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Abdominal pain caused by Shanghan (Cold Damage) is primarily categorized into four main principles: Cold, Heat, Blood stasis, and Accumulation.

If a patient presents with Taiyang syndrome symptoms, and due to failure to release the exterior in time, Chengqi Tang (Cassia Twig Decoction) is mistakenly used for purging too early, causing Yang pathogenic heat to sink inward into the Yangming channel. The body may actually not feel hot, the pulse is deep and tight, and pain extends from the chest to the abdomen. This is called Da Jie Xiong Syndrome (Major Chest Binding Syndrome) or Xiao Jie Xiong Syndrome (Minor Chest Binding Syndrome), and should be treated with Da Xian Xiong Tang (Major Sinking Chest Decoction) or Xiao Xian Xiong Tang (Minor Sinking Chest Decoction). This differs from abdominal pain caused by Yang pathogenic heat sinking inward into the Taiyin channel without prior mistaken purging; in that case, the pulse is deep and fine, and Guizhi Shaoyao Dahuang Tang (Cinnamon Twig, Peony, and Rhubarb Decoction) should be used. If Taiyang syndrome fails to release the exterior, and Chengqi Tang is mistakenly used for purging too early, failing to form an upper Jue Xiong (Chest Binding) but instead causing Yang pathogenic heat to sink into the Taiyin channel, resulting in abdominal fullness and pain, the pulse must be deep, fine, and rapid. In this case, Guizhi Shaoyao Dahuang Tang should be used. This is distinct from Yang pathogenic heat sinking into the Yangming channel, which presents with profuse sweating and requires Da Xian Xiong Tang.

In another scenario, following premature mistaken purging of Taiyang syndrome with Chengqi Tang, the Yang pathogenic heat does not bind at the Xin Xia (epigastrium) nor sink into the Taiyin channel, but instead sinks into the Large Intestine, binding with dry stool and food accumulation. This causes lower abdominal pain, accompanied by sweating, restlessness, and a deep, rapid pulse. This is abdominal pain of the Yangming Large Intestine. At this stage, Guizhi (Cinnamon Twig) and Dahuang (Rhubarb) should not be used; instead, Chengqi Tang should be continued for purging.

In yet another case, not due to mistaken purging, but because heat pathogen transmits inward on its own, binding downward in the stool, presenting with cracked lips, dry mouth and tongue, generalized abdominal pain, deep and rapid pulse, tidal fever, and spontaneous sweating, San Chengqi Zheng Xia (Three Chengqi Decoctions for Proper Purging) should be used.

If heat pathogen transmits inward, occasionally causing diarrhea, with frequent abdominal pain, this indicates heat without solid accumulation, belonging to syndromes such as dysentery where the Three Yang channels cooperate with heat. Huanglian Zhike Tang (Coptis and Aurantium Decoction) is appropriate.

If there is abdominal pain with constipation, but chills and fever have not resolved, indicating residual exterior pathogen in the Three Yang channels, even if interior excess signs exist, immediate purging is contraindicated. Instead, Da Chaihu Tang (Major Bupleurum Decoction) should be used to resolve both exterior and interior simultaneously.

If urination is difficult and the lower abdomen is hard and painful, this is Niao Se (difficulty in urination), and Bazheng San (Eight Correct Powders) or similar formulas should be used to promote urination.

If urination is normal, the area around the umbilicus is hard and painful, there is a desire to rinse the mouth but no desire to swallow water, or symptoms like mania-like behavior and forgetfulness occur, this is abdominal pain due to Blood Stasis (Xu Xue). Taoren Chengqi Tang (Peach Kernel and Cassia Twig Decoction) should be used to purge the stasis.

If the initial presentation was a Yang syndrome, but due to excessive use of cold/cooling herbs suppressing the pathogen, cold congeals in the Taiyin Spleen meridian causing abdominal pain, the pulse will be deep and slow. Lizhong Tang (Regulate the Middle Decoction) or Jianzhong Tang (Establish the Middle Decoction) are suitable.

If it was originally a Yang syndrome, but abdominal pain occurred due to overconsumption of raw/cold foods causing cold to congeal in the Yangming Stomach and Intestines, the pulse will be deep and large. Dashun Yin (Great Smooth Drink) or Pingwei San (Peace the Stomach Powder) should be used, taken with Ginger Decoction.

