经义
春脉不及，则令人胸痛引背，下则两胁 痛。○南风生于夏，病在心，俞在胸胁。○肝病者，两胁下痛引
少腹，令人善怒。○心病者，胸中痛，胁支满，胁下痛。○胆足少阳也，是动则病口苦，善太息，心胁痛不能
转侧。（《素问》）
邪在肝则两胁中痛。○肝小则脏安，无胁下之病；肝大则逼胃迫咽，苦膈中，且胁下痛；肝偏倾则胁下痛。
○脾小则脏安，脾大则苦凑 而痛，脾高则 引季胁痛。（《灵枢》）
哲言
伤寒胁痛属少阳胆经，以胁居少阳之部。杂证胁痛属厥阴肝经，以肝脉布于胁肋。其证有虚、实、寒、
热，不可概论。（《临证指南》）
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KT 聩，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；两胁拘急，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。（《证治汇补》）
胁痛病属肝、胆二经，以二经之脉皆循胁肋故也。然而心、肺、脾、胃、肾与膀胱，亦皆有胁痛之病，以
邪在诸经，气逆不解，传及少阳，厥阴，乃致胁肋疼痛耳。故凡以焦劳忧虑而致胁痛者，此心肺所传也。以饮
食劳倦而致胁痛者，此脾胃之所传也。以色欲内伤、水道壅闭而致胁痛者，此肾与膀胱之所传也。传至本经，
则无非肝、胆之病矣。至于忿怒、疲劳、伤血、伤气、伤筋，或寒邪在半表半里之间，此自本经之病。病在本
经者，直取本经。传至他经者，以拔其所病之本，自无不愈。○胁痛，诸家有左、右、血、气之辨。谓肝位于
左而藏血，肺位于右而藏气，故病在左者为血积，病在右者为气郁。脾气亦系于右，故湿痰流注者亦在右。若
执此说，则左岂无气？右岂无血？食积、痰饮，岂必无涉于左乎？古无是说，此后世之谬谈，不足凭也。然则
在气、在血，何以辨之？但察其有形、无形，可知之矣。盖血则有形而不移，或坚硬而拒按；气则流行而无迹，
或倏聚而倏散。若食积、痰饮，皆属有形，详察所因，自可识别。且凡属有形，无非由气之滞。但得气行，则
何聚不散？凡治此者，无论是血、是痰，必兼治气为主。（张景岳）
胁痛者∶瘀血，按之痛，不按亦痛，痛无休息而不膨；气痛则时止而膨，嗳即宽，旋复痛。以此辨验气血
为妙。（《见闻录》）
每验怒气易动者，最多肝痛之证。其左胁骨下痛而有块，扁大如痞，实非痞也；乃肝叶血燥不下垂故也。
（《己任编》）
损证，胁下常有一点痛不止者，名干胁痛，甚危。（《医学入门》）
补编
胁下偏痛发热，其脉紧弦，此寒也；以温药下之，宜大黄附子汤。（《金匮》）
按∶胁下偏痛之偏字，当是满字，当改之。（《医宗金鉴》）
胁痛一证，不徒责在肝胆，而他经亦累及之。有寒、热、虚、实之不同，痰积、瘀血之各异。尝考经旨，
谓肝脉挟胃、络胆，上贯膈，布胁肋。胆脉贯膈、络肝，循胁里，其直者循胸过季胁。是两胁之痛，皆属肝胆
为病。内伤不外气、血两端，外感责在少阳一经而已。盖肝为将军之官，其性暴怒。非怫意交加，则忧郁莫解；
非酒色耗扰，则风寒外袭，痛之所由生也。使其人而虚寒也者，则五内亏而痛矣；使其人而虚热也者，则隧道
塞而痛矣；使其人而实热也者，或邪气入而痛，或郁火发而痛矣。痛在气分者，治在气∶寒者温之、虚者补之、
热者清之、实者泄之，血药不宜用也。使其人而血虚也者，则肝少血养而痛矣；使其人而血热也者，则木火内
灼而痛矣；使其人而血分实热也者，或邪在半表半里而痛，或满闷惧按多怒而痛矣。痛在血分者，治在血。血
虚者以血药补之，血热者以阴药滋之，血实者以苦药通之，气药不宜用也。更有瘀血内蓄，痰饮内聚，及肥气、
痞气，皆属有形之积。非益血则邪不退，即令气寒而得此，亦易补阳在先，补阴在后，阴阳两补。痰瘀除而积
聚消，胁痛岂有不愈者哉？虽然，操心者常有此证，房劳者每有此患。医家不明肝肾同原、精髓内空、相火易
上之理，一味辛香行气，冀其奏功。不知辛能通窍，香能耗血，肝病不已，复传于肺，咳嗽喘促，甚至血动，
斯时有莫可如何者矣。是以初起确认为肝肾之病，宜乙癸合治∶用六味汤加人乳、河车之属，俾水生而木荣，母
