（脉证十二条方五首）
寸口脉动而弱。动即为惊。弱则为悸。
〔衍义〕心者。君主之官。神明出焉。不役形。不劳心。则精气全而神明安其宅。苟有
所伤。则气虚而脉动。动则心悸神惕。精虚则脉弱。弱则怔忡恐悸。盖惊自外物
触入而动。属阳。阳变则脉动。悸自内恐而生。属阴。阴耗则脉弱。是病宜和平之
剂。补其精气。镇其神灵。尤当处之以静也。
师曰。尺脉浮。目睛晕黄。衄未止。晕黄去。目睛慧了。知衄今止。
〔衍义〕尺以候肾。属水。土克之。则合相火。逼其阴血从膀胱而升。故脉浮也。肾之
精上荣瞳子。膀胱之脉上额中而作衄。故晕黄退而血亦降。所以知衄止也。明
理论。肾主阴。血统属之。伤寒衄者。责邪在表。经络热盛壅出。杂病衄者。责邪在
里也。心主血。肝藏血。肺主气。开窍于鼻。血得热则散。随气上逆。从鼻中出。则为
衄。此云尺浮。不云寸口浮。知为肾虚血逆。非外邪也。
又曰。从春至夏。衄者太阳。从秋至冬。衄者阳明。
〔衍义〕内经太阳为开。阳明为合。春夏气主发生。以开者应之。故邪气逼血从升
发冲出。秋冬主收藏。以合者应之。故邪郁内极而后发出。衄为阳盛。独不言少
阳。以太阳阳明二经。皆上交额中故也。
衄家不可发汗。汗出必额上陷。脉紧急。直视不能 。不得眠。
〔衍义〕足太阳经主表。上巅入额。贯目睛。衄在上。络脉之血已脱。若更发汗。是重
竭津液。津液竭则脉枯。故额上陷。脉紧急。牵引其目。视不能合也。无血阴虚。故
不得眠。然亦有当汗。伤寒论云。脉浮紧。不发汗。因致衄者。宜麻黄汤。又云。太阳
病。脉浮紧。发热身无汗。自衄者愈。经中之邪散。不待桂枝麻黄发之也。明理论
衄者但头汗出。无汗及汗出不至足者死。
病患面无血色。无寒热。脉沉弦者衄。脉浮弱。手按之绝者下血。烦咳者必吐血。
〔衍义〕面色者。血之华也。血充则华鲜。若有寒热。则损其血。致面无色也。今无寒
热。则自上下去血而然矣。夫脉浮以候阳。沉以候阴。只见沉弦。浮之绝不见者。
是无阳也。无阳知血之上脱。脉止见浮弱。按之绝无者。是无阴也。无阴知血之
下脱。烦咳吐血者。心以血安其神。若火扰乱。则血涌神烦。上动于膈则咳。所涌
之血。因咳而上越也。然则沉之无浮。浮之无沉。何便见脱血之证乎。以其面无
色而脉弦弱也。衄血阳固脱矣。然阴亦损。所以浮之亦弱。经曰。弱者血虚。脉者
血之府。宜其脱血之处则无脉。血损之处则脉弦弱也。
夫吐血。咳逆上气其脉数而有热。不得卧者死。
〔衍义〕此金水之脏不足故也。外不足则火浮焰。浮焰则金伤。夫阴血之安养于
内者。肾水主之。水虚不能安静。被火逼逐而血溢出矣。血出则阳光益炽。有升
无降。炎烁肺金。金受其害。因咳逆而上气。金水子母也。子衰不能救母。母亦受
害。不能生子。二者之阴。有绝而无复。脉动身热。阳独胜也。不能卧。阴已绝也。阴
绝。阳岂独生乎。故曰死也。若得卧者。如内经于司天与阳明厥逆诸条。悉有喘
咳身热呕吐血等证。未常言死。盖阴未绝也。
夫酒客咳者。必致吐血。此因极饮过度所致也。
〔衍义〕酒性太热。客焉不散。则肝气不清。胃气不守。乱于胸中。中焦之血。不布于
经络。聚而汹汹。因热射肺为咳。从其咳逆之气溢出也。此伤胃致吐血者。
寸口脉弦而大。弦则为减。大则为芤。减则为寒。芤则为虚。寒虚相击。此名曰革。妇
人则半产漏下。男子则亡血。
〔衍义〕成无己谓减为寒者。谓阳气少也。芤为虚者。谓阴血少也。所谓革者。既寒
且虚。则气虚血乖。不循常度。男子得之为真阳衰而不能内固。故主亡血。女子
得之为阴血虚而不能滋养。故主半产漏下。此条出第二卷妇人证有旋复花汤。
亡血不可发其表。汗出则寒栗而振。
〔衍义〕亡血则已伤荣。不可发汗以伤卫。若汗则荣卫两伤。荣行脉中。卫行脉外。
荣虚则经脉空而为之振。卫虚则不温腠理而寒栗。
〔补注〕伤寒云亡血。即亡阴也。阴亡则阳气孤而无偶。才一发汗。其阳必从汗尽
越。所以寒栗有加。阴阳两竭也。大法宜小建中汤。
病患胸满唇痿。舌青口燥。但欲漱水不欲咽。无寒热。脉微大来迟。腹不满。其人言胸满。为有瘀血。
〔衍义〕是证瘀血。何邪致之耶。内经有堕恐恶血留内。腹中满胀。不得前后。又谓
大怒则血菀于上。是知内外诸邪。凡有所搏积而不行者。即为瘀血也。唇者脾
之外候。舌者心之苗。脾脉散舌下。胃脉环口旁。心主血。脾养血。积则津液不布。
是以唇痿舌青也。口燥但欲漱水不欲咽者。热不在内。故但欲漱以润其燥耳。
脉大为热。迟为寒。今无寒热之病而微大者。乃气并于上。故胸满也。迟者血积
膈下也。积在阴经之隧道。不似气积于阳之盲膜。然阳道显。阴道隐。气在盲膜
者。则壅胀显于外。血积隧道。惟闭塞而已。故腹不满。因闭塞。自觉其满。所以知瘀血使然也。
病者如热状。烦满。口干燥而渴。其脉反无热。此为阴伏。是瘀血也。当下之。
〔衍义〕血、阴也。配于阳。神得之以安。气得之以和。咽得之以润。经脉得之以行。身
形之中。不须臾离也。今因血积。神无以养则烦。气无以和则满。口无以润则燥。
肠胃无以泽则渴。是皆阳失所配。荣卫不行。津液不化。而为是病也。非阳之自
强而生热者。故曰如热状。
火邪者。桂枝去芍药加蜀漆牡蛎龙骨救逆汤主之。
桂枝去芍药加蜀漆牡蛎龙骨救逆汤方
