1. All diseases with clear and cold body fluids belong to cold.The focus of this section is the clarity and coldness of body fluids, which encompasses a wide range of fluids, such as phlegm, urine, pus, nasal mucus, sweat, and the characteristics of stool and leukorrhea.Clarity and coldness imply thinness, coolness, and transparency, which are key points in determining cold pathogenic mechanisms. This corresponds to another pathogenic mechanism stating that “all diseases with turbid body fluids belong to heat.”From clinical practice, the characteristics of body fluids are indeed crucial for diagnosing cold and heat, indicating that the teachings of the Neijing are a summary of clinical experience.For example, coughing up clear and thin phlegm often indicates cold phlegm, which should be warmed and transformed; clear and prolonged urination often indicates kidney yang deficiency, which should be warmed and tonified; in surgical cases, clear and thin pus often indicates a yin syndrome, which should be treated by tonifying qi and warming yang to promote healing; in gynecology, clear and thin leukorrhea often indicates a cold syndrome, either due to cold dampness descending or spleen and kidney yang deficiency, which should be treated by warming and dispersing cold dampness or tonifying the spleen and warming the kidneys;clear and thin nasal mucus often indicates invasion of cold evil, which should be treated by dispelling wind and scattering cold; diarrhea with clear and thin stools, or resembling water, often indicates invasion of cold evil in the stomach and intestines, or spleen yang deficiency, leading to internal cold, which should be treated by warming and dispersing cold evil, or tonifying the spleen and warming the middle.Thus, differentiating cold and heat based on the characteristics of body fluids is indeed an important clinical method.Case:A 70-year-old female patient with a history of chronic bronchitis for over 10 years often experiences exacerbations in autumn and winter. Recently, due to a sudden drop in temperature, she developed a cold, followed by an exacerbation of her chronic bronchitis. She has repeatedly used antibiotics and antitussive expectorants, which slightly alleviated her symptoms but did not resolve them completely.Current diagnosis:Coughing with shortness of breath, especially worsened during walking, can still lie flat at night, coughs up white, clear, and thin phlegm, in large amounts, approximately 300ml day and night, with no obvious cold or heat symptoms, but feels cold and fatigued, with poor spirit and reduced appetite, and has scanty stools, with a white greasy tongue coating and a wiry slippery pulse.This prolonged cough has led to deficiency in the lungs, spleen, and kidneys, with internal cold arising, compounded by external pathogens, resulting in phlegm and qi obstruction. The initial treatment plan was to use Xiao Qing Long Tang (Minor Blue Dragon Decoction) combined with San Zi Yang Qin Tang (Three Seed Decoction to Nourish One’s Parents) for modification, and once the symptoms were alleviated, to address the root cause.Ingredients: Sheng Ma Huang (Ephedra) 12g, Gui Zhi (Cinnamon Twig) 12g, Gan Jiang (Dried Ginger) 9g, Zhi Ban Xia (Processed Pinellia) 12g, Xi Xin (Asarum) 6g, Wu Wei Zi (Schisandra) 9g, Lai Fu Zi (Radish Seed) 15g, Bai Jie Zi (White Mustard Seed) 12g, Zhi Su Zi (Fried Perilla Seed) 12g, Guang Xing Ren (Apricot Kernel) 12g, Ting Li Zi (Descurainia Seed) 12g, Bai Qian Hu (Cynanchum) 12g, Hou Po (Magnolia Bark) 6g, Zhi Qiao (Bitter Orange) 12g, Gan Cao (Licorice) 4.5g.After 14 doses, the cough and shortness of breath slightly improved, the amount of phlegm decreased, appetite increased, tongue coating was white, and pulse was slippery, but shortness of breath during walking persisted. The phlegm was deeply rooted, and the pathogenic fluid had not been completely resolved, so the focus should be on dispelling the evil.The formula was modified by adding Zhi Zi (Fried Purple Aster) 15g and Bai Bu (Stemona) 12g, continuing for another 14 doses. The symptoms further alleviated, phlegm became thicker, white in color, and the amount