RAYNAUD’S DISEASE: CHINESE MEDICAL PERSPECTIVE
Raynaud’s disease is characterized by a peculiar sensitivity to cold: the small arteries that supply the fingers and toes with blood contract suddenly, causing paleness and discomfort, such as numbness, tingling, or burning sensation. The fingers are more often affected than the toes, and young women suffer from this disorder in far greater numbers than any other group by age or sex. Similar symptoms may arise secondary to use of certain drugs, to arterial diseases, to regular use of powerful vibrating machinery, and to certain autoimmune disorders; this is called Raynaud’s phenomenon or Raynaud’s syndrome.
Raynaud’s disease is rarely mentioned in the Chinese medical literature. Although this may reflect a much lower incidence rate in China than in the West, it is more likely the result of having a well-defined, traditional syndrome of cold extremities: there is no need to further define the disorder as Raynaud’s. Coldness of the extremities and sensitivity to cold is one of the ancient diagnostic indicators used by Chinese physicians to evaluate the status of yin and yang and the function of the internal organs. In the Shang Han Lun, the famous text of ancient Chinese herbal prescribing (ca. 200 A.D.), there are two primary formulas discussed in relation to this problem. One is called Si Ni Tang and the other Si Ni San. The term Si Ni refers to the four distressed limbs; the distress is restricted circulation and coldness, with numbness or aching. The term “tang” simply refers to a decoction of whole crude herbs and the term “san” refers to a powder that is briefly cooked with water to make a tea.
The traditional Si Ni Tang is comprised of just three ingredients: dry ginger, raw aconite, and honey-baked licorice. Today, the raw aconite is replaced by the less toxic processed aconite. The formula is used to invigorate and warm the yang of the kidney and spleen, thereby dispelling any chill in the body. Coldness of the hands is usually attributed to spleen yang deficiency, while coldness in the feet is usually attributed to kidney yang deficiency. The formula is sometimes described as the “Decoction for Treating Yang Exhaustion.”
The traditional Si Ni San is comprised of four ingredients: bupleurum, chih-ko, peony, and honey-baked licorice. The formula is used to disperse stagnated liver qi and invigorate the spleen qi so that the energy that has been confined at the center of the body may flow out to the extremities. The formula is sometimes described as the “Powder for Regulating the Liver and Spleen.”
Another formula arising from the same period is Wen Jing Tang, or the “Decoction for Warming Channels.” It is derived from Si Ni Tang by substituting the warming combination of evodia, cinnamon, ginseng, and pinellia for aconite, and by adding some herbs—peony, ophiopogon, antler gelatin—to help balance the intense warming nature of these ingredients and, further, by adding herbs to vitalize the blood circulation (tang-kuei, cnidium, moutan). The prescription is intended to treat cold acumulation and blood stasis in the central meridians, usually manifesting as lower abdominal pain and/or menstrual disorders, with secondary affliction of the hands, which may become either hot or cold depending on the peculiarities of the case.
A modified version of Si Ni San, developed at the end of the 20th century by Wang Qingren, may be especially suitable for women suffering from coldness of the fingers, the most common manifestation of Raynaud’s disease. The formula is called Xue Fu Zhu Yu Tang, and is described as the “Decoction for Removing Blood Stasis in the Chest.” The formula is derived from Si Ni San by adding blood-vitalizing herbs: persica, carthamus, tang-kuei, red peony (substituted for the white peony in Si Ni San), achyranthes, cnidium, and raw rehmannia, and adding the herb platycodon to open the circulation in the chest. Although the formula name suggests that the prescription is mainly to be used for cardiac problems, that interpretation actually arises from a misunderstanding of Wang’s work. The prescription is intended for stagnated circulation of qi and blood in the upper body, and the reference to “chest” is actually intended to mean “above the diaphragm.” Since Raynaud’s disease is frequently characterized by restricted circulation in the fingers, the blood-vitalizing formula for the upper body seems appropriate.
