Unblock Orifices, Invigorate Blood
Tōng Qiào Huó Xuè Tāng and its applications
Some months ago, we looked at Bu Nao Wan, or Brain Tonic Pills, a modern patent formula, and examined some of its underlying treatment principles and the neuroprotective effects of some of its ingredients. As the name suggests, the basis of its composition is in tonification of Kidney Essence, and thus the Sea of Marrow, i.e. the brain.
Today we’ll examine a different treatment strategy for brain health, from an often-overlooked formula which we usually have stocked in the pill cabinet here at Clinical mulch HQ.
Tōng Qiào Huó Xuè Tāng (Unblock the Orifices and Invigorate the Blood Decoction)
Tōng Qiào Huó Xuè Tāng (TQHXT) is a formula from Yī Lín Gǎi Cuò (Correction of Errors among Physicians, 1830) by Wáng Qīngrèn. Wáng is probably best known as the composer of Xuè Fǔ Zhú Yū Tāng (Drive out Stasis in the Mansion of Blood Decoction) and its associated formulas, all from the same work. TQHXT is often omitted from required formula lists in Chinese herbal medicine programs, so many graduates are unaware of it.
Formula Composition
TQHXT is, as is the case with many blood stasis formulas, based on Táo Hóng Sì Wù Tāng (Four Substance Decoction with Safflower and Peach Pit), though with the omission of Dāng Guī (Angelicae Sinensis Radix) and Dì Huáng (Rehmanniae Radix).
The blood-quickening component is thus:
· Táo Rén (Persicae Semen), 9g
· Hóng Huā (Carthami Flos), 9g
· Chì Sháo (Paeoniae Radix rubra), 3g
· Chuān Xiōng (Chuanxiong Rhizoma), 3g
To this base formula is added a frequently used combination to nourish Qì and Blood, protect the Middle Burner and harmonize Yíng and Wèi:
· Dà Zӑo (Jujubae Fructus), 7 pieces
· Shēng Jiāng (Zingiberis Rhizoma recens), 9g
But it is the last couple of ingredients which give this formula its particular mojo, which we’ll discuss below:
· Cōng Bái (Allii fistulosi Bulbus); Wáng stipulated aged scallions (Lǎo Cōng) as opposed to fresh, 3g
· Shè Xiāng (Moschus), added with a small amount of white wine to the strained decoction, 0.15g
Clinical applications
Indications given in the source text are fairly broad, from dermatology to pediatrics to the more familiar headache and EENT applications. They include:
· Falling hair
· Eye pain
· Drinker's nose
· Purple and white patch wind (skin rashes)
· Purple or greenish spots on the face
· Childhood gān (malnutrition syndrome)
· Oral ulcerations
· Foul breath
· Exhaustion (with Huáng Qí)
· Tinnitus (with Tōng Qì Sàn: Chái Hú, Xiāng Fù, Chuān Xiōng)
In Formulas and Strategies we read:
“Although this formula is commonly interpreted to focus on the head and face, its author, Wang Qing-Ren, stated that it is able "to unblock the blood pipes" (tōng xuè guǎn). He also noted that the bluish blood vessels that become visible on the skin are a distinguishing sign for blood stasis in the blood pipes. Contemporary commentators such as the Shaanxi College of TCM therefore interpret the term 'unblocking the orifices' (tōng qiào) to mean not just the sensory organs of the head, but more generally the small apertures through which the blood enters and exits as it circulates through the body. " (Scheid et al., 2009, p. 567)
Maclean et al. (2018) list TQHXT in entries for treating headache, rhinitis/sinusitis, somnolence, tics/tremors, and tinnitus/hearing loss. In our clinic we’ve used it primarily for migraines and tinnitus.
Unblock the orifices, open the surface
Cōng Bái is an acrid warm surface-releasing medicinal that enters the Lung and Stomach. It "promotes free movement between the upper and lower body and between the inner and outer body" (Brand & Wiseman, 2008). This surface-freeing strategy is reminiscent of the venting (tòu) principle to aid in dredging a pathogen lodged in the Yíng and Xuè levels.
