Warming Yang to Stop Blood Loss
Author: He ShaoshanIn reviewing gynecological texts, discussions on blood loss (beng) often follow the principles of the Neijing, predominantly treating it from a perspective of heat. For example:
The Suwen: Yin Yang Bie Lun states “Yin deficiency and Yang counteracting is called blood loss”
The Shen’s Gynecology Essentials elaborates: “When Yin Qi is deficient, it cannot control Yang, leading to chaotic movements of Yang, resulting in abnormal blood loss. Additionally, Liver Qi is good at dispersing, and in cases of Yin deficiency, water cannot nourish wood, Liver Yang cannot be stored, and excessive dispersal leads to this type of blood loss, which is a manifestation of Yang deficiency”.The Suwen: Liu Yuan Zheng Ji Da Lun also states: “Due to excessive warmth, blood loss occurs”, identifying blood heat as a primary pathological mechanism of blood loss.Thus, Ming Dynasty physician Fang Guang advocated for “initially using hemostatic methods to stop the flow, then using cooling herbs to clear the source, and finally using blood tonics to restore the old state” (from Danxi’s Heart Method), also attributing heat as a cause of blood loss.Through long-term clinical practice, it has been observed that many cases of blood loss are caused by cold deficiency, and warming the meridians and strengthening Yang, while securing the Chong and Ren meridians, has shown significant efficacy in stopping blood loss.Weak Yang and Loss of Control over Chong and RenFrom a pathophysiological perspective, the likelihood of blood loss due to Yang deficiency is high.Young women, if their Tian Gui (menstrual essence) is insufficient, with weak Kidney Qi, the Chong meridian is unstable, leading to irregular menstruation, or during stressful periods, mental strain can deplete Heart Yang, or overwork can damage Spleen Qi, resulting in Spleen Yang deficiency. When both Heart and Kidney Yang are weak, the Chong and Ren meridians lose control, causing blood to flow uncontrollably.Women of childbearing age with a constitution of Yang deficiency, or those who overexert themselves during sexual activity or childbirth, can damage Kidney Qi, compounded by environmental stress and worries, leading to Liver Qi deficiency, cold in the Chong and Ren meridians, and loss of containment, resulting in internal blood loss.Postmenopausal women experience bodily decline, emotional disturbances, and the cessation of Tian Gui, leading to Kidney Qi deficiency, declining Mingmen fire, and Spleen Yang losing warmth, resulting in cold in the Chong and Ren meridians, and loss of control, making them prone to sudden blood loss.For those with a history of excessive menstrual bleeding, or alternating between blood loss and flooding, prolonged conditions can lead to depletion of essence and Qi, as blood loss injures Yin, causing both Qi and Yin deficiency, which can generate cold, harming Kidney Yang, leading to loss of warmth in the Chong and Ren meridians, making it easy to develop blood loss symptoms.Some patients during vaginal bleeding periods indulge in cold drinks, which can harm Yang Qi, or excessively consume cold medicines, damaging Spleen Yang, leading to Yang deficiency and weak Qi, causing the Chong and Ren meridians to become cold and unable to contain menstrual blood, resulting in blood loss.If we say that cold deficiency blood loss is merely one type of blood loss, other types such as Yin deficiency with Yang counteracting, Liver Yang hyperactivity, Qi deficiency in the Chong and Ren meridians, and blood stasis obstructing the meridians, once significant bleeding occurs, their pathological mechanisms have to varying degrees transitioned to Yang deficiency type or Yin and Yang deficiency type.As noted in the Gynecology Essentials quoting Li Dongyuan, “Blood loss that persists over time transforms into a cold condition”, indicating this transition. After sudden blood loss, Yin blood rapidly depletes, Qi follows the blood loss, heat departs with the blood, leading to insufficient Yang Qi and Yin blood, presenting a picture of cold deficiency.Even if there are signs of heat, they are often false heat due to floating Yang deficiency, thus it is essential to warm and nourish the root, returning fire to its source. Since blood is the mother of Qi, when blood is deficient, Yang loses its support, Qi and blood separate, and Yang cannot govern Yin, further exacerbating blood loss.Moreover, in severe cases, during blood loss, Yang Qi may suddenly collapse, leading to fainting and critical conditions, which Zhang Jingyue termed “blood collapse”. Immediate measures to revive Yang and rescue the patient are crucial; otherwise, “using cold to stop blood will inevitably lead to the destruction of Yang Qi, hastening death” (from Complete Works of Jingyue).Warming and Securing Yang, Containing Yin BloodWarming Yang to stop blood loss primarily involves warming the Kidneys to strengthen Yang, dispelling cold and removing stasis, enhancing the regulatory functions of Tian Gui, Kidney Qi, Chong and Ren meridians, and the uterus, allowing Yang to return and Qi to stabilize, preventing Yin blood from escaping, thus achieving the effect of stopping blood flow.1. Warming the Middle and Nourishing Qi to Contain BloodBlood loss depletes Qi, which is an ancient method.
