Liver

Liver Functions

The Liver Stores Blood (肝藏血 gān cáng xuè)

The blood-storing function was undoubtedly inferred from the deep brownish-red hue and bloody texture of the liver, which suggests heavy infusion with blood, and from the knowledge that severe rupturing of the liver as by a weapon usually caused massive hemorrhage swiftly leading to death. Thus, the blood-storing function was inferred from directly observable phenomena, even though such a function is only scantily supported by the findings of modern medical science. It is nevertheless of interest that Europeans once believed that the liver produced the blood, presumably for similar reasons.

Storing blood has two meanings: (1) holding blood to regulate the quantity of blood in circulation; (2) preventing bleeding.

Holding blood to ensure a copious supply: By its capacity to store a certain amount of blood, the liver can regulate the quantity of blood in circulation. Sù Wèn (Chapter 10) states, When a person is lying down, blood returns to the liver. (人卧血归于肝 rén wò xuè guī yú gān). A commentary on this by Wáng Bīng (王冰) states, The liver stores blood and the heart moves it. When a person moves, blood moves through all the channels; when a person is still, blood returns to the liver viscus. (肝藏血, 心行之, 人动则血运于诸经, 人静则血归于肝脏 gān cáng xuè, xīn xíng zhī, rén dòng xuè yùn yú zhū jīng, rén jìng xuè guī yú gān zàng). In other words, when the body is active, blood moves to the periphery to supply the needs of the body; when the body rests, some of the blood flows back to the liver.

Sufficient supplies of blood held by the liver are important for the liver itself. On the one hand, they ensure that the liver itself is fully nourished; on the other, they exert a moderating influence on free coursing, keeping the upbearing and stirring action of the liver’s yáng qì in check, and preventing liver qì from ascending counterflow.

Adequate supplies of blood are also important for the whole body. The Sù Wèn (Chapter 10) also states, when the liver receives blood, one can see, when the feet receive blood, one can walk; when the hands receive blood, they can grasp; when the fingers receive blood, they can hold (肝受血而能视, 足受血而能步, 掌受血而能握, 指受血而能摄 gān shòu xuè ér néng shì, zú shòu xuè ér néng bù, zhǎng shòu xuè ér néng wò, zhǐ shòu xuè ér néng shè). It is by the liver’s ability to store blood that these functions are maintained.

In women, the function of regulating the quantity of blood in circulation conjugates with the free coursing action of liver qì to control the supply of blood to the thoroughfare (chōng) and controlling (rèn) vessels, which control menstruation.

If the liver fails to maintain an adequate supply of blood, this is called insufficiency of liver blood (or as a disease pattern liver blood vacuity). This manifests in dry eyes, night blindness, numbness of the limbs, pale nails, hypertonicity of the sinews (muscular tension) that prevents bending and stretching, and in women, pale-colored menstrual discharge or amenorrhea.

Preventing bleeding: An apparently somewhat controversial traditional notion is that storing blood also means preventing bleeding. In this sense, the word store is interpreted as withholding to prevent escape. This is the same meaning as implied by storage in the term the kidney governs storage (肾主封藏 shèn zhǔ fēng cáng).

Bleeding attributed to the liver failing to store blood includes vomiting of blood, expectoration of blood, nosebleed, and in women, profuse menstruation or flooding and spotting.

The liver’s ability to prevent bleeding is explained in the following ways:

• Liver qì’s ability to contain the blood: This idea was posited by in Dān Xī Xīn Fǎ (丹溪心法 Dān Xī’s Heart Approach), which states, Vomiting of blood, nosebleed, spotting and flooding [are attributable to] the liver being unable to contain provisioning qì, causing all the blood to deviate from its paths and move frenetically (吐衄漏崩, 肝家不能收摄荣气, 使诸血失道妄行 tù nǜ lòu bēng, gān jiā bù néng shōu shè róng qì, shǐ zhū xuè shī dào wàng xíng).
• Liver’s yīn action of congealing the blood: This is based on the notion that yīn connotes a tendency toward concentration and density. The Tú Shū Biān (图书编 The Pictorial Book) by the Qīng Dynasty scholar Zhāng Huáng (章潢) states, The liver is the basis of congealing of the blood (肝者, 凝血之本 gān zhě, níng xuè zhī běn). Note here that congealing is not necessarily to be equated with the biomedical notion of coagulation.
• The liver’s capacity to hold blood and counteract the movement of its yáng qì: As discussed above, the liver’s ability to hold supplies of blood prevents excessive free coursing that results in liver qì ascending counterflow. Since the blood belongs to yīn, the principle of quiescence, this explanation has a great affinity with the notion of yīn congealing the blood.

While the notion that blood storage prevents bleeding is not denied validity, modern diagnostic textbooks only associate the liver’s failing to store blood with blood vacuity, not with prevention of blood loss. They include vomiting of blood, expectoration of blood, and nosebleed as signs of liver fire flaming upward. They do not include profuse menstruation or flooding and spotting as signs of the liver failing to store blood.

The Liver Governs Free Coursing (肝主疏泄 gān zhǔ shū xiè)

The liver belongs to wood in the five phases. A quality of wood is that it likes orderly reaching, a reference to plants’ expansive growth tendency. Just as the branches of trees like to stretch out freely, the liver’s corresponding characteristic is that its qì likes to spread freely; it likes to move. This action is called free coursing. Like trees and other plants, its habitual movement is upward and outward. This is often described as upbearing and effusion (升发 shēng fā).