decreased, with smooth bowel movements and improved appetite.Modified treatment plan:Huang Qi (Astragalus) 30g, Dang Shen (Codonopsis) 15g, Chao Bai Zhu (Fried Atractylodes) 12g, Fu Ling (Poria) 15g, Gan Cao (Licorice) 4.5g, Bai Qian Hu (Cynanchum) 12g, Zhi Ban Xia (Processed Pinellia) 12g, Chen Pi (Aged Tangerine Peel) 9g, Zhi Su Zi (Fried Perilla Seed) 12g, Zhi Zi (Fried Purple Aster) 12g, Bai Bu (Stemona) 12g, Huang Qin (Scutellaria) 12g, Zhi Qiao (Bitter Orange) 12g.This formula was adjusted and treated for several months, with all symptoms resolved, but there was still a slight cough at night, with little phlegm, and normal appetite and bowel movements, with significantly reduced shortness of breath during walking.Notes:In TCM, differentiating cold syndromes involves considering the patient’s subjective feelings of cold and cold limbs; observing the patient’s spirit, fatigue, pale complexion, and tongue color; and examining the patient’s secretions and excretions, which often have characteristics of light white, clear, thin, and transparent.The patient’s white, foamy phlegm in large amounts undoubtedly indicates cold phlegm, thus following Zhang Zhongjing’s principle that “for phlegm and fluid diseases, one should use warming herbs to harmonize them,” using Gan Jiang (Dried Ginger), Xi Xin (Asarum), Gui Zhi (Cinnamon Twig), Zhi Ban Xia (Processed Pinellia), and Chen Pi (Aged Tangerine Peel) to warm and transform cold phlegm often yields satisfactory results.Therefore, differentiating phlegm and fluid characteristics is of great significance in this case.2. All diseases with turbid body fluids belong to heat.“Turbidity” refers to the condition of the sinews and meridians being affected, leading to spasms and contractions. According to the nineteen pathogenic mechanisms, the causes of sinew and meridian spasms include wind invading the sinews, cold obstructing the sinews, dampness stagnating the sinews, and heat scorching the sinews. However, if accompanied by “turbid body fluids,” the pathogenic mechanism must undoubtedly belong to heat.Thus, this section focuses on the characteristics of body fluids, which are key to determining cold and heat pathogenic mechanisms. In understanding this, it can be compared with another pathogenic mechanism stating, “all diseases with clear and cold body fluids belong to cold.”The range of body fluids also includes phlegm, nasal mucus, stool, urine, and vomit expelled by the patient.“Turbidity” is the opposite of “clarity and coldness,” generally referring to yellowish, turbid, slightly thick, and foul-smelling characteristics.For example, in cough and asthma cases, yellow and thick phlegm often indicates heat phlegm, which is due to lung heat; yellow and thick nasal mucus with a foul smell indicates heat evil invading the nasal passages; in gynecology, yellow and turbid leukorrhea with a foul smell often indicates damp-heat descending; in surgical cases, yellow and turbid pus flowing from ulcers indicates heat toxin; yellow and turbid urine indicates damp-heat descending; and diarrhea with yellow and thick stools indicates damp-heat dysentery.Case:Ten years ago, I treated a patient with lobar pneumonia, a male in his thirties, who developed chest pain and cough after working in the rain, producing a small amount of rust-colored phlegm, accompanied by chills and fever. Two days later, his temperature rose to 39°C, and he was sent to the hospital for emergency treatment.Upon examination, the tongue coating was thick and yellow, and upon further questioning, the phlegm was thin yellow, sticky, and in small amounts, with a feeling of discomfort when coughing, and slight pain in the right chest, which occurred during coughing, with poor appetite and a slippery pulse. This indicates heat obstructing the lungs, with phlegm-heat congealing, and the treatment plan was to clear lung heat, transform phlegm, and stop coughing.Ingredients: Lu Gen (Reed Rhizome) 15g, Tao Xing Ren (Peach Kernel) 12g, Yi Yi Ren (Job’s Tears) 30g, Gua Lou Pi (Trichosanthes Peel) 12g, Huang Qin (Scutellaria) 20g, Bai Bu (Stemona) 12g, Bai Qian (Cynanchum) 12g, Yu Xing Cao (Houttuynia) 