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The Qi of the human body is constantly ascending, descending, exiting, and entering at all times; therefore, vitality never ceases. The Spleen and Stomach reside in the middle Jiao (Middle Burner); the Spleen governs the ascending of clear Yang, and the Stomach governs the descending of turbid Yin, serving as the pivot for the ascending and descending of Qi mechanism in the body. If dietary habits are irregular or physical exertion is excessive, damaging the Spleen and Stomach, it leads to deficiency of Spleen and Stomach Qi, dysfunction of transportation and transformation, obstruction of Qi mechanism ascending and descending, and generation of heat due to stagnation. The patient's symptoms also illustrate this point: if Stomach Qi fails to descend, appetite decreases; if Spleen Qi fails to ascend, loose stools occur. Fatigue, shortness of breath with reluctance to speak, dizziness, pale tongue, and weak pulse are manifestations of Spleen deficiency failing to transport, clear Yang not ascending, and inability to nourish the whole body. Wei Qi (Defensive Qi) originates from congenital essence and is nourished by acquired essence. Now, due to Spleen Qi deficiency, there is insufficient nourishment for Wei Qi, leading to Wei Qi deficiency and loss of its function to secure the exterior and protect against external pathogens; thus, spontaneous sweating occurs frequently, and susceptibility to colds increases. The fever and other symptoms that worsen after exertion occur because labor consumes Qi, further depleting it; the more deficient the Qi, the more severe the stagnation, and thus the fiercer the heat. In summary, the mechanism of Qi deficiency fever lies in Spleen and Stomach Qi deficiency, abnormal ascending and descending, obstruction of Qi mechanism, and generation of heat due to stagnation. Among these, Spleen Qi deficiency is the primary pathogenesis.

Physician Yi: Why is it common to prescribe herbs for clearing heat and purging fire, as well as nourishing Yin, for Qi deficiency fever?

Teacher: This is often due to unclear differentiation of syndromes, mistakenly identifying Qi deficiency fever as excess heat or Yin deficiency fever. Generally speaking, fever in early-stage or acute diseases is mostly excess heat. Such conditions may arise from external pathogens constraining the exterior, extreme emotional fluctuations, injury from diet or insects/animals, or trauma, causing various pathogenic factors to obstruct the smooth flow of Yang Qi, which accumulates and generates heat. This corresponds to the statement in *Nei Jing* (Inner Canon): "Excess Yang leads to heat." For this patient's persistent high fever, people often focus only on the symptom of high fever while neglecting various signs of Spleen deficiency and Qi weakness, thereby misdiagnosing it as an excess heat syndrome. Since it is considered excess heat, "treating heat with cold" is the correct method; thus, cooling herbs such as those for clearing heat and purging fire recommended in community physician manuals are deemed necessary. However, cold-natured herbs easily damage the Spleen and Stomach and injure Yang Qi; consequently, after administration, symptoms do not subside, and heat intensifies. At this stage, sweet-warm formulas should be administered, but in clinical practice, doctors often tend to adopt methods for nourishing Yin and clearing heat, forgetting the method of using sweet-warm herbs to remove heat. This is because of the saying in *Nei Jing*: "For those whose heat persists despite cold treatments, treat the Yin," and Wang Bing's commentary: "If cold does not resolve the heat, it indicates a lack of Water (Yin)." Therefore, when heat persists despite the use of heat-clearing and fire-purging agents, it is easy to switch to the method of "strengthening the source of Water to control the sunlight (Yang)." Although both Qi deficiency and Yin deficiency are deficiency syndromes, their treatment principles are completely different: one requires acrid-sweet-warm tonifying and unblocking agents, while the other uses cold-cool moistening and tranquilizing flavors. One is Yin, the other Yang; one is rigid, the other soft; they must absolutely not be confused. If Yin deficiency patients mistakenly use sweet-warm ascending and unblocking drugs, it will inevitably consume Yin and assist heat, making the fire burn even fiercer; if Qi deficiency patients recklessly apply cold-moistening and tranquilizing substances, it will surely damage the Spleen, obstruct Qi, and cause Qi mechanism to become more stagnant. This is why using Yin-nourishing agents fails to produce effects in this syndrome. If we carefully analyze the medical history, symptoms, and medication effects comprehensively, we can avoid the aforementioned errors.

