bubble_chart Concept

Reversal cold of hands and feet, also known as cold extremities, refers to the symptom of coldness in the limbs extending from the hands and feet to the elbows and knees. Generally, coldness up to the wrists and ankles is referred to as reversal cold of hands and feet, while coldness extending to the elbows and knees is termed cold extremities.

Reversal cold of hands and feet is referred to as "cold reversal" or "four reversals" in the Neijing. Cold extremities and reversal have three meanings: first, it refers to reversal cold of hands and feet; second, it refers to sudden fainting and unconsciousness, known as syncope; third, it refers to the symptoms and signs of disharmony in the six meridians. It was not until the emergence of the "Treatise on Cold Damage Diseases" that the term reversal cold of hands and feet was established. Synonyms for reversal cold of hands and feet include cold extremities, cold reversal of limbs, reversal cold, and cold hands and feet. "All cases of reversal are due to the failure of yin and yang qi to connect smoothly, resulting in reversal; reversal cold of hands and feet is one such case." This is Zhang Zhongjing's summary of the mechanism of reversal cold of hands and feet. Later physicians' understanding of reversal cold of hands and feet was based on the discussions in the "Treatise on Cold Damage Diseases." Mild cases of reversal cold of hands and feet are referred to as cold hands and feet or cool hands and feet.

