颈筋粗贲。诊其脉尺中甚乱。曰。此昨晚大犯房劳也。因出验血。色如太阳之红。再之寝所
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。内浓煎人参汤。下黑锡丹三十粒。
喉间 有声。渐入少腹。顷之舌柔能言。但声不出。急用润下之剂以继前药。遂与阿胶一
两溶化。分三次热服。半日服尽。身热渐退。颈筋渐消。进粥。与补肾药。多加秋石。服之
遂愈。
震按参汤下黑锡丹以治吐血。可补古法所未备。然继以阿胶而大效。再继以秋石补肾
药而全愈。恐未必。
又治顾枚先。年二十余岁。体肥嗜酒。孟夏患失血证。每晚去血一二盏。延至季夏。去
血无算。然色不憔悴。身不消瘦。脉不洪盛。亦无寒热。但苦上气喘促。夜多咳嗽。喉间窒
塞。胸前紧逼。背后刺胀。躁急多怒。医以人参、阿胶。治失血成法。用之月余。逾增其势
更医用滋阴膏子润上。牛膝、黄柏导下。总不见效。及服酒研三七。则血止咳定。但未久
血复至。咳复增。喻曰。是病为饮醇伤胃。胃家多气多血。故内虽渐亏。而外犹未觉。揆
其致此之繇。又必以醉饱入房而得之。盖人身气动则血动。而媾精时之气。有乾坤鼓铸之象
其血大动。精者。血之所化也。灌输原不止胃之一经。独此一经所动之血。为醉饱所阻。
不能与他经缉续于不息之途。是以开此脱血一实。今者竟成熟路矣。夫胃之脉从头走足。本
下行也。以呕血之故。逆而上行。则呼吸必致喘急。胃之气。传入大小肠膀胱等处。亦本下
行也。以屡呕之故。上逆而不下达。则胸腹必致痛闷。胃气上奔。呕逆横决。则胸中之气必
乱。所以紧逼痛楚。甚至攻入于背。以背为胸之府也。其心烦多怒者。以胃之上为膈。内经
所谓血迸于膈之上。气迸于膈之下。气血倒而使然。且胃之大络。贯膈络肺。其膈间紧逼肺
间。气胀痰胶。何莫非胃病之所传哉。当此长夏土旺。母邪尽传于子。至三秋燥金司令。咳
嗽喘满之患必增。肺痈胃痈之变必来矣。今岁少阴司天。运气热也。炎夏酷暑。时令热也。
而与胃中积热。合煽其虐。不治其热。血必不止。惟遵内经热淫血溢。治以咸寒之旨。用元
明粉化水煮黄柏。秋石化水煮知母。少加甘草以调其苦。四剂而血止。惜病家不终其用。八
月中。果生肺痈而死。
震按此案议病制方。 绝人寰。岂西昌真有隔垣之见如长桑元化哉。亦惟熟于内经。
而
善于运用。则引集经义。证合病机。头头是道。无勉强附会之陋矣。士材先生云。熟读而精
灵自启。思深而神鬼可通。诚哉是言也。
周慎斋治陈姓人。年三十五岁。性嗜酒色。忽患吐血。一日三五次。不思饮食。每日食
粥一碗。反饮滚酒数杯。次日清晨再食粥。前粥尽行吐出。吐后反腹胀。时时作痛作酸。昼
夜不眠。饮滚酒数杯略可。来日亦如此。近七月矣。医人并无言及是积血者。俱言不可治。
周诊之。六脉短数。曰。吐后宜宽反胀。饮滚酒略可。此积血之证也。盖酒是邪阳。色亦邪
阳。邪阳胜则正阳衰。又兼怒气伤肝。肝不纳血。思虑伤脾。脾不统血。中气大虚。血不归
络。积血中焦无疑。宜吐宜利。但脾胃大虚。不使阳气升发。阴寒何由而消。先用六君子汤
白术以苍术制之。加丁香温胃。草蔻治中脘痛。三十余帖。再用良姜一两。百年陈壁土四
两同煎。待土化切片。陈皮去白。草蔻、人参、白术、茯苓、甘草、胡椒、丁香各五钱。细
辛四钱。共末。空心。清盐汤或酒送下二钱。此药专在扶阳。积血因阴寒凝结。阳旺而阴自
化。服药后。血从下行者吉。乃血从上吐。约六七碗。胸中闷乱。手足逆冷。不省人事。急
煎人参五钱。炮姜八分。遂静定。后胸中闷乱。脐下火起而昏。用茯苓补心汤。一剂而安。
后用六味加人参、炮姜而痊。
震按此案认病有卓见。用药有妙解。与诸吐血治法绝不相关。因在血止后。得吐反胀
当治其胀耳。案中邪阳胜则正阳衰。至言也。凡人逞欲藉酒为助。自觉阳强可喜。不知仍靠
命门真阳作主。迨欲既遂。而邪阳息。真阳始宁。欲火频起频息。真阳必渐用渐衰。或欲起
而勿遂其欲。似与真阳无损。然如灯火本明。而于灯下另添一火以逼之。此火渐旺。则灯火
渐灭。理更可悟。故凡中年之后多病之人。必以闭关为福。尤以泊然不起欲念为大福也。
石顽治牙行陶震涵子。伤劳咳嗽。失血势如泉涌。服生地汁墨汁不止。门人周子。用热
童便二升而止。石顽诊其脉弦大而虚。自汗喘乏。至夜则烦扰不宁。与当归补血汤。四帖而
热除。时觉左胁刺痛。按之漉漉有声。此少年喜酒负气。尝与人斗狠所致。与泽术麋衔汤加
生
藕汁调服。大便即下累累紫黑血块。数日乃尽。后与四乌 骨一 茹为末。分四服。入黄牝
鸡腹中煮啖。留药蜜丸。尽剂而血不复来矣。
震按自汗喘乏。脉弦大而虚。不混投地黄汤、生脉散。高矣。用补血汤者。以其夜间
烦扰不宁耳。至因胁痛想及斗狠。则此人形色必壮实。故消瘀不补益。最为得法。
高士宗曰。友孙子度侄女。适张氏。病半产。咳嗽吐血。脉数而涩。色白。胃满脾泄。
医用理气降火止血药。益甚。予投理中汤加木香、当归。倍用参、术而血止。继用归脾汤。
及加减八味饮子。诸证渐愈。时鼓峰适从湖上来。视之曰。大虚证得平至此。非参、术之力
不能。今尚有微嗽。夜热时作。急宜温补以防将来。因定朝进加减八味丸。晡进加减归脾汤
未几。遇粗工。诧曰。血病从火发。岂可用热药。遂更进清肺凉血之剂。病者觉胃脘愈烦
惋。饮食不进。而迫于外论。强服之。逾月病大发。血至如涌。或紫或黑。或鲜红。病者怨
恨。复来招。予往视之。曰。败矣。脏腑为寒凉所逼。荣卫既伤。水火俱竭。脉有出而无入
病有进而无退。事不可为也。未几果殁。仁斋直指云。荣气虚散。血乃错行。所谓阳虚阴
必走也。曹氏必用方云。若服生地、藕汁、竹茹等药。去生便远。故古人误解滋阴二字。便
能杀人。况粗工并不识此。随手撮药。漫以清火为辞。不知此何火也。而可清乎。所用药味
视之若甚平稳。讵知其入人肠胃。利如刀锯。如此可畏哉。夫血脱益气。犹是粗浅之理。
此尚不知。而欲明夫气从何生。血从何化。不亦难乎。操刀使割。百无一生。有仁人之心者
愿于此姑少留意也欤。
震按吐血一证。近日最多。有有因而患之者。亦有无因而患之者。外因六淫之邪。动
血
犹轻。内因酒色忧愤。动血为重。及不内外因作劳举重。忍饥疾行。皆使失血。然尚可求其
因而治之。若与诸项并不相犯。无端而吐血。此则最重。内经谓地居太虚之中。大气举之也
大气偶泄。即有地震山崩之患。而水不安澜。或溢或竭。人身亦然。大气浓。足以包固。
纵犯三因。亦成他病。不至吐血。大气衰。不能担护。如堤薄则水易漏。堤坍则水必决也。
世人只守血热妄行一说。误矣。请观此案。可以猛省。但参、 、术。亦有效有不效。盖大
气无形。与营气卫气宗气中气又不同。非草木血肉之补所能补。曾见大啖肉饭。俄顷血一冒
而死者。又见日日服参。而血仍频发以死者。此皆恶疾。惟善养性修身。庶可挽回。内经云
恬淡虚无。真气从之。精神内守。病安从来。此无形之大药也。予幼年凿窍太早。犯褚氏
之戒。十四五岁。即患梦遗咯血。二十四岁更剧。咳痰必带血。一月梦遗十余次。遂咳嗽夜
热。喉痒火升。颧红背痛。自分死矣。尔时上有垂白之高堂。下无襁褓之童稚。于是忧病畏
死。苦不可言。欲却其畏死之念而末由也。父母见予形瘠。命媳分房别寝。并得复阅贤愚因
缘。视身命如敝屣。而畏死之念涣然冰释。淫欲之梦绝不复作矣。从此泰然自得。自无恼怒
自不躁急。惟戒烟酒。畏色如蝎。二年而诸病瘳。三年而儿女育。敢不举以告世。惟愿患
斯疾者。请尝试之。
震又按缪仲淳治吐血三诀。举世奉为明训。实未细绎其义。首条云。宜行血。不宜止
血
固是。然行血之药。惟有大黄。所谓血以下行为顺也。又须看其血证之新久。与失血之多
少而去取之。盖宜下于妄行之初。不宜下于脱血之后也。今本文不注明行血者何药。但云行
