Moderating the Liver?

March 17, 2023

In honor of the Spring Equinox in a few days, here is a blog on the liver, which was inspired by a student’s wonderful question:

The Question

For the past two weeks, much of my attention has been taken up by a course on “Nurturing the Fetus: The Ten Months of Pregnancy in the Chinese Medicine Classics and the Modern Clinic,” which I am currently teaching with my clinical colleague and friend Andrew Loosely. A student in that class had a great question about the recommendation for the first month of pregnancy. Here is some of that information and advice, as worded in one of our sources, Bèijí qiānjīn yàofāng 2.3 《備急千金要方》:

Food and drink must be highly refined, thoroughly cooked, and include sour broths…

The Foot Juéyīn Vessel nurtures, and you may not apply acupuncture or moxibustion to this channel. The Foot Juéyīn internally belongs to the liver, and the liver is in charge of the sinews and the blood.

Asking about the sour flavor in particular and its association with the liver, this student wanted to know what to do in the case of Qì stagnation: Wouldn’t we need acrid to disperse that, and would the acrid-sour combination of guìzhī and báisháo be appropriate?

I have chosen to dig a bit more deeply and turn my response into a public blog for two reasons: First, it’s a fun question in its own right, this duality of sour and acrid flavors in relation to the liver. At the same time, it also demonstrates the dangers of interpretation in translation and transmission of classical knowledge, which is the reason why I love to encourage Chinese medicine practitioners to study classical Chinese, even within the limitations imposed by their finances, time, and busy clinical practices. Although, in all honesty, I fear that the length of this blog and the fine details of technical terms and grammar may turn most of you off to that pursuit. But I can’t help it…..

The student’s question was specifically about the fact that, in their words, “sour consolidates things” and that sour is associated with the liver and with spring. They referenced a conversation they had had with another teacher, who had brought up Sùwèn 10 as stating “The liver longs for sour” and had contrasted that, as is commonly done and as I also did in my discussion on this topic in my book Celestial Secrets, p. 15, with Sùwèn 22. My student cited their teacher’s version of the relevant passage there: “When the liver suffers tightness [urgency], then swiftly eat sweet to moderate...When the liver desires to disperse, quickly eat pungent to disperse, for it is tonified with pungent and purged with sour…” It is no wonder that these quotations left my student confused and unsure on what to do in the first month of pregnancy when the fetus is nurtured by Foot Juéyīn and “you must not apply acupuncture or moxibustion to this channel”!

My Response

What fun! Let’s look more closely at both of these potent and foundational passages in the specific contexts of their chapters and see whether that can shed additional light on the situation. Only then can we figure out what terms like 欲 yù (translated above as “to long for”), 苦 kǔ (translated above as “suffers”), and 補 bǔ (translated above as “tonify”) and 瀉 xiè (translated above as “purge”) actually mean here in regards to the effect of flavors on the liver and the inherent nature of the liver.

SOURCE ONE: SÙWÈN 10

To start with, Sùwèn 10 is titled “What the Five Zàng Organs Engender and Form” 五藏生成篇. It is concerned with diagnosing the condition of the five zàng organs through the pulse, the complexion, and the physical constituents as outward manifestations formed by the Qì and blood of the internal organs. In this context, the five flavors are mentioned in passing for the obvious implied reason that they affect the state of the five zàng organs. Thus, this chapter does contain a useful little list of the five flavors that are the perfect match for each of the five zàng organs. As it states there,

肝欲酸

The liver desires sour.

This brief list is described in the conclusion to this section as “what the five flavors match with” 「此五味之所合也」. Importantly for my student’s question, that list is preceded by another list of “what the five flavors cause damage in 「此五味之所傷也」 where the phrase associated with the liver states: “Eating too much acrid results in tightness 急 jí in the sinews and desiccated nails.” And here we should note, for those of you who don’t have this chapter memorized, that the sinews and nails are listed in the preceding section as the physiological entities associated with the liver as the “match” 合 hé and “bloom” 榮 róng respectively, like the vessels and complexion are with the heart, the skin and body hair with the lungs, the flesh and lips with the spleen, and the bones and hair on the head with the kidney. The word 欲 yù here simply means to "desire" or "want," as in, I want a sailboat and my dog wants a bone.

