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Abdominal fullness, with pain upon pressure. In the *Shanghan Lun* (Treatise on Cold Damage), it is stated: If there is fullness in the lower abdomen, pain upon pressure, and free urination, this is a syndrome of Blood Stagnation in the Bladder (Xue Jie Pang Guang Zheng); if urination is difficult, it is a syndrome of Water Stagnation in the Bladder (Shui Jie Pang Guang Zheng); if the hands and feet are hot, and urination is scanty, dark, and painful, it is a syndrome of Heat Stagnation in the Bladder (Re Jie Pang Guang Zheng). Here, however, the hands and feet are cold, and urination is frequent and pale; thus, we know this is a syndrome of Cold Stagnation in the Bladder (Leng Jie Pang Guang Zheng).

[Collected Commentaries] Cheng Wuji said: Cold extremities without chest binding indicate the absence of heat. Fullness in the lower abdomen with pain upon pressure indicates Cold Stagnation in the Lower Jiao (Xia Jiao Leng Jie).

Cheng Zhi said: When Yang pathogens accumulate above and Yin pathogens accumulate below, resulting in cold extremities, lower abdominal fullness, and pain upon pressure, it is evident that Yin pathogens are accumulating in the lower part. In such cases, warming methods or moxibustion should be employed. Guanyuan (CV4) is an acupoint located three cun below the umbilicus. It is the seat of extreme Yin and the convergence point of the Foot Three Yin meridians and the Ren Mai (Conception Vessel), and it is the residence of the Bladder.

Cheng Yingmao said: Although cold extremities occur without chest binding, the lower abdominal fullness, firmness, pain, and stagnation seem to suggest the use of purgatives. However, stagnation in the Lower Jiao is mostly cold, unlike stagnation in the Upper Jiao which is mostly heat. Moreover, since the upper Jiao has no stagnation and only the Bladder and Guanyuan area have stagnation, it is termed Cold Stagnation.

In all cases of Jue (Cold Extremities), it is because the Yin and Yang Qi fail to connect smoothly, leading to Jue. Jue refers to the condition of cold extremities. For patients with various forms of Si Ni (Four Coldness) and Jue, purgatives must not be used. This also applies to patients with deficiency constitutions.

[Annotation] This section details the causes of various types of Jue, emphasizing that purgatives must absolutely not be used. Although Jue can occur in all Yin meridians, it belongs specifically to the Jueyin Meridian. Therefore, any Jueyin disease presents with Jue, regardless of whether it is cold or heat; without Jue, it is not a Jueyin disease. In Taiyin disease, the cold is mild, so the hands and feet are warm without Jue; in Shaoyin disease, the cold is severe, so there is only Cold Jue without Hot Jue; in Jueyin disease, where extreme Yin generates Yang, both Cold Jue and Hot Jue may occur. "Jue" refers to Jue caused by Yin/Yang and Cold/Heat imbalances. "Failure of Yin and Yang to connect smoothly" means the Qi of Yin and Yang fails to communicate and connect. When they fail to connect, Yang acts independently as Yang and manifests as heat, while Yin acts independently as Yin and manifests as cold, forming the Jue disease. The symptom of Jue is cold extremities. "Various Si Ni Jue" refers to diseases characterized by cold extremities. Since the Yin and Yang Qi in Jue disease have failed to connect, purgatives must be strictly avoided. For deficient patients presenting with Jue, purgatives are even more contraindicated, hence the statement "deficient patients are the same."

[Collected Commentaries] Cheng Wuji said: The Three Hand Yin and Three Hand Yang meridians connect at the ten fingers of the hands; the Three Foot Yin and Three Foot Yang meridians connect at the ten toes of the feet. When Yang Qi sinks inward and fails to connect smoothly with Yin, the hands and feet become cold.

Yu Chang said: Regarding Jueyin syndromes, Zhang Zhongjing generally avoids purgatives, aiming instead to return pathogens to the exterior and resolve Yin pathogens through Yang. Here, only two extreme cases where purgatives are forbidden are cited to strictly warn practitioners.

After five or six days of Shanghan, if there is no chest binding, the abdomen is soft, the pulse is weak, and Jue recurs, purgatives must not be used. This is due to loss of blood (Wang Xue); using purgatives here would lead to death.

[Note] The term "chest binding" (Jie Xiong) here should likely be "stool" (Da Bian). If there is no chest binding, the abdomen is soft, the pulse is weak, and Jue recurs, there is no rationale for purgation. Why then say "do not purge"?

