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In the course of a cold damage disease, if cold extremities appear from the first or second day to the fourth or fifth day, fever must be present. If there was fever previously, cold extremities will inevitably follow later. The deeper the cold extremities, the deeper the internal heat; the milder the cold extremities, the milder the internal heat. Cold extremities due to heat should be treated with purgation; if sweating is used in error, it will inevitably lead to oral lesions and redness.

By the fourth or fifth day, chills without fever are evident. The hands and feet are the root of all yang meridians; when yin is excessive and yang cannot reach them, cold extremities occur. After three days of cold damage, the pathogenic factors in the three yang meridians are exhausted; if cold extremities appear on the fourth or fifth day, the pathogen has entered the three yin meridians. When the yin meridians are affected, there is no heat to manifest initially. Yin governs storage; if the zang organ qi is solid and the pathogen cannot enter, it returns to the fu organs. Fever must eventually appear, which is heat generated from extreme cold. First cold extremities followed by fever indicates yang invading yin; since the yin pathogen has not dissipated, recurrence is inevitable. This represents yang within yin, where yin and yang contend causing alternating cold extremities and fever, which is distinctly different from cold extremities with collapse of yang. To know the abundance or deficiency of a person's yang qi, one observes the severity of the cold extremities. Prolonged cold extremities indicate prolonged stagnant heat; mild cold extremities indicate mild stagnant heat, hence fever and cold extremities correspond. If yang is deficient and cannot sustain itself, it becomes true cold extremities without fever. Heat in the three yang meridians that has not entered the fu organs can be treated with sweating; heat in the three yin meridians that has entered the fu organs can be treated with purgation. Yin patterns should not sweat; forcing sweating is a contraindication. Yang pathogens cannot disperse externally as sweat but must ascend to the orifices, leading to oral lesions and redness. However, this refers to heat damaging qi. If blood is disturbed, bleeding may occur from the mouth, nose, or eyes, with consequences beyond description. "Purgation and clearing" here contrasts with sweating. This is stomach heat rather than stomach excess, so the three Chengqi Decoctions are not suitable. For mild cold extremities, Sini San (Four Counterflow Powder) should be used: Shaoyao (Paeoniae Radix), Zhishi (Aurantii Fructus) to attack the interior; Chaihu (Bupleuri Radix), Gancao (Glycyrrhizae Radix et Rhizoma) to harmonize the exterior. For deep cold extremities, Baihu Tang (White Tiger Decoction) should be used: Renshen (Ginseng Radix), Gancao (Glycyrrhizae Radix et Rhizoma), Jingmi (Oryzae Semen) to support yang; Shigao (Gypsum Fibrosum), Zhimu (Anemarrhenae Rhizoma) to remove heat.

When the pulse is slippery and there are cold extremities, there is heat in the interior; Baihu Tang (White Tiger Decoction) is the primary treatment.

The previous clause explained the principle of heat-induced cold extremities; this clause explains the pulse of heat-induced cold extremities and the corresponding formula. A weak yet slippery pulse indicates the presence of Stomach Qi; a slow and slippery pulse is called "Heat in the Middle," which is vastly different from the faint, nearly imperceptible pulse of cold-induced cold extremities. One should recognize symptoms such as dry mouth and tongue, which correspond to the oral lesions and redness mentioned earlier.

In cold damage disease, if cold extremities last five days and fever lasts five days, assuming the sixth day should bring recurrent cold extremities, if they do not recur, the disease will heal spontaneously. Since cold extremities do not exceed five days, spontaneous healing is expected.

Yin excess repelling yang causes initial cold extremities; yin reaching its extreme allows yang to generate, causing subsequent fever. Correspondence between fever and cold extremities signifies yin-yang harmony, hence healing. "End of cold extremities" means cessation of cold extremities; not exceeding five days means no recurrence on the sixth day. "Healing" refers to the resolution of fever.

If cold damage presents with slight heat and mild cold extremities (only fingertips cold), silent desire not to eat, and irritability, after several days if urination becomes smooth and urine color turns white, this indicates heat elimination. Desire to eat signals recovery. If cold extremities accompany vomiting and fullness/oppression in the chest and hypochondrium, hematochezia will likely follow later.

No significant body heat, hands and feet not cold, only fingertips cold—this indicates slight heat and mild cold extremities. Those who can eat and do not vomit have not been affected by the three yin meridians. If a patient does not vomit but is silent and lacks appetite, internal cold is also slight. Irritability indicates internal heat is relatively strong. After several days, if difficulty urinating resolves and color changes from red to white, yin-yang self-harmonization and heat elimination are confirmed. Lack of appetite turning into desire to eat confirms the cessation of cold extremities. If externally slight heat and mild cold extremities are accompanied by vomiting and inability to eat, internal cold is slightly deeper; chest/hypochondriac oppression indicates deeper internal heat. Deep heat causes deep cold extremities; failure to treat early leads to heat damaging yin collaterals and subsequent hematochezia. This is a Shaoyang half-exterior half-interior syndrome: mild cases are harmonized with Xiaochaihu Tang (Minor Bupleurum Decoction); severe cases are purged with Dachaihu Tang (Major Bupleurum Decoction).

Cold damage with four days of fever followed by three days of cold extremities, then four more days of fever: fewer cold extremities and more fever suggests the disease should heal. If heat persists from the fourth to the seventh day, pus and blood in stool will likely follow later.

