Unbearable Pain Under the Ribs Reaching to the Navel? Doctor Xu Shuwei Diagnoses Shao Yang Pattern and Uses Xiao Chai Hu Tang (Minor Bupleurum Decoction) From the Treatise on Cold Damage

Patient search words: rib pain / pain on both sides of the ribs / pain reaching to the navel / bitter taste in the mouth / feeling hot and cold in turns / tight chest / excessive dreaming / nausea after a cold

Corresponding medical terms: shao yang pattern (shao yang zheng) · cold damage (shang han) · externally contracted illness · constrained liver qi (gan qi bu shu) · Xiao Chai Hu Tang pattern (xiao chai hu tang zheng)

The opening: a strange illness so painful it fooled even the doctors

Today we continue the stories of Doctor Xu Shuwei, the great formula master of the Song dynasty.

Doctor Xu Shuwei, courtesy name Zhike, was a celebrated physician of the transition between the Northern and Southern Song dynasties, known as "Scholar Xu" (Xu Xueshi). He was one of the founders of the classical formula school (jing fang pai). After Zhang Zhongjing wrote the Treatise on Cold Damage (Shang Han Lun), very few people actually used it for a long time; it was only in the Song dynasty that a group of physicians — Doctor Xu Shuwei, Doctor Zhu Gong (Zhu Hu), and others — energetically promoted and applied it, and the classical formula school took shape, carrying Zhang Zhongjing’s teachings forward and spreading them widely. Doctor Xu Shuwei kept records of every case in which he treated patients with Zhang Zhongjing’s formulas, and compiled them into Discussion of Ninety Cases of Cold Damage (Shang Han Jiu Shi Lun) — the earliest surviving case-record monograph in China. One case, one discussion — he pioneered the very genre of the medical case record.

The case we are discussing today can be called the founding clinical application of Xiao Chai Hu Tang (Minor Bupleurum Decoction). Whenever the use of Xiao Chai Hu Tang to treat disease is mentioned, this case must be listed first — because it is one of the earliest cases in Chinese medical history in which a classical formula from the Treatise on Cold Damage was used to cure disease.

💬 Note from Doctor Luo: Zhang Zhongjing wrote the formulas — but did later generations actually use them? Nobody knew. Doctor Xu Shuwei was the first person to use them for you — he did pioneering work. From now on, whenever you talk about the clinical application of Xiao Chai Hu Tang, you cannot get around this case, because he was the first to use it.

Who was the patient? Pain in both flanks reaching to the navel, unbearable

The patient’s surname was Dong — Dong Qixian. He had contracted cold damage (shang han) and had been ill for several days.

Cold damage, after all, is just an external infection with fever — normally headache, body aches, fever. But this Mr. Dong’s symptoms were very strange:

Pain in both flanks reaching to the navel, unbearable (liang xie jia qi tong bu ke ren). "Both flanks" (liang xie) means the rib areas on the two sides of the body, below the armpits; "reaching to the navel" (jia qi) means the pain ran all the way down to the navel. The ribs on both sides together with the area around the navel all hurt at once — the pain was unbearable, absolutely agonizing.

💬 Note from Doctor Luo: That is strange — a cold is a cold, so why does it hurt in this place? And with such violent pain? This is not an ordinary cold.

The other doctors’ misdiagnosis: they wanted to treat it as "ben tun"

With pain like that, of course doctors were called in. When the doctors arrived and examined him, some wanted to treat it as ben tun (running piglet syndrome).

What is ben tun? Ben tun is a disease name from the Treatise on Cold Damage and the Essentials from the Golden Cabinet (Jin Gui Yao Lue) — "ben tun" means a piglet running. When the qi mechanism of the body surges upward, a current of qi suddenly "shoots" up from the belly, pushing all the way up to the throat — like a little pig running upward — hence the name ben tun. Its mechanism is usually internal exuberance of yin cold, insufficiency of upright qi (zheng qi), and overflowing of blood and qi, causing qi to rush upward.

💬 Note from Doctor Luo: Ben tun — the rushing qi pushes upward, can push all the way to the throat, like a piglet running, so it is called "ben tun." The doctors at the time wanted to treat it in that direction — but when Doctor Xu Shuwei arrived and looked, he said: no, this is not ben tun!

