诸证名义 戴云；咳血者，嗽出痰内有血者是。呕血者，呕全血者是。咯血者，每咯出血皆是血疙瘩。
（《金匮钩玄》）（按∶《丹溪纂要》作咯出血屑也。《要诀》曰∶咯血，不嗽而咯出血也。）
呕血与吐无大异，成盆无声者为吐，成碗有声者为呕。（《入门》）
吐血即呕血，旧分无声曰吐，有声曰呕，不必。（《医碥》）
咯与嗽为一类，皆因有痰而欲出之，或费力或不费力，总以出痰为主，非欲出其血也，因值其失血，故血随
痰出耳。唾与吐为一类，此则因血而然，缘血为火所涌，上升出至咽喉，多则吐，少则唾，并不费力，皆系纯血，
无痰涎夹杂。（同上）
源由 夫吐血者，皆由大虚损及饮酒劳损所致也。但肺者五脏上盖也，心肝又俱主于血。上焦有邪则
伤诸脏，脏伤血下入于胃，胃得血则闷满气逆，气逆故吐血也。（《病源
论》）
《养生方》云∶思虑伤心，心伤则吐衄，发则发焦也。（同上）
夫心者主血，肝者藏血。愁忧思虑则伤心，恚怒气逆上而不下则伤肝，肝心二脏伤，故血流散不止，气逆则
呕而出血。（同上）
虚劳呕血候 此内伤损于脏也。肝藏血，肺主气。劳伤于血气，气逆则呕，肝伤而血随呕出也。损轻则
唾血，伤重则吐血。（同上）
许仁则论曰∶此病有两种∶一者缘堕打损内伤而致此病，一者缘积热兼劳而有此病。（《外台》）
夫吐血、呕血、唾血三者皆谓之失血。盖肺主于气，心主于血，肝藏于血，血之与气，营周一身，相随上下，
无有休息者焉。倘乖调摄，营卫差经，血随气逆，遂有妄行之患。所致之由，因大虚损，或饮酒过度，或强食过饱，
或饮啖辛热，或忧思恚怒，洞扰三经而然。（《济生续方》）
《可用方》森立夫云∶愚谓肺居膈上，与心脏则近。心主于血，肺主于气，气血相随，循环表里。若脏腑久
积热毒，则胸膈壅滞，血与气逆行，上淫于肺，肺壅不利，故令吐血。又有体肤劳损，酒食过度，愁忧思虑，恚
怒气逆，伤于心肺者，亦皆吐血不止。（《万安》）
悲气劳气等皆能致血证，但怒气致血证者则暴甚，故经云抑怒以全阴者是矣。否则五志之火动甚，火载血上，
错经妄行也。（《微义》）
脉候 关前为阳，关后为阴，阳数则吐血。寸口脉芤吐血，微芤者衄血，空虚去血故也。吐血衄血，脉
滑小弱者生，实大者死。寸口脉微而弱，气血俱虚，男子则吐血，女
子则下血，呕吐汗出者为可治。病患身热，脉小绝者，吐血若下血，妇人亡经，此为寒。脉沉为在里，荣卫内结，
胸满，必吐血。（《脉经》）
关上脉微而芤，亦吐血。（《病源论》）
吐血之脉，宜沉细，不喜浮数。（《大成》）
吐血之后，有潮热咳嗽，脉洪大而数，五至以上，不可治也。（《准绳》）
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。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。（《医
通》）
病有三种 廪丘云∶吐血有三种∶有内衄，有肺疽，有伤胃。内衄者，出血如鼻衄，但不从鼻孔出，是
近从心肺间津液出（《病源》津液出，作溢出），还流入胃中，或如豆羹汁，或如切 ，血凝停胃中，因即满闷
便吐，或去数斗（《病源》作数升）至于一石者是也，得之于劳倦饮食过常所为也。肺疽者，或饮酒之后毒满闷，
吐之时，血从吐后出，或一合、半升、一升是也。伤胃者，因饮食大饱之后，胃中冷则不能消化，不能消化便烦闷，
强呕吐之，所食之物与气共上冲蹙，因伤裂胃口，吐血色鲜正赤，腹绞痛，白汗出，其脉紧而数者，为难治也。
（《千金》）
病者诸血积聚合发为衄，而清气道闭，浊道涌溢，凝停胸胃中，因即满闷，吐出数斗至于一石者，名曰内衄。或因
四气伤于外，七情动于内，及饮食房劳，坠堕伤损，致营血蓄聚膈间，满则吐溢，世谓妄行。病者因饮啖辛热，
热燥伤肺，血得热则溢，因作呕吐，出血一合或半升许，名曰肺疽。伤于腑则属胃，伤于脏则属肺，上以此分，
不可不究。病者因坠闪挫，致伤五脏，损裂出血，停留中脘，脏热则吐鲜血，脏寒则吐瘀血如豆羹汁，此名内
伤，治之各有方。（《三因》）
五脏证治 吐血失血等证，凡见喘满咳嗽，及左右胸膈间有隐隐胀痛者，此病在肺也。若胸膈膻中之间，
觉有牵痛如缕如丝，或懊 嘈杂有不可名状者，此病在心主包络也。若胸腹膨膨，不知饥饱，食饮无味，多涎沫
者，此病在脾也。若胁肋牵痛，或躁扰喘急不宁，往来寒热者，此病在肝也。若气短似喘，声哑不出，骨蒸盗汗，
