火愈旺，此血虚有火者也。故血脱益气之法，但可施之于阴络所伤无火之血，难施之于阳络所伤，血去火旺，
劳瘵骨蒸，脉数内热之人。此等关头，从来差误。进思血之阴络、阳络，但当分别有火、无火，亦不必拘于上
溢、下脱。例如咳血、吐血，上溢之血也。若其人面色白，脉沉迟，此阳虚不能摄血也，古人有用血脱益气胃
药收功者。又阳明大肠有火而发肠红便血，此下脱之血也，古人有用黄柏、槐米以治者。总之，无论上溢下泄，
惟审其血去有火者，即为阳络所伤之血，但宜凉血养血；血去无火者，即为阴络所伤之血，乃可血脱益气也。
（《证因脉治》）
凡内伤暴吐血者，出如涌泉，口鼻皆流，须臾不救即死。急用人参一两为末，入飞罗面一钱，新汲水调服；
或用独参汤补气。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，以引火归元，正不宜用人参。及火既引归，人参又所不禁。
○凡失血后，必大发热，古方当归补血汤，用黄 一两，当归六钱，名曰补血，而以黄 为君，阳旺能生阴血
也。不明此理，见其大热、六脉洪大，误用发散，或以其象白虎汤证，误用白虎，立危。○凡治血证，前后调理，
须按三经用药，心生血，脾统血，肝藏血。归脾汤，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，总欲使血归于脾耳，有郁怒伤肝，思虑伤脾者尤宜。
（《赵氏医贯》）
仲景云∶误发少阴汗，动其经血者，下竭上厥为难治。不知下竭者，阴血竭于下也；上厥者，阴气逆于上
也。盖气之与血，两相维附，气不得血则散而无统；血不得气则凝而不流。故阴火动，而阴气不得不上奔，阴
气上奔，而阴血不得不从之上溢，血
既上溢，其随血之气散于胸中，不得复返本位，则上厥矣。阴气上逆，势必龙雷之火应之，血不尽竭不止也，
气不尽厥亦不止也。仲景所以断为难治者，非谓不治也。吾为大辟其扃，则以健脾中之阳气为第一义。健脾之
阳，一举有三善∶一者脾中之阳气旺，如天青日朗而龙雷之火潜伏也；一者脾中之阳气旺，而胸中窒塞之阴气
如太空不留纤翳也；一者脾中之阳气旺，而饮食运化精微，复生其下竭之血也。今方书妄引久嗽成劳，痰中带
血之阳证，不敢用健脾。增咳为例，不思咯血即有咳嗽，不过气逆上厥之咳，气下则不咳矣，况原无咳嗽者乎？
古方治龙雷之火，每用桂附引火归元之法，然施于暴血之证，可暂而不可常。盖已亏之血，恐不能制其悍，而
未动之血，恐不可滋其扰耳。此以崇土为先，土浓则浊阴不升，而血患自息。（喻嘉言）
失血一证，名目不一，三因之来路宜详。外因，阳邪为多。盖阴分先虚，易受天之风热燥火也。至于阴
邪为患，不过十中之一二耳。其治法，总以手三阴为要领，究其病在心营肺卫如何。内因，不出乎嗔怒郁勃之
激伤肝脏，劳形苦志而耗损心脾，及恣情纵欲以戕贼肾脏之真阴真阳。又当以足三阴为要领，再审其乘侮制化
如何。不内外因者，为饮食之偏好及努力坠堕之伤。治分脏腑经络之异。要知外因而起者，必有感候为先；内
因而起者，必有里证可据。大凡理肺卫者，用甘凉肃降，如沙参、麦冬、玉竹、川斛等类。治心营者，以轻清
滋养，如生地、元参、丹参、连翘等类。若风淫津涸，加以甘寒，如芦根、蔗汁之品；温淫火壮，参入苦寒，
如黄芩、石膏之品；暑逼气分，佐滑石、荷叶之开解；在营，与银花、犀角之清芳；秋令选纯甘以清燥；冬时
益清补以助藏。凡此为外因之大略也。所云阴邪为患者，旧有麻黄人参芍药汤，先生有桂枝加减法。内因伤损，
其治更繁，若嗔怒而动及肝阳，血随气逆者，用缪氏气为血帅法，如苏子、郁金、桑叶、丹皮、贝母之类也；
若郁勃日久而伤及肝阴，木火内燃阳
络者，用柔肝育阴法，如胶黄、生地、麦冬、白芍、甘草之类也，若烦劳不息而偏损心脾，气不摄血者，用甘
温培固法，如保元汤、归脾汤之类也；若纵欲而竭其肾真，或阳亢阴腾，或阴伤阳越者，有从阴从阳法，如青
铅、六味、肉桂、七味并加童便之类也；若精竭海空，气泛血涌者，急固真元，大补精血，如人参、枸杞、
熟地、紫石英、河车之类也。凡此为内因之大略也。至于不内外因，如烟辛泄肺，酒热戕胃，皆能助火动血，
法有治上治中，如苇茎汤、甘露饮、茅根、藕汁等剂；坠堕之伤，由血瘀而泛者，先宜导下，后宜通补；若努
力为患，属劳伤之根，阳动则络松血溢，治与虚损有间，滋阴补气，最忌凝涩，如当归建中汤、旋复花汤，取
其有循经入络之能。凡此为不内外因之大略也。但血之所主司者，乃心、肝、脾三脏；血之所生化者，莫如阳
明胃府。若胃有不和，当先治胃。仁斋云∶一切血证，经久不愈，每以胃药收功。有薄味调养胃阴者，如麦冬
汤及沙参、扁豆、茯神、石斛之类；有甘温创建中阳者，如人参建中汤及四君加减之类；有滋阴而不碍胃，甘
守津还者，如复脉汤加减之类。其余补土生金、镇肝益胃、补脾疏胃、安神理胃、肾胃相关等法，一遇胃不加
餐，不饥难运，每从此义见长，源源生化不息。（《临证指南》）
血溢、血泻诸蓄妄证，其始也，宜以行血破瘀之剂折其锐气，而后区别治之。或问失血复下，虚何以当？
答曰∶血既妄行，迷失故道，不去蓄利瘀，则以妄为常，曷以御之？且去者自去，生者自生，何虚之有？失血
家用下剂，盖施之于蓄妄之初；亡血虚家不可下，盖戒之于亡失之后。（滑伯仁）
凡蓄血有上、中、下三焦之别，血蓄上焦则善忘，宜犀角地黄汤；血蓄中焦则胸满身黄，漱水不欲咽，宜
桃仁承气汤；血蓄下焦则如狂，粪黑，小腹硬满，宜抵当汤丸。（王好古）
凡瘀血之证，今人但知闪挫则有瘀血，不知有因火载血上行，或吐或衄，病者自忍而蓄滞于中；或因医药
寒凉，而冰凝于内；
或因忧思过度，而致营血郁滞不行；或因怒伤，血逆上不得越下，不归经而留积于胸膈之间者。此皆瘀血之因
也。亦有跌扑闪挫，当时不觉，至于气衰之际，不时举发，医见吐血，妄为虚损，反用补药，气得其助，病虽
暂缓，气日愈衰，病日愈深，致成窠囊不治矣。○或问痰挟瘀血，何以验之？予曰∶子知有痰挟瘀血，不知有
瘀血挟痰。如先因伤血，血逆则气滞，气滞则生痰，与血相聚，名曰瘀血挟痰。患处按之则痛而不移，其证或
吐或衄，或大便黑，其脉轻举则滑重按则涩。治宜导痰破血，先用导痰汤，如苍术、香附、枳壳、白芥子开郁
导痰；次用芎、归、桃仁、红花、苏木、丹皮、莪术以破其血。若素有郁痰，后因血滞，与痰相聚，名曰痰挟
瘀血。患处则痛而少移，其证或为胀闷，或为寒热，其脉轻举则芤重按则滑。治宜先破其血，而后消痰，或消
痰破血二者兼治。医或误补及寒凉之剂，致病邪郁久而成窠囊。其窠囊之验，患处则痛而不能转侧，或肺膜间
偏热偏肿，咳喘痰臭，丹溪云∶痰挟瘀血，遂成窠囊者不治。正此谓也。（罗赤诚）
人有足上毛孔标血如线，流而不止即死，急以热醋三升，以足浸之；用人参一两，当归三两，穿山甲一
片炒末，参归汤调服。此证乃酒色不禁所致，方书不载，此方神效。脐中出血，亦是奇证，用六味汤加骨碎补
饮之即愈。齿血亦以此方投治。盖脐、齿俱是肾经之位，出血皆是肾火外越，六味汤滋其水，则火自息；骨碎
补专补骨中之漏也。○舌血如泉者，乃心火旺极，血不藏也。用六味汤加槐花。○七孔流血者，亦肾经虚热也。
用六味汤加麦冬、五味子、骨碎补。（《石室秘录》）
脉候
安卧脉盛，谓之脱血。（《素问》）
病患面无血色，无寒热，脉沉弦者，衄；浮弱，手按之绝者，下血；烦咳者，必吐血。（《金匮》）
脉得诸濡弱为亡血，芤为失血，涩为少血，牢为蓄血。沉、
弱、滑、小者生，实、大、弦、牢者死，关尺之脉弦细如循刀刃者死。（《证治汇补》）
诸见血，身热脉大者难治；身凉脉静者易治。（李东垣）
选案
刘公远性爱爆炙，又因心境不舒，淘饮烧酒，脾胃受伤，土中火发。始但盗汗怔忡，心包合并为眚，久
则水竭金衰，皮毛孔窍时出红汗，染衣皆赤，传为怪证。予谓∶此脾胃阴血与离宫火液相化，随气营运，达于
腠理，与吐血无异。与加减清心莲子饮，一剂止，三剂痊。○李康候久耽声色，头眩屡日，忽发丛中滴血不已，
医疑怪证，辞去。予谓∶此肾水枯竭，相火无制，合五脏虚火相煽，而炎于高巅，何怪之有？与六味汤加车前、
牛膝、血余，一剂而止。○一妇忿怒莫泄，干呕不已，口中努出血 ，自早至午长如碗大，遮满口外，呼吸不通，
