4. Treatment

4. Treatment

(1) Treatment Principles

Diabetes treatment should follow the principle of comprehensive management, including controlling hyperglycemia, hypertension, dyslipidemia, overweight and obesity, and hypercoagulability—multiple cardiovascular risk factors. On the basis of lifestyle interventions, necessary pharmacological treatments should be administered to improve the quality of life and extend the life expectancy of diabetic patients. Individualized control targets should be set according to the patient’s age, disease duration, life expectancy, and severity of complications.

(2) Treatment Goals

Comprehensive treatment for type 2 diabetes includes lowering blood glucose, reducing blood pressure, regulating lipid levels, antiplatelet therapy, weight control, and lifestyle improvement. The comprehensive control targets are shown in Table 4.

Table 4: Comprehensive Control Targets for Type 2 Diabetes in China

(3) Lifestyle Interventions

For patients already diagnosed with diabetes, lifestyle interventions should be initiated immediately and maintained consistently. The content and objectives of various lifestyle interventions are shown in Table 5.

Table 5: Content and Objectives of Lifestyle Interventions

(4) Pharmacological Treatment

1. Timing of Initiation of Pharmacotherapy
   Lifestyle interventions are the foundational treatment for type 2 diabetes and should be implemented throughout the entire course of treatment. For newly diagnosed patients whose blood glucose is well-controlled, physicians may opt for lifestyle interventions alone based on the patient’s condition and preferences. If lifestyle interventions alone fail to achieve target blood glucose levels, pharmacotherapy should then be initiated.

2. Precautions During Pharmacotherapy
   (1) Before starting medication, contraindications should be reviewed according to the drug’s package insert. Different types of drugs may be used in combination—two or three at a time—and drugs within the same class should be avoided when used concurrently.
   (2) When using hypoglycemic agents, education on hypoglycemia prevention should be provided, especially for patients using insulin secretagogues and insulin.
   (3) Blood glucose monitoring should be conducted during the use of hypoglycemic medications, particularly for patients receiving insulin therapy.
   (4) Drug selection should take into account the patient’s financial capacity.

3. Selection of Hypoglycemic Medications
   (1) Metformin: Metformin is the cornerstone medication for patients with type 2 diabetes. If there are no contraindications and the patient can tolerate the drug, metformin should be used throughout the entire course of pharmacotherapy. Pharmacological action: reduces hepatic glucose output and improves peripheral insulin resistance. Major adverse reactions: gastrointestinal side effects. Contraindications: biguanide drugs are contraindicated in patients with renal insufficiency [creatinine level in males > 132.6 mmol/L (1.5 mg/dL), in females > 123.8 mmol/L (1.4 mg/dL), or estimated glomerular filtration rate (eGFR) < 45 mL/min · 1.73 m²], as well as in cases of hepatic insufficiency, severe infection, hypoxia, major surgery, or alcohol abuse. If contrast media containing iodine are used during imaging examinations, metformin should be temporarily discontinued.
   (2) Insulin secretagogues: Insulin secretagogues include sulfonylureas and meglitinides. Commonly used drugs: sulfonylureas. Pharmacological action: stimulates pancreatic β-cells to secrete insulin, increasing endogenous insulin levels.

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| | height="0.11425087489063868in"} | | height="8.447178477690288e-2in"} | height="8.497156605424322e-2in"} | | height="8.496172353455818e-2in"} | height="0.2691469816272966in"

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+-------------------------------------------------------+------------------------------------------------------------------------------------------+---------------------------------------------------------+---------------------------------------------------------+--------------------------------------------------------+-------------------------------------------------------+-------------------------------------------------------+ | | | | height="8.641622922134733e-2in"} | height="8.641622922134733e-2in"} | height="0.26669838145231844in"} | height="8.496062992125984e-2in"} | Plain level. Major adverse reactions: hypoglycemia and weight gain. Contraindications: patients with clearly diagnosed type 1 diabetes, type 2 diabetes accompanied by ketoacidosis, infection, trauma, major surgery and other stress conditions, severe hepatic or renal insufficiency, those allergic to this class of drugs or who have experienced serious adverse reactions, etc. (3) Alpha-glucosidase inhibitors. Pharmacological action: inhibits the absorption of carbohydrates in the upper small intestine. Major adverse reactions: Gastrointestinal reactions such as bloating and flatulence. Contraindications: patients with chronic gastrointestinal dysfunction with obvious digestive and absorptive disorders, patients with diseases that may be aggravated by intestinal distension (such as severe hernia, intestinal obstruction, and intestinal ulcer), and those allergic to this class of drugs, etc. (4) Thiazolidinedione (TZD) drugs. Pharmacological action: increases the body's sensitivity to insulin. Major adverse reactions: weight gain and edema; increased risk of fractures and heart failure. Contraindications: patients with heart failure (New York Heart Association functional classification grade I or above), active liver disease or transaminase levels exceeding 2.5 times the upper limit of normal, severe osteoporosis, and a history of fractures. (5) Insulin: Insulin therapy is an important means of controlling hyperglycemia. Classification: According to differences in source and chemical structure, insulin can be divided into animal insulin, human insulin, and insulin analogs. According to differences in pharmacological characteristics, insulin can also be divided into ultra-short-acting insulin analogs, regular (short-acting) insulin, intermediate-acting insulin, long-acting insulin, long-acting insulin analogs, premixed insulin, and premixed insulin analogs. Initiation of insulin therapy: For patients with type 2 diabetes, after 3 months of combined lifestyle intervention and oral hypoglycemic drug treatment, if blood glucose still fails to reach the control target, insulin therapy should be initiated promptly. For patients with type 2 diabetes, insulin therapy can be started with 1–2 injections per day; those receiving once-daily insulin therapy often need to combine it with oral hypoglycemic drugs. For newly diagnosed type 2 diabetic patients with HbA1c ≥ 9.0% or fasting blood glucose ≥ 11.1 mmol/L accompanied by obvious symptoms of hyperglycemia, short-term (2 weeks to 3 months) intensive insulin therapy may be considered. Table 7 Common Insulins and Their Pharmacological Characteristics

Insulin preparations | > Onset time | > Peak time | > Duration of action | | > ( h) | > Time ( | | | > h) Short-acting insulin ( RI | > 15 ~ | > 2 ~4 | > 5 ~ 8 ) | > 60min | | Intermediate-acting insulin ( NPH | > 2.5 ~3 | > 5 ~7 | > 13 ~ 16 ) | > . oh | | Long-acting insulin ( PZI | > 3 ~4h | > 8 ~ 10 | > 20 ) | | | Premixed insulin | > 30min | > 2 ~ 12 | > 14 ~24 | | | ( HI 30R , HI | | | 7030 ) | | | Premixed insulin ( | > 30min | > 2 ~ 3 | > 10 ~24 50R) | | | (6) Other: Other hypoglycemic drugs such as dipeptidyl peptidase IV (DPP-4) inhibitors, sodium-glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists.

4. Drug Treatment Plan The treatment of type 2 diabetes should be individualized based on comprehensive factors such as the condition. Lifestyle intervention is the basic treatment for type 2 diabetes and should run throughout the entire course of diabetes treatment. If lifestyle alone cannot achieve target blood glucose control, monotherapy should be initiated, with metformin being the first-line drug for type 2 diabetes. As long as there are no contraindications, metformin should always be retained in the diabetes treatment regimen. Those who are not suitable for metformin treatment can choose alpha-glucosidase inhibitors or insulin secretagogues. If blood glucose remains uncontrolled with metformin alone, combination therapy can be used, adding insulin secretagogues, alpha-glucosidase inhibitors, TZDs, or insulin. Triple therapy: Different hypoglycemic drugs with different mechanisms can be used in combination—three drugs at a time. If triple therapy still fails to control blood glucose, the treatment plan should be adjusted to multiple insulin therapies. When using multiple insulin therapies, insulin secretagogues should be discontinued. (5) Comprehensive Intervention Management In addition to hypoglycemic treatment, patients with type 2 diabetes should also undergo comprehensive management of blood pressure, blood lipids, and antiplatelet therapy.
5. Blood Pressure Control Blood pressure targets: Generally, diabetic patients with hypertension should aim for blood pressure below 130/80 mmHg; diabetic patients with severe coronary heart disease or elderly patients aged 65–80 may adopt relatively looser blood pressure targets, keeping it below 140/90 mmHg; patients over 80 years old or those with severe chronic diseases (such as requiring long-term care or end-stage chronic diseases) may keep their blood pressure below 150/90 mmHg. Timing for initiating drug treatment: Diabetic patients whose blood pressure is ≥ 140/90 mmHg may consider starting antihypertensive medication. If blood pressure is ≥ 160/100 mmHg or exceeds the target value by more than 20 mmHg, antihypertensive medication should be started immediately, and combination therapy may be adopted. Drug selection: Five classes of antihypertensive drugs [angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), diuretics, calcium channel blockers, beta-blockers] can all be used for diabetic patients, among which ACEI or ARB are the preferred drugs.
6. Lipid Regulation Lipid regulation targets: It is recommended to prioritize lowering LDL-C. LDL-C targets: For patients with a clear history of atherosclerotic cardiovascular disease (ASCVD), LDL-C should be <1.8 mmol/L; for diabetic patients without ASCVD history, LDL-C should be <2.6 mmol/L. Drug selection: Statins are the clinical first choice. It is advisable to start with moderate-intensity statins, adjusting the dosage appropriately based on individual lipid-regulating efficacy and tolerance. If TC levels still fail to meet the target, other lipid-regulating drugs can be used in combination. To prevent acute pancreatitis, patients with fasting TG ≥ 5.7 mmol/L should first use drugs that lower TG.
7. Antiplatelet Therapy Aspirin (75–100 mg/day) is used as primary prevention for high-risk cardiovascular patients with diabetes, including: age ≥ 50 years and having at least one major risk factor (early-onset ASCVD family history, hypertension, dyslipidemia, smoking, or proteinuria). Diabetic patients with ASCVD need to take aspirin (75–150 mg/day) as secondary prevention; ASCVD patients allergic to aspirin need to take clopidogrel (75 mg/day) as secondary prevention. Section 2: Professor Pei Zhengxue’s Experience in Diagnosing and Treating Diabetes Diabetes refers to a metabolic disorder syndrome characterized by chronic elevation of blood glucose levels, resulting from absolute or relative insufficiency of insulin secretion by pancreatic islet cells due to the interaction of genetic and environmental factors. It is often accompanied by insulin resistance, hypertension, hyperlipidemia, obesity, and other conditions, making treatment difficult, especially with the potential for various complications that can severely endanger patients’ lives and health. In traditional Chinese medicine, diabetes is classified under the category of “Xiaoke Disease,” a term first mentioned in the “Yellow Emperor’s Inner Canon.” The “Yellow Emperor’s Inner Canon” also records terms such as “Xiao,” “Fei Xiao,” and “Xiao Zhong,” believing that overconsumption of rich and sweet foods and emotional imbalance are the causes of Xiaoke. During the Han Dynasty, Zhang Zhongjing, in his work “Jingui Yaolüe · Xiaoke, Difficulty in Urination, and Treatment of Urinary Tract Diseases,” provided a detailed discussion of Xiaoke Disease and first proposed therapeutic formulas such as Shenqi Wan and Baihu Tang with added ginseng. Causes and Pathogenesis Professor Pei Zhengxue believes that diabetes should be classified under the TCM category of “Xiaoke.” Xiaoke is divided into three types: upper, middle, and lower. Upper Xiaoke is characterized by excessive drinking and belongs to the lungs; middle Xiaoke is characterized by excessive hunger and belongs to the stomach; lower Xiaoke is characterized by frequent urination and belongs to the kidneys. However, in clinical practice, it is often difficult to clearly distinguish between these three types, as they frequently involve the lungs, stomach, and kidneys simultaneously. The disease primarily affects the lungs, stomach, and kidneys, with the main pathogenesis being deficiency of yin fluids and excess dry heat, presenting as a pattern of “yin deficiency as the root, dry heat as the manifestation.”
8. Early stage: yin deficiency and dry heat; mid-stage: qi and yin deficiency; late stage: both yin and yang deficiency—these are the characteristics of the disease’s pathogenesis. Deficiencies in innate endowment or acquired imbalances, overwork, improper sexual conduct, excessive emotional fluctuations, dietary damage, or exposure to external pathogenic factors leading to internal heat and yin depletion, causing dryness and heat to prevail, ultimately resulting in organ malnutrition. From a causal perspective, yin fluid depletion is the cause, while dry heat is the result, further exacerbating yin depletion. From a relationship between root and manifestation, yin fluid depletion is the root of the disease, while dry heat is the manifestation; therefore, when treating Xiaoke, it is essential to carefully assess causality, weigh priorities, and formulate a treatment plan to prevent disease progression. Prolonged yin deficiency and dry heat will inevitably lead to qi and yin deficiency, manifesting as varying degrees of excessive drinking, frequent urination, and increased appetite. Over time, yin damage extends to yang, resulting in qi deficiency and yang weakness, such as general fatigue, mental exhaustion, even feeling cold, difficulty digesting food, loose stools, dry mouth with reluctance to drink, nocturnal polyuria, pale tongue, thin white coating, and weak pulse—this is due to the simultaneous deficiency of yin energy in the lung, stomach, and kidney meridians, coupled with yang energy damage, leading to a dual deficiency of yin and yang.
9. Qi and yin deficiency, along with phlegm-turbidity and blood stasis obstructing the meridians, form the pathological basis for complications in Xiaoke. Due to qi deficiency preventing proper blood circulation, yang deficiency causing cold and blood stasis, and yin deficiency generating excessive fire that scorches body fluids, all these factors can lead to the formation of blood stasis and phlegm-turbidity. Prolonged Xiaoke can result in liver and kidney yin deficiency, causing insufficient nourishment of the eyes, leading to night blindness, cataracts, and even blindness. Yin deficiency and internal heat accumulation can lead to toxic buildup and abscess formation, resulting in skin sores and boils. Yin deficiency and dry heat can transform fluids into phlegm, which obstructs the meridians or blocks the heart’s orifices, causing stroke and hemiplegia. Phlegm-stasis obstructing the limbs and blocking the meridians leads to coldness and numbness in the limbs; prolonged blood stasis can turn into heat, producing gangrene. Kidney yin deficiency, extending to yang, results in spleen-kidney yang deficiency, causing water dampness to overflow and leading to edema, insufficient warmth, and impaired large intestine function, resulting in diarrhea or constipation. II. Syndrome Differentiation and Treatment Professor Pei Zhengxue believes that the root of this disease lies in yin deficiency, while lung dryness, stomach heat, and blood stasis are the manifestations. Clinical practice follows the Eight Principles of Syndrome Differentiation as the framework and organ-based differentiation as the focus. For root deficiencies, the emphasis should be on tonifying qi and nourishing yin, nourishing the liver and kidneys, and strengthening the spleen and warming yang; for manifestation deficiencies, the approach should be clearing heat and activating blood. In the later stages of the disease, when deficiency contains manifestation, the condition becomes complex, so both root and manifestation should be addressed, combining attack and tonification. Based on syndrome differentiation and treatment, combining Western hypoglycemic drugs or insulin can yield better therapeutic effects. For diabetic patients with liver and kidney yin deficiency, common symptoms include excessive thirst and drinking, dry mouth and throat, irritability and excessive sweating, and soreness in the lower back and knees. For treating this condition, Professor Pei Zhengxue often uses Liuwei Dihuang Wan and Yuquan Wan with modifications, and for internal heat due to yin deficiency, Qinggu San can be added. For lung yin deficiency, Shengmai San is used. For lung and stomach dryness and heat, common symptoms include excessive thirst and drinking, increased appetite, and dry stools. If the pulse is full and rapid, indicating real heat, White Tiger Soup and similar formulas should be prioritized to counteract the upward trend of heat. Heat easily depletes qi and yin, so when using large amounts of gypsum and zhimu, Professor Pei Zhengxue often combines them with American ginseng to nourish yin and generate fluids, tonifying qi and supporting the body. For those with damp-heat obstruction, common symptoms include being overweight, flank pain, limb fatigue, and uncomfortable bowel movements. When yang heat accumulates and toxins build up, Professor Pei Zhengxue often uses Sanhuang Xiexin Tang, Dachaihu Tang, and Fangfeng Tongsheng Wan, which have shown significant effectiveness. For those with intestinal dryness and fluid loss, common symptoms include dry mouth, dry stools, and excessive thirst, often treated with Maziren Wan combined with Shengmai Yin. For kidney yin deficiency, it is advisable to use nourishing products with abundant juice and fat, such as Huangjing, Yuzhu, Shan Yu Rou, Shengdi, and Shanyao, or Yuquan Wan with modifications. In the later stages, when kidney yang is deficient and urination is frequent while stools are dry, Jichuan Jian and similar formulas can be effective. For diabetic patients with both yin and yang deficiency combined with spleen and stomach qi deficiency, common symptoms include frequent urination, long and thin urine, constant urination in the morning and evening, sometimes urine appearing light blue, sometimes floating like pig fat, lack of appetite, pale tongue without redness, thin white coating, sometimes moist, sometimes dry, shortness of breath and low voice, cold extremities during bowel movements, and six pulses often showing sinking, especially in the chi position—this is what is known as the "cold-deficient" type of diabetes. Whenever Professor Pei Zhengxue diagnoses this condition, he invariably uses Zhuanghuo, Buxu, Gute, and Tianhui Jin Gui Shenqi Wan to treat it. If the disease has been present for a long time and blood stasis has developed, obstructing the meridians and causing limb numbness and chest tightness, he may use the Zhu Shi Hypoglycemic Formula combined with Guanxin No. 2 Formula with modifications to tonify qi, activate blood, and lower blood sugar. In addition, Professor Pei Zhengxue believes that although this disease is traditionally divided into upper, middle, and lower Xiaoke for treatment, in clinical practice, the three types of symptoms often appear together, with the lungs, stomach, and kidneys all affected simultaneously, making it impossible to clearly separate them. The root cause lies in the middle jiao. Prolonged dry heat in the middle jiao burns the heart and lungs above and depletes true yang below, leading to qi and yin deficiency in the upper jiao and impaired transformation in the lower jiao. Therefore, in clinical practice, it is often necessary to treat all three types of Xiaoke together, with the middle jiao as the focus, taking into account both upper and lower parts, and selecting Shengmai San, White Tiger Soup, and Jin Gui Shenqi Wan with modifications for treatment. If lung dryness is severe, Shengmai San is prioritized; if stomach heat is severe, White Tiger Soup is prioritized; if kidney deficiency is severe, Jin Gui Shenqi Wan is prioritized. 1. Lung and Stomach Dryness and Heat Symptoms: Excessive thirst and drinking, dry mouth and tongue, increased appetite, constipation, red tip of the tongue, thin yellow coating, and slippery, rapid pulse. Treatment: Clear and drain lung and stomach, generate fluids and quench thirst. Prescription: Shengmai Yin combined with White Tiger Soup, with additions and subtractions of ginseng. Gypsum, zhimu, shanyao, American ginseng, mai dong, wu wei zi, tian hua fen, huang lian, gan cao. For excessive thirst and drinking, add wumei and shihu to nourish yin and relieve cough and thirst; for frequent urination and oily urine, add shanyu rou to nourish the kidneys.

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, gallnuts, and Fructus Alpiniae Oxyphyllae to consolidate essence and vital energy; for those with excessive hunger and poor appetite, heavily use Coptis chinensis to clear stomach fire; for those with dry and hard stools, add Cannabis sativa seed, peach kernel, and Prunus armeniaca kernel to moisten dryness and promote bowel movements. 2. Qi and Yin deficiency Symptoms: dry throat and mouth, fatigue and weakness, spontaneous sweating and shortness of breath, frequent colds, reduced appetite and abdominal distension, palpitations and insomnia, lower back pain and weakness, normal urination, normal or loose stools, a plump tongue or teeth marks on the sides, white coating, and a deep, fine pulse. Treatment principle: tonify qi and nourish yin. Prescription: modify Shengmai Yin combined with Yuquan Wan. Radix Adenophorae, Ophiopogon japonicus, Schisandra chinensis, Flos Lonicerae, Rehmannia glutinosa, Pueraria lobata, Glycyrrhiza uralensis. For obvious dry mouth, add Rehmannia glutinosa preparata, Dendrobium, Pueraria lobata, and Phragmites communis to nourish yin and generate fluids; for limb weakness and shortness of breath and drowsiness, add Astragalus membranaceus, Dioscorea opposita, and Codonopsis pilosula to tonify qi and nourish yin; for lower back and knee pain and weakness, add stir-fried Eucommia ulmoides, Achyranthes bidentata, stir-fried Dipsacus asperoides, and Taxillus chinensis to tonify liver and kidney and strengthen lower back and knees; for dry and difficult-to-pass stools, add Cannabis sativa seed, Cistanche deserticola, Angelica sinensis, and Polygonum multiflorum to nourish essence and blood and moisten the intestines for easy bowel movements. 3. Liver and kidney yin deficiency Symptoms: dry throat and mouth, lower back and knee pain, dizziness and tinnitus, dry eyes, hot flashes and night sweats, irritability and insomnia, red tongue with little coating, and a deep, fine pulse. Treatment principle: nourish liver and kidney. Prescription: modify Yuquan Wan combined with Qiju Dihuang Tang. Rehmannia glutinosa, Cornus officinalis, Dioscorea opposita, Poria cocos, Alisma orientalis, Angelica sinensis, Moutan cortex, Polygonatum odoratum, Chrysanthemum morifolium, Lycium barbarum, Pueraria lobata, Ophiopogon japonicus, Schisandra chinensis. For numbness and tingling in the limbs, add Millettia reticulata, Chuanxiong, Paeonia lactiflora, Trachelospermum jasminoides, and Clematis armandii to nourish blood and unblock meridians; for severe dizziness, add Gastrodia elata, Uncaria rhynchophylla, and Haliotis diversicolor to calm the liver and subdue yang; for dry and difficult-to-pass stools, add Cannabis sativa seed, Cistanche deserticola, Platycladus orientalis seeds, and Polygonum multiflorum to moisten the intestines and promote bowel movements. If blood pressure is high and there is dizziness and tinnitus, use Zhen Gan Xi Feng Tang with modifications. Combine irritability and insomnia with Suanzaoren Tang. 4. Both qi and yin deficiency Symptoms: fear of cold and cold limbs, mental fatigue and lassitude, pale complexion, lower back and knee pain and coldness, drinking one one, clear and long urine, loose stools, pale and plump tongue, white and moist coating, and a deep, thin, weak pulse. Treatment principle: tonify both qi and yin. Prescription: modify Shengmai San combined with Jin Gui Shen Qi Wan. Processed Aconitum carmichaelii, Cinnamomum cassia, Rehmannia glutinosa preparata, Dioscorea opposita, Alisma orientalis, Cornus officinalis, Poria cocos, Moutan cortex, Codonopsis pilosula, Ophiopogon japonicus, Schisandra chinensis. For those with foam in urine, add Rubus chingii and Rosa laevigata to consolidate essence and vital energy; for poor appetite, add Amomum villosum, stir-fried tea leaves, stir-fried malt, and stir-fried chicken gizzard to invigorate the spleen and stimulate appetite. For those with loose stools, combine Fu Zi Li Zhong Tang to warm the middle burner and stop diarrhea. If dry heat depletes lung and stomach yin and damages spleen and kidney yang, resulting in symptoms such as excessive eating and thirst, drinking one search one, then use Bai Hu Tang to clear heat and nourish yin, while warming the kidneys and transforming qi. 5. Blood stasis obstructing the channels Symptoms: numbness and tingling in the limbs, chest oppression and heart pain, dry throat and tongue, fatigue, spontaneous sweating and shortness of breath, plump tongue or teeth marks, dark tongue or瘀spots, and a deep, thin pulse. Treatment principle: activate blood circulation and remove stasis. Prescription: modify Zhu's hypoglycemic formula. Rehmannia glutinosa, Pueraria lobata, Atractylodes lancea, Dioscorea opposita, Scrophularia ningpoensis, Astragalus membranaceus, Salvia miltiorrhiza. For those with lower back and knee pain and weakness, add stir-fried Eucommia ulmoides, Achyranthes bidentata, stir-fried Dipsacus asperoides, and Taxillus chinensis to tonify liver and kidney and strengthen lower back and knees; for palpitations and chest tightness, and sleep disturbances, add Prince Ginseng, Ophiopogon japonicus, Schisandra chinensis, and Platycladus orientalis to tonify qi and nourish yin and calm the spirit; for dry and difficult-to-pass stools, add Cannabis sativa seed, Angelica sinensis, and peach kernel to moisten the intestines and promote bowel movements; when blood stasis clearly obstructs the heart vessels and chest pain is severe, combine with Guanxin No. 2 Formula, Panax notoginseng, and leeches; if phlegm and blood stasis obstruct the heart vessels, then also combine with Gua Bai Banxia Tang; for limb numbness and tingling, add Angelica dahurica, earthworm, and centipede; for limb numbness and hemiplegia, diagnosed as ischemic stroke, combine with Buyang Huanwu Tang, or use Rehmannia Decoction combined with Guanxin No. 2 Formula with modifications. III. Clinical Case Studies Case 1: Liu, female, 56 years old, first visit on August 16, 2017. Has had diabetes for more than four years, with excessive thirst, frequent urination, and increased appetite. Diagnosed with type 2 diabetes at a Grade III hospital, and after taking hypoglycemic drugs, the condition once improved. However, over the past year, blood sugar control has been poor, with fasting blood glucose around 10 mmol/L and HbA1c at 8.3%. Current symptoms: dry mouth, fatigue, sleep disturbance, accompanied by dizziness, a feeling of cotton under the feet in both lower limbs, dark red tongue with little coating, and a deep, thin pulse. Previously had hypertension and took antihypertensive drugs for a long time, currently with blood pressure at 140/100 mmHg. Western medical diagnosis: type 2 diabetes; hypertension. Traditional Chinese medicine differentiation: liver and kidney yin deficiency. Treatment principle: nourish liver and kidney. Prescription: modify Yuquan Wan. Rehmannia glutinosa 12 g, Cornus officinalis 10 g, Dioscorea opposita 10 g, Poria cocos 10 g, Alisma orientalis 10 g, Moutan cortex 10 g, Polygonatum odoratum 10 g, Chrysanthemum morifolium 10 g, Lycium barbarum 10 g, Pueraria lobata 30 g, Ophiopogon japonicus 10 g, Schisandra chinensis 6 g, Gastrodia elata 10 g, Uncaria rhynchophylla 10 g, Haliotis diversicolor 30 g (decocted), Glycyrrhiza 6 g. 14 doses, decocted in water, taken once daily. After taking the medicine, dry mouth symptoms eased, and additional Suanzaoren 15 g, Chuanxiong 6 g, Anemarrhena asphodeloides 10 g, and Poria cocos 10 g were added, continuing for another 14 doses, all previous symptoms improved. Subsequently, the above prescription was adjusted for treatment for over seven months, HbA1c gradually dropped to 6.3%, blood sugar basically controlled within the normal range, and blood pressure decreased to 130/90 mmHg. Case 2: Han, male, 70 years old, first visit on October 23, 2018. Patient is obese, has had hypertension, type 2 diabetes, and hyperlipidemia for more than six years, and has been taking antihypertensive, hypoglycemic, and lipid-lowering medications for a long time, with relatively good disease control. In the past six months, he felt that his diabetes was completely under control, no longer following the diabetic diet guidelines, and arbitrarily increasing or decreasing hypoglycemic drugs, resulting in a significant rise in blood sugar. One month ago, he visited the hospital, where fasting blood glucose was found to be 12.3 mmol/L, HbA1c 9.5%, and after a month of improving the hypoglycemic regimen, blood sugar control remained poor, so he came for consultation. Current symptoms: dry mouth and excessive drinking, fatigue and weakness, increased appetite and hunger, bad breath, dry and hard stools, irritability and anger, frequent nighttime urination, coldness in the lower limbs, dark red tongue, thin yellow coating, and weak pulse. Fasting blood glucose 10.8 mmol/L. Western medical diagnosis: type 2 diabetes; hypertension; hyperlipidemia. Traditional Chinese medicine differentiation: dry heat in the lungs and stomach, and deficiency of kidney qi. Treatment principle: clear and nourish the lungs and stomach, warm the kidneys and transform qi. Prescription: modify Bai Hu Tang combined with Jin Gui Shen Qi Wan. Anemarrhena asphodeloides 10 g, gypsum 30 g (decocted first), Japonica rice 30 g, Glycyrrhiza 6 g, Prince Ginseng 10 g, Radix Adenophorae 10 g, Cinnamomum cassia 6 g, processed Aconitum carmichaelii 6 g, Rehmannia glutinosa preparata 12 g, Dioscorea opposita 10 g, Cornus officinalis 10 g, Poria cocos 10 g, Alisma orientalis 10 g, Moutan cortex 10 g, Scrophularia ningpoensis 10 g, Ophiopogon japonicus 10 g, Mirabilis jalapa 10 g (dissolved later), Rhubarb 6 g (added last). 14 doses, decocted in water, taken once daily. Second visit: After taking the medicine, bowel movements became 1–2 times per day, bad breath disappeared, food intake decreased, dry mouth improved, tongue dark red, coating normal, pulse weak. The previous addition of Mirabilis jalapa and Rhubarb was removed, and continued taking the medicine for another 14 doses. Third visit: After taking the medicine, dry mouth and increased appetite and hunger were greatly alleviated, but still felt fatigued and weak, frequent nighttime urination, coldness in the lower limbs, dark red tongue, and weak pulse. Fasting blood glucose measured at 8.9 mmol/L. The prescription was adjusted as follows: Anemarrhena asphodeloides 10 g, gypsum 30 g (decocted first), Japonica rice 30 g, Glycyrrhiza 6 g, Prince Ginseng 10 g, Cinnamomum cassia 6 g, Rehmannia glutinosa preparata 12 g, Dioscorea opposita 10 g, Cornus officinalis 10 g, Poria cocos 10 g, Alisma orientalis 10 g, Moutan cortex 10 g, Ophiopogon japonicus 10 g, Schisandra chinensis 10 g, and five flavors 10 g. This prescription was continued for over two months, all symptoms greatly alleviated, and blood sugar also significantly decreased, continuing to adjust this prescription for another half year, after which fasting blood glucose and HbA1c were basically restored to normal upon re-examination. The patient was instructed to strictly follow the diabetic diet, persist in traditional Chinese medicine treatment, and undergo regular check-ups. Section 3: Professor Pei Zhengxue’s Experience in Treating Diabetic Nephropathy Diabetic nephropathy refers to glomerulosclerosis caused by diabetic microvascular complications, also known as diabetic glomerulosclerosis. As a hereditary predisposition disease, its clinical characteristics are gradually developing proteinuria, hypertension, edema, and renal insufficiency after about ten years of diabetes. Diabetic nephropathy is a major complication and cause of death in diabetes, and as the incidence of diabetes increases year by year, the number of patients with diabetic nephropathy also gradually rises. In Western countries, more than half of dialysis patients have diabetic nephropathy, and in China, the incidence of diabetic nephropathy leading to dialysis is also steadily increasing, now ranking second among causes of uremia. Due to its high incidence, lack of specific treatments, and poor prognosis, diabetic nephropathy has become a serious disease that severely affects the health and quality of life of the general public. Early clinical manifestations of diabetic nephropathy mainly include trace albuminuria, followed by persistent and gradually increasing proteinuria and progressive renal function decline, eventually progressing to end-stage renal failure. Therefore, treatment should begin as soon as albuminuria appears to control disease progression. Modern medicine’s treatment of diabetic nephropathy mainly focuses on lowering blood sugar, blood pressure, and lipids, but still cannot prevent its development. Professor Pei Zhengxue, after many years of practice, believes that traditional Chinese medicine treatment of diabetic nephropathy has remarkable clinical efficacy. I. Etiology and Pathogenesis Professor Pei Zhengxue believes that in diabetic nephropathy, proteinuria and edema are the most common symptoms, and deficiency of both spleen and kidney is the main cause. Qing dynasty physician Chen Shiduo mentioned in “Bianzheng Lu”: “All cases of diabetes are due to spleen failure and kidney failure. When the spleen fails, earth cannot control water; when the kidney fails, water cannot resist fire. The combination of these two leads to illness. If the spleen does not fail and the kidney does not fail, there should be no diabetes.” In the later stages of diabetes, both spleen and kidney are deficient. If we do not actively strengthen the spleen and kidney, over time, it will inevitably lead to diabetic nephropathy, as stated in “Zhu Bing Yuan Hou Lun”: “Water-related diseases are all caused by spleen and kidney deficiency. When the spleen and kidney are deficient, water flows freely, overflowing the skin and causing the body to swell.” Spleen and kidney are physiologically interdependent: “Postnatal qi depends on innate qi, allowing continuous generation and growth; innate qi depends on postnatal qi, enabling endless transformation.” Pathologically, they also influence each other: in terms of fluid metabolism and proteinuria production, the spleen is responsible for transporting and transforming fluids, serving as the hub of fluid metabolism; the kidney controls opening and closing, being the organ primarily responsible for water, and in the Five Elements’ “generation and control” relationship, it is related to the mother and child. Protein is a basic substance that constitutes the human body and sustains life, belonging to the category of subtle substances in traditional Chinese medicine, its formation originates from the spleen, its consolidation is done by the spleen, and its storage is done by the kidney. When both spleen and kidney are deficient, subtle substances leak out, resulting in proteinuria. If left untreated for a long time, earth cannot control water, the kidney loses its ability to transform qi, water and dampness stagnate, spreading across the skin and causing edema; if the kidney loses its ability to consolidate, grain essence and water flow downward, unable to distinguish between clear and turbid, resulting in cloudy and foamy urine, with worsening proteinuria; prolonged yin deficiency damages yang, leading to spleen and kidney failure, dampness, turbidity, and blood stasis block the upper orifices, causing dizziness; dampness blocking the middle burner can lead to nausea, vomiting, and loss of appetite—symptoms of chronic renal failure. The disease involves the liver, kidneys, spleen, heart, and lungs, with the kidneys being the primary focus, affecting all five organs and six viscera. The nature of the disease is one of fundamental deficiency with superficial excess, with the liver, spleen, kidneys, heart, and lungs representing the fundamental deficiency, while qi stagnation, blood stasis, phlegm turbidity, toxic dampness, and heat-dampness represent the superficial excess. II. Syndrome Differentiation and Treatment Professor Pei Zhengxue believes that diabetic nephropathy is fundamentally characterized by yin deficiency, evolving from the basic syndrome of qi and yin deficiency. The liver, spleen, kidneys, heart, and lungs, along with the five organs’ qi and blood, represent the fundamental deficiency, while qi stagnation, blood stasis, phlegm turbidity, and toxic dampness represent the superficial excess. Treatment methods include tonifying qi and nourishing yin, nourishing the liver and kidney, tonifying qi and nourishing blood, warming the kidneys and strengthening the spleen, and activating blood circulation to remove stasis. In the later stages of the disease, when deficiency is mixed with excess, the condition becomes complex, so it is advisable to address both the root cause and the symptoms simultaneously, combining attack and support. For yin deficiency with dryness and heat, dry mouth and throat, heat in the palms and soles, frequent urination and thirst, lower back and knee pain, emaciation and easy hunger, red tongue with little coating, consider modifying Zhibai Dihuang Tang. For qi and yin deficiency, fatigue and weakness, emaciation, thirst and frequent drinking, palpitations and shortness of breath, dizziness and blurred vision, excessive sweating, constipation, use Duqi Wan combined with Shengmai Yin with additions. For spleen and kidney qi deficiency, shortness of breath and fatigue, poor appetite and abdominal distension, lower back and knee pain, frequent nighttime urination, use Shihe Ji (including realgar, Atractylodes macrocephala, Poria cocos, Dioscorea opposita, Cuscuta chinensis, Rosa laevigata, Polygonatum odoratum, Lycium barbarum, Pyrus betulaefolia, Codonopsis pilosula) or modify Shenqi Dihuang Tang. For spleen and kidney yang deficiency, lack of qi and laziness, poor appetite and abdominal distension, difficulty in defecation, lower back and knee pain, frequent nighttime urination, fear of cold and cold limbs, edema in the lower limbs, and prolonged treatment without improvement, choose Jisheng Shenqi Tang combined with Wuling San or Zhenwu Tang with modifications. For both qi and yin deficiency, blood stasis obstructing the channels, fear of cold and cold limbs, limb swelling, five hearts burning with heat, dry mouth and throat, lower back and knee pain, nocturnal clear and long urine, dry and hard stools, use Shenqi Fang with modifications (processed Aconitum carmichaelii, processed Rhubarb, White Flower Snake Tongue Grass, Motherwort, Honeysuckle, Plantain, Astragalus, Salvia miltiorrhiza, Mulberry, Lycium barbarum, Cornus officinalis, leeches). This disease often involves both deficiency and excess, with fundamental deficiency coexisting with varying degrees of dampness, phlegm turbidity, and blood stasis as superficial excess, and these superficial evils often accompany the entire course of the disease. Therefore, to achieve good therapeutic effects, it is also necessary to pay attention to the superficial evils at all times. In clinical practice, if there is fundamental deficiency combined with limb edema, low urine output, poor appetite and abdominal distension, pale tongue, teeth marks on the sides, white coating, and a deep pulse, it often indicates the presence of dampness, at which point diuretic and anti-edema drugs should be added, such as Pericarpium Citri Reticulatae, Poria cocos, ginger peel, mulberry bark, and orange peel, which can effectively improve limb swelling. If there are also symptoms of dry mouth and bitter taste, poor appetite and abdominal distension, nausea and vomiting, dry and hard stools, red tongue, yellow and greasy coating, and a slippery pulse indicating dampness and turbidity, then diuretic and clearing turbidity drugs can be used, such as Coptis chinensis, Pinellia ternata, orange peel, Poria cocos, realgar, bamboo shoot, and ginger. If there are also symptoms of dark complexion, rough skin, limb numbness and weakness, lower back pain, dark tongue, spots, and a thin, sticky pulse, it indicates blood stasis, at which point blood-activating and stasis-clearing drugs can be used, such as peach kernel, safflower, Angelica sinensis, Chuanxiong, red peony, and Salvia miltiorrhiza. In the later stages of diabetic nephropathy, edema and oliguria are common, and for patients with edema, it is natural to distinguish between yang water and yin water, choosing different treatment principles based on differences in cold, heat, deficiency, and excess. In addition, when treating edema, the focus should not only be on the kidneys, but also on the lungs and spleen. Jing Yue Quan Shu once said: “Water is the ultimate yin, its origin is in the kidneys, its manifestation is in the lungs, and its regulation is in the spleen.” The lungs are like a canopy, the source of water, through the respiratory movement of the lungs, the rise and fall of qi is regulated, so opening the lungs can have the effect of promoting diuresis and reducing edema, clinically, Yue Bi Tang can be used in combination. The spleen is responsible for transporting and transforming both water and food. When the spleen’s qi is deficient, transportation and transformation are impaired, leading to abnormal distribution of food essence and water, causing water metabolism disorders, and water and dampness overflow onto the skin, forming edema, clinically, Wuling San and Wupi Yin are often used in combination. When dampness accumulates internally, it easily leads to the formation of phlegm and blood stasis, exacerbating the condition, so regulating the spleen and stomach to ensure normal transportation and transformation of water and food is crucial, only then can water and dampness be normally distributed without stagnation, and when the spleen and stomach are strong and food intake increases, it can supplement the postnatal foundation needed, benefiting the overall recovery of bodily functions. Patients in the later stages of diabetic nephropathy generally have complex conditions, most of them also suffer from hypertension and hyperlipidemia, and their blood sugar is often poorly controlled, so treatment should be supplemented with antihypertensive and lipid-lowering drugs, and the hypoglycemic regimen should be adjusted in a timely manner to keep blood sugar within the standard range. At the same time, it is important to avoid using drugs that are toxic to the kidneys, to prevent further damage to renal function. In addition, diabetic nephropathy has a long course of disease, making treatment difficult, and patients often experience emotional distress, with obvious signs of liver depression. In addition to adding drugs to soothe the liver and relieve depression, it is also important to provide psychological counseling to patients, enhancing their confidence in overcoming the disease. Furthermore, maintaining appropriate living habits and dietary moderation are also very beneficial for improving the condition, and patients should avoid overexertion, abstaining from meat, eggs, and dairy products.

