THE QI KEEPS THE BLOOD WITHIN THE VESSELS
The story of Gui Pi Tang
This article is presented in an effort to help practitioners avoid a common error: linking a symptom to a traditional diagnostic category without considering the totality of the available evidence. The discussion, which eventually focuses on the symptom of uterine bleeding, is presented because I have noted that many Western practitioners of Chinese medicine automatically assign cases of uterine bleeding to the diagnostic category of qi failing to keep the blood within the vessels. Even when a woman presents some signs of qi deficiency (e.g., failures in the transformation and transportation of food essence, or weakness and pallor), I believe one should not necessarily assign to this observation the interpretation that this deficiency is the immediate and principal cause of bleeding. Instead, it is valuable to observe the full realm of symptoms and to take into account the practices of modern Chinese physicians and information obtained from the application of Western medical diagnostics.
The functions of qi are many. One of those reported in all standard modern texts is maintaining the flow of blood within the vessels. This function of qi is deemed a direct outcome of the spleen's activities. In The Five Organ Networks of Chinese Medicine (Heiner Fruehauf, ITM, 1998), it is stated that:
Qi does not only move body essences, but it also holds them in place. The fact that the blood circulates in the vessels without leaving its proper path is particularly attributed to the restraining function of spleen qi. The Classic of Difficulties (Nanjing) simply states: "The spleen contains the blood [Pi tong xue]." This function of the spleen [associated with the earth element or phase] is evocative of the characteristics of earth: just as the rivers and streams are contained by an earthen bed, the body's blood is contained in the channels.
The term "contains" has been used in this particular translation, but it is not the only possible meaning. Pi tong xue literally states: spleen [pi] commands, unifies, draws together, controls, rules [tong] blood [xue]. The meaning of the character tong is rendered in various ways (only some of the versions are given here), usually with the help of a second character following it to give it more specific meaning. As presented in the medical classics, without modification, the statement does not inherently imply retaining the blood within vessels, but that can be one of its interpretations. In fact, this interpretation has been relied upon for some time, though probably not during the centuries immediately following the writing of the Neijing (ca. 100 B.C.) and Nanjing (ca. 100 A.D.), when the phrase was first used. Thus, for example, the book Zhong Zang Jing (probably published around 500 A.D.) has a chapter about diseases of the spleen; despite lengthy mention of numerous serious consequences of spleen disorders, including spleen deficiency syndromes, bleeding is not one of them (1).
In the 1984 Dictionary of Traditional Chinese Medicine (2) the phrase Pi tong xue is accompanied by this simple explanation: "The spleen has the function of keeping the blood flowing within the vessels. Its impairment usually leads to chronic hemorrhagic diseases." The persistence of bleeding is one of the factors frequently, though not always, mentioned as a signifier of this type of syndrome. The modern interpretation of the ancient words is widely reported in similar ways, as in the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (3): "With the assistance of the spleen, blood circulates inside the vessels, and no blood extravasation [leakage from the vessels] occurs, therefore, 'the spleen controls blood [Pi tong xue].'"
The application of the Pi tong xue principle can be understood from analysis of the historical records and from modern medical journal reporting of contemporary practice of traditional Chinese medicine, especially herbal medicine. It will be noted, upon such examination, that one particular type of blood escaping the vessels is treated by tonifying spleen qi and is mentioned in relation to qi failing to hold the blood within the vessels: uterine bleeding. A second type of bleeding, intestinal bleeding, is also treated by tonifying the spleen qi, but that does not appear (in most instances) to be a direct application of the Pi tong xue principle; rather, it is a consequence of the general practice of treating intestinal disorders by tonifying the spleen, whether or not bleeding occurs.
The phrase "blood escaping from the vessels" is designated in Chinese by: "xue bu gui jing." Literally, this means that the blood [xue] does not [bu] return [gui] to the vessels [jing; this is the term that is often translated as meridians; originally, meridians and blood vessels were considered the same; see: Jingluo: Drawing a concept]. In other words, the original concept may have been that the blood was not rigidly contained within vessels, but flowed mainly within them, being able to seep out and seep back. Modern medicine recognizes that, in fact, blood constituents do leave the small vessels (capillaries) and return. A Western approach to treating bleeding is to utilize flavonoids (a plant constituent found in many hemostatic herbs) that reduce the leakage from capillaries. The larger vessels, such as arteries and veins that were depicted as jing and luo by the Chinese, normally do not have direct exchange of fluids across the vessel walls.