诸医无措。予令煎黄连浓汁，井中浸冷蘸涂，饭顷小去大半，再入海石少许同煎，徐涂徐咽，消归无有。此心
火暴激之病也。易用消遥散加丹皮、茱萸、炒黄连立愈。（程华仲）
一妇脚肚作痒，爬之，毛孔内鲜血一线流出，直射四、五尺远，樽盛盈樽，碗盛盈碗，昏晕仆地。余
曰∶此血箭也。令将百草霜浓敷患处，以布缚住，与补中益气汤加黄连、生地、白芍灌下，人事渐苏，血止，
再剂而愈。（周禹载）
火势越旺，这是血虚伴有内火的表现。因此，“血脱益气”的治疗方法，只适用于阴络受损且无火的出血证，很难应用于阳络受损、血液流失而火势旺盛，以及患有劳瘵骨蒸（结核病引起的低热和消瘦）、脉象数疾且体内发热的患者。在这些关键的治疗节点上，历来容易出现差错。思考血的阴络与阳络损伤，应当分别辨别是否有火，也不必拘泥于是上部溢出还是下部漏失。例如咳血、吐血，属于上部溢出的血。如果患者面色苍白，脉象沉迟，这是阳虚不能统摄血液所致，古人有用补益胃气的药物取得疗效的案例。又如阳明大肠有火导致肠红便血，这属于下部漏失的血，古人有用黄柏、槐米治疗的案例。总之，无论上部溢出还是下部漏泄，只要审察到血液流失后伴有火热之象，就是阳络受损的出血，适宜采用凉血养血的方法；血液流失后没有火热之象的，就是阴络受损的出血，才可以采用血脱益气的方法。（出自《证因脉治》）
凡是内伤导致的突然大量吐血，血流如涌泉，口鼻同时流血，片刻不救治就会死亡。急需用人参一两研成细末，加入飞罗面一钱，用新汲水调服；或者使用独参汤来补气。为什么不加入止血药呢？因为有形之血不能迅速生成，无形之气应当紧急固护，气能生血。如果是真阴亏损，虚阳上浮，也会导致大吐血，这时必须用八味地黄汤（金匮肾气丸）来固护真阴，以引火归元，此时正不宜用人参。等到火气引导回归原位后，人参又可以使用了。○凡是失血之后，必然出现大发热，古方当归补血汤，使用黄芪一两，当归六钱，名为补血，却以黄芪为君药，是因为阳气旺盛能够化生阴血。不明白这个道理，看到患者大热、六脉洪大，误用发散解表药，或者因为其症状像白虎汤证，误用白虎汤，会导致病情立刻危重。○凡是治疗血证，前后的调理，必须按照心、脾、肝三经来用药，心生血，脾统血，肝藏血。归脾汤是调理这三经的方剂。远志、酸枣仁，补肝以生心火；茯神，补心以生脾土；人参、黄芪、甘草，补脾以固肺气；木香，香气先入脾，总体目的是使血液归于脾脏，对于因郁怒伤肝、思虑伤脾的患者尤其适宜。（出自《赵氏医贯》）
张仲景说：误发少阴经的汗，扰动其经血，会导致下竭上厥，难以治疗。不知道“下竭”是指阴血在下部枯竭；“上厥”是指阴气逆乱于上部。气和血，相互依附维系，气如果没有血则散漫而无统摄；血如果没有气则凝滞而不流动。所以阴火妄动，阴气不得不向上奔冲，阴气向上奔冲，阴血不得不随之向上溢出，血液既然向上溢出，随血而出的气散漫在胸中，不能返回本位，这就形成了上厥。阴气上逆，势必引起龙雷之火（相火）响应，血不枯竭不止，气不复原也不止。张仲景之所以判断为难治，并非说不治，而是我阐明了其中的机理，那么把健脾中的阳气作为第一要义。健脾的阳气，一举有三善：一是脾中的阳气旺盛，就像天空晴朗、太阳明亮，龙雷之火就会潜伏；二是脾中的阳气旺盛，胸中窒塞的阴气就像太空中不留一丝尘埃；三是脾中的阳气旺盛，饮食运化精微，重新生成下部枯竭的血液。现在的方书错误地引用久嗽成劳、痰中带血的阳证，不敢使用健脾法，增加咳嗽为例，没考虑到咯血即使伴有咳嗽，也不过是气逆上厥引起的咳嗽，气下行就不咳嗽了，何况原本就没有咳嗽的人呢？古方治疗龙雷之火，常用肉桂、附子引火归元的方法，然而应用于急性出血的病症，可以暂时使用而不能经常使用。因为已经亏损的血液，恐怕不能制约药物的悍烈之性，而未动的血液，恐怕不可滋扰它。这里以崇土（健脾）为先，土厚则浊阴不升，而出血的病患自然平息。（喻嘉言）
失血这一证候，名目不一，三因（外因、内因、不内外因）的来源途径应该详细分辨。外因，多为阳邪。因为阴分先虚，容易受到自然界的风热燥火侵袭。至于阴邪致病，不过占十分之一二罢了。治疗方法，总以手三阴经为要领，究其病在心营和肺卫的情况如何。内因，不出乎嗔怒郁结激伤肝脏，劳累形体、苦思冥想耗损心脾，以及放纵情欲戕害肾脏的真阴真阳。又当以足三阴经为要领，再审视其乘侮制化的情况如何。不内外因，是由于饮食偏好和努力过度或坠堕造成的伤害。治疗分为脏腑经络的不同。要知道由外因而起的，必有感受外邪的症状在先；由内因而起的，必有里证可依据。大体上调理肺卫，用甘凉肃降的药物，如沙参、麦冬、玉竹、川石斛等类。治疗心营，用轻清滋养的药物，如生地、玄参、丹参、连翘等类。如果风邪淫盛津液干枯，加上甘寒药物，如芦根、蔗汁之类；温邪淫盛火势壮盛，参入苦寒药物，如黄芩、石膏之类；暑邪逼迫气分，佐以滑石、荷叶的开解；在营分，配合银花、犀角的清芳；秋季选用纯甘药物以清燥；冬季增加清补以助收藏。以上是大略的外因治疗方法。所谓阴邪致病的，旧方有麻黄人参芍药汤，先生有桂枝加减法。内因损伤，治疗更复杂，如果嗔怒而动及肝阳，血随气逆的，用缪氏“气为血帅”的方法，如苏子、郁金、桑叶、丹皮、贝母之类；如果郁结日久伤及肝阴，木火内燃伤及阳络的，用柔肝育阴的方法，如阿胶、黄芩、生地、麦冬、白芍、甘草之类；如果烦劳不息偏损心脾，气不摄血的，用甘温培固的方法，如保元汤、归脾汤之类；如果纵欲而竭尽肾真，或者阳亢阴腾，或者阴伤阳越的，有从阴从阳的方法，如青铅、六味地黄丸、肉桂、七味地黄丸并加童便之类；如果精竭海空，气泛血涌的，急固真元，大补精血，如人参、枸杞、熟地、紫石英、紫河车之类。以上是大略的内因治疗方法。至于不内外因，如烟辛泄肺，酒热戕胃，都能助火动血，治疗方法有治上治中，如苇茎汤、甘露饮、茅根、藕汁等剂；坠堕的伤害，由血瘀而泛溢的，先宜导下，后宜通补；如果努责用力为患，属于劳伤的根源，阳气妄动则络脉松弛血溢，治疗与虚损有所不同，滋阴补气，最忌凝涩，如当归建中汤、旋复花汤，取其有循经入络的能力。以上是不内外因的大略治疗方法。但是血液的主司者，乃是心、肝、脾三脏；血液生化之源，莫过于阳明胃腑。如果胃不和，应当先治胃。仁斋说：一切血证，经久不愈，每每用胃药收功。有薄味调养胃阴的，如麦冬汤及沙参、扁豆、茯神、石斛之类；有甘温创建中阳的，如人参建中汤及四君子汤加减之类；有滋阴而不碍胃，甘守津还的，如复脉汤加减之类。其余补土生金、镇肝益胃、补脾疏胃、安神理胃、肾胃相关等方法，一旦遇到胃不加餐，不饥难运，每每从这个道理见长，源源不断生化不息。（出自《临证指南》）
血溢、血泻等各种蓄积妄行证候，起初，适宜用行血破瘀的药剂折损其锐气，然后区别治疗。有人问：失血后又用下法，虚弱怎么承受？回答说：血液既然妄行，迷失了原来的通道，不去除蓄积利导瘀血，就会把妄行当作常态，用什么来抵御它？而且去掉的自然是旧的，新生的自然是新的，有什么虚的呢？失血家用下剂，是施用于蓄血妄行的初期；亡血虚家不可用下法，是告诫在亡失之后的情况。（滑伯仁）
凡是蓄血有上、中、下三焦的区别，血蓄在上焦则健忘，适宜犀角地黄汤；血蓄在中焦则胸满身黄，漱水不欲咽，适宜桃仁承气汤；血蓄在下焦则如狂，大便黑，小腹硬满，适宜抵当汤丸。（王好古）
凡是瘀血的证候，现在的人只知道闪挫会有瘀血，不知道有因火载血上行，或吐或衄，病人自己忍耐而蓄滞于中；或因医药寒凉，而冰凝于内；或因忧思过度，而导致营血郁滞不行；或因怒伤，血逆上不得越下，不归经而留积于胸膈之间的。这些都是瘀血的原因。也有跌扑闪挫，当时不觉，到了气衰的时候，不时发作，医生见到吐血，妄认为虚损，反而用补药，气得到补助，病虽然暂缓，气日愈衰，病日愈深，最终形成窠囊不治。○有人问痰挟瘀血，怎么验证？我说：你知道有痰挟瘀血，不知道有瘀血挟痰。比如先因伤血，血逆则气滞，气滞则生痰，与血相聚，名叫瘀血挟痰。患处按之则痛而不移，其证或吐或衄，或大便黑，其脉轻举则滑重按则涩。治疗宜导痰破血，先用导痰汤，如苍术、香附、枳壳、白芥子开郁导痰；次用川芎、当归、桃仁、红花、苏木、丹皮、莪术以破其血。如果素有郁痰，后因血滞，与痰相聚，名叫痰挟瘀血。患处则痛而少移，其证或为胀闷，或为寒热，其脉轻举则芤重按则滑。治疗宜先破其血，而后消痰，或消痰破血二者兼治。医生如果误用补及寒凉之剂，致病邪郁久而成窠囊。其窠囊的验证，患处则痛而不能转侧，或肺膜间偏热偏肿，咳喘痰臭，丹溪说：痰挟瘀血，遂成窠囊者不治。正是这个意思。（罗赤诚）
