天津齐××，年五旬，得胁下作疼，兼胃口疼病。
病因 素有肝气不顺病，继因设买卖赔累，激动肝气，遂致胁下作疼，久之胃口亦疼。
证候 其初次觉疼恒在申酉时，且不至每日疼，后浸至每日觉疼，又浸至无时不疼。屡次延
医服药，过用开破之品伤及脾胃，饮食不能消化，至疼剧时恒连胃中亦疼。其脉左部沉弦
微硬，右部则弦而无力，一息近五至。
诊断 其左脉弦硬而沉者，肝经血虚火盛而肝气又郁结也。其右脉弦而无力者，土为木伤，
脾胃失其蠕动健运也。其胁疼之起点在申酉时者，因肝属木申酉属金，木遇金时其气化益遏
抑不舒也。《内经》谓，“厥阴不治，求之阳明。”夫厥阴为
肝，阳明为胃，遵《内经》之微旨以治此证，果能健补脾胃，俾中焦之气化营运无滞，再少
佐以理肝之品，则胃疼可愈，而胁下之疼亦即随之而愈矣。
处方 生怀山药（一两） 大甘枸杞（六钱） 玄参（五钱） 寸麦冬（四钱带心）
于白术（三钱） 生杭芍（三钱） 生麦芽（三钱） 桂枝尖（二钱）
龙胆草（二钱） 生鸡内金（二钱黄色的捣） 浓朴（钱半） 甘草（钱半）
共煎汤一大盅，温服。
复诊 将药连服四剂，胃中已不作疼，胁下之疼亦大轻减，且不至每日作疼，即有疼时亦
须臾自愈。脉象亦见和缓，遂即原方略为加减俾再服之。
处方 生怀山药（一两） 大甘枸杞（六钱） 玄参（四钱） 寸麦冬（四钱带心）
于白术（三钱） 生杭芍（三钱） 当归（三钱） 桂枝尖（二钱） 龙胆
草（二钱） 生鸡内金（二钱黄色的捣） 醋香附（钱半） 甘草（钱半） 生姜（二钱）
共煎汤一大盅，温服。
效果 将药连服五剂，胁下之疼霍然全愈，肝脉亦和平如常矣。遂停服汤药，俾日用生怀山药
细末两许，水调煮作茶汤，调以蔗糖令适口，以之送服生鸡内金细末二分许，以善其后。
或问 理肝之药莫如柴胡，其善舒肝气之郁结也。今治胁疼两方中皆用桂枝而不用柴胡，将
毋另有取义？答曰∶桂枝与柴胡虽皆善理肝，而其性实有不同之处。如此证之疼肇于胁下，
是肝气郁结而不舒畅也，继之因胁疼累及胃中亦疼，是又肝木之横恣而其所能胜也。柴胡能
舒肝气之郁，而不能平肝木之横恣，桂枝其气温升（温升为木气），能舒肝气之郁结则胁疼可
愈，其味辛辣（辛辣为金味），更能平肝木横恣则胃疼亦可愈也。
惟其性偏于温，与肝血虚损有热者不宜，故特加龙胆草以调剂之，俾其性归和平而后用之，有益
无损也。不但此也，拙拟两方之要旨，不外升肝降胃，而桂枝之妙用，不但为升肝要药，实又为
降胃要药。《金匮》桂枝加桂汤，治肾邪奔豚上干直透中焦，而方中以桂枝为主药，是其能降胃之
明征也。再上溯《神农本草经》，谓桂枝主上气咳逆及吐吸（吸不归根即吐出，即后世所谓喘也），是
桂枝原善降肺气，然必胃气息息下行，肺气始能下达无碍。细绎经旨，则桂枝降胃之功用，更可借
善治上气咳逆吐吸而益显也。盖肝升胃降，原人身气化升降之常，顺人身自然之气化而调养之，
则有病者自然无病，此两方之中所以不用柴胡皆用桂枝也。
天津齐先生，五十岁，患有胁下疼痛，同时伴有胃脘部疼痛的病症。
病因：他素来有肝气不舒畅的旧疾，后来因为经商买卖亏损赔累，激惹了肝气，于是导致胁下开始疼痛，时间久了，胃脘部也开始疼痛。
证候：他初次感觉疼痛通常是在申时和酉时（下午3点至7点），而且并不是每天都疼，后来逐渐发展到每天都能感觉到疼痛，再后来发展到没有什么时候不疼。多次请医生服药，由于过度使用攻破散结的药物，损伤了脾胃，导致饮食无法消化，到了疼痛剧烈的时候，常常牵连到胃中也一起疼痛。他的脉象左侧呈现沉、弦且微硬，右侧则弦而无力，一呼一吸之间脉搏跳动接近五次。
