Journal of Acuherb in Medicine


Gout

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Gout

Gout is a metabolic disorder which results in raised blood levels of uric acid and the formation of crystals of uric acid salts in the joints. Uric acid is a natural element which results from the normal break down of food and the building up of body tissues. The clinical presentation of gout includes frequent attacks of arthritis, joint deformities, kidney damage and urinary stones.

From a TCM viewpoint, the clinical features of gout, such as frequent attacks of swelling, redness, heat and pain in the joints, and improper movement of limbs, place gout in the category of “bi-syndrome.” The ancient TCM classic Suwen (The Book of Plain Questions) states that “bi-syndrome is due to a combined attack of wind, cold and dampness evils.” Attacks on the meridians in the superficial areas of the body such as the feet and hands by wind, cold and dampness evils lead to stagnation of vital energy (qi) and blood circulation. It is an obstructive disorder.

Traditional Chinese medicine holds that there is a distribution network for the fundamental substances like qi, blood and body fluid throughout the body. This network is called the Meridian System. It links organs, limbs, joints, bones, tendons, tissues and skin, and provides communication between the body’s interior and exterior. 

Causes

Gout mainly originates from the invasion and accumulation of  pathogens  in the meridians. This leads to a disturbance of blood and qi circulation in the limbs. Gout is considered to be caused by both endogenous (originating from inside the body) and exogenous (originating from outside the body) factors.

Exogenous causes
An invasion occurs of external pathogens, such as wind, cold, dampness and heat evils, and these then accumulate in the meridians and joints. TCM practitioners believe that wind, cold or dampness evils invade under the following conditions: 

living or working in cold and damp environments
getting wet while recreating or being in the rain
working in water for long periods
abrupt changes in the weather, and
exposure to wind while sweating.

Also, when invasive pathogenic evils remain in the body for some time, they develop into internal heat evil. Accumulation of internal heat evil causes a more serious bi-syndrome.

Endogenous causes
Deficiency in vital energy (qi) or stress are considered endogenous causes. Deficiency of vital energy (qi) usually results from an imbalance between work and rest, innate weakness of the body, lack of physical exercise or recent recovery from chronic illness. When the protective qi  is under-functioning, the skin and subcutaneous tissues are loosely bonded and exogenous pathogens take advantage of this to invade the body. They accumulate in the meridians and lead to stagnation of blood and qi.

If attacks of bi-syndrome are frequent and lengthy, meridian obstruction and blood stagnation leads to a disturbance in the metabolism of body fluids. Accumulated substances in the fluids are transformed into phlegm and the deeper organs become affected.

Symptoms

The type or manner of pathogen invasion will result in different presentations of gout bi-syndrome. The main clinical presentation of the predominant invading pathogen is as follows:

Wind evil causes mobile or unstable joint pain (migratory-bi).
Cold evil results in localized joint pain (painful-bi).
Dampness evil produces numbness, heaviness, and swelling of joints and muscles (localized-bi).
Heat evil generates heat, redness and swelling in the joints and severe tenderness (heat-bi).

TCM practitioners are accustomed to examining the sufferer and categorize symptoms under special syndrome groups known as “disharmony patterns.” Certain disharmony patterns present at different stages of gout and are classified as the following types:

Bi-syndrome due to wind, cold and dampness evils 
The individual experiences painful joints and limbs, and in some cases severe localized joint pain. Other symptoms include limb heaviness, impaired movement of the affected joints and numbness in muscles. These symptoms will be aggravated during rain or damp weather.

Bi-syndrome due to wind, cold and heat evils
This type of bi-syndrome has an acute onset. The affected joints present with redness, swelling, heat and pain, and also severe tenderness. Relief can be provided with colder temperatures. Other symptoms include thirst, irritability and a fever that is not relieved by sweating.

Bi-syndrome due to phlegm and blood stagnation
This results from repeated attacks of acute bi-syndrome over many years. Individuals present with variable and frequent joint pain, swollen joints, and in severe cases joint deformity. Limbs cannot be flexed or extended and nodules form beneath the skin.

Bi-syndrome with associated liver and kidney damage
Individuals who suffer from long-term bi-syndrome will, without proper treatment, experience migrating bone pain, or soreness and heaviness in the limbs. In severe cases, joint deformity can occur. Symptoms can also include fatigue, pallor, shortness of breath, spontaneous sweating, improper joint movement, limb numbness, and soreness and pain in the loin region. 

