Journal of Gastroenterology and Hepatology (1998) 13, 4 3 7 4 4 2

REVIEW

The liver in traditional Chinese medicine

T H O M A S S N C H E N A N D P E T E R SY C H E N

Department of Pathology, East Orange Eterans Affairs Medical Center and New Jersey Medical School,
University of Medicine and Dentistry of New Jersey, Newark, New Jersey and Department of Radiology,
Saint Vincent’s Medical Center and University of Massachusetts Medical Center,Worcester, Massachusetts, USA

Abstract Medical thinkers in China visualized the liver in microcosmal and macrocosmal terms. An
anatomical tradition did not exist, hence the liver was described grossly in broad outline. It was recog-
nized as being functionally important in the movement of qi (vital energy) and storage of xue (‘blood’).
The liver corresponded to various phenomena in both the natural and social orders, according to the
scheme of yin-yang and five phases. These interrelationships provided the basis for the diagnosis and
treatment of liver dysfunctions. The disorders fell into three general groups: (i) hepatic qi stasis; (ii)
hepatic yang excess with yin deficiency; and (iii) hepatic yin insufficiency.The signs and symptoms rep-
resented the logical outcomes of the disturbed physiology. Acupuncture, moxibustion and herbal drugs
were used to redress the imbalance of hepatic qi and yin-yang. The impact ofWestern medicine led tra-
ditional authors to recognize the hepatobiliary role in bile secretion and in jaundice. The exchange
between the Western and Chinese medical traditions revealed that active agents were included in the
Chinese formulary, such as glycyrrhizin, which has recently been shown to be beneficial in chronic viral
hepatitis.

Key words: Chinese medicine, liver.

INTRODUCTION with medical knowledge of the liver, its functions and

To this day, physicians in China practice a traditional
form of medicine with varying fidelity depending on
their orientation towards Western biomedicine.The tra-
ditional Chinese medicine to which we refer to here
existed prior to the 20th century before the impact
of the West. Traditional Chinese medicine was not a
homogenous healing system, but included at least three
interacting traditions:’ (i) the tradition of literate
healers who derived their knowledge from classical
texts and whose patients, for the most part, were from
the elite; (ii) the popular tradition encompassing the
majority of the population in which individuals first
identified their illness and then made a decision for self-
care or for treatment from elsewhere; and (iii) the tra-
dition of folk medicine carried out by non-literate and
non-bureaucratic practitioners, including religious per-
sonnel, herbalists, bone setters and wise women. All
three traditions overlapped in their diagnostic approach
and therapy. All three shared an ideological structure
that organized medical thinking, more or less, along
certain lines. In particular, in the present paper we deal
its disorders.
IDEOLOGICAL BACKGROUND
A guiding tenet of traditional medicine in China was
the belief that man was the microcosm of the universe.
The body structure paralleled the physical design of the
world and the body fimctions mirrored the workings of
the natural and social orders. Man and the cosmos were
animated by qi, variously translated as the vital air,
energy or pneuma. Two cardinal laws governed the
organization and operations of qi (and other phenom-
ena), the doctrines of yin-yang and wu-Xing, the five
phases.’ The ideological schemes did not originate with
physicians, but were part of the intellectual framework
established before the rise of traditional Chinese
medicine.
Yin-yang represents a dualistic mode of viewing
matter and its activity.Thus, an organ can be described
in both a yin and a yang context. The substance of the
organ is either yin or yang in quality and its function is

