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[Background Information]
Book: *Records of Medicine with Chinese and Western Integration* (Yixue Zhongzhong Canxi Lu)
Author: Zhang Xichun
Dynasty: Qing
Chapter: 27. Shaoyang Disease, Xiao Chai Hu Tang Syndrome
Category: Medical Discussion

[Original Text]
Original text from *Shanghan Lun*: In the fifth or sixth day of a cold damage syndrome, if wind-stroke occurs, presenting with alternating chills and fever, fullness and distress in the chest and hypochondrium, silence with lack of appetite, mental irritability, and frequent desire to vomit. Or, if there is irritability in the chest without vomiting, thirst, abdominal pain, hardness and stuffiness under the hypochondrium, palpitations in the epigastrium, difficult urination, no thirst, slight fever on the body, or coughing, Xiao Chai Hu Tang should be administered as the primary treatment. (This section is recorded in the Taiyang Chapter.)

[Xiao Chai Hu Tang Formula]
Chai Hu (Bupleuri Radix) half jin, Huang Qin (Scutellariae Radix) three liang, Ren Shen (Ginseng Radix) three liang, Zhi Gan Cao (Prepared Glycyrrhizae Radix et Rhizoma) three liang, Xi Ban Xia (Washed Pinelliae Tuber) half sheng, Qie Sheng Jiang (Sliced Zingiberis Rhizoma Recens) three liang, Bo Da Zao (Split Jujubae Fructus) twelve pieces.

Take these seven ingredients, add one dou two sheng of water, boil to obtain six sheng, remove the dregs, decoct again to obtain three sheng. Take one sheng warm, three times a day.

Modifications for Xiao Chai Hu Tang:
If there is irritability in the chest without vomiting, remove Ban Xia and Ren Shen, add one Gua Lou Shi (Trichosanthis Fructus).
If there is thirst, remove Ban Xia, add Ren Shen to make a total of four liang and half, plus Gua Lou Gen (Trichosanthis Radix) four liang.
If there is abdominal pain, remove Huang Qin, add Bai Shao (Paeoniae Radix Alba) three liang.
If there is hardness and stuffiness under the hypochondrium, remove Da Zao, add Mu Li (Ostreae Concha) four liang.
If there are palpitations in the epigastrium and difficult urination, remove Huang Qin, add Fu Ling (Poria) four liang.
If there is no thirst but slight fever on the exterior, remove Ren Shen, add Gui Zhi (Cinnamomi Ramulus) three liang; wrap warmly to induce slight sweating for cure.
If there is coughing, remove Ren Shen, Da Zao, and Sheng Jiang, add Wu Wei Zi (Schisandrae Fructus) half sheng and Gan Jiang (Zingiberis Rhizoma) two liang.

[Appendix] Dosages of Xiao Chai Hu Tang used by later generations
Chai Hu (8 qian), Huang Qin (3 qian), Ren Shen (3 qian), Gan Cao (3 qian)
Qing Ban Xia (4 qian), Sheng Jiang sliced (3 qian), Da Zao split (4 pieces)

In Xiao Chai Hu Tang syndrome, "frequent desire to vomit" (Xi Ou) does not necessarily mean actual vomiting; it simply means frequently having the sensation of wanting to vomit. Therefore, when I treat cold damage, encountering patients who feel nauseous with slight alternating chills and fever, I immediately administer Xiao Chai Hu Tang, resulting in cure after one dose. This corresponds to what *Shanghan Lun* says: "In cold damage or wind-stroke, if there are Chai Hu signs, seeing just one sign is sufficient, it is not necessary that all are present."

