Jing He, Zhao Hongbing, Shao Ming, Chen Guangmei, Wanlingfeng and Luyuan.

The basic pathogenesis of internal injury and fever is internal injury, deficiency of qi, blood, yin and yang, and dysfunction of viscera. Internal injury heat is a kind of fever corresponding to exogenous heat, which can be seen in many diseases and is more common in clinic. Include fever caused by tumor, hematological diseases, connective tissue diseases, endocrine diseases, tuberculosis, functional low fever and chronic infectious diseases in modern medicine.

1 etiology and pathogenesis

As early as Neijing, there were records of internal injuries and fever. In the Han Dynasty, Zhang Zhongjing began to elaborate on the etiology, pathogenesis and treatment of internal injuries and fever. In Ming Dynasty, Wang Lun put forward the name of "internal injury fever" for the first time in Miscellaneous Works of Ming Medicine: "Internal injury fever is yang deficiency, which can not be reached because of yang self-injury, and internal heat due to yin deficiency." On this basis, later generations of physicians gradually improved and deepened. Chinese medicine believes that the main causes of internal injuries and fever are internal injuries, diet, fatigue, emotions, and subsequent diseases. Its pathogenesis is phlegm-dampness, qi stagnation, blood stasis and yin deficiency of qi and blood.

1. 1 phlegm dampness

As for the heat caused by phlegm-dampness, Zhang said in The Scholars: "All phlegm is on the diaphragm ... or it may cause hot flashes" and "All phlegm is in the mouth, and poison is smoked on the head ... The nose is thick and sticky, or coughing may cause a cold and fever". The phlegm-heat syndrome was described for the first time. Zhang Zhongjing in Han Dynasty clearly pointed out that dampness can cause fever. "Wet home is sick, aching all over, having a fever, and having a yellow body color." Heat caused by dampness is due to spleen and stomach damage, negligence of transportation, endogenous phlegm-dampness, depression and heat depression, which in turn leads to phlegm-heat depression. Patients with phlegm-dampness may have pathological changes such as qi stagnation, blood stasis and yin deficiency. Phlegm-dampness blocks qi movement, qi stagnation leads to blood stasis, blood circulation is not smooth, and blood stasis stops inside, leading to blood stasis; Damp-heat accumulation, consumption of vaginal fluid, consumption of vaginal fluid decreased, forming yin deficiency.

1.2 qi stagnation

Fever is caused by emotional depression, stagnation of liver qi, stagnation of qi into fire, or excessive anger and excessive liver fire, which leads to fever. As Zhu Danxi said, "Qi is full of fire", and he also said that "Qi and blood are in harmony, and all diseases are not born, and all diseases are born if there is depression". Those with fever due to qi stagnation may be excessive qi stagnation or excessive liver fire. Qi stagnation can also form pathological changes such as blood stasis, phlegm turbidity and yin deficiency. Qi stagnation in a certain part of the body can block the qi of meridians, hinder blood circulation and form blood stasis; Qi stagnation can cause disorder of body fluid metabolism, and Shui Gu subtle energy can not be transported normally, which makes water wet and stagnate, resulting in phlegm and turbidity; Qi stagnation turns into fire, fire hurts yin, consumes yin essence, and can be accompanied by pathological changes such as yin deficiency.

1.3 blood stasis

Wang Qingren described the symptoms of blood stasis causing heat as "cold outside and heat inside, hence the name lamp disease, with blood stasis inside". The symptoms and pathogenesis of lantern disease are briefly and vividly expounded. The pathogenesis of blood stasis and fever is discussed in Ling Shu Wan: "If the camp guards stay in the meridians, the blood will cry but not work;" If you can't, the defensive qi will not work, so it is hot. " It is believed that the main pathogenesis of blood stasis fever is that blood stasis blocks meridians, and qi and blood flow is not smooth and stagnant, leading to fever. In addition, blood stasis also has a certain relationship with blood deficiency and malnutrition. For example, the Theory of Deficiency in Medical Law says: "Blood stasis means that new blood is not born, and the known blood is not good, and blood stasis means glory deficiency, and glory deficiency means heat."

