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Lin said: Someone asked, regarding the syndrome of gout (Tongfeng), is it due to blood deficiency (Xue Xu) or blood heat (Xue Re)? Or is it wind generated by extreme heat (Re Ji Sheng Feng)? Or is it pain caused by wind pathogen lodging in the meridians? Is its presentation identical to painful bi (Tongbi) or different? When the pain migrates without fixed location, is it due to wind or fire? When the pain is mostly between the meridians and joints, is it a disorder of sinews (Jin) or bones (Gu)? Is it caused by static blood (Si Xue)? Why does the pain intensify at night and subside during the day? Why does mild pain shift every three days, while severe pain shifts every seven days? Furthermore, why does prolonged pain transform into flaccidity bi (Weibi)?

The answer is: Pain arises from qi stagnation and blood coagulation, causing obstruction and blockage in the meridians. Wind has the nature of moving swiftly and changing frequently, which explains the meaning of "migrating without fixed location." Generally, when cold, wind, and dampness pathogens lodge in the meridians and blood vessels and are not dispersed, they stagnate for a long time and generate heat. Extreme heat transforms into fire, combined with the changes of wind; its nature is migratory, lurking and circulating within the meridians and blood vessels of the whole body, which constitutes the pathological origin. Subsequently, if the ying and wei qi and blood occasionally encounter obstruction at the meridians and joints, this wind-heat also becomes stagnant there. It wishes to move but cannot, leading to edema and pain, and making flexion and extension difficult. After two or three days, or five or seven days, once the qi and blood in one area become unobstructed, stagnation occurs elsewhere, and thus the pain shifts. As for the wei qi circulating on the exterior of the yang aspect during the day, the ying qi also moves easily, so the pain alleviates. At night, the wei qi returns to the yin aspect, and the ying qi does not circulate; the blood vessels become stagnant and constricted, causing severe pain. Therefore, this syndrome should be attributed to liver blood deficiency and liver blood heat, where liver wood is dry and fire blazes, and deficient wind transforms due to fire. Since the liver stores blood and governs the sinews, and all joints are the convergence points of meridians, blood deficiency fails to nourish the sinews and vessels, allowing wind and fire to obstruct the collaterals. This results in edema and heat; floating belongs to wind, heat belongs to fire, and swelling is due to qi and blood obstruction. It flares up whenever damp-heat prevails. It is truly not pain caused by bone/sinew disorders or static blood. If it were bone/sinew static blood, the pain would be fixed in one place; how could it shift every three or seven days? This is actually a disease of formless wind-heat in the liver meridian. Because wind-heat belongs to fire, it travels readily. If it were cold and damp, the pain would remain fixed throughout. Although it is often said that wind-heat pain alleviates with warmth, this is because the root of deficient fire is cold, and its nature prefers warmth. Moreover, in treatment, when using extremely cold or hot medicines, one should employ the "following treatment" (Cong Zhi) method (treating according to the false appearance of the disease). If "following treatment" fails, one must seek the root cause to diminish it. "Following" and "belonging" refer to the principle that heat bi disperses easily with warmth. If pain persists for a long time, diet and daily activities will inevitably decline, and spirit and qi-blood will become deficient due to illness. Thus, sinews and bones lose strength, joints become stiff, forming flaccidity bi. (From *Huoren Lu*)

He further said: Someone asked, since the clinical manifestations of gout are no different from bi syndrome, why is it not appended to the end of the bi section, but established as a separate chapter? The answer is: Painful bi originates from cold, whereas gout belongs to wind. Blood vessels flow when warm and coagulate when cold. Cold lingering in the vessels leads to painful bi over time. Furthermore, "bi" means obstruction, referring to blockage and lack of free flow; hence, the pain remains fixed in one place, unlike wind which moves freely and changes rapidly. Generally, wind predominance leads to wandering bi (Xingbi); thus, gout is essentially the wandering bi within the bi category. However, although their meanings are similar, their realities differ due to variations in the depth of pathogenesis, the duration of the condition (new vs. old), and the ease or difficulty of recovery. Gout is usually contracted during periods of prevalent summer-heat and dampness, when qi and blood are boiling. It may result from wearing sweat-soaked clothes, sleeping on damp ground, exposure to wind after sweating, or greedily seeking coolness while sleeping deeply on lacquerware, bamboo mats, or stone beds. This causes summer-heat qi to condense upon encountering cold, adhere due to dampness, and close up due to wind. Consequently, excessive heat generates wind-like symptoms, moving within the meridians and blood vessels, shifting unpredictably with variable pain, unlike bi syndrome which is deep-seated and chronic.

