Abstract: Yang deficiency with heat symptoms refers to the manifestation of symptoms characteristic of heat (fire) under conditions of weak Yang Qi. The mechanisms believed to contribute to this condition include: (1) Yang deficiency with excessive cold, causing Yang to be constrained externally; (2) Insufficient middle Yang, leading to floating Yang and heat on the surface; (3) Insufficient kidney Yang, resulting in fire not returning to the source; (4) Weak Yang Qi, leading to stagnation and heat; (5) Weak Yang Qi, causing pathological products to stagnate and transform into heat; (6) Weak Yang Qi, making the body susceptible to external pathogens. This article briefly discusses the treatment of various types of Yang deficiency with heat symptoms.
1. Overview of Yang Deficiency with Heat Symptoms “Heat (fire)” is one of the six excesses in Traditional Chinese Medicine (TCM), characterized by: (1) Fire heat as a Yang pathogen, which tends to rise; (2) Fire heat easily disturbs the spirit; (3) Fire heat easily injures essence and consumes Qi; (4) Fire heat can generate wind and move blood, and Yang pathogens can lead to sores and abscesses. Yin and Yang are concepts from ancient Chinese philosophy, summarizing the opposing attributes of certain phenomena in nature. The relationship between Yin and Yang is characterized by “this diminishes while that increases, and vice versa.” The basic principles of TCM Yin-Yang theory state that “excess Yang leads to heat” and “excess Yin leads to cold.” “Yin deficiency generates internal heat, while Yang deficiency generates internal cold.” Therefore, heat symptoms are often seen in conditions of excess Yang or Yin deficiency. When symptoms characteristic of heat (fire) appear under conditions of weak Yang Qi, such as body heat, flushed face, irritability, sores, thirst, and a large pulse, it can be termed Yang deficiency with heat symptoms. This phenomenon does not contradict the basic theories of TCM Yin and Yang, but it has unique mechanisms and treatments. The author has reviewed some literature and combined personal experiences to analyze the mechanisms and treatments of “Yang deficiency with heat symptoms” as follows.1. Yang deficiency with excessive cold, constraining Yang externally When Yang Qi is extremely deficient and Yin cold is excessive internally, it forces Yang Qi to float outward, creating a pathological state where Yin and Yang Qi do not connect smoothly and reject each other. Yang deficiency with excessive cold is the essence of the disease, but due to the constraint of Yang externally, clinical manifestations include flushed face, irritability, thirst, and a large pulse, hence termed true cold with false heat. As stated in the “Complete Book of Jingyue: Fire Symptoms,” “When cold arises from within, Yang Qi has no place to attach and disperses outward, which is termed false fire or false heat.” The “Medical Treatise on Fever” points out, “Yang deficiency should be cold; why is there heat? This is because of deficiency and cold, with cold inside and Yang constrained externally, hence the external heat, and cold below with Yang above, hence the heat above.” Zhang Zhongjing’s formula of Ginger and Aconite Decoction indicates “restlessness and inability to sleep day and night, but calm at night,” and the Tongmai Four Reverse Decoction shows “the body does not dislike cold” and “the person’s complexion is red,” all belong to this category. In diagnosing this type of patient, attention should be paid to their desire to cover themselves despite feeling hot, thirst for warm drinks, but not drinking much, a large but weak pulse, and cold extremities, clear diarrhea, prolonged clear urination, pale tongue with white coating, and other cold signs. Treatment should target the essence of Yang deficiency with excessive cold, using the so-called “reverse treatment method” with formulas like Four Reverse Decoction to revive Yang and rescue the reverse flow.2. Insufficient middle Yang, floating Yang and heat This refers to what Li Dongyuan termed “Yin fire.” The essence and mechanism of “Yin fire” is a vague concept in Li Dongyuan’s theory of spleen and stomach injury, and has been debated by physicians throughout history. Li Dongyuan’s discussions on the formation mechanism of Yin fire mainly appear in three texts: “On Spleen and Stomach: The Initial Heat from Dietary Injury,” “Medical