实而子安，此正治之法也。倘气因精虚者，宜用八味汤加人参、河车之属，阴中求阳，坎中生火，此从治之法
也。或谓内伤胁痛，逍遥散乃不易之方；外感胁痛，小柴胡为必用之药。二者可以尽病之情乎？而犹未也。诚
以法之运用无穷，方之变化无定。通因通用者，治肝邪之有余；塞因塞用者，治肝藏之不足。而其间必以拒按、
喜按，探虚实之消息；喜温、喜冷，验寒热之假真。更宜以脉之大、小、迟、数、
有力、无力为辩，神而明之，勿泥也。且胁痛而及他脏者，亦有之矣。咳唾腥臭者，肺痈也；痛连胃脘、呕吐
酸味者，木凌脾也；痛而寒热谵语如见鬼状者，妇人热入血室也。舍气血而何所补救哉？盖甘可缓中，则木气
条达，自然右降而左升；和能平怒，则疏泄令行，渐次气充而血润，胁痛云乎哉？（《会心录》）
肝之脏在两胁，肝之治在下焦。肾肝居下，阴中之阴也。滋水所以养肝，肾为肝之母也。世人治胁痛，分左
属血、右属气，必用青皮、枳壳破气之药，谓肝得疏泄而病愈。然在初起气实者，亦或有效，久则非培其母不可。
阳气变化，内风乘胃为呕，攻胁为痛。肝居左而痛偏炽与右，肝木犯土之征。经旨调肝为刚脏，非柔不和，
当用镇阳熄风方法，如牡蛎、阿胶、生地、小麦之类。（叶天士）
内伤胁痛，用生香油、生蜜各一杯和匀，服一、二次即愈。（周慎斋）
脉候
寸口脉弦者，即胁下拘急而痛，其人啬啬恶寒也。（《金匮》）
胁痛∶脉弦数有力为肝盛有余；弦数无力为肝虚有火。弦为饮，沉为气，浮数为风，弦弱为阳虚，沉细为
阴虚。（张路玉）
选案
余弟于六月途行，受热过劳，性躁，忽左胁痛，皮肤一片红如碗大，发水泡疮三、五点，脉数而弦，夜重
于昼。医作肝经郁火，治以黄连、青皮、香附、川芎、柴胡之类。进药一服，其夜痛极热增，次早皮肤红大如
盘，疮加三十余粒。又以白矾末井水调敷，药加青黛、龙胆草。其夜痛苦叫号，次早红及半身，疮增百数。予
心不怿，载归询黄古潭先师。观脉案药方。晒曰∶切脉认药则审矣，制药订方则未也。夫用药如用兵，知己知
彼，百战百胜。今病势有烧眉之急，累卵之危，岂可执寻常泻肝之法正治耶？是谓驱羊搏虎矣。且苦寒愈资其
燥，故病转增。水泡疮发于
外者，肝郁既久，不得发越，侮所不胜，故皮腠为之溃。至于自焚则死矣。订方∶以大栝蒌一枚，连皮捣烂，
加甘草二钱、红花五分，戌时进药，少顷得睡，至丑时方醒。问之，已不痛矣。急煎药渣与服，睡至天明，微
利一度，复睡至辰，起视肤红已释，疮亦尽敛，后亦不服他药。夫病重三日，饮食不进，呻吟不辍，一剂而愈，
可谓神矣！夫栝蒌味甘寒，经云；损其肝者缓其中。且其为物，柔而滑润，甘缓润下。考之本草，栝蒌能治插
胁之痛。盖为其缓中润燥，以致于流通，故痛自止也。（孙一奎）
一妇患伤寒，寒热胁痛，块坚如石，昼夜呻吟，诊脉弦滑，用小柴胡汤去人参，加牡蛎、青皮、枳壳，服
药二剂，块消病愈。（程星海）
一人胁痛，脉右虚，左微弦小，面色黄。凡久痛必入络，络主血，药不宜刚。用《金匮》旋复花汤，加柏
子仁、归须、桃仁。（叶天士）
一人捕鱼为业。起初左肋块痛，续渐痛甚，控引背俞，诸药不效。或教取 树嫩枝，浓铺痛处，煮大麦仁
饭，乘热盖 枝上，每日两次。经年之病，数日而愈。（《见闻录》）
一人左胁痛，后传于右，断为不起。按∶肝有七叶，左三、右四。其治在左，其脏在右，痛传于右，邪入
脏矣，后果死。（周慎斋）
【背景信息】
书名：医述 作者：程杏轩 朝代：元 章节：胁痛 类别：医论
【待处理原文】
经义
春季脉象不及（指肝脉应弦而反弱），就会使人胸痛牵引至背部，向下则导致两胁疼痛。○夏季南风盛行，病位在心，背俞穴位于胸胁部位。○肝脏有病的人，两胁下疼痛牵引至小腹，使人容易发怒。○心脏有病的人，胸中疼痛，胁肋部支撑胀满，胁下疼痛。○胆经属于足少阳经，如果该经发生病变，会出现口苦、喜欢叹气、心胁部疼痛且身体不能转侧的症状。（出自《素问》）
邪气侵犯肝脏，就会导致两胁中间疼痛。○肝脏体积较小，则内脏安宁，没有胁下的疾病；肝脏体积增大，则会压迫胃部和咽喉，导致膈中不适，并且胁下疼痛；肝脏位置偏斜，则会导致胁下疼痛。
○脾脏体积较小，则内脏安宁；脾脏体积增大，则会因凑聚而疼痛，脾脏位置偏高，则会牵引季胁疼痛。（出自《灵枢》）
哲言