血则血循经络。致近日有多服山羊血而死者。安知不误于此句。至如血来汹涌。必须止之。
古方花蕊石散、十灰散。及童便、墨汁等。皆欲其止也。止之后。或消或补。尚可缓商。任
其吐而不思所以止之。何从求活。特是止血之法。贵于虚实寒热辨得明。斯于补泻温清拿得
稳耳。本文云。止之则血凝。血凝则发热恶食而病日痼。抑思今之吐血者。每多发热恶食。
何尝由于血凝耶。果系血凝。则仲景大黄 虫丸尚可救之。只虑血去无算。阴虚则病。阴竭
则死。无可奈何也。次条宜补肝不宜伐肝。注谓养肝则肝气平。而血有所归。伐之则肝虚不
能藏血。血愈不止。此说诚妙。然亦要看脉象若何。肝阴固宜养。肝阳亦宜制。设遇木火两
亢。血随气逆者。则抑青丸、龙胆泻肝汤。醋制大黄、桃仁、枳壳、青铅、铁锈水等。何尝
禁用。盖得其道。则伐之即所以补之。不得其道。而徒奉熟地、当归、萸肉、枸杞等为补肝
之药。则谬矣。末条宜降气。夫气有虚实。亦分寒热。血证之气。虚者多。实者少。热者多
寒者少。惟恃强善怒之人。肝气实而吐血。往往有之。抑肝清肝。宜降气又宜降火矣。他
如肺气虚而不降。则生脉散、观音应梦散。中气虚而不降。则四君子、参橘煎。肾阳虚不能
纳气而不降。则八味丸、黑锡丹。肾阴虚不能纳气而不降。则大补阴丸、三才封髓丹。必求
其所以不降之故而治之。斯为降。乌可恃韭汁、苏子、番降香。为下气药耶。至不宜降火之
句。医中狡狯者。藉为口实。辄称吐血服生地、麦冬。必成痨病。随将假阿胶售人以代二物
不知世之一见血证。概用生地、麦冬。诚应诃责。若将二物屏弃。岂非因噎废食。况予生
平所见。血溢上窍之人。合乎丹溪所谓阳盛阴虚有升无降者。十居八九。合乎仁斋所谓阳虚
阴必走。及曹氏必用方之甘草干姜汤。赵氏绛雪丹书之桂附者。百中一二而已。惟虚而有火
者。清补并用。虚而无火者。气血兼补。或宜降火。或不宜降火。总无一定之法也。若谓服
苦寒药必死。则仲景金匮之泻心汤。不几为罪之魁哉。
颈部的筋脉粗大突起。诊察其脉象，尺部非常紊乱。说：这是昨晚过度纵欲所致。于是取出血液检验，颜色像太阳红一样鲜红。再次询问病人住所的情况后说：少阴经脉联系舌根。少阴经属于肾。现在肾中的血液汹涌而出，舌根已经僵硬，无法救治。不得已使用丸药一服，以镇安元气。如果能使气机转至丹田，还可以慢慢图谋治疗。内服浓煎的人参汤，送服黑锡丹三十粒。喉间有痰鸣声，药液逐渐进入小腹。不久之后舌头变软能说话，但声音发不出。急忙使用润下之剂接续前面的药物。于是给予阿胶一两溶化，分三次热服，半天服完。身体发热逐渐消退，颈部筋脉逐渐平复。进食粥食，给予补肾药，多加秋石服用，于是痊愈。
俞震按语：用参汤送服黑锡丹来治疗吐血，可以弥补古法所未具备的方法。然而随后用阿胶取得大效，再随后用秋石补肾药而完全痊愈，恐怕未必如此（指对前医疗效的质疑或补充说明）。
又诊治顾枚先。年龄二十多岁。身体肥胖嗜好饮酒。孟夏时节患失血证。每晚出血一二盏。拖延到季夏，出血无数。然而面色不憔悴，身体不消瘦，脉象不洪盛，也没有寒热症状。只是苦于上气喘促，夜间多咳嗽，喉间堵塞感，胸前紧逼感，背后刺痛胀满，烦躁易怒。医生用人参、阿胶，按照治疗失血的成法，使用了一个多月，病情反而加重。更替医生使用滋阴膏子滋润上部，牛膝、黄柏引导下部，总不见效。等到服用酒研三七粉，则血止咳定，但未过多久血又复发，咳嗽又增加。喻嘉言说：这个病是因为饮用烈酒损伤了胃。胃是多气多血的脏腑，所以内部虽然逐渐亏虚，而外表还没有察觉。推究导致这种情况的原因，又一定是因为醉饱后行房事而得病的。大概人体气动则血动，而在交媾泄精时的气机，有乾坤鼓铸（天地造化）的景象，此时血大动。精是由血所化生的。精气灌输原本不止在胃这一条经络，唯独这条经络所动的血，被醉饱所阻滞，不能与其他经络在不息的运行中衔接。因此形成了这种脱血看似实证的情况。如今竟然成了熟路（习惯性病症）。胃的经脉从头走向足，本是下行的。因为呕血的关系，逆向上行，那么呼吸必然导致喘急。胃的气传入大小肠膀胱等处，也本是下行的。因为屡次呕吐的缘故，气上逆而不能下达，那么胸腹必然导致痛闷。胃气上奔，呕逆横决，那么胸中之气必然紊乱。所以感到紧逼痛楚，甚至攻入背部。因为背是胸的府库。心烦多怒的原因，是因为胃的上部为膈，《内经》所谓血迸溢于膈之上，气迸溢于膈之下，气血倒置造成的。而且胃的大络，贯穿膈膜联络肺脏。膈间的紧逼影响肺间，气胀痰胶，何尝不是胃病所传变呢？正值长夏土旺之时，母邪尽传于子（脾病及肺）。到了三秋燥金当令，咳嗽喘满的祸患必然增加。肺痈胃痈的病变必然到来。今年少阴司天，运气属热。炎夏酷暑，时令属热。与胃中积热相合煽动其虐。不治疗其热，血必不止。只有遵循《内经》“热淫血溢，治以咸寒”的宗旨，用元明粉化水煮黄柏，秋石化水煮知母，少加甘草以调和苦味。四剂后血止。可惜病家没有坚持用完药。八月中，果然生肺痈而死。
俞震按语：此案议论病情和制定方剂，绝非凡人所能企及。难道西昌真有隔墙视物如长桑君、扁鹊那样的本事吗？也只是因为熟读《内经》，并且善于运用，所以引用经典义理，印证符合病机，头头是道，没有勉强附会的陋习。士材先生说：熟读而精神自启，思虑深远而神鬼可通。确实是这样啊。
周慎斋诊治陈姓男子。年龄三十五岁。性格嗜好酒色。忽然患吐血。一天三五次。不思饮食。每天只吃一碗粥，反而喝几杯滚热的酒。第二天清晨再吃粥，前一天的粥全部吐出。吐后反而腹胀，时时作痛作酸。昼夜不眠。喝几杯滚热的酒略微舒服。第二天也是如此。接近七月了。医生没有人提及这是积血证。都说不可治。周慎斋诊察他，六脉短数。说：吐后应当宽松反而腹胀，喝滚热的酒略微舒服，这是积血证。大概酒是邪阳，色欲也是邪阳。邪阳胜则正阳衰。又兼怒气伤肝，肝不藏血；思虑伤脾，脾不统血。中气大虚，血不归经。积血在中焦无疑。应当用吐法或利法。但脾胃大虚，如果不使阳气升发，阴寒如何消除？先用六君子汤，白术改用苍术炮制。加丁香温胃，草蔻治疗中脘痛。三十余帖。再用良姜一两，百年陈壁土四两同煎。等土化成切片状，陈皮去白，草蔻、人参、白术、茯苓、甘草、胡椒、丁香各五钱，细辛四钱。共研为末。空腹，用清盐汤或酒送下二钱。此药专门在于扶阳。积血因阴寒凝结，阳气旺盛而阴寒自然化解。服药后，血从下行者吉。结果血从上吐出，约六七碗。胸中闷乱，手足逆冷，不省人事。急忙煎人参五钱，炮姜八分。于是安静下来。后来胸中闷乱，脐下火起而昏沉。用茯苓补心汤。一剂而安。后用六味地黄丸加人参、炮姜而痊愈。
俞震按语：此案认识病情有卓见，用药有妙解。与各种吐血治法绝不相关。因为在血止后，得吐反而腹胀，应当治疗其胀罢了。案中“邪阳胜则正阳衰”，是至理名言。凡人逞欲藉酒为助，自觉阳强可喜，不知仍靠命门真阳作主。待欲望既遂，而邪阳息灭，真阳始安宁。欲火频起频息，真阳必渐用渐衰。或者欲念兴起而不满足其欲望，似乎与真阳无损。然而如同灯火本明，而在灯下另添一火以逼迫它，此火渐旺，则灯火渐灭。道理更可领悟。所以凡是中年之后多病之人，必须以闭关（节制性欲）为福。尤其以淡泊不起欲念为大福。
石顽诊治牙行陶震涵之子。因劳损咳嗽，失血势如泉涌。服用生地汁、墨汁不止。门人周子，用热童便二升而止。石顽诊其脉弦大而虚，自汗喘乏，至夜则烦扰不宁。给予当归补血汤。四帖后热除。时常觉得左胁刺痛，按之漉漉有声。这是少年喜酒负气，曾与人斗狠所致。给予泽术麋衔汤加生藕汁调服。大便即下累累紫黑血块。数日乃尽。后给予四乌鲗骨一茹丸为末，分四服。放入黄牝鸡腹中煮食。留下药蜜丸。尽剂后血不再来。
俞震按语：自汗喘乏，脉弦大而虚，不混投地黄汤、生脉散，高明啊。用补血汤的原因，是因为夜间烦扰不宁。至于因胁痛想到斗狠，则此人形色必壮实。所以消瘀不补益，最为得法。