桂枝（去皮三两） 甘草（二两炙） 生姜（三两） 蜀漆（三两洗去腥）
龙骨（四两） 牡蛎（五两熬） 大枣（十二枚）
〔衍义〕此但言火邪。不言何证。考之即伤寒证脉浮。医以火逼劫之亡阳。必惊狂
起卧不安者。成无己注是方曰。汗者心之液。亡阳则心气虚。心恶热。邪内迫则
心神浮越。故惊狂卧起不安。与桂枝汤解未尽表邪。芍药益阴。非亡阳所宜。故
去之。火邪错逆。加蜀漆之辛以散之。阳气亡脱。加龙骨牡蛎之涩以固之。
心下悸者。半夏麻黄丸主之。
半夏麻黄丸方
半夏 麻黄
上二味。末之。炼蜜和丸。如小豆大。饮服三丸。日三服。
〔衍义〕悸者。心中惕惕然动。怔仲而不安也。悸有三种。伤寒有正气虚而悸者。又
有汗下后。正气内虚。邪气交击而悸者。病邪不同。治法亦异。正气虚者。小建中
汤。四逆散加桂治之。饮水多而悸者。心属火而恶水。不自安而悸也。汗下后正
气内虚。邪气交击而悸者。与气虚而悸又甚焉。治宜镇固。或化散之。皆须定其
气浮也。原病式又谓是病。皆属水衰热旺。风火燥动于中。故怔忡也。若惊悸亦
以火药劫金。不能平木。风火相搏而然。欲究心悸之邪。则非一言可尽也。或因
形寒饮冷得之。夫心主脉。寒伤荣则脉不利。饮冷则水停。水停则中气不宣。脉
不利。由是心火郁而致动。用麻黄以散荣中寒。半夏以散心下水耳。首论以脉
弱为悸。而用此汤治者。其脉必不弱。非弦即紧。岂脉弱心气不足者。犹得用此药乎。
吐血不止者。柏叶汤主之。
柏叶汤方
柏叶 干姜（各三两） 艾（三把）
上三味。以水五升。取马通汁一升。合煎取一升。分温再服。
〔衍义〕夫水者。遇寒则沉潜于下。遇风则波涛于上。人身之血。与水无异也。得寒
之和。则居经脉。内养五脏。得寒之凛冽者。则凝而不流。积而不散。得热之和者。
则营运经脉。外充九窍。得热之甚者。风自火狂。则波涛汹起。由是观之。吐衄者。风火也。
下血。先便后血。此远血也。黄土汤主之。
黄土汤方
干地黄 黄芩 附子（一两） 阿胶 白术 甘草（各三两） 灶下黄土（半斤）
上七味。以水八升。煮取三升。分温三服。
〔衍义〕肠胃者。阳明二经也。阳明主合。气本收敛。血上者为逆。下者为顺。以下血
者言之。胃居大肠之上。若聚于胃。必先便后血。去肛门远。故曰远血。若聚大肠。
去肛门近。故曰近血。虽肠胃同为一经。然胃属土。所主受纳转输。大肠属金。所
主传送。而土则喜温恶湿。金则喜寒恶热。二者非惟远近之殊。其喜恶亦异。治
远血者。黄土汤主之。然则血聚于胃者。何也。盖血从中焦听化。上行于荣。以配
于卫。荣卫之流连变化。实胃土所资也。胃与脾为表里。胃虚不能行气于三阳。
脾虚不能行津于三阴。气日以衰。脉道不利。或痹而不通于血中。积随其逆而
出。或呕或吐。或衄或泄也。若欲崇土以求类。莫如黄土。黄者。土之正色。更以火
烧之。火乃土之母。其得毋燥而不湿。血就温化。则所积者消。所溢者止。阿胶益
血。以牛是土畜。亦是取物类。地黄补血。取其象类。甘草、白术。养血补胃和平。取
其味类。甘草缓附子之热。使不僭上。是方之药。不惟治远血而已。亦可治久吐
血。胃虚脉迟细者。增减用之。盖胃之阳不化者。非附子之善走。不能通诸经脉
散血积也。脾之阴不理者。非黄芩之苦。不能坚其阴以固其血之走也。黄芩又
制黄土、附子之热。不令其过。故以二药为使。
下血先血后便。此近血也。赤小豆当归散主之。
〔衍义〕此出大肠。故先血后便。以湿热之毒蕴结。不入于经。渗于肠中而下。赤小豆能行
水湿。解热毒。梅师方皆用此一味治下血。况有当归破宿养新。以名义观之。血当有所归。则不妄行矣。
心气不足。吐血衄血。泻心汤主之。
泻心汤方
黄连 黄芩（各一两） 大黄（二两）
上三味。以水三升。煮取一升。顿服之。
〔衍义〕心者属火。主血。心气不足者。非心火之不足。乃真阳之不足也。真阳不足。
则火热甚而心不能养血。血从热溢为吐衄。大黄、黄芩。本草治血闭吐衄者用
之。而伤寒家以泻心汤之苦寒。泻心下之痞热。是知此证以血由心热而溢。泻
其心之热。而血自安矣。如麻黄、桂枝治衄。寒邪郁其经脉。化热迫成衄也。故散
寒邪。寒邪散则热解。热解则血不被迫而自安矣。此用泻心汤。正其义也。若济
众方用大黄治衄血。更有生地汁。则是治热凉血。亦泻心汤类耳。
（脉证十二条，方五首）
寸口脉动而弱。动即为惊。弱则为悸。
〔衍义〕心是君主之官，神明由此产生。如果不役使形体，不劳损心神，那么精气就充足，神明就能安居其宅。如果有所损伤，就会气虚而脉象跳动，跳动则导致心悸、神志惊恐；精虚则脉象微弱，微弱则导致怔忡、恐惧悸动。大概惊是由外物触动内心而产生的，属于阳，阳气变动则脉象跳动；悸是由内部恐惧而生发的，属于阴，阴气耗损则脉象微弱。因此这种病症适宜用平和的药剂，补益精气，镇摄神灵，尤其应当以静处之。
老师说：尺部脉浮，眼睛周围有黄晕，鼻衄未止。如果黄晕消退，眼睛明亮清晰，就知道鼻衄现在停止了。
〔衍义〕尺脉用来候察肾脏，肾属水，土克水，则相火合邪，逼迫阴血从膀胱上升，所以脉象浮。肾的精气上荣于瞳孔，膀胱的经脉上行至额中并发生鼻衄，所以黄晕退去后血液也下降，因此知道鼻衄停止。《明理论》说，肾主阴，血液统属于它。伤寒病中的鼻衄，责任在于邪气在表，经络热盛壅滞而出血；杂病中的鼻衄，责任在于邪气在里。心主血，肝藏血，肺主气，开窍于鼻，血液受热则散乱，随着气机上逆，从鼻中流出，这就叫衄。这里说尺脉浮，不说寸口脉浮，可知这是肾虚血逆，不是外邪所致。
