Classical Acupuncture Therapeutics: The Principles and Practice of Point Selection and Treatment ...

93 Pages·2009·1.15 MB·English

by  Maryanne Travaglione

Classical Acupuncture Therapeutics: The Principles and
Practice of Point Selection and Treatment Planning

Liver and Gall Bladder

Submitted in fulfillment of the requirements for the
Doctor of Acupuncture and Oriental Medicine Degree
Oregon College of Oriental Medicine
Maryanne Travaglione
September 2009
Liver & Gallbladder
The Liver
The liver holds the office of general, whence strategies emanate.
As the general, the liver maintains an important line of command, especially in relation to
the movement and regulation of qi and blood. The liver general helps to facilitate the
strategies of the emperor heart in its governance of blood and assists the prime minister,
the lung in its governance of qi. While the initial impetus for the movement of blood and
qi is assigned to the highest level of command in the heart and lung, it is the liver, as the
office of the general, to who is ascribed the responsibility for strategizing the movement
of qi and blood throughout the channels and networks.
When movement is called for it is of utmost importance to have a good plan or strategy
for successful completion. A healthy liver, that is not constrained by emotions or
depressed by evils; that has sufficient troops and nourishment for those troops, can lay
out a strategy to up bear, down bear enter and exit – to send troops and nourishment
throughout the land (the body) as required. Thus, a healthy liver is able to move the qi,
and the blood that it carries, to all parts of the inner landscape, all regions of the body.
It also is important to keep in mind the emotions of a healthy general. Planning and
strategy require a sound mind. As we know, the liver’s ability to free course is especially
vulnerable to damage by any of the seven affects. If the seven affects constrain the liver
qi, then there may be disruption of the qi dynamic, resulting in a multitude of diseases.
To understand this, we need to understand the role of the liver. When liver qi is
depressed, the liver is unable to move the blood that is required to nourish the spirit in the
heart and the ethereal soul in the liver. When this occurs, the 7 affects are not governed
by the emperor heart and so they become depressed. If the movement of the liver qi is
too great, then the emotions become unnaturally aroused. This makes the emotions
difficult to control and may cause emotional agitation. (Yan Shi Lin & Li Zheng Hua
2007, pg. 28). This concerns the general control of the emotions by the liver and heart.
Examining the seven affects and the liver more specifically, we know that anger is the
mind that is associated with the liver viscera. When thinking about the liver as the
general we can understand how, when angry, the general might not make wise decisions
(governed by the gallbladder – the internally-externally associated organ). Additionally,
from the seven affects, fright is associated with the liver and kidney. Its relationship to
the kidney is made through the close affinity of fright to fear, the mind of the kidney.
However, the Inner Classic: Simple Questions states that “liver disease is associated with
fright” (Wiseman 1998 pg. 229). How is this so? First, anger is generally thought to be
an emotion that occurs when the liver qi is not moving properly, causing ascendant liver
yang. When the liver yang rises it may cause impatience or anger and the heat associated
with the ascendant yang may generate wind. On the other hand, when the liver is
© M.Travaglione 2009 Page 1 of 93
vacuous, when there is an insufficiency of yin or blood, then wind may arise. When wind
arises, there are spasms. Fright likewise causes the sinews to spasm. Thus, because of
the physical manifestation of fright, with its wind-like presentation, it is associated with
the liver, which governs the sinews.
Essentially, because the liver acts as the general, it must remain unimpeded. When the
general is unable to move his troops, due to stagnation or blockage, then anger may result
and the general will begin to make impatient or irrational decisions, moving troops in a
hurried or irrational way. On the other hand, if the general has insufficient nourishment
for his troops, he may become frightened, tighten his control over the distribution of
nourishment and starve the extremities to keep the viscera, in particular the emperor,
nourished. This may cause spasms or tightening of the sinews and result in pain along
the channel pathway or the head may lack nourishment, resulting in blurry vision,
headaches, etc.
A second function assigned to the office of general is the responsibility to store
nourishment for the body, protect the stores and, as necessary move the stores to where
they are needed. In the body, nourishment is provided by the blood. Maintaining a
reservoir of this resource is necessary to ensure adequate support for function. It is said:
“When the body moves, blood flows through the channels, and when the body is at rest,
the blood flows back to the liver where it is stored” and “the legs receive blood and walk,
the hands receive blood and grip” (Wiseman, 1996 pg. 65). As we know, the blood
moves with the qi, thus, if the qi does not move smoothly, due to stagnation or blockage,
then the blood may be unable to reach the extremities to nourish them. Or, if there
insufficient blood stored in the liver, this may be reflected in lack of nourishment to the
limbs and head. Lack of nourishment may manifest as dryness of the skin, poor
flexibility of the limbs, numbness of the limbs, blurry vision, etc. As we saw above in
the discussion about the seven affects, the blood is also necessary to nourish the viscera
and bowels and without that nourishment there may disturbance of the spirit. As the
general, the liver will make decisions about the allocation of resources, thus, in terms of
pathology one is likely to see problems arise in the extremities or head before they occur
in the organs.
Finally we have the liver as general, responsible for maintaining the pathway for the next
generation, as it is the liver who will cyclically move the tian kui or heavenly water to the
uterus, or to the dan tian in men, via the thoroughfare vessel. In women, how smoothly
the monthly transitions from yang to yin and yin to yang occur is influenced by the ease
and regularity of a general who is well supported and amply supplied. In men, the ability
to achieve erection and ejaculation is also influenced by the regularity of the general and
his movement of troops. Only when the liver moves the blood or essence to the uterus or
dan tian can the general smoothly guide the potential for a next generation, filling the
extraordinary organ of the uterus with nourishment to ensure the possibility of gestation
and reproduction.

