Diseases are ever-changing, yet they always fall into the two major categories of Yin and Yang. However, for each individual patient, the specifics differ. Due to varying causes, constitutions, living environments, and disease progression, complex individual differences arise. Therefore, there are various conditions such as Yin excess and Yang deficiency, Yang excess and Yin deficiency, Yang deficiency with Yin excess, Yin deficiency with Yang excess, and both Yin and Yang deficiency. Throughout history, renowned physicians have diagnosed and treated diseases by not only distinguishing between Yin and Yang, exterior and interior, cold and heat, deficiency and excess, but also by considering these complex situations from both Yin and Yang perspectives simultaneously.
(1) Yang Deficiency with Yin Excess
Yang deficiency with Yin excess encompasses both Yang deficiency and Yin excess. Essentially, it is Yang deficiency, which means that the Yang Qi of the body is insufficient, leading to a decline in Zheng Qi (the body’s righteous Qi). However, due to carelessness in daily life, one may be affected by Yin-cold evils, resulting in a situation where Zheng Qi is insufficient and Yin-cold evils are internally prevalent; or, due to insufficient Yang Qi, internal Yin evils may arise, such as internal dampness or cold forming Yang deficiency with Yin excess. The treatment methods involve warming and tonifying Yang Qi while simultaneously expelling Yin-cold evils.
Case One
Zhang, 42 years old, with a deficiency of kidney Qi, caught a cold due to wind and cold while returning home on a rainy day. He presented with fever and chills, headache, body aches, and excessive drowsiness (a condition of Shaoyin disease with a desire to sleep), along with thirst and a preference for warm drinks, but not much intake. His pulse was deep, thin, and tight, and his tongue was pale with a white coating and a purple hue.
Diagnosis: Wind-cold invading the Shaoyin, obstructing the movement of true Yang.
Treatment Method: Warm the meridians and release the exterior, support the righteous Qi and expel the evils.
Prescription: He Shou Wu (black atractylodes) 30g (first decoct for 2-3 hours), Ma Huang (ephedra) 10g (first boil several times to remove foam), Bei Xi Xin (asarum) 6g, Gui Zhi (cinnamon twig) 13g.
The next day, after taking the above prescription, he sweated, the fever subsided, but he still felt dizzy and coughed, and was fearful. Although the evil was resolved, the lung cold had not yet cleared, and the Yin Qi was still deficient, so a formula of Si Ni San combined with Er Chen Tang, adding Xi Xin and Wu Wei Zi to support Yang and warm the cold was used.
He Shou Wu 50g (first decoct for 2-3 hours), Gan Jiang (dried ginger) 26g, Gan Cao (licorice) 10g, Guang Pi (citrus peel) 10g, Fa Xia (pinellia) 13g, Fu Ling (poria) 13g, Bei Xi Xin 4g, Wu Wei Zi 2g.
After one dose, the cough stopped, appetite increased, and energy was restored, leading to complete recovery.
(“Wu Peiheng Medical Cases”)
In the “Shang Han Lun”, there is a passage regarding Yang deficiency with external wind-cold evil, which states: “In Shaoyin disease, if one first experiences fever and has a deep pulse, the prescription is Ma Huang, Xi Xin, and Fu Zi Decoction.” This indicates that a person with a history of Shaoyin Yang deficiency, who also exhibits fever and other signs of external invasion, can use both warming Yang and dispersing cold together, with Ma Huang expelling the external cold evil, Fu Zi warming the body’s original Yang, and Xi Xin assisting Ma Huang in expelling cold evils while internally supporting Fu Zi to warm Yang Qi. Mr. Wu Peiheng diagnosed this case based on this principle, noting that the patient had fever and chills, headache, and body aches, which still belonged to the category of external cold evil. The patient also had excessive drowsiness, a preference for warm drinks, and a deep pulse, indicating insufficient internal Yang Qi. Therefore, Mr. Wu diagnosed it as internal Yang deficiency and external wind-cold evil, which is Yang deficiency with Yin excess, where Yin cold obstructs the movement of Yang Qi, using Ma Huang, Fu Zi, and Xi Xin Decoction to warm the true Yang internally and disperse the external cold, supporting the righteous Qi and expelling the evils. One dose led to the fever subsiding, and another dose led to complete recovery.
