典藏书目

Dang Gui (Radix Angelicae Sinensis) 3 liang, Gui Zhi (Ramulus Cinnamomi), Shao Yao (Radix Paeoniae Rubra), Xi Xin (Herba Asari), Tong Cao (Medulla Tetrapanacis) 2 liang, Gan Cao (Radix Glycyrrhizae Preparata with Honey) 2 liang, Da Zao (Fructus Jujubae, split) 25 pieces.
The above seven ingredients are decocted in 8 sheng of water, reduced to 3 sheng, the dregs are removed, and it is taken warm, 1 sheng per dose, three times a day.

To the above formula, add Wu Zhu Yu (Fructus Evodiae) half sheng, Sheng Jiang (Rhizoma Zingiberis Recens) 3 liang.
The above nine ingredients are decocted with 6 sheng of water and 6 sheng of clear wine, reduced to 5 sheng, the dregs are removed, and it is taken warm in five divided doses. Another method uses 4 sheng of water and 4 sheng of wine each.

[Formula Analysis]
In all Jue Yin diseases (diseases affecting the Jue Yin meridian), the pulse is necessarily fine and there is cold reversal of the extremities, because Jue Yin is the end of the three Yin meridians; when Yin reaches its extreme, Yang begins to generate. If affected by pathogenic factors, the Qi of Yin and Yang cannot connect smoothly, resulting in a fine pulse and cold extremities. However, Ministerial Fire resides in the Jue Yin organ; although the meridian is cold, the organ itself is not cold, so those who first experience cold reversal will subsequently develop fever. Therefore, at the onset of Cold Damage (Shang Han), if one presents with cold extremities and a pulse that is fine and nearly imperceptible, one must not hastily diagnose it as deficiency-cold and use Gan Jiang (Rhizoma Zingiberis Preparata) and Fu Zi (Radix Aconiti Lateralis Preparata). This formula takes Gui Zhi Tang (Cinnamon Twig Decoction) as a base, with Dang Gui as the sovereign herb, because Jue Yin governs the Liver, which is the repository of blood; Xiang Xi is added as an assistant, its pungent flavor penetrating the three Yin meridians, warming the meridians externally and the organs internally; Tong Cao has a highly unblocking nature, facilitating the joints, opening orifices internally, and connecting Ying (Nutritive) Qi externally; doubling the amount of Da Zao follows the method of establishing the Middle Jiao and using sweet flavors like Yi Tang (Maltose); removing Sheng Jiang prevents excessive pungency and rapid dispersion. The will of the Liver suffers from tension, while its spirit desires dispersion; combining sweet and pungent flavors allows the will to be satisfied and the spirit to be pleased. It is impossible for the Jue Yin spirit and will to be satisfied yet have a fine pulse without emergence or cold extremities. There is no need for the tonification of Ren Shen (Radix Ginseng) and Fu Ling (Poria), nor the harshness of Gan Jiang and Fu Zi, because the treatment of Jue Yin cold reversal differs from that of Tai Yin and Shao Yin. If the patient has chronic cold retained internally, which cannot be treated merely by mild pungent-warm and sweet-slow herbs, then add the pungent-hot Wu Zhu Yu and Sheng Jiang, and decoct with wine to assist Xi Xin in directly penetrating the Jue Yin organ, rapidly dispersing internal and external cold. This is another method for rescuing Jue Yin from cold injury both internally and externally.

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The patient presents with cold reversal of the hands and feet, stating: "I do not have Jie Xiong syndrome" (syndrome of heat and fluid retention binding in the chest/diaphragm), but have fullness in the lower abdomen and pain upon pressure. This indicates cold binding in the region of the Bladder and Guan Yuan (CV4).

