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Chills and fever are also pathological conditions; they do not necessarily correspond to a single specific disease, nor do they necessarily lack a corresponding disease. Since Li Dongyuan, discussions on this topic have been quite complex, and by the time of Ming dynasty physicians, although more refined, they became overly pedantic and fragmented, confusing later learners. I now excerpt only those that are clear, concise, and easy to understand, omitting the rest. The examples cited here all belong to internal causes. As for exogenous cold-heat patterns, since they are already recorded in chapters such as *Shanghan Lun* (Treatise on Cold Damage), they will not be repeated.

General Discussion: What is the pathology behind alternating chills and fever? It results from the mutual overcoming of Yin and Yang. When Yang Qi is insufficient, chills precede fever; when Yin is insufficient, fever precedes chills. Furthermore, excess in the upper jiao leads to fever, while excess in the lower jiao leads to chills. Cold skin with dryness indicates insufficient Yang; hot skin with dryness indicates insufficient Yin. Cold skin accompanied by bodily coldness indicates Yin excess; hot skin accompanied by bodily heat indicates Yang excess. Heat arising from below indicates Yang pathogen within Yin; heat arising from above indicates Yang pathogen within Yang. Cold originating from above indicates Yin pathogen within Yang; cold originating from below indicates Yin pathogen within Yin. Chills with red cheeks and excessive talking indicate Yin pathogen within Yang (Note: "Cold with red cheeks" likely has a textual omission; the original text probably lacked the thirteen characters "Fever with red cheeks and excessive talking indicates Yang pathogen within Yang"). Fever with a blueish complexion and excessive talking indicates Yang pathogen within Yin; chills with a blueish complexion and excessive talking indicates Yin pathogen within Yin. If the patient does not speak, it is difficult to treat. Yin-Yin syndrome has one survivor out of ten deaths; Yang-Yang syndrome has nine survivors out of ten deaths. Yin diseases are hard to treat; Yang diseases are easier to cure. (*Zhongzang Jing*)

Ying (Nutritive) and Wei (Defensive) Qi derive from the Middle Jiao. If there is obstruction in the Middle Jiao, Ying deficiency leads to fever, and Wei deficiency leads to aversion to cold. Therefore, disorders of Qi and Blood, diet, and phlegm can all cause alternating chills and fever; this is the principle involved. (*Yi Jin Yi Fa*)

Alternating Chills and Fever: When Cold Qi merges into Yin, chills occur; when Yang Qi merges into Yang, fever occurs. Due to the imbalance of deficiency and excess in Yin and Yang Qi, pathogens alternate, causing alternating chills and fever. A tight and rapid pulse with simultaneous chills and fever indicates the condition must resolve upward to heal (Note: These three sentences originate from *Mai Jing*; the character "upward" is written as "downward" in *Mai Jing*, so "downward" should be followed). A pulse tense like a string indicates the pathogen has entered the Yangming channel. (*Zhubing Yuanhou Lun*)

Alternating chills and fever with a fixed schedule is malaria; without a fixed schedule, it is various other diseases. Some cases involve Shaoyang syndrome where cold pathogen remains in the Shaoyang channel, or women with cold damage where heat enters the Blood Chamber, resulting in alternating chills and fever. In frail individuals, both Yin and Yang Qi are deficient, leading to alternating chills and fever due to mutual overcoming (see detailed discussion in *Shanghan Lun · Pingmai Pian* under "Patient feels chilly and afraid of cold"). This is common after illness and postpartum. Some cases result from emotional depression; for example, widows or nuns, having only Yin without Yang, have blazing desire-fire internally causing internal heat; unfulfilled desires lead to Qi stagnation internally, unable to diffuse outward, causing exterior cold; over time, the stagnant heat is released, manifesting as exterior heat. Some cases involve retained food stagnation; mild cases require digestion-promoting methods, severe cases require purgation. (*Yi Que*)

Chills and Fever with Diurnal Variation: *Jingui Dayao Lun* states: Nighttime chills are a favorable sign (Cong); nighttime fever is unfavorable (Ni). Daytime fever is favorable; daytime chills are unfavorable. The signs of favorability and unfavorability depend on careful examination. (*Zhongzang Jing*)

