DIFFERENCE BETWEEN HEAT AND FIRE

Most Chinese books use the words "Heat" and "Fire" interchangeably but in fact these two are not the same.  I think we should be precise in our diagnosis differentiating between Heat and Fire because the pathology and treatment are different.

I should clarify first the meaning of the term "Heat".  The term "Heat" has two meanings: in a broad sense, it is a general term for any pattern of Heat, external, internal, latent and including "Fire".  In a narrow sense, it refers to "Heat" as opposed to "Fire". 

In order to differentiate Heat and Fire, I would like to refer first to the patterns of the 6 Stages and 4 Levels.  The patterns of the 6 Stages (Tai Yang, Yang Ming, Shao Yang, Tai Yin, Shao Yin and Jue Yin) were formulated by Zhang Zhong Jing in his Shang Han Lun (approximately 200 AD).  The patterns of the 4 Levels were formulated by Ye Tian Shi in his Wen Bing Lun (1746 AD).

Within the 6 Stages, at the Yang Ming stage there are two separate patterns: Yang Ming Channel and Yang Ming Organ.  Within the 4 Levels, at the Qi Level, there are two patterns: Stomach-Heat and Intestines Dry Heat.  These patterns are basically identical and the formulae used are the same, so that Yang Ming Channel and Yang Ming Organ of the 6 Stages are the same as Stomach-Heat and Intestines Dry Heat (of the 4 Levels) respectively.

6 STAGES                              4 LEVELS

Yang Ming Channel       =      Stomach-Heat

Yang Ming Organ          =      Intestines Dry Heat

Yang Ming Channel and Stomach-Heat pertain to "Heat"; Yang Ming Organ and Intestines Dry Heat pertain to "Fire".

The symptoms of Yang Ming Channel pattern (and of Stomach-Heat) are: high fever that is worse in the afternoon, feeling of heat, intense thirst, profuse sweating, red tongue with yellow coating, Overflowing-Rapid pulse.

The symptoms of Yang Ming Organ pattern (and of Intestines Dry Heat) are: high fever that is higher in the afternoon, constipation, dry stools, burning in the anus, abdominal fullness and pain, irritability, delirium, red tongue with thick-yellow-dry coating, Deep-Full-Rapid pulse.

The Stomach-Heat pattern at the Qi Level (and the Yang Ming Channel pattern) is treated by pungent-cold herbs (such as Shi Gao Gypsum) which clear Heat because the Heat is still superficial enough to be expelled outwards towards the surface with pungent herbs. The formula for this pattern is Bai Hu Tang White Tiger Decoction which relies on Shi Gao to clear Heat by expelling it outwards.

The Intestines Dry-Heat pattern of the Qi Level (and the Yang Ming Organ pattern) is treated by bitter-cold herbs (such as Da Huang Radix et Rhizoma Rhei) which drain Fire by moving downwards and stimulating the bowel movement.  In the case of Fire, this is too deep in the Interior to be expelled by pungent herbs. The formula for this pattern is Tiao Wei Cheng Qi Tang Regulating the Stomach and Conducting Qi Decoction that relies on Da Huang to drain Fire downwards (through the bowel movement).

I have presented these two patterns from the 6 Stages and 4 Levels only to highlight the difference between "Heat" and "Fire": the patterns of Stomach-Heat of the 4 Levels and Yang Ming Channel of the 6 Stages are an example of "Heat"; the patterns of Intestines Dry Heat of the 4 Levels and Yang Ming Organ of the 6 Stages are an example of "Fire".

Let us now therefore further explore the difference between Heat and Fire.  First of all, they obviously have many common characteristics: both Heat and Fire pertain to "Heat" in a broad sense.

The common clinical manifestations of Heat and Fire are: feeling of heat, thirst, red face, dark urine, Rapid pulse and red tongue with yellow coating.  Fire differs from Heat in two important respects: it is simply more intense than Heat and it is at a deeper energetic level.  That is why Heat can be expelled outwards with pungent-cold herbs but Fire cannot be: it is too deep to be expelled outwards and it can only be drained downwards with bitter-cold herbs.

Fire has four characteristics that Heat does not have and these are:

1) More intense: pronounced feeling of heat, intense thirst, red face

2) More drying: dark urine, dry stools, dry tongue

3) Affects the Shen more: agitation, mental restlessness, insomnia, manic behaviour

4) May cause bleeding: epistaxis, coughing up blood, vomiting blood, blood in urine or stools.