咽干喉痛，动气忡忡者，此病在肾也。若大呕大吐，烦渴头痛，大热不得卧者，此病在胃也。于此而察其兼证，则
病有不止一脏者，皆可参合以辨之也。其于治法，凡肺病者，宜清降，不宜升浮。心主病者，宜养营，不宜耗散。
脾病者，宜温中，不宜酸寒。肝病者，或宜疏利，或宜甘缓，不宜秘滞。肾病者，宜壮水，宜滋阴，不宜香燥克伐。
胃病者，或宜大泻，或宜大补，当察兼证虚实，勿谓阳明证尽可攻也。（《景岳》）
吐血分五脏∶因悲忧所致，咳嗽血者，出于肺经。因思虑所致，痰涎血者，出于脾经。因惊所致而吐血者，
出于心经。因怒所致而吐血者，出于肝经。因房劳而咯血者，出于肾经。中气失调，邪热在中而呕血者，出于胃。
（《沙篆》）
（按∶此说本于《明医杂着》，然稍过精微，或难辨晰，姑存之。）
轻重 吐而不咳者易治，唾中带红线者难医，为其有所损故也。（《大成》）
夫吐血固甚于衄血矣，而就其吐血言之，则亦自有轻重。如一咯一块者，胃口血也，其所从来者近；痰中
见血，色如玛瑙而成块者，亦胃口血也，其所从来者亦近。二者势若可畏，而犹可调理，法当任其自出。又必
看其色，不鲜者旧血也，勿以药止之，其色鲜者，新血也，所积者必不甚多，宜以药止之。盖旧血终不归经，
不任其自出，反致增剧；新血终当归经，若所出者多，则损人矣，故宜药止之，以引血归经，此皆可以调理而
愈者也。若痰中见血，或一点之小，或一丝之细，语其势若无可畏，而病根反深，此血非胃口之血也，乃从肺
脏中来，肺为虚火所逼，血从痰出故也。其所以少者何也？盖肺脏以气为主，本多气而少血，是以所出者亦少
也。肺脏之血本少，又火逼而出之，则肺以枯，而无以领一身之气矣，所害不亦大乎。（《玉案》）
将本人血闻，不臭可治，若臭不可治也。（《回春》）
验色 或谓呕吐紫凝血为寒者，误也。此非冷凝，由热甚销铄，以为稠浊，而热甚则水化制之，故赤
兼黑而为紫也。（《原病式》）
如或暴吐紫血多者，无事，是平昔热伤死血在胃口，吐出为好（按∶此本于丹溪曰∶用四物汤、解毒汤之
类）。若止早吐不尽，后成血结块痛，难治，用活血汤。（《回春》）（活血汤见《腹痛》门。）
卒然吐血，或块或紫，伤力跌坠，瘀积致此。吐之无妨，再加调理。（《医读》）
问曰∶今见所吐，或紫或黄或黑块，非瘀积凝滞之寒血邪？答曰∶血之初来者，其色鲜红而散。少停一二
时来者，其色略紫而凝。若间半日或一日瘀积而成者，其色黑，其形结块。若吐尽之后，犹有有余未尽之血后
来者，其色淡，或
糖色，或粉红色，血丝，此非瘀血论也。若果久败之瘀血，其形如败酱，绝无血意者是。（《百问》）
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（按∶又《虚损门》曰∶剔起成片，如柿皮者），虽
能食不倦，后必暴脱而死。若血中见似肉似肺，如烂鱼肠，此胃中脂膜为邪火所烁，凝结而成，方书咸谓必死
（《虚损门》曰∶若吐淡红，如肉如肺者，谓之咳白血，此肺胃并伤，虽淹岁月，亦终不救），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。（《医通》）
[Background Information]
Book: Zabing Guangyao (Comprehensive Requirements for Miscellaneous Diseases)
Author: Tanba Genken (Japan)
Dynasty: Qing Dynasty
Chapter: Hematemesis (Vomiting Blood)
Category: Comprehensive
[Original Text Translation]
**Definitions of Various Symptoms**
Dai Yun stated: "Coughing blood" refers to blood appearing in sputum when coughing. "Vomiting blood" refers to vomiting complete blood. "Spitting blood" refers to spitting out blood clots each time.
