Library

The *Shanghan Lun* (Treatise on Cold Damage) states: "When a disease originates from Yang, and purgation is wrongly applied, heat enters and causes Jie Xiong (Chest Binding); when a disease originates from Yin, and purgation is wrongly applied, Pi Man (Stagnant Fullness) results." This has been a perplexing sentence for millennia. Observing that Zhang Zhongjing uses heavy formulas such as Da Xianxiong Tang (Major Chest-Trap Decoction) and Xiao Xianxiong Tang (Minor Chest-Trap Decoction) to treat Jie Xiong, and light formulas such as the various Xiexin Tangs (Heart-Draining Decoctions) to treat Pi Man, we can understand that "originating from Yang" and "originating from Yin" refer to the severity of the disease. Old annotations claim that fever with aversion to cold indicates originating from Yang, while absence of fever with aversion to cold indicates originating from Yin. However, one fails to realize that absence of fever with aversion to cold belongs to Yin syndromes; if purgation is wrongly applied in such cases, death ensues, so how could Pi Man result? Would Zhang Zhongjing use cold herbs like Huanglian Xiexin Tang (Coptis Heart-Draining Decoction) to treat Yin syndromes resulting from erroneous purgation! It is also stated: "In Taiyang disease, wind damages the Wei (Defensive) level, and Guizhi Tang (Cinnamon Twig Decoction) should be used; if Chengqi Tang (Gut-Preserving Decoction) is wrongly used for purgation, Jie Xiong results. In Taiyang disease, cold damages the Ying (Nutritive) level, and Mahuang Tang (Ephedra Decoction) should be used; if Chengqi Tang is wrongly used for purgation, Pi Man results." Upon careful study, I find this is not limited to Taiyang channel pathology. The text later states: "After six or seven days of cold damage, with vomiting and fever, Chaihu syndrome (Bupleurum Syndrome) is present, yet other drugs are used for purgation. If there is fullness and hardness with pain in the epigastrium, this is Jie Xiong, treated with Da Xianxiong Tang. If there is only fullness without pain, this is Pi, and Chaihu Tang is inappropriate; Xiexin Tang is suitable." Thus, erroneous purgation of the Shaoyang channel can also lead to Jie Xiong and Pi Man. Furthermore, hardness and pain in the epigastrium define Jie Xiong, while mere fullness without pain defines Pi Man. This shows that Jie Xiong and Pi Man are named based on the presence or absence of pain to distinguish disease severity. In summary, when exterior pathogens of the Three Yang channels remain unresolved and the condition is severe, premature purgation leads to hard, painful epigastrium, named Jie Xiong; when the condition is mild, premature purgation leads to mere fullness without pain in the epigastrium, named Pi Man. Zhang Zhongjing did not strictly adhere to the Taiyang channel alone, nor did he necessarily differentiate based on wind damaging Wei versus cold damaging Ying. Looking at his formula indications, Da Xianxiong Tang and Wan are used for Da Jie Xiong (Major Chest Binding) characterized by hardness and pain from the epigastrium down to the lower abdomen; Xiao Xianxiong Tang and Wan are used only for chest binding with pain in the epigastrium; and the various Xiexin Tangs are used only for Pi Qi (Stagnant Qi) characterized by epigastric fullness without pain. Carefully considering that cold damaging Ying (originating from Yin) presents with anhidrosis and is more severe than wind damaging Wei (originating from Yin) with diaphoresis, why does erroneous purgation fail to produce Jie Xiong but instead produces painless Pi Man, treated with the light Xiexin Tang? Clearly, the naming and formulation are based on symptom severity. The names "Xianxiong" (Chest-Trap) and "Xiexin" (Heart-Drain) are used because the pathological location is in the broad area of the heart and chest. If heat pathogen sinks into the lower part of the Yangming Large Intestine, it cannot be called Jie Xiong but becomes Yangming abdominal pain and downward syndrome, treated with Chengqi Tang for purgation rather than Xianxiong Tang. Similarly, if exterior symptoms are unresolved and purgation is wrongly applied, causing exterior pathogens to sink into the Taiyin Spleen Yin channel, presenting with diarrhea, Chengqi Tang is not used, but Guizhi Dahuang Tang (Cinnamon Twig and Rhubarb Decoction) is used. Dahuang (Rhubarb Root and Rhizome) eliminates filth and decay, while Guizhi (Cinnamon Twig) disperses the sunken exterior pathogen, and simultaneously restrains Dahuang from damaging Taiyin organ qi. This differs from Jie Xiong in the upper Yang channels, which can use Xianxiong Tang; and differs from heat accumulation in the lower Yangming channels, which can use Chengqi Tang. Additionally, there is Shui Jie Xiong (Water Chest Binding) treated with Shengjiang Banxia Tang (Fresh Ginger and Pinellia Decoction); and Tan Huo Jie Xiong (Phlegm-Fire Chest Binding) treated with Chuanlian Banxia Tang (Coptis and Pinellia Decoction). I further deduce that when pathogenic factors and food stagnation bind together, Pingwei Baohe San (Stomach-Calming and Harmony-Preserving Powder) is used. All these are later generations' similar-to-Jie Xiong syndromes.

