Liver-spleen Disharmony in Chinese Pediatrics

by Bob Flaws, Dipl. Ac. & C.H., FNAAOM

The clinical practice of Chinese medicine is predicated on certain basic statements of fact which every Chinese doctor is taught in their entry level education. In addition, there are supplementary statements of fact within all of Chinese medicine’s clinical subspecialties. For instance, in Chinese medical pediatrics, there is the statement, "The liver commonly [or normally] has a surplus, [while] the spleen commonly is insufficient." This statement is first found in the Dan Xi Xin Fa (Dan-xi Heart Methods) and dates from the Yuan dynasty. In this statement, surplus implies repletion (shi), and insufficiency is a synonym for vacuity (xu). If the liver is replete and the spleen is vacuous, this is a liver-spleen disharmony. A liver-spleen disharmony is at the core of many diseases, in adults as well as children. In fact, in many cases, one can trace a liver-spleen disharmony as the core disease mechanism throughout a patient’s entire life, often beginning in the first several months after birth. It is my experience as a clinician that, if one understands the implications of this statement, it can significantly help one diagnose and treat a wide variety of conditions in children. In a recent issue of the Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), Gao Hui-ling presents three cases histories which, he feels, are best understood from the perspective of the above statement of fact.[1]

Simple cough

The patient was a seven year old girl who had had a simple cough for more than two months. Sometimes this cough was better and sometimes it was worse. There were no signs or symptoms of external contraction. The patient had been treated with several different medications but without effect. At the time of examination, Gao noted a simple cough, bad breath, stools which were first dry and then loose, red veins in both eyes, and blisters and marked hyperemia in the back of her throat. The girl’s tongue fur was thin and yellow and slimy in the center.

Based on these signs and symptoms, Dr. Gao categorized the child’s pattern as liver channel depressive fire attacking and assailing the lungs and spleen. The treatment principles he formulated were to clear the liver and emolliate the liver, fortify the spleen and stop cough. For this, he prescribed: scorched Fructus Gardeniae Jasminoidis (Zhi Zi), stir-fried Rhizoma Atractylodis Macrocephalae (Bai Zhu), Radix Albus Paeoniae Lactiflorae (Bai Shao), Ramulus Uncariae Cum Uncis (Gou Teng), uncooked Radix Rehmanniae (Sheng Di), Radix Codonopsitis Pilosulae (Dang Shen), and Sclerotium Poriae Cocos (Fu Ling), 10g each, uncooked Concha Ostreae (Mu Li), 20g, Radix Scutellariae Baicalensis (Huang Qin), Cortex Radicis Moutan (Dan Pi), and Radix Angelicae Sinensis (Dang Gui), 6g each, and Radix Glycyrrhizae (Gan Cao), 3g. After administering five ji of this prescription, the cough had markedly decreased. After five more ji, the patient was judged cured.

Discussion:

According to Dr. Gao, simple cough refers to cough with sound but no sound of phlegm. The patient’s bilateral red veins in her eyes, bad breath, and stools which were first dry and then loose indicated liver fire depression and exuberance. Therefore, within the above formula, Sheng Di, Bai Shao, Dang Gui, scorched Zhi Zi, Huang Qin, and Dan Pi were for the purpose of clearing and emolliating the liver. These medicinals were then assisted by Dang Shen, Fu Ling, and Bai Zhu to fortify the spleen. The adjunct medicinals were Gou Teng and uncooked Mu Li which leveled the liver and subdued yang, and Gan Cao harmonized all the other medicinals in the formula. Therefore, without specifically using medicinals which stop coughing, coughing was automatically stopped.

Within this case, Dr. Gao’s use of Gou Teng, I think, deserves further comment. Gou Teng not only clears liver heat, it also extinguishes wind and alleviates spasms. Cough is now recognized in modern Chinese medicine as a sign of involuntary spasming or contraction of the diaphragm. Therefore, it is now common to find Chinese medicinals with a known empirical effect of alleviating spasms in formulas for cough, especially enduring coughs. Other wind-extinguishing medicinals which are commonly found in Chinese cough formulas include Lumbricus (Di Long) and Buthus Martensis (Quan Xie).

Headache

The patient was an eight year old boy who had had a headache for 3-4 days. The location of the head pain was not fixed. Sometimes it was in the front, and sometimes it was in the back, sometimes on the right, and sometimes on the left. At times, the pain was extremely severe and was accompanied by nausea. In addition, there was bad breath, torpid intake, abdominal distention, and no signs or symptoms of external contraction. Electroencephalogram and brain CT scan showed no abnormalities. The boy’s tongue fur was white and slimy.

Based on these signs and symptoms, Dr. Gao categorized the child’s pattern as spleen dampness with liver wind which was ascending and harassing the clear orifices. The treatment principles he proposed were to level the liver and extinguish wind, fortify the spleen and transform dampness. In order to accomplish these aims, he prescribed: Rhizoma Gastrodiae Elatae (Tian Ma), Rhizoma Atractylodis Macrocephalae (Bai Zhu), Rhizoma Pinelliae Ternatae (Ban Xia), Rhizoma Atractylodis (Cang Zhu), Sclerotium Poriae Cocos (Fu Ling), and Radix Codonopsitis Pilosulae (Dang Shen), 10g each, Rhizoma Coptidis Chinensis (Huang Lian), 6g, Lumbricus (Di Long) and Radix Ligustici Wallichii (Chuan Xiong), 5g each, Buthus Martensis (Quan Xie) and Radix Glycyrrhizae (Gan Cao), 3g each, and bland Fructus Evodiae Rutecarpae (Wu Zhu Yu), 2g. After administering three ji of these medicinals, the headache was completely eliminated and the slimy tongue fur had disappeared. Therefore, Dr. Gao prescribed Tian Ma Du Zhong Wan (Gastrodia & Eucommia Pills) to strengthen the treatment effect, after which the patient was judged cured.

