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Source / Liu Duzhou
The formulas for treating mixed cold and heat in the Shang Han Lun 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 combines cold and hot herbs. 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 variations based on it. It is used to treat a syndrome characterized by disharmony of the spleen and stomach qi, with fullness below the heart and phlegm retention.Due to the presence of phlegm, it also includes symptoms of vomiting. Clinical observations indicate that this syndrome may present with fullness 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 generation of phlegm and fluid. Therefore, Ban Xia Xie Xin Tang is used to bitterly descend and acrid disperse, harmonizing the stomach and clearing phlegm as the 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, the bitter cold properties of Huang Qin and Huang Lian are used to descend it, while the acrid warm properties of Gan Jiang (Dried Ginger) are used to warm it, as the coldness of the spleen qi leads to borborygmus and diarrhea. Thus, Ban Xia is used to descend the rebellious qi 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 acrid dispersion, combining cold and heat to harmonize the spleen and stomach, making it the main formula for treating fullness below the heart.【Note】The “fullness below the heart” refers to a location that is half superficial and half internal (below the chest and 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 the characteristic of poor ascending and descending of 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 “fullness below the heart” 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 a solid mass, hence pressing it feels moist, but it is merely qi fullness.Mr. 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. The pulse is wiry and slippery, and the tongue coating is white.Diagnosis: The syndrome is due to alcohol harming the spleen and stomach, with disordered ascending and descending, and phlegm generated from within. Phlegm and fluid cause the stomach qi to rebel, leading to vomiting, while spleen deficiency and cold qi result in unformed stools, and disharmony of middle qi leads to 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, the stools expelled a large amount of white, sticky phlegm, and vomiting reduced by 70%; 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, accompanied by symptoms of “chills and sweating.” Generally, fever easily leads to sweating, while chills do not easily lead to sweating. However, when chills and sweating occur simultaneously, 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 chills and sweating, hence termed 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 herbs, the soaking of the three yellow herbs and the separate decoction of Fu Zi emphasize the support of yang while clearing heat as a secondary action.A student from Ningxiang had an external pathogen for several months and was repeatedly treated without improvement. During the follow-up, he reported fullness in the chest, heat in the upper body with sweating, and aversion to wind below the waist, despite it being June. Upon reviewing the previous prescriptions, they were all common clearing and draining herbs that did not address the root cause. The tongue coating was light yellow, and the pulse was wiry. He was given Fu Zi Xie Xin Tang, and after two days, he returned for a follow-up, stating that the symptoms had significantly improved.(Cited from “Dun Yuan: Medical Cases”)Huang Lian TangHuang Lian Tang syndrome 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 causes abdominal pain or diarrhea. The treatment with Huang Lian Tang employs both cold and warm herbs, with sweet and bitter properties 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 the rebellious qi to stop 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.Mr. Li from Xuzhou suffered from vomiting and diarrhea, with three to four bowel movements a day, experiencing urgency and heaviness in the abdomen, with red and white sticky mucus. After a year of various treatments, he came to Beijing due to work and was introduced to me for diagnosis. The pulse was wiry and slippery, and the 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 aspect is treated, either cold is treated with heat or heat with cold, it will not be effective. When cold and heat are both present, the method should follow 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 a total of 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 retreat, characterized by mixed cold and heat symptoms such as “thirst, qi rising to the heart, heart pain and heat, hunger without desire to eat,” etc. Due to the mixed cold and heat, with heat above and cold below, it may present as vomiting of roundworms and coldness in the hands and feet, termed “roundworm cold 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 used to treat the mixed cold and heat of Jue Yin and roundworm cold 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, stopping thirst, and settling roundworms. 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, used to clear heat and vexation, and subdue 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 settles 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. The use of rice and honey as sweeteners in the pill not only nourishes the stomach qi but also serves as bait to attract roundworms.Ms. Zhou from Shangzhai, Gansu, suddenly experienced paroxysmal acute pain in the upper right abdomen, with cold limbs, profuse cold sweat, and vomiting. She had a history of roundworms. Examination revealed “worm spots” on her face, wiry and strong pulse, and a crimson tongue with dark coating. Diagnosis: This is a case of Jue Yin disease with “roundworm cold syndrome.” 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, there was still vomiting, and she reported not having a bowel movement for several days. A dose of Da Chai Hu Tang was then used, resulting in a significant bowel movement with many roundworms, leading to her recovery.Ma Huang Sheng Ma TangMa Huang Sheng Ma Tang treats exterior evils trapped internally, with obstructed qi, 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 deep and slow one. The pulse in the lower part is not absent, 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 trapped above 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 becoming unclear, making it difficult 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 while 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 larger doses of Ma Huang and Sheng Ma are used to disperse the trapped yang evil, while Huang Qin and Shi Gao clear the heat from the lungs and stomach. Gui Zhi and Gan Jiang warm the middle to dispel cold, while 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 but also calm the stomach and harmonize the center, facilitating the connection between the upper and lower. This formula combines tonifying and draining herbs, allowing them to assist rather than contradict each other. Although it contains up to fourteen ingredients, it is not chaotic, serving a precise purpose in treating mixed cold and heat syndromes.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. I was invited to diagnose. 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 to 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 barely detectable.After the diagnosis, I could not immediately prescribe a formula, as the reasoning was unclear. I considered various formulas such as drainage decoction, Huang Lian and Ejiao decoction, and bitter wine decoction, 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 the Li residence and could not sleep due to contemplation. 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 deep. I said: I understand now. This is a case of Ma Huang Sheng Ma Tang syndrome. The patient’s pulse was weak and easily moved, with a history of throat issues, indicating a constitution of lower deficiency and upper heat. The new illness was due to solar cold damage and mismanagement of purging, leading to the exterior evil not retreating, with internal heat descending, triggering the old throat disease, resulting in white rot and mixed pus and blood in the throat.The weak spleen and heavy dampness constitution, combined with excessive purging, led to watery diarrhea, with water flowing to the large intestine, hence the little urination. The upper jiao was hot, leading to thirst; the exterior evil had not retreated, hence the cold and heat headaches and joint pains persisted; being trapped internally, the limbs were cold; after excessive purging, qi and blood gathered internally, leading to weak yang pulses; and the fluids were directed downwards, causing the yin pulses to also become dormant.This formula includes Gui Zhi Tang with added Ma Huang, thus releasing the exterior and inducing sweating. It includes Fu Ling, Bai Zhu, and Gan Jiang to transform water and benefit urination, thus stopping diarrhea; using Dang Gui to assist in blood circulation and pulse regulation, 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, and Yu Zhu (Wei Rui) to expel pus and blood, and 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 help in resolving inflammation and detoxifying. It is better not to add it, as the classic formulas should not be altered. He eventually 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 “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 dispel cold, and Ren Shen strengthens the spleen to tonify deficiency. This formula employs both cold and hot herbs, with bitter descent and acrid dispersion, and Gan Jiang can also guide Huang Qin and Huang Lian, preventing the heat evil from causing rejection.Mr. 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 a bitter mouth. The pulse was rapid and slippery, and although the tongue coating was yellow, it was 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 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 Shang Han Lun represent a significant innovation in formula science 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; 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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