The free coursing of liver qì makes a significant contribution to the body as a whole in that it regulates the qì dynamic, i.e., the movement and activity of qì, in the channels and the bowels and viscera––throughout the body as a whole. When the liver’s free coursing action is normal and healthy, the qì dynamic is free and uninhibited. This is the basis for the ability of qì to perform all its functions normally. Free coursing is especially important for the free movement of blood and fluids, for healthy spleen-stomach function, for the discharge of bile, and for sexual functions. Furthermore, normal free coursing is also manifest in normal, balanced emotions and is easily impaired by emotional disturbances.

Impaired free coursing: The concept of free coursing most is understood most clearly when it is impaired. Pathological disturbances of free coursing are called impaired free coursing of the liver. They are attributable to numerous causes. Frustration, depression, and anger are frequent causes. Spleen-stomach damp-heat or external evils are sometimes a factor. They can also be the result of insufficiency of liver yīn or liver blood. In most cases, more than one factor is operant. There are two pathological disturbances of free coursing: deficiency and excessiveness.

Deficient free coursing (疏泄不及 shū xiè bù jí) is insufficiency of the upbearing and effusing action of liver qì that causes liver qì to become depressed and stagnant. This is called depressed liver qì, binding depression of liver qì, or liver depression and qì stagnation. This is a qì stagnation pattern that manifests in, amongst other things, distension and pain in the chest and rib-side, breasts, or in the lesser abdomen (both sides of the lower abdomen), and affect-mind disturbances such as anger, frustration, dissatisfaction, and depression. It is important to understand that deficient free coursing is deficiency of the activity of qì, not insufficiency of qì itself; hence it manifests in a repletion pattern, not a vacuity pattern.

Excessive free coursing (疏泄太过 shū xiè tài guò) is excessiveness of the upbearing and effusing action of liver qì that expresses itself in liver qì ascending counterflow, manifesting in upper body signs, such as dizziness, red eyes, heavy head and light feet (a subjective feeling of top-heaviness), and affect-mind signs such as rashness, impatience, and irascibility. It is observed in several liver disease patterns: liver fire flaming upward; ascendant hyperactivity of liver yáng; and liver yáng transforming into wind.

Affect-mind (emotions ) and liver qì: The liver’s free coursing plays a regulatory role in affect-mind (mental and emotional) activity in general. The heart spirit is the seat of consciousness and mental activity, while specific aspects of mental and emotional activity are associated with each of the viscera. The liver’s free coursing plays a regulatory role in mental activity in general. By ensuring the smooth flow of qì around the body, it ensures that qì and blood remain in harmony and that the individual maintains a happy, positive disposition.

Impairment of the liver’s free coursing action is usually associated with severe affect-mind disturbances.

• Affect-mind depression, frustration, and depressed anger (grumpiness) are associated with deficient free coursing, which manifests in depressed liver qì.
• Agitation, rashness, and irascibility that manifests in fulminant anger (sudden flights of violent anger) are associated with excessive free coursing, which is observed in liver fire flaming upward or ascendant hyperactivity of liver yáng.

Classically, anger is the mind associated with the liver. Anger takes different forms and occurs with other emotions. Some Chinese texts make a distinction between depressed anger and fulminant anger. Depressed anger (郁怒 yù nù) is suppressed or unvented anger often associated with frustration, dissatisfaction, and depression. Fulminant anger (暴怒 bào nù) is anger that frequently comes in sudden flights and associated with impatience and agitation (hence the term impatience, agitation, and irascibility). The distinction may not be very clear in actual practice. Sù Wèn (Chapter 39) states, Anger causes qì to move counterflow, in severe cases causing retching of blood and food diarrhea (怒则气逆, 甚则呕血及飱泄 nù zé qì nì, shèn zé ǒu xuè jí sūn xiè). While the retching of blood reflects excessive free coursing, food diarrhea (diarrhea with undigested food in the stool) reflects deficient free coursing. The quotation attributes both simply to anger.

Although affect-mind disturbances are often seen in liver disease patterns associated with impaired free coursing, it is important to bear in mind that they are not the only cause of them. As mentioned above, spleen-stomach damp-heat, external evils, and insufficiency of liver yīn or liver blood are contributory if not major factors.

Qì, blood, and fluids: The liver’s free coursing action ensures the smooth movement of qì around the body, preventing qì stagnation. Since the movement of blood is dependent on the propelling action of qì, free coursing is important in ensuring normal movement and distribution of qì, blood, and fluids. When free coursing is deficient and depressed liver qì arises, there are signs of qì stagnation along the course of the liver channel, sometimes accompanied by signs of blood stasis or accumulation of fluids:

• Qì stagnation: distension and pain in the chest and rib-side or in the lesser abdomen.
• Blood stasis: stabbing pain in the chest and rib-side or abdominal masses (called concretions and accumulations).
• Accumulation of fluid: phlegm-rheum, water swelling, or drum distension.

Spleen-stomach movement and transformation: The digestion and absorption of food and the excretion of waste are intimately related to the spleen’s action of upbearing the clear and the stomach’s action of downbearing the turbid. The normal bearing of the stomach and spleen is related to the liver’s free coursing action. When the liver’s free coursing action is abnormal, this can affect either the spleen or the stomach. The resulting conditions are called liver-spleen disharmony and liver-stomach disharmony respectively. Both conditions are referred to generically as wood failing to course earth (木不疏土 mù bù shū tǔ).

