潮热有作有止。若潮水之来。不失其时。一日一发。若日三五发者。即是发热。非潮热也。
有虚有实。惟伤寒日晡发热。乃胃实。别无虚证。其余有潮热者。当审其虚实。若大便坚涩。喜
冷畏热。心下 然。睡卧不着。此皆气盛。所谓实而潮热也。凉膈散、大柴胡辈下之。若胃气消
乏。精神憔悴。饮食减少。日渐 羸。病虽暂去。而五心常有余热。此属虚证。宜逍遥散、小柴
胡等加减。有每遇夜身发微热。病患不觉。早起动作无事。饮食如常。既无别证可疑。只是血虚
阴不济阳。朝用加味逍遥散。暮用六味丸。不应。用当归补血汤、加减八味丸。有潮热似疟。胸
膈痞塞。背心疼痛。气弱脉弦。服补药不效者。此属饮证。随气而潮。故热亦随饮而潮。于痰饮
门求之。气口脉滑。内有宿食。常暮发热。明日复止者。于伤饮食门求之。
经云。阳虚则外寒。奈何。曰。阳受气于上焦。以温皮肤分肉之间。今寒气在外。则上焦不通。
而寒气独留于外。故寒栗。恶寒者。虽当夏月。若遇风霜。欲得重绵。时觉凛凛战栗如丧神守。
此热伏于里。而反觉自冷。实非寒也。或曰。往往见有服热药而愈者。何也。曰。病热之人。其
气炎上。郁为痰饮。抑遏清道。阴气不升。病热尤甚。积痰得热。亦为暂退。热势助邪。其病益
深。或曰。寒势如此。谁敢以寒凉药与之。非杀而何。曰。古人遇战栗之证。有以大承气汤下燥
屎而愈者。恶寒战栗。明是热证。但有虚实之分耳。
有卫气虚衰。不能实表分肉而恶寒者。有上焦之邪隔绝营卫。不能升发出表而恶寒者。有酒
热内郁。不得泄而恶寒者。背恶寒是痰饮。仲景云。心下有留饮。其人背恶寒。冷如冰。指迷茯
苓丸。身前寒属胃。经云。胃足阳明之脉。气虚则身以前皆寒栗。掌中寒者腹中寒。鱼上白肉有
青血脉者。胃中有寒。理中丸。表虚恶贼风。上焦不通。阳气抑遏。而皮肤分肉无以温之。故寒
栗。升阳益胃汤。开发上焦。以升阳明。出外温之也。外感。内伤。伤食。湿痰。火郁。皆有恶寒。
非独阳虚也。若脉浮紧。头痛拘急。身疼微恶寒热起。是外感。审时令轻重发散之。脉缓弱。或
气口虚大。按之无力。兼见倦怠。手心热。是内伤元气证。补中益气汤加桂、附二三分。以行参、
之力。且益阳气也。脉弦滑。恶心头痛。饱闷溢酸。是内伤宿食。从伤食治。或脉来涩伏。腹
满烦热喘促者。是冷食结滞于内也。当与温消。枳实理中汤。审系肉食。加炮黑山楂一二钱。脉
滑或沉。周身疼痛而恶寒者。属湿痰。乃痰在上焦。遏绝阳气而然。肥人多此。宜二陈加二术、羌、
防。少佐桂枝。甚者先吐之。恶寒非寒。不战而栗。从火郁治。火郁汤。若郁遏阳气于脾土。令人
恶寒者。东垣升阳散火汤。内虚里急。恶寒少气。手足厥冷。少腹挛急。足胫疼酸。此阳不足也。
大建中汤。背恶寒。脉浮大而无力者。为气虚。脉弦紧。寒热兼作。乃疮肿之候。须问身中有无
肿处。大抵恶寒证。除阳虚外。属表证者多。乃表中阳气不得发越而然。须辛散之。恶寒家不可
过覆近火。寒热相搏。脉道沉伏。愈令病患寒不可遏。但去被撤火。兼以和营之药。自然不恶寒
矣。妇人恶寒。尤不可近火。寒气入腹。血室结聚。针药所不能治矣。
祝仲宁治一贵妇病恶寒。日夜以重裘覆其首。起跃入沸汤中不觉。医以为寒。祝持之曰。此
痰火上腾。所谓阳极似阴也。非大下之则火不杀。下经宿而撤裘。呼水饮之。旬日气平乃愈。
李士材治吴文邃眩晕三载。虽战栗恶寒而不喜饮热汤。五月向火。数外家拥居帷幔。屡服姜、
桂不效。脉浮之细小。沉之搏坚。是郁火内伏。不得宣越也。用金花汤加柴胡、甘草、生姜。乘
热饮之。移时而恶寒减。再剂而撤火炉。逾月而起。更以人参汤进六味丸。两月全安。
石顽曰。凡病但恶寒而不发热者。多属火郁之证。举世一以阳虚为治。误人多矣。如墅关谢
君宣之病。七月间寒热如疟。因服芩、知、石膏辈。稍间数日。后因小便。精大泄。遂脑痛如破。
恶寒振振欲擗地。医用八味、六君。三倍参、附而寒不除。继用大建中。每服人参五钱。熟附二
钱。其寒益甚。春旺人日。始延治于余。诊之脉仅三至。弦小而两寸俱伏。但举指忽觉流利。审
其证。虽五袭重裘。大畏隙风如箭而不喜近火。恶寒虽剧而忽重忽轻。口鼻气息全冷而胸中时觉
上冲。小腹坚满而块垒如石。大便坚硬而欲了不了。小便短数而时白时黄。阳道虽痿而缓纵不收。
气色虽憔悴而不晦暗。此证起先本属阳虚。因加用参、附阳药过多。壮火不能化阴。遂郁伏土中。