伤寒引起的胁痛归属于少阳胆经，因为胁部位于少阳经的循行部位。杂病引起的胁痛归属于厥阴肝经，因为肝经的脉络分布于胁肋。这类病症有虚证、实证、寒证、热证的区别，不能一概而论。（出自《临证指南》）
治疗胁痛应当区分左右，辨别虚实。左胁疼痛的，是肝脏受邪；右胁疼痛的，是肝邪传入肺脏；左右胁都疼痛的，是气机阻滞；左右胁部胀痛且伴有声音的，是痰饮停滞；左胁下有肿块且夜间疼痛加剧的，是死血（瘀血）；右胁下有肿块且饱闷疼痛的，是食积。咳嗽牵引疼痛，气喘急促发热的，是痰结；时作时止，突然发作且疼痛剧烈的，是火郁；胀闷害怕按压，烦躁易怒的，是肝实证；耳目昏花，指甲干枯容易惊恐的，是肝虚证；隐隐微痛，牵连腰胯，感觉空软且喜欢按压的，是肾虚证。胁痛伴有咳嗽吐腥臭痰，面红唾痰的，是肺气受损；胁内支撑胀满，目眩，大小便出血的，是肝血受损；两胁拘急，腰腿疼痛不能转侧的，是湿热郁结；右侧胸部靠近胁部有一点刺痛，伴有内热咳嗽的，是肺痈。（出自《证治汇补》）
胁痛病症主要属于肝、胆二经，因为这两条经脉的循行路线都经过胁肋。然而，心、肺、脾、胃、肾与膀胱，也都有可能导致胁痛，这是因为邪气在诸经之中，气机逆乱不解，传变波及少阳经和厥阴经，才导致胁肋疼痛。所以，凡是因过度劳累忧虑而导致胁痛的，这是心肺传来的病邪。因饮食劳倦而导致胁痛的，这是脾胃传来的病邪。因房事内伤、水道壅闭而导致胁痛的，这是肾与膀胱传来的病邪。病邪传变到本经（肝胆经），就无非是肝、胆的疾病了。至于因愤怒、疲劳、伤血、伤气、伤筋，或者寒邪在半表半里之间，这些是本经自有的疾病。病在本经的，直接取本经穴位或药物进行治疗。传变到其他经的，通过拔除致病之本，自然没有不愈的道理。○关于胁痛，各家都有左、右、血、气的辨析。认为肝位于左侧而藏血，肺位于右侧而藏气，所以病在左侧的是血积，病在右侧的是气郁。脾气也系于右侧，所以湿痰流注也在右侧。如果固执这种说法，难道左侧就没有气吗？右侧就没有血吗？食积、痰饮，难道一定不涉及左侧吗？古代没有这种说法，这是后世的谬误之谈，不值得相信。那么，如何辨别病在气分还是血分呢？只要观察是有形还是无形，就可以知道了。大概血积是有形的且不移动，或者坚硬且拒绝按压；气滞则是流行无迹的，或者突然聚集又突然消散。至于食积、痰饮，都属于有形之物，详细考察病因，自然可以识别。而且凡是有形的积聚，无非都是由气机阻滞引起的。只要气机运行通畅，什么积聚不能消散？大凡治疗此类病症，无论是血证还是痰证，都必须以调理气机为主。（张景岳）
胁痛的症状：如果是瘀血，按压时疼痛，不按也痛，疼痛没有休息的时候且不伴有胀满；如果是气痛，则时好时坏且伴有胀满，打嗝后感到宽舒，随即又疼痛。用这种方法辨别气血是非常巧妙的。（出自《见闻录》）
每次验证发现，容易动怒的人，最多出现肝痛的证候。其左胁骨下疼痛且有肿块，扁平宽大像痞块一样，实际上并非痞块；而是由于肝叶血燥不下垂所致。（出自《己任编》）
虚损类病症中，胁下常有一点疼痛不止的，名叫干胁痛，病情非常危险。（出自《医学入门》）
补编
胁下偏侧疼痛且发热，脉象紧弦，这是寒证；应当用温药攻下，适宜使用大黄附子汤。（出自《金匮要略》）
按语：胁下偏痛中的“偏”字，应当是“满”字，应当改正。（出自《医宗金鉴》）
胁痛这一证候，不仅仅责在于肝胆，其他经络也会累及。有寒、热、虚、实的不同，有痰积、瘀血的差异。曾经考证经典旨意，说肝脉挟持胃腑、联络胆腑，向上贯穿膈肌，分布于胁肋。胆脉贯穿膈肌、联络肝脏，沿胁肋内侧行走，直行者经过胸部过季胁。因此两胁的疼痛，都属于肝胆为病。内伤不外乎气、血两个方面，外感则责之于少阳一经而已。肝被称为将军之官，其性刚暴。如果不是意气相激，就是忧郁无法解开；如果不是酒色耗损扰乱，就是风寒外袭，这就是疼痛产生的原因。如果这个人属于虚寒体质，那么五脏亏虚而疼痛；如果这个人属于虚热体质，那么经络隧道闭塞而疼痛；如果这个人属于实热体质，或者是邪气入侵而疼痛，或者是郁火发作而疼痛。疼痛在气分的，治疗着眼于气：寒者温之、虚者补之、热者清之、实者泄之，不宜使用血分药物。