LATENT HEAT

Latent Heat or “Latent Pathogenic Factor” is a pathology that is quite unique and rather difficult to comprehend.  Essentially, Latent Heat is formed when an exterior pathogenic factor invades the body without causing symptoms at the acute stage: the pathogenic factor goes into the Interior, it changes into Heat and it then emerges later in the form of interior Heat.  I said that Latent Heat is “unique” and “difficult to comprehend” because, if the pathogenic factor invades the body without causing immediate symptoms, how do we know that it has happened?  I shall try to answer this question and others as we progress in the discussion.

Therefore, there are two types of attacks of exterior pathogenic factors: a new attack of Wind-Heat with acute onset and obvious symptoms; and an attack of Latent Heat which, at the acute stage, has no symptoms.

The distinction is based on the different aetiology and different clinical manifestations in the beginning stage. In Wind-Heat, the pathogenic factor attacks the body with acute onset and with frank clinical manifestations.  In Latent Heat, the pathogenic factor invades the body in an insidious manner without acute-onset symptoms, becoming latent in the Interior.  When it emerges causing symptoms, it is called Latent Heat.

The concept that a pathogenic factor may invade the body without causing acute symptoms at the time but causing symptoms in the following season is very old and is found in the Nei Jing. 

The earliest statements concerning Latent Pathogenic Factor are in the Su Wen chapters 3 and 5.  Chapter 3 says:  “Attack of Wind in Spring will lead to diarrhoea [in Summer] if the pathogenic factor lingers; attack of Summer-Heat in summer will lead to malaria in the Autumn; attack of Dampness in Autumn will cause cough  [in Winter] and then Wei Syndrome; attack of Cold in Winter will cause Wen Bing in Spring.”

Chapter 5 says: “Attack of Cold in Winter will lead to Wen Bing in Spring; attack by Wind in Spring will lead to diarrhoea in Summer; attack by Summer-Heat in Summer will cause malaria in Autumn; attack by Dampness in Autumn will cause cough in Winter.”

The distinction between New Attack and Latent Attack (Heat) is based not only on the onset of the disease (immediate or delayed), but also on the different substance and clinical manifestations.  The clinical significance is therefore not only in the timing of onset of clinical manifestations, but also in the different syndrome and seriousness and therefore treatment.

Generally, a New Attack is comparatively light, in the beginning the pathogenic factor is on the Exterior and it affects the Lungs: there is fever, aversion to cold, headache, cough, etc.  This is treated by releasing the Exterior and stimulating the diffusing and descending of Qi.

The Latent Attack is comparatively serious, there is Heat in the Interior from the beginning: there is fever, thirst, restlessness, etc. i.e. symptoms of interior Heat (no aversion to cold unless there is a concomitant New Attack with it). It is treated by clearing interior Heat.

Latent Heat is due to attack of pathogenic factor when body is in weak condition; in particular, development of Latent Heat is due to a Kidney deficiency, due to the connection between the Kidney’s Wei-Qi system and the immune defences.

Notice how the Nei Jing says that an invasion of Cold in Winter will cause “Wen Bing” disease in the Spring. “Wen Bing” refers to diseases due to Wind-Heat.  In the times of the Nei Jing and the Shang Han Lun, the pathology of exterior diseases was always due to Cold: therefore even diseases that clearly started with Heat symptoms (such as Wind-Heat) were deemed to be a transformation of Cold invading in Winter. It took about 14 centuries before the theory of Wen Bing diseases became an independent theory, i.e. that diseases from Wind-Heat were not a transformation of Cold.

Nevertheless, the idea that a pathogenic factor may invade in Winter, incubate without symptoms and then manifest in the Spring is at the root of the pathology of Latent Heat.  The pathology as described in the Nei Jing is illustrated in the diagram below.

Please note that we do not have to take this Nei Jing scheme literally: the invasion is not necessarily of Cold, it does not necessarily occur in Winter and it does not necessarily come out in the Spring. The essential aspect of this pathology is not the seasonal occurrence but the fact that a pathogenic factor invades the body without symptoms, i.e. without the immune system reacting properly and that the pathogenic factor incubates inside to come out later.  Also, please note that “coming out” does not mean that the pathogenic factor is being expelled, but simply that it is emerging from the Interior and manifesting itself with various symptoms.

CAUSES OF LATENT HEAT
The main cause of the development of Latent Heat, i.e. that the patient does not display symptoms at the time of infection and the pathogenic factor lurks in the Interior to emerge later, is a Kidney deficiency which causes the immune system not to react to the initial external invasion.

A contributory factor are immunizations. It could be said that immunizations inject a pathogenic factor directly at the Blood level which then emerges as Latent Heat causing many different symptoms.  In normal immunity when someone is infected, the pathogenic factor penetrates from the Wei level and leads to immunity to that bacteria or virus.

WHY LATENT HEAT DEVELOPS
Why do some invasions of Wind cause immediate exterior symptoms and some do not cause immediate symptoms and penetrate into the Interior where they “lurk” (incubate)?

The answer lies in the immune response.  If the immune system does not react, the pathogenic factor does not cause symptoms and penetrates into the Interior, to emerge later. This lack of immune response depends not only on the Lungs but also on the Kidneys.

Ye Tian Shi said that the “lurking Cold” of Winter resides in the Kidneys. Remember the Nei Jing statement “If Jing is not guarded in Winter, Wen Bing develops in Spring”.

Ye Tian Shi even advocated tonifying the Kidneys to prevent invasion of external pathogenic factors.  Some doctors of the late Qing too correlated the severity of Latent pathogenic factor to Kidney and specifically Kidney-Yin. 

Ye Tian Shi said that Latent Heat is due to “lack of storage” [of Jing] in Winter. This allows Cold to invade the body in Winter. The Kidneys control storage and Shao Yin; in Spring, the pathogenic factor emerges towards Shao Yang and the Liver and Gall-Bladder.

Another explanation is that Winter Cold invades the Tai Yang channels, it lurks inside and is transmitted to the Shao Yin.

