【纲】仲景曰。太阳中风。阳浮阴弱。阳浮热自发。阴弱汗自出。啬啬恶寒。淅淅恶风。翕翕发
热。鼻鸣干呕者。桂枝汤。发汗已。身犹灼热。脉浮自汗。身重多眠。鼻鼾。语言难出。不可下。
不可火。
【目】赵嗣真曰。风温则鼻鼾。中风则鼻鸣。由风气壅塞。卫气不利所致。阳明少阳三阴。虽
亦有中风。然亦不在表。故鼻不鸣而不鼾也。
【纲】仲景曰。脉浮。热甚。反灸之。此为实。实以虚治。因火而动。必咽燥吐血。
【目】朱肱曰。伤寒吐血。由诸阳受邪热。初在表。应发汗。而不发汗。毒热入深。络于五脏。
内有瘀积。故吐血也。瘀血甚者。抵当丸。轻者。桃仁承气汤。兼服犀角地黄汤、三黄丸。假令
已下。脉数不解。合热则消谷善饥。至六七日不大便者。有瘀血也。抵当汤。
李杲曰。余治一贫士。脾胃虚。致补剂愈。继而居旷室。卧热坑。咳而吐血数次。余谓此久
虚弱。外有寒形。而有火热在内。上气不足。阳气外虚。当补表之阳气。泻里之虚热。盖冬居旷室。
衣服单薄。是重虚其阳。表有大寒。壅遏里热。火邪不得舒伸。故血出于口。因思仲景治伤寒脉
浮紧。当以麻黄发汗。而不与之。遂成衄。却与麻黄汤。立愈。与此甚同。因与麻黄人参芍药汤。
鳌按。此言误灸所生之变也。吐血。比衄更甚矣。
【纲】仲景曰。凡服桂枝汤吐者。其后必吐脓血也。
【目】朱震亨曰。杂病吐血咯血。责为实邪。伤寒吐血咯血。皆由误汗下并火逆而致。诚非
伤寒病热之微甚者也。是为坏病。宜随其逆而调之。惟少阴厥竭误汗一症。强动经血。故云难治也。
楼英曰。吐血者。诸阳受邪。其邪在汗。当汗不汗。致使血毒入脏。积瘀于内。遂成吐血。凡
见眼闭目红。神昏语短。弦冒逆妄。烦躁漱水。惊狂谵语。吐衄。背冷足寒。四肢厥逆。胸腹急
满。大便黑利。小便频数。皆瘀血症也。虽有多般。不必悉具。但见一二。便作血症主张。初得此
病。急宜用药。至于络续不已。经数时而腹痛者。此又难于料理也。
陶华曰。经曰。服桂枝汤吐者。其后必吐脓血。犀角地黄汤。大下后。寸脉沉迟。尺脉不至。
咽喉不利。唾脓血者。此有两症。一为阳毒。宜阳毒升麻汤。一为阴毒。宜甘桔汤加半夏、生姜。
血热者。黄连阿胶汤、地榆柏皮汤、三黄泻心汤。咽喉闭塞。不可发汗。发汗则吐血。气欲绝。
手足厥冷。蜷卧不能自温。当归四逆汤。
鳌按。此指凡热淫于内者言也。故桂枝汤反能助阳。使热势涌越。致伤阳络而吐脓血也。
【纲】张仲景说：太阳中风证，脉象阳部浮而阴部弱。阳浮则发热自然发生，阴弱则汗液自然流出。患者感到畏缩怕冷，如冷水洒身般怕风，体温升高似有热感，伴有鼻腔鸣响和干呕的，用桂枝汤治疗。发汗后，身体仍然灼热，脉象浮且自汗出，身体沉重、嗜睡，鼻鼾声重，言语困难，此时不可使用下法，也不可用火疗。
【目】赵嗣真说：风温病会出现鼻鼾，中风病会出现鼻鸣，这是由于风气壅塞，卫气运行不畅所致。阳明经、少阳经及三阴经虽然也有中风证，但病邪已不在表，所以不会出现鼻鸣和鼻鼾。
【纲】张仲景说：脉象浮，热势很盛，反而用灸法治疗，这属于实证。将实证当作虚证来治，因火灸导致火热内动，必然出现咽喉干燥和吐血的症状。
【目】朱肱说：伤寒引起的吐血，是由于诸阳经受邪热侵袭，起初在表，应当发汗，但没有发汗，毒热深入，络脉受累于五脏，体内有瘀积，所以吐血。瘀血严重的，用抵当丸；轻症的，用桃仁承气汤。兼服犀角地黄汤和三黄丸。假如已经用过下法，脉数仍未解除，合热则消谷善饥，到了六七天不大便的，是有瘀血，用抵当汤。
李杲说：我治疗过一个贫穷的书生，脾胃虚弱，误用补剂治疗后病情加重。后来他居住在空旷寒冷的房间，睡在热的土炕上，咳嗽并几次吐血。我认为这是长期虚弱，外表有寒象，而内有火热。上气不足，阳气外虚，应当补益体表的阳气，清泻体内的虚热。因为冬天住在空旷房间，衣服单薄，是使阳气更虚，体表有大寒，壅遏了体内的热气，火邪不能舒展伸张，所以血液从口中涌出。由此想到张仲景治疗伤寒脉浮紧，应当用麻黄发汗，却没有给他发汗，结果导致衄血（鼻出血），却给予麻黄汤，立刻痊愈。这与本例情况非常相似。因此给予麻黄人参芍药汤。
沈金鳌按语：这里说的是误用灸法产生的变证。吐血比衄血更为严重。
【纲】张仲景说：凡是服用桂枝汤后出现呕吐的，其后必定会吐出脓血。
【目】朱震亨说：杂病中的吐血、咯血，归责于实邪。伤寒中的吐血、咯血，都是由误用汗法、下法以及火逆疗法导致的，确实不是伤寒病热轻重程度的问题。这属于坏病，应当顺着其逆乱的情况进行调理。只有少阴病厥逆衰竭时误用汗法这一种情况，强行扰动经血，所以说难治。
楼英说：吐血者，是诸阳经受邪，邪气在汗位，应当发汗而没有发汗，致使血毒进入脏腑，积聚瘀滞于内，于是形成吐血。凡是见到眼睛闭合、眼球发红、神志昏迷、言语短促、眩晕冒昧、妄言乱语、烦躁想喝水漱口、惊狂谵语、吐衄、背部寒冷、足部发凉、四肢厥逆、胸腹部急迫胀满、大便黑亮如漆、小便频数的，都是瘀血症的表现。虽然症状多种多样，不必全部具备，只要见到一两个，就按血症来处理。初得此病，急需用药。如果连续不止，经过几个时辰后出现腹痛的，这就难以料理了。
陶华说：经典记载：服用桂枝汤后呕吐的，其后必定吐出脓血，用犀角地黄汤。大下之后，寸脉沉迟，尺脉摸不到，咽喉不利，唾吐脓血的，这有两种病症。一种是阳毒，宜用阳毒升麻汤；一种是阴毒，宜用甘桔汤加半夏、生姜。血热者，用黄连阿胶汤、地榆柏皮汤、三黄泻心汤。咽喉闭塞，不可发汗，发汗则会导致吐血，气欲绝，手足厥冷，蜷卧不能自我温暖，用当归四逆汤。
