论
《内经》曰∶备化之纪，其病痞。又曰∶太阴所至，为积饮痞膈。夫痞满之证，东垣论之详矣。谓太阴湿土主壅塞，
乃土来心下为痞满也。伤寒下之太早，亦为痞满，乃寒伤荣血而然。心主血，邪入于本，故为心下痞。仲景以泻心汤，
用黄连泻心下之土邪，功效甚速。非止伤寒为然，至于酒积杂病，下之太过，亦作痞满，盖下多则亡阴也。亡阴者，谓
脾胃水谷之阴亡也。故胸中之气，因虚而下陷于心之分野，故心下痞。宜升胃气，以血药兼之。若全用利气之药导之，
则痞尤甚。痞甚而复下之，气愈下降，必变为中满鼓胀，皆非其治也。又有虚实之异，如实痞大便秘者，浓朴、枳实主
之。虚痞大便利者，芍药、陈皮主之。如饮食所伤而为痞满者，宜消导其胸中窒塞之气。上逆兀兀欲吐者，则宜吐之，
所谓在上者因而越之是也。学人宜详究焉。
脉法
《脉经》曰∶痞，脉浮紧而下之，紧反入里，因作痞。
脉濡而弱，弱反在关，濡反在颠，微反在上，涩反在下。微则阳气不足，涩则无血，阳气反微，中风汗出，而反躁
烦，涩则无血，厥而且寒，阳微不可下，下之则心下痞坚。
右关脉多弦，弦而迟者，必心下坚（此肝木克脾土，郁结涎闭于脏腑，气不舒则痞。）
方法
丹溪曰∶痞满与胀满不同，胀满内胀而外亦形，痞则内觉痞闷而外无胀急之形也。盖由阴伏阳蓄，气血不运而成，
位乎心下之中， 痞满塞，皆土邪之所为耳。有因误下，里气虚，邪乘虚而入于心之分野。有因食痰积，不能施化，郁
而作痞者。有湿热太甚，土来心下而为痞者。
用黄连、黄芩、枳实之苦以泄之，浓朴、生姜、半夏之辛以散之，人参、白术之甘温以补之，茯苓、泽泻之咸淡以
渗之，大概与湿同治，使上下分消可也。
（以上丹溪方法凡二条）
浓朴温中汤（东垣） 治脾胃虚弱，心腹胀满疼痛，时发时止。
浓朴（姜汁拌炒） 陈皮（去白，各一钱） 茯苓 草豆蔻 甘草 木香（各五分） 干生姜（一钱）
上细切，水煎服。
木香顺气汤（东垣） 治 胀，心腹满闷。
木香 益智 陈皮 苍术 草豆蔻（各五分） 浓朴（姜制） 青皮（各四分） 茯苓 泽泻 半夏（各六分） 干
生姜 茱萸（各三分） 当归 人参（各五分） 升麻 柴胡（各一钱）
上细切，作一服，水一盏半，煎至一盏，温服。
痞有痰挟血成窠囊者，用桃仁、红花、香附、大黄之类治之。
七气汤（局方） 治七情所伤，忧思郁结，腑脏气不和平，心腹痞闷。
半夏 茯苓（各二钱） 浓朴（姜制，一钱五分） 紫苏叶（一钱）
上细切，作一服，加生姜三片，水一盏半，煎至一盏，温服。
大消痞丸（东垣） 治一切心下痞，及年久不愈者。
干生姜 神曲（炒） 甘草（炙，各二钱） 猪苓（二钱五分） 泽泻 浓朴（姜汁拌炒） 砂仁（各三钱） 半
夏（汤泡七次，去皮脐） 陈皮（去白） 人参（各四钱） 黄连（陈壁土炒，去土） 黄芩（如连制，各六钱） 枳
实（五钱，去穣麸炒） 姜黄 白术（各一两）
上为细末，汤浸蒸饼为丸，如梧桐子大，每服五十丸至百丸，空心白汤下。
失 丸（一名枳实消痞丸，东垣） 治右关脉弦，心下虚痞，恶食懒倦。开胃进食。
干生姜（一钱） 甘草（炙） 麦 面（炒） 白茯苓 白术（各二钱） 半夏曲 人参（各三钱） 浓朴（姜制，
四钱） 枳实（麸炒黄色） 黄连（各五钱）
上为细末，蒸饼为丸，如梧桐子大，每服七、八十丸，白汤下。
消痞汤（一名木香化滞汤，东垣） 治因忧气郁结中脘，腹皮里微痛，心下痞满，不思饮食。
川归 枳实（炒，各四分） 陈皮 生姜 木香（各六分） 柴胡（七分） 甘草（炙） 草豆蔻（各一钱，面包
煨） 半夏（一钱五分） 红花（一分）
上细切，作一服，加生姜三片，水二盏，煎至一盏，温服。
黄连消痞丸（东垣） 治心下痞满，壅滞不散，烦热喘促不安。
泽泻 姜黄（各一钱） 干生姜（二钱） 甘草（炙） 茯苓 白术（各三钱） 陈皮（五钱） 猪苓（去黑皮，
五钱） 枳实（麸炒黄色，七钱） 半夏（汤泡七次，九钱） 黄连（一两） 黄芩（二两，炒）
上为细末，蒸饼为丸，如梧桐子大，每服五十丸，白汤下。
黄芩利膈丸（东垣） 除胸中热，利膈上痰。
生黄芩 炒黄芩（各一两） 半夏 黄连 泽泻 南星（各五钱） 枳壳（麸炒去穣） 陈皮（去白，各三钱） 白
术（二钱） 白矾（一钱） 今加萝卜子（五钱，炒） 小皂角（一钱）
上为细末，汤浸蒸饼为丸，如梧桐子大，每服五十丸，白汤下。忌酒、湿面、鱼腥。
（丹溪活套）云∶凡心下痞满，须用枳实、黄连。如肥人心下痞，内有湿饮，宜苍术、半夏、缩砂、茯苓、滑石之
类。如瘦人心下痞，乃郁热在上焦，宜枳实、黄连以导之，葛根、升麻以发之。如人饮食后，因冒风寒，饮食不消而作
痞满，宜吴茱萸、缩砂、藿香、草豆蔻之类，温以化之。如脾气虚弱，转运不调，饮食不化而作痞者，宜白术、山楂、
神曲、麦芽之类以消之。又曰∶痞满之证不一，有伤寒下早而作痞者，枳壳桔梗汤、小陷胸汤之类。有因饮食填塞胸
中而作痞者，保和丸、东垣枳实导滞丸、木香化滞汤之类。伤寒下多则亡阴而痞者，四物汤加参、苓、白术、升麻、柴
胡，少佐以陈皮、枳壳之类除之。或大病后，元气未夏而胸满气短者，宜补中益气汤、陈皮枳术丸、木香枳术丸之类。
夫痞满之证，不可执一，全在活法，详脉证虚实而调之可也。
（医案）
山头沈三十一丈，年三十余，身材肥盛，夏秋间因官差丈量田地辛苦，至冬间得痞满证，两胁气攻，胸中饱闷，
不能卧，欲成胀满证。历数医者，皆与疏气耗散之药，皆不效。十一月初旬，召予延医，两手关前皆浮洪而弦涩，两关
后脉皆沉伏。予曰∶此膈上有稠痰，脾土之气敦阜，肝木郁而不伸，当用吐法，木郁达之之理也。奈何值冬月降沉之令，
未可行此法，且先与豁痰疏肝气，泻脾胃敦阜之气。用平胃散加半夏、茯苓、青皮、川芎、草龙胆、香附、砂仁、柴
胡、黄连、栝蒌子等药，病退之十有三四。待次年二月初旬，为行倒仓法，平安。
Treatise