如果这个人属于血虚体质，那么肝脏缺少血液滋养而疼痛；如果这个人属于血热体质，那么木火在内灼烧而疼痛；如果这个人属于血分实热体质，或者是邪气在半表半里而疼痛，或者是胀闷害怕按压多怒而疼痛。疼痛在血分的，治疗着眼于血。血虚的用血分药物补益，血热的用滋阴药物滋润，血实的用苦味药物通泄，不宜使用气分药物。更有瘀血内蓄，痰饮内聚，以及肥气、痞气，都属于有形的积聚。如果不益血则邪气不退，即使是因为寒气导致得到此病，也容易先补阳后补阴，阴阳双补。痰瘀去除而积聚消散，胁痛怎么会不痊愈呢？虽然如此，操心劳神的人常有此证，房事过度的人每每有此患。医生不明白肝肾同源、精髓内空、相火容易上炎的机理，一味使用辛香行气的药物，希望取得功效。不知道辛味能通窍，但香气会耗血，肝病不已，反而传变于肺，导致咳嗽喘促，甚至动血，这时就有无可奈何的情况了。所以在初起时确认为肝肾之病，适宜采用乙癸同治的方法：使用六味地黄汤加入人乳、紫河车之类的药物，使水能生木而肝木荣盛，母实而子安，这是正治之法。如果是气因精虚导致的，适宜使用八味丸加入人参、紫河车之类的药物，在阴中求阳，在坎水中生火，这是从治之法。有人说内伤胁痛，逍遥散是不变的方子；外感胁痛，小柴胡汤是必用的药。这两种方法能穷尽病情的变化吗？还不仅如此。确实因为法度的运用无穷无尽，方剂的變化没有定式。通因通用，是治疗肝邪有余；塞因塞用，是治疗肝藏不足。而其间必须通过拒按、喜按，来探察虚实的消息；通过喜温、喜冷，来验证寒热的真假。更应当以脉象的大、小、迟、数、有力、无力作为辨别依据，神妙地领悟它，不要拘泥。而且胁痛波及他脏的，也是有的。咳嗽吐腥臭痰的，是肺痈；疼痛牵连胃脘、呕吐酸味的，是肝木凌犯脾土；疼痛伴有寒战谵语如见鬼状的，是妇人热入血室。舍弃气血辨证还能有什么补救措施呢？大概甘味可以缓和中焦，则肝气条达，自然右边下降左边上升；和法能平息怒气，则疏泄功能行使，逐渐气充而血润，胁痛还有什么难治的呢？（出自《会心录》）
肝脏的脏器位于两胁，肝脏的治疗重点在下焦。肾和肝居于下部，属于阴中之阴。滋补肾水所以能养肝，因为肾是肝的母亲。世人治疗胁痛，分为左侧属血、右侧属气，必定使用青皮、枳壳等破气药物，认为肝得到疏泄而病愈。然而在初起气实的情况下，或许有效，时间久了就必须培补其母（肾）。阳气变化，内风乘虚侵入胃腑导致呕吐，侵袭胁部导致疼痛。肝位于左侧但疼痛偏炽烈于右侧，这是肝木克伐脾土的征象。经典旨意指出调肝要视其为刚脏，非柔和不能调和，应当使用镇阳熄风的方法，如牡蛎、阿胶、生地、小麦之类的药物。（叶天士）
内伤胁痛，使用生香油、生蜂蜜各一杯混合均匀，服用一两次即痊愈。（周慎斋）
脉候
寸口脉弦，就会出现胁下拘急而痛，此人会有啬啬恶寒的表现。（出自《金匮要略》）
胁痛：脉象弦数有力是肝盛有余；弦数无力是肝虚有火。弦脉主饮，沉脉主气，浮数主风，弦弱主阳虚，沉细主阴虚。（张路玉）
选案
我的弟弟在六月途中行走，受热且过度劳累，性格急躁，忽然左胁疼痛，皮肤一片发红如碗大，发出水泡疮三、五点，脉象数而弦，夜间重于白天。医生当作肝经郁火治疗，使用黄连、青皮、香附、川芎、柴胡之类的药物。服药一次后，当夜疼痛极度剧烈且热度增加，次日早晨皮肤红大如盘，疮疹增加到三十余粒。又用白矾末井水调敷，药物中加入青黛、龙胆草。当夜痛苦叫喊，次日早晨红色蔓延至半身，疮疹增加到上百个。我心里不安，将他载回家询问黄古潭老师。观看脉案药方。老师说：切脉认药倒是审慎了，但制药订方就不对了。用药如同用兵，知己知彼才能百战百胜。现在病势有火烧眉毛之急，累卵之危，怎么能执着于寻常泻肝的正治之法呢？这叫做驱羊搏虎。况且苦寒药物更加助长其燥性，所以病情加重。水泡疮发于外部，是因为肝郁已久，不得发越，侮所不胜（肺金），所以皮肤腠理为之溃烂。如果继续这样下去就会自焚而死。重新订方：以大栝蒌一枚，连皮捣烂，加入甘草二钱、红花五分，戌时进药，过了一会儿入睡，直到丑时才醒。问他，已经不痛了。急忙煎药渣给他服用，睡到天明，轻微腹泻一次，又睡到辰时，起来看皮肤红色已消退，疮疹也已收敛，后来也没有再服其他药物。病重三日，饮食不进，呻吟不停，一剂药就痊愈了，真可谓神奇！栝蒌味甘寒，经云：损其肝者缓其中。而且它的性质柔滑滋润，甘缓润下。考据本草，栝蒌能治疗插胁之痛。大概是因为它能缓中润燥，以致流通，所以疼痛自然停止。（孙一奎）
