仲景曰。太阳病。脉浮紧。发热身无汗。自衄者愈。
又曰。伤寒。脉浮紧。不发汗。因致衄者。麻黄汤主之。雍曰。麻
黄汤发其汗。则热越而出。其衄必轻。（怡云子云。若根据时发汗。则不
衄矣。脉浮紧。当用麻黄汤发汗。非致衄后用也。衄则愈矣。）
又曰。太阳病。脉浮紧。无汗。发热。身疼痛。八九日不解。表症
仍在。此当发其汗。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。麻黄汤主之。
又曰。伤寒不大便六七日。头痛有热者。与承气汤。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。常氏
云。疑字误也。设须发汗。当用麻黄汤。不然。用桂枝麻黄各半汤。取
其小汗出而已。雍曰。此症不言有汗无汗。故后人用药有疑。然反复
详读。似无可疑者。衄家固当用麻黄汤。仲景以病仍在表。虽当发
汗。而里症不大便六七日。既不敢用承气攻里。亦不敢用麻黄大发
汗。故止用桂枝逐表邪。表解若见里症。待其可下。复用承气攻之
也。此不用麻黄之意。若头痛者必衄六字。是此症中一小变症。仲景
不言治衄法。盖此症其初里症似重。故仲景初欲与承气汤。后言仍
在表者。是表症亦轻也。表轻则衄。衄则表当解。不必用药。虽桂枝
亦不当服。当移宜桂枝汤四字于当须发汗之下看。则意亦明矣。
又曰。阳明病。口鼻燥。但欲漱水不欲咽者。此必衄。常氏云。宜
黄芩芍药汤。
又曰。脉浮发热。口干鼻燥。能食者。则衄。常氏曰。可黄芩汤。
又曰。动气在右。不可发汗。发汗则衄而渴。心苦烦。饮则吐水。
雍曰。此有衄渴吐水三症。故庞氏先五苓散以止渴。次用竹叶汤以
止烦。烦止则衄退矣。
问曰。仲景言衄家不可发汗。亡血家不可发汗。此皆用麻黄汤。
何也。雍曰。王仲弓言久衄之家。既已亡血。故不可汗。今缘失发其
汗致衄。当分其津液乃愈。此论固已当。又庞氏之言为甚明。其言
曰。脉浮紧无汗。服汤未中病。其人发烦目瞑。剧者必衄。小衄而脉
尚浮者。宜麻黄汤。衄已脉微者。不可再行也。此分有汗无汗。麻黄
桂枝。脉浮脉微。最为当理。以是论之。则小衄者。
有发汗分津液之理。大衄者。病必自解。当听之。惟虑其衄不肯止。则根据活人书以药
止之。若小衄发汗无汗。则反成大衄也。
仲景曰。少阴病。但厥无汗。而强发之。必动其血。未知从何道
出。或从口鼻。或从目出者。是名下厥上竭。为难治。雍曰。常氏用芍
药地黄汤。以治上竭。而不治下厥。雍谓下不厥。则上不竭。必先以
当归四逆汤治下厥。仍灸太溪穴、三阴交、涌泉穴。以止少阴之厥。
或三阴交难取。则太溪涌泉尤奇。
又曰。咽喉闭塞。不可发汗。发汗则吐血。气微绝。手足厥冷。欲
得蜷卧。不能自温。庞氏曰。干姜甘草汤主之。常氏曰。咽中闭塞。可
小柴胡汤。发汗吐衄者。柏叶艾叶汤。气微厥逆蜷卧者。当归四逆
汤。雍曰。亦宜灸三阴交、涌泉穴。以止厥逆蜷卧。切勿服小柴胡
汤。
张仲景说：太阳病，脉象浮而紧，发热且身体无汗，如果自然鼻出血，病情就会痊愈。
又说：伤寒病，脉象浮紧，没有发汗，导致鼻出血的，用麻黄汤主治。郭雍说：麻黄汤能发散汗液，使热邪随汗外越而出，那么鼻出血的程度必然较轻。（怡云子说：如果按照时令及时发汗，就不会发生鼻血了。脉象浮紧，应当用麻黄汤发汗，而不是在鼻出血之后才使用。既然鼻出血后病愈，就不必再用药。）
又说：太阳病，脉象浮紧，无汗，发热，身体疼痛，经过八九天仍未解除，表证依然存在，这应当发汗。服药后，症状轻微缓解，病人感到心烦、眼睛闭合不想睁开，严重的必定鼻出血，鼻出血后病邪才得以解除。之所以这样，是因为阳气郁闭太重的缘故。用麻黄汤主治。