1. Qi and yin deficiency syndrome Symptoms: fatigue and weakness, thirst and desire to drink, dizziness and frequent dreams, or frequent and abundant urination, cloudy urine, heat in the palms and soles, palpitations, thin and pale tongue, red or light red tongue, little and dry coating, and a deep, thin, weak pulse. Treatment principle: tonify qi and nourish yin. Prescription: Duqi Wan combined with Shengmai Yin with modifications. Codonopsis pilosula, Ophiopogon japonicus, Schisandra chinensis, Rehmannia glutinosa, Dioscorea opposita, Cornus officinalis, Poria cocos, Moutan cortex, Alisma orientalis. For those with severe thirst, add Flos Lonicerae, Dendrobium, Polygonatum odoratum, Pueraria lobata, and Phragmites communis to generate fluids and quench thirst; for those with frequent urination, add Rosa laevigata and realgar to consolidate and collect essence; for those with lower back pain, add Eucommia ulmoides, Achyranthes bidentata, and Dipsacus asperoides to strengthen lower back and kidneys; for those with internal heat, add Anemarrhena asphodeloides and raw gypsum to clear stomach fire; for those with dry and hard stools, add Rhubarb, Angelica sinensis, peach kernel to activate blood circulation and remove stasis, and moisten the intestines for easy bowel movements.
2. Liver and kidney yin deficiency syndrome

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Findings: Dizziness and tinnitus, vexation in the five hearts and palms, soreness and weakness in the waist and knees, dryness and irritation of both eyes, blurred vision, scanty urination, red tongue with little coating, and a fine, rapid pulse. This pattern is often accompanied by hypertension. Treatment principle: Nourish the liver and kidneys. Prescription: Modified Qiju Dihuang Decoction combined with Zhu's Hypoglycemic Formula. Ingredients: Goji berries, chrysanthemum flowers, Rehmannia root, Poria, Alisma, Chinese yam, Cornus fruit, Moutan bark, Atractylodes, Scrophularia, Astragalus, Salvia, Kudzu root. For frequent and urgent urination, add Imperata rhizome, bamboo leaves, Polygonum aviculare, and Sagittaria to clear heat, drain dampness, and promote urination; for severe dizziness, add Gastrodia, Uncaria, and Cassia seeds to nourish yin and subdue yang; for lower back pain, add Eucommia, Achyranthes, and Dipsacus to strengthen the waist and tonify the kidneys; for edema, add Calabash peel, Plantago seed, and Citrullus colocynthis to promote diuresis and reduce swelling; for positive urinary protein, add Perilla stem, Cicada slough, and Motherwort to ascend and descend qi; for positive occult blood, add Donkey-hide gelatin, Blood residue charcoal, Angelica, Ophiopogon, Gardenia, and Salvia to clear heat, cool the blood, and stop bleeding. 3. Spleen-Kidney Qi Deficiency Syndrome Findings: Fatigue and lack of energy, poor appetite, soreness in the waist and knees, turbid urine, pale or sallow complexion, pale tongue with thin white coating, and a weak pulse. Urinalysis indicates mainly positive protein. Treatment principle: Strengthen the spleen and tonify the kidneys. Prescription: Modified Shihhe Decoction. Ingredients: Coix seed, Atractylodes, Poria, Chinese yam, Dodder seed, Rosa laevigata, Polygonatum, Lily bulb, Loquat leaf, Codonopsis. For palpitations, add Ophiopogon, Schisandra, Ziziphus jujuba, and Platycladus orientalis to tonify heart qi and calm the mind; for lower back pain, add Eucommia, Achyranthes, and stir-fried Dipsacus to strengthen the waist and tonify the kidneys; for edema, add Wuling Powder or Calabash peel, Citrullus colocynthis, and Plantago seed to promote diuresis and reduce swelling; for positive occult blood in urine, add Donkey-hide gelatin, Blood residue charcoal, Rehmannia, Angelica, Ophiopogon, Gardenia, and Salvia to nourish blood and stop bleeding. 4. Spleen-Kidney Yang Deficiency Syndrome Findings: Fatigue and aversion to cold, soreness and coldness in the waist and knees, limb edema, especially in the lower limbs, pale complexion, long or scanty urination, increased nocturnal urination, or diarrhea at dawn, pale and plump tongue with tooth marks on the edges, and a deep, slow, and weak pulse. Treatment principle: Warm the kidneys and strengthen the spleen. Prescription: Modified Jisheng Shenqi Tang combined with Wuling Powder. Ingredients: Prepared Aconite, Cinnamon twig, Achyranthes, Plantago seed, Rehmannia root, Chinese yam, Cornus fruit, Moutan bark, Poria, Alisma, stir-fried Atractylodes, and Pig苓. If kidney yang deficiency is severe, add Psoralea corylifolia and Dodder seed to tonify kidney yang; for severe edema, add Calabash peel and Citrullus colocynthis to promote diuresis and reduce swelling; for significant blood stasis, add Taohong Siwu Tang to activate blood circulation and remove stasis. 5. Yin-Yang Deficiency with Blood Stasis Findings: Disease progression to renal failure, dizziness, nausea and vomiting, or somnolence, deep and rapid breathing, palpitations and shortness of breath, abdominal distension, poor appetite and fatigue, scanty urination, dark purple and greasy tongue, and a wiry, fine pulse. Treatment principle: Remove blood stasis and detoxify, while tonifying qi and strengthening the spleen. Prescription: Modified Renal Failure Formula. Ingredients: Prepared Aconite, Prepared Rheum, White Snake Tongue Herb, Motherwort, Honeysuckle, Plantago, Astragalus, Salvia, Mulberry, Goji berries, Cornus fruit, Leech. For dizziness, headache, and high blood pressure, add Gastrodia, Uncaria, and Stonecrop to calm the liver and suppress wind; for chest oppression, use Salvia, Agarwood, Red Peony, Chuanxiong, and Safflower to activate blood circulation and remove stasis; if nausea and vomiting occur, combine with Wendan Decoction; if accompanied by damp-heat and blood stasis, combine with Pei's Compound Renal-Tonifying Formula (Peach kernel, Safflower, Angelica, Chuanxiong, Red Peony, Motherwort, Salvia, Honeysuckle, Isatis root, Dandelion, Forsythia, Perilla stem, Cicada slough). III. Clinical Case Studies

Case 1: Mr. Li, male, 55 years old. Chief complaint: Dizziness for two weeks. The patient has a 10-year history of diabetes, intermittently taking hypoglycemic medications, but with poor glycemic control—fasting blood glucose 9 mmol/L, 2-hour postprandial blood glucose 13 mmol/L, and HbA1c 8.5%. Urine protein (++), triglycerides 2.5 mmol/L, blood pressure 140/90 mmHg. Symptoms include dizziness, dryness and irritation of both eyes, blurred vision, insomnia with vivid dreams, soreness and weakness in the waist and knees, night sweats and fatigue, bitter taste and dry mouth, constipation, dark red tongue with yellow, greasy coating, and a wiry, fine pulse. Western medicine prescribed metformin, glimepiride, and insulin injections. Western diagnosis: Diabetic nephropathy, hypertensive arteriosclerosis, hyperlipidemia. Traditional Chinese Medicine differentiation: Liver and kidney yin deficiency with blood stasis. Treatment principle: Nourish yin and clear heat, activate blood circulation and remove stasis. Prescription: Qiju Dihuang Decoction combined with Zhu's Hypoglycemic Formula. Goji berries 10 g, chrysanthemum flowers 10 g, Rehmannia root 12 g, Chinese yam 10 g, Cornus fruit 10 g, Poria 10 g, Moutan bark 6 g, Alisma 10 g, Atractylodes 10 g, Scrophularia 15 g, Astragalus 15 g, Salvia 20 g, Kudzu root 20 g, leeches 10 g (to be decocted separately), Gastrodia 10 g, Atractylodes 10 g, Uncaria 20 g. Decoct in water and take one dose daily for seven days. Second visit: After taking the medication, dizziness, dry mouth, and eye irritation have eased, but insomnia persists, and the tongue remains dark red with a thin yellow coating, and the pulse is still wiry and fine. The original formula was adjusted by removing Gastrodia, Atractylodes, and Uncaria, and adding fried Ziziphus jujuba and Platycladus orientalis, 15 g each. The modified formula was continued for over a year, resulting in fasting blood glucose of 7.5 mmol/L, 2-hour postprandial blood glucose of 9.2 mmol/L, HbA1c of 6.5%, normal blood pressure, reduced lipid levels, and the medication was ground into powder for better absorption, along with dietary control and regular exercise. Case 2: Ms. Liu, female, 65 years old, first visit on May 12, 2011. Chief complaint: Edema and scanty urination for half a month. She has a 20-year history of diabetes and has been treated with hypoglycemic drugs, with stable efficacy. Current symptoms: Cold and cough for nearly half a month, chest tightness and shortness of breath, generalized edema, dizziness and fatigue, sticky sensation in the mouth. Limbs are cold, tongue is dark red and thick, coating is white and greasy, pulse is deep, slow, and weak. 24-hour urine protein quantification shows 150 mg/L, fasting blood glucose 9.5 mmol/L, 2-hour postprandial blood glucose 12.6 mmol/L, HbA1c 9.0%, triglycerides 2.0 mmol/L, total cholesterol 5.0 mmol/L, blood urea nitrogen 8.5 mmol/L, creatinine 200 mmol/L. Blood pressure 150/95 mmHg. Western diagnosis: Diabetic nephropathy, renal failure, azotemia, hypertensive arteriosclerosis, hyperlipidemia. Traditional Chinese Medicine differentiation: Spleen-kidney yang deficiency with blood stasis. Treatment principle: Warm and tonify the spleen and kidneys, activate blood circulation and promote diuresis. Prescription: Modified Jisheng Shenqi Tang. Cinnamon twig 10 g, prepared Aconite 6 g, Rehmannia root 12 g, Chinese yam 10 g, Cornus fruit 10 g, Poria 10 g, Moutan bark 6 g, Alisma 10 g, Plantago seed 10 g, Achyranthes 10 g, Motherwort 20 g, Salvia 20 g, Atractylodes 10 g, dried ginger 6 g, Magnolia bark 10 g, Perilla leaf 10 g, apricot kernel 10 g. Decoct in water and take one dose daily for seven days. Second visit: After taking the medication, cough improved, edema and dizziness lessened, urine output increased, limbs gradually warmed up, tongue remained dark red with thin white coating. The original formula was adjusted by removing apricot kernels and adding three-seven 3 g and leeches 6 g to activate blood circulation and remove stasis. Third visit: After two months of taking the above formula, BUN dropped to 7.5 mmol/L, CR to 140 mmol/L, and blood glucose also returned to normal levels. The medication was made into water pills for continued consolidation of the therapeutic effect. Section 4: Professor Pei Zhengxue’s Experience in Treating Diabetic Retinopathy With the rising incidence of diabetes, diabetic retinopathy, as one of the microvascular complications of diabetes, has also seen an increase in prevalence, becoming a significant threat to vision and a leading cause of blindness. At the same time, electronic devices play a crucial role in modern learning, work, and daily life, increasing eye usage frequency and accelerating the onset and progression of this disease. The pathological features of diabetic retinopathy mainly include neovascularization, retinal hemorrhage, and disruption of the blood-retinal barrier, all of which fall under the category of diabetic microvascular lesions. Based on the severity of the condition, it is classified into non-proliferative diabetic retinopathy and proliferative diabetic retinopathy. Non-proliferative diabetic retinopathy is primarily treated medically to prevent complications from developing. Once it progresses to the proliferative stage, ruptured neovessels can lead to vitreous hemorrhage, causing irreversible damage to vision. In traditional Chinese medicine, this condition is referred to as “blurred vision,” “clouds obscuring the eyes,” “sudden blindness,” or “blood flooding the pupil,” while modern medicine calls it “dry-eye disease.” Causes and Pathogenesis

1. Diabetic retinopathy is related to dysfunction of the liver, spleen, and kidneys. During the formation and development of vision, kidney essence plays a special role. The "Spiritual Pivot · Great Confusion Theory" states: "The essence of the five zang organs and six fu organs all rises to the eyes to form the essence, and the essence forms the eyeball, while the essence of the bones forms the pupil." Fu Renyu said: "The eyes are innate orifices, the origin of primordial clarity." These records indicate that kidney essence is the material basis and driving force behind vision. The kidneys are the water organ, the source of divine water. According to the "Spiritual Pivot · Five Fluids Differentiation," "the fluids of the five zang organs and six fu organs all seep up to the eyes," so fluid transformation into divine water is closely related to the kidneys. Professor Pei Zhengxue believes that the main pathogenesis of dry-eye disease is liver and kidney yin deficiency, with liver qi carrying fire to disturb the eye network, forcing blood to flow erratically, resulting in clouded vision or sudden blindness, or prolonged dryness leading to loss of qi, blood, and fluids, leaving the eyes without nourishment and causing blurred vision. In addition, Professor Pei Zhengxue points out that diabetic retinopathy and diabetic nephropathy both belong to microvascular diseases, and their pathogenesis is quite similar to the relationship between the kidneys and the eyes in traditional Chinese medicine—mutually causal. When kidney qi is deficient and qi transformation is disordered, fluid retention leads to exudation in the fundus and macular edema, so patients with diabetic nephropathy often have retinal lesions as well. The liver plays an important role in maintaining visual function. The "Spiritual Pivot · Teacher's Transmission" says: "The liver is the commander, responsible for observing the outside world and ensuring the eyes see clearly, big or small." The "Plain Questions · Golden Treasury Truths" states: "The eastern green color enters the liver, opens the orifice to the eyes, and stores essence in the liver." The liver's storage and release of blood directly affect visual function. The "Examination of the Jade Mirror · On the Eyes as Precious Treasures" says: "True blood is the blood that the liver transports to the eyes, light and pure blood that nourishes the eye meridians." This shows that the eyes depend on liver blood to see everything and distinguish colors. The liver is responsible for dispersing and regulating qi. The "Knowledge of Medicine Must Be Discriminated" says: "Therefore, all qi transformations in the twelve meridians must rely on the liver and gallbladder to stimulate them, only then can they be regulated and remain healthy." Professor Pei Zhengxue believes that when patients with diabetes are worried, anxious, or emotionally disturbed, liver qi stagnates, blood stasis forms in the eye network, or liver blood is deficient and cannot nourish the eyes, resulting in blurred vision. Since the liver and kidneys share the same origin, if water does not generate wood, liver yang will rise excessively, forcing blood to flow erratically, leading to seeing through clouds or difficulty distinguishing light and dark. The spleen and stomach are the central link in food metabolism. The "Shanghan Ming Theory" says: "The spleen is earth, located in the center, serving as the middle state among the four organs, governing the middle burner, producing vital energy and blood, and circulating fluids." Diabetic patients often have a phlegm-damp obesity constitution, frequently eat immoderately, damaging the spleen and stomach, and prolonged internal damp-heat damages yin, leading to dryness. The "Plain Questions · Strange Diseases Theory" says: "When the five flavors enter the stomach, the spleen carries their essence, and the fluids reside in the spleen, making people crave sweetness—this is the origin of fatness... Sweetness makes people feel full, so the qi overflows and turns into dryness." Professor Pei Zhengxue believes that when the spleen fails to lift clear qi, it produces turbid qi and phlegm, covering the clear orifices and causing blurred vision, or when the spleen is deficient and loses its ability to govern, blood overflows and enters the eye network, causing blood to flood the pupil. The spleen's upward movement and downward movement are closely linked to the liver's wood-dispersing function. Professor Pei follows the preventive medicine philosophy, advocating the principle of "suppressing wood and supporting earth"—for those with strong spleen, "when seeing liver disease, first strengthen the spleen" to prevent transmission; for those with weak spleen, focus on strengthening the spleen while also dispersing liver qi, achieving "earth gains wood and reaches its goal."
2. Diabetic retinopathy is a meridian disease closely related to blood stasis. The occurrence of diabetic retinopathy is closely related to the duration of diabetes. Most cases appear only after a period of diabetes development, consistent with the premise of "long-term illness entering the meridians." The eye network is inherently delicate and deep, with slow blood flow, and when the network is empty, qi and blood are insufficient to drive it, ultimately leading to blood stasis. First, the meridians are graded layer by layer, extending to the eyes as the eye network. The eye network is delicate and deep, with slow blood flow, making it prone to stasis. The "Medical Gate Law · Meridian Disease Theory" states that meridians, collaterals, intertwined collaterals, and subsidiary collaterals are sequentially generated—twelve meridians give rise to ten collaterals, ten collaterals further refine into system collaterals, and system collaterals continue to branch into countless intertwined and subsidiary collaterals, with each level interconnected to form a network throughout the body. "The eyes are where the meridians converge." The essence of the five zang organs and six fu organs all enters the eyes through the meridians to provide nourishment. The eye network has numerous meridians, and the eye meridians are even more delicate and deep, with slower blood flow compared to other parts of the body, making the eye network more susceptible to stasis. Second, diabetic retinopathy mainly arises from meridian deficiency, leading to stasis. Diabetic retinopathy develops on the basis of diabetes and is related to deficiencies in the liver, spleen, and kidneys. The blood stasis in diabetic retinopathy is closely related to spleen meridian deficiency—the spleen governs the transport of food and water, providing the source of qi and blood production. The spleen controls blood, keeping it flowing normally; when the spleen is weak, blood flow is sluggish, leading to stasis in the meridians. When the spleen lacks the power to control blood, blood overflows and enters the meridians, causing stasis as well. The liver and kidneys share the same origin, and when both yin and yang are deficient, the meridians become blocked, leading to microvascular lesions in diabetic patients. Ultimately, this results in diabetic retinopathy. The blood stasis in diabetic retinopathy is also related to deficiencies in qi and yin. Qi deficiency leads to weak qi transformation, blood stops flowing, and fluids stagnate, forming phlegm and blood stasis—these are the results of qi and yin deficiency. Phlegm and blood stasis reinforce each other in a vicious cycle, eventually leading to retinal hemorrhage, edema, exudation, proliferation, and organization. In the early stages of diabetic retinopathy, qi stagnation and yin deficiency are dominant—blocked qi or dryness damaging fluids leads to poor blood flow and blood stasis. As the condition progresses, both qi and yin become deficient, and blood stasis worsens.

Thus, all stages of diabetic retinopathy—early, middle, and late—involve blood stasis. Deficiency is the foundation of diabetic retinopathy, with the main deficiencies being spleen deficiency, liver and kidney deficiency, qi deficiency, qi and yin deficiency, and yin and yang deficiency. These are the root causes of the disease; deficiency leads to stasis, which is the manifestation of the disease. Root and manifestation influence each other, ultimately leading to microaneurysms, exudation, hemorrhage, and retinal detachment. Therefore, the occurrence of diabetic eye disease is often related to yin deficiency and dryness, liver and kidney deficiency, and long-term illness entering the meridians. Meridian stasis is the basic pathological foundation. Physical depletion, improper diet, excessive labor, emotional trauma—all lead to dryness in the organs, deficiency of essence and fluids, and poor blood circulation. Over time, yin is damaged and yang is weakened, resulting in qi and yin deficiency, qi deficiency causing blood stasis, and fluids stagnating, leaving the eyes without nourishment, causing blurred vision, even blindness. The liver opens the orifice to the eyes, but when liver qi stagnates and blood flow is obstructed, the eye network is blocked, and qi and blood are trapped, resulting in blurred vision; when liver qi turns hot and liver and kidney are deficient, yin is overheated, and heat forces blood to flow, making the eyes appear red—this is blood flooding the pupil, commonly seen in stage III diabetic retinopathy. II. Differential Diagnosis and Treatment Professor Pei Zhengxue believes that diabetic eye disease is a typical meridian disease, with meridian stasis as the basic pathological foundation. Its occurrence is often related to yin deficiency and dryness, liver and kidney deficiency, and long-term illness entering the meridians. Treatment focuses on tonifying qi and nourishing yin, clearing heat, nourishing the liver and kidneys, and activating blood circulation and unblocking the meridians. In the later stages, when deficiency is mixed with excess and the condition becomes complex, both treatment and prevention should be considered, combining attack and support. Diabetic retinopathy develops from long-term dry-eye disease, with qi and yin deficiency being the main pathogenesis. Professor Pei Zhengxue flexibly adjusts prescriptions such as Shenqi Dihuang Decoction, Qiju Dihuang Pills, Erzhi Pills, and Zhujing Pills based on clinical conditions. Clinically, he skillfully uses Astragalus to tonify qi and strengthen the spleen, dispel stagnation and relieve pain, allowing qi to flow and blood to circulate, improving blood flow in the eye network, and using qi to control blood, keeping it within the meridians and reducing blood that escapes the meridians; Prince Ginseng and Polygonatum to tonify qi and nourish yin. For dry-eye disease caused by dryness and heat, he uses Ophiopogon, Schisandra, Honeysuckle, Rehmannia, White Peony, Dendrobium, and Kudzu root to nourish yin and generate fluids, with Schisandra and White Peony particularly effective in nourishing blood and generating fluids, keeping the fluids circulating within the meridians, while Astragalus helps reduce exudation and fundus edema by promoting diuresis and reducing swelling. Activating blood circulation and unblocking the meridians runs throughout the entire process. Diabetic retinopathy is secondary to long-term dry-eye disease, as Ye Tianshi said in his "Clinical Guide to Medical Cases": "Initially, qi stagnates in the meridians; over time, blood injury enters the meridians." Stasis in the eye network is a key pathological factor in diabetic retinopathy.

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Professor Pei Zhengxue often adjusts the selection of blood-activating and meridian-unblocking drugs based on different diseases and syndromes: For patients with Qi deficiency and blood stasis, herbs such as Astragalus, Codonopsis, Chuanxiong, and Safflower are used to tonify Qi and activate blood; for those with Yin deficiency and blood stasis, herbs such as Rehmannia glutinosa preparata, Eclipta prostrata, Ligustrum lucidum, Ophiopogon japonicus, Safflower, and Leonurus cardiaca are used to nourish Yin and activate blood; for those with Yin deficiency and excessive fire causing blood to run amok, herbs such as Anemarrhena asphodeloides, Phellodendron amurense, Salvia miltiorrhiza, Typha pollen, Imperata cylindrica root, Sophora japonica charcoal, and Sanguisorba officinalis are used to cool the blood and stop bleeding; for patients with blood deficiency and blood stasis, herbs such as Angelica sinensis and Millettia reticulata are used to activate blood and tonify blood; in the proliferative stage of retinal lesions, prolonged dampness and blood stasis obstructing the meridians lead to tumor-like congestion, so herbs such as Fritillaria thunbergii, Laminaria japonica, Kelp, Prunella vulgaris, Sparganium stoloniferum, Curcuma wenyujin, and Ziziphus jujuba spines are used to disperse nodules and unblock the meridians, while earthworms, leeches, whole scorpions, soil insects, and vinegar turtle shell—these insect-based agents—are employed to remove and dissolve blood stasis and unblock the meridians; for patients with fundus hemorrhage, the goal is to resolve blood stasis without causing bleeding and to stop bleeding without leaving blood stasis behind, often combined with Sanqi, Agrimonia pilosa, human hair charcoal, and palm fiber charcoal.

1. Liver Qi Stagnation Symptoms: dizziness, blurred vision, chest tightness, frequent sighing, dry mouth and throat, red tongue with thin yellow coating, and wiry, fine pulse. Treatment principle: soothe the liver and clear heat, regulate qi and eliminate stagnation. Prescription: Danzhi Xiaoyao San with modifications. Ingredients: Bupleurum, Angelica sinensis, Red and White Peony, Moutan Cortex, Charred Gardenia Fruit, Peppermint, Curcuma, Vinegar-processed Acorus tatarinowii, Purple Salvia, White Cudrania, Chrysanthemum, Cassia Seed, Horsetail. For those with liver and kidney deficiency and dim vision, add Goji berries and Sheng/Di Huang to strengthen the nourishment of liver and kidney and improve eyesight; for those with severe dizziness and irritability, add Dragon Bone, Oyster Shell, and Stonecrop to calm the yang and stabilize the liver and improve eyesight.
2. Liver and Kidney Deficiency Symptoms: dizziness, tinnitus, soreness and weakness in the lower back and legs, five-center heat, insomnia and dry mouth, initially feeling like there are flies or mosquitoes in front of the eyes, or seeing through clouds and mist, later seeing red light filling the field of vision, even complete darkness, red tongue with thin, less moist coating, and wiry, rapid pulse. Treatment principle: tonify the liver and kidneys, nourish essence and improve eyesight. Prescription: Zhujing Wan with modifications. Tribulus terrestris, Fructus Psoraleae, Semen Vitex, Goji berries, Plantago seeds, Cornus fruit, Schisandra, Sanqi powder, Rehmannia glutinosa preparata. For fundus hemorrhage, add Moutan Cortex, Imperata cylindrica root, Eclipta prostrata, and Agrimonia pilosa to cool the blood and stop bleeding; if the bleeding persists for a long time without being absorbed, indicating that old blood stasis remains and new blood cannot be generated, then add Safflower, Peach Kernel, and Salvia miltiorrhiza to activate blood circulation, dissolve stasis, and promote the generation of new blood.
3. Yin Deficiency and Yang Excess Symptoms: dizziness, irritability, bitter taste in the mouth and dry throat, red face and eyes, tinnitus and hearing loss, sudden blindness, or seeing red colors or stars filling the field of vision, or black shadows obscuring the eyes, red tongue with little coating, or thin yellow coating, and wiry pulse that feels empty when pressed. Treatment principle: clear heat and cool the blood, calm the liver and improve eyesight. Prescription: Qiju Dihuang Wan combined with Xijiao Dihuang Tang with modifications. Goji berries, Chrysanthemum, Rehmannia glutinosa preparata, Chinese yam, Cornus fruit, Poria cocos, Alisma orientalis, Moutan Cortex, Red Peony, Cypress leaves, Imperata cylindrica root, Gentian, Gardenia, Stonecrop. For heavier bleeding, add Sanqi powder to activate blood and stop bleeding, or combine with Shihui San to enhance hemostatic effects; for those with strong liver fire, add Uncaria rhynchophylla and Bombyx batryticatus to calm the liver and extinguish wind. III. Clinical Case Examples Case 1: Mr. Zhang, male, 71 years old, first visit on November 8, 2018. The patient has a history of type 2 diabetes for more than 10 years and has been receiving long-term glucose-lowering treatment, with relatively good glycemic control. Three months ago, he developed blurred vision and visited a Grade III hospital, where he was diagnosed with diabetic retinopathy and received corresponding treatment, but his condition did not improve significantly, so he came for consultation. Current symptoms: unclear vision, dizziness and tinnitus, hot soles at night, dry and bitter mouth, weak legs, constipation, dark red tongue with little coating, and wiry, fine pulse. HbA1c 7.3%, fasting blood glucose 8 mmol/L.

Western medical diagnosis: Diabetic retinopathy. Traditional Chinese medicine differentiation: Liver and kidney yin deficiency, water deficiency leading to dim vision. Treatment principle: nourish liver and kidney, benefit essence and improve eyesight. Prescription: Zhujing Wan combined with Qiju Dihuang Tang with modifications. Tribulus terrestris 15 g, Fructus Psoraleae 15 g, Semen Vitex 15 g, Goji berries 15 g, Plantago seeds 10 g, Cornus fruit 10 g, Schisandra 10 g, Chrysanthemum 10 g, Rehmannia glutinosa preparata 12 g, Chinese yam 10 g, Poria cocos 10 g, Alisma orientalis 10 g, Moutan Cortex 10 g, Anemarrhena asphodeloides 10 g, Phellodendron amurense 10 g. 14 doses, decocted in water and taken once daily. Second visit: After taking the medication, the patient still had blurred vision, but other symptoms had improved, with the same tongue and pulse as before. After continuing the previous prescription for another month, the blurred vision significantly improved. Subsequently, the patient continued treatment with the above formula combined with pills for more than four months, and all symptoms disappeared. A follow-up examination showed that the fundus had basically healed. Case 2: Ms. Jia, female, 68 years old, first visit on June 15, 2014. The patient has had type 2 diabetes for nearly 20 years and has been taking oral hypoglycemic drugs for a long time. One year ago, due to poor glycemic control, she switched to insulin therapy, and her blood sugar is now basically stable. In the past year, the patient has experienced dizziness and blurred vision, and a Grade III hospital diagnosed her with diabetic retinopathy, recommending laser treatment, which she refused, so she came for consultation. Current symptoms: blurred vision, dizziness, irritability, sleep disturbance, poor appetite, dry mouth, often bitter taste in the morning, frequent constipation, red tongue with thin, greasy yellow coating, and wiry pulse. Western medical diagnosis: Diabetic retinopathy. Traditional Chinese medicine differentiation: Liver Qi stagnation, obstruction of the eye meridians. Treatment principle: soothe the liver and regulate qi, clear heat and improve eyesight. Prescription: Danzhi Xiaoyao San with modifications. Bupleurum 12 g, Angelica sinensis 12 g, Red and White Peony each 10 g, Moutan Cortex 15 g, Charred Gardenia Fruit 15 g, Peppermint 3 g (added later), Vinegar-processed Acorus tatarinowii 10 g, Stir-fried Atractylodes macrocephala 10 g, Poria cocos 10 g, White Cudrania 15 g, Chrysanthemum 15 g, Cassia Seed 15 g, Horsetail 15 g, Prunella vulgaris 15 g, Scutellaria baicalensis 12 g, Pinellia ternata 10 g, Codonopsis pilosula 10 g, Citrus aurantium 10 g, Fructus Aurantii 10 g, Rhizoma Atractylodis 10 g, Rheum palmatum 6 g (added later), Glycyrrhiza 6 g. 14 doses, decocted in water and taken once daily. Second visit: After taking the medication, irritability, dizziness, dry mouth, and constipation all improved significantly, and vision slightly improved, but sleep remained poor, with red tongue and thin white coating, and wiry, fine pulse. The prescription was adjusted to soothe the liver and clear heat, nourish blood and improve eyesight. Specifically: Bupleurum 12 g, Angelica sinensis 15 g, Red and White Peony each 10 g, Moutan Cortex 15 g, Charred Gardenia Fruit 15 g, Peppermint 3 g (added later), Vinegar-processed Acorus tatarinowii 10 g, Stir-fried Atractylodes macrocephala 10 g, White Cudrania 15 g, Chrysanthemum 15 g, Cassia Seed 15 g, Horsetail 15 g, Stir-fried Ziziphus jujuba 15 g, Anemarrhena asphodeloides 10 g, Chuanxiong 6 g, Poria cocos 10 g, Rehmannia glutinosa preparata 12 g, Glycyrrhiza 6 g. 14 doses, decocted in water and taken once daily. Third visit: After taking the medication, the patient's blurred vision improved significantly, and other symptoms also eased considerably. Continuing the previous prescription with adjustments for another three months, all symptoms disappeared, and a follow-up examination showed that the fundus lesion had basically healed. Afterwards, the patient was advised to continue taking the modified Xiaoyao Wan combined with Mingmu Dihuang Wan and undergo regular follow-up examinations. Section 5: Professor Pei Zhengxue’s Experience in Treating Diabetic Peripheral Neuropathy Diabetic peripheral neuropathy is the most common complication of diabetes, with an incidence rate of 50%–70% among symptomatic patients, and even higher. Its typical clinical symptoms include pain and sensory abnormalities in the distal extremities. Specifically, it manifests as numbness, soreness, and pain in the limbs, accompanied by abnormal burning sensations, prickling sensations, muscle weakness, and weakening or even disappearance of the dorsalis pedis artery pulse. Based on clinical presentation, the disease can be divided into bilateral polyneuropathy and unilateral polyneuropathy, which may be symmetrical or asymmetrical, but bilateral symmetry is more common. Diabetic peripheral neuropathy has an insidious onset and high incidence, and its clinical symptoms often do not reflect the true severity of the pathology. Some patients may remain asymptomatic for a long time, so by the time symptoms appear, irreversible segmental demyelination and other pathological changes have usually already occurred in the peripheral nerves. The pathogenesis of diabetic peripheral neuropathy has not yet been fully elucidated; most scholars believe it is related to factors such as elevated metabolic inflammatory mediators, oxidative stress damage, deficiency of neurotrophic factors, and vascular damage and microcirculatory disorders. Currently, Western medical treatment, based on controlling blood sugar, uses drugs with nerve-nourishing and repairing effects, such as alpha-lipoic acid and methylcobalamin, but the efficacy is not very satisfactory. In view of these clinical characteristics, Traditional Chinese Medicine classifies this disease under the categories of “Bi syndrome” and “Wai syndrome,” and some scholars also call it “Xiaoke Bi syndrome.” Through syndrome differentiation and treatment, relatively good clinical results can be achieved. I. Etiology and Pathogenesis Diabetic peripheral neuropathy often develops from Xiaoke disease. Over time, Xiaoke disease leads to deficiency of yin and yang and qi and blood, blood stasis, and blockage of the meridians, resulting in symptoms such as numbness, pain, and cold intolerance in the limbs. This is closely related to factors such as prolonged illness without treatment, dietary imbalances, emotional disturbances, and excessive labor and sexual desire. Professor Zhu Yu proposed the academic viewpoint of “diabetic blood stasis syndrome” in the late 1970s, which played a positive role in promoting academic innovation in diabetes theory and standardizing TCM treatment of diabetes. In the early 1990s, he further proposed that phlegm and blood stasis mutually obstruct each other as the main pathological mechanism of chronic complications of diabetes. He also confirmed that diabetic patients exhibit abnormal red blood cell morphology and reduced deformability, with elevated thromboxane B2 levels, especially pronounced in those with blood stasis syndrome, providing objective evidence for the existence of diabetic blood stasis syndrome. Furthermore, he found that abnormalities in blood rheology and other indicators already exist in diabetic patients before clinical manifestations of blood stasis appear, and based on these research findings, he put forward the academic idea of using blood-activating and stasis-dissolving drugs early on to prevent problems before they occur. Phlegm turbidity and blood stasis can be cause and effect of each other, forming a disease together, just as Tang Rongchuan stated in his “Blood Syndrome Theory” during the Qing Dynasty: “Stagnant blood, if left for a long time, can also transform into phlegm.” Therefore, Professor Pei Zhengxue believes that both phlegm turbidity and blood stasis are pathological products, and the two often occur sequentially in the body. Prolonged phlegm turbidity blocks the flow of qi, impairs blood circulation, and can lead to blood stasis blocking the meridians; while blood stasis and qi stagnation can hinder the movement of body fluids, causing them to accumulate and form phlegm, ultimately resulting in both phlegm and blood stasis. Thus, Professor Pei Zhengxue believes that the main TCM pathogenesis of diabetic peripheral neuropathy is: Prolonged Xiaoke disease depletes qi and yin, leading to deficiency of yin and yang, qi and blood, blood stasis, obstruction of body fluid circulation, and phlegm and blood stasis blocking the meridians, constituting a syndrome of fundamental deficiency and superficial excess. The location of the disease lies in the meridians, involving organs such as the liver and kidneys, with deficiency of qi and yin as the root cause and phlegm and blood stasis as the manifestation. Yin deficiency is the key factor in the onset; qi deficiency is the reason for prolonged persistence; yang deficiency is the inevitable trend of disease progression; and blood stasis is the main cause of the disease. II. Syndrome Differentiation and Treatment Professor Pei Zhengxue believes that this disease is a syndrome of fundamental deficiency and superficial excess, with mixed deficiency and excess, so treatment must nourish yin and blood, benefit qi and warm yang to treat the root cause, and resolve phlegm and activate blood to unblock the meridians to treat the manifestation, balancing both root and manifestation to achieve good results. TCM syndrome differentiation varies, but treatment still focuses on the basic pathogenesis of the disease, namely yin deficiency, qi deficiency, and blood stasis leading to lack of nourishment in the meridians. Diabetic peripheral neuropathy presents differently depending on the type of damaged nerve fibers. Those mainly affected by small fibers are characterized by hypersensitivity and pain, manifesting as burning-like pain, sometimes intolerable even to the friction of clothing, worsening at night, often accompanied by autonomic nervous system dysfunction such as abdominal bloating and alternating constipation and diarrhea. TCM syndrome differentiation is mostly yin deficiency and blood stasis, with lack of nourishment in the meridians, treated with methods to nourish yin, activate blood, and relieve pain, using formulas such as “Jin Gui Yao Lue” Wind-Dispelling Decoction combined with Four-Vine Formula (Green Vine, Sea Vine, Climbing Vine, Chicken Blood Vine). Those mainly affected by large fibers are characterized by decreased or lost sensation, often presenting as numbness and coldness in the extremities, and some may even experience gait instability and other sensory ataxia symptoms. TCM syndrome differentiation is mostly qi deficiency and blood stasis, with lack of nourishment in the meridians or cold-induced blood stasis, treated with methods to benefit qi and warm yang, activate blood, and unblock the meridians, using formulas such as Lingdan Six Yellow Compound ( Weilingxian, Salvia miltiorrhiza, Rehmannia glutinosa preparata, Chinese yam, Cornus fruit, Black Plum, Flower Powder, Winter Jasmine, Chicken Blood Vine, Sea Vine, Climbing Vine, Hook Vine, Angelica sinensis, Codonopsis pilosula, Astragalus, Cinnamon, Whole Scorpion, Glycyrrhiza). For qi deficiency and yang deficiency, cold-induced blood stasis, limb numbness, coldness, fear of cold, and pain, alleviated by warmth and exacerbated by cold, use Jin Gui Shen Qi Wan combined with Recurrent Chuangcao Wu Compound (prepared Chuangcao Wu, Liaoning Asarum, Fried Strychnos nux-vomica) and Large Three Insect Formula (Black Snake, Whole Scorpion, Centipede) for treatment. Professor Pei Zhengxue emphasizes that when conducting overall syndrome differentiation, local syndrome differentiation should also be considered to make the differentiation more accurate and the prescriptions more targeted. For example, if limb numbness is the main symptom, it is often due to phlegm-dampness obstructing the meridians; if limb pain is the main symptom, it is often due to blood stasis obstructing the meridians; if muscle wasting is the main symptom, it is often due to spleen failing to nourish the muscles; if gait instability is the main symptom, it is often due to liver and kidney deficiency, with internal liver wind. If numbness and pain are the main symptoms, it is often due to phlegm and blood stasis obstructing the meridians, and combining overall syndrome differentiation, one can use Peach Red Four Things Qin Chuan Formula (Peach Kernel, Safflower, Rehmannia glutinosa preparata, Angelica sinensis, White Peony, Chuanxiong, Qin disturbance, Chuan Ni Xi, U Snake, Whole Scorpion, Centipede, Cypress Leaves, Papaya, Stretching Grass) combined with Four Grass Formula ( Stretching Grass, Old Crane Grass, Bone-Penetrating Grass, Rare Sign Grass) to activate blood, dissolve phlegm, and unblock the meridians. In addition, Professor Pei Zhengxue always emphasizes the importance of basic diabetes treatment throughout the process of treating diabetic peripheral neuropathy, including dietary regulation, exercise adjustment, emotional regulation, self-monitoring of blood sugar, and the use of Western hypoglycemic drugs, especially stressing strict control of metabolic indicators such as blood sugar, blood lipids, blood pressure, and body weight. Moreover, Professor Pei Zhengxue stresses that when treating each case, one must consider whether there are other chronic complications of diabetes? Is the patient obese? One must also consider whether the patient has other common chronic diseases, such as lipid abnormalities, hypertension, and coronary atherosclerotic heart disease, which should also be taken into account.

1. Qi Deficiency and Blood Stasis Symptoms: numbness in the hands and feet, as if ants are crawling, occasional pain in the extremities, especially in the lower limbs. Fatigue, lethargy and a tendency to lie down, laziness in activity, soreness in the lower limbs, or pale complexion, spontaneous sweating and aversion to wind, prone to catching colds. Tongue is dull, coating is white, pulse is thin and rough. Treatment principle: benefit qi and nourish blood, unblock the meridians and relieve pain. Prescription: Lingdan Six Yellow Compound with modifications. Weilingxian, Salvia miltiorrhiza, Rehmannia glutinosa preparata, Chinese yam, Cornus fruit, Black Plum, Flower Powder, Winter Jasmine, Chicken Blood Vine, Sea Vine, Climbing Vine, Hook Vine, Angelica sinensis, Codonopsis pilosula, Astragalus, Cinnamon, Whole Scorpion, Glycyrrhiza . For lesions mainly affecting the upper limbs, add Mulberry Branch and Cinnamon Branch; for those mainly affecting the lower limbs, add Chuan Ni Xi and Papaya; if the extremities are cold and painful, pain is relieved by warmth and worsened by cold, with the lower limbs being particularly affected and worse at night, then use Angelica Four Reverse Soup combined with Astragalus and Cinnamon Five-Ingredient Soup for modification.
2. Cold-Induced Blood Stasis

Symptoms: limb numbness, coldness and pain that are relieved by warmth and worsened by cold, often affecting the lower limbs, especially noticeable at night, fatigue, lethargy, reluctance to speak, fear of cold and shivering, pale and swollen tongue, dark tongue color, white and slippery coating, and weak, sinking pulse. Treatment principle: warm yang and dispel cold, dissolve blood stasis and unblock the meridians. Prescription: Jin Gui Shen Qi Wan combined with Recurrent Chuangcao Wu Compound and Large Three Insect Formula with modifications. Rehmannia glutinosa preparata, Chinese yam, Cornus fruit, Poria cocos, Du Zhong, Cow Knee, Prepared Aconite, Cinnamon, Angelica sinensis, Chicken Blood Vine, Prepared Chuangcao Wu, Liaoning Asarum, Black Snake, Whole Scorpion, Centipede. For severe pain, add Prepared Strychnos nux-vomica; for heavy blood stasis, add Peach Red Four Things Soup. 3. Yin Deficiency and Blood Stasis Symptoms: limb numbness, burning and stabbing pain, soreness and discomfort, soreness in the waist and knees, dizziness and tinnitus, dry mouth and thirst, or constipation. Tongue is dark red and lacks moisture, pulse is weak and rapid. Treatment principle: nourish yin and clear heat, unblock the meridians and relieve pain. Prescription: Wind-Dispelling Decoction combined with Four-Vine Formula with modifications. Raw Gypsum (raw decoction), Talc (wrapped decoction), Cold Water Stone (raw decoction), Raw Dragon Bone, Raw Oyster Shell ( raw decoction), Purple Quartz (raw decoction), Red Stone Lip (raw decoction), White Stone Lip (raw decoction), Rheum palmatum ( added later), Cinnamon, Dried Ginger, Cow Knee, Papaya, Qin, Weilingxian, Rehmannia glutinosa preparata, Angelica sinensis, White Peony, Green Vine, Sea Vine, Climbing Vine, Chicken Blood Vine, Glycyrrhiza. For those with severe yin deficiency, use more Rehmannia glutinosa preparata and add Tribulus terrestris, Goji berries, and Ligustrum lucidum; for those with severe limb numbness and pain, add Centipede, Whole Scorpion, and Python. 4. Phlegm and Blood Stasis Obstructing the Meridians Symptoms: numbness lasting for a long time, often fixed in one place, heavy limbs, soreness and fatigue, dark purple tongue or bruising, thin white and greasy coating, and sinking or rough pulse. Treatment principle: dissolve blood stasis and relieve pain, activate blood and unblock the meridians. Prescription: Peach Red Four Things Qin Chuan Formula combined with Four Grass Formula and Three Wonderful Pills with modifications. Peach Kernel, Safflower, Rehmannia glutinosa preparata, Angelica sinensis, White Peony, Chuanxiong, Qin disturbance, Chuan Ni Xi, U Snake, Whole Scorpion, Centipede, Cypress Leaves, Papaya, Stretching Grass, Old Crane Grass, Bone-Penetrating Grass, Rare Grass, Atractylodes, Huang Bai . For those with severe ant-like numbness, add Du Huo, Fang Feng, and Weilingxian; for fixed pain locations, add Frankincense, Myrrh, or Active Meridian Spirit Pill.