一位妇女患伤寒，寒热往来伴胁痛，肿块坚硬如石，昼夜呻吟，诊脉弦滑，用小柴胡汤去掉人参，加入牡蛎、青皮、枳壳，服药两剂，肿块消除病愈。（程星海）
一人胁痛，脉象右虚，左微弦小，面色黄。凡是久痛必然入络，络主血，药物不宜刚燥。使用《金匮要略》中的旋复花汤，加入柏子仁、归须、桃仁。（叶天士）
一人以捕鱼为业。起初左肋块状疼痛，随后逐渐疼痛加剧，牵涉引痛至背部俞穴，各种药物无效。有人教令取榉树嫩枝，厚铺在疼痛处，煮大麦仁饭，趁热盖在树枝上，每天两次。经年之病，数日而愈。（出自《见闻录》）
一人左胁痛，后来传变到右侧，断定为不治之症。按语：肝有七叶，左三右四。其功能主治在左侧，其脏器实体在右侧，疼痛传变到右侧，说明邪气已进入脏器，后果果然死亡。（周慎斋）
[Background Information]
Book: Yi Shu (Record of Medicine)
Author: Cheng Xingxuan
Dynasty: Yuan
Chapter: Hypochondriac Pain (Xie Tong)
Category: Medical Discourse
[Jing Yi - Classic Texts]
When the spring pulse is deficient, it causes chest pain radiating to the back, and downward, pain in both hypochondriac regions. ○ The south wind arises in summer; the disease is in the Heart, and its Shu points are located in the chest and hypochondrium. ○ When the Liver is diseased, there is pain under both hypochondria radiating to the lower abdomen, causing irritability. ○ When the Heart is diseased, there is pain in the chest, fullness and distension in the hypochondrium, and pain under the hypochondrium. ○ The Gallbladder belongs to the Foot Shaoyang Meridian. If this meridian is affected, symptoms include bitter taste in the mouth, frequent sighing, pain in the heart and hypochondrium, and inability to turn the body. (Su Wen)
When pathogenic factors are in the Liver, there is pain in the middle of both hypochondria. ○ If the Liver is small, the zang organs are peaceful, and there is no disease in the hypochondrium; if the Liver is enlarged, it presses against the Stomach and pharynx, causing discomfort in the diaphragm and pain in the hypochondrium; if the Liver is displaced, it causes pain in the hypochondrium.
