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Teacher: Very well. Let us proceed to introduce the common classifications of internal injury headaches one by one.

① Qi Deficiency Headache (Qi Xu Tou Tong): Headache occurs in the early morning, feeling vague and hollow. The complexion is pale and spiritless; limbs are fatigued with a desire to lie down; appetite is poor with loose stools; aversion to cold, shortness of breath, and reluctance to speak. The tongue is pale with a thin white coating, and the pulse is deep, weak, and powerless. It is often triggered by chronic illness or excessive fatigue. Qi belongs to Yang; early morning is the time when Yin and Yang intersect. Due to Qi deficiency and insufficient Yang, pain arises. Labor injures Qi, hence exertion easily triggers an attack. The remaining symptoms are all manifestations of Spleen and Stomach Qi deficiency. Its main mechanism is deficiency of Middle Qi leading to failure of Clear Yang to ascend. Treatment should tonify Qi and raise Yang. Formula: Buzhong Yiqi Tang (Huangqi, Renshen, Baizhu, Zhigancao, Chenpi, Danggui, Shengma, Chaihu) plus Xixin and Chuanxiong. Alternatively, Shunqi Hezhong Tang (Huangqi, Renshen, Baizhu, Chenpi, Danggui, Baishao, Zhigancao, Shengma, Chaihu, Manjingzi, Chuanwu, Xixin) may be used.

② Blood Deficiency Headache (Xue Xu Tou Tong): Headache mostly occurs at night, coming and going intermittently. During pain, there is dizziness. Pain radiates from the end of the eyebrows towards the temples. Complexion is pale, body is tired with dizziness, palpitations and restlessness. Lips and tongue are pale; pulse is fine, weak, and powerless. It is often caused by blood loss, severe illness, or postpartum conditions. Blood belongs to Yin, and night also belongs to Yin; thus, Blood Deficiency headache often worsens significantly at night. Blood deficiency fails to nourish the Heart, causing palpitations and restlessness; it fails to nourish the Brain, causing headache. Treatment should nourish Blood and disperse Wind. Formula: Jiawei Siwu Tang (Danggui, Chuanxiong, Shudi, Baishao, Baizhi, Qianghuo, Duhuo, Xixin, Manjingzi, Gancao) or Qing Shang Juan Tong Tang (Danggui, Chuanxiong, Fangfeng, Cangzhu, Baizhi, Qianghuo, Duhuo, Maidong, Huangqin, Juhua, Manjingzi, Ganjiang, Xixin).

③ Blood Stasis Headache (Xue Yu Tou Tong): Headache recurs repeatedly and persists for a long time. The painful area is fixed, feeling like needle pricks. The tongue body is purple-dark or has ecchymosis spots; the pulse is wiry-choppy or fine-choppy. There may be a history of head trauma. Chronic disease enters the collaterals, causing Qi and Blood stagnation. Blood stasis blocks the collaterals, leading to pain due to obstruction. Treatment should invigorate Blood and resolve stasis. Formula: Tongqiao Huoxue Tang (Chishao, Chuanxiong, Taoren, Honghua, Laocong, Hongzao, Shexiang, Huangjiu).

④ Liver Yang Hyperactivity Headache (Gan Yang Tou Tong): Headache worsens at noon, sensitivity to sunlight, pain偏向 sides, vertigo as if falling, tinnitus, distending eyes, preference for quietness and aversion to annoyance, nausea and urge to vomit, restless sleep. In severe cases, the vertex feels heavy pressure with numbness. Tongue is red, pulse is wiry and forceful. Noon is the time of peak Yang; combined with hyperactive Liver Yang, the two Yangs clash, worsening the headache. Liver Blood is insufficient, Yin fails to contain Yang, and Liver Yang harasses and rebels upwards, generating these symptoms. Treatment should nourish Yin and subdue Yang. Formula: Jianling Tang (Shanyao, Huainiuxi, Sheng Zheishi, Sheng Longgu, Sheng Muli, Shengdi, Sheng Hangshao, Baiziren) or Xunlong Tang (Shengdi, Danggui, Baishao, Lingyangjiao, Zhenzhumu, Longchi, Juhua, Bohe, Sangjisheng, Gouteng, Duhuo, Chenxiang).

