门人问曰。州尊暴病。呕血数升。指尖微冷。喉间窒塞。声
不易出。安危之机。关于医药。有用温补人参阿胶之属者。有用
凉血生地玄参之属者。有用降火黄柏知母之属者。漫难适从。请吾师确言其理。以开瞽 。答曰。古今论
失血之症。皆混在痰火一门。是以言之不中肯 。吾试为子详之。夫血病有新久微甚。无不本之于火。然火
有阴阳不同。治法因之迥远。州尊虽旧尝失血。不过伤损之类。其原颇轻。今入春以来。忽尔呕血数
盂。则出之暴矣。经云。暴病非阳。则其为火也。即非阳火甚明。阳火者五行之火。天地间经常可久之物。
何暴之有。设其暴也。复可以五行之水折之。不能暴矣。惟夫龙雷之火。潜伏阴中。方其未动。不知其为火
也。及其一发。暴不可御。以故载阴血而上溢。盖龙雷之性。必阴云四合。然后遂其升腾之势。若天青日
朗。则退藏不动矣。故凡用凉血清火之药者。皆以水制火之常法。施之于阴火。未有不转助其虐者也。
大法惟宜温补。而温补中之微细曲折。要在讲明有素。经曰。少阴之脉萦舌本。谓肾脉萦绕于舌根之间也。
又曰。咯血者属肾。明乎阴火发于阴中。其血咯之成块而出。不比咳嗽痨症。痰中带血为阳火也。此义从
前未有发明。惟汉代张仲景为医中之圣。于伤寒症中垂戒一款云。误发少阴汗。动其经血者。下竭上厥为
难治。后人随文读去。至下竭上厥之理。总置不讲。不知下竭者。阴血竭于下也。上厥者。阴气逆于上也。
盖气与血两相维附。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。阴血上溢。则下竭矣。血既上溢。其随血之气。散于胸中。不能复返
本位。则上厥矣。阴气上逆。不过至颈而止。不能越高巅清阳之位。是以喉间窒塞。心忡
耳鸣。胸膈不舒也。然岂但窒塞不舒已哉。阴气久居于上。势必龙雷之火。应之于下。血不尽竭。不止也。
气不尽厥。亦不止也。仲景所以断为难治者。其以是乎。但止曰难治。非谓不治也。仲
景不立治法者。以另有卒病论一十六卷。专论暴病。后世散逸无传耳。吾为子大辟其扃。则以健脾中阳
气为第一义。健脾之
阳。一举有三善也。一者脾中之阳气旺。如天青日朗。而龙雷潜伏也。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。况乎地气必先蒸土
为湿。然后上升为云。若土燥而不湿。地气于中隔绝矣。天气不常清乎。今方书皆治阳火之法。至龙雷
之火。徒有其名。而无其治。反妄引久嗽成痨。痰中带血之阳症。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。况于原无咳嗽者乎。古方治龙雷之火。每用桂附引水归原之法。然施于
暴血之症。可暂不可常。盖已亏之血。恐不能制其悍。而未动之血。恐不可滋之扰耳。究而论之。治龙雷
之火。全以收藏为主。以秋冬则龙潜雷伏也。用收藏药不效。略用燥烈为向导。以示同气相求之义则可。
既以收藏。宁敢漫用燥烈乎。先生宿有损伤失血之病。值此上下交匮。功令森严。人心欲逞。惴惴其不免。是
劳伤又益以忧恐。恐则伤肾。而少阴之血。无端溢出。与仲景所谓误发少阴汗动其血者。初无少异矣。又况肝
主谋虑。性喜疏泄。冬间肾气不藏。久已供肝木之挹取。今春令将行。而肝木居青龙之位。震雷之司。乘权
用事。是以天时之龙雷未动。身中之龙雷先动。其血已暴涌而出。不识后此春夏十二气。龙雷大发之时。将
何血以奉之耶。夫大病须用大药。大药者。天时春夏。而吾心寂然秋冬是也。昔人
逃禅二字甚妙。夫禅而名之曰逃。其心境为何如哉。子后遇此病。必以崇土为先。土浓则阴浊不升。而
血患必止。万物以土为根。元气以土为宅。不可不亟讲矣
胡卣臣先生曰。今世失血一症甚多。前后四案。发明无穷奥义。垂诲殷殷。此篇详论阴火原委。尤补千古阙失。
学生问道：“州尊大人突发重病，呕吐鲜血数升，指尖微微发凉，喉间有堵塞感，声音难以发出。病情的安危关键在于医药治疗。有人主张使用人参、阿胶等温补药物；有人主张使用生地、玄参等凉血药物；还有人主张使用黄柏、知母等降火药物。众说纷纭，让人难以适从。恳请老师明确阐述其中的医理，以开启愚蒙。”
我回答说：“古往今来论述失血症的，都将其混杂在‘痰火’这一门类中讨论，因此所说的道理往往不得要领。让我试着为你详细解释。血病有新发与久病、轻微与严重之分，但无不根源于‘火’。然而，火有阴火与阳火的不同，治疗方法也因此截然不同。州尊大人虽然过去曾有失血病史，但那不过是一般的损伤类疾病，根源尚轻。今年入春以来，突然呕吐鲜血数盂，这说明出血非常猛烈。《内经》说：‘暴病非阳’（突发急症多不属于纯阳热证），那么它属于火邪这一点是明确的，但这绝不是阳火，这是很明显的。所谓阳火，是指五行之火，是天地间经常存在且持久的事物，怎么会如此暴烈呢？假如它是暴烈的，也可以用五行之水来克制，就不会显得暴烈了。唯有龙雷之火，潜伏在阴分之中，在它未发作时，人们不知道它是火；一旦发作，便猛烈得无法抵御，导致阴血随之上溢而出。龙雷之火的特性，必须等到阴云密布四合之时，才能顺势升腾；若是天晴日朗，它就会退藏不动。所以，凡是使用凉血清火药物的，都是用水制火的常规方法，应用在阴火上，没有不反而助长其肆虐的。
