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Zhang Dairen treated a patient in critical condition. The patient described: "I have no other illness. Three years ago, during the intense heat of summer, I was walking in the countryside when someone offered me boiled wine. I drank several sheng (a unit of volume) of chilled beverage, and immediately felt stuffiness under the left hypochondrium, which gradually became painful. A mass formed, hard as stone, which has not dissipated to this day. Acupuncture, massage, and medication have yielded no effect." Zhang Dairen examined the patient and found both wrists' pulses to be deep, solid, and forceful. He first administered Dusheng San (Single Sage Powder) to induce vomiting, expelling two or three sheng of vomitus with an odor like wine; the pain ceased immediately. Subsequently, he prescribed formulas to harmonize the spleen and stomach, leading to recovery.

Yu Zhen commented: A mass under the hypochondrium hard as stone is indeed an accumulation (mass). If one were to follow the theory that "tonifying the righteous qi will cause the pathogenic accumulation to eliminate itself," and use tonics such as Renshen (Ginseng Radix) and Baizhu (Atractylodis Macrocephalae Rhizoma), how would this differ from assisting a tyrant? Fortunately, Dairen encountered this case and used the emetic method to rescue him from severe illness, relying also on the diagnosis of deep, solid, and forceful pulses. This indicates that proficiency in pulse diagnosis is like having both ritual music and weapons; both can quell chaos and restore order.

Yu Tianmin treated a man over forty years old. After falling from a horse, he suffered distending pain in the left hypochondrium the following year. Physicians prescribed Xiao Chai Hu Tang (Minor Bupleurum Decoction) with added Qingpi (Citri Reticulatae Pericarpium Viride) and Longdancao (Gentianae Radix), but it was ineffective. His pulse was wiry, rapid, and choppy at the cun and chi positions of the left hand, and hollow (kou) with rapid and frequent beats at the guan position; the three positions on the right hand were merely rapid and deficient. Yu stated: "This is clearly a case of fixed blood (stasis)." He administered Didang Wan (Didang Pill) once, resulting in the passage of approximately two sheng of dark blood. Later, he regulated the condition using Siwu Tang (Four Substance Decoction) with modifications, leading to stability.

Yu Zhen commented: Juquan treated an elderly man over eighty with severe left hypochondriac pain and swelling like an inverted cup, intolerable to touch, attributing it to blood stasis in the spleen. Lizaizhi treated a patient with right hypochondriac distending pain relieved by pressure, attributing it to Liver Wood overacting on Spleen Earth, causing Spleen Earth to fail to generate Lung Metal. If there were internal blood stasis, even thin clothing touching the skin would be unbearable. These cases serve as grand principles for syndrome differentiation. Additionally, Li Shicai treated Li Mingqi, who was robust but suddenly developed left hypochondriac pain intolerable to touch. He used Zuojin Wan (Left Metal Pill) and Xie Gan Tang (Drain the Liver Decoction). After more than a month, the painful area enlarged, right hypochondriac pain appeared, mobility ceased, spirit was dull and absent-minded, complexion was yellow, and both guan pulses were hurried. Li attributed this to deep blood retention requiring potent purgatives. He used Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction); after one dose without effect, he added Ganqi (Drynariae Rhizoma) and raw Dahuang (Rhei Radix et Rhizoma) 5 qian. More than ten blood clumps were passed, pain ceased, and consciousness cleared, leaving only fatigue. He first gave Dushen Tang (Single Ginseng Decoction), then regulated with Bazhen Tang (Eight Treasure Decoction), recovering in three months. This differs slightly from Juquan's use of Cheng Qi Tang plus Danggui (Angelicae Sinensis Radix), Shaoyao (Paeoniae Radix), Chaihu (Bupleuri Radix), Huangbai (Phellodendri Cortex), and Huanglian (Coptidis Rhizoma). However, since Huanglian and Huangbai are bitter and cold, why did the blood stasis pass?

