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Mr. Hu: Borborygmus (intestinal rumbling) in the abdomen with severe cutting pain; when the pain is severe, distension spreads to both flanks of the waist, accompanied by vomiting of sour and bitter fluids. This is due to cold-dampness invading the Spleen, indicating a deficiency of Yang Qi in the Middle Jiao (Middle Burner). Treatment should involve warming and unblocking.
Fuzi Lizhong Tang (Aconite Decoction for Regulating the Middle) minus Licorice Root, plus Sichuan Pepper, Evodia Fruit, and Red Flower Buckwheat Seed.

Re-examination: Deficiency-cold of the Spleen organ, with accumulated phlegm-fluids obstructing the mechanism. Abdominal pain occurs intermittently; severe pain leads to vomiting. Following the method of Scholar Xu.
Fuzi Lizhong Tang (Aconite Decoction for Regulating the Middle) plus Angelica Sinensis Root, Poria, Evodia Fruit, Immature Bitter Orange, and Rhubarb.

Note by Yuan: The method of warming and purging is excellent; it is a pity that subsequent physicians changed the treatment arbitrarily.

Re-examination: Abdominal pain, with distension worsening in the afternoon; pulse is deep and wiry. This belongs to deficiency-cold complicated by accumulation. Previously used warming and purging, which slightly reduced the pain. Now using warming the middle and resolving accumulation.
Prepared Aconite Root, Codonopsis Root, Dried Ginger, Betel Nut, Poria, Angelica Sinensis Root, Green Tangerine Peel, Aged Tangerine Peel, Lindera Root.

Re-examination: Abdominal pain for three years, intermittent, with cold in the Middle Jiao; warming and transforming is undoubtedly correct. However, the pulse is small, wiry, and slippery, indicating the presence of accumulated pathogens. Previous use of warming-purging and warming-unblocking methods reduced the illness but did not stabilize it. The patient reports that pain doubles during the fifth lunar month, suggesting concurrent damp-heat. Thus, the pulse is floating and small on the surface but forceful when pressed deeply, indicating hidden Yang within Yin. Treatment should regulate the pivot of Shaoyin, warm the Qi of Jueyin, move the stagnation of Taiyin, and refer to the method of "slippery substances to remove adherence."
Bupleurum Root, White Peony Root, Immature Bitter Orange, Licorice Root, Evodia Fruit, Poria, Costus Root, Atractylodes Macrocephala Rhizome.
Separately: Take three segments of eel, use the central seven inches, roast until crisp, grind into powder, divide into three doses.

Note by Yuan: Since accumulated pathogens are known, why not continue with warming-purging? A three-year illness is likely not merely chronic deficiency. A floating-small and deep-forceful pulse indicates accumulation hidden in the Lower Jiao. Pain causes Qi to gather below, hence the deep-forceful pulse. This argument is plausible but incorrect.

Re-examination: Abdominal pain, left pulse is wiry, indicating Liver Wood overacting on Spleen Earth. Zhang Zhongjing stated: For abdominal pain with a wiry pulse, Xiaojianzhong Tang (Minor Construct the Middle Decoction) is indicated. If ineffective, Xiaochaihu Tang (Minor Bupleurum Decoction) is used to vent the Wood within the Earth. My previous use of Sixian San (Four Reversal Powder) followed this intent. However, three years of abdominal pain, relieved somewhat by eating, ultimately points to Middle Jiao deficiency, with borborygmus suggesting concurrent fluid retention. I propose constructing the Middle method with added Pepper Eye to drain fluids, then observe.
Old Cinnamon Twig, White Peony Root, Dried Ginger, Honey-fried Licorice Root, Codonopsis Root, Pepper Eye.

Note by Yuan: This condition involves cold with accumulation, constituting a deficiency-excess syndrome, which does not match the sweet-warm tonification of Jianzhong Tang. Hence, after taking it, pain attacks upward because sweet substances can cause fullness in the middle, causing Stomach Qi to fail to descend smoothly.

Re-examination: After using Jianzhong method, pain attacked upward to the epigastrium and heart region; only the left pulse was wiry and slippery, indicating Liver pathogen attacking the Stomach. Tentatively prescribing liver-soothing method.
Golden Bell Fruit, Corydalis Rhizome, Evodia Fruit, Cyperus Rhizome, Galangal Root, Costus Root, Sandalwood.

