HU Jun-cong (胡俊聪), CHEN Yuan-jia-fan (陈袁嘉繁), GUO Yan (郭 燕)

1. Second Clinical Medical College, Beijing University of Chinese Medicine, Beijing 100029, China

2. The Third Affiliated Hospital of Beijing University of Chinese Medicine, Beijing 100029, China

ABSTRACT Essential Subtleties on the Silver Sea (《银海精微》) is a well-known ophthalmology work of traditional Chinese medicine (TCM). There are many discourses on eyelids diseases. This paper analyzed the classification of related diseases and their treatment methods and intends to sort out the pathogenesis of eyelids diseases related to the spleen and stomach function in TCM, thus inspiring new treatment ideas and guiding clinical treatment. Through the sorting out, it is found that the eyelids diseases are closely related to the function of the spleen and stomach such as the Qi (气) and blood generation and transformation, the blood circulation, and the Yin (阴)-Yang (阳) harmony. The corresponding treatments are various, including expelling the pathogen, moving Qi (气) and invigorating blood, warming and activating the spleen Yang (阳).

KEYWORDS Essential Subtleties on the Silver Sea(《银海精微》); Eyelids diseases; Ophthalmology;Spleen and stomach theory

OVERVIEW

An Introduction to Essential Subtleties on the Silver Sea (《银海精微》)

This book firstly appeared in the Ming Dynasty and is a well-known ophthalmology book at home and abroad. The author is unknown, but later generations called SUN Si-miao of the Tang Dynasty. The "eye" is called "Silver Sea" in Taoism.This book contains a large number of formulas for ophthalmology, so it has the meaning of "subtle essence", hence the name Essential Subtleties on the Silver Sea (《银海精微》)[1]. The book's syndrome differentiations are detailed, the pictures and texts are comprehensive, the therapeutic principles and methods are correct and balanced,and the formulas are practical and effective. It has become an important reference book for guiding the clinical practice of TCM ophthalmology and studying the achievements of ancient TCM ophthalmology.The book has also been translated into different languages by Western scholars and spread widely around the world.

Eyelids Diseases

In chapter of "Granulations of the lower lid",there is a description of "[The term] Bao stands for upper lid; [The term] Jian stands for lower lid"[1],so the eyelids disease mainly refers to a series of diseases of the upper and lower lids. According to the "the five wheels and the eight regions" theory put forward by Essential Subtleties on the Silver Sea(《银海精微》), eyelids diseases are also among the flesh wheel diseases, and are closely related to the spleen and stomach of the theory of viscera in TCM.

CLASSIFICATION AND TREATMENTS OF EYELIDS DISEASES IN ESSENTIAL SUBTLETIES ON THE SILVER SEA (《银海精微》)

By reading Essential Subtleties on the Silver Sea (《银海精微》), we can realize that the main reasons causing eyelids diseases are "the two eyelids stick together" caused by the cold damaging to the spleen and stomach. "Ulceration on the upper lid, Sty on the lower lid, Granulations of the lower lid and so on" caused by the spleen and stomach containing heat toxin, "Lid-swelling resembling a peach" caused by the heat in the spleen and lung, "Eyelashes turning inward"caused by the spleen and lungs are affected by the wind and heat, "Lid flesh of the upper lid becomes sticky and stiff" caused by stomach heat, "Stagnant blood retained in the lids" caused by liver Qi (气)stagnation and damp encumbering the spleen and so on[1]. The symptoms of these diseases will largely guide us in thinking about the treatment of the eyelids diseases. These classifications will be described in the following.

Increased Secretion of the Eyelids Diseases-"the Two Eyelids Stick Together"

The "two eyelids stick together" is similar to the "symblepharon" disease described by modern medicine, and it is a state in which the eyelids adhere to the bulbar conjunctiva and the cornea.It is described in Essential Subtleties on the Silver Sea (《银海精微》) as "the upper and lower eyelids gel tightly, the blood stasis does not scatter, and the pseudomembrane is gradually formed for a long time[1]." The spleen and stomach are like a carriage that transports food to all parts of the body.If the carriage is robbed, and then the nutrients it carries naturally cannot reach the place where it should arrive, however the nutrients then gather for the pathological product. And the eyelids may be influenced by such pathological products and becomes "The two eyelids stick together". The book provides us two formulas: "Danggui Huoxue Decoction" (当归活血煎) and "Chanhua Powder" (蝉花散). Through the original formulas, we can see that the main treatment idea is to drive away the cold and wind pathogen, and use many herbs that can dispel the wind pathogen such as Rhizoma Ligustici Chuanxiong, Rhizoma et Radix Notopterygii,Flos Chrysanthemi, Periostracum Cicadae, etc.In addition, there are herbs that can be used to promote Qi (气) and blood circulation. For example,Fructus Aurantii, Rhizoma Ligustici Chuanxiong,Rhizoma Atractylodis are particularly conspicuous in the decoction when there are many wind medicine(medicine can dispel wind pathogens), because it can dry and wet the spleen which can promote the spleen and stomach transportation. Perhaps it is influenced by the thought of LI Dong-yuan's"Spleen and Stomach Theory". In the "Spleen and Stomach Theory ", he puts forward that "the ear,the nose, the mouth, and the eyes are as cleaned as the air"[2], the spleen and stomach are the pivot of Qi (气) ascending and descending of the whole body. The harmonious movement of the spleen and the stomach can promote normal blood and normal operation and therefore make other viscus play their normal physiological functions. Rhizoma Atractylodis with capabilities of fragrant warmth and dryness will not only help other medicines to better eliminate the pathogens of wind and cold, but also awaken the spleen which can help the body to clear the turbidity and help the disease to heal[3].

