Fever, Sweating and Constipation for Days? Doctor Xu Shuwei’s Da Chaihu Tang (Major Bupleurum Decoction) for an Urgent Yangming Purgation

Patient search terms: fever / sweating / constipation / no bowel movement for days / sore eyes / can’t sleep / stomach pain / tight chest and flanks

Medical terms for this condition: urgent yangming purgation pattern · combined shaoyang-yangming pattern · Da Chaihu Tang pattern · bleeding gastric ulcer · chronic cholecystitis

Opening: the rich young man’s illness puzzled everyone — a roomful of doctors, not one dared to act

Today we continue the stories of Doctor Xu Shuwei practicing the formulas of Zhang Zhongjing’s Shang Han Lun (Treatise on Cold Damage) — and this time the star of the show is Da Chaihu Tang (Major Bupleurum Decoction) again.

Doctor Xu Shuwei’s Ninety Cases on Cold Damage records ninety case studies, and two of them use Da Chaihu Tang. He had real insight into this formula, and he valued it enormously. Today we tell the first one: from the very opening, the patient’s condition made a whole roomful of physicians break out in a cold sweat.

💬 Note from Doctor Luo: Doctor Xu Shuwei (1079–1154) was a famous physician of the late Northern and early Southern Song dynasties, and one of the founders of the jingfang school — the school devoted to the classic formulas of the Shang Han Lun. Ninety Cases on Cold Damage is his most famous work: one case, one discussion. It is the earliest surviving case-record book in Chinese medical history. Zhang Zhongjing’s formulas, in his hands, were used quickly and precisely — reading his cases, the medicine always lands with a satisfying snap, with immediate results.

Who was the patient? The son of the local rich family, ill with cold damage for days, sweating as if drenched by a bucket of water

The patient was xiang li hao zi — the son of a very wealthy local family. He had contracted cold damage, and his symptoms came in a string:

• Shen re — body heat, fever all over
• Mu tong — eye pain (and here’s a question for you: which channel are the eyes linked to? The liver channel)
• Bi gan — a very dry nose
• Bu mian — sleeplessness
• Da bian bu tong — the most critical one: his bowels had not moved

The doctors came to take his pulse. They felt: mai cun chi ju da — both the cun and chi pulses were extraordinarily large. The illness had already lasted several days, and since last night he had also been han da chu — pouring out great sheets of sweat.

Constipation, body heat, and drenching sweats — with money in the family, a whole roomful of physicians had been summoned, and of course Doctor Xu Shuwei was among them.

The doctors were terrified: “Yangming spontaneous sweating — the fluids are exhausted! All we dare use is a honey suppository”

Doctor Xu Shuwei looked at the case and, true to his decisive nature, declared: “Yi Da Chaihu Tang xia zhi!” — give Da Chaihu Tang at once! The man’s bowels are blocked and there is urgent heat — purge it down immediately!

The result: zhong yi han ran — every doctor in the room was horrified:

“Yangming zi han, jin jin ye yi jie, dang yong mi dao!” — Yangming disease naturally sweats; his fluids are already exhausted. How can you purge? What we should use is Mi Jian Dao — the honey-guided suppository: Zhang Zhongjing’s method of making a suppository from honey, inserting it into the bowel to moisten and draw the stool out.

Doctor Xu Shuwei was a man of strong character. When he lectured on the Shang Han Lun, he often met colleagues whose learning was far too shallow — he could not even be bothered to argue with them. This time he said only one line:

“Ci Zhongjing bu chuan zhi miao!” — This is the wondrous teaching that Zhongjing never passed on!

Wait — is this the wonderful secret Zhongjing didn’t write down? No. Zhang Zhongjing did write it — it is all there in the book, spelled out — but he didn’t break it down and chew it over for you again and again. You read the book carelessly, so you never learned it.

💬 Note from Doctor Luo: Doctor Xu Shuwei did not mince words — “Zhu gong an neng zhi zhi?” — how could any of you know this, reading the Shang Han Lun the way you do? And having said that, he argued all the harder: Da Chaihu Tang it must be! The patient’s family listened and thought: ah, Doctor Xu Shuwei really is learned; everything he says sounds so well reasoned! So they did use Da Chaihu Tang — and what happened? Two doses and the illness was cured.

What was Doctor Xu Shuwei thinking? The most critical stroke of the whole case

The other doctors were afraid the sweating had damaged the body fluids and would only dare to moisten the bowel with honey. How did Doctor Xu Shuwei dare to purge directly? He wrote a special defense of his reasoning at the end of the case record and explained the logic fully.

