大意
足厥阴肝经之络。令人胁痛。（内经）然亦有少阳胆经病者。亦有肝乘脾经者。有肝侮肺经者。有肝肾同治
者。当推原之。（汇补）
内因
因暴怒伤触。悲哀气结。饮食过度。风冷外侵。跌仆伤形。叫呼伤气。或痰积流注。或瘀血相搏。皆能为痛。
（医鉴）至于湿热郁火。劳役房色而病者。间亦有之。（汇补）
外候
胁痛宜分左右。辨虚实。左胁痛者。肝受邪也。右胁痛者。肝邪入肺也。左右胁胀痛者。气滞也。左右胁注痛
有声者。痰饮也。左胁下有块作痛。夜甚者。死血也。右胁下有块作痛。饱闷者。食积也。咳嗽引痛。喘急发热
者。痰结也。时作时止。暴发痛甚者。火郁也。满闷惧按。烦躁多怒者。肝实也。耳目 HT 。爪枯善恐者。肝虚也。
隐隐微痛。连及腰胯。空软喜按者。肾虚也。胁痛咳嗽腥臭。面赤唾痰者。肺气伤也。胁内支满。目眩。前后下
血者。肝血伤也。两胁搐急。腰腿疼痛。不能转侧者。湿热郁也。胸右近胁一点刺痛。内热咳嗽者。肺痈也。当
须防之。（汇补）
危候
虚甚成损。胁下常有一点痛不止者。此因酒色太过。名干胁痛。大危。（入门）
胁痛成积
凡胁痛年久不已者。乃痰瘀结成积块。肝积肥气在左。肺积息贲在右。发作有时。虽皆肝木有余。肺积
郁。不可峻攻。（汇补）
脉法
脉双弦者。肝气有余。两胁作痛。（脉经）弦而紧细者。怒气也。弦而沉涩者。郁滞也。大抵弦涩者顺。洪大者逆。
若弦急欲绝。胁下如刀刺。状如飞尸者。不治。（汇补）
治法
治宜伐肝泻火为要。不可骤用补气之剂。虽因于气虚者。亦宜补泻兼施（玉策）胁者。肝胆之区。肝为尽阴。
喜条达而恶凝滞。胆无别窍。喜升发而恶抑郁。故凡木郁不舒。而气无所泄。火无所越。胀甚惧按者。又当
疏散升发以达之。不可过用降气。致木愈郁而痛愈甚也。（汇补）
用药
主以二陈汤。加柴胡。青皮。气加香附、枳壳。火加胆草、芍药。痰加南星、苍术。食加枳实、山楂。瘀加桃仁、
红花。肝火旺者。左金丸。木气盛者。当归龙荟丸。如气血俱虚。脉细紧。或弦大。多从劳役怒气得者。用八珍汤加
木香、青皮、桂心少许。劳役太过。肝伤乘脾者。补中益气汤加芍药。或建中汤与六君子合用。房色太过。肾
肝两伤者。地黄汤加芍药、当归。有膈间停痰宿食。或挟恚怒。抑其肝气。不得上达。两胁大痛。面青或黑。脉
代者。用盐汤探吐。得吐则生。不吐则死。（汇补）
胁痛选方
柴胡疏肝散（统旨）
柴胡 陈皮 枳壳（各一钱） 芍药 川芎（各八分） 香附（三钱二分）
甘草（四分） 生姜（一片）
水煎。
左金丸 治肝火作痛。
黄连（六两） 吴茱萸（一两）
为末。水丸。
加味柴胡汤（良方） 治伤寒少阳症胁痛。
柴胡 黄芩（各二钱） 牡蛎 半夏 枳壳 甘草（各一钱）
姜、枣。水煎服。
枳壳煮散（本事） 治悲怒内郁。风寒外束。肝气受伤。两胁骨疼。筋脉急。腰脚重。两股筋急酸痛。渐至脊背。
腰急。此方主之。
枳壳（麸炒四两先煎） 细辛 川芎 桔梗 防风（各二两） 葛根（一两半） 甘草（一两）
为粗末。每服四钱。姜、枣、水同煎。空心服。
控涎丹 治痰痛。
甘遂 大戟 白芥子
香橘汤（良方） 治七情气滞。中脘不快。腹胁胀痛。
香附（炒） 橘红 半夏（各三钱） 炙甘草（一钱） 生姜（三片） 红枣（三枚）
水煎。食远服。
推气散（济生） 治气痛。
枳壳 桂心 姜黄（各五分） 甘草（三分）
姜、枣。水煎。
桃仁承气汤 治血瘀。（方见血症）
当归龙荟丸 泻肝火痛。
当归 胆草 山栀 黄连 黄芩 黄柏（各一两）
大黄 芦荟 青黛（各五钱） 木香（二钱半） 麝香（五分）
一方有青皮、柴胡。痛甚者。以姜汁吞下。
八珍汤 治虚症胁痛。（方见中风）
外治法
或用白芥子水研敷患处。或用吴茱萸研细。醋调敷。或用韭菜打烂醋拌。放在痛处。以熨斗火熨之。
[General Principle]
The collateral vessels of the Foot-Jueyin Liver Meridian (Zu Jue Yin Gan Jing) cause hypochondriac pain. (Neijing) However, there are also cases involving the Shaoyang Gallbladder Meridian (Shao Yang Dan Jing). There are cases where Liver Qi invades the Spleen Meridian (Pi Jing), and cases where Liver Qi insults the Lung Meridian (Fei Jing). There are cases of simultaneous disease of the Liver and Kidney. One must deduce the original cause. (Huibu)
[Etiology (Internal)]
Due to violent anger causing injury and disturbance, sorrow leading to Qi stagnation, excessive diet, invasion of Wind-Cold from outside, falls or blows injuring the form, shouting depleting Qi, or phlegm accumulation flowing into collaterals, or blood stasis clashing with each other, all can cause pain. (Yijian) As for diseases caused by damp-heat stagnation, fire pathogen excess, overwork, or sexual indiscretion, these occur occasionally. (Huibu)
[Clinical Manifestations]
Hypochondriac pain should be distinguished by left and right sides, and by deficiency and excess. Pain on the left side indicates the Liver meridian is affected by pathogens. Pain on the right side indicates Liver pathogens have entered the Lung meridian. Distending pain on both left and right sides indicates Qi stagnation. Pain in both left and right sides accompanied by gurgling sounds indicates Phlegm-Fluids (Tan Yin). A mass under the left hypochondrium causing pain that worsens at