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Pi syndrome refers to a sensation of fullness and blockage in the epigastrium (heart below), leading to an inability to eat. Zhang Zhongjing stated: Fullness without pain is Pi (blockage/fullness); fullness with pain is Jie Xiong (knotted chest).

Li Dongyuan said: Pi syndrome is characterized by fullness in the epigastrium without pain. The Taiyin meridian corresponds to dampness, which governs obstruction and congestion. This is caused by Earth qi (damp pathogen) invading the area below the heart, resulting in Pi fullness. In Cold Damage diseases, if purgatives are used too early, Pi syndrome may also result, as cold pathogens injure the Ying blood. Ying blood belongs to the category of blood; the Heart governs blood vessels. When pathogens invade the root, it causes fullness and stuffiness below the heart. Zhang Zhongjing established several formulas for Xiexin Tang (Drain the Heart Decoction), all using Huanglian (Coptidis Rhizoma) to drain the Earth pathogen (damp-heat) in the epigastrium, with effects as immediate as striking a drum. Thus, the *Huoren Shu* (Book of Living People) states: Once Pi syndrome is confirmed, use Jiegeng Zhike Tang (Platycodon and Aurantium Decoction) first; this is not to treat Pi specifically with this formula. Rather, because prior erroneous purgation inevitably leads to Pi syndrome, at this stage the pathogenic qi is about to sink and attempt to pass through the chest. Therefore, this formula is used first to intercept and disperse the pathogen, preventing it from forming Pi. The word "first" implies early intervention. If used after Pi has already formed, it is too late. It will not only fail to resolve Pi but also damage the upright qi in the chest; only then should one use Zhang Zhongjing's medicines for treating Pi. The classic says: Observe where the pathogen resides and regulate/treat accordingly; this precisely refers to this principle. This applies not only to Cold Damage but also to miscellaneous diseases such as alcohol accumulation; excessive purgation can also cause Pi injury. Excessive purgation leads to the loss of Yin fluids; "loss of Yin" refers to the depletion of the Yin fluids of water and grain in the Spleen and Stomach. Consequently, the Qi in the chest sinks due to deficiency into the domain of the Heart, causing epigastric Pi. It is appropriate to raise Stomach Qi, combined with Blood-invigorating herbs. If solely using Qi-regulating herbs to guide, Pi will worsen; if purged again when severe, Qi will descend further, inevitably transforming into central fullness and distension. These are incorrect treatments. There are also distinctions between excess and deficiency. For excess Pi with constipation, Nongpu Zhishi Tang (Magnolia Bark and Immature Bitter Orange Decoction) is indicated. For deficient Pi with normal bowel movements, Baishao Chenpi Tang (White Peony Root and Tangerine Peel Decoction) is indicated. If Pi and stuffiness are caused by food injury, one should promote digestion and eliminate stagnation to remove chest obstruction. If there is rebellious Qi rising with nausea and urge to vomit, emesis should be induced, as stated in the classics: "For those above, induce vomiting."

Zhu Danxi said: Treating Pi solely by tonifying the Central Earth (Spleen) and using Blood-invigorating herbs is a method that cannot be surpassed. Pi caused by Cold Damage originates from the Blood level; Pi caused by miscellaneous diseases also originates from the Blood level. Although both fall under Blood-related patterns, generally speaking, Cold Damage patterns move from exterior to interior, from substantial to insubstantial. Therefore, for insubstantial Qi disorders, bitter-draining herbs are used; for substantial Blood disorders, acrid-sweet dispersing herbs are used. Those with central fullness should avoid sweet foods; those without fullness should consume sweet foods. "Central fullness" refers to abdominal distension. If one feels full externally but lacks visible abdominal distension, it is not central fullness, but rather "non-fullness" (deficiency). Non-fullness is a deficiency disease and should be treated with sweet herbs. (Insubstantial Qi disorders are drained with bitter herbs, such as Zhishi (Immature Bitter Orange) and Huanglian (Coptidis Rhizoma); substantial Blood disorders are dispersed with acrid-sweet herbs, such as Zhang Zhongjing's Renshen Tang (Ginseng Decoction).)

Li Dongyuan's Huangqi Buzhong Tang (Astragalus Tonify Middle Decoction): Huangqi (Astragali Radix, 5 fen), Renshen (Ginseng Radix, 8 fen), Gancao (Licorice Radix et Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Cangzhu (Atractylodis Rhizoma, each 5 fen), Chenpi (Citri Reticulatae Pericarpium, 5 fen), Zexie (Alismatis Rhizoma), Zhuling (Polypori Umbellati, Fuling (Poria, each 3 fen). Decoct in water until three-sevenths remain, take warm, followed by Da Xiaopi Wan (Great Dispersing Pi Pill).

