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This syndrome belongs to the Yangming channel. Generally, those with internal heat desire to drink water; now, although desiring to drink, they do not wish to swallow, indicating that the heat is in the channels while there is no heat in the interior. The Qi and Blood of the Yangming channel are abundant; when heat within the channel becomes severe, it forces blood to move recklessly, thus we know that epistaxis (nosebleed) will inevitably occur. Yang Renzhai stated: Dry lips and dry mouth are common in various blood disorders, where patients must desire to take water to swish in their mouths. However, why do they swish without swallowing? Typically, thirst makes one eager to drink because Yang-heat has entered the interior, drying up stomach fluids, and the patient craves water for moistening. Only in cases where there is stasis of blood in the Upper Jiao and accumulation of blood in the Lower Jiao, causing lung dryness and thirst, does the symptom present as desiring to swish but not swallow. The principle of "swishing water without swallowing" applies exclusively to blood disorders. In Yangming disease, presenting with body heat, headache, dry mouth, desiring to swish water but not swallow, epistaxis will inevitably occur. For those with a faint pulse (use Xijiao Dihuang Tang [Rhinoceros Horn and Rehmannia Decoction], Maohua Tang [Cattail Flower Decoction]); if there are no exterior symptoms, no aversion to cold or fever, chest and abdominal fullness, dry lips and mouth, desiring to swish water but not swallow, and frequent urination, this indicates blood stasis, which will inevitably lead to mania. For mild cases (use Xijiao Dihuang Tang, Taoren Chengqi Tang [Peach Kernel and Rhubarb Decoction]), and for severe cases (use Didang Wan [Hit-and-Kill Pill]), until black material is completely expelled.

Wu stated: In Shaoyin disease, if the pulse is deep and fine, hands and feet are cold, and occasionally there is irritability and thirst with a desire to swish water but not swallow, Sini Tang [Counterflow Decoction] should be used to warm. In cases of diarrhea, cold limbs, absence of pulse, dry retching, irritability, thirst, and a desire to swish water but not swallow, Baitong Jia Zhuy Danzi Renshen Tang [Aconite Root Plus Pig Gallbladder and Human Urine Decoction] is indicated. In Jueyin disease, specifically Huijue (roundworm syncope), with Taiyang-Shaoyin complex presenting irritability, vomiting roundworms, dry mouth and tongue, desiring only to soak the tongue and lips in cool water without swallowing, Lizhong Tang [Regulate the Middle Decoction] plus Wumei [Mume Fruit] is indicated. Generally, in Yin syndromes, irritability and thirst preventing drinking, or drinking reluctantly followed by vomiting after a long time, or drinking leading to vomiting or hiccups, all indicate internal cold. This is due to rootless, unanchored fire wandering between the throat and pharynx, feigning irritability, thus preventing drinking; conversely, if one can drink without vomiting and desires more, it indicates heat.

Cheng Wuji stated: Epistaxis refers to bleeding from the nose. In miscellaneous diseases, epistaxis originates from the interior; in Shanghan (Cold Damage), it originates from the exterior. The *Bingyuan* states: The Heart governs blood, the Liver stores blood, the Lung governs Qi and opens into the nose. When blood is heated and rises with Qi, it exits through the nose, termed epistaxis. Therefore, epistaxis in miscellaneous diseases is attributed to interior heat. The Classic states: "In Shanghan, if the pulse is floating and tight, and sweating is not induced, epistaxis may result," treated with Mahuang Tang [Ephedra Decoction]. In Shanghan, after six or seven days, if there is constipation, headache, and fever, Xiaochengqi Tang [Minor Order the Middle Decoction] is given; if urine is clear, the disease is not in the interior but remains in the exterior, requiring sweating. If there is headache, epistaxis will likely occur, and Guizhi Tang [Cinnamon Twig Decoction] is appropriate. Thus, epistaxis in Shanghan is attributed to exterior heat. Although epistaxis involves heat in the channels, there are instances where sweating is contraindicated. The Classic states: "Epistaxis prohibits sweating"; if mistaken, the forehead may sink, the pulse becomes urgent, eyes stare fixedly without blinking, and insomnia occurs. The previously mentioned Guizhi Tang and Mahuang Tang indications were not specifically for treating epistaxis, but rather to disperse pathogenic factors in the channels, preventing them from congesting and forcing blood to move recklessly upward. Epistaxis is due to heat, not cold, hence there is no epistaxis in the Three Yin channels. The Shaoyin disease chapter states: "If there is only cold limbs and no sweat, and forced sweating is applied, blood will be disturbed, possibly exiting from the mouth, nose, or eyes; this is called Lower Cold and Upper Exhaustion, a fatal condition," which is distinct from simple epistaxis. Furthermore, epistaxis accompanied by head sweat only, no body sweat, or sweat not reaching the feet, are also fatal signs. In Taiyang Shanghan, if the pulse is floating and tight, and failure to sweat leads to epistaxis, Mahuang Tang is indicated. (*Huoren Shu* notes: After epistaxis, if the pulse is floating, Mahuang Tang is suitable; if the pulse is faint after epistaxis, Mahuang Tang is contraindicated, use Huangqin Shaoyao Tang [Peony and Scutellaria Decoction] instead). In Taiyang disease, if the pulse is floating and tight, with no sweat, fever, and body pain persisting for eight or nine days without resolution, and exterior symptoms remain, sweating should be induced. After taking medicine, if symptoms slightly improve but the patient becomes irritable and closes their eyes unwillingly, severe cases will experience epistaxis and then resolve, due to heavy Yang qi congestion. Mahuang Tang is indicated.

