Pain Under Both Ribs, and Dizzy When It Hurts Badly? Doctor Zhang Xichun’s Raw Astragalus Formula for Rib Pain from Deficient Liver Qi
Patient search terms: pain under the ribs on both sides / pain under the ribcage / left side hurts, then the right side / dizzy and confused when the pain is severe / weak liver qi / no energy Medical terms: xie tong (rib-side pain) · liver qi deficiency (gan qi xu) · liver qi insufficiency (weak liver qi, unable to perform its dredging and discharging, causing pain under the ribs)
The opening: a kind old gentleman of sixty, tormented by rib pain for over a year
The case we discuss today is about pain under the ribs on both sides (两胁下边疼) — the area below the armpits, along the sides of the body where the ribs run, all the way down to where the ribs disappear. In Chinese medicine this is called the “xie” (胁) region. The patient was Mr. Chen Xizhou (陈希周), a native of Anhui province who in his later years lived in Tianjin — this is a case from Doctor Zhang Xichun’s later years, when he practiced in Tianjin. The old gentleman was about sixty (年六旬) — sixty-odd years old, indeed well on in years.
💬 Note from Doctor Luo: Friends, note that in Chinese medicine “xie” (胁) and “le” (肋) are slightly different: the ribs in front of the body are called le (肋), and cannot be counted as xie; this xie refers specifically to the sides of the body — from below the armpits all the way down to where the ribs end. Rib-side pain (xie tong) is extremely common in clinical practice, but the root of this particular case is completely different from what people usually imagine — read on patiently, everyone.
Who was the patient? A man who opened porridge kitchens and loved to give — worn down by overwork
When Doctor Zhang Xichun described the cause of the illness, he first wrote one phrase: “by nature kind and charitable” (素性仁慈) — this old gentleman was born an exceptionally kind, good-hearted man. What did he love to do most? Giving alms (施舍): he liked to give to others, and he even contacted like-minded friends to pool money and open porridge kitchens (捐钱开设粥场), cooking porridge to feed the poor who had no food. And everything he personally managed and personally handled. Just from this overwork, he fell ill with pain under the ribs.
💬 Note from Doctor Luo: You see how Doctor Zhang Xichun sketched this man’s state in just a few strokes — though he never says it outright, I suspect this gentleman was a Buddhist, very gentle, very kind, and possibly even vegetarian. Such old men exist in real life: sixty-odd years old, thin of body, vegetarian in daily life, face a little pale, speaking gently in a low voice, going everywhere to do good deeds. So when an experienced Chinese doctor chats with you about what you do for work, how you’ve been lately — that is not idle talk; they are feeling out your whole state as a person. In this case, the final diagnosis was closely tied to this man’s state.
How bad was it? Leveling, soothing, and softening the liver — all tried, and a year later still not cured
What kind of pain was it? “Sometimes in the left rib, sometimes in the right rib, and sometimes both sides hurting together” — the left and right were not the same. The doctors called in before had all used the conventional liver treatments: leveling the liver, soothing the liver, softening the liver (平肝、疏肝、柔肝). You would think — liver illness, isn’t that the standard approach? But every one of these methods was tried, without the slightest effect, and this dragged on for over a year, with the illness growing worse and worse. When the pain was at its fiercest, the old gentleman felt his mind grow somewhat confused (精神昏聩) — drowsy and muddled, his head unclear. Only then did he come to Doctor Zhang Xichun.
💬 Note from Doctor Luo: Here let us leave a question: since it was a liver problem, and leveling, soothing, and softening the liver were all applied — why didn’t it work? The answer is right at the end — because the problem was never one of liver qi being too vigorous or stagnated. The direction was wrong from the start, and no matter how good the medicine, it was wasted. This is where Doctor Zhang Xichun’s brilliance lies: with one touch of the pulse, he knew everyone had gotten the direction wrong.
