伤寒吐血。每因失治所致。有因太阳感寒。无汗恶寒。头痛发热。寒邪外束。法当发
汗。若失于表散。阳气不得外泄。则逆走阳络。络血妄行。则致吐血。或由其人素有
血症。寒邪犯肺而咳。震伤血络。亦致咳血。均当以清疏营卫。表散寒邪为治。古人
皆以麻黄桂枝等汤治血症是也。然未免太峻。当小其制。用羌活、苏叶、荆防、薄荷
等。以去风散寒。橘红、杏仁以降气。芍药、甘草以安营。微兼渴者。少佐黄芩以清热。
则营卫之邪解散。自然嗽止身凉。血不治自止矣。
邵评∶此二方是风寒初起。邪在于表。用为表散之剂。至见吐血衄血。其邪已化
热入里。岂有再用辛温表散之理。麻桂二方。断非治血之方。古人所言风寒在
表之时。不用麻桂发表。以致邪郁成热。热入伤营分而吐血衄血。非见血之后。
再用麻桂止血也。学人切勿以麻桂二汤治血症。致误大事。此方实治寒邪不
从表达。郁而成热。热入于里。营络伤而吐血之正法。
若内有伏火。外感寒邪。热被寒束。火逼络血。而致衄血咳血者。外症亦恶寒发热。
但兼口渴舌干为异。治宜辛凉。清解营卫。须用川羌、桂枝、石膏、羚羊角、黑栀、丹皮、
黄芩、桑杏之属。散之清之。次用和血清络之品调之。
邵评∶此与上条合。是伤寒而成吐血。上条寒邪在表。失于表散。寒郁化热。入里
伤络而吐血。此条内有伏火。寒束于外。火逼伤络而吐血。学人最宜甄别。
有因风温之邪。误汗动血。有因三阳热盛。沸腾经血。皆致吐衄。凡见眼闭目红。神
昏语乱。烦躁漱水。皆热伤血络之症也。宜犀角、生地、丹皮、山楂、川郁金、净银花、赤
芍、连翘、川连之属。以清络中之瘀热。大便秘者。加制大黄尤妙。
邵评∶此风温症误用辛温发汗。热盛伤营而吐衄之正法。与前二条伤寒吐衄不同。
若兼胸满而痛者。血瘀于络也。当攻之。犀角、生地、归尾、桃仁、赤芍、楂肉、青皮、降香、
大黄之属。行之清之。
邵评∶此治瘀血阻于络中之正法。
有误发少阴之汗。动其经血。从口鼻耳目中出者。名下厥上竭。不治。有暴吐臭腐之血。名内溃。不治。
In Taiyang disease (disease of the Taiyang channel), hematemesis (vomiting blood) often results from improper treatment. In some cases, it is caused by contracting cold pathogens in the Taiyang channel, presenting with anhidrosis (absence of sweating), aversion to cold, headache, and fever. Due to the external constraint of cold pathogens, the appropriate method is diaphoresis (inducing sweating). If the opportunity for exterior dispersion is missed, Yang Qi cannot vent outward, causing it to reverse and ascend, damaging the Yang collaterals (collaterals located in the upper body and superficial tissues), leading to reckless bleeding and resulting in hematemesis. Alternatively, if the patient has a pre-existing tendency toward blood disorders, and cold pathogens invade the Lung causing coughing, the vibration may damage the blood collaterals, also resulting in hemoptysis (coughing up blood). Both conditions should be treated by clearing and dispersing Ying and Wei (nutritive and defensive Qi) and dispelling cold pathogens from the exterior. The ancients used formulas such as Mahuang Tang (Ephedra Decoction) and Guizhi Tang (Cinnamon Twig Decoction) to treat blood disorders, which is the rationale. However, these formulas are somewhat too potent; their dosage and intensity should be reduced. One may use Qianghuo (Notopterygii Rhizoma et Radix), Ziye (Perillae Folium), Jingjie (Schizonepetae Spica), Fangfeng (Saposhnikoviae Radix), and Bohe (Menthae Haplocalycis Herba) to expel wind and scatter cold; Juhong (Citri Reticulatae Pericarpium) and Xingren (Armeniacae Semen Amarum) to direct Qi downward; Shaoyao (Paeoniae Radix) and Gancao (Glycyrrhizae Radix et Rhizoma) to stabilize Ying Qi. If there is slight thirst, a small amount of Huangqin (Scutellariae Radix) can be added to clear heat. Once the pathogens in Ying and Wei are dispersed, the cough will naturally cease, the body temperature will normalize, and the bleeding will stop spontaneously without specific hemostatic intervention.
