寸口脉动而弱。动即为惊。弱则为悸。
〔沈〕惊从外入。悸是内发。悸者心神恍惚。跳动不能自主之貌也。
〔徐〕前奔豚章。既言有惊怖。有
火邪。皆从惊发得之。此又另揭惊悸言之。非详其病所从得。乃谓病有惊狂不安者。有只心悸不宁者。惊乃邪
袭于心在实边。故其寸口脉动。动者有粒如豆也。悸乃神不能主在虚边。故其寸口脉弱。弱脉来无力也。
动而弱者。有邪袭之而心本原虚也。故惊悸并见。然而脉仍分属。动则惊气之发。弱则悸气所形。
故曰。动即为惊。弱则为悸。
师曰。尺脉浮。目睛晕黄。衄未止。晕黄去。目睛慧了。知衄今止。（尺。赵程金鉴。作夫。巢源作尺中自
浮。未上。有必字。脉经云。问曰。病衄连日不止。其脉何类。师曰。脉来轻轻在肌肉。尺中自溢。注。
一云。尺脉浮。以下与本文同。）
〔尤〕尺脉浮。知肾有游火。目睛晕黄。知肝有蓄热。衄病得此。则未欲止。盖血为阴类。为肾肝之火
热所逼。而不守也。若晕黄去。目睛且慧了。知不独肝热除。肾热亦除
矣。故其衄今当止。
又曰。从春至夏衄者太阳。从秋至冬衄者阳明。
〔尤〕血从阴经。并冲任而出者。则为吐。从阳经并督脉而出者。则为衄。故衄病皆在阳经。但
春夏阳气浮。则属太阳。秋冬阳气伏。则属阳明为异耳。所以然者。就阴阳言。
则阳主外阴主内。就三阳言。则太阳为开。阳明为阖。少阳之脉。不入鼻 。故不主衄也。
衄家不可汗。汗出必额上陷。脉紧急。直视。不能 。不得眠。
〔尤〕血与汗皆阴也。衄家复汗。则阴重伤矣。脉者血之府。额上陷者。额上两旁之动脉。因血脱
于上。而陷下不起也。脉紧急者。寸口之脉。血不荣。而失其柔。如木无液而枝乃劲也。直视不 不眠者。
阴气亡。则阳独胜也。经云。夺血者无汗。此之谓夫。（详伤寒论辑又太阳中篇。）
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。（巢源。寒热上。无无字。赵徐沈尤。并无血色之血字。）
〔程〕灵枢经曰。血脱者夭然不泽。上经曰。男子面色薄者。主渴及亡血。今病患面无血色。脱血
之象也。上经曰。男子脉虚沉弦。无寒热。时目瞑兼衄。今无寒热。而脉弦衄者。则与上证不殊。为劳证也。
若脉浮弱。手按之绝者。有阳无阴也。故知下血烦咳者。病属上焦也。故知吐血。
〔尤〕无寒热。病非外
感也。衄因外感者。其脉必浮大。阳气重也。衄因内伤者。其脉当沉弦。阴气厉也。虽与前尺脉浮不同。
其为阴之不靖则一也。若脉浮弱。按之绝者。血下过多。而阴脉不充也。烦咳者。血从上溢。而心肺焦燥也。
此皆病成而后见之诊也。
夫吐血。咳逆上气。其脉数而有热。不得卧者死。（巢源。数下。有浮大二字。）
〔尤〕脉数身热。阳独胜也。吐血咳逆上气不得卧。阴之
烁也。以既烁之阴。而从独胜之阳。有不尽不已之势。故死。
夫酒客。咳者必致吐血。此因极饮过度所致也。
〔徐〕此言吐血。不必由于气不摄血。亦不必由于阴火炽盛。其有酒客而致咳。则肺伤已极。又为
咳所击动。必致吐血。故曰极饮过度所致。则治之者。当以清酒热为主也。
三因方云。病者因饮食过度伤胃。或胃虚不能消化。致翻呕吐逆。物与气上冲蹙胃口。决裂所伤吐出。
其色鲜红。心腹绞痛。白汗自流。名曰伤胃吐血。理中汤能止之者。以其功最理中脘。分利阴阳。安定血脉。（
证治要诀。加葛根川芎。）或只煮干姜甘草汤。饮之亦妙。方见养生必用。
寸口脉弦而大。弦则为减。大则为芤。减则为寒。芤则为虚。寒虚相击。此名曰革。妇人则半产漏下。
男子则亡血。
〔尤〕此条已见虚劳病中。仲景复举之者。盖谓亡血之证。有从虚寒得之者耳。
亡血。不可发其表。汗出即寒栗而振。（太阳中篇。脉经。血下。有家字。）
〔鉴〕凡失血之后。血气未复。为亡血也。皆不可发汗。失血之初。固属阳热。亡血之后。热随血去。
热虽消。而气逐血虚。阳亦微矣。若发其汗。则阳气衰微。力不能支。故身寒噤栗。而振振耸动也。发阴虚
之汗。汗出则亡阴。即发吐衄之汗也。故见不得 不得眠。亡阴之病也。发阳虚之汗。汗出则亡阳。即发亡
血之汗也。故见寒栗而振。亡阳之病也。李 曰。夺血者无汗。以汗与血。俱为心液。血亡液竭。无
复余液作汗也。今又发表。则阴虚且更亡阳。表间卫气虚极。
故寒栗而振。
病患胸满唇痿。舌青口燥。但欲漱水。不欲咽。无寒热。
脉微大来迟腹不满。其人言我满。为有瘀血。（此下。脉经有当汗出不出内结亦为瘀血十一字。）
〔鉴〕表实无汗。胸满而喘者。风寒之胸满也。里实便涩。胸满烦热者。热壅之胸满也。面目浮肿。胸
满喘不得卧者。停饮之胸满也。呼吸不快。胸满大息。而稍宽者。气滞之胸满也。今病患无寒热他病。惟胸满
唇痿。舌青口燥。漱水不欲咽。乃瘀血之胸满也。唇舌。血华之处也。血病不荣。故痿瘁色变也。热在血分。故
口燥。漱水不欲咽也。脉微大来迟。阴凝之诊。则当腹满。今腹不满。询之其人言我满。在胸不在腹也。与上
如是之证推之。为有瘀血也。
〔沈〕假令气分热盛。则腹胀满。今腹不满。而言我满者。乃外虽不满。
五内血壅气滞而胀。故言我满。知是瘀血也。
案程云。唇痿未详所以。误。
病者如热状。烦满口干燥而渴。其脉反无热。此为阴伏。是瘀血也。当下之。（阴伏之伏。赵本作状。非。）
〔鉴〕此承上文。互详证脉。以明其治也。如热状。即所谓心烦胸满。口干燥渴之热证也。其人当得
数大之阳脉。今反见沉伏之阴脉。是为热伏于阴。乃瘀血也。血瘀者当下之。宜桃核承气抵当汤丸之类也。
火邪者。桂枝去芍药加蜀漆牡蛎龙骨救逆汤主之。（沈不载此条。）
〔程〕此章。当在第八篇中。简脱在此。
〔尤〕此但举火邪二字。而不详其证。按伤寒论云。伤寒脉浮。
医以火迫劫之。亡阳必惊狂。起卧不安。又曰。太阳病。以火熏之。不得汗。
其人必躁。到经不解。必圊血。名为火邪。仲景此条。殆为
惊悸下血备其证欤。桂枝汤。去芍药之酸。加蜀漆之辛。盖欲使火气与风邪。一时并散。而无少有留滞。所
谓从外来者。驱而出之于外也。龙骨牡蛎。则收敛其浮越之神与气尔。
案外台奔豚气门。引短剧云。师曰。病有奔豚。有吐脓。有惊怖。有火邪。此四部病者。皆从
惊发得之。火邪者。桂枝加龙骨牡蛎汤主之。据此则程注为是。
桂枝救逆汤方
桂枝（三两去皮） 甘草（二两炙） 生姜（三两） 牡蛎（五两熬） 龙骨（四两）
大枣（十二枚） 蜀漆（三两洗去腥）
上为末。以水一斗二升。先煮蜀漆。减二升。内诸药。
煮取三升。去滓。温服一升。（为末。宋板伤寒论。作七味。是。）
