寸口脉动而弱。动即为惊。弱则为悸。
惊则气乱。故脉动。悸属里虚。故脉弱。动即为惊者。因惊而脉动。病从外得。弱则为悸者。因
弱而为悸。病自内生。其动而且弱者。则内已虚。而外复干之也。
师曰。尺脉浮。目睛晕黄。衄未止。晕黄去。目睛慧了。知衄今止。
尺脉浮。知肾有游火。目睛晕黄。知肝有蓄热。衄病得此。则未欲止。盖血为阴类。为肾肝之火
热所逼而不守也。若晕黄去。目睛且慧了。知不独肝热除。肾热亦除矣。故其衄今当止。
又曰。从春至夏衄者太阳。从秋至冬衄者阳明。
血从阴经并冲任而出者则为吐。从阳经并督脉而出者则为衄。故衄病皆在阳经。但春夏阳气浮。则
属太阳。秋冬阳气伏。则属阳明为异耳。所以然者。就阴阳言。则阳主外。阴主内。就三阳言。则太
阳为开。阳明为阖。少阳之脉不入鼻额。故不主衄也。
或问衄皆在阳是已。然所谓尺脉浮。目睛晕黄者。非阴中事乎。曰前所谓尺脉浮。目睛晕黄者。
言火自阴中出。非言衄自阴中来也。此所谓太阳、阳明者。言衄所从出之路也。谁谓病之在阳者。不即
为阴之所迫而然耶。
衄家不可汗。汗出必额上陷。脉紧急。直视不能 。不得眠。
血与汗皆阴也。衄家复汗。则阴重伤矣。脉者血之府。额上陷者。额上两旁之动脉。因血脱于上
而陷下不起也。脉紧急者。寸口之脉。血不荣而失其柔。如木无液而枝乃劲也。直视不 不眠者。阴气
亡则阳独胜也。经云。夺血者无汗。此之谓夫。
病患面无色。无寒热。脉沉弦者衄。脉浮弱。手按之绝者下血。烦咳者必吐血。
面无色。血脱者色白不泽也。无寒热。病非外感也。衄因外感者。其脉必浮大。阳气重也。衄因
内伤者。其脉当沉弦。阴气厉也。虽与前尺脉浮不同。其为阴之不靖则一也。若脉浮弱。按之绝者。
血下过多。而阴脉不充也。烦咳者。血从上溢。而心肺焦燥也。此皆病成而后见之诊也。
夫吐血。咳逆上气。其脉数而有热。不得卧者死。
脉数身热。阳独胜也。吐血咳逆上气不得卧。阴之烁也。以既烁之阴。而从独胜之阳。有不尽不
已之势。故死。
夫酒客咳者。必致吐血。此因极饮过度所致也。
酒之热毒。积于胃而熏于肺则咳。久之肺络热伤。其血必随咳而吐出。云此因极饮过度所致者。
言当治其酒热。不当治其血也。
寸口脉弦而大。弦则为减。大则为芤。减则为寒。芤则为虚。虚寒相搏。此名为革。妇人则半产
漏下。男子则亡血。
此条已见虚劳病中。仲景复举之者。盖谓亡血之证。有从虚寒得之者耳。
亡血不可发其表。汗出即寒栗而振。
亡血者亡其阴也。更发其表。则阳亦伤矣。阳伤者外不固。故寒栗。阴亡者内不守。故振振动摇。
前衄血
复汗。为竭其阴。此则并亡其阳。皆所谓粗工嘻嘻者也。
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。其人言我满。为有
瘀血。病者如有热状。烦满。口干燥而渴。其脉反无热。此为阴伏。是瘀血也。当下之。
此二条。辨瘀血之见证。胸满者。血瘀而气为之不利也。唇痿舌青。血不荣也。口燥欲漱水者。
血结则气燥也。无寒热。病不由表也。脉微大来迟。血积经隧。则脉涩不利也。腹不满。其人言我满。
外无形而内实有滞。知其血积在阴。而非气壅在阳也。故曰为有瘀血。
如有热状。即下所谓烦满口干燥而渴也。脉无热。不数大也。有热证而无热脉。知为血瘀不流。
不能充泽所致。故曰此为阴伏。阴伏者。阴邪结而伏于内也。故曰当下。
火邪者。桂枝去芍药加蜀漆牡蛎龙骨救逆汤主之。
此但举火邪二字。而不详其证。按伤寒论云。伤寒脉浮。医以火迫劫之。亡阳。必惊狂。起卧不
安。又曰。太阳病。以火熏之。不得汗。其人必躁。到经不解。必圊血。名为火邪。仲景此条。殆为
惊悸下血备其证欤。桂枝汤去芍药之酸。加蜀漆之辛。盖欲使火气与风邪一时并散。而无少有留滞。
所谓从外来者。驱而出之于外也。龙骨、牡蛎。则收敛其浮越之神与气尔。
桂枝去芍药加蜀漆牡蛎龙骨救逆汤方
桂枝（三两去皮） 甘草（二两炙） 龙骨（四两） 牡蛎（五两熬） 生姜（三两） 大枣（十
二枚）
蜀漆（三两洗去腥）
上为末。以水一斗二升。先煮蜀漆。减二升。内诸药。煮取三升。去滓。温服一升。
心下悸者。半夏麻黄丸主之。
此治饮气抑其阳气者之法。半夏蠲饮气。麻黄发阳气。妙在作丸与服。缓以图之。则麻黄之辛甘。
不能发越津气。而但升引阳气。即半夏之苦辛。亦不特蠲除饮气。而并和养中气。非仲景神明善变者。
其孰能与于此哉。
半夏麻黄丸方
半夏 麻黄（各等分）
上二味末之。炼蜜和丸小豆大。饮服三丸。日三服。
吐血不止者。柏叶汤主之。
按、仁斋直指云。血遇热则宣行。故止血多用凉药。然亦有气虚挟寒。阴阳不相为守。营气虚散。
血亦错行者。此干姜、艾叶之所以用也。而血既上溢。其浮盛之势。又非温药所能御者。故以柏叶抑
之使降。马通引之使下。则妄行之血顺而能下。下而能守矣。
