Syndrome of blood stagnation and formula composition

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Chapter Eleven. Syndrome of blood stagnation and formula composition

CHAPTER CONTENTS

Cautions272
Syndrome of blood stagnation273

Treatment principle 273
Herb selection principles and formula composition strategies 273
Structure of the formula and selection of herbs 274
Examples of classical formulas 281

CHAPTER OUTLINE

This chapter introduces the principles, methods and strategies for the composition of formulas that regulate blood circulation and remove congealed blood. They are used to treat blood stagnation.
If the physiological conditions are not fulfilled, the blood may stagnate. There are different degrees of blood stagnation. In a mild case, the blood moves slower than it should. If the situation does not change, blood stagnates. In a severe case, congealed blood may be complicated by phlegm, heat or cold, and forms a solid mass that blocks the circulation.
The main manifestation of blood stagnation is localized pain of a deep, sharp and piercing nature. Patients who have suffered from stagnation of blood for a long period of time may have such symptoms as a dark complexion, purple lips and nails, fragile nails and hair, and dry skin, and some may suffer from mental confusion. In women, menstruation disorders may be present.
Blood stagnation is caused by several factors:

• Heat may overstimulate the blood circulation, hasten its speed and even cause bleeding.
• Heat can consume the fluid in the blood and make the blood thicker so that the blood movement becomes slower.
• Cold may freeze the blood, allow the circulation to slow down and eventually cause stagnation.
• Blood stagnation is often the result of Qi stagnation, which is frequently caused by emotional disturbance, such as stress, anger, brooding or depression for a long period.
• Trauma or fracture may cause blood stagnation directly in the local area.
• Wind, dampness and cold that lodges in the meridians can also cause blood stagnation, as can accumulation of phlegm, water, food and parasites in the body for a long period of time.
• If the Qi and blood are deficient, they will not be able to promote the blood circulation, and this too will lead to blood stagnation.

CAUTIONS

1. Caution during pregnancy and in bleeding conditions:

Herbs that promote the blood circulation are pungent; they can make the blood circulate quickly, break up congealed blood or soften hardness. These actions may harm the fetus, causing miscarriage and heavier bleeding.
2. Use with caution in patients with weakness of the Spleen and Stomach and deficiency of Qi:

Formulas that promote blood circulation are quite strong in action and have strong smells and tastes that can easily injure the Stomach and place an extra burden on the Spleen. These formulas should therefore be taken after meals, especially in patients with a sensitive stomach. Moreover, since these formulas are very active in stimulating the blood circulation, they may also consume Qi and patients may feel tired. They should be applied with caution, especially among patients who are already suffering from Qi deficiency.
3. Select appropriate herbs from the strength scale to compose a formula for treating a specific syndrome of blood stagnation:

If the stagnation is severe and the applied herbs are too gentle, the congealed blood cannot be eliminated. If the blood stagnation is mild but the prescribed formula is very strong, the Qi and blood can be injured. Thus, appropriate herbs should be selected from the strength scale to compose a formula for treating a specific syndrome of blood stagnation. Furthermore, appropriate herbs should be selected according to the condition and constitution of the patient, the location and nature of the stagnation and the duration of the disease.
4. Be careful when using these herbs together with anticoagulants from western medicine.

Syndrome of blood stagnation

Manifestations

Main symptoms

Localized pain of a deep, sharp and piercing nature, worsening in the night, and a palpable, solid, immobile mass in severe cases.

Secondary symptoms

Dark complexion, purple lips and nails, fragile nails and fragile and dry hair, dry skin, amenorrhea, dysmenorrhea, irregular menstruation, mental confusion and mental disorders.

Tongue

A purple tongue with purple spots on the tip or border.

Pulse

Wiry and choppy.

Associated disorders in western medicine

Rheumatic arthritis, rheumatoid arthritis, trauma, strain, myocardial infarction, angina pectoris, sequelae of cerebrovascular accident, chronic hepatitis, cirrhosis of the liver, enlarged spleen, various tumors, as well as psychiatric disorders.

Analysis of the syndrome

• Pain is the first and most important sign of blood stagnation. Different from distending pain due to Qi stagnation, blood stagnation is manifested as a localized, deep, sharp pain.
• When congealed blood is formed and the blood circulation has become slow, the patient may have a dark complexion, purple lips and nails, and menstruation becomes irregular.
• When the blood is not able to nourish the body, dry skin, brittle nails, fragile and dry hair may be present.
• If the blood stagnation stays for a long period of time, in severe cases congealed blood may be complicated by phlegm, heat or cold. These can eventually form a solid mass. The masses can be tumors or enlarged, hard organs.
• Since the blood cannot circulate smoothly, a choppy pulse can be felt, and a purple tongue with purple spots can be observed, especially on the tip or border, the region of the Heart and Liver.
(See Figure 11.1 on page 284.)

Treatment principle: Activate the blood circulation, promote Qi movement and remove congealed blood

Herb selection principles and formula composition strategies

• First, herbs that are pungent, aromatic and slightly warm, enter the Heart, Pericardium, Liver and Gall Bladder meridians, and can stimulate the blood circulation are selected.
• If there is heat in the blood with blood stagnation, the first priority is to select pungent, bitter and slightly cold herbs that enter the Heart, Pericardium, Liver and Gall Bladder meridians, and can circulate the blood and clear heat.
• In the condition of stagnation of congealed blood for a long period of time, the first priority is to select pungent, bitter and salty herbs that can particularly soften hardness, along with herbs that promote blood circulation.
• Second, herbs that regulate the Qi in order to promote blood circulation are often used.
• Third, herbs that eliminate phlegm and dampness or expel the wind from meridians are also often used to assist the herbs that promote blood circulation and Qi movement.
• Herbs that can warm the interior and tonify the weakness of the internal organs are often used in a deficiency syndrome.
• Herbs that nourish the blood and Yin and herbs that tonify the Qi are often used in chronic conditions of blood stagnation.
• Finally, herbs that protect the Stomach from the side effects of harsh herbs that strongly stimulate the blood are often prescribed.

