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This syndrome belongs to Yangming disease. Generally, those with internal heat desire to drink water; now, although drinking water, there is no desire to swallow, indicating that the heat is in the meridians while the interior (stomach and intestines) lacks heat. The Qi and Blood of the Yangming meridian are abundant; when heat within the meridian becomes severe, it forces blood to move recklessly, thus knowing that epistaxis (nosebleed) will inevitably occur. Yang Renzhai stated: Dry lips and dry mouth are common manifestations of blood syndromes, where patients definitely desire to take water to rinse their mouths. However, why rinse without swallowing? Generally, thirst leading to drinking occurs because Yang-heat enters the interior, drying up stomach fluids, causing the patient to crave water for moistening. Only in cases where there is stasis in the Upper Jiao and accumulation of blood in the Lower Jiao, leading to lung dryness and thirst, does one see rinsing without desire to swallow. The rule regarding "rinsing water without swallowing" applies only to blood syndromes. In Yangming disease, manifesting as body heat, headache, dry mouth, desire to rinse but not swallow, epistaxis will inevitably occur. For those with a faint pulse (use Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction], Maohua Tang [Thrush Flower Decoction]); for those without exterior syndrome, without aversion to cold or fever, with chest and abdominal fullness, dry lips, dry mouth, desire to rinse but not swallow, and polyuria, this is blood stasis, inevitably leading to mania. For mild cases (use Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction], Tao Ren Chengqi Tang [Peach Kernel and Rhubarb Decoction]), and for severe cases (use Didang Wan [Siege Pill]), until black clots are expelled.

Wu stated: In Shaoyin disease, with a deep and fine pulse, cold hands and feet, and occasional irritability, thirst, and desire to rinse water without swallowing, Si Ni Tang [Frigid Extremities Decoction] should be used to warm. If accompanied by diarrhea, cold extremities, absence of pulse, dry heaving, irritability, thirst, and desire to rinse water without swallowing, Baitong Jia Zhuzhi Renshen Tang [Aconite Root, Scallin, and Pig Gallbladder and Human Urine Decoction] is indicated. In Jueyin disease, specifically Huizhi (ascaris-related cold extremities), with Shanghan irritability, vomiting of ascaris, dry mouth and tongue, desiring only cool water to wet the tongue and lips without swallowing, Lizhong Tang [Regulate the Middle Decoction] with Wumei [Mume Fruit] is indicated. Generally, Yin syndromes presenting with irritability, thirst, inability to drink, or vomiting after prolonged retention of ingested water, or vomiting immediately upon drinking, or hiccups, indicate internal cold. This is due to rootless, unanchored fire wandering between the throat and esophagus, feigning irritability, thus preventing drinking; if one can drink without vomiting and desires more, it indicates excess heat.

Cheng Wuji stated: Epistaxis refers to bleeding from the nose. In miscellaneous diseases, epistaxis originates from the interior; in Shanghan, 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, constipation, headache, and fever occur," treat with Xiao Chengqi Tang [Minor Order the Qi Decoction]; if urine is clear, the disease is not in the interior but remains in the exterior, requiring sweating. If headache occurs, epistaxis is likely, and Guizhi Tang [Cinnamon Twig Decoction] is suitable. Thus, epistaxis in Shanghan is attributed to exterior heat. Although epistaxis indicates heat in the meridians, there are cases where sweating is contraindicated. The classic states: "Epistaxis contraindicates sweating"; if sweating is forced, it leads to sunken forehead, tight pulse, fixed gaze, inability to blink, and insomnia. The previously mentioned Guizhi Tang and Mahuang Tang indications were not for treating epistaxis itself, but for dispersing pathogenic factors in the meridians to prevent them from congesting and forcing blood upward recklessly. Epistaxis involves heat without cold; therefore, the Three Yin meridians do not experience epistaxis. The *Shaoyin Disease* chapter states: "Only cold extremities without sweat; if forcibly sweated, blood will be disturbed, exiting from the mouth, nose, or eyes," termed Xiajue Shangjie [Lower Cold and Upper Exhaustion], which is a death syndrome, distinct from ordinary epistaxis. Additionally, epistaxis with only head sweating and no body sweat, or sweat failing to reach the feet, are also death signs.

