客曰。真假之说。至矣精矣。吾何以辨其为假而识之耶。又何以识其为伤寒与肾虚而辨之耶。曰此未
可以易言也。将欲望而知之。是但可以神遇。而不可以目遇也。将欲闻而知之。是可以气听。而不可以心符
也。将欲问而知之。可以意会。而不可以言传也。将欲切而知之。得之心而应之手。巧则在其人。父不能
传之子也。若必欲言之。姑妄言乎。余辨之舌耳。凡有实热者。舌胎必燥而焦。甚则黑。假热者。舌虽有白
胎而必滑。口虽渴而不能饮水。饮水不过一二口。甚者少顷亦吐出。面虽赤而色必
娇嫩。身作躁而欲坐卧于泥水中。此为辨也。伤寒者。寒从下受之。女人多有此证。大小便闭。一剂即愈。此
暴病也。阴虚者。大小便俱利。吐痰必多。此阴虚火衰之极。不能以一二药愈。男女俱有之。纵使引得火归。
又须以参 补阳兼补阴。岁月调理。倘不节欲。终亦必亡而已。余所传如此。此不过糟粕耳。所望于
吾子者。得意而忘言。斯得之矣。
凡治血证。前后调理。须按三经用药。心主血。脾裹血。肝藏血。归脾汤一方。三经之方也。远志枣仁
补肝以生心火。茯神补心以生脾土。参 甘草补脾以固肺气。木香者。香先入脾。总欲使血归于脾。故曰归脾。
有郁怒伤脾思虑伤脾者尤宜。火旺者加山栀丹皮。火衰者加丹皮肉桂。又有八味丸。以培先天之根。治无余法矣。
薛立斋遇星士张东谷谈命时。出中庭。吐血一二口。云久有此证。遇劳即发。余意此劳伤肺气。其血必
散。视之果然。与补中益气汤。加门冬五味山药熟地茯神远志。服之而愈。翌早请见。云服四物黄连山栀之类。
血益多而倦益甚。得公一匕。吐血顿止。精神如故。何也。薛曰脾统血。肺主气。此劳伤脾肺。致血妄行。故用
前药。健脾肺之气。而嘘血归元耳。
一男子咳嗽吐血。热渴痰盛。盗汗遗精。用六味地黄料。加门冬五味治之愈。后因劳怒。忽吐紫血块。先
用花蕊石散。化其紫血。又用独参汤渐愈。后劳则咳血一二口。脾肺肾三脉。皆洪数。用归脾汤六味丸而全愈。
一童子年十四。发热吐血。余谓宜补中益气。以滋化源。不信。用寒凉降火愈甚。始谓余曰。童子未室。
何肾虚之有。参 用之奚为。余述丹溪云。肾主闭藏。肝主疏泄。二脏俱有相火。而其系上属于心。为物
所感。则易于动。心动则相火翕然而起。虽不交会。其精已暗耗。又褚氏精血篇云。男子精未满而御女。
以通其精。则五脏有不满之处。异日必有难状之疾。遂与补中益气六味地黄而瘥。
愚谓童子之证。须看先天父母之气。而母气为尤重。凡惊风痘疹。肾虚发热。俱以母气为主。如母有火
者。其子必有火。母脾虚者。子必多脾病。母火衰者。子必从幼有肾虚证。如齿迟语迟行迟囟门开大肾疳等
证。皆先天不足。从幼填补。亦有可复之天。不必如上所言暗泄。方有血证。客问曰。吐血衄血。同是上炎之
火。一出于口。一出于鼻。何也。
东垣云。衄血出于肺。从鼻中出也。呕血出于胃。吐出成碗成盆也。咯唾血者。出于肾。血如红缕。在
痰中唾中。咳咯而出也。痰涎血者。出于脾。涎唾中有少血散漫而出也。
东垣论虽如此。然肺不特衄血。亦能咳血唾血。不特胃呕血。肝亦呕血。盖肺主气。肝藏血。肝血不藏。
乱气自两胁中。逆而出之。然总之是肾水随相火炎上之血也。肾主水。水化液为痰为唾为血。肾脉上入肺。
循喉咙。挟舌本。其支者从肺出络心。注胸中。故病则俱病也。但衄血出于经。衄行清道。吐血出
于胃。吐行浊道。喉与咽二管不同也。盖经者走经之血。走而不守。随气而行。火气急。故随经直犯清道
而出于鼻。其不出于鼻者。则为咳咯。从肺窍而出于咽也。胃者守营之血。守而不走。存于胃中。胃气虚不能
摄血。故令人呕吐。从喉而出于口也。今人一见吐衄。便以犀角地黄为必用之药。然耶否耶。曰犀
角地黄乃是衄血之的方。若阴虚火动吐血与咳咯者。可以借用成功。若阳虚劳力及脾胃虚者。俱不宜。盖犀水
兽也。焚犀可以分水。可以通天。鼻衄之血。从任督而至巅顶。入鼻中。惟犀角能下入肾水。由肾脉而上引。
地黄滋阴之品。故为对证。今方书中所载云。如无犀角。以升麻代之。犀角升麻气味形性。迥
不相同。何以代之。曰此又有说焉。盖缘任冲二脉。附阳明胃经之脉。亦入鼻中。火郁于阳明而不得泄。因成
衄者。故升麻可代。升麻阳明药。非阳明经衄者。不可代。衄亦有阴虚火衰者。其血必点滴不成流。须用壮
火之剂。不可概用犀角。有伤寒病五六日。但头汗出。身无汗。剂颈而还。小便自利。渴饮水浆。此瘀
血证也。宜犀角地黄汤桃仁承气汤。看上下虚实。用犀角地黄汤治上。桃仁承气汤治中。抵当汤丸治下也。
有血从齿缝中。或牙龈中出。名曰齿衄。亦系阳明少阴二经之证。盖肾主骨。齿者骨之标。其龈则属胃
土。又上齿止而不动属土。下齿动而不止属水。凡阳明病者。口臭不可近。根肉腐烂。痛不可忍。血出或如
涌。而齿不动摇。其人必好饮。或多啖炙 肥甘。豢养所致。内服清胃汤。外敷石膏散。甚者服调
胃承气汤。下黑粪而愈。或有胸虚热者。以补中益气加丹皮黄连亦得。少阴病者。口不臭。但浮动。或脱落出
血。或缝中痛而出血。或不痛。此火乘水虚而出。服安肾丸而愈。余尝以水虚有火者。用六味加骨碎补。无火
者八味加骨碎补。随手而应。外以雄鼠骨散敷之。齿动复固。又有齿痛连脑者。此系少阴伤寒。用麻黄附子
