Author| Xue Bi Editor| Chun Feng Reviewer| Xiao Ye
What should be done when cold and heat are mixed?
Traditional Chinese Medicine emphasizes “Four Examinations and Eight Principles”. The so-called “Four Examinations” refers to what we commonly say as “observation, listening, inquiry, and pulse-taking”, while the “Eight Principles” refers to “yin, yang, exterior, interior, cold, heat, deficiency, and excess”, which belongs to the category of basic theoretical knowledge in TCM.
In daily life, we often hear doctors say that a person’s constitution is biased towards cold or heat, or that the nature of a certain medicine is cold or hot.
The cold and heat referred to in TCM are two principles for distinguishing the attributes of diseases in the Eight Principles. Simply put, they represent the two attributes of cold and heat, which arise from “yang excess leads to heat” and “yin excess leads to cold“.
In response to cold and heat, our treatment principle is “treat cold with heat” and “treat heat with cold”. Nowadays, people’s constitutions have become more complex and diverse compared to ancient times, and many people exhibit a mixed condition of cold and heat, which refers to the pathological change where cold and heat evil qi coexist, leading to simultaneous manifestations of cold and heat.
In life, have you encountered phenomena such as: frequent acne on the face, easy occurrence of oral ulcers, feeling heat when eating fried and greasy foods, sore throat, dry mouth, and bitter taste?
At the same time, they also feel cold, with hands and feet being icy, unable to tolerate air conditioning, needing to wear thicker clothes or cover with thick blankets to keep warm, otherwise they easily catch a cold, and cannot drink ice water or eat cold foods, as it makes their stomach uncomfortable.
Do you wonder whether this person’s condition belongs to cold or heat? If it is heat, will the use of heat-clearing medicines be intolerable for the patient? If it is cold, will the use of warming yang medicines exacerbate the symptoms of heat?
In fact, the medical sage Zhang Zhongjing used his wisdom to solve these problems. Today, let us take a look at what he elaborated in the “Treatise on Cold Damage” regarding the treatment of mixed cold and heat—Ma Huang Sheng Ma Decoction.
Ma Huang Sheng Ma Decoction
Ma Huang Sheng Ma Decoction is found in the “Treatise on Cold Damage, Chapter on Differentiating and Treating Jueyin Disease”. The text records: “After six or seven days of cold damage, after a major purge, the pulse is deep and slow, hands and feet are cold, the lower pulse is absent, the throat is not smooth, expectoration of pus and blood, and continuous diarrhea are difficult to treat; Ma Huang Sheng Ma Decoction is the main treatment for this.”
The original text regarding the dosage states: “Ma Huang (Ephedra) 2.5 liang (remove joints), Sheng Ma (Cimicifuga) 1.1 liang, Dang Gui (Angelica) 1.1 liang, Zhi Mu (Anemarrhena) 18 zhu, Huang Qin (Scutellaria) 18 zhu, Wei Rui (Asparagus) 18 zhu, Shao Yao (Paeonia) 6 zhu, Tian Men Dong (Asparagus) 6 zhu (remove heart), Gui Zhi (Cinnamon Twig) 6 zhu, Fu Ling (Poria) 6 zhu, Gan Cao (Licorice, roasted) 6 zhu, Shi Gao (Gypsum, crushed, wrapped in cotton) 6 zhu, Bai Zhu (Atractylodes) 6 zhu, Gan Jiang (Dried Ginger) 6 zhu.”
The pathogenesis treated by Ma Huang Sheng Ma Decoction is due to exterior syndrome mismanaged, spleen qi being damaged, lung losing regulation, evil qi entering Jueyin, leading to qi mechanism disorder, and fire being constrained. In summary, the basic pathogenesis is evil qi invading yang and causing stagnation.
We all know that the spleen is the “source of qi and blood transformation” and is responsible for transportation and transformation. The lung is the “official of the ministerial fire, regulating the outflow”. When the functions of both are impaired, it is easy to have qi mechanism disorder, leading to obstruction between upper and lower, manifesting as the syndrome of heat above and cold below.
After six or seven days of cold damage, if a major purge is used, it will damage the spleen yang, hence the appearance of symptoms such as “deep and slow pulse”, “cold hands and feet, absent lower pulse”, and “continuous diarrhea”, which are signs of deficiency of both qi and blood. However, these are not entirely manifestations of yang deficiency due to spleen yang damage.
