Liver yang deficiency pattern refers to the mechanism of disease and a series of clinical manifestations where liver qi deficiency further develops into yang deficiency, generating cold, leading to a weakening of liver functions and overall functional decline. This syndrome often arises from excessive fear or prolonged adversity, leading to the depression of yang qi, or direct attack by cold pathogens, which, if untreated over time, depletes yang qi.

The main clinical manifestations include: emotional depression, frequent fear, unhappiness, visual disturbances such as seeing black spots, blurred vision, physical coldness, pain under the ribs, cold lower limbs, numbness of the head and body, often accompanied by a bluish facial complexion, pale nails, firm distension under the ribs, or cold-induced muscle contractions, inability to grip firmly; in terms of sexual organs and functions, there may be a lack of sexual desire, impotence or weak erections, cold testicles, damp scrotum, spermatorrhea without dreams, or atrophy of the genitals; in women, there may be cold pain in the lower abdomen, delayed or prolonged menstruation, cold leukorrhea, uterine cold leading to infertility; a pale tongue with white coating, deep, thin, wiry, and slow pulse, especially weak at the left guan position.

Liver yang deficiency pattern is commonly seen in diseases such as "fear," "impotence," "laziness," and "deficiency damage."

This syndrome should be differentiated from "pattern of liver qi deficiency" and "kidney-yang deficiency pattern."

bubble_chart Differentiation and Treatment

1. Liver yang deficiency pattern is seen in cases of fear and fright. Since the liver stores the soul, yang deficiency leads to an unsettled soul and restless spirit, which in turn causes fright. The gallbladder is attached to the liver and is internally and externally related to it; thus, liver deficiency leads to timidity, and timidity leads to fear. Therefore, in cases of liver yang deficiency, fright and fear often occur simultaneously. Zhang Jing-yue once stated that fright primarily affects the heart but can also harm the liver and gallbladder. Lingshu．Benshen states, "The color of the east is green, which connects to the liver... its disease manifests as fright." Those who experience fright due to liver disease often have an underlying deficiency of the liver and gallbladder, making them more susceptible to external stimuli that cause fear. Treatment should focus on nourishing the liver and gallbladder, supporting original qi, and calming the spirit. Formulas such as Dragon's Teeth Soul-Clearing Powder(Leizheng Zhicai) or Nacre Pill(Puji Benshi Fang) can be used.
2. If fear is severe, kidney-tonifying herbs should also be added. Lingshu．Benshen states, "The liver stores blood, and blood houses the soul. Liver qi deficiency leads to fear, while excess leads to anger." Suwen．Zangqi Fashi Lun states, "Liver disease causes pain radiating to the lower abdomen and makes one prone to anger. Deficiency leads to blurred vision, inability to hear, and fear, as if one is about to be captured." This can serve as a diagnostic basis for fear arising from liver yang deficiency. However, fear inherently damages the kidney, and the kidney is associated with the ears. Kidney damage leads to insufficient kidney qi reaching the ears, resulting in hearing loss. Therefore, in treating liver deficiency with severe fright and fear, it is essential to nourish the liver and gallbladder, support original qi, and appropriately add kidney-tonifying herbs.
3. This syndrome is seen in impotence, where liver deficiency prevents qi from reaching the genitals, leading to an inability to achieve an erection. Additionally, yang deficiency generates external cold, causing cold and dampness in the scrotum, cold lower limbs, and a deep, thin, and slow pulse. Other symptoms of liver deficiency include fatigue, timidity, and melancholy. Treatment should focus on tonifying the liver and warming yang, using formulas such as Pilose Antler Pill (from *Six Classical Formulas Explained*) or Warming Yang and Tonifying Liver Decoction (an empirical formula) with modifications (add Chinese Angelica and Barbary Wolfberry Fruit for liver yin and blood deficiency; add Ginseng and Dried Ginger for middle energizer deficiency and cold; remove Floweringquince Fruit and add Fennel, Common Fenugreek Seed, and Lychee Seed for lower abdominal hernia pain; add Evodia and Pricklyash Peel for acid regurgitation and abnormal rising of qi).
4. If this syndrome is seen in deficiency and detriment, it differs from the most common deficiency and detriment disease, which is primarily yin deficiency. First, this is a yang deficiency syndrome. Yang deficiency and detriment often result from excessive worry and overthinking damaging the spirit, overexertion damaging strength, excessive sexual desire depleting qi along with essence, or congenital yang deficiency leading to cold damage. Second, this is a liver yang deficiency syndrome, with the primary disease location in the liver rather than the kidney. Of course, liver yang originates from the kidney, so kidney deficiency can affect the liver, leading to liver deficiency. Tang Rong-chuan discusses the main symptoms of liver yang deficiency syndrome in deficiency and detriment disease in *Six Classical Formulas Explained*. He states, "Liver yang deficiency leads to cold essence and kidneys, spermatorrhea without dreams, and is treated with Big Aconite Root Powder (Jingui Yaolue)."
5. Other symptoms are similar to those of liver yang deficiency syndrome in fatigue disorders and can be cross-referenced. In fatigue disorders, liver yang deficiency syndrome is rooted in liver disease and marked by concurrent spleen and stomach qi deficiency symptoms. As a manifestation of the disease, yang qi deficiency leads to weak liver function, inability of heat to govern blood, and lack of nourishment for liver blood, resulting in symptoms such as pale and dry nails, cold and contracted tendons, inability to grip or endure labor, blurred vision, timidity, fright and vigilance, melancholy, low spirits, cold and damp scrotum, and social withdrawal. As a manifestation of the secondary disease, liver yang deficiency leads to wood failing to regulate earth, causing symptoms such as abdominal distension, anorexia, fatigue in the limbs, and shortness of breath with reluctance to speak. Prolonged fatigue disorders can easily progress to detriment, so early treatment is essential. The treatment principle should focus on warming yang and tonifying the liver, supplemented by tonifying qi and supporting the spleen. An empirical formula such as Warming Yang and Tonifying Liver Decoction can be used, with additions of Ginseng, Atractylodes, Astragalus, Licorice, Bupleurum, and other qi-replenishing and yang-raising herbs, modified according to symptoms.
6. Liver yang deficiency pattern, as seen in female patients, due to the liver being the innate basis of women, when the liver's yang qi is deficient, the Chong and Ren meridians are inevitably affected, leading to various clinical manifestations of irregular meridians. For example, qi deficiency may result in delayed menstruation or amenorrhea, cold pain in the hypochondriac region and lower abdomen, and over time, uterine cold leading to infertility and clear, cold leukorrhea. If the qi fails to lift and contain, and the liver fails to store blood, it may lead to continuous dripping menstruation. The treatment of liver yang deficiency pattern in women should focus on warming and nourishing blood and qi, regulating and supplementing the irregular meridians, and selecting appropriate formulas such as Meridian-Warming Decoction (Jingui Yaolue), Nuan Gong Wan (Zhengzhi Zhunsheng), and Major Nutrient Decoction (Jingyue Quanshu), etc. As long as the modifications are appropriate, they are all effective.

