Classification of Bi Syndrome

 JOURNAL OF CHINESE MEDICINE NUMBER 4 7 JANUARY 1995

Classification of Bi Syndrome by Sun Pei-Lin and Luc Vangermeersch Vangermeersch

T

he Chinese character ‘bi’ signifies blockage or obstruction, and in TCM this term is used to signify stagnation of qi and blood in the jing (channels) and luo (collaterals) due to attack by pathogenic factors such as wind, cold, dampness etc. Bi primarily gives rise to pain, swelling and restricted movement. For Western practitioners of TCM, bi is mostly associated with rheumatic diseases in the wider sense and there is indeed considerable overlap between these two concepts. However the category of bi syndrome is considerably wider than rheumatic diseases, whilst the typical classification of rheumatic diseases used in Western medicine is unknown in TCM, for example the differentiation  between degenerative disorders (e.g. arthritis) and autoimmune disorders (e.g. rheumatoid arthritis). This is due to a fundamentally different, and very original, conception of the aetiology of these disorders developed by the Chinese before the Han dynasty (i.e.  before the 2nd century BC). They stressed at one and the same time an external and an internal causation, whilst Western medicine focuses uniquely on internal dysfunction and takes no account of external factors. The two principal names of this disorder in TCM are   feng shi (wind-damp) and bi zheng (bi syndrome). The term ‘wind-damp’ stresses that these two pathogens are considered the primary factors giving rise to bi and is primarily a popular term, less used within the academic medical tradition which favours bi zheng.

Aetiology and Pathology Bi is frequently encountered in regions where the t he climate is damp, cold and windy, in both sexes and at all ages. Children and young adults, however, are less frequently affected than the aged. From these primary observations, traditional Chinese doctors deduced that climatic factors fact ors such as wind, cold and damp could invade the body if the  body condition was weak. Two important factors, therefore, are necessary to give rise to bi: i. the zheng the zheng qi (the qi, blood, yin, yang and most especially wei qi) qi) must be deficient, for example weak or elderly patients, and ii. the xie qi, qi, i.e. the pathogenic factors (wind, cold, damp etc.) must be strong. The pathogenic factors attack the body via the skin, and more particularly the pores. Having penetrated the body in th is way, they next attack the channels (entering via t he ShuStream points) and then progressively invade the entire channel system giving rise to a peripheral blockage in the

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circulation of qi and blood. This results in pain which is still confined to the muscles and joints of the affected limb. This is the first or superficial stage of bi syndrome, limited to the channels, of moderate intensity and generally reversible, notwithstanding the fact that the symptoms are acute. It should be noted that in this initial phase, also known as the stage of san of san bi (three bi), the pathogens wind, cold and damp always combine. That is to say that in the presence of only two pathogens there will be no bi. Thus if only wind and cold are involved, there may be a pattern of exterior wind-cold but no bi, and the same is the case for wind and damp. One of the pathogens, however, may predominate and TCM therefore differentiates this stage according to the primary pathogen: i. Feng i. Feng bi (wind bi) in which wind predominates. ii. Han ii. Han bi (cold bi) in which cold predominates. iii. Shi bi (damp bi) in which dampness predominates. There is another important characteristic that must be considered in the early stages of bi and that t hat is the possible development of heat. Re bi (hot or febrile bi) is an additional category of superficial bi characterised by pain, redness, heat sensation and limited function of the affected joints. iv. Aetiology and pathology of febrile bi Two principal conditions may give rise to febrile bi: i. attack by exterior heat, principally wind-damp-heat; in this case pathogenic cold is not involved unless it was already present in the interior. ii. the transformation of wind-cold-damp into heat within the body due to the presence of interior heat; this is known as huo hua (transformation into heat). There are many possible causes for the development of interior heat, for example: i. over-consumption of greasy, spicy foods and alcohol, ii. emotional factors such as stress, repression, perfectionism etc. which cause stagnation of  Liver qi and hence Liver fire, iii. over-exertion, infectious diseases, chronic diseases etc. which give rise to yin deficiency with empty heat. If exterior wind, cold and dampness attack the body when on the one hand wei qi is deficient and on the other there is accumulation of interior heat, then they will transform into heat and give rise to symptoms of febrile bi in the muscles and joints. In the majority of cases, this transformation is incomplete and the pattern of febrile bi shows a mixed picture of heat, wind, cold and dampness in which heat predominates.

