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By Bob Damone

In clinical practice, it is not uncommon to encounter patients with complaints of abnormal heat sensations that may or may not be measurable by a thermometer and that may be acute or enduring. Upon close observation, these patients may lack all evidence of an external contraction of evil, yet novice practitioners will be tempted to treat the patient as if they did, in large part because the practitioner lacks a deeper understanding of the many possible patterns that can lead to abnormal heat sensations. It is of the utmost importance for the practitioner to grasp the fact that such heat sensations may not be due to external contractions of evils at all and may in fact arise from interior viscera-bowel irregularities. In TCM internal medicine textbooks, abnormal heat sensations that do not result from an external contraction are fully discussed under the heading of Internal Damage Heat Effusion.

As practitioners of Chinese medicine, it is important for us to be equipped with as much knowledge as possible about the TCM disease category that most clearly relates to our patient's chief complaint. Knowledge of the TCM disease category most relevant for a given complaint organizes our thinking and reminds us to discriminate patterns more comprehensively. When we structure our clinical reasoning in this way we can tap into our predecessors' experiences on the condition we are intending to treat, including their recorded thoughts on relevant disease causes and mechanisms, the most commonly encountered patterns and treatments for the disease in question, and its prognosis. This is the incredibly important information that is unfortunately rarely translated in English-language TCM textbooks. For example, although there is a chapter in Wu and Fischer (1997), a translation compiled from standard Chinese-language TCM textbooks, devoted to "Internal Damage Fever," the history, and disease causes and mechanisms are not presented. It is my opinion that this is exactly the information that TCM practitioners need greater access to in order to progress to a deeper level of understanding and practice. !

In order to provide more information on Internal Damage Heat Effusion, I translated the following material from a standard textbook used in TCM colleges throughout the People's Republic of China-Zhong Yi Nei Ke Xue, (Chinese Internal Medicine) which was published by Shang Hai Ke Xue Ji Shu Chu Ban She (Shanghai Science and Technology Press) in 1988.

Internal Damage Heat Effusion is heat effusion that results from internal damage. Its disease mechanisms involve Qi, blood, yin, and essence depletion and vacuity and irregularities of viscera and bowel function. Ordinarily, this disease is insidious in onset and its course is relatively protracted. Clinically, it usually presents with a low-grade fever but at times there can be a high fever, but one may have a subjective experience of heat effusion and vexing heat in the five centers without having an elevated body temperature; this also falls within the scope of Internal Damage Heat Effusion.

The Inner Classic contains a relatively detailed coverage of Internal Damage Heat Effusion within its discussion of yin vacuity interior heat. Simple Questions, On Regulating Channels (Su Wen, Tiao Jing Lun, Chapter 62), states: "Yin vacuity produces interior heat". Concerning its disease mechanisms it states: "When there is taxation fatigue, debilitated and diminished physique and Qi result. [As a result], grain Qi will lack exuberance and the upper burner will lack movement. [This leads to] lower stomach duct stoppage, stomach Qi¹, and hot Qi steaming within the chest; this [is how] interior heat [comes about]." With respect to treatment, Simple Questions, The Great Treatise on the Extremely Important (Zhi Zhen Yao Da Lun, Chapter 74), advanced the principle of "obtaining yin when heat disease becomes hotter after cooling [treatments]"² Simple Questions, On Needling [For the Treatment of] Heat, (Ci Re, Chapter 32) has a detailed discussion of the symptoms, signs, and prognosis of heat diseases of the five viscera which established the foundation of the discrimination of heat diseases of the five viscera used by later generations of physicians. Essential Prescriptions of the Golden Coffer, Blood Impediment and Vacuity Taxation Disease (Chapter 6), placed "hand and foot heat vexation" within the realm of Vacuity Taxation and advocated treatment with Xiao Jian Zhong Tang (Minor Center-Fortifying Decoction). This was the first mention of using sweet and warm medicinals to eliminate heat.

On the Origin and Symptoms of Diseases³ contains many discussion of Internal Damage Heat Effusion, for example, in Symptoms [of] Vacuity Taxation Guest Heat it states: "A person with vacuity taxation [has] extreme weakness of blood and Qi, [and thus a] profound vacuity of yin and yang. Taxation engenders heat; [therefore], it is because of taxation that heat is being engendered." This passage advanced the unique idea that taxation causes heat. Symptoms [of] Vacuity Taxation discusses the disease mechanisms of yin vacuity heat effusion in the following passage: "Vacuity Taxation and heat are [due to] yin Qi insufficiency [and a] surplus of yang Qi, so [in this condition], heat is engendered in the interior and [moves outward to the] exterior; [this is] not evil Qi overwhelming via the exterior."

Both the 16^th chapter of Essential Secrets from Outside the Metropolis⁴ and the 29^th chapter of Sagacious Benevolent Formulas⁵recorded formulas for the treatment of Vacuity Taxation Heat Effusion. Craft of Medicinal Treatment for Pediatric Conditions⁶, based on the Inner Classic's theory of five viscera heat disease, proposed using Dao Chi San (Red-Abducting Powder) for heart heat, Xie Qing Wan (Green-Blue-Draining Pill) for liver heat, and Xie Huang San (Yellow-Draining Powder) for spleen heat. It also recommended reducing Shen Qi Wan (Kidney Qi Pill) down to Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill) and thus provided a very important formula for the treatment of yin vacuity interior heat.