Zhang Jingyue asked: The Classic states "those prone to epistaxis should not be sweated," as sweating causes the forehead to sink. Why is Mahuang Tang added to formulas for epistaxis? In Taiyang disease, with floating-tight pulse, fever, and no sweat, spontaneous epistaxis leads to cure; this is a fixed rule. Why use Mahuang Tang to induce sweat again? Does Zhang Zhongjing contradict himself? Actually, the phrase "Mahuang Tang is indicated" in the previous clause should follow "sweating should be induced." This follows Han dynasty textual conventions where prescriptions were appended at the end of clauses. For example, in Daqinglong Tang [Major Green Dragon Decoction] syndrome, it states "if pulse is weak, with sweat and aversion to wind, do not administer," as doing so causes cold limbs, muscle twitching, and tremors, which is adverse; yet it concludes with "Daqinglong Tang is indicated." This is the same example.

In Taiyang Wind Strike, if fire therapy is used to induce sweat, evil wind combined with fire heats the body, causing jaundice; Yang excess leads to desire for epistaxis, Yin deficiency leads to difficult urination, head sweat, abdominal fullness, slight wheezing, dry mouth, sore throat, or constipation, delirium, and in severe cases, hiccups, picking at clothes, and bed sheets. If urine flows freely, it is treatable (see Jaundice section). In Taiyang disease, if the pulse is floating and tight, with fever, no sweat, and epistaxis, the disease resolves spontaneously.

Yangming disease, with dry mouth desiring to swish water but not swallow, inevitably leads to epistaxis. (Cheng Wuji's commentary: The Yangming channel starts at the nose and connects to the mouth. Interior Yangming heat causes thirst for drinking; here, dry mouth with desire to swish but not swallow indicates heat in the channels without interior heat. Yangming has abundant Qi and Blood; severe heat in the channels forces reckless blood movement, causing epistaxis. One should address the heat with Huangqin Shaoyao Tang, and epistaxis will resolve.) With floating pulse, fever, dry mouth, dry nose, and ability to eat, epistaxis will occur (use Huangqin Tang [Scutellaria Decoction]).

Shaoyin disease, presenting only with cold limbs and no sweat, if forced sweating is applied, blood will be disturbed, exiting from mouth, nose, or eyes; this is called Lower Cold and Upper Exhaustion, difficult to treat.

Contraindications: Those prone to epistaxis must not be sweated; if sweated, the forehead will sink, pulse becomes urgent, eyes stare fixedly without blinking, and insomnia occurs. (Epistaxis prohibits sweating due to absent pulse; however, if pulse is floating-tight with body pain, fever, and aversion to cold, careful examination is required.) In Dongqi [Moving Qi] syndrome, inducing sweat causes epistaxis and thirst, and drinking leads to vomiting (see Moving Qi).

Appendix:
Li Shizhen stated: Zhang Zhongjing said epistaxis prohibits sweating for those with faint pulses. If the pulse is floating-tight, use Mahuang Tang; if floating-slow, use Guizhi Tang. If the pulse is already faint, neither drug should be used; instead, use Xijiao Dihuang Tang. (Zhang Zhongjing stated: Those prone to epistaxis must not be sweated, as sweating causes forehead sinking, tight pulse, fixed staring, and insomnia; also, those who have lost blood must not be treated with exterior-releasing methods, as sweating causes chills and trembling. Both statements refer to pulses being too faint for sweating. If the pulse is floating-tight or floating-slow, sweating is appropriate.)

Zhu Gong stated: In Shanghan epistaxis, if the pulse is faint, use Huangqin Shaoyao Tang or Xijiao Dihuang Tang.

Xijiao Dihuang Tang: Treats Shanghan where sweating was indicated but not performed, resulting in interior blood stasis, epistaxis, hematemesis, yellow complexion, and black stool. This formula digests blood stasis.
Shaoyao [Peony Root] (1 liang), Shengdihuang [Raw Rehmannia Root] (1.5 liang), Mudanpi [Tree Peony Bark], Xijiao [Rhinoceros Horn] (2.5 qian each, shaved). Coarsely crush. Take 5 qian per dose, add 1.5 cups of water, boil to 1 cup, strain. If heat and manic behavior occur, add Huangqin [Scutellaria Root] (1 liang). If the pulse is large but slow, and the abdomen is not full though the patient claims fullness, there is no heat, so do not use Huangqin.