Correspondence: Dr Thomas Chen (1 13), VA Medical Center, East Orange, NJ 07018, USA.
Accepted for publication 27 June 1997.
438 TSN Chen and PSY Chen

the opposite of the pair. Yin and yang are mutually
opposing, interdependent and interchangeable attrib-
utes that can change over time and space. In medical
discourse, yin-yang is often used to analyse the equi-
librium of qi, an imbalance of which leads to signs and
symptoms. Thus, a fever may start in the yang stage,
with sweating a yin phase supervention, requiring a
yang drug for relief.
A further refinement of the yin-yang interaction is
the doctrine of wu-xing, the five phases, which consider
configurations of phenomena in a state of change or in
qualities (Table I).’ The five phases (wood, fire, earth,
metal and water) have been mistakenly translated as the
five elements, implying a similarity with the Greek
concept of the elements. The Chinese do not think of
them primarily as essential irreducible constituents of
matter, but rather as symbolic stages of activity or being
interacting in a circular sequence? The five phases
match phenomena in cyclic systems, such as astro-
nomical, meteorological, biological, physiological etc.,
to each other and to the yin-yang (Table 2). These asso-
ciations are not arbitrary. Many have an empirical basis.
For example, the heart, the source of warm blood, is
matched to fire, the kidney is matched to water etc.The
sequence of the five phases may give rise to circles of
mutual generation and destruction (Table 3). The cor-
respondence between phenomena also provides for an
inductive method of deriving knowledge. Consider the
principle of gui-jin (‘channel tropism’), which links the
functions of foods and the organ^.^ If the liver is
qualified with the taste of bitterness, then foods or
drugs that have bitter qualities would be appropriate for
the treatment of liver disorders. The conceptual basis
for diagnosis and therapy is addressed in the Huangdi
Neijing (Yelow Emperor’s Classic of Medicine, 2nd to 1st
century BC) and the Nanjing (Classics of Di’cult Issues,
1st century AD), the two earliest compilations of
Chinese medicine.6 These classical texts, and several
later texts, remained canonical until recent times.
PHYSIOLOGICAL BASIS
According to medical theory, qi has both a yang com-
ponent (gi) and a yin component (xue, loosely trans-
lated as ‘blood’, but the meaning is wider). The former
mediates the process of change and transformation, the
latter is for nourishment and growth.’ Qi comprises one
of the vital substances; another is jing (essence), which
is derived from nutrition and is necessary for vitality
and reproduction. Both qi and jing circulate through-
out the body and constitute the functional link between
organs.The vital substances flow within conduits called
mo. These channels, not entirely identifiable with the
anatomical system of vessels, connect the visceral
organs by means of twelve main tracts. Six pairs run
parallel to the body axis and systemic vessels and
nerves. Smaller conduits, called lo, communicate with
the main channels as superficial networks. The distrib-

Table 3 Five phases: Relationship of natural phenomena and

Table 1 Equivalences between the five phases and yin-yang the five viscera
~~

Five East +Wind +Wood + Sour flavour + Liver + Muscle

phases Yin-yang State South + Heat + Fire + Bitter flavour + Heart + Blood
Centre + Humidity + Earth + Sweet flavour -+ Spleen +
Wood Immature yang; yang in yin Active growth
Flesh
Fire Mature yang; yang in yang Maximal activity
West + Dryness + Metal + Pungent flavour -+ Lung +
Earth Central house; harmony Neutral state
Skin and hair
Metal Immature yin; yin in yang Reactivity
North + Cold +Water + Salty flavour + Kidney +
Water Mature yin; yin in yin Maximal reactivity
Bones
Adapted from Sivine3
Arrows connote a process of generation.
Adapted from Sakai.’

Table 2 Correspondences in the five phases and yin-yang scheme

Phenomenon Wood Fire Earth Metal Water

Yin viscera Liver Heart Spleen Lungs Kidneys

Yang viscera Gall-bladder Small intestine Stomach Large intestine Urinary bladder
Sense organ Eyes Tongue Mouth Nose Ears
Tissue Sinews Circulatory tracts Flesh Hair Bone
Emotion Anger JOY Sympathy Grief Fear
Colour Green Red Yellow White Black
Flavour sou Bitter Sweet Pungent Salty
Climate Wind Heat Humidity Dryness Cold
Season Spring Summer Midsummer Autumn Winter