                          Cold enters Tai Yang                                        Latent Heat emerges from Shao Yin

Another doctor says that when the Winter Cold is heavy, it causes a New Invasion with immediate symptoms; if the Winter Cold is light, it causes Latent Heat after incubating inside. He says that in the latter case, the pathogenic factor enters the skin and then lurks in the Triple Burner and Membrane Source (Mo Yuan) causing a derangement of the ascending/descending of Qi and the free flow of Qi.  This causes stagnation of Qi that gives rise to internal Heat. This Heat is then attracted outwards by the emerging Yang of Spring.

This is an interesting statement that actually explains how external Cold is transformed into internal Heat when Latent Heat is formed. The “Membrane Source” (Mo Yuan) refers to the Shao Yang regions. 
Many doctors relate the formation of Latent Heat to a Kidney deficiency.  For example, one says that Winter controls storage and so do the Kidneys. When the Kidneys are healthy, Kidney-Yang and Kidney-Jing are  “stored” in winter so that Cold cannot invade the body. 

Conversely, if mental restlessness, overwork and excessive desire afflict a person, Yang Qi is dispersed, Yin is consumed and pathogenic factors can easily invade the body taking advantage of the Empty condition.
Thus, as we have seen in several of the above passages, the Kidneys and Kidney-Jing play an important role in the immune response.

THE YUAN QI AND IMMUNE RESPONSE
Chapter 8 of the Nan Jing says: “Sometimes the Cun Kou is normal and yet the patient dies.  Why is that? The pulses of the 12 channels all originate from the Yuan Qi. This Yuan Qi is the root of the 12 channels, it is the Motive Force (Dong Qi ) between the Kidneys, the root of the 5 Zang and 6 Fu and of the 12 channels, the gate of breathing and the origin of the Triple Burner.  It is the spirit that guards against pathogenic factors (or evil influences). Such Qi is the root of humankind; if the root is cut stalks and leaves wither. When the Cun Kou is normal but the patient dies, it means that the Yuan Qi has been cut off internally.”
    
This passage establishes the principle that the Yuan Qi (and therefore the Kidneys) play a role in the resistance to pathogenic factors.  Interestingly, it calls the Yuan Qi the Shen that protect from pathogenic factors (or evils).

This is of huge clinical significance because it means that our resistance to pathogenic factors depends not only on the Wei Qi and therefore Lungs but also on the Kidneys and the Yuan Qi (and also Jing due to the extraordinary vessels). In any case, Wei Qi stems from the Lower Burner.

SYMPTOMS and SIGNS of LATENT HEAT
The main clinical manifestations of Latent Heat when it emerges are:
Weary limbs
Irritability
Thirst
Lassitude with sudden onset
Dark urine
Red tongue
Rapid-Fine pulse

There may be many other symptoms of Heat such as red eyes, mouth ulcers, nosebleed, constipation. These are the general symptoms and there is a great variation of symptoms and signs depending on the location and character of the Latent Heat (Qi, Ying, Blood).

WHAT MAKES LATENT HEAT EMERGE
As mentioned above, please note that “emerging” does not mean that the Latent Heat is being expelled but simply that it is manifesting itself. 

Latent Heat emerges due to one or more of the following factors:
New invasion of Wind
Rising Yang of Spring that pulls it out
Emotional stress
Overwork
Serious illness
Medication
Drugs

HOW DO WE KNOW IT IS LATENT HEAT AND NOT JUST HEAT?
The clinical manifestations of Latent Heat are indeed Heat, so how do we know that it is Latent Heat and not just an internally-generated Heat?  There is no definite and absolute way of knowing that. The diagnosis depends a lot on the onset and history rather than the clinical manifestations.

If we happen to see a patient at the onset of Latent Heat emerging, we know that it is Latent Heat from the acute onset.  The patient complains of lassitude with acute onset and he or she does not have exterior symptoms, so we exclude an invasion of an exterior pathogenic factor.

So, the acute onset together with the clinical manifestations of Heat tells us that it is most probably Latent Heat emerging from a previous external invasion which did not cause symptoms at the time.
If we do not see the patient during the acute onset, it is more difficult. How do we know that it is Latent Heat?  First of all, from the channel location that is either Shao Yang (not common) or Shao Yin, i.e. Heart and Kidneys.  Secondly, Latent Heat will cause more vague, less specific clinical manifestations of Heat than those of Heat in a specific organ, e.g. Heart-Heat, Stomach-Heat, Liver-Heat, etc.

WHAT DIFFERENCE DOES IT MAKE TO TREATMENT?
The treatment of Latent Heat is not really different than that of Heat.  Latent Heat is treated by clearing Heat, usually at the Blood level.  However, when treating Latent Heat, I also tonify the Kidneys, usually only with one or two herbs or with acupuncture.

WHAT DIFFERENCE IT MAKES TO PROGNOSIS
It makes a big difference to prognosis.  The treatment of Latent Heat is more difficult than that of Heat and it will take longer.  Also, Latent Heat tends to cause difficult diseases such as auto-immune diseases.

NATURE OF LATENT HEAT
It has acute onset (when it emerges)
It is always Heat (it may be with Dampness)
The Heat tends to injure Yin

The Latent pathogenic factor that incubates in the body in Winter hides in the Membrane Source (Mo Yuan) and is transformed into Heat. The urine is an important diagnostic sign of Latent Heat. Firstly, dark urine is an important sign of Heat that confirms the diagnosis of Latent Heat. Secondly, the darkness of the urine itself is an important gauge of the severity of the disease: the darker, the more severe.

Latent Heat can be in the Shao Yang or Shao Yin. One must distinguish its depth, severity and Xu/Shi nature. Latent Heat in Shao Yang is Shi; in Shao Yin, Xu.

LATENT HEAT IN SHAO YANG (MEMBRANE SOURCE)
Clinical manifestations
Alternation of feeling hot and feeling cold, bitter taste, hypochondrial pain, red eyes, deafness, feeling of oppression of the chest, nausea, tongue coating half white and half yellow, Wiry pulse.
Prescription
Hao Qin Qing Dan Tang Artemisia-Scutellaria Clearing the Gall-Bladder Decoction
Da Yuan Yin Reaching the Source Decoction. 

