Professor Yan Jun-bai’s experience in treating rheumatic arthritis with suppurative moxibustion

Liu Su-jun (刘素君), Zhou Jun-mei (周俊梅), Liu Peng (刘鹏), Wei Fang (韦芳), Yan Chen (严晨), Xu Si-wei (徐斯伟), Zhang Bi-meng (张必萌), Yan Jun-bai (严君白)

Shanghai First People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China

Famous Doctor’s Experience

Professor Yan Jun-bai’s experience in treating rheumatic arthritis with suppurative moxibustion

Liu Su-jun (刘素君), Zhou Jun-mei (周俊梅), Liu Peng (刘鹏), Wei Fang (韦芳), Yan Chen (严晨), Xu Si-wei (徐斯伟), Zhang Bi-meng (张必萌), Yan Jun-bai (严君白)

Shanghai First People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China

To summarize the clinical experience of Prof. Yan Jun-bai in treating rheumatic arthritis (RA) with suppurative moxibustion and aim to guide acupuncture treatment for RA. Prof. Yan believes that contributing factors of RA include external contraction of pathogenic factors, obstructed flow of qi and blood, internal phlegm-turbidity (due to deficiency of healthy qi or improper diet), and obstruction or malnourishment of meridians. As a result, the treatment strategies are to warm yang, remove pathogenic factors, and tonify the liver, spleen and kidney. Suppurative moxibustion is a reliable therapy for RA.

Arthritis, Rheumatoid; Moxibustion Therapy; Direct Moxibustion; Scarring Moxibustion; Famous Doctor’s Experience; Yan Jun-bai

Prof. Yan Jun-bai, male, born in Pinghu City, Zhejiang Province in 1932, is the 6th-generation successor of Yan’s acupuncture. Strongly influenced by his father and brother, Prof. Yan started to learn Chinese medicine when he was young. In 1956, he attended the Shanghai College of Traditional Chinese Medicine. After graduation in 1962, he started practice of Chinese medicine. His work experience includes: the director of Acupuncture Department, Shanghai First People's Hospital, the deputy chief of China Acupuncture Center in Morocco, the council member of Shanghai Acupuncturemoxibustion Association, a professor of Shanghai Medical University (now Fudan University Medical College) and an expert who enjoys the State Council Special Allowance. He has been invited many times to Japan and Morocco to give lectures on acupuncture. Currently, Prof. Yan is the successor of Yan’s acupuncture (Intangible Cultural Heritage Project in Xuhui District, Shanghai) and a tutor at Yan Jun-bai’s Work Room for Famous Doctors.

Having dedicated to Chinese medicine and acupuncture for more than 60 years, Prof. Yan is especially good at treating autoimmune disorders such as rheumatic arthritis (RA) by suppurative moxibustion. He believes that RA mainly results from deficiency of healthy qi or hidden pathogenic factors coupled with external contraction of pathogens. As a result, the treatment strategies are to reinforce healthy qi and remove pathogenic factors. His experience in this regard is now summarized as follows.

1 Etiology and Pathogenesis of RA

Prof. Yan thinks that the contributing factors of RA include external contraction of pathogenic factors, obstructed circulation of qi and blood and internal phlegm-turbidity (due to deficiency of healthy qi or improper diet) and obstruction or malnourishment of meridians.

1.1 Obstructed flow of meridian qi and blood due to external contraction of pathogenic factors

In Chinese medicine, RA falls under the category of Bi-impediment syndrome, which results from obstructed flow of meridian qi and blood due toexternal contraction of wind, cold and dampness[1]. Clinically, Bi-impediment syndrome is categorized into migratory Bi-impediment (due to preponderance of wind), painful Bi-impediment (due to preponderance of cold) and fixed Bi-impediment (due to preponderance of dampness)[2].

1.2 Obstructed flow of meridian qi and blood due to deficiency of health qi coupled with external contraction of pathogenic factors

The underlying pathogenesis of RA lies in deficiency of healthy qi coupled with external contraction of wind, cold, dampness and heat. These factors may obstruct the joints and meridians and result in Bi-impediment syndrome. It’s said in theHuang Di Nei Jing(Yellow Emperor’s Classic of Internal Medicine) that: ‘with abundant healthy qi, one won’t get sick’. Since healthy qi is closely associated with the liver, spleen and kidney, these three organs are especially related to RA occurrence and development[3].

