2 English references Hepatomegaly
hepatomegaly
It is an important clinical sign to summarize that the liver can be caused by many diseases.
The size of normal liver is 25cm× length×15 cm× up and down diameter× front and back diameter 16cm. The average liver weight of adult males in China is 1342g, and that of females is 1234g, accounting for about 1/50. The liver of fetus and newborn is relatively larger than that of adults, accounting for about 1/20. The upper boundary of the normal liver is consistent with the diaphragmatic vault, starting from the 7th rib of the right axillary midline, reaching the 5th rib of the right clavicle midline, passing through the junction of the sternum and xiphoid process to the left clavicle midline, and reaching the 5th intercostal space slightly inside the left clavicle midline. The lower boundary of the liver is consistent with the front edge of the liver, starting from the right axillary midline 1 1 rib, and leaving the rib arch along the lower edge of the right costal arch.
The location of the liver is related to sex, age and body shape, which can change to some extent with the difference of breathing, visceral activity and * * *. The position of the liver drops when standing and inhaling, and rises when lying flat and exhaling. When breathing calmly, the difference between rising and falling is about 3cm. Children under 5 years old, people who drink plenty of water, living at high altitude for more than 2 months after meals, at night, after exercise, under the costal margin 1. Sometimes the liver touched under the ribs is not because the liver is big, but because the liver moves down, which can be seen in women with loose abdominal wall after delivery, singers or performers with excessive diaphragm movement, emphysema, massive effusion in the right chest cavity and subphrenic abscess. Sometimes gallbladder enlargement, transverse colon tumor, pancreatic cyst, gastric cancer, right nephroptosis, right hydronephrosis, right renal cyst, pheochromocytoma, etc. It can also be misdiagnosed as hepatomegaly, but the respiratory activity is not as large as that of the liver, and the margin is not as clear as that of the liver. Therefore, pathological hepatomegaly should be determined by combining the medical history, liver position, shape, texture, respiratory activity and tenderness.
4 disease name hepatomegaly
5 English name hepatomegaly
6. Alias hepatauxe Liver University; Hepatomegaly; Giant liver disease; hepatomegaly
7 Classification of Gastroenterology > Symptomatology of Digestive System
8 ICD number R 16.0
There are many diseases that cause hepatomegaly, which are summarized as follows.
9. 1 Infectious hepatomegaly (1) virus infection: viral hepatitis A, B, C, D, E, infectious mononucleosis, yellow fever, rubella, cytomegalovirus, herpes simplex virus, coxsackie virus, adenovirus, herpes zoster virus, measles virus, etc.
(2) Chlamydia infection: such as psittacosis.
(3) Rickettsia secondary infection: typhus, Q fever, etc.
(4) Bacterial infection: acute obstructive suppurative cholangitis, chronic cholangitis, primary sclerosing cholangitis, bacterial liver abscess and liver tuberculosis.
(5) Leptospirosis: Leptospirosis, relapsing fever, liver syphilis, Lyme disease, etc.
(6) Fungal infections: actinomycosis, blastomycosis, coccidiosis, cryptococcosis, histoplasmosis, candidiasis, aspergillosis, mucormycosis, etc.
(7) Protozoan infection: amebic liver abscess, leishmaniasis, malaria, toxoplasmosis, trypanosomiasis, piriform trichinosis, etc.
(8) Wormlike infection: schistosomiasis, clonorchiasis, biliary ascariasis, ascaris liver abscess, echinococcosis, clonorchiasis, Fasciola hepatica, toxoplasmosis, capillary nematodiasis, ascaris faecalis, paragonimiasis, etc.
9.2 Non-infectious hepatomegaly (1) is toxic: it can be composed of carbon tetrachloride, chloroform, ethanol, phenol, naphthalene, benzene, acetaminophen, sodium valproate, heavy metals, phosphorus, arsenic, isothiocyano compounds, trinitrotoluene, monoamine oxidase inhibitor, p-aminosalicylate, pyrazinamide, ethionamide, azathioprine and thiophanate. Mushrooms, isoniazid, cincofen, butazone, rifampicin, tetracycline, diacetyl tincture, chlorpromazine, methyltestosterone, oral contraceptives, ketoconazole, methyldopa, phenytoin sodium, phenobarbital, furazolidone, sulfonamides, thiourea, phenformin, etc.