Mr. Shen: Liver-Stomach Qi pain, vomiting sour water upon attack. Treat with warming and unblocking.
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Trichosanthes Peel, Evodia Fruit, White Pepper, Angelica Sinensis Root, Cyperus Rhizome, and Chinaberry Seed.

Ms. Shi: Epigastric pain occurring intermittently, history of vomiting roundworms, accompanied by epistaxis. Female, fourteen years old, menstruation has not yet commenced. Likely due to cold in the Stomach and fire in the Liver.
Jinlingzi San (Golden Bell Powder) plus Trogopterus Dung, Cyperus Rhizome, Dried Ginger, Coptis Rhizome, Quisqualis Fruit Flesh, Lindera Root, Mume Fruit, and Poria.

Re-examination: Liver-Stomach disharmony, epigastric and hypochondriac pain, relieved by eating, indicating Middle Qi deficiency. Prescribing draining Liver and harmonizing Stomach method.
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Coptis Rhizome, Medicated Leaven, Lindera Root, Galangal Root, Cyperus Rhizome, and Amomum Fruit.

Mr. Yin: Vomiting without desire to eat, pathology in the Stomach. Eating causes abdominal pain, pathology in the Spleen. Pain radiating to chest and hypochondrium indicates Liver involvement. Qi is weak, Blood is dry, disease is deep. Treatment focuses on harmonizing Stomach, nourishing Blood, generating fluids, and boosting Qi.
Cistanche Stem, Goji Berry, Angelica Sinensis Root, Hemp Seed, Barley Grain, Poria, Pinellia Tuber, Aged Tangerine Peel, Agarwood, Amomum Fruit.

Mr. Tan: Epigastric pain with nausea, severe cases risking cold limbs.
Codonopsis Root, Aged Tangerine Peel, Poria, Sichuan Pepper, Evodia Fruit, Cardamom Seed, Fresh Ginger.

Mr. Feng: Decline of Spleen-Stomach Yang, turbid Yin rising rebelliously. Every afternoon, a mass appears on the left side of the abdomen; when it rises, there is cardiac discomfort (heartburn), leading to epigastric pain, stopping at dusk. Stool is often difficult.
Prescribing to unblock Stomach Yang and transform turbid Yin, harmonize and nourish Blood to please Spleen Qi.
Cistanche Stem, Aged Tangerine Peel, Evodia Fruit, Poria, Biota Seed, Prunus Seed, Astragalus Complanatus Seed, Mume Fruit, Sichuan Pepper, Processed Pinellia Tuber.

Re-examination: Epigastric pain with vomiting acid, abdominal pain as well. Without acrid-warm herbs, how can cold be dispersed and fluids eliminated?
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Cistanche Stem, Angelica Sinensis Root, Dried Ginger, Evodia Fruit, Lindera Root, and Amomum Fruit.

Re-examination: Warm Kidney and unblock Yang to disperse lingering cold. Long-term use will naturally resolve abdominal pain.
Previous formula minus Angelica Sinensis Root, plus Prepared Aconite Root and Fenugreek Seed.

Mr. Gu: Hard and painful tenderness around the umbilicus, inability to eat or pass stool, external appearance of aversion to cold, internal absence of significant heat, thirst with little desire to drink. Cold food, wind, and heat mutually knot in the Spleen-Stomach. Use Wuji San (Five Accumulations Powder) from Ju Fang combined with Tongsheng San, treating exterior and interior separately.
Wuji combined with Tongsheng, ground into powder. Mix three qian with boiled water for morning and evening doses.

Re-examination: Used Wuji combined with Tongsheng for warming, unblocking, and dispersing cold. Stool passed but pain persisted. Pulse is slow, preference for sweet taste, pain at umbilicus radiating to lower back, constant shivering aversion to cold. This indicates Middle deficiency and weak Yang, with cold accumulation internally. Prescribing unblocking Yang to break lingering cold, benefiting Fire to dissipate Yin shadows.
Sijunzi Tang (Four Gentlemen Decoction) minus Licorice Root, plus Cinnamon Bark, Processed Aconite Root, Aucklandia Root, Mirabilite, Lindera Root, and Cistanche Stem.

