TCM Book Club Issue 1027
One issue daily, accompanying the growth of TCM practitioners
IIntroduction:This is a great article found in a blog, where the author summarizes the dual resolution method from the Treatise on Cold Damage, including its composition, text, and pathogenesis analysis, and concludes with clinical cases. Although I personally have not mastered the Treatise on Cold Damage well, I believe the author explains it well, and I gained a lot from reading it, so I share it with everyone. (Editor/Wang Chao)
The Special Treatment Method in TCM – Dual Resolution Method
Author/Xinglin Xiaoke
Diseases can arise from external factors, internal factors, or both. Sometimes, external pathogens penetrate internally, or there may be pre-existing conditions combined with new external influences, leading to simultaneous internal and external afflictions. In such cases, simply using methods to resolve the exterior is often ineffective, and dual resolution is required. In the Treatise on Cold Damage, there are not many formulas for dual resolution, but their significance lies in demonstrating the principles, allowing for broader application!
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Gui Zhi Ren Shen Tang (Cinnamon Twig and Ginseng Decoction)
【Composition】Gui Zhi (Cinnamon Twig), Ren Shen (Ginseng), Bai Zhu (White Atractylodes), Gan Jiang (Dried Ginger), Gan Cao (Licorice).
【Function】Warm the middle and resolve the exterior.
【Text】For Taiyang disease, if the exterior symptoms have not been resolved and there are frequent bowel movements, leading to heat and diarrhea that does not stop, with hardness and fullness below the heart, and unresolved internal and external conditions, Gui Zhi Ren Shen Tang is indicated. (163)
【Pathogenesis】This is primarily an exterior syndrome, which should be resolved externally, but repeated use of purgatives has led to unresolved exterior heat and injury to the middle qi, resulting in persistent diarrhea. This is a case of simultaneous internal and external disease, and treatment should involve dual resolution. Although this syndrome is a case of simultaneous internal and external disease, it is primarily characterized by deficiency and cold leading to diarrhea, thus the use of Ren Shen, Bai Zhu, Gan Jiang, and Gan Cao to warm the spleen and stop diarrhea, while Gui Zhi resolves the exterior. This formula is essentially Li Zhong Tang (Regulate the Middle Decoction) with Gui Zhi added.
【Case Study】Shen Yannan’s medical case: A girl, about 3 years old, had a rash that had subsided, but her fever did not resolve, with a temperature of 39°C, and it was unclear whether she had a headache or chills. She had diarrhea more than ten times a day, all yellow watery stools. The pulse was rapid and continuous, and the tongue was normal. The diagnosis was post-measles heat toxin causing diarrhea, treated with Ge Gen Qin Lian Tang (Kudzu, Scutellaria, and Coptis Decoction) plus pomegranate peel. After taking the medicine, her temperature rose to 39.5°C, and diarrhea continued. After careful consideration, observing that the child appeared quite fatigued, I decisively changed to Gui Zhi Ren Shen Tang, still adding pomegranate peel. After one dose, both fever and diarrhea decreased, and after another dose, the fever resolved and diarrhea stopped.
Note: After measles, residual pathogens can penetrate internally, causing heat and diarrhea. Since both internal and external conditions are cold, there is diarrhea without foul odor or burning sensation at the anus. Although the pulse is rapid and continuous, there is a risk of fluid damage. Moreover, the child appeared fatigued, with diarrhea more than ten times a day, and cold symptoms repeatedly emerging. Using Ge Gen Qin Lian Tang to treat cold with cold is like snow on ice, causing the yang qi to float and the heat symptoms to increase. Therefore, Gui Zhi Ren Shen Tang is used to warm and open both internal and external conditions; to prevent diarrhea, pomegranate peel is added to astringe the intestines and stop diarrhea.
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Ge Gen Qin Lian Gan Cao Tang (Kudzu, Scutellaria, and Licorice Decoction)
【Composition】Ge Gen (Kudzu), Huang Qin (Scutellaria), Huang Lian (Coptis), Gan Cao (Licorice, roasted).
【Function】Dual clearing of internal and external conditions.
