内有干血。犹须峻药去之。则其虚未成者。更不可留邪为患。故实证断不可用补虚之方。而虚证则不废
实证诸方。恐其留邪为患也。或虚中实证。则攻补兼用。或十补一攻。在医者之善治焉。
以上所论。吐血始终治法略备。惟于兼证变证不及详言。另立门类。缕分条析。查证治者。可以钩考而得
之。
吐血者。其血撞口而出。血出无声。呕血者。血出有声。重则其声如蛙。轻则呃逆。气不畅遂而已。同是血出
口中。治与吐血无异。但吐无声。而呕有声。证既小异。而治法若不加详。安能丝丝入彀。以轻重论。则吐轻
而呕重。吐则其气尚顺。呕则其气更逆也。以脏腑论。吐血其病在于胃。呕血其病在于肝。何以言之。盖肝
木之气。主于疏泄脾土。而少阳春生之气。又寄在胃中。以升清降浊。为荣卫之转枢。故伤寒论少阳为病。
有干呕呕吐不止之病。是少阳转枢不利。清气遏而不升。浊气逆而不降也。金匮呕涎沫头痛胸满者。吴
茱萸汤主之。取吴萸降肝之浊气。肝气降而呕自止。是肝木失其疏泄之常。横肆侮土。故成呕逆。主用吴
茱萸。降肝之浊气。肝气不逆。则呕止矣。由此观之。可知凡呕皆属肝胆。而血又肝之所司。今见呕血之证。
断以调肝为主。诸家皆言呕血出于肝。而未详其理。吾故旁引金匮伤寒。以证明之。但金匮伤寒之呕。乃
杂病之呕。属于气分者也。而失血之呕。则专主血分。治法自有不同耳。
先干呕。然后呕血。呕血后仍发干呕者。皆少阳之逆气也。用大柴胡汤。加蒲黄丹皮桃仁当归治之。呕血
既止。再服小柴胡汤。以调和荣卫。转枢表里。上焦得通。津液得下。胃气因和。呕哕自止。血自安静。而不上
潮矣。然肝胆相连。胆病未有不及肝者。丹栀逍遥散。可并治之。
但呕不吐。属少阳。呕吐兼有。属肝经。肝气善怒。其火最横。观伤寒论。肝气侮肺名曰纵。刺期门。肝气侮脾
名曰横。刺期门。皆取刺法以泻之。则知肝气怒逆。而为呕逆。尤宜攘除肝火。不可纵敌为患。今本仲景刺
法之意。变用汤药。宜当归芦荟丸。加丹皮蒲黄。凡发怒呕血。以及肝气横逆。其证恶闻人声。欲死不欲生。
欲按剑杀人。及惊狂骂詈。不认亲疏。皆肝经无情之火。非此大剂不能歼除。若此时因循。延至日久。病气
未衰。正气先衰。虚中挟实。不攻不愈。欲攻不堪。是犹宋用贾似道。养奸为患。至国促而始去之。晚矣。若审
其病稍轻者。但须凉肝血。调胃气。则呕血自止。犀角地黄汤。加柴胡枳壳。服后血止。再服逍遥散。加阿胶
牡蛎香附以收功。
有平时呕酸呕苦。以及失血之后。常呕酸苦者。呕酸是湿热。试观夏月热汤过夜。则变为酸味。便知呕酸
是湿热。呕苦是相火。胆寄相火。胆汁苦。故相火之味。能变胃津使苦。宜借用左金丸。再加血分药。以治血
分为宜。盖此二药。辛苦降泄。治血药中。以为引导尤效。
呕血止后。如肝胆火旺。血虚烦躁。颊赤口渴。胸胁刺痛。发热盗汗。魂梦不安。此乃相火内炽。欲作骨蒸痨
瘵。宜柴胡清骨散以治之。如兼咳嗽。喉间作痒。乃肝肺之气不相调协。宜用四逆散。香苏引。再加杏仁枳
壳枯芩知母当归白芍治之。如咽喉中常若有气哽塞。善哕气打呃者。乃肝与心之气不畅故也。香苏饮。
加柴胡薄荷射干牛蒡子尖贝当归旋复花治之。逍遥散尤为治肝经之要药。加减得宜。皆能应手而取效也。
呕虽属于肝胆。然亦未有不关胃府者也。胃气逆上。治法已详吐血门。今并为医者补言之。凡血证带呕
者。但治其血。血止而呕自止。凡呕证带血者。有如回食病。呕后见血水。此胃逆血枯。难治之证。大半夏汤。
麦门冬汤治之。玉女煎。加蒲黄麻仁亦效。四物汤。加甘草寸冬枳壳茯苓藕汁萝卜汁生姜荆竹油。皆清
利胃气。养血止呕之药。
此篇论血。单以呕血论。然失血证。未有单见一证。而不兼见诸证者。今欲详其条目。不得不分门立说。至
于用方。则须参考诸证而变化之。若拘守一门。以求方治。岂不胶柱鼓瑟。
