Library

(Asymmetry of the Four Extremities [Sini] - Attached: Corpse Jue)
What is called "Sini" (Four Extremities Asymmetry/Coldness) refers to the four extremities being not warm; what is called "Jue" (Jue Syndrome/Extremity Coldness) refers to the hands and feet being cold. When pathogenic factors are in the Three Yang meridians, the hands and feet are hot; when transmitted to the Taiyin meridian, the hands and feet are warm; upon reaching the Shaoyin meridian, asymmetry/coldness occurs without warmth; upon reaching the Jueyin meridian, severe Jue develops, which is more severe than Sini.

The progression from heat to warmth, then to Sini, and finally to Jue represents pathogenic factors transmitted through the meridians, treated primarily with Sini San (Four Extremities Powder). If Jue appears immediately upon contracting the disease, it indicates pathogenic invasion of the Yin meridians and deficiency of Yang Qi, treated primarily with Sini Tang (Four Extremities Decoction).

Weng Kentang's Commentary: Zhang Zhongjing discusses Sini and Jue in various contexts. Some refer to Sini, some to Jue, some to Jue Ni (Reversal Jue), some to Jue Leng (Jue Coldness), some to Jue Han (Jue Chilliness), and others to Shouzu Ni Leng (Hands and Feet Reversal Coldness), Shouzu Jue Ni (Hands and Feet Jue Reversal), Shouzu Jue Leng (Hands and Feet Jue Coldness), or Shouzu Jue Ni Leng (Hands and Feet Jue Reversal Coldness). All these terms refer to coldness. Therefore, the terms "Jue" and "Ni" are often used interchangeably, without distinguishing "Ni" as merely not warm and "Jue" as cold. Since "not warm" implies cold, where is the difference? However, there is a distinction between "Sizhi" (Four Extremities) and "Shouzu" (Hands and Feet). Adding the character "Si" (Four) before "Ni" (i.e., Sini) generally refers to the hands, feet, arms, and shins above the wrists and ankles. Adding "Shouzu" before terms like "Jue Ni" or "Jue Leng," or omitting "Shouzu," specifically refers only to the hands and feet. Although both Jue and Ni manifest as coldness, they differ in Yin and Yang nature. Jue Ni caused by extreme heat reflects "Extreme Yang resembling Yin," for which Zhang Zhongjing correctly uses Sini San, a cooling formula. Jue Ni caused by extreme cold reflects "Solitary Yin without Yang." Although Zhang Zhongjing does not explicitly list a clause for treating Sini with warming herbs, the name "Sini Tang" is derived from cold extremities. Thus, using Sini Tang to treat cold hands and feet implies no difference between Ni and Jue. Cheng Wuji stated that Sini is due to heat pathogens, yet in two fatal clauses of Shaoyin disease, he described Sini as extreme cold, which seems contradictory. This indicates that Sini, like Jue, can be either cold or hot, with the main difference being generalized coldness of all four extremities versus isolated coldness of just the hands and feet. Thus, Zhang Zhongjing stated: "In Shaoyin disease, if there is vomiting, diarrhea, irritability, and Sini, it is fatal." He also said: "In Shaoyin disease, if there is Sini, aversion to cold, curling up, absent pulse, no irritability but restlessness, it is fatal." He further said: "In Shaoyin disease, with vomiting, diarrhea, cold hands and feet, and severe irritability, Wuzhuyu Tang (Evodia Decoction) is indicated." Among these three clauses, two are fatal and one is treatable. Although all involve combined symptoms, those described as "Sini" tend to be fatal, while those described as "Jue Leng" tend to be treatable, showing that Sini is more severe than Jue Leng. Cheng Wuji’s claim that "Jue is more severe than Ni" is erroneous.

Note: Whenever "Sini" or "Jue/Ni" is mentioned, it indicates a severe condition referring to the four extremities. Mentioning coldness of the fingertips, or Jue/Ni/Leng of the hands and feet, indicates mild Jue. The upper hand is the wrist, above the wrist is the arm; the upper foot is the ankle, above the ankle is the shin. The severity and depth of the disease are embedded in the textual description and must be carefully examined. Progression from heat to warmth, then to Jue, indicates transmitted pathogenic factors, treated with Sini San. If Jue Ni is accompanied by constipation and dark urine, or black stool with a deep and slippery pulse, this is a Yang syndrome resembling Yin, treated with Baihu Tang (White Tiger Decoction); severe cases use Dachengqi Tang (Major Order the Qi Decoction). Do not misdiagnose.

