Yīnfire and its Pathomechanism
Jason Blalack, L.Ac.
This essay was written as a springboard for further understanding, exploration, and development on the topic of yīnfire. There might be issues that are debatable, but this is my synthesis from what I have read in Chinese and my own thought processes including extensive discussions with teachers & colleagues. It represents only a snapshot in an evolving investigation. There should, though, be a clear differentiation between what are my own ideas and what I translated from the Chinese literature. Many ideas differ from what has been previously presented. Although all words and ideas, including mine, should be taken with a grain of salt, and should always be tested in the clinic, I wouldn’t have put this together if I didn’t think that it represents some value. Comments & disagreements are encouraged, and can be posted on the CHA, or sent to my email :
Yīnfire (阴火) is a term that can evoke all sorts of ideas depending on who one is talking to. Understanding the essence and clinical relevance of yīnfire, for many, has been confusing and elusive. The terminology that surrounds it is perplexing and unclear. In this paper I will explore the terms that define and surround it, look at its relationship to its suggested pathomechanism, as well as some of the controversies and modern developments. In some respect, it will be geared towards a more simplified understanding, clarifying some of the current debate. At the same time, with the exploration of some difficult issues, readers will be presented with alterative opinions to current mainstream (Western) views, which may lead to more questions. Ultimately, though, it should start to enable one to more effectively apply yīnfire to the clinic, by understanding it more thoroughly.
Yīnfire was first coined by Li Dōng Yuán in the 13th century. Its most notable usage was for it’s inclusion in the explanation of the pathomechanism for the formula bǔ zhōng yì qì tāng (Center-Supplementing Qi-Boosting Decoction) in the Píwèilùn (Treatise of the Spleen and Stomach), although, many other uses of yīnfire exist. Some advocates have praised its ability to explain modern-complicated diseases. None the less, yīnfire has never really caught on in mainstream Chinese medicine, although there are always a few people who like to utilize it. Unfortunately anyone truly interested in the topic has numerous obstacles to overcome. The primary difficulty revolves around understanding the source text, which is partly due to translational issues, its non-inclusion of any real commentary, and lack of clarity from Dōng Yuán. This is coupled with, modern-day elaborations and perspectives that respectively deviate from the original idea creating confusion for some. Therefore, I have attempted to go back to the source, in Chinese, starting from the beginning to help unravel this mystery. I have translated passages from the Nèi Jīng, Píwèilùnand articles/commentary on the subject. Furthermore, Dōng Yuán’s choice of terminology, even in Chinese, is a source of major confusion, which only seems to hinder his ideas, especially in relation to other authors.
Important terms that need to be discussed to understand yīnfire, are lesser fire (少火), vigorous fire (壮火),
ministerial fire (相火), sovereign fire (君火), heart fire (心火), and original qì (元气). Also to be discussed are concepts like the relationship between yīnfire and original qì and the phrase ‘ministerial fire is the thief of original qì’. To begin to unravel this puzzle we must first go back to Nèi Jīng (Sùwèn).
In the Nèi Jīng (Sùwèn) chapter 5 it says, “Vigorous fire makes (original) qì decrease, and lesser fire makes qì strong.” This sets the stage for a differentiation between a pathological (vigorous fire) and a physiological fire (lesser fire). It goes on to say “vigorous fire eats (original) qì, and qì will feed lesser fire.” Therefore one sees a physiological circle between qì and lesser fire. Both will feed each other. One must note that the term ‘vigorous fire’ can also be used physiologically. Therefore, one can see, even early on, there were terms that were used in different situations to mean opposite things.
The Nèi Jīng also first discusses sovereign and ministerial fire, “sovereign fire is brilliance (illumination), and ministerial fire occupies position”. This is reference to physiological function (Nèi Jīng commentary). The heart is the sovereign and sovereign fire is heart fire (physiological) (Lǐ Nán Yí). Zhu Dan Xi states that the ministerial fire promotes the function of the visceral and bowels, which is the lesser fire of vitality. Both Zhu Dan Xi and Ye Tian Shi concur that “Fire that is peacefully in its position is lesser fire stored within the kidneys. That is the true yáng that generates original qì. This is quite frankly called Ministerial fire (Li & Liu)”. Ye Tian Shi further elaborates that when sovereign and ministerial fires are calm they can generate substance (Li & Liu, 1983). This all is referring to normal physiological fire within the body.
