天津齐××，年五旬，得胁下作疼，兼胃口疼病。
病因 素有肝气不顺病，继因设买卖赔累，激动肝气，遂致胁下作疼，久之胃口亦疼。
证候 其初次觉疼恒在申酉时，且不至每日疼，后浸至每日觉疼，又浸至无时不疼。屡次延
医服药，过用开破之品伤及脾胃，饮食不能消化，至疼剧时恒连胃中亦疼。其脉左部沉弦
微硬，右部则弦而无力，一息近五至。
诊断 其左脉弦硬而沉者，肝经血虚火盛而肝气又郁结也。其右脉弦而无力者，土为木伤，
脾胃失其蠕动健运也。其胁疼之起点在申酉时者，因肝属木申酉属金，木遇金时其气化益遏
抑不舒也。《内经》谓，“厥阴不治，求之阳明。”夫厥阴为
肝，阳明为胃，遵《内经》之微旨以治此证，果能健补脾胃，俾中焦之气化营运无滞，再少
佐以理肝之品，则胃疼可愈，而胁下之疼亦即随之而愈矣。
处方 生怀山药（一两） 大甘枸杞（六钱） 玄参（五钱） 寸麦冬（四钱带心）
于白术（三钱） 生杭芍（三钱） 生麦芽（三钱） 桂枝尖（二钱）
龙胆草（二钱） 生鸡内金（二钱黄色的捣） 浓朴（钱半） 甘草（钱半）
共煎汤一大盅，温服。
复诊 将药连服四剂，胃中已不作疼，胁下之疼亦大轻减，且不至每日作疼，即有疼时亦
须臾自愈。脉象亦见和缓，遂即原方略为加减俾再服之。
处方 生怀山药（一两） 大甘枸杞（六钱） 玄参（四钱） 寸麦冬（四钱带心）
于白术（三钱） 生杭芍（三钱） 当归（三钱） 桂枝尖（二钱） 龙胆
草（二钱） 生鸡内金（二钱黄色的捣） 醋香附（钱半） 甘草（钱半） 生姜（二钱）
共煎汤一大盅，温服。
效果 将药连服五剂，胁下之疼霍然全愈，肝脉亦和平如常矣。遂停服汤药，俾日用生怀山药
细末两许，水调煮作茶汤，调以蔗糖令适口，以之送服生鸡内金细末二分许，以善其后。
或问 理肝之药莫如柴胡，其善舒肝气之郁结也。今治胁疼两方中皆用桂枝而不用柴胡，将
毋另有取义？答曰∶桂枝与柴胡虽皆善理肝，而其性实有不同之处。如此证之疼肇于胁下，
是肝气郁结而不舒畅也，继之因胁疼累及胃中亦疼，是又肝木之横恣而其所能胜也。柴胡能
舒肝气之郁，而不能平肝木之横恣，桂枝其气温升（温升为木气），能舒肝气之郁结则胁疼可
愈，其味辛辣（辛辣为金味），更能平肝木横恣则胃疼亦可愈也。
惟其性偏于温，与肝血虚损有热者不宜，故特加龙胆草以调剂之，俾其性归和平而后用之，有益
无损也。不但此也，拙拟两方之要旨，不外升肝降胃，而桂枝之妙用，不但为升肝要药，实又为
降胃要药。《金匮》桂枝加桂汤，治肾邪奔豚上干直透中焦，而方中以桂枝为主药，是其能降胃之
明征也。再上溯《神农本草经》，谓桂枝主上气咳逆及吐吸（吸不归根即吐出，即后世所谓喘也），是
桂枝原善降肺气，然必胃气息息下行，肺气始能下达无碍。细绎经旨，则桂枝降胃之功用，更可借
善治上气咳逆吐吸而益显也。盖肝升胃降，原人身气化升降之常，顺人身自然之气化而调养之，
则有病者自然无病，此两方之中所以不用柴胡皆用桂枝也。
Mr. Qi from Tianjin, aged fifty, suffered from pain in the hypochondrium (lateral chest area) accompanied by pain in the stomach region (epigastrium).
Etiology: He had a chronic condition of stagnant Liver Qi (Liver Qi Stagnation). Subsequently, due to financial losses in business transactions, his Liver Qi was agitated, leading to pain in the hypochondrium. Over time, this extended to pain in the stomach region.
Symptoms: Initially, he felt pain primarily during the Shen and You hours (3 PM to 7 PM), and it did not occur daily. Gradually, the frequency increased to daily occurrence, and eventually, the pain became constant. Multiple consultations with physicians and medication regimens involved excessive use of dispersing and breaking agents, which damaged the Spleen and Stomach, impairing digestion. When the pain intensified, it often radiated to the stomach. His pulse was deep, wiry, and slightly hard on the left side, while wiry and forceless on the right side, with nearly five beats per breath cycle.
Diagnosis: The deep, wiry, and hard quality of the left pulse indicates Blood deficiency and Fire excess in the Liver channel, compounded by Liver Qi stagnation. The wiry and forceless quality of the right pulse suggests that Wood (Liver) has injured Earth (Spleen/Stomach), causing the Spleen and Stomach to lose their normal motility and transportive functions. The onset of hypochondriac pain during the Metal hours (Shen/You) occurs because Wood encounters Metal; at these times, the Qi transformation is further suppressed and uncomfortable. As stated in the *Neijing* (Inner Canon): "If Jueyin cannot be treated effectively, seek treatment in Yangming." Jueyin refers to the Liver, and Yangming refers to the Stomach. Following the subtle principles of the *Neijing*, if one strengthens and tonifies the Spleen and Stomach, ensuring smooth Qi transformation and circulation in the Middle Jiao, and adds a small amount of herbs to regulate the Liver, the stomach pain will resolve, and the hypochondriac pain will follow suit and heal.