© M.Travaglione 2009 Page 2 of 93
[Begin Text Box:

As the general, the liver and the foot reverting yin liver channel:
Regulate a course of action
Regulate the flow of right qi (zhèng qì / 正气) in the channels
Regulate the distribution of provisions
Regulate the free flow of qi
Store the blood and regulate its volume

End Text box]

The liver governs free coursing gān zhŭ shū xiè 肝主疏泄
This single statement that the liver governs free coursing includes three separate but
interrelated functions: free coursing of qi, free coursing of the emotions and free coursing
of bile.
Free coursing of qi refers to the proper regulation, and smooth and orderly activity of the
qi dynamic in its upbearing, downbearing, entering and exiting. The qi dynamic is the
movement of qi in the body, a movement that is multi-directional, but counter-balanced.
The yin yang dynamic of the channels and network vessels (the internally-externally
associated channels) and the inter-organ relationships based on these channel
relationships as well as other organ and channel relationships support the movement and
counterbalance of the qi dynamic. For example, the liver maintains the smooth upward
movement of qi. To counterbalance this, the lung has a strong downbearing action. If
the liver’s upward movement of qi is too strong for the lung to control or counter-
balance, then the lung qi will counterflow upward, resulting in cough. The relationship
between the lung (metal) and the liver (wood) is one of control; metal controls wood.
However, when the wood is replete, it can rebel against metal and cause counterflow.
When balanced, this regulated movement ensures that the channels and network vessels
maintain a healthy and balanced internal environment. But, when the general becomes
too strong, then the internal balance is upset and there is disease.
The second aspect of free coursing relates to the liver function in assisting the heart spirit
or spirit-mind in its ability to mediate the seven affects. Blood is the material foundation,
the yin substance that is necessary for clear mental processes. A sufficient amount of
blood in the heart is necessary for consciousness, and, through free coursing, the liver
ensures that one’s mind moves with flexibility in its relationship to presenting situations
and stimuli. A healthy, free coursing liver is neither rash nor impetuous when facing
obstacles. “The liver is the unyielding viscus”, (Wiseman 1998 pg. 359) and an
individual's emotional stability can be spoken of as a balance of the internal mind with
the external environment. The healthy upbearing effusion of the liver ensures one’s spirit
is supported and filled with a clear and calm vitality. If the liver qi is hindered or
unregulated, a situation of counterflow liver qi may arise. This disruption is often
associated with an agitation of the heart spirit and results in symptoms of psychological
and/or emotional upset,
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The third aspect of free coursing reflects the responsibility of the liver in the production
and circulation of bile. Bile is derived from the essence of liver yang qi that is stored in
the gallbladder as a material substance. One aspect of the life gate fire, the ministerial fire
is considered to reside in the gallbladder and furnish the heat that supports the process of
transformation of the spleen and stomach in the middle burner. The important role of bile
in digestion and transformation has led to an association of the gallbladder’s storing of
the ministerial fire to these functions. While the gallbladder is the storage site of this
bile, it is the liver that governs the free coursing of bile, and for the free movement of the
bile. Thus, through the free coursing of bile, and the free movement and warming of the
ministerial fire, the liver and gallbladder play an important role in digestion. When the
liver fails to course the bile, bile symptoms such as bitter taste in the mouth, possibly rib
side pain, and possibly pale stools and/or jaundice may manifest.
The liver stores blood gān cáng xuè 肝藏血
“When the body moves, blood flows through the channels, and when the body is at rest,
the blood flows back to the liver where it is stored” (Wiseman 1996 pg. 65) Only when
the liver blood is abundant can nourishment (yin) support function (yang). The liver, as
