方书皆以唇干口燥，漱水在口不得下咽以定上焦蓄血；小腹硬满，小水自利，以定下焦蓄
血。至身黄，如狂，发狂喜忘，乃是蓄血症中之症。故伤寒叙蓄血症与狂乱症中，互相发
明。看伤寒以手按其心下及两胁，渐至大小腹，但有硬处，当询其小便利否。若小便不利
者，或者气结溺涩，非蓄血症。若小便自利，兼有身黄目黄，如狂喜忘，漱水不得下咽等
症，即是蓄血，急以桃仁承气汤、抵当汤下之。若小腹绕脐硬痛，口渴消水，大便不通，时
有失气，此非蓄血，乃是燥屎硬满。按蓄血治法，有上中下三条。伤寒失汗，淤其血于上
焦，用犀角地黄汤；如狂喜忘，心下满，淤其血于中焦，桃仁承气汤；小腹硬痛，小便自利，
淤其血于下焦，抵当汤主之。然桃仁承气汤，虽治中焦，并治下焦。抵当汤虽主下焦，兼治
中焦。按仲景原文，其用抵当汤五条，用桃仁承气者一，言有淤血当下者三，至犀角地黄
汤，乃后人补入者。余谓衄血、吐血，未曾淤蓄内结者可用。若蓄聚淤结，犀角地黄凝滞，
当用桃仁承气抵当汤，散结逐淤为当矣。若蓄结既行，再以犀角地黄汤、当归红花汤调血养
血，亦为至当。陶氏云∶上焦衄血，可用犀角地黄汤。如无犀角，以升麻代之。此因同散阳
明血热之药耳。家秘治中焦血热血结，恐犀角凝滞，易以升麻清胃汤，加桃仁、红花。此又
难用犀角，以升麻代之也。
太阳不解，热结膀胱，其人如狂，血自下者愈。其外不解者，尚未可攻，当先解外。外已
解，但小腹急结者，乃可攻之。宜桃核承气汤。
此条不以小便利不利以定血，惟以其如狂，断其蓄血下焦，当攻其血。然表邪未解，当先
解外邪。表解，小腹胀急，乃可攻之。
太阳病六七日，表症仍在，脉微而沉，反不结胸，其人发狂者，以热在下焦，小腹当硬满。
小便自利，下血乃愈。所以然者，以太阳经淤热在里故也。抵当汤主之。
太阳病，六七日，表症仍在，当散表。今脉微而沉，且不结胸，而发狂者，必血结下焦。
而小腹硬满，小便自利，攻下其血乃愈。抵当汤主之。所以宜用此汤者，以淤热在太阳下
焦之里故也。
太阳病，身黄，脉沉结，小腹硬，小便不利者，为无血也。小便自利，其人如狂者。血症
谛，抵当汤主之。
太阳身黄，脉沉结，小腹硬，有两条。若小腹硬而不狂，小便不利，此热结膀胱之水，当
用五苓散；若小腹硬，小便自利如狂者，此热结下焦之血，故用抵当汤。二条并详发黄。
伤寒有热，小腹满，应小便不利，今反利者，为有血也，当下之，不可用余药。宜抵当丸。
此条重申小腹满，小便利者，的是有血。较上章多有热二字，则易抵当为丸，以示留恋浓
重去热方尽。
阳明病，其人喜忘者，必有蓄血。所以然者，本有久淤，故令喜忘。屎虽硬，大便反易，其
色必黑，抵当汤下之。
此二章申明用抵当汤真诀，血淤于内则喜忘，且大便硬，反润滑易出，验其色又黑，确是
蓄血，故用抵当汤。
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，其人自言吾
满，为有淤血。
胸满痿黄，似脾胃湿热。但舌青色，口燥漱水，不欲下咽。无寒热，脉又微大来迟，他人
不见腹满，自言胀满，则外不胀，而内胀急，故断其淤血。
病者如热状，烦满口干燥而渴，其脉反无热，此为伏阴，是淤血，也下之。
病如热状，且见烦满，口干燥而渴，其脉反不数大，乃是阳邪伏于阴分，故知其为淤血，
宜下之。前条以脉大来迟，而断其血；此条以脉反无热，而断其血也。
少阴病，脉沉细，手足冷，或时发燥作渴，亦漱水不欲咽者，宜四逆汤温之。
下利厥逆，无脉，干呕烦渴，欲漱口，不欲咽，宜通白四逆汤、加猪胆、人尿同服。厥阴蛔
厥，口燥舌燥，时时欲凉水浸舌反唇，一刻不可离，又不欲咽下，宜理中汤加乌梅主之。
以上三条，言阴极发躁，亦有漱水在口，不欲咽下者，故用四逆理中等汤温之。
红花桃仁汤
红花 桃仁 赤芍药 当归身
此方行血而无推荡，活血而无凝滞。家秘加山楂、香附，以散凝结；加山栀，以散热结；
加韭汁，以散寒结。
犀角地黄汤 见衄血。
此方本治衄血吐血，今因火伤上焦，故可用之。
桃仁承气汤
桃仁 大黄 芒硝 桂枝 甘草
此汤加桃仁佐大黄，行下焦蓄血；加桂枝散下焦凝结之血。家秘加枳朴，以血随气行；加
当归、芍药，去旧中即为生新地步。
抵当汤
水蛭 虻虫 桃仁 大黄
血蓄下焦，沉结牢实，直至小腹硬痛，不得不用此方。
当归红花汤 二味。
此活血之方，非行血者。血虚人有停淤，以此方加山楂、桃仁，为轻行之法。
当归桃仁汤 二味。
