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There is cold within, and heat in the chest transforms into fire, causing abdominal pain and a desire to vomit; therefore, this formula is used as the primary treatment. Coptis Rhizoma (Huanglian) serves as the sovereign drug to clear heat in the stomach; Ginger Rhizome (Ganjiang) serves as the minister drug to warm cold in the stomach; Pinellia Tuber (Banxia) descends rebellious Qi, assisting Huanglian to stop vomiting; Ginseng Radix et Rhizoma (Renshen) tonifies the Middle Jiao, assisting Ganjiang to eliminate abdominal pain; Cinnamon Twig (Guizhi) is used to secure the exterior; Jujube Fruit (Dazao) is used to nourish the Middle Jiao. However, since this decoction contains both cold and warm properties, and sweet and bitter flavors are administered together, Licorice Root (Gancao) must be added to harmonize the various drugs. This is a treatment method for Yin-Yang mutual rejection and simultaneous application of cold and warm therapies.

In Taiyang disease, after ten days, if the pulse is floating and fine, and the patient desires to lie down, it indicates that the exterior pathogen has resolved. If accompanied by chest fullness and hypochondriac pain, Xiao Chaihu Tang (Minor Bupleurum Decoction) should be given; if the pulse is merely floating, Mahuang Tang (Ephedra Decoction) should be given.

[Annotation] In Taiyang disease lasting more than ten days without other symptoms, if the pulse is floating and fine and the patient is lethargic, the exterior pathogen has resolved, and no medication is needed. If symptoms such as chest fullness and hypochondriac pain are present, it indicates that the pathogen in the Shaoyang channel has not resolved, so Xiao Chaihu Tang is used to harmonize it. If the pulse is merely floating without being fine, and accompanied by headache, fever, aversion to cold, and anhidrosis, it remains an unresolved Taiyang exterior pathogen, and Mahuang Tang should be used to induce sweating.

[Commentary] The text mentions that a floating and fine pulse corresponds to Taiyang and Shaoyang; a wiry and fine pulse corresponds to Shaoyang; a deep and fine pulse corresponds to Shaoyin. A floating and fine pulse with fever and lethargy indicates a Yang syndrome; a deep and fine pulse with no fever and lethargy indicates a Yin syndrome; a slow and fine pulse with a peaceful body and lethargy indicates resolution. These distinctions must not be overlooked.

[Collected Annotations] Wang Kentang stated: This clause likely refers to a combined disease of Taiyang and Shaoyang. Although chest fullness is common, a floating and fine pulse with lethargy indicates that the exterior pathogen has resolved, while hypochondriac pain indicates Shaoyang pathogen, hence Xiao Chaihu Tang is given. If the pulse is merely floating, Taiyang should be treated first, hence Mahuang Tang is given. This is a hypothetical flexible statement, not implying that the pulse becomes floating after taking Chaihu.

In Shanghan (Cold Damage) with fever, where sweating does not resolve the condition, accompanied by epigastric stuffiness and hardness, vomiting, and diarrhea, Da Chaihu Tang (Major Bupleurum Decoction) is the primary treatment.

[Commentary] The character "Xia" (down/below) in "Xiali" (diarrhea) should be "Bu" (not). If it were "Xia", how could one use Da Chaihu Tang to purge when there is both upper vomiting and lower diarrhea?

[Annotation] In Shanghan with fever, where sweating does not resolve the condition, the exterior pattern has not yet resolved; epigastric stuffiness and hardness with constipation indicate that the interior pathology is urgent. Vomiting is a symptom shared by Shaoyang and Yangming. With both Shaoyang and Yangming patterns urgent, heat accumulation forms epigastric stuffiness; thus, Da Chaihu Tang is used to release the residual exterior heat of Shaoyang externally and attack the interior excess and stuffiness of Yangming internally.

[Commentary] In Taiyang disease with fever, where sweating does not resolve the condition, epigastric stuffiness and hardness, but with diarrhea and no vomiting, this is a deficiency of both exterior and interior, corresponding to Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction). If there is vomiting and no diarrhea (or different diarrhea characteristics), this is an excess of both exterior and interior, corresponding to Da Chaihu Tang. The former presents with a weak pulse; the latter presents with a forceful pulse.

