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"Ni" (counterflow) refers to the coldness and lack of warmth in the four limbs; "Jue" (extremity cold) refers to coldness, which is more severe than "Ni". The four limbs are the root of all Yang meridians and should normally be warm. If the fingertips are slightly cold, it indicates a deficiency of Yang Qi (Yang Qi originates from the tips of the ten fingers); if the soles of the feet are cold, it indicates an excess of Yin Qi (Yin meridians converge at the soles and trend towards the sole center).

If the rash was originally scorched black, and the patient suddenly experiences irritability, thirst, mental confusion, rapid breathing, and Jue Ni (counterflow extremity cold), this signifies the internal collapse of Yang Toxin and the stagnation of Heat Qi, causing the hands and feet to become cold. This is described as "the deeper the heat, the deeper the Jue," or fire appearing like water due to extreme heat.

If the rash was originally grayish-white, accompanied by diarrhea and Jue Ni, this indicates exhaustion of Yuan Qi (Original Qi) and the failure of Yin and Yang Qi to connect smoothly, resulting in cold hands and feet. In the manifestations of rashes, the head is typically desired to be cool, and the feet to be warm. Therefore, if the head is warm but the feet are cold, it is considered incurable. Jue Ni is a malignant syndrome in patients with rashes.

For Jue caused by deep-seated Heat, accompanied by constipation, the primary formula is Sanyi Chengqi Tang (Three-Yi Cathartic Decoction) [indicated for abdominal fullness/stool retention]. For black-colored rashes, Baixiang Wan (Baixiang Pill) and Niuli Gao (Niuli Paste) are indicated (both discussed under Black Collapse). For Jue caused by diarrhea and Qi deficiency, Chen's Muxiang San (Chen's Costus Powder) [indicated for diarrhea] and Yigong San (Yigong Powder) [indicated for poor eruption] are indicated. If only the fingertips are slightly cold, Sizijunzi Tang (Four Gentlemen Decoction) [indicated for anorexia] or Lizhong Tang (Regulate the Middle Decoction) [indicated for vomiting and diarrhea], both added with Guizhi (Cinnamon Twig), are used. During fever from smallpox/rash, the hands and feet should remain warm. Although it is said that the feet belong to the Kidney and should be cool, this "coolness" does not mean "cold"; it means being consistent with normal people—while the whole body is hot, the feet are merely normal/warm, hence termed "cool," implying warmth rather than true cold. If the hands and feet are cold, it is because the patient previously suffered frequent vomiting and diarrhea, leading to Spleen deficiency and weakness. Since the Spleen governs the four limbs, they become cold. Cold extremities are a bad omen; one must not use diaphoresis (sweating method) alone, as this would damage the Spleen and Stomach. Instead, harmonize the middle and release the exterior simultaneously. Treatment of smallpox/rash focuses on the Spleen and Stomach; one should urgently administer decoctions made of Baizhu (Atractylodes Macrocephala Rhizome) for drinking. One must not procrastinate or engage in empty talk. First, use Huangjianzhong Tang (Huangjianzhong Decoction) [indicated for abdominal pain] added with Fangfeng (Saposhnikovia Root) and Qianghuo (Notopterygium Rhizome), or Sizijunzi Tang added with Huangqi (Astragalus Root), Guizhi (Cinnamon Twig), and Fangfeng to disperse the pathogen. After dispersion, use Sizijunzi Tang added with Huangqi (Astragalus Root), Shaoyao (Peony Root), Danggui (Angelica Sinensis Root), and Guixin (Cinnamon Heart) to tonify the Spleen and Stomach, nourish Qi and Blood, and assist in the maturation of the rash.

If the hands and feet become cold immediately upon the emergence of the rash, it indicates prior vomiting and diarrhea. The Qi of the four limbs is derived from the Stomach; if Spleen and Stomach Qi is weak, it cannot reach the meridians. Lizhong Tang (Regulate the Middle Decoction) added with Guizhi (Cinnamon Twig) is indicated.

Shenfu Tang (Ginseng and Aconite Decoction): Treats Yang Qi deficiency and cold in smallpox/rash, characterized by teeth chattering, rigors, cold hands and feet, vomiting, diarrhea, anorexia, and insensitivity to heat when drinking boiling water. Use Dushen Tang (Single Ginseng Decoction) added with high-quality Zhen Fuzi (Prepared Aconite Lateral Root), processed according to standard methods. Add 1 qian of Fuzi per dose initially; if ineffective, increase the dose. If still ineffective, increase to 4-5 qian, or use equal parts of Ginseng and Aconite. However, this is only used to circulate Yang Qi; if Yang Qi has already collapsed, it is untreatable.

Ershen San (Two Gods Powder): Temporarily used for cold injury and constitutional cold, manifesting as cold limbs, abdominal pain, cold breath, and difficulty in eruption and strengthening of the rash.
Ingredients: Dingxiang (Caryophylli Flos, 9 grains), Ganjiang (Zingiberis Rhizoma, 1 qian, roasted).
Grind into powder. Take 0.5 fen each time, washed down with warm water. Cover with a blanket for a period to warm the Spleen and Stomach, allowing Yin to retreat and Yang to return, thus transforming the rash into a favorable course. Dosage should be adjusted according to the child's age and severity.