The patient had actually been in yangming disease for many days already. At the start, the body heat and the large pulse showed the body in a fierce stage of resistance; but by this point, the body had begun turning toward insufficiency of upright qi — so this pattern was yangming just beginning to transform toward shaoyang: both yangming and shaoyang elements of a combined pattern were present, but yangming dominated.

Ordinary doctors, seeing the drenching sweat, feared fluid damage and dared not purge. Doctor Xu Shuwei’s view was exactly the opposite:

💬 Note from Doctor Luo: He said: even though the patient is sweating, the jin ye (body fluids) have not actually been badly damaged yet — purge now, quickly, and pull the heat out! Once the heat is discharged, the sweat will stop pouring out and no more fluids will be lost. This is what he meant by seizing the moment. If the moment passes, the heat builds hotter and hotter, the sweating grows more and more depleting, and the case turns truly dangerous.

There are many purging formulas — why did Doctor Xu Shuwei specifically choose Da Chaihu Tang? Because he could see this patient already had a shaoyang pattern:

• Bu mian (sleeplessness) and mu tong (eye pain) — linked to the liver channel, shaoyang territory
• Plus shen re (body heat), bi gan (dry nose), da bian bu tong (constipation) and mai cun chi ju da (large pulses in both cun and chi) — the foundation of yangming heat excess

A trace of shaoyang, obvious yangming heat — a combined shaoyang-yangming pattern — and one Da Chaihu Tang takes care of both sides. Two doses, complete recovery. Clean and decisive.

Treating externally contracted illness with classic formulas: Doctor Xu Shuwei’s signature skill

After this case, Doctor Luo made a remark: Doctor Xu Shuwei’s special gift was using jingfang (Zhang Zhongjing’s classic formulas) to treat externally contracted diseases — he had grasped the inner method of the Shang Han Lun, used it with remarkable results, and his patients recovered almost as soon as the medicine went down.

💬 Note from Doctor Luo: This is precisely why Doctor Xu Shuwei became a master of the classic formulas and one of the founders of the jingfang school. And as later generations gradually discovered, Zhang Zhongjing’s formulas do not only treat externally contracted illness — they also treat all kinds of internal and miscellaneous diseases, with an extraordinarily wide range of applications. How do you use them? The key is one point: grasp the main symptoms of the formula — find the tang zheng (decoction pattern). When the symptoms match, the direction appears. This is what is meant by “fang zheng dui ying” — pattern-formula correspondence.

Take Da Chaihu Tang as an example: it governs the combined shaoyang-yangming pattern — signs of the yangming pattern and signs of the shaoyang pattern together.

The shaoyang part: bitter taste in the mouth, dry throat, dizziness; “mo mo” — no desire for food or drink; alternating chills and fever; restlessness with a tendency to nausea and vomiting; insomnia with many dreams; a tight, stifling chest and flanks.

The yangming part: epigastric pain, refusing pressure over a hard, painful epigastrium, abdominal pain as well; constipation; a yellow tongue coating; because of the interior heat, sweat breaking out.

💬 Note from Doctor Luo: No matter the disease — externally contracted, internal injury, stomach trouble, heart or cerebrovascular disease — as long as these symptoms are present, you adjust for these symptoms and the illness can be cured. That is the principle of applying the classic formulas: if there is a shaoyang pattern plus interior heat binding, you can use Da Chaihu Tang to untie the knot in the body. That is the mystery of the classic formulas.

Modern case one: Doctor Liu Duzhou treated a bleeding gastric ulcer — one dose produced three black bowel movements

Doctor Luo then told three cases of modern physicians using Da Chaihu Tang for internal miscellaneous diseases — the best demonstration of how the classic formulas traveled from externally contracted illness into the treatment of miscellaneous disorders.

The first: Doctor Liu Duzhou, the great master of the classic formulas at Beijing University of Chinese Medicine (the old master has passed away, and many of the students he trained are now famous names in the field of cold-damage formulas).

The patient, a man surnamed Jia, 60 years old, had suffered a gastric ulcer for many years that never healed. Recently it flared up again after he lost his temper — and here is something especially important: when you see a patient, ask what the flare-up is related to. His was brought on by gan qi bu shu (constrained liver qi).

What did the flare-up look like? Wei wan tong ju — severe epigastric pain; ou tu suan ku — he vomited sour, bitter fluid (sourness belongs to the liver; this is the sign of liver qi invading the stomach); and the vomit was mixed with coffee-ground material — this is stomach bleeding! When bleeding starts it is fresh red, and only after a while does it turn the color of coffee. The pain was so bad he could not eat — stomach qi was rebelling upward, nothing would go down — and his bowels had not moved for five days. There was heat inside; the heat was forcing the blood to move wildly, which is why it bled.