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III. Clinical Case Reports
Case 1: Du, female, 60 years old. She has had diabetes for 3 years, initially presenting with numbness in both feet, followed by calf cramping pain, lower limb weakness, loss of pain sensation, diminished deep tendon reflexes, and a deep, fine pulse. Western medical diagnosis: Diabetic peripheral neuropathy. Traditional Chinese Medicine diagnosis: Qi deficiency and blood stasis syndrome. Prescription: Lingdan Liuhuang Mixture with modifications. Ingredients: Shengdi 15g, Shanyu Rou 15g, Shanyao 50g, Danggui 20g, Huangqi 30g, Wumei 15g, Tianhuafen 20g, Tiandong 15g, Danshen 20g, Weilingxian 15g, Jixueteng 15g, Haifengteng 15g, Luoshiteng 15g, Gouteng 15g. Total of 14 doses, decocted in water and taken once daily.
Second visit: After taking the medication, numbness in both feet significantly improved; no change in formula, continued taking this prescription for over 30 doses. Lower limb weakness gradually improved, walking returned to normal, and reflexes recovered.
Case 2: Tian, male, 76 years old, first visit on March 7, 2019. The patient has a 13-year history of hypertension and more than 6 years of type 2 diabetes, with irregular use of hypoglycemic medications and poor glycemic control. Recent HbA1c was 8.9%. He has been taking Nifedipine and Valsartan long-term, maintaining blood pressure around 135/80 mmHg. Six months ago, he gradually developed decreased sensation and numbness in both lower limbs, sometimes accompanied by burning pain. He self-treated with nonsteroidal anti-inflammatory drugs and traditional Chinese patent medicines for promoting blood circulation and removing blood stasis, but there was no improvement, so he came for consultation. Current symptoms: Decreased sensation and numbness below both knees, occasional burning pain, lumbosacral soreness, with a history of lumbar disc herniation and spinal canal stenosis; dizziness and tinnitus; dark red tongue with a wiry, fine, rapid pulse. HbA1c 8.9%, fasting blood glucose 13.7 mmol/L, continuous blood glucose monitoring shows high postprandial levels, blood pressure 130/86 mmHg. Western medical diagnosis: Diabetic peripheral neuropathy. Differentiation: Yin deficiency and blood stasis. Treatment principle: Nourish yin and clear heat, unblock collaterals and relieve pain. Prescription: Fengyin Tang combined with Sitan Fang and Taohong Siwu Tang with modifications. Ingredients: Shengshi Gao 15g (decocted first), Huashi 15g (decocted first), Hanshui Shi 15g (decocted first), Shenglonggu, Shengmuli, Shenglishi 15g (decocted first), Zishi Ying 15g, Chishi Zhi 15g, Dahuang 6g (added later), Guizhi 10g, Ganjiang 6g, Niuxi 10g, Mugua 10g, Qingguang 10g, Weilingxian 15g, Shengdi 12g, Danggui 10g, Baishao 10g, Qingfeng Teng 15g, Haifeng Teng 15g, Luoshiteng 15g, Jixueteng 15g, Duzhong 15g, Tao Ren 10g, Honghua 6g, Chuanxiong 6g, Gancao 6g. Total of 14 doses, decocted in water and taken once daily. Instructed to take Metformin Hydrochloride tablets 0.5g twice daily after meals, Dametang 80mg twice daily before meals, and Baytangping 50mg three times daily.
Second visit: After taking the medication, burning pain in both lower limbs basically disappeared, dizziness and tinnitus improved, bowel movements became twice daily, dry mouth, dark red tongue with little body fluid, and a deep, fine pulse. The original formula was adjusted by reducing Dahuang to 3g, and continued for another 14 doses.
Third visit: After taking the medication, bowel movements became once daily and mostly formed, dizziness and tinnitus markedly alleviated, numbness in both lower limbs improved, and tongue and pulse remained unchanged. No change in formula; continued treatment with adjustments for over three months, resulting in ideal glycemic control and complete resolution of symptoms such as lower limb numbness.
Section 6: Professor Pei Zhengxue’s Experience in Treating Diabetic Gastrointestinal Dysfunction
Diabetic gastrointestinal dysfunction is caused by elevated blood glucose levels in diabetes, leading to autonomic nervous system dysfunction in the viscera. It is a common complication of diabetes. Due to hyperglycemia and metabolic abnormalities, the nerves of the gastrointestinal tract (autonomic nerves and myenteric plexus) and the muscles are affected, resulting in impaired gastrointestinal motility and secretion. Clinically, it often manifests as gastroparesis, abdominal distension, upper abdominal discomfort, diarrhea, constipation, etc.
Causes and Pathogenesis
Diabetic gastrointestinal dysfunction includes diabetic gastroparesis, stress ulcers, peptic ulcers, diabetic diarrhea, and diabetic constipation. Professor Pei Zhengxue believes that this condition falls under the categories of “pi man,” “ou tu,” “wei tong,” “xie xie,” and “bian mi” in traditional Chinese medicine. Long-term illness in diabetic patients leads to depletion of qi and yin, malnutrition of the spleen and stomach, and imbalance in the ascending and descending functions of the digestive system. Coupled with improper diet—overeating and excessive drinking—food stagnation occurs, blocking the flow of qi in the stomach, causing fullness and discomfort in the epigastric region. In severe cases, turbid qi cannot descend and instead rises, leading to vomiting. Prolonged illness also causes emotional distress, liver qi stagnation that cannot be released, which invades the stomach, resulting in disharmony between the liver and stomach, unfavorable qi flow, or chronic deficiency that damages the spleen and stomach, weakening their function, causing dampness to accumulate in the middle jiao and qi to become stagnant, thus leading to epigastric fullness, stomach pain, diarrhea, and constipation. When qi is damaged and yang is weakened, the spleen's yang energy declines, its function is impaired, qi flow becomes unfavorable, food and water remain trapped in the stomach, and with soil deficiency and wood excess, liver qi invades the spleen, creating disharmony between the liver and spleen, qi stagnation, and disruption of the intestine’s ability to separate pure from turbid, leading to either constipation or diarrhea, or alternating episodes. If the disease persists without healing, dampness transforms into heat, cold and heat mix, blood stasis blocks the channels, resulting in stomach pain, diarrhea, epigastric fullness, acid reflux, and vomiting all occurring simultaneously. As the disease progresses and affects the meridians, the channels become blocked, causing stomach pain like needle pricks and postprandial abdominal distension. This condition primarily affects the spleen and stomach, while also involving the liver and kidneys; the nature of the disease is “fundamental deficiency with superficial excess,” where fundamental deficiency mainly refers to weakness of the spleen and stomach, while superficial excess involves food stagnation, cold-dampness, damp-heat, qi stagnation, and blood stasis.
II. Syndrome Differentiation and Treatment
Professor Pei Zhengxue believes that clinical syndrome differentiation and medication should be divided into two categories: deficiency and excess. Disharmony between the liver and stomach, damp-heat in the spleen and stomach, and blockage of gastric channels are mostly excess patterns; spleen and stomach qi deficiency, spleen and stomach cold deficiency, and gastric yin deficiency are mostly deficiency patterns. Those whose illness is caused by deficiency leading to qi stagnation and blood stasis belong to the category of fundamental deficiency with superficial excess. Excess patterns are treated with methods to activate blood circulation and remove blood stasis, clear heat and eliminate dampness, and soothe the liver and harmonize the stomach; deficiency patterns are treated with methods to tonify qi and strengthen the spleen, warm the center and disperse cold, and nourish yin and benefit the stomach.
Professor Pei Zhengxue is skilled at using classic formulas from the "Shanghan Lun" to treat diabetic digestive dysfunction. If these formulas are appropriately matched to the syndrome and used correctly, they often yield excellent results. Commonly used classic formulas include Banxia Xiexin Tang, Xiaochaihu Tang, Sini San, Zhuye Shigao Tang, and Wumei Wan. Since this condition often presents with symptoms of liver-spleen disharmony and mixed cold-heat, applying these formulas with appropriate modifications often produces good effects. For patients with epigastric fullness, vomiting, diarrhea, and mixed cold-heat, Banxia Xiexin Tang can be modified for treatment, as this formula is representative of balancing cold and heat, opening up the bitter and lowering the hot, making it very suitable for treating various conditions caused by weak central qi and abnormal qi flow in the middle jiao. If the patient has thick, greasy tongue coating indicating accumulation of damp-heat in the middle jiao, ginseng, dried ginger, and jujubes can be removed, and realgar and zexie added to clear damp-heat. If spleen deficiency symptoms are obvious, Xiangsha Liu Junzi Tang can be added to tonify the spleen and benefit qi. In clinical treatment of patients with weak spleen and stomach and poor appetite and bowel movements, Shenling Baizhu San with modifications is often used. If the patient has poor appetite and difficulty eating, chicken gizzard lining and fried three herbs can be added; if phlegm-dampness is prominent, Cangzhu and Chenpi can be added to dry dampness and transform phlegm; if dampness leads to severe diarrhea, Plantago seeds can be added to promote urination and solidify stool. For patients with damage to spleen qi and yin, internal latent fire causing oral ulcers, mouth sores, and gum swelling, Zhuye Shigao Tang can be modified for treatment. If heat toxicity is severe, Liangge San can be used to clear heat and release fire. For patients with disharmony of spleen qi and stomach qi, leading to hiccups, Xuanfu Daizhe Tang can be modified for treatment; if liver qi invades the stomach, causing acid reflux and flank pain, the Gallbladder-Pancreas Formula (Chaihu, Zhishi, Baishao, Gancao, Chuanxiong, Xiangfu, Danshen, Muxiang, Caodoukou, Dahuang, Huangqin, Huanglian, Yanhusuo, Chuannianzi, Zhimayu, Ganjiang, Pugongying, Baijiangcao) can be modified for treatment. For those with spleen yang deficiency and cold in the middle jiao, Fuzi Lizhong Tang and Huangqi Jianzhong Tang can be used. For those with spleen yin deficiency, Ye’s Stomach-Nourishing Soup is often used; for those with long-term illness and blood stasis, Wudi Huanglian Xiang Tang (Huangqi, Danggui, Chuanxiong, Baishao, Xiangfu) is used. And so on—syndrome differentiation and treatment with adjustments based on symptoms always yield relatively satisfactory results in clinical practice.

In addition, the dosage of prescriptions should not be too large, and the medicinal properties should not be too strong. For patients who need to clear heat, overly bitter and cold medicines should not be used to avoid further damaging the spleen and stomach yang. For patients who need to nourish yin, overly rich and greasy medicines should not be used to prevent greasiness from obstructing the spleen and aggravating the formation of phlegm-dampness in the body. For patients who need to regulate qi, overly aromatic and drying medicines should not be used to prevent damage to spleen yin and stomach yin. Diabetic gastrointestinal dysfunction is also related to emotions and psychology. From a traditional Chinese medicine perspective, emotional well-being is mainly related to the liver, because the liver is responsible for dispersing and regulating the body’s qi flow. High pressure in life, work, study, and other aspects, coupled with external emotional stimuli such as joy, anger, sorrow, worry, grief, fear, and panic, lead to liver qi stagnation and obstruction of qi flow, impairing the liver’s ability to disperse and invade the spleen and stomach, resulting in liver-stomach disharmony and liver-spleen disharmony. Treatment often needs to balance the regulation of liver and spleen, as well as the qi flow between the liver and stomach.

1. Spleen and stomach qi deficiency with mutual entanglement of cold and heat
   Symptoms: Hidden stomach pain, epigastric fullness and discomfort, worse after eating, poor appetite, hard epigastric area, bad breath after eating, rumbling in the abdomen and diarrhea, poor appetite and fatigue, thin stools, even diarrhea, or alternating constipation and diarrhea, pale red tongue, swollen tongue with tooth marks, yellow or white tongue coating, wiry and rapid pulse. Treatment: Tonify qi and strengthen the spleen, open up the bitter and lower the hot, harmonize the stomach and dispel fullness.
   Prescription: Xiangsha Liu Junzi Tang and Banxia Xiexin Tang with modifications.
   Ingredients: Muxiang, Sharen, Fuling, Banxia, Chenpi, Gancao, Jujube, Fried Baishao, Dangshen, Huangqin, Huanglian, Ganjiang, Zhishi, Baishao, Shenglonggu, Shengmuli, Wuer Gu, Danshen, Caodoukou.
   For acid reflux and heartburn, add Xiangfu, Yanhusuo, calcined brick, alum to neutralize acidity and relieve pain; for alternating constipation and diarrhea, use Shangyang Yiwu Tang with modifications to tonify the spleen and benefit qi, raise the clear and lower the turbid; for those with epigastric fullness and slow digestion, use Zhishi Xiao Pi Tang with modifications to strengthen the spleen and expand the middle jiao; for those with nausea and vomiting, combine with Xuanfu Daizhe Tang and stomach antiemetic; for those with qi deficiency and damp stagnation, epigastric bloating, poor appetite, and thick white tongue coating, use Pingwei San to dry dampness and promote spleen function.
2. Spleen and stomach cold deficiency
   Symptoms: Subtle stomach pain, preference for warmth and pressure, fondness for hot drinks, worsening after fatigue or exposure to cold, pain relieved by warmth, frequent belching, exhaustion and poor appetite, cold limbs, intestinal rumbling, or constipation, pale red tongue, swollen tongue with tooth marks, thin white coating, deep and weak or slow pulse. Treatment: Warm the center and strengthen the spleen, disperse cold and relieve pain.
   Prescription: Da Jianzhong Tang, Huangqi Jianzhong Tang, Fuzi Lizhong Tang with modifications.
   Ingredients: Huangqi, Guizhi, Baishao, Roasted Gancao, Ganjiang, Jujube, Raw Fuzi, Fried Baishao, Dangshen, Muxiang, Sharen, Fuling, Banxia.
   For stomach bloating, add Shihuo and Houpu; for acid reflux, add Shenglongmu, Wuer Gu, and calcined brick to neutralize acidity; for indigestion and food stagnation, add Baohe Wan to aid digestion and disperse stagnation; for cold invading the stomach, add Gaoliangjiang and Xiangfu to warm the stomach and disperse cold, promoting qi flow and relieving pain; for those with vomiting and acid reflux, add Wujuyu and Huanglian; for abdominal pain and diarrhea, add Wujuyu, Cinnamon, Small Fennel, and Fenugreek to strengthen the spleen and warm the yang; for those with spleen and kidney deficiency, spleen-kidney yang deficiency, and predominant diarrhea and intestinal rumbling, add Sishen Wan, or use Zhenren Yangzang Tang with Sishen Wan for modification; for those with constipation as the main issue, use Jichuan Jian with Maziren Wan for modification.
3. Liver-stomach disharmony
   Symptoms: Epigastric pain radiating to both flanks, recurrent attacks, sighs of relief when warmed, irritability and quick temper, nausea and vomiting, dry mouth and bitter taste, poor appetite, or constipation, red tongue with yellow coating, wiry pulse. Treatment: Soothe the liver and resolve qi stagnation, regulate qi and relieve pain.
   Prescription: Gallbladder-Pancreas Formula with modifications.
   Ingredients: Chaihu, Zhishi, Baishao, Gancao, Chuanxiong, Xiangfu, Danshen, Muxiang, Caodoukou, Dahuang, Huangqin, Huanglian, Yanhusuo, Chuannianzi, Zhimayu, Ganjiang, Pugongying, Baijiangcao.
   For acid reflux, add Shenglongmu, Wuer Gu, calcined brick, and alum to neutralize acidity; for nausea and vomiting, add Xuanfu, Daizhe, Banxia, and ginger to reverse the flow and harmonize the stomach; for dry mouth and bitter taste, add Banxia and Dangshen to form a Xiaochaihu Tang to reconcile Shaoyang; for severe stomach pain, add Wulingzhi, Puhuang, Zhimayu, and Zhimayu to clear blood stasis and relieve pain; for chest pain, add Danshen, Sandalwood, and Sharen to promote qi flow and relieve pain.
4. Spleen and stomach damp-heat
   Symptoms: Epigastric fullness, pain, chest tightness and nausea, dry mouth and bitter taste, bad breath, sticky sweat, constipation or diarrhea, red tongue with yellow and greasy coating, slippery and rapid pulse. Treatment: Clear heat and dampness, regulate qi and harmonize the stomach.
   Prescription: Shi Daozhi Tang combined with Xiao Chengqi Tang with modifications.
   Ingredients: Shi, Baishao, Fuling, Ze Xie, Dahuang, Huanglian, Huangqin, Shenqu, Houpu.
   For nausea and vomiting, add orange peel and bamboo leaves to clear the stomach and stop vomiting; for stomach pain, add Yuanhu and Chuannianzi to promote qi flow and relieve pain; for diarrhea, combine with Ge Gen Qin Lian Tang to clear heat and dampness, raise the clear and lower the turbid; for those with liver qi stagnation, combine with Sini San to soothe the liver and harmonize the stomach.
5. Gastric yin deficiency
   Symptoms: Burning pain in the stomach, dry mouth and throat, constipation, emaciation, oral and lingual erosion, poor appetite and reluctance to eat, postprandial fullness, dry stools, dry heaving and belching, preference for cold drinks. Tongue is red with little coating, or cracked, or coating peels off, pulse is thin and rapid. Treatment: Nourish yin and benefit the stomach, relieve acute pain.
   Prescription: Ye’s Stomach-Nourishing Soup combined with Banxia Xiexin Tang with modifications.
   Ingredients: Beisha Shen, Maidong, Yuzhu, Shihu, Bai Bian Dou, Banxia, Huangqin, Huanglian, Dangshen, Gancao, Jujube, Danshen, Baihe, Wumei, Sheng Mai Ya.
   For dry stools, combine with Zengye Chengqi Tang to nourish yin and promote bowel movements; for burning stomach pain and noisy acid reflux, add Wujuyu and Huanglian to clear liver and stomach heat; for those with severe gastric yin deficiency, add Shengdi and Baishao to nourish yin and benefit the stomach; for those with obvious qi stagnation, remove Huanglian, add Shi and Houpu to promote qi flow and reduce bloating; for those with acid reflux, remove Wumei, add Wuer Gu and calcined brick to neutralize acidity and relieve pain.
6. Blood stasis in gastric channels
   Symptoms: Long-term illness has entered the meridians, stomach pain, fixed pain, refusal to press, fatigue and weakness, poor appetite and slow digestion, nausea, constipation, dark red or purplish tongue, or spots, wiry and stiff pulse.
   Treatment principle: Regulate qi and activate blood circulation, unblock channels and relieve pain.
   Prescription: Wudi Huangliang Tang with modifications.
   Ingredients: Huangqi, Danggui, Chuanxiong, Baishao, Xiangfu, Gaoliangjiang, Banxia, Shi, Sharen, Fried Three Herbs, Houpu, Qingpi, Danshen,
   Puhuang, Wulingzhi.
   For severe constipation, add Huoma Ren, Yu Li Ren, and Tao Ren to lubricate the intestines and promote bowel movements, or combine with Tao He Chengqi Tang; for those with nausea and urge to vomit, add Wujuyu and ginger to calm the stomach and stop vomiting; for those with fatigue and weakness, add Dangshen and Baishao to tonify the spleen and benefit qi; for those with long-standing stomach pain that does not heal, add Yanhusuo, Chuannianzi, and Sanqi to activate qi and blood circulation, clear blood stasis and relieve pain.
   III. Clinical Case Reports
   Case 1: He, male, 61 years old, first visit on November 29, 2019. The patient has had type 2 diabetes for over 7 years, has been taking hypoglycemic medications long-term, with generally controlled blood sugar levels, fasting blood glucose fluctuating between 7–9 mmol/L. Four months ago, the patient gradually developed poor appetite and upper abdominal distension after eating. Two weeks ago, these symptoms significantly worsened, accompanied by nausea and vomiting, so he sought treatment at a Grade III hospital. Gastroscopy showed no obvious abnormalities, while barium meal examination indicated poor gastric emptying, diagnosed as diabetic gastroparesis. He was given Mosapride and Metoclopramide to promote gastric motility and relieve vomiting; symptoms improved after taking the medication, but reverted to previous condition upon stopping, so he came for consultation. Current symptoms:
   The patient has gastric fullness, poor appetite, nausea and vomiting, fatigue, emaciation, normal bowel movements, pale white and slightly yellowish tongue coating, and a slippery pulse.
   Western medical diagnosis: Diabetic gastroparesis.
   Traditional Chinese Medicine differentiation: Spleen deficiency with qi stagnation, mixed cold and heat.
   Prescription: Xiangsha Liu Junzi Tang combined with Banxia Xiexin Tang and Xuanfu Daizhe Tang with modifications.
   Ingredients: Muxiang 10g, Caodoukou 10g, Fuling 10g, Banxia 10g, Chenpi 6g, Fried Baishao 10g,
   Dangshen 10g, Huangqin 10g, Huanglian 6g, Ganjiang 6g, Zhishi 10g,
   Baishao 10g, Shenglonggu 15g, Shengmuli 15g, Wuer Gu 15g, Xuanfu 10g,

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Input: Dai zhe shi 30g, jiao san xian each 10g, gan cao 6g, da zao 3 pieces. 14 doses, decocted in water and taken orally, one dose per day. Second consultation: After taking the medicine, the patient's nausea, vomiting, and epigastric distension improved, but still had poor appetite and slow digestion, with a lack of appetite. The tongue was pale with a white, greasy coating, and the pulse was fine and slippery. The original formula was combined with Pingwei San to strengthen the spleen and transform dampness, and炒莱子 15g and chicken gizzard concretions 15g were added. Continue taking for another 14 doses. Third consultation: After taking the medicine, the patient's nausea and vomiting disappeared, the epigastric fullness greatly eased, and both appetite and food intake increased. The patient was instructed to monitor blood sugar levels and take hypoglycemic drugs regularly. The previous formula was made into water pills at three times the original dosage and continued for two months, after which all symptoms were cured. Case 2: Zhao Moumou, male, 70 years old, first visit on March 18, 2018. The patient has a history of type 2 diabetes for more than ten years and has been taking hypoglycemic drugs long-term, with relatively good blood sugar control. One year ago, the patient developed upper abdominal distension, occasional belching, and constipation. He intermittently took traditional Chinese medicine decoctions but did not recover. During this period, he was diagnosed with diabetic gastrointestinal dysfunction at a Grade III hospital and received prokinetic and laxative treatments, but there was no obvious improvement. Current presentation: The patient has upper abdominal distension that worsens after eating, occasional belching, irritability and poor sleep, dry stools once a week, nocturia, dry mouth, heat in the palms and soles, pale red tongue, yellow and greasy coating, and a slippery, rapid pulse. Western medical diagnosis: Diabetic gastrointestinal dysfunction. Traditional Chinese medicine differentiation: Spleen deficiency with impaired transportation, and damp-heat in the stomach and intestines. Prescription: Banxia Xiexin Tang combined with Shidaozhi Tang and Xiaochengqi Tang, with modifications. Fahansha 10g, Ganjiang 6g, Dangshen 10g, Quanshi 15g, Baizhu 10g, Fuling 10g, Zexie 10g, Dahuang 10g (added later), Huanglian 6g, Huangqin 10g, Shenqu 10g, Houpu 15g, Muxiang 10g, Binglang 10g, Gancao 6g, Da zao 3 pieces. 14 doses, decocted in water and taken orally, one dose per day. Second consultation: After taking the medicine, the patient has bowel movements once a day, but still with dry stools and frequent nocturia. The epigastric distension has significantly improved, and irritability, poor sleep, and heat in the palms and soles have all markedly lessened. The tongue is pale red with a thin, white, greasy coating, and the pulse is fine and slippery. The original formula was supplemented with Mangxiao 10g, and treatment continued for another 14 doses. Third consultation: The patient now has regular bowel movements once a day, with no more dry stools, though nocturia remains frequent. Other symptoms have basically disappeared, with a pale tongue, thin white coating, and a deep, fine pulse. The damp-heat syndrome has been eliminated, and the treatment has shifted to strengthening the spleen and kidneys, moistening the intestines and promoting bowel movements to address the root cause. The prescription is Jichuan Jian combined with Maziren Wan, with modifications. Specifically:

Rou Congrong 30g, Danggui 30g, Huainiu Xi 10g, Zhike 10g, Shengma 10g, Zexie 10g, Huomaren 30g, Yuliren 15g, Xingren 10g, Baishao 10g, Dahuang 6g, Houpu 15g. 14 doses, decocted in water and taken orally, one dose per day. Fourth consultation: After taking the medicine, the patient’s bowel movements are normal, and nocturia has improved. The above formula was made into water pills at three times the original dosage, and the patient continued taking them for over two months, ultimately achieving complete recovery. Section 7: Diabetes and Complications—Historical and Contemporary Theories Diabetes: Historical and Contemporary Theories “The Plain Questions · Chapter on Qi Deficiency”: “Consumption of the lungs leads to drinking one or two… Heat from the large intestine moves to the stomach, resulting in a strong appetite but emaciation.” Sui Dynasty · Zhen Liyan’s “Record of Ancient and Modern Experiences” (the original text is lost, quoted from “Outer Cabinet Secret Essentials · Volume 11 · Prescriptions for Thirst”) states: “Thirsty people who drink a lot of water, urinate frequently, and whose urine is sweet like bran flakes are all suffering from thirst disease.” From historical literature, it can be seen that the main symptoms of thirst disease include excessive thirst, polydipsia, polyphagia, polyuria, emaciation, and sweet-smelling urine, which are highly similar to the typical symptoms of modern diabetes—three excesses and one deficiency. Therefore, Qing Dynasty · Zhang Xichun’s “Medical Insights Integrating Traditional Chinese and Western Medicine · Prescriptions for Treating Thirst” states: “Thirst is what Western medicine calls diabetes.” The “Yellow Emperor’s Inner Canon” initially defined the concept of thirst disease and its basic pathogenesis of “internal heat,” and discovered that indulging in rich foods could trigger thirst disease, laying the foundation for future developments. “The Plain Questions · Chapter on Skin” states: “Excessive heat causes muscle relaxation and bone loss.” Diabetic patients experience severe muscle wasting, even to the point of total depletion. “Thirst” not only implies “reduction” and “emaciation,” but also carries a medical significance: “Two Yangs being blocked results in thirst.” It can be seen that “thirst” is closely linked to “heat.” The term “thirst” originates from “The Plain Questions · Chapter on Strange Diseases”: “The spleen… …is the source of this obesity, This person must eat sweet and fatty foods frequently, and fat causes internal heat while sweetness causes fullness, leading to upward qi reversal and eventually thirst.” This clearly defines thirst as the early stage of thirst disease and identifies the cause as “frequent consumption of sweet and fatty foods.” Eastern Han Dynasty · Zhang Zhongjing’s “Jingui Yaolue” dedicated a special chapter to thirst disease, for the first time comprehensively proposing “loss of appetite,” “intense thirst for water,” and “increased urination” as typical symptoms of thirst disease, and laying the foundation for the differential diagnosis and treatment of thirst disease. “Jingui Yaolue · Treatment of Thirst Disease, Urinary Retention, and Dysuria” states: “If the Yang pulse is floating and rapid, floating indicates qi, and rapid indicates loss of appetite and strong hunger; when qi is abundant, it becomes rapid, and when rapid, it becomes strong, and when strong and rapid, they clash, resulting in thirst.” Based on “The Plain Questions · Chapter on Qi Deficiency” stating that “heart heat moves to the lungs, transforming into thirst,” it specifically developed into “thirsty people wanting to drink water, with dry mouth and throat, treated with Baihu Plus Ginseng Decoction.” If we say that “internal heat” summarizes the Yellow Emperor’s Inner Canon’s understanding of thirst, then Zhang Zhongjing’s outstanding contribution lies in clarifying the role of “kidney deficiency.” As stated in “Jingui Yaolue · Treatment of Thirst Disease, Urinary Retention, and Dysuria”: “For those who constantly crave water, Wenba Powder is the primary treatment.” Zhang Zhongjing used the theory of lung and stomach heat damaging body fluids and kidney deficiency to differentiate various symptoms of thirst, and employed ginseng-baihu decoction to clear lung and stomach heat and kidney qi pills to tonify kidney qi, thus pioneering the method of differentiating and treating thirst disease. Sui Dynasty · Chao Yuanfang divided thirst disease into eight syndromes: thirst syndrome, thirst-related illness syndrome, post-thirst fatigue syndrome, etc., but this classification had little impact on later generations. However, Chao Yuanfang made important contributions to understanding the complications of thirst disease and inferred their mechanisms. As stated in “Discussions on the Origins and Symptoms of Various Diseases · Syndromes of Thirst Disease”: “Complications often manifest as carbuncles. Due to internal heat and frequent urination, when urination is frequent, body fluids are depleted; when body fluids are depleted, meridians become stagnant; when meridians are stagnant, nourishment and defensive qi cannot circulate; when nourishment and defensive qi cannot circulate, heat stagnates, leading to carbuncles and pus.” Tang Dynasty · Sun Simiao established specialized chapters on treating thirst in both “Emergency Thousand Gold Prescriptions” and “Thousand Gold Wing Prescriptions,” providing detailed discussions on the disease. Regarding the causes, he also classified alcohol consumption as a cause of thirst. As stated in “Thousand Gold Prescriptions · Prescriptions for Thirst and Urinary Retention”: “Anyone who drinks alcohol for a long time will inevitably develop thirst.” In terms of treatment, Sun Simiao largely followed the Yellow Emperor’s Inner Canon’s view of “internal heat,” using clearing heat and draining fire, as well as generating body fluids and quenching thirst as the main principles. He favored bitter-cold, sweet-cold, and tonifying herbs, heavily using ingredients such as Tianhua Fen, Mai Dong, Di Huang, and Huang Lian to create famous prescriptions like Yuquan Pill and Huang Lian Pill. Among them, “Emergency Thousand Gold Prescriptions” contains 53 formulas, while “Thousand Gold Wing Prescriptions” contains 23 formulas, totaling 142 medicinal ingredients. He also advocated combining medicine and diet, using heat-clearing and fluid-generating herbs along with nourishing foods for long-term use, achieving both clearing and tonifying effects, which aligns with the chronic nature of thirst disease and greatly enriches its treatment. Song Dynasty · Wang Huaiyin and others compiled “Taiping Holy Benefit Formulas,” introducing the term “Three Thirsts,” namely thirst, middle thirst, and kidney thirst, and elaborating on their respective conditions: “First, drinking a lot of water but urinating little—this is thirst; second, eating a lot but drinking little, with little urination and reddish-yellow urine—this is middle thirst; third, drinking water as you urinate, with sweet-tasting and cloudy urine, and waist and leg emaciation—this is kidney thirst.” Based on these main symptoms and prognoses, they categorized 177 formulas into 14 classes for differentiated treatment, covering a wide range of aspects—from the early pathological changes of what we now call thirst disease to the mid-to-late stage—and including descriptions of the same syndromes across different diseases, guiding clinical differential diagnosis and treatment. From then on, the “Three Thirsts” theory of thirst disease became popular among later generations and played a guiding role in subsequent treatments. During the Jin and Yuan dynasties, Liu Hejian developed the “Three Thirsts Theory” under the cold-and-cool school of thought, following the Yellow Emperor’s Inner Canon’s view that “two Yangs being blocked results in thirst,” and proposed the “Three Thirsts Dry Heat Theory,” with the core pathogenesis being “extremely depleted yin energy due to cold and dampness, and excessive yang energy due to dry heat.” The “Three Thirsts Theory” summarized the treatment principles as: “Tonify kidney yin energy, drain heart fire yang energy, eliminate severe dry heat in the intestines and stomach, and replenish deficient body fluids.” Liu Hejian’s “Three Thirsts Dry Heat Theory” had a significant impact on later generations, and Li Dong supported Liu’s theory in his “Lan Shi Secret Collection · On Thirst”: “Insufficient body fluids, causing dryness and lack of lubrication—these are all caused by dry heat.” Zhu Danxi, guided by the idea that “yang is always abundant while yin is always deficient,” further developed the theory of primarily nourishing yin to treat thirst. In “Danxi Heart Method · On Thirst”: “The lungs are the organ of body fluids, from top to bottom, All organs of the triple burner are immersed in the true water of heaven. According to ‘The Plain Questions,’ water originates in the kidneys and ends in the lungs—this is why true water never runs out, so how can there be thirst?” Zhang Congzheng believed in “Confucian Gate Family Matters” that the Three Thirsts should be cut off at the source of fire, a view similar to Zhu Danxi’s. Through the development of various doctors during the Jin and Yuan periods, a relatively mature set of treatment principles for thirst disease was formed: clearing heat and draining fire, nourishing yin and generating body fluids, with key herbs including Tianhua Fen, Mai Dong, Di Huang, and Huang Lian. Ming Dynasty physicians also had new perspectives on thirst disease, with the most influential being the “Qi-Boosting” theory. Two physicians deserve special mention. Dai Sigong stated in “Essential Treatments · Three Thirsts”: “The Three Thirsts arise from real qi, virtual blood, and prolonged neglect—when qi is exhausted and virtual blood is depleted, one is powerless.” He recommended using astragalus extensively in medication. Another physician, Li, further enriched the Qi-boosting theory, placing emphasis on tonifying the spleen and kidneys. In “Introduction to Medicine · On Thirst”: “When treating thirst, first nourish the lungs and lower the heart, and later nourish the kidneys and strengthen the spleen. Because the root lies in the kidneys and the manifestation in the lungs, when the kidneys are warm, qi rises and the lungs are moisturized; when the kidneys are cold, qi does not rise and the lungs burn, so kidney qi pills are an excellent remedy for thirst. However, the heart and kidneys are connected through the spleen, so nourishing the spleen naturally generates body fluids—Shenling Baizhu San is an example.” In addition, some physicians revisited Zhang Zhongjing’s “Kidney Qi Pills” theory, advocating treating thirst based on the kidneys. Zhao Xianke stated in “Medical Compendium · On Thirst”: “There is no distinction between upper, middle, and lower parts in treating thirst; the priority is to treat the kidneys first, using six, eight, or eight-plus formulas with adjustments according to the condition, to lower heart fire and nourish kidney water, and thirst will naturally subside.” Zhang Jingyue’s approach to the differential diagnosis and treatment of thirst was more balanced, believing it necessary to clearly distinguish between yin and yang deficiencies. In “Complete Works of Jingyue · Three Thirsts and Thirst”: “Ancient people all considered these three thirsts to be fire-related, but there are cases of real fire, where excess evil heat exists; and cases of virtual fire, where true yin is lacking.” As for treatment methods: “Fire in the upper and middle triple burner is also just stomach fire rising, but it should be treated differently. If the upper and middle triple burner truly has real fire, then Baihu Decoction should be used. If thirst is accompanied by hunger, and the disease mainly affects the lungs, then Ginseng-Baihu Decoction should be used. If water is deficient below and fire is abundant above, then one must clear it, using Jade Maiden Decoction or adjusting Yin Decoction accordingly.” During the Qing Dynasty, views on treating thirst disease included “treating from the liver” and “treating from phlegm.” Huang Yuanyu explicitly stated in “Four Saints’ Heart Source” that “thirst is a disease of the Foot-Jueyin Liver,” while Fei Boxiong, hailed as “a living master,” proposed treating thirst from phlegm. In “Medical Ethical Principles,” it was said: “Upper thirst… …should be treated with extensive moisturizing and clearing, supplemented with herbs that dispel dampness and transform phlegm, because when fire is abundant, phlegm becomes dry, and its destructive power is enhanced by phlegm, so Fengyuan Drink is the primary treatment; middle thirst… phlegm enters the stomach and combines with fire, making the effect even stronger… therefore, it is advisable to clear Yangming heat, moisten dryness and transform phlegm, with Anti-Irritation and Stomach-Nourishing Soup as the main treatment; lower thirst is a kidney disease… urgent need to cultivate true yin, with minimal intervention to clear and benefit, using Black Dragon Soup as the main treatment.” Modern physicians such as Shi Jinmo treat diabetes by focusing on nourishing yin and clearing heat, boosting qi and strengthening the spleen as the basic principles, and creating drugs to lower urine sugar and blood sugar, such as astragalus paired with Chinese yam, Tianhua Fen paired with Di Huang, and black plum paired with gallnuts to lower urine sugar; Cangzhu paired with Xuanshen and raw gypsum, Zhimu paired with ginseng to lower blood sugar, Danshen paired with Kudzu to invigorate blood and nourish qi, and generate body fluids. His student Zhu Yu believes that although thirst disease has both deficiency and excess, most cases of the Three Thirsts are deficient, and the root cause lies in kidney deficiency, requiring a comprehensive approach that integrates yin-yang, organ, and qi-blood differentiation for accurate diagnosis and treatment, with emphasis on nourishing yin, boosting qi, and activating blood circulation to remove stasis. Summarizing Mr. Shi Jinmo’s experience with “Cangzhu paired with Xuanshen, astragalus paired with Chinese yam,” he further developed and expanded it into a combination of drugs to lower blood sugar: 30g each of raw astragalus, Di Huang, and Xuanshen, and 15g each of Cangzhu, Kudzu, and Danshen. Contemporary physician Cheng Yichun points out that raw astragalus, Tianhua Fen, and Huang Lian are particularly effective combinations for treating diabetes characterized by both qi and yin deficiency, directly addressing the pathogenesis of diabetes patients with qi and yin deficiency and excessive internal heat. Modern pharmacological research proves that Huang Lian and astragalus have a good blood-sugar-lowering effect in treating diabetes. Danshen, Kudzu, and melon seeds help activate blood circulation and remove stasis, preventing chronic complications of diabetes, and should be applied throughout the entire course of diabetes treatment.

II. Historical and Contemporary Theories on Diabetes Complications

1. Diabetic Nephropathy (1) Ye Rengao: Diabetic nephropathy, based on clinical manifestations, can be categorized under TCM as “thirst,” “edema,” “dizziness,” and “deficiency-fatigue,” among others. In the early stages, it is mostly thirst; in the middle stages, some complications such as edema and dizziness appear; in the later stages, due to long-term illness and decline in function of all organs, deficiency-fatigue manifests. Treatment should follow the dynamic changes of the disease and adopt flexible differential diagnosis and treatment, rather than rigidly sticking to a single syndrome. (2) Zhang Qi: Diabetic nephropathy is a severe microvascular complication of diabetes, arising from improper treatment, misdiagnosis, or inadequate treatment. It is a case of deficiency-root, excess-symptom, with complex and variable pathogenesis. Clinically, there is deficiency of both spleen and kidney, damage to the five viscera, obstruction of the triple burner, accumulation of dampness, turbidity, and blood stasis, leading to numerous complications. Treatment must focus on the pathogenesis, prevent disease before it occurs, and prevent complications once the disease has developed. Since blood stasis is the pathological basis and persists throughout, attention should also be paid to the application of methods to activate blood circulation and remove stasis.
2. Diabetic Retinopathy (1) Tang Youzhi: The pathogenesis of eye diseases related to thirst is mostly long-term deficiency of qi and yin, with qi deficiency leading to insufficient blood flow and resulting in blood stasis, lack of nourishment for the eyes, yin deficiency causing fire to scorch the eye vessels, and blood spilling out of the vessels, thus forming this disease. Therefore, qi and yin deficiency combined with blood stasis is the main pathogenesis of this disease. TCM eye fundus diseases emphasize local differentiation, and the formation of blood stasis also corresponds to the Western medical view that the mechanism of this disease may be capillary occlusion and microcirculatory disorders. Treatment often uses Shengpuhuang Decoction combined with Erzhi Pill with adjustments, with the basic prescription being Shengpuhuang, ginger turmeric, early lotus grass, female privet, danshen, goji berries, raw astragalus, cow knee, cornelian cherry, dodder, and chuanxiong. (2) Wei Yuying: Optic nerve diseases are often caused by liver qi stagnation, especially in cases that have been lingering for a long time without healing, where qi and blood are inevitably stagnant and deficient, and prolonged illness entering the meridians can lead to stasis, making the condition even more stubborn and difficult to cure, falling into the category of “chronic diseases that cannot be cured without active intervention.” Therefore, treatment must include medicines that regulate liver qi and unblock the mysterious palace. For example, bupleurum is a key herb for the liver meridian, and it is essential for brightening the eyes and activating liver qi. Clinically, Danzhi Xiaoyao Pill with adjustments is often used, always emphasizing the two words “soothe the liver.”
3. Diabetic Peripheral Neuropathy (1) Lü Renhe: This disease involves organ deficiency, especially liver and kidney deficiency, and shows varying degrees of blood stasis and blood congestion in the early, middle, and late stages. Treatment focuses on tonifying the liver and kidneys and activating blood circulation, creating a formula called “Activating Blood Circulation and Eliminating Thirst”: dog spine, continuation of the break, chuanxiong, and ghost arrow feather, 10g each; danshen, cow knee, and papaya, 15g each; earthworm, 5g; leech, 3g; centipede, 2; raw licorice, 3g. Based on the basic formula of “Activating Blood Circulation and Eliminating Thirst,” if the syndrome is qi and yin deficiency, add prince ginseng, mai dong, wu wei zi, and huang jing; if it’s liver and kidney yin deficiency, add shu di huang, shan yao, sang ji sheng, and huang jing; if it’s spleen and kidney yang deficiency, add raw astragalus, dang shen, cinnamon, and processed aconite; if it’s marrow deficiency, add deer antler glue, turtle shell glue, goji berries, purple river car, and shu di huang. (2) Zhao Jifu: Diabetic peripheral neuropathy often begins in the middle stage of diabetes and worsens in the late stage, resulting from blood stasis in the meridians and presenting symmetrically in the limbs with “cold, numbness, pain, and paralysis” as the main symptoms. This disease often has characteristics such as insufficient yang qi and blood stasis in the meridians, so the main treatment method is to boost yang qi and restore its flow, while also considering activating blood circulation and removing stasis, with remarkable clinical efficacy.

