X-ray shows asymmetrical involvement of the affected joints, along with new bone formation, bony ankylosis, and sacroiliitis.

~ 30 years old, rarely occurs after age 45. ② There is a clear family history. ③ Few joints are involved, asymmetrically, with more common involvement of the lower limbs and large joints. ④ Rheumatoid factor negative, HLA-DR4 negative, HLA-B27 positive. X-ray shows asymmetrical involvement of the affected joints, along with new bone formation, bony ankylosis, and sacroiliitis. (4) Systemic lupus erythematosus: In the early stages, it is difficult to distinguish from rheumatoid arthritis; laboratory tests such as rheumatoid factor and LE cells can both be positive. The distinguishing points are: ① The appearance of the characteristic butterfly rash of systemic lupus erythematosus. ② Lupus often involves damage to multiple organs, such as the heart and kidneys. ③ Joint deformities are extremely rare. (5) Polyarteritis nodosa: This disease shares common features with rheumatoid arthritis, such as fever, joint pain, subcutaneous nodules, and positive rheumatoid factor. The distinguishing points are: ① Polyarteritis nodosa has widespread lesions, often affecting internal organs, especially the kidneys. ② It presents with characteristic subcutaneous nodules arranged along arteries, accompanied by tenderness. ③ Eosinophilia is present. (6) Dermatomyositis: This disease is characterized by symmetrical proximal muscle weakness, pain, and tenderness, along with distinctive skin manifestations (such as periorbital purplish edematous erythema and nailfold capillary telangiectasia). Laboratory tests show elevated levels of CPK, LDH, GT, and aldolase, as well as increased 24-hour urinary creatinine excretion; electromyography reveals myogenic atrophy, which helps in differentiation. (II) Western medical treatment 1. Pharmacological treatment ① Aspirin: Has anti-inflammatory and analgesic effects. The adult dosage is 2–5 g daily, taken 3–4 times a day after meals. Enteric-coated aspirin can reduce gastrointestinal reactions. However, it affects liver and kidney function, so patients with peptic ulcers or a tendency to bleed should avoid this medication. ② Indomethacin: Its anti-inflammatory effect is stronger than aspirin. The usual dosage is 25 mg daily, taken 2–3 times a day, with a total daily dose not exceeding 150 mg. Side effects include nausea, vomiting, diarrhea, loss of appetite, upper abdominal discomfort, dizziness, and even hallucinations, mental confusion, liver dysfunction, neutropenia, and allergic reactions. If oral administration is intolerable, suppositories can be used instead. ③ Ibuprofen: Its anti-inflammatory, analgesic, and antipyretic effects are similar to those of aspirin. Patients who cannot tolerate aspirin may try ibuprofen. The total daily dose is 1800–2400 mg, divided into 3–4 doses. Side effects include indigestion, rash, gastrointestinal ulcers and bleeding, and elevated transaminases. ④ Piroxicam: An anti-inflammatory and analgesic drug, characterized by a long half-life and stronger efficacy than indomethacin. The daily oral dose is 20 mg, taken once a day. Side effects occasionally include dizziness, edema, stomach discomfort, diarrhea, or constipation. Corticosteroids: For most cases, corticosteroids are not the first-line treatment. Corticosteroids can only suppress inflammation but cannot fundamentally alter the disease course or pathogenesis. Long-term use tends to require increasing doses, making it difficult to taper off or discontinue. Due to numerous side effects, their harm can even exceed that caused by rheumatoid arthritis itself. Therefore, unless other treatments have failed or the condition is rapidly progressing and severe, corticosteroids should not be used lightly. Even when used, the dose should be small, the treatment course should not be too long, and they should be combined with other medications. The typical prednisone dose is no more than 10 mg daily, taken all at once in the morning. If the effect is not obvious, the dose can be increased. Dexamethasone is administered at 0.75–1.5 mg daily, once a day in the