（恶寒发热常相兼，观彼两门自见。此篇乃以寒热往来，及内外上下寒热者言之。）
往来寒热，有期者疟也，无期者诸病也。有伤寒邪在少阳，及妇人病伤寒，热
入血室，而往来寒热者，（详《伤寒·少阳篇》。）有衰弱人，阴阳之气并虚，相为胜复而往来，
（详《伤寒·平脉篇》病有洒淅恶寒条中。）病后产后多有之。（产后黄 丸。）有郁抑而致者，如寡妇、
尼姑，独阴无阳，欲火炽于中，则内热不得遂，而气郁于里，不外达则表寒，久之
郁热得伸，则表热是也。（抑阴地黄丸。）有宿食结滞者，轻则消导，重则下之。有结热在
里者，大柴胡汤。（见疟。又气郁则痰停，而寒热作，理详疟门。）
外热内寒。仲景云∶身大热，反欲得衣者，热在皮肤，寒在骨髓也。《活人》云∶
先与桂枝汤（见伤湿）治寒，次与小柴胡汤治热。按二方谬甚，此证大抵阴盛格阳，用二
方殆矣。
外寒内热。仲景云∶身大寒，反不欲衣者，寒在皮肤，热在骨髓也。《活人》云∶
先与白虎加人参汤（见发热）治热，次与桂枝麻黄各半汤治寒。按热入三阴，其表必冷，
以阳陷于内，不达于表也。但去里热，则阳气复还于表，而外寒自解。其可印定此
二方乎？
上寒下热。（腰上寒，腰下热。）《灵枢》云∶先刺项太阳，（大杼、天柱等穴。）久留之，（久留以
补其阳。）已刺（谓已入针）则熨项与肩胛，（兼用熨法以温之。）令热下合乃止，（上热与下热相合，不复上寒下
热也。止，谓出针。）所谓推而上之者也。嵩 《尊生书》用炒栀二钱半，瞿麦五分，（二物沉
降，引上寒入下焦，则下焦之热得和。）炙草三分，葱白三根，姜三片，（姜、葱发散，推下热上行，以
解上焦之寒。）煎服。叔和谓此为阳附阴，言阳火下乘于阴部也。
上热下寒。叔和谓此为阴附阳，言阴火上乘于阳位也《经》云∶视其虚脉而陷
之于经络者取之，气下乃止，所谓引而下之者也。（上热下寒，则在下之脉必虚，虚必陷下，须
察视之。虚者不可见，而陷者可见。故视其陷下之在于经，或在于络，则取而补之，俟阳气下行乃止针。）东垣云∶
上热下寒，《经》云阴病在阳，（阳，上焦也。言阴火上乘于阳分。）当从阳引阴，（言当从上焦引去其热。）
必须先去络脉经隧之血。（指阳经脉络言，须刺出血，以去其热。）若阴中火旺，上腾于天（天，谓上
焦，）致六阳（上焦阳气）反不衰而上充者，（即《经》所谓阴病在阳也。）先去五脏之血络（阴络也），引而下行，
（引火归下）。天气降下，则下寒之病自去矣。慎勿独泻其六阳，只去阴火，只损血络经
隧之邪，勿误也。又云∶圣人以上热下寒，是有春夏无秋冬也。（有升无降。）当从天
外（犹云天上，指上焦言）引阳降入地中，此乃天上群阴火炽，（犹言阴火上乘。）反助六阳不能衰退。
先于六阳中决血络出血，使气下降。故《经》云∶视其虚脉下陷于经络者取之，所
谓引而下之也。病大者，三棱针决血，去阳中之热，使得行秋令，奉收道，下降入
地中也。（按《经》言视脉虚陷取之，谓取其穴而补之也。东垣误以为泻，故有此论。又疑独泻六阳为非，故又言
须去五脏之血络。总由不明《经》语耳。）杨参政年 七十，病面郁赤若饮酒，痰稠粘，眩运，
