The Three Treasures Newsletters
SUMMER 2003
BLOOD STASIS AND THE BLOOD-INVIGORATING METHOD
Blood stasis is a common and damaging pathogenic
factor that is at the root of many serious diseases. A characteristic
of Blood stasis is that it is the result of a long pathogenic process:
thus, it is always a relatively serious pathogenic factors and one
that leads to more serious diseases than Qi stagnation. For example,
coronary heart disease, abdominal masses, tumours, high blood pressure,
stroke, etc. all present with Blood stasis. By definition, Qi stagnation
cannot, by itself, cause any of the above problems. Thus, whenever
we see signs of Blood stasis, we know that the condition is one
of long duration and the prognosis is less good than that for Qi
stagnation.
Blood stasis never arises independently (like Qi stagnation) but
is always the consequence of other conditions, usually after a long
period of time. Thus, there are no aetiological factors (diet, emotions,
etc.) that give rise to Blood stasis by themselves as Blood stasis
itself arises from other conditions. The conditions giving rise
to Blood stasis are as follows with the main organs involved in
brackets:
| • |
Qi stagnation (Liver and Heart) |
| • |
Internal Cold (Uterus, Stomach,
Heart) |
| • |
Heat or Fire (Stomach, Intestines, Heart, Liver, Uterus) |
| • |
Qi deficiency (Stomach and Heart) |
| • |
Blood deficiency (Uterus, Heart, Liver) |
| • |
Phlegm (Stomach, Intestines, Uterus) |
1. Qi Stagnation
This is the most common cause of Blood stasis:
since Qi is the commander of Blood and Blood relies on the moving
action of Qi for its movement, any Qi stagnation may lead to Blood
stasis after some time. In this instance, it is primarily Liver-Qi
stagnation that leads to Liver-Blood stasis. However, other organs
may also be involved and Qi stagnation in an organ may induce Blood
stasis in another. For example, Heart-Qi stagnation may also lead
to Heart-Blood stasis. Liver-Blood stasis may also influence the
Uterus and the Intestines.
2. Internal Cold
Internal Cold may be full or empty. Full Cold
arises from invasion of external cold and it may settle in the Stomach,
Intestines or Uterus where it may last for some years. Eventually,
it will inevitably injure the Yang and lead to Yang deficiency so
that it will become Empty Cold. Empty Cold may also arise independently
from a Yang deficiency usually of the Spleen and/or Kidneys.
3. Heat or Fire
Heat or Fire (but especially the latter) injure
and condense the body fluids and therefore Blood since Blood is
part of body fluids. This may occur in the Heart, Liver, Stomach,
Lungs, Intestines and Uterus.
4. Qi Deficiency
In relation to Blood, Qi deficiency normally
leads to deficient Qi being unable to hold Blood in the vessels
and therefore to bleeding: this is the most common outcome of Qi
deficiency in relation to Blood. However, Qi deficiency may also
lead to Blood stasis because deficient Qi fails to move and transport
and may lead to Qi stagnation and Blood stasis. Indeed, there is
a formula precisely for this situation (Bu Yang Huan Wu Tang, p.
320 in Bensky).
5. Blood Deficiency
Blood deficiency may also lead to Blood stasis
because Blood is the mother of Qi; when Blood is deficient, Qi is
also usually deficient, Qi fails to move Blood and Blood stasis
ensues. A simultaneous Blood deficiency and stasis is more common
in women. This may result, for example, in periods that are scanty
but dark with clots.
6. Phlegm
There is a strong interaction between Phlegm
and Blood stasis as both are pathologies of Body Fluids. Phlegm
is a pathological accumulation of turbid fluids, while Blood stasis
is a pathological accumulation of Blood; since there is an interchange
between Blood and Body Fluids, Blood stasis and Phlegm interact
with each other and aggravate each other. A simultaneous condition
of Blood stasis and Phlegm is common in the elderly and it is a
particular pernicious combination leading to serious diseases which
are difficult to treat.
The first three aetiological factors are the most important ones.
CONSEQUENCES OF BLOOD STASIS
Blood stasis can itself become a cause of disease.
First of all, it may induce Blood deficiency: in fact, when stagnant
Blood obstructs the Blood vessels, Qi stagnates, this may not manufacture
Blood properly and Blood deficiency ensues.
Secondly, when stagnant Blood obstruct the blood vessels, new Blood
cannot occupy its rightful place and leaks out giving rise to haemorrhages:
thus, in an apparent paradox, Blood stasis may cause bleeding.
