Chinese Medicine Book Club Issue 1126
One issue daily, accompanying the growth of TCM practitioners
IIntroduction：This article should be studied in conjunction with the article “Using the Formulas and Methods from the “Essentials of the Golden Chamber” to Treat Rheumatic Diseases”. (Editor/Zhang Yajuan)
Exploration of the Treatment of Rheumatic Diseases in the “Essentials of the Golden Chamber”
Author/Lin Changsong
Rheumatic diseases, abbreviated as rheumatism, refer to disorders characterized primarily by pain in muscles, tendons, and joints, falling under the category of Bi syndrome in TCM. The “Essentials of the Golden Chamber” first introduced the term “rheumatism”, and discussions regarding rheumatic diseases can be found in sections on damp diseases, blood bi, joint diseases, deficiency labor, and phlegm fluid diseases. Its principles, methods, formulas, and medicines have greatly influenced later generations and continue to effectively guide clinical practice, which will be organized and discussed below.
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Etiology and Pathogenesis
Zhongjing adheres to the “Inner Canon” stating that “wind, cold, and dampness combine to form bi”, believing that wind, cold, and dampness are external pathogenic factors, but he emphasizes that “wherever the evil gathers, the qi must be deficient”, highlighting “deficiency of righteous qi” as the internal cause.
1. Wind, cold, and dampness invade, causing pain when obstructed
When wind, cold, and dampness invade, they flow through the meridians and joints, obstructing the circulation of qi and blood, leading to pain. Damp diseases manifest as “wind and dampness clashing, causing pain throughout the body”, while joint diseases present as “pain in all joints” due to the obstruction caused by rheumatic evil. Cold dampness in the kidneys results in “cold pain below the waist”, indicating the retention of cold dampness in the lower jiao.
2. Deficiency leads to susceptibility to evils
“Deficiency” refers to deficiency of righteous qi, which is a prerequisite for the occurrence of rheumatic diseases. Zhongjing repeatedly emphasizes the deficiency of defensive qi, the looseness of the pores, or insufficient qi and blood, allowing the invasion of wind, cold, and dampness, leading to joint diseases, yellow sweat disease, blood bi, etc. For example, “sweating while entering water, as if water harms the heart, yellow sweat appears in joint diseases, hence the name joint disease”; “in robust individuals, the pulse is thin and small… joint pain, unable to bend or stretch, is caused by drinking alcohol and sweating in the wind”; yellow sweat disease “is caused by sweating while bathing in water, with water entering through the sweat pores”; “rheumatism, this disease is caused by sweating in the wind, or prolonged exposure to cold”; “those of high status, with weak bones and abundant skin, are particularly susceptible to fatigue and sweating, lying still and being disturbed by a slight breeze, thus acquiring this disease”; “the Shaoyin pulse is floating and weak, weak means insufficient blood, floating means wind, wind and blood clashing leads to pain”. Causes of deficiency include congenital insufficiency, prolonged illness, postpartum blood loss, irregular sexual activity, and dietary habits.
3. Insufficient liver and kidney qi and blood lead to pain
Deficiency of liver and kidney essence, insufficient qi and blood, and inherent yang deficiency lead to pain in the limbs and joints due to the meridians being unable to nourish and warm them. For instance, kidney qi deficiency results in “deficiency labor and low back pain”. “If the patient’s pulse is… floating at the back, the disease is internal, with low back pain and stiffness, indicating kidney deficiency and insufficient essence”. Joint diseases indicate “the pulse is weak, indicating insufficient blood”, elucidating that the pathogenesis is due to insufficient liver and kidney qi and blood, leading to inadequate nourishment of the tendons and bones.
4. Body constitution and different evils combine
Individuals with a constitution of excess yang, having internal heat, are prone to transforming heat or being susceptible to wind and damp heat after exposure to wind, cold, and dampness; “robust individuals” with phlegm dampness are prone to internal and external dampness; those with yang deficiency are easily affected by cold.
