| Theoretical PartThe exact origin of Zhongjing’s insomnia-treating theory could be determined through the retrospective search in various aspects of insomnia, such as its definition, pathogeny, pathology, treatment, prescriptions, etc. Zhongjing inherited the theoretical ideas of "Neijing"(The Medical Classic of the Yellow Emperor, also known as The Inner Canon of the Yellow Emperor), especially in the context of insomnia treatment; the exertion of theory connotation, such as Zheng Xie (Good and Evil), Yin Yang (Positive and Negative), Qi (Vital Energy) and Blood, Viscera (Internal Organs), Six Meridians (Six Channels), etc. could be apparently observed.In this article, Zhongjing’s law of insomnia treatment is systematically sorted, concluded and classified into11syndromes and21prescriptions based on all39insomnia related clauses in "Shang Han Lun"(Exogenous Febrile Disease) and "Jin Kui Yao Lue"(Essential Prescriptions of the Golden Coffer). Through in-depth study, Zhongjing’s subtle system of insomnia treatment is featured in (1) Attributed to the Six Channels, with Heart and Spirit as the main focus;(2) Despite the dependence on acupuncture and medicines, detailed study and observation on syndrome differentiation is even more crucial and emphasized;(3) expert in cultivating Yin (Negative) blood and warming Yang (Positive);(4) Refine prescriptions and integrate different ways of treatment. Zhongjing carried on "Nei Jing"’s origins and pioneered its development, the contents are full and rich, the therapies and prescriptions are more abundant, exhibiting a very high clinical value, and fundamentally establishing the foundation of the insomnia treatment for future generations.Zhongjing’s insomnia treatment theory has a far-reaching influence on the later generations; many physicians integrate their own academic points of view with Zhongjing’s theoretical basis as the platform to further develop the theories, rules, prescriptions and medicines in treating insomnia, leading to the emerging theories of different schools. In addition to the above-mentioned21classical insomnia prescriptions, there are many non-classical insomnia prescriptions,39in total, which are classified into11prescription categories respectively, namely Fu Yang (Yang Strengthening) Prescriptions, Ying Wei Regulating Prescriptions, Reconciling Prescriptions, Qi Regulating Prescriptions, Damp Dispelling Prescriptions, Heat Dispelling Prescriptions, Blood Regulating Prescriptions, Replenishing Prescriptions, Expectorant Prescriptions, Purgative Prescriptions and De-worming Prescriptions. These prescriptions are proven effective clinically. Under proper guidance of the Dialectical Theory, any prescriptions can be clinically effective as long as the medicines are prescribed to precisely target at the pathogenesis, and alter the contents and dosages flexibly wherever applicable. This embodies Zhongjing’s spirit of dialectical theory that is worth popularizing.The Clinical SectionObjective:To investigate the clinical rules and characteristics of insomnia treatment to affirm organs associated with insomnia, commonly seen insomnia syndromes, medications and how is insomnia related to different genders and age groups,and study Professor Zhou Chunxiang’s laws of medication and characteristics of clinical insomnia treatment, to serve as a good guidance and reference for clinical dialectical theory and prescriptions for insomnia,to serve as a good guidance and reference for clinical dialectical theory and prescriptions for insomnia.Research Methodology:Relevant medical records of insomnia patients for the period of January2011to December2013are collected from Professor Zhou Chunxiang, Nanjing BenQ Hospital. The "Chinese Classification of Mental Disorders and Diagnostic Criteria Third Edition" is followed for Western Medicine diagnostic criteria, while the "Guidance for Clinical Trials of New Drugs of Traditional Chinese Medicine