经义
阳明司天，咳不止，而白血出者死。○怒则气逆，甚则呕血。（《素问》）
哲言
夫吐血，咳逆上气，其脉数而有热，不得卧者死。○酒客咳者，必吐血。此因极饮所致。（《金匮》）
心主血而不能藏，夜则复归于肝；肝藏血而不能主，昼则听命于心。心为君，肝为相，君火一动，相火
从之，相火一动，六经之火从之，火动则血随以动，火升则血随以升。（《明医指掌》）
涎唾中有少血散漫者，此肾中相火炎上之血也。若血如红缕，从痰中咳出者，此肺络受热伤之血也；
若咳出白血，浅红色似肉似肺者，必死。（朱丹溪）
失血于口者，有咽、喉之异。盖上焦出纳之门户，惟咽、喉二窍而已。咽为胃之上窍，故由于咽者必出
于胃；喉为肺之上窍，故由于喉者必出于肺。然喉连于肺，而实统五脏之清道；咽连于胃，而实统六腑之浊道。
此其出于肺者，人知病在五脏，而不知其出于胃者，亦多有由于脏也。《经》曰∶五脏者，皆禀气于胃。胃者，
五脏之本也。然则五脏之气，皆禀于胃，而五脏之病，独不及于胃乎？今见吐血之证，古人云呕血者出于胃，
而岂知其亦由于脏也。盖凡胃火盛而大吐者，此本胃家之病，无待言也。至若怒则气逆，甚则呕血者，亦出于
胃，此气逆在肝，木邪乘胃而然也。又知欲火上炎，甚则呕血者，亦出于胃，此火发源泉，阴邪乘胃而然也。
由此观之，则凡五志之火，皆能及胃，而血出于咽者，岂止胃家之病？但咳而出者，必出于喉，出于喉者，当
察五脏；呕咯而出者，必出于咽，出于咽者，则五脏六腑皆能及之。且胃以水谷之海，为多气多血之府，而实
为冲任血海之源，故凡血枯经闭者，当求生血之源，源在胃也；呕血吐血者，当求动血之源，源在脏也。○凡
咳血、嗽血者，诸家皆言其出于肺；咯血、唾血者，皆言其出于肾。是岂足以尽之？而不知咳、嗽、咯、唾等
血，无不有关于肾也。何也？盖肾脉从肾上贯肝膈，入肺中，循喉咙，夹舌本，其支者，从肺出，络心，注胸
中。此肺肾相连，
而病则俱病矣。且血本精类，而肾主五液，故凡病血者，虽有五脏之辨，然无不由于水亏，水亏则火盛，火盛
则刑金，金病则肺燥，肺燥则络伤而嗽血，液涸而成痰。此其病标固在肺，而病本则在肾也。苟欲舍肾而治血，
终非治之善者，第肾中自有水火，水虚本不能滋养，火虚尤不能化生，有善窥水火之微者，则洞垣之目无过是
矣。（张景岳）
心无血养则生热，热气熏胸中，以致金畏热而不敢降，一呼一吸，仅在分寸间作潜伏状，火既熏蒸于下，
气复促逼于上，凡筋膜间之若津若液，皆被火煎成血，而随燥气上升，咳、吐、咯间，莫不带红。欲求血之不
枯、液之不竭，不可得也。惟宜保定心肺之气，取生养于甘凉，使液足于上，降下荫及营阴而益水，燥热门中
雾露之溉也。○制火者，不独水也，血足亦令焰息。血，阴类也。阴虚之人，水亏不能滋木，营血必伤。所以
阳火独治，而不得血润，则必吸动肾水以自救，无奈滴水不能济盛火，反从火化而升煎成血。咯血云出于肾者
此也。（程郊倩）
吐血一证，人惟知气逆血溢，火升血泛，不知血在脏腑，另有膈膜隔定，其血不能渗溢。夫膈膜者，极
薄极脆，凡有所伤则破，破则血溢于上矣。（刘默生）
补编
吐血不止者，柏叶汤主之。○心气不足，吐血、衄血，泻心汤主之。（《金匮》）
按∶心气不足二字，当是有余二字。若是不足，如何用此方治之？必是传写之讹。（《医宗金鉴》）
治吐血有三诀∶宜行血不宜止血。血不循经络者，气逆上壅也。行血则循经络，不止自止；止之则血凝，
血凝则发热、恶食，病日痼矣。宜补肝不宜伐肝。《经》曰∶五脏者，藏精气而不泻者也。肝藏血，吐血者，
肝失其职也。养肝则肝气平，而血有所归；伐肝则肝虚不能藏血，血愈不止矣。宜降气不宜降火。气有
余便是火，气降则火降，火降则气不上升，血随气行而无溢出上窍之患矣。降火必用寒凉，反伤胃气，胃气伤
则脾不能统血，血愈不能归经矣。（缪仲淳）
《经》曰中焦取汁，化而为赤，是谓血。又曰奉心化赤而为血。是血虽生于心藏于肝，而实由于中焦水谷
之精微化生者也。医者一见血证，便以为热，概用清凉，初病火旺者，服之亦愈；若中气虚弱之人，屡发屡服，
未有不伤脾土者也。脾土一伤，绝其化源，而不毙者鲜矣。凡痰中带血，或吐一、二口不多者，乃络脉之血，
最易伤人。《经》曰∶阳络伤，血外溢。若不咳嗽，尚可医治；血虽止而咳不止，虽仙莫救。间有生者，或富
贵有力，信任明医，十中可得一、二；若贫贱之人，百无一生。其有大吐数碗，乃冲任之血充肤热肉渗皮毛者
也，能食无嗽喘证，虽多无伤，调理亦易。颇有自少吐至老者，亦有倾盆而来不可遏止，一、二日即死者。要
之，少者，经络之血，经络通脏腑，虽少最深；多者，皮肤之血，皮肤在外，虽多亦浅。俗医以为多者属胃血，
少者属脏血，不知脏者藏也，不可以伤。真藏之血，若吐一口，不出五日即死，尚奚治焉？夫吐血虽属伤阴，治
宜滋阴养血，然亦有阳虚不能摄血而外溢者，宜用参、苓、 、术补气摄血。若阳虚已极，畏寒足冷，饮食不
进，呕吐泄泻者，急用姜、桂、附子，勿泥吐血属火，而概用滋阴也。（吴仁斋）
痰中带血，多属脾经，须分痰血先后施治。先见血而后嗽痰者，此相火上炎，煎熬成痰，治宜降火为主。
若用消痰之药，则血溢而不止。先痰嗽而后见血者，是极热生痰，载血上行，治宜消痰为要。若用止血之药，
则痰滞而不行。（《证治汇补》）
气有余便是火，血随气上，补水则火自降，顺气则血不逆。阿胶、牛膝、丹皮，补水之药也；苏子、橘
红、沉香，顺气之药也。童便者，引血归下窍，兼有行瘀之能；藕汁者，达血使无滞，而有止涩之力。（《原病式》）
吐血之后，当以胃药收功。此语最好。予用参苓白术散煎去头渣，服二、三渣，或为丸药，亦煎去头渣，
甚效。（周慎斋）
脉候
肺脉搏坚而长，当病唾血。○心脉微涩，为血溢。○秋脉不及，则令人喘，呼吸少气而咳，上气见血。（《素问》）
选案
张芝园性嗜生冷，复受寒邪，自用消散，忽然吐血，又用清凉，已濒于危，诊脉微迟，身凉面白，视其血，
黑而臭。此胃气不能传化，阳虚阴走耳。用木香理中汤，霍然。○王周益失血，每岁一发，服理中汤颇效，近
发服之无功。予谓∶血证服理中，乃阳虚阴走，行浊道而出于胃者。此乃肾阴失守，夹肝气而冲于肺，肺不能
纳，故犯清道而咳逆并至也。与生地、丹皮、归尾、山药、茯苓、麦冬、五味、泽泻，加柴胡少许，立安。（程华仲）
黄湛侯素有失血证，晨起陡暴一口，倾血一盆，喉间气涌，神思飘荡，壮热如蒸，颈筋粗劲，诊脉尺中甚
乱。此犯房劳，自不用命也。验血色如太阳之红，谓曰∶少阴之脉，系舌本。少阴者，肾也。今肾家之血汹涌
而出，舌本已硬，无法可救，不得已用丸药一服，镇安元气，若得气转丹田，尚可缓图。因煎参汤，下黑锡丹
三十粒，喉间 有声，渐下入腹，顷之，舌柔能言。亟用润下之剂以继前药，遂与阿胶一两，溶化，分三次，
半日服尽，身热渐退，颈筋渐消，进粥与补肾药，多加秋石而愈。（喻嘉言）
鲍献书年二十余，每晨洗面，口觉血腥，吐血三口，因延至午后洗面，其吐亦然，诸医莫晓其故，诊脉滑
数，两寸特甚。予曰∶头面诸阳之会，阴虚则阳亢，阳亢则血不循经，因洗 而透下咽喉也。理宜滋阴凉血，
则阴分不虚，阳分不亢，阴阳平和，血循经络，喉血自无。乃用四物汤加丹皮、红花生血凉血为君，黄柏滋肾
为臣，麦冬清肺为佐，荆芥、泽兰清头面为使，少加童便降火。服十剂血减半。或议去红花、丹皮、童便，
血吐如初，
仍加前味服之而愈。（余午亭）
一人体素强，年近七旬，忽呕血，脉弦强，与清热平肝之剂，血遂止。一月后，胸中泛泛，又吐数口，服
药又止。一夕吐出肝一块，重两许，再吐如棋子大者五、六枚，遂困顿不食，数日而逝。○一妇久嗽咯血，内
热人困，病已数月，诊脉弦数无力。余曰∶此火盛灼金。夏令火旺，与泻火保金之剂，守至秋金得令，再望生
机。所服人参、麦冬、丹皮、茯苓、紫菀、百合之类。一日，吐出肺两块，状如熟猪肺，胸中隐痛，再用前
药不应而逝。（《怡堂散记》）
倪孝廉年逾四旬，素多思虑伤脾，时有呕吐之证，遇劳即发。余以理阴兼温胃饮，随饮即愈。于暑末时，
因劳心吐泄血如掌大，或紫或红，其多可畏。医云∶此因劳而火起心脾，兼以暑令，二火相济所致。与犀角、
地黄、童便、黄连、知母，服药两剂，其吐愈甚，脉益紧数，困惫垂危。其子恳视，情势俱剧，乃用人参、熟
