身黄如狂屎黑喜忘皆蓄血之证也许学士云血在上则喜忘在下则发狂
成 血留下焦而瘀者蓄血也大抵伤寒先看面目
次观口舌次观心下至少腹以手揣之若少腹硬满若小便不利者是津液留结可利小便若小便自利者是蓄血证可下瘀血其阳
明病有蓄血而喜忘者证之甚也宜抵当汤太阳有热结膀胱如狂者证之轻也宜桃仁承气汤经云病患无表里证发热七八日脉
虽浮数可下之假令已下脉数不解胃热则消谷善饥至六七日不大便者此有瘀血抵当汤主之若脉数不解而下不止必协热而
便脓血也此证当不大便六七日之际又无喜忘如狂并少腹硬满之候与承气下者多矣何以知为蓄血盖脉浮而数浮则热伤气
数则热伤血因下之后浮数俱去则已若下后数去而脉但浮者则荣血间热去并于卫气间热心中则饥也邪热不杀谷则有潮热
发渴之证也及下之后浮去而数不解者则卫气间热去合于荣血间之热热气合并逼血下行胃虚协热消谷善饥血至下焦若下
不止则血得以去泄必便脓血也若不大便六七日则血不得出泄蓄在下焦为瘀血须抵当汤下之此实证之奇异治法之元微也
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所以然者以太阳
随经瘀热在里故也抵当汤主之（成 太阳经也膀胱府也此太阳瘀热随经入腑者也六七日者邪气传里之时也脉微而沉邪气
在里之脉也表证仍在者则邪气犹浅当结于胸中若不结于胸中其人发狂者热结在膀胱也经曰热结膀胱其人如狂此发狂则
热又深也少腹硬满小便不利者为无血也小便自利者血证谛也与抵当汤以下蓄血案坑仍在字则邪气为不传于里非犹浅也
膀胱为太阳本经曰热在下焦曰少腹硬满曰小便自利皆膀胱之证故总结曰随经瘀热也在里二字要看得活非三阴之里乃随
经膀胱之里也）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抵当汤主之（身黄脉沉结少
腹硬小便不利者胃热发黄也可与茵陈汤身黄脉沉结少腹硬小便自利其人如狂者非胃中瘀热为热结下焦而为蓄血也与抵
当汤以下蓄血）
抵当汤方
水蛭（三十个熬） 虻虫（三十个去足翅熬） 桃仁（二十个去皮尖） 大黄（酒浸三两）上四味为末以水五升煮
取三升去滓温服一升不下再服（苦走血咸胜血虻虫水蛭之咸苦以除蓄血甘缓结苦泄热桃仁大黄之甘苦以下结热）人之所
有者气与血也气为阳气留而不行者则易散以阳病易治故也血为阴血蓄而不行者则难散阴病难治故也血蓄于下非大毒驶
剂则不能抵当故治蓄血曰抵当汤内经曰咸胜血血蓄于下必以咸为主故以水蛭咸寒为君苦走血血结不行必以苦为助是以
虻虫苦寒为臣肝者血之源血聚则肝气燥肝苦急食甘以缓之散血缓肝是以桃仁味苦甘平为佐大黄味苦寒湿气在下以苦泄
之血亦湿类也荡血逐热是以大黄为使四物相合虽苛毒重病亦获全济
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成 伤寒有热少腹满是蓄血于下焦若热蓄
津液不通则小便不利其热不蓄津液而蓄血不行小便自利者乃为蓄血当与桃仁承气汤抵当汤下之然此无身黄屎黑又无喜
忘发狂是未至于甚故不可与其余驶峻之药也可与抵当丸小可下之也案身黄屎黑喜忘发狂亦是推展之词若根据上文只是满
而不硬耳）
抵当丸方
水蛭（二十个） 虻虫（二十五个） 桃仁（二十个去皮尖） 大黄（三两）上四味杵分为四丸以水一升煮一丸取
七合服之 时当下血若不下者更服
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者乃可攻之宜桃核承
气汤（按犀角地黄汤以治上血如吐血衄血为上血也桃仁承气汤治中血如蓄血中焦下利脓血之类为中血也抵当汤丸治下焦
血如血证如狂之类是下血也上中下三焦各有主治此条当作三证看至下者愈是一证谓其血自下也疑有缺文至当先解外是
一证盖其人如狂是下焦血非桃仁承气证也自外解至末又是一证恐是自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妙见汤液本草水蛭条下）
桃核承气汤方
桃仁（五十个去皮尖） 桂枝（去粗皮） 芒硝 甘草（炙各二两） 大黄（四两）上五味以水七升煮取二升半去
滓纳芒硝更上火微沸下火先食温服五合日三服当微利（甘以缓之辛以散之少腹急结缓以桃仁之甘下焦蓄血散以桂枝辛热
之气寒以取之热甚搏血故加二物于调胃承气汤中也按以上证玩之当是桂非桂枝也盖桂枝轻扬治上桂浓重治下成氏随文
顺释未足据）
阳明 阳明证其人喜忘者必有蓄血所以然者本有久瘀血故令喜忘屎虽硬大便反易其色必黑宜抵当汤下之（成 内经
曰血并于下乱而喜忘此下焦本有久瘀血所以喜忘也津液少大便硬以蓄血在内屎虽硬大便反易其色黑也与抵当汤以下瘀
血）
海 初便褐色者重再便深褐色者愈重三便黑色者为尤重色变者以其火燥也如羊血在日色中须臾变褐色久则渐变
而为黑色即此意也当详察之）
病患无表里证发热七八日虽脉浮数者可下之假令已下脉不解胃热则消谷善饥至六七日不大便者有瘀血宜抵当汤若
脉数不解血下不止必协热而便脓血也
成 当不大便六七日之际无喜忘如狂之证又无少腹硬满之候何以知其有蓄血盖以
其脉浮数故也浮则热客于气数则热客于血下后浮数俱去则病已若下后数去而浮仍在则荣血中热去而卫气中热在为邪气
独留心下善饥邪热不杀谷潮热反渴也若下后浮去而数不解则卫气中热去而荣血中热在血热合并迫血下行胃虚协热消谷
善饥血至下焦若下不则止血得以泄必脓血也若不大便六七日则血不得出泄必蓄在下焦为瘀血故须以抵当汤下之
张 或
问攻下之法须外无表证里有下证然后可攻上言无表里证况脉更浮数何故言可下之曰此非风寒之所病是由内伤而致然也
若外不恶寒里无谵语但七八日发热有烁津液乃阳盛阴虚之时苟不攻之其热不已而变生焉故云虽脉浮数可下不待沉实而
攻之夫内伤者经曰趺阳脉浮而数浮则伤胃数则伤脾此非本病医特下之所为也仲景之意不外是理凡伤寒当下之证皆从太
阳阳明在经之邪而入于腑故下之今不言阳明病而止云病患无表里证此非自表之里而病也但为可下故编于阳明篇中学人
宜详玩焉
病者胸满痞痿舌青口燥但漱水不欲下咽无寒热脉微大来迟腹不满其人言我满为有瘀血（海云漱水不咽胸满心下手不
可近者桃仁承气汤主之）病者如热状烦满口干燥而渴其脉反无热此为阴伏是瘀血也当下之