治疗的大法适宜用温补，而温补中的细微曲折之处，在于平时就要讲明透彻。《内经》说：‘少阴之脉萦舌本’，意思是肾脉环绕在舌根之间。又说：‘咯血者属肾’。明白了阴火发于阴分，其血咯出成块，这与咳嗽劳症中痰中带血的阳火是不同的。这个道理以前没有被阐明过。只有汉代的张仲景是医中之圣，他在《伤寒论》中告诫一条说：‘误发少阴汗，动其经血者，下竭上厥为难治。’后人只是顺着文字阅读，对于‘下竭上厥’的道理，总是搁置不讲。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。气和血是相互依附维系的，气如果没有血，就会散漫而无统摄；血如果没有气，就会凝滞而不流动。所以阴火妄动，阴气不得不向上奔涌；阴气上奔，阴血不得不随之上溢。阴血上溢，下部就枯竭了。血液既已上溢，伴随血液运行的气也散漫于胸中，不能返回本位，这就叫‘上厥’。阴气上逆，只不过到颈部为止，不能达到最高处的清阳之位，所以出现喉间堵塞、心慌、耳鸣、胸膈不适等症状。但这难道仅仅是堵塞不适而已吗？阴气长久居于上部，势必引起下方的龙雷之火相应发动，血不枯竭不止，气不逆乱不止。张仲景之所以断言为‘难治’，大概就是因为这个原因吧。但他只说‘难治’，并非说‘不治’。张仲景没有设立具体的治法，是因为另有《卒病论》十六卷，专门论述突发急症，只是后世已经散佚失传罢了。我现在为你大大地打开这扇门，认为治疗的第一要义是健脾中的阳气。健脾中的阳气，一举有三重好处：一是脾中的阳气旺盛，就像天晴日朗，龙雷之火就会潜伏；二是脾中的阳气旺盛，胸中堵塞的阴气就会像太空中不留一丝尘埃一样消散；三是脾中的阳气旺盛，饮食运化精微，就能重新生成下部枯竭的血液。况且地气必须先蒸腾土壤化为湿气，然后上升为云，如果土壤干燥而没有湿气，地气就在中间隔绝了，天气怎么能经常晴朗呢？现在的方书都只记载治疗阳火的方法，对于龙雷之火，徒有其名而没有治法，反而错误地引用久咳成痨、痰中带血的阳症案例，不敢用健脾作为先导。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？古代方剂治疗龙雷之火，常使用桂枝、附子引火归原的方法，然而应用于急性大出血的病症，可以暂时使用，不可长期服用。因为已经亏损的血液，恐怕不能制约药性的刚悍；而未动的血液，恐怕不可滋扰它。归根结底，治疗龙雷之火，完全以‘收藏’为主，因为秋冬时节龙潜雷伏。如果使用收藏的药物无效，稍微使用燥烈性质的药物作为向导，以示同气相求的意思就可以了。既然主张收藏，怎么敢随意使用燥烈药物呢？先生您素来有劳损失血的旧疾，正值上下气血俱虚，法令森严，人心想要逞强，心中惴惴不安，恐怕难免受挫。这是劳伤又加上忧恐，恐则伤肾，导致少阴之血无端溢出，这与张仲景所说的‘误发少阴汗动其血’的情况，起初并没有多少差异。更何况肝主谋虑，本性喜欢疏泄。冬季肾气不藏，早已供肝木汲取。如今春季将行，肝木居于青龙之位，掌管震雷之事，乘势当权行事。所以天时上的龙雷尚未发动，人体内的龙雷先发动了，血液已经暴涌而出。不知道在此后的春夏十二个月，龙雷大发之时，将用什么血液来奉养身体呢？大病必须用大药。所谓大药，就是顺应天时春夏的生长之气，而内心保持寂然如秋冬的收藏之性。古人用‘逃禅’二字非常妙。既然是‘逃’禅，那心境是怎样的呢？你以后遇到这种病，必须以崇土（健脾）为先。土厚则阴浊之气不升，血患必然停止。万物以土为根，元气以土为宅，不可以不急于研究。”
胡卣臣先生说：“当今世界失血症非常多，前面的四个医案，阐发了无穷的奥义，教诲殷切。这篇详细论述了阴火的来龙去脉，尤其弥补了千古以来的缺失。”
Student asked: "The Prefect suddenly fell seriously ill, vomiting several sheng of blood. His fingertips were slightly cold, there was a sensation of obstruction in his throat, and his voice was difficult to produce. The safety or danger of his condition depends on medical treatment. Some advocate using warming and tonifying herbs such as Renshen (Ginseng Radix) and Ejiao (Donkey-hide Gelatin); others