(2) Congestive heart failure, tricuspid stenosis or insufficiency, myocarditis or cardiomyopathy, congenital heart disease, constrictive pericarditis, pericardial tamponade, hepatic vein occlusion, etc.
(3) Cholestasis: intrahepatic cholestasis, extrahepatic cholestasis, choledocholithiasis, cholangiocarcinoma, pancreatic head cancer, ampullary cancer, etc.
(4) Metabolic diseases: fatty liver, Relye syndrome, acute fatty liver during pregnancy, hepatic amyloidosis, hepatolenticular degeneration, hemochromatosis, porphyria, hyperglycemia, lipohistiocytosis, familial spleen anemia, cholesteryl ester storage disease, gangliosidosis, mucopolysaccharidosis, galactosemia, hereditary fructose intolerance, cystic fibrosis and α 65438.
(5) Cirrhosis: portal vein, schistosomiasis, necrosis, primary biliary, secondary biliary, cardiogenic cirrhosis, etc.
(6) Tumors and cysts: primary liver cancer, secondary liver cancer, hepatoblastoma, carcinoid tumor, hepatic mixed tumor, hepatic adenoma, cystadenoma, hepatic angiosarcoma, hepatic hemangioendothelioma, hepatic cavernous hemangioma, adult polycystic liver disease, non-parasitic hepatic cyst, etc.
(7) Others: such as granulomatous liver disease, sarcoidosis, autoimmune hepatitis, hepatic hematoma, various blood diseases, multiple myeloma, myelofibrosis, AIDS, etc.
10 Pathogenesis 10. 1 When infected with various pathogenic microorganisms and toxic hepatitis, vascular congestion, tissue edema, inflammatory cell infiltration and other inflammatory substances exudation, or degeneration and swelling of liver cells, or massive proliferation of hepatic reticuloendothelial system occur due to inflammation. Viral hepatitis is the most common infection.
10.2 Congestive heart failure, pericardial tamponade, constrictive pericarditis, pericardial effusion and obstruction of hepatic venous return, the liver is swollen due to congestion, with purple appearance and blunt edge.
10.3 cholestasis leads to primary biliary cirrhosis, pancreatic head cancer, cholestasis and hepatomegaly caused by biliary obstruction inside and outside the liver.
10.4 some drugs and hepatotoxin poisoning, as well as various systemic infections, pathogens can not only directly invade the liver, but also cause toxic hepatitis through toxemia, high fever, malnutrition, hypoxia and other factors. , will cause hepatocyte necrosis, resulting in microencapsulated lipomatosis, hepatitis-like injury, liver fibrosis, hepatic vein occlusion, capillary bile duct cholestasis and so on. And lead to hepatomegaly.
During the period of 10.5, fat, glycogen, lipids, amyloid, copper or iron were deposited in the liver to make it swell.
10.6 tumors and cysts liver cancer, sarcoma, benign tumors and various cysts infiltrate liver cells and make them swell.
10.7 Other immune injuries, connective tissue diseases and hematological diseases can cause hepatomegaly.
1 1 Clinical manifestations of hepatomegaly 1/range of lesions (1) Diffuse increase: due to the prevalence of liver lesions, it can be seen in various hepatitis, fatty liver, hepatic amyloidosis, hepatic congestion, cirrhosis, hepatocellular carcinoma, metastatic carcinoma and cholangiocarcinoma.
(2) Increased localization: It is caused by space-occupying lesions in the liver, such as liver abscess, liver cyst, liver tumor and liver hydatid.
1 1.2 The liver is normal in hardness, thin and soft. Hepatitis, liver abscess, schistosomiasis, fatty liver, malaria, etc., are moderately difficult to see in the liver. Liver cirrhosis, advanced schistosomiasis, blood stasis cirrhosis, malignant tumor, leukemia, liver amyloidosis, syphilis liver, etc.
1 1.3 The edge of the liver and the edge of the liver with chronic hepatitis and blood stasis are blunt and round, with smooth surface, sharp edge of liver cirrhosis and nodular surface.
1 1.4 Tenderness is obvious in acute hepatitis, acute liver congestion, acute cholangitis or biliary colic, and it is heavier in bacterial or amebic liver abscess, mainly localized tenderness. Liver cancer often has no obvious tenderness, chronic hepatitis has less tenderness, and cirrhosis, fatty liver, hepatic amyloidosis and syphilis liver generally have no tenderness.
