Chapter Nineteen. Yong (carbuncle) and Yang (ulceration) syndrome and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for composing the formulas that can clear heat, transform dampness, discharge pus, push out toxin and promote healing. They treat boils, carbuncles, ulcerations and localized open or closed wounds.
Syndrome of Yong Yang
In Chinese, Yong means carbuncle and Yang means ulceration. Yong Yang is a collective term in traditional Chinese medicine for boils, carbuncles, ulceration and localized open or closed wounds. Since these disorders are located on the skin, are observable and palpable, they are recognized as a special syndrome in differentiation. According to differences in causes, manifestations and signs, Yong Yang can be subdivided into Yang syndrome and Yin syndrome. The treatments are different.
1. Yang syndrome
The Yang type of Yong Yang syndrome is characterized by localized redness, swelling, hot sensations and pain. High fever and general pain may also exist. This syndrome appears in acute inflammations, such as carbuncles, furuncles, abscesses and infected open wounds. The book The Yellow Emperor’s Classic of Internal Medicine indicated: ‘Most of the sores which are painful, itchy and swollen are due to fire.’ In clinical practice, this syndrome is mainly related to fire disturbance of the Heart, Liver and Stomach.
The Heart is a fire organ and its fire can easily flare up in a pathological condition. The Heart-fire can also be rapidly increased by the influence of Liver-fire because the Liver is its mother organ. The blazing Heart-fire can easily generate fire-toxin and lead to a fire-toxin syndrome.
The Stomach is another source of excess fire in the body. It is a Yang Ming organ and is responsible for receiving, ripening and transporting food. All these activities increase and produce heat, and lead to fire-toxin syndrome.
A Yang-type Yong Yang syndrome often appears when patients are subject to strong emotions or are under stress, which can quickly generate internal heat-toxin, injure the flesh and blood, and lead to boils and carbuncles. A Yang-type Yong Yang syndrome is also caused by inappropriate dietary habits such as overindulgence in spicy, greasy, sweet foods and alcohol, which easily generate heat and dampness in the Middle-Jiao and influence the subcutaneous region. This situation frequently occurs in a person with a Yang constitution or a patient who suffers from internal heat due to chronic disease or taking certain medication.
Manifestations
Main symptoms
Boils, carbuncles, ulceration and localized open wounds with signs of redness, swelling, heat and pain.
Secondary symptoms
Acute condition
At the initial stage: Fever, chills, generalized pain of the body. The boil or carbuncle is hard and painful.
At the metaphase stage: Pus is formed, thus the boil or carbuncle becomes soft and the pain is less severe.
At the recovery stage: Perforation occurs, pus is discharged and the healing process starts.
Chronic condition
Pus is formed but the boil or carbuncle does not readily perforate, and the localized lesion is accompanied by mild pain, swelling and a warm sensation.
Tongue
Red tongue with yellow coating.
Pulse
Wiry, rapid and forceful.
Associated disorders in western medicine
Carbuncles, furuncles, abscesses and infected open wounds.
Analysis of the syndrome
• When heat accumulates in the skin, subcutaneous region and muscles, the patient may feel hot in the affected region and observe a red color of the skin lesions.
• Heat obstructs the Qi and blood, and causes swelling and pain.
• If heat disturbs the normal movement of Defensive-Qi in the superficial region of the body, chills and fever may appear at the initial stage.
• Heat-toxin with stagnant dampness, Qi and blood may form a hard and painful lesion.
• When excess heat blazes in the blood and flesh, pus is eventually formed.
• If the Qi and blood are strong enough in the body, the body’s resistance can push out the toxin. The lesion thus perforates, pus is discharged, and the pain and the hot sensation are reduced.
• When Qi movement and blood circulation are improved in the local region, the healing process starts.
• If the body’s resistance is not strong, the Qi and blood are too weak to push out the toxin. Pus forms but the boil or carbuncle does not perforate and discharge pus. The disorder then leads to a chronic process.
(See Figure 19.1 on page 395.)
Treatment principle
• At the initial stage: Clear heat-toxin and reduce swelling so as to prevent further development of the syndrome.
• If the pus is forming but the boil or carbuncle is not ready to perforate: Activate Qi and blood, accelerate formation of pus and perforation of the boil or carbuncle.
• If the pus is formed and the boil or carbuncle becomes soft and less painful: Discharge the pus by promoting perforation or making an incision.
• After pus has been discharged: Tonify the Qi, nourish Yin and stimulate the blood in order to promote the healing process.
Herb selection principles and formula composition strategies
• At the initial stage, the first priority is to select pungent-cold herbs or bitter-cold herbs that can effectively reduce heat-toxin, along with herbs that expel wind. They can prevent the development of the syndrome.