Li Dōng Yuán believed that yīnfire was the same as heart fire and ministerial fire. Both of these damage original qi. When there is an abnormality of the sovereign or ministerial fire the heart fire alone becomes exuberant. IF the ministerial fire is displaced, then we have ‘vigorous fire eating qi’. Dōng Yuán only spoke of yīnfire in this pathological way (or transmutation of normal fires), which is rather one-sided. Zhu Dan Xi, for example, agrees that the heart (fire) is equal to sovereign fire and with ministerial fire they are essential to life; referring to them in a purely physiological sense (Lǐ Nán Yí). Many have criticized Dōng Yuán for the way he uses his terms (i.e. Ministerial fire), but if one just realizes the above distinctions, and that Dōng Yuán is referring to transmutations of ‘normal fire’ than things will be clear. Furthermore, even the term ‘yīnfire’, in which many believe to be pathological by definition, can be understood from a purely physiological perspective. For example,
In regard to physiology, original qì is ascending and effusing, and yīnfire is sinking and storing. If original qì rises and effuses then there is a harmonious gentle warming of the heart and lung, and aids the kidneys and liver below; if yīnfire sinks and stores then it warms and nourishes the liver and kidneys and upwardly enriches the heart and lungs… Originally yīnfire sinking down into the kidneys is ‘lesser fire’ of ‘life’ which is the ‘true yáng’ that rottens and ripens the water and grains. This is the normal physiological function of the human body (Li & Liu, 1983, p.163).
Original qì (元气) has many synonyms; source qì (原气), true qì (真气) , vital qì (生气), and qì of the true
original (真元) (Lǐ Nán Yí). It says in the Nan Jing (36th difficult issue) that “the life gate (命门) is the place where all spirit-essence is stored and is the place where source qì is fastened.” It is comprised of a congenital essence qì component that can only be nourished and replenished by the essence qì of food and water (Lǐ Nán Yí). The Píwèilùn says the true qì is also called original qì and it is the essential qì prior to birth. Furthermore, the Píwèilùn emphasizes that the source of original qì’s production is primarily post-natal and it is stated, “nothing but the stomach qì can enrich it.” Original qì is constantly being consumed with daily life and it is necessary for preservation, nourishment, and development of all of the five houses and six depots, four limbs, and nine orifices (Lǐ Nán Yí). Essential qì (精气) is a general term meaning “any essential element of the body (blood, qì, fluid, essence)
(Wiseman & Ellis, 1996, p.20)” Wiseman & Ellis states, original qì is formed from the essential qì stored in the kidneys combined with the qìassimilated from the lungs and qì produced by the spleen/stomach. It flows throughout the whole body and takes the form of organ qì (脏腑之气), channel qì (经络之气), construction qì (营气), defensive qì (卫气), and ancestral qì (宗气), see figure 1. Therefore, original qì can be interpreted as part of the congenital essence of the body and the qì formed from the post-natal qì. Although, Dōng Yuán emphasizes that all the qì has its root in the spleen and stomach, he does not say that there is no differentiation between the above qì’s. This is true because original qì has its foundation congenitally, which is understood as kidney qì or life gate, and the others do not. This creates a circular dynamic that the status of the spleen and stomach is directly proportional to the waxing and waning of the body’s original qì (Lǐ Nán Yí).
There is original qì in the middle burner, upper burner, and lower burner (Lǐ Nán Yí). It is said, “when original qì becomes insufficient, all viscera become diseased, but among them the spleen and stomach are the first to become deficient (Lǐ Nán Yí)” The root spleen and stomach disease according to Dōng Yuán manifests as the following, “laziness, affinity to lying down, loss of the use of the limbs, not able to eat and are thin, diarrhea, stirring qì of the umbilicus, the pulse is slow and moderate.” If the upper burner’s original qì is insufficient, resulting from a spleen and stomach disease, it will manifest as raising qì and panting, cough, shortness of breath, sprinkle sweat, aversion to cold, melancholy and unhappiness, sick complexion, and generally feeling bad. If the spleen vacuity reaches the kidney, depleting lower burner source qì, resulting in a kidney vacuity it will manifest as frequent spittle, frequent urination, aversion to cold, weak legs, bones lack strength, lower legs are painful and unable to perform, cold testicles, waist, spine, back of body and shoulder blades are all painful, pulse is deep and thin. Therefore it is said that original qìvacuity in any of three warmers is therefore a result of spleen and stomach insufficiency (Píwèilùn).
