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(One treatise, six pulse-symptom entries, nine formulas)

The Master said: In taking the pulse, one should assess excess (Tai Guo) and deficiency (Bu Ji). When Yang is micro (Wei) and Yin is string-like (Xian), chest bi (Chest Obstruction Syndrome) with pain occurs. The reason for this is attributed to extreme deficiency. Now, knowing that Yang deficiency resides in the Upper Jiao (Upper Burner), the reason for chest bi and heart pain is precisely due to the string-like Yin pulse.

[Supplementary Note] Bi refers to obstruction and lack of free flow. The Classics state: "When there is free flow, there is no pain." Therefore, only when there is pain is it termed Bi. The cause of Bi is the invasion of pathogenic factors; the reason for pathogenic invasion is the prior deficiency of Zheng Qi (Upright Qi). Thus, it is said that assessing the pulse involves excess and deficiency: deficiency manifests as Yang Wei (micro Yang), and excess manifests as Yin Xian (string-like Yin). Due to Yang deficiency, pathogens obstruct the chest; due to Yin excess, heart pain occurs. Zhang Zhongjing has explained this clearly himself. From this, we know that this syndrome is fundamentally caused by Yang deficiency, allowing Yin to take advantage of the situation. If the pulse were not string-like, it would be evident that although Yang is deficient, Yin does not invade upward. However, chest bi varies in severity, so treatments differ accordingly. For mild cases, one merely needs to unblock and tonify the insufficient Yang of the Upper Jiao. For severe cases, one must drive out the rebellious Yin from the Lower Jiao. To unblock Yang, herbs such as Xi Bai (Allii Macrostemonis Bulbus), Bai Jiu (White Wine), Ban Xia (Pinelliae Rhizoma), Gui Zhi (Cinnamomi Ramulus), Ren Shen (Ginseng Radix et Rhizoma), and Xing Ren (Armeniacae Semen Amarum) are used. Bitter-cold herbs are not only excluded, but even cooling herbs are entirely discarded. This is because Yang is used to unblock Yang, and herbs belonging to the Yin aspect are not permitted to participate. For severe cases, Da Xin Re (Great Acrid-Heat) herbs like Fu Zi (Aconiti Lateralis Radix Praeparata), Wu Tou (Aconiti Radix), and Shu Jiao (Zanthoxyli Pericarpium) are used to drive out Yin from the Lower Jiao. Only when Yin retreats can Yang gradually recover. One must pay attention to this.

In a person without chills or fever, shortness of breath and inability to breathe deeply constitute an Excess pattern.

[Supplementary Note] When Yang is insufficient, Yin enters upward causing cold; when Yin is insufficient, Yang sinks downward causing heat. When Yin and Yang do not prevail excessively, the person appears normal without chills or fever. However, shortness of breath and inability to breathe deeply indicate that pathogens are obstructing the Middle Jiao, stagnating the ascending and descending Qi. One must not mistakenly believe this is Middle Jiao deficiency and administer tonics, thereby committing the error of "tonifying excess" (Shi Shi).

In chest bi disease, symptoms include wheezing, coughing and expectoration, chest and back pain, and shortness of breath. The pulse at Cun Kou (Radial Artery at the wrist crease) is deep and slow, while the pulse at Guan (Middle position) is slightly tight and rapid. Gua Lou Xie Bai Bai Jiu Tang (Trichosanthes Fruit, Allii Macrostemonis Bulbus, and White Wine Decoction) is the primary formula.

Formula: Gua Lou Xie Bai Bai Jiu Tang
Gua Lou Shi (Trichosanthis Fructus) - 1 fruit, crushed
Xie Bai (Allii Macrostemonis Bulbus) - 0.5 sheng
Bai Jiu (White Wine) - 7 sheng

Boil these three ingredients together until two sheng remain. Divide into two doses and take warm.

