经义
阳络伤，血外溢，血外溢则衄血。○脾移热于肝，则为惊衄。（《素问》）
哲言
师曰∶尺脉浮，目睛晕黄，衄未止；晕黄去，目睛慧了，知衄今止。○从春至夏衄者，太阳；从秋至冬
衄者，阳明。（《金匮》）
血从鼻出者，谓之鼻衄；从汗孔出者，谓之肌衄；从齿龈出者，谓之齿衄；从舌出者，谓之舌衄；从委
中出者，谓之 衄。（《医学入门》）
吐血出于胃，吐行浊道；衄血出于经，衄行清道。喉与咽二者不同也。盖经者走经之血，走而不守，随
气而行。火性急速，故随经直犯清道而出于鼻。其不出于鼻者，则夹火凌金，渗入肺窍而出于咽，为咳咯也。
胃者守营之血，守而不走，存于胃中。胃气有伤，不能摄血，故令人呕吐，从喉而出于口也。（《赵氏医贯》）
衄血一证，诸家但谓其出于肺，盖以鼻为肺之窍也。不知鼻为手足阳明之正经，而手足太阳亦皆至鼻，
故仲景曰∶太阳病，脉浮紧，发热身无汗，自衄者愈。此太阳之衄也。《原病式》曰∶阳热怫郁于足阳明，而
上热则血妄行而为衄。此阳明之衄也。若以愚见，则凡鼻衄之血，必自山根以上、精明之次而来，而精明一穴，
乃手足太阳、足阳明、阴阳跷五脉之会，此诸经皆能为衄也。然行于脊背者，无如足太阳为最；行于胸腹者，
无如足阳明为最；而尤有最者，则又惟冲脉为十二经之血海。冲之上俞，出足太阳之大杼；冲之下俞，会足阳
明之气街。故太阳阳明之至，
而冲脉无不至矣；冲脉之至，则十二经无不至矣。所以衄之微者，不过一经之近，而衄之甚者，则通身形色尽
脱，岂特手太阴一经而病至如是耶？（张景岳）
耳衄者，有肝肾二经之殊。不肿不疼者，为少阴之虚；暴出疼肿者，为厥阴之火也。眼衄亦属厥阴，以卒
视无所见者，为实火；常流血泪者，乃风热也。有诸窍血齐涌出者，多缘跌扑骤伤，或服毒药所致。若因肝肾
疲极，五脏内崩而致者，多不可治。舌衄，乃手厥阴心包之火旺，以舌尖破碎者为虚火，胀大满口者，夹龙雷
之势上侮心主也。涎中见血为唾衄，足太阴经气不约也。汗孔出血为肌衄，足阳明经气不固也。（《张氏医通》）
补编
衄家不可发汗，汗出额上陷，脉紧急，直视不能 ，不得眠。（《金匮》）
衄之为患，总由乎火。外因六淫之变化，内因五志之掀腾，气血错乱，阴阳相乘，天人交感之处，虚实
攸分矣。若风寒壅盛于经，阳气郁而迫营者，宜参麻黄、桂枝证之大意；若风温、暑热怫郁，而动血外溢者，
当用辛凉清润等剂；若火邪极甚而载血上泛者，药有苦寒、咸寒之分。此外因主治法也。至于烦冗曲运，耗及
木火之营，肝脏厥阳化火风而上灼者，甘咸柔婉，理所必需；多劳过欲，病及天一之真，阳浮引阴血而冒上窍
者，滋潜浓味，法从峻补。血脱则挽回元气，格阳则导火归原。因酒，用和阳消毒之剂；因努力，用培中益下
之方。此内因主治法也。（《临证指南》）
肺开窍于鼻，能为衄血。然肺经多气少血，惟冲任二脉为血之海，附于阳明；阳明之经，上交鼻额，又为
多血少气之乡。所以火起冲任，血流阳明，此衄血又属胃经也。大抵劳伤元气，阴虚火动，逆于肺而衄者，宜
凉血益气；逆于胃而衄者，宜清胃生脉。如六脉弦细而涩，面色枯白不泽者，此脱血大虚而挟寒，宜
甘温补血；如六脉洪大而虚，面赤心动善惊者，此心火上炎而血溢，宜甘寒凉血。有下虚上盛而衄者，当辛温
以补命门；有上焦积热而衄者，当寒凉以清心肺。衄后眩晕者，用十全大补汤；衄流不止者，用百草霜，或人
中白、胎发灰、山栀末，再以韭根、葱白捣如枣核塞鼻中，或用湿纸搭顶门，或用大蒜捣贴足心，皆法之验而
可试者。（《证治汇补》）
衄血虽多由于火，而惟阴虚者为尤多，正以劳损伤阴，则水不制火，最能动冲任阴分之血。但察其脉之
滑实有力，及素无伤损者，当作火治；若脉来洪大无力，或弦或芤，或细数无神，而素多酒色内伤者，此皆阴
虚之证，当专以补阴为主。若有微火者，自当兼清以治其标；若虽见虚热，而无真确阳证，则但用甘平之剂温
养真阴，务令阴气完固，乃可拔本塞源，永无后患。○衄血有格阳证者，以阴亏于下，而阳浮于上。但察其六
脉细微，全无热证，或脉见浮虚豁大，上热下寒，而衄不止者，治宜益火之原，古有八味汤，余有镇阴煎，其
效尤捷。此证不惟内伤有之，即伤寒亦有之，然必素多斫丧，损及真阴者，乃见此证。○血从齿缝牙龈中出者，
名为齿衄，此手足阳明二经及足少阴之病。盖手阳明入下齿中，足阳明入上齿中，又肾主骨，齿者骨之所终也。此
虽皆为齿病，然血出于经，则惟阳明为最，故凡阳明火盛，则为口臭，为牙根腐烂肿痛，或血出如涌而齿不动
摇。必其人素好肥甘辛热之物，或善饮胃强者，多有此证，宜内服抽薪饮、清胃饮、清胃散，外以冰玉散敷之；
阳明实热，便闭不通而齿衄不止者，宜调胃承气汤下之。肾水不足，口不臭，牙不痛，但齿摇不坚，或微痛不
甚，而牙缝时多出血者，此肾阴不固，虚火偶动而然，但宜壮肾，以六味丸、左归丸主之；或阳虚于下，而虚
火上浮者，宜八味丸主之。阴虚有火而病为齿衄者，其证或多燥渴，或见消瘦，或小水短涩而热，或六脉浮
大而豁，此虽阳明有余，而亦少阴不足，宜玉女煎主之，然必便实乃可用之。若便滑或脉细恶寒，
则亦有格阳而然者，当以前吐血条中格阳法治之。○舌上无故出血如缕者，以心脾肾之脉皆及于舌，诸经有
火皆能令舌出血，用蒲黄炒末敷之，或炒槐花末糁之，或冰玉散敷之，甚者须用汤剂以清三阴之火。（张景岳）
毛窍出血，名曰肌衄，乃阳气怫郁于内，不能敷扬于外，以致阴血上乘阳分，留淫腠理，不得归经，故
从毛窍而出。治宜开郁清气凉血。若相火内动而乘阴分，以致血热沸腾，治宜滋阴降火。前人主乎肺热，以
肺主皮毛故也。（《冯氏锦囊》）
乳胀流血名乳衄，起初流血，续出黄水，黑逍遥散治之。（许宣治）
选案
侄女十岁，因齿动摇，以苎麻摘之，血出不止，以小盆盛之，一日夜积十一盆，用末药止其处，少顷，
复从口中吐出，身亦不倦，亦事之稀觏也。可见人身之血，不可测量。诊脉洪大有力。以三制将军末二钱，用
枳壳汤少加童便调下，夜半去黑粪数块，其血顿止。后见一男子，齿根出血盈盆，一月一发，百治不效，每发
则昏昧。知其人好饮，投以前剂而安。又一老妪患此，一发五七日，每日血出约有升余。投以前剂亦安。但
所下皆有黑粪，是知此疾多由阳明热盛所致。缘冲任二脉，皆附阳明，阳明多气多血，故发如潮涌。急则治标，
故投以釜底抽薪之法，应手而愈。要知肾虚血出者，其血必点滴，齿则攸攸而疼，必不如此之暴甚。有余不足，
最要详察。（孙一奎）
一少年患伤寒，七日，忽尔鼻衄，以为将解之兆，自辰至申，所衄斗余，鼻息、脉息俱已将脱，身冷如
冰，目视俱直，而犹涓涓不绝，呼吸垂危。其父母号呼求救。余急投镇阴煎，一剂衄止身温，渐次调理而愈。
自后凡治此证，无不应响。（张景岳）
江蕃仲耳中出血，涓涓不止，医以八味汤加黑铅坠之，更甚，复与二剂蒲黄止涩之品，气促将危。予
谓∶胃为肾关，肾炎血当
走胃，乃不从胃而从耳者，因心包之火引之而然也。心包引肾火而出于耳，诸经所过之地，其血尽随之上泛。
桂、附淆乱经隧，止涩斩犯气机，死期迫矣。改用滋肾清心之剂，两服而瘥。是知耳亦通于心耳。（程华仲）
一妇年四十，久不乳，忽内热头昏，两乳作胀，以手捻出鲜血，医用逍遥、归脾，胀甚，血出愈多。诊
脉弦大，此肝热也。余用生地、丹皮、白芍、青皮、泽兰、车前、山栀、麦芽，三剂平，四剂愈。（许宣治）
