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Zhu Danxi stated: "Pi" (epigastric fullness/oppression) is synonymous with "Pǐ" (blockage), meaning lack of smooth flow. It arises from the latent retention of Yin and the accumulation of Yang, resulting in impaired circulation of Qi and Blood. The lesion is located at the "Xin Xia" (epigastrium/sub-xiphoid region), situated in the center of the body. Any condition characterized by a sensation of blockage and fullness belongs to disorders of the Earth element (Spleen/Stomach). There is a distinction in severity between Pi and Zhang Man (distension/fullness): Pi presents as an internal sensation of oppression without external signs of abdominal tension or rigidity.

Some cases result from chronic deficiency of Middle Qi, which fails to transport and transform essential nutrients; others arise from excessive use of digestive and purgative drugs that fail to relax and resolve food stagnation; still others are caused by excessive Damp-Heat, where Phlegm-Qi rebels upward into the Yang regions. Ancient formulas for treating Pi employ the bitter flavor of Huang Lian (Coptidis Rhizoma), Huang Qin (Scutellariae Radix), and Zhi Shi (Aurantii Fructus Immaturus) to drain downward; the acrid flavor of Hou Po (Magnoliae Officinalis Cortex), Sheng Jiang (Zingiberis Rhizoma Recens), and Ban Xia (Pinelliae Rhizoma) to disperse; the sweet flavor of Ren Shen (Ginseng Radix et Rhizoma) and Bai Zhu (Atractylodis Macrocephalae Rhizoma) to tonify; and the bland flavor of Fu Ling (Poria) and Ze Xie (Alismatis Rhizoma) to leach out dampness. Since Pi is treated similarly to Dampness, the Qi mechanism should be resolved through simultaneous upper and lower dispersion. If there are indeed signs of interior excess, mild resolving and guiding agents may be used.

People suffering from obstruction often prefer diuretic or purgative drugs for rapid effect. Although this provides temporary relief, if Pi recurs, the danger increases significantly. When Heaven and Earth Qi do not interact, Pi forms; this occurs when the Spleen's clear Qi fails to ascend and instead sinks, while the Stomach's turbid Qi fails to descend and instead rebels upward. One should use Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) plus Zhu Ling (Poria) and Ze Xie (Alismatis Rhizoma). This is because Sheng Ma (Cimicifugae Rhizoma) and Chai Hu (Bupleuri Radix) lift the clear Qi from below, while Zhu Ling and Ze Xie descend the turbid Qi from above, thereby transforming obstruction into smooth flow (Tai).

For various types of Pi obstruction and Ye Ge (dysphagia/pharyngeal obstruction), where Phlegm is stirred upward by Qi, and Qi is stagnant due to Phlegm coating, causing Phlegm and Qi to knot and preventing free flow, one should select from Lian Li Tang (Connected Spleen Decoction), Gan Jiang Huang Qin Huang Lian Ren Shen Tang (Ginger, Scutellaria, Coptis, and Ginseng Decoction), Huang Lian Tang (Coptis Decoction), or various Xie Xin Tangs (Drain the Epigastrium Decoctions). For Qi stagnation causing Pi distension, use Wu Ge Kuan Zhong San (Five Diaphragms Midsection-Widening Powder); if ineffective, switch to Ding Chen Tou Ge Tang (Cloves and Amber Throat-Penetrating Decoction). To address various Pi obstructions, distensions, chest-diaphragm discomfort, Qi rebellion, or abdominal pain, Zhi Mi Qi Qi Tang (Point-Mist Seven Qi Decoction) is suitable. Add Ren Shen and Bai Zhu for Stomach deficiency; Mu Xiang (Aucklandiae Radix) for Qi stagnation; Bing Lang (Arecae Semen) for constipation; Su Ye (Perillae Folium) for facial edema; and Mu Gua (Chaenomelis Fructus) for limb swelling. For Deficiency Pi, Ju Fang Qi Qi Tang (Formulary Seven Qi Decoction) and Ju Fang Wu Chen Er Tang (Formulary Black Pepper and Cypress Decoctions) are most effective.

For sudden Pi caused by anger, accompanied by facial edema, fullness of heart/abdomen/hypochondrium, difficult urination and defecation, and limb distension, use Zeng Sun Liu Qi Yin (Modified Flow-Qi Decoction). For cold Qi in the diaphragm, vomiting, inability to eat, regardless of Pi pain, first induce vomiting with fresh ginger juice, then administer medication. This method is especially suitable for Phlegm-Fluid retention. For Pi caused by pathogenic factors, dispersing agents are appropriate. However, if Qi fails to move smoothly and rebels upward causing Pi, this is Deficiency Pi; further dispersing will worsen the condition. Tonification should be primary, with only slight inclusion of dispersing intent, avoiding excessive use of aromatic Qi-regulating herbs. Ancients treated post-dysentery epigastric Pi using Li Zhong Wan (Regulate the Middle Pill), illustrating this principle.

