Rheumatoid arthritis (RA) is a multisystemic inflammatory autoimmune disease that predominantly involves peripheral joints, typically with chronic inflammatory lesions of multiple peripheral joints in a symmetrical fashion. Clinical manifestations include pain, swelling, and decreased function of the affected joints, with a persistent, recurrent course of disease. The pathological changes are chronic inflammation of the synovial membrane, hyperplasia and formation of vascular opacities, invasion of articular cartilage, subchondral bone, ligaments and tendons, resulting in destruction of articular cartilage, bone and joint capsule, and ultimately deformity and loss of function of the joint. The prevalence of this disease in China is about 0.32-0.36%, and it is a major cause of labor loss and disability in our population.
I. Pathological changes in Western medicine and understanding of the pathogenesis in Chinese medicine
RA is an autoimmune disease, the exact cause of which is still unclear and may be related to genetics and infection. Genetic factors cause susceptibility to RA, infection factors may trigger the disease, and a variety of complex factors are involved in the process of intra-articular and systemic immune disorders in RA. The pathology involves both articular and extra-articular pathological changes: the basic pathological change of RA joints is synovitis, the process of which can be roughly divided into synovitis phase, granuloma phase, and fibrosis phase. The inflammatory mediators, enzymes and cytokines released by synovitis stimulate the destruction of cartilage and produce erosive effects on the collagen of articular cartilage, ligaments, joint capsule and stroma, resulting in cartilage destruction, fibrosis and joint cavity narrowing and deformity, as well as disuse atrophy of the muscles near the joint; the extra-articular pathological changes in RA are mainly vasculitis and perivasculitis, involving medium and small arteries and/or veins. Rheumatoid nodules are easily formed on subcutaneous or periosteal areas under pressure or friction, and are a mass of necrotic tissue based on vasculitis, containing fibrin and immune complexes, surrounded by fenestrated histiocytes and surrounded by mononuclear cells and granulation tissue.
II. Diagnosis and differential diagnosis
(A) Diagnostic criteria
The American College of Rheumatology established the diagnostic criteria for this disease in 1958, and revised them in 1987. The 1987 diagnostic criteria are briefly described as follows.
(1) Morning stiffness lasting at least 1 h per day for at least 6 weeks.
(2) Swelling of 3 or more joints for at least 6 weeks.
(3) Swelling of the wrist, metacarpophalangeal, and proximal interphalangeal joints for at least 6 weeks.
(4) Symmetrical joint swelling for at least 6 weeks.
(5) Hand x-ray changes with at least osteoporosis and joint space narrowing.
(6) Subcutaneous nodules.
(7) Elevated serum rheumatoid factor (RF) level.
If four or more of the above indicators are present, the diagnosis can be confirmed.
(B) Differential diagnosis
1, rheumatoid arthritis: the disease is most often seen in adolescents, pre-disease history of sore throat, rapid onset, significant fever, increased white blood cells, lesions mainly invade large joints, joint redness, swelling, heat and pain is significant, wandering, joint swelling time is short, mostly in 1-6 weeks to naturally subside, no morning stiffness and muscle atrophy, after healing does not leave joint deformity, X-ray examination without bone changes. The incidence of cardiac damage is high, with skin ring-shaped erythema, serum anti-“O” increased and RF negative.
2, ankylosing spondylitis: ankylosing spondylitis (ankylosing spondylitis) mainly invades the spine, especially sacroiliac joint lesions are most common, mostly in young and middle-aged men, there is a certain family genetic tendency, more than 90% of patients HLA-B27 positive. Ankylosing spondylitis used to be called rheumatoid spondylitis, but the name has been used for as long as 20 years, because ankylosing spondylitis and rheumatoid arthritis are two completely different diseases, and ankylosing spondylitis is definitely not a specific site of rheumatoid arthritis. Ankylosing spondylitis differs from rheumatoid arthritis in that it primarily affects the fibrocartilaginous joints, such as the intervertebral discs, sternal stems, pubic symphysis, and interspinous ligaments. The sacroiliac joint is 100% involved, with cartilage destruction, erosion and sclerosis of the subchondral cortex, and finally fibrosis to bony ankylosis. There can also be focal inflammatory lesions in the joint capsule and ligaments attached to the bone, and there is also reactive fibrosis with bone deposits.