附方
治鼻衄法 用手指掐太溪穴，其血即止。穴在足里踝动脉陷处。○又法用麻线一条，两头各拴五两重锡一
块，挂在颈后，两头垂与脐平，少顷血即止。
【经义】
阳络受损，血液外溢，血液外溢则发生鼻衄。○脾脏将热邪转移至肝脏，则会出现惊悸和鼻衄。（《素问》）
【哲言】
老师说：尺部脉象浮，眼珠周围有晕黄，说明鼻衄尚未停止；如果晕黄消退，眼睛变得清明，可知鼻衄现在已经停止。○从春季到夏季发生的鼻衄，属于太阳经病变；从秋季到冬季发生的鼻衄，属于阳明经病变。（《金匮要略》）
血液从鼻子流出，称为鼻衄；从汗孔流出，称为肌衄；从牙龈流出，称为齿衄；从舌头流出，称为舌衄；从委中穴处流出，称为腘衄。（《医学入门》）
吐血源于胃，血液沿浊道下行；衄血源于经络，血液沿清道上行。喉与咽二者是不同的。所谓“经”，是指运行在经络中的血液，它流动而不固守，随着气机而行。火性急速，所以顺着经络直接侵犯清道而从鼻子出来。如果不从鼻子出来，就会夹带火邪侵犯肺金，渗入肺窍而从咽喉出来，表现为咳嗽咯血。胃中所藏的是营血，它固守而不流动，存留于胃中。如果胃气受伤，不能统摄血液，就会导致呕吐，血液从喉咙而出入口中。（《赵氏医贯》）
关于衄血这一病证，各家都只说它源于肺，大概是因为鼻子是肺的窍道。却不知道鼻子也是手足阳明经的正经所过之处，而且手足太阳经也都到达鼻子，所以张仲景说：太阳病，脉象浮紧，发热且身上无汗，如果自然发生鼻衄，病就会痊愈。这就是太阳经的衄血。《原病式》说：阳热郁结在足阳明经，而上部的热气导致血液妄行而发生衄血。这就是阳明经的衄血。若依我愚见，凡是鼻衄的血液，必定是从山根以上、明堂（鼻尖）附近而来，而明堂这一部位，是手足太阳、足阳明、阴阳跷脉五条经脉交会的地方，这些经脉都能导致衄血。然而，行走在脊背部的，没有比足太阳经更重要的；行走在胸腹部的，没有比足阳明经更重要的；而尤其重要的是，那就是冲脉作为十二经的血海。冲脉的上俞穴，出于足太阳经的大杼穴；冲脉的下俞穴，会合于足阳明经的气街穴。所以足太阳和足阳明经的气血到了，冲脉就没有不到的地方；冲脉的气血到了，那么十二经就没有不到的地方。所以衄血轻微的，不过是一两条经脉附近的病变；而衄血严重的，则全身形色都会脱失，哪里仅仅是手太阴肺经这一条经的病能严重到这种地步呢？（张景岳）
耳衄，有肝肾二经的不同。不肿不痛的，是少阴经的虚证；突然出血且疼痛肿胀的，是厥阴经的火证。眼衄也属于厥阴经，突然视力丧失的，是实火；经常流血流泪的，是风热所致。如果各个孔窍同时涌出血液，多是因为跌打损伤或服用毒药所致。如果是由于肝肾极度疲劳，五脏内部崩裂导致的，大多不可治愈。舌衄，是手厥阴心包经火旺所致，舌尖破碎的是虚火，舌体胀大充满口腔的，是夹带龙雷之火上犯心主。唾液中见血称为唾衄，是足太阴经气不能约束所致。汗孔出血称为肌衄，是足阳明经气不固所致。（《张氏医通》）
【补编】
经常鼻衄的人不可发汗，如果误用发汗法导致出汗，出现额部动脉凹陷，脉象紧急，两眼直视不能转动，无法入睡。（《金匮要略》）
衄血的祸患，总归是由于火。外因是六淫邪气的变化，内因是五志情绪的激荡，导致气血错乱，阴阳相乘，在天人感应的关键之处，虚实也就区分开了。如果风寒壅盛于经络，阳气郁结而逼迫营血，应当参考麻黄汤、桂枝汤证的大意进行治疗；如果风温、暑热郁结，而动血外溢，应当使用辛凉清润等方剂；如果火邪极盛而挟带血液上泛，药物则有苦寒、咸寒的区别。这是外因的主要治法。至于烦劳冗杂、思虑过度，耗伤肝木心火的营血，导致肝脏厥阳化生风火而上灼的，甘咸柔润的药物是理所必需的；过度劳累和房事，损伤了天一之真阴，阳气浮越牵引阴血而冒犯上窍的，滋潜厚味的药物，治法应从峻补入手。血脱则要挽回元气，格阳（虚阳外越）则要引火归原。因饮酒引起的，使用和阳解毒的方剂；因用力努挣引起的，使用培补中气、益养下元的方子。这是内因的主要治法。（《临证指南医案》）
肺开窍于鼻，能引起衄血。但是肺经多气少血，只有冲脉和任脉是血之海，依附于阳明经；阳明经的经脉，上交于鼻额部位，又是多血少气之乡。所以火起于冲任，血流注于阳明，这衄血又属于胃经。大抵因劳损伤及元气，阴虚火动，逆乱于肺而导致衄血的，宜用凉血益气法；逆乱于胃而导致衄血的，宜用清胃生脉法。如六脉弦细而涩，面色枯白无光泽的，这是脱血大虚而兼夹寒邪，宜用甘温补血法；如六脉洪大而虚，面红心跳容易受惊的，这是心火上炎而血液外溢，宜用甘寒凉血法。有下虚上盛而导致衄血的，当用辛温以补命门；有上焦积热而导致衄血的，当用寒凉以清心肺。衄血后出现眩晕的，用十全大补汤；衄血不止的，用百草霜，或者人中白、胎发灰、栀子末，再用韭根、葱白捣烂如枣核大小塞入鼻孔中，或者用湿纸贴在头顶百会穴处，或者用大蒜捣烂贴敷足心，都是有效且可以尝试的方法。（《证治汇补》）
衄血虽然多由于火，但其中阴虚的情况尤为多见，正因为劳损伤阴，导致水不制火，最容易扰动冲任阴分之血。只要观察其脉象滑实有力，以及平时没有损伤病史的，当作火证治疗；如果脉来洪大无力，或者弦或者芤，或者细数无神，而且平时多有酒色内伤的，这都是阴虚的证候，应当专门以补阴为主。如果有微火，自然应当兼用清热药以治其标；如果虽然有虚热表现，但没有确切的阳热实证，则只用甘平的药物温养真阴，务必使阴气完固，才能拔本塞源，永远没有后患。○衄血中有格阳证的，是因为阴亏于下，而阳浮于上。只要观察其六脉细微，完全没有热证，或者脉象浮虚豁大，上热下寒，而衄血不止的，治宜益火之源，古代有八味丸，我有镇阴煎，疗效尤其快捷。此证不仅内伤有，就是伤寒也有，但必须是平时多有纵欲损耗，损伤真阴的人，才会出现此证。○血液从牙齿缝隙牙龈中流出，名为齿衄，这是手足阳明二经及足少阴肾经的病变。因为手阳明经进入下齿中，足阳明经进入上齿中，又因为肾主骨，牙齿是骨的终末表现。这虽然都是牙齿的病，但血液出于经络，则以阳明经最为重要，所以凡是阳明火盛，就会出现口臭、牙根腐烂肿痛，或者出血如涌而牙齿不松动。一定是那人平时喜好肥甘辛辣热的食物，或者善于饮酒、胃气强盛的，多有此证，宜内服抽薪饮、清胃饮、清胃散，外用冰玉散敷贴；如果是阳明实热，大便闭塞不通而齿衄不止的，宜用调胃承气汤攻下。肾水不足，口不臭，牙不痛，只是牙齿摇动不坚固，或者微痛不甚，而牙缝时常多出血的，这是肾阴不固，虚火偶尔发动所致，只宜壮肾，以六味丸、左归丸为主治；或者阳虚于下，而虚火上浮的，宜用八味丸为主治。阴虚有火而病为齿衄的，其症状可能有多燥渴，或者见到消瘦，或者小便短涩而热，或者六脉浮大而豁，这虽然是阳明有余，但也兼有少阴不足，宜用玉女煎为主治，但必须是大便干燥才行。如果大便稀溏或者脉细恶寒，则是格阳所致，应当以前面吐血条中提到的格阳法治之。○舌上无故出血如线状，因为心脾肾的经脉都联系到舌头，诸经有火都能令舌出血，可用蒲黄炒成末敷贴，或者炒槐花末撒布，或者冰玉散敷贴，严重的须用汤剂以清三阴之火。（张景岳）
毛窍出血，名叫肌衄，是阳气郁结在内，不能宣发于外，导致阴血上乘阳分，留滞浸淫于腠理，不能回归经络，所以从毛窍而出。治疗宜开郁、清气、凉血。如果是相火内动而侵犯阴分，导致血热沸腾，治疗宜滋阴降火。前人主张治肺热，因为肺主皮毛的缘故。（《冯氏锦囊秘录》）