人有足上毛孔标血如线，流而不止即死，急以热醋三升，将足浸泡其中；用人参一两，当归三两，穿山甲一片炒末，用参归汤调服。此证乃酒色不禁所致，方书不载，此方神效。脐中出血，也是奇证，用六味地黄汤加骨碎补饮之即愈。齿血也以此方投治。盖脐、齿俱是肾经之位，出血皆是肾火外越，六味地黄汤滋其水，则火自息；骨碎补专补骨中之漏。○舌血如泉者，乃心火旺极，血不藏也。用六味地黄汤加槐花。○七孔流血者，亦肾经虚热也。用六味地黄汤加麦冬、五味子、骨碎补。（出自《石室秘录》）
脉候
安卧脉盛，谓之脱血。（出自《素问》）
病患面无血色，无寒热，脉沉弦者，衄血；浮弱，手按之绝者，下血；烦咳者，必吐血。（出自《金匮要略》）
脉得诸濡弱为亡血，芤脉为失血，涩脉为少血，牢脉为蓄血。沉、弱、滑、小者生，实、大、弦、牢者死，关尺之脉弦细如循刀刃者死。（出自《证治汇补》）
选案
刘公远性情喜爱爆炙食物，又因心境不舒，淘饮烧酒，脾胃受伤，土中火发。开始只是盗汗怔忡，心包合并为病，久则水竭金衰，皮毛孔窍时出红汗，染衣皆赤，传为怪证。我说：这是脾胃阴血与离宫（心）火液相化，随气营运，达于腠理，与吐血无异。给予加减清心莲子饮，一剂止住，三剂痊愈。○李康候久耽声色，头眩屡日，忽发丛中滴血不已，医生怀疑怪证，辞去。我说：这是肾水枯竭，相火无制，合五脏虚火相煽，而炎于高巅，有什么奇怪的？给予六味地黄汤加车前、牛膝、血余炭，一剂而止。○一妇忿怒莫泄，干呕不已，口中努出血，自早至午长如碗大，遮满口外，呼吸不通，诸医无措。我令煎黄连浓汁，井中浸冷蘸涂，饭顷小去大半，再入海石少许同煎，徐涂徐咽，消归无有。此心火暴激之病也。易用逍遥散加丹皮、茱萸、炒黄连立愈。（程华仲）
一妇脚肚作痒，爬之，毛孔内鲜血一线流出，直射四、五尺远，樽盛盈樽，碗盛盈碗，昏晕仆地。我说：此血箭也。令将百草霜浓敷患处，以布缚住，与补中益气汤加黄连、生地、白芍灌下，人事渐苏，血止，再剂而愈。（周禹载）
The more intense the fire, this is a condition of blood deficiency with internal fire. Therefore, the method of "tonifying Qi for blood loss" (Xue Tuo Yi Qi) can only be applied to bleeding caused by damage to the Yin collaterals without fire; it is difficult to apply to cases where the Yang collaterals are damaged, blood is lost, fire is vigorous, and the patient suffers from lao zhai gu zheng (tuberculosis with bone-steaming fever), rapid pulse, and internal heat. At these critical junctures, errors have always been common. When considering the damage to the Yin and Yang collaterals of blood, one must distinguish between the presence or absence of fire, and need not be rigidly confined to whether the blood overflows from above or leaks from below. For example, hemoptysis and hematemesis are blood overflowing from above. If the patient has a pale complexion and a deep, slow pulse, this is due to Yang deficiency failing to control the blood; in ancient times, there were cases where treating with stomach-tonifying herbs achieved success. Furthermore, if the Yangming Large Intestine has fire causing intestinal bleeding (chang hong), this is blood leaking from below; in ancient times, herbs such as Huangbai (Phellodendri Cortex) and Huaimi (Sophorae Flos) were used for treatment. In summary, regardless of whether the blood overflows from above or leaks from below, if upon examination it is found that blood loss is accompanied by fire, it is blood damaged by the Yang collaterals, and cooling blood and nourishing blood methods should be used; if blood loss is not accompanied by fire, it is blood damaged by the Yin collaterals, and the method of tonifying Qi for blood loss may be employed. (From *Zheng Yin Mai Zhi*)
In cases of sudden massive hematemesis due to internal injury, blood flows like a gushing spring, flowing from both mouth and nose, and death will occur within moments if not rescued urgently. It is necessary to use one liang of Ren Shen (Ginseng Radix et Rhizoma) ground into powder, mixed with one qian of refined wheat flour, and taken with fresh well water; or use Du Shen Tang (Single Ginseng Decoction) to tonify Qi. Why are no blood-stopping herbs added? Because tangible blood cannot be generated quickly, while intangible Qi must be urgently secured; intangible Qi can naturally generate tangible blood. If true Yin is