Much of traditional Chinese medicine (TCM) is empirical in nature and based upon the limited knowledge available at the time of conceptualization as to the state of physiology and anatomy of the human body. The knowledge base from which the philosophy of TCM has developed expanded into recent times as the practice, teaching and cataloging of TCM continued throughout the history of the Chinese people. Modern science has given us much information as to the detailed anatomy and physiology of the human body only in recent times. Thus, the terms created to define the physiological concepts of TCM may seem a bit antiquated and na´ve in some descriptive respects. However, it is to be noted that TCM has always ascribed a role for the emotions and thought of people as affects their health from very early on in the development of TCM concepts. The western sciences are only now beginning to detail these same mental and emotional aspects of the human condition in relation to the etiology of disease and their effects upon health.
This work will endeavor to bring together the best of both worlds, East and West, and offer an explanation of what Qi stagnation and Blood stasis actually is and how any clinical treatment may be derived to speed recovery and return to health, in regards to these conditions.
It is always good to start things off with a description of what is being discussed. Since we are discussion Qi stagnation (QS) and Blood stasis (BS), either separately or in combination, a brief TCM (1) and western medicine (WM) description of each condition follows.
TCM Qi Stagnation - the clinical manifestations of Qi stagnation are:
TCM Qi Stagnation Tongue signs are: normal body color or slightly red on the sides with severe Qi Stagnation. TCM Pulse signs are: wiry.
WM has no concept of anything like Qi Stagnation as such.
TCM Blood Stasis - the clinical manifestations of Blood Stasis are:
TCM Blood Stasis Tongue signs are: purple. TCM Pulse signs are: choppy or fine.
WM (2) Blood Stasis clinical manifestations are:
Criteria utilized in making a TCM diagnosis of Qi stagnation and Blood stasis take into account the quality of pain, the time of pain, the area of pain and the response of pain to pressure and temperature.
The TCM Differentiation of Zang-Fu Pain versus Channel Pain
Here we distinguish between the differentiation of pain due to the involvement of the Zang-Fu with their respective channel(s) and that due to pain in just the channel(s) alone. Most pains due to sprains, trauma or Bi syndromes (due to Wind, Cold or Dampness) involve the channels only. Thus, most pain inside of the body proper, apart from deep trauma, involves the Zang-Fu and their respective channel(s). Channel pain rarely derives from Zang-Fu disharmonies. The two most important diagnostic factors when confronted with pain then are:
The TCM diagnosis of Qi Stagnation (3)
The TCM diagnosis of Blood Stasis (4)
Qi stagnation over a long period of time (relative and different for each person but we are talking about many hours and days) is able to lead to a condition where the Qi cannot move the Blood and this causes the Blood to stagnate (pool) or congeal (coagulate). This pattern is most commonly seen in cases of Liver Qi Stagnation that is due to emotional and mental issues. If Blood becomes deficient in some way, this eventually will lead to Qi deficiency as Qi is said to move with Blood. Then, if the deficient Qi fails to move the Blood, Blood stasis ensues. This is a pattern seen commonly after childbirth, excessive menstrual bleeding and hemorrhage due to trauma. In the case of physical trauma, both Qi and Blood stagnate in the same location due in part to the disruption of vascular integrity and subsequent extravasation of "blood" into the surrounding tissues. Stagnation can also occur in the channels and the Zang-Fu depending upon the type and severity of injury. Thus, we have 3 distinct types of stagnation/stasis that needs to clarified. They are trauma that is due to: 1. direct physical injury 2. emotional and mental state disharmony and excess 3. obstruction of the channel(s).
At this point, I would like to continue with a detailed description, from a Western science view, of the sequence of events subsequent to direct physical trauma in tissue. "A wound is a type of physical trauma wherein the skin is torn, cut or punctured (an open wound) or where a blunt force trauma causes a contusion (a closed wound)". (5) Wound healing is arbitrarily divided into 4 phases that grade into one another sequentially: inflammation, proliferation, maturation and remodeling.
