Chapter One. Exterior syndrome and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that stimulate the Qi in the superficial region, expel the exogenous pathogenic factors, and treat the exterior syndrome and other disorders that appear in this pathological process.
Exterior syndrome arises when the exogenous pathogenic factors invade the superficial regions (e.g. the skin, subcutaneous region and meridians). It manifests as fever, chills, a thin tongue coating and a superficial pulse. It is often seen in the initial stage of exogenous disorders. In western medicine it is seen in disorders such as the common cold, influenza, edema, the acute or initial stage of infectious diseases and allergies. According to the different nature of exogenous pathogenic factors, this syndrome is divided into wind-cold syndrome and wind-heat syndrome.
1. Wind-cold syndrome
Wind-cold syndrome is caused by exogenous pathogenic wind and cold. According to different conditions of health and constitutions, the reaction of the body can be different, thus an excess or a deficiency condition can develop.
1.1. Excess condition
Manifestations
Main symptoms
Chills, fever, no sweating, no thirst.
Secondary symptoms
Headache, stiffness of the neck and back, general pain, blocked nose, runny nose, sneezing, shortness of breath, cough.
Coexisting symptoms
Heaviness of the head and body, nausea, vomiting, a bitter taste in the mouth and thirst.
Tongue
Normal tongue body with a white coating.
Pulse
Slightly superficial in a common case; superficial and tight or superficial and wiry in a severe case.
Associated disorders in western medicine
Common cold, influenza, acute respiratory infections, edema and allergy.
Analysis of the syndrome
This syndrome arises when the exterior cold is severe and the superficial region of the person is firm.
• When the cold, which has a contracting nature, attacks the body, the pores are quickly and tightly closed as a reaction, either from the cold itself or from the reaction of the Defensive-Qi. When the Defensive-Qi cannot reach the surface of the body and fails to bring warmth to the skin, one may have chills and aversion to wind and cold.
• When the Defensive-Qi pits its efforts against the pathogenic factors and tries to eliminate them, fever is produced. Because the Defensive-Qi cannot spread its Qi on the surface of the body, it accumulates beneath the surface and fever is produced.
• Because the pores close tightly, there is no sweating.
• Since the pathogenic factors are wind and cold, which cannot injure the body fluid, patients do not feel thirsty.
• No thirst and no sweating are the two key symptoms for differentiating between this syndrome and wind-heat syndrome, which manifests as fever, chills with sweating and thirst.
• Wind-cold, as a Yin pathogenic factor, often firstly attacks the Yang region – the back of the body where the Bladder meridian passes. When the Qi and blood are not able to flow properly in this meridian, headache, stiffness of the neck and back, and general pain may appear.
• Skin relates to the Lung. When the superficial region is blocked by wind-cold, the Lung-Qi is unable to properly disperse and descend, and a blocked or runny nose, shortness of breath and cough may develop.
• Since the disorder is acute, the internal organs are not affected, the tongue is normal and the coating is thin and white. The pulse is superficial and tight in a severe case, and slightly superficial in a common case.
Other syndromes may coexist:
• If dampness also invades the body, which happens in a humid place, it can cause a heavy sensation of the body.
• Sometimes heat can also be generated when the body’s resistance is strong and the pores are closed tightly. Patients may have a bitter taste in the mouth and feel thirsty, indicating the existence of heat.
(See Figure 1.1 on page 54.)
1.2. Deficiency condition
Manifestations
Main symptoms
Chills, fever, slight sweating, aversion to wind.
Secondary symptoms
Headache, general pain or stiffness of the body, blocked nose, runny nose, sneezing, shortness of breath, cough.
Tongue
Normal tongue body with a white coating.
Pulse
Superficial and soft.
Associated disorders in western medicine
Common cold, influenza, acute respiratory infections and allergies.
Analysis of the syndrome
The superficial region is the first defense of the body against exterior pathogenic factors. It depends on the balanced functions of Qi and blood there, specifically the Defensive-Qi and Nutritive-Yin, both of which are directly transformed from food and drink. The Defensive-Qi holds the Nutritive-Yin, circulates in the superficial region of the body, brings warmth and nutrition to this region and controls the appropriate opening and closing of the pores.
