On Spring and Liver Yīn
Zī Shuǐ Qīng Gān Yǐn
Spring is in full effect, the time when the arising yáng brings forth all life and growth. We know it as the season associated with wood and the Liver. The Běncǎo Jīng Jiě (Materia Medica Explanation), attributed to Yè Tiānshì (Yáo, 1926), says
肝者生生之臟。
“The Liver is the organ of generating life and governs flourishing.”
As we have noted earlier , springtime’s growing yáng qì not only brings forth benevolence, but can also bring about the appearance of lurking pathogens (Liu, 2005), as well as seasonal pathogenic wind in general. In cases where the Liver blood or its share of yīn-essence with the Kidney has been sub-optimally gathered and stored, the yáng qì of spring will bring with it edgy, restless Livers.
And so it has been here at Clinical mulch HQ. The season has brought with it an array of spasms, tics, fidgets, vertigo, and wiry pulses. It has been drier than usual this year, which seems to have particularly afflicted those with a predisposition to deficiency of Liver yīn, whether through time and taxation or newly piled-up smoldering stagnant Liver qì just one small spark away from a California wildfire.
Wiry pulses go with the season, but even fine pulses are morphing into super-wiry as the yīn becomes overwhelmed and heat builds up in the chest, vexing the sovereign. Stress, sleeplessness, ribs aching, climbing T4 levels, peeling tongues with crimson edges. Spring has most definitely sprung.
Liver yīn
“It is only when liver yīn is abundant that it can soften its hardness and course in accordance with its nature of orderly reaching.” (Yán & Lĭ, 2007).
The Liver, we are taught, stores blood and courses (moves) qì . Those two actions are its yīn and yáng aspects. The Liver thrives by orderly reaching (條達 tiáo dá), a phrase which expresses both its yīn-yáng aspects as well as the interplay between the flavors that most affect it, namely sour and acrid. Acrid is the reaching, yáng, expansive, coursing and discharging (疏泄 shū xiè) taste; according to Sù Wèn 22 (Unschuld & Tessenow, 2011), it supplements the Liver (meaning, in my view, it supplements the expansive tendency of wood). Sour is the orderly, yīn, contracting, restraining and astringing (收斂 shōu liǎn) taste, which drains the Liver (meaning, in my view, it drains – “sedates” is an older translation – by restraining the same expansive tendency). Were it not for the constraining, securing effect of sourness, acridity would reach beyond its proper boundaries, stirring wind and upthrusting yáng. This is why, for example, we see sour and acrid pairings throughout the harmonizing formulas, most often featuring cool and sour Bai Shao (Rx Paeoniae Alba): Bái Sháo and Chái Hú (Rx Bupleuri), Bái Sháo and Dāng Guī (Rx Angelicae Sinensis), even Bái Sháo and Gui Zhi (Rm Cinnamomi).
Formulas for Liver yīn deficiency
What formulas spring into mind when mention is made of Liver yīn deficiency? For most, maybe only Qĭ Jú Dì Huáng Wán (Lycium, Chrysanthemum and Rehmannia Pill) (“Kidney yīn deficiency with eye problems”), with Yī Guàn Jiān (Linking Decoction) an option in cases with depressed qì and heat invading the Stomach (“older people with reflux”). Thus it has been for me as well, for a long time, all the while feeling like these were unsatisfactory formulas for many of the patients I was seeing.
One answer came from generating materials for an internal medicine course I had begun teaching at East West College of Natural Medicine. My eye was caught by a recurring formula in the textbook (Practical Therapeutics of TCM by Wu & Fischer, 1997): Zī Shuǐ Qīng Gān Yǐn (Water-Enriching Liver-Clearing Beverage).
The formula is associated with Gāo Gǔ Fēng of the Qīng era. Its composition is as follows (Yáng & Wáng, 1725):
滋水清肝飲 熟地（君） 山藥（臣） 萸肉（佐） 丹皮（佐） 茯苓（佐） 澤瀉（使） 柴胡（臣） 白芍（臣） 山梔（使） 棗仁（佐） 歸身（臣）
Zī Shuǐ Qīng Gān Yǐn: Shú Dì (Rx Rehmanniae Praeparatae, chief); Shān Yào (Rz Dioscoreae, deputy); Yú Ròu (Fr Corni, assistant); Dān Pí (Cx Moutan, assistant); Fú Líng (Poria, assistant); Zé Xiè (Rz Alismatis, envoy); Chái Hú (Rx Bupleuri, deputy); Bái Sháo (Rx Paeoniae Alba, deputy); Shān Zhī (Fr Gardeniae, envoy); Zǎo Rén (Sm Zizyphi Spinosae, assistant); Guī Shēn (Rx Angelicae Sinensis, deputy).