Nighttime chills occur because Yin Qi (i.e., Cold Pathogen) is prosperous in the Yin division (Interior, Zang organs, Blood). Daytime chills occur because Yin pathogen attacks the Yang division. Chills throughout day and night indicate Heavy Yin. (Compare with the section on fever diurnal variation in *Refre Pian* for further clarity.) Note: Yang deficiency leads to aversion to cold and fear of Yin, so morning is peaceful and evening is chaotic (chills at night); Yin deficiency leads to fear of heat and aversion to Yang, so night is peaceful and morning is contentious (fever during day). These are signs of Righteous Qi deficiency. In Yang Excess syndromes, encountering Yang times makes the pathogen stronger, so morning fever and evening relief; in Yin Excess syndromes, encountering Yin times makes the pathogen stronger, so night chills and day relief. These are signs of Pathogenic Excess. When Yang is deficient and Yin pathogen invades the Yang division, illness manifests when Qi circulates through the Yang division twenty-five times, hence daytime chills and nighttime relief. When Yin is deficient and Yang pathogen sinks into the Yin division (i.e., Blood division), illness manifests when Qi circulates through the Yin division twenty-five times, hence nighttime fever and daytime coolness (observable in malaria occurring daily or nightly). These are signs of Righteous Deficiency with夹杂 Pathogen. Severe fever day and night indicates Heavy Yang without Yin; severe chills day and night indicate Heavy Yin without Yang; daytime chills and nighttime fever indicate Yin-Yang interlacing. In chronic weakness without diurnal distinction, with irregular onset and cessation, it is because Righteous Qi cannot sustain itself, and Yin and Yang attack each other with unpredictable fluctuations. (If seen in robust individuals at the onset of illness, it is due to struggle between Pathogen and Righteous Qi, causing intermittent disturbance; observe Shaoyang syndrome in cold damage where alternating chills and fever initially have no regular schedule.) (*Yi Que*)

Daytime fever with nighttime quietness indicates Yang Pathogen naturally prospering in the Yang division (Yang division refers to Exterior, Fu organs, Qi. Yang Pathogen in Yang division encounters Yang times, so fever arises). Daytime quietness with nighttime fever indicates Yang Pathogen sinking into the Yin division (observable in Heat Entering Blood Chamber syndrome where symptoms are lighter by day and heavier by night). Fever and irritability throughout day and night indicate Heavy Yang without Yin; urgently purge Yang heat and vigorously tonify Yin. (Ibid.)

Danxi discussed fever: Daytime heavy, nighttime light, with tasteless mouth indicates Yang deficiency. Afternoon fever stopping at midnight, with normal taste, indicates Yin deficiency. With full Yang and half Yin, Yang can encompass Yin, but Yin cannot encompass Yang. Cases occurring randomly day or night, intermittently, indicate deficiency of Spleen-Stomach Qi and Blood, and instability of Great Qi; these should not be confined to diurnal patterns. Yang deficiency responsibility lies in the Stomach; Yin deficiency responsibility lies in the Kidney. Irregular eating harms the Stomach; labor harms the Spleen, leading to Yang Qi deficiency. Sexual exhaustion harms the Kidney; overexertion harms the Liver, leading to Yin Blood deficiency. (*YiTong*)

Heat mostly occurring in afternoon and midnight, with emaciation and wiry-rapid pulse, belongs to Yin deficiency; prolonged, it becomes bone-steaming fever. Since Kidney governs bones, extreme Kidney Yin deficiency causes Ministerial Fire to blaze alone. (*Liu Yao*)