Case Two
Zhang Luyu treated Wen Xuanfu and Sun Zhenlin, who suffered from cold and diarrhea during the hot summer. The pulse was thin and weak, and upon palpation, it felt as if it would disappear. The tongue was pale with a black, moist center and no coating, and the breath from the mouth and nose was slightly cold, indicating that Yang was shrinking into the abdomen, and the essence was slippery like water. When asked about the cause, the patient reported that he had slept on the ground during the day and felt cold, and that night he experienced a sudden loss of essence twice, feeling a pressure in the head like a mountain, and upon sitting up, he fainted, leading to cold limbs, abdominal pain, and diarrhea, with a feeling of nausea and incoherent speech, resembling symptoms of damp-heat. The physician mistakenly thought it was due to food stagnation and treated it with dispersing and digestive herbs. After taking the medicine, he experienced sweating in the chest and head, but the back felt even colder, while the lower body felt like water, and he fainted several times throughout the day. This was a case of Yin cold combined with heat, entering the middle Jiao. It seemed that the true Yang in the kidneys was extremely deficient, hence the inability to generate heat. Therefore, a prescription of Si Ni San with Ren Shen was proposed, using Ren Shen 1 liang, Fu Zi 3 qian, Pao Jiang 2 qian, and Zhi Gan Cao 2 qian, taken day and night. After three days of treatment with six doses, the cold limbs stabilized, and on the fourth day, Yang returned. On that day, the ginger and Fu Zi were removed, and Baoyuan Decoction was used, with Ren Shen 5 qian, Huang Qi 3 qian, Zhi Gan Cao 2 qian, adding Mai Men Dong 2 qian and Wu Wei Zi 1 qian to clear the virtual Yang above. After four doses, the appetite improved, and the treatment continued with Sheng Liao Liu Wei, adding Mai Men Dong and Wu Wei Zi, with each dose using 8 qian of Shu Di to nourish the lower Jiao and restore balance between Yin and Yang, leading to recovery.
(“Zhang’s Medical Communication”)
This case involved a patient who suffered from cold due to sleeping on the ground during the day, leading to a significant Yang deficiency. The use of external dispersing medicine further depleted Yang Qi, causing cold to invade the middle Jiao, resulting in abdominal pain and diarrhea, with a feeling of nausea. Therefore, Zhang diagnosed it as Yin cold combined with heat entering the middle Shaoyin. The treatment method focused on warming and tonifying Yang to expel internal Yin cold. Compared to the first case, the former involved Yang deficiency with external cold evil, while this case involved Yang deficiency with internal cold evil, both belonging to the category of Yang deficiency with Yin excess. Thus, both cases were treated with warming Yang and expelling cold. Therefore, both ancient and modern physicians emphasize the importance of distinguishing between Yin and Yang in clinical diagnosis, not only focusing on the overall analysis but also evaluating the relative strengths and weaknesses of Yin and Yang, which is a further deepening of the analytical thinking method of Yin-Yang analysis.
(2) Yin Deficiency with Yang Excess
Yin deficiency with Yang excess also includes two aspects: one is that the body’s Qi, blood, and fluids are insufficient, unable to balance and restrain Yang Qi, leading to abnormal Yang Qi or internal heat, or Yang Qi being excessively strong externally, resulting in a disturbance of Yin and Yang in the body, becoming Yin deficiency with Yang excess; the other is that the body has always been Yin deficient and is attacked by Yang evils, leading to the simultaneous presence of Yin deficiency and Yang excess. During treatment, nourishing Yin and restraining Yang is the primary method.
Case One
Cheng Xingxuan treated Wu Shangshi’s brother, who suffered from spring warmth and was critically ill but recovered. Shang’s brother had a history of tumor consumption and fell ill during the spring. Mr. Jin and Mr. Mai accompanied him. It was reported that he first experienced cold followed by heat, headache, sweating, persistent high fever, thirst, irritability, insomnia, and fatigue. Upon examination, the pulse was weak, floating, large, and rapid, and the tongue was without coating, feeling like a dry board. I was shocked and said: “This is a critical case of spring warmth. Zhong Sheng said: ‘Fever and thirst without aversion to cold indicates a warm disease.’ After sweating, the body was still hot and dry, known as wind warmth. The “Neijing” states: ‘Winter injuries due to cold will lead to warm diseases in spring.’ If one does not store essence in winter, they will surely suffer from warm diseases in spring. If one is injured by cold and does not store essence, and both diseases occur simultaneously, it is called dual invasion. Any case of cold damage, plague, or excessive heat with a dry tongue must be treated after a certain period. Now the illness has only lasted one day, and the tongue is already dry, which is evidence of kidney water deficiency. Winter injuries due to cold lead to spring warmth, with evils lurking in Yin, secretly absorbing kidney true essence, robbing its family, hence when fever occurs, there is headache, dry mouth, and thirst. It is diagnosed as dual invasion, and it is difficult to treat. I love to use Shu Di 1 liang, Dang Gui 3 qian, Liao Dou 5 qian, Yu Zhu 5 qian, and Gan Cao 1 qian. After the prescription, I told Mr. Mai: “In my experience, treating Shaoyin, I first resolve the internal issues, and then treat the external issues. The critical condition of dual invasion of cold and spring warmth must be treated according to the new prescriptions of Jingyue, nourishing Yin and expelling evils, often yielding results. However, in this case, the fluids are already depleted, and if I add ginger and Fu Zi, the Yin will surely perish. Therefore, I will only follow the teacher’s intent and use the previous wind-damp formula as a supplement, although it is a temporary measure, it is still a desperate situation.” Mr. Mai said: “Good.” Therefore, he took the medicine, and the fever decreased, and he felt calm. The tongue became slightly moist, and I added Sha Shen, Mai Men Dong, Nu Zhen Zi, and Shi Hu, continuing with the pulse and left return, gradually recovering.