Re-examination: Warming viscera and dispersing cold, abdominal pain has stopped. Now should tonify with warmth.
Cistanche Stem, Goji Berry, Prepared Rehmannia Root, Angelica Sinensis Root, Poria, Aged Tangerine Peel, Evodia Fruit, Processed Aconite Root, Lindera Root, Amomum Fruit.

Note by Yuan: Still feels cloying and stagnant. It would be better to modify Sijunzi Tang.

Mr. Yuan: Abdominal pain frequently occurring for three to four years, extremely severe upon attack, taking several days to subside. This is cold accumulation in the Spleen organ and damp-heat in the Liver meridian, hence feeling heat in the abdomen during pain. Prescribing warming Spleen while cooling Liver.
Jinlingzi San (Golden Bell Powder) plus Aged Tangerine Peel, Poria, Dried Ginger, Atractylodes Macrocephala Rhizome, Magnolia Bark, White Peony Root, Medicated Leaven, and Amomum Fruit.

Re-examination: Abdominal pain due to mixed cold accumulation; Yue Tao San (Persimmon Calyx Powder) is best throughout ancient and modern times. Change powder to pill form.
Mild Evodia Fruit, Dried Ginger, Gardenia Fruit, White Peony Root, Honey-fried Licorice Root.
One liang of Medicated Leaven powder, cooked into paste to form pills. Take three qian every morning with boiled water.
Yue Tao San consists only of Ginger and Gardenia. Adding Evodia and White Peony repeats the Wuji method. Adding Licorice aims at harmonization.

Unknown Patient: Insufficiency of Middle Qi leads to changes in urination and defecation. Abdominal masses (jia) are also due to failure of Qi movement.
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Atractylodes Macrocephala Rhizome, Astragalus Complanatus Seed, Charred Medicated Leaven, Coix Seed, Alisma Rhizome, Amomum Fruit, and Tongcao.

Re-examination: Liver-Stomach disharmony, epigastric and abdominal pain, vomiting sour water and phlegm, abdominal pain during menstruation. First, drain Liver and harmonize Stomach.
Coptis Rhizome, Pinellia Tuber, Aged Tangerine Peel, Poria, Trichosanthes Peel, Allium Macrostemon Bulb, Dried Ginger, Cardamom Seed, Crimson Silk, Inula Flower.

Re-examination: Long-standing abdominal masses, now aggravated by cold food injuring the Middle, causing abdominal pain, diarrhea, and incessant vomiting, with sensation of heat in the heart. Prescribing bitter-acrid descending method to stop vomiting first.
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Scutellaria Root, Coptis Rhizome, Magnolia Bark, Perilla Stem, Agastache Stem, Cardamom Seed, and Alisma Rhizome. Modified formula adds Medicated Leaven.

Unknown Patient: Illness began in autumn of the 4th year of Xianfeng era after overeating and lying down, lasting five years. Overuse of resolving accumulation and breaking Qi medicines injured Middle Qi. Epigastric stuffiness and pain, relieved by eating, inability to belch or pass flatus, pulse slow and wiry. Liver-Stomach disharmony, Yang deficiency with cold gathering in the Middle. Prescribing unblocking Yang and venting Wood method.
Ling Gui Zhu Gan Tang (Poria, Cinnamon, Atractylodes, and Licorice Decoction) plus Aged Tangerine Peel, White Peony Root, Evodia Fruit, Dried Ginger, and Jujube.

Re-examination: Pain radiating between chest and back, syndrome belongs to Chest Bi (Obstruction).
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Trichosanthes Seed, Processed Aconite Root, Cinnamon Twig, Dried Ginger, Evodia Fruit, Cardamom Seed, and Bamboo Shavings.

Mr. Sun: Middle deficiency, Earth fails to control Water, Yin Qi from Lower Jiao rebels upward to Stomach. Epigastric pain, vomiting clear water, pain relieved by eating. Prescribing warming Middle and securing Lower, assisted by anchoring rebellion.
Sijunzi Tang (Four Gentlemen Decoction) minus Licorice Root, plus Dried Ginger, Lindera Root, White Peony Root, Prepared Rehmannia Root, Fluorite, Hematite, and Tangerine Rind.

Note by Yuan: Earth deficiency with abundant Water, using Prepared Rehmannia is inappropriate. To support Earth, do not remove Licorice.

