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[Outline] Zhang Zhongjing said: In cold damage disease, if the pulse is slippery and there is cold extremities (Jue), it indicates heat in the interior. It should be treated with Baihu Tang (White Tiger Decoction).

[Commentary] Yu Chang said: The slippery pulse belongs to the Yang pulse; thus, it can be known that the interior heat is blazing. Therefore, it is appropriate to use Baihu Tang (White Tiger Decoction) to resolve the heat. This is not significantly different from the treatment of the Three Yang diseases.

Wei Litong said: This refers to the transmission of heat pathogen into the Jueyin stage, where the heat pathogen is abundant in the interior. One must not mistakenly consider it a cold pathogen. Cold damage disease involving the Jueyin stage must present with cold extremities (Jue). The distinction between cold and heat in Jue is profound. If Jueyin disease presents with symptoms of cold extremities, it appears to be caused by a cold pathogen. However, the pulse is slippery. A slippery pulse is large and rapid, which is contrary to deep, fine, slow, or faint pulses. This indicates that the heat pathogen is in the interior. Is this true heat inside and false cold outside? No. The so-called "Jue" (cold extremities) refers to what is stated in other clauses: "All cases of Jue are due to the failure of Yin and Yang Qi to connect smoothly." It is caused by the lack of smooth connection between Yin and Yang Qi. It is not necessary for Yin excess and Yang deficiency to occur for Qi disconnection to cause Jue; even with Yang excess and Yin deficiency, Qi disconnection can also cause Jue. Therefore, one must diagnose the slippery pulse to know that heat is in the interior. One should urgently rescue the exhausted Yin to restrain the hyperactive Yang, rather than regarding it as false heat from solitary Yang floating upward, which is clear. The primary formula is Baihu Tang (White Tiger Decoction), using cold-cooling herbs to treat heat, combined with acrid-dispersing herbs to promote ascending and dispersing, allowing the heat to be vented to the exterior along with the developmental Qi of the Liver Wood. This is also a pathway for expelling pathogens, acting according to the momentum.

[Outline] Zhang Zhongjing said: In cold damage disease, abdominal fullness, delirium, and a floating and tight pulse at the Cun position indicate that Liver Wood is overacting on Spleen Earth. This is named "Zong" (Vertical Overaction). One should puncture the Qimen (LR14) acupoint.

