Abstract: RA belongs to the category of paralysis in Chinese medicine. From the pathogenesis site, RA is closely related to the liver, liver blood deficiency is an important internal cause of RA, liver loss of drainage is involved in the pathogenesis of RA, and the symptoms of liver loss of drainage such as emotional instability and depression manifested by RA also have the basis of modern medical research. The close relationship between the liver and RA was revealed.
RA (Rheumatoid art hritis; RA) is a systemic, progressive autoimmune disease with synovial arthropathy as the main cause and pathogenesis is unknown, and modern medicine has no satisfactory treatment method so far. The diagnosis and treatment of this disease in Chinese medicine are mostly based on the attack of wind, cold, dampness and heat, and phlegm stasis and paralysis. Although it has a positive effect on relieving the disease, it is still not satisfactory. The author combines his clinical experience and discusses the relationship between the liver and RA as follows, hoping to correct it for fellow patients. Wang Zhenliang, Department of Geriatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
I. The relationship between liver and RA from the location of the disease
RA is located in the joints. First of all, the joints are the connection of bones and the gathering place of tendons and veins, just as the Su Wen – Five Organs Theory says: “All tendons belong to the joints”. The liver is the master of the tendons, as stated in the Suwen (Treatise on the meridians and veins): “The food gas enters the stomach, disperses the essence in the liver, and lusts for the tendons. The liver collects blood, and the normal moistening of the liver is a prerequisite for the normal function of the tendons and veins. Secondly, RA is mainly a disease of the small joints of the hands and feet. The Su Wen – Five Organs Generation Chapter says: “The hands and feet are the division of the liver”, which means that the lesions of the hands and feet are closely related to the liver, and if the liver functions normally, the hands and feet of the division can move freely and take in and out flexibly, otherwise the lesions will be born. It can be seen from the onset of the site, RA and the liver have a close relationship.
The relationship between liver and RA from the etiology and pathogenesis
RA belongs to the category of “paralysis” in Chinese medicine. It is pointed out in Suwen Paralysis that “wind, cold, and dampness are combined to form paralysis, with wind prevailing as walking paralysis, cold prevailing as pain paralysis, and dampness prevailing as pain paralysis. In the Sui Dynasty, Chao Yuanfang said in the “Treatise on the Origin of Diseases – Wind Paralysis”: “The body is weak, the couples are open, and the wind evil is in the tendons. In the “Treatise on the Sources of Diseases and Patients – Wind and Dampness” said: “The symptoms of wind and dampness paralysis, …… by the blood and Qi deficiency is affected by wind and dampness, and become this disease. In the “Treatise on the Origin of Diseases and Conditions – Blood Paralysis”, it is said that “blood paralysis is caused by a deficiency of the body and the evil enters the Yin meridian”. In the “Danxi Xinfa” of the Jin-Yuan period, Zhu Danxi said: “Fat people have pain in the limbs and joints, mostly due to wind-dampness and phlegm-drink flowing into the meridians, while thin people have pain in the limbs and joints, due to blood deficiency”. In the Ming Dynasty, Qin Jingming’s “The Whole Needle of Young Medicine” said, “Paralysis is caused by the lack of blood in the liver and the cold and dampness in the outside, and the liver is the master of tendons and blood vessels. From the previous sages, it can be seen that the main etiological mechanism of RA is “a deficiency of the liver and kidney qi and blood, while the external evil is wind, cold, dampness, heat and dryness, and the internal evil is phlegm, blood stasis” [1]. Insufficient liver blood is the main internal cause of RA, and the loss of liver drainage is involved in the pathogenesis of RA.
1. Deficiency of liver blood is an important internal cause of RA
The liver is the main reservoir of blood, and Su Wen (Treatise on the Generation of Five Organs) says: “When a person is lying down, blood returns to the liver”, which indicates that the liver has the function of blood collection, and when a person is active, blood flows throughout the body to play a normal nourishing role; when it is quiet, blood flows to the liver. The Chinese medicine believes that the liver is the master of the tendons. If the liver has a normal blood collection function, “the foot can walk when it receives blood, the palm can hold when it receives blood, and the fingers can take in when it receives blood” (Su Wen – Treatise on the Generation of the Five Organs), the hands and feet can move freely, the fingers and palms can take in normally, and the tendons and joints can move in a proper way. On the contrary, if the liver blood is insufficient, the blood cannot flow normally, and the tendons and joints and the branches of the hands and feet are not moistened, then the stiffness and discomfort of the hands and feet joints or the swelling of the tendons and joints of rheumatoid rheumatism can be seen.