A deficiency syndrome arises if the Defensive-Qi is weak.
• When the exterior pathogenic wind-cold attacks the superficial region of the body, the Defensive-Qi is not strong enough to close the pores, and the pathogenic wind and cold can easily invade the body.
• The exogenous wind, which has a moving and dispersing nature, opens the pores, thus patients may have an aversion to wind and have chills.
• When the Defensive-Qi pits its efforts against the pathogenic wind-cold and tries to eliminate it, fever is produced.
• When the pores cannot close tightly, the Nutritive-Yin flows out, manifesting as sweats. When the Nutritive-Yin is weakened, the Defensive-Qi is eventually weakened as well. In a deficiency condition where the cold is not severe and the Defensive-Qi is not strong, the pulse is neither tight nor wiry, but soft.
• The pathological process in the superficial region may affect the Qi movement of both the Bladder and Lung meridians; however, the symptoms are not as severe as in the excess condition.
• When the Qi in the Bladder meridian is obstructed, patients may suffer from headache, general pain or stiffness.
• When the Lung-Qi fails to disperse and descend properly, a blocked and runny nose, sneezing, shortness of breath and cough may develop.
(See Figure 1.2 on page 54.)
Treatment principles
• In the excess condition: Stimulate the Yang and Qi, open the pores and induce sweating so as to expel wind-cold.
• In the deficiency condition: Harmonize and strengthen the Defensive-Qi and Nutritive-Yin so as to release the exterior.
Herb selection principles and formula composition strategies
• First, herbs that are pungent and warm, enter the Bladder meridian and directly stimulate the Qi, induce sweating and expel wind and cold from the superficial region of the body are selected.
• Second, herbs that are pungent and warm, and stimulate blood circulation so as to enhance the action of the herbs that expel wind and cold are selected.
• Third, herbs that are pungent and warm, and regulate the Lung-Qi so as to assist the herbs that expel wind-cold from the superficial region of the body are selected.
• Along with the herbs in the third group, herbs that descend the Lung-Qi to treat cough and wheezing are also selected.
• In a deficiency condition, herbs that are sweet and warm, and gently tonify and stimulate the Defensive-Qi should be selected along with herbs that can strengthen the Nutritive-Yin.
CAUTIONS
1. Avoid overdispersing the Qi and consuming the Yin:
Formulas that release the exterior contain pungent and warm herbs. Their action tendencies are ascending and dispersing, especially the formulas that can cause sweating. Too large a dosage may disperse the Qi too much, consume Yin and cause complications. Among patients who are deficient of Yin or Qi due to their constitution, chronic diseases, stress or dietary habit, the formulas should be used with caution.
2. Caution in bleeding conditions and pregnancy:
As pungent herbs have a moving property, these herbs should be used with caution in bleeding conditions or in pregnancy.
3. Choose appropriate dosage:
The dosage of the herbs in the formula should be adjusted to suit the condition of the individual, the syndrome and the season. For elderly people, children, people with a weak constitution and for mild syndromes, at a place of gentle climate and in the summer, the dosage should be less. For adults with a strong constitution, for treating severe syndromes, in winter or in a cold place, the dosage should be larger.
4. Induce proper sweating:
Sweating is the means of expelling the exterior pathogenic factors, especially wind and cold. The dosage of herbs should be adjusted according to the reaction and any changes in the symptoms. A mild sweat over the whole body is required. After sweating, patients should feel better. Heavy sweat can injure the Yin and the body fluid, and must be avoided.
5. Use only in a short treatment course:
As eliminating wind-cold is not difficult in common cases, formulas to release the exterior should not be used for a long period of time. A period of 3 days is recommended. If the exogenous pathogenic factors have not been removed completely, another 3-day course can be prescribed. With regard to herbs that may cause heavy sweating, the dosage and treatment course should be adjusted according to the reaction of the patient after each use.