两寸脉洪大，尺脉弦细无力，上热下寒明矣。欲药之，为高年气弱不任。记先师所
论，凡上热犹鸟巢高巅，射而取之。即以三棱针于巅前发际刺二十余，出紫血约二
合许，实时头目清利，诸苦皆去，后不复作。又治姚公六十有七，头面赤肿而痛，
耳前后肿尤甚，胸中烦闷，嗌咽不利，身半已下寒，足胫尤甚，脉浮数，按之弦细，
刺肿处五十余痛止。又灸气海百壮，助下焦阳气，退其阴寒；次灸三里各七壮，以
引阳气下行；足 寒退，遂制既济解毒汤，以黄芩、黄连酒制泻上热，桔梗、甘草
佐诸苦药治其热，升、柴以散之，连翘散结消肿，酒煨大黄引苦药上行，止烦热，
全愈。按此症有实热者，如上二案治法可也。若虚热，则是戴阳症也，不用热剂温
肾以引火归原，而反用寒凉，殆矣，审之。
（恶寒与发热通常同时出现，观察“恶寒”和“发热”两个章节即可明白。本篇主要讨论寒热往来，以及体内上下部位寒热错杂的情况。）
寒热往来有固定时间规律的是疟疾，没有固定时间规律的是其他疾病。有的因伤寒邪气停留在少阳经，或妇女患伤寒后热邪陷入血室，而出现寒热往来。（详见《伤寒论·少阳病篇》。）有的因身体衰弱，阴阳之气都虚弱，相互胜负交替而导致寒热往来。（详见《伤寒论·平脉篇》中关于“洒淅恶寒”的条文。）这类情况在病后、产后多见。（可用产后黄丸治疗。）有的因气机郁滞所致，如寡妇、尼姑等独阴无阳之人，欲火在中炽盛，导致内热不能舒展，气机郁结于体内，不能外达体表则表现为表寒；久而久之，郁积的热邪得以伸展，则表现为表热。（可用抑阴地黄丸治疗。）有的因宿食停滞结聚，轻者用消导法，重者用攻下法。有的因热邪结聚在里，可用大柴胡汤。（参见疟疾章节。另外，气机郁滞会导致痰饮停聚，从而引发寒热，道理详述于疟疾章节。）
外热内寒。张仲景说：身体大热，反而想要穿衣，这是热在皮肤表面，寒在骨髓深处。《活人书》说：先用桂枝汤治疗寒，再用小柴胡汤治疗热。我认为这两个方子错误很大，此证大多是阴盛格阳（阴寒内盛，逼迫阳气浮越于外），使用这两个方子几乎必死无疑。
外寒内热。张仲景说：身体大寒，反而不想穿衣，这是寒在皮肤表面，热在骨髓深处。《活人书》说：先用白虎加人参汤治疗热，再用桂枝麻黄各半汤治疗寒。我认为热邪进入三阴经，其体表必然寒冷，这是因为阳气陷伏于体内，不能通达于体表。只要去除体内的热邪，阳气就会回复并通达于体表，体表的寒自然解除。怎么能拘泥于这两个方子呢？
上寒下热。（腰部以上寒冷，腰部以下发热。）《灵枢》说：先针刺项部的太阳经穴位（如大杼、天柱等穴），长时间留针（长时间留针是为了补益阳气）。进针后，熨烫项部和肩胛部（兼用熨法来温煦），让热气下行与下部相合才停止（上部之寒与下部之热相合，不再出现上寒下热的情况。停止，指出针）。这就是所谓的“推而上之”的方法。嵩《尊生书》用炒栀子二钱半，瞿麦五分（这两味药性质沉降，引导上部的寒气进入下焦，使下焦的热得到调和），炙甘草三分，葱白三根，生姜三片（姜、葱具有发散作用，推动下部的热气上行，以解除上焦的寒），煎服。王叔和称此为“阳附阴”，意思是阳火下乘侵犯阴部。