Doctor Xu Shuwei’s diagnosis: the pathogen was in the shao yang gallbladder channel

Doctor Xu Shuwei examined Mr. Dong carefully and analyzed his condition. He judged: this is not ben tun — this is a shao yang pattern (shao yang zheng). The pathogen sits in the shao yang gallbladder channel!

Why? Because the pathway of the shao yang gallbladder channel (zu shao yang dan jing) happens to run along the two sides of the body:

• The foot shao yang gallbladder channel starts at the outer corner of the eye (Tongziliao GB1);
• From there it circles around the ears (which is why the gallbladder channel is connected to the ears);
• It winds around the side of the head and enters Fengchi GB20 (Wind Pool point);
• Then it descends, running diagonally down the sides of the body, all the way to the legs — and the legs are also traversed along the outer sides.

You may have heard the health-preservation saying "tap the gallbladder channel" (qiao dan jing) — what people tap is exactly this line along the outer thighs and the sides of the body — that is how the gallbladder channel travels.

💬 Note from Doctor Luo: Notice that Doctor Xu Shuwei looked at the illness by connecting the channels (jing luo) with the six channels (liu jing) of the Treatise on Cold Damage. Some TCM practitioners say the acupuncture channels and the six channels of the Treatise are two different systems and should be kept separate — actually they are not. The ancients always looked at them together. Chinese medicine is a whole; every system is closely connected to the others. When you look at the channels and the six channels together, you broaden the way you think about disease.

So when a pathogen invades the shao yang channel, the symptoms appear on the two sides of the body — under the ribs, in the flanks, even pulling into the area around the navel. Mr. Dong’s unbearable pain in both flanks reaching to the navel was exactly the manifestation of the pathogen being in the shao yang, with the channel qi unable to move freely.

The seven main symptoms of the shao yang pattern: bitter mouth, dry throat, dizziness…

Since we are on the subject, Doctor Luo systematically walks us through the main symptoms of the shao yang pattern — symptoms that you and your family have probably all experienced at some point:

💬 Note from Doctor Luo: I talk about the shao yang pattern every day. Zhang Zhongjing summarized its main symptoms as "bitter taste in the mouth, dry throat, dizziness; silence and no desire to eat; alternating chills and fever; restlessness and nausea; fullness in the chest and flanks" — and I now add one more: insomnia and excessive dreaming.

First, a bitter taste in the mouth (kou ku). The mouth tastes bitter, especially on waking in the morning. This is the single most important indicator of the shao yang pattern.

💬 Note from Doctor Luo: Check yourselves — do any of you often have a bitter mouth? Of the people I see with a bitter mouth, the vast majority have liver-gallbladder disharmony, a shao yang pattern — over ninety percent. So a bitter mouth is a standard symptom of the shao yang pattern.

Second, a dry throat (yan gan). The mouth and throat always feel dry.

Third, dizziness (mu xuan). Dizziness, vertigo — a sudden "whoosh" of the head; sometimes a lingering wooziness, and some people are dizzy enough to collapse to the ground.

Fourth, silence and no desire to eat (mo mo bu yu yin shi). No desire to eat, poor appetite, and the whole digestive system is off — some people get constipated when stressed, others get diarrhea and stomach pain. Many stomach problems are related to emotional distress.

Fifth, alternating chills and fever (han re wang lai). The body feels hot and cold in turns — cold one moment, hot the next, like having a fever; it rises, recedes, then comes up again, in a rhythm. This is the body and the pathogen locked in a tug of war: sometimes you win the round, sometimes you lose it.

Sixth, restlessness and nausea (xin fan xi ou). Feeling restless and irritable inside, easily angered, prone to nausea, vomiting, and acid reflux.

💬 Note from Doctor Luo: About being easily angered — people often don’t know it about themselves; you have to ask the family: does he have a short temper? The people around him know best. Someone will say "I’m fine, nothing wrong," while the family says "he has a terrible temper, we tiptoe around him every day" — the person himself doesn’t know, but the family knows very well.

