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Huangdi asked: How is Bi syndrome (Bi Zheng, obstruction syndrome) generated? Qibo replied: The three pathogens of Wind, Cold, and Dampness mix and invade together, combining to form Bi syndrome. (Bi sounds like "bi". Bi means obstruction. Pathogens obstruct and cause pain. This refers to the Wind, Cold, and Dampness Qi mixing and invading together, combining to form Bi.) When Wind Qi prevails, it is called Xing Bi (Wandering Bi). (Wind moves swiftly and changes frequently, so the pain migrates without a fixed location.) When Cold Qi prevails, it is called Tong Bi (Painful Bi). (Cold is a Yin pathogen, and pain belongs to Yin, so when Cold Qi prevails, it is called Tong Bi.) When Dampness Qi prevails, it is called Zhuo Bi (Fixed Bi). (Dampness flows into the joints, thus forming a Fixed Bi. According to the *Ling Shu*, there is Feng Bi; according to the *Shang Han Lun*, there is Shi Bi. These are cases where a single pathogen causes Bi. This chapter discusses the three pathogens of Wind, Cold, and Dampness mixing and combining to form Bi, which is caused by the combination of three pathogens. The *Ling Shu · Zhou Bi* chapter says: Wind, Cold, and Dampness Qi lodge between the outer fenli (muscle intervals), pressing on fluids to form foam. Foam gathers when cold, and gathering pushes apart the fenli causing separation. Separation causes pain. When pain occurs, Shen (spirit/mind) returns to the area. When Shen returns, heat is generated. Heat relieves pain. After pain relief, Qi becomes reversed, causing other Bi syndromes to erupt. This is how Cold Bi starts first and other Bi syndromes recur. This chapter discusses that Wind prevailing leads to Xing Bi, and Dampness prevailing leads to Zhuo Bi. This indicates that among the mixed three pathogens, the one that prevails determines the main pathology. The classics differ because the manifestations vary. Physicians should carefully comprehend each case.) Huangdi said: What are the five types of Bi? (Huangdi asks about the five Bi beyond the three pathogens. The previous section discussed the three heavenly pathogens; the following discusses the five human organ Qi.) Qibo said: Contracting these pathogens in Winter results in Gu Bi (Bone Bi); in Spring, Jin Bi (Tendon Bi); in Summer, Mai Bi (Vessel Bi); at Zhi Yin (Late Summer), Ji Bi (Muscle Bi); and in Autumn, Pi Bi (Skin Bi). (Skin, flesh, tendons, and bones are the external correspondences of the Zang organs. The Qi of the five Zang organs corresponds to the four seasons and five elements, so they contract disease in their respective seasons due to similar Qi resonance.) Huangdi said: What factor causes the pathogens to lodge internally in the five Zang and six Fu organs? Qibo said: Each Zang organ has an external correspondence. If the disease persists for a long time, the pathogens lodge internally in their corresponding organ. (The Lung corresponds to Skin, the Heart to Vessels, the Spleen to Muscle, the Liver to Tendons, and the Kidney to Bone. Pathogens initially injure skin, flesh, tendons, and bones. If not resolved over time, they lodge internally in the corresponding Zang, forming Zang-Fu Bi.) Therefore, if Gu Bi is not cured and pathogens are contracted again, they lodge internally in the Kidney; if Jin Bi is not cured and pathogens are contracted again, they lodge internally in the Liver; if Mai Bi is not cured and pathogens are contracted again, they lodge internally in the Heart; if Ji Bi is not cured and pathogens are contracted again, they lodge internally in the Spleen; if Pi Bi is not cured and pathogens are contracted again, they lodge internally in the Lung. This is what is meant by Bi syndrome: contracting Wind, Cold, and Dampness repeatedly during the respective seasons. (The so-called five Zang Bi occurs when Wind, Cold, and Dampness are contracted repeatedly during the seasons corresponding to the five Zang organs. Since skin, flesh, tendons, and bones internally correspond to the five Zang organs, and the Qi of the five Zang organs externally corresponds to the four seasons, the disease begins in the external有形 (formative) parts and then damages the internal five Qi. External form and internal Qi combine, and pathogens lodge inside. "Lodging" is like staying in an inn; pathogens reside there. Pathogens contend among the five Zang organs, interfering with Zang Qi but not damaging the true Zang essence, hence called "lodging" or "visiting." Symptoms such as fullness, panting, and counterflow qi appear above. If pathogens enter the Zang, death ensues. Zhang Zhaohuang said: Stating that contracting this in Winter