上热下寒。王叔和称此为“阴附阳”，意思是阴火上乘侵犯阳位。《内经》说：观察虚脉且陷入经络的部位进行取穴治疗，待气机下行后才停止，这就是所谓的“引而下之”。（上热下寒，则下部的脉象必然虚弱，虚弱必然陷下，必须仔细察视。虚弱的脉象看不见，但陷下的现象可见。所以观察陷下之处是在经脉还是络脉，就取而补之，等到阳气下行后才出针。）李东垣说：对于上热下寒，《内经》说“阴病在阳”（阳，指上焦。意思是阴火上乘侵犯阳分），应当“从阳引阴”（意思是从上焦引导去除其热），必须先去除络脉和经隧中的瘀血。（指阳经的脉络，需要刺出血，以去除热邪。）如果阴中火旺，向上腾跃至天（天，指上焦），导致六阳（上焦阳气）反而不衰反而上充（即《内经》所说的“阴病在阳”），先去除五脏的血络（阴络），引导其下行（引火归下）。天气下降，那么下寒的病自然去除。千万不要只泻六阳经，只去阴火，只损伤血络经隧的邪气，不要搞错了。又说：圣人说上热下寒，是有春夏而无秋冬（只有升发而无收敛降泄）。应当从天外（犹言天上，指上焦）引导阳气降入地中，这是因为天上群阴之火炽盛（犹言阴火上乘），反而助长六阳不能衰退。先在六阳经中刺破血络出血，使气机下降。所以《内经》说：观察虚脉下陷于经络的部位进行取穴，这就是所谓的“引而下之”。病情重的，用三棱针刺破血络，去除阳中之热，使其能够施行秋令，奉行收敛之道，下降入地中。（按：《内经》说的观察脉象虚陷取穴，是指取穴位进行补法。李东垣误以为是泻法，所以有此论述。又怀疑只泻六阳不对，所以说须去除五脏的血络。总归是不明白《内经》原意罢了。）杨参政七十岁，患病面部红赤如同饮酒状，痰稠粘，眩晕，两手寸脉洪大，尺脉弦细无力，这是明显的上热下寒。想用药治疗，但因他年高气弱，不耐受药物。记得先师所论，凡是上热犹如鸟巢在高处，需用箭射取。于是用三棱针在头顶前发际处刺二十多下，放出紫血约两合左右，立刻头目清爽，各种痛苦都消除，后来不再复发。又治疗姚公六十七岁，头面红肿疼痛，耳前后肿尤其严重，胸中烦闷，咽喉不利，身体半以下寒冷，小腿尤其严重，脉浮数，按之弦细，刺肿处五十多次痛止。又灸气海穴一百壮，以助下焦阳气，退去阴寒；接着灸足三里穴各七壮，以引导阳气下行；足寒消退，于是配制既济解毒汤，用黄芩、黄连酒制以泻上热，桔梗、甘草辅助诸苦药治疗其热，升麻、柴胡以疏散之，连翘散结消肿，酒煨大黄引导苦药上行，止烦热，完全痊愈。按：此症有实热的，如上两案的治疗方法是可以的。如果是虚热，那就是戴阳症，不用热剂温肾以引火归原，反而用寒凉药，几乎必死无疑，务必审慎。
(Chills and fever often occur together; observing the sections on "Chills" and "Fever" will make this clear. This chapter discusses alternating chills and fever, as well as cold-heat complex patterns involving the upper and lower parts of the body.)