Zhu Danxi treated a woman who, due to unsatisfactory circumstances, developed diaphragmatic fullness and inability to eat. After months of neglect, it accumulated into Pi syndrome, leaving her unable to rise or sit. Every day around noon (Si hour), she would develop fever and facial redness; after evening (You-Xu hours), the fever and redness subsided. At night, although urination was frequent, only a few drops were passed each time. All six pulses were deep, choppy, short, and small, identical on both sides, palpable even with heavy pressure. Menstruation occurred monthly but consisted of only a few drops. I said: This is Qi stagnation due to thwarted will, with blood stasis in the Stomach and concurrent blood deficiency. Stagnant Qi transforms into Phlegm residing in the Central Palace (Middle Jiao), causing anorexia. Combined tonification and draining methods were used. Baizhu (2 qian), Renshen (1 qian), Fuling (1 qian), Honghua (Carthami Flos, size of one bean), Chenpi (1 qian) were decocted to make a concentrated soup. One sip was taken hot before meals. Shortly after the medicine acted, half a spoonful of thin porridge was given. Then, Qingjianfen Qianqiu Sanhua Wan (Lightening Powder and Morning Glory Pill) was administered, sized like sesame seeds, swallowed with saliva, fifteen pills at a time. Both decoction and pills were taken four times over a day and night. By the next day, taste returned to food; by the second day, intake increased slightly; by the third day, fever subsided and facial redness disappeared. After seven days of this regimen, diet and activity returned to normal, recovering as before.

Third Aunt: Thirsty, poor appetite, Qi Pi, wiry pulse.
Baizhu (2 qian), Qingpi (Aurantii Fructus Immaturus, 2 qian), Banxia (Pinelliae Rhizoma, 2 qian), Gange (Puerariae Radix, 1.5 qian), Mutong (Akebiae Caulis, 1 qian), Gancao (Licorice Radix et Rhizoma, roasted, slight amount).
Divide into two doses. Two slices of ginger, decocted, taken with Dian Wan (Point Pill) thirty pills and Baohe Wan (Harmonize the Stomach Pill) twenty pills.

Tingli Wan (Descurainia Seed Pill) treats epigastric Pi and chest discomfort.
Kutingli (Descurainiae Semen seu Lepidii Semen, wine-soaked and stir-fried) (3 qian), Renshen (Ginseng Radix, 3 qian), Gancaogen (Licorice Radix et Rhizoma, roasted), Qianghuo (Notopterygii Rhizoma et Radix), Chaihu (Bupleuri Radix), Duhuo (Angelicae Pubescentis Radix, each 2 qian), Huangqin (Scutellariae Radix, 3 qian, half wine-soaked, half stir-fried), Sharen (Amomi Fructus), Ychen (Artemisiae Scopariae Herba, wine-fried, each 1 qian), Baidoukou (Cardamomi Rotundus Fructus, 1 qian), Qingpi (Aurantii Fructus Immaturus), Nongpu (Magnoliae Officinalis Cortex), Banxia (Pinelliae Rhizoma, each 0.5 fen), Dangguishen (Angelicae Sinensis Radix, 7 qian).
Grind into powder, make pills with steamed dough, sieve and expand in water to rice-grain size. Take one qian with plain warm water before bed.

Muxiang Xiaopi Tang (Costus Dispersing Pi Decoction) treats epigastric Pi fullness, slight abdominal pain with tight skin, aversion to eating, indigestion, and constant stuffiness due to emotional Qi stagnation in the Middle Jiao.
Chaihu (Bupleuri Radix, 0.7 fen), Chenpi (Citri Reticulatae Pericarpium, 0.8 fen), Gancao (Licorice Radix et Rhizoma, roasted, 0.5 fen), Banxia (Pinelliae Rhizoma, 1 qian), Shengjiang (Zingiberis Rhizoma Recens, 1 qian), Guishao (Angelicae Sinensis Radix tip, 2 qian), Honghua (Carthami Flos, slight amount), Zhishi (Aurantii Immaturus Fructus, 1 qian), Muxiang (Aucklandiae Radix, 0.7 fen), Cao Kou (Amomi Fructus, 1 qian).
One dose, decoct in water, strain, take hot before meals. Avoid alcohol and wheat products.

