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Question: How is Blood Bi (Blood Obstruction) disease acquired? The Master said: Those who live in comfort and luxury have weak bones but abundant flesh. If they become overly fatigued, sweat, and toss and turn during sleep, adding the invasion of a slight breeze, they will contract this disease. One should only look for a pulse that is slightly choppy and fine, with a slight tightness at the Cunkou (radial artery at the wrist) and Guan positions. It is appropriate to use acupuncture to guide Yang Qi, allowing the pulse to harmonize and the tightness to disappear, whereupon the patient will recover.

[Annotation] Lijie (Joint Striding) disease belongs to Qi injury; Qi injury causes pain, hence the manifestation of pain. Blood Bi belongs to Blood injury; Blood injury causes swelling (here referring to numbness due to stagnation), hence the manifestation of numbness. The previous text clarified that pathogenic factors gather in the Qi level; this text clarifies that pathogenic factors coagulate in the Blood level, hence it is named Blood Bi. "Those who live in comfort" refers to people who consume rich and sweet foods. Because they habitually eat sweet and fatty foods, their bones are weak and their flesh is abundant, making them unable to tolerate fatigue. Fatigue leads to sweating, and sweating opens the Couli (pores). They also cannot endure long periods of lying down; lying down leads to tossing and turning, which exposes them to slight breezes, thereby contracting the disease. This describes how people of high status, appearing robust externally but deficient internally, are susceptible even to slight wind pathogens. However, how do we know it is Blood Bi? By observing body numbness and a pulse that is slightly choppy and fine, we know the pathogen has coagulated in the Blood. The slight tightness at Cunkou and Guan is also the pulse corresponding to slight Wind-Cold pathogens. Acupuncture can guide meridians to treat various Bi syndromes; thus, it is appropriate to use acupuncture to guide Qi and Blood to drain the pathogen, making the pulse smooth and harmonious, eliminating tightness, dispersing the pathogen, and allowing Blood Bi to clear naturally.

[Collected Annotations] Zhou Yangjun said: Among all people, only those living in comfort experience physical ease but mental distress. Physical ease leads to abundant flesh; mental distress leads to weak bones. Weak bones mean one cannot bear labor; abundant flesh means Wei Qi (Defensive Qi) is not solid. Slight fatigue or distress leads to sweating. Sweating depletes Yang Qi, allowing even slight breezes to invade, causing Blood obstruction. Thus, seeing a slight pulse indicates insufficient Yang; seeing a choppy pulse indicates much obstruction in Yin/Blood. These are the fundamental pulses of Blood Bi. At the site of pathogen entry, a slight tightness manifests. "Slight" represents the image of Zheng Qi (Upright Qi) being constrained; "tight" is the sign of Cold pathogen entering. Yet Zhang Zhongjing explicitly mentions slight wind, why does one get a Cold pulse? Generally, pathogens follow the blood vessels up and down, obstructing fluids and juices, inevitably causing pain; hence pain manifests as a tight pulse. Using acupuncture to drain the pathogen and guide Yang outward allows the pathogen to leave and Zheng Qi to extend naturally.

In Blood Bi, both Yin and Yang pulses are slight. The Cunkou and Guan pulses are slight, while the Chi position is slightly tight. The external symptom is body numbness, resembling Feng Bi (Wind Bi). Huangqi Guizhi Wuwu Tang (Astragalus and Cinnamon Twig Five-Ingredient Decoction) is the primary treatment.

[Annotation] This clause continues from the previous one, detailing pulses and symptoms to clarify treatment. The previous clause mentioned six pulses being slight/choppy with slight tightness at Cunkou/Guan; this clause states Yin/Yang, Cunkou, and Guan are all slight, and Chi is also slightly tight. Viewing them together, one can understand that in Blood Bi, the pulses at floating/sinking depths and at Cunkou, Guan, and Chi positions all manifest as slight, choppy, and slightly tight. "Slight" indicates deficiency; "choppy" indicates stagnation; "slightly tight" indicates pathogen. Thus, Blood Bi should present such diagnostic signs. The external symptoms of Blood Bi are also body stiffness/numbness and insensitivity to pain/itch, hence described as "resembling Feng Bi." However, it differs from Feng Bi in that it does not wander through joints with pain. Huangqi Guizhi Wuwu Tang is used because it nourishes Ying (Nutritive) and Wei (Defensive) Qi as the root, and dispels Wind and drains pathogens as the branch.

