Qi, meaning hole or opening. In Traditional Chinese Medicine, "qiao" refers broadly to the portals connecting the body to the outside world. Pathogenic factors usually enter through these openings. As early as in "Ling Shu·Kou Wen," it was stated that pathogens travel through empty passages. For example, wind-cold pathogens typically enter through the skin pores, warm pathogens and viruses through the mouth and nose, foul odors through the mouth, and sexually transmitted diseases through the front genitalia. Once pathogens enter through these openings, they can also exit through them. Zhang Zhongjing often used these openings as pathways to expel pathogens outward, known as the "Tongqiao Quxie" method. "Wen Yi Lun·Biao Ben" states: "All orifices are vital passageways of life; pathogens entering through orifices must exit through them." Clinical practice has proven that whether pathogens enter through orifices or arise internally, they can be expelled externally by opening the orifices, such as water retention, phlegm turbidity, and blood stasis, all of which can be eliminated via the "Tongqiao Quxie" method. Thus, this method holds significant importance in therapeutic approaches.
1. Opening Orifices to Expel Pathogens – A Masterful Technique
In physiological conditions, nasal passages, sweat pores, and anterior and posterior orifices are crucial channels for eliminating metabolic waste products from the body. In pathological processes, due to pathogenic obstruction or dysfunction of internal organs, these excretory pathways often become blocked or partially obstructed. When blocked, pathogens accumulate and cause illness; when open, they have a pathway to exit. At this point, opening the path is essential for pathogens to leave. For instance, when wind-cold invades, cold constricts the pores, causing closure of the pores and trapping defensive yang, resulting in no sweating. With blocked sweat pores, the invading cold cannot be expelled, so acrid and warm herbs like Ma Huang and Gui Zhi are used to open the sweat pores and expel pathogens outward. For intestinal accumulation and constipation, strong purgatives like Da Huang are used to open the posterior orifice and expel pathogens. For blood stasis blocking the meridians leading to amenorrhea, the Di Dang Tang is used to open the path, allowing blood stasis to be removed. For fluid retention causing difficulty in urination, later generations said, "Treating dampness without promoting urination is not proper treatment," and most diuretic formulas have the function of opening the urinary passage. "Ling Shu·Ci Jie Zhen Xie" says: "To open, to clear the gateways, so that pathogens can exit, and the illness will be cured." Opening the gateways means creating a path for pathogens, applying methods such as sweating, vomiting, purging, and diuresis, making blocked passages unblocked and partially open ones fully open, thus facilitating the expulsion of pathogens. Zhang Zihe, one of the Four Great Masters of the Jin-Yuan period, believed: "Disease is not something inherent in the body; it either comes from outside or arises internally—both are pathogenic factors. When pathogenic factors invade the body, they should be attacked quickly and repeatedly." To expel pathogens swiftly, opening the orifices is the best method. Thus, Zhang Zihe excelled in using the three methods of sweating, vomiting, and purging, enabling pathogens to exit through the orifices and cure the illness.