Da Xiaopi Wan (Great Dispersing Pi Pill) treats all types of epigastric Pi fullness, especially chronic cases lasting years.
Huangqin (Scutellariae Radix), Huanglian (Coptidis Rhizoma, stir-fried, each 6 qian), Jianghuang (Curcumae Longae Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma, each 1 qian), Renshen (Ginseng Radix, 2 qian), Gancao (Licorice Radix et Rhizoma, roasted), Sharen (Amomi Fructus, each 1 qian), Zhishi (Aurantii Immaturus Fructus, stir-fried, 5 qian), Banxia (Pinelliae Rhizoma, processed, 4 qian), Ganjiang (Zingiberis Rhizoma, 1 qian), Chenpi (Citri Reticulatae Pericarpium, 2 qian), Shenqu (Massae Fermentatae Medicinalis, stir-fried, 1 qian), Zexie (Alismatis Rhizoma, 3 qian), Nongpu (Magnoliae Officinalis Cortex, 2 qian), Zhuling (Polypori Umbellati, 1.5 qian).
Grind into powder, make pills with water-soaked steamed dough. Take 60-100 pills with plain warm water long after meals.

Huanglian Xiaopi Wan (Coptidis Dispersing Pi Pill) treats epigastric Pi fullness, congestion that does not dissipate, irritability, heat, panting, and restlessness.
Huanglian (Coptidis Rhizoma, 1 liang), Zhishi (Aurantii Immaturus Fructus, stir-fried, 7 qian), Ganjiang (Zingiberis Rhizoma, 2 qian), Banxia (Pinelliae Rhizoma, 7 qian), Huangqin (Scutellariae Radix, 1 liang), Fuling (Poria), Baizhu (Atractylodis Macrocephalae Rhizoma), Gancao (Licorice Radix et Rhizoma, roasted, each 3 qian), Jianghuang (Curcumae Longae Rhizoma, 1 qian), Zexie (Alismatis Rhizoma, 1 liang), Zhuling (Polypori Umbellati).
Grind into powder, make pills with soup-soaked steamed dough. Take 50-70 pills with plain warm water before meals.

Shixiao Wan (Pain-Disappearing Pill) treats floating-wiry right Guan pulse, damp Pi in the epigastrium, aversion to food, and lethargy. Opens the stomach and promotes appetite.
Zhishi (Aurantii Immaturus Fructus), Huanglian (Coptidis Rhizoma, each 5 qian), Ganjiang (Zingiberis Rhizoma, 2 qian), Banxiaqu (Pinelliae Rhizoma fermented, 3 qian), Nongpu (Magnoliae Officinalis Cortex, roasted, 4 qian), Renshen (Ginseng Radix, 5 qian), Gancao (Licorice Radix et Rhizoma, roasted, 2 qian), Baizhu (Atractylodis Macrocephalae Rhizoma, 3 qian), Maiya (Hordei Fructus Germinatus, 2 qian).
Grind into powder, make pills with water-soaked steamed dough. Take 30 pills with plain warm water. Time and dosage adjusted according to excess or deficiency.

Zhu Danxi treated a young woman with epigastric Pi stuffiness, dry mouth, slightly yellow complexion, and surging pulse.
Huanglian (Coptidis Rhizoma), Banxia (Pinelliae Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Qingpi (Aurantii Fructus Immaturus), Mutong (Akebiae Caulis, each 3 qian).
Divide into three doses. Decoct with ginger, strain, take hot, followed by Baohe Wan (Harmonize the Stomach Pill) fifteen pills.

Huijin Wan (Return Gold Pill) drains Liver Fire, moves Dampness and Heat. Opens Pi knots, treats Liver pathogen, tonifies Spleen Earth.
Huanglian (Coptidis Rhizoma, 6 liang), Wuzhuyu (Evodiae Fructus, 1 liang).
Grind into powder, make pills with water-soaked steamed dough. Another prescription uses Huanglian (6 liang) and Wuzhuyu (0.5 liang), also named Zuojin Wan (Assist Metal Pill).

Hua Shou said: Shaoyin disease with facial redness and dysentery, epigastric Pi, examples of modifying Xiexin Tang (Drain the Heart Decoction). Yi Lao used single Huanglian Xiexin Tang alone, following Qian's method, later modified according to symptoms.
If irritable, add Zhizi (Gardeniae Fructus). If dry, add Xiangchi (Fermented Soybean). If vomiting, add Banxia (Pinelliae Rhizoma). If full, add Zhishi (Aurantii Immaturus Fructus) and Nongpu (Magnoliae Officinalis Cortex). If abdominal pain, add Shaoyao (Paeoniae Radix Alba/Rubra). If pulse is slow, add Fuzi (Aconiti Lateralis Radix Praeparata). If Lower Jiao is cold, add Ganjiang (Zingiberis Rhizoma). If stool is hard, add Dahuang (Rhei Radix et Rhizoma). If using Ginger and Aconite, decoct them thoroughly first to ensure mild heat, then add Huanglian to use together.

