衄血证，诸家但谓其出于肺，盖以鼻为肺之窍也，不知鼻为手足阴明之正经，而手足太
阳亦皆至鼻。故仲景曰∶太阳病，脉浮紧，发热身无汗，自衄者愈。此太阳之衄也。《原病
式》曰∶阳热怫郁于足阳明而上热，则血妄行为鼻衄，此阳明之衄也。若以愚见言之，则凡
鼻衄之血，必自山根以上，精明之次而来，而精明一穴，乃手足太阳、足阳明、阴阳跷五脉
之会，此诸经皆能为衄也。然行于脊背者，无如足太阳为最。行于胸腹者，无如足阳明为最
。而尤有其最者，则又惟冲脉为十二经之血海，冲之上俞出足太阳之大杼，冲之下俞会足阳
明之气街，故太阳、阳明之至，而冲脉无不至矣，冲脉之至，则十二经无不至矣。所以衄之
微者，不过一经之近。而衄之甚者，则甚至数升或至斗许，并通身形色尽脱，又岂特手太阴
一经而病至如是耶？临证者不可不察。
一、衄血之由，内热者多在阳明经，治当以清降为主。微热者，宜生地、芍药、天冬、
麦冬、玄参、丹参，或《局方》犀角地黄汤、生地黄饮子、麦门冬散之类主之。热甚者，宜
芩、连、栀、柏，或茜根散、抽薪饮、加减一阴煎；若兼头痛、口渴者，宜玉女煎、白虎汤
之类主之。或阳明热极，下不通而火壅于上者，宜《拔萃》犀角地黄汤之类，通其下而上自
愈。
一、衄血之由外感者，多在足太阳经。观仲景曰∶伤寒脉浮紧，不发汗，因致衄者，麻
黄汤主之。曰∶伤寒不大便，其小便清者，知不在里，仍在表也，当须发汗。若头痛者必衄
，宜桂枝汤。成无己曰∶伤寒衄者，为邪气不得发散，壅盛于经，逼迫于血，因致衄也。麻
黄汤、桂枝汤治衄者，非治衄也，即是发散经中邪气耳。按此论治，则凡伤寒因衄而邪得解
者，即所以代汗也，不必治之。若虽见衄血而脉仍浮紧，热仍不退，是必衄有未透，而表邪
之犹未解耳，故仍宜麻黄、桂枝等汤，然此二汤乃仲景正伤寒之治法，倘病由温热而有未宜
于此者，则但于伤寒门择散剂之宜者用之，或于余新方中诸柴胡饮随宜用之，自无不可。
一、衄血虽多由火，而惟于阴虚者为尤多。正以劳损伤阴，则水不制火，最能动冲任阴
分之血。但察其脉之滑实有力，及素无伤损者，当作火治如前。若脉来洪大无力，或弦，或
芤，或细数无神，而素多酒色内伤者，此皆阴虚之证，当专以补阴为主。若有微火者，自当
兼而清之，以治其标。若虽见虚热，而无真确阳证，则但当以甘平之剂温养真阴，务令阴气
完固，乃可拔本塞源，永无后患。如一阴煎、三阴煎、左归饮、六味地黄汤之类，皆必用之
剂。如兼气虚者，则五福饮、五阴煎之属，皆当随意用之。
一、止衄法∶凡衄血甚多不能止者，用蒜一头，捣如泥，作饼如钱大，浓一分许，贴脚
心。左衄贴右，右衄贴左，两孔俱出者，左右俱贴，即止。又止衄歌（因九四）、止衄方（因
九三）、鼻衄蒸法（因九五）、黑神散（和二二）俱可择用。
鼻衄证，各家都说是由于肺引起的，因为鼻子是肺的窍道。却不知道鼻子也是手足阳明经的正经所过之处，而手足太阳经也都到达鼻子。所以张仲景说：太阳病，脉象浮紧，发热且身体无汗，自然出现鼻衄的就会痊愈。这是太阳经引起的鼻衄。《原病式》说：阳热郁结在足阳明经而上部受热，就会导致血液妄行而出现鼻衄，这是阳明经引起的鼻衄。如果按照我的见解来说，那么凡是鼻衄的血，必定是从山根以上、精明穴附近流出来的，而精明穴这一穴位，是手足太阳经、足阳明经以及阴阳跷脉这五条经脉交会的地方，所以这几条经都能引起鼻衄。然而，运行于脊背部的经脉中，没有比足太阳经更主要的；运行于胸腹部的经脉中，没有比足阳明经更主要的。而其中尤其重要的，则是冲脉作为十二经的血海。冲脉的上俞出自足太阳经的大杼穴，冲脉的下俞会合于足阳明经的气街穴，所以足太阳、足阳明经气到达时，冲脉没有不到的；冲脉之气到达，则十二经没有不到的。因此，鼻衄轻微的，不过是一经之内的近处病变；而鼻衄严重的，甚至出血数升或达到一斗之多，并且全身形色完全脱失，这哪里仅仅是手太阴肺经一经的病就能导致如此严重的情况呢？临证诊治的人不可不仔细考察。
第一条：鼻衄的原因，内热引起的多在阳明经，治疗应当以清热降火为主。轻微发热的，适宜用生地黄、芍药、天冬、麦冬、玄参、丹参，或者《局方》犀角地黄汤、生地黄饮子、麦门冬散之类的方剂主治。热势严重的，适宜用黄芩、黄连、栀子、黄柏，或者茜根散、抽薪饮、加减一阴煎；如果兼有头痛、口渴症状的，适宜用玉女煎、白虎汤之类的方剂主治。或者是阳明热极，下部不通畅而火热壅滞于上部的，适宜用《拔萃》犀角地黄汤之类的方剂，通利下部则上部自能痊愈。
第二条：鼻衄由外感引起的，多在足太阳经。看张仲景说：伤寒脉象浮紧，如果不发汗，因而导致鼻衄的，用麻黄汤主治。又说：伤寒不大便，但小便清利的，知道病不在里，仍在表，应当需要发汗。如果头痛的必定会出现鼻衄，适宜用桂枝汤。成无己说：伤寒出现鼻衄，是因为邪气不能发散，壅盛于经脉，逼迫血液，因而导致鼻衄。使用麻黄汤、桂枝汤治疗鼻衄，并不是直接治疗鼻衄本身，而是发散经络中的邪气罢了。按照这种理论来治疗，那么凡是伤寒因鼻衄而邪气得解的情况，这就是代替发汗的作用，不需要特别治疗。如果虽然见到鼻衄血，但脉象仍然浮紧，热势仍然不退，这一定是鼻衄没有透达，而表邪还没有解除的缘故，所以仍然适宜用麻黄汤、桂枝汤等方剂。然而这两首方剂是张仲景治疗正伤寒的方法，倘若疾病是由温热病引起而不适宜用这些方法的，则在伤寒门类中选择适宜的散剂使用，或者在我新编的方剂中诸柴胡饮随宜选用，自然没有不可以的。
