Introduction:：The mixed cold and heat medicines recorded in “Shang Han Lun” can be summarized into eight formulas: Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum and Cinnamon Decoction with Dried Ginger), Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction), Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Heart), Fu Zi Xie Xin Tang (Aconite Decoction to Drain the Heart), Huang Lian Tang (Coptis Decoction), Wu Mei Wan (Mume Pill), Ma Huang Sheng Ma Tang (Ephedra and Cimicifuga Decoction), and Gan Jiang Huang Qin Huang Lian Ren Shen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction), totaling eight formulas.
Chai Hu Gui Zhi Gan Jiang Tang has been discussed previously, while Zhi Zi Gan Jiang Tang will be omitted. Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction to Drain the Heart) and Gan Cao Xie Xin Tang (Licorice Decoction to Drain the Heart) can be represented by Ban Xia Xie Xin Tang. Below is a brief description of each formula.Ban Xia Xie Xin TangBan Xia Xie Xin Tang is a formula that combines cold and hot medicines.It is a representative formula for harmonizing the cold and heat evils of the spleen and stomach.Sheng Jiang Xie Xin Tang and Gan Cao Xie Xin Tang are modifications based on its ingredients.This formula treats a syndrome characterized by disharmony of the spleen and stomach qi, with fullness and distension below the heart accompanied by phlegm and fluid retention.Due to the presence of phlegm and fluid, it also includes symptoms of vomiting. Clinical observations indicate that this syndrome may present with fullness and distension below the heart, vomiting, borborygmus, diarrhea, or irregular bowel movements. This syndrome arises from the disharmony of yin and yang in the spleen and stomach, with disordered ascending and descending qi, leading to obstruction in the middle jiao and mixed cold and heat, resulting in the generation of phlegm and fluid. Therefore, Ban Xia Xie Xin Tang is used to bitterly descend, pungently open, harmonize the stomach, and clear phlegm as its main actions.Ban Xia Xie Xin Tang consists of Ban Xia (Pinellia), Huang Qin (Scutellaria), Huang Lian (Coptis), Ren Shen (Ginseng), Zhi Gan Cao (Honey-fried Licorice), and Da Zao (Jujube). This syndrome involves poor ascending and descending of qi, with obstruction in the middle jiao, leading to heat generation due to the stomach qi not descending. Therefore, bitter cold herbs like Huang Qin and Huang Lian are used to descend it, while Gan Jiang (Dried Ginger) is used to warm it due to the cold generated by the spleen qi not ascending, causing borborygmus and diarrhea. Phlegm and fluid disturb the stomach, causing vomiting, hence Ban Xia is used to descend and harmonize the stomach to stop vomiting.With weak spleen and stomach qi unable to regulate the ascending and descending, Ren Shen, Gan Cao, and Da Zao are used to tonify it. This formula clears the upper and warms the lower, using bitter descent and pungent opening, combining cold and heat to harmonize the spleen and stomach, making it the main formula for treating fullness below the heart.【Note】The area below the heart is a half-exterior, half-interior location (below the chest, above the abdomen). Therefore, when there is a disease, it is appropriate to use Xie Xin Tang to harmonize. However, Xiao Chai Hu Tang treats the liver and gallbladder, while Xie Xin Tang treats the spleen and stomach. Both syndromes share characteristics of poor ascending and descending qi, resulting from the disharmony of yin and yang. If not treated with harmonization but with other methods, the disease cannot be cured.Especially since the “below the heart” area is a crucial pathway for the ascending and descending of qi, if the communication of yin and yang is obstructed, it leads to fullness. Fullness is obstruction, where qi stagnates and does not flow, neither blood nor water, with nothing substantial in the middle, hence pressing it feels moist, but it is merely qi fullness.