凡太阳病不解。其邪由经入腑。热结膀胱。则血凝蓄。血瘀则心气结。其人故如狂。
血自下者愈。邪从血下而解也。其外不解者。当先解其外。宜桂枝汤。外已解。但少
腹急痛者。是蓄血也。桃仁承气汤下之。
邵评∶太阳邪热。不从表出。随经入腑。腑者膀胱也。腑有余热。则经中之血。与热
相搏。蓄于下焦。名曰蓄血。热邪上熏于心。故其人如狂。若血不结而下出。则热
随血下而愈。如不愈。而少腹急结者。必用攻法以去之。欲用攻法。须先审其外
症。如外不解而攻之。血虽去。而外邪复入于里也。故必先解外邪。外邪已。而但
少腹急痛者。是蓄血也。用桃仁承气汤。以下血散热。乃先表后里之治法也。然此治蓄血之轻症。
太阳病六七日。表症仍在。脉微而沉者。病邪向里也。反不结胸者。热结下焦也。其
人发狂。少腹硬满。小便自利者。以太阳随经瘀血蓄于里也。抵当汤下之。则愈。
同一蓄血。桃仁承气治瘀血将结之时。抵当治瘀血已结之后。
邵评∶太阳六七日。表症仍在。而脉微沉。是经邪陷入太阳之府也。反不结胸而
发狂。其邪不在上。而热瘀下焦血分也。夫蓄血而致发狂。热势攻心。非用单刀
直入之将。必不能斩关取胜。是舍抵当逐血一法。更有何药破其坚垒哉。然此
蓄血之重症。故用抵当汤直攻其血。而罔顾表症。与上条先表后里不同。
又评∶此条经文表症仍在下。当有而反下之之句。误下。热邪自经入腑。结于膀
胱而下焦蓄血。不成血结胸病。则知觉昏昧。故发狂。此经病传腑。表病传里。气
病传血。上焦病而传下焦也。少腹居下焦。为膀胱之室。瘀血留结。故硬满。小便
自利者。病不在气。而在血也。下其血而气自舒。攻其里而表自解矣。
太阳病身黄。脉沉结。少腹硬。小便不利者。为无血也。此湿热不行之故。小便自利。
其人如狂者。血症谛也。
邵评∶身黄脉沉结。少腹硬。水病血病皆有之。小便不利。知水与热结。为无血而
有水。五苓散症也。若小便自利。其人如狂。乃热与血蓄于下焦。为有血无水。抵
当汤症也。故太阳热入膀胱。有水结血结之分也。
阳明病其人喜忘者。必有蓄血。盖心主血。血凝。则心气结。而失其官矣。故喜忘。此
素有瘀血。非伤寒所得者。屎虽硬。大便反易。其色必黑。以浮血随便而下故也。俱宜抵当汤下之。
邵评∶此借发黄小便不利。以辨蓄血之小便自利。瘀血是病根。喜忘是病情。此
阳明未病前症。夫心为血之主。瘀血与热蓄积既久。上干于心。故令喜忘。屎硬
者大盒饭难。今大便反易而黑色。是宿血瘀蓄之故。以此大便反易之机。因究
其色之黑。乃得其病之根。因知前此喜忘之病情耳。当用抵当汤入血破结之剂。下其瘀血。
血去。热亦不留矣。
伤寒有热。少腹满。应小便不利。今反利者。为有血也。当下之。不可峻药。宜抵当丸。
缓下其血。（以上述仲景论兼参来苏集类方注释之）
邵评∶有热。身热而表症仍在也。少腹满。热入下焦也。但满而不硬。其人未发狂。
何以知其有血。但热入下焦而少腹满。应小便不利。今小便利。预知其有蓄血
也。盖少腹之满。比硬稍轻。当小其制。故用丸以缓之。
又评∶此预蓄血。亦以小便之利与不利验之。上条以便易而黑。定其为蓄血。此
条以小便反利。辨其为蓄血。审症之精。极当细玩。
蓄血一症。虽病在血分。亦须分别阴阳治之。如血瘀上焦为阳。血蓄下焦为阴。太
阳失表。热瘀于里。血蓄下焦为阳。太阳误下。阳气下陷。血蓄下焦为阴。
邵评∶蓄血有阴阳之分。在上焦者为阳。在下焦者为阴。上焦由太阳失表。热与
血瘀。下焦由太阳误下。阳气下陷。
上焦蓄血。因不得汗。不能发斑。而蓄血也。其脉人迎必紧。紧者。数而有力之象也。
外症面红舌燥。发躁欲狂。或头摇目瞪。大便下血水。两手除食指之外。其余各指
皆抽掣是也。宜犀角、桃仁、生地、赤芍、归尾、丹皮、丹参、郁金之类。清之行之。
