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The epigastrium (upper abdomen) is full, hard, and painful; this is an excess syndrome called Jie Xiong (Chest Binding). The epigastrium is full and hard but not painful; this is a deficiency syndrome called Pi Qi (Stagnant Gas/Epigastric Fullness). It is neither full nor hard, but only feels vexatious and stifled; this is called Zhi Jie (Branch Binding). *Baoming Ji* states: If the Spleen cannot transport Qi to the four viscera, and Qi condenses without dispersing, it forms Pi Zheng (Pi Syndrome). Generally, all types of Pi are caused by Heat pathogens. Therefore, medicines for treating Pi are all cold-natured agents. In one instance, Fu Zi (Prepared Aconite Root) is added; this uses acrid-hot herbs to assist cold-cool herbs, aiming to open up the stagnation and constraint of Pi, not to attack Cold.

After initial sweating or mistaken purgation, Yang Qi becomes deficient, leading to aversion to cold and sweating. The Taiyang chapter states: "Aversion to cold after sweating indicates deficiency." Adding Fu Zi here is to prevent Da Huang (Rhubarb Rhizome) and Huang Lian (Coptis Rhizome) from damaging Yang Qi, not to tonify deficiency.

Pi Hardness: In Shanghan (Cold Damage), if there is vomiting and fever, Chai Hu patterns are present. If mistakenly treated with purgatives, resulting in epigastric fullness without pain, this is Pi, suitable for Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Epigastrium). (See discussion on differences between Jie Xiong and Pi).

Ban Xia Xie Xin Tang Formula:
Ban Xia (Pinellia Tuber, half sheng, washed), Huang Qin (Scutellaria Root), Gan Jiang (Dried Ginger), Ren Shen (Ginseng Root), Gan Cao (Licorice Root, roasted, 3 liang each above), Huang Lian (Coptis Rhizome, 1 liang), Da Zao (Jujube Fruit, 12 pieces, split). Seven ingredients, boil in 10 sheng water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily. (If Gan Cao is increased, it becomes Gan Cao Xie Xin Tang, treating Pi hardness with vomiting and diarrhea; if Sheng Jiang is added, it becomes Sheng Jiang Xie Xin Tang, treating Pi hardness with belching.) Acrid flavors enter the Lung and disperse Qi; the acridity of Ban Xia disperses condensed Qi. Bitter flavors enter the Heart and drain Heat; the bitterness of Huang Qin and Huang Lian enters the Heart to clear Pi Heat. The Spleen desires relaxation; when tense, sweet foods relax it. The sweetness of Ren Shen, Gan Cao, and Da Zao relaxes the Spleen.

Pi Hardness with Diarrhea:
After Shanghan sweating resolves the exterior, if the Stomach is disharmonious, the epigastrium is hard and full, accompanied by dry belching with food odor, fluid retention under the ribs, borborygmus (rumbling in the abdomen), and diarrhea, treat with Sheng Jiang Xie Xin Tang. (Cheng Wuji notes: The Stomach is the master of fluids and the root of Yang Qi. After profuse sweating, body fluids are lost externally, leaving the Stomach empty. Hostile Qi rebels upward, causing epigastric hardness. *Jin Gui Yao Lue* states: Disharmony of Middle Jiao Qi fails to digest grain, causing belching. Dry belching with food odor indicates Stomach deficiency failing to "kill" (digest) grain. Fluid retention under ribs and borborygmus indicate weak Earth failing to control Water. Give Xie Xin Tang to drain Pi, add Sheng Jiang to benefit the Stomach.)

Sheng Jiang Xie Xin Tang Formula:
Sheng Jiang (Fresh Ginger, 4 liang, sliced), Ban Xia (Pinellia Tuber, half sheng, washed), Gan Cao (Licorice Root, roasted), Ren Shen (Ginseng Root), Huang Qin (Scutellaria Root, 3 liang each), Huang Lian (Coptis Rhizome, 2 liang), Gan Jiang (Dried Ginger, 1 liang), Da Zao (Jujube Fruit, 12 pieces, split). Eight ingredients, boil in 10 dou water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.