Adapted from S i ~ i n . ~
 The liver in traditional Chinese medicine
Table 4 Rank and functions of organs
~~
Organ Rank Function
~~ ~
Heart Ruler Insight
Lung Minister Regulation
Liver General Calculation
Gall-bladder Officer Decision
Adapted from Sakai.’
ution of mo and lo channels is important in the prac-
tice of acupuncture, the early principles of which are
discussed in the Nezjing.’
Body function is effected by the five yin and six yang
visceral organs. The five yin organs (heart, liver, spleen,
lungs and kidneys) and the six yang organs (gall-
bladder, stomach, small and large intestines, urinary
bladder, and triple burner) are called tsang (depots) and
fu (palaces), respectively. (The identity of the triple
burner is controversial; whether it is an anatomical unit
or a functional entity is not clear.) The metaphors of
depots and palaces imply the functional roles of storage
and consumption, respectively. In physiological terms,
the yin viscera regulate and store vital substances and
the yang viscera digest food to produce vital substances
and excrete waste. The use of metaphors is common in
Chinese medical discourse and suggests a conceptual-
ization of health and illness by means of social analo-
gies.8By extension, the physiological activities of organs
can be derived by their symbolic status in a hierarchal
society (Table 4).’
HEALTH
Health is the state of normal qi, the result of body func-
tions carrying out their tasks of producing a qi in proper
proportion and distribution. Illness (bing) ensues when
normal qi is not in equilibrium or when it is depleted
or overwhelmed by evil qi. The balance of qi is
expressed in the related concept of shi (fullness) and xu
(emptiness), each representing the complementary
aspects of an illness.” The excess of external qi in the
body, shi, is a consequence of the depletion of the inter-
nal qi, xu. The loss or weakness of host vitality allows
for the intrusion of a foreign invader. Circulating
endogenous qi defends the internal environment
against evil qi, which the Chinese practitioners divide
into three groups: (i) external; (ii) internal; and (iii) mis-
cellaneous.” In the external category are climatic
factors, such as wind, cold, heat etc., which constitute
the major determinants of sickness in Chinese medi-
cine. Internal malefic qi may arise from emotional dis-
turbances: joy, anger, fear and melancholy. Among the
miscellaneous group of evil qi, poor diet, physical
under- or overactivity, poisons, parasites and epidemics
are included. Chinese thinkers emphasize the impor-
tance of harmony between body functions and the
natural and social world in achieving health.
Moderation, equilibrium and stability are the guiding
439
rules in one’s activity with regard to one’s self and the
environment.
The concept of normal qi provided the rationale for
the diagnostic procedure of taking the pulse and the
therapeutic measure of acupuncture. Examination of
the pulse gave information on the circulating qi and,
indirectly, the status of the internal organs. It evolved
into a complex process that went hand-in-hand with
the intricate permutations of the yin-yang doctrine
that later accrued to the classical dictums. Similarly,
acupuncture acquired a complex nicety as it sought to
redress the imbalance of qi by removal of the excess qi
or re-establishment of the normal flow and distribution.
LIVER ANATOMY
When the Chinese healers considered the liver, they did
not think of it as an anatomical entity with specific
physiological functions, a model familiar to the Western
mind. Rather, they conceived the liver as a system of
correspondences, with relationships to other organs and
to the natural order (Table 2). The liver did serve as a
material substrate that performed several functions. Its
structure per se attracted little attention. Hence, physi-
cal descriptions of organs appeared sparse and were
configured to fit functional needs. The Nanjing noted
‘. . . The liver weighs two catties and four ounces. It has
three lobes on its left and four lobes on its right side,
adding to seven lobes . . .’ (see Fig. l).”The weight of
a catty in ancient times is uncertain, although tradi-
tionally a catty is thought to be equivalent to lflbs. If
so, the hepatic weight of two catties and four ounces
approximates 1200g, within the accepted average for
the normal liver. The question of seven lobes is prob-
lematic, as many commentators attempt to explain. One
proffered explanation is as follows: ‘The liver is associ-
ated with the foot-ceasing-yin (conduit), which
is matched with the foot-minor-yang (conduit). The
minor-yang occupies rank seven. Hence (the liver) has
seven lobes’.‘’
The biliary tree is not clearly delineated as there is
little mention of the bile ducts, although the liver and
gall-bladder are considered as one unit. The inflow and
outflow system of the liver is seen in a schematic fashion
(Fig. 1). The conduit foot-ceasing-yin is the primary
channel connecting with the liver. It originates on
the dorsum of the big toe, traverses up the leg to the
inguinal area, down to the scrotum, ascends into the
hypogastrium, accompanies the stomach, joins with a
branch from the liver, penetrates the diaphragm, con-
tinues behind the trachae and pharynx, unites with the
ocular conduit and ends in the parietal area of the
head.I3The course of the foot-ceasing-yin merits atten-
tion as it accounts for the diffuse symptoms related to
hepatic dysfunction and serves as sites of needling in
the acupuncture treatment of liver disorder.
HEPATIC FUNCTION
Hepatic function is conceived in terms of its relation-
ship with other organs and external phenomena. These
440 TSN Chen and PSY Chen