Luo Qianfu said: Zhishi Lizhong Wan (Immature Bitter Orange Regulate Middle Pill) treats epigastric Pi fullness, stagnant Qi failing to dissipate, accumulated cold retention, and undigested food. (Formula see Chapter on Cold Damage.)

Zhang Zhongjing said: Renshen Tang (Ginseng Decoction) treats Chest Bi (Obstruction) and Heart Pi. (Formula see Chapter on Chest Bi.) Banxia Xiexin Tang (Pinellia Drain the Heart Decoction) treats Pi fullness with deep Guan pulse. (Formula see Chapter on Cold Damage.)

Zhu Danxi treated a girl at home who, due to unsatisfactory events, had Qi stagnation in the Spleen. She did not eat for half a year, eating only a few dates daily. She happened to like mantou (steamed buns) and could eat a little, but strongly disliked congee/rice. I diagnosed her Spleen Qi pattern; only Zhishi (Immature Bitter Orange) could disperse it. Thus, Wendan Tang (Warm the Gallbladder Decoction) without Zhuru (Bambusae Caulis in Taenia) was prescribed. After three months, taking 200 doses, she recovered.

Another girl, over twenty, married but husband traveled far away and did not return for two years. She became severely ill, refusing to eat, lying listlessly like a fool, with no other complaints; other doctors failed. I went to treat her, seeing her sleeping facing inward, emaciated. I thought: This is a Qi knot disease, medicine cannot cure it; anger can resolve it. I provoked her anger, slapped her face three times, and reprimanded her for having external thoughts. She indeed became furious and cried. After she cried for one to two hours, her parents calmed her down. Two doses of medicine were administered, and she immediately desired food. I told her parents: Although cured, joy is required for complete resolution; otherwise, the Qi knot will recur. Her father pretended to receive a letter from her husband, arranging a wedding date. Over a month later, her husband returned, and the illness completely resolved.

Food injury to the Spleen causing Pi stuffiness: Mild cases use Da Xiaopi Wan (Great Dispersing Pi Pill), Zhizhu Wan (Immature Bitter Orange and Atractylodes Pill), Huijin Wan (Return Gold Pill), etc. Severe cases require mild purgation or emesis. Purgation uses Binglang Wan (Arecae Semen Pill) or Zhu Huang Wan (Boiled Rhubarb Pill). Emesis uses Erchen Tang (Two Aged Decoction) or Gouti San (Melon Spicule Powder) to induce vomiting.

The *Classic* says: To treat cold Qi below the diaphragm and fullness from alcohol/food. Regularly use Qingpi (Aurantii Fructus Immaturus) four liang, divided into four parts. One part soaked in soup overnight, peeled; remaining three parts mixed with two liang salt, left for a while, then lightly stir-fried until scorched into powder. Take 1.5 qian per dose, with 0.5 qian tea powder, one cup of water, decoct to seven-tenths, take warm regularly. Taking with boiling water is especially good. Cold Pi is dispersed with acrid-sweet herbs, such as Zhishi Lizhong Wan (Immature Bitter Orange Regulate Middle Pill). Heat Pi is drained with bitter-cold herbs, such as Da Xiaopi Wan (Great Dispersing Pi Pill).

Zhu Danxi said: To treat Pi. Soft gypsum ground into powder, made into pills with vinegar paste. Drains Stomach fire, food stagnation, and phlegm-fire.

There are three types of Pi caused by Climate Factors (Yunqi):
First is Damp Pi. The classic says: Balanced Earth Qi is called Beihua. In the era of Beihua, the disease is Pi. Also: Taiyin arrival causes accumulation and fullness, fluid retention, and Pi obstruction. Also: When Taiyin rules Heaven, people suffer from cold-damp Pi and rebellion. Also: When Earth depression occurs, Pi hardness and abdominal fullness appear. Also: Earth insufficiency is called Beijian. In the era of Beijian, the disease is retention, fullness, and Pi blockage.
Second is Cold Pi. The classic says: When Water depression occurs, people suffer from Pi hardness and abdominal fullness. Also: Solar Rebound causes heart pain and Pi fullness.
Third is Dry Pi. The classic says: Yangming Rebound, severely, causes Pi fullness.

