On the treatment of Tourette's syndrome in children from the perspective of "reconciling Shaoyang"

Cong-Cong Zhang , Zhen-Qi Wu , Guang-Hua Liu

1. Graduate School of Liaoning University of TCM,Shenyang 110847, Liaoning

2. Affiliated Hospital of Liaoning University of TCM,Shenyang 110032, Liaoning

3. Department of Liaoning University of TCM,,Shenyang 110847, Liaoning

Keywords:

ABSTRACT

Multiple Tourette's syndrome, also known as Tourette's syndrome, is a syndrome characterized by the movement of muscles in one or more parts of the head, shoulders, limbs, trunk, etc., and the vocal Tourette's twitch, such as involuntary, abnormal voice or rough language in the explosive larynx. It is chronic, fluctuating and recurrent in clinical, often accompanied by attention deficit and compulsion to diあerent degrees Many common diseases such as disorder, anxiety and depression [1, 2]. The disease usually starts from childhood, with complex clinical manifestations and lingering illness, and can often continue to adulthood, seriously aあecting the growth and learning of children, and the work and life of their families [3, 4]. Western medicine lacks special drugs to treat this disease, and haloperidol, clonidine and topiramate are commonly used in clinical treatment, but the side eあects such as extrapyramidal reaction, excitement, insomnia and gastrointestinal discomfort are obvious, which can easily lead to repeated illness after forced reduction or withdrawal of drugs during treatment [5-7]. Years of clinical practice have shown that traditional Chinese medicine is eあective in the treatment of infantile polytic syndrome, which can significantly reduce or even completely control the symptoms of polytic syndrome, reduce adverse reactions, improve comorbidity and reduce recurrence rate [8].

1. Traditional Chinese medicine's understanding of children's Multiple Tourette's yndrome

There is no clear record of the disease in ancient books of traditional Chinese medicine, but there are related descriptions of similar symptoms of the disease. In “Suwen”, there is a saying that " All kinds of diseaseswith dizziness and vertigo are exclusively related to the liver "；in “Jingyue quanshu”, there is a saying: "when the liver moves, the wood can make a fire, ... Convulsion and rigidity belong to the disease of liver wood itself."Wang Kentang described in the criterion of syndrome and treatment: " Water promote liver wood, ... Wood restricts spleen earth. There is wind in the stomach. The clonic convulsion gradually appear. It's called slow shock.” Therefore, in modern clinical practice, it is mostly classified as "liver wind", "clonic convulsion" and "slow convulsion wind" in traditional Chinese medicine.

Traditional Chinese medicine believes that the disease is mainly related to the lack of innate endowment, the invasion of external evils, the disunity of diet, the lack of sentiment, and the improper nursing after the disease, and is caused by the interaction of various factors. Although the location of the disease is mainly in the liver, it is related to the other four Zang organs. The key pathogenesis is wind phlegm cementation and hyperactivity of the liver wind. Qian yi pointed out that children "The liveris always in superabundance.", and because of the liver for the wind wood of the Zang, The body is Yin and the function is Yang,Liver prefers free activity and dominates the Qi dredging mechanism, if the children's long-term emotional disorder, liver qi stagnation, the long-term fire generates wind, liver yang hyperactivity on the top of the twitch. Children's "Heart always in superabundance", easily disturbed by internal and external factors, hyperactivity of heart Yang and disturbance of mind, show symptoms such as involuntary movement, irritability and uncontrollable abuse of mouth. Children's lungs delicate, external fit in the fur, weak striae, easy to attack by external evil, lung gold down less than, liver hyperactivity on the upper. Children's "spleen is often insuきcient", Spleen is located in the middle-jiao and it's function is transportation and transformation, spleen and stomach being the acquired foundation,loss of nourishment after the disease or the diet is not appropriate, it is easy to hurt the spleen and stomach, resulting in the biochemical deficiency of Qi, blood and body fluid, the loss of the muscles and veins of the limbs,the spleen deficiency produces the wind to cause "the gluten clonus to make the convulsion ". The ancients said:Most of the strange diseases are caused by phlegm.If the function of spleen and stomach is abnormal,the water dampness stops and accumulates into phlegm,the phlegm accumulates depression for a long time,transformate fire and occur wind sydrome,performance for twitch.Or phlegm dampness obstructs collaterals, Qi and blood do not move, blood stasis stagnates in brain orifices, brain and spirit lose function, then it shows as involuntary action. Congenital endowment is insufficient, or febrile disease consuming yin, which leads to kidney water insuきcient to nourish liver wood, liver yang hyperactivity, so impetuosity and susceptibility to rage；Kidney water is Insuきcient, it is diきcult to act upward on heart fire. If the water and fire are discord, the heart fire will be hyperactive, mental restlessness, and there will be diあerent voice and coprolalia. In the treatment, the basic treatment principle is to calm endogenous wind and stop motion, the main treatment of sthenia syndrome is to calm the liver to stop the wind, eliminate phlegm to relieve depression, the main treatment of deficiency syndrome is nourishing the kidney and invigorate spleen, softening liver for calming endogenous wind, and the deficiency and excess syndrome should give consideration to both the specimen, tonification and purgation in combination.

