© Leon I. Hammer, M.D.

LESSON SIX

Contemporary Oriental
Medicine Foundation
1000 NE 16th Ave.,
Building F, Gainesville,
FL 32601, USA

Dr. Leon Hammer, M.D.

Continuing the series of clinical insights
Sharing the wisdom of over sixty years as a physician, and over forty years as a practitioner of Chinese medicine

This Lesson begins a discussion of Blood, exploring its importance in the body, and shedding
new light on the pathologies associated with Blood. Ubiquitous but frequently underestimated in
its importance, Blood is akin to the waterways and rivers of our
planet. If water becomes polluted or sluggish, all it touches - all it is
meant to nourish - will suffer. If it is not allowed to flow freely along its
“We must begin thinking
intended channels, drought ensues. As clean, healthy water is
like a river if we are to
essential to the life and well-being of the Earth and its ecosystems, so leave a legacy of beauty
too is healthy, smoothly-flowing Blood vital to our own health. We and life for future
hope that this Lesson, and the one that follows it, will give you an generations.”
increased awareness and understanding of Blood within each patient, - David Brower
and within Contemporary Oriental Medicine as a whole.

Lesson Six 1
© Leon I. Hammer, M.D.

Blood
The Nei Jing says Qi and Blood circulate in the
meridians. Confucius says that vitality is Qi and
Blood. Blood must reach everywhere, from the blood-
hungry heart muscles, to the tiny capillaries in the
skin. A purified form of it even crosses the blood-brain
barrier to become cerebrospinal fluid; there is a great
deal of blood in the brain. Blood is a substance in
much the same way as air is a substance; we are
most aware of it when it is lacking, or when there is a
problem with the way it moves.

Blood is emotion, and gives us meaning and purpose

in life. It is receptive, enhances stability and involves a
capacity for empathy. Blood nourishes life (Qi), and is
moved by life force (Qi), therefore Blood and Qi are interdependent. If one suffers pathology, the
other is affected. Problems with Blood (or Blood pathology) can be divided into categories:

Deficiency - a lack of Blood, either systemically, or within a specific organ or body area. This
does not necessarily have to be a lack of volume; it can be deficiency in the quality of Blood,
reducing its ability to perform its function.

Stagnation - the inability of Blood to move adequately, either systemically or locally.

Toxicity - when Blood contains elements of a pathological nature.

Much is written about Blood and its associated pathology. Rather than reiterating common
knowledge, this Lesson focuses predominately on material that is not readily available. It begins
by briefly considering the movement of Blood, and then introduces ways to assess and
understand the quality of the Blood itself. This is followed by an examination of Blood deficiency,
specific organ Blood deficiencies, and finally an introduction to False Blood deficiency.

Circulation
In previous Lessons I have touched upon the concept of the Heart and Circulation, primarily in
considering the effects of shock. In later Lessons I will explore the subject of the Circulation in
more detail, but for now, to foster a more complete understanding of Blood, I encourage readers
to review the material in Lessons One and Two, particularly that discussing the Heart and
Circulation.

Blood Stagnation
With so much information written about Blood stagnation in such a great number of books, it is
important to remember the essential truth: ‘Qi is the mover of Blood’. Therefore, Blood stagnates
in areas where Qi does not move well. This means that Blood also tends to stagnate in areas
where body tissue is more dense, such as the joints. As the pelvis is also a relatively dense area

Lesson Six 2
© Leon I. Hammer, M.D.

of body tissue, Blood will stagnate there when general circulation is impaired, resulting in
associated pathology in the hips, pelvic organs, and lower back. This means that, when
considering Blood stagnation in the pelvic area, one should consider problems with the general
circulation as a possible etiology.

From my perspective, the real issue here is Gravity. Whilst Qi is light, Blood is heavy, and
normally tends to sink to, and accumulate in, the pelvis (Blood stagnation). One consequence of
this is that when Blood becomes stagnant in the Lower Burner, the Qi and the Blood separate.
The Qi rises, and accounts for many headaches in women of all ages. Enhancing the Qi and
moving the stagnant Blood in the Lower Burner should be an important intervention for
headaches in women.