2. Closest Orifice for Expelling Pathogens – A Fundamental Principle
Pathogens can lodge in different parts of the body—on the surface, inside, in the meridians, or in the zang-fu organs. Treatment should identify the location of the disease and select the nearest available path for pathogen expulsion. "Su Wen·Yin Yang Ying Xiang Da Lun" states: "For those higher up, induce emesis; for those lower down, promote drainage; for those with fullness in the middle, purge internally." It also says: "For those on the skin, induce sweating." This essentially means treating diseases by targeting the site of illness and expelling pathogens nearby. Traditional Chinese Medicine has numerous methods of expelling pathogens through nearby orifices. For example, wind-cold, wind-damp, and fluid retention pathogens on the surface are treated by opening the skin pores to expel pathogens through sweating. Real pathogens such as heat accumulation, cold accumulation, dry feces, and blood stasis in the intestines are treated by attacking and purging to expel pathogens through defecation. For retained food or wind-phlegm in the chest or epigastrium, the nearest orifice—the mouth—is used for vomiting to expel pathogens. For damp-heat in the lower burner, the front genitalia are opened to promote urination and expel pathogens. Sometimes, the symptoms appear here but the disease is located elsewhere, requiring careful differentiation. For example, in "Jin Kui Yao Lue," the condition of "hiccups with abdominal distention" appears on the surface but is actually due to "disease in the lower part causing qi to rise upward." Since the pathogen is in the lower part, the anterior and posterior orifices must be impaired. Therefore, Zhang Zhongjing advised: "Observe the anterior and posterior orifices to determine which is impaired, then treat it accordingly; once both orifices are open, turbid qi descends, distention disappears, and hiccups cease." This is a classic example of expelling pathogens through nearby orifices. Treating close to the site allows the medicine to reach the affected area easily, and pathogens are more readily expelled—this is taking the shortcut, avoiding detours. Hence, Wu Ju Tong said in "Wenbing Tiaobian": "When expelling pathogens, follow their location and expel them nearby." Ignoring this principle may lead to deeper invasion of pathogens, spreading of disease, or unnecessary damage to healthy qi—these are serious consequences that must be carefully avoided.
3. Multiple Openings for Different Paths – Dispersing Pathogens
When pathogens invade and cause illness, they may be singular or multiple, coexisting together. Traditional Chinese Medicine often uses the method of opening multiple orifices to expel pathogens through different routes. This method helps disperse and break down pathogens, facilitating their expulsion through multiple or habitual pathways. For example, when fluid retention causes swelling throughout the body, the fluid cannot be expelled through sweat or urine. Treatment uses Yue Bi Jia Shu Tang: the Yue Bi Tang promotes sweating and diuresis, allowing fluid on the surface to exit through sweat pores; adding Shu (Atractylodes) enables fluid in the interior and lower part to flow out through the urinary tract—this is splitting one pathogen into two routes: upper and lower. If multiple pathogens coexist and cause illness, it is even more important to split them apart, allowing them to exit through different paths. For example, when fluid retention and accumulated food bind in the intestines, causing symptoms like abdominal distention and dry mouth, treatment uses Yi Jiao Li Huang Wan. The formula contains Fang Ji and Jiao Mu, which are acrid and bitter, to guide fluid out through the anterior orifice; Ting Li and Da Huang are used to attack and remove fluid retention and accumulated food through the posterior orifice. If there is severe heat accumulation and "thirst," add Mang Xiao to enhance the effect of purging through the posterior orifice, allowing fluid and dry accumulation to be expelled simultaneously through both orifices. Other examples include Da Huang Gan Sui Tang, where Da Huang attacks blood stasis in the posterior orifice, and Gan Sui removes blood stasis in the anterior orifice, allowing the fluid and blood pathogens trapped in the postpartum uterus to be discharged separately. Da Xian Xiong Tang and Wan use nitrate and rhubarb paired with Gan Sui and Ting Li, enabling pathogens from water-heat binding in the chest to exit through both anterior and posterior orifices. Mu Fang Ji Qu Shi Gao Jia Fu Ling Mang Xiao Tang treats severe cases of mixed deficiency and excess in drink syndrome: Fang Ji and Gui Zhi promote fluid and dispel stagnation to the skin and pores; Fu Ling and Mang Xiao dissolve hard masses and promote urination through both anterior and posterior orifices—thus, fluid and solid stagnation cannot remain. Similarly, when damp-heat binds and damages the blood, causing jaundice that spreads across the skin, Zhang Zhongjing prescribes Yin Chen Hao Tang, Zhi Zi Da Huang Tang, or Da Huang Xiao Shi Tang. Although the functions differ, all aim to expel damp-heat through the two excretory routes. Splitting and expelling pathogens is akin to Yu the Great’s approach to flood control—diverting rivers and digging channels to disperse blockages, thereby facilitating the expulsion of pathogens through multiple pathways.
