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Tidal fever (Chao Re) is like the coming and going of tides, occurring at regular times. If it occurs once a day at a fixed time, it is called tidal fever; if it occurs three to five times a day, it is ordinary fever, not tidal fever. Tidal fever belongs to Yangming disease. The Qi of the Yangming channel is vigorous during Wei (13:00–15:00) and Shen (15:00–17:00) hours; therefore, it must occur during Ribu (15:00–17:00) to be considered tidal fever.

Taiyang Disease: After severe sweating followed by erroneous purgation, leading to constipation for five to six days, dryness and thirst on the tongue, slight tidal fever at Ribu, hardness, fullness, and pain from the epigastrium down to the lower abdomen that cannot be touched, Da Xian Xiong Tang (Great Trapdoor Decoction) is indicated. (Cheng Wuji notes: Severe sweating and purgation cause severe depletion of fluids inside and outside, with heat binding internally, causing constipation for five to six days and dry tongue/thirst. Tidal fever at Ribu indicates Stomach excess. The term "slight" suggests the pathogen is not limited to the Stomach but affects the entire abdomen from epigastrium to hypogastrium, where both upper and lower pathogens are severe. One should use Xian Xiong Tang to purge the pathogen. Danbo Yuanjian observes: Taiyang disease after severe sweating has deficient exterior; subsequent purgation makes the interior also deficient. Constipation for five to six days shows fluid consumption, unlike previous chapters where purgation was done prematurely without prior sweating. Although there is hardness and pain now, can one rapidly attack? If tidal fever at Shen/You hours belongs to Yangming and is a Tiao Wei Cheng Qi Tang syndrome, yet it says "slight" tidal fever, this is doubtful and warrants waiting. Are there no other methods to achieve effect gently? Tidal fever inherently belongs to Yangming; this is the only case of tidal fever in Taiyang. In miscellaneous diseases, Taiyang tidal fever occurs during Si/Wu hours. Observing the word "slight" implies more pathogen in Taiyang than Yangming.)

Yangming Disease: With tidal fever and slightly hard stool, Da Cheng Qi Tang (Great Order the Qi Decoction) may be used; if not hard, do not use it. If there is constipation for six or seven days and concern about dry feces, to test if purgation is suitable, first give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If flatus passes after ingestion, there are dry feces, and purgation is necessary; if no flatus passes, the stool is merely hard at the beginning and likely loose later, so do not purge. Purging will cause abdominal fullness and inability to eat. Thirst for water may lead to hiccups. Subsequent fever may cause stool to become hard again but scanty; use Xiao Cheng Qi Tang to harmonize. If no flatus passes, absolutely do not purge.

In Yangming disease, if the pulse is slow, sweating occurs without aversion to cold, the body feels heavy, there is shortness of breath, abdominal fullness, wheezing, and tidal fever, this indicates the exterior syndrome is resolving and the interior can be attacked. Sweating on the hands and feet (Ji Ran Han Chu) indicates the stool has hardened; Da Cheng Qi Tang is indicated. If there is profuse sweating, slight fever, and aversion to cold, the exterior is not resolved, the fever is not tidal, and Cheng Qi Tang should not be used. If there is significant abdominal fullness and obstruction, Xiao Cheng Qi Tang may be used to mildly harmonize the Stomach Qi, avoiding drastic purgation.

In Yangming disease, delirium (Man Yu) with tidal fever and inability to eat indicates dry feces (Zao Shi) in the stomach; if able to eat, the stool is merely hard. Da Cheng Qi Tang is indicated for purging. (Cheng Wuji notes: Stomach heat usually promotes digestion; inability to eat indicates excess due to dry feces. Ability to eat suggests deficient heat in the Stomach; although hard, it is not dry feces. Dry feces are in the Large Intestine, but Zhang Zhongjing refers to the Stomach because Shaoyang disease transmits to the Stomach, not directly to the Large Intestine; treating the root is essential. Moreover, Cheng Qi Tang acts on dry feces, and the Large Intestine shares the same Dry Metal nature with the Stomach.)