心下悸者。半夏麻黄丸主之。（脉经。无此条。）
〔鉴〕此方是治寒水心下悸者。与首条之脉弱悸病不合。必是错简。
半夏麻黄丸方（肘后无方名。）
半夏（肘后云汤洗去滑干） 麻黄（等分）
上二味。末之。炼蜜和丸。小豆大。饮服三丸。日三服。
按服三丸甚少。本草纲目。作三十丸。似是。然要之此方可疑。
吐血不止者。柏叶汤主之。
〔徐〕此重不止二字。是谓寒凉止血药。皆不应矣。吐血本由阳虚。不能导血归经。然血亡而阴亏。
故以柏叶之最养阴者为君。艾叶走经为臣。而以干姜温胃为佐。马通导大便下为使。愚意无马通。童便亦得。
按本草载此方。乃是柏叶一把。干姜三升。阿胶一挺。炙合煮。入马通一升。未知孰
是。候参。
〔程〕中焦受气。取汁变化。而赤。是谓血。血
者内溉脏腑。外行肌肤。周流一身。如源泉之混混。得热则迫血妄行。而作吐衄。即后泻心汤之证是也。得
寒则不与气俱行。渗于胃中。而作吐。故有随渗随出。而令不止。柏叶汤者。皆辛温之剂。神农经曰。柏
叶主吐血。干姜止唾血。艾叶止吐血。马通者。白马屎也。凡屎必达洞肠乃出。故曰
通。亦微温。止吐血。四味皆辛温行阳之品。使血归经。遵行隧道。而血自止。
柏叶汤方（外台。引仲景伤寒论。千金。无方名。）
柏叶 干姜（各三两○千金作二两外台作青柏叶三两干姜二两切） 艾（三把○千金作一把）
上三味。以水五升。取马通汁一升。合煮取一升。分温
再服。（案外台。作上三味。以水五升。煮取一升。去滓。别绞取新出马通汁。一升。相
合煎。取一升。绵滤之。温分再服。马通。是马屎汁也。一方有阿胶。无艾。外台为是。
○证类本草云。马屎名马通。止崩中吐下血金疮。止血。）
千金。治吐血内崩。上气面色如土方。（即本方。注云。仲景柏叶
汤。不用阿胶。短剧。不用柏叶。与肘后同。）
又治上焦热膈伤。吐血衄血。或下血连日不止欲死。
于本方。去柏叶。用竹茹阿胶。
下血。先便后血。此远血也。黄土汤主之。（远。原本作近。误。今据诸本校改。）
〔程〕先便后血。以当便之时。血亦随便而下行。内经曰。结阴者。便血一升。再结二升。三结三升。
以阴气内结。不得外行。血无所禀。渗入肠间。故上经曰小肠有寒者。其人下重便血。夫肠有夹层。其
中脂膜联系。当其和平。则行气血。及其节养失宜。则血从夹层。渗入肠中。非从肠外而渗
入肠中也。渗而即下。则色鲜。渗而留结。则色黯。内经曰。
阴脉不和。则血留之。用黄土附子之气浓者。血得温即循经
而行也。结阴之属。宜于温补者如此。
〔鉴〕先便后血。此远血也。谓血在胃也。即古之所谓结阴。今之
所谓便血也。先血后便。此近血也。谓血在肠也。即古之所谓肠 为痔下血。今之所谓脏毒肠风下血也。赵
良曰。肠胃。阳明经也。以下血言胃居大肠之上。若聚于胃。必先便后血。去肛门远。故曰远血。若聚大肠。
去肛门近。故曰近血。
〔尤〕黄土温燥入脾。合白术附子。以复健行之气。阿胶地黄甘草。以益脱竭
之血。而又虑辛温之品。转为血病之厉。故又以黄芩之苦寒。防其大过。所谓有制之师也。
黄土汤方（〔原注〕亦主吐血衄血。○外台引仲景伤寒论。○千金治卒吐血。及衄血方。）
甘草 干地黄（千金用干姜注云仲景用地黄） 白术 附子（炮○千金无）
阿胶（外台有炙字） 黄芩（各三两） 灶中黄土（半斤○千金作伏龙肝半升外台作釜灶下黄焦土半升绵裹）
上七味。以水八升。煮取三升。分温二服。（外台。作煮六味取二升。去滓。内胶令烊。）
下血。先血后便。此近血也。赤小豆当归散主之。（方见狐惑中。）
〔程〕此内经。所谓饮食不节。起居不时。则阴受之。阴受之。则入五脏。为肠 下血之属。故用当归。
以和血脉。赤豆以清脏毒。与黄土汤不侔也。梅师方云。热毒下血。或食热物发动。以赤小豆为末。水
调服。则知此方治脏毒下血。黄土汤。治结阴下血。有霄壤之分也。
徐氏医法指南云。先血后便。近血也。大肠血也。感而
即发。俗谓之肠风。赤小豆当归散主之。先便后血。远血也。胃血也。积久而发。俗谓之脏毒。黄土汤主之。
案千金。诸下血。先见血后见便。此为远血。宜服黄土
汤。先见便后见血。此为近血。宜服赤小豆散。此远近二字互误。三焦虚实门。有远血近血二方。主疗与本
经同。而千金翼论。及外台引崔氏。亦误。张氏医通。却以金匮为传写之误。尤非也。巢源云。大便下血。
鲜而腹痛。冷气在内。亦大便下。其色如小豆汁。出时疼。而不甚痛。前便后下血
者。血来远。前下血后便者。血来近。此亦可以证耳。
备预百要方。血痢方。
赤小豆（三升炒令熟） 当归（三两）
上二味。捣筛为散。服方寸匕。日三。薄粥温下。
千金伏龙肝汤 治下焦虚寒损。或先见血后便转。此为近血。或利不利方。
伏龙肝（五合末） 干地黄（五两） 阿胶 牛膝 甘草 干姜 黄芩 地榆（各三两） 发灰（二合）
上九味 咀。以水九升。煮取三升。去滓。下胶煮消。下发灰。分为三服。（张氏衍义云。可见治血。
但取归经。不必究其先后远近耳。）
又续断止血汤。治下焦虚寒损。或先便转后见血。此为远血。或利或不利。好因劳冷即发。
续断 当归 桂心 蒲黄 阿胶（各一两） 甘草（二两） 干姜 干地黄（各四两）
上八味 咀。以水九升。煮取三升半。去滓。下胶取烊。
下蒲黄。分三服。（张氏衍义云。验其血色。晦淡则当用金匮法。鲜紫当用千金法。方为合辙。）
医林方。阿胶丸。治便血先便而后血。谓之湿毒。
阿胶（一钱） 黄连（三钱） 白茯苓（二钱） 白芍药（四钱）
上为细末。水和为丸。如桐子大。每服五十丸。加至一百丸。温水送下。日进四五服。
寸口脉象跳动而弱。脉动主惊证，脉弱主悸证。
〔沈〕惊邪从外部侵入，悸证由内部产生。所谓悸，是指心神恍惚、心脏跳动不能自主的状态。
〔徐〕在前面的奔豚病章节中，已经提到有惊恐恐惧，有火邪致病，都是从惊扰引发的。这里又单独提出惊和悸来论述，并非详细探究病因来源，而是说明病症中有因惊致狂乱不安的，也有仅表现为心悸不宁的。惊是邪气侵袭心脏，属于实证范畴，所以寸口脉呈现“动”象。“动”脉的特征是有颗粒感，状如豆粒跳动。悸是神志不能主宰，属于虚证范畴，所以寸口脉呈现“弱”象。“弱”脉指脉搏来势无力。既有邪气侵袭，而心之本原又虚，所以惊和悸同时出现。然而脉象仍分别归属不同病机：脉动反映惊气的发作，脉弱反映悸气的形态。所以说，脉动即为惊证，脉弱即为悸证。
