Pain Under the Ribs and in the Stomach? Doctor Zhang Xichun Treats Liver Fire and Stomach Pain with the “Strengthen the Spleen First” Iron Triangle
Search terms this page answers: pain under the ribs / pain below the ribs / rib pain plus stomach pain / stomach pain after getting angry / pain worse in the afternoon / rib and stomach pain that will not go away
Medical terms: rib-side pain (xie tong) · liver fire blazing (gan huo wang sheng) · liver qi stagnation (gan qi yu jie) · liver wood overacting on spleen earth (gan mu cheng pi) · liver-stomach disharmony (gan wei bu he)
Opening: yesterday we met liver qi deficiency — today, the exact opposite
Today we continue telling Doctor Zhang Xichun’s stories of treating patients. Yesterday’s patient suffered from liver qi deficiency (gan qi bu zu). Today’s patient is the perfect mirror image — his problem is that his liver fire is blazing hot (gan huo te bie wang).
💬 Note from Doctor Luo: As we study Chinese medicine at home, I spend a little time each day talking about how Doctor Zhang Xichun treated his patients; listen along, and bit by bit you will come to understand a good deal of Chinese medicine. And today’s patient is probably dealing with exactly what many of us face today — heavy work pressure, getting heated up the moment something goes wrong, until the ribs and the stomach hurt together. It is well worth listening to carefully.
Who was the patient? A county magistrate from Jilin who lost everything in business after retiring
This patient’s surname was Qi, full name Qi Feizhang (祁斐章). He was from Jilin province and had held office, serving as a county magistrate (xian yin). Now he was retired and living in Tianjin’s Second District — this is a case from Doctor Zhang Xichun’s later years, when he himself lived in Tianjin. Mr. Qi was fifty-sui — in his early 50s, about the same age as yesterday’s patient.
💬 Note from Doctor Luo: You see how an old-school physician will often chat with you a little — how is work going lately? What do you do for a living? Do you think this is idle chatter? It is not idle chatter. He is learning about your situation. In the ways of the world and human relationships lie the seeds of illness. Doctor Zhang Xichun sketches a person’s entire state in just a few strokes.
And what was Mr. Qi’s state? He had long suffered from liver qi stagnation (su you gan qi bu shu) — his liver qi had never flowed smoothly. Then he got involved in business and its losses and disputes: as a former county magistrate, after retiring he decided to go into trade and opened a few ventures. How did it go? Every venture he opened lost money, and every loss he tried to make back by opening another — which lost money too. Open one, lose on one — wouldn’t that make anyone furious?
💬 Note from Doctor Luo: Think about it — a retired county magistrate watching his business ventures fail one after another. Could he help but seethe? Every flare-up sent his liver qi charging upward, and he came down with pain under the ribs. The longer the pain went on, the more it spread — eventually his stomach began to hurt too.
The symptoms: pain from 3 to 7 in the afternoon, worsening, until even food would not digest
What did the illness look like? At first the pain always came in the Shen and You hours — the Shen hour runs 3 to 5 in the afternoon, the You hour 5 to 7, that is, right as the workday ended. At first it did not come every day, but gradually it did; later it became pain all the time, without a moment’s relief.
Why exactly 3 to 7 in the afternoon? There is a reason — that afternoon stretch corresponds to the lung channel (fei jing). The lung belongs to metal, the liver to wood, and metal controls wood (jin ke mu) — during the hours when lung metal is on duty, a liver channel that already has problems will show them more clearly, because lung metal comes to control it. That is why the pain clustered in the Shen and You hours.
Before this, he had consulted doctor after doctor. What did they give him? All dispersing, breaking formulas (kai po zhi pin) — herbs to dredge, to move qi, to spread qi, even to break qi. The result? They injured his spleen and stomach — gradually food no longer digested, and after meals nothing went down properly. When the pain was at its worst it reached into the stomach itself. The illness only grew worse.
Doctor Zhang Xichun takes the pulse: left wiry and hard, right wiry but weak
So Doctor Zhang Xichun was called in. He took the pulse. The left pulse? Sunken, wiry, slightly hard (chen, xian, wei ying). The left wrist houses the heart, liver and kidney — especially the liver. Sunken and wiry means what? It means the liver channel’s yin and blood are deficient, while at the same time there is liver fire; wiry, taut like a zither string, is generally the pulse of yin deficiency; and hard indicates liver fire with stagnation knotted inside.
The right pulse? On palpation it was wiry but weak (xian er wu li). The right wrist corresponds to the lung, spleen and ming men (the gate of life) — the spleen is read mainly on the right. What does wiry mean here? Liver wood has turned sideways and is attacking spleen earth (gan mu heng ni ke pi tu); and weak means the spleen and stomach are already depleted. The pulse also ran five beats per breath — slightly fast.