【Text】For Taiyang disease, with Gui Zhi symptoms, if the physician mistakenly purges, leading to persistent diarrhea and a rapid pulse, the exterior has not been resolved; if there is wheezing and sweating, Ge Gen Huang Qin Huang Lian Tang is indicated. (34)
【Pathogenesis】This syndrome should have been treated with Gui Zhi Tang to resolve the exterior, but purgatives were mistakenly used, leading to the exterior pathogen wanting to penetrate internally. When the exterior pathogen attempts to penetrate internally, the yang qi resists it, resulting in a rapid pulse. If the evil heat presses on the lungs, it causes wheezing and sweating. The lungs and large intestine are interrelated, and if the evil heat presses down on the large intestine, it leads to persistent diarrhea. Therefore, Ge Gen is used to resolve the exterior, Huang Qin and Huang Lian clear heat and stop diarrhea, and Gan Cao tonifies qi and harmonizes the middle.
【Differentiation】Although Ge Gen Qin Lian Tang and Gui Zhi Ren Shen Tang are both formulas for dual resolution, treating cases where purgatives were mistakenly used and exterior symptoms remain with persistent diarrhea, Ge Gen Qin Lian Tang treats heat-induced diarrhea, where the symptoms are caused by evil heat pressing down, and the stools are often foul and urgent. Gui Zhi Ren Shen Tang treats cold-induced diarrhea, where the symptoms are caused by spleen and stomach deficiency and cold, and the stools are often clear and cold.
【Case Study】Zhang Zhimin’s medical case: Chen, male, 5 years old. He had a fever last night, which did not resolve this morning, and had diarrhea twice with mucus, was lethargic, and had convulsions and coma. The tongue coating was slightly yellow, and the pulse was deep and rapid. This was a gastrointestinal symptom, with the pathogenic factor in the interior. Diagnosed by Western medicine as acute gastroenteritis. Treated with Ge Gen Qin Lian Tang, and after three doses, he recovered.
Note: This case is a combination of Taiyang and Yangming diseases. The evil remains in Taiyang, causing fever; when the evil penetrates into Yangming, it causes vomiting and diarrhea. The stomach channels connect to the heart, and turbid heat circulating through the channels disturbs the spirit, leading to coma and lethargy. Therefore, Ge Gen Qin Lian Tang is used for dual resolution of internal and external conditions, to stop diarrhea.
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Hou Po Qi Wu Tang (Magnolia Bark and Seven Herbs Decoction)
【Composition】Gui Zhi (Cinnamon Twig), Sheng Jiang (Fresh Ginger), Da Zao (Jujube), Gan Cao (Licorice), Hou Po (Magnolia Bark), Zhi Shi (Bitter Orange), Da Huang (Rhubarb).
【Function】Resolve the exterior and relieve fullness internally.
【Text】For abdominal fullness, fever for ten days, with a floating and rapid pulse, and normal appetite, Hou Po Qi Wu Tang is indicated.
【Pathogenesis】Abdominal fullness refers to a pre-existing condition; fever for ten days with a floating and rapid pulse indicates an exterior symptom of a new affliction. If there is abdominal fullness but normal appetite, it indicates a mild internal blockage in Yangming; if there is dryness and fullness, and inability to eat, Da Cheng Qi Tang should be used. This formula removes the exterior pathogen with Gui Zhi and Shao Yao, while using Hou Po Qi Wu Tang to relieve internal distension, achieving the effect of dual resolution.
【Case Study】Tan Riqiang’s medical case: Pan, male, 43 years old. Initially, he sweated from labor and caught a chill, then overate at dinner, leading to fever and chills, headache, body aches, and nausea. The health department provided Huo Xiang Zheng Qi Wan (Agastache Correct Qi Pill) three doses, which were ineffective, and then Baohuan Wan (Digestive Pill) three doses, which also had no effect; he continued to have fever, headache, sweating, and abdominal fullness with pain, and had not had a bowel movement for three days. The tongue coating was yellow and greasy, and the pulse was floating and slippery. This indicates that the exterior pathogen has not been resolved, and internal fullness has formed, so dual resolution is the method of choice. The treatment was Hou Po Qi Wu Tang: 10g Hou Po, 6g Zhi Shi, 10g Da Huang, 10g Gui Zhi, 3g Gan Cao, 3g Sheng Jiang, 3 dates, and 10g Bai Shao. Instructed to take two doses. After achieving smooth bowel movements, he stopped taking the medicine, and the symptoms were completely resolved. (From “Jin Kui Yao Lue Qian Shu” 1981: 159)
Note: Labor sweat should be released, and overeating leads to chills and fever; externally, there is fever and chills, sweating and aversion to wind; internally, there is abdominal fullness and pain, with no bowel movement. Therefore, Hou Po Qi Wu Tang is used for dual resolution. Tan added Bai Shao to the formula due to abdominal fullness and pain.
