Introduction: Learn from Mr. Zhou Xinyou's experience in treating Bi syndrome.

The occurrence of Bi syndrome is attributed to two main factors: one is the invasion of external pathogens, such as wind, cold, dampness, and damp-heat; the other is internal deficiency of healthy qi and obstruction of the nutritive and defensive qi as well as qi and blood.

The former refers to etiological factors, while the latter pertains to constitutional factors; only when these two combine can they lead to arthralgia.

This aligns with the statement in the *Inner Canon*: "Can the qi of the nutritive and defensive systems also cause arthralgia? ... If they do not combine with wind, cold, and dampness, they will not cause arthralgia."

Based on the causes of arthralgia syndrome, it is clinically classified into two major categories.

One category includes "wandering arthralgia," "painful arthralgia," and "fixed arthralgia," which are caused by the combined invasion of the three external pathogens—wind, cold, and dampness. The other category is "heat arthralgia," which results from the invasion of wind and dampness, stagnation transforming into heat, and dampness lingering in the joints.

Based on the above theories, my principles for treating arthralgia syndrome are:

1. Addressing external causes by expelling pathogenic factors, primarily through methods such as dispersing wind, dissipating cold, eliminating dampness, and clearing heat. However, it is important to adhere to the principles of "warming and transforming cold-dampness" and "clearing and transforming damp-heat."

2. Addressing internal causes by harmonizing the nutrient and defense systems, qi and blood, and relaxing tendons and unblocking collaterals.

3. According to the principle that "chronic illness inevitably leads to deficiency, and chronic illness affects the kidneys," arthralgia syndrome in its later stages often presents with osteoporosis and destruction of articular cartilage and bone tissue. Therefore, treatment should focus primarily on tonifying the kidneys, supplemented by expelling pathogenic factors. This principle should be applied flexibly in clinical practice based on the different manifestations of arthralgia syndrome at various stages.

In the early stage of Bi syndrome, it is often seen in the acute phase of what Western medicine calls rheumatic arthritis or rheumatoid arthritis, usually characterized by excessive damp-heat.

For heat Bi syndrome due to damp-heat obstructing the collaterals, it is appropriate to use clearing and transforming methods, often treating with wind-dispersing, heat-clearing, dampness-removing, and collateral-unblocking therapies.

Commonly used herbs include Lonicera japonica (Jinyinhua), Forsythia suspensa (Lianqiao), Mulberry twig (Sangzhi), Siegesbeckia herb (Xixiancao), Erythrina bark (Haitongpi), Stephania tetrandra (Fangji), raw Coix seed (Shengyiren), Gentiana macrophylla (Qinjiao), raw gypsum (Shengshigao), Anemarrhena rhizome (Zhimu), red and white peony root (Chibaishao), Salvia miltiorrhiza (Danshen), and Corydalis rhizome (Yanhusuo).

Prescription: Lonicera japonica (Jinyinhua) 30g, Forsythia suspensa (Lianqiao) 15g, Mulberry twig (Sangzhi) 20g, Dandelion (Pugongying) 20g, Anemarrhena rhizome (Zhimu) 15g, Gentiana macrophylla (Qinjiao) 20g, Ephedra (Mahuang) 10g, Cinnamon twig (Guizhi) 10g, Erythrina bark (Haitongpi) 15g, Siegesbeckia herb (Xixiancao) 15g, Stephania tetrandra (Fangji) 9g, raw Coix seed (Shengyiren) 30g, red and white peony root (Chibaishao) 15g each, Salvia miltiorrhiza (Danshen) 20g, Corydalis rhizome (Yanhusuo) 20g, processed myrrh and frankincense (Zhirumoyao) 15g each, decoct in water for oral administration.

Arthralgia syndrome with predominant cold-dampness is clinically manifested as "painful obstruction" or "fixed obstruction," commonly seen in chronic or active stages of rheumatoid arthritis and rheumatic arthritis.

Treatment should focus on warming and transforming, often employing methods to dispel wind, disperse cold, remove dampness, and unblock collaterals. Commonly used herbs include cinnamon twig, asarum, notopterygium root, pubescent angelica root, mulberry twig, large gentian root, lycopodium herb, prepared aconite accessory tuber, prepared Sichuan aconite root, and Chinese angelica.

Prescription: Cinnamon twig 9g, prepared aconite accessory tuber 9g, mulberry twig 20g, notopterygium root and pubescent angelica root 9g each, large gentian root 20g, asarum 6g, Chinese angelica 9g, salvia root 20g, red peony root and white peony root 9g each, corydalis tuber 20g, prepared frankincense and myrrh 15g each, spatholobus stem 20g. Decoct in water for oral administration.

In the later stages of arthralgia syndrome, it often manifests as kidney deficiency and yang decline. Patients typically present with limb joint deformities, stiffness, movement disorders, and cold limbs with aversion to cold due to factors such as osteoporosis, destruction of articular cartilage, and hyperosteogeny.