Shè Xiāng is acrid, aromatic, and warm; it enters Heart, Liver, and Spleen. It is found in the open orifice materia medica category but also quickens the Blood and thus assists the stasis-resolving ingredients. Wáng emphasized that it should be good quality (not fake) and that it is crucial to the formula’s function. However, the musk deer is endangered and, though it may be farmed, Brand & Wiseman (2008) discourage its use. Substitution is discussed below.
Premade formulas and substitutions
The formula is available in premade form in pills (Blue Poppy, Plum Flower) and granules (KPC and others).
Blue Poppy uses Sū Hé Xiāng (Styrax) (acrid, aromatic, warm, Heart & Spleen), which transforms turbidity and opens depression, and is used in cases of blocked blood vessels, though its effect is not as strong as Shè Xiāng.
Plum Flower substitutes Bái Zhĭ (Angelicae Dahuricae Radix) — acrid, warm, enters Lung and Stomach — for Cōng Bái, which can be seen to strengthen its ability to treat pain and sinus congestion. Plum Flower also substitutes for Shè Xiāng with Shí Chāng Pú (Acori Tatarinowii Rhizoma), which is bitter, acrid, and warm, enters Heart and Stomach, opens orifices, quiets the spirit, sweeps phlegm and repels foulness. It is not a blood-moving medicinal, but it excels at clearing turbidity from the orifices, and its inclusion, whether as an addition or a substitute, is beneficial to the formula’s intent. We referenced its ability to treat neurocognitive deficit in an earlier post.
One drawback to using the granule formulations is that, as far as we’ve seen, no granule manufacturer has included any ingredient from the open orifices category – no Shè Xiāng, Sū Hé Xiāng, Shí Chāng Pú, nada. One can add in a single, of course, though of the three only Shí Chāng Pú is available in granules. Given Wáng’s insistence that the formula is reliant upon a high-quality aromatic, one can’t imagine the formula would work as intended on its own in granule form. Overall, the Blue Poppy formulation is closest to the original and is the one we favor.
Research
Both the formula and its constituents have been the subject of research.
Open orifices as a category is frequently applied in cases of clouding or unconsciousness. One of the correlates in modern practice is neurodegenerative disorders as well as stroke and traumatic brain injury (TBI). TQHXT has been studied both alone (Hua et al., 2022; Li et al., 2017; Yuan et al., 2022 ) as well as alongside its better-known sister formula Bǔ Yáng Huán Wǔ Tāng (Tonify Yang to Restore Five-Tenths Decoction) (Chuanzhen, 2004) for a wide variety of nervous system disorders.
Shè Xiāng and Sū Hé Xiāng both appear in numerous studies; both have neuroprotective effects and may aid in neurovascular repair (Xie et al., 2021). The neuroprotective effects of Sū Hé Xiāng are less than that of Shè Xiāng (Ni et al., 2011). Sū Hé Xiāng can improve blood viscosity and aid in angiogenesis (Xu et al., 2021) so it would seem an adequate substitution for Shè Xiāng (as is done in the Blue Poppy formulation) given our profession’s ethical considerations on protecting wildlife.
Possible application in Long COVID?
Looking at the actions of the formula, TQHXT could be a promising option for treating brain fog and loss of taste and smell in Long COVID. The combination of blood viscosity problems and microclotting (Pretorius et al., 2022) along with the neurocognitive dysfunction and anosmia would seem to be a good match for the treatment principles of the remedy.
If there is significant fatigue, we can consider adding Huáng Qí as a single, or combining with Bǔ Yáng Huán Wǔ Tāng if prescribing pills. In cases with depression, augmenting the formula with Dān Shēn (Salviae Miltiorrhizae Radix) and Yù Jīn (Curcumae Radix) may be advisable.
Conclusion
TQHXT is a bit of a sleeper formula; it is easy to forget about it, yet it holds a lot of possibilities. Its unique mix of stasis-resolving, surface-opening, and portal-unblocking may prove extremely useful in meeting our 21st-century clinical challenges.
