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Wang Zhu-sheng on Sjogren's Syndrome.

abstracted and translated by Bob Flaws

Keywords: Chinese medicine, Chinese herbal medicine, rheumatology, autoimmune diseases, Sjogren's syndrome

This issue of the Townsend Letter is dedicated to the best of naturopathic medicine. Since the following article is the best discussion of Sjogren's syndrome that I have seen in the Chinese literature, I would like to offer it to readers of this issue. Sjogren's syndrome is an autoimmune disease that primarily occurs in females from 40 to 60 years of age and is characterized by dry mouth and eyes accompanied by inflammation of the joints, muscular pain, and skin rashes. In Bei Jing Zhong Yi Yao (Beijing Chinese Medicine and Pharmacology) issue 7, 2008, pages 506-508, Yang Mei-yu et al. published an article titled "Wang Zhu-sheng's Clinical Experiences in the Treatment of Sjogren's Syndrome." The following is a summary of the main points of this article.

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Disease causes and mechanisms

Wang divides the disease causes of Sjogren's syndrome into former and latter heaven causes. (This division allows him to discuss the genetic factors of this condition under former heaven causes and the secondary, adventitious factors under latter heaven causes. This division is becoming more common in the Chinese medical literature as genetic factors are becoming more and more recognized.) Under former heaven causes, Wang lists systemic yin vacuity with fluid and humor depletion and scantiness and systemic yang vacuity with inability to move water. Hence fluids and humors are not able to obtain lifting upward in order to nourish and moisten the clear orifices. Under latter heaven causes, Wang lists damage by the seven affects, excessive taxation fatigue, or enduring diseases resulting in loss or lack of nourishment by blood and essence, old age with exhaustion of the tian gui, faulty treatment that has damaged yin fluids, overuse of acrid, warm, upbearing, and scattering prescriptions, and/or collapse of blood-loss of essence, any of which may result in insufficiency of yin fluids and consumption and detriment of the righteous qi. Further, Wang also says that external contraction of the six excesses may disperse and burn fluids and humors. In fact Wang believes that typically there is a combination of former and latter heaven causes that then also result in the creation of phlegm and stasis which block the network vessels.

In the early stage of this disease, there is commonly contraction of external evils, which then manifests as an exterior repletion. This is during the acute phase of this condition, which is relatively short. Then, in those with a natural endowment insufficiency or the elderly with a weak body, the disease enters the interior, where it causes consumption of and damage to the yin fluids of the lungs, kidneys, liver, spleen, and stomach. This then manifests as yin vacuity fluid depletion, an interior vacuity pattern. This is the chronic stage of this condition with a relatively long course. When the disease goes from exterior to interior and transforms from repletion to vacuity, the function of the viscera and bowels is disturbed, and fluids and humors are not spread. This results in phlegm and stasis blocking and obstructing the channels and vessels. Thus typically there is a mixture of vacuity and repletion disease mechanisms in Sjogren's syndrome.

Wang also believes that the liver plays a special role in the disease mechanisms of this condition. This disease is mostly seen in females; and, in females, the blood is the root. However, the blood is the mother of the qi, and the qi is the commander of the blood. Therefore, blood disease eventually reaches the qi, and qi disease eventually reaches or affects the blood. The liver stores the blood and (its qi) governs coursing and discharge. If the seven affects damage internally, then this easily leads to loss of normalcy of the liver's function along with loss of regulation of the qi and blood. This condition also mostly occurs in women over 40. According to the Nei Jing (Inner Classic), "At six [times] seven [years of age in females], the three yang vessels are debilitated above and the face is scorched [or dry] and the hair is white; at seven [times] seven [years of age], the ren mai is vacuous, the tai chong kai is debilitated and scanty, and the tian gui is exhausted ... [therefore,] there are no [more] children." The tian gui mentioned above refers to kidney yin. Hence women of this age are prone to yin vacuity. So there can also be loss of balance between yin and yang. Due to lack of nourishment and moistening by yin-blood, liver qi may counterflow and becomes chaotic, may become depressed and bound, and may transform fire effulgence. In this case, yin and blood are consumed and exhausted while the liver vessel qi and blood are impeded and blocked, with all of this potentially resulting in this disease.

Commonly used treatment methods

Based on the preceding logic, Wang most often uses a certain group of treatment methods and medicinals when treating Sjogren's syndrome. First he divides these methods into six general categories. Then he divides the first category, treatment methods via the liver, into five subdivisions. (I believe the authors have chosen this method of outlining Wang's practice because Sjogren's syndrome typically manifests highly individualized multipattern presentations, and this method exemplifies the necessity of using a combination of treatment methods better than the more standard method of presenting individual patterns and their formulas. Therefore, unless a list of medicinals is prefaced by the name of a particular formula, the following lists are only lists to be chosen from. They are not formulas per se.)