诊断：他的左脉弦硬而沉，这是因为肝经血虚火旺，同时肝气郁结所致。右脉弦而无力，是因为木克土，脾胃受到肝木伤害，失去了正常的蠕动和健运功能。胁下疼痛起始于申酉时，是因为肝属木，申酉时属金，木遇到金的时候，其气化更加受遏制而不舒展。《内经》中说：“厥阴病治不好，要从阳明胃经去求治。”厥阴指的是肝，阳明指的是胃。遵循《内经》的微言大义来治疗这个病症，如果能健补脾胃，使得中焦的气化运行通畅无阻，再稍微佐以调理肝脏的药物，那么胃疼就可以痊愈，胁下的疼痛也会随之痊愈。
处方：生怀山药（一两）、大甘枸杞（六钱）、玄参（五钱）、寸麦冬（四钱，带心）、于白术（三钱）、生杭芍（三钱）、生麦芽（三钱）、桂枝尖（二钱）、龙胆草（二钱）、生鸡内金（二钱，黄色的捣碎）、浓朴（钱半）、甘草（钱半）。共煎煮成一大盅汤剂，温服。
复诊：将药连续服用四剂后，胃中已经不再疼痛，胁下的疼痛也大大减轻，并且不再每天疼痛，即使有疼痛也是片刻之后自行缓解。脉象也变得和缓，于是就在原方基础上稍作加减，让他继续服用。
处方：生怀山药（一两）、大甘枸杞（六钱）、玄参（四钱）、寸麦冬（四钱，带心）、于白术（三钱）、生杭芍（三钱）、当归（三钱）、桂枝尖（二钱）、龙胆草（二钱）、生鸡内金（二钱，黄色的捣碎）、醋香附（钱半）、甘草（钱半）、生姜（二钱）。共煎煮成一大盅汤剂，温服。
效果：将药连续服用五剂后，胁下的疼痛霍然全部痊愈，肝脉也恢复平和如常。于是停止服用汤药，嘱咐日常每天取生怀山药细末约两许，用水调匀煮成茶汤，加入适量蔗糖使其口感适宜，用此送服生鸡内金细末约二分，以巩固疗效善后。
或问：调理肝脏的药物没有比柴胡更好的了，它善于疏解肝气的郁结。现在治疗胁痛的两个方子中都用了桂枝而没有用柴胡，难道另有深意吗？回答说：桂枝与柴胡虽然都善于调理肝脏，但它们的药性确实有所不同。像这种疼痛起源于胁下，是肝气郁结而不舒畅；随后因为胁痛牵连及胃中也疼痛，这是肝木横逆克制它所胜的脾土。柴胡能疏解肝气的郁结，但不能平抑肝木的横逆之气；桂枝气温而升（温升对应木气的特性），能够舒解肝气的郁结从而使胁痛痊愈，它的味道辛辣（辛辣对应金的特性），更能平抑肝木的横逆之气从而使胃痛也可痊愈。
只是桂枝的药性偏于温热，对于肝血虚损且有热者不宜，所以特意加入龙胆草来调剂，使药性归于平和后再使用，只有益处没有害处。不仅如此，我拟定的这两个方子的主要宗旨，不外乎是升发肝气、降泄胃气，而桂枝的妙用，不仅是升肝的要药，实际上又是降胃的要药。《金匮要略》中的桂枝加桂汤，治疗肾邪引起的奔豚气上冲直透中焦，方中以桂枝为主药，这就是它能降胃的明显证据。再往上追溯《神农本草经》，记载桂枝主治上气咳逆以及吐吸（吸气不能归根即吐出，就是后世所说的喘证），这说明桂枝原本就善于降肺气，然而必须胃气息息下行，肺气才能下达无阻碍。仔细推究经旨，桂枝降胃的功能，可以通过善于治疗上气咳逆吐吸而更加显现出来。大概肝升胃降，本是人体气化升降的正常规律，顺应人体自然的气化进行调养，那么有病的人自然会无病，这就是这两个方子中不用柴胡而都用桂枝的原因。
Mr. Qi from Tianjin, aged fifty, suffered from pain in the hypochondrium (lateral chest area) accompanied by pain in the stomach region (epigastrium).
