Chinese Medicine Book Club Issue 1091
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IIntroduction: Zhang Zhongjing elaborated on the principles, methods, and prescriptions for rheumatic diseases in the ‘Essentials of the Golden Chamber’, such as spasmodic damp heat, wind stroke with joint pain, blood obstruction due to deficiency, etc. This article summarizes the differential diagnosis and treatment of rheumatic diseases as follows: Expel pathogens and eliminate dampness—Ma Huang Jia Zhu Tang (Ephedra and Atractylodes Decoction); Tonify Qi and warm the meridians, harmonize the Ying and unblock the obstruction—Huang Qi Gui Zhi Wu Wu Tang (Astragalus and Cinnamon Five Ingredients Decoction); Unblock Yang and relieve obstruction, expel wind and eliminate dampness, harmonize Ying and relieve pain—Gui Zhi Shao Yao Zhi Mu Tang (Cinnamon, Peony, and Anemarrhena Decoction); Warm Yang, disperse cold, and eliminate dampness—Wu Tou Tang (Aconite Decoction); Nourish Yin and warm Yang—Shen Qi Wan (Kidney Qi Pill). (Editor/Zhang Yajuan)
Utilizing Formulas and Methods from the ‘Essentials of the Golden Chamber’ to Treat Rheumatic Diseases
Author/Chen Guangxing
In a broad sense, rheumatic diseases fall under the category of “Bi Zheng” (obstruction syndrome) in TCM. This includes rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and various other rheumatic diseases, some of which remain difficult to treat clinically. Zhang Zhongjing detailed the principles, methods, and prescriptions for rheumatic diseases in the ‘Essentials of the Golden Chamber’, such as spasmodic damp heat, wind stroke with joint pain, blood obstruction due to deficiency, etc. This article summarizes the differential diagnosis and treatment of rheumatic diseases as follows:
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Expel pathogens and eliminate dampness—Ma Huang Jia Zhu Tang
In the early stages of rheumatic diseases, patients often suffer from the invasion of wind, cold, and dampness. Cold and dampness obstruct the Yang Qi, leading to stagnation and pain. Clinically, this is often seen as generalized joint pain, aversion to wind and cold, absence of sweating, abdominal distension, poor appetite, or loose stools, with a floating and tight pulse.
This condition is similar to the syndrome treated with Ma Huang Jia Zhu Tang in the section on spasmodic damp heat. The treatment involves inducing sweating to disperse cold and expel dampness. In the formula, Bai Zhu (Atractylodes) eliminates dampness, while Ma Huang (Ephedra) induces sweating without causing excessive sweating; Bai Zhu works with Ma Huang to expel dampness from both the exterior and interior. This formula is suitable for the initial onset of rheumatic diseases with wind-cold on the exterior. Clinically, if wind is predominant and the pain is migratory, Qiang Huo (Notopterygium) and Fang Feng (Siler) can be added; if dampness is predominant, Fang Ji (Stephania) and Fu Ling (Poria) can be added; if cold is predominant, Chuan Wu (Aconite) and Liu Ji Nu (Liu Ji Nu) can be added.
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Tonify Qi, warm the meridians, harmonize Ying and unblock obstruction—Huang Qi Gui Zhi Wu Wu Tang
In rheumatic diseases such as cervical spondylosis and lumbar spondylosis, numbness and pain in the limbs are often seen, which can be triggered or worsened by cold. The limbs may feel weak and painful, with a pale and swollen tongue and a weak pulse. The pathogenesis is often due to deficiency of both Qi and blood, Qi deficiency leading to blood stagnation, and insufficient nourishment of the skin and muscles, resulting in numbness. The symptoms and pathogenesis are similar to blood obstruction, where “blood obstruction is characterized by both Yin and Yang being weak, and the pulse at the cun position is weak; the external manifestation is numbness of the body, resembling wind obstruction, and Huang Qi Gui Zhi Wu Wu Tang is the main treatment.” In this formula, Huang Qi (Astragalus) tonifies the Wei Qi and promotes Qi circulation; Gui Zhi (Cinnamon) warms the meridians and unblocks Yang, assisting Huang Qi to reach the exterior and warm the blood vessels; Shao Yao (Peony) promotes blood circulation and nourishes Yin blood; Sheng Jiang (Ginger) and Da Zao (Jujube) disperse wind and cold, nourish the Ying blood, and harmonize the Ying and Wei. Although this formula does not heavily use blood-activating herbs, the underlying pathogenesis is due to Qi deficiency leading to poor blood circulation, hence the use of Qi tonification and blood activation; when Qi moves, blood moves. Huang Qi is used to guide Yin out to Yang, achieving the effect of warming Yang and unblocking obstruction. Clinically, if wind Qi is strong, Fang Feng, Chuan Xiong (Szechuan Lovage), Hong Hua (Carthamus), and Ji Xue Teng (Spatholobus) can be added to activate blood and dispel wind; if heat is significant, Bai Hua She She Cao (Hedyotis) and Huang Qin (Scutellaria) can be added to clear heat; if pain is severe, San Qi (Notoginseng) and Jiang Huang (Turmeric) can be added to activate blood and relieve pain.