 JOURNAL OF CHINESE MEDICINE NUMBER 47 JANUARY 1995

Development of Bi Syndrome Ultimately, if the development of the disease is not arrested by treatment, or if the body is unable, due to weakness, to offer sufficient resistance, wind, cold and dampness or wind, heat and dampness may progress from the exterior layer (biao) to the interior layer (li) of the  body and reach the body tissues. This is the intermediate stage of bi syndrome with the symptoms becoming more severe and tending to recur or become chronic. The final deep stage of bi syndrome occurs when the zangfu are invaded. This manifests with pronounced and chronic pain, possibly with acute attacks, irreversible swelling and deformity of the joints, limitation of movement etc.

Classification of Bi syndrome There have been, historically, numerous methods of classifying bi syndrome according to aetiology, symptoms, tissues affected, or injury to the five zang. • According to aetiology: wind bi, cold bi, damp bi and heat bi. • According to symptoms: wandering bi, painful bi, fixed  bi. • According to locality: chest bi (xiong bi). • According to the five tissues involved: cutaneous bi, muscle bi, tendon bi, bone bi, vascular bi. • According to the fu involved: intestinal bi, Bladder bi. • According to the zang involved: Lung bi, Spleen bi, Liver bi, Kidney bi, Heart bi. In current practice, the classifications according to aetiology and symptoms are most commonly used.

Correspondence with Western medicine The concept of bi syndrome in TCM can encompass the following diseases in terms of modern medicine: • Rheumatic diseases: inflammation, degeneration or metabolic disorders of the connective tissue structures of the body, especially the joints and related structures i.e. bursae, synoviae, capsulae, sheaths, tendons, muscles and other fibrous tissues. • Inflammation: acute rheumatic arthritis e.g. rheumatic fever, scapulo-humeral periarthritis, infectious (purulent) arthritis; chronic rheumatic arthritis e.g. rheumatoid arthritis, or polyarthritis chronica evolutiva (PCE), systemic lupus erythematosus (SLE) which are autoimmune diseases. • Bursitis, synovitis, capsulitis, tendinitis, fibrositis, myositis or muscular rheumatism etc. • Degenerative: osteoarthritis or arthrosis deformans, Heberden’s rheumatism, periarthritis, adhesive capsulitis (frozen shoulder). • Metabolic: gouty arthritis. • Neuralgia: the most common is lumbar neuralgia; also trigeminal neuralgia, intercostal neuralgia, sciatica etc. • Peripheral vascular diseases: such as Buerger’s disease, thromboangeitis obliterans. • Sequelae of traumatic injury such as scars which cause pain with change of weather. Within TCM there are special terms also for different kinds of bi syndrome, for example: Xiong Bi (chest bi) for obstructive disorders of the chest

such as angina pectoris, or obstructive bronchitis with phlegm. Li Jie Feng (polyarticular wind) for acute rheumatic arthritis, suppurative arthritis and gout.  He Xi Feng (crane’s knee wind) for a kind of tubercular arthritis. Cao Xie Feng (straw sandal wind) for damp-heat with swelling of the feet. Bai Hu Feng (white tiger wind) for severely painful bi due to wind.

Summary To review this presentation so far, we can say that: i. the pathology of bi is divided into three major stages: • superficial stage: attack on the channels; symptoms moderately acute. • intermediate stage: attack on the tissues; symptoms severe and recurrent. • deep stage: attack on the internal organs; symptoms chronic and extremely severe. ii. Whatever the stage, bi syndrome is always characterised by the presence of the same pathogenic factors: windcold-dampness or wind-damp-heat which are the cause of the obstruction and give rise to pain, numbness and limitation of movement. iii. the gravity of the disease depends on the relative condition of the healthy qi of the body (zheng and wei) and the virulence of the pathogenic factor (xie). iv. in healthy people whose zheng qi and wei qi are strong, there will be a vigorous battle in the superficial layers of the organism between their healthy energy and the pathogenic factors which are attempting to invade the organism. If the pathogen cannot penetrate to the deeper internal layers, then the result will be the appearance of a superficial syndrome, usually at the taiyang or shaoyang level. Most people are carriers of a cold pathogenic factor, yet no one will become ill if their wei qi is sufficiently strong. Instead, a wind-cold syndrome (rather than bi syndrome) will appear and resolve spontaneously. v. in the case of the old or feeble, whose zheng and wei qi are weak and who are consistently exposed to harmful pathogenic wind, damp, cold or heat, these external pathogens will not only penetrate the superficial (skin) level and invade the channels and collaterals, producing a  blockage of qi and blood in the muscles and joints (first stage), but can also reach the level of the body tissues (intermediate stage) and the zangfu (deep stage) and provoke interior disharmony.