Xue Lizhi treated a woman who developed malaria and vomiting after anger following meals. She recovered after two doses of Huoxiang Zhengqi San (Agaricus and Patchouli Powder). Later, upon becoming angry again, she produced much phlegm, spoke madly, had intense heat, distending pain in the chest and hypochondrium relieved slightly by pressure, and a pulse that was extremely flooding but fine and subtle upon deep pressure. This belonged to blood deficiency in the Liver and Spleen meridians. He used Jiawei Xiaoyao San (Modified Free and Easy Wanderer Powder) with Shudi (Rehmanniae Radix Praeparata) and Chuanxiong (Ligustici Chuanxiong Rhizoma). After two doses, the pulse and symptoms subsided significantly. He then used Shiquan Dabu Tang (Ten Significant Tonifying Decoction) to stabilize her. Using draining and unblocking agents in this case would violate the prohibition against "making deficiency more deficient."

Yu Zhen commented: Xue Lizhi's own annotations and Wang Jintan's later warnings are lessons scholars must remember.

Shishan treated a patient residing in Weiyang suffering from hypochondriac pain. Physicians considered it deficiency and tonified with Renshen (Ginseng Radix) and mutton, worsening the pain. Another physician administered Longhui Wan (Longhui Pill), reducing the pain. Wang diagnosed the pulse as wiry, soggy, and weak, stating: "The spleen and stomach are injured by the pain and have not yet recovered." He prescribed Jupi Zhizhu Wan (Tangerine Peel and Atractylodes Pill) with Huanglian (Coptidis Rhizoma) and Danggui (Angelicae Sinensis Radix), leading to stability. Five years later, abdominal and hypochondriac pain recurred. The patient thought it resembled the previous illness and hesitated to take Longhui Wan. Wang diagnosed the pulse as soggy, weak, and slow, stating: "The previous illness was excess; the current illness is deficiency. It cannot be treated with the previous medicine." He used Renshen (Ginseng Radix) as the sovereign herb, Chuanxiong (Ligustici Chuanxiong Rhizoma), Danggui (Angelicae Sinensis Radix), and Shaoyao (Paeoniae Radix) as minister herbs, Xiangfu (Cyperi Rhizoma) and Chenpi (Citri Reticulatae Pericarpium) as assistant herbs, and Gancao (Glycyrrhizae Radix et Rhizoma) and Shanzhi (Gardeniae Fructus) as envoy herbs. After more than ten decoctions, pain ceased and appetite improved.

Yu Zhen commented: This patient's pulse was soggy and weak before and after, differing only in wiry versus slow characteristics. Why use clearing methods first and tonifying methods later? Is it because wiry indicates Liver fire and slow indicates Spleen deficiency? However, a wiry and soggy/weak pulse also suggests tonification is preferable to clearing. Observing Lizhi treating the mother of student Ma Xiang, who had pain from the left scapula connecting to the hypochondrium, with a right guan pulse wiry and long but weak upon pressure, and a left guan pulse wiry and flooding but choppy upon pressure: Xue said, "Depressed anger injures Liver and Spleen," curing her with Liu Jun Zi Tang (Six Gentlemen Decoction) plus Chuanxiong (Ligustici Chuanxiong Rhizoma) and Danggui (Angelicae Sinensis Radix). Thus, a wiry pulse cannot be solely blamed on Liver fire.

Wang Jintan said: Qin Wenshan from Yunzhong, teaching in Pinghu, frequently suffered from hypochondriac pain triggered by labor or hunger. He introduced himself through my elder brother to seek a prescription. I provided him with Renshen (Ginseng Radix), Fuling (Poria), Baizhu (Atractylodis Macrocephalae Rhizoma), Dihuang (Rehmanniae Radix), Chuanxiong (Ligustici Chuanxiong Rhizoma), Danggui (Angelicae Sinensis Radix), Yurou (Corni Fructus), Zaoren (Ziziphi Spinosae Semen), Niuxi (Achyranthis Bidentatae Radix), Mugua (Chaenomelis Fructus), Shihu (Dendrobii Caulis), Yiren (Coicis Semen), Baizi Ren (Platycladi Semen), and Taoren (Persicae Semen) for regular consumption. He later thanked me, saying his chronic ailment was cured overnight and did not recur. I heard that Wei Kunming, a ministry official, also suffered hypochondriac pain due to labor and hunger, without serious disease. However, physicians prescribed Qikiao (Magnoliae Officinalis Fructus) and Qingpi (Citri Reticulatae Pericarpium Viride) to break qi, worsening the pain, leading to death within days. I recorded this as a warning to the world.

