bubble_chart Concept

Epistaxis, which refers to bleeding from the nose, falls within the scope of nosebleeds. Lingshu, Baibing Shisheng states: "Damage to the yang collateral causing external bleeding, when blood overflows externally, it results in nosebleeds."

If epistaxis does not stop, it is also called nasal hemorrhage; excessive nosebleeds, overflowing into the mouth, with both the nose and mouth bleeding, is called cerebral nosebleed (Xiezheng Lun); if it becomes severe with bleeding from the mouth, nose, and ears, it is called major nosebleed (Zhubing Yuanhou Lun). In cold-damage disease, Taiyang disease with fever without sweating leading to epistaxis, the nosebleed resolves the exterior condition, known as spontaneous nosebleed ("Cold-Damage Disease Treatise"). If categorized by disease cause, there are seasonal epidemic nosebleeds, cold-damage disease nosebleeds, warm disease nosebleeds, etc. (Zhubing Yuanhou Lun). For taiyang cold-damage disease with spontaneous nosebleeds, later generations have referred to it as epistaxis, indicating that bloody sweating and nosebleeds share the same origin, where the pathogen is resolved through nosebleeds rather than sweating.

Epistaxis is associated with symptoms such as stuffy nose, dry nose, nasal soreness, nasal pain, and nasal discharge.

Women experiencing epistaxis during menstruation, with regular episodes, is a compensatory menstruation known as vicarious menstruation. Yizong Jinjian. Gynecology Essentials refers to it as menstrual nosebleeds and discusses it under a separate section.

