Source: Liu DuzhouThe formulas in the Treatise on Cold Damage that combine cold and heat medicines include 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 uses both 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 it. It treats a syndrome characterized by disharmony of the spleen and stomach qi, fullness and distension below the heart, and the presence of phlegm and fluid.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. The occurrence of this syndrome is due to the disharmony of yin and yang in the spleen and stomach, disordered ascending and descending, and the obstruction of qi in the middle jiao, leading to the internal generation of phlegm and fluid. Therefore, Ban Xia Xie Xin Tang is used to bitterly descend, disperse, 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 has qi mechanism obstruction, leading to fullness in the middle jiao, and the stomach qi fails to descend, generating heat. Therefore, the bitter cold properties of Huang Qin and Huang Lian are used to descend it, while the spicy warmth of Gan Jiang is used to warm it, as the coldness of the spleen qi leads to borborygmus and diarrhea. Phlegm and fluid disturb the stomach, causing vomiting, so Ban Xia is used to descend and harmonize the stomach to stop vomiting.
With weak spleen and stomach qi, it cannot regulate the ascending and descending, hence Ren Shen, Gan Cao, and Da Zao are used to tonify it. This formula clears the upper and warms the lower, using both bitter and spicy properties, and combines 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 region (located below the chest and above the abdomen). Therefore, if 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 the characteristic of obstructed ascending and descending qi, which is caused by 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 located between the chest and abdomen, it is a crucial pathway for qi’s ascent and descent. Therefore, if the communication between yin and yang is obstructed, it leads to fullness. Fullness is a blockage, where qi stagnates and does not flow, neither blood nor water, and is not solid, hence it feels moist upon palpation, but it is merely qi fullness.Zhang, male, 36 years old. He has a habit of drinking alcohol 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, leading to disordered ascending and descending, with phlegm generated internally. Phlegm and fluid cause the stomach qi to rebel, resulting in vomiting, while spleen deficiency and cold qi lead to unformed stools, and disharmony of middle qi results in 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 seven pieces.
After taking one dose, the patient had a large amount of white, sticky phlegm in his stool, and vomiting decreased by seventy percent; after another dose, both fullness and vomiting decreased, and after taking two more doses, the illness 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, and is characterized 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, when aversion to cold occurs simultaneously with sweating, it reflects a deficiency of defensive yang and a failure to warm.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’s yang is deficient, it leads to insufficient transformation of defensive yang, losing its function of warming and protecting the muscle surface, 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 the 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 medicines, the soaking of the three yellow herbs and the separate decoction of Fu Zi primarily support yang while also clearing heat.A student from Ningxiang had an external pathogen for several months and was repeatedly treated without improvement. Upon examination, he reported fullness in the chest, heat in the upper body with sweating, and aversion to wind below the waist. It was June, and he was wrapped up. 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.Prescription: Fu Zi Xie Xin Tang. After two days, he returned for a follow-up, stating that after taking two doses, his illness was completely resolved. He was discharged after a follow-up with a good recovery. (Cited 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 properties, 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 movement 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 cold and heat yin and yang.Li from Xuzhou presented with vomiting and diarrhea, having three to four bowel movements a day, with urgency and heaviness in the abdomen, and red and white sticky mucus. After a year of illness and various treatments, he came to Beijing and was introduced to me for diagnosis. His pulse was wiry and slippery, and his pressure was 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 is treated, either cold is treated with heat or heat with cold, it will not be effective. When cold and heat are used together, 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 seven pieces.After taking six doses, the 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 advance and retreat, characterized by mixed cold and heat symptoms. Symptoms such as “thirst, qi rising to the heart, heat and pain in the heart, and hunger without desire to eat” can occur. Due to the mixed cold and heat, with upper heat and lower cold, it may present as vomiting of roundworms and coldness in the hands and feet, 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 formula for treating mixed cold and heat in Jue Yin and roundworm syndrome. The use of Wu Mei soaked in vinegar benefits the yin and harmonizes the yang, with effects of harmonizing the liver, calming the stomach, restraining yin, 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 to treat vomiting. Ren Shen tonifies qi to strengthen the spleen, while Dang Gui nourishes blood to support the liver. The combination of these herbs expels cold and heat evils, harmonizes yin and yang, softens the liver, warms the lungs, and restrains roundworms, which is the purpose of this formula.Although the formula uses both cold and hot medicines, it is primarily composed of warming herbs, and the addition of Wu Mei provides astringent properties, making it effective for treating prolonged diarrhea due to mixed cold and heat. The use of rice and honey as