又说：从春季到夏季，鼻衄者属于太阳经；从秋季到冬季，鼻衄者属于阳明经。
〔衍义〕《内经》说太阳为开，阳明为合。春夏季节气机主发生，以“开”的特性相应应，所以邪气逼迫血液从升发冲出；秋冬季节主收藏，以“合”的特性相应，所以邪气郁结在内极深后才发出。鼻衄是阳气盛的表现，唯独没有提到少阳经，因为太阳、阳明二经都上交于额中，所以如此。
经常鼻衄的人不可发汗，如果发汗必然导致额部凹陷，脉象紧急，两眼直视不能闭合，无法入睡。
〔衍义〕足太阳经主管体表，上行至头顶入额中，贯穿目睛。鼻衄发生在上部，络脉中的血液已经流失，如果再发汗，就是再次竭尽津液。津液枯竭则脉道枯槁，所以额部凹陷，脉象紧急，牵引眼球，导致视物不能闭合。无血阴虚，所以无法入睡。然而也有应当发汗的情况，《伤寒论》说：脉浮紧，不发汗，导致鼻衄的，宜用麻黄汤。又说：太阳病，脉浮紧，发热身体无汗，自行鼻衄的会痊愈。经中之邪散去，不需要桂枝汤或麻黄汤来发散。《明理论》说，鼻衄者只有头部出汗，无汗及汗出不到足的会死亡。
病人面色无血色，没有寒热感，脉象沉弦的是鼻衄；脉象浮弱，手按之断绝的是下血；心烦咳嗽的必定吐血。
〔衍义〕面色是血的荣华表现。血充盛则色泽鲜艳，如果有寒热，则会损耗血液，导致面色无华。现在没有寒热，则是从上往下出血所致。脉浮用来候察阳，脉沉用来候察阴。只见沉弦，轻取绝不见的，是无阳。无阳可知是血之上脱。脉只见到浮弱，重按绝无的，是无阴。无阴可知是血之下脱。心烦咳嗽吐血的，心依靠血来安养神志，如果火扰乱，则血涌神烦，向上扰动膈膜则咳嗽，所涌出的血，因咳嗽而上越。然而沉脉中无浮象，浮脉中无沉象，为什么便见脱血之证呢？是因为面色无色且脉象弦弱。衄血虽然阳气固脱，但阴也受损，所以轻取也弱。经书说：弱者血虚，脉是血的府库，所以在脱血之处则无脉，血受损之处则脉象弦弱。
凡是吐血，伴有咳逆上气，脉数且有发热，不能卧睡的，预后不良（死证）。
〔衍义〕这是因为金水之脏不足的缘故。外在不足则火气浮焰，浮焰则损伤肺金。体内阴血的安养由肾水主导，水虚不能安静，被火逼迫追逐而血液溢出。血液溢出则阳光更加炽盛，有升无降，炎灼肺金，肺金受其害，因而咳逆上气。金和水是母子关系，子衰不能救母，母也受害，不能生子。这两者的阴气，只有断绝而没有恢复。脉动身热，是阳气独胜。不能卧睡，是阴已绝。阴绝了，阳气难道能单独生存吗？所以说死。如果能卧睡的，如《内经》关于司天与阳明厥逆诸条，都有喘咳身热呕吐血等证，从未说死，这是因为阴未绝。
凡是嗜酒之人咳嗽，必定导致吐血，这是因为极度饮酒过度所致。
〔衍义〕酒性太热，客留不散，则肝气不清，胃气不守，混乱于胸中，中焦的血液，不布散于经络，聚集而汹涌，因热射于肺导致咳嗽，随着咳逆之气溢出。这是伤胃导致吐血。
寸口脉弦而大，弦则表示阳气减损，大则表示中空如芤。减损则为寒，中空则为虚。寒与虚相互搏击，这名叫革脉。妇女则出现半产漏下，男子则出现亡血。
〔衍义〕成无己认为减为寒，是指阳气少。芤为虚，是指阴血少。所谓革脉，既寒且虚，则气虚血乖，不循常度。男子得此脉是真阳衰而不能内固，所以主治亡血。女子得此脉是阴血虚而不能滋养，所以主治半产漏下。此条出自第二卷妇人证，有旋复花汤。
亡血之人不可发汗解表，发汗则会出现寒战颤抖。
〔衍义〕亡血则已经损伤营血，不可再发汗以损伤卫气。如果发汗则营卫两伤。营行于脉中，卫行于脉外。营虚则经脉空虚而为之振颤，卫虚则不能温煦腠理而寒战。
〔补注〕《伤寒论》说的亡血，即亡阴。阴亡则阳气孤而无偶，才一发汗，其阳必随汗液完全外越，所以寒战加剧，这是阴阳两竭。大法宜用小建中汤。
病人胸满，嘴唇枯萎，舌色青紫，口中干燥，只想漱口不想吞咽，没有寒热，脉象微大来迟，腹部不胀满，但病人自述胸满，这是有瘀血。
〔衍义〕这个证候是瘀血，是什么邪气导致的呢？《内经》说有堕坠恐惧导致恶血留于体内，腹中满胀，大小便不通。又说不大怒则血液郁积于上。由此可知内外各种邪气，凡是有搏结积聚而不运行的，就是瘀血。唇是脾之外候，舌是心之苗，脾脉散布于舌下，胃脉环绕口旁。心主血，脾养血，积滞则津液不布散，所以嘴唇枯萎、舌色青紫。口中干燥只想漱口不想吞咽，是因为热不在内，所以只想漱口来润燥。脉大为热，迟为寒，现在没有寒热之病而脉微大，是气并于上，所以胸满。迟者是血积于膈下。积滞在阴经的隧道，不像气积于阳的盲膜。阳道显，阴道隐，气在盲膜者，则壅胀显于外；血积隧道，只是闭塞而已，所以腹部不胀满，因闭塞自觉其满。所以知道是瘀血所致。
病人像有热的样子，心烦满闷，口干燥而渴，但脉象反而没有热象，这是阴分伏热，是瘀血。应当用攻下法治疗。
〔衍义〕血属阴，配于阳，神得之以安，气得之以和，咽得之以润，经脉得之以行，身形之中，片刻也不能离开。现在因为血积滞，神无以养则烦，气无以和则满，口无以润则燥，肠胃无以泽则渴。这些都是阳失所配，营卫不行，津液不化，从而产生这些病。这不是阳自强而生热，所以叫像有热的样子。