Doctor Zhang Xichun takes the pulse: the left pulse disappears at the touch — the root is not liver fire, it is weak liver qi
When Doctor Zhang Xichun felt the pulse, the left pulse was faint and thread-like, and disappeared at the touch (左部脉微细，按之即无). The left pulse corresponds to the heart, liver, and kidney — and Doctor Zhang Xichun especially valued the liver — at this touch, the liver pulse was nearly gone. Think about it: a person with stagnated liver qi, furious about everything, usually has a singly large liver pulse, wiry and hard, stretched taut; but this gentleman — gone at the touch. As for the right pulse: it seemed fairly calm, but its fluctuating force was a little weak.
💬 Note from Doctor Luo: Friends, this pulse matches the work-and-life state he described earlier seamlessly. A man who flies into rage every day can have a large, wiry liver pulse; but this Mr. Chen, who gave alms and did good deeds year after year and had a gentle nature, was drifting in the direction of weakness — the liver qi was weak, and the pulse vanished at the touch.
How did Doctor Zhang Xichun analyze it? First, the pain was located in the xie (rib-side), and the xie belongs to the liver — the liver dwells below the ribs, on the left side runs the path where liver qi rises, and on the right side is where the liver actually lives — so pain on either side relates to the liver. Second, why did leveling, soothing, and softening the liver all fail? Because this was not liver qi stagnation — it was weak liver qi (肝气弱).
💬 Note from Doctor Luo: In all our previous lectures on the liver, we talked about liver qi stagnation, liver fire flaring upward, liver wood running sideways to attack the spleen-earth — we talked about what happens when the liver is “excess” and “explosive” — very few people ever talk about weak liver qi. This is a big topic Doctor Zhang Xichun opened up. The liver governs dredging and discharging (shu xie); it is what keeps the qi mechanism flowing smoothly. When liver qi is weak, it lacks the strength to dredge and discharge, and qi stagnates under the ribs, blocked there, causing pain. And why did the mind grow confused when the pain was severe? Doctor Zhang Xichun held that the liver and the nervous system are related (肝与神经是相关的) — when the liver has a problem, the nervous system also has a problem. This is something we in Chinese medicine today can well understand.
Breaking down the prescription: one raw astragalus leads the formula — tonifying liver qi, like calling to like
How was it treated? Doctor Zhang Xichun said the approach should be mainly to tonify liver qi, with a little help from medicines that generate the liver and transform stasis. This idea of “tonifying liver qi” had rarely been mentioned by earlier doctors. Some formula books say “the liver deficiency has no method of tonification” (肝虚无补法) — Doctor Zhang Xichun refuted this outright: such a statement is not the speech of one who has seen the Way (不是见道之言) — it is not a truly enlightened understanding. Every organ can be deficient or excess; why should the liver alone have only excess and never deficiency? When the whole body grows weak, the liver qi also becomes deficient, its dredging and discharging weaken, and its power to regulate qi and blood is insufficient — that is precisely when it should be tonified.
💬 Note from Doctor Luo: Please be sure to remember this stroke: liver qi rises upward, and among the tonifying medicinals, the one whose nature is warm, and which can both generate and tonify, is astragalus (huang qi). So Doctor Zhang Xichun proposed using raw astragalus to tonify liver qi — this is one of his very important clinical experiences, and very few people have ever discussed it in this way. He called it “the wonder of like calling to like” (同气相求之妙): for tonifying the qi deficiency of the liver channel, astragalus is the most fitting herb.
The first herb in the formula: sheng huang qi (raw astragalus), five qian (about 15 g) — tonifying liver qi. But the nature of astragalus is warm — if you warm the liver too much, fire can easily flare up. So what did he pair it with? Sheng hang shao (raw white peony), four qian (about 12 g) and xuan shen (figwort root): white peony can nourish yin, restrain the liver, and soften the liver, and xuan shen is also yin-nourishing — these two herbs restrain the warm nature of astragalus.
💬 Note from Doctor Luo: Next come stir-fried ru xiang (frankincense), three qian (about 9 g), and mo yao (myrrh), three qian (about 9 g) — what are these two for? Dissolving the stagnation of liver qi — they have the power to dredge qi and blood, and especially to regulate qi and transform stasis, opening up the stagnation stuck under the ribs. Then sheng mai ya (raw malt): raw malt can express and generate liver qi — I have tonified your liver qi, but it also needs to move upward, not just sit there, so raw malt is used to regulate liver qi and generate liver qi. Note that the nature of malt is upward-moving — once you use stir-fried malt, the nature turns downward — keep this distinction firmly in mind.