○ If the Spleen is small, the zang organs are peaceful; if the Spleen is enlarged, it causes pain due to congestion; if the Spleen is high, it pulls on the costal margin causing pain. (Ling Shu)
[Zhe Yan - Philosophical Remarks]
Hypochondriac pain caused by Shanghan (Cold Damage) belongs to the Shaoyang Gallbladder Meridian because the hypochondrium is within the distribution area of the Shaoyang. Hypochondriac pain from miscellaneous diseases belongs to the Jueyin Liver Meridian because the Liver meridian distributes over the hypochondrium and ribs. These conditions can be deficiency, excess, cold, or heat, and cannot be generalized. (Lin Zheng Zhi Nan)
Treatment of hypochondriac pain should distinguish between left and right, and differentiate deficiency and excess. Pain on the left side indicates the Liver is affected by pathogens; pain on the right side indicates Liver pathogens have entered the Lung; pain on both sides indicates Qi stagnation; distending pain with sound on both sides indicates Phlegm-Fluid retention; a mass on the left side with worsening night pain indicates fixed blood (Blood Stasis); a mass on the right side with fullness and pain indicates Food Retention. Cough-induced pain with wheezing and fever indicates Phlegm Knotting; intermittent onset with sudden severe pain indicates Fire Depression; fullness, fear of pressure, irritability, and anger indicate Liver Excess; blurred vision and hearing, dry nails, and timidity indicate Liver Deficiency; dull mild pain extending to the waist and hips, feeling empty and relieved by pressure indicates Kidney Deficiency. Hypochondriac pain with coughing up foul-smelling sputum, red face, and spitting phlegm indicates Lung Qi injury; internal hypochondriac fullness, dizziness, and bleeding from the front and rear (urine/feces) indicate Liver Blood injury; tightness in both hypochondria with lower back and leg pain preventing turning indicates Damp-Heat depression; a single stabbing point near the right hypochondrium with internal heat and cough indicates Lung Abscess. (Zheng Hui Hui Bu)
Hypochondriac pain primarily involves the Liver and Gallbladder meridians because their pathways all traverse the hypochondrium. However, the Heart, Lung, Spleen, Stomach, Kidney, and Bladder can also cause hypochondriac pain because when pathogens are in these meridians, rebellious Qi fails to resolve and transmits to the Shaoyang and Jueyin meridians, resulting in hypochondriac pain. Therefore, hypochondriac pain caused by overwork and worry is transmitted from the Heart and Lung. Hypochondriac pain caused by dietary irregularities and fatigue is transmitted from the Spleen and Stomach. Hypochondriac pain caused by sexual indiscretion and obstruction of water passages is transmitted from the Kidney and Bladder. Once transmitted to the primary meridians (Liver and Gallbladder), it is purely a Liver/Gallbladder disease. Conditions caused by anger, fatigue, injury to blood, Qi, or sinews, or Cold pathogens between the exterior and interior, are primary diseases of these meridians. For diseases in the primary meridians, treat the primary meridians directly. For diseases transmitted to other meridians, address the root cause, and recovery is assured. ○ Regarding hypochondriac pain, various schools distinguish based on left/right and blood/Qi. They argue that the Liver is on the left and stores Blood, while the Lung is on the right and stores Qi; thus, left-sided disease is Blood accumulation, and right-sided disease is Qi stagnation. Since Spleen Qi is also associated with the right, damp-phlegm flow-stasis also occurs on the right. If one adheres to this view, does the left have no Qi? Does the right have no Blood? Can food retention and phlegm-fluid not involve the left? This saying did not exist in ancient times; it is a later fallacy and should not be relied upon. So how to distinguish between Qi and Blood involvement? Observe whether the condition is tangible or intangible. Blood accumulations are tangible and immovable, often hard and refusing pressure; Qi stagnation flows without trace, gathering and dispersing suddenly. Food retention and phlegm-fluid are tangible; examining the cause allows identification. Moreover, all tangible accumulations stem from Qi stagnation. If Qi moves freely, what accumulation will not disperse? In treating such cases, whether dealing with Blood or Phlegm, regulating Qi must be the primary focus. (Zhang Jingyue)
Symptoms of hypochondriac pain: If due to Blood Stasis, pressing causes pain, and non-pressing also causes pain, with no rest from pain and no distension; if due to Qi pain, it stops intermittently and causes distension, relieving after belching, but returning soon. This method of distinguishing Qi and Blood is excellent. (Jian Wen Lu)
Experience shows that those prone to anger most frequently suffer from Liver pain. Pain below the left rib cage with a mass, flat and large like a Pi syndrome (glomus), is actually not Pi syndrome; it is due to the liver lobe being dry from Blood deficiency and failing to hang down properly. (Ji Ren Bian)
In consumptive diseases, constant pinpoint pain under the hypochondrium is called Gan Xie Tong (Dry Hypochondriac Pain), which is very critical. (Yi Xue Ru Men)