connections are governed by the concepts of yin-yang

and the five phases (Tables 2,3). In this scheme, the liver
acts to harmonize the emotions. Emotional upsets alter
liver activity and vice versa (A similar belief existed in
the West. Both ancient Greeks and Western thinkers
until the 18th century held that ‘fright’and ‘passions of
the mind’ were causes of jaundice.) At the physiologi-
cal level, the liver plays several roles.3313 First, it dis-

E perses the upward and outward flow of qi, thereby

p regulating its circulation. Second, it stores xue (‘blood’)

and other vital fluids, thus controlling their flow. This
storage role allows the organ in particular to maintain
a special relationship with the eyes, its sense organ, nails
and muscle. In the clinical situation, examination of
these sites provides a monitor of hepatic activity.Third,
the liver controls bile secretion. This function is not
mentioned in the ancient classical texts, but is latterly
acknowledged by authors in the 20th ~ e n t u r y . ’ ~

Figure 1 The liver, according to traditional Chinese medi-
cine. Reproduced with permission from VeithS7
HEPATIC DYSFUNCTION
The internal logic of Chinese medicine becomes strik-
ing when one considers the three major hepatic disor-
ders, namely hepatic qi stasis, hepatic yang rising in
excess with yin deficiency and hepatic yin insufficiency
(Table 5).3,13Each or any of the three together may
evolve and coexist over time in the same patient.
Hepatic qi stasis arises when the upward and outward
flow of qi is disturbed. Emotional symptoms of irri-
tability and agitation come to the fore. Stagnation of qi
in the liver leads to pain in the rib area. Backup of qi
affects the splenic and stomach systems, resulting in
abdominal pain, poor appetite, vomiting and diarrhoea.
In women, the stagnation may induce menstrual ir-
regularity and reproductive failure. When the upward
movement of qi is excessive, the condition of hepatic
yang arising in excess with yin deficiency ensues. The
yang qi accumulates in the eyes and head, leading to

Table 5 Symptoms and signs of liver dysfunction

Hepatic yin
Pattern Qi stasis Hepatic fire Hepatic wind insufficiency

Yin-yang imbalance Yang (lire) excess Yang excess, severe Yang excess, yin Yin decrease, severe
(water) decrease
Emotional state Agitation, irritability Violent anger Anger or depression Nervous tension,
depression
Heat Mild Whole body, Periodic hot flushes Hands and feet hot,
constantly hot in head, face mild fever
Headache Mild Severe, splitting Throbbing Mild
Eyes Reddish Red, swollen, painful Reddish, mild pain Indistinct vision,
night blindness
Tongue Moist, white coat Red material, yellow Dark, purplish Red, little coat
coat
Pulse Wiry, sinking Wiry, rapid, big Wiry, rapid Wiry, rapid, thin
Other symptoms Gastrointestinal Haemorrhagic Central nervous Tremors, numbness
system of hands and feet
- ~ ~~

