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The pathogenesis of Pi Man (epigastric fullness and stuffiness) is the same as that of Jie Xiong (chest binding), both being complications resulting from premature purgation of exterior pathogens, where exterior pathogens sink inward into the heart and chest. The distinction lies in that pain characterizes Jie Xiong, while fullness without pain characterizes Pi Man. There is a difference in symptoms between painful and non-painful conditions, and treatments differ in severity between Xia Xiong Tang (Chest-Expelling Decoction) and Xie Xin Tang (Drain the Epigastrium Decoctions). Examining the various Xie Xin Tangs, they all use cold-natured herbs to attack the pi accumulation. One formula adds Fuzi (Prepared Aconite Root Lateralis), using acrid-hot herbs to control the cold herbs and attack heat accumulation, not to warm interior cold. Another condition arises not from mistaken purgation but from spontaneous fever, chest and hypochondriac fullness and oppression; this is neither Jie Xiong nor Pi Man, but a Zhi Jie syndrome (branch-binding syndrome) caused by the combined disease of exterior pathogens in the Taiyang (Greater Yang) and Shaoyang (Lesser Yang) meridians. Zhang Zhongjing uses Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction). When exterior pathogens transmit to Shaoyang, occupying the half-exterior half-interior region, causing epigastric and hypochondriac Pi Man, Zhang Zhongjing uses Xiao Chaihu Tang (Minor Bupleurum Decoction), while Tao Shi treats it with Zhiju Tang (Citrus Aurantium and Platycodon Decoction). For severe cases, Xiao Chaihu Tang is combined with Xiao Xianxiong Tang (Minor Chest-Binding Decoction).

After Taiyang disease resolves through sweating, if the stomach is disharmonious, presenting with hard epigastric fullness, dry retching with belching of food odor, fluid retention under the hypochondria, borborygmus, and diarrhea, Shengjiang Xiexin Tang (Fresh Ginger Drain-the-Epigastrium Decoction) is indicated.

If after sweating or purgation leads to surface resolution, one presents with stomach disharmony, hard epigastric fullness, dry retching with belching of food odor, this is due to water-fluid retention under the hypochondria, causing borborygmus and diarrhea; Shengjiang Xiexin Tang is used.

After severe purgation in Taiyang disease followed by sweating, if epigastric fullness occurs accompanied by aversion to cold, the exterior is not yet resolved. One must not attack the pi; first resolve the exterior. Only after the exterior is resolved can the pi be attacked. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is suitable; to attack the pi, Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Drain-the-Epigastrium Decoction) is suitable.

If sweating is performed first, the exterior pathogen is resolved. Now, since severe purgation was done first followed by sweating, the exterior may not be resolved. Moreover, with epigastric fullness and aversion to cold, the exterior syndrome persists, so attacking the pi is contraindicated. First use Guizhi Tang to resolve the exterior, then use Dahuang Huanglian Xiexin Tang.

A pulse that is floating and tight, subjected to mistaken purgation, causes the tight quality to enter the interior, forming pi. Palpation reveals softness, indicating merely Qi pi (Qi stagnation). For epigastric fullness that is soft upon palpation, with a floating pulse at the Guan position, Dahuang Huanglian Xiexin Tang is indicated. For epigastric fullness accompanied by aversion to cold and sweating, Fuzi Xiexin Tang (Aconite Drain-the-Epigastrium Decoction) is indicated.

The previous chapter clarified that epigastric pi with aversion to cold indicates an exterior pathogen. This chapter clarifies that epigastric pi with aversion to cold, due to sweating, is not an exterior pathogen. A floating-tight pulse indicates an exterior syndrome; if mistakenly purged, the cold pathogen associated with the tight pulse enters the interior to form pi. Softness upon palpation indicates no phlegm-fluid or food retention internally, only Qi pi. A floating pulse at the Guan position belongs to Yang pathogen, so Dahuang (Rhubarb Root and Rhizome) and Huanglian (Coptis Rhizome) are used to drain pi-heat. If pi is accompanied by aversion to cold and sweating, it means the pathogenic heat has been congealed by cold herbs and cannot vent, causing aversion to cold; thus, Fuzi is added to the cold herbs of Xiexin Tang to guide and disperse.