[Collected Annotations] Zhou Yangjun said: This elaborates on the situation after Bi has set in, where needle guidance failed to cure it, leading to a slight Cunkou pulse. Now, Yin and Yang are both slight, Cunkou and Guan are both slight, and Chi is slightly tight. Since slight tightness appears at Chi, the pathogen has entered deeper and is harder to expel. Why? Where Zheng Qi is deficient, there is room for the pathogen. Pulse internal/external is called Yin/Yang; upper/lower is also called Yin/Yang. Since Chi shows slight tightness, the slightness clearly pertains to internal/external deficiency. If symptoms were summarized merely by "numbness," pain and numbness would be distinct from sensation, indicating severe numbness; hence it is likened to Feng Bi, though not true Feng Bi. Therefore, Huangqi secures Wei Qi, Shaoyao nourishes Yin, Guizhi harmonizes Ying and Wei, strengthens interior/exterior, and drives pathogens out. Ginger promotes Stomach Qi, and Dates tonify Spleen Qi. This is the most appropriate and unchangeable treatment.

Huangqi Guizhi Wuwu Tang Formula
Huangqi (Astragali Radix) (3 liang), Shaoyao (Paeoniae Radix Alba) (3 liang), Guizhi (Cinnamomi Ramulus) (3 liang), Shengjiang (Zingiberis Rhizoma Recens) (6 liang), Dazao (Jujubae Fructus) (12 pieces).
The above five herbs are boiled in 6 sheng of water to yield 2 sheng. Take 7 he of warm decoction three times daily (another version includes Renshen).

In men who are otherwise healthy, a large pulse indicates Lao (Exhaustion/Labor). An extremely empty pulse also indicates Lao.

[Annotation] A healthy man should have normal pulses conforming to the four seasons and five Zang organs. Now, if the six pulses are large yet extremely empty, it is not a healthy pulse. A large but forceless pulse indicates Spleen Qi damage from overwork; an extremely empty pulse indicates internal depletion of Kidney Yin and Essence. These are all precursors to Xu Lao (Deficiency Consumption), hence such diagnostic findings.

[Collected Annotations] Li Zhongzi said: "Ping Ren" (healthy person) refers to someone whose appearance shows no illness. The Classics say: "Pulse shows disease, but the person feels well." Labor exhausts the body externally and depletes Qi internally. A large pulse does not indicate abundant Qi; deep pressure reveals emptiness and softness, indicating excess externally and deficiency internally. An extremely empty pulse indicates exhaustion of Essence and Qi. Generally, "large" is the external manifestation of the Lao pulse; "extremely empty" is the internal decline of the Lao pulse.

Wei Litong said: In healthy men, a large pulse indicates Lao, and an extremely empty pulse also indicates Lao. Large indicates pathogenic abundance; extremely empty indicates Essence/Qi depletion. These two sentences reveal the general principle of Xu Lao without specifying which pulse is large or which meridian is empty. This requires the treating physician to examine carefully according to the causes of the Five Labors and Seven Injuries.

At age fifty or sixty, if the pulse is large, Bi may travel along the back. If there is intestinal borborygmus, Hashimoto's goiter (Madao), or lateral neck lumps (Xiaying), these are all caused by Lao.

[Note] The phrase "If there is intestinal borborygmus" does not fit the context and is likely a textual error. The character "Ying" in "Xiaying" should be "Luo" (referring to scrofula/lymph node enlargement). There are cases of Lao followed by Luo, or Luo followed by Lao, but never Lao and Goiter occurring sequentially. This must be a transcription error.

[Annotation] For ordinary people aged twenty or thirty, a constant large pulse often leads to Lao disease. If a person aged fifty or sixty has a large pulse but does not immediately develop Lao, it is because although Qi and Blood are deficient, the Fire is mild; mild Fire does not cause Lao. Although not suffering from Lao, the deficiency and obstruction of Qi, Blood, Ying, and Wei lead to Madao, Shuchuang (rat sores/scrofula), and Xi Luo. This illustrates that while the pulse "large" is the same, the diseases differ.