此亦轻剂，但以桃仁易红花，则稍重前方。此等方法，示后人婉转，而戒卤莽。
医书通常以嘴唇干燥、口中含水却不愿咽下，来判定为上焦蓄血；以小腹硬满、小便通畅，来判定为下焦蓄血。至于身体发黄、神志如狂或发狂、容易遗忘等症状，则是蓄血证中伴随的症状。因此，《伤寒论》在叙述蓄血证与狂乱证时，二者相互阐发说明。诊察伤寒病时，用手按压患者心下部及两侧胁肋部，逐渐向下按压至大腹部和小腹部，只要发现有硬结之处，就应当询问其小便是否通利。如果小便不利，可能是气机郁结导致排尿涩滞，并非蓄血证。如果小便自利，兼有身体发黄、眼睛发黄、神志如狂、容易遗忘、口中含水不愿咽下等症状，即是蓄血证，应立即使用桃仁承气汤或抵当汤攻下瘀血。如果小腹部绕脐部硬痛，口渴且饮水即消，大便不通，时常放屁，这不是蓄血证，而是燥屎内结硬满。按照蓄血的治疗方法，分为上、中、下三条途径。伤寒病失于发汗治疗，瘀血阻滞于上焦，使用犀角地黄汤；出现神志如狂、容易遗忘、心下部胀满，是瘀血阻滞于中焦，使用桃仁承气汤；小腹部硬痛、小便自利，是瘀血阻滞于下焦，由抵当汤主治。然而桃仁承气汤，虽然主要治疗中焦，也兼治下焦；抵当汤虽然主治下焦，也兼治中焦。根据张仲景的原文，使用抵当汤的情况有五条，使用桃仁承气汤的有一条，提到有瘀血应当攻下的情况有三条，至于犀角地黄汤，乃是后人补入的内容。我认为对于衄血（鼻出血）、吐血，未曾形成内部瘀结滞留的情况可以使用。如果已经蓄积瘀结，犀角地黄汤性质凝滞，应当使用桃仁承气汤和抵当汤，以消散结聚、驱逐瘀血为宜。如果蓄结瘀血已经攻下排出，再使用犀角地黄汤或当归红花汤调理血液、滋养血液，也是极为恰当的。陶氏说：上焦衄血，可以使用犀角地黄汤。如果没有犀角，可以用升麻代替。这是因为它们同属于发散阳明经血热的药物。我家秘传的治法治疗中焦血热血结，担心犀角性质凝滞，改用升麻清胃汤，加入桃仁、红花。这又是难以使用犀角时，用升麻代替的方法。
太阳病不解，热邪结聚于膀胱，患者出现神志如狂的症状，如果瘀血自行排出则病愈。如果表证仍未解除，尚不可攻下，应当先解表。表证已解，仅见小腹部急迫拘结，才可以攻下。适宜使用桃核承气汤。
这一条不是通过小便通利与否来判断是否有瘀血，而是仅凭患者神志如狂，判断为下焦蓄血，应当攻逐瘀血。然而表邪未解，应当先解除外邪。表邪解除后，小腹胀急，才可以攻下。
太阳病六七日，表证仍在，脉象微而沉，反而没有形成结胸证，患者出现发狂症状，是因为热邪在下焦，小腹部应当硬满。小便自利，排出瘀血后病愈。之所以这样，是因为太阳经的瘀热内陷于里的缘故。主治方剂为抵当汤。
太阳病，六七日，表证仍在，应当疏散表邪。如今脉象微而沉，且不形成结胸，却出现发狂，必定是血结于下焦。小腹部硬满，小便自利，攻下瘀血后病愈。主治方剂为抵当汤。之所以适宜使用此方，是因为瘀热位于太阳经下焦之里的缘故。
太阳病，身体发黄，脉象沉结，小腹部硬，小便不利的，是无瘀血。如果小便自利，患者神志如狂的，是蓄血证的确凿证据，主治方剂为抵当汤。
太阳病身黄，脉沉结，小腹部硬，有两种情况。如果小腹部硬但不发狂，小便不利，这是热结膀胱的水饮病，应当使用五苓散；如果小腹部硬，小便自利且神志如狂，这是热结下焦的瘀血病，所以使用抵当汤。这两条都详细记载于发黄篇中。
伤寒病有发热，小腹部胀满，应当小便不利，如今反而小便通利，是有瘀血，应当攻下，不可使用其他药物。适宜使用抵当丸。
这一条重申小腹部胀满、小便通利的，确实是有瘀血。比上一章多了“有热”二字，则将抵当汤改为丸剂，以示药力留恋体内，浓重地去除热邪，力求尽除。
阳明病，患者容易遗忘的，必定有蓄血。之所以这样，是因为原本就有久存的瘀血，所以导致容易遗忘。大便虽然干硬，但排便反而容易，颜色必定发黑，使用抵当汤攻下。
这两章阐明使用抵当汤的真谛，瘀血在内则容易遗忘，且大便干硬，反而润滑易出，检验其颜色又发黑，确是蓄血，故使用抵当汤。
病人感觉胸部满闷痞塞，舌色青紫，口干燥，只含水漱口而不愿咽下，无恶寒发热，脉象微大且来势迟缓，腹部外观不满，但病人自己说感到胀满，这是有瘀血。
胸满痿黄，看似脾胃湿热。但舌色青紫，口干燥且含水漱口不愿咽下。无恶寒发热，脉象又微大且来势迟缓，旁人未见腹部胀满，病人自称胀满，则是外部不胀，而内部胀急，故断定为瘀血。
病人像有热状，烦闷，口干燥而渴，但脉象反而没有热象，这是伏阴，属于瘀血，应当攻下。