Structure of the formula and selection of herbs
Chief: Stimulate the Yang and Qi, induce sweating and expel wind-cold
Jing Jie ( Schizonepetae herba) and Fang Feng ( Saposhnikoviae radix)
Jing Jie and Fang Feng are the most commonly used herbs to treat mild or common cases of wind-cold syndrome. Both herbs are pungent and warm, and can expel wind and cold. In a place with a temperate climate, where wind and cold do not close the pores tightly, they are often applied as chief herbs in the formula for treating exterior wind-cold syndrome, in either excess or deficiency conditions. They treat related diseases in modern medicine such as the common cold, influenza, certain stages of infectious childhood diseases, skin diseases and allergies in which an exterior syndrome exists.
Comparing Jing Jie with Fang Feng, Jing Jie is lighter and more dispersing. It is pungent but not strong, slightly warm but not drying. It is especially good at expelling wind. Fang Feng is sweet, pungent and warm, and enters the Bladder, Lung and Spleen meridians. As its sweet taste moderates the pungent taste, Fang Feng is less strong in dispersing the wind on the surface of the body than Jing Jie. However, as Fang Feng is warmer than Jing Jie and enters the Spleen meridian, it is especially good at expelling dampness and cold in the regions deeper than the body surface, such as the subcutaneous region and muscles that are controlled by the Spleen. When the patient feels pain and heaviness of the muscles, Fang Feng is more suitable to be used than Jing Jie. Since wind-cold attacks both the skin and the subcutaneous region, Jing Jie and Fang Feng are often used together.
Xiang Ru ( Moslae herba), Zi Su Ye ( Perillae folium) and Huo Xiang ( Agastachis herba)
These three herbs are pungent and warm, and enter the Lung and Spleen meridians. They can expel wind-cold in the superficial region of the body as well as eliminate dampness, which often affects the body in a humid climate or is due to cold drinks. They can be selected as chief herbs separately or in groups in a formula.
Xiang Ru is the warmest of these three herbs. It is able to induce sweating, disperse wind and dampness, and release the exterior. It is especially useful when there is fever, general pain and heaviness of the body but no sweating. This herb is also called Summer Ma Huang because it has a similar but gentler action than Ma Huang ( Ephedrae herba)* in the function of inducing sweating. Xiang Ru is more suitable for use in the summer when the pores are not closed as tightly as in the winter. It also has the function of transforming dampness in the Middle-Jiao and treating abdominal pain, vomiting, diarrhea and edema, but this function is not as strong as that of the other two herbs.
Zi Su Ye is a light and aromatic herb. It can gently disperse and expel wind-cold in the superficial region of the body and release the exterior. It is used in a mild case of wind-cold syndrome since it is less warm and pungent than Xiang Ru and it is not able to induce sweating and disperse dampness. However, as it can relieve nausea by soothing the Stomach-Qi, it is an ideal herb to alleviate exterior syndrome that is accompanied by dampness in the Middle-Jiao, such as in gastritis.
Huo Xiang is an excellent herb to expel wind, cold and dampness; it can also transform dampness in the Middle-Jiao. Compared with Xiang Ru, it is stronger in transforming dampness in the Middle-Jiao; compared with Zi Su Ye, it not only expels wind and cold, but also disperses dampness in the superficial regions of the body to treat heaviness and stiffness of body. It is selected especially in the summer to treat the common cold, influenza and acute gastritis.
Sheng Jiang ( Zingiberis rhizoma recens) and Cong Bai ( Allii fistulosi bulbus)
Sheng Jiang and Cong Bai are often used in the initial stage of wind-cold syndrome in either excess or deficiency conditions. In China, a briefly cooked decoction of Sheng Jiang and Cong Bai is a commonly used folk remedy to treat the common cold.
Sheng Jiang is pungent and slightly warm, and enters the Lung, Spleen and Stomach meridians. It can disperse cold and wind, dissolve phlegm in the Lung and stop cough. It also enters the Spleen and Stomach meridians, can warm the Middle-Jiao, soothe the Stomach-Qi, and alleviate nausea and vomiting. This herb is a good choice if a patient suffers from a mild wind-cold syndrome complicated by ascending of the Stomach-Qi, such as in acute gastritis.