⑤ Liver Fire Headache (Gan Huo Tou Tong): Headache with distension, heat in the head, red face and eyes, prominent scalp veins, irritability, bitter taste in mouth, dry throat, constipation, and dark urine. In severe cases, sudden deafness in both ears. Tongue is red with thin yellow coating; pulse is wiry-rapid or wiry-tight. Often triggered by anger. Anger injures the Liver, causing Liver Fire to rebel upwards, generating symptoms. This is Excess Fire. Treatment should clear Liver and purge Fire. Formula: Longdan Xiegan Tang (Longdancao, Huangqin, Zhizi, Zexie, Mutong, Cheqianzi, Shengdi, Danggui, Chaihu, Gancao) plus Xiakucao.

⑥ Liver Qi Stagnation Headache (Gan Yu Tou Tong): Headache with chest tightness and discomfort, mental depression, emotional instability, frequent sighing, fatigue, poor appetite. Women often have irregular menstruation and breast distension. Pulse is wiry and deficient. Often triggered or worsened by emotional frustration. The Liver prefers free flow and dislikes depression. If injured by emotions, Liver Qi cannot flow smoothly, leading to stagnation and symptoms. Treatment should soothe the Liver and relieve stagnation. Formula: Xiaoyao San (Chaihu, Danggui, Baishao, Baizhu, Fuling, Wei Jiang, Bohe, Zhigancao) plus Chuanxiong, Baizhi, and Manjingzi.

⑦ Phlegm-Turbidity Headache (Tan Zhuo Tou Tong): Heavy and distending headache, often accompanied by vertigo, chest and epigastric fullness, vomiting and nausea. Tongue coating is white, thick, and greasy; pulse is wiry-slippery. Common in those with constitutive Phlegm-Dampness excess. Phlegm-Turbidity is a Yin pathogen harassing the clear orifices, preventing Clear Yang from extending, causing headache. The rest are signs of internal Phlegm-Dampness obstruction. Treatment should strengthen the Spleen, transform Phlegm, regulate Qi, and promote diuresis. Formula: Jiawei Erchen Tang (Banxia, Chenpi, Fuling, Gancao, Chuanxiong, Manjingzi, Xixin) or Banxia Baizhu Tianma Tang (Banxia, Tianma, Baizhu, Fuling, Juhong, Gancao, Shengjiang, Dazao) plus Cangzhu, Zexie, and Maiya.

⑧ Cold Jue Headache (Han Jue Tou Tong): Headache with aversion to wind and cold, desire to sleep covered with blankets. Complexion is bleak and depressed, slightly bluish-dull. Vomiting of clear saliva and sticky foam, cold limbs. Tongue coating is white and slippery; pulse is deep-wiry-tight. This syndrome is also called "Jueyin Headache," caused by Cold Qi rebelling upwards along the Liver Meridian. Cold Qi attacks the Spleen and Stomach horizontally, causing vomiting of clear saliva and cold limbs. Treatment should warm the Liver and direct rebellious Qi downwards. Formula: Wuzhuyu Tang (Wuzhuyu, Renshen, Dazao, Shengjiang) plus Danggui and Rougui.

