客有问于余曰。失血一证。危急骇人。医疗鲜效。或暴来而顷刻即逝。或暂止而终亦必亡。敢问有
一定之方。可获万全之利否。余曰。是未可以执一论也。请备言之。
凡血证。先分阴阳。有阴虚。有阳虚。阳虚补阳。阴虚补阴。此直治之法。人所共知。又有真阴真阳。
阳根于阴。阴根于阳。真阳虚者。从阴引阳。真阴虚者。从阳引阴。复有假阴假阳。似是而非。多以误人。
此真假二字。旷世之所不讲。举世之所未闻。在杂病不可不知。在血证为尤甚也。汝知之乎。
既分阴阳。又须分三因。风寒暑湿燥火外因也。（过食生冷。好啖炙 。醉饱无度。外之内也。）喜怒
忧思恐。内因也。（劳心好色。内之内也。）跌扑闪 。伤重瘀蓄者。不内外因也。
既分三因。而必以吾身之阴阳为主。或阴虚而挟内外因也。或阳虚而挟内外因也。盖阴阳虚者。在我之
正气虚也。三因者。在外之邪气有余也。邪之所凑。其气必虚。不治其虚。安问其余。
客问曰。吐衄血者。从下炎上之火。暑热燥火。固宜有之。何得有风寒之证。曰此六淫之气。俱能
伤人。暑热者十之一二。火燥者半。风寒者半。而火燥之后。卒又归于虚寒矣。
内经曰。岁火太过。炎暑流行。肺金受刑。民病血溢血泄。又曰少阳之复。火气内发。血溢血泄。是
火气能使人失血也。而又云太阳司天。寒淫所胜。血变于中。民病呕血血泄鼽衄善悲。又太阳在泉。寒淫所
胜。民病血见。是寒气能使人失血也。又云太阴在泉。湿淫所胜。民病血见。是湿气使人失血也。又云少阴
司天之政。水火寒热持于气交。热病生于上。冷病生于下。寒热凌犯。能使人失血者也。太阴司天之政。初之
气。风湿相薄。民病血溢。是风湿相搏血溢也。又云岁金太过。燥气流行。民病反侧咳逆。甚而血溢。是燥气
亦能使人血溢也。六气俱能使人血溢。何独火乎。况火有阴火阳火之不同。日月之火。与灯烛之火
不同。垆中之火。与龙雷之火不同。又有五志过极之火。惊而动血者。火起于心。怒而动血者。火起
于肝。忧而动血者。火起于
肺。思而动血者。火起于脾。劳而动血者。火起于肾。能明乎火之一字。而于血之理。思过半矣。
刘河间先生。特以五运六气暑火立论。故专用寒凉以治火。而后人宗之。不知河间之论。但欲与仲景伤
寒论对讲。各发其所未发之旨耳。非通论种种不同之火也。自东垣先生出。而论脾胃之火。必须温养。始禁用
寒凉。自丹溪先生出。而立阴虚火动之论。亦发前人所未发。可惜大补阴丸补阴丸二丸中。俱以黄柏知母为
君。而寒凉之弊又盛行矣。嗟乎。丹溪之书不息。岐黄之道不着。余特撰阴阳五行之论。以申明火不可以
水灭。药不可以寒攻也。
六淫中虽俱能病血。其中独寒气致病者居多。何也。盖寒伪荣。风伤卫。自然之理。又太阳寒水少阴肾
水。俱易以感寒。一有所感。皮毛先入。肺主皮毛。水冷金寒。肺经先受。血亦水也。故经中之水与血。一
得寒气。皆凝滞而不行。咳嗽带痰而出。问其人必恶寒。切其脉必紧。视其血中间。必有或紫或黑数
点。此皆寒浮之验也。医者不详审其证。便以为阴虚火动。而概用滋阴降火之剂。病日深而死日迫矣。余尝
用麻黄桂枝汤而愈者数人。皆一服得微汗而愈。盖汗与血一物也。夺血者无汗。夺
汗者无血。余读兰室秘藏而得此意。因备记以广其传。
一贫者冬天居大室中。卧大热炕。得吐血。求治于余。余料此病大虚弱而有火。热在内。上气不足。阳
气外虚。当补表之阳气。泻其里之虚热。是其法也。冬天居大室。衣盖单薄。是重虚其阳。表有大寒壅遏。里
热火邪不得舒伸。故血出于口。忆张仲景所着伤寒论中一证。太阳伤寒当以麻黄汤发汗而不与。遂成
衄血。却以麻黄汤。立愈。
独有伤暑吐衄者。可用河间法。必审其证面垢口渴喜饮。干呕腹痛或不痛。发热或不发热。其脉必
虚大汗出者。黄连解
毒主汤之。甚者白虎汤。
金匮方云。心气不足。吐血衄血者。泻心汤主之。大黄二两。黄连黄芩各一两。水三升。煮取一升。顿
服之。此正谓手少阴心经之阴气不足。本经之阳火亢甚。无所辅。肺肝俱受其火而病作。以致阴血妄行而飞
越。故用大黄泄去亢甚之火。黄芩救肺。黄连救肝。使之和平。则阴血自复而归经矣。
愚按暑伤心。心气既虚。暑气故乘而入之。心主血。故吐衄。心既虚而不能主血。恐不宜过用寒凉以泻
心。须以清暑益气汤中。加丹皮生地。兼犀角地黄治之。盖暑伤心。亦伤气。其人必无气以动。脉必虚。以
参助气。使气能摄血。斯无弊也。
