成 往来寒热者寒已而热作热已而寒起盖寒为阴热为阳里为阴表为阳邪客于表与阳争则发寒矣邪入于里与阴争
则
发热矣表邪多则寒多而热少里邪多则热多而寒少邪在半表半里之间外与阳争而为寒内与阴争而为热表里之不拘内外之
无定由是寒热往来而无常也故以小柴胡立诸加减法以和解之又寒热如疟与夫往来寒热似是而非也如疟者止作有时正气
与邪争则作分则止矣往来寒热则止作无时或往或来日有三五发或者十数发此其与疟异也虽然往来寒热属半表半里当和
解之又有病至十余日热结在里复往来寒热亦宜大柴胡下而愈
赵 伤寒百问歌第五十九问中以阴阳相胜阳不足则先寒
后热阴不足则先热后寒此特论阴阳杂病二气自相乘胜然也非可以语伤寒
伤寒五六日中风往来寒热胸胁苦满默默不欲饮食心烦喜呕或胸中烦而不呕或渴或腹中痛或胁下痞硬或心下悸小便
不利或不渴身有微热或咳者与小柴胡汤主之（成 病有在表者有在里者有在表里之间者此邪气在表里之间谓之半表半里
证五六日邪气自表传里之时中风者或伤寒至五六日也玉函曰中风五六日伤寒往来寒热即是或中风或伤寒非是伤寒再中
风中风复伤寒也经曰伤寒中风有柴胡证但见一证便是不必悉具者正是谓或中风或伤寒也邪在表则寒邪在里腹热今邪在
半表半里之间未有定处是以寒热往来也邪在表则心腹不满邪在里则心腹胀满今止言胸膈苦满知邪气在表里之间少阳行
身之侧胸胁为少阳之部故经曰其脉循胁络于耳故胸胁痛而耳聋默默静也邪在表则呻吟不安邪在里则心烦闷乱内经曰阳
入之阴则静默默者邪方自表之里在表里之间也邪在表则能食邪在里则不能食不欲饮食者邪在表里之间未至于必不能饮
食者也邪在表则不烦不呕邪在里则烦满而呕心烦喜呕者邪在表方传里也邪初入里未有定处则所传不一故有或为之证有
柴胡证但见一证便是即是此或为之证）本太阳病不解转入少阳者胁下硬满干呕不能食往来寒热尚未吐下脉沉紧者与小柴
胡汤（成 太阳转入少阳是表邪入于里胁下硬满不能食往来寒热邪在半表半里之间若已经吐下脉沉紧者邪气入腑为里实
尚未经吐下脉沉紧为传里虽深未全入腑外犹未解与小柴胡汤以和解之）若已吐下发汗温针谵语柴胡汤证罢此为坏病知犯
何逆以法治之（成 少阳之邪在表里之间若妄吐下发汗温针损耗津液胃中干燥木邪干胃必发谵语若柴胡证不罢者则不为
逆柴胡证罢者坏病也详其因何治之逆以法救之 救坏病助荣卫生津液桂枝汤求之）伤寒五六日已发汗而复下之胸胁满微
结小便不利渴而不呕但头汗出往来寒热心烦者此为未解也柴胡桂枝干姜汤主之（难知曰若用柴胡而移时于早晚气移于血
血移于气是邪无所容之地故知其欲自解也 伤寒五六日已经汗下之后则邪当解今胸胁满微结小便不利渴而不呕但头汗
出往来寒热心烦者则邪气犹在半表半里之间为未解也胸胁满微结寒热心烦者邪在半表半里之间也小便不利而渴者汗下
后亡津液内燥也若热消津液令小便不利而渴者其人必呕今渴不呕知非里热也伤寒汗出则和今但头汗出余处无汗者津液
不足而阳虚于上也与柴胡桂枝干姜汤以解表里之邪复津液以助阳也）血弱气尽腠理开邪气因入与正气相搏结于胁下正邪
分争往来寒热休作有时默默不欲饮食脏腑相连其痛必下邪高痛下故使呕也小柴胡汤主之（按血弱气尽至结于胁下是释胸
胁苦满句正邪分争三句是释往来寒热句倒装法也默默不欲饮食兼上文满痛而言脏腑相连四句释心烦喜呕也）
小柴胡汤方
柴胡（半斤） 半夏（汤洗半升） 人参 甘草 黄芩 生姜（各三两） 大枣（十二枚擘）
上七味以水一斗二升煮取六升去滓再煎取三升温服一升日三服（成 内经曰热淫于内以苦发之柴胡黄芩之苦以发传
邪之热里不足者以甘缓之人参甘草之甘以缓中和之气邪半入里则里气逆辛以散之半夏以除呕邪在半表则荣卫争之辛甘
解之姜枣以和荣卫）
加减法（少阳邪在胸中用此加减法）若胸中烦而不呕去半夏人参加栝蒌实一枚（胸中烦而不呕热聚而气不逆也甘者
令人中满方热聚无用人参之补辛散逆气既不呕无用半夏之辛温热宜寒疗聚宜苦栝蒌苦寒泄胸中蕴热）若渴者去半夏加人
参合前成四两半栝蒌根四两（半夏燥津液非渴者所宜人参甘而润栝蒌根苦而凉彻热生津二物为当）若腹中痛者去黄芩加
芍药三两（去黄芩恶寒中加芍药以通壅 通壅功少止痛功大）若胁下痞硬去大枣加牡蛎四两（甘令人中满痞者去大枣之
甘咸以软之痞硬者加牡蛎之咸）若心下悸小便不利者去黄芩加茯苓四两（饮而水蓄不行为悸小便不利内经曰肾欲坚急食
苦以坚肾得苦则水益肾故去黄芩淡味渗泄为阳茯苓甘淡以泄伏水）若不渴外有微热者去人参加桂三两温覆取微汗愈（不
渴者里和也故去人参外有微热表未解也加桂以发汗）若咳者去人参大枣生姜加五味子半升干姜二两（咳者气逆也甘则壅
气故去人参大枣内经曰肺欲收急食酸以收之五味子之酸以收逆气肺寒则咳散以辛热故易生姜以干姜之热也）
伤寒邪气在表者必渍形以为汗邪气在里者必荡涤以取利其于不外不内半表半里是当和解则可也小柴胡和解表里之
剂内经曰热淫于内以苦发之邪在半表半里则半成热矣热气内传变不可测须迎而夺之必先散热是以苦寒为主故以柴胡为
君黄芩为臣以成彻热发表之剂邪气传里则里气不治故用人参甘草为主以扶正气而复之也邪初入里气必逆也是以辛散之
物为之助故用半夏为佐以顺逆气而散邪也里气平正则邪气不得深入是以三味佐柴胡以和里内经曰辛甘发散为阳表邪未
已迤逦内传既未作实宜当两解其在外者必以辛甘发散故用生姜大枣为使辅柴胡以和表也七物相合两解之剂当矣邪气自
表未敛为实乘虚而凑则所传不一故有增损以御之胸中烦而不呕烦者热也呕者气逆也烦而不呕则热聚而气不逆邪气欲渐
成实也人参甘补去之使不助热也半夏辛散去之以无逆气也除热必以寒泄热必以苦加栝蒌实以通胸中之郁热若渴者津液
不足半夏味辛性燥渗津液物也去之则津液易生人参味甘而润栝蒌根味苦而坚坚润相合津液生而渴自已邪气入里里气不
