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The process of diagnosing a morbid condition as a disease pattern of the liver.

Physiology Recap

The liver has two functions: governing free coursing and storing blood. Its channel is the foot reverting yīn (jué yīn) channel.

Free coursing of liver qì, which is understood to be upbearing and effusing like the upward and outward stretching of trees and plants (wood thrives by orderly reaching). Free coursing has the twofold action of regulating

• the flow and activity of qì throughout the body including the other viscera and
• affect-mind, preventing abnormal depression or excitement.

Free coursing can be disturbed by yīn-yáng imbalances and especially by emotional problems.

Storing blood is the liver’s capacity to withhold blood from circulation until it is needed for physical activity, ensuring sufficient blood especially for the liver, sinews, eyes, and the thoroughfare (chōng) and controlling (rèn) vessels.

Yīn blood and yáng qì: The liver has yīn and yáng aspects:

• Liver yīn is the physical substance, the blood, and the humor of the liver itself and its related organs, notably the sinews and eyes, as well as the quiescent aspect of liver function.
• Liver yáng is the liver’s qì and the active and warming aspects of its function.

Pathomechanical Features

A general characteristic of the liver is that its yáng qì tends toward hyperactivity, counterflow, and depression, while its yīn blood easily becomes depleted. This is meant by yáng is often superabundant, while 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 the yáng evils fire and wind, usually of internal origin. The liver channel may be affected by externally contracted cold evil.

Vacuity and repletion patterns of the liver are closely interrelated in complex ways.

Insufficiency of Yīn and Blood

Insufficiency of liver blood or liver yīn gives rise to the vacuity patterns of the liver.

Liver blood vacuity results from insufficiency of the stomach and spleen failing to produce sufficient blood; bleeding; enduring illness; or blood vacuity in other viscera affecting the liver.

• Eyes, sinews, nails, network vessels: Dizzy head and vision, dry eyes, blurred vision, hypertonicity of the sinews with inhibited bending and stretching; lusterless nails; numbness and tingling of the limbs due to the network vessels being deprived of nourishment.
• General blood vacuity signs: Pale face, pale lips, dizziness, and lack of strength.
• Women: Scant menstruation, pale menstrual discharge, or amenorrhea from insufficiency of liver blood depriving the thoroughfare (chōng) and controlling (rèn) vessels of nourishment.

In a further development, when liver blood is insufficient and fails to nourish the sinews, vacuity wind may arise (blood vacuity engendering wind). This manifests in mild forms of spasm, such as jerking sinews and twitching flesh, tremor of the extremities, or in itchy skin.

Liver yīn vacuity results from insufficiency of kidney yīn with water failing to nourish wood; from depressed liver qì transforming into fire, which damages kidney yīn; or from damage to liver yīn in the latter stages of warm disease.

• Main signs: Dizziness, dry eyes, and dull scorching pain in the rib-side arising when the liver channel, head and eyes, and sinews are deprived of nourishment, allowing vacuity heat to arise internally.
• General (kidney) yīn vacuity signs: Because the liver and kidney are of the same source and because the kidney is the root of the yīn and yáng of the entire body, there are signs of kidney yīn vacuity, such as dry mouth and throat and vexing heat in the five hearts.

Liver yīn vacuity can undergo further developments. When it deprives the sinews of nourishment, it can give rise to yīn vacuity stirring wind, marked by wriggling of the extremities. Liver yīn vacuity can also give rise to ascendant hyperactivity of liver yáng, a vacuity-repletion complex usually arising when the yīn vacuity causes yáng qì to become superabundant. Severe cases of ascendant hyperactivity of liver yáng can in turn give rise to liver yáng transforming into wind, which is another form of liver wind. These developments are explained further ahead.

Free Coursing Comparison: Deficient vs/Excessive
	Deficient Free Coursing	Excessive Free Coursing
Patterns	Depressed liver qì	Liver fire flaming upward; ascendant hyperactivity of liver yáng; liver yáng transforming into wind
Affect-mind	Depressed anger; frustration; moodiness	Fulminant anger; impatience, agitation, and irascibility
Main signs and their location	Mostly chest, rib-side, and abdomen signs: distending, scurrying, unfixed location in chest, rib-side, breasts, lesser abdomen; plum-pit qì	Upper body signs: distending pain in the head and eyes; red face and eyes, sudden tinnitus, or fulminant deafness.
Other features	Erratic signs: chaotic menstruation; stool sometimes sloppy sometimes bound	Frenetic movement of hot blood

Superabundance of Yáng Qì

Disturbances of the free coursing function and affect-mind abnormalities give rise to depressed liver qì or liver fire flaming upward, which are patterns of superabundance of yáng qì. Wind patterns, which also involve superabundance of yáng qì, will be discussed further ahead.

Depressed liver qì is qì stagnation resulting from impaired free coursing of the liver (肝失疏泄 gān shī shū xiè), which most commonly stems from affect-mind depression, frustration, dissatisfaction, and anger, from enduring illness, or from insufficiency of liver blood depriving the liver of its bearing (remember, blood bears qì, that is, allows it to move smoothly). Further factors are evils, especially dampness or phlegm, which inhibit the movement of qì.

• Channel signs: Distending pain in the rib-side, breasts, and lesser abdomen.
• Affect mind: Negative emotional states such as affect-mind depression, frustration, dissatisfaction, and anger affect the liver’s free coursing actionand are the main cause of depressed liver qì. Conversely, impaired free coursing owing to other factors can cause the same negative emotional states.
• Bile: Depressed liver qì affects the production and movement of bile, giving rise to bitter taste in the mouth or jaundice. This happens most commonly when damp-heat is the cause of depressed liver qì.
• Spleen and stomach: When liver qì becomes depressed, it can move cross-counterflow to invade the liver or the stomach, causing digestive problems.

Depressed liver qì frequently gives rise to the following developments:

• Water-damp and phlegm: Depressed liver qì hampers the movement of water. It can cause water to collect in the abdomen, giving rise to drum distension (as is seen in ascites). More commonly, qì stagnation hampers the movement of water-damp so that it thickens into phlegm, which in turn binds with qì to form plum-pit qì (lump sensation in the throat) or goiter (swelling of the neck). Phlegm and qì stagnation are mutually conducive, so they often occur together.
• Fire transformation: Depressed liver qì can also transform into fire, giving way to liver fire flaming upward.
• Blood stasis: Depressed liver qì hampers the movement of blood, causing blood stasis, which can manifest in abdominal masses or clotted menstrual discharge.

Liver fire flaming upward results from depressed liver qì transforming into fire; from fulminant anger causing excessive upbearing and effusion of liver qì; or from fire-heat evil invading the inner body and spreading from other viscera to the liver.

• Upper body signs: Liver fire manifests in qì and fire surging counterflow to the head and eyes, such as headache and distension in the head, red face and eyes, sudden tinnitus, or fulminant deafness.
• Channel signs: Scorching pain in the rib-side.
• Affect-mind: Impatience, agitation and irascibility, or even mania.
• Frenetic movement of hot blood: If liver fire damages the network vessels of the lung or stomach, there may be coughing of blood, nosebleed, or vomiting of blood.