Diagnosis Bi syndrome is characterised by pain, numbness and heavy sensations in the muscles and joints, and limitation of movement. The most common symptoms are pain and limitation of movement. However the nature of the pain will vary from one patient to the next: very severe pain suggesting powerful pathogenic factors or a significant stagnation of qi and blood. Bi syndrome is generally a progressive disorder. In the initial stage some patients will have fever, sweating, thirst, sore throat and general discomfort as in the case of 

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an attack of wind-cold, wind-damp or wind-heat. Later  joint and muscle pains will manifest, indicating the development into bi syndrome. The majority of cases, however, will not present with these clear symptoms. The muscle and joint pains may be the only symptoms, beginning rapidly or slowly. The pain sensation can be fixed or mobile, and may or may not  be accompanied by numbness and/or swelling. Reaching a correct diagnosis of bi syndrome requires that one make a clear differentiation of symptoms according to aetiology, location, stage, degree of interior disharmony etc. To this end it is first of all necessary to have a good understanding of the principal symptoms.

Analysis of principal symptoms Pain Pain is the most common symptom of bi syndrome. It varies according to its shi or xu nature. In shi patterns, pain is due to obstruction, and in xu patterns to impaired nourishment of the jingluo, muscles, tendons etc. Shi pain will frequently be induced by an attack of  exterior wind-cold-damp or by phlegm and blood stasis. These factors will give rise to obstruction of the channels  by qi and blood. The pain will be severe, stabbing, distending, or contracting. This shi pain will normally be present in the initial and intermediate stages. Xu pain is caused by poor functioning of the zangfu with deficiency of qi, blood, yin and yang giving rise to malnutrition of the muscles and joints. Xu pain will mostly manifest in the last stage. In clinical practice, however, we may see patients with shi/xu mixed at any stage. Treatment is given according to the relative preponderance of each.  Numbness In TCM the term ma mu denotes numbness. The character for ma signifies pricking or tingling; mu signifies absence of normal sensation, or the sensation that the muscle is dead. Like pain, numbness may be due to a shi or xu pattern. Shi numbness is due to such factors as accumulation of  damp and phlegm, and blood stasis in the muscles and  joints. Xu numbness is due to deficiency of qi and blood which fail to adequately nourish the muscles and joints. Limitation of flexion and extension Normal flexion and extension are the result of the mechanical co-ordination and effective function of different tissues such as the joints themselves, the muscles, tendons and bones. As with the other principal symptoms, this symptom may be due to a xu or shi pattern. The Spleen qi must be sufficient to ensure proper nourishment of the muscles. At the same time Liver blood (which nourishes the tendons) and Kidney jing (which nourishes the bones and marrow) must be sufficient. When there is deficiency of qi, blood and jing which consequently fail to nourish the tissues, there will be limitation of movement of the joints. On the other hand, invasion of the tissues by pathogenic factors causes a local stagnation of qi and blood and thus aggravates the limitation of the movements of flexion and

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extension. Swelling and deformity of the joints The joints allow movement. They must be suitably nourished by qi, blood and body fluids. Penetration by pathogenic factors slows down their circulation and gives rise to poor nutrition of the joints and hence deformity. In addition, attack by exterior pathogens can provoke stagnation of qi, blood and body fluids in the joints giving rise to accumulation of water and hence swelling. Swelling of the joints may also be provoked by accumulation of dampness due to Spleen deficiency. This type often presents in patients with an improper diet (for example over-consumption of greasy foods and/or alcohol). Chronic accumulation of wind, cold, damp and heat complicated by phlegm and blood stasis in the joints aggravates their malnutrition and thus their deformity. Thickening and discolouration of the skin The mechanism of these changes is the same as for swelling and deformity of the joints. Qi, blood and body fluids are the substances which nourish the skin. Invasion by exterior pathogens provokes a blockage of the pores giving rise to retention of fluid in the skin which then swells. Prolonged swelling of the skin causes it to become thickened and in chronic cases induces stagnation of qi and blood and hence hardening and discolouration.