Structure of the formula and selection of herbs

Chief and deputy: Regulate the blood circulation and remove congealed blood by selecting appropriate herbs according to their strength and working region

A number of herbs can directly circulate the blood and remove congealed blood. In a formula, one or two herbs in reasonably large dosages are chosen as chief. They act directly against the cause of the stagnation and they reach to the affected region. To prevent side effects and to enhance the ability of the chief, herbs that move the blood should be chosen as deputies.
For convenience, the chief and deputy substances are discussed together in the following groups according to their strength of function, their nature and their particular influence on a certain region.

(A). Selection according to strength in function and nature

Chuan Xiong ( Chuanxiong rhizoma), Yan Hu Suo ( Corydalidis rhizoma), Hong Hua ( Carthami flos) and Yue Ji Hua ( Rosae chinensis flos)

These herbs can invigorate blood and promote blood circulation. They are warm in nature. The herbs in this group are used widely in different types of disorder caused by blood stagnation. Most are effective for relieving pain and some can be used topically.
Chuan Xiong is pungent and warm, and enters the Liver, Gall Bladder and Pericardium meridians. Chuan Xiong is a very effective herb to invigorate the blood and to promote the blood circulation. It is characterized by fast-moving speed and strength. As it moves upwards, downwards, inwards and outwards, and can reach every part of the body, it is regarded as the herb that moves the Qi in the blood. In a formula, it is often selected to promote blood circulation and stop pain caused by Qi and blood stagnation complicated by cold, such as headache on the lateral side of the head, intercostal neuralgia, chest pain, pain from trauma, pain in the joints, dysmenorrhea, amenorrhea and irregular menstruation. Since Chuan Xiong is very effective, it is often used as chief. In combination with other herbs, it can be used in syndromes of excess, deficiency, cold or heat.
Although Chuan Xiong is effective in promoting blood circulation, it can lead the Qi and blood to ascend rapidly and therefore it should be used with caution in patients who suffer from syndromes of Liver-Yang ascending, up-flaring of Liver-fire or Heart-fire, such as hypertension, glaucoma and cerebrovascular accident. Moreover, since this herb is warm and very pungent, a large dosage may consume the Yin and Qi, and patients with Yin deficiency or with a weak constitution should not use this herb in large dosage.
Yan Hu Suo is pungent, warm and slightly bitter. It is characterized by entering the Qi and blood level, and promoting the Qi movement and blood circulation. It is an excellent herb to relieve pain and this effect is stable and strong. In clinical practice, it can be used as a single herb, and in Chinese medicine it is considered to be a painkiller. If this herb is fried with a little vinegar, pain relief is even stronger. Yan Hu Suo is slightly poisonous and therefore should not be used for too long. It is recommended for use in a formula where it can obtain assistance from other herbs, especially in the treatment of a chronic condition of blood stagnation.
Hong Hua is pungent and warm, and enters the Heart and Liver meridians. It is able to invigorate the blood and promote the blood circulation. If a small dosage is applied, it can regulate the blood circulation; if a large dosage is applied, it can break up the congealed blood and stop pain. It can be used as chief or deputy in a formula for different types of blood stagnation, such as endometriosis, amenorrhea, dysmenorrhea, irregular menstruation and infertility. Since it can strongly move the blood, it may cause bleeding or make bleeding heavier, thus the dosage and treatment course should be controlled carefully. During menstruation, this herb should be used in a smaller dosage or should be stopped for 3 days to avoid heavy menstrual bleeding.
As well as treating menstruation disorders, Hong Hua is one of the commonly used herbs for treating trauma as it is effective for reducing swelling and pain. In these cases, it can be used both orally and topically.
Yue Ji Hua is sweet and warm. It has a fragrant smell and enters the Liver meridian. It regulates not only the blood circulation, but also the Liver-Qi movement. It is often used as deputy in a formula to harmonize Qi and blood of the Liver and it particularly treats menstruation disorders.

Dan Shen ( Salviae miltiorrhizae radix) and Chi Shao Yao ( Paeoniae radix rubra)

These herbs are cold in nature and can invigorate blood. They promote blood circulation, relieve pain and can also be used topically.
Dan Shen is bitter and slightly cold, and enters the blood level of the Heart and Liver meridians. It is able to promote the blood circulation, cool the blood, calm the mind and eliminate irritability. It is especially suitable for treating the syndrome of blood stagnation complicated by heat. The syndrome is often caused by stress and emotional disturbance, which lead to stagnation of Liver-Qi or generation of heat in the Liver and Heart. It is selected in formulas to treat chest pain, hypochondriac pain, heartburn, depression, irritability, insomnia and restlessness. It is also an important herb for treating gynecological disorders due to heat and blood stagnation, such as dysmenorrhea, irregular menstruation, premenstrual tension syndrome and menopause syndrome.
Chi Shao Yao is sour, bitter and slightly cold. It is characterized by reducing the excess heat in the blood and regulating the blood circulation. It can also reduce swelling and pain and is often used in formulas to treat abscesses, furunculosis, appendicitis, intestinal obstruction and dysmenorrhea. It can be used topically to treat pain and swelling due to trauma.

