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Below the breasts and chest/hypochondrium, a mass has condensed, feeling distended, solid, and refusing pressure. Qi in the umbilical abdomen and diaphragm cannot descend. Every hour of Xu (19:00-21:00), Hai (21:00-23:00), Zi (23:00-01:00), and Chou (01:00-03:00), the distension is unbearable. Since vomiting has occurred, purgation can be used. However, methods using Rhubarb (Rhei Radix et Rhizoma), Mirabilite (Natrii Sulfas), Samolus (Sanleng), Croton Seed (Crotonis Fructus), as well as Radish Seed (Raphani Semen), Mirabilite, and garlic poultices, all failed. The more one attacks, the more distended it becomes. (This is inevitable.) Suspecting that the Spleen Qi was injured, using tonification felt even more inconvenient. (Extremely mediocre.) For over twenty days, no soup or water could enter, leaving no options. One had to rub and press the area by hand, feeling a specific point under the ribs; pressing it caused pain radiating to the chest and abdomen. Carefully pondering, the point was exactly at Zhangmen (LR13). Zhangmen is the Front-Mu point of the Spleen and the Hui-Meeting point of the Zang organs. Moreover, the intercostal space below the breast belongs to the Xuli large collateral, which is the major pathway where Stomach Qi emerges, and Qi connects to Zhangmen. Thus, realizing that the symptoms being lighter during the day and heavier at night were not due to有形 (tangible) accumulation, but rather pressing one spot causing pain elsewhere indicated the disease was definitely in the Qi level. (This still belongs to blind guessing.) Therefore, Shen Shu San was used, administered three to four times a day, combined with moxibustion on Zhangmen for fourteen moxa cones, to disperse the stagnant Stomach Qi. (Ultimately, it was unknown that this was a Liver disease.) Within three days, the distension gradually subsided, food intake slowly improved, and life was preserved. (How fortunate.) This case's symptoms and treatment were both extraordinary and truly unpredictable.

Commentary: Mr. Zhang seemed never to have read the various medical books of Dr. Xue. Until his death, he did not know that hypochondriac pain was caused by a disorder of the Liver meridian, which is truly pitiable. The cure of this case relied entirely on moxibustion, similar to cases of hiccups where other treatments fail, and moxibustion on Xuli immediately stops the symptom.

Dr. Huang Gutang treated a patient who, in June, walked in the heat and overexerted himself. His temperament was irritable and violent. Suddenly, he experienced left-sided hypochondriac pain. A patch of redness on the skin, about the size of a bowl, appeared, along with three to five blister-like sores. The pulse was rapid (seven beats per breath) and wiry, with symptoms worsening at night compared to the day. The physician treated it as Liver meridian constrained Fire, prescribing Coptis (Coptidis Rhizoma), Tangerine Peel (Citri Reticulatae Pericarpium), Cyperus (Cyperī Rhizoma), Ligusticum (Chuanxiong Rhizoma), and Bupleurum (Bupleuri Radix). After one dose, the pain intensified and fever increased that night. The next morning, the redness expanded to the size of a plate, and the blisters increased to over thirty. The doctor advised applying Alum powder mixed with water externally and continuing the previous prescription with added Indigo Naturalis (Indigotidis Folium) and Gentian (Gentianae Radix). That night, the pain became worse, feeling like hooks tearing the hypochondrium. The next morning, the redness covered half the body, and blisters numbered over a hundred. He was brought to consult Huang, who prescribed a formula: one large Trichosanthes Fruit (Trichosanthis Fructus), weighing one to two taels, smashed with the peel, added with Licorice Root (Gancao) 2 qian and Safflower (Honghua) 0.5 qian. (Note by Xiong: Yuheng's Yi Guan Jian was likely inspired by this case, becoming more comprehensive, truly surpassing the original.) Shortly after taking the medicine, he slept, and upon waking, the pain was gone. The disease progression was urgent, but contemporary physicians stuck to standard Liver-draining agents, mostly bitter-cold, which further exacerbated dryness, causing the condition to worsen. The appearance of blisters on the exterior indicated that long-standing Liver constraint could not vent out, instead insulting the element it cannot overcome (Metal/Lungs), causing skin ulceration. Trichosanthes is sweet and cold. The Classic states, "To drain the Liver, soothe the center." Its nature is soft, slippery, and moistening, not opposing constraint. Sweet-soothing and moistening-descending is like oil washing things, ensuring cleanliness. This explains its swift efficacy. (Ibid.)