Liver fire easily damages yīn-blood, giving rise to liver yīn vacuity. This in turn can give rise to ascendant hyperactivity of liver yáng.

Yīn Vacuity and Yáng Hyperactivity

When liver yīn is insufficient, it can fail to counterbalance liver yáng, giving rise to ascendant hyperactivity of liver yáng, which is a vacuity-repletion complex manifesting in dizziness, tinnitus, headache, distension in the head, heavy head and light feet, red face and eyes, and limp aching lumbus and knees.

Liver yīn vacuity, as previously noted, results from insufficiency of kidney yīn (water failing to nourish wood); from depressed liver qì transforming into fire, which damages kidney yīn; or from damage to liver yīn in the latter stages of warm disease. Ascendant hyperactivity of liver yáng is usually the result of the first of these factors, water failing to nourish wood.

Ascendant hyperactivity of liver yáng can give rise to a liver wind pattern called liver yáng transforming into wind, which is discussed below.

Wind

The liver is classically described as the viscus of wind and wood. This phrase hints at the original conception of the liver as the living wood in the body. The sinews of the body allow the bending and stretching of limbs, just as branches of trees bend and straighten as they sway in the wind. Abnormal movements of the limbs are seen to resemble a strong wind shaking the branches of trees. Loss of movement, as in hemiplegia and paralysis, is understood to resemble a violent wind that snaps the branches of trees and hence is attributed to wind stroke. Resistance to the detrimental effects of wind requires that sinews be kept nourished and moistened by yīn-blood, just as trees are kept supple by a copious supply of sap. In addition to abnormal movements of the sinews, wind affecting the liver can cause dizziness, which is conceived of as a swirling inside the head. Hence, the Sù Wèn states, all wind with shaking and dizzy vision is ascribed to the liver (风掉眩，皆属于肝 zhū fēng diào xuàn, jiē shǔ yú gān).

Originally, liver wind was attributed to external wind but was later reassigned to internal wind. Hence, many conditions of spasm and dizziness are ascribed to liver wind stirring internally.

In the modern Chinese-language literature, liver wind stirring internally is usually described as taking one of four patterns:

• Liver yáng transforming into wind, which manifests in dizziness, headache, numbness, and in severe cases clouding collapse that can leave the patient with hemiplegia. This results from severe yīn vacuity and yáng hyperactivity.
• Extreme heat engendering wind, which manifests in convulsions and arched-back rigidity. It is seen in warm disease when intense heat causing vigorous heat effuse transforms into wind.
• Blood vacuity engendering wind, which manifests in tremor of the extremities and twitching of the flesh and dizziness. It stems from insufficiency of blood. There is a variant form called blood dryness engendering wind characterized by itchy and scaling skin (the itching being attributable to wind).
• Yīn vacuity stirring wind due to severe humor desertion: Tremor and wriggling of the extremities.

Disturbances of Free Coursing

Superabundance of liver qì is seen in depressed liver qì, liver fire flaming upward, and ascendant hyperactivity of liver yáng. To better understand these conditions, it is useful to focus on the ways in which free coursing is affected by superabundance of liver qì.

Impaired free coursing takes two forms, deficient and excessive. Deficient free coursing manifests in failure of qì to move properly, while excessive free coursing is excessive upward and outward movement of qi.

In depressed liver qì, free coursing is deficient, while in liver fire flaming upward, ascendant hyperactivity of liver yáng, liver yáng transforming into wind, and extreme heat engendering wind, free coursing is excessive.

Deficient and excessive free coursing are associated with different affect-mind states, with different abnormalities in different body areas, and with different specific signs.

Deficient free coursing (疏泄不及 shū xiè bù jí) is insufficiency of the upbearing and effusing action of liver qì observed in depressed liver qì, which is the most common form of qì stagnation and hence a repletion pattern. Deficient free coursing means deficient activity of qì, not insufficiency of qì itself, so that the resulting pattern is one of repletion, not vacuity. Deficient free coursing is marked by the following four categories of signs.

Affect-mind depression, and frustration, and anger, and what in the modern world we call stress are usually considered to be the causes of deficient free coursing, but they may also arise as a result of deficient free coursing caused by other factors such obstructive evils. Emotional frustration and deficient free coursing are mutually conducive and hence regarded as two sides of the same coin. We experience frustration in life when we fail to achieve the desired results of our efforts; deficient free coursing is failure qì to produce its normal effects.

<>Anger is classically said to be the mind of the liver. In practice, the issue is more complex. Anger is closely associated with frustration and dissatisfaction. Mental depression and lack of motivation contribute to frustration, as do excessive thinking about problems and worry or fear about outcomes. Some Chinese-language texts describe the anger associated with frustration, depression, and stress, as depressed anger (郁怒 yù nù).

Distending pain, pain of unfixed location, scurrying pain. These are signs of qì stagnation. Occurring in depressed liver qì, they affect the pathway of the liver channel, notably the rib-sides, breasts, and lesser abdomen.

Spleen and stomach problems: Liver qì running cross-counterflow (肝气横逆 gān qì héng nì) is an excessive lateral movement of depressed liver qì that affects the spleen or stomach. Affecting the stomach, it can cause distension and pain in the stomach duct, belching, and vomiting. Affecting the spleen, it causes distension and pain in the stomach duct and abdomen, sloppy stool, diarrhea and/or constipation.

Erratic functions: Depressed liver qì can manifest stop-and-go signs such as menstruation at irregular intervals (sometimes advanced and sometimes delayed); stool that is sometimes sloppy and sometimes bound; and emotionality (abnormal laughing and weeping).

Excessive free coursing (疏泄太过 shū xiè tài guò) is excessiveness of liver qì’s upbearing and effusing action. It is often referred to as upbearing and stirring (升动 shēng dòng) or liver qì ascending counterflow (肝气上逆 gān qì shàng nì). It is observed in three liver patterns:

Insufficiency of Liver Qì and Liver Yáng?
The terms insufficiency of liver qì and insufficiency of liver yáng do appear in the literature, but usually refer specifically to a disturbance of decision-making, more commonly associated with the gallbladder, that manifests in susceptibility to fright and fear. Insufficiency of liver qì is sometimes also adduced to explain liver failing to store blood.

• liver fire flaming upward, which manifests in upper body heat signs;
• ascendant hyperactivity of liver yáng, which manifests in upper body signs of yáng exuberance; and
• liver yáng transforming into wind, which manifests in sinew-related signs, such as unsteady gait, clouding collapse, hemiplegia, and deviated eyes and mouth.

Excessive free coursing is marked by the following three categories of signs:

Affect-mind: Mild disturbances of affect-mind are impatience, agitation, and irascibility, which are commonly seen in liver fire flaming upward and ascendant hyperactivity of liver yáng. Sudden flights of fulminant anger reflect more severe excessive upbearing and effusion that carries blood up to the head. People who are prone to impatience, agitation, and irascibility may frequently suffer from fulminant anger (暴怒 bào nù), that is, flights of overt anger.