Wu Ling Zhi ( Trogopterori faeces), Ze Lan ( Lycopi herba), Yue Ji Hua ( Rosae chinensis flos), Dan Shen ( Salviae miltiorrhizae radix), Yu Jin ( Curcumae radix) and Yi Mu Cao ( Leonuri herba)

The herbs in this group can be selected as chief and deputies to dissolve congealed blood; they can also stimulate blood circulation. They are mainly used to treat the more severe or chronic syndromes of blood stagnation where the blood becomes thicker and blood clots are formed, such as in atherosclerosis, hyperlipemia, thrombosis, endometriosis, adhesions in chronic infection and after surgical operations.
The herbs that are warm in nature are Wu Ling Zhi, Ze Lan and Yue Ji Hua; the herbs that are cold in nature are Dan Shen, Yu Jin and Yi Mu Cao. They can be used when cold or heat respectively is in the blood.
Wu Ling Zhi is bitter, sweet and warm. The strong point of this substance is that it can dissolve congealed blood in a gentle but constant way. As it is effective for removing congealed blood without the side effect of injuring the normal part of the blood, it is used for chronic diseases when the congealed blood is not easily removed in a short period of time. Wu Ling Zhi can also promote blood circulation and stop pain. It is often prescribed in formulas for treating gynecological disorders and liver diseases.
Ze Lan is pungent and bitter, and enters the Liver and Spleen meridians. It is slightly warm and is able to promote blood circulation and open obstructions. It is characterized by removing congealed blood without the side effect of injuring the normal blood, and it is especially suitable for treating stagnation of blood caused by cold in the Lower-Jiao and in blood. As it is an aromatic herb and is able to spread the Liver-Qi and the Spleen-Qi, it is an excellent herb to treat stagnation of Liver-Qi and blood in both excess and deficiency conditions. It is often used as deputy in the formula to treat menopause syndrome, irregular menstruation, premenstrual tension syndrome, depression, liver disease and chronic urinary tract infection.
Yue Ji Hua is sweet and warm, has a fragrant smell and enters the Liver meridian. It not only regulates the blood circulation, but also dissolves congealed blood. Moreover, it can regulate the Liver-Qi. This herb is often used as deputy in a formula to regulate Qi and blood, and to reduce congealed blood in a gentle way. It is often used for menstruation disorders and liver diseases.
Dan Shen is bitter and cold, and primarily enters the Heart meridian. It cools the blood and moderates the speed of blood circulation. It is especially effective for clearing heat in the Heart and promoting the blood circulation in the chest. It is often selected in a formula to treat heat and blood stagnation in the chest, manifested as irritability, restlessness, palpitations, insomnia and chest pain. Dan Shen can also remove congealed blood, and is used for treating more severe conditions, such as myocardial infarction, angina pectoris, atherosclerosis, hyperlipemia and thrombosis. It is also used to treat hepatosplenomegaly because it can soften the organs, reduce their size and improve their functions.
Yu Jin primarily enters the Liver meridian, on which its function focuses. It is pungent, bitter and cold, and is able to invigorate the Liver-blood. Because of the high speed of its action, it is regarded as the herb that moves the Qi in the blood and is considered as the herb that is able to break up congealed blood. Moreover, Yu Jin can cool the blood and stop bleeding. Together with other herbs, it can be used as chief or deputy in a formula to break up and remove congealed blood and stop bleeding. It is used for dysmenorrhea, mastopathy, liver cirrhosis and tumors, as well as bleeding due to Liver heat.
As well as the above-mentioned functions, this herb has other functions that can be used as a reference in selecting herbs in a formula. It is an aromatic herb, and is able to penetrate damp-heat, clear damp-heat and promote bile secretion. It can be used as deputy in a formula when there is damp-heat in the Upper- and Middle-Jiao, the symptoms of which are fullness in the chest and epigastric region, jaundice and reduced appetite, such as in malaria and hepatitis. In addition, Yu Jin can spread the Liver-Qi, clear the Liver-heat and eliminate irritability. It can be selected to treat headache and a tight sensation in the chest caused by Qi and blood stagnation and damp-heat obstruction.
Yi Mu Cao specifically treats stagnation of blood in the Lower-Jiao and is often used as deputy to treat gynecological disorders, such as dysmenorrhea, amenorrhea and irregular menstruation. It is used frequently to clear heat and remove congealed blood from the Lower-Jiao, thus it is often used in acute and chronic infections and inflammations in that region, such as cervicitis and adnexitis.

Tao Ren ( Persicae semen), Hong Hua ( Carthami flos), Yu Jin ( Curcumae radix), Ru Xiang ( Olibanum) and Mo Yao ( Myrrhae)

The substances in this group are able to break up congealed blood . They are also used to treat severe and chronic blood stagnation when congealed blood is present in the body for a long period of time. The congealed blood becomes a hard clotted or solid mass, such as a tumor or swollen glands. These substances are used in trauma when there is acute and severe blood stagnation with pain. They are pungent, salty or bitter in property.
Tao Ren is bitter, sweet and neutral, and enters the Heart, Liver and Large Intestine meridians. Since its bitter taste is dominant, this herb moves downward and can break up congealed blood. It is often used with large dosages of Hong Hua, which is warm and pungent, and enhances the ability of Tao Ren to remove the congealed blood.
Yu Jin is pungent, bitter and cold, and is able to invigorate the Liver-blood. It moves with high speed, can break up congealed blood, cool the blood and stop bleeding.
Ru Xiang is warm and pungent, and enters the Heart and Liver meridians; Mo Yao is neutral and enters the Liver meridian. Ru Xiang and Mo Yao are a pair of herbs that are often used together. They can strongly disperse and descend congealed blood, open up the meridians and collaterals, and are very effective in relieving pain.
If comparing the functions of the two herbs, Ru Xiang promotes the Qi movement and can also relax the tendons. As it is particularly suitable for conditions where the joints and muscles are very stiff, swollen and painful, it is often used in trauma or fracture, and is also more often used topically than Mo Yao. Mo Yao is more bitter and its dispersing action is stronger in breaking up congealed blood. It is used not only in trauma or fracture, but also in hard masses, such as tumor. These two herbs are often used together to enhance their therapeutic effect and they form a main part in formulas to break up congealed blood.
Since both herbs have a strong smell that can easily cause nausea, and overdose may injure the stomach, they are often used in pill form and have to be taken after a meal.