The disease of Lao presents with a floating and large pulse, vexation in the hands and feet, worsening in Spring and Summer, and improvement in Autumn and Winter. Yin deficiency leads to spontaneous emission of essence, soreness and wasting of the limbs preventing walking.

[Note] The character "Han" (Cold) in "Yin Han Jing Zi Chu" should be "Xu" (Deficiency); this is a transcription error.

[Annotation] This explains that a floating-large pulse indicates Lao, detailing the symptoms. Vexation in hands and feet refers to the modern concept of Xu Lao with five-palm heat, caused by Yin deficiency failing to anchor Yang. Yin deficiency leading to spontaneous emission refers to modern Xu Lao with nocturnal emissions, caused by Yin deficiency failing to secure. Soreness and wasting preventing walking refers to modern Xu Lao with knee soreness, emaciation, and bone weakness preventing getting out of bed. Spring and Summer belong to Yang; Yin deficiency cannot overcome Yang, hence worsening. Autumn and Winter belong to Yin; Yin deficiency finds its place (harmony with Yin), hence improvement.

[Collected Annotations] Xu Bin said: A large pulse already indicates Lao; adding floating makes the symptoms include hand/foot vexation. Since Yin is insufficient, Yang must be excessive. Thus, in Spring/Summer when Yang assists Yang, the condition worsens; in Autumn/Winter when Yin assists Yin, the condition improves. Yin deficiency with spontaneous emission eventually leads to limb soreness/wasting and inability to walk.

Cheng Lin said: Read "Han" as "Xu". Yin deficiency means Qi fails to hold, leading to spontaneous emission.

Li Zhongzi said: A floating-large pulse indicates interior deficiency with Qi surging outward. The four limbs are the root of all Yang; labor consumes Yang, Yin deficiency generates internal heat, hence hand/foot vexation. Most injuries from labor belong to Yin deficiency. During Spring/Summer when Wood/Fire is flourishing, Qi floats outward, making the interior more deficient, hence worsening. During Autumn/Winter when Metal/Water generate each other, Qi gathers inward, keeping the exterior undisturbed, hence improving. The Kidney stores Essence; spontaneous emission indicates Kidney Water failing to store. The Kidney governs bones, hence soreness/wasting and inability to walk.

In men, a pulse that is empty, deep, and wiry, without chills or fever, accompanied by shortness of breath, epigastric fullness/tightness, dysuria, pale complexion, occasional dizziness/blurred vision combined with epistaxis, and lower abdominal fullness, is caused by Lao.

[Annotation] This reiterates that extreme deficiency constitutes Lao, detailing the symptoms. An empty, deep, wiry pulse indicates insufficiency of both Yin and Yang. Absence of chills/fever indicates that although Yin/Yang are insufficient, they are not clashing. Shortness of breath, pale face, occasional dizziness/blurred vision, and epistaxis indicate Upper Jiao deficiency with Blood failing to nourish. Epigastric tightness, dysuria, and lower abdominal fullness indicate Lower Jiao deficiency with Qi failing to move. All these pulse and symptom patterns result from Lao, hence "this is caused by Lao."

Men with a pale, thin complexion primarily suffer from thirst and blood loss, sudden panting, and palpitations. A floating pulse indicates interior deficiency.

[Note] "A floating pulse indicates interior deficiency" is likely a redundant text.

[Annotation] This reiterates the pale complexion of Xu Lao, detailing symptoms. Pale complexion not due to epistaxis indicates Blood failing to generate internally; due to epistaxis indicates Blood lost externally. "Thin complexion" means pale and lusterless, indicating insufficiency. Thus, the main symptoms are thirst due to fluid insufficiency, vomiting/epistaxis with blood loss, sudden panting due to Qi deficiency, and sudden palpitations due to Blood deficiency.

