夫伤寒蓄血者。在下焦结聚而不行。蓄积而不散者是也。血菀于上而吐血者。谓之薄厥。
留于下而瘀者。谓之蓄血。此由太阳随经瘀热在里。血为热所搏。结而不行。蓄于下焦之所
致。经曰。太阳病。六七日。表证仍在。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。抵当汤主之者是也。大抵看伤寒。必先观两目。次看
口舌。然自心下至少腹。以手摄按之。觉有满硬者。则当审而治之。如少腹觉有硬满。
问其小便。若小便不利者。则是津液留结。可利小便。若小便自利者。则是蓄血之证。可下
瘀血。经曰。伤寒有热。少腹满。应小便不利。今反利者。为有血也。太阳病。身黄。脉沉
结。少腹硬。小便不利者。为无血也。小便自利。其人如狂者。血证谛也。皆须抵当丸之愈。
阳明病。其人喜忘。屎虽硬。大便反易。其色必黑。亦是蓄血之证。蓄血于下。所以如狂者
。经谓热结膀胱。其人如狂者是也。血瘀于下。所以喜忘者。内经曰。血并于下。乱而喜忘
者是也。二者。若有其一。则为蓄血证明矣。蓄血之证又有轻重焉。如狂也。喜忘也。皆蓄
血之甚者。须抵当汤丸以下之。如外已解。但少腹急结者。则为蓄血之轻者。须桃仁承气汤
以利之。医妙者何也。在乎识形证。明脉息。晓虚实。知转变。其于形证之明者。众人所共
识。又何以见其妙秘也。形证之参差。众人所未识。独先识之。乃所以为妙。且如病患无表
里证。发热七八日。虽脉浮数者。可下之。假令以下。脉数不解。合热则消谷善饥。至六七
日不大便者。此有瘀血。抵当汤主之。当不大便。六七日之际。又无喜忘如狂之证。亦无少
腹硬满之候。当是之时。与承气汤下者多矣。独能处以抵当汤下之者。是为医之妙者也。若
是者。何以知其有蓄血也。且脉浮而数者。浮则伤气。数则伤血。热客于气。则脉浮。热客
于血。则脉数。因下之后。浮数俱去。则已。若下之后。数去。其脉但浮者。则荣血间热去
。而卫气间热在矣。为邪气留心。则饥。邪热不杀谷。潮热发渴也。及下之后。浮脉去。而
数不解者。则卫气间热去。而荣血间热在矣。热则气合覆。血乃下行。胃虚协热。热消谷
。善饥。血至下焦。若下不止。则血得以出泄。必便脓血也。若不大便六七日。则血不得出
泄。必蓄在下焦。为瘀血。是须抵当汤下之。又伤寒留蓄恶血。内外俱热。昏愦谵语。亦有
耳聋虚鸣之证。与少阳经受病相似。如服小柴胡汤不效。当以黄连一分。赤茯苓半分。锉细
。入灯心煎与之。男女通用。凡大小产。热入血室。小柴胡汤力所不及者。于内加五灵脂。
仍以黄连赤茯苓汤佐之。盖心主血。黄连、茯苓皆清心凉血之剂。所以收功。若夫疏利血毒
。则活人书桃仁承气汤。有余勇矣。
方
大黄芍药汤（出圣济总录）治伤寒太阳病。随经入里。瘀热内积蓄血。喜忘如
狂。
大黄（锉炒五钱） 芍药 牡丹皮 犀角（镑生用各一两） 生干地黄（两半） 上锉
如麻豆
大。每服五钱。用水二盏。煎至一盏。去滓。温服。
大黄汤（出圣济总录）治伤寒内有瘀血。大便不利。小便急痛。
大黄（锉炒一两） 桃仁（汤浸去皮尖双仁麸炒黄研半两） 水蛭（米炒黄一两） 木
通（半
两锉） 上除桃仁外。粗捣筛。入桃仁同研令均。每服二钱。以水一盏。煎至七分。去滓。
温服
犀角地黄汤 治伤寒及温病。应发汗而不汗。内蓄为瘀血。及鼻衄血也。吐血不
尽。余血停留。致面黄。大便黑。
犀角（一两） 生地黄（六两） 芍药（三两） 牡丹皮（二两） 上 咀。水九升。
煮三升。
分三服。有热如狂者。加黄芩、大黄。腹不满。为无热。不可加。升麻与犀角。性味主治不
同。何以升麻代之。以是知引入阳明也。兼治疮疹。
芍药地黄汤 治伤寒发热疹出血。并有积。喜忘如狂。鼻衄面黄。大便黑者。
芍药 生地黄 黄芩 牡丹皮（各五钱） 上以水六升。煮取三升。去滓。温服一升。
日
三。时行本有蓄血者。腹胁满如鼓。
伤寒蓄血证，是指血液在下焦部位结聚而运行不畅，积聚不散的病症。血液郁积于上部导致吐血的，称为薄厥。瘀血留滞于下部导致的，称为蓄血。这通常是由于太阳经受邪，邪气随经入里，形成瘀热内结，血液被热邪搏结，凝结而不行，蓄积在下焦所致。《内经》说：患太阳病六七天，表证仍然存在，脉象微而沉，反而没有结胸的症状，病人出现发狂的表现，这是因为热邪在下焦。少腹部应当硬满，小便自通的，通过下血才能痊愈，应用抵当汤治疗，说的就是这种情况。
大抵诊治伤寒病，必须先观察病人的两眼，其次看口舌。然后从心下至少腹，用手按压触摸，如果感觉有胀满坚硬感的，就应当仔细审察并施治。如果少腹部感觉硬满，询问其小便情况，若小便不通利的，这是津液留滞结聚，可以用利小便的方法治疗；若小便自通的，这是蓄血证的典型表现，可以用攻下瘀血的方法治疗。《内经》说：伤寒发热，少腹胀满，按理应该小便不利，现在反而通利，说明是有瘀血存在。太阳病，身体发黄，脉象沉涩，少腹硬满，小便不利的，是无瘀血；小便通利，病人像发狂一样的，是血证的确凿证据，都需要用抵当丸才能治愈。阳明病，病人容易健忘，大便虽然干硬，但排便反而容易，颜色必定发黑，这也是蓄血证的表现。瘀血蓄积在下部，所以会出现像发狂的症状，《内经》称之为热结膀胱，病人像发狂一样。瘀血蓄积在下部，所以会出现健忘的症状，《黄帝内经》说：血气并走于下部，神志混乱而容易健忘，说的就是这个道理。这两种情况，只要具备其中一种，就可以确诊为蓄血证了。
蓄血证又有轻重之分。像发狂、健忘，都是蓄血证中较重的，必须用抵当汤或抵当丸来攻下。如果表证已解，只是少腹急迫拘结的，则是蓄血证较轻的，需要用桃仁承气汤来通利。医生的高明之处在哪里呢？在于能识别形证，明了脉息，知晓虚实，懂得病情转变。对于明显的形证，众人都能识别，又怎能体现其妙处秘奥呢？只有对错综复杂的形证，众人不能识别时，唯独医生能预先识别，这才是高明的地方。况且如病人没有明显的表证或里证，发热七八天，即使脉象浮数，也可以用下法。假如用了下法后，脉数不解，合而为热，则消谷善饥，到了六七天不大便的，这是有瘀血，应用抵当汤治疗。正当六七天不大便之际，又没有健忘、发狂的症状，也没有少腹硬满的征候，这个时候，用承气汤攻下的情况很多。唯独能处以抵当汤攻下的，这才是医家的妙处所在。
如果是这样，怎么知道他有蓄血呢？且脉浮而数，浮脉伤气，数脉伤血。热邪客于气分，则脉浮；热邪客于血分，则脉数。因为用了下法之后，浮数和数脉都消失了，那就没事了。如果下法之后，数脉去了，脉只剩下浮象，那么营血间的余热已去，而卫气间的余热还在。邪气留恋，就会感到饥饿，邪热不能腐熟水谷，会出现潮热、口渴。等到下法之后，浮脉去了，而数脉仍不解，那么卫气间的余热已去，而营血间的余热仍在。热邪使气机壅覆，血乃下行。胃虚协热，热消谷，故善饥。血至下焦，如果下利不止，则血得以泄出，必然排出脓血。如果六七天不大便，则血不得泄出，必然蓄积在下焦，成为瘀血，这时必须用抵当汤攻下。
