TCM Book Club Issue 1243
Daily updates to accompany the growth of TCM practitioners
IIntroduction：The Banxia Xiexin Decoction harmonizes yin and yang and is effective in treating fullness; the Ganjiang, Huangqin, Huanglian, and Renshen Decoction harmonizes yin and yang and is effective in treating vomiting; the Wumei Pill harmonizes yin and yang and is effective in treating roundworms; the Mahuang Shengma Decoction harmonizes yin and yang and is effective in inducing sweating; the Fuzhu Xiexin Decoction harmonizes yin and yang and is effective in supporting yang and stopping sweating.（Editor/Zhang Yajuan）
Overview of Mixed Cold and Heat Formulas
Author/Liu Duzhou
The formulas in the Treatise on Cold Damage that utilize both cold and heat medicines can be summarized as follows: Chaihu Guizhi Ganjiang Decoction, Zhizi Ganjiang Decoction, Banxia Xiexin Decoction, Fuzhu Xiexin Decoction, Huanglian Decoction, Wumei Pill, Mahuang Shengma Decoction, and Ganjiang Huangqin Huanglian Renshen Decoction, totaling eight formulas. The Chaihu Guizhi Ganjiang Decoction has been discussed, while the Zhizi Ganjiang Decoction will be briefly mentioned. The Shengjiang Xiexin Decoction and Gancao Xiexin Decoction can be represented by the Banxia Xiexin Decoction. Below is a brief description of each formula.
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Banxia Xiexin Decoction
Banxia Xiexin Decoction is a formula that combines cold and heat medicines. It is a representative formula for harmonizing the cold and heat evils of the spleen and stomach. The Shengjiang Xiexin Decoction and Gancao Xiexin Decoction are variations based on its ingredients. It is used to treat a syndrome characterized by disharmony of the spleen and stomach qi, fullness 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 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, Banxia Xiexin Decoction is used to bitterly descend, pungently open, harmonize the stomach, and clear phlegm as the main treatment.
Banxia Xiexin Decoction consists of Banxia (Pinellia), Huangqin (Scutellaria), Huanglian (Coptis), Renshen (Ginseng), Zhi Gan Cao (Honey-fried Licorice), and Dazao (Jujube). This syndrome is characterized by poor ascending and descending of qi, obstruction in the middle jiao, and heat generated due to the stomach qi not descending. Therefore, the bitter cold properties of Huangqin and Huanglian are used to descend, while the pungent heat of Ganjiang is used to warm the cold generated by the spleen qi not ascending, leading to borborygmus and diarrhea. Phlegm and fluid disturb the stomach, causing vomiting, so Banxia is used to descend and harmonize the stomach to stop vomiting; the weakness of spleen and stomach qi prevents the regulation of ascending and descending, hence Renshen, Zhi Gan Cao, and Dazao are used to tonify. This formula clears the upper and warms the lower, bitterly descends, pungently opens, and uses both 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 Xiexin Decoction to harmonize. However, Xiao Chaihu Decoction treats the liver and gallbladder, while Xiexin Decoction treats the spleen and stomach. Both syndromes share the characteristic of poor ascending and descending of qi, and both are 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 a crucial pathway for the movement of qi, if the communication of yin and yang is obstructed, it leads to fullness. Fullness is a blockage, where qi stagnates and does not move, neither blood nor water, and is not solid, hence it feels moist upon pressing, but is merely qi fullness.
Zhang, male, 36 years old. Has a history of alcohol consumption, presents with fullness below the heart, occasional vomiting, and unformed stools, three to four times a day, with no effect from various treatments. Pulse is wiry and slippery, 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 in between. Phlegm and fluid cause the stomach qi to reverse, leading to vomiting; spleen deficiency and cold qi lead to unformed stools, and disharmony of middle qi leads to fullness below the heart.
Prescription: Banxia 12g, Ganjiang 6g, Huangqin 6g, Huanglian 6g, Dangshen 9g, Zhi Gan Cao 9g, Dazao 7 pieces.
After taking one dose, the stools expelled a large amount of white, sticky phlegm, and vomiting decreased by seventy percent; after another dose, both fullness and vomiting decreased, and after taking two more doses, the illness was cured.
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Fuzhu Xiexin Decoction
Fuzhu Xiexin Decoction 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, then the transformation of defensive yang is insufficient, losing its warming and protective function, leading to chills and sweating, hence termed as upper heat and lower cold syndrome. The treatment uses Fuzhu Xiexin Decoction to clear heat fullness and warm yang qi.
