（呕血 唾血 咳血 咯血 血溢 九窍出血）
缪仲淳曰。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。肝主藏血。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。
无溢出上窍之患矣。降火必用寒凉之剂。反伤胃气。胃气伤。则脾不能统血。血愈不能归经矣。
今之疗吐血者。大患有二。一则专用寒凉之味。如芩、连、山栀、四物、知、柏之类。往往伤脾
作泻。以致不救。一则专用人参。肺热还伤肺。咳嗽愈甚。亦有用参而愈者。此是气虚喘嗽。气
属阳。不由阴虚火炽所致。然亦百中一二也。刘默生曰。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。故有阳络伤则血上溢。阴络伤则血下渗。已伤之膜。若有复伤。其吐必多。膈膜虽伤。
伤处有瘀血凝定。血来则缓。若阴火骤冲破瘀积之血。血来如潮之上涌。自觉沥沥有声。彼时喘
息不定。面赤如醉。烦躁不宁。心神昏乱。一皆龙雷之势。脉亦急疾难凭。少顷火退神清。面白
气平。血亦渐止。方可诊切。用药须乘此时。瘀积荡尽。缓缓清理。徐徐调补。然不可骤壅。亦
不可用耗气之药。悉知此义。治血有本矣。吐血者。一吐则倾
盆盈碗。或鲜散中兼紫黑大块。吐后不即凝结。盖吐血出于胃。胃为水谷之海。多气多血。所以
吐多而不即凝。以中杂水谷之气也。皆劳力内伤中气而得。亦有醉饱接内而致者。治法。不可骤
止。止则使败血留积。为瘀血之根。不时举发。为害非轻。亦不宜峻攻。复伤其血。只宜清理胃
气以安其血。如犀角地黄汤。随证加桃仁、茜根、橘红、木香、大黄、童便之属。吐久不止。内
虚寒而外假热。千金当归汤。不应。用十灰散遏之。若血色瘀晦如污泥。为阳不制阴。宜花蕊石
散温以散之。吐血初起。脉俱洪数者。属外因。须用参苏饮加归身倍茯苓。盖茯苓能守五脏真气。
泻肾中伏火。去脾胃中湿。二三剂后。脉数退而洪不退者。用六味地黄丸加沉香以纳气归元。若
洪退弱极。用四君子加橘红以补脾生肺。慎不可用凉药。盖火载上行。逆也。复用凉药强为降下。
岂非逆而又逆乎。不若发散之为愈也。上膈壅热。胸腹满痛。吐血。脉洪大弦长。按之有力。精
神不倦。或觉胸中满痛。或血是紫黑块者。用当归、丹皮、荆芥、阿胶、滑石、酒大黄、玄明粉、
桃仁泥之属从大便导之。此釜底抽薪之法。不知此。而从事于芩、连、知、柏之属辅四物而行之。
使气血俱伤。脾胃多败。百不一生也。吐血在暑天。病患口渴面垢。头晕干呕。五苓散。或桂苓
甘露饮。并加麦冬、五味、藕节汁。酒后闷呕。血从吐后出者。新定紫菀茸汤。饮酒过多。伤胃
吐血。六君子加香、砂、干葛。伤胃吐血。因饮食太过不能消化。烦闷强呕。因伤胃口吐血。腹
中绞痛自汗。其脉紧而数者难治。枳实理中汤加丹皮、扁豆灰。诸失血后。倦怠昏愦。面失色。
懒于言语。浓煎独参汤加橘皮。所谓血脱益气也。劳心太过。吐血不止。归脾汤去木香。加门冬、
阿胶。妇人倒经。血溢于上。蒸热咳嗽不除。及男子精未充而御女。而成虚劳失血。并宜乌骨鸡
丸、巽顺丸选用。若血色晦淡不鲜。无论上吐下失。俱当用温热之剂。如甘草干姜温理中气。切
禁寒凉。若至 血血水。难已。胃
中热甚。迫血妄行。犀角地黄汤加大黄灰、木香、桃仁。吐血势不可遏。胸中觉气塞滞。吐紫黑
血者。桃仁承气加茜根。千金翼治吐血。用生地汁半升。煎三两沸。调生大黄末一方寸匙。分三
服。治热毒吐血有效。有时吐血两口。随即无事。数日又发。经年累月不愈者。小乌沉汤送黑神
散。不时常服。吐甚不止者。柏叶、干姜等分。加艾少许。入童便服。失血后。头晕发热者。往
往有之。此是虚火上炎外扰之故。不可误认外感而用风药。吐血发渴。名曰血渴。十全大补汤。
或生脉散加黄 、煨葛根、枇杷叶。量胃气虚实用之。暴吐血新止后。丹方用燕窝菜、冰糖各四
钱。同煮服之。连服五七日。永不复发。吐血脉以微细为顺。洪大为逆。血若暴涌如潮。喉中
不止。脉见虚大。此火势未敛。不可便与汤药。急以热童便。或藕汁灌之。俟半日许。脉势稍
缓。可进调养之剂。倘寸关虽弱而尺中微弦。为阴虚。以防午后阴火上升。上午宜服独参、保元
以统其血。午后与六味丸加童便、牛膝以济其阴。服后脉渐调和。饮食渐进。肢体轻捷。面色不
赤。足膝不冷。身不灼热。额无冷汗。溲便如常。虽有紫黑血块。时欲咯出而无鲜血上行。方许
可治。血虽止而脉大不减。或虽小而弦细数疾。或弦硬不和。慎勿轻许可治。亦有他部柔和而左
手关尺弦强者。为阴虚火旺。最为危兆。其变有三。一则阴火引血复上而暴脱。一则虚阳发露而
发热。一则火上逼肺而喘咳。此终不救。脱血用大剂人参益气以固血。惟血色鲜明或略兼紫块者
宜之。若见晦淡者为血寒而不得归经。须兼炮黑干姜。或大剂理中温之。尺部脉弦。大剂生料六
味加肉桂引之。亦有用肉桂为末。和独参汤服者。若血色如朱。光亮如漆。吐出即干。以指甲剔
之成片而起者。虽能食不倦。后必暴脱而死。若血中见似肉似肺。如烂焦肠。此胃中脂膜为邪火
所烁。凝结而成。方书咸谓必死。然吐后凝结既去。而不发热。能进饮食。令服小剂异功、保元。
大剂六味、都
气。多有得生者。不可尽委之于无救也。此证宜与前虚损门参看。
呕血 呕血者。血从腹胁而上。大呕而出。乃肝火内旺。鼓激胃中之血上涌。犹龙奋于泽而
波涛为之沸腾也。呕血证治有三。一属暴怒火逆伤肝。其证胸胁痛甚则厥逆。柴胡疏肝散加酒大
黄。一属极劳奔驰伤肝。其证遍身疼痛。或时发热。犀角地黄汤加当归、肉桂、桃仁泥。一属竭
力房劳伤肝。其证面赤足冷。烦躁口渴。生脉散合加减八味丸。阳衰不能内守而呕者。异功散研
服八味丸。然不戒房室思虑劳役。终不救也。房室劳惫。气竭伤肝而有干血者。四乌 骨一芦茹
丸。兼童便、藕汁之类。
唾血 平时津唾中有血如丝。或浮散者。此属思虑伤脾。脾虚不能统血也。有兼心兼肾兼胃
之不同。兼心。加味归脾汤。兼肾。六味丸加五味子、肉桂。兼胃。四君子汤加黄 山药、粟米。
名七珍散。食少痰清者。异功散加枇杷叶、白扁豆灰。胃中痰食不清吐血。加半复、生姜。即白
扁豆散。
咳血 咳血者。因咳嗽而见血。或干咳。或痰中见红丝血点一两口。气急喘促。此虽肺体自
燥。亦为火逆。咳伤血膜而血随痰出也。其脉微弱平缓易治。弦数急实。气促声嘶。咽痛者不治。
得此证者。若能静养。庶有生理。治宜六味丸加门冬、五味清金壮水为生。略兼阿胶、贝母、百
合、款冬、紫菀润肺止咳之剂。血止后胃虚少食。气息不续者。劫劳散去半夏加紫菀茸。及琼玉
膏调理之。咳血久而成劳。或劳而咳血。肌肉消瘦。四肢倦怠。五心烦热。咽干颊赤。心冲潮热。
盗汗减食。异功散加阿胶。或四君子加黄 、鳖甲、麦冬、五味。阴虚火动而咳血。或痰中有血
星如珠者。生料六味丸加茜根、乌贼骨、童便。咳血不止。至夜发热吐痰。或带血丝者。六味丸
加蛤粉、童便。临卧服。肥盛酒客
辈。痰中有血。滚痰丸搜涤之。咳唾脓血。咳即胸中隐隐痛。脉反滑数。或数实者。此为肺痈。
更于本门求之。
咯血 咯血者。不嗽而喉中咯出小块或血点是也。其证最重。而势甚微。常咯两三口即止。
盖缘房劳伤肾。阴火载血而上。亦有兼痰而出者。肾虚水泛为痰也。阴虚多火。黑瘦之人。是忌
犯此。初起宜紫菀、麦冬、茯苓、枣仁、山药、白芍、丹皮、童便以清手足少阳厥阴诸经游散之
火。后以六味丸加牛膝。滋补肾阴。以安其血。慎不可用攻血药也。滑伯仁曰。咯血为病是重。
以肺为清肃之脏。金为阴火所制。水亏火旺。迫而上行。以为咯血。逆之甚矣。经谓上气见血。
下闻病音者。言喘出于肾。而咯出于肺也。余尝用生料六味丸加麦冬、五味。下灵砂丹治之。是
得内经之旨也。然多有兼挟风寒饮食而发者。不可误认本病而与前药。若兼风寒。则人迎浮虚。
或见弦紧。饮食则气口短滑。或反伏涩。风寒则黄 建中。饮食则枳实理中。不可妄用他药。
喻嘉言曰。夫血病有新久微甚。无不本之于火。然火有阴阳不同。治法因之迥异。经云。暴
