| Under the guidance of differentiation of Liujing coming from Shanghan, this study aimed to explore the physiology, pathological mechanism, character of attack, syndrome distribution, rule of differentiation, clinical characteristics, effect assessment and so on of Liujing for the patients suffering from insomnia. Initially, the systematic, complete, standard system of Liujing Differentiation on insomnia was established. This study provided a new method of thought and ideas of differentiation, displayed the distinct features and holistic advantage from other methods. otherwise, it explored the regular of distribution, the points of differentiation, the principle of therapy and the excellence of diagnose of Liujing differentiation on insomnia under the observation of clinic.1. The theory(1) The physiology, pathological mechanism of Liujing on insomniaThe physiology:the harmony between ying and wei is the function, the mediating of the zhongjiao is the key point, and the result is the connection of yin and yang. If the shen coming from the kidney and heart under the runs and humans go to sleep regularly, the rhythms of sleeping will be kept. The physiological characters such as "wei is on the position of master and ying follows", "the function of zhongjiao takes an important position" are reflected. The pathological mechanism:insomnia caused by both the six evils of external and all kinds of diseases from internal which lead the disharmony of ying and wei, imbalance of yin and yang, cardinal adverse in the shaoyang, moving upwards of qi, failure of connection between yin and yang, discordance of heart and kidney and shen fails to take the appropriate position. Throughout the outcome of Liujing disease on insomnia, the imbalance of" Confluence of ying and wei---connection of yin and yang---appropriate position of shen" lasted.(2) the character of Liujing pattern on insomniaInsomnia can be caused by all the diseases of liujing attacked by six evils in shanghan and the deficiency of zangfu. Taiyang diseases:the patterns of disharmony of ying and wei, depression of yang-qi, water retardation, blood stagnation, depression of heat in the chest. Yangming diseases:the patterns of excess of heat in yangming, excess syndrome of fu, blood stagnation of yangming, depression of heat in the chest, excess of stomach and deficiency of spleen, consumption of yin in stomach and kidney, coagulation of water and heat. Shaoyang diseases:patterns of cardinal adverse in the shaoyang, stagnation of water and fire of sanjiao. Taiyin diseases:patterns of yang deficiency and cold-damp, adverse of water, stagnation of fluid in the meridians, disharmony of ying and wei, deficiency of qi and blood, qi stagnation and abdominal distension, both deficiency of qi, blood, yin and yang, relapse of yang changes to dryness. Shaoyin diseases:patterns of yang deficiency of shaoyin (eg:yang deficiency of heart and kidney, cold-water goes up), yin deficiency of shaoyin (eg:yin deficiency and fire in excess, disharmony between the heart and kidney, coagulation of water and heat), deficiency of yin and yang, relapse of yang disturbing the heart. Jueyin diseases:blood deficiency and cold coagulation, yang depression and fails to disperse, cold-heat complex in jueyin (eg:liver heat and spleen cold, lung heat and spleen cold, stomach heat and spleen cold).(3) the character of Liujing differentiation in insomnia①distinct characteristics of Zhongjing'theory:Liujing differentiation in insomnia has outstanding character of Zhongjing'theory. Both the heart and the brain share the function of charge the shen and harmonizing the sleeping. Liujing harmonize the shen of zangfu and all of them under the charge of brain, which based on the zangfu, meridians and collaterals, ying, wei, qi and blood as the carrier, the circular motion as the form, connection of yin-yang as the character, heart-shen and brain-shen on the charge and regulate the body as the subject, transformation, distribution and regulation of qi, blood, jing, jin and fluid as the material base. The base of insomnia is the disharmony of ying-wei and yin-yang. The disharmony of ying-wei breaks the basic operation rule of "wei is on the position of master and ying follows". Also destroys the biological effects of human beings, ruins the benign inspire of light and dark material, leads the disharmony of yin-yang and the imbalance of store and spread of shen. The key of insomnia is the disharmony of stomach-qi and cardinal adverse in the shaoyang:shaoyang and jueyin assist but not separate from each other which regulate liujing powerfully. It works as the pivot of yangming and taiyin, the hub of ascending, descending, exit and enter of yin-yang, the hinge of alternate, open and close of yin-yang. All are related to the cardinal adverse, either the disharmony of stomach-qi, failure of mediate, dysfunction of exiting and entering of ying-wei, disorder of ascending and descending of yin-yang, disharmony between the heart and kidney, or failure of store of shen in the heart and brain. Blood stasis of the six channels is an important factor in insomnia:blood stasis exists in six channels and leads to each other. One of the reason is the blood fails to nourish the heat caused by blood stasis which blocking the vessels and leading the stagnation of qi.