Physician Bing: What is the principle for treating Qi deficiency fever?

Teacher: As discussed earlier, the mechanism of Qi deficiency fever is Spleen Qi deficiency, abnormal ascending and descending, and stagnation of Qi mechanism. Therefore, treating this syndrome should primarily focus on tonifying the deficiency, facilitating ascending and descending, and relieving stagnation. However, the key to this syndrome lies in Spleen Qi deficiency and the failure of clear Yang to ascend; hence, "one must solely use sweet-warm agents to tonify the center and raise the Yang" (*Pi Wei Lun* [Treatise on the Spleen and Stomach]). The method of "sweet-warm removal of heat" is precisely targeted at this syndrome. Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) is the main formula for treating this syndrome. In the formula, Ren Shen (Ginseng Root), Huang Qi (Astragalus Root), Bai Zhu (Atractylodes Rhizome), and Gan Cao (Licorice Root) tonify the Spleen and augment Qi, serving as the principal herbs. Chai Hu (Bupleurum Root) raises clear Yang, and Chen Pi (Citrus Peel) harmonizes and descends Stomach Qi. Furthermore, Chai Hu and Chen Pi possess the functions of dispersing stagnation and resolving constraint. Dang Gui (Angelica Sinensis Root) is acrid, sweet, warm, and moistening; it can nourish blood and mitigate the harsh dryness of other herbs, and its nature is moving and dispersing without being cloying, further helping to harmonize blood vessels, resolve stagnation, and disperse blockage. Synthesizing the functions of this formula, it tonifies the Spleen and augments Qi, raises clear Yang and descends turbid Yin, disperses stagnation and promotes movement, which perfectly matches the pathogenesis of Qi deficiency fever, resulting in relatively ideal efficacy.

Physician Yi: What is the rationale for adding Rou Gui (Cinnamon Bark) and Sheng Mai Ya (Raw Sprouted Barley) to this formula?

Teacher: For Qi deficiency fever syndrome, adding Rou Gui is generally unnecessary. However, since this patient has repeatedly used heat-clearing and Yin-nourishing agents, it is inevitable that the cold nature was excessive, injuring Middle Yang and causing Spleen-Stomach deficiency-cold; therefore, Rou Gui is added to warm the Spleen and Stomach and invigorate Middle Yang. Since this syndrome is neither excess heat nor Yin deficiency, there is no need to worry about Rou Gui assisting heat or damaging Yin. Moreover, Rou Gui not only dispels cold and warms the interior but also possesses an aromatic, acrid, and penetrating nature, having the function of venting stagnation and promoting smooth flow, which is harmless and beneficial to this syndrome.

Sheng Mai Ya is added to this formula because its nature excels in ascending and promoting, aiding the Spleen and Stomach. Firstly, it serves as an assistant to tonifying herbs like Ren Shen, Bai Zhu, and Huang Qi, helping to transform and transport their medicinal power, preventing bloating and fullness. Secondly, Sheng Mai Ya inherits the ascending Qi of Spring, greatly assisting in raising the clear Yang of the Spleen and Stomach and promoting the smooth flow of Liver and Gallbladder Qi, resolving stagnation, and reducing fever.

Physician Jia: When discussing the mechanism of Qi deficiency fever earlier, the teacher mentioned both Qi deficiency and Qi mechanism stagnation. My impression is that Qi deficiency and Qi stagnation seem contradictory; how did they become causally related?