细辛汤。不可不知。又小儿疳证。出血口臭肉烂者。芦荟丸主之。
有怒气伤肝。而成吐衄者。其人必唇青面青脉弦。须用柴胡栀子清肝散。
有郁气伤脾者。须用归脾汤。加丹皮山栀。推而广之。世人因郁而致血病者多。凡郁皆肝病也。木中
有火。郁甚则火不得舒。血不得藏而妄行。但郁之一字。不但怒为郁。忧为郁。怒与忧固其一也。若其人素
有阴虚火证。外为风寒暑湿所感。皮毛闭塞即为郁。郁则火不得泄。血随火而妄行。郁于经络。则从鼻
而出。郁于胃脘。则从吐而出。凡系郁者。其脉必涩。其人必恶
风恶寒。不知者便以为虚而温补之。误矣。须视其面色必滞。必喜呕。或口苦。或口酸。审有如是证。必当舒
散其郁为主。木郁则达之。火郁则发之是也。其方惟逍遥散为的药。外加丹皮茱连。随手而应。血止后。若
不用六味地黄以滋其阴。翌日必发。余于五郁论中。言之详矣。
有饮酒过多。伤胃而吐血。从吐后出者。以葛花解酲汤。加丹皮倍黄连。使之上下分消。酒病愈。血亦
愈矣。有过啖炙 辛热等物而得者。上焦壅热。胸腹满痛。血出紫黑成块者。可用桃
仁承气汤。从大便导之。此釜底抽薪之法。
以上二证。虽属内伤。犹作有余之证。可用前法。
有妇人发热。经水适来适止。谵语昼轻夜重。如见鬼。小便利或不禁。此名热入血室。须用小柴胡汤。
加红花生地丹皮官桂归尾破血之剂。详见伤寒门。
有坠车坠马。跌扑损折。失血瘀蓄肿痛发热者。先以桃仁大黄川芎当归赤芍丹皮红花。行血破瘀之剂。折
其锐气。而后区别治之以和血消毒之药。张子和尝以通经散神 丸。大下数十行。病去如扫。不致有癃残跛
之患。又尝以此法治杖疮痛肿发热绝者。十余行而肿退热消。真不虚语也。
有产后恶露未尽。儿枕作痛者。须用桃仁红花当归川芎赤芍丹皮等。行血破血之药。加姜桂辛热。以行其
瘀。又有虚痛无瘀血者。当另行温补。不可概用破血之剂。且以今时之弊言之。夫人之吐衄。非阴虚则阳虚。
余备言矣。今人一见血证。以为阴虚者。血虚也。舍四物何法乎。火动者热也。非芩连栀柏何药乎。
咳嗽者火也非紫菀百部知母贝母何物乎。丹溪节斋。俱有明训。岂能外之。谁知阴虚之证。大抵上热下寒
者多。始而以寒凉进之。上焦非不爽快。医者病者无不以为道在是矣。稍久则食减。
又以为食不化。加神曲山楂。再久而热愈盛。痰嗽愈多。烦躁愈
甚。又以药力欠到。寒凉增进。而泄泻腹胀之证作矣。乃以枳壳大腹皮宽中快气之品进矣。至此不毙。将待何
时。是故咳嗽吐血。时时发热。未必成瘵也。服四物黄柏知母之类不已。则瘵成矣。胸满膨胀。悒悒不快。未
必成胀也。服山楂神曲之药不已。则胀成矣。面浮 肿。小便秘涩。未必成水也。服渗利之药不已。则水成
矣。气滞膈塞。未必成噎也。服青皮枳壳宽快之药不已。则噎成矣。成则不可复药及阽于危。乃曰病犯条款。
虽对证之药。无可奈何也。
客人问道：“真假辨别的理论，已经非常精妙了。我该如何辨别它是假象并识别出来呢？又该如何区分是伤寒还是肾虚呢？”
我说：“这不能轻易说出口。想要通过观察来了解它，只能用心去神会，而不能仅靠眼睛看；想要通过听声音来了解它，只能通过气息去感知，而不能仅凭心思去揣测；想要通过询问来了解它，只能意会，而不能完全用言语传达；想要通过切脉来了解它，需要心领神会、手到病除，技巧全在医者个人手中，父亲无法传授给儿子。如果一定要我说，我就姑且说说吧。我主要通过舌象来辨别。凡是实热的病人，舌苔一定干燥焦黑，严重时甚至变黑；假热的病人，舌上虽然有白苔，但一定是滑润的，口中虽然觉得渴，却不能喝水，即使喝水也只喝一两口，严重的过一会儿也会吐出来。面部虽然发红，但颜色一定娇嫩；身体烦躁，却想坐在泥水中。这就是辨别的方法。
伤寒病，寒气从下部侵入，女性多见此证，大小便闭塞，服用一剂药即可痊愈。这是暴发的疾病。阴虚证，大小便都通畅，呕吐痰涎很多，这是阴虚火衰到了极点，不能靠一两副药治愈，男女都有这种情况。即使引导虚火归元，也必须用人参等药补阳兼补阴，经过长时间的调理。如果不节制欲望，最终必然死亡。我所传授的只是这些，这不过是糟粕罢了。我希望你能得意忘言，这样才能真正掌握精髓。
大凡治疗血证，前后的调理，必须按照心、脾、肝三经来用药。心主血，脾裹血，肝藏血。归脾汤是三经同治的方子。远志、酸枣仁补肝以生心火，茯神补心以生脾土，人参、甘草补脾以固肺气。木香的香气先入脾，总体目的是使血液归于脾，所以叫归脾汤。对于因郁怒伤脾或思虑伤脾的人尤其适宜。火旺的加山栀、丹皮；火衰的加丹皮、肉桂。还有八味丸，用来培补先天之本，治疗血证的方法就没有遗漏了。
薛立斋遇到星士张东谷谈论命运时，走出庭院，吐血一两口，说长久以来有这个病，劳累就会发作。我心想这是劳损伤了肺气，血液必然散乱。查看果然如此，给予补中益气汤，加麦冬、五味子、山药、熟地、茯神、远志，服用后痊愈。第二天早上请见，说之前服用了四物汤、黄连、山栀之类的药，血反而更多，疲倦更甚，得到您的一剂药，吐血立刻停止，精神恢复如常。为什么呢？薛立斋说：脾统血，肺主气。这是劳损伤了脾肺，导致血液妄行，所以用前面的药，健脾肺之气，使血液回归本源。