He further stated: If physical appearance and spirit are normal, and diet is regular, with a pulse that is surging, slippery, floating, and wiry, rapid, forceful, and accompanied by severe pain, it is an excess syndrome. If physical appearance and spirit are withered and weak, appetite is reduced, and the pulse is deficient, wiry, choppy, and rapid, or faint, spiritless, or empty and wiry, accompanied by sore weakness and irregular urination/defecation, it is a deficiency syndrome.

He further stated: In treating gout, one must distinguish between new and old, excess and deficiency, and whether it involves wind or fire. Damp-heat can also flow into meridians and joints causing pain. For new cases where ying and wei qi-blood are not yet depleted, treatment should focus on eliminating pathogens. For chronic pain with insufficient spirit, clearing and tonifying should be combined. For severe damp-heat, drying dampness and clearing heat is appropriate. For severe wind-fire, moistening dryness, nourishing blood, and greatly tonifying liver yin are indicated. Generally, to treat wind, one must first treat blood; when blood flows, wind extinguishes itself. Overuse of wind-dispelling agents and cold-drying formulas may instead consume blood and suppress fire.

Qian Qinglun said: Gout is characterized by migrating pain throughout the bones and joints, known as "White Tiger Li Jie" (White Tiger Joint Pain). Wind, qi, blood, wind-dampness, phlegm, and fire can all cause pain. It may result from labor mixed with cold water, drunkenness after alcohol and sexual indulgence, seeking coolness facing the wind, sleeping in damp places, or body steam from rain-swept clothes. Gout in the upper body mostly involves wind; in the lower body, mostly dampness. Treatment should invigorate blood, disperse wind, resolve phlegm, and eliminate dampness, using Qianghuo Tang with modifications. For treating gout, Atractylodis Rhizoma (Cangzhu), Notopterygii Rhizoma et Radix (Qianghuo), and Scutellariae Radix prepared with wine (Jiu Qin) are three miraculous herbs for dispersing wind and moving dampness. (From *Jingyan*)

He further stated: For all cases of gout with limb joint pain, pain belongs to fire, swelling belongs to dampness. Meat should not be consumed as meat is yang-fire and aids fire; consumption may lead to seminal emission, urinary incontinence, and internal masses. Even fried, roasted hot foods, fish, and noodles should be strictly avoided. Therefore, those who enjoy rich foods, consuming many fried, roasted, and hot items along with alcohol and meat, steaming the zang-fu organs, suffer most from gout, malignant sores, and carbuncles. Obese people mostly have damp-phlegm; thin people mostly have phlegm-fire.

Zhou Hexian said: In gout, wind enters the bones. Mildly, there is dull pain inside the bones; severely, the whole body bones ache. There are also cases of wandering pain between joints that is unbearable. Although the pathogen enters the marrow, and marrow belongs to the kidney, suggesting kidney treatment, one cannot treat only the kidney. One must treat the Yangming meridian to be effective. The Yangming meridian is the Stomach meridian, and the Large Intestine also belongs to Yangming. Logically, to remove wind from Yangming, Puerariae Radix (Gegen) should be used; to clear fire from Yangming, Gypsum Fibrosum (Shigao) and Anemarrhenae Rhizoma (Zhimu) should be used. However, since the pathogen remains in the marrow, qi-level herbs must first be used to extract the pathogen to the qi level, followed by kidney-tonifying herbs to nourish the marrow, before the disease can be cured. Huangbo Tang should be the primary prescription.

The Classics state: Cold, wind, and dampness mixing together cause bi. Wind predominance leads to wandering bi (Xingbi - moving不定, now called migrating pain, commonly known as flowing fire and Li Jie Feng). Cold predominance leads to painful bi (Tongbi - painful and bitter, joint swelling, commonly called gout and White Tiger Flying Corpse). Dampness predominance leads to fixed bi (Zhuobi - staying in one place without moving, commonly called numbness and insensibility, or pain fixed in one spot forever. Wind affects yang meridians, hence wandering bi; cold affects yin meridians; dampness affects skin, flesh, sinews, and bones, hence fixed bi that does not depart, causing skin insensibility. Thus, bi arises from cold, wind, and dampness).

The Classics state: Encountering this in winter causes bone bi; in spring, sinew bi; in summer, vessel bi; at the height of yin (sixth lunar month), muscle bi; in autumn, skin bi. (Named according to the season encountered and the site of invasion, correlating seasons with the five zang organs' associations. "Zhi Yin" refers to the sixth month.) It is also said: Invasion into the zang organs leads to death; lingering between sinews and bones causes prolonged pain; lingering in the skin is easy to cure. It is also said: Pain indicates abundant cold; presence of cold causes pain. Those who are neither painful nor numb have had pain for a long time, entering deeply, where ying and wei flow sluggishly and meridians are sometimes empty, hence no pain; skin lacks nourishment, hence insensibility. Bi in bones causes heaviness; in vessels, blood coagulates and stops flowing; in sinews, flexion and extension are impaired; in flesh, insensibility; in skin, coldness. These five do not hurt. All bi syndromes tighten with cold and relax with heat, rooted in internal deficiency. They can be named "wind," but should not be treated merely as wind pathogens.

