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Liver Qi Vacuity and the Nature of Our Ignorance

By Bob Damone

With the recent rise of interest in the various styles of Japanese meridian therapy, an interesting issue has come to the fore with respect to the etiology and pathomechanisms of liver disease. When diagnosing Liver depression, many American practitioners of Japanese meridian therapy (who are presumably following their Japanese masters in doing so) assert that Liver Qì vacuity is the root of many if not all cases of Liver depression. This is a bold-and to some an apparently novel assertion-which has given rise to palpable but unspoken tension between Western practitioners of meridian therapies and those who practice Chinese medicine. In my opinion, the source of this tension lies both in our mistaken assumptions about modern Chinese medicine and in our lack of a socio-political perspective on East Asia; moreover, there is no standard by which to judge such competing claims to legitimacy because we cannot read the very literature which should guide our inquiries. Thus, in abiding in our illiteracy we deny ourselves the tools that would otherwise enable us to address the much more significant issues such as whether the concept of Liver Qi vacuity exists in pre-modern or modern Chinese medical literature, what are the published opinions and clinical experiences of our Chinese colleagues, how relevant the understanding of Liver Qì vacuity is to modern Western clinical practice, and how we evaluate the stated opinions of the few Westerners who can read the Chinese literature.

The assumption that Liver Qì vacuity is not covered in modern Chinese textbooks on Chinese medicine, and is therefore being ignored by Chinese doctors, is flatly incorrect. Modern Chinese textbooks on basic theory often deeply explore the etiology and pathomechanisms of Liver Qì vacuity, and they even report the results of studies by modern doctors who are attempting to better identify this pattern by correlating it with more specific signs and symptoms. On the other side of the coin lies the equally untenable position (usually held by Westerners who cannot access Chinese sources) that the notion of Liver Qì vacuity is irrelevant, since a good coverage of it does not appear in any secondary English language textbook of Chinese medicine. If one assumes that the presentation of even basic TCM theory in secondary English language literature is complete and accurate-an assumption I do not make-then one might mistakenly embrace this latter argument.

Meanwhile, some students, as the unknowing victims of their teachers' lack of agreement on such issues, remain perplexed as to who can provide reliable answers to their questions about subtle issues of theory that are not well-addressed in their English texts, such as those related to Liver Qì vacuity. They are never sure of the reliability of the information they get, or of its clinical applicability, which adds additional stress to their already formidable study burden. Further, they are not sure when differences among their teachers constitute legitimate differences of style, or when they indicate their mentor's lack of understanding of standard consensus-supported Chinese medicine. The first teacher they ask about Liver Qì vacuity flatly denies its existence even as the second may arguably overemphasize its importance. Which teacher should they believe? Once they discover that their teachers cannot agree on even basic issues, some mistakenly conclude that Chinese medicine has no clinical standard and no firm theoretical structure; as a result, they often give it up prematurely in frustration and in favor of one of its more Westerner-friendly offshoots.

When we teachers perpetuate one-sided or ill-informed perspectives, we fail our students. If we fail them repeatedly during their formative years in Chinese medicine, the damage is greater and longer-lasting. It is precisely at this time that students require carefully crafted and reliable answers to their questions so that they may internalize a solid TCM cognitive framework. This more attentive construction leaves room for the future insertion of subtleties in that framework in an organized and accurate way. Further, we also fail each other by sabotaging the possibility of professional and informed collegial dialogue about topics such as Liver Qì vacuity when we close our minds to its very existence. This is especially true when we become unduly critical towards our peers, either publicly or behind the closed doors of our private classrooms, though we ourselves may lack the definitive data to responsibly answer the question at hand, and are terrified of admitting so to our students.

The plain facts are that Liver depression may be due to either repletion or Qì vacuity, and that the Chinese medical literature has been describing Liver Qì vacuity patterns for at least 2,000 years. We can find many quotes from various classical and modern sources (which are beyond the scope of this editorial) to establish the validity of this position. Many English language textbooks of Chinese medicine are incomplete on this topic and simply repeat the assertion of the influential J¯in-Yuán dynasty physician Zh¯u D¯an-X¯i, who maintained that there were no notable vacuity patterns of the Liver except for that of Blood vacuity. While the Zh¯u position is a legitimate vein within the Chinese medical tradition, it is apparent upon a broader investigation of its literature that his is not the only Liver-related vein through which Chinese medical blood flows.

