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Formulas pungent in flavor and warm in property for relieving exterior syndromes are applicable for the exterior cold syndrome caused by exogenous wind-cold, where the pathogen and right qi is in conflict at the skin level. In addition to the clinical manifestations of aversion to cold, fever, headache, general aching, presence or absence of sweating, floating pulse, other commonly seen signs including relatively serious aversion to cold, lack of thirst, tongue with thin, whitish coating, and a floating and tight or floating and moderate pulse. The symptoms of headache and general aching are relatively distinct in the exterior cold syndrome, because the cold property exhibits the function of contracting.
Formulas pungent in flavor and warm in property for relieving exterior syndromes mainly comprise medicinals with a pungent flavor and a warm property, with relieving exterior syndrome effects, such as má huáng (Herba Ephedrae), guì zhī (Ramulus Cinnamomi), qiāng huó (羌活, Rhizoma et Radix Notopterygii), fáng fēng (防风, Radix Saposhnikoviae), zĭ sū (紫苏, Folium Perillae), jīng jiè (荆芥, Herba Schizonepetae), xì xīn (细辛, Radix et Rhizoma Asari), bái zhĭ (白芷, Radix Angelicae Dahuricae), cōng bái (葱白, Bulbus Allii Fistulosi), and dòu chĭ (豆豉, Semen Sojae Praeparatum) are often used.
Experimental research into the diaphoretic effects of Má Huáng Tāng (Ephedra Decoction), and that of the combinations of different medicinals in this prescription, included observation of the sweat gland epidermal tissues, a sweat tincture, and saliva secretion. The results showed that the overall diaphoretic effect of the Má Huáng Tāng (Ephedra Decoction) prescription is the strongest, and its diaphoretic effect was unaffected without the presence of gān căo (Radix et Rhizoma Glycyrrhizae), but was greatly weakened without the presence of má huáng (Herba Ephedrae).This indicates that the diaphoretic effect of Má Huáng Tāng (Ephedra Decoction) is mainly attributed to má huáng (Herba Ephedrae), with guì zhī (Ramulus Cinnamomi) and xìng rén (Semen Armeniacae Amarum)playing a secondary role. ( Sichuan Journal of Physiological Sciences , 四川生理科学杂志, 1999, 4:31)
There is an intimate relationship between the formulary combination and the constitution of the patient, the concurrent syndrome and the extent of the disease. Analysis of the formulas from the past dynasties reveals the following main aspects:
For example, xìng rén (Semen Armeniacae Amarum) and jié gĕng (桔梗, Radix Platycodonis).The lung governs diffusion, purification, the descent of qi, and corresponds to the skin and hairs, so when the body is attacked by wind-cold on the exterior, the skin and hairs are closed off, and the wind cold pathogen invades the lung, and causes the lung qi to fail to diffuse, and qi dynamics to counter-flow upwards. Then cough and expectoration, even dyspnea and other symptoms may manifest. Therefore, aside from inducing sweating to relieve exterior syndromes, medicinals which can disperse the lung to relieve asthma, or relieve cough and transform phlegm should be combined in the treatment. For example, Má Huáng Tāng (Ephedra Decoction) , from the Discussion on Cold Damage and Sān Ào Tāng (Rough and Ready Three Decoction, 三拗汤), from the Formulary of the Bureau of Medicines of the Taiping Era ( Tài Píng Huì Mín Hé Jì Jú Fāng , 太平惠民和剂局方) both use má huáng (Herba Ephedrae) as the chief medicinal to induce sweating in order to relieve exterior syndromes, and to disperse the lung to relieve asthma. At the same time, these formulas both include xìng rén (Semen Armeniacae Amarum)to enhance the effect of relieving cough and asthma.
In the formula, Huá Gài Săn (Florid Canopy Powder, 华盖散) , from the Extensive Wide Salvation Formulary ( Bó Jì Fāng , 博济方), in addition to má huáng (Herba Ephedrae), xìng rén (Semen Armeniacae Amarum) and gān căo (Radix et Rhizoma Glycyrrhizae), sāng bái pí (桑白皮, Cortex Mori), zĭ sū zĭ (紫苏子, Fructus Perillae), chén pí (陈皮, Pericarpium Citri Reticulatae)and chì fú líng (赤茯苓, Poria Rubra) were added, resulting in great curative effects of relieving cough and asthma, regulating the flow of qi and transforming phlegm. Another example is Shēn Sū Yĭn (Ginseng and Perllia Beverage, 参苏饮) , as recorded in the Discussion on Illnesses, Patterns, and Formulas Related to the Unification of the Three Etiologies ( Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn , 三因极一病证方论). This formula is comprised of medicinals which invigorate qi and relieve exterior syndromes, combining jié gĕng (Radix Platycodonis), chén pí (Pericarpium Citri Reticulatae), mù xiāng (木香, Radix Aucklandiae), fú líng (茯苓, Poria), zhĭ qiào (枳壳, Fructus Aurantii), qián hú (前胡, Radix Peucedani), bàn xià (半夏, Rhizoma Pinelliae), and resulting in the effects of dispersing the lung and regulating qi, relieving cough and transforming phlegm. Moreover, this compatible method not only shows the above effects, but results in the formula being indicated for cough and dyspnea. In addition, the medicinals also supplement each other to enhance the effect of inducing sweating to relieve exterior syndromes. Analysis of Má Huáng Jiā Zhú Tāng (Ephedra Decoction Plus White Atractylodes, 麻黄加术汤) and Má Huáng Xìng Rén Yì Yĭ Gān Căo Tāng (Ephedra, Apricot Kernel, Coix, and Licorice Decoction, 麻黄杏仁薏苡甘草汤) , are both recorded in the Essentials from the Golden Cabinet for dampness syndromes rather than for cough and dyspnea, and shows that both formulas include xìng rén (Semen Armeniacae Amarum) for dispersing the lung and regulating qi, for the purpose of enhancing the effects of inducing sweating and dispelling dampness of má huáng (Herba Ephedrae) and guì zhī (Ramulus Cinnamomi). This shows that combining the formulas for relieving exterior syndromes with medicinals which can disperse the lung and relieve cough and asthma is a relatively universal compatible method.
Experimental research through the study of the asthma-relieving effects of the extract of Má Xìng Shí Gān Tāng (Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction)and Má Xìng Shí Gān Tāng (Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction) with the absence of xìng rén (Semen Armeniacae Amarum) revealed that by intragastric administration, both of the formulas could distinctly release the airway resistance in the immediate reaction period of the asthma model in guinea pigs, induced and inspired by Dermatophagoides Pteronyssinus (DP), reduced the ratio of polymorph nuclear leukocytes (PMN)in the pulmonary alveoli processing bath. The effect of the former prescription was especially excellent. This indicates that Má Xìng Shí Gān Tāng (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction) exhibits relatively remarkable effects in relieving asthma, and xìng rén (Semen Armeniacae Amarum) in this formula demonstrates the important significance of combination ( New Chinese Medicine , 1998, 4:40).
