Bloating, Rib Pain and Afternoon Fever That Kept Getting Worse? Doctor Xue Lizhai Treats Stagnant Anger Injuring the Liver and Spleen (Guipi Tang in the Morning, Augmented Xiao Yao Wan at Night — Cured in Three Months)

Search terms this page answers: stomach bloating / pain under both sides of the ribs / rib pain / fever every afternoon / irregular periods / always spitting phlegm / bloating when my mood is bad / discharge that is yellow and green / wrong medicine made it worse

Medical terms: liver-spleen disharmony · liver qi stagnation · spleen deficiency · stagnant anger injuring the liver and spleen · emotional disorder · vaginal discharge disorder (dai xia)

Opening: remember one sentence — diagnosis is like solving a mystery, not relying on a feeling

The case today comes from Doctor Xue Lizhai (Xue Ji), head of the Imperial Academy of Medicine in the Ming dynasty, and it concerns a widowed woman. But before telling the case, Doctor Luo Dalun makes a point he considers especially important: practicing TCM diagnosis is exactly like solving a crime.

💬 Note from Doctor Luo: Think about how detective work goes. Several people passed through the crime scene — Zhang San was at the first location, Zhang San was at the second location, and Zhang San was at the third one too. Then that person is highly suspicious. Treating illness works the same way: bloating has several possible causes, rib pain has several possible causes. List every possibility for every symptom, then look for which possibilities overlap — the more they overlap, the clearer the root cause. That is what proper TCM diagnosis should look like.

Who was the patient? A widow whose husband had died

Doctor Xue Lizhai wrote the patient’s identity clearly at the very start of the case record: a widowed woman — her husband had passed away and she lived alone. Many people wonder: why record that? Just treat the illness, why does this matter?

💬 Note from Doctor Luo: This detail is extremely important. With her husband gone, how could this woman’s emotions be well? In the social environment of ancient times, imagine the pressure a widow had to bear. That identity is closely tied to the illness she finally developed. Doctors like Xue Lizhai understood their patients’ situations very well when they wrote these case records, so those opening words are the key to the whole case.

How sick was she? Five symptoms laid out together

What symptoms did this woman have? Doctor Xue Lizhai wrote them clearly — five altogether: abdominal bloating with rib pain — the belly swollen, pain under both sides of the ribs (the flank area); inner heat with afternoon tidal fever — heat felt from inside the body, more noticeable in the afternoon (the ri bu / sunset hours); irregular menstruation; aching and numb limbs — arms and legs both sore and numb; and frequent spitting of phlegm — she was always spitting phlegm.

💬 Note from Doctor Luo: Each of these five symptoms has several possible causes, but put them together and the clues emerge. Bloating — most closely related to spleen deficiency. Rib pain — usually linked to liver qi not flowing smoothly. Afternoon fever — could be yin deficiency, could also be qi deficiency. Irregular periods — either qi and blood insufficiency or liver qi stagnation. Aching numb limbs — the spleen governs the four limbs; when the spleen is deficient, qi and blood don’t circulate well, so the limbs ache. Constant phlegm — the deficient spleen can’t transform fluids, so they condense into phlegm. Set all these possibilities side by side: which factor appears most often? Spleen deficiency plus liver qi stagnation — two threads gradually coming into focus.

How did the previous doctors treat her? Both times wrong

But this woman had seen doctors before. The first doctor looked at her: hot body, spitting phlegm — isn’t that phlegm-heat? So he gave her heat-clearing, phlegm-resolving herbs. The result? Her throat became even more uncomfortable (the throat and diaphragm felt blocked), her vaginal discharge turned greenish-yellow (dai xia qing huang), and her belly swelled even more.

💬 Note from Doctor Luo: See, the phlegm was born from spleen deficiency in the first place. If you don’t tonify the spleen but only dissolve phlegm and clear heat, the spleen gets weaker and weaker, the phlegm multiplies, and you also injure the stomach. The greenish-yellow discharge — normal discharge is pale, like raw egg white, and odorless. Once it turns greenish-yellow, that’s pathological, and it shows the problem is getting worse. By the way, “dai xia” (below-the-belt discharge) was the ancient term for gynecological illness in general. Historical records say that when Bian Que passed through Handan and heard that the local people held women in high regard, he became a “dai xia doctor” — that is, a gynecologist. So you can see: discharge has been an important signal of women’s health since ancient times.

The second round of doctors looked at the bloating: surely qi must be stuck inside. So they gave her qi-moving herbs. This was even worse: chest and diaphragm obstruction — her chest felt stuffed, and even breathing became an effort.

💬 Note from Doctor Luo: Why didn’t moving qi work either? Because her upright qi was already insufficient, and you were still making the body work hard with all those qi-moving, qi-regulating herbs — injuring the upright qi further. It’s like a person who is already too hungry and weak to stand, and you tell him to carry bricks — the more he carries, the more he collapses. That’s what happens when you don’t understand diagnosis and just grab one symptom to write a prescription around.

What did Doctor Xue Lizhai think? The most crucial line of the whole case

At this point Doctor Xue Lizhai was called in. He took one look and pronounced five characters: “This is stagnant anger injuring the liver and spleen.” (Ci yu nu shang sun gan pi.)