[Collected Annotations] Li Zhongzi said: This section focuses on blood loss. The Inner Classic says: "The five colors of the face are the brilliance of Qi." Also: "The heart's brilliance is in the face,充盈 in the blood vessels." Labor depletes Qi and stirs Fire, forcing Blood to move recklessly, leading to blood loss. Blood moistens; loss of Blood deprives spirit/luster, causing pale complexion; loss of fluids causes vexation and thirst. Furthermore, labor depletes both Qi and Blood. The Lung governs Qi; Qi deficiency causes panting. The Heart governs Blood; Blood deficiency causes palpitations. "Sudden" means these symptoms appear abruptly.

In men, a pulse that is floating, weak, and choppy indicates infertility, due to cold and clear Essence and Qi.

[Annotation] In men, a floating, large, and empty pulse indicates Xu Lao. A floating, weak, and choppy pulse indicates cold/clear Essence and Qi, hence infertility.

For those who frequently lose essence, there is tightness in the lower abdomen, coldness at the glans penis, dizziness, hair loss, and a pulse that is extremely empty, Kous (Bowl-like/Hollow), and slow. This indicates loose stools with undigested food, blood loss, and essence loss. If the pulse shows various Kou, Dong (Fluttering), slight, and tight qualities, men suffer essence loss, and women suffer dream intercourse. Guizhi Longgu Muli Tang (Cinnamon Twig, Dragon Bone, and Oyster Shell Decoction) is the primary treatment.

[Note] The text following "blood loss and essence loss" does not connect logically with the preceding text and should be treated as a separate clause placed later.

[Annotation] "Frequent essence loser" refers to those with insecure Kidney Yang failing to consolidate essence. Tightness in the lower abdomen indicates deficiency and cold. Coldness at the glans indicates declining Yang. Dizziness indicates depleted Essence. Hair loss indicates exhausted Blood. If the pulse is extremely empty, Kou, and slow, one should know that extreme empty indicates Lao, Kou indicates blood loss, and slow indicates cold, hence symptoms of loose stools, blood loss, and essence loss.

[Collected Annotations] Cheng Lin said: The Kidney governs closure/storage; the Liver governs dispersion. Excessive dispersion in essence loss causes lower abdominal tightness. The glans is the gathering point of Zong Jin (Major Sinews); daily depletion of True Yang causes coldness there. Dizziness indicates essence decline; hair loss indicates blood exhaustion, hence the empty/Kou/slow pulse. Empty indicates essence loss; Kou indicates blood loss; slow indicates loose stools with undigested food.

Li Zhongzi said: The Liver stores Blood; the Kidney stores Essence. Blood loss and essence loss mean both Liver and Kidney are deficient. The lower abdomen is the region of the Liver and Kidney. Lower abdominal tightness occurs because Liver/Kidney deficiency leads to interior Qi deficiency and tension, adding wiriness. The Liver governs sinews; the anterior yin is the gathering of Zong Jin; Liver decline causes glans coldness. The Liver stores Blood and opens into the eyes; the Kidney governs bones, and bone essence forms the pupil; the Kidney's brilliance is in the hair, and hair is the surplus of Blood. This Liver/Kidney dual deficiency causes dizziness and hair loss. The Kou pulse is hollow in the middle, like a reed stem, hence the name; it is the pulse of blood loss, as the pulse is the house of Blood, and Blood deficiency leads to pulse deficiency. Slow indicates involvement of the Zang organs; slow indicates cold. Extremely empty, Kou, and slow pulses indicate deficiency symptoms. Qinggu (clear grains) refers to undigested food in stool. This is Xu Lao affecting the Liver and Kidney meridians.

In men who are otherwise healthy, a pulse that is weak, empty, and fine indicates susceptibility to night sweats.

[Note] The pulse and symptoms in this section do not match; there must be missing text, so it is not explained.

A pulse that is deep, small, and slow is named Tuo Qi (Qi Collapse/Depletion). The person pants heavily when walking quickly, has cold hands and feet, abdominal fullness, and in severe cases, loose diarrhea and indigestion.

[Annotation] Deep, small, and slow pulses indicate significant Yang deficiency, hence named Tuo Qi. Tuo Qi means the Great Qi in the chest is deficient and scant, unable to support respiration, hence panting when walking quickly. Yang deficiency leads to cold; cold prevailing externally causes cold extremities. Cold prevailing internally causes abdominal fullness, loose stools, and indigestion.