The Taiyang chapter states: "Disease originating from Yang, wrongly purged, heat enters and forms Jie Xiong; disease originating from Yin, wrongly purged, forms Pi Man." The reason Jie Xiong forms is due to purgation being too early.

This clause clarifies the cause of Jie Xiong and Pi Man resulting from failure to sweat and erroneous purgation while exterior heat remains unresolved. It says that disease originating from Yang involves heavier exterior heat; premature purgation causes heat to sink inward, forming Jie Xiong. Originating from Yin involves lighter exterior heat; premature purgation forms Pi Man. Old annotations claim wind damaging Wei is Yang, and cold damaging Ying is Yin. However, one fails to realize that cold damaging Ying, presenting with anhidrosis, body ache, and fever, represents a more severe exterior pathogen than wind damaging Wei, which presents with diaphoresis. Could erroneous purgation transform it into the milder Pi Man? It must be that Yin and Yang are distinguished by the severity of exterior heat.

In Taiyang disease, the pulse is floating, moving, and rapid. Floating indicates Wind, Rapid indicates Heat, Moving indicates Pain, and Rapid indicates Deficiency. Headache, fever, slight nocturnal sweating, and contrary aversion to cold indicate the exterior is unresolved. The physician wrongly applies purgation. The moving and rapid pulse changes to slow. Rejection pain occurs inside the diaphragm. The stomach becomes empty and deficient. Hostile Qi agitates the diaphragm, causing shortness of breath, irritability, and mental restlessness (Ao Nao). Yang Qi sinks inward, causing hardness in the epigastrium, thus forming Jie Xiong. Da Xianxiong Tang is indicated. If Jie Xiong does not form, but only head sweating occurs, with no sweat elsewhere up to the neck, and urination is difficult, the body will surely become jaundiced.

Floating and moving/rapid is an exterior pulse. Headache, fever, nocturnal sweating, and aversion to cold are exterior symptoms. Wrong purgation changing the pulse to slow is the Jie Xiong pulse. Diaphragmatic rejection pain, mental restlessness, and epigastric hardness are Jie Xiong symptoms, hence Da Xianxiong Tang is used. If Jie Xiong does not form, with head sweat but no body sweat, and difficulty urinating, stasis-heat has no outlet to vent, leading to jaundice.

In Taiyang disease, after excessive sweating followed by purgation, constipation persists for five or six days, the tongue is dry and thirsty, there is slight tidal fever in the late afternoon, and hardness and fullness with unbearable pain from the epigastrium to the lower abdomen occur. Da Xianxiong Tang is indicated.