In Taiyang Cold Damage, with floating pulse, spontaneous sweating, frequent urination, vexation, slight aversion to cold, and cramped legs, administering Guizhi Tang (Cinnamon Twig Decoction) to attack the exterior is an error. Following this error, immediate Jue, dry throat, vexation, and vomiting occur; treat with Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction).

In Taiyang Wind Strike, with tight floating pulse, fever, aversion to cold, body pain, absence of sweat, and vexation, Da Qinglong Tang (Major Green Dragon Decoction) is indicated. If the pulse is weak, with sweating and aversion to wind, do not administer. Administration leads to Jue Ni and muscle twitching, which is a adverse reaction. (Zhenwu Tang is found under Diarrhea. Taiyang disease has only these two errors, both caused by improper sweating leading to loss of Yang Qi, thus requiring warming methods.)

Gancao Ganjiang Tang Formula:
Gancao (Honey-fried, 4 liang) Ganjiang (Pao-processed, 2 liang). Crush the herbs, boil in 3 sheng of water to obtain 1.5 sheng, remove dregs, and divide into two warm doses. (The Neijing states: Pungent and sweet disperse and generate Yang. The combination of Gancao and Ganjiang restores Yang Qi.)

Yangming disease, paradoxically presenting with no sweat but clear urine, followed by vomiting, cough, and cold hands and feet after two to three days, will inevitably cause headache. If there is no cough, no vomiting, and no cold hands and feet, there is no headache. In Cold Damage, a slippery pulse with Jue indicates internal heat, treated with Baihu Tang. In Combined Disease of the Three Yangs, with abdominal fullness, heavy body, difficulty turning, numbness of the mouth and face, greasy complexion, delirium, and urinary incontinence: sweating worsens delirium; purgation causes sweating on the forehead and cold reversal of hands and feet. If there is spontaneous sweating, Baihu Tang is indicated.

Shaoyin disease, with vomiting, diarrhea, cold hands and feet, and severe irritability, is treated with Wuzhuyu Tang (see Vomiting/Diarrhea section). Shaoyin disease with diarrhea and weak pulse is given Baitong Tang. If diarrhea persists, Jue Ni, absent pulse, dry retching, and vexation occur, use Baitong Jia Zhuy Dan Tang (Baitong Decoction plus Porcine Bile). Sudden emergence of pulse indicates death; gradual return indicates survival. Shaoyin disease with clear grain diarrhea, internal cold with external heat, cold hands and feet, faint pulse nearly imperceptible, yet no aversion to cold, with red facial color, or abdominal pain, dry retching, sore throat, or cessation of diarrhea with absent pulse, is treated with Tongmai Sini Tang (All see Diarrhea section). Shaoyin disease with Sini, accompanied by cough, palpitations, difficult urination, abdominal pain, or heavy sensation during defecation, is treated with Sini San (see Shaoyin Disease section). Note: "Si" is an abbreviation for "Sizhi" (Four Extremities). Sizhi refers to fingers-to-elbow and toes-to-knee, indicating deeper pathogen penetration. "Shouzu" refers to fingers-to-wrist and toes-to-ankle, indicating shallower penetration. Zhang Zhongjing’s terminology is precise; understanding it reveals severity and depth at a glance. Zhao Sizhen originally wrote "Shaoyin disease Sini," but the *Ren Sheng Huo* (Life-Saving Manual) Vol. 80 changed it to "Sizhi Jue Ni." If one encounters cold Jue with diarrhea, abdominal pain, and cough, using the cooling Sini San based on this text would be inappropriate. Pathogenic factors entering from Yang meridians causing Jue are due to extreme heat, possibly warranting such treatment. However, direct invasion of Yin meridians by cold pathogens causing Jue is adding water to water, which must be avoided. Scholars should investigate this carefully.

