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Spleen-strengthening, blood-harmonizing, and liver-leveling will naturally stop the alternating chills and fever.

Wind-injury presents with coarse nasal breathing and a tightly closed mouth, as Lung Qi connects to Heaven (the exterior). Food-injury presents with loss of taste in the mouth, inability to swallow saliva, and even nasal respiration, as Spleen Qi connects to Earth (the interior grain and water). External injury causes heat throughout the body, indicating it originates from the Taiyang channel (Foot-Taiyang Bladder Channel); this is pathogenic factors entering from the outside inward, initially manifesting as formless pathogens. Internal injury causes disharmony of the hands and feet and heat in both hypochondria, indicating it originates from the Shaoyang channel (Foot-Shaoyang Gallbladder Channel); this is disease manifesting from the inside outward, initially manifesting as formed accumulations. Simultaneous external and internal injury presents with both Renying pulse (Carotid artery, reflecting the exterior) and Qikou pulse (Cun Kou pulse, reflecting the interior) being vigorous, or both superficial and deep palpations revealing large and solid pulses; there is surface heat with aversion to cold, abdominal disharmony, and lack of fluids in the mouth; this is simultaneous external and internal injury. In all diagnoses, one must palpate the palm and the back of the hand; heat in the palm indicates internal injury, while heat on the back of the hand indicates external injury. External injury causes alternating chills and fever because accumulated pathogens are located between the exterior and interior; internal injury causes alternating chills and fever due to deficiency of both Qi and Blood. Generally, Qi deficiency generates cold, and Blood deficiency generates heat. Another view states that Spleen deficiency generates heat, and Stomach deficiency generates cold. The Spleen and Stomach are the source of Qi and Blood.

External contraction and internal injury are the keys to disease; if one is ignorant of these, how can one speak of medicine? Zhang Zhongjing has detailed external contractions, and Li Dongyuan has detailed internal injuries. However, cases of internal injury complicated by external contraction have not been thoroughly discussed. Furthermore, external wind-cold invasion causes body heat, nasal congestion, and heavy voice, with a surging and full pulse on the left hand, representing an excess syndrome that should be released rather than tonified. Internal injury caused by anger, joy, hunger, fullness, or overwork causes slight body heat and bitter taste in the mouth, with a surging and full pulse on the right hand, representing a deficiency syndrome that should be tonified rather than released. For internal injury complicated by external contraction, tonification and release must be combined; differentiation must be meticulous, and treatment must be appropriate. For internal injury complicated by external contraction, add Chuanxiong Rhizome (Chuanxiong), Saposhnikovia Root (Fangfeng), Schizonepeta Spike (Jingjie), Bupleurum Root (Chaihu), and Perilla Leaf (Zisu) to Buzhong Yiqi Tang in spring; add Kudzu Root (Gegen), Gypsum (Shigao), Mint Herb (Bohe), Licorice Root (Gancao), Cimicifuga Rhizome (Shengma), and Bupleurum Root (Chaihu) in summer; add Atractylodes Rhizome (Cangzhu), Saposhnikovia Root (Fangfeng), and Schizonepeta Spike (Jingjie) in autumn; add Ephedra Stem (Mahuang), Cinnamon Twig (Guizhi), Prepared Ginger (Paojiang), and Prepared Aconite Root (Fuzi) in winter. This applies when both wrists show surging pulses accompanied by body heat, nasal congestion, and bitter taste. If internal injury is complicated by heat or stagnation, add Huoyu Tang (Fire-Stagnation Decoction) to Buzhong Yiqi Tang. This applies to individuals who usually experience mental confusion, heat in the hands and feet, red urine, with deep-thready or surging-numerous pulses and body heat. If internal injury is complicated by phlegm, add Pinellia Tuber (Banxia), Bamboo Juice (Zhuli), and Ginger Juice (Jiangzhi) to Buzhong Yiqi Tang. This applies to obese, pale individuals with wheezing, chest fullness, expectoration, and deep-slippery or surging-slippery pulses. External contraction and internal injury differ, and releasing the exterior versus tonifying involves differences; how can one prescribe arbitrarily!

Li Dongyuan discussed diet and fatigue as deficiency syndromes, treating them with Buzhong Yiqi Tang. Wang Lüdao further discussed that within deficiency, one must distinguish dietary injury as excess and fatigue injury as deficiency. If dietary injury leads to undigested accumulation causing latent heat to emerge externally, it is an excess syndrome treated with Zhi Zhu Wan (Immature Bitter Orange and Atractylodes Pill) for digestion and guidance. If hunger and irregular meals damage the Spleen and Stomach without accumulation, tonics should be used. The Spleen and Stomach rely entirely on dietary nourishment; now, due to irregular eating, they lose their nourishment and become deficient. The Spleen governs the four limbs; laborious work damages the limbs, thereby damaging the root. Whether due solely to excessive labor, or labor added after dietary imbalance, or dietary imbalance following excessive labor, these are all internal injuries resulting in Yuan Qi deficiency, suitable for tonic treatment. One must examine these four aspects carefully, make slight modifications, and efficacy will follow.