The Blood Depth

A variety of pulse qualities may be found at the Blood depth of the pulse. However, comparing
the substantialness of the Blood depth to that of the other depths can also reveal clinical
information about the quality of Blood, including, amongst other things, whether Blood Heat is
present and if so, in what amount. In order to clarify this, the following two paragraphs are a very
brief review of Lesson Four material, specifically an explanation of the depths of the pulse.

The pulse system used by Dr. Hammer has, in modern times, been called Contemporary
Chinese Pulse Diagnosis (CCPD), but is sometimes known as the Shen-Hammer system. It
actually originates from the famous ‘Menghe current’ in China, and is a pulse system comprised
of eight depths, but for the purposes of this Lesson we will consider three of those - Qi, Blood,
and Organ.

Dr. Shen taught that each pulse depth is found at a predetermined location, using a
predetermined amount of finger pressure (adjusted by tiny wrist movements). This approach
allows for a specific depth to have no qualities at all. For example, in the diagram to the right,
the second pulse picture is considered a
Deep pulse because, when using the
correct amount of finger pressure to
access the Qi and Blood depths, nothing
can be felt there; it is only when pushing
deeper, in order to access where the Organ
depth is located, that a pulse can be felt.

There are two ways to compare the depths to each other. For the purposes of this Lesson, I will
focus on one of them:

1) First, locate the Organ depth using the correct amount of pressure.

2) Next, release pressure very slightly until the fingertips arrive at the Blood depth.

3) Then, release pressure further very slightly until the fingertips are at the Qi depth.

Lesson Six 3
© Leon I. Hammer, M.D.

Using this method, one compares the pulse sensation at the Organ depth with the sensations
found at depths above it. This only works while releasing finger pressure, moving from the
Organ, through the Blood, to the Qi depth; the reverse of this (gradually increasing finger
pressure, moving from the Qi down toward the Organ depth) reveals different information.

The above diagram illustrates the changes in sensation felt at the fingertips as one very
gradually releases pressure and moves from the Organ, through Blood, up to the Qi depth.
Normally the pulse diminishes in size and strength as pressure is released, such that the Blood
depth feels slightly diminished compared to the Organ depth, and the Qi depth diminished
compared to the Blood depth - this can be seen represented in the part of the above diagram
labelled ‘Normal’.

If, however, the pulse feels as if it fills out slightly in the Blood depth, and then diminishes at the
Qi depth, a disharmony (and pulse quality) known as Blood Unclear is present. An amplified
version of this, where the pulse fills out even more at the Blood depth and still diminishes again
at the Qi depth, indicates the presence of Blood Heat. The sensation of Blood Thick, as seen in
the fifth diagram above, feels as though the substance of the pulse continues to increase all the
way up to, and including, the Qi depth.

To reiterate, the reverse procedure - i.e. gradually increasing pressure and feeling first the Qi
depth, then the Blood depth, and then the Organ depth - does not reveal the presence of Blood
Heat, Blood Unclear, or Blood Thick. When assessing the depths in this direction, changes in
substance across the spectrum can be completely different than those found when using the
method above, and they will have quite different meanings.

This means that we can have two entirely different sensations at the same Blood depth,
depending on whether we applied pressure and moved down into it from above, or released
pressure and moved up into it from below. While this may seem to be illogical, it is nonetheless
true, and serves as an important reminder that in order to learn from the pulse, we must be
flexible about our deeply-held concepts, and free ourselves to see things as they are, not as we
feel they should be.

Now that you have an understanding of how Blood Unclear, Blood Heat, and Blood Thick
manifest on the pulse, let us examine the meanings of these qualities. Throughout this
discussion, please remember that the Blood is a principle holding area for ‘retained pathogens’.

Lesson Six 4
© Leon I. Hammer, M.D.

Blood Unclear
There is no equivalent term in TCM. Dr. Shen likened the meaning of this condition to a glass of
water in which dirt is suspended; it is a sign of toxicity in the Blood. He found associated
symptoms often included fatigue, and skin-related problems such as eczema and psoriasis. In
my practice, I have encountered more pervasive symptoms, such as joint pain (see below).

The most common cause of this quality is exposure to environmental toxins, especially inhalant
solvents. I first encountered it with artists using highly toxic solvents, often in poorly ventilated
rooms, and with the use of acetylene torches, both in art and industry (welders). Another
possible cause is Liver Qi stagnation or, more commonly in recent times, Liver Qi deficiency,
which prevents the Liver from detoxifying adequately, thus allowing the Blood to become
contaminated.

