Chapter Fourteen. Syndrome of internal wind and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that treat internal wind syndrome. Internal wind syndrome is a collective term to describe the syndromes that are characterized by moving and changing in the symptoms and signs, such as dizziness, trembling, tingling and cramping of limbs and loss of balance in walking. Wind can be generated by Liver-Yang ascending, excess fire in the Heart and deficiency of the Yin and blood. Since the causes are different, the treatment principles and the compositions of the formulas are also different and will therefore be introduced separately.
1. Syndrome of Liver-wind
Manifestations
Main symptoms
Dizziness, tingling or numbness of the fingers and limbs, tremors or spasms of the limbs, headache, nausea, vomiting, loss of balance in standing or walking; in a severe case, loss of consciousness, hemiplegia, deviation of the eyes and mouth.
Secondary symptoms
Irritability, dream-disturbed sleep, distending pain in the hypochondriac region, preference for a quiet and relaxing environment.
Tongue
Red or only red on the border, with a thin, dry and yellow coating.
Pulse
Thready and wiry, or thready, wiry and rapid.
Associated disorders in western medicine
• Liver-Yang ascending: Hypertension, menopausal complaints, tinnitus, deafness, glaucoma, asthenopia, optic nerve atrophy, primary cataract and conjunctivitis.
• Liver-wind disturbance: Epilepsy, severe case of hypertension and glaucoma, facial paralysis, facial spasms, cerebrovascular accident and its sequelae.
Analysis of the syndrome
The syndrome of Liver-Yang ascending is caused mainly by Liver-Yin deficiency. It often exists in people who are over 50 years old when the Yin of the Liver becomes weak with age; people who are under persistent stress where the restrained heat in the Liver may easily injure the Yin; people who suffer from chronic diseases, use certain medicines or have a dietary habit that leads to injury of the Liver-Yin.
• When the Liver-Yin is too weak to control the Liver-Yang, the Yang rises, which disturbs the normal movement of Qi in the upper part of the body, especially the head, and causes dizziness, a slightly tight sensation in the head, headache, blurred vision and tinnitus.
• In a severe case, the Yang and heat may severely disturb the Qi movement of the Liver and also disturb the mind, leading to irritability, dream-disturbed sleep, distending pain in the hypochondriac region and a preference for a quiet and relaxing environment.
• If the Liver-Yang and heat disturb the Stomach, patients may have a red face, a dry and bitter taste in the mouth, nausea or belching.
• A red tongue or red border of the tongue indicates heat in the Liver; a thin, dry and yellow coating suggests heat accumulation but without obvious accumulation of food or phlegm. A thready pulse indicates deficiency of Yin, wiry indicates tension of Liver-Yang ascending and rapid is the sign of heat. These features of the pulse may become more distinct when the syndrome becomes more severe.
If the Liver-Yang is not controlled with appropriate treatment, it may turn into Liver-wind, especially under strong emotional disturbance and stress. At that time, the Liver-Yang rises rapidly and its speed stirs up the wind.
• The symptoms and signs of Liver-wind are characterized by constant movement and quick change. Because the Liver controls the tendons, symptoms such as tremors or spasms of the limbs, severe dizziness, tingling or numbness of the limbs, and loss of balance in standing or walking appear.
• In severe cases, the Liver-wind may disturb the Qi movement and blood circulation, and it pushes the Qi, blood, fire and phlegm to attack the head. The blood and phlegm may block the meridians and cover the mind. In this situation, the patient may suddenly lose consciousness, and afterwards suffer from hemiplegia and deviation of the eyes and mouth.
• In this acute excess condition, a red tongue with a yellow and dry coating, and a wiry, forceful and rapid pulse indicate heat, Yang ascending and Qi disturbance of the Liver; a yellow and sticky tongue coating and a rapid, slippery and wiry pulse are the signs of phlegm-heat obstruction.
(See Figure 14.1 on page 326.)
Treatment principle: Anchor the Liver-Yang, pacify the Liver-wind, tonify the Yin and spread the Qi
Herb selection principles and formula composition strategies
• In a severe and acute condition, the first priority is to choose minerals and herbs which enter the Liver and Heart meridians, and can directly and intensively anchor the Liver-Yang and pacify the Liver-wind.
• In a sub-acute or a chronic and mild condition of Liver-Yang ascending, the first priority is to select herbs that nourish the Liver-Yin in order to control the Liver-Yang.
• Second, herbs that regulate the Qi and blood, calm the mind, remove phlegm and promote digestion should be selected in both acute and chronic conditions.
• Herbs that can open up the collaterals, extinguish wind and relieve spasm should be selected in chronic and stubborn conditions.
CAUTIONS
1. Clear differentiation of the syndrome in the treatment process:
It is important to make a clear differentiation of the syndrome and arrange appropriate treatment in order to treat the cause and the manifestations of the syndrome. In the acute situation, treat the manifestation first; in a chronic and sub-acute condition, treat both the cause and the manifestations.
2. Caution when using ascending herbs:
In the formula, herbs that can stimulate the Qi and blood and have a strong ascending tendency should be used with caution because they may cause the Liver-Yang, heat, Qi and blood to ascend.
