治吐衄脉虚濡而迟，饮食停滞胃口，不能消化，此因凉而胃气不降也，以温补开通之药，降其胃气，则血止矣。
白术（三钱） 清半夏（三钱） 生山药（六钱） 干姜（三钱） 生赭石（六钱，轧细） 生杭芍
（二钱） 川浓朴（钱半） 生姜（二钱）
或问∶此汤以温降为名，用药宜热不宜凉矣。乃既用干姜之热，复用芍药之凉，且用干姜而更用生姜者何
也？答曰∶脾胃与肝胆，左右对待之脏腑也。肝胆属木，中藏相火，其性恒与热药不宜。用芍药者，所以防干
姜之热力入肝也。且肝为藏血之脏，得芍药之凉润者以养之，则宁谧收敛，而血不妄行。更与生姜同用，且能
和营卫，调经络，引血循经，此所以用干姜又用生姜也。
《内经》厥论篇谓阳明厥逆衄呕血，所谓阳明者，指胃腑而言也，所谓厥逆者，指胃腑之气上行而言也。
盖胃以消化饮食，传送下行为职，是以胃气以息息下行为顺，设或上行则为厥逆；胃气厥逆，可至衄血、呕血，
因血随胃气上行也。然胃气厥逆因热者固多，因寒者亦间有之。岁在壬寅，邑之北境，有学生刘××者，年十三
岁，一日之间衄血四次。诊其脉甚和平，询其心中不觉凉热。因思吐衄之证热者居多，且以童子少阳
之体，时又当夏令，遂略用清凉止血之品。衄益甚，脉象亦现微弱，知其胃气因寒不降，转迫血上逆而为衄也。
投以拙拟温降汤，一剂即愈。隔数日又有他校学生，年十四岁，吐血数日不愈，其吐之时，多由于咳嗽。诊其
脉，甚迟濡，右关尤甚。疑其脾胃虚寒，不能运化饮食，询之果然。盖吐血之证多由于胃气不降，饮食不能运
化，胃气即不能下降。咳嗽之证，多由于痰饮入肺。饮食迟于运化，又必多生痰饮，因痰饮而生咳嗽，因咳嗽
而气之不降者更转而上逆，此吐血之所由来也。亦投以温降汤，一剂血止，接服数剂，饮食运化，咳嗽亦愈。
近在沈阳论及此事，李××谓，从前有老医徐××者，曾用理中汤治愈历久不愈之吐血证，是吐血诚有因寒
者之明征也。然徐××但用理中汤以暖胃补胃，而不知用赭石、半夏佐之以降胃气，是处方犹未尽善也。特是
药局制药，多不如法，虽清半夏中亦有矾，以治吐衄及呕吐，必须将矾味用微温之水淘净。淘时，必于方中原
定之分量外，多加数钱，以补其淘去矾味所减之分量及药力。
又∶薛立斋原有血因寒而吐者，治用理中汤加当归之说。特其因寒致吐血之理，未尝帮助，是以后世间有
驳其说者。由斯知着医书者宜将病之原因仔细发透，俾读其书者易于会悟，不至生疑为善。
不惟吐衄之证有因寒者，即便血之证亦有因寒者，特其证皆不多见耳。邻村高某，年四十余，小便下血久
不愈，其脉微细而迟，身体虚弱，恶寒，饮食减少。知其脾胃虚寒，中气下陷，黄坤载所谓“血之亡于便溺者，
太阴不升也。”为疏方∶干姜、于术各四钱，生山药、熟地黄各六钱，乌附子、炙甘草各三钱。煎服一剂，血
即见少。连服十余剂，全愈。此方中不用肉桂者，恐其动血分也。
治疗吐血、鼻衄，脉象虚弱、濡软且迟缓，饮食停滞在胃脘部，无法消化。这是因为受寒导致胃气不能下降的缘故，使用温补并开通的药，使胃气下降，那么出血就会停止。
白术（三钱） 清半夏（三钱） 生山药（六钱） 干姜（三钱） 生赭石（六钱，碾细） 生杭芍（二钱） 川厚朴（一钱半） 生姜（二钱）
有人问：这个汤剂以“温降”命名，用药应当用热性而不用凉性。既然已经用了干姜的热性，又复用芍药的凉性，并且用了干姜却又用生姜，这是为什么呢？回答说：脾胃与肝胆，是左右对应的脏腑。肝胆属木，中间藏有相火，其性质通常不适合与热药同用。使用芍药，是为了防止干姜的热力进入肝脏。而且肝是藏血的脏器，得到芍药的凉润来滋养它，就能安宁静谧、收敛，从而血液不妄行。再加上生姜一同使用，能够调和营卫，疏通经络，引导血液循行于经脉之中，这就是既用干姜又用生姜的原因。
《黄帝内经·厥论篇》说阳明经气逆乱会导致鼻衄、呕吐血，所谓的“阳明”，是指胃腑；所谓的“厥逆”，是指胃腑之气向上逆行。大概胃的功能是消化饮食，传送下行，所以胃气以每一息都向下行为顺，如果反而上行就是厥逆；胃气厥逆，可导致鼻衄、呕血，因为血随着胃气上行。然而胃气厥逆因热引起的固然多，因寒引起的也偶尔有。壬寅年，我县北部有个学生叫刘××，十三岁，一天之内鼻衄四次。诊他的脉象很平和，询问他心中不觉凉热。因为想到吐衄的病证热者居多，加上他是少年少阳之体，当时又是夏季，于是稍微用了些清凉止血的药。结果鼻衄更严重，脉象也现出微弱，知道他是胃气因寒不能下降，转而逼迫血液上逆而导致鼻衄。投予我拟定的温降汤，一剂就痊愈了。过了几天又有其他学校的学生，十四岁，吐血几天不好，他吐血的时候，多是由于咳嗽。诊他的脉，非常迟缓濡软，右关脉尤其明显。怀疑他是脾胃虚寒，不能运化饮食，询问后果然如此。大概吐血的病证多由于胃气不降，饮食不能运化，胃气就不能下降。咳嗽的病证，多由于痰饮进入肺脏。饮食迟缓于运化，又必然多生痰饮，因为痰饮而产生咳嗽，因为咳嗽而导致气机不降反而更加上逆，这就是吐血产生的原因。也投予温降汤，一剂血止，接着服用几剂，饮食运化正常，咳嗽也好了。最近在沈阳谈到这件事，李××说，从前有位老医生徐××，曾用理中汤治愈了长期不愈的吐血证，这确实是吐血确实有因寒引起的明确证据。然而徐××只用理中汤来暖胃补胃，却不知道用赭石、半夏辅助来降胃气，所以处方还不够完善。特别是药局制药，大多不如法，虽然清半夏中也含有矾，用来治疗吐衄及呕吐，必须将矾味用微温的水淘洗干净。淘洗时，必须在方中原定分量之外，多加几钱，以补充淘去矾味所减少的分量及药效。
