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Translation:

Note: Jue Ni (Jue Reversal/Cold Extremities), Jue Leng (Cold Extremities), and Si Ni (Four Extremities Cold) are different names for the same pathological condition. Both Yin syndromes and Yang syndromes can induce Jue. However, Yin Jue (cold extremities due to Yin-cold excess) is easy to identify. It is only Yang Jue (cold extremities due to Yang-heat constraint) that presents diagnostic challenges: some cases involve Yang pathogenic factors transmitting internally to the Yin meridians, with a rapid, deep, and thin pulse, easily mistaken for a Yin-cold syndrome; some involve Yang pathogenic factors transmitting internally to the Yang meridians, with cold sweat appearing intermittently, easily mistaken for a Yin-cold syndrome; some involve exterior pathogens lying latent within, with a cold body, no sweat, and a hidden, imperceptible pulse, easily mistaken for a Yin-cold syndrome.

One must not fail to recognize that when an illness originates from Yin-cold, the body is not feverish, there is no thirst in the mouth, urination and defecation are clear and profuse, mental spirit is clear and refreshed, hands and feet are cold and immobile, and the six pulses are deep, slow, and not rapid. These are symptoms of Cold Jue in the Yin meridians. *Shanghan Lun* (Treatise on Cold Damage) employs Sini Tang (Four Reversals Decoction), Ganjiang Gancao Tang (Dried Ginger and Licorice Decoction), and Wuzhuyu Tang (Evodia Decoction) to treat cold extremities caused by fire deficiency in the Qi level. In the section on aversion to cold, Danggui Sini Tang (Angelica Sinensis Decoction for Reversing Cold) is used to treat cold invading the Blood level. Additionally, Shaoyao Gancao Fuzi Tang (Peony, Licorice, and Aconite Decoction) is established to treat aversion to cold in the Blood level. For conditions similar to cold extremities, one can infer treatments for others based on these principles. The above describes the methods for treating Yin Jue in the Yin meridians.

If at the onset there is fever and aversion to cold, which persists without cooling down, gradually progressing to coldness in both hands and feet; or if after a brief period of fever, the patient becomes comatose and silent, or speaks deliriously alone; although the body is cold, the hands and feet remain movable; stool may be constipated or loose; urine is red and difficult; or even incontinence occurs without awareness; and the pulse is deep, thin, and rapid—this indicates Yang-heat transmitting into the Three Yin meridians, constituting Yang Jue in the Yin meridians. Using cold medicines would hinder the resolution of cold extremities, while using hot medicines would exacerbate the Yang pathogen. Therefore, Zhang Zhongjing uses Sini San (Four Reversals Powder) to unblock Stomach Yang, allowing Yang Qi to reach the exterior. Once the reversal resolves and feet become warm, the heat is then cleared.

If at the onset there is fever, spontaneous sweating, and irritability, which suddenly progresses to cold limbs on the eighth or ninth day, with dry mouth and scorched lips, extreme thirst prompting drinking, coma and silence, flinging hands and kicking feet, body cold but unwilling to cover with clothes or quilts, frequent cold sweat, and a large, deep, rapid pulse, or a rapid pulse with intermittent pauses—this indicates Yang pathogenic factors transmitting into the Three Yang meridians, constituting Yang Jue in the Yang meridians. He Jian’s Liangge San (Cool the Diaphragm Powder), Baihu Tang (White Tiger Decoction), and Huanglian Jiedu Tang (Coptis Decoction to Resolve Toxicity) are appropriate. Clearing the latent internal heat allows it to manifest outwardly, warming the hands and feet. Subsequently, if there is accumulated heat in the interior, clear it further. If there are purgative indications, choose between Dachengqi Tang (Major Order the Qi Decoction) or Xiaochengqi Tang (Minor Order the Qi Decoction).

If at the onset there is aversion to cold and fever, with pulses that are either floating and large or deep and hidden, accompanied by irritability and groaning, followed suddenly by coldness in all four limbs—this is cold extremities caused by failure of perspiration and latent exterior pathogens. Shengyang Sanhuo Tang (Raise Yang and Disperse Fire Decoction) or Qiangduo Baidu San (Notopterygium and Angelica Decoction to Overcome Toxins) should be used to disperse the exterior pathogens. Perspiration will occur, and the reversal will resolve. The above three points describe the methods for treating Yang Jue.

Additionally, cases complicated by phlegm, food stagnation, or food-Qi obstruction blocking the Zhongwan (Middle Epigastrium), leading to impaired ascending and descending functions and inability of Stomach Yang to distribute widely, also cause cold extremities. These should be treated with herbs that resolve phlegm and digest food, such as Daotan Tang (Phlegm-Resolving Decoction) or Baohe San (Preserve Harmony Powder), added with herbs that open and scatter obstructions.

Shengyang Sanhuo Tang (Raise Yang and Disperse Fire Decoction):
Shengma (Rhizoma Cimicifugae), Gegen (Radix Puerariae), Qianghuo (Rhizoma et Radix Notopterygii), Duhuo (Radix Angelicae Pubescentis), Chaihu (Radix Bupleuri), Baishao (Radix Paeoniae Alba), Fangfeng (Radix Saposhnikoviae), Gancao (Radix Glycyrrhizae).
For Jue with interior heat, use Liangge San etc. For cold extremities due to latent exterior pathogens, use this formula to raise and disperse.

Qiangduo Baidu San (Notopterygium and Angelica Decoction to Overcome Toxins):
For latent exterior pathogens in the Three Yang meridians, use Shengyang Sanhuo Tang. For latent exterior pathogens in the Taiyang (Greater Yang) meridian, use this formula.