Failure to sweat the exterior creates fear of Jie Xiong or Pi Man from purgation. Now, excessive sweating followed by purgation also forms Jie Xiong. Constipation, dry tongue with thirst, slight afternoon tidal fever, and hardness/fullness/pain from epigastrium to lower abdomen necessitate Da Xianxiong Tang.

In Jie Xiong, the neck is also stiff, resembling Rou Ji (Soft Spasm). Purging brings relief; Da Xianxiong Tang is suitable.

When Jie Xiong extends to neck stiffness, the chest pathogen is extremely tight and solid. Using Da Xianxiong Tang risks passing through without retaining effect; using Xianxiong Wan risks stagnation worsening the binding. Boiling the decoction allows gentle expulsion of the pathogen.

There are syndromes of Jie Xiong and Zang Jie (Organ Binding). What are their manifestations? Answer: Pressing causes pain, Cun pulse is floating, Guan pulse is sunken, named Jie Xiong. Similar to Jie Xiong, but eating/drinking is normal, with frequent diarrhea, Cun pulse floating, Guan pulse small, fine, sunken, and tight, named Zang Jie. A white slippery coating on the tongue indicates a difficult case to treat.

This clause differentiates Jie Xiong and Zang Jiao symptoms, distinguishing them by normal appetite versus frequent diarrhea. With floating Cun pulse, sunken Guan pulse, and tongue coating, acrid-warm herbs are contraindicated. With white slippery coating, cold-cool herbs are contraindicated, hence "difficult to treat."

If a patient has had Pi Qi (Stagnant Fullness) under the hypochondrium since long ago, connected to the side of the umbilicus, with pain radiating to the lower abdomen and genitals, this is named Zang Jie, a fatal Zang Jie. Zang Jie lacks Yang symptoms, no alternating chills and fever, the person is quiet, and with a slippery tongue coating, it cannot be attacked with purgatives.

This elaborates that in persons with pre-existing Pi Qi, pain now radiating to the lower abdomen and genitals is named fatal Zang Jie. It further states Zang Jie is not a Yang channel syndrome, hence no alternating chills and fever, the person is quiet, and with slippery tongue coating, it cannot be purged.

After six or seven days of cold damage, presenting with Jie Xiong Heat Excess syndrome, sunken and tight pulse, epigastric pain, and hardness upon palpation like stone, Da Xianxiong Tang is indicated.

This reiterates anterior chest excess-heat, sunken-tight pulse, epigastric pain, and stone-hard palpation, indicating Da Xianxiong Tang.

Minor Jie Xiong syndrome is located precisely in the epigastrium, painful only upon pressure, with floating-slippery pulse. Xiao Xianxiong Tang is indicated.

This reiterates non-pain upon non-pressure, floating-slippery pulse, not sunken-excess, indicating Xiao Xianxiong Tang.

After ten-plus days of cold damage, heat accumulates in the interior, accompanied by alternating chills and fever. Da Chaihu Tang (Major Bupleurum Decoction) is indicated. In pure Jie Xiong without significant external heat, this is Water Binding in the chest and hypochondrium. With only head sweating, Da Xianxiong Tang is indicated.

The first part discusses cold damage for ten-plus days with heat binding in the interior, ready for purgation. However, with alternating chills and fever, this is Shaoyang exterior syndrome; only Da Chaihu Tang can resolve both exterior and interior. The second part discusses pure Jie Xiong without significant external heat, which is Water Binding in the chest, blocking Yin and Yang, causing only head sweat and no body sweat. Da Xianxiong Tang must be used to expel water-fluids and open blockages. This clarifies that head-only sweating requires treating chest condensation.

After six or seven days of cold damage, with fever, slight aversion to cold, bone joint vexation/pain, slight vomiting, and epigastric support-binding sensation, with exterior symptoms unresolved, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) is indicated.

In this section, pathogen binds in the hypochondrium without forming Jie Xiong, yet Taiyang and Shaoyang exterior symptoms are present. Chaihu Guizhi Tang should be used to first disperse exterior pathogens. In Jie Xiong disease, if the pulse is floating and large, purgation is contraindicated; purging leads to death.

