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(Attachment: Heart Pain)

General Summary: Heart pain originally originates in the epigastrium. To distinguish true heart pain, the pathology lies in the Gaohuang region (a deep internal area). The root causes of the nine types of heart pain must be carefully investigated; cold, food stagnation, parasites, and fire require extra caution.

Pulse Diagnosis: A洪大 (Hongda, surging and large) pulse indicates Fire. A热滑大 (Reshua da, hot, slippery, and large) pulse indicates Phlegm. A full pulse on the right hand indicates Accumulation. A沉滑 (Chen-hua, deep and slippery) pulse indicates Food Stagnation. A弦迟 (Xianchi, wiry and slow) pulse indicates Cold. A 沉细而实 (Chen-xi er shi, deep, fine, and full) pulse is treatable. A 坚大而实 (Jian-da er shi, firm, large, and full), 浮大而长 (Fu-da er chang, floating, large, and long), 滑而利 (Hua er li, slippery and free-flowing), or 数而紧 (Shu er jin, rapid and tight) pulses are difficult to treat. If heart pain is accompanied by cyanosis of the hands and feet extending to the joints, it is incurable.

The *Neijing* states: In years when Shaoyang governs the climate, wind qi circulates on the earth, leading to symptoms such as heart pain, epigastric pain, and obstruction of the diaphragm. It also says: When Wood qi is depressed and erupts, people suffer from epigastric pain centered behind the heart, radiating upward to both hypochondria, with obstruction in the diaphragm and chest, and inability to eat or drink. This occurs because Wind-Wood qi is depressed and becomes excessive upon eruption, resulting in signs of Earth failing and Wood attacking. However, the Heart and Stomach are distinct organs with different pathological manifestations. Because the location of epigastric pain is below the heart, it is named "pain centered behind the heart." Zhu Danxi's statement that "epigastric pain is heart pain" is incorrect. The Stomach is True Wet Earth, located in the Middle Jiao, endowed with harmonious qi, rich in qi and blood, serving as the Sea of Water and Grain, and the commander of the Three Yang meridians. The qi of the five zang and six fu organs and twelve meridians all derive from it. Thus, when robust, qi flows freely and health is maintained; when weak, qi stagnates and disease arises. If the harmonious qi of the Stomach shifts towards excess cold or heat, water and grain fail to digest, remaining as fluid retention and food accumulation. True qi contends with pathogenic factors, causing clear yang to fail to ascend and turbid yin to fail to descend. The evil of Liver Wood then takes the opportunity to invade and harass, causing disease. Etiologically, this often results from indulgence in eating, favoring pungent, sour, cold, raw, fried, crispy, or hard foods. Damage accumulates day by day, forming depression, then accumulation, then phlegm. Phlegm-fire simmering causes blood to move recklessly. Phlegm and blood mix, obstructing ascending and descending mechanisms, resulting in epigastric pain. Quack doctors, failing to investigate the source, indiscriminately use pungent, aromatic, dry, and hot medicines, adding fire to fire, thus creating critical conditions, which is truly lamentable. Ancient formulas describe nine types of heart pain: Yin (Fluid), Shi (Food), Feng (Wind), Leng (Cold), Re (Heat), Ji (Palpitation), Chong (Parasite), Zhu (Infectious/Contagious), and Qulai Tong (Wandering Pain). "Cold" is merely one type. The key lies in the physician's intuitive understanding; one must not indiscriminately use hot medicines. Examining the causes closely, the pathology is in the epigastrium, not actually in the Heart, differing only in being Cold, Heat, Fire, Excess, Dead Blood, Food Stagnation, Phlegm, or Parasites.

Cold-Jue Pain: Hands and feet are cold, whole body sweats cold sweat, bowel movements and urination are free with clear urine, or bowels are loose without thirst, with faint qi and weak strength. Treat with Shu Fu Tang (Atractylodes and Aconite Decoction) to warm.

Heat-Jue Pain: Body is hot while feet are cold. Severe pain causes irritability and vomiting, spontaneous sweating on the forehead, and a Hongda (surging and large) pulse. Treat with Jin Ling Zi San (Melia Seed Powder) with modifications.

