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JOURNAL OF CHINESE MEDICINE NUMBER 31 SEPTEMBER 1989

A DISCUSSION ON THE RELATIONSHIP BETWEEN THE LUNGS AND THE LIVER WITH SOME ILLUSTRATIVE CASES
PETER DEADMAN
pain in the flanks and hypochondrium, bitter taste in the mouth, irritability etc.), symptoms of Lung-Qi failing to The Lungs as the topmost zang have the function of descend (breathlessness, asthma, paroxysmal cough), descending Qi, whilst the LIV has the function of and symptoms of heat in the Lungs (yellow or blood1 ascending the Qi. According to the cosmological tinged sputum, hot sensations in the chest, haemoptysequence of the 5 Element theory, Wood is on the left sis). and Metal is on the right (whilst Fire is above, Water Even more frequently seen in clinical practice, is the below, and Earth occupies the centre). Thus Ye Tian Shi syndrome of stagnation of Liver-Qi - without Fire said: The human body mirrors the natural world [so impairing the Lungs descending that], the Liver is on the left and function. Characteristic symptoms its Qi ascends, the Lungs are on Whilst the voice is the direct are cough, breathlessness, asthma, the right and their Qi descends. expression of the Lung-Qi, shouting, difficult breathing, sighing, abWhen their ascending and singing and assertive speech dominal distention and wiry descending are harmonised, Qi pulse. The key differentiating are all ways that help free can relax and develop ... the Liver symptoms are the wiry pulse, sighand move the Liver-Qi. makes Qi ascend to the head and ing and difficult breathing. This is upper orifices; the Lungs make experienced in a mild form as stuffiness of the chest with Qi descend to the internal organs and sinews and bones. difficulty in fully inhaling or exhaling. It may feel and be The two together permit Qi and Blood to flow and extend described by the patient as a weakness of the Lungs and 2 and the internal organs to be peaceful and balanced. chest, but unlike Lung-Xu breathlessness and dyspnoea, Physiologically the Lungs descending function assists it is improved with physical exercise, which by promotthe Livers free-going function, whilst the Livers freeing the circulation of Qi in general, assists the Livers going function assists the Lungs descending function. free-going function and moves the stagnant Qi. At the According to 5 Element theory, the Lungs control the same time, sighing, which is an instinctive response to Liver. If the controlling relationship is disturbed, there stagnant Qi in the chest, helps the Qi move. are three possible pathological consequences: Stagnation of Liver-Qi can be an important contributing i. the Lungs may fail to control the Liver i.e. Lung-Xu and inducing factor in asthma, although this syndrome leads to Liver-Shi. In clinical practice this arises when is often neglected in the traditional textbooks. In this Lung-Qi-Xu fails to assist the Liver free-going function. case, the asthma is precipitated by stress, frustration and anger. ii. the Lungs may over-control the Liver i.e. Lung-Shi Another symptom that may be seen with the syndrome overcomes the Liver. This disharmony is not seen in of Liver-Qi invading Lungs is dislike of speaking and a clinical practice. weak voice. This again should be differentiated from the iii. the Liver may insult (reverse control) the Lungs. similar symptoms seen in Lung-Qi deficiency. In the This is seen clinically in two ways: a) Invasion of the latter, the Lungs - whose Qi is expressed in the power of Lungs by Liver-Fire, and b) Invasion of the Lungs by the voice - is simply too weak. Since speaking requires Liver-Qi (Liver-Qi stagnation fails to assist the Lungs and consumes Qi there is dislike of speaking. When due descending function). to Liver-Qi stagnation, there is no lack of Qi, but the Qi THE PATHOLOGICAL RELATIONSHIP is bound up in the stagnation, whilst at the same time causing stagnation of Qi in the Lungs. The underlying One pathological relationship is emphasised in most emotion is one of repressed anger, and expressed formulations of the combined zangfu syndromes (synpsychologically the silence is punishing. When a patient dromes involving more than one zang or fu) and that is with this syndrome begins to shout, the true power of Invasion of the Lungs by Liver-Fire. In this syndrome, their voice can be experienced. Liver-Qi stagnation transforms to Fire and invades the The voice and respiration both reveal interesting aspects Lungs, impairing the Lungs descending function and of the Lungs-Liver relationship. Whilst the voice is the scorching the Lungs. The syndrome combines sympdirect expression of the Lung-Qi, shouting, singing and toms of Liver-Qi stagnation and Liver-Fire (burning

