治吐血、衄血，脉洪滑而长，或上入鱼际，此因热而胃气不降也，以寒凉重坠之药，降其胃气则血止矣。
生赭石（六钱，轧细） 清半夏（三钱） 蒌仁（四钱，炒捣） 生杭芍（四钱） 竹茹（三钱） 牛蒡子（三钱，
炒捣） 粉甘草（钱半）
《金匮》治心气不足吐衄，有泻心汤，大黄与黄连、黄芩并用，后世未窥仲景制方之意，恒多误解。不知
所谓心气不足者，非不足也，若果不足，何又泻之？盖此证因阳明胃腑之热，上逆冲心，以致心中怔忡不安，
若有不足之象。仲景从浅处立说，冀人易晓，遂以心气不足名之。故其立方，独本《内经》吐血、衄血，责重
阳明不降之旨，用大黄直入阳明之腑，以降其逆上之热，又用黄芩以清肺金之热，使其清肃之气下行，以助阳
明之降力，黄连以清心火之热，使其元阳潜伏，以保少阴之真液，是泻之实所以补之也。且黄连之性肥肠止泻，
与大黄并用，又能逗留大黄之力，使之不至滑泻，故吐衄非因寒凉者，服之莫不立愈。且愈后而瘀血全消，更
无他患，真良方也。即使心气果系不足，而吐衄不止将有立危之势，先用泻心汤以止其吐衄，而后从容调补，
徐复其正，所谓急则治标，亦医家之良图也。乃世人竟畏大黄力猛，不敢轻用，即或用之，病家亦多骇疑。是
以愚不得已，
拟此寒降汤，重用赭石，以代大黄降逆之力，屡次用之，亦可随手奏效也。
或问∶后世本草谓血证忌用半夏，以其辛而燥也。子所拟寒降汤，治吐衄之因热者，何以方中仍用半夏，
独不虑其辛燥伤血乎？答曰∶血证须有甄别，若虚劳咳嗽，痰中带血，半夏诚为所忌。若大口吐血，或衄血不
止，虽虚劳证，亦可暂用半夏以收一时之功，血止以后，再徐图他治。盖吐血之证，多由于胃气挟冲气上逆，
衄血之证，多由于胃气冲气上逆，并迫肺气亦上逆。《内经》厥论篇曰∶阳明厥逆、喘咳身热、善惊衄、呕血。
煌煌圣言，万古不易。是治吐衄者，原当以降阳明之厥逆为主，而降阳明胃气之逆者，莫半夏若也。
一童子，年十四，陡然吐血，一昼夜不止，势甚危急，求为诊视。其脉洪长，右部尤重按有力。知其胃气
因热不降，血随逆气上升也。为拟此汤，一剂而愈，又服一剂，脉亦和平。
一人，年十八，偶得吐血证，初不甚剧。因医者误治，遂大吐不止。诊其脉如水上浮麻，莫辨至数，此虚
弱之极候也。若不用药立止其血，危可翘足而待。遂投以此汤，去竹茹，加生山药一两，赭石改用八钱，一剂
血止。再诊其脉，左右皆无，重按亦不见。愚不禁骇然。询之心中亦颇安稳，惟觉酸懒无力。忽忆吕沧洲曾治
一发斑证，亦六脉皆无，沧洲谓∶脉者血之波澜，今因发斑伤血，血伤不能复作波澜，是以不见，斑消则脉出
矣。遂用白虎加人参汤，化其斑毒，脉果出（详案在青盂汤下）。今此证大吐亡血，较之发斑伤血尤甚，脉之
重按不见，或亦血分虚极，不能作波澜欤？其吐之时，脉如水上浮麻者，或因气逆火盛，强迫其脉外现欤？不
然闻其诊毕还里（相距十里），途中复连连呕吐，岂因路间失血过多欤？踌躇久之，乃放胆投以大剂六味地黄
汤，减茯苓、泽泻三分之二，又加人参、赭石各数钱，一剂脉出。又服平补之药二十余剂，始复初。
按∶因寒因热，皆可使胃气不降。然因热胃气不降者，人犹多知之，因寒胃气不降者，则知者甚鲜。黄氏
论胃气不降，专主因寒一面，盖有所感触而言也。曾有一少妇，上焦烦热，不能饮食，频频咳吐，皆系稀涎，
脉象弦细无力。知系脾胃湿寒，不能运化饮食下行，致成留饮为恙也。询其得病之初，言偶因咳嗽懒食，延本
处名医投以栝蒌、贝母、麦冬之类，旋愈旋即反复，服药月余竟至如此。遂为开苓桂术甘汤，加干姜、半夏
（细观理饮汤后跋语自知），且细为剖析用药之意。及愚旋里，其药竟不敢服，复请前医治之，月余而亡。夫
世之所谓名医者，其用药大抵如此，何不读黄氏之论，而反躬自省也哉！
门人高××实验一方∶赭石、滑石等分研细，热时新汲井泉水送服，冷时开水送服，一两或至二两，治吐
衄之因热者甚效。高××又在保阳，治一吐血证甚剧者，诸药皆不效，诊其脉浮而洪，至数微数，重按不实。初
投以拙拟保元寒降汤，稍见效，旋又反复。高××遂放胆投以赭石二两、台参六钱、生杭芍一两，一剂而愈。
附录∶
直隶青县张××来函∶
天津曹××，年二十五岁，自春日患吐血证，时发时愈，不以介意。至仲冬，忽吐血较前剧，咳嗽音哑，
面带贫血，胸中烦热，食少倦怠，屡治罔效，来寓求诊。左脉细弱，右脉则弦而有力，知其病久生热，其胃气
因热上逆，血即随之上升也。为开寒降汤方，为其咳嗽音哑，加川贝三钱，连服二剂，病大轻减。又服二剂，
不但吐血已止，而咳嗽音哑诸病皆愈。
安徽当阳吴××来函∶
孟夏二十三日，赤日晴天，铄人脏腑。有陶××者，因业商，斯日出外买粮，午后忽于路中患吐血，迨抵家
尚呕不止。凌晨来院求治。诊其脉象洪滑，重按甚实，知其为热所迫而胃气不降也。因夫子尝推《金匮》泻心
