Dry syndrome (sjogrens’ syn-drome, SS) is a chronic autoimmune disease with dry mouth and dry eyes as the main clinical symptoms, accompanied by the production of various autoantibodies and hypergammaglobulinemia, with the invasion of exocrine glands, especially salivary glands and lacrimal glands as the main pathological changes, and this disease belongs to the category of “dryness evidence” in Chinese medicine. This disease belongs to the category of “dryness” in Chinese medicine. In clinical treatment, most reports and clinicians focus on the dryness of yin deficiency, and treatment is mostly based on nourishing yin methods [1]. And often ignore the dryness of Yang deficiency evidence.
Through the understanding of the etiology and pathogenesis of SS, clinical characteristics and experience of clinical diagnosis and treatment, the author shall describe the experience of theory, prescription and medicine of Yang deficiency and dryness type of this disease as follows for the reference of fellow doctors.
1.The understanding of dry syndrome related pathogenesis and treatment rules
1.1.Yang qi is the basis of human body’s fluid generation and metabolic power
The greatest significance of the theory of “qi is divided into yin and yang” in Chinese medicine is that on the basis of qi being the basis of human body regulation, it further reflects the way of regulation of human body qi, that is, how qi promotes, regulates and maintains the changes of human body’s life activities, and what is the law to be followed. That is, the essence of life is based on yin and yang, and the harmony of yin and yang is based on the two qi of yin and yang. Yang Qi’s warming, pushing, rising and so on, and Yin Qi’s cooling, suppressing, sinking and so on, work together to achieve the balance and sympathy of Yin and Yang in the human body, so that all life activities are balanced and orderly.
Regarding the production and metabolism of fluids, it is closely related to the joint action of many internal organs and the regulation of Yin and Yang Qi. This process is accomplished through the intake of stomach qi, the production and distribution of spleen qi, the transpiration and vaporization of kidney qi, the promotion and regulation of lung qi, and the draining of liver qi.
While focusing on the cooling and moistening effect of Yin Qi in the human body, we should see that Yang Qi is actually the basis of power. Without Yang Qi’s role of inspiring and promoting the ascension and development, how can fluid be successfully completed in the above-mentioned fluid production and metabolism?
1.2. Analysis of the importance of yang qi from the perspective of onset to prognosis
It is currently believed that SS is a chronic autoimmune disease in which inflammatory and destructive lesions occur in salivary glands and lacrimal gland tissues due to abnormal proliferation and activation of the body’s B lymphocytes and the production of a large number of immunoglobulins, multiple autoantibodies and immune complexes based on genetic susceptibility, viral infection and abnormal sex hormones and other factors. Yin deficiency and Yang deficiency physiques have an innate immune deficiency to some extent. The evil qi is wounded, depending on the person, Yin deficiency is prone to dryness and heat, while Yang deficiency is more likely to lead to deficiency of the external guard, dysregulation of the Ying and Wei, and stagnation and dryness as a problem.
The clinical manifestations are mostly insidious, slow progressing, early localized mouth and eyes with dryness as the main symptom, and light visceral symptoms; in the late stage of the disease, it can be accompanied by interstitial fibrosis of the lung, interstitial nephropathy and other multi-organ involvement, resulting in two injuries to the qi and essence of the five viscera, and when the yang energy is damaged, it causes the lung to be unable to promote and regulate, the spleen to be unable to transport and transform, the kidneys to be unable to steam and the liver to be unable to regulate. The Yang energy is damaged, resulting in the lung not being able to promote and regulate, the spleen not being able to transport and transform, the kidney not being able to transpire, and the liver not being able to regulate.
1.3, Yang deficiency dryness evidence because of water, gas and fire is not to return to the root, treatment is appropriate to warm Yang to return to the source.
The clinical reports of the dryness of Yin deficiency are many, so I won’t repeat them here, but clinically the dryness of Yang deficiency is also common. When the Spleen and Kidney Yang is deficient, the patient often has signs of fatigue, lumbar acidity, cold limbs, sweating or less sweating, loose abdomen or constipation, dizziness and tinnitus, and other signs of Yang warming or insufficient promotion.
The patient’s mouth, eyes, skin and yin area are dry due to the deficiency of yang qi, which leads to water not returning to the yuan, i.e. the production and transmission of fluid is unfavorable, and the water-dampness internal stagnation and dryness are also caused by the unfavorable metabolism of water and fluid, and the author has seen some patients with dryness syndrome with swelling of lower limbs or joint cavity fluid accumulation.
Yang deficiency will also have deficiency fire, because the kidney Yang deficiency and fire does not return to the yuan will also lead to bitter mouth and throat dryness and even sores on the tongue, mood and irritability, insomnia, eye swelling and eye pain, or Yang deficiency fire floating and trapped in the lower part of the person, see dryness in the yin, hot urine, pain or detention, stool embarrassment is not smooth, etc., that is, the so-called out of place fire. As Zhang Jingyue said, “Those who are trapped in the lower part of the body and see the two yin between the stool and the drowning, although the lower part of the body is hot, the middle part is cold, so called the fire out of place.” This is also known as out-of-place fire. The deficiency fire will lead to more intense dryness.