乳房胀痛流血名为乳衄，起初流血，随后流出黄水，用黑逍遥散治疗。（许宣治）
【选案】
侄女十岁，因为牙齿松动，用苎麻去摘除刺激，导致血出不止，用小盆承接，一天一夜积了十一盆，用药粉止住出血处，过了一会儿，又从口中吐出，身体也不疲倦，这也是世间少有的事例。可见人身之血，不可估量。诊脉洪大有力。用经过三次炮制的大黄末二钱，用枳壳汤加少量童便调服，半夜排出几块黑粪，出血顿时停止。后来见到一个男子，齿根出血盈满一盆，每月发作一次，各种治疗无效，每次发作都昏迷不醒。知道他喜欢喝酒，投以此前的大黄方剂而安愈。又有一位老妇人患此病，一发就是五七天，每天出血约有升余。投以此前的大黄方剂也安愈。但所排出的都有黑粪，由此可知此疾多由阳明热盛所致。因为冲任二脉都依附于阳明经，阳明经多气多血，所以发病如潮水涌动。急则治标，所以投以釜底抽薪之法，应手而愈。要知道肾虚出血的，其血必点滴而出，牙齿则会悠悠作痛，绝不会如此暴烈严重。有余和不足，最需要详细察辨。（孙一奎）
一个少年患伤寒，第七天，忽然鼻衄，人们以为是病情将要解除的征兆，从辰时到申时，出血有一斗多，鼻息、脉息都即将断绝，身体冷如冰，两眼直视不动，仍然涓涓不绝，呼吸垂危。他的父母号呼求救。我急忙投用镇阴煎，一剂后衄止身温，逐渐调理而痊愈。从此以后凡治疗此证，无不立竿见影。（张景岳）
江蕃仲耳中出血，涓涓不止，医生用八味丸加黑铅重坠之品，病情更重，又给两剂蒲黄等止涩药物，气促将危。我说：胃为肾之关，肾炎血应当走胃，却不从胃而从耳流出，是因为心包之火引动所致。心包引肾火而出于耳，经过的各条经脉，其血都随之上泛。桂枝、附子扰乱经络，止涩药斩伐气机，死期迫近了。改用滋肾清心的方剂，两服而病愈。由此可知耳朵也通于心。（程华仲）
一位四十岁的妇女，长期没有月经，忽然内热头晕，两乳房胀痛，用手挤压流出鲜血，医生用逍遥散、归脾汤，导致胀痛更甚，出血更多。诊脉弦大，这是肝热。我用生地、丹皮、白芍、青皮、泽兰、车前子、山栀、麦芽，三剂病平，四剂痊愈。（许宣治）
【附方】
治疗鼻衄的方法：用手指掐按太溪穴，其血即止。穴位在足内踝后方动脉凹陷处。○另一种方法：用一根麻线，两头各拴一块五两重的锡块，挂在颈后，两头下垂与肚脐齐平，一会儿血就止住了。
[Scriptural Meaning]
When the Yang collaterals are injured, blood overflows externally; when blood overflows externally, epistaxis occurs. ○ When heat transfers from the Spleen to the Liver, it results in palpitations and epistaxis. (*Suwen*)
[Philosophical Sayings]
The Master said: If the Chi pulse is floating and there is yellow halo around the eyeballs, the epistaxis has not stopped; if the yellow halo disappears and the eyes become clear, one knows that the epistaxis has now stopped. ○ Epistaxis occurring from Spring to Summer belongs to the Taiyang channel; epistaxis occurring from Autumn to Winter belongs to the Yangming channel. (*Jingui Yaolue*)
Blood flowing from the nose is called Bi-Nu (epistaxis); blood flowing from sweat pores is called Ji-Nu (dermal hemorrhage); blood flowing from the gums is called Chi-Nu (gingival bleeding); blood flowing from the tongue is called She-Nu (lingual bleeding); blood flowing from the Weizhong acupoint is called Guo-Nu (popliteal hemorrhage). (*Yixue Rumen*)
Hematemesis originates from the Stomach, with blood traveling down the turbid pathway; Nu-xue originates from the channels, with blood traveling up the clear pathway. The Hou (throat) and Yan (pharynx) are two different structures. What is referred to as "channels" is the blood running within the meridians; it flows without staying fixed, moving along with Qi. Fire nature is rapid, so it follows the channels directly invading the clear pathway and exiting through the nose. If it does not exit through the nose, it carries fire to assault Metal (Lung), seeping into the Lung orifices and exiting through the pharynx, manifesting as coughing and spitting of blood. The blood stored in the Stomach is Ying-blood (nutritive blood); it stays without flowing, residing in the Stomach. If Stomach Qi is damaged and cannot control the blood, it causes vomiting, with blood exiting from the throat into the mouth. (*Zhao Shi Yi Guan*)