Diagnosis

Diagnosis in TCM places importance on determining the circumstances and manifestations of a disease through inquiry and symptom observation. Diagnosis is based on the traditional four examination techniques: 

Questioning The TCM practitioner will establish the medical history of both the patient and his family.
Observation Examination of the physical features of the body, such as the face, tongue, hair, nails, sputum (mucus that is coughed up), and location of pain, all offer clues to the problem. The tongue is a particularly useful indicator of the functioning of the internal organs.
Listening and smelling The smelling of sputum and breath and listening to the sounds produced by the chest offer additional clues to the patient’s health.
Touching Feeling the pulse is a cornerstone of TCM diagnosis and gives the practitioner much information about any bodily imbalance.

In gout, the procedures used in TCM to differentiate between disharmony patterns can be explained as follows:

Bi-syndrome due to wind, cold and dampness evils 

From a TCM viewpoint, when the body’s protective qi is weak, climatic and environmental factors (the exogenous evils such as wind, cold and dampness) can readily invade. They attack the superficial meridians  and lead to stagnation of vital energy (qi)  and blood. Although these three evils may make a combined attack on the body, one is usually dominant and different symptoms result:

Wind evil causes migrating pain involving most limbs and joints.
Cold evil results in localized and severe pain of the limbs and joints (which is relieved by heat and aggravated by cold) and impaired movement of the limbs.
Dampness evil produces heaviness and numbness of the limbs, impaired movement of limbs, joint swelling (but without heat and redness) and localized pain.

On examination, the tongue is coated in a white thin fur. The pulse is tense and wiry, or taut and moderate.

Bi-syndrome due to wind, cold and heat evils
In the conflict between the exogenous evils  and vital energy (qi), much heat is produced and the exogenous evils of wind and cold may be transformed into heat evil. Individuals not only suffer from joint and limb discomfort, but also present with general heat symptoms, such as hot and red joints, fever, thirst and sweating. On examination, the tongue is red and covered with yellow fur. The pulse is slippery and rapid.

Bi-syndrome due to phlegm and blood stagnation
In recurrent bi-syndrome, internal damage leads to the formation of phlegm and blood stasis, and symptoms become more serious. Joint pain can worsen and joints become deformed or swollen and movement is impaired. There is severe pain and numbness in the limbs and nodules form beneath the skin. On examination, the tongue is bulky and pink, with bruising, and covered with white and greasy fur. The pulse is thready and uneven.

Bi-syndrome with associated liver and kidney damage
When the circulation of blood and qi is affected over a long period, vital energy (qi) becomes exhausted. The accumulated evils then commonly damage organs such as the liver and kidneys. Individuals usually present with internal damage: fatigue, pallor, shortness of breath, spontaneous sweating, improper joint movement, and soreness and pain in the loin region. On examination, the tongue is pink in color. The pulse is fine or fine and weak.

Treatment

Treatment of bi-syndrome in TCM can involve the use of a combination of therapies, such as herbal remedies, acupuncture and qi-gong.

Herbal therapy

Bi-syndrome due to wind, cold and dampness evils
Therapeutic aim:
To dispel wind, cold and dampness evils, and remove obstructions in the meridians.

Prescription:
 Modified Yiyiren decoction.

qiang huo incised notopterygium rhizome
du huo double-teeth pubescent angelica root
fang feng divaricate saposhnikovia root
chuan wu common monkshood mother root
ma huang ephedra
gui zhi cassia twig
yi yi ren coix seed
cang zhu atractylodes root
dang gui Chinese angelica
chuan xiong Szechwan lovage root
sheng jiang fresh ginger
gan cao liquorice root

In this prescription, qiang huo, du huo and fang feng help to eliminate wind and dampness evils; chuan wu, ma huang and gui zhi clear cold evil and warm the meridians; yi yi ren and cang zhu tonify the spleen and eliminate dampness evil; dang gui and chuan xiong improve blood production and activate blood circulation; and sheng jiang and gan cao tonify the spleen and middle burner.