Insufficient kidney yang and qi does not return to the yuan, then there is erratic, shortness of breath and panting, palpitations, qi from the less abdominal upward rushing and other symptoms, qi deficiency and turbid qi rushing rebellious, clear qi trapped in the lower is more powerless to regulate the production and metabolism of water and fluid.
Therefore, Yang deficiency and dryness are mostly due to the deficiency of the spleen and kidney Yang and water does not return to the yuan, fire does not return to the yuan, Qi does not return to the yuan is the root of the disease mechanism. The principle of treatment should be to warm the yang and return to the yuan, that is, warm the spleen and kidney and make water, fire and qi return to their places, then the dryness will be removed.
2.Experience in the application of prescriptions and medicines
Through my practice and experience in the clinic, the formula for warming Yang to return to the vital energy method is mostly used in the treatment of the “Discerning the Qi” of Chen Shiduo in the Qing Dynasty, which is the addition and subtraction of Gui Huo Tang.
Chen Shiduo’s “Discernment of Qiwen” was originally used for those with sore throat due to Yin moth. According to Chen Shiduo’s “Identification of Qi Wen”, Volume 3, “Throat”, “This fire is due to water deficiency, fire can not be hidden, up the throat. It is advisable to supplement the kidney water, plus the fire, in order to attract fire to the collection, the upper heat will heal.” There is evidence that Chen Shiduo was taught by Fu Shan, so this formula is also known as Fu Shan fire-attracting soup. Recipe for the ruler of the water, wheat, taste for the adjuvant, water enough to control the fire and moisten dryness; add the warmth and moisten the barberry, the water and fire both; underwater tendency, fire and gas had to follow, increase Poria front, the water and fire with the gas tendency, together with the kidney palace, with barberry “to take its fire, and enough water, the kidney without the risk of dryness, the throat has the benefit of clearing, this barberry so better than the attached, gui also ” [2].
Modern Chinese medicine Li Ke clinical application also often add asparagus and maitong used together, take its nourishing kidney power; add cinnamon to help guide the fire back to the yuan; also like to use sand kernel, the drug into the spleen, stomach, kidney meridian, one can wake up the spleen to regulate the stomach, fire downward need to rely on the spleen and stomach for the mediation; two can lower the qi, lead the drugs back to the yuan. In the Album of Experiences of Li Ke, a veteran Chinese medicine practitioner in acute and critical illnesses and difficult diseases, this formula is especially used, and the application to dry syndrome is also corresponding [3].
In addition, I still have the following experiences in clinical use of medicine.
2.1. The necessity of combining warming Yang and nourishing Yin
When treating Yang deficiency floating fire, it is necessary to use nourishing Yin drugs in combination, because with nourishing Yin submerged products such as Shu Di, Cornu Cervi Pantotrichum, Bai Shao, Mai Dong, Tian Dong, etc., warm Yang products such as Baji Tian and Cinnamon can live in the lower part of the body, like a galloping horse that does not take off the reins, in order to achieve the purpose of returning the floating fire to its source, which has been reflected in the fire-priming soup. In addition, the application of nourishing and moistening products can also prevent the warmth of Yang’s hot drugs too dry, I have experienced in clinical practice that the effect of such a combination is more ideal than the application of warmth of Yang drugs alone.
2.2, do not forget to thicken the earth to benefit the qi and converge the fire to regulate water
Thick earth benefit qi convergence of fire mentioned first in you in the Jing Xiang House medical case: “deficiency of cold in the qi, get cold is diarrhea, and the fire rose teeth maggots, the ancient so-called chest gathered in the residual fire, the abdominal accumulation of long sinking cold. This should be warmed and replenished in the qi, the body of the earth thick and fire from convergence.” The so-called sunken cold accumulated in the abdomen for a long time is caused by the deficiency of the spleen and stomach Yang, and the residual fire gathered in the chest is also caused by earth injury. Because the kidney and the spleen are closely related, the spleen is the origin of the latter, and the kidney is the wood of the first, the spleen of the latter depends on the kidney of the first to nurture, and the kidney of the first depends on the spleen of the latter to feed, and the two depend on each other for existence and mutual transformation. The two are interdependent and mutually dependent. Because the vital fire gives birth to the spleen and earth, the vital fire is weak and the spleen yang must be weak, so the pathogenesis of the deficiency of the kidney yang mostly includes the deficiency of cold in the spleen of Taiyin.
It is for this reason that Li Dongyuan said in the spleen and stomach theory: “If the diet is out of order, cold and warm discomfort, the spleen and stomach is injured …… both spleen and stomach gas failure, insufficient vital energy and heart fire alone, heart fire, Yin fire also.” You’s statement refers to this statement in general.