活 前集云伤寒失汗热蓄在里
热化为血其人善忘而如狂血上逆则善忘血下蓄则内急甚者抵当汤丸桃仁承气汤犀角地黄汤取尽黑物为效又云若用抵当
汤丸更宜详慎审其有无表证若有蓄血而外不解亦未可便用宜先用桂枝汤以解外缘热客膀胱太阳经也
吴 凡蓄血者瘀血
留结于内盖伤寒病在太阳当汗不汗则瘀血在里必血结也大抵看伤寒病患心下两胁少腹但有硬满处以手按则痛者盒饭问
其小便何如若小便不利乃水与气也若小便自利者为有血也
陶 以手按之小腹若痛而小水自利大便黑兼或身黄谵妄燥渴
脉沉实者为蓄血桃仁承气汤下尽黑物则愈若按之小腹胀满不硬痛小水不利则溺涩也五苓散加减利之不可大利恐耗减津
液也若按小腹绕脐硬痛渴而小水短赤大便实者有燥屎也大承气汤下之
附
海 血证古人用药虽有轻重之殊而无上下之别今分作上中下三等以衄血呕血唾血吐血为上部血结胸中为中部蓄
血下焦为下部夫既有三部之分故药亦当随其轻重也
汗多为衄血脉浮灸之咽燥为唾血当汗不汗热入于里者为呕血吐血此在上也犀角地黄汤主之凉膈散加生地黄亦可然
衄唾呕吐俱在上亦当以轻重分之大凡血证皆不饮水惟气证则饮之宜详审此证乃足太阴所主脾所不里越而上行所以有吐
血呕血之候也实者犀角地黄汤虚者黄芩芍药汤凡病呕吐者以脾所主故咸用芍药主之是知太阴药也
血结胸中头痛身痛漱水不欲咽者衄无热胸满漱水不欲咽者喜忘昏迷其人如狂心下手不可近者血在中也桃仁承气汤
主之
蓄血下焦其人发狂小腹满硬小便自利大便反黑及脐下疼者抵当汤丸主之如狂者在中发狂者在下抵当汤丸药味同剂
如何是二法盖喜忘发狂身黄屎黑者疾之甚也但小腹满硬小便利者轻也故有汤丸之别桃仁大黄等分水蛭虻虫多者作汤三
之二者作丸丸之名取其数少而缓也故汤用煎服一升丸止服七合也
生地黄汤 病患七八日后两手脉沉细微肤冷脐下满或狂或躁大便实而色黑小便自利者此蓄血证也若老幼气虚
弱者宜此丸主之
生地黄（取自然汁一升如无只用生干地黄二两） 干漆（半两炒烟尽） 生藕（自然汁半升如无藕用剌蓟汁一升半）
蓝叶（一握切细干者用末半升） 虻虫（二十个去翅足麸内炒黄色） 水蛭（十个炒） 大黄（一两锉如豆大） 桃仁
（研碎半两） 上八味同一处入水三升慢火熬及二升放冷分二服先投一服至半日许血未下再投之此汤比抵当汤丸其势甚
轻如无地黄与藕汁照升数添水同煎抵当丸恐用之太过不止损血故以此汤主之
身黄、发狂、大便黑、健忘，都是蓄血证的证候。或许有学者说：血瘀在上焦则健忘，在下焦则发狂。
成无己注：血液留滞于下焦而瘀结的，称为蓄血。大抵诊治伤寒，先看面目，次看口舌，再看心下至少腹，用手触摸探查。如果少腹硬满，且小便不利，这是津液留结，可用利小便的方法；如果小便自利，这是蓄血证，可用攻下瘀血的方法。阳明病有蓄血而见健忘的，是证候严重的，宜用抵当汤（Diding Tang, Diding Decoction）。太阳病有热结膀胱而见如狂症状的，是证候较轻的，宜用桃仁承气汤（Taoren Chengqi Tang, Peach Kernel Modifying the Emissary Decoction）。《内经》云：患者没有表证和里实证，发热七八天，脉象虽然浮数，可以用下法。假如已经用了下法，脉数不解，胃中有热则消谷善饥，到了六七天不大便的，这是有瘀血，用抵当汤主治。如果脉数不解，而下利不止，必定协热而便脓血。此证应当在不大便六七天之际，又没有健忘、如狂以及少腹硬满的征候，与用承气汤攻下的情况不同。怎么知道是蓄血呢？大概因为脉浮而数，浮则热伤气，数则热伤血。因为下之后，浮数和脉象都消失了，病就好了；如果下后脉数消失而脉仍浮，则是营血间的热邪去，并入了卫气间的热邪，心中就会饥饿。邪热不能腐熟水谷，则有潮热、发渴的证候。等到下之后，浮脉去而数脉不解，则是卫气间的热邪去，合并于营血间的热邪，热气合并逼迫血液下行。胃虚协热，消谷善饥，血液至下焦，如果下利不止，则血液得以泄出，必然便脓血。如果不大便六七天，则血液不得出泄，蓄积在下焦成为瘀血，须用抵当汤攻下。这是实证中奇异的治疗方法，也是治疗细微之处的关键所在。
太阳病六七天，表证仍在，脉微而沉，反而不结胸，其人发狂的，是因为热在下焦，少腹应当硬满，小便自利的，下血乃愈。之所以这样，是因为太阳随经传入，瘀热在里的缘故，用抵当汤主治。（成无己注：太阳经也，膀胱腑也，这是太阳瘀热随经入腑的缘故。六七天是邪气传里的时间。脉微而沉是邪气在里的脉象。表证仍在，说明邪气犹浅，应当结于胸中，如果不结于胸中，其人发狂，说明热结在膀胱。《内经》说：热结膀胱，其人如狂，这里发狂，说明热邪又深了。少腹硬满，小便不利，是无血；小便自利，才是血证的确据。与抵当汤以下蓄血。“仍在”二字，说明邪气未传于里，并非犹浅。膀胱为太阳本经，说“热在下焦”、“少腹硬满”、“小便自利”，都是膀胱的证候，所以总结说“随经瘀热在里”。这“在里”二字要看得灵活，不是三阴之里，乃是随经传入膀胱之里。）
太阳病身黄，脉沉结，少腹硬，小便不利的，是无血；小便自利，其人如狂的，是血证的确据，用抵当汤主治。（身黄，脉沉结，少腹硬，小便不利，是胃热发黄，可与茵陈汤。身黄，脉沉结，少腹硬，小便自利，其人如狂，非胃中瘀热，而是热结下焦而为蓄血，与抵当汤以下蓄血。）
抵当汤方
水蛭（三十个，熬） 虻虫（三十个，去足翅，熬） 桃仁（二十个，去皮尖） 大黄（酒浸三两）上四味研为末，用水五升，煮取三升，去滓，温服一升。不下，再服。（苦走血，咸胜血。虻虫、水蛭之咸苦以除蓄血；甘缓结，苦泄热，桃仁、大黄之甘苦以下结热。）人的所有物质中，气和血是主要的。气为阳气，留滞而不行的，容易消散，因为阳病易治，所以如此。血为阴血，蓄积而不行的，难以消散，因为阴病难治，所以如此。血蓄于下，不用大毒峻猛的药，就不能抵挡，所以治疗蓄血叫抵当汤。《内经》说：咸胜血。血蓄于下，必须以咸为主，所以以水蛭咸寒为君药。苦走血，血结不行，必须以苦为助，所以以虻虫苦寒为臣药。肝是血的源头，血聚则肝气燥，肝苦急，食甘以缓之，散血缓肝，所以以桃仁味苦甘平为佐药。大黄味苦寒，湿气在下，以苦泄之，血亦湿类也，荡血逐热，所以以大黄为使药。四物相合，即使是苛毒重病，也能获得全济。