(“Xingxuan Medical Cases”)
This case involved a patient with a history of Yin deficiency who was attacked by external evils, leading to symptoms of cold and heat, headache, sweating, and thirst. However, due to the patient’s inherent Yin deficiency, the external evils further harmed the Yin, resulting in a red and dry tongue, fatigue, and insomnia, with the true Yin further damaged within one day. Therefore, Cheng first used a dispersing formula to save Yin and prevent the loss of Yin fluids, and treated it with nourishing Yin and expelling evils. This case belongs to the category of Yin deficiency with Yang excess, where Yin deficiency is the root cause, and Yang excess is caused by external warm evils. However, since the Yin deficiency is at risk of extinction, it is urgent to save Yin. This case demonstrates the importance of distinguishing between the strengths and weaknesses of Yin and Yang in clinical analysis, focusing on the primary and secondary aspects, thus saving the patient from a critical situation.
Case Two
Wu, female, 74 years old. Diagnosed on May 23, 1977.
She presented with dizziness, neck stiffness, weakness in the limbs, dry nasal scabs, dry stools, frequent yellow urination, a weak pulse in the deep and thin position, and a tongue with cracks and a slightly white coating. Blood pressure was 250/160 mmHg, diagnosed as kidney Yin deficiency and liver Yang hyperactivity. The treatment involved nourishing Yin and calming the liver, supplemented with a formula to extinguish wind.
Xuan Shen, Mai Men Dong, Niu Xi, and Fu Ling each 12g, Dai Zhi Shi 24g, Sheng Long Gu and Sheng Mu Li each 15g, Gou Teng, Ju Hua, Yuan Zhi, and Chan Tui each 6g.
Second diagnosis: After taking the above prescription for three doses, dizziness decreased, stools became dry, urination slightly reduced, and blood pressure dropped to 230/110 mmHg. However, there was also palpitations and chest tightness, with a thin and wiry pulse. The prescription was adjusted by removing Dai Zhi Shi, Chan Tui, Xuan Shen, and Fu Ling, adding Chang Pu, Bai Zhi, Nu Zhen Zi, and Chong Wei Zi each 9g, Dan Shen and He Shou Wu each 12g, and Ci Shi 15g.
Third diagnosis: After taking three doses, blood pressure dropped to 190/100 mmHg, dizziness, dry stools, chest tightness, and palpitations slightly improved, but there was swelling and pain in the lower limb joints, with a thin and rapid pulse that had intermittent stops, and the tongue was peeled. The previous prescription was adjusted by removing Chong Wei Zi, Niu Xi, Long Gu, and Nu Zhen, adding Qiang Huo, Du Huo, and Ji Xue Teng each 9g.
After one month of follow-up, blood pressure stabilized and the body felt light and strong.
[Selected Clinical Experiences of Old Chinese Medicine, Chinese Medicine Journal, 1980 (4): 13]
“All dizziness belongs to the liver.” The patient’s dizziness is mostly related to liver disease, and “only wind can reach the high peaks,” as wind evils can invade, and fire can rise, hence liver fire can also be seen. Yang is responsible for rising, thus liver Yang hyperactivity can present with these symptoms, indicating liver wind, liver fire, and liver Yang are commonly seen in clinical practice. This patient presented with dizziness, neck stiffness, dry stools, and frequent yellow urination, indicating a strong Yang excess and fire. However, the pulse was deep and thin, especially weak in the deep position, indicating kidney Yin deficiency. Mr. Shen comprehensively analyzed this case, diagnosing it as kidney Yin deficiency and liver Yang hyperactivity, belonging to the category of Yin deficiency with Yang excess, treating it with nourishing Yin, calming the liver, and subduing Yang to balance Yin and Yang, achieving good therapeutic results.
(3) Yin Excess with Yang Deficiency
Yin excess with Yang deficiency occurs due to Yin-cold evils, including the invasion of cold dampness, consumption of cold foods, etc., which invade the body and harm Yang Qi, ultimately leading to an excess of Yin evils. Although the evil is primarily real, Yang Qi has been harmed. At this time, the treatment focuses on expelling the excess Yin evils and supporting the Yang of the body. This differs from the previously mentioned Yang deficiency with Yin excess, where the latter’s Yang deficiency is the root cause, while this section discusses Yin excess as the source.
Case
Fei Chengzu stated: In the summer, there are often symptoms of abdominal pain and diarrhea. If mistakenly thought to be cholera and treated inappropriately, it can lead to a critical situation. In the summer of Jiawu, Dr. Guo Shanyi was stationed in Shenyang and suffered from abdominal pain and diarrhea, with a white tongue coating, dry mouth, cold limbs, and excessive sweating, with cold breath from the mouth and nose, and a pulse that was deep, thin, and weak. The cold was in the Taiyin, and the middle Yang was not functioning properly. Various physicians either prescribed clearing and resolving or warming and dispersing. I believed that if the heat were to penetrate the Yang, it would be dangerous. If clearing and resolving or warming and dispersing were used, there would be a risk of Yang escaping. Therefore, I prescribed Si Ni San with Bai Zhu as the main treatment.
Fu Zi 5 qian, Dan Gan Jiang 3 qian, Zhi Gan Cao 1 qian, Sheng Bai Zhu 2 qian.