The liver is the main sea of blood, and “the punching vein is the sea of blood, and women’s menstrual water and belts are all dependent on it” (Xu Lingtai). Zhang Xichen said in his book “Medicine Zhongzhong Ginseng Xilu”: “Chong is connected to the blood chamber (liver), and in women, it carries the blood of the meridians and responds to the letter of January”. Tang Rongchuan’s “Treatise on Blood Evidence” also says: “Blood is injected downward, hidden in the liver, and resides in the sea of blood”, and “the liver is the main reservoir of blood and moves downward to the middle of the cell and the sea of blood”. During pregnancy, blood gathers in the uterus to nourish the fetus, so the Sea of Blood is sufficient and the tendons and joints are not deprived of moistening, so RA can be relieved at this time; after childbirth, blood is lost and Qi is depleted, or blood is turned into breast milk, so the Sea of Blood is insufficient, so the disease is easy to recur. This is the mechanism of Chinese medicine that RA occurs more often in women and the disease is relieved during pregnancy and easily recurs after delivery.
2. Loss of drainage of the liver is involved in the pathogenesis of RA
The liver is responsible for draining and regulating the qi flow. When the liver functions normally, the qi is regulated. Qi is the master of blood and blood is the mother of qi. If qi moves, blood moves; if qi stagnates, blood clots. If liver qi is not dredged, qi stagnation for a long time, blood astringent and not smooth, not dredged qi will lead to stagnant blood; stagnation for a long time, blood in the fluid side seepage, and can produce phlegm and dampness. If stagnant phlegm and stagnant blood are combined with wind, cold, dampness and heat in the joints and block the meridians, “phlegm and stagnant blood can cause joint enlargement, ankylosis and deformity” [2], which is also a typical symptom of RA in the late stage.
The liver is responsible for draining and has an important regulatory role in the function of the spleen and stomach. If the liver drains normally, the qi of the middle jiao will be smoothly mediated, and the water and grain essence and water fluids will be properly distributed; on the contrary, water and dampness will stay, gather phlegm and turn into turbidity, and flow into the joints; or if the blood vessels are blocked for a long time, the joints may be enlarged or deformed due to phlegm stasis and paralysis. The liver is the organ of wind and wood, and the spleen is the capital of the central state, so the liver is responsible for wind and the spleen is responsible for dampness, and wind-dampness is the main cause of RA. It can also be triggered by external evil [3]. This is evident from the malfunction of the spleen due to the derangement of liver drainage, which leads to RA.
The liver is responsible for draining and regulating the emotions. On the other hand, due to the long-term torment of RA, joint pain or swelling and deformity, patients are unable to take care of themselves, their self-confidence and dignity are affected, and they are depressed and unhappy, which in turn can cause liver Qi to become unrestrained and Qi to become stagnant. Some studies have shown that 41% of RA patients have depressive symptoms [4].RA patients are mostly introverted, more sensitive, anxious and depressed, and often accompanied by emotional anxiety and aggravation when depressed, especially in female patients, whose emotional factors are more prominent [5].Weismann et al [6] found that the incidence of depression in RA patients was 21%-34%, which was significantly higher than the normal population ( 5.6%), and that depression has a more pronounced effect on RA patients and is very closely related to the clinic. It clearly illustrates the relationship between liver loss and the development of RA.
The relationship between liver and RA from the perspective of liver-kidney homology
RA disease is located in the joints, which are composed of tendons and bones. The liver is the master of tendons and the kidney is the master of bones, so RA is closely related to the liver and kidney. In Chinese medicine, liver and kidney are considered to be homologous. The liver stores blood and the kidneys store essence, so the liver and kidneys are homologous based on the mutual production of essence and blood. The liver stores and regulates blood to nourish the five viscera, six internal organs and all the limbs and bones, and the excess blood is transformed into kidney essence and stored in the kidneys; the essence stored in the kidneys can also be transformed into blood to supplement the needs of the liver. If the liver blood is insufficient, the kidney essence is drawn down, resulting in a deficiency of kidney essence, which cannot fill the bones and marrow to nourish the bones and joints, visible as tendon contracture and osteoporosis. Secondly, the liver and kidney meridians communicate with each other, as stated in the Nei Jing: “the kidney foot Shao Yin veins …… its straight, from the kidney up through the liver”. And the liver and kidney meridians both travel on the inner side of the body and meet at the “three yin jiao”. Third, the liver and kidneys are jointly part of the Punch and Ren chakra. This shows the importance of the liver in the development of RA.