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4. Diabetic Gastrointestinal Dysfunction
   (1) Treatment of diabetic gastroparesis by Xiao Lin:
   The primary symptom of this condition is vomiting, with the pathogenesis attributed to upward rebellion of stomach qi. Clinically, the treatment mainly involves modifications to Fuzi Lizhong Decoction. The formula includes: 30 g of black processed Aconite (decocted first for 1 hour), 15 g of dried ginger, 6 g of red ginseng (decocted separately and then added), 30 g of stir-fried white atractylodes, 15 g of coptis, and 6 g each of perilla leaf and stem. Three doses are prepared and taken as a decoction. The formula uses Fuzi Lizhong Decoction to tonify middle yang and restore the spleen and stomach’s ability to circulate and distribute qi. The addition of 30 g of Aconite serves as the chief herb, as Zheng Qin’an stated in “Yili Zhenchuan”: “Only Aconite can rescue the dying true yang; only ginger and atractylodes can nourish the earth qi of the middle jiao.” Furthermore, the formula emphasizes the use of bitter, sweet, warm, and drying white atractylodes to strengthen the central region, while substituting cooked red ginseng for raw ginseng to harness its warming and moistening properties. To address the patient’s main symptom of vomiting, the method of pungent opening and bitter descending is employed, using Coptis and Perilla Decoction to regulate qi, broaden the middle burner, and reverse upward qi. Coptis, with its “bitter-sour-to-sweet” nature, can lower blood sugar, and when combined with other pungent-warm herbs, it counteracts potential resistance to medication while also harmonizing qi through pungent opening and bitter descending to achieve blood sugar reduction.
   (2) Treatment experience of Zhu Yu for diabetic diarrhea:
   Diabetic diarrhea is often seen in cases of spleen yang deficiency and unresolved cold-dampness, but there are also mixed patterns of upper-jiao dry-heat that has not been eliminated and lower-jiao cold-dampness that has arisen, resulting in alternating heat and cold symptoms. During an episode, patients may have several to dozens of watery bowel movements daily without abdominal pain, which can last for weeks, sometimes accompanied by constipation or alternating between the two. Diabetic diarrhea can be classified into mild and severe cases. For mild cases, the standard approach is to use hypoglycemic agents while omitting raw rehmannia and xuan shen, adding cooked rehmannia, white atractylodes, perilla stem, hojibai stem, angelica root, fresh hui ren, yam, fructus amomi, cinnamon, nutmeg, and other herbs. For severe cases, Shen’s Kidney-Strengthening Decoction is combined with Four Gods Pill, along with the aforementioned herbs. For diarrhea with mixed heat and cold patterns, Shen’s Kidney-Strengthening Decoction or Four Gods Pill is often used in combination with Gegen Qinlian Decoction or Bai Tou Weng Decoction, plus the previously mentioned herbs, to balance heat and cold, clear the upper part and warm the lower part. For those with concurrent liver depression, Painful Diarrhea Formula is added. Among these, perilla stem paired with hojibai stem and angelica root paired with fresh hui ren are two commonly used herb pairs in Zhu Yu’s treatment of cold-damp diarrhea. Perilla stem is pungent, aromatic, and warming, excelling at regulating qi, broadening the middle burner, and relieving pain; hojibai stem has a fragrant aroma, dispels dampness, stops vomiting, and invigorates the spleen to regulate qi. When used together, the two herbs complement each other, enhancing their effects in regulating qi, broadening the middle burner, reducing swelling, and alleviating pain. Zhu Yu frequently uses them to treat chest and diaphragm fullness and intestinal rumbling caused by unresolved cold-dampness and stagnation of qi.

Chapter 11: Dyslipidemia and Lipoprotein Abnormalities
Section 1: Pathogenesis, Diagnosis, and Treatment of Dyslipidemia and Lipoprotein Abnormalities
Dyslipidemia refers to the collective term for cholesterol (TC), triglycerides (TG), and lipids such as phospholipids in serum. Dyslipidemia typically means elevated levels of TC and/or TG in the serum, commonly known as hyperlipidemia. Dyslipidemia is the most significant risk factor contributing to the development of atherosclerotic cardiovascular disease (ASCVD). Currently, ASCVD is the leading cause of death among Chinese residents. The United States has successfully reduced coronary heart disease mortality by lowering cholesterol levels, whereas in recent years, China’s coronary heart disease mortality has continued to rise, with elevated cholesterol levels accounting for 77% of the increase. Therefore, effective control of dyslipidemia is of great importance for preventing and controlling ASCVD in China.

1. Primary Hyperlipidemia
   Primary hyperlipidemia is caused by mutations in one or multiple genes. It often exhibits familial clustering and a clear genetic predisposition, especially in cases involving single-gene mutations, hence it is clinically referred to as familial hyperlipidemia. Familial hypertriglyceridemia is caused by single-gene mutations, typically affecting lipoprotein lipase involved in TG metabolism, or mutations in apolipoprotein C2 (APOC2) or apolipoprotein A5 (APOA5) genes, resulting in severe hypertriglyceridemia (TG > 10 mmol/L).

2. Secondary Hyperlipidemia
   Secondary hyperlipidemia refers to dyslipidemia caused by other diseases. Common conditions that can lead to dyslipidemia include obesity, diabetes, nephrotic syndrome, hypothyroidism, renal failure, liver disease, systemic lupus erythematosus, multiple myeloma, polycystic ovary syndrome, and others. In addition, certain medications such as diuretics, non-cardioselective beta-blockers, and glucocorticoids can also induce secondary hyperlipidemia.

II. Clinical Manifestations
Dyslipidemia can occur in people of different ages and genders, with the prevalence increasing with age. High cholesterol peaks between 50 and 69 years old, with males being more affected before age 50 and females after age 50. Some familial forms of dyslipidemia can even occur in infants and young children. Most patients with dyslipidemia exhibit no symptoms or abnormal physical signs and are discovered during routine blood biochemical tests. The main clinical manifestations of dyslipidemia are as follows:

1. Xanthomas, early-onset corneal arcus, and retinal changes associated with hyperlipidemia
   These are caused by localized lipid deposition, with xanthomas being the most common. Xanthomas are abnormal, localized skin elevations that can be yellow, orange, or brown-red in color, often appearing as nodules, plaques, or papules, with a generally soft texture. The most common type is flat, yellow xanthoma around the eyes. Early-onset corneal arcus appears in individuals under 40 and is often accompanied by dyslipidemia. Severe hypertriglyceridemia can lead to retinal changes associated with hyperlipidemia.
2. Atherosclerosis
   Lipid deposition beneath the vascular endothelium leads to atherosclerosis, causing early-onset and rapidly progressing cardiovascular and peripheral vascular diseases. Certain familial forms of dyslipidemia can result in coronary heart disease, even myocardial infarction, before adolescence. Severe hypercholesterolemia may occasionally cause migratory polyarthritis. Severe hypertriglyceridemia (especially exceeding 10 mmol/L) can trigger acute pancreatitis.

III. Diagnosis of Dyslipidemia
LDL-C or TC levels independently predict the risk of ASCVD in individuals or populations. The stratification criteria for lipid levels are shown in Table 8. A comprehensive assessment of overall ASCVD risk is a necessary prerequisite for preventing and treating dyslipidemia. Based on individual ASCVD risk stratification, the target level for dyslipidemia intervention is determined. The risk stratification and target values for dyslipidemia are presented in Table 9. Both domestic and international guidelines for the prevention and treatment of dyslipidemia emphasize that LDL-C plays a central role in the development of ASCVD and recommend prioritizing LDL-C as the primary intervention target. Genetic testing is required for primary dyslipidemia.

Table 8: Chinese Lipid Level Stratification Standards
[mmol/L (mg/dL)]

Stratification | TC | LDL-C | HDL-C | TG
Ideal Level | | | |
Appropriate Level | <5.2 (200) | <3.4 (130) | |
Borderline Level | ≥5.2 (200) and <6.2 (240) | ≥3.4 (130) and <4.1 (160) | |
Elevated Level | ≥6.2 (240) | ≥4.1 (160) | |
Reduced Level | | | |

Note: ASCVD stands for atherosclerotic cardiovascular disease; : none.

Table 9: Dyslipidemia Risk Stratification and Target Values

Risk | Disease or Risk Factors | LDL-C Target Value
Extremely High Risk | ASCVD patients a | <1.8 mmol/L
High Risk | LDL-C ≥4.9 mmol/L or TC ≥7.2 mmol/L; | <2.
| > 1 mmol/L ≤ TC <7. |
| > 2 mmol/L and age ≥40; hypertension |
| +2 or more risk factors b |
Moderate Risk | No hypertension, 2 or more risk factors b, hypertension +1 risk factor b | <3.4 mmol/L
Low Risk | No hypertension, 0–1 risk factors b, hypertension, no risk factors b | <3.4 mmol/L
Note: a: ASCVD includes acute coronary syndrome (ACS), stable coronary heart disease, post-revascularization, ischemic cardiomyopathy, ischemic stroke, transient ischemic attack, peripheral arterial atherosclerosis, etc.; b: Risk factors include smoking, age (men >45, women >55), HDL-C <1 mmol/L (40 mg/dL).

IV. Treatment
The goal of correcting dyslipidemia is to reduce the incidence and mortality of ischemic cardiovascular diseases and ischemic strokes. Elevated TC, LDL-C, TG, and VLDL-C are all risk factors for coronary heart disease, with LDL-C being the most important, while HDL-C is considered a protective factor against coronary heart disease.

(—) Treatment Principles

1. For secondary dyslipidemia, the primary focus should be on treating the underlying disease. For example, once diabetes or hypothyroidism is brought under control, lipid levels may return to normal. However, primary and secondary dyslipidemia can coexist; if lipid abnormalities persist even after the primary disease has been treated for a period of time, it indicates the presence of primary dyslipidemia, requiring corresponding treatment.
2. Treatment Measures
   Comprehensive lifestyle interventions are the primary and fundamental treatment measures. Pharmacological treatment must strictly adhere to indications, and plasma purification therapy or surgical treatment should be considered when necessary. Gene therapy is still in the exploratory stage.

(II) Lifestyle Changes
Dyslipidemia is significantly influenced by diet and lifestyle. Regardless of whether pharmacological treatment is administered, it is essential to maintain dietary control and improve lifestyle habits. On the basis of meeting daily nutritional needs, total energy intake should be controlled, with a recommendation to consume less than 300 mg of cholesterol per day, especially for high-risk patients such as those with ASCVD, whose fat intake should not exceed 20%–30% of total energy. Fat intake should prioritize foods rich in n-3 polyunsaturated fatty acids (such as deep-sea fish and vegetable oils); the proportion of various nutrients should be reasonably balanced, with carbohydrates accounting for 50%–65% of total energy intake, primarily from grains, tubers, and whole grains; weight should be controlled to maintain a healthy body weight (BMI 20.0–23.9 kg/m²); smoking should be quit, and alcohol consumption limited; regular moderate-intensity metabolic exercise should be maintained, recommended 5–7 days per week, 30 minutes each time.

(III) Lipid-Lowering Medications

1. Statins (also known as 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors) can inhibit the rate-limiting enzyme HMCG-COA reductase, thereby reducing cholesterol synthesis and subsequently upregulating LDL receptors on hepatocyte surfaces, accelerating the breakdown and metabolism of serum LDL. As a result, statins can significantly lower serum TC, LDL-C, and apolipoprotein B (APOB) levels, as well as reduce serum TG levels and slightly raise HDL-C levels. Statins are the cornerstone of drug treatment for dyslipidemia. Guidelines recommend using moderate-intensity statins (which can reduce LDL-C by 25%–50% per day) as the standard medication for dyslipidemic populations in China. Patients who are intolerant to statins or whose LDL-C levels fail to meet the target should consider combining them with non-statins lipid-lowering drugs, such as ezetimibe, while closely monitoring the therapeutic response.
   Recommended moderate-intensity statins include: atorvastatin 10–20 mg; rosuvastatin 5–10 mg; fluvastatin 80 mg; lovastatin 40 mg; pitavastatin 2–4 mg; pravastatin 40 mg; simvastatin 20–40 mg; and Xuezhikang 1.2 g.
   Applications of statins:
   (1) Primary prevention of ASCVD: For low- and moderate-risk individuals, lifestyle interventions are implemented first; after 3–6 months, if LDL-C levels still do not meet the target, moderate-intensity statin therapy is initiated. For high-risk individuals, moderate-intensity statin therapy should be started immediately alongside lifestyle interventions.
   (2) Secondary prevention of ASCVD: For patients with clinical ASCVD, it is recommended to immediately adopt moderate-intensity statins to reduce LDL-C to below 1.8 mmol/L; for those whose baseline LDL-C levels are already high and cannot reach the target, LDL-C should be reduced by at least 50%; for extremely high-risk patients whose baseline LDL-C levels are already within the target range, LDL-C should still be reduced by about 30%.
2. Cholesterol Absorption Inhibitors
   Ezetimibe is rapidly absorbed after oral administration, metabolized into ezetimibe glucuronide, and acts on the brush border of small intestinal cells to inhibit the absorption of cholesterol and plant sterols, while promoting the synthesis of hepatic LDL receptors and accelerating the clearance of LDL, thereby lowering serum LDL-C levels. Indications include hypercholesterolemia and mixed hyperlipidemia dominated by elevated cholesterol levels, either as monotherapy or in combination with statins. The usual dosage is 10 mg once daily. Common side effects include gastrointestinal reactions, headache, and muscle pain, and there is a possibility of elevated transaminases. Combining statins with ezetimibe can produce a good synergistic effect. This combination can further reduce serum LDL-C by about 18% on top of statin treatment, without increasing statin-related adverse reactions.
3. Fibrate Drugs
   Fibrates lower serum TG levels and raise HDL-C levels. Indications include hypertriglyceridemia and mixed hyperlipidemia dominated by elevated triglycerides. Main formulations include: fenofibrate 0.1 g, three times daily, or micro-pellet form 0.2 g, once daily; bezafibrate 0.2 g, three times daily, or sustained-release form 0.4 g, once nightly. Common adverse reactions are similar to those of statins.
4. High-Purity Fish Oil Preparations
   High-purity fish oil is mainly composed of n-3 fatty acids, which can lower TG and slightly raise HDL-C, but has no effect on TC or LDL-C. Indications include hypertriglyceridemia.

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Hyperviscosity syndrome and mixed hyperlipidemia primarily characterized by elevated triglycerides. The usual dosage is 0.5 to 1 g, taken orally three times daily. Nausea and abdominal discomfort caused by the fishy odor of fish oil are common adverse reactions. It is contraindicated in patients with a bleeding tendency. 5. PCSK9 inhibitors PCSK9 inhibitors have been a research hotspot in the field of lipid disorders in recent years. Inhibiting PCSK9 can prevent the degradation of LDL receptors and promote the clearance of LDL-C. PCSK9 inhibitors have a potent cholesterol-lowering effect, reducing LDL-C by 50% to 70%. The PCSK9 inhibitor evolocumab monoclonal antibody has been approved in China for the treatment of homozygous familial hypercholesterolemia. (3) Selection of lipid-modifying drugs Drug selection should be based on the subtype of the patient's lipid abnormality, the mechanism of action of the drug in modifying lipids, and other pharmacological characteristics.

1. Hypercholesterolemia Statins are the first choice; if monotherapy with statins fails to achieve the target lipid levels, ezetimibe can be added to enhance lipid-lowering effects, although clinical evidence for combination therapy remains limited.
2. Hypertriglyceridemia Fibrates are the first choice; n-3 fatty acid preparations may also be used. For severe hypertriglyceridemia, fibrates and n-3 fatty acid preparations can be used in combination.
3. Mixed hyperlipidemia If TC and LDL-C elevation are predominant, statins are preferred; if TG elevation is predominant, fibrates are chosen. When serum TG exceeds 65 mmol/L, TG should be lowered first to avoid the risk of acute pancreatitis. If TC, LDL-C, and TG are all significantly elevated or monotherapy is ineffective, combination therapy may be considered. The combined use of statins and fibrates can markedly improve the lipid profile, but the risk of myopathy and hepatotoxicity increases, which should be given high attention, especially with gemfibrozil, which should be avoided when used in combination with statins. Other fibrates, particularly fenofibrate, have a lower risk of myopathy when used with statins, but monitoring is still necessary. Fibrates are best taken in the morning, while statins are best taken at night to minimize peak plasma concentrations. When statins alone cannot control TG, combining them with n-3 fatty acid preparations can further reduce TG levels, with high safety and good tolerability. Section 2: Professor Pei Zhengxue’s Experience in Diagnosing and Treating Hyperlipidemia Although the ancient texts of Traditional Chinese Medicine do not contain the term “hyperlipidemia,” they do include related descriptions, mostly falling under categories such as “grease turbidity,” “blood turbidity,” and “phlegm turbidity.” As early as the “Yellow Emperor’s Inner Canon,” there were records of “grease,” “fat,” and “adipose membrane.” The “Spiritual Pivot” classifies obese individuals into “greasy people,” “fleshy people,” and “fat people,” stating that “greasy people have a protruding abdomen and excess fat, fleshy people have a large upper and lower body, while fat people, despite having fat, do not have much of it.” The “Clinical Guide to Medical Cases” points out that phlegm is closely related to dietary dampness and turbidity, stating that “phlegm is essentially transformed from dietary dampness and turbidity.” The “Essential Principles for Treating Diseases According to the Time” discusses “phlegm” and “drink” separately, believing that phlegm causes disease extensively, and stating that “however, phlegm and drink are different—drink is liquid that accumulates in the chest and abdomen, while phlegm is thick and turbid and can reach everywhere; any injury to the five viscera can lead to phlegm formation.” The “Plain Questions · Discussion on Deficiency and Excess” states: “All treatments for consumption, stroke, hemiplegia, paralysis, qi fullness leading to reverse flow, and obesity among the rich and fat are diseases of grease and fat.” This indicates that overeating fatty and sweet foods can cause stroke, limb hemiplegia, paralysis, and other diseases, which shares similarities with modern medical understanding of hyperlipidemia and its associated risk factors. Causes and pathogenesis Professor Pei Zhengxue believes that hyperlipidemia is related to the accumulation of pathological products such as “dampness,” “phlegm,” and “stasis blood” within the human body. Although Traditional Chinese Medicine does not have the concept of “blood lipids,” its discussions on body fat are similar. Body fat is an important substance for maintaining life activities, one of the components of body fluids and blood, derived from food and grains, and can be converted with other components of body fluids. Its normal metabolism and physiological functions are closely related to the functioning of the spleen, the distribution of the lungs, the drainage function of the liver, and the vaporization function of the kidneys. If the functions of the liver, spleen, and kidneys are disordered, or if one overeats fatty, sweet, and rich foods, body fat cannot be utilized by the body and instead accumulates, causing harm. The taste of fatty and sweet foods is sweet and slow, which slows down the spleen’s movement, preventing the transformation of turbidity into dampness. Dampness then generates phlegm and heat, forming damp-heat and phlegm-heat conditions, or the spleen becomes deficient and unable to function properly, causing the essence of food and grains to accumulate and form phlegm and drink, blocking the meridians and leading to this disease. The kidneys are the foundation of innate constitution, governing water and body fluids. After the age of forty, kidney qi gradually declines, resulting in the inability to transport dampness and the internal generation of phlegm and dampness, which condense into fat. Alternatively, due to deficiency of liver and kidney yin, internal fire arises, turning body fluids into turbid phlegm. Prolonged stagnation of phlegm and turbidity obstructs the flow of qi and blood, leading to lipid abnormalities. Phlegm and turbidity blocking the blood vessels for a long time can turn into stasis blood, infiltrating the meridians and hindering the smooth flow of qi, making chest oppression very likely. A preference for leisure and aversion to labor can impede the flow of qi and blood, weaken the functions of the spleen and stomach, and gradually deplete righteous qi. Worrying, thinking, and anger harm the liver and spleen; when the liver is out of balance and unable to drain properly, qi stagnates, leading to blood stasis or qi rebellion against the spleen, and the spleen’s inability to transform and distribute fat can result in abnormal fat distribution and trigger hyperlipidemia. Therefore, hyperlipidemia is fundamentally a condition of deficiency in the liver, spleen, and kidneys, with qi stagnation, phlegm turbidity, and stasis blood as the main manifestations. II. Syndrome Differentiation and Treatment Professor Pei Zhengxue treats this disease by first tonifying qi, removing dampness, and activating blood circulation, addressing the root cause by strengthening the spleen, soothing the liver, and nourishing the kidneys, while eliminating dampness and turbidity and activating blood circulation to treat the symptoms. The spleen is responsible for transforming and ascending clear substances; when the spleen functions well, the essence of food and grains is properly transformed and distributed. The “Blood Disorder Theory” states: “If the liver’s clear yang does not ascend, it cannot drain food and grains.” The “Medical Compendium” says: “The liver is wood energy, entirely dependent on earth for nourishment and water for irrigation.” With the help of the liver, the spleen can ascend clear substances and descend turbid ones; with the support of the spleen, the liver’s qi is abundant and its drainage is effective. Moreover, since “the kidneys store essence” and “the kidneys are the organ of water and body fluids,” the kidneys play an important role in the production of qi and blood and the metabolism of body fluids, and “spleen yang originates from kidney yang,” so the spleen’s healthy transformation and production of essence require the warmth and nourishment of kidney yang. Lipid regulation often involves nourishing the kidneys as well. By reinforcing the body’s vital organs, improving lipid metabolism, directly eliminating phlegm to reduce fat, and emphasizing drugs that activate blood circulation and remove stasis, we can ensure effective lipid-lowering effects. For those with high lipid levels, combining traditional Chinese medicine with Western lipid-lowering drugs yields better results, but attention must be paid to the side effects of lipid-lowering medications. Professor Pei Zhengxue emphasizes that treating this disease also requires careful diagnosis of the underlying cause and syndrome differentiation-based treatment, along with disease identification. Patients must be guided to control their diet, adopting a light, balanced, and nutritious diet, avoiding fried, grilled, raw, cold, sweet, and greasy foods; maintain regular exercise, gradually lose weight, keep a cheerful mood, get enough sleep, and ensure regular bowel movements. For those with spleen deficiency and dampness, treatment should focus on strengthening the spleen and eliminating dampness, with Banxia Baizhu Tianma Tang as the primary formula; for severe dampness, Pingwei San can be used, possibly with Huoxiang and Peilan; for severe damp-heat, Banxia Xiexin Tang can be used. For those with liver depression and fire transformation, qi stagnation, and phlegm obstruction, treatment should focus on soothing the liver, regulating qi, and resolving phlegm, with Yinshan Heji (Yinchen, Shan Zhi Zi, Sheng Shan Zha, Sang Ji Sheng, Gou Qi Zi, He Shou Wu, Dan Shen) combined with Xiao Chai Hu Tang and Kuding He Ye Tang (Kuding Tea, Dried Lotus Leaves, Gou Teng, Sang Ji Sheng) as the main formulas; for those with qi stagnation and blood stasis, Xuefu Zhuyu Tang can be used together with Ruanmai Ling (Dang Shen, Gou Qi Zi, Shu Di, Dang Gui, Chuan Xiong, Chi Shao, He Shou Wu, Huai Ni Xi, Dan Shen) for treatment. For those with mutual obstruction of phlegm and stasis, treatment should focus on resolving phlegm and activating blood circulation, with Gua Bai Ban Xia Tang combined with Guan Xin Er Hao Fang as the main formula; for severe stasis blood, add Sanqi and Shui Zhi. For those with liver and kidney yin deficiency, treatment should focus on nourishing the liver and kidneys, with Qiju Dihuang Wan as the primary formula; for those with weak kidney qi, use Erxian Tang combined with Yinshan Heji (Sang Ji Sheng, Gou Qi Zi, Zhi He Shou Wu, Dan Shen, Sheng Shan Zha, Yin Chen) as the main formula; for those with weak kidney yang, use Jin Gui Shen Qi Wan. In addition, based on syndrome differentiation and treatment, Professor Pei Zhengxue, according to modern pharmacological research findings, appropriately selects lipid-lowering traditional Chinese medicines such as lotus leaves, fresh Pu Huang, turmeric, Ze Xie, ginseng, Jue Ming Zi, Yu Jin, He Shou Wu, Sheng Shan Zha, Shui Zhi, Kuding Tea, Ge Gen, Dan Shen, etc., which can enhance therapeutic efficacy.
4. Kidney qi deficiency Symptoms: lower back pain and leg weakness, tinnitus and blurred vision, fear of cold and fatigue, obesity, sweating during activity, difficulty urinating, frequent nocturnal urination, pale or dark tongue, thin white coating, and deep, fine pulse. Treatment: tonify the kidneys and consolidate the foundation. Prescription: Erxian Tang combined with Yinshan Heji, adjusted as needed. Yinyang Huo, Xian Mao, Ba Ji, Dang Gui, Huang Qi, Sang Ji Sheng, Gou Qi Zi, Zhi He Shou Wu, Dan Shen, Sheng Shan Zha, Yin Chen, Ze Xie, Lotus Leaves. For those with weak kidney yang and lower limb edema, difficulty urinating, combine with Jisheng Shen Qi Wan to warm the kidneys, transform qi, and promote diuresis and reduce swelling; for those with chest tightness and shortness of breath, hidden pain in the precordial region, combine with Gua Bai Ban Xia Tang and Guan Xin Er Hao Fang to resolve phlegm and activate blood circulation; for those with heavy head and dizziness, combine with Ling Gui Zhu Gan Tang to warm yang and transform drink; for those with lower limb swelling, shortness of breath during activity, and heart failure, combine with Zhen Wu Tang to warm the heart yang, transform qi, and promote diuresis.
5. Spleen deficiency with excessive dampness Symptoms: dizziness, chest tightness, overweight and flabby physique, abdominal distension, poor appetite, fatigue, constipation, or diarrhea. Tongue is swollen, coating is thick and white, pulse is moist. Treatment: tonify qi, strengthen the spleen, eliminate dampness, and resolve phlegm. Prescription: Banxia Baizhu Tianma Tang combined with Pingwei San, adjusted as needed. Half summer, stir-fried white atractylodes, Tianma, Fu Ling, Chen Pi, Zhu Ru, Real, stir-fried Cang Zhu, Hou Pu, Yi Ren, Sheng Shan Zha, Lotus Leaves, Ze Xie . Also add stir-fried malt and leizi to relieve food stagnation; for chest tightness and pain, add melon and white ban to regulate qi and resolve phlegm; for obvious dizziness, add Gui Zhi to warm yang and transform drink; for those with heat, add Huang Lian to clear heat and dry dampness; for those with damp stagnation and severe constipation, combine with Da Cheng Qi Tang to clear the bowels and purge turbidity; for abdominal distension and fatigue, combine with Shen Ling Bai Zhu San to strengthen the spleen, eliminate dampness, and stop diarrhea; for those with spleen yang deficiency and fear of cold, combine with Fu Zi Li Zhong Wan or Yi Huang Tang to warm the middle and stop diarrhea.
6. Liver depression with fire transformation Symptoms: irritability, red face and eyes, headache and dizziness, insomnia and frequent dreams, dry throat, yellow urine and dry stool, red tongue, yellow coating, and tense pulse. Treatment: clear the liver and dissipate fire. Prescription: Yinshan Heji combined with Xiao Chai Hu Tang and Kuding He Ye Tang, adjusted as needed. Chai Hu, Huang Qin, Ban Xia, Dang Shen, Yin Chen, Shan Zhi Zi, Sheng Shan Zha, Sang Ji Sheng, Gou Qi Zi, He Shou Wu, Dan Shen, Kuding Tea, Lotus Leaves, Gou Teng, Gan Cao. For those with excessive liver yang, dizziness and headache, high blood pressure, combine with Jiang Ling Tang to calm the liver and subdue yang; for those with liver and gallbladder damp-heat, flank pain, bitter taste in mouth, and obvious dry stool, combine with Yin Chen Hao Tang to clear heat and remove dampness, or use Da Chai Hu Tang to soothe the liver and stomach, clear the bowels, and release heat; for those with insomnia and frequent dreams, combine with Suan Zao Ren Tang to nourish blood, clear heat, and calm the spirit; for those with excessive liver yang, insufficient kidney yin, dizziness, tinnitus, lower back and knee pain, choose Niu Long Ling Tong Xin Cao Fang (Niu Xi, Di Long, Ling Zhi Cao, Shi Hu, Chou Wu Tong, Xi Xin, Jue Ming Zi, Shi Jue Ming) to tonify liver and kidneys, clear liver heat, and calm liver yang; for those with obvious liver and kidney yin deficiency, dizziness, dry mouth and tongue, slightly high blood pressure, use Qiju Dihuang Wan with adjustments to nourish yin and tonify the liver; for those with liver and kidney yin deficiency, internal fire, lower back and knee pain, five-point fever, night sweats, brain fog, and dry stools, use He Che Da Zao Wan combined with San Cai Feng Sui Dan with adjustments (Sheng Di Huang, Tian Dong, Mai Dong, Dang Shen, Huang Bai, Sha Ren, Du Zhong, Niu Xi, Gui Ban) to nourish yin and clear heat; for those with liver and kidney yin deficiency, high blood lipids, but no obvious clinical symptoms, use 3 grams of Shi Hu, 3 grams of Gou Qi Zi, and 10 grams of Sheng Shan Zha to brew tea, one dose per day.
7. Qi stagnation and blood stasis Symptoms: intermittent chest pain, numbness in limbs, sometimes accompanied by dizziness, dull complexion, or brown spots, purple-dark tongue, or bruising and petechiae, fine and rough pulse. Treatment: resolve stasis, unblock meridians, and lower lipids. Prescription: Xuefu Zhuyu Tang combined with Ruanmai Ling, adjusted as needed. Chai Hu, Chi Shao, Zhi Shi, Tao Ren, Hong Hua, Sheng Di, Dang Gui, Chuan Xiong, Niu Xi, Ju Jing, Gou Qi Zi, Zhi He Shou Wu, Dan Shen. For those with obvious chest pain and stasis blood, add Shui Zhi and Sanqi to activate blood circulation and relieve pain; for those with mainly limb numbness, use Si Wu Fu Chen Yuan (Sheng Di, Bai Shao, Dang Gui, Chuan Xiong, Fu Shen, Chen Pi, Yuan Zhi, Xue Jie, Ze Lan, She Chuang Zi, Tu Si Zi, Hei Da Dou, Sang Zhen Zi, Xi Yan Cao, Wei Ling Xian) to adjust and activate blood circulation; for those with phlegm obstruction, qi stagnation, and blood stasis, frequent chest pain and tightness, use Gua Wei Bai Ban Xia Tang combined with Guan Xin Er Hao Fang to resolve phlegm, regulate qi, and activate blood circulation; if hyperlipidemia triggers pancreatitis, right upper abdominal distension, dizziness, and chest tightness, use the Gallbladder-Pancreas Combination Formula combined with Guan Xin Er Hao Fang, Gua Bai Ban Xia Tang, and Dan Shen Drink to soothe the liver, regulate qi, and activate blood circulation to resolve phlegm.
8. Phlegm and stasis obstructing the meridians Symptoms: yellow tumors around the eyes, chest pain, dizziness and bloating, limb numbness or hemiplegia, darkened tongue or bruising, white or turbid coating, and deep, slippery pulse. Treatment: activate blood circulation to remove stasis, resolve phlegm, and lower lipids. Prescription: Gua Bai Ban Xia Tang combined with Guan Xin Er Hao Fang, adjusted as needed. Half summer, melon, white, Chi Shao, Chuan Xiong, Hong Hua, Jian Xiang, Dan Shen, San Qi, Shui Zhi, Ze Xie, Lotus Leaves, Tian Ma, Jue Ming Zi, Gou Teng. For those with stomach and intestinal damp-heat, stomach bloating and heartburn, high blood pressure, combine with Ban Xia Xiexin Tang to open up and cool down, clear heat, remove dampness, and resolve phlegm and activate blood circulation; for those with cerebral infarction and limb numbness or hemiplegia, add Sang Zhi, Gui Zhi, Ji Xue Teng, Ren Dong Teng, Yi Mu Cao; for those with liver and kidney deficiency, combine with Di Huang Yin Zi, Bai Zhi, Di Long, and Wu Gong Fu Zheng Bei to resolve phlegm and activate blood circulation; for those with mild coronary heart disease, not much chest pain, or whose symptoms have improved significantly after the above treatment, use San Dan Hua Kai Wu Ze Chuan (San Qi, Dan Shen, Hong Hua, Wu Jia Pi, Ze Lan, Chuan Xiong) combined with Wu Shui Bu Hai Han San Qi (Wu Jia Pi, Shui Zhi, Hai Zao, Kun Bu, San Qi) to adjust and treat. III. Clinical Case Examples

Case 1: Luo, male, 42 years old, first visit on July 12, 2016. The patient has a history of hyperlipidemia for more than three years, once triggered acute pancreatitis, intermittently took non-fibrate and atorvastatin, but lipid levels did not reach the target. In the past three months, the patient has experienced chest tightness and dizziness, ECG showed myocardial ischemia, cranial MRI showed no obvious abnormalities, so lipid-lowering and coronary artery blood supply improvement treatment were administered, symptoms slightly alleviated, and the patient came for consultation. Current symptoms: dizziness, chest tightness and hidden pain, intermittent left upper abdominal pain, abdominal distension, bowel movements once a day, pale purple tongue, thick white coating, deep, tense, and slippery pulse. Biochemical tests: LDL-C 5. 9 mmol/L, TC 8. 6 mmol/L, TG 4.2 mmol/L. Western medical diagnosis: hyperlipidemia; coronary heart disease; chronic pancreatitis. TCM syndrome differentiation: spleen deficiency with excessive dampness, phlegm and stasis obstruction. Prescription: Gua Bai Ban Xia Tang combined with Guan Xin Er Hao Fang, Dan Shen Drink, Xiao Chai Hu Tang, and Shen Ling Bai Zhu San with adjustments. Gua Wei 15g, Tan Bai 10g, Ban Xia 10g, Chi Shao 10g, Chuan Xiong 10g, Hong Hua 6g, Jian Xiang 10g, Dan Shen 30g, Mu Xiang 10g, Cao Dou Kou 10g, Dang Shen 10g, Fu Ling 10g, Stir-fried Bai Zhu 10g, Bai Bian Dou 10g, Chen Pi 10g, Lian Zi 10g, Shan Yao 10g, Sha Ren 6g, Yi Zheng Ren 15g, Ju Jing 6g, Chai Hu 10g, Huang Qin 10g, Gan Cao 6g, Sheng Jiang 3 slices, Da Zao 3 pieces. 14 doses, decocted in water, one dose per day. At the same time, take Fenofibrate capsules 0.2g, once a day, taken with breakfast. Second visit: After taking the medication, the patient’s chest pain disappeared, dizziness and chest tightness both improved, but still had intermittent pain in the left upper abdomen, abdominal distension and bowel movements, pale tongue, thin white coating, and deep, tense, fine pulse. The previous prescription was adjusted by removing Dan Shen Drink, Xiao Chai Hu Tang, and Shen Ling Bai Zhu San, and adding the Gallbladder-Pancreas Combination Formula to soothe the liver and regulate qi, strengthen the spleen and stop diarrhea, specifically: Gua Wei 15g, Tan Bai 10g, Ban Xia 10g, Chi Shao 10g, Chuan Xiong 10g, Hong Hua 6g, Jian Xiang 10g, Dan Shen 30g, Chai Hu 10g, Zhi Shi 10g, Bai Shao 10g, Xiang Fu 10g, Chen Pi 6g, Mu Xiang 10g, Huang Qin 10g, Huo Jiao 6g, Gan Jiang 10g, Zhi Ru 6g, Pu Gong Ying 15g, Bai Jiang Cao 15g, He Ye 10g, Sheng Shan Zha 10g, Gan Cao 6g. 14 doses, decocted in water, one dose per day. Continue taking Western medicine. Third visit: After taking the medication, all symptoms greatly eased, continued treatment with adjustments for over two months, and the above symptoms basically disappeared. ECG re-examination was normal, LDL-C, TC, and TG reached the target levels.

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Example 2: Ms. Zhang, female, 58 years old, first visit on July 19, 2019. The patient is obese and was found to have mild fatty liver and hyperlipidemia during a physical examination one year ago, but she did not take it seriously or receive active treatment. Recently, she has experienced dizziness, insomnia, irritability, dry and bitter mouth, constipation, a dark red tongue with little coating, and a wiry, fine pulse on the left side. Biochemical tests show LDL-C 3.8 mmol/L and TC 6.4 mmol/L. Western medical diagnosis: hyperlipidemia. Traditional Chinese medicine syndrome differentiation: Liver-Kidney Yin deficiency with Qi stagnation turning into fire. Prescription: Yinsan mixture combined with Xiaochaihu decoction, Kuding lotus leaf decoction, and Suanzaoren decoction with modifications. Ingredients: Bupleurum 10 g, Scutellaria 10 g, Pinellia 10 g, Codonopsis 10 g, Artemisia capillaris 15 g, Gardenia jasminoides 10 g, Crataegus pinnatifida 15 g, Taxillus chinensis 10 g, Lycium barbarum 10 g, Polygonum multiflorum (processed) 10 g, Salvia miltiorrhiza 10 g, Kuding tea 15 g, Lotus leaf 6 g, Uncaria rhynchophylla 15 g, Stir-fried Ziziphus jujuba seed 15 g, Anemarrhena asphodeloides 10 g, Ligusticum chuanxiong 6 g, Poria cocos 10 g, Albizzia bark 15 g, Mucuna pruriens 15 g, Cannabis sativa seed 30 g, Prunus armeniaca kernel 15 g, Glycyrrhiza 6 g. Total of 14 doses, decocted in water and taken once daily. Patient was advised to maintain a cheerful mood, follow a low-fat diet, and increase physical exercise. Second visit: After taking the above prescription, the patient's symptoms of dry and bitter mouth and constipation disappeared, while her dizziness, insomnia, and irritability improved. The tongue and pulse remained unchanged. The previous formula was adjusted by removing Cannabis sativa seed and Prunus armeniaca kernel, and continued for another 14 doses. Third visit: After taking the medication, the patient's irritability and insomnia significantly improved, but she still felt dizzy. The tongue and pulse were unchanged. The prescription was then changed to Qiju Dihuang decoction combined with Suanzaoren decoction and Yinsan mixture, with modifications to tonify the Liver and Kidneys while clearing residual heat. Specific ingredients: Lycium barbarum 10 g, Chrysanthemum 10 g, Rehmannia glutinosa 12 g, Cornus officinalis 10 g, Dioscorea opposita 10 g, Poria cocos 10 g, Alisma orientalis 10 g, Moutan cortex 10 g, Stir-fried Ziziphus jujuba seed 15 g, Anemarrhena asphodeloides 10 g, Ligusticum chuanxiong 6 g, Poria cocos 10 g, Artemisia capillaris 10 g, Crataegus pinnatifida 15 g, Polygonum multiflorum (processed) 10 g, Salvia miltiorrhiza 10 g, Glycyrrhiza 6 g. Total of 14 doses, decocted in water and taken once daily. After taking the medication, symptoms such as dizziness improved. The patient continued this modified formula for over a month, and all symptoms eventually resolved. Follow-up biochemical tests showed LDL-C 1.9 mmol/L and TC 5.0 mmol/L, with no abnormalities detected on ultrasound. Section 3: Ancient and Modern Theories on Hyperlipidemia The "Spiritual Pivot · Five Fluids Differentiation" states: "The fluids from the five grains combine to form a kind of ointment, which permeates the bone cavities to nourish the brain and marrow, and then flows down to the yin region." The "Plain Questions · Meridian Differentiation" says: "When liquids enter the stomach, they circulate and distill essence, which is transported upward to the spleen. The spleen disperses the essence and sends it upward to the lungs, regulating the water pathways, and then downward to the bladder. The water essence is distributed throughout the body, and the five meridians operate in parallel." Under normal physiological conditions, blood lipids are part of the nutritive blood fluids, representing the refined substances produced from food and water. Through the combined action of the stomach, spleen, heart, lungs, and liver, these substances permeate the blood vessels, distribute throughout the body, nourish the internal organs and bones, warm the skin, and prevent the accumulation of phlegm-turbidity. Therefore, blood lipids remain within the normal range. Zhang Zhicong, in his "Commentary on the Spiritual Pivot," says: "The qi of the middle burner vaporizes the fluids, and the refined essence that overflows outward makes the skin and flesh plump, while the remainder inside leads to obesity." Wang Lun, in his "Miscellaneous Writings on Famous Doctors · Wind Syndrome," states: "It is precisely the fluids circulating throughout the body; these fluids are generated by the spleen, driven by food and water. The turbid ones become phlegm, so phlegm originates from the spleen." This clearly points out that the generation, transport, and distribution of fat are closely related to the spleen. The "Secret Records of the Stone Chamber" records: "Obese people often have phlegm because of qi deficiency. When qi is weak, it cannot move properly, leading to the formation of phlegm." If the spleen and stomach lose their ability to function effectively, phlegm-turbidity and dampness can accumulate inside the body. The "Blood Evidence Theory" says: "The nature of wood is to promote dispersion. When food enters the stomach, it relies entirely on the liver's qi to disperse it, and then the food is transformed." This indicates that "the spleen dispersing essence" is related to the liver's preference for smooth flow and its role in promoting dispersion. If the liver's qi is imbalanced, phlegm-turbidity may not be eliminated, causing blockage in the blood vessels and leading to blood stasis. And blood stasis can also generate phlegm. As stated in the "General Treatise on Various Diseases · Phlegm Symptoms": "All phlegms arise from blocked blood vessels and accumulated water that cannot be dispersed, thus forming phlegm." The "Blood Evidence Theory" also says: "If blood accumulates for a long time, it can also turn into phlegm and water." Thus, phlegm and blood stasis are mutually causal, leading to the retention of fat in the body and resulting in abnormal blood lipid levels. Modern renowned physician Yan Dexin believes that this disease involves all five zang organs, with particular emphasis on the spleen; phlegm and blood stasis should be treated together, with qi regulation as the priority. Contemporary physician Yang Shaoshan considers hyperlipidemia to be a category of qi-blood-fluid disorders, caused by abnormal fluid distribution and metabolism, leading to dampness obstruction and phlegm-blood stasis. The pathogenesis can be divided into two aspects: deficiency and excess. Deficiency refers to spleen weakness and qi deficiency, while excess refers to phlegm-blood stasis and qi stagnation. Therefore, treatment should focus on tonifying qi and strengthening the spleen, eliminating dampness and harmonizing the stomach, while simultaneously resolving phlegm and blood stasis. A self-designed basic lipid-lowering formula includes Codonopsis, Atractylodes, Pinellia, Alisma, Poria, Salvia, Citrus peel, and Buddha's hand. Chen Dingqi commonly uses the following four methods for treatment: tonifying the Liver and Kidneys, used for Liver-Kidney Yin deficiency type, with formulas modified based on Shouwu Yanshou Dan; strengthening the spleen and eliminating dampness, used for spleen-deficiency and damp-heavy type, with formulas modified based on Wuling San combined with Artemisia capillaris decoction; regulating qi and activating blood, used for qi-stagnation and blood-stasis type, with formulas modified based on Taohong Siwu Tang; and tonifying qi and nourishing yin, used for qi-yin dual deficiency type, with formulas modified based on Shengmai San combined with Qiju Dihuang decoction. Section 4: Pathogenesis, Diagnosis, and Treatment of Obesity Obesity refers to excessive fat accumulation and/or abnormal fat distribution, accompanied by weight gain, and is a chronic metabolic disease caused by the interaction of multiple factors, including genetic and environmental factors. Overweight and obesity are prevalent worldwide and have become one of the most serious public health crises. According to WHO statistics, as of 2016, the adult overweight rates (BMI ≥ 25 kg/m²) in major countries were as follows: United States 67.9%, Canada 64.1%, United Kingdom 63.7%, Australia 64.5%, China 32.3%, Japan 27.2%; the obesity rates (BMI ≥ 30 kg/m²) were: United States 36.2%, Canada 27.8%, Australia 29%, China 6.2%, Japan 4.5%. The "China National Nutrition and Chronic Disease Report (2020)" shows that the adult overweight rate in China is 34.3% and the obesity rate is 16.4%. Compared with the survey results from 2010–2012, the overweight rate increased by 14.0% and the obesity rate increased by 37.8%. Obesity, as one of the main components of metabolic syndrome, is closely related to various diseases such as type 2 diabetes, abnormal blood lipids, hypertension, coronary heart disease, stroke, and tumors. Obesity and its related diseases can harm patients' physical and mental health, reduce their quality of life, and shorten their life expectancy. Obesity can also serve as a clinical manifestation of certain diseases, known as secondary obesity, accounting for about 1% of all cases of obesity. Pathogenesis Obesity is a heterogeneous group of diseases with unknown causes, resulting from the interaction of multiple factors, including genetic and environmental factors. Fat accumulation occurs when energy intake exceeds energy expenditure—whether due to overeating, reduced energy consumption, or both—but the exact reasons for this energy imbalance remain unclear. Although the differences between obese individuals and normal-weight individuals are statistically insignificant, prolonged persistence of such imbalances can gradually lead to fat accumulation and the development of obesity. Currently, it is believed that genetic factors—specifically one or more gene mutations or variations—are the foundation of obesity. These genes increase susceptibility to obesity, while environmental factors act as triggering conditions. Some human obesity cases are primarily caused by genetic factors, such as certain classic genetic syndromes.