A deep-thin-deficient pulse on the left and a floating-large-numerous pulse on the right, or a hollow-large pulse lacking force, along with loss of taste for grain, results from mental strain, desires, emotional indulgence, alcohol, and overeating. This is internal injury. Initially unnoticed, it becomes a problem over time, leading to body pain, headache, tidal fever, and aversion to cold. The presentation resembles Cold Damage (Shanghan), but it is not Cold Damage. If Mahuang (Ephedra) formulas are used to induce heavy sweating, the fever will not subside. Subsequently using cold herbs to purge fire causes Clear Qi to sink and Turbid Qi to rise, leading to chest fullness after eating. Further purgation further depletes Middle Qi, leading to profuse sweating and Yang collapse, and excessive purgation leads to Yin collapse. With Yin essence dissipated, injury upon injury occurs—this is "reinforcing the excess and depleting the deficient," increasing what is insufficient and decreasing what remains. Death in such cases is indeed caused by the physician.

Internal injury causes intermittent and irregular chills and fever, with slight fever and sweat stopping at the neck or navel, loss of taste for grain daily, possibly with diarrhea. Use Buzhong Yiqi Tang with Fuzi (Prepared Aconite Root). If various Shanghan medicines fail and symptoms resemble malaria with alternating sweat and fever, headache, fever, muttering, irritability, anorexia, and generalized bone pain, use Buzhong Yiqi Tang with Qianghuo (Notopterygium Rhizome). For severe headache, add Chuanxiong Rhizome (Chuanxiong) and Vitex Fruit (Manjingzi). For unrelenting fever without sweat, or cough with blood-tinged sputum, use the standard Buzhong formula; prolonged use eliminates Yin-deficiency tidal fever. Do not use Renshen (Ginseng Root) or Huangqi (Astragalus Root - *Note: Text implies missing character, likely Huangqi*). Spots appearing in internal injury result from Stomach Qi deficiency and wandering deficient fire; treat with strong tonification to descend fire. If complicated by phlegm-heat, use mild diaphoresis to disperse. Never use purgatives, as this may lead to critical conditions.

After internal injury subsides, if dryness and thirst persist, residual heat remains in the Lung. Use Shashen (Glehnia Root), Poria (Fuling), and Gancao (Licorice Root) with a little Ginger Juice taken cold; for deficiency, add Renshen (Ginseng Root).

With a deep-thin-deficient left pulse and floating-large-numerous right pulse, if Buzhong Yiqi Tang fails and residual heat persists with diarrhea and irritability, use Baoyuan Tang (Preserve the Origin Decoction) with Baizhu (Atractylodes Macrocephala Rhizome), Chenpi (Tangerine Peel), Ginger, and Jujube. When Zheng Qi is sufficient, Xie Qi retreats. Add Fuzi (Prepared Aconite Root) 6-7 fen if the patient prefers warmth. If residual heat persists with dry mouth but no thirst, use Gui [missing character] Tang with 7 fen Gancao; using Baihu Tang would be fatal.

If Buzhong Yiqi Tang fails for internal injury, and tidal fever persists for months with abdominal distension, belching, and anorexia, use Baoyuan Tang with 7 fen Paojiang (Prepared Ginger), 5 fen Rougui (Cinnamon Bark), Wuzhuyu (Evodia Fruit), Zhi Gancao (Honey-fried Licorice), and Chenpi, plus 1 qian Baizhu and Fuzi. Decoct in water. For post-illness residual heat, empty irritability, and insomnia, use Guipi Tang (Restore the Spleen Decoction). Add Changpu (Acorus Rhizome) 3 fen for trance-like states; add Maidong (Ophiopogon Tuber) 5 fen for extreme dry mouth and irritability. Malaria-like chills and fever occurring once daily, followed by body distension and desire to strike, indicates Spleen Yin deficiency. Use Liu Junzi Tang (Six Gentlemen Decoction) with 7 fen Baishao (White Peony Root) and 7 qian Danggui Shen (Dangelica Sinensis Root Heart). Decoct with Ginger and Jujube. (*Avoid Danggui and Baishao in diarrhea*). Use Chaihu (Bupleurum Root) 5 fen (omit if spontaneous sweating). Use Huangqi (Astragalus Root) wine-fried 7 fen; add Shenqu (Medicated Leaven) for food belching; remove Huangqi and add Wuweizi (Schisandra Berry) 5 fen for clear lung phlegm; add Paojiang and Rougui 5 fen for nausea; add Zhimu (Anemarrhena Rhizome) for bone-steaming heat; treat chronic cough as deficiency. For long-standing constipation and anorexia, even if unresolved for ten days, worry not; use Shiquan Dabu Tang (Ten Great Tonics Decoction) with Ginger and Jujube.