leads to Gu Bi implies that Bi diseases often penetrate deeply. Thus, it mentions Bone first, then Tendon, then Vessel, then Skin.) For Bi pathogens lodging in the five Zang organs: Lung Bi manifests as fullness, panting, and vomiting. (This discusses how Zang Qi receiving pathogens manifests in symptoms. The Lung governs Qi and respiration. Its vessel originates in the middle Jiao, circles the stomach opening, ascends through the diaphragm, and connects to the Lung. Thus, obstruction causes fullness, panting, and vomiting. Zhaohuang said: When Zang Qi receives pathogens, the disease is in the five Zang organs; when five Zang organs are diseased, it affects meridians and physical layers.) Heart Bi manifests as blocked vessels, palpitations when vexed, sudden upward rushing of Qi with panting, dry throat, frequent belching, and fear when rebellious Qi rises. (The Heart governs vessels, so obstruction blocks vessel flow. Pathogens contend below the heart, stirring and disturbing the Heart Qi upwards, causing vexation and palpitations below the heart. The Lung is the canopy of the Heart, and Heart vessels connect to the Lung. Thus, rebellious Qi rushes up, causing panting and dry throat. The Heart governs belching; when Heart Qi rebels upwards, belching occurs. Water and Fire Qi interact上下 (up and down). If Heart Qi rebels upwards, it cannot descend to communicate with the Kidney. With deficient Kidney Qi, sorrow arises. Zhaohuang said: Palpitations below the heart and sudden upward Qi rush refer to pathogenic Qi rebelling upwards; rebellious Qi rising refers to healthy Qi rebelling.) Liver Bi manifests as fright during sleep, excessive thirst, frequent urination, and upper pulling sensations resembling pregnancy. (The Liver stores Hun (ethereal soul). During sleep, Hun is unsettled, causing fright. The Liver vessel passes through the inner thigh, enters pubic hair, crosses the genitalia, reaches the lower abdomen, flanks the stomach, connects to the Liver and Gallbladder, ascends through the diaphragm, follows the throat, and enters the nasal cavity. When Liver Qi is obstructed, Wood and Fire become stagnant and hot. Above, this causes excessive thirst; below, frequent urination. Upward pulling in the middle creates a sensation resembling pregnancy.) Kidney Bi manifests as frequent distension, sitting on the sacrum instead of heels, and spine replacing the head. (The Kidney is the gate of the Stomach. If the gate is ineffective, Stomach Qi does not rotate, causing distension. The end of the spine is the sacrum. The Kidney governs bone. With bone萎 (atrophy/withering), walking is impossible, so the sacrum replaces the heels. Yin diseases prevent supine posture, so the spine replaces the head.) Spleen Bi manifests as limpness and weakness of the four limbs, coughing, vomiting of saliva, and severe upper blockage. (Spleen Qi cannot circulate to the four limbs, causing limpness. The Spleen vessel ascends through the diaphragm and flanks the pharynx. When Qi is obstructed, coughing occurs. Drinks entering the stomach are transported to the Spleen and Lung. If Spleen Qi fails to transport, saliva is vomited. If Lung Qi fails to regulate, severe upper blockage occurs.) Intestine Bi manifests as frequent drinking but inability to urinate, abdominal borborygmi and contention, and occasional stool containing undigested food. (Intestine Bi refers to both Small and Large Intestines. The Small Intestine is the Fu organ of the Heart and governs urination. Pathogens obstructing the Small Intestine cause fire-heat to stagnate above (thirst) and block urination below. The Large Intestine is the Fu organ of the Lung and governs defecation. Pathogens obstructing the Large Intestine cause abdominal borborygmi above and undigested stool below.) Bao Bi (Bladder Bi) manifests as internal pain upon pressing the lower abdomen and bladder, a sensation of being poured with hot water, difficult urination, and clear nasal discharge above. (Bao is the chamber of the bladder, located in the lower abdomen. Pathogens obstructing Bao cause internal pain upon pressing the lower abdomen/bladder. Blocked water accumulates and generates heat, feeling like hot water, and causes difficult urination. The Bladder vessel enters the brain from the vertex; brain seepage forms nasal mucus. Clear nasal discharge above occurs because Taiyang Qi is obstructed below and cannot ascend along the meridian. I note: Only three of the six Fu organs' Bi are mentioned. Ying Qi is the essence of the Stomach Fu; Wei Qi is the fierce Qi of Yangming. Ying and Wei travel together in and out. Sanjiao Qi travels up and down. Shaoyang Gallbladder Qi rises