胃中有干血（久留体内的瘀血），仍需用峻猛的药物将其祛除。如果此时虚证尚未形成，更不可留邪气为患。因此，实证绝对不可使用补虚的方剂；而虚证则不废弃治疗实证的诸方，这是担心留邪为患的缘故。如果是虚中夹实的证候，则攻邪与补虚兼用，或者采用十补一攻的比例，这取决于医生善于调理把握。
以上所论述的，吐血始终的治疗法则大致完备了。只是对于兼证和变证没有详细言说，另外设立门类，逐一分析条理，查证治疗的医者，可以由此钩考获得。
吐血的特征是血液冲撞口腔而出，出血时没有声音；呕血则是血液排出时有声音，重时声音像青蛙叫，轻时表现为呃逆，是气机不畅顺罢了。同样是血液从口中排出，治疗方法与吐血无异。只是吐血无声，而呕血有声，证候既然有细微差别，如果治疗方法不加详细区分，怎么能丝丝入扣、精准对应呢？从轻重程度来看，吐血较轻而呕血较重。吐血时气机尚且顺降，呕血时气机更加上逆。从脏腑归属来看，吐血病位在胃，呕血病位在肝。为什么这样说呢？因为肝木之气，主司疏泄脾土，而少阳春生之气，又寄寓在胃中，负责升清降浊，作为营卫运行的枢纽。所以《伤寒论》中提到少阳病，有干呕、呕吐不止的病证，这就是少阳转枢功能不利，清气被遏不能上升，浊气上逆不能下降的缘故。《金匮要略》中提到呕涎沫、头痛、胸满者，用吴茱萸汤主治。取吴茱萸来降泄肝中的浊气，肝气下降则呕吐自然停止。这是肝木失去了其疏泄的正常功能，横逆侵犯脾胃，从而形成呕逆。主要使用吴茱萸，降泄肝之浊气，肝气不逆，则呕吐自止。由此看来，可知凡是呕吐都归属于肝胆，而血液又由肝所主管。现在见到呕血的证候，断定以调治肝脏为主。各家都说呕血出于肝，但没有详细说明其中的道理，所以我旁征博引《金匮要略》和《伤寒论》，来证明这一观点。但是，《金匮要略》和《伤寒论》中的呕吐，属于杂病的呕吐，归属于气分；而失血引起的呕吐，则专门归属于血分，治疗方法自然有所不同。
先出现干呕，然后呕血，或者呕血之后仍然发生干呕的，都是少阳经逆气所致。用大柴胡汤，加蒲黄、丹皮、桃仁、当归来治疗。待呕血停止后，再服用小柴胡汤，以调和营卫，转枢表里。上焦通畅，津液下行，胃气因而调和，呕哕自然停止，血液自然安静而不向上涌溢。然而肝胆相连，胆有病没有不波及肝脏的，丹栀逍遥散可以同时治疗。
只有呕吐而没有吐血，属于少阳经；呕吐和吐血兼有，属于肝经。肝气容易发怒，其火气最盛横暴。观察《伤寒论》，肝气侮肺称为“纵”，刺期门穴；肝气侮脾称为“横”，也刺期门穴。这都是取针刺的方法来泻除邪气。由此可知，肝气愤怒上逆而导致呕逆，尤其应当清除肝火，不可放纵敌人成为祸患。现在本乎仲景针刺法的意旨，改用汤药，适宜用当归芦荟丸，加丹皮、蒲黄。凡是因发怒导致呕血，以及肝气横逆，证候表现为厌恶听到人声，想死不想活，想要按剑杀人，以及惊狂骂詈，不认识亲疏关系，这些都是肝经无情之火，不用这种大方剂不能歼除。如果此时犹豫拖延，延至日久，病气未衰，正气先衰，虚中挟实，不攻伐不能痊愈，但身体虚弱又难以承受攻伐，这就像宋朝任用贾似道，养奸为患，直到国家危亡时才去除他，已经晚了。如果审察病情稍轻的，只需凉肝血，调胃气，则呕血自止。犀角地黄汤，加柴胡、枳壳，服用后血止，再服用逍遥散，加阿胶、牡蛎、香附来收功。
有平时呕吐酸水或苦水，以及在失血之后，经常呕吐酸苦水的。呕吐酸水是湿热所致，试看夏天热汤过夜，就会变成酸味，便知呕吐酸水是湿热。呕吐苦水是相火所致，胆寄居相火，胆汁味苦，所以相火的味道，能使胃津变得苦涩。适宜借用左金丸，再加血分药，以治疗血分为宜。因为这两类药物，辛苦降泄，在治疗血分的药物中作为引导尤为有效。