DIFFERENTIATION Wind Bi ( Feng Bi) also known as Wandering Bi (Xing Bi) This is an attack of the ‘three bi’ (combined wind-colddamp) in which wind predominates. Wind bi has four principal characteristics: 1. The symptoms are moving, wandering and erratic; thus the pain may move around the body, from one joint to another. 2. The nature of the symptoms is variable, so for example the pain may be sharp, changing to numbness and then to soreness or distention. 3. The onset of symptoms is often sudden, acute and paroxysmal. In Bai Hu Feng, for example, they are particularly acute and intense. Symptoms may equally rapidly disappear. 4. Wind is a yang pathogen with the tendency to rise to the upper part of the body, thus it will frequently affect the head, neck, shoulders, arms and hands. In addition the following symptoms may be present: • aversion to wind or draught and aggravation of symptoms in windy weather • chills, or chills and fever • sweating due to the opening of the pores by pathogenic wind invasion Tongue: thin white and superficial coating Pulse: floating ( fu) and moderate (huan)

Cold Bi ( Han Bi), also known as Painful Bi (Tong Bi) This is an attack of the ‘three bi’ (combined wind-colddamp) in which cold predominates.

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Cold freezes, contracts and obstructs. It prevents all movement. The term bi already denotes blockage and hence pain; if pathogenic cold is added, the stagnation is especially severe and so also is the pain. This type of bi, therefore, is characterised by intense, shooting, stabbing pain that is fixed in location (blood stasis due to cold). It can never be a mild pain; if the pain is mild therefore, it cannot be cold bi. Another symptom of cold bi is ankylosis or stiffness, for example frozen shoulder. Cold congeals the qi and blood locally fixing the symptoms in one place. The pain of cold bi will be ameliorated by movement and warmth and aggravated by cold and immobility. It is also aggravated by cold weather or by application of  therapeutic measures that are cold in nature. The patient has aversion to cold and may sometimes present with a low fever. Cold is a yin pathogen. After invading the organism it provokes a yang reaction in the superficial layers: the pores close tightly and the patient does not perspire. Body fluids therefore are eliminated as urine and hence there may an increase in clear urination. Chills are due to the attempt of the body to maintain normal temperature. There may be fever due to muscular fibrillation yet shivering cold will predominate. The tongue is pale with a thin white coating (slightly thicker than in the wind bi pattern). The pulse is floating ( fu), tight ( jin) and slow (chi); if the pain is intense the pulse can be wiry (xian).

Damp Bi (Shi Bi) also known as Fixed Bi (Zhao Bi) This is the third of the ‘three bi’ in which pathogenic dampness predominates. This pattern is also known as fixed bi since it is very localised and rarely shifts in location. This is due to the tendency of dampness to be heavy and sluggish (dampness is yin by nature and easily blocks the activity and movement of yang). The patient will complain of heaviness sensations, fatigue and numbness of the limbs, head or even the whole  body. At a later stage the affected parts become swollen and painful. The swelling may be of the whole body or of  the joints and there may be subcutaneous retention of  water. The pain of damp bi is never sharp or acute but rather deep, intense and dull. It never appears suddenly but slowly and progressively. The symptoms will be aggravated by damp, rainy, overcast or foggy weather, damp walls, damp localities,  buildings constructed on marshy ground etc. The tongue coating is thick, sticky, white and wet (it is never dry). The pulse is soggy (ru) or slippery (hua) and moderate (huan).