morning. Penicillamine: A basic amino acid drug, effective in treating rheumatoid arthritis by selectively inhibiting immune cells and reducing IgG and IgM levels. The initial dose is 125 mg, taken twice daily. After one month, the dose can be doubled. If there is no obvious effect, increase to 250 mg three times daily in the third month. Generally, it takes 3–6 months for the effect to appear. After symptom improvement, the dose can be reduced and maintained, allowing long-term use. Side effects include thrombocytopenia or leukopenia, proteinuria, allergic rash, loss of appetite, and elevated transaminases, with particular attention to kidney damage. ① In recent years, the use of immunosuppressants and biologics in the treatment of rheumatoid arthritis has achieved good results. 2. Other treatments ① Local treatment: Applying swelling-reducing rubber plasters externally and using swelling-relieving ointments topically can help reduce swelling and relieve pain. ② Acupuncture and massage therapy: These can be applied during the remission phase of rheumatoid arthritis. Specific treatment methods can be found in specialized books on acupuncture and massage. Physical therapy also has a certain auxiliary effect on this disease. ③ Surgical treatment: Surgery should be reserved for cases where medication fails. For example, synovectomy can be performed if drug treatment is ineffective. Although it has good efficacy, the synovium often regenerates after surgery, so the long-term outcome remains uncertain. For advanced cases with joint deformities, corrective surgery can be considered. III. Professor Pei Zhengxue’s approach to thinking From a Western medical perspective, Professor Pei Zhengxue believes that the joint pain in this disease is an autoimmune joint disorder, characterized by multiple, progressive joint pain, joint deformity, and functional impairment. The main manifestation is symmetrical involvement of the limb joints, with the hands, wrists, knees, and feet being the most commonly affected, followed by the elbows, ankles, shoulders, and hips. Locally, symptoms include morning stiffness, swelling, pain, and restricted movement. In severe cases, extra-articular manifestations such as rheumatoid nodules, rheumatoid vasculitis, cardiac involvement, coronary arteritis, pulmonary manifestations, and rheumatoid pneumoconiosis (Caplan syndrome) may occur. Rheumatoid arthritis ultimately leads to joint deformity, functional impairment, and collapse of immune function, resulting in multiple comorbidities and eventually leading to loss of self-care ability and even life-threatening conditions. With the help of tests such as erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor (RF), RANA antibodies, and X-rays, diagnosis is generally straightforward. Rheumatoid arthritis falls under the category of “Bi syndrome” in Traditional Chinese Medicine, caused by deficiency of vital energy, disharmony between Ying and Wei, and the combined action of wind, cold, and dampness. Among these three factors, cold evil is the most important pathogenic factor. Cold is a yin evil, with a nature of stagnation and contraction, easily obstructing the flow of qi. When qi flow is blocked, pain arises, which is why pain is prominent in rheumatoid arthritis. “Cold indicates insufficient yang qi; the more yang qi is deficient, the more severe the cold becomes.” Over time, the disease penetrates the meridians, damaging the blood vessels and causing blood stasis and accumulation, leading to joint deformity. In terms of treatment, Guizhi Shaoyao Zhimu Tang serves as the base formula, supplemented by Fufang Chuancaowu Heji, Jiuwei Qianghuo Tang, Fufang Sangzhi Tang, Duohuo Jisheng Tang, Wumi Heji, Jin Niu Tang, Taohong Siwu Tang, and Huolu Xiaoling Dan, among others, with adjustments made according to individual conditions. IV. TCM syndrome differentiation and prescriptions 1. Wind-cold-damp Bi syndrome Symptoms: Generalized joint or muscle soreness, migratory and unpredictable, difficulty in flexion and extension, joint swelling and heaviness, local area neither red nor hot, relief upon warming, sharp increase