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*Zhuansheng* and *Liuyao* both state: If a person's diet and daily routine are not in accordance with propriety, it can all cause blood stasis and obstruction. Therefore, many of the hundred diseases arise from foul blood (referring to degenerated or stagnant blood). However, medical texts categorize syndromes by departments; while there is "Seven Qi" disease, there is no category for "Accumulated Blood." Hence, I have added this discussion. This view is correct, although ancient practitioners did occasionally establish specific categories for Accumulated Blood, but such instances were rare.

**Pulse Diagnosis**
A pulse that is wiry and tight, accompanied by hypochondriac pain and visceral injury, indicates blood stasis (another version reads "cold blood"). A pulse that is fine and slippery, feeling empty upon pressure, where the patient suddenly holds their body straight, leading to stiffness and falling, results from a fall from a height, indicating internal pathology. (*Mai Jing*)

Sudden falling from a height, with internal blood accumulation, abdominal distension and fullness: if the pulse is firm and strong, life is possible; if the pulse is small and weak, death ensues. (Ibid.)

Verifying via pulse: In cases with blood stasis, the pulse may be intermittently choppy and rapid, flickering between visibility and invisibility, or deep, fine, and hidden. If blood and heat attack each other, the cun and guan positions on the left hand will feel surging and excessive. This is because the Heart governs blood and the Liver stores blood. (*Zhizhi*) (Refer to discussions in Shanghan Lun.)

When blood stasis accumulates internally, the pulse should ideally be firm and large. If it appears deep, small, choppy, or faint, it becomes detrimental. (*Xuyan*)

Hypochondriac pain caused by blood stasis, with a wiry and tight liver pulse, is common; do not assume it is invariably fatal. (*Yibian*)

**Etiology and Pathogenesis**
The Liver stores blood, which is governed by the Heart. When active, blood circulates through the meridians; when at rest, it returns to the Liver. The Liver nourishes the eyes allowing vision; the feet receive blood to enable walking; the palms receive blood to enable grasping; the fingers receive blood to enable holding. Thus, blood coagulating in the skin causes Bi syndrome (obstruction); coagulating in the vessels causes Qi (stagnation/sluggish flow); coagulating in the feet causes Jue (cold extremities/altered consciousness). General symptoms include mental confusion, fright, mania, oppression, thirst, vomiting, shortness of speech, internal pain, epistaxis, hemoptysis, red eyes and face, bone heat, hot skin, intestinal mucus, polyuria, chest fullness with stubborn phlegm, excessive talking with sweating, even cold extremities, and unconsciousness. Regardless of gender, these are all blood syndromes. (*Zhizhi*)

Accumulated Blood is commonly known as internal injury. It may result from chronic fatigue, excessive anger, sexual activity after a full meal, bearing heavy loads with effort, falling from heights, or frantic running/chasing. Symptoms often include fever resembling external contraction but without headache or thirst. The fever may ease slightly at dawn but worsen around noon. Sweating occurs but stops at the neck. There is spontaneous sweating with weak breathing, short gaze, anorexia, insomnia, and normal urination and defecation, though urine may be red and stool loose. (*Bencao Jingshu*)

**Differentiation by Sanjiao (Triple Burner) - Test for Diaphragmatic Syndrome**
The Classics state: Blood reversing upward causes forgetfulness; blood accumulating downward causes mania. With upper jiao blood stasis, urination must be difficult; with lower jiao blood stasis, urination must be normal. One can deduce the location of the blood based on this. (*Zhizhi*)

How to know if accumulation is in the lower jiao? The umbilical region feels knotted and tense, there is external heat and internal pain, and the chi pulse is surging and rapid. (Ibid.)

