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Coldness of the feet, desire to vomit but inability to do so, with a slow and tight pulse: this is cold pathogen stagnation and accumulation. For diseases caused by the stagnation and accumulation of cold, heat, qi, and fluids in the chest, it is certain that sweating or purging methods cannot treat them. One must use sour and bitter emetic agents to induce vomiting, thereby venting the pathogen upwards. Once the upper jiao becomes unobstructed and yang qi recovers, the sensation of fullness and hardness will dissipate, and the chest will harmonize. Geng Ti (Thunberg Fritillary Bulb) is extremely bitter, and Vigna angularis (Red Bean) is sour; they complement each other and can disperse solid pathogens in the chest, making them the premier emetic agent. Taking them mixed with fermented soybean juice utilizes grain qi to protect stomach qi. If vomiting does not occur after administration, increase the dose slightly; stop immediately once rapid vomiting occurs, to avoid damaging the yuan qi of the chest. The efficacy of this formula is faster than sweating or purging, representing the three major methods of sweating, vomiting, and purging. Today's physicians do not understand the profound principles of Zhang Zhongjing and Liu Wansu (Zihe), leaving these formulas unused, which is truly regrettable! However, for those who have lost blood or are constitutionally deficient, where qi and fluids in the chest are already depleted, this formula should not be given lightly; this prohibition is specifically reiterated.

When a disease originates from yang (e.g., wind-stroke) and is mistakenly treated with purging, heat enters and forms Jie Xiong (Chest Binding); when a disease originates from yin (e.g., cold damage) and is mistakenly treated with purging, Pi Zheng (Stagnation Syndrome) results. The reason Jie Xiong forms is due to purging too early.

[Annotation] This generally explains the causes of Jie Xiong and Pi Zheng. Wind-stroke involves yang pathogens, hence "disease originates from yang." Not sweating first but instead purging allows heat pathogens to sink into the deficiency, forming Jie Xiong. Cold damage involves yin pathogens, hence "disease originates from yin." Not sweating first but instead purging allows heat pathogens to sink into the deficiency, forming Pi Zheng. The reason for forming Jie Xiong and Pi Zheng is that the exterior syndrome was unresolved and purging was performed too early. In "disease originates from yin," "heat entering" is omitted as an ellipsis. However, when disease originates from yang and is mistakenly purged, Pi Zheng may not necessarily fail to form; when disease originates from yin and is mistakenly purged, Jie Xiong may sometimes form. This is largely because people's constitutions differ, transforming either into excess or deficiency.

[Collected Annotations] Zhang Jianshan said: Wind pathogen entering the interior forms Jie Xiong; cold pathogen entering the interior forms Pi. Yet both originate from Taiyang disease, not distinguishing separate yin or yang syndromes.

In Taiyang disease, if the pulse is floating, active, and rapid: floating indicates wind, rapid indicates heat, active indicates pain, and rapid also indicates deficiency. Headache, fever, slight nocturnal sweating, yet paradoxically aversion to cold, indicate the exterior is unresolved. If the physician mistakenly purges, the active and rapid pulse changes to slow. Rejection pain in the diaphragm, emptiness in the stomach, disturbance of the diaphragm by hostile qi, shortness of breath, irritability, and mental restlessness (Ao Na) occur as yang qi sinks inward, causing hardness below the heart, thus forming Jie Xiong, treated with Da Xian Xiong Tang (Major Decoction to Sinking Chest). If Jie Xiong does not form, but there is only sweating on the head with no sweat elsewhere, stopping at the neck, and urination is difficult, jaundice will inevitably develop.

[Comment] The phrase "rapid indicates deficiency" is suspected to be an interpolation.