第三条：鼻衄虽然多由火引起，但在阴虚体质者中尤为多见。正因为劳损伤及阴液，导致水不能制约火，最容易扰动冲任二脉阴分的血液。只要观察其脉象滑实有力，以及平时没有劳损情况的，当作火证治疗如前所述。如果脉象洪大无力，或者弦，或者芤，或者细数无神，而且平时多有酒色内伤情况的，这都是阴虚的证候，应当专门以补阴为主。如果有微火的，自然应当兼而清之，以治其标证。如果虽然有虚热表现，但没有确切的阳热实证，则只应当用甘平的药剂温养真阴，务必使阴气完固，才能从根本上解决问题，永远没有后患。如一阴煎、三阴煎、左归饮、六味地黄汤之类的方剂，都是必须使用的方剂。如果兼有气虚的，则五福饮、五阴煎之类的方剂，都应当随意选用。
第四条：止衄的方法：凡是鼻衄血量很多不能止住的，用蒜一头，捣成泥状，做成像铜钱大小、厚度约一分的饼，贴在脚心。左侧鼻衄贴右侧脚心，右侧鼻衄贴左侧脚心，双侧鼻孔都出血的，左右脚心都贴，即可止血。另外，《止衄歌》（参见因九四）、《止衄方》（参见因九三）、《鼻衄蒸法》（参见因九五）、黑神散（参见和二二）都可以择机选用。
Nosebleed (Epistaxis) syndrome, various schools of thought attribute it solely to the Lung, considering the nose as the orifice of the Lung. However, they fail to realize that the nose is also traversed by the regular channels of the Hand and Foot Yangming, and both the Hand and Foot Taiyang channels reach the nose. Thus, Zhang Zhongjing stated: In Taiyang disease, with a floating and tight pulse, fever, and absence of sweating on the body, spontaneous epistaxis leads to recovery. This is epistaxis originating from the Taiyang channel. *Yuan Bing Shi* states: When yang-heat stagnates in the Foot Yangming channel and causes heat above, blood may act recklessly resulting in epistaxis; this is epistaxis originating from the Yangming channel. From my perspective, however, all epistaxis blood flows from above the Shangen point, near the Mingjing acupoint. The Mingjing acupoint is the convergence of five channels: the Hand Taiyang, Foot Taiyang, Foot Yangming, Yin Qiao, and Yang Qiao channels. Therefore, any of these channels can cause epistaxis. Among the channels running along the back, none is more significant than the Foot Taiyang. Among those running through the chest and abdomen, none is more significant than the Foot Yangming. Most importantly, however, is the Chong Mai (Penetrating Vessel), which serves as the Sea of Blood for the twelve channels. The upper shu point of the Chong Mai emerges from the Dazhu (BL11) acupoint of the Foot Taiyang, and its lower shu point converges at the Qijie area of the Foot Yangming. Thus, when the Qi of the Taiyang and Yangming channels arrives, the Chong Mai inevitably follows; when the Chong Mai arrives, all twelve channels are affected. Consequently, mild epistaxis involves only one nearby channel, whereas severe epistaxis can involve the loss of several liters or even a dou of blood, accompanied by total pallor and collapse of physical appearance. How could such severity be attributed merely to a disorder of the Hand Taiyin Lung channel alone? Clinicians must examine this carefully.