For internal injury deficiency, regulate with Shiquan Tang removing Chuanxiong and Dihuang, reducing Danggui Shen; add Fuzi for cold, safe for 100 doses. Regulation best achieved with Shenling Baizhu San (Ginseng, Poria, and Atractylodes Powder); add Muxiang (Vladimiria Root) for abdominal pain, Danggui Shen 1 qian for dry stool, Chenpi and Huanglian (Coptis Rhizome) for acid regurgitation, wine-fried Baishao for hypochondriac pain, and Sharen (Amomum Fruit) for fullness.

For persistent internal injury with intense body heat, dry constipation, and surging-strong pulse, use Liuwei Tang (Six Flavor Decoction) with Rougui. If urination is difficult... [Text cuts off].

If Buzhong Yiqi Tang fails to produce sweat reaching the feet after 3-5 doses, or causes generalized pain after 5-6 doses, prognosis is poor. If internal injury fever and headache last six days, followed by diarrhea or sweat stopping at the neck, it is untreatable. Most feared are body pain and hard distension.

In internal injury with no high fever, mild headache, chest/diaphragm fullness, and constipation, if quacks use purgatives and obstruction persists, repeated purgation leads to impending Yin collapse. If generalized pain prevents movement with abdominal distension, there is likely blood stasis internally; even with clear spirit and appetite, it is untreatable.

For internal injury Qi deficiency causing distension, use Buzhong Yiqi Tang with Hezhong San. If the pulse is strong, it is difficult to treat.

In internal injury with loss of taste, avoid excessive cold herbs and prolonged hot herbs; only warm tonification is suitable, as pathogens arise from deficiency. Post-recovery, regulate with Shenling Baizhu San and Bazhen San (Eight Treasures Decoction). If phlegm-fire persists after a month, do not treat phlegm directly; focus on the Spleen and Stomach to ensure safety. For body heat, do not treat heat directly; use Baoyuan Tang, Shengmai Yin (Generate the Pulse Drink), or Buzhong Yiqi Tang with Guizhi and Fuzi. "Sweet-warm clears great heat" is the words of the Sages. Not only in internal injury, but in all diseases, regulating the Spleen and Stomach is the primary principle.

Most illnesses originate from the Spleen and Stomach. Spleen disease renders the four limbs useless, causing fatigue, weakness, loss of taste, fiery heat in limbs, or no significant heat with cold sweat. Use Sijunzi Tang (Four Gentlemen Decoction) or Baoyuan Tang with Fuzi. For loose stools, vomiting, spontaneous sweating, and faint-thin-deficient pulse, use Sijunzi Tang with Ginger and Fuzi, or Erchen Tang (Two Aged Herbs Decoction) with Wei Jiang (Baked Ginger). Urgently regulate the Spleen. Despite other complex symptoms, this is paramount. For deficiency tidal fever, use Shengyang Sanhuo Tang (Raise Yang and Disperse Fire Decoction), followed by major tonification. For daily tidal fever or alternating chills and fever, use Yiqi Tang, heavily using Huangqi and Gancao; this is the method of sweet-warm clearing great heat. If the pulse is extremely fine and rapid, the condition is critical; if unimproved after five doses, treatment is difficult. If Spleen/Stomach signs appear, whether cold or heat, treat from the Spleen/Stomach perspective. Treating internal injury as external contraction may not kill but will lead to consumption and weakness; this is a critical juncture of life and death. Complex chills and fever occur intermittently, whereas Shanghan chills and fever occur simultaneously without interruption.

Internal injury presents variably: fever, headache, aversion to cold; daily fever ending in sweat; hypochondriac pain, diarrhea; unpredictable changes. All suit the standard Buzhong formula. If diaphoretics fail to produce sweat, add Qianghuo and Fangfeng to Buzhong. External contraction resolves with sweat; internal injury does not. If chills and fever occur once daily resembling malaria, with abdominal disharmony and loss of taste, it is internal deficiency. If fever ends in sweat, then aversion to cold ends in heat, with ice-cold sweat, relentless cycling, extreme headache, urinary/fecal obstruction, and no internal distension, it is dryness and untreatable. If abdominal disharmony, restlessness, fever without sweat/headache, and failure of Buzhong Tang after 5-6 doses, fear transformation into consumption; though not fatal, recovery takes 3-5 months.