The Complete Works of Jingyue states: “For blood loss and similar symptoms, one must first use sweet herbs to tonify the Spleen and Stomach, to nourish the Qi that generates blood. Sweetness can generate blood and nourish the Ying, strengthening Spleen and Stomach Qi, thus Yang generates Yin, and blood returns to the meridians.”
Moreover, excess Qi is fire, while insufficient Qi is cold; tonifying Qi aids in the function of Yang.Commonly used herbs includeGoryeo Ginseng, Red Ginseng, Codonopsis, Astragalus, Bai Zhu (White Atractylodes), Poria, Chinese Yam, Licorice, Angelica, and Maltose, which warm the middle, nourish Qi, tonify Spleen Yang, and generate blood.2. Warming Yang and Supplementing Fire to Contain BloodYang transforms into Qi, while Yin forms the body. For blood loss with significant Yang deficiency and declining Mingmen fire, one should seek to nourish and stabilize the organs, strengthen Yang and Qi, and contain Yin blood. For those at risk of Yang collapse, reviving Yang and returning fire to its source is essential.Commonly used herbs includeProcessed Aconite, Dried Ginger, Cinnamon, Mild Evodia, Galangal, Mugwort, Deer Antler Glue, Epimedium, Morinda Root, Cuscuta, Sweet Cistanche, Raspberry, and Xian Mao (Curculigo), which help to warm and supplement Yang.3. Warming and Moving Stasis to Contain BloodDuring blood loss, there is inevitably “blood that has moved in the meridians cannot return, leading to stasis in the Chong and Ren meridians. Any stasis obstructs the flow of Qi and blocks its movement.” Furthermore, “if old blood does not move, new blood cannot be generated. New blood is generated daily, and stasis has no place to remain” (from Blood Syndrome Theory).Blood prefers warmth and dislikes cold; cold causes it to congeal and not flow, while warmth disperses it. Therefore, selecting warming and invigorating blood-moving herbs is appropriate.Commonly used herbs includeFried Angelica, Ze Lan (Lycopus), Shixiao San, Dragon’s Blood, Fried Hawthorn, Lotus Seed, Sanqi (Notoginseng), Yunnan Baiyao, and Fried Jujube.4. Sweet and Warm to Rescue Yin and Contain BloodWith significant blood loss, Yin blood is invariably deficient. Yin is the guardian of Yang; if Yin is deficient, Yang has no support, leading to depletion of Yin essence and the loss of Yang. Especially for those with both Yin and Yang deficiency, it is crucial to warm and invigorate Yang while quietly containing Yin, nourishing Yin without harming Yang Qi.Commonly used sweet and warm herbs to nourish Yin includeRehmannia, Processed Fo-Ti, Donkey-hide Gelatin, Deer Antler Glue, Turtle Shell, Longan Flesh, Goji Berries, Cornelian Cherry, and Jujube, which nourish Yin and fluids without harming Yang Qi.5. Warming, Astringing, and Securing BloodIn cases of prolonged blood loss, it is necessary to add warming and astringent herbs to secure the blood sea. Commonly used herbs includeRed Stone Fat, Yu Yu Liang, Dragon Bone, Oyster Shell, Sea Cucumber, Cow Horn, Schisandra, Pine Flower Charcoal, Meat Fruit Charcoal, and Pomegranate Peel, which should be used according to the situation.When formulating prescriptions, the focus should be on warming the middle and nourishing Qi and supplementing fire to strengthen Yang. Because blood loss injures Qi, leading to Yang deficiency, which further opens the Chong meridian, causing loss of containment and continuous blood loss, creating a vicious cycle. Visible blood cannot be quickly replenished, while invisible Qi must be urgently secured; warming Yang and transforming Qi is key to breaking this vicious cycle, while selecting herbs that warm, invigorate blood, sweetly warm to rescue Yang, and astringe to secure blood is crucial for effective blood loss control.The Guben Zhibeng Decoction created by Qing Dynasty physician Fu Shan can be considered a classic example of warming Yang to stop blood loss. The formula includes Ginseng, Astragalus, Bai Zhu (White Atractylodes) to sweetly warm and nourish Qi, invigorating Spleen Yang, generating and containing