论
《内经》曰∶肝病者，两胁下痛引少腹，令人善怒，虚则目KT KT 无所见，耳无所闻，善恐如人将捕之。又曰∶
怒则气逆，甚则呕血及飧泄，故气上矣。盖心生血，肝纳血，因大怒而血不归经，或随气而上出于口鼻，或留于本经而
为胁痛。又或岁木太过而木气自甚，或岁金有余而木气被郁，皆能令人胁痛。经曰∶病胁下满气逆，二、三岁不已，病
名曰息积。是亦肝木有余之证也。外有伤寒发寒热而胁痛者，足少阳胆、足厥阴肝二经病也，治以小柴胡汤，无有不
效者。或有清痰食积，流注胁下而为痛者。或有登高坠仆，死血阻滞而为痛者。又有饮食失节，劳役过度，以致脾土虚
乏，肝木得以乘其土位，而为胃脘当心而痛、上支两胁痛、膈噎不通、食饮不下之证。医者宜于各类推而治之。毋认假
以为真也。
脉法
《脉经》曰∶肝脉搏坚而长，色不青，当病坠堕若搏，因血在胁下，令人喘逆。若软而散（ 、 、濡、软古通用），
其色泽者，当病溢饮。溢饮者，暴渴多饮，而溢入于肌肤肠胃之外也。
《脉经》曰∶肝脉沉之而急，浮之亦然，若胁下痛，有气支满，引少腹而痛，时小便难，苦目眩头痛，腰背痛，足
为逆寒，时癃，妇人月水不来，时无时有，得之少时有所坠堕。
脉双弦者，肝气有余，两胁作痛。
方法
丹溪曰∶胁痛属肝，木气实（因怒气大逆，肝气郁甚，谋虑不决，风中于肝，皆使木气大实，故火盛肝气急也），有
死血（因恶血停留于肝，搏于胁下而作痛，病则咳嗽气急引胁痛），痰流注（因痰积流。注于厥阴之经，亦能使胁下痛，
病则咳嗽气急引胁痛）。
当归龙荟丸 泻肝火大盛之要药，因内有湿热，两胁痛甚，伐肝木之气，肝实宜之。
当归 龙胆草 栀子仁 黄连 黄芩 大黄（酒湿 火煨） 芦荟 青黛（各五钱） 木香（二钱五分） 麝香（五
分，另研）
上为细末，神曲糊丸，如梧桐子大，每服二十丸，生姜汤下。一方，加柴胡五钱，青皮一两，热甚者烘热服。
一方 木气实者，用川芎、苍术、青皮、芍药、柴胡、甘草、龙胆草，各等分，水煎服。
左金丸 泻肝火行湿，为热甚之反佐。
黄连（六钱） 吴茱萸（一钱）
上为细末，汤浸蒸饼为丸，如绿豆大，每服三、五十丸，淡姜汤下。
一方 破血行气，治死血作痛之证。
桃仁（去皮留尖，另研） 红花（酒拌焙干） 川芎 香附（童便浸） 青皮（各等分）
上细切，水煎服。
加味二陈汤 治湿痰流注，胁内作痛。
本方加泡南星、苍术、川芎、姜，水煎服。
肝苦急，急食辛以散之，用抚芎、苍术。或用小柴胡汤，盖本方为胁痛发寒热者必用之要药也。
左胁痛，以柴胡为君，加佐使药川芎、青皮、龙胆草之类。
两胁走痛，或用控涎丹（因清痰流注作痛者可用，盖痰在胁下，非白芥子不能达，方见痰门）。
治咳嗽胁痛者，二陈汤加南星、青皮、香附、青黛、姜汁。一云，四物汤加青皮等药，以疏肝气。
气弱之人，胁下痛，脉细紧或弦，多从劳役怒气得之，八物汤加木香、青皮，或加桂心，水煎服之。
去滞气用青皮，盖青皮乃肝胆二经药，人多怒，胁下有郁积，固宜以解二经之实者。若二经气血不足，先当补血气，
少加青皮可也（此承上条意思言也）。
肥白人气虚，发寒热而胁下痛，用参、 补气，柴胡、黄芩退热，木香、青皮调气。瘦黑人寒热胁痛多怒者，必有
瘀血，宜桃仁、红花、柴胡、青皮、大黄之类行之。
发寒热胁痛，似觉有积块，必是饮食太饱劳力所致，必用龙荟丸治之。
解痛治标药，外用琥珀膏贴之。又方，用芥菜子，水研敷。又方，以吴茱萸醋研，水调敷。又方，以韭菜叶捣细，
炒热贴而以熨斗盛火熨之。
（以上丹溪方法凡十五条）
推气散（局方） 治右胁痛甚，胀满不食。
片姜黄 枳壳（麸炒） 桂心（各五钱） 甘草（炙，三钱）
上为细末，每服二钱，姜汤调下，水煎亦可。
枳芎散（东垣） 治右胁疼痛不可忍。
枳实（麸炒） 川芎（各五钱） 甘草（炙，一钱五分）
上为细末，每服二钱，姜枣汤或酒调下。
异香散（东垣） 治腹胁膨胀，痞闷噎塞，腹胁 痛。
蓬莪术（煨） 益智仁 甘草 京三棱（各一钱） 青皮 陈皮（各五分） 石莲肉（三分） 浓朴（姜制，三分）
上细切，作一服，加生姜三片，大枣一枚，白盐少许，水一盏半，煎至一盏，去渣温服。
分气紫苏饮（河间） 治腹胁疼痛，气促喘急。
五味子 桔梗（去芦） 紫苏叶 桑白皮（蜜炙黄色） 草果仁 陈皮（去白） 大腹皮（酒洗净） 茯苓 甘草
（炙，各五分）
上细切，作一服，加生姜三片，白盐少许，水一大盏，煎至七分，去渣空心温服。
芎葛汤（河间） 治胁下疼痛不可忍者。
桂枝 川芎 细辛 干葛 防风（去芦，各八分） 芍药 枳壳 麻黄 人参 甘草（炙，各四分）
上细切，作一服，加生姜三片，水一盏半，煎至一盏，温服。
（丹溪活套）云∶凡胁痛者，多是肝木有余也，宜用小柴胡加青皮、川芎、芍药、龙胆草，甚者煎成正药，入青黛、
麝香。痰流注者，本方倍半夏，加橘红、南星、苍白术、茯苓、川芎之类。瘀血作痛者，小柴胡合四物汤，加桃仁、红
花或乳香、没药煎服。痛甚而元气壮实者，桃仁承气汤下之而愈。性急多怒之人，时常腹胁作痛者，小紫胡加川芎、芍
药、青皮之类煎服。甚者以煎药送下当归龙荟丸，其效甚速。
（医案）
金氏子，年四十余，因骑马跌扑，次年左胁胀痛。医与小柴胡汤加草龙胆、青皮等药，不效。来求治，诊其脉左手
寸尺皆弦数而涩，关脉芤而急数，右三部惟数而虚。予曰∶明是死血证。用抵当丸一剂，下黑血二升许，后以四物汤
加减调理而安。