night indicates Dead Blood (Si Xue, i.e., severe blood stasis). A mass under the right hypochondrium causing pain with fullness and stuffiness indicates Food Retention (Shi Ji). Coughing inducing pain, with panting, urgency, and fever, indicates Phlegm Knotting (Tan Jie). Pain that comes and goes, suddenly erupting with severe intensity, indicates Fire Stagnation (Huo Yu). Fullness and stuffiness with fear of pressure, irritability, and frequent anger indicate Liver Excess (Gan Shi). Blurred vision and hearing, with withered nails and a tendency toward fear, indicate Liver Deficiency (Gan Xu). Faint, slight pain extending to the waist and hips, feeling empty and soft, and preferring pressure, indicates Kidney Deficiency (Shen Xu). Hypochondriac pain with coughing and expectoration of foul-smelling sputum, red face, and spitting of phlegm indicates Lung Qi Injury (Fei Qi Shang). Internal support and fullness in the hypochondrium, dizziness, and bleeding from the anterior or posterior orifices indicate Liver Blood Injury (Gan Xue Shang). Tension and cramping of both hypochondria, pain in the waist and legs, and inability to turn the body indicate Damp-Heat Stagnation (Shi Re Yu). A single point of stabbing pain near the right hypochondrium of the chest, accompanied by internal heat and cough, indicates Lung Abscess (Fei Yong). This must be guarded against. (Huibu)
[Critical Signs]
Severe deficiency leading to consumptive damage, where there is constant unceasing pain at a specific point under the hypochondrium, is due to excessive alcohol and sexual indulgence, named Dry Hypochondriac Pain (Gan Xie Tong), which is critically dangerous. (Rumen)
[Hypochondriac Pain Becoming Mass]
Whenever hypochondriac pain persists for years without resolution, it is because Phlegm and Blood Stasis have formed a mass. The Liver accumulation named Feiqi (Fat Qi) is located on the left; the Lung accumulation named Xiben (Xi Ben) is located on the right. They occur at specific times. Although both involve excess of Liver Wood, the Lung accumulation is often due to stagnation and cannot be treated with harsh purgatives. (Huibu)
[Pulse Diagnosis]
A double wiry pulse (Shuang Xian) indicates Liver Qi excess and pain in both hypochondria. (Maijing) A wiry, tight, and fine pulse indicates anger. A wiry, deep, and choppy pulse indicates stagnation. Generally, a wiry and choppy pulse is favorable, while a flooding and large pulse is unfavorable. If the pulse is wiry, rapid, and nearly imperceptible, with hypochondriac pain like knife stabbing, resembling the condition known as Flying Corpse Disease (Fei Shi), it is incurable. (Huibu)
[Therapeutic Principles]
