（季胁痛 腋下肿痛）
经云。肝病者。两胁下痛引小腹。令人善怒。肝病内舍胸胁。邪在肝。则两胁下痛。肝热病
者。胁满痛。胆动。病心胁痛。不可反侧。肝所生病。腋下肿胁痛。肺病传肝。胁痛出食。
肝舍于 胁。故胁痛多属于肝。然经筋所过挟邪而痛者。自有多端。不可执一。且左右者。
阴阳之道路。故肝主阴血而属于左胁。脾主阳气而隶于右胁。左胁多怒伤或留血作痛。右胁多痰
积或气郁作痛。其间七情六郁之犯。饮食劳动之伤。皆足以致痰凝气聚。血蓄成积。虽然。痰气
亦有流于左胁者。然必与血相持而痛。血积亦有伤于右胁者。然必因脾气衰而致。其间虚实治法。
可默悟矣。
伤寒少阳胁痛。用小柴胡汤。硬满。加薄桂。不大便。加枳壳。兼胸胁满痛。加枳、桔。若
不因伤寒而胁痛。身体微热。枳壳煮散。盖枳壳为治胁痛专药。诸方皆用之。寒气引胁下痛。枳
实理中汤。戴复庵云。腹纳诸般冷痛。枳实理中汤加减。作无限用。胁痛而气喘。分气紫苏饮、
增损流气饮选用。有胁痛而吐血者。此热伤肝也。小柴胡去半夏、黄芩。加丹皮、鳖甲。两胁肿
痛。或腹痛。或小便涩滞者。属湿热。龙胆泻肝汤。脉弦痛在左属肝火。宜柴胡山栀、当归、青
皮、芍药。不已。加吴茱萸炒川连。甚则加酒炒龙胆草。如果肝气实。当归龙荟丸。因怒伤肝。
肝气郁甚。柴胡疏肝散。气滞作痛。两手脉沉伏或弦。痛引胸胁。不得俯仰屈伸。二陈加枳壳、
香附、木香。左胁痛者。木气实也。抑青丸。火盛
者。佐金丸从治之。有蓄血偏着左胁而痛者。复元活血汤。右胁痛。乃悲伤肺气所致。推气散加
桔梗。或只用川芎、枳壳二味作汤服之。胁下偏痛发热。其脉紧弦。此寒也。以温药下之。宜金
匮大黄附子汤。两胁走痛。脉沉弦而滑。乃湿痰流注在胁下。导痰汤加白芥子、枳壳、香附、木
香。甚则控涎丹导而下之。食积寒痰。流于胁下。痛若锥刺。手不可近。诸药不效者。神保丸。
食积胁痛发寒热。痛引心下。恶心恶食。必有一条扛起。有脉必滑。二陈加香、砂、枳、术、曲、
朴、楂、芽。甚则加吴茱萸制川连。结积痰癖冷痛。煮黄丸。气弱人胁下痛。脉弦细或紧。多从
劳役怒气得之。六君子加木香、芎、归、桂心。肥白人气虚发热而胁痛。用参、 、柴胡、黄芩、
枳壳、木香之类。甚则加桂。瘦弱人阴虚寒热。胁下痛多怒。必有瘀血。宜桃仁、红花、柴胡、
青皮、丹皮、鳖甲之类。甚则加大黄。咳嗽引胁下痛。为水饮停蓄。小青龙汤。胁下硬满引痛。
干呕短气。汗出不恶寒。有时头痛心下痞者。十枣汤。干咳引胁下痛。发寒热。为郁结所致。逍
遥散。若胁下有块痛。乃过饱劳力所致。逍遥散加木香、丹皮、青皮。死血作痛。日轻夜重。或
午后热。脉短涩。桃核承气汤。易肉桂。加穿山甲、鳖甲、青皮。不应。加熟附子一片。如跌扑
胁痛。亦宜上方。凡内伤胁痛不止者。生香油一盏。生蜜一杯。和匀服。一二次即止。房劳肾虚
之人。胸膈胁肋多隐隐微痛。乃肾虚不能纳气。气虚不能生血之故。宜补骨脂、杜仲、牛膝补肾。
当归、熟地和血。及七味丸调理。
季胁痛 经云。冬脉不及。则令人心悬如病饥。 中清。脊中痛。少腹满。小便变。又足少
阳之筋。引胁外转筋。膝不可屈伸。 筋急。前引髀后引尻。即上乘 。季胁痛。按季胁痛。无
不因肾虚者。加减八味丸、肾气丸选用。
腋下肿痛 少阳湿热留薄。则腋下肿痛。小柴胡加抚芎、枳壳。实人。去参加草龙胆。体肥
痰盛。加白芥子。有痰饮
搏聚而痛者。加味导痰汤加柴胡为向导。
〔诊〕脉双弦者。肝气有余。两胁作痛。弦数有力。为肝盛有余。弦数无力。为肝虚有火。弦
小而细为饮。脉沉为气。浮弦为风。弦小而弱者。为阳虚。沉细为阴虚。
刘默生治诸葛子立。胁痛连腰脊不能转侧。服六味丸加杜仲、续断。不效。或者以为不能转
侧。必因闪挫。与推气散转剧。刘诊之曰。脉得弦细乏力。虚寒可知。与生料八味加茴香。四剂而安。
(Ji Xi Tong [Pain in the Hypochondriac Region near the Flank] and Swelling and Pain in the Axilla)
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: When the Liver is diseased, pain occurs under both hypochondria and radiates to the lower abdomen, causing irritability. In liver disease, the pathogenic factor invades internally into the chest and hypochondrium. When the pathogen is in the Liver, pain occurs under both hypochondria. In cases of Liver Heat Disease, there is fullness and pain in the hypochondrium, with hyperactive Gallbladder Qi. In Heart-Hypochondrium Pain, the body cannot turn or lie on its side. These are diseases generated by the Liver channel, manifesting as swelling in the axilla and pain in the hypochondrium. When Lung disease transmits to the Liver, it causes hypochondriac pain accompanied by vomiting of food. The Liver meridian traverses the hypochondrium; therefore, hypochondriac pain mostly belongs to Liver disorders. However, pain caused by pathogens lodging in the meridians and sinews has various origins and cannot be rigidly attributed to a single cause. Furthermore, the left and right sides are the pathways of Yin and Yang. The Liver governs Yin Blood, so pathology often manifests in the left hypochondrium; the Spleen governs Yang Qi, so pathology often manifests in the right hypochondrium. Pain in the left hypochondrium is mostly due to anger injuring the Liver or blood stasis retention; pain in the right hypochondrium is mostly due to phlegm accumulation or Qi stagnation. Invasions of Seven Emotions and Six Stagnations, as well as injuries from diet and labor, are sufficient to cause phlegm condensation and Qi gathering, leading to blood stasis and mass formation. Although Phlegm-Qi may also flow to the left hypochondrium, it must contend with blood stasis to cause pain. Blood masses may also injure the right hypochondrium, but this must be due to Spleen Qi deficiency. The treatment methods for deficiency and excess can be intuitively understood.