before the Zang-Fu. Bi means obstruction. When healthy Qi circulates, pathogens cannot remain. The reason the three Fu organs do not suffer Bi lies here.) Yin Qi, when quiet, hides the Shen (spirit); when agitated, the Shen perishes. (This states that when Zang Qi does not hide, pathogens obstruct the Zang. Yin Qi refers to Zang Qi. Shen is the spirit stored in the five Zang organs. The five Zang are Yin; Yin governs quietness. Thus, quietness hides Shen Qi, preventing pathogen invasion; agitation causes Shen Qi to perish, allowing Bi to gather in the Zang.) Excessive food and drink injure the intestines and stomach. (This states that when intestines and stomach are injured, pathogens obstruct the Fu organs. Improper living conditions allow Wind, Cold, and Dampness to strike the Shu points. However, one must regulate diet to prevent pathogens from entering internally. If diet is improper, pathogens enter via the Shu points and lodge in the respective Fu organs.) Dysregulated Qi causing panting indicates Bi gathering in the Lung; dysregulated Qi causing worry/thought indicates Bi gathering in the Heart; dysregulated Qi causing enuresis indicates Bi gathering in the Kidney; dysregulated Qi causing exhaustion indicates Bi gathering in the Liver; dysregulated Qi causing muscle atrophy indicates Bi gathering in the Spleen. If all Bi syndromes persist, they deepen internally. Those with prevailing Wind Qi are easily cured. (This reiterates that agitated Yin Qi causes Bi to gather in the Zang. Dysregulated Qi refers to Yin Qi wandering and not hiding quietly. Dysregulated Qi leading to panting means Lung Qi is not hidden, and Bi gathers in the Lung. Dysregulated Qi leading to worry means Kidney Qi is not hidden, and Bi gathers in the Heart (Note: Text logic seems flawed, usually worry affects Heart, but commentary says Kidney Qi not hidden, Bi in Heart). Dysregulated Qi leading to enuresis means Kidney Qi is not hidden, and Bi gathers in the Kidney. Dysregulated Qi leading to blood deficiency means Liver Qi is not hidden, and Bi gathers in the Liver. Dysregulated Qi leading to muscle withering means Spleen Qi is not hidden, and Bi gathers in the Spleen. Thus, Bi in Zang-Fu and meridians, if lingering, deepens internally to become Zang-Fu Bi. Cold and Dampness are Yin pathogens of Heaven, injuring meridians, Shu points, tendons, and bones. Wind is a Yang pathogen of Heaven, injuring skin and Qi level. Therefore, when the three pathogens strike the Shu points of Zang-Fu, and Wind prevails, its nature is moving, allowing dispersal through skin pores, making recovery easy. I note: The text later says the six Fu organs also have Shu points, meaning all five Zang and six Fu have Shu points. If Wind, Cold, and Dampness strike the Shu points of the five Zang, and Zang Qi is dysregulated, pathogens enter via Shu points and gather in the Zang. If they strike the Shu points of the six Fu, and diet is excessive, injuring intestines and stomach, pathogens enter via Shu points and lodge in the Fu. The previous section discussed contracting Wind, Cold, and Dampness repeatedly in respective seasons to form five Zang Bi, combining with Zang Qi to lodge internally. This section discusses pathogens striking Zang-Fu Shu points, entering via Shu points and deepening. It first mentions Yin Qi perishing and Bi gathering in Zang, so it only mentions the six Fu having Shu points afterwards.) Huangdi said: Some Bi patients die, some suffer long-term pain, some recover easily. Why? Qibo said: Those whose pathogens enter the Zang organs die; those whose pathogens linger between tendons and bones suffer long-term pain; those whose pathogens remain in the skin recover easily. (This states that for five Zang Bi, entering the Zang via Shu points leads to death. If Wind, Cold, and Dampness strike the Shu points, and Zang Qi is solid, pathogens do not affect the Zang. If Shen Qi perishes, Bi gathers in the Zang, leading to death. Pathogens entering the five Zang from skin, flesh, tendons, and bones interfere with Zang Qi without damaging true Zang essence. Thus, Bi lodging in the Zang causes symptoms like fullness, panting, vomiting, blocked vessels, palpitations, dry throat, and belching. Lingerling between tendons and bones without lodging in the corresponding Zang causes long-term pain. Remaining in the skin allows dispersal with Qi flow. If striking the Shu points, connecting internally to the five Zang, combined with unhidden Yin Qi, pathogens enter directly into the Zang, becoming incurable fatal syndromes.) Huangdi said: What happens when pathogens lodge in the six Fu organs? Qibo said: This is also rooted in improper diet