天津陈××，年六旬，得胁下作疼证。
病因 因操劳过度，遂得胁下作疼病。
证候 其疼或在左胁或在右胁或有时两胁皆疼，医者治以平肝、舒肝、柔肝之法皆不效。迁延年
余，病势浸增，疼剧之时。觉精神昏愦。其脉左部微细，按之即无，右脉似近和平，其
搏动之力略失于弱。
诊断 人之肝居胁下，其性属木，原喜条达，此因肝气虚弱不能条达，故郁于胁下作疼也。其
疼或在左或在右者，《难经》云，肝之为脏其治在左，其藏在右胁右肾之前并胃，着于胃
之第九椎（《医宗金鉴》刺灸篇曾引此数语，今本《难经》不知被何人删去）。所谓脏者，肝脏所
居之地也，谓治者肝气所行之地也。是知肝虽居右而其气化
实先行于左。其疼在左者，肝气郁于所行之地也；其疼在右者，肝气郁于所居之地也；其疼剧时
精神昏愦者，因肝经之病原与神经有涉也（肝主筋，脑髓神经为灰白色之筋，是以肝经之病与神经有涉）。治
此证者，当以补助肝气为主。而以升肝化郁之药辅之。
处方 生箭 （五钱） 生杭芍（四钱） 玄参（四钱） 滴乳香（三钱炒）
明没药（三钱不炒） 生麦芽（三钱） 当归（三钱）川芎（二钱） 甘草（钱半）
共煎汤一大盅，温服。
方解 方书有谓肝虚无补法者，此非见道之言也。黄 为补肝之主药，何则？黄 之性温而能升，
而脏腑之中秉温升之性者肝木也，是以各脏腑气虚，黄 皆能补之。而以补肝经之气虚，实更有同
气相求之妙，是以方中用之为主药。然因其性颇温，重用之虽善补肝气，恐并能助肝火，故以芍药、玄
参之滋阴凉润者济之。用乳香、没药者以之融化肝气之郁也。用麦芽、芎 者以之升达肝气之郁也。
究之，无论融化升达，皆通行其经络使之通则不痛也。用当归者以肝为藏血之脏，既补其气，又欲
补其血也。且当归味甘多液，固善生血，而性温味又兼辛，实又能调和气分也。用甘草者以其能
缓肝之急，而甘草与芍药并用，原又善治腹疼，当亦可善治胁疼也。
再诊 将药连服四剂，胁疼已愈强半，偶有疼时亦不甚剧。脉象左部重按有根，右部亦较前有力，
惟从前因胁疼食量减少，至此仍未增加，拟即原方再加健胃消食之品。
处方 生箭 （四钱） 生杭芍（四钱） 玄参（四钱） 于白术（三钱）
滴乳香（三钱炒） 明没药（三钱不炒） 生麦芽（三钱） 当归（三钱）
生鸡内金（二钱黄色的捣） 川芎（二钱） 甘草（钱半）
共煎汤一大盅，温服。
三诊 将药连服四剂，胁下已不作疼，饮食亦较前增加，脉象左右皆调和无病，惟自觉两腿筋
骨软弱，此因病久使然也。拟再治以舒肝、健胃、强壮筋骨之剂。
处方 生箭 （四钱） 生怀山药（四钱） 天花粉（四钱） 胡桃仁（四钱）
于白术（三钱） 生明没药（三钱） 当归（三钱） 生麦芽（三钱）
寸麦冬（三钱） 生鸡内金（二钱黄色的捣） 真鹿角胶（三钱）
药共十一味，将前十味煎汤一大盅，再将鹿角胶另用水炖化和匀，温服。
效果 将药连服十剂，身体浸觉健壮，遂停服汤药，俾用生怀山药细末七八钱，或至一两，凉水
调和煮作茶汤，调以蔗糖令其适口，当点心服之。服后再嚼服熟胡桃仁二三钱，如此调养，宿病可以永愈。
Mr. Chen from Tianjin, aged sixty, suffered from pain in the hypochondrium (hypochondriac region).
Etiology The disease was caused by excessive physical and mental exertion.
Clinical Manifestations The pain occurred alternatively in the left or right hypochondrium, or sometimes in both sides simultaneously. Treatments employing methods to calm the Liver, soothe the Liver, and nourish the softness of the Liver were ineffective. After more than a year of progression, the condition worsened. During severe pain episodes, he experienced mental confusion and dizziness. His pulse on the left side was faint and thin, disappearing upon heavy pressure; the pulse on the right side seemed relatively balanced, but its pulsation force was slightly weak.
Diagnosis The human Liver resides in the hypochondrium and belongs to Wood in nature, originally preferring free flow and dispersion. In this case, due to deficiency of Liver Qi failing to flow freely, it becomes stagnant in the hypochondrium, causing pain. Regarding whether the pain is on the left or right, the *Nan Jing* (Classic of Difficult Issues) states: "As an organ, the Liver's governance lies on the left, while its physical body resides in front of the right kidney under the right hypochondrium, attaching to the ninth thoracic vertebra corresponding to the stomach" (These sentences were cited in the acupuncture and moxibustion chapter of *Yi Zong Jin Jian*, though they appear deleted in current editions of the *Nan Jing*). Here, "organ" refers to the anatomical location of the Liver, while "governance" refers to the pathway of Liver Qi circulation. Thus, although the Liver physically resides on the right, its Qi transformation actually circulates first to the left. Pain on the left indicates stagnation of Liver Qi in its pathway; pain on the right indicates stagnation in its anatomical residence. Mental confusion during severe pain occurs because Liver channel diseases involve the nervous system (The Liver governs tendons; brain marrow and nerves are grey-white tendinous tissues, hence Liver channel pathology relates to the nervous system). Treatment should primarily tonify deficient Liver Qi, assisted by herbs that raise Liver Qi and resolve stagnation.