Treatment of Insomnia" is followed for TCM diagnostic criteria. Other key references include the "Guidelines for the Diagnosis and Treatment of Internal Chinese Medicine Common Disease", the "Internal of Traditional Chinese Medicine Seventh Edition" and the "Diagnostics of Traditional Chinese Medicine Seventh Edition". Medical cases that fulfill the criteria are selected to proceed with the Chinese Medicine syndromes differentiation. Data on different syndromes, organs, genders, age groups, etc. are collected and analyzed statistically to examine their inter-relationships. By identifying the common syndromes and its associated organs, the commonly used prescriptions and medicines can be determined and listed out. Microsoft Excel has been used for data sorting and analysis.Results:A total of108insomnia cases are gathered for this research.28.7%or31patients are male, while71.3%or77patients are female, with a ratio of1:2.48. The108cases are allocated to four different age groups accordingly,10-19years,20-39years,40-59years and60-80years old. Patients are more concentrated in the age group of40-59years old, accounting for56.48%overall. Female patients are more concentrated in the40-59years old age group,66.23%, and47.22%overall. Male patients are more concentrated in the age group of20-39years old,41.94%, and12.04%overall. The most common insomnia syndrome is attributed to Yin deficiency, Qi deficiency comes second, followed by heatiness; the percentage is62.96%,33.33%and26.85%respectively. Basically, except for the cold-dampness syndrome, the rest of the insomnia syndromes as discussed by Zhongjing could be seen here.64.94%of females and58.06%of males are diagnosed with Yin Deficiency syndrome. More women than men are diagnosed with:Yin Deficiency, Blood Deficiency, Yin and Blood Deficiency, Blood Stasis, Liver Depression, Liver-Yang Hyperactivity, Turbid and Damp, etc.; more men than women are diagnosed with:Qi Deficiency, Qi and Yin Deficiency, Qi and Blood Deficiency, Yin Deficiency and Excessive Heat, Asthenia Heat, Internal Heat, Damp and Heat, Stagnant of Phlegm, etc. Obviously, for female, insomnia due to Yin deficiency occurs mostly in40-59years old, accounting for74%; while men often seen in20-39years,44.44%. Yin deficiency is most significantly seen in the kidney than other organs, as high as69.12%, followed by the liver,29.41. The organs that are highly associated with Yin deficiency are liver and kidney,20.59%in total. Female has a closer relationship with Yin deficiency in kidney, liver and liver-kidney than men, and constitute to a higher percentage. Women deficiency syndrome involving kidney, liver, liver-kidney, heart, etc. are more commonly seen in the40-59years age group; while Yin deficiency in heart alone is often seen in men of this age group. For both men and women, Qi deficiency is most commonly seen in spleen compared to other organs, accounting for75%in total,66.67%for men,79.17%for women, and the corresponding age group is40-59for both genders. Qi deficiency in heart occurs most frequently in20-39years of age. Qi deficiency in kidney is prominent for women, especially in40-59years of age. Internal heat syndrome is mainly found in males of20-39years old, accounting for54.55%and that of40-59years old for females, accounting for72.22%. The results showed that the internal heat syndrome is most commonly associated with heart,41.38%, followed by the stomach,27.59%. Internal heat syndrome associated with heart is more commonly seen in men,54.55%, mostly in the age group of20-39years, and for women, mostly in the age group of40-59years.90%of the patients are diagnosed with spleen damp-turbid syndrome. Blood deficiency associated with heart, liver and heart-liver are found in females from the age group of40-59years old. The result shows that this syndrome has the highest occurrence rate in heart and kidney, as high as47.11%in both cases. While men exhibit a closer