The military doctor knew medicine and, after discussing with others, used my prescription, and after one dose, the patient stabilized. This case was primarily a cold disease in the cold damage category, which is very different from cholera. In summer, there are often patients with this disease due to seeking coolness. I specifically noted this to clarify the distinction when treating cholera, otherwise, it could lead to serious mistakes!
(“Menghe Fei’s Medical Cases”)
This case involved cold in the Taiyin, which could be due to consuming cold foods or abdominal cold, with the evil directly affecting the Taiyin spleen, causing spleen Yang to be injured, and the middle Yang unable to transport water and dampness, leading to abdominal pain and diarrhea. The patient had a white tongue coating and abdominal pain with diarrhea, indicating the presence of cold evils invading internally. The Yin evils harm Yang, and this patient also had cold limbs, excessive sweating, and cold breath from the mouth and nose, with a deep, thin, and weak pulse, indicating that the middle Yang was injured, affecting the original Yang. Fei diagnosed this case as cold in the Taiyin, with the middle Yang not functioning properly. The urgent treatment was to restore Yang, using Si Ni San with Bai Zhu, to restore both spleen and kidney Yang Qi. If only the Yin excess in the Taiyin was focused on, neglecting the Yang Qi, it would lead to excessive expulsion of evils, further harming the righteous Qi, resulting in a transformation of the condition.
(4) Yang Excess with Yin Deficiency
Yang excess with Yin deficiency refers to the invasion of warm evils, whether from external warm evils or internal consumption of spicy foods, leading to internal heat, which over time harms Yin, resulting in Yang evils becoming excessive. In this case, it is essential to first recognize the Yang excess, followed by the Yin injury, and in clinical practice, it is crucial to distinguish the relative strengths of excess and deficiency.
Case
Wang Mengying treated Chen Zhitian from Hangzhou, who suffered from a warm disease in midsummer. Various physicians prescribed warming and dispersing herbs. After several days, he became delirious, with limb spasms and deafness, a black tongue, dry lips, and a contracted bladder with scant urination, and a faint rash on the chest. It was evident that he was in a critical condition. When Mengying was invited to diagnose, the pulse was thin, rapid, and urgent, indicating that Yin was depleted and heat was intense, leading to the depletion of fluids. Therefore, he used Xiyang Shen, Yuan Shen, Sheng Di, Er Dong, Zhi, Bai, Lian Shi, Shi Hu, Bai Shao, and Gan Cao, with a large dose. The next day, upon re-examination, the family reported that for the past seven or eight days, urination had been reduced to drops, but after taking the medicine for six or seven hours, he was able to urinate half a cup. Mengying said: “This is a turning point.” However, the Yin Qi was exhausted, and he needed to replenish fluids, so he added Gui Ban, Bie Jia, Bai He, and Hua Fen, boiling them in a large pot and frequently administering them. After eight days, his spirit began to clear. All symptoms subsided, and he was treated with nourishing Yin herbs, gradually recovering over a month.
(“Wang’s Medical Cases”)
The patient initially suffered from warm evils, which harmed him for many days, leading to Yin depletion and Yang excess. Therefore, Mengying immediately diagnosed it as “Yin deficiency with intense heat, leading to depletion of fluids.” The prescription included Yin-nourishing herbs to clear heat in the Qi, Ying, and blood levels, while using Xiyang Shen, Yuan Shen, Sheng Di, Er Dong, Shi Hu, Bai Shao, etc., to nourish the body’s Yin fluids. The reason for this prescription was that Wang Mengying, during the analysis of this disease, applied the Yin-Yang analysis method, distinguishing the nature of the invading evils as heat and Yang, and the nature of the damage to the righteous Qi as Yin fluids and Yin, thus comprehensively grasping the relationship between Yin and Yang, where Yang heat was excessive and Yin fluids were internally deficient. The treatment involved nourishing Yin and clearing heat, with the medication aligning with the pathogenesis, thus saving the patient from a critical condition, leading to recovery in eight days and a month of regulation.
(5) Mixed Deficiency and Excess
Deficiency and excess are the two major categories of clinical syndromes. The occurrence of diseases may be due to the deficiency of the body’s righteous Qi or the presence of evil Qi within the body. The former belongs to deficiency, while the latter belongs to excess. Deficiency is associated with Yin, while excess is associated with Yang. However, in clinical practice, due to insufficient righteous Qi and dysfunction of the organs, it can lead to abnormal circulation of Qi and blood, with evils arising internally, resulting in deficiency mixed with excess; or due to the harm caused by evil Qi, the righteous Qi is depleted, leading to excess mixed with deficiency, resulting in mixed deficiency and excess syndromes. Using Yin and Yang to summarize, it also belongs to the category of Yin-Yang interference. In clinical practice, we should pay attention to this differentiation, which is also part of the analytical thinking method of Yin-Yang interference. Additionally, there are various situations such as upper deficiency and lower excess, upper excess and lower deficiency, exterior deficiency and interior excess, and exterior excess and interior deficiency. The upper belongs to Yang, the lower belongs to Yin, the exterior is Yang, and the interior is Yin. The differentiation of deficiency and excess in the upper and lower parts further evolves and deepens the analytical method of Yin-Yang interference.
