Si Ni Tang - 四逆湯 - Frigid Extremities Decoction

English:	Frigid Extremities Decoction
Also Known As:	Decoction to Treat Cold Limbs Aconite, Ginger and Licorice Combination Aconite and G.L. Combination

Herbs And Actions

Pharmaceutical Latin	Pin Yin	Dosage	Actions
Rx. Aconiti Lateralis Preparata	Zhi Fu Zi	9g	Warms the Kidney and Heart Yang, stimulates exhausted Yang, warms the Ming Men Fire and the entire body by traveling through all twelve channels. With Gan Jiang, strengthens the Kidney and Spleen Yang,warms the Spleen and Kidneys, disperses Cold and treats overabundance of Yin fluids due to Deficiency Cold, Devastated Yang and debilitated Spleen and Kidney Yang with incessant diarrhea. With Gan Jiang and Zhi Gan Cao strengthens the actions of fortifying Qi and benefiting the Yang for Cold extremities and diarrhea with undigested food due to Collapse of the Spleen and Kidney Yang.
(Rx. Aconiti Lateralis)	(Sheng Fu Zi)	(1 piece)	(Use only if condition is critical.)
Rz. Zingiberis	Gan Jiang	4.5g	Expels Cold, Rescues Yang, Stops bleeding, Transforms thin mucus, Warms the channels (unblocks the pulse), Warms the Middle Jiao and Lungs. With Zhi Fu Zi, for Cold-Damp Bi. With Zhi Gan Cao, for epigastric pain and vomiting due to Spleen and Stomach Deficiency Cold and detoxifies Zhi Fu Zi.
Rx. Glycyrrhizae Preparata	Zhi Gan Cao	6g	Tonifies Qi, strengthens the Spleen and moderates the drying properties of the formula.

Formula Actions

• Rescues Yang
• Warms the Middle Jiao
• Disperses Internal Cold
• Stops diarrhea

Syndromes

• Heart Yang Deficiency Exhaustion: Yang Xu Jue Ni
• Kidney Yang Deficiency with Internal Cold
• Shao Yin Cold
• Yang Ming Han
• Excess use of diaphoretics in Tai Yang Stage leading to loss of Yang
• Kidney Yang deficiency with Cold-Evil in Shaoyin stage (Yin Jue); Yang collapse (Secondary source)
• True Cold with False Heat: flushed face and irritability, yet a desire for warm drinks and loose stools

Clinical Manifestations

Extremely cold extremities Aversion to Cold Sleeping with knees drawn up Lethargy with a constant desire to sleep Vomiting Diarrhea with undigested food Abdominal pain and Cold Lack of thirst Coma

Indigestion Edema Pale face Superficial fever Red face Cyanosis of the lips and nails T: Pale or Dark purple C: White and slippery P: Deep and thready or Deep and slow or Deep and faint Profuse cold sweating Sudden fainting Irritability Desire for warm drinks

Treats

Acute myocardial infarction Cardiac insufficiency Hypopituitarism Vomiting and diarrhea due to acute and chronic gastroenteritis Hypothyroidism Cerebrovascular insufficiency Acute gastroenteritis Cirrhosis of the Liver Chronic prostatitis Intoxication Arthritis Influenza Constipation Abdominal pain Palpitations Fatigue Chronic nephritis Congestive Heart failure Perspiration on the extremities Dyspnea Painful obstruction

Adrenal insufficiency Edema Intractable arthritis Cholera Jaundice Intestinal Heat Shock Chronic colitis Functional uterine bleeding Recurrent aphthous ulcers Gastroptosis Common cold Cough Nausea/Vomiting Diarrhea Anorexia Weakness Chronic renal failure Spontaneous perspiration Indigestion Dysmenorrhea

