Gout is a disorder of purine metabolism in which a high serum uric acid is found and there is deposit of urate crystals within joints causing exquisite pain and tenderness. The pharmacological treatment relies upon non-steroidal anti-inflammatory, drugs in the acute stage, and prophylactic drugs in the chronic state to control the level of circulating uric acid.
In traditional Chinese medicine an over-rich diet is thought to cause a build-up of damp and heat internally that causes phlegm to stagnate. There is also disturbance of the Spleen and Kidney. Treatment thus involves Spleen and Stomach acupuncture points (SP.3 and 6, and ST.36 and 40) to control heat and damp and reduce phlegm. Other local points are used according to the joint involved.
A case history is discussed illustrating the treatment and a series of 10 patients is reported in which there is a 70% success in reducing the chronic level of serum uric acid and the frequency' of acute attacks.
Acupuncture, Gout, Traditional Chinese medicine.
Gout is a disease of protein metabolism with symptoms most commonly manifest at the first metacarpo-phalangeal joint, but it can affect almost any joint or combination of joints and the patient may exhibit systemic symptoms. The typical presentation of gout is as exquisite pain and tenderness in a red, hot and swollen big toe. The acute attack usually settles within a few days, but may last several weeks. It is caused by the deposit of urate crystals; a raised serum uric acid therefore supports a diagnosis of gout, but confirmation must be through finding crystals in synovial fluid on microscopy, as there are other causes of hyperuricaemia, such as renal disease and malignancy, and the uric acid is not always abnormally high in acute attacks. The erythrocyte sedimentation rate (ESR) is also raised in an acute attack. There are no x-ray changes in the early stages, but in the advanced stage gouty calculus is deposited near the joint surface and appears as round defects in epiphyseal areas.
Treatment of the acute attack is with non-steroidal anti-inflammatory drugs (NSAIDs), particularly diclofenac or indomethacin, together with rest of the affected part, avoidance of alcohol and purine-rich foods, and omission of drugs such as the thiazide diuretics that may raise serum uric acid.
Patients having recurrent attacks or evidence of chronic disease such as renal damage or joint tophi may need prophylactic treatment with the xanthine-oxidase inhibitor, allopurinol, or a uricosuric drug such as probenecid to reduce uric acid levels. Life-style modification is an essential element in treatment. There should be advice on weight loss, and reduction of alcoholic drink and protein consumption, particularly those rich in purine such as red meat, oily fish, beer and port wine. Gout in the elderly may be mistaken for osteoarthritis, and the differential diagnosis must include infective arthritis.
Traditional Chinese interpretation
Historically, reports of gout are to be found in Chinese medical works through the ages. In ancient times it was termed lijie (arthritis) -wind, white tiger lijie or dry beriberi. It is mentioned in Zhang Zhong-jing's Essential Prescriptions of the Golden Chamber ( 1).
Zhang Zhong-jing, a master acupuncturist in about AD 300, during the Eastern Han dynasty, made a thorough study of classical texts such as Plain Questions, Canon of Acupuncture, Classic on Medical Problems and the early Song Dynasty works by Lin Yi, whose subjects include miscellaneous internal diseases, women's disorders, emergencies and dietary restrictions. He also collected extensively other effective prescriptions discovered by himself or in use by his physician colleagues. He wrote a treatise combining what he had learned from the ancient texts with his own observations in clinical practice. The book's title is Treatise on Febrile and Miscellaneous Diseases. He analyses and differentiates the febrile diseases according to the theory of the six channels, and the miscellaneous diseases according to their visceral and bowel interrelation and pathalogical changes. In doing so he establishes the theoretical system and therapeutic principles of Chinese medicine: that is, diagnosis and treatment based on the analysis of signs and symptoms, and it lays a foundation for the development of clinical medicine. Later generations have divided it into two books: the Treatise on Febrile Diseases in which there are 113 prescriptions described, and Essential Prescriptions of the Golden Chamber which details 262 prescriptions, some of which have been duplicated from the first book, giving a total of 269 in all. These prescriptions are still used in every department of clinical medicine and form the base for the study of prescription in all subsequent books.
Also, Zhang-si Yitong (Medical Understanding of Mr Zhang) ( 2) states that "the syndrome of gout in Spiritual Axis is termed as 'thief wind'". In Plain Questions ( 3), part (along with Miraculous Pivot) of the Yellow Emperor's Classic of Internal Medicine ( 4), it is called bi (rheumatism).
Traditional Chinese medicine (TCM) holds that the main cause of the disease is rich and greasy food which leads to internal pent-up heat and damp with the wind and cold invading channels and collaterals and blocking the movement of qi and fluids. This causes stasis of damp and heat that are thus transformed into phlegm which stagnates in the collaterals causing swelling and hot pain in the joint.
Another factor may be physical weakness, particularly due to ageing, leading to disturbance in the function of Spleen and Kidney. The disease is commonly manifested at the first metatarso-phalangeal joint, through which the Spleen channel passes.
Traditional treatment is therefore aimed to clear heat and damp, disperse phlegm and remove stagnancy, dredge the channels to stop pain, and regulate the function of the Spleen and Kidneys. Patients should be advised to avoid over-fatigue, wind and cold for the duration of treatment, and the diet and lifestyle need to be controlled: alcohol and smoking should be reduced or given up.
We observe the following method in acupuncture treatment: The points Taibai (SP. 3), the Yuan (Primary) point of the Spleen channel, and Zusanli (ST.36), the He (Sea) point of the Stomach channel, are selected to strengthen the function of Spleen and Stomach, clear heat and remove damp. In addition, two complementary points are used: Fenglong (ST.40) reduces phlegm and dredges the channels, and Sanyinjiao (SP.6), the crossing point of the three yin channels of the foot, helps reinforce the Spleen and Kidney, regulate qi and blood, and also clears heat, removes damp, purges toxin and disperses stagnancy.
