FEELING OF COLD, FEELING OF HEAT AND FEVER

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Chapter 43

imageFEELING OF COLD, FEELING OF HEAT AND FEVER

WHY WE ASK

We should always ask all our patients about feelings of cold or heat; the clinical significance, however, varies in internal and external conditions. In internal conditions (which constitute the overwhelming majority of most practices) the distinction between feelings of cold and feelings of heat simply tells us about the Cold or Hot nature of the prevailing pattern.

In external conditions (e.g. when a patient presents with an acute cold or influenza) questions about feelings of cold or heat are needed primarily to establish, first of all, whether it is indeed an external condition and whether the pathogenic factor is on the Exterior or Interior.

The patient’s cold or hot feeling should never be discounted, even when it contradicts the tongue or pulse, or both. For example, a patient may have a clearly Red tongue but always feel cold: although the sign of a Red tongue is very important, we should not discount the cold feeling and should investigate further to find the cause of this discrepancy.

WHEN WE ASK

As mentioned above, questions about feelings of cold and heat should always be asked routinely in all patients.

In internal conditions, questions about a patient’s feeling cold or hot are often asked towards the end of the consultation to confirm the existence of a Cold or Hot pattern. Often questions about feelings of cold or heat also help us to detect the constitutional tendency of a patient to Cold or Hot conditions. For example, patients may not have significant symptoms of Yang deficiency and Cold but, on asking, may say that they always feel cold, need to wear more clothes than other people, etc.; this symptom should never be discounted because it indicates an underlying tendency to Yang deficiency and Cold patterns.

In external conditions, questions about feelings of cold and heat are crucial and should always be asked in detail to establish whether the pathogenic factor has gone into the Interior or whether it is still on the Exterior. If we see a patient every day in the course of an acute, exterior condition, as we should, we should carefully ask about feelings of cold and heat every day to establish the exterior or interior nature of the pattern.

HOW WE ASK

In China, the questions about feeling of cold and feeling of heat coincide almost exactly with the terminology of Chinese medicine, which makes it very easy for Chinese doctors. With Western patients, it is a little more difficult and we need to make sure that we ask patients about feelings of cold and heat in a way that they can readily understand.

In interior conditions, for feelings of cold we should simply ask, ‘Do you feel cold in general?’, ‘Do you have a tendency to feel cold?’ or ‘Do you notice that you feel colder than other people?’. For feelings of heat we should ask questions such as, ‘Would you say you feel hot in general?’, ‘Do you sometimes feel unusually hot?’ or ‘Do you want to open the window when everyone else wants it closed?’ If patients answer affirmatively to one of the above questions about feelings of heat, then we should go on to ask more specifically about when they tend to feel hot in order to establish whether it is Full- or Empty-Heat. We therefore ask questions such as ‘Do you tend to feel hotter in the afternoon or evening?’

Terminology

Before discussing the various causes of feeling cold, or feeling of hot and feverish, I would like to clarify somepoints regarding terminology, particularly with regard to fever.

The cause of disease in feeling of cold, feeling of heat or fever may be external (e.g. external Wind) or internal; thus, the cause of disease simply refers to the origin of the pathogenic factor.

The pattern (or syndrome) refers to the location of the pathogenic factor, which may be on the Interior or Exterior: this is decided not according to the origin of the pathogenic factor but on the basis of the clinical manifestations. In other words, an external cause of disease (e.g. external Wind) may cause both an exterior pattern and an interior pattern (Fig 43.1).

An external cause of disease is, for example, external Wind: this causes initially an exterior pattern; if the pathogenic factor is not expelled, however, it goes on to cause an interior pattern. An internal cause of disease (such as Liver-Fire) causes an interior pattern by definition.

With regard to fever, we should not confuse a fever from an external cause with an exterior fever: an external cause may cause an exterior fever initially and later, if the pathogenic factor is not expelled, it will cause an interior fever.

FEELING OF COLD

Symptoms and Signs, Chapter 82

There are four different degrees of ‘cold feeling’ which apply both to interior and exterior conditions. In ascending order of severity with their clinical significance these are:

Aversion to wind means that the patient has goose pimples, dislikes going out in the wind and wants to stay indoors.