1.4 Qi deficiency

In Su Wen Tiaojing Lun, the pathogenesis of "qi deficiency and internal heat" is "mental fatigue, less decline of body qi, insufficient grain qi, inability to concentrate on the upper jiao, obstruction of the lower wrist, stomach heat and steaming in the chest", which is the theoretical basis of internal injury caused by spleen deficiency and fatigue. Li Dongyuan first put forward the concept of "qi deficiency and fever", which was summed up as "improper diet and discomfort caused by cold will hurt the spleen and stomach, which means that the spleen and stomach are weak, the vitality is insufficient, and the heart is full of fire". Forty-nine Difficult Classics: "How do you know that you are tired from eating and drinking ... you are hot and heavy, prone to lie down, with no limbs closed, and a large and slow pulse", describing the causes and symptoms of qi deficiency and fever.

Zhang Jingyue, a physician in the Ming Dynasty, clearly mentioned that fever due to qi deficiency is a fire with its roots floating outside. Therefore, improper diet, excessive combination of work and rest, and injury to the spleen and stomach may all lead to qi deficiency. Yang deficiency due to qi deficiency, or yin fire rising due to qi deficiency, or qi deficiency due to unstable exterior of Wei, and fever due to disharmony between camp and Wei. Zheng Xuebao and others [1] think that there are three links in the generation of fever due to qi deficiency: ① weak operation of qi; ② The hoist is blocked; ③ Stagnation of qi generates heat. Because of the close relationship between qi, blood and body fluid, qi deficiency directly affects the generation and operation of qi, blood and body fluid, and prevents its unprovoked loss, so qi deficiency will lead to blood deficiency; Qi deficiency can also cause body fluid deficiency and form pathological changes such as yin deficiency. Because "qi is handsome for blood", qi moves for blood circulation, full qi makes blood circulation slippery, and qi deficiency can't promote blood circulation, resulting in slow blood flow, slow operation and blood stasis.

1.5 blood deficiency

Tang Rongchuan put forward the pathogenesis of blood deficiency and fever in "On Blood Syndrome": "People with blood deficiency are feverish and sweaty, and if blood does not match qi, qi will be abundant and diarrhea will occur". Another example is "Treating Deficiency Based on Syndrome Differentiation", which says: "Those with fever due to blood deficiency, vomiting and hematochezia, postpartum metrorrhagia, blood loss can not match Yang, and those with fever due to hyperactivity of Yang should use nourishing blood". Therefore, blood deficiency and fever are mostly caused by blood loss such as hematemesis, hematochezia or postpartum metrorrhagia, and can also develop gradually due to internal injuries of the spleen and stomach such as dietary fatigue. Insufficient yin and blood, unable to converge yang and fever. Blood can carry qi, and most of human qi exists in blood. If there is less blood deficiency, there will be less gas in the blood, so blood deficiency will lead to qi deficiency. Essence and blood are homologous, so blood deficiency is an important aspect of yin deficiency, and blood deficiency is yin deficiency. Blood deficiency, qi and blood failure, dry and astringent pulse, unfavorable blood circulation, and long-term accumulation of blood stasis.

