Treatment of Granulomatous Mastitis with Half-Yin and Half-Yang Syndrome

Abstract Granulomatous mastitis (GM) is a refractory chronic mastitis, which belongs to the category of “acne mammary abscess” and “ulcer” in Traditional Chinese External Medicine. According to yin-yang syndrome differentiation, the disease can be divided into yin syndrome, yang syndrome, and half-yin and half-yang syndrome. Among them, the theories and treatment of yin syndrome and yang syndrome are relatively comprehensive in Traditional Chinese External Medicine. However, the half-yin and half-yang syndrome lacks a specific theoretical elaboration and treatment system, which is a special and complex syndrome of the disease, limiting the improvement of the clinical efficacy of the disease. The core pathogenesis of GM with half-yin and half-yang syndrome is “obstruction of nutritive and defensive phases, and yin-yang obstruction.” The clinical features are local yin syndrome complicated with yang syndrome, and the disease is lingering and difficult to cure. For syndrome differentiation, it is advisable to “attach more importance to the local while less importance to the whole body.” The treatment should be based on the general principle of “eliminating yin and transforming yang.” For the use of herbs, it is recommended to adopt the methods of “the combination of the herbs in cold and warm nature, mainly with herbs in warm nature, attaching more importance to use the herbs with the function of ascending and less to descending.” Finally, restore the normal circulation of qi and blood as well as the balance of yin and yang to achieve the purpose of treatment.


Introduction
Granulomatous mastitis (GM), also known as granulomatous lobular mastitis (GLM), is a chronic nonbacterial mastitis that occurs frequently in nonlactating women.It belongs to the category of plasma cell mastitis (PCM) in Traditional Chinese External Medicine, and the category of acne mammary abscess.The disease is characterized by recurrent attacks and protracted course of disease. 1 It is a difficult disease in Traditional Chinese External Medicine.In recent years, the advantages of Chinese medicine in the treatment of this disease have gradually become prominent. 2Since the incidence of GM has increased significantly in recent years, and compared with PCM, it is more common [3][4][5] and has unique clinical characteristics and different pathological mechanisms, this paper specifically discusses the relevant theories of GM.
The Complete Works of External Medicine (Yang Yi Da Quan) states: "When diagnosing and treating ulcers, yin or yang syndrome must be differentiated first, which is the guideline of the medical treatment."According to the local yin-yang syndrome differentiation, surgical sores and ulcers can be divided into: "pure yin syndrome," "pure yang syndrome," and "half-yin and half-yang syndrome."According to the clinical characteristics of GM, it belongs to half-yin and half-yang syndrome.This syndrome belongs to the difficult type of surgical sores and ulcers in Chinese medicine surgery and is also difficult to cure.It is manifested as the complexity of syndrome differentiation and the contradiction of treatment.Due to the local yin syndrome complicated with yang syndrome, it is often misdiagnosed as simple yin syndrome or yang syndrome, resulting in the misuse of herbs in warm or cold nature.If herbs in warm nature are over-used, it is prone to the yang syndrome; if herbs in cold nature are overused, the masses are hard and difficult to fester.
The research group consulted ancient books and various versions of textbooks of Traditional Chinese External Medicine in undergraduate colleges and universities and found that the theoretical exposition of the syndrome differentiation and treatment of surgical ulcers was relatively detailed, but it lacked a clear concept definition, syndrome description, and treatment methods for half-yin and half-yang syndrome of both GM and surgical ulcers.Therefore, this paper analyzes the existing theories of ancient physicians treating half-yin and half-yang syndrome of ulcers and combines with the clinical practice of breast surgery at the First Affiliated Hospital of Henan University of Chinese Medicine in the past decade, discusses and summarizes the clinical characteristics, treatment methods, medication rules and representative prescriptions of half-yin and half-yang syndrome of GM, in order to provide a reference for the study and treatment of this disease.