*(From Jin Gui Gou Xuan)*
(Note: *Dan Xi Zuan Yao* records it as spitting out blood flakes. *Yao Jue* states: Spitting blood is spitting blood without coughing.)
The difference between vomiting blood and spitting blood is not significant. What fills a basin silently is called "spitting," while what fills a bowl with sound is called "vomiting." *(From Yi Men)*
Hematemesis is the same as vomiting blood. The old distinction that silent expulsion is "spitting" and noisy expulsion is "vomiting" is unnecessary. *(From Yi Que)*
Spitting (ge) and coughing (sou) belong to one category; both involve the desire to expel phlegm, whether with effort or not, primarily aiming to expel phlegm, not blood. However, due to concurrent hemorrhage, blood comes out along with the phlegm. Saliva (tuo) and spitting (tu) belong to one category; this is caused by blood. Because blood is surged upward by fire, rising to the throat, if there is much, it is spat out; if little, it is salivated. Neither requires effort, and both consist of pure blood without phlegm mixture. *(Ibid.)*
**Etiology**
Hematemesis is caused by severe deficiency damage and injury from excessive drinking and overwork. The lung is the canopy of the five zang organs, while the heart and liver both govern blood. If pathogens affect the upper jiao, they damage the various zang organs. Damaged zang organs cause blood to descend into the stomach. When the stomach receives blood, it becomes stuffy and distended, leading to rebellious qi. Rebellious qi causes hematemesis. *(From Bing Yuan Lun / Treatise on the Sources of Diseases)*
The *Yang Sheng Fang* says: Excessive thinking damages the heart. Heart damage leads to hematemesis and epistaxis, and hair may turn gray upon onset. *(Ibid.)*
The heart governs blood, and the liver stores blood. Sorrow and worry damage the heart; anger causes qi to rebel upward and fail to descend, damaging the liver. Damage to these two zang organs causes blood to scatter and flow uncontrollably. Rebellious qi leads to vomiting and bleeding. *(Ibid.)*
**Signs of Vomiting Blood Due to Deficiency Consumption**
This is internal injury damaging the zang organs. The liver stores blood, and the lung governs qi. Labor damages blood and qi; rebellious qi causes vomiting, and liver damage causes blood to follow the vomit. Mild damage results in bloody saliva; severe damage results in hematemesis. *(Ibid.)*
Xu Renze discussed: This disease has two types: one arises from internal injury due to falling or beating; the other arises from accumulated heat combined with labor. *(From Waitai Miyao)*
Hematemesis, vomiting blood, and bloody saliva are all referred to as loss of blood. The lung governs qi, the heart governs blood, and the liver stores blood. Blood and qi circulate throughout the body, following each other up and down without rest. If regulation fails, and Ying-Wei meridians deviate, blood follows rebellious qi, leading to reckless movement. Causes include severe deficiency, excessive drinking, forced overeating, consumption of spicy and hot foods, or sorrow, worry, and anger, which violently disturb the three meridians. *(From Jisheng Xufang)*
Sen Rifu in *Keyong Fang* said: The lung resides above the diaphragm, close to the heart. The heart governs blood, and the lung governs qi; qi and blood follow each other, circulating between exterior and interior. If viscera accumulate heat toxins for a long time, chest and diaphragm become obstructed, blood and qi move in reverse, invading the lung. Lung obstruction and dysfunction cause hematemesis. Additionally, physical fatigue, excessive alcohol and food, sorrow, worry, and angry rebellious qi damaging the heart and lung also cause persistent hematemesis. *(From Wan'an)*
Sadness, labor, and other factors can cause blood disorders, but anger causing blood disorders is sudden and severe. Hence, classics state that suppressing anger preserves yin. Otherwise, the fire of the five emotions moves vigorously, carrying blood upward, causing erratic meridian movement and reckless flow. *(From Yixue Wei Yi)*
**Pulse Diagnosis**
Before the guan pulse is yang, behind is yin. A rapid yang pulse indicates hematemesis. A cun kou pulse that is Kou (hollow like a scallion stalk) indicates hematemesis; slightly Kou indicates epistaxis, due to emptiness from blood loss. For hematemesis and epistaxis, a slippery, small, and weak pulse indicates survival; a solid and large pulse indicates death. A cun kou pulse that is fine and weak indicates dual deficiency of qi and blood; men will have hematemesis, women will have lower bleeding. Vomiting and sweating indicate treatability. If a patient has fever and a minute or absent pulse, accompanied by hematemesis or lower bleeding, or amenorrhea in women, this is cold. A deep pulse indicates interior pathology, internal binding of Ying-Wei, chest fullness, and inevitable hematemesis. *(From Mai Jing)*