Proliferative Inflammatory Disease

The occurrence of hyperplastic inflammatory eyelids diseases is mostly related to the dampness and heat pathogens. The treatment begins with clearing the dampness and heat in the spleen and stomach. The commonly used medicines in the book include Rhizoma Coptidis, Poria and Radix Paeoniae Alba. At the same time, other medicines,such as Semen Plantaginis, Fructus Gardeniae,Talcum, can expel the pathogen of dampness and heat by promoting urination and unblocking the bowels.

Ulceration on the upper lid and sty on the lower lid

Such proliferative inflammatory eyelids diseases are similar as stye and chalazion recognized by modern medicine. Stye is commonly called "needle eye" and "stealing eye". It is an acute suppurative inflammation of the eyelids gland and eyelash hair follicle sebaceous glands.It is characterized by "red, swollen and painful".The chalazion is also called the phlegm node of the eyelids. The name of the disease is first seen in "Ophthalmology," which is an idiopathic aseptic chronic granulomatous inflammation of the meibomian gland. It is characterized by "there are some endogenous hard nucleus in the it has painless touch and has normal skin color[4]." These symptoms are described in Essential Subtleties on the Silver Sea (《银海精微》) as "ulceration on the upper lid is due to heat-poison in the spleen and stomach[1]." The concept of spleen and stomach heat toxicity is proposed to explain the mechanism of similar diseases. The treatment also uses "Bazheng Powder" (八正散) and "Sanhuang Decoction" (三黄汤) to clear the fire poisoning and the dampness and turbid of body[5].

Granulations of the lower lid

Such proliferative inflammatory eyelids diseases are similar to trachoma recognized by modern medicine. Trachoma is a chronic contagious conjunctival keratitis caused by Chlamydia trachomatis[6]. It forms a rough and uneven appearance on the surface of the conjunctiva, resembling sand, hence the name trachoma. These symptoms are described in Essential Subtleties on the Silver Sea (《银海精微》) as "blood has accumulated in the lids for years, leading to granulations... this heat blocked up in the spleen and the stomach, leading to the gradual development of eyelids resembling grains of rice at the upper and lower lids[1]." The concept of heat blocked in the spleen and stomach and heat toxicity are used to explain the mechanism of such diseases. The treatment also uses the Xiepi Decoction (泻脾汤) to clear spleen heat, and use Radix et Rhizoma Rhei to relieve the pathogen heat from the intestines[7].

Swollen disease-lid-swelling resembling a peach

The disease such as "Lid-swelling resembling a peach" is similar to the "severe orbital inflammatory edema" in modern medicine. It is characterized by "red, swollen, hot, and painful eyelids", which may be accompanied by conjunctival edema and congestion. In severe cases, there may be headache, fever and aversion to cold and other symptoms. Essential Subtleties on the Silver Sea(《银海精微》) describes it as "the pathogen has settled between skin and flesh"[1]. This causes the upper and the lower lids to swell and assume the shape of a peach. It has pain and roughness feeling,and unceasing tear flow which considered to be caused by "spleen and lung heat". The spleen and lungs are hot, which interferes with the metabolism of the lungs and spleen, and then causes edema.The treatment uses the "Qingliang Powder" (清凉散)to expel the heat pathogen, among which Rhizoma Atractylodis Macrocephalae and Radix Glycyrrhizae

warm spleen, and Poria restores the water and liquid metabolism pathway[8].

Other special types

The other special types include the flesh of the upper lid becomes sticky and stiff, stagnant blood retained in the lids, eyelashes turning inward,wind pulls the lower lid outward, redness of the lid margins resulting from wind.