Two Yangs Concurrent Disease: When Taiyang symptoms cease and only tidal fever, sweating on hands and feet, difficult defecation, and delirium remain, purgation leads to recovery; Da Cheng Qi Tang is indicated. (Cheng Wuji notes: This is Taiyang disease transmitting to Yangming. Cessation of Taiyang symptoms means no exterior syndrome. Tidal fever alone indicates Yangming. General sweating allows heat to vent outward; hand and foot sweating indicates heat gathering in the Stomach. This causes difficult defecation and delirium. The Classic states: Hand and foot sweating indicates hardened stool. Use Da Cheng Qi Tang to purge Stomach excess heat.)

In Yangming disease, delirium with tidal fever and a slippery, rapid pulse is treated with Xiao Cheng Qi Tang. Administer one sheng; if flatus passes, administer another sheng. If no flatus passes, do not administer further. If the next day there is still no bowel movement and the pulse becomes faint and choppy, this indicates interior deficiency, which is difficult to treat; do not give Cheng Qi Tang again. (Cheng Wuji notes: Delirium and tidal fever with a deep, solid pulse indicate interior excess suitable for purgation. A slippery, rapid pulse indicates interior heat not yet solidified, so purgation is premature. First, harmonize with Xiao Cheng Qi Tang. Flatus indicates dry feces present, allowing further administration. No flatus means no dry feces. On the second day, if the pulse becomes deep, solid, tight, or firm, it indicates interior excess. A faint, choppy pulse indicates severe interior deficiency. If this occurs after diarrhea, it is manageable; here, without prior diarrhea, a faint/choppy pulse indicates internal decline of righteous Qi overcome by pathogenic factors, hence difficult to treat.)

Da Cheng Qi Tang Formula: (Zhang Yuansu notes: Hou Po removes distension, Zhi Shi relieves fullness, Mang Xiao softens hardness, Da Huang drains excess. It is only suitable when all four syndromes—distension, fullness, dryness, and excess—are present.)
Da Huang (4 liang, washed with wine), Hou Po (half jin, roasted, coarse bark removed), Zhi Shi (5 pieces, roasted), Mang Xiao (7 qian half). Boil the first two herbs in 1 dou of water to obtain 5 sheng, strain, add Da Huang, boil to obtain 2 sheng, strain, add Mang Xiao, simmer briefly. Divide into two warm doses. If bowel movement occurs, stop remaining dose.

Cheng Wuji notes: "Cheng" means to obey or smooth. When Shaoyin/Yangming pathogen enters the Stomach, it is called entering the Fu organs. Fu means accumulation. The Stomach is the sea of water and grain, the source of Ying and Wei. Water and grain accumulate in the Stomach to transform into Ying and Wei. Pathogen entering the Stomach causes Qi stagnation, fecal retention, and excess accumulation, preventing the smooth flow of righteous Qi. Materia Medica states: Unblocking removes stagnation; draining removes blockage. Using decoctions to cleanse restores smooth flow, hence "Cheng Qi." Wang Bing states: Purging requires bitter flavors; tonifying requires sour flavors. To break hardness and resolve knots, bitter-cold is primary, so Zhi Shi is the sovereign herb. The Classic states: For dryness invading internally, treat with bitter-warm to relieve fullness and remove dryness; thus Hou Po is the minister herb. For heat invading internally, treat with salty-cold. Cold injury transforms into heat; heat gathering in the Stomach is excess. Salty-cold substances clear excess heat, so Mang Xiao is the assistant herb. For excessive dryness, treat with bitter-purgatives. Internal heat consumes fluids, causing intestinal dryness. Bitter-cold substances cleanse dryness-heat, so Da Huang is the envoy. Hence Da Huang is called the General. Cheng Qi Tang is a purgative formula; its use must be cautious. Only use for major fullness and excess with dry feces. Otherwise, cold syndromes, Jie Xiong (Chest Binding), or Pi Qi (Epigastric Fullness) may arise.

Xiao Cheng Qi Tang Formula: (Zhang Yuansu notes: Da Huang drains excess, Hou Po removes distension. Suitable when distension and excess are present.)
Da Huang (4 liang), Hou Po (2 liang, roasted, coarse bark removed), Zhi Shi (3 large pieces, roasted). Boil these three in 4 sheng of water to obtain 1.2 sheng, strain, divide into two warm doses. If defecation occurs after the first dose, do not take the rest. If no defecation, consume the remainder. (For major heat and solidification, use Da Cheng Qi Tang; for minor heat and slight binding, use Xiao Cheng Qi Tang. Heat is not severe enough to require Mang Xiao; binding is not hard enough to reduce Hou Po and Zhi Shi.)