[Annotation]
This elaborates on the previous clause regarding the symptoms. The Classic states: "On the sixth day, the Jue Yin meridian receives the pathogen." The Jue Yin meridian circulates around the genitalia and connects with the Liver, thus causing irritability, fullness, and retraction of the testicles. When pathogenic factors transmit to Jue Yin, if the patient originally has heat, it will transform according to Yang, leading to irritability, thirst, lower abdominal fullness, and testicular retraction; this is the indication for Si Ni San (Frigid Extremities Powder) or Cheng Qi Tang (Order the Qi Decoction). If the patient originally has cold, it will transform according to Yin, leading to cold extremities, lower abdominal fullness, and testicular retraction; this is the indication for Dang Gui Si Ni Tang plus Wu Zhu Yu and Sheng Jiang. Now, the patient has cold extremities and denies having Jie Xiong syndrome, meaning the greater abdomen is not full, only the lower abdomen is full and painful upon pressure. In the Treatise, lower abdominal fullness and pain with spontaneous urination indicate Blood Binding in the Bladder; with obstructed urination, it indicates Water Binding in the Bladder; with hot extremities and dark, scanty urine, it indicates Heat Binding in the Bladder. Here, with cold extremities and frequent, white urine, we know it is Cold Binding in the Bladder.

[Collected Annotations]
Cheng Wuji says: Cold extremities without Jie Xiong syndrome indicate absence of heat. Lower abdominal fullness and pain upon pressure indicate cold binding in the lower Jiao.
Cheng Zhi says: Yang pathogens bind above, Yin pathogens bind below. Cold extremities, lower abdominal fullness, and pain upon pressure indicate Yin pathogen binding below; warmth and moxibustion should be used. Guan Yuan is an acupoint located three cun below the umbilicus, a position of extreme Yin, where the three Foot Yin meridians and the Ren Mai (Conception Vessel) intersect, and where the Bladder resides.
Cheng Yingmao says: Although cold reversal occurs without Jie Xiong, the lower abdominal fullness, firmness, and pain seem amenable to purgation. However, bindings in the lower Jiao are mostly cold, unlike the upper Jiao where bindings are mostly heat. Since the extremities are cold and the upper Jiao is free of binding, the binding is only at the Bladder and Guan Yuan, hence it is called "cold binding."

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All cases of Jue (cold reversal) occur when the Qi of Yin and Yang fail to connect smoothly; this is termed Jue. Jue refers to the cold reversal of the hands and feet. For all cases of Si Ni (four limbs cold) and Jue, purgation is contraindicated; this applies equally to patients with deficiency constitutions.

[Annotation]
This details the causes of various types of Jue and emphasizes that purgation must absolutely be avoided. Although Jue can occur in all three Yin meridians, it belongs specifically to Jue Yin. Thus, any disease of Jue Yin presents with Jue regardless of cold or heat; without Jue, it is not a Jue Yin disease. Tai Yin has mild cold, so the extremities are warm without Jue; Shao Yin has severe cold, so there is cold Jue but no heat Jue; Jue Yin represents the extreme of Yin generating Yang, so both cold Jue and heat Jue exist. "Jue" refers to Jue caused by Yin-Yang and cold-heat imbalances. "Yin and Yang failing to connect smoothly" means the Qi of Yin and Yang fails to communicate and connect properly. When they fail to connect, Yang remains Yang and becomes heat, while Yin remains Yin and becomes cold, resulting in Jue disease. The manifestation of Jue is cold reversal of the hands and feet. "All cases of Si Ni and Jue" refers to all diseases presenting with cold reversal of the four limbs. Since the Yin and Yang Qi in Jue disease have already failed to connect, purgation is strictly contraindicated. For deficient patients presenting with Jue, purgation is especially contraindicated, hence it is said: "deficient patients are the same."

[Collected Annotations]
Cheng Wuji says: The three Hand Yin and Yang meridians connect at the ten fingers of the hands; the three Foot Yin and Yang meridians connect at the ten toes of the feet. When Yang Qi sinks inward and does not connect smoothly with Yin, the hands and feet become cold.
Yu Chang says: Zhang Zhongjing generally avoids purgation in Jue Yin syndromes, aiming to return pathogens to the exterior so that Yin resolves through Yang. Here, only the two most critical instances where purgation is forbidden are cited to strictly warn practitioners.