火邪所致者，用桂枝去芍药加蜀漆牡蛎龙骨救逆汤主治。
桂枝去芍药加蜀漆牡蛎龙骨救逆汤方
桂枝（去皮三两） 甘草（二两炙） 生姜（三两） 蜀漆（三两洗去腥）
龙骨（四两） 牡蛎（五两熬） 大枣（十二枚）
〔衍义〕这里只说火邪，没说具体证候。考证后即伤寒证脉浮，医生用火法逼迫劫夺导致亡阳，必定出现惊狂、起卧不安。成无己注释此方说：汗是心之液，亡阳则心气虚，心恶热，邪气内迫则心神浮越，所以惊狂卧起不安。用桂枝汤解散未尽的表邪，芍药益阴，不适合亡阳，所以去掉。火邪错逆，加蜀漆的辛味以消散它；阳气亡脱，加龙骨牡蛎的涩味以固摄它。
心下悸动者，用半夏麻黄丸主治。
半夏麻黄丸方
半夏 麻黄
以上两味，研末，炼蜜和丸，如小豆大。饮服三丸，每日三次。
〔衍义〕悸，是心中惕惕然跳动，怔忡而不安。悸有三种：伤寒中有正气虚而悸的，又有汗下后，正气内虚，邪气交击而悸的。病邪不同，治法也不同。正气虚者，用小建中汤、四逆散加桂枝治疗。饮水多而悸的，心属火而恶水，不自安而悸。汗下后正气内虚，邪气交击而悸的，比气虚而悸更严重，治宜镇固，或化解消散，都必须安定其气浮。原病式又说此病，皆属水衰热旺，风火燥动于中，所以怔忡。若惊悸也是以火药劫金，不能平木，风火相搏而成。若要究查心悸的邪气，则非一言可尽。或因形寒饮冷导致。心主脉，寒伤营则脉不利，饮冷则水停，水停则中气不宣，脉不利，由此心火郁而致动。用麻黄以散营中寒，半夏以散心下水气。首论以脉弱为悸，而用此汤治疗的，其脉必不弱，非弦即紧，难道是脉弱心气不足者，还能用此药吗？
吐血不止者，用柏叶汤主治。
柏叶汤方
柏叶 干姜（各三两） 艾（三把）
以上三味，用水五升，取马通汁一升，合煎取一升，分两次温服。
〔衍义〕水，遇寒则沉潜于下，遇风则波涛于上。人身之血，与水无异。得寒之和，则居经脉，内养五脏；得寒之凛冽者，则凝而不流，积而不散；得热之和者，则营运经脉，外充九窍；得热之甚者，风自火狂，则波涛汹起。由此观之，吐衄，是风火所致。
下血先大便后出血，这是远血，用黄土汤主治。
黄土汤方
干地黄 黄芩 附子（一两） 阿胶 白术 甘草（各三两） 灶下黄土（半斤）
以上七味，用水八升，煮取三升，分三次温服。
〔衍义〕肠胃是阳明二经。阳明主合，气本收敛。血上行为逆，下行为顺。以下血而言，胃居大肠之上，若血聚于胃，必先大便后出血，离肛门远，所以叫远血。若聚于大肠，离肛门近，所以叫近血。虽然肠胃同为一经，但胃属土，主受纳转输，大肠属金，主传送，而土喜温恶湿，金喜寒恶热。二者不仅有远近之别，其喜恶也不同。治疗远血，用黄土汤主治。那么血聚于胃的原因是什么呢？大概血从中焦化生，上行于营，以配于卫，营卫的流连变化，实赖胃土资助。胃与脾为表里，胃虚不能行气于三阳，脾虚不能行津于三阴，气日渐衰弱，脉道不利，或痹阻不通于血中，积随其逆而出，或呕或吐，或衄或泄。若想崇土以求同类，不如黄土。黄色是土的正色，再用火烧之，火乃土之母，其得毋燥而不湿。血就温化，则所积者消，所溢者止。阿胶益血，因为牛是土畜，也是取物类。地黄补血，取其象类。甘草、白术，养血补胃和平，取其味类。甘草缓附子之热，使其不僭上。此方药物，不仅治远血，也可治久吐血，胃虚脉迟细者，增减使用。盖胃之阳不化者，非附子之善走，不能通诸经脉散血积。脾之阴不理者，非黄芩之苦，不能坚其阴以固其血之走。黄芩又制黄土、附子之热，不令其过，故以二药为使。
下血先出血后大便，这是近血，用赤小豆当归散主治。
〔衍义〕此出于大肠，所以先血后便。因湿热之毒蕴结，不入于经，渗于肠中而下。赤小豆能行水湿，解热毒，梅师方都用这一味药治下血，何况有当归破宿养新，以名义观之，血当有所归，则不妄行了。
心气不足，吐血衄血，用泻心汤主治。
泻心汤方
黄连 黄芩（各一两） 大黄（二两）
以上三味，用水三升，煮取一升，顿服。
〔衍义〕心属火，主血。心气不足，并非心火不足，而是真阳不足。真阳不足，则火热甚而心不能养血，血从热溢而为吐衄。大黄、黄芩，本草记载治疗血闭吐衄时用它们。而伤寒家以泻心汤之苦寒，泻心下之痞热，由此可知此证是血由心热而溢，泻其心之热，而血自安。如麻黄、桂枝治衄，是寒邪郁其经脉，化热迫成衄，所以散寒邪，寒邪散则热解，热解则血不被迫而自安。此处用泻心汤，正是其义。若济众方用大黄治衄血，更有生地汁，则是治热凉血，也是泻心汤之类。
(Twelve pulse and syndrome patterns, five prescriptions)
The pulse at the Cun Kou (radial artery) is agitated and weak. Agitation indicates fright; weakness indicates palpitations.