1 1.5 jaundice viral hepatitis, biliary cirrhosis and extrahepatic biliary obstruction are common.
1 1.6 emaciation liver cancer and cirrhosis may be accompanied by obvious emaciation.
1 1.7 ascites, liver cancer, liver cirrhosis, acute and subacute severe hepatitis, circulatory disorders, etc.
1 1.8 Spider nevus and liver brown can be seen in chronic liver parenchymal lesions.
1 1.9, abnormal coagulation, purpura, gingival bleeding, etc. Abnormal coagulation is found in severe liver diseases, long-term obstructive jaundice, hematological diseases, leptospirosis and so on.
12 Laboratory examination 12. 1 Blood examination showed that leukocytosis was increased in bacterial infection or amebic liver abscess, and leukopenia in viral infection or hypersplenism. After esophageal vein rupture, hypersplenism or folic acid deficiency, red blood cells and hemoglobin decrease. Abnormal coagulation mechanism caused by hepatic protein synthesis disorder or disseminated intravascular coagulation in liver cirrhosis, severe hepatitis and long-term obstructive jaundice. Viral diseases can be diagnosed by increasing serum antibody titer or isolating positive virus. Leptospirosis, syphilis, mycosis and trematode can all detect specific antibodies in serum, while echinococcosis, trematode and tuberculosis can be tested intradermally.
12.2 eggs or trophozoites can be found in feces.
12.3 duodenal drainage is helpful for the diagnosis of hepatomegaly caused by biliary tract infection, and pathogenic bacteria can be found in the drainage fluid.
12.4 liver function test 12.4. 1 (1) protein metabolism test ① plasma proteins: albumin and prealbumin can be used as indicators to judge the prognosis of chronic liver disease; If the α 1 globulin in liver disease increases, it reflects that the disease is mild, while the decrease often indicates that the disease is serious, while liver cancer is obviously increased. The increase of β globulin is often accompanied by the increase of lipid and lipoprotein; Gamma globulin is normal or slightly higher in acute hepatitis and significantly higher in cirrhosis. The increase of alpha-fetoprotein in liver disease reflects the regeneration of hepatocytes and is related to the activity of the disease. Alpha-fetoprotein positive is not unique to liver cancer, but can also be increased in serum of viral hepatitis, liver cirrhosis, teratoma, gastric cancer, pancreatic cancer, colon cancer and pregnancy.
② Blood turbidity test: Cerebrophospholipid cholesterol flocculation test (CCFE) is an index to diagnose acute hepatitis and hepatitis prognosis, and many other diseases can also have positive and false positive reactions. Zinc sulfate turbidity test (znTT) can distinguish hepatitis from cirrhosis, and judge the diagnosis and prognosis of chronic hepatitis and cirrhosis. Thymol turbidimetry test (TTT) is not a special liver function test, and it can only reflect the degeneration of hepatocytes, but the false positive rate is high.
Although some of the above experiments are excluded, it is still of practical significance to understand this knowledge.
③ Ammonia resistance test: This test has certain diagnostic value for judging whether collateral circulation is formed in patients with liver cirrhosis, but it may cause hepatic encephalopathy.
12.4.2 (2) Glucose test Insulin resistance test is one of the characteristics of glucose metabolism disorder in chronic liver disease; Hypoxia of hepatocytes can block the metabolism of galactose in the liver, which is a special factor of liver disease.
12.4.3 (3) The determination of serum phospholipids in lipid metabolism test is of great significance in differentiating hepatocellular jaundice from obstructive jaundice.
12.4.4 (4) Enzymology examination is an indispensable biochemical examination method for liver diseases, which is of great significance for finding hepatobiliary diseases, clarifying the nature of the disease process and defining the intracellular localization of the lesions.
① Enzymes mainly used for liver parenchyma injury:
Transaminase mainly includes aspartate aminotransferase (GOT), alanine aminotransferase (GPT) and GOT isozyme.
B adenosine deaminase has the advantages of diagnosing acute hepatitis in convalescence, assisting in the diagnosis of chronic liver disease, and distinguishing hepatocellular jaundice from obstructive jaundice.
C glutamate dehydrogenase (GDH) can reflect the activity and severity of liver diseases.
D. Amylase, the serum amylase rises in acute necrosis of hepatocytes, which is often parallel to the elevation of transaminase.