The inflammatory process starts immediately upon rending the structural integrity of the tissue(s) involved and the blood vessels & nerves that goes to and comes from the area of trauma. The exposure of extracellular matrix (ECM) components from the edges of the cut vessels and the surrounding ECM to blood platelets, causes the platelets to begin a cascade of events that results in the formation of a clot in order to stem the extravasation of blood. The release of "blood" into the surrounding tissue(s) causes an imbalance in osmotic pressures between the tissue and the blood fluid within the vessels that results in tissue swelling. A net movement of water into the area of tissue contaminated with "blood" components is what causes the swelling as the tissue does not normally have the same types of proteins found in whole blood, i.e., albumin. Red Blood Cells (RBC) rupture and thereby release hemoglobin into the area of trauma. This adds to the osmotic imbalance and ultimately causes the discoloration of the tissue(s). Platelets also release factors that cause the tissue to increase in temperature and cause the dilation of blood vessels into and out of the area. Thus, the area becomes reddened and warm to the touch. White Blood Cells (WBC) become active and release cytokines that cause the recruitment of other WBC to the area, begin phagocytosis of cellular & protein debris and rid the area of invading bacteria. Finally, WBC release factors that stimulate adjacent tissue cells to divide and migrate into the area and begin the proliferative phase of wound healing.
The proliferative phase of wound healing is a complicated series of carefully orchestrated sequential processes that rebuilds the normal structure of the vessels, nerves and tissue(s). These processes are characterized by angiogenesis (blood vessel formation), collagen deposition, granulation tissue formation, and epithelialization (covering with skin). With angiogenesis, endothelial cells lining the vessels near to the cut edges proliferate and grow new blood vessels to serve the area of injury. In fibroplasia, tissue fibroblasts grow and form a new provisional ECM by secreting collagen and fibronectin. With granulation tissue formation, tissue fibroblasts repair the basal membrane and tissue cells proliferate and migrate into the area to form the normal tissue structure. In epithelialization, epithelial cells proliferate and crawl across the wound bed to cover the area and provide for passive defense and retard tissue desiccation.
In the maturation phase, the wound is made smaller by the action of myofibroblasts. These cells are stimulated to arise from tissue fibroblasts and attach themselves to the edges of the wound. They then begin the process of contraction and close the wound with the formation of a scar. When their role in concluded, they undergo apoptosis (cell death).
In the remodeling phase, the scar is reduced and the ECM is incorporated into the overall pattern of structure as determined by tensegrity forces exerted upon the tissue.
The repair of nerve tissue, in most cases trauma of the compressed or cut axons, is likewise a complicated series of sequential events that leads to the complete recovery of function as a best-case scenario. This process occurs in concert with blood vessel repair and wound healing. Nerve repair involves both the regeneration and elongation of the axon and the surrounding fascicles. Re-myelination of the transected area may also need to be accomplished. Neurotmesis (nerve cutting) is the most severe type of nerve injury. This kind of injury results from a disruption in the continuity of the axons and all supporting structures, including the epineurium. Injury involves a separation of the nerve ends such that axon regeneration from the proximal end may be unable to reach the distal end. This injury usually involves an open wound with nerve deficits as numbness and loss of sensation. Surgical repair is required for any return of function. The time required for return of function after repair depends on the location of the lesion and other variables as nerves regenerate slowly, progressing 1-1.5 mm/d or 1 in/mo. A very detailed account may be found here (6). Nerve injuries are associated with a burning pain and a tingling sensation occurs with regenerating nerves.
Large gaps, usually those greater than 15-30 mm, cannot be crossed reliably by axons. This is usually because proliferating Schwann cells (responsible for myelination) or fibroblasts grow between the severed nerve ends and form a physical barrier. Alternatively, if suitable tissue is not found within a set distance, the axon sprouts stop proliferating and take residence in non-neural tissue, forming a neuroma. Neuromas can occur in any situation in which an axon or collateral sprout remains in non-neural tissue and are usually very painful.
Now, we move to an area of discussion that is fraught with cultural bias and in most cases complete ignorance - that of the role of emotional and mental state in the etiology of disease. The same may be said concerning the obstruction of the channel(s). Almost nothing is said in TCM about the cause of Qi stagnation obstructing the channel(s).
In TCM, abnormal emotions and mental over-activity (usually as worry) are listed as internal evils that directly cause the obstruction of Qi & Blood and the disruption of the Zang-Fu (7). The clinical manifestations and pathology of certain organs was found to be associated with specific emotional derangements and excesses, for example: anger injures the Liver, joy injures the Heart, grief and melancholy injure the Lungs, worry injures the Spleen, fear & fright injures the Kidneys. It is the effect of the emotional outburst upon the flow of Qi that is paramount. Anger is said to cause Qi to rise up, joy causes it to move more slowly, grief drastically consumes it, fear causes it to decline, fright causes it to be deranged and worry causes it to stagnate. The subsequent derangement of Qi due to prolonged emotional excess is what then causes the stasis of Blood in the relevant organ(s).