足则壅寒而腹中痛黄芩苦寒而寒中去之则气易和芍药酸泄而利中加之则里气得通而痛自已内经曰甘者令人中满大枣甘
温去之则硬满散咸以软坚牡蛎味酸咸寒加之则痞者消而硬者软若心下悸小便不利水蓄而不行也内经曰肾欲坚急食苦以
坚之坚肾则水益坚黄芩苦寒去之则蓄水浸内联经曰淡味渗泄为阳茯苓甘淡加之则津液通流若不渴外有微热不渴则津液
足去人参以人参为主内之物也外有微热则表证多加桂枝以取汗发散表邪也若咳者肺气逆也甘补中则气愈逆故去人参大
枣之甘肺欲收急食酸以收之气逆不收故加五味子之酸盖咳本于寒寒气内淫则散以干姜之辛热生姜干姜一物也生者温干
者热故以干易生也
吴 或问小柴胡汤近世治伤寒发热不分阴阳而用之何也然柴胡之苦平乃足少阳经伤寒发热之药半表半里之热除
往
来寒热小有日晡潮热也佐以黄芩之苦寒以退热半夏生姜之辛以退寒人参大枣之甘温以助正气解渴生津液则阴阳和而邪
气解矣但太阳经之表热阳明经之标热皆不能解也如用之岂曰无害若夫令阳寒面赤发热脉沉足冷者服之立至危殆可不慎
哉及内虚有寒大便不实脉息小弱与妇人新产发热皆不可用也
凡柴胡汤病证而下之若柴胡证不罢者复与柴胡汤必蒸蒸而振却发热汗出而解（成 邪在半表半里之间为柴胡证即未
作里实医便以药下之若柴胡证仍在者虽下之不为逆可复与柴胡汤以和解之得汤邪气还表者外作蒸蒸而热先经下里虚邪
气欲出内则振振然也正气胜阳气生却复发热汗出而解也）伤寒中风有柴胡证但见一证便是不必悉具（柴胡证是邪气在表
里之间也或胸中烦而不呕或渴或腹中痛或胁下痞硬或心下悸小便不利或不渴身有微热或咳但见一证便宜与柴胡汤随或
为证以法治之不必待其证候全具也）
伤寒十余日热结在里复往来寒热者与大柴胡汤但结胸无大热者此为水结在胸胁也但头微汗出大陷胸汤主之（详结
胸）
大柴胡汤方
柴胡（半斤） 半夏（半升洗） 黄芩 芍药（各三两） 生姜（切五两） 大枣（十二枚擘） 枳实（炙四枚）
上七味以水一斗二升煮取六升去滓再煎温服一升日三服一方有大黄二两若不加大黄恐不为大柴胡汤也
成 方有峻缓轻重医当临时斟酌如大满大实坚有燥屎者非驶剂则不能泄是以有大小承气汤之峻也如不至大坚满
惟
邪热甚而须攻下者又非承气汤之可投必也轻缓之剂乃大柴胡汤用以逐邪热也经曰伤寒发热七八日虽脉浮数可下之宜大
柴胡汤又曰太阳病过经十余日反二三下之后四五日柴胡证仍在者先与小柴胡呕不止心下急郁郁微烦者为未解可与大柴
胡下之则愈是知大柴胡为下剂之缓也伤寒主于可下则为热有余应火而归心苦先入心折热必以苦为主故以柴胡苦平微寒
为君黄芩苦寒为臣内经曰酸苦涌泄为阴泄实折热必以酸苦故以芍药枳实为佐辛者散也散逆气者必以辛甘者缓也缓正气
者必以甘故用半夏生姜之辛温大枣之甘温为之使也一方加大黄以大黄有将军之号而功专荡涤必应以大黄为使
许 有人病伤寒心烦喜呕往来寒热医以小柴胡与之不除予曰脉洪大而实热结在里小柴胡安能去之仲景云伤寒十
余
日热结在里复往来寒热者与大柴胡汤三服而病除盖大黄荡涤蕴热伤寒中要药王叔和云若不用大黄恐不名大柴胡须酒洗
生用有力
张 或问大柴胡若内烦里实者固宜用也其呕而下利者亦用之何也夫治病节目虚实二者而已里虚者虽便难而勿攻
里
实者虽吐利而可下经曰汗多则便难脉迟尚未可攻以迟为不足即里气未实故也此以大柴胡主之凡吐利心腹濡软为里虚呕
吐而下利心下痞硬者是里实也下之当然况太阳病过经十余日反二三下之后四五日柴胡证仍在者先以小柴胡汤呕不止心
下急郁郁微烦者为未解也与大柴胡汤下之则愈然呕不止而微烦里热已甚结于胃中故下之则愈二节病证虽有参差其里实
同一机耳皆与大柴胡者宜也
伤寒五六日已发汗而复下之胸胁满微结小便不利渴而不呕但头汗出往来寒热心烦者此为未解也柴胡桂枝干姜汤主
之（已发汗而复下之虽不失先发后攻之序及当汗而反下之宜然既汗之邪当自散若不待其全解及内实而复下之是犹伤于早
也乌得不结然已发汗则邪势已衰虽或失之下早故结亦当微也成注欠明故着之）
柴胡桂枝干姜汤方
柴胡（半斤） 栝蒌根（四两） 桂枝（去粗皮三两） 牡蛎（ ） 干姜 黄芩（各二两） 甘草（炙一两）上
七味以水一斗二升煮取六升去滓再煎取三升温服一升日三服初服微烦再服汗出便愈（成 内经曰热淫于内以苦发之柴胡
黄芩之苦以解传里之邪辛甘发散为阳桂枝甘草之辛甘以散在表之邪咸以软之牡蛎之咸以消胸胁之满辛以润之干姜之辛
以固阳虚之汗津液不足而为渴苦以坚之栝蒌之苦以生津液）
病患脉微而涩者此为医所病也大发其汗又数大下之其人亡血病当恶寒后乃发热无休止时夏月盛热欲着复衣冬月盛
寒欲裸其身所以然者阳微则恶寒阴弱则发热此医发其汗令阳气微又大下之令阴气弱五月之时阳气在表胃中虚冷以阳气
内微不能胜冷故欲着复衣十一月之时阳气在里胃中烦热以阴气内弱不能胜热故欲裸其身又阴脉迟涩故知血亡也）
上脉微因大发汗所致故病当恶寒之时虽盛夏亦欲着复衣脉涩因大下所致故病当恶寒后发热之时虽盛冬亦欲裸其体
是皆亡血阳微阴弱不能胜冷胜热非是盛夏牵延至盛冬也
【成无己注】
往来寒热，是指寒冷过后发热发作，发热过后寒冷又起。盖因寒属阴，热属阳；里属阴，表属阳。邪气客于体表，与阳气相争，则表现为恶寒；邪气进入体内，与阴气相争，则表现为发热。若表邪多，则恶寒重而发热轻；若里邪多，则发热重而恶寒轻。邪气处于半表半里之间，向外与阳气相争则发冷，向内与阴气相争则发热。由于病位不拘泥于表或里，寒热的表现也没有定数，因此出现寒热往来的症状。所以用小柴胡汤（Minor Bupleurum Decoction）确立各种加减法以和解少阳。