When combining medicinals with the effects of dispersing the lung and relieving asthma in the formulas which are pungent in flavor and warm in property for relieving exterior syndromes, má huáng (Herba Ephedrae) is often selected as the main medicinal that can simultaneously induce sweating to relieve exterior syndromes and can disperse the lung and relieve asthma. Also, in regards to combination, it would be better to choose those medicinals that can disperse the lung, relieve cough and asthma and can disperse wind-cold, such as xìng rén (Semen Armeniacae Amarum), which is a medicinal that “ not only shows the effect of dispersing wind-cold, but also exhibits the function of descending qi to relieve asthma ” (既有发散风寒之能，复有下气除喘之功) ( Seeking Accuracy in the Materia Medica ).Thus if má huáng (Herba Ephedrae) is combined with xìng rén (Semen Armeniacae Amarum), the two medicinals will bring out the best in each other, and therefore they are the basic medicinal pair for combination in the formulas that are pungent in flavor and warm in property for relieving exterior syndromes.
Experimental research on Má Huáng Tāng (Ephedra Decoction) has showed that this formula has anti-febrile effects, along with the functions of promoting the secretions of the bronchial glands, relieving cough, dispelling phlegm, and expanding the bronchi. In particular, it can quickly depress the skin temperature of mice and can reach a maximum value in thirty minutes, with an average reduction of 5℃. This thus proved the rationale of this method for combination.( Chinese Medicine Journal , 1984, 8:63)
As far as the proportion of medicinals for dispersing the lung and relieving asthma in the formulas for exterior syndromes is concerned, it is determined by the degree of the exterior syndrome and that of the lung’s failure to diffuse and descend. For example, both Má Huáng Tāng (Ephedra Decoction) and Sān Ào Tāng (Rough and Ready Three Decoction) use má huáng (Herba Ephedrae), xìng rén (Semen Armeniacae Amarum)and gān căo (Radix et Rhizoma Glycyrrhizae)to induce sweating to relieve exterior syndromes and disperse the lung and relieve asthma, but the former formula is applicable for the relatively serious exterior cold syndrome, so guì zhī (Ramulus Cinnamomi) is added to enhance the effect of inducing sweating to relieve the exterior syndrome; the latter formula is for symptoms with serious cough, so guì zhī (Ramulus Cinnamomi) is not used to accentuate the function of dispersing the lung and relieving asthma. The medicinals in these two formulas only differ by one medicinal, but the emphasis in effects and symptoms are very different. This adequately demonstrates the strictness required in formulary combination.
For example, gān căo (Radix et Rhizoma Glycyrrhizae), shēng jiāng (生姜, Rhizoma Zingiberis Recens), and dà zăo (Fructus Jujubae)The medicinals for relieving exterior syndromes are mostly pungent in flavor, light in texture, thin in qi, and so, they not only dispel pathogens to relieve exterior syndromes, but also vent out and injure the right qi, so the appropriate combination requires pungent medicinals along with sweet medicinals in the formulas for relieving exterior syndromes. Firstly, “ pungent and sweet flavors show a diffusing characteristic and belong to yang ” (辛甘发散为阳) ( Basic Questions - Great Treatise on the Essentials of Supreme Truth ), so it can enhance the effect of inducing sweating to relieve exterior syndromes. Secondly, gān căo (Radix et Rhizoma Glycyrrhizae) can benefit qi to help the source of sweating so that the formula can induce sweating without injuring the right qi.
Analysis of the formulas for relieving exterior syndromes recorded in the Discussion on Cold Damage and the Essentials from the Golden Cabinet , such as Má Huáng Tāng (Ephedra Decoction), Guì Zhī Tāng (Cinnamon Twig Decoction) , Gé Gēn Tāng (Pueraria Decoction), Dà Qīng Lóng Tāng (Major Green-Blue Dragon Decoction), Xiăo Qīng Lóng Tāng (Minor Green-Blue Dragon Decoction), show that all these formulas used pungent flavored medicinals combined with sweet flavored medicinals. Therefore, it is somewhat limited to explain the meaning behind the combination with gān căo (Radix et Rhizoma Glycyrrhizae) in these formulas solely for the purpose of moderating the actions of other herbs.
Combining shēng jiāng (Rhizoma Zingiberis Recens) and dà zăo (Fructus Jujubae) in formulas for relieving exterior syndromes can achieve the effect of harmonizing nutritive and defensive qi. This is because taiyang governs the exterior, and commands the nutritive and defensive qi in the whole body, so when the nutritive and defensive qi are moderated, the defensive function is solid and compact and can defend against external pathogens. When external pathogens first enter the body, nutritive qi and defensive qi bear the brunt of the damage, right qi and pathogenic qi encounter and combat one another, leading to the loss of harmony between nutritive qi and defensive qi. It is the main pathomechanism of the taiyang exterior syndrome.
Thus it can be seen, that in the treatment of exterior syndromes, the key point is to regulate nutritive qi and defensive qi and restore their functions. In this way, the defensive function is strong and the pathogen is dispelled and the symptom relieved. The way of the formulas for exterior syndromes to remedy exterior syndromes is through the effects of inducing sweating and expelling pathogenic factors from the muscles and skin, regulating nutritive qi and defensive qi, leading to the expulsion of the pathogens from the exterior. For instance, Cheng Wu-ji indicated in the discussion of Guì Zhī Tāng (Cinnamon Twig Decoction) that:“ Shēng jiāng (Rhizoma Zingiberis Recens) and dà zăo (Fructus Jujubae) are sweet in flavor, and although they can disperse, they should not be used only for this purpose. As the spleen governs the movement of fluids for the stomach, the use of shēng jiāng (Rhizoma Zingiberis Recens) and dà zăo (Fructus Jujubae) is specific for helping the spleen to circulate fluids and regulate nutritive qi and defensive qi ” (姜、枣味甘，固能发散，而此又不特专于发散之用．以脾主为胃行其津液，姜、枣之用，专于行脾之津液，而和营卫者也) cited from the Clarification of the Theory of Cold Damage .The other formulas such as Dà Qīng Lóng Tāng (Major Green-Blue Dragon Decoction) and Gé Gēn Tāng (Pueraria Decoction), use shēng jiāng (Rhizoma Zingiberis Recens) and dà zăo (Fructus Jujubae) for the same purpose.