THE PHYSIOLOGICAL RELATIONSHIP

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JOURNAL OF CHINESE MEDICINE NUMBER 31 SEPTEMBER 1989

assertive speech are all ways that help free and move the Liver-Qi. As far as respiration is concerned, I have discussed the respiratory symptoms that occur when Liver-Qi or Liver-Fire invades the Lungs. At the same time, respiration can assist in resolving stagnation of Liver-Qi and Flaring-Up of Liver-Fire (Lungs controlling Liver). Breathing deeply and counting to ten is classic English advice for controlling anger. It is also the deep breathing, as well as the enhanced Qi circulation, that makes vigorous exercise an aid in promoting the freegoing of Liver-Qi. The pronounced irritability of the newly stopped smoker is in part due to Lung -Liver disharmony. Whilst in the long-term smoking injures the Lung-Qi, like all stimulants its short-term effect is to kick the Lungs into life. No longer stimulated by deep inhalations of smoke, the Lungs revert to their state of true deficiency and fail to control the Liver-Qi. Deep breathing and physical exercise are valuable ways to reduce craving and irritability. A final, speculative, illustration of the Lungs-Liver relationship concerns grief, sadness and anger. By blocking the breathing and causing the whole body to sag and thus restrict the Lungs, grief injures the Lung Qi. At the same time, underlying grief there is often profound anger at the person who has caused the grief by dying, leaving etc. This is not to suggest, however, that either grief or anger in the face of loss are pathological and need to be cured. Indeed, acceptance of both these emotions and patience in recognising the time they take to be resolved is what people in grief say they most need. Similarly, repressed anger may often be expressed as sadness, feelings of hurt and weeping, and vice-versa. In the former case (most often seen in women), anger is repressed because of social or family conditioning, or the risk to economic security that may be implied in expressing the true emotions. All the potential power, assertiveness and vigour is locked up in the unexpressed anger, but because of restraints on acknowledging anger, a person will both experience and express the more acceptable emotion, namely sadness, weeping and powerlessness. In the latter and mirror-image case (most often seen in men), sadness and hurt are repressed because of social and family conditioning and the fear of acknowledging weak and powerless emotions, and are experienced and expressed as a more familiar and acceptable emotion, anger.

CASE 1
Male 34 years This patient complained of abdominal and epigastric distention and pain which had lasted for over one year following a prolonged period of stressful work, irregular hours and irregular meals. The first onset woke him at night with a severely bloated epigastrium and a very rapid heartbeat. Fearing he was experiencing a heart attack, he called his doctor. Hospital checks were negative and the symptoms were ascribed to an anxiety attack. Subsequent attacks centred on the epigastrium with distention and pain. A barium meal test proved negative. Eventually he experienced the symptom most days.

The abdominal distention was worse after eating and with pressure. He woke most nights with bloatedness, severe mental tension and anxiety, tachycardia and missed beat sensation. The distention and other symptoms were somewhat relieved by passing gas either belching or flatulence. When the distention was severe, he experienced breathlessness and difficulty in breathing, and found talking an effort. Additional symptoms were thirst for cold water and a red complexion. The tongue body was red with a thick greasy yellow coating, and the pulse was rapid, wiry and slippery. All symptoms were better with vigorous exercise and he tried to swim every day. Diagnosis: Stagnation of Liver-Qi, disharmony of Liver and Stomach, and Stomach-Phlegm-Heat. Stagnant LiverQi transformed into heat which, combined with PhlegmHeat, rose to affect the Heart. Stagnant Liver-Qi invaded the Lungs and impaired their descending function, leading to stagnation of Qi of the Lung and hence breathlessness, difficult breathing and dislike of speaking. The breathlessness, difficult breathing and tachycardia were clearly Shi symptoms since they improved with vigorous exercise. Treatment principle: Restore the free-going function of the Liver, cool the Liver, harmonise Liver and Stomach, clear and cool the Stomach, calm the Heart, open the chest and promote the Lungs descending function. Prescription : Shanzhong REN-17, Juque REN-14, Zhongwan REN-12, Neiguan P-6, Gongsun SP-4, Taichong LIV-3. Explanation: Shanzhong REN-17 (also known as Upper Qihai) regulates Qi, opens and dispels fullness from the chest, clears the LU and descends Stomach-Qi. Juque REN-14 calms the mind, regulates the Heart, regulates Qi and pacifies the Stomach. Zhongwan REN-12 regulates Stomach-Qi and transforms rebellious Qi. Neiguan P-6 (confluent point of the Yin Linking Vessel) regulates the Heart, opens the chest, moves Qi, and with Gongsun SP4 (confluent point of the Penetrating Vessel) harmonises Liver and Stomach. Taichong LIV-3 spreads the Liver-Qi and clears Liver-Fire. All points were reduced. The patient felt great relief after the first treatment. For the following three treatments Shenmen HE-7 was added to the prescription to calm the mind and cool Heart-Fire. Improvement was maintained. After four treatments there was a return of abdominal distention but without tachycardia, palpitations, anxiety or breathlessness. Shenmen HE-7 was replaced by Zhigou SJ-6 to regulate and free the Qi of the three Jiao. After six regular treatments, he began a new (stressful and irregular) job and was unable to come more than once a month. This led to a return of some mild symptoms, especially tension at Juque REN-14.

