Overview of Principles The spleen governs transportation and transformation, ascending is its natural order, while the stomach governs reception, descending is its harmony. The spleen and stomach work together, maintaining balance in ascending and descending, facilitating endless generation and transformation. However, when damp-heat afflicts the spleen and stomach, whether due to external pathogens or internal injury from diet and overwork, it is attributed to the failure of the spleen and stomach to regulate their ascending and descending functions. As noted by the famous Qing Dynasty physician Xue Shengbai in his “Treatise on Damp-Heat Diseases”: “Injury to the Taiyin leads to dampness and stagnation, and when external pathogens invade, they interact with internal conditions, resulting in damp-heat… However, overwork injures the spleen, leading to deficiency, while dampness and stagnation are in excess.” If treatment solely relies on bitter and cold herbs to clear heat, it may further damage the spleen yang, causing the pathogen to linger. Conversely, using warming and drying methods to eliminate dampness may exacerbate heat. Given that damp-heat is sticky and obstructive, it is not easily resolved. Therefore, a combination of bitter and pungent flavors is necessary, as the pungent flavor can open and circulate, while the bitter flavor can drain and descend. This combination allows for drainage while also promoting opening, ensuring that the pungent does not harm yin and the bitter does not damage yang, thus achieving a synergistic effect to clear heat, eliminate dampness, and restore the function of the middle jiao.Diagnostic and Treatment Patterns Damp-heat stagnates in the middle jiao, creating a turbid and sticky environment. When qi is obstructed, it leads to distension and pain; when stomach qi rebels, it causes vomiting; when spleen qi fails to ascend, it results in diarrhea; and when it manifests externally, it presents as heat. Therefore, in clinical diagnosis, attention should be paid to symptoms such as epigastric distension, stomach pain, vomiting, diarrhea, and low fever, or accompanying symptoms like chest and epigastric fullness, poor appetite, nausea, bitter and sticky mouth, little thirst, sour vomiting, irritability, body heat without relief, and unproductive sweating. The stool may be loose or constipated, urine may be short and yellow, and the pulse may be slippery or rapid. However, it is essential to examine the tongue; if the tongue coating is white and greasy, despite the presence of epigastric distension or pain, it indicates damp obstruction, and only pungent opening is appropriate, not bitter draining. A yellow and greasy coating (at least slightly yellow) must be observed to confirm the presence of damp-heat, warranting the use of the bitter and pungent method for treatment. The combination of pungent opening and bitter descending herbs commonly used in clinical practice includes bitter cold herbs like Huang Lian (Coptis), Huang Qin (Scutellaria), and Zhi Zi (Gardenia); and pungent warm herbs like Gan Jiang (Dried Ginger), Ban Xia (Pinellia), Wu Zhu Yu (Evodia), Hou Po (Magnolia Bark), and Zi Su (Perilla). Among them, Huang Lian and Hou Po together excel in resolving distension; Huang Lian and Gan Jiang are effective in stopping diarrhea and alleviating pain; Huang Lian and Wu Zhu Yu are good for stopping sourness; Huang Lian and Ban Xia focus on stopping vomiting; and Huang Lian and Zi Su are effective in relieving depression and reducing heat. However, it is crucial to assess the relative severity of damp-heat, the location of the disease, and whether it involves the upper or lower jiao to clarify priorities and focus on key points. If heat predominates over dampness, presenting with fever, thirst, irritability, short yellow urine, and constipation with a yellow and greasy tongue coating, the treatment should primarily focus on bitter draining to clear the stomach, with pungent opening to assist the spleen. If dampness predominates over heat, presenting with chest and epigastric fullness, poor appetite, loose stools, nausea, vomiting, and a white, thick, slightly yellow tongue coating, the treatment should primarily focus on pungent opening to benefit the spleen, with bitter draining to clear the stomach as a supplement. Commonly used formulas include the Xie Xin Tang (Drain the Heart Decoction, excluding Da Huang Huang Lian Xie Xin Tang), Xiao Xian Xiong Tang (Minor Chest Distress Decoction), as well as Wang’s Lian Po Decoction, Su Ye Huang Lian Decoction, Zuo Jin Wan (Left Metal Pill), and Lian Li Tang. The specific application should vary according to the patient’s condition, possibly incorporating methods to transform phlegm, guide stagnation, regulate qi, or tonify deficiency. It is essential to grasp the scope of application and adapt to changes as needed.Case Study 1 Yang, female, 38 years old. The patient has experienced diarrhea accompanied by epigastric fullness and poor appetite for over a year, with loose stools occurring 2-3 times daily, occasionally mixed with mucus. Slightly eating cold or greasy foods increases the frequency of bowel movements, and after defecation, there is a lingering feeling of incompleteness. She also reports dull pain in the lower right abdomen, abdominal distension, fatigue, pale complexion, bitter mouth, and short yellow urine. The tongue is pale with a white, thick, slightly yellow coating, and the pulse is slow and slightly rapid. Diagnosis: Spleen and stomach qi deficiency with internal damp-heat. Treatment principle: Warm and regulate spleen yang, dry dampness, and clear heat. Prescription: Modified Ban Xia Xie Xin Tang. Ban Xia 9g, Huang Lian 9g, Huang Qin 6g, Gan Jiang 6g, Zhi Gan Cao (Honey-fried Licorice) 