However, it should be pointed out that there was not a consensus among the doctors of the past as to the meaning of combining zhì gān căo (炙甘草, Radix et Rhizoma Glycyrrhizae Praeparata cum Melle) with má huáng (Herba Ephedrae) and guì zhī (Ramulus Cinnamomi). Zhang Nan said, “ gān căo (Radix et Rhizoma Glycyrrhizae) can regulate the spleen and the stomach, and moderate the effect of the rapid dispersion of má huáng (Herba Ephedrae) and guì zhī (Ramulus Cinnamomi) ” (甘草和脾胃，以缓麻、桂迅发之性), cited from A Stick to Awaken Physicians - Essence of Clarification on the Theory of Cold Damage ( Yī Mén Bàng Hè - Shāng Hán Lùn Bĕn Zhĭ , 医门棒喝·伤寒论本旨 ). Zhang Bin-cheng commented: “ Considering that má huáng (Herba Ephedrae) and guì zhī (Ramulus Cinnamomi) are warm in property, and might result in the exhaustion of yang due to excessive sweating, they should be combined with gān căo(Radix et Rhizoma Glycyrrhizae), to reduce their properties, with its sweet flavor ” (又恐麻、桂之性温，以致汗多亡阳，故必监以甘草之甘缓)cited from the Convenient Reader of Established Formulas ( Chéng Fāng Biàn Dú , 成方便读). Zhang Xi-chun also said: “ Since gān căo (Radix et Rhizoma Glycyrrhizae) is sweet and soothing, it can reduce the strength of sweating of má huáng(Herba Ephedrae) and relieve the slight toxicity of xìng rén (Semen Armeniacae Amarum) ” (至于甘草之甘缓，能缓麻黄发汗之猛烈，并能解杏仁之小毒), cited from Essays on Medicine Esteeming the Chinese and Respecting the Western . Nevertheless, regarding the meaning of “ pungent and sweet flavor shows a diffusing character and belongs to yang ”(辛甘发散为阳), most doctors hold that gān căo (Radix et Rhizoma Glycyrrhizae)is sweet in flavor and neutral in property, can benefit qi to enrich the origin of sweat, and can regulate the actions of other herbs. So combining it with pungent medicinals for relieving exterior syndromes can enhance the effect of sweating. Therefore, the general consensus is that the combination with gān căo (Radix et Rhizoma Glycyrrhizae) in formulas is good for relieving exterior syndromes.
For example, sháo yào (芍药, Radix Paeoniae).For exterior deficiency syndrome due to exogenous wind-cold, marked by headache, fever, sweating, aversion to wind, and floating and moderate pulse, this is mostly because the defensive qi and yang are not consolidated, and the muscles and skin are loosened. So if the treatment were simply to dispel pathogenic factors from the muscles and skin and to expel pathogens from the exterior, sweating would be induced but nutritive qi and ying would become injured; and if treatment were to involve simply astringing yin and harmonizing nutritive qi, pathogens in the exterior would linger and become difficult to dispel.
Therefore, in the combination of two kinds of medicinals in prescription formulation and medicinal selection, one should make the formulas have the effect of astringing while dispelling, and contain the contracting effect while dispersing, so it can induce sweating without damaging ying, astringe ying and avoid lingering pathogens. This would then achieve the action of dispelling pathogenic factors from the muscles and skin, expelling pathogens from the exterior, and regulating nutritive qi and defensive qi. Guì Zhī Tāng (Cinnamon Twig Decoction) , recorded in the Discussion on Cold Damage, is a representative formula of this combination method. Wu Qian and others discussed the combination in this formula as follows: “ Guì zhī (Ramulus Cinnamomi) is pungent in flavor and warm in property, pungent flavor can disperse, while warm property can promote the flow of defensive qi and yang; sháo yào (Radix Paeoniae) is sour in flavor and cold in property, and sour flavor can astringe, while cold property can promote nutritive qi and ying. When guì zhī (Ramulus Cinnamomi) is used as the chief medicinal to sháo yào (Radix Paeoniae), the purpose is to astringe sweat while inducing sweating; when sháo yào (Radix Paeoniae) is used as the deputy medicinal to guì zhī (Ramulus Cinnamomi), it achieves the effect of regulating defensive qi while harmonizing nutritive qi ” (桂枝辛温，辛能发散，温通卫阳；芍药酸寒，酸能收敛，寒走营阴．桂枝君芍药，是于发汗中寓敛汗之旨；芍药臣桂枝，是于和营中有调卫之功), cited from Golden Mirror of the Medical Tradition - Correction of Zhong jing’s Literature ( Yī Zōng Jīn Jiàn - Dìng Zhèng Zhòng Jĭng Quán Shū , 医宗金鉴·订正仲景全书). This commentary is quite concise, and deserves to be studied.
This combination method usually requires that medicinals, pungent in flavor and warm in property, for expelling pathogens in the exterior and regulating defensive qi, be combined with medicinals sour in flavor and cold in property, for astringing yin and harmonizing nutritive qi, in the same dosage. In this way, the formulas can regulate the exterior and the interior to the same degree, and achieve the effect of regulating nutritive qi and defensive qi, as well as yin and yang, while at the same time preventing the formulas from becoming too pungent and dispelling, or too sour and astringing. For example, the dosage of guì zhī (Ramulus Cinnamomi) is the same as that of sháo yào (Radix Paeoniae) in Guì Zhī Tāng (Cinnamon Twig Decoction). This method may be imitated.
Wang Miao-da indicated that: “ Guì zhī(Ramulus Cinnamomi) is a yang medicinal in the blood, and mainly acts on exterior syndromes; sháo yào (Radix Paeoniae) is a yin medicinal in the blood, and mainly acts on interior syndromes. When the two medicinals are combined in the same dosage, guì zhī (Ramulus Cinnamomi)merges with sháo yào (Radix Paeoniae) so as not to simply act on exterior syndromes; at the same time, sháo yào (Radix Paeoniae) merges with guì zhī (Ramulus Cinnamomi), so as not to simply act on the interior. Thus the formula is suitable for syndromes which are neither completely exterior nor completely interior, and act on both nutritive and defensive qi” (桂为血分阳药，主走表；芍为血分阴药，主走里。今以二物平配，则桂得芍，而不任性走表；芍得桂，而不任性走里．适于不表不里，而行于营卫), cited from the Brief Introduction of Formulas in the Han Dynasty ( Hàn Fāng Jiăn Yì , 汉方简义 ). This discussion revealed the doctor’s ingenuity in the dosage of combination. Otherwise, if the dosage of guì zhī (Ramulus Cinnamomi) were larger than that of sháo yào (Radix Paeoniae), or vice versa, the formula would lose its effects of dispelling pathogenic factors from the muscles and skin, expelling pathogens from the exterior, and regulating nutritive qi and defensive qi. For example, in Guì Zhī Jiā Guì Tāng (Cinnamon Twig Decoction With Extra Cinnamon, 桂枝加桂汤), and Guì Zhī Jiā Sháo Yào Tāng (Cinnamon Twig Decoction Plus Peony, 桂枝加芍药汤) , both recorded in the Discussion on Cold Damage , the medicinals used are the same as those in Guì Zhī Tāng (Cinnamon Twig Decoction). However, the difference is that the former is Guì Zhī Tāng (Cinnamon Twig Decoction) with an added dosage of guì zhī (Ramulus Cinnamomi), leading to the effects of warmly promoting heart yang, calming the rush and descending the counter flow of qi, and is an effective formula for “running piglet qi syndrome” due to the heart yang deficiency leading to the ascent of water and cold. The latter formula is Guì Zhī Tāng (Cinnamon Twig Decoction) with double the dosage of sháo yào (Radix Paeoniae), leading to effects of promoting yang and benefitting the spleen, promoting blood circulation and removing stasis from the meridians, and is a formula commonly used for abdominal fullness and occasional pain due to deficiency in the spleen and stomach, and stasis of qi and blood.