② Enzymes mainly used to diagnose cholestasis:
A alkaline phosphatase is used to differentiate jaundice and diagnose space-occupying lesions of hepatobiliary diseases without jaundice.
B .γ- -glutamyltransferase (GGT) can screen hepatobiliary diseases, assist in the diagnosis of liver cancer, distinguish obstructive jaundice from hepatocellular jaundice, diagnose acute hepatitis in convalescence, judge the activity and prognosis of chronic liver disease, and diagnose alcoholic liver injury.
③ Enzymes used to diagnose liver fibrosis:
A monoamine oxidase (MAO), other diseases and some extrahepatic diseases can also cause changes in the activity of this enzyme.
B.n acetylβ -glucosaminidase is helpful to reflect fibrosis activity.
C. Prolyl hydroxylase (PHO), whose activity is parallel to progressive fibrosis.
④ Enzymes mainly used to diagnose liver tumors:
A.5' nucleotide phosphodiesterase is one of the effective methods for combining AFP with clinical diagnosis of liver cancer.
B α1antichymoprotein (ACT) can be used as one of the diagnostic methods of liver cirrhosis, especially liver cancer.
12.4.5 (5) Detection of bilirubin and bile acid metabolism. Determination of serum bilirubin can know whether there is jaundice, the degree and evolution of jaundice, reflect the degree of liver cell damage and judge the prognosis. Qualitative examination of urinary bilirubin can find liver damage early, identify extrahepatic biliary obstruction early and distinguish jaundice. Serum bile acids can sensitively detect mild liver injury at an early stage, and can distinguish hepatitis and cirrhosis from intrahepatic or extrahepatic cholestasis with normal liver cell function.
12.4.6 (6) Pigment excretion test Sodium sulfobromophthalein (BSP) excretion test can reflect the amount of liver blood flow and the state of liver cell function, and it can be used as a sensitive index to find and judge the degree of liver disease. Indigo green ICG excretion test is the best and most practical dye for detecting liver function, which is safer than BSP and better than BSP test in the application of chronic liver disease.
12.4.7 (7) hormone metabolism test. The determination of hormones or other metabolites in serum and urine can reflect the functional state of the liver except endocrine diseases or other related factors. In liver diseases, serum T3 decreases and anti-T3 increases correspondingly.
12.4.8 (8) Vitamin metabolism test During liver disease, vitamin metabolism and a series of biochemical reactions related to it may be abnormal. Detecting vitamin metabolism in vivo is not only instructive for nutritional treatment of patients with liver disease, but also helpful for understanding and understanding the mechanism of various clinical manifestations during liver disease. In a few cases, it can also be used to judge liver function and assist diagnosis. In liver disease and obstructive jaundice, the absorption of vitamin E decreases and the plasma concentration decreases, but it is not proportional to the severity of liver disease. The determination of blood transketolase can reflect the metabolic state of vitamin B 1 in vivo.
12.4.9 (9) The change of drug conversion function is consistent with the change of liver synthesis function. When the plasma albumin decreases, the prothrombin time is prolonged, and the injection of vitamin K is ineffective, the drug conversion function also decreases, and its sensitivity is higher than that of the determination of plasma protein, bilirubin and prothrombin time, which is similar to the sodium sulfobromophthalein excretion test and galactose clearance test, but not as good as GPT and indocyanine green excretion test. In patients with mild liver injury, drug conversion function test is still in the normal range, while moderate or severe liver injury is relieved, which is helpful to judge the prognosis of liver disease.
13 auxiliary examination 13. 1 ultrasound can be used to measure the position, size and shape of liver, spleen and gallbladder in the diagnosis of hepatobiliary diseases, and observe the changes of hepatic vein, portal vein and their branches; Determine the nature, location and scope of hepatobiliary diseases, confirm clinical impression diagnosis and solve special problems; Percutaneous transhepatic cholangiography, drainage and liver biopsy can be performed under the guidance of ultrasonic exploration. Follow-up observation on the treatment of confirmed hepatobiliary diseases; Further verify the results of radionuclide examination, determine the nature and depth of lesions, and the relationship between hepatobiliary diseases and adjacent organs. B-ultrasound examination is of great significance in the diagnosis of intrahepatic space occupying lesions, which can detect space occupying lesions with a diameter greater than 1cm.
