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Whenever Taiyang disease (disease of the Taiyang channel) is not resolved, its pathogenic factor enters the fu organs from the channels. Heat accumulates in the Bladder, causing blood to coagulate and stagnate. Blood stasis leads to the obstruction of Heart Qi, thus the patient exhibits symptoms resembling madness.

If blood discharges spontaneously, the disease will heal, as the pathogen resolves along with the discharge of blood. If exterior symptoms remain unresolved, the exterior should be resolved first, preferably using Guizhi Tang (Cinnamon Twig Decoction). Once the exterior is resolved, if there is only urgency and pain in the lower abdomen, this indicates blood accumulation (Xu Xue). Tao Ren Cheng Qi Tang should be used to purge it.

Commentary by Shao: The pathogenic heat of Taiyang does not exit from the exterior but follows the channels into the fu organs. The fu organ refers to the Bladder. Residual heat in the fu organ causes blood from the channels to contend with heat, accumulating in the lower jiao, termed blood accumulation. Heat steams upward to affect the Heart, hence the patient appears manic. If blood does not clot but flows out downward, heat descends with the blood and the disease heals. If it does not heal and there is urgency and binding pain in the lower abdomen, an attacking method must be used to remove it. Before employing an attacking method, one must examine for exterior symptoms. If attacking internally while the exterior is unresolved, although blood may be removed, the exterior pathogen will re-enter the interior. Therefore, the exterior pathogen must be resolved first. Only when the exterior pathogen is gone and there is merely urgency and pain in the lower abdomen is it blood accumulation. Tao Ren Cheng Qi Tang is used to dissipate heat by purging blood; this is a treatment principle of resolving the exterior first and the interior later. However, this applies to mild cases of blood accumulation.

In Taiyang disease lasting six or seven days, if exterior symptoms persist and the pulse is faint and deep, the pathogen is moving inward. The absence of Jie Xiong (chest binding) indicates that heat has accumulated in the lower jiao. The patient presents with mania, hardness and fullness in the lower abdomen, and free urination. This is due to blood stasis from the Taiyang channel accumulating in the interior. Di Dang Tang should be used to purge it, leading to recovery.

For the same condition of blood accumulation, Tao Ren Cheng Qi Tang treats the stage when blood stasis is about to form, whereas Di Dang Tang treats the stage after blood stasis has already formed.

Commentary by Shao: In Taiyang disease on the sixth or seventh day, with persistent exterior symptoms and a faint, deep pulse, channel pathogens have sunk into the Taiyang fu organ. The absence of Jie Xiong but presence of mania indicates the pathogen is not in the upper part but rather heat and stasis are in the blood level of the lower jiao. Blood accumulation causing mania implies heat attacking the Heart; without a general who strikes directly, victory cannot be won. Apart from Di Dang Tang's method of expelling blood, what other medicine can break such strongholds? This represents a severe case of blood accumulation, so Di Dang Tang is used to directly attack the blood, disregarding the exterior symptoms, differing from the previous case of resolving exterior before interior.

Another commentary: The text states "exterior symptoms remain," implying a preceding sentence about erroneous purgation. Erroneous purgation allows heat to enter the fu organ from the channel, accumulating in the Bladder and lower jiao, failing to form blood Jie Xiong, resulting in confusion and mania. This is transmission from channel to fu, exterior to interior, qi to blood, and upper jiao to lower jiao. The lower abdomen resides in the lower jiao and is the chamber of the Bladder. Stasis remains and binds, causing hardness and fullness. Free urination indicates the disease is in the blood, not the qi. Purging blood relaxes the qi; attacking the interior resolves the exterior.

In Taiyang disease, if there is yellowing of the body, a deep and knotted pulse, hardness in the lower abdomen, and difficulty urinating, there is no blood stasis; this is due to the obstruction of damp-heat. If urination is free and the patient exhibits manic-like symptoms, it is definitively a blood disease.

Commentary by Shao: Yellowing, deep knotted pulse, and lower abdominal hardness occur in both water and blood diseases. Difficulty urination indicates water and heat binding, signifying no blood stasis but water retention, characteristic of Wu Ling San syndrome. If urination is free and the patient is manic, it signifies heat and blood accumulating in the lower jiao, having blood but no water, characteristic of Di Dang Tang syndrome. Thus, heat entering the Bladder from Taiyang can result in either water binding or blood binding.

In Yangming disease, if the patient suffers from forgetfulness (Xi Wang), there must be blood accumulation. The Heart governs blood; when blood coagulates, Heart Qi becomes obstructed and loses its function, causing forgetfulness. This is pre-existing blood stasis, not acquired from Shang Han. Although stool is hard, defecation is surprisingly easy, and the color is black, because detached blood passes with the stool. All these cases should be treated with Di Dang Tang to purge.