②the character of systematic, complete, flexible and standard on clinic:Separate yin and yang first and then distinguish liujing when using Liujing differentiation on insomnia. Secondly, meridians and zang-fu should be distinguished and also the cold-heat, deficiency-excess and external-internal.Distinguish the external-internal and emergency-chronics. The treatment is different but not separated. Compared with other differentiation system, it has outstanding integral, global advantage in the aspects of pathogen, character, position, condition, history, prognosis and the wane and wax between the vital and evil. Agile and changeable differentiation for changing diseases but sings to the key.Harmonizing and dredging methods are the main methods for treating insomnia by Liujing differentiation. The decoctions such as Gui Zhi Tang, Xiao Jianzhong tang, Gui Zhigancaolonggumuli Tang and Dang Guisini Tang explain the method of "based on the liujing, harmonizing the ying-wei, leading the yang to yin and guiding the shen to the appropriate position". The decoctions Xiao Chaihu Tang, Xiao Xianxiong Tang, three Xie Xin Tang and Huang Lian Tang explain the method of "sanyang as the apartment, harmonizing shaoyang, dredging sanjiao and regulating the pivot and calming the shen". The decoctions Wu Mei Wan, Ma Huangshengma Tang, Gan Jianghuangqinhuanglianren-shen Tang and Huang Lianejiao Tang explain the method of "sanyin as the basic, balancing the ascending and descending, connecting yin-yang and harmonizing to calm the shen". At last, " dredging the fu and relieving the stagnation, resolving the water and breaking blood stasis" are explained by the decoctions such as Bai Hu Tang, Chen Qi Tang, Tao Hechenqi Tang and Zhen Wu Tang."Reinforcing the zhongjiao, tonifying the postnatal" is the key of Liujing differentiation in insomnia. Zongjiao is the place of middle earth belongs to spleen and stomach, where the jueyin mediates, the gallbladder and sanjiao meridians pass through, and the place to harmonize shaoyang. If the zhongjiao is strengthened, ying-wei may be rebuild, the circulation may be regular and day-night in order. Heart yang may be warmed, ying-yin may be moistened and the shen may be nourished in the upper jiao, while liver can be stored, kidney can be assisted and the shen-spirit may be in the appropriate position in the lower jiao. The hub of shaoyang assist the exiting and entering of yin-yang, the connecting of ying-wei and regulation sanjiao. The hinge of jueyin helps the ascending and descending of yin-yang, the intercourse of reproducing and the harmonizing of water and fire. Both shoyang and jueyin have the function of regulating and harmonizing the movement of ying-wei-qi-blood between yin and yang. By regulating the pivot, harmonizing yin and yang, handover of day and night may be achieved, which reflecting importance that "hinge makes the balance"It's the basic to care insomnia using Liujing differentiation that "nourishing yin and reinforcing yang, treating sanyin at the same time" Differentiation of taiyin should pay attention to the character of pathology that "deficiency of spleen in taiyin causing the deficiency of ying-wei, which makes the failure to nourish heart-ying and the shen fails to be in the appropriate position".The treating method is to strengthen the middle jiao and harmonizing ying and wei. Differentiation of shaoyin should pay attention to the character of pathology that "heat in shaoyin, yin deficiency and fire in excess, disharmony between the heart and kidney, discordance between water and fire". Warming the heart-yang diving down and calming the shen should be provided while yang deficiency in shaoyin and failed to store the shen. Breaking the yin and relieving and stagnation, guiding the yang to yin should be offered while the kidney-yang is badly damaged and failed to assist the shen. Nourishing yin and cleaning the fire, harmonizing the heart and kidney should be supplied while yin deficiency in shaoyin and disharmony between heart and kidney. Deficiency of yin-yang and qi-blood in shaoyin should be treated by replenishing qi, blood, yin and yang. Differentiation of jueyin should pay attention to the character of pathology that "yang depressing of jueyin, failure of the function of liver-yang, cold-heat complex and imbalance of yin-yang". Cold-heat complex, heat in liver and cold in spleen should be treated by cleaning the upper and warming the lower. Heat in lung and cold in spleen should be treated by dispersing the depressing of yang, cleaning the lung and warming the spleen. Heat in stomach and cold in spleen should be treated by cleaning the stomach-heat and warming the spleen, connecting the yin and yang. Deficiency of blood and coagulation of cold should