另外，伤寒留蓄恶血，内外俱热，神志昏愦谵语，也有耳聋耳鸣的症状，与少阳经受病相似。如果服用小柴胡汤无效，应当用黄连一分、赤茯苓半分，锉细，加入灯心草煎服，男女通用。凡是大小产，热入血室，小柴胡汤力量不及的，在里面加入五灵脂，仍以黄连赤茯苓汤辅助治疗。因为心主血，黄连、茯苓都是清心凉血的药物，所以能收效。至于疏利血毒，则《活人书》中的桃仁承气汤，更有余力。
方剂：
大黄芍药汤（出自《圣济总录》），治疗伤寒太阳病，邪气随经入里，瘀热内积蓄血，表现为健忘、像发狂一样。
大黄（锉碎炒制五钱）、芍药、牡丹皮、犀角（镑片生用各一两）、生干地黄（一两半）。以上药材锉如麻豆大小，每服五钱，用水二盏，煎至一盏，去渣，温服。
大黄汤（出自《圣济总录》），治疗伤寒内有瘀血，大便不利，小便急痛。
大黄（锉碎炒制一两）、桃仁（汤浸去皮尖双仁麸炒黄研半两）、水蛭（米炒黄一两）、木通（半两锉）。除桃仁外，粗捣筛，加入桃仁同研均匀。每服二钱，以水一盏，煎至七分，去渣，温服。
犀角地黄汤，治疗伤寒及温病，应当发汗而未发汗，内蓄为瘀血，以及鼻衄、吐血不尽，余血停留，导致面色黄，大便黑。
犀角（一两）、生地黄（六两）、芍药（三两）、牡丹皮（二两）。以上药材切碎，用水九升，煮取三升，分三次服用。如果有热像发狂的，加黄芩、大黄。腹部不满，为无热，不可加。升麻与犀角，性味主治不同，为何用升麻替代？以此可知是引入阳明经。兼治疮疹。
芍药地黄汤，治疗伤寒发热疹出血，并有积滞，健忘像发狂，鼻衄面黄，大便黑的。
芍药、生地黄、黄芩、牡丹皮（各五钱）。以上用水六升，煮取三升，去渣，温服一升，每日三次。时行病本有蓄血者，腹胁满如鼓。
Blood stasis in cold damage refers to the condition where blood accumulates and fails to circulate freely in the lower jiao (lower burner), resulting in stagnation without dispersion. When blood is depressed in the upper part causing hematemesis, it is called Bo Jue (Thin Convulsion). When blood stasis remains in the lower part, it is called Xu Xue (Accumulated Blood). This is caused by the Taiyang channel syndrome, where pathogenic factors follow the channels into the interior, forming stagnant heat within. The blood is constrained by the heat, condenses and fails to move, accumulating in the lower jiao. The Classics state: In Taiyang disease, after six or seven days, if the exterior syndrome persists, the pulse is faint and deep, there is no chest binding, but the patient becomes manic due to heat in the lower jiao. The lower abdomen should be hard and full; if urination is normal, healing occurs through the discharge of blood, treated with Shuidang Tang (Dredge the Dam Decoction). Generally, when diagnosing cold damage, one must first observe the eyes, then inspect the mouth and tongue. Then, palpate from the epigastrium down to the hypogastrium; if hardness and fullness are felt upon pressure, careful treatment is required. If the lower abdomen feels hard and full, inquire about urination. If urination is difficult, it indicates fluid retention and obstruction, treatable by promoting urination. If urination is normal, it indicates accumulated blood, treatable by purging blood stasis. The Classics state: In cold damage with fever and a full lower abdomen, urination should be difficult; if it is now normal, it indicates blood presence. In Taiyang disease, with yellowing of the body, a deep and choppy pulse, and a hard lower abdomen, if urination is difficult, there is no blood stasis; if urination is normal and the patient appears