[Supplementary Note] Cold-turbid pathogens stagnating in the Upper Jiao obstruct the Qi moving up and down, blocking the positions of anterior-posterior Yin and Yang, leading to wheezing, coughing, pain, and shortness of breath. Yin-cold coagulation prevents Yang from naturally relaxing, hence the deep and slow pulse at Cun Kou is natural. Why then does the Guan position show slightly tight and rapid? Where pathogens gather, a slightly tight pulse naturally appears. The accumulation of Yin-cold suppresses Yang, causing the pulse to appear rapid. Since Yang is suppressed, it must be unblocked. Gua Lou Shi is excellent for resolving nodules and clearing phlegm. Assisted by Xie Bai and Bai Jiu, which are acrid-dispersing and directing downward, the obstructed Yang will naturally become free.

In chest bi, if the patient cannot lie flat and heart pain radiates to the back, Gua Lou Xie Bai Ban Xia Tang (Trichosanthes Fruit, Allii Macrostemonis Bulbus, and Pinellia Decoction) is the primary formula.

Formula: Gua Lou Xie Bai Ban Xia Tang
Gua Lou Shi (Trichosanthis Fructus) - 1 fruit, crushed
Xie Bai (Allii Macrostemonis Bulbus) - 3 liang
Ban Xia (Pinelliae Rhizoma) - 0.5 sheng
Bai Jiu (White Wine) - 1 dou

Boil these four ingredients together until four sheng remain. Take one sheng warm once daily.

[Supplementary Note] Chest bi involves Qi obstruction in the Upper Jiao, so pulses are not mentioned here, differing little from the previous entry, nor do symptoms differ significantly. The difference lies only in the inability to lie flat. The Classics state: "During the day, Qi moves in Yang, so one is awake; at night, Qi moves in Yin, so one sleeps." Therefore, inability to lie flat is due to Qi moving in Yang but not entering Yin. The Classics mention Xiao Ban Xia Tang inducing sleep quickly after drinking; this is not because Ban Xia is a sedative. Rather, herbs born in summer, where the midpoint of summer marks the initial birth of Yin (transition from Yang to Yin), allow Qi to return to the Liver and Blood to enter. Adding this single herb completes the function. Is this not miraculous?

In chest bi, if there is a feeling of fullness/stuffiness in the heart, Qi knotting in the chest, chest distension, and rebellious Qi rushing from the hypochondrium to the heart, Zhi Shi Xie Bai Gui Zhi Tang (Immature Bitter Orange, Allii Macrostemonis Bulbus, and Cinnamon Twig Decoction) is the primary formula. Ren Shen Tang (Ginseng Decoction) may also be used.

Formula: Zhi Shi Xie Bai Gui Zhi Tang
Zhi Shi (Aurantii Fructus Immaturus) - 4 pieces
Nong Po (Magnoliae Officinalis Cortex) - 4 liang
Xie Bai (Allii Macrostemonis Bulbus) - 0.5 sheng
Gui Zhi (Cinnamomi Ramulus) - 1 liang
Gua Lou (Trichosanthis Fructus) - 1 fruit, crushed

Add five sheng of water to the five ingredients. First boil Zhi Shi and Nong Po until two sheng remain, discard the dregs, add the remaining herbs, boil for a few boils, divide into three doses, and take warm.

Formula: Ren Shen Tang
Ren Shen (Ginseng Radix et Rhizoma)
Bai Zhu (Atractylodis Macrocephalae Rhizoma)
Gan Cao (Glycyrrhizae Radix et Rhizoma)
Gan Jiang (Zingiberis Rhizoma) - each 3 liang

Add eight sheng of water to the four ingredients. Boil until three sheng remain. Take one sheng warm, three times daily.

[Supplementary Note] It is the same disease, yet one uses herbs to unblock obstruction and reduce distension, while the other uses acrid-warm herbs to tonify the center. They seem unrelated. Does Zhang Zhongjing contradict himself in treating one syndrome? No. One must understand that conditions vary in duration and nature (Excess vs. Deficiency). If Qi is truly stagnant, causing Upper Jiao fullness and rebellious lower Qi, it is necessary to add herbs that descend Qi, reduce fullness, and harmonize Ying and Wei within the bi-unblocking formula. However, if the disease is chronic with significant Middle Qi deficiency and ineffective Zong Qi (Pectoral Qi), causing frequent fullness or Qi rushing from the hypochondrium to the heart, sweet-warm herbs are required to tonify the Middle Jiao Qi. Without acrid-dispersing herbs, congealed Yin cannot be broken. When Qi is sufficient, clear Yang rises naturally, turbid Yin descends naturally, knots dissipate, and rebellious Qi vanishes. What bi remains?