1.6 Yin deficiency

In Su Wen's theory of inversion, it is said that "Yin Qi is few and Yang Qi is strong, so heat is full of annoyance", which is the theoretical basis of yin deficiency and fever. As for the pathogenesis of yin deficiency and heat, Wu Jutong thought it was "exhaustion of true yin and resumption of fire". "Treatment based on Differentiation of Symptoms and Signs" says that "overwork is accompanied by lewdness, internal injuries are really yin, both yin and blood are injured, yang is strong, and fever persists, especially at night". "Jing Yue Quan Shu" puts forward that "all deficiency fire syndrome is deficiency heat syndrome, yin deficiency can cause fever, and this true yin loses money, so water does not control fire". "Theory of excess, aversion to cold, aversion to cold, aversion to heat and aversion to heat" said: "Yin deficiency leads to fever, and the husband's yang is the guardian of vulva, and the yin is the guardian of internal yang. The spirit is unrestrained, the lust is unrestrained, the yin fluid dissipates, and the yang is not attached, causing the muscles to disperse between the surfaces, while the evil heat is also. If you don't have a fever, you should be yin deficiency and use nourishing methods. " . Therefore, fever consumes body fluid, or chronic illness injures the yin essence, or excessive five senses of fire injures the yin, or excessive sweating, vomiting, and excess energy, or excessive consumption of yin blood due to cancer, or abuse of warm and dry drugs, or treatment with chemical anticancer drugs or radiotherapy, all of which lead to consumption of yin fluid, yin failing to absorb yang, yin deficiency and hyperactivity of yang, and internal heat. Yin essence is the material basis of human growth and development, which can be transformed with blood. Insufficient yin essence, insufficient blood volume, insufficient blood volume, and stagnation; Heat due to yin deficiency, burning blood by heat, and coagulation due to blood decoction can all form blood stasis.

1.7 Yang deficiency

Deficiency of yang due to deficiency of the body, or excessive cold, resulting in deficiency of kidney yang, excessive yin cold, or Dai Yang, or yang deficiency floating outside, showing fever. As "Medical Science" said: "Yang deficiency is the deficiency of kidney fire, and Yang deficiency should be cold, so why fever? Then deficiency cold, internal cold and external yang, so external heat; The cold is down and the sun is up, so the heat is up. This is a rootless fire and an empty flame. " Another example is the "Jingyue Complete Book Fire Certificate" cloud: "People with yang deficiency can also have fever, which is exhausted by Yuan Yang, and the fire does not return to Yuan." Therefore, fever due to yang deficiency is mostly cold syndrome due to chronic illness, or qi deficiency, qi loss and yang deficiency due to chronic illness, and Yang Qi is weak and scattered outside.

2 treatment

2. 1 clearing phlegm (damp) heat

According to the pathological factors such as phlegm, dampness and heat, the therapeutic drugs include three categories: heat-clearing drugs, phlegm-resolving drugs and diuretics. Heat-clearing drugs can also be divided into heat-clearing and detoxicating, heat-clearing and blood-cooling, heat-clearing and dampness-promoting, heat-clearing and phlegm-resolving, heat-purging, and heat-clearing and resuscitation. To clear away heat and toxic materials, five kinds of disinfection drinks and Qingwen Baidu drinks are often used. Medicinal: Folium Isatidis, Radix Isatidis, Herba Taraxaci, Rhizoma Smilacis Glabrae, Herba Houttuyniae, Herba Patriniae, Rhizoma Belamcandae and Radix Pulsatillae; Drugs for clearing heat and cooling blood are often modified by rhinoceros horn Dihuang decoction and Qingying decoction. Medicinal: Cortex Moutan, Radix Paeoniae Rubra, Radix Arnebiae, and Cornu Bubali; Clearing away heat and promoting diuresis, Huanglian Jiedu Decoction and Sanren Decoction are often used. Medicinal materials: Scutellariae Radix, Coptidis Rhizoma, Cortex Phellodendri, Radix Sophorae Flavescentis, Coicis Semen, Talcum, medulla Tetrapanacis, etc. Fritillaria cirrhosa, Fructus Trichosanthis, pig milk, Radix Platycodi, Radix Peucedani, etc. Commonly used for clearing heat and resolving phlegm. Purging heat and dredging fu-organs is often used for Yangming fu-organs syndrome of stagnation of excess heat and dry stool, and Dachengqi decoction and Xiexin decoction are often used for addition and subtraction. Medicinal: rhubarb, mirabilite, senna leaf, coptis root, immature bitter orange, magnolia bark, etc. Angong Niuhuang Pill is a representative prescription for clearing away heat and inducing resuscitation. Its medicinal uses include bezoar, musk, buffalo horn, borneol and cinnabar.

