Apoplexy

Apoplexy is a disorder manifested as sudden onset of hemiplegia, dysphasia or aphasia and distortion of face, with or without loss of consciousness. Since it is characterized by abrupt onset, rapid development and changeful symptoms resembling the variability of wind, it is also called "wind-stroke." The cerebrovascular diseases, including hemorrhagic and ischemic, and facial paralysis with similar manifestations, may be differentiated and treated as discussed in this section.

Etiology and Pathogenesis

Apoplexy often occurs in aged people who are in poor health and have a deficiency of qi and blood and yin-yang imbalance of liver, heart and kidneys. It may be induced by emotional upset, immoderate diet and drinking, sexual indulgence or affection of exogenous evils and leads to obstruction of qi and blood circulation. it may also be cause by yin deficiency, which leads to hyperactivity of yang, agitation of liver-wind, adverse ascending of qi and blood and production of fire and phlegm; or by blockage of upper orifices, which leads to deficiency of inter-maintenance between yin and yang. In addition, deficiency of liver-yin and kidney-yin, hyperactivity of liver-yang, blood stasis, overstrain and mental stress that lead to an upsurge of liver-fire and hear-fire, insufficiency of healthy qi complicated by the attack of exogenous wind to the meridians and obstruction of meridians by phlegm-dampness are also responsible for the pathogenesis of the disease. In short, the pathogenic factor of apoplexy is either deficiency (yin-deficiency or qi-deficiency); fire (liver-fire or heart-fire); wind (liver-wind or exogenous wind); phlegm (wind-phlegm or dampness-phlegm); adverseness of qi; or blood stasis. Among them, the deficiency of liver-yin and kidney-yin constitutes the basis of pathogenesis. Besides, all the above factors may be interchanged under certain conditions.

Syndrome Differentiation and Therapeutic Principles

A. Syndrome differentiation

(a) Differentiation of the location and severity of the disease: Acute cases of apoplexy can be classified into those involving meridians (mild cases) and those involving zang-fu organs (serious cases). They are grouped according to severity under four types in the following sequence: (1) Apoplexy involving collaterals: The mildest case identified by numbness of extremities of one side and distortion of the face; (2) Apoplexy involving channels: The mild case characterized by hemiplegia, distortion of the face, general bodily numbness and dysphasia, but without disturbance of consciousness; (3) Apoplexy involving fu-organs: The serious case marked by disturbance of consciousness in addition to the above manifestations; however, the disturbance if often of milder degree, such as stupor or somnolence; (4) Apoplexy involving zang-organs: The most serious case manifested as profound coma, hemiplegia, involuntary staring, dysphagia, constipation, retention of urine or incontinence of urine and feces.

(b) Differentitation of the sthenia-syndrome of come and collapse-syndrome: Apoplexy involving zang-fu organs may be subgrouped into two types: (1) Sthenia-syndrome: Resulting from the retention of evils, manifested by lockjaw, clenching of fists, retention of urine and feces and stiffness of extremities; that associated with heat-phlegm to yin type; (2) Collapse syndrome: Caused by exhaustion of ying-qi, characterized by closed eyes, opened mouth, weak breathing, flaccid paralysis of hands and incontinence of urine.

(c) Identification of the tendency of disease progress: For the case with zang-fu organs involved at the onset, the prognosis is considered as favorable when the severity of unconsciousness and paralysis is reduced, and vice versa. Frequent hiccups, sudden occurrence of coma, convulsions, deadly coldness of limbs with hot feeling on the trunk, hematemesis or hematochezia indicate a case tending toward deterioration.

B. Therapeutic principles

(a) In the acute stage, the therapy of expelling pathogenic factors should be employed as the chief measure, such as calming the liver-wind, dispersing phlegm-heart, dredging and purging fu-organs, releasing the stagnated liver-qi, activating blood circulation, removing blood stasis etc. For cases with Athena-syndrome of coma, the therapy for dispelling evils and waking up the patient from unconsciousness should be adopted first, and for those with collapse syndrome, warming yang and benefiting qi ought to be used first. (b) In the convalescent stage, supporting healthy qi is the main principle, and expelling evils may be employed simultaneously. The therapies of benefiting qi and activating blood circulation, nourishing yin and suppressing yang, supporting yin and dredging meridians, tonifying spleen and eliminating phlegm are the measures commonly applied.

