滑伯仁治一妇。体肥而气盛。自以无子。尝多服暖宫药。积久火盛。迫血上行为衄。衄
必数升余。面赤。脉躁疾。神恍恍如痴。医者犹以上盛下虚。丹剂镇坠之。伯仁曰。经云。
上者下之。今血气俱盛。溢而上行。法当下导。奈何实实耶。即与桃仁承气汤三四下。积瘀
去。继服既济汤。二十剂而愈。
项彦章治一妇。患衄三年许。医以血得热则淖溢。服泻心凉血之剂。益困。衄才数滴。
辄昏。六脉微弱。寸为甚。曰。肝藏血而心主之。今寸口脉微。知心虚也。心虚则不能司其
血。故逆而妄行。法当养心。仍补脾。实其子。子实则心不虚矣。以琥珀诸补心药。遂安。
许学士云。一人膏粱嗜饮。常病衄。医曰。诸见血者为热。以清凉饮子投之。即止。越
数日。其疾复作。医又曰。药不胜病故也。遂投黄连解毒汤。或止或作。易数医。皆用寒苦
之剂。俱欲胜其热而已。饮食起居。浸不及初。肌寒而时躁。言语无声。口气臭秽。恶吸冷
风。其衄之余波。则未绝也。或曰。诸见血者热。衄、热也。热而寒之。理也。今不愈而反
害之。何耶。内经曰。以平为期。又言下工不可不慎也。彼惟知见血为热。而以苦寒攻之。
抑不知苦泻土。土、脾胃也。脾胃人之所以为本者。今火为病而泻其土。火未尝除而土已病
矣。土病则胃虚。虚则荣气不能滋荣百脉。元气不循天度。气随阴化而无声肌寒也。噫。粗
工嘻嘻。以为可治。热病未已。寒病复起。此之谓也。
汪石山治一人。形魁伟。色黑善饮。年五十余。病衄如注。喘嗽。喘不能伏枕。医以四
物汤加麦冬、阿胶、桑白皮、黄柏、知母进之。愈甚。诊之脉大如指。脉诀云。鼻衄失血
沉
细宜。设见浮大即倾危。据此。法不救。所幸者色黑耳。脉大非热。乃肺气虚也。此金极似
火之病。若补其肺气之虚。则火自退矣。医用寒凉降火之剂。是不知亢则害。承乃制之旨。
遂用人参三钱。黄 二钱。甘草、白术、茯苓、陈皮、神曲、麦冬、归身甘温之药进之。一
帖病减。十帖病愈。
震按以上四案。首条是实热。次条为心脾两虚。三条病因是热。而过用苦寒。四条脉形
是热。而实由气虚。不同如此。临证者可不细辨乎。
又一人形近肥而脆。年三十余。内有宠妻。三月间。因劳感热。鼻衄久而流涕不休。
鼻
秽难近。渐至目昏耳重。食少体倦。医用四物凉血。或用参 补气。罔有效者。诊之脉濡而
滑。按皆无力。曰。病不起矣。初因水不制火。肺为火扰。流涕不休。经云。肺热甚则出涕
是也。金体本燥。津液日泄。则燥者枯矣。久则头面诸阳之液。因以走泄。经云。枯涩不能
流通。逆于肉里。乃生痈肿是也。月余。面目耳旁。果作痈疮而卒。后见流涕者数人。多不
救。
震按流涕鼻秽。即鼻渊之属。何以断其必死。要之脉濡滑而无力。昔贤谓滑脉类数。仲
景所云数脉不时。则生恶疮也。脉无力者。石山必用参、 。今参、 罔效。无路可寻矣。
况流涕不休。定然枯涩。故以营气不从。逆于肉里。为是病之指归。魏注云。用滋水生肝养
肺药诚佳。然以治流涕不休者。恐亦难效。
朱圣卿鼻衄如崩。三日不止。较之向来所发之势。最剧。服犀角、地黄、芩、连、知、
柏、石膏、山栀之属。转盛。第四日。邀石顽诊之。脉弦急。如循刀刃。此阴火上乘。载血
于上。得寒凉之药。转伤胃中清阳之气。所以脉变弦紧。与生料六味加五味子作汤。另用肉
桂末三钱。飞罗面糊。分三丸。用煎药调下。甫入喉。其血顿止。少顷。口鼻去血块数枚而
愈。自此数年之患。绝不再发。
〔附〕一人衄血不已。医皆以为热。沈宗常投以参附而愈。人骇问之。曰。脉小而衰。
非补之不可。
震按此二条相同。但微有不同者。一系温补元气。一系导火归元也。
〔附〕徐德古治一人。患衄尤急。灸项后发际两筋间宛宛中三壮。立止。盖血自此入脑
注鼻中。常人以绵勒颈后。尚可止衄。此灸宜效。
震按是乃截其血之来路也。与湿纸搭囟门者同义。若邵村张教官衄。道人教以生藕一枝
捣贴颅囟。再以海巴烧存性。吹鼻二三次。饶州民季七衄。医用萝卜汁和无灰酒饮之立止
复发。用人中白新刮者。置瓦上焙干。温汤调下。又止。是皆偶合一时之病机。并非诸衄
之定法。
