Source 出处 · Jingyue Quanshu · Doses are not given here: they are set by a licensed practitioner for the individual.
Safety. The name means ferrying a stream, and the metaphor is a decent one: what is being carried across is a bowel that has run out of the fluid and the motive force to move. Zhang Jiebin's formula comes from the Ming dynasty and it is aimed at a picture his text describes in terms of kidney depletion - an older person, a dry stool, difficult evacuation, and none of the heat, distension and agitation that characterise the purging formulas of the Shanghan Lun. It belongs to the same broad branch as Ma Zi Ren Wan, the moistening purge, but it adds two things: warming and supplementing, because the failure it addresses is read as a failure of resources rather than an accumulation of something hostile.
The construction is the interesting part, and it is worth describing rather than paraphrasing, because it contains a piece of reasoning that appears elsewhere in the literature but rarely so plainly. A formula meant to move the bowels downward contains two ingredients that lift. Sheng ma, cimicifuga, is the herb of raising; zhi qiao, bitter orange, descends; and the classical account of why both are there is the phrase yu jiang xian sheng - to send it down, first raise it. The reading is that clear yang rising is what allows turbid yin to descend, which sounds like wordplay until one notices that the same shape of argument is used throughout the tradition for cough, for urination and for labour. Whether or not one accepts the mechanism, the move is deliberate and it is worth naming. There is also a plainer reading available: zhi qiao moves qi in the middle and cimicifuga appears in small quantity beside a large one of cistanche, and formulas are rarely built from one idea alone.
Then the part that has to come first, which is that constipation in an older adult is not a diagnosis and the formula is not a substitute for asking why. New constipation beginning after middle age without an obvious cause is a reason to exclude colorectal cancer, and so is constipation with blood in the stool, unexplained weight loss, iron-deficiency anaemia, or a persistent change in stool calibre. The medication list behind constipation is long - opioids first, then anticholinergics, calcium channel blockers, iron, some antidepressants and antipsychotics, and over-the-counter antihistamines - and thyroid disease, hypercalcaemia, hypokalaemia, Parkinson's disease, depression and immobility each appear on it. In older adults specifically, faecal impaction presenting as overflow diarrhoea is the presentation that most reliably gets treated the wrong way round. And acute constipation with distension, vomiting and no passage of wind is obstruction until imaging says otherwise, which is a different and far more urgent matter.
On the materials. Cistanche is a desert parasitic plant and it is the ingredient most likely to be described to a reader as gentle; it is worth knowing that wild desert cistanche has been harvested to the point of conservation concern, that supply is now substantially cultivated, and that the plant on a label is not always the plant one imagines. Angelica contains coumarin-type constituents, and although sharing a word with warfarin does not make something an anticoagulant, case reports of a raised INR when the two are combined exist, so anyone on warfarin is in monitoring territory rather than dispute territory. Achyranthes root, niu xi, is the one whose traditional cautions matter most here: it is a blood-moving and downward-directing herb and it is classically contraindicated in pregnancy, and it is also one of the names covering more than one plant - Achyranthes bidentata and Cyathula officinalis are the two usually meant - so the identity question is live each time the label is written. Alisma is a diuretic rhizome, and the caution that follows is not about toxicity but about arithmetic: a formula for dryness that contains something which increases urine output is a formula that has to be considered in a person who is already dry, dehydrated, or taking a diuretic. Cimicifuga is the one that deserves a specific note, because the genus Actaea, which includes black cohosh, has been associated with reports of liver injury, mostly for the North American species and mostly from supplement use; the Chinese material is not the same species, but the identity matters and a reader with liver disease or unexplained jaundice is not in a place to be casual about it. Bitter orange, finally, brings p-synephrine and the same stimulant concerns recorded for Ma Zi Ren Wan; zhi qiao and zhi shi are the nearly mature and immature fruit respectively and are not interchangeable.