general, is responsible for ensuring that nourishment is maintained in reserve, is stored in
a safe place, and then efficiently and effectively delivered when the need arises. As
blood is needed to support function, it is moved from its storage in the liver to the organs
and tissues in a timely and smooth manner under the strategic governance of the liver.
Menstruation is also very closely associated with the ability of liver in storing blood and
circulating it in a monthly cyclic manneri. When the liver has abundant blood, it can
overflow and fill the uterus via the thoroughfare vessel, regulating the monthly flow or
heavenly waters. Profuse or frequent menstruation may be attributed to the liver failing
to properly store blood, just as scanty menstruation may be due to the liver failing to
move the blood.
The reserve of blood stored in the liver plays an important role in the nourishment of the
entire body and provides a basis of nourishment to support development of the next
generation. Additionally, the stored blood is an important component of maintaining
proper balance within the “general” itself. It is said that, the liver is a yin organ but yang
in function. The yin yang balance of the liver organ is very delicate. If there is
insufficient yin blood then the liver yang is easily agitated and may ascend because it
does not have a root or sufficient substance to constrain it. This unrestrained movement
can generate either a disproportionate amount of yang qi or fire in the uppermost region
of the body or it can engender wind that rises and disturbs the upper body. In a healthy
body, the liver yang’s ascending and heating nature is kept in balance by the abundance
of stored yin substance, blood.
Finally, the liver is associated with the ethereal soul, and as with the heart-spirit, the liver
blood is the substance that anchors the ethereal soul, keeping it tied to the physical body.
If the liver is unable to store the blood or there is an inadequate amount of blood, signs
such as sleep walking or profuse dreaming can be attributed to a failure of the liver blood
to anchor the ethereal soul.
© M.Travaglione 2009 Page 4 of 93
The liver governs the sinews, its bloom is in the nails gān zhŭ jīn; qí huá zaì zháo 肝
主筋；其华在爪
The tendons, ligaments and muscle fibers are together referred to as the sinews. It is the
sinews that provide the body with the ability to bend and to straighten. This ability is
likened to that of wood or, more specifically, a living tree. When the Chinese speak of
the wood correspondence to Liver the metaphor is in relation to live bamboo. Live
bamboo is a very bright, lively green color and it has a very special ability to be firmly
rooted and yet, in response to a strong wind, it can bend all the way to the ground
returning to an upright position when the winds calm. This is the image of flexibility that
is inherent in the liver’s governing of the sinews. It is what one would expect from the
living, healthy, well-nourished trees, strength through flexibility. As we have discussed,
when a person moves, blood moves through the channels, and at rest, the blood returns to
the liver. When blood is delivered it enables the sinews to move in a strong, decisive and
also smooth and flexible manner. If liver blood is insufficient the sinews are not
nourished and moistened thus hindering flexibility. It is said that wood is the bending and
straightening. When dry and brittle, wood is easy to break just as sinews, when dry or
insufficiently nourished, are stiff, held with great tension and difficult to move.
The Inner Classic: Simple Questions states that the health of the liver is seen in the
fullness of the sinews and its bloom is in the nails (Wiseman 199 pg. 359). When there is
an abundance of blood to nourish the sinews, then additionally, the surplus of the liver
blood, the nails, are in turn, supple and well nourished. When the nails are healthy and
strong, then sufficient nourishment is reaching the most distal and external aspects of the
body.
The liver opens at the eye gān kāi qiáo yú mù 干开窍于目
“The liver receives blood so there is vision” (Inner Classic Simple Questions: Chapter
10) As we saw earlier, when the liver organ is filled with blood, then the eyes can be
nourished and we can see. The eyes are nourished via the hand reverting yin liver