Treatise
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: In liver diseases, pain occurs in the hypochondriac regions on both sides, radiating to the lower abdomen, causing irritability. When deficient, the eyes fail to see clearly, the ears fail to hear, and there is a tendency toward fear, as if someone were about to capture them. It also states: Anger causes qi to rebel; in severe cases, it leads to hematemesis or undigested food diarrhea, because the qi moves upward. The heart generates blood, and the liver stores blood. Due to great anger, blood may fail to return to its vessels, either ascending with the rebellious qi and exiting through the mouth or nose, or stagnating within the Liver Meridian itself, resulting in hypochondriac pain. Alternatively, in years of excessive Wood Qi, the Wood energy becomes overly vigorous; or in years where Metal Qi is surplus, Wood Qi becomes depressed. Both conditions can cause hypochondriac pain. The classics state: A condition characterized by fullness under the hypochondrium and rebellious qi, persisting for two or three years without resolution, is named "Xi Ji" (Breath Accumulation). This is also a syndrome of excess Liver Wood. Additionally, there are cases of external contraction of cold-heat pathogenic factors presenting with alternating chills and fever accompanied by hypochondriac pain; these are diseases of the Foot-Shaoyang Gallbladder Meridian and the Foot-Jueyin Liver Meridian. Treatment with Xiao Chai Hu Tang (Minor Bupleurum Decoction) is invariably effective. There are also cases caused by clear phlegm and food retention flowing into the hypochondriac region, causing pain. Or cases caused by falls from heights or trauma, where dead blood (stasis) obstructs the meridians, causing pain. Furthermore, irregular diet and overexertion can lead to deficiency of Spleen Earth, allowing Liver Wood to invade the Spleen's position, resulting in epigastric pain centered at the pit of the stomach, pain radiating upward to support both hypochondria, dysphagia, and inability to ingest food. Physicians should investigate and treat according to the specific category of etiology, avoiding mistaking false signs for true ones.
