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When internal injury and depletion have persisted for a long time, it will inevitably manifest when it reaches its extreme; there is no need for external pathogenic factors to trigger it. (Patients with chronic illness or postpartum often suffer from sudden collapse. Living in a sealed room, how could they contract an external pathogen?)

Liu Wansu attributed the cause to Fire, stating that extreme heat generates Wind. This is not the Wind of Liver Wood (meaning one should not rigidly adhere to Liver Wind), nor is it external Wind. It arises from improper regimen and excessive emotional stimulation, causing the Heart Fire to flare up violently while Kidney Water becomes deficient and unable to control it. The heat qi becomes stagnant and depressed, leading to confusion and clouding of the Spirit, resulting in sudden collapse and loss of consciousness. In mild cases, the patient merely collapses stiffly; Qi and Blood flow freely, sinews and vessels do not spasm, and the patient returns to normal after the episode. In severe cases, Qi and Blood become stagnant and blocked. Yin Qi suddenly perishes, followed by the exhaustion of Yang Qi, leading to death. His theory is quite sound. However, since he stated that Fire excess stems from Fire deficiency (Mingmen Fire decline), one should use Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill). Instead, he used Dihuang Yinzi (Rehmannia Decoction), a hot formula, because the Fire flare-up caused a sudden violent collapse of Yang. If Kidney Fire is not deficient, treatment should focus primarily on descending Heart Fire, administering large doses of Qingxin Tang (Clear Heart Decoction) or Xiexin Tang (Drain Heart Decoction). Once Heart Fire has descended, Fangfeng Tongsheng San (Saposhnikovia Powder for Unblocking the Whole Body) can be used to induce sweating. (Internal Fire is also treated with diaphoresis because although the Fire has been lowered, the heat floating and abundant at the exterior has not dissipated; thus, sweating allows it to escape outward.) If stool is obstructed, Sanhua Tang (Three Transformations Decoction) is used to purge. After both internal and external Fire pathogens are cleared, Qianghuo Yufeng Tang (Notopterygium Decoction for Preventing Wind) is used to regulate, promoting Qi and Blood circulation and unblocking meridians. (It also resolves Phlegm stagnation.) If Kidney Water is deficient and Mingmen True Fire carries Liver Wind upward, a large dose of Liuwei Dihuang Wan material should be decocted and taken. (See Deficiency Damage section). If Yang collapse occurs, Shenfu Tang (Ginseng and Aconite Decoction) should be used first in large doses to vigorously tonify Yang, followed by tonifying Yin, and then Shengmai San (Generate Pulse Powder) to nourish the source of transformation. (See Heatstroke section).

Li Dongyuan attributed the cause to Qi, describing human Yang Qi as akin to the fierce wind of heaven and earth. Stroke is not caused by external Wind but by the weakness of intrinsic Qi. After the age of forty, when Qi declines, or if Qi is further damaged (by emotions, overwork, sexual indulgence, or diet), this condition often occurs; it does not happen in youth. Obese individuals may occasionally suffer from it due to robust physique but weak Qi. This condition cannot be reversed without large doses of Renshen (Ginseng) and Huangqi (Astragalus). If the patient does not collapse but presents with tongue stiffness, slurred speech, Phlegm obstruction, and limb paralysis, Liujunzi Tang (Six-Gentleman Decoction) plus various juices should be used. (This is a syndrome of Qi deficiency and internal depletion. Weak individuals often experience sudden dizziness and collapse, similar to the Qi reversal described in the "Zhong Qi Chapter".)

Zhu Danxi attributed the cause to Phlegm, stating that dampness in Earth generates Phlegm, which stagnates and turns into extreme heat, generating Wind.

Question: Does Internal Wind also differentiate between invasion of collaterals, Fu organs, and Zang organs? Answer: Since the disease originates internally, it inevitably damages the Fu and Zang organs. Due to Fire excess, Fire flares up causing blood and Phlegm to obstruct; due to Qi deficiency, Qi stagnates causing blood and Phlegm to coagulate. Stagnant Phlegm and blood prevent food digestion, filling the Fu organs, leading to constipation and urinary retention, obstructing Zang Qi, causing coma and unconsciousness—this is severe. In mild cases, after the onset, pathogens scatter into collaterals, impairing blood vessel flow, which is inherent. Must it involve external Wind? Most symptoms listed below are caused by internal injury and do not necessarily involve external pathogens.