Raynaud’s disease is mainly mentioned in Chinese literature as secondary to scleroderma, a disease which may have similar underlying imbalances from the Chinese medical perspective. The traditional treatments that are suitable for scleroderma may be useful for Raynaud’s disease, and the modifications of treatments for scleroderma patients who have Raynaud’s syndrome may be instructive for cases of simple Raynaud’s syndrome in the absence of scleroderma.
SCLERODERMA AND RAYNAUD’S DISEASE
Raynaud’s disease is not uncommon among sufferers of scleroderma. Scleroderma is caused by an autoimmune process: it produces a thickening and tightening of the skin as its primary feature. According to an analysis of autoimmune diseases published in the Journal of the American College of Traditional Chinese Medicine (1982), scleroderma is typically associated with yang deficiency and coldness which leads to blood stagnation. The principles of therapy are to tonify the deficiency—qi, blood, yin, or yang—according to diagnosis, and to resolve stasis of blood. Additionally, one may need to resolve qi stagnation. Herbs to resolve hardening of the skin are added in cases of scleroderma, but would not be needed in simple Raynaud’s disease. A prescription mentioned in that source, which is also appropriate to treatment of simple Raynaud’s disease, is comprised of epimedium, astragalus, morinda, cistanche, cinnamon, tang-kuei, cnidium, salvia, red peony, carthamus, rehmannia, and licorice. It tonifies qi, yang, and blood, vitalizes blood circulation, and warms the body.
One of the traditional formulas selected for scleroderma is Tu-huo and Loranthus Combination (Du Huo Ji Sheng Tang), which is usually applied in the treatment of rheumatoid arthritis. This formula contains some of the herbs mentioned in the previous section, such as achyranthes, tang-kuei, ginseng, peony, rehmannia, cnidium, and licorice. In addition, it contains eucommia, tu-huo, chin-chiu, hoelen, siler, loranthus, cinnamon bark, and asarum. These added herbs warm up the circulation in the meridians and alleviate pain.
According to the Chinese reports, this formula may be modified for certain syndromes, such as yang exhaustion (add aconite and cinnamon bark), Raynaud’s syndrome (add the yang tonics morinda, curculigo, epimedium, cuscuta), more severe joint pain (add asarum), and for somewhat more advanced cases (add the tonics astragalus, cinnamon twig, gelatin, and antler gelatin). In this case, Raynaud’s is treated by enhancing the warmth of kidney yang, and chronic degenerative cases are treated by adding additional tonics that enhance the yang and nourish the kidney essence.
In the event that yang deficiency is the dominant syndrome (that is, where blood circulation is not a significant concern), it is suggested that another traditional formula might be used: Yang He Tang. This formula, known as the “Decoction for Warming Yang,” is made with cooked rehmannia, cinnamon bark, ma-huang, deer antler, sinapis, dried ginger, and licorice, and is to be modified according to specific conditions. The formula is described as providing warmth to the body just as the spring sun warms the cold winter ground. This is an apt description for the needs of some people with Raynaud’s syndrome.
Another formula recommended for scleroderma is called Pei Ben Zhi Ying Tang (Decoction to Tonify the Root and Nourish the Ying) made with codonopsis, atractylodes, hoelen, antler gelatin, raw rehmannia, cooked rehmannia, cornus, dioscorea, curculigo, epimedium, laminaria, and turtle shell. When blood stagnation is obvious, other formulas may be selected, such as Bupleurum and Peony Formula (Jia Wei Xiao Yao San), with carthamus and salvia added or Astragalus and Red Peony Combination (Bu Yang Huan Wu Tang). In cases where qi deficiency is considered the major underlying cause of the disharmony and the blood stasis, modifications of Ginseng and Astragalus Combination (Bu Yang Yi Qi Tang) are used: add lonicera and turmeric if symptoms are mainly in the upper body; add achyranthes, carthamus, and aconite if mainly in the lower body; add ma-huang, antler gelatin, cinnamon twig, and carthamus if both upper and lower. If kidney deficiency is also a concern, Ginseng and Astragalus Combination can be modified by adding curculigo, epimedium, cistanche, antler gelatin, tang-kuei, sappan, rehmannia, cnidium, persica, carthamus, clematis, and turtle shell.