[Commentary] The Heart is the sovereign official, from which the Shen (Spirit) emerges. If one does not overexert the body or labor the mind, then Jing Qi (Essence and Qi) will be abundant, and the Shen will dwell securely in its residence. If injured, Qi deficiency leads to an agitated pulse; agitation causes palpitations and mental fear. Essence deficiency leads to a weak pulse; weakness causes Zheng Chong (palpitations with anxiety) and fearful trembling. Generally, Fright arises from external stimuli touching the heart, belonging to Yang; Yang transformation leads to an agitated pulse. Palpitations arise from internal fear, belonging to Yin; Yin consumption leads to a weak pulse. Therefore, this disease is suitable for mild agents to tonify Essence and Qi, and to anchor the Spirit. It is especially important to manage it with tranquility.
The Master said: A floating pulse at the Chi position, with yellow halos around the eyes, indicates that epistaxis has not stopped. When the yellow halos disappear and the eyes become clear and bright, one knows that the epistaxis has now stopped.
[Commentary] The Chi pulse assesses the Kidney, which belongs to Water. Earth controls Water; if Xiang Huo (Ministerial Fire) combines with pathogenic factors, it forces Yin Blood to ascend from the Bladder, hence the floating pulse. The Kidney's essence ascends to nourish the pupils. The Bladder meridian ascends to the forehead and causes epistaxis. Thus, when the yellow halo recedes, blood also descends, indicating that epistaxis has stopped. *Ming Li Lun* states that the Kidney governs Yin, and Blood is subordinate to it. In Shang Han (Cold Damage) diseases, epistaxis is attributed to pathogens in the Exterior, where excessive heat in the meridians causes bleeding. In miscellaneous diseases, epistaxis is attributed to pathogens in the Interior. The Heart governs Blood, the Liver stores Blood, the Lung governs Qi and opens into the nose. When Blood is heated, it scatters and reverses upward with Qi, exiting through the nose, which is called Ni. Here, the Chi pulse is floating, not the Cun Kou, indicating Kidney deficiency with reversed Blood, not an external pathogen.