• In liver-spleen disharmony, impaired splenic upbearing manifests in torpid intake (a tendency to eat less because eating causes fullness), abdominal distension, abdominal pain, and sloppy stool with ungratifying defecation or diarrhea heralded by pain and relieved by defecation, rumbling intestines, and flatus.
• In liver-stomach disharmony, impaired stomach downbearing manifests in belching, hiccup, acid swallowing, clamoring stomach, and torpid intake.

Gallbladder: Bile produced by the gallbladder is said to be produced from surplus qì in the liver. Impaired free coursing can affect bile production, causing distension in the rib-side, bitter taste in the mouth, non-transformation of ingested food, and even jaundice.

Sexual functions: Free coursing regulates the thoroughfare (chōng) and controlling (rèn) vessels, the two extraordinary vessels that have a close bearing on menstruation in women. It also regulates the essence chamber, the place in which essence (semen) is stored.

Regulating the thoroughfare and controlling vessels: Menstruation, vaginal discharge, pregnancy, and childbirth are related to several viscera. Of these the liver is most important, an observation that is underscored by the maxim women have the liver as their earlier heaven (女子以肝为先天 nǚ zǐ yǐ gān wéi xiān tiān). The thoroughfare (chōng) vessel is the sea of blood (血海 xuè hǎi), while the controlling (rèn) governs the fetus. Both vessels are connected to the foot reverting yīn (jué yīn) liver channel, and both are regulated by the liver’s free coursing action, ensuring that menstruation occurs regularly, vaginal discharge is normal, and pregnancy and childbirth go smoothly. Any abnormality of free coursing can manifest in disturbances of menstruation, pregnancy, and childbirth, as well as excessive vaginal discharge.

Regulating the essence chamber: The essence chamber (精室 jīng shì) is the place where essence is stored in the form of semen. Traditionally the essence chamber was not described clearly in anatomical terms, and so we can only conceive it as being equivalent to the various organs that produce and discharge the components of semen. The term essence gate (精关 jīng guān) refers to the opening and closing mechanism of the essence chamber, which is a function ascribed to the kidney.

The liver’s free coursing action stands in complementary opposition to the storage function of the kidney. When these functions are in balance, the essence chamber opens and closes normally. When the liver’s free coursing action is impaired, disturbances of storage and discharge of semen and other sexual functions may appear.

• When free coursing is insufficient and inhibited, there is poor libido, impotence, scant semen, or sterility.
• When free coursing is excessive, there may be excessive libido, frequent and persistent erections, or seminal emission. Note that these signs may also be attributed to frenetic stirring of the ministerial fire.

The Liver’s Associations and Epithets

The Liver and Gallbladder Stand in Exterior-interior Relationship (肝与胆相为表里 gān yǔ dǎn xiāng wéi biǎo lǐ)

The liver and gallbladder are interconnected by their channels. Furthermore, bile, the product discharged from the gallbladder, is made of surplus liver qì.

The Liver Channel (肝经 gān jīng)

The channel associated with the liver is the foot reverting yīn (jué yīn) liver channel (LR).

The Liver Opens at the Eyes (肝开窍于目 gān kāi qiào yú mù)

The liver opens into the eyes means that the eyes are the outer orifices of the liver. Disease of the liver is often reflected in eye signs. Insufficiency of liver blood can manifest in dry eyes, blurred vision, or night blindness. Liver wind stirring internally (see under pathologies below) can cause squinting or twitching of the eyes (tic).

The Liver Governs the Sinews

The Nèi Jīng says that the liver has its fullness (充 chōng) in the sinews. The sinews are the stringy parts of the flesh that can be grasped and plucked. In Chinese medical theory, the sinews are responsible for the movement of the body, and hence it is said that the liver governs physical movement (肝主运动 gān zhǔ yùn dòng). In other words, they are ascribed the function that biomedicine attributes to muscle. When the sinews are nourished, they can move freely; if liver blood is insufficient, it may cause hypertonicity of the sinews (muscular tension). Liver wind stirring internally can cause numbness of the limbs, hemiplegia, deviated eyes and mouth, convulsions, jerking sinews and twitching flesh, or tremor.

The Liver has its Bloom in the Nails (肝, 其华在爪 gān, qí huá zài zhǎo)

The nails are the surplus of the sinews (爪为筋之余 zhǎo wéi jīn zhī yú), i.e., the outer extension of the sinews. The liver has its bloom in the nails means that the health of the liver is reflected in the nails. When liver blood is insufficient, the nails become pale, dry, thin, and soft with large white moons.

Tears Are the Humor of the Liver (肝, 在液为泪 gān, zài yè wéi lèi)

Because the eyes are the outer orifice of the liver, the humor of the liver is naturally tear fluid. Dry eyes are a sign of liver disease.

The Liver Stores the Ethereal Soul (肝藏魂 gān cáng hún)

The ethereal soul (魂 hún) is understood to represent the higher faculties of mind. Unlike the corporeal soul stored by the lung, it is believed to survive death. This concept is rarely discussed in modern clinical literature, presumably because it reflects ancient supernatural beliefs that have little use in clinical medicine. The Líng Shū (Chapter 8) states, That which follows the spirit hither and thither is the ethereal soul (随神往来者, 谓之魂 suí shén wǎng lái zhě, wéi zhī hún). The ethereal soul (魂 hún) is thus seen as subordinate to the spirit, which is stored in the heart. Unlike the spirit, however, it is not subject to voluntary control. Furthermore, the Líng Shū (Chapter 8) states, The liver stores blood; the blood is the abode of the ethereal soul (肝藏血, 血舍魂 gān cáng xuè, xuè shè hún). Thus, the ethereal soul is closely related to the blood. When the liver’s function of storing blood is normal and ensures plentiful supplies of blood for the whole body, the ethereal soul has a place of abode, so the individual can sleep quietly. When the function of storing blood is impaired and liver blood is insufficient, then the ethereal soul fails to keep to its abode (魂不守舍 hún bù shǒu shè), which means that it is not properly contained. This manifests in profuse dreaming, susceptibility to fright, disquieted sleep, sleep talking, and sleep walking. Compare the lung stores the corporeal soul.