Adapted from Sivin’ and Kaptchuk.l 3

The liver in traditional Chinese medicine
Hit by Hit by
wind Harmed humidity
1 byjeat I The symptoms of yin insufficiency mimic those of yang
Kidneys
water
evil
Sequence Sequence
of mutual of mutual
generation
Lung
metal
soil
.. metal
t
Harmed by Harmed by
(unrestrained) cold
drinking, eating,
weariness,
exhaustion
Figure 2 Sickness patterns, based on the five phases. Repro-
duced with permission f r o m Unschuld.h
painful eyes, headaches, tinnitus, irritability and insom-
nia. The severe stage of hepatic yang excess produces
two other serious conditions, preponderance of hepatic
fire and stirring of hepatic wind. Hepatic fire forces
blood into turbulent motion and damages the internal
vessels. External and internal bleeding occurs and cere-
bral symptoms intensifl. Further advancement of
hepatic fire creates a stirring of hepatic wind. The wind
attack disorder sweeps across the body. The patient
exhibits ‘. . . profuse sweating; an aversion to wind; a
tendency to grieve; pale-green colouring; dry throat;
angry temperament; occasional aversion to women. The
diagnosis is made from the greenish colouring below the
eyes’.(‘ Other symptoms, including leg cramps, muscle
rigor, hemiplegic paralysis and coma, may ensue. The
diffuse symptoms and signs are possible because the
liver is linked with other organs in cycles of supportive
and destructive effects. One such circular dynamic (see
Fig. 2) illustrates the complexities of medicine in
China.6 In any given patient, a single organ injury
pattern may spread to involve other organs. Hepatic qi
stasis, for example, may lead to the pattern of liver
invading spleen, accompanied by signs of deficient
splenic qi. Splenic dysfunction may, in turn, involve a
different cycle of pathophysiology. Figure 2 also alludes
to an important pathogen, wind. In this instance, the
liver is the major organ damaged, as both wind and liver
belong to the phase of wood. The effects spread prefer-
entially to the heart. This is called a depletion evil as the
liver is the mother depot of the heart, as wood gener-
ates fire. Such a depletion evil calls for a therapeutic
approach different from a repletion evil. Prognosis is
poor when an evil influence of the liver is transmitted
to the heart, as fire (heart) consumes wood (liver).
Another instance of the interplay between organs
is the third major hepatic disorder, hepatic yin
insufficiency. This is caused primarily by a renal yin
44 1
deficiency, in which jing (essence) is not processed, and
without jing xue (‘blood’) cannot be made in the liver.
excess, but the two can be differentiated by the exami-
nation of the pulse and tongue. Hepatic xue deficiency
is indicated by the appearance of hazy vision, flank pain,
muscle weakness and pale nails.
The periodicity and prognosis of liver disorders are
subject to macrocosmal influences, such as climatic
factors. An ancient author writes: ‘Those suffering from
liver ailments grow mentally alert during the day, reach-
ing a high point in the late afternoon; they lie down to
rest at midnight’.(‘And: ‘Illnesses of the liver heal in the
summer. If a cure is not effected in the summer, the
condition worsens in autumn’.6 Compare this with
the belief by some Western physicians that a deteriora-
tion between 16.00 and 20.00h indicates hepatic
involvement in an illness.4
THERAPY
Acupuncture, herbal drugs and moxibustion are used,
alone or together, to redress the imbalance of yin-yang
and qi of liver dysfunction. As the hepatic qi flows in
defined pathways, known in the West as meridians, fine
needles inserted in one or several points of the hepatic
meridian (approximately 20 of a total of 360 or so
points are assigned to the liver) correct the pattern of
liver dysfunction. An adjunct procedure is moxibustion,
which entails the application of heat, usually in the form
of a pack of mugwort, to the acupuncture points.
Another mainstay of Chinese therapeutics is the wide-
spread and extensive use of herbal drugs. Generally,
drugs are classified on the basis of their theoretically
derived qualities by the scheme of yin-yang and the five