高士宗记载：友人的孙子度侄女，嫁给张氏。病半产后，咳嗽吐血。脉数而涩，面色白，胃满脾泄。医生用理气降火止血药，病情更重。我投理中汤加木香、当归。倍用参、术而血止。继用归脾汤，及加减八味饮子，诸证渐愈。当时鼓峰刚从湖上来，看后说：大虚证得到平息至此，非参、术之力不能做到。现在尚有微嗽，夜热时作，急宜温补以防将来。因此定于早晨进服加减八味丸，傍晚进服加减归脾汤。未几，遇到庸医，惊讶地说：血病从火发，岂可用热药。于是改换进服清肺凉血之剂。病者觉得胃脘更加烦闷，饮食不进。而迫于外界言论，勉强服用。逾月病大发，血至如涌。或紫或黑，或鲜红。病者怨恨，又来招请我去。我去看后说：败了。脏腑为寒凉所逼，荣卫既伤，水火俱竭。脉有出而无入，病有进而无退。事不可为也。未几果然去世。仁斋《直指》说：荣气虚散，血乃错行。所谓阳虚阴必走也。曹氏《必用方》说：若服生地、藕汁、竹茹等药，去生便远。所以古人误解滋阴二字，便能杀人。何况庸医并不识此，随手撮药，漫以清火为辞。不知这是什么火，而可清乎。所用药味看起来甚平稳，谁知道它们进入肠胃，锋利如刀锯。如此可畏哉。夫血脱益气，还是粗浅之理。这尚且不知，而想明白气从何生，血从何化，不也很难吗？操刀使割，百无一生。有仁人之心者，愿于此姑少留意也欤。
俞震按语：吐血一证，近日最多。有有因而患之者，亦有无因而患之者。外因六淫之邪，动血犹轻。内因酒色忧愤，动血为重。以及不内外因作劳举重，忍饥疾行，皆使失血。然而尚可求其因而治之。若与诸项并不相犯，无端而吐血，此则最重。《内经》谓地居太虚之中，大气举之也。大气偶泄，即有地震山崩之患，而水不安澜，或溢或竭。人身亦然。大气浓厚，足以包固。纵然犯三因，亦成他病，不至吐血。大气衰，不能担护。如堤薄则水易漏，堤坍则水必决也。世人只守血热妄行一说，误矣。请观此案，可以猛省。但参、芪、术，亦有效有不效。盖大气无形，与营气卫气宗气中气又不同。非草木血肉之补所能补。曾见大啖肉饭，俄顷血一冒而死者。又见日日服参，而血仍频发以死者。此皆恶疾。惟善养性修身，庶可挽回。《内经》云：恬淡虚无，真气从之。精神内守，病安从来。此无形之大药也。予幼年凿窍太早，犯褚氏之戒。十四五岁，即患梦遗咯血。二十四岁更剧。咳痰必带血。一月梦遗十余次。遂咳嗽夜热，喉痒火升，颧红背痛。自分死矣。尔时上有垂白之高堂，下无襁褓之童稚。于是忧病畏死，苦不可言。欲却其畏死之念而末由也。父母见予形瘠，命媳分房别寝。并得复阅《贤愚因缘》。视身命如敝屣。而畏死之念涣然冰释。淫欲之梦绝不复作矣。从此泰然自得，自无恼怒，自不躁急。惟戒烟酒，畏色如蝎。二年而诸病瘳。三年而儿女育。敢不举以告世。惟愿患斯疾者，请尝试之。
俞震又按：缪仲淳治吐血三诀，举世奉为明训。实未细绎其义。首条云：宜行血，不宜止血。固是。然行血之药，惟有大黄。所谓血以下行为顺也。又须看其血证之新久，与失血之多少而去取之。盖宜下于妄行之初，不宜下于脱血之后也。今本文不注明行血者何药，但云行血则血循经络。致近日有多服山羊血而死者，安知不误于此句。至如血来汹涌，必须止之。古方花蕊石散、十灰散，及童便、墨汁等，皆欲其止也。止之后，或消或补，尚可缓商。任其吐而不思所以止之，何从求活。特是止血之法，贵于虚实寒热辨得明，斯于补泻温清拿得稳耳。本文云：止之则血凝，血凝则发热恶食而病日痼。抑思今之吐血者，每多发热恶食，何尝由于血凝耶。果系血凝，则仲景大黄䗪虫丸尚可救之。只虑血去无算，阴虚则病，阴竭则死，无可奈何也。次条宜补肝不宜伐肝。注谓养肝则肝气平，而血有所归。伐之则肝虚不能藏血，血愈不止。此说诚妙。然亦要看脉象若何。肝阴固宜养，肝阳亦宜制。设遇木火两亢，血随气逆者，则抑青丸、龙胆泻肝汤，醋制大黄、桃仁、枳壳、青铅、铁锈水等，何尝禁用。盖得其道，则伐之即所以补之。不得其道，而徒奉熟地、当归、萸肉、枸杞等为补肝之药，则谬矣。末条宜降气。夫气有虚实，亦分寒热。血证之气，虚者多，实者少。热者多，寒者少。惟恃强善怒之人，肝气实而吐血，往往有之。抑肝清肝，宜降气又宜降火矣。他如肺气虚而不降，则生脉散、观音应梦散。中气虚而不降，则四君子、参橘煎。肾阳虚不能纳气而不降，则八味丸、黑锡丹。肾阴虚不能纳气而不降，则大补阴丸、三才封髓丹。必求其所以不降之故而治之，斯为降。乌可恃韭汁、苏子、番降香，为下气药耶。至不宜降火之句，医中狡狯者，藉为口实。辄称吐血服生地、麦冬，必成痨病。随将假阿胶售人以代二物。不知世之一见血证，概用生地、麦冬，诚应诃责。若将二物屏弃，岂非因噎废食。况予生平所见，血溢上窍之人，合乎丹溪所谓阳盛阴虚有升无降者，十居八九。合乎仁斋所谓阳虚阴必走，及曹氏必用方之甘草干姜汤，赵氏绛雪丹书之桂附者，百中一二而已。惟虚而有火者，清补并用。虚而无火者，气血兼补。或宜降火，或不宜降火，总无一定之法也。若谓服苦寒药必死，则仲景《金匮》之泻心汤，不几为罪之魁哉。
The tendons in the neck are coarse and protruding. Upon palpating the pulse, the Chi position (Cun-Kou pulse at the wrist corresponding to the Kidney) is very chaotic. It was said: "This is due to excessive sexual indulgence last night." The blood was then examined; its color was bright red like the sun. After inquiring about the patient's living conditions again, it was stated: "The Shaoyin meridian connects to the root of the tongue. Shaoyin belongs to the Kidney. Now, the blood of the Kidney is gushing out, and the root of the tongue has become stiff; there is no way to save this case. As a last resort, one dose of pill medicine will be used to stabilize and secure the Yuan Qi (Primordial Qi). If the Qi can turn to the Dantian (Lower Elixir Field), treatment may proceed slowly." Strongly decocted Renshen Tang (Ginseng Decoction) was taken internally, followed by 30 pills of Heixi Dan (Black Tin Pill). There was phlegm-rattling sound in the throat, and the medicine gradually entered the lower abdomen. Soon after, the tongue became soft and the