San Leng ( Sparganii rhizoma), E Zhu ( Curcumae rhizoma), Zhe Chong ( Eupolyphaga seu opisthoplatia)*, Mang Chong ( Tabanus)* and Shui Zhi ( Hirudo)

These substances can break up or drive out congealed blood. They are used to treat a solid mass that is formed by congealed blood, phlegm, dampness, cold or heat and toxin. Some substances in this group are poisonous. Their poisonous nature can effectively conquer the pathogenic substances in the body. They are only used in formulas that treat very severe conditions, such as hepatosplenomegaly, liver cirrhosis and cancer.
San Leng and E Zhu can strongly promote Qi movement and blood circulation, and break up congealed blood. These two herbs are often used together to enhance their actions because San Leng is stronger in breaking up congealed blood and E Zhu is stronger in breaking up the constrained Qi. They can be used in formulas as chief or deputies to treat severe blood stagnation, such as hepatosplenomegaly, liver cirrhosis, ectopic pregnancy and tumors. Since San Leng and E Zhu can strongly break up congealed blood, they can also injure the Qi. For treating patients with Qi deficiency or with a weak constitution, these herbs must be used together with herbs that tonify the Qi.

Chuan Xiong ( Chuanxiong rhizoma), Ji Xue Teng ( Spatholobi caulis et radix) and Hong Hua ( Carthami flos)

These herbs can regulate the blood and promote blood circulation in the entire body.
Chuan Xiong is a commonly used herb for promoting blood circulation. It is characterized by high moving speed and strength. As it moves upwards, downwards, inwards and outwards, and can reach every part of the body, it can be used in a general condition of blood stagnation. As it is warm, pungent and moves at a high speed, it should be used with caution.
Ji Xue Teng is sweet, slightly bitter and warm, and enters the Liver meridian. It can invigorate the blood and treat blood stagnation. The difference between this herb and the other herbs that promote blood circulation is that Ji Xue Teng is able to tonify blood and can treat blood deficiency, such as in chronic diseases or in patients with a weak constitution. Moreover, according to the concept in traditional Chinese herbal medicine, Vines enter collaterals, this herb is able to regulate the collaterals and to treat numbness, stiffness and cramp of the limbs, and is often used for treating chronic arthritis, sequelae after cerebrovascular accident, restless legs and other vascular and neurological diseases.
Hong Hua is pungent and warm, and enters the Heart and Liver meridians. It has a dispersing nature and can promote the circulation of blood in the whole body and stop pain. It is also often used in a general condition of blood stagnation.

(B). Selection according to region

Chuan Xiong ( Chuanxiong rhizoma)

Chuan Xiong is particularly selected if the blood stagnation manifests in the head. It is considered as a Qi-moving herb in the blood. Its action is characterized by high moving speed and strength. It moves upwards and can reach the top of the head. It enters the Liver and Gall Bladder meridians and therefore effectively opens the blockage of blood on the lateral side of the head.

Chuan Xiong ( Chuanxiong rhizoma), Hong Hua ( Carthami flos), Dan Shen ( Salviae miltiorrhizae radix) and Chuan Niu Xi ( Cyathulae radix)

These herbs are particularly selected if the blood stagnation manifests in the chest.
Chuan Xiong and Hong Hua are pungent and warm, and enter the Heart meridian. They are often chosen to promote blood circulation in the chest. They can effectively relieve chest pain and therefore are used to treat myocardial infarction and angina pectoris.
Dan Shen also enters the Heart meridian, has similar functions to Chuan Xiong and Hong Hua, and it also is used in myocardial infarction and angina pectoris. However, it is cold in nature and is used in a syndrome with heat in the blood and in the Heart.
Like Dan Shen, Chuan Niu Xi is cold, but it can direct the blood downward. It is particularly suitable for use when the blood and heat accumulate in the head or chest, or when blood and heat have a tendency of ascending.

Yu Jin ( Curcumae radix), Chi Shao Yao ( Paeoniae radix rubra), Yan Hu Suo ( Corydalidis rhizoma) and Su Mu ( Sappan lignum)

These herbs are particularly selected if the blood stagnation manifests in the hypochondriac region and upper abdomen.
Yu Jin primarily enters the Liver meridian, on which its function focuses. It is pungent, bitter and cold, and is able to invigorate the Liver-blood at a high speed. As it can also clear damp-heat, it is often used for hypochondriac pain caused by blood, dampness, Qi stagnation and heat accumulation.
Chi Shao Yao is sour, bitter and slightly cold. It is characterized by reducing excess heat in the blood and regulating the blood circulation. It is good at reducing pain and swelling due to trauma.
Su Mu is sweet, salty, pungent and cold, and enters the Heart, Liver and Spleen meridians. The dominant pungent taste brings about a strong dispersing action. A small dosage of Su Mu can activate the blood circulation and a large dosage can break up congealed blood. It is often used for gynecological disorders caused by Liver-blood stagnation. It is also an important herb to reduce pain and swelling in trauma.

Dang Gui ( Angelicae sinensis radix), Yue Ji Hua ( Rosae chinensis flos), Ze Lan ( Lycopi herba), Yi Mu Cao ( Leonuri herba) and Wu Ling Zhi ( Trogopterori faeces)

These herbs are particularly selected if the blood stagnation manifests in the abdomen. They are often used for irregular menstruation, dysmenorrhea, endometriosis, infection and inflammation in the pelvis.
Dang Gui is pungent, sweet and warm, and enters the Liver, Spleen and Heart meridians. It can tonify and warm the blood, and stimulate the blood circulation in a gentle but steady way.
Yue Ji Hua is sweet and warm, has a fragrant smell and enters the Liver meridian. It can reduce congealed blood in a gentle way and is often used for menstruation disorders and liver diseases.
Ze Lan can disperse the constrained Liver-Qi, remove congealed blood and stop pain. It is a very important herb for regulating menstruation and is a commonly used herb for gynecological disorders.
Yi Mu Cao has functions similar to those of Ze Lan, but is cold in temperature. It is often chosen to treat dysmenorrhea, endometriosis and inflammations in the pelvis due to heat in the blood.
Wu Ling Zhi is sweet and warm, and enters the Liver meridian. It is an important substance to stop pain caused by blood stagnation. It is characterized by gradually dissolving the congealed blood without consuming the normal blood, which is the side effect of most herbs that move blood.