In Shanghan or Zhong Feng, if the physician mistakenly uses purgatives, the patient suffers diarrhea dozens of times daily with undigested food, borborygmus, epigastric hardness and fullness, dry retching, vexation, and inability to rest. Seeing epigastric Pi, the physician assumes residual pathogen and purges again, worsening the Pi. This is not accumulated Heat, but Stomach deficiency with hostile Qi rebelling upward, causing constipation/hard stool. Treat with Gan Cao Xie Xin Tang. (Cheng Wuji notes: Shanghan and Zhong Feng refer to Cold Damage or Wind Strike. Pathogen is at the exterior; mistaken purgation weakens intestines and Stomach, causing Qi to sink inward. Diarrhea with undigested food and borborygmus indicates interior deficiency and weak Stomach post-purgation. Epigastric hardness, dry retching, and vexation indicate empty Stomach with hostile Qi rebelling. Give Xie Xin Tang to drain Pi, add Gan Cao to tonify deficiency. Previous case involved exterior injury to Yang Qi from sweating, hence adding Sheng Jiang; this case involves interior damage to Yin Qi from purgation, hence adding Gan Cao.)

Gan Cao Xie Xin Tang Formula:
Gan Cao (Licorice Root, 4 liang), Huang Qin (Scutellaria Root), Gan Jiang (Dried Ginger, 3 liang each), Ban Xia (Pinellia Tuber, washed in boiling water, half sheng), Huang Lian (Coptis Rhizome), Da Zao (Jujube Fruit, 12 pieces, split). Six ingredients, boil in 10 dou water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily.

Cheng Wuji notes: Condensed Qi that does not disperse and obstructs flow is Jie Xiong; Xian Xiong Tang is a direct agent. Blocked and unsmooth is Pi; Xie Xin Tang is a resolving agent. "Draining the Heart" means draining pathogenic factors from the epigastrium. Pi and Jie Xiong differ in location. Pathogen binding in the chest is Xian Xiong Tang; pathogen lingering in the epigastrium is Xie Xin Tang. *Nei Jing* states: Bitter flavor enters the Heart first; use bitter to drain. Draining the Heart requires bitter as chief, so Huang Lian is Sovereign, Huang Qin is Minister, to descend Yang and ascend Yin. *Nei Jing* states: Acrid flavor moves Qi; use acrid to disperse. Dispersing Pi requires acrid as chief, so Ban Xia and Gan Jiang are Assistants, to divide Yin and move Yang. When Yin and Yang do not intersect, it is Pi; when upper and lower do not connect, it is Man (Fullness). To connect upper and lower, Yin and Yang must harmonize. The "Middle" refers to the Spleen and Stomach. For Spleen insufficiency, use sweet to tonify; thus Ren Shen, Gan Cao, and Da Zao are Envoys to tonify Spleen and harmonize Middle. When Middle Qi harmonizes, upper and lower connect, Yin and Yang separate, Water ascends and Fire descends, Pi dissipates, Heat clears, and profuse sweating resolves.

Pi Softness:
Pulse is floating and tight; mistaken purgation causes the tight pulse to enter the interior, forming Pi. Palpation reveals softness, indicating merely Qi Pi. ("Soft" opposes "Hard"; Pi might be a typo for Jie Xiong). Epigastric Pi, soft on palpation, with floating pulse at Guan position: Treat with Da Huang Huang Lian Xie Xin Tang. (Jie Xiong refers to chest; Pi refers to epigastrium. Jie Xiong is stone-hard on palpation; Pi is soft. Jie Xiong has floating Chi and deep Guan pulses; Pi mentions only floating Guan pulse, distinguishing the two. *Huoren Shu* states: Both Jie Xiong and Pi should have deep Guan pulses. If Guan is floating and knotted, San Huang drains Liver.)