地、干姜、炙甘草大剂与之。初服毫不为动，次服呕恶稍止，复加附子、炮姜各二钱，人参、熟地各一两，白
术四钱，炙甘草一钱，茯苓二钱，黄昏与服，竟得大睡，四鼓复进，呕止血亦止。遂大加温补调理而痊。余初
用此药，同道见之惊骇莫测，及其既愈，乃始心服，曰∶向使不有公在，必为寒凉所毙。夫童便最能动呕，犀
角、知、连最能败脾。时当二火，而证非二火，此以劳倦伤脾，而脾胃阳虚，气不摄血，再用寒凉，脾必败矣。
后有数人皆同此证，悉用此法活之，故并记焉。（张景岳）
附方
补膜丸 治吐血止后，胃膜破损。白芨灰、丝绵灰、鱼膘灰，三味等分为末，蜜丸。
治失血方 用女人顶发两许，洗净风干，装瓦瓶内，泥封，针刺数眼，火炼，冷透取灰研末，每服二钱，
藕、墨、童便三汁和匀，炖服。
【经典论述】
阳明经气主司天时，若咳嗽不止，且咳出白色血液的，预后不良，多致死亡。○发怒会导致气机逆乱，严重时会出现呕血。（出自《素问》）
【哲人言论】
凡是吐血、咳嗽气逆上冲，脉象数而伴有发热、无法安卧的，预后不良，多致死亡。○嗜酒之人发生咳嗽，必定会吐血。这是由于过度饮酒所致。（出自《金匮要略》）
心主司血液但不能贮藏血液，夜间血液则回流归于肝；肝能贮藏血液但不能主司血液，白天则听命于心。心为君主之官，肝为宰相之官，君火一旦发动，相火随之而动；相火一旦发动，六经之火随之而动。火热内动则血液随之妄动，火性炎上则血液随之升腾。（出自《明医指掌》）
唾液中有少量散漫分布的血丝，这是肾中相火上炎所致的出血。如果血色如红线般，从痰液中咳出，这是肺络受热损伤所致的出血；如果咳出白色血液，颜色浅红，形状似肉似肺组织，必定死亡。（朱丹溪）
从口中失血，有来自咽部和喉部的区别。因为上焦纳气和排气的门户，只有咽和喉这两个窍道而已。咽是胃的上窍，所以从咽部出来的血必定源于胃；喉是肺的上窍，所以从喉部出来的血必定源于肺。然而喉连接于肺，实际上统管五脏的清道；咽连接于胃，实际上统管六腑的浊道。人们只知道从肺出来的血，病在五脏，却不知道从咽部出来的血，也多有源于脏器的。《内经》说：五脏都禀受气于胃。胃是五脏的根本。既然五脏之气都禀受于胃，那么五脏的疾病，难道唯独不波及到胃吗？现在见到的吐血证候，古人说呕血源于胃，哪里知道它也源于脏器呢？大凡胃火旺盛而导致大量呕吐鲜血的，这本来就是胃家的病，无需多言。至于因愤怒导致气机逆乱，严重时呕血的，也是出于胃，这是因为气逆在肝，肝木邪气乘袭胃土所致。又比如欲火（相火）上炎，严重时呕血的，也是出于胃，这是因为火发源于肾水之源，阴邪乘袭胃土所致。由此看来，凡是五志（喜怒忧思恐）化火，都能波及到胃，而从咽部出来的血，岂止是胃家的病？但如果是咳嗽而出血的，必定出于喉，出于喉的，应当察辨五脏；如果是呕吐或咯吐而出的，必定出于咽，出于咽的，则五脏六腑都能波及。况且胃是水谷之海，是多气多血的府库，实际上也是冲任二脉血海的源头，所以凡是血枯经闭的患者，应当寻求生血的源头，源头在胃；凡是呕血吐血的患者，应当寻求动血的源头，源头在脏。○凡是咳血、嗽血的人，各家都说源于肺；咯血、唾血的人，都说源于肾。这怎么能概括全面呢？却不知咳、嗽、咯、唾等出血，无不与肾有关。为什么呢？因为肾脉从肾脏上行贯穿肝脏和膈肌，进入肺部，沿着喉咙，夹持舌根，其支脉从肺分出，联络心脏，注入胸中。这说明肺肾相连，有病则共同发病。而且血原本属于精的范畴，肾主五液，所以凡是患血证的疾病，虽然可以辨别涉及五脏，但无不由于肾水亏虚。肾水亏虚则火势亢盛，火势亢盛则刑克肺金，肺金患病则肺燥，肺燥则肺络受损而咳血，津液枯竭而成痰。这种病的标实在肺，而病的本则在肾。如果想要舍弃治肾而单纯治血，终究不是好的治疗方法。只是肾中自有水火，水虚本来就不能滋养，火虚尤其不能化生，善于窥探水火微妙变化的人，就能洞察脏腑内部的状况没有比这更透彻的了。（张景岳）
心如果没有血液滋养就会产生热，热气熏蒸胸中，导致肺金畏惧热邪而不敢肃降，一呼一吸之间，仅在分寸间处于潜伏状态。火在下部熏蒸，气在上部急促逼迫，筋膜间的津液都被火煎熬成血，随着燥气上升，在咳、吐、咯的过程中，无不带有红色。想要使血不枯竭、液不耗尽，是不可能的。只宜保定心肺之气，取法甘凉以生养，使津液充足于上，下降荫蔽营阴从而益水，如同燥热门中的雾露灌溉一样。○制约火邪，不仅仅靠补水，血液充足也能使火焰熄灭。血属于阴类。阴虚的人，水亏不能滋助肝木，营血必然受伤。所以阳火独旺，得不到血液滋润，必然会吸动肾水来自救，无奈滴水不能济助盛火，反而随火化热而升腾煎熬成血。咯血说是出于肾，就是这个原因。（程郊倩）
关于吐血这一证候，人们只知道气逆血溢、火升血泛，不知道血在脏腑之中，另有膈膜隔开固定，其血不能渗透溢出。那膈膜极薄极脆，凡是有损伤就会破裂，破裂了血就会溢于上部。（刘默生）
【补编】
吐血不止的，用柏叶汤主治。○心气不足（注：此处疑为心气有余），出现吐血、鼻衄的，用泻心汤主治。（《金匮要略》）
按语：所谓“心气不足”四个字，应当是“心气有余”。如果是不足，怎么会用这个方子治疗呢？必然是传写造成的错误。（《医宗金鉴》）
治疗吐血有三条秘诀：宜行血不宜止血。血液不循经络运行，是因为气逆上壅。行血则血液循行经络，血自会停止；强行止血则血液凝滞，血液凝滞则发热、厌食，病情日益顽固。宜补肝不宜伐肝。《内经》说：五脏是藏精气而不泄的器官。肝藏血，吐血者，是肝失职守。养肝则肝气平和，血有所归依；伐肝则肝虚不能藏血，血更加不止。宜降气不宜降火。气有余便是火，气降则火降，火降则气不上升，血随气行而没有溢出上窍的祸患了。降火必用寒凉药，反而损伤胃气，胃气受伤则脾不能统摄血液，血更加不能归经。（缪仲淳）
《内经》说：中焦接受水谷汁液，化赤而为血。又说：奉心化赤而为血。这说明血虽然生于心、藏于肝，但实际上是由于中焦水谷的精微物质化生而成的。医生一见血证，就认为是热证，一概使用清凉药，初病火旺的人，服用后也会痊愈；若是中气虚弱的人，屡次发作屡次服用，没有不损伤脾土的。脾土一旦受伤，断绝了化源，不死的人很少了。凡是痰中带血，或者吐出一两口量不多的，是络脉之血，最容易伤人。《内经》说：阳络受伤，血外溢。如果不咳嗽，还可以医治；如果血虽止而咳嗽不止，即使是神仙也无法挽救。偶尔有存活的，或者是富贵有力之人，信任名医，十人中可得一二；如果是贫贱之人，百人中无一存活。那些一次吐出几大碗血的，是冲任二脉之血充盈肌肤、温暖肌肉、渗透皮毛的，如果能进食且无咳嗽气喘症状，即使血量多也无大碍，调理也容易。颇有从年轻吐到年老的人，也有倾盆而来不可遏止，一两天即死亡的。总之，少量的血，是经络之血，经络通达脏腑，虽然量少但病位深；大量的血，是皮肤之血，皮肤在外，虽然量多但病位浅。庸俗的医生认为多的属于胃血，少的属于脏血，不知道脏是藏的意思，不可以损伤。真正的脏血，如果吐一口，不出五天即死，还谈什么治疗呢？吐血虽然属于伤阴，治疗宜滋阴养血，但也有阳虚不能摄血而外溢的，宜用人参、茯苓、[缺字]、白术补气摄血。如果阳虚已极，畏寒足冷，饮食不进，呕吐泄泻的，急用干姜、肉桂、附子，不要拘泥于吐血属火，而一概使用滋阴药。（吴仁斋）
痰中带血，多属于脾经，必须分痰和血的先后顺序施治。先见血而后嗽痰的，这是相火上炎，煎熬津液成痰，治疗宜以降火为主。如果用消痰的药，则血溢出不止。先痰嗽而后见血的，是极热生痰，载血上行，治疗宜以消痰为关键。如果用止血的药，则痰停滞不行。（《证治汇补》）
气有余便是火，血随气上逆，补水则火自降，顺气则血不逆。阿胶、牛膝、牡丹皮，是补水的药物；苏子、橘红、沉香，是顺气的药物。童便，能引血下行归入下窍，兼有行瘀的能力；藕汁，能使血达通而无滞留，而有止涩的力量。（《原病式》）
吐血之后，应当用调理胃气的药物收功。这句话非常好。我用参苓白术散煎煮，去掉头煎药渣，服用二煎、三煎药渣，或者制成丸药，也是去掉头煎药渣，效果很好。（周慎斋）
【脉候】
肺脉搏动坚实而长，应当病唾血。○心脉微涩，为血溢。○秋脉不及，则使人喘息，呼吸短气而咳嗽，气逆见血。（《素问》）
【选案】