Anger is the Mind of the Liver (肝, 在志为怒 gān, zài zhì wéi nù)

Anger is the mental state associated with the liver. Excessive anger damages the liver, impairing its free coursing action. This is discussed under liver governs free coursing above. Note that anger stands for a range of emotions: frustration, dissatisfaction, grumpiness, spitefulness, irritability, as well as overt anger.

The Liver Belongs to Wood (肝属木 gān shǔ mù)

Wood refers to the living wood and to plants in general, which have the quality of bending and straightening (曲直 qū zhí). Trees and plants naturally stretch outward as they grow. Hence, it is said that wood thrives by orderly reaching. The wood phase is associated with spring, east, wind, sourness, and green(-blue).

Why the liver is ascribed to wood: The liver is paired with wood in the five phases because it shares the qualities of wood in numerous ways.

Appearance of the liver: The liver is a large dark reddish-brown organ that resembles a tree trunk or a large piece of wood. Its bloody texture, which originally suggested its blood-storing function, hints that it is filled with blood, as trees are full of sap.

Free coursing: The liver governs free coursing, that is, it ensures uninhibited flow of qì around the body and has a regulatory effect on the movement of blood and fluids. The normal tendency of free coursing is to upward and outward movement, which is called upbearing and effusion. This movement corresponds to the normal upward and outward growth of plants (the wood phase).

Sinews: The liver governs the sinews, the stringy parts of the body that are likened to the fibrous substance of plants. Sinews enable the body to bend and straighten (屈伸 qū shēn), corresponding to the bending and straightening of wood. They rely on the abundance of blood for their suppleness, as trees rely on sap. It is interesting to note that the Chinese筋 jīn is written with a bamboo radical at the top. The character originally denoted the tough, pliant, skin of the bamboo used to make furniture and implements. Hence, for Chinese students, the very word for sinew hints directly at a connection with wood.

Eyes: The liver governs the eyes, which are our farthest-reaching sense, share the quality of reaching outward associated with wood.

Spring: Liver qì is resonant with the qì of spring. The liver’s yáng qì is strongest in the spring.

Sourness: Sourness is the flavor or plant sap. It is the flavor that enters the liver. Sour medicinals such as bái sháo (Paeoniae Radix Alba, white peony) and dāng duī (Angelicae Sinensis Radix) are used to emolliate the liver (柔肝 róu gān), which means to treat liver yīn vacuity or liver blood vacuity manifesting in dry eyes, night blindness, dizziness, and tinnitus.

Green-blue: A green-blue complexion is normally a sign of cold, pain, or blood stasis. However, a green-blue complexion between the brows, on the stem of the nose, and around the lips in infants and children is a sign of liver wind stirring internally, which is diagnosed as child fright wind disease.

Cyclical relationships: In its cyclical relationships, liver-wood is engendered by kidney-water and engenders heart-fire. It is restrained by lung-metal and restrains spleen-earth.

The Liver Holds the Office of General (肝者, 将军之官 gān zhě, jiāng jūn zhī guān)

The Sù Wèn (Chapter 8) states, the liver holds the Office of General; strategies arise from it (肝者, 将军之官, 谋虑出焉 gān zhě, jiāng jūn zhī guān, mǒu lǜ chū yān). This line, from Chapter 8 of the Sù Wèn, captures many facets of the liver, notably its association with the sinews, the nails, the eyes, and anger.

In the empire paradigm, the army general represents the country’s armed forces, whose mission is to defend the national territory against invasion and of extending its borders outward. The army is to the nation as the sinews are to the body. The nails are the surplus of the sinews, and the word for them in Chinese, 爪 zhuǎ/zhǎo, also means the claws of animals and talons of birds, which are their natural weaponry. Unfortunately, these associations are lost in the English nail, which refers to a body part exclusively found in humans and other primates, which has all but lost any function as a weapon.

The army needs the brute force of determined fighters to crush enemies, but it also needs an effective intelligence service to map the territory, understand the lay of the land, and perform reconnaissance missions. Hence, the army is to the nation as the eyes are to the body.

Furthermore, the army needs a skilled commander who can predict all the possible enemy operations through time and space and, with a calm mind, evolve effective strategies to counter them. As the Chinese say, the general, in the seclusion of his tent, is able to determine the outcome of distant battles (运筹帷幄之中, 决胜千里之外 yùn chóu wéi wò zhī zhōng, jué shènɡ qiān lǐ zhī wài). By this rationale, the liver was presumed to be the seat of the faculty to devise strategies and to solve problems with a cool head. Hence, the Nèi Jīng says, the liver holds the office of General; strategies arise from it.

The army is sent into action when it is provoked by an enemy, so anger is also related to the concept of the general, as well as to the physiology of the liver. If liver qì becomes depressed or liver yáng becomes hyperactive, the patient will become rash, impatient and irascible, like an unruly general. Anger and brute force are yáng, while intelligent strategizing is yīn. These are complementary tendencies of the liver.