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。合煮取一升。分温再服。千金加阿胶三两。亦佳。
下血、先便后血。此远血也。黄土汤主之。
下血先便后血者。由脾虚气寒。失其统御之权。而血为之不守也。脾去肛门远。故曰远血。黄土
温燥入脾。合白术、附子。以复健行之气。阿胶、生地黄、甘草。以益脱竭之血。而又虑辛温之品。
转为血病之厉。故又以黄芩之苦寒。防其太过。所谓有制之师也。
黄土汤方
甘草 干地黄 白术 附子 阿胶 黄芩（各三两） 灶中黄土（半斤）
上七味。以水八升。煮取三升。分温二服。
下血、先血后便。此近血也。赤豆当归散主之。（方见狐惑）
下血先血后便者。由大肠伤于湿热。而血渗于下也。大肠与肛门近。故曰近血。赤小豆能行水湿。
解热毒。当归引血归经。且举血中陷下之气也。
心气不足。吐血衄血。泻心汤主之。
心气不足者。心中之阴气不足也。阴不足则阳独盛。血为热迫。而妄行不止矣。大黄、黄连、黄
芩。泻其心之热而血自宁。寇氏云。若心气独不足。则当不吐衄也。此乃邪热因不足而客之。故令吐
衄。以苦泄其
热。以苦补其心。盖一举而两得之。此说亦通。济众方用大黄、生地汁治衄血。其下热凉血。亦泻心
汤类耳。
泻心汤方
大黄（二两） 黄连 黄芩（各一两）
上三味。以水三升。煮取一升。顿服之。
The pulse at the Cun Kou (radial artery) is moving and weak. "Moving" indicates fright, while "weak" indicates palpitations.
Fright causes Qi to become chaotic, hence the pulse appears moving; palpitations belong to deficiency in the interior, hence the pulse appears weak. The phrase "moving indicates fright" means that due to fright, the pulse moves, and the disease originates from external factors. The phrase "weak indicates palpitations" means that due to internal weakness, palpitations arise, and the disease originates from within. If the pulse is both moving and weak, it indicates that the interior is already deficient and has been further disturbed by external pathogens.
The Master said: If the Chi pulse (at the wrist) is floating, and there are yellow halos around the eyes, the epistaxis (nosebleed) has not yet stopped. If the yellow halos disappear and the eyes become clear, one knows that the epistaxis has now ceased.
A floating Chi pulse indicates wandering fire in the Kidney; yellow halos around the eyes indicate accumulated heat in the Liver. In cases of epistaxis, if these signs are present, the bleeding will not stop easily. This is because blood belongs to Yin, and is forced to move recklessly by the hot fire of the Kidney and Liver. If the yellow halos disappear and the eyes become clear, it indicates not only that Liver heat has cleared, but also that Kidney heat has cleared. Therefore, the epistaxis should now cease.