If various Pi medications fail, bowel movements are blocked, and the pulse is rapid and forceful, select Xiao Xian Xiong Tang (Minor Chest-Trap Decoction) or San Huang Tang (Three Yellows Decoction). In severe cases, Bao Jian Mu Xiang Bing Lang Wan (Precious Mirror Aucklandia and Areca Pill) may be used for purgation. For obese patients with Phlegm-Pi and wind-constipation, Yu Yao Yuan Mu Xiang Bing Lang Wan (Imperial Pharmacy Aucklandia and Areca Pill) is used for dispersal. Obese patients with epigastric oppression have internal Damp-Phlegm; Er Chen Tang (Two-Cured Decoction) plus Zhi Shi, Huang Qin, and Huang Lian can be used, though Xiao Xian Xiong Tang is often more expedient. Thin patients with epigastric oppression have constrained Heat in the Middle Jiao; San Huang plus Zhi Shi guides it out. For epigastric Pi with unrelenting chills and fever, Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Zhi Shi and Jie Geng (Platycodonis Radix) is indicated. If Pi results from catching wind-cold after eating, or from consuming cold foods, warm the middle and resolve stagnation using Er Chen Tang plus Sha Ren (Amomi Fructus), Zi Su (Perillae Folium), and Huo Xiang (Agastaches Herba), or Ping Wei San (Calm the Stomach Powder) plus Huo Xiang and Dou Kou (Tsaoko Fructus).

For deficient individuals with unresolved stagnation, epigastric Pi that varies in tightness, and a preference for hot substances, use Zhi Shi Li Zhong Tang (Immature Bitter Orange Regulate-Middle Decoction). For elderly or deficient persons with weak Spleen/Stomach, poor transportation, and food stagnation causing Pi, use Jiu Wei Zi Sheng Wan (Nine-Ingredient Nourishing-Life Pill); chew one pill when feeling full/distended, or use Liu Jun Zi Tang (Six-Gentlemen Decoction) plus Mu Xiang, Sha Ren, Shan Zha (Crataegi Fructus), and Shen Qu (Massa Medicata Fermentata). For chest Qi blockage and shortness of breath, use Ju Pi Zhi Shi Sheng Jiang Tang (Tangerine Peel, Immature Bitter Orange, and Ginger Decoction). For alcohol accumulation and miscellaneous diseases where excessive purging damaged the Spleen, leading to Spleen deficiency and Pi, nourish the Stomach and harmonize Blood using Ren Shen, Bai Zhu, Dang Gui (Angelicae Sinensis Radix), and Bai Shao (Paeoniae Radix Alba) combined with Sheng Ma and Chai Hu, slightly assisted by Chen Pi (Tangerine Peel) and Zhi Ke (Aurantii Fructus).

Pi following intense anger, blood in phlegm, or a bloody taste in the mouth indicates Blood stasis. Use Mu Dan Pi (Moutan Cortex), Hong Qu (Red Yeast Rice), Xiang Fu (Cyperi Rhizoma), Jie Geng, Jiang Xiang (Dalbergiae Odoriferae Lignum), Hong Hua (Carthami Flos), Su Mu (Sappan Lignum), Shan Zha, Mai Ya (Hordei Fructus Germinatus), and Tong Bian (Human Urine). In severe cases, add Da Huang (Rhei Radix et Rhizoma) and Tao Ren (Persicae Semen). If Phlegm and Blood stasis form a "nest" causing Pi with a deep, choppy pulse and chronic duration, often seen in those with excessive grief and depression, treat as Blood Depression using Tao Ren, Hong Hua, Xiang Fu, Mu Dan Pi, and Jiu Zhi (Leek Juice).

The world universally prohibits Gan Cao (Licorice Root) for mid-fullness Pi, regardless of deficiency or excess. However, the ancient saying "do not consume sweet flavors for mid-fullness" refers specifically to Excess Fullness. If one feels full internally but lacks external abdominal distension, sweet-flavored tonics should be used.

[Diagnosis] A string-taut, rapid, and slippery pulse with sudden epigastric oppression indicates Liver Qi combined with Food Stagnation, representing an Excess pattern. A string-taut, deep-string-taut, choppy, or empty-large and powerless pulse, particularly prominent at the Qi Kou (Radial Artery at the wrist), indicates chronic Spleen/Stomach injury or overuse of harsh purgatives, representing a Deficiency pattern. Chest-diaphragm oppression with a deep-slippery or slow-slippy Cun Kou (Inch Position) pulse indicates stagnation.