relationship with heart and spleen, women are proven to have a closer relationship with kidney and liver.The most frequently used insomnia medications are listed in descending order as follows: Kidney Yin Deficiency:(1) Root of Herbaceous Peony>(2) Turtle Shell>(3a) Chinese Yam (Rhizoma Dioscoreae),(3b) Chinese Angelica (Angelica Sinensis)>(4a) Dogwood,(4b) Chuanxiong (Ligusticum Wallichii).Liver Yin Deficiency:(1) Root of Herbaceous Peony>(2) Turtle Shell>(3a) Chuanxiong (Ligusticum Wallichii),(3b) Chinese Angelica (Angelica Sinensis),(3c) Semen Ziziphi Spinosae,(3d) Mulberry Leaves. Heart Yin Deficiency:(1a) Semen Ziziphi Spinosae,(1b) Radix Ophiopogonis>(2) Lily>(3) Root of Herbaceous Peony>(4a) Chinese Angelica (Angelica Sinensis),(4b) Sophora Favescens,(4c) Mulberry Leaves.Spleen Qi Deficiency:(1a) Polygala,(1b) Chinese Angelica (Angelica Sinensis)>(2) Codonopsis Pilosula>(3a) Semen Ziziphi Spinosae,(3b) Honey-Fried Licorice>(4a) Root of Herbaceous Peony,(4b) Fried Atractylodes>(5a) Jujube,(5b) Poria,(5c) Radix Ophiopogonis. Heart Qi Deficiency:(1) Root of Herbaceous Peony>(2a) Poria,(2b) Semen Ziziphi Spinosae>(3) Chinese Angelica (Angelica Sinensis)>(4a) Fried Atractylodes,(4b) Jujube,(4c) Salvia Miltiorrhiza,(4d) Radix Ophiopogonis>(5a) Codonopsis Pilosula,(5b) Radix Astragali,(5c) Polygala,(5d) Honey-Fried Licorice.Kidney Qi Deficiency:(1) Eucommia>(2a) Root of Herbaceous Peony,(2b) Salvia Miltiorrhiza,(2c) Chinese Yam (Rhizoma Dioscoreae),(2d) Dogwood,(2e) Polygala.Heart Blood Deficiency:(1) Chinese Angelica (Angelica Sinensis)>(2) Semen Ziziphi Spinosae>(3a) Root of Herbaceous Peony,(3b) Lily>(4) Poria>(5) Fried Atractylodes>(6a) Dragon Tooth (Dentes Draconis),(6b) Chinese Yam (Rhizoma Dioscoreae),(6c) Polygala.Liver Blood Deficiency:(1) Root of Herbaceous Peony>(2) Chinese Angelica (Angelica Sinensis)>(3a) Fried Atractylodes,(3b) Chuanxiong (Ligusticum Wallichii)>(4a) Dragon Tooth (Dentes Draconis),(4b) Radix Rehmanniae,(4c) Semen Ziziphi Spinosae.Heart Vain Heat:(1) Lily>(2a) Coptis Chinensis,(2b) Sophora Favescens,(2c) Radix Rehmanniae>(3a) Root of Herbaceous Peony,(3b) Chuanxiong (Ligusticum Wallichii),(3c) Salvia Miltiorrhiza,(3d) Lotus Plumule,(3e) Radix Ophiopogonis,(3f) Rhizoma Anemarrhenae.Liver-Yang Hyperactivity:(la) Root of Herbaceous Peony,(1b) Turtle Shell,(1c) Mulberry Leaves> Chinese Angelica (Angelica Sinensis).Internal Heat (Heart-Fire):(1) Sophora Favescens>(2) Coptis Chinensis>(3) Salvia Miltiorrhiza> Poria.Spleen Damp-Turbid:(1) Rhizoma Pinellinae Praeparata>(2) Polygala>(3) Tuckahoe>(4) Honey-Fried Licorice.Heart Blood Stasis:(1) Safflower>(2a) Salvia Miltiorrhiza,(2b) Amber>(3a) Japanese Polygala,(3b) Verbena,(3c) Crude Pollen Typhae,(3d) Trogopterus Dung (faeces of flying squirrel),(3e) Polygala.Spleen and Stomach Damp-Heat:(1) Rhizoma Pinellinae Praeparata>(2a) Coptis Chinensis,(2b) Baical Skullcap (2c) Polygala.Liver Depression:(1) Spring Bupleurum>(2a) Root of Herbaceous Peony,(2b) Lily,(2c) Raw Malt>(3a) Baical Skullcap,(3b) Rhizoma Anemarrhenae>(4a) Chinese Angelica (Angelica Sinensis),(4b) Rhizoma Pinellinae Praeparata,(4c) Flos Albiziae,(4d) Semen Ziziphi Spinosae,(4e) Radix Pseudostellariae,(4f) Polygala.Conclusions:Our clinical studies conclude that:1."Blood is the capital for a woman", so the best treatment methodology in treating female patients is to target at recuperating and regulating the blood."Blood is the capital for a woman" should serve as the guideline in the treatment of female insomnia patients; protect and take good care of their Yin blood and treat them according to syndrome differentiation.2. The heart governs one’s mental and emotional activities, hence it is closely related to insomnia. Since the heart acts as the governor, as long as its Qi, blood, Yin and Yang are rich and the flows are smooth, one’s state of mind will be calm and stable, and will be able to sleep well as usual. When Qi, blood, Yin and Yang are not in order