In Taiyang disease, after passing the typical duration of over ten days, if the physician mistakenly applied purgation two or three times, and four or five days later the Chaihu syndrome persists, Xiao Chaihu Tang should be given first. If vomiting continues incessantly, there is urgency in the epigastrium, and mild depression and irritability, indicating the disease has not resolved, Da Chaihu Tang should be given to purge, leading to recovery.

[Annotation] After Taiyang disease transmits through the three Yang channels for over ten days, if the physician fails to treat according to the channel progression and mistakenly applies purgation two or three times without causing adverse transformations, and four or five days later only the alternating chills and fever of Shaoyang (Chaihu syndrome) persist, Xiao Chaihu Tang should be given first to release the exterior and harmonize the interior. If it does not resolve, and symptoms include incessant vomiting, epigastric fullness and urgency, and mild depression and irritability, this indicates that both the exterior and interior of Shaoyang are unresolved. Da Chaihu Tang should be given to purge the interior and harmonize the exterior, leading to recovery.

[Collected Annotations] Fang Youzhi stated: "Passing the channel" is similar to "bad disease." Not knowing the deviation, applying purgation two or three times causes deviation, hence the term "fan" (contrary/reverse). Purging repeatedly leaves the Yangming unharmed but the Shaoyang pathogen undispelled, hence "Chaihu syndrome persists." Incessant vomiting and mild depression/irritability indicate pathogen disturbing the two Yang channels, hence "unresolved."

Cheng Zhi stated: This explains that after passing the channel and mistaken purgation, there is a method of dual resolution using Minor and Major Chaihu formulas. Since the pathogen has penetrated deeply due to repeated purgation, if the exterior pattern is not resolved, Xiao Chaihu Tang must first be used to harmonize the half-exterior before attacking the interior.

Cheng Yingmao stated: Comparing this with the clause "Frequent vomiting in Yangming channel, even with Yangming symptoms, cannot be purged": Yangming vomiting is located above, and the pathogen is above the diaphragm, not entering the fu organs, so it cannot be purged. In this clause, incessant vomiting and epigastric urgency indicate the pathogen is below the diaphragm, belonging to the Stomach, so it can be purged. The distinction between purgable and non-purgable cases is critical.

Lin Lan stated: Incessant vomiting indicates the half-exterior/half-interior pattern still exists. However, epigastric urgency and mild depression/irritability suggest dry stool accumulation, which requires purgation. Thus, Da Chaihu Tang is used to combine harmonizing and purging.

Da Chaihu Tang Formula
Bupleuri Radix (Chaihu) - Half jin
Scutellariae Radix (Huangqin) - Three liang
Pinelliae Tuber (Banxia) - Washed, half sheng
Paeoniae Radix Alba (Shaoyao) - Three liang
Immature Trifoliate Orange Fruit (Zhishi) - Roasted, four pieces
Rhei Radix et Rhizoma (Dahuang) - Two liang
Zingiberis Rhizoma Recens (Shengjiang) - Sliced, five liang
Jujubae Fructus (Dazao) - Split, twelve pieces

These eight ingredients are boiled in twelve dou of water to yield six sheng. Remove the dregs, boil again, and take one sheng warm, three times daily.

[Commentary] Xu Shuwei stated: There are versions of Da Chaihu Tang with and without Rhei Radix et Rhizoma (Dahuang). This version uses Dahuang because it has the power to cleanse accumulated heat, making it a key herb in Shanghan. Wang Shuhe said: Without Dahuang, it might not be called Da Chaihu Tang. Moreover, the text states "purging leads to recovery"; without Dahuang, what would purge the epigastric urgency? Wang Shuhe's view should be followed.

[Formula Analysis] Since the Chaihu pattern exists alongside interior pathology, a dual-resolution method for Shaoyang is established. Adding Immature Trifoliate Orange Fruit (Zhishi) and Paeoniae Radix Alba (Shaoyao) to Xiao Chaihu Tang releases the exterior and harmonizes the interior. Removing Ginseng Radix et Rhizoma (Renshen) and Glycyrrhizae Radix et Rhizoma (Gancao) is because the interior is not deficient; adding a small amount of Rhei Radix et Rhizoma (Dahuang) clears accumulated heat; doubling the amount of Zingiberis Rhizoma Recens (Shengjiang) addresses incessant vomiting.