Luo Qianfu treated a guest named Zhao from Zhending. In June, he suffered dampness injury from cooling off, presenting with epigastric fullness, intermittent irritability and heat, and restlessness. Lodging in a temple, a monk administered ten-plus pills of a purgative. After more than ten loose stools, the Pi slightly improved. The next day, exhausted and sleeping, he was robbed. His Heart spirit agitated, leading to irritability, heat, and thirst. He drank a cup of wine. That night, his umbilical and abdominal areas became painful. The monk administered the same purgative again, causing another ten-plus stools. The illness worsened severely: limbs were weak, irritability and heat persisted with restlessness, he craved cold water, rice and grains were undigested, dysentery resembled rotten fish intestines mixed with red water, he had no appetite, forced eating caused vomiting, Pi was worse than before, continuous belching occurred, feet were cold, and lower abdominal pain was unbearable. Pulse was floating and rapid (7-8 beats per breath), empty upon pressure. Luo said: Tracing the source, summer-heat had already injured healthy Qi. Using hot-toxic purgatives drained away all pathological material, leaving residual properties of E Ba Dou (Crotonis Fructus) and toxins in the intestines, causing vomiting and inability to eat, further injuring Stomach Qi. Subsequent profuse pus and blood discharge depleted flesh, dried skin and hair, and weakened Spleen Qi. Red and dry tongue, dry mouth and throat resulted from excessive loss of Yin fluids. With Yin exhausted, Fire flared alone, causing chest-heat and mental agitation. The Classic states: "Exclusive Yang does not generate, exclusive Yin does not grow; this is the cause of premature death." Luo declined further treatment. Another physician, failing to examine the pulse and trace the origin, saw only Pi and used Zhi Ke (Aurantii Fructus) pills to purge. The patient developed wheezing and fullness, uncontrollable diarrhea, and died. The *Jin Gui Yao Lue* states: "Purging when not indicated causes intestinal perforation and uncontrollable excretion," which applies here.

Shi Wan treated his brother-in-law Gu Jiuyu, who returned to Wu during an imperial decree. Suffering from chest Pi and cranial distension during extreme heat, his pulse was empty-large and soggy, with a slippery image exclusively at the Qi Kou. This indicated Damp-Heat flooding the Upper Jiao. Two doses of Qing Shu Yi Qi Tang (Clear Summerheat and Augment Qi Decoction) stopped the cranial distension but not the chest Pi. Ban Xia Xie Xin Tang (Pinellia Drain the Epigastrium Decoction) was prescribed, reducing Pao Jiang (Prepared Ginger), removing Da Zao (Jujubae Fructus), and adding Zhi Shi. One dose cured him.

My younger brother, Zeng Yu, though literate, was deeply interested in medical theory. His wife, Ms. Zheng, came from a family of renowned gynecologists. Both brothers were contemporary physicians. In the summer of Wushen year, she suffered from vomiting and rebellion, unable to eat for over a month. After twenty-plus doses of broad-diaphragm Qi-regulating medicines, nearly starving, her Pi and distension became abnormal. I examined her pulse: empty, large, and rapid. According to Zhang Zhongjing's pulse methods: "Large indicates Deficiency; Rapid indicates Deficiency." This showed severe deficiency of Stomach Yang and filling of the Upper Jiao with turbid Yin. I prescribed Lian Li Tang using three qian of Ren Shen. After four doses, Pi ceased and appetite returned. She recovered after several days of regulation with Yi Gong San (Extraordinary Merit Powder).

Madam, wife of Vice Prefect Wu Jiaoshui, suffered from Pi, vertigo, vomiting, and rebellion. Previously, fearing cold in the lower body and numbness/confusion in limbs and elbows, she had long taken Ba Wei Wan (Eight-Ingredient Pill), Ren Shen, and Fu Zi (Aconiti Lateralis Radix Preparata) without complete resolution. Six pulses were string-taut and slippery, becoming soggy upon pressure. This indicated inherent Phlegm-Dampness in the Middle Jiao and Yang Qi failing to circulate to the extremities. While the acrid-hot power of Gui Zhi (Cinnamomi Ramulus) and Fu Zi could temporarily open blockages, it did not address true Yang deficiency, and the cloying nature of Di Huang (Rehmanniae Radix) meant Pi and vertigo would never cease. I prescribed Ju Fang Qi Qi Tang plus Chen Xiang (Aquilariae Lignum), which brought immediate relief. After two doses, spirit brightened, appetite returned, and she was calm.

Mr. Zi Lao, father of Honorary Hanlin Scholar Miao Junjian, retired young, enjoying forest and spring life. Due to minor anger, he suffered vertigo and Pi oppression. For three months, expectorant and Qi-moving medicines failed, causing fatigue and reduced diet, with weakness in the Lower Yuan. In late July, I examined him. Six pulses seemed sufficient but lacked harmonious energy at the fingertips. Qi Kou was stagnant and irregular, varying in size. Both Chi positions were soggy-large and weak. This indicated inherent Phlegm-Dampness infiltrating Water and Earth meridians, compounded by repeated purgative attacks on Middle Qi, inevitably leading to fatigue and poor intake. The method required first regulating Middle Qi to transport essence of grain and water, then gradually warming and tonifying the Lower Yuan. I prescribed Liu Jun Zi Tang (Six-Gentlemen Decoction) plus Dang Gui to regulate Ying and Blood, avoiding the risk of "no Yang to transform." His wife suffered from prolonged metrorrhagia, unresponsive to various blood medicines. I used Bu Zhong Yi Qi Tang plus processed Xiang Fu and Wu Mei (Mume Fructus) to raise Yang and regulate Qi. This exemplifies "treating lower disease by taking from above," adhering strictly to ancient sage principles.