Thirdly, Blood stasis may cause dryness: this happens because Blood
is part of Body Fluids and when Blood stagnates for many years,
Body Fluids cannot be properly produced and dryness ensues.
Fourthly, Blood stasis may lead to Qi deficiency. Thus, Blood stasis
may cause the four following conditions:
| • |
Blood deficiency |
| • |
Bleeding |
| • |
Dryness |
| • |
Qi deficiency |
DIAGNOSIS
The main manifestations of Blood stasis are:
| • |
Pain |
| • |
Swellings, lumps, tumours, masses |
| • |
Colour purple |
| • |
Purple tongue |
| • |
Dark complexion |
| • |
Dry nails and hair |
| • |
Bleeding |
| • |
Maculae |
| • |
Stiffness |
| • |
Dreaming a lot |
| • |
Dark moles |
| • |
Dark eye sockets |
| • |
Purple nose bridge |
| • |
Purple venules |
| • |
Umbilicus bulging out |
| • |
Hardness of the abdomen on palpation |
| • |
Enlarged ends of fingers and toes |
| • |
Skin not elastic, lustreless, dark, scaly, dry |
| • |
A history of chronic illness with repeated
bouts |
| • |
Adhesions and scars from surgery |
| • |
Poor memory |
| • |
Aggravation at night |
| • |
Wiry, Choppy or Firm (Lao) pulse |
| • |
Irregular periods, painful periods with dark
clots, hesitant start to periods, periods starting and stopping |
| • |
Fever |
| • |
Mental restlessness |
| • |
Thirst with desire to gargle but not to swallow
|
| • |
Abdominal pain |
TREATMENT PRINCIPLES AND METHODS
BEN-BIAO AND
XU-SHI
Blood stasis is always the Manifestation (Biao)
of a condition because it arises from other conditions such as
Qi stagnation, Cold, Heat, etc. Blood stasis is a Full condition
by definition. Thus, the question arises how to approach a patient
who suffers from Blood stasis (Full-Biao) but also from an underlying
condition that is the Ben (which, itself, may be Xu or Shi).
The Ben of Blood stasis may be a Deficiency (of Qi or Blood) or
a Fullness (Cold, Heat or Phlegm). Thus, treating Ben consists
in either tonifying Qi and Blood or in scattering Cold, clearing
Heat or resolving Phlegm. Since Blood stasis is always a chronic
condition, generally speaking one needs to treat both Ben and
Biao simultaneously. However, especially when herbal medicine
is used, the question arises whether one should start with a formula
to invigorate Blood modifying it to treat the Ben, or start with
a formula to treat the Ben modifying it to invigorate Blood. The
answer is simple: in more acute cases when the symptoms and signs
of Blood stasis predominate, start with a modification of a formula
to invigorate Blood and eliminate stasis; in more chronic cases
when the symptoms and signs of Blood stasis are less pronounced,
start with a modification of a formula that treats Ben.
My personal inclination, however, is always to clear pathogenic
factors first, i.e. in the case, invigorate Blood and eliminate
stasis. Two examples will clarify this.
Example 1.
A patient suffers from Chest Bi with a severe, frequent chest
pain irradiating to the shoulder, with a very purple tongue and
wiry pulse. In his case, the Blood stasis in the chest derives
from Heart-Yang deficiency (he also suffers from a feeling of
stuffiness of the chest, cold hands, the tongue is pale-Purple
and his pulse is slow). In such as case, I would concentrate the
attention initially in invigorating Blood and eliminating stasis
in the chest with a formula such as Xue Fu Zhu Yu Tang (Red Stirring),
adding something to warm Heart-Yang such as Gui Zhi and Xie Bai.
Example 2.
Another man suffers from cold hands, palpitations, occasionally
irregular heart beat, a feeling of stuffiness of the chest, slight
breathlessness on exertion, pale tongue that is very slightly
purple on the sides in the chest area, and a slow and weak pulse;
he occasionally suffers from a slight chest tightness and pain.
In this example, there is also Blood stasis but it is secondary
compared to the Ben, that is Heart-Yang deficiency and Empty-Cold.
Thus, I would start with a formula to tonify the Heart and warm
Yang, with the addition of one or two herbs to invigorate Blood
and eliminate stasis.