张芝园生性嗜好生冷食物，又感受寒邪，自行服用消散药，忽然吐血，又用清凉药，已经濒临危险。诊脉微迟，身凉面白，观察其血，黑而臭。这是胃气不能传化，阳虚阴血走泄所致。用木香理中汤，霍然痊愈。○王周益失血，每年发作一次，服用理中汤颇有效，最近发作服用无效。我说：血证服用理中汤，是针对阳虚阴走，行浊道而出于胃的情况。此人是肾阴失守，夹带肝气冲犯于肺，肺不能纳气，所以侵犯清道而咳逆并至。给予生地、丹皮、归尾、山药、茯苓、麦冬、五味子、泽泻，加少许柴胡，立刻安定。（程华仲）
黄湛侯素有失血证，早晨起床突然暴吐一口，倾血一盆，喉间气涌，神思飘荡，壮热如蒸，颈筋粗劲，诊脉尺中非常紊乱。这是犯了房劳，不自爱身体所致。检验血色像太阳的红，我说：少阴经脉，系连舌根。少阴就是肾。现在肾家之血汹涌而出，舌根已经僵硬，无法可救，不得已用丸药一服，镇安元气，如果得气转丹田，还可以慢慢图谋救治。于是煎人参汤，送服黑锡丹三十粒，喉间有声音，逐渐下入腹中，片刻之后，舌变柔软能说话。急忙用润下的药剂接续前面的药，于是给予阿胶一两，溶化，分三次，半日内服完，身热渐退，颈筋渐消，进粥和补肾药，多加秋石而痊愈。（喻嘉言）
鲍献书二十多岁，每天早晨洗脸，口觉血腥味，吐血三口，因此延至午后洗脸，吐血依然如此，众医不明白原因。诊脉滑数，两寸特别明显。我说：头面诸阳之会，阴虚则阳亢，阳亢则血不循经，因洗脸而透下咽喉。理应滋阴凉血，则阴分不虚，阳分不亢，阴阳平和，血循经络，喉血自然消除。于是用四物汤加牡丹皮、红花作为生血凉血的主药，黄柏滋肾作为辅药，麦冬清肺作为佐药，荆芥、泽兰清头面作为使药，少加童便降火。服用十剂，血减半。有人建议去掉红花、牡丹皮、童便，结果血吐如初，仍然加上前面的药物服用而痊愈。（余午亭）
一人身体素来强壮，年近七十，忽然呕血，脉弦强，给予清热平肝的药剂，血随即停止。一个月后，胸中泛泛不适，又吐几口，服药又止。一天夜里吐出一块肝脏，重约一两，再吐出如棋子大的五六枚，于是困顿不食，几天后去世。○一妇女久咳咯血，内热人困，病已数月，诊脉弦数无力。我说：这是火盛灼伤肺金。夏令火旺，给予泻火保金的药剂，坚守到秋季金气得令，再望生机。所服人参、麦冬、牡丹皮、茯苓、紫菀、百合之类。一天，吐出两块肺，状如熟猪肺，胸中隐痛，再用前药不应而逝。（《怡堂散记》）
倪孝廉年过四十，素多思虑伤脾，时有呕吐之证，遇劳累即发作。我用理阴煎兼温胃饮，随饮即愈。在暑末时节，因劳心吐泄，血如手掌大，或紫或红，其多可畏。医生说：这是因为劳累而火起于心脾，兼以暑令，二火相济所致。给予犀角、地黄、童便、黄连、知母，服药两剂，其吐愈甚，脉益紧数，困惫垂危。其子恳请诊治，情势俱剧，乃用人参、熟地、干姜、炙甘草大剂与之。初服毫不为动，次服呕恶稍止，复加附子、炮姜各二钱，人参、熟地各一两，白术四钱，炙甘草一钱，茯苓二钱，黄昏与服，竟得大睡，四鼓（凌晨三点至五点）复进，呕止血亦止。遂大加温补调理而痊愈。我起初用这些药，同道见了惊骇莫测，等到他痊愈后，才开始心服，说：假使没有您在，必定被寒凉药害死。童便最能引发呕吐，犀角、知母、黄连最能败坏脾胃。时当二火季节，而证非二火证，这是因劳倦伤脾，而脾胃阳虚，气不摄血，再用寒凉，脾必败矣。后来有数人都同此证，全部用此法救活，所以一并记录。（张景岳）
【附方】
补膜丸 治疗吐血止后，胃膜破损。白芨灰、丝绵灰、鱼膘灰，三味等分为末，蜜丸。
治失血方 用女人顶发两许，洗净风干，装瓦瓶内，泥封，针刺数眼，火炼，冷透取灰研末，每服二钱，藕汁、墨汁、童便三汁和匀，炖服。
[Classic Discourse]
When the Yangming governs the climate, if coughing persists and white blood is expectorated, death ensues. ○ Anger causes Qi to rebel; in severe cases, hematemesis occurs. (Su Wen)
[Philosophical Remarks]
In cases of hematemesis, coughing with rebellious Qi, rapid pulse accompanied by fever, and inability to sleep, death ensues. ○ In habitual drinkers who develop coughing, hematemesis invariably follows. This results from excessive drinking. (Jin Gui Yao Lue)
The Heart governs Blood but does not store it; at night, Blood returns to the Liver. The Liver stores Blood but does not govern it; during the day, it obeys the command of the Heart. The Heart is the Sovereign, and the Liver is the Minister. When the Sovereign Fire moves, the Minister Fire follows; when the Minister Fire moves, the Fires of the Six Channels follow. When Fire stirs internally, Blood moves with it; when Fire flares upward, Blood rises with it. (Ming Yi Zhi Zhang)
If a small amount of scattered blood is found in saliva, this is bleeding caused by the flaming up of the Minister Fire from the Kidney. If the blood appears like red threads and is coughed out from phlegm, this is bleeding due to heat injury to the Lung collaterals. If white blood is coughed up, pale red in color and resembling flesh or lung tissue, death is certain. (Zhu Danxi)
Bleeding from the mouth differs depending on whether it originates from the pharynx or the larynx. The upper Jiao has only two openings for intake and output: the pharynx and the larynx. The pharynx is the upper opening of the Stomach, so blood coming from the pharynx must originate from the Stomach. The larynx is the upper opening of the Lungs, so blood coming from the larynx must originate from the Lungs. However, the larynx connects to the Lungs and actually governs the clear pathways of the Five Zang organs; the pharynx connects to the Stomach and actually governs