phases and their empirically derived properties, chiefly
from perception of their taste and thermoregulation. In
principle, herbs are selected for their capacity ‘to calm’
the excess yang and ‘to replenish’ the diminished yin
present in hepatic disorders. Similarly, drugs are given
‘to nourish’ the depletion of qi associated with liver dys-
function. Phytotherapy is also guided by the prevailing
notion of causation. For jaundice, for instance, among
the 124 or more different drugs recommended for treat-
ment, Artemisia herb and Gardinia fruit were mentioned
most often in the texts of Materia Medica.14 Addition-
ally, during the Northern Sung dynasty (10th-12th
century AD) Glycyrrhiza root and Scutellaria root were
used and during the Southern Sung dynasty (12th-13th
century AD) Poria sclerotium and Atractylodes rhizome
were preferred. The former two drugs were prescribed
for their anti-febrile and laxative properties and the
latter two were prescribed for their diuretic effect. The
belief during the Northern Sung period was that jaun-
dice was a fever that did not escape through the pores
of the skin, accumulated in the spleen and stomach, dis-
turbed the digestion of food, stopped the excretion of
stool and urine, and changed the colour of the body.
Hence, jaundice was best relieved by an anti-febrile or
laxative agent. During the Southern Sung period, jaun-
dice was regarded as a moisture stagnant in the body,
a condition curable by diuretic drugs.
442
IMPACT OF THE WEST
The intrusion of Western medicine into China acceler-
ated after the Opium War (1840s) with the influx of
Christian missionaries. They used their medical skill
and knowledge as an adjunct in evangelizingtheir faith.
Elite schools were established, including the Peking
Union Medical College (founded in 1921). The small
number of Western-trained physicians had little impact
on medical care, which remained preponderantly tradi-
tional in delivery.T h e nature and extent of the interplay
between the two medical systems in China, new and
old, have not been adequately addressed and continue
to be an open and difficult issue. Just the variation of
location (north vs south; countryside vs city) would
render an account difficult. Nevertheless, the perme-
ation of Western knowledge influenced traditional
medical thinking. Authors of Chinese texts incorpo-
rated the new facts, not without unease and inconsis-
tent results. Consider the case of jaundice.Traditionally,
this discolouration of the skin was ascribed to a moist
hot disorder from the blocked splenic and stomach
systems (particularly the yang qi), usually from an
improper diet.3 This meant the external causes
belonged to the moist and hot categories, the site of
damage was the spleen and stomach and therapy called
for 'freeing the moist and clearing the hot'.
When authors recognized that the liver played a role
in bile secretion, jaundice then represented a major
manifestation of the moist hot disorder of the hepatic
and gall-bladder systems. Symptoms included periodic
intense pains in the right rib area, yellow-tinged urine,
a bitter taste in the mouth and a hot-cold sensation.
Still others thought that jaundice arose from the
overflow of bile from the gall-bladder due to blockage
by biliary stones. The assimilation of one tradition into
another, if at all feasible, presents a continuing chal-
lenge for practitioners of traditional medicine.
However, the interchange between the two medical
systems has not been all in one direction. The efficacy
of acupuncture and herbal therapy has attracted atten-
tion in the West. From the latter, the search for active
agents from the Chinese formulary has begun in
earnest. Recently, glycyrrhizin from Glycyrrhiza root,
has been shown to be beneficial in the treatment of
chronic active hepatitis and in the prevention of the
development of hepatocellular carcinoma in chronic
hepatitis.'5,'6 Phytogenic preparations have become
TSN Chen and PSY Chen
acceptable in some Western circles for the treatment
of hepatobiliary disorders. Witness the popularity of
Hepatofalk, a patented preparation, in Germany.
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