[Annotation] In Taiyang disease, a floating, active, and rapid pulse: floating is the pulse of wind pathogen, rapid is the pulse of heat pathogen, and active is the pulse of various pains. Headache and fever are Taiyang signs. Heat steaming the yang leads to spontaneous sweating due to yang deficiency; heat steaming the yin leads to nocturnal sweating due to yin deficiency. Yin deficiency should involve aversion to heat; now there is aversion to cold, so we know this is not nocturnal sweating from yin deficiency, but from the unresolved exterior, occurring slightly. Since the exterior is unresolved, it should be released via sweating; the physician mistakenly purged, causing the active and rapid heat pulse to change to cold and slow. Generally, active and rapid pulses indicate exterior pathogens attempting to transmit; due to purging, they reverse into the diaphragm, so transmission does not occur, and the pulse changes. Exterior yang pathogens, taking advantage of stomach emptiness, sink into the chest and diaphragm, causing rejection pain, shortness of inability to breathe fully, irritability, mental restlessness, and hardness below the heart, directly transforming into excess and forming Jie Xiong. The method requires Da Xian Xiong Tang. If it does not transform into excess and does not form Jie Xiong, but there is only sweating on the head to the neck with no sweat elsewhere, heat cannot diffuse. Urination difficulty means dampness cannot drain; heat and dampness combine to transform, so jaundice inevitably develops.

[Collected Annotations] Cheng Wuji said: When active and rapid change to slow, but the floating pulse remains unchanged, it is because the pathogen is bound in the chest, in the upper jiao yang division, so the pulse cannot sink.

Zhu Zhenheng said: In Taiyang disease, attacking the interior while the exterior is unresolved leaves the interior deficient. Although yang pulses like floating, active, and rapid are seen, one mistake in purging will surely change them to slow yin pulses. Stomach emptiness, shortness of breath, and irritability indicate extreme deficiency. One might ask: if yang qi sinks inward and causes hardness below the heart, can it be rapidly attacked? The power of Da Xian Xiong Tang is no less than Cheng Qi Tang; purging again and again, how can one not fear severe depletion of righteousness? Even if yang disease excess pathogens are purged, if the stomach is empty and hostile qi disturbs the diaphragm causing mental restlessness, one could use Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) to vomit out chest pathogens. Moreover, after mistaken purging in Taiyang disease, there are clearly deficiency signs!

Comment: Zhu Zhenheng’s treatment using Zhi Zi Chi Tang to vomit is suitable for cases where Jie Xiong has not formed and transforms from chest deficiency with heat. If it transforms from chest deficiency with cold, regardless of whether Jie Xiong has formed, one should follow the warming and tonifying method of *Huo Ren Shu*, and not mix treatments.

Fang Youzhi said: The Taiyang pulse is naturally floating; active and rapid pulses also indicate transmission. Taiyang naturally has sweating, yet slight nocturnal sweating is mentioned; naturally aversion to cold, yet paradoxical aversion to cold is mentioned, indicating it has persisted for a long time. The diaphragm is between the heart and chest. Rejection means resistance. It means diaphragmatic qi resists pathogenic qi, causing pain. Hostile qi is pathogenic qi. Shortness of breath is急促 breathing unable to distribute air. Ao Na (mental restlessness) is the heart disturbed by pathogens and uneasy. Yang qi is another name for hostile qi; because it is originally external pathogen, it is called hostile qi. Because the pathogen is originally wind, it is called yang qi. Because it sinks inward due to interior deficiency, it is called sinking inward. From "If Jie Xiong does not form" to the end, it discusses milder transformations.

Da Xian Xiong Tang Formula
Da Huang (Rhubarb Root and Rhizome, peeled, 6 liang), Mang Xiao (Mirabilite, 1 sheng), Gan Sui (Kansui Root, ground separately, 1 qian).
These three ingredients: use 6 sheng of water, first decoct Da Huang to obtain 2 sheng, remove dregs, add Mang Xiao, boil for one or two boils, then add Gan Sui powder. Take 1 sheng warm. Stop subsequent doses once rapid bowel movement occurs.

[Collected Explanations] Fang Youzhi said: There is high pathogen in the upper jiao; it must be sunk to pacify it, hence Decoction to Sinking Chest. Pacifying pathogens and sweeping away bandits is the duty of a general; Da Huang is the sovereign herb. Salty flavor softens hardness; Mang Xiao is the minister herb. Penetrating up and down, breaking binding and driving out water; Gan Sui is the assistant herb. Only for great excess conditions is this appropriate. If accompanied by deficiency or floating pulse, do not try lightly.