advocate using cooling blood herbs such as Shengdi (Rehmanniae Radix) and Xuanshen (Scrophulariae Radix); still others advocate using fire-descending herbs such as Huangbai (Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma). Opinions are scattered and hard to follow. I implore you, Master, to clearly explain the rationale so as to enlighten my ignorance."
I replied: "Throughout history, discussions on hemorrhagic diseases have been mixed into the category of 'phlegm-fire', hence the explanations often miss the point. Let me explain it to you in detail. Blood diseases can be new or old, mild or severe, but all originate from 'fire'. However, fire differs in being either Yang fire or Yin fire, and the treatment methods are consequently vastly different. Although the Prefect had a history of previous hemorrhage, that was merely a type of injury with a relatively light root cause. Since entering spring this year, he has suddenly vomited several bowls of blood, indicating that the bleeding is violent. The Classic says: 'Acute illness is not Yang' (sudden acute conditions usually do not belong to pure Yang heat syndromes). Therefore, although it involves fire, it is clearly not Yang fire. Yang fire refers to the fire of the Five Elements, which is a constant and enduring phenomenon in heaven and earth; how could it be so violent? If it were violent, it could be subdued by the water of the Five Elements and would not appear so violent. Only the 'Dragon-Thunder Fire' lies hidden within the Yin aspect. When it has not yet moved, one does not know it is fire; once it erupts, it is violently uncontrollable, causing Yin blood to overflow upwards. The nature of Dragon-Thunder Fire requires dark clouds to gather around before it can ascend. If the sky is clear and sunny, it retreats and remains inactive. Therefore, any use of cooling blood and clearing fire medications follows the common method of using water to control fire. Applied to Yin fire, this invariably exacerbates its destructive power.