[Annotation] This follows the previous clause to elaborate on the principle against purgation. After five or six days of Shanghan, when pathogens reach the Jueyin stage, constipation might seem to warrant purgation. However, if the abdomen is soft, the pulse is weak, and Jue recurs, this indicates blood loss and deficiency restlessness; purgation is even more contraindicated. Purgation would violate the rule against further weakening the deficient, leading to death. This pattern is common after profuse sweating in major illnesses or in postpartum women who have lost blood.

[Collected Commentaries] Zhang Lu said: After five or six days of Shanghan, pathogens enter Jueyin, and heat is profound. Now, with a weak pulse and Jue, this is not comparable to cases where profound heat requires purgation. Due to blood loss and fluid injury causing dry stool, people might mistakenly recognize this as the dry accumulation of Yangming heat entering after five or six days. Hence, the warning against purgation. A weak pulse and soft abdomen indicate no heat inside or outside. Jue indicates Yin Qi is dominant, so it should be treated like blood loss cases. If the patient's Yin blood is more deficient than Yang, or if slight Yang pathogen is mixed within Yin, making them unable to tolerate pungent-warm herbs, it falls under the Danggui Sini Tang (Angelica Decoction for Nourishing Blood and Unblocking Collaterals) syndrome.

In Shanghan disease, if Jue lasts five days and fever lasts five days, and on the sixth day Jue should recur but does not, the disease will heal spontaneously. Since Jue does not exceed five days and fever lasts five days, we know it will heal.

[Annotation] When Shanghan pathogens transmit to Jueyin, the disease involves complex Yin-Yang interactions. If Yang connects with Yin, there is Yang within Yin, so there is no cold extremity; if Yin connects with Yang, there is Yin within Yang, so there is no fever. Only when Yin is excessive and does not connect with Yang does Yin act alone as Yin, causing cold extremities; when Yang is hyperactive and does not connect with Yin, Yang acts alone as Yang, causing fever. Generally, when Jue and Heat contend, reversal occurs, and the disease progresses; when Jue and Heat are balanced, harmony occurs, and the disease heals. Now, since the days of Jue and Heat are equal, the Qi naturally balances, indicating Yin-Yang harmony and spontaneous healing.

[Collected Commentaries] Fang Youzhi said: Five days of Jue and five days of Heat indicate no bias in Yin-Yang contention. If Jue should recur but does not, it shows Yang has prevailed. Since Yang governs life, spontaneous healing is known.

Zhang Lu said: Here, saying Jue does not exceed five days refers to the normal course of Jue; later, saying Jue lasts nine days with diarrhea refers to the variation. Normal courses are easier to treat; variations are harder to recover from.

Lin Lan said: In Three Yin Shanghan, Taiyin starts with warm hands and feet; Shaoyin has cold hands and feet; Jueyin has cold extremities. However, reaching Jueyin, the extreme of Yin, why is there fever? Because extreme Yang generates Yin, Yang diseases present with cold extremities; extreme Yin generates Yang, so Jue presents with fever lines.

In Shanghan, if heat is slight and Jue is mild, with only cold fingertips, silence, anorexia, and irritability for several days, if urination is free and white, this indicates heat has resolved. Desire to eat indicates the disease will heal. If Jue occurs with vomiting and chest/hypochondriac fullness and irritability, bloody stools will follow later.

[Annotation] Slight heat and mild Jue mean the hands and feet are not cold, only the fingertips are cold, indicating shallow cold pathogens. Silence is Yin; irritability is Yang. Anorexia indicates stomach disharmony. This is a mild case of Jueyin complex Yin-Yang disorder, corresponding to the "slight heat, slight Jue" syndrome in the text. If after several days urination is free and white, heat has gone; desire to eat indicates stomach harmony; with heat gone and stomach harmonized, Yin-Yang naturally balances, so the disease heals. If urination is difficult and red, Jue is severe rather than mild, accompanied by irritability instead of silence, and vomiting with chest/hypochondriac fullness instead of just anorexia, this indicates heat remains and has deepened, corresponding to the "deep Jue, deep heat" syndrome. If deep heat persists and lingers in the Yin aspect, bloody stools will eventually occur. "Several days" implies consecutive days.

[Collected Commentaries] Wang Kentang said: If the patient does not yet desire food, Ganjiang Gancao Tang (Dried Ginger and Licorice Decoction) is suitable. Vomiting with chest/hypochondriac fullness and irritability is a Shaoyang syndrome. Shaoyang and Jueyin are interior-exterior pairs; pathogens invading the Fu organ cause vomiting and fullness. Since the Liver governs blood, bloody stools will follow.