Huanglian Jiedu Tang (Coptis Decoction to Resolve Toxicity):
Huanglian (Rhizoma Coptidis), Huangqin (Radix Scutellariae), Huangbai (Cortex Phellodendri), Shanzhi (Fructus Gardeniae).
For Jue with heat in the Upper Jiao, use Liangge San. For heat in the Middle Jiao, use Baihu Tang. If heat exists in all three Jiaos, use this formula.

Dachengqi Tang (Major Order the Qi Decoction): See entry for Constipation.

Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction):
Gancao (Radix Glycyrrhizae), Ganjiang (Rhizoma Zingiberis).
This case originally belongs to a Yang syndrome. Due to exterior deficiency with a floating pulse and Wei (Defensive) deficiency causing spontaneous sweating, erroneous sweating further depleted Yang, causing Jue. Erroneous purging further exhausted Yin, causing dryness in the throat and irritability. Using warming methods to restore Yang would aggravate throat dryness and irritability. Using cold medicines would aggravate cold extremities. Therefore, this formula uses Ganjiang to warm the center and Gancao to relieve urgency. Wait until Stomach Yang distributes, Jue resolves, and feet warm, then prepare Shaoyao Gancao Tang to harmonize Yin blood.

Shaoyao Gancao Tang (Peony and Licorice Decoction):
Shaoyao (Radix Paeoniae Alba), Gancao (Radix Glycyrrhizae), Shigao (Gypsum Fibrosum), Jingjie (Herba Schizonepetae).
The subtle method of this formula lies in Shigao and Jingjie being acrid-cool to the Upper Jiao, moistening throat dryness and irritability; furthermore, their acrid-cool nature enters the Blood level, assisting Shaoyao and Gancao to soften Liver tension below, allowing the legs to extend. Removing the acrid-hot Ganjiang prevents Stomach heat-induced delirium, subtly hinting at the subsequent use of Tiaowei Chengqi Tang to clear Stomach heat.

Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction):
Dahuang (Radix et Rhizoma Rhei), Zhike (Fructus Aurantii), Houpo (Cortex Magnoliae Officinalis), Gancao (Radix Glycyrrhizae).
Used temporarily when excessive restoration of Yang leads to intolerance of acrid-warmth, resulting in Stomach heat and delirium.

Sini San (Four Reversals Powder):
Chaihu (Radix Bupleuri), Baishao (Radix Paeoniae Alba), Zhishi (Fructus Aurantii), Gancao (Radix Glycyrrhizae).
For latent exterior pathogens in the Three Yang meridians causing cold limbs, use Shengyang Sanhuo Tang etc. to release them. For heat pathogens transmitting internally causing cold limbs, use Liangge San etc. to clear them. For cold extremities due to cold in the Three Yin organs, use Sini Tang etc. to warm them. This case originally belongs to a Yang syndrome, but due to heat pathogens transmitting internally to the Yin meridians causing cold limbs, Chaihu and Baishao are used to unblock the Liver and Gallbladder, extending Yang Qi outward, so that since the Liver governs the four extremities, they naturally warm. Zhishi and Gancao are used to unblock the interior Qi of the Yangming, extending Stomach Yang outward, so that since the Stomach governs the hands and feet, they naturally warm. This formula treats Yang Jue in the Yin meridians differently from Yang Jue in the Yang meridians.

Liangge San (Cool the Diaphragm Powder): See entry for Mania.
Baihu Tang (White Tiger Decoction): See entry for Tidal Fever.
Wuzhuyu Tang (Evodia Decoction): See entry for Aversion to Cold.

Baitong Zhudan Tang (Arisaema with Pig Bile Decoction):
For cold extremities with a palpable pulse, use Sini Tang. If the pulse is hidden, add Congbai (Scallion White) to unblock Yang Qi. If extreme Yin causes restlessness, add bile to control it. My family's secret modification fears turbidity congealing, substituting a small amount of Chuanlian (Rhizoma Coptidis), following the method of Lianli Tang.

Danggui Sini Tang (Angelica Sinensis Decoction for Reversing Cold):
Danggui (Radix Angelicae Sinensis), Baishao (Radix Paeoniae Alba), Guizhi (Ramulus Cinnamomi), Xixin (Herba Asari), Tongcao (Medulla Tetrapanacis), Gancao (Radix Glycyrrhizae), Dazao (Fructus Jujubae).
This treats Blood deficiency exposed to pathogens, unable to perspire outwardly. Similarly, for Qi deficiency exposed to pathogens, Renshen Baidu San (Ginseng Decoction to Overcome Toxins) or Shen Su Yin (Ginseng and Perilla Drink) are used.

Mahuang Shengma Tang (Ephedra and Cimicifuga Decoction): Mahuang (Herba Ephedrae), Shengma (Rhizoma Cimicifugae), Zhimu (Rhizoma Anemarrhenae), Shigao (Gypsum Fibrosum), Danggui (Radix Angelicae Sinensis), Shaoyao (Radix Paeoniae Alba), Huangqin (Radix Scutellariae), Gancao (Radix Glycyrrhizae).
This treats pathogens lying latent due to erroneous purging, thus using a raising and dispersing method to expel them from the exterior. Zhimu, Shigao, and Huangqin clear interior heat; Danggui and Shaoyao guide the action deep into the Blood level. My family adds Qianghuo and removes Mahuang because of throat discomfort and expectoration of pus and blood.