3, osteoarthritis: The disease is most often seen in people over 50 years of age, with lesions mainly limited to the large joints of the knee, hip, ankle, spine and other frequently weight-bearing joints, and the fingers are characterized by osteophytes and nodules in the distal phalanges. There is no redness or swelling in the joints, muscle atrophy is uncommon, aggravated after activity and reduced after rest, no obvious morning stiffness, blood sedimentation is mostly normal and RF negative.
4, psoriatic arthritis: this disease occurs several years after the skin psoriasis, 30 to 50% of the patients show symmetric polyarthritis, very similar to RA. The difference is that the disease mainly involves the distal joints of the fingers or toes, and it is manifested as the attachment end of the joint and finger inflammation, and joint deformity may also occur, but the serum RF is negative.
III. Treatment
(A) Western medical treatment
1, general treatment: including rest, joint braking (acute phase), joint function exercise (recovery phase), physical therapy, etc.. Bed rest is only suitable for patients in the acute stage, fever and visceral involvement.
2, drug therapy: the treatment of RA drugs are mainly non-steroidal anti-inflammatory drugs (NSAID), disease-modifying anti-rheumatic drugs (DMARD) and glucocorticoids, etc.
(1) NSAID: is the basic drug for the treatment of RA, with analgesic and swelling effect, is a common drug to improve the symptoms of joint inflammation, but can not control the disease, must be taken with the change of condition anti-rheumatic drugs. Commonly used drugs are ibuprofen, naproxen, diclofenac, indomethacin, meloxicam, etc., at least 2 weeks to judge its efficacy, the effect is not obvious can be changed to another NSAID drugs. As the synergistic effect of this class of drugs is not obvious, it is not advisable to take two NSAIDs at the same time to avoid increasing adverse reactions.
(2) DMARD: Any patient diagnosed with RA who has progressive joint pain, significant morning stiffness or fatigue, active synovitis, persistently high levels of ESR and CRP, or imaging manifestations of joint damage should start DMARD therapy within 3 months of diagnosis, regardless of whether the use of NSAID can adequately relieve symptoms. DMARDs commonly used in RA include hydroxychloroquine (HCQ), salazosulfapyridine (SSZ), methotrexate (MTX), leflunomide, and less commonly, azathioprine, D-penicillamine, gold salts, memantine, and cyclosporine. Many rheumatologists prefer HCQ and SSZ based on drug safety, convenience, and cost, but MTX or a combination of drugs is recommended for patients with significant disease activity or a prognosis suggestive of poor outcome. For patients with RA who have relative contraindications to the use of MTX and those who cannot tolerate it due to poor efficacy (their dose has reached 25 mg/week) or intolerance, biologics or other DMARDs, either alone or in combination, are recommended.
(3) Glucocorticoids: This drug can bring about rapid relief of arthritic symptoms and improve joint function. However, it cannot cure the disease, and the symptoms will recur after stopping the drug, and long-term use will cause dependence and many adverse effects. Therefore, this drug is suitable for people with extra-articular symptoms or obvious or acute onset of arthritis.
3.Surgical treatment of RA: Surgery can be considered for those with intolerable pain, limited joint range of motion, and limited function due to structural damage of the joint. The former is suitable for more advanced joints with deformity and loss of function; the latter can provide some relief.
(2) Combined treatment with Chinese medicine
Because of its prolonged course, RA is mostly accompanied by joint ankylosis and deformation, limitation of flexion and extension, the lesion is located in the joint of tendons and bones, and the pathological mechanism is a mixture of deficiency and reality, wind, cold and dampness are entangled for a long time, phlegm and stagnation block each other, and heat is contained and breeds poison. According to the different pathological stages, the clinical treatment can be divided into the acute attack period and the remission period (including the chronic onset period).