Epistaxis indicates accumulated blood in the upper jiao. Tenderness under the heart (epigastrium) where touch is unbearable indicates middle jiao accumulation. Abdominal swelling and pain indicate lower jiao accumulation. Upper jiao accumulation may present with vomiting, epistaxis, or hematemesis, characterized by tenderness in the chest. (*Yuanrong*)

**Upper Jiao Epistaxis and Accumulated Blood**
In elderly patients with dysphagia (food sticking), where food descends tortuously, there is accumulated blood in the stomach opening. In women with emotional constraint, long-standing cases also occur. Tenderness under the heart indicates middle jiao accumulation. Those fond of roasted, spicy, and hot alcoholic beverages may develop gastric wall blood stasis over time, causing burning discomfort and pain. Abdominal swelling and pain with normal urination indicate lower jiao accumulation. In sanjiao accumulation, pulses manifest accordingly, with the middle position on the left often being wiry and choppy. (*Liuyao*)

Distension in the anterior and posterior chest, a metallic/bloody smell in the throat, and a choppy qi-kou pulse indicate accumulated blood in the diaphragm. Test method: Drink hot ginger soup; if hiccups occur, it is blood stasis. Treat with Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) plus child's urine, Tao Ren (Peach Kernel), and Dahuang (Rhubarb) to attack and disperse. Alternatively, use Pingwei San combined with Yueju Wan plus leek juice and child's urine to dissipate it. (*Yitong*)

**Shanghan (Cold Damage) Blood Stasis**
(See detailed discussion in *Shanghan* chapters.)
Symptoms of internal blood stasis in Shanghan: If a person already has internal blood結 (knots/stasis) and contracts Shanghan, if heat combats the long-standing stasis, fever and manic behavior occur. (*Bingyuanlun*)

**Residual Blood Stasis After Illness**
Patients may suffer from incomplete sweating, or incomplete vomiting/epistaxis, leaving blood stasis internally. This causes yellow complexion, white lips, black stool, weak legs, asthma/panting, and even mania/oppression, all caused by blood stasis. (*Sanyin*)

**Traumatic Fall Blood Stasis**
After any fall, evil blood remains inside. If accompanied by great anger, qi rises but cannot descend, accumulating in the left hypochondrium, injuring the Liver. Liver injury leads to emaciation, sleeping with mouth open, cyanosis of hands and feet, closed eyes, and pupil pain. This is due to Liver injury. (*Mai Jing*)

Patients suffering falls with retained evil blood, or due to great anger, may have liver blood and dampness stagnating and not dispersing, causing bilateral hypochondriac pain, leg weakness/spasms (text implies deficiency/spasm), joint swelling, and ascending qi. All are due to internal blood stasis. (*Sanyin*)

A person with aversion to cold and fever resembling Shanghan, with a hollow and choppy pulse, pain in the hypochondrium and lower abdomen intolerable to touch, black stool, and free urination, presents a definitive diagnosis of blood stasis. The hypochondrium and lower abdomen belong to the Liver, the Sea of Blood. Thus, blood stasis accumulates here. One must inquire about recent falls, twists, or kicks. Cold-natured medicines should be avoided as cold congeals blood. If blood stasis rushes upward causing coma followed by recovery, these are signs of blood syndromes; treat with qi-moving and blood-invigorating herbs. (*Lingnan Weisheng Fang*)

**Falls and Blows**
Trauma, being kicked/hit, collision, sprains, strenuous exertion, confinement, or anger may not show immediate symptoms. Onset may occur after half a day, one to three days, ten days, half a month, or a month. Generally, alternating chills and fever occur, with fullness and pain in the chest, hypochondrium, and lower abdomen, intolerable to palpation, indicating blood stasis. Severe trauma may cause immediate chills/fever; if blood stasis rushes upward, coma ensues resembling death, with eventual recovery. Mild cases use Fuyuan Huoxue Tang; severe cases use Tao Ren Chengqi Tang. Assess the patient's vital energy and purge the stasis to cure. For stasis above, drink leek juice; never drink cold water, as cold congeals blood. Even a trace of blood entering the Heart is fatal. (*Dingbu Zhizhang*)

Falls from heights, heavy impacts, arrow/blade wounds, or unresolved chest/abdominal blood stasis can be treated by decocting Dahuang (Rhubarb) with child's urine and wine, purging according to severity. Or use Xiangke San with child's urine. For dull pain in waist/hypochondrium, use Fuyuan Tongqi San (remove Qian Niu, add Zhi Ke, Chai Hu, Mudan Pi). For unbearable pain from evil blood in abdomen/hypochondrium, use Fuyuan Huoxue Tang. For stasis presenting like spirit possession, use Danggui Huoxue Tang. (*Yitong*) (Danggui Huoxue Tang contains Dang Gui, Bai Shao, Sheng Di Huang, Rou Gui, Tao Ren, Fu Ling, Zhi Ke, Chai Hu, Gan Cao, Gan Jiang, Hong Hua.)