To create more confusion, in the midst of a clearly pathological discussion, there are times Dōng Yuán throws in a statement reminiscent of a physiological Nèi Jīng passage. For example, “Heart fire is yīnfire. Yīnfire rises up from the lower burner and fastens in the heart. The heart does not master and command (yīn-fire), but the ministerial fire takes the place of the heart. Ministerial fire is fire of the lower burner uterine network vessels and is the thief of source qì (Píwèilùn).” Is this bolded statement pathological or physiological? Since is said in recent commentaries that Dōng Yuán only speaks of ministerial fire as pathological entity this might mean that the fire takes over and overwhelms the heart. But, at least to me, this is unclear, especially with its analogous wording to the Nèi Jīng. Either way, understanding the yīnfire phenomenon from just a Dōng Yuán perspective can be challenging. At this point just realize that Dōng Yuán is generally speaking of yīnfire pathologically.
What is this thief and what does the statement ‘ministerial fire is the thief of original qì’ mean? First, there is much debate throughout the years of what the thief is. Dōng Yuán, views the ministerial fire as a pathological substance that is damaging the original qì, and again with the explanation in the Píwèilùn, “Ministerial fire and source qì cannot exist together. When one is triumphant then the other will be defeated. ” Quite simply this means pathological fire damages qi, as stated in the Nèi Jīng, but he has been criticized by Zhong Jin, “whenever a thieving fire damages someone this is not the true fire of the sovereign or ministerial… evil fire can be said to be a thief, ministerial fire cannot be said to be a thief.” This is somewhat of a semantical issue based on Dōng Yuán’s choice of terminology. Ye Tian Shi further elaborates on evil fire, “If at every turn there are human desires then there will be evil fire and harm to the substance. This is called the thief”. (Li & Liu, 1983). Zhang jie bin says,
If a person has sexual passion or often acts rashly then this is completely able to make fire rise. Exuberance of fire damages original qì. Namely (this exuberant fire) is the thief of original qì …but not the true fire of the sovereign or minister (Li & Liu, 1983, p.163).
Jing yue again thinks that fire that is aroused from sexual desire, no matter sovereign or ministerial, belongs to evil fire. This is the thief of original qì. Ministerial & sovereign fire by itself does not arouse sexual desire, for they are original qì (Li & Liu, 1983).
There are two (general) types of yīnfire that Dōng Yuán puts forth in the Píwèilùn; an internal and externally caused yīnfire. First, one must understand that his presentation is far from clear, but a certain amount of clarity can be obtained. We will start with that and then expand.
A fundamental statement in understanding internally generated yīnfire is that a vacuity of original qì is an important reason for engenderment (Lǐ Nán Yí). Original qì, particularly of the spleen and stomach, becomes damaged because ‘food and drink lose their regulation’ and ‘hot and cold foods are inappropriately consumed’. The seven emotions are also said to ‘spoil’ original qì. First the spleen and stomach become deficient, which leads to original qì vacuity (of the middle). Then upbearing and downbearing are disrupted, the clear yáng or qì sinks downward into the kidneys creating an uproar (or displacement) of ministerial fire. So if fire leaves its position, it transmutes ‘lesser fire’ that ‘generates qi’ into ‘vigorous fire’ that ‘consumes qi’ (Li & Liu, 1983). Dōng Yuán only discusses yīnfire in this way, pathological transmutations of a normal physiological fire. Once the ministerial fire is stirred it is displaced and harasses the heart. The heart becomes exuberant, therefore creating yīnfire. At this point yīnfire is a pathological heart fire. Next in the pathological process is statement, “yīnfire is able to take advantage of earth’s position (Píwèilùn)” This part of the pathology is used numerous times throughout the Píwèilùn in various forms, i.e., “spleen vacuity is the result of hyperactive heart fire which overwhelms earth…(p.105)” and is mentioned much more frequently than the former ‘qì sinking’ idea. Are these two ideas connected in one circular process or do they indirectly support to Dōng Yuán using yīnfire in multiple isolated scenarios?
