Chapter Four. The internal cold syndrome and formula composition
CHAPTER CONTENTS
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that expel cold, warm the meridians and internal organs, and rescue the Yang from collapse. They are used for treating internal cold syndrome.
The internal cold syndrome
Manifestations
Main symptoms
1. Cold and severe pain of the limbs, cramp of the muscles, stiffness of the body.
2. Cramping pain of the abdomen, a preference for warm drinks, diarrhea or soft stool without a strong smell, distension of the abdomen and poor appetite.
3. Edema or frequent urination.
4. Impotence, infertility, aqueous-grainy diarrhea.
5. Yang collapse syndrome: Palpitations, shortness of breath, chest pain and a stifling sensation in the chest, shallow breathing and profuse sweating, pallid complexion, indifferent expression and slow reactions.
6. Floating-Yang syndrome: Flushed face, a floating red color that appears only on the cheeks, heavy sweating, weak and cold limbs, a pale or light purple tongue with a moist coating, and a weak and rootless pulse.
Secondary symptoms
Dysmenorrhea with cramping pain in the lateral sides of the lower abdomen, depression.
Tongue
Pale, purple or bluish color with a white coating.
Pulse
Deep, slow and weak.
Associated disorders in western medicine
Arthritis, chronic colitis, peptic ulcer, gastritis, enteritis, influenza, liver diseases, hypothyroidism, chronic nephritis, myocardial infarction, myocarditis, severe blood loss, trauma, severe dehydration and allergies.
Analysis of the syndrome
An internal cold syndrome develops under several conditions.
The exogenous pathogenic cold can directly cause internal cold syndrome. After exposure to cold, rain or snow, the exogenous pathogenic cold can invade the body through skin and subcutaneous tissue, and thereafter enter the meridians and internal organs.
• Cold has a contracting nature, can directly obstruct Qi movement and cause the typical symptom of cramping pain, which can be relieved by warmth.
• Cold obstructs the warm spreading of Yang, the movement of the Qi and the circulation of the blood. Patients therefore suffer from cold sensation, severe pain and cramp of the muscles, and stiffness of limbs, such as in a Bi syndrome caused by wind, cold and dampness.
Through inappropriate consumption of cold food and drink, the exogenous pathogenic cold can directly enter the Stomach and accumulate in the Middle-Jiao.
• When cold obstructs the Yang and Qi, patients may have acute cramping pain in the stomach or abdomen, and may have diarrhea.
The internal cold syndrome can be caused by Yang deficiency in different organs.
• Kidney-Yang deficiency is often seen in elderly people, people with a poor constitution and patients with chronic diseases. When the Kidney-Yang fails to accelerate water metabolism, edema or frequent urination may occur. When the Kidney-Yang and Qi are unable to warm the Lower-Jiao and maintain its function, impotence, infertility, dysmenorrhea and aqueous-grainy diarrhea may occur.
• Spleen-Yang deficiency often occurs in people with chronic disorders of digestion. When the Spleen-Yang is too weak to warm the internal organs, meridians and muscles, it causes a cold sensation and cramping pain of the abdomen and diarrhea. When the Qi in the Middle-Jiao is too weak, distension of the abdomen and poor appetite appear.
• Heart-Yang deficiency exists in people who have been under stress and emotional distress for a long period of time, or in patients who suffer from severe heart and lung diseases. When the Yang in the chest is too weak to promote the Qi movement and blood circulation, palpitations, shortness of breath and chest pain start.
(See Figure 4.1 on page 128.)
Syndrome of Yang collapse
The syndrome of Yang collapse is caused by serious disturbance of the balance among Yin, Yang, Qi and blood under the influence of pathogenic factors. When blood and Yin are suddenly weakened, or Qi and blood are suddenly obstructed, they fail to support the Yang and the Yang collapses.
• Since Heart-Yang and Kidney-Yang are the principal Yang of the body, Yang collapse means Heart-Yang collapse and Kidney-Yang collapse. In these severe and acute conditions, patients suffer from extremely cold extremities, a severe cold sensation that cannot be alleviated by warmth, chest pain with a stifling sensation and shallow breath.
• When the Qi is too weak to hold the Yang, heavy sweating may start.