Upper body signs: In mild cases, as often seen in liver flaming upward, there is dizziness, red eyes, and distending pain in the head and eyes. In severe cases, often associated with sudden, violent bouts of anger (fulminant anger), qì and fire ascending counterflow can carry blood upward to the head to cause headache and distension in the head, red face and eyes, sudden tinnitus, or fulminant deafness. Qì-fire ascending counterflow can also cause stiff nape, nausea, vomiting, vexation and agitation, and fear of light. In severe cases, there may be clouding reversal. This is called forceful reversal (薄厥 bó jué), which may result in death.

Frenetic movement of hot blood: In some cases, often associated with fulminant anger, liver fire stirs the blood to cause bleeding especially in the upper body, notably expectoration of blood, nosebleed, or vomiting of blood. Vomiting of blood is attributed to liver fire invading the stomach, explained in terms of fire-qì running cross-counterflow with blood running counterflow with qì.

In ascendant hyperactivity of liver yáng, excessive free coursing may give rise to wind. This is called liver yáng transforming into wind, which manifests in abnormal movement or non-movement of the sinews. In mild cases, there is shaking of the head and unsteady gait. In severe cases, excessive free coursing and internal wind cause clouding collapse, leaving the patient with deviated eyes and mouth, sluggish speech, hemiplegia, and phlegm rale in the throat. This is wind stroke.

Lastly, it is important to understand the difference between excessive free coursing and wind. While excessive free coursing manifests in signs of excessive upbearing and effusion in the upper body, wind is characterized by abnormal movement or non-movement of the sinews. Internal wind arising by other pathomechanisms other than liver yáng transforming into wind, that is, blood vacuity, yīn vacuity, or extreme heat, is not normally explained in terms of excessive free coursing, since signs of upsurge of qì are absent.

Cold and Phlegm

Cold: Externally contracted cold can affect the liver channel causing cold pain in the lesser abdomen; sagging, distension, and pain in the genitals, in some cases, with painful retraction of the scrotum.

Phlegm: Although the word phlegm does not occur in the name of any basic disease pattern of the liver, phlegm and depressed liver qì are mutually conducive and hence are often seen together (see, for example, phlegm clouding the heart spirit). Wind-phlegm is a factor in wind stroke, plum-pit qì, goiter, and scrofula.

Phlegm also figures in gallbladder disease, where it usually occurs in combination with heat. Phlegm-heat develops under the influence of depressed liver qì.

Blood Stasis

Severe liver qì depression gives rise to blood stasis. Hence, depressed liver qì patterns are often complicated by stasis. This is seen most prominently in women suffering from menstruation at irregular intervals due to depressed liver qì when they develop blood stasis signs such as acute lesser abdominal pain and clotted menstrual discharge.

Women

Women
Menstrual irregularities are related to the availability of blood and to movement of blood in the thoroughfare (chōng) and controlling (rèn) vessels. The spleen, liver, and kidney each play roles in both the supply and movement of blood. In addition, movement can be hampered by the presence of evils.

Menstruation can be affected by insufficiency of liver blood or by deficient free coursing. Excessive free coursing is an upper-body phenomenon, which does not affect menstruation.

• Liver blood vacuity causes depletion of thoroughfare (chōng) and controlling (rèn) vessels, giving rise to scant menstruation, pale menstrual discharge, or amenorrhea.
• Depressed liver qì can affect inhibit the flow of the blood in the thoroughfare (chōng) and controlling (rèn) vessels, causing menstrual irregularities, menstrual pain, or amenorrhea.

Liver and Gallbladder

The liver and gallbladder stand in exterior-interior relationship. The discharge of bile is controlled by the liver’s free coursing action. In addition, the liver governs the making of strategies, while the gallbladder governs decision-making. Hence, liver and gallbladder pathologies are closely interrelated and mutually conducive.

Gallbladder patterns typically occur with liver disturbances. They are classed as gallbladder patterns because they involve disturbances in the discharge of bile or impairment of decision-making, resulting in timidity and susceptibility to fright.

Most modern Chinese-language diagnostic textbooks include two patterns involving the gallbladder: liver-gallbladder damp-heat and depressed gallbladder and harassing phlegm. Other gallbladder patterns, such as gallbladder qì vacuity and gallbladder heat, are described in detail in reference works but do not normally figure among the main patterns discussed in textbooks.

Liver-gallbladder damp-heat arises when damp-heat arising in or affecting the spleen, marked by digestive tract signs, affects the liver’s free coursing (congested earth rebelling against the liver) giving rise to distending pain in the rib-side. Damp-heat can also pour downward through the liver channel to cause genital conditions. Impaired free coursing affects the gallbladder in different ways: affecting the lesser yáng (shào yáng) channel, it gives rise to alternating cold and heat; affecting bile, it gives rise to jaundice.

Jaundice was traditionally explained in terms of the spleen. It came to be reassigned to the gallbladder under the influence of the biomedical understanding of bile providing the skin coloration. The other major manifestations of liver-gallbladder damp-heat are directly related to damp-heat. According to modern texts, jaundice of a duller coloration is explained as being due to cold-damp affecting the gallbladder. However, this is discussed under cold-damp encumbering the spleen, not under gallbladder patterns.

Depressed gallbladder and harassing phlegm is a pattern of depressed liver qì with phlegm transforming into heat. It is marked by signs of depressed liver qì and phlegm heat with marked spirit disturbances: gallbladder timidity and susceptibility to fright; insomnia and profuse dreaming; bitter taste in the mouth; oppression in the chest and rib-side.

Gallbladder qì vacuity is marked by disturbances of the gallbladder’s governance of decision-making, that is, inability to make decisions, gallbladder timidity and susceptibility to fright, as well as signs that are otherwise associated with the heart: fright palpitation; insomnia with profuse dreaming and tendency to wake easily from sleep.

Synopsis of Causes of Liver Disease

• Enduring illness, advancing age, and loss of blood give rise to liver blood vacuity or liver yīn vacuity.
• Anger and frustration can cause depressed liver qì.
• Heat from external evils, liver qì transforming into fire, smoking, or alcohol can cause liver fire or ascendant hyperactivity of liver yáng.
• Phlegm and dampness, by their obstructive effect, can cause depressed liver qì and easily affect the gallbladder.
• Externally contracted cold can cause cold congealing in the liver vessel.

Relationship to Other Bowels and Viscera

Heart and Liver

The heart governs the blood and the liver stores blood. The heart stores the spirit, while the liver governs free coursing, a function that is intimately related to affect-mind disturbances. Pathologies involving the liver and heart are related to blood vacuity and fire. In both cases, there are affect-mind disturbances.

Since wood engenders fire in the five phases, pathologies involving the liver and spleen can be explained in terms of disease of the mother affecting the child or disease of the child affecting the mother.

Blood vacuity: When heart blood is insufficient, disease of the child can affect the mother, causing insufficiency of liver blood. When liver blood is depleted, disease of the mother can affect the child, causing insufficiency of heart blood. In either case, the result is heart-liver blood vacuity.

This manifests in heart blood vacuity signs such as heart palpitation, insomnia, profuse dreaming, pale-white complexion, pale tongue, a pulse that is fine and weak, combined with liver blood vacuity signs such as blurred vision, hypertonicity of the sinews, and lusterless nails.