反致真阴耗竭。是以二便艰涩。所谓阴虚自致泉竭也。法当升发其阳。先与火郁汤六服。继进升
阳散火、补中益气。而恶寒微除。重裘渐解。肢体微汗。口鼻气温。脉复五至。二便调适。小便
微和。阳亦渐举。嗣后令服六味丸、生脉散。异功散。调理而康。
背恶寒 背为阳位。背上恶寒。阳受病而阴邪亢逆也。其病有七。一者暴中阴寒。四肢厥冷
而背恶寒。脉必沉细。附子汤温散之。一者素禀阳衰而背上常微畏寒。脉来微弱。八味丸温补之。
一者热邪内伏。烦渴引饮而背恶寒。脉多沉滑。或伏匿。此火郁于内也。热病初发多此。白虎汤
解散之。一者中暑 热。亦多有背恶寒。人参白虎、清暑益气。按证清解之。一者湿痰内郁。肢
体疼重而痞闷头汗。其人必肥盛。其脉或缓滑。或涩滞。滑则指迷茯苓加胆星。涩则苓桂术甘加
半夏、广皮分解之。一者瘀血内滞而头汗目黄。小便清利。大便溏黑。小腹偏左或左胁中脘有疼
处。脉必关尺弦紧。或带芤状。桃核承气、犀角地黄。随上下虚实清理之。一者无故脉数。而背
恶寒疼重寒热者。为发痈疽之兆。膏粱多此。不可疑似而迟延难疗也。
Tidal fever (Chao Re) occurs at regular intervals and has pauses. Like the tide, it arrives without missing its time. If it occurs once a day, but three to five times a day, it is termed fever (Fa Re), not tidal fever.
Tidal fever can be of deficiency or excess. Only in Shanghan (Cold Damage) disease, fever occurring at the Wu hour (1:00 PM - 3:00 PM or 3:00 PM - 5:00 PM depending on context, here referring to late afternoon) belongs to Stomach Excess (Wei Shi), with no deficiency cases. For other tidal fevers, one must examine for deficiency or excess. If there is dry and hard stool, preference for cold drinks, aversion to heat, epigastric fullness and discomfort, and restless sleep, these all indicate Qi excess, known as "Excess Tidal Fever." It should be treated with purgatives such as Liang Ge San (Cooling the Chest Powder) or Da Chai Hu Tang (Major Bupleurum Decoction). If Stomach Qi is depleted, spirit is haggard, appetite is reduced, and the body becomes emaciated day by day, although symptoms may temporarily subside, there is often residual heat in the Five Centers (palms, soles, and chest). This belongs to deficiency syndromes. It is suitable to use Xiao Yao San (Free and Easy Wanderer Powder) or Xiao Chai Hu Tang (Minor Bupleurum Decoction) with modifications.