Fear of cold means that the patient feels quite cold, wants to stay indoors and close to a source of heat, and wants to cover up.

Aversion to cold means that the patient feels very cold, wants to stay indoors and likes to wrap up in bed with many blankets.

Shivers means that the patient feels extremely cold, shivers and wants to be covered up in bed under a heap of blankets.

The symptoms of feeling cold should be clearly differentiated between interior and exterior patterns.

Feeling of cold in interior conditions

In internal diseases, questions about feeling cold serve to establish the Cold nature of the presenting patterns. Cold may be Full or Empty. Whether it is Full or Empty, it always manifests with a feeling of cold.

If a person feels easily cold and experiences cold limbs, this clearly indicates either Full-Cold or Empty- Cold deriving from Yang deficiency. In patients with chronic diseases, Empty-Cold is more common than Full-Cold.

Full-Cold is characterized by an intense feeling of cold and shivers; the body also feels cold to the touch. Various parts of the body may feel particularly cold depending on the location of the Cold: if it is in the Stomach the limbs and epigastrium will feel cold, if in the Intestines the legs and lower abdomen are cold, if in the Uterus the lower abdomen feels cold. Full-Cold has usually a sudden onset and may last only a few months at the most because Cold will inevitably injure Yang and lead to Yang deficiency and therefore Empty-Cold.

Box 43.1 summarizes the clinical manifestations of Full-Cold.

BOX 43.1   CLINICAL MANIFESTATIONS OF FULL-COLD

Yang deficiency of any organ may cause a cold feeling or cold limbs, or both. It could be due especiallyto a deficiency of Yang of the Heart, Lungs, Spleen, Kidneys and Stomach. The cold feeling is both subjective and objective, that is, the patient feels easily and frequently cold and the limbs or other parts of the body will feel cold to the touch.

A deficiency of Yang of the Lungs or Heart, or both, will manifest especially with cold hands (Fig 43.2), a deficiency of Spleen-Yang with cold limbs and abdomen (Fig 43.3) and that of Kidney-Yang especially with cold legs, knees, feet and back (Fig 43.4). A deficiency of Stomach-Yang will manifest with cold epigastrium and cold limbs in a similar way to Spleen-Yang deficiency (Fig 43.3).

Box 43.2 summarizes the clinical manifestations of Empty-Cold.

BOX 43.2   CLINICAL MANIFESTATIONS OF EMPTY-COLD

There are however, other causes of cold limbs (as opposed to a general cold feeling). One is Qi stagnation: when Qi stagnates it may fail to reach the hands and feet and these become cold (Fig 43.5). This is called the ‘Four Rebellious Syndrome’, in which the ‘Four Rebellious’ indicate cold hands and feet; the famous formula Si Ni San Four Rebellious Powder is used for this pattern. An important difference between cold in the limbs due to Yang deficiency and that due to Qi stagnation is that in the former case the whole limb will be cold whereas in the latter case only the hands and feet, and especially the fingers, are cold.

Besides this, cold limbs may also derive in women from Blood deficiency; this is due to the deficient Blood not reaching the extremities. In cases of Heart-Blood deficiency only the hands and chest will be cold (Fig 43.6), whereas in cases of Liver-Blood deficiency the feet will be cold (Fig 43.7).

We should bear in mind that, even if patients feel cold in general, they may have a feeling of heat in a specific part of their body, (e.g the face) and we should therefore always remember to ask about specific parts of the body after we have asked about the generalfeeling. A very common example of this, especially in women, is a general cold feeling with occasional episodes of feeling hot in the face.

When patients feels cold in general, remember to ask then whether they feel hot in any particular part of the body.

Box 43.3 summarizes the patterns underlying a cold feeling and cold limbs in interior conditions.

BOX 43.3   FEELING OF COLD IN INTERIOR CONDITIONS

Feeling of cold in exterior conditions

External invasions

In external invasions, a feeling of cold or shivers serves to establish whether the pathogenic factor is in the Exterior or in the Interior. In fact, when the pathogenic factor is on the Exterior, the patient feels cold, shivers and dislikes the idea of going out (often referred to as ‘aversion to cold’). The cold feeling may or may not be accompanied by an actual fever, but it will be associated with heat in the skin, that is, the patient feels cold and shivers but his or her skin feels hot to the touch.