病人像有热状，且见烦闷，口干燥而渴，但脉象反而不数大，乃是阳邪潜伏于阴分，故知其为瘀血，适宜攻下。前一条通过脉大来迟，判断为瘀血；这一条通过脉象反而无热，判断为瘀血。
少阴病，脉象沉细，手足冰冷，有时出现烦躁作渴，也是口中含水不愿咽下，适宜使用四逆汤温补。
下利厥逆，无脉，干呕烦渴，想要漱口但不愿咽下，适宜使用通白四逆汤，加猪胆、人尿同服。厥阴蛔厥，口燥舌燥，时时想用凉水浸湿舌头和嘴唇，一刻也不能离开，但又不愿咽下，适宜使用理中汤加乌梅主治。
以上三条，讲的是阴极发躁，也有口中含水不愿咽下的情况，故使用四逆汤、理中汤等温补。
红花桃仁汤
红花 桃仁 赤芍药 当归身
此方行血而无推荡之力，活血而无凝滞之弊。家传秘方加入山楂、香附，以消散凝结；加入山栀，以散热结；加入韭汁，以散寒结。
犀角地黄汤 见衄血章节。
此方本用于治疗衄血、吐血，如今因火邪损伤上焦，故可以使用。
桃仁承气汤
桃仁 大黄 芒硝 桂枝 甘草
此汤加入桃仁辅助大黄，行下焦蓄血；加入桂枝消散下焦凝结之血。家传秘方加入枳实、厚朴，以使血随气行；加入当归、芍药，去旧生新。
抵当汤
水蛭 虻虫 桃仁 大黄
瘀血蓄积于下焦，沉结牢固坚实，直至小腹部硬痛，不得不用此方。
Medical books generally use dry lips and mouth, with water held in the mouth but not swallowed, to diagnose upper jiao blood stasis; and a hard, full lower abdomen with free urination to diagnose lower jiao blood stasis. Symptoms such as yellowing of the body, manic-like behavior, mania, and forgetfulness are accompanying symptoms within the blood stasis syndrome. Therefore, in the *Shanghan Lun* (Treatise on Cold Damage), the descriptions of blood stasis syndrome and manic disorder mutually elucidate each other. When examining cold damage diseases, press the patient's epigastrium and both hypochondriac regions with your hand, gradually moving down to the greater and lesser abdomens. If any hardness is found, inquire whether urination is free. If urination is obstructed, it may be due to qi stagnation causing dysuria, not blood stasis. If urination is free, accompanied by yellowing of the body and eyes, manic-like behavior, forgetfulness, and holding water in the mouth without swallowing, it is blood stasis. Immediately treat with Tao Ren Cheng Qi Tang or Di Dang Tang to purge the stasis. If there is hard pain around the umbilicus in the lower abdomen, thirst with rapid consumption of water, constipation, and frequent passage of flatus, this is not blood stasis, but dry feces accumulation. According