At this stage, treatment should focus on tonifying the kidneys, warming yang, strengthening tendons and bones, supplemented by dispelling wind, eliminating dampness, activating blood circulation, and unblocking collaterals. This approach ensures tonification without obstructing flow and attacking pathogens without damaging healthy qi.

Commonly used herbs include Psoraleae Fructus (Buguzhi), Rehmanniae Radix Praeparata (Shudi), Dipsaci Radix (Chuanduan), Drynariae Rhizoma (Gusulbu), Epimedii Folium (Yinyanghuo), and Morindae Officinalis Radix (Bajitian).

Prescription: Psoraleae Fructus (Buguzhi) 20g, Rehmanniae Radix Praeparata (Shudi) 9g, Dipsaci Radix (Chuanduan) 20g, Drynariae Rhizoma (Gusulbu) 20g, Epimedii Folium (Yinyanghuo) 20g, Morindae Officinalis Radix (Bajitian) 20g, Achyranthis Bidentatae Radix (Huainiuxi) 15g, Taxilli Herba (Sangjisheng) 20g, Cibotii Rhizoma (Gouji) 20g, Astragali Radix (Huangqi) 20g, Cinnamomi Ramulus (Guizhi) 9g, Notopterygii Rhizoma et Radix (Qianghuo) and Angelicae Pubescentis Radix (Duhuo) 9g each, Aconiti Lateralis Radix Praeparata (Zhifupian) 9g, Aconiti Radix Cocta (Zhichuanwu) and Aconiti Kusnezoffii Radix Cocta (Zhicaowu) 9g each, Angelicae Sinensis Radix (Danggui) 9g, Salviae Miltiorrhizae Radix et Rhizoma (Danshen) 20g, Spatholobi Caulis (Jixueteng) 20g, Lycopodii Herba (Shenjincao) 20g, Scorpio (Quanxie) 10g, and roasted pig bone (Zhizhugu) 15g (decocted separately and mixed in). Decoct in water for oral administration.

Based on my experience, correct application of this treatment method can not only significantly improve symptoms but also allow for a rapid reduction in the dosage of long-term steroid use, leading to complete withdrawal.

Additionally, in treating arthralgia syndrome, I place great emphasis on the use of warm and hot-natured herbs.

Warm and hot-natured herbs are indispensable in all stages and types of arthralgia syndrome because they possess the effect of dispersing and unblocking obstructions. This is highly beneficial for improving and even eliminating the pathological conditions of meridian blockages, stagnation of nutrient and defensive qi and blood, and the congealing of phlegm and blood stasis in arthralgia syndrome.

Therefore, I advocate that regardless of whether arthralgia syndrome is classified as cold or heat, herbs such as processed aconite and processed Sichuan aconite can be added to the basic formula.

Sichuan aconite excels at relieving pain, while aconite is superior at dispersing cold.

It is important to note that alcohol should not be consumed during the medication period, as ethanol can promote the absorption of aconitine, thereby enhancing the toxicity of aconite and leading to poisoning. Additionally, it should not be used together with ephedra to avoid adverse reactions.

The general dosage is 12g each of processed aconite root, processed Sichuan aconite, and cassia twig, with a maximum dose not exceeding 20g. If the dosage of processed aconite root or processed Sichuan aconite exceeds 15g, it should be decocted first.

A gradual increase method can also be adopted. For example, the dosage of processed Sichuan aconite can start from 7g and increase by 3g per dose.

Whether to continue increasing the dosage depends on two factors: first, stop when the desired therapeutic effect is achieved; second, if toxic reactions occur, the increase should be stopped or the dosage reduced.

Skillful use of insect-based medicines is also a characteristic of my approach to treating arthralgia syndromes, particularly stubborn arthralgia.

Insect-based medicines possess the properties of penetrating and eliminating pathogens, dispelling wind and unblocking collaterals, reducing swelling and relieving pain, and restoring function. For all cases of stubborn arthralgia, it is essential to combine herbal medicines with insect-based medicines to achieve optimal therapeutic effects.

This is because, at this stage, the pathogenic factors have deeply invaded the meridians, bone marrow, and joints, causing stagnation of qi and blood, coagulation of phlegm-dampness and turbid stasis, and obstruction of the meridians and collaterals. These conditions cannot be effectively addressed by herbal medicines alone; it is necessary to rely on the searching, penetrating, and dispersing actions of insect-based medicines to eliminate turbidity, resolve coagulation, unblock the meridians and collaterals, expel pathogens, and restore healthy qi.

For specific usage, generally for joint pain, add 5g of scorpion, grind into powder and take in divided doses; or add 2 centipedes, grind into powder and take in divided doses, to dispel wind and relieve pain.

Additionally, honeycomb, silkworm, and dung beetle can be used to disperse swelling through the joints.

For those with severe cold-dampness, Qishe (Agkistrodon) and Cansha (silkworm droppings) can be used to dispel wind and drain dampness; for those with excessive heat, earthworms can be used to clear heat and unblock the collaterals; for those with blood stasis, ground beetles can be used to break stasis and resolve masses. In particular, Qishe (Agkistrodon) and Wushaoshe (Zaocys) are especially effective in treating wind-damp impediment syndrome.