老师说：尺部脉象浮，眼睛周围发黄模糊，鼻出血尚未停止。如果眼周黄晕消退，眼神变得清明，可知鼻出血现在已停止。（关于“尺”，赵开美、程林、金鉴注本作“夫”，《诸病源候论》作“尺中自浮”，未上句前有“必”字。《脉经》记载：问：鼻出血连日不止，其脉象如何？老师说：脉来轻轻在肌肉层，尺部自然溢出。注：一说为尺脉浮，以下与本文相同。）
〔尤〕尺脉浮，提示肾中有游移之火；眼目睛黄晕，提示肝中有蓄积之热。鼻出血病若见此脉症，则血难以止住。因为血属阴类，被肾肝之火的热力逼迫，而不能安守。如果黄晕消退，眼神清明，不仅知肝热已除，肾热也已清除，所以鼻出血现在应当停止。
又说：从春季到夏季发生的鼻出血，属于太阳经病变；从秋季到冬季发生的鼻出血，属于阳明经病变。
〔尤〕血液从阴经以及冲脉、任脉而出，称为吐血；从阳经以及督脉而出，称为鼻出血。所以鼻出血病都在阳经。只是春夏季节阳气浮越，故归属于太阳；秋冬季节阳气潜藏，故归属于阳明，这是区别所在。之所以这样，从阴阳角度讲，阳主外，阴主内；从三阳经角度讲，太阳主开，阳明主阖。少阳经脉不进入鼻腔，所以不主鼻出血。
经常鼻出血的人不可使用发汗法。如果误用发汗，会导致额头两侧动脉凹陷，脉象紧急，两眼直视，无法闭眼，无法入睡。
〔尤〕血和汗都属于阴液。经常鼻出血的人如果再发汗，阴液就会严重受损。脉是血的府库，额头两侧凹陷，是因为额旁动脉处的血液脱失于上部，导致塌陷不起。脉象紧急，是因为寸口脉处血液不能濡养，失去了柔和之性，就像树木没有汁液而枝条干枯劲直一样。两眼直视、无法闭眼、无法入睡，是因为阴气亡失，导致阳气独盛。经文说：“夺血者无汗”，说的就是这个道理。（详见《伤寒论辑义》太阳中篇。）
病人面色苍白无血色，没有恶寒发热的表证，脉象沉弦的，是鼻出血；脉象浮弱，重按感觉断绝的，是便血；伴有烦躁咳嗽的，必定吐血。（《诸病源候论》中“寒热”前无“无”字。赵、徐、沈、尤注本均无“无血色”的“血”字。）
〔程〕《灵枢经》说：血脱的人面色枯槁无光泽。《上经》说：男子面色淡白，主渴及失血。现在病人面无血色，是脱血的表现。《上经》说：男子脉象虚沉弦，没有恶寒发热，时常头晕眼花兼有鼻出血。现在没有恶寒发热，而脉弦伴鼻出血，这与上述证候相似，属于劳损证。如果脉象浮弱，重按感觉断绝，这是有阳无阴的表现。所以知道便血；伴有烦躁咳嗽的，病位在上焦，所以知道是吐血。
〔尤〕没有恶寒发热，说明病非外感引起。因外感引起的鼻出血，脉象必然浮大，因为阳气重。因内伤引起的鼻出血，脉象应当沉弦，因为阴气亢厉。虽然与前文尺脉浮不同，但都是阴气不宁的表现。如果脉象浮弱，重按断绝，是因为下血过多，阴脉不充盈。烦躁咳嗽，是因为血从上溢，导致心肺焦燥。这些都是病情形成后才出现的诊察表现。
凡是吐血，伴有咳嗽气逆，脉数且身体发热，不能卧床休息的，预后不良（死证）。（《诸病源候论》中“数”下有“浮大”二字。）
〔尤〕脉数身热，是阳气独胜。吐血、咳嗽气逆、不能卧，是阴液被灼烧。以已被灼烧的阴液，去对抗独盛的阳气，有耗尽不止的趋势，所以预后不良。
凡是嗜酒之人，如果咳嗽，必定会导致吐血，这是因为饮酒过度所致。
〔徐〕这里说吐血，不一定由于气不摄血，也不一定由于阴火炽盛。如果是嗜酒之人导致咳嗽，那么肺脏损伤已极，又被咳嗽震动，必定导致吐血。所以说这是饮酒过度所致。治疗时，应当以清解酒热为主。
《三因方》记载：病人因饮食过度损伤胃腑，或胃虚不能消化，导致翻呕吐逆，食物与气上冲挤压胃口，决裂受伤而吐出。血色鲜红，心腹绞痛，冷汗自流，名叫伤胃吐血。理中汤能止住它，因为其功效最能调理中脘，分利阴阳，安定血脉。（《证治要诀》加葛根、川芎。）或者只煮干姜甘草汤，饮用也很好。方见《养生必用》。
寸口脉弦而且大。弦脉表示阳气衰减，大脉表示中空如芤。衰减表示有寒，中空表示有虚。寒与虚相互搏击，这种脉象名叫“革”。妇女患此脉象会出现半产（小产）及漏下（崩漏）；男子患此脉象会出现亡血。
〔尤〕这一条已在虚劳病篇中出现过，张仲景再次列举它，大概是说明亡血的病症，有从虚寒得来的。
亡血病人，不可发汗解表。如果发汗，就会出现寒冷战栗、身体颤抖的症状。（《太阳中篇》、《脉经》中“血”下有“下”字，《脉经》中“即”后有“家”字。）
〔鉴〕凡是失血之后，气血尚未恢复，称为亡血。都不可发汗。失血之初，固然属于阳热；亡血之后，热随血而去。热虽然消了，但气随着血虚而衰微，阳气也微弱了。如果发汗，则阳气更加衰微，力量不能支撑，所以身体寒冷战栗，振耸抖动。发阴虚之汗，出汗则亡阴，即发吐衄之汗，所以出现无法闭眼、无法入睡，这是亡阴的病证。发阳虚之汗，出汗则亡阳，即发亡血之汗，所以出现寒冷战栗，这是亡阳的病证。李东垣说：夺血者无汗，因为汗与血都是心之液。血亡液竭，没有剩余的液体可以化作汗了。现在又发表发汗，则阴虚且更亡阳，体表的卫气极度虚弱，所以寒冷战栗。
病人胸部胀满，嘴唇枯萎，舌色青紫，口中干燥，只想用水漱口，不想咽下，没有恶寒发热，脉象微大而来迟，腹部并不胀满，但病人自己说觉得胀满，这是有瘀血。（此段之下，《脉经》有“当汗出不出，内结亦为瘀血”十一字。）
〔鉴〕表实无汗，胸满而喘的，是风寒引起的胸满。里实便秘，胸满烦热的，是热壅引起的胸满。面目浮肿，胸满喘促不能卧的，是水饮停聚引起的胸满。呼吸不畅，胸满喜太息，稍缓解的，是气滞引起的胸满。现在病人没有恶寒等其他疾病，只有胸满、嘴唇枯萎、舌青、口燥、漱水不欲咽，这是瘀血引起的胸满。唇舌是血液荣华之处，血病不能荣养，所以枯萎变色。热在血分，所以口燥，只想漱口不想咽下。脉象微大而来迟，是阴凝的脉象，按理应当腹满。现在腹部不胀满，询问病人说觉得胀满，说明胀满在胸不在腹。结合上述证候推断，这是有瘀血。
〔沈〕假如气分热盛，则会腹胀满。现在腹部不胀满，而病人说觉得胀满，这是外表虽不满，但五脏之内血壅气滞而胀，所以说觉得胀满。由此可知是瘀血。
案语：程林注说“唇痿”的原因不详，是错误的。
病人好像有发热症状，心烦胸满，口干燥而渴，但脉象反而没有热象，这是热伏于阴分，属于瘀血。应当用攻下法治疗。（“阴伏”的“伏”字，赵本作“状”，不对。）
〔鉴〕这是承接上文，互相详述证候和脉象，以阐明治疗方法。“如热状”，就是前面所说的心烦胸满、口干燥渴的热证。此人应当得到数大的阳脉，现在反而见到沉伏的阴脉，这是热伏于阴，属于瘀血。血瘀者应当攻下，适宜用桃核承气汤、抵当汤丸之类的方剂。
