癸未夏里人马思才之内年逾五旬。偶因外事忤意。怒火激血上越。日吐数盆。脉洪缓。
余投
以逍遥散。去白术加黄连炒栀丹皮四剂即愈。愚按血症多端。尚有九窍血溢者。有肌肤血溢
者。有舌血龈血汗血有颠顶出血者。有从腋胯而渗者无非火伤经络亦当察元气之虚实施治不
可偏执苦寒之剂也昔明医吕沧洲治一人偶拨 中疥。出血如泉。不止。公视时已困极。无气
可言。脉惟尺部如丝。他部皆无。乃以四逆汤。加荆芥防风。其脉渐出更服十全大补汤。一
剂遂瘥。又治一贵客患三阳合病。脉长弦。因涉海为风涛所惊。遂吐血升许。且胁痛烦渴谵
语。适是年岁运当左尺不应。诸医咸以为肾绝。公曰此天和脉当无忧也遂投小柴胡汤。减参
加生地。俟其胃实以承气下之得利而愈。若公者法无偏执。药随人投人知寒药之治血而不知
其热剂之回生非全识也再录立斋方论于后。立斋曰愚按刘宗浓先生云。荣者水谷之精也。和
调于五脏。洒陈于六腑。乃能入于脉也源源而来生化于脾总统于心脏受于肝宣布于肺施泄于
肾灌溉一身是以出入升降濡润宣通者由此使然也故经云气主嘘之血主濡之又云肺朝百脉之气
。脾统诸经之血。气血为人身之橐 也。观此多因饮食起居。六淫七情失宜。亏损元气。以
致诸经失职。不能司摄法当调补脾肝之气使血各归其原诸症自愈矣若潮热咳嗽而脉数者。元
气虚弱。假热之脉也。尤当用甘温调补脾胃为善。立斋又云古人治血症诸方。多用寒剂。惟
上古之人。形病俱实者宜用之。今之患者多属形病俱虚。治者当求其属而主之。若前症郁热
伤肺而衄血者。用黄 益气汤。肺气虚热。不能摄血而衄者。用四君子加芎归五味。郁结伤
脾而嗽吐血者。用归脾汤。胃经有热而嗽吐血者。用犀角地黄汤。胃气弱而嗽吐血者。用四
君子加芎归升麻。肾经虚热。阴火内动。而咯吐血者。用六味丸补中益气汤。怒动肝火而见
血者。用加味逍遥散。肾涸肝火动而见血者。用六味丸。虽曰血得热而错经妄行。亦有卫气
虚。不能统摄荣血。而为妄行者。不可不察。以上诸症皆属足三阴亏损虚火内动所作非外因
所致者宜六味丸补中益气汤滋其化源是治本也其因甚多。不能枚举。治者当临症而制宜。庶
无误矣。立斋又云劳嗽见血等症。有劳伤元气。内火妄动而伤肺者。亦有劳伤肾水。阴火上
炎而伤肺者有因过服生地天门寒药。损伤脾胃。不能生肺金而不愈者有因误用黄柏知母之类
。损伤阳气。不能生阴精而不愈者凡此皆脾肺亏损而肾水不足以致虚火上炎真藏为患也治须
补中益气汤补脾土以生肺金用六味地黄丸滋肾水而生阴精否则不救。
乙丑岁余寓楚时。适有仆妇年逾二旬。每患便血。医投以藏连丸随服随愈。先是同社一
刘友
貌英伟善属文。亦病便血。服香连丸。经岁不瘥。饮食如常。抵冬娶亲。辍前药却愈。次夏
患痢。且能健啖。起居不倦。医者投香连丸之剂。仅四服。至夜发厥而死。惜哉。大都积服
寒
剂。脾气由渐而伤。及娶亲后。精血日耗。元气不支。故遇蹶即仆理也。譬如家国之亡。任
用匪类。非阳丧于刚愎之小人。则必阴败于柔逊之
奸儒。祸非旦夕。有由来矣。再按妇人崩漏诸症虽云血热妄行。治以四物汤加芩连之属。此
古今通用常法也。多有先由劳伤中气。或脾气素虚。不能统血。继因邪热迫致妄行者。初起
用前汤数服不止。则当用东垣
当归芍药汤补之
。若因循日久。清气下陷。则服补中益气汤以升举之。经云阳密乃固。先哲云血脱益气。此
良法也盖血虚须兼补气夫血犹水也气犹堤也堤坚则水不横决气固则血不妄行自然之理此方用
术为主。所以神验。世医不达此理。拘执方书。率用凉药伤脾。脾气既弱。安能固血因误
于刘守真谓诸血无寒岂知诸血无实乎无实则虚虚则不得以无寒论也故特表而正之。
明代癸未年夏天，同乡人马思才的妻子年龄超过五十岁。偶然因为外界事务不顺心意，怒火激发血液上逆溢出，每天吐出数盆血。脉象洪大而缓。
我给她投用逍遥散，去掉白术，加入黄连、炒栀子、丹皮，服用四剂后痊愈。
我按语：血症表现多种多样，还有九窍出血的，有肌肤渗血的，有舌血、牙龈出血、汗血，有头顶部位出血的，有从腋下胯部渗出的，无非是火邪损伤经络，也应当观察元气的虚实来施治，不可偏执于使用苦寒的药物。