2. Treatment of children's Multiple Tourette's syndrome from reconciliation of Shaoyang

2.1 The key to the pathogenesis is the disadvantageous of cardinal Shaoyang, which is not good for the imbalance of yin and Yang in the viscera

"On the separation and combination of yin and Yang" in Suwen: "Shaoyang The name is Shaoyang in the Yin, which means the separation and combination of the three yang. The Taiyang is open, the Yangming is closed, and the Shaoyang is pivot. ". The so-called Shaoyang refers to hand Shaoyang Sanjiao and foot Shaoyang gallbladder in meridians, which in the viscera is the liver. " All the eleven organs depend on the gall" in the theory of six stanzas of Suwen. The theory of spleen and stomach-deficiency and excess in the theory of spleen and stomach, which describes that gallbladder belongs to the spring Qi of Shaoyang, and if the spring Qi of gallbladder is as usual, the rest of the organs can follow it safely. This also explains that gall dominates the rise of Yang Qi in the body.The liver is described as "Shaoyang in the Yang" and "Connected with spring Qi" in Suwen LiuJie's theory of Zang Xiang. The liver's nature likes tobe comfortable and is in charge of catharsis. The gall bladder is also an extraordinary organs organ attached to the liver. Both of them can be in charge of catharsis and jointly regulate the balance of catharsis of functional activities of Qi in the human body.In the book of diきcult classics, it is said that "the original Qi is diあerent " has the function of "hosting various Qi". That is to say, Sanjiao is the passage for the ascending and descending of the Qi. Shaoyang is located in the halfway of the surface and the inside. The surface is yang, the inside is yin. And it is the hinge of the transformation of yin and Yang. It is responsible for the balance of yin and Yang. Liver, gall and Sanjiao are in charge of Shaoyang cardinal. If the cardinal is beneficial, the body's Qi and Yin and Yang will be harmonious, and the five internal organs will be safe.In Suwen, "Yin is static and Yang is manic", Yang is active, Yin dominates static, yin and yang balance is suitable for dynamic and static.yin and yang are harmonious, and the body is regulated orderly. Children are "Yang often surplus". If Yin is insuきcient, Yin cannot control Yang, Yin is not quiet enough, and Yang is hyperactive, they will show symptoms of involuntary convulsion, irritability, foul speech and other convulsions.From the various syndromes of multiple tic disorders, such as liver depression, spleen deficiency and liver hyperactivity, phlegm-fire disturbing the heart, heart and liver dysfunction, internal movement of virtual wind ,and external wind induced internal wind, etc., all are the phenomena of imbalance of yin and Yang in the body.Therefore, Professor Wu Zhenqi, my teacher, thinks that the key to the pathogenesis of this disease is the the disadvantageous of cardinal Shaoyang, viscera imbalance of Yin and Yang. He also puts forward the viewpoint of treating children's Multiple Tourette's syndrome from "reconciliation of Shaoyang".