Innovations: Dietary Injury Theory,” and “On Internal and External Injuries: Dietary Injury Theory.” The three passages regarding the formation mechanism of “Yin fire” are nearly identical: “If dietary habits are irregular and temperature is inappropriate, the spleen and stomach will be injured, and excessive emotions or overwork will deplete the original Qi, leading to spleen and stomach deficiency, insufficient original Qi, and excessive heart fire. Heart fire is Yin fire; it arises from the lower burner and is connected to the heart, which does not govern commands, and the fire of the heart substitutes for it; the fire of the heart is the thief of original Qi. Fire and original Qi cannot coexist; one wins and the other loses. If the spleen and stomach Qi is deficient, it flows down to the kidneys, allowing Yin fire to take its place.” For the treatment of Yin fire syndrome, Li Dongyuan recommends sweet and warm herbs to tonify the middle and benefit Qi, known as “sweet and warm to eliminate great heat.” From the above discussions and his sweet and warm treatment methods, it can be seen that spleen and stomach deficiency, i.e., insufficient middle burner Yang Qi, leads to excessive heart fire, which is the main pathological mechanism of “Yin fire.” The clinical manifestations are mainly fever, prolonged illness, and exacerbation with exertion, along with signs of spleen and stomach Qi deficiency. Treatment should follow Li Dongyuan’s method, using formulas like the Middle Qi-Boosting Decoction to sweetly and warmly eliminate heat.3. Insufficient kidney fire, fire not returning to the source Insufficient kidney Yang leads to deficiency of the Mingmen fire, excessive Yin cold in the lower burner, forcing Yang to float upward, causing fire not to return to the source, and floating Yang to disturb, resulting in excessive heart fire. Clinical manifestations include aversion to cold and heat, body heat and irritability, palpitations, insomnia, forgetfulness, oral ulcers, thirst, bitter mouth, cold pain in the lower back, coldness in the shins and knees, prolonged clear urination, coldness in the lower back and knees, pale red tongue, and weak pulse as characteristics. The treatment method is often to warm kidney Yang to lower heart fire, known as “guiding fire back to the source,” using formulas like Kidney Qi Pill from the Golden Cabinet.4. Weak Yang Qi, Yang stagnation and heat When the body’s Yang Qi is weak, it affects its smooth flow and regulation. If Yang Qi is obstructed by pathogenic factors, it becomes stagnant and generates heat, leading to symptoms such as fever, thirst, and irritability. For example, in the “Golden Cabinet: Miscellaneous Diseases of Women,” it states, “A woman aged fifty has diarrhea for several days without stopping, and in the evening develops fever, with urgency in the lower abdomen, abdominal fullness, hot palms, and dry lips…” This syndrome is due to cold pathogens injuring Yang. Although there is overall Yang Qi deficiency, Yang Qi is obstructed by pathogenic factors, leading to stagnation and heat. Therefore, Zhang Zhongjing treats it with the Warming Channels Decoction, using Cinnamon Twig and Atractylodes to warm the channels and assist Yang in dispersing cold, combined with Angelica, Chuanxiong, Peony, and Red Peony to invigorate blood and disperse stasis, allowing Yang Qi to recover, stasis to dissipate, and Qi mechanism to regulate, thus relieving stagnation heat. If there is overall Yang Qi deficiency but stagnation occurs locally, it can lead to “fire stagnation” syndrome, resulting in oral ulcers, toothache, sore throat, and abscesses. Although the constitution is Yang deficient, emotional repression can lead to Qi stagnation and heat, causing occasional feelings of body heat, with heat intensity fluctuating with emotions, leading to discomfort, a tendency to sigh, and irritability. The syndrome of Yang stagnation and heat caused by Yang deficiency should be treated not only by warming Yang but also by following the principle of “fire stagnation leads to its release” from the “Plain Questions: Great Discussion on the Six Yuan Zheng Ji,” guiding the treatment to open stagnation and allow Qi to flow, thus dissipating heat.5. Weak Yang Qi, pathological products stagnating and transforming into heat Weak Yang Qi can lead to the production of various pathological products, such as blood