May I govern my passion with an absolute sway, and grow wiser and better,
as my strength wears away, without gout or stone, by a gentle decay.
─Walter Pope c.1630–1714
痛风 TONGFENG - GOUT - 毕正 BI ZHENG - BI PATTERNS
TRADITIONAL CHINESE MEDICINE PERSPECTIVE
In Chinese medicine, 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 Suwen ─The Book of Plain Questions, states that Bi-syndromes are due to a combined attack by 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 Qi and blood circulation. It is an obstructive disorder.
Bi means obstruction or blockage. Bi pattern describes a set of patterns in which the invasion of external evils such as Wind, Cold, Dampness and Heat obstruct the flow of Qi and Blood through the channels and connections. This affects the muscles, bones, tendons and joints, presenting symptoms of aching, pain, heaviness, numbness, difficulty of movement or redness and swelling. Bi patterns include several disorders known in Western medicine as osteoarthritis, rheumatoid arthritis, and gout, among others.
Etiology and Pathogenesis
The etiology of bi-syndrome in gout usually combines an internal or preexisting deficiency of correct Qi with external evils of wind, cold, damp or heat entering the body. Simultaneous invasion by wind, cold and damp is the most common. Bi patterns are considered in four classes based on the specific external evil and the differing clinical manifestations. Bi patterns involve LV, SP and KD. LV controls tendon, SP controls muscles and KD controls bones.
Wind-Bi or Feng-Bi: also known as wandering bi XING BI, is characterized by wind evil with pain roving through various locations. Major pain in joints.
Cold-Bi or Leng-Bi: also known as painful bi TONG BI, is characterized by the accumulation of cold with severe pain in the channels.
Damp-Bi or Ji-Bi: also known as fixed bi ZHAO BI, is characterized by the accumulation of dampness with muscular and joint numbness, aching, heaviness, swelling and pain of fixed location.
Heat-Bi Re-Bi: is characterized by fever and red, swollen, and painful joints. Its causes include invasion by heat evil; untreated and chronic Cold-Dampness-Bi that has transformed into heat; or constitutions of either profuse Yang or deficient Yin, that have transformed external evils to heat.
All bi patterns involve obstruction of the channels and connections inhibiting the flow of Qi and Blood. Gout as a chronic case of bi, regardless of a particular evil’s dominance, presents two major categories of pathological change.
The first includes manifestations of blood-stasis and phlegm-turbidity such as stasis macules on the tongue, nodes in the area of affected joints and swelling, and difficulty moving the joints.
The second involves symptoms of deficient Qi and Blood. The severity will vary according to the injury and depletion of Qi and Blood during the illness.
TCM Patterns
- Wind-Dominant Bi
- Cold-Dominant Bi
- Dampness-Dominant Bi
- Heat-Dominant Bi
- Bi with Blood Stasis and Phlegm-Turbidity
- Bi with Depletion of Qi and Blood, KD and LV Deficiency
1.Wind-Dominant Bi
Symptoms: Roaming pain in the joints and limbs, pain of indeterminate locations, difficulty in flexion and extension of joints, aversion to cold and in some cases, fever.
Tongue: Thin white coating.
Pulse: Wiry, floating.
Treatment Strategy: Dispel wind, clear the connections, dissipate cold, and drain dampness. For wind problems treat blood first with UB17 and SP10, then needle the rest.
2.Cold-Dominant-Bi
Symptoms: Severe pain of the joints and limbs, pain of fixed location accompanied by sensation of cold, decrease in pain with application of heat, increase in pain upon exposure to cold, without redness or feverishness of joints, with difficulty moving the affected parts.
Tongue: Thin white coating.
Pulse: Tight, wiry.
Treatment Strategy: Dissipate cold, warm the connections, dispel wind, and drain dampness.
3.Dampness-Dominant-Bi
Symptoms: Heaviness and aching of the joints and limbs, distention and swelling in some cases, pain of fixed location, local numbness or loss of sensation, with symptoms often increasing during overcast or rainy weather. Swollen joints and dull pain.
Tongue: White slimy coating.
Pulse: Soft, tardy.
Treatment Strategy: Drain dampness, clear the connections, dispel wind, and dissipate cold.
4.Heat-Dominant Bi
Symptoms: Severe pain, local heat, redness and swelling; difficulty of movement affecting one or more joints accompanied with fever, sore throat, thirst, irritability and dark, scanty urine.