汤为治吐衄良方，遂俾用其方煎汤，送服黑山栀细末二钱。服后病稍愈而血仍不止，诊其脉仍然有力，遂为开
寒降汤，加广三七细末三钱，俾将寒降汤煎一大盅，分两次将三七细末送服。果一剂而愈。
治疗吐血、衄血（鼻出血），脉象洪大滑利且长，或者脉搏上冲至手掌大鱼际部位，这是因为热邪导致胃气不降。使用寒凉且质地沉重的药物，使胃气下降，血液就会停止外溢。
生赭石（六钱，碾碎） 清半夏（三钱） 瓜蒌仁（四钱，炒后捣碎） 生白芍（四钱） 竹茹（三钱） 牛蒡子（三钱，炒后捣碎） 粉甘草（一钱半）
《金匮要略》中治疗心气不足导致的吐血、衄血，有泻心汤一方，大黄与黄连、黄芩并用。后世医家未能洞察张仲景组方的深意，往往产生误解。不知道所谓“心气不足”，并非真正的不足，如果真的不足，为何还要用泻法？大概这个病症是因为阳明胃腑的热邪，上逆冲击心脏，导致心中悸动不安，呈现出一种类似不足的假象。张仲景从浅显的角度立论，希望人们容易理解，所以称之为“心气不足”。因此他制定方剂，完全依据《内经》关于吐血、衄血主要责之于阳明胃气不降的宗旨，使用大黄直接入阳明之腑，以降逆上的热邪；又用黄芩清肺金之热，使其清肃之气下行，以助阳明降气之力；用黄连清心火之热，使元阳潜伏，以保护少阴肾的真阴液。这实际上是“泻”即是“补”。而且黄连的性质能肥肠止泻，与大黄并用，又能留住大黄的药力，使其不至于造成滑泄腹泻，所以对于非因寒凉引起的吐血、衄血，服用此方没有不立即痊愈的。而且病愈后瘀血全消，更无其他病患，真是良方啊。即使心气真的是不足，而吐血、衄血不止将有立即危及生命的形势，先用泻心汤来止住吐血、衄血，然后从容地调理补益，慢慢恢复正气，这就是所谓的“急则治其标”，也是医家的良好策略。然而世人竟然畏惧大黄药力猛烈，不敢轻易使用，即使使用了，病人也多惊恐怀疑。因此我不得已，拟定了这个寒降汤，重用赭石，以代替大黄降逆气的力量，多次使用，也能随手取得疗效。
有人问：后世本草书籍说血证忌讳使用半夏，因为它的性味辛燥。您所拟定的寒降汤，治疗因热引起的吐血、衄血，为什么方中仍然使用半夏，难道不怕它辛燥伤血吗？回答说：血证必须加以甄别，如果是虚劳咳嗽，痰中带血，半夏确实是禁忌。如果是大口吐血，或衄血不止，即使是虚劳证，也可以暂时使用半夏以收取一时的功效，血止以后，再慢慢图谋其他治疗。大概吐血的病症，多由于胃气挟带冲气上逆；衄血的病症，多由于胃气和冲气上逆，并迫使肺气也上逆。《内经·厥论篇》说：阳明经气厥逆，会出现气喘咳嗽、身体发热、易受惊吓、衄血、呕血。这是光辉的圣人之言，万古不变。所以治疗吐血、衄血，原本应当以降阳明经气厥逆为主，而降阳明胃气逆气的，没有比半夏更好的了。
有一个童子，十四岁，突然吐血，一昼夜不止，形势非常危急，请求诊治。他的脉象洪大且长，右部尤其重按时有力。我知道这是胃气因热而不降，血随着逆乱之气上升。于是为他拟定此汤，服一剂就痊愈了，又服一剂，脉象也变得平和。
一个人，十八岁，偶然得了吐血证，起初并不严重。因为医生误治，于是大量吐血不止。诊察他的脉象像水面上漂浮的麻粒，无法辨别至数（脉搏跳动的次数），这是虚弱到了极点的征候。如果不立刻用药止血，危险就在眼前。于是投以此汤，去掉竹茹，加生山药一两，赭石改用八钱，一剂药后血止。再次诊察他的脉象，左右手都摸不到，重按也看不见。我不禁感到惊骇。询问他心中倒也安稳，只觉得酸软无力。忽然想起吕沧洲曾治疗一个发斑疹的病例，也是六脉皆无，吕沧洲说：脉是血的波澜，现在因为发斑疹伤了血，血受伤不能重新形成波澜，所以看不见，斑疹消退后脉就会出来。于是我用白虎加人参汤，化解斑疹毒邪，脉果然出来了（详细医案在青盂汤下）。现在这个病例是大吐亡血，比发斑疹伤血更为严重，脉象重按不见，或许也是血分极度虚弱，不能形成波澜吧？他在吐血时，脉象像水面上漂浮的麻粒，或许是因为气逆火盛，强迫脉象外现吧？不然的话，听说他诊毕回家（相距十里），途中又连连呕吐，难道是因为路途间失血过多吗？犹豫了很久，于是大胆投以大剂量六味地黄汤，减去茯苓、泽泻三分之二，又加人参、赭石各数钱，一剂药后脉象出现。又服用平补的药物二十多剂，才恢复如初。
按语：因寒或因热，都能使胃气不降。然而因热导致胃气不降的，人们还大多知道；因寒导致胃气不降的，知道的很少。黄氏论述胃气不降，专门主张因寒这一面，大概是有所感触而说的。曾经有一位少妇，上焦烦热，不能饮食，频频咳吐，都是稀薄的涎沫，脉象弦细无力。知道这是脾胃湿寒，不能运化饮食下行，导致形成留饮为患。询问她得病之初，说是偶然因为咳嗽懒食，延请本地名医投以瓜蒌、贝母、麦冬之类的药物，病情好转后又反复，服药月余竟到了这种地步。于是我为她开了苓桂术甘汤，加干姜、半夏（细看理饮汤后的跋语自然明白），并且仔细剖析用药的意思。等我回到家里，她的药竟然不敢服用，又请原来的医生医治，一个月后就去世了。世间所谓的名医，他们的用药大致如此，为什么不读黄氏的论述，反而反躬自省呢！