And kidney yin deficiency is often accompanied by spleen and stomach yin deficiency, which can also lead to internal heat. Xue’s Medical Case says: “A lung and spleen yin deficiency fever, is the yin blood self-injury, can not control the fire, Yang Qi ascending and internal heat. It is also Yang prosperity.” Insufficient middle earth has the difference between spleen and stomach yang deficiency and spleen and stomach yin deficiency, so the method of thick earth also has sweet and warm to help the yang of spleen and stomach, such as Li Zhong, Si Jun and so on; sweet and light to nourish spleen yin, and sweet and cool to nourish stomach yin, such as represented by Yi Zhi Tang.
2.3, warming Yang with more sweet and moist and less stern, and with adjuvant system.
I found in the clinic that many patients with dry syndrome only have slight deficiency of kidney yang or even some patients who just have the tendency of yang deficiency physique. Most of such patients generally do not need to use Radix et Rhizoma, but can use drugs such as Xian Ling Spleen, Cistanches, Baji Tian, Cinnamon, etc., which are on the side of sweet and moistening, warming Yang and also moistening dryness, and cannot be confined to critical symptoms such as Dai Yang and Geyang, then use Radix et Rhizoma, Gan Jiang and other fierce generals.
In addition, a small amount of Huanglian (about 4-6g), can be used to cure the role of warming medicine is not too much, if and cinnamon with, the effect of fire to return to the yuan is very good.
2.4.The combination of ascending and developing products
Dryness of the mouth and eyes of patients with dryness syndrome is a must, warming Yang to return to the yuan at the same time to pay attention to strengthen the Yang Qi transpiration and gasification and make the fluid spread up, Li Dongyuan day: “less gas for dryness, even the mouth without saliva. Tears also fluids, depending on the gas to lift the cloth, so that it can reach its place, overflowing its orifice. This is a deficiency of gas and fluids do not feed, it is less tears, mouth and eyes dryness of the disease carried forward.” Therefore, we should also apply Ge Gen, Sheng Ma, dry lotus leaves and other ascending and clearing products to lift Yang Qi, Ge Gen, Sheng Ma general dosage up to about 20 grams to 30 grams to play a good effect.
2.5. Selection of medicine by pharmacological action of Chinese medicine
The use of pharmacological components of Chinese medicine to regulate diseases can be called the theory of aid medicine, dry syndrome is an autoimmune disease, which is proved in modern pharmacological research. Some herbal medicines contain components that have positive effects in the regulation of suppressing autoimmunity, such as Han Fang, Tu Fu Ling, Lu Hifang, Bai Shao, etc., which can be considered on the basis of evidence-based medicine, and I have experienced satisfactory results in the clinic.
3.Examples of cases
Liu, female, 53 years old, came to the clinic for severe dry mouth and eyes for one year, had been transferred to several hospitals, had taken hormone treatment, and had applied dozens of Chinese herbal tonics in other hospitals, all of which were nourishing yin and increasing liquid, but the effect was not good, and reported that the mouth, eyes, nose, skin and skin of the eyes and yin were dry and obvious, and drinking a lot of water did not relieve it, and the dry oropharynx could not eat and swallow smoothly, and every must use water or soup to swallow smoothly, and often the mouth and tongue The sore does not resolve for several weeks, accompanied by fatigue, shortness of breath, dizziness, insomnia, irritability, sometimes irritable heat in the chest, cold feet, cold pain in the waist and knees, sweating, constipation, abdominal distension is obvious after eating, his face is dark, his eyes are covered with blood, his tongue is red and fat with teeth marks, his fur is white and thick, and his pulse is moist and slow. In addition, he was found to have significant effusion in the hip and knee joints on radiographs due to back and knee pain. Analysis: The patient has a deficiency of spleen and kidney yang qi, which leads to dryness of the mouth, eyes, nose, skin, and yin area due to deficiency of yang qi that does not return to the yuan, resulting in unfavorable fluid production, transmission, and transpiration and vaporization. If the fire does not return to the origin and generates floating fire, the mouth and tongue become sore, and the heart and liver become insomniac and irritable due to deficiency fire. Treatment to warm the Yang to astringent fire, benefit Qi to return to the water formula: induce fire soup with the following reduction.
Radix Rehmanniae 20g Radix Bacopa monniera 12g Rhizoma Cistanche 9g Cortex Cinnamomum 3g Rhizoma Huanglian 5g Mai Dong 20g Asparagus 12g Fructus Schisandrae 6g Radix Paeoniae 20g Atractylodes Macrocephala 12g Atractylodes Macrocephala 20g Rhizoma Lucidum 6g Radix Puerariae 20g Dried lotus leaf 9g Sandy nut 9g Poria cocos 20g Han Fang Hui 20g, decoction with water, one dose per day.
After 6 doses, the patient’s symptoms have been reduced, dryness symptoms improved, diet without soup can be smoothly swallowed, continue to consolidate taking 20 doses, the symptoms are greatly reduced, the above plus reduction after asking them to continue to take conditioning for 2 months, dryness symptoms basically cured.
The symptoms of dryness were basically cured.