If there is slight fever every night, which the patient does not feel uncomfortable about, rises early and acts normally, eats well, and has no other suspicious symptoms, it is due to Blood deficiency where Yin cannot assist Yang. In the morning, administer Jia Wei Xiao Yao San (Modified Free and Easy Wanderer Powder); in the evening, Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia). If ineffective, use Dang Gui Bu Xue Tang (Angelica Sinensis Decoction for Tonifying Qi and Generating Blood) or Jia Jian Ba Wei Wan (Modified Eight-Ingredient Pill).
If tidal fever resembles malaria, with chest and diaphragm stuffiness, back pain, weak Qi, and wiry pulse, and tonics are ineffective, this belongs to Fluid Retention (Yin Zheng). Heat follows the movement of Qi, so heat also fluctuates with the fluids. Seek treatment in the Phlegm-Fluids chapter.
If the Qi Kou pulse (radial artery at the cun position) is slippery, indicating retained food inside, with frequent evening fever that stops the next morning, seek treatment in the Food Retention chapter.
The Classic states: "Yang deficiency leads to external cold." Why? The answer is: Yang Qi receives energy from the Upper Jiao to warm the skin and muscle layers. Now, cold pathogen is outside, causing Upper Jiao blockage, leaving cold pathogen alone outside, thus causing shivering. Patients with aversion to cold (E Han), even in summer, if encountering wind or frost, desire heavy cotton quilts, and frequently feel chilling tremors as if losing spiritual control. This is because heat is trapped inside, yet they feel cold internally; it is not truly cold.
One might ask: Often, patients recover after taking hot medicines. Why? The answer is: In heat diseases, Qi flares upward, stagnating into phlegm-fluids, suppressing the clear pathways, preventing Yin Qi from ascending, making the heat condition worse. Accumulated phlegm, aided by heat, may temporarily recede, but heat boosts the pathogen, deepening the illness.
Another question: With such severe cold signs, who dares to give cold-cooling medicines? Isn't that killing them? The answer is: Ancient doctors encountered shivering conditions and cured them using Da Cheng Qi Tang (Major Order the Qi Decoction) to purge dry feces. Aversion to cold and shivering clearly indicates a heat syndrome, merely differing in deficiency or excess.
Some have aversion to cold due to Wei Qi (Defensive Qi) deficiency and failure to secure the exterior muscles. Some have aversion to cold due to pathogens in the Upper Jiao isolating Ying and Wei Qi, preventing their ascent and emergence to the exterior. Some have aversion to cold due to internal depression of wine-heat, unable to vent.
Back aversion to cold belongs to phlegm-fluids. Zhang Zhongjing said: "There is retained fluid in the heart region; the person experiences back aversion to cold, cold as ice." Use Zhi Mi Fu Ling Wan (Pinellia and Poria Pill). Anterior body aversion to cold belongs to the Stomach. The Classic says: "The Foot-Yangming Stomach Meridian, when Qi is deficient, causes cold shivering in the anterior body." Cold palms indicate abdominal cold. Green blood vessels on the white flesh of the fish-mound indicate cold in the Stomach; use Li Zhong Wan (Regulate the Middle Pill). Exterior deficiency makes one susceptible to thieving winds; Upper Jiao blockage suppresses Yang Qi, failing to warm skin and muscles, causing shivering. Use Sheng Yang Yi Wei Tang (Raise Yang and Benefit Stomach Decoction) to open the Upper Jiao, raise Yangming Qi, and warm the exterior.