For hypochondriac pain caused by Shaoyang syndrome in Cold Damage, use Xiao Chai Hu Tang (Minor Bupleurum Decoction). If hardness and fullness are present, add Bo Gui Zhi (Thin Cinnamon Twig); if constipation exists, add Zhi Ke (Aurantium Fructus); if accompanied by chest and hypochondriac fullness and pain, add Zhi Shi (Immature Aurantium Fruit) and Jie Geng (Platycodon Root). If hypochondriac pain is not caused by Cold Damage but accompanied by slight fever, use Zhi Ke Zhu San (Decoction of Aurantium Fructus), as Zhi Ke is a specific herb for treating hypochondriac pain and is used in various formulas. For cold pathogen inducing pain under the hypochondrium, use Zhi Shi Li Zhong Tang (Immature Aurantium and Magnolia Bark Decoction to Regulate the Middle). Dai Fu'an stated that for various types of cold pain in the abdomen, Zhi Shi Li Zhong Tang should be used with modifications as a standard remedy. For hypochondriac pain with asthma, select Fen Zi Zi Su Yin (Branchial Purple Perilla Drink) or Zeng Sun Liu Qi Yin (Increased and Reduced Flowing Qi Drink). For hypochondriac pain with hematemesis, this indicates heat damaging the Liver. Use Xiao Chai Hu Tang removing Ban Xia (Pinellia Tuber) and Huang Qin (Scutellaria Root), adding Dan Pi (Moutan Cortex) and Bie Jia (Carapax Testudinis). For swelling and pain in both hypochondria, or abdominal pain, or dysuria, this belongs to Damp-Heat; use Long Dan Xie Gan Tang (Gentian Decoction to Drain the Liver). A wiry pulse with pain on the left indicates Liver Fire; use Chai Hu (Bupleuri Radix), Shan Zhi (Gardeniae Fructus), Dang Gui (Angelicae Sinensis Radix), Qing Pi (Citri Reticulatae Pericarpium Viride), and Shao Yao (Paeoniae Radix Alba). If unrelieved, add Wu Zhu Yu (Evodiae Fructus) stir-fried with Chuan Lian Zi (Coptidis Rhizoma). In severe cases, add Jiu Chao Long Dan Cao (Alcohol-processed Gentiana Root). If Liver Qi is excessive, use Dang Gui Long Hui Wan (Angelica and Gardenia Pill). Due to anger injuring the Liver and severe Liver Qi depression, use Chai Hu Shu Gan San (Bupleurum Powder to Soothe the Liver). For pain due to Qi stagnation, with deep or wiry pulses in both hands, pain radiating to the chest and hypochondrium preventing flexion, extension, bending, or stretching, use Er Chen Tang (Two-Cured Decoction) plus Zhi Ke, Xiang Fu (Cyperus Rhizoma), and Mu Xiang (Aucklandiae Radix). Left hypochondriac pain indicates excessive Wood Qi; use Yi Qing Wan (Suppress Cyan Pill). For excessive fire, use Zuo Jin Wan (Assist Metal Pill) for counter-treatment. For blood stasis localized to the left hypochondrium causing pain, use Fu Yuan Huo Xue Tang (Restore