毒邪并迫血离经。衄流于鼻不须惊。当知热毒从兹解。血去荣中毒少轻。
吐血便血与溺血。当分热甚和血甚。热入血室劳动火。总而名为失血症。
鼻之衄血。因内热炽甚。邪火沸腾。血随火载。自肺胃上行而溢于鼻也。麻疹本乎肺胃。故初
起及未出之先而衄血者。是为顺候。亦发散之义也。盖麻毒从衄而解。而荣中之毒则轻少矣。不
必遽止。热得开泄。不药而衄自已。非错经妄行之比。但不宜久耳。如衄血过多。此为火迫。经曰。
夺血者亡。急须止之。如衄血不已。或有失血者。俱宜清肺泻火。佐以凉血之药治之。以犀角地黄
汤去白芍。加荆芥穗、枯黄芩主之。凡初热即见衄血者。乃心火上冲烦闷。其症不妨。用生地黄
栀子汤。加枯黄芩以散心火之郁热而清肺。已出而衄血者。以加减犀角地黄茅花汤去甘草治之。
已出大便下血。或小便溺血者。或吐血衄血。或二便闭涩。热渴赤痛。以犀角解毒汤去赤芍治之。
如衄血不已。急须止之。以茅根汤加黄连。或元参地黄汤去升麻、白芍、甘草。加茅根、黄连。或
茅花汤去甘草加黄连等方主之。已收之后。或出鼻血。或失血者。俱宜以加减犀角地黄茅花汤去
甘草治之。（有用四物汤加茅根治之者。）凡麻症血热。及劳动火。热入血室。吐血衄血。发狂发
黄者。俱宜用犀角地黄汤去白芍加桃仁治之。若正收及收后。仍衄不止者。以四物汤（见二十五
条）加茅根、麦冬以滋润之。然麻症衄血。或便血溺血。俱为失血之候。须当分热甚、血甚施治。热
甚者。以黄连解毒汤（见三十五条）主之。血甚者。以犀角地黄汤去白芍主之。
朱曰 衄血吐血。证虽骇人。一经清热凉血。便可奏功。此等证予治愈甚多。故一见即胸有成竹。
犀角地黄汤 治伤寒温病。本应发汗而不得汗。内蓄血及鼻衄吐血不尽。内余瘀血。大便出血。
面黄。或中脘作痛。
犀角 生地黄（酒浸另捣） 牡丹皮 白芍 各等分 水煎服。喜妄如狂加大黄、黄芩。吐血、衄血
者加扁柏、藕汁、童便。脉大来迟腹不满而自言满者加当归、肉桂。
生地栀子汤 治心火上冲、衄血。
生地黄 栀子 葛根 薄荷叶 灯心引。
加减犀角地黄茅花汤
犀角（磨汁） 生地黄 茅花 丹皮 枳壳 黄芩 栀仁 连翘 黄连 麦冬 当归尾 甘
草灯心三十根引。
犀角解毒汤
犀角 黄连 黄柏 黄芩 栀仁 生地黄 牡丹皮 赤芍 水煎服。
茅根汤
茅根 当归 生地黄 山栀仁 枯黄芩 水煎。加百草霜入药中服。
元参地黄汤 止痘疹衄。
元参 生地黄 丹皮 栀仁 升麻 甘草（各一钱五分） 白芍（一钱） 水煎。
按此方均勿宜用升麻。以塞上冲之源。勿谓但属阳明胃经。即可用升麻也。
茅花汤 治衄血。
净茅花 当归头 牡丹皮 生地黄 甘草 水煎服。
又茅花汤
茅花 郁金 生地黄 黄芩 水煎。入百草霜调服。
元参解毒汤 治衄血、失血。
元参 黄芩 栀仁（炒） 生地黄 粉葛 荆芥穗 桔梗 甘草 水煎。加茅根汁、京墨汁对服。
犀角地黄汤 治失血、衄血、便血、尿血。
犀角 升麻 生地黄 木通 桔梗 京芍 甘草 水煎服。
毒邪逼迫血液脱离正常经脉。鼻衄（鼻腔出血）无需惊慌。应当知道热毒借此得以宣泄，随着血液的流出，营分中的毒素也随之减轻。
吐血、便血和尿血，应当区分是热邪炽盛还是血虚严重所致。热邪陷入血室或因劳倦引动内火，统称为失血症。