patient could speak, but no voice came out. Urgently, a moistening and purgative formula was administered to follow the previous medication. Thus, Ejiao (Donkey-hide Gelatin), 1 liang, was dissolved and taken hot in three doses, completed within half a day. The body heat gradually subsided, and the neck tendons flattened. Porridge was consumed, and Kidney-tonifying herbs were given, with Qishi (Mineral Salt) added in large amounts. After taking them, the patient recovered.
Yu Zhen commented: Using Renshen Tang to administer Heixi Dan for treating hematemesis (vomiting blood) supplements methods not found in ancient texts. However, following up with Ejiao for great efficacy, and then with Qishi Kidney-tonifying herbs for complete recovery, is perhaps unlikely.
He also treated Gu Meixian, aged over twenty. His physique was obese, and he had a fondness for alcohol. In early summer, he suffered from a hemorrhagic syndrome, losing one or two cups of blood every night. This continued until late summer, with massive blood loss. Yet his complexion was not haggard, his body did not emaciate, his pulse was not surging, and he had no aversion to cold or fever. He only suffered from shortness of breath and panting upon exertion, frequent coughing at night, a sensation of obstruction in the throat, tightness and pressure in the chest, stabbing distension in the back, irritability, and anger. Physicians used Renshen (Ginseng) and Ejiao, following established methods for treating hemorrhage, for over a month, yet the condition worsened. Another physician used Ziyin Gaozi (Nourishing Yin Pastes) to moisten the upper jiao, and Niuxi (Achyranthes Root) and Huangbai (Phellodendron Bark) to guide downward. None were effective. When Jiuni Sanqi (Sanqi Powder prepared with wine) was taken, the bleeding stopped and coughing ceased, but soon the bleeding recurred and coughing increased. Yu Jia Yan said: "This disease is caused by strong liquor damaging the Stomach. The Stomach is a zang-fu organ rich in Qi and Blood. Although internal deficiency gradually develops, external signs are not yet apparent. Investigating the cause, it must have resulted from sexual intercourse while intoxicated and full. Generally, when Body Qi moves, Blood moves. During coitus and ejaculation, the Qi movement resembles the creative forces of Heaven and Earth, causing significant Blood disturbance. Essence is transformed from Blood. The infusion of essence is not limited to the Stomach meridian alone. However, the Blood moved in this specific meridian was blocked by intoxication and overeating, preventing it from connecting continuously with other meridians in their ceaseless circulation. Thus, an apparent excess pattern of blood loss was created. Now it has become a habitual condition. The Stomach meridian runs from head to foot, naturally descending. Due to hematemesis, it reverses and ascends, causing breathing difficulties and panting. The Qi of the Stomach transmits to the Large Intestine, Small Intestine, and Bladder, also naturally descending. Due to repeated vomiting, Qi rebels upward and fails to descend, causing