呕血停止后，如果肝胆火旺，血虚烦躁，脸颊发红口渴，胸胁刺痛，发热盗汗，魂梦不安，这是相火内炽，将要发展为骨蒸痨瘵。适宜用柴胡清骨散来治疗。如果兼有咳嗽，喉间作痒，这是肝肺之气不相调协，适宜用四逆散，配合香苏饮，再加杏仁、枳壳、枯芩、知母、当归、白芍来治疗。如果咽喉中常好像有气哽塞，喜欢打嗝呃逆的，这是肝与心之气不畅的缘故。用香苏饮，加柴胡、薄荷、射干、牛蒡子、川贝母、当归、旋复花来治疗。逍遥散更是治疗肝经的重要药物，加减得当，都能应手取效。
呕吐虽然归属于肝胆，但也无不关系到胃腑的。胃气上逆，治疗方法已在吐血门中详细论述，现在一并补充给医者知晓。凡是血证伴有呕吐的，只要治疗其血，血止而呕吐自然停止。凡是呕吐证伴有血的，有如回食病，呕吐后见血水，这是胃气上逆、血液枯竭，属于难治的证候。用大半夏汤、麦门冬汤治疗。玉女煎，加蒲黄、麻仁也有效。四物汤，加甘草、寸冬、枳壳、茯苓、藕汁、萝卜汁、生姜、荆竹油，都是清利胃气，养血止呕的药物。
本篇论述血证，单独以呕血来论述。然而失血证，没有单独出现一个证候，而不兼见其他证候的。现在想要详细列出条目，不得不分门立说。至于使用方剂，则须参考各种证候而变化运用。如果拘泥守于一门，以求方治，岂不是胶柱鼓瑟（比喻拘泥成法，不知变通）吗？
There is dried blood (stasis blood retained for a long time) within the interior. It is still necessary to use potent medicines to eliminate it. If deficiency has not yet formed, one must certainly not leave pathogenic factors to cause harm. Therefore, excess syndromes absolutely cannot use formulas for tonifying deficiency; whereas for deficiency syndromes, one does not discard all formulas used for excess syndromes, fearing that leaving pathogens will cause harm. In cases of deficiency with excess complications, attack and tonification are used simultaneously, or in a ratio of ten parts tonification to one part attack, depending on the physician's skillful management.
The above discussion roughly covers the treatment principles for hematemesis throughout its course. However, it does not detail concurrent syndromes and transformed syndromes; these are established in separate categories and analyzed item by item. Physicians verifying treatments can derive them through this examination.