Environmental factors mainly include diet and physical activity. Eating too much, preferring sweet or greasy foods, fast food, and dining out all increase energy intake. Dietary composition also plays a role; among foods with equal caloric content, fats are more likely to cause fat accumulation than sugars. Insufficient physical activity reduces energy expenditure. Cultural factors influence the occurrence of obesity through dietary habits and lifestyle. In addition, maternal malnutrition or protein deficiency during pregnancy, or low birth weight at birth, can also make individuals more prone to obesity when their dietary structure changes in adulthood. II. Clinical Manifestations Obesity can occur at any age, with women being more commonly affected. Many patients have a history of overeating and/or insufficient exercise. A family history of obesity is also common. Mild obesity often presents without symptoms. Moderate to severe obesity can cause shortness of breath, joint pain, muscle soreness, reduced physical activity, as well as anxiety and depression. Clinically, obesity is often accompanied by abnormal blood lipids, fatty liver, hypertension, coronary heart disease, impaired glucose tolerance, or diabetes—collectively known as metabolic syndrome. Obesity can also be associated with or complicated by obstructive sleep apnea, gallbladder disease, hyperuricemia and gout, osteoarthritis, venous thrombosis, and reproductive dysfunction (such as polycystic ovary syndrome in women). III. Diagnosis and Differential Diagnosis Based on the correlation between measured indicators, risk factors, and mortality rates, and referring to population statistics, there is currently no unified standard domestically or internationally. The "Chinese Adult Overweight and Obesity Prevention and Control Guidelines (2021 Edition)" defines overweight as BMI ≥ 24 kg/m² and < 28 kg/m², and obesity as BMI ≥ 28 kg/m²; abdominal obesity is defined as waist circumference ≥ 90 cm for men and ≥ 85 cm for women. In 2010, the Diabetes Branch of the Chinese Medical Association recommended that the standard definition of obesity in metabolic syndrome be BMI = 25 kg/m². It should be noted that obesity is not simply an increase in body weight; if the weight gain is due to muscle development, it should not be considered obesity. Conversely, some individuals may have normal body weight but exhibit high insulin levels and insulin resistance, making them prone to type 2 diabetes, abnormal blood lipids, and coronary heart disease, so a comprehensive assessment is necessary. When using CT or MRI scans to measure visceral fat area at the level of the fourth and fifth lumbar vertebrae, a visceral fat area ≥ 100 cm² is used as the threshold for determining increased visceral fat. Differential diagnosis: The main distinction is with secondary obesity, such as Cushing's syndrome, primary hypothyroidism, hypothalamic obesity, polycystic ovary syndrome, etc., which have clinical manifestations and laboratory test characteristics specific to the underlying disease. Drug-induced obesity is characterized by a history of taking antipsychotic drugs or glucocorticoids. IV. Treatment The two main components of treatment are reducing calorie intake and increasing calorie expenditure. Emphasis is placed on comprehensive treatment focusing on behavior, diet, and exercise, supplemented by medication or surgery when necessary. Secondary obesity should be treated by addressing the underlying cause. Any complications or comorbidities should be managed accordingly. Setting reasonable weight-loss goals based on the patient's actual condition is extremely important; overly rapid or excessive weight loss that cannot be sustained often leads to loss of confidence. Generally, it is believed that a 5%–10% reduction in body weight for obese patients can significantly improve various cardiovascular risk factors and complications associated with obesity. (1) Behavioral therapy Through publicity and education, patients and their families gain a correct understanding of obesity and its hazards, thereby cooperating with treatment, adopting healthy lifestyles, changing dietary and exercise habits, and consciously maintaining these changes over the long term. This is the most important step in treating obesity. (2) Medical nutrition therapy Control total food intake and adopt a low-calorie, low-fat diet. Only when energy intake falls below physiological needs and reaches a certain degree of negative balance can stored fat be mobilized and consumed. (3) Physical activity and sports Combined with medical nutrition therapy and maintained over the long term, physical activity can prevent obesity or help obese patients lose weight. Education and guidance are essential, and the type and amount of exercise should be tailored to the patient's specific situation, with gradual progression. Patients with cardiovascular complications or poor lung function must be especially cautious. Efforts should be made to create more opportunities for activity, reduce sedentary time, and encourage more walking. (4) Medication therapy According to the "Chinese Adult Overweight and Obesity Prevention and Control Guidelines (Trial)", the indications for weight-loss medications are: ① Excessive appetite, unbearable hunger before meals, and large meal portions; ② Concurrent high blood sugar, hypertension, abnormal blood lipids, and fatty liver; ③ Joint pain caused by obesity; ④ Respiratory difficulties due to obesity or obstructive sleep apnea syndrome; S BMI ≥ 24 kg/m² with the above-mentioned complications, or BMI ≥ 28 kg/m² regardless of complications, who after 3–6 months of strict dietary control and increased physical activity still fail to lose 5% of their weight, or even continue to gain weight, may consider using medication as an adjunct treatment. The following situations are not suitable for weight-loss medications: ① Children; ② Pregnant women and nursing mothers; ③ Individuals with adverse reactions to these drugs; ④ Those currently taking other selective serotonin reuptake inhibitors.

1. Non-central-acting weight-loss drugs Orlistat is a gastrointestinal pancreatic lipase and gastric lipase inhibitor that slows down the hydrolysis of dietary fats in the gastrointestinal tract, reducing fat absorption and promoting negative energy balance, thereby achieving weight loss. In the early stages of treatment, mild gastrointestinal side effects such as bloating, increased bowel movements, and fatty stools may occur. Attention should be paid to whether these affect the absorption of fat-soluble vitamins, as there have been reports of severe liver damage. This drug requires long-term monitoring and clinical evaluation. The recommended dosage is 120 mg, three times a day, taken before meals.
2. Central-acting weight-loss drugs These drugs mainly work by regulating neurotransmitters involved in eating, such as catecholamines and serotonin pathways, through the hypothalamus. They include catecholamine-like preparations, such as phenylbutazone, and serotonin-like preparations, such as fluoxetine. These drugs can cause varying degrees of dry mouth, insomnia, fatigue, constipation, menstrual irregularities, increased heart rate, and elevated blood pressure as side effects. Elderly people and diabetic patients should use them with caution. Hypertension, coronary heart disease, congestive heart failure, arrhythmia, or stroke patients should avoid them.
3. Metformin, a blood-sugar-lowering drug with weight-loss effects It promotes tissue uptake of glucose and increases insulin sensitivity, providing some weight-loss effect, but it has not yet been approved for treating obesity. However, it is effective for patients with diabetes and polycystic ovary syndrome. The dosage is 0.5 g, three times a day. Its main side effects are gastrointestinal reactions, with lactic acidosis being relatively rare. (5) Surgical treatment Options include liposuction, fat excision, and various procedures to reduce food absorption, such as jejunoileal bypass, gastric balloon, mini-gastric surgery, or vertical gastroplasty. Surgery can be effective, with some patients achieving long-term results and preoperative complications improving or being cured to varying degrees. However, surgery may also lead to malabsorption, anemia, and narrowing of the digestive tract, posing certain risks. It is only used for severe obesity where weight loss has failed and there are serious complications that might improve with weight loss. Section 2: Professor Pei Zhengxue’s Experience in Diagnosing and Treating Obesity Obesity falls under the TCM category of “phlegm syndrome.” The “Spiritual Pivot · On the Reversal of Fatness” describes the characteristics of obese individuals: “Broad shoulders and armpits, thin flesh with thick, black skin, lips that look sharp, dark and murky blood, and sluggish, damp qi.” The “Golden Cabinet Summary · Blood Stasis and Debility Chapter” discusses “noble people with weak bones and abundant skin,” revealing that the essence of obesity is having excess body shape and a plump physique, while the muscles and bones are fragile due to infrequent exercise. Pathogenesis Professor Pei Zhengxue believes that obesity is often caused by irregular diet, imbalance between work and rest, emotional distress, aging and physical weakness leading to spleen-stomach dysfunction, kidney yang deficiency, and stagnation of phlegm-dampness. The overall pathogenesis is spleen-kidney deficiency with a predominance of phlegm-dampness. Weak spleen qi results in poor transformation and transportation of food, causing the refined essence of food to be retained as fat and dampness, accumulating inside the body and leading to obesity; kidney yang deficiency leads to weak blood circulation, hindering the evaporation and transformation of bodily fluids, slowing down blood flow, causing dampness to stagnate internally, and ultimately resulting in obesity. The main site of pathology is the spleen and muscles, closely related to spleen deficiency, as well as dysfunction of the heart and lungs and liver's inability to disperse qi. During the course of the disease, pathological transformations often occur: First, the transformation between deficiency and excess—for example, when appetite is excessive, one overeats fatty and sweet foods, and dampness accumulates inside the body, turning into fat; dampness turns into heat, and the heat stagnates in the spleen, damaging the spleen and causing it to lose its ability to transform, even leading to spleen disease and kidney involvement, resulting in both spleen and kidney deficiency, thus transforming from a real syndrome to a virtual one; conversely, if the spleen remains deficient for a long time, transformation becomes difficult, dampness forms inside, or the liver takes advantage of the spleen's weakness, causing qi stagnation and blood stasis, or the spleen gets sick and the kidney's yang declines, leading to internal dampness that spreads to the skin, exacerbating obesity and transforming from a virtual syndrome to a real one or a mixed deficiency-excess syndrome. Second, each

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Pathological products can also transform into one another, mainly manifested as the long-term stagnation of phlegm-dampness within the body, which obstructs the circulation of qi and blood, leading to qi stagnation or blood stasis. Over time, prolonged qi stagnation, phlegm-dampness, and blood stasis often generate heat, resulting in conditions such as depression-heat, phlegm-heat, damp-heat, and blood-stasis heat. Thirdly, obesity, if left untreated for a long time, often gives rise to other diseases. The "Huangdi Neijing" already recognized the association between obesity and conditions like wasting and consumption; extremely obese individuals are prone to comorbidities such as diabetes, headache, dizziness, chest oppression, stroke, gallbladder distension, and arthralgia.

II. Syndrome Differentiation and Treatment Professor Pei Zhengxue believes that, given the characteristic of obesity being primarily deficiency with secondary excess, treatment should follow the principle of tonifying deficiency and draining excess. For tonifying deficiency, the commonly used methods include strengthening the spleen and benefiting qi; since spleen disorders can affect the kidneys, combining qi-tonifying and kidney-nourishing therapies is also recommended. For draining excess, the commonly used methods include eliminating dampness and transforming phlegm, combined with promoting qi flow, facilitating water metabolism, aiding digestion, clearing the bowels, and resolving blood stasis, all aimed at removing excess phlegm-turbidity, water-dampness, phlegm-heat, and blood-fat from the body. Among these, eliminating dampness and transforming phlegm is the most frequently employed method in treating this condition and is applied throughout the entire course of treatment. Alongside medication, increasing physical activity and adjusting dietary habits are key to successful treatment.

1. Spleen Deficiency with Phlegm-Dampness Symptoms: Obese physique, pale complexion, mental fatigue, general weakness, often accompanied by sticky mouth, heaviness and discomfort in the body, slight darkening and swelling of the eyes, full but soft abdomen, white tongue coating, swollen tongue, slippery pulse. Treatment: Strengthen the spleen and benefit qi, transform phlegm and eliminate dampness. Prescription: Xiangsha Liujunzi Tang combined with Linggui Zhugan Tang, Wuling San with modifications. Ingredients: Dangshen, stir-fried Baizhu, Fuling, Banxia, Chenpi, Muxiang, Sharen, Guizhi, Zexie, Zhuling, Helian, Gancao. For food accumulation, add ShanZha and Laizi to aid digestion and resolve accumulation; for severe virtual obesity, add Zi and Cheqianzi to promote water metabolism and reduce fat; for those with sticky mouth, add Huoxiang and Peilan to invigorate the spleen and transform dampness; for abdominal distension and loose stools, add Fuzi Lizhong Tang to warm the middle jiao, strengthen the spleen, transform dampness, and stop diarrhea.
2. Damp-Heat Obstruction Symptoms: Obese and robust build, abdominal distension, thirst and preference for drinking, or sticky mouth, often with halitosis, good appetite but easily hungry, fatigue and heaviness, prone to skin sores, dry stools, red tongue, yellow greasy coating, and wiry rapid pulse. Treatment: Promote water metabolism and clear turbidity, clear stomach heat and drain fire. Prescription: Fangfeng Tongsheng Wan with modifications. Ingredients: Jingjie Sui, Fangfeng, Bohe, Mahuang, Dahuang, Mangxiao, Zhizi, Huashi, Jiegeng, Shigao, Chuanxiong, Danggui, Baishao, Huangqin, Lianqiao, stir-fried Baizhu, Gancao. For those with dry stools and abdominal distension, Da Chengqi Tang can be added to clear the bowels and drain heat; for cases of liver-stomach heat, dry mouth, bitter taste, abdominal distension, aversion to greasy foods, and dry stools, Da Chaihu Tang can be added to soothe the liver and harmonize the stomach, clear heat and remove dampness.
3. Liver-Gallbladder Damp-Heat Symptoms: Obese physique, distending pain in the hypochondrium, abdominal distension, irritability and anger, heartburn, dry stools, insomnia and frequent dreams, red tongue, wiry rapid pulse. Commonly seen in middle-aged women. Treatment: Soothe the liver and benefit the gallbladder, clear heat and remove dampness. Prescription: Gallbladder-Pancreas Combined Formula with modifications. Ingredients: Chaihu, Baishao, Jishi, Dahuang, Huanglian, Huangqin, Danshen, Muxiang, Caodoukou, Pugongying, Baijiangcao, processed frankincense, processed myrrh, Gancao. For those with severe hypochondriac distension and qi stagnation, add Xiangfu, Qingpi, and Chuanxiong to soothe the liver and regulate qi; for those with menstrual irregularities or amenorrhea, add Yimu Cao, Jixueteng, Xiangfu, and Shuizhi to activate blood circulation and regulate menstruation; for those with insomnia and frequent dreams, combine with Suanzaoren Tang to clear heat and calm the spirit.
4. Phlegm-Stasis Obstruction Symptoms: Darkened skin due to obesity, irritability and anger, strong appetite, menstrual irregularities or amenorrhea, dark menstrual blood or blood clots, dark complexion, excessive hair growth, dry stools, purple-dark tongue, or presence of ecchymoses and petechiae, wiry pulse. Treatment: Soothe the liver and regulate qi, activate blood circulation and transform phlegm. Prescription: Taohong Siwu Tang combined with Guizhi Fuling Wan, and Da Wenjing Tang with modifications. Ingredients: Taoren, Honghua, Shengdi, Danggui, Baishao, Chuanxiong, Guizhi, Fuling, Danpi, Wujuyu, Ganjiang, Banxia, Mai Dong, Dangshen, Ajiao, Gancao. For those with irritability and anger, insomnia and frequent dreams, remove Da Wenjing Tang and add Danzhi Yaosan to soothe the liver and clear heat; for those with severe constipation, facial flushing, hot palms and soles, dry mouth and irritability, and prolonged amenorrhea, add Da Chengqi Tang, Xiangfu, Jixueteng, Yimu Cao, and Shuizhi to clear the bowels, drain heat, activate blood circulation, and regulate menstruation.
5. Spleen-Kidney Dual Deficiency Symptoms: Obese physique with a floating, swollen appearance, lower back and knee soreness, preference for warmth and aversion to cold, cold limbs and fatigue, dizziness and shortness of breath, pale and swollen tongue, thin coating, and deep, fine pulse. Treatment: Strengthen the spleen and transform phlegm, warm the kidneys and promote water metabolism. Prescription: Jin Gui Shenqi Wan combined with Linggui Zhugan Tang with modifications. Ingredients: Fuling, Baizhu, processed Fupian, Guizhi, Shudi Huang, Shanjuyu, Shanyao, Zexie, Danpi, Cheqianzi, Niuxi. Modifications: For those with weak lower back and knees, add Bugu Zhi, Du Zhong, Xu Duan, and processed He Shou Wu to tonify the kidneys and strengthen the waist; for those who fear cold and prefer warmth, with cold limbs and fatigue, add Yin Yang Huo, Bajitian, and Xianmao to warm the kidneys and assist yang; for those with dizziness and shortness of breath, combine with Baoyuan Tang to strengthen the spleen, benefit qi, and elevate clarity. III. Clinical Case Studies Case 1: Liu, female, 47 years old, first visit on October 23, 2018. In recent years, the patient’s weight has gradually increased; a month ago, a physical examination revealed severe fatty liver. Currently, her weight has reached 86 kg, with a BMI of 28.6 kg/m². Present symptoms: obese physique, frequent distending pain in the right hypochondrium, stomach pain after overeating, poor sleep, irritability and anger, dry stools, red tongue, thick yellow greasy coating, and a deep, wiry, slippery pulse. Biochemical tests show: TG 7.6 mmol/L, TC 3.6 mmol/L.

Western medical diagnosis: Obesity; severe fatty liver; hyperlipidemia. Traditional Chinese medicine syndrome differentiation: Liver-gallbladder damp-heat syndrome. Treatment principle: Soothe the liver and benefit the gallbladder, clear damp-heat. Prescription: Gallbladder-Pancreas Combined Formula with modifications. Ingredients: Chaihu 10 g, Baishao 10 g, Zhishi 10 g, Dahuang 6 g, Huanglian 6 g, Huangqin 10 g, Danshen 10 g, Muxiang 10 g, Caodoukou 10 g, Pugongying 15 g, Baijiangcao 15 g, processed frankincense 6 g, processed myrrh 6 g, Xiangfu 10 g, Qingpi 10 g, Chuanxiong 6 g, Gancao 6 g. Total of 14 doses, decocted in water and taken once daily. After taking the medication, the distending pain in the right hypochondrium significantly improved. Continued treatment with modifications for more than three months resulted in the near disappearance of all symptoms, with weight dropping to 69 kg. The severe fatty liver had transformed into mild fatty liver. Follow-up biochemical tests showed TG 5.0 mmol/L, TC 1.9 mmol/L. The condition markedly improved, and the patient requested to discontinue medication for observation. She was advised to follow a low-fat diet and increase exercise. Six months later, lipid levels and abdominal ultrasound were rechecked. Case 2: Zhang, male, 27 years old, visited on November 4, 2018. The patient has always loved sweets and high-calorie foods, with little physical exercise. Since middle school, his weight has gradually increased, currently standing at 97 kg, with a BMI of 30.6 kg/m². Present symptoms: fair-skinned and obese, profuse sweating after activity, shortness of breath, mental fatigue, dizziness, severely affecting work efficiency, strong appetite, but feeling bloated after eating, sluggish movement, pale and swollen tongue, slippery pulse. Western medical diagnosis: Obesity. Traditional Chinese medicine syndrome differentiation: Spleen deficiency with phlegm-dampness. Prescription: Xiangsha Liujunzi Tang combined with Linggui Zhugan Tang, Wuling San with modifications. Ingredients: Dangshen 10 g, stir-fried Baizhu 10 g, Fuling 15 g, Banxia 10 g, Chenpi 10 g, Muxiang 6 g (added later), Sharen 6 g, Guizhi 10 g, Zexie 10 g, Zhuling 10 g, Helian 10 g, Huoxiang 10 g, Zi 10 g, Cheqianzi 10 g, Tianma 10 g, Gancao 6 g. Total of 14 doses, decocted in water and taken once daily. The patient was instructed to increase exercise, follow a low-calorie diet, and control portion sizes. Second visit: After taking the medication, the patient reported increased urination and the feeling of fullness after eating had disappeared, but still felt tired and dizzy, with tongue and pulse remaining unchanged. Added 30 g of Sheng Huangqi, 6 g of Shengma, 6 g of Chaihu, and 10 g of Danggui to strengthen the spleen and benefit qi, elevating clarity. Continued taking 14 doses. Third visit: After taking the medication, the patient’s dizziness and fatigue significantly improved, but no further changes were observed. Continued taking the original prescription for another 14 doses resulted in the disappearance of all previous symptoms. However, the patient remained obese and fair-skinned, with profuse sweating after activity and shortness of breath. Subsequently, continued taking the modified prescription for more than six months, combined with dietary adjustments, lifestyle changes, and regular exercise, resulted in a weight reduction to 78 kg, with a BMI of 24.6 kg/m². Section 3: Historical and Contemporary Theories on Obesity "The Spirit Pivot · Abnormality of Defensive Qi": "The Yellow Emperor asked: How can we determine whether someone is obese or thin? Bo Gao replied: People have fat, grease, and flesh. The Yellow Emperor asked: How do we distinguish these? Bo Gao said: If the flesh is firm and the skin is tight, it's fat; if the flesh is not firm and the skin is loose, it's grease; if the flesh and skin are inseparable, it's flesh. The Yellow Emperor asked: What about the body's temperature—hot or cold? Bo Gao said: Grease has soft, coarse texture, making the body feel cold; fine texture makes the body feel hot. Fat has firm texture, fine texture feels hot, coarse texture feels cold. The Yellow Emperor asked: How do we determine obesity or thinness, size or smallness? Bo Gao said: Grease has abundant qi and loose skin, allowing the belly to hang down; flesh allows the body to be large; fat makes the body shrink." "Plain Questions · On Strange Diseases": "There are people with sweet tastes... When the five flavors enter the mouth, they are stored in the stomach, and the spleen distributes their essence and fluids, thus causing a sweet taste. This is the result of rich food, meaning such people must eat many sweet and fatty foods. Obesity causes internal heat, while sweetness causes fullness." Quan Xiaolin believes that the pathological location of obesity lies in the spleen and stomach, with fullness being its core pathogenesis. It is mainly divided into deficiency, excess, or a mixture of both, with three types: fat people, grease people, and flesh people. Obesity, as an early stage of spleen dysfunction, is characterized by a state of "stagnation," where the body is still in a compensatory phase and other symptoms may not be obvious. Obesity can lead to decreased insulin sensitivity and increased insulin resistance, therefore it is not only an early pathological state of the spleen but also a central link in the spleen's function. In treatment, based on whether obesity is deficient or excess, the main therapeutic principle is to tonify qi, dispel stagnation, and eliminate grease, targeting different pathogenic mechanisms with various treatment methods, including eliminating grease and clearing turbidity, promoting qi flow to dispel stagnation, and tonifying qi to strengthen the spleen. At the same time, emphasis is placed on using targeted prescriptions and medications, tailoring them to specific syndromes and symptoms to achieve precise TCM treatment, which has repeatedly proven effective in clinical practice. Wei Beihai divides obesity into deficiency and excess, with primary and secondary aspects. The causes of simple obesity are related to spleen deficiency, phlegm-dampness, depression-heat, qi stagnation, and blood stasis. Clinically, spleen qi deficiency is often considered the root cause, with phlegm-turbidity and grease as the manifestation, accompanied by qi stagnation and blood stasis, mainly affecting the spleen, stomach, liver, and kidneys. Although clinical syndrome differentiation distinguishes primary and secondary aspects, deficiencies and excesses often coexist, coinciding with elevated serum cholesterol and triglyceride levels. For patients with obesity, those with excess symptoms focus on promoting bowel movements, dispersing blood stasis, while also tonifying deficiency and supporting the body, strengthening the spleen and warming the kidneys. Those with deficiency symptoms prioritize tonifying deficiency, supplemented by eliminating pathogenic factors. Commonly used drugs for the former include Dahuang, Bansha Ye, Zexie, winter melon peel, talc, big belly skin, charred betel nut, hawthorn, cassia seeds, ephedra, and asarum; for the latter, commonly used drugs include Huangqi, Dangshen, Baizhu, Fuling, Xianmao, Yin Yang Huo, He Shou Wu, cinnamon, Guizhi, and cooked Fupian. The principle of activating blood circulation and resolving blood stasis can be applied throughout the entire course of treatment, either in combination with strengthening the spleen and warming the kidneys or promoting water metabolism and facilitating bowel movements, with adjustments made as needed. Commonly used drugs include Danshen, Chi Shao, Danggui, Chuanxiong, E Zhu, and Pu Huang. Wang Qi advocates strengthening the spleen and benefiting qi as the primary approach to treating obesity. By strengthening the spleen and benefiting qi, the spleen's transport function is enhanced, allowing phlegm-dampness to be transformed, nutrients from food to be properly distributed, and metabolic disorders to return to normal, thereby achieving the fundamental goal of treating qi-deficient obesity. Clinically, Huangqi is often heavily used to tonify qi, Baizhu and processed Cangzhu are used to strengthen the spleen and dry dampness, while Fuling, Zexie, and Yi Ren are used to strengthen the spleen and promote water metabolism. Phlegm-dampness-related obesity requires "eliminating evil" step by step. For phlegm obstructing the lungs, purple perilla seeds, laizi, and white mustard seeds are often used to descend qi and transform phlegm; for phlegm congealing in the chest, Banxia, white, and melons are often used to warm and transform cold phlegm; for phlegm condensing in the spleen, Baizhu, Fuling, and Cangzhu are often used to strengthen the spleen and eliminate phlegm. Since obesity, during its development, involves qi deficiency caused by impaired spleen transport function, followed by phlegm-dampness due to internal turbidity, ultimately leading to blood stasis, patients presenting with skin pigmentation and pain in certain parts of the body are classified as having blood-stasis-type obesity. Treatment focuses on promoting qi flow, activating blood circulation, resolving blood stasis, and reducing fat, with drugs such as turmeric, raw Pu Huang, hawthorn, cooked Dahuang, Danggui, and Su Mu used to activate blood circulation, reduce fat, and resolve blood stasis. Hyperuricemia and gout are metabolic diseases caused by purine metabolism disorders, clinically mainly manifesting as hyperuricemia and recurrent acute arthritis, gouty tophi, chronic arthritis, joint deformities, chronic interstitial nephritis, and uric acid urinary tract stones. Severe cases may develop renal failure. Hyperuricemia is the pathological basis of gout, while gout is the clinical manifestation of hyperuricemia. Not all cases of hyperuricemia present with clinical manifestations of gout, but gout is always caused by hyperuricemia. Gout often coexists with obesity, hyperlipidemia, diabetes, hypertension, and cardiovascular and cerebrovascular diseases. Gout is divided into two main categories: primary and secondary. Primary gout has a certain familial genetic component, with approximately 20% of patients having a positive family history. Except for about 1% of primary gout cases caused by congenital enzyme defects, the vast majority of cases have unknown causes. Secondary gout refers to cases arising from other diseases, such as kidney disease or blood disorders, or due to the use of certain medications, radiotherapy and chemotherapy for tumors, etc. Section: Pathogenesis, Diagnosis, and Treatment of Gout – Pathogenesis The biochemical marker of gout is hyperuricemia. Normal male serum uric acid levels are 150–380 μmol/L, while pre-menopausal women have levels of 100–300 μmol/L, and post-menopausal women's levels approach those of men. At 37°C, the saturation point of serum uric acid is about 420 μmol/L; exceeding this value constitutes hyperuricemia, though there are differences based on gender and age. When male serum uric acid exceeds 420 μmol/L, theoretically uric acid can crystallize and deposit in tissues, causing histological changes associated with gout, which is a risk factor for gout (including gouty arthritis and gouty nephropathy). However, only a portion of people with hyperuricemia actually develop clinical gout, and the exact mechanism of this transformation remains unclear. Therefore, hyperuricemia and gout are not synonymous. When serum uric acid concentration is too high and/or in an acidic environment, uric acid can crystallize and deposit in joints, kidneys, and subcutaneous tissues, causing histopathological changes that lead to gouty arthritis, gouty nephropathy, and gouty tophi—only then can it be called gout. (---) Formation of Hyperuricemia As the final product of purine metabolism, uric acid is mainly produced through enzymatic breakdown of nucleic acids and other purine compounds in cellular metabolism, as well as purines in food. In the human body, 80% of uric acid comes from endogenous purine metabolism, while only 20% originates from foods rich in purines or nucleic acid proteins. If the rate of uric acid production equals the rate of excretion in a normal person, serum uric acid levels remain stable; otherwise, hyperuricemia may occur. Regarding the causes and classification of hyperuricemia, it can be broadly divided into metabolic causes due to overproduction (10%) and renal causes due to poor excretion (90%). Primary hyperuricemia is often accompanied by obesity, diabetes, atherosclerosis, coronary heart disease, and hypertension, believed to be related to insulin resistance. Among the various risk factors for gout, obesity, diet, and alcohol consumption stand out particularly. In recent years, the increasing intake of meat and fats in the diet, coupled with relatively reduced physical activity, has led to a growing number of obese individuals. Research shows that Body Mass Index (BMI) is an independent risk factor for gout; as BMI increases, the incidence of gout rises. When BMI is between 21 and 23 kg/m², the relative risk of gout is 1.4. When BMI is between 30 and 35 kg/m², the relative risk rises to 3.26. Reducing body weight has a preventive effect against gout. A diet high in purines has always been a risk factor for hyperuricemia and gout. Meat and seafood can raise serum uric acid levels. Previous dietary guidelines recommended low-purine, low-protein diets and limited alcohol consumption. However, recent studies have found that there is no significant correlation between total protein intake and gout, and that protein can actually reduce serum uric acid levels, lowering the risk of gout. The correlation between alcohol consumption and hyperuricemia and gout is clear. Serum uric acid levels are directly proportional to total alcohol intake; for every additional 10 grams of alcohol consumed daily, the risk of gout increases by 17 times. Beer has the strongest correlation with gout; drinking more than two glasses of beer a day (about 200 ml each) increases the relative risk of gout to 2.51. Some studies suggest that only beer is associated with high uric acid levels, even non-alcoholic beer can raise serum uric acid. The reason may be that beer is made from malt, which contains more guanine nucleotides that are easier to absorb. (II) Occurrence of Gout Clinically, only a portion of people with hyperuricemia develop gout, and the exact cause remains unclear. When serum uric acid concentration is too high or in an acidic environment, uric acid can crystallize and deposit in joints,

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Kidney and subcutaneous tissues, leading to histopathological changes and resulting in gouty arthritis. Gouty nephropathy and tophi, among others. Acute arthritis is an inflammatory response caused by the deposition of urate crystals. Since urate crystals can chemotactically attract leukocytes, significant increases in leukocyte numbers and phagocytosis of urate crystals can be observed at sites of urate deposition within joint synovial cavities, followed by the release of chemical chemoattractants such as leukotriene B4; monocytes stimulated by urate crystals can also release interleukin-1. Gouty nephropathy is one of the characteristic pathological changes of gout, manifested as small white needle-like deposits in the renal medulla and pyramids, surrounded by infiltration of leukocytes and macrophages. A minority of patients with primary gout have increased uric acid production, while most cases are caused by impaired uric acid excretion. The diagnosis of primary hyperuricemia and gout must be based on excluding other diseases; secondary cases, on the other hand, are mainly due to reduced uric acid excretion caused by kidney disease, increased uric acid production due to bone marrow proliferative disorders, or inhibition of uric acid excretion by certain medications, among other reasons. II. Clinical Manifestations The initial clinical manifestation of gout patients is recurrent acute arthritis. It primarily occurs in middle-aged and elderly men over 40 years old (95%), but there has been a recent trend toward younger onset, with female patients mostly appearing after menopause. Approximately 10%–15% of patients exhibit symptoms of uric acid nephrolithiasis prior to the onset of arthritis, about 10 years earlier than the onset of arthritis itself. The clinical manifestations of gout are divided into five categories: asymptomatic hyperuricemia; acute arthritis phase; intercritical period of gout; chronic arthritis phase; and renal involvement. (---) Asymptomatic Hyperuricemia Only fluctuating or persistent hyperuricemia is present, with the time from elevated serum uric acid levels to symptom onset potentially lasting several years to decades; some individuals may never develop symptoms throughout their lives. However, the prevalence of gout increases with age and is related to the level and duration of hyperuricemia. Hyperuricemia is not synonymous with gout; only 5%–18.8% of patients with hyperuricemia eventually develop gout. (2) Acute Arthritis Phase This type may occur without any preceding signs. Cold exposure, fatigue, alcohol consumption, high-protein/high-purine diets, trauma, surgery, and infections are all common precipitating factors. Common characteristics include: ① Often sudden onset around midnight or early morning, typically severe pain that progressively worsens, feeling like a knife cut or a bite, with redness, swelling, heat, pain, and functional impairment of the affected joint appearing within hours, with pain peaking within 24–48 hours. The most commonly affected joint is the first metatarsophalangeal joint on one side, followed by the ankle, knee, wrist, metacarpophalangeal joints, interphalangeal joints, and elbow. ② Systemic manifestations include fever, chills, headache, nausea, palpitations, and other discomforts, with physical signs similar to acute local infection—localized heat, redness, swelling, and marked tenderness. ③ Treatment with colchicine usually rapidly alleviates arthritis symptoms. ④ Initial attacks are often self-limiting, resolving on their own within a few days. The skin over the affected joint may exhibit desquamation and pruritus, which are relatively characteristic features of this condition. Hyperuricemia may accompany the attack, but in some patients, serum uric acid levels are normal during acute episodes, with blood tests showing elevated white blood cell counts and accelerated erythrocyte sedimentation rate. Polarized light microscopy of synovial fluid from the joint cavity reveals birefringent needle-shaped urate crystals, which serve as the basis for confirming the diagnosis. Gout attacks can last from several days to several weeks before resolving spontaneously, entering what is known as the intercritical period, with most patients experiencing recurrence within one year. Only a very small number of patients experience no intercritical period after the initial attack, directly progressing to tophi formation and chronic arthritis. (3) Intercritical Period of Gout After an acute gout attack subsides, there are generally no obvious sequelae, sometimes only pigmentation deepening of the skin at the site of the attack, appearing dark red or purplish-red, with desquamation and pruritus, referred to as the asymptomatic intercritical period. Most patients experience a relatively long intercritical period after the initial attack (usually 1–2 years), but the length varies greatly; as the disease progresses, the intercritical period gradually shortens. If preventive measures are not taken, attacks may occur several times a year, with prolonged symptom duration, making complete remission difficult, and affecting more joints. In a few cases, the sacroiliac joint, sternoclavicular joint, or cervical spine may also be involved. Even urate deposits in periarticular bursae, tendons, and tendon sheaths can lead to increasingly atypical symptoms. (4) Chronic Arthritis Phase Repeated deposition of urate crystals causes a chronic foreign-body-like reaction in local tissues, with monocytes, epithelial cells, and macrophages surrounding the deposits, and fibrous tissue proliferation forming nodules, known as gouty nodules. Gouty nodules usually appear about 10 years after disease onset, marking the transition to the chronic phase, and can be seen in intra-articular, periarticular, subcutaneous tissues, and internal organs. Except for the central nervous system, sodium urate can deposit anywhere, with typical locations including the auricle, as well as the first metatarsophalangeal joint, interphalangeal joints, wrist, knee, and elbow. In rare cases, they may also appear in nasal cartilage, tongue, vocal cords, eyes, aorta, heart valves, and myocardium. They range in size from sesame-seed-sized to egg-sized, with even larger gouty nodules. Gouty nodules are characteristic lesions of gout. When tophi form within the joint, they can cause erosion and destruction of articular cartilage and bone, reactive hyperplasia, fibrosis of periarticular tissues, leading to persistent joint pain, swelling, stiffness, deformity, and even fractures, known as tophaceous chronic arthritis. (5) Renal Involvement Pathological examination of the kidneys in gout patients almost always reveals damage, and clinically about one-third of patients exhibit renal symptoms, which can occur at any stage of the disease course.

