We often speak of blood stagnation in terms of physical obstructions, circulatory problems and damaged tissue.

We often speak of the tai yang conformation in terms of external pathogens that need to be expelled from the body using sweating as the main treatment strategy.

So why are formulas that treat blood stagnation mentioned in relation to a tai yang disorder in the Shanghan Lun?

In order to understand this clinically important connection we need to look more carefully into the nature of the tai yang, as well as the characteristics of blood stagnation.

The tai yang conformation is responsible for our response to our external surroundings. It functions to provide protection from harmful external influences.

This does not apply only to the potential danger of external pathogens in terms of immune function. The tai yang conformation is actually better explained in terms of homeostasis. This conformation provides the ability to sense the external environment and stimulate a physical and emotional reaction in order to maintain a stable and safe internal environment. Failure to produce an appropriate bodily response can cause an internal imbalance.

Depending on the status of the body, this imbalance can manifest in different forms, including blood stagnation. Line 124 of the Shanghan Lun describes this disease mechanism. An external disease of the tai yang that is unresolved for a period of time might ultimately follow the path of the tai yang causing the external condition to transform into an internal condition of stasis of heat and blood in the lower abdomen:

Shanghan Lun line 124:

Why (this) is so is because (the evil) followed the greater yang channel, and (there is) stasis [of blood] and heat in the interior.

English translation taken from: Feng Ye, Nigel Wiseman, Craig Mitchell. Shang Han Lun: On Cold Damage, Translation & Commentaries.

It is important to understand that this disease did not transform to a different conformation, it is still a tai yang disease. Therefore, the treatment of this form of blood stagnation needs to address the tai yang dynamics.

Symptoms

Based on lines 106, 124-126 of the text, blood stagnation of the tai yang is located in the lower abdomen, involves accumulation of heat, and manifests in mental symptoms.

Three symptom groups are necessary to diagnose this disorder; lower abdominal discomfort, mental instability, and uninhibited urinary function.

Hardness, fullness and pain in the lower abdomen

This is a classic presentation of stagnation located in the lower abdomen causing physical discomfort. These symptoms could be caused by a wide variety of stagnations including heat, cold, damp cold, damp heat, qi and blood. The text informs us that the nature of stagnation in this case is an accumulation of blood and heat. The diagnosis classifying a particular case as a tai yang blood stagnation is based on the presence of all three symptom groups that combine this disorder.

Mental instability

This is characterized in the text as “manic behavior”. This could include impulsive, or irrational behavior, accompanied by a feeling of emotional distress. We often tend to associate these symptoms with heat in the upper burner disturbing the shen.

There are several examples in the Shanghan Lun that present “manic behavior” and emotional distress as deriving from obstruction, specifically obstruction of blood. These cases can widen our perspective on blood stagnation, linking it to the mind-body understanding of mental illnesses and emotional imbalance.

For example, in my practice I apply this understanding to emotional disorders related to hormonal imbalance, often those associated with gynecological disorders which locates the disease in the pelvic area.

Another interesting clinical application of this tai yang pathology is PTSD. Trauma can be a trigger for deep seated blood stagnation. If the mental clinical manifestations of this disorder are also accompanied by sensations of discomfort in the lower abdomen, this could be interpreted as a tai yang obstruction of blood.    

The urination is not obstructed

This is an important symptom for differential diagnosis. According to the text, when emotional instability and discomfort in the lower abdomen are accompanied with symptoms of urinary obstruction, this indicates a heat syndrome which does not involve either blood stagnation or the tai yang conformation. However, if the emotional instability and discomfort in the lower abdomen manifest with uninhibited urinary function, this points to a syndrome of blood stagnation of the tai yang.

This distinction is also an important clue to understanding systemic model of the conformations. In the Nei Jing, each conformation was paired with two organs. In the attempt to understand the theoretical and practical value of the conformations, there is much discussion regarding the clinical relevance of these pairings. The tai yang is associated with the small intestine and bladder organs. By emphasizing that urinary obstruction actually rules out a tai yang disorder, this specific example demonstrates that in the Shanghan Lun, these pairing had no particular clinical significance ( for further discussion on the nature of the conformations see the post What are the 6 classifications of Disease?).

Formula analysis

There are three formulas in the Shanghan Lun that are mentioned in relation to a tai yang pathology of blood stagnation. These formulas are:

Tao he cheng qi tang

Di dang tang

Di dang wan

The difference between them is in their aggressiveness both towards resolving stagnation and towards purging heat. The two di dang formulas contain leech (shui zhi 水蛭) and gadfly (meng chong 虻蟲), making them difficult to obtain and apply where I live. In addition, they are considered aggressive, appropriate for acute outbursts and extreme conditions, probably requiring urgent modern medical attention. Therefore, out of the three, I find tao he cheng qi tang the most useful in my clinic. This formula is described in line 106 of the text.

As is often the case for the formulas of the Shanghan Lun, analysis of this formula offers additional valuable insights into understanding the dynamics of the underlying pathology.

Ingredients of tao he cheng qi tang

Tao ren 50 pieces

Gui zhi 30g

Da huang 60g

Zhi gan cao 30g

Mang xiao 30g

The first three ingredients in this formula restore the mechanism for proper blood flow, the last three ingredients combine to make the formula tiao wei cheng qi tang, which drains accumulation and heat from the lower abdomen:

Tao ren, also known by the name “tao he” which is used in the name of the formula, invigorates the movement of blood in the lower abdomen.

Gui zhi is a herb associated with the tai yang conformation, stimulates and regulates the qi movement and dynamics of this conformation. Its contribution to resolving blood stagnation is three-fold:

1.  Qi moves blood, so by regulating the movement of wei qi, gui zhi actively stimulates blood circulation.
2. Gui zhi warms the vessels, thus further supporting movement of blood.
3. According to the Shen Nong Ben Cao Jing, gui zhi directly addresses this condition as it “dissipates blood amassment in the lower burner” (translated by Yang Shou Zhong).

Da huang has a double role in this formula:

1. Invigorates movement of blood, thus enhancing the action of the first two herbs.
2. Drains accumulation of heat from the lower abdomen by drawing it out through the intestines. This role is performed with the combination of zhi gan cao and mang xiao. Together these three herbs create the formula called tiao wei cheng qi tang which drains accumulation and heat from the lower abdomen.

This is a great example of how the conformations work together to create a unified system. The blood stagnation of the tai yang is located in the lower abdomen. This location requires the utilization of the draining quality of the yang ming to expel the obstruction. The formula tiao wei cheng qi tang belongs to pathologies of the yang ming. It uses bitter and cold herbs to drain accumulation located within the intestines that manifests as an obstruction of the bowel movement. However, it cannot resolve the pathology of tai yang which does not affect the bowels and urine, but does affect functions related to the pelvic area. In order to properly treat the condition, the force of the tai yang needs to be enforced to invigorate the flow of blood. This is done by combining the yang ming herbs with gui zhi.

This formula combines warm and cold herbs, dispersing and draining herbs, creating a regulating effect that helps the body remove the obstruction and regain healthy movement.

Modifications

If the heat factor is not dominant, you can remove mang xiao. If the stools are soft or there is diarrhea, mang xiao should also be removed. Da huang should not be removed because it is significant for stimulating blood flow in the lower abdomen, and its laxative properties are not significant without mang xiao and in combination with the rest of the herbs of the formula.

If the blood stagnation is more pronounced, blood invigorators can be added in accordance to the clinical manifestation of the stagnation. In my opinion, modifications should be simple and straightforward. For example, when the blood stagnation manifests in uterine cramping yi mu cao and chi shao can be added.