[Collected Annotations] Xu Bin said: Deep, small, and slow pulses undoubtedly indicate Yang decline. The combination of these three pulses indicates total Yang deficiency, hence Tuo Qi. The body is like an empty shell; walking quickly exhausts Qi causing panting; limbs lack Yang causing cold; abdomen lacks Yang causing fullness. Severe stomach deficiency causes loose stools; severe Spleen deficiency causes indigestion.

Li Zhongzi said: This involves disease in the Spleen, Lung, and Kidney meridians. The Lung governs Qi, which is Yang. Deep, small, and slow are all pulses of Yang Qi deficiency, hence Tuo Qi. Panting when walking quickly occurs because the Lung governs exhalation and the Kidney governs inhalation; they are the source of generated Qi and the gate of respiration. If Yuan Qi is depleted, Qi deficiency fails to sustain breathing; the Lung has nothing to exhale, the Kidney has nothing to inhale, hence panting. This is Lung/Kidney disease. The Spleen governs the four limbs, which are the root of all Yang. Reverse cold indicates Yang deficiency failing to warm the extremities. Abdominal fullness indicates Spleen meridian entering the abdomen with Qi deficiency causing central fullness. Loose stools and indigestion indicate Spleen deficiency failing to transport and transform water/grain, often presenting as watery or incomplete digestion diarrhea.

A pulse that is wiry and large: Wiry indicates reduction; large indicates Kou (hollow). Reduction indicates Cold; Kou indicates Deficiency. Deficiency and Cold interacting is named Ge (Leather) pulse. In women, it indicates miscarriage and bleeding; in men, it indicates blood loss and essence loss.

[Annotation] See detailed explanation in "Shanghan Lun · Bian Mai Fa" (Differentiating Pulse Methods), not repeated here.

If the pulse shows various Kou, Dong, slight, and tight qualities, men suffer essence loss, and women suffer dream intercourse. Guizhi Longgu Muli Tang is the primary treatment.

[Annotation] "Various Kou, Dong, slight, and tight" refers generally to the various pulses of Xu Lao, not implying that these specific pulses exclusively indicate male essence loss or female dream intercourse. Universally applying Guizhi Longgu Muli Tang for male/female essence loss aims to harmonize Yin/Yang and Ying/Wei, while astringing essence.

[Collected Annotations] Xu Bin said: Those with frequent essence loss have varied pulses. If Kou, Dong, slight, and tight are found, it indicates men lose essence due to Yin deficiency with accompanying Fire, and women have dream intercourse due to Yin deficiency with accompanying Fire. Using Guizhi Longgu Muli Tang: generally, Yin-deficient individuals need Kidney support. Thus, Guizhi and Shaoyao unblock Yang and secure Yin; Gancao, Ginger, and Dates harmonize the Middle; Longgu and Muli secure essence.

Guizhi Jia Longgu Muli Tang (Cinnamon Twig Plus Dragon Bone and Oyster Shell Decoction) Formula
Guizhi, Shaoyao, Shengjiang (each 3 liang), Gancao (2 liang), Dazao (12 pieces), Longgu, Muli (each 3 liang).
The above seven herbs are boiled in 7 sheng of water to yield 3 sheng. Divide into three warm doses.

In Xu Lao with interior tightness, palpitations, epistaxis, abdominal pain, dream loss of essence, limb soreness/pain, hand/foot vexation/heat, dry throat, and dry mouth, Xiao Jianzhong Tang (Minor Construct the Middle Decoction) is the primary treatment.

[Annotation] "Xu Lao..." generally describes Xu Lao symptoms, not limiting Xu Lao to only these. Hence the subsequent mention of "various deficiencies." All are treated with Xiao Jianzhong Tang to "minorly construct" the deficiency of the Middle Jiao. Combining with the next six sections, all discuss Xu Lao, each with its specific formula.

Xiao Jianzhong Tang Formula
Guizhi (3 liang), Gancao (Roasted, 3 liang), Dazao (12 pieces), Shaoyao (6 liang), Shengjiang (2 liang), Jiaoyi (Malt Sugar, 1 sheng).
The above six herbs are boiled in 7 sheng of water to yield 3 sheng. Remove dregs, add Jiaoyi, and simmer gently until dissolved. Take 1 sheng warm, three times daily. Patients with vomiting should not use Jianzhong Tang due to its sweetness.