病非阳。则其为火也。即非阳火甚明。阳火者五行之火。何暴之有。设其暴也。复可以五行之水
折之。惟夫龙雷之火。潜伏阴中。方其未动。不知其为火也。及其一发。暴不可御。以故载阴血
而上溢。故凡用凉血清火之药。未有不转助其虐者。大法惟宜温补其阳。以制阴火之僭。经谓咯
血者属肾。明乎阴火发于阴中。其血咯之成块而出。不比咳嗽痰中带血为阳火也。此义从前未有
发明。惟仲景云。误发少阴汗。动其经血者。下厥上竭。为难治。后人随文读去。总置不讲。不
知下厥者。阴气逆于下也。上竭者。阴血竭于上也。盖气与血。两相维附。气不得血。则散而无
统。血不得气。则凝而不流。故阴火动而阴气不得不上奔。阴气上奔而阴血不得不从之上溢而竭
矣。血既上溢。其随血之气。散于胸中。不得复返于本位。
则下厥矣。阴既逆于下。势必龙雷之火应之。血不尽竭不止也。仲景所以断为难治者。非直不治
也。吾为大辟其扃。则以健脾中之阳气为第一义。健脾之阳。一举有三善。一者脾中之阳气旺。
而龙雷之火潜伏也。一者脾中之阳气旺。而胸中窒塞。如太空不留纤翳也。一者脾中之阳气旺。
而饮食运化精微。复生其已竭之血也。今方书妄引久嗽成劳。痰中带血之阳证。不敢用健脾增咳
为例。不思咯血即有咳嗽。不过气逆。气下则不咳矣。况原无咳嗽者乎。古方治龙雷之火。每用
桂、附引火归元之法。然施之于暴血之证。可暂不可常。盖已亏之血。恐不能制其悍。而未动之
血。恐不可滋之扰耳。此以崇土为先。土浓则浊阴不升。而血患自息也。
血溢 原病式云。血溢者。上出也。心主血。热甚则血随火而妄行。或谓呕吐紫凝血为寒者。
误也。此非冷凝。由热甚销烁而为稠浊。热甚则水化制之。故赤兼黑而为紫也。泻心汤。盖火性
急速。故至溢脱。从未见有属阴寒者耳。或偶触破伤。血遂泉涌不止。惟用十全大补汤。频频多
服。外用杏仁研细。拌白面水调涂之。
九窍出血 是证非中毒。即跌扑受伤。中毒者。用生羊血等法。受伤者。观其人不发热。尚
能饮食者。频灌热童便。无故发热。九窍出血者。肝肾疲极。五脏内崩也。多不可治。若见血水
必死。若因劳伤者。补中益气倍参、 。或胎发灰、大蓟汁。人参汤调服。或血余灰。每服二钱。
以茅根、车前草煎汤调下。
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。脉来沉实。腹中满痛。或吐血块。或为瘀血蓄血。当归、桃仁、赤芍、延胡索、
蓬术、大黄之属。怒伤肝木。则血菀于上。使人薄厥。沉香、木香、青皮、芍药、丹皮之属。
劳心。莲肉、枣仁、薯蓣、茯神、紫菀、柏仁、丹参之属。房劳。熟地、枸杞、牛膝、杜仲、鹿
茸、人参之属。血热。地骨、丹皮、犀角。血寒。桂心、附子。血热不止。山栀灰、黄连灰。血
瘀。发灰、大黄灰、干漆灰。血寒。干姜灰。血滑。棕榈灰、莲房灰。血虚。地黄灰。三七、郁
金行血中之气。侧柏凉血中之热。大小蓟行血中之滞。茅根导之使下行也。
〔诊〕经曰。安卧脉盛。谓之脱血。失血脉数大为阳盛。涩细为少血。细数为阴火郁于血中。
芤为失血。血虚气不归附也。弦紧胁痛为瘀结。诸血皆属于肝也。脉来寸口大。尺内微。为肺中
伏火。尺中盛而寸口虚大。为肾虚阴火。尺滑而疾。为血虚有热。右手虚大。为脾胃之火。左手
数盛。为肝胆之火。大抵失血。脉微弱细小而和缓者易治。洪数实大弦急。或虽小。按之如引葛。
如循刀。及衄血身热。脉至而搏。呕血胸满引背。脉小而疾者。皆不治。
汪石山治一中年人。面色苍白。平素内外过劳。或为食伤。则咯硬痰而带血丝。因服寒凉清
肺消痰药。至五十余剂。声渐不清。而至于哑。夜卧不寐醒来口苦舌干。而常白苔。或时喉中梗
缪希雍（字仲淳）说：治疗吐血有三条原则。第一，宜行血，不宜止血。血液不循经脉运行，是因为气机逆乱上壅。行血则血液能循经而行，出血自然停止；若强行止血，则导致血液凝滞，血液凝滞就会引起发热和食欲不振，病情就会日益顽固。第二，宜补肝，不宜伐肝。《内经》说：五脏是贮藏精气而不妄泻的器官。肝主藏血，吐血的人，是肝失去了其正常职能。滋养肝脏，则肝气平和，血液有所归依；攻伐肝脏，则肝虚不能藏血，出血会更加不止。第三，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，血液随气运行，就不会有从上部七窍溢出的祸患了。降火必须使用寒凉药物，反而会损伤胃气。胃气受伤，则脾脏不能统摄血液，血液更加不能回归经脉。
当今治疗吐血的人，主要有两大弊端。一是专门使用寒凉药物，如黄芩、黄连、山栀子、四物汤、知母、黄柏之类，往往损伤脾气导致腹泻，以致无法挽救。二是专门使用人参，肺热再用参药会再次伤害肺脏，使咳嗽更加严重。也有用人参而痊愈的，那是属于气虚引起的喘嗽，气属阳，不是由阴虚火旺所致，但这只是百中有一二例罢了。
刘默生说：吐血这一病症，人们只知道是气逆血溢、火升血泛，却不知道血液在脏腑之中，另有膈膜将其分隔固定，血液因此不能渗漏溢出。所谓膈膜，极薄极脆，凡是有损伤就会破裂，破裂后血液就会向上溢出。所以有“阳络受伤则血液上溢，阴络受伤则血液下渗”的说法。已经受伤的膜，如果再次受到损伤，吐血必然很多。膈膜虽然受伤，但伤处有瘀血凝结固定，血液流出则缓慢；如果是阴火突然冲破瘀积的血液，血液就像潮水一样涌上来，自觉听到沥沥的声音，此时喘息不定，面色红得像喝醉了一样，烦躁不安，心神昏乱，这都是龙雷之火（相火）肆虐的表现，脉象也急疾难以凭靠。过了一会儿火退神清，面色变白气息平稳，血液也逐渐停止，这时才可以诊察切脉。用药必须趁这个时候，将瘀积荡涤干净，缓缓清理，徐徐调补。然而不可骤然壅补，也不可用耗气的药物。通晓了这些道理，治疗血证就有根本了。
吐血的人，一吐起来就倾盆满碗，血色或鲜红散漫中夹杂着紫黑色的大块，吐后不立即凝结。这是因为吐血出于胃，胃是水谷之海，多气多血，所以吐得多且不立即凝结，因为其中混杂了水谷之气。这些病都是因为劳力过度内伤中气而得，也有因醉酒饱食后行房事而导致的。治疗方法，不可骤然止血，止血会使败血留积，成为瘀血的根源，不时发作，危害非轻。也不宜峻猛攻下，以免再次损伤血液。只宜清理胃气以安顿血液，如犀角地黄汤，根据症状加入桃仁、茜草根、橘红、木香、大黄、童便等药。吐血日久不止，出现内虚寒而外假热的症状，用千金当归汤；无效时，用十灰散遏制。如果血色晦暗污浊像污泥一样，这是阳气不能制约阴寒，宜用花蕊石散温散之。
吐血初起，脉象都洪数，属于外因，须用参苏饮加当归身、倍量茯苓。因为茯苓能守五脏真气，泻肾中伏火，去脾胃中湿气。二三剂后，脉数退去而洪象不退的，用六味地黄丸加沉香以纳气归元。如果洪象退去而脉弱至极，用四君子汤加橘红以补脾生肺。千万不可用凉药。因为火载血上行，这是逆证，再用凉药强行降下，岂不是逆而又逆？不如发散的方法更好。
上膈壅热，胸腹满痛，吐血，脉洪大弦长，按之有力，精神不倦，或者觉得胸中满痛，或者血色是紫黑块的，用当归、丹皮、荆芥、阿胶、滑石、酒大黄、玄明粉、桃仁泥等药，从大便导引排出。这是釜底抽薪的方法。不知道这个方法，而去从事于黄芩、黄连、知母、黄柏等药辅助四物汤来治疗，会使气血俱伤，脾胃败坏，百无一活。
吐血发生在暑天，病人口渴面垢，头晕干呕，用五苓散，或桂苓甘露饮，并加麦冬、五味子、藕节汁。酒后闷呕，血从吐后出的，用新定紫菀茸汤。饮酒过多，伤胃吐血，用六君子汤加木香、砂仁、干葛根。伤胃吐血，因饮食太过不能消化，烦闷强呕，因伤胃口吐血，腹中绞痛自汗，脉紧而数的，难治，用枳实理中汤加丹皮、扁豆灰。
各种失血后，倦怠昏愦，面色失色，懒于言语，浓煎独参汤加橘皮。这就是所谓的“血脱益气”。劳心太过，吐血不止，用归脾汤去木香，加麦冬、阿胶。妇人倒经，血溢于上，蒸热咳嗽不除，以及男子精未充而御女，而成虚劳失血，都适宜选用乌骨鸡丸、巽顺丸。如果血色晦淡不鲜，无论上吐下失，都应当用温热药剂，如甘草干姜汤温理中气，切忌寒凉。如果至吐血夹水，难愈。胃中热甚，迫血妄行，用犀角地黄汤加大黄灰、木香、桃仁。吐血势不可遏，胸中觉气塞滞，吐紫黑血的，用桃仁承气汤加茜根。