SOURCE 2: SÙWÈN 22

Now let us turn to Sùwèn 22, which has different lists of associations with the liver that complicate the picture. And here it helps to keep in mind that the topic of that chapter is “Discourse on the Qì of the Zàng Organs Following the Model of the Seasons” 藏氣法時論. As such, it discusses the resonance between the physiology and pathology of the Qì in the five zàng organs, on the one hand, and the four seasons and five dynamic agents on the other. As the Yellow Emperor himself asks in the introduction, “How do we align ourselves with them and how do we go against them?” Here is what Qí Bó has to say about the liver:

肝苦急，急食甘以緩之。

The liver suffers from tightness: Urgently eat sweet foods in order to relax it.

A couple of notes are in order here, especially in response to the English version of this passage cited above, which differs from mine in small but important ways: First off, the character 急 jí occurs twice in a row here. It can mean both “tightness” (or its close cousin “tension”) and “urgency,” depending on the context. Here it is quite clear from the context of this line and from the parallel phrasing in the lines for the other zàng organs that the character has the first meaning of “tightness” in the first instance, but means “urgently” in the second instance.

Let me explain: Each of the organs are described by what they “suffer from,” in the sense of the typical pathology that they tend to suffer from, that they are likely to be affected by, their inherent weak spot or Achilles heel, like Jack having a tendency to suffer from sluggishness while Joe might be more likely to be affected by insomnia. In the parallel phrases, the heart is said to suffer from laxness, the spleen from dampness, the lung from countercurrent ascent of Qì, and the kidney from dryness. This general statement on the organ’s most likely pathology is then followed by advice to quickly consume the flavor that is associated with having the opposite effect: In the case of the liver, sweet foods will counteract its tightness by causing “laxness” 緩 huǎn, just like the laxness of the heart is countered by quickly consuming sour substances to “astringe” it, to draw it together or gather it inward 收 shōu. And as a little side note, translating this action as “consolidation,” as the student’s teacher did above, is also quite misleading because we are not talking about a structural process or a solidification but with gathering together, drawing things in, as the opposite as an outward dissipation. To return to our text, similar to the description of the liver’s tightness being addressed by the loosening effect of sweet foods, the spleen’s dampness is countered by consuming bitter foods to dry it out, the lung’s countercurrent ascent of Qì is countered by consuming bitter foods to drain it downward, and the kidney’s dryness is countered by consuming acrid foods to moisten it.

There are three problems that I see with this unnamed teacher’s translation that my student gave for this line (“When the liver suffers tightness [urgency], then swiftly eat sweet to moderate.”). Can you spot them?

1. Grammatically, the relationship between the two phrases, which I have separated with a comma in the above version, is unclear in the original. We can read them either as one of subordination or of coordination. Most translators, like Paul Unschuld and the teacher cited by my student, read the first phrase as subordinate to the second one, by adding the word “when” in front of the first phrase and thereby turning it into a conditional construction (“when the liver suffers from tightness…..”). In other words, the tightness is read not as a general tendency or potential weakness of the liver but is merely framed as a possible condition, which is then addressed with a specific treatment. “In the case of tightness, do this…..!” Reading this phrase in isolation, that makes sense and is a strategy that I myself employed in my translation of this phrase in my book Celestial Secrets, I must admit in all fairness. After writing the present blog post, however, I am going to have to change that translation in the next edition of that book. In all of our defense, adding “when” simply makes the English easier to read than just translating the two parts of the sentence as two independent phrases, as I have done above. Nevertheless, it makes so much more sense to read it in the way I suggest here, i.e., as a general statement, when we look at the chapter as a whole and attempt to understand the Chinese conception of the resonances of the liver-wood-spring association in the context of the five dynamic agents. This will become even more apparent with the second passage to discuss below.

2. In addition, the translator adds the word “urgency” in square brackets after “tightness” to translate the first instance of 急 jí. This does not make any sense clinically and only serves to cause confusion. What could it mean that the liver suffers from urgency? Are we talking about diarrhea? A tendency to rush things? Or does it simply refer to vague critical conditions? And how would that work out in relation to the very specific parallel pathologies that the other four zàng organs are said to suffer from in the subsequent lines in Sùwèn 22? Or, we must always ask ourselves in cases when additional English words just don’t make sense, is it just the translator’s effort at adding something to disguise the fact that their translation is a slightly altered copy from another translation? Tightness makes perfect sense here, as the opposite of laxness, the relaxing effect of sweetness to address this pathology. It also makes perfect sense with the second quote below.