有一个男子咳嗽吐血，发热口渴，痰多，盗汗遗精。我用六味地黄丸料，加麦冬、五味子治疗，痊愈了。后来因为劳累和愤怒，突然吐出紫黑色的血块。先用花蕊石散化解紫血，又用独参汤逐渐治愈。之后劳累就咳血一两口，脾、肺、肾三部脉象都洪数。用归脾汤合六味地黄丸而完全康复。
有一个十四岁的童子，发热吐血。我认为应该用补中益气汤来滋养化源。他不相信，用寒凉降火的药，病情反而加重。才对我说：“童子没有娶妻，怎么会有肾虚？为什么要用人参、黄芪？”我引述朱丹溪的话说：肾主闭藏，肝主疏泄，两脏都有相火，其系上属于心。被外物所感，就容易动。心动则相火随之而起，虽然没有性交，精气也已经暗中消耗。又引用褚氏《精血篇》说：男子精气未满而御女，强行通精，则五脏有不满之处，日后必有难以名状的疾病。于是给予补中益气汤和六味地黄丸，病就好了。
我认为童子的病症，必须看先天父母的气，其中母亲的气尤为重要。凡是惊风、痘疹、肾虚发热，都以母气为主。如果母亲有火，孩子一定有火；母亲脾虚，孩子一定多有脾病；母亲火衰，孩子从小就有肾虚证，如牙齿迟长、说话迟、行走迟、囟门宽大、肾疳等症状，都是先天不足，从小填补，也有可以恢复天年的可能，不必像上面所说的那样暗中耗泄，才会形成血证。
客人问：“吐血和衄血（鼻出血），同样是上炎之火，一个从口出，一个从鼻出，为什么呢？”
李东垣说：衄血出于肺，从鼻中出；呕血出于胃，吐出成碗成盆；咯唾血者，出于肾，血如红线，在痰和唾液中咳咯而出；痰涎血者，出于脾，涎唾中有少量血液散漫而出。
李东垣的理论虽然如此，然而肺不仅引起衄血，也能引起咳血、唾血；不仅胃引起呕血，肝也能引起呕血。大概是因为肺主气，肝藏血。肝血不藏，乱气自然从两胁中逆乱而出。总之，这都是肾水随着相火上炎而出的血。肾主水，水化为液成为痰、唾、血。肾脉上行进入肺，沿着喉咙，夹持舌根，其支脉从肺出来联络心，注入胸中。所以生病时都会牵连发病。但是衄血出于经络，衄血走清道；吐血出于胃，吐血走浊道。喉与咽两个管道不同。所谓经，是指运行于经络中的血，走而不守，随气而行。火气急迫，所以顺着经络直犯清道而从鼻出。不从鼻出的，就成为咳咯，从肺窍而出于咽。胃中的血是守护营分的血，守而不走，存于胃中。胃气虚弱不能摄血，所以让人呕吐，从喉而出于口。现在的人一见吐血衄血，就用犀角地黄汤作为必用之药，是这样吗？我说：犀角地黄汤确实是治疗衄血的对症良方。如果是阴虚火动引起的吐血和咳咯，可以借用它取得成功。如果是阳虚劳力及脾胃虚弱的，都不适宜。因为犀角是水兽，焚烧犀角可以分水，可以通天。鼻衄的血，从任督二脉到达头顶，进入鼻中，只有犀角能下入肾水，由肾脉而上引。地黄是滋阴的药物，所以是对证的。现在方书中记载说，如果没有犀角，可以用升麻代替。犀角和升麻的气味、形态、性质完全不同，怎么能代替呢？我说：这又有说法。大概因为任冲二脉，依附于阳明胃经的脉，也进入鼻中。火郁结在阳明而不得发泄，因此成为衄血，所以升麻可以代替。升麻是阳明经的药，如果不是阳明经的衄血，不可以代替。衄血也有阴虚火衰的，其血必定点滴不成流，必须用壮火之剂，不能一概用犀角。有伤寒病五六天，只有头部出汗，身上无汗，汗止于颈部，小便自利，口渴想喝水浆，这是瘀血证。宜用犀角地黄汤、桃仁承气汤。根据上下虚实情况，用犀角地黄汤治上部，桃仁承气汤治中部，抵当汤丸治下部。
有血从齿缝中或牙龈中流出，名叫齿衄，也是阳明、少阴二经的病证。大概肾主骨，牙齿是骨的标志，牙龈则属胃土。上齿静止不动属土，下齿活动不止属水。凡是阳明病的，口臭不可靠近，牙根肉腐烂，疼痛难忍，血出如涌，牙齿不松动。这种人一定喜欢喝酒，或多吃烤炙肥甘厚味，是喂养过度所致。内服清胃汤，外敷石膏散。严重的服调胃承气汤，排出黑粪而愈。如果有胸中虚热的，用补中益气汤加丹皮、黄连也可以。少阴病的，口不臭，但牙齿浮动，或脱落出血，或缝中痛而出血，或不痛。这是火乘水虚而出，服安肾丸而愈。我曾经对水虚有火的，用六味地黄丸加骨碎补；无火的，用八味地黄丸加骨碎补，随手见效。外用雄鼠骨散敷之，牙齿松动重新稳固。又有齿痛连脑的，这是少阴伤寒，用麻黄附子细辛汤，不可不知道。还有小儿疳证，出血口臭肉烂的，用芦荟丸主治。
有怒气伤肝，而成吐衄的，其人一定唇青面青脉弦，须用柴胡栀子清肝散。
有郁气伤脾的，须用归脾汤，加丹皮、山栀。推而广之，世人因郁而导致血病的很多。凡是郁都是肝病。木中有火，郁甚则火不得舒展，血不得藏而妄行。但“郁”这一个字，不只是怒为郁，忧也为郁，怒与忧固然是一方面。如果其人素来有阴虚火证，外受风寒暑湿侵袭，皮毛闭塞即为郁。郁则火不得发泄，血随火而妄行。郁于经络，则从鼻而出；郁于胃脘，则从吐而出。凡是属于郁的，其脉一定涩，其人一定恶风恶寒。不懂的人便以为是虚证而用温补，这就错了。必须看他的面色一定晦滞，一定喜呕，或口苦，或口酸。仔细审察有这些症状，必须当以舒散其郁为主。木郁则达之，火郁则发之。其方唯有逍遥散是真正的对症良药，外加丹皮、吴茱萸、黄连，随手见效。血止后，若不用六味地黄丸滋其阴，第二天必定复发。我在《五郁论》中讲得很详细了。