It is also said: From Spring to Summer, epistaxis belongs to the Tai Yang (Greater Yang) channel; from Autumn to Winter, epistaxis belongs to the Yang Ming (Bright Yang) channel.
[Commentary] The *Nei Jing* states that Tai Yang is "Opening" and Yang Ming is "Closing." In Spring and Summer, Qi governs growth and generation, responding to "Opening," so pathogens force Blood to surge outward. In Autumn and Winter, Qi governs storage and consolidation, responding to "Closing," so pathogens are deeply郁 (stagnant) internally before emerging. Epistaxis indicates excess Yang. Shaoyang (Lesser Yang) is not mentioned because both Tai Yang and Yang Ming meridians intersect at the forehead.
Individuals prone to epistaxis should not undergo sweating therapy. If sweating occurs, there will be depression of the forehead, an urgent/tight pulse, staring fixedly without blinking, and inability to sleep.
[Commentary] Foot Tai Yang governs the Exterior, ascending to the vertex, entering the forehead, and passing through the eyes. Epistaxis occurs in the upper part, where collateral Blood has already been lost. Further sweating would further deplete Body Fluids. Depleted fluids lead to dry pulses, causing forehead depression and urgent pulses that pull the eyes, resulting in inability to close them. Lack of Blood and Yin deficiency cause insomnia. However, there are cases where sweating is indicated. *Shang Han Lun* states: With a floating-tight pulse, if sweating is not induced leading to epistaxis, Ma Huang Tang (Ephedra Decoction) is appropriate. It also states: In Tai Yang disease, with a floating-tight pulse, fever, no sweat, spontaneous epistaxis leads to recovery. Pathogens in the channels disperse without needing Gui Zhi Tang (Cinnamon Twig Decoction) or Ma Huang Tang. *Ming Li Lun* states that those with epistaxis who only have head sweat, or no sweat/sweat not reaching the feet, will die.
Patients with a pale complexion, no aversion to cold or fever, and a deep-wiry pulse suffer from epistaxis. Those with a floating-weak pulse that disappears upon pressure suffer from lower bleeding. Those with irritability and coughing will certainly vomit blood.
[Commentary] Complexion is the bloom of Blood. Abundant Blood yields a fresh luster. Cold/Heat damages Blood, causing pallor. Without cold/heat, bleeding from above or below is the cause. Floating pulses assess Yang; deep pulses assess Yin. Only deep-wiry pulses, disappearing on light touch, indicate absence of Yang, implying upper Blood loss. Only floating-weak pulses, disappearing on heavy pressure, indicate absence of Yin, implying lower Blood loss. Irritability, coughing, and hematemesis occur because the Heart relies on Blood to calm the Shen. Heat disturbs, causing Blood surging and Shen agitation. Upward disturbance to the Diaphragm causes coughing, forcing Blood upward. Deep pulses lacking floating qualities, and floating pulses lacking deep qualities, indicate Blood loss because the complexion is colorless and pulses are wiry/weak. Although Yang escapes in epistaxis, Yin is also damaged, making the pulse weak even on light touch. Classics state: Weakness indicates Blood deficiency. The Pulse is the mansion of Blood; thus, at sites of Blood loss, the pulse may be absent, or wiry/weak where Blood is damaged.
For hematemesis accompanied by rebellious Qi and coughing, rapid pulse, fever, and inability to lie down, the prognosis is fatal.
[Commentary] This is due to insufficiency of the Metal (Lung) and Water (Kidney) organs. External insufficiency leads to floating Fire flames, damaging Lung Metal. Internal Yin Blood is nurtured by Kidney Water. Water deficiency fails to provide tranquility, allowing Fire to force Blood outflow. Blood loss intensifies Yang/Sun, creating ascent without descent, scorching Lung Metal. Metal damage causes rebellious Qi and coughing. Metal and Water are mother-child; child decline cannot save the mother, and mother decline cannot generate the child. Both Yins are exhausted without recovery. Rapid pulse and fever indicate Yang excess. Inability to lie down indicates Yin exhaustion. If Yin is exhausted, can Yang survive alone? Hence, death. If able to lie down, as in *Nei Jing* discussions on Si Tian and Yang Ming reversal with wheezing, cough, fever, vomiting, and blood, death is not predicted because Yin is not exhausted.
Alcoholics who cough will certainly vomit blood, caused by excessive drinking.
[Commentary] Wine is too hot. If retained, it clouds Liver Qi and destabilizes Stomach Qi, chaotic in the chest. Middle Jiao Blood fails to distribute to meridians, gathering turbulently. Heat shoots into the Lung causing cough, expelling Blood via rebellious Qi. This is Stomach injury causing hematemesis.
The pulse at Cun Kou is wiry and large. Wiry indicates reduction; large indicates hollow (Kou). Reduction indicates Cold; hollow indicates Deficiency. Cold and Deficiency striking each other is named Ge (Leather) pulse. In women, it indicates miscarriage and dripping bleeding; in men, it indicates loss of Blood.
[Commentary] Cheng Wuji states "reduction is Cold" means little Yang Qi; "hollow is Deficiency" means little Yin Blood. Ge pulse, being both Cold and Deficient, leads to Qi deficiency and Blood deviation, failing to follow normal pathways. In men, true Yang declines and cannot secure internally, causing Blood loss. In women, Yin Blood is deficient and cannot nourish, causing miscarriage and dripping bleeding. This item appears in Volume 2 on Women's Diseases, mentioning Xuan Fu Hua Tang (Inula Flower Decoction).
Those with Blood loss should not be treated with exterior-releasing methods. Sweating will cause chills and tremors.
