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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.