Fang Youzhi said: Slight heat and mild Jue indicate shallow pathogens, so hands and feet are not cold, only fingertips. Silence means speechlessness. Anorexia occurs because the Jueyin meridian accompanies the stomach. Irritability indicates internal heat, distinguished by urination. Desire to eat indicates pathogen retreat and stomach recovery. Jue with vomiting and chest/hypochondriac fullness occurs because the Jueyin meridian accompanies the stomach, pierces the diaphragm, and spreads to the hypochondrium. Bloody stools occur because Yin pathogens move downward through the lower orifices.

Lin Lan said: For Heat Jue, cold fingertips are mentioned. For mild Cold Jue, cold hands and feet are mentioned. For severe cases, Si Ni (four extremities cold) is mentioned. The severity and depth of Jue should be carefully appreciated.

Wang Hu said: According to this clause, Zhang Zhongjing provides no treatment method. Guo Yong states: If heat persists and causes bloody stools, Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) can be used.

If Shanghan presents with Jue between one or two days up to four or five days, fever must follow. If fever preceded Jue, Jue will follow; the deeper the Jue, the deeper the heat; the milder the Jue, the milder the heat. Jue [of the heat type] should be treated with purgation, but if sweating is induced instead, mouth sores and redness will result.

[Annotation] Jue occurring on day one or two and persisting until day four or five indicates Cold Jue due to Yin excess and Yang deficiency. Cold Jue is also called Zang Jue (Visceral Jue). If Jue occurs on day one or two, followed by fever on day four or five; or fever on day one or two, followed by Jue on day four or five, alternating Jue and heat indicates Hot Jue due to mutual Yin-Yang contention. Hot Jue is also called Yang Jue. Deep Jue corresponds to deep heat; mild Jue corresponds to mild heat. This Jue requires purgation (as it is Hot Jue), not warming dispersion (as it is not Cold Jue). Mistaking it for Cold Jue and using warming dispersion will aggravate heat ascending, causing mouth sores and redness.

[Collected Commentaries] Cheng Wuji said: The classic states, "Do not purge various Si Ni." Yet here it says "should purge," requiring careful scrutiny. Ancients noted that although Hot Jue has cold extremities, they may occasionally be warm; although cold, the palms are always warm. Dai Yuanli distinguished cold vs. heat Jue by the warmth/cold and color (red/purple) of the nails, showing utmost caution.

Wang Hu said: This clause describes transmitted heat pathogens, a condition of extreme Yang resembling Yin. Shanghan presenting with Jue on days one to five implies that while it originally febrile on days one-two, Jue on days four-five indicates transmission to Jueyin. "Must have fever" means although limbs and skin feel cold, the interior trunk is hot. "Preceding heat leads to subsequent Jue" clarifies that days one-two are prior, days four-five are posterior, showing extreme heat leads to Jue. Deeply lodged Yang pathogens require bitter-cold purgatives to clear heat, allowing Yin Qi to rise, balancing Yin-Yang and harmonizing limbs. Crude physicians see Jue, mistake it for cold, and use pungent-warm drugs. Pungent-warm drugs ascend, drawing heat upward, causing mouth sores and redness because the Jueyin meridian circles the lips.

If a patient has cold extremities, sudden tight and forceful pulse, and pathogens stuck in the chest, with epigastric fullness, irritability, hunger but inability to eat, the disease is in the chest and requires emesis, preferably Gouti San (Melon Sepal Powder).

[Annotation] Cold extremities with a faint, thin pulse indicate Cold Deficiency, treatable with warming or tonifying. A sudden tight, forceful pulse indicates Cold Excess, treatable with warming or emesis. Frequent irritability and vomiting of roundworms, hunger but inability to eat, indicate disease in the stomach. Current epigastric fullness, irritability, hunger but inability to eat indicate disease in the chest. Cold-fluid excess blocking the chest suppresses Chest Yang, preventing it from reaching the limbs, causing cold extremities, chest fullness, irritability, and anorexia. Emesis is required; Gouti San should be used to vomit out upper pathogens, resolving fullness and reversing Jue.

[Collected Commentaries] Yu Chang said: This differs significantly from Taiyang Chest Binding. The sudden tight pulse indicates sudden pathogen accumulation, so Gouti San is used to vomit out pathogens, allowing Yang pathogens to resolve via Yang.