(c) Acupuncture, moxibustion, massage and physical exercise should be used to supplement these principles.

Classification and treatment

A. Apoplexy involving meridians

(a) Attack of wind against the weakened meridians

Manifestations: Pre-existing dizziness, sudden onset of hemi-anesthesia, distortion of face, dysphasia, salivation, hemiplegia, fever, chilliness, stiffness of limbs, arthralgia, thin tongue coating and floating and tense or floating pulse.

Therapeutic principles: Expel wind, dredge collaterals and nourish blood and ying.

Prescription: The Modified Decoction of Gentianae Macrophyllae

Radix Gentianae Macrophyllae 10 g
Radix Ledebouriellae 10 g
Rhizoma seu Radix Notopterygii 6 g
Radix Paeoniae Alba 10 g
Radix Paeoniae Rubra 12 g
Lumbricus 10 g
Rhizoma Chuanxiong 9 g
Scorpio 5 g

Remarks: For cases with obstruction of meridians by dampness-phlegm or blood stasis, which fail to respond to the above prescription, add Radix Salviae Miltiorrhizae, Flos Carthami, Caulis Spatholobi, Rhizoma Typhonii and Bombyx Batryticatus. For cases with invasion of wind to the interior changing to heat, manifested by yellow tongue coating and rapid pulse, Radix Scutellariae and Gypsum Fibrosum should be used to clear away heat. For cases with distortion of face but without hemiplegia, the Modified Powder for Treating Face-Distortion should be adopted, which is composed of Rhizoma Typhonii, Bombyx Batryticatus, Scorpio, Radix Ledebouriellae, Herba Schizonepetae, Flos Carthami and retinervus Luffae Fructus.

(b) Deficiency of liver-yin and kidney-yin with upward attack of wind-yang

Manifestations: Dizziness, headache, tinnitus, fitful sleep, dreamfulness, soreness and weakness of lumbus and knees, sudden-onset face distortion, stiffness of tongue, dysphasia, heaviness and numbness of limbs or even hemipelgia, red tongue with yellow greasy coating and wiry and rapid or smooth pulse.

Therapeutic principles: Nourish yin, suppress yang, calm wind and dredge collaterals.

Prescription: The Modified Decoction for Suppressing Liver-Wind

Haematitum 30 g
Concha Ostreae (decocted first) 30 g
Radix Scrophulariae 15 g
Radix Rehmanniae 15-24 g
Radix Paeoniae Alba 10 g
Radix Paeoniae Rubra 10 g
Rhizoma Gastrodiae 10 g
Ramulus Uncariae cum Uncis 15 g
Radix Achyranthis Bidentatae 12 g
Caulis Spatholobi 15-30 g
Lumbricus 9 g

Remarks: For cases with severe affection of phlegm-heat, add Rhizoma Arisaema cum Bile to clear away heat and dissipate phlegm. For cases with severe headache, add fructus Atriplex Sibiricae, Concha Haliotidis and Cornu Saigae Tataricae to calm wind and suppress yang.

(c) Upward attack of wind-phlegm and retention of phlegm-heat in fu-organs

Therapeutic principles: Dissipate phlegm and dredge fu-organs.

Prescription: The Modification of Purgative Decoction of Trichosanthis and Arisaema cum Bile

Remarks: For cases with deficiency of qi and yin complicated by phlegm-heat, add Radix Rehmanniae, Radix Scrophulariae, Radix Ophiopogonis, Radix Adenophorae Strictae and radix Pseudostellariae to nourish yin and benefit qi.

B. Apoplexy involving zang-fu organs

(a) Sthenia-syndrome of coma of yang type Manifestations: Sudden loss of consciousness, lockjaw, clenching of fists, tonic convulsions, retention of urine and feces, profuse salivation, flushed face, fever, noisy breathing, halitosis, restlessness, red tongue with yellow greasy coating and wiry, smooth and rapid pulse.

Therapeutic principles: Wake up the patient from unconsciousness by acrid-cool drugs, clear liver-heat and calm wind.