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Unblock Yang, relieve obstruction, expel wind and eliminate dampness, harmonize Ying and relieve pain—Gui Zhi Shao Yao Zhi Mu Tang
In the mid-stage of rheumatic diseases, due to the stagnation of wind, cold, and dampness transforming into heat, or if the patient’s organs and meridians have accumulated heat, and they are again exposed to wind, cold, and dampness, Qi becomes obstructed, leading to a mixture of cold and heat, deficiency and excess. The invasion of wind, cold, and dampness leads to Qi and blood stagnation, which, over time, transforms into heat, consuming the muscles, resulting in the coexistence of cold and heat, recurrent episodes, depleting Qi and injuring Yin, damaging the spleen, stomach, liver, and kidneys, with deficiency of the righteous Qi and excess of pathogenic factors, or deficiency within excess and excess within deficiency. Zhang Zhongjing elaborated on the treatment of such mixed cold-heat deficiency-excess conditions. In the ‘Essentials of the Golden Chamber: Wind Stroke with Joint Pain’, it states: “Pain in the joints of the limbs, weakness of the body, swelling of the feet, dizziness, shortness of breath, a warm sensation with a desire to vomit, Gui Zhi Shao Yao Zhi Mu Tang is the main treatment.” Clinically, this manifests as severe pain in the joints, limited mobility, localized swelling and heat in the joints, accompanied by sweating, aversion to wind, thirst, dizziness, shortness of breath, a pale tongue with a white coating, and a thin, weak pulse. In this formula, Gui Zhi, Ma Huang, and Fang Feng warm Yang and disperse cold and dampness; Shao Yao and Zhi Mu (Anemarrhena) nourish Yin; Bai Zhu and Fu Zi (Aconite) assist Yang, eliminate dampness, and relieve pain; Sheng Jiang and Gan Cao (Licorice) harmonize the stomach and regulate the middle. Together, they achieve the effects of unblocking Yang, relieving obstruction, expelling wind, eliminating dampness, and harmonizing Ying to relieve pain. Xu Zhongke in ‘Commentary on the Essentials of the Golden Chamber’ states: “Gui Zhi promotes Yang, while Zhi Mu and Shao Yao nourish Yin; although there are many herbs in this formula, the reason for naming it after these three is to demonstrate that both Yin and Yang are obstructed.” He also states: “To control the cold, the accumulated heat above must be addressed; to treat the heat, the liver and kidneys below must be unblocked, hence Gui Zhi, Shao Yao, Zhi Mu, and Fu Zi are all included.” If there are also signs of spleen and stomach disharmony, add Fu Ling (Poria) and Sha Ren (Amomum); for women with menstrual irregularities, add Yi Mu Cao (Leonurus) and Ji Xue Teng to regulate menstruation and invigorate blood; for liver and kidney deficiency, add Chuan Xuduan (Dipsacus), Sang Ji Sheng (Mulberry Mistletoe), Gan Di Huang (Rehmannia), and Nu Zhen Zi (Ligustrum) etc.; for severe pain, add Tian Qi (Notoginseng), Jiang Huang (Turmeric), and Niu Xi (Achyranthes) to activate blood and relieve pain.