The tongue is an important and useful distinguishing sign between Heat and Fire.  In Heat, the tongue is red with a yellow coating: in Fire, it is a deeper red and it has a very thick and dry, dark coating that can range from dark-yellow to brown to black.  The two photos below illustrate this difference (the top being Heat and the bottom Fire).

I use the term "clearing Heat" for Heat and "draining Fire" for Fire.  I have indicated the different Chinese characters but unfortunately they both have exactly the same pronunciation (and tone), i.e. xie.

Please note that, from the point of view of the 4 Levels, both Heat and Fire pertain to the Qi Level: at the Qi Level, the tongue has a coating.

Why is it important to differentiate between Heat and Fire?  It is because the treatment of the two is different. As explained above, Heat can be expelled outwards with pungent-cold herbs while Fire can only be eliminated by draining downwards (through the bowel movement) with bitter-cold herbs.  Mistakenly draining Fire with bitter-cold in the case of Heat is indeed a mistake and one that may make the patient worse.

Examples of pungent-cold herbs that clear Heat are: Shi Gao Gypsum, Lu Gen Rhizoma Phragmitis, Zhu Ye Folium Phyllostachys nigrae.

Examples of bitter-cold herbs that drain Fire are: Da Huang Radix et Rhizoma Rhei, Long Dan Cao Radix Gentianae, Huang Qin Radix Scutellariae, Huang Lian Radix Coptis.

Examples of formulae that clear Heat are: Bai Hu Tang White Tiger Decoction, Zhu Ye Shi Gao Tang Phyllostachys-Gypsum Decoction,

Examples of formulae that drain Fire are: Tiao Wei Cheng Qi Tang Regulating the Stomach and Conducting Qi Decoction, Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction, Huang Lian Jie Du Tang Coptis Eliminating Toxin Decoction, San Huang Xie Xin Tang Three Yellows Draining the Heart Decoction.

Let us take the Stomach as an example and illustrate the difference between Stomach-Heat and Stomach-Fire.

Stomach-Heat

Slight epigastric pain, thirst, feeling of heat, red tongue with yellow coating. The tongue below illustrates Stomach-Heat.

A representative formula for Stomach-Heat would be Yu Nu Jian Jade Woman Decoction which contains Shi Gao Gypsum.

Stomach-Fire

Epigastric pain, excessive hunger, intense thirst, dry mouth, feeling of heat, mental restlessness, dry stools, deep-red tongue with thick-brown coating. The tongue below illustrates Stomach-Fire.

A representative formula for Stomach-Fire would be Qing Wei San Clearing the Stomach Powder which contains Huang Lian Rhizoma Coptidis.

With acupuncture, there is no major difference in the treatment of Heat and Fire: ST-44 Neiting, for example, will clear Stomach-Heat and drain Stomach-Fire.  However, there is one difference in the treatment of Fire as opposed to Heat.  In order to treat Fire, it is necessary to stimulate the bowel movement with points such as ST-25 Tianshu, SP-15 Daheng and BL-25 Dachangshu.  Thus, if I was treating Stomach-Fire, I would use the above points in addition to ST-44 Neiting.

EMPTY HEAT

This post continues the discussion of Heat.

EMPTY HEAT

"Empty Heat" derives from Yin deficiency. There are two aspects I would like to clarify straight away.  The term "Empty" Heat may give the impression that Empty Heat is not "real" Heat. Although deriving from Yin deficiency, Empty Heat is "real" Heat and it heats up as much as Full Heat.

The second important clarification is that, although Empty Heat derives from Yin deficiency,  this may occur by itself for years before giving rise to Empty Heat.  Thus, although Empty Heat derives from Yin deficiency, it takes time for it to develop.  Therefore one may have Yin deficiency for years without Empty Heat.

The tongue shows this very clearly. Yin deficiency  manifests on the tongue with lack of coating; if there is only Yin deficiency without Empty Heat, the tongue will lack a coating but will have a normal colour. I have several dozens pictures of tongues that lack a coating but have a normal colour.  The tongue below is an example of this.