LATENT HEAT IN SHAO YIN
Clinical manifestations
Dry mouth and teeth, listlessness, night-sweating, lower backache, dizziness, tinnitus, red tongue without coating, Floating-Empty pulse.
Prescription
Xi Jiao Di Huang Tang Cornu Bufali-Rehmannia Decoction.
Zuo Gui Wan Restoring the Left [Kidney] Pill. 

LATENT HEAT IN JOINTS
Clinical manifestations
Alternation of feeling hot and feeling cold, swelling and pain of joints,  hypochondrial pain, red eyes, tongue coating half white and half yellow, Wiry pulse.
Prescription
Da Yuan Yin Reaching the Source Decoction.
Cao Guo, Hou Po, Bing Lang, Huang Qin, Zhi Mu, Bai Shao, Gan Cao, plus Hai Feng Teng, Sang Zhi, Hai Tong Pi.  

Please note that the above prescriptions are only examples from Chinese books and many other formulae can be used.

Case history, woman, 49
Bouts of exhaustion for the previous four months (starting in Winter), can hardly move in the morning, muscles have no strength, feeling of heaviness, feeling cold from waist down, muzziness (fuzziness), dizziness, sticky taste, painful eyes, chronic sore throat.
Tongue: slightly red sides, swollen, teethmarks.
Pulse: Soggy, both Chi Weak.
Diagnosis
The onset of the exhaustion indicates Latent Heat. The Heat is mixed with Dampness (muscle weakness, heaviness, sticky taste) and some Phlegm (dizziness, muzziness, swollen tongue).
Treatment
Da Yuan Yin Reaching the Source Decoction plus Huo Xiang, Hou Po, Sha Ren, Yi Yi Ren.
Acupuncture: Ren-9, SP-9, Ren-12, ST-36.

Case history, woman, 32
A few weeks before her consultation she had a cold, congested chest, neckache, headaches, alternation of feeling cold and hot. Now: loose stools, hypochondrial pain, exhaustion, depression.
Tongue: Red with coating.
Pulse: Wiry.
Diagnosis
The onset of the exhaustion indicates Latent Heat. The presentation of the acute attack weeks before is of the Shao Yang type but most probably Latent Heat type. Now the Heat has injured the Spleen, hence the loose stools. The hypochondrial pain indicates Shao Yang pattern.
Treatment
Acupuncture: TB-5 reduced, TB-6 reduced, Du-14 reduced. She felt much better and her energy returned with this very simple treatment.

Case history, woman, 41
One month before the consultation she felt quite suddenly ill with tiredness, headache, nausea, ache in the joints. Now she also has irritability and dry mouth. Also mouth ulcers.
Tongue: slightly red, sticky coating.
Pulse: Fine, Weak.
Diagnosis
The onset of the exhaustion indicates Latent Heat. The presentation of the acute attack weeks before is Latent Heat in the Shao Yang and the joints.
Treatment
Hao Qin Qing Dan Tang Artemisia-Scutellaria Clearing the Gall-Bladder Decoction
Acupuncture: TB-5 reduced, ST-36, SP-6 reinforced.

PHLEGM-HEAT

As discussed for Damp-Heat, in Phlegm-Heat, the primary aspect is the Phlegm rather than the Heat.  It is Phlegm that is hot rather than the Heat having Phlegm.  In a similar way as we said for Damp-Heat, a better name would be “Hot Phlegm” rather than “Phlegm-Heat”.  This has important implications in treatment as this should be aimed at resolving Phlegm primarily and clearing Heat secondarily.
Interestingly, the Chinese character for Phlegm ( 痰 ) is based on the radical for “disease” and that for “Fire” (twice). This would seem to imply that Phlegm derives from Heat: indeed, in many cases it does but we should remember that Phlegm is also frequently combined with Cold.

AETIOLOGY
Emotional stress
Emotional stress in the beginning stages leads to Qi deficiency or Qi stagnation and sometimes both.  Phlegm is a pathological accumulation of fluids which itself derives either from Qi deficiency or Qi stagnation or both as it is Qi that transforms, transports and excretes fluids. Therefore both Qi deficiency or Qi stagnation in time may lead to the accumulation of fluids and to Phlegm.
However, please note that there is no emotion that would be lead to Phlegm directly, e.g. we could not say “anger leads to Phlegm”.  Each emotion would cause a derangement of Qi first.   Li Ding says: “Phlegm is due to the accumulation of Qi deriving from the seven emotions.”
However, there are quotations from Chinese doctors who say that emotional stress leads to Phlegm.  For example, Chen Wu says: “The seven emotions cause chaos and lead to Phlegm.”  Li Yong Cui says: “Shock, fear, worry and pensiveness lead to Phlegm.”
Most emotions initially cause Qi stagnation and it is important to stress that many organs, not just the Liver, may suffer from Qi stagnation.  Indeed, in the mental-emotional field, the Heart and Lungs frequently suffer from Qi stagnation from worry, sadness and grief.
A modern Chinese book says: “When emotions cause stagnation of Liver-Qi this impairs the Spleen transformation which leads to Phlegm; or emotional stress may lead to Qi stagnation which may turn into Fire: this condenses the body fluids and leads to Phlegm”.

Figure 1 illustrates the derangement of Qi from emotional stress.

Figure 1.  Derangement of Qi from emotional stress.

Diet
Diet is of course an important aetiological factor leading to Phlegm.  The excessive consumption of greasy foods, sugar, sweets and dairy foods leads to Phlegm. Overeating itself is also a cause of Phlegm.
In the particular case of Phlegm-Heat, this is often due to the excessive consumption of greasy foods together with that of alcohol.

Excessive physical work
Excessive physical work weakens the Spleen and this leads to Phlegm.

Dampness
Long-term retention of Dampness easily leads to Phlegm.

PATHOLOGY
Phlegm is always due to a pathology of the transformation, movement and excretion of fluids. This involves a dysfunction of many organs, e.g. Lungs, Spleen, Stomach, Kidneys, Liver, Bladder, Intestines and Triple Burner.