Alternating chills and fever with a regular schedule is malaria (Nue, 疟疾); without a regular schedule, it belongs to various other diseases. Some cases arise from Cold Damage pathogenic factors lingering in the Shaoyang (Lesser Yang) meridian, or from women suffering from Cold Damage where heat enters the Blood Chamber (Xueshi, 血室), resulting in alternating chills and fever. (See *Shanghan Lun · Shaoyang Chapter*.) Some cases occur in debilitated individuals where both Yin and Qi are deficient, leading to alternating chills and fever due to mutual overcoming and recovery. (See *Shanghan Lun · Pingmai Chapter*, under the section on "shivering chills".) These are common after illness or postpartum. (Huang Wan for postpartum may be used.) Some result from Qi stagnation, such as in widows or nuns who possess only Yin without Yang; if desire-fire blazes within, internal heat cannot circulate freely, causing Qi to stagnate internally. Since it cannot reach the exterior, surface chills occur. Over time, when the stagnant heat is released, surface fever appears. (Yin Yin Dihuang Wan may be used.) Some result from retained food stagnation; mild cases require digestion-promoting methods, while severe cases require purgation. Some involve heat binding internally; Da Chaihu Tang (Major Bupleurum Decoction) may be used. (See Malaria section. Additionally, Qi stagnation leads to phlegm retention, causing chills and fever; the rationale is detailed in the Malaria section.)
Exterior Heat, Interior Cold. Zhang Zhongjing stated: "The body is very hot, yet the patient desires to wear clothes; this indicates heat at the skin level and cold in the bone marrow." *Ren Shu* (Book of Vitality) stated: "First administer Guizhi Tang (Cinnamon Twig Decoction) to treat the cold, then Xiao Chaihu Tang (Minor Bupleurum Decoction) to treat the heat." I consider these two prescriptions erroneous. This condition is generally caused by Excess Yin repelling Yang (Yin Cheng Ge Yang, 阴盛格阳); using these two prescriptions is likely fatal.
Exterior Cold, Interior Heat. Zhang Zhongjing stated: "The body is very cold, yet the patient does not desire to wear clothes; this indicates cold at the skin level and heat in the bone marrow." *Ren Shu* stated: "First administer Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) to treat the heat, then Guizhi Mahuang Ban Tang (Cinnamon Twig and Ephedra Half-Dose Decoction) to treat the cold." I believe that when heat enters the Three Yin meridians, the exterior must be cold because Yang Qi is trapped inside and cannot reach the exterior. If the interior heat is removed, Yang Qi will return to the exterior, and the exterior cold will resolve naturally. How can one rigidly adhere to these two prescriptions?
Upper Cold, Lower Heat. (Cold above the waist, heat below the waist.) *Ling Shu* stated: "First needle the Taiyang points in the neck (such as Dazhu BL11, Tianzhu BL10), retain the needles for a long time (long retention tonifies Yang). After needling, apply moxibustion or warming to the neck and shoulder blades (using warming methods to heat the area), allowing the heat to descend and merge until the condition resolves (upper cold and lower heat merge, ceasing the pattern of upper cold/lower heat. 'Stop' refers to removing the needles). This is called 'pushing upwards.'" Song's *Zunsheng Shu* uses fried Gardenia (Zhizi, 栀子) 2.5 qian, Dianthus superbus (Qumai, 瞿麦) 0.5 fen (these two herbs are heavy and sinking, guiding upper cold into the Lower Jiao, harmonizing the lower heat), roasted Licorice (Gancao, 甘草) 3 fen, green onion white (Congbai, 葱白) three stalks, ginger (Shengjiang, 生姜) three slices (Ginger and Green Onion are dispersing, pushing lower heat upward to resolve upper Jiao cold). Decoct and take orally. Wang Shuhe called this "Yang attaching to Yin," meaning Yang fire descends to invade the Yin regions.