the turbid pathways of the Six Fu organs. People know that bleeding from the Lungs indicates disease in the Five Zang organs, but they do not realize that bleeding from the pharynx often also originates from the Zang organs. The Classics state: "The Five Zang organs all receive Qi from the Stomach." The Stomach is the root of the Five Zang organs. Since the Qi of the Five Zang organs is derived from the Stomach, can diseases of the Five Zang organs fail to affect the Stomach? In current observations of hematemesis, ancients stated that vomiting blood comes from the Stomach, yet how could one know it also originates from the Zang organs? Generally, massive vomiting of bright red blood due to excess Stomach fire is indeed a disease of the Stomach itself, which needs no further explanation. As for anger causing Qi rebellion leading to hematemesis, although the blood emerges from the Stomach, the Qi rebellion lies in the Liver, where Wood pathogen overacts on Earth. Similarly, for hematemesis caused by flaming Desire Fire (Minister Fire), although the blood emerges from the Stomach, the fire originates from the source of Kidney Water, and Yin pathogen overacts on the Stomach. From this, we see that Fire generated by the Five Emotions can all affect the Stomach; thus, blood from the pharynx is not merely a Stomach disease. However, blood coughed up must come from the larynx, and bleeding from the larynx requires examination of the Five Zang organs. Vomited or spat-out blood must come from the pharynx, and bleeding from the pharynx can involve both the Five Zang and Six Fu organs. Moreover, the Stomach is the Sea of Water and Grain, the residence of abundant Qi and Blood, and actually the source of the Chong and Ren vessels' Blood Sea. Therefore, for amenorrhea due to Blood deficiency, one should seek the source of Blood generation, which is the Stomach; for hematemesis, one should seek the source of Blood disturbance, which is the Zang organs. ○ Regarding hemoptysis and sputum-blood, various schools attribute it to the Lungs; regarding spitting blood and salivary blood, they attribute it to the Kidneys. Is this sufficient? One fails to realize that hemoptysis, sputum-blood, spitting blood, and salivary blood are all related to the Kidneys. Why? Because the Kidney meridian ascends from the Kidney, passes through the Liver and diaphragm, enters the Lungs, follows the throat, and flanks the base of the tongue. Its branch leaves the Lungs, connects with the Heart, and pours into the chest. This shows the connection between Lungs and Kidneys; when diseased, both are affected. Furthermore, Blood belongs to the category of Essence, and the Kidney governs the Five Fluids. Thus, in all Blood diseases, although differentiation involves the Five Zang organs, the root cause is always Kidney Water deficiency. Water deficiency leads to Fire excess; Fire excess injures Metal; Metal disease leads to Lung dryness; Lung dryness damages collaterals causing hemoptysis, and fluid depletion forms phlegm. The manifestation (Biao) is in the Lungs, but the root (Ben) is in the Kidneys. To treat Blood without addressing the Kidneys is ultimately ineffective. The Kidney contains both Water and Fire; Water deficiency cannot nourish, and Fire deficiency cannot transform. Those who skillfully observe the subtleties of Water and Fire can see through the internal organs clearly. (Zhang Jingyue)