The liver as General is closely related to the gallbladder’s holding the office of Justice.

The Liver Is Averse to Wind (肝恶风 gān wù fēng)

The environmental qì associated with the liver is wind, which has a stirring quality like the growth of plants. Plants bend and sway in the wind, having evolved suppleness to resist wind’s destructive effects. Bodily movement is a product of the sinews, and abnormal movements, such as spasm and tremor, are likened to the effect of wind on plants. Hence, it is said that the liver is averse to wind. Just as plants remain supple when they have enough sap, the sinews need an adequate supply of blood to move freely.

Spasm of various kinds is often associated with blood vacuity arising when failure of the liver to keep enough blood in store or yīn-yáng imbalances cause internal liver wind to stir. Sudden loss of movement, which occurs in stroke patients, is attributed to liver wind likened to a violent storm that breaks the branches and trunks of trees. Stroke in English is so named because it is a sudden, violent affliction, and indeed the medical term apoplexy reflects a similar conception. The Chinese used precisely the same metaphor but also added their word for wind. They call stroke wind stroke (中风 zhòng fēng). In this way, wood, the liver’s blood-storing function, and the sinews are all clearly linked together in pathology.

Wind is swift and mobile and moves from one place to another. Itching, a condition that affects different areas at different time, is often attributed to wind or to blood dryness giving rise to wind.

Wind is the greatest threat to trees and plants. The liver is also particularly susceptible to wind. For this reason, it is said that the liver is the viscus of wind and wood (肝为风木之脏 gān).

Miscellaneous

The following are commonly encountered classical statements about the liver.

The liver is yīn in substance and yáng in function (肝, 体阴而用阳 gān, tǐ yīn yòng yáng): This phrase refers to the polarity between yīn substance and yáng function, seen in all the bowels and viscera, is most clear in the case of the liver. Liver yīn and liver blood are the substantial aspects of the liver, whereas liver qì and liver yáng are its functional aspects.

The maxim that the liver’s yáng is often superabundant and its yīn is often insufficient reflects the fact that morbidity of the qì and yáng of the liver mostly take the form of repletion patterns, rather than vacuity patterns. By contrast, morbidity of liver yīn and liver blood takes the form only of vacuity, rather than repletion.

The liver is the unyielding viscus (肝为刚脏 gān wéi gāng zang4): The liver holds the office of General. It governs upbearing and stirring. Its yáng qì is susceptible to repletion patterns of hyperactivity and counterflow, which are associated with impatience, agitation, and irascibility. For these reasons, the liver is described as the unyielding viscus.

The liver is the root of resistance to extreme fatigue (肝者, 罢极之本 gān zhě, ba4 jí zhī ben3): This statement from the Nèi Jīng means that the ability to tolerate physical fatigue is related to the liver’s blood-storing and free coursing functions, especially as reflected in the sinews. Note that modern texts usually attribute fatigue to impaired spleen function (the spleen is the source of qì and blood formation).

The liver lives on the left (肝生于左 gān shēng yu2 zuo3): This is a statement from the Sù Wèn that is little discussed in modern basic theory textbooks. However, it is of interest from the viewpoint of understanding the influence of analogical thinking. When one faces the south, the left side of the body points east, while its right-hand side points west. The position of the viscera within the body provided the basis for an older pairing of them to the five phases, in which the liver was paired with metal, the phase associated with the west (the right side of the body). When the pairing of the viscera with the phases was changed to the modern scheme, which is based on similarities of organ functions to the qualities of the phases, the liver became associated with wood and hence the east. The Sù Wèn’s statement that the liver lives on the left seems to represent an effort to bring the function of this organ in line with the five-phase association of wood with the east, despite the contradiction with its anatomical location. The liver lives on the left is contrasted with the lung stores on the right, which is interpreted to mean that although the lung is located on both sides of the chest, its qì descends into the body on the right side, which corresponds to the position west. This issue is discussed in detail in Unschuld and Tessenow’s Huang Di Nei Jing Su Wen, page 741 and in Chinese Medicine: The Ideas that shaped it, Chapter 3.

Liver Disease Signs

Liver signs are observed in its associated body parts (sinews, eyes, nails, rib-side, throat, external genitals) and its channel pathway. They also include affect-mind disturbances (anger, frustration, rashness, impatience, irascibility) and menstrual problems.

• Sinews: Jerking sinews and twitching flesh, convulsions, tremor associated with liver wind stirring internally.
• Eyes: Dry eyes and blurred vision associated with liver yīn vacuity; red eyes associated with liver fire flaming upward.
• Channel pathway (throat, rib-side, breast, lesser abdomen, genitals): Plum-pit qì; distending pain; scurrying pain; retracted scrotum.
• Affect-mind: Depression (as arising from frustration and dissatisfaction) associated with deficient free coursing; impatience, agitation and irascibility associated with excessive free coursing.
• Women’s problems: Since normal menstruation and pregnancy rely on the liver’s blood-storing capacity to ensure an adequate supply of blood to the uterus, many disorders of menstruation and pregnancy are associated with the liver. Note also that the thoroughfare (chōng) and controlling (rèn) vessels help to ensure adequate supplies of blood for the liver, and so these are often mentioned in the context of women’s problems.