Fuzhu Xiexin Decoction consists of Dahuang (Rhubarb), Huanglian (Coptis), Huangqin (Scutellaria), and Pao Fuzhu (Processed Aconite). In this formula, Dahuang, Huanglian, and Huangqin are soaked in boiling water to treat the heat fullness in the qi level, while Fuzhu 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 heat, the soaking of the three huangs and the separate decoction of Fuzhu emphasize the support of yang as the main action, with heat clearing as a secondary action.
A student from Ningxiang had an external condition for several months, repeatedly treated without improvement. During the consultation, he reported: fullness in the chest, heat in the upper body with sweating, and chills below the waist, while it was June. Upon reviewing the previous prescriptions, they were all common clearing and purging medicines that did not address the root cause. The tongue coating was light yellow, and the pulse was wiry.
Diagnosis: This is a syndrome of external invasion with cold and heat mixed, affecting the upper and lower 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 Huanglian Decoction.
Prescription: Huanglian 9g, Ganjiang 9g, Guizhi 9g, Banxia 9g, Renshen 6g, Zhi Gan Cao 6g, Dazao 7 pieces.
After taking six doses, the year-long illness was cured.
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Wumei Pill
Wumei Pill is the main formula for treating the Jueyin disease. When the disease reaches the Jueyin, 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, hunger without desire to eat,” etc. Due to the mixed cold and heat, upper heat and lower cold, it can manifest as vomiting roundworms and cold extremities, termed as “roundworm syndrome,” all of which can be treated with Wumei Pill.
Wumei Pill consists of Wumei (Mume), Xixin (Asarum), Ganjiang (Dried Ginger), Huanglian (Coptis), Fuzhu (Aconite), Danggui (Angelica), Shuzhizhi (Sichuan Pepper), Guizhi (Cinnamon Twig), Renshen (Ginseng), and Huangbai (Phellodendron). This formula is the main treatment for the mixed cold and heat of Jueyin and roundworm syndrome. The use of Wumei soaked in vinegar benefits the yin and harmonizes the yang, having the effect of harmonizing the liver and calming the stomach, astringing yin and stopping thirst. Fuzhu, Ganjiang, and Guizhi warm the channels and support yang to overcome cold; Chuanjiao and Xixin are pungent and warm, capable of unblocking yang and breaking yin, and can kill roundworms. Huanglian and Huangbai are bitter and cold to clear heat and vexation, and subdue roundworms to treat vomiting. Renshen tonifies qi to strengthen the spleen, and Danggui 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 purpose of the formula. Although both cold and heat are used in the formula, the warming herbs are predominant, and the sourness of Wumei helps to astringe and solidify, thus treating the long-standing diarrhea caused by 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.
A woman 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. Diagnosed as Jueyin disease with “roundworm syndrome,” the formula was modified from Wumei Pill to a decoction, taken in three doses. After two doses, the pain ceased and she 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 Dazhuohua Decoction, and after taking it, she had a bowel movement with many roundworms, and from then on, she recovered.
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Mahuang Shengma Decoction
Mahuang Shengma Decoction treats the exterior evil trapped inside, with obstructed qi, upper heat and lower cold, and disharmony of yin and yang. Due to the internal entrapment of yang evil, the originally floating and rapid pulse changes to a sinking and slow pulse. When palpating the lower pulse, it does not reach the depth, indicating that the qi is obstructed, and the pulse pathway is not smooth. When the qi is obstructed, the yin and yang do not connect smoothly, leading to cold extremities. If the internal entrapment of yang evil lingers above, it causes 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, and the distinctions between deficiency and excess, cold and heat are also blurred, making it a difficult syndrome to treat. However, Zhongjing’s Mahuang Shengma Decoction 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.