[Commentary] Zhu Gong said: The Foot Jueyin Meridian is the meridian of the Liver. "Jue" means exhaustion. The Ling Shu states: Hai hour corresponds to the Left Foot Jueyin, and Wu hour corresponds to the Right Foot Jueyin. When two Yins meet at their extreme, it is called Jueyin. The end of Yin is termed Hui (darkness/new moon eve), and the emergence of Yin is termed Shuo (new moon). Jueyin signifies the meaning of Yin exhaustion. Its meridian circulates around the genitalia and connects to the root of the tongue. If the pulse does not nourish the sinews, the sinews become tense. Tense sinews pull on the tongue and testicles, resulting in blue lips, curled tongue, and retracted testicles. If both the Cun and Chi positions show a slightly slow pulse, it is known that the Jueyin Meridian is affected. Generally, in cold damage disease, the transformation of pathogens among Zang-Fu organs begins with the Yang meridians, which then sequentially transmit to the Yin meridians. Because Yang governs generation, Taiyang Water transmits to Yangming Earth, and Earth transmits to Shaoyang Wood, constituting minor pathogens. Yin governs killing, so Wood transmits to Taiyin Earth, Earth to Shaoyin Water, and Water to Jueyin Wood. By the sixth or seventh day, the pathogen should reach the Jueyin Liver Wood. It will inevitably transfer Qi to overcome Spleen Earth. If the Spleen is again attacked by pathogens, all five Zang and six Fu organs will be distressed and endangered. Ying and Wei circulation will be blocked, leading to deafness, testicular retraction, loss of consciousness, and death. Rapidly using Chengqi Tang (Gut-Draining Decoction) to purge can save one life out of five chances of death. Ancients said: If Spleen Heat disease occurs, the five Zang organs are endangered. Also, if Earth fails and Wood attacks, death ensues. If on the sixth or seventh day the pathogen transmits to Jueyin, and the pulse becomes slightly slow or slightly floating, these are pulses of the Spleen and Stomach. Thus, one knows the Spleen Qi is intact and no longer being overcome. With nowhere for the pathogen to reside, Ying and Wei will recover, Water will rise and Fire descend, and upon the occurrence of chills and fever, profuse sweating will resolve the disease. The Jueyin Liver Meridian governs Xiao Ke (Wasting-Thirst), Qi rushing up to strike the Heart, pain and heat in the heart region, hunger without desire to eat, vomiting roundworms after eating, and diarrhea if purged. If Yin Qi alone is excessive and Yang Qi suddenly exhausts, it becomes Yin Du (Yin Toxin). Symptoms include cold extremities, severe pain in the umbilical and abdominal regions, body pain as if beaten by a club, deep and rapid pulse, vomiting or diarrhea. One should urgently apply moxibustion and administer acrid-hot medicines to restore Yang Qi, resolving through profuse sweating. Ancients said: Acrid and sweet dispersing constitutes Yang, referring to herbs like Guizhi (Cinnamon Twig), Gancao (Licorice), Ganjiang (Dried Ginger), and Fuzi (Aconite Root), which can restore Yang Qi. Mild cases use acrid-sweet; severe cases use acrid-bitter. Extreme Yin causes restlessness; Yin excess mimics Yang. Differentiation is done via the pulse.

Yang Shiying said: Pulse methodology states: A floating and tight pulse is named Xian (Bowstring). Xian is the Liver pulse.

[Outline] Zhang Zhongjing said: In Jueyin Wind Strike, a slightly floating pulse indicates impending recovery; if not floating, recovery has not yet occurred.

[Commentary] Zhu Gong said: On the sixth or seventh day of cold damage, irritability, abdominal fullness, and testicular retraction with a slightly slow pulse at both Cun and Chi positions indicate disease of the Foot Jueyin Meridian. In Jueyin disease, a slightly floating pulse indicates impending recovery; non-floating indicates no recovery. Xiaojianzhong Tang (Minor Construct the Middle Decoction) is appropriate. If the pulse is slightly slow, there will definitely be no testicular retraction; external symptoms will likely include fever and aversion to cold resembling malaria, indicating impending recovery. Guizhi Mahuang Banxia Tang (Half Dosage of Cinnamon Twig and Ephedra Decoction) is appropriate. If both Cun and Chi pulses are deep and short, there will definitely be testicular retraction, and toxic factors have entered the Zang organs. Chengqi Tang (Gut-Draining Decoction) should be used to purge.

Su Song said: The Jueyin pulse is slightly slow and not floating. When Wind Strike transmits to Jueyin, if the pulse turns slightly floating, it indicates the pathogen returning to the exterior, signifying impending recovery.