Teacher:所谓 Qi stagnation refers to the sluggish and unsmooth flow of Qi mechanism. There are many causes for Qi mechanism stagnation, which can be summarized into two categories: excess and deficiency. Excess refers to flourishing pathogenic factors. It may be caused by external constraints of the Six Evils (Six Pathogenic Factors), emotional dissatisfaction, phlegm-dampness or fluid retention, or retained food and blood stasis, etc., obstructing the smooth flow of Qi and causing stagnation; "six types of stagnation diseases" mostly belong to this category. Deficiency refers to stagnation caused by weakness of Qi and Blood. The Qi of the human body is constantly ascending, descending, exiting, and entering to maintain life activities. If Zheng Qi (Upright Qi) is abundant and pushing force is strong, then Qi and Blood flow smoothly, fluids distribute, and Ying and Wei (Nutritive and Defensive) Qi are harmonious, so stagnation will not occur. If Qi is deficient and fails to move, it not only forms Qi stagnation but can also lead to blood stasis, phlegm stagnation, or water-dampness retention. Ancient sages compared the Qi and Blood of the human body to the water of rivers. If the water volume is vast, rushing and spreading freely, where would stagnation be? Once the water volume weakens, or even dries up, the water flow becomes unsmooth, accumulating everywhere. In clinical practice, cases of stagnation caused by deficiency are very common; therefore, the method of using tonification as unblocking is also commonly used. However, people often see stagnation syndromes without distinguishing between excess and deficiency, universally treating them with dredging and draining methods. For those with stagnation caused by deficiency, this inevitably commits the error of "depleting the deficient."

Key Points in Differentiation and Treatment of Bi Syndrome

Wang Wuxing, Department of TCM Clinical Teaching and Research, Hubei Yichang Medical College

Bi Syndrome refers to a disease condition where external pathogens such as Wind, Cold, Dampness, and Heat invade the human body, causing obstruction of meridians and channels, and poor circulation of Qi and Blood, manifesting clinically mainly as pain, numbness, heaviness, limited flexion and extension in muscles, bones, joints, and even joint swelling and burning sensation.

1. Pathological Evolution If this syndrome is untreated, mistreated, or incompletely treated during the acute phase, it forms a chronic course, with the disease process lingering and often undergoing the following pathological changes:

① Pathogenic factors remain stagnant, Qi and Blood circulation is unsmooth, obstruction worsens day by day, body fluids condense and fail to flow, gathering to form Phlegm, leading to the knotting of stubborn Phlegm and dead Blood, presenting as skin ecchymosis, nodules around joints, joint swelling, limited flexion and extension, and even paralysis, wasting, and deformity, forming "Stubborn Bi" (Chronic Refractory Bi).

② Prolonged illness consumes Zheng Qi, leading to deficiency of Qi and Blood, malnourishment of meridians and channels, or deficiency of Liver Essence and Blood, generating internal empty heat, forming "Empty Bi" (Deficiency Bi).

③ Bi syndrome persists, and external pathogens are contracted again; pathogenic factors move from meridians and channels to affect Zang-Fu organs, forming "Zang-Fu Bi," among which Heart Bi is particularly common.

2. Key Points in Differentiation

① Explore the etiology, inquire in detail about the patient's exposure to external pathogens (Wind, Cold, Dampness, Heat, living environment, working environment, etc.).

② Differentiate pain and local symptoms, ask clearly about the nature, location, aggravating or inducing factors of the patient's pain, and reaction to cold and heat. For example: swollen, hot, painful joints, with or without sweating, or white papules (white millet grains rash), are characteristics of Heat Bi. Sometimes skin erythema may also be seen, or accompanied by sore throat and tonsillar swelling/pain. If the local area feels cold, worsening upon exposure to cold or immersion in water (sensitive to rainy days), it is Wind-Cold-Damp Bi; prolonged illness can transform into Empty Bi or Stubborn Bi.

③ Differentiate joint movement. Besides swelling and slight hardness upon palpation, joints and muscles commonly show inability to flex and extend, functional impairment. Long-term illness may show muscle atrophy. In the acute phase, joint effusion or pus accumulation may occur inside the joints, mostly seen in knee joints, presenting as joint swelling and severe pain.