blood; with the bitter, spicy, and warming Black Ginger to supplement fire and generate Yang, allowing Yang to return and Qi to stabilize; with the sweet and mildly warming Rehmannia to quietly rescue Yin; and with the sweet and warming Angelica to invigorate and tonify blood.Because simply tonifying Qi does not easily generate blood, and simply tonifying blood without supplementing fire will lead to blood stagnation, preventing it from quickly generating with Qi (from Fu Qingzhu’s Gynecology). Thus, although the formula contains six herbs, it integrates methods of nourishing Qi, supplementing fire, rescuing Yin, and transforming stasis into one formula, collectively achieving the effects of sweetly warming and assisting Yang, securing the root, and stopping blood loss. Due to the appropriateness of the herbs to the syndrome, it has been proven effective and continues to be widely used today.Different Ages, Severity, and Flexible TreatmentBlood loss itself varies in severity and urgency, and one should closely observe symptoms, adjusting treatment based on the amount, color, and quality of bleeding, along with accompanying symptoms, tongue, and pulse, flexibly applying methods to warm Yang and stop blood loss.Patients with Yang deficiency type blood loss present with large amounts of bleeding, worsening with movement, and lessening when lying down.The blood is pale and thin, or resembles black bean juice, or contains stasis, with a pale complexion, a puffy face, cold pain in the abdomen, preferring warmth and pressure, feeling cold in the limbs, with sore lower back and legs, poor appetite, loose stools, and fainting episodes, with a pale, swollen tongue with teeth marks, thin white coating, and a deep, thin, and slow pulse.The treatment should focus on warming the meridians and strengthening Yang, securing the Chong and Ren meridians.Different age stages are important bases for syndrome differentiation.In adolescent patients, the focus is on warming and invigorating the Heart and Spleen, securing the Kidneys to stop blood loss. In women of childbearing age, the focus is on nourishing the Liver and Kidneys, securing the Chong to stop blood loss. At the same time, for those with prolonged blood loss and deficiency of both Qi and blood, both Yin and Yang should be supplemented, and Qi and blood should be treated together. For those who have excessively consumed cold foods, warming the middle and dispelling cold, strengthening the Spleen and Stomach is advisable. For those with wind-cold invading the uterus, it is necessary to dispel wind and scatter cold, warming the uterus and containing blood.If blood loss does not stop, and Qi loses its containment, blood lacks Qi protection, presenting as large amounts of blood loss, worsening with movement, and not lessening when lying down, ancient texts describe it as a spring that flows continuously without closure. The limbs are wet and cold, consciousness is dim, and tilting the head causes dizziness, with heart palpitations and nausea, and food intake leads to vomiting, with a pulse that is either thin or deep and small. This indicates Yin damage affecting Yang, with Yang Qi on the verge of collapse.At this time, blood pressure may not have dropped, but signs of impending collapse are present.Delayed treatment can lead to a situation where Yin is exhausted and Yang is lost. In critical situations of impending collapse, even if bleeding has decreased, the limbs are cold, sweating profusely, breathing is shallow, and the pulse is weak and about to disappear, further rescue efforts may be difficult to achieve quickly.Thus, during the stage before collapse, when Yang Qi is on the verge of collapse, it is essential to act quickly to achieve maximum results with minimal effort. Given that the forms of traditional Chinese medicine still require reform, the prescription, preparation, decoction, and administration take a long time to take effect, which does not meet the urgent needs of treating acute conditions in traditional