The formulas for mixed cold and heat in the Shang Han Lun include Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum and Cinnamon Decoction with Dried Ginger), Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction), Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Heart), Fu Zi Xie Xin Tang (Aconite Decoction to Drain the Heart), Huang Lian Tang (Coptis Decoction), Wu Mei Wan (Mume Pill), Ma Huang Sheng Ma Tang (Ephedra and Cimicifuga Decoction), and Gan Jiang Huang Qin Huang Lian Ren Shen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction), totaling eight formulas. Below is a brief description of each formula.
Overview of Mixed Cold and Heat Formulas
Ban Xia Xie Xin Tang is a formula that combines cold and hot herbs. It is a representative formula for harmonizing the cold and heat evils of the spleen and stomach. Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction to Drain the Heart) and Gan Cao Xie Xin Tang (Licorice Decoction to Drain the Heart) are variations based on it. It treats the syndrome of disharmony of qi in the spleen and stomach, characterized by fullness and distension below the heart with phlegm and fluid. Due to the presence of phlegm and fluid, it is also associated with vomiting. Clinical observations indicate symptoms such as fullness below the heart, vomiting, borborygmus, diarrhea, or irregular bowel movements. This syndrome arises from the disharmony of yin and yang in the spleen and stomach, with disordered ascending and descending qi, leading to obstruction in the middle jiao and the generation of phlegm and fluid. Therefore, Ban Xia Xie Xin Tang is used to bitterly descend, acridly disperse, harmonize the stomach, and clear phlegm as its main actions.
This formula consists of Ban Xia (Pinellia), Huang Qin (Scutellaria), Huang Lian (Coptis), Ren Shen (Ginseng), Zhi Gan Cao (Honey-fried Licorice), and Da Zao (Jujube). The 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 herbs Huang Qin and Huang Lian are used to descend, while Gan Jiang (Dried Ginger) is used to warm and alleviate the cold, as the coldness of the spleen qi leads to borborygmus and diarrhea. Phlegm and fluid disturb the stomach, causing vomiting, thus Ban Xia is used to descend and harmonize the stomach to stop vomiting; the weakness of spleen and stomach qi prevents proper regulation of ascending and descending, hence Ren Shen, Gan Cao, and Da Zao are used to tonify. This formula clears the upper and warms the lower, combining bitter descent and acrid dispersion, using 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 region (located below the chest and above the abdomen). Therefore, when there is a disease in this area, it is appropriate to use Xie Xin Tang to harmonize. However, Xiao Chai Hu Tang (Minor Bupleurum Decoction) treats the liver and gallbladder, while Xie Xin Tang 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 the key pathway for the ascending and descending 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 flow, not blood or water, and is not a solid mass, hence pressing it feels moist, but it is merely qi fullness.
Mr. Zhang, male, 36 years old, has a habit of drinking. He presented with fullness below the heart, occasional vomiting, and unformed stools, occurring three to four times a day, with no improvement despite various treatments. His pulse was wiry and slippery, and his tongue had a white coating.Diagnosis: The syndrome is due to alcohol harming the spleen and stomach, leading to disordered ascending and descending, with phlegm generated internally. Phlegm and fluid cause the stomach qi to rebel, resulting in vomiting, and spleen deficiency with cold qi leads to unformed stools, with disharmony of middle qi causing fullness below the heart.Prescription: Ban Xia 12g, Gan Jiang 6g, Huang Qin 6g, Huang Lian 6g, Dang Shen 9g, Zhi Gan Cao 9g, Da Zao 7 pieces.After taking one dose, he had a large amount of white, sticky phlegm in his stool, and vomiting decreased by seventy percent; after another dose, both fullness and vomiting reduced, and after two more doses, he was cured.
Fu Zi Xie Xin Tang is used to treat heat fullness below the heart, with yang deficiency unable to protect the exterior, accompanied by symptoms of “aversion to cold and sweating.” Generally, fever easily leads to sweating, while aversion to cold does not easily lead to sweating. However, when aversion to cold is accompanied by sweating, it reflects a deficiency of defensive yang and a failure to warm the body.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, it leads to insufficient transformation of defensive yang, losing its warming and protective functions, resulting in aversion to cold and sweating, hence termed as “upper heat and lower cold syndrome.” The treatment uses Fu Zi Xie Xin Tang to clear heat fullness and warm yang qi.Fu Zi Xie Xin Tang consists of Da Huang (Rhubarb), Huang Lian (Coptis), Huang Qin (Scutellaria), and Pao Fu Zi (Processed Aconite). The herbs are soaked in boiling water to treat the heat fullness in the qi level, while Fu Zi is decocted separately 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 yellow herbs and the separate decoction of Fu Zi emphasizes the support of yang while clearing heat as a secondary action.
