Library

For epistaxis caused by miscellaneous diseases, the pathology is attributed to heat in the interior; for epistaxis caused by Cold Damage (Shanghan), the pathology is attributed to heat in the exterior. The *Treatise* states: In a patient with Cold Damage, if the urine is clear, it indicates that the pathogen is not in the interior but remains in the exterior, and sweating therapy should be employed; if accompanied by headache, epistaxis will inevitably occur, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. It also states: In a patient with Cold Damage presenting with a floating and tight pulse, if sweating was not induced initially leading to epistaxis, Mahuang Tang (Ephedra Decoction) should be used. This explains that epistaxis in Cold Damage occurs because the heat is not in the interior but in the exterior. However, the *Treatise* also states: Patients who are prone to epistaxis (Nujia) should not undergo sweating therapy. Then why are Guizhi Tang and Mahuang Tang repeatedly used? Generally speaking, epistaxis resulting from Yin deficiency is due to hyperactivity of fire caused by Yin deficiency, so further sweating should be avoided to prevent the loss of Yin fluids; epistaxis resulting from unresolved exterior pathogens requires the use of Guizhi Tang or Mahuang Tang to disperse the exterior. Furthermore, the *Treatise* states: In Taiyang disease, if the pulse is floating and tight, there is fever, no sweating, and spontaneous epistaxis occurs, the disease resolves. This is because the exterior pathogen is about to resolve; instead of exiting through sweat, it exits through blood, commonly known as "red sweat," so the disease heals after epistaxis. From this, we can see that some cases heal via epistaxis because the meridians become unblocked and the pathogen disperses; in other cases, treatment still requires dispersion because the pathogen is resolving but not yet fully resolved, aiming to scatter residual pathogens. Thus, the methods for treating epistaxis are evident here. If the cold pathogen is not severe, using Mahuang or Guizhi might be too harsh; alternatively, using herbs like Chaihu (Bupleuri Radix) or Gegen (Puerariae Lobatae Radix) would be perfectly acceptable, leaving the choice to the practitioner's discretion.

The *Treatise* states: In Yangming disease, if the mouth feels dry and the patient desires only to rinse water in the mouth without swallowing, epistaxis will inevitably occur. This is because the Yangming meridians connect to the mouth and nose; when the patient rinses water but does not swallow, it indicates heat in the meridians but no heat in the interior, leading to nasal bleeding.

1. There is a condition involving the disturbance of Yin blood, which is distinct from typical epistaxis. The *Treatise* states: In Shaoyin disease, if there is only cold extremities without sweating, and sweating is forcibly induced, it will inevitably disturb the blood. It is unknown from which orifice the blood will exit; thus, it may flow from the mouth and nose or from the eyes. This is termed "Lower Jue and Upper Exhaustion." This involves damage to Yin blood and constitutes a critical syndrome.

Cold Damage with Blood Stasis (Xuxue) occurs when heat binds in the interior, contends with the blood level, and causes stasis to remain stagnant in the Lower Jiao without moving. The *Treatise* states: In a patient with Cold Damage who has fever and abdominal fullness, one should expect difficulty in urination; however, if urination is actually free, it indicates the presence of blood stasis. It also states: In Taiyang disease, if the body is yellow, the pulse is deep and knotted, and the lower abdomen is hard, but urination is difficult, there is no blood stasis. If urination is free and the patient exhibits a manic-like state, the diagnosis of blood stasis is confirmed. Generally, heat accumulating in the blood level and binding in the Lower Jiao generates mania and restlessness, as stated in the *Treatise*: "Heat binding in the Bladder, causing the patient to act like a madman." Additionally, there are Yangming symptoms where the patient suffers from forgetfulness; although the stool is hard, defecation is surprisingly easy, and the color is black; this is also a sign of blood stasis. Therefore, whenever diagnosing Cold Damage, if the lower abdomen is hard, full, and painful, one must inquire about urination. If urination is free, it indicates blood stasis, because urination depends on Qi transformation; since the pathology is in the blood level rather than the Qi level, urination remains normal. For stasis located in the lower part, removing the stasis leads to recovery. According to Zhang Zhongjing's methods, Didang Tang (Must-Drain Decoction) or Didang Wan (Must-Drain Pill) are the primary treatments. I suggest that using Chengqi-class formulas added with Taoren (Persicae Semen) and Honghua (Carthami Flos) to purge stasis, or using Yuzhu San (Jade Candle Powder) to purge in cases with concomitant deficiency, will naturally eliminate blood stasis, ensuring the disease is cured.

Cheng Wuji stated: Epistaxis in Cold Damage occurs because the pathogen cannot be dispersed, becomes congested in the meridians, forces the blood to move recklessly, and thus causes epistaxis. Blood stasis refers to aggregation in the Lower Jiao that fails to move or dissipate. Blood stagnating in the upper part causing hematemesis is called "Bo Jue" (Thin Quake); stasis remaining in the lower part is called "Xuxue" (Accumulated Blood). These result from heat-stasis in the Taiyang meridian binding in the interior and accumulating in the Lower Jiao.

The *Classic* states: After seven or eight days of Taiyang disease, if the exterior syndrome persists, the pulse is deep and faint, and contrary to expectations, no Jie Xiong (Chest Binding) has formed, but the patient acts like a madman, it is because heat is in the Lower Jiao. The lower abdomen should be hard and full. If urination is free, purging blood will lead to recovery.