Bi-syndrome due to wind, cold and heat evils 
Therapeutic aim: To eliminate heat, wind and dampness evils, and remove obstructions in the meridians.
Prescription: Modified Baihu Guizhi decoction 

sheng shi gao unprocessed gypsum
zhi mu common anemarrhena root
gan cao liquorice root
jing mi polished round-grained rice
gui zhi cassia twig

In this prescription, sheng shi gao, zhi mu, gan cao and jing mi clear the heat evil and help soothe its symptoms; and gui zhi eliminates the wind evil in the meridians. 

Bi-syndrome due to phlegm and blood stagnation

Therapeutic aim: To expel wind evil, remove phlegmblood stasis and obstructions in meridians.
Prescription: Modified Taohong drink

tao ren peach seed
hong hua safflower
dang gui wei Chinese angelica
chuan xiong Szechwan lovage root
wei ling xian Chinese clematis

In this prescription, tao ren and hong hua activate the blood and eliminate stasis; dang gui wei and chuan xiong activate the blood and improve blood production; wei ling xian eliminates the wind and dampness evils, and removes obstructions in the twelve meridians. 

Bi-syndrome associated with liver and kidney damage 
Therapeutic aim: To benefit the liver and kidneys, and remove the cold, wind and dampness evils.
Prescription: Modified Duhuo Jisheng decoction

 

shu di huang processed rehmannia root
du zhong eucommia
niu xi achyranthes root
sang ji sheng Chinese taxillus herb
ren shen ginseng
fu ling Indian bread
gan cao liquorice root
dang gui Chinese angelica
chuan xiong Szechwan lovage root
du huo double-teeth pubescent angelica root
qin jiao large-leafed gentian
xi xin Manchurian wild ginger
gui zhi cassia twig

In this prescription, shu di huang, du zhong, niu xi and sang ji sheng benefit the liver and kidneys, and also strengthen the bones and tendons; ren shen, fu ling and gan cao replenish the vital energy (qi) and tonify the spleen; dang gui and chuan xiong nourish the blood and regulate ying-fen ; du huo, qin jiao, xi xin and gui zhi eliminate the wind, cold and dampness evils and help relieve the bi-syndrome.

 

Non-herbal therapy

Acupuncture and moxibustion
This is generally indicated for chronic bi-syndrome that results in deficiency ofvital energy (qi). For bi-syndrome caused by wind, cold and dampness evils, a combination of acupuncture and moxibustion is recommended. For bi-syndrome caused by wind, cold and heat evils, acupuncture alone is better.

The commonly used acupuncture points for pain relief are: 

Shoulder: jian-zhen and localized trigger-points
Wrist: yang-chi, wai-guan and he-gu
Elbow: he-gu, shou-san-li and qu-chi
Knee: yang-ling-quan and xi-yan duo
Ankle: zhong-feng, kun-lun, jie-xi and qiu-xu.

Qi-gong
Qi-gong assists in regulating the meridians and anyone with bi-syndrome can benefit from it. It activates the blood circulation and helps restore the balance of yin and yang in the body. Performing qi-gong can increase muscle strength and relieve pain. It also helps rehabilitate damaged joints. Suggested types of qi-qong are fang-song gongand nei-yang gong

Qi-gong is a breathing exercise that uses mental and physical training techniques for health maintenance and the prevention and treatment of disease. It uses the mind to control the breathing and spirit of the individual.

Prevention

There is no cure for gout. The therapeutic aim is to focus on symptom relief and to control the progress of the disorder. The following measures help to prevent attacks of gout:

Dietary control: eat a balance diet and avoid eating animal organs, bean products and fermented food such as preserved salty fish.
Abstain from drinking alcohol.
Maintain moderate body weight.
Try to avoid the risk factors of gout, such as stress, over-tiredness, low body temperature and accidents that may damage joints.
   
Drink plenty of water to encourage the excretion of toxins.
Western medicine taken for the condition should be on advice of a doctor. Both TCM and Western doctors should be informed of all the therapies being used to relieve gout symptoms.
   
Individuals with a family history of gout should undergo regular check-ups as they may be predisposed to the disorder.

Dietary measures
From the TCM viewpoint, both food and drugs come from the same source and food can vary in character. This means that food can promote health or have an adverse effect on it. In TCM, dietetic restraint is urged, meaning that some foods should be avoided in certain disorders or while certain medicines are being taken. For example, intake of salty food should be limited in edematous patients and a greasy diet avoided in cases of diarrhea. In gout, it is bean products, red meat, offal and fermented and salty foods that should be avoided.

 

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