Introduction: <Shang Han Lun> is a specialized text that elaborates on the treatment of various externally contracted febrile diseases, but this does not mean that Zhang Zhongjing’s formulas are limited to treating these conditions. In fact, <Shang Han Lun> contains many so-called “Wen Bing formulas”. In this article, Professor Shizhen Sheng summarizes the six major methods and various formulas used by Zhang Zhongjing to treat damp-heat, which is shared here for the readers’ benefit.<Shang Han Lun> is a specialized text that elaborates on the treatment of various externally contracted febrile diseases. <Su Wen: Re Lun> states: “Currently, febrile diseases are all similar to cold damage.” <Nan Jing> points out: “There are five types of cold damage: wind stroke, cold damage, damp-warm, heat disease, and warm disease.” Regarding the treatment of damp-heat syndrome, although the content in <Shang Han Lun> is relatively brief, its discussions on the differentiation and treatment of damp-heat are quite instructive. Here, we summarize the six methods as follows. 1 Method of Promoting the Upper Jiao Damp-heat affliction varies according to the location of the disease, and thus the treatment methods differ. The practitioner must carefully examine which meridian, organ, or cavity is affected and adopt the corresponding method. In the early stages of externally contracted damp-heat, the disease manifests on the skin, with symptoms such as headache, body heaviness and pain, chills, afternoon fever, pale yellow complexion, chest tightness, lack of appetite, white tongue coating, and floating, slippery pulse. Since the lung governs the skin and hair, and is responsible for the qi of the entire body, the treatment should promote the lung qi in the upper jiao. When the lung qi descends, the skin surface becomes unblocked, and the qi mechanism can transform and disperse dampness and heat. The formula Ma Huang Lian Qiao Chi Xiao Dou Tang in <Shang Han Lun> states that it treats “cold damage with stagnant heat internally, leading to yellowing of the body,” which is due to damp-heat accumulation internally, preventing sweating externally, and obstructing bile, resulting in skin discoloration. Jaundice falls under the category of damp-warm, using Ma Huang and Xing Ren to promote the lung and clear the upper jiao, while Lian Qiao, Chi Xiao Dou, and Sheng Zi Bai Pi clear heat and drain dampness, with ginger and jujube harmonizing the nutritive and defensive qi. Therefore, for damp-heat on the surface that obstructs lung qi, one can lightly promote the upper jiao, smooth the qi mechanism, expel damp turbidity externally, and clear internal heat, thus separating the internal and external. This method is also commonly used in modern treatments for skin eczema. One may ask: Damp-warm conditions prohibit sweating, as “sweating leads to confusion and deafness, and in severe cases, to blindness and muteness”; why then use sweating methods? The prohibition against sweating in damp-warm conditions is due to the avoidance of purely using pungent-warm herbs, as they assist heat, evaporate damp turbidity, and obscure the clear orifices, hence they should be avoided. However, in the case of damp-heat on the surface, it is necessary to achieve “a slight sweat” to relieve the condition; without a slight sweat, the illness cannot be resolved. For damp-heat on the surface, there is a prohibition against purely using pungent-warm sweating methods, yet there is also a need for sweating to resolve the condition, so clinical practice must be flexible. The formula Ban Xia Xie Xin Tang in <Jin Kui Yao Lue> treats wind-damp on the surface, with symptoms of “whole body pain, fever, and severe symptoms in the afternoon,” also employing the method of promoting lung and transforming dampness, which is similar to the treatment of upper jiao damp-warm in <Wen Bing Tiao Bian> with the formula San Ren Tang. Lightly promoting lung qi and unblocking the upper jiao is a major method for treating damp-heat in the early stages, whether in the upper or on the surface, hence Wu Ju Tong pointed out that “all methods that promote and unblock the three jiao are aimed at the upper jiao, as it is the initial site of the disease and the first step of qi transformation.” 2 Method of Elevating and Descending the Middle Jiao The damp-heat pathogen, transmitted from the upper jiao downward, most easily affects the spleen and stomach, causing dysfunction in the elevation and descent of the middle jiao, leading to stagnation of the qi mechanism. Damp-heat as a disease is predominantly in the middle jiao, and during its transmission from the upper jiao to the middle jiao, it can obstruct the qi mechanism in the chest, resulting in feelings of discomfort in the heart. To treat symptoms of irritability and insomnia, <Shang Han Lun> uses Zhi Zi Chi Tang, employing the cold nature of Zhi Zi to clear heat, the bitterness to dry dampness and descend, and Dou Chi to aromatically transform dampness, dispersing it outward. This is a feasible formula. The San Xiang Tang in <Wen Bing Tiao Bian> builds upon this formula, adding Yu Jin, Jiang Xiang, Gua