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In Cold Damage, after five or six days, if there is no Jie Xiong syndrome, the abdomen is soft, the pulse is deficient, and cold reversal recurs, purgation is contraindicated. This is due to loss of blood (blood deficiency); purgation will lead to death.

[Commentary]
The term "Jie Xiong" should likely be "Da Bian" (stool/bowel movement). No bowel movement, soft abdomen, deficient pulse, and recurrent cold reversal present no rationale for purgation, yet it says "purgation is contraindicated," implying a rhetorical question or correction.

[Annotation]
This continues the previous clause to elaborate on why purgation is contraindicated. In Cold Damage, on the fifth or sixth day, when pathogens reach Jue Yin, constipation might suggest purgation. However, if the abdomen is soft, the pulse is deficient, and cold reversal recurs, this indicates blood loss and deficiency agitation; purgation is even more contraindicated. Purgation would violate the rule against further weakening the deficient, leading to death. Patients recovering from major illnesses, post-sweating, parturient women, and those with blood loss often present such syndromes.

[Collected Annotations]
Zhang Lu says: In Cold Damage, on the fifth or sixth day, pathogens enter Jue Yin, and heat is deep. Now, with a deficient pulse and cold reversal, this is not comparable to deep heat requiring purgation. Due to blood loss and fluid injury, the stool is dry and difficult to pass. One might mistakenly recognize the fifth/sixth day heat entering Yang Ming as dry accumulation, hence the warning against purgation. With a deficient pulse and soft abdomen, we know there is no heat internally or externally. Cold reversal indicates Yin Qi is dominant; treat it as blood loss. If the person's Yin blood is more deficient than Yang, or if slight Yang pathogen is mixed within Yin, unable to tolerate pungent-hot herbs, it falls under the indication for Dang Gui Si Ni Tang.

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In Cold Damage, if cold reversal lasts five days and fever also lasts five days, assuming on the sixth day cold reversal should recur again, but if it does not recur, the disease will heal spontaneously. Cold reversal never exceeds five days; since fever lasted five days, we know the disease will heal.

[Annotation]
When Cold Damage pathogens transmit to Jue Yin, the disease involves complex Yin-Yang interactions. If Yang enters Yin (Yang within Yin), there is no cold reversal; if Yin enters Yang (Yin within Yang), there is no fever. Only when Yin is excess and does not interact with Yang does Yin remain Yin, causing cold reversal; when Yang is hyperactive and does not interact with Yin, Yang remains Yang, causing fever. When cold reversal and fever contend, the condition reverses (worsens); when they balance, the condition proceeds (improves). Now, since the days of cold reversal and fever are equal, the Qi naturally balances, indicating Yin-Yang harmony and spontaneous healing.

[Collected Annotations]
Fang Youzhi says: Five days of cold reversal and five days of fever indicate balanced Yin-Yang contention. If cold reversal should recur but does not, it indicates Yang dominance. Since Yang governs life, spontaneous healing is evident.
Zhang Lu says: "Cold reversal never exceeds five days" refers to the normal pattern of cold reversal; later, "cold reversal returns for nine days with diarrhea" refers to the variant pattern. Normal patterns are easier to treat; variants are harder to recover from.
Lin Lan says: In Three Yin Cold Damage, Tai Yin starts with warm extremities, Shao Yin with cold extremities, and Jue Yin with cold reversal of the four limbs. However, reaching Jue Yin, the extreme of Yin, why is there fever? Because extreme Yang generates Yin, Yang diseases can present with cold reversal; extreme Yin generates Yang, so cold reversal can present with fever.