The areas that are usually touched to gauge this are the dorsum of the hands and the forehead. It should be stressed that the feeling of cold and fever (or body feeling hot to the touch) are simultaneous and not alternating: thus, if a patient feels cold in the morning without a fever and without body feeling hot to the touch and has a fever in the evening, this would correspond to the Lesser-Yang syndrome and would not constitute the beginning stage of an invasion of Wind. Figure 43.8 differentiates the manifestations of cold feeling in exterior and interior conditions.

In exterior syndromes, the presence of a cold feeling and shivering is a determining factor in diagnosing that the pathogenic factor is still on the Exterior and that the pattern is therefore an ‘Exterior’ one. As soon as the cold feeling disappears and the patient feels hot, this is a certain sign that the pathogenic factor is in the Interior and it has transformed into Heat. One can see these signs very clearly in small children: when the pathogenic factor is on the Exterior, the child will tend to go to bed and cover himself or herself with lots of blankets. As the pathogenic factor enters the Interior (usually changing into Heat), the child throws the blankets off.

Box 43.4 summarizes the clinical manifestations of interior and exterior pathogenic factors.

BOX 43.4   INTERIOR VERSUS EXTERIOR PATHOGENIC FACTOR

How to distinguish between external and internal causes of feeling of cold

The distinction between a cold feeling from an invasion of external Wind and a cold feeling from internal Cold (which may be Full or Empty) is fairly easy as the accompanying symptoms are quite obvious. During an external invasion with the pathogenic factor still on the Exterior, the patient feels cold, dislikes the idea of going out, shivers, and may have a fever, and the dorsum of the hand feels hot; in addition, there will be sneezing, a cough, a nasal discharge, a sore throat, a headache, body aches and a Floating pulse.

When the patient suffers from interior Cold, there are none of the above symptoms. Another distinction between a cold feeling in exterior syndromes and one in interior syndromes is that in the former case the cold feeling is not alleviated by covering oneself, while in the latter case it is. In fact patients who feel cold and shiver from an invasion of exterior Wind will want to go to bed and cover up with blankets, but this will not alleviate the cold feeling and shivering. If a patient suffers from internal Cold, this will be alleviated by covering oneself. Table 43.1 summarizes the differentiation between external and internal Cold.

Table 43.1

Differentiation between external and internal Cold

External invasion of Cold Internal Cold
Feels cold, shivers, dislikes going out, fever, sneezing, cough, sore throat, nasal discharge Feels cold, none of the symptoms associated with an external invasion is present
Cold feeling not alleviated by wrapping up in clothes and blankets Cold feeling is alleviated by wrapping up warm

Differentiation of pathology of a feeling of cold from external or internal causes

The pathogenesis of a cold feeling in exterior patterns is different from that in interior patterns. In exterior patterns, the cold feeling is due to the fact that the external Wind obstructs the space between skin and muscles where the Defensive Qi circulates; as Defensive Qi warms the muscles, its obstruction by Wind causes the patient to feel cold and shiver (even if the pathogenic factor is Wind-Heat). Thus, Defensive Qi is not necessarily weak but only obstructed in the space between skin and muscles.

In interior patterns, the cold feeling is usually due either to a Yang deficiency and a failure of Yang Qi to warm the muscles and limbs (in case of Empty-Cold) or to Cold obstructing the flow of Yang Qi to the muscles and limbs (in case of Full-Cold).

SIMULTANEOUS FEELING OF COLD AND FEVER IN EXTERIOR CONDITIONS

First of all, we should define ‘fever’. ‘Fever’ does not indicate an actual raised temperature (as measured by a thermometer) but an objective emanation of heat from the patient’s body felt on palpation (especially on the forehead and dorsum of hands). This is discussed in more detail below.

