【纲】仲景曰。太阳病。六七日。表症仍在。而反下之。脉微而沉。反不结胸。其人发狂者。
以热在下焦。少腹当硬满。小便自利者。下血乃愈。所以然者。以太阳随经瘀热在里也。抵当汤主
之。太阳病。脉沉结。少腹硬。小便自利。其人如狂者。血结症也。抵当汤主之。伤寒有热。少腹
满。应小便不利。今反利者。为有血也。当下之。不可余药。宜抵当丸。太阳病不解。热结膀胱。其人如狂。血自下。
下者愈。其外不解者。尚未可攻。当先解外。外解已。但少腹急结。乃可攻之。宜桃仁承气
汤。
【目】朱肱曰。太阳症。下焦有热。少腹必满。应小便不利。而小便反利者。下血症也。抵当汤。
张介宾曰。观仲景诸论。则知伤寒蓄血者。以热结在里。抟于血分。留于下焦而不行。故易生
烦躁也。然又有阳明症喜忘。亦为蓄血之症。故诊伤寒。但见少腹硬满而痛。盒饭问其小便。若小
便自利者。知为蓄血之症。盖小便由于气化。病在血而不在气。故小便利而无恙也。血瘀于下者。
血去则愈。其在仲景。则以抵当汤丸主之。愚谓但以承气之类加桃仁、红花以逐之。或其兼虚者。
以玉烛散下之。则蓄血自去。而病无不除矣。
柯琴曰。此亦太阳病误下热入之症也。太阳病。六七日不解。脉反沉微。宜四逆汤救之。此因
误下。热邪随经入腑。结于膀胱。故少腹硬满而不结胸。小便自利而不发黄也。太阳经少气而多血。
病六七日而表症仍在。阳气重可知。阳极则扰阴。故血燥而蓄于中耳。血病。则知觉昏昧。故发
狂。此经病传腑。表病传里。气病传血。上焦病而传下焦也。少腹居下焦。为膀胱之室。厥阴脉所
聚。冲任血海所由。瘀血留结故硬满。然下其血而气自舒。攻其里而表自解矣。沉为在里。凡下后
热入之症。燥血结于膀胱而发狂。营气不敷之故也。有热。即表症仍在。少腹但满而未硬。其人未发
狂。只以小便自利。预知其为有蓄血。故小其制而丸以缓之。阳气太重。标本俱病。故如狂。血得
热则行。故尿血。血下则不结。故愈。冲任之血会少腹。热极则血不下而反结。散结先发表。而用
桃仁承气。不用抵当者。以少腹未硬满也。首条。以反不结胸句。知其为下后症。末条。以尚未可
攻句。知其为未下症。结急者易解。只须承气。硬满者不易解。必仗抵当。
李中梓曰。少阴下血。桃花汤。腹满身热下脓血。黄连阿胶汤、地榆散。
王肯堂曰。按犀角地黄汤以治上血。如吐血衄血是也。桃仁承气汤以治中血。如蓄血中焦不
利脓血是也。抵当汤
丸以治下血。如血症如狂之类是也。上中下三焦。各有主治。此条当作三症看。起至下者愈。是一
症。至当先解外。是一症。盖其人如狂。是下焦血。非桃仁承气症也。自外解至末。又是一症。恐
是下只去得下焦血。而中焦道远。未能尽去。故尚留于少腹耳。又抵当汤丸。其中虻虫、水蛭。性
为猛厉。不若四物汤加酒浸大黄各半下之为妙。
【纲要】张仲景说：太阳病，经过六七天，表证仍然存在，反而误用泻下法，脉象微而沉，反而没有形成结胸证。病人出现发狂的症状，这是因为热邪在下焦。少腹部应当坚硬胀满，如果小便通畅自如，那么通过泻下瘀血才能痊愈。之所以这样，是因为太阳经的邪热随经脉内陷，瘀热结聚在体内。主治方剂为抵当汤。
太阳病，脉象沉而结滞，少腹部坚硬，小便通畅，病人神情如狂，这是血结证。主治方剂为抵当汤。
伤寒发热，少腹部胀满，按理说应该小便不利，现在反而小便通利，这是有瘀血的表现。应当攻下瘀血，不可使用其他药物，适宜用抵当丸。
太阳病未解，热邪结聚于膀胱，病人神情如狂。如果瘀血能自行排出，病就会好。如果表证仍未解除，则暂时不可攻里，应当先解表。待表证解除后，仅见少腹部急迫结聚，才可以攻下瘀血，适宜用桃仁承气汤。
【注释】朱肱说：太阳病，下焦有热，少腹部必然胀满。按理说应该小便不利，而小便反而通利，这是下血证（蓄血证）。宜用抵当汤。
张介宾说：观察张仲景的各种论述，可知伤寒蓄血证，是由于热邪结聚在体内，搏结于血分，留滞于下焦而不能运行，所以容易产生烦躁。然而又有阳明病喜忘（健忘）的症状，也属于蓄血证的表现。所以在诊断伤寒时，只要见到少腹部坚硬胀满且疼痛，就应当询问其小便情况。如果小便自利，就知道是蓄血证。因为小便的通利依赖于气化功能，病在血分而不在气分，所以小便通利而无碍。瘀血停滞在下焦，瘀血去除则病愈。对于张仲景的治法，主要使用抵当汤和抵当丸。我认为只需使用承气汤类方剂加入桃仁、红花来逐瘀；或者对于兼有虚证的患者，使用玉烛散攻下，那么蓄血自然去除，疾病无不清除。
柯琴说：这也是太阳病误用下法导致热邪内入的证候。太阳病，经过六七天未解，脉象反而沉微，本应使用四逆汤急救阳气。这里是因为误用下法，热邪随经脉进入腑中，结聚于膀胱，所以少腹部坚硬胀满而不形成结胸证，小便通利而不发黄。太阳经气少而血多，患病六七天而表证仍在，可知阳气亢盛至极。阳极则扰动阴分，所以血液干燥而蓄积在中焦。血病则知觉昏昧，所以发狂。这是经病传变为腑病，表病传变为里病，气病传变为血病，上焦病传变为下焦病。少腹位于下焦，是膀胱所在之处，也是厥阴经脉汇聚之地，冲任二脉作为血海由此而出。瘀血留滞结聚，所以坚硬胀满。然而，攻下瘀血则气机自然舒畅，攻逐里实则表证自然解除。脉沉表示病在里。凡是误下后热邪内入的证候，燥血结聚于膀胱而发狂，是因为营气不能敷布所致。如果有热，即表证仍在，少腹部只是胀满而未坚硬，病人尚未发狂，只凭小便自利，预先判断其为有蓄血，所以减小药量制成丸剂以缓和药势。如果阳气太重，标本俱病，所以表现为如狂（似狂非狂）。血得热则运行，所以会出现尿血，瘀血下行则不结聚，所以病愈。冲任之血会聚于少腹，热极则血液不下行反而结聚。此时应先解散表结，所以使用桃仁承气汤。不用抵当汤的原因，是因为少腹部尚未坚硬胀满。第一条原文，通过“反不结胸”一句，知道这是误下后的证候；最后一条，通过“尚未可攻”一句，知道这是尚未误下的证候。少腹急结者容易化解，只需使用承气汤；少腹硬满者不易化解，必须依靠抵当汤。