When there is bleeding from other sites, such as the nose, gums, or lungs, and when there is discharge of blood in the urine, or spontaneous appearance of bleeding beneath the skin (purpura), this is most often interpreted as the result of an excess of heat. This heat excess may be associated with a deficiency of yin and/or blood, so that it is depicted as "deficiency heat"; but that term means that the heat, which is an excess, arises from a deficiency. These symptoms of bleeding usually reflect the traditional principle that heat can cause the blood to run wild and escape from the vessels (unable to return, due to its disorderly exit). Many textbooks will list potential causes for bleeding at these other sites, and include a section on qi deficiency as one potential cause (depicting the patient as having characteristic qi and blood deficiency symptoms and signs), but it is not common to find clinical reports of treatments actually based on this principle, unlike the situation for prolonged uterine bleeding.
It is stated in The Foundations of Chinese Medicine (4) that:
When spleen qi is deficient, it can not hold the blood in the vessels and bleeding appears from various sources, such as under the skin, in the stools or urine, or from the uterus. This is bleeding of deficient nature, as opposed to the bleeding from heat in the blood which is of an excess nature.
When describing bleeding of "deficient nature," the author is not referring to deficiency heat, but rather, spleen qi deficiency only. The Advanced Textbook... states: "If the spleen and stomach are deficient and affected by cold, or if the qi of the middle jiao is insufficient, either bloody stools or uterine bleeding will occur." Under the subsection of the chapter on bleeding, with the heading "deficiency of qi and blood," it says the clinical manifestations are: "bleeding in the nose or gums, or pores in severe cases...."
There is something amiss here in these text book descriptions that is mirrored in the Western practice of Chinese medicine, and I propose it is the spontaneous adherence to a simple traditional statement without due consideration of the full spectrum of clinical presentation. The textbook passages reveal two deviations from what is frequently reported clinically:
The best known traditional formula for addressing bleeding that is attributed to spleen-qi deficiency is Gui Pi Tang (Ginseng and Longan Combination). In fact, this formula (or a modification of it) is prominently featured in virtually every text that mentions the herbal treatment of bleeding disorders associated with qi deficiency following the principle of Pi tong xue. One of the few exceptions is a passing mention in the Advanced Textbook... of both Gui Pi Tang and Shiquan Dabu Tang (Ginseng and Tang-kuei Ten Combination). In some books on formula applications, Buzhong Yiqi Tang (Ginseng and Astragalus Combination) is said to treat this type of bleeding. These three formulas all have the following herbs in common: astragalus, ginseng (with codonopsis often used in modern China as a substitute), atractylodes, licorice; this basic combination of four herbs tonifies qi. The three formulas also contain tang-kuei (danggui), but this is a minor ingredient of Gui Pi Tang.
Gui Pi Tang (5, 6)
Coarsely grind the ingredients, use 12 grams each time, with 5 slices of fresh ginger and a piece of jujube, and decoct. The recipe is for a two week supply, which is a standard course of therapy for this formula.
|licorice (baked)||8 g|
The origin of Gui Pi Tang is attributed to the book Ji Sheng Fang (Formulas for Saving Lives) by Yan Yonghe (1253 A.D.). Gui means to return or restore; the formula name appears to mean "the decoction [tang] for restoring the vitality of the spleen [pi]." The original formula did not contain tang-kuei or polygala (yuanzhi); these two ingredients were added in small amounts about 300 years later when the formula was listed in a book on treating women's disorders (Jiaozhu Furen Liangfang).
The indication of the formula to treat bleeding was first added about 100 years after the formula was written (6). It is not entirely clear, however, whether the actual effect of this formula is to stop the bleeding by helping the qi to control the blood, as would be implied by the Pi tong xue principle, or to compensate for the blood loss that occurs with bleeding, by generating more blood. Modern interpretations of the formula's actions more often focus on generation of blood. The formula is sometimes described in English as "the decoction for invigorating the spleen and nourishing the heart," referring its ability to nourish heart blood rather than on its anti-hemorrhagic action.