Chuan xiong (ligusticum) and the later dang gui (Chinese angelica) both nourish the blood — the liver stores blood; tonifying liver qi alone while qi and blood are insufficient will not do, so the main thrust is tonifying liver qi, assisted by nourishing the blood. Finally gan cao (licorice) — why? To harmonize the various medicinals of the middle burner; especially since the formula includes peony, and peony paired with licorice forms Shao Yao Gan Cao Tang (Peony and Licorice Decoction), which can turn sour and sweet into yin (酸甘化阴) — softening the liver, restraining it, easing the urgency of the liver channel, and nourishing yin to generate fluids.
💬 Note from Doctor Luo: People usually use Peony and Licorice Decoction to ease urgency and stop pain in abdominal pain — in fact it works the same for rib pain: wherever there is pain, once you relieve that contracted, urgent state, you no longer hurt. So you see this formula: astragalus tonifies liver qi; white peony and figwort root nourish yin and restrain the warm nature; frankincense and myrrh dissolve stagnation; malt generates liver qi; ligusticum and angelica nourish blood; peony and licorice ease urgency — supplementing both qi and blood while attending to yin, a quite complete formula.
The result: four doses cured more than half — but the appetite still would not return
How did this formula work after four consecutive doses? The rib pain was more than half gone! When pain came occasionally, it was no longer severe. The pulse was taken again: the left pulse now had a bit of root at the touch, and the right side was stronger than before too. But because of the rib pain the old gentleman had been eating very little, and even now his appetite had not increased — he had always been a man with a very weak spleen and stomach. What to do about this?
💬 Note from Doctor Luo: Doctor Zhang Xichun treated illness step by step: once the rib pain eased, he immediately spotted the next weak link — the spleen and stomach. When the spleen and stomach are weak, the appetite does not return, and afterward there is no strength. So he wrote a new formula, still based on raw astragalus, white peony, and figwort root — the approach of tonifying liver qi unchanged, the yin-nourishing unchanged — and then what did he add?
Second visit: tonifying the liver while strengthening the spleen — adding atractylodes and raw chicken gizzard lining
The second-visit formula: raw astragalus, white peony, and figwort root unchanged, plus bai zhu (atractylodes), three qian (about 9 g) — atractylodes tonifies the spleen and stomach; frankincense, myrrh, malt, angelica, and ligusticum all unchanged; plus sheng ji nei jin (raw chicken gizzard lining), two qian (about 6 g), crushed — for aiding digestion and guiding stagnation downward; and licorice increased by one and a half qian. You see, compared with the first visit, only atractylodes and raw chicken gizzard lining were added: one tonifies, one aids digestion and guides stagnation — making up the short board of the spleen and stomach.
💬 Note from Doctor Luo: Decoct one large cup, and drink it warm. This formula was again taken for four consecutive doses, and the result: the pain under the ribs was gone, and the appetite began to increase, the pulse was harmonious on both sides, and he felt there was nothing much wrong anymore. But then the old gentleman said: these two legs — the sinews and bones are a little weak. Why was that?
Third visit: the legs have no strength? The liver governs the sinews — so treat the spleen and stomach to strengthen the bones
Why, once the rib pain was cured, were the legs weak? The liver governs the sinews (肝主筋) — whenever liver qi is insufficient, the sinews become lax and flaccid, and the person loses strength; when liver yin is insufficient, the sinews become contracted and cramped, prone to cramping. So liver problems directly affect the state of the limbs. This was because the illness had lasted so long that the body had not yet been replenished. Doctor Zhang Xichun said: all right, let me soothe the liver and strengthen the stomach for you, and strengthen the sinews and bones. The third formula appeared: still raw astragalus, paired with tian hua fen (trichosanthes root) and mai dong (ophiopogon root) — astragalus tonifies qi; trichosanthes root nourishes yin and moistens dryness; ophiopogon nourishes yin and generates fluids — he swapped in two cool-natured herbs to assist the qi-tonifying effect of astragalus.