This tongue lack a coating and has scattered Stomach cracks: it therefore shows a pronounced deficiency of Stomach-Yin. Its colour is normal and this indicates that there is no Stomach-Heat yet.  Eventually, without treatment, this tongue will become red and, when it does, it means that, besides Stomach-Yin deficiency, there is also Empty Heat of the Stomach.

Therefore, a tongue without coating with normal tongue-body colour indicates Yin deficiency, while a tongue without coating and a red body colour indicates Yin deficiency with Empty Heat.

The tongue below is red without coating.

The diagram below illustrates the timeline of Yin deficiency and Empty Heat and it highlights how one can have Yin deficiency before the development of Empty Heat.  The blue line illustrates Yin and the red line Empty Heat.

The clinical manifestations of Empty Heat in general (irrespective of organ) are:

-   a feeling of heat in the afternoon/evening
-   a dry mouth with desire to drink in small sips
-   malar flush (red cheekbones)
-   a dry throat at night
-   a feeling of heat in the chest and palms and soles (also called A5-palm heat@)
-   dry stools
-   scanty-dark urine
-   a Floating-Empty and Rapid pulse
-   a red tongue without coating.

Thus for every organ, there is a pattern of Yin deficiency (without Empty Heat) and one of Empty Heat.  This distinction is very apparent also from the categories of herbs and formulae in Chinese herbal medicine.  The category of herbs and formulae that nourish Yin is quite distinct from that of herbs and formulae that clear Empty Heat.  Herbs that nourish Yin are sweet and cold and while those that clear Empty Heat are bitter and cold.

For example, herbs that nourish Yin are Mai Men Dong and Bei Sha Shen and these do not necessarily clear Empty Heat.  An example of a formula that nourishes Yin is Sha Shen Mai Dong Tang Adenophora-Ophiopogon Decoction.

Examples of herbs that clear Empty Heat are Qing Hao Herba Artemisiae annuae and Di Gu Pi Cortex Lycii.  Examples of formulae that clear Empty Heat are Qing Hao Bie Jia San Artemisia annua-Carapax Trionycis Powder or Qing Gu San Clearing the Bones Powder. Of course, one can simultaneously nourish Yin and clear Empty Heat in which case one would start from a Yin-nourishing formula and add some herbs that clear Empty Heat.

With acupuncture too, there is a difference between nourishing Yin and clearing Empty Heat.  To nourish Yin, one would use points such as SP-6 Sanyinjiao, Ren-12 Zhongwan or KI-3 Taixi.  Generally, one can use the Yuan points of the Yin organs to nourish Yin (KI-3 Taixi, LIV-3 Taichong, SP-3 Taibai, LU-9 Taiyuan, HE-7 Shenmen).

To clear Empty Heat, one would use Fire points such as P-8 Laogong, HE-8 Shaofu, LIV-2 Xingjian, etc.  Acupuncture is less Aprecise@ than herbal medicine as the Fire points can also be used to clear Full Heat.

Aetiology of Empty Heat

As Empty Heat derives from Yin deficiency, there is no specific aetiology of Empty Heat, only of Yin deficiency.  In my experience, the main cause of Yin deficiency is overwork in the sense of working long hours without adequate rest, leaving home in the early morning and returning in the late evening, year after year.  Overwork intended in this sense is particularly detrimental because it always involves two other causes of disease, i.e. emotional stress and irregular diet which are associated with overwork.

However, there is in my opinion a cause of disease that would favour the rise of Empty Heat and that is emotional stress.  In particular, emotions that cause a rising of Qi. In fact, Empty Heat is particularly associated with a rising of Qi towards the chest, throat and head. Empty Heat causes a rising of Qi because it derives from Yin deficiency.  Yin is the root that should Aanchor@ Qi: when the root is weakened, Qi rises.

Emotions that cause a rising of Qi and therefore favour Empty Heat are anger, frustration, resentment, guilt, shame, worry and fear.  Yes I know, the Nei Jing says that fear Amakes Qi descend@ but I think that is more fright than fear. A chronic state of fear, such as that seen in chronic anxiety, makes Qi rise and it causes a disconnection between the Lower and the Upper part and between the Kidneys and Heart.  The rising Qi combines with the Empty Heat (which has a tendency to rise anyway) causing a feeling of heat of the face and malar flush (red cheekbones).

I will now describe the Empty Heat patterns for each of the Yin organs plus the Stomach. For each organ, I will give the pattern of Yin deficiency (without Empty Heat) and that of Yin deficiency with Empty Heat.