Regarding the syndrome of Nu-xue, various schools only attribute it to the Lung, presumably because the nose is the orifice of the Lung. They do not know that the nose is also the main pathway of the Hand and Foot Yangming channels, and that the Hand and Foot Taiyang channels also reach the nose. Therefore, Zhang Zhongjing said: In Taiyang disease, with a floating and tight pulse, fever, and no sweating, spontaneous epistaxis leads to recovery. This is Taiyang epistaxis. *Yuan Bing Shi* states: Yang-heat stagnates in the Foot Yangming channel, and upper heat causes blood to move recklessly, resulting in epistaxis. This is Yangming epistaxis. If I may offer my humble opinion, all blood from nasal epistaxis must come from above the Shangen (root of the nose) and near the Mingting (tip of the nose). The Mingting area is the convergence point of five channels: Hand Taiyang, Foot Taiyang, Foot Yangming, Yin Qiao, and Yang Qiao. All these channels can cause epistaxis. However, among those traveling along the back, none is more significant than the Foot Taiyang; among those traveling along the chest and abdomen, none is more significant than the Foot Yangming; and most importantly, it is the Chong Mai (Penetrating Vessel) which serves as the Sea of Blood for the twelve channels. The upper shu point of the Chong Mai emerges at Dazhu (BL11) of the Foot Taiyang; the lower shu point converges at Qijie of the Foot Yangming. Thus, when Foot Taiyang and Foot Yangming arrive, the Chong Mai is inevitably reached; when the Chong Mai is reached, all twelve channels are inevitably reached. Therefore, mild epistaxis involves merely one or two nearby channels, while severe epistaxis causes the entire body's form and color to fade away. How could this severity be attributed solely to the Hand Taiyin Lung channel? (Zhang Jingyue)
Er-Nu (auricular hemorrhage) differs between the Liver and Kidney channels. Non-swollen and non-painful cases indicate deficiency of the Shaoyin channel; sudden onset with pain and swelling indicates fire of the Jueyin channel. Yan-Nu (ocular hemorrhage) also belongs to the Jueyin channel; sudden loss of vision indicates excess fire; chronic bleeding of tears indicates wind-heat. If blood gushes from all orifices simultaneously, it is mostly due to sudden trauma or ingestion of toxic drugs. If caused by extreme exhaustion of the Liver and Kidney leading to internal collapse of the Zang organs, it is mostly incurable. She-Nu (lingual bleeding) is caused by flourishing fire of the Hand Jueyin Pericardium channel; broken tongue tip indicates deficient fire; swollen tongue filling the mouth indicates Dragon-Lei fire assaulting the Heart Master. Tuo-Nu (saliva hemorrhage) is seen in saliva and is due to the inability of the Foot Taiyin channel Qi to constrain blood. Ji-Nu (dermal hemorrhage) is blood from sweat pores and is due to insecurity of Foot Yangming channel Qi. (*Zhang Shi Yi Tong*)
[Supplement]