Distinction between External Injury and Internal Injury in Chills and Fever: External injury by Cold Pathogen, dietary indiscretion, physical overwork, and internal injury by diet all present with chills and fever. The world generally mistakes internal injuries from diet, indiscretion, and overwork for external cold injury with exterior excess, treating them by purging the exterior, leading to countless wrongful deaths. This stems from failing to distinguish the nature of chills and fever. Now, I will analyze them in detail. External cold injury presents with fever and aversion to cold, occurring simultaneously. The fever is like feathers brushing (Xi Xi Re or Fu Fu Re), arising on the skin and hair pores, indicating heat in the exterior; this is Cold Pathogen attacking the high exterior. Skin and pores are the domain of Yang, nourished by Wei Qi Yuan Qi. Cold pathogen invades, suppressing Yang Qi, preventing its extension, thus causing fever. Patients may have red faces, nasal congestion, mental restlessness, feeling slightly naked, unable to tolerate cold even with exposed skin. This superficial false heat ends here. Regarding aversion to cold, even with thick clothes, curtains, and proximity to fire, one cannot ward off the cold. It worsens daily until the pathogen transmits to the interior forming interior excess syndromes, then stops. Chills and fever occur together without interruption. Internal injury from undigested food or overwork may also present with headache, stiff neck, and back pain, slightly resembling Taiyang exterior syndrome, but otherwise different, as analyzed in the treatise. Internal deficiency diseases lack Yang Qi on the exterior, making them unable to withstand wind and cold; this is constant. Occasional heat arising from the Kidney area differs slightly from external cold injury. Aversion to wind and cold occurs because Spleen-Stomach deficiency causes Ying Qi to flow downward, attacking Liver and Kidney, a precursor to flaccidity and reversal cold. If Stomach Qi is normal, food enters the Stomach, Ying Qi flows upward to Heart and Lung, nourishing the Qi of the upper jiao skin and pores. Since Ying Qi flows downward, Heart and Lung receive nothing; skin lacks Yang Qi, losing Ying-Wei protection. Thus, Yang Qi in skin and pores is weak; seeing wind or cold, or staying in dark/cold places without sunlight, causes aversion. This is constant and uninterrupted. Avoiding wind/cold, staying warm, or adding clothes relieves the aversion. This heat is not exterior cold-induced fever in skin/pores, but dampness from Spleen-Stomach downward flow blocking the lower body, causing Yin Fire to rush upward, creating steaming irritant heat penetrating head and skin. Relief comes from exposing oneself to cool air or sweating profusely. Does external cold injury with chills/fever cause sweating? No, sweating indicates recovery. Distinguishing them is as easy as distinguishing black from white. (*Bian Huo Lun*)

Overview of Aversion to Wind: Internal injury aversion to cold has five types: 1. Yang decline and exterior deficiency; 2. Yin invading Yang position; 3. Yang Qi depression and sinking; 4. Heat excess dispersing Qi; 5. Lung punished by Fire. (*Yi Que*)

Aversion to cold differs between Yang deficiency and Yang depression. Yang deficiency requires tonification and warming; Yang depression requires opening the upper jiao to vent Yangming Qi, as Danxi said: long-term aversion to cold requires resolving depression. (*Jingui Yi*)

Yang Deficiency Aversion to Cold (Body Weakness with Cold Invasion): Yang deficiency pulse is deep, fine, and weak, lacking spirit upon pressing, without rapidity. Body is cool, face pale, no headache, no thirst, fearful even in deep rooms without wind, palpitations, timidity, suspicion, spontaneous sweating, insomnia, fatigue, reluctance to speak, normal appetite, preference for hot/cold aversion. All are signs of extreme Primordial Yang deficiency. In heaven called severe cold; in humans called true cold. Requires large doses of warming tonics to cure. (*Bai Wen*)

Yang deficiency causes aversion to cold; use Ginseng and Astragalus. Severe cases add small amounts of Aconite to move the Qi of Ginseng and Astragalus. (*Danxi*)

Yu Zi Yuan suffered from chills and tremors, unable to hold still, hands soaked in cold sweat. Thick clothes and fires did not help. Ying Ningsheng prescribed Zhen Wu Tang using six pieces of Aconite. One day the patient went out unexpectedly. People were surprised. Patient said: "Once my aversion to cold ceases, I am fine." Asked Ying Ningsheng, he replied: "His pulse was deep and faint in both hands, with no other exterior-interior signs. This is body weakness with cold invasion, extreme loss of Yang. Initially, skin and Qi tunnels were blocked by Cold Pathogen, preventing Yang extension. Thus, blood tunnel heat blockage needs Nitre and Rhubarb; Qi tunnel cold blockage needs Cinnamon and Aconite. Yin and Yang uses differ due to formless vs. formed distinctions." (*Yi Shi*)

Heat Excess Aversion to Cold: Visceral excess heat or unresolved deficiency heat may manifest with cold-like symptoms, appearing chilly. However, unlike Yang deficiency fearfulness, it may start with aversion but become normal later. Symptoms include dry thirst craving cold drinks, constipation, scanty dark urine, phlegm cough with dry throat, mouth ulcers, red eyes, surging or deep-rapid pulses strong upon pressing, indicating Excess Heat. In contrast, Yin deficiency/Blood deficiency pulses are rapid, choppy, and weak. Despite exterior aversion to cold, treatment focuses on clearing and dispersing heat. This pattern is caused by Yang Pathogen rising internally, forcing Yin outward, resulting in internal heat and exterior cold. Acrid-warm herbs are strictly contraindicated; sweet-cool herbs bring peace. (*Bai Wen*)