Since Dōng Yuán believes that yīnfire (heart fire & ministerial fire) all consume and damage original qì, there becomes a certain amount of circular logic that exists. Quite simply, original qì vacuity causes yīnfire, and yīnfire damages original qì. In the clinic, if one can actually assess which comes first is hard to say, but as above (commentaries) mentioned, original qì must first be vacuous. Nonetheless, once this pathological fire is created it rises up and disturbs the heart and damages qì (see figure 2). The original passage in the Píwèilùn mentions the heat symptoms of fever and vexation, but further elaborations also include insomnia with many dreams, seminal emissions (Lǐ Nán Yí).
The external cause of yīnfire comes about from a pre-existing qì vacuity which allows for further damage from summer-heat (Li & Liu, 1983). Dōng Yuán says, “Since the spleen and stomach are vacuous, unable to rise and float, their engendering and perfusing qì are damaged by yīnfire…” In the Nèi Jīng Sùwèn it says, “qì vacuity produces body heat, when there is damage from the summer.” It is also said that “summerheat damages original qì.” Again we have a seemingly circular pathomechanism, but the yīnfire here in my opinion is not the result of a stirring of ministerial fire (as presented above), as much as it is an invasion of ‘heat or damp-heat’ from the environment.
Dōng Yuán points out,
In the season of late-summer, and damp-heat is extremely prevalent, and there is a rising and flourishing of intense heat, many times the patient will feel a sense of fatigue in the 4 limbs, diminished essence-spirit, a feeling of laziness to work, fullness in the chest with hasty breathing, deeply painful joints, or raised qì and panting, generalized fever and vexation, expansion glomus below the heart, urination is yellow and frequent, bowel movements are sloppy and frequent, dysentery that is yellow and spoiled that is the color of water of washed rice; they may or may not be thirsty, no thought of food or drink, heavy or light spontaneous full body sweating (Li & Liu, 1983, p. 164).
In this scenario, qīng shǔ yì qì tāng (Summerheat-Clearing Qi-Boosting Decoction) is suggested. Even though it is debatable if this formula actually clears summerheat, the presentation is laid out in relation to the term yīnfire. This use is only sufficient if one can provide some evidence of external influence. To summarize, one has to be careful when one encounters such terms as yīnfire, making sure to pay close attention to context and the era/ writer and not generalize. This is one reason why a simple dictionary is far from adequate in grasping some terminology in Chinese medicine.
My commentary/ Analysis:
One can see that Dōng Yuán uses yīnfire differently in various situations. Support is found in further reading of the Píwèilùn. For example, different treatments are given for different scenarios (i.e. for the typical qì sinking type yīnfire bǔ zhōng yì qì tāng is recommended. For summer-heat (damp) qīng shǔ yì qì tāng is recommended, and other places bitter cold herbs like huáng bài (Phellodendri, Cortex), huáng lián (Coptidis Chinensis, Rhizoma) or huáng qín (Scutellariae Baicalensis, Radix) are advised to downbear yīnfire. Yet after the basic yīnfire explanation it says “the use of bitter, cold medicinals which might damage the spleen and stomach is absolutely prohibited (Píwèilùn).” Because of this difference in treatments and the lack of continuity in yīnfire discussions, I hypothesize that Dōng Yuán’s uses ‘yīnfire’ in a general non-specific way, especially in regard to pathomechanism. To further elaborate, yīnfire in one situation may be caused by a different pathomechanism than in another. It is not a fixed term. Therefore, the idea that the yīnfire (qì sinking) pathomechanism for bǔ zhōng yì qì tāng is universal for all yīnfire passages is questionable. I will make possible distinctions and correlations between this ‘basic’ yīnfire scenario, discussed previous to bǔ zhōng yì qì tāng in the Píwèilùn, with the ‘other’ uses.
