【纲】仲景曰。伤寒不大便。六七日。头痛有热者。与小承气汤。其大便圊者。知不在里。仍
在表也。当须发汗。若头痛者。必衄。宜桂枝汤。伤寒脉浮紧者。麻黄汤主之。不发汗。因致衄。
【目】成无己曰。病源云。心主血。肝藏血。肺主气。开窍于鼻。血得热则散。随气上从鼻中出。
则为衄。是杂病衄者。责在里热也。如仲景此二条之论。知伤寒衄者。责其表分热故也。
戴原礼曰。古论鼻衄属太阳经。风寒皆有之。既衄而表症仍在。于寒。当用麻黄汤。于风。当
用桂枝汤。且谓发烦目瞑。是太阳侵入阳明。汗下俱难。若衄已而热不退者。惟升麻葛根汤、败毒
散、阳旦汤为妥。衄而烦渴。饮则吐水。先服五苓散。次服竹叶石膏汤。大衄不止。茅花汤。或黄
芩芍药汤加茅花一撮。
柯琴曰。此辨太阳阳明法也。太阳主表。头痛为主。阳明主里。不大便为主。然阳明亦有头痛
者。浊气上冲也。太阳亦有不大便者。阳气太重也。头痛必衄者。阳邪盛于阳位。阳络受伤。故必
衄也。衄乃解矣。宜桂枝句。直接发汗来。不是用桂枝止衄。亦非用在已衄后也。（此旨要明）
【纲】仲景曰。太阳病。脉浮紧。无汗。发热。身疼痛。八九日不解。表病仍在。当发其汗。
麻黄汤主之。服药已。微除。其人发烦。目瞑。剧者必衄。衄乃解。所以然者。阳气重故也。阳盛
则欲衄。阴虚则小便难。言衄为经中阳盛也。
【目】朱肱曰。伤寒衄血者。乃解。盖阳气重故也。仲景所谓阳盛则欲衄。若脉浮紧无汗。服麻
黄汤不中病。其人发烦目瞑。剧者必衄。小衄而脉尚浮紧者。宜再与麻黄汤也。衄后。脉已微者。
不可行麻黄汤也。若脉浮自汗。服桂枝汤不中病。桂枝症尚在。必头疼甚而致衄。小衄而脉尚浮者。
宜再与桂枝也。衄后。脉已微者。不可行桂枝也。大抵伤寒衄
血。不可发汗者。为脉微故也。治法。衄家不可发汗。汗出额上陷。脉紧急。直视不能 。不得眠。
然而无汗而衄。脉尚浮紧者。再与麻黄汤。有汗而衄。脉尚浮缓者。再与桂枝汤。脉已微者。黄
芩芍药汤、犀角地黄汤。
张元素曰。或谓经言衄家不可发汗。汗必额上陷。今衄血之症。皆缀麻黄于其下。何也。夫太
阳脉浮紧。发热无汗。
自汗者愈。此一定之论也。何故复用麻黄汗之。仲景岂有前后相反之理哉。然本条麻黄汤主之五字。合当用于当发汗之
下。盖以汗之文法。用药诸方。皆赘于外条之末。且如大青龙汤症。既云脉微弱汗出恶风者。不可服。服之厥逆。筋惕
肉。此为逆也。又以大青龙汤主之。皆此例。
鳌按。柯氏引黄氏将真武汤改正大青龙汤之谬。已详在前。
王好古曰。仲景言衄家不可发汗者。盖为脉微也。若浮紧者。麻黄汤。浮缓者。桂枝汤。脉已
微。二药不可用。犀角地黄汤主之。
韩祗和曰。千金翼云。吐血有三种。一曰肺疽。二曰伤胃。三曰内衄。既吐血家谓之内衄。则
鼻中出血。可谓之外衄。是经络之血妄行也。经络热盛。阳气拥重。迫血妄行。上出于鼻。则为衄。
柯琴曰。血之与汗。异名同类。不得汗。必得血。不从汗解而从衄解。此与热结膀胱血自下者。
同一局也。太阳脉从目内 络阳明脉于鼻。鼻者。阳也。血虽阴。从阳气而升。则从阳窍而出。
故阳盛则衄。汗者。心之液。是血之变见于皮毛者也。寒邪外敛。腠理不开。阳气内扰。迫血妄行。
假道肺窍。故称红汗。
【纲】仲景曰。衄家不可发汗。汗出必额上陷。脉急紧。目直视。不能 。不得眠。
【目】成无己曰。衄家虽为邪热在经。而又不可发汗如此。前用桂枝麻黄者。非治衄。用以
发散经中邪气也。若邪不得散。拥盛于里。逼迫于血。因而致衄。即不可用此二汤以治衄矣。
吴绶曰。凡吐血衄血。无表症。脉不浮紧者。不可发汗也。东垣云。脉微者。宜黄芩芍药汤。
脉滑数者。犀角地黄汤。热甚血不止者。河间地黄汤、古方四生丸。血虚者。东垣麦门冬饮子、三
黄补血汤。若不止者。活人茜根散、茅花汤主之也。以上皆治吐衄之良方。但在出入通变耳。大抵
吐衄。脉滑小者生。脉实大者死。吐衄后。脉微者易治。若热反盛。脉反急数者。死也。若衄而头
汗出。或身有汗不至足者。难治。凡血得热则行。得冷则凝。见黑则止。所以犀角地黄汤中加好京
墨汁一二匙。搅药令黑。最效也。
张介宾曰。杂病衄血。积热在里。伤寒衄血。积热在表。论曰。伤寒小便清者。知不在里。仍
在表也。当发其汗。若头痛者必衄。宜桂枝汤。曰。伤寒脉浮紧。不发汗。因致衄者。麻黄汤主之。
此以伤寒之衄为其热不在里而在表也。然论又曰。衄家不可发汗。而何以复用桂枝麻黄等汤。盖衄
由乎阴者。以阴虚火动也。故不宜再汗以亡阴。衄由乎阳者。以表邪未解。故当用桂枝麻黄以发散。
论又曰。太阳病。脉浮紧。发热身无汗。自衄者愈。此以表邪欲解。不从汗而从血。所以衄后
当愈也。由此观之。则有因衄而愈者。以经通而解散也。有治衄仍当发散者。以邪之将解未解而因
散其余邪也。若寒气不甚。而用麻黄桂枝。似属太刚。易以柴、葛之类可也。
柯琴曰。已脱血而复汗之。津液枯竭。故脉急紧而目直视。亦心肾俱绝矣。
【纲】仲景曰。太阳病。脉浮紧。发热身无汗。自衄者愈。
【目】成无己曰。此经中之邪。已随而散解。故愈。故知衄者。不待麻黄、桂枝发散者也。
陶华曰。衄血固为欲解。若衄不止而头汗出。其身无汗。乃发热汗不至足者。亦为恶候。当明辨之。
李中梓曰。血紫黑成块。脉迟细。口不渴。小便清。理中汤加丹皮。汗后热退。鼻血不止。新汲
水浸草纸数层。贴项上。及项脊温则易。必止。
鳌按。李氏草纸外治法。施之杂病则稳妥。若治伤寒。还宜酌量。