"Kou Jin" (Jaw lock) refers to the inability to open the jaw. It is caused by Qi and Blood coagulating at the jaw, preventing sinew movement. Suhe Wan (Styrax Pill) or a powder of raw Xingren (Areca Seed - *Note: Text says Sheng Nanting/Banlian Nanxing likely implies Pinellia*, Bingpian (Borneol), and Wumei Rou (Mume Fruit Flesh) can be rubbed on the teeth. Or Yujin (Curcuma Rhizome) and Lili (Veratrum) powder can be insufflated into the nose. Acupuncture points Renzhong (GV26) and Jiache (ST6) can be needled 0.4 cun. Alternatively, half liang of Baifan (Alum) and one fen of Yanhua (Salt flower), finely ground, can be applied to the gum root. A cotton-wrapped half-qian bi can be placed at the end of the teeth. Use Gancao (Licorice Root), cut into five segments matching the middle finger joint, soaked in sesame oil, and roasted over charcoal fire until oil penetrates. Use it to pry open the jaw, letting the patient bite down on the licorice. After walking about ten li, replace with another segment, then administer medicine. This is highly effective.

"Mouth and Eye Deviation" (Facial Paralysis). The fine tendons of the Stomach Meridian form the lower eyelid margin; those of the Bladder Meridian form the upper margin. the Gallbladder Meridian starts at the outer canthus, where its tendons also gather. Small Intestine and Sanjiao tendons also reach the outer canthus. Stomach and Large Intestine meridians flank the lips and mouth. Wind-Cold pathogens attack where meridian tendons are deficient. Left deficiency leads to left Cold, causing tendon contraction and deviation to the left; right deficiency causes deviation to the right. Qingyang Tang (Clear Yang Decoction) or Qinjiao Shengma Tang (Gentian and Cimicifuga Decoction) can disperse it. If there is internal heat, add acrid-cool herbs. Moxibustion is suitable for the affected area: Chengqi (ST1) for eye deviation (Note: Chengqi is contraindicated for moxa, requires re-examination), Dicang (ST4) for mouth deviation. If ineffective, add Yingtang (ST9) and Jiache (ST6). If deviation is purely due to Internal Wind-Fire, it results from heat scorching sinews, causing shortening and contraction, opposite to Cold-induced contraction. Moxibustion and warm-dispersing herbs are contraindicated. Bitter-cold herbs to descend Fire are needed; Chengqi Tang (Major Order of the Yellow Emperor Decoction) has cured such cases. General prescription Qianzheng San (Straighten Correct Powder): Baifuzi (Typhonii Rhizoma), Jiangcan (Bombyx Batryticatus), Quanxie (Scorpio) in equal parts, powdered, taken with wine. Externally, mash one liang of Bibo (Ricini Semen) with three fen of Bingpian (Borneolum Syntheticum) into a paste. In cold months, add one qian each of Ganjiang (Zingiberis Rhizoma) and Fuzi (Aconiti Lateralis Radix Praeparata). Apply right deviation to the left side, left deviation to the right side. Old theory states "Left Cold requires Right Heat," referring to internal heat with external Cold. If only external Cold without internal heat, or only internal heat without external Cold, then Left Cold does not require Right Heat treatment. Generally, pure Internal Wind with mild heat does not cause this; severe heat does. Mild deviation is rare because even violent Fire does not immediately wither the root. If combined with external Wind-Cold, it is more severe due to the clash of Cold and Heat. Pure Wind-Cold is also severe due to easy contraction, but only affects deficient persons. (Those who develop deviation in whirlwinds are always deficient).

"Hemiplegia". The Classic states: Stomach pulse sinking and drumming with choppy quality, or bulging large externally (bulging means floating and drumming under finger); Heart pulse small, firm, and rapid (firm means excess, rapid means tight) all indicate hemiplegia. Men develop it on the left, women on the right. If aphasic but tongue moves, it is treatable (pathology limited to vessels, not Zang-Fu). Stomach and Spleen are interior-exterior pairs, alternating excess and deficiency. Stomach Yang deficiency leads to Spleen Yin abundance, so Stomach follows Spleen, resulting in a sinking, drumming, choppy pulse. Choppy indicates much blood but little Qi (Qi is scarce, so blood does not flow freely). Stomach Yang excess leads to Spleen Yin deficiency, so Spleen follows Stomach, resulting in a bulging, large pulse externally. Large indicates much Qi but little blood (Qi is abundant, so pulse is large despite little blood, but must be large and deficient). Heart Yuan Yang is insufficient, allowing Yin-Cold to invade, causing small, firm, rapid pulses (small/rapid indicates Yang deficiency; firm/rapid indicates Yin-Cold pathogen). Presence of any of these three pulse types (Heart, Stomach, Spleen) indicates hemiplegia. Why? Because Heart Spirit pervades everywhere, Stomach Qi flows everywhere. When Spirit moves and Qi flows, full and overflowing, there is no disease. If Spirit and Qi are injured, circulation fails to pervade, leading to hemiplegia. Thus, no disease occurs without Qi deficiency. But is it only Heart and Stomach? Any Zang-Fu dysfunction can cause hemiplegia. Zhu Danxi said: Left side often involves static blood and Blood deficiency, treated with Siwu Tang (Four Substances Decoction) etc. Right side often involves Qi deficiency and Phlegm, treated with Sijunzi Tang (Four Gentlemen Decoction) etc., plus Zhuli (Bamboo Juice) and Jiangzhi (Ginger Juice) to move Phlegm. This is generally true but should not be rigidly applied. Ancient formulas like Shunfeng Yunqi San, Hugu San, Hu Jinggu Jiu, and Huangqi Jiu can be selected. Externally, steam two shi of Can Sha (Mulberry Midge Frass) in three bags. Apply one bag to the affected area, replacing when cool. Cook lamb stomach stuffed with rice, green onion, ginger, pepper, and fermented soybeans until soft; eat one daily for ten days.

