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(Asiatic Cold Extremities [Sini], with Corpse Cold [Shijue] attached)
What is called "Sini" (Asiatic Cold Extremities) refers to the limbs not being warm; what is called "Jue" (Cold Extremities) refers to the hands and feet being cold. When pathogenic factors are in the three Yang meridians (Taiyang, Yangming, Shaoyang), the hands and feet are hot; when transmitted to the Taiyin meridian, the hands and feet are warm; when transmitted to the Shaoyin meridian, they become reversed and not warm; when transmitted to the Jueyin meridian, it develops into "Jue," 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 Counterflow Powder). If cold extremities appear immediately upon onset, it indicates pathogenic factors affecting the Yin meridians with insufficient Yang Qi, treated primarily with Sini Tang (Four Counterflow Decoction).

Weng Kentang's Commentary: Zhang Zhongjing mentions various conditions of Sini and Jue. Some refer to Sini, some to Jue, some to Jue-Ni (reversed cold), some to Jue-Leng (cold extremities), some to Jue-Han (cold reversal), and others to Shou-Zu Ni-Leng (hands and feet reversed cold), Shou-Zu Jue-Ni (hands and feet cold and reversed), Shou-Zu Jue-Leng (hands and feet cold and chilled), or Shou-Zu Jue-Ni-Leng (hands and feet cold, reversed, and chilled). All these terms refer to coldness. Thus, "Jue-Ni" are often used interchangeably, without distinguishing "Ni" as merely not warm and "Jue" as cold. Since "not warm" implies cold, what is the difference? However, there is a distinction between "four limbs" (sì zhī) and "hands and feet" (shǒu zú). Adding the character "four" before "Ni" (e.g., Sini) generally refers to the hands, feet, arms, and shins above. Adding "hands and feet" before terms like "Jue-Ni" or "Jue-Leng," or omitting "hands and feet," refers specifically to the hands and feet alone. Although both "Jue" and "Ni" indicate coldness, there is a distinction between Yin and Yang. Jue-Ni caused by extreme heat is "Yang extreme resembling Yin," correctly treated by Zhang Zhongjing with Sini San, a cooling formula. Jue-Ni caused by extreme cold is "Yin extreme without Yang." Although Zhang Zhongjing did not explicitly write a section on using heating medicines for Sini, the name Sini Tang is derived from cold limbs. Using Sini Tang to treat cold hands and feet now suggests that "Ni" and "Jue" are not different. Cheng Wuji stated that Sini is due to heat pathogens, yet also described Sini as extreme cold in two death cases of Shaoyin disease, which seems contradictory. Therefore, Sini, like Jue, can be either cold or heat; the difference lies between general coldness of the four limbs versus isolated coldness of the hands and feet. Thus, Zhang Zhongjing said: "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, absence of pulse, no irritability but restlessness, it is fatal." He also said: "In Shaoyin disease, vomiting, diarrhea, cold hands and feet, and severe irritability are treated with Wuzhuyu Tang." Among these three cases, two are fatal, and one is treatable. Although all involve combined symptoms, those described as "Sini" are fatal, while those described as "cold extremities" are treatable, indicating that "Sini" is more severe than "cold extremities." Cheng Wuji’s statement that "Jue is more severe than Ni" is erroneous.

Note: Whenever "Sini," "Jue," or "Ni" is mentioned, it refers to a severe condition involving the four limbs. If only the tips of the fingers/toes are cold, or if "Jue," "Ni," or "cold" is specified for hands and feet, it refers to 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 terminology 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, red urine, or black stool with a deep and slippery pulse, it is a Yang syndrome resembling Yin, treated with Baihu Tang; severe cases are treated with Dachengqi Tang. Do not mistake this.

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. This leads to immediate cold extremities, dry throat, vexation, and vomiting/reversal of Qi. Treat with Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction).

In Taiyang Wind Strike, with tight floating pulse, fever, aversion to cold, body pain, anhidrosis, and vexation, treat with Daqinglong Tang (Major Blue-Green Dragon Decoction). If the pulse is weak, with sweating and aversion to wind, do not administer. Administration causes reversed cold, twitching of sinews, and trembling of flesh, which is a counter-indication. (Zhenwu Tang is found under Diarrhea. These two Taiyang cases result from erroneous sweating, leading to loss of Yang Qi; thus, warming methods are used.)