Skin symptoms are an obvious attempt to discharge this

toxicity. Blood toxicity, associated by Dr. Shen with a type of
joint problem, can also be revealed inside the lower eyelid, as
we saw in Lesson Two. The arteries will appear irregular,
varying in thickness and color.

Another cause of Blood Unclear is a Qi-deficient Spleen that

does not build the Blood well due to poor absorption and
digestion of food, and especially of protein. Instead of being
completely digested down to amino acids, protein is only
partially digested into short-chain polypeptides: the size of
viruses. The short-chain polypeptides are absorbed and pollute the blood and lymph of the
intestinal tract. The body then reacts to them as if they were viruses by mobilizing the immune
system. Some of these polypeptides will get transported to the liver for processing, and some of
those will escape this detoxification process and end up circulating in the blood. Due to its
nourishing nature, Blood reaches virtually every part of the body. As a result, toxicity in the blood
is a strain not only on the immune system and liver, but also on virtually every other organ and
body tissue. Blood Unclear can also lead to the development of autoimmune diseases.

Blood Heat
This pulse quality is a sign of Excess Heat in the Blood. Dr. Shen compares this condition to a
glass containing hot water (in contrast to one containing dirty water, his metaphor for Blood
Unclear).

Two main patterns can give rise to this pulse, and often occur simultaneously.

The first pattern, increasingly common in our time, is one of excess Heat that is associated with
an extremely tense nervous system (‘Nervous System Tense’): one working beyond its capacity.
Over a very long period of time, this accumulated Heat can lead to a hypertensive condition if
the body cannot eliminate the Heat, and ultimately, Kidney Yin deficiency can ensue as the body
attempts to balance the Heat with fluid. In my opinion, people most commonly use tobacco in
an attempt to reduce this tension, but tobacco itself adds a great deal of heat to the Blood,
through the Lungs.

Lesson Six 5
© Leon I. Hammer, M.D.

With the second pattern, the excess Heat has its

origins in the digestive system, and is usually
associated with foods such as spices, wine, shellfish,
coffee, chocolate, and other Heat-inducing items.
The organs directly affected are the Liver and
Stomach, and secondarily, the Heart and Lungs.
Excess Heat from the digestive system can also be
generated when the Spleen-Stomach is engaged in
working beyond its energy, as with excessive intake
of food, food that is difficult to digest, or ‘normal’
food eaten by someone with deficient Spleen-
Stomach Qi.

I have found Heat coming from both ‘nervous system’ and digestive sources. I have also
observed Heat stemming from any situation in the body-mind wherein the body in unable to
overcome stagnation, or to excrete the excess Heat (through bowels, urine, skin, or breath) that
tends to accumulate as a result of the body’s failed attempts to overcome stagnation.

When the Blood depth is also Slippery, Blood Heat is associated with inadequate digestion and
metabolism of lipids. The Slippery quality also appears as a sign that the organism is attempting
to balance the Heat with fluids. If found at the Blood depth, the Choppy quality signals further
obstruction of the vessels, and also deterioration of the blood vessel walls. Dr. Shen said that, if
the skin feels hot when you first touch it, then stops being hot, the heat is from the Qi. If the skin
feels hot when you first touch it, then gets hotter, this indicates Blood Heat.

Blood Thick
According to Dr. Shen, an early sign of this condition can be persistent acne after adolescence.
The later signs are usually of a cardiovascular nature, such as hypertension and coronary
occlusion. In either case, the sclera and vessels of the lower eyelids are very red, and the tongue
is scarlet.

Blood Thick may develop from Heat in the Blood, described in the entry immediately above, in
which the etiologies are greater in degree and last longer. Blood Thick may also result from Liver-
Spleen-Stomach dysfunction or an excessive dietary intake of fat and sugar, and is a process
that gradually interferes with Heart function by increasing resistance in the circulation. Over time,
the Heat involved with this condition gradually depletes the
compensating Yin, drying out the intima and media of the vessels,
and leading to a Ropy pulse and atherosclerosis.

Blood Deficiency
As we saw in Lesson Two, Blood deficiency can also manifest in the
blood vessels inside the lower eyelid, where the arteries there will
appear pale and faded.

Lesson Six 6
© Leon I. Hammer, M.D.