bubble_chart Pattern Analysis

1. Decline of Yang Qi︰Abbreviated as "cold reversal." Reversal cold of hands and feet, or even reversal cold of limbs, with a shivering and curled-up posture, pale complexion, listlessness, or clear-grain diarrhea, or joint pain, pale tongue texture, thin white and moist coating, and a faint, almost imperceptible pulse. Also known as "cold reversal." Clinically, there are three easily confused symptoms and signs that should be distinguished. One is due to spleen-kidney yang decline and excessive pudendal coldness, manifesting as reversal cold of hands and feet. Another is due to excessive pudendal coldness repelling yang outward, also manifesting as reversal cold of hands and feet. The third is due to yin exuberance below repelling yang upward, again manifesting as reversal cold of hands and feet. Although all three involve reversal cold of hands and feet caused by yang qi decline failing to warm the extremities, the degree of yang decline varies, leading to different clinical manifestations and treatments. Symptoms such as reversal cold of hands and feet, aversion to cold with a curled-up posture, clear-grain diarrhea, and a faint, almost imperceptible pulse indicate spleen-kidney yang decline and excessive pudendal coldness. Treatment should focus on restoring yang to rescue from collapse, with the formula selection being Cold-Extremities Decoction. If accompanied by an absence of aversion to cold, a flushed complexion, retching, or sore throat, this indicates yin exuberance internally repelling yang outward—a repelling yang syndrome, i.e., true cold internally with false heat externally. This is more critical than the Cold-Extremities Decoction syndrome and requires expelling yin and restoring yang to unblock the pulse. The formula selection is Vessel-Unblocking Cold-Extremities Decoction. If "shaoyin disease with diarrhea and a faint pulse," use White Unblocking Decoction. After taking White Unblocking Decoction, if diarrhea persists, limb coldness worsens, the pulse becomes hidden, and retching with restlessness occurs, this indicates yin exuberance below repelling yang upward—a floating yang syndrome. The formula selection is White Unblocking Decoction with Pig Bile, which adds the bitter-cold corrective pig bile and human urine to guide yang medicine into yin, rapidly restoring yang to rescue from collapse. This treatment aligns with Neijing principles of "treating heat with cold" and "treating severe cases in compliance with pseudo-symptoms."
   Another type is shaoyin disease with yang deficiency and interior cold pattern reversal cold of hands and feet. Due to yang deficiency failing to reach the extremities and cold-damp stagnation, symptoms include cold limbs, body pain, joint pain, and a deep (not floating) pulse. Treatment may first employ moxibustion (e.g., on Guanyuan and Dazhui) to support yang and dispel yin, followed by Aconite Decoction to warm yang, replenish qi, and disperse cold-damp. Unlike the overall cold presentation, the repelling yang syndrome and floating yang syndrome lack the external heat signs of pathogenic heat internal stagnation. For instance, the flushed complexion resembles rouge rather than the deep red of internal heat; retching with restlessness but no thirst differs from the thirst and heavy drinking of internal heat. Crucially, the forceful rapid pulse and red tongue with yellow, dry, scanty coating in internal heat contrast sharply with the faint pulse and thin white moist coating in repelling yang and floating yang syndromes. Therefore, for reversal cold of hands and feet due to pathogenic heat internal stagnation, clearing heat and purging fire or unblocking the bowels is appropriate. Formula selections include White Tiger Decoction or Major Purgative Decoction.
2. Internal Stagnation of Pathogenic Heat︰Abbreviated as "heat reversal." Reversal cold of hands and feet, without sweating, high fever, flushed face and irritability, thirst with excessive drinking, restlessness, severe constipation, scanty dark urine, red and deep tongue texture with thick, dry, yellow coating, deep and rapid or slippery and rapid pulse. Reversal cold of hands and feet occurs when external pathogens transform into heat, transmitting from the exterior to the interior, leading to excessive interior heat and stagnation of yang qi, preventing it from reaching the extremities. As stated in the *Treatise on Cold Damage Diseases*, "The deeper the reversal, the deeper the heat; the milder the reversal, the milder the heat," precisely refers to this syndrome. The key diagnostic points are: reversal cold of hands and feet coexisting with systemic heat signs (aversion to heat, dry mouth and tongue, excessive thirst with drinking, severe constipation, rapid and forceful pulse, dry yellow tongue coating, etc.). The pathogenesis of both types of reversal cold of hands and feet is related to the obstruction of qi movement, but the former is due to the stagnation of upright (yang) qi.
3. Yang Qi Depression and Obstruction︰Cold limbs, accompanied by fullness and discomfort in the chest and hypochondrium, belching, vomiting, diarrhea, or abdominal pain, or cough, or palpitations, or dysuria, thin white tongue coating, and wiry pulse. This is due to stagnation of yang qi. The treatment should focus on relieving stagnation and unblocking yang, promoting qi movement. The recommended formula is Cold-Limbs Powder.
4. Blood Deficiency with Cold Invasion︰It belongs to one of the "cold reversal" types. Reversal cold of hands and feet, cold limbs, bodily chills and pain, pale and bluish skin, or possible cold pain in the epigastrium and abdomen, tongue texture pale red with thin white moist coating, and deep thin pulse. This condition arises from constitutional blood deficiency combined with exposure to cold pathogens, leading to impeded blood circulation and cold stagnation in the limbs. The key diagnostic points are: constitutional blood deficiency (shallow yellow complexion, pale lips and tongue color, deep thin pulse) and prominent invasion of external cold (often occurring in winter and spring, or worsening during rainy weather). This syndrome also falls under the category of cold reversal but is milder than reversal cold of hands and feet due to yang qi depletion. The latter is more commonly seen in critical stages of illness, affecting the viscera, whereas this syndrome is clearly related to sudden temperature drops and involves the meridians. In the latter, cold extremities do not improve with warmth, whereas in this syndrome, warmth provides relief. In treatment, the latter focuses on restoring yang, while this syndrome emphasizes warming the meridians. Therefore, for this syndrome, the formula Angelica Cold-Extremities Decoction is selected to warm and nourish the blood vessels, dispel cold, and harmonize the nutrient level. If there is chronic internal cold accompanied by lower abdominal cold pain, or retching and frothy salivation, Evodia Fruit and Fresh Ginger Rhizome can be added to warm the liver and stomach, dispel cold, and direct qi downward, resulting in Angelica Cold-Extremities plus Evodia and Fresh Ginger Decoction.
5. Phlegm-dampness Obstruction︰Abbreviated as "phlegm syncope." Reversal cold of hands and feet, fullness and oppression in the chest and epigastrium, gurgling phlegm sounds in the throat, or vomiting of phlegmatic drool, hunger without appetite, white and greasy tongue coating, and a deep, slippery, forceful pulse or occasionally tight. It is caused by inherent exuberance of phlegm-dampness, preventing the chest yang from spreading. The key points for pattern identification are: habitual fullness and oppression in the chest and epigastrium, phlegm sounds in the throat, sticky mouth, or vomiting of frothy phlegm; the tongue coating must be white and greasy; reversal cold of hands and feet often appears due to wind-cold triggering or anger. If phlegm-turbidity ascends to cloud the mind, it may also be accompanied by dizziness, mental confusion, or manic restlessness. Without external disturbances, it commonly manifests as cold hands and feet without reaching the level of syncope. Treatment should focus on {|###|}regulating qi and relieving depression{|###|} to expel phlegm, with the formula selection being Phlegm-Guiding Decoction; if accompanied by mental confusion, Muskmelon Base Powder may be chosen to induce vomiting. Once the phlegm is expelled and qi flows smoothly, the mind will clear and syncope will cease.
6. Ascaris Wandering Disturbance︰Abbreviated as "gallbladder ascariasis." Reversal cold of hands and feet, paroxysmal pain in the upper abdomen, vomiting clear fluid or ascaris, or accompanied by restlessness and thirst, tongue texture pale or dull, tongue coating thin and moist, pulse deep and thin or deep and wiry. This syndrome is caused by ascaris disturbance and qi movement disorder. Ascaris lurking internally, spleen-stomach weakness, often manifests as abdominal dull pain, cold hands and feet, and other symptoms. If ascaris ascend and disturb the spleen and stomach, qi movement becomes obstructed, preventing middle yang from reaching the extremities, leading to reversal cold of hands and feet, or even coldness extending beyond the elbows and knees. The key diagnostic points are: reversal cold of hands and feet often appears alongside severe pain in the upper abdomen, accompanied by vomiting clear fluid or gall, or even vomiting ascaris, complexion turning bluish, cold sweating, pulse deep and thin or barely perceptible, and the reversal cold of hands and feet often subsides as abdominal pain alleviates. This syndrome is commonly seen in children and occasionally in adults. Treatment should focus on warming the viscera and quieting ascaris, Mume Pill is used for treatment.