Clinical Manifestations of Half-Yin and Half-Yang Syndrome of Granulomatous Mastitis
In the past clinical diagnosis and treatment of GM, if the local skin of the breast is usually not red or swollen, without obvious pain or fluctuation sensation after palpation, and the pus is thin after ulceration, it is diagnosed as yin syndrome, treated with yang-warming prescriptions of Shengong Neituo powder, Yanghe decoction, etc.; if the local skin of the breast is bright red, swelling, with sharp pain after palpation and thick pus after ulceration, it is diagnosed as yang syndrome, treated with heat-clearing prescriptions of Chaihu Qinggan decoction, etc.However, if after long-term treatment the effect is still not good, and even some patients have aggravated symptoms of hardened breast masses or abscesses difficult to fester and resolve, it makes the TCM treatment of GM difficult.
The research group found that the half-yin and half-yang syndrome of GM has the clinical characteristics of nonyin, nonyang, and both yin and yang, and there are four main manifestations: (1) external yin and internal yang syndrome: no red skin and no tenderness or fluctuation sensation, but large pus cavity and pus formation can be seen on color Doppler ultrasound; (2) external yang and internal yin syndrome: red skin, obvious tenderness, loose, and swollen masses, thin pus after ulceration, and the mouth of the sore difficult to heal up; (3) excessive yin and deficient yang syndrome: large hard mass under the inner skin (excessive yin syndrome); only a small area of the reddish outer skin or only a small range of pus cavity and pus can be seen on internal color Doppler ultrasound (deficient yang); (4) nonyin and nonyang syndrome: it is difficult to distinguish between yin and yang, and previous treatment according to yin or yang syndrome with poor curative effect.
In the textbook of the 13th Five-Year Plan for Higher Education in the National Chinese Medicine Industry, Traditional Chinese External Medicine (hereinafter referred to as the textbook of Traditional Chinese External Medicine), 6 the definition of half-yin and half-yang syndrome of TCM surgical diseases is "In clinical practice, if it is not a typical yin syndrome or yang syndrome, that is, it is between the two syndromes, it is called half-yin and half-yang syndrome."Therefore, the above four syndromes should all belong to half-yin and half-yang syndrome of GM.How to recognize half-yin and half-yang syndrome in clinical practice and how to give consideration to both yin and yang in treatment should be further summarized based on ancient physicians' half-yin and half-yang theories.It is also urgent to discuss the characteristics and treatment of the half-yin and half-yang syndrome of GM.

History of Half-Yin and Half-Yang Syndrome
In the Southern Song Dynasty, the doctor Ziming Chen first divided the syndrome patterns of surgical diseases into yin syndrome, yang syndrome, and half-yin and half-yang syndrome in Essentials of External Medicine (Wai Ke Jing Yao) 7 and the concept of half-yin and half-yang syndrome first appeared.
In the Ming Dynasty, the treatment theories of half-yin and half-yang syndrome were gradually enriched.Yizhen Zhao, a doctor in the late Yuan and early Ming Dynasty, described in details in the Collection of Prescriptions for External Medicine (Xian Chuan Wai Ke Ji Yan Fang) 8 that Chonghe Xiangao was used to treat "unknown cold or heat syndrome with carbuncle on the back and deep multiple abscess".Among them, the "unknown cold or heat" refers to the local cold and heat signs that are difficult to distinguish, which is very similar to the current "half-yin and half-yang syndrome."The medical scientist Shizhen Li in the Ming Dynasty, renamed the Chonghe Xiangao in his book Compendium of Materia Medica (Ben Cao Gang Mu) as Chonghe plaster and has been used since ancient times.
The doctor Ji Xue of the Ming Dynasty, said in The Core of External Medicine (Wai Ke Shu Yao) 9 , "It seems to be swollen but not swollen, to be broken but not broken and to be red but not red.The pulse was full but forceless.It belongs to halfyang and half-yin syndrome with external use of Yinyang Powder.Qi and blood will be harmonious and the blood stasis will disappear automatically."Ji Xue attached importance to local syndrome differentiation and combined with pulse diagnosis.He summarized the characteristics of local yin complicated with yang syndrome and emphasized the combination of internal use of Chonghe decoction with the external use of Chonghe plaster, which is of great significance for the treatment of the half-yin and half-yang syndrome.
Up to the Qing Dynasty, the syndrome differentiation and treatment of half-yin and half-yang syndrome tended to be mature.The doctor Shicheng Gu in the Qing Dynasty, said in The Complete Works of Sores (Yang Yi Da Quan) 10 , "For the syndromes of sores, the pure yang syndrome is relatively more while the pure yin syndrome is less, but the syndrome of half-yang and half-yin is the most common."He pointed out the universality of the half-yin and half-yang syndrome.In The Treatise on the Treatment of Carbuncle on the Back (Fa Bei Dui Kou Zhi Jue Lun), Suiqiao Xie in the Qing Dynasty summarized the syndrome characteristics of inconsistent yin and yang in local differentiation of half-yin and half-yang syndrome as "painful carbuncles which are soft externally and hard internally, while those soft internally and hard externally are not painful; the external shape pertaining to yang while the color pertaining to yin; the color pertaining to yang while the external shape pertaining to yin." 11 At this point, the theoretical understanding of the half-yin and halfyang syndrome has been relatively mature.
The research group found through summarizing the theoretical understanding of the doctors in previous dynasties that the clinical symptoms of half-yin and half-yang syndrome were "yin complicated with yang, difficult distinguishing between yin and yang."The syndrome differentiation and treatment by the ancient doctors were mainly "attaching more importance to the local while less importance to the whole body," and mainly differentiating the local external, internal, yin or yang syndromes and assisted by the diagnosis of tongue coating, pulse and the syndromes of the whole body.

