Are Cold Hands and Feet Always a Sign of Yang Deficiency?

Many patients who consult me mention that their hands and feet are cold, saying they have read some TCM books and watched health experts on television, and learned that cold hands and feet are a sign of yang deficiency, requiring warming-tonifying drugs or foods to supplement yang. As a result, some patients take Angelica and Mutton Decoction, or herbs like aconite (Fuzi), cinnamon (Rougui), or dried ginger (Ganjiang) that warm and tonify kidney yang; after taking them, all sorts of problems arise and their bodies deteriorate sharply.

Some go further, claiming that chronic diseases such as cancer and diabetes without exception all belong to yang deficiency. I have also read articles by some TCM physicians arguing that cancer is all Shaoyin syndrome and should be treated with formulas of the Mahuang Xixin Fuzi Tang series, so they often prescribe ephedra and aconite to patients. As a result, patients sweat profusely year-round after taking the medicine and suffer greatly.

These years the TCM community has greatly promoted yang-supporting therapy; there are no few TCM physicians who give cancer patients large amounts of aconite, dried ginger, and other yang-warming herbs.

When a certain yang-supporting master was alive, many cancer patients sought his treatment; it could truly be described as people flocking to him. I was fortunate, while he was alive, to encounter many patients he had treated; most had, after taking his medicines for three to five days, seen their condition worsen sharply and were referred to me.

After this master died, many of his views were regarded by patients as gospel; people often send me his articles on yang-supporting theory via WeChat. But those who send me these articles understand him far less than I do. To these pushes, I generally remain silent and do not reply.

I know that before his death he cured many difficult diseases truly due to yang deficiency, especially heart-failure patients, because yang-supporting herbs are particularly effective for heart failure. But because he was not a TCM physician specializing in oncology, the number of tumor patients he cured was very small; still, most cancer patients were influenced by his view that cancer mostly belongs to yang deficiency—he almost thought every disease, cancer included, was yang deficiency, which is truly extreme.

Cancer is a very complex disease, but people mostly are unwilling to think complexly and prefer simple theories to interpret complex problems. Many people believe cancer is yang deficiency; some cancer patients believe they can cure cancer by drinking large amounts of ginger decoction to change their yang-deficient constitution, and as a result many medical accidents occurred. This prejudice has now become a widespread abuse, so I write this article to refute this erroneous view.

Cold hands and feet are called "sini" in TCM, or "jueni," or simply "jue." In the Jueyin disease chapter of the Shanghan Lun (Treatise on Cold Damage) there is this statement: "Whenever there is jue, it is because the yin and yang qi do not connect smoothly; that is jue. Jue means reversal-coldness of the hands and feet." This sentence explains in detail what "jue" is: the symptom of jue is reversal-cold hands and feet. Normal people's hands and feet are warm; those with jue have cold hands and feet.

Here it does not say that "jue" is caused by yang deficiency, but rather that it is due to "yin and yang qi not connecting smoothly." Professor Hu Xishu said that this non-connection of yin and yang qi is actually what is now called arteries and veins not connecting with each other (see Chapter 8, "Pattern Differentiation and Treatment of Jueyin Disease," in Hu Xishu's Lectures on the Shanghan Zabing Lun). Is Professor Hu's view correct? I personally cannot judge, nor dare I lightly agree.

Once the phenomenon of arteries and veins failing to connect occurs, I fear the patient would be in mortal danger. For example, the human liver has a dual arterial and venous blood supply; about 1,000 ml of blood flows through the liver per minute. If the liver's arteries and veins did not connect, the patient might not live long.

General non-connection of arteries and veins is mostly caused by thrombus or tumor embolus, which usually causes limb gangrene or sudden death—not merely "reversal-coldness of the hands and feet." Yet among people with cold hands and feet I have encountered in practice, many have had cold hands and feet for years. Most patients with cold hands and feet have excellent stamina and their lives are unaffected; some are even athletic. So I think these explanations of reversal-cold hands and feet are not scientific: some people's cold hands and feet are pathological, while others' are non-pathological.

Cold hands and feet are an objective phenomenon, and the causes are very complex; I myself can hardly spell them out, but I will not glibly attribute all cold hands and feet to yang deficiency. Personally, I do not think the phenomenon of cold hands and feet can be simply attributed to yang deficiency, or to the non-connection of arteries and veins as Professor Hu Xishu said. Some people have cold hands and feet long-term, but they are healthy, with no major illness, and can live to a very advanced age; moreover, scientists have found in recent years that people with lower body temperatures live longer.

I once encountered a 93-year-old man with cold hands and feet; during consultation I asked in detail when they had become cold. The old man told me it had been so since childhood—cold hands and feet his whole life—yet he lived to 93 and remained basically healthy, showing that cold hands and feet are not to be worried about. When we encounter people with cold hands and feet, we should ask more about their overall condition and not rashly diagnose yang deficiency just because their hands and feet are cold.

Zhang Zhongjing also never said reversal-cold hands and feet are yang deficiency; he only said it is "yin and yang qi not connecting smoothly." Moreover, in Zhang Zhongjing's Shanghan Lun, there are two formulas directly named for jue in treating reversal-cold hands and feet: one is Sini Decoction, the other is Sini Powder. Although both formulas are named for sini, the herbs used are entirely different. Sini Decoction is an aconite formula that warms yang; Sini Powder is a bupleurum formula that soothes the liver and moves qi. Let us look separately at the medication indications for Sini Decoction and Sini Powder.