客问曰。既云须分阴阳。则吐衄血者。阴血受病。以四物汤补血是矣。参 补气。奚为用之。而复
有谓阳虚补阳之说何耶。曰子正溺于世俗之浅见也。自王节斋制本草集要。有云阴虚吐血者。忌人参。服之则
阳愈旺。而阴愈消。过服人参者死。自节斋一言。而世之受病治病者。无问阳虚阴虚而并弃之若砒毒矣。冤哉冤
哉。盖天地间之理。阳统乎阴。血随乎气。故治血必先理气。血脱必先益气。古人之妙用也。
凡内伤暴吐血不止。或劳力过度。其血妄行。出如涌泉。口鼻皆流。须臾不救即死。急用人参一两或二两
为细末。入飞罗面一钱。新汲水调如稀糊。不拘时啜服。或用独参汤亦可。古方纯用补气。不入血药何也。盖
有形之血。不能速生。无形之气。所当急固。无形自能生有形也。若有真阴失守。虚阳泛上。亦大吐血。又须
八味地黄汤固其真阴。以引火归原。正不宜用人参。及火既引之而归矣。人参又所不禁。阴阳不可不辨。而先
后之分。神而明之。存乎人耳。
凡失血之后。必大发热。名曰血虚发热。古方立当归补血汤。用黄 一两。当归六钱。名曰补血。
而以黄 为主。阳旺能
生阴血也。如丹溪于产后发热。用参 归芎黑姜以佐之。或问曰。干姜辛热。何以用之。曰姜味辛。能引血药
入气分。而生新血。神而明之。不明此理。见其大热。六脉洪大。而误用发散
之剂。或以其象白虎汤证。而误用白虎。立见危殆。慎之哉。
客又问曰。阳能统阴。闻命矣。伤寒吐血。亦闻命矣。然除伤寒外。或者寒凉之药。不能不少加一二。以
杀其火气。至于辛热之品。以火济火。恐一入口而直冲不止。奈何。宁和平守中。以免谤怨。何如。若丹溪产
后用干姜者。为有恶露凝留。故用之以化其瘀。未必可为典耍也。余见先生治血证。不惟不用寒凉。
而反常用大辛热之药。屡以奏功。不已霸乎。曰子之言。不读古书。不穷至理。不图活人之命者也。试检古人
已验之名言以示之。
金匮方云。吐血不止。柏叶汤主之。柏叶干姜各二两。艾三把。以水五升。取马通一升。合煮取一升。
分温再服。
凡吐血不已。则气血皆虚。虚则生寒。是故用柏叶。柏叶生而西向。乃禀兑金之气而生。可制肝木。木主
升。金主降。取其升降相配。夫妇之道和。则血得以归藏于肝矣。故用是为君。干姜性热。炒黑则止而不走。
用补虚寒之血。艾叶之温。能入内而不炎于上。可使阴阳之气。反归于里。以补其寒。用二味为佐。取马通者
为血生于心。心属午。故用午兽之通。主降火消停血。引领而行为使。仲景治吐血准绳。可以触类而长之。
仁斋直指云。血遇热则宣流。故止血多用凉药。然亦有气虚挟寒。阴阳不相为守。荣气虚散。血亦错行。
所谓阳虚阴必走耳。外必有虚冷之状。法当温中。使血自归于经络。可用理中汤加南木香。或干姜甘草汤。其
效甚着。又有饮食伤胃。或胃虚不能传化。其气逆上。亦能吐衄。木香理中汤甘草干姜汤。出血诸证。每以胃药收功。
曹氏必用方。吐血须煎干姜甘草作汤与服。或四物理中汤亦可。如此无不愈者。若服生地黄藕汁竹茹。去
生便远。
三因方云。理中汤能止伤胃吐血。以其方最理中脘。分别阴阳。安定气血。按患人果身受寒气。口受冷
物。邪入血分。血得冷而凝。不归经络而妄行者。其血必黑黯。其色必白而夭。其
脉必微迟。其身必清凉。不用姜桂而用凉血之剂。殆矣。临病之工。宜详审焉。
褚氏遗书云。喉有窍咳血伤人。肠有窍便血杀人。便血犹可治。咳血不易医。饮溲溺百不一死。服寒凉百
不一生。血虽阴类。运之者其阳和乎。玩阳和二字。褚氏深达阴阳之妙者矣。
海藏云。胸中聚集之残火。腹里积久之太阴。上下隔绝。脉络部分阴阳不通。用苦热以定于中。使辛热以
行于外。升以甘温。降以辛润。化严肃为春温。变凛冽为和气。汗而愈也。然余毒土苴。犹有存者。周身阳
和。尚未泰然。胸中微燥而思凉饮。因食冷物服凉剂。阳气复消。余阴再作。脉退而小。弦细而迟。激而为衄
血吐血者有之。心肺受邪也。下而为便血溺血者有之。肾肝受邪也。三焦出血。色紫不鲜。此重沓寒湿化毒。
凝泣水谷道路。浸溃而成。若见血证。不详本末。便用凉折。变乃生矣。
客又问曰。吐血可用辛热。为扶阳抑阴。始闻命矣。然复有真阴真阳之说。可得闻乎。答曰。世之言阴阳
者。气血尽之矣。岂知火为阳气之根。水为阴血之根乎。吾所谓水与火者。又非心与肾之谓。人身五行之外。