be treated by warming the meridians and expelling the cold, nourishing the blood and dredging the vessels. Failure of expel caused by yang depressing should be treated by smoothing the liver and strengthening the spleen, expelling the depressing yang. While the three yin be attached at the same time, the character of treating" treating the three yin at the same time but hinge at the top position" should pay attention to. Yang deficiency of liver and kidney, deficiency of spleen, deficiency of wei and stagnation of ying and dysfunction of shen should be treated by tonify the kidney and warm the liver, invigorate the middle jiao. Yin Deficiency of both liver and kidney, deficiency of jing and blood, disharmony of water and fire, floating of heart-shen should be treated by moistening liver and nourishing yin, tonify the kidney and replenish the marrow and tonify yin and yang.(4) the advantage of Liujing differentiation on insomniaLiujing differentiation on insomnia has the character of holistic advantage and dynamic changes. Most are excess evils at the first step of sanyang diseases while deficiency for the diseases of sanyin with long history. The pathology is disharmony between ying and wei, cardinal adverse in the shaoyang deficiency of zangfu, discordance between yin and yang, disturbing the heart-shen. Sanyang are attached at the first stage, and most are the patterns such as disharmony between ying and wei, cardinal adverse, disharmony of stomach-qi, heat in the chest and stagnation of jing and qi of sanjiao. While sanyin are attached at the end stage, most are the patterns such as coagulation of cold and damp, deficiency of qi and blood, yang deficiency and qi float, yin deficiency and fire in excess, cold-heat complex, kidney fire goes upward and discordance of yin and yang. The three yin are all attached at the same time and neither the meridians nor the zangfu are damaged when the insomnia belongs to sanyin. Mostly, superficies in excess when three yang are attached while origin in deficiency when three yin are attached. It's important in Liujing differentiation on insomnia that "treating the three yin at the same time but jueyin on the first place". "harmonizing ying and wei, balancing yin and yang, regulating the upper and lower and calming shen to smoothing the spirit" is the secondary aspects of Liujing differentiation on insomnia while the primary aspects is "strengthening the prenatal, reinforcing the postnatal, harmonizing the liver and gallbladder, regulating the hinge". Also, eliminating the phlegm and resolving the water, promoting the circulation and resolving the blood stasis.2.The clinic(1) The backgroundAt present, most people tend to eight principle differentiation, differentiation of zangfu and differentiation of qi, blood, jing and fluid. Related to warming diseases, wei-qi-ying-blood differentiation and sanjiao differentiation are regularly adopted which leads to lack of whole consciousness and the idea of dynamic changes on the clinic. Formula-pattern differentiation which lack of systematic, perfect and standard rule of differentiation was adopted in the clinic when using the Liujing differentiation on insomnia.(2) objectiveThis study aimed to set up the main syndromes, patterns, and the rule of distribution of liujing for insomnia. Comparing the classic formula with Estazolamum on the clinical effect and the differences on side-effect in treating insomnia.(3) methodThe observed cases were admitted following the relevant provisions of Guiding Principles for New Drug Clinical Research of Chinese Medicine and Classification and Diagnostic Criteria for Mental Illness. The secondary insomnia caused by psychosis was excluded by SCL-90. The clinic syndromes, signs, the tongue and the pulse of all the into cases were recorded by the clinical observation form. The positive syndromes were measured by the quantitative index of 4 grades. The main syndromes, patterns and the regularity of distribution were determined by the frequency distribution of syndrome integration and the frequency distribution of liujing patterns.The cases were recorded by the clinical observation form, HAMA, HAMD and PSQL. Classic formula were supplied to the treatment group while Estazolamum for the control group. After the drug treatment lasted for 4 weeks, the effects were evaluated by the main symptoms and the changes of numerical value from the forms of clinical observation form, HAMA, HAMD and PSQL. Otherwise, the safety index was the side-effect.