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: In years characterized by the "Baihua" phase (excessive Earth qi), the prevalent disease is Pi (痞, stuffiness/obstruction). It further states: When Taiyin (太阴, Great Yin) damp-earth qi arrives, it manifests as accumulation of drinking fluids and obstruction in the chest and diaphragm. Regarding the syndrome of Pi-Man (痞满, fullness and obstruction), Li Dongyuan (Li Gao) discussed it in detail. He asserted that Taiyin damp-earth qi governs stagnation and blockage; thus, Earth evil invading the epigastrium causes Pi-Man. If the Shaoyang disease (Shanghan, Cold Damage) is treated with purgatives too early, Pi-Man also results, caused by cold damaging the Ying (Nutritive) blood. The Heart governs blood; when pathogenic factors invade the Heart's domain, Pi at the epigastrium occurs. Zhang Zhongjing utilized Xiexin Tang (Coptis Decoction to Drain the Epigastrium), employing Huanglian (Rhizoma Coptidis) to clear the Earth evil in the epigastrium, achieving rapid efficacy. This is not limited to Shanghan; even in miscellaneous diseases such as alcohol accumulation, excessive purgation leads to Pi-Man because excessive purging destroys Yin. "Destruction of Yin" refers to the loss of the Yin essence derived from water and food in the Spleen and Stomach. Consequently, the Qi in the chest sinks due to deficiency into the Heart's territory, causing epigastric Pi. Treatment should involve raising Stomach Qi, combined with blood-nourishing herbs. If one uses only Qi-moving and guiding herbs, the Pi will worsen. If Pi is severe and purgatives are used again, the Qi descends further, inevitably transforming into Zhongman Guzhang (中满鼓胀, abdominal distension like a drum). These are all incorrect treatments. There are distinctions between Excess and Deficiency. For Excess Pi accompanied by constipation, Houpo (Cortex Magnoliae Officinalis) and Zhishi (Fructus Aurantii Immaturus) are indicated. For Deficient Pi accompanied by normal bowel movements, Shaoyao (Radix Paeoniae Alba) and Chenpi (Pericarpium Citri Reticulatae) are indicated. If Pi-Man is caused by dietary injury, one should resolve the obstructed Qi in the chest. If Qi rebels upward causing nausea and a desire to vomit, emesis (vomiting therapy) is appropriate, following the principle: "For pathogens located above, induce vomiting." Students should investigate this thoroughly.