In Xu Lao with interior tightness and various deficiencies, Huangqi Jianzhong Tang (Astragalus Construct the Middle Decoction) is the primary treatment.

[Annotation] "Xu Lao interior tightness and various deficiencies" includes the deficiencies mentioned in the previous clause. Huangqi Jianzhong Tang constructs both interior and exterior deficiency, not just treating interior tightness. Guizhi Longgu Muli Tang is Guizhi Tang plus Longgu/Muli; Xiao Jianzhong Tang is Guizhi Tang plus Jiaoyi; Huangqi Jianzhong Tang is Guizhi Tang plus Jiaoyi and Huangqi. I have often reflected on how Zhang Zhongjing uses variations of Guizhi Tang with infinite efficacy. Why do later generations see Guizhi only as a sweating agent for Shanghan? They only know Zhang Zhongjing used Guizhi Tang for Shanghan, not for Xu Lao. Understanding Guizhi Tang's role in treating Xu Lao reveals Zhang Zhongjing's core method. Guizhi Tang is acrid-sweet and warm. If taken with hot porridge and covered to induce sweat, it disperses Ying/Wei to drive out external pathogens (Acrid-Sweet disperses Yang, focusing on Acrid). If plus Longgu/Muli, Jiaoyi, Huangqi, it tonifies and secures interior/exterior to treat Xu Lao (Labor requires warming, Sweet medicines regulate, focusing on Warm/Sweet). From this, one can deduce the infinite subtleties of modifying drug properties and functions.

[Collected Annotations] Wei Litong said: For severe Qi deficiency, add Huangqi; for severe fluid depletion, add Renshen, to treat Xu Lao interior tightness. Here, "interior tightness" does not solely refer to tightness, but to abdominal pain from various Xu Lao deficiencies. Hence named "Jianzhong" (Construct Middle), precisely to support Middle Qi, allowing Yin/Yang to gradually generate, reach Ying/Wei, and distribute to the limbs.

You Yi said: Interior deficiency with wiry pulse causes牵引 pain in the abdomen. "Various deficiencies" means all Yin/Yang pulses are deficient, leading to dizziness, palpitations, panting, essence loss, and blood loss. To soothe tightness, one must use Sweet; to tonify deficiency, one must use Warm. To fill voids, Huangqi is particularly effective.

Huangqi Jianzhong Tang Formula
Add 1.5 liang of Huangqi to Xiao Jianzhong Tang. Follow the remaining methods above. If there is shortness of breath and chest fullness, add Shengjiang. If there is abdominal fullness, remove Dates and add Fuling (1.5 liang). To treat Lung deficiency/inadequacy and tonify Qi, add Banxia (3 liang).

In Xu Lao with lower back pain, lower abdominal拘急 (tightness/spasm), and dysuria, Bawei Shenqi Wan (Eight-Ingredient Kidney Qi Pill) is the primary treatment.

[Annotation] In Xu Lao, lower back pain is due to Kidney Qi deficiency failing to move. Lower abdominal tightness and dysuria are due to Bladder Qi deficiency failing to transform. Bawei Shenqi Wan is used to warm and tonify the Lower Jiao. When the interrelated Qi of the Kidney and Bladder is sufficient, lower back pain, lower abdominal tightness, and dysuria will surely resolve.

[Collected Annotations] Cheng Lin said: The lower back is the external indicator of the Kidney; Kidney deficiency causes back pain. The Kidney and Bladder are exterior-interior partners; without Sanjiao Yang Qi to regulate water passages, dysuria and lower abdominal tightness occur. This formula benefits Qi in the Kidney gate; strong Qi allows urination to flow and resolves lower abdominal tightness.

You Yi said: In Xu Lao, Shaoyin Kidney Qi is damaged, causing back pain, lower abdominal tightness, and dysuria. Bawei Shenqi Wan tonifies Yin deficiency to generate Qi, and assists weak Yang to transform water. It is an excellent formula for treating the Lower Jiao.