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

Yangming Disease presenting with anhidrosis but free urination, followed after two to three days by vomiting, coughing, and cold hands and feet, will necessarily involve headache. If there is no vomiting, no coughing, and no cold hands/feet, there is no headache. In Cold Damage, a slippery pulse with cold extremities indicates internal heat, treated with Baihu Tang (White Tiger Decoction). In a combination of the three Yang meridians, with abdominal fullness, heavy body, difficulty turning over, insensitivity of the mouth, greasy facial complexion, delirium, and urinary incontinence: sweating worsens delirium; purgation causes sweating on the forehead and reversed cold hands/feet. If there is spontaneous sweating, treat with Baihu Tang.

Shaoyin Disease with vomiting, diarrhea, cold hands and feet, and severe irritability is treated with Wuzhuyu Tang (Evodia Decoction). Shaoyin Disease with diarrhea and weak pulse is given Baitong Tang (White Passage Decoction). If diarrhea persists, with reversed cold, absent pulse, dry heaving, and vexation, use Baitong Jia Zhu Danzhi Tang (White Passage Decoction plus Pig Gallbladder Bile). If the pulse suddenly appears, it is fatal; if it slowly returns, there is life. Shaoyin Disease with clear undigested food in diarrhea, internal cold with external heat, reversed cold hands/feet, and faint-to-absent pulse, yet the body does not feel cold, and the face is red, or with abdominal pain, dry heaving, sore throat, or cessation of diarrhea with absent pulse, is treated with Tongmai Sini Tang (Pulse-Returning Four Counterflow Decoction). Shaoyin Disease with Sini, where the patient may have cough, palpitations, difficult urination, abdominal pain, or feeling of heaviness in defecation, is treated with Sini San (Four Counterflow Powder). Note: "Si" is an abbreviation for "Si Zhi" (four limbs). Four limbs extend from fingers to elbows and toes to knees, indicating deeper pathology. "Hands and feet" extend from fingers to wrists and toes to ankles, indicating shallower pathology. Zhang Zhongjing’s terminology is precise; understanding it reveals the severity and depth at a glance. Zhao Tizhen in *Huoren Shu* changed the text to "Si Zhi Jue Ni." For patients with cold Jue, diarrhea, abdominal pain, and cough, using the cooling Sini San would be inappropriate. Pathogenic factors entering from Yang meridians causing Jue are due to extreme heat, where this might apply. However, for direct invasion of Yin meridians by cold pathogens causing Jue, this is adding water to water and must be avoided. Scholars should investigate this carefully.

Shaoyin Disease with aversion to cold, curling up, diarrhea, and reversed cold hands/feet is untreatable. Shaoyin Disease with vomiting, diarrhea, irritability, and Sini is fatal. Shaoyin Disease with Sini, aversion to cold, curling up, absent pulse, no irritability but restlessness is fatal. Shaoyin Disease with only Jue and no sweat, forcibly induced sweating will cause blood disturbance, bleeding from mouth/nose or eyes, known as Lower Jue and Upper Exhaustion, which is difficult to treat. (Jue without sweat indicates heat entering interior with severe exterior cold. Warming is indicated; forced sweating makes Wei Qi cold, preventing sweat release, injuring Ying Blood internally. All Jue belong to Lower Jue; blood loss upwards is Upper Exhaustion.)

Jueyin Cold Damage: Initially cold extremities, then fever with diarrhea, which will stop spontaneously; if cold extremities return, diarrhea returns. (Sini San. Zhang Yuansu stated: In Three Yin Cold Damage, starting with Taiyin, hands/feet are warm; Shaoyin, hands/feet are cold/clear; Jueyin, hands/feet are reversed cold. However, Jueyin is the extreme of Yin, so why is there fever? Because Yang extreme generates Yin, and Yin extreme generates Yang, following the law of Yin-Yang transformation. *I Ching* says: At the limit, change occurs. Yang extreme generates Yin, hence Yang diseases have cold extremities; Yin extreme generates Yang, hence Jue diseases have fever. "Deep Jue means deep heat" is the normal change at extremes. *Neijing* says: Hyperactivity causes harm, succession brings regulation.) In Cold Damage, Jue with palpitation below the heart requires treating water first with Fuling Ganjiang Tang (Poria and Ginger Decoction) before treating Jue. Otherwise, water infiltrates the stomach, causing diarrhea. (Cheng Wuji notes: *Jinkui Yaolue* states severe water retention below the heart causes palpitation. Although Jue is due to cold excess, palpitation indicates internal water abundance. Treat Jue with Fuling Ganjiang Tang first, then water. Treating Jue first allows water to infiltrate the stomach, causing diarrhea.)