Student from Ningxiang, after suffering from an external pathogen for several months, was repeatedly treated without improvement. During the follow-up, he reported: fullness in the chest, heat in the upper body with sweating, and aversion to wind below the waist. It was June, and he was wrapped up. Upon reviewing the previous prescriptions, they were all common clearing and draining herbs that did not address the root cause. His tongue coating was light yellow, and his pulse was wiry. He was given Fu Zi Xie Xin Tang, and after two days, he returned for a follow-up, stating that the medicine had worked wonders. He was discharged after a successful recovery. (Excerpt from “Dun Yuan: Medical Cases”)
Huang Lian Tang is indicated for the pathological changes of “cold damage with heat in the chest and evil qi in the stomach.” Heat in the chest leads to vomiting, while evil qi in the stomach causes abdominal pain or diarrhea. The treatment with Huang Lian Tang employs both cold and warm herbs, with sweet and bitter actions to regulate the yin and yang of the upper and lower, harmonizing the evil.Huang Lian Tang consists of Huang Lian (Coptis), Zhi Gan Cao (Honey-fried Licorice), Gan Jiang (Dried Ginger), Gui Zhi (Cinnamon), Ren Shen (Ginseng), Ban Xia (Pinellia), and Da Zao (Jujube). The formula uses Huang Lian to clear heat in the chest, Gan Jiang to warm the cold in the spleen and stomach, Gui Zhi to promote the yang qi of the upper and lower, Ban Xia to descend and stop vomiting, and Ren Shen, Gan Cao, and Da Zao to nourish the stomach and calm the center, facilitating the regulation of the upper and lower, and harmonizing the cold and heat yin and yang.
Mr. Li from Xuzhou presented with vomiting and diarrhea, occurring three to four times a day, with urgency and heaviness in the abdomen, accompanied by red and white mucus. His illness had persisted for a year, and he had not improved despite seeking treatment everywhere. He came to Beijing for work and was introduced to me for diagnosis. His pulse was wiry and slippery, and he had weak pressure, with a red tongue and white coating.Diagnosis: This is a syndrome of mixed cold and heat evil, affecting the spleen and stomach. If only one aspect is treated, either cold is used to treat heat or heat to treat cold, it will not be effective. When cold and heat are used together, it should follow the method of Huang Lian Tang.Prescription: Huang Lian 9g, Gan Jiang 9g, Gui Zhi 9g, Ban Xia 9g, Ren Shen 6g, Zhi Gan Cao 6g, Da Zao 7 pieces.After taking six doses, he was cured of his year-long illness.
Wu Mei Wan is the main formula for treating the Jue Yin disease. When the disease reaches the Jue Yin stage, the characteristics of mixed cold and heat syndrome are evident, such as “thirst, qi rising to the heart, heat in the heart, and hunger without desire to eat.” Due to the mixed cold and heat, with heat above and cold below, it can manifest as vomiting of roundworms and coldness in the hands and feet, termed “roundworm cold syndrome,” which can be treated with Wu Mei Wan.Wu Mei Wan consists of Wu Mei (Mume), Xi Xin (Asarum), Gan Jiang (Dried Ginger), Huang Lian (Coptis), Fu Zi (Aconite), Dang Gui (Angelica), Shu Jiao (Sichuan Pepper), Gui Zhi (Cinnamon), Ren Shen (Ginseng), and Huang Bai (Phellodendron). This formula is the main treatment for the mixed cold and heat of the Jue Yin disease and roundworm cold syndrome. The use of Wu Mei soaked in vinegar benefits the yin and harmonizes the yang, with effects of harmonizing the liver, calming the stomach, astringing yin to stop thirst, and calming roundworms. Fu Zi, Gan Jiang, and Gui Zhi warm the channels and support yang to overcome cold; Chuan Jiao and Xi Xin are spicy and warm, capable of promoting yang and breaking yin, and can kill roundworms. Huang Lian and Huang Bai are bitter and cold to clear heat and irritability, and can subdue roundworms and treat vomiting, while Ren Shen tonifies qi to strengthen the spleen, and Dang Gui nourishes blood to support the liver. The combination of these herbs expels cold and heat evils, harmonizes yin and yang, softens the liver, warms the lungs, and calms roundworms, which is the essence of the formula. Although both cold and heat are used in the formula, the warming herbs are predominant, and Wu Mei provides a sour astringent effect, making it suitable for treating prolonged diarrhea due to mixed cold and heat. The use of rice and honey as auxiliary materials to make pills not only nourishes the stomach qi but also serves as bait to attract roundworms.