Furthermore, if there is no initial fever, the pulse is deep and slow, urination and defecation are clear and free, there is slight abdominal pain, and no thirst, this is Yin syndrome abdominal pain of the Three Yin channels. For mild cases, Lizhong Tang is used; for severe cases, Sini Tang (Frigid Extremities Decoction) is used.

In Shanghan disease, if there is heat in the chest, pathogenic qi in the stomach, abdominal pain, and a desire to vomit, Huanglian Tang (Coptis Decoction) is the primary treatment.

"Heat in the chest" refers to heat in the Upper Jiao. "Pathogenic qi in the stomach" refers to heat pathogen in the Middle Jiao. "Abdominal pain" refers to heat in the Lower Jiao. With heat in all three Jiaos accompanied by vomiting, Huanglian Tang is used.

In Shanghan disease presenting with Sini (Frigid Extremities), if the patient also has cough, palpitations, difficulty urinating, abdominal pain, or diarrhea with a sensation of heaviness in the rectum, Sini San (Frigid Extremities Powder) is the primary treatment.

Although this section mentions cold extremities, the presence of difficulty urinating, abdominal pain, and diarrhea with rectal heaviness indicates heat-type pain. Therefore, Sini San is used first to treat the frigid extremities.

In Shanghan disease, if the Yang pulse is choppy (Se) and the Yin pulse is taut (Xian), with acute abdominal pain, according to the method, one should first administer Xiao Jianzhong Tang (Minor Establish the Middle Decoction). If it does not improve, Xiao Chaihu Tang (Minor Bupleurum Decoction) with added Shaoyao (Peony) should be given.

A choppy Yang pulse and taut Yin pulse with acute abdominal pain resemble Three Yin abdominal pain, so Xiao Jianzhong Tang is administered first. If it does not improve, it indicates that Shaoyang stagnant fire has not been released, hence the taut and choppy pulse. Xiao Chaihu Tang is used to clear the Shaoyang, and adding Shaoyao harmonizes the taut and choppy pulse.

In Shaoyin disease, if after two to three days the condition persists, and by the fourth or fifth day abdominal pain, heavy and painful limbs, and spontaneous diarrhea occur, this is Water Qi (fluid retention). If the patient also has cough, vomiting, diarrhea, or normal urination, Zhenwu Tang (True Warrior Decoction) is the primary treatment.

This represents Cold-Dampness of the Shaoyin channel transmitting to the Taiyin, causing abdominal pain. Zhenwu Tang is used to tonify the Fire within Earth (Spleen Yang) to control the Water Qi causing diarrhea.

In Jueyin Shanghan, after four to five days, if there is abdominal pain and gas moves downward toward the lower abdomen, this indicates impending diarrhea.

When Yang pathogenic heat transmits inward with dry stool, passing flatus (Zhuan Shi Qi) downward toward the anus; whereas when Yin-Cold is internal and diarrhea is impending, gas moves downward toward the lower abdomen. Generally, heat desires to exit directly through the anus, while Yin-Cold desires to exit but stops by moving downward toward the lower abdomen.

Da Xian Xiong Tang: See "Jie Xiong" (Chest Binding) and "Pi Man" (Stagnant Fullness).

Guizhi Shaoyao Dahuang Tang (Cinnamon Twig, Peony, and Rhubarb Decoction)
Ingredients: Guizhi (Cinnamon Twig), Baishao Yao (White Peony Root), Dahuang (Rhubarb), Gancao (Licorice).
Chengqi Tang treats Yangming abdominal pain; Guizhi Dahuang Tang (Guizhi Shaoyao Dahuang Tang) treats Taiyin abdominal pain. For Large Intestine heat binding, Guizhi and Dahuang are not used; for Spleen deficiency with turbid decay, Chengqi Tang is not used.

San Yi Chengqi Tang: See "Da Bian Jie" (Constipation).

San Huang Zhike Tang (Three Yellows and Aurantium Decoction)
Ingredients: Huangbai (Phellodendron Bark), Huanglian (Coptis Rhizome), Huangqin (Scutellaria Root), Zhike (Aurantium Fruit), Mutong (Akebia Stem).
For abdominal pain with constipation, use Chengqi Tang. For diarrhea cooperating with heat accompanied by abdominal pain, use San Huang Tang. Abdominal pain is generally due to Qi stagnation, so Zhike and Mutong are used to separate and drain both urine and stool.