• At the metaphase stage, the first priority is to select pungent-cold herbs that accelerate perforation of the boil or carbuncle and discharge pus, along with herbs that cool the blood. Herbs that can stimulate Qi and blood so as to accelerate the formation of pus are often used when pus is forming.
• At the recovery stage, the first priority is to select herbs that tonify the Qi and Yin. Herbs that remove dampness and promote blood circulation are also used.
• In a chronic condition, herbs that tonify the Qi and herbs that promote blood circulation are used, along with herbs that remove heat-toxin and dampness.
Structure of the formula and selection of herbs
Chief: Clear wind-heat, remove heat-toxin or damp-heat in order to stop the pathogenic development at the initial stage
Jin Yin Hua ( Lonicerae flos) and Lian Qiao ( Forsythiae fructus)
Jin Yin Hua is sweet and cold, and enters the Heart, Liver and Stomach meridians. It is a strong herb to clear heat in these organs and meridians. Its sweet and cold properties may generate body fluids so it can prevent Yin consumption from internal heat. As Jin Yin Hua is collected in the early summer when the flowers are still in bud, this herb has a light fragrant smell that has dispersing and ascending abilities. It may slightly disperse and ascend the fire, especially the constrained fire, and can therefore effectively clear heat and remove heat-toxin. Because of these characteristics, it is often selected as chief at the initial stage of Yang-type Yong Yang syndrome.
Lian Qiao is less cold than Jin Yin Hua but has a bitter taste. It enters the Heart and Small Intestine meridians. Bitterness may descend fire from the Heart and cold may clear heat. This herb possesses strong dispersing and ascending abilities and is especially effective in dispersing heat in the Heart and relieving restlessness and a warm sensation in the chest. It is also able to dissipate clumps and nodules caused by constrained heat, accumulation of food and phlegm, and stagnation of blood. Its dispersing and dissipating actions are stronger than those of Jin Yin Hua. It is especially used for treating Yang-type Yong Yang syndrome caused by blazing Heart-fire.
As Jin Yin Hua and Lian Qiao have similar properties and actions, they are often used together to enhance the strength of reducing heat-toxin.
Pu Gong Ying ( Taraxaci herba), Di Ding ( Violae herba) and Ye Ju Hua ( Chrysanthemi indici flos)
These herbs can strongly reduce heat-toxin and are often applied in the formula to treat Yang-type Yong Yang syndrome.
Pu Gong Ying is bitter, sweet and cold, and enters the Liver and Stomach meridians. It can effectively reduce swelling and clear heat-toxin. It can be used at the initial stage of boils and carbuncles when they are warm and swelling. The fresh herb of Pu Gong Ying can be smashed and applied on the swelling and painful places. When there is an ulcer characterized by a red color, a hot sensation and burning pain, Pu Gong Ying can also be used. In this case, it is not only used orally, but also topically as a local compress after the herb is cooked.
Di Ding is bitter, pungent and cold, and enters the Heart and Liver meridians. It should be selected in the formula if a boil is hard, deep-based and very painful. It is suitable for use when the cause of the disorder is blazing Heart-fire rather than heat in the Stomach.
Ye Ju Hua is bitter and neutral, and enters the Lung, Liver and Kidney meridians. It can effectively clear heat-toxin and also reduce swelling. Like Pu Gong Ying, it can be used both orally and topically.
Huang Qin ( Scutellariae radix), Huang Lian ( Coptidis rhizoma), Huang Bai ( Phellodendri cortex), Zhi Zi ( Gardeniae fructus) and Long Dan Cao ( Gentianae radix)
These herbs are very cold and bitter, and can intensively clear heat and dry dampness. They treat severe damp-heat syndrome, which can be observed in infections of skin and subcutaneous regions, ulcers, eczema and some open wounds where the lesions are red, painful and weeping. When a person has fat skin or overindulges in greasy, sweet and pungent food, skin infections with thick pus can develop easily, which is considered as damp-heat accumulation in syndrome differentiation. Huang Qin, Huang Lian and Huang Bai are often selected in the formula to remove the damp-heat. If Yang-type Yong Yang syndrome is linked directly with strong emotions and stress, Huang Lian and Long Dan Cao are often used as they enter the Heart and Liver meridians and can reduce the blazing fire.
These herbs can be used separately according to the syndrome features and location of the lesions.
Huang Qin enters the Lung and Large Intestine meridians. It particularly clears heat in the Lung and the Upper-Jiao and damp-heat in the intestine. As skin is related to the Lung, Huang Qin can be used for the initial and metaphase stages of Yang-type Yong Yang syndrome, which is characterized by itchy and red superficial skin eruptions, and red and weeping ulcers. When damp-heat also accumulates in the Large Intestine due to inappropriate dietary habit with symptoms such as sticky and stinking feces, this herb is more suitable for selection.
