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In the category of miscellaneous diseases, epistaxis (nosebleed) is considered a interior syndrome, suitable for clearing interior heat; in the category of external contraction diseases, epistaxis is considered an exterior syndrome, suitable for dispersing exterior pathogens. Therefore, it is said that epistaxis caused by external contraction involves pathogenic heat in the meridians. Although there are distinctions among different meridians, there is no fundamental difference between cold and heat syndromes; they all return to exterior heat. The Three Yin meridians (Taiyin, Shaoyin, Jueyin) typically do not present with epistaxis. Only when Yang pathogens transmit into the Shaoyin meridian, presenting with limb coldness and anhidrosis (absence of sweating), might a physician, seeing cold hands and feet without sweat, mistakenly recognize it as unextended Taiyang exterior pathogens, and use Mahuang Tang (Ephedra Decoction) or Guizhi Tang (Cinnamon Twig Decoction) to forcibly induce sweating. This agitates Yin blood internally, causing blood to flow from the mouth and nose, a condition termed "Jue at the bottom and exhaustion at the top" (lower Yang collapse and upper Yin depletion). This results from interior heat in the Shaoyin meridian being mishandled with acrid-warm herbs, stirring up Yin blood to rush upward. Dai stated: Zhang Zhongjing discussed treating epistaxis with diaphoresis, using Mahuang Tang as the primary formula. This treats winter cold damage, Taiyang exterior syndrome, where there is no accumulated interior heat causing epistaxis, and does not refer to the hot seasons of spring, summer, and autumn. In these three seasons, even if Taiyang exterior symptoms exist, one should disperse the exterior using Qianghuo Chonghe Tang, and must not use Mahuang Tang or Guizhi Tang. If Taiyang pathogens have already invaded the Yangming meridian, Taiyang and Yangming treatments should be combined. If epistaxis is caused by severe heat in the Yangming meridian itself, Taiyang herbs should not be used; instead, Shengma Gange Tang should be used to resolve Qi-level pathogens in the Yangming meridian, followed by Maohua Tang combined with Huangqin Shaoyao Tang, Xijiao Dihuang Tang, or Shengma Qingwei Tang to resolve Blood-level heat in the Yangming meridian.

Haizang stated: Zhang Zhongjing said that patients with a history of epistaxis should not undergo diaphoresis; doing so will cause depression of the forehead. This refers to cases with a faint pulse and interior heat. If a patient with epistaxis has a floating-tight pulse, diaphoresis is permissible. However, if the pulse has become faint and the exterior syndrome has resolved, further diaphoresis will cause forehead depression. Thus, the *Shanghan Lun* states: For epistaxis with a now-faint pulse, use Huangqin Shaoyao Tang and Xijiao Dihuang Tang. This indicates that epistaxis due to interior heat requires cooling the blood, and acrid-warm dispersing methods are contraindicated. Wu stated: For epistaxis, if the pulse is floating-tight, diaphoresis is indicated; if not, it is contraindicated. Dongyuan treated epistaxis with a faint pulse using Huangqin Shaoyao Tang, and with a deep-rapid pulse using Xijiao Dihuang Tang. My commentary notes: Zhang Zhongjing’s use of Mahuang Tang for epistaxis applies to Taiyang cold pathogens that have not dispersed, presenting with a floating-tight pulse; Dongyuan’s use of Huangqin Shaoyao Tang applies to dispersing Blood heat when the pulse is not floating-tight but faint. Huangqin cools blood, and Shaoyao astringes and cools blood. Astringing the blood stops epistaxis naturally. Furthermore, the use of Xijiao Dihuang Tang applies to cases where exterior pathogens have resolved, the pulse is deep-rapid, and interior heat is severe, requiring heat-clearing treatment. Xijiao Dihuang Tang cools Yangming Blood heat and clears Fire from the Liver and Kidneys. A deep-rapid pulse indicates heat in the Lower Jiao; clearing Liver/Kidney and Lower Jiao Fire prevents blood from rising, thus preventing epistaxis. Therefore, Zhang Zhongjing’s Mahuang Tang treats only winter Taiyang exterior epistaxis; Dongyuan’s Huangqin Tang and Xijiao Dihuang Tang treat interior heat epistaxis in all four seasons, and also treat internal injury epistaxis. Dihuang Yinzi and Mendong Yinzi treat internal injury, not external contraction. Shengma Qingwei Tang treats external contraction and also internal injury. This is the distinction in treatment. For external contraction epistaxis, a large pulse is easy to treat, while a deep-choppy pulse is difficult; for internal injury epistaxis, a slow pulse is easy to treat, while a rapid pulse is difficult. This is the distinction in pulses.