3. Treatment Principles

Since Bi syndrome is always caused by contracting Wind, Cold, Dampness, and Heat, and its pathological changes can transform from excess to deficiency and from mild to severe, treatment should fully consider this. The proposed 12-character principle is: "Dispel Wind, Scatter Cold, Remove Dampness, Clear Heat, Unblock Collaterals, Tonify Deficiency." The overall plan should grasp the following three points:

Eliminate Pathogenic Factors -- Wind, Cold, Dampness, Heat, etc. {Phlegm-Dampness: Resolve Phlegm, Remove Dampness, Unblock Collaterals} Eliminate Pathological Factors {Blood Stasis: Move Blood, Invigorate Blood, Unblock Collates} Support Upright Qi and Tonify Deficiency -- Nourish Blood, Augment Qi (Augment Qi to Secure Wei), Benefit Liver and Kidney. In the acute phase, heat is often excessive and damages fluids; while eliminating pathogens, do not forget sweet-cool herbs to benefit Yin. In the chronic phase, True Yin is depleted, and Essence and Blood are exhausted; it is appropriate to tonify Essence and Blood.

4. Usage of Several Common Formulas for Bi Syndrome

① Fang Feng Tang (Saposhnikovia Decoction) Originates from Jin Dynasty Liu Wansu's *Xuan Ming Lun Fang*. This formula treats "Moving Bi" (Migratory Bi) within Wind-Cold-Damp Bi, characterized by wandering pain in muscles and joints. Fang Feng (Saposhnikovia Root) is the sovereign herb, paired with Ma Huang (Ephedra Herb) to dispel Wind, scatter Cold, and release the exterior; Dang Gui (Angelica Sinensis Root) and Qin Jiao (Gentiana Macrophylla Root) are minister herbs to nourish Blood and unblock collaterals. Modern pharmacological research shows that Qin Jiao and Fang Feng have good anti-rheumatic effects. Based on my experience, Fang Ji (Stephania Root) and Du Huo (Angelica Pubescens Root) are often added to enhance the effect of dispelling Wind and overcoming Dampness. Chi Ling (Poria with Red Host) is replaced by Sheng Yi Yi Ren (Raw Coix Seed Decoction); *Ben Jing* records that Yi Ren can treat tendon tightness and spasmodic inability to flex and extend. Although Chi Ling can drain dampness, it lacks the function of unblocking collaterals. Dang Gui should be stir-fried with wine to strengthen its blood-invigorating power. The administration method of this formula is: grind into coarse powder, take 15-30g each time, add 3 large slices of Sheng Jiang (Fresh Ginger) and 3 dates (Da Zao), decoct with half water and half wine. After taking, the patient may feel slightly warm, sweat, and feel relaxed throughout the body; cover with a warm quilt, avoid Wind and Cold, and the disease can be rapidly relieved.

② Wu Tou Tang (Aconite Decoction) From *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet). This formula treats "Painful Bi" (Fixed Pain Bi) within Wind-Cold-Damp Bi, with good efficacy for joint and muscle pain caused by Yin-Cold coagulation and meridian spasm. The key to applying this formula lies in selecting herbs and decoction method. The formula uses 5 raw Chuan Wu (Aconitum Carmichaelii Deauxn. Radix) as the sovereign herb, sliced, added into 500ml honey, decocting Aconite with honey until reduced to 200ml, then removing the Aconite. Then add Ma Huang 9g, Bai Shao (White Peony Root) 9g, Huang Qi 9g, Zhi Gan Cao (Honey-fried Licorice Root) 9g, Sheng Jiang Zhi (Ginger Juice) 9g, and add 1000ml water, decoct until reduced to 300ml, discard the dregs, add the decoction to the Aconite-honey mixture, and decoct again until 300ml remains for consumption. Take 2/3 for the first dose, and finish the remaining 1/3 for the second dose. Using raw Wu Tou (Aconite) paired with Ma Huang can break Yin and scatter Cold, warm meridians, and relieve pain. Furthermore, the tonifying nature of Huang Qi, the neutralizing nature of Bai Shao, the moderating nature of Gan Cao, and the sweet nature of honey constrain the pungent, hot, toxic nature of Wu Tou, allowing the elimination of pathogens without damaging Zheng Qi.