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In Cold Damage, with slight heat and mild cold reversal, only the fingertips are cold, the patient is silent and anorexic, irritable for several days, with free urination and white color, this indicates heat has resolved. Desire to eat indicates the disease will heal. If there is cold reversal with vomiting and chest/epigastric irritability and fullness, hematochezia (blood in stool) will follow later.

[Annotation]
Slight heat and mild cold reversal mean the hands and feet are not cold, only the fingertips are cold, indicating shallow cold pathogen. "Silent" is Yin. "Irritable" is Yang. Anorexia indicates stomach disharmony. This is a mild case of Jue Yin Yin-Yang complexity, corresponding to "slight heat implies slight cold reversal" in the Treatise. If after several days urination is free and white, this means pathogenic heat has departed. Desire to eat indicates stomach harmony restored. With heat gone and stomach harmonized, Yin and Yang naturally balance, so the disease heals. If urination is obstructed and red, and cold reversal is severe rather than mild, accompanied by irritability instead of silence, and vomiting/chest fullness instead of mere anorexia, this means heat persists and has deepened, corresponding to "deep cold reversal implies deep heat." Persistent deep heat lingering in the Yin aspect will eventually cause hematochezia. "Several days" implies consecutive days.

[Collected Annotations]
Wang Kentang says: If still anorexic, Gan Jiang Gan Cao Tang is suitable. Vomiting with chest/epigastric irritability and fullness is a Shaoyang syndrome. Shaoyang and Jue Yin are interior-exterior pairs; pathogen invading the fu-organ causes vomiting and chest/epigastric fullness. The Liver governs blood, so hematochezia follows.
Fang Youzhi says: Slight heat and mild cold reversal indicate shallow pathogen, hence hands/feet are not cold, only fingertips. "Silent" means speechless. Anorexia occurs because the Jue Yin meridian accompanies the stomach. Irritation indicates internal heat, distinguished by urination. Desire to eat indicates pathogen retreat and stomach recovery. Cold reversal with vomiting/chest fullness occurs because the Jue Yin meridian accompanies the stomach, pierces the diaphragm, and spreads to the hypochondrium. Hematochezia is a Yin pathogen exiting via the lower orifice.
Lin Lan says: In heat Jue, fingertip cold is mentioned. In mild cold Jue, hand/foot cold is mentioned. In severe cases, four-limb cold reversal is mentioned. The severity and depth of cold reversal should be carefully appreciated.
Wang Hu says: This clause by Zhang Zhongjing lacks a treatment method. Guo Yong states: If heat persists and causes hematochezia, Xi Jiao Di Huang Tang can be used.

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From the first or second day to the fourth or fifth day of Cold Damage, if cold reversal occurs, fever must follow. If fever preceded, cold reversal will follow; if cold reversal was deep, heat is deep; if cold reversal was mild, heat is mild. This type of cold reversal requires purgation. If sweating is used instead, mouth ulcers and redness will result.

[Annotation]
Cold reversal on the first or second day persisting until the fourth or fifth day indicates cold Jue due to Yin excess and Yang deficiency. Cold Jue is also called Zang Jue (Organ Cold Reversal). If cold reversal occurs on days 1-2 and fever appears on days 4-5, or vice versa, alternating cold reversal and fever indicates heat Jue due to mutual contention of Yin and Yang. Heat Jue is also called Yang Jue. Deep cold reversal implies deep heat; mild cold reversal implies mild heat. This cold reversal is heat Jue requiring purgation, not cold Jue requiring warming and dispersing. Mistaking it for cold Jue and using warming/dispersing methods will aggravate heat ascending, causing mouth ulcers and redness.