In Taiyang disease, after heavy sweating and subsequent purging, if there is no bowel movement for five or six days, dry tongue with thirst, slight tidal fever in the late afternoon (You hour), hardness, fullness, and pain from below the heart to the lower abdomen, intolerable to touch: Da Xian Xiong Tang is indicated.

[Annotation] This continues the previous clause to mutually elaborate its meaning and detail the syndrome and treatment. Taiyang disease, heavy sweating followed by purging, injures body fluids. No bowel movement for five or six days indicates stomach fu dryness. Dry tongue and thirst indicate stomach dryness. Tidal fever in the late afternoon indicates abundant stomach heat. Hardness, fullness, and pain from below the heart to the lower abdomen, intolerable to touch, means the entire chest and abdomen are hard, solid, large, and painful, such that the hand cannot approach. Thus, Da Xian Xiong Tang is undoubtedly indicated.

[Collected Annotations] *Nei Tai Fang Yi* says: "You suo" should be "fa fa" (onset).

Fang Youzhi said: This clarifies the differentiation between Jie Xiong and suspected Yangming interior excess. You refers to the Shen hour (3-5 PM). "Slight" means faintly perceived. Generally, constipation, dry thirst, tidal fever in the late afternoon, and hardness/fullness/pain from below the heart to the lower abdomen all resemble Yangming interior heat. However, the slight tidal fever does not match the severe heat of Yangming. Therefore, Yangming is primarily defined by stomach house excess; any trace of Taiyang signs prevents inclusion in Yangming examples, for this very reason.

Cheng Zhi said: Taiyang Jie Xiong combined with Yangming interior excess requires Da Xian Xiong Tang, which can cleanse everything from the chest and hypochondrium to the intestines and stomach. If one only purges intestinal and stomach heat but leaves phlegm-fluids in the upper chest, it is not the correct method.

Wu Renju said: In one abdomen, if pathogenic qi is abundant above and below, and the syndrome is completely excess, the pulse is often deep and hidden. Do not hesitate; purging will cause the pulse to gradually emerge.

Xiao Jie Xiong (Minor Chest Binding): Disease is located exactly below the heart; pain upon pressure; floating and slippery pulse. Xiao Jie Xiong Tang is indicated.

[Annotation] Da Jie Xiong involves heavy pathogen and deep heat, extending from below the heart to the lower abdomen, with hardness, fullness, and pain intolerable to touch, and a deep, solid pulse. Thus, Da Xian Xiong Tang is suitable to attack the binding and purge heat. Xiao Jie Xiong involves shallow pathogen and light heat, located exactly below the heart with hardness and fullness, painful only upon pressure, and a floating, slippery pulse. Thus, Xiao Jie Xiong Tang is used to open the binding and cleanse heat.

[Collected Annotations] Cheng Yingmao said: Looking at the Jie Xiong clauses: "Pain below the heart, stone-hard upon pressure" and "Fullness and hardness below the heart with pain." Here it says: "Disease is exactly below the heart." We know Jie Xiong is not limited to below the heart or upper chest; differentiation lies only in pain or no pain. Thus, Pi syndrome also has hardness below the heart, but without pain.

Zhang Xiju said: Decoctions have size differences; syndromes have severity differences. Many today use Xiao Jie Xiong Tang to treat Da Jie Xiong syndromes, leading to untreatable outcomes, and then claim Jie Xiong is incurable. They do not know that only one or two sections of Jie Xiong are incurable; the rest are treatable. If one does not comprehend the classic principles, one will shift blame at the critical moment, costing lives.

Wei Litong said: Xiao Jie Xiong lacks solid heat pathogens; it is merely slight heat combined with phlegm-fluids causing harm. Thus, although it is Jie Xiong, it cannot occupy the peak of the chest, but is located exactly below the heart; it cannot cause solid pain, only pain upon pressure; the pulse is not deep but floating and superficial; it is not stone-hard, but void and obstructed. Therefore, Da Xian Xiong Tang is not applicable, and Xiao Jie Xiong Tang is specially designed. Between height/depth, hardness/softness, severity/lightness, and floating/sinking, the pathology and treatment methods are clear. He also said: Pi is yin pathogen, Jie Xiong is yang pathogen. However, within yang pathogens, there are size distinctions; students must examine carefully. For all syndromes of mixed cold and heat without great excess or heat, one should cautiously consider purging methods, avoiding rashness.

