Face Red and Swollen, Legs Ice Cold? Doctor Luo Tianyi’s Upper-Heat-Lower-Cold Case (Pu Ji Xiao Du Yin Zi / Universal Relief Toxin-Removing Decoction)
Patient search words: face red and swollen / legs ice cold / ear swelling and pain / hot upper body cold lower body / chest tightness ｜ Medical terms: shang re xia han (upper heat, lower cold) · fu xie (latent pathogen) · yin yang ge ju (mutual rejection of yin and yang) · gan dan shi re (damp-heat of liver and gallbladder)
The opening scene: an illness that forced a chancellor to sleep half on a bed, half on a heated brick platform
In the spring of 1268 AD (the fifth year of the Zhiyuan era of the Yuan dynasty), a 67-year-old chancellor — Yao Gongmao, Right Grand Councillor of the Secretariat — was tormented by such a strange illness that he could no longer sleep.
💬 Note from Doctor Luo: Today’s case is what Chinese medicine calls shang re xia han — upper heat and lower cold. Whenever we analyze a case, we first ask: what do this person’s job and age tell us? The Right Grand Councillor of the Secretariat — chancellor rank, working beside the emperor, incredibly busy. At 67, in a time when the saying ran “since ancient times, few live past seventy,” he was already very old. Worry and stress are the common trait of people like this; and at his age, the upright qi (zheng qi) is no longer sufficient. Don’t underestimate those two sentences — they carry a great deal of information. When we analyze a patient, we always take these factors into account.
Who was the patient? A worried chancellor — exactly like today’s office workers
Yao Gongmao’s illness did not come on in a day. The case record states it plainly: su you shi du — he had long harbored damp toxin, having caught an epidemic-type pathogenic qi (external evil) years before that had never been fully cleared; the root of the illness stayed in his body. Then: zhi yuan wu chen chun, yin jiu bing fa — in the spring of the fifth year of the Zhiyuan era, because he drank wine, the illness suddenly erupted.
💬 Note from Doctor Luo: Why does illness so often break out in spring? Spring corresponds to the liver; the liver qi rises and yang qi ascends, and some illnesses ride that rising momentum out into the open — especially fu xie, the latent pathogen (pathogenic qi hiding inside the body), which is most likely to burst out at this time of year. And drinking wine? That involves the spleen and stomach, and it involves damp-heat. You see — the cause is deduced step by step. People carrying a latent disease-root still exist today: someone catches an infectious illness, it is suppressed at the time, and the pathogenic qi rides along inside him — it may flare up again at any time. So some people truly do carry a hidden disease-root.
How severe was the eruption? Tou mian chi zhong — his whole face was red and swollen and painful; the swelling in front of and behind the ears was especially severe; his chest was oppressed and frustrated (xiong zhong fan men); his throat was uncomfortable (yan hou bu li) — sore, with phlegm inside. But the lower half of his body? Shen ban yi xia jie han — everything below the waist was cold, and his shins (zu jing) were especially freezing.
💬 Note from Doctor Luo: When the area in front of and behind the ears is swollen and painful, you should think of damp-heat of the liver and gallbladder (gan dan shi re) — this is a genuine blazing fire. Many people who later develop facial paralysis first feel severe pain in front of and behind the ears in spring, and they too tend to be quick-tempered with internal fire, which then develops into facial neuritis. This chancellor had heat above: a red face, severe pain in front of and behind the ears; yet everything below his waist was cold — upper heat, lower cold. How miserable! He was driven to desperation: he joined his bed to a heated brick platform (kang) — the upper half of his body slept on the raised bed to cool off, and the lower half lay on the heated platform to warm up. A chancellor-rank official, forced to rig his sleeping arrangements like that every night — that shows how much this illness tormented him.
How far had the illness progressed? No appetite, no energy, utterly drained
Beyond the upper-heat-lower-cold pattern, there was also yin shi jian shao — a very poor appetite — and jing shen kun juan — the body was weak and drained, without energy. What to do? Doctor Luo Tianyi was called in.