[Collected Annotations]
Cheng Wuji says: The Classic states "all Si Ni are not to be purged," yet here it says "should be purged," requiring careful examination. Ancients noted that in heat Jue, although extremities are cold, they may occasionally be warm; although reversed, the palms are always warm. Dai Yanli distinguished cold/heat Jue by the warmth/cold and color of nails, showing utmost caution.
Wang Hu says: This clause describes transmitted pathogenic heat, a condition of extreme Yang resembling Yin. Cold reversal on days 4-5 following initial fever on days 1-2 indicates pathogen transmitting to Jue Yin. "Must have fever" means although limbs and skin are cold, the interior body is hot. "Preceding heat leads to subsequent cold reversal" clarifies that days 1-2 are prior and 4-5 are posterior, showing extreme heat leads to cold reversal. Deeply lodged Yang pathogen requires bitter-cold herbs to purge heat, allowing Yin Qi to extend, balancing Yin-Yang and harmonizing limbs. Unskilled physicians see cold reversal, mistake it for cold, and use pungent-warm herbs. Pungent-warm herbs ascend, drawing heat upward, causing mouth ulcers/redness because the Jue Yin meridian circles the lips.

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If a patient presents with cold reversal of hands and feet and a pulse that suddenly becomes tight, the pathogen is bound in the chest. Fullness and irritability below the heart, hunger but inability to eat indicate the disease is in the chest. Emetic therapy is required; Gua Di San (Melon Sepal Powder) is indicated.

[Annotation]
Cold reversal with a faint, fine pulse indicates cold-deficiency, treatable with warming and tonifying. A suddenly tight, forceful pulse indicates cold-excess, treatable with warming and emesis. Occasional irritability and vomiting of roundworms with hunger/anorexia indicate disease in the Stomach. Current irritability/fullness below the heart with hunger/anorexia indicates disease in the Chest. Cold-fluid excess blocking the chest suppresses Chest Yang, preventing it from reaching the extremities, causing cold reversal, chest fullness, irritability, and anorexia. Emesis is required to expel upper pathogens using Gua Di San; fullness will resolve, and cold reversal will reverse.

[Collected Annotations]
Yu Chang says: This differs significantly from Tai Yang Jie Xiong. The sudden tight pulse indicates sudden pathogen binding; Gua Di San expels the pathogen, allowing Yang pathogen to resolve via Yang.
Cheng Yingmao says: Cold reversal with internal pathogen obstruction and sudden tight pulse (tight but intermittent) indicates the pathology.

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In Cold Damage, a slippery pulse with cold reversal indicates internal heat; Bai Hu Tang (White Tiger Decoction) is the primary treatment.

[Annotation]
Cold Damage with micro-fine pulse, no body heat, clear/white urine, and cold reversal is cold-deficiency Jue, treated with warming. Sudden tight pulse, no body heat, chest fullness/irritability/cold reversal is cold-excess Jue, treated with emesis. Excess pulse, obstipation, abdominal fullness/pain/cold reversal is heat-excess Jue, treated with purgation. Now, slippery pulse with cold reversal: slippery is a Yang pulse, indicating internal heat, i.e., heat Jue. However, without abdominal fullness/pain/obstipation, although there is heat, the interior is not excess. Purgation is contraindicated, but clearing is appropriate; thus, Bai Hu Tang is used.

[Collected Annotations]
Cheng Yingmao says: Slippery pulse with cold reversal is Yang-excess rejecting Yin. Bai Hu Tang clears interior heat with coolness and releases exterior with pungency. Thus, one should follow the pulse over the symptoms.
Lin Lan says: Heat Jue varies. If pathogen transmits to the fu, causing obstipation and dry feces, purgation with Cheng Qi Tang is necessary. If fire extreme resembles water, with intense internal heat but no obstipation/dry feces, a slippery pulse indicates deep internal heat, and cold reversal indicates extreme pathogen sinking. Without Bai Hu Tang to cleanse extreme heat, how can hyperactive Yang be cleared?
Wu Renju says: Jue arises from failure of Yang Qi to connect, typically showing Yin pulses. A slippery pulse indicates Qi excess, Yang excess internally, repelling Yin externally, creating internal real heat and external false cold. Bai Hu Tang clears real heat, resolving Jue. Differentiation: cold is not severe; superficial touch feels cold, but deep palpation reveals heat.