另有一无形之火。无形之水。流行于五脏六腑之间。惟其无形。故人莫得而知之。试观之天。日为火之精。故气
随之。月为水之精。故潮随之。如星家看五行者。必以太阳太阴为主。然此无形之水火。又有一太极为之主宰。
则又微乎微矣。此天地之正气。而人得以生者。是立命之门。谓
之元神。无形之火。谓之元气。无形之水。谓之元精。俱寄于两肾中间。故曰五脏之中。惟肾为真。此真水
真火真阴真阳之说也。
又问曰。真阴真阳。与血何干乎。曰子但知血之为血。而不知血之为水也。人身涕唾津液痰汗便溺。皆水
也。独血之水。随火而行。故其色独红。肾中之真水干。则真火炎。血亦随火而沸腾矣。肾中之真火衰。则真
水盛。血亦无附而泛上矣。惟水火奠其位。而气血各顺布焉。故以真阴真阳为要也。
又问曰。既是火之为害。正宜以水治之。而先生独曰火不可水灭。反欲用辛热何耶。曰子但知火之为火。
而不知火有不同也。有天上之火。如暑月伤暑之病是也。方可以井水沃之。可以寒凉折之。若垆中之火。得水
则灭。在人身即脾胃之火。脾胃之中无火。将以何者蒸腐水谷。而分温四体耶。至于相火者。龙雷之火。水中之
火也。龙雷之火。得雨而益炽。惟太阳一照。而龙雷自息。及秋冬阳气伏藏。而雷始收声。龙归大海矣。
此火不可水灭。而用辛热之义也。当今方书亦知龙雷之火。不可水灭。不可直折。但其注皆曰黄柏知母之类是
也。若是依旧。是水灭直折矣。误天下苍生者。此言也。哀哉。
又问曰。黄柏知母既所禁用。治之将何如。若与前所论。理中温中无异。法何必分真阴真阳乎。曰温中者。
理中焦也。非下焦也。此系下焦两肾中先天之真气。与心肺脾胃后天有形之体。毫不相干。且干姜甘草当归等
药。俱入不到肾经。惟仲景八味肾气丸斯为对证。肾中一水一火。地黄壮水之主。桂附益火之原。水火既济之
道。盖阴虚火动者。若肾中寒冷。龙宫无可安之穴宅。不得已而游行于上。故血亦随火而妄行。今用桂附二
味纯阳之火。加于六味纯阴水中。使肾中温暖。如冬月一阳来复于水土之中。龙雷之火。自然归就于原宅。
不用寒凉而火自
降。不必止血而血自安矣。若阴中水干而火炎者。去桂附而纯用六味。以补水配火。血亦自安。亦不必去火。
总之保火为主。此仲景二千余年之玄秘。岂后人可能笔削一字哉。
客又问曰。假寒假热之说何如。曰此真病之状。惑者误以为假也。经曰。少阴司天之政。水火寒热持于
气交。热病生于上。冷病生于下。寒热凌犯而争于中。民病血溢血泄。内经盖指人之脏腑而言。言少阴司
天者。肾经也。凡肾经吐血者。俱是下寒上热。阴盛于下。逼阳于上之假证。世人不识而为其所误者多矣。吾
独窥其微。而以假寒治之。所谓假对假也。但此证有二。有一等少阴伤寒之证。寒气自下肾经。而感小腹痛。或
不痛。或呕或不呕。面赤口渴不能饮水。胸中烦躁。此作少阴经外感伤寒看。须用仲景白通汤之法治之。一服
即愈。不再作。又有一等真阴失守。命门火衰。火不归元。水盛而逼其浮游之火于上。上焦咳嗽气喘恶热面红
呕吐痰涎出血。此系假阳之证。须用八味地黄。引火归元。兹二方俱用大热之药。倘有方无法。则上焦烦热正
甚。复以热药投之。入口即吐矣。须以水探冷。假寒驱之。下嗌之后。冷性既除。热性始发。因而呕哕皆除。
此加人尿猪胆汁于白通汤。下以通拒格之寒也。用八味汤者。亦复如是。倘一服寒凉。顷刻立死。慎之哉。
A guest asked me, "Hemorrhage is a critical and alarming condition, with few effective treatments. Some cases appear suddenly and become fatal within moments; others stop temporarily but inevitably lead to death eventually. May I ask if there is a specific formula that can ensure complete success?" I replied, "This issue cannot be discussed by adhering to a single viewpoint. Please allow me to elaborate."