In Taiyang disease, after passing the channel for over ten days, if the patient feels nauseous, has chest pain, loose stools, slight abdominal fullness, mild depression, and irritability, and if previously subjected to extreme emesis or purgation, Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) should be given; otherwise, it should not be given. If there is only a desire to vomit, chest pain, and loose stools, this is not a Chaihu pattern; due to vomiting, it is known to be caused by extreme emesis or purgation.

[Commentary] Wang Kentang stated: "Wenwen" should be "Yunyun" (feeling stifled/uncomfortable). Also, there may be missing text after "due to vomiting."

[Annotation] In Taiyang disease passing the channel for over ten days, if unresolved after extreme emesis or purgation: extreme emesis vacates the chest, allowing pathogenic heat to enter vacuously, causing nausea and chest pain. Extreme purgation vacates the interior, allowing pathogenic heat to enter, causing loose stools, slight abdominal fullness, mild depression, and irritability. If confirmed that extreme emesis/purgation occurred, the exterior pathogenic heat has sunk into the chest and abdomen, presenting as interior disharmony; thus, Tiaowei Chengqi Tang should be given to purge and harmonize. If not caused by extreme emesis/purgation, this decoction should not be given. Desire to vomit indicates Shaoyang; chest pain indicates Taiyang; loose stools indicate Taiyang-Shaoyang combined disease diarrhea. Without nausea/fullness/irritability, Chengqi Tang is contraindicated. Nor is this a Chaihu pattern, so Chaihu Tang is also contraindicated. For Taiyang-Shaoyang combined disease with diarrhea and vomiting, Huangqin Banxia Shengjiang Tang (Scutellaria, Pinellia, and Fresh Ginger Decoction) should be used.

[Collected Annotations] Fang Youzhi stated: Chest pain indicates pathogen at the diaphragm. After extreme emesis, one should feel nausea; why? Because the stomach opening is damaged by emesis, and pathogenic heat rises to the diaphragm, causing desire to vomit without ability to do so. Slight abdominal fullness and irritation indicate pathogen in the Stomach. After extreme purgation, one should have loose stools; why? Because purgation vacates the Stomach; although pathogen is excess in the Stomach, stools cannot harden. Hence, "if previously subjected to extreme emesis/purgation, give Tiaowei Chengqi Tang," meaning to cleanse heat and harmonize the Stomach. "Otherwise" means not subjected to extreme emesis/purgation. The rest clarifies the previous points.

Yu Chang stated: In Taiyang disease passing the channel for over ten days, with nausea, chest pain, loose stools, slight abdominal fullness, and irritation, two distinctions apply: If previously subjected to extreme emesis/purgation, the exterior pathogen resolved via emesis and entered the interior; Tiaowei Chengqi method can be used. If not subjected to extreme emesis/purgation, with only desire to vomit, chest pain, and loose stools, the pain is not from emesis damage, and loose stools are not from purgation; the Tiaowei method is contraindicated.

Cheng Zhi stated: "Passing the channel" refers to illness lasting seven to thirteen days, where channel qi has circulated but not resolved. It can last twenty-plus days. Illness lingering past the channel stays in the Yang channels; if in Yin channels, it would not last so long. If it cannot persist, how can life be sustained?

Cheng Yingmao stated: Loose stools allow Qi to descend, so the abdomen should not be full, nor should there be irritation. Current slight fullness and irritation indicate gastric obstruction and incomplete relief after purgation. Though resembling Yangming, lacking typical Yangming signs and showing only Shaoyang signs suggests mismanagement. One must trace the cause of symptoms to identify the disease.

After thirteen days of Shanghan unresolved, with hypochondriac fullness and vomiting, afternoon tidal fever, and subsequent mild diarrhea, this was originally a Chaihu pattern. Purging failed to produce diarrhea. Now, diarrhea occurs because the physician used pill-based purgatives, which is incorrect treatment. Tidal fever indicates excess. First, use Xiao Chaihu Tang to release the exterior, then use Chaihu Jia Mangxiao Tang (Bupleurum with Natrii Sulfas Decoction) as the primary treatment.