火邪致病的，用桂枝去芍药加蜀漆牡蛎龙骨救逆汤主治。（沈注本不载此条。）
〔程〕这一章应当在第八篇中，简册脱落在此处。
〔尤〕这里只举出“火邪”二字，而没有详细说明证候。查《伤寒论》云：伤寒脉浮，医生用火法强迫发汗，亡阳必定惊狂，起卧不安。又说：太阳病，用火熏法，不得汗，其人必定躁扰，到了经期不解，必定大便下血，名为火邪。张仲景这一条，大概是为惊悸、下血准备证候吧。桂枝汤去掉芍药的酸收，加入蜀漆的辛散，是想让火气与风邪一时并散，不留丝毫滞碍，这就是所谓将外来邪气驱逐出去。龙骨、牡蛎，则是收敛浮越的神气。
案语：《外台秘要·奔豚气门》引《短剧》云：老师说：病有奔豚、吐脓、惊怖、火邪这四种病，都是从惊扰引发的。火邪者，用桂枝加龙骨牡蛎汤主治。据此，则程林的注释是正确的。
桂枝救逆汤方
桂枝（三两，去皮） 甘草（二两，炙） 生姜（三两） 牡蛎（五两，熬） 龙骨（四两）
大枣（十二枚） 蜀漆（三两，洗去腥味）
以上七味，切碎，用水一斗二升，先煮蜀漆，减少二升，加入其他药物，
煮取三升，去渣，温服一升。（“为末”二字，宋版《伤寒论》作“七味”，是对的。）
心下悸动的，用半夏麻黄丸主治。（《脉经》无此条。）
〔鉴〕此方是治疗寒水引起的心下悸，与第一条脉弱悸的病机不合，必定是错简（竹简次序错乱）。
半夏麻黄丸方（《肘后备急方》无方名。）
半夏（《肘后》云汤洗去滑，晒干） 麻黄（等分）
以上两味，研成细末，炼蜜和丸，如小豆大小，饮水送服三丸，每日三次。
按：服用三丸太少，《本草纲目》作三十丸，似乎合理。总之，这个方子值得怀疑。
吐血不止的，用柏叶汤主治。
〔徐〕这里着重强调“不止”二字，是说凉血止血药都不应验了。吐血本来是由于阳虚，不能引导血液归经。然而血亡而阴亏，所以以最能养阴的柏叶为君药，艾叶走经络为臣药，以干姜温胃为佐药，马通导大便下行为使药。我的意见是没有马通，童便也可以代替。
按《本草》记载此方，乃是柏叶一把，干姜三升，阿胶一挺，炙合煮，入马通一升。不知哪种正确，等待参详。
〔程〕中焦受纳水谷之气，提取津液变化而成赤色，这就叫血。血在内滋养脏腑，在外运行肌肤，周身流动，像源泉滚滚不断。遇到热则逼迫血液妄行，而作吐衄，就是后面泻心汤证的病机。遇到寒则不与气一起运行，渗入胃中，而作吐，所以有随渗随出而令血不止的情况。柏叶汤都是辛温的药物。《神农本草经》说：柏叶主吐血，干姜止唾血，艾叶止吐血。马通，就是白马屎。凡是屎必须通达肠道才排出，所以叫“通”，也是微温的，止吐血。这四味都是辛温行阳的药物，使血液归经，遵循隧道而行，血自然停止。
柏叶汤方（《外台秘要》引《仲景伤寒论》，《千金方》无方名。）
柏叶 干姜（各三两○《千金方》作二两，《外台》作青柏叶三两，干姜二两，切） 艾叶（三把○《千金方》作一把）
以上三味，用水五升，取马通汁一升，合煮取一升，分两次温服。（案《外台》作：以上三味，用水五升，煮取一升，去渣，另绞取新出马通汁一升，相合煎，取一升，用绵过滤，温分两次服。马通，是马屎汁。一方有阿胶，无艾叶，《外台》版本是对的。○《证类本草》云：马屎名马通，止崩中、吐下血、金疮出血。）
《千金方》：治吐血内崩，上气，面色如土。（即本方，注云：仲景柏叶汤不用阿胶。《短剧》不用柏叶，与《肘后》同。）
又治上焦热膈伤，吐血衄血，或下血连日不止欲死。
在本方基础上，去掉柏叶，用竹茹、阿胶。
下血，先排便后出血，这是远血，用黄土汤主治。（“远”字，原本作“近”，错误。现在依据诸本校改。）
〔程〕先便后血，是在排便的时候，血也随着粪便下行。《内经》说：结阴病，便血一升，再结二升，三结三升。因为阴气内结，不能外行，血无所禀受，渗入肠间，所以上经说小肠有寒的人，会下重便血。肠道有夹层，其中有脂膜联系。当其和平时，则运行气血；当其调养失宜时，则血从夹层渗入肠中，不是从肠外渗入肠中。渗下即下，则血色鲜红；渗下留结，则血色黯黑。《内经》说：阴脉不和，则血留滞其中。用黄土、附子气味浓厚的药物，血得温即循经而行。结阴这类病症，适宜用温补法，就是这样。
〔鉴〕先便后血，这是远血。谓血在胃中。即古之所谓结阴，今之所谓便血。先血后便，这是近血。谓血在肠中。即古之所谓肠澼、痔疮下血，今之所谓脏毒、肠风下血。赵良说：肠胃是阳明经。以下血而言，胃居大肠之上，若血聚于胃，必先便后血，距离肛门远，所以叫远血。若聚于大肠，距离肛门近，所以叫近血。
〔尤〕黄土温燥入脾，配合白术、附子，以恢复健运之气；阿胶、地黄、甘草，以补充耗竭之血；而又担心辛温之品，转为血病的祸害，所以又以黄芩的苦寒，防止其太过。这就是所谓有节制的军队。
黄土汤方（〔原注〕也主治吐血、衄血。○《外台》引《仲景伤寒论》。○《千金方》治卒然吐血及衄血方。）
甘草 干地黄（《千金方》用干姜，注云仲景用地黄） 白术 附子（炮制○《千金方》无）
阿胶（《外台》有炙字） 黄芩（各三两） 灶中黄土（半斤○《千金方》作伏龙肝半升，《外台》作釜灶下黄焦土半升，绵裹）
以上七味，用水八升，煮取三升，分两次温服。（《外台》作：煮六味取二升，去渣，加入胶令烊化。）
下血，先出血后排便，这是近血，用赤小豆当归散主治。（方见狐惑病篇中。）
〔程〕这是《内经》所说的饮食不节，起居不时，则阴经受邪。阴受之，则入五脏，成为肠澼下血之类。所以用当归来调和血脉，赤小豆来清脏毒，与黄土汤不同。梅师方云：热毒下血，或吃热物诱发，以赤小豆为末，水调服。由此可知此方治脏毒下血，黄土汤治结阴下血，有天壤之别。
徐氏《医法指南》云：先血后便，是近血，在大肠，感邪即发，俗谓之肠风，用赤小豆当归散主治。先便后血，是远血，在胃，积久才发，俗谓之脏毒，用黄土汤主治。
案语：《千金方》说，各种下血，先见血后见便，此为远血，宜服黄土汤；先见便后见血，此为近血，宜服赤小豆散。这里的远近二字互错了。《三焦虚实门》有远血、近血二方，主治与本经相同，而《千金翼论》及《外台》引崔氏，也错了。《张氏医通》却认为《金匮》是传写错误，尤非如此。《诸病源候论》云：大便下血，鲜红且腹痛，冷气在内，也是大便下，其色如小豆汁，出来时疼，但不甚痛。前便后下血者，血来远；前下血后便者，血来近。这也可以用来验证。
《备预百要方》：血痢方。
赤小豆（三升，炒熟） 当归（三两）
以上两味，捣筛为散，服方寸匕，每日三次，薄粥送下。