In clinical practice, ineffective use of this formula is often due to the fear of using raw Wu Tou and not following the processing and decoction methods of Master Zhang Zhongjing, which is something clinicians should pay attention to.

③ Gui Zhi Shao Yao Zhi Mu Tang (Cinnamon Twig, White Peony, and Anemarrhena Decoction) is the preferred formula for treating Heat Bi, originating from *Jin Gui Yao Lue*. The formula contains pungent-warm Gui Zhi (Cinnamon Twig) and Ma Huang to scatter dampness at the exterior, while Shao Yao, Gan Cao, and Zhi Mu (Anemarrhena Rhizome) clear heat in the interior; Bai Zhu and Fu Zi (Prepared Aconite Child Root) drive out dampness below. In acute rheumatism, lingering heat pathogens easily damage Yin; herbs that can both clear heat and nourish Yin should be selected, with Zhi Mu being the top choice. Modern pharmacological research: Gan Cao combined with Sheng Di Huang (Rehmannia Root) promotes the secretion of adrenal cortical hormones, benefiting anti-inflammation. This formula has excellent efficacy for Heat Bi transformed from Cold stagnation. Clinically, if lower Jiao Damp-Heat is heavy, with redness and swelling of bilateral ankles and knee joints, one can appropriately add Jin Yin Teng (Honeysuckle Stem), Tong Cao (Tetrapanax Pith), or Sheng Gan Cao Jie (Raw Licorice Knots) to strengthen heat-clearing and collateral-unblocking effects. If joint redness, swelling, and pain are severe, even with joint effusion or pus accumulation, a heavy dose of Er Miao San (Two Marvels Powder), Cang Zhu (Atractylodes Rhizome), and Huang Bo (Phellodendron Bark) 500g each, ground into fine powder, taken 50g each time, mixed with Liu Yi San (Six-to-One Powder) dissolved in water, twice a day, supplemented with local acupuncture (Du Bi [ST35], Yin Lingquan [SP9]) yields excellent results. Generally, within about 1 week, redness and swelling can subside, and effusion gradually absorbs.

5. Medication for Stubborn Bi

Application of Toxic and Potent Chinese Herbs: Stubborn Bi is a relatively common clinical syndrome, mostly caused by prolonged illness leading to blood stasis and phlegm obstruction, presenting as persistent joint and muscle pain, even joint deformity, limited movement, and eventually paralysis and wasting. Conventional treatments for this type of Bi syndrome often fail to achieve results. Based on recent domestic research progress and personal transmission and clinical experience, treating this syndrome generally requires adding certain special herbs or insect-type searching and penetrating herbs to the basic formula based on syndrome differentiation to achieve efficacy. The so-called special medication mainly involves the application of a portion of toxic and potent Chinese herbs that have specific effects on Stubborn Bi, roughly introduced as follows:

① Wu Tou Category (Chuan Wu, Cao Wu, Fu Zi): Sheng Nan Xing (Raw Arisaema Rhizome), Zhi Ma Qian Zi (Processed Strychnos Seed), Xi Xin (Asarum Root).
② Insect and Snake Category: Jiang Can (Silkworm), Quan Chong (Scorpion), Shan Jia (Tarsius Pangolin Squama), Tu Bie Chong (Ground Beetle), Lu Feng Fang (Honeycomb), Qiang Lang (Dung Beetle), Di Long (Earthworm), Wu Gong (Centipede), Wu Shao She (Zaocys), Qi She (Agkistrodon), Fu She (Protobothrops), Bai Hua She (Bungarus multicinctus), etc.

③ Huang Teng (Cyrtophyllum Caulis) and Kun Ming Shan Hai Tang (Tripterygium wilfordii). Their uses can be divided into two major categories:

Dispel Cold and Break Yin, Remove Dampness and Resolve Phlegm to Relieve Pain: Such as Er Wu (Chuan Wu and Cao Wu), Nan Xing, Fu Zi, Xi Xin, etc.

Unblock Meridians and Invigorate Blood, Dispel Wind and Remove Dampness: Huang Teng category, Insect and Snake category.