When the Heart lacks Blood nourishment, Heat generates. Heat steams the chest, causing Metal (Lung) to fear Heat and lose its descending function. During respiration, Qi remains latent within inches. Fire steams below while Qi rushes above, frying fluids and Jin-Ye into Blood, which rises with Dryness. Coughing, vomiting, and spitting will all contain redness. It is impossible to prevent Blood from drying up and fluids from exhausting. One should stabilize the Qi of the Heart and Lungs, using sweet-cool methods to generate nourishment, ensuring sufficient fluids above to descend and shade Ying-Yin, thereby benefiting Water, like mist and dew irrigating a hot door. ○ Controlling Fire is not solely achieved by supplementing Water; sufficient Blood also extinguishes flames. Blood is Yin. In Yin deficiency, Water deficiency fails to nourish Wood, injuring Ying-Blood. Thus, Yang Fire reigns unchecked; lacking Blood lubrication, it draws upon Kidney Water for self-rescue. However, a drop of water cannot quench raging Fire; instead, it transforms with Fire, rising and frying into Blood. This is why spitting blood is said to originate from the Kidneys. (Cheng Jiaoqian)
Regarding hematemesis, people only know of Qi rebellion causing Blood overflow and Fire rising causing Blood flooding. They do not know that Blood within the Zang-Fu organs is separated by the diaphragm membrane, preventing leakage. The diaphragm membrane is extremely thin and brittle; any injury causes rupture, leading to Blood overflowing upwards. (Liu Mosheng)
[Supplement]
For persistent hematemesis, Bo Ye Tang (Cassia Twig Decoction) is indicated. ○ For heart Qi insufficiency manifesting as hematemesis and epistaxis, Xie Xin Tang (Drain the Heart Decoction) is indicated. (Jin Gui Yao Lue)
Note: The phrase "heart Qi insufficiency" should likely be "heart Qi excess". If it were insufficiency, how could this formula be used? It must be a transcription error. (Yi Zong Jin Jian)
There are three principles for treating hematemesis: Promote Blood circulation rather than stop bleeding. Blood failing to follow meridians is due to Qi rebellion and congestion. Promoting circulation allows Blood to follow meridians, stopping bleeding naturally; forcing cessation causes Blood stasis, leading to fever and anorexia, making the condition chronic. Tonify the Liver rather than attack it. The Classics state: "The Five Zang organs store Essence-Qi and do not drain." The Liver stores Blood; hematemesis indicates Liver dysfunction. Nourishing the Liver pacifies Liver Qi, allowing Blood to return; attacking the Liver causes Liver deficiency and inability to store Blood, worsening hemorrhage. Descend Qi rather than descend Fire. Excess Qi becomes Fire; descending Qi descends Fire. When Fire descends, Qi does not rise, and Blood follows Qi without overflowing from the upper orifices. Descending Fire requires cold-cooling herbs, which damage Stomach Qi. Damaged Stomach Qi impairs Spleen control over Blood, causing further extravasation. (Miao Zhongchun)
