Exploring Blood and Immunity in TCM

There is often a tendency in TCM education to equate the TCM concept of Wèi Qì (衞氣) with the immune system and this leads to oversimplification and misunderstanding. In traditional Chinese medicine, while there are obvious areas of conceptual overlap, the biomedical “immune system” must also include other facets of Qi plus aspects of the TCM concepts of Blood, Yang, Yin, Jing, and Marrow to be properly understood. In this article, I want to explore a more complete understanding of how to assess the condition of a patient’s blood by providing insight into the use of a common laboratory test, i.e., the Complete Blood Count (CBC) with Differential.

In TCM theory, True Qi (Zhēn Qì 真氣) is comprised of Defensive Qi (Wèi Qì 衛氣) and Nutritive Qi (Yíng Qì 營氣). Defensive Qi is located in the Exterior, under the skin, and circulates outside of the Channels. Nominally under the control of the Lungs, it originates from Essence (Jīng 精) and Original Qi (Yuán Qì 原氣) and is transformed by Kidney Yang (Shèn Yáng 腎陽). Defensive Qi corresponds to barrier immunity in the biomedical model, which is the first line of defense to protect the body from disease. Nutritive Qi is closely related to Blood (Xuè 血) providing nourishment to all cells, organs and tissues in the body and flows in the channels of acupuncture and the arterial, venous, and lymphatic vessels.

Aspects of Blood are derived from both Pre- and Post-Natal Essence and consequently depend on the Qi of the Spleen/Stomach and Kidney, and specifically to the Kidney’s connection with Bone Marrow. Blood also depends on the Lung to infuse Qi into the vessels and assist the Heart in moving the Blood. In fact, the Blood is considered a very dense form of Qi, while also a type of Yin. The relationship of Blood and Qi is fourfold: Qi generates Blood, Qi moves Blood, Qi holds Blood in the vessels, and Blood nourishes Qi. This last aspect points directly to Blood as the source of major facets within the biomedicine concept of active immunity, both innate and adaptive. In addition, one should remember the dependence on the quality of Blood influencing healthy Spleen and Lung Qi, along with the role of the Kidney Yang in filling the Marrow.

In our March 2022 Newsletter, the medical description of the immune system was described in some detail within the article, “TCM Heat and Inflammation”. I strongly recommend it for context. One key to understanding the immune system is that it is delivered via the circulatory system, including the lymphatic system. Additionally, the cells that comprise blood and lymph, viz. erythrocytes, leukocytes, lymphocytes, reticulocytes, and thrombocytes are derived from bone marrow.

What is Blood?

Blood represents about 7% of an adult’s body weight and the average person has around 11 liters of blood circulating in their heart and arterial, venous, and lymphatic vessels. Around 54% of blood and 99% of lymph is plasma, which is 92% water. Red blood cells (RBCs/ erythrocytes) comprise 42-45% of blood; platelets (thrombocytes) and white blood cells (WBCs/ leukocytes) encompass about 1%. Lymph does not contain RBCs or platelets. The non-aqueous portion of plasma includes plasma proteins (albumin, globulin, and fibrinogen), glucose, minerals (electrolytes), fatty acids (including triglycerides), cholesterol, enzymes, hormones, antibodies, and waste products including carbon dioxide, urea, and lactic acid. Some components of plasma are dissolved within the aqueous solution, while many are transported by specialized plasma proteins (polypeptides). Blood is in continual contact with every cell to provide nourishment, communication, and information, while also removing waste.

Importantly, in the context of immunity, the blood contains leukocytes, lymphocytes (also found in lymph), antibodies, complement proteins, and many other chemical mediators including histamines, prostaglandins, thromboxanes, cytokines, and leukotrienes, all of which play a significant role in operating the human immune system. Obviously, the quality of the blood in all its aspects is a vital component in immunity.

Classically, a TCM diagnosis of Blood Deficiency requires among its signs and symptoms a pale or sallow complexion, pale lips, dizziness, poor memory, blurred vision, insomnia, a pale and slightly dry tongue, and a choppy, fine, or frail pulse. In women, there may also be various gynecologically related symptoms. Treating Blood Deficiency calls for tonifying Qi and Blood and assessing any Liver excess and/or Kidney deficiencies. However, these signs and symptoms point mostly to anemic conditions where either the number of RBCs or the amount of hemoglobin is inadequate for optimum health. In assessing the immune function, it is necessary to gather additional information about blood, especially the quantity and activity of leukocytes.