Figure 2 illustrates the dysfunction of the fluids metabolism leading to Phlegm.

Figure. 2. Dysfunction of the fluids metabolism leading to Phlegm.

TYPES OF PHLEGM-HEAT

There are many types of Phlegm as this can combine with Cold, Dampness, Heat or Wind.  When diagnosing Phlegm-Heat, I make a basic distinction between Phlegm-Heat on a physical or mental-emotional level. Of course, this may seem a complete contradiction of the fundamental characteristic of Chinese medicine, i.e. the unity of body and mind.  However, with this distinction, I mean cases of actual phlegm (sputum) in the Lungs following invasions of Wind as opposed to those of non-actual phlegm but of Phlegm obstructing the Shen: the two are very different situations with different aetiology, pathology and treatment.
On a physical level, Phlegm-Heat affects primarily the Lungs but also the Stomach and Liver. On a mental-emotional level, Phlegm-Heat affects the Heart and Liver.  Phlegm-Heat on a physical level always presents with profuse expectoration of sputum and often cough.  Phlegm-Heat on a mental-emotional level does not necessarily present with the expectoration of actual sputum.  The main symptoms of Phlegm in the latter case would be a feeling of oppression of the chest, a Swollen tongue and a Slippery pulse.  However, in cases of mental-emotional Phlegm-Heat, there may also be the occasional expectoration of scanty sputum.  This may also be just the expectoration of some sputum just once in the morning.
Of course, such a distinction between physical and mental-emotional conditions should not be taken too rigidly as Phlegm-Heat on a physical level may of course affect the Shen.  However, this distinction is important for the choice of herbal treatment.

PHLEGM-HEAT ON A PHYSICAL LEVEL
Phlegm-Heat on a physical level may be acute or chronic.

Acute Phlegm-Heat
In acute cases, Phlegm-Heat is the consequence of an invasion of external Wind that has penetrated into the Interior and changed into Heat. The dysfunction of the Stomach and Spleen caused by the pathogenic factors contributes to the formation of Phlegm; this combines with Heat to form Phlegm-Heat which settles in the Lungs. This is the most common consequence of an invasion of external Wind.
This causes the cough with expectoration of yellow sputum that comes after the beginning stages of a cold or influenza.  This is a very common consequence of invasions of Wind and, in the context of the 4 Levels, it  corresponds to the Qi Level.
The formula for the acute form of Phlegm-Heat in the Lungs is Qing Qi Hua Tan Tang Clearing Qi and Resolving Phlegm Decoction.
The points I use for Phlegm-Heat in the Lungs are LU-7 Lieque, LU-5 Chize, Ren-22 Tiantu, LU-1 Zhongfu, BL-13 Feishu, ST-40 Fenglong.

Chronic Phlegm-Heat
Chronic Phlegm-Heat in the Lungs is usually the consequence of a residual Phlegm-Heat in the Lungs following an invasion (or repeated invasions) of external Wind. This happens when the external pathogenic factor penetrates into the Interior to form Phlegm-Heat, the patient appears to get better but there is a residual Phlegm-Heat in the Lungs.  This is more likely to occur if the patient takes antibiotics.
Often there are no symptoms of the Phlegm-Heat except on the tongue: the front third of the tongue (Lung area) will be swollen and slightly red. This area may also have red points (which indicates that the Heat is pronounced).

Swollen and red front third  

Red front third with red points
 

The formula I use for chronic Phlegm-Heat in the Lungs is Wen Dan Tang Warming the Gall-Bladder Decoction with the addition of Gua Lou Fructus Trichosanthis and Sang Bai Pi Cortex Mori.
With acupuncture, I use LU-5 Chize, LU-7 Lieque, Ren-17 Shanzhong, BL-13 Feishu, P-6 Neiguan, ST-40 Fenglong.

PHLEGM-HEAT ON A MENTAL-EMOTIONAL LEVEL
Phlegm-Heat has a deep effect on the Shen because Heat agitates it and Phlegm obstructs it. Agitation of the Shen causes anxiety and insomnia while obstruction of the Shen causes mental confusion, some obsessive behaviour and occasionally a slight manic behaviour. When to an extreme degree, Phlegm-Heat in the Heart may cause severe mental illness (e.g. bipolar disease or schizophrenia).
On a physical level, this Shen disturbance is felt in the chest with a feeling of oppression of the chest.  Other symptoms include sighing and perhaps the occasional expectoration of scanty sputum.
For this pattern, I use the same formula as above i.e. Wen Dan Tang Warming the Gall-Bladder Decoction with the addition of Yuan Zhi Radix Polygalae, Shi Chang Pu Rhizoma Acori tatarinowii  and Gua Lou Fructus Trichosanthis.
With acupuncture, I use LU-7 Lieque, P-6 Neiguan, HE-7 Shenmen, Ren-17 Shanzhong, Ren-15 Jiuwei, Du-24 Shenting, ST-40 Fenglong.

I shall now list the patterns of Phlegm-Heat in the Lungs, Heart, Liver and Stomach.

PHLEGM-HEAT IN THE LUNGS
Clinical manifestations
Barking cough with profuse sticky-yellow or green sputum, shortness of breath, wheezing, a feeling of oppression of the chest, a feeling of heat, thirst, insomnia, agitation.
Tongue: Red, Swollen with a sticky-yellow coating.
Pulse: Slippery-Rapid.
Acupuncture
LU-5 Chize, LU-7 Lieque, LU-10 Yuji, L.I.-11 Quchi, LU-1 Zhongfu, BL-13 Feishu, Ren-12 Zhongwan, ST-40 Fenglong.
Prescription
Qing Qi Hua Tan Tang Clearing Qi and Resolving Phlegm Decoction.  For acute case.
Wen Dan Tang Warming the Gall-Bladder Decoction. For chronic case.

Comment
This is Phlegm-Heat in the Lungs on a physical level. This is either an acute case following an invasion of external Wind, or a chronic case due to repeated invasions that have not been expelled properly and have led to the formation of a residual pathogenic factor (i.e. Phlegm-Heat).