Hua Shou asked: Jing-Well points treat epigastric fullness. All twelve meridians have Jing-Well points; which one should be treated? If one is clean-loving, has a greenish complexion, and is prone to anger, it is Shaoyang meridian disease; treat Jin Jing Qiaoyin (Metal Well, Qiaoyin GB-45). If there is urinary retention, strangury, difficult defecation, and tetany, it is Foot-Jueyin Liver meridian disease; treat Mu Jing Dacun (Wood Well, Dacun LR-1). If there is headache, stiff neck/back, fever, and aversion to cold, it is Foot-Taiyang Bladder meridian disease; treat Yang Jing Zhiyin (Yang Well, Zhiyin BL-66 - *Note: Text says "Yang Jing Zhiyin", likely referring to Bladder Jing-Well*). If hands and feet are naturally warm, spontaneous diarrhea, and no thirst, it is Foot-Taiyin Spleen meridian disease; treat Yin Ying Baiyin (Yin Well, Baiyin SP-1).

A guest named Luo had Pi syndrome, with accumulation inside, latent and unable to descend, external pathogens resisting and unable to enter. He consulted a doctor who said: Purging is necessary. He took the medicine, experienced violent purging immediately, and within a day, the latent pathogens scattered completely, and resistant pathogens became soft and unsupported. His chest cleared, breathing opened, feeling as if he had never been ill. But within days, Pi returned. Using the same medicine brought back the relief. Within a month, Pi appeared five times and was purged five times, resolving each time. However, his vital Qi was exhausted; a few words drew out sweat three times, legs trembled without walking, muscles wasted, yet internal softness remained unknown. Alas! Must Heart Pi always be purged? I followed him in purging, my technique was flawless. Yet why this outcome? I heard of a good physician in southern Chu and went to ask. The doctor laughed: Do not be surprised! Your method inherently causes this. Sit, let me tell you. In the world, whatever brings extreme pleasure often brings harm at the end. Seeking no harm internally means abandoning the hope of extreme pleasure. Yin latent and Yang stored, Qi and Blood failing to circulate form Pi, obstructing your chest, causing great burden. Striking it away removes the burden quickly, but peaceful/harmonious drugs cannot do this; forceful beating and shaking are required. Human harmonious Qi is subtle and fragile. Once the forceful beating is done, your harmony is already damaged. Thus, every time your Pi is relieved, your harmony is injured. Five reliefs in a month mean your harmonious Qi is exhausted. Hence the relief lasts less than a day. To remove Pi without harming harmony, go home, live quietly for three months, then take medicine. The guest returned, fasted for three months, and requested medicine again. The doctor said: Your Qi has slightly recovered. Here is the medicine. Take it for three months, illness will stabilize; another three months, slight recovery; a year to fully recover. Medicine must not be advanced hastily. The guest followed this advice. Initially frustrating, delaying treatment, three doses led to three reversals. No daily effect seen, but comparing month by month, different seasons showed progress. Finally, after a year, the illness平息 (subsided). The guest bowed twice to thank the doctor, sat and asked why. The doctor said: This is the theory of governing a state, not just treating disease! Have you not seen how Qin governed its people? Fierce, disobedient, lazy, lawless. Commands ignored, governance unchanged, Qin's people were perpetually in Pi (stagnation). Lord Shang saw this Pi, used harsh laws and execution threats, fierce and merciless, cutting deeply and forcing change. Thus Qin's politics flowed like water from a high vessel, reaching everywhere, none daring to resist, and Qin's Pi was once greatly relieved. From Duke Xiao to Second Emperor, how many times was Pi relieved? The stubborn broke, the strong softened, and Qin's people lost fear. Thus, each fierce relief cost a piece of joyful heart. Accumulating relief endlessly left Qin's limbs empty, mere forms. People's hearts drifted away, ruler isolated. So a commoner shouted, and within a day, people rose up. Qin wanted to move its limbs, but they responded indifferently. Thus Qin's fall was the fault of those seeking quick relief. Former Kings' people were initially in Pi too. Did Kings not know quick striking was fast? They feared internal harm, so dared not seek quick pleasure. They gently nurtured them, taught benevolence/righteousness, guided with rites/music, secretly untied chaos and removed Pi. Looking aside, it seemed stagnant, but month-by-month, year-by-year, customs changed. No striking or fighting, no opposition, thus daily removing hostile Qi without hurting joyful hearts. Politics succeeded, education reached, peace lasted long, then disasters removed. Thus Three Dynasties governance took several sages and centuries to shape customs. So your medicine taking a year to cure is no wonder. Thus: Whatever brings extreme pleasure brings harm at the end. Seeking no final harm means abandoning hope for quick pleasure. Though so, is this not true for governing the world too? The guest bowed twice and recorded his words.