另外，“寒热如疟”与“往来寒热”看似相似实则不同。“寒热如疟”是指发作和停止都有定时，这是正气与邪气相争时发作，正气退却时停止。而“往来寒热”则是发作和停止没有定时，有时发作有时停止，一天可能发作三五次，或者十几次，这与疟疾是不同的。虽然如此，往来寒热属于半表半里证，应当采用和解法治疗。又有病情持续十余日，热邪结聚在里，却又出现往来寒热的情况，也适宜用大柴胡汤（Major Bupleurum Decoction）攻下而痊愈。
【赵嗣真注】
《伤寒百问歌》第五十九问中提到，阴阳相互克制，阳气不足则先恶寒后发热，阴气不足则先发热后恶寒。这仅仅是论述阴阳杂病中二气互相乘胜的情况，并不能用来解释伤寒病。
伤寒发病五六日，或是中风，出现往来寒热、胸胁部苦闷胀满、神情沉默不欲饮食、心烦喜呕，或者胸中烦闷但不呕吐，或者口渴，或者腹中疼痛，或者胁下痞塞坚硬，或者心下悸动、小便不利，或者不渴但身体有轻微发热，或者咳嗽的，以小柴胡汤为主治方剂。（成无己注：疾病有的在表，有的在里，有的在半表半里之间。邪气位于表里之间，称为半表半里证。发病五六日是邪气从表传里的时期，无论是中风还是伤寒，到了五六日都可能出现这种情况。《玉函经》说：“伤寒往来寒热”，即是指出或者是中风，或者是伤寒，并非指伤寒再次感受风邪，也不是中风复感伤寒。经文说：“伤寒中风，有柴胡证，但见一证便是，不必悉具。”正是指或者是中风，或者是伤寒。邪在表则恶寒，邪在里则腹热。如今邪在半表半里之间，位置未定，所以寒热往来。邪在表则心腹不满，邪在里则心腹胀满。如今只说胸膈苦满，可知邪气在表里之间。少阳经行于身侧，胸胁是少阳经的部位，所以经文说其脉循行胁肋联络耳朵，故胸胁痛且耳聋。默默静默是因为邪气正从表向里传变，处于表里之间。邪在表则能进食，邪在里则不能进食。不欲饮食，说明邪在表里之间，尚未严重到完全不能进食的程度。邪在表则不烦不呕，邪在里则烦满而呕。心烦喜呕，说明邪气刚从表传入里。邪初入里，位置未定，所以传变不一，因此出现各种或然证。所谓“有柴胡证，但见一证便是”，指的就是这些或然证。）
本为太阳病未解，转入少阳，出现胁下硬满、干呕、不能食、往来寒热，尚未经过吐法或下法，脉象沉紧的，与小柴胡汤。（成无己注：太阳病转入少阳，是表邪入于里。胁下硬满、不能食、往来寒热，说明邪在半表半里之间。如果已经经过吐下，脉象沉紧，说明邪气入腑形成里实证。如果尚未经过吐下，脉象沉紧，说明虽传里较深但未完全入腑，外邪仍未解除，故用小柴胡汤以和解之。）
如果已经经过吐法、发汗、温针，出现谵语，且柴胡汤证已消失，这属于坏病。需查明犯了何种误治逆乱，根据具体情况施治。（成无己注：少阳之邪在半表半里之间，若妄用吐、下、发汗、温针，会损耗津液，导致胃中干燥，木邪干犯胃腑，必然引发谵语。如果柴胡证未消失，则不属于误治逆乱。柴胡证消失的，即为坏病。详细考察其因何误治，依法救治。救治坏病以助营卫、生津液为目的，可参考桂枝汤（Cinnamon Twig Decoction）之法。）
伤寒发病五六日，已经发汗而又再次攻下，出现胸胁满闷微结、小便不利、口渴但不呕吐、仅头部出汗、往来寒热、心烦的，此为病邪未解，主方为柴胡桂枝干姜汤（Bupleurum, Cinnamon Twig and Dried Ginger Decoction）。（难知曰：如果使用柴胡汤，经过一段时间，气血运行变化，邪气无处容身，故知其欲自解。伤寒五六日，已经汗下之后，邪气应当解除。如今胸胁满闷微结、小便不利、口渴但不呕吐、仅头部出汗、往来寒热、心烦，说明邪气仍在半表半里之间，病未解除。胸胁满闷微结、寒热心烦，是邪在半表半里之间。小便不利而口渴，是汗下后津液亡失，内部干燥。如果是热邪消耗津液导致小便不利而口渴，病人必然呕吐。如今口渴但不呕吐，可知非里热所致。伤寒汗出则周身调和，如今仅头部出汗，其余部位无汗，是津液不足且上部阳气虚。给予柴胡桂枝干姜汤以解表里之邪，恢复津液以助阳气。）
血气虚弱，正气耗尽，腠理开泄，邪气因而侵入，与正气相搏结于胁下。正邪分争，往来寒热，休作有时，神情沉默不欲饮食。脏腑相连，疼痛必向下牵引，邪高痛下，故使呕吐。主方为小柴胡汤。（按：从“血弱气尽”至“结于胁下”是解释“胸胁苦满”一句；“正邪分争”三句是解释“往来寒热”一句，此处用了倒装手法。“默默不欲饮食”兼承上文满痛而言。“脏腑相连”四句解释“心烦喜呕”。）
小柴胡汤方：
柴胡（半斤），半夏（汤洗，半升），人参，甘草，黄芩，生姜（各三两），大枣（十二枚，掰开）。
以上七味，用水一斗二升，煮取六升，去渣，再煎取三升。温服一升，每日三次。（成无己注：《内经》说：“热淫于内，以苦发之。”柴胡、黄芩之苦，用以发散传入之邪热。里气不足者，以甘味缓急。人参、甘草之甘，用以缓和中和之气。邪气半入里，则里气上逆，以辛味散之。半夏用以除呕。邪在半表，则营卫相争，以辛甘解之。生姜、大枣用以调和营卫。）
加减法（少阳邪气在胸中，使用此加减法）：
若胸中烦闷但不呕吐，去掉半夏、人参，加栝蒌实一枚。（胸中烦闷而不呕吐，是热邪聚集而气机不逆。甘味药令人中满，如今热邪聚集，无用补益之人参；辛散逆气，既然不呕吐，也无需用半夏之辛温。宜用寒凉药治疗聚热，宜用苦味药泄热。栝蒌实苦寒，能泄胸中蕴热。）
若口渴，去掉半夏，加入人参，合前共成四两半，加栝蒌根四两。（半夏燥伤津液，非口渴者所宜。人参甘润，栝蒌根苦凉，清热生津，二者恰当。）
若腹中疼痛，去掉黄芩，加芍药三两。（去黄芩是因其苦寒伤中；加芍药以通壅滞。通壅滞功效较小，止痛功效较大。）
若胁下痞塞坚硬，去掉大枣，加牡蛎四两。（甘味药令人中满。痞塞者，去大枣之甘；咸味药能软坚。痞硬者，加牡蛎之咸。）