⑨ Kidney Deficiency Headache (Shen Xu Tou Tong): Divided into Kidney Yin Deficiency and Kidney Yang Deficiency.
Kidney Yin Deficiency Headache: Empty headache in the head, vertigo and tinnitus, soreness and weakness of waist and knees, empty vexation and insomnia. Tongue is red with little coating; pulse is fine and powerless. Kidney Essence deficiency fails to nourish the Brain, causing empty headache. Remaining symptoms indicate insufficiency of Kidney Water. Treatment should nourish Kidney Yin. Formula: Qiju Dihuang Wan (Shudi, Shanzhuyu, Shanyao, Fuling, Zexie, Danpi, Juhua, Gouqi) plus Niuxi and Baishao.
Kidney Yang Deficiency Headache: Headache extends from the vertex to the forehead, extreme aversion to cold. Feeling wind as if entering directly into the brain; warmth relieves pain, so thick hats are worn even in hot weather. Limbs are cold, tongue is pale, pulse is deep-fine-weak. Kidney Yang insufficiency leads to decline of Mingmen Fire, deficiency-cold of the Du Meridian, and decline of the Yangming Meridian, causing cold pain at the vertex and forehead. Treatment should warm the Kidney and support Yang. Formula: Yougui Yin (Shudi, Shanyao, Shanzhuyu, Gouqi, Zhigancao, Duzhong, Rougui, Zhifuzi) plus Tianma.

Treating Hypochondriac Pain by Draining Fluids and Unblocking Collaterals — Introduction to Xiangfu Xuanfuhua Tang
Director of TCM Research Office, Leshan People's Hospital, Sichuan Province: Yu Guojun

Patient: Female, 35 years old. Suffered from chronic hepatitis for 3 years, frequently experiencing pulling and stabbing pain in the hypochondrium, accompanied by chest tightness, abdominal distension, vomiting/nausea, and belching. Symptoms improved insignificantly after using Chinese and Western medicines. Tongue body was slightly red with purple-dark spots covering the edges and tip; coating was thin-yellow and slightly greasy; pulse was wiry-fine. Physical examination: Liver palpable 3cm below the costal margin; GPT 60u, TTT 9u. Syndrome differentiation: Xuan Yin (suspended fluid) obstructing Liver collaterals. Prescribed modified Xiangfu Xuanfuhua Tang: Xiangfu (vinegar-processed) 10g, Xuanfuhua 10g (wrapped), Faxia 10g, Fuling 15g, Chenpi 10g, Xingren 10g, Yiyiren 20g, Gualouren 10g, Jiangxiang 15g, Jiegeng 10g. One dose every two days. After taking 15 doses, hypochondriac pulling pain disappeared, and stabbing pain along with other symptoms alleviated. Maintained the previous formula, removed Faxia and Chenpi, added Danshen 15g, Danpi 10g, Qiancao 15g, Chishao 10g, Guangchong 3g (roasted, finely ground and swallowed), and Congjing 9 roots. After another 15 doses, hypochondriac stabbing pain disappeared, tongue turned light red with no purple spots on edges/tip, coating became thin-white, pulse wiry-slow. Subsequently prescribed Chaishao Liujunzi Tang with modifications for consolidation. After more than 3 months of medication, except for occasional poor appetite, fatigue, and easy tiredness, the patient was normal as before. Follow-up examination showed liver palpable 1.5cm below costal margin, liver function normal (this case is recorded in *Selected Papers of Chinese and Japanese Young TCM Practitioners*).

Student A: This medical case seems ordinary. However, after participating in exchanges with Japan and being published in *Selected Papers*, it was reprinted in *Secret Formulas for Treating 17 Stubborn Diseases*, indicating certain inspirational value.

Teacher: What secret formula! It is clearly Xiangfu Xuanfuhua Tang from *Wenbing Tiaobian*.

Student B: Although not a secret formula, this case of chronic hepatitis hypochondriac pain was cured by switching to modified Xiangfu Xuanfuhua Tang (draining fluids and unblocking collaterals) after long-term use of soothing Liver, regulating Qi, clearing Heat, draining Dampness, invigorating Blood, resolving stasis, nourishing Yin, and softening Liver methods yielded insignificant improvement. This shows the formula has value for promotion and use. As far as I know, clinical treatment of hypochondriac pain indeed neglects this method of draining fluids and unblocking collaterals.