有饮酒过多，伤胃而吐血，从吐后出的，用葛花解酲汤，加丹皮、倍量黄连，使之上下分消。酒病好了，血也就好了。有过食烤炙辛辣热物而得的，上焦壅热，胸腹满痛，血出紫黑成块的，可用桃仁承气汤，从大便导下。这是釜底抽薪的方法。
以上两种证候，虽然属于内伤，还当作有余（实证）的证候处理，可以用前面的方法。
有妇人发热，月经刚来或刚停，谵语白天轻晚上重，像看见鬼一样，小便通利或不禁，这叫热入血室。须用小柴胡汤，加红花、生地、丹皮、官桂、归尾等破血之剂。详见伤寒门。
有坠车坠马，跌扑损伤骨折，失血瘀蓄肿痛发热的，先用桃仁、大黄、川芎、当归、赤芍、丹皮、红花等行血破瘀之剂，挫其锐气，然后区别治疗，用和血消毒的药。张子和曾用通经散、神祐丸，大泻数十次，病去如扫，不致有癃残跛脚的祸患。又曾用此法治杖疮痛肿发热将死的，十余次腹泻后肿退热消，真是不虚传啊。
有产后恶露未尽，儿枕作痛的，须用桃仁、红花、当归、川芎、赤芍、丹皮等行血破血之药，加姜、桂等辛热药，以行其瘀。又有虚痛无瘀血的，应当另行温补，不可一概用破血之剂。况且谈谈当今的弊端。人的吐血衄血，不是阴虚就是阳虚，我已经详细说明了。现在的人一见血证，就认为是阴虚，血虚嘛，除了四物汤还有什么办法呢？火动就是热，不是黄芩、黄连、山栀、黄柏是什么药呢？咳嗽就是火，不是紫菀、百部、知母、贝母是什么东西呢？朱丹溪、戴元礼（节斋）都有明确的教导，怎么能违背呢？谁知道阴虚的证候，大抵上热下寒的多。开始用寒凉药进服，上焦虽然不是不爽快，医生和病人无不认为道理就在这里。稍久则食欲减退，又以为是食不消化，加神曲、山楂。再久则热更盛，痰嗽更多，烦躁更甚，又以为药力不够，增加寒凉药，于是泄泻腹胀的证候出现了，乃用枳壳、大腹皮等宽中快气的药进服。到了这个时候不死，还要等到什么时候？所以咳嗽吐血，时时发热，未必成痨瘵。服四物汤、黄柏、知母之类不停止，则痨瘵形成了。胸满膨胀，郁郁不快，未必成胀满。服山楂、神曲的药不停止，则胀满形成了。面浮肿，小便便秘涩，未必成水肿。服渗利药不停止，则水肿形成了。气滞膈塞，未必成噎膈。服青皮、枳壳等宽快药不停止，则噎膈形成了。一旦形成，就无法用药，濒临危险，却说病犯了条款，即使是对症的药，也无能为力了。
Guest said, "The theory of distinguishing true from false is extremely refined. How can I distinguish the false and identify it? And how can I differentiate between cold damage (Shanghan) and kidney deficiency?"
I replied, "This cannot be spoken lightly. To desire to know through observation, one can only encounter it with the spirit (Shen), not merely with the eyes. To desire to know through listening, one can only listen with Qi, not merely with the mind. To desire to know through inquiry, one can only comprehend with intention, not merely transmit with words. To desire to know through pulse diagnosis, it must be understood in the heart and responded to by the hand; skill lies within the individual, a father cannot transmit it to his son. If you insist on my speaking, I will speak tentatively. I distinguish primarily through the tongue. For those with excess heat, the tongue coating must be dry and scorched, even turning black in severe cases. For those with false heat, although there is a white coating, it must be slippery; although the mouth feels thirsty, they cannot drink water, or if they do, only one or two sips, and in severe cases, they vomit it up shortly after. Although the face may appear red, the color must be delicate and tender. The body feels restless, yet they wish to sit or lie in mud or water. This is the method of differentiation.