Sini Decoction: Honey-fried Licorice 2 liang, Dried Ginger 1.5 liang, Aconite 1 piece (raw, broken into 8 pieces).

There are ten provisions in the Shanghan Lun related to Sini Decoction, distributed across several chapters; I list them all below:

Cold damage; the physician purges, and subsequently there is incessant diarrhea of undigested food; if the body aches, urgently rescue the interior; afterward, if the body aches and urination and defecation are normal, urgently rescue the exterior. To rescue the interior, Sini Decoction is appropriate; to rescue the exterior, Guizhi Tang is appropriate. (Clause 91)

Illness with fever and headache, but the pulse is instead deep; if not resolved, with body pain, rescue the interior; Sini Decoction formula. (Clause 92)

Pulse floating and slow, exterior heat and interior cold, diarrhea of undigested food; Sini Decoction governs it. (Clause 225)

Spontaneous diarrhea without thirst belongs to Taiyin; because the viscera has cold, it should be warmed; Sini-type formulas are appropriate. (Clause 277)

Shaoyin disease with a deep pulse; urgently warm it; Sini Decoction is appropriate. (Clause 323)

Great sweating, fever not resolved, internal cramping, pain in the limbs, plus diarrhea and reversal-coldness with aversion to cold; Sini Decoction governs it. (Clause 352)

Great sweating, or great diarrhea with reversal-coldness; Sini Decoction governs it. (Clause 353)

Diarrhea with abdominal distending pain and body pain; first warm the interior, then attack the exterior. To warm the interior, Sini Decoction is appropriate; to attack the exterior, Guizhi Tang is appropriate. (Clause 371)

Vomiting with a weak pulse, and urination instead frequent, with mild heat on the body and seeing jue; difficult to treat; Sini Decoction governs it. (Clause 376)

Both vomiting and diarrhea, urination instead frequent with great sweating, diarrhea of undigested food, internal cold and exterior heat, and a pulse so faint it is about to expire; Sini Decoction governs it. (Clause 388)

Of these ten provisions, three explicitly have the symptom of reversal-coldness. We can see that the patients treated with Sini Decoction, while having "reversal-coldness," also mostly have spontaneous diarrhea or diarrhea of undigested food. Spontaneous urination means urine that is pale, clear, long, and frequent—a symptom of vacuity cold. Spontaneous stool or diarrhea of undigested food means diarrhea with food not transformed—also a symptom of vacuity cold. The remaining faint or slow pulses all belong to deficient pulses, indicating cold syndrome. Here, Zhang Zhongjing does not diagnose yang deficiency based solely on cold limbs; it is only after obvious accompanying signs that he uses a yang-warming formula like Sini Decoction.

Now let us look at Sini Powder.

Sini Powder is made of four herbs—honey-fried licorice, immature bitter orange (Zhishi), bupleurum (Chaihu), and peony (Shaoyao)—in equal parts, ground into powder, and taken with warm water in a "square-inch spoon" (fangcunbi). The "square-inch spoon" used the small hole on the dagger Han-dynasty people often carried as a measure; the dose is very small, about 1–3 g.

What does Sini Powder treat? The Shanghan Lun says: "Shaoyin disease with reversal-coldness; the patient may cough, or palpitations, or difficult urination, or abdominal pain, or diarrhea with tenesmus; Sini Powder governs it."

Regarding the indication of Sini Powder, commentators on the Shanghan Lun have long disagreed. Professor Hu Xishu believed that "Shaoyin disease" here is a scribal error for "Shaoyang disease," because Sini Powder is a bupleurum-series formula, and bupleurum-series formulas treat Shaoyang disease. In addition, Dr. Chen Ming compiled a book, Selected Proven Cases of Famous Physicians on the Shanghan Lun, in which the vast majority of patients selected for "Sini Powder" had the accompanying signs of "wiry pulse, bitter mouth, and hypochondriac fullness"—all typical symptoms and pulse of Shaoyang syndrome. So I lean toward Professor Hu Xishu's view being correct: Sini Powder treats the "reversal-coldness syndrome" of Shaoyang disease.

If the Shaoyin syndrome here is a scribal error for Shaoyang syndrome, then it shows that Shaoyang syndrome can also present with cold hands and feet. Even if it is not a scribal error, we can still see that Zhang Zhongjing did not categorically treat all cold hands and feet as yang qi decline and treat them all with yang-warming aconite and dried ginger.

In the Sini Powder pattern, the patient has possible accompanying signs such as difficult urination; these accompanying signs are not a picture of pure vacuity cold, so yang-warming herbs cannot be used—using them would be counterproductive. Instead, one uses bupleurum, immature bitter orange, peony, and honey-fried licorice to soothe and regulate the qi dynamic. Later formulas such as Chaihu Shugan Powder and Xiaoyao Wan were all developed on the basis of Sini Powder.

In folk speech there is also the saying of "getting so angry that one's hands and feet turn cold," showing that cold hands and feet are not necessarily yang deficiency; obstructed qi movement can also cause cold hands and feet. How can one, upon seeing cold hands and feet, rashly conclude that the patient has yang deficiency? Even less should one rashly say that all cancer patients have yang deficiency, thereby misleading them.

In treating disease, one must carefully analyze the patient's condition. TCM pattern differentiation especially emphasizes comprehensive analysis of the patient's symptoms, and does not draw conclusions based on a single symptom alone. Patients likewise should not, after touching only a superficial bit of TCM, rashly judge themselves to have yang deficiency and abuse yang-warming herbs to harm themselves.