The work of Greenwood (8) attempts to bring together TCM concepts with those of Western Psychology in order to explain the origin of Qi and Blood stagnation. He suggests that the root of stagnation lies in the attempt of the mind to control existential anxiety through strategies of energy containment. It is the process of containment that leads to Qi stagnation and subsequent Blood stasis. Pain is due to some kind of stagnation, weakness is due to deficient Qi and numbness to deficient Blood.
The pain and numbness due to Qi and Blood stagnation is the direct affect of the processes that lead to the reduction of nutrient(s) and the build up of toxins & waste products in the immediate area of nerve tissue, i.e., peripheral neuropathy. The swelling and obstruction caused by the influx of water, blood proteins, cellular debris and WBCs, as well as the injury itself, have the effect of reducing the normal flow of fluid from the blood vessels into the tissues and back into blood circulation (90%) and through the lymphatic system (10%) (9). The injury and obstruction reduces the efficiency of lymphatic return due to the severing of lymph channels and local osmotic imbalances. Downstream from the site of injury, the lymph nodes swell and the WBCs therein keep pace with the influx of waste and debris. The integrity of the lymph vessels are repaired along with the rest of the injured tissue and are an integral part of wound healing.
TCM describes the cause of certain diseases as the obstruction of the channel(s) due to sprains, trauma and Painful Obstruction Syndromes (due to Wind, Cold or Dampness) (10). However, all the information published in English that I have been able to find merely describes the result of obstruction of the channels but not what directly causes or just exactly what is obstruction of the channels, most disconcerting to say the least! The treatments for this condition are stated as to move channel Qi & Blood and unblocking the channel(s). The TCM system of channels is stated to: 1. transport Qi & Blood and the regulate the balance of Yin & Yang of the whole body 2. resist pathogens and reflect symptoms & signs 3. transmit needling sensation and regulate excess & deficiency conditions (11). How are we to understand the underlying Western physiology of this condition of obstruction of the channel(s)? Blood moves in the blood vessels, interstitial fluid derives from the blood and either moves into the vessels again or becomes lymph after transiting the tissues. The concept of Qi in TCM is completely deduced and has no "real" basis. What are the channels? For any concept concerning these topics, the only Chinese espoused philosophy that is relevant is that of Medical QiGong (12).
The contribution of the TCM conditions of Dampness to the etiology and pathogenisis of QS & BS are well known (17). In the USA today, it seems that chronic blood vessel inflammation is responsible for many of the dieases of today (18). Chronic conditions of BS will need to be looked at for any contributing factors due to TCM Dampness.
The TCM treatment of Qi Stagnation and Blood Stasis involves the use of Acupuncture, Herbal Formulae, Tui Na and Moxibustion.
HERBS AND HERBAL FORMULAE (14)
TUI NA (15)
It is the stated purpose of Tui Na to promote Qi circulation and activate Blood stasis by strengthening the Spleen & Stomach and soothing the Liver to regulate Qi. Kneading manipulation, pressing manipulation and pushing manipulation with one-finger meditation are applied to UB20, UB21, St36 and Ren12 in order to improve the function of the Spleen/Stomach and promote the circulation of Qi & Blood. Pressing and kneading Lv13, Lv14, UB18, UB19 is used to disperse stagnant Liver Qi. Grasping slightly GB21 has the immediate effect of promoting Qi circulation to activate dissipation of BS. Various manipulations are applied near to local areas of pain and trauma in order to stimulate Qi circulation and activate BS in the channel(s).
The functions of moxabustion are:
Some acupuncture points are contraindicated with the use of needles (like zhongkui & zhongjian) and are used exclusively with Tui Na or Moxibustion.
The first stagnation is almost invariably that of QS. This results from either physical trauma or emotional/mental disturbance. The second stagnation is BS that is the result of QS or in rare cases causes QS. The area of QS is diffuse while that of BS is well defined. The continued presence of QS will eventually cause BS. Untreated BS in time will start to interfere with the smooth flow of Qi. QS and BS are very much tied together!
Oriental Medicine Section