Discussing Yin and Yang, the Five Elements, and the various diseases in the world. Understand and learn to establish a TCM mindset as we listen to Wendon discuss the “Huangdi Neijing”.
Hello everyone!
Today, we will talk about xue xu (血虚), or blood deficiency. As the name suggests, it refers to insufficient blood in the body. When blood deficiency is mentioned, many people think of anemia. It should be noted that the concept of blood deficiency in TCM and anemia in Western medicine are similar yet completely different. What are the differences?
First, we need to understand what anemia is.
Western medicine defines anemia as a condition where the peripheral blood red cell volume is below the normal lower limit. There are many types of anemia defined by Western medicine, such as: acute and chronic anemia based on the progression speed; macrocytic, normocytic, and microcytic anemia based on red blood cell morphology; mild, moderate, severe, and very severe anemia based on hemoglobin concentration; and based on bone marrow hematopoietic disorders, it can be classified into hemolytic anemia, iron deficiency anemia, megaloblastic anemia, and aplastic anemia. It is known that aplastic anemia is essentially leukemia. In summary, the key indicator is that the red blood cell volume is below the normal lower limit.
However, the concept of blood deficiency in TCM differs from anemia in Western medicine. TCM believes that blood deficiency does not necessarily mean the patient has anemia. So, what does TCM consider blood deficiency to be?
In TCM, blood deficiency refers to a deficiency of blood that leads to the malnourishment of the organs, meridians, and body. If a person exhibits a pale or sallow complexion, and their lips, tongue, and nails appear pale and not rosy, along with symptoms such as dizziness, palpitations, vivid dreams, and numbness in the hands and feet, it can be diagnosed as blood deficiency. For women, issues such as scanty menstrual flow, pale color, delayed menstruation, or amenorrhea are also indicators. When these symptoms appear, TCM can determine it as blood deficiency. These symptoms are also present in patients with anemia as defined by Western medicine, which is why blood deficiency and anemia symptoms are similar. However, a patient with blood deficiency does not necessarily have anemia. Therefore, TCM and Western medicine define anemia and blood deficiency differently. Thus, it cannot be said that anemia is blood deficiency, or that blood deficiency is anemia.
So, why do symptoms like a sallow complexion, dizziness, palpitations, vivid dreams, and numbness in the hands and feet occur with blood deficiency? We need to start with the functions of blood. The “Nanjing” (难经) states: “Blood is the master of nourishment.” Here, nourishment refers to the essence of nutrition.
The Ming dynasty physician Zhang Jingyue stated: “Blood irrigates the entire body, reaching everywhere; thus, it nourishes the seven orifices, supports the limbs, softens the muscles and bones, enriches the flesh, nourishes the organs, calms the spirit, enhances complexion, fills the defensive and nutritive qi, and ensures the smooth flow of fluids and the balance of the two yin. Everything in the body relies on blood for sustenance; hence, the existence of the human form depends solely on blood.”
This means that blood in the human body is like water in a field, used for irrigation. Our blood vessels are like a large net, spreading throughout the body and the five organs, nourishing every cell through blood circulation. Therefore, it reaches everywhere. The seven orifices refer to the eyes, ears, nose, and mouth, with two for each eye and ear, two for the nose, and one for the mouth, totaling seven orifices. The term “spirit” here means agility. Only with the nourishment of blood can our eyes, ears, nose, and mouth function normally, meaning clear vision, acute hearing, taste recognition, and the ability to speak.
For the limbs, it means that when a person has abundant qi and blood, their limbs will be agile, muscles will be soft, and flesh will be strong and powerful. Conversely, insufficient qi and blood can lead to uncoordinated limbs, stiff muscles and bones, and weakness. This state is commonly seen in stroke patients.
The next part states: “It nourishes the organs, calms the spirit, enhances complexion, fills the defensive and nutritive qi, and ensures the smooth flow of fluids and the balance of the two yin.” This means that blood has the function of nourishing the organs and calming the spirit. A person who is under no stress may feel lost and confused; in the past, TCM would say their spirit is unsettled. What does unsettled spirit mean? It means that the spirit, governed by the heart, and the three souls governed by the liver are not receiving nourishment from blood, leading to an unsettled mind and confusion.
