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Guest said, "The theory of distinguishing true from false is extremely refined. How can I distinguish the false and identify it? And how can I differentiate between cold damage (Shanghan) and kidney deficiency?"

I replied, "This cannot be spoken lightly. To desire to know through observation, one can only encounter it with the spirit (Shen), not merely with the eyes. To desire to know through listening, one can only listen with Qi, not merely with the mind. To desire to know through inquiry, one can only comprehend with intention, not merely transmit with words. To desire to know through pulse diagnosis, it must be understood in the heart and responded to by the hand; skill lies within the individual, a father cannot transmit it to his son. If you insist on my speaking, I will speak tentatively. I distinguish primarily through the tongue. For those with excess heat, the tongue coating must be dry and scorched, even turning black in severe cases. For those with false heat, although there is a white coating, it must be slippery; although the mouth feels thirsty, they cannot drink water, or if they do, only one or two sips, and in severe cases, they vomit it up shortly after. Although the face may appear red, the color must be delicate and tender. The body feels restless, yet they wish to sit or lie in mud or water. This is the method of differentiation.

Cold damage (Shanghan): Cold enters from below. This condition is common in women. With constipation of both stool and urine, one dose brings recovery. This is an acute illness. Kidney Yin deficiency: Both stool and urine are free. Vomiting of phlegm is profuse. This indicates extreme deficiency of Yin fire failing to function properly. It cannot be cured in one or two doses. It occurs in both men and women. Even if the floating fire is guided back to its source, one must use Ren Shen (Ginseng Root) to tonify Yang while simultaneously tonifying Yin, requiring months or years of regulation. If sexual desires are not restrained, death is inevitable. What I have transmitted is but dregs. What I hope for you is to grasp the meaning and forget the words; then you will truly understand.

In treating blood disorders, regulation before and after must follow the meridians of the Heart, Spleen, and Liver. The Heart governs Blood, the Spleen envelops Blood, and the Liver stores Blood. Gui Pi Tang (Restore the Spleen Decoction) is a formula for these three meridians. Yuan Zhi (Polygala Root) and Suan Zao Ren (Ziziphus Seed) tonify the Liver to generate Heart Fire; Fu Shen (Poria with Hostwood) tonifies the Heart to generate Spleen Earth; Ren Shen (Ginseng Root) and Gan Cao (Licorice Root) tonify the Spleen to secure Lung Qi. Mu Xiang (Aucklandia Root) has an aroma that first enters the Spleen; the overall aim is to return Blood to the Spleen, hence the name 'Gui Pi' (Restore the Spleen). It is especially suitable for cases where anger injures the Spleen or overthinking injures the Spleen. If Fire is excessive, add Zhi Zi (Gardenia Fruit) and Mu Dan Pi (Moutan Cortex); if Fire is deficient, add Mu Dan Pi (Moutan Cortex) and Rou Gui (Cinnamon Bark). There is also Ba Wei Wan (Eight-Ingredient Pill) to cultivate the root of the congenital foundation. Thus, the treatment of blood disorders leaves no methods unexplored.

Xue Li Zhai once met the astrologer Zhang Donggu discussing fate. Walking out into the courtyard, he vomited one or two mouthfuls of blood, saying he had long suffered from this condition, which flared up upon exertion. I reasoned that this was Lung Qi injured by fatigue, causing Blood to scatter. Upon examination, this was indeed the case. I prescribed Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) plus Mai Dong (Ophiopogon Tuber), Wu Wei Zi (Schisandra Berry), Shan Yao (Dioscorea Rhizome), Shu Di Huang (Rehmannia Root), Fu Shen (Poria with Hostwood), and Yuan Zhi (Polygala Root). After taking it, he recovered. The next morning, he requested an audience, stating that previous treatments with Si Wu Tang (Four Substances Decoction), Huang Lian (Coptis Rhizome), and Zhi Zi (Gardenia Fruit) caused more bleeding and greater fatigue. With your single dose, the bleeding stopped instantly, and his spirit returned to normal. Why? Xue said: The Spleen controls Blood, and the Lung governs Qi. Fatigue injured the Spleen and Lung, causing Blood to move recklessly. Therefore, I used the aforementioned herbs to tonify Spleen and Lung Qi, exhaling Blood back to its origin.