《千金翼方》治吐血，用地黄汁半升，煎三两沸，调生大黄末一方寸匙，分三次服，治热毒吐血有效。有时吐血两口，随即无事，数日又发，经年累月不愈的，用小乌沉汤送服黑神散，不时常服。吐甚不止的，用柏叶、干姜各等分，加艾少许，入童便服。失血后，头晕发热的，往往有之，这是虚火上炎外扰的缘故，不可误认外感而用风药。吐血发渴，名叫血渴，用十全大补汤，或生脉散加黄芪、煨葛根、枇杷叶，根据胃气虚实使用。暴吐血新止后，丹方用燕窝菜、冰糖各四钱，同煮服之，连服五七日，永不复发。
吐血的脉象以微细为顺，洪大为逆。血若暴涌如潮，喉中不止，脉见虚大，这是火势未敛，不可便与汤药，急以热童便，或藕汁灌之，等待半天左右，脉势稍缓，可进调养之剂。倘若寸关虽弱而尺中微弦，为阴虚，以防午后阴火上升，上午宜服独参汤、保元汤以统其血，午后与六味丸加童便、牛膝以济其阴。服药后脉渐调和，饮食渐进，肢体轻捷，面色不赤，足膝不冷，身不灼热，额无冷汗，溲便如常，虽有紫黑血块，时欲咯出而无鲜血上行，方才许可治疗。血虽止而脉大不减，或虽小而弦细数疾，或弦硬不和，慎勿轻许可治。也有他部柔和而左手关尺弦强的，为阴虚火旺，最为危兆。其变证有三种：一则阴火引血复上而暴脱，一则虚阳发露而发热，一则火上逼肺而喘咳，这最终都不救。
脱血用大剂人参益气以固血，惟血色鲜明或略兼紫块者适宜。若见晦淡的为血寒而不得归经，须兼炮黑干姜，或大剂理中汤温之。尺部脉弦，大剂生料六味丸加肉桂引之，也有用肉桂为末，和独参汤服的。如果血色如朱，光亮如漆，吐出即干，以指甲剔之成片而起的，虽然能食不倦，后来必暴脱而死。如果血中见似肉似肺，如烂焦肠，这是胃中脂膜为邪火所烁，凝结而成，方书都说必死，然而吐后凝结既去，而不发热，能进饮食，令服小剂异功散、保元汤，大剂六味丸、都气丸，多有得生者，不可尽委之于无救也。此证宜与前虚损门参看。
呕血：呕血者，血从腹胁而上，大呕而出，乃肝火内旺，鼓激胃中之血上涌，犹龙奋于泽而波涛为之沸腾也。呕血证治有三：一属暴怒火逆伤肝，其证胸胁痛甚则厥逆，柴胡疏肝散加酒大黄。一属极劳奔驰伤肝，其证遍身疼痛，或时发热，犀角地黄汤加当归、肉桂、桃仁泥。一属竭力房劳伤肝，其证面赤足冷，烦躁口渴，生脉散合加减八味丸。阳衰不能内守而呕者，异功散研服八味丸。然而不戒房室思虑劳役，终不救也。房室劳惫，气竭伤肝而有干血者，用四乌贼骨一芦茹丸，兼童便、藕汁之类。
唾血：平时津唾中有血如丝，或浮散的，此属思虑伤脾，脾虚不能统血也。有兼心、兼肾、兼胃的不同。兼心，加味归脾汤。兼肾，六味丸加五味子、肉桂。兼胃，四君子汤加黄芪、山药、粟米，名七珍散。食少痰清的，异功散加枇杷叶、白扁豆灰。胃中痰食不清吐血，加半夏、生姜，即白扁豆散。
咳血：咳血者，因咳嗽而见血，或干咳，或痰中见红丝血点一两口，气急喘促。此虽肺体自燥，亦为火逆，咳伤血膜而血随痰出也。其脉微弱平缓易治，弦数急实，气促声嘶，咽痛者不治。得此证者，若能静养，庶有生理。治宜六味丸加麦冬、五味清金壮水为生。略兼阿胶、贝母、百合、款冬、紫菀润肺止咳之剂。血止后胃虚少食，气息不续者，劫劳散去半夏加紫菀茸，及琼玉膏调理之。咳血久而成劳，或劳而咳血，肌肉消瘦，四肢倦怠，五心烦热，咽干颊赤，心冲潮热，盗汗减食，异功散加阿胶，或四君子加黄芪、鳖甲、麦冬、五味。阴虚火动而咳血，或痰中有血星如珠者，生料六味丸加茜根、乌贼骨、童便。咳血不止，至夜发热吐痰，或带血丝者，六味丸加蛤粉、童便，临卧服。肥盛酒客辈，痰中有血，滚痰丸搜涤之。咳唾脓血，咳即胸中隐隐痛，脉反滑数，或数实者，此为肺痈，更于本门求之。
咯血：咯血者，不嗽而喉中咯出小块或血点是也。其证最重，而势甚微，常咯两三口即止。盖缘房劳伤肾，阴火载血而上，亦有兼痰而出者，肾虚水泛为痰也。阴虚多火，黑瘦之人，是忌犯此。初起宜紫菀、麦冬、茯苓、枣仁、山药、白芍、丹皮、童便以清手足少阳厥阴诸经游散之火。后以六味丸加牛膝，滋补肾阴，以安其血。慎不可用攻血药也。滑伯仁曰：咯血为病是重，以肺为清肃之脏，金为阴火所制，水亏火旺，迫而上行，以为咯血，逆之甚矣。经谓上气见血，下闻病音者，言喘出于肾，而咯出于肺也。余尝用生料六味丸加麦冬、五味，下灵砂丹治之，是得内经之旨也。然多有兼挟风寒饮食而发者，不可误认本病而与前药。若兼风寒，则人迎浮虚，或见弦紧；饮食则气口短滑，或反伏涩。风寒则黄芪建中汤，饮食则枳实理中汤，不可妄用他药。
喻嘉言曰：夫血病有新久微甚，无不本之于火，然火有阴阳不同，治法因之迥异。经云：暴病非阳，则其为火也，即非阳火甚明。阳火者五行之火，何暴之有？设其暴也，复可以五行之水折之。惟夫龙雷之火，潜伏阴中，方其未动，不知其为火也，及其一发，暴不可御，以故载阴血而上溢。故凡用凉血清火之药，未有不转助其虐者。大法惟宜温补其阳，以制阴火之僭。经谓咯血者属肾，明乎阴火发于阴中，其血咯之成块而出，不比咳嗽痰中带血为阳火也。此义从前未有发明，惟仲景云：误发少阴汗，动其经血者，下厥上竭，为难治。后人随文读去，总置不讲，不知下厥者，阴气逆于下也；上竭者，阴血竭于上也。盖气与血，两相维附，气不得血，则散而无统，血不得气，则凝而不流。故阴火动而阴气不得不上奔，阴气上奔而阴血不得不从之上溢而竭矣。血既上溢，其随血之气，散于胸中，不得复返于本位，则下厥矣。阴既逆于下，势必龙雷之火应之，血不尽竭不止也。仲景所以断为难治者，非直不治也。吾为大辟其扃，则以健脾中之阳气为第一义。健脾之阳，一举有三善：一者脾中之阳气旺，而龙雷之火潜伏也；一者脾中之阳气旺，而胸中窒塞，如太空不留纤翳也；一者脾中之阳气旺，而饮食运化精微，复生其已竭之血也。今方书妄引久嗽成劳，痰中带血之阳证，不敢用健脾增咳为例，不思咯血即有咳嗽，不过气逆，气下则不咳矣，况原无咳嗽者乎。古方治龙雷之火，每用桂、附引火归元之法，然施之于暴血之证，可暂不可常。盖已亏之血，恐不能制其悍，而未动之血，恐不可滋之扰耳。此以崇土为先，土浓则浊阴不升，而血患自息也。
血溢：《原病式》云：血溢者，上出也。心主血，热甚则血随火而妄行。或谓呕吐紫凝血为寒者，误也。此非冷凝，由热甚销烁而为稠浊，热甚则水化制之，故赤兼黑而为紫也。泻心汤。盖火性急速，故至溢脱，从未见有属阴寒者耳。或偶触破伤，血遂泉涌不止，惟用十全大补汤，频频多服，外用杏仁研细，拌白面水调涂之。
九窍出血：是证非中毒，即跌扑受伤。中毒者，用生羊血等法。受伤者，观其人不发热，尚能饮食者，频灌热童便。无故发热，九窍出血者，肝肾疲极，五脏内崩也，多不可治。若见血水必死。若因劳伤者，补中益气汤倍人参、黄芪，或胎发灰、大蓟汁，人参汤调服。或血余灰，每服二钱，以茅根、车前草煎汤调下。
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。脉来沉实，腹中满痛，或吐血块，或为瘀血蓄血，当归、桃仁、赤芍、延胡索、蓬术、大黄之属。怒伤肝木，则血菀于上，使人薄厥，沉香、木香、青皮、芍药、丹皮之属。劳心，莲肉、枣仁、薯蓣、茯神、紫菀、柏仁、丹参之属。房劳，熟地、枸杞、牛膝、杜仲、鹿茸、人参之属。血热，地骨、丹皮、犀角。血寒，桂心、附子。血热不止，山栀灰、黄连灰。血瘀，发灰、大黄灰、干漆灰。血寒，干姜灰。血滑，棕榈灰、莲房灰。血虚，地黄灰。三七、郁金行血中之气，侧柏凉血中之热，大小蓟行血中之滞，茅根导之使下行也。
〔诊〕《内经》说：安卧脉盛，谓之脱血。失血脉数大为阳盛，涩细为少血，细数为阴火郁于血中，芤脉为失血，血虚气不归附也。弦紧胁痛为瘀结，诸血皆属于肝也。脉来寸口大，尺内微，为肺中伏火；尺中盛而寸口虚大，为肾虚阴火；尺滑而疾，为血虚有热；右手虚大，为脾胃之火；左手数盛，为肝胆之火。大抵失血，脉微弱细小而和缓者易治。洪数实大弦急，或虽小，按之如引葛，如循刀，及衄血身热，脉至而搏，呕血胸满引背，脉小而疾者，皆不治。
