The epigastric region (upper abdomen) is full, hard, and painful; this is an excess syndrome, known as Jie Xiong (Chest Binding). The epigastric region is full and hard but not painful; this is a deficiency syndrome, known as Pi Qi (Stagnant Qi/Epigastric Fullness). It is neither full nor hard, but only feels vexatious and stifled; this is called Zhi Jie (Branch Binding). *Baoming Ji* states: When the Spleen cannot transport Qi to the four viscera, and Qi knots and does not disperse, Pi (epigastric fullness) forms. Generally, all types of Pi are caused by Heat. Therefore, medicines for treating Pi are mostly cold in nature. In one formula where Fuzi (Prepared Aconite Root) is added, it uses acrid-hot herbs to assist the cold-heat herbs, aiming to open up the stagnation and obstruction of Pi, not to attack Cold. This is because after initial sweating or purging, Yang Qi becomes deficient, leading to aversion to cold and sweating. The Taiyang chapter states: "Aversion to cold after sweating indicates deficiency." Adding Fuzi here is to prevent Dahuang (Rhubarb Rhizome) and Huanglian (Coptis Rhizome) from damaging Yang Qi, not to tonify deficiency.

Pi Hardness
In Shanghan (Cold Damage), vomiting with fever indicates that the Chaihu Tang (Bupleurum Decoction) pattern is present. If other medicines are mistakenly used to purge, and the epigastric region becomes full but not painful, this is Pi. Banxia Xiexin Tang (Pinellia Decoction to Drain the Epigastrium) is appropriate. (See discussion on differences between Jie Xiong and Pi).
Banxia Xiexin Tang Formula (This formula's ingredients likely originate from Lizhong Renshen Huangqin Tang).
Banxia (Pinellia Tuber, half sheng, washed) Huangqin (Scutellaria Root) Ganjiang (Dried Ginger) Renshen (Ginseng Root) Gancao (Licorice Root, roasted, each three liang) Huanglian (Coptis Rhizome, one liang) Dazao (Jujube Fruit, twelve pieces, split) These seven ingredients are boiled in ten dou of water to obtain six sheng. Strain, then boil again to obtain three sheng. Take one sheng warm, three times daily. (If Gancao is increased, it becomes Gancao Xiexin Tang, treating Pi hardness with vomiting and diarrhea; if Shengjiang is increased, it becomes Shengjiang Xiexin Tang, treating Pi hardness with belching. Acrid flavors enter the Lung and move Qi; Banxia's acridity disperses knotted Qi. Bitter flavors enter the Heart and drain Heat; Huangqin and Huanglian's bitterness enters the Heart to clear Pi Heat. The Spleen desires relaxation; sweet foods can soothe it. Renshen, Gancao, and Dazao's sweetness soothes the Spleen.)

Pi Hardness with Diarrhea
After sweating resolves the exterior in Shanghan, if the Stomach is disharmonious, the epigastric region is hard and full, there is dry belching with food odor, fluid accumulation under the ribs, borborygmus (rumbling in the abdomen), and diarrhea, Shengjiang Xiexin Tang (Fresh Ginger Decoction to Drain the Epigastrium) is the primary treatment. (Cheng Wuji notes: The Stomach is the master of body fluids and the root of Yang Qi. After profuse sweating, exterior body fluids are lost, leaving the Stomach empty. Pathogenic Qi rebels upward, causing epigastric hardness. *Jingui Yaolue* states: Disharmony of Middle Jiao Qi prevents digestion, causing belching. Dry belching with food odor occurs because the Stomach is deficient and cannot digest food. Fluid under the ribs and borborygmus indicate Earth weakness failing to control Water. Provide Xiexin Tang to drain Pi, add Shengjiang to benefit the Stomach.)
Shengjiang Xiexin Tang Formula
Shengjiang (Fresh Ginger, four liang, sliced) Banxia (Pinellia Tuber, half sheng, washed) Gancao (Licorice Root, roasted) Renshen (Ginseng Root) Huangqin (Scutellaria Root, each three liang) Huanglian (Coptis Rhizome, two liang) Ganjiang (Dried Ginger, one liang) Dazao (Jujube Fruit, twelve pieces, split) These eight ingredients are boiled in ten dou of water to obtain six sheng. Strain, then boil again to obtain three sheng. Take one sheng warm, three times daily.