Fire-Excess Pain: Caused by Qi stagnation and Food accumulation, sudden onset of pain. Bowels may be closed. After a long time, there is stuffiness and distension, the chest and heart area protrude, pressing increases pain, and eating is impossible. Treat with mild purgation.

Dead Blood Pain: Pain is fixed in one location and does not shift.

Food Stagnation Pain: Pain is severe with an urge to defecate; pain decreases after defecation.

Phlegm Pain: Dull pain that temporarily stops after taking pungent-hot decoctions.

True Heart Pain: Must result in death and is incurable. This refers to the Pericardium drawing evil into the proper meridian of the Heart. The Heart organ belongs to Minister Fire (Note: Text says Jun Huo/Emperor Fire, but context implies vulnerability via Pericardium), the residence of the Spirit, and the Hand-Shaoyin meridian, which are generally protected from injury. Additionally, if one usually likes eating hot foods, causing dead blood to remain at the stomach opening and cause pain, treat with Tao Ren Cheng Qi Tang (Peach Kernel and Rhubarb Decoction) to purge.

Supplementary Notes:
Zhu Danxi said: For all epigastric pain, warm medicines must be used. This is because depression prevents flow, obstructing qi movement. Therefore, pain located lower down mostly belongs to Dampness and should be treated with warming and draining methods.

Generally, heart pain must be distinguished by newness or chronicity. If clearly caused by external cold exposure or ingestion of cold substances, during the initial stage, one should use warming dispersal or warming drainage. If the disease persists for a while, it forms depression; long-term depression generates heat; long-term heat generates fire, as detailed in the *Yuan Bing Shi*. If one attempts warming dispersal or drainage at this stage, would it not assist fire and worsen the disease? Therefore, Gardenia (Shan Zhi) is often used as a guide for heat-clearing medicines, allowing evil to be subdued and disease to recede, so that righteous qi can recover. Use fifteen Gardenias (nine large ones), remove skin, stir-fry until black, decoct, add ginger juice to make it pungent, and take. Alternatively, add one qian of Chuanxiong, or use Er Chen Tang plus Chuanxiong and Cangzhu, doubling the dosage of Banxia, decoct and take. For severe cases, add Ganjiang (Dried Ginger); for mild cases, disperse with Mahuang (Ephedra) and Guizhi (Cinnamon Twig). For those with Qi deficiency suffering epigastric pain, take Caodoukou Wan (Cardamom Pill).

[Attached Formulas]
Caodoukou Wan (Cardamom Pill): Caodoukou (Tsaoko Cardamom Fruit), Juhong (Exocarpium Citri Reticulatae), Renshen (Ginseng Root), Ganjiang (Dried Ginger), Huangqi (Astragalus Root), Yizhi (Alpinia Oxyphylla Fruit), Danggui (Angelica Sinensis Root), Qingpi (Green Tangerina Peel), Zexie (Alisma Rhizome), Banxia (Pinellia Tuber), Taoren (Peach Seed), Maiya (Hordeum Germinatum), Shenqu (Massa Medicata Fermentata), Jianghuang (Curcuma Longa Rhizome). Grind into powder, mix with steamed dough to form pills, take with Ginger Decoction. Can add Wuzhuyu (Evodia Fruit), Sheng Gancao (Raw Licorice Root), and Shu Gancao (Prepared Licorice Root).

Shu Fu Tang (Atractylodes and Aconite Decoction): See section on Convulsions.

Jin Ling Zi San (Melia Seed Powder): Jinlingzi Rou (Sarcotesta of Melia Toosendan), Yuanhusuo (Corydalis Rhizome) (one liang each). Grind into powder, take. After pain ceases, take Zhizhu Wan (Immortelle and Atractylodes Macrocephala Pill).

Zhizhu Wan (Immortelle and Atractylodes Macrocephala Pill): Zhishi (Immature Bitter Orange), Baizhu (Atractylodes Macrocephala Rhizome).

Tao Ren Cheng Qi Tang (Peach Kernel and Rhubarb Decoction): See section on Dysentery.