A simultaneous feeling of cold and fever indicates the invasion of an exterior pathogenic factor and that this factor is still on the Exterior. The simultaneous presence of a cold feeling or shivers with a fever, or both, usually indicates an acute invasion of Wind and it denotes that the pathogenic factor is still on the Exterior: as long as there is a feeling of cold the pathogenic factor is on the Exterior. The clinical situations when the pathogenic factor is on the Exterior are described in the Greater-Yang pattern within the Six Stages from the ‘Discussion of Cold-induced Diseases’ (Shang Han Lun) and the Defensive-Qi level within the Four Levels described by the School of Warm Diseases (Wen Bing) of the Qing dynasty (see Part 6). As mentioned above, it is important to stress that the feeling of cold and fever (or body feeling hot to the touch) are simultaneous and not alternating (Fig 43.9).

Although it is the simultaneous occurrence of cold feeling and fever that defines an exterior pattern due to invasion of exterior Wind, I shall discuss the pathology of cold feeling and fever in more detail separately.

The aetiology and pathology of Wind-Heat can be used as a blueprint to explain the aetiology and pathology of Summer-Heat, Damp-Heat and Dry-Heat.

The pathogenic factors discussed are:

Before discussing the above pathogenic factors, we should first discuss the pathology and clinical manifestation of ‘feeling of cold’ and ‘fever’.

Cold feeling (‘aversion to cold’) in exterior patterns

In exterior patterns, as explained above, the cold feeling is due to the fact that the external Wind obstructs the space between the skin and muscles (called Cou Li) where the Defensive Qi circulates; and Defensive Qi is not necessarily weak but only obstructed. Also, since the cold feeling is caused by the obstruction of Defensive Qi by Wind (whether it is Wind-Cold or Wind-Heat) in the space between the skin and muscles, the cold feeling and shivering are present also in invasions of Wind-Heat, albeit to a lesser degree than in Wind-Cold.

As mentioned above, there are four different degrees of ‘cold feeling’ in Exterior conditions: ‘aversion to wind’, ‘fear of cold’, ‘aversion to cold’ and ‘shivers’. The clinical significance of these four degrees of feeling of cold in the context of exterior invasions is listed in Box 43.5.

BOX 43.5   DEGREES OF FEELING COLD

Thus, generally speaking, there are three aspects to the ‘cold feeling’ in invasions of exterior Wind: the patient feels cold, has ‘waves’ of shivers and is reluctant to go out and wants to stay indoors near sources of heat. Except in mild cases, the cold feeling is not relieved by covering oneself.

In conclusion, a feeling of cold in exterior invasions is due to the obstruction of Defensive Qi in the space between skin and muscles and it indicates that the pathogenic factor is on the Exterior; as soon as the feeling of cold goes, the pathogenic factor is in the Interior.

Fever in exterior patterns

As for ‘fever’ it is important to understand that the Chinese term Fa Shao does not necessarily indicate what we mean by fever. ‘Fever’ is a sign in modern Western medicine, not in old Chinese medicine. In old China, there were obviously no thermometers and the symptom Fa Shao described in the old texts does not necessarily mean that the patient has an actual fever. It literally means ‘emitting burning heat’ and it indicates that the patient’s body feels hot, in severe cases almost burning to the touch; the areas touched are usually the forehead and especially the dorsum of the hands (as opposed to the palms, which tend to reflect more Empty-Heat).

In fact, it is a characteristic of Fa Shao (so-called ‘fever’) in the exterior stage of invasions of Wind that the dorsum of the hands feels hot compared with the palms and the upper back feels hot compared with the chest.1 This objective hot feeling of the patient’s body may or may not be accompanied by an actual fever. Indeed, in fevers of internal origin, there may even be cases when the patient has an actual low-grade fever and the body feels cold to the touch.

Thus, it is important to remember that, in the context of exterior conditions from invasions of Wind, ‘fever’ indicates the objective hot feeling of the patient’s body (with or without an actual raised body temperature) and not a feeling of heat; in fact, as described above, the patient feels cold.

‘Fever’ does not necessarily indicate a raised temperature: it indicates that the patient’s forehead and dorsum of hands feel hot to the touch. The patient may or may not have an actual fever.