[Bu Bian - Supplementary Compilation]
Unilateral hypochondriac pain with fever and a tight, string-like pulse indicates Cold; treat with warming purgatives, using Da Huang Fu Zi Tang (Rhubarb and Aconite Decoction). (Jin Gui Yao Lue)
Note: The character "pian" (unilateral/side) in "hypochondriac unilateral pain" should likely be "man" (fullness/distension) and should be corrected. (Yi Zong Jin Jian)
The syndrome of hypochondriac pain is not solely attributed to the Liver and Gallbladder; other meridians are also involved. It varies by Cold, Heat, Deficiency, and Excess, and by Phlegm accumulation and Blood Stasis. Examining the classics, the Liver meridian夹 (clamps) the Stomach, connects with the Gallbladder, pierces the diaphragm, and distributes over the hypochondrium. The Gallbladder meridian pierces the diaphragm, connects with the Liver, follows the interior of the hypochondrium, and its straight branch passes through the chest and costal margin. Thus, pain in both hypochondria belongs to Liver/Gallbladder pathology. Internal injuries involve only Qi and Blood; external invasions concern only the Shaoyang meridian. The Liver is the General; its nature is violent. Unless there is emotional frustration or unresolved melancholy, or consumption by wine and sex leading to Wind-Cold invasion, pain would not arise. If the person is Deficient-Cold, the five viscera are deficient, causing pain. If Deficient-Heat, the collaterals are blocked, causing pain. If Excess-Heat, either pathogens enter or depressed fire erupts, causing pain. For pain in the Qi level, treat the Qi: Warm the Cold, Tonify the Deficiency, Clear the Heat, Drain the Excess; do not use Blood-invigorating herbs. If the person is Blood Deficient, the Liver lacks nourishment, causing pain. If Blood Heat, Wood-Fire burns internally, causing pain. If Blood Excess-Heat, either pathogens are at the half-exterior/half-interior level or fullness/anger causes pain. For pain in the Blood level, treat the Blood: Tonify Blood Deficiency with Blood herbs, Nourish Blood Heat with Yin herbs, Unblock Blood Excess with Bitter herbs; do not use Qi-regulating herbs. Furthermore, internal accumulation of Blood Stasis and Phlegm-Fluid, as well as Fei Qi (Fat Qi) and Pi Qi (Pi Mass), are tangible accumulations. Without nourishing Blood, pathogens will not retreat; even if caused by Cold, tonifying Yang first and Yin second, or tonifying both, is effective. Once Phlegm and Stasis are removed and accumulations dissipate, hypochondriac pain will surely heal. Although, those who worry excessively often have this syndrome, and those with excessive sexual activity often suffer from it. Physicians who do not understand that Liver and Kidney share the same source, that essence is internally empty, and that Ministerial Fire easily ascends, will blindly use acrid-aromatic Qi-moving drugs hoping for success. They do not know that Acrid opens orifices but Aromatic consumes Blood; unhealed Liver disease transmits to the Lung, causing cough and wheezing, even hemoptysis, leaving no remedy. Therefore, at the onset, confirming it as a Liver-Kidney disease requires Yi-Gui simultaneous treatment: Use Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) added with Human Milk and He Che Da Zao (Placenta) to generate Water so Wood flourishes, making the Mother solid and the Child peaceful; this is the direct treatment. If Qi is deficient due to Essence deficiency, use Ba Wei Wan (Eight-Ingredient Pill) added with Ginseng and Placenta to seek Yang within Yin, generating Fire in Kan (Water); this is the indirect treatment. Some say Xiaoyao San (Free and Easy Wanderer Powder) is the unchangeable formula for internal injury hypochondriac pain, and Xiao Chai Hu Tang (Minor Bupleurum Decoction) is essential for external contraction hypochondriac pain. Can these two cover all pathological states? No. Indeed, the application of methods is infinite, and formulas vary endlessly. Using Unblocking to Treat Obstruction treats Liver Excess; Using Obstructing to Treat Obstruction treats Liver Deficiency. One must probe deficiency/excess via rejection/appreciation of pressure, and verify true/false Cold/Heat via preference for warmth/cold. Differentiate further by pulse magnitude, speed, strength, and weakness, applying wisdom without rigidity. Also, hypochondriac pain affecting other organs exists: Foul-smelling sputum indicates Lung Abscess; pain radiating to the epigastrium with sour vomiting indicates Liver Wood invading Spleen Earth; pain with chills, fever, and delirium resembling seeing ghosts in women indicates Heat entering the Blood Chamber. Abandoning Qi and Blood differentiation leaves no remedy. Sweet flavors soothe the center, allowing Liver Qi to flow smoothly, descending right and ascending left; Harmonizing pacifies anger, allowing dispersion functions to proceed, gradually filling Qi and moistening Blood, resolving hypochondriac pain. (Hui Xin Lu)