Fuling Ganjiang Tang Formula:
Fuling, Guizhi (bark removed, 2 liang each), Shengjiang (sliced, 3 liang), Gancao (fried, 1 liang). Boil four ingredients in 4 sheng of water to obtain 2 sheng, strain, and 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, reversed cold hands/feet, absent Chi pulse, blocked throat, vomiting of pus/blood, and unceasing diarrhea. This is difficult to treat, managed with Mahuang Shengma Tang (Ephedra and Ma Huang Shen Decoction). Cold hands/feet with fine, nearly absent pulse is treated with Danggui Sini Tang (Angelica Sinensis Four Counterflow Decoction). (Cheng Wuji notes: Cold hands/feet indicates deficient exterior Yang failing to warm extremities; fine/almost absent pulse indicates deficient interior Yin-Blood obstructing pulse flow. Danggui Sini Tang assists Yang to generate Yin.)

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

Diarrhea with deep/slow pulse, slightly red face, slight body heat, and clear undigested food in diarrhea leads to dizziness, sweating, and resolution. The patient likely has mild Jue because the red face indicates "Dai Yang" (floating Yang) and lower deficiency.

After diarrhea, if pulse disappears and hands/feet are cold, but pulse returns and hands/feet warm, there is life; if pulse does not return, death. Clear undigested food in diarrhea, internal cold with external heat, sweating, and Jue are treated with Tongmai Sini Tang. Profuse sweating, persistent heat, internal cramping, limb pain, diarrhea, Jue, and aversion to cold are treated with Sini Tang. Cold hands/feet with sudden tight pulse indicates pathogen knotting in the chest, chest fullness, vexation, hunger but inability to eat. The disease is in the chest, requiring emesis with Gouti San (Melon Seed Powder). Cold Damage progressing from one-two days to four-five days with Jue will have fever. Previous heat followed by Jue indicates transmission. Deep Jue means deep heat; mild Jue means mild heat. Jue should be treated with purgation; if sweating is used instead, mouth ulcers and redness occur. (One-two to four-five days with Jue implies transmitted pathogen. Heat precedes Jue, also transmitted. Assess heat depth by Jue severity. If Jue-heat enters Fu organs and becomes excess, purgation is needed. Sweating dries Stomach fluids, increasing heat, causing mouth ulcers. Although texts say "do not purge Sini," here purgation is appropriate. Ancestors note: In Heat Jue, hands/feet may be warm occasionally; palms/soles are warm. Dai Yuanli distinguished Heat/Cold Jue by nail temperature. Physicians must be cautious.) All Sini/Jue cases (contraindicated) should not be purged; this applies to deficient patients too. Cold Damage after five-six days, no Chest Binding, soft abdomen, empty pulse, and recurrence of Jue should not be purged; this is Blood exhaustion. Purging leads to death. Cold Damage with rapid pulse and reversed cold hands/feet can be moxa-ed.