The Core Pathogenesis of Half-Yin and Half-Yang Syndrome of Granulomatous Mastitis
The core pathogenesis of GM with half-yin and half-yang syndrome is the basic contradiction within the disease and is the intrinsic essence and root cause contributing to the occurrence and development of the disease. 12The study group believed that the core pathogenesis of half-yin and half-yang syndrome of GM is "blocked nutrient qi and defensive qi, blockage of yin and yang."

Blocked Nutrient Qi and Defensive Qi
Defensive phase, qi phase, nutritive phase, and blood phase mark the four levels of pathogenic factors from the exterior to the interior.Ancient doctors believed that the occurrence and development of carbuncles and sores were closely related to the defensive phase, qi phase, nutritive phase, and blood phase.
In the Miraculous Pivot (Lingshu Jing), it records that "At the initial stage of disease, frequent emotional changes such as sudden rejoicing and sudden rage and intemperance in eating lead to insufficiency of yin qi and excess of yang qi, giving rise to of stagnation of nutritive qi and causing carbuncle."This is an internal cause of ulcers, including GM.In clinical practice, patients often fall and collide inad-vertently, resulting in the rapid formation of GM masses.The research group believed that this was caused by the external force impact, which caused the nutritive yin blood of the breast to overflow out of the vessels and condense in the nutritive phase, and then, the defensive qi was affected, the nutritive phase and defensive phase failed to flow, which was the external cause of GM.
According to Juanzi Liu's Ghost-Bequeathed Formulas (Liu Juan Zi Gui Yi Fang), "The nutritive phase and defensive phase are blocked in the meridians, and gradually blood will fail to flow smoothly.If the blood flow is not smooth, the defensive qi will be obstructed and cause continuous fire, which will further cause the flesh turn into pus."Therefore, obstruction of nutritive phase and defensive phase, and qi and blood stagnation are the important causes of GM.The defensive qi is in the exterior, belonging to yang, also known as "defensive yang"; nutritive phase flows within the meridians and belongs to yin of the human body, also known as nutritive yin.The pathogenic factors linger in the nutritive-defensiveqi-blood phases.The disease location is half-exterior and half-interior and the nature half-yin and half-yang, which is the key premise of half-yin and half-yang syndrome of GM.