门人高××实验一方：赭石、滑石等量研细，天热时用新打的井泉水送服，天冷时用开水送服，用量一两到二两，治疗因热引起的吐血、衄血非常有效。高××又在保阳，治疗一个吐血证很严重的患者，各种药都不见效，诊察他的脉象浮而洪大，至数略微偏快，重按不实。起初投以我拟定的保元寒降汤，稍微见效，随即又反复。高××于是大胆投以赭石二两、党参六钱、生白芍一两，一剂药就痊愈了。
附录：
直隶青县张××来函：
天津曹××，二十五岁，从春天患吐血证，时好时坏，不以为意。到了仲冬，忽然吐血比以前剧烈，咳嗽声音嘶哑，面色贫血，胸中烦热，食欲少且倦怠，多次治疗无效，来到寓所求诊。左脉细弱，右脉则弦而有力，知道他是久病生热，胃气因热上逆，血随之上升。为他开寒降汤方，因为咳嗽声音嘶哑，加川贝母三钱，连服两剂，病情大减。又服两剂，不但吐血已止，而且咳嗽声音嘶哑等病都好了。
安徽当阳吴××来函：
孟夏二十三日，烈日晴天，酷热灼烧脏腑。有个陶××，因为做生意，这天外出买粮，午后忽然在路上患吐血，等到到家还在呕吐不止。凌晨来院求治。诊察他的脉象洪大滑利，重按非常实，知道他是被热邪逼迫而胃气不降。因为老师曾经推崇《金匮》泻心汤为治疗吐血、衄血的良方，于是让他用该方煎汤，送服黑山栀细末二钱。服用后病情稍好但血仍不止，诊察他的脉仍然有力，于是为他开寒降汤，加广三七细末三钱，让将寒降汤煎一大杯，分两次将三七细末送服。果然一剂药就痊愈了。
Treatment for hematemesis (vomiting blood) and epistaxis (nosebleed), where the pulse is surging, slippery, and long, or rises to reach the thenar eminence (Yuji area of the palm). This is caused by heat leading to the failure of Stomach Qi to descend. Using heavy, cold, and descending herbs to lower the Stomach Qi will stop the bleeding.
Raw Hematite (Lithodis, Shi Gao) [6 qian, crushed]
Clear Pinellia Rhizome (Ban Xia) [3 qian]
Trichosanthes Seed (Gua Lou Ren) [4 qian, stir-fried and crushed]
Raw White Peony Root (Bai Shao) [4 qian]
Bamboo Shavings (Zhu Ru) [3 qian]
Arnebiae Radix seu Lithospermi Semen (Niu Bang Zi) [3 qian, stir-fried and crushed]
Powdered Licorice Root (Gan Cao) [1.5 qian]
In *Jin Gui Yao Lue* (Essential Prescriptions from the Golden Cabinet), there is the Xie Xin Tang (Drain the Epigastrium Decoction) for treating heart Qi deficiency manifesting as hematemesis and epistaxis, which uses Rhubarb (Da Huang) combined with Scutellaria Root (Huang Lian) and Scutellaria Root (Huang Qin). Later generations failed to grasp Zhang Zhongjing's intent in formulating this prescription and often misunderstood it. They did not realize that the so-called "heart Qi deficiency" is not a true deficiency; if it were truly deficient, why would one use draining methods? Essentially, this condition arises from