Many times, patients categorized with spleen-qi deficiency who have a bleeding disorder (usually uterine bleeding) receive a modified version of this Gui Pi Tang containing herbs with specific hemostatic properties. In those cases, the hemostatic herbs (common additions are gelatin and fulonggan, also called zaoxintu, the oxidized clay from heating stoves) may have the primary function to halt the blood flow, while the rest of the formula nourishes the depleted blood and quickly restores the vitality of the individual. As an example, in the treatment of metrorrhagia in a women with spleen-qi-deficiency diagnosis, Shang Xianmin recommends (7) a slightly modified Gui Pi Tang as the base formula, with the following comments: "For cases with profuse bleeding, add agrimony and gall, and omit tang-kuei; for cases with prolonged dripping bleeding, add typha and sepia bone."
Domei Yakazu (8) reported these indications for Gui Pi Tang, relaying the information recorded in Ji Shi Chuan Su:
Hemorrhage of the spleen meridian [bleeding associated with weakness of spleen qi]; insomnia with fever and profuse perspiration; a spleen injured by over worry which in turn leads to poor blood transformation and the resultant reckless acts; amnesia and melancholy; over palpitation [heart stimulation] causing sleeplessness; the pains of an injured spleen and heart that result in a fondness for lying in bed and poor appetite; a spleen injured by over worry that results in fever and insufficiency of blood; pains in the limbs and trunk; irregular bowel movements; menoxemia; fever in the chest or the interior; scrofula which is suppurating and can't be dispersed, outbursted, or astringed.
Relaying information from the Nü Shan Fang Gao, a summary of applications of this formula is given:
Summing up his views on the use of Gui Pi Tang, Domei Yakazu states:
It is especially effective for those who have been so worn out in body and mind that they have reached an extremity of exhaustion and fatigue. It is also good for those who have had ceaseless superior and inferior [upper and lower body] hemorrhages, rendering an extreme anemia; for those with amnesia and nervous excitement such that the palpitation and anxiety make them unable to sleep....
From all this description, it remains somewhat unclear whether Gui Pi Tang, the formula almost universally selected to treat patients who are diagnosed with the spleen-deficiency-type bleeding, actually stops the bleeding or treats the "extreme anemia" that occurs as the result of chronic bleeding disorders. Clinical trials conducted in recent years have not shed much light on this subject.
Uterine bleeding associated with a qi-deficiency syndrome is characterized in Chinese medical texts by prolonged bleeding (sometimes incessant bleeding), of thin, pale blood (indicates blood deficiency), usually accompanied by chilly sensations (affecting the lower abdomen and legs/feet). Although one can simply state that the cause of the prolonged bleeding is due to the qi deficiency, this is merely a restatement of the Pi tong xue dogma that has developed. What were the causes, as we describe them in modern terms, of such bleeding?
Unfortunately, we cannot know with any certainty the reason why women in China, particularly in ancient China (when Pi tong xue was established as a principle related to bleeding disorders), experienced unusual uterine bleeding. Certainly, the conditions that the Chinese women were exposed to differed markedly from those of modern Western women. For example, there were different diets with markedly different levels of important nutrients, there were fewer STD's (sexually transmitted diseases), no use of high-dosage hormone therapies (there may have been some limited use of herbal therapies that affected hormones, but that is not likely to be prevalent), and more and earlier childbirths. These factors and others mean that the particular manifestation of diseases and disorders of the uterus would likely be different than today, even when the symptoms are similar.
From the modern perspective, we understand that blood escapes the vessels as a result of the following general causes:
As to the first category of causation, injuries were understood in traditional China much as they are today, and the bleeding wasn't correlated with failure of spleen-qi function. Infection, inflammation, and swelling often have a parallel to the traditional concept of heat syndrome (e.g., a lung-heat syndrome leading to hemoptysis would correspond, roughly, to a modern description of lung infection with inflammation, with some bleeding at the site of inflamed and damaged vessels). As to the second category, these particular disorders were probably quite rare; the incidence of ITP, leukemia, and hemophilia have apparently increased markedly during recent decades and were unlikely to be common disorders in ancient times. However, bleeding may also occur as the result of various nutritional deficiencies that rarely affect the modern population, except during illness, but may have been a problem from time to time in China's history even in the absence of illness.
