If you went to the same kind of medical school I did and took the same kind of licensing exam I took, you were trained to seek out and expect to find primary deficiencies here in the U.S. However, after several years out of school, I and many of my colleagues came to realize that the only primary deficiency that will walk into our clinics is wei qi deficiency. All other primary deficiencies in this country will be found only in hospitals, in patients who are near the end of life.
Let us define deficiency (xu) as an inadequate supply of something necessary. But we have to ask, necessary for what? The answer is, necessary for life, especially a healthy life.
A primary diagnosis is one that comes first, that must be addressed above all others and that likely contributes to all other symptoms. A primary diagnosis denotes the chief herbs in a formula and the primary points in an acupuncture prescription. A primary diagnosis can refer to an excess or a deficiency.
The concept of a primary deficiency emphasizes the immediate necessity of supplying an adequate amount of yin, yang, blood, or qi for life to continue. A primary deficiency requires emergency intervention.
A secondary deficiency does not. A secondary deficiency is generally the incidental result of a primary excess and its resolution depends on the successful resolution of that primary excess.
Chinese Deficiencies and American Excesses
The idea that chronic deficiencies are commonly found in the general population is a Chinese one. Like all underdeveloped countries now and in times past, China has experienced its share of famines which have caused mass starvation and chronic malnutrition. Malnutrition will bring about deficiencies of everything – yin, yang, qi, blood, and jing. As late as the early 1960s, China experienced the mass starvation to death of millions of people. Even between periodic famines, there were always poor people existing on the edge of starvation who exhibited symptoms and signs of primary deficiencies that needed direct and immediate tonification.
This deficiency consciousness was transmitted across the Pacific to our shores as Chinese medicine became legalized and organized in the U.S. in the late 1970s and early 1980s. From the beginning, it was an entrenched fixture in the schools, exams and minds of licensed acupuncturists here in the "Land of Excess." And it found a ready audience among the American people, who are thoroughly conned by advertisers into filling voids by consuming endlessly.
Endless consumption requires a population with a desperate perceived need for more and more, a nagging fear of never having enough – never enough money, cars, gadgets, clothes, shoes, water, and of course nutrition. The world has never witnessed such an over-nutritionized collection of overweight and obese residents, in a nation that to my knowledge has never truly experienced mass famine. Today's U.S. population has no reality-based conception of starvation and yet is terrified of "hunger."
Below are the different components of the Deficiency Myth, which is blithely and unconsciously promoted by many members of our profession.
Qi Deficiency and Spleen Damp
Muscular and mental fatigue, poor digestion, and lack of hunger (an empty feeling in the upper abdomen) are the chief symptoms of Spleen qi deficiency. It is an interesting fact that these symptoms are felt by obese people and by starving people – two sides of the same spleen qi deficiency coin.
In a country where 20% of children are obese, a third of adults are obese, and another third are officially overweight, these Spleen qi deficiency symptoms are clearly secondary to the primary cause – Spleen Damp. A digestion, which is continuously clogged with food and calories renders a spleen barely capable of transforming food into qi and transporting the qi to where it is needed. In addition, carrying extra pounds of fat every day will exhaust the body's limited supply of qi, compounding the fatigue.
It would be a mistake to focus on tonifying qi, even though Americans will often complain primarily of fatigue. The proper focus is to clear the damp/food stagnation, attending to the Chinese maxim: "When presented simultaneously with an excess and a deficiency, clear the excess first."
In the U.S., this practice makes complete sense, because most deficiencies that we see in our clinics are the direct result of the chronic excesses in American culture. And instead of tonifying the deficiency – in this case with a formula like Liu Jun Zi Six Gentlemen for example – we end up tonifying the excess damp, by giving the patient rich, difficult-to-digest herbs.
It would be more judicious to prescribe for these patients herbs and points that move food and damp stagnation from the middle and lower burners, counseling for the reduction of food intake, and possibly including mild, supporting qi tonics such as Bai Zhu Atractylodis that strengthen by drying damp.