In Shanghan or Zhongfeng (Wind Strike), if the physician incorrectly uses purgatives, the patient suffers diarrhea dozens of times a day with undigested food, borborygmus, epigastric hardness and fullness, dry retching, vexation, and inability to rest. Seeing the epigastric fullness, the physician assumes pathogens remain and purges again, worsening the Pi. This is not accumulated Heat, but rather Stomach deficiency with rebellious pathogenic Qi, leading to hardness. Gancao Xiexin Tang (Licorice Decoction to Drain the Epigastrium) is the primary treatment. (Cheng Wuji notes: Shanghan or Zhongfeng implies pathogens in the Exterior. Incorrect purging weakens the Intestines and Stomach, causing Qi to sink inward. Diarrhea with undigested food and borborygmus indicate interior deficiency and Stomach weakness post-purging. Epigastric hardness, dry retching, and vexation result from an empty Stomach and rebellious pathogenic Qi. Use Xiexin Tang to drain Pi, add Gancao to tonify deficiency. Previously, sweating damaged exterior Yang, so Shengjiang was added; here, purging damages interior Yin, so Gancao is added.)
Gancao Xiexin Tang Formula
Gancao (Licorice Root, four liang) Huangqin (Scutellaria Root) Ganjiang (Dried Ginger, each three liang) Banxia (Pinellia Tuber, washed in decoction, half sheng) Huanglian (Coptis Rhizome) Dazao (Jujube Fruit, twelve pieces, split) These six ingredients are boiled in ten dou of water to obtain six sheng. Strain, then boil again to obtain three sheng. Take one sheng warm, three times daily.

Cheng Wuji notes: Qi knotting and not dispersing, blocking and not flowing, is Jie Xiong (Chest Binding); Xianxiong Tang (Plumulae Scrophulariae Decoction) is a direct agent. Obstruction without flow, blockage without smoothness, is Pi; Xiexin Tang is a resolving agent. "Draining the Heart" refers to draining pathogens in the epigastric region. Pi and Jie Xiong differ in location. Pathogens knotting in the Chest are treated with Xianxiong Tang; pathogens lingering in the epigastrium are treated with Xiexin Tang. *Neijing* states: Bitter flavors enter the Heart first; use bitter to drain. Draining the Heart requires bitter as the main ingredient, hence Huanglian is the Sovereign herb, Huangqin is the Minister herb, to descend Yang and ascend Yin. *Neijing* states: Acrid flavors move Qi; use acrid to disperse. Dispersing Pi requires acrid as the Sovereign, hence Banxia and Ganjiang are Assistant herbs, to separate 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 and harmonize Yin and Yang, one must harmonize the Middle, which refers to the Spleen and Stomach. For Spleen deficiency, use sweet to tonify; hence Renshen, Gancao, and Dazao are Envoy herbs to tonify the Spleen and harmonize the Middle. When Middle Qi is harmonized, Upper and Lower connect, Yin and Yang separate, Water ascends and Fire descends, Pi dissipates, Heat clears, and profuse sweating resolves the condition.

Pi Softness
Pulse floating and tight, followed by incorrect purging, causes the tight pulse to enter the interior, forming Pi. Palpation reveals softness, indicating merely Qi Pi. ("Soft" contrasts with "Hard"; forming Pi might be a mistake for Jie Xiong). Epigastric fullness, soft upon palpation, with a floating pulse at the Guan position, is treated with Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Decoction to Drain the Epigastrium). (Jie Xiong refers to the Chest; Pi refers to the epigastrium. Jie Xiong is rock-hard on palpation; Pi is soft. Jie Xiong has a floating Chi pulse and deep Guan pulse; Pi does not mention Chi but specifies floating Guan pulse, distinguishing the two diseases. *Heren Shu* states: Both Jie Xiong and Pi should have deep Guan pulses. If Guan pulse is floating and knotted, use Sanhuang [Three Yellows] to drain the Liver.)
Dahuang Huanglian Xiexin Tang Formula
Dahuang (Rhubarb Rhizome, two liang) Huanglian (Coptis Rhizome, one liang) These two ingredients are soaked in two sheng of boiling water for a moment, strained, and taken warm in two doses. (*Neijing* states: Fire-Heat pathogens cause Heart disease. Bitter enters the Heart, Cold removes Heat. Dahuang and Huanglian's bitter-cold nature drains deficient Heat in the epigastrium. Soaking in boiling water utilizes their light aroma to drain deficient Heat.)