Seventh, fullness and oppression in the chest and flanks (xiong xie man men). A tight chest, a blocked feeling in the chest, always wanting to let out a long sigh, even palpitations and a racing heart — many people think it is a heart problem, but distending pain in the chest and flanks, stuffiness, and sighing are all manifestations of the shao yang pattern.

Add the symptom Doctor Luo supplements — insomnia and excessive dreaming: people with a shao yang pattern have trouble sleeping, and their dreams are especially abundant. Among people who dream a great deal, the proportion with liver-gallbladder disharmony and shao yang channel problems is very high.

💬 Note from Doctor Luo: Morning corresponds to the liver, and the liver and gallbladder are interior-exterior paired organs — so a bitter mouth in the morning, or nausea when brushing teeth in the morning, is often related to the liver and gallbladder. Match any one of these seven symptoms, and you should think of the shao yang pattern.

Unpacking the mechanism: why does the pathogen "bind below the flanks"?

So why does the pathogen run into the shao yang channel and bind below the flanks? Doctor Luo explains the reasoning of the Treatise on Cold Damage thoroughly:

When an external cold pathogen reaches the surface of the body, the first line of defense is the tai yang channel — the battle between upright qi and pathogen on the body surface is the tai yang disease. If that battle is lost, the pathogen moves deeper, and the body mobilizes greater energy to fight it — the struggle becomes fiercer, and high fever appears. That is called yang ming disease. If that battle is also lost, the pathogen continues inward, and now the body’s energy is running low — and when energy is insufficient yet the body still resists, it can only fight for a while, then stop, producing the alternating chills and fever of han re wang lai — this is entering the shao yang disease stage.

How did Zhang Zhongjing describe this state? Four characters: xue ruo qi jin — "blood is already weakened, qi is already insufficient." At this point the interstices (cou li, the skin pores) open, the pathogen enters, and it struggles against the upright qi. The battlefield of that struggle is below the flanks (xie xia) — the two sides of the body.

💬 Note from Doctor Luo: Zhang Zhongjing said: "When blood is weak and qi exhausted, the interstices open, the pathogen enters, and it fights with the upright qi, binding below the flanks." When upright and pathogen struggle, you get alternating chills and fever — you beat me, I beat you, a war of attrition, and "xiu zuo you shi" — sometimes it stops and sometimes it fights, in a rhythm. "Mo mo bu yu yin shi" — no desire to eat — because digestion is affected. "The viscera are connected, so the pain necessarily descends; the pathogen is high and the pain low, therefore it causes vomiting" — that is why vomiting occurs easily.

The shao yang pattern is the stage where resistance is starting to weaken but is still fighting — if resistance fails completely, the pathogen enters tai yin, shao yin, and jue yin, and the body’s upright qi collapses entirely, turning into a yin pattern. So the shao yang step is the most critical turning point — the pathogen must be blocked and harmonized right here.

The prescription unpacked: seven herbs, one rising and one descending, one cold and one warm

And the treatment? Zhang Zhongjing wrote it long ago: "When the tai yang disease is not resolved and transmits into the shao yang, with fullness below the flanks and dry retching, Xiao Chai Hu Tang governs." — Xiao Chai Hu Tang (Minor Bupleurum Decoction)!

What is Xiao Chai Hu Tang made of? You should be familiar with it: chai hu (bupleurum), huang qin (baical skullcap root), ren shen (ginseng), ban xia (pinellia), gan cao (licorice), sheng jiang (fresh ginger), da zao (jujube dates) — seven herbs, very simple. The Xiao Chai Hu granules (xiao chai hu ke li) sold in pharmacies today are made from exactly these seven herbs. Doctor Luo unpacks the intention behind each herb:

• Chai hu (bupleurum) — the largest dose, the chief herb. Chai hu is warm in nature; it disperses outward and can dredge the pathogenic qi of the liver and gallbladder channels, opening up bound-up qi;
• Huang qin (baical skullcap root) — cool in nature; it clears heat and can clear the heat of the liver and gallbladder — the heat of the shao yang channel and viscera, and the heat of the san jiao (triple burner) channel, are all dispersed by it. Chai hu is warm, huang qin is cool — one warm, one cool;
• Ban xia (pinellia) — descends rebellious qi and stops vomiting, transforms phlegm, letting qi move downward. Chai hu disperses upward, ban xia moves downward — one rising, one descending — and together they open the qi mechanism;
• Sheng jiang (fresh ginger) — assists ban xia, with the action of descending rebellious qi and stopping vomiting;
• Ren shen (ginseng) — supplements qi. Zhang Zhongjing said "blood is weak and qi exhausted" — at this stage the upright qi is certainly insufficient, so qi must be supplemented;
• Da zao (jujube dates) — nourishes the blood, working with ren shen to supplement qi and nourish blood;
• Gan cao (licorice) — supplements qi, and works with sheng jiang and da zao to harmonize the spleen and stomach and guard the middle.

💬 Note from Doctor Luo: Look at this formula — it has things that rise and things that descend, cold and warm, it opens up the middle burner for you, and it also supplements — it supplements the spleen and stomach. When the spleen and stomach are strong, they can send the clear upward and the turbid downward; the middle burner is no longer bound up; the binding in the chest opens, phlegm transforms, dampness transforms, the ascending and descending of the qi mechanism return to normal — and the pathogen is naturally driven out. So Xiao Chai Hu Tang, though simple, is a formula that sets the entire "ascending, descending, exiting, entering" of qi in motion.

The result: pain stopped after three doses, resolved with sweating

Doctor Xu Shuwei gave Mr. Dong Xiao Chai Hu Tang. What happened?

The pain stopped after three doses — after taking it three times, the fierce flank pain was arrested; then came resolution through sweating — a sweat broke, the pathogen left through the sweat, and the illness resolved.

💬 Note from Doctor Luo: This case is recorded very simply — it ends in a few sentences. But don’t underestimate it: Doctor Xu Shuwei saw a patient with pain in both flanks, other doctors had diagnosed it wrongly, and with one look he recognized the shao yang pattern and solved the problem quickly. What does this show? That when the pattern differentiation is accurate, a classical formula acts like a drum responding to the stick — immediate and effective. That is the charm of the classical formulas: as long as it matches the pattern, a few doses usually solve the problem, and it works very fast.

Modern application (1): residual cough after a cold, and colds during menstruation, can both be treated with Xiao Chai Hu

The case is done, but Doctor Luo wants to focus on how Xiao Chai Hu Tang is used in modern times — because today it is used far too widely.

First, cough caused by external contraction. Some experienced old practitioners have a rule: when a cough refuses to clear up no matter how it is treated after an external contraction, and lingers on at the end, use Xiao Chai Hu Tang. Why? Because after a cold, the upright qi is no longer sufficient — the body has entered the state of "blood weak, qi exhausted" — and Xiao Chai Hu Tang can harmonize the shao yang and dissolve the residual pathogen.

Second, colds during menstruation. A cold caught just before or during a period can basically be treated with Xiao Chai Hu Tang — it has a special use relating to the blood chamber (xue shi), and it can resolve the condition in one go.

Third, "seeing but one symptom is enough" (dan jian yi zheng bian shi). Zhang Zhongjing said: "seeing but one symptom is enough" — as long as any one of the symptoms is present, you can use it. For example, if you catch a cold and feel a little nauseated, or a little dizzy, or your mouth tastes bitter — you can use Xiao Chai Hu Tang.

💬 Note from Doctor Luo: Xiao Chai Hu Tang is basically "broad-spectrum" — its range is wide. It is especially good at harmonizing the shao yang, but sometimes problems of the three yang channels — tai yang, yang ming, shao yang — can all be treated with it as long as symptoms related to these appear.

Modern application (2): the secret weapon for emotional disorders — Chai Hu Jia Long Gu Mu Li Tang

However, Doctor Luo says that the way he uses this formula nowadays is mostly to regulate emotions.

Why? Because the liver and gallbladder are interior-exterior paired organs — when liver qi is constrained (gan qi bu shu), the liver and gallbladder lose harmony: liver qi cannot rise, gallbladder qi cannot descend, and everything binds in the middle. Zhang Zhongjing wrote this formula to treat externally contracted disease — but the principle by which the human body regulates itself is the same: when people are in a bad emotional state, liver qi gradually becomes constrained, and they develop a bitter mouth, dry throat, dizziness, no desire to eat, alternating chills and fever, restlessness, distending fullness in the chest and flanks, insomnia and excessive dreaming — that same string of shao yang symptoms.