• When the Heart-Qi is unable to support the Heart-shen, pallid complexion, indifferent expression and slow reactions are shown.
(See Figure 4.2 on page 128.)
Floating-Yang syndrome
Like the collapse of Yang, floating-Yang syndrome is a dangerous situation. It appears when the Kidney-Yang is extremely weak and the internal cold in the Lower-Jiao is at its maximum.
• When the cold forces the Yang to move upwards, the manifestations are flushed face, a floating red color that appears only on the cheeks and heavy sweating.
• The cold manifests as very weak and cold limbs, a pale or light purple tongue with a moist coating, and a weak and rootless pulse.
(See Figure 4.3 on page 128.)
Treatment principle: Warm the Yang of the Heart, Spleen and Kidney; expel cold; harmonize the Qi and blood
Herb selection principles and formula composition strategies
• First, herbs that are very pungent and hot, enter the Heart, Spleen and Kidney meridians, can disperse cold, warm the interior, relieve cramp, open up the meridians and promote Qi movement are selected.
• Second, herbs that are sweet and slightly warm, enter the Spleen and Kidney meridians, can tonify Qi of the internal organs and thereby gently promote the function of the Yang are selected.
• A small amount of sour and cold herbs should be selected to nourish the Yin and blood and generate the body fluids, as well as reduce the side effects of pungent and hot herbs.
• Herbs that regulate Qi and blood, can dry cold-dampness and eliminate it can be used.
• In the syndrome of Yang collapse, if the Yang is extremely weak and the internal cold exceeds its maximum, and the conflict between the cold pathogenic factor and the hot herbs is very severe, a small amount of cold herb, which follows the nature of the pathogenic cold, can be added. This herb serves as strategic assistant in the large amount of hot herbs used to reduce the conflict and is helpful in fulfilling the therapeutic effect.
CAUTIONS
1. Make a clear differentiation:
In many conditions, when the Qi is obstructed, cold sensation can also appear. When the Yin is too weak to nourish the tendons and muscles, cramp of limbs may also appear. Many patients with blood deficiency also have Yin deficiency with heat in the blood; they are often afraid of cold since the Qi is not strong. A clear and correct differentiation of the syndrome is therefore required at the outset.
2. Protect the Yin:
Many of the herbs in the formula that warm the interior are very pungent and hot, and can consume the Yin and body fluids if they are used for too long or in a large dosage. They may bring about side effects, such as dry mouth, throat and nasal passages, thirst, sore throat, constipation, itchy and dry skin, a burning sensation in the stomach and palpitations. Thus they should not be used long term or in large dosage, especially in patients with Yin and blood deficiency.
3. Caution in bleeding conditions and pregnancy:
In formulas that warm the interior, very pungent and hot herbs, which are able to stimulate the blood circulation, should not be used in bleeding conditions or in pregnancy.
Structure of the formula and selection of herbs
Chief: Directly stimulate the Yang or tonify the Yang, warm the internal organs and meridians and expel cold
These herbs are pungent and hot, and can directly scatter internal cold. They are used for treating excess internal cold syndrome. They can also stimulate the Yang of the internal organs and accelerate their functions so as to disperse the internal cold in both excess and deficiency conditions.
Gui Zhi ( Cinnamomi cassiae ramulus) and Xi Xin ( Asari herba)*
Gui Zhi and Xi Xin are able to warm meridians, promote Qi movement and blood circulation, and expel cold. They are selected in formulas to warm the meridians and treat Bi syndrome.
Gui Zhi is sweet and warm, and primarily enters the Heart meridian. It has an aromatic smell that gives this herb a thin pungent property, which makes it move quickly and lightly. It can particularly warm the blood, stimulate the Heart and promote the blood circulation; thus it can treat cold hands and feet, cramp of the muscles and pain due to cold obstruction of the blood circulation. In addition, Gui Zhi also enters the Lung and Bladder meridians, is able to expel wind and cold in the superficial region and can therefore treat exterior wind-cold syndrome.