3. Provide lifestyle and dietary advice:
Patients should avoid the factors that may cause ascending of Liver-Yang in their lifestyle and diet, such as stress and strong emotions, spicy food and alcohol.
4. Caution when using minerals:
Since the mineral substances are heavy in weight, they are also heavy for the Stomach. For patients who are weak in the Spleen and Stomach, the mineral substances should be used in smaller dosage, with a shorter treatment course or combined with herbs that protect the Stomach. Moreover, the mineral substances should not be used in pregnant women.
5. Caution when using poisonous substances:
Of the substances that descend the Yang and extinguish wind of the Liver, Dai Zhe Shi ( Haematitum)*, Quan Xie ( Scorpio)* and Wu Gong ( Scolopendra)* are poisonous, thus the dosages should be carefully controlled.
Structure of the formula and selection of herbs
Chief: Anchor the Liver-Yang and extinguish the Liver-wind
Shi Jue Ming ( Haliotidis concha), Zhen Zhu Mu ( Concha margaritifera usta), Ci Shi ( Magnetitum), Long Gu ( Mastodi fossilium ossis) and Dai Zhe Shi ( Haematitum)
These substances are minerals, heavy in weight and strong in function. They have a descending tendency in action, can anchor the Liver-Yang, extinguish Liver-wind and direct the rebellious Qi and blood downward. These minerals can be selected separately or in a group as chief substances in the formula.
Shi Jue Ming is salty and slightly cold, and enters the Kidney and Liver meridians. It is able to intensively descend the Liver-Yang, clear the Liver-fire and therefore extinguish the Liver-wind. It is also able to improve vision by treating disorders of the eyes due to Liver-Yang ascending and up-flaring of Liver-fire. It is often selected as one of the chief substances in formulas in both acute and chronic conditions.
Zhen Zhu Mu is salty and cold, and enters the Heart and Liver meridians. Compared with Shi Jue Ming, it has the same function of descending the Liver-Yang and pacifying the Liver-wind, and can be used for the same indications, but the strength of this substance is weaker. However, the strong point of this substance is that, as it enters the Heart meridian, it can calm the mind and clear the heat there. In the formula that extinguishes the Liver-wind and anchors the Liver-Yang, it is particularly selected as chief in the condition of restless sleep, insomnia and palpitations.
Long Gu is sweet, astringent and neutral, and enters the Heart, Liver and Kidney meridians. It descends the Liver-Yang and calms the Liver-wind. Since it is sweet and neutral, and causes less irritation to the Stomach, it can be used for a longer period of time. Long Gu can also be used to calm the mind and treat restlessness.
Dai Zhe Shi is bitter and cold, and enters the Liver and Pericardium meridians. This mineral is the strongest of these four substances to anchor the Liver-Yang and extinguish the wind. As it can intensively and quickly descend the Yang, wind, fire, phlegm, Qi and blood, it is often used for acute situations. However, since Dai Zhe Shi is a heavy, cold and bitter substance, can easily injure the Stomach and contains a little bit of arsenic, it cannot be used in a large dosage or for a long period of time.
Tian Ma ( Gastrodiae rhizoma)** and Gou Teng ( Uncariae ramulus cum uncis)
Tian Ma and Gou Teng are sweet in nature and enter the Liver meridian. They are able to pacify the Liver and extinguish Liver-wind. They are used to treat dizziness, headache, convulsions, tremor and spasm caused by Liver-wind.
Tian Ma is sweet and neutral, and enters the Liver meridian. It has a moderate and moist nature. It is the first-line choice to extinguish Liver-wind because it not only pacifies the Liver and extinguishes wind, and treats the manifestations (dizziness, headache, dry and tired eyes), but also treats the cause (deficiency of Liver-Yin and blood). It can remove wind-phlegm and open the collaterals, and is used to treat dizziness with nausea and vomiting. If it is combined with herbs that promote the Qi movement and blood circulation, it can treat stiffness, pain, numbness and tingling of limbs, such as in the sequelae of cerebrovascular accident.
Gou Teng is sweet and cold, and enters the Liver and Pericardium meridians. It has a strong function of clearing and reducing the Liver-heat, whether or not it is excess heat or empty-heat, and thus can calm the wind. It is particularly used to treat dizziness, headache, tinnitus, irritability, and red and irritated eyes. Because it enters the Pericardium meridian, it is also very effective for cooling the Heart, relaxing the tendons and calming the mind.
Tian Ma and Gou Teng are often used together to accentuate their therapeutic actions in extinguishing Liver-wind and are often selected in the formula as chief to treat sub-acute and chronic conditions.
Deputy: Pacify the Liver-Yang, calm the mind, nourish the Liver-Yin and Kidney-Yin, reduce Liver-heat and descend the Qi and blood
Ci Shi ( Magnetitum), Long Gu ( Mastodi fossilium ossis), Mu Li ( Ostrea concha) and Zhen Zhu Mu ( Concha margaritifera usta)
These mineral substances can effectively and quickly descend the Liver-Yang and Heart-fire. In the formula to pacify the Liver in a sub-acute condition, they are particularly selected to strongly sedate the Heart-spirit and calm the mind. Since the Liver is the mother organ of the Heart, Liver-Yang ascending may cause up-flaring of Heart-fire, which manifests as restlessness, anxiety, irritability, insomnia, a bitter taste in the mouth and a red face.