The following picture is an example of chronic Phlegm-Heat in the Lungs (swollen and red in the front third).

PHLEGM-HEAT HARASSING THE HEART
Clinical manifestations
Palpitations, mental restlessness, thirst, red face, a feeling of oppression of the chest, dark urine, occasional expectoration of phlegm, bitter taste, insomnia, dream-disturbed sleep, agitation, mental confusion, slight manic behaviour.
Tongue: Red with redder and swollen tip and a sticky-yellow coating.  In severe cases there will be a deep Heart crack with a sticky-dry yellow coating inside it.
Pulse: Slippery-Rapid or Slippery-Overflowing-Rapid.
Acupuncture
P-5 Jianshi, HE-7 Shenmen, HE-8 Shaofu, P-7 Daling, Ren-15 Jiuwei, BL-15 Xinshu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, BL-20 Pishu, G.B.-13 Benshen, G.B.-17 Zhengying, Du-24 Shenting.
Prescription
Wen Dan Tang Warming the Gall-Bladder Decoction.

Comment
This is Phlegm-Heat on a mental-emotional level. Heat agitates the Shen and causes anxiety and insomnia; Phlegm obstructs the Shen and causes mental confusion and possibly a slight manic behaviour.
This pattern is caused my a combination of emotional stress (especially worry, fear, shame or guilt) and the excessive consumption of Phlegm-inducing foods together with alcohol.

The following picture is a good example of Phlegm-Heat in the Heart.  It is red (indicating Heat), swollen (indicating Phlegm) and has a deep Heart crack with sticky-yellow coating inside it (indicating Phlegm-Heat in the Heart).

LIVER PHLEGM-HEAT
Clinical manifestations
Irritability, propensity to outbursts of anger, tinnitus and/or deafness (with sudden onset), temporal headache, dizziness, red face and eyes, thirst, bitter taste, dream-disturbed sleep, dark-yellow urine, a feeling of oppression of the chest and hypochondrium, a feeling of muzziness (fuzziness) of the head, occasional expectoration of sputum.
Tongue: Red with redder sides, Swollen and with sticky-yellow coating.
Pulse: Wiry-Slippery-Rapid.
Acupuncture
LIV-2 Xingjian, LIV-3 Taichong, G.B.-20 Fengchi, G.B.-13 Benshen, L.I.-11 Quchi, Du-24 Shenting, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-9 Yinlingquan.
Prescription
Wen Dan Tang Warming the Gall-Bladder Decoction.
Ling Jiao Gou Teng Tang Cornu Antelopis-Uncaria Decoction.
Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction.

Comment
The first two formulae would have to be modified with the addition of herbs that clear Liver-Heat such as Mu Dan Pi Cortex Moutan and Shan Zhi Zi Fructus Gardeniae and herbs that calm the Shen such as Suan Zao Ren Semen Ziziphi and Zhen Zhu Mu Concha Margaritiferae. The third formula would have to be modified with the addition of the two herbs mentioned above to calm the Shen.

The two pictures below illustrate Phlegm-Heat in the Liver.  The one on the top is a case of Liver-Heat while the one below of Liver-Fire (because it has a thicker and drier coating). They are both red, with redder sides and with a sticky-yellow coating.

STOMACH PHLEGM-HEAT
Clinical manifestations
Burning epigastric pain, thirst without desire to drink, mental restlessness, bleeding gums, dry stools, dry mouth, mouth ulcers, sour regurgitation, nausea, vomiting soon after eating, excessive hunger, foul breath, a feeling of heat, a feeling of oppression of the chest and epigastrium,  insomnia, excessive dreaming, expectoration of phlegm.
Tongue: Red in the centre with  a sticky-yellow or dark-yellow (or even black) coating, Stomach crack with a rough, sticky-yellow coating inside it.
Pulse: Slippery-Rapid and slightly Overflowing on the Right-Middle position.
Acupuncture
ST-44 Neiting, ST-34 Liangqiu, ST-21 Liangmen, Ren-12 Zhongwan, Ren-13 Shangwan, L.I.-11 Quchi, L.I.-4 Hegu, Ren-11 Jianli, ST-40 Fenglong, SP-9 Yinlingquan, Ren-9 Shuifen.
Prescription
Wen Dan Tang Warming the Gall-Bladder Decoction.


The picture below is an example of Phlegm-Heat in the Stomach.  It is red, swollen (indicating Phlegm), it has a wide Stomach crack with sticky-dry-yellow coating inside it.

DAMP-HEAT

Before starting our discussion I would like to clarify something regarding the nature of Damp-Heat. In Damp-Heat, Dampness is the predominant pathogenic factor: it is the Dampness that is hot, not the Heat that is damp. In fact, it would be better to call it “Hot Dampness” rather than “Damp-Heat”; however, I will continue calling it “Damp-Heat” because this term is in such common use. This means that, in the treatment of Damp-Heat, we must concentrate on draining or resolving Dampness rather than on clearing Heat. However, we do of course use cold herbs too to clear Heat.

I would like also to point out that generally Chinese books and doctors overstate the frequency of Damp-Heat and always talk about Damp-Heat, seldom of “Dampness”. For example, in China, every urinary problem is due to Damp-Heat, whereas we also see a lot of urinary problems with Dampness but without Heat, and a lot of urinary problems caused by Qi stagnation or Qi sinking. Similarly, any Gall-Bladder problem will always be attributed to Gall-Bladder Damp-Heat, whereas in the West we see a lot of patients with Gall-Bladder problems and Dampness but not much Heat. I discuss here Dampness in the context of Heat because it is such a common pathogenic factor in many different symptoms and diseases.


AETIOLOGY OF DAMPNESS

EXTERNAL

Dampness can derive from environmental or climatic dampness: thus, it may be due to humid weather (whether hot or cold), but also to damp living conditions, such as living in damp houses. Exterior Dampness can also be caught by wearing wet clothes, wading in water, working in damp places or sitting on damp ground.

Seasonal
External Damp-Heat is more predominant in summer and late summer, and specifically from the “Great Heat” period (of the 24 periods of a year) to the “White Dew” period, i.e. roughly two months before the Autumn equinox.