Modern research believes that [2] this prescription can also reduce body temperature, intracranial pressure, relieve brain edema and improve local circulation. The expectorant drugs usually include Pinellia ternata, Rhizoma Arisaematis, Gleditsia sinensis, seaweed, kelp, lapis lazuli and so on. Treatment of phlegm often requires reasonable gas drugs. "Jing Yue Quan Shu" points out that "those who are good at governance should treat qi by not treating phlegm, and if qi is smooth, the whole body fluid will be smooth". Qi and phlegm complement each other, qi stagnation leads to phlegm, phlegm follows pneumatics, qi stagnates due to phlegm, phlegm and gas are depressed, reaching from top to bottom, and external resistance leads to internal resistance, which is everywhere. Phlegm accumulation leads to qi stagnation, and qi smoothness leads to phlegm elimination. Therefore, phlegm should be supplemented with qi-regulating products, so that it is easy to remove qi and phlegm. Therefore, to treat phlegm, we must first regulate qi, treat the source of its movement, and eliminate the source of sputum, so that no new sputum will be produced, and the formed sputum can also be lost because of the smooth flow of qi, and regulating qi is the most expensive method to treat phlegm.

To treat dampness, it is necessary to spread the lung, promote diuresis and relieve constipation. As The Synopsis of the Golden Chamber says, "Treating dampness is not conducive to urination", "... If the pulse floats, it will cause sweating, and it will be treated with Guizhi and Huangqi Decoction". It is also said that jaundice is full in the abdomen, urine is unfavorable and red, and spontaneous sweating is also on the exterior and interior. Appropriate rhubarb digestion soup. "Poria cocos, Alisma orientalis, Pogostemon, Eupatorium odoratum, Herba Artemisiae Scopariae, Herba Lysimachiae Christinae, wax gourd peel, mulberry bark, almond and rhubarb are often selected. Of course, "Do not forget to strengthen the spleen when treating dampness", and properly choose some drugs for strengthening the spleen, such as Coicis Semen, Atractylodes macrocephala, lentils and lotus seeds. If the spleen and stomach are transported and turbid, and the blood regulation function is restored, the internal heat will be easy to retreat and the spleen will be fine.

2.2 Qi and blood running

As for the mechanism of internal injury and fever, Chinese medicine believes that the key is that there is an obstacle in the hub of regulating qi, which is the liver and spleen. Therefore, conditioning the liver and spleen is conditioning qi, which is an important link in treating fever. Therefore, activating qi is a necessary method to treat fever, while soothing the liver and regulating qi leads to heat depression. Danzhi Xiaoyao Powder is often used for addition and subtraction. Medicinal: Cortex Moutan, Fructus Gardeniae, Radix Bupleuri, Pericarpium Citri Tangerinae, Radix Aucklandiae, Fructus Aurantii, Fructus Citri Sarcodactylis, and Fructus Citri Tangerinae. Because of qi stagnation, a series of pathological changes such as blood stasis, phlegm and yin deficiency can be formed. If there is blood stasis, peach kernel and safflower can be used. If there is phlegm coagulation at the same time, Pinellia ternata, Nanxing and Orange can be used. If there is yin deficiency, Radix Rehmanniae, Radix Scrophulariae and Radix Ophiopogonis can be used to nourish yin.