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Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction)
【Composition】Chai Hu (Bupleurum), Huang Qin (Scutellaria), Ban Xia (Pinellia), Ren Shen (Ginseng), Gui Zhi (Cinnamon Twig), Shao Yao (Peony), Da Zao (Jujube), Sheng Jiang (Fresh Ginger), Gan Cao (Licorice).
【Function】Resolve both Taiyang and Shaoyang evils.
【Text】For cold damage lasting six to seven days, with fever, slight aversion to cold, joint pain, slight nausea, fullness below the heart, and unresolved exterior symptoms, Chai Hu Gui Zhi Tang is indicated. (146)
【Pathogenesis】“Cold damage lasting six to seven days, with fever and slight aversion to cold” indicates that the Taiyang channel’s exterior evil has not been resolved; “slight nausea and fullness below the heart” indicates that the exterior evil has transmitted to the Shaoyang channel! Chai Hu Gui Zhi Tang is a combination of Xiao Chai Hu Tang (Minor Bupleurum Decoction) and Gui Zhi Tang, resolving the Taiyang evil and the Shaoyang evil, allowing both channel evils to be resolved.
【Case Study】Xinglin Xiaoke’s medical case: A male, 27 years old, had a headache and slight tightness in the shoulder and neck. Upon further examination, the headache was primarily at Fengchi (GB20) point, and he had a cold several days prior. Treated with Chai Hu Gui Zhi Tang: 25g Chai Hu, 10g Huang Qin, 15g Ban Xia, 15g Ren Shen, 15g Gui Zhi, 15g Shao Yao, 6 dates, 5 slices of Sheng Jiang, and 5g Gan Cao. After three doses, the condition improved, and after two more doses, he recovered, with one extra dose remaining. The key point in this case was the tenderness at Fengchi point, which is where the Taiyang and Shaoyang channels intersect; the shoulder well is governed by the Shaoyang channel, and the neck is governed by the Taiyang channel, thus Chai Hu Gui Zhi Tang was effective.
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Ma Huang Sheng Ma Tang (Ephedra and Cimicifuga Decoction)
【Composition】Ma Huang (Ephedra), Gui Zhi (Cinnamon Twig), Sheng Ma (Cimicifuga), Shi Gao (Gypsum), Zhi Mu (Anemarrhena), Huang Qin (Scutellaria), Bai Zhu (White Atractylodes), Fu Ling (Poria), Gan Jiang (Dried Ginger), Gan Cao (Licorice), Wei Rui (Polygonatum), Tian Dong (Asparagus), Dang Gui (Angelica), Shao Yao (Peony).
【Function】Resolve exterior evil, clear stagnant heat, warm the middle, stop diarrhea, nourish yin, and enrich blood.
【Text】For cold damage lasting six to seven days, after a large purge, with a deep and slow pulse, cold extremities, and no pulse in the lower body, sore throat with purulent blood, and persistent diarrhea, this is difficult to treat. Ma Huang Sheng Ma Tang is indicated.
【Pathogenesis】This should have resolved the exterior, but purgatives were mistakenly used; a deep and slow pulse indicates that the exterior evil has penetrated internally; cold extremities and no pulse in the lower body indicate yang deficiency; sore throat with purulent blood indicates lung and kidney yin deficiency, with evil heat above. This is a case of simultaneous internal and external disease, with both yin and yang deficiencies, and mixed cold and heat, hence it is difficult to treat. The formula uses Ma Huang, Gui Zhi, and Sheng Ma to disperse the exterior evil, Shi Gao, Zhi Mu, and Huang Qin to clear the evil heat, and Wei Rui, Tian Dong, Dang Gui, and Shao Yao to nourish yin and enrich blood, while Bai Zhu, Fu Ling, Gan Jiang, and Gan Cao warm the middle and stop diarrhea.