*Yuan Bing Shi* states: Severe heat patients feeling cold internally are suffering from heat, not cold. Someone asked: Why do some improve slightly with hot herbs? I say: Heat patients have flaming Qi, stagnating into phlegm-fluids, obstructing clear pathways, preventing Yin ascent, worsening heat. Phlegm temporarily retreats with heat, but heat aids the pathogen, deepening the disease. (*Gezhi Yulun*) (Note: Liu Hejian and Zhu Danxi based this on Luck Theory. *Tongzhi* says: Aversion to cold belonging to heat is logical and needs no doubt. However, slight improvement with hot herbs only happens in mild heat cases; in deep heat, hot herbs worsen the condition, never curing it. Mild heat treated with hot herbs may seem better briefly but recurs soon. Unobservant doctors think medicine hasn't taken effect, continue giving hot herbs, intensifying fire and deepening disease, potentially leading to Yang hyperactivity and Yin exhaustion, irrecoverable. Beware!)

Duke Xia Ying often consumed Aconite and Typha pollen, living in silk tents. Unaware that damp-phlegm accumulated in the middle, suppressing Yang Qi from diffusing outward, causing body aversion to cold. Classic says: Hyperactivity causes harm; control brings balance. Liu Hejian said: Extreme fire resembles water. Thus, treat with salty-cold herbs assisted by sweet-warm, considering root/branch priority and excess/deficiency of Zheng/Xie. Why use Aconite, Typha, dan pills, and drying drugs, akin to adding fuel to fire or acting like executioners? Ancients cured tremors with Da Cheng Qi Tang purgation. Aversion to cold and tremors are clearly heat syndromes, often caused by long-term hot herb use, differing only in excess/deficiency. Scholar Zhou Bendao, nearly forty, had aversion to cold. After taking Aconite for days, condition worsened. I diagnosed wiry-slow pulse. Used Jiang tea with ginger juice and sesame oil, vomited one sheng of phlegm, reduced silk clothing by half. Then gave Tong Sheng San, removing Ephedra, Rhubarb, Mirabilite, adding Angelica and Rehmannia. Over a hundred doses brought stability. Also, Lady Jiang, fifty-plus, thin black-faced, preferring heat/hating cold in June, deep-choppy pulse seeming rapid on heavy press. Given San Huang Wan with ginger juice, 30 pills per dose, 30 doses brought slight sweating and stability. (*Ju Fang Fa Hui*)

A woman with cold body and faint pulse ate boiling porridge, wore heavy clothes in June, covered head with fox hat, still felt cold, with continuous diarrhea. She took Ginger, Aconite, Sulfur, and hot drugs, achieving only mild stability; any cold drug worsened her condition. She remained ill for three years. Dai Ren found her pulses firm like a rope, 6-7 beats per breath. *Mai Jue* says: Six rapid/seven extreme indicates much heat. Placed cool cloth on heart, then splashed fresh water on lesions. Woman screamed. Held down, splashed with cold water, 30-40 buckets. Profuse sweating, unconscious for 1-2 days, all previous aversions removed. Hua Yuanhua used this method before, unfortunately unknown. (*Shi Xing San Liao*)

Madrigate Qian Xin's wife suffered aversion to cold, covering head with thick fur day and night, jumping into boiling water unaware. Doctors thought severe cold. Weng Chi said: This is Phlegm-Fire rushing up, extreme Yang resembling Yin. Must purge, or fire won't die. After purging overnight, removed fur, called for water, recovered in ten days with calm Qi. (*Yi Shi Ju Quan Weng Zhuan*)

Xue Lizhai treated a man with internal heat/thirst, constipation, fear of wind/cold, cold limbs. This is internal true heat with external false cold. Treated with Huang Lian Jie Du Tang, cured. Later used Di Huang Wan to strengthen Water Master to suppress Yang Light. (*Da Hai*) (Source to be verified)

