JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002

UNDERSTANDING RHEUM
by Ning Ma

heum (yin), as a term, was first mentioned in the Nei Jing (The Yellow Emperors Classic of Internal Medicine, first published c.100BC), and later the four rheum patterns were defined in the Jin Gui Yao Lue (Synopsis of the Golden Chamber, first published c. 220CE) as, phlegm-rheum (tan yin), suspending-rheum (xuan yin), spillage-rheum (yi yin) and propping-rheum (zhi yin). It says: When water travels in the intestines with gurgling sounds, it is phlegm-rheum. A patient with phlegmrheum loses weight as well. Suspending-rheum is characterised by rheum trapped under the ribs, and the patient will have chest or hypochondriac pain with distention, and a cough with expectoration of foam. The cough will exacerbate the pain. With spillage-rheum, rheum spreads over the four limbs, and the patient has body aches with a heavy sensation. But the patient has no perspiration, in situations where one should normally sweat. With propping-rheum, the patient will have a cough, difficulty in breathing, and be unable to lay flat. A patient with propping-rheum may have oedema as well. Following on from the original definition, modern scholars have translated the four rheum patterns as follows: 1. rheum in the stomach and intestines, 2. rheum in the chest and hypochondrium, 3. rheum in the limbs and soft tissue, and 4. rheum in the Lung and Pericardium. My purpose in this paper is to historically review rheum as a term and explain the rheum patterns according to modern science.

Another clause discussing phlegm-rheum in the Jin Gui Yao Lue stated that the patient will feel cold on the back. This indicates that phlegm-rheum is cold in nature. Most modern scholars believe that phlegm-rheum is really coldrheum due to Spleen yang deficiency. Therefore, the clinical features of the phlegm-rheum pattern should include obvious gurgling sounds with clear fluid reflux, and various other gastrointestinal symptoms. The treatment principle for this pattern of rheum in the stomach and intestines is to warm yang and strengthen the Spleen, to promote urination and eliminate the rheum. The standard herbal formula is Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction).

Suspending rheum Rheum in the chest & hypochondrium

The Jin Gui Yao Lue describes the key symptom of suspending-rheum as pain in the chest and ribs with distention which is more severe when the patient is coughing. According to modern biomedicine, this is a typical clinical feature of pleurisy. Because traditional Chinese medicine had not yet discovered the pleura as an anatomical feature, modern scholars translated suspending-rheum pattern as rheum in the chest and hypochondrium. As we know, there are two layers to the pleura. There is almost no space between them and there is very little fluid there. The anatomical construction of the pleura allows the lungs to move upward and downward without friction, the fluid in the pleura working like lubricating oil. When a patient has pleurisy, there is chest pain and these fluids increase. Any kind of motion that might force the pleura to move, such as coughing, deep breathing and turning the body, can exacerbate the chest pain, which is caused by friction of the inflamed membrane. As the fluid increases, the difficulty in breathing will become more severe because the rheum is crowding the lungs space, while the chest pain will decrease because the fluid filled space is separating the wounded membranes more completely at this stage. Therefore, we might suggest that the pattern of rheum in the chest and hypochondrium is the same as the disease of pleurisy in biomedicine. The treatment principle for this pattern is to break up the rheum accumulation and promote urination. The standard herbal formula is Shi Zao Tang (Ten-Jujube Decoction).

Phlegm-rheum: Rheum in the stomach & intestines

According to the Jin Gui Yao Lue, the most significant symptom manifested by a patient with phlegm-rheum is gurgling sounds in the stomach and abdomen with weight loss. Later Jingyue Zhang (1562-1639), a famous scholar of the Qing dynasty, further clarified the phlegm-rheum pattern in his book Jing Yue Quan Shu (Complete Book of Jing Yue). The phlegm-rheum patient vomits either clear fluids or undigested food, and has acid reflux. The patient has distention of the epigastrium and abdomen with gurgling sounds. Therefore, we can assume that the pattern of phlegm-rheum is a condition of excess fluid in the gastrointestinal tract caused by gastrointestinal inflammation or other pathological conditions.