Pulse Diagnosis
The *Mai Jing* (Pulse Classic) states: In Pi, if the pulse is floating and tight but purgatives are administered, the tightness enters the interior, resulting in Pi.
If the pulse is Ru (Ruo, soft and weak) and Ruo, with the Ruo position reversed at the Guan (middle) position, and the Ru position reversed at the Cun (superficial/distal) position; if the Wei (fine) pulse appears at the upper position and the Se (choppy) pulse at the lower position. A Wei pulse indicates insufficient Yang Qi; a Se pulse indicates lack of Blood. If Yang Qi becomes faint, wind-stroke occurs with sweating, yet restlessness and irritability appear instead; a Se pulse indicates lack of Blood, leading to Jue (cold extremities) and cold. Faint Yang Qi contraindicates purgation; purging will result in hard Pi at the epigastrium.
The Right Guan pulse is often Xian (string-taut); if Xian and Chi (slow), there will certainly be hardness at the epigastrium (This is Liver Wood overcoming Spleen Earth, with phlegm-fluids binding in the Zang-Fu organs; Qi fails to flow freely, causing Pi.)
Methods
Zhu Danxi stated: Pi-Man differs from Zhang-Man (distension). Zhang-Man involves internal distension and external manifestation of swelling/tightness, whereas Pi-Man involves internal sensation of stuffiness and obstruction without external signs of distension. This is generally caused by latent Yin and stored Yang, with impaired circulation of Qi and Blood. The location is in the middle of the epigastrium. Pi-Man obstruction is all due to Earth evil. Causes include: erroneous purgation leading to interior deficiency, allowing pathogens to enter the Heart's territory; food and phlegm accumulation failing to transform, leading to stagnation and Pi; or excessive Damp-Heat, where Earth evil invades the epigastrium causing Pi.
Use the bitter properties of Huanglian (Rhizoma Coptidis) and Huangqin (Radix Scutellariae) to drain; the acrid properties of Houpo (Cortex Magnoliae Officinalis), Shengjiang (Rhizoma Zingiberis Recens), and Banxia (Rhizoma Pinelliae) to disperse; the sweet-warm properties of Renshen (Radix Ginseng) and Baizhu (Rhizoma Atractylodis Macrocephalae) to tonify; and the salty-light properties of Fuling (Poria) and Zexie (Rhizoma Alismatis) to leach out moisture. Generally, treat it similarly to Dampness, allowing the pathogen to be eliminated from above and below.
(Above are two methods from Danxi.)
Houpo Wenzhong Tang (Magnolia Decoction to Warm the Middle) [Dongyuan]: Treats Spleen-Stomach deficiency, abdominal distension and pain, occurring intermittently.
Houpo (stir-fried with ginger juice) 1 qian, Chenpi (de-white) 1 qian, Fuling 5 fen, Caodoukou (Cardamomi Fructus) 5 fen, Gancao (Licorice Root) 5 fen, Muxiang (Aucklandiae Radix) 5 fen, Gan Jiang (Dried Ginger) 1 qian.
Cut finely, decoct in water, and take warm.
Muxiang Shunqi Tang (Costus Decoction to Smooth Qi) [Dongyuan]: Treats distension, epigastric and abdominal fullness.
Muxiang 5 fen, Yizhi (Alpiniae Oxymatary Fructus) 5 fen, Chenpi 5 fen, Cangzhu (Rhizoma Atractylodis Lanceae) 5 fen, Caodoukou 5 fen, Houpo (processed with ginger) 4 fen, Qingpi (Green Tangerine Peel) 4 fen, Fuling 6 fen, Zexie 6 fen, Banxia 6 fen, Gan Jiang 3 fen, Zhuyu (Evodiae Fructus) 3 fen, Danggui (Angelicae Sinensis Radix) 5 fen, Renshen 5 fen, Shengma (Cimicifugae Rhizoma) 1 qian, Chaihu (Bupleuri Radix) 1 qian.
