Shi Zai-xiang’s Academic Thoughts And The Theoretical And Clinical Studies On Filling Up Qi Collapse And Removing Blood Stasis For The Treatment Of Cardiovascular Diseases

Professor Shi Zai-xiang is one of the mentors of the third and fourth generation for training qualified Traditional Chinese Medicine (TCM) doctors to carry on the experience of national well-known and senior TCM experts. With more than forty years of clinical practice in integrated TCM and Western medicine, he is an experienced physician, specialized in treating cardiovascular diseases, chronic kidney diseases, diabetes as well as other various kinds of complicated diseases. This thesis is composed of two chapters. The first chapter provides an introduction to Professor Shi Zai-xiang’s primary academic thoughts and clinical experience. From the perspectives of theoretical origin and investigation, clinical studies, etc. the second chapter probes into his theories of "filling up qi collapse and removing blood stasis" for the treatment of cardiovascular diseases.The first chapter begins with an introduction to main academic thoughts of Professor Shi Zai-xiang, which is summarized as follows.1. Elucidating the theory of promoting blood circulation to remove blood stasis. Professor Shi Zai-xiang encapsulated the pathogenesis of the blood-stasis syndrome into three aspects, i.e."stagnation of circulation","blood leaving the channel " and "filthy blood", which further enriched and developed the pathogenesis theories of the blood-stasis syndrome and expanded the scope of this syndrome. He argued that "blood stasis" is a common pathological factor of many diseases and thereby promoting blood circulation to remove blood stasis plays an important role in treating many difficult, complicated and chronic diseases. According to the causes of the blood-stasis syndrome and its complications, he developed different therapeutic formulas to remove blood stasis, such as dispersing coldness, clearing heat, activating qi, benefiting qi, nourishing blood, stopping bleeding, eliminating phlegm, resolving masses, etc. He classified medicines for promoting blood circulation to remove blood stasis according to their sources, intensity, and clinical applications and this classification serves as guiding principles for drug selection in clinical practice.2. Emphasizing the correlation of qi, blood and water. Professor Shi Zai-xiang proposed that qi, blood and water transform into each other in the physiological condition and jointly contribute to maintain normal functions of organs. In the pathological condition, their interaction may serve as the internal causes for organ dysfunction and occurrence and development of diseases. To some extent, the three materials reflect the law of disease development and prognosis. Of the three materials, qi takes the leading role. The treatment should target at these materials together.3. Using eight extraordinary channels for diagnosis and treatment. Professor Shi Zai-xiang proposed that using extraordinary channels for differentiation of symptoms is an important component of TCM, which plays an especially significant role in diagnosis and treatment of some chronic, difficult and complicated diseases. When adopting extraordinary channels for symptom differentiation, he often began with:(1) the running course of the channels,(2) the syndromes governed by the channels and (3) in combination of other approaches of symptom differentiation. In treating the diseases governed by extraordinary channels, he carried on Ye Tianshi’s therapy of "overall supplementing" and prescribed medications taken from creatures having blood and flesh, aiming predominantly at invigorating liver and filling up lower jiao. The application of these theories in clinical practice is presented as treating cerebral and spinal diseases from the governor channel, treating gynecological diseases from conception and chong channels, and treating cardiodynia from the yin link channel.4. Excelling at prescribing classical formulae. Professor Shi Zai-xiang was proficient at prescribing classical formulae for the treatment of modern difficult, complicated and severe diseases. He demonstrated the following characteristics when using classical formulae:(1) identifying the exclusively core symptom;(2) analyzing the causes of diseases and expanding the scope of using classical formulae;(3) stressing symptom differentiation to improve clinical efficacy;(4) combining TCM and Western medicine and closely integrating modern and traditional medicines.5. Making appropriate adaptations when necessary. He held that the dose of TCM should depend on and vary with disease conditions. He had rich experience in urgent prescriptions and toxic drugs. For urgent prescriptions, special attention should be paid to drug processing, usage and dose and the medication should be stopped as soon as the symptoms are gone. Drugs for external use are emphasized as well to improve treatment efficacy.6. Advocating the integration of TCM and Western medicine. He argued that scientific and technological achievements of modern medicine must be taken full use of to support TCM inheritance and development. One should be good at seeking for the