Internal injury chills/fever with intermittent sweat: fear extreme headache, obstructed/scanty urination/defecation, or cessation of food intake with dysentery. Though not dual-channel Shanghan, it is Qi/Blood deficiency; prevent untreatability.

For internal injury deficiency, use Baoyuan Tang with Danggui and Chuanxiong; add Fuzi and Guizhi for fever/aversion to cold; sweet-warm clears great heat. For diarrhea, remove Danggui. Irritability and dry mouth indicate fluids not reaching the throat, not true thirst; it is Blood deficiency. Avoid Baihu Tang. Use Baoyuan Tang with Danggui Shen, Dengcao (Juncus Effusus), Zhuye (Bamboo Leaf), and Maidong. Add Zaoren (Ziziphus Seed) 3 qian for insomnia. If clearly deficiency with extreme heat and sweating, where Yang escapes with sweat, use Baoyuan Tang with Fumai (Floating Wheat) and Muli (Oyster Shell), or fried Cottonseed Kernel. If Anshen Wan fails for restless mind, recognize lower deficiency failing to support upper, and deflected Yang failing to descend. Use Baoyuan Tang with Mugua (Chaenomeles Fruit) to restore internal Yang; apply Fuzi and Wuzhuyu to soles to guide downward. Add Niuxi (Achyranthes Root) for urinary difficulty, Huren (Hemp Seed) for fecal obstruction, or Liuwei Tang with Cheqianzi (Plantago Seed) for interior excess. For diarrhea with large pulse, use Buzhong Tang or Baoyuan Tang with Baizhu and Fuzi. For cough, do not treat directly. For fine-rapid-deficient pulse with diarrhea and shortness of breath, use Baoyuan Tang with Mugua; for vomiting, add Chenpi, Beimu (Fritillaria Bulb), and Wei Jiang. Outside of Shanghan, avoid excessive attacking herbs to preserve Yuan Qi; treatment should be gradual.

For internal injury constipation, add Su Geng (Perilla Stem) and Xingren (Apricot Seed) to Buzhong; add Niuxi for urinary difficulty; add Baishao for excessive sweat; reduce Shengma and add Baishao if sweating; add Gegen and Wuweizi for dry mouth. For prolonged fever and shortness of breath, use Baoyuan Tang with Guizhi and Fuzi; add Danggui, Baishao, Maidong, and Wuweizi for irritability. For large pulse with alternating heat/cold, use Liuwei Tang with Maidong and Guizhi. For constipation without actual feces and reluctance to defecate, never purge. Seven to eight days of constipation without appetite or distension is common. Unresolved stool passage indicates Qi deficiency; incomplete resolution indicates Blood deficiency. Always use Yiqi Tang, adjusting with Baizhu and Danggui.

When using Zhuyeshigu Tang for internal injury, fear hemorrhage; reversal occurs after 21 days. When using Huangbai (Phellodendron Bark), fear vomiting and diarrhea... [Text cuts off].

For internal injury Yiqi Tang syndrome, if pathology is in the upper jiao hypochondria, it is wind-heat stagnant fire; add wind-dispersing and fire-clearing herbs, avoiding Ginger and Cinnamon. Only for lower/middle jiao pathology should Ginger and Cinnamon be used heavily.

Regardless of varied symptoms, if internal injury affects twelve channels, regulate via Spleen/Stomach, as they are the root of all channels.

If exterior heat resolves but damp-heat remains in the upper jiao during regulation, add Fuling and Banxia to clear phlegm and resolve dampness. If damp-heat remains in the middle jiao, add Muxiang and Sharen to guide dampness and strengthen the Spleen.

