Rheumatism results when genuine Qi is deficient so that Wind, Cold, Dampness, or Heat is able to invade and block the meridians, muscles and joints. This blockage impedes the flow of Qi and blood and results in aching pain, numbness, heaviness, burning or reduced mobility of the bones, joints and sinews. In more severe cases, there may be swelling or changes in shape. Rheumatism is also regarded as a Bisyndrome.
Etiology and Pathology
Rheumatism results from invasion by Wind, Cold, Dampness or Heat when the body’s genuine Qi is deficient. The illness is located in the tendons, muscle, bones and joints. Several visceral organs are intimately involved, since the liver is in charge of the tendons, the spleen is in charge of the muscles, and the kidney is in charge of the bones.
Genuine-Qi Deficiency. This may be due to chronic weakness of the constitution from imbalance between work and leisure or malnutrition following an illness. In females it may occur during menstruation or following parturition. When genuine Qi is deficient, resistance is compromise and attack by exogenous pathogenic evil is facilitated.
Invasion by Wind, Cold, Dampness and Heat. The most common circumstances are residing in humid and damp places, wading through water or being caught in rain, exposure to wind while sweating, and drastic changes in weather, especially marked fluctuations in cold and heat. When an exogenous evil invades and lodges in the meridians, it can lead to rheumatism by impeding the flow of Qi and blood through the sinews. Because four exogenous evils are implicated there are four main types of rheumatism: Wind-rheumatism, also known as migratory rheumatism, Cold rheumatism, Dampness-rheumatism, and Heat-rheumatism. These are not exclusive, and each may manifest some features of another. In particular, Heat is often transformed from another exogenous evil, either from prolonged accumulation of Wind, Cold or Dampness or as complication of Yang excess or Yin deficiency.
In all forms of rheumatism, the key pathologic mechanism is blockage of the meridians with impedance of the flow of Qi and blood.
If rheumatism becomes protracted, three patterns of consequences may develop. (1) Blood stasis may develop and fluids may gel and form Phlegm as a result of the chronic impedance of Qi and blood flow. Intermingled static blood and Phlegm block the meridians and channels and may lead to deformity and swelling of joints with ecchymosis in the overlying skin. (2) Consumption of Qi and blood leads to consequent liver and kidney insufficiency. (3) The illness extends from the meridians to the zang-fu viscera, producing so-called zang-fu-rheumatism.
Clinical Manifestation
The key symptom is the abrupt or gradual appearance of pain in the joints and sinews in the limbs. Typically, there is also compromised mobility of the joints.
Rheumatic pain presents several different patterns. It may be migratory with aversion to cold or wind. It may be exquisite, aggravated by cold and ameliorated by warmth. It may be heavy in quality, with heaviness and reduced mobility in the hands and feet, or numbness. It may be mainly limited to the joints, with a burning quality to the pain and spasm in the sinews. The pain may be excruciating and accompanied by swelling and deformity of the joint. It may be continual but vague, with prominent numbness and accompanied by weakness and palpitation of the heart.
The progression of rheumatism is variable. It may begin in the upper body before the lower, or vice versa.
Key Points of Analysis
Rheumatism is a condition of exogenous pathogenic evils invading a body that is already deficient in genuine Qi. Thus it tends to show symptoms of both disease evil strength and deficiency. The main task of differential diagnosis is to identify the type of rheumatism. There are five main types, four of which are based on the predominant exogenous pathogenic factors. The fifth type, called wasting rheumatism, is a sort of common syndrome of protracted rheumatism.
Heat-rheumatism tends to begin abruptly. Its main characteristics are local redness, swelling and burning pain in the affected joint. There may be fever, a red tongue with yellow coating, and a rapid pulse. In contrast, the other types tend to begin more gradually and do not have local inflammation or associated fever.
In Wind-rheumatism the joint pain is characteristically migratory, affecting different joints at different times, because of the changeable nature of Wind. For this reason it is also known as migratory rheumatism.
Cold-rheumatism, also known as pain-rheumatism, characteristically does not migrate but affects one or several specific joints. Cold tends to contract and gel, and it readily blocks meridians and channels.
