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During the course of smallpox (or variola), the head and face should be cool, while the hands and feet should be warm; if this is reversed, it is termed "Ni" (Reversal). The condition of "Jue" (Cold Extremities) is even more severe than "Ni," manifesting as coldness. "Ni" indicates a decline in Yang Qi (Vital Energy), whereas "Jue" signifies an excess of Yin Qi (Cold/Dark Energy). The head is the convergence point of all Yang meridians; due to the upward steaming of the toxin from the pox, the head should remain warm. Coldness in the feet indicates that the Qi of Yin and Yang has severed at the lower body, which is considered incurable. The four limbs belong to the Spleen, which governs the entire body and serves as the root of all Yang Qi. If the fingertips are slightly cold, it indicates a decline in Yang Qi, as Yang Qi originates from the ends of the ten fingers. If the soles of the feet are cold, it indicates an excess of Yin Qi, as the Yin meridians gather at the soles and tend toward the center of the foot. However, if one presents with blackened lesions, irritability, thirst, sudden chest oppression, panting, and Jue Ni (Reversal Cold), this represents deep heat leading to deep Jue, where extreme fire resembles water, indicating the internal collapse of Yang Toxin. If the lesions are grayish-white with depressed crowns, accompanied by vomiting, diarrhea, and Jue Ni, this indicates exhaustion of Yuan Qi (Primal Qi) and a lack of connection between Yin and Yang; these are all ominous signs. If the hands and feet are cold and there has been frequent vomiting and diarrhea, this is due to deficiency and weakness of the Spleen organ. The four limbs derive their Qi from the Stomach; when the Qi of the Spleen and Stomach is weak, it cannot reach the meridians. If this occurs before the eruption of the pox, one should combine harmonizing the middle jiao (digestive system) with releasing the exterior (dispelling external pathogens); one must not solely use exterior-releasing methods, which would further deplete Stomach Qi. In cases of Yang Qi deficiency and cold, where even boiling water fails to stay hot, one should urgently administer Ginseng Radix et Rhizoma (Renshen) and Aconiti Lateralis Radix Praeparata (Fuzi) repeatedly, covering the patient to restore Yin and return Yang, thereby achieving natural harmony. If Yang Qi is severely depleted and coldness extends above the knees, it is incurable.

Jue Leng (Cold Extremities) in pox diseases is mostly caused by toxic vapors stagnating internally, preventing Yuan Qi from circulating within and outside the body, resulting in a lack of Yang at the surface. It is appropriate to administer modified Lizhong Tang (Regulate the Middle Decoction). However, there are two patterns: Yin and Yang. When both urination and defecation are obstructed, accompanied by irritability, delirium, abdominal distension, panting, and thirst, it is classified as Yang Jue (Yang Reversal); it is suitable to use draining and promoting methods to diffuse Yang Qi. If there is vomiting and spontaneous diarrhea, indicating impending collapse of Yang Qi, it is classified as Yin Jue (Yin Reversal); treatment should focus on warming and tonifying to recover Yuan Yang. Generally, acute onset is rarely Yin pattern, while chronic illness is rarely Yang pattern. This is because damage to the Stomach generates Wind leading to vomiting, and damage to the Spleen generates Wind leading to Jue Ni; these mostly belong to a lack of Yang in the Spleen palace, leaving the four limbs without Qi reception.