鼻衄，是因为体内热势极盛，邪火沸腾，血液随火势上行，从肺胃部位溢出至鼻腔。麻疹病本源于肺胃，所以在初起及疹子未发出之前出现鼻衄，属于顺证，这也符合发散邪气的原理。大概麻毒通过鼻衄而得以解除，营分中的毒素也就减轻了，不必急于止血。热邪得以开泄，即使不用药，鼻衄也会自然停止，这不同于错经妄行（非正常的出血）。只是不宜出血时间过长。如果鼻衄过多，这是火邪逼迫所致，《内经》说：大量失血会导致亡阴/亡血，必须紧急止血。如果鼻衄不止，或者有其他失血情况，都适宜用清肺泻火的药物，配合凉血药治疗。以犀角地黄汤去掉白芍，加入荆芥穗、枯黄芩为主方。凡是初发热就出现鼻衄的，是心火上冲导致烦闷，症状无大碍，用生地黄栀子汤，加入枯黄芩以疏散心火的郁热并清肺。疹子已发出后出现鼻衄的，用加减犀角地黄茅花汤去掉甘草治疗。疹出后大便下血，或小便尿血，或吐血、鼻衄，或大小便闭塞涩痛、热渴、尿赤疼痛的，用犀角解毒汤去掉赤芍治疗。如果鼻衄不止，必须紧急止血，可用茅根汤加黄连，或元参地黄汤去掉升麻、白芍、甘草，加入茅根、黄连，或茅花汤去掉甘草加黄连等方剂主治。疹子收没之后，或再次流鼻血，或有其他失血的，都适宜用加减犀角地黄茅花汤去掉甘草治疗。（也有使用四物汤加茅根治疗的。）凡是麻疹病症中血热，以及因劳倦引动内火、热入血室，出现吐血、鼻衄、发狂、发黄等症状的，都适宜用犀角地黄汤去掉白芍加入桃仁治疗。如果在正收期及收没后，仍然鼻衄不止的，用四物汤（见第二十五条）加茅根、麦冬以滋润之。然而麻疹引起的鼻衄，或便血、尿血，都属于失血的表现，必须根据热邪重还是血虚重来施治。热邪重的，用黄连解毒汤（见第三十五条）主治。血虚重的，用犀角地黄汤去掉白芍主治。
朱氏说：鼻衄、吐血，证候虽然骇人，一旦采用清热凉血的方法，就能见效。这类证候我治愈了很多，所以一见此症便胸有成竹。
犀角地黄汤：治疗伤寒温病，本应发汗却未能发汗，导致体内蓄积瘀血及鼻衄、吐血不尽，体内残留瘀血，大便出血，面色发黄，或中脘部疼痛。
组成：犀角、生地黄（酒浸后另捣）、牡丹皮、白芍，各等分。水煎服。若出现谵语如狂，加大黄、黄芩；吐血、鼻衄者，加侧柏叶、藕汁、童便；脉象大而来迟，腹部不胀满但自述胀满者，加当归、肉桂。
生地栀子汤：治疗心火上冲、鼻衄。
组成：生地黄、栀子、葛根、薄荷叶，以灯心草为引。
加减犀角地黄茅花汤
组成：犀角（磨汁）、生地黄、茅花、丹皮、枳壳、黄芩、栀仁、连翘、黄连、麦冬、当归尾、甘草，以三十根灯心草为引。
犀角解毒汤
组成：犀角、黄连、黄柏、黄芩、栀仁、生地黄、牡丹皮、赤芍，水煎服。
茅根汤
组成：茅根、当归、生地黄、山栀仁、枯黄芩，水煎。加入百草霜一同服用。
元参地黄汤：止痘疹鼻衄。
组成：元参、生地黄、丹皮、栀仁、升麻、甘草（各一钱五分），白芍（一钱），水煎。
按语：此方均不宜使用升麻，以免堵塞上冲之源，不要认为仅属阳明胃经就可以使用升麻。
茅花汤：治疗鼻衄。
组成：净茅花、当归头、牡丹皮、生地黄、甘草，水煎服。
又一方茅花汤
组成：茅花、郁金、生地黄、黄芩，水煎。加入百草霜调服。
元参解毒汤：治疗鼻衄、失血。
组成：元参、黄芩、栀仁（炒）、生地黄、粉葛、荆芥穗、桔梗、甘草，水煎。加入茅根汁、京墨汁对服。
Toxic pathogens force blood to leave the normal meridians. Epistaxis (nosebleed) need not cause alarm. One should know that heat-toxins are thereby resolved; as blood is lost, the toxins in Ying (Nutritive Qi) are also alleviated.