另外：薛立斋原本认为血因寒而吐，治疗用理中汤加当归的说法。只是他对于因寒导致吐血的道理，没有加以帮助说明，因此后世世间有驳斥他说法的人。由此可知写医书的人应该将病因仔细阐明透彻，让读他的人容易领悟，不产生疑惑才是好的。
不只是吐衄的病证有因寒引起的，即便血（大便下血）的病证也有因寒引起的，只是这些证候都不多见罢了。邻村高某，四十多岁，小便下血很久不好，脉象微细而迟，身体虚弱，怕冷，饮食减少。知道他是脾胃虚寒，中气下陷，正如黄坤载所说的“血从大小便流失的，是因为太阴脾土不升。”为他开方：干姜、白术各四钱，生山药、熟地黄各六钱，乌附子、炙甘草各三钱。煎服一剂，血就减少。连续服用十余剂，完全痊愈。这个方子中不用肉桂，是担心它扰动血分。
Treat hematemesis (vomiting blood) and epistaxis (nosebleed) with a pulse that is deficient, soggy, and slow; food stagnation in the stomach region unable to be digested. This is due to cold causing the Stomach Qi to fail to descend. Using herbs that warm, tonify, and unblock will cause the Stomach Qi to descend, and the bleeding will stop.
Baizhu (Atractylodis Macrocephalae Rhizoma) 3 qian, Qing Banxia (Pinelliae Rhizoma Preparatum) 3 qian, Sheng Shanyao (Dioscoreae Rhizoma) 6 qian, Ganjiang (Zingiberis Rhizoma) 3 qian, Sheng Zhe shi (Ochre) 6 qian (crushed fine), Sheng Hangshao (Paeoniae Radix Alba) 2 qian, Chuan Houpo (Magnoliae Officinalis Cortex) 1.5 qian, Shengjiang (Zingiberis Rhizoma Recens) 2 qian.
One might ask: Since this decoction is named "Wen Jiang" (Warm Descending), the herbs used should be hot rather than cool. Since hot Ganjiang (Zingiberis Rhizoma) is already used, why is cool Shaoyao (Paeoniae Radix) reused? And since Ganjiang (Zingiberis Rhizoma) is used, why is also Shengjiang (Zingiberis Rhizoma Recens) used? The answer is: The Spleen and Stomach, and the Liver and Gallbladder are paired organs on the left and right. The Liver and Gallblender belong to Wood, harboring Ministerial Fire within, and their nature is generally unsuitable for hot herbs. Shaoyao (Paeoniae Radix) is used to prevent the heat of Ganjiang (Zingiberis Rhizoma) from entering the Liver. Moreover, the Liver is the organ that stores Blood; nourishing it with the cooling and moistening properties of Shaoyao (Paeoniae Radix) allows it to become tranquil and convergent, preventing Blood from flowing recklessly. Furthermore, using it together with Shengjiang (Zingiberis Rhizoma Recens) can harmonize Ying and Wei (Nutritive and Defensive Qi), regulate the meridians, and guide Blood to circulate along the vessels. This is why both Ganjiang (Zingiberis Rhizoma) and Shengjiang (Zingiberis Rhizoma Recens) are used.