Resembling wind-injury, this is internal deficiency caused by diet and labor. It features aversion to wind and spontaneous sweat, which cease in warmth, similar to wind-injury. However, unlike wind-injury, exposure to strong wind outdoors is not dreaded, while small drafts from window cracks are; thus, wind aversion is not absolute. Internal injury presents with clear nasal discharge, headache, spontaneous sweat, occasional shortness of breath, weak speech, dysphagia or anorexia, abdominal disharmony, loss of taste, yellow-red urine, difficult stool (dry, hard, yellow like gruel, or pale loose), epigastric stuffiness, chest tightness like knife pain, epigastric pain, and hypochondriac pain. Ministerial Fire ascends, disturbing the chest, damaging Yuan Qi, causing coarse breathing, limb flaccidity, lethargy, and preference for lying down. These signs are absent in external contraction, making differentiation easy. Use Buzhong Yiqi Tang. Diet and labor cause Heart Fire to invade the Earth position, harming the Lung first, impairing its control over the body and the moistening of Ying and Wei. Thus, Huangqi is most important in this formula, followed by Renshen and Gancao. Spleen/Stomach deficiency harms Lung Qi first; Huangqi benefits the skin/hair to prevent sweat; Renshen tonifies Yuan Qi damaged by panting/shortness of breath. Gancao drains Heart Fire invading the Spleen ("treat urgency with slackening"). Baizhu removes Stomach heat; Shengma and Chaihu lift sinking Clear Qi. Chenpi regulates chaotic Qi in the chest. Yin Fire damages Qi generating Blood, leading to Blood deficiency and blazing fire; Danggui harmonizes Blood; slightly add Huangbai to nourish Kidney Water and drain latent Yin fire. If irritability persists, add Shengdi Huang (Rehmannia Root) to tonify Kidney. Abundant Water calms Fire. Chills/fever indicate Six Fu organ Yin deficiency externally; free urination/defecation indicates Five Zang organ Yang deficiency internally.

Those with chronic illness who feel energetic during labor experience boiling Yin Fire supporting internally, masking Yuan Qi deficiency. Rest allows Yin Fire to recede and Yang to return, revealing fatigue. However, Yang return marks recovery in internal injury.

Long-standing internal injury transforms before recovery. String-like pulse indicates transformation into malaria for cure; slow pulse indicates transformation into dysentery for cure; insufficient Lung Qi indicates transformation into wind-cough for cure. Malaria transformation opens Shaoyang Yang; dysentery transformation opens Yangming Yang; wind-cough transformation opens Taiyang Yang.

Internal injury chest fullness with wheezing indicates sinking Yang, rising Yin Fire, heat damaging Yuan Qi, and Spleen Qi deficiency. Treating as excess fire with Sangbai (Morus Root Bark) further damages Lung Qi.

Cough resembling wind-injury due to Lung deficiency failing to protect the exterior should be treated with Wenfei Tang (Warm the Lung Decoction) to secure the Lung. Cold herbs further damage Lung Qi, preventing generation of Kidney Water; dry Kidney Water leads to blazing Ministerial Fire, steaming marrow, causing Phthisis (Laozai). Phthisis without diarrhea indicates dried Yin Blood and Marrow; good appetite indicates strong Stomach Fire digesting grain.

Internal injury fever is floating deficient Yang, cold below/heat above, cold inside/heat outside; the heat is false. Liver, Spleen, and Kidney Yin reside below; within Yin resides Yang. If Yang is deficient and Yin prevails, Yang rebels upward, Yin stagnates below. Taiyin lacks Yangming Yang; Shaoyin lacks Taiyang Yang; Jueyin lacks Shaoyang Yang. Floating Yang above causes body heat. (Wang Xushan notes: Taiyin is Spleen, Yangming is Stomach... Shaoyin is Kidney, Taiyang is Bladder... Jueyin is Liver, Shaoyang is Gallbladder... Yin and Yang complement each other.) Use Paojiang to return Yangming to Spleen, Rougui to return Shaoyang to Liver, and Xixin (Asarum Root) to return Taiyang to Kidney. Descending Yang returns fire to its origin, stopping heat. Hence, Wenfei Tang is a holy medicine for reducing fever.

Internal injury is Middle Qi deficiency. Middle Qi is the hollow space at the navel, between the hypochondria. Spleen Qi resides within Middle Qi, relying on it, but is not identical to it. Middle Qi values emptiness, achieved by Spleen transport and ascending Yang. If Spleen Qi sinks and fills this space, the roots of Zang-Fu are damaged, and Qi/Blood pathways blocked. Spleen ascending relies on Stomach ascending. Spleen disperses essence upward to Heart, then Lung, then skin/hair. Light pure parts enter meridians as Ying; fierce parts enter skin as Wei. Food enters Stomach, transported by Spleen; essence ascends to Lung, transforms to fluids, descends, distributes to Heart, Spleen, Liver (becoming Blood), and Kidney (becoming Essence). Turbid parts enter幽门 (Yumen), Small Intestine, Large Intestine, Lamen, and exit via Changchang. Fluids seep into Bladder. Clear rises, Turbid falls, sustaining life and health. If diet damages Stomach or labor damages Spleen, transport fails, Qi stagnates in the middle, and Metal lacks... [Text cuts off]