💬 Note from Doctor Luo: When a patient comes in, I look at the tongue first — if the tongue is pointed at the tip, I ask: is your mouth bitter? If yes, I keep going: do you have insomnia? Do you dream a lot? Do you feel nauseated, or have a stuffy, rising sensation in the chest? Acid reflux? Dizziness? With this string of symptoms, usually if one is present, the rest are there to some degree — some people are not sensitive to their own bodies and will say no, though actually yes, they just haven’t noticed. I run into this all the time: "Don’t you vomit?" "No" — then they think about it: "Well, I did throw up a couple of mouthfuls yesterday"; later they message me: "I’ve been vomiting for two years now, vomiting and burping whenever, never paid it any attention."

How to regulate it? Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction) — Xiao Chai Hu Tang as the base, plus long gu (fossilized dragon bone) and mu li (oyster shell), plus gui zhi (cinnamon twig) and fu ling (poria) (some add da huang, some do not). This is Zhang Zhongjing’s formula from the Treatise on Cold Damage for emotional disorders, constrained liver qi, and binding depression.

💬 Note from Doctor Luo: For the constrained liver qi caused by bad emotions, Chai Hu Jia Long Gu Mu Li Tang works extremely well. Later I met many practitioners who use this formula as their secret weapon — whenever a patient’s illness is related to bad emotions, they regulate it with this formula. How many illnesses today are caused by bad emotions? Far too many. There is even a legend of an old practitioner who spent his whole career on one formula — Xiao Chai Hu Tang with additions and subtractions — every patient got Xiao Chai Hu Tang plus or minus one herb. I used to think that was impossible; later I realized that the vast majority of patients have conditions related to bad emotions, and their bodily imbalances are related to bad emotions — and it really works.

Even skin problems caused by emotions — some people break out in skin conditions when emotionally upset, and a few doses of Xiao Chai Hu Tang start clearing them. This shows how many problems constrained liver qi can cause.

A warning bonus: even the best formula cannot be taken forever

Xiao Chai Hu Tang is so good — can you take it every day as a health supplement?

Absolutely not!

💬 Note from Doctor Luo: Every medicine is three parts poison (shi yao san fen du). All medicines follow the rule of "stop when the disease is resolved" (zhong bing ji zhi) — regulating the body has its measure; you cannot keep taking something for a very long time. There was a major incident in Japan: a big pharmaceutical company advertised Xiao Chai Hu Tang as "so wonderful it cures everything, everyone should take it" — so ordinary people took it for two years, some developed serious problems like interstitial pneumonia, there were lawsuits, and the company paid enormous compensation.

Zhang Zhongjing’s formulas are called classical formulas (jing fang), and there is a saying about them: "jing fang bu guo san" — no more than three doses. As long as the formula matches the pattern, three doses solve the problem; it will not drag on for months. Used normally — say, one or two weeks, two or three weeks, three or four weeks — that is fine; especially when the shao yang pattern is present, it works immediately.

💬 Note from Doctor Luo: So no matter how good a formula is, it must be used on the basis of accurate pattern differentiation. Used correctly, it works extremely fast, and there is no need to take it long-term. This is also a warning for everyone — don’t just because you hear something is "good" start taking it heavily.

In this case, Doctor Xu Shuwei cured the bizarre illness of unbearable pain in both flanks reaching to the navel with three doses of Xiao Chai Hu Tang, leaving later generations a timeless formula that treats the shao yang pattern — and, even more, treats "emotional illness." From bitter mouth, dry throat, and dizziness to insomnia, excessive dreaming, and restlessness — match one symptom, and think of the shao yang pattern; for constrained liver qi and emotional binding, Xiao Chai Hu Tang with additions and subtractions often works at once. But remember: the classical formulas stop at three doses — when the pattern matches, you are cured; do not take it long-term.

Compiled from Doctor Luo Dalun’s commentary on Doctor Xu Shuwei’s case record; the case comes from Discussion of Ninety Cases of Cold Damage (Shang Han Jiu Shi Lun), by Doctor Xu Shuwei.