Hematemesis (vomiting blood), hematochezia (blood in stool), and hematuria (blood in urine) must be differentiated into cases of excessive heat versus severe blood deficiency. When heat enters the Blood Chamber or labor/strenuous activity stirs internal fire, these are collectively termed "Loss of Blood Syndromes."
Epistaxis occurs due to extreme internal heat, where pathogenic fire boils vigorously, carrying blood upward from the Lung and Stomach to overflow from the nose. Measles originates fundamentally in the Lung and Stomach; therefore, epistaxis occurring at the onset or before the rash erupts is a favorable sign (Shun Hou), consistent with the principle of dispersing pathogens. Essentially, measles toxins are resolved through epistaxis, reducing toxins in the Ying level. It is unnecessary to hastily stop the bleeding. Once heat is vented, epistaxis will cease spontaneously without medication; this differs from erratic or reckless bleeding. However, prolonged bleeding is inadvisable. If epistaxis is excessive, it indicates forcing by fire; as stated in the classics, "Severe loss of blood leads to exhaustion," so emergency hemostasis is required. If epistaxis persists or other bleeding occurs, clearing Lung heat and purging fire, assisted by blood-cooling herbs, is appropriate. The primary formula is Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) with Baishao (White Peony Root) removed, plus Jingjie Sui (Schizonepeta Spike) and Ku Huangqin (Scutellaria Root). For those presenting with epistaxis immediately upon initial fever, indicating Heart Fire rushing upward causing restlessness, the condition is manageable; use Shengdi Zhi Zi Tang (Rehmannia and Gardenia Decoction) with added Ku Huangqin to dissipate constrained Heat of Heart Fire and clear the Lung. For epistaxis after the rash has erupted, use Jiajian Xijiao Dihuang Maohua Tang (Modified Rhinoceros Horn and Rehmannia with Imperata Decoction) without Gancao (Licorice). For post-eruptive hematochezia, hematuria, hematemesis, epistaxis, or constipation/dysuria accompanied by heat-thirst, red urine, and pain, use Xijiao Jiedu Tang (Rhinoceros Horn Detoxification Decoction) with Chishao (Red Peony Root) removed. If epistaxis persists, urgent hemostasis is needed using Maogen Tang (Imperata Decoction) with Huanglian (Coptis Rhizome); or Yuanshen Dihuang Tang (Scrophularia and Rehmannia Decoction) with Shengma (Cimicifuga Rhizome), Baishao, and Gancao removed, plus Maogen (Imperata Rhizome) and Huanglian; or Maohua Tang (Florets of Imperata Decoction) without Gancao plus Huanglian. After the rash subsides, if epistaxis recurs or other bleeding occurs, treat with Jiajian Xijiao Dihuang Maohua Tang without Gancao. (Some practitioners use Siwu Tang [Four Substances Decoction] plus Maogen.) For all measles cases involving Blood Heat, labor-induced fire, heat entering the Blood Chamber, hematemesis, epistaxis, mania, or jaundice, use Xijiao Dihuang Tang with Baishao removed and Taoren (Peach Kernel) added. If epistaxis persists during the resolution phase or after resolution, use Siwu Tang (see Article 25) plus Maogen and Maidong (Ophiopogon Tuber) to moisten and nourish. However, since epistaxis, hematochezia, and hematuria in measles are signs of blood loss, treatment must distinguish between excess heat and blood deficiency. For excess heat, use Huanglian Jiedu Tang (Coptis Detoxification Decoction) (see Article 35). For severe blood deficiency, use Xijiao Dihuang Tang with Baishao removed.