2.2 "Reconciling Shaoyang" method and representative prescription Xiaochaihu decoction

The occurrence of diseases is caused by the imbalance between Yin and Yang in the body. The canon of internal medicine put forward the treatment principle of " reduce superabundance,make up a deficiency ". Its original meaning is "the method of harmony", which is the prototype of "the method of harmony" in the eight methods."Harmony" refers to the balance of Yin and Yang in the body, the peace of viscera and viscera, the harmony of Qi and blood, and the orderly rise and fall of Qi, while "harmony law" is established to correct the imbalance of the body [9]. The concept of harmony is clearly put forward in treatise on febrile diseases. Zhongjing's "reconciliation of Shaoyang" is one of the "harmony" methods, which is the main treatment of evil in Shaoyang. Xiaochaihu Decoction is a representative prescription created by Zhongjing for "reconciling Shaoyang, strengthening the healthy and eliminating pathogenic factors". In the Qing Dynasty, Ke Yunbo praised it as "the agent of Shaoyang machine pivot" and "the general prescription of reconciling exterior and interior".This prescription is not turbid, sluggish or attacked, which is just in accordance with the physiological characteristics of children's "delicate viscera, not full of form and Qi". Xiaochaihu Decoction is composed of bupleurum, Scutellaria, ginger, Pinellia ternata, jujube, ginseng and roasted licorice.Bupleurum has a bitter taste and a slight cold nature. It can enter Shaoyang meridians, clear away the stagnant heat of Shaoyang meridians, lift up Yang Qi, and regulate the Qi mechanism of Sanjiao. It's the monarch drug. Scutellaria has a bitter cold nature and is longer than clearing away the fire of Qingxie Shaoyang. It's the ministerial drug. The combination of the monarch and the minister is suitable for the rise and fall, which can relieve the stagnant Qi and help the harmony of yin and Yang.Pinellia ternate and ginger, tasted symplectic and powder, are used to help the bupleurum to ease the stagnation, while relieving fluid retention and eliminating dampness, to change the phlegm dampness water which is caused by the stagnation of Qi. Ginseng and jujube can strengthen the spleen and replenish Qi, which can help Shaoyang to get rid of pathogenic factors and go out, or help the healthy Qi to prevent the evil Qi from spreading. They are all adjuvants.Roasted licorice can help ginseng and jujube to support healthy qi, dispel evil go out, and can reconcile the medicine, so it's called conductant drug. Xiaochaihu Decoction is a combination of pungent，warm，bitter, cold and sweet taste, playing the roles of reconciliation of Shaoyang, Smooth cardinal [10].

2.3 Chaihu formula for the treatment of children's Tourette Syndrome

Based on the pathogenesis of ‘yin-yang disharmony of viscera’, the theory of "Shaoyang as the pivot" can be used to treat the disease from "reconciling Shaoyang". Because of its complex and changeable clinical symptoms, Chaihu is commonly used as the treatment. The introduction is as follows.

2.3.1 Chaihu jia Longgu Muli Decoction

Chaihu jia Longgu Muli Decoction, take half of the Xiaochaihu Decoction, remove roast licorice, add keel, oyster, Poria cocos, cinnamon twigs, rhubarb and lead. Xiaochaihu Decoction can reconcile Shaoyang, reach the axis smoothly, support the healthy and eliminate the evil； Cinnamon twigs and Bupleuri are combined to open the surface and reach the Stagnant Yang Qi； rhubarb and scutellaria are matched to clear the heat of Shaoyang and Yangming； Poria cocos calms the heart and mind, seeps water and dampness； keel and oyster are important to calm the mind； plumbum lowers the fire and calms the nerves, and combined with keel and oyster can increase the eあect of calming and stopping the pumping.All the above herbs are used together to reconcile Shaoyang, relieve fire and annoyance, calm down and stop twitch, and strengthen the power of rectifying evil. It is suitable for children with multiple tic syndrome with liver depression and long-term fire melting and internal movement of liver wind. If the disease course is long, it often occurs or worsens after emotional stimulation, usually with upper twitch as the main manifestation, such as shaking head, extending neck, shrugging shoulders, etc.