Impatience, agitation, and irascibility (急躁易怒 jí zaò yì nù): A habitually agitated state of mind that manifests in rash behavior and impatient attitude to others. It is usually a sign of excessive free coursing.

Distending pain in the chest and rib-side, breasts, or lesser abdomen (胸胁、乳房、少腹胀痛 xiōng xié, rǔ fáng, shaò fù zhang4 tòng): Distension and pain, which when occurring together are called distending pain, are signs of qì stagnation. When they appear in these areas, which are located on the liver channel, they indicate depressed liver qì. Sometimes the pain takes the form of a scurrying pain (窜痛 cuan4 tòng), one that darts quickly from one place to another. This falls within the scope of pain of unfixed location, which is a major mark of qì stagnation. Note that the rib-side is the side of the chest from the armpit down to the ribs and the adjacent area of the abdomen just below the rib cage. Because symptoms usually affect the lower part of this area, the term 胁 xié is often rendered as hypochondrium. Note also that lesser abdomen refers to lateral areas of the part of the abdomen below the umbilicus.

Plum-pit qì (梅核气 méi hé qì): A subjective sensation of a lump in the throat called globus hystericus in biomedicine. It is associated with depressed liver qì.

Convulsions (抽搐 choū chù); arched-back rigidity (角弓反张 jiǎo gōng fan3 zhāng): Convulsions are violent involuntary movements of the limbs. Arched-back rigidity, known in biomedicine as opisthotonos, is an involuntary arching of the spine. Both signs occur in liver wind stirring internally.

Jerking sinews and twitching flesh (筋惕肉膶 jīn tì roù shùn); wriggling of the extremities (手足蠕动 shǒu zu2 ru2 dòng); tremor (震颤 zhèn chan4): Jerking of the sinews and twitching of the flesh refers to sporadic sudden motions in the flesh, such as in the twitching of the eyes. Wriggling of the extremities refers to gentle movements of the hands, fingers, feet, and toes. Tremor refers to quivering motions of the extremities. All three indicate mild forms of liver wind stirring internally.

Deviated eyes and mouth (口眼喎斜 kǒu yan3 waī xié): Tension in the sinews on one side of the face and relaxation in those of the other side, manifesting in skewing of the mouth to one side and sometimes inability to close the eyes. This corresponds in biomedicine to Bell’s palsy and or stroke-related facial paralysis. It is attributed mostly to wind or wind-phlegm obstructing the channels. Traditionally, this condition was usually classed as wind stroke, although now the term wind-stroke is often reserved for conditions known in biomedicine as stroke or apoplexy (cerebrovascular accident).

Hemiplegia (半身不遂 ban4 shēn bu2 suì): Paralysis of one side of the body; a major sign of wind stroke.

Dry eyes (两目干涩 liang3 mù gān se4): Lack of fluid to ensure the smooth movement of the eyelids. It is mostly attributed to liver yīn vacuity.

Red eyes (目赤 mù chì): A condition in which the whites of the eyes (sclerae) appear red. In liver disease, it is caused by liver fire flaming upward or ascendant hyperactivity of liver yáng.

Blurred vision (视物模湖 shì wù mo2 hu2): Poor visual acuity. It is a sign of liver blood vacuity.

Retracted scrotum (阴囊收缩 yīn náng shoū suo1): Shrinking of the contents of the scrotum and partial withdrawal into the abdominal cavity. It occurs in cold stagnating in the liver vessel and in other cold patterns, such as yáng desertion. It can also occur when yáng ming2 (yáng ming2) heat enters the reverting yīn (jué yīn) channel.

Liver Patterns

For fuller information than is given below, follow the pattern links. See liver and gallbladder pattern identification.

It is said of the liver that [its] yáng is often superabundant and [its] yīn is often insufficient (阳常有余阴常不足 yáng cháng yǒu yú yīn cháng bù zú). The liver is susceptible to insufficiency of its yīn and blood and to superabundance of its yáng and qì. It is vulnerable to fire. The liver channel (but not the liver itself) is vulnerable to cold.

Vacuity Patterns

Liver blood vacuity (肝血虚 gān xuè xū) arises when general blood vacuity causes the liver to have insufficient blood to store. The main signs are dizziness and tinnitus, lusterless white complexion, lusterless nails, profuse dreaming at night, loss of visual acuity or night blindness, numbness and tingling of the limbs, and a fine pulse. Women may suffer from scant pale menstrual discharge or even amenorrhea. When blood vacuity engenders wind, there is dizziness, tremor of the limbs, and jerking sinews and twitching flesh. The facial complexion is white and lusterless. The tongue is pale. The pulse is fine.

Liver yīn vacuity (肝阴虚 gān yīn xū) develops from damage to yīn by liver fire or by scorching of yīn humor in febrile disease, or from kidney yīn vacuity. It manifests in liver blood vacuity signs in conjunction with signs of yīn vacuity with internal heat such as slight heat effusion (low fever), tidal heat effusion, vexing heat in the five hearts, reddening of the cheeks, night sweating, and dry mouth and pharynx. When yīn vacuity stirs wind, there is dizziness, tinnitus, and wriggling of the extremities. The tongue is red with scant liquid. The pulse is stringlike, fine, and rapid.

