Gouty arthritis is a common disease in rheumatology. Acute attacks of this disease mostly present with severe red, swollen and hot pain in the joints, and patients are afraid to move around, with pain increasing at night, and often seek medical attention because of unbearable pain. In clinical practice, most of the patients asked about such acute attacks are diet-related, often occurring after eating seafood, animal offal or drinking alcohol, or after exertion, strenuous exercise, or feeling cold.
These triggering factors are external and internal injury factors in terms of TCM theory. Why can external sensation and internal injury factors cause such severe pain? The author believes that an important mechanism is the involvement of toxicity. Then what is toxin? What are the characteristics of poisonous evil causing disease?
1. The nature of poison
The word “poison” is very widely used in rheumatism, but what is poison in the end? Poison has the meaning of “harm, harm”, “violent, violent”. The original meaning of the word “poison” in the Dictionary has three meanings.
(1) evil, also harm;
(2) pain is also painful;
(3) things that can harm people are said to be poison.
It can be seen that all serious damage to the organism, so that people feel the pain of the causative factors can be considered as “poison” effect. The occurrence of active rheumatism is both external poisonous evil and internal poisonous evil. External poisonous evil is blamed on the wind, cold, dampness and heat of the evil depressed and poisonous, and the endogenous poison is blamed on the pathological products caused by the dysfunction of the internal organs, such as phlegm poison, dampness poison, stasis poison, etc.. Therefore, it can be understood that toxicity is the result of the depression of evil qi without transformation for a long time. You said in Jing, “Poison is the term for the accumulation of evil that does not resolve.” Heat toxicity is the result of heat stagnation, which is stored in the blood, and is produced over a long period of time; damp toxicity is the result of the internal brewing of damp evil. The “re-defined Yan’s Jisheng formula” said: “The white tiger calendar section of the disease, the world’s deficient people, will not be appropriate, by the wind, cold and moisture poison gas, so that the tendons and veins stagnant, blood does not flow, contained in the bones and joints, or in the limbs, the flesh color does not change.
The disease is quiet day and night, its pain through the bone like a tiger’s rodent, called the disease of white tiger.” Combined with the results of modern medical research, rheumatism of foreign poison, at least including foreign antigens such as bacteria, viruses, mycoplasma, chlamydia and other pathogenic microorganisms; endogenous poison can include the body excess of various autoantibodies, antigen-antibody complexes, blood uric acid and other substances. These excessive substances in the body lead to tissue damage in the human body, so in line with the concept of “poison” in Chinese medicine.
2.The source of toxicity
The sources of toxicity are internal and external. The external cause is the wind, cold, dampness and heat of the evil of depression and intoxication. The internal cause is mainly blamed on the dysfunction of the internal organs, and the internal poison has a more important role in this disease. In detail, internal toxicity mainly comes from the following three aspects.
(1) poor diet, spleen and stomach disorders, internal toxicity
The usual over-eating sorghum thick taste, alcoholic wine fatty sweet, spicy and fishy products, hindering the stomach stagnation spleen, diet does not return to the right chemistry, and the brewing of dampness and turbidity. Therefore, “Su Wen – Paralysis” said “diet since the times, the intestines and stomach is injured.” When the spleen and stomach are damaged, the clear yang does not rise, the cloudy yin does not descend, the water and grain essence cannot be dispersed, blocking the middle jiao, and brewing dampness and turbidity. This provides the basis for the generation of internal toxicity and becomes the source of toxicity. Dampness and turbidity stay in the middle jiao, affecting the lift and lower of the qi, long contained but not eliminated, damp heat and turbidity poison. Dampness, heat, and turbid toxins flow around the body and infiltrate all the veins, and every time the joints and tendons become entangled, the qi and blood are lost, and the meridians are blocked, resulting in redness, swelling, and pain. That is, “Su Wen – Paralysis” said: “This is also the diet and residence, as the origin of the disease.” The turbid toxins are found in the blood vessels, and are transformed over time with the yin and yang of the organism, either from yang into heat or from yin into cold.