Upper Heat, Lower Cold. Wang Shuhe called this "Yin attaching to Yang," meaning Yin fire ascends to invade the Yang regions. *Jing* (Classic) stated: "Observe the deficient pulse sinking into the collaterals and meridians, select points accordingly, and stop when the Qi descends. This is called 'drawing downwards.'" (In Upper Heat/Lower Cold, the pulse in the lower part is necessarily deficient; deficiency implies sinking. One must examine carefully. Deficient pulses are invisible, but sinking phenomena are visible. Thus, observe where the sinking occurs in the meridians or collaterals, select points to tonify, and stop needling once Yang Qi descends.) Li Dongyuan stated: For Upper Heat/Lower Cold, *Jing* says "Yin disease in Yang" (Yang refers to the Upper Jiao; meaning Yin fire ascends to invade the Yang division). One should "draw Yin from Yang" (meaning draw heat away from the Upper Jiao). It is necessary first to remove blood stasis from the collaterals and meridians. (Referring to Yang meridian networks; pricking to bleed removes heat.) If Fire within Yin is excessive and rises to Heaven (Heaven refers to the Upper Jiao), causing the Six Yang (Yang Qi of the Upper Jiao) to fail to decline and instead fill upwards (i.e., "Yin disease in Yang"), first remove blood from the Five Zang collaterals (Yin collaterals) and guide it downward (guiding fire back to its source). When Heavenly Qi descends, the Lower Cold pathology will naturally resolve. Do not merely purge the Six Yang meridians; do not just remove Yin fire; do not merely damage the pathogens in blood collaterals and meridians. Do not err. He also said: The Sages describe Upper Heat/Lower Cold as having Spring/Summer but no Autumn/Winter (only ascending, no descending). One should guide Yang from the Heavens (Upper Jiao) down into the Earth. This is because group Yin fires blaze in the heavens (Yin fire ascending), assisting the Six Yang so they cannot decline. First, prick blood collaterals in the Six Yang meridians to bleed, causing Qi to descend. Thus, *Jing* states: "Observe the deficient pulse sinking into the collaterals and meridians, select points accordingly," which is called "drawing downwards." In severe cases, use a three-edged needle to prick blood collaterals, removing heat from Yang, allowing the Autumn function to operate, following the Dao of gathering, and descending into the earth. (Note: *Jing*'s instruction to observe deficient/sinking pulses and select points refers to tonification. Li Dongyuan mistakenly interpreted this as purgation, hence this discussion. Suspecting that purging only the Six Yang is incorrect, he added removing Five Zang blood collaterals. Ultimately, this stems from a misunderstanding of the *Jing*.) Official Yang, aged seventy, suffered from a red, congested face resembling drunkenness, thick sticky phlegm, dizziness. Both Cun pulses were surging and large; Chi pulses were wiry, thin, and weak. This was clearly Upper Heat and Lower Cold. Medication was desired, but due to his advanced age and weak Qi, he could not tolerate it. Recalling my master's teaching: Upper heat is like a bird's nest high on a peak; one must shoot it down. Using a three-edged needle, I pricked over twenty times at the anterior hairline of the vertex, releasing about two he of dark purple blood. Immediately, the head and eyes became clear, all suffering ceased, and it did not recur. I also treated Elder Yao, aged sixty-seven, with red, swollen, painful head and face, especially around the ears. Chest oppression, throat discomfort, coldness below the half-body, particularly in the calves. Pulse was floating and rapid, wiry and thin upon pressure. Pricked the swollen areas fifty-plus times until pain stopped. Then moxa Qihai CV6 for one hundred moxa cones to assist Lower Jiao Yang Qi and dispel Yin cold; next moxa Zusanli ST36 seven cones each side to guide Yang Qi downward. As foot cold receded, I formulated Jiji Jiedu Tang (Ji Ji Detoxifying Decoction): Huangqin (Scutellariae Radix) and Huanglian (Coptidis Rhizoma) processed with wine to purge Upper Heat; Jiegeng (Platycodonis Radix) and Gancao (Glycyrrhizae Radix) assist the bitter herbs to treat heat; Shengma (Cimicifugae Rhizoma) and Chaihu (Bupleuri Radix) to disperse; Lianqiao (Forsythiae Fructus) to dissipate nodules and reduce swelling; wine-baked Dahuang (Rhei Radix et Rhizoma) to guide bitter herbs upward, stopping irritability and heat. Complete recovery. Note: For cases with Excess Heat, the treatment methods of the above two cases are applicable. If it is Deficiency Heat, it is Dai Yang Syndrome (Floating Yang); failing to use warm agents to tonify Kidney and guide fire back to its source, instead using cold/cool herbs, is likely fatal. Exercise caution.