bubble_chart Differentiation of Similar Patterns

1. Pattern of liver qi deficiency and liver yang deficiency pattern: Both are liver diseases, both belong to deficiency pattern, and both manifest as symptoms of functional decline, making them easily confused. It is essential to be familiar with their similarities and differences. By setting aside the similarities, the differences will naturally become apparent. First, let's describe their similarities as follows: The liver governs the tendons, and when yang qi is deficient, the tendons lose nourishment, leading to fatigue, lethargy, and inability to endure labor. The liver, being a firm-characterized zang organ, is associated with the gallbladder. When yang qi is deficient, it often results in timidity, fear, melancholy, and unhappiness. The liver stores blood, and when yang qi is insufficient to transport blood and nourish the tendons, symptoms such as numbness in the head and body, cold limbs, and firm distension below the ribs due to qi stagnation and gallbladder depression may occur. When the liver's yang qi is deficient and unable to regulate the spleen, it leads to abdominal distension, fullness, and anorexia. The liver resuscitates the eyes, and when yang qi is insufficient to reach the eyes, it causes blurred vision or the appearance of black spots. The liver governs the tendons, and the liver meridian encircles the genitalia. When yang qi is deficient and ministerial fire declines, yang qi cannot reach the genitalia, often resulting in impotence and timidity during sexual activity. The left guan pulse reflects the liver, and in cases of liver yang deficiency, the left guan pulse is often deep, thin, and wiry. Women, whose congenital constitution is associated with the liver, may experience delayed menstruation, continuous menstrual flow, and cold pain in the lower back and lower abdomen due to damage to the Chong and Ren meridians when yang qi is deficient. These are the general similarities between the two syndromes. Based on these, one can preliminarily confirm that the condition is either liver qi deficiency or liver yang deficiency. Then, by distinguishing their differences and examining whether there are symptoms of yang deficiency leading to cold, one can further determine whether it is qi deficiency or yang deficiency. Symptoms of yang deficiency leading to cold include: 1) cold intolerance and pale nails; 2) cold testicles, impotence, or atrophy of the genitalia, nocturnal emission without dreams, and difficulty in conception; 3) a slow pulse or a deep and weak left guan pulse. Not all cold symptoms need to be present; the presence of one or two is sufficient to indicate yang deficiency. As for Zhang Jing-yue's assertion that a condition showing weakness without any heat pattern is a sign of yang deficiency, equating qi deficiency with yang deficiency, this is a biased view and should not be followed.
2. Kidney-yang deficiency pattern and liver yang deficiency pattern: The kidney and liver have a mutually nourishing relationship. Normally, kidney water nourishes the liver wood, and in disease, they can influence each other. Moreover, both syndromes are related to lower energizer yang deficiency and can clinically present with symptoms such as cold intolerance, cold limbs, fatigue, cold essence, impotence, spermatorrhea without dreams, lumbago, abdominal distension and fullness, a pale tongue with white coating, and a deep, slow, or deep and weak pulse. Those who are not precise in diagnosis may easily misdiagnose liver yang deficiency pattern as kidney-yang deficiency pattern. There are three ways to differentiate them:
   1. Kidney-yang deficiency pattern originates in the kidney. The kidney stores essence, governs the bones, generates marrow, serves as the official of strength, resuscitates the ears, and is associated with the bladder. Therefore, when kidney disease leads to yang qi deficiency, in addition to the common symptoms mentioned above, other characteristics of kidney deficiency may also be observed, such as premature ejaculation, soreness and weakness in the lower back and knees, tinnitus resembling the sound of cicadas, hearing loss, frequent and clear urination, dribbling after urination, frequent nocturia, and a weak pulse at both chi positions. These symptoms are distinct from those of liver yang deficiency pattern.
   2. Liver yang deficiency pattern originates in the liver. The liver stores blood, governs the tendons, resuscitates the eyes, and is associated with the gallbladder. Therefore, when liver disease leads to yang qi deficiency, in addition to the common symptoms mentioned above, specific manifestations of liver deficiency may also be observed, such as black spots in the vision, blurred vision, firm distension below the ribs, numbness in the head and body, cold and contracted tendons, and a deep, wiry, or deep and weak left guan pulse. These symptoms help distinguish it from kidney-yang deficiency pattern.
   3. The similar or identical symptoms of the aforementioned two syndromes can also be differentiated based on the following experiences:
      1. In kidney deficiency, cold intolerance and cold limbs, along with fatigue, are often accompanied by a pale complexion or facial puffiness, soreness and weakness in the lower back and knees, and a lack of interest. In contrast, liver deficiency's fear of cold and cold extremities are often accompanied by a non-pale, non-puffy face with a bluish tint, along with pale and bloodless nails. The fatigue in liver deficiency is often accompanied by timidity, melancholy, and unhappiness.
      2. In kidney deficiency, cold essence and impotence often begin with kidney qi not reaching the genitalia, leading to the ability to achieve an erection but not sustain it, gradually progressing to insecurity of kidney qi, spermatorrhea, premature ejaculation, and finally impotence. In contrast, liver deficiency's impotence is purely due to liver qi not reaching the genitalia, starting with an erection that is not firm, cold and damp scrotum, and quickly progressing to impotence without the intermediate stage of insecurity of kidney qi and premature ejaculation.
      3. Abdominal distension and fullness due to kidney deficiency are mostly caused by water flooding the abdomen and obstruction of qi movement, so appetite is often unaffected, unlike abdominal distension and fullness due to liver deficiency, which is caused by the failure of wood to regulate earth, often resulting in fullness without the desire to eat.
   By synthesizing the above three for differentiation, yang deficiency in the kidney or liver can be clearly identified.