2.3.2 Chaihu Guizhi Decoction

Chaihu Guizhi Decoction is the combination of Xiaochaihu Decoction and Guizhi Decoction, which reduce the dosage by half. Chaihu upward dispersion through the surface and reconciles Shaoyang； Guizhi publishes muscle relieving and reconciles Yingwei, which is the monarch drug； paeony is acid and sweet to gather Yin, softens the liver and slows down, which can also help Guizhi to reconcile Yingwei； Scutellaria is bitter and cold, which can clear Shaoyang's fire and help Chaihu reconcile Shaoyang, which is the ministerial drug. Pinellia ternate can reduce Qi and phlegm, which can change the phlegm carried by the internal and external wind； Angelica can nourish blood and soften the liver, nourish blood and calm nerves, slow down and stop convulsion； ginseng and jujube can promote the spleen and stomach, replenish Qi and camp； Pinellia ternate and ginger can descend adverse Qi and stop vomiting, and the combination of the two drugs to regulating stomach is more eあective, which are the adjuvants.The roasted licorice is used as an adjuvant to nourish Qi and regulating middle energizer, so as conductant drug to harmonize various medicines. In addition to the eあect of reconciling Shaoyang and regulating Yingwei, it also has the eあect of softening the liver, calming the wind and stopping the convulsion. It is suitable for those who are induced by exogenous pathogenic factors to move the liver wind. The symptoms of convulsion are more than those of attack or aggravation after exogenous factors, and most of them are accompanied by respiratory symptoms, often accompanied by wrinkled nose, sucking nose, clearing throat, etc.

2.3.3 Chai Qin Wen Dan Decoction

Chai Qin Wen Dan Tang, originated from the Golden Mirror of Medicine. In the prescription, Radix Bupleuri can clear away the pathogenic factors of Shaoyang depression； Scutellaria can clear away the heat in the liver, and the two drugs can calm the liver wind as the monarch drug； Pinellia and tangerine peel can warm and clear the phlegm, Bamboo Shavings can clear the heat in the gallbladder, Citrus sinensis can clear the phlegm and dispersing abdominalmass to enhance the eあect of Pinellia and tangerine peel and Bamboo Shavings, These are ministerial drugs； Poria cocos can invigorate the spleen and tranquilize the heart, and the roasted licorice can invigorate the spleen and the middle, which are the ministerial drugs and adjuvants. The roasted licorice can also be used to mix various drugs. The whole Party played the eあect of clearing away the heat of liver and gall, resolving phlegm, relaxing wind and calming the spirit. It is suitable for children with multiple tic syndrome of liver and gall depression and phlegm fire disturbance. Children often have a history of being frightened or beaten or scolded. They are impatient. When they are criticized, beaten or scolded, their convulsive symptoms become worse.

2.3.4 Chaigui Wendan Decoction

Chaigui Wendan Decoction consists of Chaihu Jia Longgu Muli Decoction and Wendan Decoction.In the formula, Chaihu Jia Longgu Muli Decoction is used to reconcile Shaoyang and settle fright and calm mind； Bamboo Shavings is used to clear the dysphoric fever of upper-jiao, dried orangepeel and Pinelliae regulate the middle warmer, and warm the middle-jiao and turbid phlegm, Citrus aurantium is used to regulate qi-flowing for activating stagnancy, and release the heat of lower-jiao, which has the special eあect of clearing the damp-heat of Sanjiao.Poria cocos can invigorate the spleen, remove dampness and promote diuresis. The whole formula works together to clear dampness-heat of liver and gallbladde, reconcile Shaoyang, and dredge Sanjiao.The formula is suitable for Children's Tourette Syndrome of dampness-heat of liver and gallbladder,turbid phlegm stagnanting heat .In addition to general twitch symptoms, children are often accompanied by emotional depression, anxiety, and other mental symptoms.

Bupleurum formula "reconciling Shaoyang" also has its modern pharmacological significance: the main pharmacological component of Bupleurum is saikoside, which has the eあects of anti convulsion, anti epilepsy, antipyretic and anti-inflammatory, and liver protection [11]. The main component of Scutellaria baicalensis Georgi is baicalin, which has antipyretic and anti-inflammatory effects, enhancing immunity, protecting liver [12]； the total glucosides of paeony, in addition to anti-inflammatory and analgesic effects, have sedative eあect on nervous system and good relaxation eあect on skeletal muscle system [13]； The main active components of Poria cocos are triterpenoids and polysaccharides, which have obvious pharmacological eあects of anti inflammation, diuresis, liver protection, immunity enhancement, sedation of excitatory neurons and anticonvulsion [14]； the main components of keels are calcium carbonate, calcium phosphate, phosphorus pentoxide, magnesium oxide, iron oxide, etc.； the main components of oysters are various amino acids, trace elements and calcium carbonate compounds , both of them have antidepressant, anticonvulsant and tranquilizing eあects [15].