Patients prone to epistaxis should not undergo diaphoresis (sweating therapy). If sweating is induced, it may result in depression of the arteries on the forehead, urgent pulse, staring gaze unable to move, and insomnia. (*Jingui Yaolue*)
The harm of epistaxis generally stems from Fire. External causes involve changes from the Six Excesses (pathogenic factors); internal causes involve agitation from the Five Emotions. This leads to disorder of Qi and Blood and interaction of Yin and Yang. At the intersection of Heaven and Human感应 (interaction), deficiency and excess are distinguished. If Wind-Cold is abundant in the channels, causing Yang Qi to stagnate and force Ying blood, one should refer to the general principles of Mahuang Tang (Ephedra Decoction) and Guizhi Tang (Cinnamon Twig Decoction). If Wind-Warmth or Summer-Heat stagnates and moves blood to overflow externally, pungent-cool and moistening-clearing formulas should be used. If Fire pathogen is extremely severe and carries blood upward, medicines should be bitter-cold or salty-cold. These are the main treatments for external causes. As for mental fatigue and excessive calculation consuming the Ying blood of Wood and Fire, causing Jue-Yang of the Liver to transform into wind-fire and scorch upwards, sweet-salty and soft/gentle remedies are necessary. For overwork and excessive desire damaging Tianyi (Primordial Water/Yin), causing floating Yang to draw Yin blood upward to invade the upper orifices, nourishing and submerging thick/flavorful remedies follow the method of vigorous tonification. For blood loss, rescue Yuan Qi; for Ge-Yang (deficient Yang floating outward), guide fire back to its source. Due to alcohol, use harmonizing Yang and detoxifying agents; due to straining/effort, use formulas to tonify Middle and benefit Lower. These are the main treatments for internal causes. (*Linzheng Zhinan*)
The Lung opens into the nose and can cause epistaxis. However, the Lung channel is abundant in Qi and deficient in Blood. Only the Chong Mai and Ren Mai are the Seas of Blood, attaching to the Yangming channel. The Yangming channel intersects the nose and forehead and is a region abundant in Blood and deficient in Qi. Therefore, when fire arises in the Chong and Ren vessels, blood flows into the Yangming; thus, this epistaxis also belongs to the Stomach channel. Generally, epistaxis caused by labor injuring Yuan Qi, Yin deficiency with fire hyperactivity reversing into the Lung, should be treated with cooling blood and benefiting Qi. Epistaxis reversing into the Stomach should be treated with clearing Stomach and generating Pulse. If the six pulses are wiry, thin, and choppy, with a withered white complexion lacking luster, this is massive blood loss with great deficiency and cold accumulation; treat with sweet-warm blood tonification. If the six pulses are flooding and empty, with red face, palpitations, and fearfulness, this is Heart fire flaming upward causing blood