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The exterior syndrome. If the pulse is deep and tight, it indicates that cold pathogenic factors have penetrated deeply. This statement refers to a condition caused by cold damaging the Ying (Nutrient) level, characterized by headache, fever, body ache, lower back pain, aversion to wind, and absence of sweating. If left untreated for a long time, heat pathogenic factors may sink inward spontaneously, forming hard knots in the chest. Consequently, heat becomes excess internally. The appearance of a deep and tight pulse confirms that the pathogenic factors are firmly knotted at a deep level. Therefore, there is spontaneous pain in the epigastrium even without pressure, and upon palpation, the area feels as hard as stone. Given such firm knotting of pathogenic factors, how else could Da Xianxiong Tang (Major Intrapleural Decoction) break this hardness?

After more than ten days of Shanghan (Cold Damage), with heat knotted internally and accompanied by alternating chills and fever, Da Chaihu Tang (Major Bupleurum Decoction) should be administered. However, in cases of Jie Xiong (Chest Binding Syndrome) where there is no significant fever externally, this indicates water retention knotted in the chest and hypochondrium. If only slight sweating is observed on the head, Da Xianxiong Tang (Major Intrapleural Decoction) is the primary treatment.

This is also a case of Jie Xiong (Chest Binding Syndrome) resulting from mishandling of Taiyang (Greater Yang) disease. It implies that when cold damages the Ying (Nutrient) level, if Mahuang Tang (Ephedra Decoction) is not used to induce sweating for resolution, after ten days, although the pathogen has not fully entered the interior, the stagnant heat has knotted internally to form Jie Xiong (Chest Binding Syndrome). This appears to be a pattern suitable for purgation. However, the presence of alternating chills and fever, similar to Chaihu Tang (Bupleurum Decoction) patterns, indicates that the half-exterior pathogen has not been purged. With pathogens present in both the exterior and interior, Da Xianxiong Tang (Major Intrapleural Decoction) cannot be used directly for purgation, as it can only attack internal heat but cannot resolve exterior pathogens. Therefore, Da Chaihu Tang (Major Bupleurum Decoction) is used to resolve both exterior and interior simultaneously. If there is merely Jie Xiong (Chest Binding Syndrome) without significant external fever, it is evident that the pathogen is not in the exterior. This occurs because heat is knotted internally, stomach Qi fails to circulate, and fluid retention knots in the chest and hypochondrium, marking a time when purgation is appropriate. Furthermore, one must observe sweating only on the head to confirm that although the body has high fever, the pathogen is not in the Yin meridians; rather, Yang pathogens are confined to the Upper Jiao (Triple Burner) Yang division, blocked by the knotted pathogen from descending. Fluids accumulate and cannot drain downward. Thus, Da Xianxiong Tang (Major Intrapleural Decoction) is indicated. One might ask: How do we know that head sweating indicates Yang pathogens in the Yang division? The answer is: The Shaoyang (Lesser Yang) chapter states, "Yin meridians do not produce sweating." Since there is head sweating, we know it is not Shaoyin (Lesser Yin). Moreover, since Da Xianxiong Tang (Major Intrapleural Decoction) treats excess heat, we know the pathogen is Yang in the Yang division. Cheng Wuji stated that "Jie Xiong (Chest Binding Syndrome) without significant fever" means there is no heat knot. He did not realize that the phrase "merely Jie Xiong (Chest Binding Syndrome)" refers to heat knotted internally, meaning there is only interior pathology. "No significant fever" means the absence of alternating chills and fever, indicating no exterior pathogen. Only when there is interior pathology without exterior pathology can Da Xianxiong Tang (Major Intrapleural Decoction) be used. If it were not a heat knot, would Dahuang (Rhubarb Rhizome) and Mangxiao (Mirabilite) not be drugs for treating heat excess? Would Zhang Zhongjing use them recklessly? The Shanglun school erroneously claimed that besides Jie Xiong (Chest Binding Syndrome), there is another syndrome called Water Jie Xiong (Water Chest Binding), and that the subsequent mention of Zhi Jie (Branch Knot) refers to Zhi Yin (Branching Fluid) accumulation, constituting a separate syndrome. This is ridiculous. I argue that if fluid retention never combined with heat pathogens, why would Gansui (Kansui Root), a drug for draining water and resolving phlegm, be included in Da Xianxiong Tang (Major Intrapleural Decoction)? This clarifies the confusion.

