Heat and the 4 Levels

Heat is an extremely common pattern in practice and it is therefore very important that we understand its aetiology, pathology, diagnosis, patterns and treatment. To give an idea of the frequency of Heat in practice, in my clinic in England in a database of over 2500 patients, 46% had a red tongue and 32 a pale tongue. In other countries with a warmer climate, I suspect the incidence of red tongue (and Heat) would be even higher. One reason why Heat is so common is that it is often the consequence of emotional stress, but this will be discussed later.

I decided to write something on Heat also because I found that even in Chinese books, the subject was not discussed properly and the terminology used was often not precise as they sometimes used the terms “Heat” and “Fire” interchangeably and they are not.

The discussion of Heat will be structured under the following headings:

Aetiology of Heat
Full Heat
Heat from Qi stagnation
Empty Heat
Distinction between Heat and Fire
External Heat
Latent Heat
Yin Fire


Aetiology of Heat

First of all, when we talk about the aetiology of Heat, we mean Full Heat (or Wind-Heat), not Empty Heat. This is because Empty Heat derives from Yin deficiency, so the aetiological factors that lead to Yin deficiency eventually lead to Empty Heat. In my experience, the most important aetiological factor leading to Yin deficiency is overwork: I do not mean excessive physical work but ‘overwork’ in the sense of working long hours without adequate rest, leaving home in the early morning and returning in the late evening for years on end. This life habit is also combined with stressful situations at work (or the commute) and irregular eating. All these factors combine to deplete Yin of the Stomach, Liver and Kidneys. Yin deficiency eventually leads to Empty Heat.

In my experience, there are three major causes of Full Heat: emotional stress, diet and an external pathogenic factor that penetrates into the Interior.

a) Emotional stress

All emotions eventually lead to Heat and that is why a red tip of the tongue is so common and also such a reliable indicator of emotional stress.

Initially, emotions affect only Qi and do not cause Heat directly: they cause either Qi stagnation or Qi deficiency or both. Thus, initially (and I stress initially), all emotions affect Qi only. Emotions such as worry, pensiveness, anger, fear, shame and guilt cause Qi stagnation; emotions such as sadness and grief cause Qi deficiency. However, also the emotions that cause Qi deficiency, often also cause a concomitant Qi deficiency. For example, sadness and grief weaken Lung-Qi: a weak Lung-Qi in the chest leads to some impairment in the circulation of Qi in the chest and therefore to some Qi stagnation as well.

After some time (and this may not be very long, e.g. weeks), Qi stagnation leads to Heat. As all emotions affect the Heart, the tip of the tongue becomes red. All emotions affect the Heart because the Heart houses the Shen and the Shen is the one that recognizes and feels the emotions. When we say ‘I feel angry’ who is that ‘I’? It is the Shen of the Heart. Anger will affect the Liver automatically but it is the Heart who ‘feels’ it.


This picture shows a good example of a red tip. The tip is bright-red (a different shade than the rest of the tongue body) and it is also swollen.

b) Diet

First of all, it is important to realize that when we say ‘diet’ in the context of aetiology of disease, that includes drinks. Indeed, excessive consumption of alcohol is probably the main source of heat in a diet. Any type of alcohol is hot and the higher the alcohol content, the hotter the drink. Thus, vodka is hotter than wine.

Apart from alcohol, all meats are hot (or warm) but especially lamb and beef: therefore excessive consumption of these two types of meat is also a source of heat. All wild meats are also hot, e.g. pheasant, grouse, rabbit, deer, elk, reindeer, wild boar, etc.

Apart from the above foods, most spices are also a source of heat, e.g. mace, ginger, curry, cumin, chilly, etc.

c) External pathogenic factor penetrating into the Interior

An external pathogenic factor frequently penetrates into the Interior if it is not expelled at the Exterior stage. When this happens, every external pathogenic factor has the tendency to change into Heat: thus, even Wind-Cold can turn into Heat once in the Interior. Indeed, this is exactly what happens in the 6 Stages patterns from the Shang Han Lun: the Tai Yang stage is characterized by Wind-Cold and this can transform into the Yang Ming stage of Stomach-Heat. Of course, external Wind-Heat and Summer-Heat have even a stronger tendency to turn into Interior Heat.

I find this aetiology of internal Full Heat actually quite common, especially for Lung-Heat. Many people suffer an invasion of Wind-Heat: if the Wind-Heat is not expelled at the exterior stage, it may go into the Interior and turn into Lung-Heat or Lung Phlegm-Heat. This is more likely to happen when antibiotics are resorted to. This is called Residual Heat, i.e. Heat left over from an invasion of Wind-Heat. It is very common in children.

This type of Lung-Heat is often symptomless but the tongue shows it very clearly with a redness or red points in the front third. The tongue below has red points in the front third (Lung area).