Shaoyin disease with aversion to cold, curled body, diarrhea, and cold hands and feet is incurable. Shaoyin disease with vomiting, diarrhea, irritability, and Sini is fatal. Shaoyin disease with Sini, aversion to cold, curled body, absent pulse, no irritability but restlessness is fatal. Shaoyin disease with only Jue and no sweat, forcibly inducing sweat, will disturb blood, potentially bleeding from mouth, nose, or eyes. This is called Lower Jue and Upper Exhaustion, a difficult-to-treat condition. (Only Jue and no sweat indicate heat entering interior with severe exterior cold. Warming is required; forcing sweat makes Wei Qi cold, preventing sweat, damaging Ying Blood, causing hemorrhage. All Jue belong to Lower Jue; blood loss upwards is Upper Exhaustion.)

Jueyin Cold Damage: Initially Jue, then fever with diarrhea; diarrhea stops spontaneously. Seeing Jue again causes diarrhea to recur. (Sini San. Zhang Jiebin notes: Some say Cold Damage of the Three Yin meridians starts with Taiyin (warm hands/feet), then Shaoyin (cold hands/feet), then Jueyin (reversal Jue). But Jueyin is the extreme of Yin; why is there fever? Because Extreme Yang generates Yin, and Extreme Yin generates Yang, following the law of Yin-Yang transformation. The I Ching says: "When exhausted, change occurs." Exhaustion means reaching the limit. Extreme Yang generates Yin, so Yang diseases have cold Jue symptoms; Extreme Yin generates Yang, so Jue conditions have fever clauses. "Deep Jue implies Deep Heat" is the normal pattern of extreme change. The Neijing says: "Hyperactivity causes harm, succession brings restraint.") In Cold Damage, Jue with epigastric palpitations requires treating water retention first with Fuling Ganjiang Tang (Poria and Ginger Decoction) before treating Jue. Otherwise, water infiltrates the stomach causing diarrhea. (Cheng Wuji notes: *Jingui Yaolue* states severe water retention in the epigastrium causes palpitations. Although Jue is due to cold excess, epigastric palpitation indicates severe internal water retention. Treat Jue first with Fuling Ganjiang Tang, then water. If Jue is treated first, water infiltrates the stomach causing diarrhea.)

Fuling Ganjiang Tang Formula:
Fuling Guizhi (Bark removed, 2 liang each) Shengjiang (3 liang, sliced) Gancao (Honey-fried, 1 liang). Boil four ingredients in 4 sheng of water to obtain 2 sheng, remove dregs, divide into three warm doses. (Sweetness of Fuling and Gancao benefits fluids and harmonizes Wei Qi; pungency of Guizhi and Shengjiang assists Yang Qi and releases the exterior.)

Cold Damage after six or seven days, following severe purgation, presents with deep and slow Cun pulse, cold reversal of hands and feet, absent Chi pulse, obstructed throat, pus and blood expectoration, and unceasing diarrhea. This is difficult to treat, managed with Mahuang Shengma Tang (Ephedra and Ma Huang Shen Decoction) (see Diarrhea section).

Cold hands and feet with fine, nearly imperceptible pulse are treated with Danggui Sini Tang (Angelica Sinensis Five-Extremities Decoction). (Cheng Wuji notes: Cold hands and feet indicate deficient exterior Yang failing to warm the extremities; fine, nearly imperceptible pulse indicates deficient interior Yin-Blood with poor circulation. Danggui Sini Tang assists Yang to generate Yin.)

Danggui Sini Tang Formula:
Danggui Guizhi (Bark removed) Shaoyao Xixin (3 liang each) Gancao (Honey-fried) Tongcao (2 liang each) Dazao (25 pieces, split). Boil seven ingredients in 8 sheng of water to obtain 3 sheng, remove dregs, take 1 sheng warm, three times daily. (The Neijing states: Pulse is the house of Blood; all Blood belongs to the Heart. To unblock pulses, one must tonify the Heart and benefit Blood. Bitter enters the Heart first; Danggui’s bitterness aids Heart Blood. Heart suffers from laxity, sour收敛es; Shaoyao’s sourness收敛es Heart Qi. Liver suffers from urgency, sweet moderates; Dazao, Gancao, Tongcao sweetness moderates Yin-Blood.)

Diarrhea with deep, slow pulse, slightly red face, slight body heat, and clear grain diarrhea leads to vertigo, sweating, and resolution. The patient likely experiences mild Jue because the face shows "Floating Yang" due to lower deficiency.