Contraindications And Herb/Drug Interactions

Notes

• Composition: Fu Zi 6-9g, Gan Jiang 6-9g, Zhi Gan Cao 6g (Secondary source)
• Wu Zhu Yu Tang vs Si Ni Tang: both can show cold limbs, vomiting and diarrhea; Wu Zhu Yu Tang has irritability and severe agitation, whereas Si Ni Tang has a constant desire to sleep.
• Nine Needles for Returning Yang (from the "Glorious Anthology of Acupuncture and Moxibustion"): LI4, ST36, SP6, KD1, KD3, PC8, GB30, DU15, RN12; used for Yang collapse with loss of consciousness, aversion to cold and purple lips.
• Chief herb comparison: Li Zhong Wan relies on Gan Jiang for Taiyin Cold; Wu Zhu Yu Tang on Wu Zhu Yu for Cold in Yangming, Jueyin or Shaoyin; Si Ni Tang on Fu Zi for Shaoyin Cold; Da Jian Zhong Tang on Hua Jiao for Excess Cold with Spleen Yang deficiency.

Modifications

For edema or leukorrhea due Kidney and Spleen Yang Deficiency:		For a red face with extreme irritability:
+ Rx. Codonopsis	Dang Shen	+ Take formula Cold
+ Poria	Fu Ling	For intractable arthritis due to Wind-Damp:
+ Rz. Alismatis	Ze Xie	+ Cx. Cinnamomi	Rou Gui
Or		+ Rz. Atractylodes Macrocephalae	Bai Zhu
+ 24g Rx. Astragali	Huang Qi
+30g Poria	Fu Ling	For chronic arthritis due to Cold:
For shortness of breath or accelerated respiration:		+ Ram. Cinnamomi	Gui Zhi
+ Rx. Paeoniae Alba	Bai Shao
+ Rx. Ginseng	Ren Shen	For abdominal pain due to Cold:
For severe coma:		+ Ram. Cinnamomi	Gui Zhi
+ Rx. Ginseng	Ren Shen	+ Rx. Paeoniae Alba	Bai Shao
For extreme coldness of the extremities:		For edema and palpitations:
+ Hb. cum Rx. Asari	Xi Xin	+ Rx. Ginseng	Ren Shen
+ Ram. Cinnamomi	Gui Zhi	+ Poria	Fu Ling
For abdominal pain due to Blood Deficiency:		For diarrhea with undigested food:
+ Four-Substance Decoction Si Wu Tang		+ Regulate the Middle Decoction Li Zhong Tang
For nausea, vomiting and a sore throat:		For aversion to Cold:
+ Rz. Zingiberis Recens	Sheng Jiang	+ 9g Rz. Atractylodis Macrocephalae	Bai Zhu
+ Rx. Platycodi	Jie Geng
For sudden stopping of diarrhea:		For fever with insomnia and palpitations:
+ Rx. Ginseng	Ren Shen	+ Sm. Zizyphi Spinosae	Suan Zao Ren
For collapse of Qi and Yang:		+ Rx. Polygalae	Yuan Zhi
+ Rx. Ren Shen Rubra	Hong Shen	For diarrhea:
For gastroptosis with abdominal pain:		+ Rz. Coptidis	Huang Lian
+ Cx. Cinnamomi	Rou Gui	For gastroptosis with abdominal distention:
+ Camphora	Zhang Nao	+ Fr. Gardeniae	Zhi Zi
+ Fr. Evodiae	Wu Zhu Yu	+ Rx. Aucklandiae	Mu Xiang
For gastroptosis with nausea:		+ Cx. Magnoliae Officinalis	Hou Po
+ Fr. Amomi	Sha Ren
+ Rz. Pinelliae Preparatum	Zhi Ban Xia	For gastroptosis with belching:
+ Fr. Crataegi	Shan Zha
For low back pain due to Jue Yin Cold-Damp:		+ Fr. Hordei Germinatus	Mai Ya
+ Rx. Bupleuri	Chai Hu	For secondary dysmenorrhea:
+ Rx. Angelicae Pubescentis	Du Huo	+ Flow-Warming Decoction Wen Jing Tang
For secondary dysmenorrhea with cold limbs and a pale face:		+ Fol. Artemisiae Argyi	Ai Ye
+ Fr. Foeniculi	Xiao Hui Xiang
+ Flow-Warming Decoction Wen Jing Tang
+ Fol. Artemisiae Argyi	Ai Ye
+ Fr. Foeniculi	Xiao Hui Xiang
+ Rx. Ophiopogonis	Mai Men Dong
+ Colla Corii Asini	E Jiao