overflow; treat with sweet-cool blood cooling. For epistaxis due to lower deficiency and upper excess, use pungent-warm to tonify the Gate of Vitality (Mingmen). For epistaxis due to accumulated heat in the Upper Jiao, use cold-cool to clear Heart and Lung. For dizziness after epistaxis, use Shiquan Dabu Tang (Ten Significant Tonifying Decoction). For unceasing epistaxis, use Baicaoshuang (Charred Herb Powder), or Renzhongbai (Calcined Human Urine Deposit), Taifa Hui (Ash of Fetal Hair), Zhizi Mo (Gardenia Powder), mixed with Jiugen (Perilla Root) and Congbai (Scallion White) pounded like a jujube pit and stuffed into the nose; or apply wet paper to the Baihui acupoint on the vertex; or apply pounded garlic to the Yongquan acupoint on the sole. These are effective methods worth trying. (*Zhengzhi Huibu*)
Although epistaxis is mostly due to fire, Yin deficiency is particularly common. Labor damages Yin, leading to Water failing to control Fire, easily disturbing the Yin aspect of the Chong and Ren vessels. Observe if the pulse is slippery, solid, and forceful, and if there is no history of injury; treat as Fire. If the pulse is flooding and weak, or wiry, knotted, thin, rapid, and spiritless, and if there is a history of alcohol and sexual indulgence causing internal damage, these are all Yin deficiency syndromes; focus primarily on tonifying Yin. If there is slight fire, combine with clearing heat to treat the branch. If there is deficient heat but no definitive excess heat signs, use only sweet-neutral agents to warm-nourish True Yin, ensuring Yin Qi is complete and solid, to pull up the root and block the source, preventing future trouble. ○ Epistaxis with Ge-Yang syndrome is due to Yin deficiency below and floating Yang above. Observe if the six pulses are subtle, with no heat signs, or if the pulse is floating, empty, and large, with upper heat and lower cold, and unceasing epistaxis; treatment should benefit the origin of Fire. Anciently, there was Bawei Wan (Eight-Ingredient Pill); I have Zhenyin Jian (Settling Yin Decoction), which is even more effective. This syndrome exists not only in internal injuries but also in Shanghan (Cold Damage), but it appears only in those who have previously indulged excessively, damaging True Yin. ○ Blood flowing from the teeth gaps and gums is named Chi-Nu (gingival bleeding); this is a disease of the Hand and Foot Yangming channels and the Foot Shaoyin channel. The Hand Yangming enters the lower teeth; the Foot Yangming enters the upper teeth. Since the Kidney governs bones, and teeth are the culmination of bones, this is related to bone health. Although these are dental diseases, since blood comes from the channels, the Yangming is most significant. Thus, when Yangming fire is exuberant, it causes bad breath, gum rot/swelling/pain, or gushing blood with stable teeth. This usually occurs in people who prefer rich, sweet, spicy, and hot foods, or those who drink