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Warm Yang, disperse cold, eliminate dampness and unblock obstruction—Wu Tou Tang
Wu Tou Tang is from the section on wind stroke with joint pain, and the full formula can warm Yang, disperse cold, and eliminate dampness, primarily treating cold-damp obstruction with severe joint pain, inability to flex or extend, aversion to cold, and preference for warmth, with a white and slippery tongue coating and a submerged or slippery pulse. This condition is due to the invasion of cold-dampness obstructing the joints, causing stagnation and preventing the flow of Qi and blood. The pain from cold and the heaviness from dampness do not shift, hence the severe joint pain and inability to flex or extend. If unable to extend, the problem lies in the bones; if unable to flex, the problem lies in the tendons, indicating that both tendons and bones are affected. In this formula, Wu Tou (Aconite) is pungent and warm, driving away cold and eliminating dampness; Ma Huang disperses cold, unblocks Yang, and relieves obstruction; Shao Yao and Gan Cao regulate the meridians and alleviate pain; Bai Mi (Honey) sweetens and mitigates the toxicity of Wu Tou. The combination of these herbs allows the cold-damp pathogen to be released with sweat, achieving the effect of expelling the pathogen without harming the righteous Qi. Clinically, it is used for severe cold pain, and in addition to joint pain, it is necessary to differentiate based on the tongue appearance indicating cold-dampness or the overall coldness of the limbs, indicating internal cold-dampness. However, Wu Tou is a highly pungent and hot toxic substance, which can easily cause poisoning, so it is advisable to decoct for a longer time and appropriately increase the dosage of Gan Cao or use Bai Mi to mitigate its toxicity, ensuring safe use of the medicine.
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Nourish Yin and warm Yang—Shen Qi Wan
The kidneys govern the bones, the liver governs the tendons, and store blood. Deficiency of liver and kidney leads to insufficient essence and blood, resulting in inadequate nourishment of the tendons and bones, which can lead to deformities and functional limitations of the limbs, as described in the ‘Essentials of the Golden Chamber: Wind Stroke with Joint Pain’: “The pulse at the cun position is submerged and weak; submerged indicates the kidneys, weak indicates the liver. Sweating and entering water is like water injuring the heart; yellow sweat from the joints indicates the presence of wind stroke.” On the other hand, this deficiency makes it easy to be invaded by wind, cold, and dampness, leading to obstruction of the Ying and Wei. The deficiency of liver and kidney essence and blood interacts with the invasion of wind, cold, dampness, phlegm, and stasis, where the early invasion of wind, cold, dampness, and heat obstructs the muscles and blood vessels, and over time, it settles in the liver and kidneys, causing simultaneous disease of the tendons and bones, leading to bone damage and tendon spasms. In the later stages, the deficiency of liver and kidney essence and blood cannot nourish the muscles and bones, and the wind, cold, dampness, and heat pathogens become entrenched, exacerbating the growth of pathogenic factors. Clinically, this often presents as a pale complexion, fatigue, weakness, soreness of the lower back and knees, joint pain, swelling, deformity, limited mobility, morning stiffness of the joints, edema of the lower limbs, frequent night urination, and scant menstrual flow in women, with a pale tongue, white coating, and tooth marks on the edges, and a thin, weak pulse. Nourishing the liver and kidneys and harmonizing the Ying and Wei is key to treating the later stages of obstruction syndrome, which addresses the root cause, and can be achieved with Ba Wei Shen Qi Wan (Eight Ingredients Kidney Qi Pill) with modifications. If Qi and blood deficiency is also present, Huang Qi, Dang Shen (Codonopsis), Ji Xue Teng, and He Shou Wu (Polygonum) can be added; if Yin deficiency is present, Nu Zhen Zi, Han Lian Cao (Eclipta), and Yu Zhu (Polygonatum) can be added; if there is poor appetite and abdominal distension, add Si Jun Zi Tang (Four Gentlemen Decoction) along with Ji Nei Jin (Chicken Gizzard Lining), Sha Ren (Amomum), and Gu Ya (Barley Sprouts) to strengthen the spleen and stomach, consolidating the postnatal foundation, promoting the generation of Qi and blood, which can often improve the patient’s constitution, alleviate pain, and achieve the effect of “strengthening the spleen can eliminate dampness, and abundant Qi can naturally dispel stubborn numbness.”
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