to the treatment methods for blood stasis, there are three pathways: upper, middle, and lower. If cold damage is treated by neglecting sweating therapy, blood stasis occurs in the upper jiao; use Xi Jiao Di Huang Tang. If there is manic-like behavior, forgetfulness, and epigastric fullness, blood stasis is in the middle jiao; use Tao Ren Cheng Qi Tang. If there is lower abdominal hard pain with free urination, blood stasis is in the lower jiao; Di Dang Tang is the primary formula. However, Tao Ren Cheng Qi Tang, although treating the middle jiao, also treats the lower jiao; Di Dang Tang, although primarily for the lower jiao, also treats the middle jiao. According to Zhang Zhongjing's original text, Di Dang Tang is used in five instances, Tao Ren Cheng Qi Tang in one instance, and there are three mentions of purging when blood stasis is present. Xi Jiao Di Huang Tang was added by later authors. I believe that for nasal bleeding (nu xue) or hematemesis without internal stasis accumulation, it can be used. If stasis has accumulated and knotted, Xi Jiao Di Huang Tang is too cloying/stagnant; one should use Tao Ren Cheng Qi Tang and Di Dang Tang to dissipate knots and drive out stasis. After the stasis accumulation has been expelled, using Xi Jiao Di Huang Tang or Dang Gui Hong Hua Tang to regulate and nourish the blood is also highly appropriate. Tao Shi stated: For upper jiao nasal bleeding, Xi Jiao Di Huang Tang can be used. If Rhinoceros Horn is unavailable, Sheng Ma can substitute it. This is because they share the property of dispersing Yangming blood heat. My family's secret method for treating middle jiao blood heat and knotting avoids the stagnant nature of Rhinoceros Horn by using Sheng Ma Qing Wei Tang, adding Tao Ren and Hong Hua. This is another substitution for Rhinoceros Horn.