In a study of spleen-qi deficiency patients (10), comprised mainly of individuals with chronic gastro-intestinal diseases, it was found that the blood status differed from that of normal patients. Not surprisingly, there was a lower hematocrit, indicating a nutritional deficiency condition, but there was also a reduction in blood viscosity. In such cases, if there is a potential for bleeding, such as when there are distended, inflamed, or damaged capillaries, then it is more likely that bleeding will occur. If Gui Pi Tang helps reduce the gastro-intestinal inflammation, thereby rendering food nutrients more absorbable, the blood viscosity may return to normal and bleeding will be reduced. This may reflect the fundamental mechanism whereby qi-deficiency patients with bleeding report less bleeding after qi-tonifying and blood-nourishing prescriptions are administered.
Uterine bleeding presents some unique considerations. From the modern perspective, there are three major causes:
It is estimated that about 25% of the cases of abnormal uterine bleeding (in the West) are due to uterine fibroids. These occur with high frequency in women who are about 35-50 years old (fibroids tend to grow substantially during the years just prior to menopause, and then tend to shrink with menopause), affecting about 20% of all women. These abdominal masses are interpreted from the traditional Chinese viewpoint as a blood-stasis syndrome (usually secondary to a qi-stagnation syndrome). There is also a traditional principle that bleeding occurs at sites of blood stasis because the static blood impairs the normal flow of blood and therefore causes it to exit from the vessels under duress. This traditional principle is reasonably close to our modern understanding of fibroids.
The other 75% of cases of abnormal bleeding are related to hormonal imbalances. The thickening of the endometrium is treated in Western medical practice by removing it (d & c procedure) and then administering hormonal pills; this condition would usually be treated by traditional Chinese physicians using blood-vitalizing herbs (with some hemostatics to address the immediate problem of bleeding) followed by a "female formula," that has the effect of regulating menstruation. Modern physicians treat the hormonal imbalance that leads directly to bleeding by using hormone pills (e.g., birth control pills) or by other measures, in some cases, by hysterectomy in women who are approaching menopause. From the Chinese perspective, the treatment would vary depending upon the constitution of the patient and manifestation of the bleeding. Only in cases of weakness and pallor (indicating spleen-qi deficiency) would the imbalance likely be treated with qi-nourishing herbs: specifically, with Gui Pi Tang (weakness and pallor could be the result of the excessive bleeding, rather than the cause). For example, Gui Pi Tang is indicated for the treatment of "preceded menstrual cycle with pale blood," (pale blood indicates a qi and blood deficiency syndrome; darker red blood would suggest a heat syndrome as cause of the bleeding, a condition of short menstrual cycling that corresponds to hormonal imbalance.)
The modern Chinese medical practice of utilizing Gui Pi Tang more frequently for treatment of uterine bleeding than other types of bleeding is illustrated by the descriptions in some recent texts. For example, applications of Gui Pi Tang in the book Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (5) are: "...for poor memory due to heart and spleen deficiency, anxiety impairing the heart and spleen, and deficiency of qi and blood, manifesting palpitation, insomnia, night sweating, decreased intake of food, fatigue, sallow complexion, uterine bleeding or menorrhagia, whitish tongue, with thin white coating and thready weak pulse." In an article on spleen disorders by Zhang Hai Feng (10), the section on "tonifying spleen and holding blood in the vessels," states that "It generally occurs in gynecological hemorrhages." Gui Pi Tang is mentioned as the formula of choice.
Of course, not all of the Chinese literature focuses on uterine bleeding; this is only the dominant clinical application for the formula (or its modification) in relation to bleeding. In A Comprehensive Guide to Chinese Herbal Medicine (11), the section on bleeding problems lists numerous causes from the traditional viewpoint, as well as the associated therapies. With regard to spleen-qi deficiency, it specifically lists "spitting up of dark or reddish blood" [indicating bleeding in the stomach, hematemesis; bright red blood would indicates bleeding from the lungs] and "melena" [dark feces, usually caused by having bleeding in the intestines]. These are the only bleeding conditions mentioned, implicating bleeding in the gastro-intestinal tract. This focus may have been the result of associating stomach/spleen deficiency, in modern terms, primarily with the gastro-intestinal tract. New Practical Syndrome Differentiation of TCM (12) mentions, under failure of qi in controlling blood, manifestations of "hematemesis, bloody stool, subcutaneous ecchymosis, and metrorrhagia [uterine bleeding that persists apart from the normal menstrual bleeding]." In actual practice, hematemesis, mentioned in both texts, is almost never treated by tonifying qi as the principle of therapy.