Prescription Raw Astragali Radix (Sheng Huangqi, 5 qian), Raw Paeoniae Radix Alba (Sheng Baishao, 4 qian), Scrophulariae Radix (Xuan Shen, 4 qian), Frankincense with Drip (Di Ruxiang, 3 qian, stir-fried), Myrrh (Ming Moyao, 3 qian, unroasted), Raw Malto (Sheng Maiya, 3 qian), Angelicae Sinensis Radix (Danggui, 3 qian), Ligustici Chuanxiong Rhizoma (Chuanxiong, 2 qian), Glycyrrhizae Radix et Rhizoma (Gancao, 1.5 qian). Decoct together in a large cup of water, take warm.
Formula Analysis Some medical texts claim there is no method to tonify Liver deficiency; this is not a profound understanding. Astragalus Radix (Huangqi) is the principal herb for tonifying the Liver. Why? Huangqi is warm in nature and ascending. Among the Zang-Fu organs, the Liver (Wood) possesses the nature of warmth and ascent. Therefore, Huangqi can tonify Qi deficiency in various organs. Specifically, for Liver Qi deficiency, it works through the principle of similar affinity (Tong Qi Xiang Qiu). Hence, it is used as the principal herb. However, since it is quite warm, heavy use might assist Liver Fire. Thus, cooling and moistening herbs like Paeoniae Radix Alba (Baishao) and Scrophulariae Radix (Xuan Shen) are used to moderate it. Frankincense (Ruxiang) and Myrrh (Moyao) are used to dissolve Liver Qi stagnation. Malto (Maiya) and Ligustici Chuanxiong Rhizoma (Chuanxiong) are used to ascend and disperse Liver Qi stagnation. Ultimately, whether dissolving or ascending, these actions promote meridian circulation, achieving pain relief through unblocking ("Tong Ze Bu Tong"). Angelicae Sinensis Radix (Danggui) is used because the Liver stores Blood; after tonifying Qi, we also wish to tonify Blood. Danggui is sweet and juicy, good at generating Blood, yet warm and pungent, effectively harmonizing the Qi aspect. Glycyrrhizae Radix et Rhizoma (Gancao) is used to relieve Liver urgency. Gancao combined with Baishao is traditionally effective for abdominal pain, and thus is expected to be effective for hypochondriac pain as well.
Second Visit After taking four doses, hypochondriac pain improved significantly, with occasional mild pain remaining. The left pulse root became palpable upon heavy pressure, and the right pulse gained strength compared to before. However, appetite remained reduced due to previous pain. It is proposed to add spleen-strengthening and digestion-promoting herbs to the original formula.
Prescription Raw Astragali Radix (Sheng Huangqi, 4 qian), Raw Paeoniae Radix Alba (Sheng Baishao, 4 qian), Scrophulariae Radix (Xuan Shen, 4 qian), Atractylodis Macrocephalae Rhizoma (Yu Baizhu, 3 qian), Frankincense with Drip (Di Ruxiang, 3 qian, stir-fried), Myrrh (Ming Moyao, 3 qain, unroasted), Raw Malto (Sheng Maiya, 3 qian), Angelicae Sinensis Radix (Danggui, 3 qian), Raw Endothelium Corneum Gigeriae Galli (Sheng Jineijin, 2 qian, yellow variety crushed), Ligustici Chuanxiong Rhizoma (Chuanxiong, 2 qian), Glycyrrhizae Radix et Rhizoma (Gancao, 1.5 qian). Decoct together in a large cup of water, take warm.
Third Visit After four doses, hypochondriac pain ceased completely, and food intake increased. Pulses on both sides were harmonious and normal. However, he complained of weakness in the tendons and bones of both legs, attributed to the chronicity of the illness. The treatment plan shifts to soothing the Liver, strengthening the Spleen/Stomach, and fortifying tendons and bones.
Prescription Raw Astragali Radix (Sheng Huangqi, 4 qian), Raw Dioscoreae Hypoglaucae Rhizoma (Sheng Huai Shanyao, 4 qian), Typhonii Radix (Tianhuafen, 4 qian), Juglandis Semen (Hetao Ren, 4 qian), Atractylodis Macrocephalae Rhizoma (Yu Baizhu, 3 qian), Raw Myrrh (Sheng Ming Moyao, 3 qian), Angelicae Sinensis Radix (Danggui, 3 qian), Raw Malto (Sheng Maiya, 3 qian), Ophiopogonis Tuber (Cun Maidong, 3 qian), Raw Endothelium Corneum Gigeriae Galli (Sheng Jineijin, 2 qian, yellow variety crushed), True Cervus Nucleus Cornu Gelatinum (Zhen Lujiao Jiao, 3 qian). Eleven ingredients in total. Decoct the first ten in a large cup of water. Separately melt the Cervus Nucleus Cornu Gelatinum (Lujiao Jiao) in water, mix evenly, and take warm.
Outcome After ten doses, the patient felt progressively stronger. He discontinued the decoction and switched to consuming fine powder of Raw Dioscoreae Hypoglaucae Rhizoma (Huai Shanyao), 7-8 qian up to 1 liang, mixed with cold water and boiled into a tea-like consistency, sweetened with sucrose for taste, taken as a snack. This was followed by chewing 2-3 qian of cooked Juglandis Semen (Hetao Ren). With such maintenance therapy, the chronic ailment can be permanently cured.