Chinese medicine. Additionally, patients may experience dizziness when sitting up, making administration often lead to nausea and vomiting. As a temporary measure, it is often necessary to provide Yang-reviving and rescue medications in advance, which can effectively control the condition.Commonly Used Formulas:1. Complete Works of Jingyue Six Flavor Returning Yang Decoction: Ginseng, Processed Aconite, Dried Ginger, Licorice, Rehmannia, Angelica.2. Complete Works of Jingyue Right Returning Decoction: Rehmannia, Cornelian Cherry, Goji Berries, Chinese Yam, Deer Antler Glue, Cuscuta, Eucommia, Angelica, Cinnamon, Processed Aconite.3. Complete Medical Records Aconite Regulating Middle Decoction: Processed Aconite, Ginseng, Dried Ginger, Bai Zhu (White Atractylodes), Licorice.4. Fu Qingzhu’s Gynecology Guben Zhibeng Decoction: Astragalus, Codonopsis, Bai Zhu (White Atractylodes), Black Ginger, Rehmannia, Angelica.5. Jiyin Gangmu Deer Antler Pill: Deer Antler, Red Stone Fat, Yu Yu Liang, Angelica, Rehmannia, Dipsacus, Aconite, Mugwort, Cypress Leaf. “For excessive menstrual flow, with dark black color, severe cases lead to blood loss, shallow breathing, cold pain in the abdomen, profuse sweating, and a weak pulse, due to deficiency in the Chong and Ren meridians, caused by wind-cold invading the uterus, leading to Qi being unable to stabilize.”Using basic formulas as the foundation, adjustments should be made according to the severity and urgency of the condition at different stages.Choosing Herbs with Method and PrecisionAdditionally, attention should be paid to the selection of warming herbs, ensuring that combinations and dosages are just right.Blood conditions avoid harsh and dry herbs, and should be harmonized with gentle herbs.Thus, in clinical practice, it is common to select warm and moistening herbs to nourish essence and support Yang. When using Aconite, Cinnamon, Dried Ginger, and other spicy and warming herbs, caution is needed to avoid harming Yin, and they should be complemented with Ginseng, Rehmannia, Licorice, Cornelian Cherry, Deer Antler Glue, Cuscuta, Sweet Cistanche, Goji Berries, and Chinese Yam to tonify blood and Qi, rescuing Yin and invigorating Yang. The Right Returning Decoction serves as an example.For those experiencing tidal fever after blood loss, avoid using cold and cooling herbs to stop bleeding.Xue Lizhai believes:
“If there are tidal fevers, cough, and a rapid pulse, it indicates weakness of the original Qi, with a pulse of false heat, and one should use Ginseng to warm and tonify. These symptoms are all due to prior damage to the Spleen and Stomach, hence the pulse is large and strong, indicating that if there is Spleen Qi, tonifying can save the situation. If cold and cooling herbs are used to stop bleeding, it will further damage the Spleen and Stomach, and cannot stabilize the blood, which hastens danger.”
For conditions of excessive cold or mixed cold and heat, one may also select some sweet and neutral or slightly cool herbs, such as Fried Jujube, Lotus Root, Arborvitae Charcoal, Aged Brown Sugar, Bloodwort Charcoal, and Eclipta, using warmth and coolness together, or as guiding herbs to draw Yang into Yin.Some herbs, when fried and charred, can assist in warming Yang and stopping blood loss.For example, Dried Ginger, Mugwort, and Schizonepeta can be fried and charred to mitigate their harsh dispersing properties; while Arborvitae Leaves, Raw Rehmannia, Moutan Root, and Guanzhong can be fried and charred to eliminate their cold properties; and Fried Rhubarb can also alleviate its harsh purging effects. However, caution should be exercised with astringent charred herbs, as they can congeal blood and hinder the removal of stasis.After warming Yang and stopping the flow, when Yang returns and Qi recovers, leading to a reduction in blood loss, one should carefully adhere to the pathophysiology, differentiating syndromes and treating accordingly, to clarify the source and restore the old state, without continuing to warm excessively.