1.Acute attack period
(1) Heat and toxicity
Main symptoms: swollen joints, redness, swelling, hot pain, severe pain, worse when touched, unfavorable movement, constriction of tendons and veins, local preference for cold and fear of heat, thirst and sweating, boredom and restlessness, or fever, short yellow urine, dry stool, red tongue, yellow coating, string or slippery pulse.
Treatment: Clearing heat and detoxifying the toxin, cooling the blood, activating blood circulation and relieving pain.
Direction: Reduce the pain by clearing heat and removing toxins.
Honeysuckle, Wild Chrysanthemum, Forsythia, Radix et Rhizoma, Radix Angelicae Sinensis, Radix Angelicae Sinensis, Radix Rehmanniae, Radix Salviae Sinensis, Radix Paeoniae Alba, Radix Gentianae Macrophyllae, Radix Wei Ling Xian, Radix Lobatae Sinensis, Radix Glycyrrhiza Uralensis.
The main pathogenesis of this disease is due to heat and toxicity, blocking the meridians and joints. In this formula, honeysuckle, wild chrysanthemum and forsythia clear heat and detoxify; xuan ginseng nourishes yin and clears heat and detoxifies; water hyacinth is good at clearing heat and toxicity in the blood, raw earth cools the blood and clears heat and nourishes yin; angelica, salvia and red peony invigorate blood circulation and resolve blood stasis, pass through the channels and relieve pain; wei ling xian, luo shi teng and gentiana dispel wind and dampness, pass through the channels and relieve pain. The combination of Yin nourishing herbs and pungent heat-clearing herbs in this formula can permeate Yin and meridian joints to resolve heat toxicity; the combination of heat-clearing and detoxifying herbs and blood-stasis invigorating herbs can clear heat without the disadvantage of coldness to suppress blood vessels. The combination of these drugs can clear heat and detoxify, cool the blood and invigorate the blood, as well as promote blood circulation and relieve pain.
If the pain is untouchable and affects one or more joints, with fever, vicious wind, and irritable thirst, then Bai Hu Gui Zhi Tang can be used to clear the heat and detoxify the joints, clear the blood and relieve pain.
(2) Damp-heat congestion
Main symptoms: swollen joints, redness, swelling, heat and pain, severe pain, worse when touched, unfavorable movement, constricted tendons and veins, localized coldness and fear of heat, thirst and sweating, boredom and restlessness, or fever, short yellow urine, dry stools, red tongue, yellow coating, string count or string slippery pulse.
Treatment: Clear heat and dry dampness, invigorate blood and promote circulation.
Direction: Clearing heat and drying dampness, activating blood circulation.
Water hyacinth, gardenia, astragalus, cypress, atractylodes, coix seed, rhubarb, haitongpi, wei lingxian, lonicera.
The main pathogenesis of this disease is to feel the evil of cold and dampness, which turns into heat inside, or to feel the evil of dampness and heat congested in the meridians and joints, so the treatment is to clear heat and dry dampness, invigorate blood and open the meridians. It helps to remove the pain of all the meridians; Haitongpi is bitter and calm, treats the waist and feet, paralysis of blood vessels; Wailingxian, dispels wind and dampness, opens the meridians, eliminates phlegm and saliva, disperses fetish accumulation; Ligustrum clears heat and detoxifies the meridians; in the formula, the products that clear heat and nourish yin are used in combination with the products that dry dampness so that the dampness goes without hurting the yin fluid; the diarrhea of heat makes heat come out from the front and back of the two yin, so that the heat evil has a way out; the medicine that clears heat is combined with the medicine that activates blood and dispels stasis to avoid the drawback of ice bondage. The effect of the combination of all the drugs to clear heat, dry dampness and invigorate blood circulation.
