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For all diseases, there are few that do not present with fever. The key distinction lies between internal injury (Neishang) and external contraction (Waigan), which have been categorized separately with detailed treatment methods discussed previously. Here, a chapter on "Fever" is established to emphasize internal injuries, demonstrating general principles for treating fever. *Mingyi Zazhuo* states: Among the various febrile conditions in the world, several resemble Taiyang disease (Shanghan). Their treatments differ. Zhang Zhongjing's discussion of Taiyang disease and wind-stroke refers to external contractions. Because pathogenic factors of wind and cold invade from the exterior, moving from the surface inward, it is appropriate to use methods that release the exterior to disperse them; this is the rationale behind Mahuang Tang (Ephedra Decoction) and Guizhi Tang (Cinnamon Twig Decoction). Since these illnesses occur during the cold months of winter and spring and manifest immediately upon exposure, they are termed Taiyang disease. Medications should be pungent and hot to overcome the cold. However, if the season is not cold, the medications must change. In the warm months of spring, pungent-cool medications should be used; in the hot months of summer, sweet-bitter-cold medications should be employed. Thus, it is said that if Taiyang disease does not manifest immediately, it may transform into Warm Disease (Wenbing) in spring or Heat Disease in summer, and its treatment must vary according to the season. There is also a condition called Winter Warmth, described as "having the qi of another season at the wrong time." Although winter is cold, warmth illness occurs instead; this indicates improper heavenly timing where yang qi leaks abnormally, so warming medications should not be used. Another condition is seasonal cold epidemic, occurring during warm times when warmth prevails but cold becomes pathogenic due to improper heavenly timing and rebellious yin qi; cooling medications should not be used. Additionally, there are epidemic heat diseases caused by pestilential qi of heaven and earth, often spreading throughout households and regions during spring and summer. Treatment should follow the seasonal qi and luck cycles, utilizing Liu Hejian's (Liu Wansu's) pungent-cool, sweet-bitter-cold medications to clear heat and resolve toxicity. All the above conditions result from external contraction of heaven-and-earth pathogenic factors.

In contrast, dietary irregularities and overexertion cause internal injury to primordial qi, leading to the sinking of true yang and the generation of internal deficiency heat. Therefore, Li Dongyuan proposed the theory of tonifying middle qi and raising yang, using sweet-warm medications such as Renshen (Ginseng Radix et Rhizoma) and Huangqi (Astragali Radix) to greatly tonify qi and lift the sinking qi; this uses qi-tonifying herbs to address qi insufficiency. Furthermore, mental overwork and excessive sexual activity injure true yin. Once yin blood is damaged, yang qi becomes hyperactive and transforms into fire. This is known as deficiency-fire hyperactivity in consumptive disease (Laozai). Zhu Danxi proposed the theory of "hyperactive yang and insufficient yin," using Siwu Tang (Four Substances Decoction) plus Huangbai (Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma) to nourish yin, causing fire to subside naturally; this uses blood-nourishing herbs to address blood insufficiency. Tonifying qi and nourishing yin both belong to internal injuries. One addresses sinking yang qi by tonifying and lifting it; the other addresses rising yang fire by nourishing yin to descend it. One lifts, one descends; they are fundamentally different.

There is also Summerheat Injury occurring in summer. Although it is an external contraction, it resembles internal injury and differs greatly from Taiyang disease. Cold injures the form; cold pathogens lodge in the exterior, representing an excess syndrome, so sweating is indicated. Summerheat injures qi; primordial qi is damaged and scattered by heat, representing a deficiency syndrome, so tonification is indicated. This is what Li Dongyuan referred to as clearing summerheat and benefiting qi. There are also cases where, due to seasonal summerheat, one consumes excessive cold foods damaging the interior, or seeks excessive cool winds damaging the exterior. These are not illnesses caused directly by summerheat, but self-induced conditions due to summerheat. Treatment requires pungent-hot exterior-releasing or pungent-warm middle-regulating medications, similar to Taiyang disease treatment. All these conditions appear similar externally but differ实质上. Treatments are diverse and must not be erroneous. One must ascertain whether it is Taiyang disease, wind-stroke, or cold epidemic to apply Zhongjing's methods; whether it is Warm Disease or plague to apply Hejian's methods; whether it is qi deficiency to apply Dongyuan's methods; or whether it is yin deficiency to apply Danxi's methods. Only then can errors harming patients be avoided.