Because Dampness is heavy and turbid and also gels readily, the characteristics of Dampness-rheumatism are swelling, heaviness, pain and numbness in the affected joints and adjacent sinews. Dampness-rheumatism is also known as fixed rheumatism.
In rheumatism caused by Wind, Cold or Dampness, the tongue coating is mostly white and the pulse mostly even or impeded. It is usually worse on overcast or rainy days.
If rheumatism becomes protracted, the liver and the kidney may become insufficient and the meridians and channels blocked by gelled Phlegm or static blood. The affected joints become swollen, deformed and rigid, with wasting of adjacent soft tissues. This is wasting rheumatism.
Herbal Treatment
Wind (Migratory) Rheumatism
Main Symptoms. Aching pain that migrates between the joints of the body and the limbs. During the initial acute phase there may be redness and swelling, or wind-intolerance. The tongue coating is thin and white, and the pulse floating.
Therapeutic Principle. Dispel Wind and unblock channels, assisted by the mobilization of blood.
Treatment. Fangfeng Tang (Saposhnikovia Decoction). It has the following basic composition: fangfeng (Saposhnikovia) 10 g, Qinjiao (Gentiana) 6 g, mahuang (Ephedra) 6g, rougui (Cinnamomum) 6g, danggui (Angelica) 10 g, gegen (Puer-aria) 10 g, fuling (Poria) 10 g, shengjiang (Zingiber) 10 g, gancao (Glycyrrhiza) 10 g, and dazao (Ziziphus) 6g.
If rheumatic pain is mainly in the joints of the upper limbs, add Qianghuo (Notopterygium), baizhi (Angelica dahurica), weilingxian (Clematis) and chuanx-iong (Ligusticum) to dispel Wind and unblock the channels.
If rheumatic pain is mainly in the joints of the lower limbs, add niuxi (Achyran-thes), duhuo (Angelica pubescens) fangji (Stephania) and mugua (Chaenomeles) to unblock meridians and channels.
If rheumatic pain is mainly in the joints of the lumbar spine, add duzhong (Eucommia), xuduan (Dipsacus), sangjisheng (Loranthus) and bajitian (Morinda) to warm and restore the lumbar spine.
Cold (Pain) Rheumatism
Main Symptoms. Severe pain in the joints of the limbs, fixed in location, aggravated by cold and ameliorated by warmth; reduced mobility in the joints; and absence of redness, warmth or swelling in the affected joints. The tongue coating is white, and the pulse is taut and tight.
Therapeutic Principle. Dispel cold and warm the meridians, assisted by the harmonization of Nutritive-Qi.
Treatment. Wutou Tang (Aconitum Decoction). It has the following basic composition: processed wutou (Aconitum carmichaeli) 5g, mahuang (Ephedra) 5g, huangqi (Astragalus) 30 g, baixhaoyao (Paeonia) 10 g, and gancao (Glycyrrhiza) 10 g. (Note: wutou is the tuberous root and fuzi the secondary root of Aconitum carmichaeli. Processed fuzi is usually preferred to processed wutou.)
If pain is intense, add processed fuzi (Aconitum carmichaeli), ganjiang (Zingiber), guizhi (Cinnamomum), xixin (Asarum) and other herbs that dispel Cold and stop pain.
If protracted rheumatism has led to gelling of Cold and stasis of blood, add prepared ruxiang (Boswellia), moyao (Commiphora), wugong (Scolopendra), fried chuanshanjia (Manis pentadactyla) and jixueteng (Spatholobus suberectus) to mobilize blood, unblock channels and stop pain.
Dampness-Rheumatism
Main Symptoms. Aching pain, heaviness and swelling in the joints of the limbs; numbness of adjacent tissues; generalized aches; heaviness in the hands and feet; and reduced mobility. The tongue coating is white and greasy, and the pulse soft and even.
Therapeutic Principle. Eliminate Dampness and unblock channels, assisted by the strengthening of the spleen.