Prevailing Qi of the place
The seasonal is a heavenly exterior factor, the prevailing Qi of a place is an earthly exterior factor. This is due to prevailing conditions of a place, i.e. a low-lying, damp place, a place prone to fog, damp living conditions in the house, etc.

INTERNAL

Diet
Dampness may result from the excessive consumption of greasy foods, dairy foods, sweets, sugar, cold-raw foods. Damp-Heat may also arise from excessive alcohol drinking together with that of greasy-fried foods. Dampness may also be due to overeating (in the same way as Retention of Food) or from irregular eating habits.

Work
Excessive physical work (including sports, exercises, lifting, gym, etc.) can weaken the Spleen and lead to Dampness. Internal injury of Spleen Weakness of the Spleen deriving from a chronic illness.

CONSTITUTIONAL

A constitutional weakness of the Earth element predisposes the patient to Spleen deficiency and Dampness. On the other hand, a constitutional tendency to a Fullness of the Earth (for example, people with a constitutional tendency to Stomach-Heat) may lead to Heat in the Stomach and Spleen which combines with Dampness.

CHARACTERISTICS OF DAMPNESS

The following are the characteristics of Dampness:

- it is sticky
- it is difficult to get rid of
- it is heavy
- it slows things down
- it infuses downwards
- it causes repeated attacks
- it is lingering

When exterior Dampness invades the body, it tends to invade the lower part first, typically the legs. From the legs, it can flow upwards in the leg channels to settle in any of the pelvic cavity organs. If it settles in the female genital system it causes vaginal discharges, if it settles in the Intestines it will cause loose stools and if it settles in the Bladder it will cause difficulty, frequency and burning of urination. However, Dampness is also common in the head and always the cause of sinusitis for example.

The clinical manifestations of Dampness are extremely varied according to its location and nature (hot or cold), but the general ones are:

- a feeling of heaviness of body or head
- no appetite
- a feeling of fullness of chest or epigastrium
- a sticky taste
- a vaginal discharge
- a sticky tongue coating
- Slippery or Soggy pulse.

According to its location, the more specific clinical manifestations of internal Dampness are:

- Head: feeling of heaviness of the head
- Eyes: red-swollen eyelids, eyes oozing a fluid, sties
- Mouth: mouth ulcers on gums, swollen-red lips
- Stomach and Spleen: feeling of fullness of epigastrium, feeling of fullness after eating, sticky taste, loose
  stools, poor appetite, Soggy pulse.
- Lower Burner: excessive vaginal discharge, painful periods, infertility, turbid urine, difficult and painful
  urination, scrotal sweating or eczema, genital eczema, genital itching.
- Skin: papules (Damp-Heat with more Heat), vesicles (Dampness without Heat), pustules, (Damp-Heat
  with Toxic Heat), greasy sweat, boils, any oozing skin lesion, oozing eczema, puffy skin.
- Joints: swollen-painful joints (Fixed Bi syndrome).
- Luo Channels: numbness and loss of sensation.

Figure 1 illustrates the classification of Dampness.

TREATMENT PRINCIPLES FOR DAMPNESS

There are many treatment principles when treating Dampness depending on its nature (hot or cold) and its location.  I will discuss only the three major ones: drain Dampness through urination with bland-neutral herbs, resolve Dampness from the digestive system and muscles through sweating with fragrant-pungent herbs and dry Dampness with bitter-cold herbs.

Table 1, 2 and 3 illustrate the main herbs and formulae according to the above treatment principles.

Table 1. Bland-neutral herbs and formulae for Dampness which drain Dampness through urination.

Table 2. Fragrant-pungent herbs and formulae for Dampness in the digestive system and muscles which resolve Dampness through sweating.

Table 3. Bitter-cold herbs and formulae for Damp-Heat which dry Dampness.

SUMMARY OF TASTES/TEMPERATURE AND ACTIONS

To summarize the three main treatment principles for Dampness with examples of herbs, these are:
Drain Dampness through urination, diuretics (FU LING)
Resolve Dampness through sweating (CANG ZHU)
Dry Dampness (HUANG QIN)

These are also summarized in Figure 2.

Figure. 2. The three main treatment principles for Dampness with sub-types.

Damp-Heat should be discussed separately from Heat because it is such a common pathogenic factor that can be the cause of a very wide variety of problems.

Damp-Heat is particularly important as a pathogenic factor because it itself can become a cause of disease.  In fact, not only Dampness obstructs the Qi mechanism leading to more Dampness, but Heat also dries up the fluids and condenses them into more Dampness.  Furthermore, the Heat part of Damp-Heat (especially if predominant) may also injure Yin. These pathological processes are illustrated in Figure 3.

Figure 3.  Consequences of Damp-Heat.

CHARACTERISTICS OF DAMP-HEAT

I discussed above the characteristics of Dampness; here I describe the characteristics of Damp-Heat.

1) Seasonal character
Prevalent in summer and late summer, even in countries that are not that hot but are damp in the summer.  The seasonal Damp-Heat also exacerbates a pre-existing internal condition of Damp-Heat (e.g. urinary problems, Gall-Bladder problems, Wei syndrome, MS, intestinal problems, etc.).

2) Lingering, long course of disease
Damp-Heat is lingering. The Heat part of Damp-Heat also perpetuates the problem as Heat condenses the body fluids into Dampness.

3) Gives rise to Phlegm
Damp-Heat easily gives rise to Phlegm and Phlegm-Heat because the Heat in Damp-Heat can condense the body fluids into Phlegm.

4) Manifests with complex symptoms
Due to the combination of Dampness and Heat which may give rise to contradicting symptoms and signs.  For example, the patient may feel hot (from Heat) but the skin may be cold to the touch, or he may have cold feet.  Or the patient may feel cold in general, but he may also get hot easily.  There may be a feeling of heat but the pulse is not rapid or vice versa.  There may be a thirst (because of the Heat) but with no desire to drink (because of the Dampness).  The bowels may be sometimes loose (from Dampness) and sometimes dry (from Heat).