Repletion Patterns

Depressed liver qì (肝气郁 gān qì yù) is a repletion pattern that results from deficient free coursing due mostly to emotional causes. The main signs are distension or scurrying pain in the chest, rib-side, or lesser abdomen, oppression in the chest, sighing, depressed anger, and plum-pit qì (a subjective yet insubstantial lump in the throat called globus hystericus in biomedicine). The tongue fur is thin and white. The pulse is stringlike. Symptoms can worsen with bad moods. Since liver qì is responsible for ensuring the timely appearance of menstrual periods, depressed liver qì almost invariably manifests in menstrual irregularities, and in fact is one of this sign’s most frequent causes. Since the liver channel passes through the breasts, distending pain in the breasts before menstruation is also attributed to depressed liver qì.

Liver fire flaming upward (肝火上炎 gān huǒ shàng yán) is a pattern of upper body repletion heat that is associated with excessive free coursing. It is attributable to a variety of causes but mostly occurs in patients suffering from depressed liver qì, when depressed qì transforms into fire. It manifests in red face and eyes, dizziness, distension in the head, tinnitus with ringing in the ears like the sound of waves breaking on the shore, bitter taste in the mouth, and dry pharynx, scorching pain in the rib-side, constipation, and short voidings of yellow urine. The tongue is red with a yellow fur. The pulse is stringlike and rapid. In some cases, there is vomiting of blood or nosebleed. Sudden deafness is also possible. Patients are often impatient, agitated, and irascible.

Vacuity/Repletion

Patterns due to either vacuity or repletion or to both.

Ascendant hyperactivity of liver yáng (肝阳上亢 gān yáng shàng kàng), like liver fire flaming upward, is a pattern of upper body repletion signs associated with excessive free coursing. It differs by being associated with yīn vacuity, since it most commonly develops when liver-kidney yīn vacuity fails to keep liver yáng in check (water failing to moisten wood) or less commonly when depressed liver qì transforms into fire that damages yīn. The main signs are dizziness, distension, and pain in the head and eyes. Other signs include tinnitus, red face and eyes, and emotional signs such as impatience, agitation, and irascibility. The tongue is red with scant liquid. The pulse is stringlike and forceful or stringlike, fine, and rapid.

Ascendant hyperactivity of liver yáng is similar to liver fire flaming upward. However, while liver fire is a repletion heat pattern that often develops rapidly and that is marked by pronounced fire signs, ascendant liver yáng is a vacuity-repletion complex, since it is always accompanied by yīn vacuity and usually develops gradually.

Liver wind stirring internally (肝风内动 gān fēng nèi dòng) develops from ascendant hyperactivity of liver yáng, from high fever, from liver blood vacuity, or from liver yīn vacuity. Internal wind, by contrast to external wind, is a specific form of yáng hyperactivity, characterized by dizziness and spasm or loss of the use of the limbs. From the biomedical viewpoint, it is observed in numerous diseases characterized by paralysis or spasm, such as stroke, Parkinson’s disease, and encephalitis.

Since the liver belongs to wood and governs the sinews (as a tree governs its branches), the violent flexing and shaking of the sinews affects the liver similarly to the way in which shaking branches affect a tree. Liver wind stirring internally is like wind in the environment, which affects the upper and peripheral parts of trees. For this reason, liver wind mostly affects the upper part of the body and the limbs.

• Liver yáng transforming into wind is wind developing as a result of ascendant hyperactivity of liver yáng and manifests in dizziness and loss of balance, headache, shaking of the head or tremor of the limbs, and unsteady gait. The facial complexion is red. The tongue is red, often with a slimy tongue fur. The pulse is stringlike, rapid, and forceful. Especially when wind combines with phlegm, it can cause wind stroke, which is characterized by sudden collapse and loss of consciousness, leaving the patient with deviated eyes and mouth, hemiplegia, sluggish speech, and phlegm rale in the throat.
• Extreme heat engendering wind occurs in high fever in infants, a condition called fright wind. It manifests in manic agitation or clouding of the spirit, convulsions of the limbs, clenched jaw, and in severe cases, arched-back rigidity (opisthotonos) and upward staring eyes. The tongue is red with a dry yellow fur. The pulse is stringlike and rapid.

Various forms of spasm that occur in cases of liver blood vacuity or liver yīn vacuity are explained in terms of (liver) blood vacuity engendering wind or (liver) yīn vacuity stirring wind. Blood vacuity engendering wind manifests in dizziness and by numbness and tingling of the limbs. Yīn vacuity stirring wind manifests in dizziness, tinnitus, and wriggling of the extremities.

Cold stagnating in the liver vessel (寒滞肝脉 hán zhì gān maì) arises when externally contracted cold evil enters the liver channel to cause stagnation there. It is marked by cold pain on the pathway of the liver channel, usually in the lower abdomen and genitals, and in men, retracted scrotum, together with general repletion cold signs. The tongue is pale with a moist white tongue fur. The pulse is sunken and tight or stringlike and tight.

The Liver’s Relationships

Liver and Heart

The relationship between the liver and heart mainly concerns the blood and spirit-mind.

Blood: The heart governs the blood, whereas the liver stores the blood. Only when heart blood is abundant and heart qì is exuberant can blood flow be normal and the liver have blood to store. Conversely, only when the liver has plentiful amounts of blood to store and can meet the varying demand for blood needed for physical activity is the heart able to perform its function of propelling the blood. Hence, heart blood and liver blood are mutually reliant.

Insufficiency of heart blood can cause insufficiency of liver blood, and vice versa. In both cases, the result is heart-liver blood vacuity characterized by a lusterless complexion, heart palpitation, dizzy head or vision, and scant menstruation.