Xiao Jie Xiong Bing (Minor Chest Binding Disease) is located precisely in the epigastrium. Pain occurs only upon palpation, and the pulse is floating and slippery. Xiao Xianxiong Tang (Minor Intrapleural Decoction) is the primary treatment.

Regarding "precisely in the epigastrium," Fang Youzhi argued that it is not as high as in major Jie Xiong (Chest Binding Syndrome). However, Zhang Zhongjing originally stated: "If the epigastrium is full, hard, and painful, it is Jie Xiong (Chest Binding Syndrome)." He also said: "If the epigastrium becomes hard, it is Jie Xiong (Chest Binding Syndrome)." And again: "Jie Xiong (Chest Binding Syndrome) involves heat and excess, causing epigastric pain that feels hard as stone upon palpation." From this, we know Jie Xiong (Chest Binding Syndrome) originates in the epigastrium and does not require epigastric stuffiness to be termed so. The distance between the chest and the epigastrium is not great; it is merely between the Jiutwei (CV15) point and the Shangwan (CV13) point. If one insisted on locating it in the chest wall, the sternum itself would be hard, making it impossible to determine hardness and pain through palpation. Saying "precisely in the epigastrium" means the location is limited to one spot in the epigastrium, unlike the severe and extensive knotting in the chest and hypochondrium seen in cases of epigastric fullness, hardness, pain, and stone-hard palpation. Pain upon palpation differs from rejection pain within the diaphragm or hardness and pain extending from the heart down to the lower abdomen that makes one unable to bear touch. Regarding the epigastric pain that hurts spontaneously without pressure: A floating and slippery pulse belongs to Yang. Floating indicates Yang pathogen; slippery is close to rapid and moving pulses, but unlike the slow change from moving pulses or the deep and tight pulse indicating deep sinking and firm knotting. Therefore, violent attacking agents are unnecessary, and Xiao Xianxiong Tang (Minor Intrapleural Decoction) is used.

Formula for Xiao Xianxiong Tang (Minor Intrapleural Decoction):
Huanglian (Coptis Rhizome) - 1 liang
Banxia (Pinellia Tuber) - 0.5 sheng
Gualou Shi (Trichosanthes Fruit) - 1 large fruit

Process these three ingredients: Boil Gualou Shi (Trichosanthes Fruit) in 6 sheng of water first until reduced to 3 sheng. Remove the dregs. Add the other herbs and boil until reduced to 2 sheng. Remove the dregs. Divide into three warm doses.

Because the invading heat pathogen is lighter, the treatment method changes its scale to create Xiao Xianxiong Tang (Minor Intrapleural Decoction). Its designation as "minor" does not mean reducing the dosage like Xiao Chengqi Tang (Minor Order the Qi Decoction), nor changing the method like Xiao Qinglong Tang (Minor Blue Dragon Decoction). Here, "minor" shares the name but differs in actual ingredients. Although the ingredients differ, the intent is the same. Although the intent is the same, the efficacy differs. Although the pathogen knot is small, it is still a heat knot. Therefore, Huanglian (Coptis Rhizome) is used for its bitter and cold nature. Cold resolves heat, and bitterness opens knots. This differs from the bitter-cold scouring action of Dahuang (Rhubarb Rhizome). When pathogens knot in the chest, Stomach Qi stagnates, and phlegm-fluid accumulates. Therefore, Banxia (Pinellia Tuber) is used for its acrid, warm, and slippery properties to transform phlegm, drain fluids, and dissipate stagnation. Gualou Shi (Trichosanthes Fruit), according to Li Shizhen, is sweet and cold, does not harm Stomach Qi, descends fire in the Upper Jiao (Triple Burner), and causes phlegm-Qi to descend, likely chosen for its slippery and moistening qualities. This differs from the harsh salty-cold water-draining actions of Mangxiao (Mirabilite) and Gansui (Kansui Root). However, both Banxia (Pinellia Tuber) and Gualou Shi (Trichosanthes Fruit) utilize their slippery nature. Why? Because "slippery" is one of the Ten Categories of Formulas, meaning "slipperiness removes adherence." "Adherence" refers to tangible pathogens adhering in the chest, diaphragm, and intestines, or intangible pathogens adhering in meridians and organs. Ancients said: "What adheres and is difficult to remove, remove with slipperiness," likening it to using oil to wash objects. The formulation principle here is that if the disease is minor, the formula is minor, consistent with the Neijing (Inner Canon) saying: "Whether toxic or non-toxic, treat the primary disease; adjust the size according to the condition."