Xiao Jie Xiong Tang Formula
Huang Lian (Coptis Rhizome, 1 liang), Ban Xia (Pinellia Tuber, washed, 8 jin), Gua Lou Shi (Trichosanthes Fruit, large, 1 piece).
These three ingredients: use 6 sheng of water, first decoct Gua Lou to obtain 3 sheng, remove dregs, add other herbs, decoct to obtain 2 sheng, remove dregs. Divide into three warm doses.

[Formula Explanation] Huang Lian cleanses heat; Ban Xia guides fluids; Gua Lou moistens dryness and descends. Combined, they cleanse phlegm-heat in the chest and diaphragm and open chest qi binding. Although the attack is not harsh, it can break through, hence named Minor Decoction to Sinking Chest. Dividing into three warm doses is the method of treating the upper jiao slowly.

After cold damage for six or seven days, if Jie Xiong heat-excess presents with a deep and tight pulse, pain below the heart, and stone-hardness upon pressure: Da Xian Xiong Tang is indicated.

[Annotation] In cold damage, if the exterior is unresolved and mistaken purging forms Pi, this is the norm. However, cold damage may occasionally form Jie Xiong due to mistaken purging; this is the variation. Now, after six or seven days of cold damage, Jie Xiong forms as this heat-excess syndrome without mistaken purging. If the pulse is deep and tight, it is a pulse of interior excess. Pain below the heart, stone-hard upon pressure, is an interior excess syndrome. Since both pulse and disease are excess, Da Xian Xiong Tang is indicated.

[Collected Annotations] Yu Chang said: The two characters "Heat Excess" describe the state of Jie Xiong very clearly, showing pathogenic heat filling the chest without scattering. Floating-tight indicates cold damage without sweat; deep-tight indicates cold damage Jie Xiong. This is distinctly different from wind-stroke yang pathogen Jie Xiong, hence floating is not mentioned. He also said: Yang pathogen mistaken purging forms Jie Xiong; yin pathogen mistaken purging forms Pi. However, wind-stroke occasionally has Pi syndromes, and cold damage occasionally has Jie Xiong syndromes; this must be known.

Cheng Yingmao said: Although it is said yang pathogen sinks inward, the terms "yin" and "yang" are distinguished by excess/deficiency and cold/heat, not by wind-stroke/cold damage. If exterior heat excess transfers to the stomach fu, it becomes Yangming syndrome; if exterior heat excess does not transfer to the stomach fu but sinks into the diaphragm, it becomes Jie Xiong syndrome. Thus, it does not require mistaken purging to form. Jie Xiong forming without purging implies the person has dry pathogen in the chest; losing sweat allows exterior pathogen to combine with it, forming interior excess. Seeing "cold damage six or seven days" and "deep and tight pulse" confirms this.

Wang Hu said: One asks: How do we know deep-tight pulse is not cold-excess Jie Xiong? Answer: The chest is the gathering place of yang qi. If pathogenic heat binds in the chest, reaching down to the heart, becoming stone-hard and painful, the pulse is not only deep-tight, but even hidden and invisible. How can one say deep-tight pulse is not heat? Generally, the method to differentiate Jie Xiong relies most accurately on symptoms.

For cold-excess Jie Xiong with no heat signs, San Wu Xiao Jie Xiong Tang (Three-Ingredient Minor Chest Binding Decoction) is given; Bai San (White Powder) may also be taken.

[Comment] Under "no heat signs," "San Wu Xiao Jie Xiong Tang" should be "San Wu Bai San." The four characters "Xiao Jie Xiong Tang" are likely transcription errors. Jie Geng, Bei Mu, and Ba Dou are all white, fitting the meaning of San Wu Bai San. It is warm and attacking, consistent with cold-excess theory. Xiao Jie Xiong Tang consists of Gua Lou and Huang Lian, both cold-natured herbs; how can they treat cold-excess Jie Xiong? The three characters "may also be taken" are also interpolations.