Tongue: Yellow coating.
Pulse: Rapid, slippery.
Treatment Strategy: Drain heat, clear the connections, dispel wind, drain dampness.
5.Bi with Blood Stasis and Phlegm-Turbidity
Symptoms: In each of the above bi patterns, chronic illnesses that have not been properly treated lead to blood stasis and phlegm-turbidity. This blocks the channels, connections and joints. Symptoms include swelling, stiffness and deformity of the joints, incessant pain and complete immobility.
Tongue: Dark or purple, with white slimy coating.
Pulse: Deep-rough, or deep-slippery.
Treatment Strategy: Dispel stasis, transform phlegm, free the connections, relieve pain.
6.Bi with Depletion of Qi and Blood, KD and LV Deficiency
Symptoms: Prolonged cases of bi pattern often present symptoms of depletion of Qi and Blood as well as deficiency of the LV and KD. These include aching pain in the lower back and knees, difficulty in the flexion and extension of joints, numbness or loss of sensation in affected areas, palpitations and shortness of breath, in some cases aversion to cold and symptoms relieved by warmth.
Tongue: Pale with white coating.
Pulse: Weak, thready.
Treatment Strategy: Supplement Qi and Blood, benefit LV and KD, dispel wind, cold and dampness.
MISCELLANEOUS REMEDIES FOR GOUT FLARE-UPS
Chinese Barley Drink ─ Chinese Barley/Job’s Tears and not Pearl Barley
1 Cup of Chinese Barley/Job’s Tears
2 litres of water
Candied winter melon (optional)
Rinse and soak the Chinese barley for a few hours.
Bring the barley, water, and candied winter melon, if using, to a boil in a pot. Reduce the heat and let it simmer for 30 minutes until the grains are softened and cooked. Add more water if necessary.
Strain the barley water.
Drink 2-3 times a week to reduce heat dampness of the body. As Chinese Barley tea is cool-natured, it is not advisable for people who feel cold easily to drink it often.
Birch Tree
Hua Mu Pi, Hong Hua Pi
Common name: Asian White Birch Bark, Japanese White Birch Bark
Meridians: Lung
Constituents: Flavonoids (hyperoside, quercitin, luteolin), Volatile oil, Salicylates, tannins, resins, saponins, betulin & betulinic acid.
Actions: Clears Heat/Relieves Inflammation, Tonic, analgesic, antiseptic, anti-inflammatory, astringent, diaphoretic, bitter, cholagogue, mild laxative, diuretic, antispasmodic.
Parts used: Young leaf and bark
Medicinal use: Promotes the detoxification of waste products from the body such as uric acid. Can be used in arthritis, rheumatism, gout, muscular and arthritic pain. Topically, the fresh wet bark placed over affected area ─inner side touching the skin, helps to alleviate 
muscle pain.
Pharmacology: The flavonoids in leaf are diuretic. Volatile oils contain methyl-salicylates with antiseptic and aspirin-like effects.
Birch Tea:
Dried herb: 2-3g in formularies.
Infusion: dried leaves 1 tsp/cup, infuse 10 min, TID (3 times a day).
Decoction: inner bark 1 tsp/cup, TID.
Tincture: 1:5, 25%, 1-2ml TID.
Tart Cherry Juice
Purchase from Amazon, Whole Foods, or anywhere available. During flare-ups and several days afterwards, drink 4 to 6 ounces 3 to 5 times a day every day and have it always handy at home. If desired for prevention, drink 1 bottle as indicated above once a month, once every other month or when you have a “feeling’ of doing it.
Dry Tart Cherry No Sugar Added
Purchase from Amazon or anywhere available. During flare-ups eat a handful as a snack several times a day. For prevention, eat it as a snack once a day or every now and then. Should be part of your lifestyle.
Blended Pumpkin
Buy a pumpkin from the grocery store. Peel a slice, approximately 100g and cut it in small pieces. Put it in the blender raw and add 6 to 8 ounces of water. Blend it, drink it with an empty stomach 30 minutes before meals 3 times a day.
Keeping up this regimen for a whole month and up to 6 months, can cure gout and a resolve or alleviate several causes of gout, such as metabolic syndrome, diabetes, hypertension, inflammation, atherosclerosis, arteriosclerosis, and ulcers.
