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[From *Huoren Shu* (Book of Living People)] Cold Jue syndrome: On the first day of illness, the four limbs become cold immediately. The pulse is deep and faint, not rapid. The feet often cramp. While lying down, the patient feels aversion to cold or pulls clothes to cover themselves. They do not desire water. There may be diarrhea with undigested food (*qinggu*), or normal bowel movements, or frequent urination. Externally, the symptoms are mostly clear-headed and quiet. Although the pulse may feel deep and solid, pressing it reveals a slow and weak quality. This indicates Cold Jue. Treat according to specific symptoms using Sini Tang (Four Reversal Decoction), Lizhong Tang (Regulate the Middle Decoction), Tongmai Sini Tang (Pulse-Resuscitating Four Reversal Decoction), Danggui Sini Tang (Angelica Sinensis Four Reversal Decoction), Danggui Sini Jia Zhuyu Shengjiang Tang (Angelica Sinensis Four Reversal Decoction plus Cornus officinalis and Fresh Ginger Decoction), or Baitong Zhu Danjiang Tang (Baitong Decoction plus Pig Bile).

Hot Jue syndrome: During the course of the disease, there must be fever and headache, with external Yang syndrome manifestations. The Jue (reversal cold) typically occurs after two to five days. In cases of concurrent Hot Jue, if Jue lasts for half a day and then fever returns, it is because the heat is deep-seated, which causes Jue; this usually requires two or more days to manifest. If mild Jue is followed by fever, it is due to deep heat. The pulse may be hidden (*fu*), but slippery upon pressure, indicating interior heat. The patient may fear heat, desire water, toss arms and legs about, suffer from restlessness and insomnia, constipation, and dark urine. Externally, they appear confused or delirious. This indicates Hot Jue. Treat according to specific symptoms using Baihu Tang (White Tiger Decoction) or Chengqi Tang (Assist the Qi Decoction).

There are cases where all signs of Yangming Fu excess are present, yet four limbs are cold. This results from improper purgation leading to blocked Qi and Blood, causing limb reversal cold. If physicians fail to recognize this and suspect Yin Jue, administering hot medicines can cause disaster instantly. Generally, Hot Jue presents with a deep, hidden, and slippery pulse, sweating on the head, and although hands and feet are cold, the fingertips occasionally warm up. One should promptly use Chengqi Tang to purge; do not be constrained by taboos.

[From Haizang] Jueyin syndrome: Four limbs are cold, nails are cyanotic, pulse is deep and rapid. If forceful upon pressure, it is Yang type; purge it. Use Dachengqi Tang (Major Order the Qi Decoction). If the pulse is deep and slow, and weak upon pressure, it is Yin type; warm it. Use Sini Tang (Four Reversal Decoction) and apply moxibustion urgently.

[From Luo Qianfu] The wife of Cao Deyu, Provincial Administrator, fell ill in early February with Shaoyin/Taiyin cold damage for eight or nine days. I treated her. The pulse was deep, fine, and faint. Four limbs were cold. She had spontaneous diarrhea and abdominal pain. Her eyes did not want to open. She held her hands under her armpits, felt drowsy and lethargic, and had dry mouth and tongue. I asked: Did previous doctors leave Baibu Jia Renshen Tang (White Tiger Plus Ginseng Decoction)? Can it be taken? I said: Although Baibu Tang treats dry mouth and tongue, relying solely on this indication is incorrect. There are three reasons why this case cannot take Baibu Tang: First, Shaoyin/Taiyin texts state that before Lixia (Start of Summer) and after Liqiu (Start of Autumn), one should not use it recklessly. Second, Taiyang syndrome with no sweat and thirst contraindicates its use. Third, the patient exhibits all Yin syndrome signs, and spring Qi is still cold. Zhang Zhongjing says: For diarrhea with undigested food, urgently rescue the interior. Use Sini Tang (5 liang), Renshen (1 liang), Shengjiang (over 10 slices), Congbai (9 stalks with roots), Water (5 large bowls). Decoct to 3 bowls, remove dregs, divide into three doses. Take within one day, stop at night. When hands and feet warm, the next day resolve with profuse sweating. Follow with several doses of Lizhong Tang (Regulate the Middle Decoction) for recovery. Sun Simiao in *Xiye Lun* (Discourse on Study) says: To become a Grand Physician, one must meticulously study *Jiayi Jing*, *Suwen*, *Huangdi Zhenjing*, *Mingtang Liuzhu*, Twelve Meridians, Three Regions and Nine Parts, and Materia Medica. One must also master the works of Zhang Zhongjing and Wang Shuhe. Only then is one a Grand Physician. Otherwise, it is like wandering blindfolded at night, likely to fall and die. Those prescribing based on such understanding should reflect further.