3. Lastly, this translator has made an unfortunate choice by using "moderate" as a translation of 緩 huǎn, which is a technical term in Chinese medicine that I translate as “laxness” or “to relax.” While “moderate” can be correct in other contexts, in this particular sentence it is bound to cause a misunderstanding that alters the meaning of this sentence quite a bit and obscures its very specific intent: The word here does not mean to “moderate” the tightness of the liver, but is a technical term that specifically refers to making things lax or loose, as you can see in the next line on the heart, where the same “laxness” is identified as the pathology that the heart suffers from, to be counteracted by the astringing 收 effect of the sour flavor. Laxness is the opposite of 急 jí "tightness" so it makes perfect sense in the context here, and is much more specific than sweetness just having a general “moderating” effect.

Now let us look at the second passage on the liver, which is found further down in Sùwèn 22, after information on disease progression in relation to the seasons and days:

肝欲散，急食辛以散之，用辛補之，酸瀉之。

The liver desires dispersal: Urgently eat acrid foods in order to disperse it. Use acrid [foods] to mend it; use sour [foods] to drain it.

This is my very literal translation, and you can easily see how it complements the previous line by means of their parallel construction. When I look at the Chinese, this passage actually now makes good sense to me. When I look at my student’s teacher’s version (“When the liver desires to disperse, quickly eat pungent to disperse, for it is tonified with pungent and purged with sour”), however, I am left confused in terms of the advice to take away from this. To support the liver in the spring, do we recommend sour foods, or do we recommend acrid foods? Which one is it? And what is the effect of the sour flavor on the liver in the end?

To me, it helps to look at the interaction between these two passages as one between pathology versus physiology. The first passage above discusses the pathological tendency of the liver towards excessive tightness and thus gives an “urgent” treatment recommendation of sweetness to counteract that, since sweetness has a relaxing effect. The second passage simply describes physiology, i.e., the healthy normal state of the liver. As the liver likes “dispersal/scattering” 散 sàn, pungency/acridity makes perfect sense as the flavor of choice to make the liver happy. Can you see how important these specific terms are, such as the difference between “laxness” 緩 and the action of “dispersal/scattering” 散 sàn, or between “tightness” 急 jí and the action of “drawing inward/astringing” 收 shōu? Here it might help to visualize the activity of plants in the spring, the season of sprouting 生 shēng, when the sap rises and the little buds explode on the branches of trees, as they are currently doing in my neck of the woods. Or envision a sickly rootbound plant in the reject pile in a neglected corner of your local nursery, which is the image I find most helpful to explain the famous liver pathology of 肝氣鬱 gān qì yù, which is so often gravely mistranslated as “Liver Qì stagnation” or, even worse, “depression.” Far from that, and a completely different character from the many terms for lack of flow, like Qi stagnation 氣滯 qì zhì or “blood stasis” 血瘀 xuè yū! If you allow me a bit of etymological indulgence here, the character specifically associated with liver pathology 鬱 yù “rootbound” or “constraint,” if you must give it an English word, is inspired by the impenetrable entangled thicket of an overgrown unhealthy forest shaded by plants growing too densely together. As the result of this unfortunate situation, the plants lack the space to do the happy expanding and outward reaching that is the inherent nature of plants. By extension, the character 鬱 yù can mean “gloomy” and describe a feeling of being stifled, constrained, matted together and bound up, unable to freely expand and move. Doesn’t it make perfect sense that tightness is a pathology that develops out of this inability of the liver to express its natural desire to expand, to unfold and unfurl, to reach far into the tips of the most distant branches? And that our line above describes the liver as “desiring dispersal” in the sense of scattering things that are knotted and constricted, and recommends acridity as the ideal flavor to counteract this state? So far so good, I hope!