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。（成无己注：伤寒有热，少腹满是蓄血于下焦。若热蓄津液不通，则小便不利；其热不蓄津液而蓄血不行，小便自利者，乃为蓄血。当与桃仁承气汤、抵当汤下之。然此无身黄、屎黑，又无喜忘、发狂，是未至于甚，故不可与其余峻猛之药。可与抵当丸小可下之也。按：身黄、屎黑、喜忘、发狂，亦是推展之词。若根据上文，只是满而不硬耳。）
抵当丸方
水蛭（二十个） 虻虫（二十五个） 桃仁（二十个，去皮尖） 大黄（三两）上四味杵分为四丸，用水一升，煮一丸，取七合服之。时当下血，若不下者，更服。
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，但少腹急结者，乃可攻之，宜桃核承气汤。（按：犀角地黄汤以治上血，如吐血、衄血为上血也；桃仁承气汤治中血，如蓄血、中焦下利脓血之类为中血也；抵当汤丸治下焦血，如血证如狂之类是下血也。上中下三焦各有主治，此条当作三证看。“至下者愈”是一证，谓其血自下也，疑有缺文。“至当先解外”是一证，盖其人如狂是下焦血，非桃仁承气证也。自外解至末又是一证，恐是自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妙，见汤液本草水蛭条下。）
桃核承气汤方
桃仁（五十个，去皮尖） 桂枝（去粗皮） 芒硝 甘草（炙，各二两） 大黄（四两）上五味，用水七升，煮取二升半，去滓，纳芒硝，更上火微沸，下火。先食温服五合，日三服。当微利。（甘以缓之，辛以散之。少腹急结，缓以桃仁之甘；下焦蓄血，散以桂枝辛热之气；寒以取之，热甚搏血，故加二物于调胃承气汤中也。按：以上证玩之，当是桂非桂枝也。盖桂枝轻扬治上，桂浓重治下。成氏随文顺释，未足据。）
阳明证，其人喜忘者，必有蓄血。所以然者，本有久瘀血，故令喜忘。屎虽硬，大便反易，其色必黑，宜抵当汤下之。（成无己注：《内经》曰：血并于下，乱而喜忘。此下焦本有久瘀血，所以喜忘也。津液少，大便硬，以蓄血在内，屎虽硬，大便反易，其色黑。与抵当汤以下瘀血。）
海藏云：初便褐色者重，再便深褐色者愈重，三便黑色者为尤重。色变者，以其火燥也。如羊血在日光中，须臾变褐色，久则渐变而为黑色，即此意也。当详察之。）
病患无表里证，发热七八日，虽脉浮数者可下之。假令已下，脉不解，胃热则消谷善饥，至六七日不大便者，有瘀血，宜抵当汤。若脉数不解，血下不止，必协热而便脓血也。
成无己注：当不大便六七日之际，无喜忘、如狂之证，又无少腹硬满之候，何以知其有蓄血？盖以其脉浮数故也。浮则热客于气，数则热客于血。下后浮数俱去，则病已。若下后数去而浮仍在，则荣血中热去而卫气中热在，为邪气独留心下，善饥，邪热不杀谷，潮热，反渴也。若下后浮去而数不解，则卫气中热去而荣血中热在，血热合并，迫血下行，胃虚协热，消谷善饥，血至下焦，若下不止，则血得以泄，必脓血也。若不大便六七日，则血不得出泄，必蓄在下焦为瘀血，故须以抵当汤下之。
张元素问：攻下之法，须外无表证，里有下证，然后可攻。上言无表里证，况脉更浮数，何故言可下之？答曰：此非风寒之所病，是由内伤而致然也。若外不恶寒，里无谵语，但七八日发热，有烁津液，乃阳盛阴虚之时，苟不攻之，其热不已而变生焉，故云虽脉浮数可下，不待沉实而攻之。夫内伤者，《内经》曰：趺阳脉浮而数，浮则伤胃，数则伤脾。此非本病，医特下之所为也。仲景之意不外是理。凡伤寒当下之证，皆从太阳、阳明在经之邪而入于腑，故下之。今不言阳明病，而止云病患无表里证，此非自表之里而病也，但为可下，故编于阳明篇中学人宜详玩焉。
病者胸满痞痿，舌青，口燥，但漱水不欲咽，无寒热，脉微大来迟，腹不满，其人言我满，为有瘀血。（海藏云：漱水不咽，胸满心下手不可近者，桃仁承气汤主之。）病者如热状，烦满，口干燥而渴，其脉反无热，此为阴伏，是瘀血也，当下之。
李东垣前集云：伤寒失汗，热蓄在里，热化为血，其人善忘而如狂。血上逆则善忘，血下蓄则内急，甚者抵当汤丸、桃仁承气汤、犀角地黄汤，取尽黑物为效。又云：若用抵当汤丸，更宜详慎，审其有无表证。若有蓄血而外不解，亦未可便用，宜先用桂枝汤以解外。缘热客膀胱，太阳经也。
吴崑云：凡蓄血者，瘀血留结于内。盖伤寒病在太阳，当汗不汗，则瘀血在里，必血结也。大抵看伤寒病患，心下、两胁、少腹，但有硬满处，以手按则痛者，便饭问其小便何如。如若小便不利，乃水与气也；若小便自利者，为有血也。
陶华云：以手按之，小腹若痛而小水自利，大便黑，兼或身黄、谵妄、燥渴，脉沉实者，为蓄血，桃仁承气汤下尽黑物则愈。若按之小腹胀满不硬痛，小水不利，则溺涩也，五苓散加减利之，不可大利，恐耗减津液也。若按小腹绕脐硬痛，渴而小水短赤，大便实者，有燥屎也，大承气汤下之。
海藏云：血证古人用药虽有轻重之殊，而无上下之别。今分作上、中、下三等，以衄血、呕血、唾血、吐血为上部，血结胸中为中部，蓄血下焦为下部。夫既有三部之分，故药亦当随其轻重也。
汗多为衄血，脉浮灸之；咽燥为唾血；当汗不汗，热入于里者为呕血、吐血，此在上也，犀角地黄汤主之，凉膈散加生地黄亦可。然衄、唾、呕吐俱在上，亦当以轻重分。大凡血证皆不饮水，惟气证则饮之，宜详审。此证乃足太阴所主，脾所不里越而上行，所以有吐血、呕血之候也。实者犀角地黄汤，虚者黄芩芍药汤。凡病呕吐者，以脾所主，故咸用芍药主之，是知太阴药也。
血结胸中，头痛身痛，漱水不欲咽者，衄无热，胸满漱水不欲咽者，喜忘昏迷，其人如狂，心下手不可近者，血在中也，桃仁承气汤主之。
蓄血下焦，其人发狂，小腹满硬，小便自利，大便反黑，及脐下疼者，抵当汤丸主之。如狂者在中，发狂者在下，抵当汤丸药味同剂，如何是二法？盖喜忘、发狂、身黄、屎黑者，疾之甚也；但小腹满硬，小便利者，轻也。故有汤丸之别。桃仁、大黄等分水蛭、虻虫多者作汤，三分之二者作丸。丸之名取其数少而缓也，故汤用煎服一升，丸止服七合也。