[Annotation] For Jie Xiong syndrome, if there is no significant fever and no dry mouth/thirst, it is a non-heat excess syndrome, i.e., cold-excess. Give San Wu Bai San. However, in this syndrome, the pulse must be deep and tight. If the pulse is deep-slow or three-yin signs appear, it is not comparable to cold-excess Jie Xiong; Zhi Shi Li Zhong Tang (Immature Bitter Orange and Atractylodes Macrocephala Decoction to Regulate the Middle) should be used.

[Collected Annotations] Wang Kentang said: For heat-excess Jie Xiong and cold-excess Jie Xiong, *Huo Ren Shu* uses Xian Xiong Tang regardless of cold or heat. If ineffective, use Zhi Shi Li Zhong Wan, and recovery is immediate.

Fang Youzhi said: "Cold" refers to fluids; fluids are originally cold. Combining with water-cold, two colds bind and become solid in the chest, hence "no heat signs."

Cheng Zhi said: Jie Xiong has distinctions of size and differences of cold/heat; one cannot indiscriminately use Mang Xiao and Da Huang.

Zheng Zhongguang said: Water-cold binding solidly in the chest occupies heart yang, which is no small matter. Using San Wu Bai San to purge cold and break binding is a不得已 (last resort) military action.

San Wu Bai San Formula
Jie Geng (Platycodon Root, 3 fen), Ba Dou (Croton Seed, peeled and heart removed, roasted black, ground to paste, 1 fen), Bei Mu (Fritillaria Thunbergii Bulb, 3 fen).
Grind the first two ingredients into powder, add Ba Dou, and pound further in a mortar. Mix with white rice drink for administration. Strong persons take half a qian bi; weak persons reduce the dose. If the disease is above the diaphragm, vomiting will occur; if below the diaphragm, purging will occur. If no purging, give one cup of hot porridge; if purging continues excessively, give one cup of cold porridge.

[Formula Explanation] This formula treats cold-excess water-binding in the chest; it is an extremely harsh medicine. Ba Dou is the sovereign herb, extremely pungent and fierce, attacking cold and driving out water, breaking gates and seizing doors, destroying everything it reaches. Bei Mu is the assistant, opening chest binding. Jie Geng is the envoy, acting as a boat to carry Ba Dou to search and eliminate chest pathogens completely. Above the diaphragm, vomiting occurs; below the diaphragm, purging occurs. However, those who rely solely on toxic herbs to attack pathogens without assessing strength/weakness rarely achieve good outcomes. Hence, reduce dose for weak persons; give hot porridge if no purging, cold porridge if excessive purging. Ba dou is hot in nature; it moves with heat and stops with cold. Using porridge instead of water utilizes grain qi to protect the stomach.

After cold damage for ten-plus days, if heat binds in the interior and there is alternating chills and fever: Da Chai Hu Tang (Major Bupleurum Decoction) is given. If it is merely Jie Xiong without significant heat, this is water-binding in the chest and hypochondrium; if there is only slight sweating on the head: Da Xian Xiong Tang is indicated.

[Annotation] After cold damage for ten-plus days, heat binds in the interior. If there is chest/hypochondrium fullness and hardness, this is Jie Xiong. Now, if there is no fullness/hardness, but alternating chills and fever, this is Shaoyang exterior-interior disease, not Jie Xiong; Da Chai Hu Tang should be given to resolve both. However, Jie Xiong syndromes can also involve water-binding. Water-binding in the chest has no significant heat in the exterior or interior. With Jie Xiong appearance and slight head sweating, this is water stopping in the chest, caused by heat steaming upward. Hence, "water-binding in the chest and hypochondrium." Da Xian Xiong Tang is also used to attack both fluid and heat.

[Collected Annotations] Fang Youzhi said: Water is fluid; since it is not solid/hard, it is called water-binding. Chest and hypochondrium are also interior; since heat binding is not high, it is called "in the interior."

Cheng Zhi said: This states that if heat binds in the interior combined with Shaoyang, Xian Xiong is inappropriate; if water binds in the chest, even without significant heat, Da Xian Xiong Tang is still appropriate.