Case One
Wan Mizhai treated a child who had eaten meat too early and developed a spleen and stomach disease, possibly diarrhea, with a distended and hard abdomen, and emaciation, leading to malnutrition. His mother was worried, and the child’s condition worsened. I felt pity and prepared a prescription: Ren Shen, Huang Qi (honey-fried), Bai Fu Ling, Bai Zhu, Fen Pi, Dang Gui, and Chuan Xiong to tonify the spleen and stomach and nourish Qi and blood; Chen Pi, Qing Pi, Ban Xia Qu, Mu Xiang, Sha Ren, Zhi Shi, Hou Po, Shen Qu, and Mai Yao Mian to resolve accumulation; San Leng, E Zhu (stir-fried), Jiu Lei Bie Jia (vinegar-boiled) to resolve phlegm; Huang Gan Chan (burnt ash) to eliminate heat. A total of twenty-two ingredients were ground into powder, made into pills the size of millet, with a dosage of twenty-five pills taken with fried rice soup, to regulate and stabilize.
(“Pediatric Experience”)
Case Two
Qi You, 2 years old.
Initial diagnosis (April 13): Weaning too early, with stomach excess and spleen deficiency, a preference for sweet and fragrant foods, leading to abdominal distension and hardness, visible veins, fatigue, and inconsistent stools. The child’s organs are delicate, and the essence has not yet been fully developed, leading to damage to the spleen and stomach, resulting in malnutrition. The treatment should focus on strengthening the spleen and harmonizing the stomach, guiding stagnation and transforming turbidity.
Fried Chan Pi 1.5 qian, Bing Lang 3 qian, Zhi Shi 2.5 qian, Shi Jun Zi 3 qian, Lei Wan 2 qian, Chuan Po 8 fen, Fried Ji Nei Jin 1.5 qian, Sha Ren 5 fen, and Fried E Zhu 1.5 qian.
Follow-up: After taking the guiding and harmonizing medicine, the child had a large bowel movement, which was thick and foul-smelling, indicating a good sign. The abdomen gradually softened, and upon palpation, it was soft, indicating a favorable prognosis. For the next step, the treatment should continue to harmonize the spleen and stomach, with slight support for the righteous Qi.
Tai Zi Shen 3 qian, Fried Zhi Ke 1.5 qian, Ban Xia 1.5 qian, Guang Pi 1 qian, Yun Ling 3 qian, Huai Shan Yao 3 qian, Fried Shan Zha 3 qian, Fried Ji Nei Jin 1.5 qian, Xiang Gu Ya 4 qian, and Chun Sha Ren 5 fen.
This case reflects a congenital abundance followed by postnatal imbalance, thus treated according to the principles of the spleen and stomach, using a method of attacking first and then supplementing.
[Xi’s Pediatric Experience. Shanghai Journal of Traditional Chinese Medicine, 1962, (6): 5]
Both cases involve pediatric malnutrition. Malnutrition is one of the four major syndromes in pediatrics, often caused by irregular diet, improper feeding, and nutritional imbalance, leading to spleen and stomach deficiency, weak vital energy, and deficiency of Qi and blood. At the same time, due to the weakness of the spleen and stomach, the function of transforming and transporting food and fluids is insufficient, leading to the accumulation of stagnation and forming mixed deficiency and excess syndromes. Case One was treated by the famous Ming Dynasty physician Wan Quan, who was a renowned pediatrician. This child exhibited symptoms of emaciation and diarrhea, indicating spleen and stomach deficiency, along with abdominal distension and hardness, indicating excess in the middle Jiao. Therefore, Wan used Qi-nourishing and blood-nourishing herbs to supplement the deficiency, while also using herbs to resolve accumulation and eliminate malnutrition, achieving a successful outcome. Case Two presented with emaciation, visible veins, and inconsistent stools, indicating deficiency of vital energy and weakness of the spleen and stomach, along with abdominal distension and hardness, indicating stagnation. Therefore, Xi also diagnosed it as mixed deficiency and excess, but the treatment method adopted was to attack first and then supplement, initially using guiding and expelling methods, followed by strengthening the spleen and supporting the stomach, achieving efficacy. Both cases reflect the importance of distinguishing between deficiency and excess, especially in identifying mixed deficiency and excess in clinical thinking.
Case Three
Lin Peiqin treated Shi, who had jaundice due to dampness transforming into heat, with stasis heat in the interior, steaming the bile, leading to yellowing, resembling an orange. Now the eyes are yellow, the complexion is bright, with dizziness, chest fullness, no thirst, fatigue, and heat in the palms and soles, with constipation, and upon exertion, the symptoms worsen. The pulse is large on the right and weak on the left, indicating that although dampness is severe, heat is also present, and the pulse is large due to labor, indicating that the prolonged jaundice has harmed Qi. The treatment used the method of tonifying the middle and draining dampness: Lu Ren, Yi Yi Ren, Fu Ling, and Bai Zhu each 0.5 qian, Ji Nei Jin, Yin Chen, and Zhen Sha each 2 qian, Shan Zhi, Gan Ju, and Dan Pi each 1 qian, and Zhi Gan Cao 5 fen. After several doses, the chest fullness was relieved, appetite improved, and the prescription was adjusted by removing Gan Ju and Shan Zhi, adding Huang Qi, Bai Shao, and Lian Zi, and after several more doses, the jaundice gradually receded.