Cold damage (Shanghan): Cold enters from below. This condition is common in women. With constipation of both stool and urine, one dose brings recovery. This is an acute illness. Kidney Yin deficiency: Both stool and urine are free. Vomiting of phlegm is profuse. This indicates extreme deficiency of Yin fire failing to function properly. It cannot be cured in one or two doses. It occurs in both men and women. Even if the floating fire is guided back to its source, one must use Ren Shen (Ginseng Root) to tonify Yang while simultaneously tonifying Yin, requiring months or years of regulation. If sexual desires are not restrained, death is inevitable. What I have transmitted is but dregs. What I hope for you is to grasp the meaning and forget the words; then you will truly understand.
In treating blood disorders, regulation before and after must follow the meridians of the Heart, Spleen, and Liver. The Heart governs Blood, the Spleen envelops Blood, and the Liver stores Blood. Gui Pi Tang (Restore the Spleen Decoction) is a formula for these three meridians. Yuan Zhi (Polygala Root) and Suan Zao Ren (Ziziphus Seed) tonify the Liver to generate Heart Fire; Fu Shen (Poria with Hostwood) tonifies the Heart to generate Spleen Earth; Ren Shen (Ginseng Root) and Gan Cao (Licorice Root) tonify the Spleen to secure Lung Qi. Mu Xiang (Aucklandia Root) has an aroma that first enters the Spleen; the overall aim is to return Blood to the Spleen, hence the name 'Gui Pi' (Restore the Spleen). It is especially suitable for cases where anger injures the Spleen or overthinking injures the Spleen. If Fire is excessive, add Zhi Zi (Gardenia Fruit) and Mu Dan Pi (Moutan Cortex); if Fire is deficient, add Mu Dan Pi (Moutan Cortex) and Rou Gui (Cinnamon Bark). There is also Ba Wei Wan (Eight-Ingredient Pill) to cultivate the root of the congenital foundation. Thus, the treatment of blood disorders leaves no methods unexplored.