Fire: When heart fire is hyperactive, disease of the child can affect the mother, causing effulgent liver fire. When there is liver fire flaming upward, disease of the mother can affect the child, causing hyperactive heart fire. The resulting pattern is called effulgent liver-heart fire.

Hyperactive heart fire is reflected in heart vexation, insomnia, and in severe cases manic agitation. Liver fire is reflected in impatience, agitation, and irascibility.

Lung and Liver

The lung and liver both have important functions as regards qì, notably the lung’s downbearing action and the liver’s upbearing action. In pathology, the two viscera tend to affect each other in the presence of heat.

• When exuberant dryness heat in the lung impedes diffusion and downbearing actions, this can affect the liver and inhibit free coursing. This manifests as cough with distension and fullness in the chest and rib-side, headache, dizzy head, and red face and eyes.
• When liver fire causes excessive upbearing of liver qì, it can invade the lung and cause cough in addition to liver heat signs (wood fire tormenting metal).
• Depressed liver qì affecting qì dynamic in the lung causes sighing. It can also cause or exacerbate the formation of phlegm. In severe cases, depressed liver qì can affect breathing, giving rise to panting and counterflow ascent of qì.

Spleen-Stomach and Liver

In physiology, the relationship between the spleen and liver concerns free coursing, movement and transformation, and the production of blood. In pathology, the mutual influence of these two viscera occurs in digestive disorders, dampness disease, and the production and movement of blood.

Digestive disorders: The spleen qì is reliant on the liver’s free coursing action to perform its functions. Especially when spleen qì is weak, depressed liver qì arising from excesses among the seven affects can deprive the spleen of this action, and this is called wood failing to course earth (木不疏土 mù bù shū tǔ). In such cases, liver qì moving cross-counterflow to affect the spleen causes disturbances of the movement and transformation function. This pathomechanism is called liver depression invading the spleen (肝郁犯脾 gān yù fàn pí) or liver depression overwhelming the spleen (肝郁乘脾 gān yù chéng pí). The resulting pattern is one of liver-spleen disharmony (肝脾不和 gān pí bù hé). When, as is usually the case, spleen qì vacuity is a factor, it is called liver depression and spleen vacuity (肝郁脾虚 gān yù pí xū). This manifests in distending pain in the rib-side, affect-mind depression, reduced eating, abdominal distension, and sloppy stool. Similarly, depressed liver qì can also invade the stomach (肝气犯胃 gān qì fàn wèi), causing liver-stomach disharmony (肝胃不和 gān wèi bù hé), which manifests in distending pain in the stomach duct, belching, nausea, and vomiting.

Disharmony between liver and spleen-stomach usually starts with the liver. However, because the liver’s free coursing action is to some extent dependent upon normal splenic movement and transformation, impaired splenic movement and transformation can impair the liver’s free coursing. This is called congested earth depressing wood (土壅木郁 tǔ yōng mù yù). Here, signs of depressed liver qì develop in a patient previously suffering from spleen vacuity.

Dampness disease: Deficient free coursing can cause or exacerbate an impairment of the spleen’s function of moving and transforming dampness. Since dampness can form with heat or cold, either damp-heat or cold-damp may arise.

Either damp-heat or cold-damp may bind in the liver and gallbladder, disturbing the liver’s free coursing and the gallbladder’s discharge of bile.

Damp-heat affecting the liver and gallbladder results in liver-gallbladder damp-heat. This is marked by distending pain in the right rib-side, abdominal distension, bitter taste in the mouth, aversion to greasy foods, nausea, and vomiting. When bile spills out to the skin, there is jaundice marked by the bright color of tangerines.

Cold-damp affecting the liver and gallbladder results in jaundice characterized by a dull yellow coloration.

Production and movement of blood: Pathological influences between the spleen and liver can be seen in blood vacuity, blood stasis, and bleeding.

Blood vacuity: Blood vacuity arises when impaired movement and transformation causes insufficiency of the source of blood formation or when the spleen failing to control the blood causes great blood loss. Blood vacuity, in turn, can affect the liver, causing insufficiency of liver blood. Insufficiency of liver blood can, in turn, weaken splenic movement and transformation. The resulting condition is marked by dizziness, blurred vision, reduced eating, abdominal distension, fatigue and emaciation, numbness of the limbs, scant menstruation, or amenorrhea.

Blood stasis: Blood stasis can arise when liver depression invading the spleen persists for a long time or when damp-heat or damp-cold in the center burner affects the spleen causing qì stagnation and blood stasis. This can manifest in lumps under the rib-side, enlarged abdomen with fullness and hardness, and protrusion of the blood vessels on the surface of the abdomen (caput medusae ).

Bleeding: According to some sources, the spleen failing to control the blood and liver failing to store the blood are mutually conducive disorders that manifest in various kinds of bleeding.

Liver Failing to Store Blood

Storing blood usually means ensuring sufficient supplies of blood to nourish the liver itself and its related organs. Hence, the liver failing to store blood means the liver not having enough blood to provide nourishment, that is, insufficiency of liver blood. According to one traditional view, storing blood also includes the function of containing the blood within the vessels, that is, the prevention of bleeding (vomiting of blood, expectoration of blood, nosebleed, and in women, profuse menstruation or flooding and spotting). This is variously explained in terms of liver qì retaining the blood, liver yīn governing congealing, and/or liver blood being sufficient to counteract excessive upbearing and stirring of yáng qì that can stir the blood. While modern scholars recognize preventing bleeding as part of the liver’s function of storing blood, they argue that the liver failing to store blood causes bleeding usually only when other factors are involved. The fact that treatments address the other factors suggests that these are the most important. Liver qì vacuity failing to retain the blood occurs with the spleen failing to control the blood and is treated by fortifying the spleen. Liver yīn vacuity failing to congeal the blood occurs with qì vacuity, so that in treatment enriching liver yīn-blood is complemented by a qì-supplementing action. Liver fire involves counterflow ascent of qì, and in treatment clearing and draining of liver fire is complemented by a qì-downbearing action. Standard textbook listings of causes of bleeding do not include the liver failing to store the blood. They generally ascribe bleeding to: damage to blood vessels in trauma static blood blocking the vessels and preventing the blood from pursuing its normal courses spleen failing to control the blood (qì failing to contain the blood) or fire-heat or yīn vacuity with effulgent fire causing frenetic movement of hot blood or, the case of upper-body bleeding, fire-qì ascending counterflow, forcing blood upward. This would suggest a modern view that bleeding that may have been previously ascribed by some to the liver failing to store blood can be simply explained in terms of fire-qì ascending counterflow (as when liver fire causes vomiting of blood or nosebleed) or by the spleen failing to control the blood. This is borne out by standard modern Chinese diagnostic texts: These generally do not recognize liver qì vacuity as a pattern and attribute qì failing to contain the blood to the spleen failing to control the blood. They do not include profuse menstruation or flooding and spotting in any liver pattern. They suggest that these signs can occur in kidney yīn vacuity as a result of vacuity fire. Of course, liver yīn vacuity often stems from kidney yīn vacuity (water failing to moisten wood) and hence the two often occur together. Furthermore, modern texts state that liver fire flaming upward can be responsible for upper body bleeding but attribute it directly to the effect of fire rather than to the liver failing to store blood.