Ms. Zhou from Shangzhai, Gansu, 36 years old, 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. Diagnosis: This is a “roundworm cold syndrome” of the Jue Yin disease. The prescription was modified from Wu Mei Wan to a decoction, taken in three doses. After two doses, the pain ceased, and she felt at ease.However, due to severe bitterness in her mouth, she still had vomiting and reported that she had not had a bowel movement for several days. I then prescribed Da Chai Hu Tang (Major Bupleurum Decoction) for one dose, which resulted in a large bowel movement and expulsion of several roundworms, leading to her recovery.
Ma Huang Sheng Ma Tang is used to treat exterior evils trapped internally, with obstructed qi, upper heat and lower cold, and disharmony of yin and yang. Due to the internal trapping of yang evils, the originally floating and rapid pulse changes to a deep and slow one. The pulse at the lower position is not absent, indicating that the qi mechanism is obstructed, leading to unfavorable pulse pathways. When the qi mechanism is obstructed, the yin and yang qi do not connect smoothly, resulting in coldness in the hands and feet.
If the internal trapped yang evil lingers above, it leads to upper heat, resulting in throat discomfort and vomiting of pus and blood. The yang is trapped above and cannot govern below, hence the syndrome also presents with persistent diarrhea. This syndrome involves both yin and yang being affected by the disease, with the distinctions between deficiency and excess, cold and heat becoming unclear, making it difficult to treat. However, Zhang Zhongjing proposed Ma Huang Sheng Ma Tang to treat 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 the harmony of yin and yang for recovery.Ma Huang Sheng Ma Tang consists of Ma Huang (Ephedra), Sheng Ma (Cimicifuga), Dang Gui (Angelica), Zhi Mu (Anemarrhena), Huang Qin (Scutellaria), Wei Rui (Polygonatum), Bai Shao (White Peony), Tian Dong (Asparagus), Gui Zhi (Cinnamon), Fu Ling (Poria), Zhi Gan Cao (Honey-fried Licorice), Shi Gao (Gypsum), Bai Zhu (Atractylodes), and Gan Jiang (Dried Ginger). The formula uses a larger dosage of Ma Huang and Sheng Ma to expel the trapped yang evil, while Huang Qin and Shi Gao clear the lung and stomach heat evil, Gui Zhi and Gan Jiang promote yang and warm the middle to dispel cold, Dang Gui and Bai Shao nourish blood to harmonize yin; Zhi Mu, Tian Dong, and Wei Rui nourish yin and lower fire to harmonize yang; Zhi Gan Cao, Fu Ling, and Bai Zhu not only strengthen the spleen and benefit qi to stop diarrhea but also calm the stomach and harmonize the center to facilitate the connection of the upper and lower. This formula combines both tonifying and draining herbs, ensuring they assist rather than contradict each other. 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 two previous episodes of throat disease and one episode of diarrhea, all of which were cured. Now, he suffers from a cold and heat disease that has persisted for over ten days without improvement, and he invited me for diagnosis. 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. All six pulses were floating, and both middle positions were weak, with no discernible count, and pressing felt slightly slow, making it impossible to determine the exact number. He was thirsty and needed water, with scanty 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 purging decoctions, Huang Lian and A Jiao Tang, and bitter wine decoction, but none felt appropriate. I then proposed Gan Jiang Huang Qin Huang Lian Ren Shen Tang, but still felt it was not suitable. After further contemplation, I considered Xiao Chai Hu Tang (Minor Bupleurum Decoction) with modifications for stability. However, due to rain, I stayed near the Li residence, and while pondering, I could not sleep. I asked Mr. Li: Has the patient sweated at all? He replied: No sweat at all. Has he taken any purgatives? He said: He had taken purgatives three times, leading to frequent watery diarrhea, and the pulse suddenly changed to a weak state.