邵评∶蓄血上焦。有阳症而无阴症。治以清热破血之法。蓄血下焦。有阴症阳症
之不同。非比上焦蓄血。有阳症而无阴症也。下焦阳症。由邪热内入下焦。热邪
与瘀血蓄结膀胱。用攻血攻下治之。
下焦阳症蓄血即仲景所称热结膀胱之症。桃仁、大黄之属。下之是也。若下焦阴
症蓄血。乃因误下。阳气下陷。阴血受伤。血因寒而凝也。其见症面白目青。眉皱目
瞪。寒战口噤。舌苔白滑。大便下血水。两手除食指之外。其余各指皆抽掣是也。宜
温补之。如人参、附子、白术、当归、肉桂、桃仁、升麻、炙草之类。温补以升阳气。如服药
后。寒噤稍止。一二时复作者。此药力不及。再进之。以续阳气。寒噤得止者生。不已
则死。（参伤寒第一书）
凡蓄血症。大便下血水。见粪者生。不见者死。
邵评∶下焦阴症蓄血。由于误下。正气受伤。阳虚气陷。阴血凝蓄。此阴寒症也。与
阳邪内结而蓄血者。大为不同。医者极当留心。
凡是太阳病（太阳经受邪所致的病证）未能解除，其邪气由经络传入腑脏。热邪结聚于膀胱，导致血液凝滞蓄积。血瘀则心气郁结，因此患者会出现神志失常、似狂非狂的症状。
如果瘀血能自行排出，疾病就会痊愈，因为邪气随着瘀血的排出而得以解除。如果表证仍未解除，应当先解表证，适宜使用桂枝汤（Cinnamon Twig Decoction）。表证解除后，如果仅出现少腹拘急疼痛，这就是蓄血证。应用桃仁承气汤（Tao Ren Cheng Qi Tang）攻下治疗。
邵评：太阳经的邪热，不从体表发散，而是随经脉传入腑脏。腑脏指的是膀胱。腑中有残留的热邪，则经络中的血液与热邪相互搏结，蓄积在下焦，称为蓄血。热邪上熏于心，所以患者出现如狂的症状。如果血液不凝结而向下排出，则热邪随血液下行而病愈。如果病未愈，且少腹拘急结痛，必须用攻逐的方法去除病邪。想要使用攻法，必须先审查是否有表证。如果在表证未解时强行攻里，虽然瘀血去除了，但外邪会再次陷入体内。所以必须先解除外邪。外邪已解，仅仅出现少腹急痛，这才是蓄血证。使用桃仁承气汤，通过泻下瘀血来散热，这是先解表后治里的治疗方法。然而，这适用于蓄血的轻症。
太阳病经过六七天，表证仍然存在，脉象微而沉，说明病邪向里发展。反而没有形成结胸证，是因为热邪结聚在下焦。患者出现发狂、少腹硬满、小便自利的症状，这是因为太阳经的瘀血蓄积在体内。应用抵当汤（Di Dang Tang）攻下治疗，即可痊愈。
同样是蓄血证，桃仁承气汤用于治疗瘀血即将凝结之时；抵当汤用于治疗瘀血已经凝结之后。
邵评：太阳病六七天，表证仍在，脉象微沉，这是经邪陷入太阳之腑的表现。反而没有结胸却出现发狂，说明邪气不在上部，而是热瘀在下焦的血分。蓄血导致发狂，是热势攻心，如果不是用单刀直入的猛将，一定不能攻克关隘取得胜利。除了抵当汤逐血这一方法，还有什么药能攻破这种坚垒呢？然而，这是蓄血的重症，所以用抵当汤直接攻逐瘀血，而不顾表证，这与上一条先表后里的治法不同。
又评：这条经文说“表证仍在”，下面应当有“误下”的句子，意思是误用下法，热邪从经络传入腑脏，结于膀胱而导致下焦蓄血，没有形成血结胸病，导致知觉昏昧，所以发狂。这是经病传腑，表病传里，气病传血，上焦病传下焦。少腹位于下焦，是膀胱所在的部位。瘀血留结，所以少腹硬满。小便自利，说明病不在气分，而在血分。泻下瘀血则气机自然舒畅，攻逐里实则表证自然解除。
太阳病出现身黄，脉象沉结，少腹硬，小便不利的，是无瘀血，这是湿热阻滞不通的缘故。如果小便自利，患者出现如狂症状的，才是确凿的瘀血证。