Clinical Manifestations of Heat

The general clinical manifestations of Full Heat are a feeling of heat, red face, thirst, anxiety, dry stools, scanty-dark urine, a Rapid-Full pulse, and a red tongue with yellow coating.

Beyond these, it is difficult to generalize as other manifestations will depend on the organ affected. Note that some of these symptoms and signs may be caused by Empty Heat too and therefore tongue and pulse are important to differentiate Full from Empty Heat: in Empty Heat the tongue is without coating and red and the pulse must have some Empty quality and especially Floating-Empty.

Aside from the above clinical manifestations, there are other diagnostic guides which indicate Heat. Any raised, red skin eruption which feels hot, indicates Heat. For example, acute urticaria normally takes this form. As for pain, any burning sensation indicates Heat. For example, the burning sensation of cystitis, or a burning feeling in the stomach. Any loss of blood with large quantities of dark-red blood, indicates Heat in the Blood. As far as the mind is concerned, any condition of extreme restlessness or manic behaviour, indicates Heat in the Heart.

a) Lung-Heat

Cough, slight breathlessness, feeling of heat, slight chest ache, thirst, red face.

Tongue: Red in the front third with yellow coating.
Pulse: Overflowing on the right cun, possibly slightly rapid.

LU-5 Chize, LU-10 Yuji, LU-7 Lieque, L.I.-11 Quchi, LU-1 Zhongfu, BL-13 Feishu.

Qing Bai San Clearing White Powder

b) Stomach-Heat

Burning epigastric pain, thirst, acid reflux, nausea, vomiting soon after eating, excessive hunger, foul breath, a feeling of heat.

Tongue: red in the centre with a yellow coating.
Pulse: Rapid and slightly Overflowing on the Right-Middle position.

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.

Bai Hu Tang White Tiger Decoction.
Yu Nu Jian Jade Woman Decoction.
Qing Wei San Clearing the Stomach Powder.

c) Liver-Heat

Irritability, propensity to outbursts of anger, temporal headache, dizziness, red face and eyes, thirst, bitter taste.

Tongue: Red with redder sides and dry-yellow coating.
Pulse: Wiry-Rapid.Note: this pattern is usually described as ‘Liver-Fire’ in Chinese books. Liver-Fire is a more intense form of Liver-Heat. I will discuss the difference between Heat and Fire later. The clinical manifestations listed above are those of Liver-Heat.

LIV-2 Xingjian, LIV-3 Taichong, G.B.-20 Fengchi, Taiyang extra point, G.B.-13 Benshen, Du-24 Shenting. In case of headaches: G.B.-1 Tongziliao, G.B.-9 Tianchong, G.B.-8 Shuaigu, G.B.-6 Xuanli.

Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction.
Dang Gui Long Hui Tang Angelica-Gentiana-Aloe Decoction.

Please note that these prescriptions are for Liver-Fire. Therefore, for Liver-Heat, I would reduce the dosage of the bitter-cold herbs such as Long Dan Cao Radix Gentianae scabrae and Huang Qin Radix Scutellariae.

d) Heart-Heat

Palpitations, thirst, mental restlessness, insomnia, feeling of heat, red face.

Tongue: Red with redder tip and yellow coating. In more severe cases the tip could also be swollen.
Pulse: Overflowing-Rapid especially on the Left-Front position.

Note: this pattern is usually described as ‘Heart-Fire’ in Chinese books. Heart-Fire is a more intense form of Heart-Heat. I will discuss the difference between Heat and Fire later. The clinical manifestations listed above are those of Heart-Heat.

HE-9 Shaochong, HE-8 Shaofu, HE-7 Shenmen, Ren-15 Jiuwei, Du-24 Shenting, Du-19 Houding.

Dao Chi San Draining Redness Powder.

Please note that this prescription is for Heart-Fire. Therefore, for Heart-Heat, I would reduce the dosage of the bitter-cold herbs such as Huang Lian Radix Coptis.

e) Spleen-Heat

The Spleen can have Heat! Of course, it is much more prone to Cold but the pattern of Spleen-Heat does exist and it is usually combined with that of Stomach-Heat. The clinical manifestations are listed below.

Burning epigastric and/or abdominal pain, excessive hunger, red tip of the nose, dry lips, thirst, dry stools, feeling of heat, yellow complexion.

Tongue: red on the sides, middle section, with dry-yellow coating.
Pulse: Overflowing (especially on the right guan position) and slightly rapid.

SP-2 Dadu, L.I.-11 Quchi, ST-44 Neiting, Ren-11 Jianli.

Xie Huang San Draining the Yellow Powder.


This tongue is red on the sides in the middle section (Middle Burner): this is more apparent on the right side. The sides of the tongue usually reflect the Liver but when they present a pathological aspect only in the middle section of the sides (Middle Burner), they reflect a pathology of the Spleen, in this case Heat because they are red.