💬 Note from Doctor Luo: Notice whom Doctor Luo Tianyi treated — the Right Grand Councillor of the Secretariat; the cases of imperial physicians are full of high officials. Why is studying these cases so meaningful today? The imperial physicians’ patients lived with habits very similar to ours: we moderns also worry, our spleens and stomachs are also injured, our upright qi is also insufficient — all of it falls exactly within the imperial physicians’ scope of treatment. So these old cases are not far from us at all; they deserve careful analysis.
How Doctor Luo Tianyi thought: one pulse diagnosis, and he already knew
Doctor Luo Tianyi felt the pulse: floating and rapid (fu shu) — floating suggested some external pathogen; rapid suggested heat; pressing deeper, the pulse also felt somewhat deficient — the upright qi was insufficient. Isn’t this precisely upper heat and lower cold?
Doctor Luo Tianyi cited the classics: the Huangdi Neijing (Yellow Emperor’s Inner Classic) says “re sheng ze zhong — when heat prevails, there is swelling,” and also “chun qi zhe bing zai tou — in spring, illness strikes the head” — in spring the yang qi rises and the qi mechanism moves upward, so illness tends to erupt in the upper body; this patient’s illness was indeed in the head. The Nanjing (Classic of Difficult Issues) says “xu ze zhong re, bian she zhi ye — when pathogen accumulates, there is swelling and heat; pierce it and shoot it out” — when pathogenic qi accumulates, it swells and heats, so use stone-needle bloodletting (bian shi) to shoot it out, like an arrow, and drive it away.
💬 Note from Doctor Luo: When pathogen accumulates and produces heat and swelling, if you use the right method and let it out with needling, it disperses very easily. Doctor Luo Tianyi’s signature approach was to use needling, moxibustion, and herbal decoction in combination — all three at once. This is a strategy especially worth learning from: while writing the formula, he also used acupuncture and moxibustion, and the patient recovered faster.
Move one: bloodletting — fifty-odd needles, and dark purple blood oozed out drop by drop
Doctor Luo Tianyi pierced the swollen areas in about fifty-odd places. After the needles, blood came out — dark purple-black, beading out drop by drop like dew. After the bloodletting, the swelling and pain quickly dispersed — in an instant, the pain was gone.
💬 Note from Doctor Luo: What does dark purple-black blood tell us? Stasis. Why stasis? Because qi and blood could not circulate — and why could they not circulate? Because heat toxin had accumulated inside. Chinese medicine’s reasoning is fascinating: heat toxin accumulates and blocks the flow of qi and blood, so I let the stagnant blood out with bloodletting; once qi and blood move freely, they can expel the pathogen. This is the method of draining heat by bloodletting — the same approach as cases we discussed earlier.
Move two: moxibustion — nine hundred cones on Qihai (CV6), and twenty-one cones on each Zusanli (ST36)
The heat toxin above was drained by bloodletting and would be cleared further by herbs; but what about the cold below? Doctor Luo Tianyi applied moxibustion with moxa cones to Qihai (CV6) — nine hundred cones in all, burning one, replacing it with another, a full nine hundred cones of moxa! Why moxa Qihai? The lower jiao yang was deficient — this rekindles the primal yang qi and warms the yang to disperse cold. Then at Zusanli (ST36), on both legs, twenty-one cones each — specifically for the freezing shins, and at the same time to guide the heat downward: there was heat above and no communication between upper and lower, so he opened up the qi and blood and let the heat above travel down — then the lower body would no longer be cold.
💬 Note from Doctor Luo: This brings us to Doctor Luo Tianyi’s moxibustion triad — whenever he met a patient with weak spleen and stomach and insufficient primal qi, he loved to moxa three points: Zhongwan (CV12), Qihai (CV6), and Zusanli (ST36). He simplified the entire moxibustion procedure into this triad, and you should definitely remember it. If you have the chance, moxa these points — you will feel your constitution improve noticeably. It really is different! Doctor Luo Tianyi used moxibustion and needling alongside herbal formulas at every turn — this approach is worth learning.