Currently, people see only fever and assume it is always Taiyang disease or external contraction, rashly using diaphoretic drugs to release the exterior. If fever persists after sweating, they use cooling exterior-releasing drugs. If it is a deficiency syndrome, would this not be fatal? Occasionally, some recognize fever as deficiency and use tonics, yet fail to distinguish between qi and blood, treating qi disorders with blood tonics or blood disorders with qi tonics, misleading many. Thus, external contraction vs. internal injury, cold disease vs. heat disease, qi deficiency vs. blood deficiency are like ice and charcoal. If treated incorrectly, mild diseases become severe, and severe diseases become fatal. Should one not fear this?

To differentiate internal injury from external contraction: Renying pulse larger than Qikou pulse indicates external contraction; Qikou pulse larger than Renying pulse indicates internal injury. External contraction presents with simultaneous chills and fever without interval; internal injury presents with alternating chills and fever irregularly. External contraction involves aversion to cold that cannot be relieved even by proximity to fire; internal injury involves aversion to cold that resolves with warmth. External contraction involves aversion to wind, intolerant of all wind and cold; internal injury involves aversion to wind, sensitive only to slight drafts. External contraction signs manifest in the nose, causing nasal congestion and forceful breathing; internal injury signs manifest in the mouth, causing loss of taste and abdominal discomfort. External contraction has excess pathogenic qi, resulting in loud speech starting soft and becoming strong; internal injury has deficient primordial qi, resulting in weak speech starting strong and becoming soft. External contraction headache is constant; internal injury headache comes and goes. External contraction causes heat in the back of the hand but not the palm; internal injury causes heat in the palm but not the back of the hand. These are the main points of Li Dongyuan's differentiation. Cases exist with only internal injury or only external contraction; distinguishing them clarifies the diagnosis. If both internal and external factors coexist, pulses and symptoms appear together, making differentiation difficult, requiring careful inquiry. If internal signs predominate, internal injury is heavy and external contraction light; tonification and nourishment should take priority. If external signs predominate, external contraction is heavy and internal injury light; dispersing and releasing should be urgent. This is an implication not explicitly stated by Dongyuan.

Dongyuan stated: Each of the five zang organs has pathogenic heat with distinct manifestations. Palpation reveals three methods: Light palpation yields heat, heavy pressure yields no heat → heat is in skin/hair and vessels. Heavy pressure to sinews/bone yields intense heat, light touch yields no heat → heat is in sinews/bones. Light touch yields no heat, heavy pressure yields no heat, moderate pressure yields heat → heat is in muscles (between sinews/bones and skin/vessels). These three methods are generally treated with Sanhuang Wan (Three Yellows Pill). Differentiated by organ: Lung heat is detected lightly, disappears with slight pressure, visible on skin because lung governs skin. Worse in evening, heat in skin. Symptoms include panting/coughing, chills/shivering. Mild cases use Xiebai San (Drain White Powder); severe cases use Liangge San (Cool Diaphragm Powder) or Baihu Tang (White Tiger Decoction), or Dihuang Digupi San (Rehmannia and Bark of Ground Tree Bark Powder). (Haizang said: Skin feels like burning fire but deep pressure is not very hot = Lung heat. Red whites of eyes, irritability, thirst → single herb Huangqin