Yin Deficiency and Yin Excess
Do you remember ever studying "yin excess" in school? Of course not. It was all about "yin deficiency," right? My synonym for yin deficiency is "starving." My synonym for yin excess is "excess body fat." But that's not what we learned. Essentially, we were trained to label any chronic heat pattern as "yin deficiency," while the subject of excess body fat was hardly addressed at all.
Yin is material, while yang is energy. Yin is the mountain, and yang is the mist circling the mountain. "Deficiency yin" means "not enough material to survive." Have you (as an American) ever seen anyone like that? Unless you work in a hospital or have traveled to poor countries, you have only seen yin deficiency in startling photos. Conversely, "excess yin" is an everyday fact of life, a condition that can be recognized from across the street, regardless of what the tongue and pulse might say.
Here's a question for you. How can someone be chronically yin excess and at the same time chronically yin deficient? Simultaneously fat and starving? If you have an answer, please contact me and inform me.
If your answer is "menopausal heat flashes," you would be mistaken. While it is true that a drop in estrogen levels (yin) occurs in that situation, for most women in the world just a little bit of extra body fat quickly compensates, preventing heat symptoms. But for American women, a lifetime of hurry and worry generates a chronic excess heat pattern that goes off like a volcano whenever there is a slight dip in yin. Needless to say, menopausal heat is an American epidemic, not a Chinese one.
Immediately reaching for the heavy, greasy yin tonics as we were trained to do – Shu Di Huang for example – will mainly add to her already damp spleen, and the result is diarrhea or nausea. A much better strategy is to cool and drain the excess heat from the heart, liver, and wherever else it has lodged while merely supporting the yin with a mild tonic, depending upon how much damp (excess yin) her spleen is suffering from.
Yang Deficiency and Yin Deficiency
Low back pain, cold extremities, fatigue, and watery stool – are these symptoms really pathognomonic for yang deficiency? They are not.
"Yang deficiency" means not enough yang to survive. Is someone near death's door really going to visit you in your clinic? For someone who is yang deficient, their pilot burner is about to flicker out! They will not be ambulatory. They need emergency intervention, and that's what Western medicine does best. In a true yang deficiency situation, we are at best assistants.
Any yang deficiency symptoms will always be coupled with yin deficiency symptoms. The obverse is also true. Originating in kidney – the "root of yin and yang" – yang commands yin while yin generates yang. In any kidney deficiency condition, deficiency heat and deficiency cold symptoms will coincide, usually with one predominating over the other and often switching back and forth in this very unstable situation.
As a supervisor in a student clinic, I was commonly watching interns interpret low back pain as "kidney deficiency." The fact is that anyone with low back pain who walks into your clinic is likely suffering from qi and blood stagnation in the channels due to poor posture or liver qi stagnation or both, although other excesses such as toxic heat stagnation in the lower burner (a kidney infection, in Western terms) can be the cause and must be taken very seriously. Stagnation of any type is an excess, and in America, stagnation easily becomes a chronic excess (chronic pain!).
Blood Deficiency and Blood Blockage
When tissues fail to receive nourishment, the general symptoms are dizziness, numbness and spasms (wind due to the vacuum created). In historical China and other pre-industrial societies, starvation and chronic malnutrition regularly are to blame. The blood becomes deficient due to poor nutrition. This is the reason that our textbooks are full of advice on the administration of blood and qi tonics for these symptoms.
However, in the modern American clinic, "blood deficiency" would usually be a misdiagnosis for these symptoms. Flooding the body with greasy blood tonics is simply not the wisest answer. Both liver qi stagnation due to chronic anxiety and qi and blood stagnation due to poor posture are at epidemic levels. These tight and constricting conditions will block the flow of blood downstream, precipitating all symptoms commonly associated with nutritionally-related blood deficiency.
Recognize and Clear the Excess First
It is time that we as a profession swim against the stream of cultural conformity and genuinely start addressing the pathogenic excesses in American life. As practitioners, instructors, textbooks and qualifying exams begin to put to rest the Deficiency Myth, we are bound to become more effective and more influential.
E. Douglas Kihn a doctor of Oriental medicine, is the author of "Chinese Medicine for the Modern World." He resides in West Los Angeles and can be reached at