It is also said: Epistaxis occurring from spring to summer belongs to the Taiyang (Greater Yang) channel; epistaxis occurring from autumn to winter belongs to the Yangming (Yang Brightness) channel.
Blood flowing out from Yin channels along with the Chong and Ren vessels constitutes hematemesis (vomiting blood), whereas blood flowing out from Yang channels along with the Du vessel constitutes epistaxis. Thus, epistaxis always involves Yang channels. However, during spring and summer when Yang Qi floats outward, it is attributed to Taiyang; during autumn and winter when Yang Qi sinks inward, it is attributed to Yangming. This is the distinction. The reason is this: regarding Yin and Yang, Yang governs the exterior and Yin governs the interior; regarding the Three Yang channels, Taiyang governs opening, Yangming governs closing, and Shaoyang (Lesser Yang) does not enter the nose or forehead, so it does not primarily govern epistaxis.
One might ask: It is accepted that epistaxis involves Yang channels. But what about the previously mentioned floating Chi pulse and yellow halos around the eyes? Are these not matters of Yin? The answer is: The previously mentioned floating Chi pulse and yellow halos refer to fire emerging from the Yin, not that the epistaxis itself originates from the Yin channels. Here, mentioning Taiyang and Yangming refers to the pathway through which the epistaxis exits. Who says that a disease located in the Yang channels is not compelled by Yin?
Patients who frequently suffer from epistaxis must not be treated with sweating methods. If sweating is induced, the arteries on both sides of the forehead will sink, the pulse will become tight and urgent, the eyes will stare fixedly without movement, and sleep will be impossible.
Both blood and sweat belong to Yin fluids. For a patient who frequently bleeds from the nose, inducing sweating will severely damage Yin. The pulse is the residence of blood. The sinking of the forehead arteries is due to blood loss from above, causing the arteries to collapse. A tight and urgent pulse occurs because the blood fails to nourish the vessels at the Cun Kou, losing their softness, just as tree branches become stiff without sap. Fixed staring and insomnia occur because the loss of Yin leads to the dominance of Yang. The Classic states: "Those who have lost blood should not sweat," which refers to this situation.
If a patient's face is colorless, without chills or fever, and the pulse is deep and wiry, it indicates epistaxis. If the pulse is floating and weak, and feels interrupted upon pressure, it indicates lower bleeding (hematochezia). If there is irritability and coughing, hematemesis will certainly occur.
A colorless face indicates blood loss, appearing white and lusterless. Absence of chills or fever indicates the disease is not due to external contraction. Epistaxis caused by external contraction typically presents with a floating and large pulse due to heavy Yang Qi. Epistaxis caused by internal injury typically presents with a deep and wiry pulse due to aggressive Yin Qi. Although different from the floating Chi pulse mentioned earlier, both reflect instability of Yin. If the pulse is floating and weak, feeling interrupted upon pressure, it is due to excessive lower bleeding failing to fill the Yin pulses. Irritability and coughing indicate blood overflowing from above, causing dryness and agitation in the Heart and Lungs. These are diagnostic signs appearing after the disease has formed.
In cases of hematemesis accompanied by coughing, upward rushing of Qi, a rapid pulse, fever, and inability to lie down, the prognosis is fatal.
A rapid pulse and body heat indicate the dominance of Yang. Hematemesis, coughing, upward rushing of Qi, and inability to lie down indicate the consumption of Yin. With Yin already consumed confronting dominant Yang, there is a trend toward complete exhaustion, hence death.
Patients who drink excessively and cough will inevitably develop hematemesis, caused by extreme overindulgence in alcohol.
The heat toxicity of alcohol accumulates in the Stomach and steams into the Lungs, causing cough. Over time, the collateral vessels of the Lungs are damaged by heat, and blood will be expectorated with the cough. Saying this is caused by excessive drinking implies that treatment should target the alcohol-heat, not merely the bleeding.
If the pulse at the Cun Kou is wiry and large: wiry indicates decline, large indicates hollow (like a scallion stalk). Decline indicates cold, and hollow indicates deficiency. The combination of deficiency and cold is named "Ge" (Leather) pulse. In women, this leads to spontaneous abortion or metrorrhagia; in men, it leads to massive blood loss.
This clause appeared in the chapter on Deficiency Consumption. Zhang Zhongjing repeats it here to emphasize that conditions of blood loss can arise from deficiency-cold.
Patients with massive blood loss must not be treated with surface-releasing methods. If sweating is induced, they will experience chills and trembling.