Local points are used according to the affected joint: Taichong (LR.3), the Yuan (Primary) point of the Liver channel, Taibai (SP.3), the Yuan (Primary) point of the Spleen channel, and Dadu (SP.2), the Ying (Spring) point of the Spleen channel, are selected to purge heat and toxins in the blood when joints of the foot are involved, and Waiguan (TE.5) and tender (ashi) points are used for disease in the joints of the hand.
The points are manipulated with a pinch skin method, but in acute cases a reducing method of lifting and thrusting is used. During convalescence, the method of even reducing and reinforcing is used. The needles are retained for an hour at each treatment and, in order to reinforce the effect, they may be electrically stimulated to the maximum intensity acceptable to the patient. The treatment is given daily or on alternate days, with ten treatments constituting a course. Advice on life-style changes, particularly diet and fluid intake, is also given.
We judge the therapeutic effect on the following criteria:
Full recovery: The clinical symptoms totally disappear and the serum uric acid and ESR falls to normal. There is no recurrence within a year of recovery.
Markedly improved: The clinical symptoms totally disappear and the serum uric acid level decreases by more than 3mg/100ml.
Improved: The clinical symptoms disappear or are relieved, and the serum uric acid decreases more than 1mg/100ml. The interval between recurrences increases.
Not improved: The symptoms and the serum uric acid level remain unchanged.
A 77 year old man was brought in by his family complaining that he had been suffering from swelling and pain in the big toe joint of the left foot for more than 10 years. A particularly severe acute attack had started a week prior to his hospital visit and had not yet abated.
Initially the pain in his first metatarso-phalangeal joint had been lasting only two or three days at a time, but the attacks had grown more frequent and severe. The pain had for a long time been ineffectually treated as osteoarthritis with non-steroidal anti-inflammatory drugs, but eventually the disease was diagnosed as gout, and two years of prophylacic drug treatment followed. This therapy failed to stabilise the condition and recurrences remained frequent. In this current attack, he had suffered unbearable, hot, swelling pain, and had had difficulty walking and sleeping. His serum uric acid was 9.8mg/100ml and the ESR was 68mm/h. Rheumatoid factor, blood picture and alkaline phosphatase were all normal.
He was treated with acupuncture to ST.36 and 40, SP.6, left SP.3 and LR.3. After needling on three successive days, the pain had improved and he was able to walk unaided for 10 minutes. Two weeks later, the swelling and hot pain had nearly gone and the serum uric acid had dropped to 8.8mg/100ml; the ESR was 72mm/h.
After 3 courses of ten treatments each, his uric acid was 7.9mm/100ml, the ESR was 57mm/h and all symptoms had virtually gone, apart from a few brief relapses on cloudy days. A fourth course of treatment saw a decrease in ESR to 10mm/h, and by the sixth course only a little soreness was felt in the affected joint and the uric acid level had returned to normal. One further course was given to stabilise the therapeutic effect. Since then no relapse has been reported at the four month or one year follow-up.
We treated a group of 10 gouty patients: 7 male and 3 female, with an age range of 14 to 77 years, 7 being over the age of 55. The shortest duration of the gout was one month and the longest 10 years. In 8 cases the big toe was affected and in 2 cases a finger. Of the 10 patients treated, 3 achieved full recovery, 4 were markedly improved, 2 improved and one had no benefit; thus there is significant benefit in 70% of these patients. The average number of treatments given was 30, with a range of from 8 to 72 treatments.
The diagnosis of gout was made clinically by the sudden onset of fiery pain in a red, hot, swollen joint accompanied by a serum uric acid in excess of normal, which we took as over 6mg/100ml, and an elevated ESR. In the advanced stages of the disease this was confirmed by noting the x-ray changes, but we were unable to perform synovial fluid microscopy, so a definitive diagnosis could not be made.
This work was done while the team was working on secondment in Zanzibar. Frustratingly much of the clinical and laboratory detail was lost when we returned to our hospital base in China. As a result, conclusions that we regarded as definite can not be presented as such because of the lack of corroborative evidence.
Since acute attacks of gout normally settle naturally within a short period of time, it is not possible to claim that our acupuncture treatment produced a positive response in acute gout, although we believe that our patients gained faster and more complete relief with acupuncture. However, because the majority of the patients suffered from chronic gout and could give detail of the frequency of their exacerbations, we are able to claim benefit in the reduction of the number of acute attacks and the serum uric acid levels which we measured: we have demonstrated a significant improvement in 70% of our patients after a varying number of courses of acupuncture.
Pang Jun, Huang Bo-ling, Li Yu-shun, Zhou Yu-yan
Nan Jing Traditional Chinese Medical Hospital, China
Shaanxi Institute of Finance and Economics, Xi'an, China
Mnazi Mmoja Hospital, Zanzibar, Tanzania
Address for Correspondence
Box 15-3-302, Post code 710061, Shaanxi Institute of Finance and Economics, Xi'an, China
1. Zhang Zhong-jing. Essential prescriptions of the golden chamber. China; c.AD 300.
2. Zhang Lu. Zhang-si Yitong [Medical understandings of Mr Zhang]. China. Qing dynasty. [Modern publication: Shanghai: Science and Technology Press; 1963].
3. Plain Questions. China; Warring States period. [Modern publication: Beijing: People's Health Press; 1963].
4. Veith I, trans. The Yellow Emperor's classic of internal medicine (Huang Ti Nei Ching Su Wen). Berkeley: University of California Press; 1972.
By Pang Jun; Huang Bo-ling; Li Yu-shun and Zhou Yu-yan