External contraction, internal injury, food retention, damp-phlegm, and fire depression all cause aversion to cold, not solely Yang deficiency. If the pulse is floating and tight, with headache, stiffness, body ache, and mild aversion to cold/fever, it is an external contraction. Assess the season's severity and disperse accordingly. If the pulse is slow and weak, or Qi Kou is empty and large, pressing powerless, accompanied by fatigue and hot palms, it is an internal injury to Yuan Qi (Original Qi). Use Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) with 2-3 qian of Gui Zhi (Cinnamon Twig) and Fu Zi (Aconite Root) to facilitate the action of Ren Shen (Ginseng) and Huang Qi (Astragalus), thereby benefiting Yang Qi. If the pulse is wiry and slippery, with nausea, headache, fullness, and acid regurgitation, it is internal injury from retained food. Treat according to food retention. If the pulse is choppy and hidden, with abdominal fullness, irritability, heat, and panting, it is cold food stagnation inside. Use Wen Xiao (Warming and Dissolving) methods, specifically Zhi Shi Li Zhong Tang (Immature Bitter Orange and Regulate the Middle Decoction). If meat retention, add 1-2 qian of charred Shan Zha (Hawthorn Fruit). If the pulse is slippery or deep, with whole-body pain and aversion to cold, it belongs to damp-phlegm. Phlegm in the Upper Jiao obstructs Yang Qi. This is common in obese people. Use Er Chen Tang (Two-Aged Decoction) plus Bai Zhu (Atractylodes Macrocephala Rhizome), Cang Zhu (Atractylodes Lancea Rhizome), Qiang Huo (Notopterygium Rhizome), Fang Feng (Saposhnikovia Root), with a little Gui Zhi. Severe cases require vomiting first. Aversion to cold is not true cold; shivering without trembling indicates fire depression. Treat fire depression with Huo Yu Tang (Depressed Fire Decoction). If Yang Qi is depressed in Spleen Earth causing aversion to cold, use Dong Yuan's Sheng Yang San Huo Tang (Raise Yang and Scatter Fire Decoction).
Internal deficiency with interior urgency, aversion to cold, shortness of Qi, cold limbs, lower abdominal cramping, and sore legs indicate Yang insufficiency. Use Da Jian Zhong Tang (Great Construct the Middle Decoction). Back aversion to cold with a floating, large, and powerless pulse indicates Qi deficiency. Wiry and tight pulse with alternating chills and fever indicates carbuncles/sores. Ask if there are swellings on the body. Generally, except for Yang deficiency, most aversion to cold belongs to exterior syndromes, where exterior Yang Qi cannot diffuse. It requires acrid dispersal. Patients with aversion to cold should not over-cover themselves or stay near fire, as cold and heat contend, sinking the pulse, worsening the chill. Remove blankets/fire and use harmonizing Ying-blood medicines; aversion to cold will naturally cease. Women with aversion to cold must not stay near fire; otherwise, cold enters the abdomen, coagulating the Blood Chamber (Xue Shi), becoming untreatable by needles or drugs.
Zhu Zhongning treated a noblewoman with aversion to cold. She covered her head with thick fur day and night and jumped into boiling water without feeling heat. Doctors thought it was cold. Zhu insisted: "This is phlegm-fire surging upward, known as 'Extreme Yang resembling Yin.' Without major purging, the fire will not die." After one night of purging, she removed the fur and drank water. Her breath stabilized after ten days, and she recovered.
Li Shicai treated Wu Wenzhui for dizziness for three years. Although he shivered and had aversion to cold, he did not like hot drinks. In May, he sought warmth by fire, surrounded by family members under curtains. Ginger and Cinnamon were ineffective. Floating pulse was fine and small; deep pulse was firm and strong. This was depressed fire trapped inside, unable to diffuse. He used Jin Hua Tang (Golden Flower Decoction) plus Chai Hu (Bupleurum Root), Gan Cao (Licorice Root), and Sheng Jiang (Fresh Ginger), taken hot. After a while, aversion to cold decreased. After two doses, the stove was removed. He rose after a month. Later, Ginseng decoction was used to deliver Liu Wei Di Huang Wan. He fully recovered in two months.