Zhu stated: Although epistaxis and hematemesis appear alarming, they respond well to heat-clearing and blood-cooling methods. I have cured many such cases, so I am confident upon seeing them.
Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction): Treats Shanghan (Cold Damage) and Wenbing (Warm Diseases) where sweating was indicated but failed, leading to internal blood accumulation, incomplete epistaxis/hematemesis, residual intra-abdominal blood stasis, hematochezia, yellow complexion, or epigastric pain.
Ingredients: Xijiao (Rhinoceros Horn), Shengdihuang (Raw Rehmannia Root, soaked in wine and pounded separately), Mudanpi (Moutan Cortex), Baishao (White Peony Root), equal parts. Decoct in water. If delirium and mania occur, add Dahuang (Rhubarb Rhizome) and Huangqin (Scutellaria Root). For hematemesis/epistaxis, add Bianbo (Platycladi Seed), Ouji (Lotus Root Juice), and Tongbian (Child's Urine). If the pulse is large and slow with abdominal fullness despite no distension, add Danggui (Angelica Sinensis) and Rougui (Cinnamon Bark).
Shengdi Zhi Zi Tang (Rehmannia and Gardenia Decoction): Treats Heart Fire rushing upward and epistaxis.
Ingredients: Shengdihuang, Zhizi (Gardenia Fruit), Gegen (Kudzu Root), Boheye (Mentha Leaf), with Dengxincao (Juncus Effusus) as an guide herb.
Jiajian Xijiao Dihuang Maohua Tang (Modified Rhinoceros Horn and Rehmannia with Imperata Decoction)
Ingredients: Xijiao (ground into juice), Shengdihuang, Maohua (Florets of Imperata), Danpi (Moutan Cortex), Zhike (Aurantium Fructus), Huangqin, Zhiren (Gardenia Seed), Lianqiao (Forsythia Fruit), Huanglian, Maidong, Dangguiwei (Angelica Tail), Gancao, with 30 roots of Dengxincao as a guide.
Xijiao Jiedu Tang (Rhinoceros Horn Detoxification Decoction)
Ingredients: Xijiao, Huanglian, Huangbai (Phellodendron Bark), Huangqin, Zhiren, Shengdihuang, Mudanpi, Chishao. Decoct in water.
Maogen Tang (Imperata Decoction)
Ingredients: Maogen, Danggui, Shengdihuang, Shanzhiren (Gardenia Seed), Ku Huangqin. Decoct. Add Baicaoshuang (Charred Herb Ash) to the medicine for administration.
Yuanshen Dihuang Tang: Stops epistaxis in smallpox/measles.
Ingredients: Yuanshen (Scrophularia Root), Shengdihuang, Danpi, Zhiren, Shengma, Gancao (1.5 qian each), Baishao (1 qian). Decoct in water.
Note: This formula should not use Shengma, as it blocks the source of upward rushing. Do not assume that because it belongs to the Yangming Stomach Meridian, Shengma can be used.
Maohua Tang: Treats epistaxis.
Ingredients: Jing Maohua (Clean Imperata Florets), Dangguitou (Angelica Head), Mudanpi, Shengdihuang, Gancao. Decoct in water.
Another Maohua Tang
Ingredients: Maohua, Yujin (Curcuma Tuber), Shengdihuang, Huangqin. Decoct. Mix with Baicaoshuang for administration.
Yuanshen Jiedu Tang: Treats epistaxis and blood loss.
Ingredients: Yuanshen, Huangqin, Zhiren (stir-fried), Shengdihuang, Fenge (Pueraria Lobata Root), Jingjie Sui, Jiegeng (Platycodon Root), Gancao. Decoct. Administer mixed with Maogen juice and Jingmoju (Beijing Ink Juice).
Xijiao Dihuang Tang: Treats blood loss, epistaxis, hematochezia, and hematuria.
Ingredients: Xijiao, Shengma, Shengdihuang, Mutong (Akebia Stem), Jiegeng, Jingshao (Peony Root), Gancao. Decoct in water.