The term “enhances complexion” refers to the facial color. A person with abundant qi and blood will have a complexion that is rosy and vibrant, while a patient with blood deficiency will have a pale complexion. In cases of severe blood loss, the complexion may appear ashen.
The next phrase, “fills the defensive and nutritive qi,” refers to the relationship between defensive qi and nutritive blood. The so-called defensive qi is the qi within the blood, while nutritive blood refers to the blood itself. TCM states that qi and blood are inseparable; thus, the “Huangdi Neijing” states: “Qi is the commander of blood, and blood is the mother of qi.” Qi and blood interact; qi promotes blood circulation, while blood generates and stores qi.
The next part states: “The fluids can flow smoothly, and the two yin can be balanced.” This means that the fluids in the body can run smoothly, and the metabolism of water and food can proceed without hindrance, as well as smooth urination and defecation, all of which are closely related to the abundance of blood.
Finally, the phrase “everything in the body relies on blood for sustenance” means that all the organs, muscles, bones, and even the spirit and the three souls rely on blood for nourishment. Therefore, the existence of the human form depends on blood.
From this, we can understand the quality of a person’s life is determined by the abundance of blood, and we can thus appreciate the importance of blood to the human body.
Since blood is so important, how is it generated?
The “Huangdi Neijing” states: “The spleen is the foundation of postnatal life and the source of qi and blood production.” It also states in the “Lingshu: Pathogenic Factors”: “The nutritive qi secretes its fluids, infuses them into the vessels, and transforms them into blood.” Here, nutritive qi refers to the qi generated by the spleen and stomach through the absorption of nutrients from food, which can transform into fluids and infuse into the blood vessels, thus becoming blood. After the transformation of nutritive qi into blood, it is referred to as nutritive blood. This means that the spleen and stomach absorb nutrients and transform them into qi, then into fluids, and finally into blood.
Regarding the process of food entering the stomach and intestines and being classified and transformed into the five organs, the “Huangdi Neijing” has extensive descriptions, but this content is too complex to cover here. We only need to know that blood is transformed from food.
In addition, TCM believes that another source of blood production is essence. TCM posits that there is a mutual nurturing and transformation relationship between essence and blood. The generation of blood relies on the catalysis of the essence in the kidneys, and the abundance of essence also relies on the nourishment of blood. Therefore, it can be said that essence can generate blood, and blood can transform into essence, which is referred to as “jing xue tong yuan” (精血同源).
For example, the hematopoietic stem cells mentioned in Western medicine are extracted from the bone marrow, which has a strong ability to produce blood and renew blood. The transplantation of hematopoietic stem cells has a significant improvement effect on patients with leukemia. These stem cells are stored in large quantities in our bone marrow. In TCM, the bone marrow and spinal cord are considered the essence of the body. Therefore, the “Huangdi Neijing” states that the kidneys govern the bones and produce marrow, and also store essence. The essence here includes not only reproductive essence but also the essence of the bone marrow.
Thus, a person with insufficient essence and blood can also be considered as having insufficient liver and kidney function. For instance, kidney essence deficiency can lead to liver blood deficiency. So, what are the manifestations of liver blood deficiency?
The “Huangdi Neijing” states: “The liver is the root of the sinews and the residence of the soul; its manifestation is in the nails, and its fullness is in the sinews, which generate blood and qi.”
This means that the liver governs the activity of the body’s sinews and can endure fatigue, serving as the foundation of physical activity. A person with abundant liver blood can endure fatigue, while the opposite is true for someone who tires easily, reflecting a character that avoids work, commonly referred to as a lazy person.
The phrase “the residence of the soul” means that the liver is the dwelling place of the three souls, which include the heavenly soul, earthly soul, and life soul. There is another term for them: fetal light, clear spirit, and hidden essence. I remember when I was a child, my grandfather would check a child’s pulse and say the soul was incomplete, indicating the child was frightened. He would call the child back to normal, and it would work. When a child is frightened, they exhibit abnormal behavior, crying incessantly. In such cases, laying them down and calling them back would help. Some children with fever do not respond to any medication, but calling them back would reduce the fever. According to traditional TCM understanding, the soul has returned to its place. This cannot be elaborated on too much, as it may be labeled as superstitious.