Mr. Qin: Hanging fluid residing under the ribs, causing pain and vomiting clear water. Using Zhang Zhongjing's method.
Kansui Root, Genkwa Flower, Kansui, White Mustard Seed, Evodia Fruit (3 qian each), Jujube (20 pieces).
Boil five herbs in two large bowls of river water until concentrated to one large bowl, strain, then add Jujubes and boil until soft and dry. Eat two Jujubes early every morning.

Note by Yuan: This is a modification of Shizao Tang (Ten Jujube Decoction). Replacing Torreya Seed with Evodia shows ingenuity.

Unknown Patient: Cold Qi condensing, forming abdominal masses in Lower Abdomen, occasionally attacking upward causing pain. Method: Warming and unblocking.
Fennel Seed, Evodia Fruit, Aucklandia Root, Green Tangerine Peel, Lindera Root, Corydalis Rhizome, Burreed Tuber, Amomum Fruit, Cyperus Rhizome.

Mr. Qian: Pulse is faint and fine, a sign of Yin. Mass in Lower Abdomen attacking upward to epigastrium, Qi blockage from epigastrium to throat, upon attack mass causes severe pain nearly leading to syncope, profuse sweating on head.
General principle of prescription: Warming and unblocking is certain. However, yellow greasy turbid tongue coating and foul-smelling diarrhea indicate concurrent damp-heat; mass pain relieved by pressure indicates deficiency.
Jinlingzi San (Golden Bell Powder) plus Ginseng Root, Mume Fruit, Lindera Root, Alisma Rhizome, Psoralea Fruit, Evodia Fruit, Aucklandia Root, Cinnamon Bark, Goji Berry, Schisandra Berry, Poria, and Areca Seed.

Re-examination: Water-fluids, phlegm, and turbid Yin Qi from Lower Jiao occupy the Middle. Masses in epigastrium and hypochondrium causing distending pain, severe pain leading to syncope. Yesterday used warming-unblocking, pain slightly reduced.
But pulse remains faint and fine, diarrhea still foul-smelling, aversion to food, severe Middle Qi deficiency, Yin Qi condensing, hard pain at umbilicus, fearing Zang-Jie (Visceral Knotting). Attacking is impossible, tonifying is difficult, still troublesome.
Previous formula minus Ginseng, Schisandra, Lindera, Psoralea, and Areca Seed; add White Peony Root, Dried Ginger, Daylily Flower, and Tangerine Rind.

Unknown Patient: Cold in abdomen, incessant pain, method should be warming and unblocking.
Jinlingzi San (Golden Bell Powder) plus Dried Ginger, Evodia Fruit, Angelica Sinensis Root, Goji Berry, Official Cinnamon, Aucklandia Root, Lindera Root, and Fluorite.

Mr. Zhang: Cold Qi lingering, Qi mechanism unfavorable. Radiating pain in chest and back, Qi attacking in epigastrium and hypochondrium with masses. Suitable for acrid-warm unblocking.
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Trichosanthes Peel, Allium Macrostemon Bulb, Dried Ginger, Evodia Fruit, Corydalis Rhizome, and Aspongopus.

Unknown Patient: Liver-Stomach disharmony, radiating pain in waist, hypochondrium, chest, and back. Tongue bare without coating, Ying-Yin internally deficient. Loose stools, Spleen Qi also weak, no vomiting of phlegm or sour water. Suitable for acrid-warm unblocking Yang, sour-sweet generating Yin.
Aged Tangerine Peel, Poria, Perilla Stem, Evodia Fruit, Astragalus Complanatus Seed, Goji Berry, Allium Macrostemon Bulb, White Peony Root, Tangerine Rind.

Note by Yuan: Spleen-Kidney deficiency-cold suits sweet-warm; Ying-Yin internal deficiency suits softening and slowing; thus avoiding acrid-hot drying herbs like Ginger and Aconite.

Unknown Patient: Fluid retention in Middle Epigastrium, borborygmus in epigastrium and abdomen, distending pain. Stool hard as chestnut, able to belch but not pass flatus, indicating Stomach failing to descend and Qi rebelling upward.
Harmonize Stomach and direct rebellion downward, expel water and eliminate fluids.
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Hematite, Inula Flower, Medicated Leaven, Dried Ginger, White Peony Root, Sichuan Pepper, Kansui, and Alisma Rhizome.