Complete Blood Count with Differential

The best informative tool for monitoring the quality of blood is a common laboratory test, the Complete Blood Count (CBC) with Differential. The Differential, in particular, provides insight into the number and activity of the leukocytes involved in the immune system. In some states, acupuncturists, naturopaths, and chiropractors can order this test, but in many cases, the test must be ordered by a medical doctor. However, anyone can read and interpret the results, which provide a wealth of information.

Since each laboratory may use slightly different technology or procedures, one should rely on the reference ranges provided by the lab. Bear in mind that “normal ranges” are a statistical analysis that represents the average values in a population of people plus two standard deviations from the mean, which means that 95% of “normal” values (i.e., not representing pathology) are found in the reference range.

The CBC is composed of a quantitative analysis, a “count” of cells per standard volume of the major cell types plus indices that provide additional information. Specifically, the CBC test reveals the amount of RBCs, hemoglobin, hematocrit, reticulocytes, platelets, WBCs, mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration. The differential distinguishes the amount of various WBCs, i.e., leukocytes and lymphocytes. See the highlighted section for the various tests conducted and what the information provides.

Red blood cells

RBCs are the number of erythrocytes in 1 cubic mm of whole blood. Erythrocytes are unnucleated and their primary function is to transport oxygen-carrying hemoglobin. The RBC count will be low with iron deficiency, blood loss, hemolysis, and bone marrow suppression (bone marrow suppression is a potential side effect of chemotherapy and other drugs). In TCM terms, it is possible that a patient with Blood Deficiency may have low RBCs.

Hemoglobin

Hemoglobin is the oxygen-carrying pigment of red blood cells. Hemoglobin is a compound polypeptide, closely related to but smaller than a protein molecule. Hemoglobin holds a molecule of iron, which is the actual transporter of oxygen from the lungs to the body tissues and then returns the carbon dioxide waste from the tissues back to the lungs. There are millions of hemoglobin molecules in each red cell. Hemoglobin represents the oxygen carrying capacity of blood. Women normally have about a 10% lower hemoglobin than men. Decreases in hemoglobin occur for the same reasons as decreased RBCs and may also be a harbinger of Blood Deficiency.

Hematocrit

The hematocrit is a measure of the volume of all cells present in blood as a percentage of the total volume of cells plus plasma in whole blood. This percentage is usually three times greater than that of hemoglobin. After hemorrhage, blood loss, or excessive intravenous fluid infusion, the hematocrit will be low. If the patient is dehydrated, the hematocrit will be higher. The hemoglobin and hematocrit should appear roughly in the same range of normal values. Women normally have about a 10% lower hematocrit than men.

Reticulocytes

Reticulocytes are the new cells released by the bone marrow and normally appear in the range of around 1% of cells. The reticulocyte count is used to assess bone marrow function and can indicate the rate and production of RBCs. Slightly elevated reticulocyte counts may occur in patients with anemia when there is an underproduction of red cells with iron or folate deficiencies. Elevated levels may indicate blood loss or hemolysis and the body is attempting to respond.

Platelet Count

Platelets (thrombocytes) help to control bleeding by forming an occlusion at small injurious openings in blood vessels and by a thromboplastic function which stimulates the coagulation cascade. Platelets are also produced in bone marrow. Platelet count measures only platelet number, not function. Low platelets may indicate thrombocytopenia which can occur in loss of bone marrow function or leukemia, among other diseases. A high platelet count occurs in cases of chronic infection or inflammation (including atherosclerosis), iron deficiency anemia, essential thrombocythemia (literally, high platelets), and various malignancies including certain (other) leukemias. Patients with diabetes, elevated lipids (including cholesterol), and smokers may have higher platelet counts and this contributes to the risk of thrombosis in these individuals.

Indices

Indices measure the average characteristics of the RBCs. The indices usually noted include the mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), the mean corpuscular hemoglobin concentration (MCHC) and red cell distribution width (RDW).

MCV

The mean corpuscular volume measures the average size of the RBC and can be calculated by dividing hematocrit X10 by RBC count. Low values indicate smaller cells and are often evident with conditions such as iron deficiency, lead poisoning and thalassemia. High values indicate larger than normal RBCs and are found with such conditions as megaloblastic anemia, folate, or Vitamin B12 deficiency, liver disease, post-splenectomy, chemotherapy, or hypothyroidism.

