Six. Examples of Clinical Cases Treated by Professor Pei Zhengxue

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Patients with economic difficulties or limited conditions are advised to apply the herbal residue from water-decocted traditional Chinese medicine topically after oral administration, which can help promote blood circulation, unblock meridians, reduce swelling, and relieve pain.

In summary, Professor Pei Zhengxue commonly uses classic formulas and sometimes modified formulas in treating rheumatoid arthritis, with the primary goal of alleviating joint pain; however, the indications for each formula vary slightly. The Nine-Ingredient Qianghuo Decoction and Daqin Decoction are suitable for rheumatoid arthritis attacks triggered by a cold when the cold symptoms still persist, accompanied by severe joint pain, headache, and fever. If there is coughing, they can be combined with Maxing Gan Tang. The Compound Sangzhi Decoction is appropriate for long-standing, refractory rheumatoid arthritis with joint deformity and impaired mobility. The Gui Formula is suitable for individuals who feel cold and have deficiency-cold constitutions. The Duhuo Jisheng Decoction, along with Jiming San and Wujisuan, is often used when the pain of rheumatoid arthritis has been somewhat controlled, but the body's qi and blood are both deficient, requiring tonifying medications. The Five-Measure Mixture and Jin Niu Tang are suitable for patients with concurrent degenerative changes in the bones and joints, spinal ankylosis, and sciatica. In addition to adjusting the formulas, individual herbs can also be added or subtracted based on changes in the patient’s condition: for severe pain, add 15g of Chuanwu (decocted first for 1 hour) and 15g of Caowu (decocted first for 1 hour); for severe lower limb pain, add 1 whole Strychnos nux-vomica seed (fried in oil); for severe upper limb pain, add 15g of Liaoxixin (decocted first for 1 hour); for headache, add 10g of Qianghuo, 10g of Duhuo, and 10g of Fangfeng; for lower back pain, add 15g of Duzhong, 10g of Chuan Niuxi, 10g of Chuan Xuduan, and 15g of Sangjisheng; for neuralgia, add 10g of Qingfengteng, 10g of Haifengteng, and 10g of Jixueteng; for back pain, add 10g of Qianghuo and 10g of Duhuo; for shoulder pain, add 10g of Jianghuang, and if cold predominates, add 10g of Ma Huang, 6g of Fuzi, and 10g of Wutou; if heat predominates, add 30g of Shengshi Gao and 20g of Shengren; to prevent colds, add Yupingfeng San; for joint deformity, add 10g of Jixueteng, 15g of Lu Xian Cao, and 10g of Lixian Cao; to strengthen the body and consolidate the root, add 20g of Danshen, 30g of Huangqi, 10g of Danggui, 10g of Baishao, and 15g of Dangshen; for wind dominance, add 15g of Xungufeng and 15g of Lu Xian Cao; for dampness dominance, add Simiao San; for those with annular erythema and subcutaneous nodules, add 30g of Shui Niu Jiao and 10g of Danpi, among others.

Six. Examples of Clinical Cases Treated by Professor Pei Zhengxue

Case 1: Ms. Chen, female, 34 years old, with swollen and painful finger joints, morning stiffness, aversion to cold, sensitivity to wind, excessive sweating, RF (+), BP: 120/75 mmHg, pale-dark tongue, and a deep, fine, weak pulse.

[Western Medical Diagnosis] Rheumatoid Arthritis. [Traditional Chinese Medicine Syndrome Differentiation] Wind-Cold-Dampness Bi Syndrome. [Treatment Principle] Dispel cold and remove dampness, disperse wind and unblock meridians.

[Formula] Gui Zhi Shaoyao Zhimu Tang combined with Modified Compound Sangzhi Decoction: Gui Zhi 10g, Bai Shao 15g, Zhimu 20g, Chuan Wu 15g (decocted first for 1 hour), Caowu 15g (decocted first for 1 hour), Liaoxixin 15g (decocted first for 1 hour), 1 whole Strychnos nux-vomica seed (fried in oil), Ganjiang 6g, Gancao 6g, Fangfeng 12g, Baizhu 10g, Ma Huang 10g, Danggui 10g, Huangqi 30g, Shengdi 12g, Sangzhi 30g, Xiyangcao 15g, Weilingxian 10g, Qianghuo 10g, Duhuo 10g, Qin 10g, Qingfengteng 15g, Haifengteng 15g. Decocted in water and taken once daily, for a total of 7 doses. After taking the medication, joint pain significantly improved, and sweating decreased.