The signs and symptoms of Blood deficiency are well known – a very brief review of them is as
follows:

Blood deficiency

Symptoms

Vision Blurred, Cloudy

Weight Weight loss

Nails Fragile

Limbs Tingling

Muscles Spasm

Heart Palpitations

Menstrual Amenorrhea

Skin Itching and Dry

Emotion Decreased Empathy,

Stability

Mouth Dry, Mild Thirst

Neurological Dizziness (Orthostatic),

Reduced Memory

Signs

Skin Lustreless, Dry

Neurological Numbness and Tingling

Facial color Pale

Tongue Pale, dry

Pulse Thin, Slow, Slightly

(Partially) Hollow

Blood and the Organs

Some of what is described below is new, and some of it is conventional information worth
repeating. What is perhaps most noteworthy here is that it is possible, using the pulse, to
measure accurately Blood’s relationship to each organ. Each organ depends upon Blood to be
able to perform various functions, and Blood itself also depends, for its production,
management, and circulation, upon the contribution of each organ. The pulse can show us if,
and precisely where, this complex process is not functioning effectively.

Lesson Six 7
© Leon I. Hammer, M.D.

The Thin quality is a definitive sign of significant Blood deficiency; the degree of deficiency is
revealed by the Thinness of the pulse. This quality is common in women on the entire pulse, if
for no other reason that that women lose Blood through Menstruation, as well as during
childbirth. When I was in China in 1981, girls received Blood-nourishing herbs from menarche at
least until menopause, however this has not been the case in the West. A simultaneous
presentation of the Thin and Tight qualities is a sign of both Blood deficiency and Yin deficiency,
and is common especially on women’s pulses. Clinical experience shows that a man - especially
a young man - who presents with a Thin quality on the entire pulse is likely to be relatively
seriously ill.

A lesser degree of Blood deficiency manifests as a quality that we call Yielding Partially Hollow. If
present, this quality is usually found in individual pulse positions. To the fingertip, it feels as if the
Qi depth of the pulse has substance. When pushing down slightly further, one feels that the
Blood depth yields and separates away from the fingertip as pressure is increased. Then, with
additional pressure, substantialness is felt at the
Organ depth. In effect, all three depths together
give the impression of the pulse feeling slightly,
but not completely, Hollow. The Hollow qualities
can only be detected when moving down through
the depths, and not up: the exact opposite of the
method described earlier for detecting Blood
Unclear, Blood Heat, and Blood Thick.

A global/system-wide Blood deficiency will create Blood deficiency in all organs and tissues, and
manifests as a Thin quality on the entire pulse. With regard to more organ-specific Blood
deficiencies, the pulse in an Individual (organ) position can be Thin or Yielding Partially Hollow.
The location of these qualities reveals the precise source of the symptoms of Blood deficiency,
in a more accurate way than the symptoms alone can. This is useful if we consider that each
organ has its own role when it comes to Blood. A Blood-deficient quality in an individual pulse
position can show us in which way exactly Blood is affected, and this information allows us to
understand precisely how and why Blood is deficient. It also helps us to tailor the Management/
treatment of Blood deficiency to those organs most involved.

Kidney
Kidney Blood deficiency is associated with the ability of the Kidney to support the marrow,
where half of the blood is produced. Essence is the source of Blood and its ingredients (white as
well as red cells), and Blood nourishes Essence.

Liver
Liver Blood deficiency is associated with the Liver’s ability to store the Blood and deliver it to the
tendons, ligaments, muscles and peripheral nerves. The Liver also detoxifies the blood. In my
experience, it is Liver Blood (not the Spleen) that controls and nourishes the muscles, as well as
the ligaments, tendons, and the autonomic and peripheral nervous systems. Circulating in the
daytime, Liver Blood returns to the Liver (from the Heart and Circulation) at night.

Lesson Six 8
© Leon I. Hammer, M.D.

Heart
Heart Blood deficiency is associated with the ability of Heart Qi to circulate Blood through the
heart (coronary arteries), the body, and the brain. Clinically, it is important to differentiate Heart
Blood deficiency from Heart Yin deficiency, and also from Liver Blood deficiency. With Heart
Blood deficiency, the Thin quality will be in the Left Distal Position (Heart position), whereas with
Liver Blood deficiency, it would be in the Left Middle position (Liver position). Heart Yin
deficiency tends to manifest as a Tight quality in the Left Distal Position. Signs and symptoms
can also be useful distinguishing factors, in addition to the pulse.