Epigastric fullness with aversion to cold and sweating is treated with Fuzi Xiexin Tang (Aconite Decoction to Drain the Epigastrium). (Fuzi is added due to aversion to cold and sweating to warm the channels and secure Yang.)
Fuzi Xiexin Tang Formula
Dahuang (Rhubarb Rhizome) Huanglian (Coptis Rhizome) Huangqin (Scutellaria Root, each one liang) Fuzi (Prepared Aconite Root, one piece, processed, skin and umbilicus removed, broken, decocted separately to extract juice) Chop the herbs, soak in two sheng of hot boiling water for about one hour, strain, mix with the Fuzi juice, and take warm in two doses.

After severe purging and subsequent sweating in Shanghan, if there is epigastric fullness and aversion to cold, the Exterior pattern remains unresolved. Do not attack Pi; resolve the Exterior first. Once the Exterior is resolved, attack Pi. Resolve Exterior with Guizhi Tang (Cinnamon Twig Decoction); attack Pi with Dahuang Huanglian Xiexin Tang. (*Heren Shu* states: Generally, Jie Xiong and Pi require purging, but not if Exterior is unresolved. If Exterior is unresolved and epigastric oppression exists, it is not Pi but Zhi Jie (Branch Binding), treated with Chaihu Guizhi Tang. Chest and hypochondriac fullness with slight knotting is treated with Xiao Chaihu Tang plus Ganjiang and Muli.) Originally, purging caused epigastric Pi. Given Xiexin Tang, Pi did not resolve. The patient is thirsty, dry-mouthed, vexed, and has scanty urination. Wuling San (Five-Ingredient Powder with Poria) is the primary treatment. (Cheng Wuji notes: Purging caused Pi, initially treated with Xiexin Tang. If Pi persists with thirst, dry mouth, vexation, and scanty urine, it is internal fluid retention preventing fluid circulation, not Heat Pi. Use Wuling San to induce sweating and dissipate fluid. Another method suggests abstaining from drinking for a day; without external water intake, retained fluid moves, and Pi resolves.)

Pi Hardness with Vomiting and Diarrhea
Shanghan with fever, sweating that does not resolve, epigastric hardness, vomiting, and diarrhea is treated with Da Chaihu Tang (Major Bupleurum Decoction). Epigastric hardness, retching, and diarrhea, if Exterior is resolved and body temperature normalizes with hypochondriac pain, is treated with Shizao Tang (Ten Dates Decoction). (Formulas discussed under Hypochondriac Pain.)
*Heren Shu* states: Both Shizao Tang and Da Chaihu Tang treat epigastric Pi. Shizao Tang is particularly difficult to use. It is indicated only when Exterior symptoms cease, no aversion to cold, body is cool, sweating occurs intermittently, headache is present, epigastric fullness radiates to the hypochondrium, dry retching, and shortness of breath occur. If Exterior is unresolved, strictly avoid using it.

Diarrhea with Unresolved Exterior and Interior
Taiyang disease with unresolved Exterior symptoms subjected to repeated purging leads to heat-carrying diarrhea, unceasing diarrhea, epigastric hardness, and unresolved Exterior and Interior. Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) is the primary treatment. (Cheng Wuji notes: Repeated purging while Exterior remains severely weakens the Interior, allowing pathogenic heat to enter. Deficiency with heat causes unceasing diarrhea and epigastric Pi. If Exterior resolves and diarrhea/Pi persist, treat with Xiexin Tang. If no diarrhea and Exterior unresolved with epigastric Pi, resolve Exterior first, then attack Pi. Since both are unresolved, use Guizhi Renshen Tang to harmonize Interior and resolve Exterior.)
Guizhi Renshen Tang Formula
Guizhi (Cinnamon Twig, bark removed) Gancao (Licorice Root, roasted, each four liang) Baizhu (Atractylodes Rhizome) Renshen (Ginseng Root) Ganjiang (Dried Ginger, each three liang) These five ingredients are boiled in nine sheng of water. First boil the first four ingredients to obtain five sheng, add Guizhi, boil to obtain three sheng. Take one sheng warm, twice daily and once at night. (Acrid disperses unresolved Exterior; Sweet soothes insufficient Interior. Due to severe Interior deficiency and unresolved Exterior, Guizhi and Gancao are added to Lizhong Tang.)