deficient and deficient Yang floats upward, massive hematemesis also occurs; in this case, Ba Wei Di Huang Tang (Eight-Ingredient Rehmannia Root Decoction) must be used to secure true Yin and guide fire back to its source, and Ren Shen should not be used at this time. Once the fire has returned to its source, Ren Shen can then be used. ○ After any blood loss, high fever inevitably occurs. The ancient formula Dang Gui Bu Xue Tang uses one liang of Huang Qi (Astragali Radix) and six qian of Dang Gui (Angelicae Sinensis Radix). Although named for tonifying blood, Huang Qi is the sovereign herb because vigorous Yang can generate Yin blood. Those who do not understand this principle, seeing high fever and surging pulses in all six positions, may mistakenly use dispersing methods, or mistake the presentation for Bai Hu Tang syndrome and erroneously administer Bai Hu Tang, leading to immediate danger. ○ When treating blood disorders, regulation before and after must follow the principles of the Heart, Spleen, and Liver meridians: the Heart generates blood, the Spleen controls blood, and the Liver stores blood. Gui Pi Tang is a formula for these three meridians. Yuan Zhi (Polygalae Radix) and Suan Zao Ren (Ziziphi Spinosae Semen) tonify the Liver to generate Heart Fire; Fu Shen (Poria Cum Radix) tonifies the Heart to generate Spleen Earth; Ren Shen, Huang Qi, and Gan Cao tonify the Spleen to consolidate Lung Qi; Mu Xiang (Vladimiriae Radix) enters the Spleen first, with the overall aim of returning blood to the Spleen. This is especially suitable for patients injured by anger damaging the Liver or worry damaging the Spleen. (From *Zhao Shi Yi Guan*)
Zhang Zhongjing stated: Misapplying sweating to the Shaoyin meridian disturbs the channel blood, resulting in lower exhaustion and upper reversal, which is difficult to treat. One does not realize that "lower exhaustion" refers to the depletion of Yin blood in the lower body, and "upper reversal" refers to the rebellion of Yin Qi in the upper body. Qi and Blood are mutually attached; without Blood, Qi scatters without control; without Qi, Blood coagulates and fails to flow. Thus, when Yin fire moves, Yin Qi must rush upward; as Yin Qi rushes upward, Yin blood must overflow upward. Once blood overflows, the Qi accompanying it scatters in the chest and cannot return to its original position, causing upper reversal. With Yin Qi rebelling upward, Long Lei fire (ministerial fire) responds accordingly; bleeding stops only when blood is exhausted, and reversal stops only when Qi is restored. Zhang Zhongjing judged this as difficult to treat not because it is untreatable, but I elucidate the mechanism: prioritizing the tonification of Yang Qi in the Spleen is the primary principle. Tonifying Spleen Yang has three benefits: First, vigorous Spleen Yang is like clear skies and bright sun, causing Long Lei fire to subside; Second, vigorous Spleen Yang clears obstructive Yin Qi from the chest like empty space free of dust; Third, vigorous Spleen Yang aids digestion and transformation of essences, regenerating the depleted lower blood. Modern formularies wrongly cite chronic cough leading to consumption with blood-streaked sputum as a Yang syndrome, fearing the use of Spleen-tonifying methods and citing increased cough as an example. They fail to consider that