in pain with changes in qi, pale tongue, white or greasy white coating, deep and taut or soft and fine pulse. Treatment principle: Dispel wind, unblock the meridians, dispel cold, and remove dampness. Prescription: Taohong Siwu Tang, plus Fufang Chuancaowu Heji with added ingredients: peach kernel 10 g, safflower 6 g, Shengdi 12 g, Chi Shao 10 g, Chuanxiong 6 g, Danggui 10 g, Chuan Niuxi 15 g, Jiangcan 10 g, Yu Gong 2 pieces, Cebo Ye 15 g, Muguai 10 g, Shenjin Cao 15 g, Chuan Wu 15 g (decocted for 1 hour), Cao Wu 15 g (decocted for 1 hour), Liaoxixin 15 g (decocted for 1 hour), Maqianzi 1 piece (fried), Leigongteng 15 g (peeled and decocted for 1 hour). 2. Wind-heat Bi syndrome Symptoms: Joint pain, localized burning and redness, unbearable pain, slight relief with cold, can affect one or more joints, often accompanied by systemic symptoms such as fever, aversion to wind, thirst, and restlessness, red tongue, thin yellow or greasy yellow coating, slippery and rapid pulse. Treatment principle: Clear heat, unblock the meridians, dispel wind, and remove dampness. Prescription: Guizhi Shaoyao Zhimu Tang combined with Fufang Sangzhi Tang, with added ingredients: Guizhi 10 g, Bai Shao 15 g, Zhimu 20 g, Chuan Wu 15 g (decocted for 1 hour), Cao Wu 15 g (decocted for 1 hour), Maqianzi 1 piece (fried), Leigongteng 15 g (peeled and decocted for 1 hour), Ganjiang 6 g, Gancao 6 g, Fangfeng 12 g, Baishu 10 g, Mahuang 10 g, Yiren 30 g, Xingren 10 g, Shengshi 30 g, Ren Dong Teng 20 g, Sangzhi 30 g, Yancao 15 g, Weiling Xian 10 g, Qianghuo 10 g, Duohuo 10 g, Qin Rao 10 g, Qingfeng Teng 15 g, Haifeng Teng 15 g. 3. Qi and blood as well as liver and kidney deficiency syndrome Symptoms: Body is emaciated, sweating and feeling cold, lower back and knees are weak and sore, joint pain recurs frequently and does not heal, muscles are stiff and bones are loose, joints are deformed, flexion and extension are difficult, or numbness occurs, even to the point of walking on tiptoes, pale tongue, thin white coating, and deep, weak pulse. Treatment principle: Remove pathogenic factors and relieve pain, tonify the liver and nourish the kidneys. Prescription: Huolu Xiaoling Dan, Duohuo Jisheng Tang with adjustments: Duohuo 10 g, Sangjisheng 10 g, Duzhong 10 g, Niuxi 10 g, Xinxin 6 g, Qin 10 g, Fu Ling 12 g, Rou Gui 6 g, Fangfeng 10 g, Chuanxiong 10 g, Renshen 10 g, Gancao 6 g, Danggui 10 g, Bai Shao 10 g, Di Huang 10 g, Zhi Ru Xiang 6 g, Zhi Mei Yao 6 g, Sangzhi 30 g. V. Analysis of Professor Pei Zhengxue’s prescriptions Professor Pei Zhengxue believes that the foundational prescription for treating this disease is Guizhi Shaoyao Zhimu Tang. Guizhi Shaoyao Zhimu Tang originates from “Jin Gui Yao Lue”: “For pain in all limbs and joints, body emaciation, swollen feet as if detached, dizziness and shortness of breath, and a warm sensation with an urge to vomit, Guizhi Shaoyao Zhimu Tang is the primary remedy.” This formula treats external wind-cold invasion and internal dampness stagnation. External cold causes headache, chills, and limb pain; internal dampness causes swollen feet. Cold enters the kidneys, dampness affects the spleen, and prolonged cold-dampness leads to dual deficiency of the spleen and kidneys. Spleen deficiency results in emaciation and a warm sensation with an urge to vomit; kidney deficiency leads to dizziness and shortness of breath. Professor Pei Zhengxue uses this formula to treat rheumatoid arthritis, substituting Fuzi with Chuan Wu and Cao Wu, each 15 g (decocted for 1 hour), Liaoxixin 15 g (decocted for 1 hour), Leigongteng 15 g, and adding Maqianzi 1 piece (fried), consistently achieving remarkable therapeutic effects. In this formula, Guizhi warms the meridians, promotes yang energy, improves blood circulation, resolves stasis, dispels cold, harmonizes Ying and Wei, and relieves pain; Shaoyao nourishes the blood and softens the muscles and meridians, nourishes yin and clears stagnation, working together with Guizhi to regulate qi and blood, move the joints, improve blood circulation, and effectively alleviate acute and chronic conditions; Zhimu clears heat, calms irritability, moistens