Tao Ren ( Persicae semen) and Hong Hua ( Carthami flos)

These herbs are particularly selected if the blood stagnation manifests in the lower abdomen.
Tao Ren and Hong Hua are warm and pungent. Since Tao Ren moves downward and can break up congealed blood, and Hong Huan can enhance this function, they are often used together to treat blood stagnation in the Lower-Jiao.

Chuan Xiong ( Chuanxiong rhizoma), Su Mu ( Sappan lignum), Chuan Niu Xi ( Cyathulae radix) and Jiang Huang ( Curcumae longae rhizoma)

These herbs are particularly selected if the blood stagnation manifests in the limbs.
They all have a strong moving ability, are able to open up the meridians and treat stiffness and pain of the limbs. As their high speed and strength can also expel cold, wind and dampness, they are often used for treating Bi syndrome caused by wind, cold and dampness.

Wang Bu Liu Xing ( Vaccariae semen), Lu Lu Tong ( Liquidambaris fructus) and Di Long ( Pheretima)

These herbs are particularly selected if the blood stagnation manifests in the collaterals.
Wang Bu Liu Xing, Lu Lu Tong and Di Long are commonly used substances to open the collaterals. They can eliminate congealed blood from the collaterals and promote Qi movement and blood circulation. They are often used as deputies in formulas to treat chronic pain, stubborn pain, tingling and stiffness or numbness of the limbs, such as in migraine, sequelae of cerebrovascular accident and other neurological disorders.

Tao Ren ( Persicae semen), Hong Hua ( Carthami flos), Ru Xiang ( Olibanum), Chuan Xiong ( Chuanxiong rhizoma), Dan Shen ( Salviae miltiorrhizae radix), San Qi ( Notoginseng radix) and Xue Jie ( Daemonoropsis resina)

These herbs are particularly selected for topical use. They can be used for making lotions, ointments, tinctures and plasters. They should be applied when the bleeding has stopped and not on an open wound. San Qi is an exception. As it can stop bleeding and remove congealed blood at the same time, it can be applied to an open wound.

Assistant: (A) Promote the Qi movement, warm the interior, eliminate dampness and phlegm, tonify the Qi so as to promote blood circulation and remove congealed blood. (B) Nourish the blood and Yin, protect the Stomach and Spleen to reduce the side effect of the herbs that stimulate blood

She Xiang ( Moschus)**, Cong Bai ( Allii fistulosi bulbus) and alcohol

These substances particularly promote Qi movement in the head. They are warm and pungent, and move quickly and forcefully. They have a strong ascending and dispersing ability, and therefore are often used to stimulate the Qi to promote blood circulation in the head.

Tan Xiang ( Santali albi lignum) and Jiang Zhen Xiang ( Dalbergiae odoriferae lignum)

These herbs particularly promote Qi movement in the chest. They are aromatic herbs and have a strong and quick action to stimulate the Qi movement in the chest to promote blood circulation. They can broaden the chest and relieve pain and a stifling sensation in the chest.

Jie Geng ( Platycodi radix) and Chai Hu ( Bupleuri radix)

These herbs particularly regulate the Qi in the Upper-Jiao.
Jie Geng and Chai Hu are pungent in nature and enter the Lung and Gall Bladder meridians respectively. They have ascending and dispersing properties, and can ascend and spread the constrained Qi in the Upper-Jiao. They are often used together with herbs that descend the Qi in the chest to activate the Qi and blood in this region.

Xiang Fu ( Cyperi rhizoma), Chai Hu ( Bupleuri radix) and Mu Xiang ( Aucklandiae radix)**

These herbs particularly promote Qi movement in the Liver.
Xiang Fu is the most commonly used herb to regulate the Liver-Qi in the San Jiao meridian. It is a gentle but effective herb and can be used for a long period of time.
Chai Hu enters the Liver and Gall Bladder meridians. It has an ascending property and is more suitable for spreading the constrained Qi and treating hypochondrial distension.
Mu Xiang is an aromatic herb. It can effectively move the Qi. It particularly relieves pain due to its strong action of moving the Qi. Since it also enters the Spleen and Large Intestine meridians, it is more suitable for treating pain in the hypochondriac region and abdomen.

Xiang Yuan ( Citri fructus) and Fo Shou ( Citri sarcodactylis fructus)

These two herbs particularly promote Qi movement in the Liver and Stomach.
Xiang Yuan and Fo Shou are sour and warm, and enter the Liver and Stomach meridians. They can harmonize the Qi of the Liver and Stomach, and are often used in the condition where Liver-Qi overacts on the Stomach, causing poor appetite and fullness in the stomach and hypochondriac regions.

Chen Pi ( Citri reticulatae pericarpium) and Zhi Ke ( Aurantii fructus)

These herbs particularly promote Qi movement in the upper abdomen.
Chen Pi and Zhi Ke can regulate the Qi in the Lung and Stomach, remove phlegm and promote digestion. They can reduce fullness of the stomach and improve appetite. Both are pungent, but as Chen Pi is warm and Zhi Ke is cold, they can be selected separately to meet treatment need.