Original Blood-Activating Decoction). Right hypochondriac pain is caused by sadness damaging Lung Qi; use Tui Qi San (Pushing Away Qi Powder) plus Jie Geng, or simply use Chuan Xiong (Ligusticum Chuanxiong Rhizome) and Zhi Ke decocted together. Pain in one side of the hypochondrium with fever and a tight, wiry pulse indicates Cold; treat with warming purgatives, using Jin Gui Da Huang Fu Zi Tang (Da Huang, Aconite, and Ma Huang Decoction from the Golden Cabinet). Wandering pain in both hypochondria with a deep, wiry, and slippery pulse indicates Wet-Phlegm flowing into the hypochondrium; use Dao Tan Tang (Guiding Phlegm Decoction) plus Bai Jie Zi (Brassicae Semis Albus), Zhi Ke, Xiang Fu, and Mu Xiang. In severe cases, use Kong Xian Dan (Controlling Fluids Pill) to guide downward. For food stagnation and cold phlegm flowing into the hypochondrium, causing stabbing pain intolerable to touch, unresponsive to other medicines, use Shen Bao Wan (Divine Treasure Pill). Food stagnation hypochondriac pain with chills and fever, pain radiating to the epigastrium, nausea, and anorexia, accompanied by a visible raised band and a slippery pulse, uses Er Chen Tang plus Xiang Fu, Sha Ren (Amomi Fructus), Zhi Shi, Bai Zhu (Atractylodis Macrocephalae Rhizoma), Shen Qu (Massa Medicata Fermentata), Hou Po (Magnoliae Officinalis Cortex), Shan Zha (Crataegi Fructus), and Mai Ya (Hordei Fructus Germinatus). In severe cases, add Wu Zhu Yu processed Chuan Lian Zi. For accumulated phlegm-paralysis and cold pain, use Zhu Huang Wan (Boiled Yellow Pill). For Qi-deficient individuals with hypochondriac pain, wiry-thin or tight pulses, often arising from labor and anger, use Liu Jun Zi Tang (Six-Gentlemen Decoction) plus Mu Xiang, Chuan Xiong, Dang Gui, and Gui Xin (Cinnamomi Cortex). For obese, white-complexioned individuals with Qi deficiency fever and hypochondriac pain, use Ren Shen (Ginseng Radix), [missing character], Chai Hu, Huang Qin, Zhi Ke, and Mu Xiang. In severe cases, add Gui Zhi (Cinnamon Twig). For emaciated individuals with Yin deficiency alternating chills and fever, hypochondriac pain with irritability, and likely blood stasis, use Tao Ren (Pruni Semen), Hong Hua (Carthami Flos), Chai Hu, Qing Pi, Dan Pi, and Bie Jia. In severe cases, add Da Huang (Rhei Radix et Rhizoma). Cough inducing hypochondriac pain indicates fluid retention; use Xiao Qing Long Tang (Minor Green Dragon Decoction). Hardness and fullness in the hypochondrium inducing pain, dry retching, shortness of breath, sweating without aversion to cold, and occasional headache with epigastric stuffiness indicate Shi Zao Tang (Ten Jujube Decoction). Dry cough inducing hypochondriac pain with chills and fever indicates constraint; use Xiao Yao San (Free and Easy Wanderer Powder). If a mass in the hypochondrium causes pain due to overeating and labor, use Xiao Yao San plus Mu Xiang, Dan Pi, and Qing Pi. For fixed blood stasis pain, lighter during the day and heavier at night, or afternoon fever, with a short and choppy pulse, use Tao He Cheng Qi Tang (Peach Kernel and Rhubarb Decoction), replacing Rou Gui (Cinnamon