Herbal Treatment
Invigorating Blood is such an important method
of treatment in gynaecology and other disorders that Tang Zong
Hai, author of the "Discussion on Blood Syndromes" (1884),
said: "In Blood syndromes
one must always eliminate stasis of Blood".1
There are many herbs that eliminate stasis of Blood. Practically
all Blood-invigorating herbs are contraindicated in pregnancy:
unless absolutely necessary, it is strongly recommended that they
are not given to a pregnant patient. The only Blood-invigorating
herbs that might be relatively safe to use in pregnancy are Chi
Shao Radix Paeoniae rubrae,
Si Gua Luo Fasciculus
vascularis Luffae, Ji Xue Teng Radix
et Caulis Jixueteng and Dan Shen Radix
Salviae miltiorrhizae.
Since there are so many Blood-invigorating herbs, to classify
them in a rational way makes their use easier. A threefold classification
around which there is some consensus is between herbs that invigorate
Blood herbs that invigorate
Blood and eliminate stasis and herbs
that break up Blood and
eliminate stasis, in ascending order
of strength.2 A list of herbs according to this threefold
classification is as follows:
1) Herbs that invigorate Blood
Chuan Xiong Radix Ligustici Chuanxiong,
Yan Hu Suo Rhizoma Corydalis
Yanhusuo, Yu Jin Tuber
Curcumae, Ru Xiang Gummi
Olibanum, Mo Yao Myrrha,
Wang Bu Liu Xing Semen
Vaccariae segetalis.
2) Herbs that invigorate Blood and eliminate stasis
Dan Shen Radix Salviae
miltiorrhizae, Yi Mu Cao Herba
Leonori heterophylli, Tao Ren Semen
Persicae, Hong Hua Flos
Carthami tinctorii, Chuan Niu Xi Radix
Cyathulae, Ze Lan Herba
Lycopi lucidi, Su Mu Lignum
Sappan.
3) Herbs that break-up Blood and eliminate stasis
E Zhu Rhizoma Curcumae
zedoariae, San Leng Rhizoma
Sparganii stoloniferii, Shui Zhi Hirudo
seu Whitmania, Meng Chong Tabanus
bivittatus, Di Bie Chong Eupolyphaga
seu Opisthoplatia, listed here in ascending
order of strength. These herbs are particularly strong and are
said to "break up" (rather than "invigorate")
Blood. Herbs that break up Blood are suitable to dissolve masses
from stasis of Blood and should be used with great care and sparingly.
Apart from this classification, the Blood-invigorating herbs can
be classified according to various other criteria as follows:
According to nature (hot or cold)
Hot: Chuan Xiong Radix
Ligustici Chuanxiong, Ji Xue Teng Radix
et Caulis Jixueteng, Yan Hu Suo Rhizoma
Corydalis Yanhusuo, Ze Lan Herba
Lycopi lucidi, Hong Hua Flos
Carthami tinctorii, E Zhu Rhizoma
Curcumae zedoariae, Ru Xiang Gummi
Olibanum, Wu Ling Zhi Excrementum
Trogopteri.
Cold: Dan Shen Radix
Salviae miltiorrhizae, Yu Jin Tuber
Curcumae, Yi Mu Cao Herba
Leonori heterophylli, Chi Shao Radix
Paeoniae rubrae, Mu Dan Pi Cortex
Moutan radicis, Chuan Shan Jia Squama
Manitis pentadactylae, Di Bie Chong
Eupolyphaga seu Opisthoplatia.
Herbs that invigorate Blood and stop bleeding
Pu Huang Pollen Typhae
San Qi Radix Notoginseng
Qian Cao Gen Radix Rubiae
cordifoliae
Su Mu Lignum Sappan
Wu Ling Zhi Excrementum
Tragopteri
Herbs that invigorate and cool Blood
Mu Dan Pi Cortex Moutan
radicis
Chi Shao Radix Paeoniae
rubrae
These two herbs are very widely used in gynaecology to cool and
invigorate Blood simultaneously.
Blood-invigorating herbs that affect the breasts and the Connecting
channels
Some Blood-invigorating herbs are also said to "penetrate
the Connecting channels": this means that they move Qi and
Blood and remove obstructions from the Connecting channels. They
can be used for channel problems, but in gynaecology, they can
also be used for breast problems. These herbs are: Si Gua Luo
Fasciculus vascularis
Luffae, Chuan Shan Jia Squama
Manitis pentadactylae and Lu Lu Tong
Fructus Liquidambaris
taiwanianae.