Wu Yao ( Linderae radix), Qing Pi ( Citri reticulatae viride pericarpium) and Zhi Shi ( Aurantii fructus immaturus)

These herbs particularly promote Qi movement in the lower abdomen.
These herbs are able to promote Qi movement in the Lower-Jiao and stimulate blood circulation there. They also treat Qi stagnation and reduce distension directly. They are all strong herbs and can effectively reduce pain caused by Qi stagnation. Since they enter different meridians, they can treat Qi stagnation in different regions: Wu Yao enters the Kidney and Bladder meridians, Qing Pi the Liver meridian and Zhi Shi the Large Intestine meridian.

Qin Jiao ( Gentianae macrophyllae radix), Qiang Huo ( Notopterygii rhizoma), Du Huo ( Angelicae pubescentis radix), Wei Ling Xian ( Clematidis radix), Fu Zi ( Aconiti radix lateralis preparata)*, Di Long ( Pheretima), Quan Xie ( Scorpio)* and Wu Gong ( Scolopendra)*

These herbs particularly expel wind, damp and cold, and promote Qi movement in the limbs.
In chronic Bi syndromes, blood stagnation often presents with wind, damp, cold or heat in the syndrome. Because wind, dampness and cold can block the Qi and blood circulation, they should be removed in order to improve the blood circulation.
Qin Jiao is particularly used to expel wind-dampness; Qiang Huo and Du Huo can expel wind, cold and dampness; Wei Ling Xian and Fu Zi, the toxic but strong herbs, can expel the cold and particularly reduce pain; Di Long, Quan Xie and Wu Gong are able to expel wind from the collaterals and relax the stiffness and numbness. They are often used with herbs that regulate the blood, particularly those entering the meridians and collaterals.

Xing Ren ( Armeniacae semen), Bai Dou Kou ( Amomi fructus rotundus), Yi Yi Ren ( Coicis semen), Hou Po ( Magnoliae cortex), Qin Jiao ( Gentianae macrophyllae radix) and Cang Zhu ( Atractylodis rhizoma)

These herbs are particularly selected for eliminating dampness and phlegm.
When blood stagnates, the Qi is also obstructed. If it fails to accelerate the digestion and the water metabolism, dampness, phlegm and food may accumulate. Herbs that eliminate these pathological products can also reduce the causes of blood stagnation and therefore improve the condition of the blood.
Xing Ren, pungent and warm, is able to remove the phlegm and descend the Lung-Qi. It is particularly suitable for use when there is damp-phlegm in the Lung.
Both Bai Dou Kou and Yi Yi Ren can eliminate dampness from the Middle-Jiao. Bai Dou Kou can regulate the Qi and transform dampness; Yi Yi Ren is able to promote urination and therefore to leach out dampness.
Hou Po is pungent and warm, and can remove the dampness from the Upper-, Middle- and Lower-Jiao. It can also remove phlegm, descend the Qi and reduce the fullness and distending sensation. It is thus a very commonly used and effective herb in a general sense to activate Qi, and to remove damp and phlegm.
Qin Jiao and Cang Zhu are pungent herbs that can dry and disperse dampness. As they can eliminate dampness from muscles and meridians, they are often used in treating Bi syndrome.

Cong Bai ( Allii fistulosi bulbus), Xie Bai ( Allii macrostemi bulbus), Sheng Jiang ( Zingiberis rhizoma recens), Gan Jiang ( Zingiberis rhizoma), Gui Zhi ( Cinnamomi cassiae ramulus) and Rou Gui ( Cinnamomi cassiae cortex)

These herbs are selected to warm the interior, promote blood circulation and remove congealed blood.
All the herbs in this group are warm and pungent. Cong Bai and Xie Bai are often used to disperse cold in the Upper-Jiao and to stimulate Heart-Yang. Sheng Jiang is more suitable to warm the Stomach, and Gan Jiang to warm the Spleen. As for Gui Zhi and Rou Gui, the former enters the Heart meridian and is effective for promoting Yang and Qi circulation in the meridians and limbs; the latter enters the Kidney meridian and is particularly able to warm the Lower-Jiao and the Kidney-Yang.

Huang Qi ( Astragali radix), Dang Gui ( Angelicae sinensis radix), Sheng Di Huang ( Rehmanniae radix), Hei Zhi Ma ( Sesami semen nigricum) and E Jiao ( Asini corii colla)

These herbs are selected to tonify the Qi, and to nourish the blood and Yin to reduce the side effect of herbs that stimulate the blood.
Since the herbs that promote blood circulation and remove or break up congealed blood are pungent, they easily consume the Qi and injure the blood and Yin. Patients may feel tired during treatment, especially patients who suffer from chronic diseases or have a weak constitution, and therefore herbs that tonify should be used as assistants.
Huang Qi is warm and sweet, and enters the Lung and Spleen meridians. It can powerfully tonify the Qi and strengthen the muscles. It can be used as corrective assistant in the formula to prevent and treat Qi deficiency. It can also be used as assistant for strengthening the Qi to invigorate the blood and promote blood circulation.
Hei Zhi Ma and E Jiao can tonify the blood and Yin, and moisten dryness. They are used to treat dry skin, fragile nails and brittle hair due to blood stagnation and blood deficiency.
Sheng Di Huang is sweet, bitter and cold. It can nourish the Yin and reduce heat to allow blood to move smoothly and calmly. It is particularly suitable for situations where blood and Yin are weak and heat is in the blood, or where pungent and warm herbs have injured the Yin of the body. All of these can make the blood circulation slow down.