Xue Li Zhai once met the astrologer Zhang Donggu discussing fate. Walking out into the courtyard, he vomited one or two mouthfuls of blood, saying he had long suffered from this condition, which flared up upon exertion. I reasoned that this was Lung Qi injured by fatigue, causing Blood to scatter. Upon examination, this was indeed the case. I prescribed Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) plus Mai Dong (Ophiopogon Tuber), Wu Wei Zi (Schisandra Berry), Shan Yao (Dioscorea Rhizome), Shu Di Huang (Rehmannia Root), Fu Shen (Poria with Hostwood), and Yuan Zhi (Polygala Root). After taking it, he recovered. The next morning, he requested an audience, stating that previous treatments with Si Wu Tang (Four Substances Decoction), Huang Lian (Coptis Rhizome), and Zhi Zi (Gardenia Fruit) caused more bleeding and greater fatigue. With your single dose, the bleeding stopped instantly, and his spirit returned to normal. Why? Xue said: The Spleen controls Blood, and the Lung governs Qi. Fatigue injured the Spleen and Lung, causing Blood to move recklessly. Therefore, I used the aforementioned herbs to tonify Spleen and Lung Qi, exhaling Blood back to its origin.
A man suffered from coughing and vomiting blood, fever, thirst, profuse phlegm, night sweats, and spermatorrhea. I treated him with Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) modified with Mai Dong (Ophiopogon Tuber) and Wu Wei Zi (Schisandra Berry), and he recovered. Later, due to fatigue and anger, he suddenly vomited clots of purple blood. First, Hua Rui Shi San (Flower Ochre Stone Powder) was used to resolve the purple blood, followed by Du Shen Tang (Single Ginseng Decoction) for gradual recovery. Afterwards, exertion triggered one or two mouthfuls of hemoptysis. Pulses at the Spleen, Lung, and Kidney positions were all surging and rapid. Gui Pi Tang (Restore the Spleen Decoction) combined with Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) led to full recovery.
A fourteen-year-old boy presented with fever and hematemesis. I advised using Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) to nourish the source of transformation. He did not believe me and used cooling herbs to subdue Fire, which worsened his condition. He then told me, "The boy is unmarried, how could he have Kidney deficiency? Why use Ren Shen (Ginseng Root) and Huang Qi (Astragalus Root)?" I quoted Zhu Dan Xi, saying: The Kidney governs closure and storage; the Liver governs dispersion and excretion. Both viscera contain Ministerial Fire, whose connection ascends to the Heart. When stimulated by external objects, it moves easily. When the Heart moves, Ministerial Fire rises vigorously. Even without intercourse, Essence is secretly consumed. Furthermore, Chu Shi's *Jing Xue Pian* states: If a male engages in intercourse before his Essence is full, forcing the release of Essence, the Five Viscera will have areas of insufficiency, leading to difficult-to-describe illnesses later. Thus, I prescribed Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) and Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia), and he healed.
I believe that for boys' conditions, one must examine the congenital Qi of the parents, with the Mother's Qi being particularly important. Conditions such as convulsions, smallpox, and Kidney deficiency fever are primarily governed by the Mother's Qi. If the mother has Fire, the child will surely have Fire; if the mother's Spleen is deficient, the child will likely suffer many Spleen diseases; if the mother's Fire is weak, the child will have Kidney deficiency symptoms from childhood, such as delayed tooth eruption, speech, walking, wide fontanelle, and Kidney rickets. These are all signs of congenital insufficiency. Filling deficiencies from childhood can restore natural lifespan, avoiding the secret leakage mentioned above that leads to blood disorders.
The guest asked: "Hematemesis and epistaxis are both caused by Fire flaming upward. One exits from the mouth, the other from the nose. Why?"
Li Dong Yuan said: Epistaxis originates from the Lung, exiting from the nose. Hematemesis originates from the Stomach, vomited in bowlfuls or basinfuls. Spitting blood originates from the Kidney; the blood appears like red threads within phlegm and saliva, coughed up. Saliva mixed with blood originates from the Spleen; small amounts of blood scatter diffusely within saliva.
Although Li Dong Yuan's theory holds, the Lung causes not only epistaxis but also hemoptysis and spitting blood. The Stomach causes not only hematemesis but also the Liver can cause vomiting of blood. Generally, the Lung governs Qi, and the Liver stores Blood. When Liver Blood fails to store, chaotic Qi reverses from the hypochondrium and exits. Ultimately, this is Blood rising with Ministerial Fire following Kidney Water. The Kidney governs Water; Water transforms into fluids, becoming phlegm, saliva, and blood. The Kidney meridian enters the Lung, follows the throat, and夹ps the base of the tongue. Its branch emerges from the Lung, connects with the Heart, and pours into the chest. Thus, when diseased, they affect each other. However, epistaxis comes from the meridians, traveling the clear pathways; hematemesis comes from the Stomach, traveling the turbid pathways. The larynx and pharynx are different tubes. Meridional blood travels and does not stay, moving with Qi. Fire is urgent, so it attacks the clear pathway directly along the meridian and exits from the nose. If it does not exit from the nose, it becomes coughing/spitting, exiting from the Lung orifice into the pharynx. Stomach blood guards Ying (Nutritive) Blood, staying and not traveling, stored in the Stomach. Stomach Qi deficiency fails to control Blood, causing vomiting from the throat into the mouth.