Bark) with Yi Rou Gui, plus Chuan Shan Jia (Manis Squama), Bie Jia, and Qing Pi. If ineffective, add one piece of Shu Fu Zi (Prepared Aconiti Lateralis Radix). For trauma-induced hypochondriac pain, the above formula is also suitable. For internal injury hypochondriac pain unrelenting, take one liang of raw sesame oil and one cup of raw honey, mixed and taken orally; it stops after one or two doses. For individuals with Kidney deficiency due to sexual exhaustion, there is often dull, slight pain in the chest, diaphragm, and hypochondrium, due to Kidney deficiency failing to grasp Qi and Qi deficiency failing to generate Blood. Use Bu Gu Zhi (Psoraleae Fructus), Du Zhong (Eucommiae Cortex), and Niu Xi (Achyranthis Bidentatae Radix) to tonify the Kidney; Dang Gui and Shu Di Huang (Rehmanniae Radix Praeparata) to nourish and harmonize Blood; and Qi Wei Wan (Seven-Ingredient Pill) for regulation.
Ji Xi Tong (Pain in the Hypochondriac Region near the Flank): The *Neijing* states: If the Winter pulse is deficient, it causes a sensation of hunger with the heart hanging empty, internal cold, spinal pain, lower abdominal fullness, and abnormal urination. Additionally, the sinews of Foot-Shaoyang draw the hypochondrium outward causing twitching, knee inability to flex or extend, tendon tension, anterior drawing to the thigh and posterior drawing to the sacrum, reaching up to Ji Xi, causing Ji Xi pain. Generally, Ji Xi pain is invariably due to Kidney deficiency; select Jia Jian Ba Wei Wan (Modified Eight-Ingredient Pill) or Shen Qi Wan (Kidney Qi Pill).
Swelling and Pain in the Axilla: Shaoyang Damp-Heat lingering and pressing causes swelling and pain in the axilla. Use Xiao Chai Hu Tang plus Fu Xiong (Cyathulae Radix) and Zhi Ke. For robust constitutions, remove Gan Cao (Glycyrrhizae Radix) and add Long Dan Cao (Gentiana Root). For obese individuals with abundant phlegm, add Bai Jie Zi (Brassicae Semis Albus). For pain caused by phlegm-fluid aggregation, use Jia Wei Dao Tan Tang (Modified Guiding Phlegm Decoction) with Chai Hu as a guiding herb.
[Diagnosis]: A double-wiry pulse indicates Liver Qi excess, causing bilateral hypochondriac pain. A wiry, rapid, and forceful pulse indicates Liver Excess; a wiry, rapid, and weak pulse indicates Liver Deficiency with Empty Fire. A wiry, small, and thin pulse indicates Fluid retention; a deep pulse indicates Qi stagnation; a floating-wiry pulse indicates Wind. A wiry, small, and weak pulse indicates Yang deficiency; a deep-thin pulse indicates Yin deficiency.
Liu Mosheng treated Zhuge Zili, who suffered from hypochondriac pain radiating to the lumbar spine, unable to turn or move. After taking Liu Wei Wan (Six-Ingredient Pill) plus Du Zhong and Xu Duan (Dipsaci Radix) with no effect, some believed the immobility was due to sprain/strain and prescribed Tui Qi San, which worsened the condition. Liu diagnosed: "The pulse is wiry, thin, and powerless, indicating deficiency-cold." He prescribed Sheng Liao Ba Wei Wan (Raw Material Eight-Ingredient Pill) plus Hui Xiang (Foeniculi Fructus). After four doses, the patient recovered.