What this knowledge base will say without hedging: the formula is the clearest worked example in the literature of a purge that is built by looking upward, and a person of eighty who has suddenly stopped opening his bowels needs a clinician before he needs a metaphor.
方名的意思是「渡过一条河」，这个比喻不坏：被渡过去的，是一副已经耗尽了津液与推动力的肠道。张介宾这首方出自明代，对准的是他的书里以「肾虚」来描述的一幅画面：一位老年人，大便干，排出困难，而没有《伤寒论》那些攻下方所对应的热、胀与烦躁。它与麻子仁丸同属润下这一大支，但多加了两条：温与补——因为它所对的那次失败被读作资源的亏耗，而不是某种敌对之物的停积。
有意思的是它的构造，值得描述而不是转述，因为它含有一处推理：这个推理在文献别处也出现，但很少这么明白地摆出来。一首要把大便往下送的方里，有两味是往上升的。升麻是升提之药，枳壳是降气之药；关于为什么两味都在，古典说法是那句「欲降先升」。读法是：清阳得升，浊阴才得降。这听起来像文字游戏，直到人注意到同一个论证形状被传统用在咳嗽上、用在小便上、用在难产上。不论是否接受这个机制，这个动作是刻意的，值得点出来。也另有一个更平实的读法：枳壳在中焦行气，升麻在小量上出现在大剂量肉苁蓉的旁边，而一首方很少只由一个观念构成。
然后是必须先说的部分：老年人的便秘不是一个诊断，而这首方也不是「为什么」的替代品。中年后无明确原因新发的便秘，是排除结直肠癌的理由；便秘伴便血、不明原因的体重下降、缺铁性贫血，或粪便变细且持续，同样是。便秘背后的药物清单很长——阿片类居首，其后是抗胆碱药、钙通道阻滞剂、铁剂、某些抗抑郁药与抗精神病药，以及药店自购的抗组胺药；甲状腺疾病、高钙血症、低钾血症、帕金森病、抑郁与长期卧床也各在其列。在老年人身上，表现为溢液性腹泻的粪便嵌塞，是最可靠地会被反向处理错的那一种。而急性便秘伴腹胀、呕吐、不排气，在影像作出别的判定之前就是梗阻，那是一件不同而且急得多的事。
单味药：肉苁蓉是一种荒漠寄生植物，也是这一方里最容易被描述成「缓和」的一味；值得知道的是野生荒漠肉苁蓉被采伐到成为保护关注对象，今天的货源很大程度来自栽培，而标签上的那株植物并不总是人们想象的那一株。当归含香豆素类成分；与华法林共用「香豆素」这个词并不意味着它是抗凝药，但确有两者合用使 INR 升高的个案报告，所以服用华法林的人处在需要监测的位置，而不是需要争论的位置。牛膝是这里传统禁忌最要紧的一味：它是活血而引下行的药，古典上孕期禁用；它同时是一个覆盖不止一种植物的名称——通常指的是牛膝（Achyranthes bidentata）与川牛膝（Cyathula officinalis）——所以每次写标签时基原问题都是活的。泽泻是利水的根茎，跟着它的告诫与毒无关，与算术有关：一首对准「燥」的方里含一味增加尿量的药，对于一个本来就干、已经脱水或正在服利尿剂的人来说，是要重新算一遍的。升麻值得专门写一条，因为 Actaea（升麻属，含北美黑升麻）这一个属有过肝损伤的报告，主要来自北美种、主要来自补充剂使用；中国所用不是同一种，但基原要紧，而一个有肝病或不明原因黄疸的读者没有余裕对这件事随便。最后是枳壳，它带来对辛弗林以及麻子仁丸那条里记下的同样的兴奋剂顾虑；枳壳与枳实分别是近成熟与幼嫩的果实，不可互代。
本站可以不含糊地写的是：这首方是文献里「通过往上看去造一首泻下方」最清楚的范例；而一位八十岁、忽然不再解大便的人，需要先有医生，再要这个比喻。