Heat Bi (Re Bi) Heat bi is a distinct category among the superficial bi syndromes. It appears when the ‘three bi’ (wind-colddamp) invade an organism which shows signs of interior

heat and subsequently transform into wind-damp-heat. Alternatively heat bi may simply be due to attack of  exterior wind-damp-heat. The symptoms are often mixed, manifesting characteristics of the three bi described above, with the addition of  local or systemic signs of the predominant heat. • fever, sometimes accompanied by slight chills, but the fever and sensations of heat predominate • intolerance of heat • thirst and dry mouth. • irritability, restlessness and agitation • painful joints with swelling, redness, heat sensation and difficulty in movement as seen in acute inflammatory arthritis Tongue: red body with yellow coating. Pulse: rapid (shuo) and slippery (hua) reflecting the presence of both heat and dampness.

Differentiation according to the stage of penetration Primary attack: the stage of the three bi This is the first stage of bi syndrome which is superficial and can be described in the four clinical pictures given above. If the progress of the pathogenic factors cannot be arrested, the disease will progressively penetrate more deeply and reach the level of the ‘five bi’ in which the five tissues and the five zang are involved. The prolonged presence of the three bi will lead to the stage of the five bi. The deeper penetration of wind-colddamp-heat due to weakness of the zheng qi can affect the five zang and their corresponding body tissues. We can distinguish two patterns according to the degree of penetration:  Intermediate stage: bi of the five tissues (wu zhu bi)  Final stage: bi of the five zang (wu zang bi) In the intermediate stage the zang are not yet affected. It generally precedes the final stage since the tissues are considered to be more superficial than the zangfu and the pathogenic factors invade the body from the exterior towards the interior. In the stage of the five bi, differentiation is not made according to aetiology as in the stage of  the three bi, but according to the locality of the disease:

Vascular Bi ( Mai Bi) and Heart Bi ( Xin Bi) i. Vascular bi primarily involves disorders of blood such as blood stasis which blocks the vessels and causes pain: • pain typical of blood stasis: sharp, fixed, piercing, aggravated at night etc. • pain of the muscles and joints Stagnation of blood and qi on the interior may also give rise to: • uneasiness, discomfort, distress and anxiety, especially in the region of the Heart • mental depression • sensation of fullness and distention, especially in the epigastric region • sometimes sudden dyspnoea • dryness in the upper part of the throat • frequent belching • burning sensation in the skin

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• red or purple spots on or beneath the skin (eruptions, rubella-like rash) Vascular bi develops in those who overeat and drink and smoke to excess. These habits generate excessive interior heat and exhaust qi and yin. Invasion of wind-cold-damp into the channels and collaterals of an organism already weakened in this way easily leads to blood stasis and provokes vascular bi. In addition to acupuncture and herbal medicine, dietary adjustment is therefore of major importance in the treatment of vascular bi. Vascular bi appears more often in summer, a time also when it can more easily evolve towards the deeper stage of the organs, giving rise to Heart bi. ii. Heart bi mostly follows chronic vascular bi, and is induced by a new attack of wind-cold-damp. It may also develop in a person with Heart blood xu. In addition to pain of the kind experienced in vascular  bi, there is • palpitations, Heart erethism • dyspnoea, asthma • frequent dryness of the throat • restlessness, irritability, excited and agitated manner • anxiety, fearfulness, greater susceptibility to panic

Tendon Bi ( Jin Bi) and Liver Bi (Gan Bi) i. Tendon bi mostly affects the function of the muscles: • weakness and pain of the tendons and joints • the joints may be flexed but not extended (as in Dupuytren’s contracture where the fingers remain in the flexed position) • excessive intake of food and drink, psychological desire to eat (bulimia), insatiability • nightmares, horrible dreams of struggle • frequent urination Tendon bi principally affects those who are frustrated, angry and excitable, and in whom, after an attack of windcold-damp, cold persists in the tendons which are especially sensitive to cold. Tendon bi occurs more often in springtime, the season where it can most easily develop into the deeper stage of Liver bi. ii. Liver bi usually follows a case of chronic tendon bi: • extreme weakness of the tendons and limbs • headache due to uprising of Liver yang • numerous nightmares • thirst • excessive urination • pain of the ribs and flanks • hypochondriac pain and distention • abdominal distention • lower back pain • sensation of cold in the feet and lower limbs

