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[Collected Commentaries] Zhang Jianshan stated: Chest binding (Jie Xiong) is a syndrome suitable for purgation. However, if the pulse is floating and large, although there is binding in the epigastrium, it indicates that exterior pathogenic factors are still abundant. Applying purgation at this time would severely deficiency the interior, causing exterior pathogens to gather again, leading to death.

Cheng Zhi stated: There are cases of chest binding where purgation is contraindicated; one must carefully examine the pulse to determine treatment. Chest binding involves pathogens binding in the upper jiao. If the cun pulse is floating and the guan pulse is sunken or sunken-tight, it indicates the disease is in the interior and purgation may be used. If the pulse is floating and large, the pathogen remains in the exterior; purging would cause further binding, hence death. If all symptoms of chest binding are present and restlessness (Fan Zao) occurs, it is also a fatal sign.

[Annotation] "All symptoms of chest binding are present" refers to hardness, fullness, and pain, with binding above and below the diaphragm. "All present" means from below the chest to above the lower abdomen, on both left and right hypochondriac regions, there is no area without hardness, fullness, and pain. This is more severe than Great Chest Binding (Da Jie Xiong). At this stage, urgent purgation should be applied; there may be a chance of survival. If delayed, evil will overcome righteous qi, form and qi will separate, and restlessness will occur. Whether purged or not, death ensues.

[Collected Commentaries] Fang Youzhi stated: When all symptoms of chest binding are fully present, death is indicated. If restlessness is added, even without purging, death is indicated.

Cheng Yingmao stated: In chest binding, improper purging is inadvisable, but failing to purge when necessary is also inadvisable. The key lies in appropriateness; removing evil is the way to protect righteous qi.

Wei Litong stated: This passage follows the previous discussion on the floating-large pulse. One can only predict death if all chest binding symptoms are present, the pulse is floating and large, and restlessness is added. Otherwise, restlessness is merely one of the symptoms of chest binding; why declare it fatal?

Question: There are diseases called chest binding and zang binding. What are their manifestations? Answer: Pain upon pressure, floating cun pulse, and sunken guan pulse indicate chest binding.

What is zang binding? Answer: Manifestations similar to chest binding, normal appetite, frequent diarrhea, floating cun pulse, and small, fine, sunken, tight guan pulse indicate zang binding. A white, slippery coating on the tongue indicates a difficult-to-treat case.

[Annotation] When pathogens bind in the three Yang meridians, it is called chest binding; when they bind in the three Yin meridians, it is called zang binding. Both result from pathogens entering the interior due to deficiency after improper purging, but their pulses and symptoms differ. Hardness, fullness, and pain upon pressure characterize chest binding. Floating cun and sunken guan pulses characterize chest binding. Floating cun indicates chest and exterior; sunken guan indicates stomach and interior. Thus, pathogens have moved from the chest exterior into the stomach interior to bind. Symptoms resembling chest binding, with normal diet and frequent diarrhea, characterize zang binding. Floating cun and small, fine, sunken, tight guan pulses characterize zang binding. Small, fine, sunken, and tight pulses indicate cold pain in zang binding, showing pathogens have moved from the chest exterior into the zang interior to bind. Although zang binding presents with hardness, fullness, and pain like chest binding, chest binding belongs to interior obstruction and precludes eating; zang binding belongs to interior emptiness, hence eating remains normal. Chest binding is excess-heat, presenting with hardness, pain, constipation, and stone-like sunken pulses; zang binding is deficiency-cold, presenting with hardness, pain, diarrhea, and fine-tight pulses. A white, slippery tongue coating indicates no heat in the chest. Zang binding is yin pathogen; seeing a slippery white coating is favorable, allowing treatment with warming formulas like Lizhong Tang. Chest binding is yang pathogen; seeing a slippery white coating is unfavorable, prohibiting attack/purgation, hence difficult to treat.

[Collected Commentaries] Cheng Wuji stated: Qi should flow freely; blockage causes pain. Pathogens binding in the yang aspect prevent yin qi from descending; pathogens binding in the yin aspect prevent yang qi from ascending. Thus, both present with pain and hardness upon pressure.