even if hemoptysis is accompanied by cough, it is merely a cough caused by rebellious Qi; once Qi descends, the cough ceases, let alone in those who originally had no cough. Ancient formulas treated Long Lei fire using Rou Gui (Cinnamomi Cortex) and Fu Zi (Aconiti Lateralis Radix Praeparata) to guide fire back to its source, but this is applicable temporarily, not chronically, for acute bleeding. Depleted blood may not control the harsh nature of these herbs, and undisturbed blood may be irritated by them. Here, strengthening Earth (Spleen) is paramount; thick Earth prevents turbid Yin from rising, and blood disorders cease naturally. (Yu Jiayan)
Blood loss syndromes have various names, and the origins of the Three Causes (External, Internal, and Neither Internal nor External) must be detailed. External causes are mostly Yang pathogens. Since Yin deficiency exists first, one is easily susceptible to external wind-heat, dryness, and fire. Pathogens of Yin cause disease only in one or two out of ten cases. The treatment generally focuses on the Hand Three Yin meridians, investigating the pathology in the Ying (Nutrient) level of the Heart and Wei (Defensive) level of the Lung. Internal causes involve anger and depression injuring the Liver, physical labor and mental strain depleting the Heart and Spleen, and indulgence in sex damaging the True Yin and True Yang of the Kidney. Treatment should focus on the Foot Three Yin meridians, examining their mutual overcoming and regulating transformations. Neither internal nor external causes include dietary preferences and injuries from straining or falling. Treatment varies by organ and meridian. External causes must have signs of pathogen invasion first; internal causes must have interior symptoms. Generally, to regulate Lung and Wei, use sweet-cool descending herbs like Sha Shen (Glehniae Radix), Mai Dong (Ophiopogonis Radix), Yu Zhu (Polygonati Odorati Rhizoma), and Chuan Hu (Dendrobii Caulis). To treat Heart Ying, use light-clear nourishing herbs like Sheng Di Huang (Rehmanniae Radix), Xuan Shen (Scrophulariae Radix), Dan Shen (Salviae Miltiorrhizae Radix), and Lian Qiao (Forsythiae Fructus). If wind excess dries fluids, add sweet-cold herbs like Lu Gen (Phragmitis Rhizoma) and Zhe Zhi (Saccharum Japonicum Juice); if warmth excess strengthens fire, add bitter-cold herbs like Huang Qin (Scutellariae Radix) and Shi Gao (Gypsum Fibrosum); if summerheat forces the Qi level, assist with Hua Shi (Talcum) and He Ye (Nelumbinis Folium) to open and resolve; if in the Ying level, combine with Jin Yin Hua (Lonicerae Japonicae Flos) and Xi Jiao (Rhinocerotis Cornu) for clearing and aromatic action; in autumn, select pure sweet herbs to clear dryness; in winter, increase clear-tonification to aid storage. These are the general principles for external causes. For Yin pathogen diseases, old formulas include Ma Huang Ren Shen Shao Yao Tang, and Mr. [Author] has Guizhi modification methods. Internal injuries are more complex to treat. If anger moves Liver Yang and blood follows rebellious Qi, use Miao's method "Qi is the commander of Blood," with Su Zi (Perillae Fructus), Yu Jin (Curcumae Radix), Sang Ye (Mori Folium), Dan Pi (Moutan Cortex), and Bei Mu (Fritillariae Bulbus). If stagnation damages Liver Yin over time, and Wood-Fire internally burns the