Add and subtract: if strong heat and thirst, add raw gypsum and Zhi Mu to clear heat and quench thirst; for constipation, increase the dosage of rhubarb and add mangosteen to relieve fire and detoxify the bowels; for heat and injury to fluid, add Xuan Shen, Sheng Di and Sha Shen to nourish Yin and promote fluid; for upper extremity, add Mulberry and Jiang Huang; for lower extremity, add Chuan Niu Knee to induce the medicine to reach the place of illness; for severe heat and toxicity, use Si Miao Yong An Tang to add flavor, taking Xuan Shen, Sheng Di, Yin Hua, Sheng Gan Cao, Mao Dong Qing and Bai Hua Snake
2.Chronic remission or chronic onset
(1) Liver and kidney deficiency, cold and dampness blocking the ligaments
Symptoms: joint pain, swelling, morning stiffness, relieved by warmth or activity, normal or fat tongue, light red or light white tongue, thin white or white greasy moss, string or smooth string or tight string pulse.
Treatment: Nourishing the liver and kidney, dispersing cold, resolving dampness, clearing the ligaments and relieving pain.
Radicals: Yang He Tang combined with Releasing Palsy Tang plus or minus.
Qiang Wu, Jiang Huang, Radix Angelicae Sinensis, Astragali, Radix Paeoniae Alba, Fructus Anemarrhenae, Radix Gentianae Macrophylla, Poria, Morinda Citrifolia, Radix et Rhizoma, Radix et Rhizoma Ginseng, Radix et Rhizoma Glycyrrhiza.
The mechanism of this disease is deficiency of liver and kidney, cold and dampness blocking the ligaments, which are in the tendons, bones, muscles and blood vessels. Although the paralysis of wind, cold and dampness are different and all have wind, the root of the disease must be the Ying and Wei deficiency around the body, the thief wind to bear. Therefore, astragalus benefits the qi and solid table, support the righteousness to dispel evil; wind wind evacuation, the two together with the actual table qi, roasted licorice for the spleen and stomach to help the Wei Qi, angelica for the blood and blood; red peony to clear heat and cool the blood, can disperse blood to ease the pain; poria sweet light permeate dampness, water and swelling; turmeric to move the gas and break the stasis, through the menstrual pain, favoring the upper extremities; gentiana to dispel cold and dampness, water, urine, stop pain in the limbs; qiangwu to disperse cold, dispel wind and dampness, joints; mulberry to dispel wind and dampness It is used to dispel wind, dispel cold, move water and open the orifices; Niu Knee invigorates the blood and channels the meridians, leads the blood downward, and leads all the medicines down to the disease, mainly treating rheumatic paralysis of the lower limbs. The whole formula tonifies the Blood, invigorates the Blood and cools the Blood. The combination of the Blood-supplementing herbs with the Qi-supplementing and Wind-dispersing herbs makes the Wei-Qi solid and the Ying-Blood harmonious, so that the deficient evil and thieving wind can’t take advantage of the deficiency. The combination of those who are good at going up and those who are good at going down allows the qi to flow around the body, leading the medicines to reach the disease directly. The combined use of all the medicines makes the wind, cold and dampness dispelled, the qi and blood are filled, the meridians are activated, the tendons and veins are nourished, then all the evidence will be removed.
Add and subtract: if wind prevails and joint pain wanders, add Thornbush to dispel wind and relieve pain; if dampness prevails and limb joints are heavy, with normal or fat tongue, add Fangji, Job’s Tear and Doklam to promote dampness and circulation; if joints are swollen, add Dioscorea Z and Mouton to promote water and circulation; if skin is unkind, add Haitongpi and G Datu Cao to dispel wind and circulation; if edema and itchy limbs, add Mulberry to dispel wind and dampness and move Qi and blood; if cold prevails and chest and abdomen are cold and painful, and limbs are soft, add If coldness prevails, see cold pain in the chest and abdomen and softness of the limbs, add Cao Wu or Wu Tau to warm the middle and relieve pain.
