Rheumatoid arthritis (RA) is a systemic autoimmune disease of unknown origin characterized by chronic inflammatory lesions of joint tissue. There is no specific treatment available. The disease belongs to the category of “paralysis” in Chinese medicine, and according to its clinical manifestations, it is similar to the ancient Chinese medical records such as “joint disease”, “white tiger joint disease”, “bone paralysis” and “stubborn paralysis”. The clinical manifestations of the disease are similar to those recorded in ancient Chinese medical texts, such as “joint disease”, “white tiger joint”, “bone paralysis” and “stubborn paralysis”.
1. Etiology and pathogenesis
According to the theory of Chinese medicine and the clinical characteristics of RA, it is believed that deficiency of liver, kidney, qi and blood is the internal cause of the disease, while the attack of wind, cold and dampness is the causative factor of the disease. In the development and regression of the disease, on the one hand, the deficiency of positive attracts evil, and the evil loves to damage positive, so repeatedly, both deficiency and reality; on the other hand, with the influence of factors such as physical superiority, medicine and food, the evil of wind and dampness may turn into heat from Yang, or cold from Yin, or loss of Yin and Yang, or loss of Yang and Yin, manifesting as a mixture of cold and heat, and deficiency of both Yin and Yang. The end is the dysfunction of the internal organs, the dampness does not resolve, phlegm and stagnation of joints and tendon injury and bone loss, limb deformity and uselessness. The basic pathology of the disease is that there is a deficiency of the positive and the evil, a mixture of cold and heat, dampness and stasis, and the disease is long-lasting. The genetic background and the role of infectious factors in the pathogenesis of RA, the immune dysfunction with the participation of multiple complex factors in the pathological process, as well as the varying degrees of anemia, hypoproteinemia, hyperviscosity and hypercoagulability of blood, elevated serum lipid peroxide, and low suppressive T cells in RA patients all reflect this etiologic and pathological feature of RA.
2. The development of “Tongzhi Ling”, a treatment for RA
As early as in the book of “Jin Kui Yao Yao” written by Zhang Zhongjing, a medical doctor in the Eastern Han Dynasty, the treatment of RA is described in the chapter of “Stroke and Stroke Disease”. In the book “The Disease of Stroke”, Zhang Zhongjing of the Eastern Han Dynasty described that the disease was caused by the deficiency of liver and kidney qi and blood, as well as by wind, cold and dampness, and that the clinical manifestations of rheumatoid arthritis were similar to those of modern rheumatoid arthritis. This formula consists of nine herbs: “four taels of cinnamon stick, three taels of peony, two taels of licorice, two taels of ephedra, five taels of ginger, five taels of atractylodes, four taels of Zhi Mu, four taels of windbreak, and two pieces of eucommia (concoction)”, which have the effect of dispelling wind and dampness, warming the meridians and dispersing cold, nourishing yin and clearing heat. It treats wind-cold-damp paralysis, which gradually turns into heat and injures yin. Pharmacological studies have also revealed that this formula has the functions of generating sweat to lower temperature, anti-inflammatory and analgesic, and regulating immunity. In view of the etiological and pathological characteristics of RA, the treatment should be based on the method of dispelling wind and dampness, warming the meridians and dispersing cold, nourishing Yin and clearing heat, and invigorating the blood and opening the channels. The original formula of Gui Zhi and Shao Yao Zhi Mu Tang is composed of Yi Shen Zi plus Chuan Wu, Yu Zhu, Boswellia, Myrrh, Strychnine and Centipede. In this formula, Gui Zhi, Ephedra and Wu Tang promote paralysis through Yang, warming the meridians and dispersing cold; Ephedra with Atractylodes can remove the dampness in the exterior and the interior, and Ephedra with Wu Tang can disperse the cold in the exterior and the interior. White peony with Zhi Mu to benefit yin and clear heat, with licorice to sour sweet yin, with white atractylodes to benefit qi and yin nourish blood; yu zhu to help white peony, nourish yin and produce fluid to nourish tendons and bones; centipede is good at running, internal organs, external meridians, where blood and qi cohesion can be opened, especially through the bones to search for wind, picking up the complex to remove evil; frankincense, myrrh shall be used for each other, can promote the internal organs, penetrate the meridians, blood circulation to remove blood stasis, soothe tendons and relieve pain; anti-feng good at dispelling wind It is good at dispelling wind and swelling; strychnine is good at dispelling swelling and pain, and dispersing blood heat; ginger, licorice and Chinese medicine. The whole formula works to dispel wind and cold, remove dampness and heat, harmonize Ying and benefit Qi, resolve blood stasis and open the channels. Clinical observation shows that Tong Piao Ling has anti-inflammatory and pain relief effects on rheumatoid arthritis and ankylosing spondylitis, regulates immune function and improves physical fitness, and can stabilize and improve bone damage and accelerate the repair of joint damage. Long-term observation has no obvious toxic side effects. Experiments have shown that Tongparin can significantly inhibit the proliferation of synovial fibroblasts and reduce the mRNA and protein expression of matrix metalloproteinase (MMP-2, -3, -9).