It then becomes unclear that when Dōng Yuán discusses details (i.e. etiology) in ‘other’ places, if this is in reference to all yīnfire situations. For example, he discusses the etiological factors of over-taxation, diet, and the 7 emotions leading to yīnfire which overwhelms earth (Píwèilùn).  I interpret ‘overwhelming earth’ as damaging original qi of earth, but does this mean that the etiologies directly cause yīnfire or does it imply the qìsinking Æ stirring of ministerial fire pathomechanism? There is a definite murkiness surrounding the issue at hand. To draw universal conclusions based on the various usages may be erroneous.
Flaws (2) does come to a cohesive conclusion that yīnfire can be interpreted to include qì vacuity heat as well as heat arising from damp-heat, liver qì depression/ (depressive heat), or yīn / blood vacuityÆ heat. This stance suggests that any internal heat can be labeled as yīnfire. Basically he suggests that after one treats the spleen and stomach root vacuity problem, and rectifies qì, and clears heat with bitter and cold medicinals, one then treats whatever disease mechanisms and symptoms are present. This strategy is said to be based on analyzing Dōng Yuán’sformulas, and I agree that many of his formulas (many times over 20 ingredients) do suggest such an approach; for it is not uncommon to see multiple patterns treated simultaneously, and many of which are normally contradictory. For example, he will use herbs that nourish and drain, cool and warm, move and astringe, dry and moisten. As this may give a template for an incredible custom formula for the experienced practitioner, this approach, for the not so experienced, has a high potential for confusion and laziness. For example, if someone is thirsty it might be thought to add some fluid nourishes. Although this may be appropriate, I do think a broader view should be encouraged; one based on pathomechanism. For example, maybe the thirst may be from dampness blocking the fluids from reaching the mouth, and the more eloquent treatment is to disihibit damp to relieve thirst.
This advanced thinking may be overlooked by the less experienced practitioner.
This multi-pattern approach has appeal to some because one can address everything at once. My observation, though, is for the many non-master herbalists, this can easily turn into a very symptomatic based approach, forgoing the search for an underlying pathomechanism. This is somewhat encouraged in the Píwèilùn due to the plethora of symptom based combos. It was even said by Qin Bowei, Dōng Yuán should not be studied for his formulas but for his combos (Chace, 2003). I take this to mean, he had great ideas for herbal pairings (duiyao– symptom based medicine), but his underlying formulas lacked a fundamental focus (or pathomechanism). Therefore, can this broad style be considered yīnfire or just an extrapolation from Dōng Yuán’s formulas? In my opinion, the labeling of yīnfire in this manner somewhat devalues the term, and encourages a less precise type of non-pathomechanism based diagnosis/ treatment. It is also evident that the majority of modern Chinese do not view yīnfire in this broad context, because it shows up so rarely in the literature. Furthermore, one might rationalize that it does not show up more often because calling these ‘complex’ somewhat ‘normal’ situations yīnfire leads one to nothing different that common biàn zhèng / zàng fǔ diagnoses, and actual yīnfire presentations are somewhat rare. Furthermore, the articles and commentary that I translated I did not find support for this expanded view/ idea. I did find a more expanded view, that yīnfire can lodge in different organs. This was presented with a predominance of spleen and stomach vacuity with, for example, yīnfire lodging in the liver. The question for me becomes, does the treatment reflect the pathomechanism suggested by yīnfire, or just treating what one sees – liver heat with spleen vacuity. One may choose to call the latter yīnfire, but this just seems to be semantical. In my opinion, this creates confusion, foregoing the potential for pathomechanism and the ‘rules’ that surround it. This does not say yīnfire cannot be used successfully in that manner, but getting closer to the original meaning may lend to some more clarity. In almost all situations that involve (fire, heat, yīnfire) in the Píwèilùn we see bitter cold / heat clearers that address the heat, except in one spot; the discussion before bǔ zhōng yì qì tāng. If anywhere there is evidence of something to explore it is here. The basic qì sinking yīnfire scenario (figure 2) brings forth a couple of questions.
- What distinguishes the qì sinking yīnfire (bǔ zhōng yì qì tāng) from other usages.