The *Jue Lun* chapter of the *Huangdi Neijing* states that Yangming Jue Ni (rebellious Qi) causes epistaxis and vomiting blood. What is meant by "Yangming" refers to the Stomach Fu-organ; what is meant by "Jue Ni" refers to the Qi of the Stomach Fu-organ moving upward. Generally, the function of the Stomach is to digest food and transport it downward; thus, it is favorable for Stomach Qi to descend with every breath. If it moves upward, it constitutes Jue Ni (rebellious Qi). Stomach Qi rebelling upward can lead to epistaxis or hematemesis because Blood follows the ascending Stomach Qi. However, while most cases of Stomach Qi rebellion are due to Heat, some are indeed due to Cold. In the year Ren Yin, in the northern part of my county, there was a student named Liu XX, aged thirteen, who suffered epistaxis four times in one day. His pulse was very peaceful, and he reported no sensation of cold or heat in his heart. Considering that most cases of hematemesis and epistaxis are due to Heat, and given that he was a youth in the prime of life (Shaoyang constitution) during midsummer, I slightly used cooling and hemostatic herbs. The epistaxis worsened, and the pulse became weak and thready. I realized that his Stomach Qi failed to descend due to Cold, forcing Blood to rebel upward, causing epistaxis. I administered my formulated Wen Jiang Tang (Warm Descending Decoction), which cured him after one dose. A few days later, another student from a different school, aged fourteen, had been suffering from hematemesis for several days without relief. His vomiting often occurred during coughing fits. His pulse was very slow and soggy, especially at the Right Guan position. I suspected Spleen and Stomach deficiency-cold failing to transform and transport food, which proved correct upon inquiry. Generally, hematemesis is mostly due to Stomach Qi failing to descend; when food cannot be transformed, Stomach Qi cannot descend. Coughing is mostly due to Phlegm-Fluids entering the Lungs. When food transformation is delayed, excessive Phlegm-Fluids are generated. These Phlegm-Fluids cause coughing, and the cough causes the already non-descending Qi to rebel further upward, leading to hematemesis. I also administered Wen Jiang Tang (Warm Descending Decoction); bleeding stopped after one dose. After taking several more doses, food transformation normalized, and the cough resolved. Recently in Shenyang, discussing this case, Li XX mentioned that an old physician, Xu XX, once cured chronic hematemesis using Lizhong Tang (Regulate the Middle Decoction). This is clear evidence that hematemesis can indeed be caused by Cold. However, Xu XX only used Lizhong Tang (Regulate the Middle Decoction) to warm and tonify the Stomach, not knowing to use Zhe shi (Ochre) and Banxia (Pinelliae Rhizoma) as assistants to descend Stomach Qi, so the prescription was not yet perfect. Specifically, pharmaceutical preparations are often substandard. Although Qing Banxia (Pinelliae Rhizoma Preparatum) contains alum, when treating hematemesis, epistaxis, or vomiting, the alum taste must be washed out with lukewarm water. During washing, add several qian extra to the original dosage to compensate for the loss of weight and efficacy due to removing the alum.
Furthermore: Xue Lizhai originally stated that bleeding due to Cold vomiting should be treated with Lizhong Tang (Regulate the Middle Decoction) plus Danggui (Angelicae Sinensis Radix). However, he did not elaborate on the rationale for Cold causing hematemesis, leading to later refutations of his view. This shows that authors of medical books should thoroughly elucidate the causes of diseases, making them easy for readers to understand and avoiding doubt, which is good practice.
Not only do hematemesis and epistaxis have cases caused by Cold, but also hematochezia/haematuria (blood in stool/urine) has cases caused by Cold, though such presentations are rare. Gao XX from a neighboring village, over forty years old, suffered from long-standing haematuria. His pulse was minute, fine, and slow; his body was weak, he feared cold, and his appetite was reduced. I diagnosed Spleen and Stomach deficiency-cold with sinking of Middle Qi, as described by Huang Kunzai: "Blood lost through urination or defecation is due to the failure of Taiyin [Spleen] to ascend." I prescribed: Ganjiang (Zingiberis Rhizoma) 4 qian, Baizhu (Atractylodis Macrocephalae Rhizoma) 4 qian, Sheng Shanyao (Dioscoreae Rhizoma) 6 qian, Shu Dihuang (Rehmanniae Radix Praeparata) 6 qian, Wufuzi (Aconiti Lateralis Radix Praeparata) 3 qian, Zhigancao (Glycyrrhizae Radix et Rhizoma Preparatum cum Melle) 3 qian. After one dose of decoction, the bleeding decreased. After continuous administration for over ten doses, he was completely cured. Rougui (Cinnamomi Cortex) was not used in this formula for fear of disturbing the Blood level.