In Taiyang Shanghan, with a floating and tight pulse, failure to sweat leading to epistaxis, Mahuang Tang [Ephedra Decoction] is indicated. (*Huoren* states: After epistaxis, if the pulse is floating, use Mahuang Tang [Ephedra Decoction]; if the pulse is faint after epistaxis, Mahuang Tang [Ephedra Decoction] is contraindicated; use Huangqin Shaoyao Tang [Scutellaria and Peony Decoction] instead.) In Taiyang disease, with a floating and tight pulse, no sweat, fever, and body pain persisting for eight or nine days without resolution, with exterior signs remaining, sweating is indicated. After medication, symptoms slightly alleviate, but the patient experiences vexation and closed eyes; in severe cases, epistaxis occurs, followed by resolution. This is due to heavy Yang qi stagnation. Mahuang Tang [Ephedra Decoction] is indicated.

Zhang Jingyue asked: The classic states "those prone to epistaxis must not be sweated," as sweating causes sunken foreheads. Why is Mahuang Tang [Ephedra Decoction] added to formulas for epistaxis? In Taiyang disease, with floating and tight pulse, fever, and no sweat, spontaneous epistaxis leads to cure—a fixed principle. Why repeat Mahuang Tang [Ephedra Decoction] to induce sweating? Does Zhongjing contradict himself? However, the phrase "Mahuang Tang [Ephedra Decoction] is indicated" in the previous clause should follow "when sweating is required." This follows Han dynasty syntax, where prescriptions are appended at the end of clauses. For example, in Da Qinglong Tang [Major Green Dragon Decoction], it states "if pulse is weak, sweat is present, and aversion to wind exists, do not administer"; if administered, it causes cold extremities and muscle twitching, which is an error. Yet it concludes with "treat with Da Qinglong Tang [Major Green Dragon Decoction]," following this same pattern.

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

In Yangming disease, dry mouth with desire to rinse but not swallow indicates inevitable epistaxis. (Cheng Wuji notes: The Yangming meridian originates at the nose and connects to the mouth. Interior Yangming heat causes thirst for drinking; here, dry mouth with desire to rinse but not swallow indicates heat in the meridian without interior heat. Yangming has abundant Qi and Blood; severe meridian heat forces reckless blood movement, causing epistaxis. Address the heat with Huangqin Shaoyao Tang [Scutellaria and Peony Decoction]; epistaxis leads to resolution.) Floating pulse, fever, dry mouth, dry nose, and ability to eat indicate impending epistaxis (use Huangqin Tang [Scutellaria Decoction]).

In Shaoyin disease, only cold extremities without sweat; if forcibly sweated, blood is disturbed, exiting from mouth, nose, or eyes, termed Xiajue Shangjie [Lower Cold and Upper Exhaustion], which is difficult to treat.

Contraindications: Those prone to epistaxis must not be sweated; sweating causes sunken forehead, tight pulse, fixed gaze, inability to blink, and insomnia. (Epistaxis contraindicates sweating due to absent pulse; if pulse is floating and tight with body pain, fever, and aversion to cold, careful observation is needed.) Dongqi syndrome contraindicates sweating; sweating causes epistaxis, thirst, and vomiting upon drinking (see Dongqi).

Li Shizhen stated: Zhongjing's statement that epistaxis contraindicates sweating applies to faint pulses. If the pulse is floating and tight, use Mahuang Tang [Ephedra Decoction]; if floating and slow, use Guizhi Tang [Cinnamon Twig Decoction]; if the pulse is faint, neither is applicable; use Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction]. (Zhongjing stated: Those prone to epistaxis must not be sweated; sweating causes sunken forehead, tight pulse, fixed gaze, inability to blink, and insomnia; also, those who have lost blood must not have their exterior released; sweating causes chills and tremors. Both sayings apply to faint pulses where sweating is contraindicated. If the pulse is floating and tight or floating and slow, sweating is appropriate.)

Zhu Gong stated: In Shanghan epistaxis, if the pulse is faint, use Huangqin Shaoyao Tang [Scutellaria and Peony Decoction] or Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction].

Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction]: Treats Shanghan where sweating was indicated but not performed, resulting in internal blood stasis, epistaxis, hematemesis, yellowish complexion, and black stool. This formula digests blood stasis.
Shaoyao [Peony Root] (1 liang), Sheng Dihuang [Raw Rehmannia Root] (1.5 liang), Mudanpi [Tree Peony Bark], Xijiao [Rhino Horn] (2.5 qian each, shaved). Chop ingredients. Take 5 qian per dose, add 1.5 cups of water, decoct to 1 cup, strain. If heat-like madness occurs, add Huangqin [Scutellaria Root] (1 liang). If the pulse is large but slow, abdomen is not full but patient claims fullness, there is no heat; do not use Huangqin [Scutellaria Root].