heat in the Yangming Stomach fu-organ reversing upward and rushing into the Heart, causing palpitations and restlessness, presenting an appearance similar to deficiency. Zhang Zhongjing established his theory from a superficial perspective to facilitate understanding, thus naming it "heart Qi deficiency." Therefore, his prescription strictly follows the principle in *Nei Jing* (The Inner Canon) that hematemesis and epistaxis are primarily attributed to the failure of Yangming to descend. He used Rhubarb to directly enter the Yangming fu-organ to drain the rebellious heat; used Scutellaria Root to clear Lung Metal heat, allowing its purifying and descending qi to assist the descending force of Yangming; and used Coptis Rhizome (Huang Lian) to clear Heart Fire heat, preserving the primal Yang and protecting the true Yin fluids of Shaoyin. Thus, "draining" is actually "tonifying." Moreover, Coptis Rhizome has the property of thickening the intestines and stopping diarrhea. When used with Rhubarb, it retains Rhubarb's power, preventing excessive loose stools. Therefore, for hematemesis and epistaxis not caused by cold, this prescription brings about immediate recovery. Furthermore, after recovery, all stasis dissipates, leaving no other ailments; it is indeed an excellent prescription. Even if the Heart Qi were truly deficient, and continuous bleeding posed an immediate life-threatening danger, using Xie Xin Tang first to stop the bleeding, followed by gradual tonification to restore healthy Qi, exemplifies the principle of "treating the acute symptoms first," which is also a sound strategy for physicians. However, people generally fear the potent nature of Rhubarb and dare not use it lightly; even when used, patients often react with shock and doubt. Consequently, I reluctantly formulated this Han Jiang Tang (Cold Descending Decoction), heavily utilizing Raw Hematite to replace Rhubarb's descending power. Repeated use has yielded prompt results.