Before choosing failure of spleen to control the blood as the mechanism involved in a patient experiencing uterine bleeding, one must consider the other causes of uterine bleeding, most notably fibroids, and the appropriate treatment. Fibroids can certainly occur in women with qi deficiency (chronic qi deficiency is one of the traditionally-recognized ways in which pathological processes are able to arise). However, according to Chinese clinical reports, fibroids and resulting uterine bleeding are rarely, if ever, treated by focusing on qi tonification therapy (at least by herbal prescription). In a review I conducted of the Chinese medical literature on clinical experience treating fibroids and uterine bleeding (Treatment of uterine myoma with Chinese herbs), I found that qi-tonification therapies were briefly mentioned but almost never utilized, with the exception that after the uterine bleeding was controlled via other methods, Gui Pi Wan (the pill form of Gui Pi Tang) was sometimes recommended as a follow-up.
A case presentation was made by Shao Nian-fang in his book Treatment of Knotty Diseases... (13), after describing the main categories of concern for functional uterine bleeding, of which deficiency of spleen and kidney was the last one mentioned. A 44-year-old woman presented with menstruation twice per month, each time lasting ten days, with a large amount of blood of light color and no evidence of pathological conditions such as uterine tumors. Today, we would probably describe this as a likely case of perimenopausal menstrual irregularity due to hormonal changes, though this possibility was not mentioned by the author. The woman's constitutional condition was that of qi and blood weakness. The physician's diagnosis was "over strain and over fatigue with impairment of spleen qi, inability to govern the blood, and the debility of the chong and ren channels (conception and governor vessels). The formula administered was a modification of Gui Pi Tang, with gelatin (donkey hide extract), cardamon, barley sprout, and magnetite added, and with zizyphus, polygala, and licorice deleted. She took this formula as a decoction for three weeks, and did not have any uterine bleeding during this time. She then took Gui Pi Wan as follow-up for one month (about 6 grams each time, three times daily). The result, according to the author of the report, was that she had normal menstruation for the next six months. Some questions arise: Did the formula restore the ability of qi to control blood? Did the formula alter the woman's hormones to delay a case of premature menopause or prolonged perimenopausal menstrual irregularity? Is there a difference? These questions may be considered by the Western practitioner in defining their own utilization of and reliance upon different models for interpreting symptoms, determining therapies, and evaluating results of treatment.
The situation outlined in this article represents one of several cases where modern diagnosis (e.g., gynecological examination, something not done in traditional Chinese medicine until this century) might help to offer guidance in ultimately reaching the correct traditional diagnosis and resulting treatment plan. While a highly skilled practitioner of traditional medicine might be able to make the correct diagnosis without the assistance of modern diagnostic techniques, the more limited training of traditional practitioners in the West makes it imperative that they avoid jumping to conclusions, which seem to be reinforced in several textbooks, based on common phrases (e.g., qi keeps the blood in the vessels). Modern diagnostics may help us get past such natural tendencies of the human mind that lead to erroneous conclusions. I am not proposing that spleen-qi deficiency is never the cause of uterine bleeding (or other bleeding disorder), rather:
For the past 650 years Gui Pi Tang has been repeatedly suggested as the remedy for bleeding, especially uterine bleeding, in persons with qi deficiency syndrome. This persistent response suggests that relatively little effort has been expended by Chinese physicians in further analyzing the Pi tong xue principle and the therapeutic methods of addressing it in light of the large number of spleen-qi-invigorating herbs that are available. Modern analyses of the traditionally-defined spleen system have largely focused on its relevance to the digestive system, metabolism, autonomic nervous system, blood constituents, and immune functions (9, 14). Modern analyses of the pharmacological properties and applications of qi-tonic herbs have focused on these same areas (15), without investigating their potential role in treating bleeding disorders.