Blood-invigorating herbs that invigorate the lower back and
knees
Chuan Niu Xi Radix Cyathulae
and Ji Xue Teng Radix
et Caulis Jixueteng. Chuan Niu Xi is
particularly important because, besides invigorating the lower
back and knees, it has a descending movement and is often used
for upwards bleeding (such as epistaxis, haematemesis or haemoptysis)
deriving from stasis of Blood.
Herbs that invigorate Blood and calm the Mind
Dan Shen Radix Salviae
miltiorrhizae invigorates Blood and
calms the Mind. It is such an important Blood-invigorating herb
that some doctors say that using Dan Shen in the proper dosage
is like using the formula Si Wu Tang Four
Substances Decoction: this is because
in small dosages, Dan Shen can also nourish Blood. According to
modern research, this herb also has an anti-allergic effect.3
Yu Jin Tuber Curcumae
also calms the Mind and opens the Mind's orifices in cases when
this is obfuscated by stasis of Blood or Phlegm. It is especially
indicated in depression.
Pharmacology of Blood-Invigorating
Herbs
Finally, something should be said about the complex pharmacology
of the Blood-invigorating herbs which makes them some of the most
useful herbs in the Chinese pharmacopoeia. The pharmacological
actions of these herbs may be summarized as follows:
| • |
They improve the dynamics of blood flow and dilate the peripheral,
coronary, cerebral, renal and mesenteric arteries. |
| • |
They improve microcirculation. Disturbance
of microcirculation causes many diseases such as coronary
heart disease, angiitis, endometriosis, chronic hepatitis,
hepatic cirrhosis and scleroderma. |
| • |
They improve concentration, coagulation and
accumulation of blood and prevent thrombosis by inhibiting
accumulation of platelets. |
| • |
They influence connective tissues and can treat diseases
of these tissues such as skin warts, burn scars and adhesions. |
| • |
They readjust cellular and humoral immunity. |
| • |
They have an analgesic effect. |
| • |
They increase uterine contractions. |
| • |
They combat inflammation and bacterial infection. |
Interaction with Western Medication
Generally speaking, all invigorating-Blood
herbs are contraindicated if the patient is taking anticoagulants.
TREATMENT
The method of invigorating Blood is often combined with other
methods of treatment according to the condition. The main treatment
methods combined with invigorating Blood are:
| • |
Move Qi |
| • |
Tonify Qi |
| • |
Nourish Blood |
| • |
Warm the menses and scatter Cold |
| • |
Clear Heat |
| • |
Move downwards |
| • |
Transform Water and resolve Phlegm |
| • |
Open the orifices |
| • |
Soften hardness |
| • |
Nourish Yin |
These combinations will now be discussed in detail.
Move Qi
The treatment method that combines moving Qi with invigorating Blood
is extremely common It is for this reason that very many Blood-invigorating
prescriptions contain herbs that move Qi.
Three Treasures remedy: Break into a Smile, Release Constraint,
Women's Treasure remedy: Freeing Constraint, Free Flow.
Tonify Qi
Stasis of Blood may arise from Qi deficiency. When Qi is deficient
it does not circulate as it should and it therefore fails to move
Blood properly.
The formula Bu Yang Huan Wu Tang Tonifying
Yang and Restoring Five-Tenths Decoction
is an example of a prescription for Blood stasis occurring against
a background of Qi deficiency, for which the formula uses a very
large dose of Huang Qi Radix
Astragali membranacei.
Nourish Blood
It is often necessary to nourish Blood when invigorating it either
because Blood deficiency may be at the root of Blood stasis or because
the latter may cause the former. This happens because stagnant Blood
obstructs the channel and blood vessels and prevents new Blood from
taking its rightful place.
Examples of Blood-invigorating formulae that also nourish Blood
are Si Wu Tang Four Substances
Decoction (which can be classified as
a Blood-invigorating formula) and Wen Jing Tang Warming
the Menses Decoction.
Women's Treasure remedy: Precious Sea, Warm the Menses.
Warm the menses and scatter Cold
The method of warming the menses and scattering Cold is used when
there is Blood stasis deriving from Cold obstructing the Uterus.
This condition may cause dysmenorrhoea, infertility or abdominal
masses.
Women's Treasure remedy: Warm the Menses.
Clear Heat
Heat is another pathogenic factor that may lead to stasis of Blood:
it does so by condensing Blood and therefore slowing down its circulation.
Women's Treasure remedy: Cool the Menses.
Move downwards
The method of moving downwards (i.e. eliminating pathogenic factors
through defecation) is frequently used in conjunction with that
of invigorating Blood and eliminating stasis in the treatment of
stasis of Blood in the Middle of Lower Burner (not Upper Burner).