HEART-YIN DEFICIENCY

Clinical manifestations

Palpitations, insomnia, dream-disturbed sleep, poor memory, anxiety, propensity to be startled, mental restlessness, uneasiness, dry mouth and throat in the afternoon or evening.

Tongue: normal-coloured without coating or with rootless coating.

Pulse: Floating-Empty, especially in the left-Front position.

Acupuncture

HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, Ren-4 Guanyuan, SP-6 Sanyinjiao.

Prescription

Sha Shen Mai Dong Tang Adenophora-Ophiopogon Decoction. 

HEART-YIN DEFICIENCY WITH EMPTY HEAT

Clinical manifestations

Palpitations, insomnia, dream-disturbed sleep, poor memory, anxiety, propensity to be startled, mental restlessness, uneasiness, "feeling hot and bothered", dry mouth and throat in the evening, thirst with desire to drink in small sips, a feeling of heat in the evening, malar flush, night-sweating, 5-palm heat.

Tongue: Red, redder on the tip, without coating.

Pulse: Floating-Empty, especially on the left-Front position and Rapid.

Acupuncture

HE-7 Shenmen, Ren-14 Juque, Ren-15 Jiuwei, Ren-4 Guanyuan, HE-6 Yinxi, SP-6 Sanyinjiao, KI-6 Zhaohai, P-7 Daling, L.I.-11 Quchi, HE-9 Shaochong, HE-8 Shaofu.

Prescription

Tian Wang Bu Xin Dan Heavenly Emperor Tonifying the Heart Pill.

LIVER-YIN DEFICIENCY

Clinical manifestations

Dizziness, numbness or tingling of limbs, insomnia, blurred vision, Afloaters@ in eyes, dry eyes, diminished night-vision, scanty menstruation or amenorrhoea, dull-pale complexion without lustre but with red cheek-bones, muscular weakness, cramps, withered and brittle nails, very dry hair and skin, depression, a feeling of aimlessness.

Tongue: normal-coloured  without coating or with rootless coating.

Pulse: Floating-Empty

Acupuncture

LIV-8 Ququan, SP-6 Sanyinjiao, ST-36 Zusanli, Ren-4 Guanyuan, KI-3 Taixi.

Prescription

Yi Guan Jian One Linking Decoction.

LIVER-YIN DEFICIENCY WITH EMPTY-HEAT

Clinical manifestations

Dizziness, numbness or tingling of limbs, insomnia, blurred vision, Afloaters@ in eyes, dry eyes, diminished night-vision, scanty menstruation or heavy menstrual bleeding (if Empty Heat is severe), red cheek-bones, muscular weakness, cramps, withered and brittle nails, very dry hair and skin, depression, a feeling of aimlessness, anxiety, a feeling of heat in the evening, night-sweating, 5-palm heat, thirst with desire to drink in small sips.

Tongue: Red without coating.

Pulse: Floating-Empty and slightly Rapid.

Acupuncture

LIV-8 Ququan, SP-6 Sanyinjiao, ST-36 Zusanli, Ren-4 Guanyuan, KI-3 Taixi, LIV-2 Xingjian, L.I.-11 Quchi.

Prescription

Yi Guan Jian One Linking Decoction plus Zhi Mu Radix Anemarrhenae asphodeloidis and Mu Dan Pi Cortex Moutan radicis.

Qing Hao Bie Jia Tang Artemisia Annua-Carapax Trionycis Decoction.

Qing Gu San Clearing the Bones Powder.

LUNG-YIN DEFICIENCY

Clinical manifestations

Cough which is dry or with scanty-sticky sputum, weak and/hoarse voice, dry mouth and throat, tickly throat, tiredness, dislike to speak, thin body or thin chest, night-sweating.

Tongue: normal-coloured, dry without coating (or with rootless coating) in the front part.

Pulse: Floating-Empty.

Acupuncture

LU-9 Taiyuan, Ren-17 Shanzhong, BL-43 Gaohuangshu,  Ren-12 Zhongwan, SP-6 Sanyinjiao.

Prescription

Bai He Gu Jin Tang Lilium Consolidating Metal Decoction.

Sha Shen Mai Dong Tang Adenophora-Ophiopogon Decoction.

