原病式曰衄者阳热怫郁干于足阳明而上热则血妄行鼻衄也 血溢者上出也心养于血故热
甚则
血有余而妄行或谓呕吐紫凝血为寒者误也此非冷凝由热甚销烁以为稠浊而热甚则水化制之故
赤兼黑而为紫也 血泄热客下焦而大小便血也 衄 血污血出也污者浊也心火热极则血有
余热气上甚则为血溢热势亢极则燥而污浊害承乃制则色兼黑而为紫也
成无己曰伤寒衄者为邪气不得发散壅盛于经逼迫于血则因致衄也桂枝汤麻黄汤治衄者非
治衄
也即是发散经中邪气尔至蓄血者血在下焦结聚而不行蓄积而不散者是也血菀于上而吐血者谓
之薄厥留于下而瘀者谓之蓄血此由太阳随经瘀热在里血为热所搏结而不行蓄于下焦之所致经
曰太阳病七八日表证仍在脉微而沉反不结胸其人如狂者以热在下焦少腹当硬满小便自利者下
血乃愈
伤寒例少阴证下利便脓血者桃花汤以固脱散寒补正
许氏治少阴误汗衄血及脐中出血用姜附汤治少阴之本
阴证略例治三焦出血色紫不鲜此重沓寒湿化毒凝泣浸渍而成治要用黑锡丹(见直指方)
按所论以上证皆寒邪之变病也至又有甚者如论云服桂枝汤吐血其后必吐脓血又厥阴证伤
寒六
七日大下后寸脉沉而迟手足厥冷下部脉不至咽喉不利唾脓血泄利不止者为难治宜麻黄升麻汤
火邪亦咽燥唾血阳毒亦吐血皆变证之极者也非衄证之比大抵伤寒蓄血下血为传变故下血衄血
身凉乃愈其不传变入里邪气不得发散逼迫于血因致妄行于下者为逆下血必多不能止为难治也
《原病式》说：衄血（鼻出血）是由于阳热之气郁结，侵犯足阳明经，导致上部热气亢盛，血液妄行而出。血溢是指血液向上涌出。心主血脉，所以热邪极盛时，血气有余而妄行。有人说呕吐出的紫黑色凝固血液是寒证，这是错误的。这并非因为寒冷凝结，而是由于热邪极盛，煎熬血液使其变得稠厚浑浊；且热极则水气来制约它，所以血色赤中带黑而呈现紫色。血泄是指热邪客居下焦，导致大便或小便出血。衄血是污浊之血排出，所谓“污”即指浊。心火极盛则血气有余，热气上冲严重则为血溢；热势亢极则使血液干燥并变得污浊，当危害到承制关系时，颜色兼有黑色而呈现紫色。
成无己说：伤寒病中出现衄血，是因为邪气不能发散，壅盛于经脉之中，逼迫血液，从而导致衄血。使用桂枝汤、麻黄汤治疗衄血，并不是直接治疗衄血本身，而是为了发散经络中的邪气罢了。至于蓄血证，是指血液在下焦结聚而不运行，积蓄不散。血液郁积于上部而吐血，称为“薄厥”；留滞于下部而瘀阻，称为“蓄血”。这是由于太阳病邪随经入里，瘀热在体内，血液被热邪搏结而不能运行，蓄积于下焦所致。《内经》说：太阳病经过七八天，表证仍在，脉象微而沉，反而没有形成结胸证，病人神志如狂，这是因为热邪在下焦，少腹部应当硬满，如果小便自利，通过下血才能痊愈。
《伤寒例》说：少阴病出现下利、便脓血的症状，用桃花汤来固脱、散寒、补益正气。
许氏治疗少阴病误用发汗法导致的衄血及脐中出血，使用姜附汤治疗少阴病的根本原因。
《阴证略例》记载：治疗三焦出血，血色紫暗不鲜亮，这是重沓的寒湿化毒，凝涩浸渍而成。治疗要用黑锡丹（见《直指方》）。
按语：以上所论述的证候，都是寒邪变化而成的疾病。又有更严重的情况，如论中说：服用桂枝汤后出现吐血，之后必定会吐出脓血。还有厥阴病伤寒，六七日经过大泻下后，寸脉沉而迟，手足冰冷，下部脉搏摸不到，咽喉不利，唾吐脓血，腹泻不止，这种情况难以治疗，宜用麻黄升麻汤。火邪也会导致咽干、唾血；阳毒也会导致吐血，这些都是变证的极端情况，不能与一般的衄血证相比。大抵而言，伤寒病中的蓄血和下血属于传变后的病变，如果下血后身体凉爽，说明病愈；如果不发生传变入里，邪气不得发散，逼迫血液导致妄行，若血从下出则为逆证，下血量多且无法止住，属于难治之症。
The *Yuan Bing Shi* (Treatise on the Original Causes of Disease) states: Nasal bleeding (Nasal hemorrhage, Bi Xue) occurs when Yang-heat pathogen is constrained and invades the Foot-Yangming Meridian, causing excessive heat in the upper body and forcing blood to flow recklessly. "Blood overflow" refers to blood flowing upwards. The Heart governs the blood vessels; therefore, when heat is extreme, blood qi becomes excessive and flows recklessly. Some claim that vomiting purple, coagulated blood indicates a Cold syndrome, which is incorrect. This is not due to cold condensation, but rather because extreme heat scorches the blood, making it thick and turbid. Furthermore, when heat reaches its peak, Water elements act to control it, resulting in a color that is red mixed with black, appearing purple. "Blood discharge" refers to blood in stool or urine caused by heat pathogens lodging in the Lower Jiao. Nasal bleeding involves the expulsion of turbid blood; "turbid" implies impurity. When Heart-fire is extreme, blood qi is excessive, and severe upward rushing of heat causes blood overflow. When heat intensity is extreme, it dries the blood and makes it turbid; when this harms the regulatory mechanism, the color mixes with black to appear purple.