Treatment should focus on subduing the Liver and draining Fire. One should not abruptly use tonifying Qi formulas. Even if caused by Qi deficiency, tonification and purgation should be combined. (Yuce) The hypochondrium is the region of the Liver and Gallbladder. The Liver is the organ of complete Yin, favoring free flow and disliking stagnation. The Gallbladder has no separate orifice, favoring ascending and dispersing and disliking depression. Therefore, whenever Wood Qi is depressed and unrelieved, with Qi unable to vent and Fire unable to escape, resulting in severe distension and fear of pressure, one should use methods of dispersing and ascending to promote flow. One must not overuse descending Qi herbs, lest the Wood Qi become more depressed and the pain intensify. (Huibu)
[Medication]
The main formula is Erchen Tang (Two-Aged Decoction), added with Chai Hu (Bupleuri Radix) and Qing Pi (Citri Reticulatae Pericarpium Viride). For Qi stagnation, add Xiang Fu (Cyperi Rhizoma) and Zhi Ke (Aurantii Fructus). For Fire, add Long Dan Cao (Gentianae Radix) and Shao Yao (Paeoniae Radix). For Phlegm, add Nan Xing (Arisaematis Rhizoma Preparatum) and Cang Zhu (Atractylodis Rhizoma). For Food retention, add Zhi Shi (Aurantii Fructus Immaturus) and Shan Zha (Crataegi Fructus). For Blood stasis, add Tao Ren (Persicae Semen) and Hong Hua (Carthami Flos). For hyperactive Liver Fire, use Zuojin Wan (Left Metal Pill). For exuberant Wood Qi, use Danggui Longhui Wan (Angelica Dahurica and Gardenia Pill). If both Qi and Blood are deficient, with a fine and tight pulse, or wiry and large pulse, mostly arising from overwork and anger, use Bazhen Tang (Eight-Treasure Decoction) added with Muxiang (Aucklandiae Radix), Qing Pi, and a small amount of Guixin (Cinnamomi Cortex). For overwork damaging the Liver which then invades the Spleen, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) added with Shao Yao. Alternatively, combine Xiaojianzhong Tang (Minor Construct the Middle Decoction) with Liujunzi Tang (Six-Gentlemen Decoction). For excessive sexual activity damaging both Liver and Kidney, use Dihuang Tang (Rehmannia Decoction) added with Shao Yao and Danggui. If there is retained phlegm and old food in the diaphragm, or if accompanied by resentment suppressing Liver Qi so it cannot ascend, causing severe pain in both hypochondria, with a blue or black complexion, and a intermittent pulse (Dai Mai), use salt water to induce vomiting. Vomiting leads to survival; failure to vomit leads to death. (Huibu)
[Selected Formulas for Hypochondriac Pain]
Chaihu Shugan San (Bupleurum Powder for Soothing the Liver) (from Tongzhi)
Chai Hu (Bupleuri Radix), Chen Pi (Citri Reticulatae Pericarpium), Zhi Ke (Aurantii Fructus) (each 1 qian); Shao Yao (Paeoniae Radix), Chuan Xiong (Ligustici Chuanxiong Rhizoma) (each 8 fen); Xiang Fu (Cyperi Rhizoma) (3 qian 2 fen); Gan Cao (Glycyrrhizae Radix et Rhizoma) (4 fen); Sheng Jiang (Zingiberis Rhizoma Recens) (1 slice).
Decoct in water and take.
Zuojin Wan (Left Metal Pill) Treats pain caused by Liver Fire.
Huang Lian (Coptidis Rhizoma) (6 liang); Wu Zhu Yu (Evodiae Fructus) (1 liang).
Grind into powder, make pills with water.
Jiawei Chaihu Tang (Modified Bupleurum Decoction) (from Liangfang) Treats hypochondriac pain in Shaoyang syndrome of Cold Damage.