Move three: the small preparation of Pu Ji Xiao Du Yin Zi — herbs aimed entirely upward
Doctor Luo Tianyi judged that this patient’s external pathogen was hiding in the orifices of the head and face (the nose, throat, and such), and had erupted this spring with the season — so ride the momentum and clear it out completely — clear it fully, and it would never flare again. The formula he wrote followed the clear-heat and resolve-toxin strategy — a small preparation of Pu Ji Xiao Du Yin Zi (a streamlined version of the Pu Ji Xiao Du Yin, Universal Relief Toxin-Removing Decoction).
Huangqin and huanglian lead the formula: two bitter-cold herbs, both processed and stir-fried with wine — they resolve toxin, and serve as the sovereign herbs. Why fry them in wine? Wine is dispersing and ascending in nature, and it opens the channels; when bitter-cold herbs are wine-fried, their action travels upward, devoted to draining the heat above.
Jiegeng and gancao: pungent-sweet and warm, ascending — jiegeng (platycodon root) moves upward; the ancients called it the “boat-and-oar herb” (zhou ji zhi yao), ferrying the other herbs up like a boat; gancao (licorice) also has an ascending action, and here it resolves the toxin of the throat. In Doctor Li Dongyuan’s formulas — Bu Zhong Yi Qi Tang (Tonifying the Middle and Augmenting Qi Decoction) and Pu Ji Xiao Du Yin Zi alike — you will find this “upward-moving” herb jiegeng.
Chaihu and shengma: bitter and neutral, thin in flavor — they are yang within yang, able to rise and disperse heat: chaihu (bupleurum) raises the lesser yang qi, shengma (cimicifuga) raises the yangming qi, and together they carry the medicinal action upward.
Lianqiao (forsythia fruit): bitter, pungent, neutral — scatters masses and reduces swelling, clears heat and resolves toxin.
Danggui (angelica root): pungent and warm — invigorates the blood and stops pain — when qi and blood are disharmonized and there is stagnant blood, it regulates them.
Wine-processed dahuang (rhubarb): bitter and cold — rhubarb steamed or roasted with wine is used for two reasons: first, to soften its purging power (not as cold and fierce as raw rhubarb); second, to borrow the wine’s ascending nature and guide the heat of the upper jiao downward to be drained (Doctor Luo Tianyi’s own words: “yin ku xing shang xing zhi dian, qu re er xia yi wei shi” — draw the bitter nature up to the crown, then drive the heat down as envoy). The formula adds a special note: once the bowels move, drop the dahuang — do not continue it.
💬 Note from Doctor Luo: Overall this formula is a small preparation of Pu Ji Xiao Du Yin Zi — fewer ingredients than the full Pu Ji Xiao Du Yin, with danggui and wine-processed dahuang added, but the strategy is the same: clear heat and resolve toxin + wine-processed herbs that act upward + jiegeng, shengma, and chaihu guiding everything up, resolving the toxin of the upper jiao and of the head and face. This is precision-targeted medication: since the illness is in the head and face, every herb I use rises. This theory of deciding ascending and descending by an herb’s qi and flavor — thick or thin — was proposed and clinically applied by the Zhang Yuansu – Li Dongyuan – Luo Tianyi lineage, and later generations benefited enormously. Look at Doctor Zhang Xichun’s Sheng Xian Tang (Ascending the Sinking Decoction) — jiegeng, chaihu, and shengma are all there too — Chinese medical theory runs in an unbroken line. In my own practice, when I encounter this kind of swelling, I often use sangi powder (Panax notoginseng, 三七粉) to break open the stasis, and lianqiao (forsythia) is always included.
One piece of advice: spare your speech, moderate your diet
After writing the formula, Doctor Luo Tianyi gave two instructions: spare your speech (shen yan yu) and moderate your diet (jie yin shi). Taking the herbs while moxibustion continued — what was the result? Bu xun ri er yu — in less than ten days, he was cured!