This case best elucidates the efficacy of Trichosanthes, yet does not exhaust its potential.

Wu Qiao treated Chen Quan, who in middle age suffered extreme pain in both hypochondria, with cold sweat pouring down, lying on his pillow with retching, unable to drink anything for six days. Wu Qiao diagnosed: "No injury, this is Blood Stasis." The family said: "Indeed, he vomited several sheng of blood before, so the stasis should be exhausted." Wu Qiao replied: "The stasis is not exhausted. If it were exhausted, the illness would heal." In the evening, a formula to tonify the Middle and move blood was given. He drank only half. By midnight, he lay motionless like a corpse, and the family climbed onto the roof wailing. Wu Qiao said: "Give him the remaining half. Yang will return. Let him sleep to await recovery. When recovery comes, the stale blood will move. Prepare Ginseng Decoction to wait." At cockcrow, he woke up, experiencing profuse sweating, vomiting, and diarrhea. The stool nearly filled the vessel, resembling rotten liver and decaying flesh. Then, Ginseng Decoction was administered, and the sweating gradually stopped. Seven days later, he recovered. Initially, someone asked: Why is the abdomen not distended in Blood Stasis? And since he vomited several sheng of blood before, why is there so much stasis now? Wu Qiao said: "The disease resulted from anger injuring the Liver, or from falling causing stasis to injure the Liver. Then blood is not retained, and stasis blocks the pathways. It is like a ditch blocked; old and new flow are both congested, hence the abundance." (Tai Han Ji.)

Wang Yun Cheng, near seventy years old, suffered from chest and hypochondriac pain, worsening with turning, alternating chills and fever, panting, coughing, and irritability, unable to rest his head on the pillow again. Physicians purged him, deepening the illness. Wu Qiao diagnosed: Six pulses were floating, slippery, large, and beating against the finger. He said: "The disease resulted from excessive drinking and subsequent purging, causing Fire to flare upward." One dose of a cooling agent cured him. (Tai Han Ji.)

Wei Yuheng stated: Fan Kanghou, in his early twenties, suffered from hypochondriac pain for six or seven years. He saw many doctors, becoming increasingly emaciated, eating little, with weak Qi, lazy speech, and fatigue. Slight travel caused palpitations in the epigastrium, and exertion caused tearing pain in the diaphragm. Upon consulting me, he reported initial abdominal and hypochondriac pain. Doctors gave Xiao Yao San, which provided temporary relief followed by recurrence, then became ineffective. Si Mo Yin was tried, also providing temporary relief then failing. Wu Xiang San and Yue Ju Wan were tried, resulting in immediate recurrence upon healing, and suddenly masses appeared in the abdomen. Other doctors diagnosed Pi Accumulation, prescribing Tangerine Peel, Magnolia Bark, Trogopterus Dung, and Corydalis. The masses increased, appearing and disappearing, moving up, down, left, and right, about six or seven, fist- or palm-sized, causing pulling pain. Recently, an old doctor diagnosed deficiency, prescribing Angelica Sinensis, White Peony Root, Cyperus, and Curcuma. There was no improvement. I said: "Your condition is common throughout the land. How many have died due to misdiagnosis? Ancient formularies lack key insights for this condition, no wonder people are confused. The root of error lies in the phrase 'Liver has no tonification method,' causing millions to die unjustly. Some become consumptive from dispersing, develop obstruction from aromatic-drying herbs, suffer drum-distension from attacking/purging, or develop abscesses from acrid-hot herbs. The variations are too numerous to record. Fortunately, you are young, have strong constitution, and are unmarried, so it is only this severe. Otherwise, it would be unspeakable. Your pulse is currently fine, rapid, wiry, and choppy. Organ Qi is depleted. Fortunately, it is not rapid, and there is no cough or night fever, so it is treatable. My prescriptions aim for long-term effect, not quick results. Given Raw/Cooked Rehmannia, Glehnia, Ophiopogon, Goji Berry, and Jujube Seed, he stabilized. After dozens of doses, masses decreased. The formula was made into pills, taken for years until full recovery. He is now married; if he exercises moderation, there may be no future trouble. Only Liang Yi Gao is most excellent for this condition, but requires sufficient resources to use."