Decoction. Danxi's Qingjin Wan or Huangqin Porcelain Pill suppress spleen/lung fire, draining blood-level heat in lungs. Xiebai San drains qi-level heat in lungs.) Heart heat is governed by heart vessels. Slight pressure below skin/above muscle detects heat. Heat in vessels. Worst at noon, heart heat. Symptoms: vexing heart, chest pain, hot palms, hiccups. Treated with Huanglian Xiexin Tang (Coptis Decoction to Drain the Heart), Daochi San (Directing Red Powder), Zhusha Wan (Cinnabar Pill), Anshen Wan (Calming Spirit Pill), or Qingliang San (Cooling Clearing Powder). (Qianjin's Dihuang Wan, Mendong Wan, Qingxin Wan, Huofu Dan. Daochi San drains Bing [Small Intestine], Xiexin Tang drains Ding [Heart], Huofu Dan drains both.) Spleen heat: Light touch no heat, heavy pressure to bone no heat, moderate pressure detects heat in muscles. Worse at night. Symptoms: lethargy, desire to lie down, limbs unresponsive, lack of qi to move. For excess heat: Xiehuang San (Drain Yellow Powder) or Tiaowei Chengqi Tang (Regulate Stomach and Direct Downward Decoction). For middle deficiency with heat: Renshen Huangqi San or Buzhong Yiqi Tang (Tonify Middle and Benefit Qi Decoction). Liver heat: Pressure below muscle to above bone detects liver heat. Worst at Yin/Mao hours (3-7 AM), pulse wiry. Symptoms: limb fullness/stuffiness, difficult defecation, tendon cramping, anger/fright, limb heat, tendon weakness unable to rise from bed. Treated with Xieqing Wan (Drain Green Pill) or Chaihu Yin (Bupleurum Drink). Wiry pulse in both hands or onset at Yin/Shen hours indicates liver heat. (Danggui Longhui Wan, Huijin Jiu, Zuojin Wan.) Kidney heat: Light pressure no heat, heavy pressure to bone yields intense heat like fire. Bones feel sore/weak, like insects biting bones, unbearable heat, unable to rise. Treated with Zishen Wan (Nourish Kidney Pill) or Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill). Pulse differentiation: Light pressure (weight of 3 beans) matching skin, surging/rapid = Lung heat. Weight of 6 beans matching vessels, surging/rapid = Heart heat. Weight of 9 beans matching muscle, surging/rapid = Spleen heat. Weight of 12 beans matching sinews, surging/rapid = Liver heat. Pressure to bone, rapid return, surging/rapid = Kidney heat.

Heat with exterior signs is Exterior Heat; heat without exterior signs is Interior Heat. Bitter flavors treat five zang (yin, interior). Pungent flavors treat six fu (yang, exterior). Thus, interior heat is purged downward, exterior heat is released outward. Nourishing blood and benefiting yin removes body heat naturally. Pulse: Floating-rapid is exterior heat; sunken-rapid is interior heat. Floating-large-forceful is exterior heat; sunken-large-forceful is interior heat. Fever by day, quiet by night = Yang qi flourishing in yang divisions. Quiet by day, fever/vexation by night = Yang qi sinking into yin, named "Heat Entering Blood Chamber". Fever/vexation by day and night = Extreme Yang without Yin, urgently drain Yang and tonify Yin. Day fever moves through 25 Yang degrees → Chaihu Yinzi. Night fever moves through 25 Yin degrees → Sishun Yinzi. Dawn fever, heat in Yang division, governed by Lung qi → Baihu Tang to drain qi-level fire. Afternoon tidal fever, heat in Yin division, governed by Kidney qi → Digupi San to drain blood-level fire. Baihu Tang treats surging pulse, suppressing it to allow Autumn qi to descend. Digupi San treats wiry pulse, lifting it to allow Spring qi to ascend. Qi-level heat: Chaihu Yinzi, Baihu Tang. Blood-level heat: Qingliang Yinzi, Taoren Chengqi Tang. (Qianniu pungent/acrid, drains damp-heat from qi, not blood. Fangji bitter/cold, drains damp-heat from blood, unblocks blood stasis.) When yin of bone/flesh/sinew/blood/skin is sufficient but heat dominates, it is Excess Heat. Bone atrophy, flesh dryness, tendon laxity, blood depletion, skin