6g, Dang Shen (Codonopsis) 12g, Guang Mu Xiang 9g, Zhi Ke (Bitter Orange) 9g, Jiao Shan Zha (Fried Hawthorn) 15g. Second diagnosis: After taking 5 doses, the patient reports that the epigastric fullness and bowel sounds have resolved, appetite has slightly increased, and there is no mucus in the stools, but the loose stools and abdominal pain remain unchanged. The prescription was adjusted by reducing Mu Xiang and Zhi Ke, and adding Cang Zhu 15g and Chao Bai Bian Dou (Fried Hyacinth Bean) 30g. A total of 5 doses were given. The patient subsequently received treatment with Lian Li Tang for follow-up and recovered. Commentary: Diarrhea can have multiple causes, and treatment methods vary. This patient had spleen deficiency with damp obstruction, leading to heat transformation in the intestines. Clearing heat would damage spleen yang, while drying dampness would exacerbate heat. Therefore, Ban Xia Xie Xin Tang was used to open and drain, regulating the qi mechanism to resolve damp-heat, with the addition of Mu Xiang, Zhi Ke, and Shan Zha to harmonize the stomach and aid digestion. This promotes the movement of qi and dampness, followed by Lian Li Tang for follow-up, focusing on warming and regulating spleen yang while clearing residual pathogens.Case Study 2 Xu, male, 52 years old. The patient has experienced stomach pain for over 2 years, with intermittent episodes. In the past two weeks, the pain has worsened, and he feels a sensation of obstruction in the throat when eating, with difficulty swallowing, chest fullness, frequent belching, bitter and dry mouth, nausea, reduced appetite, and constipation. The tongue coating is thin, yellow, and greasy, and the pulse is wiry and slippery. He has taken multiple doses of qi-regulating and phlegm-resolving herbs without effect and suspects he has esophageal cancer. An endoscopy revealed mild inflammation of the squamous epithelium of the esophagus. Diagnosis: Damp-heat obstructing the middle jiao, with qi stagnation. Treatment principle: Pungent opening and bitter descending to relieve obstruction and alleviate pain. Prescription: Modified Zuo Jin Wan combined with Si Ni San. Wu Zhu Yu 12g, Huang Lian 6g, Huang Qin 3g, Chai Hu 9g, Bai Shao (White Peony) 12g, Zhi Ke 12g, Yu Jin (Curcuma) 12g, Zi Su Gen (Perilla Stem) 9g, Ban Xia 9g, Gan Jiang 3g, Zhi Gan Cao 3g. Second diagnosis: After taking 3 doses, the patient reports relief from stomach pain, chest fullness, and throat obstruction. Continuing with the original prescription for 5 more doses, the patient’s stomach pain disappeared, and he resumed normal eating. Follow-up treatment with Xiang Sha Liu Jun Zi Tang was given, and after a month of medication, all symptoms resolved. Commentary: The patient’s stomach pain, chest fullness, and throat obstruction are indicative of damp-heat stagnation in the heart area, with qi failing to ascend and descend. Although he had previously taken phlegm-resolving and liver-regulating herbs, they were not suitable for his condition. Only the combination of bitter and pungent herbs can smooth the qi mechanism and resolve damp-heat to alleviate pain. In this formula, Zuo Jin Wan combined with Zhi Ke and Gan Jiang allows for drainage while promoting opening, relieving fullness and assisting yang qi transformation; Si Ni San combined with Yu Jin, Zi Su Gen, and Ban Xia regulates the liver and qi, descending and harmonizing the stomach. This aligns with the principle that “to clear heat, one must transform dampness; to transform dampness, one must smooth the qi mechanism,” thus achieving excellent results.Case Study 3 Zhang, female, 43 years old. The patient has a weak constitution, experiencing abdominal fullness and loose stools for over 2 months, with the condition worsening in the summer. She also has vomiting, low fever without sweating, increased fullness, and a lack of appetite. The tongue is pale with a yellow, greasy coating, and the pulse is wiry and thin. She had previously taken Da Yuan Decoction for treatment, but her condition did not improve. Diagnosis: Stomach heat with intestinal cold, obstructed by summer dampness. Treatment principle: Pungent opening, bitter descending, and aromatic damp-transforming. Prescription: Modified Ban Xia Xie Xin Tang. Ban Xia 12g, Huang Lian 6g, Huang Qin 6g, Gan Jiang 6g, Dang Shen 12g, Zhi Gan Cao 6g, Huo Xiang (Agastache) 12g, Fresh He Ye (Lotus Leaf) 30g. Second diagnosis: After taking 1 dose, the patient reports reduced vomiting; after 2 doses, vomiting stopped, but loose stools and poor appetite persist. The application of Shen Ling Bai Zhu San was modified to strengthen the spleen and transform dampness for follow-up. Commentary: Vomiting can be due to excess heat or dampness, and treatment should focus on expelling pathogens and harmonizing the stomach. However, this patient has a history of spleen deficiency and loose stools, compounded by summer dampness, leading to a mix of cold and heat. The treatment should combine bitter and pungent herbs with aromatic damp-transforming herbs. In the formula, Huang Qin and Huang Lian clear heat to eliminate stomach heat; Gan Jiang and Ban Xia open and warm to dry dampness; Dang Shen and Zhi Gan Cao tonify the spleen and stomach deficiency; and Huo Xiang and Fresh He Ye provide aromatic damp-transforming properties, lightly clearing and guiding the pathogens. The entire formula addresses both deficiency and excess, treating the spleen and stomach together, promoting yang and moving qi, resolving damp-heat without the pitfalls of mixed deficiency and excess. This ensures the stomach qi is harmonized, vomiting ceases, and subsequent treatment focuses on strengthening the spleen and supporting the body’s overall recovery.
Editor: Zhang ChiReview: Liu YangFinal Review: Gao Fuguo