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Taiyang disease with blood accumulation. How is its pathology elucidated? Blood accumulation refers to the condition where blood coagulates and gathers in the Lower Jiao (Lower Burner), stagnating without flowing, and accumulating without dispersing. When blood becomes depressed in the upper part of the body leading to hematemesis, it is called Bo Jue (Thin Convulsion). When stasis remains in the lower part, it is called Blood Accumulation. This arises from Taiyang pathogenic factors following the meridians into the interior, where stasis-heat condenses within. The blood is constrained by heat, condensing and failing to circulate, thus accumulating in the Lower Jiao. The Classic states: "In Taiyang disease, after six or seven days, if the exterior syndrome persists, the pulse is faint and deep, yet there is no formation of Jie Xiong (Chest Binding), and the patient exhibits mania, this is because heat resides in the Lower Jiao. The hypogastrium should be hard and full. If urination is normal, evacuation of blood will lead to recovery, treated primarily with Dishui Tang." This describes the typical presentation of blood accumulation.

Generally, in diagnosing Shanghan (Cold Damage), one must first observe the eyes, then inspect the mouth and tongue, and finally palpate from the epigastrium down to the hypogastrium. If hardness and fullness are felt upon pressure, careful examination and treatment are required. If the hypogastrium feels hard and full, one must inquire about urination. If urination is difficult, it indicates retention of body fluids; diuretics may be used. If urination is spontaneous and free, it indicates a blood accumulation syndrome, requiring purgation of stasis. The Classic says: "In Shanghan with heat, if the hypogastrium is full, urination should be obstructed; if it is now free, it indicates the presence of blood." It also states: "In Taiyang disease, if the body is yellow, the pulse is deep and knotted, and the hypogastrium is hard, but urination is obstructed, there is no blood stasis. If urination is free and the patient appears manic, the blood syndrome is confirmed." In such cases, Dishui Wan (Dishui Pill) must be used to purge the stasis for recovery. In Yangming syndrome, if the patient suffers from forgetfulness, although the stool is hard, defecation is relatively easy, and the color is black, this is also a sign of blood accumulation. Stasis accumulated in the lower part causes manic-like symptoms, as the Classic states: "Heat binding in the Bladder leads to mania." Stasis stagnant in the lower part causes forgetfulness, as stated in the Neijing: "When blood congregates in the lower part, confusion and forgetfulness occur." If either of these conditions is present, the diagnosis of blood accumulation is established.

Blood accumulation syndromes vary in severity. Mania and forgetfulness represent severe forms of blood accumulation, requiring purgation with Dishui Tang or Dishui Wan. If the exterior syndrome has resolved, but only urgency and clumping in the hypogastrium remain, it is a mild form of blood accumulation, treated with Tao Ren Cheng Qi Tang (Peach Kernel Decoction to Order the Qi) to promote flow. Where lies the subtlety of the physician? It lies in recognizing clinical manifestations, understanding pulses, discerning deficiency and excess, and knowing the progression of the disease. Obvious manifestations are recognized by all; how does one demonstrate subtlety? True subtlety is shown when manifestations are complex and unrecognized by others, yet the physician identifies them first. For instance, consider a patient without typical exterior or interior signs, feverish for seven or eight days. Even if the pulse is floating and rapid, purgation may be considered. If purgation has been performed but the rapid pulse persists, and fever subsides while appetite increases (easy hunger), and after six or seven days there is no bowel movement, this indicates blood stasis, treated with Dishui Tang. During the period of constipation lasting six or seven days, if there are no signs of forgetfulness or mania, nor hypogastric hardness and fullness, most physicians would administer Cheng Qi Tang (Order the Qi Decoction). Only those who correctly prescribe Dishui Tang demonstrate medical subtlety. How does one know there is blood accumulation in such cases? A floating and rapid pulse indicates that floating damages Qi and rapid damages Blood. Heat affecting Qi causes a floating pulse; heat affecting Blood causes a rapid pulse. After purgation, if both floating and rapid pulses disappear, the disease resolves. If after purgation the rapid pulse disappears but the floating pulse remains, heat in Ying Blood (Nutritive Blood) has cleared, but heat in Wei Qi (Defensive Qi) remains. Pathogenic factors lingering in the heart cause hunger; pathogenic heat fails to digest food, leading to tidal fever and thirst. If after purgation the floating pulse disappears but the rapid pulse persists, heat in Wei Qi has cleared, but heat in Ying Blood remains. Heat combines and forces blood downward. With deficient Stomach Qi cooperating with heat, digestion accelerates causing easy hunger. Blood flows to the Lower Jiao; if diarrhea persists, blood is expelled, resulting in pus and blood in the stool. If there is no bowel movement for six or seven days, blood cannot be expelled via diarrhea and accumulates in the Lower Jiao as stasis, requiring purgation with Dishui Tang. This represents the uniqueness of pathological presentations and the profundity of therapeutic methods. Those who can carefully discern these principles are truly skilled physicians.