A fine and Kou pulse at the guan position also indicates hematemesis. *(From Bing Yuan Lun)*
For hematemesis, a deep and fine pulse is appropriate; a floating and rapid pulse is undesirable. *(From Yixue Dacheng)*
After hematemesis, if tidal fever and cough appear, and the pulse is洪大 (surging and large) and rapid, exceeding five beats per respiration, it is untreatable. *(From Yixue Zhunsheng)*
For hematemesis pulses, fine and thin is favorable; surging and large is unfavorable. If blood gushes violently like a tide, and [missing character] in the throat does not stop, and the pulse appears empty and large, this indicates the fire pathogen has not subsided. Do not immediately administer decoctions. Urgently administer hot child urine or lotus root juice. After about half a day, when the pulse trend slows, tonifying agents can be given. If the cun and guan pulses are weak, but the chi pulse is slightly wiry, this indicates yin deficiency. Even if bleeding stops, if the pulse remains large, or is small but wiry, fine, rapid, or hard and discordant, do not lightly claim it is curable. There are cases where other parts are soft, but the left guan and chi are wiry and strong, indicating yin deficiency with hyperactive fire, which is a critical sign. Variations include: 1. Yin fire drawing blood upward causing sudden collapse; 2. Deficient yang revealing itself causing fever; 3. Fire pressing on the lung causing wheezing and cough. These are ultimately incurable. *(From Yixue Tong)*
**Three Types of Disease**
Lin Qiu said: Hematemesis has three types: Internal Epistaxis (Nei Nu), Lung Abscess (Fei Ju), and Stomach Injury (Shang Wei).
Internal Epistaxis: Bleeding resembles epistaxis but does not come from the nose. It originates near from fluids between the heart and lung, flows back into the stomach, resembling bean soup or chopped [missing character]. Blood coagulates in the stomach, causing fullness and vomiting, potentially discharging several dou or even one shi. This results from fatigue and irregular diet.
Lung Abscess: After drinking, toxicity causes fullness. During vomiting, blood appears afterward, ranging from one he, half sheng, to one sheng.
Stomach Injury: After overeating, if the stomach becomes cold and cannot digest, it causes irritability. Forced vomiting makes food and qi rush upward, tearing the stomach opening. The vomited blood is bright red, accompanied by abdominal colic and cold sweat. A tight and rapid pulse indicates difficult treatment. *(From Qianjin Yaofang)*
Various blood accumulations causing epistaxis, with blocked clear pathways and surging turbid pathways, condensing in the chest and stomach, causing fullness and vomiting of several dou to one shi, is named Internal Epistaxis. This can be caused by external four qi injuries, internal seven emotions, dietary/sexual excess, or falls, causing Ying blood to accumulate in the diaphragm. When full, it vomits out, known as reckless flow. Eating spicy/hot foods damages the lung with heat/dryness; blood overflows with heat, causing vomiting of one he or half sheng, named Lung Abscess. Injury to Fu organs belongs to the stomach; injury to Zang organs belongs to the lung. Injury from falls damaging five zang organs causes bleeding stopping in the middle jiao. Heat in zang causes fresh blood; cold in zang causes stasis like bean soup. This is internal injury, treated with specific formulas. *(From Sanyan Ji Yi Bing Zheng Fang Lun)*
**Treatment of Five Zang Organs**
For hematemesis and blood loss:
If wheezing, chest fullness, cough, and dull pain/distension in the left/right chest/diaphragm occur, the disease is in the **Lung**.
If pulling pain like threads in the chest/diaphragm/Shanzhong area, or mental vexation/irritability indescribable, the disease is in the **Heart Pericardium**.
If abdominal distension, unknown hunger/fullness, tasteless food/drink, and excessive saliva occur, the disease is in the **Spleen**.
If rib pulling pain, restlessness, urgent wheezing, alternating chills/fever occur, the disease is in the **Liver**.
If shortness of breath resembling asthma, hoarseness, bone-steaming night sweats, dry throat/sore throat, palpitations occur, the disease is in the **Kidney**.
