Case Background

The patient was an adult practitioner of Traditional Chinese Medicine who sought treatment for functional dyspepsia characterized by recurrent epigastric obstruction, chest oppression, and stress-related digestive distress. To protect privacy, specific age, workplace, and identifying information have been omitted. The condition persisted for approximately one year before stable improvement was achieved after adjustment of the herbal prescription. Although the primary pathomechanism centered on digestive dysfunction and rebellious stomach qi, the case also involved prominent emotional triggers and psychosomatic manifestations.

The patient’s chief complaints included recurrent obstruction and blockage sensations in the epigastrium and below the heart, upward surging qi, palpitations, chest oppression in the shanzhong region, nausea, belching, abdominal distension, cold hands and feet, and a terrifying inability to breathe deeply after eating. During severe attacks, the patient felt as if respiration or circulation might suddenly fail.

History of Present Illness

The illness began after a major emotional shock. Prior to this event, the patient had not experienced recurrent attacks involving the epigastrium and chest in this pattern. After the emotional event, she began intermittently experiencing a sensation of blockage in the epigastric region, described as “stuck below the heart” or “blocked in the middle.” This was followed by a sensation of qi surging upward.

As the attacks intensified, the patient developed palpitations, cold extremities, chest oppression in the shanzhong region, nausea, belching, and difficulty breathing. The severity became so intense that she feared imminent death, inadequate cardiac circulation, or impending respiratory collapse. This was one of the reasons she sought biomedical evaluation to exclude serious cardiopulmonary disease.

The discomfort was especially aggravated after eating to fullness. Over time, the patient became afraid of eating large dinners because attacks frequently followed evening meals. Since postprandial fullness and epigastric pressure are core features of functional dyspepsia, this meal-related aggravation supported the clinical judgment that dysfunction of the middle burner and failure of stomach qi to descend were central mechanisms in the case (Kim et al., 2023).

Biomedical cardiopulmonary evaluations did not reveal a structural cause. Gastroscopy demonstrated excessive gastric acid and laxity of the cardia. These findings provided a partial modern correlate for rebellious qi and discomfort, but they did not fully explain the emotional triggers, paroxysmal upward surging sensations, or overwhelming feeling of impending death.

Before consulting the treating physician, the patient had already self-prescribed a modified Banxia Xiexin Tang–based formula. However, she had added tonic herbs in the earlier versions. Clinically, this was considered inappropriate at that stage of the illness. The primary issue was not simple deficiency. More urgently, the middle burner was obstructed, the pivot mechanism was impaired, and stomach qi was failing to descend. In this context, adding tonifying substances may further burden already constrained qi dynamics, worsening fullness, pressure, and discomfort.

The final treatment strategy removed the prematurely tonifying emphasis and instead adopted a more focused modification centered on Banxia Xiexin Tang and Banxia Houpo Tang. In other words, the issue was not merely identifying the correct formula family, but determining the correct proportions, priorities, and therapeutic direction.

After using the adjusted prescription for a period of time, the attacks ceased to recur. Approximately six months later, another emotional disturbance triggered a relapse. The patient restarted the formula but independently reduced one of the key middle-jiao-opening and qi-descending ingredients. The second treatment course still produced substantial improvement, but the effect was incomplete and residual symptoms persisted. Once the patient was instructed to return to the physician’s original proportions, the remaining symptoms resolved. At the time of writing, no relapse had been reported for approximately one year.

Review of Systems

Digestive symptoms included epigastric obstruction, postprandial aggravation, rebellious qi, belching, nausea, abdominal distension with excessive gas, worsening after fullness—especially dinner—and a yellow tongue coating.

Chest and respiratory symptoms included oppression in the shanzhong region, inability of the chest to fully expand, an urge to force deep breathing during attacks, and a sensation that qi was trapped and unable to descend.

Emotional symptoms included intense fear during attacks, with the onset closely associated with a prior severe emotional shock and later relapse similarly triggered by another emotional event.

Cardiovascular and autonomic symptoms included palpitations and cold hands and feet during episodes. Symptoms were severe enough to prompt cardiopulmonary assessment, though no major structural abnormalities were identified.

Tongue, Pulse, and Physical Examination

The tongue was enlarged and mildly swollen with teeth marks along the edges. The coating was yellow and greasy. A depressed area was visible at the tongue tip, and several fissures were present in the middle burner region of the tongue.

The pulse was described as follows: the cun position was deep and at times thin; the guan position was slippery. The patient also reported a palpable knot or obstructed sensation at the jiuwei region.