若心下悸动、小便不利，去掉黄芩，加茯苓四两。（水饮停蓄不行则为悸，小便不利。《内经》说：“肾欲坚，急食苦以坚之。”得苦味则水益坚于肾，故去黄芩。淡味药渗泄为阳。茯苓甘淡，以泄伏留之水。）
若不渴，体表有轻微发热，去掉人参，加桂枝三两，温覆取微汗即愈。（不渴说明里气和顺，故去人参。体表有微热，说明表邪未解，加桂枝以发汗。）
若咳嗽，去掉人参、大枣、生姜，加五味子半升，干姜二两。（咳嗽是气机上逆。甘味药壅滞气机，故去人参、大枣。《内经》说：“肺欲收，急食酸以收之。”五味子之酸，用以收敛逆气。肺寒则咳，散寒宜用辛热，故易生姜为干姜之热性。）
伤寒邪气在表者，必须通过渍形发汗来治疗；邪气在里者，必须通过荡涤通便来治疗。至于邪气既不在表也不在里，处于半表半里之间，应当采用和解法。小柴胡汤是和解表里的方剂。《内经》说：“热淫于内，以苦发之。”邪在半表半里，则热势已成一半。热气内传变化不可预测，须迎头痛击，必先散热，因此以苦寒药为主。故以柴胡为君药，黄芩为臣药，以成就彻热发表之剂。邪气传里，则里气失调，故用人参、甘草为主药以扶助正气并恢复之。邪气初入里，气机必然上逆，因此用辛散药作为辅助，故用半夏为佐药，以顺降逆气而散邪。里气平正则邪气不得深入，这三味药辅助柴胡以和里。《内经》说：“辛甘发散为阳。”表邪未已，逐渐内传，尚未形成实证，应当表里双解。对于在表者，必用辛甘发散，故用生姜、大枣为使药，辅助柴胡以和表。七味药相合，成为表里双解之剂，是恰当的。邪气自表而来，未敛结成实，乘虚而入，故传变不一，因此有增减损益以应对。胸中烦闷而不呕吐，烦是热，呕是气逆。烦而不呕，则热聚而气不逆，邪气欲渐成实。人参甘补，去掉它以免助热。半夏辛散，去掉它因为无逆气可散。除热必用寒药，泄热必用苦药，加栝蒌实以通胸中之郁热。若口渴，是津液不足。半夏味辛性燥，渗伤津液，故去之，则津液易生。人参味甘而润，栝蒌根味苦而坚，坚润相合，津液生而口渴自愈。邪气入里，里气不足，则壅滞寒凝而腹中痛。黄芩苦寒，寒中去之则气易和。芍药酸泄而利中，加之则里气得通而痛自愈。《内经》说：“甘者令人中满。”大枣甘温，去之则硬满消散。咸味药能软坚，牡蛎味酸咸寒，加之则痞者消而硬者软。若心下悸、小便不利，是水饮停蓄不行。《内经》说：“肾欲坚，急食苦以坚之。”坚肾则水益坚，黄芩苦寒，去之则蓄水浸内。《灵枢经》说：“淡味渗泄为阳。”茯苓甘淡，加之则津液通流。若不渴，体表有微热，不渴则津液足，去人参以人参为主内之物也。外有微热则表证多加桂枝以取汗发散表邪也。若咳者肺气逆也，甘补中则气愈逆，故去人参大枣之甘。肺欲收，急食酸以收之，气逆不收，故加五味子之酸。盖咳本于寒，寒气内淫则散以干姜之辛热。生姜干姜一物也，生者温，干者热，故以干易生也。
【吴谦等注】
有人问：近代治疗伤寒发热，不分阴阳而使用小柴胡汤，为什么呢？然而柴胡味苦平，是足少阳经治疗伤寒发热的药物，能除半表半里之热及往来寒热，小有日晡潮热。辅以黄芩之苦寒以退热，半夏、生姜之辛以退寒，人参、大枣之甘温以助正气、解渴、生津液，则阴阳和而邪气解。但是，太阳经的表热、阳明经的标热都不能解除。如果使用，难道说没有害处吗？如果是阳气虚寒、面赤发热、脉沉、足冷的患者，服用后立刻危及生命，可不谨慎吗？以及体内虚寒、大便不实、脉息小弱的，与新产后发热的妇女，都不可使用。
凡是用柴胡汤的病证，如果误用攻下法，若柴胡证未罢的，再给予柴胡汤，必定会出现蒸蒸而振栗，随后发热汗出而解。（成无己注：邪在半表半里之间，为柴胡证，此时并未形成里实证，医生便用药攻下。若柴胡证仍在，虽经攻下也不为逆，可再给予柴胡汤以和解。服药后，邪气还表，外在表现为蒸蒸而热，先前经过攻下导致里虚，邪气欲出，内在则振振然。正气胜，阳气生，随后发热汗出而解。）
伤寒或中风，有柴胡证，但见一个证候即可，不必所有证候都具备。（柴胡证是邪气在表里之间。或者胸中烦闷而不呕，或者口渴，或者腹中痛，或者胁下痞硬，或者心下悸、小便不利，或者不渴、身有微热，或者咳嗽。但见一个证候，就适宜给予柴胡汤，随或然证以法治之，不必等待证候全部具备。）
伤寒十余日，热邪结聚在里，又出现往来寒热的，与大柴胡汤。若是结胸证，无大热，这是水结在胸胁，仅头部微汗出，主方为大陷胸汤（Major Thoracic Trap Decoction）。（详见结胸篇）
大柴胡汤方：
柴胡（半斤），半夏（半升，洗），黄芩，芍药（各三两），生姜（切，五两），大枣（十二枚，掰开），枳实（炙，四枚）。
以上七味，用水一斗二升，煮取六升，去渣，再煎取三升。温服一升，每日三次。一方有大黄二两。如果不加大黄，恐怕不能称为大柴胡汤。
【成无己注】
方剂有峻猛与缓和、轻重之分，医生应当临时斟酌。如大满、大实、坚且有燥屎者，非峻猛之剂不能泄，所以有大、小承气汤（Major/Minor Chengqi Decoction）之峻猛。如不至于大坚满，只是邪热甚而需攻下的，又不是承气汤可投，必用轻缓之剂，乃是大柴胡汤，用以逐邪热。经文说：“伤寒发热七八日，虽脉浮数，可下之，宜大柴胡汤。”又说：“太阳病，过经十余日，反二三下之，后四五日，柴胡证仍在者，先与小柴胡汤。呕不止，心下急，郁郁微烦者，为未解也，可与大柴胡汤，下之则愈。”由此可知，大柴胡汤是下剂中的缓剂。伤寒主治可下，则为热有余，应火而归心，苦先入心，折热必以苦为主，故以柴胡苦平微寒为君，黄芩苦寒为臣。《内经》说：“酸苦涌泄为阴。”泄实折热必以酸苦，故以芍药、枳实为佐。辛者散也，散逆气者必以辛；甘者缓也，缓正气者必以甘，故用半夏、生姜之辛温，大枣之甘温为之使。一方加大黄，因大黄有将军之号，功专荡涤，必应以大黄为使。