**Difficulty and Prognosis**
Passing black stool like lacquer indicates severe accumulated blood, most critical. If spirit calms slightly and pulse stabilizes after purging, it is treatable. If spirit remains confused, pulse shows collapse, accompanied by cold extremities and hiccups, it is likely incurable. (*Yitong*)

**Treatment Principles**
*Xiaochaihu Tang*, *Xijiao Dihuang Tang*, and *Tao Ren Chengqi Tang* listed in *Huoren Zongkuo* are essential. For blood knots, add vinegar to decoctions as an assistant. (*Zhizhi*)

Avoid qi-breaking and qi-tonifying herbs. Purging, bitter-cold, and pungent-dry methods are contraindicated; favor blood-moving and pungent-warm methods, assisted by salty-cold. After stasis moves, tonify blood, benefit spleen, and harmonize liver. (*Bencao Jingshu*)

For body chills/fever with jaundice, wiry/fine/depressed pulse, unresponsive to tonifying/purging herbs: *Qianjin* formula uses Dahuang, Mangxiao, Guowei, Tao Ren, Renshen, Guixin powdered, taken with wine. Borrow strength from Ginseng and Cinnamon to attack. Obese individuals with rich diets often have phlegm-damp-heat-blood stasis in the stomach, possibly with hypochondriac fullness or lower abdominal knotting/pain. Morning: Junxue Wan (tonifies stomach qi). Evening: Bentong Didang Wan (disperses accumulated blood). This achieves the subtlety of using harsh drugs gently. For deficient persons with stasis (pulse hollow, one section wiry), combine tonification with blood removal: Taohe Chengqi Tang plus 5 qian Renshen, divided into three doses, gentle purging saves 20-30%. For mid-jiao deficient persons with dead blood in stomach (hiccups after ginger tea): Renshen and Baizhu (2 liang each) powder, mixed with Tao Ren (1 liang) stir-fried with Gansui/Ganqi (remove Ganqi), refined honey pills, chewed slowly morning/evening with pure wine. (*Yitong*)

**Phlegm and Blood Interaction**
Initial blood injury causes blood reversal, leading to qi stagnation, which generates phlegm. Phlegm and blood gather, named "Blood Stasis with Phlegm." Pain at the site is fixed upon pressure. Symptoms: phlegm wraps blood, sweating up to neck, hematemesis, epistaxis, black stool with clear urine. Treat by guiding phlegm out and eliminating blood. If pre-existing constrained phlegm exists, followed by blood injury, blood stagnates with phlegm, named "Phlegm with Blood Stasis." Pain is less fixed. Symptoms: blood wraps phlegm, distension/oppression, chills/fever. Treat by breaking blood then resolving phlegm, or both simultaneously. Mistaken use of tonics or cold-cool herbs may cause pathogens to form "nests" (chronic collections), which are incurable. Signs of nests: heat in armpit, immobile painful site, or lung membrane heat/swelling with foul-smelling watery sputum (sinks in water). Danxi said: "Phlegm with blood stasis forming nests is incurable." (*Cuiyan*) (Note: This theory is considered too rigid, preserved for reference.)