Pathology of fever

The fever, or hot feeling of the body in external invasions of Wind, is due to the struggle between the body’s Qi (Upright Qi) and the external pathogenic factor. Thus, the strength of the fever (or hot feeling of the body) reflects the intensity of this struggle; this depends on the relative strengths of the external pathogenic factor and the Upright Qi. The stronger the external pathogenic factor, the higher is the fever (or hot feeling of the body); likewise, the stronger the Upright Qi, the higher is the fever (or hot feeling of the body). Thus the fever will be highest when both the external pathogenic factor and the Upright Qi are strong.

The relative strength of the pathogenic factor and the Upright Qi is only one factor which determines the intensity of the fever (or hot feeling of the body). Another is simply the constitution of a person: a person with a Yang constitution (i.e. with predominance of Yang) will be more prone to a higher fever (or hot feeling of the body).

The intensity of fever in exterior conditions is related to the struggle between the Upright Qi and the external pathogenic factor and has nothing to do with whether the pathogenic factor is Wind-Cold or Wind-Heat.

Wind-Cold and Wind-Heat

Wind-Cold: differentiation between ‘Attack of Wind’ and ‘Attack of Cold’

So far we have talked about Wind-Cold in general but the ‘Discussion of Cold-induced Diseases’ differentiates between two types of Wind-Cold invasions: one with prevalence of Wind, called ‘Attack of Wind’, and the other with prevalence of Cold, called ‘Attack of Cold’. The Attack of Wind is described in Clause 2 of the ‘Discussion of Cold-induced Diseases’: ‘The Greater-Yang pattern with fever, sweating, aversion to wind and a Floating and Slowed-down pulse is called Attack of Wind’.2 It may seem strange that the pulse is Slowed-down in this pattern as Wind is a Yang pathogenic factor that moves and opens. However, it is also true that Wind may cause stiffness (as in occipital stiffness in Wind-Cold invasions), rigidity and paralysis; thus it is quite possible for the Attack of Wind of external Wind-Cold to cause a Slowed-down pulse (which is less slow than the Slow pulse). The commentary to Clause 2 confirms that Huan in this case means a ‘moderate and slow (Chi) pulse’.3

Clause 3 describes the Attack of Cold: ‘The Greater-Yang pattern with fever or no fever, aversion to cold, body aches, retching and Tight pulse on both Yin and Yang, is called Attack of Cold’.4

In Attack of Wind, the patient’s Nutritive Qi is more deficient than in the Attack of Cold and this causes a slight sweating. Other symptoms are tabulated in Table 43.3.

Apart from Wind-Heat and Wind-Cold, simultaneous shivers and fever may also occur with invasions of Summer-Heat, Damp-Heat and Dry-Heat.

ALTERNATING FEELING OF COLD AND FEELING OF HEAT

An alternating feeling of cold and feeling of heat (or fever) should not be confused with the simultaneous feeling of cold and fever which characterizes invasions of external Wind. There are two main differences. First, in alternating feeling of cold and feeling of heat, the feeling of heat is a subjective feeling of the patient, whereas in the simultaneous aversion to cold and fever of external invasions the feeling of heat is an objective feeling of heat on palpation of the patient’s forehead and hands. Secondly, in alternating feeling of cold and feeling of heat, the cold and hot sensations alternate whereas in aversion to cold and fever, they are simultaneous.

Alternating feeling of cold and feeling of heat occurs also in external invasions, but only those affecting the Lesser-Yang channels (whereas aversion to cold and fever occurs in external patterns affecting the Greater-Yang channels). This symptom is a chief symptom of the Lesser-Yang pattern within the Six Stages (Chapter 105) or of the Gall-Bladder Heat pattern within the Four Levels (Chapter 104). The latter is also a Lesser-Yang-type of pattern but with the prevalence of heat rather than cold. This is reflected in the patient’s sensations in that the feeling of heat is predominant over the feeling of cold.

Case history 43.1 illustrates a pattern causing alternating feeling of heat and feeling of cold.

Case history 43.1

An 18-year-old girl complained of an acute illness manifesting with alternation of shivers and feeling of heat, swollen glands, sore throat, headache, lethargy and a feeling of heaviness of the head. These symptoms had started 3 weeks before the consultation. Her tongue was Red with red points in the front with a thin yellow coating. Her pulse was Floating in general, especially on both Front positions and slightly Slippery on the right side.