MCH

The mean corpuscular hemoglobin is the average weight of hemoglobin per RBC. Although the normal range is wide, low levels may show up in anemia, folate, or Vitamin B12 deficiency, among other conditions.

MCHC

The mean corpuscular hemoglobin concentration is the average concentration of hemoglobin per erythrocyte. Normal levels can be seen with acute blood loss, folate, and Vitamin B12 deficiency but these cells will still be normochromic (normal in color). Hypochromic or “pale cells” will be seen with conditions such as iron deficiency and thalassemia. The presence of hypochromic cells will be noted in the report.

RDW

The red cell distribution width is a quantitative estimate of the uniformity of individual cell size. Elevated levels may indicate iron deficiency or other conditions with a wide distribution of various cell sizes. Normally only 11.5 percent to 14.5 percent of RBCs will be present in various stages of development, the remainder will be mature cells.

WBCs

White blood cells (leukocytes), are larger in size and much less numerous than red cells. They also develop from stem cells in the bone marrow. WBCs function primarily as the source of innate and adaptive immunity, especially in response to an inflammatory process or injury. The first response to high WBCs should be an assessment of acute infection or chronic inflammation.

Differential

The Differential is used to measure the percentage of the diverse types of WBCs present, especially when the white count is abnormal. Differential counts add up to 100 percent of WBCs. The differential usually includes neutrophils, bands, eosinophils, monocytes, and lymphocytes.

Neutrophils

The function of neutrophils is to destroy and ingest bacteria (phagocytosis). Neutrophils are the first to arrive at the site of inflammation; therefore, their numbers will increase greatly immediately after an injury or during the inflammatory process. Their life span is approximately 10 hours, then a cycle of replenishing neutrophils must occur. Neutrophils also increase with such conditions as stress, necrosis from burns and heart attack. Note that stress is a contributing cause of chronic inflammation. Neutrophils comprise most WBCs in normal conditions (54-62%).

Bands

Bands are immature neutrophils which are released after injury or inflammation. The presence of bands indicates that an inflammatory process is occurring and ongoing. Bands are normally present at less than 4% of WBCs.

Eosinophils

Eos are found in such areas as skin and the airway in addition to the bloodstream. They increase in number during allergic and inflammatory reactions and parasite infections. They are also active in removing other substances and foreign materials that may harm the body and are normally present at 1-3% of WBCs.

Basophils

Called basophils when found in the blood, these cells are also known as “mast” cells when found in the tissues. Tissue basophils are found in the gastrointestinal and respiratory tracts and the skin. They contain heparin and histamine and are believed to be involved in allergic and stress situations, including asthma attacks. Basophils may contribute to preventing clotting in microcirculation (capillaries, et al.). A normal basophil count is .5-1% of WBCs.

Monocytes

These cells arrive at the site of injury in about five hours or more. The monocytes are phagocytic cells that remove foreign materials such as injured and dead cells, microorganisms, and detritus from the site of injury, particularly during viral or bacterial infections. During an inflammatory condition, monocytes are the backup to neutrophils. Normal values are 0-9% of WBCs.

Lymphocytes

Lymphocytes play a key role in the formation of immunoglobins (humoral immunity) and provide cellular immunity. B cells and T cells are the two major types of lymphocytes. B cells mature within bone marrow, while T cells mature in the thymus. T cells occur in two major types, Helper T cells and Killer T cells, which work together in combating antigens that are presented by pathogenic micro-organisms. Killer T cells are also involved in so-called auto-immune diseases since the tissues attacked by the Killer T cells are recognized as presenting an antigen, which is “not-self”, that is, not normal healthy tissue. B cells also work with Helper T cells but respond to antigens directly by deploying antibodies. The antibody tagged bacteria are destroyed by complement system or by phagocytes. Higher than normal levels of lymphocytes are suggestive of a viral infection, chronic infection (including hepatitis), lymphoma, multiple myeloma, or lymphocytic leukemia. (Lymphocytes comprise around 25-30% of WBCs.)

Incorporating Blood as a Strategy to Improve Immune Function

Understanding the relationship between blood and immunity within the clinical practice of a TCM herbalist is another tool to support your choices for constructing herbal formulas for your patients. Additionally, there is a tremendous amount of scientific research that has been conducted with Chinese herbs and immunity. This can be accessed via Google Scholar or perhaps from your local library, via PubMed/Medline. Here you will find that the same herbs that traditionally belong to the Tonify Qi and Blood categories also have been found to possess effects that are anti-inflammatory, immunomodulating, promoting leukocytic and lymphocytic activity, and phagocytosis. (A few examples of this research are listed in the References below.)