Massive blood loss represents the loss of Yin. Further releasing the surface will injure Yang. Injury to Yang leads to insecurity of the exterior, causing chills. Loss of Yin leads to insecurity of the interior, causing trembling. The previous case of epistaxis followed by sweating exhausted Yin; this case exhausts both Yin and Yang. Such errors are characteristic of incompetent physicians.
If a patient has chest fullness, withered lips, blue tongue, dry mouth desiring to rinse but not swallow, no chills or fever, and a pulse that is slightly large and slow, yet the abdomen is not distended although the patient claims fullness, this indicates Blood Stasis. If the patient appears to have heat symptoms, such as irritability, fullness, dry mouth, and thirst, but the pulse shows no heat signs, this is "Yin Fu" (hidden Yin pathogen), indicating Blood Stasis. It should be treated with purgation.
These two clauses differentiate manifestations of Blood Stasis. Chest fullness results from Qi stagnation due to blood stasis. Withered lips and blue tongue indicate failure of blood to nourish. Dry mouth desiring to rinse indicates Qi dryness due to blood coagulation. No chills or fever indicate the disease is not in the exterior. A slightly large and slow pulse indicates blood accumulation in the meridians causing sluggish flow. Abdominal distension claimed by the patient despite no physical distension indicates internal obstruction rather than external form, confirming blood accumulation in the Yin rather than Qi congestion in the Yang. Hence, it is Blood Stasis.
"Appearing to have heat" refers to the aforementioned irritability, fullness, dry mouth, and thirst. A pulse without heat signs (not rapid or large) combined with heat symptoms indicates that blood stasis prevents proper circulation and nourishment. This is called "Yin Fu," meaning Yin pathogens are knotted and hidden internally. Therefore, purgation is indicated.
For cases caused by Fire Pathogens, Guizhi Qu Shaoyao Jia Shu Xin Mu Li Long Gu Jiuni Decoction (Cinnamon Twig Decoction minus Peony plus Chinese Tatararoot, Oyster Shell, and Dragon Bone to Rescue Deviation) is the primary formula.
This clause mentions only "Fire Pathogen" without detailing symptoms. Consulting the *Shanghan Lun*: In Taiyang disease, if a physician uses fire methods to force sweating, leading to Yang collapse, the patient will likely experience fright, mania, restlessness, and inability to sit or lie still. Also, if Taiyang disease is treated with fire moxibustion without sweating, the patient will become irritable, and if unresolved, will likely bleed from the rectum. This clause by Zhang Zhongjing likely prepares for syndromes of fright, palpitations, and lower bleeding. Removing Sour Peony from Guizhi Tang and adding Acrid Shu Xin allows the fire and wind pathogens to scatter together without retention, expelling external pathogens outward. Dragon Bone and Oyster Shell converge floating Shen (Spirit) and Qi.
Guizhi Qu Shaoyao Jia Shu Xin Mu Li Long Gu Jiuni Decoction Formula
Guizhi (Cinnamon Twig, 3 liang, bark removed)
Gancao (Licorice Root, 2 liang, honey-fried)
Longgu (Dragon Bone, 4 liang)
Muli (Oyster Shell, 5 liang, cooked)
Shengjiang (Fresh Ginger, 3 liang)
Dazao (Jujube, 12 pieces)
Shuxin (Chinese Tatararoot, 3 liang, washed to remove fishy odor)
Grind all ingredients into powder. Boil in 12 sheng of water, first boiling Shuxin until reduced by 2 sheng. Add remaining herbs and boil to obtain 3 sheng. Strain and take 1 sheng warm.
For palpitations in the epigastrium, Banxia Mahuang Wan (Pinellia and Ephedra Pill) is the primary formula.
This treats conditions where Phlegm-Fluid inhibits Yang Qi. Banxia eliminates Phlegm-Fluid, and Mahuang releases Yang Qi. The brilliance lies in using pills for slow action. This ensures Mahuang's acrid-sweet nature does not overly disperse Jin-Ye (body fluids) but instead lifts Yang Qi; similarly, Banxia's bitter-acrid nature not only eliminates Phlegm-Fluid but also harmonizes and nourishes Middle Qi. Only Zhang Zhongjing, with his divine adaptability, could achieve this.
Banxia Mahuang Wan Formula
Banxia (Pinellia Tuber)
Mahuang (Ephedra Herb)
(Equal parts)
Grind the two ingredients into powder. Mix with refined honey to form pills the size of adzuki beans. Take 3 pills with water, three times daily.