1.3 Malnourishment of muscles/tendons due to improper diet and internal phlegm-turbidity

Excessive ingestion of sweet and fat food can damage the transportation and transformation of the spleen and stomach, leading to internal phlegm-turbidity to obstruct the flow of qi. Excessive ingestion of sour food can damage the liver, and excessive ingestion of salty food can damage the kidney. Deficiency of liver blood and kidney essence can further cause malnourishment of tendons and bones, resulting in RA[4]. Consequently, improper diet is another important factor contributing to RA.

2 Treatment Strategy and Method of RA

Prof. Yan believes that the essential pathogenesis of RA involves damage to the liver, spleen and kidney due to healthy qi deficiency coupled with external contraction of pathogenic factors or improper diet. The treatment strategies are therefore to warm yang, remove pathogenic factors, tonify the liver, spleen and kidney, and strengthen the tendons and bones. In acute stage, the treatment mainly aims to remove pathogenic factors, plus tonify healthy qi and warming yang. As a result, patients are treated with acupuncture and herbal formula to unblock meridians and warm yang. In remissive stage, the treatment mainly aims to reinforce healthy qi and yang, assisted by regulating the liver, spleen and kidney and strengthening the tendons and bones. As a result, patients are treated with suppurative moxibustion at Dazhui (GV 14), bilateral Gaohuang (BL 43), Ganshu (BL 18), Pishu (BL 20) and Shenshu (BL 23). Dazhui (GV 14) activates yang qi of the Governor Vessel which is the sea of all yang meridians[5]. Gaohuang (BL 43) in this article is located below the spinous process of T5(traditionally T4in textbooks) and 3 cun lateral to the spine. It stores pectoral qi and is closely associated with vital activities[6], pectoral qi is essential to maintain free qi activities of the entire body.

3 Yan’s Suppurative Moxibustion for RA

3.1 Theoretical features

Prof. Yan believes RA occurs as a result of healthy qi deficiency coupled with external contraction of wind, cold, dampness and heat. Modern studies have confirmed that compromised immunity can make people vulnerable to virus and bacteria. In addition, pathogenic factors are harder to remove in people with compromised immunity, which are known as hidden pathogenic factors in Chinese medicine. Since wind is the spearhead of other pathogens, it’s often mixed with other factors when attacking the body. All types of Bi-impediment syndrome are associated with wind to a certain extent. As a result, RA falls under the category of wind syndrome in Prof. Yan’s opinion. Considering yang qi deficiency in most RA patients, it’s not advisable to use too many points for suppurative moxibustion in order to damage yang qi instead of reinforcing healthy qi and warming yang. Generally, patients need to rest for approximately one month after moxibustion. It’s also important to limit sexual activity but to eat more stimulating food to induce suppuration.

3.2 Location of points

Prof. Yan thinks the accurate locations of points are directly associated with the treatment effect. Unlike descriptions in the textbooks, the point locations in Yan’s family are more similar to that of a Japanese acupuncturist named Sawada[7]. They both believe that except for Ba Liao [Shangliao (BL 31), Ciliao (BL 32), Zhongliao (BL 33) and Xialiao (BL 34)] points, points on the Governor Vessel and the Bladder Meridian are located one vertebra inferior to the vertebra recorded in the textbooks. Let’s take Dazhui (GV 14) for example, it’s generally believed that it’s located in the depression below the spinous process of C7[8-9]; however, Yan’s ancestors argued that its real location should be in the depression below the spinous process of T1, at the same level of Jugu (LI 16)[10].

3.3 Moxibustion season

Yan’s suppurative moxibustion is often conducted between the Slight Heat (11th solar term) and White Dew (15th solar term) to balance yin and yang and remove hidden pathogenic factors. Chinese medicine maintains ‘nourishing yang in spring and summer, and nourishing yin in autumn and winter’. Yang qi flourishes in the hottest summer days, so moxibustion at this time can activate yang qi and eradicate cold from the body because of the opening skin pores and smooth circulation of qi and blood[11].

4 Suppurative Moxibustion Method for RA

Most RA patients have yang deficiency. As a result, Dazhui (GV 14) and bilateral Gaohuang (BL 43) are often selected for the first course of treatment. Dazhui (GV 14) activates yang qi of the Governor Vessel. Gaohuang (BL 43) reinforces the deficient Zang organs. The two points can reinforce healthy qi, warm yang and remove pathogenic factors. The specific method is described as follows [taking Dazhui (GV 14) as an example].