manic, the blood syndrome is confirmed, requiring Shuidang Wan (Dredge the Dam Pill) for cure. In Yangming disease, if the patient suffers from forgetfulness, although stools are hard, defecation is easy and the color is black, this is also a sign of accumulated blood. Blood stasis in the lower part causes mania, described as heat binding in the bladder. Forgetfulness is caused by blood stasis in the lower part, as stated in the Inner Canon: "When blood gathers in the lower part, confusion and forgetfulness occur." Either of these confirms the diagnosis of accumulated blood. Accumulated blood varies in severity. Mania and forgetfulness indicate severe cases, requiring Shuidang Tang or Shuidang Wan to purge. If the exterior is resolved but only the lower abdomen is urgently knotted, it is a mild case, treated with Tao Ren Cheng Qi Tang (Peach Kernel Decocture to Order the Qi). The subtlety of a physician lies in recognizing syndromes, understanding pulses, knowing deficiency and excess, and grasping transformations. Obvious syndromes are recognized by all; true skill is shown in recognizing complex syndromes others miss. For instance, if a patient has no clear exterior or interior signs but has had fever for seven or eight days, even with a floating and rapid pulse, purgation may be used. If after purgation the rapid pulse persists, combined heat causes hunger and easy digestion; if after six or seven days there is no bowel movement, this indicates blood stasis, treated with Shuidang Tang. At this time, without forgetfulness, mania, or lower abdominal hardness, many would use Cheng Qi Tangs; using Shuidang Tang alone demonstrates medical skill. How do we know there is blood stasis? A floating pulse damages Qi, a rapid pulse damages Blood. Heat in Qi causes a floating pulse; heat in Blood causes a rapid pulse. After purgation, if both disappear, it is fine. If the rapid pulse disappears but the floating remains, heat in Ying Blood is gone, but heat in Wei Qi remains. Lingering pathogenic heat causes hunger, inability to digest food, tidal fever, and thirst. If after purgation the floating pulse disappears but the rapid pulse remains, heat in Wei Qi is gone, but heat in Ying Blood remains. Heat causes Qi to cover and Blood to descend. With deficient Stomach and協 heat, digestion accelerates causing hunger. Blood reaches the lower jiao; if diarrhea persists, blood is discharged as pus and blood. If no bowel movement for six or seven days, blood cannot discharge, accumulates in the lower jiao as stasis, requiring Shuidang Tang. Additionally, lingering evil blood in cold damage causes internal and external heat, confusion, delirium, and