Mr. Fang, over thirty, lived separately near a wall, suffering hypochondriac pain. A mass like [missing character] existed under the left hypochondrium, hard to touch, causing distension after eating and severe pain preventing side-lying. Hundred treatments failed; he was withered like firewood.偶然ly at a pharmacy, someone told him: "Only Wei Mou of Chunyou Bridge can cure this." He consulted. Pulse was wiry and urgent. I said: "This is Liver Rising Syndrome. The Liver has three lobes on the left and four on the right. When blood is sufficient, it is moist and hangs down. Now, Fire anger injures Yin, making the lobes dry and hard, thus rising and not descending. The Classic says, 'Liver disease forces Stomach Qi to rebel upwards.' So, left lobe expansion supports the axilla, preventing side-lying; right lobe expansion invades the epigastrium, preventing food intake. Ignorant doctors prescribe aromatic dispersants, adding fuel to the fire. Prescribed Raw/Cooked Rehmannia, Glehnia, Ophiopogon, Trichosanthes Seed, Coix Seed, Goji Berry, and Toosendan Fruit. Over ten doses, the disease vanished."

Mrs. Zhan Weifeng, over sixty, had spontaneous sweating after malaria in September, which I cured. In November, severe hypochondriac pain erupted. Doctors used Modified Black Xiao Yao San, which was not wrong. After one dose, she fainted near death at midnight. Bupleurum and Atractylodes Macrocephala are not suitable for those with Yin deficiency and flourishing Fire. At dawn, I was urgently consulted. Pulses at both Guan positions were hidden; Chi positions were extremely faint. Feet were cold above the knees. Face was like ash paper. She said initial left hypochondriac pain shifted to the right after medication, causing syncope. Though syncope ceased, pain was severe, preventing movement, and the painful area was tender to touch. Tongue was dry, hard, like dried lychee. Critical. Temporarily prescribed Raw/Cooked Rehmannia and Goji Berry 5 qian each, Glehnia and Ophiopogon 3 qian each. Pain slightly reduced. Doubling the previous formula, adding Coix Seed 5 qian and Trichosanthes Seed 2 qian, pain returned to the left hypochondrium, allowing movement. Continued previous formula for several doses until cured. I often treat poor patients who, after febrile diseases, cannot eat, resembling Bai He Bing. Pulses are wiry or choppy. Hypochondriac tenderness varies left/right, with or without masses, all reporting severe pain. Checking their prescriptions, besides various drying herbs, some took Bupleurum up to 2-3 liang. Tongues were dry in the center, parched, or purple-red. These are harms from excessive purgation/injury to Liver and Kidney. Using the previous formula, adjusting dosage based on severity, they cured in a few doses. Also, Zhao's son (16) and Jin's daughter (17), from wealthy families, suffered hypochondriac pain. Taking Xiao Yao San for over fifty doses worsened their condition. Giving the previous formula minus Cooked Rehmannia, they refused, switched to aromatic-drying herbs, and died. Globally, people fear Rehmannia and Goji Berry like tigers because Materia Medica says Rehmannia is cloying and Goji is hot. This has killed many. Those discussing medicine must be cautious.