【Medical Case】Zhang, male, 36 years old. He has a history of alcohol consumption and presents with fullness below the heart, occasional vomiting, and unformed stools, three to four times a day. Despite various treatments, there was no effect. His pulse is wiry and slippery, and his tongue coating is white.Diagnosis: The syndrome is due to alcohol harming the spleen and stomach, with disordered ascending and descending, leading to phlegm generation. Phlegm and fluid cause the stomach qi to rebel, resulting in vomiting, while spleen deficiency and cold qi lead to unformed stools, with disharmony of middle qi causing fullness below the heart.Prescription: Ban Xia 12g, Gan Jiang 6g, Huang Qin 6g, Huang Lian 6g, Dang Shen 9g, Zhi Gan Cao 9g, Da Zao 7 pieces.After taking one dose, he had a large amount of white, sticky phlegm in his stool, and vomiting decreased by 70%; after another dose, both fullness and vomiting decreased, and after two more doses, he was cured.Fu Zi Xie Xin TangFu Zi Xie Xin Tang is used to treat heat fullness below the heart, with yang deficiency unable to protect the exterior, accompanied by symptoms of “aversion to cold and sweating.” Generally, fever easily leads to sweating, while aversion to cold does not easily lead to sweating. However, if aversion to cold occurs simultaneously with sweating, it reflects a deficiency of defensive yang and a loss of warming function.Defensive yang refers to the yang qi that protects the exterior, originating from the lower jiao, transformed from the kidney’s yang qi, reaching the body surface to “warm the flesh, fill the skin, nourish the pores, and control opening and closing.” If the lower jiao yang is deficient, it leads to insufficient transformation of defensive yang, losing its warming and protective function, resulting in symptoms of aversion to cold and sweating, hence termed as upper heat and lower cold syndrome. The treatment uses Fu Zi Xie Xin Tang to clear heat fullness and warm yang qi.Fu Zi Xie Xin Tang consists of Da Huang (Rhubarb), Huang Lian (Coptis), Huang Qin (Scutellaria), and Pao Fu Zi (Processed Aconite). In this formula, Da Huang, Huang Lian, and Huang Qin are soaked in boiling water to treat heat fullness in the qi level, while Fu Zi is boiled separately in water to extract its strong flavor and power to specifically tonify the deficiency of kidney yang. Although this formula uses both cold and hot herbs, the soaking of the three yellow herbs and the separate decoction of Fu Zi emphasize the support of yang as the main action, with heat clearing as a secondary action.【Medical Case】A student from Ningxiang had an external contraction for several months and was repeatedly treated without improvement. During the consultation, he reported fullness in the chest, heat in the upper body with sweating, and aversion to wind below the waist, while it was June, and he was wrapped in blankets. Upon reviewing the previous prescriptions, they were all common clearing and draining medicines that did not address the root cause. His tongue coating was light yellow, and his pulse was wiry.He was given Fu Zi Xie Xin Tang, and after two days, he returned for a follow-up, stating that after taking two doses, his illness was resolved. He was advised to continue with the follow-up treatment. (Quoted from “Dun Yuan: Medical Cases”)Huang Lian TangThe syndrome of Huang Lian Tang belongs to the pathological changes of “cold damage with heat in the chest and evil qi in the stomach.” Heat in the chest leads to vomiting, while evil qi in the stomach leads to abdominal pain or diarrhea. The treatment with Huang Lian Tang uses both cold and warm herbs, with sweet and bitter actions to regulate the yin and yang of the upper and lower, harmonizing the evil.Huang Lian Tang consists of Huang Lian (Coptis), Zhi Gan Cao (Honey-fried Licorice), Gan Jiang (Dried Ginger), Gui Zhi (Cinnamon), Ren Shen (Ginseng), Ban Xia (Pinellia), and Da Zao (Jujube). In this formula, Huang Lian is used to clear heat in the chest, Gan Jiang warms the cold of the spleen and stomach, Gui Zhi promotes the upward and downward flow of yang qi, Ban Xia descends and stops vomiting, while Ren Shen, Gan Cao, and Da Zao nourish the stomach and calm the center, facilitating the regulation of the upper and lower and harmonizing the cold and heat of yin and yang.