Treatment. Yiyiren Tang (Coix Decoction). It has the following basic composition: yiyiren (Coix) 30 g, cangzhu (Atractylodes) 10 g, Qianghuo (Notopterygium) 10 g, duhuo (Angelica pubescens) 10 g, fangfeng (Saposhnikovia) 10 g, Sichuan wutou (Aconitum) 5 g, mahuang (Ephedra) 5 g, guizhi (Cinnamomum) 10 g, dang-gui (Angelica) 10 g, chuanxiong (Ligusticum) 10 g, shengjiang (Zingiber) 10 g, and gancao (Glycyrrhiza) 6 g.
If joint swelling is marked, add beixie (Dioscorea hypoglauca), mutong (Akebia quinata) and jianghuang (Curcuma) to promote diuresis, eliminate Dampness and unblock the channels.
For numbness of the sinews and skin, add add fangfeng (Saposhnikovia), baizhu (Atractylodes) and baishaoyao (Paeonia) to eliminate Wind and Dampness and to unblock the meridians and channels.
Heat-Rheumatism
Main Symptoms. Burning joint pain with redness and swelling, ameliorated by cold; often with fever, thirst, and palpitations of the heart. The tongue is red, with yellow and dry coating, and the pulse is slippery and rapid.
Therapeutic Principle. Cool Heat, unblock channels, dispel Wind and eliminate Dampness.
Treatment. Bai Hu Jia Guizhi Tang (White Tiger plus Cinnamomum Decoction).
If necessary to enhance the ability to cool Heat and unblock the channels, add jinyinhua stem (Lonicera), lianqiao (Forsythia), huangbai (Phellodendron chinense), fangji (Stephania) and sangzhi stem (Morus alba).
If purpuric spots appear on the skin, add mudanpi (Paeonia suffruticosa), shengdihuang (Rehmannia), chishaoyao (Paeonia) and difuzi (Kochia scoparia) to cool blood and extinguish Wind.
Wasting Rheumatism
Main Symptoms. Protracted rheumatism, joints that are swollen, deformed and stiff, with reduced mobility. In severe cases, muscle wasting and atrophy, tendon contracture, inability to extend the elbow and the knee joints; or, generalized ankylosis and disability. The tongue is dusky red, and the pulse is threadlike and impeded.
Therapeutic Principle. Strengthen the kidney and dispel Cold, assisted by the mobilization of blood and unblocking of channels.
Treatment. Bu Shen Qu Han Zhi Bi Tang (Kidney-Nourishing Cold-Dispelling Rheumatism-Treating Decoction). Its basic composition is as follows: xud-uan (Dipsacus) 15 g, buguzhi (Psoralea) 10 g, processed fuzi (Aconitum) 6 g, shudihuang (Rehmannia) 12 g, gusuibu (Drynaria fortunei) 10 g, yinyanghuo (Epimedium) 10 g, guizhi (Cinnamomum) 10 g, duhuo (Angelica pubescens) 12 g, weilingxian (Clematis) 12 g, and baishaoyao (Paeonia) 5 g.
If blood stasis is marked, add xuejie (Daemonorops draco), zaojiaoci (Gleditsia sinensis), ruxiang (Boswellia) and moyao (Commiphora).
If bone deformity is marked, add tougucao (Speranskia tuberculata) and ziran-tong (pyrite). But if the patient has a history of allergy to any drugs or seafood, these animal-derived herbs should be avoided.
For limb spasm, add animal-derived herbs such as baihuashe (Agkistrodon acutus), wushaoshe (Zaocys dhumnades), chuanshanjia (Manis pentadactyla), quanxie (Buthus), wugong (Scolopendra) and dilong (Pheretima). These are very effective in dispelling Wind from the meridians and channels, but they must not be used in large amounts.
If protracted rheumatism has led to deficiency of Qi and blood and insufficiency of the liver and the kidney, the therapeutic approach requires both attacking the rheumatism and restoration of the deficient. At the same time as dispelling the exogenous pathogenic evils treatment must include such formulas as Ba Zhen Tang (Eight Treasures Decoction), Zuo Gui Wan (kidney-Yin-Augmenting Pill) or You Gui Wan (kidney-Yang-Augmenting Pill) to restore Qi and blood and nourish the liver and the kidney.