Cut finely, take as one dose, decoct 1.5 cups of water to 1 cup, and take warm.
For Pi formed by Phlegm entangling Blood into nests/cysts, use Taoren (Persicae Semen), Honghua (Carthami Flos), Xiangfu (Cyperi Rhizoma), Dahuang (Rhei Radix et Rhizoma), etc.
Qi Qi Tang (Seven Qi Decoction) [Jufang]: Treats damage from Seven Emotions, worry and thought leading to stagnation, disharmony of Zang-Fu Qi, and epigastric fullness.
Banxia 2 qian, Fuling 2 qian, Houpo (processed with ginger) 1.5 qian, Zisu Ye (Perillae Folium) 1 qian.
Cut finely, take as one dose, add 3 slices of fresh ginger, decoct 1.5 cups of water to 1 cup, and take warm.
Da Xiao Pi Wan (Great Pill to Eliminate Pi) [Dongyuan]: Treats all types of epigastric Pi, especially chronic cases lasting years.
Gan Jiang 2 qian, Shenqu (Massa Medicata Fermentata) stir-fried 2 qian, Gancao (roasted) 2 qian, Zhuling (Polyporus) 2.5 qian, Zexie 3 qian, Houpo (mixed with ginger juice and fried) 3 qian, Sharen (Amomi Fructus) 3 qian, Banxia (soaked in boiling water seven times, skin removed) 4 qian, Chenpi (de-white) 4 qian, Renshen 4 qian, Huanglian (fried with old wall soil, remove soil) 6 qian, Huangqin (prepared like Huanglian) 6 qian, Zhishi (5 qian, bran-fried, remove pith), Jianghuang (Curcumae Longae Rhizoma) 1 liang, Baizhu 1 liang.
Grind into fine powder, mix with steamed dough soaked in water to form pills the size of paulownia seeds. Take 50-100 pills per dose on an empty stomach with plain boiled water.
Shi Wan (One Name: Zhishi Xiaopi Wan, Acupunctured Pi-Eliminating Pill) [Dongyuan]: Treats Xian pulse at Right Guan, deficient Pi at epigastrium, aversion to food, and lassitude. Opens the stomach and promotes appetite.
Gan Jiang 1 qian, Gancao (roasted), Mai Mian (Wheat Flour) stir-fried, Baifuling, Baizhu (each 2 qian), Banxia Qu (Pinelliae Fermentatum) 3 qian, Renshen 3 qian, Houpo (ginger-processed) 4 qian, Zhishi (bran-fried yellow), Huanglian (each 5 qian).
Grind into fine powder, make into pills with steamed dough, size of paulownia seeds. Take 70-80 pills per dose with plain boiled water.
Xiao Pi Tang (Pi-Eliminating Decoction) [Dongyuan], also known as Muxiang Huazhi Tang: Treats Qi stagnation in the Zhongwan region due to sorrow and anger, slight pain under the abdominal skin, epigastric Pi-Man, and loss of appetite.
Chuan Gui (Angelicae Sinensis Radix) stir-fried 4 fen, Zhishi stir-fried 4 fen, Chenpi 6 fen, Shengjiang 6 fen, Muxiang 6 fen, Chaihu 7 fen, Gancao (roasted), Caodoukou (wrapped in bread and baked) (each 1 qian), Banxia 1.5 qian, Honghua 1 fen.
Cut finely, take as one dose, add 3 slices of fresh ginger, decoct 2 cups of water to 1 cup, and take warm.
Huanglian Xiao Pi Wan (Coptis Pi-Eliminating Pill) [Dongyuan]: Treats epigastric Pi-Man, stagnation not dispersing, irritability, heat, panting, and restlessness.
Zexie 1 qian, Jianghuang 1 qian, Gan Jiang 2 qian, Gancao (roasted), Fuling, Baizhu (each 3 qian), Chenpi 5 qian, Zhuling (remove black skin) 5 qian, Zhishi (bran-fried yellow) 7 qian, Banxia (soaked in boiling water seven times) 9 qian, Huanglian 1 liang, Huangqin (fried) 2 liang.
Grind into fine powder, make into pills with steamed dough, size of paulownia seeds. Take 50 pills per dose with plain boiled water.