Spirit-mind: The heart governs the spirit, while the liver governs free coursing and regulation of the spirit-mind. A normal heart spirit is beneficial to the liver’s free coursing. Likewise, normal free coursing is beneficial to the heart spirit.

Disquieted heart spirit can affect the liver’s free coursing and emotional balance. Conversely, impaired free coursing can cause disquieted heart spirit. In both cases, the result is effulgent heart-liver fire characterized by heart vexation, insomnia, and impatience, agitation, and irascibility.

Liver and Lung

The liver governs free coursing; the lung governs regulation and management. The relationship between the liver and lung is mainly seen in the upward and downward bearing of qì. The liver governs upbearing, while the lung governs downbearing. These mutually complementary actions coordinate to ensure regulated qì dynamic throughout the whole body.

Liver affecting the lung: If the liver’s upbearing action is excessive, the result can be counterflow ascent of qì and fire, which manifests in cough and counterflow ascent of qì, in some cases with expectoration of blood. This is called liver fire invading the lung. In terms of five-phase theory, it is wood rebelling against metal when the restrained phase, wood, grows inordinately strong. Hence, it is also called wood fire tormenting metal.

Lung affecting the liver: When the lung’s clearing depuration is impaired, and dryness-fire is internally exuberant, this can affect the liver by inhibiting free coursing. When this happens, there is cough together with liver signs such as distending pain in the chest and rib-side, dizziness, headache, and red face and eyes. In terms of the five phases, this is wood rebelling against metal when the restraining phase, wood, grows inordinately weak.

Liver and Spleen

The spleen governs movement and transformation, is the source of qì and blood production, and controls the blood (prevents extravasation). The relationship between the liver and spleen is primarily seen in the mutual influence between the liver’s free coursing and splenic movement and transformation. Less importantly, the liver and spleen are related in the realm of production, storage, and movement of blood, and its retention in the vessels.

Digestion: Digestion is performed by the combined action of spleen and stomach qì, which is in turn dependent upon the liver’s free coursing. When free coursing is normal, the spleen performs its movement and transformation function adequately.

If liver’s free coursing action is deficient, it cannot assist the spleen’s upbearing action. This is called wood failing to course earth or more commonly liver-spleen disharmony. This is marked by depressed anger, mental depression, distension and fullness in the chest and rib-side, abdominal distension and pain, and sloppy stool or diarrhea.

Dampness arising internally owing to impaired splenic movement and transformation can, under the influence of heat or cold, develop into spleen-stomach damp-heat or cold-damp, which then invades the liver and gallbladder, giving rise to jaundice. Damp-heat steaming the liver causes the bile to discharge excessively and gives rise to yáng yellowing, characterized by a bright yellow complexion. Cold-damp obstructing the gallbladder hampers the flow of the bile, making it move in abnormal directions. The result of this is yīn yellowing, marked by a dark-yellow complexion.

Blood: When the spleen is healthy, it produces adequate supplies of blood and keeps it within the vessels, the liver has blood to store. If the spleen fails to produce blood and fails to control it and allows excessive bleeding, this can cause insufficiency of liver blood.

The liver’s function of storing blood and the spleen’s function of controlling the blood coordinate to prevent bleeding. When these two functions are disturbed, bleeding can develop in numerous forms, such as bloody stool, bloody urine, spontaneous bleeding of the flesh, nosebleed, bleeding gums, profuse menstruation, or flooding and spotting.

Liver and Kidney

The relationship between the liver and kidney is extremely close. The liver stores blood, while the kidney stores essence. The relationship between the two is threefold: (a) the relationship between blood and essence; (b) the complementarity of storage and free coursing; and (c) the yīn and yáng of the liver and kidney.

Liver and kidney are of the same source: The production of blood is dependent upon the qì transformation action of the essential qì in the kidney. The exuberance of kidney essential qì is dependent upon the nourishing action of the blood. Hence, it is said that essence can engender blood, and blood can engender essence. This is often also expressed as essence and blood are of the same source. For this reason, it is also said that liver and kidney are of the same source (肝肾同源 gān shen4 tong2 yuán).

Pathologies of essence and blood can give rise to each other:

• When kidney essence is damaged, this can cause insufficiency of liver blood.
• Conversely, when liver blood is insufficient, this can damage kidney essence.

In both cases, signs include dizzy head and vision, deafness, tinnitus, limp aching lumbus and knees.

Mutual complementarity of storage and free coursing: A mutually opposing and complementary relationship exists between the kidney’s storage function and the liver’s free coursing function, which primarily pertains to female menstruation and male ejaculation. The liver governs free coursing (encouraging flow of blood and semen), while the kidney governs storage (preventing loss of blood or semen). Imbalance between the two functions is often referred to as disharmony of storage and free coursing.

• In women, menstrual problems such as profuse menstruation or amenorrhea.
• In men, seminal emission (loss of semen during sleep) or seminal efflux (loss of semen when asleep or awake), or frequent and persistent erections without ejaculation.

Yīn and yáng of the liver and kidney: Because the liver and kidney are of the same source, the yīn and yáng of the liver and kidney are intimately related. Several imbalances are possible:

• Insufficiency of kidney yīn can cause insufficiency of liver yīn. This is called water failing to moisten wood.
• When liver yīn is insufficient and fails to counterbalance liver yáng, ascendant hyperactivity of liver yáng can develop.
• Insufficiency of liver yīn can give rise to depletion of kidney yīn and cause the ministerial fire to become hyperactive.
• Excessively exuberant liver fire can damage kidney yīn, causing insufficiency of kidney yīn.