*Tongzhi* states: Wind bi wanders up and down, clashing with deficient evil and qi-blood, gathering at joints and sinews, causing flaccidity and inability to contract. Cold bi causes limb spasms and pain, joint swelling. Damp bi stays fixed, causes profuse sweating, limb weakness, skin insensibility, and mental confusion. Heat bi involves internal organ heat transferring externally, meeting external pathogens, lodging in meridians, blocking flow. Yang encounters yin, causing stifling oppression, extreme muscle heat, sensation like mice running on the body, cracked lips/mouth, and skin color changes. (The classics mention only cold, wind, and damp bi; heat bi exists here because stagnation generates heat, which arises within the three pathogens.) When the three pathogens combine to form bi, skin becomes thick and tough, or muscles ache. This is evil invading the whole body, clashing with blood vessels. Unresolved for years, it becomes eczema or wind sores, painless upon scratching, hair falls out. Treatment should disperse wind and cool blood. Ultimately, it is due to ying and wei deficiency, allowing external evil to linger, causing qi-blood coagulation. Generally, dampness causes swelling; heat causes pain. Yin deficiency leads to wiry-rapid pulse, worse at night; yang deficiency leads to large-deficient pulse, worse during the day.

Feng Luzhan said: Bi means obstruction. When the righteous qi of the five zang and six fu organs is blocked by evil, bi and insensibility occur. Although there are five types of bi, they mostly arise in constitutionally weak individuals with loose cou li, allowing cold, wind, and dampness to invade skin, vessels, flesh, sinews, and bones. Unable to disperse them promptly, they linger internally, becoming bi over time. Pathologically, cold predominance causes pulling pain; wind predominance causes migrating pain; dampness causes heaviness. Cold, wind, and dampness in meridians cause various diseases: pain, itching, numbness/insensibility, or limb weakness. This depends on newness/oldness and severity, and differences in damp-phlegm and static blood. Treatment requires simultaneous attack and tonification, addressing both root and branch. Guang Gui (Thin Cinnamon Twig) has a light flavor, travels horizontally in arms, leading Nanxing, Cangzhu, etc., to the pain site. Weilingxian treats upper body gout; Han Fangji treats lower body gout. However, weak patients must use qi-blood tonics to effectively transport the medicinal power.

He further stated: Gout, anciently named painful bi, commonly called White Tiger Li Jie Feng, is migrating pain in the four limbs' bones and joints. Qi flows outside vessels, blood inside. Daytime flows in yang, nighttime in yin, each twenty-five cycles. Cold slows flow, causing insufficiency; heat speeds flow, causing excess. Internal injury and external contraction trigger disease. In gout, blood heated boils; if exposed to cold/damp/coolness, hot blood becomes turbid and stagnant, ying and wei struggle to flow, creating firm obstacles. Evil and righteous qi battle, causing pain. Night pain is severe because it flows in yin. Treatment should use pungent, fierce agents to scatter cold-damp, open depression, move qi, break stasis, resolve phlegm, soothe wind, harmonize blood, and open cou li. Then depression opens, blood flows, qi harmonizes, and health returns. Generally, excess requires dispersing and attacking evil; deficiency requires nourishing qi-blood. However, methods vary: due to wind-heat, phlegm, wind-damp, or blood deficiency. If damp-phlegm/turbid blood flows to the lower jiao (distant path), non-strong qi herbs like Wutou and Fuzi cannot travel; thus, they are used as guiding herbs, not main treatments. Overall, limb joint swelling/pain results from cold-wind in meridians, stagnating into damp-heat, flowing into joints. Pain is fire; swelling is damp. Treatment should disperse wind, dry dampness, assist with qi-blood tonification to aid drug transport, and finally nourish liver-kidney to strengthen sinews/bones. This is the treatment. However, if pain feels like knife-cutting, it indicates evil-righteous struggle. If completely painless, evil and righteous merge, resting peacefully.