In chest bi, if there is Qi sensation of blockage and shortness of breath in the chest, Fu Ling Xing Ren Gan Cao Tang (Poria, Apricot Seed, and Licorice Decoction) is the primary formula. Ju Pi Zhi Jiang Tang (Tangerine Peel, Immature Bitter Orange, and Ginger Decoction) may also be used.

Formula: Fu Ling Xing Ren Gan Cao Tang
Fu Ling (Poria) - 3 liang
Xing Ren (Armeniacae Semen Amarum) - 50 grains
Gan Cao (Glycyrrhizae Radix et Rhizoma) - 1 liang

Add one dou of water to the three ingredients. Boil until five sheng remain. Take one sheng warm, three times daily. If not cured, continue administration.

Formula: Ju Pi Zhi Jiang Tang
Ju Pi (Citri Reticulatae Pericarpium) - 1 jin
Zhi Shi (Aurantii Fructus Immaturus) - 3 liang
Sheng Jiang (Zingiberis Rhizoma Recens) - 0.5 jin

Add five sheng of water to the three ingredients. Boil until two sheng remain. Divide into two doses and take warm.

[Supplementary Note] Chest bi has both excess/deficiency and light/severe distinctions. Severe bi involves pain radiating through to the back and heart. Light bi is different. Yet why is it still called bi? Because Qi is blocked and uncomfortable, short and unsmooth. One case belongs to the Hand-Taiyin Lung Meridian; fluid retention in the Lung causes Qi to be congested and unfavorable. Thus, Fu Ling is used to drain water, and Xing Ren to resolve nodules. Why use Gan Cao? Because shortness of breath indicates insufficiency of the Middle Earth (Spleen/Stomach). Earth is the mother of Metal. Another case belongs to the Foot-Yangming Stomach Meridian; excess in the Stomach requires Ju Pi as the sovereign herb to regulate Qi, and Zhi Shi to reduce fullness, ensuring stagnation is removed and mechanisms open. Added with the acridity of Sheng Jiang, dispersion occurs everywhere without suppression. Thus, pathogens leave and Zheng Qi feels comfortable. Even within the same excess pattern, there are differences between Zang and Fu organs.

In chest bi, where symptoms alternate between relaxation and urgency/spasm, Yi Yi Fu Zi San (Coix Seed and Aconite Powder) is the primary formula.

Yi Yi Ren (Coicis Semen) - 15 liang
Da Fu Zi (Aconiti Lateralis Radix Praeparata) - 10 pieces, prepared

Grind these two ingredients into a powder. Take one fang cun bi (square-inch spoonful) per dose, three times daily.

[Supplementary Note] "Bi alternating between relaxation and urgency" refers to an acute presentation of chest bi. Cold-fluid accumulating above the heart and diaphragm prevents Yang Qi from reaching, creating a critical situation. Therefore, Yi Yi Ren is used as the sovereign herb to drain water, and the acrid-heat of Fu Zi as the assistant to expel cold congealation, sweeping it downward. How could this fail to be effective and satisfying?

If there is stuffiness in the heart, various rebellious Qi causing a hanging pain in the heart, Gui Zhi Sheng Jiang Zhi Shi Tang (Cinnamon Twig, Ginger, and Immature Bitter Orange Decoction) is the primary formula.

Formula: Gui Zhi Sheng Jiang Zhi Shi Tang
Gui Zhi (Cinnamomi Ramulus) - 3 liang
Sheng Jiang (Zingiberis Rhizoma Recens) - 3 liang
Zhi Shi (Aurantii Fructus Immaturus) - 5 pieces

Add six sheng of water to the three ingredients. Boil until three sheng remain. Divide into three doses and take warm.