(2) Kidney failure to open and close, dampness and turbidity accumulation, breeding turbidity and toxicity
The excessive and abnormal metabolic products of the organism, if they produce acute and serious damage to the organism, can be called poison. Under normal circumstances, through the coordination of the internal organs, such as the spleen, the stomach and the kidneys, the main role of the two stools, the metabolites of the body can be discharged in a timely manner, not to accumulate for harm. If there is an imbalance of yin and yang in the body, external evil attacks, or internal injuries, dysfunction of the internal organs, the metabolites can not be discharged in a timely manner, it will become toxic and stay and become harmful. Among them, the kidney is particularly important to lose open and close. The kidneys are open and closed, and when they are open, excess water and metabolites can be excreted as urine; when they are closed, the body needs fluid to be kept in the body. For example, “Su Wen – The Theory of Reverse Adjustment” says: “Kidney is the water organ and the master of fluids”. Ling Shu – Ying San Hui” said: “The lower jiao is like a dou”. If the kidney is weak, or if the toxins are contained within the kidney, depleting the blood and qi, the kidney’s qi is not conducive to transformation and has no power to open and close, then the toxins will remain and not go away, and will be deeply embedded in the blood vessels. At the same time, because the spleen is not healthy, water and dampness are not transformed, phlegm and dampness are generated internally, and they are combined with turbid toxins, so they are in trouble and become more harmful.
(3) The three jiao are not favorable, clear and turbid are mixed, and water channels are congested
Sanjiao presides over all qi and is responsible for the qi and qi-transformation of the whole body, and at the same time is the pathway for water and liquid to run. For example, Suwen Linglan Secret Discourse says, “Sanjiao is the official of the dysfunction, and the water channels come out of it.” The function of the middle Jiao is especially important. If the middle Jiao does not have the right to differentiate between clear and turbid, the essence of water and grain and filth are not separated and injected into the blood vessels together, which is the source of brewing turbidity and toxicity. At the same time, if the lower jiao waterway is not working, excess water and metabolites cannot be discharged in time. In time, the spleen, kidney and the three jiao all fail, which can lead to edema, retention of urine, guangs and other critical evidence.
3. Acute attack etiology and pathogenesis
(1) Accumulation of heat in the internal organs and internal poisonous evil
Patients have been eating alcohol, wine, thick flavors, sorghum and spices, heat, damp heat and poisonous evil in the internal organs, or by the kidneys do not open and close, the three jiao unfavorable and other reasons to cause turbid poison can not be discharged from the body, poisonous evil internal ambush, this is the root cause of the gout attack. As stated in the “Spring of All Diseases”: “All gout limb pain, pain is fire, swelling is wet, so people with sorghum, more food fried, sweating when the wind, water as a matter of business, long-term injury to get cold, dampness, etc.), from Yang into heat, thus forming heat poison attack in the hands and feet bones, stagnant tendons and veins, paralyzing the meridians of heat paralysis.
(2) The poison attacked the bones and joints due to the touch of external factors.
If the toxin is not touched, it only consumes qi and blood, and the damage is not obvious. In case of external touching, such as local joint injury, tight shoes, walking, drinking, straining, trauma, infection, medicine, wind, cold and dampness, etc., the toxin will block the vasculature and blood. If the blood is not flowing smoothly, the Qi and blood will not flow smoothly. If the Qi wants to push the blood, the blockage will be aggravated, so the pain will be sudden and severe. The disease can be triggered by the six external influences, but it is not the only cause, and the disease has its own evolutionary pattern, rather than following the six meridians or the transmission of Wei Qi and Ying Blood. As Li { “Introduction to Medicine” said: “…… wind-cold although due to involve cold sitting wet, when the wind to take cool, but must be blood heat and coagulation turbidity.” Medical practitioners are mud in the wind, cold and wet three gas mixed to say, along with the dispel wind and damp dispersing cold drugs, only to treat its symptoms of pain, no root cause of internal toxicity, can be described as a lack of understanding.