生地黄汤：病患七八日后，两手脉沉细微，肤冷，脐下满，或狂或躁，大便实而色黑，小便自利者，此蓄血证也。若老幼气虚弱者，宜此丸主之。
生地黄（取自然汁一升，如无只用生干地黄二两） 干漆（半两，炒烟尽） 生藕（自然汁半升，如无藕用刺蓟汁一升半） 蓝叶（一握切细，干者用末半升） 虻虫（二十个，去翅足，麸内炒黄色） 水蛭（十个，炒） 大黄（一两，锉如豆大） 桃仁（研碎半两） 上八味同一处，入水三升，慢火熬及二升，放冷，分二服。先投一服，至半日许，血未下，再投之。此汤比抵当汤丸其势甚轻，如无地黄与藕汁，照升数添水同煎。抵当丸恐用之太过不止损血，故以此汤主之。
Jaundice resembling yellow, mania, black stools, and amnesia are all manifestations of blood accumulation (Xue Ju). It is perhaps said by scholars that if blood stasis is in the upper jiao, it causes amnesia; if in the lower jiao, it causes mania.
Cheng Wuji commented: When blood remains stagnant in the lower jiao and forms stasis, it is called blood accumulation. Generally, when treating Shaoyang diseases, one first observes the face and eyes, then the mouth and tongue, and finally palpates from the epigastrium to the hypogastrium. If the hypogastrium is hard and full, and urination is difficult, this indicates retention of body fluids, which can be treated with diuretics. If urination is normal, this is a case of blood accumulation, which should be treated with purgatives to remove blood stasis. In Yangming disease, blood accumulation presenting with amnesia indicates a severe condition, and Diding Tang (Diding Decoction) is appropriate. In Taiyang disease, heat binding in the Bladder presenting with manic-like symptoms indicates a milder condition, and Taoren Chengqi Tang (Peach Kernel Modifying the Emissary Decoction) is appropriate. The Classic states: "If a patient has neither exterior nor interior excess syndromes, but has fever for seven or eight days, and the pulse is floating and rapid, purgation may be used." Suppose purgation has already been administered, but the rapid pulse persists; stomach heat leads to excessive hunger and digestion. If after six or seven days there is no bowel movement, this indicates blood stasis, and Diding Tang should be used. If the rapid pulse persists and diarrhea continues, heat will combine with blood leading to pus and blood in the stool. This condition should be distinguished during the period of constipation for six or seven days, without symptoms of amnesia, manic-like behavior, or hardness/fullness of the hypogastrium, which differs from cases treated with Chengqi decoctions. How do we know it is blood accumulation? Likely because the pulse is floating and rapid; floating indicates heat damaging Qi, and rapid indicates heat damaging Blood. After purgation, if both floating and rapid pulses disappear, the illness resolves. If after purgation the rapid pulse disappears