Maohua Tang: Treats persistent epistaxis. Use one handful of cattail flower tips, add 3 cups of water, decoct strongly to obtain 1 cup of juice, divide into two doses. Cure. If flowers are unavailable, use roots. If epistaxis is accompanied by thirst, irritability, and vomiting after drinking, first administer Wuling San [Five-Ingredient Powder with Poria], then Zhugen Tang [Bamboo Root Decoction].

Huashi Wan [Talcum Pill]: Treats Shanghan epistaxis.
Huashi [Talcum] powder, amount unspecified, pill with rice paste like wisteria seeds. Take 10 pills per dose, chew slightly, swallow with fresh water. Stops immediately. Alternatively, take 1 qian of powder with a little rice, chew together. Suitable for all ages. Tang Hui shu stated: Epistaxis results from failing to sweat when indicated; the blood is dark/black and stops eventually. Mild medicines should be taken to harmonize the Wei Qi. If bright red blood appears, treat urgently with this medicine.

Dai Yuanli stated: Ancient theories attribute epistaxis to Taiyang Wind-Cold. If exterior symptoms persist after epistaxis, use Mahuang Tang for Cold patterns and Guizhi Tang for Wind patterns. Irritability and eye closure indicate severe cases leading to epistaxis. Since irritability and eye closure occur, it cannot be solely Taiyang; the Yangming channel circulates around the nose, indicating Taiyang invading Yangming, making both sweating and purging difficult. If heat persists after epistaxis, Shengma Gegen Tang [Kudzu and Cimicifuga Decoction], Baidu San [Eliminate Toxicity Powder], or Yangdan Tang [Yang Morning Decoction] are stable choices. For epistaxis with irritability/thirst and vomiting after drinking, first use Wuling San, then Zhuye Shigao Tang [Bamboo Leaf and Gypsum Decoction]. For massive epistaxis, use Maohua Tang or Huangqin Shaoyao Tang plus cattail flowers. If Shaoyin disease is initially misdiagnosed and treated with stopping-sweat methods, forcing blood to move recklessly, causing epistaxis from nose, mouth, ears, or eyes, combined with Yang sinking into Yin and cold limbs, if the doctor treats the cold limbs as exterior Cold and induces sweat, leading to blood disturbance, this is Lower Cold and Upper Rebellion, difficult to treat. Ancients said: "Once Guizhi enters the throat, Yang excess leads to death." This is precisely the meaning. Essentially, lack of thorough sweating is Yang epistaxis; mistaken sweating is Yin epistaxis; these are very different. Also stated: If Yang Qi is deficient and Yin is deficient, sweating leads to death.

Tao Hua stated: For Shanghan epistaxis flowing continuously, stir-fry Gardenia [Zhizi] until black, grind to fine powder, insufflate into nostrils, and apply wet grass paper over the nose; bleeding stops. For dripping flow, the pathogen is in the channels, not addressed by this method. Use ink juice or burnt Chinese Gallnut [Wubeizi], administered orally or insufflated. Alternatively, needle Quchi [LI11] and Hegu [LI4] to drain.

Wu Kun stated: For hematemesis and epistaxis without exterior symptoms and non-floating-tight pulses, do not induce sweating. Dongyuan stated: Faint pulse suits Huangqin Shaoyao Tang; slippery-rapid pulse suits Xijiao Dihuang Tang. If heat is excessive and bleeding continues, Hejian Dihuang San [Rehmannia Powder] or ancient Sisheng Wan [Four Generations Pill]; for blood deficiency, Dongyuan's Maidong Yin [Ophiopogon Drink] or Sanhuang Buxue Tang [Three Yellows Blood-Nourishing Decoction]. If bleeding continues, Huoren's Qigen San [Rubia Root Powder] or Maohua Tang. These are excellent formulas for hematemesis and epistaxis, adaptable in usage. Generally, for hematemesis/epistaxis, small/slippery pulses indicate life, large/firm pulses indicate death. Post-hemorrhage faint pulse is easy to treat; excessive heat with rapid pulse is fatal. Head sweat or body sweat not reaching feet during epistaxis is difficult to treat. Blood moves with heat, coagulates with cold, and stops when black. Therefore, adding good Beijing Ink [Jingmo] to Xijiao Dihuang Tang turns the medicine black, which is most effective. Tao Shangwen once treated a patient with Shanghan for four to five days with continuous hematemesis. Doctors used Xijiao Dihuang Tang and Maohua Tang, worsening the condition. Tao felt the pulse: floating-tight and rapid, and administered Mahuang Tang. One dose induced sweat and cured. This truly reflects Zhang Zhongjing's methodology. If the pulse is not floating-tight but rapid, this method is inappropriate.