Originally due to mistaken purgation, epigastric pi occurred, and Xie Xin Tang was given. If the pi does not resolve, and the patient presents with thirst, dry mouth, irritability, and difficult urination, Wuling San (Five-Ingredient Powder with Poria) is indicated.

Mistaken purgation leading to epigastric fullness should have been treated with Xie Xin Tang. Now, if the pi does not resolve, and the patient instead presents with thirst, dryness, irritability, and difficult urination, this indicates that the Taiyang pathogen has not only bound in the epigastrium but also descended to bind in the Bladder; thus, Wuling San is used.

In Taiyang disease, if fever persists despite sweating, accompanied by hard epigastric fullness, vomiting, and diarrhea, Da Chaihu Tang (Major Bupleurum Decoction) is indicated.

In Taiyang disease, if fever persists despite sweating, this represents a Taiyang Wind-strike exterior syndrome with sweating, hard epigastric fullness, and diarrhea, combined with Yangming interior syndrome. Due to vomiting, Chengqi Tang formulas are avoided; instead, both exterior and interior are resolved simultaneously.

After Taiyang disease is treated with sweating, emesis, or purgation, and the pathogen is resolved, if hard epigastric fullness and persistent belching occur, Xuanshen Dahezeshi Tang (Imperata and Hematitum Decoction) is indicated.

Before sweating, emesis, or purgation, if hard epigastric fullness and persistent belching are seen, this indicates phlegm-Qi and Stomach excess, requiring Xiaoxiong Tang or Xiexin Tang. After these treatments, however, tonifying healthy Qi, eliminating phlegm, supporting Yuan Qi, and descending rebellious Qi are required.

In Taiyang Wind-strike, if diarrhea and vomiting are present, treatment to attack can proceed only after the exterior is resolved. If the patient sweats, with periodic attacks, headache, hard epigastric fullness and distension, pain radiating to the hypochondria, dry retching, shortness of breath, sweating without aversion to cold, this indicates interior disharmony; Shizao Tang (Ten-Date Decoction) is appropriate.

With external Taiyang Wind-strike symptoms and internal diarrhea and vomiting, if the exterior pathogen is resolved, attack can proceed. If sweating occurs periodically, with headache, hard epigastric fullness and distension, pain radiating to the hypochondria, dry retching, shortness of breath, sweating without aversion to cold, this indicates the exterior is resolved, and there is phlegm-fluid accumulation internally causing pain; thus, this formula is used.

Shengjiang Xiexin Tang: Shengjiang (Fresh Ginger Rhizome), Banxia (Pinellia Tuber), Gancao (Licorice Root), Renshen (Ginseng Root), Huangqin (Scutellaria Root), Huanglian (Coptis Rhizome), Jiangjiang (Dried Ginger Rhizome), Dazao (Jujube Fruit).

Among the five Xiexin Tangs, three use Jiangjiang, Banxia, Huanglian, and Huangqin, combining two hot and two cold herbs to resolve phlegm and clear heat. This formula, because sweating has resolved the exterior and Stomach Yang deficiency fails to distribute fluids, causing borborygmus and diarrhea, uses Shengjiang to assist Jiangjiang in harmonizing Stomach Yang. This derives a method for expelling cold-fluid from a phlegm-heat formula.

Dahuang Huanglian Xiexin Tang: Dahuang (Rhubarb Root and Rhizome), Huanglian (Coptis Rhizome).

The Xiexin formulas for Pi Man all use half hot and half cold herbs. This formula removes the acrid-warm Jiangjiang and Banxia, using only Dahuang and Huanglian. This derives a method for purely clearing interior heat from a phlegm-heat formula.

Fuzi Xiexin Tang: Dahuang (Rhubarb Root and Rhizome), Huanglian (Coptis Rhizome), Huangqin (Scutellaria Root), Fuzi (Prepared Aconite Root Lateralis).

