皆因邪热中三焦。当汗医家失审量。热毒入深成吐血。桃仁承气地黄汤。
吐血者。诸阳受热。其邪在表。当汗不汗。致使热毒入腑。积瘀于内。迫血妄行而吐也。宜以桃仁承气汤主之。亦
有服桂枝汤而吐血者。宜犀角地黄汤主之。大抵吐血衄血。有阳乘阴者。有阴乘阳者。阳乘阴者。血热妄行是也。阴乘
阳者。血不归经是也。
太阳衄血病将瘳。犀角黄芩芍药搜。漱水阳明犀角进。当归四逆少阴授。
衄血者。经络
及服桂枝汤后而衄者。此皆阳气盛长病欲解也。宜犀角地黄汤。及黄芩芍药汤。茜根汤。茅
花汤。加减主之。有因少阴发汗而动衄者。此症难治。亦可用当归四逆汤主之。大抵吐血衄
血。脉滑小者生。脉实大者死。脉微者易治。若热甚。脉反数急者死也。衄而头汗出。或身
上有汗。不至足者。皆难治也。凡衄血亡血家不可发汗。发汗则阴阳俱虚。针经曰。夺汗者
无血。夺血者无汗。此之谓也。
当归四逆桂枝芍。细辛甘草木通合。直加大枣治阴厥。脉细阳虚由血弱。
伤寒脉伏是何缘。阳极如阴大汗全。更有夹阴沉伏见。须投姜附灸关元。
伤寒一手脉沉曰单伏。两手脉沉曰双伏。不可以阳症见阴为诊。乃火邪内郁。不得发越
极似阴。故脉伏。必有大汗而解。正如久旱将雨。六合阴晦。雨后庶物皆苏之义。又有夹阴
伤寒。先有伏阴在内。外复感寒。阴盛阳衰。四肢厥冷。六脉沉伏。须投姜附及灸关元。脉
乃复出也。若太溪冲阳。皆无脉者必死。
This is all due to pathogenic heat invading the Sanjiao (Triple Burner). Physicians failed to carefully assess when sweating therapy was indicated. When heat-toxins penetrate deeply, it results in hematemesis (vomiting blood). Tao Ren Cheng Qi Tang combined with Di Huang Tang should be used.
Hematemesis occurs when the Yang meridians are affected by heat. The pathogen remains in the exterior; if sweating is not induced as required, heat-toxins enter the Fu organs, causing stasis to accumulate internally and forcing blood to flow recklessly, resulting in vomiting. Tao Ren Cheng Qi Decoction (Peach Kernel Cathartic Decoction) is appropriate as the primary treatment. In some cases, hematemesis occurs after taking Gui Zhi Tang (Cinnamon Twig Decoction); in such instances, Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) is appropriate. Generally speaking, hematemesis and epistaxis (nosebleed) can result from Yang pathogens attacking Yin, or Yin pathogens attacking Yang. "Yang attacking Yin" refers to reckless bleeding due to blood-heat. "Yin attacking Yang" refers to blood failing to return to its vessels.
In Taiyang (Greater Yang) disease, epistaxis indicates the illness is about to resolve. Xi Jiao (Rhinoceros Horn), Huang Qin (Scutellaria Root), and Shao Yao (Peony Root) can be used to clear residual pathogens. For Yangming (Bright Yang) epistaxis characterized by rinsing the mouth without swallowing, Xi Jiao should be advanced. Shaoyin (Lesser Yin) epistaxis should be treated with Dang Gui Si Ni Tang (Angelica Sinensis Decoction for Frigid Extremities).
Epistaxis includes conditions affecting the meridians and those occurring after taking Gui Zhi Tang. These situations indicate that Yang Qi is flourishing and the disease is resolving. Appropriate treatments include Xi Jiao Di Huang Tang, Huang Qin Shao Yao Tang (Scutellaria and Peony Decoction), Qian Gen Tang (Rubia Root Decoction), and Mao Hua Tang (Cat-tail Flower Decoction), modified as needed. Epistaxis caused by improper sweating in Shaoyin disease is difficult to treat but may be managed with Dang Gui Si Ni Tang. Generally, a slippery and small pulse in hematemesis or epistaxis indicates survival, while a solid and large pulse indicates death. A faint pulse is easy to treat. If heat is severe but the pulse becomes rapid and urgent, it indicates death. Epistaxis accompanied by sweating only on the head, or sweating on the body that does not reach the feet, are all difficult to treat. Patients with epistaxis or blood loss must not undergo sweating therapy; doing so leads to deficiency of both Yin and Yang. The *Ling Shu* (Spiritual Pivot) states: "Those who lose sweat have no blood; those who lose blood have no sweat." This principle applies here.
Dang Gui Si Ni Tang consists of Gui Zhi (Cinnamon Twig), Shao Yao (Peony Root), Xi Xin (Asarum), Gan Cao (Licorice Root), Tong Cao (Tetrapanax Pith), and Da Zao (Jujube Fruit), and is used to treat cold extremities. A fine pulse indicates Yang deficiency stemming from blood weakness.
Why is the pulse hidden (Fu) in Shanghan? This represents extreme Yang resembling Yin, often following profuse sweating. It may also appear in Cold-Yin complicated Shanghan. Ginger and Aconite preparations along with moxibustion at Guan Yuan (CV4) are required.
A hidden pulse in one hand is called Dan Fu (Single Hidden Pulse); in both hands, it is called Shuang Fu (Double Hidden Pulse). One cannot diagnose this as a Yin syndrome merely because Yin-type pulses appear in a Yang syndrome. This occurs because Fire pathogens are constrained internally and cannot vent out, closely mimicking Yin syndrome, hence the hidden pulse. Resolution typically comes through profuse sweating, similar to the sky darkening before rain after a long drought, followed by the revival of all things. In Cold-Yin complicated Shanghan, latent Yin exists internally, and external cold invasion causes Yin excess and Yang deficiency, leading to cold extremities and hidden pulses in all six positions. Ginger and Aconite preparations and moxibustion at Guan Yuan are necessary for the pulse to reappear. If pulses are absent at both Tai Xi (KI3) and Chong Yang (ST42), death is certain.