Wei Litong said: This describes the pulse of recovery in Jueyin disease to clarify the exit route of the pathogen in Jueyin disease, establishing treatment at the end of the Six Meridians, which is the general principle of cold damage Six Meridians. Whenever pathogens are abundant, they must eventually decline; when pathogens enter, they must eventually exit. This is because the patient's original Yang Qi is robust, preventing the pathogen from staying long in the middle, so it must travel the course of the meridian and heal itself. However, Jueyin is the end of the three Yins. When its pathogen travels the meridian course and desires to exit, there is no way but through Shaoyang, and no gate but through Taiyang. Therefore, for the Jueyin meridian, whether the pathogen entered directly from cold (originating from Shaoyin) or transmitted as heat (also originating from Shaoyang), the exit route involves warming and dispersing, or lifting and raising, always passing through the half-exterior of Shaoyang to penetrate the exterior of Taiyang. Thus, discussing the exit route in Jueyin applies regardless of cold or heat. Testing with the pulse: In Jueyin disease, the pulse should be deep, possibly tight or rapid, neither of which is a micro pulse. There are cases of Yang pulses that are micro, meaning both floating and deep palpations feel micro. Now, deep palpation shows no tightness or rapidity, like a healthy person, indicating the Yin-pathogen has departed. Floating palpation reveals micro, indicating the Yang-pathogen desires to emerge. This "micro" is the same as the "Yang floating and Yin weak" of Taiyang Wind Strike. Why speak of Wind Strike in Jueyin? Because the pulse feels micro upon floating palpation. Since it is neither rootless Yang escaping outward nor Jueyin Yang sinking inward, this is the mechanism of Jueyin pathogen following Yang Qi from Shaoyang to Taiyang, indicating impending recovery. Hence, it can be named "Jueyin Wind Strike." Seeing Jueyin disease with Taiyang Wind Strike pulse indicates Yang rising and pathogen detaching, recognizable as the sign of meridian completion and resolution. This is entirely decided by the floating diagnosis: floating means recovery; non-floating means no recovery. It is known that if the pathogen penetrates the exterior, the illness ends; if not fully penetrated, the illness continues. The main treatment is Guizhi Tang (Cinnamon Twig Decoction), used to raise Yang and drive out pathogens. When Master Zhongjing mentions using Guizhi Tang for attacking the exterior in other clauses, it is precisely crucial here. Since the pathogen already has the trend of reaching Taiyang and penetrating the exterior from the Yang aspect, there is no need to treat via Shaoyang using Chaihu (Bupleurum); instead, treating Taiyang treats Shaoyang, and indeed treats Jueyin.

[Outline] Zhang Zhongjing said: In cold damage disease, if the pulse is micro and there are cold extremities, and by the seventh or eighth day, the skin is cold, and the person is restless with no moment of peace, this is Zang Jue (Organ Cold Extremities), not Hui Jue (Roundworm Cold Extremities). The person with Hui Jue should vomit roundworms. The current patient is quiet but occasionally irritable. This is not Zang Cold; the roundworms have moved up into the Diaphragm, causing irritability, which stops after a while. Vomiting after eating and subsequent irritability occur because the roundworms emerge upon smelling food odor, causing the person to vomit roundworms. For vomiting roundworms, Wumei Wan (Mume Pill) is the primary treatment. It also treats chronic dysentery.

[Commentary] Yu Chang said: The subtle meaning of this clause has been unrecognized for thousands of years. I summarized the main idea at the beginning of the chapter, highlighting Kidney Yang and Stomach Yang, believing it has some basis. Zang Jue refers specifically to the Kidney; Hui Jue refers specifically to the Stomach. Saying "pulse micro and cold extremities" indicates Yang Qi deficiency and microcosm. However, it is not yet determined as Zang Jue or Hui Jue. Only when the skin is cold and there is restlessness without pause is it Zang Jue, for which Sini Tang (Recover the Extremities Decoction) and moxibustion are appropriate. If the cold extremities do not return, death is indicated. Hui Jue features intermittent irritability and cessation, which is not a death omen. But if this gradually leads to no Yang in the Stomach, death will ensue. Wumei Wan (Mume Pill) uses sour, bitter, acrid, and warm herbs mutually to calm roundworms, warm the stomach, and benefit deficiency. For chronic dysentery with pus and blood in stool, this formula is also used because it can resolve complex Yin-Yang pathogens.

[Outline] Zhang Zhongjing said: In dysentery (lowering diarrhea), if the pulse is deep and bowstring, there is a sensation of heaviness in the rectum (tenesmus). If the pulse is large, the disease has not stopped. If the pulse is micro, weak, and rapid, the disease will stop spontaneously. Even with fever, death will not occur.