Discussion:

According to Dr. Gao, most cases of pediatric headache are due to external contraction, with internal damage resulting in relatively few cases, at least in China. However, this child did not present any signs or symptoms of external contraction. Within the above formula, Dang Shen, Bai Zhu, Ban Xia, Fu Ling, and Cang Zhu were the rulers in order to fortify the spleen and transform dampness. The assistants were Tian Ma, Di Long, and Quan Xie to level the liver and extinguish wind. Chuan Xiong was an adjunct to quicken the blood and free the flow of the network vessels as well as to guide the other medicinals upward. Wu Zhu Yu and Huang Lian harmonize the stomach and disperse distention, and Gan Cao harmonized all the other medicinals in the formula. Because these medicinals matched the patient’s pattern, they were able to achieve the proper effect.

Although Dr. Gao says the combination of Wu Zhu Yu and Huang Lian was used for the purposes of harmonizing the stomach and dispersing distention, a fuller description of their use is that they harmonize the liver and stomach and clear heat. In fact, this combination is a formula within its own right. It is called Zuo Jin Wan (Left Metal Pill). The bitter and cold Huang Lian drains fire from the liver and clears stomach heat, while the acrid and hot Wu Zhu Yu courses the liver and rectifies the qi, harmonizes the stomach and downbears counterflow. This case is yet another instance where there is not just a liver-spleen disharmony but liver dpression/depressive heat is conducted to the stomach, resulting in a liver-stomach disharmony as well.

Polyuria

The patient was a six year old boy who had had frequent urination for more than two weeks. Sometimes he was even incontinent. There was no pain on urination or terminal dribbling and dripping, and the color of the urine was normal. There was no edema, no blood in the urine, and urine analysis was normal. X-ray examination of the lumbosacral region and ultrasound also showed no abnormalities. The child’s polyuria had been precipitated by emotional stress associated with the boy’s relationship with his mother. There was no nocturia and his sleep was undisturbed. Over a period of days, this polyuria had become complicated by reduced appetite, constipation, and flushing of both cheeks as if the child had drunk alcohol. In addition, the child watched a lot of television and was easily stimulated. His tongue fur was yellow in the center and slimy at the root.

Based on these signs and symptoms, Dr. Gao categorized the child’s Chinese medical pattern as liver effulgence repressing the spleen. As treatment principles, Dr. Gao suggested draining the liver and fortifying the spleen, freeing the flow of the stools and reducing urination. Therefore, he prescribed: uncooked Radix Rehmanniae (Sheng Di), Fructus Citri Aurantii (Zhi Ke), Radix Albus Paeoniae Lactiflorae (Bai Shao), Ramulus Uncariae Cum Uncis (Gou Teng), and Semen Cannabis Sativae (Huo Ma Ren), 10g each, Radix Bupleuri (Chai Hu), Radix Scutellariae Baicalensis (Huang Qin), Radix Ledebouriellae Divaricatae (Fang Feng), Lumbricus (Di Long), and Fructus Alpiniae Oxyphyllae (Yi Zhi Ren), 6g each, Radix Glycyrrhizae (Gan Cao) and Radix Polygalae Tenuifoliae (Yuan Zhi), 5g each, and uncooked Radix Et Rhizoma Rhei (Da Huang), 3g. After administering five ji of these medicinals, all the child’s symptoms were eliminated. Another five ji of the same formula was administered to secure the treatment effect, and the case was judged a success.

Discussion:

According to Dr. Gao, this was a case of neurotic polyuria in terms of Western medicine, and the child’s emotions had resulted in the disease. Within the formula, Chai Hu and Huang Qin drain liver fire. Sheng Di, Gou Teng, Bai Shao, and Di Long nourish yin, level the liver, and extinguish wind. Huo Ma Ren and uncooked Da Huang freed the flow of the stools. Yi Zhi Ren secured, astringed, and reduced urination. Fang Feng and Bai Shao regulated and rectified the liver and spleen. Yuan Zhi quieted the child’s spirit, Zhi Ke rectified the qi, and Gan Cao harmonized the center. Again, since the medicinals matched the patient’s pattern, they eliminated the disease.

What Dr. Gao does not mention but what I think is also important to state is that the polyuria was not just due to spleen qi vacuity failing to upbear the clear. In Chinese medicine, it is said that, "The kidneys are the bar of th stomach." This statement implies that there is a reciprocal relationship between the stomach and kidneys vis á vis urination. When the stomach is hot, it hyperfunctions. The function of the stomach is to downbear turbidity. On the one hand, this means the turbid residue of foods. On the other, it includes the turbid residue to liquids. Because of the close reciprocal relationship between the liver and stomach, if the liver becomes depressed and, therefore, transforms heat, this heat may easily be conducted to the stomach. If such stomach heat is combined with spleen qi vacuity, then this provides two mechanisms for polyuria, neither of which has anything to do with kidney vacuity. In this case, Huang Qin not only drains liver fire but also clears stomach heat and is an important medicinal for the treatment of this disease mechanism of frequent urination.  

Copyright © Blue Poppy Press, 2001. All rights reserved.

For further information on Chinese medical pediatrics, practitioners should see Bob Flaws’s A Handbook of TCM Pediatrics, while lay readers should see Flaws’s Keeping Your Child Healthy with Chinese Medicine. Blue Poppy Press also publishes a number of Research Reports on various pediatric conditions. In addition, Blue Poppy Seminars has a one hour Distance Learning program taught by Bob Flaws, titled The Essence of Chinese Pediatrics, as well as a one year Distance Learning certificate program also taught by Flaws.