Lou Pi, Jie Geng, and Zhi Ke to clear heat, transform dampness, and relieve stagnation, treating damp-heat pathogens that cause symptoms of “not hungry, not eating, and unresponsive qi orifices.” It can both promote the upper jiao, allowing “the pathogen from the upper jiao to return to the upper jiao,” and elevate and descend the middle jiao, regulating the spleen and stomach. Damp-heat pathogens obstruct the middle jiao and stagnate in the stomach and intestines, leading to fullness in the heart, loss of stomach qi leading to vomiting, and the spleen losing its ability to transport leading to diarrhea. Ban Xia Xie Xin Tang, Sheng Jiang Xie Xin Tang, and Gan Cao Xie Xin Tang, with their bitter descending and pungent dispersing properties, regulate the qi mechanism, using cold to clear heat and bitterness to dry dampness, thus restoring the healthy function of the spleen and stomach. For those with damp-heat obstruction in the middle jiao, primarily presenting with fullness in the heart, these can be selected as appropriate. For example, in treating yangming damp-warm with symptoms of “severe vomiting and fullness,” Ban Xia Xie Xin Tang removes Ren Shen, Gan Jiang, Da Zao, and Gan Cao, adding Zhi Shi and Sheng Jiang as the main ingredients. For yangming summer-warm, with a slippery and rapid pulse, lack of appetite, and no bowel movement, with turbid phlegm accumulating and fullness in the heart, Ban Xia Xie Xin Tang removes Ren Shen, Gan Jiang, Da Zao, and Gan Cao, adding Zhi Shi and Xing Ren as the main ingredients. For those with “stagnation of damp-heat internally, fullness in the middle jiao, and confusion of the spirit,” the method of Xie Xin Tang can also be used. This shows that the adjustments of this formula are widely applicable in damp-heat diseases. Other formulas such as Huang Lian Tang, Gan Jiang Huang Qin Huang Lian Ren Shen Tang can also be used for middle jiao damp-heat obstruction, whether for abdominal pain, diarrhea, or vomiting. Damp phlegm is similar, with damp-heat obstructing, causing water not to flow, and phlegm-heat can also bind. To treat phlegm-heat binding in the heart, with pain upon palpation and a floating, slippery pulse, Xiao Xian Xiong Tang can also be used for damp-heat accumulation in the heart. Wang Xu Gao said, “The stomach resides below the heart,” thus the heart belongs to the middle jiao. In <Wen Bing Tiao Bian>, yangming summer-warm presents with “a pulse that is surging and slippery, a red face and body heat, dizziness, no aversion to cold but aversion to heat, a yellow slippery tongue coating, thirst for cool drinks, and drinking does not relieve thirst, vomiting upon drinking, pain upon palpation in the chest, short urination, and constipation,” indicating damp pathogens obstructing, with phlegm-water accumulating, causing upward reversal leading to vomiting, stomach harmony lost leading to constipation, and the spleen losing its healthy function leading to diarrhea. Xiao Xian Xiong Tang with added Zhi Shi is the main treatment. This formula bitterly descends and pungently disperses, guiding water downward, clearing heat, transforming phlegm, and drying damp turbidity, making it very suitable. In addition, clinically, Xiao Xian Xiong Tang can be modified to treat damp-heat jaundice, especially for severe jaundice, often achieving good results in reducing jaundice, indicating that its role in treating damp-heat should not be overlooked. 3 Method of Draining and Benefiting the Lower Jiao Damp-heat as a disease can be biased towards heavy heat or heavy dampness. Dampness is a yin pathogen, heavy and turbid in nature, easily tending towards the lower jiao; at this time, the treatment should drain and benefit the bladder, allowing water and dampness to be expelled and settled. The so-called Wu Ling San treats taiyang water retention, with symptoms of difficulty urinating, slight fever and thirst, sweating, floating pulse, or thirst for drinking water, vomiting upon drinking, or vomiting and diarrhea, along with headache and body pain, which is a manifestation of damp-heat syndrome in the early stages biased towards dampness. For those with external taiyang symptoms and internal water retention, this formula can be used to promote yang, transform qi, and lightly drain dampness. Gui Zhi Qu Gui Jia Fu Ling Bai Zhu Tang can also be used to treat this. In damp-heat diseases, Wu Ling San is often used in combination with other medicines, such as when Zhang Zhongjing treats various jaundice, with short urination, using Yin Chen Wu Ling San as the main treatment, which is this formula plus Yin Chen, promoting the exterior and interior, clearing and draining damp-heat, with the function of reducing jaundice. Edema can be caused by damp-heat, as Liu He Jian said, “All edema is a combination of dampness and heat.” In clinical practice, we treat damp-heat edema using Da Ju Pi Tang, which consists of Wu Ling San plus Mu Xiang, Bing Lang, Hua Shi, Gan Cao, Chen Pi, and Sheng Jiang, often achieving good results. Some may ask: In damp-heat combined diseases, why use the warm and pungent Wu Ling San? This is because damp-heat can be