💬 Note from Doctor Luo: One liver, one spleen — everything matches! This woman was a widow; her mood could hardly be good. She had anger she couldn’t release, so she could only swallow it — that’s “yu nu,” stagnant anger. The liver qi stagnated, then ran sideways and bullied the spleen and stomach. Day after day the spleen and stomach were bullied, and in time they became deficient: spleen deficiency → bloating; liver stagnation → rib pain; liver fire plus spleen deficiency → afternoon fever; liver-spleen disharmony → irregular periods; spleen governs the four limbs → aching, numb limbs; spleen deficiency turning fluids into phlegm → constant spitting. Run through every earlier symptom again, and each one lines up — that’s how you know you’ve found the cause.

The prescription: Guipi Tang in the morning, Augmented Xiao Yao Wan at night

Once the root was found, the formula was simple. Doctor Xue Lizhai prescribed a pair of medicines, taken at different times of day:

• In the morning: Gui Pi Tang (Spleen-Restoring Decoction) — tonify spleen qi, relieve spleen stagnation, and calm the spirit. Gui Pi Tang is built on Si Jun Zi Tang (Four Gentlemen Decoction); it focuses on tonifying qi, and inside it there is mu xiang (costus root) to help relieve spleen stagnation, plus yuan zhi (polygala root) and other herbs that settle the spirit.
• At night: Jiawei Xiao Yao Wan (Augmented Free and Easy Powder) — nourish liver blood and drain liver fire. Xiao Yao Wan (Free and Easy Powder) soothes the liver, nourishes blood, and tonifies the spleen; the augmented version adds mu dan pi (moutan bark) and zhi zi (gardenia fruit), which specifically drain liver fire.

💬 Note from Doctor Luo: Tonify the spleen in the morning, nourish the liver at night — these two formulas work together beautifully, especially for women with liver qi stagnation and spleen qi deficiency. The augmented Xiao Yao formula leans toward soothing the liver, while Gui Pi Tang leans toward tonifying the spleen — one soothes the liver, one tonifies the spleen, and the stagnation of both organs is untied. Why put Guipi Tang in the morning? Because Doctor Xue Lizhai judged that this patient’s spleen deficiency was severe — in the morning you first tonify the spleen qi to lay the foundation. Xiao Yao is on the cooler side, so it goes in the evening alongside blood-nourishing. Just grasp the direction of this morning-evening pairing; you don’t need to memorize every detail.

The result: over a hundred doses, three months, every symptom cured

Following Doctor Xue Lizhai’s plan, this woman took over one hundred doses over roughly three months — and every single complaint resolved completely.

💬 Note from Doctor Luo: After getting better, a woman like this still needs to manage her emotions carefully. Modern society is kinder — she could change her environment, change her way of life. In ancient times, if she stayed in the same circumstances, recovery would not come easily. So you see — emotion really does cause tangible, physical harm.

Bonus: the plight of widows in ancient times — the story of Qian Qianyi and Liu Rushi

Tying into this case, Doctor Luo Dalun tells a poignant historical story: Qian Qianyi, the great writer of the late Ming and early Qing dynasties, married the famous courtesan Liu Rushi, and the two were deeply devoted. But the moment Qian Qianyi died — he had no children — his entire clan decided his fortune should belong to the family. They besieged Liu Rushi, demanding she hand over the property. In the end, unable to bear the humiliation, she hanged herself.

💬 Note from Doctor Luo: Think about it — a woman that famous, and the moment her husband died she was pushed to the edge. In ancient times a widow with children had to swallow endless humiliations within the clan. So when Doctor Xue Lizhai read the word “widowed,” he immediately understood: this illness is rooted in emotion. Understand this: when ancient doctors wrote case records, not a single character was written idly.

Doctor Luo’s closing reflection: why can Doctor Xue Lizhai cure illness with such plain little formulas?

Doctor Luo Dalun sums up at the end: the reason Doctor Xue Lizhai could cure this illness with two such simple, common patent medicines is that his localization of the problem was extremely accurate. Before he wrote down the case, he had already run all the patient’s symptoms quickly through his mind: this symptom has these possibilities, that symptom has those possibilities — which possibility overlaps? Only after sorting it all out did he put pen to paper.

💬 Note from Doctor Luo: In the old days TCM practitioners loved to say “yi zhe yi ye” — “the physician’s art lies in intuition” — as if diagnosis depended entirely on mental flashes and feelings, saying a disease is “probably” this or “mostly” that, all vague. But medicine is a rigorous science. TCM diagnosis should be crystal clear — like a court case: list the possibilities one by one, then cross-check them against each other. A doctor with clear logical thinking is bound to be a good doctor: he analyzes thoroughly, localizes precisely, and his herbs strike directly. Everyone, remember: only when you see the whole problem can your diagnosis be accurate.

Compiled from Doctor Luo Dalun’s commentary on the case records of Doctor Xue Lizhai (Xue Ji); the case is from Xue’s Medical Cases (《薛氏医案》), Ming dynasty.