《千金方》伏龙肝汤：治下焦虚寒损，或先见血后便转，此为近血，或利或不利的方子。
伏龙肝（五合，末） 干地黄（五两） 阿胶 牛膝 甘草 干姜 黄芩 地榆（各三两） 发灰（二合）
以上九味，切碎，用水九升，煮取三升，去渣，下胶煮化，下发灰，分为三服。（《张氏衍义》云：可见治血，只要取归经之法，不必追究先后远近。）
又续断止血汤：治下焦虚寒损，或先便转后见血，此为远血，或利或不利，好因劳冷即发。
续断 当归 桂心 蒲黄 阿胶（各一两） 甘草（二两） 干姜 干地黄（各四两）
以上八味，切碎，用水九升，煮取三升半，去渣，下胶取烊化。
下蒲黄，分三服。（《张氏衍义》云：验其血色，晦淡则当用《金匮》法，鲜紫当用《千金》法，方为合辙。）
《医林方》：阿胶丸。治便血先便而后血，谓之湿毒。
阿胶（一钱） 黄连（三钱） 白茯苓（二钱） 白芍药（四钱）
以上为细末，水和为丸，如梧桐子大，每服五十丸，加至一百丸，温水送下，每日进四五服。
The pulse at the cun position is both moving (Dong) and weak (Ruo). A moving pulse indicates fright, while a weak pulse indicates palpitations.
[Shen] Fright enters from the outside, while palpitations arise from within. Palpitations refer to a state where the heart spirit is confused and the heartbeat is uncontrollable.
[Xu] In the previous chapter on Running Piglet disease, it was mentioned that there are cases of fright and terror, and fire pathogen diseases, all of which originate from fright. Here, fright and palpitations are discussed separately, not to detail the origin of the disease, but to indicate that among the diseases, some involve fright-induced mania and restlessness, while others only present with palpitations and uneasiness. Fright involves evil invading the heart and belongs to excess patterns; thus, the pulse at the cun position is moving. A "moving" pulse feels granular, like a bean jumping. Palpitations involve the spirit failing to govern and belong to deficiency patterns; thus, the pulse at the cun position is weak. A "weak" pulse arrives without strength. The combination of moving and weak pulses indicates that while evil has invaded, the original root of the heart is deficient, leading to simultaneous manifestations of fright and palpitations. However, the pulse still distinguishes the two: a moving pulse reflects the emission of fright qi, and a weak pulse reflects the formation of palpitation qi. Therefore, it is said that a moving pulse indicates fright, and a weak pulse indicates palpitations.
The Master said: If the chi pulse is floating, and the eyes have a yellow halo, epistaxis has not stopped. If the yellow halo disappears and the eyes become clear, one knows that the epistaxis has now stopped. (Regarding "chi," Zhao Kaimei, Cheng Lin, and Jin Jian's editions read "fu." *Zhu Bing Yuan Hou Lun* reads "chi zhong zi fu." There is no "bi" character before the sentence in some versions. *Mai Jing* records: Question: What is the pulse when epistaxis persists for days? Answer: The pulse comes lightly in the muscle layer, and the chi position naturally overflows. Note: Some say the chi pulse is floating; the following text is the same as this article.)