I said: I understand now. This is a case of Ma Huang Sheng Ma Tang. The patient’s pulse is weak and easily moves, indicating a constitution of upper heat and lower cold. The new onset of solar cold damage and the mistaken use of purgatives have not resolved the exterior evil, leading to internal heat and triggering an old throat disease, hence the white rot and mixed pus and blood in the throat. The weak spleen and heavy dampness have further led to frequent watery diarrhea, causing the water to flow into the large intestine, hence the scanty urination. The upper jiao is overheated, leading to thirst; the exterior evil has not resolved, hence the symptoms of cold and heat headaches and joint pain persist; being trapped internally leads to coldness in the limbs; after the purgation, qi and blood gather in the interior, hence the yang pulse is weak; and the water and fluids trend towards the lower part, leading to the yin pulse also being closed off.
The composition of this formula includes Gui Zhi Tang with added Ma Huang, which helps to release the exterior and induce sweating, and Fu Ling, Bai Zhu, and Gan Jiang transform water and benefit urination, thus stopping diarrhea; Dang Gui assists in blood circulation and unblocking the pulse, while Huang Qin, Zhi Mu, and Shi Gao clear inflammation and heat, while also generating fluids; Sheng Ma resolves the toxicity in the throat, Yu Zhu (which is Wei Rui) expels pus and blood, and Tian Dong clears phlegm and pus. This formula can be taken as prescribed tomorrow.
Mr. Li was concerned about the possibility of a severe condition, fearing that the warmth of Ma Huang and Gui Zhi would be too much, and wanted to add Li Shen. I said: The weak and cold pulse indicates yang stagnation, not yang deficiency. Adding ginseng would not be as effective as not adding it, as the classic formulas should not be altered. He ultimately recovered. (Excerpt from “Chen Xunzhai Medical Cases”)
Gan Jiang Huang Qin Huang Lian Ren Shen Tang is used to treat the cold and heat rejection syndrome 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.Gan Jiang Huang Qin Huang Lian Ren Shen Tang consists of Gan Jiang (Dried Ginger), Huang Qin (Scutellaria), Huang Lian (Coptis), and Ren Shen (Ginseng). The formula uses Huang Qin and Huang Lian to drain the upper heat, while Gan Jiang warms the spleen to eliminate cold, and Ren Shen strengthens the spleen to tonify deficiency. This formula employs both cold and heat, with bitter descent and acrid dispersion, and Gan Jiang can also guide Huang Qin and Huang Lian to prevent the heat evil from causing rejection. Therefore, some commentators believe this formula also treats “fire counterflow” vomiting.Mr. Yu, male, 29 years old, experienced severe heat in summer, indulged in cold foods, leading to alternating vomiting and diarrhea, with vomiting being more frequent than diarrhea. He also had symptoms of irritability and bitterness in the mouth. His pulse was rapid and slippery, and his tongue coating was yellow but moist.Diagnosis: This is heat above and cold dampness below, and with the alternating vomiting and diarrhea, how can the stomach qi not be harmed? This is a syndrome of middle deficiency with mixed cold and heat.Prescription: Huang Qin 6g, Huang Lian 6g, Ren Shen 6g, Gan Jiang 3g, and instructed to add 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 Shang Han Lun represent a significant innovation in the study of formulas by Zhang Zhongjing.They hold high scientific value, 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, Ban Xia Xie Xin Tang harmonizes yin and yang but focuses on treating fullness; Gan Jiang Huang Qin Huang Lian Ren Shen Tang harmonizes yin and yang but focuses on treating vomiting; Wu Mei Wan harmonizes yin and yang but focuses on treating roundworms; Ma Huang Sheng Ma Tang harmonizes yin and yang but focuses on inducing sweating; and Fu Zi Xie Xin Tang harmonizes yin and yang but focuses on supporting yang and stopping sweating.These all reflect the characteristic of TCM to treat according to the syndrome.
I Copyright StatementThis article is excerpted from “Liu Duzhou’s Seven Medical Books: Fourteen Lectures on the Shang Han Lun,” published by the People’s Health Publishing House, author/Liu Duzhou. The copyright belongs to the rights holder. This is for learning and exchange purposes only; please do not use the medicine indiscriminately.· END ·
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