Da Huang Huang Lian Xie Xin Tang:
Da Huang (Rhubarb Rhizome, 2 liang), Huang Lian (Coptis Rhizome, 1 liang). Two ingredients, steep in 2 sheng boiling water for a moment, squeeze out dregs, take warm in two doses. (*Nei Jing*: Fire-Heat pathogen generates Heart disease. Bitter enters Heart, Cold removes Heat. The bitter-cold of Da Huang and Huang Lian guides out deficient Heat in the epigastrium. Steeping in boiling water extracts thin Qi to drain deficient Heat.)

Epigastric Pi with aversion to cold and sweating: Treat with Fu Zi Xie Xin Tang. (Add Fu Zi due to aversion to cold and sweating to warm meridians and secure Yang.)

Fu Zi Xie Xin Tang Formula:
Da Huang (Rhubarb Rhizome), Huang Lian (Coptis Rhizome), Huang Qin (Scutellaria Root, 1 liang each), Fu Zi (Prepared Aconite Root, 1 piece, processed, skin and umbilicus removed, broken, decocted separately for juice). Chop herbs, steep in 2 sheng hot water for one hour, squeeze out dregs, mix with Fu Zi juice, take warm in two doses.

After severe purgation and subsequent sweating in Shanghan, if epigastric Pi and aversion to cold persist, the exterior is unresolved. Do not attack Pi; resolve exterior first. Resolve exterior with Gui Zhi Tang (Cinnamon Twig Decoction); attack Pi with Da Huang Huang Lian Xie Xin Tang. (*Huoren Shu*: Generally, Jie Xiong and Pi require purgation, but not if exterior is unresolved. If exterior unresolved with epigastric oppression, it is Zhi Jie, treat with Chai Hu Gui Zhi Tang. Chest/flank fullness with slight knotting: Xiao Chai Hu Tang plus Gan Jiang and Mu Li. Originally caused by mistaken purgation leading to Pi; if Xie Xin Tang fails, and patient has thirst, dry mouth, vexation, and scanty urine, use Wu Ling San (Poria Pill). Cheng Wuji notes: Post-purgation Pi should be treated with Xie Xin Tang. If ineffective, and symptoms include thirst, dry mouth, vexation, and urinary difficulty, it is internal fluid retention blocking Jin Ye, not Heat Pi. Use Wu Ling San to induce sweating and dissipate water. Alternatively, abstain from drinking for a day; external water does not enter, retained water moves, Pi resolves.)

Pi Hardness with Vomiting and Diarrhea:
Shanghan fever, sweating without resolution, epigastric hardness, vomiting, and diarrhea: Treat with Da Chai Hu Tang. Epigastric hardness, retching, diarrhea, if exterior resolved and body cool with flank pain: Treat with Shi Zao Tang. (*Huoren Shu*: Shi Zao Tang and Da Chai Hu Tang both treat epigastric Pi. Shi Zao Tang is difficult to use; indicated only when exterior signs cease, no aversion to cold, body cool, sweating, paroxysmal headache, epigastric fullness radiating to flanks, dry retching, shortness of breath. Contraindicated if exterior unresolved.)

Diarrhea with Unresolved Exterior and Interior:
Taiyang exterior signs persist despite multiple purgations, leading to heat-carrying diarrhea, continuous diarrhea, epigastric hardness, and unresolved exterior-interior: Treat with Gui Zhi Ren Shen Tang. (Cheng Wuji notes: Multiple purgations while exterior persists severely weaken interior, allowing heat pathogen to enter, causing deficiency-with-heat diarrhea and Pi. If exterior resolved with Pi and diarrhea, use Xie Xin Tang. If no diarrhea, unresolved exterior with Pi, resolve exterior first then attack Pi. Here, unresolved exterior-interior requires Gui Zhi Ren Shen Tang to harmonize interior and resolve exterior.)

Gui Zhi Ren Shen Tang Formula:
Gui Zhi (Cinnamon Twig, bark removed), Gan Cao (Licorice Root, roasted, 4 liang each), Bai Zhu (Atractylodes Macrocephala Rhizome), Ren Shen (Ginseng Root), Gan Jiang (Dried Ginger, 3 liang each). Five ingredients, boil in 9 sheng water, decoct first four to 5 sheng, add Gui Zhi, decoct to 3 sheng. Take 1 sheng warm, twice daily, once at night. (Acrid disperses unresolved exterior; sweet moderates interior insufficiency. Due to severe interior deficiency and unresolved exterior, Gui Zhi and Gan Cao are added to Li Zhong Tang.)