stasis, phlegm turbidity, and water retention. These pathological products can stagnate and transform into heat, resulting in symptoms such as fever, thirst, irritability, and abscesses. For instance, blood stasis can lead to afternoon or nighttime fever, with symptoms lighter during the day and heavier at night, or localized heat in certain areas, dry mouth and throat without desire to drink, etc. Additionally, in the case of water counterflow syndrome, the “Treatise on Cold Damage: Differentiating the Pulse and Symptoms of Taiyang Disease” states: “Wind stroke causes fever, lasting six or seven days without resolution, with both exterior and interior symptoms, thirst for water, and vomiting after drinking; this is called water counterflow.” This syndrome arises from Yang Qi being injured, leading to abnormal Qi transformation, with internal water retention as the cause. The treatment should focus on unblocking Yang and promoting urination using Five-Ingredient Powder. For all syndromes caused by weak Yang Qi, where pathological products stagnate and transform into heat, treatment should be based on warming Yang while eliminating pathological products, allowing heat to dissipate naturally.6. Weak Yang Qi, susceptibility to external pathogens Weak Yang Qi and insufficient protective function make the body susceptible to external pathogens, which can also lead to fever, such as Yang deficiency with a cold. Patients with this condition often exhibit Yang deficiency signs alongside fever, such as aversion to cold, curling up, spontaneous sweating, generalized joint pain, pale complexion, pale and swollen tongue, and a pulse that is not floating but often deep and thin. Treatment should combine both attacking and tonifying methods, assisting Yang and expelling pathogens, such as using Ren Shen Fu Zi Zai Zao Wan for Yang deficiency with cold. In summary, although Yang deficiency leading to heat symptoms is a special case, its mechanisms are diverse. Understanding these mechanisms is beneficial for correctly identifying and treating syndromes related to Yang deficiency with heat symptoms. It also reminds us that in clinical differentiation, we should not isolate our judgment based on a single symptom or sign, but rather observe the overall manifestations of the disease, especially paying attention to the emergence of special cases to prevent misdiagnosis and mistreatment. Mastering both general rules and special rules is essential to grasping the essence of differentiation and treatment. Cold and heat are the two main principles for distinguishing the nature of diseases. Generally speaking, cold syndromes indicate conditions where the body’s Yang Qi is insufficient or where cold pathogens are present, while heat syndromes indicate conditions where the body’s Yang Qi is excessive or where heat pathogens are present. The discussions on cold and heat in the “Inner Canon” are extensive and relatively clear, such as in the “Plain Questions: Great Discussion on the Correspondence of Yin and Yang,” which clearly states: “Excess Yang leads to heat, excess Yin leads to cold,” and in the “Plain Questions: Great Discussion on the True Essentials,” it proposes the treatment principle that “cold leads to heat, and heat leads to cold.” Cold syndromes are characterized by the invasion of cold pathogens or by Yang deficiency with excessive Yin, leading to a decline in the body’s functional activities. Clinical symptoms include: aversion to cold, preference for warmth, pale tongue, clear prolonged urination, loose stools, and a slow pulse. The etiology and pathogenesis are due to the invasion of cold pathogens or insufficient Yang Qi, both of which can lead to unstable body temperature, hence the symptoms of aversion to cold, pale complexion, and preference for warmth; excessive Yin leads to uninjured fluids, hence the pale tongue and lack of thirst; insufficient Yang Qi leads to the inability to warm and transform fluids, hence clear prolonged urination and loose stools; insufficient Yang Qi leads to the generation of internal cold, hence the pale tongue with white coating and moistness; and Yang deficiency leads to weak Qi, hence the slow pulse. Heat syndromes are characterized by the invasion of heat pathogens or by excessive Yang with deficient Yin, manifesting as hyperactivity of the body’s functional activities. Clinical symptoms include: fever with a preference for coolness, thirst for cold drinks, flushed face, dry stools, red tongue with yellow and dry coating, and a rapid pulse. The etiology can arise from external heat pathogens or from emotional disturbances, dietary heat accumulation, or overexertion, leading to Yin deficiency and Yang excess. If Yang heat is excessive, the body feels hot and prefers coolness; if fire heat injures Yin, fluids are consumed, leading to thirst for cold drinks and short, red urination; if the large intestine lacks fluids, stools become dry and hard; and if Yang heat is excessive, blood flow accelerates, hence the rapid pulse. The relationship between cold and heat syndromes Cold and heat mixed: This refers to the simultaneous presence of cold and heat symptoms. Clinically, it is common to see upper heat with lower cold, upper cold with lower heat, exterior cold with interior heat, and exterior heat with interior cold. Upper heat with lower cold: Excess Yang above and excess Yin below. Symptoms include chest heat, frequent desire to vomit (upper heat); abdominal pain with a preference for pressure, thin stools (lower cold). Upper cold with lower heat: Excess Yin above and excess Yang below. Symptoms include cold pain in the stomach, vomiting clear fluids (upper cold); short, red urination, dry stools (lower heat). Exterior cold with interior heat: Invasion of cold pathogens externally, with the exterior not resolving and the pathogen entering the interior to transform into heat; or there is pre-existing heat internally and then an invasion of cold pathogens. Symptoms include: aversion to cold, fever, no sweating, body aches (exterior cold); shortness of breath, irritability, thirst for cold drinks, red urination, constipation (interior heat). Exterior heat with interior cold: Invasion of wind-heat externally leading to internal cold injury, or pre-existing spleen and stomach deficiency with external wind-heat invasion. Symptoms include: fever, headache, sore throat (exterior heat); prolonged clear urination, loose stools, aversion to cold, cold extremities (interior cold). Transformation between cold and heat One is the initial cold syndrome, which later transforms into a heat syndrome, with the cold syndrome gradually receding; the other is the initial heat syndrome, which later transforms into a cold syndrome, with the heat syndrome gradually receding. This transformation mainly depends on the rise and fall of both the righteous and evil forces. Any transformation from cold to heat indicates that the evil is strong while the righteous Qi is still sufficient, and Yang Qi is vigorous, thus transforming Yang into heat. For example, when cold pathogens are first felt, symptoms include aversion to cold, fever, body aches, no sweating, white coating, and floating tight pulse, indicating exterior cold syndrome. As the disease progresses, the cold pathogen enters the interior and transforms into heat, with symptoms of aversion to cold disappearing and symptoms of irritability, thirst, yellow coating, and rapid pulse appearing, indicating that the syndrome has transformed from exterior cold to interior heat. Conversely, when heat transforms into cold, it is often due to evil heat injuring the righteous Qi, leading to the righteous Qi being unable to withstand the evil, and Yang Qi declining. For instance, in cases of high fever, due to continuous sweating, Yang Qi is lost through sweat, or frequent vomiting and diarrhea lead to Yang Qi being lost through fluids, resulting in cold extremities, pale complexion, and a pulse becoming deep and slow, indicating a transformation from heat syndrome to cold syndrome. True cold and false heat refer to a critical stage of the disease, where clinical signs may not match the essence of the disease, i.e., heat symptoms appearing with cold signs, and cold symptoms appearing with heat signs. True heat with false cold: Internal Yang heat is stagnant and cannot express outward, constraining Yin externally. Symptoms include a dull complexion, but bright eyes, red and dry lips, confusion but occasionally irritable, restless movements, hot breath, foul-smelling breath, foul-smelling excretions, thirst for cold drinks, cold body but not wanting to wear clothes, short urination, constipation, deep pulse with strength upon pressure, cold hands and feet but hot chest and abdomen, red tongue, dry and