Diagnosis:

This is a very clear case of acute invasion of Wind-Damp-Heat still at the exterior level at the time of consultation. It is still at the exterior level because she still experiences shivers. Together with the typical symptoms of Wind-Heat, there is also acute, exterior Dampness manifesting with swollen glands, a feeling of heaviness of the head and the Slippery quality on the right side of the pulse.

FEELING OF HEAT FROM INTERNAL CAUSES

A subjective feeling of heat may be caused by Full-Heat or Empty-Heat of any organ. In Full-Heat, the feeling of heat is somewhat more intense than in Empty-Heat; another difference is that in Empty-Heat, the feeling of heat tends to be more marked in the afternoon or evening. Also, Empty-Heat is characterized by a feeling of heat especially in the Yin areas of the body, and particularly in the chest, palms and soles. Of course, the differentiation between Full-Heat and Empty-Heat is done on the basis of other manifestations such as thirst, complexion and most of all the tongue, which will be Red with a coating in Full-Heat and Red without coating in Empty-Heat. The main differentiating manifestations of Full-Heat and Empty-Heat are shown in Box 43.7.

BOX 43.7   DIFFERENTIATION BETWEEN FULL-HEAT AND EMPTY-HEAT

With Full-Heat, the organs that are most often involved are the Liver, Heart, Stomach and Lungs; with Empty-Heat, the organs that are most often involved are the Kidneys, Heart, Stomach and Lungs.

We should bear in mind that, in some cases, a person may feel hot in general but simultaneously experience cold feet, for example. Therefore, when a patient replies affirmatively to the question ‘Do you have a tendency to feel hot in general?’, our questioning should not stop there; rather it should continue in order to ascertain whether there is any cold feeling in any particular parts of the body. For a discussion on the clinical significance of simultaneous (and contradictory) hot and cold feelings in internal conditions, see below.

When a patient feels hot in general, remember to ask about any possible cold feeling in a particular part of the body (and vice versa).

INTERIOR FEVER

Symptoms and Signs, Chapter 82

By ‘fever’ is meant the situation when the patient has a fever but no simultaneous cold feeling or shivers; thus, we are now discussing interior fevers, which, it should be remembered, may be of external or internal origin. An interior fever of external origin is one caused by an exterior pathogenic factor (such as Wind-Heat, Wind-Cold or Damp-Heat) which has penetrated into the Interior and caused a fever; an interior fever of internal origin stems from an internal disharmony such as interior Heat, Yin deficiency, Qi or Blood deficiency and Blood stasis (Figs 43.10 and 43.11).

In some of the patterns discussed, there may not be an actual fever but only a feeling of heat: the pathology and pathogenesis of interior fever or feeling of heat is the same. Generally speaking, acute fevers are characterized by an actual fever, (i.e. raised body temperature), whereas chronic ‘fevers’ may be characterized simply by a feeling of heat without a rise in body temperature. Thus, contrary to the situation in exterior syndromes when ‘fever’ indicates an objective hot feeling of the body, in chronic interior syndromes with fever of internal origin, ‘fever’ may indicate a subjective feeling of heat.

There are three degrees of interior fever (or hot body sensation); these are listed in Box 43.8.

BOX 43.8   DEGREES OF INTERIOR FEVER

Acute fever

When discussing fevers of internal origin, it is important to differentiate between acute and chronic fever. Acute interior fevers usually develop from the acute stage of an invasion of external Wind: both Wind-Cold and Wind-Heat may lead to an interior fever. Thus, the fever discussed here is primarily an acute fever deriving from external causes but at the interior stage. In such acute fevers the identification of patterns according to the Four Levels provides the best framework of interpretation and is clinically more relevant than the identification of patterns according to the Six Stages. However, there may be other acute interior fevers that are of internal origin, for example from Damp-Heat in the Liver and Gall-Bladder (febrile episode of cholecystitis) , or Damp-Heat in the Bladder (cystitis with fever) (Fig 43.12).