Causes of and Interrelationships Between Patterns

Liver and gallbladder patterns have numerous causes and evince more complex causal interrelationships than those of any other bowel or viscus.

• Liver blood vacuity is caused by insufficient blood production by the spleen, enduring illness, or blood loss. It can give rise to liver wind (blood vacuity engendering wind).
• Liver yīn vacuity can develop from damage to yīn by liver fire (often caused by depressed liver qì transforming into fire) or in advanced-stage warm-heat disease, from enduring illness, or from kidney yīn vacuity (water failing to moisten wood). It can cause liver wind (yīn vacuity stirring wind). It is also disposing factor for the development of ascendant hyperactivity of liver yáng, which in turn can give rise to liver yáng transforming into wind.
• Depressed liver qì can caused by anger and frustration, by damp-heat or cold-damp developing in the spleen, or by liver blood vacuity. It can transform into fire, giving rise to liver fire. It also affects the gallbladder, causing dampness and phlegm to bind there.
• Liver fire flaming upward can develop from depressed liver qì or from splenic damp-heat or external evils). It can give rise to liver yīn vacuity.
• Ascendant hyperactivity of liver yáng is caused by liver-kidney yīn vacuity or from depressed liver qì transforming into the fire and damaging yīn. It easily gives rise to liver wind (liver yáng transforming into wind). Since it involves superabundance of yáng, it can also cause liver fire flaming upward.
• Liver wind stirring internally can arise when ascendant hyperactivity of liver yáng unleashes a process of liver yáng transforming into wind, causing wind stroke. Milder forms can result from liver blood vacuity or liver yīn vacuity. Thus, liver wind stirring internally can be the direct result of any of three liver patterns; it may also be the culmination of one or more conversions of liver patterns. It can also occur in febrile disease as a result of extreme heat engendering wind.
• Cold stagnating in the liver vessel is caused by externally contracted cold.
• Liver-gallbladder damp-heat arises when damp-heat brewing in the spleen binds in the gallbladder under the influence of depressed liver qì.
• Depressed gallbladder and harassing phlegm arises when phlegm stemming from failure of the spleen to warm and transform water-damp develops into phlegm-heat and binds in the gallbladder under the influence of depressed liver qi.

Liver Signs

Liver signs are the most numerous and varied of all bowel and visceral signs. They include channel signs, head and eye signs, affect-mind signs, sinew signs, and menstrual signs.

Head and Eyes

Headache (头痛 tou2 tong4): Any pain in the head. It can arise when qì and blood are obstructed or when they are insufficient and fail to nourish the head. In liver disease, it figures prominently in ascendant hyperactivity of liver yáng, which is often characterized by pain on both sides or at the vertex, often associated with dizziness.

Distending pain in the head and eyes (头目胀痛 tou2 mù zhang4 tong4): A painful sensation of pressure in the head and eyeballs. It occurs in ascendant hyperactivity of liver yáng.

Clouding reversal (昏厥 hun1 jué): Sudden loss of consciousness resulting from disruption of qì, most commonly liver qì ascending counterflow in ascendant hyperactivity of liver yáng, which can carry blood upward to the head, causing loss of consciousness.

Dizziness ( 头晕目眩 tou2 yun1 mù xuàn, 眩晕 xuàn yun1): A subjective feeling of fogginess, often called clouded head (头昏 tou2 hun1) or, in more severe cases, of spinning within the head and visual disturbances. A distinction is made between dizzy head (头晕 tou2 yun1) and dizzy vision (目眩 mù xuàn), although the two are not always clearly distinguishable. Dizziness is attributed to insufficiency of qì and blood depriving the head and eyes of nourishment or to evils (fire, wind, phlegm-rheum, static blood) disturbing the normal movement of qì and blood. Dizziness that threatens collapse (眩晕欲仆 xuàn yun1 yù pū) is severe dizziness that causes a loss of balance; it indicates liver wind stirring internally. Because of its wide range of causes, dizziness appears in many disease patterns:

• qì and/or blood vacuity;
• liver and/or kidney yīn vacuity;
• ascendant hyperactivity of liver yáng (liver yáng transforming into wind);
• liver fire flaming upward;
• wind-phlegm;
• phlegm-rheum or phlegm-damp;
• blood stasis caused by trauma.

Dizzy vision (目眩 mù xuàn): Also called flowery vision (目花 mù hua1). When the visual field appears to turn or move, as if one were on a moving boat or vehicle, or when flies appear to cross the eyes (mouches volantes), this is called dizzy vision. Vacuity patterns include from liver-kidney yīn vacuity, where depletion of essence and blood deprives the eyes of nourishment, and spleen vacuity qì fall with clear yáng failing to ascend. Repletion patterns include wind-fire harassing the clear orifices and phlegm-damp clouding the clear orifices.

Fulminant deafness (暴聋 bao4 long2) is sudden and severe deafness, as if the ears were plugged. It is associated with bitter taste in the mouth, headache, nasal congestion. It is attributable to liver-gallbladder fire rising to the head through the channel or to external evils affecting the lesser yáng (shao4 yáng) channel, which passes through the ears. Fulminant deafness stands in contrast to gradual deafness, which is attributable to insufficiency of kidney essence.

Tinnitus (耳鸣 er3 ming2) is ringing or other sounds subjectively felt in the ear. A distinction is made between vacuity and repletion.

Repletion: Tinnitus of sudden onset that is like the prolonged low croaking sound of a frog, the rushing sound of the sea on the shore and that continues when the ears are pressed is ascribed to repletion and is mostly associated with exuberant liver-gallbladder fire or phlegm-fire.

Vacuity: Tinnitus that develops gradually, is faint like the sound of cicadas or mosquitoes and is relieved by pressure is ascribed to vacuity. It is usually attributable to liver-kidney yīn vacuity, ascendant hyperactivity of liver yáng, or insufficiency of kidney essence. It can also occur in spleen vacuity qì fall.

Heavy head and light feet (头重脚轻 tou2 zhong4 jiao3 qing1): A feeling of top-heaviness. It occurs in ascendant hyperactivity of liver yáng. The heavy head reflects yáng hyperactivity in the upper body, while the light feet reflect the liver-kidney yīn vacuity in the lower body.

Dry eyes (目干涩 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, colloquially often described in as blood-shot eyes (as from conjunctival hyperemia). This condition, sometimes referred to as fire eye, is usually attributable to externally contracted wind-heat (wind-fire eye) or epidemic toxin (heaven-current red eye). These forms are equivalent to acute conjunctivitis in biomedicine. Other possible causes include liver fire flaming upward, ascendant hyperactivity of liver yáng, liver-kidney yīn vacuity, and intense heart fire. In some cases, red eyes are associated with copious eye discharge.

Clouded vision (目昏 mù hun1) and double vision (视歧 shì qí, 视一为二 shì yi1 weí er4): Clouded vision, also called blurred vision (视物模湖 shì wù mo2 hu2) is blurred vision is the inability to see objects clearly. Double vision is seeing one object as two. Both conditions are mostly caused by liver-kidney depletion with insufficiency of essence and blood depriving the eyes of nourishment. They occur in the elderly, in people with weak constitutions, and in patients in a weak state of health resulting from enduring illness.