pain and stuffiness in the chest and abdomen. Stomach Qi surges upward, vomiting rebels and breaks through horizontally, causing chaos in the Qi of the chest. Hence the sensation of tightness and pain, even radiating to the back, as the back is the mansion of the chest. The irritability and anger arise because the upper part of the Stomach is the Diaphragm. As stated in the *Neijing*: 'Blood spurts above the diaphragm, Qi spurts below the diaphragm.' This reversal of Qi and Blood causes it. Moreover, the great collateral of the Stomach penetrates the diaphragm and connects to the Lung. The tightness between the diaphragm affects the Lung space; Qi distension and sticky phlegm—aren't these all transmissions from Stomach disease? During the long summer when Earth Qi is prosperous, the pathogen of the mother (Spleen/Stomach) fully transmits to the child (Lung). By the third autumn when Dry Metal rules, the afflictions of coughing, panting, and fullness will surely increase. Lung abscess and Stomach abscess transformations will surely arrive. This year, Shaoyin governs the Heaven Qi, which is Hot. The intense summer heat is the seasonal Heat. Combined with accumulated Heat in the Stomach, they fan the disaster. Without treating the Heat, the bleeding will not stop. One must follow the principle in the *Neijing*: 'When Heat floods and causes blood overflow, treat with Salty-Cold substances.' Use Yuanmingfen (Mirabilite) dissolved in water to decoct Huangbai, and Qishi dissolved in water to decoct Zhimu. Add a little Gancao (Licorice Root) to moderate the bitterness. After four doses, the bleeding stopped. Unfortunately, the family did not complete the course. In mid-August, he indeed developed a lung abscess and died.
Yu Zhen commented: This case's discussion of the disease and prescription formulation is far beyond ordinary reach. Did Xichang truly possess the ability to see through walls like Changsang Yuanhua (Bian Que)? It is merely being well-versed in the *Neijing* and skilled in its application, so that citing classic meanings and verifying them against pathogenesis leads to logical coherence, avoiding forced interpretations. Mr. Shicai said: "Thorough reading awakens the spirit; deep thinking allows communication with spirits." Truly so.
Zhou Shenzhai treated a man surnamed Chen, aged thirty-five. He had a nature fond of alcohol and lust. Suddenly, he suffered from hematemesis, three to five times a day. He had no appetite, eating only one bowl of porridge daily, but drinking several cups of boiling wine. The next morning, after eating porridge again, the previous day's porridge was completely vomited up. After vomiting, abdominal distension occurred, with intermittent pain and sourness. He slept neither day nor night. Drinking several cups of boiling wine provided slight relief. The next day was the same. Approaching July, no physician mentioned this was a Blood-stasis syndrome. All said it was incurable. Zhou examined him; the six pulses were short and rapid. He said: "After vomiting, one should feel relaxed, yet there is distension; drinking boiling wine brings