In the Jin-Yuan period, Li Dong-Yuan, in On the Spleen and Stomach, Treatise on the Initiation of Heat in the Center Due to Damage by Food and Drink and Taxation Fatigue⁷ pointed out that when spleen and stomach Qi become decrepit and original Qi becomes insufficient, yin fire is internally engendered. He proposed the following treatment guidelines: "The only choice is to employ acrid, sweet, and warm ingredients to supplement the center and upbear yang along with sweet and cold (ingredients) to drain fire"⁸. Li drafted Bu Zhong Yi Qi Tang (Center-Supplementing Qi-Boosting Decoction) as the principal formula for this condition thus solidifying the treatment method of using sweet and warm medicinals to eliminate heat. In so doing, Li made an important contribution to the pattern discrimination and the treatment of Qi vacuity heat effusion. In Clarifying Doubts about Injury from Internal and External Causes⁹, Master Li3 proposed Dang Gui Bu Xue Tang (Tangkuei Blood-Supplementing Decoction) as a treatment for blood vacuity heat effusion and clarified the differences between Internal Damage Heat Effusion and External Contraction Heat Effusion.

Zhu Dan-Xi's discussion on yin vacuity heat effusion was one of the first and was relatively deep. Dan Xi's Experiential Methods,¹⁰, Six Depressions¹¹, advanced the idea that "many diseases of the human body are engendered through depression". His discussion established the theory of the six depressions and named them Qi depression, blood depression, dampness depression, phlegm depression, heat depression, and food depression. This supplemented the existing knowledge of the disease mechanisms and treatments of Internal Damage Heat Effusion.

In the Ming Dynasty, Qin Jing-Ming was the first to clearly promote "Internal Damage Heat Effusion" as a distinct disease name. Pathoconditions, Causes, Pulses, and Treatments, Internal Damage Heat Effusion¹², divided Internal Damage Heat Effusion into the two broad categories of "Qi Aspect Heat Effusion" and "Blood Aspect Heat Effusion." Instead of relying on ancient formulas for the treatment of Internal Damage Heat Effusion, he added four formulas for its treatment, including Xue Xu Chai Hu Tang (Blood Vacuity Bupleurum Decoction).

Supplement to Diagnosis and Treatment¹³, Heat Effusion, labeled externally contracted heat effusion as external heat effusion, and differentiated eleven other types of heat effusion: depressive fire heat effusion, yang depression heat effusion, bone-steaming heat effusion, internal damage heat effusion (primarily indicating blood and Qi vacuity heat effusion), yang vacuity heat effusion, yin vacuity heat effusion, blood vacuity heat effusion, phlegm pattern heat effusion, food damage heat effusion, static blood heat effusion, and sore-toxin heat effusion. This text also listed separate formulas for the treatment of each type of heat effusion and gave a relatively complete summary of the topic. Medical Insights¹⁴, Explanation of the Character Fire, called externally contracted fire "enemy fire", and internally engendered fire "child fire". It described four main methods of treatment for internal fire which are listed below:

1. Reaching - "This indicates reaching wood depression with [formulas] such as Xiao Yao San (Free Wanderer Powder."
2. Enriching - "This mainly indicates invigorating water [and] settling yang brightness with [formulas] such as Liu Wei Tang (Six Flavor Decoction)."
3. Warming - "[The] classic states that taxation should be warmed. [It] also states that sweat warm [medicinals] can eliminate fire and heat. [Use formulas] such as Bu Zhong Yi Qi Tang (Center-Supplementing Qi4-Boosting Decoction)."
4. Leading - Using acrid hot medicinals combined with water-invigorating medicinals to abduct and move [fire] downward. This is called abducting the dragon into the sea and leading fire back to the source; use [formulas such as] Ba Wei Tang (Eight Flavor Decoction).

Wang Qing Ren¹⁵ made a very important contribution to the diagnosis and treatment of static blood heat effusion. In Corrections of Errors Among Physicians,¹⁶ Section on the Treatment of the House of Blood Stasis-Expelling Decoction Pattern, Master Wang explained that static blood can manifest with "body exterior cold [and] heat within the heart," "evening heat effusion," and "fever in the afternoon and before midnight." He drafted a new formula and called it Xue Fu Zhu Yu Tang (House of Blood Stasis-Expelling Decoction) to be the main formula to treat this condition. On Blood Patterns¹⁷, Heat Effusion, also discussed many different manifestations of static blood and their treatments. The diagnosis and treatment of Internal Damage Static Blood Heat Effusion was perfected through the efforts of masters Wang, and Tang.

Disease Causes and Disease Mechanisms

This disease results from non-exterior causes such as irregularities of affect-mind and diet and taxation fatigue. A minority of cases begin with an external contraction which over time causes viscera-bowel vacuity detriment. The common disease mechanisms occurring in Internal Damage Heat Effusion are depletion and vacuity of Qi, blood, yin, and essence, and loss of regulation of viscera and bowel function. The viscera-bowel related causes of Internal Damage Heat Effusion are discussed in the differentiation below.