and living habits. (This states that Bi of the six Fu organs enters internally via Shu points. Improper living allows external pathogens; irregular diet injures internal intestines and stomach. Thus, diet and living are the root of Fu organ diseases. Zhang Zhaohuang said: Bi gathering in the five Zang is due to unhidden Yin Qi and perished Shen Qi; Bi lodging in the six Fu is due to diet and living. The three "also" characters in this section should be noted.) The six Fu organs also have Shu points. When Wind, Cold, and Dampness strike these Shu points, and diet is improper, pathogens enter via the Shu points and lodge in the respective Fu organs. (Food enters the Stomach; small and large intestines separate waste; bladder drains turbid fluids; steaming transforms essence to nourish meridians. If living is improper and diet is improper internally, meridians become deficient, and pathogens enter via Shu points to lodge in the Fu. Zhang Zhaohuang said: Pathogens striking Zang Shu points respond to dysregulated Yin Qi; pathogens striking Fu Shu points respond to improper diet. Hence, "the six Fu also have Shu points, responding to improper diet." Also, the *Ling Shu · Kou Wen* chapter says: All diseases originate from wind, rain, cold, heat, Yin-Yang, joy, anger, diet, living, great shock, and sudden fear. Wind, cold, rain, and dampness combine to form Bi. Improper living strikes Zang-Fu Shu points. Joy and anger disease the Zang; fear and shock injure Yin, causing Yin Qi to perish. Excessive diet injures intestines and stomach. Thus, ancients regulated diet, had regular living, did not labor excessively, harmonized with Yin-Yang, preserving form and spirit to live past a hundred years.) Huangdi said: How to treat with acupuncture? Qibo said: The five Zang have Shu points, and the six Fu have He-sea points. Following the meridian distributions, each has specific reaction points. Treating according to the lesion site cures the disease. (This discusses treating Zang-Fu Bi with specific methods. Ying Shu points treat meridians, so for Bi in Zang, select Shu points. He-sea points treat internal Fu, so for Bi in Fu, select He-sea points. Also, follow body meridian distributions; skin, flesh, tendons, and bones have specific sites. Select points based on pathological areas to cure the disease.) Huangdi said: Do Ying and Wei Qi also cause Bi? Qibo said: Ying Qi is the essence of food and drink, harmonizing with the five Zang and spreading to the six Fu, entering the vessels. Thus, it circulates up and down the vessels, penetrating the five Zang and connecting the six Fu. (*Ling Shu* says: Humans receive Qi from grain. Grain enters the Stomach, transmits to the Lung, and nourishes all Zang-Fu. Clear parts become Ying, turbid parts become Wei. Ying travels within vessels, Wei travels outside. *Ying Qi* chapter says: Ying Qi's path relies on grain. Grain enters Stomach, transmits to Lung, spreads internally and externally. Refined parts travel in meridians, circulating endlessly. This means water-grain essence, via Lung Qi, first harmonizes with Zang-Fu, nourishing them before entering vessels. Entering vessels, it circulates up and down, penetrating five Zang and connecting six Fu. This means Zang-Fu receive grain essence, Ying travels in meridians, and meridian Ying Qi connects back to Zang-Fu, mutually supporting and nourishing.) Wei Qi is the fierce Qi of food and drink. Its Qi moves swiftly and smoothly, unable to enter vessels. Thus, it circulates between skin and fenli, steaming the huangmo (membranes), and spreading in the chest and abdomen. (Wei Qi is the fierce Qi of food and drink. Its Qi is swift and smooth, so it cannot enter vessels. Not entering vessels, it circulates between skin and fenli. Fenli are muscle intervals. Li are textures of skin and Zang-Fu. Externally, it travels between skin and muscle textures; internally, it travels in the mu-yuan (origin membranes) of connecting Zang and Fu. Mu-yuan are fatty membranes with interconnected textures, hence "textures of skin and Zang-Fu." The membrane connecting to the Small Intestine is called huang. In the middle Jiao, it steams huangmo; above the diaphragm, it spreads to Heart and Lung mu-li; in the abdomen, it spreads to Gastrointestinal, Liver, and Kidney mu-yuan. Thus, externally and internally, up and down, skin, flesh, and Zang-Fu all receive Qi. In one day and night, it completes 50 cycles around the body.) Reversing this Qi causes disease; following it leads to recovery. Without combining with Wind, Cold, and Dampness, it does not form Bi. (Ying and Wei Qi: Ying travels in vessels, Wei travels outside, circulating endlessly, meeting