Dr. Qin Wanzhang at the Shanghai University of Medical Sciences reported that scleroderma could be effectively treated with salvia, millettia, lycopus, turmeric, leonurus, sappan, cnidium, raw rehmannia, persica, carthamus, red peony, and tang-kuei taken internally and also used as a wash. This formula is comprised of blood-vitalizing herbs exclusively. Of the 123 cases of scleroderma so treated, 53 were markedly improved and 67 more were improved; only 3 patients failed to respond. Treatment time was typically three months or more.
Dr. Wang Dexiang, at the Tianjin College of Traditional Chinese Medicine, reported treatment of 100 cases of scleroderma using a combination of codonopsis, astragalus, cinnamon, rehmannia, red peony, carthamus, ho-shou-wu, millettia, salvia, citrus, cyperus, antler gelatin, and licorice (and modified further according to specific symptoms). As a result of treatment that averaged one year in duration, 8 were cured, 43 were markedly improved, and 40 improved; 9 failed to respond.
In the Chinese Journal of Dermatology, a study was described in which systemic scleroderma patients were were treated with a decoction of astragalus, codonopsis, tang-kuei, salvia, red peony, cnidium, carthamus, cinnamon, millettia, cinnamon bark, epimedium, licorice, and two species of agkistrodon (often used for rheumatoid arthritis). When severe Raynaud’s syndrome was present, salvia with dextran was given intravenously. Depending on individual needs, various Western drugs and vitamins might also be applied. Treatment time was six months to two years. Of 182 cases, there were 38 patients markedly improved, 109 improved, and 35 not improved.
An extensive evaluation of scleroderma treatment was described in the Chinese Journal of Integrated Traditional and Western Medicine (1989). In 725 cases of scleroderma, the patients were classified as belonging to one of three groups for treatment. The first group was treated with a formula comprised mainly of the blood-vitalizing herbs myrrh, frankincense, and curcuma; the second group with alisma, salvia, and sappan, and the third group, which was by far the largest, with tang-kuei, carthamus, cnidium, and pueraria. Further details about the third group were reported separately by Dr. Fan Si at the Beijing Joint Hospital. There were 414 cases of scleroderma treated using a tablet prepared with the four herbs mentioned, in equal proportions. The herbs were taken in the amount of 4–8 one-gram tablets each time, three times daily (total dose: 12–24 grams). Of the 118 cases that had systemic scleroderma, 41% markedly improved and 56% improved; of the 296 with scleroderma mainly limited to the skin area, 45% were markedly improved and 53% improved. About 3% of the the scleroderma patients treated by herbs failed to respond to therapy.
In sum, there are two fundamental principles used in treating either Raynaud’s disease or scleroderma: warming up the body (with herbs such as aconite, dry ginger, cinnamon, evodia, and yang tonics) and vitalizing the circulation of qi and blood (with herbs such as bupleurum, cyperus, chih-ko, salvia, cnidium, tang-kuei, peony, moutan, carthamus, curcuma, etc.). It would appear that treatments relying on one or the other, or both together are reasonably successful.
NOTE: The information about clinical trials and recommended formulas was derived primarily from two sources. One is the journal Abstracts of Chinese Medicine edited by Paul Pui-Hay But (Shatin, N.T., Hong Kong), and the other is in-house translations of various Chinese langauge reports, some of them prepared by Heiner Fruehauf, Ph.D. The traditional formulas and the English designations for them are found in Chinese-English Manual of Commonly Used Prescriptions in Traditional Chinese Medicine by Ou Ming (Joint Publishing Co, Hong Kong).