Maohua Tang [Thrush Flower Decoction]: Treats persistent epistaxis. Use one handful of thrush flower tips, add 3 cups of water, decoct strongly to 1 cup, divide into two doses for immediate cure. If flowers are unavailable, use roots. If epistaxis is accompanied by thirst, vexation, and vomiting upon 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, made into pills the size of paulownia seeds with rice paste. Take 10 pills per dose, chew slightly, swallow with fresh water for immediate cessation. Alternatively, take 1 qian of powder with a little rice, chew together. Suitable for all ages. Tang Huishu stated: Epistaxis results from failure to sweat when indicated; the blood is dark blue-black and stops regardless of volume. Use mild medicines to harmonize the Defensive Qi. Upon seeing fresh blood, treat urgently with this medicine.

Dai Yuanli stated: Ancient theories attribute epistaxis to Taiyang Wind-Cold. If exterior signs remain after epistaxis, use Mahuang Tang [Ephedra Decoction] for Cold and Guizhi Tang [Cinnamon Twig Decoction] for Wind. It is stated that severe vexation and eye closure lead to epistaxis. Since vexation and eye closure occur, it is not purely Taiyang, involving the Yangming meridian which circles the nose, indicating Taiyang invading Yangming, making 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 Dawn Decoction] are stable choices. For epistaxis with vexation/thirst and vomiting upon drinking, first use Wuling San [Five-Ingredient Powder with Poria], then Zhuye Shigao Tang [Bamboo Leaf and Gypsum Decoction]. For massive epistaxis, use Maohua Tang [Thrush Flower Decoction] or Huangqin Shaoyao Tang [Scutellaria and Peony Decoction] with a pinch of thrush flowers. If Shaoyin disease is initially misdiagnosed and treated with stopping-sweat methods, forcing blood to move recklessly and causing epistaxis from nose, mouth, ears, or eyes, combined with Yang sinking into Yin and cold extremities, if the physician treats the cold extremities as exterior Cold and induces sweating (instead of purging), causing blood disturbance, this is Xiajue Shangni [Lower Cold and Upper Rebellion], which is difficult to treat. Ancients stated: "Once Guizhi Tang [Cinnamon Twig Decoction] enters the throat, if Yang is excessive, death ensues." This is precisely the meaning. Essentially, epistaxis without complete sweating is Yang epistaxis; epistaxis caused by erroneous sweating is Yin epistaxis; these are vastly different. It is also said that in Yang deficiency and Yin exhaustion, sweating leads to death.

Tao Hua stated: For Shanghan epistaxis becoming continuous flow, stir-fry Gardenia [Gardeniae Fructus] until black, grind to fine powder, insufflate into nostrils, and apply wet grass paper over the nose to stop bleeding. Differentiate between dripping and flowing. If the pathogen is in the meridian, this method is not applicable. Use ink juice or calcined Chinese Gallnut [Galla Chinensis] ash, either orally or insufflated. Or prick Quchi [LI11] and Hegu [LI4] acupoints to drain.

Wu Kun stated: For hematemesis and epistaxis without exterior signs and non-floating/tight pulses, sweating is contraindicated. Dongyuan stated: For faint pulses, use Huangqin Shaoyao Tang [Scutellaria and Peony Decoction]; for slippery and rapid pulses, use Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction]. For excessive heat and unceasing bleeding, use Hejian Dihuang San [Rehmannia Powder] or ancient Sisheng Wan [Four Generations Pill]. For blood deficiency, use Dongyuan Maidong Yin [Ophiopogon Drink] or Sanhuang Buxue Tang [Three Yellows Blood-Nourishing Decoction]. If bleeding continues, use Huoren Qigen San [Qilian Root Powder] or Maohua Tang [Thrush Flower Decoction]. These are excellent formulas for hematemesis and epistaxis, requiring flexible application. Generally, for hematemesis and epistaxis, slippery and small pulses indicate survival; solid and large pulses indicate death. After vomiting or epistaxis, faint pulses are easy to treat; if heat increases and pulse becomes rapid and urgent, death ensues. If epistaxis is accompanied by head sweating or body sweat failing to reach the feet, it is difficult to treat. Blood moves with heat, coagulates with cold, and stops when black. Therefore, adding good Beijing Ink [Carbon Black] to Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction] to darken the medicine is most effective. Tao Shangwen once treated a patient with Shanghan for four to five days with continuous hematemesis. Doctors used Xijiao Dihuang Tang [Rhino Horn and Rehmannia Decoction] and Maohua Tang [Thrush Flower Decoction], worsening the condition. Tao palpated a floating, tight, and rapid pulse, and administered Mahuang Tang [Ephedra Decoction]; one dose induced sweating and cure. This reflects mastery of Zhongjing's principles. If the pulse is not floating and tight but rapid, this method is inappropriate.