Yang collaterals, use softening Liver and nourishing Yin methods, with E Jiao (Asini Corii Colla), Huang Qin, Sheng Di Huang, Mai Dong, Bai Shao (Paeoniae Radix Alba), and Gan Cao. If fatigue damages Heart and Spleen, and Qi fails to control blood, use sweet-warm fortification methods, such as Bao Yuan Tang and Gui Pi Tang. If indulgence exhausts Kidney Essence, or Yang hyperactivity floats Yin, or Yin injury allows Yang to escape, use methods following Yin or Yang, such as Qing Qian (Plumbum), Liu Wei Di Huang Wan, Rou Gui, Qi Wei Di Huang Wan, plus Tong Bian (Human Urine). If essence is exhausted and the sea is empty, with Qi floating and blood surging, urgently secure True Yuan and greatly tonify essence and blood, using Ren Shen, Gou Qi (Lycii Fructus), Shu Di Huang (Rehmanniae Radix Praeparata), Zi Shi Ying (Fluoritum), and He Che Da Zao (Placentae Humana). These are the general principles for internal causes. Regarding neither internal nor external causes, smoking irritates the Lung, and alcohol heat damages the Stomach, both aiding fire and moving blood. Treatments for upper and middle jiao include Wei Jing Tang, Gan Lu Yin, Mao Gen (Imperatae Rhizoma), and Ou Zhi (Nelumbinis Rhizoma Sanguis). Falls causing blood stasis and overflow should first be guided downward, then supplemented and unblocked. Straining is rooted in labor injury; Yang movement relaxes collaterals causing blood overflow. Treatment differs from deficiency; tonifying Yin and Qi must avoid astringents. Formulas like Dang Gui Jian Zhong Tang and Xuan Fu Hua Tang are chosen for their ability to enter collaterals along meridians. These are the general principles for neither internal nor external causes. However, the organs governing blood are the Heart, Liver, and Spleen; the source of blood generation is the Yangming Stomach. If the Stomach is disharmonious, treat the Stomach first. Ren Zhai said: All blood disorders that persist for a long time often conclude with stomach medicine. There are thin-flavored methods to nourish Stomach Yin, such as Mai Dong Tang, Sha Shen, Bian Dou (Dolichoris Semen), Fu Shen, and Shi Hu (Dendrobii Caulis); there are sweet-warm methods to establish Middle Yang, such as Ren Shen Jian Zhong Tang and Si Jun Zi Tang modifications; there are Yin-nourishing methods that do not hinder the Stomach, preserving sweetness and returning fluids, such as Fu Mai Tang modifications. Other methods like tonifying Earth to generate Metal, calming Liver and benefiting Stomach, tonifying Spleen and soothing Stomach, calming Spirit and regulating Stomach, and Kidney-Stomach interaction, when encountering loss of appetite, lack of hunger, and difficult transport, often show efficacy based on this principle, generating resources continuously. (From *Lin Zheng Zhi Nan*)
For blood overflow and leakage with accumulation and reckless discharge, initially, use blood-moving and stasis-breaking agents to curb their vigor, then differentiate and treat. A question arises: If purgatives are used after blood loss, how can the deficiency bear it? The answer is: Since blood is acting recklessly and has lost its proper pathway, if accumulated stasis is not removed and unblocked, reckless behavior becomes the norm, and how can it be controlled? Moreover, what is removed is old, and what is born is new; why speak of deficiency? Purgatives are used by blood-loss patients only in the initial stage of accumulation and reckless discharge; they are contraindicated for hemorrhagic deficiency patients after significant blood loss. (Hua Bo Ren)