When the disease is in the Yang level, it should be resolved by sweating. If instead treated by spraying or pouring cold water, the heat is suppressed and cannot escape, leading to increased irritability, goosebumps on the skin, a desire to drink water but without actual thirst. In such cases, Wenli San (Clam Shell Powder) should be administered. If there is no improvement, Wuling San (Five-Ingredient Powder with Poria) should be given. For Han Shi Jie Xiong (Cold-Excess Chest Binding Syndrome) without heat signs, Sanwu Xiao Xianxiong Tang (Three-Ingredient Minor Intrapleural Decoction) or Baisan (White Powder) may be used.

"Disease in the Yang" generally refers to pathogens in the Taiyang (Greater Yang) meridian. How do we know Zhang Zhongjing refers exclusively to Taiyang? In the opening of the Yangming (Yang Brightness) chapter, he states: "Body heat, spontaneous sweating, aversion to neither cold nor preference for heat" constitutes Yangming exterior syndrome. Since there is spontaneous sweating, sweating therapy is contraindicated. Only when pathogens enter Yangming but Taiyang symptoms persist are Gegen Tang (Kudzu Decoction) or Guizhi Jiagegen Tang (Cinnamon Twig plus Kudzu Decoction) used for sweating. There are no other specific exterior-releasing drugs for Yangming. Thus, it is not Yangming. Shaoyang (Lesser Yang) has half-exterior pathogens, but sweating, vomiting, and purging are all prohibited, so the phrase "should be resolved by sweating" does not apply. Thus, it is not Shaoyang. Only Taiyang (Greater Yang), being the outermost layer, governs Ying (Nutrient) and Wei (Defensive) and wind-cold invasion, requiring sweating for resolution. Due to the inability to sweat, irritability and heat arise. Instead of sweating, cold water is sprayed or poured. "Spraying" means misting; "pouring" means washing. Using cold water aims to treat heat with cold, which is the reckless act of the ignorant. This suppresses the郁 (stagnant) heat in the skin, preventing dispersion, thereby increasing irritability and heat. Although irritability is severe, the original pathogen involved aversion to cold and no sweating. The added cold water invades the skin, causing goosebumps. The desire to drink results from irritability; the lack of actual thirst results from cold-water invasion. Such manifestations suggest sweating might seem appropriate. However, due to external cold-water invasion suppressing heat, the pathogen is no longer in the exterior. Therefore, Wenli San (Clam Shell Powder), salty-cold and lubricating, promotes urination to guide water out. If ineffective, it indicates cold-water has invaded the Taiyang Fu organs, affecting the Bladder. Wuling San (Five-Ingredient Powder with Poria) should be given to assist lower Jiao (Triple Burner) vaporization, allowing Qi transformation to flow and water qi to dissipate. Even if exterior pathogens remain, Wuling San (Five-Ingredient Powder with Poria) includes drinking warm water to induce sweating. This clause should be read alongside the Shui Ni (Water Reversal) syndrome in Wind-Stroke mishandling, where thirst leads to immediate vomiting upon drinking. That case involves internal cold-water from drinking; this case involves external cold-water from spraying/pouring. The conditions are similar, hence similar treatments.