Reversal cold of hands and feet is one of the interior pattern. It is generally divided into two major categories: heat reversal and cold reversal. Compared to heat reversal, the degree of cold reversal can range from mild to severe, extending from the hands and feet to the elbows and knees, whereas heat reversal usually does not extend beyond the feet and ankle joints. In addition to the differences in the degree of coldness, there are also significant differences in the heat or coolness of the chest and abdomen, the presence of constipation or diarrhea, the pulse manifestations (rapid or faint), and the tongue coating (yellow or white).

bubble_chart Documentation

1. Weisheng Baojian．cold extremities: "heat reversal, although the hands and feet are cold, they may sometimes be warm, the palms and soles must be warm, although the pulse is deep and hidden, it feels slippery when pressed, the symptoms may include fear of heat, thirst and desire to drink water, or waving hands and throwing feet, dysphoria and inability to sleep, severe constipation, and red urine. This is called heat reversal, what the ancients called the extreme yang causing syncope. Treatment uses White Tiger Decoction, Major Purgative Decoction, Shuangjie Powder, Diaphragm-Cooling Powder four prescriptions, ... cold reversal, the limbs are cold, the body is not hot, nausea, curling up to lie down, or covering oneself with clothes and blankets, not thirsty or diarrhea, or normal bowel movements, the pulse is deep and faint and not rapid, or although deep and solid, it feels slow and weak when pressed, this is called cold reversal. Treatment uses Vessel-Unblocking Cold-Extremities Decoction, or Angelica Cold-Extremities Decoction, or Bai Tong Decoction with pig gall and bile."
2. Leizheng Zhicai．syncope: "qi rises from below, cold hands and feet are syncope. Syncope means exhaustion, a critical condition. The classic says: deficiency below causes syncope, so yang deficiency below causes cold reversal. Yin deficiency below causes heat reversal, the qi of yin and yang does not connect smoothly, then the disease of cold extremities occurs. ... cold reversal, the body is cold and the face is blue, the limbs are cold, the nails are cold, curling up to lie down and not thirsty, smooth bowel movements, the pulse is faint and slow, this is cold reversal. Heat reversal, the body is hot and the face is red, the limbs are cold, the nails are warm, thirsty and confused, short and unsmooth pulse, slippery and rapid, this is heat reversal."