Mulberry Twig Tea
10 grams of mulberry twig (4-5 pieces)
Add boiling water and let it steep for 10 minutes
Drink 2-3 times a week to promote blood circulation and clear the collateral channels.
BIOMEDICAL PERSPECTIVE
Gout: joint disease, c. 1200, from Old French gote “a drop, bead; the gout, rheumatism” (10c., Modern French goutte), from Latin gutta “a drop,” in Medieval Latin “gout,” a word of unknown origin. In old medicine the disease was thought to be caused by drops of viscous humors seeping from the blood into the joints, which turns out to be close to the modern scientific explanation. It often was caused by the drinking of heavy or sweet wines, or excessive beer drinking combined with insufficient food.
Gout is a metabolic disorder which results in raised blood levels of uric acid in the bloodstream and the formation of crystals of uric acid salts in the joints, soft tissues and urinary tract. These produce acutely painful attacks of arthritis and soft tissue inflammation. If left untreated, long-term destruction of the joints, formation of tophi in the skin and cartilage, and kidney disease follow. Uric acid is a natural element and the end product of purine metabolism, generated from the breakdown of DNA, RNA and ATP, and is also the result from the normal breakdown of food in metabolism; and tophi are hard, chalky deposits of crystalline uric acid and its salts; tophi are commonly found in the ears of the gout patient. Gout is more common in men than women and rarely occurs in boys before puberty or women before menopause. The clinical presentation of gout includes frequent attacks of arthritis, joint deformities, kidney damage and urinary stones.
Uric acid levels in serum ─the clear fluid that separates from blood on clotting─ are invariably raised, resulting in hyperuremia; although not all those who are hyperuremic suffer from gout. Serum uric acid concentrations are influenced by a number of factors of which age, gender, body-weight and genetic constitution are some of the most important. In olden times it was called the disease of kings due to the higher levels found in urban rather than rural communities and were associated with social class, obesity, alcohol consumption, and high protein diet.
Gout is a common and complex form of arthritis that can affect anyone. It is characterized by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe. An attack of gout can occur suddenly, often waking up the sufferer in the middle of the night with the sensation that the big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable. Gout symptoms may come and go, but there are ways to manage symptoms and prevent flare-ups. Gout attacks that go untreated can lead to worsening pain and joint damage.
SYMPTOMS
The signs and symptoms of gout almost always occur suddenly, and for reasons unknown, often at night. They include:
Intense joint pain: Gout usually affects the large joint of the big toe, but it can occur in any joint. Other commonly affected joints include the ankles, knees, elbows, wrists, and fingers. The pain is likely to be most severe within the first four to 12 hours.
Lingering discomfort: After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints.
Inflammation and redness: The affected joint or joints become swollen, tender, warm and red.
Limited range of motion: As gout progresses, the patient may not be able to move the joints normally.
Common causes of flare-ups: The body produces uric acid when it breaks down purines — substances found naturally in the body, but also found in certain foods, such as steak, organ meats and seafood. Other foods that promote higher levels of uric acid, include alcoholic beverages, especially beer, and drinks sweetened with fruit sugar, or fructose.
Normally, uric acid dissolves in the blood and passes through the kidneys into the urine. But sometimes either the body produces too much uric acid or the kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needle-like urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.
RISK FACTORS
Those with high levels of uric acid in the body are more likely to develop gout. Factors that increase the uric acid levels include:
Diet: Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar raise the levels of uric acid, which increase the risk of gout. Alcohol consumption, especially of beer, also surge the risk of gout.
Obesity: The obese body produces more uric acid and the kidneys have a more difficult time eliminating it.
Medical conditions: Certain diseases and conditions increase the risk of gout, such as untreated high blood pressure and chronic conditions like diabetes, metabolic syndrome, and heart and kidney diseases.
Certain medications: The use of thiazide diuretics —used to treat hypertension. Low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.
Family history of gout: If other family members have had gout, one is more likely to develop the disease.
Age and gender: Gout occurs more often in men, primarily because women tend to have lower uric acid levels. After menopause, however, women’s uric acid levels approach those of men. Men are also more likely to develop gout earlier —usually between the ages of 30 and 50, whereas women generally develop signs and symptoms after menopause.
Recent surgery or trauma: Experiencing recent surgery or trauma has been associated with an increased risk of developing a gout.
COMPLICATIONS
People with gout can develop more-severe conditions, such as:
Recurrent gout: Some people may never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause erosion and destruction of a joint.