If Taiyang disease does not resolve, and heat knots in the Bladder, the person becomes manic-like. If blood passes spontaneously, the disease heals. If exterior symptoms remain unresolved, attack is not yet permissible; first resolve the exterior. Once the exterior is resolved, if only the lower abdomen feels urgent and knotted, then attack is permissible. Use Tao He Cheng Qi Tang.
This clause does not determine blood stasis by the presence or absence of free urination, but solely by the manic-like state, diagnosing lower jiao blood stasis requiring attack. However, since exterior pathogens are unresolved, exterior pathogens must be resolved first. Once the exterior is resolved and the lower abdomen is distended and urgent, attack can proceed.
In Taiyang disease lasting six or seven days, if exterior symptoms persist, the pulse is faint and deep, and there is no Jie Xiong (Chest Binding) syndrome, but the person goes mad, it is because heat is in the lower jiao, and the lower abdomen should be hard and full. With free urination, passing blood leads to recovery. The reason is that heat from the Taiyang channel has entered the interior as stasis-heat. Di Dang Tang is indicated.
In Taiyang disease, after six or seven days, if exterior symptoms persist, exterior should be dispersed. Now, with a faint and deep pulse, no Jie Xiong, but madness, it must be blood knotting in the lower jiao. With a hard, full lower abdomen and free urination, purging the blood leads to recovery. Di Dang Tang is indicated. This formula is suitable because stasis-heat resides in the interior of the lower jiao of the Taiyang channel.
In Taiyang disease, if the body is yellow, the pulse is deep and knotted, the lower abdomen is hard, and urination is obstructed, there is no blood stasis. If urination is free and the person is manic-like, this is definitive evidence of blood stasis; Di Dang Tang is indicated.
There are two cases of Taiyang with yellowing, deep knotted pulse, and hard lower abdomen. If the lower abdomen is hard without mania and urination is obstructed, this is water-knotting in the Bladder due to heat; use Wu Ling San. If the lower abdomen is hard, urination is free, and the person is manic-like, this is blood-knotting in the lower jiao due to heat; thus, use Di Dang Tang. These two cases are detailed in the Jaundice chapter.
In cold damage with fever, if the lower abdomen is full, urination should be obstructed. If it is now free, there is blood stasis; purge it. Do not use other medicines. Use Di Dang Wan (Pill).
This clause reiterates that lower abdominal fullness with free urination indicates definite blood stasis. Compared to the previous chapter, the addition of "with fever" suggests changing Di Dang Tang to a pill form to indicate a lingering, heavy action to thoroughly remove heat.
In Yangming disease, if the person is prone to forgetfulness, there must be blood stasis. The reason is pre-existing long-standing stasis causes forgetfulness. Although stool is hard, defecation is surprisingly easy, and the color is definitely black; use Di Dang Tang to purge.
These two chapters clarify the true principle of using Di Dang Tang. Internal blood stasis causes forgetfulness; stool is hard but slippery and easy to pass; checking the color reveals blackness. This confirms blood stasis, hence Di Dang Tang is used.
The patient presents with chest fullness and stifling, cyan tongue, dry mouth, holding water in the mouth without swallowing, no aversion to cold or fever, pulse slightly large and slow in arrival, no visible abdominal distension though the patient claims fullness. This indicates blood stasis.