[You] A floating chi pulse indicates wandering fire in the kidney; a yellow halo around the eyes indicates accumulated heat in the liver. If epistaxis presents with these signs, the bleeding will not stop easily. Blood belongs to yin and is forced by the heat of kidney and liver fire, failing to remain contained. If the yellow halo disappears and the eyes become clear, it indicates that not only has liver heat been eliminated, but kidney heat has also cleared. Thus, the epistaxis should now stop.
It is also said: Epistaxis occurring from spring to summer belongs to the Taiyang channel; epistaxis occurring from autumn to winter belongs to the Yangming channel.
[You] Bleeding from yin channels and the Chong and Ren vessels is termed hematemesis; bleeding from yang channels and the Du vessel is termed epistaxis. Therefore, epistaxis always involves yang channels. The difference lies in seasons: in spring and summer, yang qi floats, so it belongs to Taiyang; in autumn and winter, yang qi hides, so it belongs to Yangming. This is because, regarding yin and yang, yang governs the exterior and yin governs the interior; regarding the three yang channels, Taiyang governs opening, and Yangming governs closing. The Shaoyang channel does not enter the nose, so it does not primarily govern epistaxis.
Patients prone to epistaxis should not be treated with sweating methods. If sweat is induced, the temples may sink, the pulse becomes tight and urgent, the eyes stare fixedly without blinking, and sleep is impossible.
[You] Both blood and sweat belong to yin fluids. If a patient prone to epistaxis undergoes sweating, yin fluids are severely damaged. The pulse is the residence of blood. The sinking of the temples refers to the depression of the arteries on both sides of the forehead due to blood loss above. A tight and urgent pulse occurs because the blood at the cun position fails to nourish, losing its softness, like wood branches becoming stiff without sap. Fixed staring, inability to blink, and insomnia occur because yin qi is exhausted, leaving yang qi unopposed. The classic states: "Those who lose blood should not sweat," which refers to this situation. (See *Shanghan Lun Ji Yi*, Taiyang Middle Chapter.)
If a patient has a pale complexion without cold or fever, and the pulse is deep and wiry, it indicates epistaxis; if the pulse is floating and weak, disappearing upon pressure, it indicates lower gastrointestinal bleeding; if accompanied by irritability and cough, hematemesis is certain. (*Zhu Bing Yuan Hou Lun* lacks the word "wu" before "han re." Zhao, Xu, Shen, and You editions lack the character "xue" in "wu yan se.")
[Cheng] *Ling Shu* states: Those who suffer blood loss have a sallow, lusterless complexion. *Shang Jing* states: Pale complexion in men indicates thirst and blood loss. The current patient's pale face indicates blood depletion. *Shang Jing* also states: Men with empty, deep, and wiry pulses, without cold or fever, often experience dizziness and epistaxis. The current case, lacking cold/fever but having a wiry pulse and epistaxis, resembles this labor disease pattern. If the pulse is floating and weak, disappearing upon pressure, it indicates yang without yin. Thus, lower bleeding is known; irritability and cough indicate pathology in the upper jiao, confirming hematemesis.
[You] No cold or fever means the disease is not due to external contraction. Epistaxis from external causes typically presents with a floating and large pulse due to heavy yang qi. Epistaxis from internal injury typically presents with a deep and wiry pulse due to aggressive yin qi. Although different from the floating chi pulse mentioned earlier, both indicate yin instability. A floating, weak pulse disappearing upon pressure indicates excessive lower bleeding and insufficient yin pulses. Irritability and cough indicate blood overflowing from above, causing dryness in the heart and lungs. These are diagnostic signs appearing after the disease is established.
Hematemesis accompanied by cough, upward rushing of qi, a rapid pulse, fever, and inability to lie down indicates a fatal prognosis. (*Zhu Bing Yuan Hou Lun* adds "floating and large" after "rapid".)
[You] A rapid pulse and body heat indicate unopposed yang. Hematemesis, cough, upward rushing of qi, and inability to lie down indicate the scorching of yin. With yin already scorched opposing unopposed yang, there is a trend of complete exhaustion, hence death.
Wine drinkers who cough will inevitably develop hematemesis, caused by excessive drinking.
[Xu] This indicates that hematemesis is not necessarily due to qi failing to control blood or blazing yin fire. In wine drinkers, coughing indicates extreme lung damage. The vibration from coughing forces blood to vomit. Thus, it is caused by excessive drinking. Treatment should focus on clearing wine-heat.
*San Yin Fang* records: Patients injured by overeating or suffering from stomach deficiency unable to digest food may experience retching and vomiting. Food and qi rush up, crushing the stomach gate, causing rupture and bleeding. The blood is bright red, accompanied by severe heart and abdominal pain and spontaneous white sweat. This is called "stomach-injury hematemesis." Lizhong Tang can stop it because it regulates the middle jiao, separates yin and yang, and stabilizes blood vessels. (*Zheng Zhi Yao Jue* adds Ge Gen and Chuan Xiong.) Alternatively, boiling Gan Jiang and Gan Cao decoction is also effective. See *Yang Sheng Bi Yong*.
The pulse at the cun position is wiry and large. Wiry indicates reduction (deficiency), and large indicates hollow (Kou). Reduction indicates cold, and hollow indicates deficiency. Cold and deficiency striking each other is named "Ge" (Leather) pulse. In women, this leads to miscarriage and metrorrhagia; in men, it leads to blood loss.
[You] This clause appears in the Consumption Disease chapter. Zhang Zhongjing repeats it to emphasize that blood loss syndromes can arise from deficiency-cold.
In cases of blood loss, surface-releasing methods should not be used. If sweat is induced, chills and tremors will occur. (*Taiyang Middle Chapter*, *Mai Jing* adds "xia" after "blood" and "jia" after "ji".)
[Jian] After any blood loss, when qi and blood have not recovered, it is called blood loss. Sweating must be avoided. Initially, blood loss involves yang-heat; afterward, heat leaves with the blood. Although heat subsides, qi follows blood into deficiency, and yang becomes weak. If sweating is induced, yang qi becomes critically weak and cannot support the body, resulting in cold chills and trembling. Inducing sweat in yin-deficiency leads to yin collapse (similar to sweating from hematemesis/epistaxis), causing inability to close eyes and insomnia. Inducing sweat in yang-deficiency leads to yang collapse (similar to sweating from blood loss), causing cold chills and tremors. Li Dongyuan said: "Those who lose blood should not sweat," because sweat and blood are both fluids of the heart. When blood is lost and fluids exhausted, no fluid remains to form sweat. Further releasing the exterior causes yin deficiency and further yang collapse, leaving defensive qi extremely weak, hence chills and tremors.
A patient with chest fullness, withered lips, blue tongue, dry mouth, desiring to rinse water but not swallow, without cold or fever, with a pulse that is slightly large and slow, and an abdomen that is not distended though the patient claims fullness, has blood stasis. (*Mai Jing* adds eleven characters below: "When sweat should be released but is not, internal binding also causes blood stasis".)