Pulse Diagnosis
The *Mai Jing* (Classic of Pulse Diagnosis) states: If the Liver pulse is firm and long, but the complexion is not green, the disease is likely due to falling or being struck, with blood remaining in the hypochondriac region, causing wheezing and rebellious qi. If the pulse is soft and scattered ("Ru" and "Ruan" were used interchangeably in ancient texts), but the complexion is lustrous, the disease is "Yi Yin" (Overflowing Drink). Yi Yin refers to sudden thirst with excessive drinking, where fluids overflow into the spaces outside the skin, muscles, and intestines.
The *Mai Jing* states: If the Liver pulse is rapid when pressed deeply and similarly rapid when superficially palpated, accompanied by pain in the hypochondrium, a sensation of qi distending and filling the area, pain radiating to the lower abdomen, occasional difficulty in urination, dizziness, headache, backache, cold feet, occasional urinary retention, and amenorrhea or irregular menstruation in women, this results from past trauma such as falling.
A double-wiry pulse indicates excess Liver Qi, causing pain in both hypochondriac regions.
Methods
Zhu Danxi stated: Hypochondriac pain belongs to the Liver and is caused by excess Wood Qi (due to great anger causing severe qi rebellion, deep depression of Liver Qi, indecisiveness, or wind pathogens invading the Liver, all leading to excessive Wood Qi, thus fire flourishing and Liver Qi becoming urgent); or by dead blood (due to evil blood stagnating in the Liver, clumping in the hypochondrium causing pain, accompanied by cough and急促 breathing pulling on the hypochondrium); or by phlegm flow-injection (due to phlegm accumulation flowing into the Jueyin Meridian, also causing hypochondriac pain, accompanied by cough and急促 breathing pulling on the hypochondrium).
Dang Gui Long Hui Wan (Angelica Sinensis and Aloe Pill): This is a key medicine for purging excessive Liver Fire. It is indicated for internal damp-heat causing severe hypochondriac pain, as it suppresses Liver Wood Qi and is suitable for Liver Excess syndromes.
Ingredients: Dang Gui (Radix Angelicae Sinensis), Long Dan Cao (Radix Gentianae), Zhi Zi Ren (Semen Gardeniae), Huang Lian (Rhizoma Coptidis), Huang Qin (Cortex Scutellariae), Da Huang (Radix et Rhizoma Rhei, soaked in wine and stir-fried with fire), Lu Hui (Resina Aloes), Qing Dai (Indigo Naturalis) (each 5 qian); Mu Xiang (Radix Aucklandiae) (2.5 qian); She Xiang (Moschus) (0.5 qian, separately ground).
Grind the above into fine powder, make pills using Shen Qu (Massa Medicata Fermentata) paste, sized like paulownia seeds. Take 20 pills per dose, washed down with Ginger Decoction. Another prescription adds Chai Hu (Radix Bupleuri) 5 qian and Qing Pi (Pericarpium Citri Reticulatae Viride) 1 liang; take warm if heat is severe.
Another prescription for excess Wood Qi: Use Chuan Xiong (Rhizoma Chuanxiong), Cang Zhu (Rhizoma Atractylodis Chinensis), Qing Pi, Shao Yao (Radix Paeoniae Alba), Chai Hu, Gan Cao (Radix Glycyrrhizae), and Long Dan Cao in equal parts. Decoct in water and take.
Zuo Jin Wan (Left Metal Pill): Purges Liver Fire and promotes dampness movement, serving as a counter-agent for severe heat.
Ingredients: Huang Lian (6 qian), Wu Zhu Yu (Fructus Evodiae) (1 qian).
Grind into fine powder, make pills using steamed bread dough soaked in decoction, sized like mung beans. Take 30–50 pills per dose, washed down with dilute Ginger Decoction.