The phrase "Han Shi Jie Xiong (Cold-Excess Chest Binding Syndrome) without heat signs" initially seems incompatible with the bitter-cold Xiao Xianxiong Tang (Minor Intrapleural Decoction). However, reviewing the text above, cold water suppression prevented heat dissipation, causing heat to sink inward and increase irritability. Heat thus knotted excessively in the chest due to cold constraint, termed "Cold-Excess Chest Binding," not implying cold excess knotted in the chest. If it were truly Yin-cold, it would manifest as Epigastric Stuffiness (Pi). The first clause of Jie Xiong (Chest Binding Syndrome) states: "Originating in Yang, if wrongly purged, heat enters, resulting in Jie Xiong (Chest Binding Syndrome)." This confirms heat entry, not Yin-cold. Without heat, it cannot be called Jie Xiong (Chest Binding Syndrome). This distinguishes Yin/Yang and Cold/Heat. "Without heat signs" refers to the absence of exterior heat, citing the earlier mention of goosebumps, not the absence of heat in both interior and exterior. Therefore, Sanwu Xiao Xianxiong Tang (Three-Ingredient Minor Intrapleural Decoction) is used to open chest excess knots. Although Baisan (White Powder) is harsh, it addresses cold-excess knotted in the chest where cold-water injures the Lung, causing wheezing, coughing, and rebellious Qi. Jiegeng (Platycodon Root) opens Lung Qi; Beimu (Fritillaria Bulb) enters the Lung; and Badou (Croton Seed), acrid, hot, and toxic, acts as a general breaking through gates to destroy chest knots. Heat is insufficient to open cold-water; harshness is insufficient to break excess knots. This is a method for treating excess, not deficiency.

Formula for Wenli San (Clam Shell Powder):
Wenli (Clam Shell) - 5 liang

Wenli resembles clams but has purple spots on the back; it is the flower clam eaten in Wu regions today, mistakenly called Cangluo or Chang'e.
Grind this single ingredient into powder. Mix with boiling water and take one qianbi dose. Use five he of water.

Sanwu Xiao Xianxiong Tang (Three-Ingredient Minor Intrapleural Decoction) is the aforementioned Xiao Xianxiong Tang (Minor Intrapleural Decoction).

Formula for Baisan (White Powder):
Jiegeng (Platycodon Root) - 3 fen (choose bitter ones)
Badou (Croton Seed) - 1 fen (remove skin and heart, roast black, grind into paste)
Beimu (Fritillaria Bulb) - 3 fen

Grind Jiegeng (Platycodon Root) and Beimu (Fritillaria Bulb) into powder. Add Badou (Croton Seed). Pound further in a mortar. Mix with Baiyin (rice water) for administration. Strong individuals take half a qian; weak individuals reduce the dose. If the disease is above the diaphragm, vomiting will occur; if below, diarrhea will occur. If no diarrhea, drink one cup of hot porridge soup. If diarrhea persists uncontrollably, drink one cup of cold porridge soup.

In Jie Xiong (Chest Binding Syndrome), if the pulse is floating and large, purging is contraindicated; purging leads to death.

Generally, when pathogens are in the exterior, the pulse floats. Jie Xiong (Chest Binding Syndrome) arises from mistaken inward sinking of Taiyang (Greater Yang) exterior pathogens. Once knotted, pathogens enter the interior, and the Guan (Gate) pulse should be deep. How can a floating and large pulse reappear? Now that the chest is knotted, yet the pulse remains floating and large, the remaining exterior pathogens are still strong. Moreover, floating and large pulses originally indicate interior deficiency. As stated in the Yangdan clause: "Floating indicates wind; large indicates deficiency." With deficient Zheng Qi (Upright Qi), further purging causes remaining exterior pathogens to sink again. This results in exterior pathogens sinking twice and chest pathogens knotting twice, described as "deficiencyizing the deficient and excessizing the excess." Heavy sinking of pathogens overwhelms Zheng Qi (Upright Qi); death is inevitable. Hence, purging is contraindicated; purging leads to death.

In Jie Xiong (Chest Binding Syndrome), if all symptoms are present and restlessness (Fan Zao) appears, it is also a death sign.

This follows the previous discussion, presenting cases that lead to death even without purging. "All symptoms present" means all syndromes binding the chest are fully manifested. With all symptoms present, the severity of pathogens and depth of sinking are evident. The appearance of Fan Zao (restlessness) indicates Fan (irritability) as scattered deficient Yang and Zao (agitation) as rebellious Yin pathogens. Severe pathogen knotting isolates upper and lower parts, leading to failure of Stomach Qi. The Neijing (Inner Canon) Heat Theory states: "If Ying (Nutrient) and Wei (Defensive) do not circulate, and Zang-Fu organs do not communicate, death ensues."