Note: this newsletter is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Brand, E., & Wiseman, N. (2008). Concise Chinese materia medica. Paradigm Publications.
Chuanzhen, L. (2004). Clinical observation: Tongqiao Huoxue Tang and Buwang Huanwu Tang for treatment of vascular dementia. The Journal of Chinese Medicine, (75), 53+. https://link.gale.com/apps/doc/A153911716/AONE?u=googlescholar&sid=bookmark-AONE&xid=13423bd0
Hua, Y., Zhai, Y., Wang, G., Wang, N., Wu, Q., Huang, Q., Seto, S., & Wang, Y. (2022). Tong-Qiao-Huo-Xue decoction activates PI3K/Akt/mTOR pathway to reduce BMECs autophagy after cerebral ischemia/reperfusion injury. Journal of Ethnopharmacology, 298, 115585. https://doi.org/10.1016/j.jep.2022.115585
Li, L., Wang, N., Jin, Q., Wu, Q., Liu, Y., & Wang, Y. (2017). Protection of Tong-Qiao-Huo-Xue Decoction against Cerebral Ischemic Injury through Reduction Blood-Brain Barrier Permeability. Chemical & Pharmaceutical Bulletin, 65(11), 1004–1010. https://doi.org/10.1248/cpb.c17-00267
Maclean, W., Lyttleton, J., Bayley, M., & Taylor, K. (2018). Clinical handbook of internal medicine: The treatment of disease with traditional Chinese medicine. Eastland Press.
Ni, C., Zeng, N., Xu, F., Gou, L., Liu, J., Wang, J., & Xia, H. (2011). Effects of aromatic resuscitation drugs on blood brain barrier in cerebral ischemia-reperfusion injury model rats. Zhongguo zhongyao zazhi = China Journal of Chinese Materia Medica, 36(18), 2562–2566.
Pretorius, E., Venter, C., Laubscher, G.J., Kotze, M.J., Oladejo, S.O., Watson, L.R., Rajaratnam, K., Watson, B.W., & Kell, D.B. (2022). Prevalence of symptoms, comorbidities, fibrin amyloid microclots and platelet pathology in individuals with Long COVID/Post-Acute Sequelae of COVID-19 (PASC). Cardiovascular Diabetology 21(148). https://doi.org/10.1186/s12933-022-01579-5
Scheid, V., Bensky, D., Ellis, A., & Barolet, R. (2009). Chinese Herbal Medicine: Formulas & Strategies (2nd ed.). Eastland Press.
Wang, Q.R. (2007). Yi lin gai cuo (Correcting the errors in the forest of medicine)(Y. Chung, H. Oving, S. Becker, Trans.). Blue Poppy Press. (Original work published 1830)
Xie, Q., Ma, R., Guo, X., Chen, H., & Wang, J. (2021). Benzoinum from Styrax tonkinensis (Pierre) Craib ex Hart exerts a NVU protective effect by inhibiting cell apoptosis in cerebral ischaemia rats. Journal of Ethnopharmacology, 265, 113355. https://doi.org/10.1016/j.jep.2020.113355
Xu, Z., Lu, D., Yuan, J., Ren, M., Ma, R., Xie, Q., Li, Y., Li, J., Wang, J. (2021). Storax, A Promising Botanical Medicine for Treating Cardio-Cerebrovascular Diseases: A Review. Frontiers in Pharmacology, 12. https://doi.org/10.3389/fphar.2021.785598
Yuan, M., Zhang, Y., Wang, L., Hua, Y., Wang, Y., Cheng, H., Wang, N., Wang, G., & Seto, S. (2022). Study on the mechanism of Tong-Qiao-Huo-Xue decoction regulating apoptosis via ASK1/MKK4/JNK pathway in MCAO/R rats. Phytomedicine : International Journal of Phytotherapy and Phytopharmacology, 106, 154437. https://doi.org/10.1016/j.phymed.2022.154437