Etiology: He had a chronic condition of stagnant Liver Qi (Liver Qi Stagnation). Subsequently, due to financial losses in business transactions, his Liver Qi was agitated, leading to pain in the hypochondrium. Over time, this extended to pain in the stomach region.
Symptoms: Initially, he felt pain primarily during the Shen and You hours (3 PM to 7 PM), and it did not occur daily. Gradually, the frequency increased to daily occurrence, and eventually, the pain became constant. Multiple consultations with physicians and medication regimens involved excessive use of dispersing and breaking agents, which damaged the Spleen and Stomach, impairing digestion. When the pain intensified, it often radiated to the stomach. His pulse was deep, wiry, and slightly hard on the left side, while wiry and forceless on the right side, with nearly five beats per breath cycle.
Diagnosis: The deep, wiry, and hard quality of the left pulse indicates Blood deficiency and Fire excess in the Liver channel, compounded by Liver Qi stagnation. The wiry and forceless quality of the right pulse suggests that Wood (Liver) has injured Earth (Spleen/Stomach), causing the Spleen and Stomach to lose their normal motility and transportive functions. The onset of hypochondriac pain during the Metal hours (Shen/You) occurs because Wood encounters Metal; at these times, the Qi transformation is further suppressed and uncomfortable. As stated in the *Neijing* (Inner Canon): "If Jueyin cannot be treated effectively, seek treatment in Yangming." Jueyin refers to the Liver, and Yangming refers to the Stomach. Following the subtle principles of the *Neijing*, if one strengthens and tonifies the Spleen and Stomach, ensuring smooth Qi transformation and circulation in the Middle Jiao, and adds a small amount of herbs to regulate the Liver, the stomach pain will resolve, and the hypochondriac pain will follow suit and heal.
Prescription: Raw Huai Shan Yao (Dioscoreae Hypoglaucae Rhizoma, 1 liang), Large Gan Gou Qi (Lycii Fructus, 6 qian), Xuan Shen (Scrophulariae Radix, 5 qian), Cun Mai Dong (Ophiopogonis Radix, 4 qian, including the heart), Yu Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 qian), Sheng Hang Shao (Paeoniae Radix Alba, 3 qian), Sheng Mai Ya (Hordei Fructus Germinatus, 3 qian), Gui Zhi Jian (Cinnamomi Ramulus Apex, 2 qian), Long Dan Cao (Gentianae Radix, 2 qian), Sheng Ji Nei Jin (Galli Gigerii Endothelium Corneum, 2 qian, yellow variety, crushed), Nong Po (Magnoliae Officinalis Cortex, 1.5 qian), Gan Cao (Glycyrrhizae Radix et Rhizoma, 1.5 qian). Decoct together in a large cup of water, take warm.
Second Visit: After taking four doses, the stomach pain ceased, and the hypochondriac pain significantly decreased, no longer occurring daily. Any remaining pain subsided spontaneously within moments. The pulse became harmonious and moderate. Therefore, the original prescription was slightly modified for continued use.