Wu Kun asks: Why does Zhang Zhongjing name Cheng Qi Tang as Major, Minor, and Harmonizing Stomach? When Shaoyang/Yangming pathogenic heat transmits inward, it is called entering the Fu. Fu means accumulation. Pathogenic heat and feces bind to form excess. Excess causes tidal fever, delirium, and palmar sweating due to dry feces. For major heat and excess, use Da Cheng Qi Tang. For minor heat and excess, use Xiao Cheng Qi Tang. For heat binding without significant fullness, Hou Po and Zhi Shi are removed, and Gan Cao is added to harmonize and mildify, hence "Harmonizing Stomach Cheng Qi." Attacking a major disease with a minor formula fails to subdue the pathogen; attacking a minor disease with a major formula damages righteous Qi excessively. Failure to act allows recurrence; over-action is irreparable. Be cautious. Zhang Zhongjing states: Before using Da Cheng Qi Tang, first give Xiao Cheng Qi Tang. If flatus passes, dry feces are present, and Da Cheng Qi Tang can be used. If no flatus, do not purge. Purging causes abdominal fullness and anorexia, making treatment difficult. Also: If purgation occurs after taking Cheng Qi Tang, do not repeat. This is earnest warning. Purgative methods require precise calculation. Improper use kills.

After vomiting or purgation in Shaoyin/Yangming disease, if unresolved, with constipation for five to ten days, tidal fever at Ribu, no aversion to cold, talking alone as if seeing ghosts: If severe, with confusion, grasping at clothes, bed sheets, fearfulness, slight wheezing, and staring eyes, a string-like pulse indicates survival, a choppy pulse indicates death. If only fever and delirium, Da Cheng Qi Tang is indicated. Stop subsequent doses after beneficial purgation.

In Yangming disease, tidal fever with loose stool, free urination, and persistent chest/hypochondriac fullness is treated with Xiao Chai Hu Tang (Minor Bupleurum Decoction). (Yangming disease usually implies Stomach excess. Loose stool here refers to the external Yangming syndrome: fever, sweating, no aversion to cold, aversion to heat.)

Yangming Wind Strike: String-taut, floating, large pulse; shortness of breath, abdominal fullness, hypochondriac and heart pain, nasal dryness, inability to sweat, lethargy, jaundice, difficult urination, frequent hiccups, and tidal fever are treated with Xiao Chai Hu Tang plus Fu Ling.

Shaoyin/Yangming disease unresolved for thirteen days, with chest/hypochondriac fullness, vomiting, tidal fever at Ribu, followed by slight diarrhea: This was originally a Chai Hu syndrome. Purging should not have caused diarrhea. The physician erroneously used pill-based purgatives. Tidal fever indicates excess. First, use Xiao Chai Hu Tang to resolve the exterior, then use Chai Hu Jia Mang Xiao Tang (Bupleurum Decoction plus Mang Xiao).

Chai Hu Jia Mang Xiao Tang Formula:
Chai Hu (1 liang), Huang Qin, Ren Shen, Gan Cao (roasted), Sheng Jiang (each 5 qian), Ban Xia (soaked in boiling water, 3 pieces), Da Zao (3 pieces), Mang Xiao (1 liang). Take 5 qian per dose, boil in 1.5 cups of water until reduced to 0.8 cup, strain, add Mang Xiao, simmer briefly, take warm.

In Yangming disease, a floating and tight pulse indicates tidal fever occurring at specific times. If only floating, night sweats (Dao Han) occur. (Cheng Wuji notes: Floating pulse indicates exterior; tight indicates interior excess. Floating and tight indicate exterior heat and interior excess, causing tidal fever at set times. Only floating indicates exterior heat, causing night sweats. Night sweats occur during sleep. Interior heat Yangming causes spontaneous sweating; exterior heat causes night sweats.)

*Qiu Ren Shu*: In winter, Yangming tidal fever with floating and tight pulse occurs at specific times. If only floating, night sweats occur. Huang Qin Tang is indicated. (Formula see under Diarrhea section.)