(“Essence of Famous Doctors in the Qing Dynasty”)
Jaundice is classified into Yang jaundice and Yin jaundice, both of which are related to dampness evil in the middle Jiao. Generally speaking, Yang jaundice is associated with excess and heat, while Yin jaundice is often due to cold dampness harming the Yang of the spleen and stomach. This case presented with bright yellow jaundice, indicating Yang jaundice, which should be treated as a case of excess heat. However, the famous physician also paid great attention to the condition of deficiency and excess, inquiring about fatigue and weakness, which worsened with exertion, indicating a deficiency condition, and the pulse was large on the left and weak on the right, indicating kidney Yin deficiency. Mr. Lin diagnosed this as a case of deficiency of the righteous Qi and excess of the evil Qi, belonging to the category of mixed deficiency and excess. Therefore, he used the method of tonifying the middle and draining dampness to support the righteous Qi and expel the evils, restoring the righteous Qi and eliminating dampness, leading to recovery from the disease.
(6) Mixed Cold and Heat
Cold belongs to Yin, while heat belongs to Yang; the two are opposing forces and represent a form of Yin-Yang opposition. In the process of disease occurrence and development, generally, there may be either cold syndrome or heat syndrome. However, due to the various factors that cause disease, there may also be cases where a patient presents with both cold and heat syndromes simultaneously. For example, a patient with a history of stomach cold may recently be affected by external warm evils and catch a cold, leading to a mixed condition of external heat and internal cold. Additionally, some patients with a history of heart fire may also experience cold due to consuming cold foods, resulting in a mixed condition of upper heat and lower cold. Throughout history, renowned physicians have placed great importance on the overall analysis of Yin and Yang, cold and heat, and have also paid close attention to the cold and heat manifestations in each part of the body, comprehensively analyzing the specific situations of mixed cold and heat to provide targeted treatment. This analytical thinking method has a long history, as early as in Zhang Zhongjing’s “Shang Han Lun”, there is a prescription for Huang Lian Decoction to treat abdominal pain and vomiting due to heat in the chest and cold in the stomach, using Huang Lian combined with Gan Jiang and Gui Zhi, employing both cold and warm herbs to clear the upper heat and eliminate the middle cold. Throughout history, many physicians have followed Zhang Zhongjing’s methods, and I will present cases to illustrate.
Case One
Zhu, male, 29 years old, has been hospitalized for six days, diagnosed with epidemic type B encephalitis.
Hospital check summary (omitted).
Course of illness and treatment: Before the consultation, he had been given large doses of pungent, cool, bitter, and cold herbs, as well as rare and precious medicines, but the high fever did not subside, with cold limbs, a confused state of consciousness, sometimes clear and sometimes faint, able to move his eyes but unable to speak, with fullness in the chest and abdomen, and loose stools, with little output, and urination was not smooth, with sweating on the head, and he did not want to swallow water, with dry lips, a pale tongue, and a white coating, with a weak pulse in the deep and thin position, and a slow pulse. After consultation, the pulse and symptoms indicated a mixture of deficiency and excess, with the evil penetrating the middle Jiao, which is different from the evil entering the heart. I used Wu’s “Warm Disease Theory” stating that “if the damp heat in the upper Jiao is not cleared, the interior is weak and sinks,” and prescribed Ren Shen to clear the heart and remove Zhi Shi, replacing Ban Xia with a pungent, bitter, and descending method. The prescription was:
Ren Shen 3 qian, Gan Jiang 2 qian, Huang Lian 1.5 qian, Huang Qin 1.5 qian, Fa Ban Xia 3 qian, Bai Shao 4 qian.
After taking the medicine, urination increased, abdominal fullness decreased, and sweating occurred all over the body, with the fever subsiding. However, at this time, although the evil heat was removed, the original Qi was greatly damaged, leading to muscle twitching, cold limbs, and sweating, with a pulse that was weak and nearly absent, indicating a risk of Yang collapse. Urgently, I used Sheng Mai Decoction combined with Fu Zi and Long Mu to restore Yang and stabilize Yin. The prescription was:
Dang Shen 1 liang, Mai Men Dong 5 qian, Wu Wei Zi 2 qian, Shu Chuan Fu Zi 2 qian, Sheng Long Gu (crushed) 8 qian, Sheng Mu Li (crushed) 6 qian.
Concentrated decoction was taken gradually, without time restrictions, and he gradually began to sleep well, with cold limbs returning to normal, and shivering gradually subsiding, with consciousness slightly clearer, sweating reduced, tongue and teeth becoming moist, Yin returning and Yang reviving, and the pulse gradually recovering. Later, I used nourishing Yin and benefiting the stomach, combined with clearing residual heat, using San Cai Decoction with Jujube, E Jiao, and Shi Hu for several doses, and everything returned to normal, with the patient discharged after observation.