The heavy use of Chai Hu in the formula is precisely to assist the pivot function of Shaoyang to guide the pathogen outwards. Fearing that its pivoting power might be weak, Ren Shen is added to strengthen its ascending force, so that the Shaoyang pathogen can directly follow the Shaoyang qi to penetrate through the diaphragm and emerge upwards. The use of Ban Xia is because it grows in mid-summer, capable of connecting Yin and Yang, harmonizing interior and exterior. Moreover, since the disease inherently involves a desire to vomit, and Chai Hu and Ren Shen are used to ascend, although Shaoyang can ascend, we fear the Stomach Qi may also reverse upwards due to this, making the desire to vomit difficult to cure. Thus, Ban Xia is used in coordination with Gan Cao, Sheng Jiang, and Da Zao to descend and harmonize the Stomach. The use of Huang Qin is because its shape is originally hollow, making it good at clearing heat in the body shell, and also to resolve the excessive heat nature of Ren Shen.

Xiao Chai Hu Tang syndrome originally contraindicates sweating methods. The method of removing dregs and decocting again is originally intended to reduce the releasing-exterior power of Chai Hu, desiring it to only ascend rather than reach the exterior. However, in Section 103 of the Taiyang Chapter, there is text stating that after taking Xiao Chai Hu Tang, fever and sweating occur. Readers of *Shanghan Lun* often doubt this, and commentators have rarely explained its meaning in detail. Now, let us record the original text and study it carefully.

Original text from *Shanghan Lun*: Whenever a Chai Hu Tang syndrome is treated with purgatives, and if the Chai Hu signs do not cease, administering Chai Hu Tang again will inevitably result in intense internal heat and trembling, followed by fever, sweating, and resolution.

Taking Xiao Chai Hu Tang to guide the Shaoyang pathogen to penetrate through the diaphragm and emerge upwards without causing sweating is the standard treatment principle for Xiao Chai Hu Tang syndrome. However, the ascending and penetrating power of the medicine is quite difficult, relying heavily on the patient's healthy qi being unharmed; the medicine borrows the healthy qi to circulate and operate before it can take effect. In cases of mistaken purgation, the Foot Shaoyang pathogen often scatters within the hand Shaoyang San Jiao fatty membranes. Still administering Xiao Chai Hu Tang, the pathogen scattered in the Hand Shaoyang can borrow its harmonizing and unblocking power to reach the Taiyang and resolve via sweating. The pathogen remaining in the subcostal plate oil, due to mistaken purgation injuring the qi, lacks the strength to ascend, thus borrowing the pathway of the Hand Shaoyang to follow and resolve via sweating. Hence, the character "que" (yet/however) is specifically added to the sweating description, indicating that it is not inducing sweating, but rather resolving via sweating. This occurs due to the mistaken purgation, clarifying that Xiao Chai Hu Tang is originally not a sweating medicine. When sweating occurs, there must be intense heat and trembling, indicating shaking before sweating. Generally, resolving Shaoyang disease via sweating is not the correct path, and resolving pathogen remaining in the subcostal area via sweating is even more difficult. Even after taking Xiao Chai Hu Tang, which originally intends to penetrate the diaphragm upwards, due to qi deficiency after purgation, it cannot emerge from above. The pathogen scattered in the Hand Shaoyang, attracted by similarity, opens a collateral pathway at the time of extreme accumulation. At this moment, there is nearly a situation where healthy qi cannot overcome pathogenic qi, hence before sweating, there must be heat and trembling. This is why Ren Shen is included in Xiao Chai Hu Tang to assist. Therefore, when I use this formula, for those with strong qi, I often do not use Ren Shen, but for those who have mistakenly taken descending medicines or have qi deficiency, I must use Ren Shen.

The membrane origins of the human body are interconnected everywhere; the uterus of women is also a membrane. Its substance is originally two membranes combined, with a夹层 chamber in the middle, present in both men and women. Men use it to transform essence, women use it to regulate menstruation, so the uterus of women is also called the Blood Chamber (Xue Shi). When menstrual flow has just ended, if an external pathogen transmitting through meridians takes advantage of the deficiency to invade, presenting Shaoyang syndrome symptoms, it should also be treated with Xiao Chai Hu Tang. *Shanghan Lun* has discussed this in detail.

Original text from *Shanghan Lun*: In women with wind-stroke, if chills and fever continue for seven or eight days, occurring at specific times, and menstruation happens to stop, this is Heat Entering the Blood Chamber. The blood must be congealed, causing symptoms like malaria, occurring at specific times. Xiao Chai Hu Tang should be administered as the primary treatment.