Prescription:

1) Bolus of Precious Drugs or Calculus Bovis Bolus for Resurrection

2) The Modification of Cornu Saigae Tataricae Decoction

Pulvis Cornu Saigae Tataricae (mixed with the
decoction) 0.5 g
Fructus Atriplex Sibiricae 10 g
Spica Prunellae 12 g
Radix Paeoniae Alba 10 g
Radix Rehmanniae 15 g
Cortex Moutan Radicis 10 g
Radix Achyranthis Bidentatae 12 g
Concha Haliotidis (decocted first) 30 g
Radix Curcumae 10 g
Rhizoma Acori Graminei 10 g

Remarks: For cases with convulsion, add Scorpio, Scolopendra, and Bombyx Batryticatus to suppress wind and relieve convulsions. For cases with profuse salivation, add Rhizoma Arisaema cum Bile, Concretis Silicea Bambusae and Succus Lophatheri to eliminate sputum and wake up patient from unconsciousness. For cases with halitosis, abdominal distension and constipation, add fructus Trichosanthis, Rhizoma et Radix Rhei, Fructus Aurantii Immaturus and Natrii Sulfas to dispel heat by purgation.

Manifestations: Sudden loss of consciousness, lockjaw, clenching of fists, tonic convulsion, cold limbs, retention of urine and feces, pale complexion, dull lips, lying quietly, profuse salivation, dull tongue with white greasy coating and deep, smooth and slow pulse.

Therapeutic principles; Eliminate phlegm, suppress wind and wake up the patient's consciousness with acrid-warm drugs.

Prescription:

1) Bolus of storax by nasal feeding

2) The Modification of Decoction for Eliminating Phlegm

Poria 30 g
Exocarpium Citri Grandis 10 g
Rhizoma Pinelliae 10 g
Rhizoma Acori Graminei 10 g
Radix Polygalae 10 g
Bombyx Batryticatus 10 g
Rhizoma Gastrodiae 10 g
Rhizoma Arisaema cum Bile 10 g

C. Collapse-syndrome

Manifestations: Sudden loss of consciousness, closed eyes, opened mouth, snoring, weak breathing, flaccid paralysis of limbs, cold limbs, profuse sweating, incontinency of urine and feces, atrophied and curled tongue, shrunken scrotum and fading pulse.

Therapeutic principles: Benefit qi, restore yang and support healthy qi.

Prescription: Decoction of Ginseng and Aconiti Lateralis praeparata with Powder for Restoring Pulse Beat

Radix Ginseng (decocted separately) 10 g
Radix Aconiti Lateralis Praeparata 10 g
Radix Ophiopogonis 10 g
Fructus Schisandrae 10 g

Remarks: For cases with profuse sweating, add radix Astragali, Os draconis and Concha Ostreae to arrest sweating.

D. Sequela

(a) Hemiplegia

(1) Qi deficiency with obstruction of meridians by blood stasis

Manifestations: Hemiplegia, flaccid limbs, sallow complexion, fatigue, numbness of extremities, deviation of tongue and mouth, dysphasia, edema of affected hands and feet, dull tongue with petechiae and white coating and thready and uneven pulse.

Therapeutic principles: Benefit qi, activate blood circulation and dredge collaterals.

Prescription: The Modified Decoction for Invigorating Yang

Radix Astrgali 30 g
Flos Carthami 10 g
Radix Paeoniae Rubra 10 g
Radix Salviae Miltiorrhizae 30 g
Lumbricus 10 g
Poria 20 g
Exocarpium Citri Grandis 10 g
Caulis Spatholobi 30 g

Remarks: For cases with dysphasia, add Rhizoma Pinelliae, Rhizoma Acori Graminei and Radix Polygalae to eliminate phlegm and ease the orifices. For cases with deviation of mouth and tongue, add Bombyx Batryticatus, Scorpio and Rhizoma Typhonii to eliminate wind and dissipate phlegm. For cases with incontinence of urine, add Ootheca Mantidis and fructus Alpiniae Oxyphyllae to tonify the kidneys and preserve body fluids. For cases with flaccidity of limbs, add Ramulus Taxilli, Cortex Eucommiae and radix Achyranthis Bidentatae to reinforce the kidneys and strengthen bones and tendons.

(2) Yin-deficiency and yang-hyperactivity with obstruction of meridians by blood stasis.