💬 Note from Doctor Luo: Sparing speech means regulating the emotions — set your mind at ease; don’t worry about everything, don’t stick your nose into everything. Often the more you fret, the more constrained your liver qi becomes. Doctor Luo Tianyi treated officials and could hardly say to their faces “you worry too much, your liver qi is constrained, your mood is off” — but he wrote the official title plainly in the case record, and a practiced eye understands at once: officials of this sort fret, and their liver qi is certainly constrained; constrained liver qi knots, then runs transversely and attacks the spleen-earth (gan qi heng ni ke pi tu), and the spleen and stomach can no longer raise the clear and lower the turbid — that is the core of upper heat and lower cold. So in regulating upper heat and lower cold, regulating the emotions is absolutely crucial.
Why upper heat and lower cold? The middle jiao is blocked, and water and fire never meet
Upper heat and lower cold is a very special concept in Chinese medicine: the qi mechanism is blocked, and upper and lower cannot communicate. The spleen cannot raise the clear and the stomach cannot lower the turbid — the middle jiao is plugged: the heart fire above cannot descend into the kidneys to warm the kidney water; the kidney water below cannot rise to cool the heart fire — the heart fire burns hotter and hotter above while the kidney water grows colder and colder below. This is what is called yin yang li jue — the separation of yin and yang: yin and yang should embrace and warm each other; once they part, a person falls ill. When the upper body is not hot and the lower body is not cold, that is a “ping ren” — a normal person. Once the pathological state sets in — hotter above, colder below — illness has arrived.
💬 Note from Doctor Luo: Moderating the diet means protecting the spleen and stomach. We modern people eat even better than the ancient high officials — buffets, seafood, big prawns, all you can eat — so our spleens and stomachs get blocked far more often than the ancients’. Most modern spleens and stomachs are not starved into weakness; they are overfed into it. A doctor friend of mine once said something very blunt: those with chronic diarrhea and gastrointestinal complaints — if they truly ate some coarse grains, eggplant, cabbage, day in and day out, they would not have those illnesses; eat like that for two months and they would cure themselves. So do not dismiss “spare your speech and moderate your diet” — one regulates the emotions, the other protects the spleen and stomach; these are extremely important matters in recovering from a serious illness.
Bonus: the story of cutting off a latent pathogen at the root
💬 Note from Doctor Luo: The first concept I want to teach you today is fu xie — the latent pathogen: you caught an external pathogen long ago, it hid in your body (especially in the orifices — mouth, nose, throat), and it stays quiet most of the time, flaring up at the slightest trigger. For example, some people, after a cold, always feel a bit of pathogen lingering in the throat; at the slightest draft the throat swells or hurts again — that is the external pathogen never fully cleared, leaving a disease-root behind. I have seen a more typical case: a person’s tonsils kept swelling; whenever he caught a cold, they swelled until he could not speak, his voice gone hoarse. I treated him with Pu Ji Xiao Du Yin, and after just two courses the condition was cut off at the root — the frequently recurring tonsil swelling disappeared! Why? Because a hidden pathogen had been lodging in his mouth, nose, and throat all along; since his constitution never changed, the external pathogen kept flaring. Formulas like Pu Ji Xiao Du Yin target the pathogen precisely, clear it out, and the root is severed. This approach was a specialty of the Qing-dynasty warm-disease school (wen bing xue pai): clear repeatedly, clean out the latent pathogen thoroughly, and it will no longer erupt every so often.
Aftercare: once the heat is cleared, build the spleen and stomach back up
💬 Note from Doctor Luo: One last word: after the bitter-cold herbs have resolved the external pathogen and heat pathogen, you should actually take some spleen-stomach tonics, gently regulate the digestion, and restore the upright qi to fullness — Doctor Luo Tianyi’s school specialized in the spleen and stomach, so aftercare certainly existed, the case record just does not dwell on it. Treating the root is the real treatment: clearing the heat toxin is only the first step; nursing the spleen and stomach back to health and replenishing the upright qi is the true recovery.
Case source: Weisheng Baojian (Precious Mirror of Hygiene), medical case of Doctor Luo Tianyi (case title: Shang Re Xia Han Zhi Yan — a Case of Upper Heat and Lower Cold); commentary based on public lectures by Doctor Luo Dalun (PhD in TCM diagnostics, Beijing University of Chinese Medicine).