30g, Qi Ye Yi Zhi Hua (Seven Leaf One Branch Flower) 30g, Chuan Bei Mu (Fritillaria) 12g, Gan Cao (Licorice) 4.5g.After 5 doses, the above symptoms significantly improved, with reduced cough, less phlegm, improved tongue coating, and a feeling of dryness in the mouth. As the phlegm-heat gradually receded, the formula was modified by removing Yi Yi Ren and adding Tian Mai Dong (Ophiopogon) 12g. After 7 doses, all symptoms resolved, and the patient was discharged after two weeks of recovery.Notes:This case of rust-colored phlegm is a typical symptom of lobar pneumonia and is also a focal point for TCM differentiation of phlegm-heat. The condition was urgent, and the treatment was effective and rapid, with follow-up showing no recurrence after one month.3. All diseases with swelling and pain belong to fire.Swelling is a type of necrosis. Fire toxins invade, scorching the blood and corrupting the skin, leading to swelling and pain, and causing great distress.This condition is similar to erysipelas, often occurring in the lower leg and foot, with local redness, swelling, heat, and pain, resembling a red coating. This is due to the underlying heat in the blood, combined with damage to the skin, allowing damp-heat fire toxins to invade, obstructing the skin and causing the condition.Case:I once treated a young male patient whose right lower limb skin had been red and swollen for two weeks, with a color resembling a red coating. He had received penicillin treatment at a hospital for a week, which alleviated the pain, but the redness and swelling persisted. He sought TCM treatment through a friend’s recommendation.Upon examination, the right lower limb skin was red and swollen, with a feeling of heat upon palpation, slight pain, and difficulty walking. The patient was generally healthy, with a tendency towards excess yang, fond of rich foods, and had a history of hyperlipidemia, hypertension, and diabetes. The tongue was dry with little moisture, slightly yellow and thick coating, and a red body, with a wiry and full pulse.This indicates that the patient has internal damp-heat accumulated in the blood, and recent busy work and frequent walking have triggered the fire. However, he denied any previous history of fire disease. The treatment should focus on clearing heat, cooling the blood, and detoxifying, with both internal and external treatment.Internal formula:Dan Pi (Moutan Cortex) 12g, Chi Shao (Red Peony) 15g, Lian Qiao (Forsythia) 12g, Yin Hua (Honeysuckle) 12g, Hong Teng (Sargentodoxa) 30g, Bai Jiang Cao (Patrinia) 30g, Yao Xiu (Hedyotis) 30g, Huang Hua Di Ding (Yellow Flower) 30g, Zihua Di Ding (Purple Flower) 30g, Sheng Gan Cao (Raw Licorice) 6g.14 doses.Externally, apply Jin Huang San (Golden Yellow Powder) to the affected area once a day. After two weeks, the redness and swelling decreased, the heat sensation improved, and the pain subsided, allowing the patient to walk. The treatment was effective, and no changes were necessary, continuing with the original formula for internal and external treatment. After another two weeks, the patient fully recovered and has not experienced a recurrence in three years of follow-up.4. All abdominal distension belongs to heat.Distension is a subjective symptom, while abdominal distension is a physical manifestation of swelling. Distension and abdominal distension belong to fullness.The Suwen states, “When the pulse is strong, the skin is hot, and the abdomen is distended, with no passage before and after, this is a case of five excesses.” This “abdominal distension” indicates that the pathogenic mechanism belongs to heat and is a case of excess distension. It is caused by internal heat congealing in the stomach and intestines, leading to stagnation of qi and obstruction of the bowels, resulting in fullness.The Dan Xi Xin Fa states that blood accumulation, food stagnation, great anger, external cold, and internal heat can all cause abdominal distension, and also points out that “emotional injuries and external invasions, irregular diet, and sexual exhaustion can lead to deficiency, injuring the yin of the spleen, causing the transport function to