This is the previous formula plus Huangqin to form a major-cold preparation of the "Three Yellows"; plus Shu Fuzi (Prepared Aconite Root Lateralis) for its acrid-hot nature to disperse congealment. This derives an acrid-warm guiding method from a heat-clearing formula.

Banxia Xiexin Tang: Banxia (Pinellia Tuber), Huangqin (Scutellaria Root), Jiangjiang (Dried Ginger Rhizome), Renshen (Ginseng Root), Gancao (Licorice Root), Huanglian (Coptis Rhizome), Dazao (Jujube Fruit).

All Xiexin Tangs use Banxia, but this one is named specifically because Pi Man and vomiting are caused by phlegm-saliva; thus, Banxia is heavily increased in this decoction. This derives a method for heavily treating phlegm-saliva from the Xiexin formulas.

Gancao Xiexin Tang: Gancao (Licorice Root), Huangqin (Scutellaria Root), Jiangjiang (Dried Ginger Rhizome), Banxia (Pinellia Tuber), Huanglian (Coptis Rhizome), Dazao (Jujube Fruit).

This formula heavily increases Gancao in the Xiexin Tang to clarify that mistaken purgation damages the Middle, causing hard epigastric pi, where sweet-warm herbs that cause distension are contraindicated. Carefully studying the Xiexin formulas shows that mastering formulas for treating diseases relies on adjusting dosages.

Shizao Tang (Ten-Date Decoction): Yuanhua (Genkwa Flower), Gansui (Kansui Root), Daji (Euphorbia Root), Dazao (Jujube Fruit).

For hard epigastric fullness, dry retching, and hypochondriac pain, one must distinguish whether the exterior pathogen is resolved. If fully exterior symptoms are present, Zhang Zhongjing uses Xiao Qinglong Tang (Minor Blue-Green Dragon Decoction) to release the exterior and scatter fluid-retention. If the pathogen is in the half-exterior half-interior, Xiao Chaihu Tang is used for harmonization. If the exterior pathogen is completely dispersed and there is fluid-retention internally, Shizao Tang is used.

Xuanshen Dahezeshi Tang: Xuanshenhua (Stemona Flower), Gancao (Licorice Root), Renshen (Ginseng Root), Dahezeshi (Hematitum), Shengjiang (Fresh Ginger Rhizome), Banxia (Pinellia Tuber), Dazao (Jujube Fruit).

After sweating, emesis, and purgation, when exterior and interior pathogens are resolved, but hard epigastric fullness and belching persist without signs of congealment or pain-excess, this indicates Stomach deficiency failing to transform and transport, with retained phlegm accumulating and failing to descend; thus, this formula is used.

Chaihu Guizhi Tang: Chaihu (Bupleurum Root), Guizhi (Cinnamon Twig), Huangqin (Scutellaria Root), Shaoyao (Peony Root), Gancao (Licorice Root), Dazao (Jujube Fruit), Banxia (Pinellia Tuber), Shengjiang (Fresh Ginger Rhizome).

There are two types of Zhi Jie: If Shaoyang-Yangming symptoms appear, combine Xiao Chaihu Tang with Xiao Xianxiong Tang; if Taiyang-Shaoyang symptoms appear, combine Xiao Chaihu Tang with Guizhi Tang. One addresses phlegm-heat binding in the heart and chest, hence combining with Xiao Xianxiong Tang; the other addresses exterior pathogens transmitting inward to the heart and chest, hence combining with Guizhi and Shaoyao.

Zhiju Tang: Zhike (Citrus Aurantium Peel), Jiegeng (Platycodon Root).

Zhang Zhongjing used Zhizhu Tang (Citrus and Atractylodes Decoction) to treat pi from Spleen deficiency and food stagnation; and used various Xiexin Tangs to treat pi from Taiyang heat diseases. Now, Zhiju Tang is established to resolve anterior chest Qi pi and concurrently treat chest-hypochondriac branch-binding.