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。
伤寒病中出现吐血症状，往往是因为治疗不当所致。有的因为感受太阳经寒邪，表现为无汗、怕冷、头痛、发热。由于寒邪束缚在体表，按照治法应当发汗解表。如果错过了表散（发散表邪）的时机，阳气不能向外宣泄，就会逆冲向上损伤阳络（指分布于人体上部及体表的脉络），导致血液妄行，从而引起吐血。或者因为患者本身就有血症体质，寒邪侵犯肺部引发咳嗽，震动损伤了血络，也会导致咳血。这两种情况都应当以清疏营卫之气、表散寒邪作为治疗方法。古人使用麻黄汤、桂枝汤等方剂来治疗血症，就是这个道理。然而这些方剂药力未免过于峻猛，应当减小其剂量和强度，使用羌活、苏叶、荆芥、防风、薄荷等药物，以祛除风邪、散发寒邪；用橘红、杏仁来降气；用芍药、甘草来安固营血。如果轻微伴有口渴，可少量佐以黄芩来清热。这样营卫之邪得以解散，自然咳嗽停止、身体凉爽，血液不经过专门止血治疗也会自行停止。
邵评：这两个方子适用于风寒初起、邪气在表的情况，用作表散之剂。等到出现吐血、衄血（鼻出血）时，说明邪气已经化热入里，哪里还有再用辛温药物进行表散的道理？麻黄汤、桂枝汤绝不是治疗出血的方子。古人所说的，是在风寒在表之时，如果不及时用麻黄汤、桂枝汤发表，导致邪气郁结变成热邪，热邪深入损伤营分而导致吐血、衄血。这并不是指见到出血之后，再用麻黄汤、桂枝汤来止血。学习者千万不要用麻黄汤、桂枝汤治疗血症，以免误事。这个方子实际上是治疗寒邪不从体表发散，郁结而成热邪，热邪入里损伤营络而吐血的正确方法。
如果体内有潜伏的火邪，又外感寒邪，热邪被寒邪束缚，火邪逼迫络脉中的血液，从而导致衄血、咳血。外在症状也是怕冷、发热，但兼有口渴、舌干作为区别。治疗宜用辛凉之法，清解营卫之气，必须使用川羌活、桂枝、石膏、羚羊角、黑栀子、牡丹皮、黄芩、桑白皮、杏仁这一类药物。通过发散和清热的方法，随后使用和血、清络的药物进行调理。
邵评：此条与上一条合并来看，都是伤寒导致的吐血。上一条是寒邪在表，因未及时表散，寒邪郁结化热，入里损伤络脉而吐血。这一条是体内有伏火，寒邪束缚于外，火邪逼迫损伤络脉而吐血。学习者最应该仔细辨别。
有的因为风温邪气，误用发汗法而动血；有的因为三阳经热盛，使经血沸腾，都导致吐血、衄血。凡是见到眼睛闭合、眼目发红、神志昏迷、胡言乱语、烦躁不安、想漱口但不欲咽下，都是热邪损伤血络的症状。适宜使用犀角、生地黄、牡丹皮、山楂、川郁金、金银花、赤芍、连翘、黄连这一类药物，以清除络脉中的瘀滞热邪。如果大便秘结，加入制大黄尤为巧妙。
邵评：这是风温病症误用辛温发汗，导致热盛损伤营分而吐衄的正确治法。与前两条伤寒引起的吐衄不同。
如果兼有胸部胀满且疼痛，说明血液瘀阻在络脉中。应当攻逐瘀血，使用犀角、生地黄、当归尾、桃仁、赤芍、山楂肉、青皮、降香、大黄这一类药物。通过行气和清热的方法。
邵评：这是治疗瘀血阻滞于络脉中的正确方法。
有误发少阴经汗法，扰动经血，从口、鼻、耳、目中流出的，名为“下厥上竭”，属于不治之症。如果有突然吐出臭秽腐败血液的，名为“内溃”，也属不治之症。
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.