(3) heat toxicity torment, breeding phlegm and stasis
If the heat paralysis does not stop, the heat toxin will injure yin and consume qi. If the qi deficiency is not enough to push the blood to run, the blood will be stagnant because of it. In the case of Yin deficiency, the fluid is depleted and cannot carry the blood to run, which also leads to stasis. Heat toxins also burn Qi, blood and fluids, and blood is prone to clotting and stasis when it is burned. Stasis blocked in the veins can also depress and turn into heat, aggravating heat toxicity. For example, “Ling Shu – carbuncle and gangrene” says: “Ying and Wei stay in the meridians, then blood weeping and not allowed to go, not then the Wei Qi from which it does not pass, congestion is not allowed to go, so heat.” Dampness is heat fumigation, stagnation as phlegm, phlegm and dampness follow the meridians, nowhere to go. The phlegm and stasis are intertwined and penetrate deep into the bones and joints and meridians and tunnels, thus the chronic illness is deep and the disease is difficult to be cured. Different areas of phlegm and stasis have different manifestations. If the blood vessels are stagnant and the skin is not nourished, the skin is purple and dull. Phlegm stasis in the bones and tendons will result in nodules around the joints, enlarged and deformed joints, and unfavorable flexion and extension. If phlegm is stagnated in the kidney, it forms stone shower and retention of urine.
4. Discussion on the etiology and pathogenesis of intermittent period
(1) The evil is contained in the body, waiting for an opportunity to develop
The main contradiction of gout is recurrence, and the main source of recurrence is the increase of blood uric acid, which can lead to acute attack when the patient’s blood uric acid is continuously increased. The increased blood uric acid belongs to the scope of “blood toxicity” and “turbid toxicity” in Chinese medicine. Therefore, the intermittent period is mainly characterized by the presence of blood poison and turbid poison, which is in line with the viewpoint of Chinese medicine. The ancient people have long discussed the paralysis caused by volatile evil. In the Qing dynasty, Liu Jiren’s “New Book of Fuchsia” said: “Those who feel six perversions and are immediately ill are called injured in the lighter cases, and in the heavier ones.
The six perversions that do not cause the disease, but only after the onset of the disease, are always called voodoo. Those who have already developed but can not be treated, the disease is hidden, is also called voodoo. There is the first feeling can not be treated, the righteousness of internal injury, the evil within the trapped, temporary false healing, and later still author, is also called voodoo. There has been cured, but failed to get rid of the root of the disease, the legacy of the evil within the ambush, and then recurrence, is also said to be volatile evil.” Although the gout patients are not “those who feel the six sexes and have the onset of disease”, they should be classified as “those who have been cured but have not gotten rid of the root of the disease, and the residual evil is still inside and then recurs”, so the “blood poison” and “turbid poison” of gout should also be classified as “blood poison” and “turbid poison”. “turbid poison” should also belong to the category of ambiguous evil.
(2) The poisonous evil stays for a long time, the deficiency of positive energy
If the disease is prolonged and does not heal, and the poisonous evil depletes the body’s vital energy, various deficiencies can be manifested. Qi deficiency is the deficiency of essence. It is manifested by heavy limbs, weakness, short pneumatic sweating, soreness and weakness of the waist and knees, pale tongue, sunken pulse, etc. Kidney qi deficiency cannot be fixed, essence is injected; kidney yang deficiency, qi deficiency cannot transform water, water dampness floods limbs, chest and abdomen and see edema. Qi deficiency cannot produce blood, and blood deficiency does not allow for anger. If the Qi is deficient, Yang will gradually decline, and if the Blood is deficient, Yin will be insufficient. If Yin is lost for a long time, Yang will be affected; if Yang is lost for a long time, Yin will be affected, and finally, Qi and Blood will fail. The deficiency of positive qi makes it easier for the toxins to accumulate, and it is susceptible to external evil, which aggravates the damage.