In hematemesis (vomiting blood forcefully), blood spurts out of the mouth without sound. In emesis of blood (vomiting blood with effort/noise), there is sound upon expulsion; when severe, the sound resembles a frog's croak; when mild, it manifests as hiccuping, merely indicating unsmooth qi flow. Although both involve blood exiting the mouth, the treatment is no different from hematemesis. The distinction lies in hematemesis being silent while emesis of blood is noisy. Since the syndromes differ slightly, if treatment methods are not detailed, how can they fit precisely like threads entering an eye? Regarding severity, hematemesis is lighter and emesis of blood is heavier. In hematemesis, qi remains relatively smooth; in emesis of blood, qi is more rebellious. From the perspective of zang-fu organs, hematemesis originates in the Stomach, while emesis of blood originates in the Liver. Why is this so? The Qi of Liver Wood governs the dredging and draining of Spleen Earth, and the Shaoyang (Lesser Yang) spring-generating Qi resides within the Stomach, responsible for ascending clear turbidity and descending cloudy turbidity, serving as the pivot for Ying and Wei circulation. Thus, in the *Shanghan Lun* (Treatise on Cold Damage), Shaoyang disease presents with dry retching and incessant vomiting, indicating that the Shaoyang pivot function is impaired: clear Qi is obstructed and fails to ascend, while turbid Qi rebels and fails to descend. In the *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet), cases of vomiting saliva/froth, headache, and chest fullness are treated with Wuzhuyu Tang (Evodia Decoction). Evodia fruit is used to descend the turbid Qi of the Liver; once Liver Qi descends, vomiting stops naturally. This occurs because Liver Wood loses its normal dredging and draining function, invading Earth horizontally, thus forming rebellious vomiting. Using Evodia primarily descends Liver turbid Qi; if Liver Qi does not rebel, vomiting ceases. From this, we can see that all vomiting belongs to the Liver and Gallbladder, and since blood is governed by the Liver, seeing emesis of blood dictates that treatment should focus on regulating the Liver. Various schools state that emesis of blood comes from the Liver but fail to explain the rationale. Therefore, I cite the *Jingui Yaolue* and *Shanghan Lun* to prove this. However, the vomiting in these texts refers to miscellaneous disease vomiting belonging to the Qi level, whereas vomiting due to blood loss specifically belongs to the Blood level, so treatment methods naturally differ.
If dry retching occurs first, followed by emesis of blood, or if dry retching persists after emesis of blood, this is due to rebellious Qi of the Shaoyang channel. Treat with Dachaihu Tang (Major Bupleurum Decoction) plus Puhuang (Cattail Pollen), Danpi (Moutan Bark), Taoren (Peach Seed), and Danggui (Angelica Sinensis). Once emesis of blood stops, administer Xiaochaihu Tang (Minor Bupleurum Decoction) to harmonize Ying and Wei and pivot the exterior and interior. When the Upper Jiao is unobstructed and fluids descend, Stomach Qi becomes harmonious, retching and hiccups cease, blood calms down, and stops surging upward. Since the Liver and Gallbladder are connected, gallbladder disease invariably affects the liver; Danshi Xiaoyao San (Red Peony and Gardenia Rambling Powder) can treat both.
Vomiting without spitting blood belongs to the Shaoyang; vomiting accompanied by spitting blood belongs to the Liver channel. Liver Qi is prone to anger, and its fire is most rampant. Observing the *Shanghan Lun*, when Liver Qi insults the Lung, it is called "Zong" (Vertical/Unrestrained); puncture Qimen (LR14). When Liver Qi insults the Spleen, it is called "Heng" (Horizontal/Excessive); also puncture Qimen. These utilize needling to drain the pathogen. Thus, when Liver Qi anger and rebellion cause vomiting, it is especially appropriate to dispel Liver Fire and not let the enemy go unchecked. Following Zhongjing's intent from needling, we now use decoctions: Danggui Luye Wan (Angelica and Aloe Pill) plus Danpi and Puhuang is suitable. For any emesis of blood caused by anger, or Liver Qi rebelling horizontally, presenting with aversion to human voices, desire to die rather than live, urge to kill with a sword, mania, cursing, and ignoring kinship ties, these are ruthless fires of the Liver channel. Only large-dose prescriptions can eradicate them. If one hesitates and delays, allowing the condition to persist until the pathogen remains strong while healthy Qi declines, resulting in deficiency with excess complications, neither attacking nor tonifying works well, yet attacking is unbearable due to weakness. This is like Song Dynasty employing Jia Sidao, nurturing treachery until the nation was near collapse before removing him—too late. If the disease is assessed as milder, simply cool Liver Blood and regulate Stomach Qi, and emesis of blood will stop. Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) plus Chaihu and Zhike, taken until bleeding stops, followed by Xiaoyao San (Rambling Powder) plus Ejiao (Donkey-hide Gelatin), Muli (Oyster Shell), and Xiangfu (Cyperus Rhizome) to conclude treatment.