Cheng Yingmao said: Cold extremities indicate internal pathogen obstruction. Sudden tight pulse means tightness is intermittent, appearing suddenly during pulse flow.

If Shanghan presents with a slippery pulse and Jue, there is internal heat, treated with Baihu Tang (White Tiger Decoction).

[Annotation] Faint/thin pulse, no fever, clear urine, and Jue indicate Cold Deficiency Jue, treated with warming. Sudden tight pulse, no fever, chest fullness, irritability, and Jue indicate Cold Excess Jue, treated with emesis. Forceful pulse, constipation, abdominal fullness/hardness/pain, and Jue indicate Heat Excess Jue, treated with purgation. Now, a slippery pulse with Jue: Slippery is a Yang pulse, indicating internal heat, i.e., Hot Jue. However, without abdominal fullness/pain/constipation, the interior is not solid despite heat. Purging is contraindicated; clearing is appropriate. Thus, Baihu Tang is used.

[Collected Commentaries] Cheng Yingmao said: Slippery pulse with Jue is Yang excess rejecting Yin. Baihu Tang clears interior heat with its cool nature and resolves exterior with its pungent nature, so one should follow the pulse over the symptoms.

Lin Lan said: Hot Jue varies. If pathogens transmit to Fu organs, causing blockage and dry feces, purgation with Chengqi Tang is necessary. If fire extreme resembles water, with intense internal heat but no constipation/dry feces, a slippery pulse indicates deep internal heat, and Jue indicates extreme pathogen sinking. Without Baihu Tang to cleanse extreme heat, how can hyperactive Yang be cleared?

Wu Renju said: Jue results from failure of Yang Qi connection, typically showing Yin pulses. A slippery pulse indicates Qi excess, meaning Yang excess internally repelling Yin externally—internal real heat, external false cold. Baihu Tang clears real heat, resolving Jue. Differentiation: Cold is not severe; superficial touch feels cold, but deep pressure reveals heat.

If Shanghan presents with a rapid pulse and cold extremities, moxibustion may be used.

[Annotation] Yin syndromes showing Yang pulses are not fatal and need not wait for spontaneous resolution. Here, rapid pulse with cold extremities suggests moxibustion because warming is doubted by the Yang pulse, and clearing is hindered by Yin Jue. With no clear evidence of cold/heat in symptoms/pulse, using the rapid Yang pulse for clearing risks misinterpreting the pulse; using the Yin Jue for warming risks misinterpreting the syndrome. Thus, moxibustion offers a middle way, unblocking Yang without aiding heat, restoring extremities without injuring Yin.

[Collected Commentaries] Yu Chang said: Rapid pulse indicates Yang presence. With cold extremities, Yang is likely rejected by Yin and cannot return, so moxibustion is suitable to unblock Yang.

Zhang Lu said: Cold extremities usually require Si Ni Tang. However, the rapid pulse indicates internal Yang obstruction, not Yang deficiency. Thus, only moxibustion is used to unblock Yang, avoiding warm-meridian tonics.

If Shanghan features four days of fever, followed by three days of Jue, then four more days of fever, with less Jue and more heat, the disease should heal. If fever persists from day four to seven, bloody pus stools will occur. If Shanghan features four days of Jue, followed by three days of fever, then five more days of Jue, the disease progresses. More cold than heat indicates Yang decline, hence progression.

[Annotation] In Jueyin Shanghan, Yang pathogens cause fever, Yin pathogens cause Jue/cold, creating complex Yin-Yang alternation. Four days fever, four days Jue indicates contention. Now, three days Jue, four days fever indicates more heat, less Jue, Yang prevailing over Yin, so healing is expected. If healing fails and heat persists, heat stagnates in Yin, leading to bloody pus stools. If four days Jue, three days fever, then five days Jue, more Jue less heat indicates Yin prevailing over Yang, hence progression.

[Collected Commentaries] Cheng Zhi said: This is the mechanism of Jue-Heat alternation. Understanding Yin-Yang advance-retreat clarifies that Jue focuses on Yang, revealing the essence of Jueyin.

Zhang Lu said: Taiyang disease progression is marked by aversion to cold and fever (fear of transmission to interior). Jueyin disease retreat is marked by less Jue and more heat (joy of Yin exhaustion and Yang recovery).