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Pattern Differentiation Characteristics
Pattern differentiation and treatment are the essence of Zhongjing’s theory. Zhongjing’s differentiation of rheumatic diseases employs the theories of yin and yang, exterior and interior, deficiency and excess, cold and heat, organs, meridians, and the three jiaos from the “Inner Canon” to clarify the etiology, nature, location, and severity of the disease, focusing on the following three aspects.
1. Differentiating disease nature
Wind, cold, and dampness are the main pathogenic evils of rheumatic diseases, with different manifestations depending on the predominance of wind, cold, or dampness. Wind is characterized by its ability to change rapidly; when wind predominates, it manifests as migratory pain in multiple joints; wind is also the leader of all diseases, and when it causes illness, it is often accompanied by cold and dampness; wind is dry and fierce, and when combined with dampness, it can easily injure yin and transform into heat. For instance, damp diseases manifest as “wind and dampness clashing, causing pain throughout the body”; rheumatic joint diseases present as “pain in all limbs and joints… dizziness and shortness of breath, with a desire to vomit”, often accompanied by low fever, dry throat, and dry mouth, indicating a combination of wind and dampness, with prolonged illness leading to yin injury and heat transformation. Dampness is sticky and heavy; when dampness predominates, it leads to swelling or a feeling of heaviness in the body, such as when dampness flows into the limbs and muscles, causing “heavy body pain”; in cases of heat stroke combined with dampness, it obstructs the muscles and meridians, leading to “heavy and painful body”; yellow sweat disease indicates dampness obstructing the skin, leading to “heavy body pain”; and the symptoms of “wind and dampness, floating pulse, and heavy body” are all manifestations of dampness predominating. Cold is constricting and stagnating; when cold predominates, it causes pain. Exposure to cold evils can easily lead to stagnation of qi and blood, resulting in limb pain, as seen in cold damp joint diseases, which prominently present as “pain in the joints, unable to bend or stretch”. Damp diseases with wind and dampness manifest differently from those with wind and cold. For example, “in exterior cold diseases, joint pain is accompanied by restlessness, with a pulse that is deep and thin, indicating damp bi”, showing that wind and cold primarily harm the muscles, while dampness easily flows into the joints, obstructing yang qi, leading to joint pain and restlessness. Only by clarifying the nature of the pathogenic evil can one establish the correct treatment method, whether to dispel wind, scatter cold, or eliminate dampness.
2. Differentiating disease location
The “Essentials of the Golden Chamber: Diseases of the Organs and Meridians” states: “There are countless diseases, but they fall into three categories: first, when the meridians are invaded by evils and enter the organs, causing internal issues; second, when the limbs and nine orifices are obstructed, causing external skin issues; third, when injuries occur from sexual activity, sharp instruments, or insects and beasts.” It can be seen that Zhongjing distinguishes between internal and external evils, indicating that when differentiating patterns, one must first clarify whether the disease is superficial or deep, in the organs or the meridians. For instance, in damp diseases, differentiating wind and dampness at the surface corresponds to the Ma Huang Jia Zhu Tang formula; at the upper level corresponds to the Ma Xing Yi Gan Tang formula; and dampness in the interior and lower levels indicates that “in cases of damp bi, if urination is not smooth and defecation is frequent, one should focus on promoting urination”. By clarifying the disease location, treatment can be guided accordingly, using methods such as mild sweating for superficial wind-dampness, dispersing lung qi for upper issues, and promoting urination for middle and lower issues.