Fang Youzhi stated: This Q&A clarifies the similarities and differences between chest binding and zang binding. Frequent diarrhea in zang binding results from yin pathogens binding in yin zang with severe cold. Due to severe cold, the pulse is small, fine, and tight; this is the difference. Chest binding involves yang pathogens binding in yang aspects; zang binding involves yin pathogens binding in yin aspects.

Wang Hu stated: In chest binding, food is originally present in the stomach. Premature purging leaves undigested food, allowing exterior pathogens to enter and bind in the chest, causing pain on pressure and inability to eat. In zang binding, no food is originally in the stomach. Excessive purging causes zang deficiency, allowing pathogens to enter and bind with cold in the yin aspect. Thus, it resembles chest binding but is painless on pressure, allows eating, and features frequent diarrhea.

Wei Litong stated: People know this passage distinguishes chest binding, not discussing zang binding, but fail to see that zang binding resembles Pi (glomus) but differs significantly from chest binding. Chest binding is yang pathogen; Pi and zang binding are yin pathogens. Pi retains floating yang above; zang binding lacks yang above and below. These are errors caused by improper purging or vomiting.

[Note] Previous commentators interpreted "white, slippery tongue coating indicates difficult to treat" as referring solely to zang binding, which was unclear and misleading. Actually, a white, slippery coating in the presence of full chest binding symptoms indicates false excess; a dry, yellow coating in the presence of full zang binding symptoms often hides true heat. For zang binding (yin pathogen), white/slippy is favorable and amenable to warming/dispersing; for chest binding (yang pathogen), it is unfavorable and resistant to purging, hence difficult. This shows that writing medical texts requires personal experience and profound insight for practical utility. Merely relying on old texts and forcing interpretations is akin to looking for a steed by following a drawing.

If a patient has a chronic pi mass under the hypochondrium extending to beside the umbilicus, with pain radiating to the lower abdomen and into the genital tendons, this is called zang binding, a fatal condition.

[Annotation] In patients with zang binding, if there is a chronic pi mass beside the umbilicus, combining old and new diseases, with pain radiating to the lower abdomen and into the genital tendons, the pathogen has advanced to the Jueyin meridian, constituting a fatal zang binding.

[Collected Commentaries] Cheng Zhi stated: Chronic binding pathogens and newly bound pathogens intertwine unresolved. Pi beside the umbilicus indicates spleen binding; pain radiating to the lower abdomen indicates kidney binding; progression from hypochondrium to genital tendons indicates liver binding. With binding in all three yin zang, death is indicated.

Zang binding lacks yang syndromes: no alternating chills and fever, and the patient appears quiet. With a slippery tongue coating, attack/purgation is contraindicated.

[Annotation] Zang binding lacks three-yang syndromes. No fever means no Taiyang syndrome; no alternating chills and fever means no Shaoyang syndrome; the patient's quietness means no Yangming syndrome. A slippery white coating indicates cold in the chest; thus, warming is appropriate, not attacking.

[Collected Commentaries] Fang Youzhi stated: Slippery coating arises from heat in the dantian and cold in the chest. Dantian is yin; chest is yang. Heat in yin and cold in yang make attack contraindicated.

Cheng Zhi stated: The classic text says zang binding with white slippery coating is difficult to treat, not untreatable. It says zang binding with no heat and slippery coating cannot be attacked, not that zang binding with heat and non-slippy coating cannot be attacked. I surmise that cases of heat in dantian and cold in chest require methods to harmonize heat and warm-disperse cold, allowing internal pathogens to dissipate and external pathogens to resolve gradually. This reflects the careful intent of skilled physicians!

When the disease is in the yang aspect, sweating should be used for resolution. If instead cold water is sprayed or poured on the body, the heat is suppressed and cannot escape, increasing irritability. Gooseflesh appears on the skin. The patient desires to drink water but does not feel thirsty. Administer Wenli San. If not cured, administer Wuling San. If body heat and gooseflesh persist and the patient desires to cover themselves with clothes, and cold water is sprayed or washed on them, the heat is further suppressed and cannot exit. Sweating should occur but does not, causing irritability. If sweating occurs and abdominal pain follows, administer 3 liang of Shaoyao (Paeoniae Radix) according to the aforementioned method.

Wenli San Formula
Wenli (5 liang)
Grind the single ingredient into powder. Mix one qianbi with boiling water (5 he) and take.

[Note] Wenli is equivalent to Wubeizi (Galla Chinensis).