For incessant hematemesis, Baiye Tang (Cunninghamia Branch Decoction) is the primary formula.
According to *Zhizhi Fang*: Blood flows freely when heated, so hemostatics often use cooling herbs. However, in cases of Qi deficiency with cold, where Yin and Yang fail to guard each other, and Ying Qi is deficient and scattered, blood may also flow recklessly. This explains the use of Ganjiang (Dried Ginger) and Aiye (Mugwort Leaf). Furthermore, since blood has already overflowed upward, its surging momentum cannot be controlled by warming herbs alone. Therefore, Baiye (Cunninghamia Branch) is used to suppress and direct it downward, and Matong (Horse Dung Juice) guides it down, allowing reckless blood to flow smoothly downward and stabilize.
Baiye Tang Formula
Baiye (Cunninghamia Branch)
Ganjiang (Dried Ginger, 3 liang each)
Ai (Mugwort Leaf, 3 bundles)
Boil the three ingredients in 5 sheng of water, adding 1 sheng of Matong juice. Reduce to 1 sheng. Divide into two doses and take warm. Adding Ejiao (Donkey-Hide Gelatin, 3 liang) as in *Qianjin Fang* is also excellent.
For lower bleeding where stool precedes blood, this is "Yuan Xue" (Remote Bleeding). Huangtu Tang (Yellow Earth Decoction) is the primary formula.
Lower bleeding with stool preceding blood is caused by Spleen deficiency and Cold Qi, leading to a loss of the Spleen's controlling function over blood. Since the Spleen is distant from the anus, it is called Remote Bleeding. Huangtu (Stove Earth) is warm and drying, entering the Spleen; combined with Baizhu (Atractylodes Macrocephala) and Fuzi (Prepared Aconite Root), it restores vigorous Qi. Ejiao (Donkey-Hide Gelatin), Shengdihuang (Rehmannia Root), and Gancao (Licorice Root) replenish depleted blood. To prevent the acrid-warm herbs from becoming harmful to blood disorders, Huangqin (Scutellaria Root) is added for its bitter-cold property to check excessiveness. This is like a disciplined army.
Huangtu Tang Formula
Gancao (Licorice Root)
Shengdihuang (Rehmannia Root, Prepared)
Baizhu (Atractylodes Macrocephala)
Fuzi (Prepared Aconite Root)
Ejiao (Donkey-Hide Gelatin)
Huangqin (Scutellaria Root)
(Each 3 liang)
Zaotuhuangtu (Stove Earth, 8 liang)
Boil the seven ingredients in 8 sheng of water to obtain 3 sheng. Divide into two doses and take warm.
For lower bleeding where blood precedes stool, this is "Jin Xue" (Close Bleeding). Chidou Danggui San (Adzuki Bean and Angelica Powder) is the primary formula. (See Huo Huo Disease chapter for formula).
Lower bleeding with blood preceding stool is caused by Damp-Heat injuring the Large Intestine, causing blood to seep downward. Since the Large Intestine is close to the anus, it is called Close Bleeding. Chixiaodou (Adzuki Bean) promotes water metabolism, resolves dampness, and clears heat toxicity. Danggui (Angelica Sinensis) guides blood back to its vessels and lifts Qi sunk within the blood.
For insufficient Heart Qi manifesting as hematemesis and epistaxis, Xiexin Tang (Drain the Heart Decoction) is the primary formula.
"Insufficient Heart Qi" refers to insufficiency of Yin Qi in the Heart. When Yin is insufficient, Yang becomes dominant. Blood is forced by heat to flow recklessly. Dahuang (Rhubarb Root), Huanglian (Coptis Rhizome), and Huangqin (Scutellaria Root) drain Heart heat, allowing blood to settle. Kou Shi stated: If Heart Qi were solely deficient, there would be no vomiting or nosebleeding. Here, evil heat exploits the deficiency to lodge in the Heart, causing bleeding. Using bitter herbs to drain heat and "tonify" the Heart achieves two goals at once. This explanation is valid. *Jizhong Fang* uses Dahuang and Shengdihuang juice for epistaxis; its heat-draining and blood-cooling action is similar to Xiexin Tang.
Xiexin Tang Formula
Dahuang (Rhubarb Root, 2 liang)
Huanglian (Coptis Rhizome, 1 liang)
Huangqin (Scutellaria Root, 1 liang)
Boil the three ingredients in 3 sheng of water to obtain 1 sheng. Take in one dose.