(“Pu Fuzhou Medical Cases”)
Pu Fuzhou, an old Chinese physician, placed great emphasis on the mutual transformation of deficiency and excess, cold and heat in the treatment of febrile diseases, especially in acute infectious febrile diseases such as pneumonia and encephalitis. These diseases have sudden onset, rapid changes, and severe conditions, which can easily harm Yin and Yang. Additionally, in the initial treatment phase, the use of cold and cooling medicines and expelling evils can further damage the righteous Qi, making the mixed conditions of cold and heat, deficiency and excess more complex. This case is an example. Initially, a large amount of cold and cooling medicines were used, but due to the deep-seated evil heat, not only was the righteous Qi harmed, but the cold and cooling medicines also caused the evil heat to stagnate internally, preventing it from dispersing. Therefore, the evil heat did not subside, but there was also fullness in the abdomen, loose stools, a pale tongue, and a weak pulse, indicating a state of deficiency. Therefore, I chose to use the Xie Xin Decoction to clear the upper heat while treating the middle deficiency, allowing the Qi deficiency to be replenished and the Qi mechanism to be unblocked, thus allowing the evil heat to have an outlet, leading to the reduction of heat, abdominal fullness, and stopping diarrhea. However, as the evil heat was removed, the previous use of a large amount of clearing heat medicines revealed the signs of damage to the righteous Qi. Therefore, with sweating and cold limbs, a weak pulse, and a risk of collapse, I changed to using Qi tonics to prevent Yang collapse and Yin exhaustion, using Sheng Mai Decoction and Ren Shen Decoction combined. When the cold limbs returned and the pulse recovered, I then nourished Yin and restored the pulse, removing residual evils to achieve treatment and stabilization. In this case, Pu emphasized the importance of distinguishing between cold and heat, deficiency and excess, and analyzing the mixed conditions, achieving satisfactory therapeutic results.
Case Two
Miao Zhongchun treated a flower servant who developed a fever due to cold exposure, with a splitting headache, pain in both eyes, and severe pain in the limbs, especially in the lower body, feeling as if cut by a knife, with extreme thirst, and having a bowel movement once a day, with fullness in the chest and abdomen that did not resolve, indicating a critical condition. I prescribed a formula: Gan Ge 3 qian, Shi Gao 1 liang 5 qian, Mai Men Dong 8 qian, Zhi Mu 3 qian 5 fen, Qiang Huo 2 qian 5 fen, Da Gua Lou half (crushed with seeds), Zhi Shi 1 qian, Jie Geng 1 qian, and Zhu Ye 100 pieces, boiled in river water, for four doses, and the condition stabilized. This is a case of Taiyang and Yangming disease, as the patient had a history of labor, leading to more severe pain in the lower body. Therefore, I used Qiang Huo to expel the Taiyang evil, while Shi Gao, Zhu Ye, Gan Ge, Mai Men Dong, and Zhi Mu cleared the Yangming heat, and Da Gua Lou, Zhi Shi, and Jie Geng resolved the retained evils in the chest and abdomen, leading to recovery.
(“Continuation of Famous Doctors’ Cases: Cold Damage”)
This case initially arose from exposure to external cold, leading to fever, headache, and muscle pain. However, the patient also presented with pain in both eyes, indicating a Yangming meridian disease. The extreme thirst, fullness in the chest and abdomen, and the disease had already entered the interior, indicating a transformation of external cold into internal heat. Therefore, Miao diagnosed it as a Taiyang and Yangming disease. In Taiyang disease, there is exterior cold evil, while Yangming pertains to the interior, which has already transformed into heat. However, a comprehensive evaluation of the symptoms indicates that the exterior cold symptoms are mild, while the interior heat symptoms are severe. Therefore, using the analytical thinking method of distinguishing between exterior and interior cold and heat, I prescribed Qiang Huo to disperse the exterior cold, while Shi Gao, Zhu Ye, Gan Ge, and Mai Men Dong cleared the interior heat, and Da Gua Lou, Zhi Shi, and Jie Geng resolved the Qi mechanism in the chest and abdomen, leading to effective treatment. This case illustrates that both ancient and modern physicians not only focus on the mixed conditions of cold and heat but also distinguish between their relative severity, analyzing the details, which is evident in this case.
Case Three
Zhang, male, 50 years old.
One week ago, after bathing in the evening, he felt a cold wind penetrate his bones on the way home, leading to a high fever that night, nasal congestion, heaviness in the body, and general aches. After taking over-the-counter medicine, he sweated but the cold did not resolve, with cold and heat symptoms fluctuating, dry mouth, constipation, chest tightness, and loss of appetite, with a yellow thick tongue coating and a strong pulse.
Diagnosis and treatment method: After feeling cold post-bath, the pores were tightly closed, preventing Yang Qi from rising, leading to high fever. Although he took over-the-counter medicine, sweating occurred but the cold evil transformed into heat without resolution, thus it was necessary to clear the interior to guide the evil out, and I proposed the Seven Clearing and Three Resolving method for treatment.
Prescription: Hang Bai Shao (stir-fried with Gui Zhi 1.5 qian) 3 qian, Dan Dou Chi 3 qian, Jiu Tiao Qin 2 qian, Chao Shan Zhi 2 qian, Zi You Po 1.5 qian, Quan Gua Lou 8 qian, Chao Zhi Ke 1.5 qian, Xing Ren Mi 3 qian, Xie Bai Tou 3 qian, Bai Mao Gen 5 qian, Zhi Cao Shao 1 qian, Bai Wei Gen 5 qian, Da Hong Zao 3 pieces, and fresh ginger 3 slices.