俞伯仁治疗一位妇女。她身体肥胖且气机旺盛。因为自己不能生育，曾经长期服用暖宫的药物。日久导致体内火热炽盛，逼迫血液向上逆行而引发鼻衄（鼻出血）。每次出血多达数升以上，面色红赤，脉象躁动急疾，神志恍惚如同痴呆一般。医生仍然认为是上实下虚，使用丹剂进行镇坠治疗。俞伯仁说：“《内经》云：‘上者下之’。如今血气俱盛，溢出而上行，治法应当向下疏导。怎么能用实证的方法去对待实证呢？”随即给予桃仁承气汤攻下三四次，积瘀去除后，继服既济汤，二十剂后痊愈。
项彦章治疗一位妇女，患鼻衄三年左右。医生认为“血得热则淖溢”（血液受热则流动加速而溢出），服用泻心凉血的药剂，结果病情更加困顿。鼻衄仅出几滴，人就昏厥。六脉微弱，寸脉尤为明显。项彦章说：“肝藏血而心主之。如今寸口脉微，可知心气虚弱。心虚则不能统摄血液，所以血液逆乱妄行。治法应当养心，同时补脾，以充实心脏的子脏（脾为心之子）。子脏充实，心脏就不会虚弱了。”于是使用琥珀等补心药物，病情遂安。
许学士说：有一人喜好膏粱厚味和饮酒，经常患鼻衄。医生说：“凡是见血证多属热”，投以清凉饮子，出血即止。过了几天，疾病复发。医生又说：“是药力不胜病邪的缘故。”于是投以黄连解毒汤。有时止血，有时发作。更换了几位医生，都使用寒苦性质的药剂，都想以此战胜热邪。然而患者的饮食起居，逐渐不如当初，肌肉寒冷而时常烦躁，言语无声，口气臭秽，厌恶吸入冷风。其鼻衄的余波尚未断绝。有人说：“凡见血证多为热，鼻衄也是热证。热证用寒药治疗，是常理。现在不愈反而受害，为什么呢？”《内经》说：“以平为期。”又说要谨慎对待下工（医术低劣的医生）。那些医生只知道见血就是热，而用苦寒药攻伐，却不知道苦味能泻土（脾胃）。土对应脾胃，是人体根本所在。如今因火致病而泻其土，火未除而土先病了。土病则胃虚，虚则营气不能滋养百脉，元气不能遵循正常的运行规律，气随阴化而表现为声音不出、肌肉寒冷。唉！粗疏的医生嘻嘻哈哈，以为可以治愈。热病未已，寒病复起，说的就是这种情况。
汪石山治疗一人，形体魁伟，肤色黑，喜好饮酒，五十多岁。患鼻衄如注，伴有喘嗽，气喘严重到不能伏枕而卧。医生用四物汤加麦冬、阿胶、桑白皮、黄柏、知母进服，病情反而加重。诊察其脉大如手指。《脉诀》云：“鼻衄失血沉细宜，设见浮大即倾危。”据此，此法不可救。所幸的是患者肤色黑。脉大并非热证，而是肺气虚。这是“金极似火”的病证。如果补益肺气的虚弱，那么火自会消退。医生使用寒凉降火的药剂，是不懂得“亢则害，承乃制”的道理。于是用人参三钱，黄芪二钱，甘草、白术、茯苓、陈皮、神曲、麦冬、当归身等甘温药物治疗。一帖后病情减轻，十帖后痊愈。
俞震按语：以上四个医案，第一条是实热证，第二条是心脾两虚证，第三条病因虽是热，但过用苦寒药物损伤正气，第四条脉象看似热，实则由气虚引起。情况各不相同，临证时怎能不仔细辨别呢？
又有一人，形体接近肥胖但体质脆弱，三十多岁。家中宠爱妻子，三月间，因劳累感受热邪，鼻衄久而流涕不止。鼻涕秽浊难近，逐渐发展到目昏耳重，食少体倦。医生用四物汤凉血，或用人参补气，都没有效果。诊察其脉濡而滑，按之皆无力。说：“病无法治愈了。”起初是因为水不制火，肺被火扰，所以流涕不止。《内经》云：“肺热甚则出涕”，正是此意。肺金本体本燥，津液每日泄耗，则干燥者枯槁了。久而久之，头面诸阳之液的津液也因走泄而枯竭。《内经》云：“枯涩不能流通，逆于肉里，乃生痈肿”。一个多月后，面目耳旁果然发生痈疮而死亡。后来见到流涕的人有好几个，大多无法救治。
俞震按语：流涕且鼻涕秽浊，属于鼻渊一类。为什么断定必死？关键在于脉濡滑而无力。以前的贤者说滑脉类似数脉，张仲景所说“数脉不时，则生恶疮”。脉无力者，汪石山必定使用人参、黄芪。如今用人参、黄芪无效，无路可寻了。况且流涕不休，定然枯涩。所以用“营气不从，逆于肉里”作为此病的最终归宿。魏注说：使用滋水生肝养肺的药物诚然很好，但对于治疗流涕不休的患者，恐怕也难以见效。