Da Chaihu Tang: See "Han Re" (Chills and Fever).

Taoren Chengqi Tang (Peach Kernel and Cassia Twig Decoction)
Ingredients: Taoren (Peach Kernel), Dahuang (Rhubarb), Zhike (Aurantium Fruit).
If exterior pathogen remains after mistaken purging, with heart/chest pain radiating to the lower abdomen, use Da Xian Xiong Tang. For pathogen sinking into Taiyin causing abdominal pain, use Guizhi Dahuang Tang. For Taiyang organ obstruction causing abdominal pain, use Chengqi Tang. For diarrhea with heat causing abdominal pain, use San Huang Zhike Tang. For abdominal pain with unresolved exterior syndrome, use Da Chaihu Tang. For current Blood Stasis abdominal pain, use this formula (Taoren Chengqi Tang).

Lizhong Tang (Regulate the Middle Decoction)
Ingredients: Renshen (Ginseng), Baizhu (Atractylodes Macrocephala), Ganjiang (Dried Ginger), Gancao (Licorice).
For Yang syndrome abdominal pain, clearing heat is indicated; for Yin syndrome abdominal pain, this formula is used.

Sini Tang: See "Shen Tong" (Body Pain).

Jianzhong Tang (Establish the Middle Decoction)
Ingredients: Baishao Yao (White Peony Root), Guizhi (Cinnamon Twig), Gancao (Licorice).
For abdominal pain due to Middle Qi deficiency, use Lizhong Tang; for abdominal pain due to True Yang insufficiency, use Sini Tang. For Liver-Spleen blood deficiency and cold, Wuji Tang (Five Earths Decoction) with added Guizhi is used.

Dashun Yin (Great Smooth Drink)
Ingredients: Suosha (Amomum Villosum), Caodoukou (Cardamom Seed), Nongpo (Magnolia Bark), Qingpi (Green Tangerine Peel).
For Yang syndrome abdominal pain, clearing heat is indicated; for Yin syndrome abdominal pain, warming the meridians is indicated. Since this was originally a Yang syndrome but abdominal pain resulted from excessive intake of cold/cool substances, acrid-dispersing and draining methods are used.

Huanglian Tang (Coptis Decoction)
Ingredients: Huanglian (Coptis Rhizome), Guizhi (Cinnamon Twig), Ganjiang (Dried Ginger), Banxia (Pinellia Tuber), Renshen (Ginseng), Gancao (Licorice), Dazao (Jujube).
Mistaken use of cold herbs leads to Phlegm-Fluid and Heat Pathogen obstructing the Middle Jiao. Thus, Xiexin Tang (Drain the Epigastrium Decoction) type formulas are used, balancing cold and heat to dissipate them. Now, adding Renshen and Dazhao transforms the Xiexin Tang into a formula that harmonizes the middle and disperses pathogen.

Sini San (Frigid Extremities Powder)
Ingredients: Chaihu (Bupleurum Root), Baishao Yao (White Peony Root), Zhike (Aurantium Fruit), Gancao (Licorice).
For Yin syndrome abdominal pain with cold extremities, use Sini Tang; for Yang syndrome abdominal pain with cold extremities, use Liangge San (Cool the Diaphragm Powder). For Yin channel Yang syndrome abdominal pain with cold extremities, sudden use of cold/cool herbs is contraindicated. Therefore, first unblock the Liver-Gallbladder blood vessels and harmonize the Stomach's Middle Qi. Once the limbs warm up, then clear the heat.

Zhenwu Tang (True Warrior Decoction)
Ingredients: Fuling (Poria), Baizhu (Atractylodes Macrocephala), Baishao Yao (White Peony Root), Fuzi (Aconite Lateral Root).
Yang pathogen abdominal pain mostly involves the Stomach and Intestines; Yin-Cold abdominal pain involves Spleen cold, so Zhenwu Tang is used.

Tongmai Sini Tang (Pulse-Restoring Frigid Extremities Decoction)
Ingredients: Fuzi (Aconite Lateral Root), Ganjiang (Dried Ginger), Guangpi (Tangerine Peel), Gancao (Licorice), Congbaitou (Scallion White).
For Yin syndrome abdominal pain with diarrhea and cold extremities, with a hidden pulse, indicating collapse of True Yang, Tongmai Sini Tang is used.