First: The cause of epistaxis due to internal heat mostly lies in the Yangming channel. Treatment should primarily focus on clearing heat and descending fire. For mild heat, Sheng Di Huang (Rehmanniae Radix), Bai Shao (Paeoniae Radix Alba), Tian Dong (Asparagi Rhizoma), Mai Dong (Ophiopogonis Radix), Xuan Shen (Scrophulariae Radix), and Dan Shen (Salviae Miltiorrhizae Radix) are suitable, or formulas such as Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) from *Ju Fang*, Sheng Di Huang Yin Zi, or Mai Men Dong San. For severe heat, Huang Qin (Scutellariae Radix), Huang Lian (Coptidis Rhizoma), Zhi Zi (Gardeniae Fructus), and Huang Bo (Phellodendri Cortex) are suitable, or formulas such as Qian Gen San, Chou Xin Yin, or Jia Jian Yi Yin Jian. If accompanied by headache and thirst, Yu Nu Jian or Bai Hu Tang (White Tiger Decoction) are suitable. In cases where Yangming heat is extreme, causing blockage below and fire stagnation above, *Ba Cui* Xi Jiao Di Huang Tang can be used to unblock the lower part, allowing the upper part to heal spontaneously.
Second: Epistaxis caused by external contraction mostly occurs in the Foot Taiyang channel. As Zhang Zhongjing stated: In Shanghan (Cold Damage) with a floating and tight pulse, if sweating is not induced, epistaxis may result; Ma Huang Tang (Ephedra Decoction) is indicated. He also stated: In Shanghan with constipation but clear urine, the disease is not in the interior but remains in the exterior, requiring sweating therapy. If headache is present, epistaxis will likely occur; Gui Zhi Tang (Cinnamon Twig Decoction) is indicated. Cheng Wuji stated: Epistaxis in Shanghan occurs because pathogenic factors cannot be dispersed, becoming congested in the channels and forcing blood, leading to epistaxis. Using Ma Huang Tang or Gui Zhi Tang to treat epistaxis does not directly stop bleeding but rather disperses pathogenic factors within the channels. According to this theory, if epistaxis resolves the pathogen in Shanghan, it acts as a substitute for sweating, and no specific treatment is needed. However, if epistaxis occurs but the pulse remains floating and tight and fever persists, it indicates incomplete release of the pathogen via bleeding, meaning the exterior pathogen has not yet been resolved. In such cases, Ma Huang Tang or Gui Zhi Tang should still be used. Note that these two formulas are Zhang Zhongjing's standard treatments for true Shanghan. If the disease arises from warm pathogens and these formulas are unsuitable, select appropriate powders from the Shanghan category or use various Chai Hu Yin (Bupleurum Infusions) from my new formulas as appropriate.
Third: Although epistaxis is often caused by fire, it is particularly common in individuals with Yin deficiency. Labor and overwork damage Yin, leading to an inability of Water to control Fire, which easily disturbs the blood in the Yin aspect of the Chong and Ren vessels. If the pulse is slippery, full, and forceful, and there is no history of injury, treat it as a fire condition as described above. If the pulse is flooding and weak, wiry, knotted, or thready and rapid without spirit, and there is a history of alcohol and sexual excess causing internal injury, these are signs of Yin deficiency. Treatment should focus exclusively on tonifying Yin. If slight fire is present, clear it concurrently to address the branch symptoms. If there is deficient heat but no definitive excess heat signs, use sweet and neutral agents to warmly nourish True Yin, ensuring the Yin Qi is solidified to address the root cause and prevent future issues. Formulas such as Yi Yin Jian, San Yin Jian, Zuo Gui Yin, and Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) are essential. If Qi deficiency is also present, Wu Fu Yin or Wu Yin Jian may be used as appropriate.
Fourth: Methods to stop epistaxis: For severe epistaxis that cannot be stopped, take one head of garlic, mash it into a paste, form it into a cake the size of a coin with a thickness of about one fen, and apply it to the sole of the foot. Apply to the right sole for left-sided epistaxis, to the left sole for right-sided epistaxis, and to both soles if bleeding occurs from both nostrils; this will stop the bleeding. Additionally, *Zhi Xu Ge* (Song to Stop Bleeding), *Zhi Xu Fang* (Formula to Stop Bleeding), *Bi Xu Zheng Fa* (Steaming Method for Nosebleed), and Hei Shen San (Black Divine Powder) can be selected for use.