every 50 cycles, Yin and Yang interconnecting like an endless circle, rotating without rest. Thus, reversing Qi causes disease; following Qi leads to recovery. Not combining with Wind, Cold, and Dampness pathogens, and not lingering in skin and vessel networks, it does not form Bi. This means Bi in skin is governed by Lung Qi; Bi in muscle by Spleen Qi; Bi in vessel by Heart Qi. Although Ying and Wei Qi travel in skin and collaterals without lingering, they do not combine with pathogens.) Huangdi said: Good. Some Bi are painful, some not; some numb, some cold, some hot, some dry, some damp. Why? (Numbness means lack of pain/itch sensation. Dry means no sweat; damp means profuse sweating and wetness.) Qibo said: Pain is due to excess Cold. Presence of Cold causes pain. (When Cold prevails, it is Tong Bi; thus, pain indicates excess Cold. *Ling Shu · Ci Jie Zhen Ye* says: Painful symptoms are Yin. Human Yin-Cold causes pain. The first "Cold" refers to Heavenly Cold pathogen; the second "Cold" refers to Human Cold Qi. Heaven has Yin-Yang; humans have Yin-Yang. If one contracts Heavenly Yin-Cold but possesses strong Human Yang, Cold can transform into Heat. If two Colds contend, they condense into Tong Bi.) Lack of pain and numbness occur when disease is deep and chronic, Ying and Wei circulation is sluggish, meridians are sometimes sparse, so there is no pain. Skin lacks nourishment, resulting in numbness. ("Tong" should be read as "Tong" [pain]. Deep chronic disease implies lingering pathogens lodging in corresponding Zang. Long-standing pathogenic disease injures Ying and Wei pathways, causing sluggish flow. Deeply entered pathogens do not obstruct physical form, but meridians become sparse, hence no pain. Sluggish Ying and Wei cannot nourish skin, causing numbness.) Coldness is due to little Yang Qi and much Yin Qi, which augment the pathogenic condition, causing cold. (This explains that cold/heat depend on human Yin-Yang transformation. Little human Yang and much Yin augment the pathogenic Yin-Cold. Both pathogen and healthy Qi are Yin, hence cold.) Heat is due to much Yang Qi and little Yin Qi. Pathogenic Qi prevails, Yang encounters Yin, resulting in Bi-Heat. (Much human Yang and little Yin allow pathogens to exploit human Yang excess, making pathogenic Qi prevail. Strong human Yang encountering Heavenly Yin pathogens causes pathogens to transform with Qi into Bi-Heat. Zhang Zhaohuang said: "Augmenting pathogenic condition" means human Yin excess augments pathogenic Yin-Cold. "Pathogenic Qi prevails" means human Yang excess augments pathogenic Heat. This discusses Heavenly Yin-Yang pathogens and human Cold-Heat Qi transformations.) Profuse sweating and wetness occur when Dampness is severe. Little Yang Qi and abundant Yin Qi, interacting, cause sweating and wetness. (Dampness is a Heavenly Yin pathogen. Contracting Heavenly Yin-Cold while possessing abundant human Yin Qi, the two interact, causing sweating and wetness. Zhaohuang said: Abundant Yang-Heat causes sweating, but wet sweat belongs to Yin-Cold. Physicians should examine this.) Huangdi said: Why does Bi sometimes not hurt? Qibo said: Bi in bone causes heaviness; in vessel, blood coagulates and stagnates; in tendon, flexion and extension are impaired; in muscle, numbness occurs; in skin, coldness occurs. Having all five of these symptoms means no pain. (The classic says Qi injury causes pain. Here, pathogens obstruct有形 (formative) parts like meridians, bone, and flesh without injuring Qi, so there is no pain. Bone has Bone Qi, vessel has Vessel Qi, tendon has Tendon Qi, muscle has Muscle Qi, skin has Skin Qi. All are Qi of the five Zang, externally corresponding to the body. If disease affects form without injuring Qi, one sees only heaviness in Bone Bi, blood stagnation in Vessel Bi, limited movement in Tendon Bi, numbness in Muscle Bi, and coldness in Skin Bi. Thus, presenting these five form-symptoms results in no pain.) Generally, Bi syndromes, when encountering Cold, feel like insects crawling; when encountering Heat, muscles relax and loosen. Huangdi said: Good. (This continues the previous discussion. For these five Bi types, encountering human Yin-Cold feels like insects crawling in the skin; encountering human Yang-Heat causes tendons and bones to relax. This differs from pathogenic Cold causing pain or abundant Yang causing Bi-Heat. This describes distinct form-Qi diseases, hence Huangdi praised him.) Zhaohuang said: Externally, skin is Yang, tendons/bones are Yin. Encountering Cold makes Yang also Yin-Cold, so skin feels like insects crawling. Encountering Heat makes Yin also Yang-Heat, so tendons/bones relax.)