Bai Shao Yao ( Paeoniae radix lactiflora), Tian Men Dong ( Asparagi radix) and Sheng Di Huang ( Rehmanniae radix)
Bai Shao Yao is sour and cold, and primarily enters the Liver meridian. It can effectively nourish the Liver-Yin and soften the Liver. It can be selected as deputy in the formula to pacify the Liver-wind and descend the Liver-Yang in a chronic condition.
Tian Men Dong and Sheng Di Huang are sweet and cold, and enter the Kidney meridian. Because the Liver and Kidney are closely related in physiology and pathology, deficiency of Liver-Yin and Kidney-Yin often exists at the same time. These herbs can indirectly tonify the Liver-Yin as well. Since Sheng Di Huang has a bitter taste, it can effectively cool the blood and reduce the fire.
Zhi Zi ( Gardeniae fructus) and Long Dan Cao ( Gentianae radix)
Zhi Zi and Long Dan Cao are bitter and cold. They are often selected in formulas when excess Liver-heat presents. They can directly treat irritability, a bitter taste in the mouth, red eyes, tinnitus and scanty urine due to Liver-heat.
Zhi Zi enters the Heart, Lung and San Jiao meridians, is able to drain heat from the San Jiao, especially the Heart, and lead the heat out of the body through urination . Long Dan Cao directly enters the Liver meridian. It can powerfully and quickly drain the Liver-fire. Since these herbs have a descending tendency in action, they can enhance the strength of the substances that descend the Liver-Yang.
Chuan Niu Xi ( Cyathulae radix), Yi Mu Cao ( Leonuri herba) and Dan Shen ( Salviae miltiorrhizae radix)
These three cold herbs all enter the Liver meridian, and have the functions of clearing heat in the blood, promoting blood circulation and removing congealed blood. They are selected in the formula to treat disturbance of blood circulation and blood stagnation.
Regulating blood circulation is important in the treatment process of extinguishing Liver-wind and descending Liver-Yang because disturbance of blood always coexists in the syndrome of Liver-Yang and Liver-wind; it needs to be treated as a secondary syndrome. Moreover, when the blood circulation is disturbed, congealed blood can be formed. This is pushed by rebellious Qi and Yang, attacks and blocks the meridians, and causes related symptoms, such as in a cerebrovascular accident and heart attack, which are regarded as wind-stroke and chest Bi syndrome respectively in traditional Chinese medicine. Furthermore, when the blood circulation is obstructed, blood may leave its pathway and bleeding starts. In order to prevent these serious consequences, the herbs that regulate and descend the blood, dissolve congealed blood and clear heat in the blood should be used in the formula.
Chuan Niu Xi is bitter, sour and neutral, and enters the Liver and Kidney meridians. It can effectively descend the blood, promote urination, remove congealed blood and open the meridians. It also has the function of strengthening the Kidney. It is often selected for treating acute and sub-acute conditions.
Yi Mu Cao is pungent, bitter and cold, and can promote blood circulation, clear heat and remove the congealed blood. It has a descending tendency in action and can promote urination. It is often selected for treating sub-acute and chronic syndromes of Liver-Yang ascending.
Dan Shen is bitter and slightly cold, and enters the Heart and Liver meridians. Besides promoting blood circulation, it can effectively cool the blood and remove congealed blood, and treat chest pain, hypochondriac pain, a stifling sensation in the chest and irritability, especially under stress.
All of these herbs help the chief to descend the Yang and pacify the wind in a more effective and quicker way. They are important deputies in the formula.
Chuan Lian Zi ( Toosendan fructus), Xiang Fu ( Cyperi rhizoma), Fo Shou ( Citri sarcodactylis fructus), Xiang Yuan ( Citri fructus) and Xuan Fu Hua ( Inulae flos)
These herbs can regulate the Qi, which is disturbed by the quick ascending of Liver-Yang and Liver-wind. As soon as the Qi descends or moves smoothly, Liver-wind is extinguished. For this reason, these herbs are often selected as deputies to treat the secondary syndrome.
Chuan Lian Zi is very bitter and cold. It enters the Liver meridian and can directly and powerfully drain the fire and descend the Qi of the Liver. It is particularly selected in an acute or sub-acute condition where severe hypochondriac pain and distension exist. Since it is a poisonous herb, it is used for only a short period of time in an acute condition.
Xiang Fu is pungent, bitter, sweet and neutral, and enters the Liver and San Jiao meridians. As Xiang Fu can spread and regulate the Liver-Qi in a moderate way, it can be used in both acute and chronic conditions.
Fo Shou and Xiang Yuan are able to harmonize the function of the Liver and Stomach. They are particularly used for the condition where the Liver-Qi attacks the Stomach. The manifestations are loss of appetite, belching and a full sensation in the upper abdomen and hypochondriac region.
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