Case 2: Ms. Zhang, female, 48 years old, with pain, deformity, and morning stiffness (lasting more than 1 hour) in both hands and wrists, as well as functional impairment. Other joints throughout the body also experience pain, and RF (+). Tongue is dark with thin coating, and pulse is fine and涩.

[Western Medical Diagnosis] Rheumatoid Arthritis. [Traditional Chinese Medicine Syndrome Differentiation] Chronic illness entering the meridians with blood stasis. [Treatment Principle] Activate blood circulation and remove blood stasis, unblock meridians and relieve pain.

[Formula] Gui Zhi Shaoyao Zhimu Tang, Taohong Siwu Tang, and Modified Compound Sangzhi Decoction: Gui Zhi 10g, Bai Shao 15g, Zhimu 20g, Chuan Wu 15g (decocted first for 1 hour), Caowu 15g (decocted first for 1 hour), Liaoxixin 15g (decocted first for 1 hour), 1 whole Strychnos nux-vomica seed (fried in oil), Ganjiang 6g, Gancao 6g, Fangfeng 12g, Baizhu 10g, Ma Huang 10g, Danggui 10g, Tao Ren 10g, Honghua 6g, Chuanxiong 6g, Shengdi 12g, Sangzhi 30g, Xiyangcao 15g, Weilingxian 10g, Qianghuo 10g, Duhuo 10g, Qin 10g, Qingfengteng 15g, Haifengteng 15g. Taken once daily, for a total of 7 doses. After taking the medication, pain in all joints eased somewhat, and after 30 doses, symptoms improved markedly, with reduced joint pain and increased joint mobility.

Case 3: Ms. Wang, female, 48 years old, suffering from rheumatoid arthritis for 5 years, with widespread joint pain. Physical examination reveals enlarged and deformed interphalangeal joints in both hands, pale tongue with thin white coating, and a涩 pulse.

[Western Medical Diagnosis] Rheumatoid Arthritis. [Traditional Chinese Medicine Syndrome Differentiation] Wind-Cold-Dampness Bi Syndrome. [Treatment Principle] Dispel cold and unblock meridians, dispel wind and remove dampness.

[Formula] Qiangfang Qincao Tang combined with Gui Zhi Shaoyao Zhimu Tang with modifications: Qianghuo 12g, Duhuo 12g, Fangfeng 12g, Huangqin 10g, Gancao 6g, Danggui 10g, Zhimu 12g, Yinchen 20g, Shengma 6g, Gegen 20g, Dangshen 10g, Kusen 10g, Baizhu 10g, Cangshu 10g, Fuling 12g, Zexie 10g, Gui Zhi 10g, Bai Shao 30g, Chuan Wu 15g (decocted first for 1 hour), Caowu 15g (decocted first for 1 hour), Leigongteng 15g (decocted first for 1 hour), 1 whole Strychnos nux-vomica seed (fried in oil), decocted in water and taken once daily, for a total of 20 doses. After taking the medication, joints no longer hurt, and mobility is normal.