【Medical Case】Li from Xuzhou presented with vomiting and diarrhea, three to four times a day, with urgency and heaviness in the abdomen, accompanied by red and white sticky mucus. His illness persisted for a year, and he had not improved despite seeking treatment everywhere. He came to Beijing due to work and was introduced to me for diagnosis. His pulse was wiry and slippery, and pressing it felt weak, with a red tongue and white coating.Diagnosis: This is a syndrome of mixed cold and heat evils, affecting the spleen and stomach. If only one aspect is treated, whether using cold for heat or heat for cold, it will not be effective. When cold and heat are both present, it should follow the method of Huang Lian Tang.Prescription: Huang Lian 9g, Gan Jiang 9g, Gui Zhi 9g, Ban Xia 9g, Ren Shen 6g, Zhi Gan Cao 6g, Da Zao 7 pieces. After taking six doses, his year-long illness was cured.Wu Mei WanWu Mei Wan is the main formula for treating the Jue Yin disease. When the disease reaches Jue Yin, the yin and yang mutually retreat, characterized by mixed cold and heat symptoms. Symptoms may include “thirst, qi rising to the heart, heat and pain in the heart, and hunger without desire to eat.” Due to the mixed cold and heat, with heat above and cold below, it may also present as vomiting of roundworms and cold limbs, termed “roundworm syndrome,” which can be treated with Wu Mei Wan.Wu Mei Wan consists of Wu Mei (Mume), Xi Xin (Asarum), Gan Jiang (Dried Ginger), Huang Lian (Coptis), Fu Zi (Aconite), Dang Gui (Angelica), Shu Jiao (Sichuan Pepper), Gui Zhi (Cinnamon), Ren Shen (Ginseng), and Huang Bai (Phellodendron). This formula is the main treatment for the mixed cold and heat of Jue Yin and roundworm syndrome. Wu Mei is soaked in vinegar to nourish the yin and harmonize the yang, with effects of harmonizing the liver, calming the stomach, and stopping thirst. Fu Zi, Gan Jiang, and Gui Zhi warm the channels and support yang to overcome cold.Chuan Jiao and Xi Xin are spicy and warm, capable of promoting yang and breaking yin, and can kill roundworms. Huang Lian and Huang Bai are bitter and cold, clearing heat and vexation, and subduing roundworms while treating vomiting. Ren Shen tonifies qi to strengthen the spleen, and Dang Gui nourishes blood to support the liver. The combination of these herbs eliminates cold and heat evils, harmonizes yin and yang, softens the liver, warms the lungs, and stops roundworms, which is the essence of this formula.Although the formula uses both cold and hot herbs, it leans more towards warming herbs, and the sourness of Wu Mei helps to consolidate and secure, thus treating prolonged diarrhea due to mixed cold and heat. Using rice and honey as sweeteners in the pills not only nourishes the stomach qi but also serves as bait to attract roundworms.【Medical Case】Zhou, female, 36 years old, from Shangzhai, Gansu, suddenly experienced paroxysmal severe pain in the upper right abdomen, cold limbs, profuse cold sweat, and vomiting. She had a history of roundworms. Examination revealed “worm spots” on her face, a wiry and strong pulse, and a crimson tongue with dark coating. Diagnosis: This is a “roundworm syndrome” of Jue Yin disease. The prescription was modified from Wu Mei Wan to a decoction, taken in three doses. After two doses, the pain ceased, and she felt at ease.However, due to severe bitterness in her mouth, she still had vomiting and reported that she had not had a bowel movement for several days. I switched to a dose of Da Chai Hu Tang, which resulted in a large bowel movement with many roundworms, and she was cured thereafter.Ma Huang Sheng Ma TangMa Huang Sheng Ma Tang treats the syndrome of exterior evil trapped internally, with qi stagnation, mixed cold and heat, and disharmony of yin and yang. Due to the internal entrapment of yang evil, the originally floating pulse changes to a deep and slow pulse. The pulse at the lower part of the wrist is not absent, indicating that qi stagnation leads to obstruction, resulting in an unfavorable pulse pathway.When qi is obstructed, the yin and yang qi do not connect smoothly, leading to coldness in the hands and feet. If the internal entrapment