Liver Channel Depressive Heat

When there is affect-mind repression and depression, the liver cannot orderly reach; as a result, Qi depression transforms fire and heat effusion ensues. Excessive anger and indignation cause internal exuberance of liver fire and heat effusion. These disease mechanisms and pathophysiology are well stated in Dan-Xi's Experiential Methods, Fire where it states: "[When] and Qi is [in] surplus, there is fire". This type of heat effusion is intimately related to affect-mind and is also called "five minds' fire".

Static Blood Obstruction

This is caused by phenomena such as affect-mind damage, taxation fatigue, trauma, and bleeding. Static blood obstructs the channels and network vessels and inhibits the flow of Qi and blood. As a result, Qi and blood become obstructed, stoppage and lack of free flow develop, and heat effusion arises. This is the main disease mechanism behind static blood heat effusion. The Spiritual Pivot, Welling Abscess (Yong1 Ju1, Chapter 81) discussed the disease mechanisms of blood astringency and lack of free flow causing heat effusion in the following passage: "[When] construction and defense are detained¹⁸ within the channels and network vessels, the blood weeps¹⁹ and does not move. Because of this lack of movement, the defensive Qi is inhibited. Obstruction, stoppage, and lack of movement cause heat." Static Blood Heat Effusion is also related to blood vacuity and lack of nourishment. According to Precepts for Physicians²⁰, On Vacuity Taxaction, "blood impediment causes non-engendering of new blood. Blood accumulation and lack of movement, [that is], blood stasis, causes construction vacuity, and construction vacuity causes heat effusion."

Middle Qi Insufficiency

Excessive taxation and fatigue, dietary irregularities, and loss of regulation from enduring disease lead to spleen and stomach Qi vacuity, internal engenderment of yin fire, and heat effusion. Currently, this is also called Qi Vacuity Heat Effusion.

Blood Vacuity and Loss of Nourishment

Loss of nourishment occurs in enduring disease with liver and heart blood vacuity, in spleen vacuity not engendering blood, when there has been great blood loss (such as after surgery), and after parturition. The root of blood is yin; when yin and blood are insufficient, yang cannot be constrained and heat effusion arises. According to Supplement to Diagnosis and Treatment, Heat Effusion, "blood vacuity heat effusion may be due to blood ejection, hemafecia, post-partum flooding and leaking, and blood desertion. [As a result, there is] an inability to join with yang, hyperactive yang, and heat effusion; treatment requires nourishing blood."

Yin Essence Depletion and Vacuity

This pattern results from factors such as constitutional bodily yin vacuity, enduring heat consuming and damaging yin humor, and inappropriate or excessive use of warm drying medicinals, When yin is debilitated, yang overcomes, water is unable to restrain fire, yang Qi becomes effulgent, and heat effusion results. According to Jing-Yue's Great Compendium²¹, Fire Conditions, "yin vacuity can engender heat effusion. This is caused by true yin depletion-detriment and an inability of water to restrain fire."

Of the fore-mentioned disease causes and disease mechanisms, Qi depression and blood stasis are ascribed to repletion and Qi vacuity, blood vacuity and yin vacuity are ascribed to vacuity. In the majority of cases, however, heat effusion results from a combination of disease mechanisms such as Qi depression and blood stasis, dual vacuity of Qi and yin, and dual vacuity of Qi and blood. Additionally, conversion among these various disease mechanisms may occur. For example, in enduring cases, repletion commonly converts to vacuity, mild cases convert to severe cases, and enduring cases may involve static blood. Detriment reaches Qi , blood, yin, and yang, and although there is differentiation between Qi vacuity, blood vacuity, yin vacuity, and yang vacuity, it is more common to encounter combinations of vacuity and repletion patterns. Other common combinations include enduring Qi depression heat effusion with correct Qi vacuity; if heat then damages yin, the condition converts to Qi depression with yin vacuity heat effusion. When enduring Qi vacuity heat effusion and detriment reaches yang, yang Qi becomes debilitated and weak, and yang vacuity heat effusion develops.

References

Bensky, D., Barolet, R. (1990). Chinese Herbal Medicine; Materia Medica. (Rev. Ed.). Seattle, WA: Eastland Press

Li, Dong-Yuan. (1993). The Treatise on the Spleen and Stomach. (Yang, S.Z., Li, J.Y., Trans.). Boulder, CO: Blue Poppy Press. (Original work published 13^th. c.).

Wiseman, N., Ye, F. (1998). A Practical Dictionary of Chinese Medicine. Brookline, MA.: Paradigm Publications.

Wu, N.L, Wu, A.Q. (1999). Yellow Empero's [sic] Canon [sic] Internal Medicine. Beijing, PRC: China Science and Technology Press.

Wu, Y. and Fischer, W. (1997). Practical Therapeutics of Traditional Chinese Medicine. Brookline, MA. Paradigm Publications

Footnotes

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