The combination of Tongkou Ling is made from the decoction of Southern Snake Vine and Chicken Blood Vine, which is suitable for people with severe RA.
3. Treatment by evidence
In addition to the treatment of Tong Piao Ling, according to the strengths and weaknesses of Qi, blood, yin and yang of the internal organs, and the deficiencies of heat and cold, Chinese herbal medicine should be given to treat the disease to support the righteousness and eliminate the evil, so as to control the disease quickly. Generally, the treatment can be divided into the following types of evidence.
3. 1. Cold and damp paralysis
The main evidence: pain, swelling or heaviness in the joints of the limbs, local skin color is not red, not hot to the touch, morning stiffness is obvious, joint flexion and extension is unfavorable, when cold, the pain is very painful, when hot, the pain is reduced, or see evil wind and fever, sweating, skin numbness, light or light red tongue, thin white or white thick moss, tight or floating slow pulse.
Treatment: Dispel wind and disperse cold, remove dampness and promote circulation.
Formula: Wu Tau Tang with reduction.
Prepared Wu Tau 12g, White Peony 15g, Astragalus membranaceus 15g, Fang Feng 15g, Roasted Licorice 6g, Gui Zhi 15g, Qiang Wu 12g, Dou Shu 15g, Hai Feng Vine 30g.
Addition and subtraction: if windy joints wandering pain, vicious wind, add Angelica dahurica 12g, mulberry 30g, white flower snake 1 to dispel the wind and relieve pain; cold joint pain is intense, get warm to relax, add Radix et Rhizoma Pinelliae 12g, Sinense 6g to warm the Yang to dispel cold and relieve pain; wet joint swelling and heavy, skin numbness, add Dioscorea Z 30g, Zedoary 15g, Poria bark 30g to benefit dampness and eliminate swelling.
3. 2. Damp-heat paralysis and obstruction
Main symptoms: red, swollen, hot and painful joints with fluid, morning stiffness, sore and heavy limbs, unfavorable joint flexion and extension, or with fever, bitterness, thirst, lack of appetite, red or dark red tongue with yellowish greasy coating, string or string pulse.
Treatment: Clearing heat and detoxifying toxins, relieving dampness and dispelling wind, invigorating blood and promoting circulation.
Remedy: Si Miao Wan with flavour.
Huang Bai 15g, Cang Zhu 15g, Coix Seed 30g, Chuan Niu Kne 15g, Jiang Huang 15g, Ze Lan 12g, Dioscorea Z 30g, Yin Hua Vine 30g, Fang Feng 15g, Qiang Wu 12, Dou Wu 12g.
Addition and subtraction: for very swollen joints, add 15g of Zelenia, 15g of Poria, 12g of Fangji to promote water retention and reduce swelling; for very hot and feverish joints, add 15g of Chaihu, 50g of Buffalo Horn, 30g of White Flowering Serpent’s Tongue to clear heat and detoxify; for dampness in the middle Jiao, with loose stools and thick, greasy coating, add 20g of Mian Yin Chen, 10g of Sharen (later), 30g of Tu Fu Ling to move Qi and resolve dampness; for severe joint pain, add 10g of Panax quinquefolium to invigorate blood and relieve pain. For severe joint pain, add Panax notoginseng 10g to activate blood circulation and relieve pain; for sore throat, add Radix Platycodon grandiflorus 12g, Radix Gangmuangen 30g, Glycyrrhiza glabra 10g to detoxify the throat.
3. 3, mixed cold and heat
Main symptoms: Pain or swelling in the joints of the extremities, restricted movement, or vicious cold and wind, pale or light red tongue, yellow and white tongue coating, and thin pulse.
Treatment: Dispel wind and dispel cold, remove dampness and clear heat.
Radix: Gui Zhi Shao Yao Zhi Mu Tang with addition and subtraction.
Gui Zhi 15g, Red and White Peony 15g each, Zhi Mu 12g, Fang Feng 15g, Atractylodes Macrocephala 15g, Roasted Licorice 6g, Turmeric 15g, Ze Lan 12g, Danshen 15g, Centipede 2.