Differentiating Heart Blood deficiency from Heart Yin deficiency:

Heart Blood deficiency
 Heart Yin deficiency

Signs Signs

Pale face and lips Malar flush

Pale, dry tongue Red tongue

Pulse: Thin and Weak, Slow Pulse: Thin and Rapid

Symptoms Symptoms

Palpitations Night sweats

Poor memory Five Hearts hot

Dizziness (Orthostatic) Maybe thirst

Differentiating Heart Blood deficiency from Liver Blood deficiency:

Heart Blood deficiency
 Liver Blood deficiency

Symptoms Symptoms

Palpitations with activity Palpitations at rest

Dry eyes Blurred vision (muscles)

Poor memory Numbness

Insomnia Tremor

Lesson Six 9
© Leon I. Hammer, M.D.

The balance between Blood in the Heart and in the Liver is important to sleep. This depends on
the emptying of Heart Blood to the Liver at night, while enough remains in the circulation to
maintain function (life), but not consciousness.

Spleen
The Spleen contributes to the formation of Blood for the entire organism. Spleen Qi deficiency
reduces the Spleen’s ability to extract nutrients from food. The Spleen requires these nutrients to
contribute to the formation of Gu Qi; this combines with Kong Qi (or Da Qi/Cosmic Qi) at Ren-17
to form Zong Qi. Via the catalyst of Yuan Qi, Zong Qi becomes Zhen Qi, which divides into Wei
Qi (entering the meridians at LU-1) and Ying Qi (for the organs). In the Stomach, Ying Qi then
combines with Jin Ye to form Blood, which some say then goes to the Heart to be given the red
color. There are, however, several different versions of this process described in various texts.

The textbooks say that the Spleen holds Blood in the vessels, and holds organs in their places.
Perhaps it does, imperceptibly. I have not observed this to be the case, despite testing the idea
often in clinical practice. In only one instance - an almost imperceptible prolapse of the stomach
(detected via the pulse) in a person with mild digestive discomfort - did needling Spleen,
Stomach, and Ren points eliminate the mild prolapse and relieve the symptoms. Treating the
Spleen with either extensive acupuncture or herbs has not changed the rest of the prolapses or
varicosities I have encountered.

Varicose veins, which are ascribed to Spleen Qi deficiency, actually seem to be the result of
excess Heat in the Blood. The Heat ‘vulcanizes’ the valves that hold and help move blood
towards the heart. When veins lose their flexibility the venous blood pools, and expands the
veins to varicosities. Based on my clinical experience, I have found that Excess Heat in the
Blood, and not Spleen Qi deficiency, is the etiology of varicose veins.

Lungs
The Lungs contribute Kong Qi (oxygen) to the formation of Blood, combining it with Gu Qi from
the Spleen-Stomach to create Zong Qi at Ren-17. The Lungs also eliminate CO2 from blood.

False Blood Deficiency

It is important to consider that Blood deficiency can be apparent symptomatically, but may not
be real. False Blood deficiency is the inability of a deficient Heart-Circulation to move Blood
where it needs to go. This results in organs or body areas being deficient of Blood through no
dysfunction of their own. The pulse will confirm this.

It is necessary to treat False Blood deficiency early in the Management process, since the
effective circulation of Blood is vital to the effective delivery of any herbs prescribed and any
nutrients ingested. False Blood deficiency may arise as a result of Heart Blood stagnation, Heart
Qi stagnation, Heart Qi agitation, or Heart Qi deficiency, each of which will be examined in detail
next month.

Lesson Six 10
© Leon I. Hammer, M.D.

In the next Lesson:

We will explore further the significance and implications of Blood and its functions by discussing
the causes of False Blood deficiency, examining hemorrhage, and describing the Liver’s
involvement in the menstrual cycle.

More information about Dr. Hammer’s work, as well as his regular posts and musings, can be
found at www.comfoundation.org

Lessons are freely circulated by the Contemporary Oriental Medicine Foundation.


Lesson content is produced by Dr. Leon Hammer, M.D. and Oliver Nash. Editing and design by Kira Nash.

Eyelid illustrations by Laisha Canner-Ward.

Lesson Six 11