4.1 Point location

The patient was asked to sit upright, straighten up the low back and place the hands over the knees or cross the hands to place on the contralateral shoulder to square the back. The point is located in the depression below the spinous process of T1, approximately at the same level of Jugu (LI 16). Then the point was marked using gentian violet or mercurochrome, followed by a circle of 1 cm in diameter for direct moxibustion.

4.2 Body position

Then the patient was asked to take a prone lying position to fully expose the treatment area. It’s better to conduct moxibustion after eating food or feeling energetic.

4.3 Moxibustion method[12]

Moxa cones of 8 mm in bottom diameter and 5 mg in weight were made with extremely fine and old mugwort floss. Spread some garlic juice over the moxibustion area and place the moxa cone on the area. Then ignited the moxa cone using incense stick and exchanged for a total of 7 cones. When the patient felt a burning pain, the practitioner could tap the area surrounding the point with the thumb, index or middle fingers (high frequency and appropriate force) to alleviate pain and circulate qi and blood. The local skin became dark and hard after moxibustion. The moxibustion sore was covered with Yan’s special paste. The paste was exchanged every day. The suppuration usually took 3-10 d. It’s not necessary to conduct debridement of moxibustion sore. More pus indicates a better effect.

4.4 Cautionary notes

Only one point was selected for one treatment. A group of points consist 2-3 points. The suppurative moxibustion was done within one week, followed by plenty of rest (1-2 months) afterwards. It’s important to remind the patients to limit sexual activity but to eat more stimulating food to induce suppuration. For patients with a poor constitution, it’s also necessary to take Chinese herbal decoction to induce suppuration and enhance the treatment effect.

4.5 Case studies

4.5.1 Case one

A 53-year-old female patient came for the first visit on 6th of August, 2012.

Chief complaints and history of present illness: Symmetrical joint swelling and pain in four limbs for 9 years and aggravated over the recent 1 month. The patient has been treated intermittently with acupuncture, cupping, adhesive plaster, oral administration of Chinese medicine and Western drugs (no detailed information). The symptoms sometimes got better but sometimes got worse. The condition was often induced or aggravated by fatigue or common cold. At the time of treatment, the patient developed swelling and pain in bilateral ankle, elbow and knee joints, coupled with morning stiffness for 1 hour or longer period of time. In addition, the patient was susceptible to common cold. The swelling and pain below the ankle and knee joints became more pronounced over the recent month. She hadn’t received other therapies.

Diagnosis: RA.

Treatment: Yan’s suppurative moxibustion.

Method: One course of treatment at Dazhui (GV 14) and bilateral Gaohuang (BL 43).

Return visit on 9th of August, 2013: The patient had significantly decreased frequencies of common cold and RA attack, coupled with improved body constitution. The same moxibustion method was conducted at bilateral Shenshu (BL 23) and Mingmen (GV 4).

Return visit on 25th of August, 2014: The patient had not contracted common cold in the last year, coupled with decreased frequencies of RA attack. The same moxibustion method was conducted on bilateral Ganshu (BL 18) and Qihai (CV 6).

The follow-up telephone interview a couple of months later found less frequencies of RA attack and the patient wished to continue with suppurative moxibustion to consolidate the treatment effects.

Note: Points on the back can regulate functions of Zang-fu organs and strengthen the connection between internal organs with the surface of the body. The Governor Vessel regulates yang qi of the entire body. Dazhui (GV 14) is a gathering point of all yang meridians and therefore often used to reinforce yang. Gaohuang (BL 43) is indicated for all types of deficiencies. Direct moxibustion at these two points can regulate yang qi of five Zang and six Fu organs and unblock qi activity of the body and remove pathogenic factors out of the body. Direct moxibustion at Ganshu (BL 18) and Shenshu (BL 23) can tonify the liver and kidney. Qihai (CV 6) and Mingmen (GV 4) are two important healthcare points. A combination of all above points can warm and reinforce kidney yang and regulate qi activity of the body.

4.5.2 Case two

A 35-year-old female patient came for the first visit on 20th of July, 2012.

Chief complaints and history of present illness: A joint pain in the small toe of the right foot started in 2004, which was gradually followed by pain, swelling andlimited movement of the wrist joints, pain in multiple interphalangeal joints and morning stiffness. In 2007, the patient was diagnosed as RA in Shanghai Renji Hospital. Since then, she had been treated with both Chinese and Western medicine (no detailed information). At the time of the treatment, the patient complained of pain, swelling and restricted motion of wrist joints and interphalangeal joints of the small and index fingers, coupled with a poor appetite and loose stools.

Diagnosis: RA.

Treatment: Acupuncture combined with Chinese herbal medicine, because this patient was scared of direct moxibustion.