[Jian] Exterior excess with no sweat, chest fullness, and wheezing is wind-cold chest fullness. Interior excess with constipation, chest fullness, and irritability is heat obstruction chest fullness. Facial edema, chest fullness, and wheezing preventing lying down is fluid retention chest fullness. Uncomfortable breathing, chest fullness relieved by sighing is qi stagnation chest fullness. Now, the patient has no cold/fever or other illnesses, only chest fullness, withered lips, blue tongue, dry mouth, and desiring to rinse but not swallow. This is blood stasis chest fullness. Lips and tongue are where blood flourishes; blood disease fails to nourish, causing withering and color change. Heat in the blood level causes dry mouth and desire to rinse but not swallow. A pulse that is slightly large and slow is a diagnosis of yin condensation, which should present with abdominal fullness. Since the abdomen is not full, but the patient claims fullness, the fullness is in the chest, not the abdomen. Inferring from the above symptoms, this is blood stasis.
[Shen] If qi-level heat were excessive, abdominal distension would occur. Since the abdomen is not full, but the patient claims fullness, it is internal blood congestion and qi stagnation causing distension, despite the exterior appearing normal. Thus, it is known to be blood stasis.
Commentary: Cheng Lin's note that the reason for "withered lips" is unknown is incorrect.
A patient presenting with sensations of heat, irritability, chest fullness, dry mouth, and thirst, but whose pulse shows no heat signs, has heat hidden in the yin levels. This is blood stasis. It should be treated with purgation. ("Fu" in "Yin Fu" is read as "Zhuang" in Zhao's edition, which is incorrect.)
[Jian] This continues the previous discussion, detailing symptoms and pulses to clarify treatment. "Sensations of heat" refers to the heat syndrome of heart irritability, chest fullness, and dry mouth/thirst. Such a person should have a rapid and large yang pulse. Instead, a deep and hidden yin pulse is seen, indicating heat hidden in yin, which is blood stasis. For blood stasis, purgation is indicated, using formulas like Tao He Cheng Qi Tang or Di Dang Tang/Wan.
Fire pathogen disease is treated with Gui Zhi Qu Shao Yao Jia Shu Xi Mu Li Long Gu Jiu Ni Tang. (Shen's edition does not record this clause.)
[Cheng] This chapter should be in the eighth section; bamboo slips were misplaced here.
[You] Only "fire pathogen" is mentioned without detailed symptoms. According to *Shanghan Lun*: In typhoid with a floating pulse, if the doctor uses fire methods to force sweating, yang collapse leads to fright, mania, and restlessness. Also: In Taiyang disease, if fire moxibustion is used and no sweat results, the patient becomes agitated; if unresolved by the cycle, rectal bleeding occurs, named fire pathogen. Zhang Zhongjing's clause likely prepares for symptoms of fright/palpitations and lower bleeding. Removing Sour Shao Yao from Gui Zhi Tang and adding Acrid Shu Xi allows fire and wind evil to scatter simultaneously without retention, driving out external pathogens. Dragon Bone and Oyster Shell converge floating spirit and qi.
Commentary: *Waitai Miyao·Running Piglet Gate* cites *Duan Ju*: The Master said: Diseases include running piglet, pus vomiting, fright/terror, and fire pathogen. These four diseases all originate from fright. Fire pathogen is treated with Gui Zhi Jia Long Gu Mu Li Tang. Based on this, Cheng's note is correct.
Gui Zhi Jiu Ni Tang Formula
Gui Zhi (3 liang, peeled) Gan Cao (2 liang, honey-fried) Sheng Jiang (3 liang) Mu Li (5 liang, calcined) Long Gu (4 liang)
Da Zao (12 pieces) Shu Xi (3 liang, washed to remove fishy odor)
Grind into powder. Use 1 dou 2 sheng of water. First boil Shu Xi, reduce by 2 sheng. Add other herbs.
Boil to obtain 3 sheng. Remove dregs. Warm dose of 1 sheng. ("Powder" version in Song edition *Shanghan Lun* lists seven ingredients, which is correct.)
Palpitations in the epigastrium are treated with Ban Xia Huang Qin Wan. (*Mai Jing* lacks this clause.)
[Jian] This formula treats epigastric palpitations due to cold-water, inconsistent with the weak-pulse palpitation in the first clause. It is likely a misplaced slip.
Ban Xia Huang Qin Wan Formula (*Zhou Hou Bei Ji Fang* has no formula name.)
Ban Xia (*Zhou Hou*: wash in decoction to remove slipperiness, dry) Huang Qin (equal parts)
Grind the two ingredients into powder. Mix with refined honey to make pills the size of adzuki beans. Take 3 pills with water, three times daily.
Note: Three pills is very few; *Ben Cao Gang Mu* suggests 30 pills, which seems plausible. However, this formula is questionable.
Unremitting hematemesis is treated by Bai Ye Tang.
[Xu] Emphasis is placed on "unremitting," implying cold-cooling hemostatic drugs are ineffective. Hematemesis originates from yang deficiency failing to guide blood into vessels. However, blood loss leads to yin deficiency. Thus, Bai Ye (Cassia Twig), which nourishes yin most effectively, is used as the sovereign herb. Ai Ye (Mugwort Leaf), which travels through meridians, is the minister. Gan Jiang (Dried Ginger) warms the stomach as the assistant. Ma Tong (Horse Dung Juice) guides downward as the envoy. Without Ma Tong, child urine (Tong Bian) is acceptable.
According to *Ben Cao*, this formula uses one handful of Bai Ye, 3 sheng of Gan Jiang, one piece of E Jiao, boiled together with 1 sheng of Ma Tong. Uncertainty remains.
[Cheng] The middle jiao receives qi, extracts juices, transforms them into red blood. Blood nourishes organs internally and flows in muscles externally, circulating like a spring. Heat forces blood to run wild, causing hematemesis/epistaxis (see Xie Xin Tang syndrome). Cold prevents blood from flowing with qi, causing it to seep into the stomach and vomit, leading to continuous bleeding. Bai Ye Tang consists of acrid-warm agents. *Shen Nong Ben Cao Jing* states: Bai Ye stops hematemesis; Gan Jiang stops spitting blood; Ai Ye stops hematemesis. Ma Tong is horse dung. Feces must pass through the intestines to exit, hence "Tong" (through/unblocked); it is slightly warm and stops hematemesis. All four are acrid-warm yang-moving agents, guiding blood back into vessels and tunnels, stopping bleeding.
Bai Ye Tang Formula (*Waitai* cites *Shanghan Lun*; *Qian Jin* has no name.)
Bai Ye Gan Jiang (each 3 liang ○ *Qian Jin* 2 liang; *Waitai* Qing Bai Ye 3 liang, Gan Jiang 2 liang, sliced) Ai Ye (3 bundles ○ *Qian Jin* 1 bundle)
Boil the three ingredients in 5 sheng of water, adding 1 sheng of Ma Tong juice. Boil to obtain 1 sheng. Divide into two warm doses. (Note: *Waitai* says: Boil three ingredients in 5 sheng water to 1 sheng, remove dregs, squeeze fresh Ma Tong juice 1 sheng, mix and boil to 1 sheng, filter through silk, warm divide two doses. Ma Tong is horse dung juice. One version has E Jiao, no Ai Ye; *Waitai* is correct. ○ *Zheng Lei Ben Cao*: Horse dung is Ma Tong, stops metrorrhagia, hematemesis, melena, and traumatic bleeding.)