sweeteners in the pills not only nourishes the stomach qi but also serves as bait to attract roundworms.Zhou, female, 36 years old, 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 stopped, and the patient felt at ease.However, due to severe bitterness in the mouth, there was still vomiting, and she reported not having a bowel movement for several days. The prescription was changed to Da Chai Hu Tang, and after taking it, she had multiple bowel movements and expelled several roundworms, leading to her recovery.Ma Huang Sheng Ma TangMa Huang Sheng Ma Tang treats exterior evils trapped internally, with obstructed qi mechanism, upper heat and lower cold, and disharmony of yin and yang. Due to the internal trapping of yang evils, the originally floating pulse changes to a sinking and slow pulse. The pulse at the lower part of the wrist is not present, indicating that the qi mechanism is obstructed, leading to unfavorable pulse pathways.When the qi mechanism is obstructed, the yin and yang qi do not connect smoothly, causing coldness in the hands and feet. If the internal trapped yang evil lingers above, it leads to upper heat, resulting in throat discomfort and vomiting of pus and blood. The yang is trapped above and cannot govern below, leading to continuous diarrhea.This syndrome involves both yin and yang being affected, with the distinctions between deficiency and excess, cold and heat also becoming 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 disperse the trapped yang evil. Huang Qin and Shi Gao are used to 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 between the upper and lower. This formula combines tonifying and draining properties, allowing them to assist rather than contradict each other. Although it contains up to fourteen ingredients, it is not chaotic, as it is designed to treat mixed cold and heat syndromes, embodying precise significance.Li Mengru’s child had throat issues twice and diarrhea once, all treated successfully. Now, he suffers from a cold and heat illness that has persisted for over ten days without resolution, so he invited me for diagnosis. Upon pulse examination, he had already had diarrhea twice, with headaches, abdominal pain, and joint pain, and his throat was completely white and rotten, with purulent phlegm mixed with blood. The six pulses were floating, and both middle pulses were absent, with a weak response upon deep pressure, making it impossible to determine their exact number. He was thirsty and needed water, with little urination, and the pulse in the lesser yin was faint.After the diagnosis, I could not immediately prescribe, as the reasoning was unclear. I considered various prescriptions, including drainage decoctions, Huang Lian and Jiao Tang, and bitter wine decoctions, but none felt appropriate. I then proposed Gan Jiang Huang Qin Huang Lian Ren Shen Tang, but still felt it was not suitable. After pondering and unable to sleep due to the rain, I inquired with Li’s father: Has the patient sweated at all?He replied: No sweat 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 yin. I said: I understand now. This is a case for Ma Huang Sheng Ma Tang. The patient’s pulse is weak and easily disturbed, with a history of throat issues, indicating a constitution of lower deficiency and upper heat. The new illness of Tai Yang cold damage, combined with excessive purging, has not resolved the exterior evil, leading to internal heat and triggering the old throat disease, hence the white rot and mixed pus and blood in the throat.The weak spleen and heavy dampness, combined with excessive purging, have led to watery diarrhea, with water flowing to the large intestine, hence the little urination. The upper jiao is hot, leading to thirst; the exterior evil has not resolved, hence the cold and heat headaches and joint pains persist; and being trapped internally, the limbs are cold. After the excessive purging, qi and blood gather in the interior, leading to a weak yang pulse; the fluids are directed downwards, hence the yin pulse is also closed off.This formula includes Gui Zhi Tang with Ma Huang added, which releases the exterior and induces sweating, while Fu Ling, Bai Zhu, and Gan Jiang transform water and benefit urination, thus stopping diarrhea; Dang Gui assists in blood circulation and unblocking the pulse, while Huang Qin, Zhi Mu, and Shi Gao reduce inflammation and clear heat, while also generating fluids; Sheng Ma detoxifies the throat, while Yu Zhu (Wei Rui) expels pus and blood, and Tian Dong clears phlegm and pus.Tomorrow, this formula can be taken as prescribed. Li still suspected there might be signs of failure, 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 obstruction, not yang deficiency. Adding Ren Shen would hinder the expulsion of inflammation and detoxification, so it is better not to add it. The classic formula should not be altered. Eventually, the patient recovered. (Cited 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 that occurs with upper heat and lower cold, leading to symptoms of “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 upper heat, while Gan Jiang warms the spleen to dispel cold, and Ren Shen tonifies the spleen to replenish deficiency. This formula uses both cold and hot medicines, with bitter descending and spicy opening properties, 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.Yu, male, 29 years old. During the hot summer months, he indulged in cold foods, leading to alternating vomiting and diarrhea, with vomiting more 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 in the upper and cold dampness in the lower, 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 instruct to add a bowl of fresh ginger juice to the decoction.After one dose, the vomiting stopped, and the illness was cured.The mixed cold and heat formulas in the Treatise on Cold Damage represent a significant innovation in formula studies by Zhang Zhongjing. Their scientific value is very high, and we should inherit and promote them well. The seven formulas discussed above, while all harmonizing yin and yang and resolving 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.
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