The so-called method of combining cold and heat refers to the simultaneous use of cold and heat properties in medicinal substances. In the eight therapeutic methods, it belongs to the warming and clearing methods, also known as the warming and clearing combination. Cold and heat, cool and warm, have completely opposite medicinal properties. If they belong to the same meridian and act on the same area, their cold and heat properties will be reduced when combined in the same formula; if they belong to different meridians and act on different areas, their cold and heat properties will not be reduced. The Suwen (Plain Questions) states: “Cold treats heat, and heat treats cold”; it further emphasizes: “Treat cold with heat, treat heat with cold, and the physician cannot abandon the rules and change the method.” This is a principle of treatment in Traditional Chinese Medicine (TCM).
Clinically, while there are certainly many cases of pure heat syndrome or pure cold syndrome, the combination of cold and heat, the mixing of cold and heat, the confusion of cold and heat, and the rejection of cold and heat are even more common. If one only clears heat, the heat may not dissipate, or may even worsen; if one only warms yang, the cold may not retreat, or may even worsen. Only by using and adjusting both cold and heat can one achieve a combined treatment. As stated in the Yi Zong: “The combination of cold and heat is due to the presence of both cold and heat evils mixed within the person, necessitating the use of a mixture of cold and heat medicines.” This is especially true when encountering the rejection of cold and heat, where without counteracting assistance, harmony cannot be achieved.
In the Shang Han Lun (Treatise on Cold Damage), there are 112 recorded formulas, of which 53 formulas utilize the combination of cold and heat, accounting for 47.32%. This widespread application is evident. The combination of cold and heat includes the pairing of large pungent and hot herbs like Fu Zi (Aconite) and Gan Jiang (Dried Ginger) with large bitter and cold herbs like Huang Qin (Scutellaria) and Huang Lian (Coptis); it also includes the pairing of warm pungent Gui Zhi (Cinnamon Twig) with cool pungent Ge Gen (Kudzu Root). It includes the combination of the hot Fu Zi with the mildly cold Bai Shao (White Peony) and the pairing of the cold Shi Gao (Gypsum) with the warm Ban Xia (Pinellia). Zhang Zhongjing not only pioneered the method of combining cold and heat in TCM but also created exquisite combinations. His applications are both flexible and diverse, yet follow inherent principles:
When selecting herbs, the “nature” refers to the four natures of herbs: cold, hot, warm, and cool. “Use” refers to the functions of the herbs. Some formulas in the Shang Han Lun that combine cold and heat select herbs based on both their nature and their function. For example, the Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction) is used for upper heat and lower cold (heat disturbing the chest above, spleen and stomach deficiency and cold below) in cases of “cold damage, where the physician uses pills to purge heavily, and the body heat does not dissipate, with slight agitation.” In this formula, Zhi Zi is cold in nature and functions to clear heat and eliminate agitation; Gan Jiang is hot in nature and functions to return yang and warm the center. The use of Zhi Zi is based on its cold nature and its function to clear heat and eliminate agitation to resolve the evil heat above; the use of Gan Jiang is based on its warm nature and its function to return yang and warm the spleen and stomach’s yang qi below. Although the two herbs have opposite properties, their actions complement each other and proceed harmoniously, and after their combination, Gan Jiang also mitigates the damage Zhi Zi may cause to the spleen and stomach’s yang qi, while Zhi Zi counteracts Gan Jiang’s effect on the heat disturbing the chest.
As for the proportions of cold and hot herbs, the Shang Han Lun also has its considerations. In principle, it is determined based on the primary and secondary roles and the severity of cold and heat. Generally speaking, for the primary and severe herbs, more varieties and larger quantities are selected; for the secondary and lighter herbs, fewer varieties and smaller quantities are selected. For example, in the Fu Zi Xie Xin Tang (Aconite Decoction), three large bitter and cold herbs, Da Huang (Rhubarb), Huang Qin, and Huang Lian, are used to purge heat and eliminate fullness, while one large pungent and hot herb, Fu Zi, is used to warm yang and dispel cold. In the Huang Lian Tang (Coptis Decoction), one large bitter and cold herb, Huang Lian, is used to clear and drain upper heat, while four warm and sweet herbs, Ban Xia, Gui Zhi, Ren Shen (Ginseng), and Zhi Gan Cao (Honey-fried Licorice), are used to harmonize and warm the lower cold. The Da Qing Long Tang (Major Blue Dragon Decoction) uses the warm pungent herbs Ma Huang (Ephedra) and Gui Zhi, with a small addition of the cold and pungent Shi Gao, primarily to release exterior cold and secondarily to clear internal heat. The Tao He Cheng Qi Tang (Peach Kernel Decoction) uses Da Huang, Mang Xiao (Mirabilite), and Tao Ren (Peach Kernel), which are bitter, salty, and cold to drain heat and eliminate stasis, with a small addition of warm pungent Gui Zhi to assist Da Huang and Tao Ren in promoting blood flow. Its application is very flexible.