Addition and subtraction: If the joints of upper limbs are seriously ill, add 18g of Mulberry, 12g of Qiangwu, 12g of Weilingxian to dispel wind and relieve pain; if the joints of lower limbs are seriously ill, add 12g of Doklam, 15g of Niu Knee, 12g of Fangqi, 30g of Dioscorea Z to clear the meridians and activate the channels, dispel dampness and relieve pain.
3. 4. Phlegm stasis blocking the ligaments
Main symptoms: Intense pain in the peripheral joints, with fixed and immovable parts, unfavorable flexion and extension of the joints, hard nodules around the joints, skin nail fault, petechiae on the limbs, thirst without desire to drink, or fever in the afternoon or at night, purple and dark tongue or petechiae, white or thin yellow tongue coating, fine and astringent pulse.
Treatment: Invigorate blood circulation and resolve blood stasis, dispel wind and overcome dampness.
Remedy: Gui Zhi Fu Ling Pill with flavor.
Gui Zhi 15g, Fu Ling 20g, Mudan Pi 12g, Red Peony 15g, Tao Ren 12g (beaten), Angelica Sinensis 12g, Chuan Xiong 12g, Wei Ling Xian 15g, Sequoia 15g, Niubizi 15g.
Addition and subtraction: if blood stasis and stagnation are more serious, add 10g of Andrographis paniculata, 12g of Dilong and 6g of Scorpion to strengthen the function of activating blood circulation; if the local swelling of the joint does not subside after a long time and is like cotton wool or cystic when pressed, add 15g of Fructus zhebeijian, 12g of Silkworm and 12g of White Mustard Seed to eliminate phlegm and disperse knots.
3. 5. Liver and kidney deficiency
Main symptoms: prolonged joint pain, soreness and coldness of the waist and knees, unfavorable flexion and extension of the joints, or constriction of the hands and feet, or joint deformity and ankylosis, dizziness and tinnitus, palpitations, muscle thinning, light red tongue with thin white fur and sunken pulse.
Treatment: Tonifying the liver and kidney, dispelling wind and clearing ligaments.
Remedy: Duluxiaoshen Tang with addition and subtraction.
Duluxiang 12g, Sang Sang Sang 30g, Fu Ling 20g, Gui Zhi 15g, Bai Shao 15g, Shu Di 15g, Angelica Sinensis 12g, Atractylodes Macrocephala 15g, Fang Feng 15g, Hossein 6g, Niu Knee 15g, Eucommia 15g, Radix et Rhizoma 15g, Gentiana Macrophylla 12g, Radix Codonopsis 20g.
Addition and subtraction: If the tongue is dark red or there are stasis spots and petechiae, add 10g of peach kernel and 10g of safflower to activate blood circulation and resolve blood stasis; if the tendons and veins of hands and feet are constricted, add 12g of papaya and 15g of stretching herbs to relax the tendons and activate the collaterals.
3. 6, deficiency of Qi and Blood
Main symptoms: Soreness and pain in the joints of the limbs, numbness of the skin, especially at night, with pain relieved after activity. It is accompanied by fatigue, less color, dizziness and tinnitus, palpitation and shortness of breath, spontaneous sweating, pale tongue, thin white fur, sunken and weak pulse.
Treatment: Benefit Qi, tonify blood, invigorate blood circulation.
Remedy: Radix Astragali, Cinnamomum Cassia, plus or minus five substances.
Huang Qi 30g, Gui Zhi 12g, Bai Shao 15g, Shu Di 15g, ginger 3 slices, jujube 10 pieces, Angelica Sinensis 12g, Niu Knee 15g, Chicken Blood Vine 30g, Radix Codonopsis Pilosulae 20g, Rhizoma Atractylodis Macrocephalae 15g, Poria 20g, roasted licorice 6g.
Addition and subtraction method: for obvious blood deficiency, with a yellowish face and pale white lips and nails, add 15g of Colla Corii Asini (closed) and 15g of Zi He Che to replenish essence and blood; for paralysis with numbness in the limbs for a long time, add 12g of Ocimum sanctum and 12g of Dilong to search for wind and open the ligaments.