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In Cold Damage, a rapid pulse with cold reversal of the four limbs can be treated with moxibustion.

[Annotation]
In Cold Damage, if a Yin syndrome presents with a Yang pulse, danger is minimal, and waiting is unnecessary. Here, rapid pulse with cold reversal suggests moxibustion. Warming is hesitant due to the Yang pulse; clearing is hindered by the Yin cold reversal. With no definitive cold/heat evidence, using the rapid Yang pulse to guide clearing risks misinterpreting the pulse; using the Yin cold reversal to guide warming risks misinterpreting the syndrome. Moxibustion offers a middle way, promoting Yang without aiding heat, reversing cold without injuring Yin.

[Collected Annotations]
Yu Chang says: Rapid pulse indicates constrained Yang. With cold reversal, Yang is rejected by Yin and cannot return; moxibustion promotes Yang.
Zhang Lu says: Cold reversal usually warrants Si Ni Tang. However, the rapid pulse indicates internal Yang obstruction, not Yang deficiency. Thus, moxibustion alone promotes Yang without warming meridians to aid Yang.

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In Cold Damage, fever for four days, followed by three days of cold reversal, then four days of fever again (less cold reversal, more fever) indicates the disease will heal. If fever persists from day four to seven without abating, hematochezia (pus and blood in stool) will occur. If cold reversal lasts four days, followed by three days of fever, then five days of cold reversal again (more cold reversal, less fever), the disease progresses due to excess cold and declining Yang.

[Annotation]
Pathogens in Jue Yin cause fever (Yang pathogen) or cold reversal (Yin pathogen), with complex Yin-Yang contention causing alternating fever and cold reversal. Four days fever, four days cold reversal indicates equal contention. Now, three days cold reversal, four days fever indicates more heat, less cold reversal, Yang winning, Yin retreating, so healing is expected. If healing fails and heat persists, heat stagnates in Yin, leading to pus/blood in stool. Nine days cold reversal, three days fever indicates more cold, less heat, Yin winning, Yang retreating, so disease progresses.

[Collected Annotations]
Cheng Zhi says: This illustrates the mechanism of alternating cold/heat and the meaning of Yin-Yang advance/retreat. Understanding that Jue focuses on Yang clarifies the essence of Jue Yin.
Zhang Lu says: Tai Yang disease progression is marked by aversion to cold and fever (fear of transmission); Jue Yin improvement is marked by less cold reversal and more fever (joy of Yin ending and Yang restoring).
Cheng Yingmao says: Jue Yin and Shaoyang are a zang-fu pair. Shaoyang ends the Three Yang; Yang end generates Yin, causing alternating cold/heat. Jue Yin ends the Three Yin; Yin end generates Yang, causing alternating cold/heat. Regardless of origin, focus on the quantity of cold vs. heat. More heat/less cold = Yang winning = healing. More cold/less heat = Yin winning = progression. Persistent late heat = Yang excess, Yin cannot restore, leading to bleeding/heat syndromes. Persistent late cold = Yin excess, Yang cannot restore, leading to Yang collapse/death. Treatment must balance Yin-Yang dynamics: Yang excess requires purgation, Yin excess requires warming. Delay leads to Yin exhaustion/Yang collapse and death.
Wu Renju says: The *Nei Jing* states cold injury causes heat; even severe heat is not fatal, valuing heat in Cold Damage. However, insufficient heat is pathological, as is excessive heat. These sections discuss heat/cold quantities to show neither excess nor deficiency is acceptable.

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Cold Damage begins with fever for six days, followed by nine days of cold reversal and diarrhea. Generally, those with cold reversal and diarrhea cannot eat. Now, the patient can eat, which fears being "Chu Zhong" (extinction of the middle/stomach qi dying out). Feeding Suo Bing (noodles/wheat cakes), if no fever ensues, it indicates stomach qi remains, and healing is certain. Fearing sudden heat appearing and disappearing, check the pulse after three days; if the heat...