又说：伤寒病六七天不大便，头痛且有发热的，给予承气汤。如果小便清长的，知道病不在里，仍在表，应当发汗。如果头痛的必定鼻出血，适宜用桂枝汤。常氏说：“宜”字可能是误字。假设需要发汗，应当用麻黄汤。不然，就用桂枝麻黄各半汤，取其微微出汗即可。郭雍说：此症没有说明有汗还是无汗，所以后人用药有所怀疑。然而反复详细阅读，似乎没有什么可怀疑的。经常流鼻血的人固然应当用麻黄汤（注：此处原文逻辑似有争议，通常衄家忌汗，但郭雍在此处解释为表实），张仲景因为病仍在表，虽然应当发汗，但里有六七天不大便的症状，既不敢用承气汤攻下里实，也不敢用麻黄汤大发其汗，所以只用桂枝汤驱逐表邪。表邪解除后若见到里证，等到可以攻下的时候，再用承气汤攻下。这就是不用麻黄汤的意思。“若头痛者必衄”这六个字，是此症中的一个微小变证。张仲景没有提及治疗鼻出血的方法，大概是因为此症起初里证看似严重，所以张仲景起初想用承气汤。后来又说“仍在表”，说明表证也轻。表证轻则容易鼻出血，鼻出血则表邪应当解除，不必用药。即使是桂枝汤也不应当服用。应当将“宜桂枝汤”四个字移到“当须发汗”之下阅读，意思就明白了。
又说：阳明病，口鼻干燥，只想含水漱口而不想咽下的，这必定会发生鼻出血。常氏说：适宜用黄芩芍药汤。
又说：脉浮发热，口干鼻燥，能进食的，就会鼻出血。常氏说：可用黄芩汤。
又说：动气在右侧，不可发汗。发汗就会导致鼻出血且口渴，心中烦苦，喝水则呕吐出水。郭雍说：这里有鼻出血、口渴、吐水三个症状，所以庞氏先用五苓散来止渴，接着用竹叶汤来止烦。烦止则鼻出血也就退去了。
问：张仲景说经常流鼻血的人不可发汗，失血的人不可发汗，这里却都用麻黄汤，为什么呢？郭雍说：王仲弓说久患鼻出血的人，已经亡血，所以不可发汗。现在是因未能及时发汗而导致鼻出血，应当分利津液才能痊愈。这个论述固然恰当。另外庞氏的说法更为明确。他说：脉浮紧无汗，服药后未中病机，病人发烦目瞑，严重的必定鼻出血。少量鼻出血且脉仍浮的，适宜用麻黄汤。鼻出血后脉微弱的，不可再行发汗。这是区分有汗无汗、麻黄桂枝的使用以及脉浮脉微的区别，最为合理。据此而论，少量鼻出血的，有发汗分利津液的道理；大量鼻出血的，病邪必定自行解除，应当听之任之。只担心鼻出血不止，就根据《活人书》用药物止血。如果是少量鼻出血却强行发汗无汗，反而会导致大量鼻出血。
张仲景说：少阴病，只是四肢厥冷无汗，如果强行发汗，必定扰动血液，不知道从哪个通道流出，有的从口鼻出，有的从眼睛出，这叫下厥上竭，属于难治之症。郭雍说：常氏用芍药地黄汤治疗上竭，但不治疗下厥。郭雍认为如果不解决下部的厥冷，上部就不会停止枯竭。必须先用当归四逆汤治疗下厥，同时艾灸太溪穴、三阴交穴、涌泉穴，以制止少阴经的厥逆。如果三阴交穴难以取穴，那么太溪和涌泉穴尤为奇特有效。
又说：咽喉闭塞，不可发汗。发汗就会导致吐血，气息微弱欲绝，手脚冰冷，想要蜷缩而卧，不能自我温暖。庞氏说：用干姜甘草汤主治。常氏说：咽喉闭塞，可用小柴胡汤。对于发汗、催吐、鼻出血者，用柏叶艾叶汤。对于气息微弱、四肢厥逆、蜷卧者，用当归四逆汤。郭雍说：也适宜艾灸三阴交、涌泉穴，以制止厥逆蜷卧。切勿服用小柴胡汤。
Zhang Zhongjing said: In Taiyang disease (disease of the Taiyang channel), with a floating and tight pulse, fever, and absence of sweating on the body, if epistaxis (nosebleed) occurs spontaneously, the illness will resolve.