1 3.2 x-ray examination (1) chest x-ray: the position, shape and movement of the right diaphragm can be determined.
(2) Gastrointestinal barium meal: esophageal varices can be found, which is helpful to find biliary obstruction caused by pancreatic head cancer or ampullary cancer.
(3) Cholecystography or cholangiography: It has diagnostic value for gallbladder lesions or biliary obstruction, but it is not suitable for patients with jaundice. At this time, percutaneous transhepatic cholangiography must be performed to determine whether there are stones or tumor obstruction. The clarity of cholangiography is better than that of endoscopic retrograde cholangiopancreatography and excretory cholangiography, but it is contraindicated when prothrombin time is obviously prolonged. The effect of retrograde cholangiography with duodenoscope is similar to that of percutaneous puncture.
13.3 CT and MRI are not as good as CT in the diagnosis of cirrhosis, fatty liver and hepatic adenoma, but MRI is better than CT in the diagnosis of hepatic cyst and hepatic hemangioma.
13.4 radionuclide scanning can dynamically observe the concentration and passage of radioactivity in the liver, bile duct and gallbladder, and can display the size, position and shape of the liver, which is mainly used to diagnose space-occupying lesions in the liver. Blood pool filling has diagnostic significance for hemangioma, and also helps to distinguish intrahepatic cholestasis from extrahepatic obstructive jaundice. It is superior to X-ray cholangiography.
13.5 laparoscopy is helpful for the diagnosis and differential diagnosis of various liver diseases, and is used to diagnose hepatitis, hepatitis staging and hepatitis complications. Etiology, nature and degree of liver cirrhosis; The nature, location and degree of the tumor; Decide whether laparotomy is needed and whether the tumor can be removed; It is also helpful to distinguish extrahepatic obstruction from intrahepatic cholestasis.
13.6 hepatic angiography includes splenic portography, hepatic portography, hepatic arteriography and transumbilical portography. Spleen portography can understand the obstruction of portal vein system and measure portal vein pressure. Hepatic venography can understand the obstruction of hepatic veins. Hepatic arteriography is helpful to estimate the possibility and scope of surgical resection of liver tumors. MRI can replace some invasive angiography.
13.7 hepatic rheogram is a non-invasive method to examine liver and vascular function. By measuring the impedance change of liver tissue to high frequency current, we can reflect the blood circulation state of the liver, judge the liver function and pathological changes, and diagnose and understand the evolution, prognosis and outcome of the disease. Although the hepatic rheogram is not specific to the etiology, it is meaningful to reflect the degree of liver lesions, and is useful for chronic hepatitis, cirrhosis, early portal hypertension and cardiogenic liver.
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13.8 The indication of liver biopsy is unexplained hepatomegaly, which provides a reliable scientific basis for definite diagnosis, judging curative effect and prognosis, and understanding the evolution of various liver diseases. Severe jaundice, ascites or coagulation disorders are prohibited.
14 diagnosis 1. Medical history: Medical history can often provide clues for the diagnosis of liver disease. Attention should be paid to knowing whether there is a history of contact with infectious diseases, receiving blood products and living in epidemic areas, which is helpful for the diagnosis of infectious diseases and parasitic diseases. A history of exposure to drugs or poisons can lead to toxic hepatomegaly. Patients with liver cirrhosis often have a history of hepatitis, jaundice and chronic alcoholism. Patients with liver pain are more common in liver inflammation, acute liver congestion and space-occupying lesions in the liver, mostly dull pain, but the pain of liver cancer can be quite severe. Accompanied by fever, hepatitis, liver abscess, biliary tract infection, liver cancer or other acute infectious diseases, blood system diseases, connective tissue diseases and so on are often prompted. Viral or drug hepatitis with anorexia.
2. Clinical manifestations.
3. Laboratory and other auxiliary inspections.
15 Differential diagnosis of viral hepatitis 15. 1 Patients with hepatomegaly caused by viral hepatitis often have a history of close contact with patients with viral hepatitis, unclean diet, blood transfusion or drug injection. The clinical manifestations are fatigue, loss of appetite, nausea, abdominal distension, liver pain and so on. Symptoms include hepatomegaly, liver pain, jaundice and so on. The activity of serum enzymes is increased by liver function test, and various hepatitis (A, B, C, D, E, F, G) virus antigens or antibodies can be detected by serological examination.