[Commentary] Kou Zongshi said: Lowering diarrhea with tenesmus is Dysentery. Regardless of whether the disease is within cold damage or not, the symptoms are governed by the Jueyin Liver Meridian. If only cold-cooling herbs are used, it damages the free-flowing nature of Liver Wood, causing the condition to sink further, becoming difficult to treat. One must distinguish the ascending and descending of Yang Qi; if Yang ascends, recovery occurs; if Yang sinks, danger ensues.

Yu Chang said: Dysentery with a deep and bowstring pulse indicates tenesmus, forming the syndrome of stagnation-downward. Large refers to the largeness within the deep and bowstring; micro, weak, and rapid refer to the micro, weak, and rapid qualities within the deep and bowstring. With a micro, weak, and rapid pulse, even with fever, death will not occur; thus, with a large pulse and body heat, death is evident.

[Outline] Zhang Zhongjing said: In dysentery, if there is slight fever and the Yang pulse (Cun) is weak, spontaneous recovery is expected. In dysentery, if the pulse is rapid and there is thirst, spontaneous recovery is expected. If it does not improve, pus and blood will certainly appear in the stool, due to heat. In dysentery, if the pulse is rapid, there is slight fever, and sweating occurs, spontaneous recovery is expected. If the pulse becomes tight again, the disease is unresolved. In dysentery, if the Cun pulse is reversely floating and rapid, and the Chi pulse is naturally choppy, pus and blood will certainly appear in the stool.

[Commentary] Wei Litong said: These two clauses elaborate on Jueyin dysentery, using pulse diagnosis to examine and determine the ascending and descending of pathogens to judge recovery. In Jueyin disease, Yang ascending is auspicious; Yang descending is ominous. This is particularly relevant to the symptom of dysentery. However, within dysentery, there is also the mechanism of Zheng Yang (Upright Yang) ascending and descending, which must be carefully distinguished to determine recovery. One cannot assume that any dysentery in Jueyin disease is incurable. For example, dysentery with slight fever and thirst is a Yang syndrome, and the dysentery is due to heat. Diagnosing a weak pulse indicates Yang Qi ascending; the pulse would be floating, not deep and tight. This is the normal pulse of Yang ascending, not a pathological pulse of Yang deficiency. Thirst also reflects Yang excess and heat rising to the Upper Jiao. Observing pulse and symptoms together, one can allow spontaneous recovery without treatment. Normally, dysentery pulses should be deep and tight; Yin excess makes the pulse deep and slow. Now, although it is Jueyin dysentery, the pulse is weak with rapidity, indicating Yang is easily ascending, the exterior is easily penetrated, and the pathogen desires to cease, hence spontaneous recovery without reckless treatment. If it does not improve, pus and blood will appear. Is the pulse inconsistent with symptoms? No. The heat pathogen has entered deeply into the Yin aspect. Due to heat in the Yin aspect, it cannot cease abruptly, hence no improvement. If dysentery pulse is rapid with slight heat, Yang must ascend and penetrate the exterior, expelling the pathogen with sweat, moving from Jueyin to Shaoyang, and the pathogen exits. If it enters deeply into the Yin aspect and lingers in the middle, unable to escape, prolonged internal heat accumulation will lead to pus and blood in stool, similar to bleeding in Shaoyin disease due to scorching intestines and stomach, with filth descending. This is the same principle. If the pulse is not weak but tight, it is either cold pathogen re-invading interior and exterior, or Yang has sunk deeply, making sudden resolution impossible. This is why pulse diagnosis must examine the reason for Yang Qi ascending and descending to clarify recovery in Jueyin disease; this is the key. Regarding pus and blood syndromes, this is also recognized via pulse. Cun reversely floating and rapid, with Yang ascending and sweating, indicates recovery without doubt. But if Chi is naturally choppy, although Yang floats upward, heat in the Yin muddies it. Deep heat invasion obstructs the Yin aspect, leading to pus and blood in stool, causing Yang to sink with the discharge, losing its floating quality and becoming tight again, rendering it incurable. These two clauses address heat pathogen transmitting to Jueyin, causing dysentery, and distinguishing the ascent and descent of Zheng Yang to determine disease progression. Students must not confuse Zheng Yang with heat pathogen, nor believe that besides Zheng Yang ascending externally, there is another heat pathogen to eliminate. Only then can one discuss treating Jueyin heat pathogen. These two clauses serve as annotations for the non-recovery mentioned in the middle of the first clause, showing that diagnosing Cun floating and rapid should lead to recovery, but due to Choppy Chi, pus and blood prevent recovery. The original text provides no formula, knowing that urgent symptom differentiation is required. Once symptoms are clear, choosing the formula depends on the individual.