He also said: In Shanghan (cold damage disease), with a floating and tight pulse, if sweating is not induced, leading to epistaxis, Mahuang Tang (Ephedra Decoction) should be administered. Guo Yong stated: Mahuang Tang induces sweating, allowing heat to escape outward through sweat; thus, the epistaxis will necessarily be mild. (Yi Yunzi said: If sweating were induced in accordance with the season/time, epistaxis would not have occurred. With a floating and tight pulse, Mahuang Tang should be used to induce sweating, not after epistaxis has already occurred. Since the illness resolves after epistaxis, no further medication is needed.)
He also said: In Taiyang disease, with a floating and tight pulse, absence of sweating, fever, and body pain, if eight or nine days pass without resolution, and exterior symptoms remain, sweating should be induced. After taking the medicine, symptoms may slightly alleviate, but the patient may experience irritability and a desire to keep eyes closed. In severe cases, epistaxis will occur, and the illness resolves only after bleeding. The reason for this is that Yang qi is heavily constrained. Mahuang Tang (Ephedra Decoction) should be administered.
He also said: In Shanghan disease, if there is constipation for six or seven days accompanied by headache and fever, Chengqi Tang (Gastro Drainage Decoction) should be given. However, if urination is clear, it indicates the pathogen is not in the interior but remains in the exterior, and sweating should be induced. If headache is present, epistaxis will likely occur, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. Chang Shi noted that the character "yi" (appropriate/suitable) might be an error. Assuming sweating is required, Mahuang Tang (Ephedra Decoction) should be used. Alternatively, Guizhi Mahuang Ban Tang (Half Cinnamon Twig and Half Ephedra Decoction) could be used to achieve slight sweating. Guo Yong stated: This case does not specify whether sweating is present or absent, causing doubt among later practitioners regarding medication. However, upon careful reading, there seems to be little cause for doubt. Although patients prone to epistaxis generally contraindicate sweating, Zhang Zhongjing, noting the pathogen remains in the exterior despite internal constipation for six or seven days, dared not use Chengqi Tang (Gastro Drainage Decoction) to purge the interior nor Mahuang Tang (Ephedra Decoction) to induce heavy sweating. Thus, he used only Guizhi Tang (Cinnamon Twig Decoction) to expel exterior pathogens. Once the exterior is resolved and interior symptoms appear, one should wait for the appropriate time to use Chengqi Tang (Gastro Drainage Decoction) for purging. This explains why Mahuang Tang was not used. The phrase "if headache occurs, epistaxis will follow" represents a minor variation in this case. Zhang Zhongjing did not provide a treatment for epistaxis here because initially, the interior symptoms seemed severe, prompting the initial consideration of Chengqi Tang (Gastro Drainage Decoction). Later, stating the pathogen remains in the exterior implies the exterior syndrome is also mild. A mild exterior syndrome predisposes to epistaxis, which resolves the exterior pathogen naturally without medication. Even Guizhi Tang (Cinnamon Twig Decoction) should not be taken. Reading "yi Guizhi Tang" (suitable for Guizhi Tang) under "dang xu fa han" (sweating should be induced) clarifies the intent.