💬 Note from Doctor Luo: Then he paired sheng huai shan yao (raw Huai mountain yam) and bai zhu (atractylodes) — these two tonify the spleen. This is where Doctor Zhang Xichun’s brilliance lies: when you truly treat the liver, in the end you must treat the spleen and stomach. Where does liver qi come from? Only when the spleen and stomach are strong, and the essence of food and drink (shui gu jing wei) comes in, can liver qi rise. So he added mountain yam and atractylodes to tonify the spleen — this is a very important line of thinking, and the next case will speak of it again: to treat the liver, treat the spleen and stomach.
Then mo yao (myrrh), three qian (about 9 g) (transforming stasis), dang gui (Chinese angelica), three qian (about 9 g) (nourishing blood), sheng mai ya (raw malt) (soothing the liver), sheng ji nei jin (raw chicken gizzard lining) (aiding digestion and guiding stagnation, and also transforming stasis), and finally genuine lu jiao jiao (deer antler glue), three qian (about 9 g). What is deer antler glue? It is the glue made by boiling deer antler — note, not deer velvet (lu rong): deer velvet is the first-year, downy young antler; when the antler has aged and become fully ossified into a large antler, the glue boiled from that is deer antler glue. What does it do? Tonifies the governing vessel (du mai), tonifies yang qi, and strengthens the sinews and bones. Doctor Zhang Xichun thought very highly of this deer antler glue, and will give it a dedicated lecture someday.
💬 Note from Doctor Luo: After adding deer antler glue, and with several consecutive doses of this formula, the old gentleman’s body began to grow strong. So Doctor Zhang Xichun told him: you no longer need to take medicine — the liver qi has been largely restored; from here on it is a matter of convalescence.
The finish: mountain yam powder drunk as tea — Doctor Zhang Xichun’s signature recovery trick
How to convalesce? Doctor Zhang Xichun had him take raw Huai shan yao powder (the powder of dried Huai mountain yam), each time seven or eight qian to one liang — seven or eight qian is 21 to 24 grams, one liang is 30 grams; this amount is actually quite large. Blend the yam powder with cold water, heat it on the stove, and boil it into a tea-soup and drink it as tea; after it is prepared, add a little white sugar, so he found it pleasant to drink, and took it every day as a snack.
💬 Note from Doctor Luo: Friends, as we have said before, this is Doctor Zhang Xichun’s killer trick — whenever he met a weak, depleted patient, the one special move after curing them was to eat Huai shan yao powder every day, as tea and as a snack. Mountain yam tonifies the qi of the spleen and stomach; when the spleen and stomach are strong, qi and blood are generated at their source, and the body naturally gets better and better. And eating the yam powder was not enough — he also had him chew a little hu tao ren (walnut kernel), two or three qian (about 6–9 g) — walnut kernel tonifies the kidney. Every day yam powder plus walnut kernels, eaten little by little, convalescing the body — it would surely get better and better.
Note from the commentator: do not think “liver” means only soothing and draining fire — the liver qi can be deficient too
The knowledge point this case offers us is: liver qi can be deficient — something basically never mentioned by other doctors. What do you do when liver qi is deficient? Tonify liver qi — and with what? With raw astragalus.
💬 Note from Doctor Luo: When we study medical cases, we must grasp them little by little and savor them. Such people truly exist in life: vegetarian for years, spleen and stomach weak, face a little pale, not much exercise — when such people grow older, many of them turn out to have weak liver qi. You cannot think of the liver and immediately go to soothing, softening, leveling, and draining liver fire — it is not like that. Once you know this line of thinking, when you meet such a person, you know how to help them. The case we will discuss tomorrow is exactly the opposite — what happens when the liver qi is too vigorous and liver fire is strong? We will explain it tomorrow. Thank you all, and see you tomorrow!
Based on the lectures of Doctor Luo Dalun (PhD in TCM diagnostics, Beijing University of Chinese Medicine) explaining the medical cases of Doctor Zhang Xichun; the case is from Yi Xue Zhong Zhong Can Xi Lu (Records of Integrating Chinese and Western Medicine).