of yang evil lingers above, it causes heat above, resulting in throat discomfort and vomiting of pus and blood. Yang is trapped above and cannot govern below, leading to continuous diarrhea.This syndrome involves both yin and yang being affected, with deficiency and excess, cold and heat also mixed and unclear, making it a difficult syndrome to treat. However, Zhong Jing’s Ma Huang Sheng Ma Tang treats both cold and heat, expelling the trapped yang evil externally while nourishing the yin of the lungs and stomach, clearing the upper and warming the lower, ensuring that yin and yang harmonize for recovery.Ma Huang Sheng Ma Tang consists of Ma Huang (Ephedra), Sheng Ma (Cimicifuga), Dang Gui (Angelica), Zhi Mu (Anemarrhena), Huang Qin (Scutellaria), Wei Rui (Ophiopogon), Shao Yao (Peony), Tian Dong (Asparagus), Gui Zhi (Cinnamon), Fu Ling (Poria), Zhi Gan Cao (Honey-fried Licorice), Shi Gao (Gypsum), Bai Zhu (Atractylodes), and Gan Jiang (Dried Ginger). In this formula, the dosages of Ma Huang and Sheng Ma are larger, used to expel the trapped yang evil. Huang Qin and Shi Gao clear the heat from the lungs and stomach, while Gui Zhi and Gan Jiang promote yang and warm the interior to dispel cold. Dang Gui and Shao Yao nourish blood to harmonize yin.Zhi Mu, Tian Dong, and Wei Rui nourish yin and lower fire to harmonize yang; Gan Cao, Fu Ling, and Bai Zhu not only strengthen the spleen and benefit qi to stop diarrhea but also calm the stomach and harmonize the center to facilitate the connection of the upper and lower. This formula combines tonifying and draining herbs, allowing them to assist each other without conflict. Although it uses up to fourteen ingredients, it is not chaotic, serving a precise purpose in treating mixed cold and heat syndromes.【Medical Case】Li Mengru, who had suffered from throat diseases twice and diarrhea once, was treated and cured. Now, he suffers from a cold and heat disease that has persisted for over ten days. He invited me for diagnosis. Before I could finish taking his pulse, he had diarrhea twice, with headaches, abdominal pain, and joint pain, and his throat was completely white and rotten, vomiting pus-like phlegm mixed with blood. His six pulses were floating, and both middle pulses were absent, with a weak pulse upon pressing, making it difficult to determine the count. He felt thirsty and needed water, with scanty urination, and the pulse of the lesser yin was barely detectable.After diagnosis, I could not immediately prescribe a formula, as the reasoning was unclear. I considered several formulas, including drainage decoctions, Huang Lian and Ejiao decoctions, and bitter wine decoctions, but none felt appropriate. I then proposed Gan Jiang Huang Qin Huang Lian Ren Shen Tang, but it still felt unsatisfactory. I modified it to Xiao Chai Hu Tang for stability. However, due to rain, I stayed near Li’s residence, pondering sleeplessly, and inquired with Li’s father: How many times has the patient sweated?He replied: There has been no sweating at all. Has he taken any laxatives? He said: He had taken purgatives three times, leading to frequent watery diarrhea, and the pulse suddenly changed to deep. I said: I understand now. This is a case for Ma Huang Sheng Ma Tang. The patient had a weak and easily movable pulse, with a constitution prone to throat diseases. The new illness was due to solar cold damage, and the misapplication of purgatives led to the exterior evil not retreating, with internal heat trapped, aggravating the old throat disease, hence the white rot and mixed pus and blood in the throat.The weak spleen and heavy dampness led to frequent watery diarrhea, causing the water to flow into the large intestine, hence scanty urination. The heat in the upper jiao caused thirst; the exterior evil not retreating led to cold and heat headaches and joint pains still present; and being trapped internally led to coldness in the limbs. After the significant purging, qi and blood gathered in the interior, leading to a weak yang pulse; the water liquid flowed to the lower part, hence the yin pulse also ceased.The composition of this formula includes Gui Zhi Tang with added Ma