CASE 2
Male 57 years This patient was a train driver whose cab caught fire in a tunnel. Following this incident he began to experience severe abdominal distention. Diagnosis revealed a hiatus

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JOURNAL OF CHINESE MEDICINE NUMBER 31 SEPTEMBER 1989

hernia due to severe coughing. His main symptoms were distention in the abdomen, flanks and hypochondrium, rising as far as the neck and locking in the throat. When severe, the distention moved to the chest causing coughing, difficulty in breathing, spitting of clear fluid, inability to lie flat and intense pain. When he could vent the distention by belching he was able to relieve the chest symptoms. The symptoms were brought on or aggravated by stress and frustration at work, irregular shifts, or by eating certain foods such as spices, fatty meats, salad, onions, alcohol etc. Diagnosis: Injury to the diaphragmatic Qi due to the trauma of coughing smoke. This led to failure of the descending function of the Stomach which was then susceptible to invasion by Liver-Qi. Stagnant Liver-Qi and rebellious Stomach-Qi invaded the Lungs and chest. Impairment of the Lungs descending function and hence rebellious Lung-Qi led to coughing, spitting of clear fluid and inability to lie flat. Treatment principle: harmonise the Stomach and Lungs, and descend rebellious Qi, promote the free-going function of Liver-Qi. Prescription: Tiantu REN-22, Shanzhong REN-17, Qimen LIV-14, Zhongwan REN-12, Zhigou SJ-6, Zusanli ST-36, Taichong LIV-3. Explanation : Tiantu REN-22 regulates the Lungs, descends and disperses Lung-Qi and directs rebellious Qi downwards. Shanzhong REN-17, Zhongwan REN12, Zhigou SJ-6, Taichong LIV-3 (see above). Qimen LIV14 regulates the Liver, spreads Liver-Qi and expands and relaxes the chest. Zusanli ST-36 regulates the Stomach, reduces digestive stagnation and redirects rebellious Qi downwards. All points were reduced. After four treatments, the symptoms were controlled and he had no attacks of distention, coughing etc. During the following year, periodic treatments and the use of the patent formula Shu Gan Wan kept the symptoms under control. He then retired from his job and experienced no further attacks.

Diagnosis : stagnation of Liver-Qi due to long-term emotional problems, and damp-Heat of Liver and Gallbladder due to excessive alcohol consumption. LiverQi invaded the intestines giving rise to the abdominal pain, and the Lungs leading to rebellion of Lung-Qi. The night sweats 3, lethargy, desire to lie down and heavy head were due to damp-heat. Treatment principle: resolve stagnation of Liver-Qi, clear the Lungs and descend Lung-Qi, clear Liver and Gallbladder damp-heat. Prescription: i. Shanzhong REN-17, Qihai REN-6, Zhigou SJ-6, Yanglingquan GB-34, Xiajuxu ST-39, Gongsun SP-4, Taichong LIV-3. ii. Feishu BL-13, Zhiyang DU-9, Ganshu BL-18, Danshu BL-19, Yinlingquan SP-9, Sanyinjiao SP-6. All points were reduced except Feishu BL-13 and Sanyinjiao SP-6 which were treated by even method. The two prescriptions were alternated at each treatment. Explanation: Yanglingquan GB-34 regulates the Liver and Gallbladder, spreads the Liver-Qi and transforms Liver and Gallbladder damp-heat. Xiajuxu ST-39, the lower He-Sea point of the Small Intestine, regulates the Stomach and Intestines and redirects rebellious Qi downwards. Gongsun SP-4 regulates Stomach and Spleen Qi and is particularly indicated for pain at the umbilicus. Feishu BL-13 regulates the Lung-Qi, Ganshu BL-18 and Danshu BL-19 regulate the Liver and Gallbladder. Zhiyang DU-9 regulates the Liver and Gallbladder and transforms damp-heat. Yinlingquan SP-9 and Sanyinjiao SP-6 resolve damp-heat by tonifying the Spleen and promoting urination. After four treatments this patient had begun to feel more energy, a more positive outlook and a reduction in the abdominal pain. Treatment is still continuing.

NOTES
1. The Liver has the function of spreading and dominating the free-going of Qi through the whole body, especially the trunk. However its normal movement is said to be ascending. Pathologically the Liver-Qi either ascends excessively or transversely invades the Stomach, Spleen or Intestines. 2. 'Simple Questions' Page 51. Translated and quoted by Giovanni Maciocia in The Foundations of Chinese Medicine. Pub: Churchill Livingstone, 1989. 3. Whilst night sweats are commonly listed as a Yin-Xu symptom, they are commonly seen within a dampheat pattern.

CASE 3
Male 24 years This patient had suffered from abdominal pain centred around the umbilicus for ten years. The pain was constant, every day, but better after passing stool or gas. There was a past history of asthma. When the abdominal tension built up and he could not pass gas, he experienced tightness in the chest with a hacking cough. When he finally passed wind, he coughed up a lot of mucus and the chest was relieved. This patient had started drinking heavily at the age of eighteen to relieve emotional stress and had become a regular drinker (half a bottle of spirits a day). He had recently joined Alcoholics Anonymous and had stopped drinking. He felt lonely, fearful and anxious. He experienced great fatigue and lethargy, with a desire to lie down and sleep, heavy head and unclear thinking, constipation with soft stool, and night sweats which were worse when he was drinking. His tongue was red and slightly purple, swollen, with a yellow sticky coating ,and his pulse was wiry, slippery and rapid.

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