Taken together, these findings did not indicate a simple deficiency-cold pattern. The yellow greasy coating and slippery guan pulse pointed toward phlegm turbidity and disharmony in the middle burner. The swollen tongue with teeth marks suggested underlying weakness of transformation and transportation. The deep thin cun pulse, together with the near-cardiopulmonary nature of the attacks, reflected disturbance rising upward into the chest and heart region.

Pattern Identification

The primary pattern was disharmony of the middle burner, impaired pivot function, rebellious stomach qi, and pi fullness below the heart.

Associated mechanisms included qi stagnation obstructing the chest and diaphragm, phlegm and qi binding along the chest-throat axis resembling globus disorder (mei he qi), failure of stomach qi to descend after eating, and dramatic paroxysmal upward surging resembling running piglet qi (ben tun qi).

This case should be understood as layered rather than singular. To reduce it merely to “anxiety” would overlook essential dimensions. To reduce it only to rebellious stomach qi would underestimate the emotional trigger and dramatic upward surging quality. To label it solely as ben tun would also be overly narrow, because the dominant pivot disorder was not purely located in the lower burner nor based simply in kidney cold.

The clinical value of the case lies in understanding how multiple classical categories overlap while a single core mechanism remains central throughout: the middle burner lost its ability to open, close, harmonize, and direct qi downward.

Pathomechanism Analysis

The pathomechanism may be understood through four interconnected layers.

First, the most direct and clinically practical layer is disharmony of the middle burner. The Nan Jing locates the middle burner in the stomach region and associates it with the transformation of food and fluids, supporting its understanding as the functional pivot for digestion, fluid metabolism, and qi movement (Nan Jing, 1999). In this case, once the middle burner lost its capacity for orderly opening and movement, the ascending and descending dynamics became disordered. Stomach qi failed to descend and instead surged upward, producing epigastric fullness, gastric pressure, chest oppression, and distressing shortness of breath.

Second, the case clearly belonged to the category of pi fullness. In the classical tradition, pi does not refer to a fixed mass, but rather a sense of blockage, fullness, or focal obstruction below the heart arising from dysregulated ascending and descending dynamics, often involving complex interactions of cold, heat, and rebellious qi. In the Jin Gui Yao Lue, the passages most relevant to this case identify Banxia Xiexin Tang as a principal treatment for pi fullness below the heart (Zhang, ca. 220/2013; Zhang, ca. 220/2020). Although the patient did not exhibit every textbook manifestation, the essential structure was similar: middle burner disharmony, focal fullness below the heart, and upward rebellious qi.

Third, the case partially overlapped with the category of mei he qi. The Jin Gui Yao Lue describes Banxia Houpo Tang for the sensation of obstruction in the throat, a disorder later interpreted as binding of qi and phlegm following emotional dysregulation (Zhang, ca. 220/2013; Zhang, ca. 220/2020). In modern medicine, Lee and Kim (2012) describe globus pharyngeus as a persistent or intermittent, painless sensation of a lump or foreign body in the throat. In this patient, however, the obstruction was felt lower, along the epigastric and thoracic axis rather than fixed in the throat. Nevertheless, the mechanism was similar: emotional injury caused qi dynamics to bind and lose their capacity for smooth movement; the chest could not comfortably expand; breathing felt restricted; and the obstruction was functional rather than structural. Thus, mei he qi was not the complete diagnosis but remained an important secondary interpretive layer.

Fourth, the attacks exhibited striking similarities to the classical description of ben tun qi. The Jin Gui Yao Lue describes ben tun as a disorder of paroxysmal upward surging qi often precipitated by fear or fright, with severity great enough to create the sensation of impending death (Zhang, ca. 220/2013; Zhang, ca. 220/2020). Strictly speaking, the case did not fully conform to the canonical lower-abdomen-to-throat pathway. The center of obstruction was more strongly localized in the middle burner, especially the epigastrium and below-the-heart region, and was closely associated with eating. Nevertheless, the emotional trigger, sudden upward surging, palpitations, cold extremities, and recurrent near-death sensation made the ben tun comparison clinically meaningful. Liu and Ma (2024) likewise emphasized that upward-surging disorders described in the Jin Gui Yao Lue should be understood through pattern differentiation and formula correspondence rather than rigid disease labels.

In other words, this was neither a pure lower-burner ben tun disorder, nor merely mei he qi, nor an ordinary functional dyspepsia case. It was a composite disorder in which the middle burner lost its pivot role, qi became constrained below the heart, and emotionally triggered surging episodes dramatically rose upward. The chest discomfort and near-death sensation represented the experiential peak of the attacks, but the functional root remained centered in the middle burner.