Admittedly, the signs and symptoms of Liver Qì vacuity can be summarized under the heading of Qì and Blood vacuity with Liver depression, and can usually be successfully treated as such. However, I feel that sometimes simplifying an issue like this can gut a whole section of the TCM conceptual framework and that this gutting may have unforeseen clinical consequences; consequently, future insight that might result in new therapies could be stifled in its absence. Similarly, it is true that Gallbladder Qì vacuity can be dissected into a combination of Qì vacuity (especially of the Heart), Liver depression, and Blood vacuity, with a special focus on fear, timidity, and anxiety. Acumoxatherapists, however, in the absence of the concrete mental connection to the Gallbladder inherent in the name "Gallbladder Qì vacuity," might not otherwise consider using the Gallbladder channel in their treatments, and might thereby lose access to a vital cognitive cue that would otherwise prompt them to treat this channel. Thus, I argue that without identifying Liver Qì vacuity as the etiology of a given case of Liver depression, one may not emphasize supplementing the Liver with certain medicinals, or may not associate it with resultant Liver channel cold, and therefore may not choose points or techniques that are either more able to supplement Liver Qì or likewise more able to warm the Liver channel and dissipate cold. Furthermore, one may advance similar arguments in support of consciously mentioning the Triple Burner in one's diagnosis.

Many modern Japanese doctors and their students are admirably witnessing to the fact that the Chinese literature itself contains many references to Liver Qì vacuity; to them we owe a debt of gratitude for opening the debate. But why has this become such a point of contention between Western practitioners who either practice Chinese or Japanese expressions of East Asian medicine? I submit that the history of Sino-Japanese socio-political relations in the past two centuries plays a significant role in the fray. All too often I find that Westerners who lack the background knowledge of this history become naïve participants in the perpetuation of such acrimony. Also, in the absence of a historical understanding, we are more apt to internalize rivalrous claims to superiority from one side or the other and to mistake them for proven clinical superiority. This is especially problematic when students of East Asian medicine, who often lack the background knowledge to fairly evaluate competing claims to legitimacy, fall prey to the lure of these polemics. The only way to deepen the debate on such conflicts, and to evaluate competing claims of validity, is to accept the responsibility for searching the literature ourselves by studying Chinese language (and perhaps Japanese as well). Also, we must carefully select English language sources that represent responsible translations of the subtleties of this and other significant topics from their source languages. Indeed, by taking these steps we can instantly elevate the debate to a new height.

I further submit that even the cursory glance at Sino-Japanese relations in the past two centuries must yield the consideration of Sino-Japanese rivalry as a potential factor in any differences of medical opinion between modern Japanese and Chinese doctors. There are many unresolved issues between Japanese and Chinese people related to the events of World War II. These events still influence their mutual interactions and can, if left unchallenged by reason and compassion, give rise to destructive attitudes. I point this out so that Westerners should understand that we must factor this in when evaluating any statements made by Japanese doctors about Chinese doctors (and vice versa), and so that Chinese and Japanese doctors may realize the impact of their more hypercritical statements about each other on Westerners, who are more vulnerable to their impact due to their lack of understanding of their historical basis.

It would be irresponsible to suggest that Maoist committees in newly established 1950s TCM colleges did not make curriculum choices based partially on a political agenda, and that their choices did not affect the transmission of Chinese medical knowledge in the 20th century and beyond. We are relatively ignorant of the enormous social health care challenges faced by the early Maoist regime and how these pressures affected those decisions; consequently, we are too quick to criticize their performance. So, one should be cautious of conjuring up undocumented images of mass PRC state-sponsored medical book burnings, in which all the previous medical literature was fervently incinerated by Red Guards and thereby lost to humanity forever. While small-scale book burnings did occur, and while many lives were lost and untold suffering was inflicted during the Cultural Revolution, the classical medical literature survived essentially intact and is readily available for our study; moreover, so is the body of modern TCM writings which reflect the continually evolving and forever self-reflective nature of Chinese medicine. Indeed, the very existence of this body of modern literature directly derives from Maoist policies towards Chinese medicine. The claim that although the classical texts themselves may have survived the Cultural Revolution, but the modern Chinese interpretation of them was misguided by the Maoists is seriously flawed. This argument then continues to the logical yet audacious conclusion that it is the Westerner's role to find and preserve the "original" Chinese medicine (as if there were such a thing), which the Chinese themselves have sought to destroy, even though he cannot read its seminal literature.

I assert that there is a scarcity of professional and collegial dialogue within the Acupuncture and Oriental medicine profession in the West. Also, I submit that the nature of this debate on Liver Qì vacuity reveals itself as a microcosm for the state of debate within the profession as a whole, and that the flavor of its prosecution sheds some light on the very root of our ignorance-that too few of us can read or even value the exploration of the past or current professional Chinese literature attached to this field, and that our resistance to doing so runs deep. Ironically, this literature is irrefutably the wellspring from which the definitive answers to our queries can be drawn, and from which we must derive a historically based and culturally appropriate expression of East Asian medicine. How else are we to verifiably claim its 2,000 year-old tradition as our medical forebear? These issues are among the most vital for us to address as we consider the future development of East Asian medicine in non-Asian countries. They concern the past, current, and future state of Chinese medicine both in and outside of East Asia, the relationship between Chinese and Japanese streams of East Asian medicine, and they demonstrate the reality of our own ignorance of the extant professional academic and clinical literature that is available to us should we only embrace the challenge of learning the languages to which it is inseparably bound.