The Classics state: "The Middle Jiao extracts juice, transforming it into red, which is called Blood." Also: "Nurtured by the Heart, it transforms into red Blood." This indicates that although Blood is generated by the Heart and stored by the Liver, it is actually produced from the essence of Water and Grain in the Middle Jiao. Physicians seeing Blood syndromes immediately assume Heat and use cooling herbs indiscriminately. In early stages with strong Fire, this may work; but in patients with weak Middle Qi, repeated use inevitably damages Spleen Earth. Once Spleen Earth is damaged, the source of transformation is cut off, and few survive. Blood mixed with phlegm or small amounts of vomited blood indicate collateral injury, which is most dangerous. The Classics state: "Damage to Yang collaterals causes external Blood overflow." If there is no cough, it is treatable; if Blood stops but cough persists, even immortals cannot save them. Rare survivors are usually wealthy individuals trusting skilled physicians, where one or two in ten might live; among the poor, survival is rare. Massive vomiting of several bowls indicates Blood from the Chong and Ren vessels filling the skin and muscles; if appetite is preserved without cough or asthma, it is less dangerous and easier to manage. Some bleed from youth to old age; others experience uncontrollable torrential bleeding and die within days. In summary, small amounts are collateral Blood, deep-seated despite low volume; large amounts are superficial Skin Blood, shallow despite high volume. Vulgar doctors believe large amounts are Stomach Blood and small amounts are Zang Blood, not realizing that Zang means storage and should not be injured. True Zang Blood, if even one mouthful is vomited, leads to death within five days; what treatment remains? Although hematemesis involves Yin injury and requires nourishing Yin and Blood, some cases involve Yang deficiency failing to secure Blood, requiring Ginseng, Poria, [missing character], and Atractylodes to tonify Qi and secure Blood. In extreme Yang deficiency with cold limbs, anorexia, vomiting, and diarrhea, use Ginger, Cinnamon Twig, and Aconite urgently; do not rigidly adhere to the notion that hematemesis is Fire and use only Yin-nourishing herbs. (Wu Renzhai)
Blood in phlegm mostly relates to the Spleen Meridian; treatment depends on whether blood or phlegm appears first. If blood appears before phlegm-cough, it is Minister Fire flaming up, frying fluids into phlegm; treatment prioritizes descending Fire. Using phlegm-resolving herbs here causes uncontrolled bleeding. If phlegm-cough precedes blood, it is extreme heat generating phlegm carrying Blood upward; treatment prioritizes resolving phlegm. Using hemostatics here causes phlegm stagnation. (Zheng Hui Hui Bu)
Excess Qi becomes Fire; Blood follows Qi upward. Supplementing Water lowers Fire naturally; smoothing Qi prevents Blood rebellion. E-Jiao (Donkey-Hide Gelatin), Achyranthes Root, and Moutan Bark supplement Water; Perilla Seed, Tangerine Peel, and Agarwood smooth Qi. Child's urine guides Blood downward to the lower orifices and promotes Blood circulation; Lotus Root Juice ensures Blood flow without stagnation and has astringent properties. (Yuan Bing Shi)
After hematemesis, recovery should be achieved with Stomach-tonifying formulas. This saying is excellent. I use Shen Ling Bai Zhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder), decocting and discarding the first decoction, taking the second and third decoctions, or making pills discarding the first decoction, which is very effective. (Zhou Shenzhai)
[Pulse Diagnosis]