从前明代名医吕沧洲治疗一个人，偶然挑破身上的疥疮，出血如泉水般涌出，不止。吕公诊视时，病人已经困倦至极，没有力气说话，只有尺部脉搏像丝线一样微弱，其他部位的脉搏都摸不到。于是他用四逆汤，加入荆芥、防风。病人的脉象逐渐显现，再服用十全大补汤，一剂后就痊愈了。
他又治疗一位贵客患三阳合病，脉象长而弦。因为出海被风浪惊吓，于是吐血约一升，并且胁痛、烦躁口渴、说胡话。恰逢这一年岁运导致左尺脉不应指（摸不到），众医生都认为这是肾气绝灭。吕公说：“这是天和之脉，不必担忧。”于是投用小柴胡汤，减少人参用量，加入生地黄。等到胃气充实后，再用承气汤攻下，大便通畅后痊愈。
像吕公这样，治疗方法没有偏执，药物随病情和体质施用。人们只知道寒凉药能治血证，却不知道温热药也能起死回生，这不是全面的认识。
再次记录立斋的方论如下。立斋说：我按刘宗浓先生的说法，营气是水谷的精微物质，调和于五脏，散布于六腑，然后才能进入脉中。它源源不断地产生于脾，统属于心，受纳于肝，宣布于肺，施泄于肾，灌溉全身。因此出入升降、濡润宣通都是由此而实现的。所以《内经》说：“气主嘘之，血主濡之。”又说：“肺朝百脉之气，脾统诸经之血。”气血是人身的橐龠（风箱）。看这些情况，多因饮食起居、六淫七情失宜，亏损元气，导致各经失职，不能司职统摄。法当调补脾肝之气，使血液各自回归本源，诸症自然痊愈。如果有潮热咳嗽且脉数的，是元气虚弱出现的假热脉象，尤其应当用甘温药物调补脾胃为好。
立斋又说：古人治疗血症的各种方剂，多用寒凉药剂，只有上古时期形体与病邪都实盛的人适宜使用。现在的患者多属于形体与病邪都虚弱的情况，治疗者应当探究其根本属性而主治。如果前面的症状是郁热伤肺导致鼻衄的，用黄芪益气汤；肺气虚热，不能摄血而鼻衄的，用四君子汤加川芎、当归、五味子；郁结伤脾导致咳嗽吐血的，用归脾汤；胃经有热导致咳嗽吐血的，用犀角地黄汤；胃气弱导致咳嗽吐血的，用四君子汤加川芎、当归、升麻；肾经虚热，阴火内动导致咯血吐血的，用六味丸配合补中益气汤；怒动肝火而出血的，用加味逍遥散；肾水枯竭肝火妄动而出血的，用六味丸。虽然说血得热则错经妄行，也有卫气虚弱，不能统摄营血而导致妄行的，不可不仔细考察。以上诸症都属于足三阴亏损、虚火内动所作，并非外因所致，适宜用六味丸、补中益气汤滋养化源，这是治本的方法。原因很多，不能一一列举。治疗者应当根据临证情况灵活制宜，才不会出错。
立斋又说：劳嗽见血等症状，有因劳伤元气，内火妄动而伤肺的；也有因劳伤肾水，阴火上炎而伤肺的；有因过服生地、天门冬等寒凉药物，损伤脾胃，不能生养肺金而不愈的；有因误用黄柏、知母之类，损伤阳气，不能生养阴精而不愈的。凡此种种，都是脾肺亏损而肾水不足，导致虚火上炎，真脏为患。治疗必须用补中益气汤补脾土以生肺金，用六味地黄丸滋肾水而生阴精，否则无法救治。
乙丑年，我寓居楚地时，恰好有一位女仆年龄超过二十岁，经常患便血。医生投用藏连丸，随服随愈。在此之前，同社的一位刘友，相貌英伟，善于写文章，也患便血，服用香连丸，经过一年也没有痊愈。饮食正常，到了冬天娶亲，停止前药却痊愈了。次年夏天患痢疾，而且能大口吃饭，起居不知疲倦。医生投用香连丸的药剂，仅服四剂，到夜晚就发生厥逆而死，可惜啊。大多是长期积累服用寒凉药剂，脾气逐渐受伤，等到娶亲之后，精血日渐消耗，元气不支，所以遇到厥逆就倒下，这是理所当然的道理。譬如家国的灭亡，任用非类之人，不是阳气丧亡于刚愎自用的小人，就是阴气败坏于柔顺谦逊的奸儒，祸患并非朝夕之间形成，是有由来已久的。
再按：妇人崩漏诸症，虽然说是血热妄行，治疗用四物汤加黄芩、黄连之类的，这是古今通用的常法。但多有先由劳伤中气，或脾气素来虚弱，不能统血，继而又因邪热逼迫导致妄行的。初起用前面提到的汤药几服不止，则应当用东垣的当归芍药汤来补益。如果因循日久，清气下陷，则服用补中益气汤来升举。经云：“阳密乃固。”先哲说：“血脱益气。”这是良法。大概血虚须兼补气，血犹如水，气犹如堤坝，堤坝坚固则水不横决，气固则血不妄行，这是自然的道理。此方以白术为主药，所以神验。世间的医生不明白这个道理，拘泥固执于方书，一律使用凉药伤脾。脾气既然虚弱，怎么能固摄血液？这是因为错误地听从刘守真的“诸血无寒”之说，岂知“诸血无实”呢？没有实证则是虚证，虚证就不能用“无寒”来论述。所以特意表彰并纠正这一观点。
