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Pi (Pih, a sensation of fullness and obstruction) refers to the blockage and lack of free flow; Man (Man, distension/fullness) refers to distension with stagnation. Generally speaking, Man is close to Zhang (Zhang, abdominal distension), but Pi does not necessarily involve distension. Therefore, in distinguishing the syndrome of Pi-Man, the key lies in the differentiation between Deficiency (Xu) and Excess (Shi). Pi caused by pathogenic factors or stagnation is Excess Pi; Pi without substantial pathological products or stagnation is Deficiency Pi. Fullness accompanied by distension and pain is Excess Man; fullness without distension or pain is Deficiency Man. Excess Pi and Excess Man can be treated with dispersing and resolving methods; Deficiency Pi and Deficiency Man must be treated with warming and tonifying methods. Misapplication of other treatments often leads to medical errors.

1. Deficiency-Cold Pi: This condition can occur in individuals who have overthought, overworked, had irregular eating habits, suffered from spleen Qi deficiency after illness, or have inherently weak spleen and stomach. If such individuals mistakenly use cold and purgative medicines, causing severe damage to spleen Qi, they may develop this condition. The symptoms include no distension or oppression, only a lack of hunger and loss of appetite. When asked about chest or abdominal fullness, patients may report a slight sensation of Pi but deny significant distension. This is not true distension but rather self-doubt due to anorexia. The pulse is typically slow and weak, lacking spirit, or string-like with insufficient Stomach Qi. The complexion is pale, and the breath is timid. These signs indicate that spleen deficiency fails to transport, leading to Qi blockage. This syndrome is common. One must not recklessly use draining and consuming herbs simply because the patient refuses food, as this will further damage Stomach Qi and lead to various complications. Treatment should employ warming and tonifying methods. Once Spleen and Kidney Qi are strengthened, Pi and Man will resolve, appetite will return, and Yuan Qi (Original Qi) will recover. Furthermore, Spleen and Stomach deficiency often accompanies Cold syndromes. Why? Because Spleen and Stomach belong to Earth. Earth deficiency often stems from a lack of Fire (Mingmen Fire/Ministerial Fire). When Earth is cold, Qi transformation lacks authority, resulting in Pi and Man; this is known as "Cold generated within." It can also result from invasion by raw/cold foods or external Cold, causing Middle Jiao Cold. However, if Stomach Qi is strong, Cold cannot invade; conversely, Cold prevails when it wins out, which ultimately boils down to Spleen Qi weakness. This principle is detailed in the *Treatise on Mingmen Fire Heat*, which should be consulted. For mild Spleen and Stomach deficiency, where there is a sensation of fullness without actual distension, reduced intake, and indigestion, Si Jun Zi Tang (Four Gentlemen Decoction) or Yi Gong San (Yi Gong Powder) are appropriate. For Heart-Spleen Qi deficiency or stagnant Qi, Gui Pi Tang (Restore the Spleen Decoction) or Zhi Zhong Tang (Regulate the Middle Decoction) are suitable. For deficiency of Qi and Blood in all three Yin meridians, with impaired regulatory function and unsuitability for warming, Wu Fu Yin (Five Blessings Drink) is indicated. For Middle Jiao cold, belching of rotten food, acid regurgitation, and Pi-Man requiring warming and tonification, Wen Wei Yin (Warm the Stomach Drink), Wu Jun Zi Jian (Five Gentlemen Decoction), Li Zhong Tang (Regulate the Middle Decoction), Sheng Zhu Jian (Holy Atractylodes Decoction), or Shen Jiang Yin (Ginseng and Ginger Drink) are appropriate. For combined Spleen-Kidney Cold with Mingmen deficiency failing to warm, leading to Middle Jiao failure to transform, loose stools, preference for warmth and aversion to cold in the chest/abdomen, distension of upper and lower abdomen, and yellow, scanty urine, Li Yin Jian (Nourish Yin Decoction) is indicated; for severe cases, Liu Wei Hui Yang Yin (Six-Ingredient Decoction to Restore Yang) is used. These two formulas are excellent yet rarely known. I once treated a scholar named Jin, whose spleen Qi was damaged by fatigue and overthinking, presenting only with prolonged anorexia. I prescribed a formula containing Ren Shen (Ginseng Root), Bai Zhu (Atractylodes Rhizome), Dang Gui (Angelica Sinensis), Shu Fu Zi (Prepared Aconite Root), Gan Jiang (Dried Ginger), Rou Gui (Cinnamon Bark), and Gan Cao (Licorice Root). He recovered in half a month. Later, he relapsed after illness, believing he would die, but again recovered after increasing Gan Jiang and Shu Fu Zi to 3 qian each. Another woman, suffering from prolonged anorexia post-illness, claimed she ate beef before falling ill and begged me to remove it. I feigned agreement but continued the same tonic treatment, leading to her full recovery. Thus, for such conditions, only warming and tonifying are suitable; moving Qi and resolving stagnation should be avoided. (New Note)