The phrase “its manifestation is in the nails” means that nails are like flowers nourished by blood. The beauty of the flowers depends on the liver blood. Conversely, one can tell if a person has sufficient liver blood by looking at their nails. If a person’s nails are bright, of moderate thickness, flexible, and smooth, it indicates sufficient qi and blood.
The phrase “its fullness is in the sinews, which generate blood and qi” means that liver blood governs the sinews of the body. A person whose sinews move freely requires the nourishment of qi and blood. Therefore, “to generate blood and qi” should be understood as “to be nourished by qi and blood.” A person with abundant liver blood will have agile limbs and be full of strength.
Conversely, if a person has liver blood deficiency, it can lead to symptoms such as numbness in the limbs, difficulty bending and stretching joints, dizziness, dry eyes, blurred vision, scanty menstruation, or amenorrhea, and skin itching. Additionally, liver blood deficiency can cause hair to become dry and fall out. TCM believes that hair is the surplus of blood. What does surplus mean? It means that when qi and blood are abundant, hair can grow well. Why do patients undergoing chemotherapy lose their hair first? It is because the blood is damaged. When blood is deficient, its nourishing function is impaired, leading to hair loss. Therefore, a TCM practitioner can make a basic judgment about whether a person has blood deficiency just by observing their complexion, hair, and nails.
For the treatment of liver blood deficiency, the focus is on nourishing yin, enriching blood, and tonifying the liver and kidneys. A well-known formula in TCM is Si Wu Tang (四物汤), which consists of four herbs: Shu Di Huang (熟地, Rehmannia), Bai Shao (白芍, White Peony), Chuan Xiong (川芎, Ligusticum), and Dang Gui (当归, Angelica). Thus, it is called Si Wu Tang. Si Wu Tang has the effects of nourishing yin, enriching blood, and supporting the liver and kidneys.
There are many variations of Si Wu Tang, such as Tao Hong Si Wu Tang (桃红四物汤), which adds Tao Ren (桃仁, Peach Kernel) and Hong Hua (红花, Safflower) to promote blood circulation. This is because prolonged blood deficiency often leads to blood stasis. Additionally, there is Ba Zhen Tang (八珍汤), which adds Si Jun Zi Tang (四君子汤) to Si Wu Tang to enhance spleen tonification. There are many variations of Si Wu Tang because blood deficiency can lead to various issues, so this formula is not recommended for patients without diagnostic ability.
Next, I recommend a formula for treating blood deficiency-related insomnia. In the “Jin Gui Yao Lue: Blood Bi and Deficiency Syndromes” it states: “For xuliao (虚劳) and xufan (虚烦) leading to insomnia, Suan Zao Ren Tang (酸枣仁汤) is the main treatment.” This Suan Zao Ren Tang is specifically used for insomnia caused by liver blood deficiency, suitable for patients with mild insomnia, referred to as xuliao (虚劳), which indicates chronic physical weakness, and xufan (虚烦) means mild restlessness, leading to difficulty sleeping.
This formula consists of five herbs: Suan Zao Ren (酸枣仁, Ziziphus), 15g; Zhi Mu (知母, Anemarrhena), 6g; Chuan Xiong (川芎, Ligusticum), 6g; Fu Ling (茯苓, Poria), 6g; and Zhi Gan Cao (炙甘草, Honey-fried Licorice), 3g.
Suan Zao Ren Tang has the effects of nourishing blood, calming the spirit, clearing heat, and relieving restlessness. It is indicated for liver blood deficiency with internal heat disturbance, leading to insomnia, palpitations, dizziness, dry throat, red tongue, and thin wiry pulse. Clinically, it is often used to treat neurasthenia, cardiac neurosis, and menopausal syndrome associated with heart and liver blood deficiency and internal heat disturbance.
Next, we will discuss heart blood deficiency syndrome.
The “Huangdi Neijing” states: “The heart is the root of life and the residence of the spirit; its essence is manifested in the face and is filled in the blood vessels.”
This means that the heart is fundamental to life. The spirit we often refer to is stored in the blood vessels governed by the heart, thus the heart is also called the residence of the spirit.