Acupuncture Treatment
For rheumatism due to Wind, Cold or Dampness, apply both acupuncture and moxibustion. For rheumatism due to Heat, apply acupuncture without moxibustion and bloodletting as appropriate.
The selection of acupoints depends on the location of disease.
Shoulder: Jianliao (SJ-14), Jianyu (LI-15) and Naoshu (SI-10).
Elbow: Hegu (LI-4), Quchi (LI-11), Tianjing (SJ-10), Waiguan (SJ-5) and Chize (LU-5).
Wrist: Yangchi (SJ-4), Waiguan (SJ-5), Yangxi (LI-5) and Wangu (SI-4).
Back and spine: Shuigou (GV-26), Shenzhu (GV-12) and Yaoyangguan (GV-3). Hip: Huantiao (GB-30), Biguan (ST-1), Xuanzhong (GB-39) and Yanglingquan (GB-34).
Femur: Zhibian (BL-54), Futu (ST-32) and Yinlingquan (SP-9).
Knee: Dubi (ST-35), Heding (LE-2), Xiyangguan (GB-33) and Yanglingquan (GB-34).
Ankle: Qiuxu (GB-40), Shenmai (BL-62), Kunlun (BL-60) and Zhaohai (KI-6). The selection of acupoints is further modified in accordance with the cause. Migratory (Wind) rheumatism: add Fengmen (BL-12), Geshu (BL-17) and Xue-hai (SP-10). Pain (Cold) rheumatism: add Shenshu (BL-23) and Guanyuan (CV-4).
Dampness-rheumatism: add Pishu (BL-20), Zusanli (ST-36) and Yinlingquan (SP-9).
Heat-rheumatism: add Dazhui (GV-14) and Quchi (LI-11).
Protracted rheumatism: add Guanyuan (CV-4), Qihai (CV-6) and Zusanli (ST-36).
Case Study
The patient was a 30-year old female who had joint pains for over a year. She carelessly exposed herself to cold and wind following parturition. Soon thereafter, she began having generalized joint aches and pains. Initially, the pain was like being jabbed with needles. It was most severe in the finger joints. She sought medical treatment on many occasions, with no relief. For the past month, her condition had worsened.
At the time of examination, all her large joints were painful, including shoulders, elbows, knees, ankles, lumbar spine and neck. All these joints had significantly reduced mobility. She was unable to sit or crouch comfortably for long. Walking was difficult. She also had aches, pain and swelling in the finger joints, so much so that she could not form a fist, dress herself or take care of ordinary daily activities. She had aversion to wind and cold. Exposure to cold or changes in the weather aggravated the pain. Appetite was reduced, but urination and defecation were both normal. Her pulse was taut and threadlike, and her tongue coating was thin but slippery.
Diagnosis. Genuine Qi deficiency following parturition; rheumatism due to Wind and Cold invasion.
Therapeutic Principle. Regulate Qi and blood, assisted by extinction of Wind and elimination of Dampness.
Treatment and Course. The prescribed formula had the following composition: danggui (Angelica) 12 g, baishaoyao (Paeonia) 9g, chuanxiong (Ligusticum) 4.5 g, shengdihuang (Rehmannia) 15 g, raw huangqi (Astragalus) 15 g, fangfeng (Saposh-nikovia) 12 g, Qinjiao (Gentiana) 12 g, sangjisheng (Loranthus) 15 g, ganjiang (Zingiber) 12 g, duhuo (Angelica pubescens) 12 g, niuxi (Achyranthes) 12 g, raw yiyiren (Coix) 24 g, and baizhu (Atractylodes) 9 g.
After over 30 daily doses, the patient showed much improvement. The pain and swelling in the finger joints resolved. The joints in the whole body no longer had pain and had full mobility. The only remaining symptom was a generalized mild ache. The prescription was continued for another half a month, with complete resolution of all symptoms.