The relationship between liver and RA from modern medical research
Emotional changes are closely related to the liver, which is due to the fact that the liver is the master of drainage. Modern medical research has also shown that RA patients have a wide range of poor mental health conditions, manifested by somatization symptoms, anxiety, depression and fear, while RA patients have poor personality characteristics, manifested by an introverted personality and emotional instability [7]. These psychological and emotional influences cause changes in the hypothalamus, endocrine system and vegetative nervous system, abnormalities in humoral hormones and enzymes, decrease in endogenous pain-inhibiting substances and increase in pain-causing substances, which prolongs the duration or increases the degree of pain, thus establishing a vicious cycle mechanism of psychology → pain → psychology [8]. Emotions lead to activation of the autonomic nervous system, mostly associated with abnormalities in the function of the central inhibitory neurotransmitters r-aminobutyric acid (GABA), dopamine (DA), serotonin (5-HT), and norepinephrine (NE) [9]. Timely emotional regulation and psychological de-escalation can improve the condition of RA. This can be regarded as a modern interpretation of the relationship between liver draining and the development of RA.
V. Treatment of RA from the liver
Based on the above understanding, the author treats RA from the liver according to the early, middle and late stages according to the different onset of RA. In each stage, according to the prevalence of wind, cold, dampness and heat, we use medicines to dispel wind, dispel cold, remove dampness and clear heat, and combine with western medicine as appropriate. Generally, the disease can be completely controlled and clinically cured in about 6 months.
Early stage: to dredge the liver and Qi, nourish the blood and open the ligaments as the method. The main drugs are: Chai Hu, Bai Shao, Radix Angelicae Sinensis, Sheng Di, Chuan Xiong, Atractylodes Macrocephalae, Poria, Peppermint, Xiang Fu, Sang Sang Sang, Qing Feng Vine, Centipede, etc.
Medium-term: to dredge the liver and activate blood circulation, resolve phlegm and open the ligaments as the method. The main drugs are: Chai Hu, Citrus Aurantium, Radix Angelicae Sinensis, Rhizoma Chuanxiong, Radix Paeoniae Alba, Radix Boswelliae Praeparata, Radix Myrrh, Radix Bupleurum, Radix Bupleurum, Radix Rehmanniae, etc.
Late stage: To nourish the liver and kidney, to promote the circulation and relieve pain. The main drugs are: Duluxiang, Mulberry, Huai Niu Knee, Eucommia, Cuscuta, Radix Angelicae Sinensis, Chuanxiong, Bai Shao, Radix Rehmanniae, Panax notoginseng, Hesperidin, Heilongjiang, Qingfeng Vine, etc.
References
1. Wang ZL. Rheumatoid arthritis. In: Wu Yiling, ed. Ligamentology [M]. Beijing: China Science and Technology Press, 2004. 580-594
2. Lu C.C., Jiao Shude, eds. Practical Chinese medicine rheumatology [M]. Beijing: People’s Health Publishing House, 1996.453
3. Qin Lin, Teng Jialin, Ye Lei, et al. Overview of research on rheumatoid arthritis from liver and spleen [J]. Shanghai Journal of Traditional Chinese Medicine, 2006, 40(3):65-67
4. Shao W-L, Wang Z-G. Psychosocial problems of patients with rheumatic diseases and their psychological care [J]. Zhongyuan Medical Journal, 2005,40(7):18-19
5. Liu FY, Zhang ZG, Liu HY, et al. Rheumatoid arthritis and psychosocial factors[J]. Chinese Journal of Mind and Body,1991,5(2):53
6. Weisman MM,Myers JK.Affective disorders in a U.S urban community[J] .Arch Gen Psychiatry, 1978, 35:1304.
7.Dai L, Tang M A, Zhang Y Z, et al. Mental health status and personality characteristics of patients with rheumatoid arthritis[J]. Chinese Behavioral Medicine Science, 1997,6(4):272-274
8. Yang M.Y.. Influence of rheumatoid arthritis on patients’ psychological factors[J]. China Rehabilitation, 2006,21(6):413-414
9. Hong Guiying, Wen Ruolan, Zhu Yumei, et al. Effect of nursing intervention on depression and anxiety in patients with functional dyspepsia [J]. Journal of Continuing Nursing Education, 2003,18(3):206