Orthogonal design was applied to observe the effects of Guì Zhī Tāng (Cinnamon Twig Decoction) as a whole, as well as its different combinations on the inhibition of viral flu pneumonia in mice, the inhibition of swelling of the foot caused by carrageenin, as well as their ability to reinforce the function of clearance of carbon particles in the blood(Reticuloendothelial System, RES). The results showed that Guì Zhī Tāng (Cinnamon Twig Decoction) as a whole distinctly excelled its decomposed combinations in both its effects of anti-inflammation and reinforcing RES function. The influence of different medicinal combinations to different observed targets was varied. In terms of a single medicinal, guì zhī (Ramulus Cinnamomi) showed the best antiinflammatory effect, sháo yào (Radix Paeoniae)showed the best effect of inhibiting viruses, and dà zăo (Fructus Jujubae) showed the best effect of enhancing the function of RES. In the aspect of medicinals compatibility, guì zhī (Ramulus Cinnamomi) combined with sháo yào (Radix Paeoniae) resulted in a reinforced effect of antiinflammation; guì zhī (Ramulus Cinnamomi)combined with shēng jiāng (Rhizoma Zingiberis Recens) showed an increase in strength of the anti-inflammatory effects and RES function; sháo yào (Radix Paeoniae) combined with gān căo (Radix et Rhizoma Glycyrrhizae) enhanced the anti-viral and anti-inflammatory effects, as well as phagocytosis; sháo yào (Radix Paeoniae)combined with dà zăo (Fructus Jujubae)enhanced the effect of resisting the pathological changes of pneumonia, but antagonized RES activity; gān căo (Radix et Rhizoma Glycyrrhizae) combined with dà zăo (Fructus Jujubae) enhanced the anti-inflammatory effects of anti-inflammation as well as the RES function.( Traditional Chinese Medicine Magzine , 1990, 12:41.)
What should be especially noted is that, through the same dosage compatibility, consisting of ingredients which both opposed and complement each other, Guì Zhī Tāng (Cinnamon Twig Decoction) can both regulate ying qi and defensive qi, and regulate yin and yang. On this matter, Xu Zhong-ke said: “ When applied to exterior syndromes, the formula can expel pathogenic factors from the muscles and skin, and regulate nutritive and defensive qi; when applied to interior syndromes, the formula can transform qi and regulate yin and yang ”(表证得之，为解肌和营卫；内证得之，为化气和阴阳), cited from the Commentary on Essentials from the Golden Cabinet ( Jīn Guì Yào Luè Lùn Zhù , 金匮要略论注). So Guì Zhī Tāng (Cinnamon Twig Decoction) can always be used for both exterior syndromes due to exogenous factors, with or without the presence of sweating, as well as for complicated syndromes caused by internal damage, where the pathomechanism is attributed to a disharmony of nutritive qi and defensive qi, resulting in a disorder of yin and yang. Its dual-adjusting effects have gained increasing recognition in clinical practice and in experiment research as well. Current experimental studies of Guì Zhī Tāng (Cinnamon Twig Decoction) on the secretory effect of sweat glands have shown that this formula has distinct effects of inducing sweating on normal rats. It has the effect of promoting sweating in mice infected by the flu virus whose sweat gland secretory function was inhibited, and lead to the recovery of sweat gland function; for those rat models whose sweat glands are inhibited by atropine, it can enhance the secretion of their sweat glands; for those rat models with an accentuated sweat secretory function induced by atropine, it can reduce their diaphoretic activity, and lead to a recovery to normal levels of sweat gland activity. This illustrates that Guì Zhī Tāng (Cinnamon Twig Decoction) exhibits dual-adjusting effects on the secretion of sweat glands ( Modern Journal of Integrated Traditional Chinese Medicine , 1991, 1:34).
For example, shí gāo (Gypsum Fibrosum), huáng qín (Radix Scutellariae), and shēng dì (Radix Rehmanniae). Generally speaking, for simple exterior cold syndromes, medicinals with the function of clearing heat but that are cold in property are prohibited in order to prevent the possibility of trapping the cold inside and closing up the exterior. However, because when the exterior is restricted by pathogenic cold and defensive yang becomes trapped and transforms into heat, or when existent interior heat is aggravated by pathogenic qi due to windcold, the syndrome of exterior cold and interior heat is often produced. Therefore, when the clinical symptoms are mainly characterized by exterior cold syndromes, it is suitable to combine medicinals with the function of clearing heat, in the formulas pungent in flavor and warm in property, for relieving exterior syndromes. For example, Dà Qīng Lóng Tāng (Major Green-Blue Dragon Decoction) , recorded in the Discussion on Cold Damage , was formulated for the combined syndrome of exterior excess due to wind-cold and interior clogged heat, in which má huáng (Herba Ephedrae) was used in a large dosage, guì zhī (Ramulus Cinnamomi) was coordinated with it to induce sweating to relieve the exterior syndrome, and shí gāo (Gypsum Fibrosum) was combined for clearing heat and eliminating dysphoria, thus achieving the effects of treating the exterior and interior syndrome. Another example is Jiŭ Wèi Qiāng Huó Tāng (Nine-Ingredient Notopterygium Decoction) , recorded in the Medicine Difficult to Know . This has many medicinals that are pungent in flavor and warm in property for diffusing cold, dispelling wind and eliminating dampness, such as qiāng huó (Rhizoma et Radix Notopterygii), fáng fēng (Radix Saposhnikoviae), chuān xiōng (川芎, Rhizoma Chuanxiong), xì xīn (Radix et Rhizoma Asari), cāng zhú (苍术, Rhizoma Atractylodis), bái zhĭ (Radix Angelicae Dahuricae), which are the main ingredients for treating an exterior cold syndrome due to exterior wind-cold-damp evil, are combined with huáng qín (Radix Scutellariae) and shēng dì (Radix Rehmanniae) in order to clear and purge the interior heat and to prevent the medicinals pungent and aromatic in flavor and warm and dry in property, in the formulas from causing impairment to body-fluids.
In this kind of combination, it is recommended that medicinals, with the functions of clearing and purging interior heat and expelling pathogenic factors from the muscles and skin, be chosen. An example is shí gāo (Gypsum Fibrosum), which is “ cool and diffusible, with the force of expelling pathogenic factors from the muscles and skin, and thus can be used without consideration for diseases caused by an exogenous pathogenic factor with sthenic fever ” (凉而能散，有透表解肌之力．外感有实热者，放胆用之), cited from Essays on Medicine Esteeming the Chinese and Respecting the Western . Not only are these the medicinals of choice, in formulas pungent in flavor and warm in property, for relieving exterior syndromes, they are also the best choice, in formulas pungent in flavor and cool in property, for relieving exterior syndromes. As for medicinals for clearing heat that are bitter and cold, or sweet and cold, such as huáng qín (Radix Scutellariae) and shēng dì (Radix Rehmanniae), they can be used only for the syndrome with original interior heat, but are not suitable for the syndrome with “clogged heat” or without heat at all. Wang Ang noted, regarding the formula Jiŭ Wèi Qiāng Huó Tāng (Nine-Ingredient Notopterygium Decoction), that “ huáng qín(Radix Scutellariae) is bitter and cold, and shēng dì (Radix Rehmanniae) is cold and stagnant; the two medicinals are suitable for syndromes after the occurrence of fever and should be reduced in dosage for syndromes without fever ” (黄芩苦寒，生地寒滞，二味苟用于发热之后，则当；若未发热，犹当议减也), cited from the Medical Formulas Collected and Analyzed.