yellow-black coating. True cold with false heat: Excessive Yin internally, constraining Yang externally. Symptoms include body heat, flushed face, thirst, large pulse, etc., resembling heat syndrome, but desiring to cover up despite feeling hot, flushed face but cold extremities, thirst but preferring warm drinks, and not drinking much, a large but weak pulse, along with prolonged clear urination, loose stools, pale tongue with white coating, etc.2. Warming Yang and Dispelling Heat Method The Inner Canon states: “When Yin prevails, Yang suffers… When Yin prevails, it is cold,” “Yang deficiency generates external cold,” “wherever evil gathers, its Qi must be deficient.” Once the righteous Qi (Yang Qi) is insufficient, external cold invades the body, leading to cold syndromes, which can be classified into deficiency and excess. (“When evil Qi is strong, it is excess; when essence is depleted, it is deficiency.”) Cold excess syndromes may present with cold extremities, abdominal pain, chest tightness, or constipation, with a deep, wiry, or deep, slow, strong pulse; deficiency cold syndromes may present with reduced appetite, pale tongue, vomiting of saliva, shortness of breath, loose stools, or diarrhea, pale tongue with white coating, and a weak or thin pulse. The two have distinct differences in pulse, tongue, and symptoms, and the treatment methods are also different. The former can use warming and unblocking methods. In cases where cold cannot be transformed without warmth, and accumulation cannot be resolved without downward movement, the Warming Spleen Decoction is selected. Using Aconite, Dried Ginger, Codonopsis, and Licorice to warm Yang and tonify the spleen, combined with Rhubarb to purge and unblock the bowels. This formula supports the righteous Qi without being attached to the evil, attacks the evil without harming the righteous, truly embodying the principle of combining attack and tonification. Once the cold accumulation is removed, the spleen and stomach can function normally, and the disease will resolve. Rhubarb, being bitter and cold, can be said to resolve hidden heat in the intestines, right? The latter can use the warming Yang and strengthening spleen method, as Yang is already strong. In the cold within the body, there are also distinctions among the five organs, and different formulas should be selected, which will not be elaborated here. When cold invades the body, the following clinical situations are often observed:1. Heart and kidney Yang deficiency or sudden heart Yang collapse (equivalent to modern heart failure or respiratory failure). Patients in this condition are critically ill. Symptoms include cold extremities, profuse sweating, cyanosis of lips, shortness of breath, or weak breathing, cold and moist skin, even confusion or fainting, limbs swollen like mud, weak pulse, and heart and kidney Yang collapse, life hanging by a thread. Urgent measures must be taken to revive Yang and rescue the reverse flow, using formulas like Four Reverse Decoction (from the Treatise on Cold Damage), or Four Reverse Decoction with Ginseng (to benefit Qi and generate fluids due to weak Yang Qi and depleted Yin fluids), or Ren Shen Fu Zi Long Mu Jiu Ni Decoction and Zhang Yangchun’s Recovery Decoction (with 60g of Schisandra, 30g each of raw Longmu and Muli, 18g of raw White Peony, 12g of wild Tai Shan Ginseng, and 6g of honey-fried Licorice), to supplement the deficiencies of Four Reverse Decoction. Among these, Aconite is the main herb for reviving Yang and rescuing the reverse flow; heavy doses are required to rescue the reverse flow. The general dosage is between 30-200g, with Dried Ginger 60g, honey-fried Licorice 60g, Korean Ginseng 10-30g, raw Longmu powder 30g each, Schisandra 60-120g, active magnet 30g, and Musk 0.5g taken in divided doses. This formula is based on the experience of Shanxi’s old TCM doctor Li Ke, who has successfully rescued over a thousand critically ill cases, breaking the misconception that TCM cannot rescue acute, critical, and severe patients, but only treats chronic conditions! It can serve as a reference. Especially the two herbs Longmu and Muli, “stabilize the kidney, gather essence, and restrain floating and dispersing original Qi,” hence termed “guiding Yang back!” For warm diseases with heat entering the lower burner, with Yin deficiency and Yang excess, internal wind agitation can