The main distinguishing feature surrounds the type of heat. For some reason the (qì vacuity) heat can be eliminated here through a purely root, seemingly contradictory treatment, of bǔ zhōng yì qì tāng. Its discussion lies under the heading for spleen and stomach damage with heat in the center in the initial stages. It is differentiated between an external attack, and bǔ zhōng yì qì tāng is recommended for situations before they have transmuted into cold (Píwèilùn). Lu (1994) when discussing how qì vacuity causes fever concludes that heat signs (i.e. fever) only tend to last for a short time (acute exasperation of a chronic illness) or initial stages and will turn cold with time.
Other yīnfire scenarios in the Píwèilùn (or by modern authors) tend to either be from external causes (qīng shǔ yì qì tāng) or more severe or chronic heat signs and the huang’s are recommended.
- Is the typical qì sinking pathomechanism for yīnfire valid or necessary?
In my opinion if the pathomechanism for a condition is correct then one should be able to treat the root (pathomechanism) and the problem will disappear. For example, if yīnfire is caused by qì vacuity / qì sinking then treating this root (i.e. with bǔ zhōng yì qì tāng) should take care of the yīnfire. This mentality is most thoroughly supported by the Shāng Hún Lùn and its formulas and discussions. The above scenario with bǔ zhōng yì qì tāng seems to fit the bill. As already discussed, in regard to the Píwèilùn, I am uncertain about other uses of yīnfire. Because of this murkiness and the ‘main’ discussion revolving around non-chronic situations, I question the actual pathomechanism involved.
The Píwèilùn statement “…ministerial fire and source qì cannot exist together” also can be puzzling. It is used to explain the fact that when the spleen qì (physiological but vacuous) sinks into the kidney and ministerial fire is forced out, or stirred, that this is because they cannot exist together (Li & Liu, 1983). When qì sinks, why does a normal ‘physiological’ qì disrupt/agitate ministerial fire (a physiological fire in the kidneys)? Because at the point of qì sinking down, there is no disruption (yet), just a vacuity. Therefore since yīnfire has not yet been created, how can ministerial fire be viewed at pathological? The above statement makes sense from the perspective of ministerial fire being pathological, referring to the pathological fire damaging qì as in the Nèi Jīng. With the below discussion it further puts into question the validity of the qi sinking pathomechanism.
Interestingly, in the descriptions of yīnfire there are no signs of actual qì sinking involved, i.e. prolapse of organs etc. It can be thought that these ‘actual prolapses’ are a more extreme manifestations of qì sinking. As a matter of fact, as the observed amount of qì sinking increases, one is instructed to apply more qì lifting medicinals (Flaws (1)). Therefore the question arises, if this is a more extreme situation then why don’t modern presentations and descriptions of normal qì sinking patterns (with prolapses etc.) normally contain heat signs, as the basic yīnfire explanations suggest? For example, Wiseman & Ellis (1986) lists the following signs and symptoms for a qì falling pattern, “dizziness and vacuity, distension or vacuity fullness in the stomach duct, enduring diarrhea efflux desertion and prolapse of the rectum, or proplaspe of the uterus (p.23).” There are no heat signs. If qì sinking causes yīnfire why is it, that in normal cases of qì sinking, heat signs do not occur? It is a well known fact that yīnfire in general is not a very common diagnosis in China, and many times a last resort attempt for a difficult case. Therefore, qì sinking without heat might occur for two reasons:
- as mentioned above, when qì vacuity (with sinking) gets to a chronic or severe state then these (vacuity/ yīnfire) heat sings are replaced by cold or no heat at all. There is evidence for this in the Píwèilùn.
- That Dōng Yuán’s pathomechanism described for yīnfire is a case of making up theory to fit a situation/ treatment! There is no doubt that heat signs occur with qì vacuity signs and symptoms in the clinic. But it is clearly stated, as far back as the Nèi Jīng, that pathogenic fire damages qì. If the 3 etiological factors listed in the Píwèilùn can be seen to cause heat without the qì sinking pathomechanism, and the herbs to treat these are not directly related to qì sinking, then maybe this intangible pathomeachism is not as useful as one would like to believe. All three of the etiological factors can be seen as leading to heat without the qì sinking idea, and this is worth exploring.