李中梓说：少阴病下血，用桃花汤；腹部胀满、身热、下脓血，用黄连阿胶汤或地榆散。
王肯堂说：按犀角地黄汤治疗上焦出血，如吐血、衄血等。桃仁承气汤治疗中焦出血，如蓄血在中焦不利、便脓血等。抵当汤和抵当丸治疗下焦出血，如蓄血证、如狂等症状。上、中、下三焦各有主治。这一条文应当看作三个证候来看。从开头到“下者愈”，是一个证候；到“当先解外”，是另一个证候。大概病人如狂，是下焦血热，不属于桃仁承气汤证。从表解之后到最后，又是一个证候。恐怕是之前的攻下只去除了下焦的血，而中焦距离较远，未能完全清除，所以仍有残留于少腹。另外，抵当汤和抵当丸中的虻虫、水蛭，药性猛烈严厉，不如使用四物汤加上酒浸大黄各半同用更为巧妙。
[Outline] Zhang Zhongjing stated: In Taiyang disease (Taiyang syndrome), after six or seven days, if the exterior syndrome persists and purgation is mistakenly applied, the pulse becomes faint and deep. If there is no formation of Jie Xiong (chest binding syndrome) but the patient exhibits mania, it is due to heat in the Lower Jiao (lower abdomen/organ region). The lower abdomen should be hard and full. If urination is normal, healing occurs only after bloodletting/purging blood. This is because the pathogenic heat of the Taiyang channel has followed the meridians inward, resulting in stasis-heat accumulation within. The principal formula is Didang Tang (Resist Decoction).
In Taiyang disease, if the pulse is deep and knotted, the lower abdomen is hard, urination is normal, and the patient appears delirious-like, this is a Blood Stasis Syndrome. The principal formula is Didang Tang (Resist Decoction).
In Shanghan (Cold Damage) with fever, if the lower abdomen is full, one would expect difficulty in urination; however, if urination is now free, it indicates the presence of blood stasis. It should be purged. Do not use other medicines; Didang Wan (Resist Pill) is appropriate.
If Taiyang disease remains unresolved and heat accumulates in the Bladder, causing the patient to appear delirious-like, spontaneous passage of blood leads to recovery. If the exterior syndrome is not yet resolved, internal attack is contraindicated; one must first resolve the exterior. Once the exterior is resolved, if only urgency and binding in the lower abdomen remain, then an attack on the interior is permissible. Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction) is appropriate.
[Commentary] Zhu Gong stated: In Taiyang syndrome, if there is heat in the Lower Jiao, the lower abdomen must be full. One would expect difficulty in urination, but if urination is free, it is a Lower Bleeding Syndrome (Blood Accumulation Syndrome). Didang Tang (Resist Decoction) is indicated.