When cold damage disease transmits from Yangming to Shaoyang, occasionally following Shaoyang treatment methods, the syndrome may revert to Yangming. Although this is a rarely seen syndrome, the treatment method should be examined in detail.

Original text from *Shanghan Lun*: After taking Chai Hu Tang, if thirst occurs, it belongs to Yangming; treat according to the method.

Yu Jiayan said: Wind-cold pathogen, transmitting from Yangming to Shaoyang, initially presents without thirst, interior signs are not complete. After taking Xiao Chai Hu Tang, if severe thirst is added, then the pathogen returns to Yangming, and the stomach should be regulated to preserve body fluids. However, it does not say "purge," but says "treat according to the method," implying infinite meaning. Given that Shaoyang alternating chills and fever sometimes involve thirst, if Shaoyang has not ceased and one rashly speaks of purging, is it not violating the contraindications of Shaoyang? Therefore, seeing Shaoyang reverting to Yangming syndrome, it only says "treat according to the method." What is this method? It refers to the saying about sweating and promoting urination, leading to restlessness in the stomach and difficulty in defecating. If urination is not promoted, there are methods using Zhu Ling Tang or Wu Ling San. If body fluids are consumed by intense heat, there is the method of Ren Shen Bai Hu Tang. Zhang Zhongjing's flexible wisdom is profound; "when the person exists, the policy is implemented," which is not easy to discuss.

Shaoyang syndrome does not necessarily transmit from Yangming. If a person has accumulated heat in the Gallbladder habitually, and accidentally receives an external pathogen, they may present with bitter taste, mental irritability, and alternating chills and fever. Add Sheng Shi Gao (Raw Gypsum Fibrosum), Hua Shi (Talcum), and Sheng Hang Shao (Raw Paeoniae Radix Alba) each six qian to the Chai Hu Tang, dispersing the heat through urination, curing after taking. If the left Guan pulse is very forceful, Sheng Shi Gao can be used up to one liang (There are many cases suitable for adding Shi Gao to Xiao Chai Hu Tang syndrome, not just this case), eliminating the worry of transforming into Yangming.

Xiao Chai Hu Tang is originally a mild agent, but the medical community at that time feared using it, avoiding Chai Hu due to its ascending and lifting properties. Even famous doctors like Ye Tianshi often avoided using Chai Hu where it was indicated, substituting it with Qing Hao (Artemisiae Annuae Herba). Indeed, people of ancient and modern times have different constitutions. Ancient people had rich and dense constitutions, not fearing the ascending and lifting properties of medicines. Modern people often have excess in the upper jiao and deficiency in the lower jiao, with floating heat in the upper jiao. Seeing some who suffer from headache and vertigo after taking Chai Hu, or gingival bleeding after taking Chai Hu, those who habitually suffer from hematemesis and cerebral congestion especially should avoid taking it. As for me, when using Xiao Chai Hu Tang, I always modify the original formula. Now, let me cite several verified cases to clarify this.

Zhang XX from the same village, eight years younger than me, is a good doctor in the region. When he first studied medicine, he suffered from Shaoyang cold damage, with alternating chills and fever, headache and fever, mental irritability and frequent desire to vomit, pulse string-taut and fine, forceful upon heavy pressing. I prescribed a formula for treatment: Chai Hu four qian, Huang Qin, Ren Shen, Gan Cao, Ban Xia each three qian, Da Zao four pieces, Sheng Jiang three large slices, Sheng Shi Gao one liang, decocted in a large bowl to drink. Zhang XX doubted and asked: "This formula is Xiao Chai Hu Tang plus Sheng Shi Gao. According to the original dosage, Chai Hu half jin converted to today's three qian per liang would be two liang four qian, divided by three would be eight qian today. In the current formula, other herbs use their original dosages, only Chai Hu is halved, and it is decocted into one bowl to drink, without removing dregs and decocting again. Why is this? I am new to medicine and do not understand medical principles; I wish you to teach me clearly!"