In addition, if both the exterior syndrome and interior heat syndrome are serious, medicinals for clearing heat should be increased in proportion so as to be used as formulas for relieving both the exterior and interior syndrome. For example, in Sān Huáng Shí Gāo Tāng, recorded in Six Texts on Cold Damage ( Shāng Hán Liù Shū , 伤寒六书), má huáng (Herba Ephedrae) and dòu chĭ (Semen Sojae Praeparatum) are combined with shí gāo (Gypsum Fibrosum), zhī zĭ (Fructus Gardeniae) and “the three huáng ”: Huáng qín (Radix Scutellariae), huáng lián (Rhizoma Coptidis) and huáng băi (Cortex Phellodendri Chinensis); and in Dà Qiāng Huó Tāng (Major Notopterygium Decoction) , recorded in Medicine Difficult to Know , qiāng huó (Rhizoma et Radix Notopterygii), dú huó (独活, Radix Angelicae Pubescentis), chuān xiōng (Rhizoma Chuanxiong), xì xīn (Radix et Rhizoma Asari), cāng zhú (Rhizoma Atractylodis) and fáng fēng (Radix Saposhnikoviae) are combined with zhī mŭ (知母, Rhizoma Anemarrhenae), shēng dì (Radix Rehmanniae), huáng qín (Radix Scutellariae) and huáng lián (Rhizoma Coptidis).Both of them are the representative formulas for relieving the exterior syndrome and clearing the interior. It is indicated by Wu Qian, et al. in the discussion on Sān Huáng Shí Gāo Tāng (Three Yellows and Gypsum Decoction, 三黄石膏汤)that “ má huáng (Herba Ephedrae) and dòu chĭ(Semen Sojae Praeparatum), when combined with shí gāo (Gypsum Fibrosum) and the three huáng, can greatly diffuse exterior heat while keeping interior heat untouched; the three huáng and shí gāo (Gypsum Fibrosum), when combined with má huáng (Herba Ephedrae) and dòu chĭ(Semen Sojae Praeparatum), can notably clear interior heat without obstructing the exterior pathogenic qi ” (麻、豉得石膏、三黄，大发表热而不动里热；三黄、石膏得麻、豉，大清内热而不碍外邪), cited from the Golden Mirror of the Medical Tradition - Discussions of Selected Formulas from Eminent Physicians ( Yī Zōng Jīn Jiàn - Shān Bŭ Míng Yī Fāng Lùn , 医宗金鉴·删补名医方论). This indication provides further theoretical explanation for the use of formulas for relieving exterior syndromes and clearing the interior.
For example, fù zĭ (Radix Aconiti Lateralis Praeparata), gān jiāng (Rhizoma Zingiberis), ròu guì (肉桂, Cortex Cinnamomi). When the body is deficient in yang and interior cold encounters the exogenous wind-cold, the pathogen not only stays in the exterior, but also goes deep into the interior, thus forming either the syndrome of cold in both the exterior and interior, or the syndrome caused by exterior wind-cold and internal injury from digestion of raw and cold foods. When treating this kind of syndrome, we should not only treat the exterior but also consider the interior. An example is Xiăo Xù Mìng Tāng (Minor Life-Prolonging Decoction, 小续命汤) , recorded in the Important Formulas Worth a Thousand Gold Pieces [for Any Emergency] . In this formula, má huáng (Herba Ephedrae), fáng fēng (Radix Saposhnikoviae), fáng jĭ (防己, Radix Stephaniae Tetrandrae) and shēng jiāng (Rhizoma Zingiberis Recens) are used for dispelling wind and diffusing cold to open up the exterior, while fù zĭ (Radix Aconiti Lateralis Praeparata), ròu guì (Cortex Cinnamomi) and rén shēn (Radix et Rhizoma Ginseng) are combined for aiding yang and benefitting qi to warm the interior. Combining the two kinds of medicinals can lead to the effects of warming the interior and dispelling wind, and this formula has become a representative formula for treating real apoplexy due to exogenous wind-cold. Another example is Wŭ Jī Săn (Five Accumulations Powder, 五积散) , recorded in Secret Prescriptions on Curing Fractures Imparted by Immortals ( Xiān Shòu Lĭ Shāng Xù Duàn Mì Fāng , 仙授理伤续断秘方), in this formula, má huáng (Herba Ephedrae) and bái zhĭ (Radix Angelicae Dahuricae) are used for inducing sweating to relieve the exterior syndrome; gān jiāng (Rhizoma Zingiberis) and ròu guì (Cortex Cinnamomi) are used for warming the interior and dispelling cold; cāng zhú (Rhizoma Atractylodis) and hòu pò (厚朴, Cortex Magnoliae Officinalis) are used for drying dampness and strengthening the spleen; bàn xià (Rhizoma Pinelliae), chén pí (Pericarpium Citri Reticulatae), fú líng (Poria), jié gĕng (Radix Platycodonis) and zhĭ qiào (Fructus Aurantii) are used for regulating qi and transforming phlegm; dāng guī (当归, Radix Angelicae Sinensis)and chuān xiōng (Rhizoma Chuanxiong) are used for moderating and invigorating blood; chì sháo (赤芍, Radix Paeoniae Rubra) and gān căo (Radix et Rhizoma Glycyrrhizae) are used for harmonizing the interior and easing pain. All of the above medicinals are combined to formulate a formula for inducing sweating to relieve exterior syndromes and warming the interior, and are very suitable for syndromes due to exogenous wind-cold in the exterior and internal injury due to ingestion of raw and cold foods, marked by fever without sweating, aches in the body and head, fullness in the stomach and anorexia, vomiting and bellyache.