but the floating pulse remains, it means heat in Ying Blood has gone, merging with heat in Wei Qi, causing hunger in the heart. Pathogenic heat fails to digest food, leading to tidal fever and thirst. After purgation, if the floating pulse disappears but the rapid pulse persists, heat in Wei Qi has gone, merging with heat in Ying Blood. Combined heat forces blood downward. Stomach deficiency combined with heat leads to excessive hunger. Blood reaching the lower jiao, if diarrhea continues, blood will leak out, inevitably resulting in pus and blood in the stool. If there is no bowel movement for six or seven days, blood cannot exit, accumulating in the lower jiao as stasis, requiring Diding Tang for purgation. This is an unusual treatment method for excess syndromes and a subtle aspect of therapy.
In Taiyang disease lasting six or seven days, if exterior signs remain, the pulse is faint and deep, and there is no chest binding, but the patient exhibits mania, it is because heat is in the lower jiao. The hypogastrium should be hard and full, and urination normal; bleeding will lead to recovery. This occurs because Taiyang pathogenic factors follow the meridians into the interior, causing blood-heat stasis. Diding Tang is indicated. (Cheng Wuji commented: Taiyang Meridian corresponds to the Bladder Fu organ. This is Taiyang blood-heat following the meridian into the Fu. Six or seven days is the time for pathogenic factors to transmit inward. A faint and deep pulse indicates pathogenic factors in the interior. Exterior signs remaining suggests pathogenic factors are still shallow and should bind in the chest. If not binding in the chest but causing mania, heat binds in the Bladder. The Classic says: "Heat binding in the Bladder causes manic-like behavior." Here, mania indicates deeper heat. Hardness/fullness of the hypogastrium with difficult urination indicates no blood stasis; normal urination confirms blood stasis. Diding Tang is used to purge blood accumulation. The phrase "still present" implies pathogenic factors have not transmitted inward, meaning they are not shallow. The Bladder is the primary organ of Taiyang. Statements like "heat in the lower jiao," "hardness/fullness of the hypogastrium," and "normal urination" are all Bladder syndromes. Thus, it concludes "blood-heat following the meridian into the interior." The term "in the interior" must be understood flexibly; it does not refer to the Three Yin interiors, but rather the interior of the Bladder via the meridian.)