For all hemorrhagic conditions, one must first distinguish between Yin and Yang. There is Yin deficiency and Yang deficiency. For Yang deficiency, tonify Yang; for Yin deficiency, tonify Yin. This is the direct method of treatment, which everyone knows. Furthermore, there are True Yin and True Yang. Yang is rooted in Yin, and Yin is rooted in Yang. In cases of True Yang deficiency, draw Yang from Yin; in cases of True Yin deficiency, draw Yin from Yang. Additionally, there are False Yin and False Yang, which appear similar but are fundamentally different, often leading people astray. The concepts of 'true' and 'false' have long been neglected and unheard of by the general public. They are essential to know in miscellaneous diseases and particularly crucial in hemorrhagic conditions. Do you understand?
Having distinguished Yin and Yang, one must also differentiate the Three Causes (etiology). Wind, cold, summer-heat, dampness, dryness, and fire belong to external causes. (Excessive consumption of raw/cold foods, preference for roasted/grilled items, and uncontrolled indulgence in alcohol and heavy meals are factors entering from outside into the interior.) Joy, anger, worry, thought, and fear belong to internal causes. (Overwork of the mind and excessive sexual activity are factors injuring from within.) Falls, trauma, sprains, and injuries causing blood stasis accumulation belong to neither internal nor external causes.
Having distinguished the Three Causes, one must prioritize the body's own Yin and Yang. It may be Yin deficiency complicated by external or internal causes, or Yang deficiency complicated by external or internal causes. Since Yin and Yang deficiency refers to the weakness of the body's righteous Qi (Zheng Qi), while the Three Causes refer to the excess of external pathogenic factors. Where pathogens gather, Qi must be deficient. If one does not treat the deficiency of Qi, what else is there to discuss?
The guest asked, "Hematemesis (vomiting blood) and epistaxis (nosebleed) are caused by fire flaring upwards from below. Summer-heat, heat, and dryness-fire are indeed causes, but how can wind-cold be involved?" I said, "All six climatic pathogens (Liu Yin) can injure the human body. Summer-heat accounts for one or two tenths, fire and dryness account for half, and wind-cold also account for half. After fire and dryness, the condition ultimately returns to deficiency-cold."
The *Neijing* states: "When Fire is excessive in the year, hot weather prevails, damaging Metal (Lung), and the people suffer from blood overflow and leakage." It also says: "In the recurrence of Shaoyang, Fire Qi erupts internally, causing blood overflow and leakage." This indicates that Fire can cause hemorrhage. It further states: "When Taiyang governs the year, Cold dominates excessively, blood changes within, and the people suffer from hematemesis, blood leakage, epistaxis, and sadness." It also says: "When Taiyang is in the lower position, Cold dominates excessively, and the people suffer from bleeding." This indicates that Cold can cause hemorrhage. It also states: "When Taiyin is in the lower position, Dampness dominates excessively, and the people suffer from bleeding." This indicates that Dampness can cause hemorrhage. It also states: "In the administration where Shaoyin governs the year, Water, Fire, Cold, and Heat contend at the Qi intersection. Heat diseases arise above, Cold diseases arise below. The invasion of Cold and Heat can cause hemorrhage." It also states: "In the administration where Taiyin governs the year, during the first phase, Wind and Dampness interact, and the people suffer from blood overflow." This indicates that Wind-Damp interaction causes blood overflow. It also states: "When Metal is excessive in the year, Dryness prevails, and the people suffer from restlessness, coughing, and counterflow Qi, severely leading to blood overflow." This indicates that Dryness can also cause blood overflow. All six Qi can cause blood overflow; why attribute it solely to Fire? Moreover, Fire differs into Yin Fire and Yang Fire. The fire of the sun and moon differs from candle fire; the fire in a furnace differs from Dragon-Lei Fire. There is also Fire arising from the extreme excess of the Five Emotions: startle moving blood originates in the Heart; anger moving blood originates in the Liver; sorrow moving blood originates in the Lungs; overthinking moving blood originates in the Spleen; fatigue moving blood originates in the Kidneys. Understanding the concept of 'Fire' allows one to comprehend more than half of the principles of blood.