Muscle Bi ( Ji Bi) or Flesh Bi (Rou Bi) and Spleen Bi (Pi Bi) i. Muscle bi, or flesh bi, principally affects the muscle tissues and the connective tissue. It is the bulk of the muscles, therefore, rather than their function, which is affected in this pattern: • pain, numbness, weakness, stiffness, paraesthesia, mus-

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cular paralysis, loss of force of the four limbs • heaviness of the limbs, body and/or head • extreme fatigue, exhaustion on the slightest effort • spontaneous sweating, sweating on the least effort • digestive disorders, poor digestion, malabsorption etc. As with vascular bi, muscle bi occurs in those who overindulge in rich and greasy food and alcohol, or who indulge in irregular eating etc. Muscle bi occurs most often during the second (lunar) month of summer. At this time also it may most easily penetrate to the level of the zangfu giving rise to Spleen bi. ii. Spleen bi often follows a persistent case of muscle bi or follows excessive sweating due to intense physical effort which is followed by exposure to draught or wind. Deficiency of wei qi allows the pathogen to penetrate directly into the body, reaching the middle jiao where the qi can  become blocked producing symptoms of abdominal accumulation: • weakness of the four limbs • oppressive and weighty feeling in the chest • shortness of breath and full sensation in the chest • productive cough • vomiting, impaired digestion • excessive watery salivation Tongue: the body is swollen with teethmarks, the coating slippery or greasy Pulse: weak (ruo) and slippery (hua), especially in the right middle ( guan) position which corresponds to the Spleen

Skin Bi (Pi Bi) and Lung Bi ( Fei Bi) i. The principal symptoms of skin bi are: • numbness and cold sensation of the skin • shortness of breath, or rapid shallow respiration (like a panting dog) According to TCM the Lung governs the skin. When pathogenic factors invade the skin, the wei qi, which is also governed by the Lung, cannot circulate properly in the superficial layers. Symptoms of blockage (numbness or impaired sensitivity of the skin) therefore appear. In addition there will be sensations of shivering chills and cold since the blocked wei qi cannot warm the skin. The dyspnoea is due to the exterior-interior relationship of the skin and Lung. Interior emotional factors such as severe grief or worry are considered to be the principal cause of skin bi. According to five phase theory these emotions are linked to the Lung. Skin bi occurs most often in Autumn, a time also when it can most easily penetrate to the zangfu level and give rise to Lung bi. ii. Lung bi follows chronic skin bi, or is due to invasion of  the skin by exterior pathogenic factors which give rise to stagnation of the Lung qi: • dyspnoea, shortness of breath, panting • chills, sensation of cold, aversion to cold • fever • fullness and oppression of the chest • anxiety, restlessness

Bone Bi (Gu Bi) and Kidney Bi (Shen Bi) i. The principal symptoms of bone bi are:

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• soreness and pain of the joints and bones • numbness and heaviness of the body and limbs • stiffness of the joints with immobility The Kidneys govern the bones. If, at the time of an attack  by pathogenic wind-cold-damp there is an underlying Kidney deficiency, bone bi can easily develop. Excessive sexual activity which exhausts the qi and yang of the Kidneys is considered the principal cause of bone bi. Bone bi occurs most often in winter, the season when it can also penetrate most easily to the zangfu level and give rise to Kidney bi. ii. Kidney bi most often occurs after a chronic bout of bone  bi and manifests with the following symptoms: • stooped posture, difficulty in standing erect after bending • stiffness and swelling of the joints, ankylosis • limited flexion and extension of the knees, elbows, limbs and trunk • weakness of the lower limbs • difficulty in walking • loss of hair, ‘three hair scalp’ (san mao) Organ bi, since it involves the zang, is considered the deepest stage of bi syndrome. Kidney bi, especially, appears after a long history of bi, and invasion of the Kidneys is in effect the ultimate stage of all the syndromes of bi.