If severe vomiting, thirst/headache, high fever preventing lying down occur, the disease is in the **Stomach**.
Observe concomitant symptoms to identify multi-zang involvement.
Therapeutic principles:
Lung: Clear and descend; avoid ascending/floating.
Heart Pericardium: Nourish Ying; avoid dispersing.
Spleen: Warm the center; avoid sour/cold.
Liver: Soothe and drain, or use sweet/mild; avoid constipation/stagnation.
Kidney: Strengthen water, nourish yin; avoid aromatic/drying attacks.
Stomach: Purge heavily or tonify heavily; observe deficiency/excess of concomitant symptoms. Do not assume Yangming patterns are always suitable for purgation. *(From Jing Yue Quanshu)*
Hematemesis divided by five zang:
Caused by sadness/worry, coughing blood: Lung Meridian.
Caused by thinking, bloody phlegm: Spleen Meridian.
Caused by fright, vomiting blood: Heart Meridian.
Caused by anger, vomiting blood: Liver Meridian.
Caused by sexual exhaustion, spitting blood: Kidney Meridian.
Middle qi imbalance, evil heat in center, vomiting blood: Stomach. *(From Sha Zhuan)*
(Note: Based on *Ming Yi Za Zhu*, but too subtle for clear differentiation; retained for reference.)
**Severity**
Vomiting without coughing is easy to treat; saliva with red threads is difficult, due to underlying damage. *(From Yixue Dacheng)*
Hematemesis is worse than epistaxis, but varies in severity.
Spitting a clot: Blood from the stomach opening, source is proximal.
Blood in sputum, agate-colored clots: Also stomach blood, proximal source.
Though alarming, these can be regulated; allow them to exit naturally.
Check color: Non-fresh is old blood; do not stop with medicine. Fresh is new blood; little accumulation; stop with medicine to guide blood back to meridians. Old blood won't return; forcing it worsens condition. New blood should return; if excessive, it harms; stop it to guide return. Both can heal with regulation.
Blood in sputum, tiny drops/threads: Seeming mild, but deep root. Not stomach blood, but from Lung. Lung pressured by deficient fire, blood exits with phlegm. Why little? Lung governs qi, abundant in qi, scarce in blood. Scarce blood expelled by fire dries the lung, failing to lead body qi. Harm is great. *(From Yu An)*
Smell the blood: Odorless is treatable; odorous is untreatable. *(From Huichun)*
**Examining Color**
Some say purple coagulated blood from vomiting is cold; this is wrong. It is not cold coagulation, but heat consuming and thickening blood. Heat controlled by water element turns red/black to purple. *(From Yuanbing Shi)*
Sudden vomiting of much purple blood is harmless; it is old dead blood from past heat injury in the stomach opening, expelling it is good. (Note: Based on Danxi: Use Siwu Tang, Jiedu Tang). If vomiting stops early leaving residue, later forming painful blood clots, difficult to treat; use Huoxue Tang. *(From Huichun)* (Huoxue Tang see Abdominal Pain section).
Sudden hematemesis, clots or purple, from strain/falls, stasis accumulation. Vomiting is fine; add regulation. *(From Yidu)*
Q: Are purple/yellow/black clots not cold stasis?
A: Fresh blood is bright red and scattered. Stopped 1-2 hours, slightly purple and coagulated. Stopped half-day/day, black and clotted. Post-vomit residual blood is pale, sugar-colored, pink, or thread-like; this is not stasis. True old stasis looks like spoiled sauce, devoid of blood vitality. *(From Baiwen)*
**Collapse and Prognosis**
For collapse (massive blood loss), use large dose of Ginseng to boost qi and secure blood. Suitable only if blood is bright or slightly purple-clotted. If dull/pale, due to cold blood failing to return, add charred Dried Ginger or large dose Lizhong Tang to warm. Chi pulse wiry: Large dose Shengli Liuwei Dihuang Wan + Cinnamon to guide. Or Cinnamon powder with Dushen Tang.
If blood is vermilion, glossy like lacquer, dries instantly, scrapes off in sheets like persimmon skin: Though appetite is good and no fatigue, sudden collapse and death will follow.
If blood contains meat/lung-like matter, like rotten fish intestines: Gastric fat membrane scorched by evil fire, coagulated. Classics say fatal. (Xu Sun men: Pale red, meat/lung-like is "coughing white blood," lung/stomach dual injury, incurable even after years). However, if after vomiting, coagulation clears, no fever, able to eat, taking small doses Yigong San, Baoyuan Tang, large doses Liuwei Dihuang Wang, Duqi Wan, many survive. Do not dismiss as incurable. *(From Yixue Tong)*