LUNG-YIN DEFICIENCY WITH EMPTY HEAT

Clinical manifestations

Dry cough or with scanty sticky sputum which could be blood-tinged, dry mouth and throat at night, weak and/or hoarse voice, tickly throat, night-sweating, tiredness, malar flush, dislike to speak, a feeling of heat or a low-grade fever in the evening, 5-palm heat, thirst with desire to drink in small sips, insomnia, anxiety, thin body, thin chest.

Tongue: Red without coating.

Pulse: Floating-Empty and Rapid.

Acupuncture

LU-9 Taiyuan, Ren-17 Shanzhong, BL-43 Gaohuangshu, Ren-12 Zhongwan, SP-6 Sanyinjiao, LU-10 Yuji, L.I.-11 Quchi.

Prescription

Yang Yin Qing Fei Tang Nourishing Yin and Clearing the Lungs Decoction.

KIDNEY-YIN DEFICIENCY

Clinical manifestations

Dizziness, tinnitus, vertigo, poor memory, hardness of hearing, night-sweating, dry mouth and throat at night, lower backache, ache in bones, nocturnal emissions, constipation,  dark-scanty urine, infertility, premature ejaculation, tiredness, lassitude, depression, slight anxiety.

Tongue: normal-coloured without coating.

Pulse: Floating-Empty.

Acupuncture

Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, SP-6 Sanyinjiao, Ren-7 Yinjiao, LU-7 Lieque and KI-6 Zhaohai in combination (opening points of the Ren Mai).

Prescription

Zuo Gui Wan Restoring the Left [Kidney] Pill.

Liu Wei Di Huang Wan Six-Ingredient Rehmannia Pill.

KIDNEY-YIN DEFICIENCY WITH EMPTY HEAT

Clinical manifestations

Dizziness, tinnitus, vertigo, poor memory, hardness of hearing, night-sweating, dry mouth at night, 5-palm heat, a feeling of heat in the evening, malar flush, thirst with desire to drink in small sips, lower backache, ache in bones, nocturnal emissions with dreams, constipation,  dark-scanty urine, infertility, premature ejaculation, tiredness, depression, anxiety, insomnia, excessive menstrual bleeding.

Tongue: Red without coating; in severe cases also cracked.

Pulse: Floating-Empty and slightly Rapid.

Acupuncture

Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, KI-10 Yingu, SP-6 Sanyinjiao, Ren-7 Yinjiao, LU-7 Lieque and KI-6 Zhaohai in combination (opening points of the Ren Mai), KI-2 Rangu.

Prescription

Zhi Bo Di Huang Wan Anemarrhena-Phellodendron-Rehmannia Pill.

Da Bu Yin Wan Great Tonifying Yin Pill.

Er Zhi Wan Two Solstices Pill.

STOMACH-YIN DEFICIENCY

Clinical manifestations

No appetite or slight hunger but no desire to eat, constipation (dry stools), dull or slightly burning epigastric pain, dry mouth and throat especially in the afternoon, slight feeling of fullness after eating.

Tongue: without coating in the centre, or with rootless coating, normal body colour.

Pulse: Floating-Empty on the Right-Middle position.

Acupuncture

Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-3 Taibai.

Prescription

Sha Shen Mai Dong Tang Glehnia-Ophiopogon Decoction.

Shen Ling Bai Zhu San Ginseng-Poria-Atractylodis Powder.

Yi Wei Tang Benefiting the Stomach Decoction.

STOMACH-YIN DEFICIENCY WITH EMPTY HEAT

Clinical manifestations

Dull or burning epigastric pain, feeling of heat in the afternoon, constipation (dry stools), dry mouth and throat especially in the afternoon, thirst with desire to drink in small sips, feeling of hunger but no desire to eat, slight feeling of fullness after eating, night-sweating, 5-palm heat, bleeding gums, feeling of heat in the evening.

Tongue: Red and without coating in the centre.

Pulse: Floating-Empty on the Right-Middle position and slightly Rapid.

Acupuncture

Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, SP-3 Taibai, ST-44 Neiting, ST-21 Liangmen, L.I.-11 Quchi.

Prescription

Sha Shen Mai Dong Tang plus Zhi Mu Radix Anemarrhenae asphodeloidis and Shi Hu Herba Dendrobii.

Qing Wei San Clearing the Stomach Powder.