*Qian Jin Fang*: Treats hematemesis, internal collapse, upward rushing qi, sallow complexion. (Same formula; note: Zhongjing's Bai Ye Tang does not use E Jiao. *Duan Ju* does not use Bai Ye, same as *Zhou Hou*.)
Also treats upper jiao heat damaging diaphragm, hematemesis, epistaxis, or continuous lower bleeding threatening life.
Remove Bai Ye from this formula, add Zhu Ru and E Jiao.
Lower bleeding where stool precedes blood is distant blood (Yuan Xue), treated by Huang Tu Tang. ("Yuan" originally printed as "Jin," error. Corrected per collation.)
[Cheng] Stool preceding blood means blood descends with stool. *Nei Jing* states: Jie Yin disease, one sheng of bloody stool, twice two sheng, thrice three sheng. Yin qi binds internally, cannot move outward; blood lacks guidance and seeps into intestines. Upper Classic states: Cold in small intestine causes heaviness and bloody stool. Intestines have夹层 (interlayers) with fatty membranes. When harmonious, qi and blood flow; when dysregulated, blood seeps from interlayers into intestines, not from outside. Immediate seepage yields bright red blood; retained seepage yields dark blood. *Nei Jing* states: Disharmony of yin pulses causes blood stasis. Using thick-scented Huang Tu and Fu Zi, blood warmed follows meridians. Jie Yin types suit warming tonification.
[Jian] Stool preceding blood is distant blood, meaning blood is in the stomach. Ancient term: Jie Yin; modern term: Melena. Blood preceding stool is near blood (Jin Xue), meaning blood is in the intestines. Ancient term: Chang Pi/Hemorrhoids; modern term: Zang Du/Chang Feng. Zhao Liang says: Gut/intestines are Yangming channels. Below blood refers to stomach above large intestine. If blood gathers in stomach, stool precedes blood, far from anus, hence "distant." If in large intestine, near anus, hence "near."
[You] Huang Tu is warm/dry entering spleen, combined with Bai Zhu and Fu Zi to restore movement. E Jiao, Di Huang, Gan Cao replenish depleted blood. Fearful that acrid-warm agents harm blood, Huang Qin (bitter/cold) prevents excess. This is a disciplined army.
Huang Tu Tang Formula ([Original Note]: Also treats hematemesis/epistaxis. ○ *Waitai* cites *Shanghan Lun*. ○ *Qian Jin* treats sudden hematemesis/epistaxis.)
Gan Cao Gan Di Huang (*Qian Jin* uses Gan Jiang, note: Zhongjing uses Di Huang) Bai Zhu Fu Zi (prepared ○ *Qian Jin* none)
E Jiao (*Waitai* has "roasted") Huang Qin (each 3 liang) Zao Zhong Huang Tu (8 liang ○ *Qian Jin* Fu Long Gan 0.5 sheng; *Waitai* Fu Zao Xia Huang Jiao Tu 0.5 sheng, wrapped in silk)
Boil seven ingredients in 8 sheng water to 3 sheng. Divide into two warm doses. (*Waitai*: Boil six ingredients to 2 sheng, remove dregs, melt E Jiao.)
Lower bleeding where blood precedes stool is near blood (Jin Xue), treated by Chi Xiao Dou Dang Gui San. (Formula in Huo Huo chapter.)
[Cheng] This refers to *Nei Jing*: Irregular diet/lifestyle injures yin. Yin injury enters five zang, causing Chang Pi/bloody stool. Dang Gui harmonizes blood vessels; Chi Xiao Dou clears zang toxin. Different from Huang Tu Tang. Mei Shi Fang: Heat-toxin lower bleeding or triggered by hot food, use Chi Xiao Dou powder mixed with water. Thus, this formula treats Zang Du lower bleeding; Huang Tu Tang treats Jie Yin lower bleeding. Vast difference.
Xu's *Yi Fa Zhi Nan*: Blood before stool is near blood, large intestine, acute onset, folk name Chang Feng, treat with Chi Xiao Dou Dang Gui San. Stool before blood is distant blood, stomach, chronic onset, folk name Zang Du, treat with Huang Tu Tang.
Commentary: *Qian Jin Fang* states: Various lower bleeds, blood before stool is distant blood, use Huang Tu Tang; stool before blood is near blood, use Chi Xiao Dou San. The terms distant/near are swapped here. *San Jiao Xu Shi Men* has distant/near blood formulas matching this classic. *Qian Jin Yi Lun* and *Waitai* citing Cui Shi also err. *Zhang Shi Yi Tong* claims *Jin Gui* transcription error, which is wrong. *Zhu Bing Yuan Hou Lun*: Bloody stool bright red with abdominal pain, cold qi inside, stool color like adzuki bean juice, painful upon exit but not severe. Stool then blood comes from far; blood then stool comes from near. This verifies the point.
*Bei Yu Bai Yao Fang*: Blood Dysentery Formula.
Chi Xiao Dou (3 sheng, roasted熟) Dang Gui (3 liang)
Grind/sift to powder. Take 1 fang cun bi, three times daily, with thin gruel.
*Qian Jin* Fu Long Gan Tang: Treats lower jiao deficiency-cold injury, or blood before stool turning to near blood, or with/without diarrhea.
Fu Long Gan (5 he, powder) Gan Di Huang (5 liang) E Jiao Niu Xi Gan Cao Gan Jiang Huang Qin Di Yu (each 3 liang) Fa Hui (2 he)
Nine ingredients, cut. Boil in 9 sheng water to 3 sheng. Remove dregs, melt E Jiao, add Fa Hui. Divide into three doses. (*Zhang Shi Yan Yi*: Treating blood, follow meridian entry, do not obsess over sequence/distance.)
Another Xuan Duan Zhi Xue Tang: Treats lower jiao deficiency-cold injury, or stool turning then blood (distant blood), with/without diarrhea, triggered by labor/cold.
Xuan Duan Dang Gui Gui Xin Pu Huang E Jiao (each 1 liang) Gan Cao (2 liang) Gan Jiang Gan Di Huang (each 4 liang)
Eight ingredients, cut. Boil in 9 sheng water to 3.5 sheng. Remove dregs, melt E Jiao.
Add Pu Huang, divide into three doses. (*Zhang Shi Yan Yi*: Check blood color. Dark/pale use *Jin Gui* method; bright purple use *Qian Jin* method.)
*Yi Lin Fang*: E Jiao Wan. Treats melena (stool before blood), called damp-toxin.
E Jiao (1 qian) Huang Lian (3 qian) Bai Fu Ling (2 qian) Bai Shao Yao (4 qian)
Grind fine, mix with water, make pills size of wutong seeds. Take 50 pills, increase to 100, with warm water, 4-5 times daily.