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Hemorrhagic diseases should be divided into three levels: epistaxis (nosebleed), hemoptysis (blood in saliva), hematemesis (vomiting blood), and vomiting belong to the upper level; blood binding in the chest belongs to the middle level; blood accumulation in the lower jiao (lower burner) belongs to the lower level. How, then, can blood accumulate?

Wu said: When the disease is in the Taiyang meridian (Taiyang channel syndrome), if sweating should have been induced but was not, stasis of blood remains inside, leading inevitably to blood binding. The *Huoren* (Book for Saving People) states: If sweating is missed and heat accumulates internally, the heat transforms into blood; the patient suffers from forgetfulness and behaves like a madman. When blood reverses upward, it causes forgetfulness; when blood accumulates downward, it causes internal urgency. Wu Youke stated: In plague diseases, if purgation is missed, pathogenic heat lingers for a long time without being discharged. Blood is constrained by heat, remaining in the meridians, deteriorating into purple-black blood, overflowing into the intestines and stomach, rotting into black blood. The stool color is like lacquer, yet defecation is surprisingly easy. Combining these three theories, the meaning of blood accumulation is fully elucidated. Generally, when the disease is in the Taiyang meridian and sweating is missed, heat is trapped inside. Blood is constrained by heat, first flowing into the meridians, then overflowing into the intestines and stomach; at this point, purgation should be employed. If purgation is again missed at this time, pathogenic heat lingers for a long time without discharge, stasis occurs in the lower jiao, causing fullness, urgency, and distension in the lower abdomen, with blue-purple veins visible on the skin, thus forming the syndrome of blood accumulation. Its manifestations include forgetfulness, behaving like a madman or actual madness, free urination, dark-colored stools, delirium, dryness, thirst, and a deep, solid, or knotted pulse; all are signs of blood accumulation.

When physicians examine patients, they should palpate whether the lower abdomen is full and painful, and immediately ask about urination. If urination is difficult, it indicates retention and binding of body fluids, and diuretics may be used. (This aspect requires double attention.) If urination is free, it is blood accumulation. If it is a Taiyang disease with heat binding in the Bladder (the primary meridian of Taiyang) accompanied by behaviors resembling madness, it is a mild case, suitable for treatment with Tao Ren Cheng Qi Tang (Peach Kernel Decoction to Order the Qi). (This aspect requires even greater attention.) If it is a Yangming disease with blood accumulation accompanied by forgetfulness, it is a severe case. Di Dang Tang (Wait-and-See Decoction) is difficult to use; one may substitute it with formulas similar to Cheng Qi Tang, adding blood-breaking herbs such as Tao Ren (Peach Kernel), Hong Hua (Safflower), and Gui Wei (Tail of Angelica Sinensis). Or, if there is concomitant deficiency, one may use Yu Zhu San (Jade Candle Powder) to purge, thereby removing blood accumulation and curing the disease.

What has been described above represents the general rule. I had a grandson named He, aged fourteen or fifteen. He contracted plague which persisted for over twenty days without resolution. His pulse was empty and weak, unresponsive to firm pressure, and he exhibited no symptoms of forgetfulness or madness. He merely slept drowsily throughout the day without waking clearly. Palpation of his abdomen revealed slight pain but no fullness, urgency, or distension. Some physicians proposed tonification, but I strongly opposed it. At that time, I was attending to my son’s illness and had no time to attend to my grandson; he had not taken any medicine. After waiting quietly for several days, he suddenly felt the urge to defecate and passed several dou [a unit of volume] of purple-black blood, instantly becoming clear-headed. Only then did I realize it was blood accumulation. Had tonics been administered at that moment, he would have died immediately. This suffices to show that those who treat plague know only the general rules but not the variations, much like writers and readers who die under the influence of punctuation marks. Can one not be cautious? I record this for the consideration of experts.