**Methods to Break Stasis**
For reckless bleeding and stasis, Tao Ren and Dahuang are essential for moving and breaking blood. Degenerated blood cannot return to vessels; if not removed, it causes harm. Removal is necessary regardless of deficiency or excess; add tonics for the weak. (*Yibian*)

**Jiming San**: For falls, crushing injuries, any trauma with blood stasis, impending death, chronic stasis, irritability, pain, inability to cry out. Promotes renewal, effective for fractures.
Ingredients: Dahuang (1 liang, wine-steamed), Xingren (37 kernels, peeled/split, or Tao Ren per Gangmu).
Grind fine, decoct in 1 bowl wine to 60%, strain when bowl cracks. Take at dawn. Next day, pass stasis and recover. If sudden collapse/unconsciousness, force open mouth and灌 (pour) hot urine. (*Sanyin*)

**Danggui Daoshi San**: For trauma, horse/carriage accidents, constipation, swelling/ecchymosis, pain/coma, internal壅 (blockage) nearing death.
Ingredients: Chuan Dahuang (1 liang), Dang Gui (3 qian), Shexiang (small amount, separately ground).
Powder, mix Shexiang. Take 3 qian with warm wine before meals. (*Baojian*)

**Fuyuan Huoxue Tang**: For falls, evil blood in hypochondrium, unbearable pain.
Ingredients: Dahuang (1 liang, wine-soaked), Chai Hu (5 qian), Gualou Gen, Chuanshanjia (fried), Dang Gui (3 qian each), Honghua, Gan Cao (2 qian each), Tao Ren (50 kernels, soaked/peeled/grinded).
Chop ingredients (except Tao Ren paste). Take 1 liang dose, decoct in 2.5 bowls water + 0.5 bowl wine to 70%. Add Tao Ren paste, boil briefly, strain, take warm before meals. Stop when bowels move. (Ibid.) (Note: *Zhuansheng*'s Dai Dang Wan varies from this. *Yitong* notes it treats deficient persons' stasis gently.)

**Xijiao Dihuang Tang**: For floating main pulse, hollow guest pulse, blood accumulation in chest, intense heat in upper jiao.
Ingredients: Xijiao (shaved), Dahuang (1 qian each), Huang Qin, Huang Lian (2 qian each), Sheng Di Huang (4 qian).
One dose, decoct in 2 zhong water to 1 zhong. Take after meals. (*Xuanyao*) (Note: Originally Yunqizi's formula, now adds Xijiao. *Yitong* cites *Bacui* also having Xijiao.)

**Harmonizing Blood Formulas**
**Jiajian Siwu Tang**: For blood/qi deficiency, limb weakness, stasis abdominal pain, or excessive bleeding.
Ingredients: Dang Gui, Chuan Xiong, Bai Shao Yao, Gan Jiang (fried, 0.5 liang each), Nan Mu Xiang, Gan Cao (fried, 2.5 qian each).
Cut coarse, take 3 qian, decoct before meals. If no abdominal pain, no stasis. Adding Renshen benefits blood. (*Zhizhi*)

**Chaihu Shugan San**: For anger injuring Liver, hypochondriac pain, blood stagnating upward.
Ingredients: Chai Hu, Ju Pi (vinegar-fried, 2 qian each), Chuan Xiong (soaked in child's urine/cut), Shao Yao, Zhi Ke (fried, 1.5 qian each), Gan Cao (roasted, 0.5 qian), Xiang Fu (vinegar-fried, 1.5 qian), Shan Zhi (blackened with ginger juice, 1 qian), Wei Jiang (1 slice).
Decoct in water, take warm before meals. For hematemesis, add 0.5 zhong child's urine. (*Yitong*)

**Xiangke San**: For sudden onset of accumulated blood, chest/hypochondrium/lower abdominal pain.
Ingredients: Xiang Fu (ginger-fried, 3 qian), Zhi Ke (fried, 2 qian), Qing Pi (fried), Chen Pi, Wu Yao, Chi Shao Yao, Peng Ze (vinegar-fried, 1 qian each), Guo Wei (3 qian), Hong Hua (0.5 qian), Gan Cao (roasted 0.2 qian, raw 0.3 qian).
Powder, take 4-5 qian, decoct, strain, add 0.5 zhong child's urine, take warm on empty stomach. Assist with Taohe Black Sugar Wine. If ineffective, add Yan Hu Suo, Chuanshanjia. (Ibid.)