In addition, because inducing sweating is the main approach for relieving pathogens in the exterior, and the formation of sweat is transformed from yin blood and is also dependent on the transpiration of yang qi, so when the body is deficient in yang and interior cold is affected by exogenous pathogens, it would be difficult to transpire and induce sweating, as well as to dispel the pathogens outward. In this situation, if the emphasis were only on inducing sweating to relieve exterior syndromes, the yang qi would become more deficient. If the patient’s disease were mild, then the sweating would not be induced and the disease may become serious; if the patient’s disease were severe, the syndrome of profuse sweating and exhaustion of yang may occur and the disease may become dangerous at once. So for those with deficient yang and interior cold combined with exterior cold syndrome, sweating and aiding yang should both be applied in treatment. An example is Má Huáng Fù Zĭ Xì Xīn Tāng (Ephedra, Aconite, and Asarum Decoction) , recorded in the Discussion on Cold Damage . In this formula, má huáng (Herba Ephedrae) which is pungent and warm, is used for sweating and for relieving exterior syndromes and diffusing cold; fù zĭ (Radix Aconiti Lateralis Praeparata) is used for warming channels, aiding yang, and dispelling pathogens outward; xì xīn (Radix et Rhizoma Asari) is used for aiding má huáng (Herba Ephedrae) in relieving exterior syndromes in the exterior, and aiding fù zĭ (Radix Aconiti Lateralis Praeparata)to warm the yang in the interior. This is the representative formula for aiding yang in order to relieve exterior syndromes. Ke Qin had the following analysis of this formula: “ Only the combination of fù zĭ (Radix Aconiti Lateralis Praeparata) and má huáng (Herba Ephedrae)can regulate both the exterior and the interior, so that wind-cold would be diffused, yang can recover naturally, and essence may be hidden and ying not disturbed ”(惟附子与麻黄并用，内外咸调，则风寒散而阳自归，精得藏而阴不扰), cited from the Collected Writings on Renewal of the Discussion on Cold Damage - Further Appendices to the Discussion on Cold Damage . The compatible actions of Má Huáng Fù Zĭ Xì Xīn Tāng (Ephedra, Aconite, and Asarum Decoction) and the medicinals in this formula have been observed through studies on the influence on the primary immunological response in mice. Results showed that the action of prepared fù zĭ (Radix Aconiti Lateralis Praeparata) was the most distinct among the single medicinals in relation to the action of accelerating the production of antibody IgM, and the action of the combination of má huáng (Herba Ephedrae) and xì xīn (Radix et Rhizoma Asari)was the most conspicuous among all of the medicinal pairs. It showed that in the compound formulas, the compatible actions were not simply the summarization of the action of each single medicinal ( Journal of Natural Medicine , 和汉医药学杂志, 2001, 2:89). The other instance is Zài Zào Săn (Renewal Powder, 再造散) , recorded in Six Texts on Cold Damage , in which Chinese medicincals including qiāng huó (Rhizoma et Radix Notopterygii), fáng fēng (Radix Saposhnikoviae), chuān xiōng (Rhizoma Chuanxiong), xì xīn (Radix et Rhizoma Asari), guì zhī (Ramulus Cinnamomi), shēng jiāng (Rhizoma Zingiberis Recens) were all used for diffusing cold and relieving exterior syndromes. At the same time, fù zĭ (Radix Aconiti Lateralis Praeparata), rén shēn (Radix et Rhizoma Ginseng) and huáng qí (黄芪, Radix Astragali) were combined for aiding yang and benefitting qi. This represents another example of this compatible method. As for the syndrome of deficient yang affected by exogenous factors where the deficiency of yang is the main syndrome, treatment should first warm the yang, then relieve the exterior. The Discussion on Cold Damage indicated: “ To treat the syndrome marked by diarrhea, fullness in the abdomen, with aches in the body, we should warm the interior first, and then relieve the exterior. To warm the interior, Sì Nì Tāng ( Counterflow Cold Decoction ) is suitable and to relieve the exterior, Guì Zhī Tāng ( Cinnamon Twig Decoction ) is suitable ” (下利腹胀满，身体疼痛，先温其里，乃攻其表．温里宜四逆汤，攻表宜桂枝汤). This method of respectively treating the syndrome of deficiency of yang in the spleen and kidney and then the exterior syndrome, may be referenced in clinical applications. At the same time, it demonstrates that medicinals for warming the interior and helping yang have compatible significance in holding the balance in formulas for helping yang to relieve exterior syndromes.
For example, rén shēn (Radix et Rhizoma Ginseng) and huáng qí (Radix Astragali).When exogenous pathogens invade people with deficient qi in the spleen and lung, and with weak defensive qi, then the right qi and deficient qi become intermingled and often form the disease of lingering pathogens in the exterior, which is difficult to cure. In this situation, if the emphasis is on relieving the exterior syndrome, then it would be difficult to induce sweating; if only medicinals for tonifying qi were used, it would be easy to induce the stasis of the pathogen and the disease may become intractable. So for the syndromes affected by exogenous factors due to qi deficiency, medicinals for tonifying qi are often adequately combined in formulas for relieving exterior syndromes, and achieve the effect of benefitting qi to relieve the exterior syndrome. Zhao Yuhuang reflected on this: “… because in treatment, when combining diffusing with tonifying, the pathogens would be unable to remain; when combining tonifying with diffusing, true qi and original qi would not become exhausted and dispersed. This is just the subtly wonderful point made when ancient doctors created this formula ”(盖补中兼发，邪气不至于流连；发中带补，真元不至于耗散，此古人制方之妙也), cited from Formula Discussions by Famous Physicians from the Past and Present ( Gŭ Jīn Míng Yī Fāng Lùn , 古今名医方论). His discussion deeply revealed the compatible mechanism of medicinals for tonifying qi in formulas for relieving exterior syndromes. An example is Rén Shēn Bài Dú Săn (Ginseng Toxin-Vanquishing Powder, 人参败毒散) , recorded in the Formulary of the Bureau of Medicines of the Taiping Era , which was originally used for“ Injury by cold and pathogenic qi, headache and stiff neck, strong fever, aversion to cold, restlessness and aches in the body, cough due to cold stasis, nasal blockage, headache due to wind-phlegm, vomiting, chills and fever ” (伤寒时气，头痛项强，壮热恶寒，身体烦疼，及寒壅咳嗽，鼻塞声重，风痰头痛，呕哕寒热). In this formula, along with medicinals for relieving exterior syndromes and diffusing the lung, and dispelling wind and dampness, and regulating qi and transforming phlegm, rén shēn (Radix et Rhizoma Ginseng) was combined for benefitting qi and supporting the right qi to dispel the pathogens outward, and to strengthen the action of relieving exterior syndromes. Thereafter, its application has been extended for exterior syndromes due to exogenous factors in people who are old, weak, or whose original qi has not recovered postpartum or after illness. This usually results in satisfactory curative effects, so it has been praised as being the representative formula for benefitting qi in order to relieve the exterior. In Zài Zào Săn (Renewal Powder) , recorded in Six Texts on Cold Damage , the Chinese medicinals for tonifying qi such as rén shēn (Radix et Rhizoma Ginseng) and huáng qí (Radix Astragali) are used, so it also belongs to this category of compatible methods.
Generally speaking, rén shēn (Radix et Rhizoma Ginseng) can greatly tonify original qi, and huáng qí (Radix Astragali) can benefit qi and strengthen the exterior, so they are not suitable for syndromes with unresolved exogenous pathogens. However, in cases of body deficiency affected by exogenous pathogens, combining just a few medicinals with the function of tonifying qi achieves the dual purpose of tonifying deficiency and benefitting depletion, while supporting the right qi to strengthen the effects of dispelling the pathogens. Yu Chang analyzed Rén Shēn Bài Dú Săn (Ginseng Toxin-Vanquishing Powder, ) in this way: “ To treat those who are weak, rén shēn (Radix et Rhizoma Ginseng) must be used in three, five or seven fen, so that when combined with medicinals for relieving exterior syndromes, it can slightly help the original qi to dispel the main pathogen, and make the pathogenic qi disgorge when encountering the Chinese medicinals. So the purpose here is not to tonify deficiency ”, cited from the Moral Grass ( Yù Yì Căo , 寓意草). This is a profound explanation, but what is significant is that when combining medicinals for tonifying qi in formulas for relieving exterior syndromes, they should only be used in small dosages; if the compatible proportion were increased, they would then belong to the category of tonic formulas.
