Dreaming of Mushrooms in Springtime
On Liver Qì Vacuity
In our practice of Chinese medicine in the West, we have become accustomed to adopting certain thought limitations regarding pathomechanism (among other things). The nature of the liver with regard to the qì is one of these. I’ve heard colleagues explain that, for example, the liver has an inexhaustible supply of qì and yáng and thus the only pathology involving those aspects of the liver are excess in nature: that is to say depression/stagnation and fire. Yet the idea of vacuity/deficiency of liver qì is as old as canonical Chinese medicine itself. Look at Sù Wèn (Simple Questions) chapter 80:
肝氣虛則夢見菌香生草，得其時則夢伏樹下不敢起。
Liver qì vacuity results in dreams of mushrooms and fresh herbs, and in the season of the liver. (Translation by Sabine Wilms)
In Japanese meridian therapy, liver deficiency patterns are quite commonly diagnosed and treated. In the meridian therapy that I learned, the differentiation of qì-blood-fluids was not included, so there was generally no discrete aspect of the liver that is thought to be deficient. Ikeda Masakazu has done some work in differentiating liver yīn and yáng vacuity patterns, and we’ll look at some of his material in a future installment.
While qì and yang vacuity of the liver are not generally included in most TCM textbooks available in English, there are some references in the literature. One of these is the book Pathomechanisms of the Liver (Yán & Lĭ, 2007), which serves as the primary source for this brief discussion.
There are several aspects to liver qì vacuity, but we will just touch on a few here. The differentiations for liver qì vacuity have a lot in common with liver qì depression or liver blood vacuity, as well as some overlap with other types of qì vacuity. Since the liver qì has the function of coursing and discharging, this factors into liver qì vacuity as well; the difference lay in the liver’s inability to move and upbear with sufficient force. The symptom set includes
· fatigue, weakness
· blurry vision
· dizziness
· contracture or weakness of sinews
· timidity
· fear "as if about to be seized by someone"
· inability to sigh deeply or frequent sighing
· scant fur on a pale tongue
In Zhì Gān Sà Fǎ (30 Methods to Treat the Liver), Wáng Xùgāo (1798-1862) included the following combination of medicinals, which is named in Yán & Lĭ (2007) as Bǔ Gān Qì Fāng (Formula to Supplement Liver Qi):
天麻、白朮、菊花、生薑、細辛、杜仲、羊肝。
Tiān Má (Rz Gastrodiae), Bái Zhú (Rz Atractylodis Macrocephalae), Jú Huā (Fl Chrysanthemi), Shēng Jiāng (Rz Zingiberis Recens), Xì Xīn (Hb Asari), Dù Zhòng (Cx Eucommiae), Yáng Gān (Iecur Caprae seu Ovis).
In this combination, only Bái Zhú is, by modern standards, a qì tonic. In treating liver qì depression the coursing function is fairly straightforward, utilizing primarily acrid qi-regulating agents (often along with sour flavors to emolliate the liver). In treating liver qì vacuity, the choice of medicinals needs to take into account both the boosting and moving of qì. The qì, after all, needs to be invigorated enough to course itself.
Huáng Qí
Zhāng Xīchún (1860–1933) would use Huáng Qí (Rx Astragali) as a chief herb in liver qì and yáng vacuities (Long, 2003). While today we tend to categorize Huáng Qí as primarily a lung and spleen qì tonic, its upbearing and effusive qualities are strongly suggestive of wood-phase dynamics. We read in Běn Cǎo Jīng Jiě (Explanation of Materia Medica), attributed to Yè Tiānshì (1667–1747):
黃耆氣微溫。稟天春升少陽之氣。
Huáng Qí's temperature is slightly warm. It is endowed by heaven to upbear the qì of shàoyáng in spring.
as well as
黃耆入少陽補生生之元氣
Huáng Qí enters shàoyáng to supplement the flourishing of the original qì
Yán & Lĭ (2007) add the following to Wáng’s Bǔ Gān Qì Fāng:
Shēng Huáng Qí (Radix Astragali Cruda), Dāng Guī (Rx Angelicae Sinensis), Chái Hú (Radix Bupleuri), Shēng Mǔ Lì (Concha Ostreae Cruda), Shēng Lóng Gǔ (Os Draconis Cruda), Chǎo Bái Sháo (Rx Paeoniae Alba Fricta), Zhì Xiāng Fù (Rz Cyperi praeparatum)
This addition boosts the qì, nourishes blood, courses the liver, and settles the spirit.