朱圣卿鼻衄如崩，三天不止。比起以往发作的势头，最为剧烈。服用犀角、地黄、黄芩、黄连、知母、黄柏、石膏、山栀等药物，出血反而加重。第四天，邀请石顽诊治。脉弦急，如循刀刃。这是阴火上乘，载血于上。得到寒凉药物，反而损伤了胃中的清阳之气，所以脉变弦紧。与生料六味地黄丸加五味子煮汤，另用肉桂末三钱，飞罗面糊制成三丸，用煎好的药汤送服。刚入喉，其血顿时停止。过了一会儿，口鼻排出数枚血块而痊愈。从此数年之患，绝不再发。
〔附〕有一人鼻衄不止，医生都认为是热证。沈宗常投以人参、附子而痊愈。人们惊讶地问他。他说：“脉小而衰，非补益不可。”
俞震按语：这两条相同，但略有不同。一条是温补元气，一条是导火归元。
〔附〕徐德古治疗一人，患鼻衄尤其紧急。灸项后发际两筋间宛宛中穴三壮，立即停止。大概血液由此处入脑注入鼻中。常人用绵带勒住颈后，尚可止衄，此灸法理应有效。
俞震按语：这是截断血液来路的方法。与湿纸搭囟门的意思相同。若邵村张教官鼻衄，道人教他用生藕一枝捣烂贴敷颅囟，再用海巴烧存性，吹入鼻中二三次，也止住了。饶州百姓季七鼻衄，医生用萝卜汁和无灰酒调饮，立止但复发。用人中白新刮者，放在瓦上焙干，温汤调下，又止住了。这些都是偶然契合一时的病机，并非治疗各种鼻衄的定法。
Yu Boren treated a woman. She was obese and had vigorous Qi. Because she could not conceive, she had long taken warming uterus medicines. Over time, this accumulated to cause excessive internal fire, forcing blood to move upward and causing nasal bleeding (bi xu). Each episode involved the loss of several sheng (a traditional unit of volume) of blood. Her face was red, her pulse was restless and rapid, and her spirit was恍惚 (trance-like) as if she were dazed. The physician still considered it an excess above and deficiency below, using cinnabar preparations for sedation and sinking. Yu Boren said, "The Classics state: 'Treat what is above by directing it downward.' Now that both blood and Qi are abundant, overflowing and moving upward, the method should be to guide them downward. How can one treat an excess condition with an excess-inducing approach?" He immediately administered Tao Ren Cheng Qi Tang (Peach Kernel Decoction to Order the Qi), inducing defecation three or four times. After the accumulated stasis was removed, he continued with Ji Ji Tang (Ji Ji Decoction). After twenty doses, she recovered.
