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Tidal fever (Chao Re) arrives like the tide, without missing its time. 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 merely fever (Fa Re), not tidal fever. Tidal fever belongs to the Yangming (Yangming Jing) channel. The Qi of Yangming is most vigorous during the Wei (13:00-15:00) and Shen (15:00-17:00) hours; therefore, it must occur during the Ribu period (15:00-17:00) to be considered true tidal fever.

In Taiyang disease (Taiyang Bing), after severe sweating followed by mistaken purgation, if there is no bowel movement for five or six days, dryness on the tongue with thirst, and slight tidal fever occurring around Ribu time, accompanied by hardness, fullness, and pain from the epigastrium down to the lower abdomen that cannot be tolerated to touch, Da Xian Xiong Tang (Major Chest-Trapping Decoction) should be administered. (Cheng Wuji notes: Severe sweating followed by purgation causes a heavy loss of fluids inside and outside, leading to internal heat binding, resulting in no bowel movement for five or six days, dry tongue, and thirst. Tidal fever at Ribu belongs to Stomach excess; however, "slight" tidal fever here indicates that the pathogen is not only in the Stomach but extends from the epigastrium to the lower abdomen, where both upper and lower pathogens are severe. Thus, Xian Xiong Tang is needed to purge the pathogen. Danbo Yuanjian comments: Taiyang disease has already undergone severe sweating, so the exterior is deficient; subsequent purgation makes the interior deficient. No bowel movement for five or six days shows fluid consumption, unlike the previous chapter where purgation was done early without prior sweating. Although there is hardness and pain now, can rapid purgation be used? If tidal fever at Shen and You hours belongs to Yangming and fits Tiao Wei Cheng Qi Tang, but it says "slight" tidal fever, this is suspicious. Is there another method for a milder approach? Tidal fever inherently belongs to Yangming; this is the only case of Taiyang tidal fever. In miscellaneous diseases, Taiyang tidal fever occurs at Si and Wu hours. Observing the word "slight" suggests the pathogen is mostly in Taiyang and less in Yangming.)

In Yangming disease, if there is tidal fever and slightly hard stool, Da Cheng Qi Tang (Major Order the Qi Decoction) may be given; if not hard, do not give it. If there is no bowel movement for six or seven days and one fears dry feces, to verify if purgation is suitable, first give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If gas passes after ingestion, this indicates dry feces, and purgation is necessary. If gas does not pass, the stool is likely hard at the beginning and loose later; do not purge. Purging will cause abdominal fullness and inability to eat. If the patient desires water, giving water will cause hiccups (Yue). Subsequent fever will cause the stool to become hard again but scanty; use Xiao Cheng Qi Tang to harmonize. If gas does not pass, 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 has resolved, and the interior can be attacked. If sweat oozes continuously from the hands and feet, the stool is already hard; Da Cheng Qi Tang is indicated. If there is much sweating, slight fever, and aversion to cold, the exterior is not resolved, the heat is not tidal, and Cheng Qi Tang should not be given. If the abdomen is greatly full and obstructed, Xiao Cheng Qi Tang may be given to mildly harmonize the Stomach Qi, avoiding excessive purgation.

In Yangming disease, if there is delirium (Man Yu), tidal fever, and paradoxically an inability to eat, there must be dry feces (Zao Shi) in the stomach/intestines. If the patient can eat, the stool is merely hard; Da Cheng Qi Tang is suitable for purgation. (Cheng Wuji notes: Stomach heat should digest food and stimulate appetite; inability to eat indicates dry feces causing excess. If able to eat, it indicates deficient heat in the Stomach; although hard, it is not dry feces. Note the word "merely," suggesting the last sentence might belong under "if able to eat." Dry feces are in the Large Intestine, but referred to as "Stomach" because Sha Jing transmits to the Stomach, not the Large Intestine; treating disease requires seeking the root, so Zhongjing speaks from the root. Moreover, Cheng Qi Tang purges dry feces; the Large Intestine and Stomach both belong to Dry Metal.)