bubble_chart Pattern Analysis

1. Wind-cold Resolving︰aversion to cold with fever, body pain, headache, without sweating, epistaxis with fever subsiding and symptoms alleviating, floating and tight pulse, thin tongue coating. Generally, the amount of epistaxis is not excessive and can stop spontaneously. It is caused by wind-cold stagnating in the taiyang, where external pathogens cannot be resolved through sweating but instead disturb the nasal orifice, using epistaxis as an outlet. Once epistaxis occurs, symptoms may alleviate, fever may subside, and epistaxis may cease on its own. Its characteristics include aversion to cold, without sweating, headache, body pain, and floating-tight pulse, presenting as an exterior cold pattern. Generally, no treatment is necessary. If epistaxis occurs while the exterior pattern persists, inducing sweating to release the exterior is appropriate, using Ephedra Decoction. For those with a yin deficiency constitution, manifesting as emaciation, physical weakness, restlessness, red tongue, etc., treatment should focus on nourishing yin while inducing sweating to release the exterior, using Ephedra, Ginseng and Peony Decoction. It must be emphasized that releasing the exterior with pungent-warm herbs is only suitable for cases of taiyang cold-damage disease where spontaneous epistaxis occurs but the exterior pattern remains unresolved; only then can it be applied.
2. Wind-heat Congesting the Lung︰Fever, sweating, thirst, sore throat, cough with scanty sputum, dry and painful nose, bright red bleeding in small amounts, floating and rapid pulse, tongue coating thin white and dry. It is caused by wind-heat stagnation in the exterior muscles, disturbing the nasal orifices. The fever is severe, with sweating and no aversion to cold, which can be distinguished from the pattern of wind-cold. Additionally, symptoms such as dry and painful nose, cough, sore throat, thirst, and rapid pulse indicate lung heat. The characteristic feature is that the fever does not subside after epistaxis. The treatment should focus on dispersing wind and clearing heat. The prescription is Mulberry Leaf and Chrysanthemum Decoction with added moutan bark and cogongrass rhizome to clear heat and cool blood.
3. Stomach Heat︰Dry and painful nose, heavy bleeding with bright red color, irritability, thirst with desire to drink, fetid mouth odor, rapid digestion with frequent hunger, severe constipation, yellow urine, red tongue with yellow coating, and surging rapid pulse. This is caused by excessive alcohol consumption or overindulgence in spicy and rich foods, leading to internal blazing stomach fire that disturbs and forces blood out. As stated in Jingyue Quanshu, "The Gate of Hemorrhagic Syndromes": "Internal heat is often the cause of epistaxis, mostly in the Yangming channel." Excessive stomach fire results in dry mouth, fetid mouth odor, and severe constipation. The treatment should focus on clearing stomach fire, using Sanhuang Heart-Draining Decoction with modifications.
4. Liver Fire Invading Lung︰Triggered by emotional agitation, the nosebleed is profuse with bright red blood and frequently recurs, accompanied by head distending pain, irritability, bitter taste in mouth, dry throat, fullness and discomfort in the chest and hypochondrium, red eyes, yellow urine, red tongue texture, and wiry-rapid pulse. It is caused by emotional frustration leading to liver depression transforming into fire, resulting in the liver failing to store blood. Hence, it often occurs after emotional agitation and is frequently associated with irritability. As stated in Yangke Xinde Ji, "Discourse on Sinusitis, Nasal Polyp, and Epistaxis": "Some cases are due to injury by the seven emotions, which internally stir the blood, causing it to overflow with the rising of qi." The up-flaming of liver fire invades the lung orifices, leading to nosebleeds that often recur and are characterized by symptoms of liver fire such as fullness and discomfort in the chest and hypochondrium, red eyes, head distending pain, dry throat, and bitter taste in mouth. The treatment principle should focus on clearing the liver and draining fire. The formula used may be Rhinoceros Horn and Rehmannia Decoction with additions such as Gentian, or Huanlong Decoction.
5. Spleen Failing to Control Blood︰Persistent nosebleeding with light red blood, recurrent episodes, easy to stop but also easy to recur, {|###|}complexion{|###|} lacking luster, poor appetite, {|###|}mental fatigue lack of strength{|###|}, shortness of breath and reluctance to speak, {|###|}abdominal distension and fullness loose stool{|###|}, {|###|}bland taste in mouth{|###|} tasteless, {|###|}palpitation{|###|} dizziness, {|###|}tongue texture{|###|} pale, pulse soggy, thin, and weak. Caused by {|###|}spleen deficiency{|###|} failing to control blood, leading to blood not following its normal pathway and spilling outward. It mostly manifests as the {|###|}pattern of spleen deficiency{|###|}, such as {|###|}complexion{|###|} lacking luster, poor appetite, {|###|}abdominal distension and fullness loose stool{|###|}, {|###|}mental fatigue lack of strength{|###|}, {|###|}bland taste in mouth{|###|} tasteless, pale tongue, and soggy, thin pulse as characteristics. Treatment focuses on {|###|}tonifying the spleen and replenishing qi{|###|} to control blood. The prescription is modified from Returning to Spleen Decoction.
6. Kidney Yin Deficiency︰The nosebleed is not excessive in amount, with bright red blood, occurring intermittently and recurring repeatedly. There is dry mouth and thirst, dizziness, dizzy vision, palpitation, tinnitus, soreness and weakness in the lower back and knees, vexing heat in the chest, palms and soles, flushed complexion, occasional night sweats, a thin and rapid pulse, and a red tongue texture. It is caused by congenital kidney deficiency or kidney injury due to overexertion, leading to yin deficiency with effulgent fire ascending and forcing blood out. Jingyue Quanshu states in the "Discussion and Treatment of Nosebleed": "Although nosebleeds are mostly caused by fire, those due to yin deficiency are particularly common, precisely because overexertion injures yin, leading to water failing to control fire, which most easily stirs the blood of the thoroughfare and conception vessels in the yin aspect." The syndrome is characterized by symptoms of kidney yin deficiency and exuberant ministerial fire, such as soreness and weakness in the lower back and knees, palpitation, vertigo, tinnitus, vexing heat in the chest, palms and soles, flushed complexion, night sweats, a red tongue, and a thin and rapid pulse. The treatment should focus on nourishing yin and reducing fire, using a modified Anemarrhena, Phellodendron, and Rehmannia Decoction with added cogongrass rhizome, yerbadetajo herb, and donkey-hide gelatin.
7. Yin Exhaustion and Yang Collapse︰Profuse epistaxis that does not stop, with heavy bleeding, and even bleeding from the mouth, nose, ears, teeth, or skin, accompanied by profuse sweating, pale complexion, open mouth and closed eyes, cold limbs, limp hands, urinary incontinence, unconsciousness, panting respiration, pale tongue texture, and a faint, barely perceptible pulse or an irregular, rapid, and large pulse. This is often seen in cases of massive hemorrhage, where bleeding is profuse and unstoppable, leading to qi collapse following blood loss. It represents the most severe and critical symptoms and signs of epistaxis. Due to yin exhaustion and yang collapse, the limbs become cold, profuse sweating occurs, respiration becomes panting, the complexion turns pale, and the mind loses control, resulting in unconsciousness, limp hands, urinary incontinence, open mouth and closed eyes, and a pulse that is faint and barely perceptible or irregular, rapid, and large, indicating a state of extreme deficiency and sudden collapse. The treatment principle should focus on restoring yang to save from collapse and tonifying qi to control bleeding. The recommended formulas are Dushan Tang (Ginseng Decoction) or Shenfu Longmu Tang (Ginseng, Aconite, Dragon Bone, and Oyster Shell Decoction) combined with Pulse-Reinforcing Powder with modifications.

