In TCM, pterygium is called nŭ ròu pān jīng (excrescence creeping over the eye), which is discussed in the third passage of the Essentials from the Silver Sea ( Yín Hăi JīngWēi, 银海精微). The membranous growth is called mă huáng jī (leech accumulation), referring to its curved and triangular shape.

The description at the beginning of this chapter makes it obvious that the disease is the result of virtually every permutation of heat with the exception of damp-heat. Wind heat, stomach and spleen heat, heart fre and yin defciency with excessive fre all factor into the development of pterygia.

Pterygium tends to occur in people who are depressed and over think or worry at night. Those who overindulge in food and drink and have a generally decadent lifestyle, which causes the triple jiao to accumulate heat, ³ will also be predisposed. Thus, an underlying pattern of spleen and stomach deficiency combines with qi stagnation and liver heat, which, consequently, scorch the spleen and stomach yin fluids. Ultimately this leads to blood stagnation in the inner canthus and the pterygium develops.

The patterns of spleen yin deficiency [ pí yīn xū] and spleen heat [ pí rè] are infrequently discussed. ⁴ This pattern is a consequence of stomach yin deficiency. Injured stomach yin-fluids lead to injury of the spleen yin, causing dryness, which in turn induces thirst, burning epigastric pain and constipation. The tongue will be reddish, with litle moss and many small cracks.

The pathogenesis of the pterygium closely parallels the theory of Yin Fire discussed in Li Dong-yuan’s Treatise on the Spleen and Stomach ( Pí Wèi Lùn, 脾胃论). The following is a brief summary of his theory: A combination of poor diet, irregular lifestyle and emotional strain damage the spleen and stomach qi. ⁴ The spleen loses its normal transportive movement of raising the pure and descending the turbid, causing damp accumulation in the lower jiao. Depressive heat stirs the ministerial fire that ascends, causing heat in the upper jiao.

Another factor to consider is that the disease originates from the inner canthus; thus, according to fve-wheel theory, we know that the heart channel is afected. This circles back to Qin Bo-wei’s emphasis on frst identifying the location of the disease and then discriminating the patern presentation.

For the primary case, we start with the patient’s constitutional presentation, which is robust. Then we consider the disease location, which is the inner canthus, and finally his symptoms, which reflect a pattern of heat. Working with a diagnosis of heart fre blazing, the formula selection is supplemented Dăo Chì Săn and Sān HuángXiè Xīn Tāng.

We can tie this discussion together by referring to the frst passage of the Essentialsfrom the Silver Sea. In discussing Red Vessels That Spread from the Inner Canthus to theEyeball, the author explains that the condition indicates that excessive heart fire invades the liver. The heart is associated with the fre phase and controls blood, and the liver is associated with the wood phase and controls the tendons. ³ The tendons obtain blood (from the heart) and over time will grow to cover the black part (the cornea) of the eye. In this case, the tendons most likely refer to the red vessels in the eye. The causative factor is ministerial fire that flares upwards. Alternately, mental fatigue or heavy drinking and excessive consumption of spicy, greasy food will lead to the development of pterygium.

For the primary case, the formula begins with Dăo Chì Săn, which drains heart fire through urination. The indications for the formula encompass the full scope of symptoms of heart fre afecting the body, the spirit, and the heart channel. Symptoms include thirst for cold beverages, mouth and tongue sores, irritability, insomnia and burning urination. Because heart fre scorches the collaterals, there can be symptoms of bloody urination as well as, in this case, a red and irritated inner canthus. Despite the cold nature of the formula, the formula is sweet, cooling and moistening, counterbalancing the next formula, Sān Huáng Xiè Xīn Tāng, which is commonly known simply as Xiè Xīn Tāng (Heart-Draining Decoction). This trio drains fre, dries dampness and clears fire toxin. It is considered one of the strongest fire draining formulas in Chinese medicine and its actions are primarily focused on the middle and upper jiao. It enters the blood level to stop bleeding from heat stirring the blood. Huáng lián specifcally enters the heart channel to relieve irritability and restlessness. Its drying nature is moderated by the shēng dì huáng and gān căo from Dăo Chì Săn. The combination of these two formulas drains heat and fre from the upper jiao through the stool and urination.

Jīn yín huā and lián qiào are frequently paired to expel wind heat. However, there is subtle reasoning for their inclusion: jīn yín huā is sweet and cold, thus its favor and thermal nature match dàn zhú yè. In addition to venting wind and heat, it is specifc for cooling the blood and resolving fre toxin. Its light, sweet nature is the opposite of the biter cold of huáng lián, yet it is complementary. Lián qiào also has a light and foating nature with similar actions to jīn yín huā, however, it enters the heart channel and is specifc for dispersing clumping. Thus, it supports the actions of the formula to relieve irritability and clear heat in the heart channels to relieve the pterygium. In keeping with the theme of the formula, dān pí also clears heat from the heart. It has a relationship with chì sháo, in which they clear heat from the blood and dispel stasis. It also works with shēng dì huáng to clear heat from yin defciency, and combines with dàhuáng to treat intestinal abscesses.

By the second visit, the worst of the fre symptoms have been resolved, but signs of heat remain. The formula refocuses to clear heat and generate fuids. Sān Huáng XièXīn Tāng is omited from the formula and mài dōng and xuán shēn are added. These two medicinals, along with shēng dì huáng, create the formula Zēng Yè Tāng (Humor-Increasing Decoction), shifting the focus of the entire formula from one that clears excessive heat to one that clears defciency heat and nourishes the yin-fuids.