Unknown Patient: Cold in Dantian, heat in Chest, Middle Jiao fails to transport, excessive dampness generates parasites. Give Huanglian Tang (Coptis Decoction).
Coptis Rhizome, Cinnamon Bark, Evodia Fruit, Dried Ginger, Amomum Fruit, Quisqualis Fruit, Pinellia Tuber, Green Tangerine Peel, Lindera Root, Betel Nut.

Re-examination: Parasitic pain, yellow face, vomiting saliva. Prescribe bitter-acrid method.
Coptis Rhizome, Cinnamon Twig, Sichuan Pepper, Cardamom Seed, Mume Fruit, Wormseed, Charred Medicated Leaven, Cyperus Rhizome, combined with Jinlingzi San.

Mr. Zhang: Epigastric pain for two years, recent attacks more frequent. Relieved by warmth, worsened by overwork. Mass in Middle Epigastrium, skin at lesion is cold, method is warming and unblocking.
Erchen Tang (Two-Aged Decoction) minus Licorice Root, plus Roasted Ginger, Evodia Fruit, Aucklandia Root, Magnolia Bark, Angelica Sinensis Root, Medicated Leaven, Alisma Rhizome, and Raw/Cooked Barley Sprouts.

Re-examination: Abdominal pain with mass, Liver-Spleen disharmony, poor appetite, yellow complexion. Treat with soothing and harmonizing.
Salvia Root, White Peony Root, Chinese Yam, Poria, Poria cocos (with wood), Winter Atractylodes, Medicated Leaven, Cyperus Rhizome, Amomum Fruit.

Ren Yuan said: Epigastric pain belongs to Stomach, abdominal pain belongs to Spleen. Acid regurgitation and vomiting bitter fluid, commonly called Liver Qi, is actually a disease of accumulated fluids. It may result from fondness for raw/cold food or worry/thought depression. Liver and Gallbladder belong to Wood and prefer ascending and spreading, rooted in Earth. Now Spleen-Stomach Yang-heating Qi is injured by raw/cold food and worry/thought, failing in distribution and transportation. Liver-Gallbladder lose their moist-warm ascending mechanism, become depressed and act violently, insulting what they overcome, causing Spleen-Stomach to be suppressed. Qi mechanism and phlegm-fluids stagnate in Middle Epigastrium, causing pain. Those with acid regurgitation and bitter vomiting have Spleen cold failing to transform, Stomach fluids accumulating; like food left in a vessel, its taste changes. Sweet taste belongs to Earth (Grain); now Stomach cannot transform, Wood overacts on its conquered element, changing Wood's taste to sour, and Gallbladder Fire's taste to bitter. Wood Qi rebels, causing incessant vomiting; long-term fluid accumulation forms sacs and masses. Caused by cold food, it is treatable; caused by emotions, it often becomes dysphagia. Prolonged worry injures Middle Yang, frequent vomiting dries Stomach juices; initially Yang is injured, then Yin fluids exhausted, Ying-Wei lack source of generation, stomach tube shrinks, intestinal fluids deplete. Relying solely on medicine is useless; must calm spirit and rest quietly. Yu Shi's method of advancing/retreating Huanglian Tang has deep meaning: Acrid transforms Stomach, Bitter directs rebellion downward, "changing the Stomach without being changed by it." Luo Qianfu's Zhizhong Tang also fits, using Metal to control Wood. Zhang Zhongjing's Trichosanthes and Allium formulas, whether acrid or bitter, unblocking or moistening, are all usable, aiming to unblock Middle Jiao Yang, allowing Spleen-Stomach Yin coagulation to open and Liver Wood depression to spread, pain resolves itself. Abdominal pain must be differentiated by location: Umbilicus is Taiyin, beside umbilicus is Shaoyin, Lower Abdomen is Jueyin. Especially differentiate cold-heat deficiency-excess; generally cold is more than heat, deficiency more than excess, heat mostly excess, deficiency mostly cold. Neijing · Ju Tong Lun states: Eight or nine parts cold, one or two parts heat; must carefully distinguish via pulse and symptoms. In years of damp depression, many such cases occur, also due to Spleen-Stomach depressed by cold-damp, Yang Qi unable to diffuse and transform.