There is no problem seeing that emotional activity through the involvement of the liver/ heart can lead to heat, especially from a modern perspective. We know that the 7 emotions cause constraint in the liver Æ heat which can agitate the heart, or attack the spleen. The Píwèilùn says that spleen vacuity is the result of hyperactive heart fire which overwhelms earth. As we know heart-fire in synonymous to yīnfire. Furthermore, the Píwèilùn illustrates yīnfire confined in earth is always first a result of the 5 emotions. From a modern perspective we treat emotional activity Æ heat, not with qì boosting medicinal, but qì rectifying, or cool/cold herbs to clear heat from liver or heart. Spleen qì supplementing herb may be employed depending on the extent of spleen damage, or as a protective measure, but not the focus.
Dietary irregularity, especially if it involves spicy, hot food or drink can be easily seen as creating internal heat which can harass the heart. Although, this irregularity damages the spleen, the important thing to realize is that the herbs from a modern perspective to treat such a condition, involve herbs to clear heat, as well as tonify the qì vacuity that has occurred from the damage.
Finally over-taxation leading to heat can be explained in the following way. Activity is dependent upon qì as its material basis (Lu, 1994). The Nèi Jīng states that activity consumes qì. Lu points out that, “when qì becomes vacuous because of over activity, qì in the interior may go to the exterior of the body to compensate for the consumption of qì in this area, giving rise to fever.” Lu further points out that the Nèi Jīng says that exertion can cause hyperactivity of qì, accelerating the flow of qì and blood; thus qì flows outward more easily even though there is a vacuity. Either way, no matter how the heat arrives, it is there with spleen vacuity, and one must treat it.
3) How do we use yīnfire in the clinic?
Since the all-encompassing approach suggested by Flaws applying the expanded yīnfire idea to a wide spectrum of clinical situations has been discussed at length in the past, I will focus on the more narrow view. This approach deals with what I feel is the most important clinical manifestation, being qì vacuity heat (yīnfire) and its application of bǔ zhōng yì qì tāng. I must preface this discussion in saying that I in no way feel that bǔ zhōng yì qì tāng should at all limited to this approach or yīnfire in general. It is a very useful formula that has gained extensive applications far beyond its original intention, much like xiǎo chái hú tāng (Minor Bupleurum).
In the clinic one can almost always find some justification for spleen qì vacuity, either through direct signs and symptoms or indirect physiological/pathological relationships. Because of this, many doctors consider the spleen and stomach to be the root of most diseases and therefore treatments always were based on supplementing earth. There is a certain amount of wisdom here and it is said that Dōng Yuán based his flexible use of medicinals on the relative balance of qì vacuity and yīnfire (Lǐ Nán Yí). For example, the more yīnfire (heat) that is seen the more he actually started using herbs to clear heat, but he still supplemented earth. When can someone feel confident to use bǔ zhōng yì qì tāng with heat signs without adding cold bitter herbs to clear heat? First I believe that standard spleen and stomach vacuity signs should be predominate. Heat signs should be mild. One should be careful with heat that has been going on for sometime. In these situations one should first try to rule out other obvious possibilities for heat (liver qì depression, yīn and blood vacuity, damp heat, etc.). In acute situations, these possibilities should also be ruled out, as well as an excess heat presentation. For example as Lǐ Nán Yí suggests there may be great heat but it is intermittent and easily tolerated. Symptoms may seem severe or excess but there is always an underlying vacuity, for example the pulse maybe surging and large but when one presses down there is lack of strength. This is an appropriate time. As mentioned above qi vacuity heat is usually not long-term or serious. Bensky (1990), suggest that many times signs and symptoms have an on again off again nature usually brought on by exertion. This is because, “the extent of the injury to the qi… does not always prevent the clear yang from rising” (Bensky, p.242). He also states that chronic low-grade fever may be helped with this approach.