Seven. A Collection of Ancient and Modern Theories

The "Zuo Zhuan" states: "Wind-induced diseases affect the extremities." The "Suwen · Bi Lun" says: "When wind, cold, and dampness combine, they cause bi syndrome. If wind predominates, it becomes traveling bi; if cold predominates, it becomes painful bi; if dampness predominates, it becomes fixed bi." "If one encounters this in winter, it becomes bone bi; if in spring, it becomes tendon bi; if in summer, it becomes pulse bi; if in late autumn, it becomes muscle bi; if in early autumn, it becomes skin bi." "Kidney bi causes swelling, replacing the heels with bones and the head with the spine." "Spleen bi leads to limb weakness, coughing, and vomiting, with major blockages above." The "Lingshu · Zhou Bi" explains: "Wind, cold, and dampness invade the space between the outer flesh and muscles, pressing tightly to form foam. When cold sets in, the foam gathers, and the gathering splits the flesh and muscles. This splitting causes pain, and when pain occurs, the spirit retreats. When the spirit retreats, heat arises, and when heat arises, the pain subsides. When the pain subsides, paralysis occurs, and then other bi syndromes emerge, repeating the cycle." "This internal condition does not reside in the organs but remains outside the skin, isolated in the space between the flesh and muscles, where true qi cannot circulate freely. Therefore, it is called 'circulating bi'." The "Jingui Yaolue Fanglun · Zhongfeng Lijie Bing Mai Zheng Bing Zhi" states: "When wind causes disease, it may result in hemiplegia or arm paralysis, which is considered bi. The pulse is weak and rapid due to the stroke." The "Zhubing Yuanhou Lun · Fengbing Zhuhou Shang" mentions: "Wind, cold, and dampness combine to form bi, and these three energies come at different times, with some being more prevalent than others. When wind energy is dominant, it is called wind-damp bi... Thus, wind-damp bi results in loss of control over the limbs." The "Wai Tai Mi Yao" says: "White Tiger Disease is mostly caused by the toxicity of wind, cold, and heat. Due to deficiency, improper diet, and exposure to wind pathogens, the meridians become blocked." The "Jisheng Shi" states: "When qi and blood do not flow smoothly, they accumulate in the joints or limbs, without changing the color of the flesh. The illness is mild during the day but severe at night, with pain that pierces the bones like a tiger's bite. This is called White Tiger Disease." The "Mai Yin Zheng Zhi · Bi" says: "According to the 'Bi Lun,' all three energies can invade the five zang organs, and wind, cold, and dampness take advantage of the body's weaknesses to invade them." The "Zhengzhi Junsheng · Wei Bi Men" states: "Traveling bi refers to unpredictable movement, such as wandering pain and intermittent episodes. ... Painful bi refers to intense, agonizing pain, often associated with wind, White Tiger, and flying corpses. ... Fixed bi refers to immobility, often described as numbness and insensitivity. Bi means closure. When the righteous qi of the five zang organs and six fu organs is blocked by evil qi, it becomes bi and loses its sensitivity." Modern medical practitioners have diverse understandings and treatment approaches for this disease, reflecting a multitude of schools of thought. Professor Zhao Kai proposed the therapeutic concept of "distinguishing evil qi and treating accordingly," judging the predominant type of evil qi based on the patient's symptoms. For those with wind dominance, he recommends adding herbs that dispel wind, unblock meridians, and relieve pain while harmonizing ying and wei, such as Fangfeng, Gegen, Qin, Haifengteng, Quanxie, Silu Luo, Wugong, and Gui Zhi. For those with cold dominance, he generally suggests using Ganjiang, Ma Huang, Fuzi, and Duhuo to dispel wind, scatter cold, unblock meridians, and relieve pain. For those with dampness dominance, he recommends adding Zhengren, Wujia Pi, Fangji, and Bai Bian Dou to promote diuresis and reduce swelling. For those with heat dominance, he suggests adding Huangbo, Jin Yin Hua, Lianqiao, Shengshi Gao, Zhimu, Hu Zhang, and Ren Dong Teng to clear heat, disperse stagnation, and relieve pain. For those with phlegm-turbidity dominance, he recommends adding Cangshu, Bai Jingzi, Banxia, Zhi Dan Nanxing, and Shan Cigu to transform phlegm, remove turbidity, and relieve pain. For those with blood stasis dominance, he suggests adding Honghua, Danggui, Chuanxiong, Danshen, and Jixueteng to activate blood circulation, remove blood stasis, and unblock meridians. Upper limb pain is often treated with Qianghuo and Sangzhi; arm pain is often treated with Jianghuang; lower limb and knee pain is often treated with Duhuo, Niuxi, and Haitongpi. Duhuo is often used together with Haitongpi to remove dampness, making it effective for treating lower limb joint pain, and is frequently paired with Haifengteng to dispel wind and unblock meridians, with Shengjing Cao and Tougu Cao to facilitate joint movement. Fuzi and Chuan Wu are used to dispel cold and relieve pain. Given that many wind-dispelling and dampness-removing herbs can hinder spleen and stomach digestion, they are often paired with herbs that protect the spleen and stomach.

Professor Xie skillfully uses insect and vine-based medicines, believing that vine-based drugs generally have the effect of soothing the meridians and activating the circulation. Clinically, he often uses Qingfengteng, Jixueteng, Luoshiteng, and Ren Dong Teng, which can also serve as guiding herbs to direct the medicinal power directly to the site of the disease, thereby improving clinical efficacy. Drawing on the characteristic of "insects swiftly flying away like mosquitoes," he uses insect-based medicines to treat RA, often employing Zhong, Quanxie, Tuibiechong, Jiangcan, Wushaoshe, Dilong, and other insects. Tuibiechong is good at breaking blood stasis and relieving pain, while Wugong, Quanxie, and Dilong excel at dispelling wind and unblocking meridians, and snake-based medicines can penetrate deeply into the body to reach the site of the disease.