💬 Note from Doctor Luo: Western doctors diagnosed a gastric ulcer with possible perforation and urged surgery. The son refused and brought the old man to Doctor Liu. Doctor Liu took the pulse: mai xian hua you li — wiry, slippery and forceful. Wiry is the liver pulse, tied to emotional upset; slippery suggests food stagnation, accumulated matter in the bowel; forceful means heat inside. Looking at the tongue, the coating was yellow and greasy — heat truly gathered within.

Doctor Liu’s diagnosis: combined shaoyang-yangming pattern — liver fire pent up in the stomach, scorching the stomach yin, hence the coffee-ground vomit; fire moving from the liver to scorch the stomach, hence the sour, bitter vomiting; fire binding and qi stagnating, the bowel qi blocked, hence the stool would not come down.

The prescription: Da Chaihu Tang — chai hu (bupleurum) 12 g, huang qin (scutellaria) 12 g, ban xia (pinellia) 9 g, da huang (rhubarb) 6 g, shao yao (white peony) 9 g, zhi shi (immature bitter orange) 6 g, sheng jiang (fresh ginger) 12 g, and 4 jujube dates (be sure to break them open).

One dose and the bowels moved freely three times, passing black material and mucus, in great quantity — you see, this is the stomach bleeding that had flowed into the bowel: the fresh red had turned black, and the accumulated matter was being pushed out. After it came out, the epigastric pain was largely released and the vomiting stopped. Since the man had gone many days without eating and was weary, Doctor Liu closed with medicines to nurture the stomach qi.

💬 Note from Doctor Luo: You see — this is not an externally contracted disease, but the two elements were both present: constrained liver qi (shaoyang) plus heat binding in the middle with blocked stool (yangming) — so Da Chaihu Tang was used. Pattern-formula correspondence: when the mechanism matches, the formula naturally matches too.

Modern case two: Doctor Yue Meizhong treated chronic cholecystitis — three added herbs to clear damp-heat

The second: Doctor Yue Meizhong, also a great master of Chinese medicine.

The patient, a woman surnamed Li, had chronic cholecystitis: spontaneous pain in the right hypochondrium (where the gallbladder lies), painful on pressure; frequent slight fever; nausea and loss of appetite; abdominal fullness; borborygmus and belching — the belly constantly rumbled with trapped gas pushing upward.

💬 Note from Doctor Luo: Nausea and vomiting are among the most typical signs of the shaoyang pattern — when a patient keeps feeling sick and retching, first consider whether a shaoyang pattern is at work, because shaoyang is tied to the liver and gallbladder channels, with qi moving rebelliously upward. And the abdominal fullness, slight fever, borborygmus and belching — that is interior heat trying to push outward, and it relates to yangming. A large, wiry pulse is also a sign of vigorous interior heat.

Doctor Yue prescribed Da Chaihu Tang: chai hu 12 g, shao yao (white peony) 9 g, zhi shi 6 g, da huang (rhubarb) 6 g, huang qin 9 g, ban xia 9 g, sheng jiang 15 g, 4 jujube dates — and then added three herbs:

• Jin qian cao (Christina loosestrife) 24 g: clears damp-heat, soothes the liver and benefits the gallbladder
• Hua shi (talc) 12 g: clears damp-heat
• Ji nei jin (chicken gizzard lining) 12 g: unblocks and aids digestion

After seven doses the appetite improved steadily; the borborygmus and belching greatly diminished. Four more doses of the same formula and the rib-flank pain cleared completely (rib pain is a shaoyang sign) — only a slight fever remained. Doctor Yue then switched to Xiao Chaihu Tang plus bie jia (turtle shell) and qing hao (sweet wormwood), adding to the minor bupleurum decoction’s outward-transmitting action some herbs that clear and vent lingering heat, drew that last bit of heat out — and closed the case.

💬 Note from Doctor Luo: You see — this is flexible modification on a classic-formula foundation. Da Chaihu Tang as the base, adding jin qian cao, hua shi and ji nei jin to clear damp-heat — it is still the classic-formula path.

Modern case three: Doctor Zhao Shouzhen treated massive hematemesis — he wrote the patient’s character before writing the formula

The third: Doctor Zhao Shouzhen, a master of the classic formulas. He had a habit in writing case records: he wrote the patient’s personality first.