In Jie Xiong disease, a floating-large pulse indicates exterior pathogen, hence purging leads to death.

After five or six days of cold damage, with vomiting and fever, Chaihu syndrome is complete. If other drugs are used for purgation, and Chaihu syndrome persists, Chaihu Tang should be administered again. Although purgation has occurred, this is not a counter-indication. There will be shivering and shaking, followed by fever and sweating, leading to resolution. If epigastric fullness with hardness and pain occurs, this is Jie Xiong, treated with Da Xianxiong Tang. If merely full without pain, this is Pi, Chaihu Tang is inappropriate, and Banxia Xiexin Tang (Pinellia Heart-Draining Decoction) is suitable.

This clarifies that erroneous purgation transforms into three syndromes with three treatments. Jie Xiong and Pi Man are not solely caused by premature purgation in Taiyang; even Shaoyang exterior syndrome, if wrongly purged, can result in these conditions. Thus, after five or six days of cold damage with vomiting and fever, if Chaihu Tang syndrome is present but other drugs are wrongly used for purgation, if fever/exterior symptoms persist and Jie Xiong does not form, Chaihu Tang should be given again, leading to resolution via sweating. If post-purgation body heat ceases but epigastric hardness/pain appears, Jie Xiong forms, requiring Da Xianxiong Tang. If full without pain, it is Pi Qi, requiring Banxia Xiexin Tang.

Da Xianxiong Tang
Yuanhua (Kerria Flower), Gansui (Radix Kansui), Daji (Radix Euphorbiae Pekinensis)
When heat pathogen transmits to the interior and binds in the lower abdomen, Dachengqi Tang (Major Gut-Preserving Decoction) is used. If failure to sweat leads to erroneous purgation, causing heat to sink inward and creating chest/abdominal pain, Da Xianxiong Tang/Wan is used.

Xiao Xianxiong Tang
Chuanlian (Rhizoma Coptidis), Banxia (Rhizoma Pinelliae), Gualou Shi (Fructus Trichosanthis)
This formula addresses chest fullness. Banxia disperses phlegm acridly, Gualou clears evil turbidity, and Chuanlian removes accumulated heat, thereby dissipating heat and resolving phlegm.

Chengqi Tang See Bianjie (Constipation).
Upper Jie Xiong does not originally require Chengqi Tang. If full without pain, with abdominal pain and constipation, Chengqi Tang is variedly used to descend, thereby relieving the upper region.

Guizhi Dahuang Tang See Fentong (Abdominal Pain).
Erroneous purgation causes exterior pathogen to sink. Yangming Stomach pain with sunken-tight pulse uses Da Xianxiong Tang. Sink into Large Intestine causing pain with rapid-excess pulse uses Chengqi Tang. Sink into Taiyin causing pain with fine-rapid pulse uses Guizhi Dahuang Tang.

Shengjiang Banxia Xiexin Tang
Shengjiang (Fresh Ginger), Banxia (Pinellia Tuber), Zhike (Aurantii Fructus), Houpo (Magnolia Bark), Renshen (Ginseng Radix), Chuanlian (Coptis Rhizome), Gancao (Licorice Root)
This formula generally treats Pi Man resulting from failed sweating or premature purgation. Adding more Gancao makes Gancao Xiexin Tang, treating Stomach deficiency and hostile Qi rebelling upward. Adding more Shengjiang makes Shengjiang Xiexin Tang, treating subcostal water-fluids and borborygmus.

Pingwei Baohe San Is Pingwei San (Stomach-Calming Powder) and Baohe Wan (Harmony-Preserving Pill) ground together.
For exogenous pathogens complicated by food stagnation, causing chest condensation and pain intolerable to touch, resembling Jie Xiong but actually Phlegm-Food Stagnation, this formula is used.

Chaihu Guizhi Tang See detailed notes on Pi Man.