Xiang Yanzhang treated a woman who had suffered from nasal bleeding for about three years. Physicians believed that "blood becomes fluid and overflows when heated," so they administered Xie Xin Tang (Drain the Heart Decoction) and cooling-blood agents, which only worsened her condition. When only a few drops of blood came out, she would faint. Her six pulses were weak, especially at the Cun (inch) position. Xiang said, "The Liver stores blood, and the Heart governs it. Now that the Cun pulse is weak, we know the Heart Qi is deficient. Heart deficiency fails to control the blood, causing it to reverse and act recklessly. The treatment should nourish the Heart and simultaneously tonify the Spleen, strengthening its child organ (the Spleen is the child of the Heart). Once the child is solid, the Heart will not be deficient." He then used Hu Po (Amber) and other heart-nourishing medicines, and the patient stabilized.
Scholar Xu stated: A man who favored rich foods and alcohol often suffered from nasal bleeding. The physician said, "All manifestations of blood indicate heat," and administered Qing Liang Yin Zi (Cooling Drink Formula), which stopped the bleeding immediately. A few days later, the disease recurred. The physician said, "The medicine was insufficient against the pathogen," and administered Huang Lian Jie Du Tang (Coptis Decoction to Relieve Toxicity). The bleeding stopped intermittently. Several physicians changed, all using bitter-cold agents, attempting to overcome the heat. However, his diet and lifestyle gradually deteriorated compared to the beginning; his muscles felt cold yet he was occasionally irritable, he spoke without voice, his breath was foul, and he disliked inhaling cold wind. The residual effects of his nasal bleeding had not ceased. Someone asked, "All blood manifestations are due to heat; nasal bleeding is also heat. Treating heat with cold is logical. Why does it fail and cause harm now?" The Inner Canon states, "The goal is balance." It also warns that inferior physicians must be cautious. Those physicians only knew that blood manifestations imply heat and attacked it with bitter-cold drugs, ignoring that bitter flavors drain Earth (Spleen/Stomach). Earth corresponds to the Spleen and Stomach, which are the root of human life. Now, because of fire pathology, they drained the Earth; the fire was not eliminated, but the Earth became diseased. Earth disease leads to Stomach deficiency; deficiency means Ying Qi (Nutritive Qi) cannot nourish the vessels, and Yuan Qi (Original Qi) cannot follow its natural course. Qi transforms with Yin, leading to silence and cold muscles. Alas! Crude physicians laughingly believe it is curable. Heat pathology has not ended, yet cold pathology arises anew. This is what is meant.
Wang Shishan treated a man who was robust, dark-skinned, and fond of drinking, aged over fifty. He suffered from profuse nasal bleeding accompanied by wheezing and coughing; the wheezing was severe enough to prevent him from resting his head on the pillow. The physician administered Si Wu Tang (Four Substance Decoction) with added Mai Dong (Ophiopogonis Radix), E Jiao (Donkey-hide Gelatin), Sang Bai Pi (Morus Bark), Huang Bo (Phellodendri Cortex), and Zhi Mu (Anemarrhenae Rhizoma), but the condition worsened. His pulse was large, as thick as a finger. The Pulse Classic states, "For nasal bleeding and blood loss, deep and fine pulses are appropriate; if floating and large pulses appear, it indicates peril." Based on this, the case seemed untreatable. Fortunately, his skin was dark. The large pulse did not indicate heat, but rather Lung Qi deficiency. This is a condition where Metal extreme resembles Fire. If the Lung Qi deficiency is tonified, the fire will naturally retreat. The physician's use of cold-cooling fire-reducing agents showed ignorance of the principle "When things reach an extreme, they cause harm; regulation follows." He therefore used Ren Shen (Ginseng Radix et Rhizoma) 3 qian, Huang Qi (Astragali Radix) 2 qian, Gan Cao (Licorice Root), Bai Zhu (Atractylodis Macrocephalae Rhizoma), Fu Ling (Poria), Chen Pi (Citrus Reticulatae Pericarpium), Shen Qu (Massa Medicata Fermentata), Mai Dong, and Dang Gui Shen (Angelica Sinensis Radix tip)—all sweet-warm herbs. After one dose, symptoms decreased; after ten doses, he recovered.
Yu Zhen commented: Among the above four cases, the first is excess-heat; the second is Heart-Spleen dual deficiency; the third's etiology is heat, but excessive bitter-cold usage damaged the healthy Qi; the fourth's pulse shape suggests heat, but the reality is Qi deficiency. They differ thusly. Can clinicians not distinguish carefully?