Wind-cold resolving epistaxis and wind-heat congesting the lung epistaxis: Both syndromes are caused by external pathogens binding the exterior and disturbing the nasal orifices, hence presenting with floating pulse, thin white tongue coating, and fever as exterior pattern. The epistaxis in these cases is not profuse, and the condition is mild and easy to treat.

Intense stomach fire epistaxis and liver fire invading the lung epistaxis: Both syndromes are caused by intense fire-heat flaring upward, scorching the yang collaterals, and forcing blood to spill outward, presenting as yang-heat interior excess syndrome. Symptoms include profuse nosebleeds with bright red blood, irritability, thirst, yellow urine, rapid pulse, and red tongue.

Spleen failing to control blood epistaxis and kidney yin deficiency damaging epistaxis: Both syndromes are caused by constitutional weakness or prolonged illness leading to deficiency, hence the nosebleeds, though not profuse, are prone to recurrent episodes triggered by factors such as fatigue.

Epistaxis presents with a variety of clinical symptoms and signs. Wind-cold resolving and wind-heat congesting the lung are seen in exterior pattern, caused by external contraction. The others are interior syndromes. For interior pattern epistaxis, differentiation based on disease cause: those with a history of alcohol consumption or spicy food intake are often stomach fire epistaxis; those with emotional factors are often liver fire epistaxis; those triggered by fatigue are often spleen deficiency or kidney deficiency epistaxis; those caused by massive blood loss often progress to yin exhaustion and yang collapse epistaxis. In terms of disease progression, wind-cold, wind-heat, stomach fire, liver fire, and yin exhaustion and yang collapse epistaxis have an acute onset, while spleen deficiency and kidney deficiency epistaxis have a slower onset. In terms of the amount of nosebleed, stomach fire, liver fire, and yin exhaustion and yang collapse epistaxis involve profuse bleeding, with yin exhaustion and yang collapse being the most severe.

bubble_chart Documentation

1. Shanghai Lun-Shaoyin Disease, Pulse, Pattern, and Treatment: "In shaoyin disease, there is only cold extremities without fever, and if one forcefully expels the pathogen from the exterior, it will inevitably disturb the blood. It is uncertain through which pathway the blood will exit; it may come out from the mouth and nose, or from the eyes. This condition is known as lower cold and upper exhaustion, and it is difficult to treat."