tinnitus, resembling Shaoyang channel disease. If Xiao Chai Hu Tang is ineffective, use Huang Lian (Coptis Rhizome) 1 part, Chi Fu Ling (Red Poria) 0.5 parts, finely cut, decocted with Deng Xin Cao (Juncus Effusus Stem). Suitable for both genders. For postpartum heat entering the Blood Chamber where Xiao Chai Hu Tang is insufficient, add Wu Ling Zhi (Trogopterus Dung) and support with Huang Lian Chi Fu Ling Tang. Since the Heart governs Blood, Huang Lian and Fu Ling clear Heart heat and cool Blood. To drain blood toxins, Tao Ren Cheng Qi Tang from *Ren Shu* is more potent.
Formulas:
Da Huang Shao Yao Tang (from *Sheng Ji Zong Lu*) treats Taiyang cold damage where pathogens enter the interior, causing stagnant heat and accumulated blood, with forgetfulness and mania.
Da Huang (cut and stir-fried, 5 qian), Shao Yao (Peony Root), Mu Dan Pi (Moutan Cortex), Xi Jiao (Rhinoceros Horn - substitute with water buffalo horn in modern practice), Sheng Gan Di Huang (Prepared Rehmannia Root). Cut like hemp seeds. Take 5 qian per dose, decoct in 2 cups of water to 1 cup, strain, and take warm.
Da Huang Tang (from *Sheng Ji Zong Lu*) treats cold damage with internal blood stasis, difficult defecation, and painful urgent urination.
Da Huang (cut and stir-fried, 1 liang), Tao Ren (Peach Seed, soaked, peeled, halved, bran-fried, ground, 0.5 liang), Shui Zhi (Leech, rice-fried, 1 liang), Mu Tong (Akebia Caulis, 0.5 liang). Coarsely crush except Tao Ren, mix with ground Tao Ren. Take 2 qian per dose, decoct in 1 cup of water to 0.7 cup, strain, and take warm.
Xi Jiao Di Huang Tang treats cold damage and warm diseases where sweating was indicated but not performed, leading to internal blood stasis, epistaxis, incomplete hematemesis, residual blood stagnation, yellow complexion, and black stools.
Xi Jiao (1 liang), Sheng Di Huang (Fresh Rehmannia Root, 6 liang), Shao Yao (3 liang), Mu Dan Pi (2 liang). Cut, decoct in 9 sheng of water to 3 sheng, divide into three doses. If heat causes mania, add Huang Qin (Scutellaria Root) and Da Huang (Rhubarb Root). If abdomen is not full, there is no heat, do not add. Sheng Ma (Cimicifuga Rhizome) differs from Xi Jiao in nature and action; its substitution guides the formula to the Yangming channel. Also treats sores and rashes.
Shao Yao Di Huang Tang treats cold damage with fever, rash bleeding, accumulation, forgetfulness, mania, epistaxis, yellow face, and black stools.
Shao Yao, Sheng Di Huang, Huang Qin, Mu Dan Pi (each 5 qian). Decoct in 6 sheng of water to 3 sheng, strain, take 1 sheng warm, three times daily. For epidemic diseases with existing accumulated blood, presenting with abdominal and hypochondriac fullness like a drum.