situations where TCM can be used for treatment, so as to demonstrate the overall TCM advantages of multi-layer and multi-target treatment and its distinctive effects.Then, Professor Shi Zai-xiang’s primary clinical experience in treating cardiovascular diseases, diabetes and chronic kidney diseases are summarized.1. Coronary heart diseases. The pathogencsis of coronary heart diseases is composed of both deficiency and excess. Firstly, the pain can result from blockade of heart vessel by phlegm and blood stasis, since daqi collapses in lungs and is unable to promote circulation of qi, blood and fluid. Secondly, the pain can result from lack of flourishment due to yang and yin deficiency in kidney, which leads to the inability to warm eight extraordinary channels and further causes poor blood circulation in the heart. The treatment of the diseases places a great emphasis on differentiating between manifestation and root causes, and between urgent and chronic symptoms. For unstable angina pectoris, the treatment should focus on eliminating pathogenic factors by means of warmly dredging blood vessels by spicy materials and removing blood stasis and phlegm. For stable angina pectoris, comparable emphasis should be placed on strengthening body resistance and eliminating pathogenic factors This can be achieved via benefiting qi, raising the collapse and promoting blood circulation to remove blood stasis, or warmly invigorating yang and yin and regulating extraordinary channels.2. Chronic heart failure. The initial stage of chronic heart failure shows the syndrome of heart qi deficiency and daqi collapse, whereas the later stage presents with kidney yang deficiency and fluid-dampness excess. Blood stasis can be found throughout the disease process. Accordingly, different types of treatment should be given at different stages. At the initial stage, the disease is treated by benefiting and raising qi and promoting blood circulation to remove blood stasis. At the later stage, the disease is treated by warming and recuperating kidney yang, activating blood circulation and inducing diuresis. During treatment, doctors should be skillful at seeking yang in Yin, promoting blood circulation and inducing diuresis.3. Hypertension. The main pathogenesis of hypertension is haptic hyperactivity and phlegm obstruction. Therefore, the treatment should target at suppressing hyperactive liver yang, dissipating phlegm and calming endogenous wind. Some special types of hypertension, e.g. involutional hypertension and hypertension in pregnancy, have their distinctive pathogenetic characteristics, such as deficiency of both yin and yang, and dampness obstruction due to spleen deficiency. During the treatment, emphasis should be placed on the integration of TCM and Western medicine and combining their strong points to improve the efficacy.4. Achyarrhythmia. This disease roots in the heart and closely correlates with the dysfunction of liver, spleen and kidney. Both deficiency and excess contribute to the pathogenesis of the disease. Deficiency can manifest itself in qi and kidney whereas excess can be shown as phlegm-heat and blood stasis. Therefore, for treatment, special attention should be paid to syndrome differentiation as well as combination with achievements in modern pharmacological studies.5. Bradyarrhythmia. The pathogenesis of the disease involves both deficiency and excess. Deficiency can manifest itself in qi and kidney and excess can be shown as blood stasis and turbid phlegm. Treatment of this disease should focus on both reinforcement and elimination, by means of benefiting and raising qi, invigorating kidney and reinforcing yang, and removing phlegm and blood stasis.6. Viral myocarditis. This disease is caused by exogenous seasonal pathogens such as warm-heat and wind-heat, which invade heart and lungs and consume up qi and yin. When this condition lasts long enough, daqi in the chest will collapse and lead to blood stasis and fluid-dampness inside the body. Thus, the treatment for this disease should target at benefiting and raising qi and promoting blood circulation to remove toxic substances.7. Diabetes. Basic syndrome types of diabetes have changed. The pathogenetic features of diabetes and its complications are deficiency in qi and yin and blood stasis blocking collaterals. Therefore the treatment involves benefiting qi and nourishing yin and promoting blood circulation to remove obstruction in collaterals.8. Insomnia. Insomnia is primarily ascribed to yang excessiveness and yin deficiency, which results in inability of yang to transform into yin and disturbance of heart-mind. Treating excess symptoms usually start with phlegm-heat and heart fire. Treating deficiency symptoms generally start with deficiency of both yin and yang. For patients long suffering from the disease, the treatment can start with blood stasis.9. Chronic glomerulonephritis. The pathogenesis of the disease primarily involves excessive pathogens and to a lesser extent, deficiency of body resistance probably resulting from excess. Dampness-heat stagnating in lower jiao and causing heat accumulation inside the body constitutes the major pathological basis of the disease. Therefore, the treatment