Diagnosis: Jue occurs when Yin and Yang Qi fail to connect smoothly, resulting in cold extremities. (Cheng Wuji notes: Hand/Foot Three Yin/Yang meridians connect at ten fingers/toes. Internal sinking of Yang Qi prevents smooth connection with Yin, causing cold extremities.) Cold Damage with fever for four days, Jue for three, then fever for four days. Less Jue, more heat indicates recovery. If heat persists from day four to seven, pus-blood in stool follows. (Cheng Wuji notes: Heat then Jue is Yang pathogen transmitting inward. Fever is exterior; Jue on day four is transmission to Yin. Recovery of heat after three days is transmission back to Yang. Less Jue/more heat means pathogen weak/Yang strong, indicating recovery. By day seven, transmission ends, heat clears. Persistent heat means excess heat attacking Jueyin Blood, causing pus-blood in stool.) Cold Damage with Jue for four days, heat for three, then Jue for five days indicates progression. More cold, less heat means Yang retreats, so disease advances. Cold Damage starting with fever for six days, Jue for nine days with diarrhea. Normally, Jue/diarrhea patients cannot eat. If eating, suspect "Chu Zhong" (Elimination of Middle). Feeding Suobing (noodles): if no fever, Stomach Qi remains, recovery expected. Fear is sudden heat coming and going. After three days, if pulse shows continuous heat, recovery expected at dawn/midnight. Originally fever 6 days + Jue 9 days + fever 3 days = 9 days, matching Jue duration. 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 Yin-Cold, should not eat. Eating suggests Chu Zhong (elimination of Stomach Qi). Excess pathogen forces Stomach to seek food. Test with noodles: if Stomach Qi exhausted, fever ensues with flour; if no fever, Stomach Qi remains. Fear is cold extreme transforming to heat, sudden heat enabling eating, not Chu Zhong. *Jinkui*: inability to eat but sudden craving causes fever. Continuous heat after three days means Yang dominance, recovery at dawn/midnight. No recovery, rapid pulse, persistent heat means excess heat, causing abscess. Text: Irregular rapid pulse causes sores.) Cold Damage with Jue five days, heat five days. If sixth day should recur Jue but doesn't, self-heals. Jue does not exceed five days; heat five days confirms self-healing. (Cheng Wuji notes: Yin dominance causes Jue, Yang dominance causes heat. Five days Jue is Yin dominance. Day six Yang recovers, heat five days. Recurrence of Jue means Yin returns. No Jue means Yang complete dominance, self-healing. Text: Fever 4 days, Jue 3 days, fever 4 days, less Jue more heat, recovery.) Cold Damage with little heat, mild Jue, cold finger tips, silence, anorexia, vexation. After several days, clear urine, white color indicates heat removal. Desire to eat indicates recovery. If Jue with vomiting and chest/hypochondriac fullness/vexation, blood in stool follows later. (Cold fingertips mean mild Jue/little heat. Silence/anorexia/vexation means pathogen heat entering interior. Clear urine/white color later means interior heat gone. Desire to eat means Stomach Qi harmonized. If no desire to eat, Gancao Ganjiang Tang is suitable. Vomiting/chest fullness is Shaoyang syndrome. Shaoyang and Jueyin are exterior-interior pairs; pathogen affects Fu organ, causing vomiting/fullness. Liver governs Blood, hence blood in stool later.) Fullness/pain in lower abdomen with Jue indicates Cold Knotting at Guanyuan (see Lower Abdomen Pain). Fever (untreatable) with Jue for seven days and diarrhea is difficult. Cold Damage six-seven days, faint pulse, cold hands/feet, vexation. Moxa Jueyin points; if Jue does not reverse, death. (Are the six Jueyin points moxa-ed according to seasons/Well-Spring-Stream-River-Sea?) Cold Damage with fever, diarrhea, reversed cold, restlessness unable to lie down is fatal. Fever, severe diarrhea, persistent Jue is fatal. Diarrhea, cold hands/feet, absent pulse. Moxa but not warm; if pulse doesn't return and slight panting occurs, fatal.

Appendix:
*Huoren Shu*: Cold Jue begins with cold extremities, deep/faint/non-rapid pulse, curled legs, aversion to cold, covering with clothes, no thirst, clear undigested diarrhea, or normal stool, or frequent urination. Exterior signs are alert/conscious. Pulse deep/solid but slow/weak on pressure indicates Cold Jue. Use Sini Tang, Lizhong Tang, Tongmai Sini Tang, Danggui Sini Tang, Danggui Sini Jia Wuzhuyu Shengjiang Tang, Baitong Jia Zhu Danzhi Tang as indicated.

Heat Jue involves fever/headache and other Yang signs. Jue appears after two-three to four-five days. With Heat Jue, Jue lasts half a day then heat returns. Deep heat causes Jue, appearing after two-three days. Mild Jue with returning heat indicates deep heat. Pulse hidden but slippery on pressure indicates interior heat. Patient fears heat, drinks water, throws limbs, vexation, insomnia, constipation, red urine. Exterior signs include confusion. This is Heat Jue. Use Baihu Tang or Chengqi Tang as indicated.

If all purgation signs exist but Sini appears, it is due to missed purgation causing Qi/Blood blockage and cold limbs. Misdiagnosing as Yin Jue and giving heating drugs causes disaster. Heat Jue requires deep/hidden/slipping pulse, sweat on head, cold hands but warm nails occasionally. Use Dachengqi Tang to purge; do not hesitate.

All reversed cold hands/feels belong to Jueyin, contraindicating sweating/purging. However, sweating/purging may be needed if hands/feet are cold but occasionally warm, especially palms/soles, indicating non-standard Jue. Analyze carefully.