fail. Thus, although the stomach receives food, it cannot transform it, leading to the yang rising and the yin descending, resulting in the failure of heaven and earth to communicate, with clear and turbid mixing, leading to obstruction and heat, which generates dampness, and damp-heat generates fullness.”Dan Xi’s analysis is quite comprehensive, but from clinical practice, cold distension is more common than heat distension in miscellaneous diseases, while heat distension is more common than cold distension in externally contracted diseases.Case:Five years ago, I treated a patient with intestinal obstruction, a male aged 45.He had undergone surgery for colon cancer ten years ago and had reactions to chemotherapy. For five years, he had been using TCM to regulate his condition, focusing on tonifying, detoxifying, resolving stasis, and dispersing masses, and had been relatively stable.He frequently complained of dull pain in the right lower abdomen and unsatisfactory bowel movements. Recently, the dull pain in the right lower abdomen intensified, and upon inquiry, he had not had a bowel movement for a week. He had used Dang Gui Long Hui Wan (Angelica and Dragon’s Blood Pill) and other remedies to relieve constipation without success.Last night, the abdominal pain and distension worsened, and he went to the hospital for emergency treatment. An X-ray of the abdomen indicated intestinal obstruction, and after treatment with Western medicine, the abdominal pain alleviated, but bowel movements remained minimal.Upon examination, there was still slight distension and dull pain in the lower abdomen, with scanty stools accompanied by mucus, a thick and greasy tongue coating, and a slippery pulse. This indicates adhesive intestinal obstruction, with heat accumulation in the intestines not resolved, leading to stagnation of qi and obstruction, requiring urgent treatment to clear the heat accumulation in the intestines.Formula:Yuan Ming Fen (Yuanming Powder) 9g (to be taken last), Sheng Da Huang (Raw Rhubarb) 9g (to be taken last), Zhi Qiao (Bitter Orange) 12g, Hou Po (Magnolia Bark) 9g, Da Fu Pi (Areca Peel) 15g, Huang Lian (Coptis) 6g, Gan Cao (Licorice) 4.5g, Ma Ren (Sesame Seed) 30g.After 2 doses, the patient had 5 bowel movements, passing watery stools, followed by a small amount of foul-smelling mucus, with reduced abdominal distension and pain, and normal bowel sounds.Continuing with the formula:Chao Bai Zhu (Fried Atractylodes) 12g, Jiao Mi Ren (Fried Job’s Tears) 30g, Zhi Qiao (Bitter Orange) 12g, Mu Xiang (Aucklandia) 9g, Fu Ling (Poria) 15g, Zhi Xiang Fu (Processed Cyperus) 12g, Huang Lian (Coptis) 6g, Huang Qin (Scutellaria) 12g, Wu Yao (Lindera) 9g, Ma Ren (Sesame Seed) 20g, Gan Cao (Licorice) 4.5g, Da Zao (Jujube) 10 pieces.After 7 doses, all symptoms resolved, and the patient was advised to maintain regular bowel movements and consume more fruits and vegetables rich in fiber. Over the next five years, he experienced two similar episodes, but the symptoms were milder, and each time he used TCM to clear the heat accumulation in the intestines, resolving the distension and constipation.5. All vomiting of sour substances, violent diarrhea, and urgent defecation belong to heat.This is due to heat from the gallbladder invading the stomach, or food stagnation transforming into heat, causing the stomach to lose its harmony and descend, leading to sour and rotten vomiting; heat moving through the intestines causes abnormal transformation, resulting in diarrhea; heat causing yang movement leads to urgent and forceful diarrhea, characterized by explosive diarrhea; damp-heat congealing in the intestines leads to qi stagnation, resulting in urgency and heaviness in the lower abdomen, with foul-smelling stools, which in ancient times was referred to as “heat diarrhea.”The Zheng Yin Mai Zhi states, “The cause of heat diarrhea is due to heat overwhelming, damp fire steaming, and those with accumulated heat, if they encounter evil heat, will have heat diarrhea.”The Yi Zong Bi Du refers to it as “fire diarrhea.” “Fire diarrhea” is characterized by abdominal pain and watery stools, with alternating pain