Teacher: I believe the primary oversight is ignoring the special syndrome type of hypochondriac pain caused by Xuan Yin obstructing Liver collaterals. Everyone knows the Liver resides under the hypochondrium, and its meridians distribute to the hypochondrium; thus, hypochondriac pain is a definitive sign of Liver disease. *Ling Shu · Wu Xie Pian* states, "When pathogens are in the Liver, there is pain in the middle of both hypochondria." This "pathogen" includes Fluid pathogens, as ancient sages clearly instructed. For example, *Jin Gui Yao Lue* says, "After drinking, water flows under the hypochondrium, coughing and spitting induce pain, called Xuan Yin." Article 41 of the Lower Jiao Chapter in *Wenbing Tiaobian* states, "For hypochondriac pain due to latent summerheat or damp-warmth, with or without cough, no chills but tidal fever, or even chills and fever like malaria, do not mistakenly diagnose as Chaihu syndrome; Xiangfu Xuanfuhua Tang governs it." Wu Jutong believed this type of hypochondriac pain corresponds to the *Jin Gui* case of water in the Liver where Shizao Tang would still be used. Because the pathology is relatively mild, simply using Xiangfu Xuanfuhua Tang to drain fluids and unblock collaterals suffices.

Intern A: Ancient texts mention hypochondriac pain caused by drinking, latent summerheat, or damp-warmth, but this case is caused by hepatitis!

Teacher: Clinical observation shows that hypochondriac pain due to Fluid pathogens has diverse origins, not limited to drinking, latent summerheat, or damp-warmth. However, the pathogenesis of Fluid pathogens obstructing Liver collaterals causing pain due to obstruction remains consistent. Modern medicine considers this syndrome similar to exudative pleurisy and pleural effusion. In recent years, some cases of acute hepatitis, chronic hepatitis, chronic cholecystitis, asthma, etc., that I treated presented similarly. Nevertheless, to use this formula accurately, the key is to master the characteristic symptom of this hypochondriac pain—pulling pain (Che Tong). Please note, it is not distending, stabbing, or dull pain, but pulling pain. When body position is fixed, there is no pain or only slight pain; once the body position moves, such as turning over, twisting, bending, or walking, pulling pain becomes unbearable. This is obtained through inquiry, so those negligent in inquiry must beware! Early in this syndrome, it is easily misdiagnosed as Chaihu syndrome because the characteristic symptom was not mastered.

Advanced Student A: How did you discover this characteristic symptom and deduce the special treatment?

Teacher: The ancients said, "Three broken arms make a good doctor." Did I have such insight and understanding in my early years? No, this was entirely taught by Elder Jiang. Elder Jiang himself, in his youth, while treating his own illness and facing difficulties, had his confusion resolved by his teacher, Mr. Chen Dingsan. When Elder Jiang was 20 years old, in mid-autumn, he caught a cold, coughed, experienced hypochondriac pulling pain, and chills/fever like malaria. He self-prescribed modified Xiao Chaihu Tang without effect. His teacher smiled and said, "This is not Chaihu syndrome, but Xiangfu Xuanfuhua Tang syndrome." He immediately wrote the original formula (Sheng Xiangfu, Xuanfuhua, Suzi, Guang Chenpi, Fuling each 9g; Faxia, Yiren each 15g). Elder Jiang disliked the bitter taste, vomiting upon swallowing. Within half a day, he intermittently vomited about a bowl of sticky saliva. Unexpectedly, the hypochondriac pain and chills/fever completely disappeared. Secretly pleased with the formula's efficacy, he consulted his teacher. When his teacher showed him Article 41 of the Lower Jiao Chapter in *Wenbing Tiaobian*, Elder Jiang suddenly understood: he had mistakenly diagnosed Chaihu syndrome! But since it was not Chaihu syndrome, how to explain the hypochondriac pain and chills/fever? Wu Jutong's self-note says, "This is due to seasonal pathogens newly combining with interior fluids..." Truly hitting the nail on the head! As Elder Jiang gained experience, he compared Chaihu syndrome with Xiangfu Xuanfuhua Tang syndrome, realizing that although their chills/fever were similar, their chest/hypochondrium symptoms were vastly different. Chaihu syndrome presents with chest/hypochondriac fullness and distress, or pain, but absolutely not pulling pain; it is formless pathogen stagnating in Shaoyang,偏向 half-exterior. Xiangfu Xuanfuhua Tang syndrome presents with chest/hypochondriac pulling pain, not fullness/distress; it is formed fluid retention in chest/hypochondrium,偏向 half-interior. The differential diagnosis lies precisely here.