Mother of Chen Litang, over sixty, suffered chronic hypochondriac pain, requiring her to lie face down for weeks when flaring. Doctors prescribed Cyperus, Curcuma, Tangerine Peel, Aucklandia, Fennel, Corydalis, Trogopterus Dung, and Gentian. Sometimes combined with Liu Yu formula or Zuo Jin Wan. Recent flare-ups caused back/waist distension, retching, constipation, dry mouth, insomnia. Pulses: Cun positions beat against fingers; Guan positions were wiry lacking resonance. Approaching Guan Ge syndrome. Prescribed fluids-nourishing and Lung-metal-supporting agents, sometimes adding Toosendan Fruit or Coptis. Cured in one or two doses. Advised continued use to prevent recurrence. However, she feared medicine and stopped when cured. Will Guan Ge occur in the future?

This is identical to the case of Mrs. Hu in the Ge Syndrome section.

Huang Jinfang treated Liu Shangqing, with right hypochondriac pain, cough, headache. Liver pulse slightly raised; Right pulse sinking and slippery; a small nodule felt in the Spleen area. Cough required effort; sputum was clear/thin with white foam, stretching like lotus root threads. Prescribed Aconite 2 qian, Poria 2 qian, Pinellia 2 qian, Psoralea 0.3 fen, Aucklandia 0.5 fen, Achyranthes 1 qian. Advised avoiding cloying/greasy foods to promote water metabolism, resolve phlegm, calm Qi, and stop pain. Patient asked origin of phlegm. Huang said: "Phlegm diseases are numerous, presenting differently by organ. In Spleen: Wet Phlegm. Signs: slow pulse, yellow face, heavy limbs, lethargy, abdominal distension, food stagnation. Sputum is slippery/easy to expectorate. Treat with Er Chen Tang or Liu Jun Zi Tang. In Lung: Qi Phlegm (Dry Phlegm). Signs: choppy pulse, pale face, asthma, aversion to cold, sorrow. Sputum is sticky/hard to expectorate. Treat with Li Ge Qing Fei Yin modified. In Liver: Wind Phlegm. Signs: wiry pulse, green face, chest/flank fullness, urinary/fecal retention, irritability. Sputum is blue/bubbly. Treat with Shi Wei Dao Tan Tang or Qian Min Tang modified. In Heart: Heat Phlegm. Signs: surging pulse, red face, irritability, heart pain, dry mouth/lips, frequent laughter. Sputum is hard/clumped. Treat with Liang Ge San plus Poria/Pinellia. In Kidney: Cold Phlegm. Signs: sinking pulse, black face, painful urination, cold feet, fear. Sputum has black spots/is thin. Treat with Gui Ling Wan or Ba Wei Wan. Fundamentally, Phlegm transforms in the Spleen but originates in the Kidney. If Fire fails to generate Earth, Water is unchecked, Yin overcomes Yang—this is deficiency of Fire within Yin. If Fire flourishes and Metal dries, Essence does not reside, Fluids wither, Metal and Water harm each other—this is deficiency of Water within Yin. Cold/Wet Phlegm is a Spleen disease but stems from Kidney Water deficiency. Wood constraint generating Wind is a Liver disease but stems from Kidney Water deficiency. Fire flourishing overcoming Metal causes Lung phlegm but stems from Kidney Fire excess. In this case, although phlegm is in the hypochondrium, Stomach, and Spleen, it actually arises from Kidney Fire deficiency. Thus, Aconite rapidly tonifies True Fire to strengthen Earth; Poria/Pinellia remove Spleen dampness; Aucklandia moves stagnant Qi; Achyranthes guides Left Qi down to Kidney; Psoralea guides Right Qi down to Kidney. When Qi returns, phlegm clears. Indeed, cured in a few doses."