【许叔微注】
有人患伤寒，心烦喜呕，往来寒热，医生用小柴胡汤治疗，病不除。我说：脉洪大而实，热结在里，小柴胡汤怎么能去除呢？仲景说：“伤寒十余日，热结在里，复往来寒热者，与大柴胡汤。”服三剂而病除。盖大黄荡涤蕴热，是伤寒中的重要药物。王叔和说：“若不用大黄，恐不名大柴胡。”须酒洗生用，才有力。
【张元素注】
有人问：大柴胡汤若用于内烦里实者固然适宜，但对于呕吐而下利的患者也使用，为什么呢？治病关键在于虚实二者而已。里虚者，即使大便困难也不要攻下；里实者，即使呕吐下利也可攻下。经文说：“汗多则便难，脉迟尚未可攻，以迟为不足，即里气未实，故也。”此以大柴胡汤主治。凡呕吐下利，心腹濡软为里虚；呕吐而下利，心下痞硬者是里实也。攻下是理所当然的。况且太阳病过经十余日，反复攻下后，四五日柴胡证仍在，先以小柴胡汤，若呕不止，心下急，郁郁微烦，为未解，与大柴胡汤下之则愈。然而呕不止而微烦，里热已甚，结于胃中，故下之则愈。这两节病证虽有参差，但其里实机理相同，皆与大柴胡汤是适宜的。
伤寒五六日，已经发汗而又再次攻下，出现胸胁满闷微结、小便不利、口渴但不呕吐、仅头部出汗、往来寒热、心烦的，此为病邪未解，主方为柴胡桂枝干姜汤。（已经发汗而又再次攻下，虽然没有违背先发汗后攻下的顺序，但在应当发汗时反而攻下，是不对的。既然已经发汗，邪气应当自行消散，若不待其全解，在未形成里实之前就再次攻下，这就叫攻下过早。乌能不结聚？然而已经发汗，邪势已衰，虽然失误于攻下过早，但结聚也应当轻微。成无己的注解不够明确，故在此阐述。）
柴胡桂枝干姜汤方：
柴胡（半斤），栝蒌根（四两），桂枝（去粗皮，三两），牡蛎（），干姜，黄芩（各二两），甘草（炙，一两）。
以上七味，用水一斗二升，煮取六升，去渣，再煎取三升。温服一升，每日三次。初服时微烦，再服后汗出便愈。（成无己注：《内经》说：“热淫于内，以苦发之。”柴胡、黄芩之苦，用以解传入里之邪。辛甘发散为阳，桂枝、甘草之辛甘，用以散在表之邪。咸以软之，牡蛎之咸，用以消胸胁之满。辛以润之，干姜之辛，用以固阳虚之汗。津液不足而为渴，苦以坚之，栝蒌之苦，用以生津液。）
病患脉微而涩，这是被医生误治所致。大发其汗，又多次大幅攻下，其人亡血。病当恶寒，随后发热，无休止之时。夏季盛热，想穿厚衣；冬季盛寒，想裸露身体。之所以这样，是因为阳气微弱则恶寒，阴气虚弱则发热。这是医生发其汗令阳气微弱，又大下之令阴气虚弱。五月之时，阳气在表，胃中虚冷，以阳气内微，不能胜冷，故想穿厚衣。十一月之时，阳气在里，胃中烦热，以阴气内弱，不能胜热，故想裸露身体。又因阴脉迟涩，故知血亡也。（脉微是因大发汗所致，故病当恶寒之时，虽盛夏亦想穿厚衣。脉涩是因大下所致，故病当恶寒后发热之时，虽盛冬亦想裸露身体。这都是亡血、阳微、阴弱，不能胜冷、胜热，并非是从盛夏拖延到盛冬。）
[Cheng Wuji's Commentary]
"Alternating chills and fever" refers to the phenomenon where fever arises after chills subside, and chills return after fever subsides. This is because chills belong to Yin, while fever belongs to Yang; the interior belongs to Yin, and the exterior belongs to Yang. When pathogenic factors lodge in the exterior and contend with Yang Qi, chills manifest; when pathogenic factors enter the interior and contend with Yin, fever manifests. If exterior pathogenic factors are predominant, chills are severe and fever is mild; if interior pathogenic factors are predominant, fever is severe and chills are mild. When pathogenic factors reside in the half-exterior half-interior region, contending outwardly with Yang Qi causes coldness, and contending inwardly with Yin Qi causes heat. Since the disease location is not fixed strictly in the exterior or interior, and the manifestation of chills and fever has no fixed pattern, alternating chills and fever occur. Therefore, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is used to establish various modification methods for harmonizing the Shaoyang stage.