"Aphonia". The Classic states: Internal depletion (loss of essence and blood) leading to Jue (reversal, Qi/Fire rushing upward) causes "Yin Fei" (aphonia), due to Kidney deficiency (Kidney Water deficiency allows Fire to flare upward). Shaoyin (Kidney) pulse failing to reach the top (failure to ascend, meaning Kidney Water does not moisten) indicates Jue. If Kidney pulse does not ascend, it cannot follow the throat and grasp the tongue base, hence inability to speak. Dihuang Yinzi, Liuwei Dihuang Wan, Bawei Dihuang Wan etc. are indicated. Alternatively, mix Zhuli (Bamboo Juice), Jingli (Phyllostachys Juice) [to resolve Phlegm], Lizhi (Pear Juice) [to clear heat, 3 cups each], Shengge Zhi (Pueraria Juice) [to clear heat], Renru Zhi (Human Milk) [to moisten dryness, 2 cups each], and Chenjiang Zhi (Aged Soy Sauce Juice, 0.5 cup). Warm in a water bath and take. (Tongue is the sprout of the Heart. Excess Phlegm-Fire dries and contracts Heart vessels, causing tongue stiffness and aphasia. Phlegm confusing Heart orifices renders Heart vessels useless, preventing tongue movement and speech due to Spirit confusion). For Phlegm, use Tantan Tang (Eliminate Phlegm Decoction). For internal heat, use Liangge San (Cool Diaphragm Powder) plus Shichangpu (Acori Tatarinowii Rhizoma) and Yuanzhi (Polygalae Radix) [to open Heart orifices], powdered, honey-pilled, cinnabar-coated, taken one pill dissolved in mint tea, named Zhanshe Gao (Tongue-Straightening Paste). Or Hezi Tang (Persimmon Sepal Decoction), Zhengshe San, Fushen San. Externally, apply turtle urine to the tongue for miraculous effect. Slurred speech, tongue protrusion, or tongue numbness are all treated as Phlegm-Fire using Wayao (Litseae Fructus), Jiangcan, Danning (Arisaema cum Bile), Huangqin (Scutellariae Radix), Huanglian (Coptidis Rhizoma), Zhike (Aurantii Fructus), Fangfeng (Saposhnikoviae Radix), Zhuli, and Jiangzhi.

For excessive Phlegm: One jin of Juhong (Citri Reticulatae Pericarpium Rubrum) boiled in five bowls of reverse-flowing water, boiled several times, remove Juhong, boil remaining liquid to one bowl, take at once, guided by white water (drink white water afterwards, stimulate throat to vomit). This is the holy medicine for vomiting Phlegm. After stroke, if Qi is not smooth and Phlegm not fully removed, use Huoxiang Zhengqi San harmonized with Xingxiang San. Especially suitable for Zhong Qi, Zhong E, and Huoluan. For post-stroke deficiency with Phlegm, use Sijunzi Tang or Liujunzi Tang harmonized with Xingxiang San, or Yangzheng Dan. To settle Phlegm and calm Qi: use Xingxiang San for excess Qi, Liujunzi Tang for deficient Qi.

"Limbs unable to rise". Excess type: Spleen Dampness is abundant, making sinews soft; treat by removing Dampness. Deficient type: Spleen Dryness-Heat, Strong Fire consumes Qi, leaving no Qi to move; use Shiquan Dabu Tang (Ten Complete Tonification Decoction) modified to eliminate evil and preserve righteousness.