[Outline] Zhang Zhongjing stated: In Taiyang Wind Strike syndrome, the pulse is floating on the superficial level (Yang) and weak on the deep level (Yin). Floating Yang indicates spontaneous fever; weak Yin indicates spontaneous sweating. The patient feels shrinking and aversion to cold, shivering and aversion to wind, and has a warm sensation of fever. If accompanied by nasal resonance (bi ming) and dry retching, Guizhi Tang (Cinnamon Twig Decoction) should be used. After inducing sweating, if the body remains burning hot, the pulse is floating with spontaneous sweating, the body feels heavy, there is excessive sleepiness, snoring, and difficulty in speech, purgation (xia fa) must not be used, nor fire therapy (huo fa).
[Commentary] Zhao Sizhen stated: Bi han (snoring) occurs in Fengwen (Wind-Warmth), while bi ming (nasal resonance) occurs in Zhongfeng (Wind Strike). This is caused by the obstruction of Wind Qi and the dysfunction of Wei Qi (Defensive Qi). Although Yangming, Shaoyang, and the Three Yin meridians may also experience Zhongfeng, the pathogen is no longer at the exterior level; therefore, neither bi ming nor bi han occurs.
[Outline] Zhang Zhongjing stated: When the pulse is floating and the heat is severe, applying moxibustion (jiu) in reverse is indicated. This constitutes an Excess condition. Treating an Excess as Deficiency, and causing Fire to move internally, will inevitably result in dry throat and hematemesis (vomiting blood).
[Commentary] Zhu Gong stated: Hematemesis caused by Shanghan (Cold Damage) results from Heat pathogens affecting the Yang meridians. Initially located at the exterior, it should have been treated with diaphoresis (fa han). Failure to induce sweating allows toxic heat to penetrate deeply, affecting the collaterals and the Five Zang organs, leading to internal stasis accumulation, thus causing hematemesis. For severe blood stasis, Didang Wan (Didang Pill) is used; for mild cases, Tao Ren Chengqi Tang (Peach Kernel and Rheum Decoction) is used. These can be taken concurrently with Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) and Sanhuang Wan (Three Yellow Pill). If purgation has already been administered but the rapid pulse persists, combined heat leads to efficient digestion and frequent hunger. If after six or seven days there is no bowel movement, this indicates blood stasis, treated with Didang Tang (Didang Decoction).