In the summer of the Guiwei year, the wife of Ma Sicai, a fellow townsman, was over fifty years old. Accidentally due to dissatisfaction with external affairs, anger stimulated blood to flow upward and overflow, causing her to vomit several basins of blood daily. The pulse was surging (Hong) and slow (Huan).
I prescribed Xiaoyao San (Free and Easy Wanderer Powder), removing Baizhu (Atractylodis Rhizoma), and adding Huanglian (Coptidis Rhizoma), Chao Zhizi (Gardeniae Fructus fried), and Danpi (Moutan Cortex). After four doses, she recovered.
My commentary: Blood disorders manifest in various ways. There are cases of bleeding from the nine orifices, oozing from the skin and muscles, bleeding from the tongue, gums, or sweat, bleeding from the vertex of the head, and oozing from the armpits and groin. These are all caused by fire pathogenic factors damaging the meridians. One must observe the deficiency or excess of Yuan Qi (Original Qi) to determine treatment and should not rigidly adhere to bitter-cold agents.
Previously, the famous Ming dynasty physician Lv Cangzhou treated a patient who accidentally pricked a boil on his body, causing blood to gush like a spring without stopping. When Dr. Lv examined him, the patient was extremely exhausted, unable to speak, with only the Chi position pulse feeling thread-like (Si), while pulses at other positions were imperceptible. He then prescribed Sini Tang (Recover the Initial Decoction) added with Jingjie (Schizonepetae Herba) and Fangfeng (Saposhnikoviae Radix). The patient's pulse gradually reappeared, and after taking Shiquan Dabu Tang (Comprehensive Great Tonifying Decoction), he recovered after one dose.