1. Sodium Urate Nephropathy Sodium urate deposits in renal tissues, causing chronic progressive interstitial nephritis, particularly evident in the medulla and pyramids, potentially leading to tubular atrophy and degeneration, fibrosis, and sclerosis, subsequently affecting the glomerular vascular bed. Approximately 85% of patients begin to show renal lesions after the age of 30. Early symptoms include mild unilateral or bilateral flank pain, with 40%–45% developing mild edema and moderate hypertension. Urine becomes acidic, with intermittent or persistent proteinuria. Almost all patients experience decreased renal concentrating function, nocturnal polyuria, and low urine specific gravity. After 5–10 years, renal disease worsens, with late-stage glomerular dysfunction leading to decreased creatinine clearance and elevated blood urea nitrogen, eventually progressing to uremia, with 17%–25% dying from renal failure.
2. Uric Acid Stones Increased uric acid concentration in urine leads to deposition and formation of urinary tract stones, with an overall incidence of about 20% among gout patients, and these stones may appear even before the onset of gouty arthritis. Smaller stones may be expelled in the urine as sand-like particles, often without any sensation. Larger stones can obstruct the urinary tract, causing renal colic, hematuria, pyelonephritis, hydronephrosis, etc., requiring surgical removal. Due to the lower pH of urine in gout patients, urate is mostly converted to uric acid, which has lower solubility than urate, making it easier to form pure uric acid stones. X-rays often fail to visualize these stones, though a small portion mixed with calcium oxalate or calcium phosphate may show stone shadows.
3. Acute Uric Acid Nephropathy Commonly seen in secondary hyperuricemia, due to markedly elevated serum uric acid levels, uric acid crystals rapidly deposit in the renal collecting ducts, renal pelvis, calyces, and ureters. Often secondary to chemotherapy or radiotherapy for bone marrow proliferative disorders, where rapid cell division and proliferation, coupled with abrupt nucleic acid breakdown, result in massive uric acid production. Sometimes serum uric acid levels can reach as high as 2400–3600 μmol/L, with uric acid crystals depositing in the renal tubules and severely obstructing the urinary tract. Clinical manifestations include oliguria, anuria, and rapidly developing azotemia, with large amounts of uric acid crystals and red blood cells visible in the urine. Without timely treatment, renal failure can lead to death. Effective treatments such as alkalinizing the urine, administering large volumes of fluids, and using diuretics can often quickly restore renal function. Primary gout-related acute obstructive nephropathy is relatively rare. III. Diagnosis Men and postmenopausal women with serum uric acid > 420 μmol/L, and premenopausal women > 350 μmol/L, can be diagnosed with hyperuricemia. Middle-aged and elderly men presenting with characteristic arthritic manifestations, urinary tract stones, or renal colic attacks, accompanied by hyperuricemia, should be considered for gout. Recurrent monoarticular redness, swelling, and severe pain, asymptomatic intercritical periods with hyperuricemia, or those who respond remarkably well to colchicine treatment can all serve as references for diagnosing gout, but the most specific diagnostic method is detecting needle-shaped urate crystals phagocytosed by neutrophils in joint aspiration fluid during an acute attack. 10%–15% of patients exhibit renal stone symptoms before the onset of arthritis. The clinical presentation of this disease is diverse, and sometimes clinical manifestations can be atypical.
4. Acute Gouty Arthritis Acute gouty arthritis is the main clinical manifestation of gout and often serves as the initial symptom. Accurate diagnosis of the acute phase of gout is crucial, and currently the 1997 classification standards of the American College of Rheumatology (ACR) are widely used for diagnosis. At the same time, it should be differentiated from rheumatic fever, erysipelas, cellulitis, suppurative arthritis, traumatic arthritis, pseudogout, and other conditions. 1977 American College of Rheumatology (ACR) classification criteria for acute gouty arthritis: ① Specific urate crystals found in joint fluid. ② Chemical methods or polarized light microscopy confirm the presence of urate crystals in gouty nodules. ③ Meeting 6 out of the following 12 items (clinical, laboratory tests, X-ray findings). Acute arthritis attacks > 1 time; inflammatory response peaks within one day; monoarticular arthritis attack; visible joint redness; pain or swelling in the first metatarsophalangeal joint; unilateral involvement of the first metatarsophalangeal joint; unilateral involvement of a single joint; suspected gouty nodule; hyperuricemia; asymmetric intra-articular swelling (confirmed by X-ray); subcortical cysts without bone erosion (confirmed by X-ray); negative microbial culture in joint fluid during arthritis attack.
5. Intercritical Period of Gout This period represents a state of remission between recurrent acute attacks, usually with no discomfort or only mild joint symptoms. Therefore, diagnosis during this period must rely on the patient’s past history of acute gouty arthritis attacks and hyperuricemia.
6. Chronic Phase of Gout The chronic phase of gout results from prolonged disease progression over many years, with persistently high serum uric acid levels that remain unsatisfactorily controlled. The clinical characteristics of this phase include tophus formation or persistent unrelieved joint symptoms. By combining X-ray or nodule biopsy to detect urate crystals, diagnosis is not difficult. This phase should be differentiated from rheumatoid arthritis, psoriatic arthritis, bone tumors, and other conditions.
7. Renal Involvement Patients with urate nephropathy initially present with increased nocturnal urination, followed by decreased urine specific gravity, hematuria, proteinuria, and even renal insufficiency. At this point, it should be differentiated from secondary gout caused by kidney disease. Uric acid urinary tract stones, on the other hand, primarily manifest as renal colic and hematuria, with X-rays often failing to reveal them, while intravenous pyelography or ultrasound examinations may detect them. For patients with widespread tumor metastasis or those undergoing radiotherapy and chemotherapy who suddenly develop acute renal failure, the possibility of acute uric acid nephropathy should be considered, as characterized by a sharp and rapid increase in serum uric acid levels in the early stages. IV. Treatment of Hyperuricemia and Gout The goals of preventing and treating primary hyperuricemia and gout are: controlling hyperuricemia and preventing urate deposition; promptly terminating acute arthritis attacks; and preventing uric acid stone formation and renal damage. (---) General Treatment Control total dietary calories; limit alcohol consumption and intake of high-purine foods (such as heart, liver, and kidney); drink more than 2000 ml of water daily to increase uric acid excretion; use caution when taking drugs that inhibit uric acid excretion, such as thiazide diuretics; avoid triggering factors and actively treat related diseases, etc. Special attention should be paid to closely monitoring serum uric acid levels during radiotherapy or chemotherapy. (2) Treatment of Asymptomatic Hyperuricemia
8. Uric Acid Excretion Drugs Inhibit proximal renal tubule reabsorption of urate, thereby increasing uric acid excretion and lowering uric acid levels, suitable for patients with good renal function; ineffective when endogenous creatinine clearance < 30 ml/min; contraindicated if urate stones have already formed, or if daily uric acid excretion exceeds 3.57 mol/L (600 mg/dl); during medication, drink plenty of water and take 3–6 g of sodium bicarbonate per day; dosage should start low and gradually increase. Commonly used drugs: ① Benzbromarone: 25–100 mg/day, with mild adverse reactions that do not affect liver or kidney function; occasional gastrointestinal reactions, allergic dermatitis, and fever are rare. ② Probenecid: initial dose of 0.25 g, twice daily; dosage can be gradually increased after two weeks, with a maximum dose of 2 g/day. About 5% of users may experience rash, fever, gastrointestinal irritation, and other adverse reactions.
9. Uric Acid Production Inhibition Drugs Allopurinol inhibits xanthine oxidase, reducing uric acid production, suitable for patients with excessive uric acid production or those who cannot use uric acid excretion drugs. Take 100 mg each time, 2–4 times daily, with a maximum dose of 600 mg/day. Once serum uric acid drops below 360 μmol/L, dosage can be reduced to the minimum or switched to sustained-release allopurinol tablets at 250 mg/day, which works better when combined with uric acid excretion drugs. Adverse reactions include gastrointestinal irritation, rash, fever, liver damage, bone suppression, etc.; dosage should be halved for patients with renal insufficiency.
10. Alkaline Medications Sodium bicarbonate can alkalinize the urine, making it less likely for uric acid to accumulate and form crystals. Adults take 3–6 g/day; long-term high-dose use can lead to metabolic alkalosis and edema due to excessive sodium load. (3) Treatment of Gouty Arthritis
11. Treatment of Acute Gouty Arthritis All three types of drugs listed below should be used early and in sufficient doses, with gradual tapering off once effective. During the acute attack phase, uric acid-lowering treatment is not performed, but patients already taking such medications do not need to stop, to avoid fluctuations in serum uric acid levels that could prolong the attack or cause recurrence. (1) Nonsteroidal Anti-inflammatory Drugs (NSAIDs): All NSAIDs are effective in relieving acute gout symptoms and serve as first-line drugs for acute gouty arthritis. Commonly used drugs: ① Indomethacin, 50 mg each time, 3–4 times daily; ② Diclofenac, 50 mg each time, 2–3 times daily; ③ Etoricoxib, 120 mg once daily. Common adverse reactions include gastrointestinal ulcers and bleeding, as well as cardiovascular toxicity. Contraindicated for active peptic ulcers, and use with caution in patients with renal insufficiency. (2) Colchicine: Traditionally used to treat acute attacks, but due to its toxicity, it is now rarely used. Generally, the initial dose is 1 mg, followed by 0.5 mg every 1–2 hours, with a total dose not exceeding 6 mg in 24 hours. Colchicine has many adverse reactions, mainly severe gastrointestinal reactions such as nausea, vomiting, diarrhea, abdominal pain, etc., and can also cause bone marrow suppression, liver cell damage, allergies, neurotoxicity, etc.; dosage should be reduced for patients with renal insufficiency. (3) Glucocorticoids: Have obvious therapeutic effects for acute gout, usually used for patients who cannot tolerate NSAIDs or colchicine, or those with renal insufficiency. Small to medium doses of glucocorticoids can be administered orally, intramuscularly, or intravenously. For example, oral prednisone at 20–30 mg/day may lead to “rebound” symptoms after discontinuation.
12. Management during the Interictal and Chronic Phases The goal of treatment is to maintain normal serum uric acid levels, aiming for serum uric acid < 360 μmol/L, to reduce or eliminate deposited monosodium urate crystals in the body. Indications for using uric acid-lowering drugs include: Recurrent acute gout attacks involving multiple joints, appearance of tophi, chronic tophaceous arthritis, imaging changes in affected joints, and concurrent uric acid nephrolithiasis, among others. Currently, the main uric acid-lowering drugs used clinically fall into two categories: drugs that inhibit uric acid production and drugs that promote uric acid excretion. Both should be started at low doses two weeks after the acute attack subsides, gradually increasing the dosage according to the target serum uric acid level, adjusting to the minimum effective dose, and maintaining it long-term or even lifelong. Only when a single drug is ineffective, serum uric acid rises significantly, or numerous tophi form, can both types of uric acid-lowering drugs be used in combination. When starting uric acid-lowering drugs, NSAIDs can be taken for 2–4 weeks to prevent recurrence of acute arthritis. Section 2: Professor Pei Zhengxue’s Experience in Diagnosing and Treating Gout Gout is a crystal-induced arthritis caused by the deposition of monosodium urate crystals, resulting from increased purine metabolism in the human body, excessive uric acid production, or impaired uric acid excretion, leading to rising uric acid levels that gradually accumulate. Urate crystals deposit in joint synovium, bursae, cartilage, and other tissues, causing an inflammatory disease. Severe cases can lead to fibrosis of surrounding tissues, joint destruction, and even deformity, while recurrent attacks can cause renal damage. Modern research shows that gout is closely related to metabolic syndrome, coronary heart disease, hypertension, dyslipidemia, and stroke. Western medicine often treats this disease with nonsteroidal anti-inflammatory drugs and glucocorticoids, but due to long treatment durations, significant adverse reactions, and numerous contraindications, clinical practice faces many inconveniences. Traditional Chinese Medicine, however, integrates disease patterns with syndrome differentiation and individualized treatment. Herbal compound formulas can act through multiple pathways and mechanisms simultaneously, with fewer adverse reactions and safer usage, thus offering significant advantages in treating gouty arthritis. I. Etiology and Pathogenesis Gout has been discussed in ancient Chinese medical texts since early times. The “Danxi Xinfa · Gout” states that gout is “the White Tiger’s Wind Syndrome,” with symptoms described as “pain traveling through all four limbs and hundred joints” and “pain like a tiger bite.”

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. The Ming Dynasty scholar Zhang Jingyue, in his "Complete Works of Jingyue · Foot Qi," argued: "Externally, it is yin-cold and water-dampness, which allows damp evil to invade the skin, muscles, and meridians; internally, it arises from excessive consumption of rich and sweet foods over time, leading to dampness in the lower jiao; cold and damp evil combine and stagnate, transforming into heat, which then accumulates in the skin... ... ... The affected areas become red, swollen, and hot; if left untreated for a long time, bone erosion occurs." In the Qing Dynasty, Lin Peiqin's "Classified Diagnosis and Treatment" records: "Gout is one manifestation of pain-induced paralysis... Initially, wind, cold, and dampness obstruct the yin aspect, but over time, this transforms into heat, causing pain that worsens at night." Traditional Chinese Medicine considers gout to fall under the category of "bi syndrome," with the primary cause being an indulgence in rich, greasy, and heavy foods, resulting in internal accumulation of damp-heat, combined with external invasion of wind-cold, which attacks the meridians and obstructs the flow of qi, blood, and body fluids, thereby causing damp-heat to condense into phlegm and stasis, blocking the channels and leading to joint redness, swelling, burning pain. Some patients also have congenital deficiency or are elderly and frail, with imbalanced organ functions, leading to internal generation of damp-heat, prolonged accumulation turning into heat, and the aggregation of phlegm and stasis, resulting in wind-damp-stasis and obstruction of the meridians. The disease often involves the liver, spleen, and kidneys.

1. Congenital deficiency, dietary indiscretion, and advanced age are the underlying factors for onset. The kidney is the foundation of innate constitution, the source of primordial yin and yang. If one’s innate constitution is deficient, yin-yang imbalance occurs, and primordial essence is insufficient, preventing the transformation of essence into qi, leading to internal retention of turbid dampness, which accumulates and causes harm, spreading to joints, muscles, tendons, bones, and meridians, ultimately resulting in gout. Regular overconsumption of strong alcohol, rich foods, and greasy, spicy items damages the spleen and stomach, impairing their ability to transform and transport substances, and over time, spleen damage extends to the kidneys, further compromising the kidneys’ functions of qi transformation and clearing turbid substances. As the saying goes, “People who indulge in rich foods often eat fried, roasted, grilled, and alcoholic dishes that heat the internal organs, so they are most prone to gout and severe sores.” Gout is more common in middle age and beyond, so it is closely related to declining organ function, especially the spleen and kidneys. When kidney essence is depleted, the kidneys lack the power to transform and clear turbid substances; when spleen qi is insufficient, the spleen generates dampness, which in turn produces heat, causing damp-turbid toxins to descend and cause illness, leading to gout.
2. External exposure to wind, cold, dampness, and heat is a common causative factor. Prolonged residence in damp environments, severe frostbite, sleeping outdoors in the wind, being drenched by rain, or sweating and then entering water—these conditions allow cold-damp evil to take advantage of weakened defenses and invade the meridians and joints, combining with internal phlegm-damp-stasis to block the flow of qi and blood, resulting in intense pain. If one’s innate yang energy is abundant and there is also internal damp-heat coupled with wind-cold-damp evil, the condition may transform from yang to heat; or if wind-cold-damp bi persists for a long time without healing, it can also accumulate and transform into heat. Prolonged residence in hot, humid environments exposes one to wind-damp-heat, which attacks the muscles, blocks the meridians, impedes the flow of qi and blood, and stagnates in the joints and tendons, all of which can trigger gout.
3. Damp-heat, phlegm-turbidity, and blood stasis mutually reinforcing each other are key to disease progression. Congenital deficiency, advancing age with declining organ function, or dietary indiscretion—such as excessive drinking and indulgence in rich, sweet, and fatty foods—can lead to impaired spleen function and kidney dysfunction, preventing the elimination of phlegm-dampness, allowing turbid dampness to accumulate internally and form toxic substances, which then combine with blood to create turbid stasis, stagnating in the meridians. Prolonged dampness can also transform into heat, resulting in mutual reinforcement of damp-heat and toxic stasis, leading to joint swelling and pain, joint deformities, and even ulceration with oozing fat. Long-term kidney damage can develop into gout-related nephropathy, clinically manifesting initially as urinary stones, low back pain, and hematuria, and eventually progressing to obstruction of the three burners, leading to critical conditions such as uremia.
4. The disease primarily affects the kidneys, closely related to the liver, spleen, and other organs. The kidneys reside in the lower jiao and are responsible for water metabolism; the kidney’s vaporization function can lift clear qi and sink turbid substances. Therefore, excessive consumption of rich foods leads to persistent damp-heat, and the root cause is not only inadequate spleen function but also the kidneys’ impaired ability to clear turbid substances. According to the "Plain Questions · Generation of the Five Zang Organs," "Excessive consumption of sweets leads to bone pain and hair loss." Wang Bing’s commentary explains, "The kidneys are connected to the bones and nourish the hair. Sweets benefit the spleen more than the kidneys; since the kidneys cannot handle them, bone pain and hair loss occur." If one consumes too many rich foods, it damages the spleen and generates dampness, and the earth element overwhelms the water element, causing spleen dampness to invade the kidneys, making the kidneys’ qi transformation difficult or the kidneys themselves unable to perform the function of lifting clear qi and sinking turbid substances, leading to stagnant damp-heat, which accumulates and transforms into heat, spreading through the tendons and bones and invading the joints, blocking the flow of qi and blood, thus causing joint pain. If gout persists for a long time without healing, the prolonged damp-heat burns body fluids, damaging the liver and kidney essence and blood, leading to malnutrition of the tendons and bones and potentially causing joint disuse. II. Syndrome Differentiation and Treatment Professor Pei Zhengxue believes that during the acute phase of this disease, excess patterns predominate, while in the chronic phase, both deficiency and excess patterns are present. During the acute phase, treatment focuses on addressing the symptoms: dispelling wind, clearing heat, resolving dampness, promoting blood circulation, and eliminating phlegm are commonly used methods; in the chronic phase, treatment addresses both the symptoms and the root cause, focusing on warming and tonifying the spleen and kidneys or nourishing the liver and kidneys while simultaneously eliminating pathogenic factors. Febuxostat tablets are currently among the drugs with good uric acid-lowering effects and few side effects; for patients in the acute phase, based on syndrome differentiation and treatment, taking this medication can enhance therapeutic efficacy. The main clinical manifestations during the acute phase include sudden onset at midnight or early morning. The most common site of onset is the first metatarsophalangeal joint on one side, followed by other joints such as the toes, ankles, knees, fingers, and elbows. The primary symptoms are local redness and swelling of the joint, increased skin temperature, obvious tenderness upon palpation, and limited range of motion; in severe cases, it may manifest as limping or inability to stand. Most cases are triggered by external pathogenic factors, with damp-heat toxins descending to affect the tendons and joints. Tongue diagnosis shows a red tongue body with yellow, greasy coating, and pulse diagnosis reveals a slippery, rapid pulse. Professor Pei Zhengxue believes that the pathogenesis during this phase mainly involves wind, dampness, heat, and toxin obstructing the meridians, possibly accompanied by phlegm and blood stasis. Depending on the degree and predominance of pathogenic factors in each patient, the primary prescription is either "Gout Formula No. 1" (Atractylodes, Phellodendron, Angelica pubescens, Adzuki beans, Silkworm excrement, Loofah fiber, Stephania tetrandra, Polygonum cuspidatum, Salvia miltiorrhiza, Smilax glabra) or "Gui Zhi Shaoyao Zhimu Decoction," with adjustments made according to individual symptoms. For those with predominant blood stasis and toxicity, the main symptoms are localized joint swelling and sharp pain, dark purple skin color, hard texture upon palpation, often accompanied by joint deformity and difficulty in flexion and extension. Tongue diagnosis shows a dark purple tongue or bruising, thin yellow coating, and pulse diagnosis reveals a deep, taut or fine, rough pulse; in such cases, use "Taohong Siwu Decoction" or add peach kernel, safflower, Salvia miltiorrhiza, angelica, chuanxiong, and chicken blood vine to the formula. For those with predominant heat and toxicity, the main symptoms are sudden joint redness, swelling, and burning pain, with resistance to pressure and a burning sensation upon palpation; often accompanied by irritability, thirst, yellow urine, and fever. Tongue diagnosis shows a red tongue with yellow, greasy coating, and pulse diagnosis reveals a slippery, rapid pulse; in such cases, use "White Tiger Decoction." For those with predominant dampness, the main symptoms are localized or diffuse joint swelling, non-red skin color, local numbness, soreness, and hardness upon palpation, often accompanied by facial and limb edema, dizziness, and chest and flank distension. Tongue diagnosis shows a dark tongue body with white, greasy coating, and pulse diagnosis reveals a slow or taut, slippery pulse; the primary prescription adds Stephania tetrandra, Alisma orientalis, Plantago major, Polyporus umbellatus, Shengyi Zhengren, and white bean to the formula. The chronic remission phase is the stable period of gouty arthritis, characterized by fluctuating or persistent hyperuricemia. If external pathogenic factors invade, gout symptoms can suddenly flare up acutely. Professor Pei Zhengxue believes that the key to treating this phase is preventing recurrence. The pathogenesis is often due to latent pathogenic factors, so treatment should focus on addressing the root cause when symptoms are mild. Prolonged retention of damp-heat toxins turns them into latent pathogens; and when these latent pathogens are triggered by external factors, gout symptoms recur or the original condition worsens. The main cause in this phase is liver and kidney deficiency, so the treatment principle should be "tonify the liver and kidneys, strengthen the spleen to drain dampness and eliminate toxins, and fortify the tendons and bones." Symptoms include recurrent joint pain, severe nighttime pain, difficulty walking, stiffness of the meridians, numbness upon palpation, joint pain like being struck with a stick, possibly accompanied by joint deformity and difficulty in flexion and extension. Tongue diagnosis shows a red tongue with little coating, and pulse diagnosis reveals a taut, thin or fine pulse. The prescription is "Shenshan Bashi Decoction" (Stretching Grass, Turtle Shell, Tortoise Shell, Magnetite, Angelica sinensis, Processed Frankincense, Processed Myrrh, Atractylodes, Phellodendron, Achyranthes bidentata, Ren, Wang Bu Liu Xing, Stephania tetrandra, Fangfeng, Weilingxian, Silkworm Cocoon, Whole Scorpion, Centipede). For patients with long-term spleen and kidney deficiency, joint pain recurs frequently, lower back and knee soreness, cold limbs, frequent and clear nocturnal urination, shortness of breath, fatigue, cold extremities, poor appetite and abdominal distension, loose stools, a plump tongue with faint tooth marks along the edges, and a deep, thin pulse. The prescription is "Baoyuan Decoction combined with Shaoyao Gancao San Teng Decoction" (Peony, Licorice, Green Wind Vine, Sea Wind Vine, Chicken Blood Vine, Papaya, Shengyi Zhengren, Chuan Ni Xi, Weilingxian, Gui Zhi, Peach Kernel, Safflower, Rehmannia, Angelica, Chuanxiong). For patients with long-term involvement of the meridians, joint pain recurs frequently, sometimes mild, sometimes severe, or the pain becomes fixed, or there are localized hard nodules, or gout stones appear; the prescription is "Gout Formula No. 2" (Qianghuo, Fangfeng, Zhimu, Honeysuckle Vine, Peach Kernel, Zelan, Bamboo Charcoal, Blood Resin) combined with "Phlegm-Dissolving Decoction" and "Meridian-Activating Elixir Decoction." Professor Pei Zhengxue believes that treating gouty arthritis should emphasize addressing the root causes to prevent recurrence. According to "Spring Returns to All Diseases," "All cases of gout, where the limbs ache, involve fire in the pain and dampness in the swelling. Therefore, people who indulge in rich foods often eat fried, roasted, grilled, and alcoholic dishes that heat the internal organs, so they are most prone to gout and severe sores." Thus, daily diet should be carefully regulated, emotions should be balanced, and exposure to external pathogenic factors and excessive fatigue should be avoided. In terms of diet, one should eat less or avoid high-purine foods such as seafood, animal offal, shiitake mushrooms, mung bean sprouts, soybean sprouts, sunflower seeds, cashews, peanuts, soybeans, etc.; reduce intake of rich, sweet, and greasy foods, drink more water, and limit or avoid alcohol. During the treatment of gout patients, the principles of preventing recurrence and preventing relapse are particularly important. The principle of preventing recurrence mainly focuses on preventing the formation of gout stones, protecting the kidneys, and preventing bone destruction and joint deformities caused by long-term uric acid crystal deposition. Treatment for such patients should focus on clearing damp-heat and unblocking the waterways, keeping uric acid levels within a relatively healthy range; for potential complications such as coronary heart disease, hypertension, and diabetes, preventive measures should be taken before the disease develops. The principle of preventing relapse is the most important aspect of disease treatment, mainly reflected in treating the root cause. Filling the kidney essence and strengthening the tendons and bones should be the main strategies for preventing relapse. Throughout the entire process of diagnosing and treating gouty arthritis, uric acid level is one of the most important biochemical indicators. Controlling and lowering uric acid is the top priority throughout the entire process of preventing the disease, preventing recurrence, and preventing relapse. During syndrome differentiation and treatment, one must always pay attention to uric acid levels, and at any stage of disease development, apply traditional Chinese medicines that can lower blood uric acid and promote uric acid excretion. Professor Pei Zhengxue commonly uses Tufuling and Ge in uric acid-lowering treatments, and often uses Plantago major, Alisma orientalis, Fuling peel, Shengyi Zhengren, Da Fu Pi, and Houttuynia cordata in uric acid-excreting treatments; and appropriately combines them with heat-clearing and detoxifying herbs such as Viola philippica and honeysuckle.
5. Acute Phase (1) Damp-Heat Obstruction Symptoms: Sudden onset, often waking up at night in pain, affected joints red, swollen, and painful, accompanied by fever. Younger patients often experience migratory arthritis. Tongue coating is yellow and greasy, pulse is taut and slippery. Treatment: Clear heat and drain dampness, unblock the meridians and relieve pain. Prescription: Gout Formula No. 1 (Compound Er Miao San) with modifications. Atractylodes, Phellodendron, Angelica pubescens, Adzuki beans, Silkworm excrement, Loofah fiber, Stephania tetrandra, Polygonum cuspidatum, Salvia miltiorrhiza, Tufuling, Gui Zhi, Peony, Zhimu, processed Chuan Cao Wu (decocted for 1 hour), Xixin (decocted for 1 hour), Ma Qianzi (fried), Achyranthes bidentata, Huigu Ren. For those with high fever and discomfort, add raw gypsum and Zhimu to clear heat and dissipate fire; for those whose joint swelling does not subside, add Green Wind Vine, Sea Wind Vine, and Loshitou Vine to dispel wind and dampness, reduce swelling and relieve pain; if damp-heat is internal and triggered by external factors, use "Danggui Niantong Tang" with modifications to dispel wind and remove pathogenic factors, clear heat and resolve dampness. (2) Cold-Damp Obstruction Symptoms: Joint pain and swelling, difficulty in flexion and extension, or localized subcutaneous nodules or gout stones. Joints prefer warmth, limbs feel numb, urine is clear and copious, stools are loose. Tongue is pale red or slightly plump, coating is thin and white, pulse is tight or deep. Treatment: Dispel wind and cold, remove dampness and unblock the meridians. Prescription: Gui Zhi Shaoyao Zhimu Decoction combined with Shaoyao Gancao San Teng Decoction with modifications. Gui Zhi, Peony, Zhimu, Ephedra, Ginger, White Atractylodes, Fangfeng, Licorice, processed Chuan Cao Wu ( decocted for 1 hour), Xixin (decocted for 1 hour), Ma Qianzi (fried), Green Wind Vine, Sea Wind Vine, Chicken Blood Vine, Papaya, Shengyi Zhengren, Chuan Ni Xi, Weilingxian, Peach Kernel, Safflower, Rehmannia, Angelica, Chuanxiong. For those with predominant cold evil, add processed Aconite and dried ginger to warm yang and dispel cold; for those with subcutaneous nodules or gout stones, add processed Turtle Shell, Earthworm, and Bai Jingzi to transform phlegm and unblock the meridians. For those with spleen deficiency and excessive dampness, limb swelling and constipation, add Codonopsis pilosula, Astragalus membranaceus, Atractylodes, and Huigu Ren to strengthen the spleen and transform dampness.
6. Chronic Phase (1) Spleen-Kidney Yang Deficiency, Cold-Damp Invading the Meridians Symptoms: Recurrent joint pain, lower back and knee soreness, cold limbs, frequent and clear nocturnal urination, shortness of breath, fatigue, cold extremities, poor appetite and abdominal distension, loose stools, a plump tongue with faint tooth marks along the edges, and a deep, thin pulse. Treatment: Strengthen the spleen and warm the kidneys, dispel cold and transform dampness. Prescription: Shaoyao Gancao San Teng Decoction combined with Baoyuan Decoction with modifications. Peony, Licorice, Green Wind Vine, Sea Wind Vine, Chicken Blood Vine, Papaya, Huigu Ren, Chuan Ni Xi, Weilingxian, Gui Zhi, Peach Kernel, Safflower, Rehmannia, Angelica, Chuanxiong, Codonopsis pilosula, Astragalus membranaceus, processed Aconite, Snake, Scorpion, Centipede, all of which are added to address the specific needs of the patient. For those with lower back and knee soreness, add Du Zhong and Bu Gu Zhi to tonify the kidneys and strengthen the lower back; for those with severe limb pain, remove processed Aconite and add processed Chuan Cao Wu, Liao Xixin, fried Ma Qianzi to dispel wind and dampness, and alleviate cold and pain. (2) Persistent Damp-Heat, Liver-Kidney Yin Deficiency Symptoms: Recurrent joint pain, long-term persistence without healing, sometimes mild, sometimes severe. Joint deformity, nodules visible, difficulty in flexion and extension. Accompanied by lower back and knee soreness, bitter taste and dry mouth, reddish or sandy urine, flushed face or forehead. Tongue is red or dry red, coating is thin and slightly moist, pulse is taut or fine. Treatment: Clear heat and transform dampness, tonify the liver and kidneys. Prescription: Shenshi Decoction with modifications. Stretching Grass, Turtle Shell, Tortoise Shell, Magnetite, Angelica sinensis, Processed Frankincense, Atractylodes, Phellodendron, Achyranthes bidentata, Shengyi Zhengren, Wang Bu Liu Xing, Stephania tetrandra, Fangfeng, Weilingxian, Silkworm Cocoon, Whole Scorpion, Centipede. For those with heavier damp-heat, add Polygonum cuspidatum, Silkworm Excrement, Papaya, and Slippery Stone to clear heat and drain dampness; for those with obvious liver-kidney yin deficiency, combine with "Great Yin Supplement Pill" to nourish the liver and kidneys. (3) Phlegm-Stasis Blockage Symptoms: Recurrent joint pain, sometimes mild, sometimes severe. Or the pain becomes fixed, or there are localized hard nodules, or gout stones appear, or joint deformities occur, difficulty in flexion and extension, or the joint has a dark red skin color locally. Tongue is dark red or plump, with bruises and spots along the edges, coating is white or yellow, pulse is deep and slippery or taut and rough. Treatment: Transform phlegm and dissolve stasis, activate blood circulation and unblock the meridians. Prescription: Gout Formula No. 2 combined with Taohong Siwu Decoction, plus Phlegm-Dissolving Decoction with modifications. Qianghuo, Fangfeng, Zhimu, Honeysuckle Vine, Peach Kernel, Zelan, Bamboo Charcoal, Blood Resin, Safflower, Rehmannia, Angelica, Chuanxiong, White Peony, Banxia, Chenpi, Fuling, Dan Nanxing, Real, Licorice. For those with significant blood stasis and joint pain, add "Active Meridian Elixir" to activate blood circulation, dissolve stasis, and relieve pain. IV. Clinical Case Studies Case 1: Mr. Wang, male, 56 years old. First visit on December 10, 2014. The patient reported intermittent swelling and pain in the first toe joint of his right foot for over a month. Western medicine diagnosed him with gout, but treatment did not bring significant relief, so he came for consultation. Current symptoms: heaviness and soreness in both lower limbs, pain in multiple toe joints of the right foot, severe pain, swelling and deformation, relief with coolness, aggravation with heat, thirst, yellow urine, dry stools, red tongue with yellow coating, floating and rapid pulse. Western medical diagnosis: Gouty arthritis. Traditional Chinese medicine syndrome differentiation: Damp-Heat Obstruction. Treatment principle: Clear heat and drain dampness, dispel wind and unblock the meridians. Prescription: Gout Formula No. 1 with modifications. Atractylodes 10g, Phellodendron 6g, Angelica pubescens 10g, Adzuki beans 10g, Silkworm excrement 10g, Loofah fiber 10g,

Stephania tetrandra 10g, Polygonum cuspidatum 10g, Salvia miltiorrhiza 10g, Tufuling 12g, Gui Zhi 10g, Peony 15g, Zhimu 10g, Chuan Cao Wu each 15g (decocted for 1 hour), Xixin 20g (decocted for 1 hour), Ma Qianzi 1 piece (fried). 7 doses, decocted in water, one dose per day. At the same time, take Febuxostat tablets 20mg once daily. It is recommended to check blood uric acid before and after taking the medication. One week later, the patient returned for a follow-up visit and reported significant pain relief. Laboratory results showed that blood uric acid decreased from 725 umol/L before medication to 372 mol/L after medication, indicating effective treatment. Continued treatment for another 20 doses resulted in complete resolution of swelling and disappearance of pain, and no recurrence was observed during the subsequent 3-month follow-up. Case 2: Mr. Liu, male, 46 years old, first visit on June 10, 2018. The patient discovered high uric acid levels during a physical examination one year ago but did not pay much attention to it and had no dietary restrictions. One week ago, after drinking beer and getting chilled, he woke up at night with pain in the left ankle joint, accompanied by local redness and swelling, and went to a Grade III hospital for treatment. Biochemical tests showed a blood uric acid level of 869 mol/L, diagnosed as acute gouty arthritis, received appropriate treatment, improved, but did not fully recover, so he came for consultation. Current symptoms: Pain and swelling in the left ankle joint, increased local skin temperature, pain is more pronounced at night, slight limitation in movement, pale tongue with thin white coating, taut pulse. Western medical diagnosis: Acute gouty arthritis. Traditional Chinese medicine syndrome differentiation: Cold-Damp Accumulation and Heat. Treatment principle: Warm the meridians to dispel cold, remove dampness and unblock the meridians, while also clearing accumulated heat. Prescription: Gui Zhi Shaoyao Zhimu Decoction with modifications.

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Input: Gui Zhi 10g, Shaoyao 10g, Zhimu 10g, Fresh Ginger 3 slices, Ma Huang 10g, Bai Zhu 10g, Fang Feng 10g, Gan Cao 6g, Prepared Chuan Cao Wu each 15g (decocted first for 1 hour), Liaoning Xixin 15g (decocted first for 1 hour) , Ma Qian Zi 1 piece (deep-fried), Sang Zhi 15g, Xi Yan Cao 15g, Wei Ling Xian 15g. 14 doses, Decocted in water and taken orally, one dose per day. Second consultation: After taking the medicine, the patient's left ankle joint swelling and pain improved, and movement is no longer restricted; since the effect remains, the original formula will continue for another 14 doses. Third consultation: After taking the medicine, the patient's pain has significantly reduced, with aversion to wind and cold. Biochemical examination shows serum uric acid at 573 mmol/L, tongue is pale, and pulse is fine. The pathogenic factors are gradually eliminated, but the righteous qi has not yet recovered, so the prescription is changed to Shaoyao Gan Cao San Teng Fang combined with Baoyuan Tang with modifications. The specific composition is as follows: Shaoyao 15g, Gan Cao 6g, Qing Feng Teng 15g, Hai Feng Teng 15g, Ji Xue Teng 15g, Mu Gua 15g, Sheng Yi Ren 15g, Chuan Niu Xi 10g, Wei Ling Xian 10g, Gui Zhi 10g, Tao Ren 10g, Hong Hua 6g, Sheng Di 12g, Dang Gui 10g, Chuan Xiong 6g, Dang Shen 10g, Huang Qi 15g, Zhi Fu Zi 6g, Wu She 10g, Quan Xie 3g, Wu Gong 1 piece. 14 doses, decocted in water and taken orally, one dose per day. After taking this formula for more than two months, a follow-up examination showed serum uric acid at 381 pmol/L, and the condition was completely cured. Follow-up for half a year showed no recurrence. Section 3: Ancient and Modern Theories on Gout Zhu Danxi proposed the term "gout" and comprehensively discussed its etiology, pathogenesis, clinical features, treatment methods, and differential diagnosis, thereby establishing gout as an independent disease entity. In "Danxi Shou Jing," he also made a differential diagnosis: "Lijie Feng Tong walks without fixed location; gout has a fixed location and worsens at night; He Xi Feng has large knees, sometimes with paralysis or pain, sometimes without, making it difficult to move the joints or causing numbness; Yin Bi comes and goes like Lijie Feng; Bai Hu Fei Shi Pain is superficial and relieved by pressing; Fu Gu Ju Pain is deep and unrelieved by pressing." He pointed out the differences between gout, Lijie, He Xi Feng, and Bai Hu Feng. Zhu Danxi also used the term "gout" to summarize the previously mentioned Lijie and Bai Hu Lijie Feng. For example, in "Danxi Xin Fa," he said: "Gout refers to pain that moves through all the joints of the limbs, which others call Bai Hu Lijie Feng syndrome." "Whole-body joint pain, quiet during the day and severe at night, like being bitten by a tiger—this is called Bai Hu Lijie Feng." Since Zhu Danxi proposed the concept of gout, later medical practitioners have largely endorsed it, leading to a significant increase in discussions about gout. Most people now accept the term and use it widely. Later generations generally followed Danxi's explanation and specifically established "gout" as a topic for discussion. However, due to differences in individual expertise, regional environments, and patient populations, medical scholars throughout history have had varying understandings of gout, resulting in diverse interpretations. Some believe gout is simply a type of bi syndrome, such as in "Tui Qiu Shi Yi": "Gout is essentially the combination of wind, cold, and dampness described in the 'Huangdi Neijing,' which together cause bi..." And in "Xue Zheng Lun": "Gout is characterized by numbness in the body and pain in the limbs; today we call it gout, but in ancient times it was known as bi syndrome." Most scholars consider Danxi's description of gout to be equivalent to pain-related bi, also referred to as Bai Hu Lijie Feng, as stated in "Yi Xue Zheng Zhuan": "The so-called pain-related bi in ancient times is precisely what we now call gout, and some texts even refer to it as Bai Hu Lijie Feng." This view has had a wide influence on later generations. For example, in "Yi Xue Liu Yao," it says: "Gout is essentially the pain-related bi described in the 'Neijing'... ...and is also known as Bai Hu Lijie Feng." In Japan, Tanba Genken's "Zabing Guang Yao" states: "Tang people sometimes called it Bai Hu disease, while Song people referred to it as Bai Hu Lijie Feng and also as gout, and after the Yuan dynasty, the term was exclusively used for this condition." However, others believe gout is different from bi syndrome, as in "Shi Fang Miao Yong," which argues that bi and gout are similar but distinct: "Bi is stagnation; wind, cold, and dampness combine to form bi. It's similar to gout, but wind affects the yang, whereas bi affects the yin." Historical treatments for gout. During the Song and Yuan dynasties and earlier, "Ming Yi Bie Lu" recommended using Du Huo to treat "gout affecting all joints, regardless of whether it's new or old." "Ge Zhi Yu Lun" suggested treating gout with "pungent and warming herbs to disperse cold and dampness, promote circulation, allow blood to flow freely, harmonize with qi, and thus naturally alleviate the illness. However, there were also several other methods with slightly different approaches," listing three case studies: one involved deficiency syndrome, requiring tonifying blood and warming blood, treated with modified Si Wu Tang; another involved phlegm and qi syndrome, requiring harmonizing blood, dispersing qi, and eliminating phlegm, treated with modified Qian Xing San; and the third involved blood stasis entering the meridians, treated with Si Wu Tang plus blood-activating herbs, Qian Xing San, and dozens of doses of alcohol; additionally, acupuncture at Weizhong point was used to draw out nearly three liang of dark blood, bringing relief. "Danxi Xin Fa" provided differentiated treatment for gout: for those with wind, dampness, phlegm, or blood deficiency, it prescribed Xiaoxu Ming Tang, Cang Bai Zhu, Er Chen Tang with modifications, and Xiong Gui Tang, among others. The main formulas included Cang Zhu, Chuan Xiong, Bai Zhi, Nan Xing, Dang Gui, and Jiu Huang Qin. Later medical practitioners largely followed Danxi's approach to differential diagnosis and treatment. "Zheng Zhi Yao Jue" recommended treating gout with "Wu Yao Shun Qi San and Jian Fu Yuan Tong Qi San, Yandi Xian Dan or Qing Long Wan; if ineffective, use Da Fang Feng Tang or Wu Ji San mixed with frankincense powder." "Yi Xue Zheng Zhuan" continued Danxi's approach to treating gout and added treatment contraindications: "It's best to be cautious with diet and sexual restraint, otherwise discomfort may arise... ...no meat should be eaten, as meat is yang and can greatly fuel fire"; "Wei Ling Xian is suitable for upper-body gout, but should not be used by those who are weak"; it listed "formulas for treating upper, middle, and lower gout" and "formulas for highly effective treatment of gout," recommending Qian Xing San for "blood-deficiency and yin-fire gout" and "Jiu Teng Wine for long-term gout." "Jie Wei Yuan Shu" advocated treating gout with "Da Ding Wan, Yi Tong Sheng San, Yang Qi Sheng Ling Dan, Shen Niang Wan, and other medicines." "Yi Xue Ru Men" followed Danxi's approach to treating gout, stating: "...for those with phlegm, fire, and wind-dampness, the ancient Long Hu Dan is the primary remedy." Treatment was differentiated based on deficiency vs. excess, cold vs. heat, upper vs. lower, internal vs. external, surface vs. interior, phlegm vs. blood stasis, etc. "Ben Cao Gang Mu" noted: "For hand and foot gout with pain like being bitten by a tiger, use camphor wood shavings and rushing water to fumigate." "Ji Jiu Guang Sheng Ji" agreed with this. "Yi Fang Kao" listed five gout prescriptions, such as "Danxi's general formula for upper, middle, and lower gout" and "Gan Tong Tang for those with blood stasis and damp-phlegm accumulation in the joints causing pain." "Wan Bing Hui Chun" stated: "Treatment involves activating blood, dispersing wind, eliminating phlegm, and removing dampness, with Qiang Huo Tang adjusted accordingly; whenever treating gout, use Cang Zhu, Qiang Huo, and Jiu Qin—these three herbs are excellent for dispelling wind and dampness." "Dian Zheng Lu" used Xiao Kuai Zhi Tong Dan to treat gout caused by phlegm-stagnation. "Zheng Zhi Hui Bu" provided differentiated treatment for this disease, using modified Si Wu Tang to address deficiency, excess, upper vs. lower, phlegm vs. blood stasis, etc., and explicitly outlined dietary restrictions. "Za Bing Yuan Liu Xi Zhu" followed Danxi's practice of using Wu Ji San with modifications to treat gout, adjusting according to different conditions. "Yi Ji" emphasized: "Although the disease is called gout, avoid overusing wind-drying drugs; instead, focus on nourishing the righteous qi and suppressing wind." "Shi Fang Miao Yong" suggested treating this disease "based on pulse diagnosis and prescribing medicine accordingly"; "newly infected cases should use Wu Ji San... ...long-standing gout requires major tonification of qi and blood... ...should use Shi Quan Da Bu Tang with modifications." "Lei Zheng Zhi Cai" provided differentiated treatment for gout: "If it's cold, use Wen San and Tianma Tang; if it's hot, use Xi Jiao San with adjustments," conducting treatment based on cold vs. heat and deficiency vs. excess. Modern renowned physician Zhu Liangchun believes that the main pathogenesis of this disease is turbid toxin, which does not come from outside but originates internally. Patients often have congenital deficiencies, or their organ qi declines with age, or they do not practice dietary moderation, indulging in alcohol and rich, greasy foods, leading to dysfunction of the internal organs, loss of the ability to ascend clear and descend turbid, inability to eliminate phlegm and dampness, which then combine with blood to form turbid stasis, accumulating in the meridians, causing joint swelling, deformity, and even ulceration, with fat oozing out. If turbid stasis accumulates for a long time and turns into toxin, it damages the spleen and kidneys, initially causing lower back pain and hematuria, and eventually leading to blockage of the triple burner, resulting in critical conditions such as renal failure due to gouty nephritis. All these problems are caused by internal obstruction of turbid stasis, not by wind evil, nor by external cold and dampness. Therefore, it should be named "turbid stasis bi." Treatment focuses on eliminating turbid stasis and nourishing the spleen and kidneys; during the acute phase, eliminating turbid stasis can help excrete uric acid and reduce swelling and pain; during the chronic and intermittent phases, combining this with nourishing the spleen and kidneys can restore and stimulate overall bodily functions, effectively inhibiting uric acid production. When selecting medicines, emphasis should be placed on Tu Fu Ling and Ge, and insect-based medicines should be used wisely. Commonly used medicines include: Tu Fu Ling, Ge, Yi Zheng Ren, Wei Ling Xian, Ze Lan, Ze Xie, Qin Rao, Chi Shao, Tao Ren, Can Sha, Zhi Jiang Can, Di Long, etc. During acute attacks, Tu Fu Ling and Ge should be heavily used to clear heat, remove dampness, and eliminate turbid stasis; if joints are red, swollen, and painful, add Sheng Di Huang, Han Shui Shi, Zhi Mu, Shui Niu Jiao, Cao, Hu Zhang, etc., to clear heat and unblock the meridians; if limbs are swollen and sensitive to cold, add Zhi Chuan Wu, Zhi Cao Wu, Gui Zhi, Xi Xin, Yin Yang Huo, Lu Jiao Shuang, etc., to warm the meridians and dispel cold; for severe pain, add Quan Xie, Yu Gong, Yan Hu Suo, Wu Ling Zhi to dissolve stasis and relieve pain; for severe swelling, add Jiang Can, Shan Ci Gu, Che Qian Zi, Bai Jie Zi, Dan Nan Xing, etc., to eliminate phlegm and reduce swelling; for stiff joints, add Pao Chuan Shan Jia, Lang Chong, Lu Feng Fang, etc., to soften hard masses and dissolve stasis. During the chronic or intermittent phases, add Sheng Bai Zhu, Fu Ling, Cang Zhu, Yi Zheng Ren, He Shou Wu, Nu Zhen Zi to nourish the spleen and kidneys. Contemporary renowned physician Xiao Lin believes that patients' early overconsumption of rich foods leads to stagnation of fats and oils, forming zhongman, which then evolves into food stagnation, phlegm stagnation, damp stagnation, qi stagnation, and heat stagnation—these are the foundations for zhongman turning into internal heat. Initially, zhongman is mostly a real syndrome; as it progresses, it transforms into internal heat, disrupting the body's metabolism and causing uric acid to accumulate as turbid matter. Therefore, zhongman and internal heat combined with turbid stagnation constitute the basic pathogenesis. Clinically, treatment is divided into stages: during the hyperuricemia stage, when there is liver-gastric heat stagnation, the treatment is to clear the stagnation and cool the stomach, using Da Chai Hu Tang; for gastrointestinal heat stagnation, the treatment is to purge the heat stagnation, using Da Huang Huang Lian Xie Xin Tang; for gastrointestinal damp-heat stagnation, the treatment is to clear heat and drain dampness, using Ge Gen Qin Lian Tang; for phlegm-heat internal stagnation, the treatment is to clear heat and eliminate phlegm, using Xiao Xian Xiong Tang. During the acute phase of gout, the treatment should focus on dispelling wind-cold, removing damp-heat, activating blood circulation, unblocking the meridians, and relieving pain, mainly using formulas for upper, middle, and lower gout combined with Fang Ji Huang Qi Tang, with Huang Bai 30g, Cang Zhu 15–30g, Han Fang Ji 15–30g, and for those with edema, more Sheng Huang Qi is used, with a minimum dosage of 30g (often supplemented with small doses of Chen Pi, Sha Ren, etc., to regulate qi and prevent stagnation); Wei Ling Xian 15–30g, Qin Pi 30g, Gui Zhi 15–30g, Ji Xue Teng 30g, Wu Tou can be used up to 60g, but to avoid toxic side effects, Wu Tou is paired with roasted licorice or fresh ginger to reduce toxicity, and when Wu Tou exceeds 15g, it must be decocted for 2 hours, and when it exceeds 30g, it must be decocted for 8 hours, ensuring the patient tastes no numbness before mixing the decoction with other herbs. Clinically, for those with severe pain, add Dang Gui Nian Tong Tang to clear heat, disperse wind, activate blood circulation, and relieve pain; for those with convulsions and spasms, add Shaoyao Gan Cao Tang to calm the spasms; for those with arterial plaque formation, add Jiu Da Huang and leech powder to emulate the effect of Di Dang Tang, or use O Shu Huo to activate blood circulation and dissolve stasis; if joints become red, swollen, and painful, add Gui Zhi Shaoyao Zhi Mu Tang; for those with damp-heat intermingling, use Liu Yi San to separate damp and heat, and for severe cases, use San Shi Tang. During the chronic phase of gout, for those with qi and blood deficiency, the treatment should focus on tonifying qi and blood, warming the meridians and unblocking bi, using Huang Qi Gui Zhi Wu Wu Tang plus Dang Gui Tonifying Blood Soup, and for those with severe blood stasis blocking the meridians, use vine-based medicines to unblock them; for those with heat symptoms, use Luo Shi Teng paired with Ren Dong Teng, 30g each, to cool the blood and unblock the meridians; for those with blood deficiency, use Ji Xue Teng 30g paired with Ye Jiao Teng 30g to nourish blood and unblock the meridians, and in severe cases, use Tian Xian Teng 15–30g, but must be paired with Ji Xue Teng 30g or Sheng Gan Cao 15–30g to neutralize kidney toxicity; for those with wind-cold-damp evil transforming into heat, the treatment should focus on nourishing yin and clearing heat, using Gua Wei Mu Li San with modifications, where Gua Wei Ren 30g, and raw oysters 30–120g; if gout stones appear, the treatment should focus on clearing heat, draining dampness, and removing stones, using Si Jin Tang, where Jin Qian Cao 30g, Hai Jin Sha 30g, Yu Jin 15g, and Ji Nei Jin 15–30g; for those with water retention causing swelling, the treatment should focus on tonifying qi and promoting diuresis, using Fang Ji Huang Qi Tang, with heavy use of Fu Ling 30–60g, and for severe swelling, up to 240g, along with Yi Mu Cao, Ze Lan, Ze Xie 30g; for those with muscle and tendon issues needing nourishment, and joints with limited flexion and extension, the treatment should focus on nourishing yin and blood, alleviating stiffness, using Shaoyao Gan Cao Tang, where Bai Shao 30–45g, paired with roasted licorice 15g. Metabolic Syndrome Section: Pathogenesis and Diagnosis & Treatment of Metabolic Syndrome Metabolic Syndrome (MS) refers to a pathological state in which the body's proteins, fats, carbohydrates, and other substances undergo metabolic disorders, constituting a complex syndrome of metabolic disturbances. The central link in MS is obesity and insulin resistance, with obesity being the main component, especially central obesity. MS patients have risk factors for diabetes (DM) and cardiovascular diseases (CVD), with the incidence of cardiovascular events and mortality risk being 2–3 times higher than non-MS individuals. Among non-diabetic MS patients, the risk of developing type 2 diabetes is about five times higher than that of non-MS non-diabetic individuals. With rising living standards and changes in lifestyle, the prevalence of MS in China has also increased significantly, making it urgent to focus on disease prevention, early diagnosis, and intervention, reducing the multiple metabolic disorders that increase the risk of cardiovascular diseases, and effectively improving public health. Pathogenesis The fundamental causes and pathogenesis of MS have not yet been fully elucidated. The occurrence of MS is the result of complex interactions between genetic and environmental factors. First, obesity is both an independent disease within metabolic syndrome and an independent or important risk factor that can lead to other related diseases; it is the core factor of metabolic syndrome and closely related to the development of insulin resistance. Second, high blood sugar is the central link and underlying cause of its onset. Third, lipid abnormalities causing lipid metabolism disorders are one of the risk factors for cardiovascular diseases in MS patients, easily leading to atherosclerosis and serving as an important risk factor for coronary heart disease. Fourth, obese individuals have increased cardiac output, with more blood being pumped through the vessels every minute, raising blood pressure; insulin resistance increases insulin levels, stimulating the sympathetic nervous system, causing vasoconstriction, increasing peripheral vascular resistance, and further elevating blood pressure. Fifth, endothelial cell dysfunction: under conditions of insulin resistance, elevated blood sugar, small dense low-density lipoproteins (SLDL), and increased cytokines from adipocytes can damage endothelial cell function, reducing NO release, weakening vasodilation, and diminishing vascular protective effects, leading to microalbuminuria and increased von Willebrand factor (VWF). Sixth, abnormal blood coagulation: increased fibrinogen, VWF, and plasminogen activator inhibitor-1 (PAI-1), coupled with reduced antiplatelet aggregation, collectively lead to a hypercoagulable state. Seventh, chronic, low-grade inflammation: obesity and associated metabolic pathologies are accompanied by chronic, low-grade inflammatory responses, characterized by the production of abnormal cytokines, increased acute-phase reactants, and activation of inflammatory signaling pathways, which not only contribute to insulin resistance but also directly participate in the entire process of atherosclerosis. Although each disease in MS may have multiple pathways of occurrence, the development and progression of each risk factor are closely related, mutually influencing each other and potentially sharing a common pathophysiological basis. Insulin resistance may not be the only mechanism behind the clustering of MS diseases. Currently, it has been found that not all people with MS necessarily have insulin resistance, and not all people with insulin resistance necessarily have MS, suggesting that this phenomenon of multiple metabolic risk factors clustering in an individual may have a more complex or diversified pathophysiological basis. II. Clinical Manifestations The clinical manifestations of MS refer to the clinical presentations of the various diseases it encompasses and their complications and comorbidities, which may occur simultaneously or sequentially in the same patient, such as obesity, lipid abnormalities, diabetes, hypertension, coronary heart disease, and stroke. III. Diagnostic Criteria According to the "Chinese Guidelines for the Prevention and Treatment of Adult Lipid Abnormalities (2016 Edition)," based on research evidence from the Chinese population, the diagnostic criteria for MS are met if three or more of the following conditions are present: ① Abdominal obesity: waist circumference > 90 cm for men and > 85 cm for women; ② Fasting TG ≥ 1.7 mmol/L (150 mg/dL); fasting HDL-C < 1.0 mmol/L (40 mg/dL); ④ Blood pressure ≥ 130/85 mmHg and/or already diagnosed with hypertension and receiving treatment; fasting blood glucose ≥ 6.