Xi Xin is a very pungent and hot herb with an aromatic smell. It enters the Kidney meridian. Because of its strong aromatic smell, pungent taste and hot nature, it can easily penetrate into the deep regions of the body. It is very effective in eliminating cold and wind in these regions, such as the bones and tendons, as its ability to enter the Kidney meridian makes it easy to reach these structures. Xi Xin has the characteristic of seeking and eliminating wind, cold and dampness no matter if they are in the corners or chinks of the deep regions of the body. It is often used to stop pain when wind, cold and dampness stay in the deep regions of the body and the Kidney-Yang is weak. In such cases, patients not only have pain and a cold sensation in the affected joints, they also feel pain in the bones. They have difficulty with walking or cannot stand for long, have very stiff and painful tendons, especially in the lower body, feel cold in the extremities and are also afraid of cold. In winter or humid weather all the symptoms get worse.
The side effects of Xi Xin are the likelihood of injuring the Yin, blood and body fluids and it can weaken the Qi. As Xi Xin is a poisonous herb, the dosage should be controlled carefully.
Gao Liang Jiang ( Alpiniae officinari rhizoma), Wu Zhu Yu ( Evodiae fructus) and Ding Xiang ( Caryophylli flos)
All of these herbs are pungent and warm, and enter the Stomach meridian. They can warm the Stomach, expel cold and relieve cramping pain of the Stomach.
Gao Liang Jiang is hot and pungent, and its action is strong in warming the Stomach and alleviating pain. It can be used as chief in the formula to treat cramping pain in the upper abdomen, vomiting of clear fluid and a preference for warm drinks, such as in chronic gastritis and gastroduodenal ulcer.
Wu Zhu Yu is very pungent, bitter and hot, and enters the Liver, Spleen and Kidney meridians. It can warm the meridian, descend the Liver-Qi and treat ascending of the Liver-Qi due to excess cold in the Liver meridian. The indication is headache, particularly on the top of the head. In addition, Wu Zhu Yu can spread the Liver-Qi and can be used when the Liver-Qi attacks the Stomach, which manifests as cramping pain with a cold sensation in the Stomach and in the lateral sides of the lower abdomen, vomiting of clear fluid, and a wiry and slow pulse. This pattern can be found in disorders such as migraine, hypertension, peptic ulcer, chronic gastritis and dysmenorrhea.
Ding Xiang is warm and pungent, and enters the Stomach, Spleen, Lung and Kidney meridians. It can descend the Stomach-Qi, expel cold and reduce the cramping pain. It treats belching and hiccup caused by coldness in the Stomach.
Gan Jiang ( Zingiberis rhizoma), Xiao Hui Xiang ( Foeniculi fructus), Cao Dou Kou ( Alpiniae katsumadai semen) and Hua Jiao ( Zanthoxyli fructus)
All of these herbs are pungent and warm, and enter the Spleen meridian. They can expel cold and warm the Spleen-Yang. They can be used as chief herbs separately in formulas that treat coldness in the Middle-Jiao.
Gan Jiang is very pungent and hot, and enters the Spleen, Stomach, Heart and Lung meridians. It moves reasonable quickly and its action tendency remains in the Middle-Jiao. As it is particularly effective in warming the Spleen and Stomach, expelling cold and drying dampness, it can treat cramping and cold in the abdomen, vomiting and diarrhea due to internal cold in the Middle-Jiao.
Xiao Hui Xiang, Cao Dou Kou and Hua Jiao can all warm the Middle-Jiao and expel damp-cold. These three herbs are pungent and warm, and enter the Spleen and Stomach meridians. They are used to treat abdominal pain, distension, poor appetite, vomiting and diarrhea.
Xiao Hui Xiang is an aromatic herb. As it can disperse cold and promote Qi movement, it is able to alleviate pain and improve appetite.
Cao Dou Kou is also an aromatic herb. Unlike Xiao Hui Xiang, which promotes Qi movement, its strong point is to dry dampness and warm the Spleen. As a result, it can treat nausea, vomiting, diarrhea and poor appetite.
Hua Jiao has similar functions to Cao Dou Kou, but is much warmer, so its ability to dry dampness and disperse cold is stronger. Since this is a poisonous herb and it moves quickly in the Middle-Jiao, it is only used for acute excessive damp-cold syndrome for a short period of time, such as for severe cramping pain in the abdomen, frequent and urgent bowel movement and watery stools.
Fu Zi ( Aconiti radix lateralis preparata
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