After six or seven days of cold damage, when the evil qi reaches the stage of “two yin crossing completely” in Jueyin, if a major purge is used at this time, it will constrain the upward movement of ministerial fire, causing cold evil to accumulate, and the evil heat to sink into yin, burning the yin fluids, leading to symptoms of yin deficiency such as “throat not smooth, expectoration of pus and blood”.
Overall, this forms a syndrome of mixed deficiency and excess, heat above and cold below, with both yin and yang being deficient. Ma Huang Sheng Ma Decoction is precisely suitable for this condition.
As noted by the famous Qing Dynasty physician Wang Jinzang in the “Selected Notes on Ancient Formulas”:
“Gao (Glycyrrhiza), Qin (Scutellaria), and Zhi Mu (Anemarrhena) are bitter and cold, clearing and descending the fluids of the upper jiao; Shao Yao (Paeonia) and Tian Men Dong (Asparagus) are sour and bitter, drawing the fluids of the lower jiao; Fu Ling (Poria) and Gan Cao (Licorice) are sweet and bland, generating stomach fluids; Dang Gui (Angelica), Bai Zhu (Atractylodes), and Wei Rui (Asparagus) nourish the spleen to produce fluids.”
However, this ten-ingredient formula, while having harmonizing effects, cannot expel the heat evil from the yin portion, thus Ma Huang (Ephedra), Sheng Ma (Cimicifuga), Gui Zhi (Cinnamon Twig), and Gan Jiang (Dried Ginger) are used to enter the yin portion, combining with cold and cool medicines to transform the heat, so that the dryness in the upper can be eliminated and the cold qi in the lower can be resolved, thus alleviating the mixed evil of Jueyin.
In summary, the efficacy of Ma Huang Sheng Ma Decoction is as recorded in the “Lecture on the Treatise on Cold Damage”: “Expel the constrained heat, clear above and warm below”.
Application of Ma Huang Sheng Ma Decoction
I have a good case nearby, where the patient had a craving for rich and greasy foods, and emotional distress led to phlegm transforming into fire, qi stagnation transforming into fire, burning the fluids, resulting in acne on the face, and symptoms such as easy heat, dry mouth, and bitter taste, with obvious signs of excess heat and yin deficiency.
Later, he mistakenly used a large amount of heat-clearing medicines for treating facial acne, leading to damage to spleen yang, becoming intolerant to cold, feeling cold even in the hot summer, needing to cover with thick cotton blankets to sleep, and feeling bloated and uncomfortable in the stomach after eating even a little cold food, which belonged to the situation of deficiency cold and yang deficiency.
Overall, it was a case of coexisting excess heat and deficiency cold, with both yin and yang being deficient. After using five doses of Ma Huang Sheng Ma Decoction, the above symptoms were greatly alleviated.
But why do I say this formula is a “special prescription”? Compared to the other 112 formulas in the “Treatise on Cold Damage”, Ma Huang Sheng Ma Decoction has as many as 14 ingredients and is biased towards nourishing yin, which is contrary to the habit of Zhang Zhongjing using fewer types of medicines, larger quantities, and more yang properties.
Therefore, since the Qing Dynasty, Ke Yunbo and later generations have expressed “doubt” about Ma Huang Sheng Ma Decoction, believing it to be “a crude technique of later generations, definitely not a formula of Zhongjing”.
Thus, although this formula is effective, few people know the name Ma Huang Sheng Ma Decoction compared to other formulas for treating mixed cold and heat discussed in the “Treatise on Cold Damage”, so I want to introduce this formula to everyone.
In fact, the “Treatise on Cold Damage” also contains many famous formulas for treating heat above and cold below, such as Zhi Zi Gan Jiang Decoction, Gan Jiang Huang Qin Huang Lian Ren Shen Decoction, and Wu Mei Pill, etc.
These formulas also have differences; for example, Zhi Zi Gan Jiang Decoction targets the upper heat in the chest, Gan Jiang Huang Qin Huang Lian Decoction targets the upper heat in the stomach, and Wu Mei Decoction targets the upper heat in the liver and pericardium. The distinctions in these relationships of cold and heat need to be carefully analyzed and gradually considered by practitioners in clinical practice.
The content of this article is for reference only; non-professionals in TCM should not attempt to use the medicine.Original submission: cjcmmxinmeiti@126.com (email), chunfeng52566 (WeChat)