channel which has an internal pathway directly to the eye system. The moisture of the
eyes, and the ability to see with clarity and precision are reliant on the nourishment of the
liver blood. The storing and delivery of adequate blood is the responsibility of the liver
and is accomplished in both its function to store blood and its ability to free course qi.
These complementary functions maintain the flexibility of the small sinews, the muscles
that are intimately involved with both the flexible movement of the eyes and visual
acuity. Without the blood traveling from the liver organ, via the foot reverting yin liver
channel, to the eye system, the eyes may become dry, there may be problems with
movement of the eyes, or there may be blurry vision, floaters in the eyes or poor vision.
Additionally, the liver general is informed about the path ahead and obstacles that lie in
the way of movement through the relationship to the eyes.
The gallbladder stores bile. The gallbladder is the official residence of clear fluids;
inside it is deposited ministerial fire.
© M.Travaglione 2009 Page 5 of 93
As we discussed above, bile is formed from the essence of liver yang qi and may in fact
be a physical manifestation of the ministerial fire. It is stored in the gallbladder and
secreted by the free coursing of liver qi when it is needed to assist the spleen in
transforming food and water into qi. The presence of the bile in the gallbladder has
several important implications. The first is that it is an essential substance that can be
seen as a physical form of qi, leading to an understanding of qi as both energetic and
substantive. Second, the action of the bile on the functions on the spleen points to the
close relationship between the liver, the gallbladder and the spleen. Clinically, when
there are digestive issues, we tend to look primarily to the spleen, in particular the spleen
qi or the spleen yang. Or, we look to the liver overwhelming the spleen/stomach. This is
typically treated by harmonizing wood and earth. This treatment might include smoothing
the flow of liver qi, and supplementing the earth. Most of us are quite familiar with this
pattern and understand primarily in relation to the liver and the spleen/stomach. When
one looks at it from a slightly broader perspective however, and includes the concepts of
the gallbladder, of the bile and of the ministerial fire, then additional treatment options
are revealed. If there is not free flow of bile, via the free coursing of the liver, then
moving the liver qi is important. However, if the ministerial fire of the gallbladder is
insufficient, then there may not be enough warmth added to the digestive fires, causing
signs that may appear to be spleen qi vacuity but in fact need to be addressed via both the
gallbladder and the spleen.
The gallbladder is an extraordinary organ.
The gallbladder is the only one of the viscera and bowels that is classified as both a
bowel and also an extraordinary organ. The curious organs are like the bowels in their
form in that they are hollow and substances move through them and like the viscera in
that they store things. The gallbladder acts as a bowel in relation to its functions in the
processing and movement of food and fluids. However, because it also stores and
secretes bile, a clear substance rather than a turbid substance, the gallbladder also acts
like a viscera. Thus, it is classified as an extraordinary organ, along with the uterus, the
brain, the marrow, the bones, and the vessels.
[BeginText Box: Some thoughts on the three fires
•
o What does it mean to say: “The essence of the liver yang qi is the surplus
that is said to fill the gallbladder as bile.
o How does the ministerial fire get to the gallbladder?
• There are three burners in the body regulated by the flow of the hand lesser yang
triple burner.
o The hand lesser yang circulates the source qi that is housed in the kidney
and related to life gate fire. Source qi is circulated via the triple burner, a
yang organ that has function but no form. The source qi circulates through
the channels and network vessels and emerges at the source points of each
of the twelve regular channels. From here emerges the idea of the lesser
yang triple warmer as related to a circulation of transformative fire in the
© M.Travaglione 2009 Page 6 of 93
body.