A person traveling in June suffered heat exposure and overexertion, and being naturally irritable, suddenly developed left hypochondriac pain. A patch of redness the size of a bowl appeared on the skin, along with three or five blister-like sores. The pulse was seven beats per breath and wiry, worse at night than during the day. Physicians treated it as Liver meridian depressed fire, administering Huanglian (Coptidis Rhizoma), Qingpi (Citri Reticulatae Pericarpium Viride), Xiangfu (Cyperi Rhizoma), Chuanxiong (Ligustici Chuanxiong Rhizoma), and Chaihu (Bupleuri Radix). After one dose, the pain intensified severely at night, accompanied by aversion to heat. The next morning, the redness expanded to the size of a plate, and the blisters increased to over thirty. Physicians advised applying alum powder mixed with water externally and adding Qingdai (Indigo Naturalis) and Longdancao (Gentianae Radix) to the internal formula. Nighttime pain worsened, feeling like hooks tearing inside the hypochondrium. The next morning, redness spread to half the body, and blisters numbered over a hundred. They sought Wang Gutan, who prescribed a large Trichosanthes fruit (Gualou) weighing one to two liang, mashed with peel, plus Fugancao (Licorice Root) 2 qian and Honghua (Carthami Flos) 5 fen. Shortly after taking the medicine, the patient slept and woke up pain-free. The pain was urgent, but contemporary doctors adhered to standard liver-draining formulas, mostly bitter and cold, increasing dryness and exacerbating the condition. The external blisters occurred because prolonged Liver depression failed to vent, leading to counter-attack on the conquering element (Metal/Lung), causing skin breakdown. Gualou is sweet and cold; the Classic states, "To drain the Liver, soothe the center." Moreover, Gualou is soft and slippery, non-opposing to depression, sweet-soothing and moistening downward, like oil cleaning objects. This explains its swift efficacy.

Yu Zhen commented: Wang Jintan's brilliant explanation flows from Confucian principles. Laypeople seeing this formula initially understand nothing. But this formula suits this specific syndrome. Scholars should not hastily treat it as a secret strategy.

Sun Dongsu treated Lady Li Yuezhai with pain in the chest, hypochondrium, and abdomen, delirious speech resembling madness, slightly lighter during Yin, Mao, and Chen hours, but severe pain biting people during afternoon and night, sleepless day and night, and no food intake for eighteen days. Investigating the cause, she had pre-existing phlegm-fire, headache, and toothache. After menstruation ended three days prior, she developed headache with chills and fever. Physicians treated it as malaria. Due to extreme aversion to heat, three or four fans fanned her, and she immersed her hands in cold water, holding water in her mouth without swallowing, with slight nasal bleeding. She often wept sadly, eyes swollen from crying, urine flowed uncontrollably, throat felt blocked making swallowing difficult, pulse was wiry and rapid on the left, and flooding and slippery at the right guan. Sun said: "This is Heat Entering the Blood Chamber syndrome." Misuse of drying and warm agents agitated phlegm-fire, causing root and branch manifestations. Others claimed Heat Entering the Blood Chamber only causes nighttime delirium seeing ghosts, not severe hypochondriac pain and biting. Sun said: "Zhang Zhongjing stated that diseases occurring when menstruation begins or stops are all treated as Heat Entering the Blood Chamber. Severe pain and biting indicate Stomach deficiency with worms seeking food but failing, hence the throat blockage." He used Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Taoren (Persicae Semen) and Danpi (Moutan Cortex), reducing delirium. The next day, An Hui Tang (Calming Ascaris Decoction) stopped pain and restored appetite.

Yu Zhen commented: Interpreting severe pain and biting combined with throat blockage as hungry worms seeking food is coincidental. Relying on this for syndrome differentiation is unreliable.