In the formulas that combine cold and heat in the Shang Han Lun, some are designed to eliminate their nature and utilize their function. The method of eliminating nature is through changes in combinations to constrain their properties. For example, the Ma Huang Xing Ren Gan Cao Shi Gao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) treats exterior evil transforming into heat entering the interior, obstructing the lungs. In this formula, the warm pungent Ma Huang is constrained by the cold and bitter Shi Gao, eliminating its warm nature while preserving its function to stop cough and relieve wheezing. Therefore, although Ma Huang, a strong sweating herb, is used in the formula, it does not belong to the category of warm sweating agents but is classified as a strong cold agent. The Huang Qin Jia Ban Xia Sheng Jiang Tang (Huang Qin with Ban Xia and Ginger Decoction) treats Shao Yang evil heat pressing Yang Ming, causing vomiting and diarrhea. In this formula, the warm nature of Ban Xia and Sheng Jiang is constrained by the heavily used bitter cold Huang Qin, eliminating its warm nature while preserving its function to harmonize the stomach, descend counterflow, and stop vomiting. Thus, the Huang Qin Jia Ban Xia Sheng Jiang Tang is classified as a clearing heat agent. The Dang Gui Si Ni Tang (Tangkuei Decoction) treats blood deficiency and cold stagnation causing cold extremities. In this formula, the sweet and cold Tong Cao (Rice Paper Plant) is constrained by the warm pungent Gui Zhi and Xi Xin (Asarum), eliminating its cold nature while preserving its function to open the meridians, and so on.
Regarding the pairing of herbs, it refers to the effective use of two opposing medicinal substances in the formulas of the Shang Han Lun. Some of these herbs appear in multiple formulas within the Shang Han Lun, some appear in other formulas in the Jin Kui Yao Lue (Essential Prescriptions from the Golden Cabinet), and some appear in famous formulas created by later physicians. After pairing, some enhance efficacy, some expand functions, and some constrain tendencies. The Shang Han Lun contains many pairs of cold and heat herbs, with over 20 pairs still commonly used today. For example, Gui Zhi and Bai Shao (Cinnamon Twig and White Peony) (Gui Zhi Tang, Xiao Qing Long Tang, Xiao Jian Zhong Tang), one warm and one cold, one disperses and one gathers, harmonizes Ying and Wei, balances Yin and Yang, and alleviates pain. Gui Zhi and Da Huang (Cinnamon Twig and Rhubarb) (Tao He Cheng Qi Tang, Gui Zhi Jia Da Huang Tang) are one warm and one cold, promoting circulation and resolving stasis, harmonizing collaterals and alleviating pain. Fu Zi and Bai Shao (Aconite and White Peony) (Zhen Wu Tang, Shao Yao Gan Cao Fu Zi Tang, Gui Zhi Jia Fu Zi Tang, Fu Zi Tang) are one hot and one mildly cold, one drying and one softening, balancing rigidity and flexibility, warming without drying, warming yang and benefiting yin, and alleviating pain. Ma Huang and Shi Gao (Ephedra and Gypsum) (Ma Huang Xing Ren Gan Cao Shi Gao Tang, Da Qing Long Tang, Yue Bi Tang) are one warm and one cold, one disperses and one clears, dispersing the lungs and relieving wheezing, clearing heat and eliminating agitation, and promoting the flow of water. Huang Qin and Ban Xia (Scutellaria and Pinellia) (Xiao Chai Hu Tang, Da Chai Hu Tang, Huang Qin Jia Ban Xia Sheng Jiang Tang) are one cold and one warm, one opens and one descends, clearing and transforming damp-heat, dispersing and eliminating fullness. Gan Jiang and Huang Lian (Dried Ginger and Coptis) (Gan Jiang Huang Qin Huang Lian Ren Shen Tang, Ban Xia Xie Xin Tang, Gan Cao Xie Xin Tang, Sheng Jiang Xie Xin Tang, Huang Lian Tang, Wu Mei Wan) are one hot and one cold, one opens and one descends, balancing yin and yang, dispersing and eliminating fullness. Xuan Fu Hua and Dai Zhe Shi (Inula and Hematite) (Xuan Fu Dai Zhe Tang) are one mildly warm and one cold, one disperses and one descends, calming counterflow and stopping vomiting, transforming phlegm and eliminating fullness. Gan Sui and Yuan Hua (Euphorbia and Genkwa) (Shi Zao Tang) are one warm and one cold, attacking and expelling water, draining the accumulation of water in the chest and flanks. Ban Xia and Gua Lou (Pinellia and Trichosanthes) (Xiao Xian Xiong Tang) are one warm and one cold, transforming phlegm and dispersing fullness, broadening the chest and eliminating fullness. Ban Xia and Mai Dong (Pinellia and Ophiopogon) (Zhu Ye Shi Gao Tang) are one warm and one mildly cold, one drying and one moistening, nourishing yin and benefiting the stomach, descending counterflow and stopping vomiting, and so on.