Shi Wan said: Any disease with only aversion to cold and no fever mostly belongs to fire depression. The world generally treats it as Yang deficiency, harming many people. For example, Mr. Xie Xuanzhi from Shuguan had chills and fever like malaria in July. After taking Huang Qin (Scutellaria Root), Zhi Mu (Anemarrhena Rhizome), and Shi Gao (Gypsum), he improved slightly for a few days. Then, after urination, he lost significant essence. His head hurt as if broken, and he shivered violently, wanting to fall to the ground. Doctors used Ba Wei Wan (Eight-Ingredient Pill) and Liu Jun Zi Tang (Six-Gentleman Decoction) with tripled Ren Shen and Fu Zi, but the cold remained. Then Da Jian Zhong Tang was used, with 5 qian Ren Shen and 2 qian Shu Fu Zi (Prepared Aconite Root) per dose, making the cold worse. On the Spring Day of Prosperous Humans, I was consulted. The pulse was only three beats per respiration, wiry and small, with both Cun positions hidden. However, lifting the finger felt smooth. Examining the symptoms: wearing five layers of thick fur, fearing drafts like arrows, yet disliking fire. Severe but fluctuating aversion to cold, cold breath from mouth/nose but sensation of Qi rushing up in the chest, hard and full lower abdomen like stone, hard stool difficult to pass, scanty urine varying from white to yellow, impotence with flaccidity, haggard but not dark complexion. Initially, it was Yang deficiency. But excessive use of Yang-tonifying drugs (Ren Shen, Fu Zi) prevented Zhuang Huo (Vigorous Fire) from transforming Yin, trapping it in the Earth element, depleting True Yin. Thus, difficulty in urination/defecation, known as "Yin deficiency leading to dried springs." The method should be to raise and diffuse Yang. First, six doses of Huo Yu Tang. Then, Sheng Yang San Huo Tang and Bu Zhong Yi Qi Tang. Aversion to cold slightly subsided, fur coats gradually removed, slight sweating on limbs, warm breath, pulse returned to five beats, bowel/bladder regulated, urine clearer, Yang gradually rose. Afterwards, Liu Wei Di Huang Wan, Sheng Mai San (Generate the Pulse Powder), and Yi Gong San (Benefit the Work Powder) were used for regulation and recovery.
Back Aversion to Cold: The back is the Yang position. Back aversion to cold indicates Yang pathology with Yin pathogen hyperactivity. There are seven types:
1. Sudden attack of Yin-cold, cold limbs, back aversion to cold, pulse deep and fine. Use Fu Zi Tang (Aconite Decoction) to warm and disperse.
2. Constitutionally Yang-deficient, constant slight fear of cold on the back, pulse weak and faint. Use Ba Wei Wan (Eight-Ingredient Pill) to warm and tonify.
3. Heat pathogen trapped inside, irritability, thirst, drinking water, back aversion to cold, pulse deep and slippery or hidden. This is fire depression inside. Common in early heat diseases. Use Bai Hu Tang (White Tiger Decoction) to resolve.
4. Summerheat-heat, often with back aversion to cold. Use Ren Shen Bai Hu Tang (Ginseng White Tiger Decoction) or Qing Shu Yi Qi Tang (Clear Summerheat and Benefit Qi Decoction) to clear and resolve according to symptoms.
5. Damp-phlegm depression inside, heavy painful limbs, chest stuffiness, head sweat, usually obese people. Pulse slow/slippery or choppy/stagnant. Slippery: Zhi Mi Fu Ling Wan plus Dan Xing (Apricot Seed/Bile-treated). Choppy: Ling Gui Zhu Gan Tang (Poria, Cinnamon, Atractylodes, and Licorice Decoction) plus Ban Xia (Pinellia Tuber) and Guang Pi (Tangerine Peel) to resolve.
6. Blood stasis inside, head sweat, yellow eyes, clear urine, loose black stool, pain in lower left abdomen or left hypochondrium/epigastrium. Pulse Guan and Chi wiry/tight or knotted. Use Tao He Cheng Qi Tang (Peach Kernel Order the Qi Decoction) or Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) to clear according to upper/lower deficiency/excess.
7. Unexplained rapid pulse with back aversion to cold, heaviness, chills/fever. This is a sign of developing abscess/carbuncle. Common among those eating rich foods. Do not hesitate or delay treatment.