The Four Levels

The Four Levels patterns are discussed in Chapter 104. Within the Four Levels, the Defensive-Qi level is the only Exterior one and therefore there is simultaneous fever and shivering with a cold feeling. At the other three levels (Qi, Nutritive Qi and Blood), Heat is in the Interior and the fever is interior. The identification of patterns according to the Four Levels describes the symptomatology of invasions of Wind-Heat. However, fever, to a lesser degree, may be present also in invasions of Wind-Cold, for which the identification of patterns according to the Six Stages is used.

The three interior levels, Qi, Nutritive-Qi and Blood levels, within the Four Levels represent three different depths of penetration of the Heat, the Qi being the most superficial (or rather least deep) and Blood the deepest. At the Qi level, the Upright Qi is still strong and it engages in a fight with the pathogenic factors leading to a high fever and acute, strong manifestations characterized by restlessness, high fever, profuse sweating, etc. At the Nutritive-Qi and Blood levels, the Upright Qi is injured, the Heat has injured the fluids and there is Yin deficiency. These levels are usually characterized by a fever at night and by the Mind being affected, causing delirium, severe mental restlessness and, in severe cases, coma. At the Blood level, internal Wind can develop and bleeding occurs. At the Blood level and, to a lesser extent, at the Nutritive-Qi level, there are maculae.

The tongue is an important and objective sign to differentiate the Qi level from the Nutritive-Qi level andthe Blood levels: at the Qi level the tongue is Red and has a thick coating, whereas at the Nutritive-Qi and Blood levels the tongue is dark Red and has no coating.

The clinical manifestation of the Four Levels in fever is summarized in Box 43.9.

BOX 43.9   THE FOUR LEVELS IN A NUTSHELL

The clinical manifestations of the Defensive-Qi level, which causes a simultaneous feeling of cold and fever, have already been discussed above. The detailed clinical manifestations of the main patterns appearing at the Qi, Nutritive-Qi and Blood levels are described below.

Chronic fever

Chronic interior fevers may be due to Deficiency or Excess. Yin deficiency is a common and obvious cause of chronic interior fever, but Qi and Blood deficiency may also cause it. Among the Full causes of internal fever are stagnant Liver-Qi turned into Heat and Blood stasis. Thus, there are five main causes of chronic interior fever:

Empty-Heat from Yin deficiency

Clinical manifestations Low-grade fever or feeling of heat in the afternoon or evening, five-palm heat, malar flush, thirst with desire to drink in small sips, dry mouth and throat at night, mental restlessness, night sweating, insomnia, dream-disturbed sleep, dry stools, dark-scanty urination, a thin red line on the inside of the lower eyelid, Red tongue without coating and with cracks, and Fine-Rapid pulse.

These are the general symptoms of Empty-Heat deriving from Yin deficiency; they may arise from the Lungs, Heart, Stomach, Spleen, Liver and Kidneys. Other accompanying symptoms (or more accentuated symptoms) according to the organ involved are listed in Box 43.10.

BOX 43.10   CLINICAL MANIFESTATIONS OF EMPTY-HEAT FROM YIN DEFICIENCY

Qi deficiency

Clinical manifestations Low-grade fever or feeling of heat that is aggravated by overwork, dizziness, tiredness, depression, muscular weakness, spontaneous sweating, shortness of breath, loose stools, poor appetite, weak voice, Pale tongue and Weak or Empty pulse.

This fever is caused by a severe deficiency of Qi, usually of the Spleen, Stomach and Lungs, and a deficiency of the Original Qi. This situation was described by Li Dong Yuan in the famous classic ‘Discussion on Stomach and Spleen’ (Pi Wei Lun) (see Bibliography). He said that overwork and irregular diet weaken the Qi of the Stomach and Spleen and the Original Qi, which resides in the Lower Field of Elixir (Dan Tian); here it shares a place with the (physiological) Minister Fire. If the Minister Fire is stirred by overwork and emotional problems, it becomes pathological, ‘displaces’ the Original Qi in the Lower Field of Elixir and it rises upwards causing a low-grade fever or a feeling of heat (Fig 43.13).