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JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002

Spillage-rheum Rheum in the limbs & soft tissue

According to the original records, spillage-rheum manifests as body aches with a heavy sensation. The reason for the aching is that the rheum stays in the soft tissues of the limbs, such as the muscles, hindering free movement of qi; the consequent stagnation gives rise to pain. When the body functions normally, it has the ability to metabolise body fluids and get rid of the extra fluids in the muscles and soft tissue by sweating. Since in this pattern the patient has lost the ability to sweat, the extra body fluids in the limbs accumulate and become spillage-rheum. If the rheum continues to gather, it develops into water accumulation which manifests as oedema. We can therefore assume that the spillage-rheum pattern corresponds to the early stage of oedema in modern medicine. The clinical feature is aching of the limbs with heaviness but at the stage of the spillage rheum pattern there should not yet be any oedema present. Modern scholars have translated spillage-rheum as rheum in the limbs and soft tissues. If we assume that the spillagerheum pattern is the pre stage of oedema, it can correspond to the very early stages of nephritis, or a very mild condition of nephritic syndrome. Because there is no clear delineation between spillage-rheum and water accumulation, the spillage-rheum pattern has not been included in the diagnostic textbook (Zhong Yi Zhen Duan Xue) of Chinese colleges since the fifth edition (1986). The traditional treatment of the spillage-rheum is to apply the sweating method to expel the rheum which is why the author of the Jin Gui Yao Lue chose Da Qing Long Tang (Major Bluegreen Dragon Decoction) and Xiao Qing Long Tang (Minor Bluegreen Dragon Decoction) as the chief herbal formulas its treatment.

Propping-rheum Rheum in the Lung & Pericardium

Propping-rheum was defined in the Jin Gui Yao Lue as a group of symptoms that include difficult breathing, coughing and inability to lie flat. Modern scholars have translated the pattern of propping-rheum as rheum in the Lung and Pericardium. From the symptoms, we can assume that the pattern of propping-rheum is similar to the condition of pulmonary oedema and congestive heart failure. As we know, the ventricles of the heart act as circulation pumps. When the right ventricle fails, the systemic veins become congested, reflected in an increased jugular ventricle pressure, and elevated back pressure causes peripheral oedema, ascites, and an enlarged, tender liver. When the left ventricle fails, the pulmonary venous and pulmonary capillary pressure rise. Fluid leaks into the pulmonary interstitium and alveoli, producing pulmonary oedema1. There are two stages to rheum in the Lung and Pericardium. Rheum in the Lung specifically indicates a condition where fluid has leaked into the pulmonary interstitium and alveoli, which in modern medicine is called pulmonary oedema. The key symptom is difficult breathing with coughing of pink foam. Rheum in the Pericardium is character-

ised by increased jugular ventricle pressure and elevated back pressure due to congestive heart failure. The key symptom is heart palpitations with peripheral oedema. The treatment principle is to promote urination in order to reduce the overload in the Lungs and Pericardium and the standard herbal formula is Ting Li Da Zao Xie Fei Tang (Descurainia and Jujube Decoction to Drain the Lungs). In addition to the four patterns described above, a further group of symptoms might also be evidence of rheum: dizziness, vomiting, a pale tongue with a slimy coat, and a wiry pulse. These are caused by a failure of yang to rise due to rheum obstruction and this group of symptoms may be seen in any of the four rheum patterns. One might ask whether it is fair to attempt to correlate the rheum patterns to specific biomedical conditions since we know that there is a huge difference between the patterns of traditional Chinese medicine and biomedical diseases. The patterns of traditional Chinese medicine describe pathological conditions that might be present in many different diseases or at different stages of their development. For example, the pattern of rheum in the Lung and Pericardium might be symptomatic of either pulmonary oedema or congestive heart failure. Likewise, the pattern of rheum in the chest and hypochondrium might be symptomatic of pleurisy due to either tuberculosis or cancer, or even the result of severe ascites. The differences between dampness, phlegm, rheum and water are quite clear. In terms of quantity, rheum refers to a relative pathological overproduction of body fluid. When the quantity of increased body fluids becomes more severe, it is defined as water accumulation. Therefore, the terms water and rheum are often used together (water-rheum). Rheum and water accumulation are thin and clear in nature, with water accumulation being the more mobile and visible of the two. Dampness and phlegm refer primarily to the quality of the accumulation. Dampness represents the steam stage, which is light and invisible, while phlegm is the thick, sticky stage of pathogenic body fluids. Rheum patterns manifest in the body in places where a certain amount of body fluids normally exist to lubricate and nourish, the amount depending on the individual needs of the organs and tissues. Therefore, rheum can be understood as a possible pathogenic product of the body fluids that normally exist in places such as the stomach and intestines, lungs and pericardium, pleura, and limbs and soft tissues. With this new, more detailed understanding of rheum and the rheum patterns, modern scholars have been able to define the condition of brain oedema as waterrheum in the brain, and the condition of the Menieres syndrome as cold-rheum invasion.
1 MEDICINE Mark C. Fishman 4th ed. 1996 Lippincott-Raven Publishers, Philadelphia/New York).

Ning Ma, Licensed Acupuncturist, department chair of clinic practice at Pacific College of Oriental Medicine (New York). 915 Broadway, 3rd Floor, New York, NY 10010, USA.

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