Li Gao stated: I treated a poor scholar who had Spleen-Stomach deficiency. His condition worsened due to improper use of tonifying agents. Subsequently, he lived in a spacious, cold room and slept on a heated kang (brick bed). He coughed and vomited blood several times. I reasoned that this was long-standing weakness, presenting with external cold signs but internal heat. There was insufficiency of Upper Qi and deficiency of Yang Qi at the exterior. Treatment should tonify the exterior Yang Qi and drain the interior deficient heat. Because he dwelled in a cold room in winter with thin clothing, his Yang was doubly depleted. Severe exterior cold obstructed interior heat, preventing the Fire pathogen from dispersing, thus forcing blood out through the mouth. This reminded me of Zhang Zhongjing’s treatment of Shanghan with a floating-tight pulse, where failure to use Mahuang (Ephedra) for diaphoresis led to epistaxis (nosebleed), which was then cured immediately by administering Mahuang Tang (Ephedra Decoction). This case is very similar. Therefore, I prescribed Mahuang Renshen Shaoyao Tang (Ephedra, Ginseng, and Peony Decoction).
Shen Jin'ao's note: This passage describes complications arising from erroneous moxibustion. Hematemesis is more severe than epistaxis.
[Outline] Zhang Zhongjing stated: Generally, if vomiting occurs after taking Guizhi Tang (Cinnamon Twig Decoction), pus and blood will subsequently be vomited.
[Commentary] Zhu Zhenheng stated: Hematemesis and hemoptysis in miscellaneous diseases are attributed to Excess pathogens. In Shanghan, hematemesis and hemoptysis are caused by erroneous diaphoresis, purgation, and fire-ni (fire reversal) therapies. They are not merely reflections of the severity of Shanghan heat. These constitute Huai Bing (ruined/complicated diseases) and should be regulated according to the nature of the reversal. Only in the specific case of Shaoyin Jue Ni (Jueyin collapse) where erroneous diaphoresis forcibly disturbs the Jing blood, is it considered difficult to treat.
Lou Ying stated: Hematemesis occurs when pathogens affect the Yang meridians and reside in the sweat-releasing stage. Failure to induce sweating when indicated allows blood-toxicity to enter the Zang organs, accumulating as stasis internally, resulting in hematemesis. Symptoms such as closed eyes with redness, coma, shortness of speech, dizziness, delirious speech, irritability, desire to rinse the mouth without swallowing, fright, mania, hematemesis/epistaxis, cold back, cold feet, limb coldness (Jue Ni), acute chest/abdominal fullness, black loose stools, and frequent urination all indicate Blood Stasis syndrome. Although symptoms vary widely, not all need to be present; observing one or two is sufficient to diagnose and treat as a blood stasis case. Upon initial onset, urgent medication is required. If bleeding continues uninterrupted and abdominal pain develops after several hours, the condition becomes difficult to manage.
Tao Hua stated: The classics state: "If vomiting occurs after taking Guizhi Tang, pus and blood will subsequently be vomited," treated with Xijiao Dihuang Tang. After severe purgation, if the Cun (inch) pulse is deep and slow, the Chi (cubit) pulse is imperceptible, the throat is obstructed, and pus-blood is expectorated, there are two conditions: one is Yang Du (Yang Toxin), treated with Yang Du Shengma Tang (Yang Toxin and Cimicifuga Decoction); the other is Yin Du (Yin Toxin), treated with Ganjie Tang (Licorice and Platycodon Decoction) plus Banxia (Pinellia) and Shengjiang (Fresh Ginger). For Blood Heat, use Huanglian Ejiao Tang (Coptis and Donkey-Hide Gelatin Decoction), Diyú Baipi Tang (Sanguisorba and Phellodendron Decoction), or Sanhuang Xiexin Tang (Three Yellow Heart-Draining Decoction). If the throat is blocked, diaphoresis is contraindicated; inducing sweating will cause hematemesis, Qi exhaustion, cold hands and feet, and curling up inability to self-warm, treated with Danggui Sini Tang (Angelica Sinensis and Cinnamon Twig Decoction).
Shen Jin'ao's note: This refers to situations where Heat pathogens overflow internally. Thus, Guizhi Tang (Cinnamon Twig Decoction) may inadvertently assist Yang, causing heat to surge upward, damaging the Yang collaterals and resulting in vomiting of pus and blood.