4, treatment and medication experience
4.1. Supporting the righteous and dispelling the evil
RA as a whole is characterized by deficiency of Qi, Blood, Liver and Kidney, and locally in the joints is characterized by dampness, phlegm and stagnation. Therefore, the general principle of treatment should be to help the righteousness and dispel the evil, taking into account both the symptoms and the root cause. The key to improving the therapeutic effect is how to help the righteous without leaving the evil, and to eliminate the evil without harming the righteous. By examining the tongue and pressing the pulse, the combination of the whole body and the local situation can help determine the amount of deficiency and determine the scale of attack and supplementation. (1) If the tongue is light or pale, with thin white coating, the main purpose is to support the righteousness and eliminate the evil. If you see emaciation, weakness, lack of energy, lack of facial color, little appetite, swollen and deformed joints, or even swollen limbs, and weak pulse, you are suffering from weakness of the spleen and stomach, weakness of transportation and transformation, and deficiency of qi and blood, so you should supplement the middle qi to transport the four sides, so it is appropriate to supplement the middle qi soup or Huangqi Gui Zhi Wuwuwu Tang with addition and subtraction; if you are prone to cold, you can add flavor with Yu Pingfeng San to benefit qi and fix the surface; if you see soreness and weakness of the waist and knees, swollen and painful joints, or with dizziness and tinnitus, frequent urination at night, urine (2) If the tongue is pale or light red with thick moss, it is advisable to eliminate evil and take into account Yin and Yang, Qi and Blood. If the joints are swollen and painful, with morning stiffness, unfavorable flexion and extension, white fur, and thin pulse, Gui Zhi Shao Yao Zhi Mu Tang should be used to dispel wind and remove dampness, and to promote Yang and Ying; if the fur is yellow, Er Miao Wan should be used to clear heat and dry dampness. If the tongue is pale and the moss is white and thick, the joints are swollen, painful and cold, and the pulse is thin or sunken, it is advisable to add and reduce Wu Tang to dispel cold and remove dampness, and to benefit Qi and consolidate the surface. If it is accompanied by coughing and asthma, swollen joints, or swollen limbs, strong and solid body, and a tight pulse, add flavor to Ma Heng Coixi Gan Tang to promote the dispersal of cold in the lung and remove dampness to clear the ligaments. (3) If the tongue is red or dark red with little moss or peeling moss, to support the righteousness and eliminate the evil, add flavor to Six Flavors Dihuang Tang to nourish kidney yin, resolve dampness and clear the ligaments; if you see dry mouth and throat with yellow greasy moss, add flavor to Zhi Bai Dihuang Tang to nourish yin and clear heat, dry dampness and clear the ligaments; if you see tinnitus and dizziness, red eyes and bitter mouth, add flavor to Qie Ju Dihuang Wan to clear the liver and kidney, supplement with filling essence and harmonizing the ligaments. (4) If the tongue is red, red-red or dark red, with localized redness, swelling, heat and pain in the joints, and obvious morning stiffness, regardless of the thickness of the tongue moss, it is advisable to dispel evil. If the moss is yellow and thick, it is dampness and heat, so it is advisable to add flavor to Sifu Wan to clear heat and remove dampness, cool the blood and open the ligaments; if you see moderate to high fever, dry mouth and thirsty drinking, with a stringed pulse and a non-thick tongue moss, it is more heat than dampness, so it is advisable to add flavor to Bai Hu plus Gui Zhi Tang to clear the Yang Ming meridian heat; if you have low to moderate fever, or you have cold and heat, with a bitter mouth, dry throat and dizziness, or a bitter fullness in the chest, with a fine pulse or stringed pulse, add reduction to Xiao Chai Hu Tang to reconcile Shao Yang. In the active stage of RA, even though the deficiency is positive, it should not be over-supplemented, otherwise it is easy to retain the evil and the disease is difficult to be relieved. The most popular remedies are those that strengthen the spleen and tonify the qi, such as Bei Qi, Dang Ginseng and Prince’s Ginseng, but for those with weak pulse and weak qi, they can be used.
5.3. Dispel dampness and eliminate blood stasis
Wind, cold and dampness are indispensable factors leading to RA. Among them, the dampness is the first. Dampness is feminine, heavy and sticky, most likely to stagnate in the meridians, joints and muscles, paralyzing the qi and blood, for a long time, the dampness will gather as phlegm, phlegm and dampness will stick together, stagnating qi and blood and becoming stasis. No dampness is no phlegm, no phlegm is less stasis, so removing dampness is the first priority of treatment and should be carried out throughout the treatment of this disease. The use of dampness elimination drugs, it is appropriate to light percolation and dampness, such as poria, coix seed, zedoary, dioscorea, artemisia, etc., when cautious to use pungent and dry products, because the pungent and dry products are easy to dry injury tendons and veins, so that although the wet to go but also injured, is not conducive to the recovery of joint function. In the use of drugs to resolve blood stasis, the use of blood stasis is rare, and the use of slow products to invigorate blood circulation and resolve blood stasis is generally preferred, in the sense that “it is advisable to attack slowly”, commonly used are angelica, Chuanxiong, Dan Shen, Jiang Huang, Red Peony, Dan Pi, Panax ginseng, Ze Lan, Boswellia, Myrrh, Chicken Blood Vine, Motherwort, Tao Ren, Chuan Hong Hua, etc. The swelling of joints for a long time and repeated pain are mostly due to the deep penetration of dampness, phlegm and stasis into the tendons and joints, which is difficult to get rid of. At this time, you can use insects to search the wind and pick up the luo, such as the whole scorpion, centipede, stiff silkworm, dragon, wuzhang snake, piercing nail, beehive, etc.. Ye Tianshi cloud: insects and ants such as “quickly fly away from the spirit, so that those who fly up, go down, blood without coagulation, gas can be declared open”; “search for wind, cold, phlegm and stasis in the meridians like insects”. But insect drugs are more toxic, more long serving, easy to break the blood, so the clinical evidence of the choice of 1 to 2 flavors, should not be complicated, too much. Large poisonous treatment, the majority of its decline has been, with the effective, should be appropriate to stop. It can be paired with astragalus and ginseng to help its search and expel evil, yu zhu, Huai Shan and so on to prevent its injury to yin, with each other to highlight the curative effect.