be treated with salty and cold substances like oyster shell, tortoise shell, and turtle shell to nourish Yin, guide Yang, and extinguish wind, termed “guiding Yang back!”2. Mixed cold and heat syndrome: This syndrome is very common clinically and is not comparable to urgent rescue. Generally, if using ginger and Aconite to warm Yang, the dosage is between 6-15g. For patients with chronic gastrointestinal dysfunction, common symptoms include dry mouth, abdominal distension and pain, burning sensation in the stomach, belching, bowel sounds, and loose stools, with a white coating and red tip on the tongue, and a weak pulse in the second position. This indicates upper heat (stomach) and lower cold (spleen), with a strong stomach and weak spleen, a mixed cold and heat syndrome, and it is advisable to use the Banxia Xiexin Decoction method, combining Huanglian and Huangqin with Dried Ginger and Yizhi Ren, which is widely used clinically and often yields good results. Is this not the “warming Yang and dispelling heat” method?!3. True cold with false heat syndrome: In cases of heart and kidney Yang deficiency, with clear diarrhea, weak pulse, and the body not disliking cold, flushed face, and sore throat, this indicates Yang constraint and Yang being worn down, true cold with false heat. Use Four Reverse Decoction, but if the strength is insufficient, use Tongmai Four Reverse Decoction, increasing the warming Yang intensity to disperse Yin and unblock Yang, achieving the balance of Yin and Yang. This provides a diagnostic basis for clinically distinguishing true and false cold and heat. I have previously written about such treatment experiences. Kidney Qi Pill is a representative formula for warming and tonifying kidney Yang. The kidneys reside in the lower burner, the source of innate Qi, containing both water and fire Qi, and are essential for promoting human growth, development, aging, and death. Kidney Yang is like a fire hidden in water; Zhang Jingyue said, “The Yang of the five organs cannot be generated without this.” Once this Yang is depleted, symptoms such as soreness and weakness in the lower back and knees, cold limbs, tightness in the lower abdomen, difficulty urinating, or residual dribbling, incontinence, edema, phlegm retention, thirst, and cough can often be seen. Kidney Yang relies on Kidney Yin as its material foundation, and when clinically supplementing and warming kidney Yang herbs, they are often combined with herbs that nourish Kidney Yin, following the principle of “those who are good at supplementing Yang seek Yang within Yin.” Otherwise, it can easily deplete Kidney Yin. Kidney Yin is the material foundation for life existence, and “the Yin of the five organs cannot nourish without this.” Six-Ingredient Rehmannia Pill contains Shudihuang and Zexie, Shan Yao and Fuling, and Yuzhu and Danpi, three tonifying and three draining herbs, which clearly maintain the balance of Yin and Yang. Excessive attacking herbs can be harmful, and excessive tonifying herbs can also be harmful! Understanding the role of Danpi in the formula as clearing hidden heat from the blood contradicts the original intention of the formula! Moreover, if there is hidden heat in the blood, it must be accompanied by symptoms of hidden heat. Each syndrome’s change must be accompanied by corresponding clinical symptoms. For warm diseases with hidden pathogens in the interior, it is advisable to clear and dispel; for warm diseases with heat pathogens stagnating in the lungs, it is advisable to use dispersing methods; for rashes that have not yet dispersed, it can also be used based on the cause; for warm diseases with heat entering the Ying level, Ye’s theory states: it is especially advisable to “disperse heat and transform Qi,” etc., all of which are guided by the situation, allowing the evil to have an exit. However, Yang deficiency leads to cold; how can there be heat pathogens? There can be mixed cold and heat, upper heat and lower cold… Yang deficiency with hidden heat is incomprehensible. The “warming Yang and dispelling heat method” dispels heat while benefiting Yang deficiency, and warming Yang increases heat! Only in cases of mixed cold and heat syndrome can both cold and heat be used, and the amounts of cold and heat must be distinguished to determine the dosage of both sides, achieving a balance as the goal.
Published by/He Guangming