邵评：身黄、脉沉结、少腹硬，水病和血病都可能出现。小便不利，可知是水与热结聚，属于无血而有水的情况，是五苓散证（Wu Ling San Syndrome）。如果小便自利，患者如狂，则是热与血蓄积在下焦，属于有血无水的情况，是抵当汤证。所以太阳热邪侵入膀胱，有水结和血结的区别。
阳明病患者如果出现健忘（喜忘），必定有蓄血。因为心主血，血液凝滞，则心气郁结，失去其正常功能，所以出现健忘。这是素来就有瘀血，并非伤寒新得的病证。大便虽然干硬，但排便反而容易，颜色必定发黑，这是因为离经之血随大便排出的缘故。这些都适宜用抵当汤攻下治疗。
邵评：这里借用发黄和小便不利，来辨别蓄血证的小便自利。瘀血是病根，健忘是病情表现。这是患者在阳明病发生之前的症状。心是血的主宰，瘀血与热邪蓄积日久，上扰于心，所以导致健忘。大便干硬通常难以排出，现在大便反而容易且呈黑色，这是宿血瘀蓄的缘故。根据大便反易的现象，进而探究其颜色发黑，才找到病的根源，从而知道此前健忘的病机。应当使用抵当汤这种入血破结的药剂，攻下瘀血。瘀血去除了，热邪也不复存在了。
伤寒发热，少腹胀满，应该小便不利，现在反而通利，是有瘀血的表现。应当攻下，但不可用峻烈药物，适宜用抵当丸（Di Dang Wan），缓攻以祛除瘀血。（以上论述参考仲景理论并参合《类方注释》）
邵评：发热，指身体发热且表证仍在。少腹胀满，说明热邪进入下焦。只是胀满而没有硬结，患者也没有发狂。如何知道有瘀血呢？只要热邪进入下焦导致少腹胀满，按理应该小便不利，现在小便通利，预先推断是有蓄血。因为少腹胀满比硬满稍轻，所以应减小药量，故用丸剂以缓和攻下。
又评：此条是预判蓄血，也是通过小便的通利与否来验证。上一条通过大便易下且色黑，确定其为蓄血；此条通过小便反利，辨别其为蓄血。审察病症的精微之处，极应当仔细玩味。
蓄血一症，虽然病在血分，也必须分别阴阳进行治疗。如血瘀在上焦为阳证，血蓄在下焦为阴证。太阳病失于发汗解表，热邪瘀滞在里，血蓄在下焦，此为阳证。太阳病误用下法，阳气下陷，血蓄在下焦，此为阴证。
邵评：蓄血有阴阳之分。在上焦的为阳证，在下焦的为阴证。上焦蓄血是由于太阳病失于解表，热与血瘀结；下焦蓄血是由于太阳病误下，阳气下陷。
上焦蓄血，因为不能出汗，不能发斑疹，而导致的蓄血。其脉象人迎穴必紧，紧脉是数而有力的脉象。外在症状表现为面红舌燥，烦躁欲狂，或者头摇目瞪，大便下血水，两手除食指外，其余各指皆出现抽搐。适宜使用犀角、桃仁、生地、赤芍、归尾、丹皮、丹参、郁金等药物，进行清热活血治疗。
邵评：上焦蓄血，只有阳证而没有阴证，治疗采用清热破血的方法。下焦蓄血，有阴证和阳证的不同，不像上焦蓄血只有阳证而无阴证。下焦阳证蓄血，是由邪热内入下焦，热邪与瘀血蓄结膀胱所致，用攻血攻下的方法治疗。
下焦阳证蓄血，即仲景所称的热结膀胱之症，使用桃仁、大黄之类的药物攻下即是。如果是下焦阴证蓄血，乃因误用下法，阳气下陷，阴血受伤，血液因寒而凝滞。其症状表现为面色白、眼睛青暗，皱眉目瞪，寒战口噤，舌苔白滑，大便下血水，两手除食指外，其余各指皆抽搐。适宜温补治疗，如人参、附子、白术、当归、肉桂、桃仁、升麻、炙甘草等药物，温补以提升阳气。如果服药后，寒战稍止，过一二小时又发作，这是药力不够，再进服药物，以接续阳气。寒战停止者可生，不停止则死。（参《伤寒第一书》）
凡是蓄血证，大便下血水，见到粪便的预后良好（生），不见到粪便的预后不良（死）。
邵评：下焦阴证蓄血，由于误用下法，正气受伤，阳虚气陷，阴血凝蓄，这是阴寒证。与阳邪内结而导致的蓄血，大为不同。医者极应当留心注意。
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.