When two Yang channels are involved simultaneously (Er Yang Bing Bing), and the Taiyang syndrome has ceased, presenting only with tidal fever, continuous sweating from hands and feet, difficulty in defecation, and delirium, purgation will cure it; Da Cheng Qi Tang is suitable. (Cheng Wuji notes: Originally Taiyang concurrent with Yangming, named concurrent disease. Cessation of Taiyang symptoms means no exterior syndrome. Only tidal fever indicates Yangming involvement. Whole-body sweating indicates heat dispersing; now hand/foot sweating indicates heat gathering in the Stomach. Defecation difficulty and delirium follow. The Classic states: continuous sweating from hands and feet implies hard stool. Give Da Cheng Qi Tang to purge Stomach excess heat.)

In Yangming disease, if there is delirium, tidal fever, and a slippery and rapid pulse, Xiao Cheng Qi Tang is the primary treatment. Administer one sheng of decoction. If gas passes in the abdomen, administer another sheng. If no gas passes, do not give more. If the next day there is still no bowel movement and the pulse becomes faint and choppy, this indicates interior deficiency, which is very difficult to treat; do not give Cheng Qi Tang again. (Cheng Wuji notes: Yangming delirium and tidal fever with a deep and solid pulse indicate interior excess, allowing purgation. A slippery and rapid pulse indicates interior heat not yet solid, so purgation is premature. First give Xiao Cheng Qi Tang to harmonize. Gas passage indicates dry feces, allowing another dose. No gas passage means no dry feces, so do not give more. By the next day, when pathogens transmit, a deep, solid, tight, or firm pulse indicates interior excess. A faint and choppy pulse indicates severe interior deficiency. If pulse is faint/choppy after diarrhea, it is just interior deficiency and still treatable. Here, no bowel movement yet, but pulse is faint/choppy, indicating internal decline of healthy Qi overcome by pathogens, hence difficult to treat.)

Da Cheng Qi Tang Formula (Zhang Yuansu states: Hou Po removes distension, Zhi Shi relieves fullness, Mang Xiao softens hardness, Da Huang purges excess. It can only be used when all four syndromes of distension, fullness, dryness, and excess are present.)
Da Huang (4 liang, washed with wine) Hou Po (roasted, coarse bark removed, 8 liang) Zhi Shi (5 pieces, roasted) Mang Xiao (7.5 qian)
These four ingredients are boiled in 1 dou of water. First boil Hou Po and Zhi Shi to obtain 5 sheng, remove dregs, add Da Huang, boil to obtain 2 sheng, remove dregs, add Mang Xiao, boil briefly over fire for 1-2 boils. Divide into two warm doses. If bowel movement occurs, stop taking the remainder.

Cheng Wuji notes: "Cheng" means to obey or smooth. When Sha Jing pathogens enter the Stomach, it is called entering the Fu organs. "Fu" means gathering. The Stomach is the sea of water and grain, the source of Ying and Wei. Water and grain gather in the Stomach and transform into Ying and Wei. Pathogens entering the Stomach cause Stomach Qi stagnation, fecal retention, blockage, and excess, preventing healthy Qi from flowing smoothly. Materia Medica states: "Unblocking removes stagnation, purging removes closure." Using decoctions to cleanse prevents blockage, allowing the blocked to open and the obstructed to flow, enabling healthy Qi to smooth out, hence "Cheng Qi." Wang Bing states: Purging requires bitter flavors; tonifying requires sour flavors. Softening hardness and breaking knots relies mainly on bitter-cold, so Zhi Shi is the sovereign herb. The Inner Canon states: "For dryness invading internally, treat with bitter-warm to relieve fullness and remove dryness." Bitter-warm serves as the minister, so Hou Po is the minister. The Inner Canon states: "For heat invading internally, treat with salty-cold." Injury by cold leads to heat disease; heat gathering in the Stomach is called excess. Salty-cold substances eliminate excess heat, so Mang Xiao is the assistant. The Inner Canon states: "For excess dryness, purge with bitter." Internal heat victory consumes fluids, causing intestinal dryness. Bitter-cold substances cleanse dryness and heat, so Da Huang is the envoy. Hence Da Huang is called the General. Cheng Qi Tangs are purgatives; their use requires extreme caution. They are for major fullness and excess with dry feces. If not major fullness, cold syndromes, chest trapping, or palpitations may arise.