[Annotation] When Shanghan passes the channel unresolved, heat often transfers to the Stomach fu organ and requires purgation. Here, after thirteen days, with hypochondriac fullness, vomiting, afternoon tidal fever, and mild diarrhea, this was originally a Da Chaihu pattern. Failure to purge effectively, followed by diarrhea, indicates the physician used rapid pill-based purgatives incorrectly. Rapid purgation removes fluid but leaves dryness intact. The physician might mistake post-purgation diarrhea for deficiency, but tidal fever confirms excess, warranting further treatment. Since hypochondriac pathogen persists, Xiao Chaihu Tang is first used to release Shaoyang exterior, followed by Xiao Chaihu Tang plus Natrii Sulfas (Mangxiao) to address Shaoyang interior. Natrii Sulfas replaces Rhei Radix et Rhizoma (Dahuang) because the interior is not urgently excessive and has been rapidly purged; the goal is to soften hardness and moisten dryness. This combines purging with harmonizing.

[Collected Annotations] Neitai Fangyi stated: Tidal fever indicates excess. Why not use Da Chaihu or Da/Xiao Chengqi? Because prior pill purgation injured the zang-fu organs; using Rhei Radix et Rhizoma (Dahuang) again would injure Spleen Qi and cause bad disease. Only Natrii Sulfas (Mangxiao) is used to moisten dryness and induce mild purgation.

Fang Youzhi stated: Thirteen days indicates passing the channel. Unresolved indicates bad disease due to medical error. The preceding text analyzes the cause of deviation; the following text provides remedial treatment.

Chaihu Jia Mangxiao Tang Formula
To the Xiao Chaihu Tang formula, add Natrii Sulfas (Mangxiao) six liang. Follow the previous preparation and administration methods. Take if unresolved.

After thirteen days of Shanghan unresolved, passing the channel with delirium, indicates heat requiring purgation with decoction. If urination is free, stools should be hard; if diarrhea occurs instead, and the pulse is harmonious, it indicates the physician used pill-based purgatives incorrectly. If diarrhea occurred spontaneously, the pulse should be faint and cold; if the pulse is harmonious instead, this indicates interior excess. Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) is the primary treatment.

[Annotation] This elaborates on the previous clause. After thirteen days of Shanghan unresolved, passing the channel with delirium indicates heat requiring purgation. Unlike the previous tidal fever (heat in exterior/interior, stools not hard), delirium heat resides in the Stomach fu, so stools should be hard. If urination is free, stools should be hard; if diarrhea occurs with a harmonious pulse, it indicates iatrogenic diarrhea from pill purgatives. Spontaneous diarrhea would present with faint/cold pulses (deficiency). Harmonious pulse indicates interior excess-heat, not deficiency-cold. Despite diarrhea, it is heat-diarrhea, requiring heat-purging via Tiaowei Chengqi Tang.

On the third day of Shanghan, the three Yang channels are exhausted, and the three Yin channels should receive the pathogen. If the patient can eat and does not vomit, this indicates the two Yin channels (Taiyin and Shaoyin) are not receiving the pathogen.

[Annotation] Shanghan pathogens follow a sequence: Day 1 Taiyang, Day 2 Yangming, Day 3 Shaoyang, Day 4 Taiyin, Day 5 Shaoyin, Day 6 Jueyin. On day three, if Yang exterior pathogens are exhausted and Yin channels should be affected, the patient should be unable to eat and vomit. Ability to eat without vomiting indicates interior harmony, preventing transmission to Yin channels. Note: The Nei Jing speaks generally; one should not rigidly adhere to days.

[Collected Annotations] Cheng Wuji stated: Transmission to interior causes disharmony, leading to anorexia/vomiting. Ability to eat without vomiting indicates pathogen remains in Yang, not transmitting to Yin.

Fang Youzhi stated: Yang refers to exterior, Yin to interior. Eating without vomiting indicates interior harmony and restored Stomach Qi, confirming Yin channels are unaffected.

Wang Hu stated: Pathogen in Shaoyang typically causes vomiting/anorexia. Ability to eat without vomiting verifies interior harmony and spontaneous resolution of Shaoyang pathogen. With interior harmony and Shaoyang resolution, transmission to Yin channels is impossible.

On the sixth or seventh day of Shanghan, with no significant fever but restlessness and irritability, this indicates the pathogen leaving Yang and entering Yin.

[Annotation] Days six or seven mark the time when pathogen enters the interior. No significant fever indicates mild exterior heat. Restlessness and irritability indicate severe interior heat. This is "Yang leaving to enter Yin," meaning exterior pathogen moves inward to the three Yin channels.