2.3 Promote blood circulation

No matter what kind of fever, it will torture the blood, make the blood thicken, the blood circulation is not smooth, and the meridians are blocked. Therefore, promoting blood circulation and removing blood stasis is also an essential medicine for every type of fever. Lin Yi Gaicuo pointed out that fever due to blood stasis often manifests as "cold outside and heat inside", "fever at night", and fever in the afternoon and the first half of the night. Representative Fang Ruxue Fu Xue Zhu Tang. The choice of drugs for promoting blood circulation can be divided into four categories: ① cooling blood and promoting blood circulation: for the purpose of clearing blood stasis and heat, making blood vessels unblocked and clearing blood stasis and heat. Red peony root, peony bark, buffalo horn, Arnebia euchroma and mirabilite are often used. ② Nourishing blood and promoting blood circulation: Blood stasis for a long time will consume yin and damage body fluid, and nourishing blood with blood-nourishing and blood-activating drugs will not help heat, promote blood circulation and remove blood stasis. Commonly used: Radix Salviae Miltiorrhizae, Radix Angelicae Sinensis, Caulis Spatholobi, etc. ③ Softening and promoting blood circulation: Long-term stagnation of blood stasis will inevitably lead to disease accumulation, but attention should be paid to prevent the disadvantages of excessive bleeding. Spatholobus suberectus, Caulis Polygoni Multiflori, Carapax Trionycis, Carapax et Plastrum Testudinis, Lumbricus, Bombyx Batryticatus, Leech, Scolopendra, Scorpio, Squama Manis, etc. (4) Warming meridians and dredging veins: cold blood can coagulate, while heat can warm it. It is necessary to warm meridians and dredge veins, speed up blood circulation and eliminate blood stasis. Commonly used Chinese medicines: cassia twig, dried ginger, aconite, etc. In addition, according to the causes of blood stasis, we can properly match the products that promote qi to dispel cold, replenish qi to nourish yin and warm yang, so that blood stasis can be discharged, new blood can be born and heat can be eliminated by itself.

2.4 invigorating qi

The key to treatment is to replenish the middle energizer, warm the stomach to remove heat, and warm the stomach to replenish qi and raise yang. Buzhong Yiqi Decoction and Huangqi Jianzhong Decoction are often used for addition and subtraction. The front is the representative of invigorating yang and qi, and it is also a good recipe for warming the middle warmer and clearing heat. Li Dongyuan emphasized "strengthening the spleen and stomach, promoting Yang Qi, especially Yang Qi's growth and promotion", and thought that the yin fire could only be hidden when the grain gas rose, the temper rose and the vitality was abundant. Huangqi Jianzhong decoction is also a good prescription for invigorating qi. Zhang [3] treated 36 cases of fever due to qi deficiency with modified Huangqi Jianzhong decoction, and 9 cases were clinically cured/kloc-0, accounting for 52.8%; 10 cases, accounting for 27.8%; 5 cases were effective, accounting for13.9%; 2 cases were ineffective, accounting for 5.5%, and the total effective rate was 94.5%. We should be careful in choosing drugs for invigorating qi in clinic. Although qi deficiency and fever must benefit qi, drugs that are too warm and dry are more likely to help fire. Therefore, when choosing drugs, we should try to choose drugs with mild smell, and of course, we should choose drugs according to the specific condition and the severity of qi deficiency, such as coix seed, yam, lentils and so on. Pseudostellaria heterophylla, Astragalus membranaceus and Atractylodes macrocephala are often used for patients with severe qi deficiency. In addition, qi-promoting drugs must be compatible when invigorating qi, so that even if invigorating qi, qi will not be depressed. Blood stasis is combined with drugs for promoting blood circulation, yin deficiency with drugs for nourishing yin, and blood deficiency with drugs for nourishing blood.

2.5 enriching blood

Tonifying blood and nourishing blood is the treatment of blood deficiency and fever, and Guipi Decoction and Danggui Buxue Decoction are often used. Medicinal: Radix Astragali, Radix Codonopsis, Radix Angelicae Sinensis, Radix Rehmanniae Preparata, Radix Glycyrrhizae Preparata, Atractylodis Rhizoma, Poria, etc. Blood is the mother of qi, and blood deficiency can be accompanied by qi deficiency symptoms, so both of the above prescriptions are supplemented with qi-invigorating drugs at the same time to achieve the purpose of benefiting qi and generating blood. Chen Mingbo [4] treated 4/kloc-0 cases of blood deficiency fever after hip replacement with Danggui Buxue Decoction, and set 40 cases as control group, and observed 1 course of treatment (6 d). The results showed that the total effective rate of the treatment group was 97.5%. Essence and blood are homologous, and blood deficiency is yin deficiency. At the same time, blood is supplemented with Radix Rehmanniae Preparata, Radix Scrophulariae and Fructus Lycii for nourishing yin. Blood deficiency is not conducive to blood circulation, and blood stasis will form after a long time. At the same time, Salvia miltiorrhiza, Angelica sinensis, Radix Curcumae and Notoginseng should be properly compatible to promote blood circulation and nourish blood. Radix Pseudostellariae, Radix Astragali, and Fructus Schisandrae Chinensis are added for patients with dizziness, shortness of breath, and fatigue due to qi deficiency, so as to replenish qi and nourish yin.