Prescription: Raw Huai Shan Yao (Dioscoreae Hypoglaucae Rhizoma, 1 liang), Large Gan Gou Qi (Lycii Fructus, 6 qian), Xuan Shen (Scrophulariae Radix, 4 qian), Cun Mai Dong (Ophiopogonis Radix, 4 qian, including the heart), Yu Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 qian), Sheng Hang Shao (Paeoniae Radix Alba, 3 qian), Dang Gui (Angelicae Sinensis Radix, 3 qian), Gui Zhi Jian (Cinnamomi Ramulus Apex, 2 qian), Long Dan Cao (Gentianae Radix, 2 qian), Sheng Ji Nei Jin (Galli Gigerii Endothelium Corneum, 2 qian, yellow variety, crushed), Cu Xiang Fu (Cyperi Rhizoma processed with vinegar, 1.5 qian), Gan Cao (Glycyrrhizae Radix et Rhizoma, 1.5 qian), Sheng Jiang (Zingiberis Rhizoma Recens, 2 qian). Decoct together in a large cup of water, take warm.
Outcome: After taking five doses, the hypochondriac pain completely resolved, and the Liver pulse returned to a normal, peaceful state. Decoction therapy was discontinued. The patient was instructed to consume approximately two qian of finely powdered Raw Huai Shan Yao daily, mixed with water and boiled into a tea-like consistency, sweetened with sucrose to taste, taken to deliver approximately two fen of finely powdered Sheng Ji Nei Jin, to consolidate the recovery.
Inquiry: Among herbs for regulating the Liver, Chai Hu (Bupleuri Radix) is unparalleled for its ability to soothe Liver Qi stagnation. Why were both prescriptions for hypochondriac pain using Gui Zhi (Cinnamomi Ramulus) instead of Chai Hu? Is there another rationale?
Response: Although both Gui Zhi and Chai Hu are effective in regulating the Liver, their properties differ significantly. In this case, the pain originated in the hypochondrium, indicating stagnant and unsmooth Liver Qi. Subsequently, the hypochondriac pain affected the stomach, indicating the horizontal aggression of Liver Wood over its controlled element (Earth/Spleen-Stomach). Chai Hu can soothe stagnant Liver Qi but cannot pacify the horizontal aggression of Liver Wood. Gui Zhi has a warm and ascending nature (corresponding to Wood Qi), which can relieve Liver Qi stagnation to cure hypochondriac pain. Its pungent and spicy flavor (corresponding to Metal flavor) can further pacify Liver Wood's horizontal aggression to cure stomach pain.
However, since Gui Zhi is warm in nature, it is unsuitable for cases involving Liver Blood deficiency with heat. Therefore, Long Dan Cao (Gentianae Radix) was specifically added to balance the formula, ensuring a neutral property before use, providing benefit without harm. Moreover, the core principle of my two prescriptions is to ascend Liver Qi and descend Stomach Qi. Gui Zhi’s subtle utility lies not only in being a key herb for ascending Liver Qi but also for descending Stomach Qi. In the *Jin Gui Yao Lue* (Essential Prescriptions from the Golden Cabinet), the Gui Zhi Jia Gui Tang (Cinnamon Twig Plus Cinnamon Twig Decoction) treats Ben Tun (Rushing Pig) caused by Kidney pathogenic Qi rushing upward through the Middle Jiao, with Gui Zhi as the principal herb, demonstrating its ability to descend Stomach Qi. Tracing back to the *Shennong Ben Cao Jing* (Divine Farmer’s Materia Medica), it states that Gui Zhi treats upper Qi, cough, and reverse flow (inhaling without rooting, expelling air, known as asthma in later periods). This shows Gui Zhi naturally descends Lung Qi. However, Lung Qi can only descend smoothly if Stomach Qi descends continuously. Careful interpretation of these classics reveals that Gui Zhi’s function in descending Stomach Qi is further highlighted by its efficacy in treating upper Qi, cough, and reverse flow. The ascent of Liver Qi and descent of Stomach Qi constitute the normal pattern of Qi transformation in the human body. By nourishing and regulating according to this natural physiological process, disease resolves naturally. This explains why Chai Hu was omitted and Gui Zhi was used in both prescriptions.