Haizang: Jueyin syndrome with cold extremities, blue nails, deep/rapid pulse, forceful on pressure is Yang; purge with Dachengqi Tang. If deep/slow pulse, weak on pressure is Yin; warm with Sini Tang. Moxa quickly.

Luo Qianfu: A woman of official Cao Deyu fell ill with Cold Damage for eight-nine days in early spring. Pulse deep/fine/faint, cold extremities, spontaneous diarrhea, abdominal pain, eyes closed, arms hugging armpits, drowsy, dry mouth/tongue. Asked if Baibu Jia Renshen Tang could be used. I said: Although Baibu treats dry mouth/tongue, it is inappropriate here for three reasons: 1. Before Lixia/After Liqiu, do not use rashly. 2. Taiyang syndrome with anhidrosis and thirst should not use it. 3. Patient has all Yin signs, and spring air is still cold. Zhang Zhongjing says: Clear undigested diarrhea requires urgent interior rescue with Sini Tang (5 liang), Renshen (1 liang), Shengjiang (10+ slices), Congbai (9 stalks), Water (5 large cups). Boil to 3 cups, strain, divide into three doses. By night, hands/feet warm. Next day, profuse sweat resolves disease. Follow with Lizhong Tang. Sun Simiao’s thesis: Great physicians must master *Jia Yi*, *Suwen*, *Huangdi Zhenjing*, *Mingtang*, *Liuzu*, meridians, *Bencao*, *Shennong*, *Zhang Zhongjing*, *He Hu*. Without this, it is wandering blind. Reconsider such medication.

Yang Syndrome Case Study: Zhao Jifu, 33, in May (Zhiyuan era), suffered spleen/stomach damage from labor/diet, causing irritability/thirst. Overconsumption of cold food led to fatigue, headache, cold extremities, vomiting, epigastric fullness. Doctor misdiagnosed as Yin Toxic Cold Damage due to cold extremities/vomiting/fullness, gave Guizhi powder in hot wine, covered with cotton. Suddenly profuse sweat, followed by dry mouth/tongue, red eyes, stiff neck, rigid limbs, red painful urination, constipation, picking at bedclothes, delirium. Tongue red/cracked, better morning/worse evening. Family despaired. Neighbor Ji Zhongwan consulted me. Pulse 7-8 beats per breath confirmed Heat Syndrome. Used Dachengqi Tang (pungent/bitter/great cold, 1 liang). Three bowel movements reduced excess. Next day, Huanglian Jiedu Tang (great bitter/cold, 2 liang) slowly to remove heat. After three 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. Must respect annual Qi, not harm Heaven-Harmony. In summer heat, sages use cold to save Kidney Water source and supplement Lung Metal. Even with external cold, Zhang Zhongjing adds Huangqin/Zhimu/Shigao to Mahuang Tang to prevent yellow spots/rashes, and warns against Guizhi Tang. Using Guizhi in hot wine deviates from method. Error of a hair leads to mile deviation. Text: Not harming harmony, not assisting excess/recovery, not missing Qi suitability prevents new diseases.

Use Heat Far From Heat, Treat from the Middle: Friend Liu Juyuan, 65, in summer (Zhengtong era), fell ill from labor/diet/cold drinks. Doctors treated as seasonal illness without success. Ten days later, I examined him. Right hand pulse deep/fine/faint (Taiyin syndrome). Left hand pulse slightly floating/string-like (deficient Yang on exterior). Yin excess, Yang deficiency. Symptoms: heavy body, cold extremities, clear undigested diarrhea, covering self, short breath, reluctance to speak. Spleen cold-damp, middle Qi deficiency. Zhang Zhongjing: Clear undigested diarrhea requires urgent interior rescue with Sini Tang. *Neijing* warns: Use heat far from heat. Dry mouth, rinses but doesn't swallow. Morning cool with gooseflesh; afternoon vexation,不愿 remove clothes, drowsy red face, faint red spots on skin. Exterior excess, interior deficiency. Interior deficiency changes exterior signs with time. Detailed analysis shows diet/labor/cold damaged spleen/stomach, not seasonal. Treat based on root/branch. Time is branch, disease is root. Cold medicine follows time but violates root; heat medicine follows root but violates time. Both cold and heat injure; must treat from the "Middle." Middle treatment means warming. Used Qian Shi Baizhu...