slight relief. This is a Blood-stasis syndrome. Wine is Evil Yang; lust is also Evil Yang. When Evil Yang prevails, Righteous Yang declines. Additionally, anger injures the Liver, so the Liver fails to store Blood; overthinking injures the Spleen, so the Spleen fails to control Blood. Middle Qi is greatly deficient, and Blood does not return to the vessels. There is undoubtedly Blood stasis in the Middle Jiao. Vomiting or purging methods should be used. But since the Spleen and Stomach are greatly deficient, if Yang Qi is not allowed to ascend, how can Yin Cold dissipate?" First, Liujunzi Tang (Six Gentlemen Decoction) was used, with Baizhu (Atractylodes Macrocephala Rhizome) processed using Cangzhu (Atractylodes Rhizome). Dingxiang (Clove) was added to warm the Stomach; Cao Kou (Cardamom Fruit) treated epigastric pain. Over thirty doses were taken. Then, Liangjiang (Alpinia Officinarum Rhizome), 1 liang, and Chentubi (Old Wall Soil), 4 liang, were decocted together. Once the soil melted into slices, Chenpi (Tangerine Peel) without white pith, Caokou, Renshen, Baizhu, Fuling (Poria), Gancao, Hujiao (Pepper), and Dingxiang, each 5 qian, and Xixin (Asarum), 4 qian, were ground into powder. Taken on an empty stomach, delivered with clear salt water or wine, 2 qian per dose. This medicine specifically aims to support Yang. Blood stasis, congealed by Yin Cold, resolves naturally when Yang becomes vigorous. If blood flows downward after taking the medicine, it is auspicious. However, the blood vomited upward, approximately six or seven bowls. Chest oppression and confusion ensued, hands and feet turned cold, and consciousness was lost. Urgently, Renshen, 5 qian, and Paojiang (Prepared Ginger), 8 fen, were decocted. Then calmness returned. Later, chest oppression/confusion and fire rising from below the navel with dizziness occurred. Fuling Buxin Tang (Poria Heart-Nourishing Decoction) was given. One dose brought peace. Later, Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia) plus Renshen and Paojiang led to recovery.
Yu Zhen commented: This case shows outstanding insight in recognizing the disease and ingenious understanding in medication. It is completely unrelated to standard hematemesis treatments. Because after stopping bleeding, vomiting caused distension, the distension should have been treated. "Evil Yang prevails, Righteous Yang declines" in the case record is a profound truth. People indulge desires relying on alcohol, feeling pleased with apparent yang strength, unaware that they still rely on Mingmen True Yang. Once desires are satisfied and evil Yang subsides, True Yang finally rests. Frequent rising and subsiding of desire fire gradually depletes True Yang. Even if desires arise but are not fulfilled, seemingly sparing True Yang, it is like adding another fire under a bright lamp; as this extra fire grows strong, the lamp's light dims. The logic is understandable. Therefore, those who fall ill frequently after middle age must find blessing in closing the gate (abstaining from sex). Especially finding great blessing in remaining detached and free of desire.