[General Principle] Zhang Zhongjing stated: In cases of Shanghan (Cold Damage), if there is constipation for six or seven days accompanied by headache and fever, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be administered. If the patient has had a bowel movement, it indicates that the pathogen is not in the interior but remains in the exterior; sweating therapy should be employed. If headache is present, epistaxis (nosebleed) will likely occur, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. In Shanghan with a floating and tight pulse, Mahuang Tang (Ephedra Decoction) is the primary treatment. Failure to induce sweating may lead to epistaxis.
[Commentary] Cheng Wuji stated: The *Bing Yuan* records: The Heart governs blood, the Liver stores blood, and the Lung governs qi and opens into the nose. When blood encounters heat, it scatters and ascends with the qi, exiting through the nose, which is termed "nu" (epistaxis). Thus, in miscellaneous diseases, epistaxis is attributed to internal heat. As indicated by Zhang Zhongjing's two preceding statements, epistaxis in Shanghan is attributed to heat in the exterior.
Dai Yuanli stated: Ancient texts attribute epistaxis to the Taiyang (Greater Yang) channel, occurring in both wind and cold patterns. If the exterior syndrome persists after epistaxis, Mahuang Tang should be used for cold patterns, and Guizhi Tang for wind patterns. Furthermore, if irritability and blurred vision occur, it signifies the invasion of the Taiyang channel into the Yangming (Bright Yang) channel, making both sweating and purging therapies difficult. If fever persists after epistaxis, Shengma Gegen Tang (Kudzu Root and Rhizoma Cimicifugae Decoction), Baidu San (Decoction to Overcome Toxins), or Yangdan Tang are suitable. For epistaxis with irritability and thirst, where drinking leads to vomiting water, Wuling San (Five-Ingredient Powder with Poria) should be taken first, followed by Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction). For severe, unceasing epistaxis, Maohua Tang (Reed Catkin Decoction) or Huangqin Shaoyao Tang (Scutellaria and Peony Decoction) with a pinch of reed catkins is appropriate.