汪石山治疗一个中年人，面色苍白，平素内外过劳，或为食伤，则咯硬痰而带血丝，因服寒凉清肺消痰药，至五十余剂，声渐不清，而至于哑，夜卧不寐醒来口苦舌干，而常白苔，或时喉中梗
(Ou Xue [Vomiting Blood], Tuo Xue [Spitting Saliva with Blood], Ke Xue [Coughing Blood], Ge Xue [Gargling Blood], Xue Yi [Blood Overflow], Jiu Qiao Chu Xue [Bleeding from Nine Orifices])
Miao Zhongchun (courtesy name Zhongchun) said: There are three principles for treating Tu Xue (Hematemesis/Spitting Blood). First, it is appropriate to promote blood circulation and inappropriate to stop bleeding. When blood does not follow the meridians, it is due to Qi rebellion and upward congestion. Promoting blood circulation allows it to follow the meridians, and bleeding will stop naturally; stopping it forcibly leads to blood stasis. Blood stasis causes fever and loss of appetite, making the disease increasingly stubborn. Second, it is appropriate to tonify the Liver and inappropriate to attack the Liver. The *Classic* states: The Five Zang organs store Jing-Qi (Essence-Qi) and do not leak. The Liver governs storing blood. In cases of hematemesis, the Liver has lost its proper function. Nourishing the Liver calms Liver Qi, allowing blood to return to its repository; attacking the Liver causes Liver deficiency and inability to store blood, leading to even more persistent bleeding. Third, it is appropriate to direct Qi downward and inappropriate to clear Fire. Excess Qi becomes Fire. When Qi descends, Fire descends; when Fire descends, Qi does not rise, and blood follows Qi without overflowing from the upper orifices. Clearing Fire requires cold-cooling agents, which damage Stomach Qi. Damaged Stomach Qi impairs the Spleen's ability to control blood, causing blood to fail to return to the vessels.
Currently, those treating hematemesis have two major pitfalls. One is the exclusive use of cold-cooling herbs such as Huang Qin (Scutellariae Radix), Huang Lian (Coptidis Rhizoma), Shan Zhi Zi (Gardeniae Fructus), Si Wu Tang (Four Substances Decoction), Zhi Mu (Anemarrhenae Rhizoma), and Bai Zhu (Atractylodis Macrocephalae Rhizoma - *Note: Context implies Huang Bo*, Huang Bo (Phellodendri Cortex)). This often damages Spleen Qi, causing diarrhea, leading to untreatable conditions. The other is the exclusive use of Ren Shen (Ginseng Radix et Rhizoma). If Lung Heat exists, using Ren Shen further injures the Lung, worsening cough. There are cases where Ren Shen cures the condition; these are气喘 (wheezing/cough) due to Qi deficiency, where Qi belongs to Yang, not caused by Yin deficiency with blazing Fire. However, this accounts for only one or two in a hundred.
Liu Mosheng said: Regarding hematemesis, people only know that Qi rebellion causes blood overflow and Fire rising causes blood flooding. They do not realize that blood within the Zang-Fu organs is separated and fixed by the diaphragm (Ge Mo), preventing leakage. The diaphragm is extremely thin and fragile; any injury causes rupture, leading to blood overflowing upward. Thus, "injury to Yang collaterals causes blood to overflow upward; injury to Yin collaterals causes blood to seep downward." If an already injured membrane suffers further injury, vomiting will be severe. Although the diaphragm is injured, if