3. Examples

The patient, Liu XX, male, 8 years old, was initially diagnosed on June 3, 2019. The chief complaint was: the child's neck extended, shoulders shrugged for half a year, aggravating with blinking and throat clearing for one month. Present medical history: the child occasionally has neck extension and shrug symptoms for half a year, which the parents didn't care about. After being scolded by the parents one month ago, the child has frequent neck extension and shrug, blinking symptoms, pharyngeal discomfort and occasional abnormal voice. The symptoms are as follows: the child's neck is extended, shoulders are shrugged, eyes are blinked, voice is sighed, occasionally there is a strange voice, chest tightness often appears, the temper is impatient, the diet is poor, it is diきcult to fall asleep, two stools are normal. Physical examination: the complexion is lusterless, the tongue is reddened, the moss is yellow, the pulse string slippery. Western medicine diagnosed as Tourette's syndrome. Traditional Chinese medicine diagnosis is slow convulsion, traditional Chinese medicine dialectics is Shaoyang disadvantageous, spleen deficiency and liver hyperactivity syndrome. The treatment is to reconcile Shaoyang, soothe the liver and regulate the spleen. Prescription: Chaihujialonggumuli Decoction. The prescriptions are as follows: radix bupleuri 6g, Scutellaria 10g, ginger processed pinellia 6g, roasted licorice 6g, Poria 20g, keel 30g, oyster 30g, paeony 20g, Pueraria 20g, fried Fructus aurantii 6g, Acorus 6g, Cortex Albiziae 15g, Celosia seeds 10g, chrysanthemum 18g, scorpion 3g, 14 doses, one dose a day, morning and evening. At the same time, the children were asked to adjust their mood, eat light food, do not eat stimulating food and poultry meat, do not drink carbonated drinks, balance nutrition, and do not play with electronic products.

On June 17, the second diagnosis, the child's blink symptoms disappeared, neck extension, shrug symptoms reduced, temper is still impatient, the diet is poor, sleep is not good. Physical examination: the complexion is lusterless, the tongue is reddened, the moss is slightly yellow, the pulse string slippery. The above formula reduce Celosia and Chrysanthemum, continue to take 14 doses, 1 dose a day, morning and evening. Care as before.

On July 1, the third diagnosis, the child is now twitching symptoms disappear, temper and mood improved significantly, the diet is good, sleep light, weight increased, check: the complexion is ruddy, lthe tongue is light reddened, the moss is thin white, pulse slightly string. Take another 10 doses of formulaes for secondary diagnosis (1 dose for 1.5 days) and take care of the patient as before. After a follow-up of 2 months, the child's tic symptoms were not repeated, his temper improved, and the eあect was satisfactory.