The phrase “the residence of the spirit” can be understood as the consciousness, which is our ability to perceive the world. The term “transformation” here can be explained in the “Yijing: Xici” as: “The opening and closing of one cycle, endlessly returning, is called communication.” This means that the transformation refers to the opening and closing of the heart, continuously allowing blood to flow in and out.
The next phrase, “its essence is manifested in the face, and is filled in the blood vessels,” indicates that the essence of heart blood is reflected in the face. A person with sufficient heart blood will have a complexion that is rosy, while someone with heart blood deficiency will have a pale or ashen complexion. The phrase “filled in the blood vessels” means that heart blood fills the blood vessels. A person with abundant heart blood will have a stable spirit, steady heartbeat, strong memory, clear consciousness, and restful sleep. If a person has heart blood deficiency, they may experience palpitations, irritability, anxiety, insomnia, forgetfulness, dizziness, and a pale complexion. Generally, TCM treatment for heart blood deficiency syndrome will use formulas like Yang Xin Tang (养心汤). These formulas may not be suitable for most people to understand, so I will not elaborate further.
Next, we will discuss the role of the spleen. We previously mentioned that the spleen is the source of qi and blood production. Additionally, the “Huangdi Neijing” assigns another function to the spleen, which is to govern blood. The term “govern” means to control and manage, indicating that the spleen has the function of regulating blood flow in the meridians and preventing overflow.
The “Nanjing: Difficulty 42” states: “The spleen wraps blood and warms the five organs.” Here, “wrap” refers to the spleen’s ability to contain blood and prevent overflow, which essentially indicates the spleen’s function of governing blood. The primary mechanism of the spleen’s governance of blood is the consolidating effect of qi.
The “Jin Gui Yao Lue” states: “The blood of the five organs and six bowels relies entirely on the spleen qi for governance.” The spleen’s ability to govern blood is closely related to its role as the source of qi and blood production. When the spleen’s transport and transformation functions are strong, qi and blood will be abundant, and the consolidating effect of qi will be sound, preventing blood from leaking out of the vessels and causing bleeding. Conversely, if the spleen’s transport and transformation functions decline, qi and blood production will lack a source, leading to qi and blood deficiency, and the consolidating function of qi will weaken, resulting in bleeding.
Currently, some female friends often experience prolonged menstrual bleeding, with one period lasting half a month, and before one ends, another begins. These are all issues related to the spleen’s inability to govern blood. In such cases, if there are also symptoms of qi deficiency or uterine prolapse, gastric prolapse, etc., Bu Zhong Yi Qi Wan (补中益气丸) can be used, which has the effect of tonifying spleen qi to consolidate qi and blood.
Additionally, there is a category of patients with spleen and stomach deficiency and cold leading to insomnia, whose symptoms reflect gastric cold, fear of cold, and increased alertness at night, with clear thinking and a sharp mind. Patients with insomnia due to spleen and stomach deficiency and cold also have a characteristic of feeling that time passes quickly at night, as if they have not slept much. It is recommended that such patients can use Fu Zi Li Zhong Wan (附子理中丸) combined with Shu Gan He Wei Wan (疏肝和胃丸). If there is heat in the liver and gallbladder, use Fu Zi Li Zhong combined with Shu Gan Zhi Tong Wan (舒肝止痛丸).
Fu Zi Li Zhong has the effect of warming and nourishing the spleen and stomach, helping to calm the spleen and stomach, and promoting sleep. Additionally, this medicine is quite remarkable; after taking it, one feels that time slows down at night. It should be noted that this is not suitable for patients with irritability-induced insomnia, as irritability is often associated with internal heat. If Fu Zi Li Zhong Wan is misused, it may be harmful rather than beneficial. Therefore, it is essential to diagnose clearly and not use medications indiscriminately.
Shu Gan He Wei Wan and Shu Gan Zhi Tong Wan have similar but distinct functions; the former treats liver qi stagnation caused by spleen and stomach cold, while the latter treats disharmony between the liver and stomach due to heat in the liver channel. If patients need to use these two medications, they must be diagnosed clearly and not used indiscriminately.
Alright, the course ends here. Thank you all, and see you next time.
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