After diarrhea, if pulse vanishes and hands/feet are cold, but pulse returns and hands/feet warm, life is saved; if pulse does not return, death ensues. Clear grain diarrhea, internal cold with external heat, sweating, and Jue require Tongmai Sini Tang. Profuse sweating, persistent heat, internal cramping, limb pain, plus diarrhea, Jue, and aversion to cold require Sini Tang (see Vomiting/Diarrhea section).

Patient with cold hands/feet and sudden tight pulse: Pathogen knots in the chest, epigastric fullness and vexation, hunger but inability to eat. Pathology is in the chest; induce vomiting with Gouti San (Melon Seed Powder) (see Rushing Qi Upward section).

Cold Damage, days one to four or five, presenting with Jue, implies prior fever. Previous heat followed by Jue indicates transmitted pathogen. Judge heat depth by Jue severity: Deep Jue = Deep Heat; Mild Jue = Mild Heat. Jue should be treated with purgation; if sweating is used instead, oral ulcers and redness result. (Jue appearing days one to five with fever indicates transmitted pathogen. Prior heat followed by Jue is also transmitted pathogen. Assess heat depth by Jue severity. If Jue-Heat enters the Fu organs and becomes excess, purgation is needed. Forced sweating dries Stomach fluids, increasing heat, causing oral ulcers. Although texts say "Do not purge Sini," here purgation is indicated. Careful examination is essential. Ancients state: In Heat Jue, hands/feet may occasionally warm; palms/soles remain warm despite coldness. Dai Yuandi distinguishes Heat/Cold Jue by nail temperature. Clinicians must be cautious.) All Sini/Jue conditions (Forbidden) should not be purged; this applies to deficient patients as well.

Cold Damage, days five to six, no Chest Binding, soft abdomen, empty pulse, recurring Jue: Do not purge; this indicates Blood loss. Purging leads to death.

Cold Damage with rapid pulse and cold reversal of hands/feet: Moxibustion is applicable.

Diagnosis: Jue occurs when Yin and Yang Qi fail to connect smoothly. Jue manifests as cold reversal of hands and feet. (Cheng Wuji notes: Hand Yin/Yang meridians connect at ten fingers; Foot Yin/Yang meridians connect at ten toes. Internal sinking of Yang Qi prevents smooth connection with Yin, causing cold hands/feet.)

Cold Damage fever for four days, Jue for three, then fever for four days. Less Jue, more Heat suggests recovery. If heat persists from day four to seven, dysentery with pus/blood follows. (Cheng Wuji notes: Heat then Jue indicates Yang pathogen transmitting inward. Fever is exterior; Jue on day four indicates transmission to Yin. Recovery of heat after three days indicates return to Yang. Less Jue means less pathogen; more Heat means Yang victory, indicating recovery. By day seven, transmission ends; heat clears. Persistent heat means excess heat attacking Jueyin Blood, leading to dysentery.)

Cold Damage Jue for four days, Heat for three, then Jue for five days: Disease progresses. More Cold, less Heat indicates Yang retreat.

Cold Damage initial fever for six days, Jue for nine days with diarrhea. Usually, Jue/Diarrhea patients cannot eat. If able to eat, suspect "Chu Zhong" (Elimination of Middle). Feed Suobing (noodle cake); if no fever, Stomach Qi remains, recovery expected. Fear is sudden heat coming and going. Check pulse after three days; if heat persists, recovery expected at dawn/midnight. Initial fever 6 days + Jue 9 days + subsequent fever 3 days = 9 days total, matching Jue duration, hence recovery time. If pulse is rapid and heat persists after three days, excess heat causes abscess/pus. (Cheng Wuji notes: Initial fever is exterior. Day six transmission to Jueyin, Yin dominance causes Jue/Diarrhea. Nine days Jue means much Cold Qi; inability to eat is normal. Sudden eating suggests Chu Zhong (elimination of Stomach Qi). Excess pathogen forces Stomach to seek food. Test with noodles: if Stomach Qi is exhausted, eating causes fever; if no fever, Stomach Qi remains. Fear is extreme cold transforming to heat, causing temporary eating ability, not Chu Zhong. *Jingui Yaolue*: Patient unable to eat suddenly craving food implies fever. Pulse check after three days: persistent heat means Yang victory, recovery at dawn/midnight. If no recovery, rapid pulse and persistent heat mean excess heat, causing abscess. Text: Irregular rapid pulse produces malignant sores.)