He also treated a noble guest suffering from San Yang He Bing (Combined Disease of the Three Yang Meridians), with a long and wiry (Xian) pulse. Due to being startled by wind and waves during a sea voyage, he vomited approximately one sheng of blood, accompanied by hypochondriac pain, irritability, thirst, and delirious speech. Coinciding with that year's annual climate influence causing the Zuo Chi (Left Chi) pulse to be non-responsive, most physicians believed it indicated Kidney Qi exhaustion. Dr. Lv said, "This is a natural harmony pulse; there is no need to worry." He then prescribed Xiao Chai Hu Tang (Minor Bupleurum Decoction), reducing the amount of Renshen (Ginseng Radix et Rhizoma) and adding Shengdihuang (Rehmanniae Radix). Once the Stomach Qi was solidified, he administered Chengqi Tang (Purgative Decoction) to promote bowel movement, and the patient recovered after achieving defecation.
Physicians like Dr. Lv had no rigid biases in their methods, prescribing medicines according to the condition and constitution. People know that cold-natured drugs treat blood disorders but do not realize that warm-natured drugs can also restore life; this is not a comprehensive understanding.
I record below the formula theories of Lizhai (Li Dongyuan): I follow Mr. Liu Zongnong's statement that Ying Qi (Nutritive Qi) is the essence of food and drink. It harmonizes within the Five Zang Organs, spreads throughout the Six Fu Organs, and then enters the vessels. It originates continuously from the Spleen, is controlled by the Heart, received by the Liver, distributed by the Lungs, and excreted by the Kidneys, irrigating the whole body. Thus, entering, exiting, ascending, descending, moistening, and unblocking are all facilitated by this. Therefore, the Classics state: "Qi governs respiration, Blood provides nourishment." It also states: "The Lung directs the Qi of all vessels, the Spleen controls the Blood of all meridians." Qi and Blood are the bellows (Tuoyue) of the human body. Observing these situations, they are mostly caused by improper diet and lifestyle, or imbalance of the Six Exogenous Pathogens (Liu Yin) and Seven Emotions (Qi Qing), leading to damage of Yuan Qi. This causes dysfunction of various meridians, which fail to control and retain blood. The method should be to regulate and tonify the Qi of the Spleen and Liver, allowing blood to return to its origin, and the symptoms will heal themselves. If there is tidal fever, cough, and a rapid pulse, it indicates weak Yuan Qi presenting as false heat; it is best to use sweet-warm herbs to tonify the Spleen and Stomach.
Lizhai further stated: Ancient formulas for treating blood disorders mostly used cold-natured agents, suitable only for people in ancient times whose physical constitution and pathogenic factors were both excess. Patients today mostly have both deficient constitution and deficient pathology. Treaters should seek the root cause and treat accordingly. If the previous symptoms involved damp-heat injuring the Lung causing epistaxis, use Huangqi Yiqi Tang (Astragalus Qi-Supplementing Decoction). If Lung Qi deficiency and heat prevent blood retention causing epistaxis, use Sijunzi Tang (Four Gentlemen Decoction) added with Xiong (Chuanxiong Rhizoma), Gui (Danggui Radix), and Wuweizi (Schisandrae Fructus). If emotional constraint injures the Spleen causing cough and hematemesis, use Guipi Tang (Restore the Spleen Decoction). If Stomach Meridian heat causes cough and hematemesis, use Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction). If Stomach Qi weakness causes cough and hematemesis, use Sijunzi Tang added with Xiong, Gui, and Shengma (Cimicifugae Rhizoma). If Kidney Meridian deficiency heat and internal moving Yin Fire cause hemoptysis and hematemesis, use Liuwei Wan (Six-Ingredient Pill) combined with Buzhong Yiqi Tang (Center-Boosting Qi-Supplementing Decoction). If anger moves Liver Fire causing bleeding, use Jiawei Xiaoyao San (Modified Free and Easy Wanderer Powder). If Kidney fluid depletion and moving Liver Fire cause bleeding, use Liuwei Wan. Although it is said that heat causes blood to flow recklessly, there are also cases where Wei Qi (Defensive Qi) is weak and cannot control Ying Blood, leading to reckless flow; this must be carefully observed. All the above conditions belong to deficiencies of the Foot Three Yin meridians with internal moving deficiency fire, not caused by external factors. It is appropriate to use Liuwei Wan and Buzhong Yiqi Tang to nourish the source of transformation; this treats the root. The causes are numerous and cannot be listed exhaustively. Treaters should adapt to clinical situations to avoid errors.