Lǐ Dōngyuán
In his exploration of liver qì vacuity prescriptions, Long (2003) gives an example of Lǐ Dōngyuán’s (1180-1251) formula Bǔ Gān Tang from Lán Shì Mì Cáng (Secrets from the Orchid Chamber). In Lǐ’s original text, the symptom picture for the formula is given as
治前陰冰冷並陰汗兩腳痿弱無力
Treats icy cold of the anterior yīn as well as genital sweating, and wilting, feebleness and lack of strength in both legs.
This doesn’t quite describe the same thing as we have been discussing here. The formula is large and complex, and contains Huáng Qí, Rén Shēn (Rx Ginseng), Bái Fú Líng (Poriae), Zhì Gān Cǎo (Rx Glycyrrhizae Praeparatum), as well as Chái Hú, Dāng Guī, and Shēng Má (Rz Cimicifugae) along with a variety of other damp-draining, wind-damp, and heat-clearing ingredients. For our purposes, it seems to be relevant enough to simply consider Lǐ’s Bǔ Zhōng Yì Qì Tāng (Center-Supplementing Qi-Boosting Decoction) as a candidate in treating liver qì vacuity.
Liver qì vacuity leading to blood stasis
One possible consequence of insufficiency of the liver’s coursing function is blood stasis; usually we think of blood stasis as secondary to liver qì depression but qì vacuity is a plausible etiology as well. In this case, Yán & Lĭ (2007) recommend another Huáng Qí prescription, Wáng Qīngrèn’s (1768-1831) formula Bǔ Yáng Huán Wǔ Tāng (Supplement Yáng to Restore Five-Tenths Decoction):
Huáng Qí, Dāng Guī Wěi (Rx Angelicae Sinensis Extremitas), Chì Sháo (Rx Paeoniae Rubrum), Dì Lóng (Lumbricus), Chuān Xiōng (Rz Ligustici Chuanxiong), Táo Rén (Sm Persicae), Hóng Huā (Fl Carthami)
To this Yán & Lĭ (2007) add Chái Hú and Qīng Pí (Pc Citri Reticulatae Viride) to aid in coursing the liver. Bǔ Yáng Huán Wǔ Tāng is best known as a post-windstroke prescription, but with the addition of acrid herbs to upbear and spread liver qì horizontally it makes a lot of sense to use in the context of liver qì vacuity leading to blood stasis.
Conclusion
When considering pathomechanisms involving liver qi, we needn’t limit our focus to standard conceptions such as liver invading the spleen. There can be qualitative differences to weigh, including strength of qì flow, pain levels and emotional states, as well as pulse and tongue findings. Paying close attention to the patient’s presentation can help us better understand and treat the people who come to us seeking alleviation of their distress.
Note: this newsletter is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
(unless otherwise noted, passages are translated by the author; any mistakes are his)
Lǐ, D.Y. (n.d.). Lán Shì Mì Cáng. https://jicheng.tw/tcm/book/%E8%98%AD%E5%AE%A4%E7%A7%98%E8%97%8F/index.html . Retrieved May 4, 2023.
Long, R. (2003). Qi and yang deficiency of the liver. Journal of Chinese Medicine, 71, 16-22.
Wáng, X.G. (n.d.). Xī Xī Shū Wū Yè Huà Lù. https://jicheng.tw/tcm/book/%E8%A5%BF%E6%BA%AA%E6%9B%B8%E5%B1%8B%E5%A4%9C%E8%A9%B1%E9%8C%84/index.html . Retrieved April 15, 2023.
Wiseman, N. (2022). Chinese-English dictionary of Chinese medical terms. Paradigm Publications.
Wiseman, N., & Brand, E. (2020). Comprehensive Chinese materia medica. Paradigm Publications.
Yán, S.L. & Lĭ , Z.H. (2007). Pathomechanisms of the liver (Sabine Wilms, Trans.). Paradigm Publications.
Yáo, Q. (1926). Jīng xiào Yè Tiānshì běn cǎo jīng jiě. Guǎng Yì Book Company. Retrieved December 14, 2022, from https://jicheng.tw/tcm/book/%E6%9C%AC%E8%8D%89%E7%B6%93%E8%A7%A3/index.html