*Neijing* discusses bi: Four seasons' commands can all become evil; five zang qi can all receive disease. Among six qi, cold, wind, and damp account for half. "Mixing together" implies no single pathogen causes bi alone. Wind/cold/damp predominance distinguishes severity. Skin/flesh/sinews/bones/vessels correspond to five zang. Initial disease is external; if persistent, it enters zang via correspondence. External removal is easy; internal attack is hard. Treating external prioritizes dispersing evil; treating internal prioritizes nurturing righteousness. Treating wandering bi focuses on dispersing wind; dispelling cold/damp is still necessary, generally adding blood-nourishing agents, for treating wind requires treating blood first; when blood flows, wind extinguishes. Treating painful bi focuses on dispersing cold; dispersing wind/drying damp is still necessary, generally adding fire-tonifying agents; only great pungent-warm herbs can release凝寒 (congealed cold). Treating fixed bi focuses on promoting dampness; dispelling wind/resolving cold is still necessary, generally adding spleen/qi-tonifying agents; strong earth controls dampness, sufficient qi eliminates numbness. After recovery, regulate desires to preserve essence, avoid cold to repel external evil, abstain from alcohol/noodles to prevent damp-heat, take tonics to generate qi-blood, preventing recurrence.

He further stated: Bi syndrome presents with sinew spasm/inextension and muscle insensibility, resembling wind syndrome. But wind affects yang meridians, bi affects yin meridians, hence heavy/fixed pain. Among the three pathogens, wind creates wandering bi, moving without staying, anywhere in joints, shifting every 3-5 days, commonly called flowing fire or White Tiger Wind (pain like tiger bite, lighter by day, heavier by night). Cold predominance creates painful bi, blood-vessel cold coagulation, pain fixed in one place, commonly called White Tiger Flying Corpse. Dampness predominance creates fixed bi, upper/lower vessel blockage, muscle numbness then anesthesia (insensibility). Classics name bi by season and site, not implying separate bone/sinew bi beyond wandering/painful/fixed. Cui Zixu said: Cold-wind-damp combining forms bi. Pulse floating-tight-choppy indicates exhaustion. Tight-choppy pulse and heavy-fixed pain are pure yin; use yang-assisting warming dispersants for correct diagnosis.

*Ling Shu* states: Wei qi not flowing causes numbness. Danxi said: Numbness (Ma) is qi deficiency; anesthesia (Mu) is damp-phlegm/static blood. Thus, Ma and Mu divide insensibility into two. Although qi-blood dual deficiency causes Ma without Mu, deficiency with dampness causes both. Deficiency allowing cold-wind-damp invasion causes whole-body pulling pain and numbness, anciently called Zhou Bi. Treatment should induce sweating then tonify, applying similar logic. Numbness is the onset of insensibility; Ma is mild Mu; Mu is severe Ma, anciently called Ma Bi. *Yuan Bing Shi* states: Ma is like涩 (choppy/stagnant); due to fluid deficiency and dryness-dampness imbalance, qi-blood stagnation prevents smooth flow. Strong qi attacks wei, causing numbness. Folk remedies use Wutou/Fuzi to violently move qi, opening pathways, allowing middle qi to flow and numbness to heal. However, Wutou/Fuzi only warm and move; they must be combined with tonification, as numbness stems from qi-blood deficiency. Some say numbness is wind, even children agree. But rising after sitting long, or releasing tight binding, causes temporary numbness due to qi stagnation, not wind. Thus, treat lung qi deficiency rather than wind. Also, yin fire attacking yang levels causes numbness; treat yin fire by nourishing yin to extinguish fire. Generally, excess pulses indicate superficial bi; deficiency pulses indicate interior bi.

He further stated: Wind is qi of four seasons/eight directions entering nose, heavenly qi. Phlegm is taste of grains/foods entering mouth, condensed spleen-stomach dampness, earthly qi. Thus, wind predominance treats wind first; phlegm predominance treats phlegm first; equal wind/phlegm treats phlegm before wind, a fixed rule. Classics state: Wind enters skin/hair, then muscle, then sinew/vessel, then marrow. Good practitioners treat skin/hair first, then muscle. Thus, progression is right to left. Skin/hair governed by Right Lung; muscle by Right Stomach; sinew/vessel by Left Liver; marrow by Left Kidney. Entering from outside goes deeper. Treating skin/muscle prevents deep invasion. He further stated: Dampness enters from feet, ascending from bottom to top,不分左右 (no left/right distinction). External entry drives out gradually; ascending entry drives down gradually. This is the treatment.

Ten fingers numbness: Danxi said: Stomach has damp-phlegm/static blood. Use Erchen Tang plus Cangzhu, Baizhu, Taoren, Honghua, Fuzi. Numbness in one muscle patch of leg/foot/shoulder/back: Yang qi insufficient to circulate, causing yin-cold stagnation. Body itchy deficiency: Blood fails to nourish cou li. Use Siwu Tang plus Huangqin decoction, mixed with Fuping powder.