Prescription: Raw Huai Shan Yao (Dioscoreae Hypoglaucae Rhizoma, 1 liang), Large Gan Gou Qi (Lycii Fructus, 6 qian), Xuan Shen (Scrophulariae Radix, 5 qian), Cun Mai Dong (Ophiopogonis Radix, 4 qian, including the heart), Yu Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 qian), Sheng Hang Shao (Paeoniae Radix Alba, 3 qian), Sheng Mai Ya (Hordei Fructus Germinatus, 3 qian), Gui Zhi Jian (Cinnamomi Ramulus Apex, 2 qian), Long Dan Cao (Gentianae Radix, 2 qian), Sheng Ji Nei Jin (Galli Gigerii Endothelium Corneum, 2 qian, yellow variety, crushed), Nong Po (Magnoliae Officinalis Cortex, 1.5 qian), Gan Cao (Glycyrrhizae Radix et Rhizoma, 1.5 qian). Decoct together in a large cup of water, take warm.
Second Visit: After taking four doses, the stomach pain ceased, and the hypochondriac pain significantly decreased, no longer occurring daily. Any remaining pain subsided spontaneously within moments. The pulse became harmonious and moderate. Therefore, the original prescription was slightly modified for continued use.
Prescription: Raw Huai Shan Yao (Dioscoreae Hypoglaucae Rhizoma, 1 liang), Large Gan Gou Qi (Lycii Fructus, 6 qian), Xuan Shen (Scrophulariae Radix, 4 qian), Cun Mai Dong (Ophiopogonis Radix, 4 qian, including the heart), Yu Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 qian), Sheng Hang Shao (Paeoniae Radix Alba, 3 qian), Dang Gui (Angelicae Sinensis Radix, 3 qian), Gui Zhi Jian (Cinnamomi Ramulus Apex, 2 qian), Long Dan Cao (Gentianae Radix, 2 qian), Sheng Ji Nei Jin (Galli Gigerii Endothelium Corneum, 2 qian, yellow variety, crushed), Cu Xiang Fu (Cyperi Rhizoma processed with vinegar, 1.5 qian), Gan Cao (Glycyrrhizae Radix et Rhizoma, 1.5 qian), Sheng Jiang (Zingiberis Rhizoma Recens, 2 qian). Decoct together in a large cup of water, take warm.
Outcome: After taking five doses, the hypochondriac pain completely resolved, and the Liver pulse returned to a normal, peaceful state. Decoction therapy was discontinued. The patient was instructed to consume approximately two qian of finely powdered Raw Huai Shan Yao daily, mixed with water and boiled into a tea-like consistency, sweetened with sucrose to taste, taken to deliver approximately two fen of finely powdered Sheng Ji Nei Jin, to consolidate the recovery.
Inquiry: Among herbs for regulating the Liver, Chai Hu (Bupleuri Radix) is unparalleled for its ability to soothe Liver Qi stagnation. Why were both prescriptions for hypochondriac pain using Gui Zhi (Cinnamomi Ramulus) instead of Chai Hu? Is there another rationale?
Response: Although both Gui Zhi and Chai Hu are effective in regulating the Liver, their properties differ significantly. In this case, the pain originated in the hypochondrium, indicating stagnant and unsmooth Liver Qi. Subsequently, the hypochondriac pain affected the stomach, indicating the horizontal aggression of Liver Wood over its controlled element (Earth/Spleen-Stomach). Chai Hu can soothe stagnant Liver Qi but cannot pacify the horizontal aggression of Liver Wood. Gui Zhi has a warm and ascending nature (corresponding to Wood Qi), which can relieve Liver Qi stagnation to cure hypochondriac pain. Its pungent and spicy flavor (corresponding to Metal flavor) can further pacify Liver Wood's horizontal aggression to cure stomach pain.
However, since Gui Zhi is warm in nature, it is unsuitable for cases involving Liver Blood deficiency with heat. Therefore, Long Dan Cao (Gentianae Radix) was specifically added to balance the formula, ensuring a neutral property before use, providing benefit without harm. Moreover, the core principle of my two prescriptions is to ascend Liver Qi and descend Stomach Qi. Gui Zhi’s subtle utility lies not only in being a key herb for ascending Liver Qi but also for descending Stomach Qi. In the *Jin Gui Yao Lue* (Essential Prescriptions from the Golden Cabinet), the Gui Zhi Jia Gui Tang (Cinnamon Twig Plus Cinnamon Twig Decoction) treats Ben Tun (Rushing Pig) caused by Kidney pathogenic Qi rushing upward through the Middle Jiao, with Gui Zhi as the principal herb, demonstrating its ability to descend Stomach Qi. Tracing back to the *Shennong Ben Cao Jing* (Divine Farmer’s Materia Medica), it states that Gui Zhi treats upper Qi, cough, and reverse flow (inhaling without rooting, expelling air, known as asthma in later periods). This shows Gui Zhi naturally descends Lung Qi. However, Lung Qi can only descend smoothly if Stomach Qi descends continuously. Careful interpretation of these classics reveals that Gui Zhi’s function in descending Stomach Qi is further highlighted by its efficacy in treating upper Qi, cough, and reverse flow. The ascent of Liver Qi and descent of Stomach Qi constitute the normal pattern of Qi transformation in the human body. By nourishing and regulating according to this natural physiological process, disease resolves naturally. This explains why Chai Hu was omitted and Gui Zhi was used in both prescriptions.