Mr. Liu Hejian specifically established his theory based on the Summer-Fire of the Five Movements and Six Qi, thus exclusively using cold-cooling herbs to treat Fire. Later generations followed him, unaware that Liu's theory was merely intended to contrast with Zhang Zhongjing's *Treatise on Cold Damage*, each expounding upon previously unexpressed principles, rather than being a comprehensive discussion of all types of Fire. Since Mr. Li Dongyuan emerged, discussing Fire of the Spleen and Stomach, which requires warming and nourishing, the use of cold-cooling herbs began to be prohibited. Since Mr. Zhu Danxi emerged, establishing the theory of Yin Deficiency with Fire Hyperactivity, he also expounded upon previously unexpressed ideas. Unfortunately, in both the *Da Bu Yin Wan* (Great Tonification of Yin Pill) and *Bu Yin Wan* (Tonify Yin Pill), Huangbai (Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma) serve as the sovereign herbs, causing the弊端 (drawbacks) of cold-cooling to prevail again. Alas! If Danxi's writings do not cease, the Way of Qi and Huang will not be illuminated. I have specially written on Yin-Yang and Five Elements to clarify that Fire cannot be extinguished by Water, and medicine should not attack with Cold.
Although all six climatic pathogens can cause blood diseases, Cold is the most common cause. Why? Generally, Cold injures Ying (Nutritive) Qi, and Wind injures Wei (Defensive) Qi, which is the natural order. Furthermore, Taiyang Cold Water and Shaoyin Kidney Water are prone to contracting Cold. Once contracted, the skin and hair are affected first. The Lungs govern the skin and hair; Cold water makes Metal cold, so the Lung Meridian is affected first. Blood is also Water; thus, when the Water and Blood in the meridians encounter Cold, they stagnate and cease to flow. Coughing up phlegm occurs; the patient will definitely feel aversion to cold; the pulse will be tight; looking at the blood, there will be purple or black spots. These are all signs of floating Cold. If physicians do not carefully examine the syndrome and assume it is Yin Deficiency with Fire Hyperactivity, indiscriminately using yin-nourishing and fire-reducing formulas, the disease deepens daily, approaching death. I once cured several patients using Mahuang Guizhi Tang (Ephedra and Cinnamon Twig Decoction); they recovered after one dose with slight sweating. Sweat and blood are essentially the same thing; those who lose blood have no sweat, and those who lose sweat have no blood. I derived this meaning from reading *Lan Shi Mi Cang* (Secrets of the Chamber Room) and recorded it here to spread its knowledge.
A poor man lived in a large room in winter, sleeping on a very hot kang (heated brick bed), and developed hematemesis. He sought my treatment. I deduced that this illness involved severe deficiency with Fire, heat inside, insufficiency of Upper Qi, and exterior Yang deficiency. The treatment should be to tonify exterior Yang and drain interior deficiency-heat. Living in a large room in winter with thin clothing and blankets doubly depleted his Yang. Exterior Cold obstructed heavily, preventing the interior Fire-Heat Evil from dispersing, causing blood to exit from the mouth. I recalled a syndrome in Zhang Zhongjing's *Treatise on Cold Damage*: Taiyang Cold Damage should be treated with Mahuang Tang (Ephedra Decoction) to induce sweating; if not given, it leads to epistaxis. However, using Mahuang Tang cured it immediately.
Only hemorrhage caused by Summer-Heat injury can be treated using Hejian's method. One must carefully examine the syndrome: greasy complexion, thirst with desire to drink, dry retching, abdominal pain or no pain, fever or no fever, pulse must be deficient with profuse sweating. Use Huanglian Jiedu Tang (Coptis Decoction for Resolving Toxicity) as the main formula. For severe cases, use Baihu Tang (White Tiger Decoction).
The *Jingui Yaolue* formula states: "For insufficiency of Heart Qi causing hematemesis and epistaxis, Xiexin Tang (Drain the Epigastrium Decoction) is indicated." Dahuang (Rhei Radix et Rhizoma) 2 liang, Huanglian (Coptidis Rhizoma) and Huangqin (Scutellariae Radix) 1 liang each. Boil in 3 sheng of water to obtain 1 sheng, take in one dose. This precisely refers to the insufficiency of Yin Qi in the Hand-Shaoyin Heart Meridian, with hyperactive Yang Fire in the same meridian lacking support. The Lungs and Liver are affected by the Fire, causing pathology, leading to reckless movement of Yin Blood. Therefore, Dahuang is used to drain the hyperactive Fire, Huangqin saves the Lungs, and Huanglian saves the Liver, bringing them to harmony, so that Yin Blood naturally recovers and returns to its vessels.
My commentary: Summer-Heat injures the Heart; since Heart Qi is already deficient, Summer-Heat enters乘 (takes advantage of) this deficiency. The Heart governs Blood, hence hematemesis and epistaxis. Since the Heart is deficient and cannot govern Blood, it is advisable not to overuse cold-cooling herbs to drain the Heart. One should add Mudanpi (Moutan Cortex) and Shengdi (Rehmanniae Radix) to Qingshu Yiqi Tang (Clear Summer-Heat and Tonify Qi Decoction), combined with Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction). Summer-Heat injures the Heart and also Qi; the patient will likely lack energy to move, and the pulse will be deficient. Using Renshen (Ginseng Radix et Rhizoma) to assist Qi enables Qi to control Blood, avoiding drawbacks.