[Supplementary Note] Zhi Shi and Sheng Jiang are originally used to treat Qi blockage, let alone stuffiness. Therefore, the dosage is slightly reduced compared to the previous entry to help those with stuffiness descend their Qi to open it. Hanging pain due to fluid retention is dispersed by Sheng Jiang, which is sufficient for efficacy. Why remove Ju Pi and use Gui Zhi? Because the rebellious Qi is not singular; it might be Kidney Qi rushing upward. Gui Zhi can attack Kidney pathogens, fulfilling its role. It not only harmonizes Ying and Wei but serves as the minister herb to remove stuffiness.

If heart pain radiates to the back, and back pain radiates to the heart, Wu Tou Chi Shi Zhi Wan (Aconite, Red Kaolin Pill) is the primary formula.

Formula: Wu Tou Chi Shi Zhi Wan
Wu Tou (Aconiti Radix) - 1 fen, prepared
Chi Shi Zhi (Kaolinite) - 1 liang
Shu Jiao (Zanthoxyli Pericarpium) - 1 liang
Fu Zi (Aconiti Lateralis Radix Praeparata) - 0.5 liang, prepared
Gan Jiang (Zingiberis Rhizoma) - 1 liang

Grind these five ingredients into powder. Mix with honey to form pills the size of wu zi (mulberry seeds). Take one pill before meals, three times daily. If ineffective, increase the dose slightly.

[Supplementary Note] Heart pain radiating to the back and back pain radiating to the heart is caused by Yin-cold Qi rebelling upward and interfering, lodging horizontally between the meridians of the chest and back, causing牵连 (interconnected) pain, disrupting Qi and Blood, and confusing boundaries. Using Qi-regulating herbs here would only worsen the pain and lead to danger. Zhang Zhongjing uses Shu Jiao and Wu Tou, a batch of acrid-hot herbs, to warm and disperse Yin pathogens. However, fearing the chaotic Qi in the chest and back cannot be stabilized, he adds Gan Jiang's stabilizing nature and Chi Shi Zhi's astringency within the warming formula team to fill the new channels breached by the rebellious Qi. This allows Qi in the chest to stay in the chest, and Qi in the back to stay in the back, preventing mutual interference, thus removing the affliction. This is the essence of "smelting stones to repair heaven." Today, people know methods of warming, tonifying, moving, and dispersing Qi. Do they also know how to block the pathways of pathogenic aggression, allowing Yin and Yang Qi of the chest and back to coexist without conflict?

Jiu Tong Wan (Nine Pain Pill) treats nine types of heart pain. (Not a formula from Zhang Zhongjing)
Fu Zi (Aconiti Lateralis Radix Praeparata) - 2 liang, prepared
Sheng Ye Lang Ya (Spiraeae Flavae Herba, raw) - 1 liang, roasted until fragrant
Ba Dou (Crotonis Fructus) - 1 liang, skin and heart removed, roasted and ground into paste
Ren Shen (Ginseng Radix et Rhizoma)
Gan Jiang (Zingiberis Rhizoma)
Wu Zhu Yu (Evodiae Fructus) - each 1 liang

Grind these six ingredients into powder. Refine honey to form pills the size of mulberry seeds. Take with wine. Strong individuals take three pills initially, three times daily. Weak individuals take two pills.

[Supplementary Note] The pill is named "Nine" and treats nine types of heart pain, though I do not know exactly which nine are treated. It also treats sudden onset of evil with abdominal distension and pain, inability to speak, chronic accumulated cold flowing into the chest and heart pain, cold rushing upward Qi, blood disorders from falling off horses or cars, etc. From this, we see that heat is used to remove cold, acridity to open depression, descending to treat rebellion, fragrance to scatter nodules, sweetness to tonify Zheng, and toxicity to attack toxicity. Gathering many forces into one formula, combining various toxic substances without hesitation, achieving much with little effort, is because the sovereign territory must not allow pathogens to emerge secretly. Thus, disrespectful pathogens on the side are chased away like eagles. How much more so when the Bao Luo (Pericardium) is harmed, akin to shocking the capital? This approach seeks speed rather than slowness. Can fire-pain also be treated? Yes. Why? This is the method of "following treatment" (Cong Zhi). Looking at injuries from falls and blood disorders, all involve stagnation due to trauma or pre-existing blood stasis. Even if the pain does not concern the Heart itself, it can certainly be treated. This is clear.