and lose the balance, and the state of mind is unstable and not at peace, Yang is unable to integrate well with Yin, thus causing insomnia. Anything capable of affecting the functionalities of heart and mind could induce insomnia. Clinically, prescribe according to the syndrome, it’s suggested to add some heart-recuperating and mind-calming medicines such as Poria, Polygala, Semen Ziziphi Spinosae, Amber and so on.3. Our clinical findings reveal that kidney associated insomnia is the most commonly seen syndrome. This is because kidney is the innate fundamental governing the essence of the five main internal organs. As such, if kidney essence is deficient, the essence of other organs will also be lacking, leading to uneasiness of body and mind. Kidney and brain are connected, the Yin essence in kidney plays a part in forming brains to maintain one’s spirit, so in case the kidney essence is insufficient, the reservoir of marrow will be in a state of deficiency, thus spirit fails to be well maintained and insomnia occurs. The clinical treatment for insomnia due to kidney Yin deficiency emphasizes on nourishing both Yin and blood, as well as recuperating both liver and kidney. The Root of Herbaceous Peony being the main medicine, accompanied by Chinese Angelica (Angelica Sinensis), Chuanxiong (Ligusticum Wallichii) and other blood nourishing medicines, or use Siwu Decoction (consists of Radix Rehmanniae Preparata, Chinese Angelica, Root of Herbaceous Peony, Chuanxiong) flexibly and appropriately to nourish liver’s Yin blood. In addition, use Turtle Shell plus Chinese Yam and Dogwood to nourish the liver and kidney, which will in turn nourish the Lower Warmer’s Yin.4. The clinical result shows that middle-aged women’s insomnia syndromes are closely related to liver and kidney. Hence the wellbeing of liver and kidney should not be overlooked throughout the treatment process. 5. The laws of medication and characteristics of clinical insomnia treatment of Professor Zhou Chunxiang for commonly seen insomnia syndromesKidney Yin Deficiency:In this treatment, the main medicines used are the Root of Herbaceous Peony and Turtle Shell. The main characteristics of this medication include nourishing both Yin and blood, as well as recuperating both liver and kidney. The Root of Herbaceous Peony, accompanied by Chinese Angelica and Chuanxiong, aim at nourishing the Yin and blood of the liver. On top of that, use Turtle Shell plus Chinese Yam and Dogwood to nourish the liver and kidney, which will in turn nourish the Lower Warmer’s Yin.Liver Yin Deficiency:In this treatment, while nourishing the liver’s Yin, the liver’s blood should be taken care of simultaneously. Use the Root of Herbaceous Peony, together with Turtle Shell and Semen Ziziphi Spinosae to nourish the liver’s Yin; use Chinese Angelica and Chuanxiong to nourish and regulate the blood. In case of Yin deficiency induced heat, add Mulberry Leaves to the main prescriptions for Yin deficiency to help cooling the blood and supplementing the Yin.Heart Yin Deficiency:In this treatment, the main focus is to replenish Yin, meanwhile, supplement blood simultaneously. The most commonly used medicines are Semen Ziziphi Spinosae and Radix Ophiopogonis; consume together with Lily to nourish heart Yin and to calm one’s mind. When taken with the Root of Herbaceous Peony and Chinese Angelica, it helps to supplement the blood. In case of heart Yin deficiency induced heat, add Sophora Favescens or Mulberry Leaves to the main prescriptions for Yin deficiency.Spleen Qi Deficiency:Polygala helps to calm one’s mind; consume together with Qi replenishing medicines to utilize Middle Warmer’s Qi to elevate the plunging Qi of kidney up to the heart. Codonopsis Pilosula is the most commonly used medicine for Spleen Qi Deficiency syndrome, when consumed together with Honey-Fried Licorice, Fried Atractylodes, Poria, etc., the significances of Sijunzi Decoction (consists