Method: Ten times of acupuncture at Shousanli (LI 10), Zusanli (ST 36), Yangchi (TE 4), Yanggu (SI 5) and Yanglao (SI 6).

Return visit on November 2012: The patient had alleviated pain in the wrist joints and interphalangeal joints of the small and index fingers. Considering the poor appetite and loose stools due to spleen yang deficiency, a cream formula was prescribed to strengthen spleen qi, warm yang and unblock meridians.

Formula:Dang Shen(Radix Codonopsis) 200 g,Sheng Shai Shen(Radix et Rhizoma Ginseng Cruda) 150 g,Dang Gui(Radix Angelicae Sinensis) 200 g,Qin Jiao(Radix Gentianae Macrophyllae) 60 g,Zhi Huang Qi(Radix Astragali Praeparata cum Melle) 180 g,Bai Shao(Radix Paeoniae Alba) 120 g,Xu Duan(Radix Dipsaci) 120 g,Shan Yao(Rhizoma Dioscoreae) 120 g,Bi Xie(Rhizoma Dioscoreae Hypoglaucae) 90 g,Sang Ji Sheng(Herba Taxilli) 120 g,Chong Wei Zi(Fructus Leonuri) 100 g,Shan Yu Rou(Fructus Corni) 90 g,Sheng Shou Wu(Radix Polygoni Multiflori) 120 g,Gou Ji(Peni et Testes Canitis) 150 g,Hu Zhang(Rhizoma Polygoni Cuspidati) 90 g,Du Zhong(Cortex Eucommiae) 150 g,Sheng Di Huang(Radix Rehmanniae) 150 g,Shu Di Huang(Radix Rehmanniae Praeparata) 150 g,Sha Ren(Fructus Amomi) 24 g,Huai Xiao Mai(Fructus Tritici) 120 g,You Song Jie(Lignum Pini Nodi) 150 g,Di Bie Chong(Eupolyphaga seu Steleophaga) 50 g,Sang Zhi(Ramulus Mori) 80 g,Gui Zhi(Ramulus Cinnamomi) 30 g,Mu Gua(Fructus Chaenomelis) 50 g,Bie Jia Jiao(Colla Carapacis Trionycis) 120 g,E Jiao(Colla Corii Asini) 240 g, crystal sugar 240 g and rice wine 500 g.

Decoction method: Except forBie Jia Jiao(Colla Carapacis Trionycis),E Jiao(Colla Corii Asini), crystal sugar and rice wine, the other herbs were decocted with water for 3 times. After filtration, mixed the decoction with yellow rice meltedBie Jia Jiao(Colla Carapacis Trionycis) andE Jiao(Colla Corii Asini) to condense into sugarless paste. Then dissolved the paste with crystal sugar and water and made concentrated paste. The paste was taken twice a day, 10 g for one dose.

Return visit on 11th of July 2013: Since the middle of March in 2013, the patient started to experience pain and severe swelling in right wrist joint and interphalangeal joints of the small and index fingers. The symptoms alleviated upon oral administration of immunosuppressants such as methotrexate and chloroquine. Then she was treated with acupuncture and Chinese herbal medicine. In addition, she agreed to receive suppurative moxibustion on 15th of August.

The suppurative moxibustion started on 15th of August, 2013. Dazhui (GV 14) and bilateral Gaohuang (BL 43) were used for the first course of treatment within one week. One point was selected for one treatment (a total of 9 cones).

Return visit on 31st of October 2013: The patient had significantly alleviated symptoms, except for pain, swelling and restricted movement of the right wrist joint. Her bowel movements became normal. The tongue was pale with a thin coating. The pulse was thready. As a result, a formula was prescribed to strengthen the spleen and resolve dampness. Ingredients:Chao Bai Zhu(Rhizoma Atractylodis Macrocephalae) 12 g,Ban Xia(Rhizoma Pinelliae) 9 g,Ju Hong(Exocarpium Citri Rubrum) 6 g,Hou Pu(Cortex Magnoliae Officinalis) 4 g,Shi Hu(Caulis Dendrobii) 12 g,Yu Jin(Radix Curcumae) 9 g,Bai Dou Kou(Fructus Amomi Kravanh) 3 g (decoct later),Xian Ling Pi(Herba Epimedii)9 g,Ze Xie(Rhizoma Alismatis) 9 g,Shan Yao(Rhizoma Dioscoreae) 12 g,Jiao Shan Zha(Fructus Crataegi Fermentata Praeparata) 10 g andJiao Shen Qu(Massa Medicata Fermentata Praeparata) 10 g. One formula was decocted with water for 400 mL (daily dose), 200 mL in the morning and 200 mL in the evening, for a total of 7 d. Acupuncture points: bilateral Pishu (BL 20) and Shenshu (BL 23) (swift insertion and immediate removal upon qi sensation), Waiguan (TE 5) towards Neiguan (PC 6) on the right arm, and Yangchi (TE 4), Yanggu (SI 5), Yangxi (LI 5) and Hegu (LI 4) towards Laogong (PC 8) on the right side. The needles were retained for 20 min.