Yang Syndrome Case Verification: Zhao Jifu of Zhending Prefecture, aged 33, in May of the Zhiyuan era, suffered spleen and stomach injury due to overwork and irregular diet. He experienced irritability and thirst. Overconsumption of cold foods led to fatigue, headache, cold limbs, vomiting, and epigastric fullness. Physicians failed to examine carefully. Seeing cold limbs, vomiting, and epigastric fullness, they used Guizhi Mo (Cinnamon Twig Powder) mixed with hot wine, covered him with cotton clothes, and treated him as Yin Du Shanghan (Yin Toxic Cold Damage). Suddenly, he sweated profusely. After sweating, his condition worsened with dry mouth, rough tongue, red whites of eyes, stiff neck, rigid limbs, dysuria with red urine, constipation, picking at bedclothes, and manic behavior. Speech was disordered. The tongue was red and cracked. Symptoms were lighter in the morning and worse at night, lasting seven to eight days. Family thought he was dying. Neighbor Ji Zhongwan recommended me. Pulse beat seven or eight times per breath, confirming Heat syndrome. I used Dachengqi Tang (Major Order the Qi Decoction), a bitter, acrid, and very cold formula, one liang, taken once. He defecated three times, reducing the excessive pathogenic factor. The next day, I gave Huanglian Jiedu Tang (Coptis Decoction to Resolve Toxicity), a very bitter and cold formula, two liang, administered slowly to clear heat. After three days, symptoms reduced by 50-60%. Then, I gave Baibu Jia Renshen Tang (White Tiger Plus Ginseng Decoction), about half a jin, to clear heat and tonify Qi. Previous symptoms receded. Advised careful lifestyle and diet regulation. He recovered gradually over a month. *Neijing* states: Do not violate seasonal timing, do not oppose appropriate Qi, do not hope for excessive victory, do not assist recurrence. This is supreme treatment. It also says: First understand annual Qi, do not harm Heavenly Harmony. When summer heat is strong, sages use cold/cool herbs to save Kidney Water source and supplement Lung Metal deficiency. Even if external cold invades, Zhang Zhongjing advises adding Huangqin, Zhimu, Shigao to Mahuang Tang to prevent jaundice or macules. Furthermore, using Guizhi Tang is contraindicated here. Using Guizhi powder with hot wine is "missing by a hair's breadth, resulting in a thousand miles error," violating Zhang Zhongjing's methods. Classics say: Do not harm Heavenly Harmony, do not assist recurrence, do not exaggerate victory, do not miss appropriate Qi. Otherwise, old diseases persist, new ones arise.

Using Heat Far from Heat, Treating from the Middle: Friend Liu Juyuan, aged 65, in summer of the Zhengtong era, fell ill due to overwork, irregular diet, and consumption of cold drinks. Physicians treated it as seasonal miscellaneous diseases without success. Ten days later, I treated him. Right hand pulses (three positions) were deep, fine, and faint, indicating Taiyin syndrome. Left hand pulses were slightly floating and wiry, indicating deficient Yang on the exterior. Generally, Yin is abundant, Yang is scarce. His suffering includes heavy body, cold limbs, diarrhea with undigested food, pulling clothes to cover, difficult breathing, and reluctance to speak. This is Spleen affected by Cold-Damp, insufficient Middle Qi. Zhang Zhongjing says: For diarrhea with undigested food, urgently rescue the interior. Use Sini Tang to warm. *Neijing* warns against using heat far from heat. Dry mouth but rinsing water without swallowing, cool body in morning with gooseflesh, irritability in afternoon wanting to keep clothes on, drowsiness with red face, faint red macules on skin. This is Exterior Excess and Interior Deficiency. Interior deficiency causes exterior symptoms to change with time. Analyzing internal and external symptoms, it is clearly dietary and fatigue-induced Cold damaging Spleen/Stomach, not a seasonal disease. Treating illness requires observing current conditions. Now is peak summer heat, yet he has interior Cold. By Root/Branch theory, Season is Branch, Disease is Root. Using Cold herbs follows season but violates root; using Heat herbs follows root but violates season. This is dual injury of Cold and Heat. Must treat from the Middle. "Treating from the Middle" means warming. I used Qian Shi Baizhu San (Childhood Modifying Atractylodes Powder) plus Shengma. Added Gegen (Kudzu Root) and Gancao (Licorice) to resolve macules. Added small amounts of Baizhu and Fuling to drain dampness and promote urination. Ren Shen, Huoxiang, Muxiang to harmonize Spleen/Stomach and promote appetite. Crushed herbs, one liang, decocted and taken. After second dose, macules faded, diarrhea stopped, body warmed, spirit returned. Next, used Yigong San and Zhizhong Tang (Regulate Middle Decoction), mildly warm formulas, one or two doses. Recovered in five days, stopped medication. Someone asked: Illness improved slightly, can we stop medicine? I said: Medicine attacks pathogens. *Neijing* says: Treatment aims for balance. Once pathogens are gone, forcing medicine causes transformation syndromes. Better to nourish with diet, wait for True Qi to return. This is "treating without medicine." Within ten days, he healed well. "Observing current conditions" refers to Qianfu's point about appropriateness of timing.

[From *Huoren Shu*] If patients have alternating cold/heat and Jue, lusterless complexion, dizziness, and sudden absence of pulse in both hands or one hand, positive sweating is imminent. Wrap hands and feet in cotton clothes to keep warm. Urgently administer Wuweizi Tang (Schisandra Decoction) or combine with Mahuang Xixin Gancao Tang (Ephedra, Asarum, Licorice Decoction). Profuse sweating will resolve the condition shortly.

Wuweizi Tang: Treats Shanghan with panting, hidden pulse, and Jue.
Renshen (1 fen), Wuweizi (0.5 liang), Maidong (heart removed), Xingren (skin and tip removed), Shengjiang, Chenpi (each 1 fen), Zaozi (2 pieces).
Crush, decoct in water, and take.

[From *Zhaixuan Fang*] Treats Shanghan with cold hands and feet: Dada (Needle 1 fen).

[From *Jiyi Fang*] Treats Shanghan with absent six pulses: Fuliu (Tonify method, restores six pulses), Hegu, Zhongji, Zhigou (1.5 cun, this point harmonizes pulse extinction), Fuliu (insert along bone downwards), Juque (3.3 cun), Qichong (Moxa 7 zhuang).

[From *Huoren Shu*] All cold hands and feet belong to Jueyin. Do not induce sweat or purge. However, there are cases requiring sweat or purge. If hands and feet are cold but occasionally warm, and palms are always warm, it is not true Jue. Exercise discretion.

[From *Maijue*] If limbs are cold and pulse is surprisingly floating, large, and short, death ensues.