As long as the application methods and dosages of these drugs are correctly mastered, unexpected efficacy can be achieved.

Huang Teng and Kun Ming Shan Hai Tang: Both belong to the Celastraceae family and Cyrtophyllum genus vines. They were first used domestically by Honghu County Traditional Chinese Medicine Hospital in Hubei Province. This product has a special effect on Rheumatoid Arthritis. Due to its outstanding efficacy, it has been gradually adopted nationwide in recent years. Pharmacological experiments conducted by relevant scientific research units on the crude drug and Huang Teng Glycoside extract found that its alkaloids are a relatively strong immunosuppressant. Later, this product was applied to Systemic Lupus Erythematosus, Lupus Nephritis, and Nephrotic Syndrome, also showing good efficacy. Kun Ming Shan Hai Tang from Yunnan has similar efficacy to Huang Teng. The daily dosage of the crude drug of this product should be below 15g, decocted in water or soaked in wine for consumption. After taking, discomfort such as epigastric distension and stuffiness may occur; those with stomach diseases should use it with caution. In case of poisoning (nausea, vomiting, arrhythmia), fresh sheep blood (50-100ml) can be taken immediately, or decoction of Wu Bai Tree (Sapium Sebiferum) white bark can be used to detoxify.

Insect and Snake Preparations: Shanghai Guanghua Hospital has used Agkistrodon soaked in wine to treat Rheumatoid Arthritis since the 1970s, achieving good efficacy. Reports indicate that treating 140 cases of Rheumatoid Arthritis with this preparation, followed up in outpatient clinics for 13 years, yielded an effective rate of 78.56%. Personal transmission experience: Often add Wu Shao She 30g, Qi She 15g, Quan Chong 9g, Tu Bie Chong 10-12g, Wu Gong 3-5 pieces to the basic formula based on syndrome differentiation. For insect-type drugs, generally crude drugs have better efficacy, but the dosage should be light. In our clinical practice, we often grind these drugs into powder, fill them into capsules, take 1-2g each time, 3 times a day, which has higher efficacy than decoctions.

Bee Venom Category: The commonly used medicine is Honeycomb. This product can invigorate blood, break stasis, and relieve pain. Recent research confirms that this product is an immune regulator. However, the more effective one is live bee venom. Personal transmission experience: Treating Stubborn Bi, take live bees to sting around swollen joints and according to TCM meridian acupoints. Each time, 3-5 acupoints can be stung; for those who cannot tolerate it, 1-2 acupoints are sufficient. Its efficacy is fast, with no obvious side effects. However, care must be taken to prevent individual allergies; Epinephrine or Dexamethasone added to 40ml of 50% Glucose can be injected subcutaneously for emergency rescue.

Wu Tou, Ma Qian Zi, and Xi Xin Preparations. These drugs are all extremely pungent and hot. Ma Qian Zi is highly toxic, and Wu Tou and Xi Xin also have significant toxicity. However, when used properly, they have excellent efficacy for Stubborn Bi. The key lies in proper processing, dosage, and usage.

a. Ma Qian Zi (Strychnos Seed): This product contains Gelsemium Alkaloid, its component being "Strychnine". Dosage is 0.25-0.75g per day. It must be processed; generally, sand-frying and oil-frying are two methods to reduce toxicity. Sand-frying: Put cleaned fine river sand in a pot and fry until hot, then add Ma Qian Zi, frying until the outside is scorched and the inside is crisp; Oil-frying: Fry Ma Qian Zi in fragrant oil until scorched and crisp. Grind the processed Ma Qian Zi into powder, store tightly, and administer internally with Chinese herbs, with the dosage as above. Mr. Li once reported treating 1890 cases of Bi syndrome with Ma Qian Zi San, resulting in 1227 cured cases (64.92%), 538 improved cases (28.47%). The total effective rate was 93.39%. Contraindications for taking the medicine: Forbidden for patients with acute or chronic nephritis, pulmonary tuberculosis, hypertension, acute or chronic infectious diseases, and Heat Bi. Forbidden for children under 12 years old.