yin, and unblocks the joints. Large doses of Wu Tou without Zhimu result in excessive yang and injury to yin; without Guizhi, yang energy cannot reach the extremities; without Bai Shao, yang energy cannot penetrate the internal organs. Therefore, in this formula, the three key herbs—Wu Tou, Guizhi, and Shaoyao—are actually the main ministers, listed first in the formula name, symbolizing the protection of the main medicine within. Ma Huang promotes sweating and opens the exterior, revealing the light of yang energy. Baishu strengthens the spleen and boosts qi to prevent overuse of medicinal substances that might harm the spleen; Ganjiang warms the middle jiao, while Gancao harmonizes; Fangfeng dispels wind and removes dampness. Together, the entire formula achieves the effects of dispelling wind and removing dampness, dispelling cold, and relieving pain. In addition to Guizhi Shaoyao Zhimu Tang, Taohong Siwu Tang, Fufang Chuancaowu Heji (Chuan Wu, Cao Wu, Liaoxixin, Maqianzi, Leigongteng), Fufang Sangzhi Tang (Sangzhi, grass, Weiling Xian, Qin, Qingfeng Teng, Haifeng Teng, Fangfeng), Huolu Xiaoling Dan, Duohuo Jisheng Tang, Shaoyao Gancao San Teng Gua (Bai Shao, Gancao, Qingfeng Teng, Haifeng Teng, Jixueteng, Muguai, Niuxi, Sheng Ren), Jin Niu Tang (Jinmaogouji, Niuxi, Qianghuo, Sheng Ren, Jixueteng), Wumi Heji (Wujia Pi, Sheng Ren, Niuxi, Po Gu Paper, Cangshu, Qingfeng Teng, Haifeng Teng), Qiang Fang Qin Cao Tang (Fangfeng, Huang Qin, Gancao, Danggui, Zhimu, Yin Chen, Sheng Ma, Ge Gen, Dang Shen, Ku Shen, Bai Shu, Cangshu, Fu Ling, Ze Xie), Jiuwei Qianghuo Tang, Da Qin Tang, Ji Ming San (Su Geng, Binglang, Muguai, Chenpi, Gancao, Guizhi, Fupian, Banxia, Wu Zhu Yu, He Shou Wu from “Zhu’s Experience Collection”), Wu Ji San (Danggui, Bai Shao, Lu Rong, Cangshu, Hou Pu, Chenpi, Banxia, Fu Ling, Mahuang, Bai Shu, Jie Geng, Gan Jiang, Rou Gui, Zi Ke from “Ju Fang”), Ma Huang Guizhi Tang, San Yin Tong Bi Tang, and other formulas are commonly used by Professor Pei Zhengxue under the principle of syndrome differentiation and treatment. Professor Pei Zhengxue’s treatment of this disease has several distinct personal characteristics: First, he emphasizes the use of Chuan Wu and Cao Wu. Professor Pei Zhengxue says, “Cold indicates insufficient yang qi; the more yang qi is deficient, the more severe the cold becomes.” Based on this understanding, he advocates for the extensive use of Chuan Wu and Cao Wu in treating rheumatoid arthritis. This is what he calls “nourishing the source of fire to dispel the shadows of yin,” and he formulates his own compound preparation, Chuancaowu Heji: Chuan Wu 15 g (decocted for 1 hour), Cao Wu 15 g (decocted for 1 hour), Liaoxixin 5 g (decocted for 1 hour), Maqianzi 1 piece (fried), and Leigongteng 15 g (peeled and decocted for 1 hour). Among them, the active ingredient in Chuan Wu and Cao Wu is aconitine, which is highly toxic, but boiling for 1 hour can completely destroy the toxic components while relatively preserving the effective ones. Therefore, Chuan Wu and Cao Wu must be decocted for 1 hour before being used in medicine. The active ingredient in Liaoxixin is mainly methyl eugenol, with toxic components such as safrole. The latter is highly volatile, and prolonged decoction significantly reduces its toxicity, but has little impact on the effectiveness of the active ingredients. Thus, Liaoxixin must also be decocted for 1 hour to eliminate its toxicity. This formula has a very significant analgesic effect, with its mechanism of action being activation of GABAA receptors and inhibition of NO release. Based on many years of clinical experience, Professor Pei Zhengxue believes that its effect is similar to that of corticosteroids. There have been many cases of patients with severe rheumatoid pain who, after taking this formula, not only had their pain relieved but also saw a significant control of their condition, repeatedly verified in clinical practice. Second, he makes good use of blood-activating drugs. This is another major feature of Professor Pei Zhengxue’s treatment of rheumatoid arthritis. The disease often leads to joint deformity and