Shi Wen treated the son of Tao Zhenhan, a tooth merchant. Suffering from labor-induced consumption and coughing, blood loss gushed like a spring. Taking Shengdi Juice (Rehmannia Juice) and Mo Zhi (Ink Stick) failed to stop it. A disciple, Zhou Zi, used 2 sheng of hot Tongbian (Child's Urine) to stop it. Shi Wen palpated the pulse: wiry, large, and deficient. Spontaneous sweating, panting, and fatigue. At night, restlessness and agitation. Danggui Buxue Tang (Dongquiang Blood-Nourishing Decoction) was given. After four doses, heat cleared. Occasionally felt stabbing pain in the left hypochondrium, with rattling sounds upon pressing. This was caused by youthful fondness for wine and arrogance, leading to fights. Zeshu Mijian Tang (Plantain, Atractylodes, and Elsholtzia Decoction) plus fresh Lotus Root Juice was administered orally. Dark purple-black blood clumps were passed in stool, clearing over several days. Later, Si Wu Gai Ru San (Four Oyster Shell and Rubus Powder) was given as powder, divided into four doses. Cooked inside the belly of a yellow hen and eaten. Remaining medicine formed honey pills. After finishing the course, bleeding did not recur.
Yu Zhen commented: Spontaneous sweating, panting, fatigue, wiry-large-deficient pulse, without indiscriminately prescribing Dihuang Tang or Shengmai San, is highly commendable. Using Buxue Tang was due to nighttime restlessness. Considering the fight history due to hypochondriac pain implies the person's physique must be robust. Thus, resolving stasis without tonification is most appropriate.
Gao Shizong recorded: The niece of my friend's grandson, Du, married into the Zhang family. After a miscarriage, she suffered coughing and hematemesis. Pulse was rapid and choppy; complexion pale. Fullness in the Stomach and Spleen diarrhea. Physicians used Qi-regulating, Fire-descending, and Hemostatic drugs, worsening the condition. I prescribed Lizhong Tang (Middle-Warming Decoction) plus Muxiang (Aucklandiae Root) and Danggui (Angelica Sinensis). Doubling the dosage of Renshen and Baizhu stopped the bleeding. Subsequently, Guipi Tang (Spleen-Restoring Decoction) and Jiaban Bawei Yinzi (Modified Eight-Flavor Drink) were used, and various symptoms gradually improved. At that time, Gu Feng arrived from Hu Lake. Examining her, he said: "Such severe deficiency has been stabilized to this extent; only the power of Renshen and Baizhu could achieve this. Currently, there is slight coughing and intermittent night fever. Urgent warming and tonification is needed to prevent future issues." Therefore, Jiaban Bawei Wan (Modified Eight-Flavor Pills) were taken in the morning, and Jiaban Guipi Tang in the evening. Shortly after, a quack physician exclaimed: "Blood diseases originate from Fire; how can hot medicines be used?" Consequently, Lung-clearing and Blood-cooling agents were advanced. The patient felt increasing gastric distress and loss of appetite. Forced by external opinion to take them, after more than a month, the disease flared severely. Bleeding surged like a fountain, varying in color from purple to black to bright red. The patient resented this and summoned me again. I examined her and said: "It is ruined. The zang-fu organs are coerced by Cold-Coolling [drugs]. Ying and Wei are damaged, Water and Fire are exhausted. The pulse exits but does not enter; the disease advances but does not retreat. Nothing can be done." Shortly after, she indeed died. Renzhai's *Zhizhi* states: "When Ying Qi is deficient and scattered, Blood flows erratically. This is what is meant by 'When Yang is deficient, Yin must flee.'" Cao's *Bi Yong Fang* states: "If one takes Shengdi, Lotus Root Juice, Zhuru (Bamboo Shavings), etc., life is far away." Thus, misunderstanding the term "Nourishing Yin" in ancient times could kill people. Moreover, quacks do not understand this, grabbing herbs casually, making excuses of "clearing Fire." What kind of Fire is this, that it can be cleared? The ingredients seem stable, but who knows they cut into the intestines and stomach like saws. How terrifying! "Tonifying Qi for Blood Loss" is a rudimentary principle. Not knowing even this, how can one understand where Qi is generated and how Blood is transformed? Is it not difficult? Wielding the knife to cut, fewer than one in a hundred survives. Those with benevolent hearts should pay some attention here.
Yu Zhen commented: Hematemesis is currently very common. Some occur due to causes, others without. External pathogens of the Six Evils disturbing Blood are lighter. Internal causes of alcohol, lust, worry, and anger disturbing Blood are heavier. And non-internal/external causes like overwork, lifting heavy objects, enduring hunger, and walking fast all cause blood loss. However, one can still seek the cause and treat accordingly. If none of these apply, and hematemesis occurs without reason, this is the most severe. The *Neijing* says: "Earth resides in the Great Void, held up by Great Qi." If Great Qi leaks occasionally, earthquakes and mountain collapses occur, and waters become turbulent, overflowing or drying up. The human body is the same. If Great Qi is thick, it suffices to contain and secure. Even if the Three Causes are violated, other diseases form, not hematemesis. If Great Qi is weak, it cannot support. Like a thin dike leaking water easily, or a collapsed dike bursting. People only adhere to the theory of "Heat forcing Blood to run wild," which is wrong. Observe this case and reflect sharply. However, Renshen, Huangqi (Astragalus), and Baizhu are sometimes effective, sometimes not. Great Qi is formless, different from Ying Qi, Wei Qi, Zong Qi, and Zhong Qi. It cannot be supplemented by herbs or animal products. I have seen people devouring meat and rice, only to die shortly after a sudden burst of blood. I have also seen people taking Ginseng daily, yet still dying from frequent bleeding. These are malignant diseases. Only cultivating character and regulating life can possibly reverse them. The *Neijing* says: "Tranquil and empty, True Qi follows. Spirit remains within, how can disease arise?" This is the formless Great Medicine. In my youth, I opened the apertures too early, violating Chu Shi's warning. At fourteen or fifteen, I suffered from nocturnal emissions and spitting blood. At twenty-four, it worsened. Coughing phlegm always contained blood. More than ten nocturnal emissions a month. Then coughing, night fever, throat itching, fire rising, malarial flush, and back pain. I considered myself doomed. At that time, I had elderly parents with white hair above, and no infants below. Worried by illness and fearing death, the suffering was indescribable. I wanted to dispel the fear of death but had no way. Seeing my emaciation, my parents ordered my wife to sleep in a separate room. I also re-read *Xianyu Yinyuan*. Viewing life and body as worn-out shoes, the fear of death melted like ice. Lustful dreams never occurred again. From then on, I was peaceful and content, naturally free of annoyance and impatience. I quit smoking and alcohol, fearing women like scorpions. After two years, all illnesses healed. After three years, children were born. Dare I not share this with the world? I hope those suffering from this disease will try it.