The patient, Huang Xiangqun, was quick-tempered; though past fifty (“zhi ming” in classical usage — the age of knowing one’s fate) he still carried a young man’s bold spirit. In his youth he had suffered hematemesis, which had not recurred for thirty years. But in 1946, his circumstances turned harsh and his heart was constricted — his emotions were troubled, liver qi was stagnating, and no trace of joy could be seen on his face — and one morning he suddenly vomited a great amount of blood, mostly dark-purple clots, and through the rest of the day continued to spit up occasional specks of blood.

The man knew a bit of medicine himself. He burned some of his own hair to ash (xue yu tan, charred human hair) and took it with tong bian (the urine of a young boy) — both are hemostatic — and the bleeding did stop. But then came fullness and distension of the chest and flanks, a foul, fishy smell in the mouth, and afternoon tidal fever. For half a month the illness was left untreated and began to worsen, until a cousin in the clan treated him for several days without effect, and only then did they call in Doctor Zhao.

Doctor Zhao took the pulse: mai xian shu — wiry and rapid. Wiry, taut like a plucked zither string, tied to shaoyang and constrained liver qi; rapid, beating fast, meaning heat. The tongue coating was thick and yellow — heat binding within. Looking at the symptoms: fullness and stuffiness of the chest and flanks (a shaoyang sign), vomiting and retching (a shaoyang sign), bitter taste with no desire for food (a shaoyang sign), a bowel movement only once every several days, and afternoon tidal fever (heat consuming fluids, so the stool would not pass freely).

💬 Note from Doctor Luo: Chest and flank stuffiness, vomiting, bitter taste with no appetite — these shaoyang signs you should be able to recite from memory: bitter mouth, dry throat, no desire for food or drink, alternating chills and fever, restlessness and a tendency to vomit. Add interior heat and blocked stool, and it is again a combined shaoyang-yangming pattern. Doctor Zhao judged the root of this man’s illness to be disharmony of the liver and gallbladder, constrained liver qi, plus heat in the body.

The prescription: Da Chaihu Tang to open constraint and clear heat, plus hua rui shi (ophicalcite) — which stops bleeding and resolves stasis — and jiang xiang (Dalbergia heartwood) — which regulates qi.

Two doses brought no obvious change; on the third dose, blood passed with the stool several times, expelling stasis clumps — the stagnant blood was coming out! With it, the tidal fever receded, the chest and flanks relaxed, and the foul smell in the mouth disappeared. Doctor Zhao then moved to relieving constraint, harmonizing the liver and clearing the remaining heat with Dan Zhi Xiao Yao San (Moutan and Gardenia Free and Easy Powder) plus qian cao (madder root) and dan shen (salvia) — which cool and invigorate the blood — for five more doses, and the various symptoms gradually settled; finally, with medicines to nourish the blood and open the appetite, the man slowly recovered.

💬 Note from Doctor Luo: This Mr. Huang vomited blood in his youth and went thirty years without a relapse — because there was heat in his body, pent-up heat inside, and the moment an emotional wave struck, it burst out. Doctor Zhao first used Da Chaihu Tang to drain the pent-up heat open, then Dan Zhi Xiao Yao San to regulate the liver, and finally nourished the blood and opened the appetite as aftercare — layer by layer, perfectly clear.

Doctor Luo’s own study method: drawing out the indicators of all ninety cases, one by one

After telling these three cases, Doctor Luo shared something from the heart — this is how he himself studied Chinese medicine:

💬 Note from Doctor Luo: In the first year of my doctorate, I spent a whole year taking the case records of the classic formulas — these ancient physicians’ cases — and drawing out the diagnostic indicators one by one: why did he use the formula this way? That year of work was enormously important for my understanding of Chinese medicine. That book was read until it fell apart — the pages flew out one by one, no longer a book; every time before I read it, I had to tap the pages straight before I could turn them. But once that work was done, when I looked at Chinese medicine again, I could see far more clearly: what is the basis for using this treatment for this condition? Why does this formula follow this line of thinking? Diagnosis, classic formulas and treatment direction — all of it clicks together.

The classic formulas are not only for externally contracted disease, not only for cold damage — they guide the treatment of miscellaneous internal disorders and all kinds of conditions. Because inside every formula there is packed a line of thinking, and the treatment direction is extraordinarily clear. That is the greatness of Zhang Zhongjing.

💬 Note from Doctor Luo: And once you grasp the line of thinking, you don’t necessarily have to use the original formula exactly — you can do what Doctor Yue Meizhong did and add jin qian cao, hua shi and ji nei jin. Use its thinking, and the treatment effect is the same. That is the mystery of the classic formulas, and the most precious thing about them.

Based on Doctor Luo Dalun’s explanation of the case of Doctor Xu Shuwei, from Ninety Cases on Cold Damage (《伤寒九十论》).