Affect-Mind

Affect-mind depression (情志优郁 shen2 zhì yoū yù): A depressed emotional and mental state marked by moodiness, depressed anger (irritability, grumpiness), excessive worry, and emotionality (unusual laughing or weeping). It is associated with depressed liver qì.

Impatience, agitation, and irascibility (急躁易怒 jí zao4 yì nù): A habitually agitated state of mind that manifests in an impatient attitude to others, rash behavior, and sudden flights of anger (fulminant anger). It is a sign of excessive free coursing and occurs in ascendant hyperactivity of liver yáng and in liver fire flaming upward.

Sinews

Hypertonicity of the sinews (筋脉拘挛 jīn maì jū luan2): Also called hypertonicity of the limbs (四肢拘急 sì zhi1 jū jí). Tension in the sinews marked by inhibited bending and stretching. In liver disease, it is attributed to liver blood vacuity, but there are numerous other causes: cold-damp; damp-heat; external contraction of wind-cold; exuberant heat; yáng collapse; and humor desertion.

Stiff nape (项强 xiang4 jiang4): Stiffness and discomfort in the back of the neck. In liver disease, it is a sign of liver yáng transforming into wind. Stiff nape may also be caused by externally contracted wind-cold or wind-damp, by damage to liquid by evil heat, or by wind toxin entering wounds (lockjaw). When severe, it is often referred to as rigidity of the nape and neck (颈项强直 jing3 xiang4 jiang4 zhí), which is associated with extreme heat engendering wind or with lockjaw, which is caused by external wind toxin damage.

Convulsions (抽搐 choū chù): Also called tugging and slackening (瘈瘲 chì zong4). Convulsions are pronounced involuntary movements of the limbs. They occur in liver wind stirring internally.

Clenched jaw (牙关紧闭 ya2 guān jin3 bì): A tightly closed jaw, called trismus in biomedicine. It occurs most commonly in fright wind caused by extreme heat engendering wind, in lockjaw caused by external wind toxin damage, and other tetanic disease patterns.

Arched-back rigidity (角弓反张 jiao3 gōng fan3 zhang1): Arched-back rigidity, known in biomedicine as opisthotonos, is an involuntary arching of the spine. It is a sign of liver wind stirring internally.

Jerking sinews and twitching flesh (筋惕肉膶 jīn tì roù shun4); wriggling of the extremities (手足蠕动 shoǔ zu2 ru2 dong4); tremor of the extremities (手足震颤 shoǔ zu2 zhen4 chàn): Jerking sinews and twitching 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.

Shaking of the head (头摇 tou2 yao2): Uncontrollable wobbling of the head. It is a sign of liver yáng transforming into wind.

Unsteady gait (步履不正 bù lu94 bù zheng4, 步履不稳 bù lu94 bù wen3): Inability to walk smoothly and straight. It is a sign of liver yáng transforming into wind.

Hemiplegia (半身不遂 bàn shen1 bu2 suì): Paralysis of one side of the body; a major sign of wind stroke.

Deviated eyes and mouth (口眼喎斜 koǔ yan3 wai1 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. It can occur in wind stroke with hemiplegia (mostly attributed to wind-phlegm) but may occur on its own (in which case it corresponds to Bell’s palsy and is usually attributed to external wind).

Numbness and tingling of the limbs (肢体麻木 zhi1 ti3 ma2 mù): Reduced or abnormal sensation in the skin and flesh. In liver disease, it is mainly attributed to liver blood vacuity depriving the network vessels of nourishment. Other causes include wind-cold entering the network vessels; qì stagnation and blood stasis; liver wind stirring internally; wind-phlegm obstructing the network vessels; damp-heat.

Nails

The nails are the surplus of the sinews. Their condition reflects the state of liver yīn-blood.

Pale nails (爪甲色淡 zhao3 jia3 se4 dàn): Nails that are pale in color. They are the result of liver blood vacuity depriving the nails of nourishment.

Lusterless nails (爪甲不荣 zhao3 jia3 bù rong2): Nails that lack a fresh, bright coloring and luster. They are the result of liver blood vacuity depriving the nails of nourishment. A more severe condition of dry nails (爪甲干枯 zhao3 jia3 gān kū) is attributable to severe depletion of liver blood and liver yīn.

n>def3,liver pattern identification

Women

Menstrual Irregularities
Timing	Volume	Color	Consistency
Qì Vacuity
Advanced; chaotic	Scant or profuse	Pale-red	Thin
Blood Vacuity
Delayed	Scant	Pale-red	Thin
Congealing cold and blood stasis
Delayed; amenorrhea	Scant	Dark purple	Clotted
Qì stagnation (depressed liver qì)
Delayed; amenorrhea	Scant	Purple-red	Clotted
Blood Stasis
Amenorrhea	Scant or profuse	Dark-red	Clotted
Phlegm-Damp
Delayed; amenorrhea	Scant
Blood heat (depressed liver qì transforming into fire; yīn vacuity with effulgent fire)
Advanced	Profuse	Deep-red	Thick

The liver’s functions of storing blood and free coursing exerts a strong influence over the thoroughfare (chōng) and controlling (rèn) vessels, which control menstruation and gestation.

Note that menstrual irregularities are related to the availability of blood and to movement of blood in the thoroughfare (chōng) and controlling (rèn) vessels. The spleen, liver, and kidney each play roles in both the supply and movement of blood. In addition, movement can be hampered by the presence of evils.

Menstrual irregularities (月经不调 yuè jīng bù tiáo): Any abnormality of the timing of periods or of the color, consistency, or smell of the menstrual discharge. In liver disease, menstrual irregularities are mostly attributed to liver blood vacuity or depressed liver qì.

• Liver blood vacuity: scant menstruation with pale discharge.
• Depressed liver qì: delayed menstruation; menstruation at irregular intervals; abdominal pain before or during menstruation.
• Blood stasis resulting from depressed liver qì: Menstruation at irregular intervals; amenorrhea.

Menstrual pain (痛经 tòng jīng): Abdominal pain during or around the time of the menstrual period. In liver diseases, it mostly results from depressed liver qì, especially when qì stagnation causes blood stasis. Menstrual pain can also be attributable to dual vacuity of the qì and blood, congealing cold or yáng vacuity, or damp-heat.

Amenorrhea (闭经 bì jīng): Absence of the menses after menarche and before menopause. It is attributed to depressed liver qì, qì stagnation and blood stasis (liver depression and qì stagnation giving rise to blood stasis), liver blood vacuity, dual vacuity of qì and blood, or phlegm-damp or congealing cold and phlegm obstruction attributable to yáng vacuity. Hence, this is a condition in which impairment of the blood storage and free coursing functions of the liver are prominent.

Pulse

Stringlike (弦 xián): A stringlike pulse is usually seen in repletion patterns of the liver.

Fine (细 xì): A fine pulse is usually seen in vacuity patterns of the liver.