2.6 nourishing yin

For the treatment of fever due to yin deficiency, Su Wen Zhi Zhen Da Lun said that "those who are sick with heat are also cold and hot". The great method of treating internal heat due to yin deficiency, that is, "controlling yang with strong water", has been used by later generations. As "The Complete Book of the Pure Moon" says, "Yin deficiency leads to fever, so strong water can level it". The standard of syndrome differentiation and treatment is Qinggu Powder and Artemisia annua Biejia Decoction. Medicinal: Artemisia annua, Anemarrhena asphodeloides, Picrorhiza picrorhiza, Cortex Lycii, Cynanchum atratum, Bupleurum, Carapax Trionycis, etc. Wang Shaobo [5] treated 74 patients with postoperative fever with Jiawei Qinggu Powder for 5 days 1 course. After two courses of treatment, 58 cases were markedly effective, 3 cases were effective/kloc-0, and 3 cases were ineffective, with a total effective rate of 95.95%. Clinically, according to the different degree of yin deficiency of various zang-fu organs, the choice of nourishing yin drugs is also different. Ophiopogon japonicus, asparagus, lily, glehnia littoralis, etc. Often selected as nourishing lung yin; People with spleen and stomach yin deficiency often choose Radix Pseudostellariae, Radix Panacis Quinquefolii, Rhizoma Dioscoreae, Rhizoma Polygonati Odorati and Rhizoma Polygonati; Radix Paeoniae Alba, Semen Ziziphi Spinosae, Cornus officinalis, Fructus Ligustri Lucidi, Radix Rehmanniae, etc. It is often chosen as the yin of liver and kidney. While applying yin-nourishing drugs, blood-activating drugs and warming drugs should be properly compatible to prevent over-nourishing.

2.7 aphrodisiac

Yang tonics are generally called warm tonics. In fact, it is necessary to distinguish between yang-warming drugs and yang-tonifying drugs. Yang-warming drugs, such as aconite, dried ginger, cassia twig, asarum and so on, are a kind of drugs with the functions of warming and activating yang. Yang-tonifying drugs refer to drugs with the function of warming and tonifying, such as Cistanche deserticola, Morinda officinalis, Eucommia ulmoides, Gecko, Hippocampus, Astragalus, etc. For fever due to yang deficiency, warming drugs are generally not selected, because warming drugs cannot replenish deficiency. Moreover, while applying yang-tonifying drugs, we must properly choose some drugs that nourish yin. On the one hand, it is Zhang Jingyue's saying that "those who are good at nourishing yang must seek yang in yin"; on the other hand, patients with yang deficiency are bound to lose money in vaginal fluid, so we must pay attention to nourishing yin. Shenqi pill in synopsis of the golden chamber is often selected as addition and subtraction. Medicinal: Radix Aconiti Lateralis Preparata, Ramulus Cinnamomi, Cornus officinalis, Radix Rehmanniae Preparata, Rhizoma Dioscoreae, Poria, Cortex Moutan, etc. Codonopsis pilosula and Astragalus membranaceus are added for patients with severe qi deficiency; For patients with diarrhea in loose stool, Atractylodes macrocephala and Rhizoma Zingiberis Preparata should be added to transport coke at moderate temperature.

In a word, fever caused by internal injuries can be divided into deficiency syndrome and excess syndrome. Deficiency syndrome is common, and deficiency syndrome should be supplemented. Prescription should be based on deficiency of qi, blood, yin and yang, and diarrhea should be demonstrated in excess. According to the pathological factors such as phlegm-dampness, qi stagnation, blood stasis, etc., distinguish deficiency syndrome from excess syndrome, give due consideration to it, and avoid using spicy or bitter cold products when you see fever.