Once you analyze the formula constituents, you may realize that this is basically a combination of Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) with Dān Zhī Xiāo Yáo Sӑn (a.k.a. Jiā Wèi Xiāo Yáo Sӑn) (Moutan and Gardenia Free Wanderer Powder), minus some of the more Spleen-tonic and drying elements of the latter. It is listed in Formulas and Strategies (Scheid et al, 2009), as an associated formula with Yī Guàn Jiān – associated by function rather than composition, otherwise it would be listed with the myriad variations of Liù Wèi Dì Huáng Wán. Even so, it managed to elude me for years. Now, of course, it seems so obvious, a Reese’s Peanut Butter Cup of a combination. Two of the most popular formulas on Earth sharing the same stage, with a special appearance by Suān Zǎo Rén to calm the spirit and help secure the Liver yīn.
Yan & Li (2007) in their Pathomechanisms of the Liver, mention the formula under the category of Liver yīn depletion, in the subpattern Yin vacuity engendering heat. Scheid et al (2009) write: “Enriches the yīn and clears the Liver. For Kidney yīn deficiency and Liver constraint transforming into fire manifesting with indistinct burning pain in the flanks, irritability, bouts of anger, a dry mouth with a bitter taste, insomnia or dreamdisturbed sleep, dry stools, or burning pain in the epigastric area, gnawing hunger, acid reflux, soreness and weakness of the back and knees, dizziness, headaches, early periods, a red tongue with little coating, and a wiry, thin, and rapid pulse.”
For me, it looks like a useful formula for many of the cases I am seeing. In comparison to Yī Guàn Jiān, it better activates the Liver’s coursing and discharging and addresses the depressive heat aspect much more thoroughly. Yī Guàn Jiān, in my mind, is lacking in qì-moving ability, but is a better choice to engender fluids in the Lungs and Stomach, or to benefit the eyes.
I can envision using Zī Shuǐ Qīng Gān Yǐn perhaps with an addition here or there: Gōu Téng (Rm Uncariae cum uncis) for the wind manifestations, or Dān Shēn (Rx Salviae Miltiorrhizae) to cool blood and calm the spirit. There are no commercial preparations of the formula as far as I know. It is patent-hackable to an extent, being largely a combination of two readily-available formulas, but I’m thinking I will have some granules of it made up to have on hand.
Acupuncture for Liver yīn deficiency
Acupuncture remains the mainstay of my practice, so developing strategies to treat Liver yīn deficiency with needles has been necessary. For treatment of the root pattern, in general, I use LR1 and LR8 with KD10 to boost and secure the yīn. This follows the writings of Ikeda (2005). Additionally I will swap in LR4 if there are spasms (as the jing-river points are used for sinews) or where coursing and discharging is needed (as the metal point resonates with the acrid flavor and its actions). LR2 is used in cases of fire (fire point) or to extinguish wind (Ellis et al, 2004). Additional points may be chosen according to the branch or symptom presentation.
Conclusion
Zī Shuǐ Qīng Gān Yǐn is a practical answer to a bunch of clinical problems in that it is made up of two highly versatile formulas with familiar ingredients. Liù Wèi Dì Huáng Wán is known as a well-balanced prescription (perhaps too well-balanced on its own), while Dān Zhī Xiāo Yáo Sӑn is likely the most commonly-used Liver heat formula today. Looking through some of the Qing era authors such as Gao, I am seeing a number of instances where this abstracted form of Dān Zhī Xiāo Yáo Sӑn – various combinations of Chái Hú, Bái Sháo, Mŭ Dān Pí, and Shān Zhī Zĭ – are folded into other classic prescriptions. But we will leave that for another time.
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
Ellis, A., Wiseman, N., Boss, K., & Cleaver, J. (2004). Fundamentals of Chinese acupuncture (Revised ed). Paradigm Publications.
Ikeda, M. (2005). The practice of Japanese acupuncture and moxibustion: Classical principles in action (E. Obaidey, Trans.). Eastland Press. (Original work published 1996).
Liu, G. (2005). Warm pathogen diseases: A clinical guide. Eastland Press.
Scheid, V., Bensky, D., Ellis, A., & Barolet, R. (2009). Chinese Herbal Medicine: Formulas & Strategies (2nd ed.). Eastland Press.
Unschuld, P.U., & Tessenow, H. (2011). Huang Di Nei Jing Su Wen : An Annotated Translation of Huang Di's Inner Classic - Basic Questions: Volume 1. University of California Press.
Wu, Y., & Fischer, W. (1997). Practical therapeutics of traditional Chinese medicine. Paradigm Publications.
Yán, S.L., & Lĭ, Z.H. (2007). Pathomechanisms of the Liver (S. Wilms, Trans.). Paradigm Publications.
Yáng, C.L., & Wáng, R.Q. (1725). Yī zōng jǐrèn piān. Retrieved December 25, 2022, from https://jicheng.tw/tcm/book/%E9%86%AB%E5%AE%97%E5%B7%B1%E4%BB%BB%E7%B7%A8/index.html
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