Return visit on 28th of May, 2014: The patient had significantly decreased frequency and severity of joint pain. She came back because of joint pain after gradually discontinuing methotrexate. She presented with an intolerance of cold but basically normal bowel movements. The tongue was pale with teeth marks and a white coating.

For acupuncture treatment, bilateral Dazhu (BL 11) and Houxi (SI 3) on the right side were combined. For herbal formula,Shi Hu(Caulis Dendrobii) was removed; andYan Hu Suo(Rhizoma Corydalis) 9 g andWei Ling Xian(Radix et Rhizoma Clematidis) 9 g were combined, for a total of 7 formulae.

Afterwards, the patient was treated with 1-2 acupuncture a week and herbal decoction every day. Her joint pain and neck stiffness gradually alleviated.

Return visit on 2nd of July, 2014: The patient had significantly alleviated joint pain. Suppurative moxibustion was then conducted to cultivate Yuan-primordial qi and warm yang. Shenzhu (GV 12) and Zhiyang (GV 9) were selected for direct moxibustion, one point a day for 2 d and 7 cones for each point. During these two days, the patient discontinued oral administration of Chinese herbal medicine but continued with the acupuncture treatment.

The follow-up telephone interview a couple of months later found that the patient had significantly less frequency of RA attack; however, she still had pain and was willing to continue with moxibustion.

Note: Since this patient was diagnosed with deficiency in the root cause and excess in symptoms, acupuncture treatment was employed to unblock meridians and alleviate pain; the cream formula was prescribed to strengthen the spleen, reinforce qi and warm yang; and suppurative moxibustion was combined to remove hidden pathogenic factors out of the body. Moxibustion at Dazhui (GV 14) and Gaohuang (BL 43) can regulate yang qi of Zang-fu organs, unblock qi activity of the whole body, reinforce healthy qi, remove pathogenic factors and alleviate pain.

5 Conclusion

RA is a chronic autoimmune disorder. Prof. Yan used suppurative moxibustion for this condition because direct moxibustion can cause blisters, suppuration and result in suppurative inflammation. Modern studies have confirmed that moxibustion can regulate the immune system[13-15]. During the whole suppurative process, moxibustion can generate antibodies to remove hidden pathogenic factors out of the body[16-17].

The neuroendocrine immune system can modulate harmful interferences to the body to maintain health. Direct moxibustion can activate this system to restore systemic functions, remove pathogenic factors and obtain health.

Conflict of Interest

There was no potential conflict of interest in this article.

Acknowledgments

This work was supported by Construction Project of Work Room for Academic Experience of Famous Physicians of Traditional Chinese Medicine in Shanghai (上海市名中医学术经验研究工作室建设项目，No. ZYSNXD-CC-MZY023); Supporting Project for Schools of Shanghai Traditional Chinese Medicine and Special Technique (海派中医流派及特色技术扶持项目, No. ZYSNXD-CC-HPGC-FC-011).

Received: 23 December 2014/Accepted: 29 January 2015

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Translator: Han Chou-ping (韩丑萍)

严君白教授使用化脓灸治疗类风湿性关节炎经验介绍

总结严君白教授使用化脓灸治疗类风湿性关节炎(rheumatoid arthritis, RA)的临床经验, 以指导RA的针灸治疗。严教授认为RA多由感受外邪、正气虚弱或饮食失调引起的气血不通、痰浊内生、经络壅塞或筋脉失养所致。治疗应扶正温阳祛邪, 补益肝、脾、肾。采用化脓灸治疗RA疗效可靠。

关节炎, 类风湿; 灸法; 直接灸; 瘢痕灸; 名医经验; 严君白

R245.8 【

】A

Author: Liu Su-jun, master degree candidate

Zhang Bi-meng, M.D., associated chief physician, associate professor, a supervisor of master degree candidate.

E-mail: pjzhtiger08@aliyun.com