Note: the liver is located in the middle-jiao of the body, which can reach the Qi machine of triple energizer. It is mainly used for relieving and dislike depression. The child's liver Qi is blocked, and the Qi machine is not releasing stagnation. Therefore, he is usually impatient and irritable, and the depression is long-lasting, the fire generates wind, and the liver Yang is hyperactivity, so he has convulsions, and the liver depression is more serious after being scolded, and the convulsions are aggravated. In addition, because the liver is the Yang in the Yin, the above limbs are mainly convulsed. If the children are deficiency of spleen since the birth of the child, in addition, if the children are fed improperly, if the essence of the cereal is not enough, the source of blood and Qi will be exhausted, and the blood of the liver will not be sufficient to nourish the muscles and eyes. If the muscles and eyes are out of nourishment, there will be twitching symptoms such as neck extension, shoulder shrug and blinking. Spleen-earth can not nourish liver-wood, liver yang hyperactivity and twitch frequently. The spleen and stomach are not healthy, the water-dampness stops and gathers, then turned into phlegm. The phlegm is stagnant for a long time, and the fire generates wind. The wind is strong and moving. The throat feels uncomfortable and the throat clears. Phlegm and Qi mingle in the chest, Qi stagnants, blinding the mind and spirit, so the temper is perverse, the mouth makes a strange sound. Shaoyang cardinal is disadvantageous, spleen deficiency and liver multiply, the Yang is excessive and the Yin is quiet, which leads to the imbalance of Yin and Yang in the viscera. With the method of "reconciling Shaoyang", the liver and spleen can be dredged and the Yin and yang can be adjusted. So it is treated with "chaihu jia Longgu Muli Decoction add and subtract". In the prescription, bupleurum can dredge the liver and relieve the depression, clear the Shaoyang muggy, regulate the liver Qi, and scutellaria can clear the Shaoyang phase fire, and the two drugs can rise and fall properly, reconcile the cardinal of Shaoyang and coordinate the Yin and Yang of the viscera； Ginger and Pinellia has a warm and spicy taste, which can dry and damp to dissipate phlegm, reduce the adverse to eliminate the ruきan, and can also help Bupleurum and scutellaria to fluent the Sanjiao Qi mechanism； Poria cocos can invigorate the spleen, calm the heart, remove phlegm and help the movement； the keels and oysters can calm the liver Yang and calm the nerves； Paeonia lactiflora is bitter and slightly cold, which can calm the liver Yang, regulate the liver qi, nourish the liver Yin and relieve the spasm； Pueraria can relieve the upper limb twitch, and also help Bupleurum to raise the body Yang, so as to enhance the coordination eあect of yin and Yang； The Fructus aurantii can remove phlegm, eliminate glomus and smooth Qi； Grass-leaved sweetflag can release phlegm, open orifices and stop abnormal speech； Albizia bark can relieve depression and calm the nerves, semen Celosiae and chrysanthemum can clear liver, relieve fire, suppress liver Yang and stop blinking and twitching； scorpion can stop wind and spasm； Roasted licorice can nourish the temper and harmonize the medicinal properties, relieve the toxicity of insect drugs, and It can be used with paeony to nourish Yin and Yang. The whole prescription is used to reconcile Shaoyang, soothe the liver and spleen, regulate and protect the spleen, then the Yin and Yang will be reconciled and the convulsion will stop.

4. Conclusion

Due to the lack of specific description of this disease in ancient Chinese medicine books, modern doctors have diあerent views on the specific causes and pathogenesis of this disease. Professor Xuan Guiqi [16] thinks that the disease is related to exogenous wind evil. Children "have pure Yang". After being affected by the evil, the evil Qi is easy to be created fire, disturbing the liver wind, and the external wind causes the internal wind to twitch. Professor Zhang Biao [17] thinks that the disease is mainly caused by insufficient endowment and excessive five wills. The key pathogenesis of the disease is kidney deficiency and liver hyperactivity, and wind Yang promote. Children are the body of childish Yin and childish Yang, with a little carelessness, which is easy to cause the imbalance of Yin and Yang in the viscera. Professor Liu Bichen [18] believed that although the disease originated from the liver, it was "found in the lung"； therefore, "wind phlegm agitation" was the root of the disease. Professor Wang Shouchuan [19] said that the disease was deficiency in origin and excess in superficislity, which mainly caused by wind phlegm and imbalance of yin and Yang, and congenitally deficient and poor-nourishment after birth. Its standard was the disturbance of wind, fire and phlegm, and its original was the deficiency of the liver, spleen and kidney. Based on the previous experience, our teacher thinks that the pathogenesis of the disease is the imbalance of Yin and Yang in the viscera, and the key to the pathogenesis is "the disadvantageous cardinal Shaoyang". When treating children, according to the theoretical basis of "Shaoyang as the pivot", we add and subtract the Chaihu formula of "reconciling Shaoyang", so as to clear away the Shaoyang heat, harmonize the Yin and Yang in the viscera, and dredge the Qi mechanism, so as to achieve the eあect of "equilibrium between Yin and yang, ensure a vigorous spirit". In addition, our teacher thinks that the daily care of the disease is also very important. During the treatment, first, we should pay attention to the prevention of extraneous feelings； second, we should regulate children's mood, less reprimand and more encouragement； third, we should avoid children's frequent contact with electronic products. In addition, diet should be rich in nutrition and light food, avoid poultry meat, stimulating food, carbonated drinks, etc. Traditional Chinese medicine treatment and daily care are equally important, then the clinical eあect will be good.