Accumulated blood is distinguished by Upper, Middle, and Lower Jiao. Accumulation in the Upper Jiao causes forgetfulness; Xi Jiao Di Huang Tang is indicated. Accumulation in the Middle Jiao causes chest fullness, yellow skin, rinsing water without swallowing; Tao Ren Cheng Qi Tang is indicated. Accumulation in the Lower Jiao causes mania-like state, black stool, hardness and fullness in the lower abdomen; Di Dang Tang/Wan is indicated. (Wang Haogu)
Regarding blood stasis syndromes, people today only know that sprains cause stasis. They do not know that fire carrying blood upward, causing vomiting or epistaxis, may lead to retention if the patient endures it; or that cold-herbal medicines may cause internal coagulation; or that excessive worry leads to stagnation of Ying blood; or that anger causes blood to rebel upward, unable to descend, failing to return to its vessels, and accumulating in the chest and diaphragm. These are causes of blood stasis. Also, falls and sprains may not be felt immediately but manifest later when Qi declines. Doctors seeing hematemesis may misdiagnose deficiency and use tonics; Qi gains support, the illness temporarily eases, but Qi declines daily, the illness deepens, eventually forming a "nest" (chronic lesion) that is incurable. ○ A question asks: How to verify phlegm combined with blood stasis? I say: You know phlegm combining with stasis, but do you know stasis combining with phlegm? If blood injury occurs first, blood rebellion causes Qi stagnation; Qi stagnation generates phlegm, which gathers with blood, named "stasis combining with phlegm." Pressing the affected area causes fixed pain; symptoms include vomiting, epistaxis, or black stool; pulse is slippery on light pressure and choppy on heavy pressure. Treatment should guide phlegm and break stasis: first use Dao Tan Tang (Cang Zhu, Xiang Fu, Zhi Ke, Bai Jie Zi to open stagnation and guide phlegm); then use Xiong (Chuan Xiong), Gui (Dang Gui), Tao Ren, Hong Hua, Su Mu, Dan Pi, E Zhu to break stasis. If phlegm stagnation exists first, followed by blood stasis gathering with phlegm, named "phlegm combining with stasis." Pain shifts slightly; symptoms include distension or alternating chills/fever; pulse is hollow on light pressure and slippery on heavy pressure. Treatment should break stasis first, then resolve phlegm, or do both simultaneously. Mistaken use of tonics or cold herbs may cause pathogens to stagnate and form nests. Verification of nests: pain prevents turning; or heat/swelling in lung membranes, coughing wheezing with foul sputum. Danxi said: "Phlegm combining with stasis forming nests is incurable." This is exactly what is meant. (Luo Chicheng)