Cheng Yingmao said: Jueyin and Shaoyang are a Zang-Fu pair. Shaoyang ends the Three Yang; Yang end generates Yin, causing cold-heat alternation. Jueyin ends the Three Yin; Yin end generates Yang, causing Jue-heat contention. Regardless of origin, focus on Jue vs. Heat quantity. More heat/less Jue = Yang prevails = healing. More Jue/less heat = Yin prevails = progression. Persistent late heat = Yang excess, Yin cannot recover, leading to bleeding/heat syndromes. Persistent late Jue = Yin excess, Yang cannot recover, leading to Yang collapse/death. Treatment must balance Yin-Yang dynamics: Yang excess needs purging, Yin excess needs warming. Delay leads to Yin exhaustion/Yang collapse and death.

Wu Renju said: *Neijing* states cold invasion causes heat. Even severe heat is not fatal, valuing heat in Shanghan. However, insufficient heat causes illness, and excess heat also causes illness. These sections discuss heat/cold quantities to show neither excess nor deficiency is acceptable.

If Shanghan starts with six days of fever, followed by nine days of Jue with diarrhea, patients with Jue/diarrhea normally cannot eat. If the patient now eats, suspect Chu Zhong (Stomach Qi extinction/rebound). Feed noodle cakes; if no fever ensues, Stomach Qi remains, and healing is certain. Fear is that sudden heat comes and goes. Check pulse after three days; if heat persists, expect healing at dawn/midnight next day. Reason: Originally 6 days fever, 9 days Jue. Plus 3 days new fever equals 9 days total, matching Jue days, hence expectation of healing at dawn/midnight. If pulse is rapid after three days and heat persists, this is excess heat, likely causing carbuncles/pus.

[Note] The character "bu" (not) in "no fever" should be "ruo" (if). If it were "not," it would be Chu Zhong, contradicting the following text about fearing sudden heat.

[Annotation] Heat without Jue is Yang; Jue without heat is Yin. Six days fever, six days Jue, then fever without Jue on day seven indicates Yang recovery and healing. Now, nine days Jue (three more than fever) indicates Yin prevailing over Yang, causing diarrhea. Normally, Jue/diarrhea implies middle cold and anorexia. Eating suggests Yin pathogens destroying Stomach Yang, forming Chu Zhong. "Suspect" implies uncertainty. Testing with noodles: No fever after eating = Chu Zhong. Fever after eating = Stomach Qi remains, not Chu Zhong, healing certain. If sudden fever occurs, fear it is transient Chu Zhong. Wait three days; if heat persists and matches Jue duration, expect healing at dawn/midnight. If after three days heat persists without healing and pulse is rapid, this is excess heat lingering in Ying/Blood, likely causing carbuncles/pus.

[Collected Commentaries] Fang Youzhi said: "Shi" means feed. "Suo" means common/plain. Feed plain noodles. Another view: "Suo" means meatless, avoiding dietary taboos. "Dan ri" is tomorrow morning, time of Yang growth. "Ye ban" is midnight, Yin end/Yang birth. Carbuncles/pus occur because Jueyin governs blood; prolonged blood heat causes stasis and putrefaction.

Wu Renju said: "Chu" means remove; "Zhong" means Middle Qi. Middle Qi is removed, seeking external food for self-rescue.

If Shanghan presents with a slow pulse for six-seven days, and Huangqin Tang (Scutellaria Decoction) is wrongly used to clear heat, knowing slow pulse indicates cold, giving Huangqin Tang again clears heat. The abdomen should be cold, and the patient should not eat. If the patient now eats, this is named Chu Zhong, and death is certain.

[Note] Under "Shanghan slow pulse, six-seven days," the characters "Jue and diarrhea" should be inserted. Without them, it is not Chu Zhong. With them, it aligns with the subsequent wrong use of Huangqin Tang.

[Annotation] If Shanghan has a rapid pulse for six-seven days with Jue and diarrhea, it is Heat Jue diarrhea, treated with Huangqin Tang to clear heat. Now, Shanghan has a slow pulse for six-seven days with Jue and diarrhea, it is Cold Jue diarrhea, treated with Lizhong Tang to warm cold. Instead, giving Huangqin Tang clears heat, causing abdominal cold and anorexia. If the patient eats, this is Chu Zhong. Stomach Qi is nearly extinct, seeking food for rescue, offering no benefit to the stomach, hence death is certain.

[Collected Commentaries] Fang Youzhi said: "Fan" means contrary to the Dao. Huangqin Tang is a cold medicine. "Che" also means clear/remove. "Ying" also means should. "Fan neng shi" (contrary ability to eat) means the stomach desires...