The guest asked, "Since it is said that one must distinguish Yin and Yang, then for hematemesis and epistaxis, where Yin Blood is diseased, using Siwu Tang (Four Substances Decoction) to tonify Blood should suffice. Renshen tonifies Qi, why use it? And what is the saying about tonifying Yang for Yang deficiency?" I said, "You are immersed in shallow worldly views. Since Wang Jiezhai compiled *Bencao Ji Yao* (Essentials of Materia Medica), stating that those with Yin deficiency and hematemesis should avoid Renshen, as it increases Yang and depletes Yin further, and overdose can be fatal. Since Jiezhai's statement, patients and physicians alike, regardless of Yang or Yin deficiency, have discarded Renshen as if it were arsenic. How unjust! The principle of heaven and earth is that Yang commands Yin, and Blood follows Qi. Therefore, treating Blood requires regulating Qi first; in Blood loss, tonifying Qi is paramount. This is the subtle application of the ancients."
For sudden massive hematemesis due to internal injury, or excessive labor causing reckless Blood flow, gushing like a spring, flowing from mouth and nose, death occurs quickly if not saved urgently. Immediately use 1 or 2 liang of Renshen ground into fine powder, mixed with 1 qian of refined flour, stirred with fresh well-water into a thin paste, taken anytime. Or use Dushen Tang (Single Ginseng Decoction). Ancient formulas use only Qi-tonifying herbs, without Blood-invigorating herbs. Why? Because substantial Blood cannot be generated quickly, whereas intangible Qi must be urgently secured. Intangible Qi naturally generates substantial form. If True Yin is lost, and Deficient Yang floats upward, causing massive hematemesis, one must use Bawei Dihuang Wan (Eight-Ingredient Pill with Rehmannia) to secure True Yin and guide Fire back to its source. At this stage, Renshen is inappropriate. Once Fire has returned to its source, Renshen is no longer forbidden. Yin and Yang must be distinguished; the sequence and subtlety depend on the physician's wisdom.
After hemorrhage, high fever often occurs, named Blood Deficiency Fever. Ancient formulas created Danggui Buxue Tang (Angelica Tonify Blood Decoction), using Huangqi (Astragali Radix) 1 liang and Danggui (Angelicae Sinensis Radix) 6 qian. Named 'Tonify Blood', but Huangqi is the sovereign herb. Strong Yang generates Yin Blood. For example, Danxi used Renshen, Huangqi, Danggui, Chuanxiong, and Heijiang (Blackened Ginger) for postpartum fever. Someone asked, "Ginger is pungent and hot, why use it?" I said, "Ginger is pungent, capable of guiding Blood herbs into the Qi level to generate new Blood. Understand this subtly. Without understanding this principle, seeing high fever and surging pulses, one might mistakenly use dispersing formulas, or mistake the presentation for Baihu Tang syndrome and use Baihu Tang, leading to immediate danger. Be cautious!"
The guest asked again, "Yang can command Yin, understood. Taiyang Cold Damage with hematemesis, understood. But apart from Taiyang Cold Damage, perhaps some cold-cooling herbs should be added to reduce Fire. As for pungent-hot substances, adding Fire to Fire, fearing they will rush uncontrollably upon ingestion, what should be done? Is it better to remain neutral and moderate to avoid blame? Regarding Danxi using Ginger postpartum, it was for retained lochia to resolve stasis, not necessarily a standard model. I see you treating hemorrhage not only avoiding cold-cooling but frequently using large pungent-hot drugs with success. Isn't this too domineering?" I said, "Your words show you have not read ancient books, exhausted profound principles, or cared for human life. Let me cite verified ancient sayings."
The *Jingui Yaolue* formula states: "For persistent hematemesis, Boxie Tang (Cypress Leaf Decoction) is indicated." Boxie (Cupressi Cacumen) and Ganjiang (Zingiberis Rhizoma) 2 liang each, Aiye (Artemisiae Argyi Folium) 3 bundles. Boil in 5 sheng of water, add Matong (Equi Feces) 1 sheng, boil to obtain 1 sheng, divide into two warm doses.
When hematemesis persists, both Qi and Blood are deficient, leading to Cold. Thus, Boxie is used. Boxie grows facing west, inheriting the Qi of Dui-Metal, controlling Liver Wood. Wood governs ascent, Metal governs descent; taking their mutual regulation harmonizes the husband-wife relationship, allowing Blood to return to storage in the Liver. Hence, it is the sovereign herb. Ganjiang is hot; charred black, it stops and does not disperse, used to tonify deficiency-Cold Blood. Aiye is warm, entering internally without flaming upwards, returning Yin-Yang Qi to the interior to supplement Cold. These two are assistant herbs. Matong is used because Blood is born in the Heart, which corresponds to Wu (South/Horse); thus, the feces of the Horse animal are used to descend Fire and dissolve stagnant Blood, acting as the guide herb. Zhang Zhongjing's standards for treating hematemesis can be extended by analogy.