2. Pi-Man caused by accidental dietary injury should be treated based on the presence or absence of food stagnation. If Pi-Man arises from un-digested food, possibly with pain, Da He Zhong Yin (Great Harmonize the Middle Drink) or He Wei Yin (Harmonize the Stomach Drink) with modifications are indicated; Zhi Zhu Wan (Immature Bitter Orange and Atractylodes Pill) is also suitable; for severe cases, Shen Xiang San (Divine Fragrance Powder) is used. Clinical notes on this are found in the Distension chapter. If food stagnation has resolved but Spleen Qi is injured and unable to circulate, leading to Deficiency Pi, one should focus on supporting Spleen Qi. For mild cases, Yi Gong San or Yang Zhong Jian (Nourish the Center Decoction); for severe cases, Wu Fu Yin, Wen Wei Yin, or Sheng Zhu Jian. If Mingmother Qi (Kidney Essence/Qi) is insufficient, treat as previously described. If Cold damages the Stomach due to accidental ingestion of cold substances, causing Pi-Man that cannot be tonified, add Shan Zha (Hawthorn Fruit) and Mai Ya (Sprouted Barley Seed) to He Wei Yin, or use Hou Po Wen Zhong Tang (Magnolia Bark to Warm the Middle Decoction).

3. Excess Stagnation Pi should be treated according to its cause. If dampness predominates causing Qi stagnation and Pi, Ping Wei San (Peace the Stomach Powder) or Hou Po Tang (Magnolia Bark Decoction) from *Liang Fang*, or Wu Ling San (Five Ingredient Powder with Poria) are indicated. If Cold stagnates the Spleen and Stomach, causing pain or Pi, without Middle Qi deficiency, Hou Po Wen Zhong Tang is used. If Spleen Cold and Qi stagnation cause Pi, He Wei Yin is indicated. If sudden anger injures the Liver, causing unresolved Liver Qi stagnation and Pi, Jie Gan Jian (Resolve the Liver Decoction) is used. If Qi constipation causes blockage and Pi, He Jian's Hou Po Tang is indicated. If Phlegm stagnates at the Stomach entrance causing Pi, Er Chen Tang (Two-Chen Decoction) or Ju Pi Ban Xia Tang (Tangerine Peel and Pinellia Decoction) are used. If Stomach Cold, Qi stagnation, and retained Phlegm cause Pi with vomiting, Jia Jian Er Chen Tang (Modified Two-Chen Decoction) is indicated. If sticky Phlegm blocks the Stomach entrance and resists medication, emesis must be induced first, followed by syndrome-specific treatment. If fecal impaction causes Pi-Man, mild purgation is appropriate.

4. Pi caused by External Pathogens: When Cold pathogens invade, they move from the exterior to the interior. If the pathogen is shallow in the channels and has not entered the fu organs, diet remains normal. If slightly deeper, it enters the chest and gradually invades the Stomach entrance, causing inability to eat; this is also a form of Pi. Treatment involves resolving the external pathogen through dispersing, resolving, warming, or tonifying as needed. Once the pathogen is eliminated, the Stomach harmonizes, and Pi-Man resolves. Refer to the Shang Han (Cold Damage) chapter for methods. Additionally, Shang Han scholars state: premature purgation in Yang syndromes leads to Jie Xiong (Chest Binding); premature purgation in Yin syndromes leads to Pi Qi (Pi Syndrome). This occurs because treating the interior while the pathogen is in the exterior, or attacking Yin while the pathogen is in Yang, constitutes inappropriate purgation. This allows the pathogen to sink into the deficiency and knot at the epigastrium, representing the most dangerous harm of misdiagnosis. Excess presents as hard, full, and painful Jie Xiong; Deficiency presents as full but painless Pi Qi. Careful differentiation and treatment are required. See the section on Jie Xiong and Abdominal Fullness for detailed methods.