Gegen Huangqin Huanglian Tang for “Xiere Li” (Fever with Chills and Diarrhea) in the Shanghan Lun
What TCM calls “xiere li” (concurrent-heat diarrhea) refers to a condition in which an exterior pattern (fever and aversion to cold) coexists with diarrhea. The Shanghan Lun (Treatise on Cold Damage) contains this passage: “In a taiyang disease of the guizhi presentation, if the doctor wrongly purges, diarrhea ensues and does not stop. If the pulse is hurried (cu), the exterior has not been resolved; if there is panting and sweating out, Gegen Huangqin Huanglian Tang governs. Gegen: half a jin; Gancao: two liang (fried); Huangqin: three liang; Huanglian: three liang. Take these four, boil in eight sheng of water; first boil the Gegen, reduce by two sheng, add the other herbs, boil to two sheng, remove the dregs, and divide into two warm doses.”
The Gegen Huangqin Huanglian Tang here is precisely what resolves “xiere li.” In the Han dynasty, half a jin was eight liang, and today one Han-dynasty liang is commonly converted to 3 g. Thus the modern adult dose of this formula is: Gegen (Pueraria) 24 g, Zhi Gancao (Honey-fried Licorice) 6 g, Huangqin (Scutellaria) 9 g, Huanglian (Coptis) 9 g. Boil the Gegen first in 800 ml of water down to 600 ml, add the other herbs, and boil to 200 ml; divide into two warm doses. Reduce appropriately for children.
Zhang Zhongjing considered this “xiere li” a transformed pattern arising when a taiyang wind-stroke guizhi-tang presentation was wrongly purged by a physician. In clinical practice, however, many patients who have not been mistreated also present with both fever/chills and diarrhea—such as viral enteritis, gastrointestinal-type cold, bacillary dysentery, summer diarrhea, and diarrhea from food poisoning. Physicians have reported Gegen Huangqin Huanglian Tang effective for all of the above, and some have even used modified Gegen Huangqin Huanglian Tang with good results for poliomyelitis. Modern pharmacological research confirms that Gegen Huangqin Huanglian Tang has antibacterial, antipyretic, immune-enhancing and anti-hypoxic effects. Radiation proctitis arising after radiotherapy in cancer patients may not necessarily present with fever and chills, but good results with Gegen Huangqin Huanglian Tang have also been reported. When taking this formula, avoid pork, cold water, seaweed and songcai (potherb mustard).
TCM holds that Gegen releases the muscle layer and clears heat, promotes eruption of measles, generates fluids and stops thirst, and raises yang to stop diarrhea; it is used for exterior-pattern fever, stiffness and pain of the neck and back, measles with inadequate eruption, thirst in febrile disease, wasting-thirst from yin deficiency, heat diarrhea and heat dysentery, and spleen-deficiency diarrhea. Huangqin clears heat and dries dampness, drains fire and resolves toxicity, stops bleeding, and calls the fetus; it is used for damp-warmth and summerheat-dampness, chest stuffiness and nausea, damp-heat glomus and fullness, diarrhea and dysentery, jaundice, lung-heat cough, high fever and vexed thirst, bleeding from blood heat, and welling-abscesses and sores. Huanglian is a famous antidiarrheal; modern pharmaceutical companies extract berberine and make it into berberine tablets alone, which treat enteritis and diarrhea. Zhi Gancao harmonizes the other herbs, moderates the bitter-cold nature of Huanglian and Huangqin, and fortifies the spleen and boosts qi. Thus the combined formula has a strong antidiarrheal effect while also clearing heat. Clinically this compound outperforms berberine alone.
The key indication for Gegen Huangqin Huanglian Tang is foul-smelling diarrhea with burning sensation in the anus; an exterior pattern (aversion to cold and fever) is not strictly required. Of course, if both the exterior pattern and the foul diarrhea with anal burning are present, the formula is even more precisely indicated. But insisting that an exterior pattern must be present to use Gegen Huangqin Huanglian Tang would unduly narrow its indications.
Gegen Huangqin Huanglian Tang may also present with accompanying symptoms such as stiffness and discomfort of the shoulder and neck, dry mouth with thirst, panting with sweating, vexatious heat in the chest and epigastrium, and a rapid pulse. When treating, the physician need not add separate medicines for these accompanying signs. The TCM idea of “pattern differentiation and treatment” emphasizes grasping the patient’s principal contradiction; Professor Yin Huihe summarized this as “grasping the main symptom.” As long as we see the main presentation of Gegen Huangqin Huanglian Tang, we may use it, and often the inexplicable accompanying signs disappear along with the main symptom.