Cold Damage Jue for five days, Heat for five days. If Jue recurs on day six, disease continues; if no Jue, self-heals. Jue does not exceed five days; since Heat lasted five days, self-healing is predicted. (Cheng Wuji notes: Yin dominance causes Jue, Yang dominance causes Heat. Five days Jue is Yin dominance. Day six Yang recovery causes five days Heat. Recurring Jue means Yin resurgence. No Jue means complete Yang victory, hence self-healing. Text: Fever 4 days, Jue 3 days, Fever 4 days; less Jue more Heat means recovery.)

Cold Damage with little Heat and mild Jue (cold fingertips), silent desire not to eat, vexation. After several days, clear urine with white color indicates Heat clearance. Desire to eat indicates recovery. If Jue with vomiting and chest/hypochondriac fullness/vexation, hematochezia follows later. (Cold fingertips = mild Jue/little Heat. Silent/unwilling to eat/vexation = Heat initially transmitting inward. Clear white urine later = interior Heat gone. Desire to eat = harmonized Stomach Qi, recovery. If still unwilling to eat, Ganjiang Gancao Tang is suitable. Vomiting/chest fullness = Shaoyang syndrome. Shaoyang and Jueyin are exterior-interior pairs; pathogen affects the Fu organ, causing vomiting/fullness. Liver governs Blood, hence later hematochezia.)

Lower abdominal fullness/pain with Jue indicates Cold Knot at Guanyuan (see Lower Abdominal Fullness/Pain).

Fever with Jue for seven days, followed by diarrhea: Difficult to treat.

Cold Damage, days six/seven, faint pulse, cold hands/feet, vexation: Moxibustion Jueyin points. If Jue does not reverse, death. (Are the six Jueyin points moxa’d according to seasons/Well-Spring-Stream-River-Sea?)

Cold Damage with fever, diarrhea, Jue Ni, restlessness, inability to lie down: Fatal.

Cold Damage with fever, severe diarrhea, unremitting Jue: Fatal.

Diarrhea, cold hands/feet, absent pulse: Moxa fails to warm; if pulse does not return and slight panting occurs: Fatal.

Appendix:
Huoren (Life-Saving Manual): Cold Jue presents immediately with cold reversal of four extremities, deep/faint/non-rapid pulse, leg cramps/restlessness, aversion to cold, covering oneself, no thirst, clear grain diarrhea, normal stool, or frequent urination. Exterior signs are alert/conscious. Though pulse is deep/solid, slow/weak upon pressure indicates Cold Jue. Treat with Sini Tang, Lizhong Tang, Tongmai Sini Tang, Danggui Sini Tang, Danggui Sini Jia Wuzhuyu Shengjiang Tang, Baitong Jia Zhuy Dan Tang according to syndrome.

Heat Jue: Initial illness features body heat, headache, and other Yang signs. Jue appears days 2-4 or 5. In Heat Jue, Jue lasts half a day then heat returns. Deep heat causes Jue, appearing after 2-3 days. Mild Jue with returning heat indicates deep heat. Pulse may be hidden but slippery on pressure indicates interior heat. Aversion to heat, drinking water, tossing limbs, vexation, insomnia, constipation, dark urine, confused exterior signs indicate Heat Jue. Treat with Baihu Tang or Chengqi Tang.

Another case: Full purgation indications present but Sini appears due to missed purgation causing Qi/Blood stagnation and limb coldness. Misdiagnosed as Yin Jue and treated with hot herbs causes disaster. Heat Jue typically has deep/hidden/slipping pulse, sweating on head, cold hands but warm nails intermittently. Use Chengqi Tang to purge; do not hesitate.

All cold reversal of hands/feet belongs to Jueyin; generally avoid sweating/purging. However, sweating/purging may be needed if hands/feet are cold but occasionally warm, especially palms/soles, indicating non-standard Jue. Exercise judgment.

Haizang (Li Dongyuan): Jueyin syndrome with cold extremities, blue nails, deep/rapid forceful pulse indicates Yang; purge with Dachengqi Tang. Deep/slow weak pulse indicates Yin; warm with Sini Tang and urgent moxibustion.