Zhi Gan Cao ( Glycyrrhizae radix preparata), Sheng Jiang ( Zingiberis rhizoma recens) and Da Zao ( Jujubae fructus)

These herbs are selected to protect the Stomach and Spleen.
Herbs that promote blood circulation and break up congealed blood can injure the Stomach and Spleen, disturb their ascending and descending functions and cause nausea, fullness or pain of the stomach. Zhi Gan Cao, Sheng Jiang and Da Zao are often used to prevent these disorders.
Sheng Jiang can soothe the Stomach Qi and promote digestion, and Da Zao can tonify the Qi and blood. They are often used together to strengthen the function of the Stomach and Spleen, protecting them from damage by disease as well as from the side effects of the harsh herbs.
Zhi Gan Cao not only tonifies the Qi and moderates the harsh action of the strong herbs, it also eases the muscles. Furthermore, as it can reduce tension in the Middle-Jiao, it is often used to protect the Stomach and Spleen.

Envoy: Harmonize the formula

Zhi Gan Cao ( Glycyrrhizae radix preparata)

Zhi Gan Cao can moderate the herbs that have strong actions and integrate the functions of all the herbs that work on different aspects and in different directions in a formula.

Examples of classical formulas

The following six formulas are all devised by a famous, courageous physician, Wang Qing-ren (1766–1831). He did not follow the previous theory that there is only clear Qi moving in the chest. He observed different organs and blood vessels and he came to the conclusion that the chest is the residence of the blood.
In his book Correcting the Errors in the Forest of Medicine (Yi Lin Gai Cuo), he created these formulas to drive out congealed blood and promote blood circulation. In his formulas, he selected herbs to treat blood stagnation in different regions. In addition, he paid attention to the relationship between Qi and blood, and selected herbs to move and tonify Qi and to stimulate Yang respectively.

Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction) B9780702031328000177/if1.jpg is missing

Source: Yi Lin Gai Cuo B9780702031328000177/if2.jpg is missing

Composition

Tao Ren ( Persicae semen) 12 g
Hong Hua ( Carthami flos) 9 g
Dang Gui ( Angelicae sinensis radix) 9 g
Chuan Xiong ( Chuanxiong rhizoma) 5 g
Chi Shao Yao ( Paeoniae radix rubra) 6 g
Chuan Niu Xi ( Cyathulae radix) 9 g
Chai Hu ( Bupleuri radix) 3 g
Jie Geng ( Platycodi radix) 5 g
Zhi Ke ( Aurantii fructus) 6 g
Sheng Di Huang ( Rehmanniae radix) 9 g
Gan Cao ( Glycyrrhizae radix) 3 g

Analysis of the formula

This formula can drive out blood stasis in the chest. The manifestations are pain in the chest and hypochondria, stubborn headache with a fixed piercing quality, hiccups, palpitations, restlessness, insomnia, irritability, a dull complexion, dark purplish lips, purple tongue with dark spots on the border, and a choppy, wiry or tight pulse.
The composition of the formula can be divided into two parts:

• The second part is to activate the Qi movement in the chest to drive out the blood stasis – Chai Hu, Jie Geng, Zhi Ke and Chuan Niu Xi are in this group.

Commentary on strategies

The strategies are shown in combining Chai Hu, Jie Geng, Zhi Ke and Chuan Niu Xi. Chai Hu and Jie Geng disperse and ascend the Qi; Zhi Ke moves Qi horizontally so that it can open and broaden the chest; Chuan Niu Xi, together with Tao Ren, can lead the blood downwards. With this combination, Qi and blood are moving actively in the chest in a clear downward direction because the dosages of Chuan Niu Xi and Tao Ren are larger than the ascending herbs. In this way the congealed blood can be driven out from the chest.

Tong Qiao Huo Xue Tang (Unblock the Orifice and Invigorate the Blood Decoction) B9780702031328000177/if3.jpg is missing

Source: Yi Lin Gai Cuo B9780702031328000177/if4.jpg is missing

Composition

She Xiang ( Moschus)** 0.15 g
Cong Bai ( Allii fistulosi bulbus) 3 pieces
Chi Shao ( Paeoniae radix rubra) 3 g
Chuan Xiong ( Chuanxiong rhizoma) 3 g
Tao Ren ( Persicae semen) 9 g
Hong Hua ( Carthami flos) 9 g
Da Zao ( Jujubae fructus) 7 pieces
Alcohol

Analysis of the formula and commentary on strategies

This formula is used for treating blood stasis in the head. The manifestations are stubborn headache, vertigo, tinnitus, deafness, hair loss, dark color around the eyes, a dull complexion, a purple tongue and a choppy pulse.
• In this formula, in addition to using blood-moving herbs, She Xiang and Cong Bai – strong, pungent and aromatic substances – are used because they can reach the head, disperse the Qi to stimulate the blood and open up the meridians in the head.
• Alcohol can enhance the moving speed and strength of all the herbs in the formula.

Ge Xia Zhu Yu Tang (Drive out Blood Stasis Below the Diaphragm Decoction) B9780702031328000177/if5.jpg is missing

Source: Yi Lin Gai Cuo B9780702031328000177/if6.jpg is missing

Composition

Wu Ling Zhi ( Trogopterori faeces) 9 g
Dang Gui ( Angelicae sinensis radix) 9 g
Chuan Xiong ( Chuanxiong rhizoma) 6 g
Tao Ren ( Persicae semen) 9 g
Mu Dan Pi ( Moutan cortex) 6 g
Chi Shao Yao ( Paeoniae radix rubra) 6 g
Wu Yao ( Linderae radix) 6 g
Yan Hu Suo ( Corydalidis rhizoma) 3 g
Gan Cao ( Glycyrrhizae radix) 9 g
Xiang Fu ( Cyperi rhizoma) 3 g
Hong Hua ( Carthami flos) 9 g
Zhi Ke ( Aurantii fructus) 5 g

Analysis of the formula and commentary on strategies

This formula is used for blood stasis and Liver-Qi stagnation in the area below the diaphragm. The manifestations are palpable abdominal masses accompanied by fixed pain, and chronic malnutrition in children.
• In the composition, in addition to using the blood-moving herbs in general, Wu Ling Zhi and Yan Hu Suo are selected. They enter the Liver meridian and are particularly used to treat blood stagnation in the hypochondriac region.
• In addition, both warm and cold herbs are used. Herbs that tonify the blood and herbs that reduce congealed blood are used together. They balance the physiological need of the blood and the function of the Liver.
• Moreover, just like the composition of other formulas in this series, the herbs Xiang Fu, Zhi Ke and Wu Yao can promote Qi movement and are used to stimulate the blood in this specific region.

