Zhibai Siwu Decoction for Blood-Deficiency Heat and Bleeding
Siwu Decoction (the Four Substances Decoction) is a famous TCM formula for nourishing and invigorating blood. It was originally used by orthopedic physicians and comes from the Divine Tested Prescriptions for Treating Injuries and Mending Fractures (Xian Shou Li Xu Duan Mifang); later it also became a famous gynecological formula for nourishing blood and regulating menstruation. Siwu Decoction consists of four herbs—Angelica sinensis (danggui), Ligusticum chuanxiong (chuanxiong), Paeonia (shaoyao) and Rehmannia (dihuang)—hence the name "Four Substances." When Anemarrhena (zhimu) and Phellodendron (huangbai) are added to Siwu Decoction, it is called Zhibai Siwu Decoction. Made into a pill according to the Zhibai Siwu prescription, it is named Kanli Pill; Kan and Li are the water trigram and fire trigram of the Book of Changes, and Kanli Pill implies that this formula can enrich water and downbear fire.
Zhibai Siwu Decoction first appears in the Manifestations, Causes, Pulses and Treatments (Zhengyin Maizhi), which records this formula for treating excessive menstrual flow with bright-red blood, a red tongue with yellow coating and a rapid pulse, caused by yin deficiency with effulgent fire. Ye's Gynecology Syndrome Differentiation and Treatment (Ye Shi Nvke Zhengzhi) also records it for damage to the Conception and Thoroughfare vessels (Chong and Ren) with blood depletion causing amenorrhea, or for mistakenly eating pungent, hot foods that deplete blood and leave hidden fire in the Chong and Ren vessels. The Huiyue also records it for premature menstruation in patients who had mistakenly taken pungent, hot, womb-warming medicines and who have blood heat with hidden fire in the Chong and Ren vessels. The famous surgical text Yangyi Xinde Ji (Reflections of a Surgery Physician) also records Zhibai Siwu Decoction for blood deficiency with vexing heat. The Yifang Jijie (Collection of Explanations of Medical Prescriptions) records Kanli Pill for cough with blood caused by yin deficiency.
In addition, the Shanghan Dabai (Explicating Cold-Damage) contains a formula called Zhibai Dihuang Decoction, composed of Anemarrhena (zhimu), Phellodendron (huangbai), Angelica (danggui), white peony (baishao), raw rehmannia (shengdi) and Moutan bark (mudanpi), indicated for "hidden fire in the blood chamber of the liver channel, causing discharge of blood." Here Ligusticum (chuanxiong) is replaced by Moutan bark, making it more suitable for bleeding due to blood-deficiency heat.
The above records show that the indication of Zhibai Siwu Decoction is the pattern of blood deficiency with vexing heat. Clinically one may see five-center heat (heat in the palms, soles and chest), menorrhagia or incessant spotting—these are common symptoms of gynecological conditions such as uterine fibroids and uterine cancer. It can also treat cough with blood due to yin deficiency, usually caused by lung lesions. Anemia from other causes may sometimes show this pattern, and some patients with very poor blood counts often run a fever.
The dosages of the herbs in Zhibai Siwu Decoction can be adjusted according to the patient's specific condition. The author's recommended usual adult dose is: Angelica sinensis (danggui) 9 g, white peony (baishao) 9 g, prepared rehmannia (shoudi) (or raw rehmannia, shengdi) 15 g, Ligusticum chuanxiong (chuanxiong) 6 g, Anemarrhena (zhimu) 6 g, Phellodendron (huangbai) 6 g. The amount of Ligusticum in this formula should not be too large; if bleeding is the main symptom, consider replacing Ligusticum with Moutan bark (mudanpi) at a dose of 9 g. If bleeding is excessive, add Rubia madder (qiancao) 9 g, carbonized Trachycarpus palm (zonglü tan) 9 g, and carbonized human hair (xueyu tan) 9 g. If the patient's vexing heat is severe, add Lycium bark (digupi) 9 g, Stellaria dichotoma (yinchaihu) 6 g and Gentiana macrophylla (qinjiao) 9 g on top of this formula.