Lizhai further stated: Symptoms such as consumptive cough with blood may be caused by labor injuring Yuan Qi, with internal fire moving recklessly to injure the Lung; or by labor injuring Kidney Water, with Yin Fire flaming upward to injure the Lung; or by excessive consumption of cold herbs like Shengdi (Rehmanniae Radix) and Tianmendong (Asparagi Radix), damaging the Spleen and Stomach so they cannot generate Lung Metal, resulting in non-recovery; or by misuse of herbs like Huangbai (Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma), damaging Yang Qi so it cannot generate Yin Essence. All these are due to Spleen and Lung deficiency with insufficient Kidney Water, causing deficiency fire to flare upward and harming the True Viscera. Treatment requires Buzhong Yiqi Tang to tonify Spleen Earth to generate Lung Metal, and Liuhuang Diwan (Six-Ingredient Rehmannia Pill) to nourish Kidney Water to generate Yin Essence; otherwise, rescue is impossible.
In the Yichou year, while residing in Chu, I encountered a female servant over twenty years old who frequently suffered from hematochezia. Physicians prescribed Canglian Wan (Coptis and Cinnabar Pill), and she recovered immediately upon taking it. Previously, a fellow scholar named Liu You, who was handsome and skilled in writing, also suffered from hematochezia. He took Xianglian Wan (Costus and Coptis Pill) for a year without recovery. His diet was normal, and he recovered after marrying in winter and stopping the previous medicine. In the following summer, he suffered from dysentery but could eat heartily and lived energetically. A physician prescribed Xianglian Wan; after only four doses, he fell into Jue (syncope/collapse) at night and died. What a pity! Mostly, long-term accumulation of cold-natured agents gradually injured Spleen Qi. After marriage, essence and blood were consumed daily, and Yuan Qi could no longer support him, hence falling into collapse upon encountering Jue. This is logical. It is like the fall of a home or nation, employing unworthy people: either Yang Qi is lost due to obstinate villains, or Yin fails due to treacherous scholars who appear gentle; disaster does not happen overnight but has a long history.
Furthermore: Various symptoms of Bang Lou (uterine bleeding) in women are often attributed to blood heat causing reckless flow, treated with Siwu Tang (Four Substances Decoction) added with Qin (Scutellariae Radix) and Lian (Huanglian Rhizoma). This is a common method used since ancient times. However, many cases initially stem from labor injuring Middle Qi, or inherent Spleen Qi deficiency failing to control blood, followed by pathogenic heat forcing reckless flow. If initial treatment with the aforementioned decoction fails to stop bleeding after a few doses, one should use Dongyuan's Danggui Shaoyao Tang (Angelica and Peony Decoction) to tonify. If neglected for a long time, leading to sinking of Clear Qi, one should administer Buzhong Yiqi Tang to raise it. The Classics state: "When Yang is dense, solidity is achieved." Ancients said: "In blood loss, tonify Qi." This is an excellent method. Generally, blood deficiency requires concurrent Qi tonification. Blood is like water; Qi is like a dike. If the dike is firm, water does not burst across; if Qi is solid, blood does not flow recklessly. This is the natural principle. This formula uses Baizhu (Atractylodis Rhizoma) as the main ingredient, hence its miraculous effect. Modern physicians do not understand this principle, rigidly adhering to medical texts and indiscriminately using cooling herbs that injure the Spleen. Once Spleen Qi is weak, how can it consolidate blood? This error stems from Liu Shouzhen's assertion that "all blood disorders lack cold," ignoring that "all blood disorders lack excess." Without excess, it is deficiency; deficiency cannot be discussed in terms of lacking cold. Therefore, I specifically highlight and correct this view.