Cong Bai is pungent and warm, and enters the Lung and Stomach meridians. The sharp smell and taste can directly stimulate the Qi, expel wind and open up the obstructions. It can be used to treat the sensation of discomfort in the body, sneezing and a blocked and runny nose in a mild exterior wind-cold syndrome.
Qiang Huo ( Notopterygii rhizoma), Cang Zhu ( Atractylodis rhizoma) and Qin Jiao ( Gentianae macrophyllae radix)
These three herbs are able to expel wind, cold and dampness from the skin, subcutaneous region and muscles. They can be selected as chief in a formula to treat a severe excess condition of wind-cold syndrome.
Qiang Huo is commonly used to expel wind, dampness and cold from the body. It has a pungent, bitter taste and is warm in nature. It enters the Bladder meridian primarily and the Liver and Kidney meridians secondly. The pungent and warm nature gives Qiang Huo a strong dispersing and ascending ability, thus it is very effective in quickly expelling wind, dampness and cold from the skin, subcutaneous region and muscles, especially in the upper half of the body. As a result, it can relieve general pain, headache and stiffness of the back.
Cang Zhu can be selected as chief in the formula to treat a reasonably severe excess condition of wind-cold syndrome that includes the symptom of heaviness of the body. Because Cang Zhu is pungent and warm, and enters the Stomach and Spleen meridians, it can strongly dry dampness and disperse wind and cold.
Qin Jiao is neutral, bitter and pungent. Its function of expelling wind, dampness and cold is gentler than that of the other two herbs. It is more suitable for treating a deficiency condition of wind-cold syndrome. It is also used for conditions where there is coexisting heat.
Ma Huang ( Ephedrae herba)*
Ma Huang is used as chief in a formula to treat a severe excess condition of wind-cold syndrome. This herb is considered as the strongest one to induce sweating. Ma Huang is very pungent and warm, its moving speed is high and its action is strong. Ma Huang enters the Lung meridian and can disperse Lung-Qi. It enters the Bladder meridian and can activate the Defensive-Qi; thus it opens the pores, induces sweating and expels wind and cold.
Gui Zhi ( Cinnamomi cassiae ramulus)
Gui Zhi is pungent, warm and sweet, and is used as chief in a formula to treat a deficiency condition of wind-cold syndrome. Its therapeutic effect is achieved through the approach of warming the blood, promoting blood circulation, opening up the meridians and activating the Yang-Qi so that it can expel wind and cold. Compared with Ma Huang, Gui Zhi is not as warm and pungent, but it is sweet. It enters the Heart meridian primarily and the Lung and Bladder meridians secondly. The warm nature of this herb can reduce the cold in the blood. The warm and pungent characters may also activate the blood circulation and open up the meridians. The sweetness moderates the warm and pungent effects so that the medicinal action may be sustained evenly. Since it enters the Lung and Bladder meridians, Gui Zhi can activate Yang-Qi to eliminate wind and cold in the exterior region.
Deputy: Regulate the Qi and blood, enhance the strength of the chief herbs to expel wind-cold; treat the secondary syndrome and coexisting syndromes
Gui Zhi ( Cinnamomi cassiae ramulus)
Gui Zhi is pungent, warm and sweet. Besides expelling wind and cold to treat exterior syndrome, Gui Zhi is able to warm the blood, promote blood circulation and reduce the general pain, stiffness and cold. It is particularly chosen as deputy to enhance the strength of chief herbs to expel wind-cold in treating a severe excess condition of wind-cold syndrome when the general pain of the body is severe.
Chuan Xiong ( Chuanxiong rhizoma)
Chuan Xiong is pungent and warm, and enters the Liver, Gall Bladder and Pericardium meridians. Chuan Xiong is a very effective herb to invigorate the blood and to promote the blood circulation. It is characterized by high moving speed and strength, and is regarded as the herb that moves the Qi in the blood. In treating an exterior wind-cold syndrome, it can be selected as deputy to enhance the herbs that expel wind-cold, as well as to relieve pain of the body and headache.