💬 Note from Doctor Luo: Feel the contrast. Yesterday’s patient with liver qi deficiency — what kind of person would you picture? Pale face, low thin voice, spare and lean, no strength, and not given to anger. Today’s patient? Likely forceful in manner, sharp in speech; once his qi knots up he easily flares and loses his temper — and on top of that his business was failing. One with liver qi deficiency, one with blazing liver fire — they are twin extremes, and you can feel the difference for yourself.
Doctor Zhang Xichun’s thinking: “When jueyin cannot be cured, seek yangming”
When liver fire is this fierce and liver qi so bound up that it has already dragged the spleen and stomach into trouble, created stagnation, and produced pain in both ribs — how should you treat it? Doctor Zhang Xichun quoted a line from the Neijing (Huangdi’s Inner Canon): “When jueyin cannot be cured, seek yangming.”
What does that mean? It means that when the jueyin liver channel is ill and treating the liver directly does not work well, you must seek yangming — go to the yangming stomach channel, to the spleen and stomach for your strategy.
💬 Note from Doctor Luo: Doctor Zhang Xichun said: if you can vigorously tonify the spleen and stomach, so that the qi transformation of the middle burner runs without obstruction, then add just a little medicine to comb out the liver qi — and the stomach pain can be cured, and the rib-side pain will be cured too. The headlong, charging force of liver fire will be dissolved. So where do you treat the liver? You treat the spleen and stomach.
The prescription: Huai yam, Atractylodes, white peony — this is where the real master shows
Let us look at the formula. The very first herb: sheng huai shan yao (raw Huai Chinese yam) 30 g (one liang).
💬 Note from Doctor Luo: In all the case records I have told you so far, you can see which herb Doctor Zhang Xichun loved most. Raw hematite and raw gypsum come second; his use of Huai yam has reached perfection — he knew exactly what this herb can do. He opens with raw Huai yam to tonify the spleen and stomach.
Then yu bai zhu (that is, Atractylodes). Huai yam and Atractylodes set side by side — let me tell you, the moment I first read this case I raised my hand in salute: this is a master at work.
When we ordinary physicians treat the liver, what do we think of? Calming the liver and subduing yang, soothing the liver and resolving stagnation, softening the liver, nourishing liver blood… all of it aimed at the liver. But to truly treat this liver, you must treat the spleen and stomach. Whenever liver fire is this great, liver qi this bound up and charging sideways, the way to control it is to make the spleen and stomach strong first.
Then he adds gou qi zi (wolfberry) — to nourish the yin of the liver and kidney; and xuan shen (figwort root) and mai dong (dwarf lilyturf) — both yin-nourishing. Why? Because this patient’s liver yin and blood were insufficient, which is why the liver fire burned so high; nourish the yin and blood back up, and the liver fire cannot surge so violently.
Then sheng hang shao — that is, raw white peony. White peony astringes and softens the liver. This is so important I will say it again:
💬 Note from Doctor Luo: Raw Huai yam + Atractylodes + white peony — that is an iron triangle. Whenever I meet someone with bound-up liver qi and want to regulate the spleen and stomach, to control liver wood by building up earth, I absolutely must use Huai yam plus Atractylodes plus white peony. Why? Because liver wood is blazing and lunges sideways to attack spleen earth; I first build the spleen earth up strong so it cannot be toppled; and at the same time I keep the liver wood from being so violent — white peony astringes and softens the liver, telling it not to charge; and once the spleen earth is full, the whole situation is under control.
Then sheng mai ya (raw malt) 9 g (three qian) — raw malt generates liver qi, helping the liver qi spread out instead of bottling up inside; and gui zhi jian (cinnamon twig tips) 6 g (two qian) — the fine tips of the cinnamon twig, whose dredging action is exceptionally strong.
Why cinnamon twig and not chai hu? A great deal of learning hides here
The pairing with cinnamon twig is superb. Why? We usually reach for chai hu (bupleurum) to untie liver qi. Chai hu is a common herb, but Doctor Zhang Xichun said: chai hu and gui zhi both excel at regulating the liver — yet they are different.
Chai hu rises and scatters upward; for horizontal liver qi rebellion (gan qi heng ni), its power to undo the knot is not as good as gui zhi’s. Gui zhi, meanwhile, also soothes liver qi stagnation, but gui zhi can both rise and descend — the qi moves upward with it or downward with it. Using it against the sideways, charging force of liver fire works especially well.