For example, dà huáng (Radix et Rhizoma Rhei) and máng xiāo (芒硝, Natrii Sulfas) It is suitable for syndromes with unresolved exogenous pathogens in the exterior and excess food stagnation in the interior. The method of first relieving the exterior syndrome then attacking the interior from the Discussion on Cold Damage has universal clinical significance. However, in the syndromes in which the exterior syndrome is not relieved and the interior syndrome is very serious, if we only used diffusing medicinals for the exterior, then the pathogens in the interior would not be dispelled; and if we only treated the interior syndrome, then the pathogen in the exterior would not be relieved. In this situation, we must balance the degree and importance between the exterior and interior syndrome, treating both the exterior and interior syndrome at the same time, thus targeting the heart of the disease. An example is Guì Zhī Jiā Dà Huáng Tāng (Cinnamon Twig Decoction Plus Rhubarb) , recorded in the Discussion on Cold Damage , which was modified from Guì Zhī Tāng (Cinnamon Twig Decoction) through combining with dà huáng (Radix et Rhizoma Rhei) and increasing the dosage of chì sháo (Radix Paeoniae Rubra), thereby providing Guì Zhī Tāng (Cinnamon Twig Decoction) with the function of expelling pathogenic factors from the muscles and skin to relieve the exterior syndrome, and regulating ying and defensive qi. Chì sháo (Radix Paeoniae Rubra) was used in a large dosage to combine with dà huáng (Radix et Rhizoma Rhei) for the purpose of relaxing the bowels and relieving pain, allowing solid stasis to be expelled from the faeces. This has shown very good curative effects for fullness in the abdomen, bellyache with excess, and other symptoms due to mishandled diseases in the taiyang channel. Another example is Hòu Pò Qī Wù Tāng (Officinal Magnolia Bark Seven Agents Decoction, 厚朴七物汤) , recorded in the Essentials from the Golden Cabinet , in which hòu pò (Cortex Magnoliae Officinalis) and zhĭ shí (Fructus Aurantii Immaturus) were used for promoting the flow of qi, eliminating sensations of fullness in the chest and leading stagnation outward. Guì zhī (Ramulus Cinnamomi), gān căo (Radix et Rhizoma Glycyrrhizae), shēng jiāng (Rhizoma Zingiberis Recens) and dà zăo (Fructus Jujubae)were combined for expelling pathogenic factors from the muscles and skin to relieve the exterior syndrome, and regulating the ying and defensive qi, so this was a formula mainly used for treating interior syndromes while addressing the exterior syndrome simultaneously, which was suitable for fullness in the abdomen, constipation, fever, a floating and tight pulse, along with other symptoms. It was distinguished from the former formula which was mainly applied for exterior syndromes while considering the interior syndrome simultaneously. Thus it can be seen, that combing purgative medicinals in formulas for relieving exterior syndromes is suitable for syndromes in which the exterior pathogens have not been expelled and where the interior syndrome is very serious, and the condition cannot be cured unless both the exterior and interior syndrome were treated simultaneously. However, balance must be achieved in this therapeutic method, namely inducing sweating without hurting the exterior, and using purgative medicinals without hurting the interior. As for the formulas for relieving both exterior and interior syndromes, equal attention is paid to relieving the exterior syndrome and attacking the interior, so the compatible mechanism is basically uniform.
For example, bàn xià (Rhizoma Pinelliae), fú líng (Poria), xì xīn (Radix et Rhizoma Asari), and gān jiāng (Rhizoma Zingiberis), etc. When wind-cold restricts the exterior, and the qi of the lung loses its function of governing diffusion, fluids cannot be distributed, and accumulate to become phlegm, thus forming an exterior cold syndrome combined with phlegm retention; or if the body originally has phlegm retention and is then affected by exogenous pathogens, then the pathogens in both the exterior and the interior are combined, and with exterior cold inducing phlegm retention, phlegm retention may deteriorate with the influence of cold, thus forming the syndrome with fluid retention in the interior and cold in the exterior. In the former situation, medicinals for dispelling phlegm and transforming fluid retention were often properly combined in formulas for relieving syndromes to relieve and dispel pathogens in the exterior, and transform phlegm retention. For example, both in Shēn Sū Yĭn (Ginseng and Perllia Beverage) , recorded in the Discussion on Illnesses, Patterns, and Formulas Related to the Unification of the Three Etiologies , and in Rén Shēn Bài Dú Săn (Ginseng Toxin-Vanquishing Powder) , recorded in the Formulary of the Bureau of Medicines of the Taiping Era , qián hú (Radix Peucedani), jié gĕng (Radix Platycodonis), zhĭ qiào (Fructus Aurantii) and fú líng (Poria) were combined to transform phlegm, regulate qi and relieve cough. Both of these are examples of this compatible method. In the latter situation, it would not be comprehensive if only the exterior syndrome were relieved or if only fluid retention were treated. In treatment, relieving the exterior syndrome and transforming fluid retention must be combined, so that pathogens in the exterior are relieved and fluid retention in the interior are transformed, and both the exterior and interior syndrome are cured simultaneously. For example, in Xiăo Qīng Lóng Tāng (Minor Green-Blue Dragon Decoction) , recorded in the Discussion on Cold Damage , má huáng (Herba Ephedrae) and guì zhī (Ramulus Cinnamomi)were used for inducing sweating to relieve the exterior syndrome and for dispersing lung qi to calm asthma; chì sháo (Radix Paeoniae Rubra)was combined with má huáng (Herba Ephedrae)and guì zhī (Ramulus Cinnamomi) to achieve the effect of astringing while diffusing in order to prevent too much diffusion injuring the right qi; gān jiāng (Rhizoma Zingiberis), xì xīn (Radix et Rhizoma Asari) and bàn xià (Rhizoma Pinelliae) were used for warming the middle and transforming fluid retention, diffusing cold and descending counterflow; wŭ wèi zĭ (五味子, Fructus Schisandrae Chinensis), which is sour and astringent, was combined for astringing. In this way, medicinals for diffusing and medicinals for astringing are combined, so that this formula not only warms and dispels cold and fluid retention, but also astringes the lung and relieves cough to prevent the shortcomings of lung qi exhaustion, thus achieving the effects of opposing while complementing each other. Therefore, this formula is a representative formula for relieving exterior syndromes while transforming fluid retention.