"Body Pain". Wind, Cold, and Dampness stagnate in meridians, causing blockage and pain. Tidanz Wan, Shiwei Cuo San (suitable if no heat), Juanbi Tang.

"Coma/Clouding". Huoming Jin Dan, Zhibao Dan, Zhisheng Baoming Jin Dan, Niuhuang Qingxin Wan.

"Urinary Retention". Bai San Zi from San Yin Fang, add Mutong (Akebiae Caulis), Dengxincao (Junci Medulla), Maogen (Imperatae Rhizoma) to decoct. Remove Fuzi if heat is severe. Jiegu said: If spontaneous sweating, fluids escape externally, urine is naturally scant; do not promote urination, as this depletes Ying and Wei, leaving no power to control Fire. Instead, reduce heat and stop sweating; urine will flow naturally.

"Incontinence". Decoct Renshen (Ginseng) strongly, add a little Yizhiren (Alpiniae Oxyphyllae Fructus), sip frequently.

"Polyphagia". Excess Fire causes Spleen Yin deficiency and dryness, enabling digestion. Clear Fire; when Spleen Yin recovers, appetite decreases, proving the diagnosis. Old theory says Spleen deficiency seeks help from food. Classic: "Excess dreams giving, deficiency dreams taking." This aligns. (Food nourishes Blood; Spleen Yin deficiency craves food. Ability to digest indicates Fire).

"Stroke must distinguish Yin and Yang". (Qi deficiency tends toward Cold, Fire excess tends toward Heat). Yin Stroke: Face blue-white, cold limbs, profuse sweating. (Internal Wind-Fire can turn into Cold syndrome. Wind-Fire dissipating causes excessive sweating, Yang escapes outward, turning to Yin-Cold. Ancient view: Stroke Phlegm starts as Hot Phlegm, becomes Cold Phlegm later). Yang Stroke: Face red as drunk, angry eyes staring up, stiffness, tremors, vertigo. Classic: Tremors, pain, stiffness, and sinew contraction belong to Jueyin Wind-Wood Qi. Wood excess generates Fire; Wind-Fire belongs to Yang, often transforming together into Heat. Wind conquers Dampness, causing dryness. Severe Wind disease causes sinew contraction and stiffness, indicating extreme Dryness-Heat. Baojian states: If one initially feels numbness or paralysis in thumb and index finger, stroke will occur within three years (Lung Meridian ends at thumb, Large Intestine starts at index finger; Metal disease makes skin/hair insecure, prone to Wind). Take Yufeng Tang and Tianma Wan prophylactically. Xue Lizhai said: Prevention requires nourishing Qi and Blood, regulating diet, controlling emotions, avoiding sexual indulgence. Taking medicines for prevention actually invites Wind and Stroke. Qiankun Shengyi states: If hands/feet gradually feel clumsy, numb, or deviated (Meridian diseases, prone to external Wind), speech slurred, chest oppression, continuous Phlegm (Phlegm-Fire diseases, prone to internal Wind), and six pulses are wiry, slippery, and powerless, stroke/collapse is imminent. Must prevent.

Case: A woman first had chest/hypochondriac distension/pain (Liver Blood deficiency, Liver Fire excess with stagnation), then limbs flaccid (Blood deficiency failing to nourish sinews), profuse sweating like rain (Liver Heat leaking fluids), urinary incontinence (Liver Heat causing Yin prolapse, failure to store), loose stools (Fire steaming Spleen Earth moving Dampness), jaw lock and eye deviation (Sinew contraction), good appetite (Zang-Fu not injured). After ten days, some thought it was Zang Stroke. Lizhai said: Incorrect. If Wind hit Zang, True Qi would collapse, bad signs would appear, death would be imminent, not lasting ten days. (Stroke strikes suddenly, no prior chest symptoms). Color was blue-red (Wood-Fire colors), pulse was surging and rapid, especially Liver. Used Xijiao San (Rhinoceros Horn Powder) for four doses, cured instantly. Then regulated with Jiawei Xiaoyao San. Later relapsed due to depression/anger, with fever, vomiting, menorrhagia, poor appetite. Wood overacting on Earth, Spleen failing to control blood. Used Jiawei Guipi Tang assisted by Xiaoyao San, cured.

Another case: Person previously healthy, suddenly appeared dead, immobile, eyes closed, jaw locked, silent, aversion to sound, dizzy-like, woke after some time. Caused by excessive sweating, Blood deficiency, Yang Qi stagnating in Stomach above, failing to descend. Qi descended later, waking him. Named Yuwei (Stagnant Stomach). Treat with Baiwei Tang or Cangong San. These two cases illustrate differentiation methods.