Obstruction of Yin and Yang
In the Miraculous Pivot (Lingshu Jing), it records that "Stagnation of nutritive qi causes carbuncle.When yin and yang cannot communicate with each other, heat caused by insufficient yin qi and heat caused by insufficient yang qi mix up, steam the skin and cause pustules."It indicates that blocked nutrient qi and defensive qi can cause carbuncles and gangrene, and then the blocked yin and yang, accumulation of pathogenic heat can lead to gangrene and pus.Since the inner nutritive phase belongs to yin and the outer defensive phase belongs to yang, the inner nutritive toxin is mainly yin stagnation and cold coagulation and the pathogenic factors of the outer defensive phase are mainly yang depression and heat toxin.External heat and internal cold as well as external yang and internal yin is already half-yin and half-yang syndrome.If the treatment fails to reach the target, both yin and yang syndromes can progress rapidly, and the inner yin swelling may turn into putrefaction, and the external yang toxin may also become hardened, which can lead to a more complicated condition of half-yin and half-yang syndrome over time.
Therefore, nutritive-defensive obstruction and yin-yang blockage are the core pathogenesis of the half-yin and halfyang syndrome of GM.The treatment should be "resolving toxin and obstruction, unblocking nutritive phase and defensive phase" in order to eliminate carbuncles.

Medication Rules for Half-Yin and Half-Yang Syndrome in Ancient Prescriptions
Yin toxin deposited in the half-yin and half-yang syndrome of GM inhibits the rise of yang qi, resulting in local coexisting yin and yang syndrome and difficulty to heal over time.For the treatment, it is better to use ascending and floating herbs, which are warm and hot in nature, pungent, sweet, and salty

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in taste, assisted with some sinking and descending herbs, which are, cold and cool in nature, sour and bitter in taste.Simultaneous treatment of yin and yang can penetrate into yin and transform yang.
The representative ancient prescriptions for the half-yin and half-yang syndrome are Chonghe Plaster, Huoluo Xiaoling Bolus, and Neituo Shengji powder.Ji Xue, a doctor of the Ming Dynasty, proposed for the first time in The Core of External Medicine (Wai Ke Shu Yao) that Chonghe Plaster has a significant effect on the treatment of "half-yin and half-yang syndrome," which has been used by doctors of later dynasties.Huoluo Xiaoling Bolus is recorded in the Records of Traditional Chinese and Western Medicine in Combination (Yi Xue Zhong Zhong Can Xi Lu) by the modern and contemporary physician Xichun Zhang.Oral administration of it can treat breast sores with half-yin and half-yang syndrome, and the curative effect is particularly good.Neituo Shengji powder is also recorded in this book.The description of chronic ulcers cured by this prescription in this book is very similar to the manifestation of half-yin and half-yang syndrome that is, "the external ulcer is very small, and the internal ulcer is very large." Baizhi (Angelicae Dahuricae Radix),Shichangpu (Acori Tatarinowii Rhizoma), Duhuo (Angelicae Pubescentis Radix) in Chonghe Plaster, and Danggui (Angelicae Sinensis Radix), Huangqi (Astragali Radix), Ruxiang (Olibanum) and Tianhuafen (Trichosanthis Radix) in Huoluo Xiaoling Bolus, and Neituo Shengji powder are mainly warm herbs with pungent and sweet tastes and used in large dosages, which can help yang to lift toxin and eliminate swelling.Chishao (Paeoniae Radix Rubra) in Chonghe Plaster, Danshen (Salviae Miltiorrhizae Radix et Rhizoma) in Huoluo Xiaoling Bolus, and Baishao (Paeoniae Radix Alba) in Neituo Shengji powder are all bitter and sour cold herbs used in small doses, which have the function of sinking and ascending and preventing the pungent herbs from rising to the surface and expanding the abscess region; they can also prevent the superficial toxic pathogens from dispersing after the pus is lifted to the exterior.
It can be seen from the analysis that ancient doctors believed that for the treatment of sores and ulcers with half-yin and half-yang syndrome, the medication should comply with the theory of "four properties and five flavors" and the theory of "ascending, descending, floating and sinking."They highly regarded "the combination of herbs in cold and warm nature, with herbs in warm nature as the main ones" and "emphasizing more on ascending than descending, lifting pus and astringing toxin".