3. Differentiating deficiency and excess
Deficiency and excess are the criteria for distinguishing the strength of righteous qi and the decline of pathogenic qi, determining the basis for treatment, and are of great significance in guiding clinical treatment. The first chapter of the “Essentials of the Golden Chamber” cites: “Do not let ‘deficiency and excess’ be confused; one should ‘supplement the insufficient and reduce the excessive'”. This highlights the importance of distinguishing deficiency and excess. In damp diseases with wind and dampness at the surface, Zhongjing lists the Ma Huang Jia Zhu Tang formula for excess at the surface, the Gui Zhi Fu Zi Tang formula for deficiency of yang at the surface, and the Gan Cao Fu Zi Tang formula for deficiency of both surface and interior yang. This elucidates the spirit of treating the same disease differently and treating deficiency and excess differently. Furthermore, he states, “Even if the patient has pain, one should not induce sweating”, indicating that in cases of chronic sores, with deficiency of fluids and blood, and re-invasion of external evils, sweating methods should not be used. Thus, Zhongjing’s approach to differentiating deficiency and excess is meticulous. In the early stages of illness, there is often excess, while prolonged illness leads to a transition from excess to deficiency, with a mixture of deficiency and excess. The Gui Zhi Shao Yao Zhi Mu Tang formula for rheumatic joint diseases indicates that with prolonged rheumatism, righteous qi is deficient, gradually transforming into heat and injuring yin, leading to mixed symptoms of deficiency and excess: “pain in all limbs and joints, emaciation, swelling of the feet, dizziness, shortness of breath, and a desire to vomit”. There are also cases of blood bi with more deficiency than excess, treated with the Huang Qi Gui Zhi Wu Wu Tang formula; severe deficiency is treated with the Xiao Jian Zhong Tang formula or Shen Qi Wan formula. It is essential to clarify the degree of deficiency and excess, whether to dispel evils, supplement deficiency, or apply both attacking and supplementing methods.
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Treatment Principles and Methods
1. Mild sweating method
This is a method that follows the situation. When the rheumatic evil is located at the skin surface, inducing sweating can help expel the evil through perspiration, but due to the sticky nature of dampness, a mild sweating method should be employed. Zhongjing states: “If treating rheumatism, induce sweating, but only a slight amount, then both wind and dampness will be expelled.” Sweating methods are the primary treatment for rheumatism, and it should be done to the extent of slight sweating. Especially in Jingyun: “Mild sweating allows yang qi to steam internally without sudden release, filling the muscles and joints, thus leaving no place for damp evil to reside.” If excessive sweating occurs, the wind evil may be expelled, but damp evil will remain, leading to dryness and injuring yin, or cold transformation injuring yang. Zhongjing employs the mild sweating method to treat rheumatic diseases with the following methods:
(1) Sweating to dispel wind and excess dampness
This method is used for excess wind-dampness at the surface. Damp diseases manifest as “dampness causing body discomfort and pain; it is appropriate to use Ma Huang Jia Zhu Tang to induce sweating, but caution should be taken not to use fire to attack it”, as it is caused by the invasion of wind, cold, and dampness, leading to obstruction and stagnation of yang, resulting in body pain and discomfort. The formula uses Ma Huang, which induces sweating without causing excessive sweating; Bai Zhu helps to expel dampness from both the surface and interior.
(2) Lightly clearing and dispersing qi to transform dampness
This method promotes lung qi and disperses dampness. “If the patient has pain throughout the body, fever, and the symptoms worsen in the afternoon, it is called rheumatism… it is appropriate to use Ma Huang Xing Ren Yi Gan Cao Tang”. Wind dampness obstructs the meridians, with wind being a yang evil, and when combined with dampness, it can easily transform into heat and dryness, causing body pain and fever. If the evil is in the ying and wei, sweating should still be induced; if heat symptoms have developed, treatment should focus on lightly clearing and dispersing, resolving the exterior and expelling dampness, using the Ma Xing Yi Gan Tang formula. In this formula, the amount of Gan Cao is doubled to moderate the harshness of Ma Huang, preventing excessive sweating.