• The eight extraordinary vessels circulate essence. The girdling vessel begins
below the 3rd lumbar vertebra (Ni, 1996, pg. 120) and connects with the foot
lesser yin kidney channel divergence. The girdling vessel is defined by three
gallbladder channel points: Girdling Vessel GB 26, Fifth Pivot GB 27, and
Linking Path GB 28. This pathway and these point connections establishes a
pathway through which the essence and life gate fire that is housed in the kidney
can travel to the gallbladder channel. Under the action of the liver yang, the
essence and life gate fire are then condensed into the bile that is stored in the
gallbladder and associate with the ministerial fire. The Inner Classic Simple
Questions Chapter 66 (The Movement and Changes of Nature) speaks about the
yin and yang of the five phases and the six climatic qi as the guiding principles.
Each of the 6 channels has a season in which they are ascendant and during that
season a particular climate or weather governs it. The exception is the lesser yang
which is governed not by a climate, but by the ministerial fire (Inner Classic
Simple Questions, 2005 pg 740). Thus, we can say that the life gate fire, which is
responsible for the spleen yang fire, for giving transformative strength to the
spleen, arrives in the middle burner via the girdling vessel, is stored in the
gallbladder and is called the ministerial fire. This ministerial fire has an active
role in assisting digestion and transformation in the middle burner.