"The flesh of the upper lid becomes sticky and stiff" is quite the same as the "two eyelids stick together", but the degree is not the same. The Golden Mirror of Medicine (《医宗金鉴》) said that"the flesh in the eyelids is picked up, the small ones are getting bigger, the eyes are stunned and wet,and the tears are adhesive[9]." "Hidden heat blocked up inside the stomach" is the main pathogenesis of the disease, and the treatment uses the Tongpi Xiewei Decoction (通脾泄胃汤). The special treatment in this formula is "nourishing the stomach Yin (阴)" to suppress the virtual fire, accompanied by Radix Saposhnikoviae to transport the spleen, by the Radix et Rhizoma Rhei to clear the residual fire in the body.

"Stagnant blood retained in the lids" is described as "Qi (气) congeals and is blocked in the liver and wind-dampness is retained in the spleen and in the stomach, or because the patient cannot recover after getting "epidemic red-eye". All this causes the blood to congeal in the upper and lower lids; this is called 'stagnant blood' retained in the lids[1]." Because of the Qi (气) stagnation, the blood cannot be pushed and becomes stagnant; besides the spleen governs ascent of the clear, which is also responsible for this disease. When dampness damaging spleen Yang (阳), clear Yang (阳) fails to ascend, turbid Yin (阴) failing to descend, lingering and hindering the operation of the head and causing Qi (气) stagnation and blood stasis. Treatment should be Danggui Powder (当归散) which can not only soothe the liver and resolve constraint but also promote urination and percolate dampness.

"Eyelashes turning inward" is described as"the spleen and the lungs have received wind and heat[1]." In the theory of TCM, the lung is like a canopy occupying the topmost position of the five viscera, and it is in the charge of the body's skin and hair. When the lung is deficient, the skin shrinks and the eyelashes curl, besides "when the spleen stores too much dampness and heat, this causes the upper lid to swell frequently." The patient often rubs his eyes with his hands. And this causes the eyelashes to fall over. Treatment can use Xixin Decoction (细辛汤) to scatter wind and clear heat of the spleen and lung, in order to clear the internal pathogen heat,scatter and dissipate external wind.

"Wind pulls the lower lid outward" is described as "the wind pulls the lower lid outward, spleen and stomach have received wind, and this poison accumulates and becomes manifest at the upper and lower lids. When the lower lid is affected by wind, its skin tightens, and when the spleen is affected by wind, the muscle flesh is blocked. This tightness of the skin and blockage of the muscle flesh of the lids is the basis of the condition.Irrespective of the four seasons, tears flow because the earth of the dam yields and cannot dike the water any longer[1]." When abnormal wind affects the spleen and stomach, so that they lose function of the accumulation of the essence of the water and grain, which causes tears to come out. This book uses external methods to dispel the wind, first by embrocating with the Mofeng Ointment (摩风膏) disperse the external wind-pathogen from the spleen, and then apply the Bailian Ointment (白敛膏) in order to diminish and disperse the wind-toxin.The description contains many wind-like medicines,which are light and disperse in order to remove the wind pathogen.

"Redness of the lid margins resulting from wind" is similar to the category of "Blepharitis ciliaris"recognized by modern medicine. Blepharitis ciliaris is a subacute, chronic inflammation of the marginal skin, the hair follicles of the eyelashes and their glands. The eyelids margin is rich in glandular tissue and fat secretions, which are easily contaminated by dirt and bacteria. These symptoms are described in Essential Subtleties on the Silver Sea (《银海精微》)as "spleen collects dampness and heat. When the spleen is weak and cannot transform the dampness,the Qi (气) of dampness and heat attack each other and are transmitted to the upper and lower lids,where they break out and cause photophobia and tear flow. Contained inside the lids, the heat-poison of these tears causes the lid margins to become red and to fester[1]." The original text is treated with the Huangqi Decoction (黄芪汤). Rhizoma Atractylodis[10]in the decoction can dry dampness and activate spleen, and Rhizoma Coptidis can dissipate the heat of the spleen and stomach and with the help of Semen Plantaginis to excrete the pathogen of the body from the urine.

EMBODIMENT AND APPLICATION OF THE SPLEEN AND STOMACH THOUGHTS USED FOR TREATING EYELIDS DISEASES IN ESSENTIAL SUBTLETIES ON THE SILVER SEA (《银海精微》)

Eyelids Diseases is Related to Qi (气) and Blood Production by the Spleen and Stomach