(3) Benefiting qi, securing the exterior, and eliminating dampness
“For wind dampness, with a floating pulse and heavy body, sweating and aversion to wind, use Fang Ji Huang Qi Tang”. When wind dampness is at the surface, if sweating has already occurred without medication, this indicates that the defensive qi is deficient, and the skin is not secure. Therefore, instead of using Ma Huang and others to induce sweating, Fang Ji Huang Qi Tang is used to benefit qi and eliminate dampness. In this formula, Fang Ji expels water dampness, Huang Qi warms the flesh and secures the pores, Bai Zhu and Gan Cao warm and supplement spleen qi, while ginger and jujube harmonize the ying and wei, providing both supportive and expelling functions. However, this formula primarily acts to promote diuresis, and to ensure that yang qi reaches the surface, mild sweating to expel dampness must be followed by covering the patient to “warm and induce slight sweating”, which remains a specific application of the mild sweating method.
(4) Warming the meridians, assisting yang, and dispelling wind and dampness
“If after eight or nine days of cold damage, wind and dampness clash, causing body pain and discomfort, unable to turn or lie down, with no nausea or thirst, and a floating, weak, and rough pulse, use Gui Zhi Fu Zi Tang; if the stool is hard and urination is smooth, remove Gui and add Bai Zhu Tang”. Wind, cold, and dampness are at the surface, and dampness is not dispelled, leading to deficiency of surface yang, hence the pulse is floating, weak, and rough. The treatment is to warm the meridians, assist yang, and dispel wind and transform dampness, using Gui Zhi Fu Zi Tang: Gui Zhi dispels wind, Fu Zi warms the meridians and assists yang to eliminate dampness, while ginger, jujube, and gan cao strengthen the middle qi, harmonizing the ying and wei, and supporting surface yang. This helps to expel superficial wind and dampness. If after taking the medicine, one observes “hard stool and smooth urination” but body pain persists, this indicates that the wind evil is gradually leaving, but dampness remains; however, the interior is harmonized without dampness, and dampness still exists at the surface. Therefore, remove Gui and add Bai Zhu, reducing the dosage of each herb by half, resulting in Bai Zhu Fu Zi Tang, which combines Bai Zhu and Fu Zi to expel water dampness. If symptoms present as “joint pain, unable to bend or stretch, with severe pain upon approach, sweating and shortness of breath, urination not smooth, aversion to wind, and a desire to keep warm, or slight swelling of the body”, this indicates deficiency of both surface and interior yang qi, with both wind and cold dampness being excessive, and the formula used is Gan Cao Fu Zi Tang, which warms the meridians, assists yang, dispels wind, scatters cold, and eliminates dampness, with the later statement “if slight sweating occurs, it will resolve” also belonging to the mild sweating category.
2. Promoting urination
“In exterior cold diseases, joint pain and restlessness, with a deep and thin pulse, this is called damp bi. In cases of damp bi, if urination is not smooth and defecation is frequent, one should focus on promoting urination.” When spleen yang is not functioning, internal dampness arises, leading to external dampness, which flows into the joints, and if yang qi is obstructed, joint pain occurs; dampness obstructs the qi transformation of the three jiaos, leading to difficulty in urination and frequent defecation. The treatment should focus on promoting dampness and unblocking yang, allowing the qi transformation of the three jiaos to unfold, thus dispelling dampness, which is the meaning of “promoting yang is not about warming, but about promoting urination”, and can use Wu Ling San.
3. Warming and dispersing cold
The basis of this method is found in the “Su Wen: Treatise on the True Essentials” stating, “Cold should be treated with heat”, “Guests should be eliminated”, and “Labor should be warmed”. Specifically, the following methods are employed:
(1) Warming yang and promoting circulation
This is used for blood bi due to deficiency of yang, where the exterior is not secure, and wind and cold invade, obstructing the meridians, leading to numbness and lack of sensation in the limbs. Internal treatment uses Huang Qi Gui Zhi Wu Wu Tang to warm yang and promote circulation, supplementing qi and moving blood; external treatment uses acupuncture to draw yang qi, harmonizing the pulse and promoting circulation to eliminate bi.