[Commentary] Blood loss injures Ying (Nutritive) Qi; one must not sweat to injure Wei (Defensive) Qi. Sweating injures both Ying and Wei. Ying moves within vessels; Wei moves outside. Ying deficiency empties vessels, causing tremors. Wei deficiency fails to warm pores, causing chills.
[Supplementary Note] *Shang Han Lun* says Blood loss is Yin loss. Yin loss leaves Yang solitary and unpaired. Upon sweating, Yang escapes completely with sweat, worsening chills, indicating dual exhaustion of Yin and Yang. The general method suggests Xiao Jian Zhong Tang (Minor Construct the Middle Decoction).
Patients with chest fullness, withered lips, cyan tongue, dry mouth desiring to rinse but not swallow, no cold/heat, micro-large slow pulse, abdominal non-distension but subjective chest fullness, have Blood stasis.
[Commentary] This syndrome is Blood stasis. What pathogen causes it? *Nei Jing* mentions falling/fear causing evil Blood retention, abdominal distension, and bowel/bladder obstruction. Great anger causes Blood stagnation upward. Thus, any internal/external pathogen clumping and stagnating constitutes Blood stasis. Lips reflect Spleen; tongue reflects Heart. Spleen meridian spreads under tongue; Stomach meridian circles mouth. Heart governs Blood; Spleen nourishes Blood. Stagnation prevents fluid distribution, causing withered lips and cyan tongue. Dry mouth desiring rinse but not swallow indicates heat is not internal, so rinsing moistens. Large pulse indicates Heat; slow indicates Cold. No cold/heat symptoms but micro-large pulse indicates Qi merging upward, causing chest fullness. Slow pulse indicates Blood accumulation below the diaphragm. Accumulation in Yin channels' tunnels differs from Qi accumulation in Yang blind membranes. Yang paths are manifest; Yin paths are hidden. Qi in blind membranes causes visible distension; Blood in tunnels causes only blockage, so abdomen is not distended, though patient feels full. Thus, it is known to be Blood stasis.
Patient resembles heat syndrome: irritability, fullness, dry mouth/thirst, but pulse lacks heat signs. This is Yin伏 (hidden/stagnant), indicating Blood stasis. Purge it.
[Commentary] Blood is Yin, paired with Yang. Shen rests on it, Qi harmonizes with it, throat moistens with it, meridians flow with it. It is inseparable from the body. Now, due to Blood stasis, Shen lacks nourishment (irritability), Qi lacks harmony (fullness), mouth lacks moisture (dryness), intestines/stomach lack lubrication (thirst). These result from Yang losing its pairing, Ying/Wei not moving, fluids not transforming. This is not Yang generating heat itself, hence "resembling heat."
Caused by Fire Pathogen: Treat with Gui Zhi Qu Shao Yao Jia Shu Ku Mu Li Long Gu Jiu Ni Tang (Cinnamon Twig Decoction minus Peony plus Chinese Tussilaginea Herb, Oyster Shell, and Dragon Bone to Rescue Deviation).
Gui Zhi Qu Shao Yao Jia Shu Ku Mu Li Long Gu Jiu Ni Tang Formula
Gui Zhi (Cortex Cinnamomi, peeled, 3 liang) Gan Cao (Radix Glycyrrhizae, honey-fried, 2 liang) Sheng Jiang (Rhizoma Zingiberis Recens, 3 liang) Shu Ku (Herba Thlaspidis, washed to remove fishy odor, 3 liang)
Long Gu (Os Draconis, calcined, 4 liang) Mu Li (Concha Ostreae, calcined, 5 liang) Da Zao (Fructus Jujubae, 12 pieces)
[Commentary] This mentions only Fire Pathogen, not specific symptoms. Examining it reveals Shang Han with floating pulse, treated by doctor with fire methods causing Yang collapse, leading to fright, mania, restlessness. Cheng Wuji notes: Sweat is Heart fluid. Yang collapse causes Heart Qi deficiency. Heart dislikes Heat; internal pathogenic pressure causes Shen floating, leading to fright/mania/restlessness. Gui Zhi Tang resolves residual exterior pathogens. Shao Yao nourishes Yin, unsuitable for Yang collapse, so removed. Fire pathogen rebellion requires Shu Ku's acridity to dissipate. Yang collapse requires Long Gu/Mu Li's astringency to secure.
Palpitations below the heart: Treat with Ban Xia Ma Huang Wan (Pinellia and Ephedra Pill).
Ban Xia Ma Huang Wan Formula
Ban Xia (Rhizoma Pinelliae) Ma Huang (Herba Ephedrae)
Grind these two into powder, mix with refined honey to form pills the size of small beans. Take three pills with water, three times daily.
[Commentary] Palpitations are the heart's fluttering sensation, Zheng Chong (palpitations with anxiety). There are three types: Shang Han with Zheng Qi (Upright Qi) deficiency; post-sweating/purging with internal Zheng Qi deficiency and pathogenic clash. Different pathogens require different treatments. Zheng Qi deficiency uses Xiao Jian Zhong Tang or Si Ni San plus Gui Zhi. Excessive water intake causing palpitations: Heart is Fire and dislikes Water, feeling uneasy. Post-sweating/purging deficiency with pathogenic clash is worse than Qi deficiency; treatment requires anchoring/securing or resolving/dispersing, stabilizing floating Qi. *Yuan Bing Shi* states this disease belongs to Water deficiency and Heat prosperity, Wind/Fire/Dryness moving internally, causing Zheng Chong. Fright/Palpitations also result from Fire drugs injuring Metal, failing to pacify Wood, Wind/Fire clashing. Investigating palpitation pathogens is complex. It may arise from cold exposure or cold drinks. Heart governs pulses; Cold injures Ying, impeding pulses. Cold drinks cause Water retention, blocking Middle Qi, impeding pulses, causing Heart Fire depression and movement. Ma Huang disperses Ying Cold; Ban Xia disperses Heart Water. The first chapter links weak pulses to palpitations, but this formula is used when pulses are not weak, likely wiry or tight. Would weak Qi deficiency allow such herbs?