Shao Fu Zhu Yu Tang (Drive out Blood Stasis in the Lower Abdomen Decoction) B9780702031328000177/if7.jpg is missing

Source: Yi Lin Gai Cuo B9780702031328000177/if8.jpg is missing

Composition

Xiao Hui Xiang ( Foeniculi fructus) 1.5 g
Gan Jiang ( Zingiberis rhizoma) 3 g
Yan Hu Suo ( Corydalidis rhizoma) 3 g
Dang Gui ( Angelicae sinensis radix) 9 g
Chuan Xiong ( Chuanxiong rhizoma) 3 g
Mo Yao ( Myrrhae) 3 g
Rou Gui ( Cinnamomi cassiae cortex) 3 g
Chi Shao Yao ( Paeoniae radix rubra) 6 g
Pu Huang ( Typhae pollen) 9 g
Wu Ling Zhi ( Trogopterori faeces) 6 g

Analysis of the formula and commentary on strategies

This formula is used for blood stasis in the lower abdomen. The symptoms are palpable masses or pain in the lower abdomen, irregular menstruation, dark purple menstrual flow with black clots, and a cold, cramping sensation in the lower abdomen.
• In this formula, in addition to using blood-moving herbs in general, the warm herbs Pu Huang, Rou Gui, Xiao Hui Xiang and Gan Jiang are chosen to warm the Yang of the Kidney and Spleen so as to activate the Qi movement and warm the blood in the Lower-Jiao.
• At the same time, herbs that promote blood circulation and remove congealed blood in the Lower-Jiao, particularly in the Liver meridian, such as Yan Hu Suo, Wu Ling Zhi and Mo Yao, are selected.

Shen Tong Zhu Yu Tang (Drive Out Blood Stasis from a Painful Body Decoction) B9780702031328000177/if9.jpg is missing

Source: Yi Lin Gai Cuo B9780702031328000177/if10.jpg is missing

Composition

Qin Jiao ( Gentianae macrophyllae radix) 3 g
Chuan Xiong ( Chuanxiong rhizoma) 6 g
Tao Ren ( Persicae semen) 9 g
Hong Hua ( Carthami flos) 9 g
Gan Cao ( Glycyrrhizae radix) 6 g
Qiang Huo ( Notopterygii rhizoma) 3 g
Mo Yao ( Myrrhae) 6 g
Dang Gui ( Angelicae sinensis radix) 9 g
Wu Ling Zhi ( Trogopterori faeces) 6 g
Xiang Fu ( Cyperi rhizoma) 3 g
Chuan Niu Xi ( Cyathulae radix) 9 g
Di Long ( Pheretima) 6 g

Analysis of the formula and commentary on strategies

This formula is used for blood stasis in the meridians and collaterals of the limbs. The symptoms are chronic pain of all joints and general pain of the body.
In this formula, the herbs that promote blood circulation are used as in the other formulas mentioned previously.
• Moreover, substances such as Di Long and Chuan Xiong, which can reach the collaterals, are applied.
• Herbs that expel wind, cold and dampness are also used, such as Qin Jiao and Qiang Huo, to encounter the need of treating Bi syndrome.
Chuan Xiong, Mo Yao and Xiang Fu are also used to stimulate the Qi so as to enhance the strength of eliminating the congealed blood, wind, cold and dampness.

Bu Yang Huan Wu Tang (Tonify the Yang to Restore Five (tenths) Decoction) B9780702031328000177/if11.jpg is missing

Source: Yi Lin Gai Cuo B9780702031328000177/if12.jpg is missing

Composition

Huang Qi ( Astragali radix) 120 g
Dang Gui ( Angelicae sinensis radix) 6 g
Chuan Xiong ( Chuanxiong rhizoma) 3 g
Chi Shao Yao ( Paeoniae radix rubra) 6 g
Tao Ren ( Persicae semen) 3 g
Hong Hua ( Carthami flos) 3 g
Di Long ( Pheretima) 3 g

Analysis of the formula

This formula tonifies the Qi, invigorates the blood and opens up the meridians. It is used for treating sequelae of wind-stroke, including hemiplegia, paralysis and atrophy of the lower limbs due to deficiency of Qi and stasis of blood. The blood stagnates in the collaterals for a long period of time, resulting in coldness, swelling, numbness, tingling and pain of the affected limbs. The tongue is pale or dark with a white coating and the pulse is weak and slow.
In this formula:

Huang Qi, as chief, is used in a very large dosage. The strategy is to tonify the Qi strongly in order to stimulate the blood circulation. Huang Qi can also warm and strengthen the muscles directly. The remaining substances in the formula are deputies.
Dang Gui, Chuan Xiong, Chi Shao and Hong Hua stimulate the blood circulation.
Tao Ren breaks up the congealed blood in the collaterals with the help of Di Long which opens the collaterals.

Commentary on strategies

• This formula suggests a treatment method by tonifying the Qi and therefore stimulating the blood.
• In clinical practice, the dosage of Huang Qi should be reduced to a dosage in a common range.
Dr Wang Qing-ren explained that the circulation of the blood in the entire body can be considered in ten portions and that, in the situation of hemiplegia, half of the ten portions are blocked. With the help of this formula, the blood circulation in that half can be recovered, hence the name of this formula – Tonify the Yang to Restore Five (tenths) Decoction.
B9780702031328000177/u1.jpg is missing
Figure 11.1 •.
Etiology and pathology of blood stagnation syndrome.