Ke Qin stated: This section distinguishes between Taiyang and Yangming syndromes. Taiyang governs the exterior, with headache as the main symptom; Yangming governs the interior, with constipation as the main symptom. However, Yangming disease can also present with headache due to turbid qi ascending, and Taiyang disease can present with constipation due to excessive yang qi. Headache inevitably leading to epistaxis occurs because yang pathogens are abundant at yang locations, injuring the yang collaterals. Epistaxis resolves the condition. The phrase "Guizhi Tang is appropriate" directly follows the concept of inducing sweating; it is not used to stop epistaxis, nor is it applied after epistaxis has already occurred. (This principle must be clearly understood.)
[General Principle] Zhang Zhongjing stated: In Taiyang disease, with a floating and tight pulse, absence of sweat, fever, and body pain persisting for eight or nine days without resolution, the exterior pathology remains, and sweating therapy should be employed using Mahuang Tang. After taking the medicine, symptoms may slightly alleviate, causing irritability and blurred vision in the patient. In severe cases, epistaxis will occur, resolving the condition. This happens because of heavy accumulation of yang qi. Excessive yang qi desires epistaxis, while yin deficiency leads to difficulty in urination. This refers to excess yang in the meridians.
[Commentary] Zhu Gong stated: Epistaxis in Shanghan indicates resolution of the pathogen, generally due to heavy accumulation of yang qi. As Zhang Zhongjing said, "excessive yang qi desires epistaxis." If the pulse is floating and tight with no sweat, and Mahuang Tang fails to cure, resulting in irritability and blurred vision, severe cases will experience epistaxis. If there is minor epistaxis but the pulse remains floating and tight, Mahuang Tang should be administered again. After epistaxis, if the pulse becomes faint, Mahuang Tang is contraindicated. If the pulse is floating with spontaneous sweating, and Guizhi Tang fails to cure, leaving the Guizhi syndrome intact, severe headache may lead to epistaxis. If there is minor epistaxis but the pulse remains floating and relaxed, Guizhi Tang should be administered again. After epistaxis, if the pulse becomes faint, Guizhi Tang is contraindicated. Generally, epistaxis in Shanghan precludes sweating therapy due to a faint pulse. Regarding treatment: patients prone to epistaxis should not undergo sweating therapy; if sweating causes depression of the forehead, a tight and urgent pulse, staring eyes without ability to move, and insomnia, it is critical. However, if there is no sweat and epistaxis occurs with a still-floating and tight pulse, Mahuang Tang may be given again; if there is sweat and epistaxis with a still-floating and relaxed pulse, Guizhi Tang may be given again; if the pulse is faint, Huangqin Shaoyao Tang or Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) should be used.
Zhang Yuansu stated: Some ask why Mahuang Tang is often appended to treatments for epistaxis, given that classics state patients prone to epistaxis should not sweat, as it causes forehead depression. In Taiyang disease with floating/tight pulse, fever, and no sweat, spontaneous sweating indicates healing. Why use Mahuang Tang? Did Zhang Zhongjing contradict himself? Actually, the five characters "Mahuang Tang is appropriate" in this clause should follow "sweating therapy should be employed." Textual conventions place prescriptions at the end of related clauses. For example, in Da Qing Long Tang (Major Blue Green Dragon Decoction) indications, it states those with faint pulse, sweating, and aversion to wind should not take it, as it causes cold limbs and muscle twitching (a misapplication). Yet it concludes with "Da Qing Long Tang is appropriate." This is the same textual pattern.
Shen Jin'ao noted: Ke Qin cited Huang's correction of Zhenwu Tang to Da Qing Long Tang, detailed previously.
Wang Haogu stated: Zhang Zhongjing's statement that patients prone to epistaxis should not sweat applies when the pulse is faint. If floating and tight, use Mahuang Tang; if floating and relaxed, use Guizhi Tang. If the pulse is faint, neither is applicable; Xijiao Dihuang Tang is appropriate.
Han Zhihe stated: *Qianjin Yi Fang* records three types of hematemesis: lung abscess, stomach injury, and internal epistaxis. Since hematemesis is called internal epistaxis, nasal bleeding can be called external epistaxis, representing reckless flow of blood in the collaterals. Heat abundance in collaterals and heavy congestion of yang qi force blood to rush upward through the nose, causing epistaxis.
Ke Qin stated: Blood and sweat are different names for the same substance. If sweat cannot be released, blood must be released. Resolution via epistaxis instead of sweating parallels the case of blood discharge from the bladder due to heat binding. The Taiyang meridian connects from the inner canthus to the Yangming meridian at the nose. The nose is a yang orifice. Although blood is yin, it ascends with yang qi and exits through yang orifices. Thus, excessive yang leads to epistaxis. Sweat is the fluid of the Heart, a manifestation of blood on the skin surface. External cold constrains the pores, preventing opening; internal yang disturbance forces blood recklessly through the lung orifice (nose), hence termed "red sweat."