blood stasis solidifies at the site, bleeding is slow. However, if Yin Fire suddenly breaks through accumulated blood stasis, blood surges like a tide, accompanied by audible gurgling sounds. At this moment, breathing is irregular, the face is red as if drunk, there is restlessness, and mental confusion. This is the manifestation of Long Lei Zhi Huo (Dragon-Thunder Fire/Ministerial Fire). The pulse is rapid and difficult to assess. After a while, when Fire subsides and consciousness clears, the face turns pale, breath stabilizes, and bleeding gradually stops. Only then can diagnosis be made. Medication should be administered at this time to thoroughly clear stasis, followed by gradual regulation and slow tonification. One must avoid sudden cloying tonics or Qi-consuming drugs. Understanding these principles provides the foundation for treating blood disorders.
In hematemesis, vomiting fills bowls and basins. The blood may be fresh and scattered, mixed with dark purple clots, and does not coagulate immediately after vomiting. This is because hematemesis originates from the Stomach, which is the Sea of Water and Grain, rich in Qi and Blood. Therefore, large volumes do not coagulate quickly due to the mixture with food and fluids. These conditions arise from internal injury to Middle Qi due to overexertion, or from intercourse after drunkenness and full meals. Treatment should not abruptly stop bleeding, as this leaves failed blood to accumulate, becoming a root for future stasis attacks, causing significant harm. Nor should harsh purgatives be used, which would re-injure the blood. Instead, one should clear Stomach Qi to settle the blood, using Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction), adding Tao Ren (Persicae Semen), Qian Gen (Rubiae Radix et Rhizoma), Ju Hong (Citri Reticulatae Pericarpium), Mu Xiang (Aucklandiae Radix), Da Huang (Rhei Radix et Rhizoma), Tong Bian (Human Urine), etc., according to symptoms. For chronic, unceasing hematemesis presenting with internal deficiency-cold and external false-heat, use Qian Jin Dang Gui Tang (Thousand Gold Angelica Decoction). If ineffective, use Shi Hui San (Ten Charcoals Powder) to arrest bleeding. If the blood color is dull and muddy like sludge, indicating Yang failing to control Yin, use Hua Rui Shi San (Flower Ochre Stone Powder) to warm and disperse.
For early-stage hematemesis with a洪 Shu (Surging-Rapid) pulse, attributed to external factors, use Shen Su Yin (Ginseng and Perilla Drink) with added Dang Gui Shen (Dong Quai Root Tip) and doubled Fu Ling (Poria). Fu Ling guards the True Qi of the Five Zang, drains latent Fire in the Kidney, and removes dampness from the Spleen and Stomach. After two or three doses, if the Rapid pulse subsides but the Surging pulse remains, use Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) with Chen Xiang (Aquilaria Wood) to guide Qi back to its origin. If the Surging pulse subsides and the pulse becomes extremely weak, use Si Jun Zi Tang (Four Gentlemen Decoction) with Ju Hong to tonify the Spleen and generate Lung Qi. Strictly avoid cold medicines. Since Fire carries blood upward (a rebellious state), using cold medicine to force descent is doubly rebellious. Dispersing methods are superior.