Furthermore, "chills and fever resembling malaria" and "alternating chills and fever" appear similar but are distinct. "Chills and fever resembling malaria" have a regular onset and cessation time; they occur when healthy Qi contends with pathogenic factors and cease when healthy Qi retreats. In contrast, "alternating chills and fever" have irregular onset and cessation times, occurring intermittently, possibly three to five times or even more than ten times a day. This differs from malaria. Although both involve the half-exterior half-interior stage and require harmonization therapy, there is another scenario: if the disease persists for over ten days, with heat binding in the interior yet presenting with alternating chills and fever, Da Chai Hu Tang (Major Bupleurum Decoction) should be used to purge the interior heat.
[Zhao Sizhen's Commentary]
The 59th question of *Shanghan Baiwen Ge* states that when Yin and Yang mutually overcome each other, insufficient Yang leads to chills first followed by fever, while insufficient Yin leads to fever first followed by chills. This specifically discusses the mutual overcoming of Yin and Yang in mixed diseases and cannot be applied to explain Shanghan (Cold Damage).
In Shanghan, on the fifth or sixth day, whether due to Wind Strike or Cold Damage, symptoms such as alternating chills and fever, fullness and discomfort in the chest and hypochondrium, silence with lack of desire for food, irritability and frequent vomiting, or alternatively, chest irritability without vomiting, thirst, abdominal pain, hardness and stuffiness under the hypochondrium, palpitations with urination difficulty, absence of thirst with slight body heat, or coughing, are primarily treated with Xiao Chai Hu Tang. (Cheng Wuji notes: Diseases may be located in the exterior, interior, or between the two. Pathogenic factors between the exterior and interior constitute the half-exterior half-interior syndrome. On the fifth or sixth day, pathogenic factors transmit from the exterior to the interior. Whether it is Wind Strike or Cold Damage, these symptoms may appear. The *Yuyuan Jing* states: "Shanghan with alternating chills and fever," indicating either Wind Strike or Cold Damage, not necessarily Cold Damage re-infected by Wind or vice versa. The classic text says: "In Shanghan or Wind Strike, if Chai Hu patterns are present, observing one symptom is sufficient; all symptoms need not be present." This applies to either condition. Exterior pathogens cause chills; interior pathogens cause abdominal heat. Currently, with pathogens in the half-exterior half-interior, their position is undetermined, hence alternating chills and fever. Exterior pathogens do not cause heart/abdominal fullness; interior pathogens cause distension. Current chest diaphragm fullness indicates pathogens between exterior and interior. The Shaoyang meridian runs along the side of the body, and the chest/hypochondrium are Shaoyang regions. Hence, the text mentions pain in the chest/hypochondrium and deafness due to the meridian connecting the ear. Silence indicates pathogens moving from exterior to interior, residing between the two. Exterior pathogens allow eating; interior pathogens prevent it. Lack of desire for food indicates pathogens are between exterior and interior, not yet severe enough to completely prevent eating. Exterior pathogens cause no irritability/vomiting; interior pathogens cause fullness and vomiting. Irritability and frequent vomiting indicate recent transmission from exterior to interior. As pathogens initially enter the interior, their location is unstable, leading to various potential symptoms. "Observing one Chai Hu symptom" refers to these potential symptoms.)
If the original Taiyang disease does not resolve and transmits to Shaoyang, presenting with hardness/stuffiness under the hypochondrium, dry retching, inability to eat, and alternating chills and fever, before any purgative or emetic treatment, and with a deep-tight pulse, Xiao Chai Hu Tang is indicated. (Cheng Wuji notes: Transmission from Taiyang to Shaoyang means exterior pathogens entering the interior. Symptoms indicate pathogens in the half-exterior half-interior. If emetics/purgatives were already used and the pulse is deep-tight, pathogens have entered the Fu organs forming interior excess. If not yet used, a deep-tight pulse indicates deep transmission but incomplete entry into Fu organs, with exterior unresolved. Thus, Xiao Chai Hu Tang harmonizes.)
If emesis, sweating, or warm needle therapy was incorrectly applied, resulting in delirium and the disappearance of Chai Hu patterns, this constitutes a damaged disease (Huai Bing). Treatment must address the specific iatrogenic error. (Cheng Wuji notes: Incorrect use of emesis, purgation, sweating, or warm needles damages fluids, drying the stomach. Wood pathogen attacks the stomach, causing delirium. If Chai Hu patterns persist, it is not an error. If they disappear, it is a damaged disease. Investigate the cause of the error and treat accordingly. To rescue damaged diseases by nourishing Ying-Wei and generating fluids, Guizhi Tang may be referenced.)
In Shanghan, on the fifth or sixth day, after sweating and subsequent purgation, if symptoms include slight constriction of chest/hypochondriac fullness, urination difficulty, thirst without vomiting, only head sweating, alternating chills and fever, and irritability, the disease is unresolved. Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig and Dried Ginger Decoction) is the primary formula. (Nan Zhi notes: Using Chai Hu allows time for Qi and Blood to shift, leaving no place for pathogens, indicating resolution. After sweating and purgation on day 5-6, pathogens should resolve. Persistent symptoms indicate pathogens remain in the half-exterior half-interior. Chest/hypochondriac fullness and irritability confirm this location. Urination difficulty and thirst result from fluid loss due to sweating/purgation. If heat consumed fluids causing thirst, vomiting would likely occur. Thirst without vomiting rules out interior heat. Head-only sweating indicates insufficient fluids and deficient Yang above. Chai Hu Gui Zhi Gan Jiang Tang resolves exterior/interior pathogens and restores fluids/Yang.)