Mahuang Shengma Decoction consists of Mahuang (Ephedra), Shengma (Cimicifuga), Danggui (Angelica), Zhimu (Anemarrhena), Huangqin (Scutellaria), Weirui (Ophiopogon), Shaoyao (Paeonia), Tiandong (Asparagus), Guizhi (Cinnamon Twig), Fuling (Poria), Zhi Gan Cao (Honey-fried Licorice), Shigao (Gypsum), Baizhu (Atractylodes), and Ganjiang (Dried Ginger). The formula uses a larger dosage of Mahuang and Shengma to expel the trapped yang evil downwards, while Huangqin and Shigao clear the heat from the lungs and stomach. Guizhi and Ganjiang warm the middle to dispel cold, while Danggui and Shaoyao nourish blood to harmonize yin; Zhimu, Tiandong, and Weirui nourish yin and lower fire to harmonize yang; Zhi Gan Cao and Fuling not only strengthen the spleen and benefit qi to stop diarrhea but also harmonize the stomach and regulate the ascending and descending. This formula combines tonifying and purging herbs to work together without conflict. 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, and he invited me for a consultation. 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 the middle two were not palpable, and even with heavy pressure, they were slightly slow, making it impossible to determine their exact number. He was thirsty and needed water, with little urination, and the pulse of 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 Pus Drainage Decoction, Huanglian Ejiao Decoction, and Bitter Wine Decoction, but none felt appropriate. I then proposed Ganjiang Huangqin Huanglian Renshen Decoction, but it still felt unsatisfactory. After further contemplation, I inquired about the patient’s sweating history. The answer was that there had been no sweating at all. He had taken purgatives three times, leading to frequent watery diarrhea, and the pulse suddenly changed to a yin pulse. I concluded that this was a case of Mahuang Shengma Decoction. The patient’s pulse was weak and easily moved, with a constitution prone to throat issues. The new illness was a result of solar cold damage, and the previous purgation had not resolved the exterior evil, leading to internal heat and aggravating the old throat condition, resulting in the white rot and mixed pus and blood. The spleen was weak and damp, and the excessive purging led to watery diarrhea, causing the small intestine to be unresponsive, hence the little urination. The upper jiao was overheated, leading to thirst; the exterior evil had not resolved, hence the cold and heat headaches and joint pains persisted; and being trapped internally led to cold extremities. After the excessive purging, qi and blood gathered in the interior, leading to a weak yang pulse; the fluids were directed downwards, hence the yin pulse was also obstructed. The composition of this formula includes Guizhi Decoction with Mahuang added, which resolves the exterior and induces sweating, while Fuling, Baizhu, and Ganjiang transform water to benefit urination, thus stopping diarrhea; using Danggui helps to move blood and open the pulse, while Huangqin, Zhimu, and Shigao clear inflammation and heat, and also generate fluids; Shengma resolves the toxicity in the throat, while Weirui clears pus and blood, and Tiandong clears phlegm and pus. The next day, this formula can be taken as prescribed. Li was still concerned about the possibility of adverse reactions, fearing that the warmth of Mahuang and Guizhi would be too much, and wanted to add Renshen. I advised against it, stating that the weak and cold pulse indicated trapped yang, not yang deficiency. Adding Renshen would not be as effective as adhering to the original formula without modifications. Eventually, he recovered.
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Ganjiang Huangqin Huanglian Renshen Decoction
Ganjiang Huangqin Huanglian Renshen Decoction 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.
Ganjiang Huangqin Huanglian Renshen Decoction consists of Ganjiang (Dried Ginger), Huangqin (Scutellaria), Huanglian (Coptis), and Renshen (Ginseng). In this formula, Huangqin and Huanglian are used to drain the upper heat, while Ganjiang warms the spleen to dispel cold, and Renshen tonifies the spleen to replenish deficiency. This formula employs both cold and heat, bitterly descending and pungently opening, and Ganjiang can also guide Huangqin and Huanglian, preventing the heat evil from causing rejection. Therefore, some commentators believe this formula also treats “fire counterflow” vomiting.
Y, male, 29 years old. During the hot summer, he indulged in cold foods, leading to alternating vomiting and diarrhea, with vomiting being more frequent. He also experienced irritability and bitterness in the mouth. His pulse was rapid and slippery, and although his tongue coating was yellow, it was moist.
Diagnosis: This is a case of heat in the upper and cold dampness in the lower, and with the alternating vomiting and diarrhea, how could the stomach qi not be harmed? This is a syndrome of middle deficiency with mixed cold and heat.
Prescription: Huangqin 6g, Huanglian 6g, Renshen 6g, Ganjiang 3g, and instruct to add a bowl of fresh ginger juice to the decoction.
One dose was sufficient to stop vomiting and cure the illness.
The mixed cold and heat formulas in the Treatise on Cold Damage 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, Banxia Xiexin Decoction harmonizes yin and yang and is effective in treating fullness; Ganjiang, Huangqin, Huanglian, and Renshen Decoction harmonizes yin and yang and is effective in treating vomiting; Wumei Pill harmonizes yin and yang and is effective in treating roundworms; Mahuang Shengma Decoction harmonizes yin and yang and is effective in inducing sweating; Fuzhu Xiexin Decoction harmonizes yin and yang and is effective in supporting yang and stopping sweating. These all reflect the TCM principle of treating according to the syndrome.
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