• Channel and network theory maintains that the hand lesser yang triple burner
channel governs disorders of qi

• These ideas concerning the triple burner organ, the hand lesser yang triple burner
channel, the foot lesser yang gallbladder channel and the girdling vessel could be
seen to establish the triple burner and the gallbladder as having an important
regulatory effect on the interaction of fire and its circulation in the body, either by
draining effulgent fire or by coursing qi to reestablish a pathway for fire to
motivate action.

o The connection to the emperor fire can also be explained via a channel
divergence: the foot lesser yang gallbladder channel divergence has a
pathway from the gallbladder bowel to the heart viscus. It is interesting to
note that while the liver viscus has a direct connection to the lung, the
connection to the heart is via the gallbladder channel divergence.

End Text Box]

© M.Travaglione 2009 Page 7 of 93
The gallbladder is the office of justice and governs decisions

The office of justice is probably one of the least well understood roles of the organs. It
involves both deliberation and determination. Because of this role, the gallbladder is able
to ‘ride herd’ on the yang of the liver, thus keeping the liver in check and forcing it to
deliberate so that the decisions of the general are just. In this role, the gallbladder also
draws on its relationship with the orientation-will of the kidney, via the ministerial fire.
Thus, once the liver general has determined a strategy, the gallbladder, via the kidney
will has the ability to judge the strategy and make the decision to execute the direction.
Just as the Pentagon (or the people at the Pentagon) make plans to invade anywhere and
defend from anything, so the liver has strategies and tactics that can go anywhere. In
response to these strategies and tactics, the gallbladder must stand up for things and
pursue a course of action that, in relation to the will, assesses, considers and deliberates
the wisdom of the action.
Another element of this role concerns the gallbladder’s responding to adversarial
situations with courage, without a thought for the self. Thus there is the wisdom and will
involved in judging and acting out a strategy, but there is also having the courage to make
the ultimate decision to take the action. When faced with difficult decisions, it is the job
of the gall bladder to maintain emotional and physical equilibrium. Thus, when an
individual is fearful about making decisions because of a concern that it might be the
wrong decision, one may look to the gallbladder. This is often described as a pattern of
“gallbladder timidity” or “gallbladder vacuity and qi timidity.” A pattern of gallbladder
vacuity and qi timidity will manifest with signs such as anxiety and indecision, tinnitus or
poor hearing, dizziness, a lack of courage and susceptibility to fright. These symptoms
are related to the gallbladder’s role in making decisions and the pathway of the foot lesser
yang gallbladder channel which begins in the head and passes through the eyes and the
ears. As the foot lesser yang gall bladder channel moves down the lateral aspect of the
body to the feet, it plays an important role both in maintaining the physical balance
required for proper stability and also in the ability for an individual to make a smooth and
courageous step forward.
It is important to remember that this decision making role is one that stems from the
gallbladder’s relationship to the liver’s strategic ideas and to the kidney’s will via the
ministerial fire. It is a strong ministerial fire that is associated with have a strong will to
make a just decision and it is the gall bladder that supplies a decisive and courageous
mode with which to carry out the will.
The gallbladder vessel connects with (enmeshes) the ear like a net
While the kidney opens to the ears, and essence supports the ability to hear the five notes
clearly, it is the foot lesser yang gallbladder channel that surrounds and flows through the
ear, thus maintaining a clear and uninhibited flow of qi through the passageway. When
diminished hearing or tinnitus has an insidious and slow onset we look to a decline in
kidney essence as the main pathological mechanism. However, when we have a more
acute disturbance in hearing we look to a disruption of the qi dynamic, often related to a
pathogenic damp-heat obstruction blocking the flow of qi in the foot lesser yang
© M.Travaglione 2009 Page 8 of 93
gallbladder channel. Finally, it is of note that the relationship to loss of balance and the
inner ear it often addressed via distal points on the foot lesser yang gallbladder channel,
both reinforcing its connection to the ear and its relation to the sound footing and balance
the channel provides that is seen with the ability to initiate and maintain steady, decisive
and unwavering movement.
The Foot Reverting Yin Liver Channel
Regular Channel Overview
The foot reverting yin liver channel begins on the dorsum of the big toe. It passes
between the 1st and 2nd metatarsal bones (Supreme Surge LR 3) and then runs up the
dorsum of the foot to about 1 cun in front of the medial malleoulus (Mound Center LR 4).
It then continues upward along the anterior medial aspect of the lower leg, intersects at
Three Yin Intersection SP 6, and than, at 8 cun above the medial malleolus crosses the
foot greater yin spleen channel and moves to the medial midline of the leg. It continues
in this position up the thigh. It crosses over the inguinal groove, intersecting with the
spleen channel again and then circles the genitals. On the lower abdomen in intersects
with the controlling vessel at Curved Bone CV 2, Central Pole CV 3 and Origin Pass CV
4. It then ascends laterally to the rib-side, and the external pathway ends in the 6th
intercostals space at Cycle Gate LR 14. Internally, the channel continues up, skirting
around the stomach, homing the liver and netting the gallbladder. It then continues up
through the diaphragm, dispersing over the rib-side. This internal branch continues up
the posterior aspect of the neck, enters the naso-pharynx and ascends up to the eye
system. The foot reverting yin liver channel continues up to the vertex of the head,
intersecting with the governing vessel. From the vertex, a branch descends to the cheek
and wraps around the inside of the lips. Finally, from the liver organ, a branch passes
through the diaphragm to the lung, completing the cycle of qi.

Regular Channel Pathology

The Yellow Emperor’s Inner Classic: Magic Pivot (Ch 10 Channels and Networks)
describes the pathology of the liver channel as follows: “Stirring here [in the channel]
causes [these] diseases: lumbar pain [to the extent that one] cannot look up or down,
prominent mounting in men, swelling of the lesser abdomen in women. When severe
[there may be] dryness of the throat [and] color desertion of the face. It [the channel]
governs diseases of the liver such as chest fullness, retching, swill diarrhea, vulpine
mounting, enuresis, and dribbling urinary block.” (pg. 224)
Regular Channel Detail
The liver channel begins on the lateral aspect of the big toe,ii It moves between the
first and second metatarsal, Supreme Surge LR 3 and follows the dorsum of the foot
to the area anterior to the medial malleolus, Mound center LR4. From here, it goes
up the leg intersecting Three Yin Intersection SP 6. It then travels on the most
medial aspect of tibia to the level of 8 cun above the medial malleolus. Here it
crosses the spleen channel and moves between the foot greater yin spleen channel
© M.Travaglione 2009 Page 9 of 93