When blood is weak and Qi exhausted, pores open, and pathogens enter, contending with healthy Qi and knotting under the hypochondrium, Zheng-Xie struggle causes alternating chills and fever with periodic rest. Silence and lack of desire for food follow. Connected organs imply pain radiating downward; high pathology causing low pain induces vomiting. Xiao Chai Hu Tang is indicated. (Note: "Blood weak...knotting under hypochondrium" explains "chest/hypochondriac fullness"; "Zheng-Xie struggle..." explains "alternating chills and fever" using inverted syntax. "Silence..." relates to previous fullness/pain. "Connected organs..." explains "irritability and frequent vomiting".)
**Xiao Chai Hu Tang Formula:**
Chai Hu (8 liang), Ban Xia (half sheng, washed in boiling water), Ren Shen, Gan Cao, Huang Qin, Sheng Jiang (each 3 liang), Da Zao (12 pieces, broken).
Boil seven ingredients in 12 sheng of water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily. (Cheng Wuji notes: *Nei Jing* states: "Heat rampant within, disperse with bitter." Chai Hu and Huang Qin's bitterness disperses transmitted heat. Interior deficiency requires sweet relaxation. Ren Shen and Gan Cao's sweetness moderates middle Qi. Pathogens halfway to interior cause reverse Qi flow; pungent herbs disperse. Ban Xia stops vomiting. Exterior pathogens cause Ying-Wei conflict; pungent-sweet herbs resolve. Sheng Jiang and Da Zao harmonize Ying-Wei.)
**Modifications (for Shaoyang pathogens in the chest):**
If chest irritability without vomiting: Remove Ban Xia and Ren Shen; add Gua Lou Shi (one piece). (Irritability without vomiting indicates heat accumulation without Qi reversal. Sweet herbs cause fullness; useless here. Pungent herbs disperse reversal; unnecessary without vomiting. Use bitter-cold Gua Lou Shi to drain chest heat.)
If thirst: Remove Ban Xia; increase Ren Shen to total 4.5 liang; add Gua Lou Gen (4 liang). (Ban Xia dries fluids, unsuitable for thirst. Ren Shen is sweet-moistening; Gua Lou Gen is bitter-cool, clearing heat and generating fluids.)
If abdominal pain: Remove Huang Qin; add Shao Yao (3 liang). (Remove Huang Qin to avoid damaging middle Jiao cold; add Shao Yao to unblock stagnation and relieve pain.)
If hypochondriac hardness/stuffiness: Remove Da Zao; add Mu Li (4 liang). (Sweet herbs cause fullness; remove Da Zao. Salty herbs soften hardness; add Mu Li.)
If epigastric palpitations and urination difficulty: Remove Huang Qin; add Fu Ling (4 liang). (Fluid retention causes palpitations. *Nei Jing*: "Kidney desires firmness, feed with bitter to firm it." Bitter hardens Kidney/Water, so remove Huang Qin. Fu Ling's bland-sweet nature drains retained water.)
If no thirst but slight exterior heat: Remove Ren Shen; add Gui Zhi (3 liang); cover warmly for slight sweating. (No thirst indicates interior harmony; remove Ren Shen. Slight exterior heat indicates unresolved exterior; add Gui Zhi to induce sweating.)
If cough: Remove Ren Shen, Da Zao, Sheng Jiang; add Wu Wei Zi (half sheng) and Gan Jiang (2 liang). (Cough indicates reverse Qi flow. Sweet herbs obstruct Qi; remove Ren Shen/Da Zao. *Nei Jing*: "Lung desires gathering, feed with sour to gather it." Wu Wei Zi's sourness gathers reverse Qi. Cough stems from cold; disperse with pungent-hot. Replace warm Sheng Jiang with hot Gan Jiang.)
For pathogens in the exterior, induce sweating via soaking; for pathogens in the interior, purge via bowel movement. For pathogens in the half-exterior half-interior, harmonization is appropriate. Xiao Chai Hu Tang harmonizes exterior and interior. *Nei Jing*: "Heat rampant within, disperse with bitter." Half-exterior half-interior heat requires dispersal. Anticipate internal transmission by clearing heat first, using bitter-cold as main agents. Chai Hu is Sovereign, Huang Qin is Minister. For interior transmission disrupting interior Qi, Ren Shen and Gan Cao support healthy Qi. Initial interior transmission causes Qi reversal; Ban Xia assists with pungency to descend Qi. Stabilized interior Qi prevents deep invasion. These three assist Chai Hu in harmonizing interior. *Nei Jing*: "Pungent-sweet disperses Yang." Unresolved exterior pathogens gradually transmitting internally but not yet solid require dual resolution. Pungent-sweet (Sheng Jiang, Da Zao) assists Chai Hu in harmonizing exterior. The seven ingredients form a proper dual-resolving agent. Modifications address varying transmission: remove Ren Shen/Ban Xia if no Qi reversal; add Gua Lou Shi for heat; adjust for thirst, pain, hardness, palpitations, or cough based on specific mechanisms (fluid loss, stagnation, water retention, lung cold).
[Wu Qian et al.'s Commentary]
Why is Xiao Chai Hu Tang used indiscriminately for fever in modern Shanghan treatment? Chai Hu is bitter-pungent and neutral, treating Shaoyang fever and resolving half-exterior half-interior heat, including alternating chills/fever and slight afternoon tidal fever. Huang Qin clears heat; Ban Xia/Sheng Jiang dispel cold; Ren Shen/Da Zao support Qi, resolve thirst, and generate fluids, harmonizing Yin-Yang and resolving pathogens. However, it does not resolve Taiyang exterior heat or Yangming branch heat. Indiscriminate use can be harmful. Specifically, in cases of Yang deficiency with cold, red face, fever, deep pulse, and cold feet, it can be fatal. It is also contraindicated in internal deficiency-cold with loose stools, weak pulse, and postpartum fever.
If Chai Hu Tang indications are present but purgatives are mistakenly used, and Chai Hu patterns persist, administer Chai Hu Tang again. The patient will experience vigorous shaking (Zhen) followed by fever and sweating, leading to resolution. (Cheng Wuji notes: Pathogens in half-exterior half-interior constitute Chai Hu patterns. Purging is incorrect unless interior excess exists. If patterns persist, purging is not detrimental. Re-administering Chai Hu Tang returns pathogens to the exterior. Pre-existing interior deficiency from purging causes shaking as pathogens exit. Healthy Qi prevails, Yang generates, fever/sweating ensues, and disease resolves.)