Now, what do we do with the second part of the sentence, the advice to eat acrid foods to “mend” it and sour foods to “drain” it? To appreciate this advice, we may have to take a closer look at the meaning of 補 bǔ and 瀉 xiè here: They are common technical terms in Chinese medicine that are usually translated as "supplement/boost" and "drain/reduce," as, for example, in reference to needling techniques or the effect of medicinal formulas. Following some historical commentators, I suggest that the meaning here differs subtly from the standard technical meaning. Perhaps it might help to return to the very literal meanings of the characters, as "mending/patching" and "leaking" respectively? The Míng dynasty commentator Wú Kūn 吳昆 suggests that we should read 補 bǔ “to mend” here as supporting the liver’s innate characteristics, while 瀉 xiè "drain" refers to its opposite, namely to go against its inherent nature (of liking dispersal). Furthermore, you all are probably familiar with the famous saying “Liver wood likes to reach far into the small branches and dislikes being repressed and rootbound. Dispersing it results in reaching far into the small branches.” 肝木喜條達。而惡抑鬱。散之則條達。

When read with this understanding, the line above describes the liver’s inherent nature of being happy when it engages in “dispersing,” as the opposite of being wound up tight. And we can then employ dietary therapy in this way: We use acridity to support that natural tendency of unfurling and breaking through knots, sweetness to counter the pathology of tightness that an unhappy liver tends to suffer from, and sourness to perhaps temper or mellow out this natural expansive and “sprouting” tendency of the liver when that is needed.

As a final note, I want to refer the reader to my book Celestial Secrets, my translation of the medieval text Fǔxíngjué zàngfǔ yòngyào fǎyào 輔行訣臟腑用藥法要 (or yes, that text is so often still referred to as the mythical “Decoction Classic” 湯液經 Tāngyèjīng. That text states in the famous essay on the five flavors and twenty-five medicinals that “[Medicinals that are] acrid in flavor all belong to wood” and, in the accompanying chart, depicts sour and acrid as the “substance” 體 and “application” 用 associated with wood (Celestial Secrets, p. 165). And the section on “differentiating patterns of liver disease” contains this terse statement: “The liver's special power lies in dispersing.”

At least for tonight, I personally feel like I can wrap my head around this and have learned a little bit about wood, spring, liver, and the interaction of sour and acrid. On this note, I think I am going to cook myself a pot of “Sweet and Sour Soup” 酸辣湯 now!

Here is the RECIPE FROM WOKS OF LIFE if you want to join me (the photo is also from their website).

LATE NIGHT ADDITION:

Apparently I am still not making sense so here is another angle from which to try this:

Picture the liver as a fierce general, a powerful ill-mannered battle-scarred force of nature like the infamous Ān Lùshān 安祿山, a Turkic general who almost brought down the most powerful empire in the world, the Táng dynasty, in the eighth century. What this general hates more than anything in the world, what he suffers most from is being constrained, being forced into tight-laced clothing in a formal audience in front of the emperor, where he has to stand still for hours with no room to move, surrounded by uptight bureaucrats who are constantly reminding him not to spit on the floor or stamp his feet in his choleric outbursts of uncontrollable anger. He does not care about getting parched in the desert or freezing on a Tibetan mountaintop or getting beaten up by the enemy, and he can fight for days without eating or sleeping. But don’t you dare try and “fence him in” or “cramp his style”! He just doesn’t like uptight city slickers with perfectly trimmed mustaches and finger nails. He loves to roam the steppe, go wherever his horse wants to race, let the reins loose and his long hair fly whole roaring in delight and enjoying his freedom, especially after a long dark cold late-winter snowstorm that has kept him stuck inside for too many days. Because of this wild and rage-filled nature, he is great at scattering his enemies, especially when he finds them in tight clusters.

What should we feed this general? Now the Sùwèn tells us, get out the sweet wine and sugary desserts to make him relax and let down his guard. Offering him some sweet plum wine will really help to chill him out. On the other hand, if he is getting ready for a challenging military expedition, you may want to get him all fired up with some extra spicy Korean barbecue or spicy bamboo shoots.

And what is that about the sourness, you still ask? Well, sourness astringes, it draws things inward, toward the center, so it may be just what his wife needs to serve him when she wants to keep him home after a few too many months of fighting and roaming all over the farthest corners of the empire, so that she can take care of his aching body and bleeding battle scars while keeping his wild explosive tendencies in check. Like I said, Suan La Tang (hot and sour soup) to the rescue!

MARCH 17, 2023SUN SIMIAO, HERBS, NEIJING