Qi (气) and blood are the material basis for the function of the human body. The two eyes of the human body undoubtedly need continuous perfusion of Qi (气) and blood to better exert their functions.According to Inner Canon of Yellow Emperor (《黄帝内经》), there are "All the meridians are all belong to the eyes. The essence of the internal organs is all transfused to the eye for the purpose". Therefore,when the spleen Qi (气) is sufficient, the blood is filled and the two eyes can see. In many of the eyelids diseases described in Essential Subtleties on the Silver Sea (《银海精微》), whether it is injured by the wind, or the spleen and lungs are affected by the wind and heat, there are inevitably related to obstacles of the spleen and stomach to generate Qi (气) and blood. Therefore, regulating and harmonizing Qi (气) and blood is very important in the treatment of eyelids diseases. Essential Subtleties on the Silver Sea (《银海精微》) uses Rhizoma Cimicifugae, Radix Bupleuri, Rhizoma et Radix Notopterygii, Radix Saposhnikoviae to ascent and disperse Yang (阳), scatter wind and dissipate cold in the decoction of "Danggui Huoxue Decoction" (当归活血煎) and "Chanhua Powder" (蝉花散) in the treatment of "two eyelids stick together". Meanwhile, the decoction also specially adds Radix Astragali seu Hedysari, Radix Glycyrrhizae intended to warm and supplement the spleen and stomach, which can invigorate spleenstomach and replenish Qi (气).

Eyelids Diseases is Related to Conditioning Blood by the Help of Spleen and Stomach

The spleen controls the blood keeps it within the vessels. And the spleen and stomach are the source of Qi (气) and blood production. When there is a problem with the blood circulation of the spleen and stomach, there may be a condition similar to "Stagnant blood retained in the lids". LI Dongyuan's treatise on the spleen and stomach "points out that "the nine orifices, which is mastered by the five visceral. And the five viscera can be promoted by the stomach Qi (气)"[2]. Radix Angelicae Sinensis is called "the holy medicine to reconcile the blood"by LI Dong-yuan, because it can nourish the blood,invigorate blood and calm the mind, which is a good medicine for ophthalmology[11]. And the almost every treatment formula for eyelids diseases in Essential Subtleties on the Silver Sea (《银海精微》)uses Radix Angelicae Sinensis, which is intended to restore the function of spleen and stomach transportation with the help of Dang-gui (当归).

Eyelids Diseases is Related to the Governing of Ascending and Descending of Yin (阴)-Yang(阳) by the Spleen and Stomach

In modem studies, the Yang lifting method is most commonly used in ophthalmology to treat eyelid disease. There are a large number of scholars who are clinically effective in using this method[12-14].

FAN Yu-lan[15]pointed out the cause of the"Pain as if possessed by a spirit" in Essential Subtleties on the Silver Sea (《银海精微》), "The disharmony of Yin (阴) and Yang (阳) and abnormal exuberance of Qi (气) and blood can cause the diseases." Zhuyang Hexue Decoction (助阳和血汤)can treat "the disharmony of Yin (阴) and Yang (阳)causes painfulness from time to time" by regulating the disharmony of Yin (阴) and Yang (阳) can be seen as the effect of Yin (阴) and Yang (阳) on the eye disease, the treatment of the use of LI Dongyuan's representative ophthalmology formula[Zhuyang Hexue Decoction (助阳和血汤)] to treat the eye diseases.

We also found that when treating "Eyelashes turning inward", the book's formulas not only use the Rhizoma Coptidis and Radix Puerariae to remove the wind and heat of the spleen and lungs,but also use Radix Glycyrrhizae, Radix Ginseng to supple the center, and use Radix Saposhnikoviae to ascend clear Yang (阳) of the spleen and stomach.Therefore, the spleen Qi (气) can produce normal clear Yang (阳), in order to cure the symptoms and the recovery of eye diseases can be accelerated.

DISCUSSION

Essential Subtleties on the Silver Sea (《银海精微》) takes the lungs and spleen as the entry point to treat the eyelids diseases. We come out three treatment ideas: expel the pathogen, move Qi (气) and invigorate blood, warm and activate the spleen Yang (阳). Based on this, many effective formulas have been invented, and various dosage forms and various moxibustion methods are used to match the medicines to exert better effects. In the selection of the corresponding medicines, the usage of medicines for regulating the spleen and stomach and regulating blood vessels are very often in 180 flavors[15], which is also in line with the treatment idea of attaching importance to the function of the spleen and stomach.

In the clinical application prospects, TCM treats eyelids disease by conditioning of the function of the viscera, using the decoction, powder and other internal and external treatment. Compared with the surgery used by modern medicine in the treatment of related diseases, they are safer. They are easy to be accepted by the patients and have low medical cost, which provide a safer and more effective way for people to treat eyelids diseases. Of course, it is also possible to provide conditions for the treatment of eyelids diseases with integrated Chinese and Western medicine, to learn from each other's strengths and improve curative effect.

Essential Subtleties on the Silver Sea (《银海精微》) not only pays attention to the treatment from the spleen and stomach, but also has many novel perspectives on the diagnosis and treatment of ophthalmology diseases, which is worthy of medical scholars to continue to explore.