Student C: This makes it impossible to completely avoid a longstanding medical controversy—the location of Shaoyang disease.

Teacher: Although it cannot be completely avoided, we can at least avoid pure theoretical entanglements and focus on clinical practice. Elder Jiang believed that Chaihu syndrome and Xiangfu Xuanfuhua Tang syndrome are the two most common syndromes of Shaoyang disease clinically. Determining the location of Shaoyang disease ultimately comes down to determining which Zang-Fu organs the Couli (pores/collaterals) and hypochondrium belong to. *Jin Gui Yao Lue* states, "Cou refers to the place where the Triple Burner connects with Yuan Zhen (original Qi), where Blood and Qi flow; Li refers to the texture of skin and Zang-Fu organs." Thus, Couli belongs to the Triple Burner. The hypochondrium is the thoracic and abdominal cavity, inside the body shell but outside the Zang-Fu organs, also belonging to the Triple Burner region. Therefore, Chen Xiuyuan said, "Shaoyang internally governs the Triple Burner and externally governs Couli." This is the location of Shaoyang disease.

Advanced Student B: I believe what should especially not be avoided is that this case of chronic hepatitis hypochondriac pain lacks external symptoms like alternating chills/fever or malaria-like fever. If strictly adhering to the principle of "formula-syndrome correspondence," Xiangfu Xuanfuhua Tang should not be used.

Teacher: External symptoms are not required to use this formula. This point was also summarized by Elder Jiang from his personal experience. He described it as "Like a fish drinking water, knowing whether it is warm or cold oneself." When he was nearly 60, after recovering from facial neuritis, also in mid-autumn, he caught a chill. External symptoms were not obvious, only right hypochondriac pulling pain, which he ignored. By night, the pulling pain intensified, radiating to the kidney area. At midnight, pain worsened, unable to turn over or breathe deeply. Supported by family, he could hardly endure. Next morning, Western medicine diagnosed "lobar pneumonia" and wanted to use antibiotics. Elder Jiang self-prescribed this formula plus Jiangxiang, Baijiezi, and Gualouren. After one dose, pain greatly reduced by evening; after another dose, pain stopped. Over decades, Elder Jiang used this formula to cure many patients with pleurisy and pleural effusion, mostly without external symptoms. Generally, 2-4 doses stop hypochondriac pulling pain. Expanding this formula to treat chronic hepatitis, chronic cholecystitis, asthma, etc., caused by Fluid pathogens blocking Liver collaterals, also mostly lacked external symptoms. By maintaining the method and formula, modifying according to symptoms, and persisting in administration, rapid effects could be silently achieved. Therefore, Elder Jiang advocated when reading ancient books: first, do not let words harm meaning; second, do not detach from clinical practice and die by the text.

Intern B: I see the herbs in this formula are quite plain, yet the efficacy is extraordinary. There must be secrets in modification to turn plain into magical. Is this true?