Taiyang disease, with a floating pulse, anhidrosis, fever, and body pain, persisting for eight to nine days without resolution, indicates the exterior syndrome remains. Diaphoresis is indicated. After medication, symptoms may slightly improve. The patient may feel vexed and desire to keep eyes closed; severely, epistaxis occurs, leading to recovery. This occurs because Yang Qi is heavily constrained. Mahuang Tang is the primary formula.

Taiyang disease, with a floating-tight pulse, anhidrosis, fever, and body pain, persisting for eight to nine days without resolution. Exterior pathogens remain undispersed; Mahuang Tang should be used to induce sweating. If the patient takes Mahuang Tang and symptoms slightly improve, but then becomes vexed and desires to keep eyes closed, severe cases will see Taiyang pathogens exit via epistaxis rather than sweat. This is because Yangming heat pathogens are heavy; the acrid-warm nature of Mahuang causes them to exit upward through the Yangming meridian, eye collaterals, and nasal orifices. The phrase "Mahuang Tang is the primary formula" should appear after "diaphoresis is indicated"; otherwise, if Yang Qi is too heavy, epistaxis resolves the condition, making subsequent use of Mahuang Tang inappropriate.

Taiyang disease, with a floating-tight pulse, fever, and anhidrosis, resolves spontaneously upon epistaxis.

This explains that for Taiyang fever, tight pulse, and anhidrosis, Mahuang Tang is indicated. However, if the patient’s pathogen is mild and Zheng Qi is strong, spontaneous epistaxis cures the disease without medication. This clarifies that after epistaxis resolves the syndrome, Mahuang Tang need not be used again.

Taiyang cold damage, with a floating-tight pulse, if not treated with diaphoresis and resulting in epistaxis, Mahuang Tang is the primary formula.

Having established that Mahuang Tang should not be overused, this clause states that failure to use Mahuang Tang initially leads to epistaxis. Since Taiyang symptoms persist, Mahuang Tang is still indicated, clarifying that even after epistaxis, if Taiyang exterior pathogens remain, exterior release is still necessary.

Taiyang Wind Strike, treated with fire therapy to force sweating, allows wind pathogens to combine with fire heat. Blood and Qi overflow, losing their normal course. The combination of two Yangs (wind and fire) scorching the body causes jaundice. Excess Yang leads to impending epistaxis; Yin deficiency leads to difficult urination. With both Yin and Yang deficient, the body becomes dry and rough.

Taiyang Cold Damage without fever, treated with fire therapy, causes little harm. However, Taiyang Wind Strike with fire therapy exacerbates Yang pathogens with fire heat, causing blood and Qi to overflow abnormally. Jaundice ensues. Fire injuring the upper jiao: if Yin blood is sufficient, epistaxis may occur to resolve the condition. Fire injuring the lower jiao: if Yin blood is depleted, urinary difficulty ensues, Yin and Yang both become deficient, and muscles waste away.

Yangming disease, with dry mouth desiring only to rinse water in the mouth without swallowing, indicates impending epistaxis.

This clarifies that epistaxis is not solely caused by Taiyang pathogens invading Yangming. Yangming meridian itself can cause epistaxis. For example, Yangming disease with dry mouth, desiring only to hold water in the mouth without swallowing, indicates heat in the Blood level of Yangming, which will likely cause epistaxis.