shriveling/hair loss with heat disease is Deficiency Heat. Eating well with heat, dry mouth/tongue, difficult stool = Excess Heat. Use acrid/bitter/great-cold purgatives to drain heat and tonify yin. Classic: "Yang excess, yin deficiency, purgation cures." Surging-forceful pulse confirms this. Poor appetite with heat, spontaneous sweating, short breath = Deficiency Heat. Use sweet-cold agents to drain heat and tonify qi. Classic: "Treat heat with cold, administer warm." Weak-pulseless confirms this. *Jingui Yaolue*: Heat in upper jiao causes cough and Lung萎 (Flaccidity). Heat in middle jiao causes hardness. Heat in lower jiao causes hematuria and strangury obstruction. *Lingshu*: Heat in front of elbow = heat above waist. Heat in front of hand = heat below waist. Heat only in front of elbow = heat in chest front. Heat only in back of elbow = heat in shoulder/back. Heat in arm = heat in waist/abdomen. Heat 3-4 cun below back of elbow = worms in intestines. Heat in palm = heat in abdomen. Stomach Meridian of Foot-Yangming abundance = heat along front of body. Stomach heat digests food, causes hanging heart/hunger, heat above navel. Intestinal heat causes yellow mushy stool, heat below navel. Stomach is above navel, so stomach heat heats above navel. Intestines are below navel, so intestinal heat heats below navel. Liver/Gallbladder in flanks, heat there heats flanks. Lung in chest/back, heat there heats chest/back. Kidney in waist, heat there heats waist. Inferable similarly. Upper jiao heat, body heat, surging pulse, no sweat, much thirst → Jiegeng Tang. Yi Lao's method: Liangge San minus Dahuang/Mangxiao, add Jiegeng as boat/pilot agent to float upward, treating chest/diaphragm and six meridians heat. Shaoyang qi descends through diaphragm to chest; Sanjiao qi travels with Ministerial Fire on body surface. Diaphragm/six meridians are highest parts; this drug floats to highest part, removing heat from chest/diaphragm and six meridators. General Sanjiao heat meds: Upper jiao heat → Zhizi, Huangqin. Middle jiao heat, dysuria → Huanglian, Shaoyao. Lower jiao heat → Huangbai, Dahuang. Upper jiao heat formulas: Qingshen San, Lianqiao Fangfeng Tang, Liangge San, Longnao Yinzi, Longnao Jisu Wan, Shuijiao Dihuang Tang. Middle jiao heat formulas: Xiao Chengqi Tang, Tiaowei Chengqi Tang, Xixin San, Sishun Qingliang Yin, Taoren Chengqi Tang, Xiepi San, Guanzhong San. Lower jiao heat formulas: Da Chengqi Tang, Wuling San, Lixiao San, Bazheng San, Shiwei San, Siwu Tang, Sancai Fengsui Dan, Zishen Wan. General for severe Sanjiao heat: Sanhuang Wan, Huanglian Jiedu Tang. Sudden heat = disease in Heart/Lung. Accumulated heat = disease in Kidney/Liver. Sudden heat → Ju Fang Xionghuang Jiedu Wan. Accumulated heat → Ju Fang Miaoxiang Wan. Sudden upper panting = High Panting, disease in Heart/Lung → Muxiang Jinlingzi San. Upper jiao heat with vexation → Niuhuang San. Chronic emaciation, fever, night sweats = Five Zang total damage, Heat Labor/Bone-steaming disease. Emaciation, deficiency, vexing panting, bloody diarrhea = Steaming Labor. Treatment: Nourish blood, benefit yin, heat retreats naturally ("treating by not treating"). Qian's Dihuang Wan. Huanglian Jiedu Tang treats severe heat/vexation, delirium, insomnia. Add Fangfeng/Lianqiao → Jinhua Wan (Wind-Heat). Add Chaihu → Pediatric tidal fever. Combined half-half with Siwu Tang → Female tidal fever. Yin covering Yang, fire cannot extend → Sweating indicated. Classic: "Body like burning charcoal, sweat disperses it." Wiry-rapid pulse = Yin qi. Use wind drugs to raise Yang and vent fire stagnation, rapidly reducing rapid pulse. For rapid pulse in this disease, use Huangbai, add small amounts of Huanglian, Chaihu, Cangzhu, Huangqi, Gancao, plus Shengma. Sweating causes pulse to drop, meaning "venting fire stagnation." Men/women limb heat, muscle