(4) resultsThere were 15 main symptoms in insomnia:hard to fall asleep, restlessness, easy to be frightened and manic psychosis, sweating, thirsty or with dryness, palpitation, depressing sensation in the chest, fullness or oppression in the chest, hypochondriac fullness or oppression, epigastric stuff or distress, abdominal fullness or distension, constipation or dry stools, loose stools or diarrhea, lack of qi and fatigue of the four limbs, cold sensation of the four limbs. There were nine main patterns of liujing in insomnia:①yin defficiency and fire in excess, disharmony between heart and kidney;②evil stagnating in the middle jiao, coagulation of qi;③dysfunction of shaoyang;④disharmony between ying and wei;⑤yang depression and fails to disperse in jueyin;⑥cold-heat complex, liver heat and spleen cold, fire stairs up and confused shen;⑦blood deficiency and cold coagulation, dysfunvtion of liver-yang, disharmony between yin and yang;⑧both deficiency of qi, blood, yin and yang;⑨yang deficiency and cold in taiyin, deficiency of qi and blood. The 15 main syndromes matches up with the patterns of liujing. Restlessness and depressing sensation in the chest were closely related to hard to fall asleep. Three were belongs to sanyang and the other six belongs to sanyin in the nine main patterns. And there were six patterns relating to gallbladder, sanjiao and cardinal of jueyin while four relating to ying-wei. The distribution of patterns emphasised on sanyin, shaoyang and jueyin.Comparing with the simple sedative hypnotic and anxiolytic of Estazolamum, there were obvious advantages in the clinic syndromes and the improvement of index of anxiety, depression and the quality of sleeping in HAMA,HAMD,PSQI and so on while using Liujing differenciation.①effectively improve the main patterns:After the treatment, compared with the control group, there were no statistical significant difference between the two groups on the syndromes such as "thirsty or with dryness, abdominal fullness or distension" (P> 0.05), but there were statistical significant difference between the two groups on the other main syndromes (P<0.05 or 0.01). "hard to fall asleep, palpitation, lack of qi and fatigue of the four limbs" were difference between the two groups (P<0.01). There were no statistical significant difference between the two groups on the syndromes such as" cold sensation of the four limbs, sweating, thirsty or with dryness, palpation, constipation or dry stools" before and after the treatment (P>0.05), but there were statistical significant difference between the two groups on the other main syndromes (P <0.05). Estazolamum was not good at improving the syndromes such as "sweating, thirsty or with dryness, constipation or dry stools". But the classic formulas were special in improving the syndromes except "cold sensation of the four limbs" caused by yang deficiency. It pointed out that Estazolamum focusing on symptoms but the classic formulas were good at the essence.②effectively improve the index of HAMA,HAMD and PSQI:Compared with the control group, there were statistical significant difference between the two groups on the changes of numerical value from HAMA,HAMD,PSQI (P<0.05). There were statistical significant difference between the two groups on the index of PSQI(disability of sleeping, ability in the day time, total scores of PSQI) (P<0.05), but there were no statistical significant difference between the two groups on the other index (quality of sleeping, time needed to fall to sleep, time of sleeping and the efficiency of sleeping) (P>0.05). The Liujing differentiation were good at the improvement of insomnia with anxiety, depression, nightmare, fever, easy to wake up, early to wake up and so on and better for the insomnia with lassitude in the day time, lack of spirit, restness and inattention.③comparison of curative effect:The overall efficiency was similar, but there were statistical significant difference between the two groups on the "the rate of recovery, invalid and the rate of excellent recovery" (P<0.05). The classic formulars were better for the mild and moderate while Estazolamum was better for the severe. That's probably related to the clinic main patterns of liujing and the overall improvement of main symptoms.④low side-effect, low recurrence rate and non-dependence:There were statistical significant difference between the two groups on the severe and moderate side-effect(somnolence, thirsty, blurred vision, vertigo, constipation, diarrhea and reduced appetite) and the rate of side-effect (P<0.05). Lower side-effect, without dependence and lower relapse rate after stopping the treatment while using the Liujing differentiation. But Estazolamum on the contrary.(5) conclusionRestlessness and depressing sensation in the chest which relating to the yang deficiency of sanyin, deficiency of ying, wei, qi and blood, yin deficiency and fire in excess, disharmony between heart and kidney, cardinal adverse in the shaoyang and the minister fire stires up were one of the main syndromes in insomnia.Treating the three yin at the same time but cardinal on the first place and harmonizing ying and wei were the characters of Liujing differentiation. It improved the syndromes of restlessness and depressing sensation in the chest, improved the sleeping quality. And there were compared advantages in the improvement of clinic syndromes, improving the patients' compliance and life quality, reducing the rate of side-effect and the recovering rate after stop the treatment. |
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