1. Treating via the liver

A. Clear and drain liver fire

For this pattern, Wang commonly uses medicinal such as:

Qing Dai (Pulvis Indigonis)

Ye Ju Hua (Flos Chrysanthemi Indici)

Chan Yi (Periostracum Cicadae)

Cgou Teng (Ramulus Uncariae Cum Uncis)

Zi Bei Chi (Concha Mauritiae/Cypreae)

Long Dan Cao (Radix Gentianae)

Xia Ku Cao (Spica Prunellae)

Ling Yang Jiao (Cornu Antelopis Saiga-tatarici)

B. Level and repress liver yang

The commonly used medicinals the professor uses in this method include:

Sang Ye (Folium Mori)

Gou Teng (Ramulus Uncariae Cum Uncis)

Chai Hu (Radix Bupleuri)

Long Gu (Fossilia Ossis Mastodi)

Zhen Zhu Mu (Concha Margaritiferae)

Shi Jue Ming (Concha Haliotidis)

Mu Li (Concha Ostreae)

Zi Bei Mu (Concha Mauritiae/Cypreae)

Da Zhi Shi (Haemititum)

Ling Yang Jiao (Cornu Antelopis Saiga-tatarici)

C. Course the liver and resolve depression

Here the commonly used ingredients include:

Chai Hu (Radix Bupleuri)

Xiang Fu (Rhizoma Cyperi)

Mei Gui Hua (Flos Rosae Rugosae)

Yu Jin (Tuber Curcumae)

A commonly used formula in this case is Chai Hu Shu Gan San with additions and subtractions:

Chuan Xiong (Rhizoma Chuanxiong)

Xia Ku Cao (Spica Prunellae)

Xiang Fu (Rhizoma Cyperi)

Zhi Qiao (Fructus Aurantii)

Quan Xie (Scorpio)

Long Dan Cao (Radix Gentianae)

Gan Cao (Radix Glycyrrhizae), 10g each

Yu Jin (Tuber Curcumae)

Dang Gui (Radix Angelicae Sinensis)

Chai Hu (Radix Bupleuri)

Mei Gui Hua (Flos Rosae Rugosae)

Huang Qin (Radix Scutellariae), 15g each

Ji Xue Teng (Caulis Spatholobi), 20g

Huang Qi (Radix Astragali)

Sha Shen (Radix Glehniae)

Cou Teng (Ramulus Uncariae Cum Uncis)

Long Gu (Fossilia Ossis Mastodi)

Mu Li (Concha Ostreae)

Zi Shi Ying (Flouritum)

Zi Bei Chi (Concha Mauritiae/Cypreae)

Bai Shao (Radix Alba Paeoniae), 30g each

D. Nourish the blood and emolliate the liver

In this case, Wang uses heavy doses of Bai Shao (Radix Alba Paeoniae) to nourish the blood and emolliate the liver combined with Shu Di Huang (cooked Radix Rehmanniae) and Dang Gui (Radix Angelicae Sinensis) if there is liver blood depletion vacuity. If there is blood vacuity and liver depression, then he adds Chai Hu (Radix Bupleuri) and Dang Gui. If there is liver yin and blood vacuity with loss of nourishment of the sinews and vessels resulting in cramping and pain of the hands and feet, then he combines Bai Shao with Gan Cao (Radix Glycyrrhizae) to relax cramping and stop pain.

E. Enrich and supplement the liver and kidneys

Here Wang commonly uses:

Ba Ji Tian (Radix Morindae Officinalis)

Du Zhong (Cortex Eucommiae)

Xu Duan (Radix Dipsaci)

Rou Cong Rong (Herba Cistanchis)

Bu Gu Zhi (Fructus Psoraleae)

Tu Si Zi (Semen Cuscutae)

Sha Yuan Zi (Semen Astragali Complanati)

Dong Chong Xia Cao (Cordyceps)

Gou Qi Zi (Fructus Lycii)

Nu Zhen Zi (Fructus Ligustri Lucidi)

Han Lian Cao (Herba Ecliptae)

Shan Yao (Radix Dioscoreae)

As a formula, Wang commonly uses Yi Guan Jian (One Link Decoction) plus Zuo Gui Yin (Return the Left Beverage):

Gou Qi Zi (Fructus Lycii)