Consequently, when considering how to utilize herbal strategies to improve the immune function in our patients, many time-tested formulas will prove helpful. The classic example is Jade Screen Teapills/ Yu Ping Feng San which focuses on supporting the Spleen and Lung Qi and stabilizing the Exterior. Then, in order to tonify the Qi and Blood, consideration should be given, at minimum, to Dang Gui Bu Xue San. However, Zhi Gan Cao Tang Wan, Nu Ke Ba Zhen San/ Women’s Precious Teapills, and Shi Chuan Da Bu Wan/ Ten Flavor Teapills will provide a more comprehensive approach to tonifying both Qi and Blood. To promote the Kidney Yang Qi while Nourishing Liver and Kidney Yin and Blood, Ba Ji Yin Yang Teapills or Maway’s newest product, Majestic Yang Teapills/ Xiong Wei Da Bu Wan are recommended.

In conclusion, when there is a desire to build a patient’s immunity, the wise practitioner will not only tonify the Wei Qi, but will also augment the Zhen Qi, Blood, Yang, Yin, Jing, and Marrow. These physiological substances work together to support not only the immune function, but a patient’s overall health.

References

Formulas & Strategies, Bensky, D. & Barolet, R., Eastland Press: 1990. 
Chinese Herbal Medicine Materia Medica, 3rd Edition, Bensky, D. et al., Eastland Press, Seattle, 2004.
Blood Differential Test, https://www.healthline.com/health/blood-differential
“Complete Blood Count”, https://my.clevelandclinic.org/health/diagnostics/4053-complete-blood-count
“Anti-inflammatory and immunomodulatory effects of Paeonia lactiflora Pall., a traditional Chinese herbal medicine”, Frontiers in Pharmacology February 2011, Ethnopharmacology Section, Dong-Yi He and Sheng-Ming Dai, https://doi.org/10.3389/fphar.2011.00010
Immunology 2nd Ed., Hood, L.E., et al., Benjamin/Cummings Pub., Menlo Park, CA, 1984.
“Enhanced transformation of human lymphocytes by Chinese herbs”, Zhonghua Zhong liu za zhi [Chinese Journal of Oncology], Hu, YL,  01 Nov 1985, 7(6):417-419
https://europepmc.org/article/med/3015528
“Interpreting the Complete Blood Count and Differential”, https://www.elitelearning.com/resource-center/laboratory/interpreting-the-complete-blood-count-and-differential/
The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists, Maciocia, G., Churchill Livingstone: London 1989.
Fundamentals of Anatomy & Physiology, 11th Ed., Martini, F. et al., Pearson Education, 2018.
“Effects of ten traditional Chinese herbs on immune response and disease resistance of Sciaenops ocellatus (Actinopterygii: Perciformes: Sciaenidae)”, Pan, T., et al., Acta Ichthyologica ET Piscatoria, 2013 - researchgate.net
The Immune System, 3rd Edition, Parham, P., Garland Science, Taylor and Francis Group, LLC. (2009)
“A Chinese Herbal Decoction, Danggui Buxue Tang, Prepared from Radix Astragali and Radix Angelicae Sinensis Stimulates the Immune Responses”, Qiu, T., et al., Planta Medica 2006; 72(13): 1227-1231
https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-2006-947186
“Comparative study on adjuvanticity of compound Chinese herbal medicinal ingredients”, Wang, D., et al., Vaccine, Volume 23, Issue 28, 25 May 2005, https://doi.org/10.1016/j.vaccine.2005.02.011
A Practitioner’s Formula Guide, Wrinkle, A. et al., Elemental Essentials Press: 2008. 
"Effect of two Chinese herbs (Astragalus radix and Scutellaria radix) on non-specific immune response of tilapia, Oreochromis niloticus." Yin, G., et al., Aquaculture 253, no. 1-4 (2006): 39-47. fhs-afs.net

About the Author

Skye Sturgeon is the Quality Assurance Manager and Special Consultant for Mayway, USA. Skye was the former Chair of Acupuncture & East Asian Medicine and core faculty member at Bastyr University, core faculty member and Faculty Council Chair at the American College of Traditional Chinese Medicine, and President and Senior Professor of the Acupuncture & Integrative Medicine College, Berkeley. Before making Chinese medicine his career choice, Skye held various positions in the Natural Foods Industry for 12 years and prior to that was a clinical biochemist and toxicologist.