4. Expelling Pathogens According to Natural Flow – Promoting External Elimination
In the course of disease progression, sometimes the body naturally shows signs of resisting and expelling pathogens outward. Traditional Chinese Medicine often takes advantage of these physiological or pathological responses that favor the body’s ability to expel pathogens, using "assistance" to facilitate the process.
If there is a desire to vomit, open the upper orifice to induce vomiting. Vomiting, normally treated by suppressing reverse flow and stopping vomiting, becomes a sign of pathogen in the upper part when the patient experiences "food immediately vomits" and "feels nauseous and wants to vomit" (from Shang Han Lun, 324). The desire to vomit indicates that the body is trying to expel pathogens upward. Zhang Zhongjing advocated following this natural tendency, opening the upper orifice to induce vomiting, allowing the solid pathogens in the chest to be expelled. Similarly, when pus forms in abscesses, it is a physiological response to expel pathogens. Even if the person is prone to vomiting, the pus should be allowed to come out; stopping vomiting would prevent the pus from exiting. Once the pus is expelled, vomiting stops. Likewise, in malaria approaching the surface, retained food in the upper part, or alcohol-induced jaundice with heat and nausea, these are signs of the body’s attempt to expel pathogens outward. These situations should be utilized to assist the body in expelling pathogens through vomiting.
If there is a desire to defecate, open the lower orifice to expel pathogens. For example, in cases of lingering fluid retention, if the patient "wants to defecate, and defecation brings relief, yet the abdomen remains full," the underlying mechanism is "the fluid is about to leave." However, although some fluid leaves, new fluid continues to accumulate. Despite defecation, the abdomen remains full. Zhang Zhongjing, recognizing this desire to expel, used Gan Sui Ban Xia Tang, which opens the water channel to assist in the process. Furthermore, in cases of bloody stool due to blood stasis (from Shang Han Lun, 239), Zhang Zhongjing recognized that blood stasis tends to move downward, so instead of stopping bleeding, he used the active blood-moving and purgative Di Dang Tang. For postpartum women with retained lochia causing abdominal pain and bleeding, if Zhi Shi Shao Yao San fails, use Xie Yu Xue Tang, which makes "new blood come out like pig liver," and even menstrual disorders can be treated this way—this is known as "opening the hidden passages and clearing obstructions."
For retained food or dry feces in the lower burner with a tendency toward diarrhea, treatment supports their expulsion through the lower orifice. For example, if diarrhea presents with pulse that is "all three positions level," or "slow and slippery," or "slippery," and symptoms include hardness and fullness in the chest and abdomen, or delirium, the underlying mechanism is that diarrhea is a symptom, while real heat, retained food, or damp-heat is the root cause. The accumulated pathogens have a tendency to move downward. Zhang Zhongjing used the "treat the symptom with the same method" approach, which is essentially opening the orifice according to the natural flow to guide pathogens out.
5. Using Orifices as a Strategy – Expelling Pathogens Through Indirect Routes
Using indirect routes to expel pathogens is a variation of the "Tongqiao Quxie" method. It involves expelling pathogens from one location by utilizing another orifice. Common scenarios include:
Proximity-Based Use of Orifices: Based on the location of the pathogen, when no other route is available or inconvenient, use a nearby orifice to expel pathogens. For example, in treating lung abscess with Jie Geng Tang or Jie Geng Bai San, patients are made to "vomit pus and blood." This method expels heat toxins and pus from the lungs through the mouth. Since both the digestive and respiratory tracts pass through the throat, using Jie Geng and Ba Dou to promote lung clearance causes the lung's pus and toxins to rise. When passing through the trachea and stimulating the throat, vomiting is induced, thus achieving the goal of expelling lung pathogens through the mouth. If pus were to exit through the nose, it would only increase the patient's suffering and fear. Therefore, in the "Qian Jin" Wei Jing Tang for lung abscess, although the formula focuses on activating blood and expelling pus, it contains no emetic herbs. Yet Zhang Zhongjing intentionally increased the dosage (re-administered) to induce vomiting, allowing the lung's pus and toxins to be expelled through the mouth.