Floating pulse, fever, dry mouth and nose, and ability to eat indicate impending epistaxis.

Floating pulse and fever indicate Yangming exterior heat; dry mouth/nose and ability to eat indicate Yangming interior heat. Heat in both exterior and interior forces blood to overflow, causing epistaxis.

Shengma Gange Tang: See section on Vexation.

Maogen Tang: Consists of only Maohua (reed catkins).

Reed is cool in nature; its root cools blood and relieves vexation; its flowers specifically cool Upper Jiao blood heat, hence treating epistaxis.

Huangqin Shaoyao Tang
Ingredients: Huangqin (Scutellaria Root), Baishao Yao (White Peony Root), Chuanlian (Coptis Rhizome), Gancao (Licorice Root).
For Yangming exterior heat with epistaxis, the previous formula Shengma Gange Tang is used; for Yangming exterior heat with epistaxis, this formula is used. My secret addition includes Shengdi (Rehmannia Root) and Danggui (Angelica Sinensis). Because Danggui is acrid and dispersing, combined with Huangqin, Lian, and Shengdi, it cools blood and guides it back to the vessels.

Xijiao Dihuang Tang
Ingredients: Sheng Xijiao (Fresh Rhinoceros Horn - note: substitute with Water Buffalo Horn in modern practice), Shanzhi (Gardenia Fruit), Baishao Yao (White Peony Root), Jingjie (Schizonepeta Spike), Mudanpi (Tree Peony Bark), Chishao Yao (Red Peony Root), Shengdi (Rehmannia Root), Huangqin (Scutellaria Root).
This formula treats not only epistaxis but also hemoptysis and hematemesis; it treats not only Liver/Kidney internal injury blood heat but also Yangming external contraction, requiring modifications based on this base. Adding Huangqin and Jingjie cools blood and prevents upward rushing; if stool is hard, add Danggui and Jiuhuang Da (Rhubarb steamed with wine) to immediately guide blood back to the vessels. Using Danggui with blood-cooling herbs maximizes the effect of guiding blood downward and returning it to the vessels.

Dihuang Yinzi
Ingredients: Shengdi (Rehmannia Root), Danpi (Moutan Cortex), Tianmendong (Asparagus Tuber), Huangqin (Scutellaria Root), Digupi (Lycium Bark), Baishao (White Peony Root).
This formula treats exhaustion of Liver/Kidney essence, blood dryness, and consumptive disease. If the Chi pulse is large, add Huangbai (Phellodendron Bark) and Zhimu (Anemarrhena Rhizome). External contraction epistaxis often stems from fire in the original Yuan Blood level, hence this formula is established.

Mendong Yinzi
Ingredients: Maimendong (Ophiopogon Tuber), Digupi (Lycium Bark), Zhimu (Anemarrhena Rhizome), Shigao (Gypsum Fibrosum), Shengdi (Rehmannia Root), Danpi (Moutan Cortex), Baishao Yao (White Peony Root).
This formula generally treats nasal bleeding. If Yangming exterior symptoms exist, add Shengma, Gange, Jingjie, and Huangqin; if interior heat with constipation exists, add Danggui and Dahuang.

Gange Shigao Tang
Ingredients: Gange (Pueraria Lobata Root), Shigao (Gypsum Fibrosum), Zhimu (Anemarrhena Rhizome), Gancao (Licorice Root), Danpi (Moutan Cortex), Shengdi (Rehmannia Root), Huangqin (Scutellaria Root).
This formula specializes in treating external contraction epistaxis. It cools Yangming Qi-level heat; my addition of Danpi, Shengdi, and Huangqin extends its action to cool Blood heat.

Shengma Qingwei Tang: See section on Thirst.

Epistaxis is caused by latent fire in the Yangming Blood. Thus, this formula clears heat from the Yangming Blood level.