Renzhai's *Zhizhi Fang* states: "Blood flows freely when heated, so stopping blood often uses cooling medicines. However, there are cases of Qi deficiency with Cold, where Yin and Yang do not guard each other, Ying Qi is deficient and scattered, and Blood moves erratically. This is called 'Yang deficiency leads to Yin escape.' Externally, there must be deficiency-cold signs. The method should be warming the middle to let Blood return to meridians naturally. Use Lizhong Tang (Regulate the Middle Decoction) plus Nanmuxiang (Styracis Resina) or Ganjiang Gancao Tang (Ginger and Licorice Decoction); effects are significant. Also, dietary injury to the Stomach, or Stomach deficiency failing to transport and transform, causing rebellious Qi, can also cause hematemesis and epistaxis. Muxiang Lizhong Tang and Ganjiang Gancao Tang often conclude treatment of various bleeding syndromes successfully using Stomach-regulating herbs. Cao's *Bi Yong Fang* states that for hematemesis, decoct Ganjiang and Gancao as a soup. Or Siwu Lizhong Tang is also acceptable. Such cases heal invariably. Taking Shengdi (Rehmanniae Radix), Lotus Root Juice, or Zhuru (Bambusae Caulis in Taenia) keeps one far from death (implies these are dangerous/wrong here)."
The *Sanyin Fang* states: "Lizhong Tang can stop hematemesis due to Stomach injury. Its formula best regulates the Middle Jiao, distinguishes Yin and Yang, and stabilizes Qi and Blood. If the patient indeed contracted Cold externally and ingested cold food, pathogen enters Blood level, Blood congeals due to Cold, fails to return to meridians, and bleeds recklessly. The blood will be dark black, complexion pale and dull, pulse faint and slow, body cool. Not using Ginger and Cinnamon but using Blood-cooling agents is perilous. Physicians should examine carefully."
Chu's *Yishu* states: "The throat has orifices; coughing blood harms the person. The intestines have orifices; passing blood kills. Passing blood is still treatable; coughing blood is difficult to cure. Drinking urine saves one in a hundred; taking cold-cooling herbs kills one in a hundred. Although Blood is Yin, what moves it is Yang Harmony? Playing with the words 'Yang Harmony,' Chu deeply understood the wonders of Yin and Yang."
Haizang stated: "Residual Fire accumulated in the chest, Taiyin Cold accumulated in the abdomen, upper and lower separated, meridians blocked, Yin and Yang不通 (unconnected). Use bitter-hot to stabilize the middle, pungent-hot to circulate externally. Ascend with sweet-warm, descend with pungent-moisten. Transform severity into spring warmth, change biting cold into harmonious Qi. Sweating cures it. However, residual toxins remain. Whole-body Yang Harmony is not yet peaceful. Chest slightly dry, desiring cool drinks, eating cold food or taking cold formulas causes Yang to dissipate again, residual Yin to flare. Pulse becomes small, wiry-thin and slow,激 (provoked) into epistaxis or hematemesis—this is Pathogen affecting Heart and Lungs. Descending into melena or hematuria—this is Pathogen affecting Kidney and Liver. Sanjiao bleeding, color purple and dull, results from repeated Cold-Damp transforming into toxin, coagulating the pathways of water and grain, infiltrating and forming. If seeing bleeding syndromes without investigating origin and consequence, and immediately using cold-cooling to suppress, complications arise."
The guest asked again, "Using pungent-hot for hematemesis is for supporting Yang and suppressing Yin, understood. But there is also the theory of True Yin and True Yang; may I hear it?" I answered, "People speaking of Yin and Yang today only refer to Qi and Blood. How do they know Fire is the root of Yang Qi, and Water is the root of Yin Blood? The Water and Fire I speak of are not the Heart and Kidney organs. Outside the Five Elements of the human body, there is another Formless Fire and Formless Water circulating among the five zang and six fu organs. Because they are formless, people do not know them. Observe the sky: the Sun is the essence of Fire, so Qi follows it; the Moon is the essence of Water, so tides follow it. Astrologers viewing the Five Elements must prioritize Taiyang (Sun) and Taiyin (Moon). However, this formless Water and Fire are governed by a Taiji, which is extremely subtle. This is the Righteous Qi of Heaven and Earth, by which humans live—the Gate of Life, called Yuan Shen (Original Spirit). The Formless Fire is called Yuan Qi (Original Qi). The Formless Water is called Yuan Jing (Original Essence). Both reside between the two Kidneys. Thus, among the five zang, only the Kidney is True. This is the theory of True Water, True Fire, True Yin, and True Yang."
Asked again, "How do True Yin and True Yang relate to Blood?" I said, "You only know Blood as Blood, not knowing Blood is Water. Tears, saliva, fluids, phlegm, sweat, urine, and feces in the body are all Water. Only the Water of Blood travels with Fire, hence its unique red color. When True Water in the Kidneys dries up, True Fire flares, and Blood boils with Fire. When True Fire in the Kidneys declines, True Water abounds, and Blood has no attachment and floats upward. Only when Water and Fire are settled in their positions do Qi and Blood distribute smoothly. Thus, True Yin and True Yang are key."