biased; for those with heavy heat, it should not be used alone, but for those with heavy dampness, how can dampness be expelled without using warming and draining methods? However, in clinical application, it should depend on the condition; for those with severe dampness, it may be temporarily used to drain dampness below, isolating the heat, and then switch to clearing and draining methods; or this formula can be modified according to the severity of damp-heat, for those with equal dampness and heat, or those with more heat, it should be adjusted to include clearing heat herbs for treatment. For example, Liu He Jian treated summer heat with dampness and diarrhea using Gui Ling Gan Lu Yin, which is Wu Ling San plus Liu Yi San for cold and light draining, and then adding San Shi to clear heat and resolve summer heat. Also, in <Wen Bing Tiao Bian>, treating “diarrhea that is not smooth, wanting to stagnate below, with abdominal cramping, and short urination” using Si Ling He Qin Shao Tang, which is also based on Wu Ling San, reducing Gui Zhi, replacing Bai Zhu with Cang Zhu, and adding Bai Shao, Huang Qin, Guang Pi, Mu Xiang, and Hou Po. For “damp-warm diarrhea,” there is also the method of adding cold water stone to Wu Ling San, all of which are flexible applications of this formula. When damp-heat accumulates in the lower jiao and injures yin, leading to deficiency, one should use methods that drain dampness, clear heat, and nourish yin. To treat symptoms of floating pulse, fever, thirst for drinking water, and difficulty urinating, Zhu Ling Tang uses Er Ling, Ze Xie to lightly drain and benefit water, Hua Shi to drain dampness and clear heat, and E Jiao to nourish yin and moisten dryness, addressing both the root and branch, making it a good formula for treating lower jiao water damp-heat combined with yin deficiency. If the qi transformation in the lower jiao is abnormal, with damp-heat stagnating, the bladder not discharging, and water accumulating below the waist leading to edema, combined with yin deficiency and fluid loss, <Shang Han Lun> uses Mu Li Ze Xie San. This formula uses Mu Li to soften hardness and promote water, while also preserving yin, Ze Xie to drain water dampness, Shu Qi to expel phlegm and water, Ting Li Zi to promote lung and drain water, and Hai Zao to soften hardness and transform phlegm, with Gua Lou Gen to relieve thirst and generate fluids, moistening without being greasy, which is also a method worth noting for treating lower jiao damp-heat. From this, it is clear that the prohibition against using nourishing yin in damp-warm conditions should also be analyzed specifically. Although damp-warm and yin deficiency both present with afternoon fever, one must carefully observe the overall symptoms for differentiation, and must not confuse them. For those with damp-warm combined with yin deficiency, nourishing yin products should be used, but care should be taken to select those that nourish without being greasy. 4Method of Unblocking the Three Jiao The three jiao are the channels for the metabolism of water and fluids, and the three jiao and gallbladder belong to the hand and foot shaoyang. Unblocking the shaoyang is beneficial for the smooth flow of the three jiao’s water pathways, which is another important method for treating damp-heat, emphasizing the promotion of the qi aspect. In <Shang Han Lun> 230, it mentions that after taking Xiao Chai Hu Tang, it can lead to “the upper jiao being unblocked, fluids descending, stomach qi harmonizing, and sweating occurring, thus resolving the condition,” highlighting this issue. For “yangming wind stroke, with a pulse that is wiry, floating, large, and short of breath, fullness in the abdomen, pain under the ribs and in the heart, persistent pressure causing qi stagnation, dry nose, inability to sweat, desire to lie down, and yellowing of the body, with difficulty urinating, tidal fever, and occasional belching, swelling in front and back of the ears,” acupuncture is first used, followed by Xiao Chai Hu Tang to unblock the shaoyang, regulate the qi mechanism, restore qi transformation, open the pores, and promote urination, thus resolving dampness and heat. Additionally, Chai Hu Gui Zhi Gan Jiang Tang is often used for damp-warm conditions, with case reports available. Currently, in clinical treatment of hepatitis and biliary infections diagnosed as damp-heat, Chai Hu formulas are frequently used, demonstrating the application of this method. 