Sheng Di Huang (uncooked Radix Rehmanniae)

Han Lian Cao (Herba Ecliptae)

Mu Gua (Fructus Chaenomelis)

Shi Hu (Herba Dendrobii)

Dang Gui (Radix Angelicae Sinensis)

Shu Di Huang (cooked Radix Rehmanniae), 10g each

Yu Zhu (Rhizoma Polygoni Odorati), 15g

Shan Zhu Yu (Fructus Corni)

Shan Yao (Radix Dioscoreae), 20g each

Sha Shen (Radix Glehniae)

Mai Men Dong (Tuber Ophiopogonis)

He Shou Wu (Radix Polygoni Multiflori)

Bai Shao (Radix Alba Paeoniae)

Ju Huan (Flos Chrysanthemi)

Huang Qi (Radix Astragali), 30g each

2. Boost the qi and nourish yin

If this disease has endured for a long time and not healed, it easily transforms into a qi and yin dual vacuity pattern. This pattern may also present in those who are elderly, who have had a bad diet for a long time, or with a habitual bodily qi and yin vacuity with a concurrent external contraction of wind, cold, damp evils. In that case, Wang commonly uses:

Huang Qi (Radix Astragali)

Sha Shen (Radix Glehniae)

Mai Men Dong (Tuber Ophiopogonis)

Shi Hu (Herba Dendrobii)

Yu Zhu (Rhizoma Polygoni Odorati)

Huang Jing (Rhizoma Polygonati)

Dang Shen (Radix Codonopsis)

3. Cleat heat and resolve toxins

If external evils invade, they may disperse and burn fluids and humors, easily transforming fire and engendering heat. Thus heat toxins may be produced and become exuberant internally. Therefore, the treatment principles of clearing heat and resolving toxins are commonly used in treating this condition and especially in the early stage. Wang's commonly used medicinals for this purpose include:

Huang Qin (Radix Scutellariae)

Zi Cao (Radix Arnebiae/Lithospermi)

Jin Yin Hua (Flos Lonicerae)

Lian Qiao (Fructus Forsythiae)

Bai Hua She She Cao (Herba Oldenlandiae)

Pu Gong Yin (Herba Taraxaci)

Xia Ku Cao (Spica Prunellae)

Lu Gen (Rhizoma Phragmitis)

Bai Mao Gen (Rhizoma Imperatae)

Sheng Di Huang (uncooked Radix Rehmanniae)

Mu Dan Pi (Cortex Moutan)

Chi Shao (Radix Rubra Paeoniae)

Zhu Ru (Caulis Bambusae In Taeniam)

Zhi Zi (Fructus Gardeniae)

4. Clear the lungs and moisten dryness

"Dry evils assailing the lungs" refers to either external contraction of dry evils or external contraction of wind heat evils transforming dryness and damaging yin. In either case, lung fluids are consumed and damaged. During the early stage of this disease, it is common to combine this treatment method with the previous one of clearing heat and resolving toxins. Commonly medicinals for this treatment method are:

Sang Ye (Folium Mori)

Pi Ba Ye (Folium Eriobotryae)

Sha Shen (Radix Glehniae)

Mai Men Dong (Tuber Ophiopogonis)

Xing Ren (Semen Armeniacae)

Wang commonly uses the formula Qing Zao Qiu Fei Tang (Clear Dryness and Rescue the Lungs Decoction) with additions and subtractions for this purpose:

E Jiao (Gelatinum Corii Asini)

Gan Cao (Radix Glycyrrhizae)

Ma Ren (Semen Lini Usitatissimi)

Dang Gui (Radix Angelicae Sinensis)

Chuan Xiong (Rhizoma Chuanxiong), 10g each

Dang Shen (Radix Codonopsis)

Yu Zhu (Rhizoma Polygoni Odorati), 15g each

Shi Gao (Gypsum)

Sheng Di Huang (uncooked Radix Rehmanniae)

Xing Ren (Semen Armeniacae)

Pi Bao Ye (Folium Eriobotryae)

Tian Hua Fen (Radix Trichosanthis), 20g each

Sanh Ye (Folium Mori)

Mai Men Dong (Tuber Ophiopogonis)

Bai He(Bulbus Lilii)

Sha Shen (Radix Glehniae), 30g each

5. Dispel phlegm and transform stasis

During the chronic progressive stage of this disease, the condition goes from the exterior to the interior and from light or slight to heavy or severe. At this point, the function of the viscera and bowels has lost its regulation, and, therefore, there is the production of phlegm turbidity and blood stasis. The combination of these two then block and obstruct the channels and network vessels. In this case, the treatment principles Wang uses are to dispel phlegm and transform stasis. Commonly used medicinals for these purposes include:

Dang Gui (Radix Angelicae Sinensis)

Yu Jin (Tuber Curcumae)

Chuan Xiong (Rhizoma Chuanxiong)

Jiang Huang (Rhizoma Curcumae Longae)

Ji Xue Teng (Caulis Spatholobi)

Tao Ren (Semen Persicae)

Hong Hua (Flos Carthami)

Chaun Shan Jia (Squama Manitis)

Dan Shen (Radix Salviae Miltiorrhizae)

Ru Xiang (Olibanum)

Mo Yao (Myrrha)

Yan Hu Suo (Rhizoma Corydalis)

Tao Hong Si Wu Tang (Perica and Carthamus Four Materials Decoction) with additions and subtractions is a commonly used formula by Wang to treat phlegm turbidity and blood stasis:

Chuan Shan Jia (Squama Manitis)

Chuan Xiong (Rhizoma Chuanxiong), 6g each

Niu Xi (Radix Achyranthis Bidentatae)

Gan Cao (Radix Glycyrrhizae)

Bai Jiang Can (Bombyx Batryticatus)

Bai Jie Zi (Semen Sinapis)

Chi Shao (Radix Rubra Paeoniae)

Yi Mu Cao (Herba Leonuri)

Xia Ku Cao (Spica Prunellae)

Qin Jiao (Radix Gentianae Macrophyllae)

Dang Gui (Radix Angelicae Sinensis), 10g each

Sheng Di Huang (uncooked Radix Rehmanniae)

Tao Ren (Semen Persicae)

Hong Hua (Flos Carthami)

Yu Jin (Tuber Curcumae), 15g each

Bai Shao (Radix Alba Paeoniae)

Ji Xue Teng (Caulis Spatholobi)

Dan Shen (Radix Salviae Miltiorrhizae)

Huang Qi (Radix Astragali), 30g each

6. Dispel wind, eliminate dampness and free the flow of the network vessels

The six excessive external evils are the external cause of this disease. In that case, wind, damp, and/or cold evils may block and obstruct the channels and network vessels as well as the joints, thus making the movement of the qi and blood uneasy or not smooth. If this endures for many days (that is, a long time). The fluids and humors are dispersed and burned, thus resulting in this disease. When this happens, there is accompanying joint aching and pain and bodily discomfort requiring the use of dispelling wind and eliminating dampness medicinals. According to Wang's practice, commonly used medicinals in this case include:

Qiang Huo m(Radix Et Rhizoma Notopterygii)

Du Huo (Radix Angelicae Pubescentis)

Wei Ling Xian (Radix Clematidis)

Mu Gua (Fructus Chaenomelis)

Qin Jiao (Radix Gentianae Macrophyllae)

Han Fangji (Radix Stephaniae)

Sang Zhi (Ramulus Mori)

Chuan Shan Jia (Squama Manitis)

Si Gua Luo (Fascularis Vascularis Luffae Cylindricae)

Quan Xie (Scorpio)

Bai Jiang Can (Bombyx Batryticatus)

Shou Wu Teng (Caulis Polygoni Multiflori)

Lu Lu Tong (Fructus Liquidambaris)

These medicinals should then be combined with ingredients that free the flow of yang. Once the flow of the yang qi is freed and spread, the qi mechanism is regulated and easily flowing. Thus fluids and humors are transported and spread, and the symptoms of this condition automatically disappear. Wang commonly uses the following medicinals to free the flow of and spread the yangqi:

Gui Zhi (Ramulus Cinnamomi)

Fu Zi (Radix Lateralis Praeparatus Aconiti)

Xi Xin (Herba Asari)

It is important to note that, because this condition typically presents multiple, interlocking patterns simultaneously, Wang uses more than a single one of the treatment principles per case. Rather, he determines the presenting patterns, states the treatment principles for each pattern, and then selects several of the medicinals he commonly uses for each treatment principle, thus building a complex formula precisely fitting the combination of disease mechanisms each individual patient presents.