of Ginseng, Atractylodes, Tuckahoe, Licorice) can be seen. On top of that, use Chinese Angelica, Semen Ziziphi Spinosae, Honey-Fried Licorice, Fried Atractylodes, the Root of Herbaceous Peony, Jujube, Poria, etc. Prescribe Guipi Decoction (Decoction for invigorating the spleen) and alter the contents or dosages accordingly wherever applicable.Heart Qi Deficiency:In this treatment, it’s suggested to supplement Qi and blood simultaneously, especially the acquired Qi of spleen and stomach. Besides, mind-calming medicines can be added. Poria is the first choice, plus Semen Ziziphi Spinosae, Salvia Miltiorrhiza, Polygala, etc. to improve the effect of mind calming. The Root of Herbaceous Peony plus Chinese Angelica help to nourish the blood of heart and liver. Fried Atractylode, Jujube, Codonopsis Pilosula, Honey-Fried Licorice, Radix Astragali, etc. can be used regularly to replenish essential substances acquired from water and cereals so as to supplement the vital energy of heart.Kidney Qi Deficiency:The main medicine used in this treatment is Eucommia, accompanied by Chinese Yam and Dogwood, to nourish the kidney and induce astringency. On top of that, use Polygala to calm the spirit and stabilize the mind, and also to enhance the flow of vital energy between heart and kidney.Heart Blood Deficiency:This treatment emphasizes on nourishing the heart and the liver, especially blood supplement, followed by Yin nourishment. Chinese Angelica is known to be the most commonly used medicine to supplement blood of the heart. It has a sweet and heavy taste, a good supplement for blood, it smells light and pungent, promotes blood circulation, and the nourishing process is dynamic. As such, it acts as a good medicine for replenishing Qi in blood, and is known as a divine medicine for blood. Consume together with the Root of Herbaceous Peony, Lily, Semen Ziziphi Spinosae and Chinese Yam to help nourishing Yin and blood in heart and liver. Fried Atractylodes is good at strengthening spleen and replenishing Qi. Poria, Lily, Dragon Tooth (Dentes Draconis) and Polygala are good at calming one’s mind, thus helping one to sleep well at night.Liver Blood Deficiency:Chinese Angelica and the Root of Herbaceous Peony are the most commonly used medicine for liver blood supplement, and are often used together with Chuanxiong and Radix Rehmanniae. This prescription is derived from the Siwu Decoction, which targets specifically at supplementing blood. Fried Atractylodes improve appetite and food digestion, so it is the first choice of medicine for replenishing spleen Qi. The wonder of this prescription is that it is capable of maintaining adequate sources of Qi and blood, allow spleen to govern the blood and the liver to store the blood. Siwu Decoction, Fried Atractylodes plus Semen Ziziphi Spinosae and Dragon Tooth (Dentes Draconis) provide constant source of Qi and blood; the liver is filled with Yin and blood, and the mind is calm and stable, as such, one will be able to sleep soundly.Heart Vain Heat:Lily is the most commonly used medicine for this syndrome, Radix Rehmanniae comes second. Combine the two to form Lily and Rehmanniae Decoction, which is Zhongjing’s prescription for Lily Disease treatment. This decoction maintains Yin and dispels heat, expels the evil and secures the good. Coptis Chinensis and Sophora Favescens get into the Heart Channel and expel the heart-fire. Often combine the two with Yin and blood nourishing medicines such as the Root of Herbaceous Peony, Radix Ophiopogonis, Chuanxiong, Salvia Miltiorrhiza, etc. to strengthen the good.Liver-Yang Hyperactivity:In this treatment, the Root of Herbaceous Peony, Turtle Shell and Mulberry Leaves are most commonly used. The Root of Herbaceous Peony is coupled with Turtle Shell to nourish Yin of liver and kidney, to suppress hyperactive liver, and to subside the liver Yang. Mulberry Leaves can be added to disperse Qi and to calm the liver. The