should aim at clearing heat and promoting dieresis, cooling blood and promoting blood circulation.10. Chronic renal failure. The disease presents with deficiency of root causes and excess in manifestation. The former can be shown as yang deficiency in spleen and kidney and the latter can exhibited as dampness, poisoning and stagnation. So it is primarily treated by warmly invigorating spleen and kidney, promoting dieresis and evacuation and removing blood stasis. A common formula for this disease is the combination of the decoction of warming spleen and the Suplemented Zhenwu Decoction. Typical cases for each disease are provided as well.The second chapter begins with a literature review on the origin of the daqi theory and clinical application of the Shengxian Decoction in the treatment of cardiovascular diseases. The first documented appearance of the word "daqi" was found in Huangdi Neijing, based on which Zhang Zhong-jing was the first one to apply this theory into clinical practice. In the Qing Dynasty, Yu Jia-yan interpreted the theory more clearly and further developed it in clinical treatment. By the late Qing and early Republic periods, combined with his own clinical experience, Zhang Xi-chu enriched the theory of daqi by providing a systematic elaboration on the physiology, pathology, diagnosis and treatment of daqi. Daqi originates in congenitally primordial qi in the kidney, grows in acquired qi from food and water, stores in the chest and communicates with qi from the nature. The physiological roles of daqi include:1) governing breathing in the respiratory tract;2) rotating qi and blood in the cardiovascular system;3) governing qi movement in the whole body. The pathological changes of daqi can be summarized in three aspects:blockade, adverse rising and collapse, which could be treated by rotating, lowering and raising qi, respectively. In addition, studies on clinical application of the Shengxian Decoction, the typical prescription for raising and supplementing qi, in cardiovascular diseases are also reviewed in this section.Next, the theoretical background of qi collapse and blood stasis is discussed. Based on symptoms of cardiovascular diseases and deeply influenced by the theory of daqi collapse in Integrating TCM and Western Medicine written by Zhang Xi-chun, Professor Shi Zai-xiang combined the theory of qi and blood and the theory of qi ascending and descending and proposed that qi collapse and blood stasis is a common pathogenesis of cardiovascular diseases. He discussed the similarities and differences between qi collapse and qi deficiency and the relationships between qi collapse and blood stasis. Modern studies on the nature of daqi and daqi collapse suggested that daqi collapse is closely associated with cardiopulmonary insufficiency and that the syndrome of daqi collapse is one of the common syndrome of several cardiovascular diseases. Moreover, Professor Shi Zai-xiang also elaborated on the possible roles of qi collapse and blood stasis in different cardiovascular diseases.Finally, the effect of Shengjie Tongyu granules in the treatment of angina pectoris resulting from coronary heart diseases was investigated. Objective:to investigate the effect and safety of Shengjie Tongyu granules in the treatment of angina pectoris resulting from coronary heart diseases. Methods:108patients with the qi-deficiency-and-blood-stasis type of angina pectoris were randomly divided into treatment group (N=56) and control group (N=52). For four weeks, patients in the treatment group were treated with Shengjie Tongyu granules whereas patients in the control group were given the Tongxinluo capsule. We evaluated the treatment efficacy, cardiograph, TCM syndromes, blood lipids and safety indices. Results:Both groups showed significant improvement in symptoms of angina pectoris and TCM syndromes (P＜0.01), but no significant differences were found between groups (P＞0.05). Total efficacy rate of angina pectoris in the treatment group (83.92%) was superior to that in the control group (73.08%), even though there was no significant differences between groups (P＞0.05). Total efficacy rate of TCM syndromes in the treatment group (82.14%) was significantly higher than that in the control group (59.62%, P＜0.05). Additionally, the treatment group showed an increased level of HDL-C compared with the baseline (P＜0.01). Conclusion:Shengjie Tongyu granules can effectively improve the symptoms of angina pectoris resulting from coronary heart disease and the effects are comparable with the Tongxinluo capsule. In addition, this drug displays superiority over the Tongxinluo capsule in improving TCM symptoms. It can also increase HDL-C levels and ameliorate the blood lipid metabolism abnormalities in patients with coronary heart disease. Finally, the safety of treating angina pectoris with Shengjie Tongyu granules is satisfactory.A key for TCM inheritance and development is to inherit, discover and sort out academic thoughts and clinical experience of well-known and senior TCM experts, and to summarize new theories and doctrines. Only through this approach can TCM theories undergo continuous deepening and improvement, and better fulfill modern clinical demands.