Bai Zhi ( Angelicae dahuricae radix)
Bai Zhi is warm and pungent with a rich aromatic smell; it possesses strong ascending properties. As it can expel wind-cold, transform phlegm and pus and dry dampness, it can therefore reduce swelling and open the obstruction of the nose. Because it enters not only the Lung meridian, but also the Stomach meridian, it is often applied to treat pain in the forehead where the Yang Ming meridian passes through.
Chai Hu ( Bupleuri radix)
Chai Hu is pungent and neutral, and enters the Liver and Gall Bladder meridians. It is particularly effective in spreading Qi in the Shao Yang meridians, and in treating headache (especially on the lateral sides of the head) and a sensation of fullness in the hypochondriac region. When there is stagnation of Liver-Qi due to stress, which weakens the Defensive-Qi and leads to an exterior syndrome, Chai Hu can be selected.
Xi Xin ( Asari herba)*
Xi Xin is a very pungent and hot herb with an aromatic smell. It does not enter the Bladder meridian, but does enter the Kidney meridian. It can be selected as deputy in the formula to enhance the action of the chief herbs in treating an excess condition of wind-cold syndrome and can release pain.
Xi Xin is very effective in eliminating cold and wind in very deep regions of the body, such as the bones and tendons. Because of its strong aromatic smell, pungent taste and hot nature, it can easily penetrate into the deep layers of the body and is often used in exterior wind-cold syndromes if there is Kidney-Yang deficiency, such as in elderly people, patients who suffer from chronic diseases with internal cold, and patients who suffer from Bi syndrome due to wind-cold invasion. Among these individuals, wind and cold may invade the body more deeply than in common cases. Alternatively, the development can be very acute, the patient feels severe pain in the whole body and the pulse is deep and tight instead of superficial and tight.
As Xi Xin enters the Lung meridian and has an aromatic smell, it is often used for transforming cold and thin phlegm from the Lung, opening the nasal orifices and improving the sense of smell.
A side effect of Xi Xin occurs when it is applied incorrectly. Because it is very hot and pungent, it can easily injure the Yin, blood, body fluid and Qi. It should not be used, or must be used with caution, in patients who suffer from exterior wind-cold syndrome where internal heat also coexists and the Yin, blood and body fluids are deficient. The dosage of Xi Xin should also be controlled carefully in the range of 1–3 g per day for crude herbs. If the powdered herbal extract is used, the dosage should be reduced to 0.1–0.5 g per day. Overdose may cause numbness in the throat and tongue, a stifling sensation in the chest and even death due to paralysis of the diaphragm. Modern research indicates that this herb should be used with caution in patients who suffer from renal disease as it has nephrotoxic effects.
Bai Shao Yao ( Paeoniae radix lactiflora)
Bai Shao Yao is often selected in the deficiency condition of an exterior wind-cold syndrome when the Yin, body fluids and blood are weakened through sweating.
Bai Shao Yao is sour, bitter and slightly cold. Sour and cold may generate the blood, and therefore supplements the shortage of the Yin. It is often used with Gui Zhi ( Cinnamomi cassiae ramulus), which is pungent, sweet and warm, expels wind-cold, and warms and stimulates the blood and Qi. When they are used together, they can harmonize the Defensive-Qi and Nutritive-Yin in the superficial region so as to stabilize the exterior.
Dang Shen ( Codonopsis radix)
Dang Shen is sweet and neutral. It primarily enters the Spleen meridian. It can be used as deputy in an exterior syndrome when the Qi is too weak to eliminate the exterior pathogenic factors. It can tonify the Spleen-Qi so as to strengthen the Lung-Qi and Defensive-Qi, and accelerate the speed of eliminating the exterior pathogenic factors.
Assistant: Regulate the Lung-Qi, stop cough; strengthen the Middle-Jiao in order to assist the chief herbs in expelling wind-cold
Jie Geng ( Platycodi radix) and Xing Ren ( Armeniacae semen)
Jie Geng and Xing Ren are often used together in the formula because they can effectively disperse and descend the Lung-Qi, eliminate phlegm and relieve cough, which is a secondary pathogenic change in a wind-cold syndrome.
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