Those who usually vomit sour or bitter fluids, or frequently vomit sour/bitter fluids after blood loss: Vomiting sour indicates Damp-Heat. Observe that hot soup left overnight in summer turns sour; thus, vomiting sour is Damp-Heat. Vomiting bitter indicates Ministerial Fire. The Gallbladder houses Ministerial Fire, and bile is bitter; thus, the taste of Ministerial Fire can alter Stomach fluids to become bitter. Borrow Zuojin Wan (Left Metal Pill) plus blood-level medicines is appropriate for treating the blood level. These two types of medicines are pungent, bitter, descending, and draining; used as guides among blood-treating herbs, they are particularly effective.
After emesis of blood stops, if Liver/Gallbladder fire is hyperactive, Blood deficiency causes irritability, cheeks are red with thirst, chest/hypochondriac stabbing pain, fever with night sweats, and restless dreams, this is Ministerial Fire blazing internally, potentially developing into bone-stealing consumption (Gu Zheng Lao Zhai). Treat with Chaihu Qinggu San (Bupleurum Clearing Bone Decoction). If accompanied by cough and throat itching, this is disharmony between Liver and Lung Qi. Use Sixian San (Four Reversal Powder) combined with Xiangsu Yin (Perilla Drink), plus Xingren (Apricot Seed), Zhike (Aurantium Fructus), Kuxin Pi (Phellodendron Bark), Zhimu (Anemarrhena Rhizome), Danggui, and Baishao (White Peony Root). If there is a constant sensation of Qi obstruction in the throat, frequent belching and hiccups, this is unsmooth Qi between Liver and Heart. Use Xiangsu Yin plus Chaihu, Bohe (Mint), Shegan (Belamcanda Rhizome), Niubangzi (Arctium Fruit), Tianbeimu (Fritillaria Bulb), Danggui, and Xuanfuhua (Inula Flower). Xiaoyao San is a crucial herb for treating Liver channel disorders; with appropriate modifications, it yields prompt results.
Although vomiting belongs to the Liver and Gallbladder, it always involves the Stomach Fu organ. Stomach Qi rebelling upward was detailed in the Hematemesis section; I supplement this for physicians here. For blood syndromes accompanied by vomiting, treat the blood; once blood stops, vomiting stops naturally. For vomiting accompanied by blood, such as in "Huishi Bing" (Regurgitation Disease) where bloody fluid appears after vomiting, this is Stomach Qi rebellion and Blood exhaustion—a difficult-to-treat syndrome. Banxiaren Tang (Pinellia and Semen Trichosanthis Decoction) and Maimendong Tang (Ophiopogon Decoction) treat it. Yinvu Jian (Jade Woman Decoction) plus Puhuang and Hama Ren (Hemp Seed) is also effective. Siwu Tang (Four Substances Decoction) plus Gancao (Licorice), Cundong (Ophiopogon), Zhike, Fuling (Poria), Oujiang (Lotus Root Juice), Luobojiang (Radish Juice), Shengjiang (Fresh Ginger), and Jingzhuyou (Bamboo Sap) are all clearing, draining, Stomach-regulating, Blood-nourishing, and anti-emetic agents.
This chapter discusses blood, focusing solely on emesis of blood. However, no blood-loss syndrome presents as a single isolated symptom without accompanying others. To detail items, I had to establish separate categories. Regarding formula usage, one must refer to various syndromes and adapt accordingly. If one rigidly adheres to one category to seek treatment, is it not like gluing the tuning pegs of a zither (being inflexible and unable to adapt)?