Zhang Yuansu asked: Da Chaihu Tang is purgative; Guizhi Renshen Tang is tonic. Why do both treat diarrhea and epigastric hardness? I reply: This is not Interior Excess, but premature purging causing Pi, Interior deficiency with heat-carrying diarrhea. Cheng Wuji notes: If Exterior resolves and diarrhea/Pi persist, it is Interior Excess, treat with Xiexin Tang. If no diarrhea and Exterior unresolved with Pi, resolve Exterior first, then attack Pi. Here, unresolved Exterior and Interior warrant Guizhi Renshen Tang to harmonize Interior and resolve Exterior. Fever, unresolved sweating, epigastric hardness, vomiting, and diarrhea indicate Harmonized Exterior but diseased Interior. Epigastric hardness indicates Excess, requiring Da Chaihu Tang to purge. Although both present with epigastric hardness, Excess and Deficiency patterns differ, hence different therapeutic approaches (purging vs. tonifying).

Pi Hardness with Belching
After sweating, vomiting, or purging in Shanghan resolves the condition, if epigastric hardness and persistent belching remain, Xuanshu Daizhe Shi Tang (Inula, Hematite, and Oyster Shell Decoction) is the primary treatment. (Belching is colloquially known as eructation. *Heren Shu* states: For Xuanshu Daizhe Shi Tang pattern, if coughing/wheezing and Qi deficiency exist, take Sini Tang first; if Stomach Cold exists, take Lizhong Wan first, then Xuanshu Daizhe Shi Tang.)
Xuanshu Daizhe Shi Tang Formula
Xuanfuhua (Inula Flower) Gancao (Licorice Root, roasted, each three liang) Renshen (Ginseng Root, two liang) Daizheshi (Hematite, one liang) Shengjiang (Fresh Ginger, sliced, five liang) Banxia (Pinellia Tuber, washed in decoction, half sheng) Dazao (Jujube Fruit, twelve pieces, split) These seven ingredients are boiled in ten dou of water to obtain six sheng. Strain, boil again to obtain three sheng. Take one sheng warm, three times daily. (Hardness implies firm Qi; salty flavor softens it. Xuanfuhua's saltiness softens Pi hardness. Deficiency implies floating Qi; heavy agents settle it. Daizheshi's heaviness settles rebellious Qi due to deficiency. Acrid disperses; Shengjiang and Banxia's acridity disperses deficient Pi. Sweet soothes; Renshen, Gancao, and Dazao's sweetness tonifies weak Stomach.)

After illness resolution, if epigastric hardness and belching occur without diarrhea, use Xuanshu Daizhe Shi Tang. If diarrhea occurs, use previous Shengjiang Xiexin Tang.

Pi Hardness with Qi Rushing Upward
Epigastric fullness in the chest, Qi rushing up to the throat, obstructing breathing, is treated with Gouti San (Melon Seed Powder). If epigastric hardness, hypochondriac pain, Qi rushing to throat, dizziness, and vertigo occur, it belongs to Wei (collapse/stagnation) (See discussion on Qi Rushing Upward to Heart).
*Heren Shu* states: For diarrhea with epigastric Pi, if Shengjiang Xiexin Tang and Gancao Xiexin Tang fail to stop diarrhea, treat the Lower Jiao with Chishizhi Yuyuliang Tang (Red Stone and Hematite Decoction). Shengjiang and Gancao Xiexin Tangs treat Middle Jiao; this diarrhea is in Lower Jiao. Treating only Middle Jiao worsens diarrhea. If Chishizhi Yuyuliang Tang fails, promote diuresis with Wuling San. Also states: If Pi does not resolve with Xiexin Tang, Xianxiong Wan (Plumulae Scrophulariae Pill) may be used to purge (Do not use Xianxiong Tang as it is too harsh).

Fever, aversion to cold, body pain, unresolved Exterior, with branch binding in epigastrium causing oppression, is treated with Chaihu Guizhi Tang (See Taiyang Disease). If epigastric fullness resembling Pi with abdominal distension, resolve Exterior with Guizhi Tang first, then use Dahuang Huanglian Xiexin Tang. Epigastric fullness resembling Pi with cold extremities, intermittent knotted/tight pulse, vexation, hunger but no desire to eat, is treated with Gouti San. Fine, deep pulse, head sweating, aversion to cold, hard stool, is treated with Xiao Chaihu Tang (See Jue/Cold Extremities).