5) Damp-Heat may injure Yin
The Heat part of Damp-Heat, if predominant, may injure Yin: this leads to even more complex clinical manifestations, e.g. the patient has obvious symptoms of Damp-Heat but the tongue has no coating.

6) Damp-Heat is frequently toxic (Toxic Heat)
Damp-Heat frequently gives rise to Toxic Heat.  Toxic Heat is characterized by heat, swelling, pain and often pus.  A skin bacterial infection causing pustules is an example of Toxic Heat.

7) Damp-Heat easily damages Stomach and Spleen
Of course, Dampness by itself also damages Stomach and Spleen but Damp-Heat even more because Dampness tends to injure the Spleen while Heat tends to injure the Qi and Yin of the Stomach.

SYMPTOMS OF DAMP-HEAT

The following is a summary of the symptoms of Damp-Heat.  Please note that symptoms such as low-grade fever or afternoon fever are not common and they appear only when the Heat is pronounced.

greasy skin
weariness
ache in muscles
night-sweating
low-grade fever
feeling of heat
body hot to touch
afternoon fever (rare)

poor appetite
a feeling of oppression of the epigastrium
a feeling of heaviness of body and head
nausea
vomiting
abdominal distension
sticky taste
thirst with no desire to drink

turbid urine
scanty-dark urine
difficult urination
loose-smelly stools

SKIN SYMPTOMS OF DAMP-HEAT             

There are many skin diseases that manifest with Damp-Heat; for example, eczema and acne. There are three main skin eruptions to consider: papules, vesicles and pustules.

Papules
Papules are red and stick out. They may indicate Damp-Heat but they may also indicate Heat.  Examples of papules from Damp-Heat are eczema, acne and herpes.

Vesicles

Vesicles also stick out but are not red and are filled with a clear fluid. An example of vesicles is the rash that appears in chicken pox.

Pustules

Pustules are like vesicles but they are red and filled with pus. Acne presents with pustules if the skin spots are large, red and painful.

Many signs indicate Damp-Heat such as oozing skin eruptions, swollen-painful eyes, sty on eyelids, oozing eyes, mouth ulcers. The following three pictures are examples of Damp-Heat.

The picture below  is an example of Damp-Heat with Toxic-Heat.

When diagnosing Damp-Heat we must differentiate between prevalence of Dampness and prevalence of Heat because it makes a difference to the treatment.  In prevalence of Dampness we will use bland-neutral  or pungent-fragrant herbs and formulae.  In prevalence of Heat, we will use bitter-cold herbs and formulae.


The following illustrates the differentiation between prevalence of Dampness and prevalence of Heat in Damp-Heat.

Prevalence of Dampness
Fever, feeling of heat, greasy sweat, greasy skin
Face pale-yellow
Feeling of heaviness of eyes and head
Sweet-sticky taste, no thirst, likes warm drinks
Weariness, likes to lie down, feeling of oppression of the chest, likes to be quiet, no irritability
Poor Appetite
Stools with mucus or watery, turbid urine
Sticky-white or sticky-yellow tongue coating
Pulse Slow, Weak-Floating   

Prevalence of Heat
More fever or feeling of heat, skin not greasy
Face red
Slightly red eyes, dizziness, headache
Bitter taste, no desire to drink
Irritability, insomnia
Hungry but no desire to eat
Constipation, scanty-dark urine
Red tongue-body, or red sides, sticky-dry-yellow coating
Pulse Rapid and weak-Floating or Rapid and Wiry

TREATMENT OF DAMPNESS WITH ACUPUNCTURE

With acupuncture, when treating Damp-Heat, we must concentrate the attention on draining or resolving Dampness. In order to do that, I stimulate the movement, transformation and excretion of fluids in each of the three Burners with the points listed below.

- Upper Burner: Du-26 Shuigou, LU-7 Lieque, LI-4 Hegu, LI-6 Pianli, TB-4 Yangchi, TB-6 Zhigou, Ren-
  17 Shanzhong.
- Middle Burner: Ren-9 Shuifen, Ren-12 Zhongwan, ST-22 Guanmen, Ren-11 Jianli.
- Lower Burner: ST-28 Shuidao, BL-22 Sanjiaoshu, Ren-5 Shimen, BL-39 Weiyang, SP-9 Yinlingquan,
  SP-6 Sanyinjiao, KI-7 Fuliu.

For example, for Dampness in the Lower Burner, I would use several points from the Lower Burner list but also some of the Upper and Middle Burner, e.g. Ren-5 Shimen, BL-39 Weiyang, SP-9 Yinlingquan, BL-22 Sanjiaoshu  (Lower Burner) plus LU-7 Lieque (Upper Burner) and Ren-9 Shuifen (Middle Burner).

I will now list the most common Zangfu Damp-Heat patterns with their treatment.

DAMP-HEAT IN THE SPLEEN

Clinical manifestations
A feeling of fullness of the epigastrium and/or lower abdomen, epigastric and/or abdominal pain, poor appetite, a feeling of heaviness, thirst without desire to drink, nausea, loose stools with offensive odour, burning sensation in the anus, a feeling of heat, scanty-dark urine, low-grade fever, dull headache with feeling of heaviness of the head, dull-yellow complexion like tangerine peel, yellow sclera of the eyes, oily sweat, bitter taste, itchy skin or skin eruptions (papules or vesicles), if there is a fever and sweating, this does not relieve the fever and does not lead to the clearing of Heat.

Tongue: Red with sticky-yellow coating.
Pulse: Slippery-Rapid.

Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, Du-9 Zhiyang, L.I.-11 Quchi, BL-20 Pishu, G.B.-34 Yanglingquan, Ren-9 Shuifen, Ren-11 Jianli, ST-22 Guanmen, ST-28 Shuidao, BL-22 Sanjiaoshu.

Prescription
Lian Po Yin Coptis-Magnolia Decoction.

DAMP-HEAT IN THE LIVER

Clinical manifestations
Fullness of the hypochondrium, abdomen or hypogastrium, bitter taste, poor appetite, nausea, feeling of heaviness of the body,  yellow vaginal discharge, vaginal itching, vulvar eczema or sores, mid-cycle bleeding and/or pain, pain, redness and swelling of the scrotum, genital, papular or vesicular skin rashes and itching, urinary difficulty, burning on urination, dark urine.

