claim is that if the stagnation is not cleared the diarrhoea will not settle, and that treating the discharge directly would be treating the consequence. Whether a reader finds that reasoning persuasive is a separate matter from whether the reasoning is accurately reported, and this entry reports the reasoning. The classical framing is explicit that this belongs to a replete presentation and a short course, and that it is withdrawn once the accumulation has moved. A modern reader should know what diarrhoea can be. Blood in the stool, fever, signs of dehydration, unintentional weight loss, diarrhoea that wakes a person from sleep, or a persistent change in bowel habit beginning after the age of fifty needs investigation rather than self-management. The differential spans infection including Clostridioides difficile, inflammatory bowel disease, coeliac disease, microscopic colitis, bile acid diarrhoea, pancreatic insufficiency, thyroid disease, diabetes and medicines — antibiotics, metformin and proton pump inhibitors among the most common. None of these is separable by pulse and tongue. Safety, and this is the most important part of the entry. Abdominal pain of undetermined cause is not a situation for a draining formula. Pain with no passage of stool or gas, a distended tympanic abdomen, or pain with vomiting can indicate bowel obstruction or a surgical abdomen, where a purgative is actively harmful. Mesenteric ischaemia presents with pain out of proportion to findings on examination and should be thought of first in atrial fibrillation, and an inferior myocardial infarction can present as upper abdominal pain. Da huang contains anthraquinones and acts as a stimulant laxative: prolonged use is associated with dependence, potassium loss and melanosis coli, and potassium loss compounds with diuretics and with digoxin. Zhi shi contains p-synephrine, the amine for which bitter orange extracts have attracted regulatory attention over cardiovascular events. Huang qin and huang lian contain berberine, with the enzyme, transporter and bilirubin interactions described elsewhere in this library. Ze xie has a literature on renal effects at high exposure that has not reached a conclusion. Shen qu is a gluten source. This formula is not for pregnancy or breastfeeding, nor for anyone already dehydrated or electrolyte-depleted. This library does not claim it resolves food stagnation or treats diarrhoea.