💬 Note from Doctor Luo: My friends, the choice of a single herb reveals Doctor Zhang Xichun’s entire craft. He did not use chai hu; he used gui zhi, because he judged precisely that this illness was liver qi rebellion charging sideways — a horizontal collision — not simply qi stagnation failing to rise. Using medicine is like deploying troops: change one herb and the whole strategy changes.
Lay the formula out, and the shadow of Xiao Jian Zhong Tang appears
The formula holds white peony and cinnamon twig, and later licorice and fresh ginger — add da zao (jujube dates) and yi tang (malt sugar) and it brings to mind Zhang Zhongjing’s Xiao Jian Zhong Tang (Minor Fortify the Middle Decoction).
What is Xiao Jian Zhong Tang? It is the Gui Zhi Tang (Cinnamon Twig Decoction) — the classic for wind-cold invasion of the exterior — with the peony doubled plus malt sugar. It treats spleen-stomach deficiency with cold. What do we use it for today? Stomach ulcers — add huang qi (astragalus) and it becomes Huang Qi Jian Zhong Tang, which is remarkably effective for gastric ulcers.
Why can Xiao Jian Zhong Tang heal stomach ulcers? Because most ulcers are tied to bad moods — tension, anxiety — and therefore to liver qi stagnation. In the formula, white peony astringes the liver, cinnamon twig soothes the liver, and there is a full set for tonifying and regulating the spleen and stomach: ginger and jujube regulate the middle, malt sugar tonifies the deficiency of the spleen and stomach, licorice guards the middle and strengthens the spleen.
💬 Note from Doctor Luo: A formula for wind-cold exterior invasion — double the peony and it can treat all sorts of spleen-stomach disorders from deficiency cold? I believe 70 to 80 percent of stomach ulcers can be cured with this Xiao Jian Zhong Tang (or Huang Qi Jian Zhong Tang) line of thinking. Why does it work so well? Because of the strategy inside — tonify the spleen and stomach, soften the liver. It is the same strategy as Doctor Zhang Xichun’s whole formula. When a master’s formula appears, you see at a glance: of course it works — because he has grasped the pivot of regulation.
More subtleties in the first-visit formula: long dan cao drains fire, ji nei jin resolves stasis
Because cinnamon twig is slightly warming, Doctor Zhang Xichun was careful about its heat and paired it with long dan cao (gentian root) 6 g (two qian) — to drain liver-gallbladder fire and check the warmth of the twig; sheng ji nei jin (raw chicken gizzard lining) 6 g (two qian), the yellow kind, crushed — to resolve stasis, because there was stagnation, and it also aids digestion; plus hou po (magnolia bark) — to move and regulate qi; and gan cao (licorice) with sheng jiang (fresh ginger) — licorice harmonizes the middle, and paired with the peony it forms the Shao Yao Gan Cao Tang (Peony and Licorice Decoction), while the cinnamon twig gives the whole thing the structure of Xiao Jian Zhong Tang.
💬 Note from Doctor Luo: One look at this formula and you know it comes from a master. It is as if a question I had puzzled over for years — here, in one formula, the man lays out the answer crystal clear. Our earlier experiments match this exactly: Doctor Zhang Xichun, when he sees a liver disease, opens by regulating the spleen. That is what a master does.
The results: four doses and the stomach stops hurting; five more and the rib pain vanishes
The formula was decocted and taken warm. How did it go? After four doses, the stomach pain was completely gone; the rib-side pain eased greatly — the relief was obvious, and the pain no longer came daily — where before it hurt every day, now it did not; and even when it flared, it passed within moments; the pulse, too, had grown calm and harmonious.
At this point Doctor Zhang Xichun told him: “The original formula, with slight adjustments — keep taking it.” The second-visit formula was close to the first: Huai yam, Atractylodes, wolfberry, figwort root, dwarf lilyturf, white peony, cinnamon twig — with dang gui (Chinese angelica) 9 g (three qian) added, to nourish liver blood and strengthen the tonifying side; long dan cao 6 g to check the twig’s warmth and drain liver-gallbladder fire; sheng ji nei jin as before; and cu xiang fu (vinegar-prepared cyperus) 4.5 g (one and a half qian) to regulate qi — xiang fu took the place of the malt and magnolia bark from before, roughly the same idea; licorice and fresh ginger were retained.
After five doses of this formula, the rib-side pain vanished completely (huo ran quan yu), and the liver pulse had returned calm and normal. So he told the patient to stop the decoction — no more needed; nine doses in all were quite enough.