Nowadays, upon seeing hematemesis or epistaxis, people immediately consider Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) as essential. Is this correct? I say: Xi Jiao Di Huang Tang is indeed the specific formula for epistaxis. For hematemesis and hemoptysis caused by Yin deficiency and Fire agitation, it can be borrowed successfully. However, for Yang deficiency due to fatigue/labor and Spleen/Stomach deficiency, it is unsuitable. Xi Jiao (Rhinoceros Horn) is from a water animal; burning rhino horn can divide water and connect to heaven. Epistaxis blood travels from the Ren and Du meridians to the vertex, entering the nose. Only Xi Jiao can descend into Kidney Water and ascend via the Kidney meridian. Di Huang (Rehmannia Root) is a Yin-nourishing agent, making them a matched pair. Current formularies state that if Xi Jiao is unavailable, Sheng Ma (Cimicifuga Rhizome) can substitute. But Xi Jiao and Sheng Ma differ completely in odor, shape, and nature. How can they substitute? I say: There is another explanation. The Ren and Chong meridians attach to the Stomach Meridian of Foot-Yangming, which also enters the nose. If Fire stagnates in Yangming and cannot vent, epistaxis results. Thus, Sheng Ma can substitute. Sheng Ma is a Yangming herb; it should not substitute for non-Yangming epistaxis. Epistaxis can also result from Yin deficiency and Fire decline, where blood drips drop by drop without forming a stream. In such cases, strong Fire-tonifying agents are needed, and Xi Jiao should not be used generally.
For cold damage lasting five or six days, with sweating only on the head, no sweat on the body, stopping at the neck, free urination, and thirst for drinks, this is a Blood stasis syndrome. Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) and Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction) are appropriate. Based on upper/middle/lower deficiency or excess, use Xi Jiao Di Huang Tang for the upper, Tao Ren Cheng Qi Tang for the middle, and Di Dang Tang/Wan (Breakthrough Decoction/Pill) for the lower.
Blood flowing from gum fissures or gums is called dental epistaxis, involving the Yangming and Shaoyin meridians. The Kidney governs bones; teeth are the markers of bones. Gums belong to Stomach Earth. Upper teeth are static and belong to Earth; lower teeth move and belong to Water. Yangming disease presents with foul breath intolerable to others, rotting gum flesh, unbearable pain, and gushing blood, but teeth remain firm. Such patients love alcohol or consume excessive roasted/fatty/sweet foods, resulting from pampering. Internal treatment uses Qing Wei Tang (Clear Stomach Decoction); external application uses Shi Gao San (Gypsum Powder). Severe cases use Tiao Wei Cheng Qi Tang (Regulate the Waist Magnolia Bark Decoction) to pass black stools and heal. For chest deficiency heat, Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) plus Mu Dan Pi (Moutan Cortex) and Huang Lian (Coptis Rhizome) works. Shaoyin disease presents with no foul breath, but loose or falling teeth, bleeding from fissures or painless bleeding. This is Fire exploiting Water deficiency. An Shen Wan (Calming the Kidney Pill) heals it. I often treat Water deficiency with Fire using Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) plus Gu Sui Bu (Drynaria Rhizome), and without Fire using Ba Wei Di Huang Wan (Eight-Ingredient Pill with Rehmannia) plus Gu Sui Bu (Drynaria Rhizome), achieving immediate results. Externally, Xiong Shu Gu San (Male Rat Bone Powder) is applied to stabilize loose teeth. Toothache radiating to the brain indicates Shaoyin cold damage, treated with Ma Huang Fu Zi Xi Xin Tang (Ephedra, Aconite, and Asarum Decoction). Pediatric rickets with bleeding, foul breath, and rotting flesh is treated with Lu Hui Wan (Aloe Pill).
Anger injuring the Liver causing hematemesis/epistaxis presents with blue lips/face and wiry pulses. Chai Hu Zhi Zi Qing Gan San (Bupleurum and Gardenia Liver-Clearing Powder) is required.
Stagnation injuring the Spleen requires Gui Pi Tang (Restore the Spleen Decoction) plus Mu Dan Pi (Moutan Cortex) and Zhi Zi (Gardenia Fruit). Expanding on this, many people suffer blood disorders due to stagnation. All stagnation involves the Liver. Wood contains Fire; severe stagnation prevents Fire from dispersing and Blood from storing, causing reckless movement. 'Stagnation' includes not only anger but also sorrow. Anger and sorrow are aspects of it. If one inherently has Yin deficiency and Fire, and is affected by Wind-Cold-Damp-Heat, closing the skin pores creates stagnation. Stagnation prevents Fire from venting, and Blood moves recklessly with Fire. Stagnation in meridians causes nasal bleeding; stagnation in the stomach cavity causes vomiting. Stagnation syndromes always present with choppy pulses and aversion to wind/cold. Ignorant practitioners mistake this for deficiency and use warming tonification, which is wrong. One must observe dull complexion, desire to vomit, bitter taste, or sour taste. If these signs exist, the primary treatment must be to disperse stagnation. 'For Wood stagnation, extend it; for Fire stagnation, vent it.' Xiao Yao San (Wandering Free Powder) is the precise formula, added with Mu Dan Pi (Moutan Cortex), Zhu Yu (Evodia Fruit), and Huang Lian (Coptis Rhizome), yielding immediate results. After bleeding stops, if Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) is not used to nourish Yin, recurrence is certain the next day. I discussed this in detail in *Treatise on Five Stagnations*.