Huang Lian enters the Heart and Stomach meridians. It can strongly reduce fire in the Heart and Stomach, and treat boils or carbuncles developed under stress and strong emotions, or due to consumption of very spicy food.
Huang Bai enters the Kidney and Bladder meridians. It can clear heat and dry dampness in the Lower-Jiao. It is an appropriate herb to treat boils and carbuncles in the groins, buttocks and external genital area. It is also used for treating pruritus vulvae, scrotitis and penitis due to damp-heat in the Lower-Jiao and disturbance of empty-fire of the Kidney.
Huang Qin, Huang Lian and Huang Bai can also be applied topically in lotions or pastes to clear heat and dry dampness. They can also be used together in a cream, called San Huang Gao (the three yellow cream), to treat boils and carbuncles.
Zhi Zi enters the San Jiao meridian. It can be combined with any other herbs in this group to enhance their function of clearing heat. At the same time, it leaches out the damp-heat by promoting urination. The latter is the strong point of this herb as it can clear damp-heat of the Heart, Liver and Bladder and lead it to exit the body by urination.
Long Dan Cao enters the Liver meridian and can strongly clear Liver-heat. If Yang-type Yong Yang syndrome appears on the lateral sides of the face, neck and hypochondriac region, such as in cases of herpes zoster, Long Dan Cao can be selected. Long Dan Cao can also be selected in the formula to treat damp-heat in the Liver meridian in the Lower-Jiao, such as in cases of vaginitis, scrotitis and penitis.
Deputy: Promote blood circulation and reduce heat in the blood
Chuan Xiong ( Chuanxiong rhizoma), Dan Shen ( Salviae miltiorrhizae radix), Mu Dan Pi ( Moutan cortex) and Chi Shao Yao ( Paeoniae radix rubra)
Chuan Xiong is pungent and warm, and enters the Liver, Gall Bladder and Pericardium meridians. Pungency can disperse congealed blood, and warmth can activate blood circulation and dissipate blood stagnation. Chuan Xiong is a very effective herb to invigorate blood and to promote blood circulation. It is characterized by high moving speed and strength. For treating Yang-type Yong Yang syndrome, since it can remove congealed blood and reduce pain, it can be selected at all stages of the disorder. It should be mentioned that this herb is warm and very pungent, and a large dosage or long-term use may consume the Yin and Qi. Herbs that nourish the Yin and tonify the Qi should therefore be selected along with Chuan Xiong when treating a chronic condition.
Dan Shen is bitter and slightly cold, and enters the blood level of the Heart and Liver meridians. It is able to promote blood circulation, cool the blood, calm the mind and eliminate irritability. It is a good choice for treating Yang-type Yong Yang syndrome when the color of the skin turns to deep red or purple, which indicates stagnation of blood. Dan Shen can also be applied topically to reduce pain and swelling. The syndrome is often caused by stress and emotional disturbance, which lead to Liver-Qi stagnation, Liver-fire or Heart-fire generation, when the heat further enters the blood and consumes the blood.
Mu Dan Pi and Chi Shao Yao are both cold in nature. They are very often used for cooling the blood and treating heat in the blood. Moreover, they are both able to promote blood circulation and are often chosen because they have fewer side effects than other cold herbs of generating congealed blood in the process of cooling the blood.
Chi Shao Yao is bitter and cold, and enters the Liver meridian, the blood level. It is especially effective in clearing excess heat in the blood. As it is strong in promoting blood circulation and removing congealed blood, it can effectively alleviate pain and reduce swelling. Moreover, it is one of the commonly selected herbs to apply topically to relieve pain and reduce swelling in strain and acute closed injury.
Mu Dan Pi is pungent and cold, and enters the Liver meridian. It is able to clear empty-heat in the blood and is often selected in the formula to treat a sub-acute condition of Yang-type Yong Yang syndrome when the excess heat has consumed the Yin, especially the Liver-Yin.
Zi Cao ( Arnebiae/Lithospermi radix) and Qian Cao Gen ( Rubiae radix)
Zi Cao is salty, sweet and cold, and enters the Heart and Liver meridians; Qian Cao Gen is bitter and cold, and enters the Liver and Pericardium meridians. These two herbs enter the blood and cool the blood. At the same time, they can reduce congealed blood. Qian Cao Gen can also stop bleeding. They are particularly selected in the condition when the skin lesion is deep red or purple in color, which suggests that heat has entered the blood and blood stagnation exists, such as in the sub-acute or chronic condition of boils and carbuncles, ulcers, closed injury of muscles and joints, or bleeding under the skin.
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