I answered: Using formulas of ancients should originally be modified according to syndrome and time, not rigidly adhering to fixed rules. This is because the qi transformation of ancient and modern times is slightly different, and thus human constitutions have slight discrepancies. Therefore, when I use Xiao Chai Hu Tang, its dosage and ingredients are often adjusted. The nature of Chai Hu is not only ascending and lifting, but originally also has releasing-exterior power. The ancient method of removing dregs and decocting again is to reduce its releasing-exterior power. Today, adding one liang of Sheng Shi Gao to the formula transforms its releasing-exterior power. Even without removing dregs and decocting again, there is naturally no risk of releasing exterior. Moreover, because it has not been decocted again, its ascending and lifting power is undiminished. Therefore, using only half the amount, its power can still penetrate the diaphragm and emerge upwards. Take it with confidence, and there will naturally be no error. Zhang XX indeed trusted my words, decocted and took one dose, and all diseases were cured.

A woman surnamed Liu from a neighboring village suffered from Shaoyang syndrome of cold damage, with irregular alternating chills and fever, heat in the heart, vomiting phlegm and saliva continuously without end, pulse deep and string-taut. I prescribed the original Xiao Chai Hu Tang formula, also halving Chai Hu to four qian, adding Sheng Shi Gao one liang, and Yun Ling Pian (Poria Slices) four qian. A knowledgeable doctor present doubted and asked: "In Shaoyang meridian syndromes, continuous vomiting of sticky saliva without end has not been seen. Now Mr. uses Xiao Chai Hu Tang, and adds Shi Gao and Fu Ling. Could it be not only a Shaoyang meridian disease, but also involving another meridian?" I answered: "Your question is indeed valid. This is Shaoyang disease connected to Taiyin. The pathway of Shaoyang originally leads to the Taiyin meridian. Taiyin in the abdomen is damp-earth qi. If combined with Shaoyang, damp-heat combines, producing much sticky saliva. Therefore, adding Shi Gao and Fu Ling to Xiao Chai Hu Tang clears Shaoyang heat, thereby draining Taiyin dampness." The knowledgeable doctor heard this and was greatly impressed. The formula was decocted and taken, cured completely in two doses.

In Liaoning, I once treated a woman with alternating chills and fever, heat heavier than chills, constantly delirious at night, pulse deep, string-taut, and forceful. Recalling that *Shanghan Lun* states for women's Heat Entering the Blood Chamber syndrome, "clear during the day, delirious at dusk," I inquired carefully, learning that she had received an external pathogen for three or four days, menstruation suddenly started, and after menstruation stopped, this syndrome changed. Based on what was said, knowing it was indeed Heat Entering the Blood Chamber, hence her pulse was deep, string-taut, and forceful. I prescribed the original Xiao Chai Hu Tang formula, halving Chai Hu, additionally adding Sheng Huang Qi (Raw Astragali Radix) two qian and Chuan Xiong (Ligustici Chuanxiong Rhizoma) one and a half qian to lift the sinking pathogen, and further adding Sheng Shi Gao one and a half liang to clear the sinking heat. Using Xiao Chai Hu Tang in such a modified way, although the external pathogen was deeply sunk, it was actually not difficult to drive it out. Decocted and taken one dose, the illness improved by more than half; taken one more dose, fully cured.

Note: For Heat Entering the Blood Chamber syndrome, if the heat is severe, Shi Gao should be heavily used, two or three liang, to clear the heat. In the Blood Chamber, not allowing any of this external heat to remain ensures no other dangers. I have treated several people with ulcerated Blood Chamber containing pus and blood. Investigating their origin, most resulted from residual external pathogens, indicating they were sequelae of Heat Entering the Blood Chamber. When initially getting sick, even if doctors knew to treat with Xiao Chai Hu Tang, in cases of severe heat, not knowing to heavily use Shi Gao to clear the heat of the Blood Chamber led to dangerous syndromes. This is truly the fault of the doctor. Doctors treating Heat Entering the Blood Chamber syndrome should deeply ponder my words.