by
Bob Flaws, Lic. Ac., FNAAOM (USA), FRCHM (UK)

Keywords: Chinese medicine, hypertension, liver-spleen disharmony

For the last year or so I have been saying that a central assumption in standard professional Chinese medicine is wrong, i.e., that hypertension always involves some element of ascendant liver yang hyperactivity. Based on clinical experience, this is patently wrong and is one of the likely reasons that hypertension is considered a "difficult-to-treat disease" in Chinese medicine. Patients are being treated on an erroneous idea about hypertension and are, therefore, being given the wrong Chinese medicinals. While I have published my own opinions on this subject, it is always nice to see some other practitioner working towards the same conclusions. One such case is an article published in issue #5, 2004 on pages 264-266 of the Shan Dong Zhong Yi Za Zhi (Shandong Journal of Chinese Medicine). Written by Zhuang Yuan and titled, "An Analysis of the Treatment of Middle-aged & Young [Sufferers] of Essential Hypertension by the Methods of Coursing & Rectifying the Liver & Spleen and Regulating & Smoothing the Qi Mechanism." In this article, Dr. Zhuan emphasizes the role of a liver-spleen disharmony as the key mechanism of essential hypertension in younger and middle-aged patients. This is also my own experience. Below I present some of the salient parts of Dr. Zhuan’s thesis.

Liver-spleen disharmony, phlegm turbidity & blood stasis

According to Dr. Zhuan, essential hypertension in the young and middle-aged is mostly due to a loss of regulation in liver-spleen function. In this case, the liver qi initially becomes depressed and bound. It is Dr. Zhuan’s opinion that the main cause of liver qi depression and binding is loss of normalcy of the affects. Secondarily, this may give rise to ascendant liver yang hyperactivity or liver fire flaring upward. As Dr. Zhuan says further on, liver depression, liver fire, and liver yang all have their origin in liver depression. While Dr. Zhuan mentions that liver depression may transform into yang hyperactivity or liver fire, he does not insist that this is a necessary part of hypertension. Nor does his protocol (presented below) require it. At the same time, the spleen loses its fortification and movement and upbearing and downbearing lose their duty. This is due to over-eating fatty, sweet, thickly flavored foods, too much or too little exercise, too much thinking and worry, and the natural result of liver depression. This is what is referred to in the contemporary Chinese medical literature as a liver-spleen disharmony. Hence the qi and blood lose their harmony and the qi mechanism loses its constancy or normalcy. This then results in the complications of blood stasis and/or phlegm turbidity obstructing and stagnating in the channels and vessels. In Dr. Zhuan’s experience, none of these complications typically occur in the young and middle-aged unless there is liver qi depression and binding and spleen loss of fortification and movement.

Dr. Zhuan quotes a number of classical sources for the close relationship between liver depression and spleen dysfunction. According to the Ling Shu (Spiritual Pivot), "[When] disease first occurs in the liver, in three days, it will also be in the spleen." Along the same vein, Zhang Zhong-jing, in the Jin Gui Yao Lue (Essentials of the Golden Cabinet), "[When] liver disease appears, know that the liver transmits to the spleen. [Therefore,] one must first replete the spleen." When liver disease transmits to the spleen and the spleen loses its fortification and movement, the clear yang is not upborne and turbid yin is not downborne. This then gives rise to the internal engenderment of phlegm dampness. Further, because the spleen is the latter heaven source for the engenderment and transformation of qi and blood, spleen vacuity may lead to insufficient qi to stir the blood and insufficient blood to nourish the vessels. In either case, there will be a tendency towards the creation of blood stasis, especially if the qi is already stagnant as it is if there is liver depression. Because water fluids and the blood move together, phlegm dampness encourages the formation of blood stasis, and blood stasis encourages the engenderment of phlegm dampness. Thus all these disease mechanisms are mutually engendering and promoting.

Treatment methods & formula

As for treatment, Dr. Zhuan advises that one should course the liver and resolve depression, move the qi and transform stagnation. However, in addition to this, he also says that it is important to moisten and enrich the liver. "When the liver is depressed... one cause may be that scanty blood is not able to nourish the liver." In addition, enduring depressive heat, yang hyperactivity, or flaming fire may all damage and consume yin fluids. In terms of the principles for the addressed the spleen, Dr. Zhuan says to rectify the spleen and transform dampness, upbear the clear and downbear the turbid. Not only will this aid in the elimination of phlegm dampness but will also help in coursing the liver and resolving depression. Dr. Zhuan quotes Zhang Xi-chun as saying, "[If] one desires to treat the liver, one must first upbear the spleen and downbear the stomach, bank and nourish the central palace. When the central palace’s qi transformation becomes generous, liver wood is automatically rectified."