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1 mmol/L (110 mg/dL) or 2 hours after glucose loading
Glucose ≥ 7.8 mmol/L (140 mg/dL) or a history of diabetes
Individuals meeting any three or more of the above criteria can be diagnosed with MS.

IV. Principles of Prevention and Treatment

1. Early Prevention and Treatment
   Regular screening of high-risk populations, early diagnosis, and early treatment to reduce triggering factors and lower the incidence of all MS-related conditions. Promote education on healthy lifestyle patterns, including balanced diet and appropriate physical activity to reduce insulin resistance. Control relevant risk factors as early as possible, such as weight management, treatment of hyperglycemia, hypertension, dyslipidemia, hyperuricemia, and hypercoagulability, to achieve comprehensive target attainment, reduce vascular complications, lower disability and mortality rates, improve patients' quality of life, and alleviate medical (economic) burden.

2. Comprehensive Intervention Combined with Individualized Treatment
   Based on the characteristics of MS, implement multi-factor, multi-method, multi-level, multi-cause, and multi-target interventions. Conduct a comprehensive assessment according to the specific condition, stage of disease progression, MS subgroup classification, and number of comorbidities, then select an appropriate treatment plan. Lifestyle modification is the primary and most fundamental therapeutic measure and must be maintained throughout the entire treatment process.
   ① Dietary adjustments should be tailored to individual needs, balancing intake with expenditure. Limit total caloric intake through dietary control and healthy eating habits, appropriately manage energy intake, ensuring daily protein intake is <15%–25%, fat intake is <20%–30%, and carbohydrate intake is 55%–65%. Distribute daily food intake as evenly as possible, ensure adequate intake of vitamins, minerals, and dietary fiber, limit salt and ethanol consumption, and avoid oily and fried cooking methods.
   ② Exercise should be consistent; the amount of exercise should be determined based on one's own health condition. During exercise, heart rate = (220 - age) × (60%–70%). It is generally recommended to start exercising 1.5–2 hours after meals, for 45–60 minutes, 5–6 times per week.
   Obesity is often the earliest manifestation; patients should strive to lose weight. If non-pharmacological treatments are ineffective, pharmacological weight-loss agents may be added, including central appetite suppressants and drugs that inhibit the absorption of sugars and fats.
   For type 2 diabetes in MS, drug selection should be based on pancreatic function: when insulin resistance is predominant, prioritize insulin sensitizers that do not increase plasma insulin levels, biguanides, alpha-glucosidase inhibitors, or medications that do not induce prolonged insulin secretion but act on cells, such as glipizide, glibenclamide, and mealtime regulators. When pancreatic insufficiency is the main issue, insulin therapy alone may be used, or it can be appropriately combined with the aforementioned drugs.
   Dyslipidemia in MS is characterized by hypertriglyceridemia and low high-density lipoprotein cholesterol (HDL-C) levels. Elderly patients have a high prevalence of various lipid metabolism abnormalities, which are greatly influenced by diet, leading to fluctuating lipid levels and a high overall prevalence (>50%), low treatment rates, increasing mixed lipid disorders, and difficulty in achieving target lipid levels. When selecting medications for treating dyslipidemia, prioritize statins, fibrates, and other drugs based on the patient's specific lipid profile while also considering their impact on glucose metabolism.
   Treatment of hypertension should emphasize combination therapy, using multiple low-dose drugs with long-acting formulations. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers are preferred.
   Other treatments include managing hyperuricemia with vasodilators and antiplatelet agents.
   In summary, the treatment of MS involves a comprehensive strategy that integrates lifestyle modifications, lipid-lowering, blood pressure reduction, blood sugar control, weight loss to improve insulin sensitivity, antiplatelet therapy, antifibrinolytic therapy, and uric acid-lowering measures. Drug selection should be guided by a holistic approach, following relevant treatment guidelines, and monitoring adverse reactions and drug interactions.

Section 2: Professor Pei Zhengxue’s Experience in Diagnosing and Treating Metabolic Syndrome
Metabolic syndrome is a clinical syndrome characterized by the clustering of multiple cardiovascular risk factors, including abdominal obesity, hyperglycemia (disordered glucose metabolism or diabetes), hypertension, and dyslipidemia [hypertriglyceridemia and/or low HDL-C]. Abdominal obesity is the key feature, and insulin resistance serves as the common pathophysiological basis. Among these, the three major links are obesity, insulin resistance, and cardiovascular disease—multiple metabolic risk factors—with insulin resistance being the core link. Traditional Chinese Medicine does not have a specific term for metabolic syndrome, but based on its clinical manifestations, most practitioners classify it under categories such as "fēmǎn" (obesity), "xuányūn" (dizziness), "xiāo" (wasting), and "xiāokě" (diabetes).

Etiology and Pathogenesis
Professor Pei Zhengxue believes that the primary affected organs in this condition are the spleen, liver, and kidneys. Spleen dysfunction leads to impaired transportation and transformation of nutrients, resulting in phlegm-turbidity stagnation, qi stagnation, blood stasis, and water-dampness accumulation. If pathogenic turbidity persists for a long time, it can transform into heat and fire, deplete qi and injure yin, ultimately leading to deficiency and the development of other syndromes.

1. Early-stage dysfunction of the liver, spleen, and kidneys is the root cause
   When the spleen loses its ability to transport and transform, it cannot disperse essence properly, causing substances to fail to return to their proper channels, manifesting as phlegm, dampness, turbidity, and fat. As stated in the "Plain Questions · On the Differentiation of Channels": "After drinking enters the stomach, excess essence flows upward to the spleen, where the spleen disperses essence and sends it upward to the lungs, regulating water pathways and sending it downward to the bladder. Water essence is distributed throughout the body, and the five meridians operate in parallel."
   If kidney qi is insufficient, it cannot vaporize and transform fluids, leading to fluid retention, failure to distribute water essence, and the formation of damp-phlegm. Some scholars say, "All the blood and essence of the human body are derived from water," so the ascending-clear and descending-turbid aspects of water metabolism depend entirely on kidney qi's transformation. The liver governs the flow of qi throughout the body; if emotions are not well managed, liver qi becomes stagnant, qi circulation is obstructed, the Sanjiao's qi transformation is disrupted, and the flow of qi, blood, and body fluids is impeded. Alternatively, if liver qi overcomes spleen qi, the spleen loses its ability to transport and transform food essence and water-dampness pathogens, leading to accumulation of fluids and phlegm. In addition, prolonged liver qi stagnation can transform into heat and fire, with manifestations such as liver heat, stomach heat, intestinal heat, and heart fire. As recorded in the "Spiritual Pivot · Five Transformations": "When one is overly rigid, anger arises; anger causes qi to rise against the normal flow, accumulating in the chest, blocking blood and qi, filling the hip muscles, preventing blood and qi from flowing, and eventually turning into heat. Heat consumes flesh and skin, hence the term 'xiaoxiao,' referring to people who are extremely rigid yet have weak muscles."

2. Mid-stage: Phlegm, dampness, and heat combine to form the key pathology
   During the early phase of spleen-kidney deficiency and liver qi stagnation, if timely and effective treatment is not received, the disease course will prolong, and over time, phlegm and dampness will become increasingly severe, causing the patient's physique to gradually gain weight. At this point, excessive qi consumption leads to qi deficiency, which can both generate phlegm through fluid accumulation and cause blood stasis, resulting in a combined condition of phlegm and blood stasis. Regarding the relationship between phlegm and blood stasis, the "Blood Evidence Treatise" states: "It should be understood that the obstruction caused by phlegm and water is due to blood stasis... However, if there were no blood stasis, phlegm and qi would naturally dissolve on their own." The "Collection of External Disease Medical Cases" also notes: "When stagnation occurs, it condenses into phlegm, qi becomes blocked, blood becomes stagnant, and phlegm forms." This clearly indicates that phlegm-turbidity and blood stasis share a common origin, mutually permeate each other, and influence one another. Professor Pei Zhengxue believes that phlegm-turbidity and blood stasis are both pathological products and new causative factors; they can transform into each other, serve as cause and effect, and persist throughout the entire course of metabolic syndrome, leading to various metabolic disorders. Therefore, phlegm-turbidity and blood stasis constitute the pathological core of metabolic syndrome. Simultaneously, Sanjiao qi transformation is disrupted, unable to regulate water pathways, resulting in impaired fluid metabolism and increased internal retention of water-dampness. Phlegm, dampness, blood stasis, and heat intermingle within the body, further disrupting organ function and promoting the progression of metabolic syndrome. As recorded in the "Jisheng Formula": "If the Sanjiao qi is blocked and the pulse pathways are closed, fluids accumulate and cannot be dispersed, forming phlegm and drink, leading to numerous diseases."

3. Late-stage: Complex mix of deficiency and excess symptoms
   If timely and appropriate treatment is not administered during the early and mid-stages of metabolic syndrome, and organ qi transformation remains uncorrected, phlegm, dampness, blood stasis, and heat will accumulate within the body. Prolonged stagnation transforms into heat, and the resulting heat damage can lead to depletion of qi and yin. Once both qi and yin are damaged, yang is also affected, resulting in a state of dual deficiency. Over time, the patient's qi and blood become chaotic, meridians dry up, organs deteriorate, and a complex mixture of deficiency and excess symptoms emerges. For example, if phlegm, dampness, and blood stasis remain in the heart vessels, it can cause blockage of the heart vessels, leading to chest oppression and pain, even severe heart pain. If they remain in the kidneys, the renal vessels become obstructed, kidney qi is damaged, and opening and closing functions are impaired, resulting in symptoms such as lower back pain, edema, and cloudy urine. If they remain in the limbs, the blood vessels lack nourishment, meridians are out of balance, leading to numbness and pain in the limbs, coldness and swelling in the lower extremities, and even ulcers that fail to heal over time. If phlegm, dampness, and blood stasis block the ears and eyes, the accumulated heat burns yin fluids, leading to vision impairment, sudden blindness, or deafness. If they block the brain's meridians, the clear orifices lack nourishment, causing dizziness and headaches, even stroke. In severe cases, complete depletion of yin and yang can result in coma, limb paralysis, and extremely weak pulse—life-threatening emergencies. Therefore, early prevention and treatment are especially important.

II. Syndrome Differentiation and Treatment
Professor Pei Zhengxue believes that this condition falls under the category of "deficiency at the root, excess at the surface": "Root deficiency" refers to spleen deficiency or kidney deficiency, while "surface excess" refers to pathological products such as phlegm, dampness, blood stasis, and heat. Phlegm, dampness, blood stasis, and heat are both pathological products of metabolic syndrome and further causes of "complicated symptoms" and "bad symptoms." These four factors coexist throughout the entire course of metabolic syndrome, so addressing phlegm, dampness, blood stasis, and heat is crucial. Clearing heat and draining dampness, eliminating phlegm and clearing turbidity, and activating blood circulation to remove stasis are the main therapeutic approaches. Professor Pei Zhengxue frequently uses Xiangsha Liujunzi Decoction to treat phlegm-turbidity and dampness; for severe dampness, he adds Danningxing and Shichangpu, adjusting dosage with Jiaosanxian and Jishi Huatan Xiaoji. For treating damp-heat, he uses Banxia Xiexin Tang with modifications, adding herbs like Banxia, Huanglian, and Huangqin to clear heat and drain dampness. For blood stasis, he commonly uses Huoxue Huayu medicines such as Honghua, Chuanxiong, Danshen, Chishao, and Jiangxiang; for severe blood stasis, he may add Sanleng, Eshu, Shuihui, Dilong, and Sanqi. However, for those with both blood stasis and heat, Da Chaihu Tang with additional ingredients works better. In clinical practice, medication is adjusted according to the condition, applied flexibly. Decline in liver, spleen, and kidney function is a major factor contributing to the prolonged and difficult-to-cure nature of this disease. Ancient sages said, "The spleen is the source of phlegm," "The kidneys are the foundation of phlegm," and "The liver and kidneys share a common origin." Therefore, treatment must consider the liver, spleen, and kidneys simultaneously to regulate organ function and prevent or slow down disease progression. For patients who are overweight, have abdominal distension and poor appetite, pale complexion, limb fatigue, shortness of breath, thin tongue coating, and deep pulse—indicating spleen deficiency and dampness—treatment should focus on strengthening the spleen, benefiting qi, and draining dampness. Commonly used is Xiangsha Liujunzi Decoction with modifications, emphasizing Shan Yao, Baizhu, and Fuling to strengthen the spleen and replenish qi. For those with lower back and knee soreness, dizziness and tinnitus, fear of cold and cold limbs, thin tongue coating, and deep pulse—indicating liver and kidney yin deficiency—commonly used is Qiju Dihuang Tang with modifications, emphasizing Shan Yao, Chuan Niuxi, and Zhimu to replenish kidney qi and nourish kidney yin. For those with chest tightness, shortness of breath, palpitations, worsening after activity, occasional chest pain, fatigue, fear of cold, lower extremity edema, pale and slippery tongue, and weak pulse—indicating spleen, liver, and kidney deficiency—use Zhenwu Tang combined with Linggui Shugan Tang to strengthen the spleen and kidneys, warm yang, and transform qi. If both yin and yang are deficient, with dizziness, headache, limb movement difficulties, lower back and leg soreness, fatigue, desire to sleep, cold limbs, white and dry tongue coating, and deep, weak pulse—use Dihuang Yin Zi with modifications for better results.

1. Phlegm and Dampness Obstruction
   Symptoms: Heavy body, limb fatigue, chest and diaphragm fullness, dizziness and vertigo, sticky and uncomfortable bowel movements, pale red tongue, white and greasy tongue coating, or yellowish coating, slippery pulse. Treatment: Dry dampness and eliminate phlegm, strengthen the spleen and regulate qi.
   Formula: Xiangsha Liujunzi Decoction combined with Banxia Xiexin Tang with modifications.
   Ingredients: Dangshen, Baizhu, Fuling, Chenpi, Banxia, Muxiang, Sharen, Huanglian, Huangqin, Gancao. If limbs are heavy, abdominal distension is severe, and lipid levels are high, combine with Pingwei San, Shengzhengren, and He Ye to dry dampness and strengthen the spleen; for obvious dizziness, add Gouteng and Laizi to eliminate phlegm, calm qi, and soothe the liver; for long-term phlegm and dampness with heat, dizziness, and high blood pressure, use Geqin Qingdan Tang (Wendan Tang with Gegen and Huangqin) to clear heat and eliminate phlegm; for long-term phlegm and dampness with heat, stagnation, and joint redness and pain, along with high uric acid, switch to Tongfeng No. 1 formula with modifications to clear heat, drain dampness, and relieve pain.

2. Liver-Gastric Heat Stagnation
   Symptoms: Dry mouth and excessive eating, irritability and quick temper, dizziness and vertigo, flank pain, bitter taste and bad breath, dry bowel movements, red and yellow tongue, tense pulse. Treatment: Clear heat and resolve stagnation.
   Formula: Da Chaihu Tang combined with Yueju Wan with modifications.
   Ingredients: Chaihu, Baishao, Dahuang, Quanshi, Huangqin, Banxia, Xiangfu, Chuanxiong, Cangzhu, Zhizi, Shenqu, Gancao. For obvious mid-jiao damp-heat and high blood pressure, combine with Huanglian Jiedu Tang to clear heat and drain dampness; for bilateral flank pain, add Yanhusuo and Chuanlianzǐ to relieve pain; for strong liver fire and restlessness, add Zhizi and Longdan Cao, or combine with Danggui Longhui Wan to clear liver fire; for those with hypertension, add Banxia, Gouteng, Cheqianzi, Xia Kusao, and Dai Zhe Shi to clear heat and calm the liver; for those with fierce stomach fire, dry mouth and excessive drinking, and good appetite, use Baihu Jia Shen Tang with modifications to clear heat and generate fluids; for those with damp-heat and blood stasis, difficulty urinating, lower back pain and edema, sore throat, red tongue, greasy tongue coating, and positive occult blood and protein in urine, use Shanxi Institute of Traditional Chinese Medicine's Compound Yishen Tang with modifications to clear heat, detoxify, activate blood circulation, and promote diuresis.

3. Phlegm and Blood Stasis Blocking Meridians
   Symptoms: Obesity, chest tightness and pain, dizziness, restless sleep, dark red tongue or petechiae, deep or slippery pulse. Treatment: Activate blood circulation to remove stasis and unblock meridians.
   Formula:
   Guanxin No. 2 formula combined with Gua Bai Banxia Tang with modifications.
   Chishao, Chuanxiong, Honghua, Jiangxiang, Danshen, Gua Wei, Banxia, Bai, Sanqi, Shuihui. For those with fatigue, shortness of breath, and dry mouth, add Shengmai Yin to benefit qi and nourish yin; for those with lower extremity edema, add Hulu Pi, Dafu Pi, and Cheqianzi to promote diuresis and reduce swelling; in severe cases, combine with Zhenwu Tang to warm yang, transform qi, and promote diuresis; for those with dizziness, chest pain, and high blood pressure, use Puji Benshi Fang's Gouteng San (Shigao, Maidong, Fangfeng, Chrysanthemum, Banxia, Chenpi, Fuling, Ren Shen, Gouteng, Gancao) to eliminate phlegm, activate blood circulation, and dispel wind to calm the liver; for those with qi stagnation and blood stasis,
   chest tightness and pain are obvious, use Xuefu Zhuyu Tang combined with Gua Wei Tan Bai Banxia Tang with modifications to move qi, activate blood circulation, and eliminate phlegm.

4. Liver-Kidney Yin Deficiency
   Symptoms: Dizziness, tinnitus, forgetfulness, insomnia, frequent dreams, lower back and knee soreness, dry mouth and excessive drinking, red tongue, thin tongue coating, and fine pulse. Treatment: Nourish the liver and kidneys, replenish yin and fill essence.
   Formula: Qiju Dihuang Wan with modifications.
   Goji berries, chrysanthemums, Shu Di Huang, Shan Zhu Yu, Shan Yao, Fuling, Ze Xie, Dan Pi. For those whose water does not nourish wood, with excessive liver yang and high blood pressure, use Zhen Gan Xi Feng Tang or Jiangling Tang with modifications to nourish yin and subdue yang; for those with insomnia and frequent dreams, combine with Suanzaoren Tang to nourish blood, clear heat, and calm the mind; for those with internal heat due to yin deficiency, add Zhimu and Huangbo to nourish yin and clear heat; for those with both qi and yin deficiency and high blood sugar, combine with Yu Ye Tang to strengthen the spleen, benefit qi, and nourish yin; for those with obvious dizziness and high blood pressure, and where dizziness is disproportionate to the degree of blood pressure elevation, consider vertebral-basilar artery sclerosis, add Maidong, Wuweizi, Tianma, Baizhu, Gouteng, Quanxie, and Ginger to nourish the liver and kidneys, dispel wind, and calm the liver; for those with dizziness, tinnitus, and high lipid levels, combine with Yinshan Compound to nourish the liver and kidneys.

5. Heart-Kidney Yang Deficiency
   Symptoms: Chest tightness and shortness of breath, palpitations, worsening after activity, sometimes chest pain, fatigue, fear of cold, lower extremity edema, reduced urine output, pale and tender tongue, and weak pulse. Treatment: Strengthen the spleen and kidneys, warm yang, transform qi, and promote diuresis to calm the heart.
   Formula: Zhenwu Tang combined with Linggui Shugan Tang and Shengmai San with modifications.
   Ingredients: Zhi Fu Zi, Fuling, Fried Baizhu, Baishao, Ginger, Gui Zhi, Gancao, Red Ginseng, Maidong, Wuweizi. For those with chest pain, combine with Guanxin No. 2 formula to activate blood circulation and relieve pain; for those without chest tightness, shortness of breath, or palpitations, but mainly suffering from spleen and kidney yang deficiency, manifested as lower back fatigue, lower extremity edema, difficulty urinating, or excessive drinking and urination, use Gui Fu Di Huang Tang with modifications to warm yang and promote diuresis.

6. Dual Deficiency of Yin and Yang
   Symptoms: Dizziness and headache, limb movement difficulties, lower back and leg soreness, fatigue, desire to sleep, cold limbs, white and dry tongue coating, and deep, weak pulse. Treatment: Nourish yin and warm yang, strengthen the kidneys.
   Formula: Dihuang Yin Zi with modifications.
   Shu Di Huang, Shan Zhu Yu, Maidong, Wuweizi, Shihu, Rou Cong Rong, Ba Ji Tian, Gui Xin, Fu Zi, Bo He, Shi Chang Pu, Yuan Zhi. For those with blocked meridians, limb movement difficulties, or cerebral infarction, combine with Guanxin No. 2 formula, then add Wusha, Quanxie, and Wugong to activate blood circulation and remove stasis, dispel wind, and unblock meridians; or add Sangzhi, Gui Zhi, Ren Dong Teng, Ji Xue Teng, Yi Mu Cao to activate blood circulation and unblock meridians; for those with dizziness, headache, and high blood pressure, combine with Si Wu Yi Huang formula (Shu Di, Dang Gui, Baishao, Chuanxiong, Huangqin, Gouteng) to nourish blood and calm the liver; for those with lower extremity edema, add Hulu Pi, Dafu Pi, and Cheqianzi to promote diuresis and reduce swelling.

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Or combine Wuling Powder to promote diuresis and reduce edema; for patients with dizziness, palpitations, poor sleep, lumbosacral fatigue, hypertension, and arteriosclerosis, use Erxian Decoction combined with Guanxin No. 2 Formula and Ban Gouche Xia Shi Formula with modifications (Xianmao, Bajitian, Zhimu, Huangbo, Danggui, Chishao, Chuanxiong, Honghua, Jiangxiang, Danshen, Han Sanqi, Shui Zhi, Banxia, Gouteng, Cheqianzi, Xiakucao, Sheng Zhesi) to tonify yin and yang, activate blood circulation and remove blood stasis, dispel wind and calm dizziness.

III. Clinical Case Studies
Case 1: Mr. Li, male, 72 years old, first visit on January 13, 2017. The patient developed chest tightness and chest pain in December 2016 without any obvious cause and was admitted to the emergency department, where he was diagnosed with coronary heart disease. After receiving integrated traditional Chinese and Western medicine treatment, his condition improved and he was discharged. The patient is obese and has a history of type 2 diabetes and sequelae of cerebral infarction for more than three years. Biochemical tests showed fasting blood glucose at 8.3 mmol/L and triglycerides at 3.2 mmol/L. Current medications include atorvastatin calcium tablets 20 mg once nightly; isosorbide mononitrate 20 mg three times daily; metoprolol tartrate tablets 12.5 mg twice daily; acarbose tablets 50 mg three times daily; and metformin hydrochloride tablets 0.5 g twice daily. Present symptoms: chest tightness, chest pain, palpitations after activity, dry mouth, swollen and large tongue with dark purple color, slippery and white greasy coating, and slippery pulse. Western medical diagnosis: metabolic syndrome. Traditional Chinese medicine differentiation: phlegm-stasis obstructing collaterals syndrome. Treatment principle: resolve phlegm and unblock obstructions, activate blood circulation and remove blood stasis. Prescription: Gualou 10 g, Banxia 10 g, Tanbai 10 g, Chishao 10 g, Chuanxiong 6 g, Honghua 10 g, Jiangxiang 10 g, Danshen 10 g, Han Sanqi 3 g (to be decocted and taken), Shui Zhi 10 g (to be decocted and taken). Total of 14 doses, to be decocted and taken once daily. After taking the medication, chest tightness and chest pain significantly alleviated, with thin white greasy coating on the tongue. Since the effect was satisfactory, the original formula was modified by adding Gegen 15 g, and another 14 doses were taken, further relieving chest tightness, chest pain, and palpitations. Subsequently, the above formula was adjusted and used for over four months, until all symptoms disappeared. Follow-up biochemical tests showed fasting blood glucose at 7.2 mmol/L and triglycerides at 1.6 mmol/L. The patient was advised to continue treatment while strengthening exercise, controlling diet, and losing weight to reduce fat.

Case 2: Ms. Wei, female, 68 years old, first visit on March 19, 2019. The patient is obese and has had hyperlipidemia and hypertension for more than six years, long-term treated with nifedipine sustained-release tablets for blood pressure control, but with unsatisfactory results, and hyperlipidemia remains untreated. Recently, the patient experienced dizziness, heaviness in the head, and weakness in the legs. Three days ago, biochemical tests showed TG at 2.4 mmol/L, blood pressure at 170/110 mmHg, and BMI at 26 kg/m², prompting her to seek medical attention. Present symptoms: obesity, dizziness and heaviness in the head, tinnitus, leg weakness as if stepping on cotton, intermittent chest tightness and dull pain, dry mouth at night, dark red tongue with little coating, and deep, fine, string-like pulse. Western medical diagnosis: metabolic syndrome. Traditional Chinese medicine differentiation: liver-kidney yin deficiency, liver yang excess, and blood stasis obstructing the heart vessels. Prescription: Zhen Gan Xi Feng Tang combined with Yinshan Heji and Guanxin No. 2 Formula with modifications. Ingredients: Sheng Zhesi 30 g (decocted first), Huai Niuxi 30 g, Sheng Longgu 15 g (decocted first), Sheng Muli 15 g (decocted first), Gui Ban 15 g (decocted first), Bai Shao 15 g, Tian Dong 10 g, Mai Dong 10 g, Xuan Shen 10 g, Yin Chen 10 g, Mai Ya 10 g, Chuan Zi 6 g, Sheng Shan Zhu 10 g, Sang Ji Sheng 15 g, Zhi He Shou Wu 10 g, Danshen 20 g, Chishao 10 g, Chuan Xiong 6 g, Honghua 6 g, Jiangxiang 10 g. Total of 14 doses, to be decocted and taken once daily. The patient was advised to follow a low-salt, low-fat diet, increase exercise, and persist in weight loss. After taking the medication, chest pain disappeared, and dizziness, leg weakness, and tinnitus all improved. After continuing the original formula for another 14 doses, all symptoms greatly eased, with blood pressure measured at 150/96 mmHg. Chest pain did not recur, and the Guanxin No. 2 Formula was removed from the prescription, with emphasis placed on nourishing and calming the liver. Ingredients: Sheng Zhesi 30 g (decocted first), Huai Niuxi 30 g, Sheng Longgu 15 g (decocted first), Sheng Muli 15 g (decocted first), Gui Ban 15 g (decocted first), Bai Shao 15 g, Tian Dong 10 g, Mai Dong 10 g, Xuan Shen 10 g, Yin Chen 10 g, Mai Ya 10 g, Chuan Zi 6 g, Sheng Shan Zhu 10 g, Sang Ji Sheng 15 g, Zhi He Shou Wu 10 g, Danshen 20 g, Chuan Xiong 6 g, Dang Gui 10 g, Sheng Di 12 g, Huang Qin 10 g, Gouteng 30 g. Total of 14 doses, to be decocted and taken once daily. After taking the medication, dizziness, leg weakness, and tinnitus further subsided, and nighttime dry mouth disappeared. Following further adjustments to the above formula for over four months, all symptoms were cured, with blood pressure measured at 140/80 mmHg and TG at 1.5 mmol/L. The patient was advised to persist in weight loss, continue a low-salt, low-fat diet, strengthen physical exercise, maintain a cheerful mood, and regularly monitor blood pressure, blood lipids, and body weight.

Section 3: Historical and Contemporary Theories on Metabolic Syndrome
“Danxi Xinfa · Touxuan”: “Dizziness is caused by phlegm combined with qi deficiency and fire; treatment should focus on resolving phlegm, supplemented by qi-tonifying and fire-reducing herbs. Without phlegm, there is no dizziness; phlegm arises from the movement of fire.”
“Jingyue Quanshu · Xuanyun”: “According to Danxi, dizziness cannot occur without phlegm, so treatment should primarily focus on resolving phlegm while also using other herbs. In contrast, according to others, dizziness cannot occur without deficiency, so treatment should mainly address deficiency while appropriately addressing its manifestations.”
“Leizheng Zhicai · Xiongbi”: “Chest obstruction occurs when yang energy in the chest is weak and unable to circulate; over time, yin energy takes over the yang position, leading to stagnation and blockage. Symptoms include chest fullness, shortness of breath, difficulty breathing, and pain radiating to the heart and back. Due to the lack of smooth flow of yang energy in the chest, turbid yin energy rises upward, blocking the normal ascending and descending movements, which can even lead to coughing up phlegm and severe chest pain. All yang energies receive their qi in the chest, so the chest must be spacious and open to allow clear qi to circulate and spread. The pulse in cases of chest obstruction shows weak yang and strong yin; weak yang indicates problems in the upper burner, while strong yin suggests heart pain. Both the ‘Jin Gui’ and ‘Qian Jin’ classics emphasize treating the yang to relieve chest obstruction.”
“Yijing Sují · Zhongfeng Bian”: “Stroke is not caused by external wind pathogens, but rather by internal qi disorders. When people pass the age of forty and their qi begins to decline, or when they experience excessive worry, joy, anger, or resentment that damages their qi, they are prone to this illness. Younger people generally do not suffer from it, though obesity may occasionally lead to it, as obesity often accompanies declining qi. … However, those who mistakenly attribute it to wind are actually experiencing true stroke. Those caused by fire, qi, or dampness are considered similar to stroke but are not true stroke. To distinguish between them, one should look at the origins of the problem: if it’s due to wind, treat it accordingly; if it’s due to fire, qi, or dampness, treat it based on these three factors. This approach ensures clear reasoning and appropriate application of methods.”
Modern renowned physician Lu Zhizheng believes that metabolic syndrome is far more complex than simple obesity, involving multiple organs and closely related to the spleen, stomach, liver, and gallbladder. Phlegm, dampness, stasis, turbidity, and deficiency all coexist, making it a syndrome of underlying deficiency with superficial excess—a systemic disease. During the progression of the disease, it is closely linked to conditions such as diabetes, dizziness, chest obstruction and heart pain, arthritis, and even stroke and internal injuries due to deficiency. Therefore, treatment of metabolic syndrome should prioritize regulating the spleen and stomach to restore their normal physiological functions of ascending clear qi and descending turbid qi, addressing both root and branch. Common therapeutic approaches include strengthening the spleen and stomach, soothing the liver and regulating qi, aromatizing and clearing turbidity, resolving phlegm and dampness, activating blood circulation and removing stasis, clearing heat and detoxifying, and tonifying qi and nourishing yin. Clinically, treatment should be tailored to individual patterns, employing flexible and adaptive methods, adjusting prescriptions according to symptoms, while maintaining consistency, adhering to established protocols, incorporating appropriate exercise, eating a balanced diet, and managing emotions—only then can the disease be reversed, symptoms alleviated, and health restored.
Contemporary renowned physician Xiao Lin adopts a holistic approach to diagnosing and treating metabolic syndrome, focusing on the interplay of phlegm-turbidity, blood stasis, and stagnant heat. Treatment emphasizes clearing stagnant heat, resolving phlegm and dampness, and activating blood circulation and removing stasis, using formulas such as Xiao Xianxiong Tang combined with Didang Tang with modifications. He stresses the importance of integrating disease patterns with treatment outcomes, using efficacy of disease, pattern, medication, and dosage as guiding principles. First, he emphasizes disease and pattern efficacy—accurately identifying the disease and pattern, prescribing medications accordingly, “addressing the primary issue while tackling the root cause.” For example, since the initial pathology is characterized by pathogenic excess and the combination of phlegm and heat, he uses Huanglian, Huangqin, Dahuang, and Gualiu to clear internal heat, break up stagnation, and slightly supplement with ginseng to replenish postnatal qi. Second, he stresses the importance of drug and dosage efficacy, particularly in the precise dosages of key ingredients—for instance, heavily using Huanglian and Huangqin to clear heat in the upper and middle jiao, slightly adding ginger to achieve a pungent opening and bitter descending effect, and using raw Dahuang to fully exploit its heat-clearing and purgative effects, starting with relatively high doses to directly counteract the heat, then gradually adjusting the dosage as the heat subsides to prevent the cold nature from damaging the middle yang.
Section 4: Pathogenesis, Diagnosis, and Treatment of Primary Osteoporosis
Osteoporosis (OP) is a metabolic bone disease characterized by decreased bone mass and deterioration of bone microstructure, leading to increased bone fragility and susceptibility to fractures. Based on etiology, it can be divided into primary and secondary types. Secondary OP has clearly defined underlying causes, often resulting from endocrine and metabolic diseases (such as hypogonadism, hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, type 1 diabetes, etc.) or systemic diseases. Type 1 primary OP refers to postmenopausal osteoporosis (PMOP), occurring in women after menopause. Type 2 primary OP refers to senile osteoporosis, seen in elderly individuals.

Pathogenesis
Normal bone metabolism in mature individuals mainly occurs through bone remodeling. After menopause, the rate of decline in bone mineral density (BMD) in men is generally slower than in women, because women, in addition to aging, also experience estrogen deficiency. Any factor that increases bone resorption and/or decreases bone formation will lead to bone loss and reduced bone quality, increasing fragility and ultimately causing fractures.
(1) Factors promoting bone resorption:

• Estrogen deficiency: Estrogen deficiency enhances osteoclast activity, accelerating bone loss, which is the main cause of PMOP; androgen deficiency also plays an important role in the development of senile OP.
• Vitamin D deficiency and elevated parathyroid hormone (PTH): Due to aging and declining kidney function, intestinal calcium absorption and production of 1,25-(OH)₂D₃ decrease, leading to compensatory increase in PTH secretion, which accelerates bone turnover and bone loss.
• Dysregulation of cytokine expression: Increased levels of IL-1, IL-6, and TNF in bone tissue, coupled with decreased osteoprotegerin (OPG), enhance osteoclast activity and bone resorption.
  (2) Factors affecting bone formation:
• Decline in peak bone mass: The period of rapid bone growth during adolescence is the fastest phase of bone mass accumulation, reaching peak bone mass (PBM) around the age of 30. PBM is mainly determined by genetic factors and is associated with clinical characteristics such as ethnicity, family history of fractures, tall and slender physique, as well as development, nutrition, and lifestyle. If puberty is delayed, PBM decreases, increasing the likelihood of developing OP in adulthood and advancing the age of onset. After PBM, the occurrence of OP mainly depends on the amount and speed of bone loss.
• Decline in bone remodeling function: This may be an important cause of senile OP. Defects in osteoblast function and vitality lead to insufficient bone formation and bone loss.
  (3) Decline in bone quality: Bone quality is mainly related to genetic factors, including bone geometry, degree of mineralization, cumulative micro-damage, and physicochemical and biological properties of bone minerals and bone matrix. Declining bone quality leads to increased bone fragility and fracture risk.
  (4) Unhealthy lifestyle and living environment: There are many risk factors for OP and OP-related fractures, such as advanced age, smoking, immobilization, insufficient physical activity, alcohol abuse, falls, prolonged bed rest, long-term use of glucocorticoids, reduced sunlight exposure, and inadequate intake of calcium and vitamin D. Insufficient protein intake, malnutrition, and muscle dysfunction are also important causes of senile OP. The more risk factors present, the higher the probability of developing OP and OP-related fractures.