Analysis of the Treatment Rule of GM of Half-Yin and Half-Yang Syndrome Taking Yin-Yang Syndrome Differentiation as the Guideline
Yin and yang is the guideline to classify the nature and category of the syndromes of diseases.The textbook of Traditional Chinese External Medicine 6 points out in explaining the "yin-yang syndrome differentiation" that "Yin and yang are not only the general guideline of the eight principal syndrome differentiation, but also the general guideline of all surgical diseases."The focus of the yin-yang syndrome differentiation in Chinese medicine surgical diseases is on local symptoms.The research group take yin-yang syndrome differentiation as the guideline, attach importance to local areas, and summarize the clinical characteristics of GM with half-yin and half-yang syndrome as simultaneous yin syndrome and yang syndrome in the exterior and interior, and the disease is lingering and difficult to cure.
Therefore, according to the clinical characteristics of GM, the treatment should be eliminating yin and transforming yang.It has two meanings: one is to disperse yin swelling and eliminate yang pathogens and apply yang-warming, ascending and dispersing method to warm and eliminate yin hardness; at the same time, heat-clearing and toxin-resolving herbs are used to remove yang toxin and purulent pathogens.Second, it drives yin swelling into yang pathogens.Shigong Chen, a doctor in the Ming Dynasty, emphasized the treatment of sores: "It is easy to treat yang syndrome, and the patients are more likely to survive; while it is hard to treat yin syndrome, and the patients are more likely to die. 13" Therefore, in the treatment of GM with halfyin and half-yang syndrome, the emphasis is on the transformation of yin syndrome into yang syndrome and the prevention of the transformation of yang syndrome into yin syndrome, so as to achieve a dual solution of both yin and yang.

Warming and Lifting, Lifting Pus and Resolving Toxin
In Plain Questions of Yellow Emperor's Inner Classic (Huang Di Nei Jing Su Wen), it records that "Huangdi asked, 'What are the causes of carbuncles and furncles, cramps of sinews and pain of bones?' Qibo answered, 'These are caused by accumulation of cold qi and the changes of the eight directions of wind '."It clarified the kind of carbuncles and furuncles due to cold.According to the Ten Methods of Surgery (Wai Ke Shi Fa): "The treatment of half yin and half yang should be warming but not assisting the pathogens."The physician Dezhi Qi in Yuan Dynasty said: "All surgeons cannot treat diseases without interior-lifting herbs".It can be seen that carbuncles, sores, ulcers, and half-yin and half-yang syndrome are cold in nature, so the method of warming and lifting should be applied for the treatment.
However, if warming and lifting is too much, it is easy to cause the spread of toxin, cold coagulation, yin swelling, and stiffness.Therefore, in the treatment of GM with half-yin and half-yang syndrome, cold and warm methods should be combined to restrict each other.Besides, we should use large doses of herbs with warming and lifting effects assisted by the cold and cool herbs of proper dosage and proportion.For the selection of prescription, modified Shengong Neituo powder can be used.Large doses of Chao Jiezi (fried Sinapis Semen), Paojiang (Zingiberis Rhizoma Praeparatum), Rougui (Cinnamomi Cortex), Shudihuang (Rehmanniae Radix Praeparata), Lujiaojiao (Cervi Cornus Colla), and Fuzi (Aconm Lateralis Radix Praepapaia) are used to warm yang and extract pus or prevent toxin from sinking inside, 14