Another person, near-obese but fragile, in his thirties, indulged in marital relations. In March, due to labor and heat contraction, he suffered prolonged nasal bleeding and unceasing runny nose. The nasal discharge was foul and unpleasant. Gradually, his vision blurred and hearing dulled; he ate little and felt body fatigue. Physicians used Si Wu Tang to cool blood or Ren Shen to tonify Qi, with no effect. His pulse was soggy and slippery, and pressing revealed weakness. Yu Zhen said, "The illness is incurable." Initially, Water failed to control Fire, disturbing the Lung, causing unceasing rhinorrhea. The Classic states, "Severe Lung heat causes discharge of mucus." Metal constitution is inherently dry; daily leakage of fluids causes dryness to wither. Over time, fluids of the Yang aspects of the head and face leak away. The Classic states, "Withered and astringent, unable to circulate, reversing into the flesh, abscesses form." More than a month later, abscesses indeed formed around his face, ears, and cheeks, leading to death. Later, several people with similar runny noses were seen, mostly incurable.
Yu Zhen commented: Runny nose with foul discharge belongs to Bi Yuan (Nasal Sinusitis). Why judge it as fatal? Primarily because the pulse is soggy, slippery, and weak. Former sages stated that slippery pulses resemble rapid pulses. Zhang Zhongjing said, "If rapid pulses persist, malignant sores arise." For weak pulses, Wang Shishan would definitely use Ren Shen and Huang Qi. Since these were ineffective, there was no path left. Moreover, unceasing rhinorrhea implies withering and astringency. Thus, "Ying Qi failing to follow its course, reversing into the flesh" serves as the conclusion of this disease. Wei's annotation says: Using herbs to nourish Water to support Liver and Lung is excellent, but for treating unceasing rhinorrhea, it may hardly be effective.
Zhu Shengqing suffered from nasal bleeding like a collapse, lasting three days without stopping. Compared to previous episodes, this was the most severe. He took Xi Jiao (Rhinoceros Horn), Di Huang (Rehmanniae Radix), Huang Qin (Scutellariae Radix), Huang Lian (Coptidis Rhizoma), Zhi Mu, Huang Bo, Shi Gao (Gypsum Fibrosum), and Shan Zhi Zi (Gardeniae Fructus), yet the bleeding intensified. On the fourth day, he invited Shi Wen for consultation. The pulse was wiry and urgent, like touching a blade. This indicated Yin Fire ascending, carrying blood upward. The cold-cooling medicines injured the clear Yang Qi in the Stomach, changing the pulse to wiry and tight. Shi Wen prescribed Sheng Liu Wei Di Huang Wan (Six Ingredient Pill with Rehmannia) with Wu Wei Zi (Schisandrae Fructus) as a decoction. Separately, he made three pills using Rou Gui (Cinnamon Bark) powder 3 qian and refined wheat flour paste, to be taken down with the decoction. As soon as it entered the throat, the bleeding stopped instantly. Shortly after, several clots of blood were expelled from the mouth and nose, and he recovered. For years thereafter, the affliction never recurred.
[Appendix] A man suffered from persistent nasal bleeding. Physicians all attributed it to heat. Shen Zongchang administered Ren Shen and Fu Zi (Aconiti Lateralis Radix Praeparata), and he recovered. People were shocked and asked why. He replied, "The pulse was small and declining; tonification was indispensable."
Yu Zhen commented: These two cases are similar but slightly different. One warms and tonifies Original Qi; the other guides fire back to its source.
[Appendix] Xu Degu treated a man with acute nasal bleeding. He moxa'd the point Wanyangzhong (located between the two tendons behind the nape at the hairline) with three moxa cones. The bleeding stopped immediately. Blood likely enters the brain from here and pours into the nose. Common people can sometimes stop nasal bleeding by tying a cotton band tightly around the neck; thus, this moxibustion should be effective.
Yu Zhen commented: This cuts off the source of the blood flow, similar in meaning to placing wet paper on the fontanelle. For example, Instructor Zhang of Shacun suffered nasal bleeding; a Daoist priest advised applying crushed fresh lotus root to the skull fontanelle, followed by blowing powdered Hai Ba (likely a marine product processed by calcination) into the nose two or three times, which also stopped the bleeding. Ji Qi, a commoner from Raozhou, suffered nasal bleeding; a physician used radish juice mixed with unadulterated wine, which stopped it temporarily but it recurred. Freshly scraped Ren Zhong Bai (Ureter Calculus) was dried on a tile and taken with warm water, which also stopped it. These instances coincidentally matched the pathogenesis at that specific moment and are not fixed methods for all types of nasal bleeding.