In Taiyang disease, if there is jaundice, a deep and knotted pulse, hardness of the hypogastrium, and difficult urination, there is no blood stasis. If urination is normal and the patient exhibits manic-like behavior, this confirms blood stasis, and Diding Tang is indicated. (Jaundice, deep/knotted pulse, hypogastric hardness, and difficult urination indicate stomach heat causing jaundice; Yinchen Tang may be used. Jaundice, deep/knotted pulse, hypogastric hardness, normal urination, and manic-like behavior indicate heat binding in the lower jiao causing blood accumulation, not stomach heat-stasis; Diding Tang is used to purge blood accumulation.)
Formula: Diding Tang (Diding Decoction)
Shuizhi (Leech, Hirudo), 30 pieces, processed.
Mengchong (Dragonfly Larva, Anisoptera Larva), 30 pieces, feet and wings removed, processed.
Taoren (Peach Seed, Persicae Semen), 20 pieces, skin and tips removed.
Dahuang (Rhubarb Root, Radix et Rhizoma Rhei), 3 liang, soaked in wine.
Grind the above four herbs into powder. Boil in 5 sheng of water to obtain 3 sheng. Strain. Take 1 sheng warm. If no effect, take another dose. (Bitter enters Blood, Salty overcomes Blood. The salty and bitter nature of Mengchong and Shuizhi removes blood accumulation. Sweet moderates binding, bitter drains heat; the sweet and bitter nature of Taoren and Dahuang purges bound heat.)
Qi and Blood are essential to humans. Qi is Yang Qi; if stagnant, it disperses easily because Yang diseases are easier to treat. Blood is Yin Blood; if accumulated, it is hard to disperse because Yin diseases are difficult to treat. Blood accumulation in the lower jiao requires potent toxic agents to "withstand" (Di Dang), hence the name Diding Tang. The Classic states: "Salty overcomes Blood." Since blood accumulates in the lower jiao, Salty substances are primary. Thus, Shuizhi (Saline-Cold) is the Sovereign herb. Bitter enters Blood; since blood stasis does not move, Bitter substances assist. Thus, Mengchong (Bitter-Cold) is the Minister herb. The Liver is the source of Blood; blood pooling dries Liver Qi. The Liver dislikes urgency, so Sweet flavors moderate it. To scatter blood and moderate the Liver, Taoren (Bitter-Sweet-Ping) is the Assistant. Dahuang is Bitter-Cold; dampness in the lower jiao is drained by Bitter. Blood is also a damp category. To sweep blood and drive out heat, Dahuang is the Envoy. These four herbs combined can cure even severe toxic diseases.
In Shanghan with heat and fullness of the hypogastrium, urination should be difficult. If it is now normal, there is blood stasis. Purge it. Do not use other medicines; use Diding Wan (Diding Pill). (Cheng Wuji commented: Shanghan with heat and hypogastric fullness indicates blood accumulation in the lower jiao. If heat retains body fluids blocking flow, urination is difficult. If heat does not retain fluids but blood stasis prevents flow, urination is normal; this is blood accumulation. Taoren Chengqi Tang or Diding Tang should be used. However, without jaundice, black stools, amnesia, or mania, the condition is not severe, so harsh purgatives are contraindicated. Diding Wan, a milder purgative, is suitable. Note: Jaundice, black stools, amnesia, and mania are extended descriptions. Based on the previous text, there is only fullness without hardness.)
Formula: Diding Wan (Diding Pill)
Shuizhi (Leech, Hirudo), 20 pieces.
Mengchong (Dragonfly Larva, Anisoptera Larva), 25 pieces.
Taoren (Peach Seed, Persicae Semen), 20 pieces, skin and tips removed.
Dahuang (Rhubarb Root, Radix et Rhizoma Rhei), 3 liang.
Pound the above four herbs into powder and divide into four pills. Boil one pill in 1 sheng of water to obtain 7 he. Take orally. Blood should pass; if not, take another dose.