15.2 toxic hepatitis often has a history of drug or poison contact before onset, followed by symptoms such as hepatomegaly, fever, rash, pain in liver area, jaundice, etc. Toxic hepatitis is also accompanied by functional damage of other organs, and eosinophils in peripheral blood increase, while serum antigens or antibodies of various viral hepatitis are mostly negative. Generally, it can return to normal after stopping taking drugs or contacting poisons, but the same symptoms appear when contacting drugs or poisons again.
15.3 generally, the onset of liver abscess is slow, and chills and fever often occur due to obvious inflammatory manifestations, followed by pain in the liver area, hepatomegaly, smooth liver surface, tenderness, percussion pain, corresponding abdominal edema, and increased peripheral blood white blood cell and neutrophil counts. Ultrasound, radionuclide, CT scan and other auxiliary examinations can assist diagnosis, and diagnostic puncture examination is feasible when necessary.
15.4 patients with primary or metastatic liver cancer are mostly over 40 years old, mostly male, with slow onset. Clinical manifestations include emaciation, loss of appetite, liver pain, fever, jaundice and so on. The liver can be enlarged obviously, with tough texture and palpable nodules. The value of serum alpha-fetoprotein (AFP) in patients with primary liver cancer often increases, and serum AKP, γGT and carcinoembryonic antigen can also increase. Abdominal ultrasound, CT, radionuclide and MRI can find cancer focus. Metastatic liver cancer, B-ultrasound and other examinations can often see multiple cancer foci of different sizes in liver parenchyma.
15.5 patients with hepatic cysts often have no obvious symptoms or only nonspecific symptoms such as epigastric discomfort, most of which are congenital and a few are acquired. Ultrasound, CT, MRI and other examinations can find clear liquid dark areas in the liver, and strong echo light clusters can be seen when calcification occurs.
Treatment of hepatomegaly 16 There are many reasons for hepatomegaly, and hepatomegaly is an important sign of a disease in most cases. Therefore, patients with hepatomegaly should actively seek the exact cause of hepatomegaly and actively treat the primary disease, instead of hoping that the liver will return to normal after applying some liver-protecting drugs. If hepatomegaly is caused by a single giant abscess or cyst, it can be treated by puncture and aspiration. In the former, antibiotics or metronidazole solution can be injected into the abscess cavity after the pus is extracted, and sclerosing agents such as anhydrous alcohol or compound aluminum solution can be injected into the cyst cavity after the cyst is extracted, so as to prevent the cyst wall from continuously oozing liquid into the cavity.
17 related drugs acetaminophen, sodium valproate, oxygen, salicylic acid, pyrazinamide, ethionine, azathioprine, methotrexate, amiodarone, isoniazid, phenylbutazone, rifampicin, tetracycline, chlorpromazine, methyltestosterone, testosterone, ketoconazole, methyldopa, phenytoin sodium, phenobarbital and barbital.
18 related tests include monoamine oxidase, testosterone, trypsin, folic acid, hemoglobin, zinc sulfate turbidity test, thymol turbidity test, insulin, serum phospholipids, glutamic acid, glutamate dehydrogenase, amylase, chymotrypsin, vitamin e, prothrombin time and vitamin K.
Acupoint selection for treatment of hepatomegaly; opening the gallbladder in the courtyard of Zhuzhigou at Jiaoguan Chongye Gate; Yin Xia Xi Foot near Chuiyang Assisting Yanglingquan Liver Pier Inter-row Taichong Zhongfeng Ququan Hand Yin San and Hand Sanyang Wushu Point Foot, Foot. ...
Yujiao Guanchong Shuimen Zhuzhigou patio gallbladder summer foot near the vertical Yang Fu Yang Ling Quan liver pier between the lines is too blunt to seal Qu Quan hand, hand Sanyang martial arts point foot, ...
Shudian rubber hose flushing door Zhuzhigou patio gallbladder summer foot near the vertical Yang Fu Yang Ling Quan liver pier line is too blunt to seal Qu Quan hand, hand Sanyang martial arts point foot, ...
Jiaoguan Chongmen Zhuzhigou patio, the hole where the hole is lost, timid; Summer's feet are almost crying; The lines of Yang Lingquan's liver pier are too blunt; Ququan has three yin hands, three yang hands, and five Shu points have three yin feet. ...
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