One might ask: Later materia medica states that Ban Xia (Pinellia Rhizome) is contraindicated in blood disorders due to its acrid and drying nature. In your proposed Han Jiang Tang, which treats hematemesis and epistaxis caused by heat, why do you still include Ban Xia? Are you not concerned that its acrid dryness will damage the blood? The answer is: Blood disorders require differentiation. If it is consumptive cough with blood-streaked sputum, Ban Xia is indeed contraindicated. However, if there is massive hematemesis or unceasing epistaxis, even in consumptive cases, Ban Xia can be temporarily used to achieve immediate effect. After the bleeding stops, other treatments can be planned gradually. Generally, hematemesis is mostly due to Stomach Qi carrying Chong Qi (Penetrating Vessel Qi) rebelling upward; epistaxis is mostly due to Stomach and Chong Qi rebelling upward, forcing Lung Qi to rebel as well. *Nei Jing · Jue Lun Pian* (Treatise on Rebellious Qi) states: "Yangming rebellious qi leads to panting, cough, body heat, fright, epistaxis, and vomiting blood." This is a glorious sage teaching, immutable through the ages. Therefore, treating hematemesis and epistaxis should primarily focus on descending Yangming rebellious qi. Among herbs that descend Stomach Qi rebellion, none is superior to Ban Xia.
A boy, aged fourteen, suddenly began vomiting blood continuously for a day and night, in a critical state. Upon examination, his pulse was surging, long, and particularly forceful upon deep pressure on the right side. I determined that Stomach Qi failed to descend due to heat, and blood rose with the rebellious qi. I prescribed this decoction. One dose cured him; a second dose normalized the pulse.
An eighteen-year-old man occasionally suffered from hematemesis, initially mild. Due to medical error, he began massive, unceasing vomiting of blood. His pulse felt like floating hemp seeds on water, indistinguishable in rate, indicating extreme weakness. Without immediate medication to stop the bleeding, death was imminent. I administered this decoction, removing Zhu Ru (Bamboo Shavings), adding raw Dioscorea Rhizome (Shan Yao) 1 liang, and increasing Hematite (Dai Zhe Shi) to 8 qian. One dose stopped the bleeding. On re-examination, the pulse was imperceptible on both sides, even upon deep pressure. I was startled. He reported feeling mentally stable but physically weak and sore. I recalled Lü Cangzhou treating a case of macular eruption where all six pulses were absent. Lü stated: "The pulse is the wave of blood. Now, due to the eruption damaging blood, the blood cannot generate waves, hence the absence of pulse. Once the eruption subsides, the pulse will emerge." I used Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng) to resolve the eruption toxin, and the pulse indeed emerged (see detailed case under Qing Yu Tang). In this case, massive blood loss from vomiting was more severe than blood damage from eruption. The absence of pulse upon deep pressure might be due to extreme deficiency in the blood level, unable to generate waves? Or perhaps during the vomiting, the pulse felt like floating hemp seeds because rebellious qi and flourishing fire forced the pulse to manifest externally? Alternatively, hearing that he traveled ten li home and vomited repeatedly along the way, could excessive blood loss during the journey be the cause? After much hesitation, I boldly administered a large dose of Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia), reducing Poria (Fu Ling) and Alisma Rhizome (Ze Xie) by two-thirds, and adding Ginseng (Ren Shen) and Hematite (Dai Zhe Shi) several qian each. One dose brought out the pulse. After taking twenty-plus doses of mild tonifying medicine, he fully recovered.