The most common case is the mutual use of anterior and posterior orifices. For example, when dampness blocks qi and accumulates in the intestines, causing diarrhea, Zhang Zhongjing advised "promoting urination." Promoting urination helps separate intestinal dampness; once dampness is gone, qi flows freely, and diarrhea stops. This is what Yu Jia Yan referred to as "quickly opening the river." Later generations used promoting urination to treat persistent diarrhea caused by fluid in the intestines, a method derived from this principle. As "Wenbing Tiaobian" states: "Opening the anterior orifice is to protect the posterior orifice. If Tai Yang is not opened, Yang Ming will not connect; opening Tai Yang is precisely to protect Yang Ming." For rectal diseases causing urinary retention, promoting bowel movements can relieve urinary obstruction; for urinary retention with uremic toxin accumulation, medications are administered through the intestine for "dialysis"—all are examples of using nearby routes to expel pathogens.
Following the Natural Flow: Based on the body's natural resistance to pathogens, using appropriate orifices can also expel pathogens. For example, yin-yang toxicity, a type of acute infectious rash, is treated by Zhang Zhongjing with Qing Re San Yu Tang, which clears heat and disperses blood stasis. But fearing the pathogen would have no outlet, he noted that since the pathogen is on the skin and the appearance of rashes itself indicates a tendency to expel toxins, he followed this natural tendency to expel the pathogen, using the method of "taking another dose to induce sweating," allowing the pathogen to exit through the sweat pores. Alternatively, reversing the direction: for "immediate vomiting after eating," which follows the principle that "all rebellious conditions belong to fire." Gastric heat rises upward, and the disease trend is upward, so it seems logical to treat with vomiting. But "if vomiting continues without descending, it should be reversed and guided downward" (quoted from Wang Ken Tang). Zhang Zhongjing used Da Huang Gan Cao Tang, aiming to use the posterior orifice to guide gastric heat outward. Once the posterior orifice is open, the heat trend is suppressed, and vomiting stops. This is precisely what is meant by "to draw the southern breeze, first open the northern shop." Li Dongyuan was inspired by this and created the Tong You Tang, a classic example of reversing the direction to expel pathogens.
Surface-Interior Orifice Use: Based on the relationship between zang-fu organs, expelling pathogens from internal organs through their corresponding exterior organs is a common method. For example, in cases of cough or "zhǐ yǐn jiā" due to fluid accumulation in the lungs, since the lung connects with the large intestine, lung pathogens can be treated by promoting bowel movements. Thus, Shi Zao Tang is used to attack and eliminate fluid, taken in the morning with warmth, requiring "rapid bowel movement" for the pathogen to be expelled—this is treating upper disease by addressing lower organs, using indirect routes to expel pathogens. As Wang Mengying said in "Wen Re Jing Wei": "Transferring the pathogen to exit through the fu organ is indeed the path to recovery." Tang Rongchuan also wrote in "Jin Kui Yao Lue Jian Zhu Bu Zheng": "The 'Huang Di Nei Jing' says each zang organ has its corresponding fu organ—when disease occurs in a zang organ, it should be treated by targeting its corresponding fu organ." The heart connects with the small intestine; when heart fire is excessive, it is often treated by promoting urination to allow heat to exit through urine. The kidney connects with the bladder; for damp-heat in the lower burner, using herbs to promote bladder function eliminates damp-heat.
In conclusion, the "Tongqiao Quxie" method utilizes drugs or other means to open the body's channels to the outside world, expelling pathogens through orifices. This method aligns with physiology, follows the disease progression, targets the exact site, and provides a clear path for pathogen removal—making it a practical and commonly used clinical method. Further study of this method will greatly benefit the application of Zhang Zhongjing's theories in clinical practice and improve treatment outcomes.
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