Intestine Bi (Chang Bi), Bladder Bi (Bao Bi) In addition to bi of the zang, which belongs to the ‘five bi’, TCM also describes two particular kinds of bi of the fu. These two patterns are equally deep stages and are comparable to the bi of the five zang. In the same way, they can only appear after invasion of pathogenic wind-cold-damp. Intestine Bi Pathogenic factors attack the intestines and cause a local  blockage of qi. If the Small Intestine is affected, the pure portion of food and drink cannot be separated from the impure portion. If the Large Intestine is affected, one part of the fluids cannot be reabsorbed:

• sensation of swelling and distention in the abdomen • diarrhoea • dysuria • pronounced thirst • bi syndrome soreness and pain Bladder Bi Bladder bi is due to attack by pathogenic qi and subsequent blockage of the Bladder qi mechanism: • sensation of swelling, distention, fullness and extreme sensitivity of the lower abdomen which is aggravated  by pressure • dysuria, difficult urination

Differentiation according to Locality Chest Bi or Thorax Bi (Xiong Bi) Chest bi is an important concept in TCM which goes  beyond the Western medicine concept of rheumatism. It is a popular term designating certain illnesses which can  be classified as a special kind of bi syndrome. Chest bi corresponds to rheumatic pain of the chest, angina pectoris, or a pulmonary disease. Chest bi is due either to blockage of yang in the chest deriving from invasion by pathogenic factors or to accumulation of phlegm-dampness in the chest from interior disharmony. These different causes have similar symptoms: • pain of the chest and ribs occurring in the whole chest, the precordial region, the flanks or the upper back • dyspnoea, shortness of breath, oppressive sensation in the chest • cough accompanied by expectoration which can be profuse, thick and sticky

Correspondence with Western medicine There are numerous causes of thoracic pain, the principal ones being: • pulmonary diseases: asthma, bronchitis, pneumonia, pleurisy, pleurodynia

Comparison between Bi and Wei Syndromes

Pathology Symptoms

Location

Bi syndrome

Wei syndrome

Obstruction of the channels Pain of the muscles and joints mostly related to weather changes, absence of muscular atrophy Diffuse involvement

Deficiency of jing and blood Weakness of the limbs, muscular atrophy, paresis or paralysis, absence of pain; no relation to weather changes Bilateral involvement of the four limbs or unilateral

Comparison between Bi syndrome and Windstroke

Pathology Symptoms

Location

Bi syndrome

Windstroke

Obstruction of the channels Pain of the muscles and joints mostly related to weather changes, limitation of movement due to stiffness and pain Musculoskeletal disorder

Disorder of qi and blood, yin and yang, zang and fu Weakness of the limbs with limitation of movement due to paresis or paralysis; impairment of sensitivity Disorder of the central nervous system

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• cardiac diseases: angina pectoris, myocardial infarction, cardiomyopathy etc. (the majority of these are described in TCM as true heart pain (zhen xin tong) as in the Jin Gui Yao Lue written by Zhang Zhong Jing in the 3rd century. • nervous system diseases: intercostal neuralgia, herpes zoster etc. • rheumatic diseases: muscular or articular rheumatism • other chest diseases From this, we can understand that chest bi is not a rheumatic disease in the Western sense of the term.

Differentiation with Other Diseases Differentiation between Bi and Wei The term wei refers to a plant which is in need of water and therefore withers and wilts. This image corresponds clinically to decline of fluids and blood leading to malnutrition, weakness and emptiness of the channels, muscles and zangfu. The tendons become slack, impairing their motor function; the limbs become weak and their movement is limited. Paresis is followed by paralysis. Western diseases corresponding to Wei syndrome • nerve root compression with neuritis • polyneuritis • syringomelia • amyotrophic lateral sclerosis (Charcot’s disease) • multiple sclerosis • progressive muscular dystrophy (Aran-Duchenne type) • myasthenia • poliomyelitis Differentiation between Bi and Windstroke Windstroke, literally “attack by wind”, refers to apoplexy (sudden loss of consciousness accompanied by facial paralysis, dysphasia and hemiplegia as seen in cerebrovascular accident/CVA). The two principal types according to TCM are i. attack by exterior wind causing facial paralysis, ii. attack of interior wind corresponding to CVA. Windstroke, like bi, is divided into different clinical stages according to location, severity etc.: • windstroke affecting the channels and collaterals only • windstroke affecting the fu • windstroke affecting the zang This article was first published in Médecine Chinoise & Médecines Orientales, No. 6, July/August/September 1993.

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