Yu Zhen further commented: Miu Zhongchun's Three Principles for Treating Hematemesis are revered as clear instructions by the world. Their meaning has not been carefully expounded. The first principle states: "It is suitable to move Blood, not to stop Blood." This is correct. However, among Blood-moving herbs, only Dahuang (Rhubarb) applies, as Blood moving downward is smooth. One must also consider whether the Blood syndrome is new or old, and the amount of blood lost, to decide usage. Purging is suitable at the beginning of reckless flow, but not after massive depletion. The current text does not specify which herb moves Blood, only stating "moving Blood makes it follow the collaterals." This has led to recent deaths from taking too much Shan Yang Xue (Mountain Goat Blood). Who knows if this sentence is misleading? Regarding surging blood, it must be stopped. Ancient formulas like Huarui Shi San (Flower Coral Stone Powder), Shihui San (Ten Ashes Powder), Tongbian, and Mo Zhi all aim to stop it. After stopping, resolving or tonifying can be discussed later. Letting it vomit without thinking how to stop it, how can one seek survival? Specifically, the method of stopping blood values clear differentiation of Deficiency/Excess and Cold/Heat, so that tonifying/draining and warming/cooling are handled steadily. The text says: "Stopping it causes Blood congealing; congealing causes fever and food aversion, making the disease chronic." Consider that modern hematemesis patients often have fever and food aversion; is it ever due to Blood congealing? If it is Blood congealing, Zhang Zhongjing's Dahuang Zhechong Wan (Rhubarb and Ground Beetle Pill) could still save it. The worry is endless Blood loss; Yin deficiency leads to disease, Yin exhaustion leads to death, leaving no remedy. The second principle: "Suitable to tonify Liver, not to attack Liver." The annotation says: "Nourishing the Liver calms Liver Qi, allowing Blood to return to its source. Attacking it makes Liver deficient, unable to store Blood, causing more bleeding." This explanation is clever. However, one must look at the pulse. Liver Yin certainly needs nourishing, but Liver Yang also needs controlling. If encountering Wood-Fire hyperactivity with Blood rebelling with Qi, Yi Qing Wan (Suppress Green Pill), Longdan Xiegan Tang (Gentian Liver-Draining Decoction), Vine-processed Dahuang, Taoren (Peach Kernel), Zhike (Bitter Orange), Qingqian (Blue Lead), and Tieshui (Iron Rust Water)—were these ever forbidden? Mastering the way, attacking is also tonifying. Failing to master the way, and merely regarding Shudi (Prepared Rehmannia), Danggui, Yurou (Cornus), and Gouqi (Goji Berry) as Liver-tonifying herbs, is erroneous. The final principle: "Suitable to descend Qi." Qi has Deficiency/Excess and Cold/Heat. In Blood syndromes, Qi is mostly Deficient, rarely Excess; mostly Hot, rarely Cold. Only for those who are strong and prone to anger, with Excess Liver Qi causing hematemesis, suppressing and clearing the Liver, descending Qi and descending Fire are suitable. Others: If Lung Qi is deficient and fails to descend, use Shengmai San or Guanyin Yingmeng San. If Middle Qi is deficient and fails to descend, use Sijunzi Tang or Shenju Jian. If Kidney Yang is deficient and fails to grasp Qi, leading to failure to descend, use Bawei Wan or Heixi Dan. If Kidney Yin is deficient and fails to grasp Qi, leading to failure to descend, use Dubuyin Wan or Santian Fengsui Dan. One must seek the reason for failure to descend and treat accordingly; this is descending. How can one rely on Jiu Zhi (Leek Juice), Suzi (Perilla Seed), or Fan Jiangxiang (Sandalwood) as Qi-descending herbs? Regarding the phrase "Not suitable to descend Fire," cunning physicians use it as an excuse, claiming that taking Shengdi and Maidong for hematemesis inevitably leads to consumption. They then sell fake Ejiao to replace these two. Not knowing that seeing a Blood syndrome and generally using Shengdi and Maidong deserves criticism. But discarding these two items is throwing the baby out with the bathwater. Moreover, in my experience, nine out of ten people with upper orifice bleeding fit Danxi's description of "Yang Excess, Yin Deficiency, ascending without descending." Only one or two in a hundred fit Renzhai's "Yang Deficiency, Yin Flees" or Cao's Gancao Ganjiang Tang (Licorice and Ginger Decoction), or Zhao's Jiangxue Danshu's Guifu (Cinnamon and Aconite). For those deficient with Fire, clear and tonify together. For those deficient without Fire, tonify Qi and Blood together. Whether to descend Fire or not depends on the case; there is no fixed method. If taking bitter-cold drugs inevitably leads to death, then Zhang Zhongjing's Xiexin Tang (Drain the Epigastrium Decoction) in the *Jinkui Yaolue* would be the chief culprit, wouldn't it?