Cheng Yingmao said: Both Da Chai Hu Tang and Da Xian Xiong Tang can break binding. Da Chai Hu Tang breaks binding to prevent lingering pathogens in the exterior division; Da Xian Xiong Tang breaks binding to prevent lingering pathogens in the interior division.

Lin Lan said: This distinguishes water-binding in the chest from heat-binding in the interior. At ten-plus days, pathogens deeply enter the fu organs. However, if heat binds in the interior while half-exterior/half-interior pathogens remain, causing alternating chills and fever, Da Chai Hu Tang must be used to resolve both. If there is merely chest/hypochondrium binding/fullness with no initial significant heat, contracting inward, this is not a Da Chai Hu Tang syndrome, but water-binding in the chest and hypochondrium. How do we know? Water-binding in the chest causes head sweating; now there is only slight head sweating, clearly indicating water-binding in the chest. Give Da Xian Xiong Tang.

In Jie Xiong, if the neck is also stiff, resembling Rou Ji (Soft Spasm): purging brings harmony; Da Xian Xiong Wan (Major Decoction to Sinking Chest Pill) is suitable.

[Annotation] If Jie Xiong extends from above the heart to the lower abdomen with hardness, fullness, and pain intolerable to touch, the momentum is heavier downwards; treating the lower requires rapid attack with Da Xian Xiong Tang. If Jie Xiong is from the upper chest, with fullness, stiffness, and neck rigidity resembling Rou Ji, the heat is heavier upwards; treating the upper requires slow attack with Da Xian Xiong Wan to directly attack chest-lung pathogens. Boiling with double honey allows harsh treatment to act slowly, purging to bring harmony. Because the shape of the disease momentum (fast/slow) differs, the preparation of decoction vs. pill also differs. Thus, we know this neck stiffness is Jie Xiong neck stiffness; purging brings harmony, unlike Rou Ji neck stiffness.

[Collected Annotations] Cheng Wuji said: Neck stiffness is due to pathogen binding in the chest; chest-diaphragm binding/fullness allows looking up but not bending down; this is neck stiffness.

Cheng Zhi said: Neck stiffness resembling Rou Ji means chest pathogen qi is tight and solid, causing the neck to constantly tilt back, resembling Rou Ji. However, spasm involves stretching of hands and body; here, only neck stiffness exists, originally not spasm. This borrows the term to verify that chest pathogen is extremely pressing.

Wang Hu said: "Purging brings harmony" means that when excess pathogen is removed, the chest harmonizes and the neck relaxes naturally. If it did not say "resembling Rou Ji," physicians might mistake it for unresolved Taiyang wind-cold pathogen and suspect sweating herbs are needed. Little do they know, although the neck is stiff, the exterior syndrome is resolved, and the interior syndrome is urgent; the treatment method should be purging.

Da Xian Xiong Wan Formula
Da Huang (Rhubarb Root and Rhizome, 8 liang), Ting Li Zi (Periploca Seed, roasted, 1/2 sheng), Mang Xiao (Mirabilite, 1/2 sheng), Xing Ren (Apricot Kernel, peeled and tips removed, roasted black, 1/2 sheng).
Grind two ingredients, add Xing Ren and Mang Xiao, grind together until pasty, and mix. Take one pill-sized amount. Separately grind Gan Sui powder (1 qian bi), mix with 2 he of white honey and 2 sheng of water. Decoct to obtain 1 sheng. Take warm in one dose. Bowel movement occurs overnight. If no movement, take again. Movement is the effect. Follow medication prohibitions.

In Jie Xiong syndrome, if the pulse is floating and large: do not purge. Purging leads to death.

[Annotation] In Jie Xiong syndrome, if the pulse is large, it indicates stomach excess; knowing the binding heat is solid allows purging, leading to cure. Now, if the pulse is floating and large, it indicates the pathogen is still in the exterior; knowing the heat binding is not solid, purging is contraindicated. If mistakenly purged, remaining exterior pathogens re-enter the interior taking advantage of deficiency. Mistake upon mistake, binding upon binding, disease heat deepens, righteous qi depletes, leading to death.