The general principle of treatment should favor warming and tonifying. However, the subtle nuances within warming and tonifying must be thoroughly understood beforehand. The Classic states: 'The Shaoyin meridian winds around the root of the tongue,' meaning the Kidney meridian encircles the base of the tongue. It also states: 'Hemoptysis belongs to the Kidney.' Understanding that Yin fire arises from within the Yin, the blood expectorated comes out in clots, which differs from the Yang fire seen in coughing consumptive diseases where blood is mixed with phlegm. This principle has never been elucidated before. Only Zhang Zhongjing of the Han Dynasty, the Sage among physicians, issued a warning in his Treatise on Cold Damage: 'Mistakenly inducing sweating in Shaoyin disturbs the channel blood, leading to exhaustion below and reversal above, which is difficult to treat.' Later generations simply read the text without discussing the rationale behind 'exhaustion below and reversal above.' They did not know that 'exhaustion below' refers to the depletion of Yin blood at the lower part, and 'reversal above' refers to the counterflow of Yin Qi to the upper part. Qi and Blood mutually support and attach to each other. Without Blood, Qi scatters without control; without Qi, Blood coagulates and fails to flow. Thus, when Yin fire moves, Yin Qi cannot help but rush upward; as Yin Qi rushes upward, Yin blood inevitably overflows upwards. As Yin blood overflows, the lower part becomes exhausted. Once blood overflows, the Qi accompanying it scatters in the chest and cannot return to its original position, which is called 'reversal above'. Yin Qi counterflows only up to the neck and cannot reach the highest position of clear Yang, resulting in sensations of throat obstruction, palpitations, tinnitus, and chest discomfort. But is it merely obstruction and discomfort? If Yin Qi resides in the upper part for a long time, it will inevitably trigger the Dragon-Thunder Fire below to respond. Bleeding will not stop until blood is exhausted, nor will it stop until Qi reversal is resolved. This is likely why Zhang Zhongjing judged it as 'difficult to treat.' He said only 'difficult to treat,' not 'untreatable.' Zhang Zhongjing did not establish specific treatment methods because he had another work, *Shu Bing Lun* (Treatise on Sudden Diseases), consisting of sixteen volumes, specifically discussing sudden acute illnesses, which has since been lost and transmitted nowhere. I now open this door widely for you: the primary principle of treatment is to strengthen the Yang Qi of the Spleen. Strengthening the Yang Qi of the Spleen yields three benefits: First, when the Yang Qi in the Spleen is vigorous, like a clear sunny day, the Dragon-Thunder Fire will lie dormant. Second, when the Yang Qi in the Spleen is vigorous, the Yin Qi obstructing the chest will dissipate like no dust remaining in the vast sky. Third, when the Yang Qi in the Spleen is vigorous, the transformation and transportation of food and fluids into essence will regenerate the depleted blood below. Moreover, Earth Qi must first evaporate soil moisture to form wetness, then rise to become clouds. If the soil is dry and lacks moisture, Earth Qi is isolated within, and how can Heaven's Qi remain clear? Current formularies only record methods for treating Yang fire. Regarding Dragon-Thunder Fire, they have only the name but no treatment. They erroneously cite cases of chronic cough leading to consumption with blood in sputum (Yang syndromes) and dare not use strengthening the Spleen as a precursor. They fail to consider that even if hemoptysis is accompanied by coughing, it is merely a cough caused by Qi counterflow and reversal; once Qi descends, the cough ceases. How much more so for those who originally had no cough? Ancient formulas for treating Dragon-Thunder Fire often used Guizhi (Cinnamon Twig) and Fuzi (Aconite Lateralis Radix Praeparata) to guide fire back to its source. However, applied to acute massive hemorrhage, this can be used temporarily but not chronically. The already depleted blood may not be able to restrain the fierce nature of the drugs, and the unmoved blood might be disturbed by nourishing agents. Ultimately, treating Dragon-Thunder Fire relies entirely on 'collecting and storing,' just as dragons hide and thunder rests in autumn and winter. If collecting and storing medications are ineffective, slightly using drying and acrid agents as guides to demonstrate the principle of similar energies attracting each other is acceptable. Since we advocate collection and storage, how dare we casually use drying and acrid agents? The Prefect has a history of damage and hemorrhage. Facing this situation where both upper and lower aspects are deficient, under strict regulations, and with human desires running wild, he is anxious and fears failure. This adds worry and fear to his劳伤 (labor-induced injury). Fear injures the Kidney, causing the blood of Shaoyin to overflow unexpectedly, which is initially no different from what Zhang Zhongjing described as 'mistakenly inducing sweating in Shaoyin disturbing the blood.' Furthermore, the Liver governs planning and loves free flow. During winter, when Kidney Qi was not stored, it had already been drawn upon by Liver Wood. Now that spring is approaching, Liver Wood occupies the position of the Azure Dragon and controls Thunder. Riding this authority, it acts. Thus, while the celestial Dragon-Thunder has not yet moved, the internal Dragon-Thunder of the body moves first, causing blood to surge violently. Who knows what blood will be available to sustain him during the twelve months of spring and summer, the time of vigorous Dragon-Thunder activity? Major illnesses require major medicines. The so-called major medicine is to align with the seasonal growth of spring and summer, while keeping the mind silent and still like autumn and winter. The ancients used the term 'fleeing to Zen' (Tao Chan), which is very apt. If it is called 'fleeing,' what must the state of mind be? In the future, when encountering this disease, you must prioritize strengthening the Earth element. When Earth is thick, turbid Yin will not ascend, and blood disorders will cease. All things take Earth as their root; Yuan Qi (Original Qi) takes Earth as its dwelling. This cannot be neglected."
Mr. Hu Youchen said: "Hemorrhagic diseases are very common in today's world. The preceding four cases have elucidated infinite profound meanings with earnest instruction. This article details the origins and course of Yin fire, particularly making up for a gap in knowledge that has existed for millennia."