Chai Hu (Bupleuri Radix), Huang Qin (Scutellariae Radix) (each 2 qian); Mu Li (Ostreae Concha), Ban Xia (Pinelliae Rhizoma), Zhi Ke (Aurantii Fructus), Gan Cao (Glycyrrhizae Radix et Rhizoma) (each 1 qian).
Add Jiang (Zingiberis Rhizoma Recens) and Zao (Jujubae Fructus), decoct in water and take.
Zhi Ke Zhusan (Aurantii Fructus Boiled Powder) (from Benshi Fang) Treats internal depression from sorrow and anger, external constraint by Wind-Cold, injury to Liver Qi, pain in bones of both hypochondria, tension of sinews and vessels, heaviness of waist and feet, cramping and soreness of sinews in both thighs, gradually extending to the back and spine, and stiffness of the waist. This formula is indicated.
Zhi Ke (Aurantii Fructus, stir-fried with bran, 4 liang, decocted first); Xi Xin (Asari Radix et Rhizoma), Chuan Xiong (Ligustici Chuanxiong Rhizoma), Jie Geng (Platycodonis Radix), Fang Feng (Saposhnikoviae Radix) (each 2 liang); Ge Gen (Puerariae Lobatae Radix) (1.5 liang); Gan Cao (Glycyrrhizae Radix et Rhizoma) (1 liang).
Grind into coarse powder. Take 4 qian per dose, decoct with Jiang (Zingiberis Rhizoma Recens), Zao (Jujubae Fructus), and water. Take on an empty stomach.
Kongxian Dan (Phlegm-Fluid Expelling Pill) Treats pain caused by Phlegm-Fluids.
Gan Sui (Kansui Radix), Da Ji (Euphorbiae Pekinensis Radix), Bai Jie Zi (Sinapis Semen).
Xiangju Tang (Fragrant Orange Decoction) (from Liangfang) Treats Qi stagnation from seven emotions, discomfort in the middle jiao, and abdominal-hypochondriac distending pain.
Xiang Fu (Cyperi Rhizoma, stir-fried), Ju Hong (Citri Reticulatae Pericarpium), Ban Xia (Pinelliae Rhizoma) (each 3 qian); Zhi Gan Cao (Prepared Glycyrrhizae Radix et Rhizoma) (1 qian); Sheng Jiang (Zingiberis Rhizoma Recens) (3 slices); Hong Zao (Jujubae Fructus) (3 pieces).
Decoct in water. Take long after meals.
Tuiqi San (Qi-Pushing Powder) (from Jisheng Fang) Treats Qi pain.
Zhi Ke (Aurantii Fructus), Gui Xin (Cinnamomi Cortex), Jiang Huang (Curcumae Longae Rhizoma) (each 5 fen); Gan Cao (Glycyrrhizae Radix et Rhizoma) (3 fen).
Add Jiang (Zingiberis Rhizoma Recens) and Zao (Jujubae Fructus), decoct in water.
Taoren Chengqi Tang (Peach Kernel and Rheum Decoction) Treats Blood Stasis. (See Formula in Blood Disease section)
Danggui Longhui Wan (Angelica Dahurica and Gardenia Pill) Drains Liver Fire to relieve pain.
Dang Gui (Angelicae Sinensis Radix), Dan Cao (Gentianae Radix), Shan Zhi (Gardeniae Fructus), Huang Lian (Coptidis Rhizoma), Huang Qin (Scutellariae Radix), Huang Bo (Phellodendri Cortex) (each 1 liang); Da Huang (Rhei Radix et Rhizoma), Lu Hui (Aloe), Qing Dai (Indigo Naturalis) (each 5 qian); Mu Xiang (Aucklandiae Radix) (2.5 qian); She Xiang (Moschus) (5 fen).
One prescription includes Qing Pi (Citri Reticulatae Pericarpium Viride) and Chai Hu (Bupleuri Radix). For severe pain, swallow with Ginger Juice (Jiang Zhi).
Bazhen Tang (Eight-Treasure Decoction) Treats deficiency-type hypochondriac pain. (See Formula in Stroke section)
[External Treatment Methods]
Alternatively, grind Bai Jie Zi (Sinapis Semen) with water and apply to the affected area. Or grind Wu Zhu Yu (Evodiae Fructus) finely, mix with vinegar, and apply. Or mash fresh Jiu Cai (Allii Tuberosi Herba), mix with vinegar, place on the painful spot, and warm it using a heated iron warmer.