II. Clinical Manifestations

1. Pain: Mild cases may have no discomfort, while more severe patients often complain of lower back pain or generalized bone pain. Patients may experience soreness in the lower back or throughout the body when turning over, sitting up, or walking, with pain worsening at night or under load, sometimes accompanied by muscle spasms and limited mobility. Bone pain is usually diffuse, with no fixed tender point, and examination often fails to reveal specific tender areas. It typically worsens after exertion or activity, with reduced ability to bear weight or inability to bear weight at all. Limb fractures or hip fractures significantly restrict limb movement, exacerbating local pain and sometimes accompanied by deformity or positive signs of fracture.
2. Shortened stature and kyphosis: Commonly seen in vertebral compression fractures, which may be single or multiple, with or without identifiable triggers, causing patients to become shorter. Severe cases may be accompanied by kyphosis, but neurological compression symptoms and signs are rare. Vertebral compression fractures in osteoporosis patients often lead to thoracic deformity, which can cause chest tightness, shortness of breath, difficulty breathing, and even cyanosis. Lung capacity and maximum ventilation decrease, making respiratory infections more likely. Severe thoracic deformity reduces cardiac output and impairs cardiovascular function.
3. Fractures: Often triggered by minor activities or trauma, such as bending over, bearing weight, squeezing, or falling. Common sites include the spine, hips, and forearms, but other sites can also be affected, such as ribs, pelvis, femur, and even clavicle and sternum. Spinal compression fractures are most common in postmenopausal osteoporosis patients, with sudden lower back pain appearing after a fracture, followed by passive positioning in bed. Hip fractures are more common in elderly osteoporosis patients, usually occurring after falls or compressions. Most hip fractures occur at the femoral neck or intertrochanteric region. If patients remain bedridden for a long time, bone loss is further exacerbated, often leading to death due to complications such as infection, cardiovascular disease, or chronic failure. Survivors often have limited mobility and a significant decline or loss of self-care ability.
4. Psychological symptoms: Mainly include fear, anxiety, depression, and loss of confidence. Elderly patients often develop psychological burdens due to declining independent living abilities and lack of contact and communication with the outside world after fractures.
5. Sarcopenia: Characterized by overall reduction in muscle mass and/or decreased muscle strength or impaired muscle function. Sarcopenia significantly increases the risk of OP, making falls and fractures more likely, while also increasing the prevalence of sarcopenia itself.

III. Diagnosis

1. Fragile fracture: One of the criteria for diagnosing OP, without relying on bone density measurement. A fragile fracture refers to a fracture that occurs without external trauma or with only minor trauma, which is a clear manifestation of decreased bone strength and thus also the final outcome and complication of osteoporosis. The diagnosis of a fragile fracture requires the following conditions:
   ① No clear history of violent injury or only a history of low-energy injury; ② Evidence from imaging examinations confirming the fracture; ③ Exclusion of fractures caused by tumors or other reasons. Once a fragile fracture occurs, osteoporosis can be clinically diagnosed.
   Lateral X-ray of the thoracolumbar spine can be used as the preferred method for determining vertebral compression fractures due to osteoporosis. Routine lateral X-rays of the thoracolumbar spine should cover T4–L1 and Ti2–L5 vertebrae. MRI can show bone marrow edema in the vertebrae, helping to distinguish whether it is a fresh fracture and thus guiding treatment. For those who cannot undergo MRI, whole-body bone imaging can be used to determine whether it is a fresh fracture.
2. Bone density measurement: It is recommended to follow the diagnostic standards of the World Health Organization. Based on dual-energy X-ray absorptiometry: A bone density value lower than the peak bone mass of healthy adults of the same gender and ethnicity by less than 1 standard deviation is considered normal; a decrease of 1–2.5 standard deviations indicates low bone mass (bone loss); a decrease of 2.5 or more standard deviations indicates osteoporosis; if the degree of bone density decrease meets the diagnostic criteria for osteoporosis and is accompanied by one or more fractures, it is considered severe osteoporosis.
   Bone density is usually expressed as a T-score, calculated as (measured value – peak bone mass) / standard deviation of bone density in healthy adults. The T-score is used to indicate the bone density level of postmenopausal women and men over 50. For children, premenopausal women, and men under 50, it is recommended to use a Z-score instead, calculated as (measured value – average bone density of peers) / standard deviation of peer bone density.
3. Bone turnover markers (BTM): These are products of bone tissue breakdown and synthesis metabolism, and changes in their levels reflect the dynamic state of whole-body bone metabolism. BTM helps differentiate primary and secondary OP, determine the type of bone turnover, predict the rate of bone loss, assess fracture risk, understand disease progression, select intervention measures, monitor drug efficacy and compliance, and so on. Usually, exclusionary methods are used for differentiation. The diagnosis of primary osteoporosis must exclude all possible secondary causes before it can be confirmed.

IV. Treatment
(1) General treatment:

1. Lifestyle adjustment:
   (1) Balanced nutrition: It is recommended to consume a balanced diet rich in calcium, low in salt, and moderate in protein, with a daily protein intake of 0.8–1.0 g per kg of body weight, and to drink 300 ml of milk or equivalent dairy products every day. Quit smoking, limit alcohol consumption, and avoid excessive coffee drinking.

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, Avoid excessive consumption of carbonated beverages and avoid or minimize the use of medications that affect bone metabolism. (2) Adequate sunlight exposure: Sunbathe twice a week for 15–30 minutes each time to promote vitamin D synthesis in the body. Be careful to avoid intense sunlight that can burn the skin, but try not to apply sunscreen, as it may interfere with the effectiveness of sunlight exposure. (3) Increase physical activity: Engage more in outdoor activities, strengthen weight-bearing exercises, enhance adaptability, and reduce the risk of fractures. The type, method, and amount of exercise should be tailored to the patient's specific condition. The focus of aerobic exercise and weight-bearing training should be on improving endurance and balance to reduce the risk of falls and fractures. Avoid immobilization of limbs, enhance resistance, and strengthen personal care. (4) Correct unhealthy lifestyle habits and behavioral deviations: Promote a diet low in sodium, high in potassium, high in calcium, and high in unsaturated fatty acids; quit smoking; abstain from alcohol. 2. Avoid using drugs that cause OP such as antiepileptic drugs, phenytoin, phenobarbital, carbamazepine, primidone, valproic acid, lamotrigine, clonazepam, gabapentin, and ethosuximide, among others. 3. Supplement calcium and vitamin D Regardless of the type of OP, appropriate calcium supplementation is necessary to ensure a total daily intake of elemental calcium ranging from 800 to 1,200 mg. In addition to increasing dietary calcium intake, supplements such as calcium carbonate, calcium gluconate, and calcium citrate can also be used. At the same time, supplement vitamin D at 400–600 units. Inactive vitamin D is mainly used for OP prevention, while active vitamin D can promote intestinal calcium absorption, increase renal tubular reabsorption of calcium, and inhibit PTH secretion, thus being applicable for the treatment of various OPs. The usual dosage of calcitriol or calcifediol is 0.25 g, and during treatment, blood calcium and phosphorus levels should be monitored regularly to prevent hypercalcemia and hyperphosphatemia. (II) Pharmacological Treatment

1. Symptomatic treatment For those experiencing pain, appropriate doses of nonsteroidal anti-inflammatory drugs can be administered, such as aspirin, 0.3–0.6 g each time, no more than 3 times daily; or indomethacin (Indocin) tablets, 25 mg each time, 3 times daily; or celecoxib, 100–200 mg each time, once daily. In cases of fracture or persistent severe pain, calcitonin preparations may be used. For patients with bone deformities, local immobilization or other orthopedic measures should be taken to prevent further deformity. Fracture patients should receive traction, immobilization, reduction, or surgical treatment, along with physical rehabilitation therapy to restore motor function as soon as possible. When necessary, healthcare professionals should provide passive exercises to avoid worsening the condition due to immobilization or disuse.
2. Bone resorption inhibitors (1) Bisphosphonates: Bisphosphonates are stable analogs of pyrophosphate that specifically bind to active bone surfaces undergoing remodeling, inhibiting osteoclast function and thereby reducing bone resorption. Currently, bisphosphonates used for the prevention and treatment of OP include alendronate sodium, zoledronic acid, risedronate sodium, ibandronate sodium, etidronate disodium, and clodronate disodium, among others. After 5 years of oral bisphosphonate use or 3 years of intravenous zoledronic acid administration, the condition should be reassessed. (2) Calcitonins: Calcitonin is a calcium-regulating hormone that can inhibit osteoclast biological activity, reduce the number of osteoclasts, decrease bone loss, increase bone mass, and relieve OP-related bone pain. Continuous use of calcitonin generally does not exceed 3 months. (3) Estrogens: Clinical studies have shown that estrogen replacement therapy (ET) and combined estrogen-progestogen replacement therapy (EPT) can reduce bone loss and lower the risk of vertebral, non-vertebral, and hip fractures associated with OP, making them effective measures for preventing and treating postmenopausal OP. Women who have not undergone hysterectomy must combine estrogen therapy with progestogen to reduce the risk of endometrial cancer, while also adhering to regular follow-up and safety monitoring (especially of the breasts and uterus). (4) Selective estrogen receptor modulators (SERMs): After binding to estrogen receptors, SERMs cause different conformational changes in receptor spatial structure depending on the target tissue, thereby exerting either estrogen-like or anti-estrogen effects. The SERM drug raloxifene binds to bone and estrogen receptors, exerting estrogen-like effects, inhibiting bone resorption, increasing bone density, and reducing the risk of vertebral fractures. Raloxifene can be used to treat postmenopausal OP and reduce the risk of vertebral fractures, but before medication, patients' thromboembolic risk should be strictly assessed.
3. Bone formation promoters Parathyroid hormone analogs (PTHa) are representative bone-forming drugs; teriparatide is currently available in China. Systematic reviews on the effectiveness of PTHa in improving postmenopausal OP bone density and reducing fracture incidence show that it outperforms alendronate sodium. For OP patients at high risk of vertebral or non-vertebral fractures whose response to bone resorption inhibitors is poor, contraindicated, or intolerant, PTHa can be selected to increase bone density and reduce fracture risk. Treatment duration should not exceed 2 years. Section 2: Professor Pei Zhengxue’s Experience in Diagnosing and Treating Primary Osteoporosis Osteoporosis is a modern medical diagnosis; there is no explicit record of it in ancient Chinese medical texts. However, based on its clinical manifestations, it is broadly similar to what traditional Chinese medicine refers to as “bone wasting,” “bone dryness,” and “extreme bone weakness.” For example, the Suwen · Discussion on Paralysis states: “If kidney qi is overheated, the lower back and spine will lose their strength, the bones will become dry and the marrow will diminish, resulting in bone wasting.” The Lingzhu · Meridians records: “If the qi of the Shaoyin meridian is exhausted, the bones will become dry.” The Qianjin Yaofang · Extreme Bone Weakness notes: “Extreme bone weakness primarily affects the kidneys; the kidneys govern the bones, and the bones and kidneys are interconnected... If the kidneys are diseased, the bones become extremely weak, teeth ache, hands and feet hurt, one cannot stand for long, movement is difficult, the body feels numb, and the brain and marrow feel sore. Winter’s ‘evil wind’ harms the kidneys, and the wind penetrates the bones, hence the term ‘extreme bone weakness.’” Causes and Pathogenesis
4. Kidney deficiency and essence depletion are the root causes of primary osteoporosis. The close relationship between the kidneys and this disease is determined by the physiological function that “the kidneys store essence, govern the bones, and generate marrow.” When kidney essence is insufficient, it cannot nourish the bones, leading to weakness and flaccidity of the muscles and bones. Since the lower back is the residence of the kidneys, and “if it is not nourished, it will ache,” patients often experience pain in the lower back and spine, which in severe cases can lead to mobility impairment and even fragile bones prone to fractures. As stated in the Jingyi Jingyi: “The kidneys store essence, essence generates marrow, and marrow generates bones; therefore, bones are contained within the kidneys. Marrow is produced by kidney essence—when the essence is sufficient, the marrow is sufficient, and since marrow resides within the bones, when the marrow is sufficient, the bones are strong.” The main symptoms of this disease include lower back and spine pain, soreness and weakness in the shins and knees, numbness and cramping in the limbs, all of which correspond to the kidney-deficiency-related bone pain described in traditional Chinese medicine. Patients often also experience dizziness, tinnitus, memory loss, thinning hair, loose teeth, and sluggish movement—all manifestations of kidney deficiency. Therefore, osteoporosis originates in the kidneys; when the kidneys are deficient, the bones lose their marrow nourishment, leading to osteoporosis.
5. Liver and spleen weakness are important factors in the onset of primary osteoporosis. Osteoporosis is closely related to the functions of the spleen and stomach. According to the Bianzheng Lu · Chapter on Paralysis: “The stomach produces qi, and the body fluids naturally moisten and nourish the kidney meridians, thereby nourishing the bone marrow.” If the spleen and stomach are malnourished, the bones become dry; if the yang qi of the spleen and kidneys is deficient, yang deficiency leads to cold, impairing warming and propelling functions, causing blood circulation to stagnate, resulting in blood clotting in the vessels, blood stasis blocking joints and bones, and difficulty in nourishing them, thus causing pain and limited mobility. The Suwen · Discussion on Taiyin and Yangming also states: “Nowadays, when the spleen is diseased, it cannot deliver body fluids to the stomach, the limbs cannot receive the qi of food and grain, the qi declines day by day, the meridians become obstructed, and the muscles, bones, and tendons lack the qi needed to grow, so they are useless.” Patients often exhibit fatigue, weakness, and flaccidity in the limbs—symptoms consistent with spleen deficiency. “The spleen governs the body’s muscles,” and well-developed, robust muscles are the mechanical guarantee for strong bones. If one indulges in rich, sweet foods and excessively consumes tobacco and alcohol, the spleen and stomach are damaged, the production of vital essence from food and grain is insufficient, leading to malnutrition of muscles and marrow, and the limbs become useless. Spleen deficiency cannot replenish innate resources, which in turn leads to kidney essence deficiency, muscle and bone malnutrition, and bone wasting, ultimately causing metabolic disorders in the bones. Clinically, chronic gastric diseases can also lead to nutritional deficiencies in the bones, providing further evidence. When the functions of the spleen and stomach decline, both qi and blood become deficient, unable to generate marrow and nourish bones, and the muscles, bones, skin, flesh, and blood vessels all become weak, leading to osteoporosis. The liver is the organ of wind and wood, responsible for dispersing and storing blood. When the liver is weakened, its dispersing function declines, inevitably affecting the spleen’s transformation and the kidneys’ storage functions, causing qi and blood circulation to become stagnant, ultimately leading to qi and blood deficiency, and the muscles, bones, and limbs failing to receive normal nourishment. The liver governs the tendons, and tendons are connected to bones, with qi flowing through the meridians; when tendons and bones become weak, it inevitably affects the nourishment and function of the bones. The liver stores blood, and essence and blood share the same origin; when the liver’s blood-storage function is insufficient, it inevitably leads to insufficient generation of kidney essence. In women, there is the saying “liver and kidneys share the same origin,” with the liver considered the innate foundation, so when the liver is imbalanced, the impact on osteoporosis is even greater. This also aligns with the fact that women often exhibit emotional abnormalities after menopause, which are closely related to osteoporosis. Therefore, liver qi and blood deficiency are an important factor in the development of osteoporosis.
6. Blood stasis is both a cause and a pathological consequence of primary osteoporosis. Wang Qingren’s Medical Forest Correction points out: “When original qi is deficient, it cannot reach the blood vessels, and the vessels lack qi, so blood inevitably stagnates.” This indicates that blood circulation depends on the propulsion of original qi, which is generated from kidney essence. If kidney essence is insufficient, blood circulation becomes weak and gradually turns into blood stasis. Once blood stasis forms, the meridians become blocked, leading to pain, blood stasis obstructing the channels, qi and blood becoming stagnant, and the bones losing nourishment, ultimately triggering osteoporosis. Patients with osteoporosis are prone to fractures, and the main pathogenesis and consequences of fractures are precisely blood stasis obstruction, so osteoporosis is closely related to blood stasis. II. Syndrome Differentiation and Treatment The term “bone wasting” first appeared in the Suwen · Discussion on Paralysis, which states: “When kidney qi is overheated, the lower back and spine lose their strength, the bones become dry and the marrow diminishes, resulting in bone wasting... The kidneys are water organs; now water cannot overcome fire, so the bones become dry and the marrow becomes deficient, thus the legs cannot support the body, leading to bone wasting.” Professor Pei Zhengxue believes that bone wasting is closely related to the kidneys, spleen, and liver, and the basic pathogenesis lies in spleen-kidney yang deficiency, liver-kidney yin deficiency, dual deficiency of qi and blood, and qi deficiency with blood stasis. During syndrome differentiation and treatment, it is necessary to grasp the characteristic of this disease—that it is “mostly deficient and mostly stasis.” Spleen-kidney yang deficiency prevents the warming and nourishment of blood vessels, leading to cold-induced blood stasis; liver-kidney yin deficiency causes fiery yin to scorch, resulting in blood coagulation and stasis; qi and blood deficiency leads to weak transformation and nourishment, blood fails to fill the meridians, and stasis forms. If there is external injury, the meridians are damaged, the collateral channels are blocked, qi stagnates, and over time, qi deficiency with blood stasis forms. Qi deficiency with blood stasis results in blockage of the meridians, stagnation of the channels, malnutrition of muscles and bones, and tendon weakness and bone dryness accompanied by pain. Therefore, “deficiency” and “stasis” run throughout the entire disease. Professor Pei Zhengxue believes that kidney essence deficiency is the root cause of osteoporosis, so tonifying the kidneys and strengthening the bones is the core of osteoporosis treatment. Patients often present with pain and soreness in the lower back, spine, and joints, hunchback, fatigue, and other symptoms. Those with kidney yang deficiency may also experience aversion to cold, frequent urination, and loose stools, while those with kidney yin deficiency may appear thin, experience five-heart heat, and have hot flashes and sweating. Therefore, for those with kidney yang deficiency, use Yanghe Decoction combined with Huangqi Guizhi Wuwu Decoction with modifications; for those with obvious yang deficiency, add Fuzi, YinYangHuo, and Bajitian. For those with kidney yin deficiency, choose Duohuo Jisheng Decoction combined with Shuji Yurou Decoction (Shudihuang, Jixueteng, YinYangHuo, RouCongrong, Lujiaojiao, Gousuibu, Laizi), and add GuiBan, Nüzhenzi, and Gouqizi to tonify the kidneys and replenish essence. The water and grain nutrients processed by the spleen and stomach can nourish the kidney water to strengthen muscles and bones, and also nourish the liver blood to regulate qi flow, so strengthening the spleen and stomach is key to treating osteoporosis. Those with spleen and stomach deficiency may experience poor appetite, diarrhea or constipation, limb weakness and fatigue, and muscle atrophy. Use Shengyang Yiwu Decoction with modifications to strengthen the spleen; if phlegm-dampness is heavy, add Chenpi, Baizhu, and Fuling to dispel dampness and strengthen the spleen. If patients exhibit severe spleen deficiency symptoms such as fatigue, poor appetite, diarrhea, exhaustion, and emaciation, increase the dosage of Dahuangqi and combine it with Dangshen to enhance qi-tonifying and spleen-strengthening effects. “Liver and kidneys share the same origin” is an abbreviation for “Yi and Gui share the same origin, liver and kidneys are treated together.” “Yi and Gui share the same origin” is the theoretical basis for the connection between the liver and kidneys. The kidneys govern the bones, and the bones are dry, so they can leverage their power; the liver governs the tendons, and the tendons are rigid, so they can constrain the bones. Bones and tendons are interdependent and influence each other physiologically, and mutually support each other functionally. Professor Pei Zhengxue skillfully applies the treatment principle of “tonifying the liver and kidneys, strengthening the tendons and bones” when treating bone wasting, insisting on simultaneously strengthening the tendons and bones, tonifying the liver and benefiting the kidneys. “Using tendons to nourish bones” means “bones are upright and tendons are flexible,” while “using bones to guide tendons” means “tendons are strong and bones are robust.” Only by treating tendons and bones equally can the balance between them be maintained. The Reading Notes on Medicine states: “All twelve meridians of the internal organs rely on the qi of the liver and gallbladder to stimulate them, only then can they function smoothly without illness.” This suggests that the normal operation of the kidneys, spleen, and other organs depends on the liver’s dispersing function, which distributes qi, blood, and body fluids throughout all organs, meridians, bodies, and orifices, allowing them to be nourished. Emotional imbalance, irritability, apathy, insomnia, excessive dreaming, etc., are caused by liver qi stagnation and depression, where qi stagnates and turns into heat, depleting yin blood, leading to liver blood deficiency, and consequently, the liver loses its ability to nourish itself; when the liver is imbalanced, its dispersing function is impaired, qi and blood distribution becomes obstructed, organs are deprived of nourishment, and the functions of the spleen and kidneys cannot operate normally; the liver is integrated with the tendons, and its brilliance manifests in the claws, so when the liver blood is deficient, the tendons and meridians are malnourished, the marrow becomes dry and the tendons become brittle, leading to limited limb movement and mobility issues. Therefore, Professor Pei Zhengxue believes that “treating the liver” is the key to treating osteoporosis. “Treating the liver” should be done with “softening the liver,” which is both “dispersing the liver” and “nourishing the liver.” The treatment method should focus on “softening the liver and nourishing the blood.” For dispersing the liver, choose Chaihu, Chuannianzi, and other herbs that can disperse qi and relieve liver stagnation; for nourishing the liver and blood, choose BaiShao, DangGui, GouQizi, Nüzhenzi, and other herbs that can both nourish the liver, tonify the kidneys, and replenish blood, balancing dispersing and nourishing functions, enhancing dispersing ability, and ensuring abundant liver blood, so that the tendons and meridians are nourished, achieving the goal of “treating tendons and bones equally.” For those with long-term liver and kidney deficiency and qi and blood deficiency, combined with blood stasis, use Duohuo Jisheng Decoction to tonify liver and kidney qi and blood, activate blood circulation, and relieve pain. Bone joint pain, pain has a fixed location, the painful area resists pressure, muscles contract, or there is a fracture, localized swelling and pain, limited mobility, often with a history of trauma or long-term illness, purple-dark tongue, presence of blood spots or patches, pulse is rough or string-like—indicating severe blood stasis—use Taohong Siwu Decoction combined with Huoluo Xiaoling Dan with modifications; for severe pain, add Wusha, Quanxie, and Wugong to clear wind and unblock channels. In addition, Professor Pei Zhengxue also emphasizes the application of the “preventive treatment” concept in this disease, stressing the importance of paying attention to the following five points: Follow the four seasons, avoid external evils, and keep warm. Bones are formed congenitally, while bone wasting occurs postnatally, and bone wasting does not happen overnight. Therefore, people need to adapt to the four seasons of life, and young, middle-aged, and elderly individuals should all take care of themselves, rather than focusing solely on the elderly. Modern research shows that human bone peak occurs around age 30; before age 30, bone density continuously increases, and after age 30, bone density begins to decline. Thus, during youth, one needs to build up and store enough bone mass; in middle age, one needs to warm the body to reach the bone peak; in middle age, one needs to nourish the spleen to ensure a smooth transition; and in old age, one needs to conserve energy and reduce bone loss. Professor Pei Zhengxue emphasizes that osteoporosis prevention should start from daily life, following the four seasons—spring for growth, summer for expansion, autumn for harvest, and winter for conservation—to avoid external evils that damage muscles and bones, and to achieve “positive qi inside, evil outside.” Cold evils easily attack the human body, stagnating muscles and bones, leading to qi and blood stasis, cold attracting and contracting, blood vessels shrinking, and blockages causing pain, so it is often necessary to keep warm, harmonize defensive qi and nutritive qi, ensure smooth qi and blood flow, and avoid pain. Engage in appropriate labor and exercise, and avoid falls. The Suwen · Ancient Heavenly Truths already proposed the idea of “moderate work and rest” and “physical labor without fatigue.” Professor Pei Zhengxue advocates reasonable exercise and strengthening functional training; Taijiquan, Five Animal Frolics, and other practices help improve bone quality, increase coordination between muscles and bones, and prevent fractures. However, exercise should be moderate, conducted properly, and sometimes avoided to prevent injuries during exercise. Take daily baths, supplement calcium, and increase bone mass. Professor Pei Zhengxue recommends walking in the sun for 30 minutes every day to meet the daily vitamin D requirement, while also supplementing adequate calcium. Modern research shows that when the human body lacks vitamin D, bone density decreases and the risk of fractures increases. Regular sun exposure is a simple yet effective way to improve bone mass in the elderly. Adjust diet, tonify liver and kidneys, and limit smoking and drinking. The Suwen · Discussion on Seasonal Qi proposes the idea of “five grains for nourishment, five fruits for assistance, five livestock for benefit, and five vegetables for filling,” stating that “grains, meat, fruits, and vegetables together fully nourish the body.” This indicates that a reasonable diet promotes bone salt deposition and prevents bone wasting. It is also important to quit smoking and limit alcohol consumption.

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Input: Control the intake of coffee, strong tea, and carbonated beverages; balancing your diet can help manage bone mass loss. Nicotine and excessive caffeine can increase calcium release from bones and calcium excretion in urine, Alcohol can inhibit bone formation and indirectly promote bone resorption, leading to osteoporosis. For those who have already experienced a fracture, it is crucial to prevent complications and maintain continuous treatment. Patients who have suffered a fracture need to focus on preventing further fractures and managing their condition effectively. After a fracture, bed rest can lead to complications such as pressure ulcers, aspiration pneumonia, and urinary tract infections, so proactive prevention is essential. Additionally, long-term, consistent treatment for osteoporosis is necessary to avoid complications and secondary fractures. Doctors should strengthen patient education, promote mental and physical harmony, alleviate patients' psychological burdens, boost their confidence in overcoming the disease, stabilize the course of the illness, and strive for optimal therapeutic outcomes.

1. Liver and Kidney Deficiency Syndrome Symptoms include: lower back and waist pain, soreness and weakness, even leading to hunchback and kyphosis, dizziness and tinnitus, limited range of motion, fear of cold and preference for warmth, which worsens when exposed to cold—especially in the lower limbs, frequent urination, pale tongue with white coating, and a deep, fine or deep, tense pulse. Treatment principle: Tonify the kidneys and replenish essence, strengthen muscles and bones. Prescription: A modified version of Duhuo Jisheng Tang combined with Shuji Ji Yang Tang. Sangji Sheng, Duhuo, Qin, Xixin, Du Zhong, Niu Xi, Gui Zhi, Fang Feng, Dang Shen, Fu Ling, Dang Gui, Chuan Xiong, Bai Shao, Shu Di Huang, Ji Xue Teng, Yin Yang Huo, Rou Cong Rong, Lu Zi, Gan Cao. For those with significant lower back and waist pain, supplement with Bu Gu Zhi, Guo Sui Bu, Xu Duan, and Gou Ji to nourish the liver and kidneys and strengthen muscles and bones; for those with wind-damp obstruction and heavy, aching lower back and legs, combine with Jin Niu Bai Hua Tang (Jin Mao Gou Ji, Niu Xi, Bai Shao, Qiang Du Hua, Sheng Yi Ren, Gui Zhi, Ji Xue Teng) to tonify the liver and kidneys, dispel wind-damp, and unblock the meridians.
2. Spleen and Kidney Yang Deficiency Syndrome Symptoms include: cold pain in the lower back and hips, soreness and weakness in the lower back and knees, fear of cold and preference for warmth, poor appetite with abdominal distension, pale, plump complexion, white, slippery tongue coating, and a deep, weak pulse. Treatment principle: Tonify the spleen and kidneys, strengthen muscles and bones. Prescription: For those primarily suffering from spleen deficiency, use a modified version of Sheng Yang Yi Wei Tang. Qiang Huo, Duhuo, Fang Feng, Fa Ban Xia, Huang Lian, Chen Pi, Chai Hu, Bai Shao, Fu Ling, Ze Xie, Dang Shen, Bai Zhu, Huang Qi, Gan Cao. Prescription: For those primarily suffering from kidney deficiency, use Yang He Tang combined with Huang Qi Gui Zhi Wu Wu Tang, adjusted accordingly. Shu Di Huang, Lu Jiao Gao, Pao Jiang, Rou Gui, Ma Huang, Bai Jie Zi, Huang Qi, Gui Zhi, Bai Shao, Fu Zi, Gan Cao, Sheng Jiang, Da Zao. For those with blood stasis, add Dan Shen and Dang Gui to nourish blood, activate blood circulation, and relieve pain; for severe pain, add Zhi Chuan Cao Wu, Liao Xi Xin, and fried Macha to warm and unblock the meridians, dispel cold and relieve pain. For those with cold pain in the lower back and hips, fear of cold and preference for warmth, and obvious yang deficiency with cold stagnation, you can use Wu Mi Niu Gu Tang (Wu Jia Pi, Sheng Ren, Niu Xi, Po Gu Zhi, Guo Sui Bu, Bo He, Qing Feng Teng, Qin Ruo, Qing Feng Teng, Zhi He Tou Wu, Bai Shao, Gan Cao, Gui Zhi, Zhi Chuan Cao Wu, Fried Macha) to adjust the formula, dispel wind and remove dampness, warm yang and disperse cold, while also tonifying the liver and kidneys.
3. Blood Stasis and Qi Stagnation Syndrome Symptoms include: joint pain, localized pain, pain that is resistant to pressure, muscle and tendon contractures, or fractures, local swelling and pain, limited range of motion. Often accompanied by trauma or a history of chronic illness; the tongue is dark purple with ecchymoses or bruises, and the pulse is slow or string-like. Treatment principle: Regulate qi, activate blood circulation, resolve blood stasis and relieve pain. Prescription: A modified version of Tao Hong Si Wu Tang combined with Huo Luo Xiao Ling Dan. Tao Ren, Hong Hua, Sheng Di, Bai Shao, Chuan Xiong, Dang Gui, Zhi Ru Mo, Dan Shen, Xiang Fu. For those whose bone pain is mainly in the upper limbs, add Sang Zhi and Turmeric to activate blood circulation and unblock the meridians; for those whose lower limbs are more affected, add Duhuo and Fang Ji to dispel wind and relieve pain. For those with long-standing joint deformities and severe pain, add Wu She, Quan Xie, and Wugong to search for wind and clear the meridians. For those with long-term liver and kidney deficiency, insufficient qi and blood, and accompanying blood stasis, you can combine Duhuo Jisheng Tang to tonify the liver and kidneys, nourish qi and blood, activate blood circulation, and relieve pain. III. Clinical Cases and Treatments Case 1: Zhang, female, 52 years old, first visited the clinic on February 3, 2017. The patient had been experiencing lower back and waist pain for over a year, and was diagnosed with postmenopausal osteoporosis at a Grade III hospital. Present symptoms included: lower back and waist pain, significant difficulty turning over at night, weakness in both lower limbs, frequent calf cramps, irritability and anger, burning sensation in the palms and soles, poor sleep quality, dark red tongue with little coating, and a deep, fine pulse. Western medical diagnosis: Postmenopausal osteoporosis. Traditional Chinese Medicine diagnosis: Liver and kidney deficiency. Treatment principle: Nourish the liver and kidneys, replenish essence and marrow, clear heat and calm the mind. Prescription: A modified version of Duhuo Jisheng Tang. Sang Ji Sheng 15g, Duhuo 10g, Qin 10g, Du Zhong 10g, Niu Xi 10g, Fang Feng 10g, Chuan Xiong 6g, Shu Di Huang 10g, Sheng Di Huang 10g, Zhi Mu 10g, Huang Bai 10g, Gui Ban 10g (first decocted), Dang Gui 10g, Bai Shao 10g, Chao San Zao Ren 30g, Chuan Xiong 6g, Fu Ling 10g, Gan Cao 6g. After 14 doses, decocted in water and taken once daily. After taking the medication, the lower back and waist pain improved, sleep significantly improved, though still feeling hot in the palms and soles, and the tongue and pulse remained unchanged. Add 15g of Nu Zhen Zi, 15g of Han Lian Cao, 10g of Xu Duan, and 10g of Dan Shen to the previous formula, continuing treatment for another 14 doses. After taking the medication, all symptoms improved significantly. Subsequently, the above formula was adjusted and used for more than five months. All symptoms were fully resolved, and follow-up bone density tests showed results close to normal. Case 2: Liu, male, 70 years old, first visited the clinic on March 8, 2019. Three months prior, the patient began experiencing joint pain throughout his body and sought treatment at a Grade III hospital, where he was diagnosed with senile osteoporosis. He was treated with calcitriol, vitamin D calcium chewable tablets, and celecoxib, and his symptoms improved, but his appetite gradually declined. He came for consultation again. Present symptoms included: general body pain, particularly pronounced at night, lower back and leg fatigue, occasional tinnitus, poor appetite, constipation, frequent nighttime urination, dark, plump tongue with little coating, and a deep, fine pulse. Western medical diagnosis: Senile osteoporosis. Traditional Chinese Medicine diagnosis: Deficiency of kidney essence. Treatment principle: Tonify the kidneys and replenish essence, nourish blood and unblock the meridians. Prescription: A modified version of Shu Ji Ji Yang Tang combined with Ji Chuan Jian. Shu Di Huang 12g, Ji Xue Teng 15g, Yin Yang Huo 10g, Rou Cong Rong 15g, Rou Gui 6g (added later), Lu Jiao Gao 10g (prepared), Guo Sui Bu 10g, Lu Zi 15g, Shan Yao 10g, Shan Zhu Yu 10g, Ke Qi Zi 10g, Dang Gui 15g, Du Zhong 10g, Niu Xi 15g, Zhi Ke 10g, Sheng Ma 6g, Ze Xie 6g. After 14 doses, decocted in water and taken once daily. It was advised to stop using celecoxib and continue taking calcitriol and vitamin D calcium chewable tablets. Second visit: After taking the medication, the patient’s body pain lessened, constipation improved, but his appetite remained poor, and he continued to experience frequent nighttime urination. The tongue and pulse remained unchanged. Add 6g of Sha Ren, 10g each of Jiao San Xian, 10g of Ji Nei Jin, and 6g of Zhi Fu (decocted first) to warm the kidneys and replenish qi, stimulate the spleen and open the stomach, and continue treatment for another 14 doses.

Third visit: After taking the medication, all symptoms improved significantly. Subsequently, the above formula was adjusted and used for more than one month, and the lower back and leg pain disappeared. However, the patient still experienced lower back and leg fatigue, intermittent tinnitus, and constipation with frequent urination. Increase the dosage of honey pills threefold, taking two courses, and all symptoms were completely resolved. Section 3: Primary Osteoporosis – Ancient and Modern Theories From “Su Wen · Wei Lun”: “When kidney qi is hot, the lower back cannot be lifted, bones become dry and marrow diminishes, leading to bone atrophy.” In “Jin Kui Yao Lü · Zhong Feng Li Jie Bing Mai Zheng Shi He Zhi,” it is stated: “Sour tastes harm tendons; when tendons are harmed, they become slack, known as ‘xie’; salty tastes harm bones; when bones are harmed, they become weak.” Wang Bing of the Tang Dynasty said: “The lower back is the residence of the kidneys, and the kidney meridian runs inward along the inner thighs, passing through the spine and belonging to the kidneys. Therefore, when kidney qi is hot, the lower back and spine cannot be lifted. The kidneys govern bone marrow; thus, when qi is hot, bones become dry and marrow diminishes, leading to bone atrophy.” Zhang Jie Bin of the Ming Dynasty said: “Kidney atrophy is also bone atrophy. The lower back is the residence of the kidneys, its meridian runs through the spine, and it governs bone marrow; therefore, when kidney qi is hot, the signs manifest as such.” Based on these discussions, it is evident that in “Su Wen · Wei Lun,” the site of bone atrophy lies in the bones, and bones are governed by the kidneys. Since the kidneys govern the production of bone marrow, bone atrophy in later generations is often referred to as “kidney atrophy.” “Su Wen · Wei Lun” describes the symptoms of bone atrophy as “lower back and spine unable to lift, bones dry and marrow diminished,” “yellowish color,” and “unable to stand up.” In “Jin Kui Yao Lü · Zhong Feng Li Jie Bing Mai Zheng Shi He Zhi,” it is noted: “Sour tastes harm tendons; when tendons are harmed, they become slack, known as ‘xie.’ Salty tastes harm bones; when bones are harmed, they become weak, known as ‘ku.’ When weakness and excess coexist, it is called ‘duan xie.’ When vital energy is blocked and defensive energy does not flow freely, both vital energy and defensive energy become weak, the three jiao lose their control, the body becomes emaciated, the feet swell, yellow sweat appears, the shins grow cold, yet fever may occur—this is what we call ‘li jie.’ It has been recognized that if bone atrophy progresses further, it can evolve into the characteristic patterns of ‘li jie.’” During the Qing Dynasty, physician Wang Qingren pointed out: “Both ‘wei’ and ‘bi’ are different conditions. ‘Wei’ refers to paralysis of both legs, with no pain at all throughout the entire process.” Physician Gao Shishi of the Ming Dynasty said: “‘Wei’ means weakness and paralysis of the limbs, making movement impossible—like being abandoned and unused.” “Su Wen · Wei Lun” believed that bone atrophy originates in the kidneys; overwork, exposure to external pathogens, and internal organ injuries can all lead to bone atrophy. Relevant passages state: “When one travels far and becomes fatigued, encountering intense heat and thirst… this leads to bone atrophy.” “Su Wen · Wei Lun” also mentions that abnormal weather patterns and the invasion of external evils during the four seasons can directly cause ‘little qi and bone atrophy.’ The kidneys are black in color and govern bones; kidney disorders can also lead to bone atrophy. “The kidneys are the water organs; when water fails to overcome fire, bones become dry and marrow deficient, causing the feet to bear the weight of the body—and this is how bone atrophy arises.” If kidney essence is already depleted, then bone atrophy may present as “lower back unable to lift, bones dry and marrow diminished,” “yellowish color,” and “teeth,” among other manifestations of kidney disorder. Furthermore, “Ling Shu · Jing Mai” records that “when the kidneys are diseased, bone atrophy occurs.” “Su Wen · Yin Yang Bie Lun” mentions that the Taiyin and Taiyang meridians can cause bone atrophy: “When the three yang and three yin diseases arise, it is easy to develop partial atrophy and weakness, with the four limbs unable to lift.” “Jin Kui Yao Lü · Zhong Feng Li Jie Bing Mai Zheng Shi He Zhi” states that excessive saltiness in the five flavors of food harms bones, leading to bone atrophy: “...salt harms bones; when bones are harmed, they become weak.” Regarding the treatment of bone atrophy, “Su Wen · Wei Lun” did not explicitly specify a particular approach, but it proposed general principles for treating ‘wei’ conditions: “When treating ‘wei,’ focus solely on Yangming,” “Each should nourish its own vital energy and unblock its own meridians, regulate its deficiencies and excesses, harmonize its opposing forces, and treat muscles, tendons, bones, and flesh according to the time of year.” These principles provided strong guidance for later physicians in treating bone atrophy. Moreover, “Ling Shu · Gen Jie” states: “Sunlight opens, Yangming joins, and Shaoyang serves as the pivot. When opening and breaking, the muscles and joints become loose, and acute illnesses arise; therefore, for acute illnesses, treat them with Sunlight… when joining and breaking, qi cannot be contained, and ‘wei’ diseases arise; therefore, for ‘wei’ diseases, treat them with Yangming.” “Yangming is the sea of the five internal organs and six viscera, governing the lubrication of tendons and ligaments; tendons and ligaments govern the bones and facilitate the movement of joints.” High-shi Zong of the Qing Dynasty commented: “Yangming is the stomach, receiving and transforming water and grains, thus serving as the sea of the five internal organs and six viscera. Skin, flesh, tendons, veins, and bones all rely on the essence of water and grains; therefore, Yangming governs the lubrication of tendons and ligaments. Tendons and ligaments are the primary tendons of the anterior region, thus governing the bones and facilitating the movement of joints. When ‘wei’ arises, the joints become unbalanced, tendons and bones are not harmonized; when tendons and bones are not harmonized, it is because Yangming cannot provide sufficient lubrication. Therefore, when treating ‘wei,’ focus solely on Yangming.” This was a profound explanation of “treating ‘wei’ solely with Yangming.” However, the human body is an organic whole; we cannot focus solely on Yangming while neglecting the others. We should discern deficiencies and excesses based on individual circumstances, examine the balance between opposing forces, and tailor treatment to the time, place, and person. As stated in “Su Wen · Wei Lun”: “Each should nourish its own vital energy and unblock its own meridians, regulate its deficiencies and excesses, harmonize its opposing forces, and treat muscles, tendons, bones, and flesh according to the time of year.” Ming Dynasty physician Zhu Su, in his book “Pu Ji Fang,” treated bone atrophy caused by five types of ‘wei,’ drawing on extensive experience and emphasizing treatment of bone atrophy from the perspective of “the kidneys.” For those with “cold kidneys,” he used Long Gu Wan; for those with “deficiency of the kidney meridian,” he used Qiqi Dan; for those with damage to the yin essence, he used Jing Gang Wan; and for those with kidney and liver deficiency, he used Niu Xi Wan—using specific medicinal formulas tailored to each case. During the Qing Dynasty, physician Wang Qingren, in his work “Yi Lin Gai Cuo · Fan Wei Lun,” pointed out: “‘Wei’ and ‘bi’ are different conditions. ‘Wei’ refers to paralysis of both legs, with no pain at all throughout the entire process… and when qi is deficient and cannot circulate downward, we should use qi-nourishing medicines…” He emphasized the use of methods that invigorate qi, activate blood circulation, and unblock the meridians in treating ‘wei’ conditions. His pioneering formula, “Bu Yang Huan Wu Tang,” became an important remedy for treating ‘wei’ in later generations. Contemporary renowned traditional Chinese medicine practitioner Liu Qingsi believes that the pathogenesis of primary osteoporosis involves kidney deficiency, spleen deficiency, and blood stasis, with kidney deficiency being the primary factor. The disease location is in the kidneys, spleen, and meridians. Clinically, it is divided into four syndromes: kidney yang deficiency syndrome, kidney yin deficiency syndrome, spleen-kidney deficiency syndrome, and qi stagnation with blood stasis syndrome—among which kidney yang deficiency syndrome is most common, accounting for about 80%. The basic treatment approach is to “tonify the kidneys and strengthen bones, nourish the spleen and enhance qi, activate blood circulation and unblock the meridians,” creating formulas like “Bu Shen Jian Pi Huo” (15g Bu Gu Zhi, 10g Yin Yang Huo, 15g Shu Di Huang, 15g Bai Shao, 15g Huang Qi, 15g Dan Shen, 15g Dang Gui, 10g Rou Cong Rong) to treat this condition, with remarkable therapeutic effects. Veteran traditional Chinese medicine practitioner Zhang Wentai believed that this condition is mostly characterized by fundamental deficiency—deficiency in the liver, kidneys, and spleen—but there are also varying degrees of overt symptoms mixed with underlying conditions such as overwork, cold dampness, and blood stasis. In some cases, overt symptoms may exacerbate underlying deficiencies. Once the liver, kidneys, and spleen are weakened, they become more susceptible to factors like overwork, cold dampness, and blood stasis. These factors, once activated, can further weaken the liver, kidneys, and spleen, leading to increasingly severe conditions. Treatment should begin with a comprehensive and clear understanding of the etiology and pathogenesis, emphasizing holistic thinking and differentiated diagnosis and treatment. The focus should be on nourishing the liver and kidneys, strengthening muscles and bones, supporting the spleen and promoting digestion, while also nourishing tendons and bones.