Another prescription for breaking blood and moving qi to treat pain caused by stasis:
Ingredients: Tao Ren (Semen Persicae, skin removed, tip kept, separately ground), Hong Hua (Flos Carthami, mixed with wine and dried), Chuan Xiong, Xiang Fu (Rhizoma Cyperi, soaked in children's urine), Qing Pi (each in equal parts).
Cut finely, decoct in water and take.
Jia Wei Er Chen Tang (Modified Two-Aged Phlegm Decoction): Treats wet-phlegm flow-injection causing pain inside the hypochondrium.
Add Pao Nan Xing (Prepared Rhizoma Pinelliae), Cang Zhu, Chuan Xiong, and Sheng Jiang (Fresh Rhizoma Zingiberis) to the base formula. Decoct in water and take.
"The Liver suffers from tension; urgently consume pungent substances to disperse it." Use Fu Xiong (Chuan Xiong) and Cang Zhu. Or use Xiao Chai Hu Tang, as this formula is an essential medicine for hypochondriac pain with alternating chills and fever.
For left-sided hypochondriac pain, use Chai Hu as the sovereign herb, adding ministerial and envoy herbs such as Chuan Xiong, Qing Pi, and Long Dan Cao.
For wandering pain in both hypochondria, use Kong Yan Dan (Controlling Saliva Pill) (suitable for pain caused by clear phlegm flow-injection, as phlegm in the hypochondrium cannot be reached except by Bai Jie Zi [Semen Mustardae]; see the Phlegm section for the formula).
For cough with hypochondriac pain, use Er Chen Tang plus Nan Xing, Qing Pi, Xiang Fu, Qing Dai, and Jiang Zhi (Ginger Juice). Another view suggests Si Wu Tang (Four Substances Decoction) plus Qing Pi etc., to soothe Liver Qi.
For persons with weak qi, hypochondriac pain with a fine-tight or wiry pulse, often caused by exertion and anger, use Ba Wu Tang (Eight Substances Decoction) plus Mu Xiang and Qing Pi, or add Gui Xin (Cortex Cinnamomi), decoct in water and take.
To remove stagnant qi, use Qing Pi, as it enters the Liver and Gallbladder meridians. People prone to anger often have depression and accumulation in the hypochondrium; it is appropriate to use this herb to resolve excess in these two meridians. If the Qi and Blood of these two meridians are insufficient, one should first tonify Qi and Blood, adding a small amount of Qing Pi (This continues the meaning of the previous paragraph).
For fat, white-complexioned individuals with Qi deficiency, presenting with chills/fever and hypochondriac pain, use Ren Shen (Radix Ginseng) and Huang Qi (Radix Astragali) to tonify Qi, Chai Hu and Huang Qin to reduce fever, and Mu Xiang and Qing Pi to regulate Qi. For thin, dark-complexioned individuals with chills/fever, hypochondriac pain, and irritability, there must be blood stasis; use Tao Ren, Hong Hua, Chai Hu, Qing Pi, Da Huang, etc., to move blood.
For chills/fever with hypochondriac pain, feeling as though there is a mass, it is certainly due to overeating and labor; Long Hui Wan must be used.
Symptom-relieving topical treatments: Apply Hu Po Gao (Amber Plaster) externally. Another method: Grind Jie Cai Zi (Mustard Seed) with water and apply. Another method: Grind Wu Zhu Yu with vinegar, mix with water, and apply. Another method: Crush Chive leaves, heat them in a pan, apply to the site, and iron over with a hot iron.
(Above are fifteen methods from Danxi.)
Tui Qi San (Pushing Away Qi Powder, from *Ju Fang*): Treats severe right-sided hypochondriac pain, fullness, and loss of appetite.
Ingredients: Pian Jiang Huang (Rhizoma Curcumae Longae), Zhi Ke (Fructus Aurantii, bran-fried), Gui Xin (each 5 qian), Gan Cao (roasted, 3 qian).
Grind into fine powder. Take 2 qian per dose, mixed with Ginger Decoction. Decocting in water is also acceptable.
Zhi Xiong San (Zhi Shi and Chuan Xiong Powder, from Dong Yuan/Li Dongyuan): Treats unbearable right-sided hypochondriac pain.
Ingredients: Zhi Shi (Fructus Aurantii Immaturus, bran-fried), Chuan Xiong (each 5 qian), Gan Cao (roasted, 1.5 qian).