(2) Deficiency of liver and kidney, mutual obstruction of dampness and stasis, stasis and heat
Symptoms: Palsy that does not heal over time, pain in bones, swelling and deformity, inability to flex and extend, fatigue, dizziness and tinnitus, soreness and weakness of the waist and knees, restless sleep at night, hot flashes and night sweats, persistent low fever. The tongue is light or light red, the coating is thin or thin and white and dry, and the pulse is sunken and fine or sunken and feeble. This type is seen in the chronic stage of RA.
Treatment: Tonifying the liver and kidney, dispersing cold, resolving dampness, dispelling blood stasis and clearing heat.
Treatment: Tonifying the liver and kidney, dispersing cold and dampness, eliminating stasis and clearing heat.
Tiger bone (can be substituted with dog bone), cow’s knee, rehmannia, angelica, white peony, locking yang, chicken blood vine, stretching grass, turmeric, wei ling xian, gentiana, peach kernel, safflower, dulcimer, lonicera.
The pathogenesis of this syndrome is prolonged paralysis, loss of qi and blood, deficiency of liver and kidney, deficiency of the right and evil, phlegm and stasis blocking the ligaments, stasis and heat. In this formula, Shu Di nourishes Yin and Blood, Tiger Bone strengthens bones and tendons, Lock Yang warms Yang and benefits essence, moistens dryness and nourishes Yin, and Du Zhong nourishes Liver and Kidney and strengthens tendons and bones; all four work together to nourish Liver and Kidney. Chicken Blood Vine, promoting blood circulation, tonifying blood, soothing the meridians and activating the channels; Lonicera japonica, clearing heat and detoxifying the channels. The formula nourishes the liver and kidneys and nourishes the blood, invigorates the blood, dissolves siltation and moves the qi, so that the tonic does not stagnate, the siltation is dispelled and the new blood is born; eliminates phlegm and dampness and moves the blood to replenish the blood, dispels the tangible evil and plays a role in soothing the meridians and activating the collaterals. The combination of those who are good at going up and those who are good at going down allows the qi to flow around the body, leading the medicines to reach the disease. The combined use of all the herbs can achieve the purpose of tonifying the liver and kidney, dispersing cold and dampness, removing blood stasis and clearing heat.
If you see redness and swelling of the lower limbs, add Zhi Mu to clear the fire and treat the swelling of the legs, and lead the medicine downward; if the stagnant heat and fire hurt the fluid, see the pain and redness of the joints, especially at night, with red tongue and little fluid, and a string pulse, use Rhizoma Rhizoma, add Fang Ji and Haitong Pi to clear heat and remove dampness, and pass through the ligaments to relieve pain; if the joints are tense, with a dull tongue, white greasy coating, and a thin and astringent pulse, the treatment should be If the pain in the upper extremity is severe, add Qiang Wu and Sang Zhi; if the pain in the lower extremity is severe, add Dou Wu and Fang Zhi to clear the channels and activate the channels; if the pain is severe due to excessive cold and dampness, add Chuan and Cao Wu to warm the channels and disperse cold to relieve pain; if the joints are red and swollen, add Dioscorea Z, Job’s tear and Dilong to relieve pain. For those with Yang deficiency for a long time, dampness flowing into the joints, phlegm and deformity of joints, Yang He Tang is added, with deer horn gum and rehmannia to tonify the essence and blood, ephedra, ginger and cinnamon to pass Yang and open paralysis, fried white mustard seeds to remove phlegm, safflower, peach kernel, angelica and whole worm to invigorate blood and remove blood stasis and promote circulation.
(3) Stagnation of phlegm and stagnation
Main symptoms: Recurrent attacks of joint pain, sometimes light and sometimes heavy, enlarged joints, even ankylosis and deformity, unfavorable flexion and extension, dull skin around the joints, more severe pain, stopping, or heavy limbs, numbness and insensitivity, purple and dark tongue, or petechiae, thin white or white greasy coating, thin and astringent or sunken pulse.
Treatment: Expel phlegm and eliminate blood stasis, dispel wind and open the ligaments.
Formula: Er Chen Tang combined with Live Loop Effect Dan plus or minus.