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some Baishao (Paeoniae Radix Alba), Huangqin (Scutellariae Radix), Zicao (Arnebiae Radix), Pugongying (Taraxaci Herba), etc., to detoxify and astringe the ulcer mouth so that the warmth does not help the pathogens.In addition, according to the disease condition, qi and blood-activating herbs can be also added to promote the release of toxic pathogens or herbs with clearing and dispersing effects can be used to clear the residual toxin. 15solving Toxin and Stagnation, Unblocking Nutritive Phase and Defensive Phase Obstruction of the nutritive phase and defensive phase leads to qi and blood stagnation and thus yin and yang blockage.The core pathogenesis of GM with half-yin and half-yang syndrome is "obstruction of nutritive phase and defensive phase, blockage of yin and yang."Blood stasis and pus stagnating and blocking nutritive, defensive, qi, and blood phases.If they are not dissipated or discharged in time, local yin and yang stagnation will become more serious.Subsequently, yin and yang syndromes can be further developed or converted to each other in different degrees, making the disease more complicated.Therefore, in order to treat GM with half-yin and half-yang syndrome, it is necessary to dredge the nutritive phase and defensive phase through "removing toxin and stagnation."It can be cured by clearing away heat and toxicity, breaking blood stasis, unblocking stagnation with herbs of Zaojiaoci (Gleditsiae Spina), Shancigu (Cremastrae Pseudobulbus Pleiones Pseudobulbus), Chuanshanjia (Manis Squama), Ezhu (Curcumae Rhizoma), Baishao (Paeoniae Radix Alba), Zicao (Arnebiae Radix), Pugongying (Taraxaci Herba), Jinyinhua (Lonicerae Japonicae Flos), Baizhi (Angelicae Dahuricae Radix) in order to resolve toxin and stagnation, restore the nutritive phase, defensive phase, qi and blood, yin and yang, and promote the cure of disease.
Therefore, according to the medication rule and clinical practice of Chonghe plaster and other ancient prescriptions for the treatment of ulcer of half-yin and half-yang syndrome, the treatment of GM with half-yin and half-yang syndrome should take "eliminating yin and transforming yang" as the general rule.Warm herbs with lifting and ascending effects are used to expel pus and resolve toxin, and transform carbuncle to unblock the nutritive and defensive phases, so as to achieve the double release of yin and yang and the elimination of pathogenic toxin.

Clinical Practice of the Research Group
In the clinical treatment of GM with half-yin and half-yang syndrome, there are four common syndromes, namely, internal yin and internal yang syndrome, external yang and internal yin syndrome, excessive yin and deficient yang syndrome, and nonyin and nonyang syndrome.In recent years, the research group, under the guidance of the veteran Chinese medicine Professor Wanlin Wang, advocated that for patients with the lingering condition of these four syndromes for 2 to 3 months, or patients with poor curative effect after 2 to 3 weeks of continuous Chinese medicine treatment, the doctors should pay more attention to the local part than the whole body and consider the syndrome differentiation as half-yin and half-yang syndrome.The selected formula is mainly composed of herbs in warm nature and with the function of ascending and assisted by herbs in cold nature and with the function of descending; the empirical formula of the research group, Jingfang Wenxiao prescription, is also taken into consideration.This formula is modified from Shengong Neituo powder for the treatment of yin syndrome of ulcer and Chaihu Qinggan decoction for the treatment of yang syndrome of ulcer.The formula consists of the herbs of Jingjie (Schizonepetae Herba), Fangfeng (Saposhnikoviae Radix), fried Baijiezi (Sinapis Semen Albae), Paojiang (Zingiberis Rhizoma Praeparatum), Shudihuang (Rehmanniae Radix Praeparata), Lujiaojiao (Cervi Cornus Colla), Danfuzi (Aconm Lateralis Radix Praepapaia), Renshen (Ginseng Radix et Rhizoma), Fuling (Poria), Baizhu (Atractylodis Macrocephalae Rhizoma), Baizhi (Angelicae Dahuricae Radix), Chenpi (Citri Reticulatae Pericarpium), Zaojiaoci (Gleditsiae Spina), Shancigu (Cremastrae Pseudobulbus Pleiones Pseudobulbus), Ezhu (Curcumae Rhizoma), Baishao (Paeoniae Radix Alba), Huangqin (Scutellariae Radix), Zicao (Arnebiae Radix), Gancao (Glycyrrhizae Radix et Rhizoma).After long-term clinical observation, this formula can relieve the disease condition with excellent effects within the short time.
In Jingfang Wenxiao prescription, it attaches great importance to the herb pair of Jingjie (Schizonepetae Herba)-Fangfeng (Saposhnikoviae Radix).The effect of Jingjie (Schizonepetae Herba) runs half-interiorly and half-exteriorly, and its pungent taste and warm property can activate qi flow; Fangfeng (Saposhnikoviae Radix) has the effects of dispersing and ascending and its pungent and sweet taste can clear and resolve.These two herbs are used as monarch herbs and special herb pair for the treatment of GM with half-yin and half-yang syndrome.In the representative formula Yanghe decoction, the fried Baijiezi (Sinapis Semen Albae), Paojiang (Zingiberis Rhizoma Praeparatum), Rougui (Cinnamomi Cortex), Shudihuang (Rehmanniae Radix Praeparata), and Lujiaojiao (Cervi Cornus Colla) are the main herbs used for the treatment of yin gangrene; added with Danfuzi (Aconm Lateralis Radix Praepapaia), they can also help warm yang and resolve yin; Renshen (Ginseng Radix et Rhizoma), Fuling (Poria), Baizhu (Atractylodis Macrocephalae Rhizoma), and Baizhi (Angelicae Dahuricae Radix) are sweet in taste and warm in nature and have the effects of strengthening the spleen and tonifying deficiency; Chenpi (Citri Reticulatae Pericarpium) is warm and heat in nature and pungent in taste, which can regulate qi and spleen.The above herbs are used together as the ministerial herbs to warm yang and lift toxin, reduce swelling, and disperse yin.The herbs of Zaojiaoci (Gleditsiae Spina), Shancigu (Cremastrae Pseudobulbus Pleiones Pseudobulbus), and Ezhu (Curcumae Rhizoma) can detoxify and resolve stagnation, dispel blood stasis and clear stagnation, unblock nutritive phase, and defensive phase; a small dose of cold herbs of Baishao (Paeoniae Radix Alba), Huangqin (Scutellariae Radix) and Zicao (Arnebiae Radix) can astringe yin and reduce swelling, restrict excessive ascending and lifting effects of pungent and warm herbs