5Method of Bitter Cold and Drying Dysentery and jaundice are often attributed to damp-heat diseases. <Shang Han Lun> provides effective methods for treating diarrhea and jaundice, bitter cold and drying is one of them. “In taiyang disease, with Gui Zhi syndrome, if the physician purges, and diarrhea does not stop, with a rapid pulse, it indicates that the exterior has not resolved; if there is wheezing and sweating, Ge Gen Huang Qin Huang Lian Tang is indicated,” which is a commonly used formula for the initial stage of damp-heat diarrhea combined with exterior heat, employing bitter cold and drying to resolve muscle. To treat “taiyang and shaoyang combined disease with diarrhea,” Huang Qin Tang uses Huang Qin to clear heat and dry dampness, Shao Yao to astringe yin and harmonize blood, with herbs like Cao and Jujube to regulate the middle. In later generations, treatment of damp-heat dysentery often builds upon this foundation, such as Zhang Jie Gu’s Shao Yao Tang. In <Wen Bing Tiao Bian>, treating “stagnation has formed, with abdominal distension and pain” using Qin Shao Tang, which is based on this formula, reducing Cao and Jujube, and adding Huang Lian, Hou Po, Mu Xiang, and Guang Pi to achieve bitter cold and drying, moving qi and aromatically transforming, unblocking damp-heat in the intestines. For damp-heat diarrhea biased towards heat, with symptoms of heaviness in the lower abdomen and red stools, <Shang Han Lun> uses Bai Tou Weng Tang, which has a more pronounced bitter cold and drying effect. In <Wen Bing Tiao Bian>, this formula is further enhanced with Huang Qin and Bai Shao to strengthen the drying effect, astringing yin and harmonizing blood, alleviating pain, which is commonly used for treating heat dysentery. The treatment for yangming damp-heat with internal stagnation leading to yellowing is Yin Chen Hao Tang, which is bitter cold and drying, also using Da Huang to guide fire downward, combined with the method of unblocking the intestines. This indicates that damp-heat as a disease should be unblocked in the intestines. Whether the disease is in the three jiao, gallbladder, or intestines, it should be applied in a timely manner. The so-called prohibition against purging in damp-warm conditions should also be analyzed specifically; for those with spleen deficiency, purging is not appropriate, but for those with damp-heat accumulation in the intestines and gallbladder, if the qi mechanism is obstructed and the pathogen has no outlet, how can the disease be cured? Clinical practice has proven that the use of Da Huang in Yin Chen Hao Tang and Gua Lou in Xiao Xian Xiong Tang has a positive effect on the reduction of jaundice. For dysentery with obstruction, early use of Da Huang and Bing Lang to promote downward movement is very beneficial for clearing damp-heat and preventing the pathogen from remaining. 6Method of Balancing Hard and Soft The formula Wu Mei Wan recorded in <Shang Han Lun> can treat “roundworm convulsions,” which is well-known. This formula “also treats prolonged diarrhea,” combining the properties of great bitterness and cold to clear heat and dry dampness, along with great pungency and heat to warm yang and transform dampness, while also tonifying qi and nourishing blood, astringing and consolidating. This is particularly suitable for prolonged diarrhea with both deficiency and excess, mixed cold and heat, and lingering damp-heat. For example, in <Wen Bing Tiao Bian>, treating prolonged dysentery affecting the jueyin, invading the yangming, with qi rising to the heart, causing hunger without desire to eat, dry retching and abdominal pain, this formula is used. To treat “summer pathogens deeply invading the jueyin, with gray tongue, thirst, hard tongue under the tongue, vomiting, and diarrhea with blood and water, even inability to speak, with resistance above and below,” Jiao Mei Tang is used. This formula consists of Huang Lian, Huang Qin, Gan Jiang, Chuan Jiao, Ren Shen, Wu Mei, Bai Shao, Zhi Shi, and Ban Xia, which is the method of Zhang Zhongjing’s Wu Mei Wan, combining bitter, sour, pungent, and sweet, balancing hard and soft, softening to nourish yin, and hardening to support yang. Thus, it enlightens us that prolonged damp-heat can injure yang, while heat can injure yin, leading to deficiency of both qi and blood. Therefore, prolonged damp-heat diseases must also pay attention to rescuing yang and protecting yin, and tonifying qi and blood. However, one must not solely tonify, to avoid the residual damp-heat pathogen remaining, making it difficult to cure; it is necessary to continue to add clearing heat and drying dampness to eliminate the root cause. In summary, although Zhang Zhongjing’s records on damp-heat diseases are brief, the principles and major methods for treating damp-heat are well established based on his discussions and the application of formulas. Combined with the discussions of later physicians and verified in clinical practice, they provide valuable insights and benefits, warranting serious exploration. Note: This article is excerpted from <Shizhen Sheng Shang Han Fa Hui>, compiled by Xiao Xiangru, published by China Traditional Chinese Medicine Press. This public account uses this article for academic exchange; please indicate the source when reprinting.Recommended ReadingClick to read the original text:Methods of Treating Damp-Heat by Renowned TCM Masters Shizhen Sheng and Zhao Shaoqin: Classical Formulas vs. Modern FormulasShimen Medical Discourse (Shizhen Sheng): Views on the Six Meridians Differentiation in <Shang Han Lun> and Its TransmissionShimen Medical Discourse (Shizhen Sheng): The Unity of Six Meridians Differentiation and the Differentiation of Wei, Qi, Ying, and Blood, and the Three Jiao//////////
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