He also said: In Yangming disease, with dryness in the mouth and nose, and a desire to rinse the mouth with water but not swallow it, epistaxis will certainly occur. Chang Shi suggested Huangqin Shaoyao Tang (Scutellaria and Peony Decoction).
He also said: With a floating pulse, fever, dry mouth, and dry nose, if the patient can eat, epistaxis will occur. Chang Shi suggested Huangqin Tang (Scutellaria Decoction).
He also said: If pulsation is felt on the right side, sweating should not be induced. Inducing sweating will lead to epistaxis and thirst, mental distress, and vomiting water upon drinking. Guo Yong stated: These three symptoms—epistaxis, thirst, and vomiting water—are addressed by Pang Shi, who first used Wuling San (Five-Ingredient Powder with Poria) to stop thirst, followed by Zhuye Tang (Bamboo Leaf Decoction) to relieve distress. Once distress is relieved, epistaxis subsides.
Question: Zhang Zhongjing stated that those prone to epistaxis and those who have lost blood should not undergo sweating therapy, yet Mahuang Tang (Ephedra Decoction) is used here. Why? Guo Yong replied: Wang Zhonggong argued that those with chronic epistaxis have already lost blood and thus should not sweat. However, in this case, epistaxis resulted from failing to induce sweating earlier. One must separate and regulate fluids for recovery. This argument is sound. Furthermore, Pang Shi’s explanation is very clear: With a floating, tight pulse and no sweating, if medication fails to address the pathology, causing irritability and eye closure, severe cases result in epistaxis. If epistaxis is minor and the pulse remains floating, Mahuang Tang (Ephedra Decoction) is suitable. If epistaxis has occurred and the pulse becomes faint, sweating should not be repeated. This distinguishes between presence/absence of sweating, the use of Mahuang vs. Guizhi, and floating vs. faint pulses, which is most logical. Based on this, minor epistaxis allows for sweating to regulate fluids; major epistaxis indicates the disease will resolve spontaneously, so one should let nature take its course. Only if bleeding does not stop should hemostatic drugs be used according to *Ren Shu*. If minor epistaxis occurs alongside failure to sweat, it may worsen into major epistaxis.
Zhang Zhongjing said: In Shaoyin disease, with cold limbs and no sweating, forcing sweating will disturb the blood, causing it to exit from unknown pathways, such as the mouth, nose, or eyes. This is called "Lower Jue and Upper Exhaustion" and is difficult to treat. Guo Yong stated: Chang Shi used Shaoyao Dihuang Tang (Peony and Rehmannia Decoction) to treat Upper Exhaustion but ignored Lower Jue. Guo Yong believed that if Lower Jue is not resolved, Upper Exhaustion will not cease. Therefore, Danggui Sini Tang (Angelica Decoction for Frigid Extremities) should be used first to treat Lower Jue, combined with moxibustion at Taixi (KI3), Sanyinjiao (SP6), and Yongquan (KI1) acupoints to stop Shaoyin Jue. If Sanyinjiao (SP6) is difficult to locate, Taixi (KI3) and Yongquan (KI1) are particularly effective.
He also said: With throat obstruction, sweating should not be induced. Forcing sweating leads to hematemesis (vomiting blood), faint breath, cold hands and feet, a desire to curl up, and inability to self-warm. Pang Shi recommended Ganjiang Gancao Tang (Dried Ginger and Licorice Decoction). Chang Shi suggested Xiaochaihu Tang (Minor Bupleurum Decoction) for throat obstruction, Baiye Aiye Tang (Artemisia and Bloodwort Decoction) for cases involving sweating, vomiting, or epistaxis, and Danggui Sini Tang (Angelica Decoction for Frigid Extremities) for faint breath, cold limbs, and curling up. Guo Yong added: Moxibustion at Sanyinjiao (SP6) and Yongquan (KI1) is also suitable to stop cold limbs and curling up. Xiaochaihu Tang (Minor Bupleurum Decoction) must absolutely not be taken.