A Lung pulse that is firm and long indicates disease with spitting blood. ○ A Heart pulse that is slightly choppy indicates Blood overflow. ○ An insufficient Autumn pulse causes wheezing, shortness of breath, coughing, and hemoptysis. (Su Wen)
[Selected Cases]
Zhang Zhiyuan loved raw and cold foods and contracted Cold pathogens. Self-medicating with dispersants, he suddenly vomited blood. Further use of cooling herbs brought him to the brink of death. His pulse was slight and slow, body cool, face pale, and blood black and foul-smelling. This was Stomach Qi failure to transport and transform, with Yang deficiency allowing Yin Blood to escape. Mu Xiang Li Zhong Tang (Costus Root and Center-Regulating Decoction) cured him instantly. ○ Wang Zhouyi suffered recurrent blood loss annually, responding well to Li Zhong Tang previously, but recently it failed. I reasoned: Taking Li Zhong Tang for blood syndromes addresses Yang deficiency with Yin escaping via the turbid pathway from the Stomach. This case involved Kidney Yin failing to hold, combined with Liver Qi rushing to the Lungs. The Lungs could not receive Qi, invading the clear pathway causing cough and rebellion. Prescribed Rehmannia Root, Moutan Cortex, Angelica Sinensis Tail, Chinese Yam, Poria, Ophiopogon Tuber, Schisandra Berry, and Alisma Rhizome, with a little Bupleurum Root. He stabilized immediately. (Cheng Huazhong)
Huang Zhanhou had a history of blood loss. One morning, he suddenly vomited a basin-full of blood, with Qi surging in the throat, drifting consciousness, high fever like steaming, and stiff neck tendons. His Chi pulse was chaotic. This resulted from sexual exhaustion and lack of self-care. The blood was bright red like the sun. I said: The Shaoyin meridian connects to the tongue root. Shaoyin refers to the Kidney. Now Kidney Blood is gushing out, and the tongue root is stiff; no cure exists. Desperately, I gave one dose of pills to anchor Yuan Qi. If Qi returned to the Dantian, recovery might be possible. I decocted Ginseng Soup and administered thirty Black Tin Pills (Hei Xi Dan). Sound was heard in the throat as it descended. Soon, his tongue softened, and he could speak. Urgently following with moistening purgatives, I gave one liang of E-Jiao (Donkey-Hide Gelatin), dissolved and taken in three doses over half a day. Fever subsided, neck tendons relaxed. He consumed congee and Kidney-tonifying herbs with Autumn Stone (Qiu Shi) and recovered. (Yu Jiayan)
Bao Xianshu, in his twenties, tasted blood every morning while washing his face, vomiting three mouthfuls. This persisted into the afternoon. Physicians were baffled. Pulse was slippery and rapid, especially at the Cun positions. I said: The head and face are the meeting of all Yang. Yin deficiency leads to Yang hyperactivity; Yang hyperactivity causes Blood to leave meridians, leaking down the throat during washing. Treatment should nourish Yin and cool Blood. With four substances (Si Wu Tang) plus Moutan Cortex and Safflower as the sovereign to generate and cool Blood, Phellodendron Bark as minister to nourish Kidney, Ophiopogon Tuber as assistant to clear Lungs, Schizonepeta Spike and Lygodium Spore as envoys to clear the head/face, and a little child's urine to descend Fire. After ten doses, bleeding halved. Others suggested removing Safflower, Moutan, and child's urine; bleeding recurred. Reinstating the original ingredients cured him. (Yu Wuting)