The real masterstroke is in the aftercare: Huai yam congee with a pinch of ji nei jin powder
The decoction stopped — what next? Here comes the secret weapon — Doctor Zhang Xichun’s private finishing move:
💬 Note from Doctor Luo: Every day take sheng huai shan yao powder — the powder of dried Huai yam — 30 g (one liang). Mix it with water and cook it into a congee drink — today you can heat it in the microwave, or in a small milk pan. When it becomes a paste, add a little sugar (bai tang) to make it pleasant. And with this paste, take powdered sheng ji nei jin — the chicken gizzard lining ground to powder, about two fen. How much is two fen? One qian equals ten fen, so two fen is barely a fifth of one qian — roughly 0.6 g, just a tiny pinch.
What is it for? To consolidate the cure (yi shan qi hou) — tonifying the spleen and stomach on one side, while a little ji nei jin powder opens the stomach and resolves stasis on the other. That is Doctor Zhang Xichun’s finishing craftsmanship: the illness is cured, but the spleen and stomach must be nourished back slowly — you do not just drop the patient the moment the decoction stops.
💬 Note from Doctor Luo: If I were prescribing for this patient today, what would I tell him? Steep some rose tea (mei gui hua cha), and add a little chen pi (tangerine peel) to the roses — to move and regulate the qi. We have many ways — but the core is always the same: nourish the spleen and stomach well.
Doctor Luo Dalun’s private experience: “When you see liver disease, know it transmits to the spleen — fortify the spleen first”
The case ends here, but Doctor Luo Dalun shares a piece of his own experience that is especially precious:
💬 Note from Doctor Luo: When I was young, I also used to think see a liver disease, treat the liver. What changed my mind? Zhang Zhongjing — he said: “When you see liver disease, know that it will transmit to the spleen, and therefore fortify the spleen first (jian gan zhi bing, zhi gan chuan pi, dang xian shi pi).” Inspired by that line, I decided the first move should be to regulate the spleen and stomach — to fight a defensive battle first. And the moment I regulated the spleen and stomach, I discovered the liver disease got better. So it is not only about regulating deficient liver qi — with genuine liver disease too — very high transaminases, actual hepatitis — I also regulate the spleen and stomach, and the results are far better than treating the liver alone.
Later I also met a child whose liver qi was bound up and whose fire was enormous, causing all sorts of problems in his body. For a long time I racked my brains: how do you regulate a child’s emotions? Eventually I found: you must build up the spleen and stomach fully, then add a little liver-soothing medicine — only then does the child’s state turn around. So when I regulate a child’s bound-up liver qi and blazing liver fire, my focus is also on the spleen and stomach — this is experience, and the results really are excellent.
💬 Note from Doctor Luo: Let me tell you about a case: a boy in fourth grade who had hiccuped for four straight years. His father is a good friend I know through work. He said, “Teacher Luo, please help my son — he has been hiccuping for four years straight. We have walked through hospitals in Beijing and Shanghai, tried Chinese and Western medicine alike — why can nothing stop it?” I took one look at the boy and said: this child has liver qi stagnation and too much pressure — why? Because the parents wanted him to succeed so badly; the pressure to excel was enormous. How did I treat him? The core of the formula was all spleen-tonifying herbs like huai shan yao and lian zi rou (lotus seeds), with just a little sheng mai ya (raw malt) and the like to soothe the liver — this I learned from Doctor Zhang Xichun. And the result? In just five doses, the boy’s four-year hiccup stopped. Later a small symptom shifted, and I gave five more doses — cured. Ten doses in all, completely well. His father said, “I have really seen a miracle of Chinese medicine! I had given up on it before — I thought it did not work.” — He had truly witnessed one.
What to take away: don’t treat the liver just because you see liver disease — the spleen and stomach are the pivot
Today’s case is the exact opposite of yesterday’s — yesterday was liver qi deficiency; today is blazing liver fire. But Doctor Zhang Xichun’s strategy was the same road: regulate the spleen and stomach.
💬 Note from Doctor Luo: What should we take away? Do not treat the liver just because you see liver disease. Instead — “see liver disease, know it transmits to the spleen” — go regulate the spleen and stomach. The spleen and stomach are absolutely pivotal; this is the thinking that truly soothes the liver, moves the qi, and unties stagnation. People marvel at a master like Doctor Zhang Xichun: how is it that whatever illness reaches him, seven or eight doses solve the whole problem? Because his thinking is exceptionally clear. This way of thinking is what we should all learn and master. Broaden your understanding — and the next time you meet a problem, you will have some idea how to approach it.
Adapted from Doctor Luo Dalun’s commentary on Doctor Zhang Xichun’s case records, from Records of Chinese Medicine with Western Reference (《医学衷中参西录》), published serially 1918–1934.