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and prevent the spreading of purulent toxicity.Gancao (Glycyrrhizae Radix et Rhizoma) acts as the envoy herb to detoxify, benefit qi, and moderate the herbs.
For the core pathogenesis of GM with half-yin and halfyang syndrome, that is, obstruction of nutritive and defensive phases and yin-yang blockage, the general principle is to expel yin and transform yang, pay more attention to lifting with the herbs in warm nature and having the function of floating.The herbs with the function of lifting and ascending and in warm nature are advocated as the main principle and the herbs with the function of descending and in cold nature can be used as the auxiliary principle, so as to penetrate into yin and transform yang, remove the deep to the shallow of the yin swelling in the breast.If necessary, external treatments such as medicated thread of Chinese medicine and operation can be applied to cure the disease.

Conclusion
In the syndrome differentiation and treatment of GM, patients with pure yang syndrome should be treated with herbs in cold nature to clear heat and resolve toxin; patients with pure yin syndrome should be treated with herbs in warm nature to warm and tonify and unblock stagnation.However, yin and yang of the defensive phase and nutritive phase is blocked, mostly resulting in the half-yin and halfyang syndrome.The local yin-yang syndrome is complicated, and the course of the disease is long.Therefore, it is advisable to treat both yin and yang, expel yin and transform yang, warm lift and ascend, resolve toxin and stagnation, so as to restore the normal operation of yin and yang of the nutritive phase and defensive phase and promote the cure of disease.
In this paper, the author and his research group summarized the theory of GM with half-yin and half-yang syndrome in order to provide a reference for its theoretical understanding and clinical treatment and improve the theory of half-yin and half-yang syndrome in Chinese External medicine.In the future, it will take a longer period of clinical practice and observation to carry out standardized clinical studies and further deepen the understanding of GM with half-yin and half-yang syndrome.
CRediT Authorship Contribution Statement X.C. was responsible for conceptualization, methodology, project administration, supervision, and writing-review & editing.Z.L. was responsible for date curation, formal analysis, investigation, methodology, validation, visualization and writing-original draft.W.Z. was responsible for writing-review & editing.H.Z. was responsible for supervision and writing-review & editing.