[Collected Annotations] Cheng Wuji stated: Internal heat causes irritability (mental distress); external heat causes restlessness (physical agitation). Internal heat is rooted fire (treatable); external heat is rootless fire (untreatable).

Fang Youzhi stated: "Leaving" means going. Exterior pathogen moves inward, causing internal restlessness/irritability without external heat.

In women with Fengzhong (Wind Strike), fever and aversion to cold, menstruation occurring during the course, after seven to eight days, if fever subsides, pulse slows, body cools, but hypochondriac fullness resembles Jiechest (Knotted Chest), and delirium occurs, this is Re entering the Blood Chamber. Acupuncture Qimen (Liv 14) should be performed to drain excess.

[Annotation] Wind Strike with fever/aversion to cold is an exterior pattern. If menstruation had not occurred, heat would not transmit to the Blood Chamber. With menstruation occurring, after seven to eight days, slowing pulse and cooled body suggest exterior resolution. However, hypochondriac fullness resembling Jiechest and delirium indicate heat entered the Blood Chamber vacuously due to menstruation. Treatment requires acupuncture at Qimen (Liver Front-Mu point). As the Liver stores blood, needling Qimen drains excess heat from the blood level.

[Collected Annotations] Fang Youzhi stated: The Blood Chamber is where nutritive blood gathers (Chong Mai/Blood Sea). Its vessel originates at Qichong, runs with Shaoyin, ascends to the chest. Heat entry causes these symptoms. Qimen (Liv 14) is the Liver Front-Mu point. Needling it drains blood-level excess heat.

Wang Hu stated: Pathogen transmitting to Shaoyang and entering the Blood Chamber causes delirium. Zhang Zhongjing warns against mistaking this for Yangming Fu excess and using Chengqi formulas, which would injure Stomach Qi. Instead, he prescribes needling Qimen.

In women with Fengzhong for seven to eight days, developing intermittent chills and fever coinciding with menstruation cessation, this is Re entering the Blood Chamber. Blood clots, causing malaria-like paroxysms. Xiao Chaihu Tang (Minor Bupleurum Decoction) is the primary treatment.

[Annotation] Intermittent chills/fever coinciding with menstruation cessation indicates Re entering the Blood Chamber. Blood and heat bind, causing clotting. However, absence of Jiechest/delirium indicates clotting without full excess. Malaria-like chills/fever indicate pathogen in Shaoyang (half-exterior/half-interior). Xiao Chaihu Tang harmonizes exterior/interior, resolving heat.

[Collected Annotations] Fang Youzhi stated: Previous case (menstruation starting) allowed heat to exit with blood. This case (menstruation stopping) allowed heat to enter and bind with blood, causing clotting. Cheng Zhi stated: Previous case (clotting/delirium) indicated pathogen excess in Zang, treated by needling. This case (malaria-like chills) indicates pathogen manifesting in Channel, treated by harmonizing with Xiao Chaihu Tang.

In women with Shanghan, fever, and menstruation occurring, if conscious during the day but delirious at night (seeing ghosts), this is Re entering the Blood Chamber. Do not violate Stomach Qi or the Upper/Middle Jiao; it will self-resolve.

[Annotation] Previous clauses addressed Wind Strike Re entering Blood Chamber; this addresses Cold Damage. Fever/anhidrosis with menstruation allows heat entry. Daytime clarity indicates pathogen not in Yang; nighttime delirium indicates pathogen in Yin. "Do not violate Stomach Qi or Upper/Middle Jiao" prohibits sweating, vomiting, and purging. Wait for menstruation to complete; heat will exit with blood.

[Collected Annotations] Fang Youzhi stated: Self-resolution occurs as heat exits with blood, similar to epistaxis ("red sweat"). This warns against reckless attacking.

Lin Lan stated: Cold transforming to heat enters empty Blood Chamber. Daytime delirium implies pathogen in Fu/Yang; nighttime delirium implies pathogen in Blood Chamber/Yin. Yang excess delirium requires purging (violates Stomach Qi here). Previous malaria-like cases used Xiao Chaihu Tang (sweating); this case has no binding, so avoid sweating (violates Upper Jiao). Jiechest cases required needling Qimen; this case has no binding, so avoid needling (violates Middle Jiao). Self-resolution occurs as heat exits with blood.

When Qi and Blood are weak, pores open, pathogen enters, binds with healthy Qi at the hypochondrium, fighting for dominance, causing alternating chills and fever...