Huangqin Lige Wan (Scutellaria Diaphragm-Relieving Pill) [Dongyuan]: Clears heat in the chest, relieves phlegm in the diaphragm.
Sheng Huangqin (Raw Scutellaria) 1 liang, Chao Huangqin (Fried Scutellaria) 1 liang, Banxia 5 qian, Huanglian 5 qian, Zexie 5 qian, Nanting (Arisaematis Rhizoma) 5 qian, Zhike (Aurantii Fructus) (bran-fried, remove pith), Chenpi (de-white) (each 3 qian), Baizhu 2 qian, Baijian (Alumen) 1 qian. Now add Luobozi (Brassicae Semens) 5 qian (fried), Xiao Zaojiao (Gleditsiae Spina) 1 qian.
Grind into fine powder, make into pills with steamed dough soaked in water, size of paulownia seeds. Take 50 pills per dose with plain boiled water. Avoid alcohol, wet wheat noodles, and fishy foods.
(Danxi Huotao / Flexible Patterns of Danxi) states: For any epigastric Pi-Man, Zhishi and Huanglian must be used. For obese individuals with epigastric Pi due to internal damp-drinking, use Cangzhu, Banxia, Suosha (Amomi Fructus Rotundus), Fuling, Huashi (Talcum), etc. For thin individuals with epigastric Pi due to stagnant heat in the Upper Jiao, use Zhishi and Huanglian to guide, and Gegen (Puerariae Radix) and Shengma to release. If Pi-Man arises after eating due to exposure to wind-cold and indigestion, use Wuzhuyu (Evodiae Fructus), Suosha, Huoxiang (Agastaches Herba), Caodoukou, etc., to resolve with warmth. If Pi-Man arises from Spleen Qi deficiency, poor transportation, and indigestion, use Baizhu, Shanzha (Crataegi Fructus), Shenqu, Maiya (Hordei Fructus Germinatus), etc., to digest. Furthermore: Pi-Man syndromes vary. Those caused by premature purgation in Shanghan can be treated with Zhike Jiegeng Tang (Aurantii Fructus and Platycodon Decoction) or Xiao Xiantong Tang (Minor Trap-the-Thorax Decoction). Those caused by food blocking the chest can be treated with Baohe Wan (Preserve Harmony Pill), Dongyuan Zhishi Daozhi Wan (Acupunctured Pi Guiding Stasis Pill), or Muxiang Huazhi Tang. Those caused by excessive purgation in Shanghan leading to Yin destruction and Pi can be treated with Siwu Tang (Four Substances Decoction) plus Renshen, Fuling, Baizhu, Shengma, Chaihu, with small amounts of Chenpi and Zhike to eliminate. Or, for post-major illness cases with unrecovered Yuan Qi, chest fullness, and shortness of breath, use Buzhong Yiqi Tang (Middle-Warming Qi-Supporting Decoction), Chenpi Zhizhu Wan (Tangerine Peel and Atractylodes Pill), or Muxiang Zhizhu Wan (Costus and Atractylodes Pill).
Regarding Pi-Man, one must not adhere rigidly to a single method; flexibility is key. One must carefully examine the pulse and symptoms to determine excess or deficiency and regulate accordingly.
Medical Case
Mr. Shen San-shiyi-zhang from Shantou, over thirty years old, was of robust build. During summer and autumn, he suffered hardship while surveying land for official duties. By winter, he developed Pi-Man, with Qi attacking both hypochondria, chest fullness and oppression, inability to lie down, and impending transformation into Zhang-Man (distension). Several physicians treated him with Qi-moving and dissipating drugs, all without effect. In early November, I was summoned. The pulses at the front of both Guan positions were floating, surging, string-taut, and choppy; the pulses behind both Guan positions were deep and hidden. I said: "There is thick phlegm in the diaphragm; the Spleen Earth Qi is overly abundant and elevated; Liver Wood is stagnant and unable to extend. Vomiting therapy should be used, following the principle 'When Wood is stagnant, unblock it.'" However, since it was winter, the season of descending Qi, this method could not be applied immediately. Instead, I first prescribed herbs to resolve phlegm, soothe Liver Qi, and drain the excessive Qi of the Spleen Earth. I used Pingwei San (Peaceful Stomach Powder) added with Banxia, Fuling, Qingpi, Chuanxiong (Ligustici Chuanxiong Rhizoma), Cao Longdan (Gentianae Radix), Xiangfu, Sharen, Chaihu, Huanglian, and Gualouzi (Trichosanthis Semen). The condition improved by three or four tenths. By early February of the following year, I performed Daocang Fa (Inversion Granary Method, a drastic purging/emetic therapy), and he recovered safely.