Luo Qianfu treated Cao Deyu’s wife for Cold Damage days 8-9 in early spring. Pulse deep/fine/faint, cold reversal, diarrhea, abdominal pain, eyes closed, arms hugging armpits, lethargic, dry mouth/tongue. Asked about Baibu Jia Renshen Tang. Luo rejected it for three reasons: 1. Not to use Baibu before Start of Summer/Autumn Equinox; 2. Taiyang syndrome with no sweat/thirst contraindicates it; 3. Patient has full Yin syndrome signs in cold spring weather. Prescribed Sini Tang (5 liang Gancao, 1 liang Renshen, 10+ slices Shengjiang, 9 stalks Congbai, 5 large bowls water, boiled to 3 bowls, divided 3 doses). By night, hands/feet warmed. Next day, profuse sweat resolved disease. Followed with Lizhong Tang for recovery. Sun Simiao’s *Xiyelun*: Great physicians must master *Jiayi*, *Suwen*, *Huangdi Zhenjing*, *Mingtang Liuzhu*, meridians, *Bencao*, and works of Zhongjing/Shuhe. Otherwise, practicing medicine is like wandering blind at night, leading to disaster. Reflect on this medication principle.

Yang Syndrome Case Study: Zhao Jifu, 33, May, Yuan Dynasty. Overwork/diet irregularity damaged Spleen/Stomach, causing irritability/thirst. Overconsumption of cold foods led to fatigue, headache, cold reversal, vomiting, epigastric fullness. Doctor misdiagnosed as Yin Toxic Cold Damage due to cold limbs/vomiting/fullness, administered Guizhi powder in hot wine, covered with cotton. Result: Profuse sweat, dry mouth/tongue, red eyes, stiff neck, rigid limbs, painful urination, constipation, picking at bedclothes, delirium, red cracking tongue, worse at night. Family despaired. Neighbor Ji Zhongwan consulted Luo. Pulse 7-8 beats per breath confirmed Heat syndrome. Administered Dachengqi Tang (1 liang, single dose), resulting in 3 bowel movements, reducing excess. Next day, Huanglian Jiedu Tang (2 liang, slow administration) cleared heat. After 3 days, 50-60% improvement. Given Baibu Jia Renshen Tang (~0.5 jin) to clear heat/tonify Qi. Symptoms resolved. Advised lifestyle/diet control. Recovered in a month. *Neijing*: Do not miss seasonal timing, oppose Qi suitability, assist excess, or aid recovery. This is perfect treatment. First respect annual Qi, do not harm Heavenly Harmony. In peak summer heat, sages use cold/herbals to save Kidney Water origin and supplement Lung Metal deficiency. Even with external cold, Zhongjing adds Huangqin/Zhimu/Shigao to Mahuang Tang to prevent jaundice/spots, and warns against Guizhi Tang. Using Guizhi in hot wine is a minor error with major consequences, opposing Zhongjing’s methods. Text: Do not harm harmony, assist excess, or miss Qi suitability, or old disease remains, new disease arises.

Use Heat Far from Heat, Follow Middle Treatment: Friend Liu Juyuan, 65, Summer, Zheng Dynasty. Overwork/diet irregularity, cold drinks caused illness. Doctors treated as seasonal disease without success. Consulted Luo on day 10. Right hand pulse deep/fine/faint (Taiyin syndrome). Left hand pulse slightly floating/wiry (deficient Yang on exterior). Overall Yin excess, Yang deficiency. Symptoms: Heavy body, cold reversal, clear grain diarrhea, covering self, short breath, reluctance to speak. Spleen cold-damp, middle Qi deficiency. Zhongjing: Clear grain diarrhea requires saving interior with warming Sini Tang. *Neijing* warns: Use heat far from heat season. Dry mouth, rinsing without swallowing, cool morning with gooseflesh, afternoon vexation/unwillingness to uncover, sleepy red face with faint rash. Exterior excess, interior deficiency. Interior deficiency changes exterior signs with time. Detailed analysis shows diet/labor/cold damage to Spleen/Stomach, not seasonal disease. Treating must observe bottom (root). Currently peak summer heat with interior cold disease. Time is branch, disease is root. Cold meds follow time but violate root; Hot meds follow root but violate time. Both cold and heat hurt; must follow "Middle Treatment" (Warming). Used Qianshi Baizhu...