Root of Herbaceous Peony and Chinese Angelica nourish the blood and the liver. With the combined effects of the above-mentioned medicines, the Yin and blood supplies to liver and kidney will be adequate, liver Yang can be subsided, spirit is calm and stable, thus one is able to sleep well naturally.Internal Heat (Heart-Fire):"The heart governs one’s mental and emotional activities" is the academic point of view that serves as the starting point in the treatment of Heart-Fire syndrome. In addition to heat-expelling medicines, mind-calming medicines such as Salvia Miltiorrhiza and Poria should be applied simultaneously. Sophora Favescens is most frequently used to purge the heart-fire, followed by Coptis Chinensis. Combine the two to purge heat and damp, and to expel fire and toxin.Spleen Damp-Turbid:This treatment focuses on expelling spleen damp and evil, while not forgetting to strengthen the good. Cure both symptoms and root causes. Tuckahoe and Honey-Fried Licorice are good for Middle Warmer, spleen and stomach.Heart Blood Stasis:In this treatment, promote blood circulation and remove blood stasis, and always add mind-calming medicines such as Polygala. Safflower is most commonly used, other medicines promoting blood circulation include Japanese Polygala, Crude Pollen Typhae, Trogopterus Dung, etc. Couple Salvia Miltiorrhiza with Amber to help in blood circulation and mind calming.Spleen and Stomach Damp-Heat:Rhizoma Pinellinae Praeparata and Polygala are the two most commonly used medicines in this treatment. On the other hand, Coptis Chinensis and Baical Skullcap are commonly used in treating damp and heat symptoms in the Middle Warmer. Combine the above-mentioned prescriptions to effectively expel damp and heat, regulate spleen and stomach, calm mind and spirit. As such, one can sleep well.Liver Depression:Spring Bupleurum is the most commonly used medicine to resolve liver depression, and together with the Root of Herbaceous Peony, they form half of the Sini Decoction, which is able to disperse liver’s evil, and nourish liver’s Yin and fluids. When taken together with Baical Skullcap, Pinellia Ternata, Radix Pseudostellariae, etc., the significances of Minor Bupleurum Decoction will be exhibited; that is, able to reconcile Shaoyang Cardinal to disperse liver depression. Lily and Rhizoma Anemarrhenae form the Lily and Anemarrhena Decoction, which is good at nourishing Yin, moistening dryness, relieving restlessness and calming mind. Add Raw Malt and Radix Pseudostellariae to strengthen spleen, improve digestion and nourish the Middle Warmer. Professor Zhou combines the connotations of Zhongjing’s three different prescriptions, namely "Sini Decoction","Minor Bupleurum Decoction"(Xiao Chai Hu Tang) and "Lily and Anemarrhena Decoction"(Bai He Zhi Mu Tang) in his treatment methodology for liver depression. In addition, he practices protection of Middle Warmer, spleen and stomach, and add mind-calming medicines appropriately, such as Flos Albiziae, Semen Ziziphi Spinosae, Polygala, etc.Basically, except for the cold-dampness stasis syndrome, the rest of the insomnia syndromes as discussed by Zhongjing could be seen in this clinical study. Obviously, Zhongjing’s theory on insomnia’s syndrome differentiation and treatment has been adopted ever since. Professor Zhou has inherited Zhongjing’s study on insomnia’s syndrome differentiation and treatment, and further develops from this basis.Zhongjing carried on predecessors’ knowledge on insomnia, develop and enrich the theories, methodologies, prescriptions and medication of insomnia treatment. The contents are full and rich, which exhibit a very high clinical value and establish the fundamental foundation of insomnia syndrome differentiation for future generations. Based on this foundation, the future generations will be able to expand and further develop well in insomnia treatment. |
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