Xiao Cheng Qi Tang Formula (Zhang Yuansu states: Da Huang purges excess, Hou Po removes distension. Suitable when distension and excess are present.)
Da Huang (4 liang) Hou Po (roasted, coarse bark removed, 2 liang) Zhi Shi (3 large pieces, roasted)
These three ingredients are boiled in 4 sheng of water to obtain 1.2 sheng, remove dregs, divide into two warm doses. After the first dose, if defecation occurs, stop; if not, drink the rest. If defecation occurs, do not take again. (Major heat and solid excess use Da Cheng Qi Tang; minor heat and slight binding use Xiao Cheng Qi Tang. Heat is not severe, so Mang Xiao is omitted from Da Cheng Qi Tang; binding is not hard, so Hou Po and Zhi Shi are not reduced.)

Wu Kun asks: Why does Zhongjing have names like Major, Minor, and Harmonizing Stomach for Cheng Qi Tang? When Sha Jing pathogenic heat transmits inward, it is called entering the Fu organ. Fu means gathering. Pathogenic heat and fecal matter accumulate to form excess. Excess manifests as tidal fever, delirium, and palm sweating, caused by dry feces. For robust patients with major heat and excess, Da Cheng Qi Tang is used for purgation. For minor heat and excess, Xiao Cheng Qi Tang is used. For heat binding without significant fullness, Hou Po and Zhi Shi are removed, and Gan Cao is added to make it mild, hence "Harmonizing Stomach Cheng Qi." If a major disease is treated with Xiao Cheng Qi Tang, pathogens remain unconquered; if a minor disease is treated with Da Cheng Qi Tang, healthy Qi is overly damaged. If insufficient, it can be repeated; if excessive, it cannot be rescued. Must one not be cautious? Zhongjing said: Before using Da Cheng Qi Tang, first give Xiao Cheng Qi Tang. If gas passes, there are dry feces, and Da Cheng Qi Tang can be used. If no gas passes, absolutely do not purge. Purging causes abdominal fullness, inability to eat, and difficulty. Also: If Cheng Qi Tang produces diarrhea, do not take again. This is earnest warning. Any purgative method requires precise calculation and appropriateness for immediate effect. Reckless purgation without calculation will kill.

After Sha Jing vomiting or purgation, if the disease persists, no bowel movement for five or six days up to ten-plus days, tidal fever at Ribu time, no aversion to cold, talking alone as if seeing ghosts. If severe, episodes of not recognizing people, grasping at clothes and bedrails, fright, restlessness, slight wheezing, and staring straight ahead. If the pulse is string-like, survival; if choppy, death. If merely fever and delirium, Da Cheng Qi Tang is the main treatment. One dose, if bowel movement occurs, stop subsequent doses. (See detailed entry on grasping at clothes/bedrails.)

In Yangming disease, if there is tidal fever, loose stool, free urination, and persistent fullness in the chest and hypochondrium, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the main treatment. (Yangming disease refers to Stomach excess. Mentioning Yangming with loose stool refers to the Yangming exterior syndrome: body heat, sweating, no aversion to cold, but aversion to heat.)

In Yangming wind-strike, if the pulse is string-like, floating, and large, with shortness of breath, abdominal fullness, pain in the hypochondrium and heart region, dry nose, inability to sweat, lethargy, jaundice, difficult urination, frequent hiccups, and tidal fever, Xiao Chai Hu Tang plus Fu Ling is the main treatment.

If Sha Jing remains unresolved after thirteen days, with chest/hypochondriac fullness and vomiting, tidal fever at Ribu time, followed by slight diarrhea: this was originally a Chai Hu syndrome. Purgation should not have caused diarrhea. Now that diarrhea occurred, we know the physician used pill-based purgatives, which was incorrect. 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 Sodium Sulfate).

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 0.8 cup remains, remove dregs, add Mang Xiao, boil briefly, and take warm.

In Yangming disease, if the pulse is floating and tight, there must be tidal fever occurring at specific times. If the pulse is only floating, there must be night sweats (Dao Han). (Cheng Wuji notes: Floating pulse indicates exterior; tight indicates interior excess. Floating and tight indicates exterior heat and interior excess, causing tidal fever at specific times. If only floating and not tight, it is merely exterior heat, causing night sweats. Night sweats mean sweating during sleep. Yangming interior heat causes spontaneous sweating; exterior heat causes night sweats.)

*Huojren Shu* (Book of Vitality): In winter, Yangming tidal fever with a floating and tight pulse occurs at specific times. If the pulse is only floating, there must be night sweats. Huang Qin Tang (Scutellaria Decoction) is the main treatment. (Formula see entry on Diarrhea.)