If Taiyang disease is unresolved, heat binds in the Bladder, and the patient exhibits manic-like behavior, spontaneous bleeding leads to recovery. If exterior signs are unresolved, attack is premature; resolve the exterior first. Once the exterior is resolved, if only the hypogastrium is tense and knotted, attack may proceed with Taohe Chengqi Tang (Peach Pit Modifying the Emissary Decoction). (Note: Xijiao Dihuang Tang treats Upper Bleeding, such as hematemesis or epistaxis. Taohe Chengqi Tang treats Middle Bleeding, such as blood accumulation or pus/blood in stool from the middle jiao. Diding Tang/Wan treats Lower Jiao Bleeding, such as blood accumulation with mania. The three jiaos have specific indications. This passage should be read as three syndromes. "Recovery upon bleeding" is one syndrome, implying spontaneous bleeding. There may be missing text. "Resolve exterior first" is another syndrome; manic-like behavior indicates lower jiao blood, not a Taohe Chengqi Tang syndrome. From "exterior resolution" to the end is a third syndrome, likely implying that spontaneous bleeding only clears lower jiao blood, while middle jiao pathology remains distant, leaving residue in the hypogastrium. Also, Mengchong and Shuizhi in Diding Tang/Wan are fierce; adding wine-soaked Dahuang to Siwu Tang might be more effective, see Materia Medica under Leech.)
Formula: Taohe Chengqi Tang (Peach Pit Modifying the Emissary Decoction)
Taoren (Peach Seed, Persicae Semen), 50 pieces, skin and tips removed.
Guizhi (Cinnamon Twig, Ramulus Cinnamomi), bark removed.
Mangxiao (Mirabilite, Natrii Sulfas).
Gancao (Licorice Root, Radix Glycyrrhizae), roasted, 2 liang each.
Dahuang (Rhubarb Root, Radix et Rhizoma Rhei), 4 liang.
Boil the above five herbs in 7 sheng of water to obtain 2.5 sheng. Strain. Add Mangxiao. Heat briefly until boiling. Remove from fire. Take 5 he warm before meals, three times daily. Mild diarrhea is expected. (Sweet moderates, Pungent disperses. Hypogastric tension is moderated by the sweetness of Taoren. Lower jiao blood accumulation is dispersed by the pungent-warm nature of Guizhi. Cold is used to clear heat; intense heat clots blood, so these two are added to Tiaowei Chengqi Tang. Note: Analyzing the above syndromes, it should be Gui (Cinnamon Bark) not Guizhi (Cinnamon Twig). Guizhi is light and ascending, treating the upper; Gui is heavy and descending, treating the lower. Cheng's interpretation following the text is insufficient evidence.)
In Yangming syndrome, if the patient exhibits amnesia, there must be blood accumulation. This is because long-standing blood stasis exists, causing amnesia. Although stools are hard, defecation is actually easy, and the color is definitely black. Diding Tang is indicated to purge blood stasis. (Cheng Wuji commented: The Classic states: "Blood gathering in the lower jiao causes confusion and amnesia." Long-standing blood stasis in the lower jiao causes amnesia. Low body fluids cause hard stools. With blood stasis inside, although stools are hard, defecation is easier, and the color is black. Diding Tang is used to purge blood stasis.)
Haizang stated: Brown stool initially indicates severity; dark brown stool indicates greater severity; black stool indicates extreme severity. Color change is due to fire dryness. Like sheep blood in sunlight, it turns brown quickly, then gradually blackens. Observe carefully.)
Patients with no exterior or interior syndromes, fever for seven or eight days, and a floating/rapid pulse may be treated with purgation. If purgation has been done and the pulse remains rapid, stomach heat causes excessive hunger. If after six or seven days there is no bowel movement, there is blood stasis; use Diding Tang. If the rapid pulse persists and bleeding continues, heat combines with blood leading to pus and blood in the stool.
Cheng Wuji commented: During the period of constipation for six or seven days, without amnesia/mania or hypogastric hardness/fullness, how do we know there is blood accumulation? Because the pulse is floating and rapid. Floating indicates heat in Qi; rapid indicates heat in Blood. After purgation, if both floating and rapid pulses disappear, the illness ends. If after purgation the rapid pulse disappears but floating remains, heat in Ying Blood goes, heat in Wei Qi remains, pathogenic factors linger in the epigastrium causing hunger, pathogenic heat fails to digest food, leading to tidal fever and thirst. If after purgation the floating pulse disappears but rapid persists, heat in Wei Qi goes, heat in Ying Blood remains. Blood-heat merges, forcing blood downward. Stomach deficiency with heat causes excessive hunger. Blood reaches the lower jiao; if diarrhea continues, blood leaks out, inevitably becoming pus and blood. If no bowel movement for six or seven days, blood cannot exit, accumulating in the lower jiao as stasis, requiring Diding Tang for purgation.
Zhang Yuansu asked: The method of attacking with purgatives requires no exterior syndrome and an interior excess syndrome before attacking. The text mentions no exterior or interior syndromes, and the pulse is floating/rapid. Why is purgation recommended? Answer: This is not caused by Wind-Cold, but by internal injury. If there is no aversion to cold externally and no delirium internally, but fever for seven or eight days consuming body fluids, it is a time of Yang excess and Yin deficiency. If not purged, heat will persist and complications will arise. Hence, even with a floating/rapid pulse, purgation is allowed without waiting for a deep/solid pulse. Regarding internal injuries, the Classic states: "Fuyang pulse floating and rapid; floating damages Stomach, rapid damages Spleen." This is not the original disease but caused by improper purgation. Zhang Zhongjing's intent aligns with this principle. All Shanghan cases requiring purgation involve pathogenic factors from Taiyang/Yangming meridians entering the Fu organs. Here, it does not say Yangming disease, but "patient with no exterior/interior syndromes," indicating it did not come from the exterior to the interior, but is simply purgable, hence included in the Yangming chapter for students to study carefully.