Radix et Rhizoma, Pericarpium Citri Reticulatae, Poria, Radix Biliaryis, Radix Angelicae Sinensis, Radix Salviae Miltiorrhizae, Radix Myrrhicae Sinensis, Rhizoma Pentaphyllum, Radix Scorpion, Rhizoma Silkworm, Radix Centipede.
The recipe is described as follows: Hexia, Chen Pi, Poria, Biliary South Star, dry dampness and resolve phlegm; Angelica, Danshen, Boswellia, Myrrh, and Ling Lipid invigorate blood circulation and resolve blood stasis and activate the meridians; together with Scorpion, White Deadly Silkworm, Centipede and other insects that search for wind and resolve phlegm, to enhance the power of circulation. The whole formula works to resolve phlegm and eliminate blood stasis, search the wind and open the ligaments.
Add and subtract: if Qi deficiency is seen, add Radix Astragali and Radix Codonopsis to benefit Qi; if swelling and stiffness of joints are seen, and wind and phlegm are obvious, add Asparagus, Tooth Soap and White Radix to dispel wind and resolve phlegm.
(C) Specialized prescriptions and medicines for treatment
1, compound three snake wine: white snake, herb snake, wuzhusu snake, centipede, antibacterial, wind, scorpion, dung beetle, dung beetle, beehive, raw earth, qiangwu, lonicera vine, sea wind vine, gold bird flower root, mulberry, astragalus, licorice. The above medicines are taken with sorghum wine leachate, mixed with water and wine. For rheumatoid arthritis symptoms stubborn, joint deformation is obvious.
2, papaya pill: composition of papaya, Chuanxiong, Angelica dahurica, Wei Lingxian, dog’s back, cow knee, chicken blood vine, sea wind vine, ginseng, Chuan Wu, grass wu, angelica, function of dispelling wind and removing dampness, warming the meridians, strengthen tendons and bones, pass paralysis and relieve pain, for damp paralysis.
3, Shu tendon pill: composition of Dulvu, parasite, Chuan break, Hosanna, Gentiana, Poria, Gui Zhi, Fang Feng, Chuanxiong, Bai Shao, Chuan Wu, Cao Wu, Angelica, Sheng Di, roasted licorice. Functions to invigorate the blood and dispel wind, soothe the tendons and open the ligaments.
4.Hu Qian Wan: composition of Phellodendron, Zhi Mu, Shu Di, Angelica, Paeonia lactiflora, Niubizi, Tortoise Board, tiger shin bone, locking Yang, Chen Pi, dry ginger, mutton, mainly for the treatment of tendon weakness, leg and foot wasting, walking weakness.
5, rheumatism sacred medicine capsule: composition of Fu Ling, Tao Ren, Yu Zhu, Wu Wei Zi, Phellodendron, Ginseng, Safflower, Pierced Dragon, Dou Wu, Angelica, etc. eighteen flavors, function of soothing tendons and activating the channels, dispel blood stasis and pain, invigorate blood and dispel wind.
6, wind chasing cream: composition of musk ketone, Guangxi blood scorpion, angelica, douhu, etc., efficacy of dispelling wind and dispersing cold, moving qi and invigorating blood, promoting menstruation and relieving pain.
7.Special dog skin ointment: composed of raw Sichuan wu, raw grass wu, qiang wu, wei ling xian, fenugreek, cinnamon, blood exhaust, frankincense, myrrh, green wind vine, camphor, belladonna fluid infusion, etc. 48 flavors, functions to dispel wind and cold, relax tendons and blood, activate blood circulation, relieve pain.
Fourth, the difficulties and countermeasures of the combined treatment of disease and evidence
Rheumatoid arthritis is different from the general wind-cold-damp or rheumatic-heat paralysis, the evil in the meridians and muscles, can be solved by slight sweating. Rheumatoid arthritis belongs to the category of persistent paralysis and bone paralysis in Chinese medicine, and the evil is mostly in the bones, joints, meridians and tendons, and blood stasis and phlegm are stuck together, which is difficult to resolve.