Transform Water and resolve Phlegm
There is a interrelationship between stasis of Blood and Phlegm,
especially in chronic conditions. When Blood stagnates over many
years, the stagnant Blood obstructs the proper movement of Qi and
functioning of the internal organs and impairs the transformation
of body fluids, leading to the formation of Phlegm.
Open the orifices
The orifices of the Heart may be clouded not only by Phlegm or Phlegm-Fire
but also by stagnant Blood. Obstruction of the Heart's orifices
may occur with various degrees of severity and in serious cases
it causes total loss of insight giving rise to psychotic episodes.
Stagnant Blood affects the Heart's orifices because this organ houses
the Mind and governs Blood and in conditions of not only Heart-Blood
deficiency but also of Blood stasis the Mind therefore suffers.
Three Treasures remedy: Red Stirring.
THREE TREASURES REMEDIES AND WOMEN'S TREASURE
REMEDIES TO INVIGORATE BLOOD
Main Ones
Red Stirring: Blood stasis in the Upper Burner
This is the main remedy for Blood stasis in the Upper Burner affecting
the Heart. As it acts on the Upper Burner, it can also be used for
Blood stasis in the channels of the Upper Burner.
Stir Field of Elixir: Blood stasis in the Lower Burner
This is the main remedy for Blood stasis in the Lower Burner: it
is the remedy of choice for women suffering from Blood stasis in
the Uterus causing gynaecological problems. The best time to take
this remedy is during the 4th (pre-menstrual) and 1st phase (period
itself) of the menstrual cycle. This remedy should not be taken
during the period if the period is heavy (see below).
Invigorate Blood and Stem the Flow: Blood stasis with excessive
menstrual bleeding
This is the remedy of choice for women suffering from gynaecological
problems from Blood stasis but who suffer from heavy bleeding. It
contains herbs that simultaneously invigorate Blood and reduce bleeding:
this is invaluable when the periods are painful with dark clots
but also heavy. It can be taken during the period itself.
Harmonizing the Moon: Blood stasis with endometriosis
This is a new remedy formulated specifically to treat endometriosis
from Blood stasis. It contains some herbs that "break"
Blood, i.e. invigorate Blood strongly to break up masses. It should
be taken during the 4th and 1st phases, unless the period is heavy,
in which case, the woman can take this remedy during the 4th phase
and Invigorate Blood and Stem the Flow during the
1st phase.
Other Remedies
Release Constraint
This remedy primarily moves Qi but it also contains herbs that invigorate
Blood. It is therefore given when there is some Blood stasis but
primarily Qi stagnation. It is specific for emotional problems and
depression deriving from Qi stagnation.
Freeing Constraint
This remedy is similar to Release Constraint and
it was specifically formulated to treat pre-menstrual tension deriving
from Qi stagnation. Like Release Constraint, it
also mildly invigorates Blood.
Warm the Menses
Warm the Menses invigorate Blood in the Uterus by expelling Cold.
It is the remedy of choice for painful periods from Blood stasis
deriving from Cold.
Cool the Menses
This remedy is specifically formulated to reduce bleeding in women
suffering from menorrhagia from Blood Heat. It is also mildly invigorates
Blood.
Clear the Root
This is remedy is specific for prostate problems such as hypertrophy.
In this condition, there is always an element of Blood stasis and
this remedy contains herbs that invigorate Blood.
END NOTES
1. Cited in Li Fei, Discussion about Formulae to Invigorate Blood
and Eliminate Stasis, in Journal of the Nanjing College of Traditional
Chinese Medicine (Nanjing Zhong Yi Xue Yuan Xue Bao), 1, 1987, p.
44.
2. There are actually several terms used to say "eliminate
stasis": qu yu, hua yu and zhu yu. Qu yu means to "eliminate"
or "dispel" stasis, hua yu means to "resolve"
stasis and zhu yu means to "drive out" or "expel"
stasis. The first and the third are the same except for a difference
of degree, the latter being stronger. The second, hua yu, "resolving
stasis" indicates a different way of eliminating stasis.
3. Journal of Chinese Medicine (Zhong Yi Za Zhi), Vol. 32, no. 12,
p. 4.
4. Cited in Li Fei, Discussion about Formulae to Invigorate Blood
and Eliminate Stasis, p. 43.
5. Ibid, p. 43.
6. Ibid, p. 44.
7. Shang Xian Min 1990 Practical Traditional Chinese Medicine and
Pharmacology, p. 227.
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