In Shanghan or Wind Strike, if Chai Hu patterns exist, observing one symptom is sufficient; all symptoms need not be present. (Chai Hu patterns indicate pathogens between exterior and interior. Potential symptoms include chest irritability without vomiting, thirst, abdominal pain, hypochondriac hardness, epigastric palpitations with urination difficulty, no thirst with slight heat, or cough. Observe one symptom and treat with Chai Hu Tang accordingly, without waiting for all symptoms to appear.)
If Shanghan persists for over ten days with heat binding in the interior and recurring alternating chills and fever, administer Da Chai Hu Tang. If Jie Xiong (Chest Binding) presents with no significant heat, it is water binding in the chest/thorax, with only slight head sweating; Da Xian Xiong Tang (Major Thoracic Trap Decoction) is indicated. (See Jie Xiong section.)
**Da Chai Hu Tang Formula:**
Chai Hu (8 liang), Ban Xia (half sheng, washed), Huang Qin, Shao Yao (each 3 liang), Sheng Jiang (cut, 5 liang), Da Zao (12 pieces, broken), Zhi Shi (roasted, 4 pieces).
Boil seven ingredients in 12 sheng of water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily. Some versions include Da Huang (2 liang). Without Da Huang, it arguably ceases to be Da Chai Hu Tang.
[Cheng Wuji's Commentary on Da Chai Hu]
Formulas vary in potency (harsh vs. mild). Physicians must judge clinically. Severe excess/fullness with dry stool requires harsh purgatives like Da/Xiao Cheng Qi Tang. For severe heat requiring purgation but lacking severe fullness, milder agents like Da Chai Hu Tang are used. Classics state: "Shanghan fever for 7-8 days, even with floating-rapid pulse, may be purged with Da Chai Hu Tang." Also: "Taiyang disease passing its period (>10 days), wrongly purged multiple times, then Chai Hu patterns persist. First try Xiao Chai Hu Tang. If vomiting persists, epigastric urgency, and depression/irritability remain, use Da Chai Hu Tang to purge." Thus, Da Chai Hu Tang is a mild purgative. Shanghan purgation targets excess heat (Fire/Heart). Bitter enters Heart first to reduce heat. Chai Hu (bitter-pungent-mild cold) is Sovereign; Huang Qin (bitter-cold) is Minister. *Nei Jing*: "Sour-bitter涌泄 (upward/downward discharge) is Yin." Sour-bitter (Shao Yao, Zhi Shi) aids discharge. Pungent disperses reverse Qi (Ban Xia, Sheng Jiang); sweet moderates healthy Qi (Da Zao). Da Huang (General) is added in some versions to scour accumulated heat.
[Xu Shimwei's Commentary]
A patient had Shanghan with irritability, frequent vomiting, and alternating chills/fever. Xiao Chai Hu Tang failed. I diagnosed a洪大实 (surging-large-excess) pulse, indicating heat binding in the interior. Xiao Chai Hu Tang cannot clear this. Zhongjing states: "Shanghan >10 days, heat binding in interior with alternating chills/fever, use Da Chai Hu Tang." Three doses cured him. Da Huang scours accumulated heat and is essential. Wang Shuhe noted: "Without Da Huang, it is not truly Da Chai Hu Tang." Use raw, wine-washed Da Huang for efficacy.
[Zhang Yuansu's Commentary]
Why use Da Chai Hu Tang for vomiting/diarrhea? Treatment depends on Deficiency vs. Excess. Interior Deficiency prohibits purging even with constipation. Interior Excess permits purging even with vomiting/diarrhea. *Nei Jing*: "Excessive sweating causes constipation; slow pulse indicates insufficiency/interior not yet solid; do not purge." Here, Da Chai Hu Tang is used. Vomiting/diarrhea with soft abdomen indicates Interior Deficiency. Vomiting/diarrhea with epigastric hardness indicates Interior Excess. Purge accordingly. In the case of prolonged Taiyang disease, wrongly purged, with persistent Chai Hu patterns, epigastric urgency, and irritability, Da Chai Hu Tang purges the interior heat binding in the Stomach. Both cases share Interior Excess, justifying Da Chai Hu Tang.
[Chai Hu Gui Zhi Gan Jiang Tang Section]
After sweating and purgation on day 5-6, if chest/hypochondriac fullness with slight constriction, urination difficulty, thirst without vomiting, head-only sweating, alternating chills/fever, and irritability persist, the disease is unresolved. Chai Hu Gui Zhi Gan Jiang Tang is indicated. (Sweating then purging is improper timing. Early purging causes binding, but since pathogens were weakened by sweating, binding is slight. Cheng Wuji's explanation was unclear; this clarifies.)
**Chai Hu Gui Zhi Gan Jiang Tang Formula:**
Chai Hu (8 liang), Gua Lou Gen (4 liang), Gui Zhi (remove bark, 3 liang), Mu Li, Gan Jiang, Huang Qin (each 2 liang), Gan Cao (roasted, 1 liang).
Boil seven ingredients in 12 sheng of water to obtain 6 sheng, remove dregs, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily. Initial dose may cause slight irritability; subsequent doses induce sweating and cure. (Cheng Wuji notes: *Nei Jing*: "Heat within, disperse with bitter." Chai Hu/Huang Qin clear transmitted interior heat. "Pungent-sweet disperses Yang." Gui Zhi/Gan Cao disperse exterior pathogens. "Salty softens hardness." Mu Li resolves chest/hypochondriac fullness. "Pungent moistens." Gan Jiang secures Yang-deficient sweating. Thirst from fluid deficiency requires "bitter to firm." Gua Lou Gen generates fluids.)
[Pulse Diagnosis Section]
Patients with faint (Wei) and choppy (Se) pulses suffer from iatrogenic error: excessive sweating and repeated purging led to blood loss. They experience chills followed by unremitting fever. In summer heat, they desire heavy clothing; in winter cold, they desire nudity. Faint Yang causes chills; weak Yin causes fever. Sweating depleted Yang; purging depleted Yin. In May (Yang in exterior), stomach is cold due to deficient Yang, unable to resist cold, hence desiring warmth. In November (Yang in interior), stomach is hot due to deficient Yin, unable to resist heat, hence desiring coolness. Choppy/cdelayed Yin pulses confirm blood loss. (Faint pulse from sweating causes chills even in summer. Choppy pulse from purging causes fever even in winter. This reflects blood loss, Yang deficiency, and Yin deficiency, not seasonal delay.)