If hair follicles on the feet bleed like threads and flow incessantly, death ensues. Urgently soak the feet in three sheng of hot vinegar; take one liang of Ren Shen, three liang of Dang Gui, and one slice of Chuan Shan Jia (Manis Squama) fried and powdered, mixed with Shen Gui Tang. This condition results from unrestrained alcohol and sex; it is not recorded in formularies, but this formula is miraculous. Bleeding from the umbilicus is also a rare syndrome; Liu Wei Tang (Six-Ingredient Rehmannia Pill) plus Gu Sui Bu (Drynariae Rhizoma) cures it. Tooth bleeding is also treated with this formula. The umbilicus and teeth are locations of the Kidney meridian; bleeding here is Kidney fire escaping outward. Liu Wei Tang nourishes Water, extinguishing fire; Gu Sui Bu specifically repairs bone leaks. ○ Tongue bleeding like a spring indicates extreme Heart fire failing to store blood. Use Liu Wei Tang plus Huai Hua (Sophorae Flos). ○ Bleeding from seven orifices indicates Kidney meridian deficiency heat. Use Liu Wei Tang plus Mai Dong, Wu Wei Zi (Schisandrae Fructus), and Gu Sui Bu. (From *Shi Shi Mi Lu*)
Pulse Signs
Resting with a vigorous pulse is called blood depletion. (From *Su Wen*)
Patients with pale faces, no chills/fever, and a deep, wiry pulse have epistaxis; floating and weak, disappearing on pressure, indicates lower bleeding; irritability and cough indicate hematemesis. (From *Jin Gui Yao Lue*)
Ruo and Ruo pulses indicate blood loss; Kou pulse indicates hemorrhage; Se pulse indicates scant blood; Lao pulse indicates accumulated blood. Deep, weak, slippery, and small pulses indicate survival; solid, large, wiry, and firm pulses indicate death. Wiry and thin pulses at Guan and Chi positions, like touching a blade, indicate death. (From *Zheng Hui Bu*)
In all bleeding cases, body heat and large pulse are difficult to treat; cool body and quiet pulse are easy to treat. (Li Dongyuan)
Selected Cases
Mr. Liu Yuan loved roasted foods, was emotionally distressed, and drank strong liquor, damaging the Spleen and Stomach, igniting fire in Earth. Initially, he had night sweats and palpitations, affecting the Pericardium. Later, Water dried up and Metal weakened, causing red sweat from pores, staining clothes red, a strange syndrome. I said: This is Spleen/Stomach Yin blood transforming with Pericardium fire fluid, circulating with Qi to the interstices, similar to hematemesis. Prescribed Modified Qing Xin Lian Zi Yin; stopped in one dose, cured in three. ○ Li Kanghou indulged in sex/sound, suffered vertigo for days, suddenly bled from hair follicles incessantly. Doctors suspected a strange syndrome and left. I said: This is Kidney Water exhaustion, uncontrolled ministerial fire, stirring five-Zang deficient fire, flaming to the vertex. Not strange at all. Prescribed Liu Wei Tang plus Che Qian, Niu Xi, Xu Yu Tan; stopped in one dose. ○ A woman suppressed anger, vomited dryly, forced blood from her mouth, growing bowl-sized from morning to noon, filling her mouth, blocking breathing. Doctors were helpless. I ordered decocting concentrated Huang Lian juice, cooling it in a well, applying it. After a meal, half reduced. Added Hai Shi, decocted together, applied slowly and swallowed gradually, resolved completely. This is violent Heart fire agitation. Easily cured with Xiao Yao San plus Dan Pi, Zhu Yu, fried Huang Lian. (Cheng Huazhong)
A woman’s calf itched; scratching caused a thread of fresh blood to shoot four to five chi away, filling jars and bowls, fainting. I said: This is Blood Arrow. Ordered dense application of Bai Cao Shuang, binding with cloth, and administering Bu Zhong Yi Qi Tang plus Huang Lian, Sheng Di Huang, Bai Shao. Consciousness returned, bleeding stopped, cured in two doses. (Zhou Yuzai)