(“Shi Jinmo Clinical Experience Collection”)
Case Four
Liu, male, 38 years old.
One week ago, he was suddenly exposed to wind and cold, with sudden pain in the left arm, severe coughing, and inability to sleep at night. After taking medicine and acupuncture treatment, there was no significant effect, and last night he suddenly coughed up blood, with constipation for four days, body temperature at 38°C, a yellow tongue coating, and a tight pulse.
Diagnosis and treatment method: The pulse was tight, indicating wind, while the tightness indicated cold, with wind-cold obstructing the meridians, causing sudden pain in the left arm. The lung governs the skin and hair, and wind-cold invading the lung presented as coughing, with constipation indicating internal heat. Therefore, I primarily used the Five Resolving and Five Clearing method for treatment. The prescription was:
Chi Shao 2 qian, Bai Shao 2 qian, Chuan Gui Zhi (stir-fried) 1.5 qian, Zhi Su Zi 3 qian, Zhi Bai Qian 2 qian, Piao Jiang Huang 3 qian, Zhi Zi 3 qian, Zhi Bai Wei 2 qian, Bai Xing Ren 3 qian, Zhi Ma Huang 1 qian, tender mulberry branches 1 liang, bitter Zhi Ke 1.5 qian, Da Ji Tan 2 qian, Bai Wei Gen 5 qian, Jiu Huang Qin 3 qian, Xiao Ji Tan 2 qian, Bai Mao Gen 5 qian, Zhi Gan Cao 1 qian, Zi Xue Dan 1 qian (to be taken with warm water in two doses).
Second diagnosis: After taking two doses of the previous prescription, the fever subsided, arm pain decreased, and coughing improved, with no more blood in the sputum, and bowel movements resumed.
(“Shi Jinmo Clinical Experience Collection”)
Shi Jinmo was a famous physician in Beijing during the Republic of China, who placed great emphasis on the differentiation of cold and heat, exterior and interior, deficiency and excess, and the relationship between Qi and blood in the treatment of external warm diseases. The so-called differentiation of Qi and blood means distinguishing the levels and the differences in the layers of evil in Wei, Qi, Ying, and blood. In distinguishing deficiency and excess, it is necessary to consider the relationship between the righteous and evil Qi, and during treatment, both expelling evils and supporting the righteous Qi must be considered. In distinguishing between exterior and interior, cold and heat, it is essential to carefully observe the relative weight of exterior and interior symptoms, as well as the differences in cold and heat symptoms. External diseases are often susceptible to wind and cold, while once they enter the interior, they are prone to generate internal heat. Therefore, Shi always paid attention to the lightness of exterior cold and the heaviness of interior heat in clinical practice, creating various treatment principles such as Seven Resolving and Three Clearing, Six Resolving and Four Clearing, Half Resolving and Half Clearing, Four Resolving and Six Clearing, and Three Resolving and Seven Clearing.
The causes of the diseases in the above four cases were due to exposure to wind and cold, with the pores tightly closed, indicating that the external evil had not been resolved. However, there was also high fever, dry mouth, constipation, a yellow thick tongue coating, and a strong pulse, indicating internal heat. The relative weight of the internal heat symptoms was greater than that of the external cold symptoms, thus the Seven Clearing and Three Resolving method was proposed. The external treatment used Gui Zhi Decoction, while the internal treatment used Zhi Zi Decoction to resolve both the exterior and interior. The fourth case also involved exposure to wind and cold, but the pulse was floating and tight, with pain in the left arm indicating a clear external wind-cold symptom, while there were also symptoms of coughing blood, constipation, and a yellow tongue indicating internal heat. Therefore, both methods of resolving the exterior and clearing the interior were used, with Gui Zhi Decoction for the exterior and Zi Xue Dan for the interior, demonstrating a unique approach to treatment.
These four cases all illustrate the mixed conditions of cold and heat, with some having upper and lower mixed conditions, while others have mixed conditions of exterior and interior. Throughout history, renowned physicians have placed great importance on analyzing the different mixed conditions of cold and heat, using both cold and warm medicines in their prescriptions. This analytical thinking method is worth learning and emphasizing. This knowledge has been recorded in the writings of ancient famous physicians, such as Zhang Zhongjing’s use of Ban Xia Xie Xin Decoction for treating phlegm, using both pungent and bitter herbs, combining cold and heat; or using Da Qing Long Decoction to treat Taiyang disease without sweating and restlessness, using Ma Huang Decoction to resolve exterior cold and Shi Gao to clear interior heat, all belong to this category. However, later physicians did not limit themselves to a single prescription for a single syndrome, but rather extended this approach to various aspects of clinical diagnosis and treatment, enriching and developing it further.
This article is selected from Lu Zhaolin’s “Methods of Clinical Thinking in Traditional Chinese Medicine”, with copyright belonging to the relevant rights holders. This public account is used solely for academic exchange. If there is any infringement, please contact the editor for deletion.