Asked again, "If Fire is the harm, surely Water should treat it. Why do you say Fire cannot be extinguished by Water, and instead advocate pungent-hot herbs?" I said, "You only know Fire as Fire, not knowing Fire differs. There is Heavenly Fire, such as Summer-Heat injury in summer, which can be cooled with well water or cold-cooling herbs. But Furnace Fire, which extinguishes with water, corresponds to Spleen-Stomach Fire in the body. Without Fire in the Spleen and Stomach, what steams and rots food and warms the four limbs? As for Minister Fire, Dragon-Lei Fire, it is Fire within Water. Dragon-Lei Fire intensifies with rain; only when the Sun shines does Dragon-Lei subside. In autumn and winter, when Yang Qi hides, Thunder falls silent, and Dragons return to the sea. This Fire cannot be extinguished by Water, which is the meaning of using pungent-hot herbs. Modern formularies know Dragon-Lei Fire cannot be extinguished by Water or directly suppressed. But their annotations say things like Huangbai and Zhimu. If continued, this is extinguishing with Water and suppressing directly. These words mislead the world. Alas!"
Asked again, "If Huangbai and Zhimu are prohibited, how to treat? If it is no different from the previously discussed warming the middle, why distinguish True Yin and True Yang?" I said, "Warming the middle regulates the Middle Jiao, not the Lower Jiao. This concerns the Pre-heaven True Qi in the two Kidneys of the Lower Jiao, unrelated to the Post-heaven substantial forms of Heart, Lungs, Spleen, and Stomach. Moreover, herbs like Ganjiang, Gancao, and Danggui do not enter the Kidney Meridian. Only Zhang Zhongjing's Bawei Shenqi Wan (Eight-Ingredient Kidney Qi Pill) is appropriate. In the Kidney, there is one Water and one Fire. Dihuang (Rehmanniae Radix) strengthens the master of Water; Guifu (Cinnamomi Cortex and Aconiti Lateralis Radix Praeparata) benefits the source of Fire. This is the way of Water and Fire interacting. In Yin Deficiency with Fire Hyperactivity, if the Kidney is cold, the Dragon Palace has no dwelling place, forcing it to wander upward, causing Blood to follow Fire and bleed recklessly. Now, using Guifu, two pure Yang Fires, added to the six pure Yin Waters of Liuwei Dihuang Wan, warms the Kidney. Like the arrival of one Yang in winter within soil and water, Dragon-Lei Fire naturally returns to its original home. Fire descends without cold-cooling; Blood calms without hemostatics. If Water in Yin is dry and Fire flares, remove Guifu and use only Liuwei Dihuang Wan to supplement Water to match Fire, calming Blood without removing Fire. Ultimately, preserving Fire is primary. This is Zhang Zhongjing's mystery for over two thousand years, impossible for later generations to alter even one word."
The guest asked, "What about the theory of False Cold and False Heat?" I said, "These are true pathological states, mistaken by confused people as false. The *Neijing* says: 'In the administration where Shaoyin governs the year, Water, Fire, Cold, and Heat contend at the Qi intersection. Heat diseases arise above, Cold diseases arise below. Cold and Heat invade and contend in the middle, and the people suffer from blood overflow and leakage.' The *Neijing* likely refers to human organs. Shaoyin governing the year refers to the Kidney Meridian. All hematemesis from the Kidney Meridian is Lower Cold and Upper Heat, a false syndrome where Yin abundance below forces Yang upward. Many people are misled by not recognizing this. I alone perceive the subtlety and treat it with False Cold methods, i.e., false treating false. But there are two types of this syndrome. One type is Shaoyin Cold Damage: Cold Qi rises from the Kidney Meridian, causing lower abdominal pain (or no pain), vomiting (or no vomiting), red face, thirst unable to drink, chest irritability. View this as external Cold Damage of the Shaoyin Meridian; treat with Zhang Zhongjing's Baitong Tang (White Connecting Decoction); one dose cures, no recurrence. Another type is True Yin loss, Mingmen Fire decline, Fire not returning to source, Water abundance forcing floating Fire upward. Upper Jiao symptoms include cough, asthma, aversion to heat, red face, vomiting phlegm and blood. This is a False Yang syndrome; treat with Bawei Dihuang Wan to guide Fire back to its source. Both formulas use large hot drugs. If there is a formula but no method, and Upper Jiao烦热 (irritating heat) is severe, giving hot drugs orally will cause immediate vomiting. One must use the 'water-probing cold' method: use false cold to drive it out. After swallowing, the cold nature disappears, and the hot nature activates, resolving vomiting. This is why Renao (Human Urine) and Zhuchidan (Pig Gallbladder Bile) are added to Baitong Tang—to penetrate the rejecting Cold. Using Bawei Tang is similar. If one dose of cold-cooling is taken, death occurs instantly. Be cautious!"