and diarrhea, indicating heat.Food stagnation and alcohol accumulation can also lead to similar conditions.The Zheng Yin Mai Zhi states, “The cause of food stagnation diarrhea is due to excessive eating and drinking, damaging the spleen and stomach, leading to inability to digest, resulting in food stagnation diarrhea.” “The cause of alcohol accumulation diarrhea is due to excessive drinking, or drinking cold alcohol, damaging the stomach and intestines, leading to damp-heat qi, steaming and brewing within, resulting in accumulated dampness transforming into heat.”In terms of treatment, if it is heat diarrhea, one can use Huang Qin Tang (Scutellaria Decoction) with Chai Hu (Bupleurum) and Ge Gen (Kudzu) as needed.Qin Jingming treated external heat diarrhea, using Chai Ge Ling Lian Tang (Bupleurum and Kudzu Decoction) for heat on the surface, and Zhi Qiao Huang Lian Tang (Bitter Orange and Coptis Decoction) for heat in the interior.If there is a case of typhoid fever with Yangming bowel excess, leading to dryness and dampness accumulation, one may also see clear watery diarrhea, indicating heat accumulation flowing around, and treatment should focus on clearing the dry accumulation, using Da Cheng Qi Tang (Major Order the Qi Decoction) or Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction) for modification.If it is food stagnation diarrhea, one can use Bao He Wan (Preserve Harmony Pill) or Zhi Shu Wan (Bitter Orange and Atractylodes Pill). If food stagnation is severe and diarrhea is not smooth, one can guide the treatment according to the situation, using Zhi Shi Dao Zhi Wan (Bitter Orange to Guide Stagnation Pill) to push and clear the accumulated stagnation, leading to the cessation of diarrhea.If it is diarrhea due to alcohol accumulation, one should clear damp-heat and assist in detoxifying alcohol, using herbs such as Huang Lian (Coptis), Hou Po (Magnolia Bark), Ge Hua (Kudzu Flower), Zhi Qiao (Bitter Orange), Shan Zha (Hawthorn), Mai Ya (Barley Sprout), Chen Pi (Aged Tangerine Peel), Mu Tong (Akebia), and Gan Cao (Licorice). Ge Hua Jie Xing Tang (Kudzu Flower Detoxifying Decoction) and Ping Wei Si Ling San (Calm the Stomach and Four Spirits Powder) can also be modified as needed.Case:Cai, male, 36 years old, July 1967.Chief complaint:Low back pain and diarrhea, accompanied by urgency and heaviness in the lower abdomen for one month.Medical history:The patient has a fondness for alcohol, and during the hot summer, he worked under the blazing sun, sweating profusely, feeling both hungry and thirsty, and drank two bottles of ice-cold beer, followed by seafood. He slept outdoors at night.On the next day, he experienced sour vomiting, with a foul odor, and in the afternoon, he developed diarrhea, initially watery, accompanied by abdominal pain, followed by foul-smelling stools and urgency, with a yellow greasy tongue coating and a slippery and rapid pulse.He was sent to the local health center for emergency treatment, and after Western medicine treatment, he improved, but the abdominal pain and diarrhea with urgency persisted, with 4 bowel movements per day, accompanied by a small amount of mucus, and stool tests were negative. He then sought TCM treatment. This case involved a combination of alcohol, food, heat, and cold, compounded by a history of alcohol consumption, leading to internal damp-heat accumulating in the intestines, resulting in abnormal transformation.The treatment plan was based on the Mu Xiang Bing Lang Wan (Aucklandia and Areca Pill) method: Mu Xiang 9g, Bing Lang 12g, Qing Chen Pi (Green Aged Tangerine Peel) 9g, Ge Gen 30g, Chuan Lian 6g, Huang Qin 15g, Ma Chi Xian 30g, Yan Hu Suo 12g, Chao Bai Zhu (Fried Atractylodes) 12g, Gan Cao 4.5g. After 7 doses, all symptoms resolved.Then, the formula was adjusted for follow-up: Chao Bai Zhu (Fried Atractylodes) 12g, Jiao Mi Ren (Fried Job’s Tears) 15g, Huo Pei Lan (Houttuynia) 12g, Zhi Ban Xia (Processed Pinellia) 12g, Chuan Lian 4.5g, Fu Ling (Poria) 15g, Mu Xiang 6g, Qing Chen Pi (Green Aged Tangerine Peel) 9g, Huang Qin (Scutellaria) 12g, Jiao Zha Qu (Fried Hawthorn) 12g, for 7 doses, and the patient was cured.