Overview of Fever: Fever is heat manifesting on the muscle surface. Most diseases involve fever; heat generates from Fire, Fire originates from Qi (Danxi said: Excess Qi is Fire, illustrating this principle). The mechanism involves Qi deviation and Qi stagnation. Qi deviation has three types: 1. Yang hyperactivity fever; 2. Yin deficiency fever (same as Blood deficiency); 3. Yang deficiency fever. Qi stagnation has seven types: 1. Wind-Cold stagnating heat; 2. Diet stagnating heat; 3. Phlegm-Fluid stagnating heat; 4. Blood Stasis stagnating heat; 5. Water-Dampness stagnating heat (these five are covered in other sections, so omitted here); 6. Liver Qi stagnating heat; 7. Spleen Qi stagnating heat. (*Yi Que*) (Note: *Jingui Yi* classifies into eight categories: Fatigue, Fire Stagnation, Blood Deficiency, Yang Floating, Phlegm Accumulation, Blood Stasis, Bone Steaming, Food/Wine Toxicity, somewhat similar to this.)

True vs. False Heat: Sheng Qidong said: Treating heat requires distinguishing true/false. True heat presents with fever/aversion to cold, rapid-strong pulse, deeper pressure reveals solidity, irritability/thirst, dry stool, dark/scanty urine, or foul diarrhea, loud speech, dislike of clothing. Exterior-proximate cases need dispersion; interior-proximate cases need purgation. False heat also presents with fever/aversion to cold, but feet are not hot, pulse is large-empty, weak on pressure. Body hot but not irritable/thirsty, or false madness/thirst unable to drink, subsides quickly after onset, voice not loud/cursing. Classic says: Heat has true/false, treatment has reverse/follow. This is what is meant. (*YiTong*)

Excess vs. Deficiency Heat: Abundant flesh/blood, lustrous skin/hair, Yin excess with heat, able to eat with heat, bitter/dry mouth, difficult stool, surging pulse indicates Excess Heat. Bone atrophy, dry flesh, lax tendons, depleted blood, gathered skin, fallen hair, Yin deficiency with heat, unable to eat with heat, shortness of breath, empty pulse indicates Deficiency Heat. (*Yi Que*)

Sudden persistent fever with slippery-rapid or surging pulse indicates Excess Heat; clear based on exterior/interior severity. Deep pulse solid upon pressing indicates Interior Excess; must use bitter-cold purgation. Persistent fever with empty-rapid-weak pulse, unresponsive to tonics, tasteless food, nighttime thirst/irritability, or dry cough indicates Yin Blood injury; tonify Yin with Blood herbs, Yang heat will transform. Must carefully examine Yin/Yang excess/deficiency mechanisms and urgently shift the course. (*YiTong*)

Origin of Fever: Yin insufficiency leads to Yang bias; Yang bias causes fever. Heat starting from back or limbs, spreading gradually, dry mouth/tongue, craving water, frequent irritability. Caused by Yin Qi deficiency, little water cannot extinguish盛 fire. Yang Qi starts from extremities, circulates on back; Yin cannot contain Yang, hence fever. Day fever/night peace, or night fever/morning light, pulse empty-rapid-small (Note: Original location Shaoyao Huangqi Tang uses Peony, Astragalus, Licorice, Artemisia). Heat starting from abdomen, moving up chest/axilla, around neck/forehead, initially warm, becoming hot, irregular onset, worse with hunger, epigastric discomfort, polyphagia with emaciation, sallow face, dull muscles, dry lips. Caused by weak Spleen Qi, mistakingly given hot herbs after other illnesses, entering Spleen. Spleen heat digests food eagerly, consumes muscles. Pulse soft-weak-rapid (Note: Original location Shenju Wan uses Tangerina, Ophiopogon, Ginseng). Heat from abdomen or back spine, gradual steaming heat, worse at dusk, fading at night, sweating during sleep, urine red/cloudy/frequent/sperm emission, dreams of intercourse, gradual emaciation. Caused by excessive thinking, Heart Qi consumption, Yang Qi dissipation, Spirit unrestrained, Yin unsupported. Treatment belongs to Consumption Disease (Note: Original location Da Jian Zhong Tang). Heat from waist up, extreme sweating, cooling after sweat, returning to normal, then dizziness, abdominal distension, Qi attacking upward, frequent cough, rib pain牵引, nocturnal palpitations, wiry-rapid-pulse. Caused by external cold clashing, internal cold combining. Cold contracts Qi, fluid gathers and stagnates,