If Upper Jiao heat congestion causes chest and abdominal fullness/pain, hematemesis, with a洪 Da Xuan Chang (Surging-Large-Wiry-Long) pulse that is forceful upon pressure, and the patient is not fatigued mentally, or feels chest fullness/pain, or vomits dark purple-black clots, use Dang Gui (Angelicae Sinensis Radix), Dan Pi (Moutan Cortex), Jing Jie (Schizonepetae Herba), E Jiao (Colla Corii Asini), Hua Shi (Talcum), Jiu Da Huang (Wine-processed Rhubarb), Xuan Ming Fen (Mirabilite), and Tao Ren Ni (Peach Kernel Paste) to guide blood out through the bowels. This is the method of "removing firewood from under the cauldron." Ignoring this and using Huang Qin, Huang Lian, Zhi Mu, Bai Zhu assisting Si Wu Tang will injure both Qi and Blood, ruin the Spleen and Stomach, and result in death in nearly all cases.
For hematemesis occurring in summer, with thirst, greasy face, dizziness, and dry retching, use Wu Ling San (Five-Ingredient Powder with Poria) or Gui Ling Gan Lu Yin (Cinnamon Twig, Poria, and Sweet Dew Drink), adding Mai Dong (Ophiopogonis Radix), Wu Wei Zi (Schisandrae Fructus), and Ou Jie Zhi (Lotus Node Juice). For post-drinking stifling retching with blood appearing after vomiting, use Xin Ding Zi Wan Rong Tang (Newly Formulated Aster Bud Decoction). For alcohol-induced stomach injury causing hematemesis, use Liu Jun Zi Tang (Six-Gentlemen Decoction) plus Mu Xiang, Sha Ren (Amomi Fructus), and Gan Ge (Puerariae Radix). For hematemesis due to excessive food intake causing indigestion, irritability, forced retching, and mouth injury, with abdominal colic, sweating, and a tight-rapid pulse (difficult to treat), use Zhi Shi Li Zhong Tang (Immature Bitter Orange and Middle-Regulating Decoction) plus Dan Pi, Bian Dou Hui (Lablab Albus Ash).
After various blood losses, if there is fatigue, confusion, pallor, and reluctance to speak, administer dense Du Shen Tang (Single Ginseng Decoction) with Ju Pi (Tangerine Peel). This is the principle of "Tonifying Qi in cases of Blood Depletion." For uncontrollable hematemesis due to excessive mental labor, use Gui Pi Tang (Spleen-Restoring Decoction) minus Mu Xiang, adding Mai Dong and E Jiao. For women with Dao Jing (Reverse Menstruation) where blood overflows upward, accompanied by steaming fever and persistent cough, and for men who engage in intercourse before essence is fully developed, resulting in Xu Lao (Deficiency Consumption) and blood loss, select Wu Gu Ji Wan (Black-Bone Chicken Pill) or Xun Shun Wan (Submissive and Smooth Pill). If the blood color is dull and pale, regardless of upward vomiting or downward loss, warm agents should be used, such as Gan Cao Gan Jiang Tang (Licorice and Dried Ginger Decoction) to warm and regulate Middle Qi. Cold agents are strictly prohibited. If blood mixes with water, it is difficult to cure. If Stomach heat is severe, forcing blood to move recklessly, use Xi Jiao Di Huang Tang plus Da Huang Hui (Rhubarb Ash), Mu Xiang, and Tao Ren. For unstoppable hematemesis with chest qi stagnation and vomiting of dark purple-black blood, use Tao Ren Cheng Qi Tang (Peach Kernel and Major Order the Qi Decoction) plus Qian Gen.
*Qian Jin Yi Fang* (Supplement to the Thousand Gold Formulas) treats hematemesis by decocting half a sheng of Sheng Di Zhi (Rehmanniae Radix Praeparata Juice) for three boils, mixing in one square-inch spoonful of raw Da Huang powder, divided into three doses. It is effective for heat-toxin hematemesis. For intermittent hematemesis (two mouthfuls, then relief, recurring days later, lasting years), send Hei Shen San (Black Divine Powder) with Xiao Wu Chen Tang (Minor Black and Deep Blue Drink), taken occasionally. For severe, unceasing vomiting, mix equal parts Bai Ye (Chimonanthi Folium) and Gan Jiang (Zingiberis Rhizoma), add a little Ai Ye (Artemisiae Argyi Folium), and take with Tong Bian.
Dizziness and fever after blood loss are common, caused by deficient Fire flaring upward and disturbing externally. Do not mistake this for external contraction and use Wind-dispelling drugs. Thirst accompanying hematemesis is called "Blood Thirst." Use Shi Quan Da Bu Tang (Comprehensive Great Tonifying Decoction) or Sheng Mai San (Generate the Pulse Powder) plus Huang Qi (Astragali Radix), Wei Ge Gen (Prepared Kudzu Root), and Pi Pa Ye (Loquat Leaf), dosed according to Spleen-Stomach Qi deficiency or excess. For newly stopped acute hematemesis, a folk prescription uses Yan Wo Cai (Swallow's Nest Vegetable) and Bing Tang (Rock Sugar), four qian each, boiled together. Taken for five to seven days, it prevents recurrence.
For hematemesis, a subtle and fine pulse is favorable (Shun); a surging and large pulse is unfavorable (Ni). If blood surges like a tide and does not stop from the throat, with a deficient-large pulse, the Fire pathogen has not yet敛 (gathered/subdued). Do not give decoctions immediately. Urgently灌 (irrigate) with hot Tong Bian or Ou Zhi (Lotus Root Juice). Wait about half a day until the pulse slows slightly, then administer conditioning agents. If Cun Guan pulses are weak but Chi pulse is slightly wiry, indicating Yin deficiency, prevent afternoon Yin Fire ascent. Take Du Shen Tang or Bao Yuan Tang in the morning to control blood; take Liu Wei Wan plus Tong Bian and Niu Xi (Achyranthis Bidentatae Radix) in the afternoon to nourish Yin. After medication, if the pulse harmonizes, diet improves, limbs feel light, face is not red, feet/knees are not cold, body is not burning, forehead has no cold sweat, and urination/bowel movements are normal, and although dark clots are expectorated occasionally without fresh blood ascending, treatment is permissible. If bleeding stops but the pulse remains large, or is small but wiry-fine-rapid-scurrying, or wiry-hard and discordant, do not lightly declare curability. If other pulse positions are soft but the Left Guan-Chi positions are wiry-strong, indicating Yin deficiency with Fire hyperactivity, this is a critical sign. Three transformations may occur: 1) Yin Fire draws blood upward causing sudden collapse; 2) Deficient Yang reveals itself causing fever; 3) Fire presses on the Lung causing wheezing/cough. These are ultimately incurable.