Cold damage prioritizes yang; more fever implies healing. Persistent heat indicates excess; deep heat with mild cold extremities damages yin collaterals. Physicians should nourish yin proactively during yang excess to manage outcomes.

Days four to seven refer to the period from onset of fever to cessation of cold extremities. "Heat not eliminated" refers to the second four-day fever period. The phrase "four more days of fever" emphasizes "the disease should heal."

Cold damage with four days of cold extremities, three days of fever, then five more days of cold extremities: the disease is progressing. More cold and less fever indicates yang decline, hence progression.

Any mismatch between cold extremities and fever is termed "counter." The previous case (fever then cold extremities) prioritizes yang; this case (cold extremities then fever) prioritizes yin. Fever duration is less than half that of cold extremities, while cold extremities exceed twice the fever duration. With mild heat but dominant cold extremities, failing to urgently support yang leads to yin excess and yang collapse.

Cold damage starting with six days of fever, nine days of cold extremities with diarrhea: typically, cold extremities with diarrhea preclude eating. If the patient can eat, suspect "Chu Zhong" (extinction of middle jiao qi). Feed them Suobing (noodle cakes). No sudden fever indicates remaining Stomach Qi and probable recovery. Fear of sudden transient heat followed by disappearance warrants pulse check after three days. If heat persists and pulse is harmonious, recovery is predicted at midnight. Reason: originally six days fever, nine days cold extremities, plus three more days fever equals nine days total, matching the cold extremity duration, thus predicting recovery at midnight. If pulse is rapid and heat persists after three days, heat excess will cause carbuncles and suppuration.

Though originating in yang, yin prevails with cold extremities and diarrhea, indicating impending exhaustion of Stomach Yang. If Stomach Yang remains, abdomen is warm, food digests normally, and eating is tolerated. In "Chu Zhong," excessive appetite appears paradoxically, akin to "running out of livelihood." Here, yang pathogen enters yin; it is heat-induced cold extremities and diarrhea, so eating does not constitute "Chu Zhong." External irritability indicates deep heat and deep cold extremities; recurrence of fever on day nine stops cold extremities and diarrhea. Persistent heat differs from sudden heat. Three days of persistent heat yields a harmonious pulse. Heat should cease naturally, corresponding to cold extremities, signaling healing. "Healing" refers to fever resolution. Midnight represents yang resolving through yin. If heat persists three days with rapid pulse, heat continues, indicating yang excess and risk of carbuncles. Pus/blood in stool indicates yang pathogen sinking to yin orifices; carbuncles indicate yang pathogen overflowing to the body. This is what laypeople call "lingering toxin from cold damage."

Fever with cold extremities for seven days and diarrhea is difficult to treat.

Yang-originating diseases should heal in seven days. Persistent cold extremities with diarrhea suggest "Chu Zhong," making it difficult to treat. If irritability coexists with ability to eat, it remains heat-induced cold extremities with diarrhea. Pus/blood in stool or carbuncles indicate deficiency allowing excess to follow; fever with cold extremities and "Chu Zhong" indicates excess preceding deficiency.

Cold damage with initial cold extremities and diarrhea, followed by fever: diarrhea stops spontaneously; recurrence of cold extremities brings back diarrhea.

Initial cold extremities/diarrhea followed by fever indicates cold pathogen excess and weak yang, suppressed by yin. Initially, no fever, chills, cold extremities, and diarrhea suggest absence of yang. Subsequently, fever with cessation of cold extremities/diarrhea indicates delayed yang emergence. Self-harmonization of yin-yang leads to healing; if yin wins, false heat retreats, true cold generates internally, and cold extremities/diarrhea recur. Correspondence of cold extremities and diarrhea cessation indicates yang decline and yin growth dynamics.

Cold damage with initial cold extremities and diarrhea, followed by fever: diarrhea stops spontaneously. If sweating and sore throat occur instead, Bi syndrome of the throat develops. Fever without sweat and diarrhea: diarrhea stops spontaneously. If it persists, pus/blood in stool occurs; if pus/blood occurs, throat Bi does not develop.

This parallels the previous section (yin then yang). Both are cold-excess generating heat, but differ in yang deficiency/excess. Previous case: yang fails against yin, so yang retreats and yin advances. Current case: though fever follows cold extremities, yang overcomes yin, so cold extremities/diarrhea stop and do not recur. However, excess yang manifests differently upward or downward, distinguishable by presence/absence of sweat during fever. Diarrhea should not have sweat; sweat indicates yang ascending, causing sore throat and throat Bi. No sweat indicates yang emerging from center, heat corresponds to cold extremities, stopping cold extremities/diarrhea and resolving cold/heat. If cold extremities stop but heat/diarrhea persist, yang pathogen sinks, causing pus/blood in stool; descending without ascending means no sore throat or throat Bi.

Upper section resembles Shaoyin collapse of yang; lower section resembles Yangming協熱利 (collateral heat diarrhea). Sweat originates from Heart; no sweat means Heart Qi is calm, fire does not flare up, throat is pain-free. Diarrhea relates to Stomach; cessation of diarrhea conserves Stomach fluids, fire does not sink, no pus/blood.

Cold damage with fever, severe diarrhea, and unceasing cold extremities: death.

Cold damage with fever, diarrhea, cold extremities, and restlessness preventing lying down: death.

Unceasing cold extremities and diarrhea indicate exhaustion of zang-fu qi; restlessness preventing lying down indicates loss of spirit. Weak yang cannot remain long, hence death.