The formula Dr. Zhuan proposes for the above purposes consists of:

Ge Gen (Radix Puerariae Lobatae)
Chai Hu (Radix Bupleuri)
Bai Zhu (Rhizoma Atractylodis Macrocephalae)
Fu Ling (Sclerotium Poriae Cocos)
Han Fang Ji (Radix Stephaniae Tetrandrae)
Bai Shao (Radix Albus Paeoniae Lactiflorae)
Dang Gui (Radix Angelicae Sinensis)
Gou Teng (Ramulus Uncariae Cum Uncis)
Wei Ling Xian (Radix Clematidis Chinensis)

Within this formula, Ge Gen’s flavor is sweet and acrid and its nature is level or neutral. It enters the spleen and stomach channels where its function is to upbear and effuse spleen-stomach clear yang. It also is able to course and resolve depression and binding of the liver channel’s qi mechanism. Chai Hu’s flavor is bitter and its nature is cool. It enters the liver and gallbladder channels where it courses and spreads the liver qi. It also diffuses and smooths the flow of the qi and blood, upbears and lifts the clear yang.. When these two medicinals are combined together, they course and resolve depression and binding in the liver channel and qi mechanism and also upbear and lift the spleen and stomach clear yang. They are the sovereign medicinals in this formula. Bai Zhu’s flavor is bitter and sweet and its nature is warm. It enters the spleen and stomach channels where it fortifies and moves the spleen and stomach, dries dampness and harmonizes the center. Fu Ling’s flavor is sweet and bland and its nature is level. It enters the heart, spleen, and lung channels where it boosts the spleen and harmonizes the stomach, seeps dampness and disinhibits water, settles the heart and quiets the spirit. Han Fang Ji’s flavor is bitter and its nature is cold. It enters the liver, spleen, and kidney channels. It is used to disinhibit water and discharge turbidity. These are the ministerial medicinals in this formula. When these three medicinals are used together, they are able to fortify and move the spleen and stomach so that upbearing and downbearing are strengthened. They also seep dampness and disinhibit water so that turbid qi is descended and downborne. When combined with the sovereign medicinals, upbearing and downbearing are mutually benefitted and balanced. Bai Shao’s flavor is sour, bitter, and slightly sweet, while its nature is slightly cold. It gathers in the liver, spleen, lung, and large intestine channels. It softens the liver and stops pain, nourishes the blood and secures yin. Bai Shu is combined with Chai Hu in order to prevent Chai Hu’s consumption and damage of liver yin. Dang Gui’s flavor is sweet, acird, and bitter and its nature is warm. It enters the liver, heart, and spleen channels. Its sweetness supplements, while its acridity scatters or dissipates. Its bitter discharges and its warmth frees the flow. Likewise, it helps prevent Chai Hu from damaging yin blood. It is also able to transform static blood and smooth and ease the flow of the blood vessels. Combined with Ge Gen and Chai Hu these can regulate and rectify the qi and blood. Gou Teng’s flavor is sweet and its nature is cool. It enters the heart and liver channels where it clears floating and rising liver fire and extinguishes frenetically stirring liver wind. When these three medicinals are combined together, they are able to supplement the liver and prevent damage to liver yin at the same time as strengthening the sovereign and ministerial medicinals’ coursing and rectifying of the liver and spleen, upbearing of the clear and downbearing of the turbid. These are the assistant medicinals in this formula. Wei Ling Xian’s flavor is acrid and salty and enters the bladder channel. Its nature is rising (or moving) and not abiding. It diffuses and frees the flow of the five viscera and frees the flow and moves the 12 channels. It guides the other medicinals to move throughout the entire body. It is the guiding medicinal within this formula. Thus when all these medicinals are combined together, they have the power to course and rectify the liver and spleen, upbear the clear and downbear the turbid, regulate and smooth the flow of the qi mechanism.

Basically, Dr. Zhuan’s protocol for essential hypertension in the young and middle-aged with a liver-spleen disharmony is a modification of Xiao Yao San (Rambling Powder), a famous liver-spleen harmonizing formula. It is a nice option when the patient with hypertension does not present with yang hyperactivity. It can be further modified for depressive heat, more phlegm and dampness, more qi vacuity, or more blood stasis.

Copyright © Blue Poppy Press, 2004. All rights reserved.

For more information on the Chinese medical treatment of hypertension, see Simon Becker, Bob Flaws & Robert Casañas’s The Treatment of Cardiovascular Diseases with Chinese Medicine available from Blue Poppy Press in late 2004.