【Case Study】Li Shoushan’s medical case: Han, female, 50 years old. Previously healthy, with one son and two daughters, menstruation has not yet ceased. For the past six years, she has frequently experienced dizziness, facial flushing with sweating, dry mouth and throat, but no desire to drink, occasional oral ulcers, chest tightness, irritability, and insomnia with many dreams. Half a month ago, she caught a wind-cold, with chills and fever, headache, and body aches. After taking Ling Qiao Jie Du Wan (Lonicera Detoxifying Pill) and other medicines, the exterior was not resolved, and her throat pain increased, with nausea and thin stools two to three times a day.
She had previously been diagnosed by Western medicine with upper respiratory tract infection and autonomic dysfunction. After intramuscular injection of penicillin and oral antipyretics and sedatives, she did not improve, and the condition persisted for three weeks. On December 1, 1981, she came for diagnosis. The pulse was large at both cun positions, thin and weak at the guan and chi positions, the tongue was red with a red tip and a white greasy coating at the root, the throat was red but not swollen, temperature was 37.8°C, blood pressure was 140/90 mmHg, and white blood cell count was 12800/mm³, with no other abnormalities.
Combining pulse and symptoms, the diagnosis was a case of pre-existing yin deficiency with excess fire, combined with wind-cold externally closing in, leading to unresolved exterior evil and simultaneous internal and external evil, resulting in mixed cold and heat. The treatment was to disperse the stagnant yang externally, adjust the cold and heat internally, tonify qi and nourish yin, and clear the upper while warming the lower. The formula used was Ma Huang Sheng Ma Tang with modifications: 7.5g Ma Huang, 7.5g Sheng Ma, 5g Gan Jiang, 15g Gui Zhi, 15g Bai Shao, 15g Bai Zhu, 15g Fu Ling, 15g Dang Gui, 15g Tian Dong, and 25g Shi Gao, with 10g Zhi Mu and Gan Cao. Decoction was taken, two doses. After taking the medicine, all symptoms improved, and she continued with bamboo leaf and gypsum decoction for several doses to stabilize.
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Ma Huang Fu Zi Xi Xin Tang (Ephedra, Aconite, and Asarum Decoction)
【Composition】Ma Huang (Ephedra), Xi Xin (Asarum), Fu Zi (Aconite).
【Function】Warm yang and resolve the exterior.
【Text】For Shaoyin disease that has just begun, with a return of fever and a deep pulse, Ma Huang Xi Xin Fu Zi Tang is indicated. (301)
【Pathogenesis】If there is fever and aversion to cold, it indicates a yang condition; if there is no fever and aversion to cold, it indicates a yin condition. In Shaoyin disease, a deep pulse indicates that there should not be fever; if fever is present, it indicates that the Taiyang channel is also affected! The Taiyang and Shaoyin channels are interrelated, and this is a case of simultaneous disease in both channels, known as “Tai Shao Liang Gan” syndrome. This formula heavily uses Fu Zi to warm kidney yang, while Ma Huang disperses exterior cold, and Xi Xin penetrates internally and externally, achieving the effect of dual resolution.
【Case Study】Medical case: Male, over 30 years old. Suffering from a cold and cough that has not resolved. Previously took Western and Chinese medicine, but the cough persisted. Lung X-ray showed no abnormalities. After taking medicine for a month, the cough still did not improve, so he came to me for treatment. Temperature was 37.5°C, with a scratchy throat and cough, thin white sputum in small amounts, appearing fatigued, voice hoarse, drowsy and lethargic, tongue pale with a thin moist white coating, pulse deep and wiry with a floating pulse at the chi position. Based on pulse and symptoms, this is wind-cold entering the Shaoyin. Although it is not the exact syndrome of “Shaoyin disease that has just begun,” it is undoubtedly a manifestation of Shaoyin disease. Therefore, I used Ma Huang Xi Xin Fu Zi Tang, giving two doses, and the mild fever subsided, cough stopped, and voice improved. The original formula was adjusted, and additional tonics were given to restore physical strength.
Note: Wind-cold invading the Shaoyin causes lung qi to rebel and cough; this is a case of “Tai Shao Liang Gan” syndrome. The “Zhang’s Medical Communication” states: “If there is sudden hoarseness, throat pain, or an inability to cough, or if there is no phlegm, or clear phlegm overflowing, the pulse is often deep and tight, or rapid and chaotic, this indicates great cold invading the kidney. Ma Huang Xi Xin Fu Zi Tang warms it, and honey should be used to prepare Fu Zi for sublingual use; be cautious not to use cold or cool medicines lightly.”
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