Zhang Yuansu asked: Da Chai Hu Tang is purgative; Gui Zhi Ren Shen Tang is tonic. Why both treat diarrhea and epigastric hardness? I reply: This is not interior excess, but premature purgation causing Pi, interior deficiency with heat-carrying diarrhea. Cheng Wuji notes: If exterior resolved with Pi and diarrhea, it is interior excess, use Xie Xin Tang. If no diarrhea, unresolved exterior with Pi, resolve exterior first. Here, unresolved exterior-interior requires Gui Zhi Ren Shen Tang. Fever and sweating without resolution, epigastric hardness, vomiting, diarrhea: Exterior is harmonized, interior is diseased. Epigastric hardness indicates excess, requiring Da Chai Hu Tang. Though both present epigastric hardness, one is excess, one deficiency; thus treatments differ (purgation vs. tonification).

Pi Hardness with Belching:
After Shanghan sweating, vomiting, or purgation resolves, if epigastric hardness and persistent belching remain: Treat with Xuan Fu Dai Zhe Shi Tang. (Belching is common belching. *Huoren Shu*: If coughing, rebellious Qi, or deficiency, take Si Ni Tang first; if Stomach Cold, take Li Zhong Wan first, then Xuan Fu Dai Zhe Shi Tang.)

Xuan Fu Dai Zhe Shi Tang Formula:
Xuan Fu Hua (Inula Flower), Gan Cao (Licorice Root, roasted, 3 liang each), Ren Shen (Ginseng Root, 2 liang), Dai Zhe Shi (Hematite, 1 liang), Sheng Jiang (Fresh Ginger, sliced, 5 liang), Ban Xia (Pinellia Tuber, washed in boiling water, half sheng), Da Zao (Jujube Fruit, 12 pieces, split). Seven ingredients, boil in 10 dou water to 6 sheng, remove dregs, decoct again to 3 sheng. Take 1 sheng warm, three times daily. (Hardness implies firm Qi; salty flavor softens. Xuan Fu Hua's saltiness softens Pi hardness. Deficiency implies floating Qi; heavy agents anchor. Dai Zhe Shi's heaviness anchors rebellious Qi. Acrid disperses; Sheng Jiang and Ban Xia's acridity disperses deficient Pi. Sweet moderates; Ren Shen, Gan Cao, and Da Zao's sweetness tonifies weak Stomach.)

Post-illness epigastric hardness and belching without diarrhea: Xuan Fu Dai Zhe Shi Tang. With diarrhea: Sheng Jiang Xie Xin Tang.

Pi Hardness with Qi Rushing Upward:
Chest Pi hardness, Qi rushing to throat, inability to breathe: Gua Di San (Melon Seed Powder). Epigastric hardness, flank pain, Qi rushing to throat, vertigo: Wei pattern. (*Huoren Shu*: Diarrhea with Pi, if Sheng Jiang Xie Xin Tang and Gan Cao Xie Xin Tang fail, treat Lower Jiao with Chi Shi Zhi Yu Liang Tang. These Xie Xin Tangs treat Middle Jiao; this diarrhea is Lower Jiao. Treating only Middle worsens diarrhea. If Chi Shi Zhi Yu Liang Tang fails, promote urination with Wu Ling San. Also: If Pi unresponsive to Xie Xin Tang, use Xian Xiong Wan (not Xian Xiong Tang, which is too strong).)

Fever, aversion to cold, body ache, unresolved exterior, with branch-binding oppression in epigastrium: Chai Hu Gui Zhi Tang. Epigastric fullness resembling Pi with cold limbs, intermittent knotted/tight pulse, vexation, hunger but no desire to eat: Gua Di San. Fine, deep pulse, head sweating, aversion to cold, hard stool: Xiao Chai Hu Tang.