Zhang Jiebin stated: Observing Zhang Zhongjing's various discussions, we know that Blood Accumulation in Shanghan results from heat accumulating internally, condensing into the blood level, and stagnating in the Lower Jiao without moving, thus easily generating irritability. However, forgetfulness (Xi Wang) in Yangming syndrome is also a manifestation of Blood Accumulation. Therefore, when diagnosing Shanghan, upon seeing hardness, fullness, and pain in the lower abdomen, one must inquire about urination. If urination is free, it is known as Blood Accumulation. Since urination depends on Qi transformation, and the pathology is in the blood rather than Qi, urination remains unimpeded. When blood stasis resides in the lower part, removing the blood leads to recovery. Regarding Zhang Zhongjing's methods, he primarily used Didang Tang (Resist Decoction) and Didang Wan (Resist Pill). I suggest using formulas like Cheng Qi Tang (Magnitude Borne Down Decoction) added with Tao Ren (Peach Kernel) and Hong Hua (Safflower) to expel stasis; or for those with concomitant deficiency, using Yu Zhu San (Jade Candle Powder) to purge, thereby eliminating blood accumulation and curing the disease.
Ke Qin stated: This is also a syndrome where heat enters the interior due to mistaken purgation in Taiyang disease. In Taiyang disease, if unresolved after six or seven days, and the pulse becomes faint and deep, Si Ni Tang (Frigid Extremities Decoction) should ideally be used to rescue Yang. Here, due to mistaken purgation, heat follows the meridians into the Fu organs, accumulating in the Bladder, causing hardness and fullness in the lower abdomen without forming Jie Xiong, and allowing free urination without jaundice. The Taiyang channel has little Qi and much Blood. With the exterior syndrome persisting after six or seven days, extreme Yang excess is evident. Extreme Yang disturbs Yin, causing blood dryness and accumulation in the middle. Blood pathology causes mental confusion, leading to mania. This represents the transmission of Jing disease to Fu disease, exterior to interior, Qi to Blood, and Upper Jiao to Lower Jiao. The lower abdomen resides in the Lower Jiao, is the chamber of the Bladder, the gathering place of the Jueyin channel, and the origin of the Chong and Ren vessels as the Sea of Blood. Stagnant blood accumulation causes hardness and fullness. However, purging the blood allows Qi to relax, and attacking the interior resolves the exterior. A deep pulse indicates interior pathology. In all cases of heat entering the interior after purgation, dry blood accumulating in the Bladder causing mania is due to the failure of Ying Qi (Nutritive Qi) to distribute. If there is heat, meaning the exterior syndrome persists, and the lower abdomen is merely full but not hard, and the patient has not yet become manic, the free urination alone predicts blood accumulation. Thus, the dosage is reduced and made into pills to act gently. If Yang Qi is excessively heavy and both root and branch are diseased, the patient appears delirious-like. Blood moves with heat, so hematuria may occur; if blood passes, it does not accumulate, so recovery ensues. Chong and Ren blood converges in the lower abdomen; extreme heat causes blood to fail to descend and instead accumulate. To scatter accumulation, one must first release the exterior, hence using Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction). Didang Tang (Resist Decoction) is not used because the lower abdomen is not yet hard and full. The first clause, by mentioning "contrarily no Jie Xiong," indicates a post-purgation syndrome. The last clause, by mentioning "not yet ready to attack," indicates a pre-purgation state. Urgency and binding are easy to resolve, requiring only Cheng Qi Tang; hardness and fullness are difficult to resolve, requiring reliance on Didang Tang.
Li Zhongzi stated: For Lower Shaoyin bleeding, Tao Hua Tang (Peach Blossom Decoction) is used. For abdominal fullness, fever, and passage of pus and blood, Huang Lian E Jiao Tang (Coptis and Donkey-Hide Gelatin Decoction) or Di Yu San (Sanguisorba Powder) are used.
Wang Kentang stated: Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) treats upper bleeding, such as hematemesis and epistaxis. Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction) treats middle bleeding, such as blood accumulation in the middle Jiao causing obstruction and passage of pus and blood. Didang Tang (Resist Decoction) and Didang Wan (Resist Pill) treat lower bleeding, such as blood accumulation syndromes and delirium-like states. The Upper, Middle, and Lower Jiao each have their specific treatments. This text should be viewed as three distinct syndromes. From the beginning to "passage of blood leads to recovery" is one syndrome. Up to "must first resolve the exterior" is another syndrome. Presumably, the delirium-like state indicates Lower Jiao blood heat, which is not a Tao Ren Cheng Qi Tang syndrome. From the resolution of the exterior to the end is yet another syndrome. It is feared that previous purgation only removed Lower Jiao blood, while the Middle Jiao is distant and not fully cleared, leaving residue in the lower abdomen. Furthermore, the Leech (Meng Chong) and Leech (Shui Zhi) in Didang Tang/Wan have fierce properties; it is more ingenious to use Si Wu Tang (Four Substances Decoction) added with wine-steeped Da Huang (Rhubarb Root and Rhizome) at half doses.