Advanced gout: Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi. Tophi can develop in several areas such as fingers, hands, feet, elbows, Achilles tendons along the backs of the ankles, and ear lobes. Tophi usually are not painful, but they can become swollen and tender during gout attacks.
Kidney stones: Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.
PREVENTION
During symptom-free periods, these dietary guidelines may help protect against future gout attacks:
Drink plenty of fluids: Stay well-hydrated, including plenty of water. Limit consumption of sweetened beverages, especially those sweetened with high-fructose corn syrup. If possible avoid high-fructose corn syrup entirely.
Limit or avoid alcohol: Recent evidence suggests that beer may be particularly likely to increase the risk of gout symptoms, especially in men.
Get your protein from low-fat dairy products: Low-fat dairy products may actually have a protective effect against gout, so these are good protein sources.
Limit the intake of meat, fish and poultry: A small amount may be tolerable, but close attention must be paid to what types, and how much of it seem to cause problems for each individual.
Maintain a desired body weight: Maintain a healthy weight. Losing weight may decrease uric acid levels in the body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.
DIAGNOSIS
For reasons that still aren’t understood, uric acid levels in the blood sometimes go down when someone is having a gout attack, so a blood test at the time of an attack is not a reliable way to diagnose gout. Instead, doctors use a special polarizing light microscope to look for uric acid crystals in a small sample of fluid drawn from the afflicted joint with a syringe.
There are several arthritic conditions caused by crystal deposits of various kinds, and polarizing light microscopy is essential to distinguishing among them. The most common of these other disorders has a misleading name, pseudo gout: it may not be gout, but there is no question that it is real; it is caused by deposits of calcium pyrophosphate dehydrate crystals in the joints.
TREATING AN ATTACK
As is true for many painful conditions, the first-line treatment for a gout attack is taking one of the nonsteroidal anti-inflammatory drugs or NSAIDs, such as diclofenac, ibuprofen, or indomethacin. For people who cannot take NSAIDs, a drug called colchicine is an alternative. It has been used for centuries —maybe longer— specifically for gout. The trouble with colchicine is its side effects, especially the copious diarrhea. If neither an NSAID nor colchicine is an option, then gout attacks can be treated with an oral corticosteroid, such as prednisone, or with corticosteroid injections into the joints.
PREVENTING ATTACKS
Follow a purine-restricted diet to stave off attacks. It is best to lose weight, and to cut back on alcohol or stop drinking altogether, especially beer. Low-fat dairy foods are recommended. Diuretics tend to increase uric 
acid levels. If someone with gout is taking one, a doctor might explore lowering the dose or switching to a different medication.
The most important decision for gout sufferers is whether to start taking a drug that will lower uric acid levels. Once people start taking these drugs, they usually must take them for the rest of their lives. Going on and off a uric acid–lowering medication can provoke gout attacks. Experts have differing opinions, but many agree that the criteria for starting therapy include frequent attacks ─about three times a year, severe attacks that are difficult to control, gout with a history of kidney stones, or attacks that affect several joints. An interesting aspect of gout is that uric acid–lowering medications cannot be started during an attack because they can make the attack worse.
__________________________________________________________________________________________________________________________REFERENCES
-Haldane JBS. Princetone: Princeton University Press; 1932. The Causes of Evolution. [Google Scholar]
-Ames BN, Cathcart R, Schwiers E, Hochstein P. Uric acid provides an antioxidant defense in humans against oxidant- and radical-caused aging and cancer: a hypothesis. Proceedings of the National Academy of Sciences of the United States of America; 1981. pp. 6858–62. [PMC free article] [PubMed] [Google Scholar]
-Wacker WE. Man: sapient but gouty. The New England Journal of Medicine. 1970;283:151–2. [PubMed] [Google Scholar]
-Johnson RJ, Titte S, Cade JR, Rideout BA, Oliver WJ. Uric acid, evolution and primitive cultures. Semin Nephrol. 2005;25:3–8. [PubMed] [Google Scholar]
-Hallfrisch J. Metabolic effects of dietary fructose. Faseb J. 1990;4:2652–60. [PubMed] [Google Scholar]
-Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. The New England Journal of Medicine. 2004;350:1093–103. [PubMed] [Google Scholar]
-Personal Classroom Notes. 2005-2011
-Above Article Written by Dr. Osorio, Gloria, DAOM, L.Ac. 2014. (Updated 2020)