bubble_chart Documentation

1. Zhongcang Jing: "Liver deficiency and cold cause firm pain under the ribs, blindness and arm pain, chills resembling malaria, anorexia, women's menstruation not coming, shortness of breath, and a deep and weak pulse at the guan position."
2. Zhubing Yuanhou Lun．Five zang and six fu-organs diseases: "Insufficient liver qi leads to unclear vision, tightness in both flanks, muscular spasms, inability to sigh, withered nails, a greenish complexion, frequent sadness and fear, as if someone is about to catch them. This is a deficiency of liver qi and should be treated with tonification."
3. Taiping Shenghui Fang: "Liver deficiency leads to cold, which causes bitter firmness and distension under the ribs, chills and fever, abdominal distension and fullness, lack of appetite, depression, feeling as if someone is about to catch them, unclear vision, black spots in the eyes, bitter taste in the mouth, headache, stiff joints, muscle spasms, dry and withered nails, frequent sadness and fear, inability to sigh, and a deep and slippery pulse. These are all signs of liver deficiency."
4. Xixi Shuwu Ye Hua Lu: "One method is to tonify liver yang with Cassia Bark, Pricklyash Peel, and Cistanche.…… Another method is to tonify liver qi with Gastrodia Tuber, White Atractylodes Rhizome, Chrysanthemum Flower, Fresh Ginger Rhizome, Asarum, Eucommia Bark, and Sheep Liver."
5. Qianzhai Yixue Jianggao．On Liver Diseases: "From the perspective of the entire liver physiology, the liver uses blood as its substance and qi as its function. Blood belongs to yin, and qi belongs to yang, hence it is said to have a yin substance and yang function. Therefore, the pattern of liver deficiency includes both blood deficiency leading to insufficient substance and qi deficiency leading to weak function, encompassing qi, blood, yin, and yang, namely liver blood deficiency, liver qi deficiency, liver yin deficiency, and liver yang deficiency. Normal liver qi and liver yang are the abilities that allow the liver to ascend and regulate, hence they are referred to as "function." In disease, qi counterflow and yang hyperactivity occur, commonly referred to as "liver qi" and "liver yang syndrome"; or it may manifest as fatigue, depression, timidity, headache, numbness, and cold limbs, which are symptoms and signs of liver qi deficiency and liver yang deficiency."