- Example 1:
Chen, 40 years old, first diagnosed on March 15, 1982.The patient had one childbirth and two abortions, with a history of heavy menstrual flow. On February 30, menstruation began, with prolonged bleeding, and for over ten days, the blood volume increased, leading to sudden heavy bleeding, unable to move while lying down, with significant blood loss, pale and thin blood. The local doctor prescribed cooling and hemostatic herbs along with hemostatic injections, but there was no effect, and this morning the family brought the patient to the hospital.
Diagnosis:Pulse was deep and weak, tongue pale with white coating, face lacking luster, puffy eyelids, palpitations, shortness of breath, sore lower back, fatigue, poor appetite, and loose stools.The diagnosis is blood loss. “At forty years old, Yin Qi is already half gone.” Blood loss is chaotic, not healing for a long time, true Yin is depleting, Yang Qi is not transforming, and further use of cold will severely injure Spleen Yang. The pulse and symptoms indicate Spleen and Kidney Yang deficiency, with loss of control in the Chong and Ren meridians, so warming and tonifying herbs should be urgently used to stop the flow.
Prescription
Red Ginseng 10g, Processed Aconite Charcoal 6g, Dried Ginger Charcoal 5g, Licorice 5g, Fried Astragalus Charcoal 20g, Fried Bai Zhu (White Atractylodes) 10g, Deer Antler Glue 12g, Fried Bu Gu Zhi 10g, Fried Red Stone Fat 10g, Meat Fruit Charcoal 6g, Bloodwort Charcoal 10g. 1 dose.
In the next visit, the family continued the prescription, reporting that after taking the medicine, the bleeding had decreased, the spirit was slightly lifted, and the patient could eat, so the original prescription was continued, and after taking 2 more doses, the condition stabilized.
- Example 2:
Hu, 29 years old, first diagnosed on January 15, 1980.The patient had her first menstruation at 17, and since 1971, she has experienced excessive menstrual flow, diagnosed as “adolescent dysfunctional uterine bleeding”. In September and December 1977, she had two episodes of significant bleeding, requiring hospitalization in a hospital in Zhejiang, with curettage indicating “hyperplasia of the endometrial glands”. This month, she began to experience continuous bleeding, with dark red blood, and recently had intermittent abdominal pain, with pain leading to blood flow, in clots, and sudden heavy bleeding last night, leading to fainting, and today came for diagnosis with a hemoglobin level of 95g/L.
Diagnosis:The patient is overweight, with a pale complexion, cold and wet limbs, dizziness, tinnitus, and discomfort in the abdomen, with a pale red tongue and dark spots on the edges, and a fine, slippery, and weak pulse.The diagnosis is phlegm-damp obstructing the meridians, with clear Yang not rising, stasis obstructing the uterus, blood not returning to the meridians, blood loss injuring Yin, and Yin damaging Yang. Immediate measures should be taken to support Yang, contain Yin, dispel stasis, and stop blood loss, clarifying the source.
Prescription
Processed Ginseng 6g, Processed Aconite 5g, decocted for consumption.
Fried Astragalus 30g, Codonopsis 30g, Dried Ginger Charcoal 5g, Fried Licorice 5g, Dragon’s Blood 5g, Shixiao San 10g (in a bag), Sanqi 3g, Fried Jujube Charcoal 6g, Bloodwort Charcoal 10g, Bloodwort 12g.
Next Visit:Blood loss decreased, the bleeding has slowed, but there is abdominal pain and lower back soreness, so the original method was continued, and after taking the medicine, a membrane-like substance was expelled, abdominal pain disappeared, and bleeding reduced, with the spirit improving, and by the fifth day, blood was clear.