For blood depletion, use large doses of Ren Shen to tonify Qi and secure blood. This is suitable only if blood is bright red or slightly mixed with purple clots. If blood is dull-pale, indicating cold-blood failing to return to vessels, combine with Pao Hei Gan Jiang (Charred Dried Ginger) or large-dose Li Zhong Tang to warm. If Chi pulse is wiry, use large-dose Sheng Liao Liu Wei Wan plus Rou Gui (Cinnamomi Cortex) to guide. Some use Rou Gui powder mixed with Du Shen Tang. If blood is vermilion, glossy like lacquer, dries instantly upon exit, and flakes off in sheets when scraped with a fingernail, the patient may eat without fatigue but will eventually die of sudden collapse. If blood contains tissue resembling meat or lung, like rotten scorched intestines, this indicates gastric mucosa burned by evil Fire and coagulated. Medical texts consider this fatal. However, if after vomiting the coagulation clears, fever does not appear, and the patient can eat, administering small doses of Yi Gong San (Extraordinary Work Powder) and Bao Yuan Tang, and large doses of Liu Wei Wan and Du Qi Wan, many survive. Do not dismiss all cases as incurable. This condition should be cross-referenced with the Deficiency Consumption chapter.
Ou Xue (Vomiting Blood): Blood rises from the abdomen/hypochondrium and is vomited forcefully. This is due to internal Liver Fire agitation stirring Stomach blood upward, like a dragon rising from a marsh causing waves. There are three treatments for Ou Xue: 1) Caused by violent anger injuring the Liver, with severe hypochondriac pain and cold extremities: Chai Hu Shu Gan San (Bupleurum Liver-Soothing Powder) plus Jiu Da Huang. 2) Caused by extreme physical exertion/injury to the Liver, with body pain and intermittent fever: Xi Jiao Di Huang Tang plus Dang Gui, Rou Gui, and Tao Ren Ni. 3) Caused by sexual exhaustion injuring the Liver, with red face, cold feet, restlessness, and thirst: Sheng Mai San combined with Jia Jian Ba Wei Wan (Modified Eight-Ingredient Pill). For vomiting due to Yang deficiency failing to hold inward, take Yi Gong San powdered with Ba Wei Wan. Without abstaining from sex, worry, and labor, recovery is impossible. For sexual exhaustion depleting Qi and injuring the Liver with dried blood, use Si Wu Gu Yi Lu Ru Wan (Four Parts Black-Bone Chicken, One Part Rubia and Ludouju Decoction) with Tong Bian and Ou Zhi.
Tuo Xue (Spitting Saliva with Blood): Blood threads or floating spots in saliva indicate Spleen deficiency from overthinking, failing to control blood. Variations depend on involvement of Heart, Kidney, or Stomach. With Heart involvement: Jia Wei Gui Pi Tang. With Kidney involvement: Liu Wei Wan plus Wu Wei Zi and Rou Gui. With Stomach involvement: Si Jun Zi Tang plus Huang Qi, Shan Yao (Dioscoreae Rhizoma), and Su Mi (Finger Millet), named Qi Zhen San (Seven Treasures Powder). For poor appetite and clear phlegm: Yi Gong San plus Pi Pa Ye and Bai Bian Dou Hui (White Hyacinth Bean Ash). For Stomach phlegm-food turbidity causing hematemesis: Ban Xia (Pinelliae Rhizoma) and Sheng Jiang (Zingiberis Recens Rhizoma), i.e., Bai Bian Dou San.
Ke Xue (Coughing Blood): Blood appears due to coughing, either dry cough or blood threads/dots in sputum, with shortness of breath and wheezing. Although Lung tissue is dry, this is also due to Fire rebellion damaging blood membranes. A weak/moderate pulse is easy to treat; a wiry-rapid-forceful pulse with shortness of breath, hoarseness, and sore throat is incurable. Quiet rest offers hope. Treatment: Liu Wei Wan plus Mai Dong and Wu Wei Zi to clear Metal and strengthen Water. Add E Jiao, Bei Mu (Fritillariae Bulbus), Bai He (Lilii Bulbus), Kuan Dong Hua (Farflos Flos), Zi Wan (Asteris Radix) for moistening lungs and stopping cough. After bleeding stops, if Stomach deficiency causes poor appetite and weak breath, use Jie Lao San minus Ban Xia plus Zi Wan Rong, and Qiong Yu Gao (Jade Jade Paste) for regulation. Chronic coughing blood leading to consumption, with emaciation, limb fatigue, five-palm heat, dry throat/red cheeks, tidal fever, night sweats, and reduced appetite: Yi Gong San plus E Jiao, or Si Jun Zi Tang plus Huang Qi, Bie Jia (Testudinis Carapax et Plastrum), Mai Dong, Wu Wei Zi. For Yin deficiency with Fire moving causing coughing blood or pearl-like blood stars in sputum: Sheng Liao Liu Wei Wan plus Qian Gen, Hai Piao Xiao (Sepiae Endoconcha), and Tong Bian. For unceasing coughing blood with night fever/sputum or blood streaks: Liu Wei Wan plus Ha Fen (Concha Meretricis) and Tong Bian, taken before bed. For obese drinkers with blood in phlegm: Gun Tan Wan (Rolling Phlegm Pill) to search and cleanse. Coughing up pus-blood with hidden chest pain and slippery-rapid or rapid-forceful pulse indicates Fei Yong (Lung Abscess); refer to that section.
Ge Xue (Gargling Blood): Small pieces or blood spots are gargled out from the throat without coughing. The condition is severe but mild in intensity, usually stopping after two or three gargles. This is due to sexual exhaustion injuring the Kidney, with Yin Fire carrying blood upward, or accompanied by phlegm due to Kidney deficiency causing water flooding. Yin deficiency with much Fire makes this dangerous for thin, dark-skinned individuals. Early stage: Zi Wan, Mai Dong, Fu Ling, Zao Ren (Ziziphus Spinosae Semen), Shan Yao, Bai Shao (Paeoniae Radix Alba), Dan Pi, Tong Bian to clear wandering Fire in Shaoyang/Jueyin meridians. Later: Liu Wei Wan plus Niu Xi to nourish Kidney Yin and settle blood. Strictly avoid blood-breaking drugs. Hua Borren said: Ge Xue is serious because the Lung is a pure organ; Metal is constrained by Yin Fire. Water deficiency and Fire hyperactivity force blood upward. The Classic says: "Upper Qi with blood, lower sound of disease" refers to wheezing originating from the Kidney and gargling from the Lung. I once treated this with Sheng Liao Liu Wei Wan plus Mai Dong, Wu Wei Zi, and Ling Sha Dan, understanding the *Neijing*. However, many cases involve concurrent Wind-Cold or dietary issues. Do not mistake these for the primary disease. If Wind-Cold: Ren Ying pulse is floating-deficient or wiry-tight. If Dietary: Qi Kou pulse is short-slippery or hidden-choppy. For Wind-Cold: Huang Qi Jian Zhong Tang. For Diet: Zhi Shi Li Zhong Tang. Do not use other drugs arbitrarily.