Representative case history

The patient was a 55-year-old female who has had Sjogren's syndrome from five years. However, in the last year, this woman's dry mouth and eyes had gotten worse. All diagnostic tests and indications, including serum analysis for autoimmune disease in general and Sjogren's syndrome in particular, confirmed this diagnosis. The patient was first seen by Wang on September 20, 2006, as an outpatient in the Dermatology Department of the Beijing Chinese Medical Hospital affiliated with the Capital University of Medical Science. Beside dry mouth and eyes, the patient reported difficulty in swallowing food, heart vexation, irritability, decreased stirring or activity, disinclination to speak (due to fatigue), chilling of her hands and feet, torpid intake, poor mood, but normal defecation and urination. Her tongue was dark red and cracked with scanty fur, and her pulse was bowstring and fine. Therefore, Wang discriminated this woman's pattern of Sjogren's syndrome as qi and yin dual vacuity with liver qi not soothed and blood stasis blocking the network vessels. ("Liver qi not soothed" is another way of saying liver depression qi stagnation.) Thus Wang's treatment principles were to boost the qi and nourish yin, course the liver and resolve depression, quicken the blood, and transform stasis. The formula he prescribed for these purposes included:

Bai Zhu (Rhizoma Atractylodis Macrocephalae), 6g

Mai Men Dong (Tuber Ophiopogonis)

Wu Wei Zi (Fructus Schisandrae)

Nu Zhen Zi (Fructus Ligustri Lucidi)

Gui Zhi (Ramulus Cinnamomi)

Fu Ling (Poria)

Gan Cao (Radix Glycyrrhizae)

Xiang Fu (Rhizoma Cyperi)

Xia Ku Cao (Spica Prunellae)

Shi Hu (Herba Dendrobii), 10g each

Mei Gui Hua (Flos Rosae Rugosae)

Yu Zhu (Rhizoma Polygoni Odoroati)

Yu Jin (Tuber Curcumae), 15g

Sheng Di Huang (uncooked Radix Rehmanniae), 25g

Huang Qi (Radix Astragali)

Ji Xue Teng (Caulis Spatholobi)

Zi Shi Ying (Flouritum)

Zi Bei Chi (Concha Mauritiae/Cypreae)

Long Gu (Fossilia Ossis Mastrodi)

Mu Li (Concha Ostreae)

Xian He Cao (Herba Agrimoniae)

Bai He (Bulbus Lilii)

Dan Shen (Radix Salviae Miltiorrhizae)

Xuan Shen (Radix Scrophulariae)

Bai Shao (Radix Alba Paeoniae), 30g each

One packet of these medicinals was decocted in water and administered per day in two divided doses.

After taking the above formula consistently day by day, the patient's second visit to Wang occurred on January 3, 2007. At that time, the patient reported that her mouth and eye dryness was markedly less than before, her appetite was OK, her mood was OK, and her two excretions were also regulated or normal. Her tongue was still dark red with cracks and scanty fur, but her pulse was now only fine, not bowstring and fine. Therefore, Wang's treatment principles were now to mainly boost the qi and nourish yin, quicken the blood, and transform stasis. (In other words, the liver depression had become insignificant at this point and no longer needed treatment.) The new formula consisted of:

Mai Men Dong (Tuber Ophiopogonis)

Wu Wei Zi (Fructus Schisandrae)

Dang Gui (Radix Angelicae Sinensis)

Huang Jing (Rhizoma Polygonati)

Tong Cao (Medulla Tetrapanacis)

Nu Zhen Zi (Fructus Ligustri Lucidi)

Gan Cao (Radix Glycyrrhizae), 10g each

Shi Hu (Herba Dendrobii)

Yu Jin (Tuber Curcumae), 15g each

Si Gua Luo (Fascularis Vascularis Luffae Cylindricae), 20g

Sheng Di Huang (uncooked Radix Rehmanniae)

Tian Hua Fen (Radix Trichosanthis), 25g each

Huang Qi (Radix Astragali)

Sha Shen (Radix Glehniae)

Ji Xue Teng (Caulis Spatholobi)

Long Gu (Fossilia Ossis Mastrodi)

Mu Li (Concha Ostreae)

Dan Shen (Radix Salviae Miltiorrhizae)

Xuan Shen (Radix Scrophulariae)

Bai Shao (Radix Alba Paeoniae), 30g each

After taking these medicinals for an unspecified period of time, all the patient's symptoms decreased even more. She continued using this formula with minor adjustments from time to time based on her signs and symptoms, and eventually her condition returned to normal. This return to normal importantly also included all the serum markers for autoimmune disease in general and Sjogren's syndrome in particular.

by Bob Flaws, L.Ac., FNAAOM (USA), FRCHM (UK)

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Title Annotation:Chinese Medicine
Author:Flaws, Bob
Publication:Townsend Letter
Article Type:Clinical report
Geographic Code:9CHIN
Date:Feb 1, 2009
Words:3192
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