Unceasing hematemesis: Treat with Bai Ye Tang (Cupressus Leaf Decoction).
Bai Ye Tang Formula
Bai Ye (Folium Cupressi) Gan Jiang (Rhizoma Zingiberis Secatum, 3 liang each) Ai Ye (Folium Artemisiae Argyi, 3 bundles)
Boil these three in 5 sheng of water, add 1 sheng of Ma Tong Zhi (Horse dung juice), decoct to 1 sheng. Divide into two warm doses.
[Commentary] Water sinks in cold, rises in wind. Human Blood is similar. Mild cold keeps Blood in meridians, nourishing organs. Severe cold coagulates Blood, preventing flow. Mild heat circulates Blood, filling orifices. Severe heat creates wild winds/fire, causing turbulent waves. Thus, hematemesis/epistaxis results from Wind/Fire.
Lower bleeding with stool before blood is distant bleeding (Yuan Xue): Treat with Huang Tu Tang (Yellow Earth Decoction).
Huang Tu Tang Formula
Gan Di Huang (Radix Rehmanniae Preparata) Huang Qin (Radix Scutellariae) Fu Zi (Radix Aconiti Lateralis Preparata, 1 liang) E Jiao (Colla Corii Asini) Bai Zhu (Rhizoma Atractylodis Macrocephalae) Gan Cao (Radix Glycyrrhizae, 3 liang each) Zao Xia Huang Tu (Caulis Fictorici, 0.5 jin)
Decoct these seven in 8 sheng of water to 3 sheng. Divide into three warm doses.
[Commentary] Intestines/Stomach are Yang Ming channels. Yang Ming governs closing; Qi naturally converges. Upward Blood flow is rebellious; downward is smooth. Regarding lower bleeding: Stomach is above Large Intestine. If Blood gathers in Stomach, stool precedes blood, far from anus, hence "distant bleeding." If in Large Intestine, near anus, hence "near bleeding." Though same channel, Stomach is Earth (governs reception/transformation, likes warmth/dislikes dampness); Large Intestine is Metal (governs transmission, likes cold/dislikes heat). Differences include distance and preferences. Huang Tu Tang treats distant bleeding. Why Blood in Stomach? Blood transforms in Middle Jiao, ascends to Ying to pair with Wei. Ying/Wei changes rely on Stomach Earth. Stomach/Spleen are interior-exterior. Stomach deficiency fails to move Qi to Three Yang; Spleen deficiency fails to move fluids to Three Yin. Qi declines, pulses obstruct, Blood accumulates and rebels, causing vomiting/epistaxis/diarrhea. To support Earth, use Yellow Earth. Yellow is Earth's true color; fired, it becomes Mother of Earth, dry not damp. Warmth transforms Blood, dissolving accumulation, stopping overflow. E Jiao benefits Blood (cow is Earth animal, symbolic). Di Huang nourishes Blood (symbolic). Gan Cao/Bai Zhu nourish Blood/Stomach (flavor similarity). Gan Cao moderates Fu Zi's heat. This formula treats distant bleeding and chronic hematemesis with weak/slow pulses. Stomach Yang failure requires Fu Zi's mobility to open meridians and disperse stasis. Spleen Yin disorder requires Huang Qin's bitterness to solidify Yin and secure Blood. Huang Qin also moderates Huang Tu/Fu Zi heat, acting as envoy.
Lower bleeding with blood before stool is near bleeding (Jin Xue): Treat with Chi Xiao Dou Dang Gui San (Adzuki Bean and Angelica Powder).
[Commentary] Originates from Large Intestine, hence blood before stool. Damp-Heat toxin accumulates, infiltrating intestines. Chi Xiao Dou moves Damp-Heat, resolves toxins. Mei Shi Fang uses this alone for lower bleeding. Dang Gui breaks old Blood, nourishes new. Symbolically, Blood returns to its source, ceasing erratic flow.
Heart Qi insufficiency with hematemesis/epistaxis: Treat with Xie Xin Tang (Drain the Epigastrium Decoction).
Xie Xin Tang Formula
Huang Lian (Rhizoma Coptidis) Huang Qin (Radix Scutellariae, 1 liang each) Da Huang (Radix et Rhizoma Rhei, 2 liang)
Decoct these three in 3 sheng of water to 1 sheng. Take all at once.
[Commentary] Heart is Fire, governs Blood. "Heart Qi insufficiency" refers not to Heart Fire deficiency, but True Yang deficiency. True Yang deficiency leads to excess Heat, preventing Heart from nourishing Blood, causing Heat-driven hemorrhage. Huang Lian/Huang Qin treat Blood closure/hemorrhage in Materia Medica. Shang Han practitioners use Xie Xin Tang's bitter-cold nature to drain Epigastric Fullness-Heat. Thus, this syndrome involves Heart Heat driving Blood out; draining Heart Heat calms Blood. Ma Huang/Gui Zhi treat epistaxis from Cold constraint transforming to Heat; dispersing Cold resolves Heat, calming Blood. Xie Xin Tang addresses this directly. Ji Zhong Fang uses Da Huang + Sheng Di汁 for epistaxis to cool Blood, similar to Xie Xin Tang.