A man, constitutionally strong, near seventy, suddenly vomited blood. Pulse was wiry and strong. Given clearing-heat and calming-Liver herbs, bleeding stopped. A month later, chest discomfort returned, with a few mouthfuls of blood, stopped by medication. One night, he vomited a piece of liver weighing about one qian, followed by five or six pieces the size of chess pieces. He became lethargic, refused food, and died days later. ○ A woman with chronic cough and hemoptysis, internal heat, and fatigue for months, had a wiry, rapid, and deficient pulse. I said: This is Fire excess scorching Metal. In summer Fire season, given Fire-draining and Metal-protecting herbs, waiting for Autumn Metal season for hope. She took Ginseng, Ophiopogon, Moutan, Poria, Aster Tataricus, and Lily Bulb. One day, she vomited two pieces of lung, resembling cooked pig lung, with dull chest pain. The previous herbs failed, and she died. (Yi Tang San Ji)
Ni Xiaolian, over forty, had chronic spleen injury from overthinking, with occasional vomiting triggered by labor. I used Li Yin Jian (Nourish Yin Decoction) combined with Wen Wei Yin (Warm Stomach Infusion), curing him instantly. At the end of summer, mental labor caused vomiting and diarrhea with palm-sized blood clots, purple or red, alarming in volume. Doctors attributed this to Fire arising from Heart and Spleen due to labor, compounded by summer heat (two Fires combining). Prescribed Rhinoceros Horn (now prohibited, substitute with Buffalo Horn), Rehmannia Root, child's urine, Coptis Rhizome, and Anemarrhena Rhizome. After two doses, vomiting worsened, pulse became tight and rapid, condition critical. His son begged for consultation. Given large doses of Ginseng, Prepared Rehmannia Root, Dried Ginger, and Honey-fried Licorice Root. Initially no effect; second dose reduced nausea. Added two qian each of Aconite Root and Roasted Ginger, one liang each of Ginseng and Prepared Rehmannia, four qian Atractylodes Macrocephala Rhizome, one qian Honey-fried Licorice, and two qian Poria. Administered at dusk, he slept deeply. Taken again at midnight, vomiting and bleeding stopped. Large doses of warming and tonifying herbs led to full recovery. Colleagues were initially shocked by my prescription but convinced after recovery, stating: "Without you, he would have died from cold-cooling herbs." Child's urine induces vomiting; Rhinoceros Horn, Anemarrhena, and Coptis damage Spleen. In a season of two Fires, the syndrome was not two Fires, but Spleen injury from labor with Yang deficiency failing to control Blood. Using cold-cooling herbs would have destroyed the Spleen. Several subsequent cases with identical symptoms were saved by this method, hence recorded. (Zhang Jingyue)
[Attached Formulas]
Bu Mo Wan (Repair Membrane Pill) Treats gastric membrane damage after hematemesis ceases. Equal parts of Bletilla Striata Ash, Silk Cotton Ash, and Fish Swim Bladder Ash, ground to powder, formed into pills with honey.
Zhi Shi Xue Fang (Formula for Treating Blood Loss) Use two qian of a woman's topknot hair, washed and air-dried, placed in a clay bottle, sealed with mud, pierced with needles, calcined, cooled, and ground to powder. Take two qian per dose, mixed with Lotus Root Juice, Ink Stick Juice, and child's urine, stewed and taken.