[General Principle] Zhang Zhongjing stated: Patients prone to epistaxis should not undergo sweating therapy. If sweating is induced, it will cause depression of the forehead, an urgent and tight pulse, staring eyes unable to move, and insomnia.
[Commentary] Cheng Wuji stated: Although patients prone to epistaxis have pathogenic heat in the meridians, they must not be treated with such sweating methods. Previous uses of Guizhi Tang or Mahuang Tang were not to treat epistaxis itself, but to disperse pathogenic qi in the meridians. If the pathogen does not disperse but congests in the interior, forcing blood, thereby causing epistaxis, these two decoctions should not be used to treat the epistaxis.
Wu Shou stated: For hematemesis or epistaxis without exterior syndrome and non-floating/tight pulses, sweating is contraindicated. Dongyuan stated: For faint pulses, Huangqin Shaoyao Tang is appropriate; for slippery and rapid pulses, Xijiao Dihuang Tang. For severe heat with unceasing bleeding, Hejian Dihuang Tang or the ancient formula Sisheng Wan (Four Living Pills) is used. For blood deficiency, Dongyuan's Maimendong Yinzi or Sanhuang Buxue Tang (Three Yellows Blood-Nourishing Decoction) is used. If bleeding continues, Huoren Qiangensan or Maohua Tang is appropriate. These are excellent formulas for treating hematemesis and epistaxis, requiring flexible application. Generally, for hematemesis/epistaxis, a slippery and small pulse indicates survival, while a solid and large pulse indicates death. After bleeding, a faint pulse is easy to treat. If heat increases and the pulse becomes urgent and rapid, it is fatal. If epistaxis is accompanied by head sweating or body sweating that does not reach the feet, it is difficult to treat. Blood flows with heat, coagulates with cold, and stops upon contact with black. Therefore, adding one or two spoons of high-quality Jingmo juice (Beijing ink) to Xijiao Dihuang Tang to turn the medicine black is most effective.
Zhang Jiebin stated: In miscellaneous diseases, epistaxis is due to accumulated heat in the interior; in Shanghan, it is due to accumulated heat in the exterior. The text states: In Shanghan, clear urine indicates the pathogen is not in the interior but in the exterior, requiring sweating. If headache occurs, epistaxis is likely, and Guizhi Tang is appropriate. It also states: In Shanghan with floating/tight pulse, failure to sweat leads to epistaxis, treated with Mahuang Tang. This views Shanghan epistaxis as heat in the exterior, not interior. However, the text also says patients prone to epistaxis should not sweat. Why then use Guizhi or Mahuang Tang? Epistaxis caused by yin deficiency involves fire stirring due to yin deficiency, so further sweating should be avoided to prevent loss of yin. Epistaxis caused by yang involves unresolved exterior pathogens, so Guizhi or Mahuang Tang should be used to disperse. The text also states: In Taiyang disease, with floating/tight pulse, fever, and no sweat, spontaneous epistaxis leads to healing. This is because the exterior pathogen is resolving via blood rather than sweat. Thus, some heal via epistaxis due to meridian patency and pathogen dispersal; others require dispersion to clear residual pathogens. If cold is mild, using Mahuang/Guizhi may be too harsh; Chaihu or Gegen alternatives are preferable.
Ke Qin stated: Sweating after significant blood loss depletes fluids, causing an urgent/tight pulse and staring eyes, indicating exhaustion of Heart and Kidney.
[General Principle] Zhang Zhongjing stated: In Taiyang disease, with floating/tight pulse, fever, and no sweat, spontaneous epistaxis leads to healing.
[Commentary] Cheng Wuji stated: The pathogenic qi in the meridians disperses with epistaxis, leading to healing. Thus, epistaxis resolves the condition without waiting for Mahuang or Guizhi decoctions.
Tao Hua stated: While epistaxis often indicates impending resolution, unceasing epistaxis with head sweating, no body sweating, and fever not reaching the feet is a malignant sign requiring careful differentiation.
Li Zhongzi stated: If blood is purple-black and clotted, with a slow/fine pulse, no thirst, and clear urine, Lizhong Tang (Regulate the Middle Decoction) plus Mudanpi is used. If fever subsides after sweating but epistaxis continues, apply several layers of paper soaked in fresh well-water to the neck; replace when warm until bleeding stops.
Shen Jin'ao noted: Li's external paper therapy is stable for miscellaneous diseases but requires caution in Shanghan.