[Outline] Zhang Zhongjing said: In cold damage disease, initial fever for six days, followed by nine days of reverse cold extremities and diarrhea. Generally, those with cold extremities and diarrhea should not be able to eat. Now, if the patient can eat, one should fear Chu Zhong (Elimination of the Middle). Feed them Suobing (noodles/wheat cakes). If there is no fever afterward, it is known that Stomach Qi remains, and recovery is certain. One fears sudden heat appearing and then disappearing. Three days later, palpate the pulse. If the heat continues, expect recovery at midnight of the next day. The reason is: originally fever for six days, reverse cold for nine days, plus three more days of fever, totaling nine days with the previous six, corresponding to the nine days of cold. Hence, recovery is expected at midnight. Three days later, palpate the pulse. If the pulse is rapid and the heat does not cease, this indicates excess heat, and carbuncles/pus will certainly develop.

[Commentary] Yu Chang said: The Shaoyin Meridian contains True Yang internally and is most prone to Sini (Cold Extremities). Thus it is said: Vomiting, diarrhea, with hands and feet not cold but feverish indicates no Jue. The Jueyin Meridian lacks True Yang internally; it does not fear Jue, but fears inability to generate heat, or heat being less than cold extremities. The text worries about sudden heat appearing and not leaving. Palpating the pulse three days later, if heat remains, it describes the severity of heat in Jue syndrome. Readers must not be careless. However, if heat and cold extremities correspond, there are no subsequent complications. If heat is in excess, although the disease trend recedes, carbuncles and pus will develop because Jueyin governs Blood. Prolonged holding of heat and blood without dispersion leads to obstruction and decay.

Wei Litong said: In Jueyin disease, Jue (cold extremities) is heavy. The duration of Jue and fever must be carefully distinguished, along with the盈 (fullness) and 绌 (deficiency) of Qi. This is a major junction of disease progression and regression, which must be understood.

Fever for six days, reverse cold for nine days, then fever for three days; the numbers of Yin and Yang are equal. Yang entering Yin for nine days, Yang exiting Yin for nine days; one entry and one exit constitute one flexion and one extension, one flexion and one extension constitute one curve and one straight, which is the nature of Wood. In Shaoyang of the Three Yang, it is alternating chills and fever, belonging to Fu organs; thus Yang sinking is shallow, and the time of alternation is short. In Jueyin of the Three Yin, it is entering/exiting cold and heat, belonging to Zang organs; thus Yang sinking is deep, and the time of entry/exit is long. Recovery at midnight: Yin-Yang numbers reach nine, the extreme; extremes must change. Yang generates at midnight, hence recovery.

The Liver is the organ of Blood. Heat muddying within it causes carbuncles and pus. This shows Jueyin disease is caused by Yang sinking and healed by Yang ascending. Yang ascending must penetrate the exterior and dissipate to achieve full recovery. If it remains in Jueyin, burning causes harm. Ascending is still like not ascending. All mentions of days by Zhongjing are approximate terms. Such nine days should not be rigidly adhered to for comparing heat and cold equality. Fever seven-eight days, cold nine days seven-eight days is also acceptable. Fever five-six days, cold five-six days is also acceptable. It merely compares Yin-Yang abundance and deficiency, not strictly requiring nine days of fever and nine days of cold to verify accuracy.