Note: Both cold and heat can cause Stomach Qi to fail to descend. However, while many know that heat causes this, few understand that cold can also cause it. Mr. Huang's discussion on Stomach Qi failure focuses exclusively on cold, likely based on specific experiences. I once treated a young woman with upper jiao irritability and heat, inability to eat, frequent coughing up of thin saliva, and a wiry, fine, and powerless pulse. I diagnosed spleen-stomach damp-cold failing to transform and transport food downward, leading to retained fluid pathology. She reported that initially, due to cough and poor appetite, a local famous doctor prescribed Trichosanthes Root (Gua Lou), Fritillaria Bulb (Bei Mu), and Ophiopogon Tuber (Mai Dong). Her condition improved then relapsed. After a month of medication, she reached this state. I prescribed Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Glycyrrhiza Decoction) with added Dried Ginger (Gan Jiang) and Pinellia Rhizome (Ban Xia) (see postscript of Li Yin Tang for details), explaining the rationale carefully. However, upon my return, her family dared not administer the medicine and consulted the previous doctor. She died after another month. This illustrates how so-called "famous doctors" prescribe medicines. Why do they not read Mr. Huang's treatises and reflect upon themselves?
My disciple Gao XX experimentally tested a formula: Equal parts of Hematite (Dai Zhe Shi) and Talcum (Hua Shi) ground into fine powder. Taken with fresh well-water in hot weather, or boiled water in cold weather, dosage 1–2 liang. It is very effective for hematemesis and epistaxis caused by heat. Gao XX also treated a severe hematemesis case in Baoyang where other medicines failed. The pulse was floating, surging, slightly rapid, and empty upon deep pressure. Initially, I prescribed my Bao Yuan Han Jiang Tang (Protective Origin Cold Descending Decoction), which showed slight effect but relapsed. Gao XX then boldly administered Hematite 2 liang, Codonopsis Root (Tai Shen) 6 qian, and Raw White Peony Root 1 liang. One dose resulted in cure.
Appendix:
Letter from Zhang XX of Qing County, Zhili:
Cao XX of Tianjin, aged 25, suffered from intermittent hematemesis since spring, ignoring it. In mid-winter, the bleeding became severe, accompanied by hoarseness, anemia, chest irritability, poor appetite, and fatigue. Multiple treatments failed. Left pulse was fine and weak; right pulse was wiry and forceful. I diagnosed chronic illness generating heat, causing Stomach Qi to rebel upward due to heat, dragging blood with it. I prescribed Han Jiang Tang. For hoarseness, I added Fritillaria Bulb (Chuan Bei Mu) 3 qian. Two doses significantly reduced symptoms. Two more doses stopped the bleeding and cured the cough and hoarseness.
Letter from Wu XX of Dangyang, Anhui:
On the 23rd day of early summer, under scorching sun, Tao XX, a merchant, went out to buy grain. In the afternoon, he suddenly vomited blood on the road and continued vomiting upon returning home. He sought treatment at dawn. Pulse was surging, slippery, and solid upon deep pressure, indicating heat forcing Stomach Qi to fail to descend. Since the master praised Jin Gui Xie Xin Tang as an excellent prescription for hematemesis and epistaxis, I advised using that decoction taken with 2 qian of finely ground Black Gardenia Fruit (Hei Shan Zhi). Symptoms improved slightly, but bleeding persisted. Pulse remained forceful. I then prescribed Han Jiang Tang with 3 qian of finely ground Panax Notoginseng Root (San Qi). The patient took the decoction in two portions, swallowing the San Qi powder with each. One dose resulted in a cure.