Yu Jiayan said: Blood diseases, new or old, mild or severe, all originate from Fire. However, Fire differs in Yin/Yang, requiring different treatments. The Classic states: "Acute illness is not Yang," meaning this Fire is clearly not Yang Fire. Yang Fire (Five Elements Fire) is not acute. If it were, it could be checked by Five Elements Water. But Long Lei Zhi Huo (Dragon-Thunder Fire) hides in Yin. Before activation, it is unknown as Fire; once activated, it is uncontrollable, carrying Yin blood upward. Thus, cooling blood-clearing Fire drugs only exacerbate it. The general rule is to warm-tonify Yang to constrain Yin Fire. The Classic says Ge Xue belongs to the Kidney, clarifying that Yin Fire arises from Yin, producing clotted blood, unlike coughing blood with sputum which is Yang Fire. This insight was previously undeveloped. Zhang Zhongjing stated: "Mistakenly inducing sweat in Shaoyin disturbs channel blood, causing Lower Jue and Upper Jie, difficult to treat." Later scholars ignored this. Lower Jue means Yin Qi rebels downward; Upper Jie means Yin Blood exhausts upward. Qi and Blood support each other; Qi without Blood scatters, Blood without Qi coagulates. Thus, Yin Fire movement forces Yin Qi upward, dragging Yin blood with it, exhausting it. Blood escaping upward leaves Qi scattered in the Chest, unable to return, causing Lower Jue. Yin rebelling downward triggers Dragon-Thunder Fire, continuing until blood is exhausted. Zhang Zhongjing called it difficult not because it is untreatable, but to open the door wide: Tonifying Spleen Yang is paramount. Benefits: 1) Strong Spleen Yang suppresses Dragon-Thunder Fire. 2) Strong Spleen Yang clears chest obstruction like empty space. 3) Strong Spleen Yang transforms food into essence, regenerating exhausted blood. Current texts wrongly cite chronic cough/phlegm-blood as Yang syndrome, fearing spleen-tonifying increases cough. But Ge Xue cough is merely Qi rebellion; descending Qi stops cough. Ancient formulas used Gui/Fu to guide Fire back to source, but for acute blood, this is temporary only. Consumed blood cannot control fierce Fire; unactivated blood should not be disturbed by tonics. Prioritize strengthening Earth (Spleen); thick Earth prevents turbid Yin ascent, resolving blood issues.
Xue Yi (Blood Overflow): *Yuan Bing Shi* states: Blood overflow exits upward. Heart governs blood; extreme heat causes blood to move recklessly with Fire. Some claim vomiting purple-clotted blood is cold; this is wrong. It is not cold condensation but heat consuming fluids into thick turbidity. Heat controls Water transformation, so Red mixes with Black to become Purple. Use Xie Xin Tang (Drain the Epigastrium Decoction). Fire nature is rapid, leading to overflow/depletion; never Yin-Cold. If accidentally cut, blood gushes like a spring; use Shi Quan Da Bu Tang frequently. Externally, apply ground Almond mixed with wheat paste.
Jiu Qiao Chu Xue (Nine Orifices Bleeding): This is not poisoning but trauma. For poisoning, use raw sheep blood methods. For trauma, if the patient has no fever and can eat, irrigate frequently with hot Tong Bian. Unexplained fever with nine orifices bleeding indicates extreme Liver/Kidney exhaustion and internal collapse of Five Zang, mostly incurable. Blood-water mixture is fatal. For fatigue-induced cases, use Bu Zhong Yi Qi Tang doubled with Ren Shen/Huang Qi, or Tai Fa Hui (Hair Ash)/Da Ji Zhi (Urticae Herba Juice), taken with Ren Shen Tang. Or Xue Yu Hui (Hair Ash), 2 qian per dose, mixed with Mao Gen (Imperatae Rhizoma) and Che Qian Cao (Plantaginis Herba) decoction.
Excess Qi becomes Fire; blood follows Qi upward. Nourishing Water lowers Fire; smoothing Qi prevents rebellion. E Jiao, Niu Xi, Dan Pi are Water-nourishing. Su Zi (Perillae Fructus), Ju Hong, Chen Xiang are Qi-smoothing. Tong Bian guides blood down and moves stasis. Ou Zhi reaches blood to prevent stagnation and has astringent power. Deep-forceful pulse with abdominal fullness/pain or blood clots/stasis: Dang Gui, Tao Ren, Chi Shao (Paeoniae Radix Rubra), Yan Hu Suo (Corydalis Rhizoma), Peng Ze (Curcumae Rhizoma), Da Huang. Anger injuring Liver Wood causes blood depression upward (Bo Jue): Chen Xiang, Mu Xiang, Qing Pi (Citri Reticulatae Pericarpium Viride), Shao Yao, Dan Pi. Mental labor: Lian Rou (Nelumbinis Semen), Zao Ren, Shu Yu (Dioscoreae Rhizoma), Fu Shen (Poria cum Radix), Zi Wan, Bai Ren (Platycladi Semen), Dan Shen (Salviae Miltiorrhizae Radix et Rhizoma). Sexual labor: Shu Di (Rehmanniae Radix Praeparata), Gou Qi (Lycii Fructus), Niu Xi, Du Zhong (Eucommiae Cortex), Lu Rong (Cervi Cornu Pantotrichum), Ren Shen. Blood Heat: Di Gu Pi (Lycii Cortex), Dan Pi, Xi Jiao (Rhinoceri Cornu). Blood Cold: Gui Xin (Cinnamomi Ramulus), Fu Zi (Aconiti Lateralis Radix Praeparata). Unstoppable Blood Heat: Shan Zhi Hui (Gardeniae Fructus Ash), Huang Lian Hui (Coptidis Rhizoma Ash). Blood Stasis: Fa Hui (Capillis Humana Cinis), Da Huang Hui, Gan Qi Hui (Lac Columnae Ash). Blood Cold: Gan Jiang Hui. Blood Slippery: Zong Lv Hui (Palmae Fructus Ash), Lian Fang Hui (Nelumbinis Nuciferae Calyx Ash). Blood Deficiency: Di Huang Hui. San Qi (Notoginseng Radix) and Yu Jin (Curcumae Radix) move Qi in Blood. Ce Bai Ye (Biota Tops) cools Heat in Blood. Da/Xiao Ji (Urticae Herba / Glehniae Radix) moves Stagnation in Blood. Mao Gen guides downward.
[Diagnosis] The Classic says: Resting with a strong pulse is called Blood Depletion. Post-hemorrhage, Rapid-Large pulse indicates Yang Excess; Choppy-Fine indicates Blood Deficiency; Fine-Rapid indicates Yin Fire郁 (depressed) in Blood; Kou (Hollow) pulse indicates Blood Loss and Qi failing to attach. Wiry-Tight with hypochondriac pain indicates Stasis accumulation; all blood disorders relate to the Liver. Cun pulse large, Chi pulse weak indicates latent Lung Fire; Chi pulse strong, Cun pulse deficient-large indicates deficient Kidney Yin Fire; Chi slippery-rapid indicates Blood Deficiency with Heat; Right Hand deficient-large indicates Spleen-Stomach Fire; Left Hand Rapid-excessive indicates Liver-Gallbladder Fire. Generally, post-hemorrhage, weak-fine-harmonious pulses are easy to treat. Surging-Rapid-Forceful-Large-Wiry-Urgent, or small but feeling like pulling a vine or tracing a knife, plus nasal bleeding with fever and pounding pulse, or vomiting blood with chest fullness/back radiation and small-rapid pulse, are all incurable.
Wang Shishan treated a middle-aged man, pale complexion, chronically overworked internally/externally, or food-injured, coughing hard phlegm with blood streaks. After taking 50+ doses of cold-cooling Lung-clearing phlegm-resolving drugs, voice became unclear then mute, insomnia, bitter taste, dry tongue with white coating, occasional throat obstruction...