persistent pain over time. He believes that cold stagnation causes blood stasis, so treatment often requires adding Danggui, Danshen, Zhi Ru Xiang, and Zhi Mei Yao to activate blood circulation and unblock the meridians. He thinks that when yang is strong, it’s like sunlight shining everywhere, so tonifying yang is “nourishing the source of fire to dispel the shadows of yin.” When yin evil penetrates deeply into the blood vessels, only blood-activating and stasis-resolving medicines can overcome it. Taohong Siwu Tang is perfectly suited for this task. As the ancients said, “To treat wind, first activate the blood; when the blood is activated, the wind will naturally dissipate.” Whether it’s wind, cold, dampness, heat, or weakened vital energy, all can lead to blood stasis. Ancient physicians also recognized the connection between Bi syndrome and blood stasis, for example, in “Zabing Yuanliu Xizhu · Zhubi Yuanliu,” it is stated: “Bi means closure; when the three qi combine, they block the meridians, preventing qi and blood from circulating freely, thus leading to Bi over time.” In “Leizheng Zhicai · Bi Syndrome,” it is written: “If Bi persists without healing, it must be due to damp phlegm and blood stasis blocking the meridians.” In “Yilin Gaicuo,” it is also clearly pointed out: “Bi syndrome involves blood stasis.” Therefore, treatment of Bi syndrome must include blood-activating and stasis-resolving measures. Third, he attaches great importance to reinforcing the body’s vital energy. Professor Pei Zhengxue believes that regardless of whether it’s wind, cold, or dampness, with wind being the primary factor, cold and dampness accompany it, but the root cause is the deficiency of vital energy, which allows pathogenic factors to take advantage and trigger the disease. Over time, Bi syndrome consumes qi and blood, damages the internal organs, and impairs the smooth flow of qi and blood, making it easier for blood stasis and phlegm to block the meridians and spread the disease. Pathogenic factors travel through the meridians and invade the internal organs. Modern medicine also fully recognizes that rheumatoid arthritis can cause lesions in multiple systems over time, with immune system damage being the fundamental issue, followed by multi-organ involvement. This is precisely why biological immunomodulators have been applied in the treatment of rheumatoid arthritis. Traditional Chinese medicine’s reinforcement of vital energy is essentially about regulating immune function, and TCM can both reinforce vital energy and dispel pathogenic factors simultaneously, employing multiple strategies in parallel for richer effects. For example, Gancao and Baishu in Guizhi Shaoyao Zhimu Tang; Bajin in Duohuo Jisheng Tang; Danggui and Danshen in Qian Niu Tang; Danggui and Danshen in Wumi Niu Gu Tang; Chuanxiong and He Shou Wu in Yi Gua Zi Po Tang—all these are medicines that reinforce vital energy. He believes that “when wind, cold, and dampness combine, they form Bi,” and that the combination of these three factors is “where evil gathers, and the qi must be weak.” If the three qi are exhausted, then vital energy will be abundant, which can be described as “vital energy resides within, and evil cannot intrude.” This provides another line of thought for future treatment of Bi syndrome. Fourth, he emphasizes the care and management of rheumatoid arthritis. Given the long course of the disease and its tendency to recur, patients should pay special attention to their daily routines. During the acute phase or flare-ups, when there is fever and obvious joint swelling and pain, bed rest is recommended. During the remission phase, a balance of activity and rest should be maintained to prevent prolonged bed rest from causing joint stiffness and disuse. Throughout the entire disease course, factors that can trigger the onset of the disease, such as cold, dampness, fatigue, psychological stress, trauma, and infection, should be avoided. For patients with extremely severe conditions, they should also actively cooperate with the use of immunosuppressants and biologics in the treatment of rheumatoid arthritis. For