Liver Diseases

Specific diseases are mostly related to the liver rather than the gallbladder. Rib-side pain, headache, and dizziness, traditionally regarded as diseases as well as symptoms, are discussed under Liver Signs above.

Epilepsy (癫痫 diān xián): A disease marked by brief episodes (seizures) in which there are spasms and temporary loss of spirit.

• Mild cases: Temporary loss of spirit, white complexion, and fixity of the eyes.
• Severe cases: Sudden clouding collapse, foaming at the mouth, upward-staring eyes, clenched jaw, convulsion of the limbs, and even squealing like a goat or pig.

The convulsions are explained by internal wind, while the loss of consciousness is explained by the wind carrying phlegm upward to cloud the heart spirit. The term fright epilepsy, which is commonly seen in traditional literature, refers to epileptic fits triggered by fright or emotional shock.

Wind stroke (中风 zhòng fēng): A disease characterized by the sudden development of deviated eyes and mouth, stiff tongue and sluggish speech, and hemiplegia, sometimes heralded by sudden collapse and loss of consciousness, from which recovery may not be total. The classical form corresponds to what we call stroke (apoplexy, cerebrovascular accident ). Mild forms with only deviated eyes and mouth correspond to facial paralysis (Bell’s palsy ) in biomedicine.

Originally ascribed to externally contracted wind evil, wind stroke was later attributed in many cases to internal causes, primarily liver wind stirring internally, which arises most commonly when insufficiency of kidney and liver yīn fails to keep liver yáng in check so that liver yáng becomes hyperactive and transforms into wind. Phlegm is invariably a factor in wind stroke too, so the cause of the disease is often described as wind-phlegm. Blood stasis may also be a factor.

In modern clinical practice, a broad twofold distinction is made:

Channel and network strike(中经络 zhòng jīng luò): This manifests in deviated eyes and mouth, in severe cases with hemiplegia and inhibited speech, but without any impairment of spirit-mind. It is attributed to external wind, internal wind or a combination of both. When only the face is affected, this corresponds to facial paralysis in biomedicine.

Bowel and visceral strike (中脏腑 zhòng jīng luò) This differs in that the condition is heralded by sudden collapse and loss of consciousness. Here, a further twofold distinction is made between block and desertion patterns.

Wind stroke block patterns (中风闭证 zhòng fēng bì zhèng) are characterized by clenched jaw, clenched fists, hypertonicity of the limbs, and urinary and fecal stoppage.

Wind stroke desertion patterns (中风脱证 zhòng fēng tuō zhèng), which are more severe, are marked by open eyes and mouth.

Night blindness (夜盲 què máng): Reduced visual acuity in poor light. It is attributed to liver blood vacuity. In Chinese medicine, night blindness is also called sparrow vision (雀目 què mù) because sparrows see poorly in the dark.

Clear-eye blindness (青盲 qīng máng): Gradual blindness that in severe cases can be total. It is attributable to insufficiency of the liver and kidney and depletion of essence-blood, combined with spleen-stomach vacuity preventing essential qì from reaching up to the eyes. It corresponds to optic atrophy in biomedicine. We call it clear-eye blindness because there is no visible obstruction in the pupil (the Chinese term, somewhat confusingly, translates literally black/green-blue blindness).

Goiter (瘿病 yǐn bìng, 瘿瘤 yǐng liú): A swelling at the front and sides of the neck that moves up and down as the patient swallows. According to biomedicine, it corresponds mainly to enlargement of the thyroid gland usually from lack of iodine in the diet. It is attributed to various factors including phlegm, qì stagnation, blood stasis, and heat. Often it involves the liver. Modern sources often differentiate the following patterns:

• qì depression and phlegm obstruction;
• phlegm bind and blood stasis;
• exuberant liver fire;
• heart-liver yīn vacuity.

Scrofula (瘰疬 luǒ lì): Lumps under the skin, mainly on the side of the neck and under the armpits. Scrofula is mostly attributed to lung-kidney yīn vacuity and enduring depressed liver qì with vacuity fire concentrating fluids into phlegm, which binds locally to form lumps. In some cases, it is caused by wind-fire toxin.

Cold mounting (寒疝 hán shan4): The term cold mounting refers to specific conditions.

1. A condition of cold in the umbilical region with cold sweating and counterflow cold of the limbs, attributable to accumulation of cold evil in the abdomen arising from repeated contraction of wind-cold fostered by spleen-stomach vacuity or from postpartum blood vacuity.
2. A condition of cold pain in the scrotum attributable to cold evil invading the reverting yīn (jue2 yīn) channel. The scrotum becomes swollen, hard as stone, cold, and painful. Attending signs may include impotence, fear of cold, and cold limbs. The pulse is sunken stringlike and tight.

Depression patterns (郁证 yù zhèng): Disease patterns reflecting impairment of qì dynamic (deficient free coursing) that stems from affect-mind disturbances (emotional problems). They mostly involve depressed liver qì and disturbance of the heart spirit but also involve other factors such as dampness, phlegm, and blood stasis that often foster or are fostered by depressed liver qì. They are marked by affect-mind signs as well as physical signs:

• Affect-mind: Affect-mind depression; frustration; moodiness; emotionality; depressed anger.
• Physical: Distending pain in the chest and rib-side; sighing; plum-pit qì.

Depression patterns are not entirely distinct from mania and withdrawal disease and can easily develop into it. However, their key distinguishing feature is that the spirit-mind is clear: patients retain normal mental faculties.

Concretions, conglomerations, accumulations, and gatherings (癥瘕积聚 zhēng jia3 ji1 jù): Four kinds of abdominal mass associated with distension and pain.

• Concretions and accumulations are masses of definite form and fixed location, associated with pain of fixed location. They are associated with disease of the viscera and the blood (blood stasis).
• Conglomerations and gatherings are masses of indefinite form that gather and disperse at irregular intervals and are attended by pain of unfixed location. They are associated with disease of the bowels and of qì (qì stagnation).

Accumulations and gatherings occur in the center burner, while concretions and conglomerations occur in the lower burner and are seen in many gynecological diseases.

Abdominal Masses
	Hard	Soft
Center burner	Accumulations	Gatherings
Lower burner	Concretions	Conglomerations

Mammary aggregation (乳癖 ru3 pi3): A mass in the breast that moves when pushed. It is mostly attributable to depressed liver qì and phlegm.

Jaundice (黄疸 huáng dan3): Jaundice is a disease characterized by generalized yellowing of the skin and whites of the eyes. It arises when contraction of external evils or dietary irregularities cause damage to the spleen and stomach that gives rise to damp evil. The damp evil obstructs the center burner and affects the liver and gallbladder (congested earth rebelling against wood). This causes the bile to deviate from its normal path and spill into the blood, and from the blood into the skin. Jaundice can take the form of yīn yellowing (also called yīn jaundice) or yáng yellowing (also called yáng jaundice), depending on whether the dampness forms with cold or with heat.

Wilting (痿证 wei3 zhèng): A disease characterized by weakness and limpness of the sinews that in severe cases prevents the lifting of the arms and legs. It is attributable to liver-kidney depletion, spleen-stomach vacuity, or lung heat with damage to liquid.