Huang, which releases the exterior and induces sweating, with Fu Ling, Bai Zhu, and Gan Jiang transforming water to benefit urination, hence stopping diarrhea; using Dang Gui to assist in blood circulation, and Huang Qin, Zhi Mu, and Shi Gao to reduce inflammation and clear heat, while also generating fluids; using Sheng Ma to relieve throat toxicity, using Yu Zhu (Wei Rui) to expel pus and blood, and using Tian Dong to clear phlegm and pus.Tomorrow, this formula can be taken as prescribed. Li was still concerned about the possibility of adverse reactions, fearing that the warmth of Ma Huang and Gui Zhi would be too much, wanting to add Ren Shen. I said: The weak and cold pulse indicates yang stagnation, not yang deficiency. Adding Ren Shen would not be as effective as not adding it, as the classic formula values not adding or subtracting. He eventually recovered. (Quoted from “Chen Xunzhai Medical Cases”)Gan Jiang Huang Qin Huang Lian Ren Shen TangGan Jiang Huang Qin Huang Lian Ren Shen Tang is used to treat the cold and heat rejection syndrome that occurs with “vomiting immediately after eating” and severe diarrhea. Therefore, this formula clears the upper and warms the lower, treating both cold and heat.Gan Jiang Huang Qin Huang Lian Ren Shen Tang consists of Gan Jiang (Dried Ginger), Huang Qin (Scutellaria), Huang Lian (Coptis), and Ren Shen (Ginseng). In this formula, Huang Qin and Huang Lian are used to drain the upper heat, while Gan Jiang warms the spleen to eliminate cold, and Ren Shen strengthens the spleen to tonify deficiency. This formula uses both cold and hot herbs, with bitter descent and pungent opening, and Gan Jiang can also guide Huang Qin and Huang Lian, preventing the heat evil from causing rejection. Therefore, some commentators believe this formula also treats “fire counterflow” vomiting.【Medical Case】Yu, male, 29 years old. During the hot summer months, he indulged in cold foods, leading to alternating vomiting and diarrhea, with vomiting being more frequent than diarrhea. He also experienced irritability and bitterness in the mouth. His pulse was rapid and slippery, and his tongue coating was yellow yet moist.Diagnosis: This is heat above and cold dampness below, and with the alternating vomiting and diarrhea, how can the stomach qi not be harmed? This is a syndrome of middle deficiency with mixed cold and heat.Prescription: Huang Qin 6g, Huang Lian 6g, Ren Shen 6g, Gan Jiang 3g, and instructing him to additionally crush fresh ginger juice into the medicinal soup. After one dose, vomiting stopped, and he was cured.
The mixed cold and heat formulas in “Shang Han Lun” represent a significant innovation in the study of formulas by Zhang Zhongjing. Their scientific value is very high, and we should inherit and promote them well. The seven mixed cold and heat formulas discussed above, while all serving to harmonize yin and yang and resolve cold and heat evils, each have their own characteristics.For example, Ban Xia Xie Xin Tang harmonizes yin and yang but focuses on treating fullness; Gan Jiang, Huang Qin, Huang Lian, and Ren Shen Tang harmonize yin and yang but focus on treating vomiting; Wu Mei Wan harmonizes yin and yang but focuses on treating roundworms; Ma Huang Sheng Ma Tang harmonizes yin and yang but focuses on inducing sweating; and Fu Zi Xie Xin Tang harmonizes yin and yang but focuses on supporting yang and stopping sweating. These all reflect the characteristic of TCM to treat according to the syndrome.Text from “Liu Du Zhou Medical Books Seven Types: Fourteen Lectures on Shang Han Lun” published by People’s Health Publishing House, Author/Liu Du Zhou
【Essentials】
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【News】● Good article sharing: Differentiating Odd Meridians in Chronic and Severe Illness ● People’s Daily: Awakening More Classic Famous Formulas【Learning】● Video learning: Free access to “Twelve Unique Skills of Mongolian Medicine” ● Free access to the complete internal teaching of “Dong’s Unique Points” The various prescriptions and formulas mentioned in this article are for reference and learning purposes only. Non-professionals should not use them blindly!