Acute onset, red, swollen and hot joints, severe pain, accompanied by fever and thirst, although the symptoms of real heat in the qi part can be manifested, but not Baihu class can be effective in clearing the evil heat in the qi part, and not a large dose of gardenia, scutellaria, cypress and other bitter cold to clear heat, so as not to hurt Yin and dryness. This period is mostly wind, damp, heat, dampness and stasis blocking each other, and the accumulation of heat for a long time, blocking the meridians, blood vessels, bones and joints, at this time, a large dose of nourishing yin and clearing heat, cooling blood and activating blood, accompanied by dispersing wind and dampness, clearing the channels and relieving pain. A large dose of nourishing Yin, one can lead the drugs deep into the blood and Yin; the second can nourish Yin to glory tendons. The medicine uses 40-60 grams of raw earth, 15 grams of red peony, 30 grams of Xuan Shen, 30 grams of Dan Shen, 15 grams of angelica, 30 grams of goat’s horn, 15 grams of white peony, 30 grams of Lonicera japonica, 15 grams of Gentiana macrophylla, 15 grams of daidian, 15 grams of wei lingxian, 30 grams of coix seed.
In chronic onset or remission of swollen and painful joints and stiffness, the disease is mostly due to kidney deficiency, cold-heat mismatch, phlegm and stagnation. At this time, the treatment should not only pay attention to the pain if it does not pass, but also pay attention to the pain if it does not glory. The pain that does not pass is due to wind, phlegm, dampness and stasis, blocking the meridians, blood vessels and bones; the pain that does not glory is due to Yang (qi) deficiency without warmth and Yin deficiency without its glory. At this time, the treatment should be both hot and cold, yin and yang and tonic, with emphasis on kidney tonic, especially in the sweet and warm tonic yang. Blood vessels and tendons can be warmed by Yang Qi in order to regulate smoothly, and gum and dampness can be warmed by Yang Qi. It can be treated by combining Gui Zhi Paeonia and Zhi Mu Tang with Si Miao San and adding Sheng Di, Chuan Guan, Ba Ji Tian, Angelica, Bone Broken Tonic and Xian Ling Spleen. For small joint swelling and pain, add 5 grams of whole worm, 15 grams of Ling Xian and 15 grams of Mulberry branch; for hip and knee pain, add 15 grams of deer horn gum and reuse 30 grams of Chuan Jian; for swollen joints, especially large joints, add 15 grams of Fang Wei and 15 grams of Haitongpi. This formula is both cold and warm, nourishing yin when tonifying the kidney, supplemented with sweet and warm to help yang to slightly produce less fire and warm the yin and cold of the kidney meridian. In addition, the kidneys pay attention to strengthening the tendons and bones, the tendons and bones are strong, it is difficult for the evil to stay. To dispel dampness and turbidity, we use Si Miao San, not San Ren Tang, because the dampness and turbidity are in the tendons, deep in the lining, not lightly promote the promotion of the solution.
Rheumatoid joints with localized joint enlargement, external treatment can be used. Drugs are applied externally, so that the drug acts directly on the local area. Most of the swollen joints are due to phlegm, dampness and stasis, which accumulate in the joints of the tendons and bones. Even if the joints have mild localized fever, it is mostly due to stagnation and heat, not due to heat, but to the fact that the evil closes the meridians and joints and causes fever, so we should not rashly apply cold and heat-clearing drugs to curb the qi and blood channels and aggravate the disease. On the contrary, damp heat or evil toxins blocking the qi and blood, blood vessels, limbs can also have a feeling of cold, if the investment of warmth to disperse cold, but also aggravate the disease.
The identification of rheumatoid or other chronic diseases is heat or cold, should be integrated with the systemic symptoms and tongue and pulse. In addition, the speed of blood sedimentation, and the cold and heat of the disease also has a certain relationship. Generally speaking, if the blood sink is fast, it is mostly heat and deficiency heat; if the blood sink is not fast, it is mostly deficiency cold or cold and heat mixed.