Excessive drinking injuring the Stomach causing hematemesis post-vomiting is treated with Ge Hua Jie Cheng Tang (Kudzu Flower Relieving Intoxication Decoction) plus Mu Dan Pi (Moutan Cortex) and doubled Huang Lian (Coptis Rhizome) to drain downward and upward. When the wine disease heals, the bleeding stops. Overconsumption of roasted/spicy/hot foods causing upper Jiao heat congestion, chest/abdominal fullness/pain, and purple-black bloody clots is treated with Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction) to guide out via bowels. This is the method of removing firewood from under the cauldron.
These two cases, though internal injury, are treated as excess syndromes using the above methods.
Women with fever, menstruation just starting or ending, delirium lighter by day and heavier by night, seeing ghosts, and frequent/incontinent urination, are diagnosed with Heat Entering the Blood Chamber. Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Hong Hua (Safflower), Sheng Di Huang (Rehmannia Root), Mu Dan Pi (Moutan Cortex), Guan Gui (Cinnamon Twig), and Gui Wei (Cinnamon Twig tip) for breaking blood stasis is required. See Shanghan Section.
Falls from horses/carts, bruises, fractures, blood loss, stasis accumulation, swelling, pain, and fever are first treated with Tao Ren (Peach Kernel), Da Huang (Rhubarb Root), Chuan Xiong (Ligusticum Rhizome), Dang Gui (Angelica Root), Chi Shao (Red Peony Root), Mu Dan Pi (Moutan Cortex), and Hong Hua (Safflower) to break stasis and reduce sharpness. Then, differentiate and treat with harmonizing blood and detoxifying herbs. Zhang Zi He used Tong Jing San (Unblock Meridians Powder) and Shen Yun Wan (Divine Elixir Pill) to purge dozens of times, removing disease like sweeping, preventing disability. He also used this for beating injuries with swelling, pain, fever, and near-death state; after ten-plus purges, swelling receded and fever vanished. Truly not empty talk.
Postpartum lochia未尽 (not fully discharged) causing Elizabeth pillow pain requires Tao Ren (Peach Kernel), Hong Hua (Safflower), Dang Gui (Angelica Root), Chuan Xiong (Ligusticum Rhizome), Chi Shao (Red Peony Root), and Mu Dan Pi (Moutan Cortex) to move and break blood, plus Jiang (Ginger) and Gui (Cinnamon) for warmth to move stasis. For deficiency pain without stasis, separate warming tonification is needed; do not indiscriminately use blood-breaking agents. Discussing current flaws: Hematemesis and epistaxis are either Yin deficiency or Yang deficiency, as I detailed. Now, seeing blood disorders, people assume Yin deficiency/blood deficiency, asking what else but Si Wu Tang (Four Substances Decoction)? Assuming Fire agitation is heat, asking what else but Huang Qin (Scutellaria Root), Huang Lian (Coptis Rhizome), Zhi Zi (Gardenia Fruit), and Huang Bai (Phellodendron Bark)? Assuming cough is Fire, asking what else but Zi Wan (Aster Root), Bai Bu (Stemona Root), Zhi Mu (Anemarrhena Rhizome), and Bei Mu (Fritillaria Bulb)? Zhu Dan Xi and Dai Yuan Li gave clear instructions; how can one deviate? Who knows that Yin deficiency syndromes mostly present with upper heat and lower cold? Initially, cooling herbs bring relief to the upper Jiao, and doctors/patients think this is the way. Soon, appetite decreases. They assume indigestion and add Shen Qu (Massa Fermentata) and Shan Zha (Hawthorn Fruit). Longer still, heat intensifies, phlegm-cough increases, irritability worsens. They assume insufficient dosage and increase cooling herbs, leading to diarrhea and abdominal distension. Then, Zhi Ke (Aurantii Fructus) and Da Fu Pi (Areca Pericarpium) for widening the middle and moving Qi are added. At this point, if not dead, when will one die? Thus, coughing/vomiting blood with intermittent fever does not necessarily become consumption (Zhai). Continuing Si Wu Tang (Four Substances Decoction), Huang Bai (Phellodendron Bark), and Zhi Mu (Anemarrhena Rhizome) creates consumption. Chest fullness/distension and depression do not necessarily become abdominal distension. Continuing Shan Zha (Hawthorn Fruit) and Shen Qu (Massa Fermentata) creates abdominal distension. Facial edema and scanty/difficult urination do not necessarily become edema (Shui). Continuing diuretic herbs create edema. Qi stagnation and chest blockage do not necessarily become dysphagia (Ye). Continuing Qing Pi (Aurantii Fructus Immaturus) and Zhi Ke (Aurantii Fructus) creating relief forms dysphagia. Once formed, medicine cannot cure, and danger approaches. Then they say the disease violates protocols, and even correct medicines are helpless.