heavily and have strong Stomach Qi. Internally, use Chouxin Yin, Qingwei Yin, or Qingwei San; externally apply Bingyu San. If Yangming excess-heat causes constipation and unceasing gingival bleeding, use Tiaowei Chengqi Tang to purge. If Kidney Water is insufficient, with no bad breath or toothache, but loose/unstable teeth or slight pain with frequent bleeding from gaps, this is insecure Kidney Yin with occasional deficient fire; strengthen the Kidney using Liuwei Wan (Six-Ingredient Pill) or Zuogui Wan. If Yang is deficient below with floating deficient fire, use Bawei Wan. For Yin deficiency with fire causing gingival bleeding, symptoms may include dryness/thirst, emaciation, short/scanty hot urination, or floating/large/empty pulses. Although this shows Yangming excess, it also involves Shaoyin insufficiency; use Yunu Jian, but only if stools are solid. If stools are loose or pulse is fine with aversion to cold, it is Ge-Yang; treat according to the Ge-Yang method described in the Hematemesis section. ○ Spontaneous thread-like bleeding from the tongue occurs because the meridians of Heart, Spleen, and Kidney all connect to the tongue; fire in any channel can cause lingual bleeding. Apply fried Puhuang (Pollen Typhae) powder, or fried Huaihua (Flos Sophorae) powder, or Bingyu San. Severe cases require decoctions to clear fire of the Three Yin channels. (Zhang Jingyue)
Maoqiao Chuexue (bleeding from hair follicles), named Ji-Nu (dermal hemorrhage), is caused by Yang Qi stagnating internally and failing to disseminate externally, leading to Yin blood ascending to the Yang level, lingering in the Couli (interstices), and failing to return to the channels, thus exiting through the follicles. Treatment should open stagnation, clear Qi, and cool blood. If Minister Fire moves internally and assaults the Yin level, causing boiling blood-heat, treatment should nourish Yin and descend fire. Predecessors focused on Lung heat because the Lung governs skin and hair. (*Feng Shi Jin Nang*)
Ruzhang Liuxue (breast swelling with bleeding), named Ru-Nu, initially bleeds then discharges yellow fluid; treat with Hei Xiaoyao San (Black Bupleurum Powder). (Xu Xuanzhi)
[Selected Cases]
My niece, aged ten, had loose teeth. She plucked them with Ramie fiber, causing unceasing bleeding, collected in small basins. One day and night yielded eleven basins. Applied powdered medicine to stop the bleeding locally, but shortly after, she vomited blood again, yet her body showed no fatigue. This is a rare occurrence, showing that human blood volume is immeasurable. Her pulse was flooding and forceful. Administered 2 qian of Sanzhi Jiangjun (Sanctified Rhubarb) powder, mixed with Zhike Tang (Magnolia Bark Decoction) and a little Tongbian (Child's Urine). At midnight, several pieces of black stool were passed, and the bleeding stopped instantly. Later, I saw a man whose gum bleeding filled a basin, recurring monthly, unresponsive to