Commentary by Shao: Here, yellowing and difficulty urinating are borrowed to distinguish the free urination of blood accumulation. Blood stasis is the root cause; forgetfulness is the manifestation. These are pre-Yangming disease symptoms. The Heart is the master of blood; long-term accumulation of stasis and heat harasses the Heart, causing forgetfulness. Hard stool usually makes defecation difficult; now defecation is easy and black, indicating retained old blood. By observing the ease of defecation and investigating the black color, the root of the disease is found, explaining the prior forgetfulness. Di Dang Tang, a formula that enters the blood to break clots, should be used to purge the stasis. Once blood is removed, heat also disappears.

In Shang Han, if there is fever and lower abdominal fullness, urination should be difficult. If it is instead free, there is blood stasis. It should be purged, but not with harsh medicines; Di Dang Wan (Di Dang Pill) is suitable to gently purge the blood. (The above discussion references Zhang Zhongjing's theories and annotations from *Lei Fang Zhu Shi*).

Commentary by Shao: Fever here means body heat with persistent exterior symptoms. Lower abdominal fullness indicates heat entering the lower jiao. Fullness without hardness and absence of mania suggest how to know there is blood stasis? Merely heat entering the lower jiao causing fullness should lead to difficulty urination; since urination is free, blood accumulation is predicted. Lower abdominal fullness is slightly milder than hardness, so the dosage should be reduced; thus, pills are used for gentle action.

Another commentary: This clause predicts blood accumulation by verifying through the freedom or difficulty of urination. The previous clause determined blood accumulation by easy passage of black stool; this clause distinguishes it by free urination. The precision in symptom examination deserves careful study.

Blood accumulation, although a disease of the blood level, must be treated differently based on Yin and Yang. Blood stasis in the upper jiao is Yang; blood accumulation in the lower jiao is Yin. Failure to sweat in Taiyang disease causes heat and stasis in the interior, with blood accumulating in the lower jiao—this is Yang. Erroneous purgation in Taiyang disease causes Yang Qi to sink, with blood accumulating in the lower jiao—this is Yin.

Commentary by Shao: Blood accumulation has Yin and Yang distinctions. Upper jiao accumulation is Yang, caused by failure to resolve Taiyang exterior, leading to heat-blood stasis. Lower jiao accumulation is Yin, caused by erroneous purgation sinking Yang Qi.

Upper jiao blood accumulation, due to inability to sweat or manifest macules, results in stasis. The Ren Ying pulse at the neck must be tight; a tight pulse is rapid and forceful. Exterior symptoms include red face, dry tongue, restlessness resembling mania, head shaking, staring eyes, passage of bloody water in stool, and spasms in all fingers except the index finger. Suitable herbs include Rhinoceros Horn (Xijiao), Tao Ren, Sheng Di, Chi Shao, Gui Wei, Dan Pi, Dan Shen, and Yu Jin, to clear heat and promote circulation.

Commentary by Shao: Upper jiao blood accumulation presents only with Yang symptoms, not Yin. Treatment employs clearing heat and breaking blood methods. Lower jiao blood accumulation differs, presenting with both Yin and Yang symptoms. Lower jiao Yang-type blood accumulation results from pathogenic heat entering the lower jiao, where heat and stasis bind in the Bladder, treated by attacking blood and purging.

Lower jiao Yang-type blood accumulation corresponds to Zhang Zhongjing's description of heat binding in the Bladder, treated with Tao Ren, Da Huang, etc., to purge. If it is lower jiao Yin-type blood accumulation, caused by erroneous purgation sinking Yang Qi and injuring Yin blood, causing blood to coagulate due to cold, symptoms include pale face, blueish eyes, frowning, staring, chills, locked jaw, white slippery tongue coating, passage of bloody water in stool, and spasms in all fingers except the index finger. Warm tonification is suitable, using herbs like Ren Shen, Fu Zi, Bai Zhu, Dang Gui, Rou Gui, Tao Ren, Sheng Ma, and Zhi Gan Cao to warm and tonify to raise Yang Qi. If chills subside after medication but recur after one or two hours, the medicinal power is insufficient; administer again to sustain Yang Qi. Survival is expected if chills stop; otherwise, death ensues. (Refer to *Shang Han Di Yi Shu*).

In all blood accumulation cases, if bloody water is passed in stool with visible feces, prognosis is good (life); if no feces are seen, prognosis is poor (death).

Commentary by Shao: Lower jiao Yin-type blood accumulation, due to erroneous purgation injuring righteous Qi, sinking Yang Qi, and coagulating Yin blood, is a Yin-cold syndrome. It differs significantly from blood accumulation caused by internal binding of Yang pathogenic factors. Physicians must pay close attention.