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An introduction:

What we now understand as 蓄血证 appears in two places in 《伤寒论》

1. First, we have 太阳蓄血证，where three sub-patterns and hence prescriptions are indicated:

   1. 桃核承气汤

   2. 抵当汤

   3. 抵当丸

2. Now we have 阳明蓄血证, where instead of exhibiting exterior signs like in 太阳蓄血证, the patient exhibiting 阳明 signs. Continue reading to understand more:

One situation (阳明蓄血证):

“阳明证，其人喜忘者，必有蓄血。所以然者，本有久瘀血，故令喜忘。(line 237a)

屎虽硬，大便反易，其色必黑者，宜抵当汤下之。(line 237b)

Line 237a: Here, we have a Yangming pattern where the person is absent-minded. Zhang avers that he HAS 蓄血. He explains further the reason is that blood stasis has been present for a long time already. This we can imagine as blood clogging up in his head, and lack of sufficient blood to his brain. This also suggest that the stasis is like to be not just in the head, but throughout the body.

Line 237b: Zhang goes on to elucidate on the symptoms. The shit that comes out is hard, however it’s easy to pass motion - different from most 阳明府施证 situatios where constipation is part of the deal. Also the shit that comes out is black in color. We can guess from the black shit that there should be a certain amount of upper-GIT bleeding, could be GU, could be DU. We also can infer from here the properties of 抵当汤 and its component herbs.

1. 大黄 (rhubarb), for example, is not just a laxative - it’s an excellent mover of blood, to take away the stasis, in this situation (see line 237a) specifically to treat any minor ishcemia in the brain.
2. 水蛭 (leeches) are not just blood-breakers (破血 i.e. aggressive blood movers), they are now know to be hemostatics, even from cerebral hemorrhage. They must be useful in treating what is likely GIT bleeding.

Another situation (阳明蓄血证):

“病人无表里证，发热七八日，虽脉浮数者，可下之。“ (line 257a)

假令已下，脉数不解，合热则消谷喜饥 ，至六七日不大便者，有瘀血，以抵当汤。” (line 257b)

Line 257a: The patient is not exhibiting exterior signs like fever, chills, aching; nor is he exhibiting interior signs like digestive problems and talking nonsense. Rather, he just continues having fever for seven, eight days. Despite the floating and rapid pulse (which tells us it is a n exterior illness treated by resolving the exterior), we can use precipitation.

Here, we get a sense of how this person is actually exhibiting a yangming pattern, but not too strongly. His fever is probably not that high - telling us that a 阳明实热证 diagnosis is out. The feeling you get is that making him sweat is not suitable, and his floating and rapid pulse doesn’t indicate “sweat it out” to me. It just tells me that his immune system is still working hard to get rid of some external pathogen, and not doing to well. The implication fromline 257a is that we could use a mild form of 承气汤, perhaps 调胃承气汤.

Line 257b: We are told that perhaps nothing will change even with precipitation. The patient’s immune system will still be working hard against the pathogen (read: rapid pulse) and he will be eating vociferously due to a metabolism which is at overdrive. And here’s the highlight: despite all the eating, he is not shitting for six to seven days - big time constipation! Mr. Zhang calls this blood-stasis, which makes sense from an imagery point of view. He suggests the use of 抵当汤.

I feel that 抵当汤 in line 257 is used slightly differently than in line 237. In line 237, it feels more like a regulator of blood rheology (血液流变学). Here in line 257, he feels more like a purgative with added blood-breaking effect of the two leeches 水蛭 and 虻虫. With this in mind, I would ask: why not 大小承气汤 instead? Why do we HAVE to use blood-breakers?

Last Point:

“若脉数不解，而下不止，必协热便脓血也。”

If still the rapid pulse remains (i.e. immune system still working hard) AND (WHAT’S WORSE) the precipitation is now overdone, we will definitely see pus and blood in the shit - this he calls 协热.

One thought: the pus and blood may not be due to the treatment. It could have already been developing as part of the disease process and just appeared after treatment was administered. This guy could already have contracted bacillary dysentery (细菌痢疾) or amoebic dysentery (阿米巴痢疾), whose symptoms only show now.

Using the available decoctions during Mr. Zhang’s time, 白头翁汤 and 黄芩汤 are possible treatment choices.