4. 3, care for the spleen and stomach
”Spleen healthy dampness can be removed, the Qi is strong and stubborn palsy since removed”. However, RA patients often appear in the treatment process of gastric distension and discomfort, belching and nausea, loss of appetite, and even faint blood in the stool and other gastrointestinal symptoms. The reasons for this are mostly due to the prolonged use of drugs that damage the spleen and stomach, such as non-steroidal anti-inflammatory drugs, glucocorticoids, slow-acting drugs, tretinoin, etc., and due to the lingering disease, dark depletion of qi and blood, emotional and mental disorders, liver depression and spleen deficiency, or bitter cold attack that damages the yang in the middle, or improper regulation and misapplication of multiple taboos, resulting in impaired spleen and stomach function. The spleen and the stomach are the origin of the posterior, the source of Qi and blood biochemistry, and the essence of the kidney and the yin and blood of the liver depend on the continuous decomposition and transformation of the water and grain essence and nourishment. If the spleen and stomach are healthy and the qi and blood are vigorous, the qi and blood will flow smoothly, the Ying and Wei will be harmonized, and evil will not be attached; secondly, the liver and kidney will be full of essence and blood, and the tendons and bones and joints will be nourished and strengthened. If the spleen and stomach are damaged, medicine and food will be rejected and not accepted. Therefore, taking care of the spleen and stomach should not be neglected. At the time of prescription, even if there are no obvious digestive symptoms, we should add dampness to open the stomach, control acidity and relieve pain, such as sandy nuts and squid bones, etc. Once symptoms of damage to the spleen and stomach appear, the main focus should be on protecting the spleen and stomach, such as stuffy stomach and poor appetite, nausea and abdominal distension, loose or knotted stools, little qi and lethargy, pale tongue with thin white fur, thin pulse and other spleen qi weakness, we can give Si Jun Zi Tang with flavor. If the stomach and epigastric noisy and easy to hunger, red tongue, little moss, thin pulse or thin number of gastric Yin deficiency, we can add and reduce Maimendong Tang; if the stomach and epigastric stuffiness and discomfort, indigestion, nausea and belching, less color, loose or hard stool, fat tongue with light red moss and thin yellow moss is spleen deficiency and stomach heat, cold and heat mismatch, we can add and reduce Han Xia Di Xuan Xin Tang; if we see stuffiness and discomfort, chest tightness and belching, depression, low menstrual flow is liver depression and spleen deficiency, we can add and reduce Yi Yao San. Toning the spleen and stomach can not only improve the patient’s general condition, but also significantly reduce the side effects of some anti-rheumatic drugs on the gastrointestinal tract, so that the patient can adhere to the drug treatment.
5. Conclusion
RA is a chronic recurrent disease with a long duration. The purpose of treatment is to reduce symptoms, stop irreversible bone damage, and protect the function of joints and muscles as much as possible, so as to improve the quality of life of patients. Therefore, treatment should focus on controlling rheumatic activity, reducing the impact of triggering factors, protecting surviving joints, and improving the function of diseased joints. During the active stage of the disease, the main focus should be on eliminating the evil, and the selection of prescriptions should be calm, avoiding warm and dry, bitter and cold to attack too much in order to rush to success, and pay attention to keeping the prescription to get the effect. The prescriptions should be used to calm the yin and yang for a period of time, taking into account the qi, blood and fluids. When the disease is in remission, we should still adhere to the treatment, tonify the liver, kidney, spleen and stomach, replenish qi and blood, and strengthen protection to reduce recurrence.