In conclusion, yīnfire can be viewed in a very broad context (any internal heat) where one treats what one sees and may have great clinical success. Although, the broader the term gets, the more I feel it loses any real significance. In regard to broadness, it is also warned that all disease mechanisms must be simultaneously addressed or the “remaining disease mechanisms will quickly reestablish the mechanism which was temporarily cured (Flaws (2), p.2).” I am unsure that I totally agree with this. For example, I have not seen this in my practice or while observing my more experienced teachers and colleagues. I did/do not see them a) making a habit of addressing everything seen, or, b) when they didn’t, I did not see some reemergence of ‘cured’ mechanisms. Therefore, I feel that finding the key mechanism(s), does not have to include every sign, symptom, or pattern that one (thinks they) see. This topic, though, on ‘how much one treats and when’ is complex and important. My experience does not have any answers more than that. I am sure there are times when it is best to treat everything at once. I am equally convinced that there are times when this shotgun approach is far from essential, and the best approach is dealing a quick blow focused on the ‘main’ pathomechanism. I am unsure when to choose the latter vs. the former. Although, when I can see a clear path via for example, a Shāng Hún Lùn or ‘basic’ yīnfire scenario, I jump on the opportunity to try my hand at what I feel is a more eloquent treatment style, which I have witnessed in many of my mentors.
Therefore, if there is any pathomechanism, related to yīnfire, handed down from Dōng Yuán, let us keep it intact. For this to occur, one may choose to start from a more basic traditional or simple viewpoint, discussed above. Keeping one’s treatment simple has a further advantage; if your original idea /diagnosis is wrong, then your failed treatment becomes easily diagnostic. With a formula that addresses every symptom/ pattern / pathomechanism, one’s ability to see where one went wrong can become obscured. Dōng Yuán was a master of treating what he sees, basing almost everything on a spleen and stomach vacuity, and this worked for him. These are my thoughts of the moment, and let us not forget that everyone must find their own way.
Bensky & Barolet (1990). Chinese Herbal Medicine, Formulas & Strategies. Eastland Press, Inc. Seattle Washington.
Chace, Charles (2003). Personal conversations
Flaws, Bob (1). Chinese Articles & Essays Advocating the Use of Li Dong-Yuan’s Ideas in Modern Clinical Practice. http://www.bluepoppy.com/press.
Flaws, Bob (2). The Formulas of Li Dong-Yuan: Complex Formulas for Complex Conditions.
Lǐ Cōng Fǔ (李聪甫) & Liú Bǐng Fán (刘炳凡) (Compiled by) (1983). 金元四大医家 学术思想之研穷。湖南省中医药研穷所, 人民卫生出版社.
Lǐ Dōng Yuán. 脾胃论。
Lǐ Nán Yí (李南夷). 《脾胃论》的元气阴火学说。 Original qì and yīnfire theory of the Píwèilùn. Unknown date, unknown journal. P. 345-347.
Lu Yu Bin. Difficult Questions in Chinese Medicine Theory (1994). Journal of Chinese Medicine, No.
- Electronic version no page number.
Wiseman, Nigel & Ellis, Andrew (1996). Fundamentals of Chinese Medicine. Paradigm Publication, Brookline, Mass.
 喜唾 – frequent spitting/ or spittle (the saliva of the kidneys)
 足不任身 – literally ‘legs no bear body’
 This is reminiscent of the Nei4 Jing1 statement “sovereign fire is brilliance (illumination), and ministerial fire occupies position”. This is interpreted that ministerial fire takes the active role for the sovereign fire (which does not master) (Physiological) (Nei4 Jing1 commentary).
 There is an English translation (Flaws (1)) that says dampness is what sinks down into the kidneys, although this could make sense, I find no evidence for this in the original text or in the commentary/ articles that I have translated.
I have not seen ‘dampness or damp-heat sinking down in the kidneys’ referred to in the pathomechanism for yīnfire.
 This idea, as discussed below, is not in the pre bǔ zhōng yì qì tāng discussion.
 This chart is extrapolated from the (qì sinking) Píwèilùn discussion preceding bǔ zhōng yì qì tāng. The dotted lines are from other parts of the book that discuss yinfire.
 This phrase relating the etiologies and the end result (overwhelming earth) is found in other places besides the bǔ zhōng yì qì tāng discussion. This is why under figure 2, there are dotted lines leading to yīnfire from the above etiological factors.
 This may be why the majority of his formulas have never became popular.
 This just seems routine, and does not warrant any elaborate explanation.
 qīng shǔ yì qì tāng may also offer an interesting pathomechanism discussion for summerheat, but as mentioned above many believe that the formula does not even treat this pattern (Lǐ Nán Yí).
 I think these standard patterns, even with spleen qì vacuity, our best handled in a standard fashion