Cheng Wuji stated: In Shanghan (Cold Damage), nasal bleeding occurs because the pathogen cannot be dispersed, becoming congested in the meridians and forcing the blood, thereby causing nasal bleeding. Using Guizhi Tang (Cinnamon Twig Decoction) or Mahuang Tang (Ephedra Decoction) to treat nasal bleeding does not directly treat the bleeding itself, but rather aims to disperse the pathogen within the meridians. Regarding "accumulated blood" (Xu Xue), it refers to blood coagulating and stagnating in the Lower Jiao without circulating. Blood stagnating in the upper body causing hematemesis is called "Bo Jue" (Thin Frenzy); blood remaining in the lower body causing stasis is called "Xu Xue". This results from Taiyang disease where the pathogen follows the meridians into the interior, creating stagnant heat inside. The blood is bound by heat and fails to circulate, accumulating in the Lower Jiao. The Classic states: In Taiyang disease lasting seven to eight days, if exterior symptoms persist, the pulse is faint and deep, there is no formation of Jie Xiong (Chest Binding), and the patient exhibits mental restlessness akin to madness, it is because heat resides in the Lower Jiao. The lower abdomen should be hard and full. If urination is normal, healing occurs through the passage of blood.
The *Shanghan Li* (Examples of Cold Damage) states: For Shaoyin syndrome presenting with diarrhea and pus/blood in stool, Taohua Tang (Peach Kernel Decoction) is used to secure collapse, dispel cold, and tonify healthy qi.
Xu treated Shaoyin syndrome complicated by nasal bleeding and umbilical bleeding due to erroneous sweating, using Jiang Fu Tang (Ginger and Aconite Decoction) to address the root of Shaoyin disease.
The *Yin Zheng Lue Li* (Brief Principles of Yin Syndromes) records: Treating bleeding from the Three Jiao where the blood color is dark purple and dull indicates that severe damp-cold has transformed into toxin, causing coagulation and infiltration. Treatment requires Hei Xi Dan (Black Tin Pill) (see *Zhi Zhi Fang*).
Commentary: The syndromes discussed above are all variations of Cold pathogen diseases. There are even more severe cases, such as described in the text: after taking Guizhi Tang, if hematemesis occurs, it will likely progress to vomiting pus and blood. Additionally, in Jueyin Cold Damage, after severe purgation on the seventh day, if the Cun pulse is deep and slow, hands and feet are cold, the Chi pulse at the lower position is imperceptible, the throat is obstructed, there is expectoration of pus and blood, and uncontrollable diarrhea persists, this is difficult to treat and requires Mahuang Shengma Tang (Ephedra and Ascending Dragon Decoction). Fire pathogen also causes dry throat and bloody saliva; Yang Du (Yang Toxin) also causes hematemesis. These are extreme variations and cannot be compared to simple nasal bleeding syndromes. Generally speaking, accumulated blood and lower bleeding in Shanghan are complications of transmission. If lower bleeding occurs followed by cooling of the body, the disease resolves. If there is no transmission to the interior, and the pathogen cannot be dispersed, forcing blood to flow recklessly downward, this is an adverse sign. Profuse lower bleeding that cannot be stopped is considered difficult to treat.