Counteracting assistance refers to the method of counteracting treatment in TCM. The Suwen states: “If the odd does not leave, the even remains, this is called a heavy formula. If the even does not leave, then counteracting assistance is used to obtain it. The so-called cold, heat, warmth, and coolness, counteract according to the disease.” Counteracting assistance is a method of counteracting treatment in TCM, originating from the Huang Di Nei Jing (Yellow Emperor’s Inner Canon). The counteracting assistance method in the Shang Han Lun has two contents: one is to assist hot medicines with cold medicines to treat heat syndromes; the other is to assist cold medicines with hot medicines to treat cold syndromes. This is the pairing of counteracting assistance; the second is “treat heat with cold, warm and act; treat cold with heat, cool and act.” This is the method of taking medicine with counteracting assistance. The counteracting assistance used in the Shang Han Lun is the pairing of counteracting assistance. For example, in the Tong Mai Si Ni Jia Zhu Gan Zhi Tang (Four Reverse Decoction with Pig Gallbladder), the pig gallbladder, Bai Tong (White Tong), and pig gallbladder in the Bai Tong Jia Zhu Gan Zhi Tang are all counteracting assistance medicines, used in the strong pungent and hot warming yang medicines, counteracting with salty and cold bitter descending, taking the meaning of “the extreme follows it,” and having the effect of guiding according to the situation, eliminating the rejection of cold and heat, and so on, used in special stages where the primary treatment is ineffective, or when there is rejection of medicine, or when there are false cold and heat, etc. If used appropriately, it can often yield significant results. As stated in the Suwen: “Counteracting treatment… heat uses heat, cold uses cold, blockage uses blockage, and flow uses flow, must follow its master, and precede its cause, its beginning is the same, its end is different, it can break accumulation, it can dissolve hardness, it can harmonize qi, it can ensure it is eliminated.”
Since Zhang Zhongjing established the method of combining cold and heat, it has had a significant impact on later generations. Later physicians have created many famous formulas using this method. Examples include Yin Qiao San (Honeysuckle and Forsythia Powder) (Jing Jie and Bo He), Jing Fang Bai Du San (Jing Jie and Chai Hu), Shen Su Yin (Su Ye and Ge Gen), Huang Long Tang (Dang Gui and Da Huang), Wen Pi Tang (Fu Zi and Da Huang), Hao Qing Qing Dan Tang (Ban Xia and Zhu Ru), Xiao Yao Wan (Dang Gui and Bai Shao), Bai Zhu Shao Yao San (Bai Zhu and Bai Shao), Si Miao Yong An Tang (Jin Yin Hua and Dang Gui), Zuo Jin Wan (Huang Lian and Wu Zhu Yu), Xiang Lian Wan (Huang Lian and Mu Xiang), Hu Qian Wan (Huang Bai and Suo Yang), Mu Li San (Mu Li and Huang Qi), An Gong Niu Huang Wan (She Xiang and Niu Huang), Yue Ju Wan (Chuan Xiong and Zhi Zi), Ju Pi Zhu Ru Tang (Ju Pi and Zhu Ru), Dan Shen Yin (Dan Shen and Tan Xiang), Jian Pi Wan (Rou Dou Kou and Huang Lian), San Ren Tang (Bai Dou Kou and Yi Ren), Er Miao San (Huang Bai and Cang Zhu), Liu Mei Di Huang Wan (Shan Yao and Dan Pi), and many more.
As an important therapeutic principle in TCM, the method of “combining cold and heat” continues to effectively guide clinical practice in TCM. This principle can be applied not only to common and frequently occurring diseases but is also frequently used for various difficult and complicated diseases, as well as critical illnesses. In recent years, I have been engaged in clinical work for kidney diseases, and in the clinical process, I often use the method of “combining cold and heat” to treat kidney diseases, which has been greatly beneficial.
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