Commentary by Shao: These two formulas are suitable for the initial stage of Wind-Cold when the pathogen is at the exterior, serving as agents for exterior dispersion. By the time hematemesis or epistaxis (nosebleed) occurs, the pathogen has transformed into heat and entered the interior. How could one still use acrid-warm exterior-dispersing methods? Neither Mahuang Tang nor Guizhi Tang is a formula for treating bleeding. What the ancients meant was that during the phase where Wind-Cold is at the exterior, failure to use Mahuang Tang or Guizhi Tang to release the exterior leads to pathogen stagnation transforming into heat, which then enters and damages the Ying level, causing hematemesis and epistaxis. This does not mean using Mahuang Tang or Guizhi Tang to stop bleeding after hemorrhage has occurred. Students must not use these two formulas to treat blood disorders, lest they cause serious errors. This formula is actually the correct method for treating hematemesis caused by cold pathogens failing to disperse from the exterior, stagnating into heat, entering the interior, and damaging Ying collaterals.
If there is latent fire within and cold pathogens externally contracted, the heat is constrained by the cold, and the fire forces blood out of the collaterals, resulting in epistaxis or hemoptysis. The external symptoms include aversion to cold and fever, but differ by the presence of thirst and dry tongue. Treatment should employ acrid-cool methods to clear and resolve Ying and Wei. Ingredients such as Chuan Qianghuo (Notopterygii Rhizoma et Radix), Guizhi (Cinnamomi Ramulus), Shigao (Gypsum Fibrosum), Lingyangjiao (Saigae Tataricae Cornu), Hei Zhizi (Gardeniae Fructus Praeparatus), Danpi (Moutan Cortex), Huangqin (Scutellariae Radix), Sangbaipi (Mori Cortex), and Xingren (Armeniacae Semen Amarum) should be used. Through dispersing and clearing, followed by harmonizing blood and clearing collaterals to regulate the condition.
Commentary by Shao: Combined with the previous clause, this addresses hematemesis resulting from Taiyang disease. The previous clause describes cold pathogens at the exterior, which, due to lack of dispersion, stagnate and transform into heat, entering the interior and damaging collaterals to cause hematemesis. This clause describes internal latent fire constrained externally by cold, where fire forces damage to collaterals causing hematemesis. Students must distinguish carefully between them.
Some cases arise from Wind-Warmth pathogens where improper diaphoresis disturbs the blood; others result from excessive heat in the Three Yang channels boiling the channel blood, both leading to hematemesis and epistaxis. Symptoms such as closed eyes, redness of the eyes, coma, delirious speech, irritability, and rinsing the mouth without swallowing indicate heat damaging blood collaterals. Suitable ingredients include Xijiao (Rhinocerotis Cornu - *note: substitute with water buffalo horn in practice*), Sheng Dihuang (Rehmanniae Radix), Danpi (Moutan Cortex), Shanzha (Crataegi Fructus), Chuan Yujin (Curcumae Radix), Jingyinhua (Lonicerae Japonicae Flos), Chi Shao (Paeoniae Radix Rubra), Lianqiao (Forsythiae Fructum), and Huanglian (Coptidis Rhizoma) to clear stasis-heat in the collaterals. If constipation is present, adding Zhi Dahuang (Rhei Radix et Rhizoma Praeparata) is particularly effective.
Commentary by Shao: This is the correct method for hematemesis and epistaxis caused by Wind-Warmth where acrid-warm diaphoretics were improperly used, leading to excessive heat damaging Ying Qi. It differs from the Taiyang hematemesis described in the previous two clauses.
If accompanied by chest fullness and pain, it indicates blood stasis obstructing the collaterals. Attack measures should be taken using Xijiao (Rhinocerotis Cornu), Sheng Dihuang (Rehmanniae Radix), Guiwei (Angelicae Sinensis Radix), Taoren (Persicae Semen), Chi Shao (Paeoniae Radix Rubra), Zharon (Crataegi Fructus), Qingpi (Citri Reticulatae Pericarpium Viride), Jiangxiang (Dalbergiae Odoriferae Lignum), and Dahuang (Rhei Radix et Rhizoma) to move and clear.
Commentary by Shao: This is the correct method for treating blood stasis obstructing the collaterals.
If the sweat of the Shaoyin channel is improperly induced, disturbing the channel blood, which flows out from the mouth, nose, ears, or eyes, it is named "Lower Jue and Upper Exhaustion" (Xia Jue Shang Jie), which is incurable. If there is sudden vomiting of foul-smelling, putrid blood, it is named "Internal Collapse" (Ne Kui), which is also incurable.