Patients with chest fullness, bloating, stiff tongue, blue tongue, dry mouth, rinsing water without swallowing, no chills/fever, pulse slightly large and slow, abdomen not distended but patient claims fullness, indicates blood stasis. (Haizang stated: Rinsing water without swallowing, chest fullness, tenderness in epigastrium: Taohe Chengqi Tang is indicated.) Patients appearing hot, irritable, full, dry mouth/thirst, but pulse shows no heat, this is hidden Yin, indicating blood stasis. Purge it.
Li Dongyuan's Pre-collection states: Shanghan due to missed sweating leads to heat accumulating in the interior, transforming into blood. The patient suffers amnesia and manic-like behavior. Blood reversing upward causes amnesia; blood accumulating downward causes internal urgency. Severe cases require Diding Tang/Wan, Taohe Chengqi Tang, or Xijiao Dihuang Tang until black material is expelled. Also, if using Diding Tang/Wan, be cautious about exterior syndromes. If blood accumulation exists with unresolved exterior, do not use immediately; first resolve the exterior with Guizhi Tang. This is because heat attacks the Bladder, the Taiyang Meridian.
Wu Kun stated: Blood accumulation is stasis retained internally. In Shanghan at Taiyang stage, if sweating is missed, blood stasis remains in the interior, forming blood knots. Generally, observe Shanghan patients for hardness/fullness in the epigastrium, flanks, or hypogastrium. Pressing causes pain. Ask about urination. If difficult, it is water/Qi retention. If normal, it is blood stasis.
Tao Hua stated: Pressing the hypogastrium causing pain with normal urination, black stools, possibly jaundice, delirium, dry thirst, and deep/solid pulse indicates blood accumulation. Taohe Chengqi Tang purges black material for recovery. If pressing causes hypogastric distension without hardness/pain and difficult urination, it is urinary obstruction; Wuling San modified promotes urination. Do not promote urination excessively to avoid damaging body fluids. If pressing around the navel causes hardness/pain, thirst, short/red urine, and solid stools, it is dry feces; Dachengqi Tang is indicated.
Haizang stated: Ancients used medicines for blood syndromes with varying potency but no distinction between upper/lower. Now divided into Upper, Middle, Lower. Epistaxis, hematemesis, spitting blood, vomiting blood are Upper. Blood binding in the chest is Middle. Blood accumulation in the lower jiao is Lower. Since there are three divisions, medicine should match the severity.
Excessive sweating leads to epistaxis; pulse floats, moxa is applied. Dry throat indicates spitting blood. Missed sweating allows heat to enter the interior, causing hematemesis/vomiting blood. This is Upper; Xijiao Dihuang Tang is indicated, or Liangge San with Shengdihuang. Epistaxis, spitting, vomiting are all Upper, but severity varies. Generally, blood syndromes do not involve thirst, while Qi syndromes do. Examine carefully. This syndrome is governed by Foot-Taiyin (Spleen). Spleen fails to control blood, allowing it to rise, causing hematemesis/vomiting blood. Excess cases: Xijiao Dihuang Tang. Deficiency cases: Huangqin Shaoyao Tang. Vomiting involves the Spleen, so Shaoyao is commonly used, indicating Taiyin medicine.
Blood binding in the chest, headache, body ache, rinsing water without swallowing, epistaxis without heat, chest fullness, rinsing water without swallowing, amnesia, coma, manic-like behavior, tenderness in epigastrium: Blood is in the Middle. Taohe Chengqi Tang is indicated.
Blood accumulation in the lower jiao, mania, hypogastric fullness/hardness, normal urination, black stools, pain below the navel: Diding Tang/Wan is indicated. Manic-like behavior is Middle; Mania is Lower. Diding Tang and Wan have same ingredients/dosage, why two methods? Amnesia, mania, jaundice, black stools indicate severe disease. Only hypogastric fullness/hardness with normal urination indicates mild disease. Hence, Tang vs. Wan. More Leech/Dragonfly makes Tang; less makes Wan. "Wan" implies fewer doses and slower action. Tang is taken 1 sheng; Wan is taken 7 he.
Shengdihuang Tang: Patients after 7-8 days, deep/fine/weak pulses in both hands, cold skin, umbilical fullness, mania or restlessness, solid black stools, normal urination: This is blood accumulation. For elderly/young or Qi-deficient patients, this pill is indicated.
Shengdihuang (Fresh Rehmannia Juice, 1 sheng; or dried, 2 liang). Ganqi (Dry Resin, 0.5 liang, fried until smoke stops). Shengou (Fresh Lotus Root Juice, 0.5 sheng; or Ci Ji juice, 1.5 sheng). Lanye (Isatis Leaf, 1 handful cut fine; or powder, 0.5 sheng). Mengchong (Dragonfly Larva, 20 pieces, wings/feet removed, fried in bran until yellow). Shuizhi (Leech, 10 pieces, fried). Dahuang (Rhubarb, 1 liang, chopped bean-sized). Taoren (Peach Seed, crushed, 0.5 liang). Mix the above eight ingredients. Add 3 sheng of water. Simmer slowly to 2 sheng. Cool. Divide into two doses. Take one dose first. After half a day, if blood has not passed, take the second dose. This Tang is milder than Diding Tang/Wan. If Shengdihuang/Lotus juice is unavailable, add water according to volume. Diding Wan might be too harsh, damaging blood further, so this Tang is used.