heat, tendon bi heat, marrow heat, like fire burning, touching feels hot. Limbs governed by Spleen (Earth). Heat hidden in earth, often due to blood deficiency. Also due to Stomach deficiency, excessive cold food/water, stifling Yang qi in Spleen Earth. Classic: "Vent fire stagnation" → Chaihu Shengyang Tang. Five-center heat = fire stagnating in earth. Limbs = Earth. Heart fire sinks into Spleen Earth → Raise/Vent fire stagnation → Huoyu Tang. Palm/sole heat → Zhizi, Xiangfu, Cangzhu, Baizhi, Banxia, Chuanxiong powder, Shenqu paste pill. Extreme hand heat = Bone Jue, like in fire, mo Yongquan point 3 moxibustions cures instantly. *Suwen* Emperor: Why limbs hot, feeling like roasting/fire when encountering wind/cold? Qibo: Yin qi deficient, Yang qi abundant. Limbs are Yang. Two Yangs combine, Yin deficient. Little water cannot extinguish great fire, Yang rules alone. Alone ruling cannot grow, only wins temporarily. Encountering wind like roasting = flesh wasting. Zhongjing's Sanwu Huangqin Tang treats female limb vexing heat. Post-smallpox residual heat, scabs not healing, constipation = Blood Dryness. Treat with yin drugs, tonify, use Qingliang Yinzi to unblock stool and drain heat. Jiuguo: Cool wind arrives, plants fruit. Qingliang Yinzi is autumn wind clearing heat agent. Taiyang exterior pathogen enters interior, afternoon tidal fever, great thirst, delirium/manic agitation, constipation = Stomach Excess, can be purged. Stomach qi injured by heat, Chengqi Tang drains upper excess, allowing primordial qi to circulate freely, hence name "Chengqi" (Supporting Qi). People today use bitter to drain fire, so I state this clearly. Removing heat/draining fire requires Sweet-Cold, not Bitter-Cold. Bitter-cold draining fire is useless and harmful. Great heat, surging-large pulse, bitter-cold fails to reduce heat → Add Shigao (Gypsum). Symptoms subside but pulse remains rapid/surging/worsening → Reduce bitter-cold, add Shigao. Soft stool/diarrhea → Add Jiegeng, take after meals. Misuse harms significantly; add gradually. Low appetite → Do not use Shigao. Shigao removes rapid pulse. If symptoms subside but pulse remains rapid, untreatable. Muscle heat/dry heat, red eyes/face, vexing thirst, day/night ceaseless, floating-large-deficient pulse, empty on heavy pressure = Blood Deficiency Fever. Resembles Baihu Tang pattern, distinguished by pulse not long/excess. Mistaken Baihu Tang use is dangerous. Use Danggui 2 qian, Huangqi 1 liang, decoct. Kidney deficiency, fire not returning to channel, wandering exterior causing fever, vexing thirst, red face/tongue, tongue prickles, black cracked lips, throat like smoke/fire rising, sole heat like branding, phlegm-saliva congestion, panting, surging-rapid chaotic pulse, weak on pressure → Shiquan Dabu Tang, swallow Bawei Wan. Question: Such dry-heat, adding Gui/Fu, isn't it adding fire to fire? Answer: Pericardium Ministerial Fire attaches to Mingmen (Right Chi). Men store essence, women connect to uterus. Depletion by desires leaves fire without attachment, rebelling upward. Gui/Fu share nature with fire, pungent flavor opens pores, promotes fluids/qi channels, occupies nest to attract fire. Same nature attracts, fire descends. Fire from Kidney is Fire in Water. Fire can be broken by water, but Fire in Water cannot. Bashu has Fire Wells: water makes them burn, fire makes them extinguish. Thus Gui/Fu are correct medicines for Ministerial Fire. Yang Renzhai: Severe heat/vexation → Chaihu, Huangqin, Dahuang to resolve. Heat slightly lighter but persists → Huangqin, Chuanxiong, Gancao, Wu Mei decoction, or Huanglian, Shengdihuang, Chifuling decoct, add Dengxin (Juncus) before finishing. Effect fast. Chuanxiong/Shengdihuang regulate blood. Once Heart blood regulated, heat retreats. Pulsing choppy →必有 rinsing water symptom, vomiting/phlegm, cold feet symptoms.