Tongue: Red body with redder sides, sticky-yellow coating.
Pulse: Slippery-Wiry-Rapid.

Prescription
Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction.

DAMP-HEAT IN THE GALL-BLADDER

Clinical manifestations
Hypochondrial pain, fullness and distension, nausea, vomiting, inability to digest fats, yellow complexion, scanty and dark yellow urine, fever, thirst without desire to drink, bitter taste, dizziness, tinnitus, irritability, feeling of heaviness of the body, numbness of the limbs, swelling of the feet, loose stools or constipation, alternation of hot and cold feeling, yellow sclera, feeling of heat.

Tongue: thick-sticky-yellow coating, either bilateral in two strips or unilateral.
Pulse: Slippery-Wiry-Rapid.

Acupuncture
G.B.-24 Riyue, LIV-14 Qimen, Ren-12 Zhongwan, G.B.-34 Yanglingquan, extra point Dannangxue, Du-9 Zhiyang, BL-19 Danshu, BL-20 Pishu, L.I.-11 Quchi, T.B.-6 Zhigou, ST-19 Burong.

Prescription
Yin Chen Hao Tang Artemisia Capillaris Decoction.

DAMP-HEAT IN LIVER AND GALL-BLADDER

Clinical manifestations
Fullness of the hypochondrium, abdomen or hypogastrium, bitter taste, poor appetite, nausea, feeling of heaviness of the body,  yellow vaginal discharge, vaginal itching, vulvar eczema or sores, mid-cycle bleeding and/or pain, pain, redness and swelling of the scrotum, genital, papular or vesicular skin rashes and itching, urinary difficulty, burning on urination, dark urine, hypochondrial pain, fever,  yellow complexion and eyes, vomiting.

Tongue: Red body with redder sides, unilateral or bilateral sticky-yellow coating.
Pulse: Slippery-Wiry-Rapid.

Acupuncture
LIV-14 Qimen, G.B.-24 Riyue, G.B.-34 Yanglingquan, BL-18 Ganshu, BL-19 Danshu, Du-9 Zhiyang, Ren-12 Zhongwan, SP-9 Yinlingquan, SP-6 Sanyinjiao, SP-3 Taibai, L.I.-11 Quchi, LIV-2 Xingjian, LIV-3 Taichong.

Prescription
Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction.

STOMACH DAMP-HEAT

Clinical manifestations
A feeling of fullness and pain of the epigastrium, a feeling of heaviness, facial pain, stuffed nose or thick-sticky nasal discharge, thirst without desire to drink, nausea, a feeling of heat, dull-yellow complexion, a sticky taste, mouth ulcers.

Tongue: Red tongue with sticky-yellow coating.
Pulse: Slippery-Rapid.

Acupuncture
ST-44 Neiting, ST-34 Liangqiu, ST-21 Liangmen, Ren-12 Zhongwan, Ren-13 Shangwan, L.I.-11 Quchi, L.I.-4 Hegu, Ren-11 Jianli, ST-25 Tianshu, ST-40 Fenglong, SP-9 Yinlingquan, Ren-9 Shuifen.

Prescription
Lian Po Yin Coptis-Magnolia Decoction.

DAMP-HEAT IN THE SMALL INTESTINE
Clinical manifestations
Loose stools or diarrhoea with mucus in the stools, abdominal fullness and pain, mental restlessness, scanty and dark urine, burning pain on urination, blood in urine.

Tongue: Red with redder and swollen tip, yellow coating.
Pulse: Overflowing-Rapid, especially in the Front position.  If there are urinary symptoms the pulse would be Wiry on the Left-Rear position.

Acupuncture
ST-25 Tianshu, ST-37 Shangjuxu, ST-39 Xiajuxu, ST-28 Shuidao, SP-9 Yinlingquan, BL-27 Xioaochangshu.

Prescription
Bai Tou Wen Tang Pulsatilla Decoction.

DAMP-HEAT IN THE LARGE INTESTINE

Clinical manifestations
Abdominal pain that is not relieved by a bowel movement, diarrhoea, mucus and blood in stools, offensive odour of stools, burning in the anus, scanty-dark urine, fever, sweating which does not decrease the fever, a feeling of heat, thirst without desire to drink, feeling of heaviness of the body and limbs.

Tongue: Red with sticky-yellow coating.
Pulse: Slippery-Rapid.

Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, ST-25 Tianshu, ST-27 Daju, Ren-6 Qihai, BL-25 Dachangshu, L.I.-11 Quchi, Ren-12 Zhongwan, ST-37 Shangjuxu, BL-20 Pishu.

Prescription
Ge Gen Qin Lian Tang Pueraria-Scutellaria-Coptis Decoction.
Bai Tou Weng Tang Pulsatilla Decoction.
Shao Yao Tang Paeonia Decoction.

DAMP-HEAT IN THE BLADDER

Clinical manifestations
Frequent and urgent urination, burning on urination, difficult urination (stopping in the middle of flow), dark-yellow and /or turbid urine, blood in the urine, fever, thirst with no desire to drink, hypogastric fullness and pain, feeling of heat.

Tongue: thick-sticky-yellow coating on the root with red spots.
Pulse: Slippery-Rapid and slightly Wiry on the Left-Rear position.

Acupuncture
SP-9 Yinlingquan, SP-6 Sanyinjiao, BL-22 Sanjiaoshu, BL-28 Pangguangshu, Ren-3 Zhongji, BL-63 Jinmen, BL-66 Tonggu, ST-28 Shuidao.

Prescription
Ba Zheng Tang Eight Upright Powder.

THE TONGUE IN DAMP-HEAT

Dampness manifests on the tongue primarily on the coating and Heat on the tongue-body colour. Therefore Damp-Heat manifests with a sticky-yellow coating and a red tongue-colour.  The more Heat there is, the more the tongue body is red: the more Dampness there is, the thicker the coating.

The following are examples of tongue with a sticky-yellow coating from Damp-Heat.

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.