Formulas in this combination are used for chronic bronchitis, bronchial asthma, emphysema and other illnesses combined with syndromes affected by exogenous factors marked by fever, aversion to cold, cough with watery phlegm, and have proven to be relatively effective in curing these conditions. Experimental research on Xiăo Qīng Lóng Tāng (Minor Green-Blue Dragon Decoction) has shown that the formula as a whole has distinct protective actions for asthma in guinea pigs, but that after omitting má huáng (Herba Ephedrae) and bàn xià (Rhizoma Pinelliae), the protective actions were stronger. It also showed that when only má huáng (Herba Ephedrae) and bàn xià (Rhizoma Pinelliae)were used, the protective actions were greatly diminished; the combination of xì xīn (Radix et Rhizoma Asari), guì zhī (Ramulus Cinnamomi)and wŭ wèi zĭ (Fructus Schisandrae Chinensis)showed even greater protective actions than má huáng (Herba Ephedrae) and bàn xià (Rhizoma Pinelliae). These results explained that the conspicuous function of calming cough was related to má huáng (Herba Ephedrae) and bàn xià (Rhizoma Pinelliae), but these two medicinals were not the main ingredients for calming cough in this formula, but rather the other medicinals, such as xì xīn (Radix et Rhizoma Asari) and wŭ wèi zĭ (Fructus Schisandrae Chinensis) perhaps had more important effects. ( Chinese Pharmacological Journal , 药学通报, 1982, 5:51)
For example, xiāng fù (香附, Rhizoma Cyperi), chén pí (Pericarpium Citri Reticulatae), wū yào (乌药, Radix Linderae), and sū gĕng (苏梗, Caulis Perillae). In cases when the human body is affected by exogenous wind-cold combined with non-flowing qi dynamics, or when the human body originally exhibits stasis in liver qi and ache in the liver and stomach due to qi and then is affected by exogenous wind-cold, or when women are affected by exogenous wind-cold during menstruation with subsequent qi and blood in maladjustment, exterior cold syndrome combined with qi stagnation may be formed. Since the property of a cold pathogen is stagnating and astringent, it can often aggravate qi stagnation, but qi stagnation would also affect the relieving and dispersing of cold in the exterior, so to treat this syndrome, attention should be paid to both relieving the exterior and regulating qi. Only in this way can complicated diseases be cured. An example is Xiāng Sū Săn (Cyperus and Perilla Powder, 香苏散) , recorded in the Formulary of the Bureau of Medicines of the Taiping Era , which is comprised of zĭ sū yè (Folium Perillae)for inducing sweating to relieve the exterior syndrome, xiāng fù (Rhizoma Cyperi) and chén pí (Pericarpium Citri Reticulatae) for regulating qi and soothing the chest, and zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle)for harmonizing the actions of the other herbs. As explained in the Discussion on Medical Formulas ( Yī Fāng Lùn , 医方论): “ To disperse wind in the exterior and promote the flow of qi in the interior, the medicinals with relaxative actions are preferred, and medicinals with drastic actions should not be swiftly used ” (外疏风而内行气，正以轻松疏利为佳，不必动辄峻剂也). The other example of a formula which belongs to this compatible method is Zhèng Chái Hú Yĭn (Right Bupleurum Beverage, 正柴胡饮) , recorded in the Collected Treatises of[Zhang] Jing-yue ( Jĭng Yuè Quán Shū , 景岳全书), in which chái hú (Radix Bupleuri), fáng fēng (Radix Saposhnikoviae ) and shēng jiāng (Rhizoma Zingiberis Recens) are used mainly for dispelling wind-cold, and chén pí (Pericarpium Citri Reticulatae) is used for promoting the flow of qi to relieve the stasis.
In this kind of combination, aside from the medicinals which are pungent in flavor and warm in property with functions of diffusing, medicinals for regulating qi should first be chosen in order to promote the flow of qi to relieve stasis and smooth the qi dynamics, such as xiāng fù (Rhizoma Cyperi), wū yào (Radix Linderae) and chuān xiōng (Rhizoma Chuanxiong). As for selecting medicinals for relieving exterior syndromes, it would also be better to choose medicinals with the function of relieving exterior syndromes combined with the function of promoting the flow of qi, such as zĭ sū (Folium Perillae), which can “ open the skin and pores in the outer, purge lung qi and connect the striae and interstitial spaces. In the upper region, it can clear through obstruction in the nose and clear the head and eyes; it is an effective medicinal for wind-cold syndrome affected by exogenous factors. In the middle region, it can open stasis in the chest and awaken the spleen and stomach, dispel and transform phlegm and fluid retention, relieve stasis and be beneficial in resolving qi stagnation ” (外开皮毛，泄肺气而通腠理．上则通鼻塞，清头目，为风寒外感灵药；中则开胸膈，醒脾胃，宣化痰饮，解郁结而利气滞), cited from the Rectification of the Meaning of Materia Medica ( Bĕn Căo Zhèng Yì , 本草正义). So it is the first choice in formulas for regulating qi to relieve exterior syndromes. Since both the above medicinals for relieving exterior syndromes and the medicinals for regulating qi are pungent in flavor and warm in property, and both of these can dispel and promote, they can combine the action of promoting the flow of qi in relieving exterior syndromes, and elicit the effects of ascending and dispelling in regulating qi. So the combination of the two kinds of medicinals can bring out the best in each other. For example, regarding Zhèng Chái Hú Yĭn (Right Bupleurum Beverage) , recorded in the Collected Treatises of [Zhang]Jing-yue , experimental research on the effects of separating the formula, formulating the formula, and medicinal-pairs of ingredients in this formula on viral flu pneumonia in mice has shown that the whole formula is effective in this respect. Furthermore, it showed that the single medicinal, bái sháo (Radix Paeoniae Alba), showed effective actions, and that when any medicinal in this formula was omitted the function of the whole formula would be distinctly decreased. The relationship of medicinals in this formula is very complicated, in that when two medicinals with no apparent function were combined, the action may be found; when the effective medicinal was combined with one without the function, the effects may be strengthened; and medicinals without effects could antagonize other medicinals with effects. This illustrates the presence of mutual promotion, enhancement and antagonism ( Journal of Chinese Medicine , 中医杂志, 1986, 2:58).
As for the dosage and proportion between medicinals for relieving exterior syndromes and medicinals for regulating qi, it should be determined according to the specific disease. If exterior cold were more serious, the proportion of medicinals for relieving the exterior syndrome may be increased accordingly, such as in Jiā Wèi Xiāng Sū Săn, recorded in the Medical Revelations ( Yī Xué Xīn Wù , 医学心悟)and Xiāng Sū Cōng Chĭ Tāng, recorded in the Popular Guide to the Discussion on Cold Damage ( Tōng Sú Shāng Hán Lùn , 通俗伤寒论). The former formula was modified based on Xiāng Sū Săn (Cyperus and Perilla Powder) through adding jīng jiè (Herba Schizonepetae), fáng fēng (Radix Saposhnikoviae), qín jiāo (秦艽, Radix Gentianae Macrophyllae) and màn jīng zĭ (蔓荆子, Fructus Viticis) for dispelling wind to relieve the exterior syndrome; the latter formula combined Xiāng Sū Săn (Cyperus and Perilla Powder) and Cōng Chĭ Tāng (Scallion and Fermented Soybean Decoction, 葱豉汤)in one formula, so both of the functions of the relieving exterior syndrome and dispelling cold were stronger than those in the original Xiāng Sū Săn (Cyperus and Perilla Powder). If qi stagnation were more serious, the proportion of medicinals for regulating qi should be increased; this can be studied in comparison with the compatible methods of formulas for regulating qi.