(2) Warming and dispersing cold dampness
For severe pain in the joints due to cold dampness, treatment involves Wu Tou Tang to warm the meridians, disperse cold, eliminate dampness, and relieve pain. In this formula, Wu Tou warms the meridians, disperses cold, and eliminates dampness to relieve pain, while Ma Huang disperses and penetrates the surface to expel cold dampness, Shao Yao promotes circulation and moves blood, combined with Gan Cao to moderate pain; Huang Qi benefits qi and secures the defensive layer, assisting Ma Huang and Wu Tou in warming the meridians to relieve pain, while also controlling the dispersive nature of Ma Huang; Bai Mi moderates the toxicity of Wu Tou. Together, they promote the circulation of yang qi and expel cold dampness.
(3) Warming the meridians, promoting circulation, dispelling wind and dampness, and assisting with nourishing yin and clearing heat
In joint diseases, wind and dampness flow through the meridians and joints, and with prolonged illness, they gradually transform into heat and injure yin. The treatment involves Gui Zhi Shao Yao Zhi Mu Tang to harmonize the ying and wei, warm yang, dispel stasis, and eliminate wind and dampness.
(4) Warming the kidneys and benefiting yang
Deficiency labor and low back pain are due to insufficient kidney yang and declining Mingmen fire, treated with Shen Qi Wan. This formula contains a large amount of kidney-nourishing herbs combined with Fu Zi and Gui Zhi to warm and supplement kidney yang, aiming to generate slight fire, warming without drying, nourishing without being greasy. This method of seeking yang within yin is a significant feature of Zhongjing’s kidney warming method, pioneering the warming and supplementing of kidney yang.
(5) Warming the spleen and building the center
“Deficiency labor… with soreness in the limbs… Xiao Jian Zhong Tang is the main treatment.” In deficiency labor, yin damages yang, or yang damages yin, ultimately leading to deficiency of both yin and yang, with qi and blood deficiency, causing pain in the limbs due to lack of nourishment. The treatment involves warming the spleen and building the center with Xiao Jian Zhong Tang, which includes sweet ingredients like Gan Cao, Da Zao, and Jiao Yi, along with the spicy warmth of ginger and gui, and the sour astringency of Shao Yao, collectively providing sweet warmth to build the center and support yang, while sour and sweet nourish yin. With the restoration of yin and yang, qi and blood are replenished, thus alleviating limb pain.
4. Clearing heat and resolving muscle tension
“For warm malaria… with bone and joint pain and discomfort… Bai Hu Jia Gui Zhi Tang is the main treatment”, indicating internal heat and external cold, with cold hidden in the tendons and joints, leading to joint pain. The treatment involves Bai Hu Tang to clear heat and Gui Zhi to resolve muscle tension and harmonize the ying and wei. This formula has been widely used in later generations to treat rheumatic heat bi.
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Conclusion
1. Focus on warming and dispersing evils
In the early stages of rheumatic diseases or during acute episodes, it is often due to the invasion of wind, cold, and dampness, which obstructs the skin surface, causing yang qi to be trapped, leading to joint pain, accompanied by chills, fever, no sweating, or ineffective sweating. At this time, only by opening the pores and inducing sweating can the wind, cold, and dampness be dispersed from the skin surface, allowing the trapped yang to flow freely, and thus alleviating the pain. Opening the pores and inducing sweating should primarily use Ma Huang. Ma Huang Jia Zhu Tang and Ma Xing Yi Gan Tang both primarily use Ma Huang. However, when paired with Bai Zhu and Yi Mi, they can induce sweating without causing excessive sweating and can also expel dampness from both the surface and interior. “Cold predominates, leading to pain”; if the patient exhibits severe joint pain and aversion to cold, indicating cold stagnation, one should warm the meridians and disperse cold, externally removing cold dampness and internally invigorating yang qi, allowing qi and blood to circulate, thus alleviating pain. The primary herbs for warming the meridians and dispersing cold are Wu Tou and Fu Zi, which are both very spicy and hot, possessing the strongest ability to dispel cold and relieve pain. Wu Tou Tang, Gui Zhi Shao Yao Zhi Mu Tang, Gui Zhi Fu Zi Tang, Bai Zhu Fu Zi Tang, and Gan Cao Fu Zi Tang all utilize Wu Tou and Fu Zi for their warming and dispersing effects to relieve pain. Modern pharmacology has proven that the alkaloids contained in Fu Zi and Wu Tou have strong anti-inflammatory and analgesic effects.