Chen Xiangjun treats RA primarily by strengthening the body, combining internal and external treatments. During the active phase, she focuses on tonifying qi, especially when there is qi-yin deficiency, requiring both qi-tonifying and meridian-clearing measures, while also emphasizing nourishing yin. She often uses Gui Zhi Shaoyao Zhimu Tang combined with San Miao Wan with adjustments, and externally applies formulas that clear heat and drain dampness, using herbs like Tougu Cao, Ku Fan, and Bing Pian to alleviate symptoms. During the remission phase, she emphasizes nourishing the liver and kidneys, and for stubborn cases, she uses insect-based medicines to unblock meridians. For those with liver and kidney deficiency, she often uses Zuogui Wan, supplemented with Biejia, Guiban, and Lujiaopian to nourish the liver and kidneys, warm yang, and unblock meridians. For cases with phlegm-stasis obstruction, she uses herbs that activate blood circulation and remove blood stasis, such as Xu Changqing, E Zhu, Bai Jiezi, Jiangcan, and Zhi Nanxing to transform phlegm. For heat-related bi, she adds Dilong, and for cases with phlegm and dampness, she adds Jiangcan. For pain above the waist, especially in the shoulders and back, she adds Fengfang and Quanxie, while for pain below the waist, she adds Chuan Shan Jia and Wugong.

Professor Liu Xide, based on the "Suwen," believes that "when righteous qi resides within, evil qi cannot invade" and "evil qi always seeks out weakness," thus concluding that the root cause of rheumatoid arthritis lies in inherent deficiencies leading to liver and kidney deficiency, insufficient production of qi and blood, and overall deficiency of righteous qi, with evil qi being the manifestation. If patients are elderly and their qi, blood, liver, and kidneys are deficient, or if they suffer from chronic illnesses that lead to imbalances in ying and wei, resulting in long-term joint deformities, dislocations, limb atrophy, numbness, aversion to cold and wind, pale complexion, fatigue, poor appetite, pale tongue with white coating, and a deep, fine, weak pulse, then tonifying qi and blood, as well as nourishing the liver and kidneys, should be added. Those with qi and blood deficiency can add Danggui, Gui Zhi, Baizhu, Chuanxiong, and Xinxin, while those who need to nourish the liver and kidneys can add Lujiaojiao, Du Zhong, Jixueteng, Sangjisheng, Shu Di Huang, and Dangshen.

Physiology and Pathology

Ankylosing spondylitis (AS) is a chronic progressive disease that primarily affects the sacroiliac joints, vertebral prominences, paravertebral soft tissues, and peripheral joints, and may also present with extra-articular manifestations. Severe cases can lead to spinal deformity and joint ankylosis. The etiology of AS remains unclear, but pathological markers and early manifestations include sacroiliitis and enthesitis. The synovitis of peripheral joints is histologically similar to that of rheumatoid arthritis, making it difficult to distinguish. The typical late-stage manifestation of spinal involvement is a bamboo-like spine. Epidemiological studies show that genetic and environmental factors play a role in the development of this disease.

Sacroiliitis is a pathological marker of AS and is often one of its earliest manifestations. Early pathological changes in sacroiliitis include the formation of subchondral granulation tissue, with histological evidence of synovial hyperplasia, accumulation of lymphoid cells and plasma cells, formation of lymphoid follicles, and plasma cells containing lgG, lgA, and IgM. Bone erosion and cartilage destruction follow, eventually being replaced by degenerated fibrocartilage, ultimately leading to bony ankylosis.

The initial damage to the spine involves the formation of granulation tissue at the intervertebral disc annulus fibrosus and the junction of the vertebral margins. The outer layer of the annulus fibrosus may eventually be replaced by bone, forming ligamentous osteophytes, which further develop into the bamboo-like spine seen on X-rays. Other spinal injuries include diffuse osteoporosis, destruction of the vertebral bodies near the intervertebral discs, deformation of the vertebral bodies, and ankylosis of the intervertebral discs. Similar axial joint pathological changes can also be observed in other spinal joint diseases.

Enthesitis occurs at the sites where ligaments or tendons attach to bones,

and in ankylosing spondylitis, it often occurs around the spine and pelvis, eventually leading to ossification. This is another pathological marker of spinal joint disease, whereas in other spinal joint diseases, it is more common in peripheral areas, such as the attachment of the Achilles tendon to the calcaneus.

Two. Diagnosis and Treatment

(---) Clinical Diagnosis 1. Clinical Manifestations

(1) Systemic Manifestations: The onset is usually subtle, with early non-specific systemic symptoms such as mild loss of appetite, low-grade fever, and fatigue. Severe cases may present with fever, exhaustion, weight loss, anemia, or involvement of other organs.