Taiyang disease, after sweating and purgation, leads to fever, aversion to cold, epigastric Pi, simultaneous exterior-interior deficiency, exhaustion of Yin and Yang. Without Yang, Yin stands alone. Adding moxibustion causes chest vexation, bluish-yellow complexion, muscle twitching: Difficult to treat. Mild yellow complexion and warm hands/feet: Easy to cure.

Floating and large pulse, epigastric hardness contrary to expectation, presence of Heat: If belonging to Zang, purge, do not sweat. If belonging to Fu, do not cause frequent urination. Frequent urination hardens stool; excessive sweating increases Heat; scanty sweating causes difficulty defecating. If pulse is slow, purgation is not yet appropriate. Yangming Pi with full Stomach and epigastric hardness/fullness: Do not purge.

Appendix: Jie Geng Zhi Ke Tang treats Shanghan Pi with chest fullness nearing death.
Zhi Ke (Bitter Orange, bran-fried, pith removed), Jie Geng (Platycodon Root, 2 liang each). Chop, boil in 2 cups water to 1 cup, remove dregs, take in two doses.

Li Dongyuan says: Shanghan originally has no Pi; should sweat, but mistaken purgation causes Pi. Zhi Shi Li Zhong Wan is best. Confirming Pi, use Jie Geng Zhi Ke Tang first to move Qi downward through diaphragm; always effective.

Zhao Sizhen says: *Huoren Shu* Q76 states: If Pi unresponsive to Xie Xin Tang, use Xian Xiong Tang. I examine Zhang Zhongjing's texts; Xian Xiong Tang has no example for Pi, likely too strong. Chest and epigastrium differ; pain vs. non-pain differs in Yin/Yang pathology. Excluding Jie Xiong, classify Pi into transmitted pathogen and sinking pathogen. 1. Originating in Yin, no fever, mistaken purgation sinks pathogen inward, Guan pulse deep (Yin sinking): First Jie Geng Zhi Ke Tang, then Ban Xia Xie Xin Tang variants. If thirsty, dry mouth, vexation, scanty urine after Xie Xin Tang: Wu Ling San. 2. Fever, pathogen transmits inward without purgation, Guan pulse floating (Yang entering): Resolve exterior first if no aversion to cold, use San Huang Xie Xin Tang. If Pi with sweating and aversion to cold, Yang pathogen enters with exterior Zheng Qi, causing exterior deficiency sweating/aversion: Add Fu Zi to secure exterior. Since Jie Xiong has Cold/Excess and Heat/Excess, Pi also has Yin/Yang distinctions. External Pi hardness may be warmed by Gui Zhi Ren Shen Tang or purged by Da Chai Hu Tang/Shi Zao Tang. *Huoren Shu* claims floating Guan indicates Heat knotting, San Huang drains Liver. But Heat knotting forms Jie Xiong, not Pi. Epigastrium is Middle Jiao, Guan pulse governs Middle. Hence "Xie Xin" (Drain Heart/Epigastrium), not "Drain Liver" based on left Guan Liver association.

Zhang Yuansu says: Some argue Pi with mixed symptoms and epigastric hardness is unsuitable for Ban Xia Xie Xin Tang. I reply: Patterns differ, treatment follows. All aforementioned PIs involve mixed symptoms, not just premature purgation. Zhang Zhongjing treats according to suitability. Premature purgation Pi, full but painless, no other exterior signs: Ban Xia Xie Xin Tang is appropriate to drain Pi.

Wu Kun says: Pi is Qi stagnation and lack of smoothness. If not from premature purgation, it may be Phlegm, Food, or Qi knotting. *Baoming Ji* states: Treat Pi with Xie Xin formulas, distinguishing Cold/Heat. Heat-excess Pi: Da Huang Huang Lian Xie Xin Tang. Cold-excess/Heat-deficient: Ban Xia Xie Xin Tang variants. Ultimately, "Xie Xin" does not drain Heart Fire Heat, but drains epigastric Pi fullness.