Manifestations: Hemiplegia, stiffness and convulsion of limbs, headache, dizziness, flushed face, tinnitus, red tongue with yellow coating and wiry and forceful pulse.

Therapeutic principles: Calm the liver, suppress yang, eliminate wind and dredge collaterals.

Prescription: The Modified Decoction of Gastrodiae and Uncariae cum Uncis

Radix Gastrodiae 10 g
Ramulus Uncariae cum Uncis 15 g
Radix Rehmanniae 15 g
Radix Achyranthis Bidentatae 12 g
Radix Salviae Miltiorrhizae 20 g
Caulis Spatholobi 20 g
Concha Halitidis (decocted first) 30 g
Radix Paeoniae Rubra 10 g
Radix Paeoniae Alba 10 g
Retinervus Luffae Fructus 10 g

(1) Obstruction of meridians of wind-phlegm

Manifestations: Stiffness of tongue, dysphasia, curled tongue, or dysphasia, limited movability o numbness of extremities, dull or red tongue with white or yellow greasy coating and wiry and smooth pulse.

Therapeutic principles: Eliminate wind and phlegm, dredge collaterals and ease the orifices.

Prescription: The Modified Pill of Jieyu Rhizoma

Gastrodiae 10 g
Scorpio 6 g
Rhizoma Arisaema cum Bile 10 g
Rhizoma Acori Graminei 10 g
Radix Polygalae 10 g
Radix Curcumae 10 g
Rhizoma Pinelliae 10 g
Lumbricus 10 g
Radix Salviae Miltiorrhizae 30 g
Pericarpium Citri Reticulatae 10 g

(2) Consumption of kidney-essence

Manifestations: Aphasia, soreness and weakness of lumbus and knees, palpitation, shortness of breath, small and thin or curled tongue with white coating and deep and thready pulse.

Therapeutic principles: Nourish yin, tonify the kidneys and ease the orifices.  

Prescription: The Modification of Rehmanniae Decoction

Radix Rehmanniae Praeparata 20-30 g
Fructus Corni 12 g
herba Dendrobii 12 g
Rhizoma Acori Graminei 10 g
Radix Polygalae 10 g
Poria 20 g
Radix Salviae Miltiorrhizae 20 g
Rhizoma Gastrodiae 10 g

(3) Hyperactivity of liver-yang and obstruction of orifices by phlegm-heat

Manifestations: Dysphasia, profuse salivation, expectoration of thick yellow sputum, headache, dizziness, red tongue with yellow coating and wiry, smooth and forceful pulse.

Therapeutic principles: Calm the liver, suppress yang, eliminate phlegm and wake up the patient from unconsciousness.

Prescription: The Modified Decoction for Calming the Liver and Eliminating Wind

Rhizoma Gastrodiae 10 g
Ramulus Uncariae cum Uncis 20 g
Scorpio 6 g
Radix Curcumae 10 g
Rhizoma Acori Graminei 10 g
Radix Polygalae 10 g
Rhizoma Arisaema cum Bile 10 g
Fructus Trichosanthis 20 g

(c) Distortion of face

Manifestations: Deviation of eyes and mouth, usually resulting from obstruction of collaterals by wind-phlegm.

Therapeutic principles: Eliminate wind, dissipate phlegm and dredge collaterals.

Prescription: The Modification of Powder for Treating Face Distortion

Rhizoma Typhonii 10 g
Bombyx Batryticatus 10 g
Scorpio 6 g
Retinervus Luffae Fructus 10 g
Poria 15 g
Rhizoma Gastrodiae 10 g

Experiential Prescriptions

A. Spina Gleditsiae (250 g) and Radix Notoginseng 915 g) prepared as powder; mix 30-50 grams of the powder with vinegar to form a paste and prepare as a plaster over a low fire; spread the plaster on a cloth, and apply it to the corner of the mouth on the affected side while the plaster is still warm; change the dressing every 3 to 7 days. This is applicable to cases with distortion of the face.

B. Equal amount of Radix Angelicae Sinensis, Rhizoma Chuanxiong, Flos Caryophylli, Herba Asari, Fructus Piperis Longi and Radix Angelicae Dahuricae prepared as a fine powder; the powder is introduced into the nostril of the unaffected side with a cotton ball. This is also applicable to cases with distortion of the face.

Copyright 1995 Hopkins Technology