Teacher: Most Jingfang (classical formulas) or famous Shifang (contemporary formulas) have relatively plain herb compositions. In my view, as long as they accurately target the etiology and pathogenesis, yield significant efficacy, and withstand repetition, what does "plain" matter! Wu Jutong's self-note on this formula states, "Xiangfu and Xuanfuhua excel at unblocking Liver collaterals and driving out fluid under the hypochondrium; Suzi and Xingren (originally no Xingren in the formula—note by author) descend Lung Qi and transform fluid, known as building Metal to calm Wood; Guangpi and Banxia eliminate phlegm-fluid; Fuling and Yiren open Taiyang and close Yangming, known as 'those who treat water must solidify the upper, and divert branches when the main stream floods'." Judging by clinical efficacy, Wu's self-note contains no exaggeration.

Intern B: Wu said, "Xiangfu and Xuanfuhua excel at unblocking Liver collaterals and driving out fluid under the hypochondrium...", but Xuanfuhua fundamentally does not enter the Liver Meridian.

Teacher: Xiangfu primarily enters the Liver Meridian and can guide Xuanfuhua into the Liver to unblock collaterals. If accompanied by pathogen blocking Couli with alternating chills/fever, add Qinghao and Chaihu to open Couli and vent pathogens; if accompanied by rebellious Fluid pathogens causing dizziness/dizziness, combine with Linggui Zhugan Tang to transform fluid and direct rebellion downwards; if accompanied by Spleen deficiency failing to transport, epigastric fullness/distension, combine with Xiangsha Liujunzi Tang to strengthen Spleen and assist transport; if accompanied by turbid Dampness trapping Spleen with thick greasy coating and poor appetite, heavily add Shichangpu, Peilan, and Guang Huoxiang to transform turbidity and awaken Spleen; if accompanied by Blood stasis凝 collaterals with stabbing hypochondriac pain, add Jiangxiang, Danshen, Qiancao, and Shuchong to remove stasis and unblock collaterals. This is not a secret; it is merely observing pulse and symptoms, carefully examining concurrent factors, and modifying according to the syndrome.

Discussing Several Thinking Methods for Using Mahuang Fuzi Xixin Tang
Director of TCM Research Office, Leshan People's Hospital, Sichuan Province: Yu Guojun

*Mahuang Fuzi Xixin Tang* from *Shanghan Lun* is a highly effective formula for treating simultaneous Taiyang and Shaoyin diseases. The original text states, "In early Shaoyin disease, contrary to expectation, there is fever and a deep pulse; Mahuang Fuzi Xixin Tang governs it." *Tangtou Gejue* says, "Mahuang Fuzi Xixin Tang, revealing exterior and warming meridians, two methods are manifest; if not treating exterior and interior simultaneously, how can Shaoyin fever recover?" The basic pathogenesis of simultaneous Taiyang and Shaoyin diseases is Heart-Kidney Yang deficiency compounded by Cold pathogen invasion, affecting both exterior and interior. Thus, Mahuang is used to release the exterior and scatter cold, Fuzi to warm the Kidney and strengthen the Heart, and Xixin to search out and warm-scatter Cold pathogens penetrating deeply into Shaoyin. This formula contains only three herbs, with precise compatibility, specific function, and grand efficacy. It has many clinical applications, far exceeding the scope of the original text, and can be widely used in Internal Medicine, Surgery, Gynecology, Pediatrics, and Otorhinolaryngology.

The main problem currently existing in clinical practice is: some physicians fear Mahuang, Xixin, and Fuzi and dare not use them; others, even when encountering indications, are unwilling to use it alone or with slight modifications (adding only one or two herbs), but must modify it beyond recognition or let secondary herbs overshadow the principal ones. In such cases, efficacy naturally decreases, even becoming ineffective. When reflecting, instead of blaming errors in thinking methods, they complain that classical formulas are difficult to use. As the proverb goes, "To do a good job, one must first sharpen one's tools." Here, combining several cases, I discuss several thinking methods for using this formula, hoping to throw a brick to attract jade.