Mounting

The term mounting (疝 shan4) refers to any of various diseases characterized by pain or swelling of the abdomen, groin, or scrotum. Traditional literature describes many different diseases and patterns labeled as mounting. Mounting disease includes the following: (a) conditions marked by enlargement of the scrotum, including inguinal hernia or scrotal hydrocele; (b) other diseases of the external genitals in males or females; (c) conditions marked by severe abdominal pain with urinary and fecal blockage. Conditions characterized by the protrusion of the abdominal contents through the abdominal wall, the groin, or base of the abdominal cavity, and usually associated with qì pain. Terms for such conditions include mounting qì (疝气 shan4 qì), foxlike mounting (狐疝 hú shan4), small intestine mounting qì (小肠疝气 xiaǒ cháng shan4 qì), and small intestine mounting qì pain (小肠疝气痛 xiaǒ cháng shan4 qì tòng). Rú Men2 Shì Qīn (儒门事亲 Confucian Filiality) by Zhang1 Cong2-Zhèng 张从正 (Zi3-He2 子和) describes this condition as follows: In foxlike mounting.... when lying, it goes into the smaller abdomen; when walking or standing, it comes out of the smaller abdomen and goes into the [yīn] sac. Note that the Chinese term 疝气 shan4 qì (mounting qì) has been adopted as the biomedical equivalent on inguinal hernia.

Liver Patterns

Below is a brief description of the major liver disease patterns, with links to entries that provide more detail.

Simple Patterns

Liver blood vacuity (肝血虚 gān xuè xu1): Sinews, nails, and eyes deprived of nourishment; scant menstruation; blood vacuity signs. It stems from decreased blood production (spleen vacuity); enduring illness; blood loss.

Liver yīn vacuity (肝阴虚 gān yīn xu1): Dizzy head; tinnitus; dry eyes, loss of visual acuity; dull scorching rib-side pain; yīn vacuity signs. It develops from enduring illness; advanced-stage warm-heat disease; kidney yīn vacuity (water failing to moisten wood); or liver fire flaming upward.

Depressed liver qì (肝气郁 gān qì yù): Anger, frustration, and affect-mind depression; distending pain along the liver channel; plum-pit qì; menstrual irregularities. It develops from excess among the seven affects (frustration, dissatisfaction, anger, worry, sorrow) that inhibits the qì dynamic; spleen-stomach damp-heat invading the liver; or liver blood vacuity.

Liver fire flaming upward (肝火上炎 gān huǒ shang4 yán): A repletion fire pattern marked by dizzy head; distending pain in the head; scorching pain in the rib-side; impatience, agitation, and irascibility; repletion fire signs. It stems from depressed liver qì transforming into fire; excessive consumption of hot-spicy, fatty, or sweet food, or alcohol and smoking causing the formation of fire; externally contracted heat; liver yīn vacuity.

Ascendant hyperactivity of liver yáng (肝阳上亢 gān yáng shang4 kang4): A vacuity-repletion complex of liver-kidney yīn vacuity with hyperactivity of liver yáng. It manifests in dizzy head; distending pain in the head; heavy head and light feet; aching lumbus and knees. It results from liver-kidney yīn vacuity failing to keep liver yáng in check (water failing to moisten wood) stemming from taxation fatigue or yīn depletion in advancing years; constitutional yáng exuberance with rash, impatient temperament; liver qì depression stemming from anger, worry, and worry transforming into fire and damaging yīn humor.

Liver wind stirring internally (肝风内动 gān fēng neì dòng): A disease pattern marked by wind signs such as dizziness and spasm, (convulsions, arched-back rigidity, tremor, or wriggling of the extremities). Different forms of the pattern are distinguished by cause and signs.

• Liver yáng transforming into wind (肝阳化风 gān yáng hua4 fēng): Ascendant hyperactivity of liver yáng with sudden stirring of wind, in severe cases with clouding collapse and hemiplegia.
• Extreme heat engendering wind (热极生风 rè ji2 shēng fēng): High fever and clouded spirit with convulsions, rigidity of the neck and nape, arched-back rigidity, upward-staring eyes, and clenched jaw.
• Blood vacuity engendering wind (血虚生风 xuè xu1 shēng fēng): Tremor; twitching of the flesh; inhibited bending and stretching; dizziness; tinnitus; liver blood vacuity signs.
• Yīn vacuity stirring wind (阴虚动风 yīn xu1 dòng fēng): Wriggling of the extremities; dizziness; tinnitus; liver yīn vacuity signs.

Cold stagnating in the liver vessel (寒滞肝脉 hán zhì gān maì): Cold pain on the pathway of the liver channel with repletion cold signs such as cold limbs. It is attributed to contraction of cold evil.

Combined Patterns

Liver-gallbladder damp-heat (肝胆湿热 gān dan3 shi1 rè): Distending pain in the rib-side, aversion to food, abdominal distension, yellowing of the body and eyes, genital itch with signs of damp-heat. It results from contraction of external or internal dampness combining with heat.

Heart-liver blood vacuity (心肝血虚 xīn gān xuè xu1): Heart palpitation; insomnia; eyes and sinews deprived of nourishment; blood vacuity signs. It is caused by excessive thought and preoccupation damaging yīn blood, by excessive bleeding, or by enduring illness.

Liver fire invading the lung (肝火犯肺 gān huǒ fan4 feì): Also called wood fire tormenting metal (木火刑金 mù huǒ xing2 jīn). Cough (in some cases with coughing of blood); scorching pain in the chest and rib-side; impatience, agitation, and irascibility; repletion heat signs. It is caused by affect-mind frustration causing qì depression that transforms into fire and damages the lung.

Liver-spleen disharmony (肝脾不調 gān pi2 bù tiáo): Also called liver depression and spleen vacuity (肝郁脾虚 gān yù pi2 xu1). Distension and fullness and scurrying pain in the chest and rib-side; frequent sighing; torpid intake; abdominal distension; sloppy stool with ungratifying defecation; abdominal pain heralding diarrhea with relief from pain on defecation; rumbling intestines; passing of flatus. It can arise when affect-mind depression resulting from dissatisfaction or other negative emotions damage the liver causes depressed liver qì that moves cross-counterflow and overwhelms spleen-earth. It can also arise when dietary irregularities or taxation fatigue damage spleen qì and, as a result, the spleen rebels against wood and impairs the liver’s free coursing action.

Liver-stomach disharmony (肝胃不和 gān weì bù he2): Distension and scurrying pain in the stomach duct and rib-side; belching; and acid swallowing. It arises when affect-mind frustration and depressed anger damage the liver, causing depressed liver qì that moves cross-counterflow to invade the stomach.

Liver-kidney yīn vacuity (肝肾阴虚 gān shèn yīn xu1): Dizziness; tinnitus; limp aching lumbus and knees; rib-side pain; insomnia; vacuity heat signs. It is caused by enduring illness damaging yīn humor; affect-mind causing internal damage and formation of fire that damages yīn; sexual intemperance (excessive sexual activity) damaging kidney yīn; advanced-stage warm-heat disease that damages the fluids. Kidney yīn depletion affecting liver yīn is described as water failing to moisten wood.

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