various treatments, becoming comatose during episodes. Knowing he drank alcohol, I administered the aforementioned Rhubarb formula, and he recovered. Another elderly woman suffered similarly, bleeding for 5-7 days per episode, over a sheng daily. The same formula worked. The passage of black stool confirmed this disease is mostly due to exuberant Yangming heat. Since the Chong and Ren vessels attach to the Yangming, and Yangming is abundant in Qi and Blood, outbreaks surge like tides. Treating the branch in emergencies, I used the "remove firewood from under the cauldron" method, achieving immediate cure. Note that Kidney deficiency bleeding is点滴 (dripping), with lingering tooth pain, never so violent. Excess and deficiency must be carefully distinguished. (Sun Yikui)
A youth contracted Shanghan. On the seventh day, sudden epistaxis occurred. It was thought to be a sign of resolution. From Chen hour to Shen hour, over a dou of blood was lost. Nasal and pulse breaths were nearly extinct. Body cold as ice, eyes staring straight, yet dripping continuously. Respiration critical. Parents cried for help. I urgently administered Zhenyin Jian (Settling Yin Decoction). After one dose, epistaxis stopped, body warmed, and gradual调理 (conditioning) led to recovery. Since then, treating this syndrome with this method has always been effective. (Zhang Jingyue)
Jiang Fanzhong had continuous auricular bleeding. Physicians used Bawei Wan (Eight-Ingredient Pill) with heavy Black Lead, worsening the condition. Then gave two doses of Puhuang (Typha Pollen) astringents. Breathing became急促 (rapid) and critical. I said: The Stomach is the gate of the Kidney. Kidney pathology blood should flow to the Stomach, but here it flows to the ear because it is drawn by Pericardium Fire. Pericardium draws Kidney fire out through the ear; blood follows upward along all passing channels. Cinnamon (Guizhi) and Aconite (Fuzi) disrupt the meridians; astringents cut off Qi mechanism. Death is imminent. Changed to Kidney-nourishing and Heart-clearing agents. Two doses cured him. Thus, we know the ear connects to the Heart. (Cheng Huazhong)
A forty-year-old woman, amenorrheic for a long time, suddenly developed internal heat, dizziness, and breast swelling. Squeezing produced fresh blood. Physicians used Xiaoyao San and Guipi Tang, worsening swelling and increasing bleeding. Pulse was wiry and large; this is Liver heat. I used Shengdi, Danpi, Baishao, Qingpi, Zelan, Cheqian, Zhizi, and Maiya. Three doses stabilized; four doses cured. (Xu Xuanzhi)
[Attached Formulas]
Method for treating epistaxis: Pinch the Taixi acupoint with fingers; bleeding stops immediately. The acupoint is located in the depression behind the medial malleolus where the posterior tibial artery is palpable. ○ Another method: Take a piece of hemp string, tie a five-liang tin weight to each end, hang it behind the neck so both ends hang level with the navel. Bleeding stops shortly.