Grind into fine powder. Take 2 qian per dose, mixed with Ginger and Jujube Decoction or wine.
Yi Xiang San (Rare Fragrance Powder, from Dong Yuan): Treats abdominal and hypochondriac distension, stuffiness, choking, and abdominal/hypochondriac pain.
Ingredients: Peng E Zhu (Rhizoma Curcumae Phaeocaulis, roasted), Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), Gan Cao, Jing San Leng (Rhizoma Sparganii) (each 1 qian), Qing Pi, Chen Pi (Pericarpium Citri Reticulatae) (each 0.5 qian), Shi Lian Rou (Endocarpium Nelumbinis) (0.3 qian), Hou Po (Cortex Magnoliae Officinalis, ginger-processed) (0.3 qian).
Cut finely, prepare as one dose. Add 3 slices of Sheng Jiang, 1 date, and a pinch of salt. Add 1.5 cups of water, decoct to 1 cup, strain, and take warm.
Fen Qi Zi Su Yin (Separating Qi Perilla Decoction, from He Jian/Liu Wansu): Treats abdominal and hypochondriac pain, shortness of breath, and急促 breathing.
Ingredients: Wu Wei Zi (Fructus Schisandrae), Jie Geng (Radix Platycodonis, de-lumed), Zi Su Ye (Folium Perillae), Sang Bai Pi (Cortex Mori Radicis, honey-roasted to yellow), Cao Guo Ren (Semen Tsaoko), Chen Pi (de-whitened), Da Fu Pi (Pericarp Arecae, washed with wine), Fu Ling (Sclerotium Poriae), Gan Cao (roasted, each 0.5 qian).
Cut finely, prepare as one dose. Add 3 slices of Sheng Jiang and a pinch of salt. Add 1 large cup of water, decoct to 0.7 cup, strain, and take warm on an empty stomach.
Xiong Ge Tang (Chuan Xiong and Kudzu Decoction, from He Jian): Treats unbearable hypochondriac pain.
Ingredients: Gui Zhi (Ramulus Cinnamomi), Chuan Xiong, Xi Xin (Herba Asari), Gan Ge (Radix Puerariae), Fang Feng (Radix Saposhnikoviae, de-lumed) (each 0.8 fen), Shao Yao, Zhi Ke, Ma Huang (Herba Ephedrae), Ren Shen, Gan Cao (roasted, each 0.4 fen).
Cut finely, prepare as one dose. Add 3 slices of Sheng Jiang. Add 1.5 cups of water, decoct to 1 cup, and take warm.
(Danxi Flexible Patterns) states: Generally, hypochondriac pain is due to excess Liver Wood. Use Xiao Chai Hu Tang plus Qing Pi, Chuan Xiong, Shao Yao, and Long Dan Cao. In severe cases, decoct the main medicine and add Qing Dai and She Xiang. For phlegm flow-injection, double the Ban Xia in the base formula, add Ju Hong, Nan Xing, Cang Bai Zhu, Fu Ling, and Chuan Xiong. For blood stasis pain, combine Xiao Chai Hu Tang with Si Wu Tang, add Tao Ren, Hong Hua, or Ru Xiang and Mo Yao, decoct and take. If pain is severe and the vital qi is strong, use Tao Ren Cheng Qi Tang to purge and cure. For irritable persons with frequent abdominal/hypochondriac pain, use Xiao Chai Hu Tang plus Chuan Xiong, Shao Yao, and Qing Pi. In severe cases, send down Dang Gui Long Hui Wan with the decoction for rapid effect.
Medical Case
The son of Mr. Jin, over forty years old, fell while riding a horse. The following year, he experienced distending pain in the left hypochondrium. Physicians treated him with Xiao Chai Hu Tang plus Cao Long Dan and Qing Pi, but it was ineffective. He sought treatment from me. His pulse was wiry, rapid, and choppy at the Cun and Chi positions on the left hand, and hollow, rapid, and numerous at the Guan position. On the right hand, all three positions were merely rapid and deficient. I said: This is clearly a dead blood (stasis) syndrome. I administered one dose of Di Dang Wan (Epoxy Pill), which expelled approximately two sheng of black blood. Afterwards, he recovered after regulation with modified Si Wu Tang.