2. Supporting the righteous qi, focusing on the spleen and kidney
The spleen and stomach are the foundation of postnatal life, responsible for the transformation and transportation of water and dampness, serving as the source of qi and blood generation. If spleen and stomach qi is deficient, qi and blood will be insufficient, leading to lack of nourishment for the limbs and tendons; if spleen dampness is not transformed, it can easily combine with external dampness. Therefore, in cases of rheumatic diseases with spleen deficiency, individuals may be either thin and weak or suffer from dampness obstructing digestion, leading to swelling and pain in the joints. Throughout the treatment of rheumatic diseases in the “Essentials of the Golden Chamber”, formulas often include ginger, jujube, roasted gan cao, and Huang Qi to warm and support the spleen, or Bai Zhu, Yi Mi, Shan Yao, and Fu Ling to strengthen the spleen and transform dampness. Protecting the spleen and stomach is a major principle in the treatment of rheumatic diseases. Clinically, it is often seen that using excessively bitter and cold herbs without recognizing the need to protect the middle yang can lead to persistent abdominal pain and a transition to a stubborn deficiency condition. The kidneys are the source of congenital essence, storing essence and governing bones. The liver governs tendons, and the liver and kidneys share a common source. Kidney essence also relies on the nourishment of postnatal food essence. Wind, cold, dampness, and heat are external factors causing rheumatic diseases, while deficiency of righteous qi is the internal cause. After the onset of illness, the body is unable to expel the evils, allowing them to penetrate from the surface to the skin, muscles, and gradually deeper into the meridians, blood vessels, and bones. With deficiency of liver and kidney essence, the tendons and bones cannot be nourished, leading to weakness and retention of evils. Therefore, benefiting the kidneys and replenishing essence is a key treatment method during the stable and recovery phases of rheumatic diseases. Zhongjing established the Shen Qi Wan formula for “deficiency labor and low back pain”, pioneering the method of treating bi by supplementing the kidneys.
3. Mixed deficiency and excess, requiring both attacking and supplementing methods
Deficiency and excess represent two aspects of the struggle between righteousness and evil. In cases of mixed deficiency and excess, it is necessary to distinguish which is more prevalent to determine the focus of treatment. Zhongjing’s treatment of rheumatic diseases emphasizes supporting righteousness and dispelling evils, with a primary focus on dispelling evils.
Zhongjing’s discussions on the treatment of rheumatic diseases embody the essence of TCM pattern differentiation and treatment, with principles, methods, formulas, and medicines that continue to effectively guide clinical practice. Professor Chen Jifan, based on his years of clinical experience, applies Zhongjing’s theories and believes that the clinical manifestations of rheumatoid arthritis are similar to those of joint diseases, with the etiology and pathogenesis being due to liver and kidney insufficiency, weakness of qi and blood, and subsequent invasion of wind, cold, and dampness. The basic pathological characteristics are deficiency of righteousness with the presence of evils, and a mixture of cold and heat. The modified Gui Zhi Shao Yao Zhi Mu Tang formula has been clinically and experimentally proven to have a definite therapeutic effect on rheumatoid arthritis.
It is evident that exploring the application of classical formulas remains an effective approach in the treatment of difficult and complicated diseases.
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