Chest fullness and sallow complexion resemble Spleen-Stomach damp-heat. But with a cyan tongue, dry mouth, and holding water without swallowing, plus no chills/fever and a slightly large, slow pulse, while others see no abdominal distension but the patient complains of it, the exterior is not distended but the interior is urgently distended; thus, blood stasis is diagnosed.
The patient appears to have heat, with irritability and fullness, dry mouth and thirst, but the pulse shows no heat signs. This is hidden Yin, indicating blood stasis; purge it.
The patient resembles heat presentation with irritability, dry mouth, and thirst, but the pulse is not rapid or large. This indicates Yang pathogen hidden in the Yin level, confirming blood stasis; purge it. The previous clause diagnosed blood stasis via a large, slow pulse; this clause diagnoses it via a pulse lacking heat signs.
In Shaoyin disease, with a deep, fine pulse, cold hands and feet, occasional irritability and thirst, and holding water in the mouth without swallowing, use Si Ni Tang to warm.
For diarrhea, cold extremities, absent pulse, dry heaves, irritability, thirst, wanting to rinse the mouth but not swallow, use Tong Bai Si Ni Tang, administered with Pig Gallbladder juice and Human Urine. For Jueyin Ascaris colic, with dry mouth and tongue, constantly desiring to soak tongue and lips in cool water without swallowing, use Li Zhong Tang with Mei Zi (Mume Fruit).
The above three clauses discuss extreme Yin generating false agitation, where water is held in the mouth without swallowing; thus, warming formulas like Si Ni Tang and Li Zhong Tang are used.
Hong Hua Tao Ren Tang (Safflower and Peach Kernel Decoction)
Hong Hua (Carthami Flos)
Tao Ren (Persicae Semen)
Chi Shao Yao (Paeoniae Radix Rubra)
Dang Gui Shen (Angelicae Sinensis Radix - Root Body)
This formula moves blood without harsh pushing/draining, and invigorates blood without causing stagnation. Family secret adds Shan Zha (Crataegi Fructus) and Xiang Fu (Cyperi Rhizoma) to dissipate knotting; adds Shan Zhi (Gardeniae Fructus) to clear heat knotting; adds Jiu Zhi (Allii Tuberosi Juice) to dissipate cold knotting.
Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) See Nu Xue (Nasal Bleeding) section.
This formula originally treats nasal bleeding and hematemesis. Now, due to Fire injuring the upper jiao, it can be used.
Tao Ren Cheng Qi Tang (Peach Kernel Decoction to Direct the Qi)
Tao Ren (Persicae Semen)
Da Huang (Rhei Radix et Rhizoma)
Mang Xiao (Natrii Sulfas)
Gui Zhi (Cinnamomi Ramulus)
Gan Cao (Glycyrrhizae Radix et Rhizoma)
This decoction adds Tao Ren to assist Da Huang in moving lower jiao blood stasis; adds Gui Zhi to dissipate coagulated blood in the lower jiao. Family secret adds Zhi Shi (Aurantii Fructus Immaturus) and Hou Po (Magnoliae Officinalis Cortex) so blood follows Qi movement; adds Dang Gui and Shao Yao to eliminate the old and generate the new.
Di Dang Tang (Di Dang Decoction)
Shui Zhi (Hirudo)
Meng Chong (Ophryognathia)
Tao Ren (Persicae Semen)
Da Huang (Rhei Radix et Rhizoma)
When blood accumulates in the lower jiao, sinking and knotting firmly, leading to hard, painful lower abdomen, this formula is indispensable.
Dang Gui Hong Hua Tang (Angelica and Safflower Decoction) Two ingredients.
This is an invigorating blood formula, not a moving/purging blood formula. For blood-deficient persons with stagnant stasis, add Shan Zha and Tao Ren to this formula as a mild moving method.
Dang Gui Tao Ren Tang (Angelica and Peach Kernel Decoction) Two ingredients.
This is also a mild formula. Replacing Hong Hua with Tao Ren makes it slightly heavier than the previous formula. This method teaches later generations to be tactful and warns against rashness.