The Liver organ is located in the two hypochondria, and its treatment focuses on the Lower Jiao. Kidney and Liver reside in the lower part, being Yin within Yin. Nourishing Water nourishes the Liver because the Kidney is the Mother of the Liver. People treating hypochondriac pain divide left as Blood and right as Qi, inevitably using Qi-breaking herbs like Qing Pi (Tangerine Peel) and Zhi Ke (Aurantium), believing Liver dispersion cures the disease. While effective initially for Qi Excess, long-term treatment requires nourishing the Mother (Kidney). Yang transformation allows Internal Wind to attack the Stomach causing vomiting or the hypochondrium causing pain. Liver is on the left but pain may be more intense on the right, a sign of Liver Wood attacking Spleen Earth. Classics state the Liver is a "Gan Zang" (Hard Organ) and requires softening; use calming Yang and extinguishing Wind methods like Mu Li (Oyster Shell), E Jiao (Donkey-hide Gelatin), Sheng Di Huang (Rehmannia Root), and Xiao Mai (Wheat). (Ye Tianshi)
Internal injury hypochondriac pain can be treated with raw sesame oil and raw honey mixed equally; one or two doses cure it. (Zhou Shenzhai)
[Mai Hou - Pulse Diagnosis]
A wiry pulse at the Cun Kou position indicates hypochondriac tightness and pain, accompanied by aversion to cold. (Jin Gui Yao Lue)
Hypochondriac pain: A wiry, rapid, and forceful pulse indicates Liver Excess; wiry, rapid, and weak pulse indicates Liver Deficiency with Fire. Wiry indicates Fluids, Deep indicates Qi, Floating-Rapid indicates Wind, Wiry-Weak indicates Yang Deficiency, Deep-Fine indicates Yin Deficiency. (Zhang Luyu)
[Xuan An - Selected Cases]
My brother traveled in June, suffering heat and overwork, with an irritable temperament. Suddenly, he had left hypochondriac pain, with a patch of skin red as a bowl, developing three to five blistering sores. The pulse was rapid and wiry, worse at night. Physicians diagnosed Liver Meridian Depressed Fire and treated with Huang Lian (Coptis), Qing Pi (Green Tangerine Peel), Xiang Fu (Cyperus), Chuan Xiong (Sichuan Lovage), and Chai Hu (Bupleurum). After one dose, that night pain and heat increased severely. Next morning, the redness expanded to plate-sized, with over thirty sores. White alum powder mixed with well water was applied externally, and Qing Dai (Indigo Naturalis) and Long Dan Cao (Gentian) were added to the decoction. That night, he cried out in agony. Next morning, redness spread to half the body, and sores numbered over a hundred. I was uneasy, brought him home, and consulted my teacher Huang Gutan. Reviewing the pulse record and prescription, he said: "Pulse diagnosis and herb recognition were careful, but prescription formulation was incorrect. Using medicine is like using troops; knowing oneself and the enemy ensures victory. The current condition is critical, like burning eyebrows or stacking eggs. How can one stick to ordinary Liver-draining orthodox treatment? This is driving sheep to fight tigers. Moreover, Bitter-Cold herbs exacerbate dryness, worsening the disease. The blisters appearing externally indicate long-standing Liver depression unable to vent, insulting the conquering element (Metal/Lung), causing skin collapse. Continuing this leads to self-immolation death." Revised prescription: One large Gua Lou (Trichosanthes Fruit), crushed with peel, added with Gan Cao (Licorice) 2 qian and Hong Hua (Safflower) 5 fen. Administered at Xu hour. He slept shortly after, woke at Chou hour. Asked him, pain was gone. Urgently decocted the dregs and administered them. He slept until dawn, had a mild bowel movement, slept until Chen hour, then rose. Skin redness had faded, sores had healed. He took no other medicines thereafter. Ill for three days, unable to eat, groaning constantly, cured in one dose—truly miraculous! Gua Lou is sweet and cold. The Classics say: "For Liver injury, soothe the center." Its nature is soft, slippery, and moistening; sweet, soothing, and lubricating downwards. Materia Medica records Gua Lou treats piercing hypochondriac pain. Because it soothes the center and moistens dryness, promoting circulation, pain stops naturally. (Sun Yikui)
A woman suffered from Shanghan with alternating chills and fever, hypochondriac pain, and a stone-hard mass, groaning day and night. Pulse was wiry and slippery. Used Xiao Chai Hu Tang (Minor Bupleurum Decoction) removing Ren Shen (Ginseng), adding Mu Li (Oyster Shell), Qing Pi (Tangerine Peel), and Zhi Ke (Aurantium). Two doses eliminated the mass and cured the disease. (Cheng Xinghai)
A man had hypochondriac pain, right pulse deficient, left pulse slightly wiry and small, yellow complexion. Chronic pain enters collaterals; collaterals govern Blood; herbs should not be harsh. Used Xuan Fu Hua Tang (Inula Flower Decoction) from Jin Gui Yao Lue, added Bai Zi Ren (Biota Seed), Gui Xu (Angelica Tail), and Tao Ren (Peach Kernel). (Ye Tianshi)
A man made his living fishing. Initially, left rib mass-pain, gradually worsening, radiating to back Shu points. Various drugs failed. Someone advised taking young branches of the Yu tree (Zelkova), thickly laying them on the painful area, cooking barley rice, covering the branches with the hot rice, twice daily. A year-long illness cured in a few days. (Jian Wen Lu)
A man had left hypochondriac pain, later transmitting to the right, diagnosed as incurable. Note: The Liver has seven lobes, three left, four right. Its functional governance is on the left, its physical organ on the right. Pain transmitting to the right indicates pathogens entering the Zang organ. The outcome was indeed death. (Zhou Shenzhai)