The original text says Jueyin disease starts with fever for six days, immediately knowing the pathogen came from Shaoyin, indicating a heat pathogen. Why? Shaoyin disease has no fever; fever is a sign of recovery. Upon transmitting to Jueyin, there must be reverse fever. Because Shaoyin is the interior of Yin meridians among the three Yins, heat cannot manifest. Jueyin, although the end of Yin among the three Yins, is connected internally and externally with Shaoyang, so heat can manifest.

[Outline] Zhang Zhongjing said: In cold damage disease, if the pulse is Jie Dai (knotted and intermittent) and there is palpitations, Zhigancao Tang (Roasted Licorice Decoction) is the primary treatment. A pulse that comes slowly and stops occasionally before resuming is named Jie (Knotted) pulse. A pulse that comes rapidly and stops occasionally before resuming is named Cu (Surging) pulse. Yang excess causes Cu; Yin excess causes Jie. These are both pathological pulses.

Also, a pulse that moves and stops, then returns with a smaller number, with a return movement, is named Jie pulse, belonging to Yin. A pulse that moves and stops, then resumes movement, is named Dai (Replacement) pulse, belonging to Yin. Obtaining this pulse indicates difficult treatment.

A pulse flickering like fat floating on soup indicates Yang Qi deficiency. A pulse winding like a spider thread indicates Yin Qi deficiency. Floating and vacuously large indicates Yang has no root. Deep and vacuously thin indicates Yin has no root.

If the pulse is floating, and sweating occurs like flowing pearls, Wei Qi (Defensive Qi) is deficient. A pulse continuous like the end of pouring lacquer indicates loss of Blood. In cold damage cough and rebellious Qi, if the pulse is scattered, death occurs, due to damage of form. A pulse floating and surging, with sweat like oil, panting without rest, inability to take fluids, insensibility of the body, alternating stillness and chaos, indicates the extinction of Life.

[Commentary] Ke Qin said: The first clause: Cold damages the Heart Master; the Heart no longer governs the pulse, losing its normal degree, hence Jie and Dai. Jie and Dai are both Yin pulses. Having this in cold damage is what is meant by "Yang syndrome presenting with Yin pulse indicates death." The second clause: Five beats per respiration is normal. Excess or deficiency indicates Yin-Yang bias, losing normal degree. Biased pulses are further obstructed by pathogens. Yang pathogen excess with stopping in rapidity is named Cu, having the image of hurried running and falling. Yin pathogen excess with stopping in slowness is named Jie, having the appearance of continuous lacquer pouring. Yang excess indicates Yin deficiency pathology. Yin excess indicates Yang deficiency pathology. The third clause: Yin and Yang contend causing pulse movement. Seeing this in cold damage indicates cold form and aversion to cold, damaging all three Jiaos. Moreover, stopping in movement, returning smaller, with return movement, resembles the pecking of a sparrow. Not named Cu but Jie because it is the true Zang Yin pulse of the Heart. Further, stopping in movement, unable to self-return, then resuming, resembles the swimming of a shrimp. Cannot be named Jie; obtaining the name Dai because irregular intervals indicate the dying Yin pulse of the Spleen.

The fifth clause: Floating pulse indicates Yang excess; normally there should be no sweat. But sweating like flowing pearls indicates Yang deficiency failing to defend the exterior and consolidate, resulting in absolute sweat. Yin deficiency failing to store essence and govern blood, continuously departing like lacquer.

The sixth clause: External cold damages form; internal cold damages Qi. Unstopping cough, Qi rising, pulse scattering and not gathering, indicates the Qi of Heart and Lung has extinguished.

The seventh clause: Floating and surging pulse is not a death pulse, but sweat like oil indicates Heart fluid completely depleted, a pulse where Yang remains alone.