Li Dong Yuan called this pathological Minister Fire a ‘thief’ of the Original Qi; the Heat generated by the pathological Minister Fire is called ‘Yin Fire’ and it is neither Full- nor Empty-Heat, although it is more similar to the latter. Li Dong Yuan said that this Yin Fire is treated not by clearing it with bitter-cold herbs but by tonifying the Original Qi with sweet-warm herbs: as the Minister Fire and the Original Qi share the sameplace, tonifying the Original Qi will automatically displace and subdue the pathological Minister Fire.

The representative prescription to subdue Yin Fire is Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction, within which Ren Shen Radix Ginseng tonifies the Original Qi.

This condition of Yin Fire and feeling of heat deriving from Qi and Blood deficiency is very common nowadays and is frequently seen in chronic cases of ME (CFIDS, postviral fatigue syndrome) and other modern autoimmune diseases, such as lupus or rheumatoid arthritis.

FIVE-PALM HEAT

This is a feeling of heat in the palms, soles and chest, which is also sometimes called five-centre heat or five-heart heat; this may or may not be accompanied by an actual fever. It is usually accompanied by mental restlessness, night sweating and insomnia. This is frequently seen in practice; however, it may sometimes manifest only in the soles and palms, or palms and chest.

Yin deficiency of any organ may cause five-palm heat: Lungs, Heart, Liver, Spleen, Kidneys, Stomach. However, there are other, less common, possible causes of five-palm heat: these include Blood deficiency, Latent Heat in the Lesser Yin and Liver-Fire.

In Blood deficiency, the five-palm heat is experienced mainly in the afternoon and is accompanied by other symptoms of Blood deficiency. This occurs almost exclusively in women.

Latent Heat in the Lesser Yin is characterized by Heat in the Kidneys and is frequently seen in ME (postviral fatigue syndrome). The main manifestations are a low-grade fever or feeling of heat in the afternoon or evening, feeling cold in the morning, dizziness, tinnitus and night sweating.

Liver-Fire may also cause five-palm heat although not frequently; this symptom will be accompanied by other manifestations of Liver-Fire.

Box 43.11 summarizes the patterns underlying five-palm heat.

BOX 43.11   FIVE-PALM HEAT

CONTRADICTORY FEELINGS OF COLD AND HEAT IN INTERNAL CONDITIONS

Contradictory hot and cold feelings are very common especially in women and especially those over the age of 40. This is due to four possible causes:

Simultaneous deficiency of Kidney-Yin and Kidney-Yang

A simultaneous deficiency of Kidney-Yin and Kidney-Yang is very common in women over the age of 40; indeed, it is probably more the norm than the exception. Kidney-Yin and Kidney-Yang have a common root and, especially after 40, a deficiency of one often involves also a deficiency of the other, albeit in different degrees. Thus, when there is a deficiency of both Kidney-Yang and Kidney-Yin with a predominance of the latter there will be dizziness, tinnitus, night sweating, malar flush, five-palm heat and a feeling of heat, but possibly also cold feet; when there is a predominance of Kidney-Yang deficiency there will be dizziness, backache, tinnitus, frequent urination, a pronounced feeling of cold and cold feet, but possibly also a feeling of heat in the afternoon.

NOTES

1. Tao, Deng Tie. Practical Chinese Diagnosis (Shi Yong Zhong Yi Zhen Duan Xue image). Shanghai: Shanghai Science Publishing House, 1988; 90.

2. Shang Han Lun Research Group of the Nanjing College of Chinese Medicine. An Explanation of the ‘Discussion of Cold-induced Diseases’ (Shang Han Lun Yi Shi image). Shanghai: Shanghai Science Publishing House, 1980; 351.

3. Shang Han Lun Research Group of the Nanjing College of Chinese Medicine. An Explanation of the ‘Discussion of Cold-induced Diseases’ (Shang Han Lun Yi Shi image). Shanghai: Shanghai Science Publishing House, 1980; 351.

4. Shang Han Lun Research Group of the Nanjing College of Chinese Medicine. An Explanation of the ‘Discussion of Cold-induced Diseases’ (Shang Han Lun Yi Shi image). Shanghai: Shanghai Science Publishing House, 1980; 354.

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