Taiyang disease, treated with sweating leading to fever and aversion to cold, then incorrectly purged, causing epigastric Pi. Exterior and Interior are both deficient, Yin and Yang exhausted. Without Yang, Yin stands alone. Adding cauterization causes chest vexation, bluish-yellow complexion, and muscle twitching; this is difficult to treat. If complexion is slightly yellow and hands/feet are warm, it is easy to cure.

Pulse floating and large, epigastric region unexpectedly hard, with Heat. If belonging to Zang (Interior/Organ), purge it; do not induce sweating. If belonging to Fu (Exterior/Channel), do not allow frequent urination. Frequent urination makes stool hard; profuse sweating increases Heat; scanty sweating makes stool difficult. If pulse is slow, purging is not yet appropriate. Yangming Pi with Stomach Excess and epigastric hardness/fullness cannot be purged (See Stomach Excess).

Appendix
Jiegeng Zhike Tang: Treats Shanghan Pi Qi with chest fullness nearing collapse.
Zhike (Bitter Orange Peel, bran-fried, core removed) Jiegeng (Platycodon Root, each two liang) Chop, boil in two cups of water to one cup, strain, divide into two doses.

Li Dongyuan states: Shanghan originally has no Pi; sweating should be induced. Incorrect purging causes Pi. Zhishi Lizhong Wan is excellent. Confirming Pi, use Jiegeng Zhike Tang first, which is even more effective. Jiegeng and Zhike move Qi downward through the diaphragm; using them first yields reliable results.

Zhao Sizhen states: *Heren Shu* Question 76 says: If Pi does not resolve with Xiexin Tang, Xianxiong Tang may be used to purge. I examine Zhang Zhongjing's discussion; Xianxiong Tang has no example for treating Pi, fearing it is too harsh. Moreover, Chest and Epigastrium locations differ; pain vs. non-pain indicates different Yin/Yang pathogens. Excluding Jie Xiong, I classify Pi into two types based on transmitted pathogens and sinking pathogens: 1. Illness originating from Yin, no fever, incorrectly purged, causing Pi. Pulse Guan is deep, indicating Yin pathogen sinking. First use Jiegeng Zhike Tang, then Banxia Xiexin Tang variations. If thirst, dry mouth, vexation, and scanty urine occur post-Xiexin Tang, use Wuling San. 2. Illness with fever, not due to purging, but transmitted pathogen entering Interior causing Pi. Pulse Guan is floating, indicating Yang pathogen following channel into Interior. Must resolve Exterior first if no aversion to cold; use Sanhuang Xiexin Tang. If epigastric Pi with sweating and aversion to cold, Yang pathogen combined with Exterior Zheng Qi enters Interior, causing Exterior deficiency sweating and aversion to cold; add Fuzi to secure Exterior. Since Jie Xiong has Cold-Excess and Heat-Excess distinctions, Pi also has Yin-Yang pathogen distinctions. External Pi with hardness may be warmed with Guizhi Renshen Tang or purged with Da Chaihu Tang/Shizao Tang, following the same principle. *Heren Shu* also states: Floating Guan indicates knotted Heat; Sanhuang drains Liver. Knotted Heat forms Jie Xiong, not Pi. Epigastrium belongs to Middle Jiao; Guan pulse governs Middle. Hence named Xiexin (Draining Heart), how can one cite miscellaneous disease pulse examples assigning Left Guan to Liver and calling it Draining Liver?

Zhang Yuansu states: Some say Pi patterns often mix with other symptoms, and epigastric hardness is not suitable for Banxia Xiexin Tang. I reply: Patterns differ, treatments vary. All aforementioned Pis involve mixed symptoms, not just premature purging. Zhang Zhongjing treats each according to suitability. If Pi results from premature purging, presenting only with fullness without pain and no other exterior symptoms, Banxia Xiexin Tang is appropriate to drain Pi.

Wu Kun states: Pi is stagnant Qi failing to flow smoothly. If not due to premature purging, Pi may result from Phlegm, Food, or Qi knotting. *Baoming Ji* states: Treat Pi primarily with Xiexin formulas, distinguishing Cold and Heat. For Heat-Excess Pi, use Dahuang Huanglian Xiexin Tang type. For Cold-dominant with little Heat, use Banxia Xiexin Tang type. Ultimately, Xiexin does not drain Heart Fire Heat, but drains Pi-fullness in the epigastrium.