A man suffered from coughing and vomiting blood, fever, thirst, profuse phlegm, night sweats, and spermatorrhea. I treated him with Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) modified with Mai Dong (Ophiopogon Tuber) and Wu Wei Zi (Schisandra Berry), and he recovered. Later, due to fatigue and anger, he suddenly vomited clots of purple blood. First, Hua Rui Shi San (Flower Ochre Stone Powder) was used to resolve the purple blood, followed by Du Shen Tang (Single Ginseng Decoction) for gradual recovery. Afterwards, exertion triggered one or two mouthfuls of hemoptysis. Pulses at the Spleen, Lung, and Kidney positions were all surging and rapid. Gui Pi Tang (Restore the Spleen Decoction) combined with Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) led to full recovery.

A fourteen-year-old boy presented with fever and hematemesis. I advised using Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) to nourish the source of transformation. He did not believe me and used cooling herbs to subdue Fire, which worsened his condition. He then told me, "The boy is unmarried, how could he have Kidney deficiency? Why use Ren Shen (Ginseng Root) and Huang Qi (Astragalus Root)?" I quoted Zhu Dan Xi, saying: The Kidney governs closure and storage; the Liver governs dispersion and excretion. Both viscera contain Ministerial Fire, whose connection ascends to the Heart. When stimulated by external objects, it moves easily. When the Heart moves, Ministerial Fire rises vigorously. Even without intercourse, Essence is secretly consumed. Furthermore, Chu Shi's *Jing Xue Pian* states: If a male engages in intercourse before his Essence is full, forcing the release of Essence, the Five Viscera will have areas of insufficiency, leading to difficult-to-describe illnesses later. Thus, I prescribed Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) and Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia), and he healed.

I believe that for boys' conditions, one must examine the congenital Qi of the parents, with the Mother's Qi being particularly important. Conditions such as convulsions, smallpox, and Kidney deficiency fever are primarily governed by the Mother's Qi. If the mother has Fire, the child will surely have Fire; if the mother's Spleen is deficient, the child will likely suffer many Spleen diseases; if the mother's Fire is weak, the child will have Kidney deficiency symptoms from childhood, such as delayed tooth eruption, speech, walking, wide fontanelle, and Kidney rickets. These are all signs of congenital insufficiency. Filling deficiencies from childhood can restore natural lifespan, avoiding the secret leakage mentioned above that leads to blood disorders.

The guest asked: "Hematemesis and epistaxis are both caused by Fire flaming upward. One exits from the mouth, the other from the nose. Why?"

Li Dong Yuan said: Epistaxis originates from the Lung, exiting from the nose. Hematemesis originates from the Stomach, vomited in bowlfuls or basinfuls. Spitting blood originates from the Kidney; the blood appears like red threads within phlegm and saliva, coughed up. Saliva mixed with blood originates from the Spleen; small amounts of blood scatter diffusely within saliva.

Although Li Dong Yuan's theory holds, the Lung causes not only epistaxis but also hemoptysis and spitting blood. The Stomach causes not only hematemesis but also the Liver can cause vomiting of blood. Generally, the Lung governs Qi, and the Liver stores Blood. When Liver Blood fails to store, chaotic Qi reverses from the hypochondrium and exits. Ultimately, this is Blood rising with Ministerial Fire following Kidney Water. The Kidney governs Water; Water transforms into fluids, becoming phlegm, saliva, and blood. The Kidney meridian enters the Lung, follows the throat, and夹ps the base of the tongue. Its branch emerges from the Lung, connects with the Heart, and pours into the chest. Thus, when diseased, they affect each other. However, epistaxis comes from the meridians, traveling the clear pathways; hematemesis comes from the Stomach, traveling the turbid pathways. The larynx and pharynx are different tubes. Meridional blood travels and does not stay, moving with Qi. Fire is urgent, so it attacks the clear pathway directly along the meridian and exits from the nose. If it does not exit from the nose, it becomes coughing/spitting, exiting from the Lung orifice into the pharynx. Stomach blood guards Ying (Nutritive) Blood, staying and not traveling, stored in the Stomach. Stomach Qi deficiency fails to control Blood, causing vomiting from the throat into the mouth.

Nowadays, upon seeing hematemesis or epistaxis, people immediately consider Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) as essential. Is this correct? I say: Xi Jiao Di Huang Tang is indeed the specific formula for epistaxis. For hematemesis and hemoptysis caused by Yin deficiency and Fire agitation, it can be borrowed successfully. However, for Yang deficiency due to fatigue/labor and Spleen/Stomach deficiency, it is unsuitable. Xi Jiao (Rhinoceros Horn) is from a water animal; burning rhino horn can divide water and connect to heaven. Epistaxis blood travels from the Ren and Du meridians to the vertex, entering the nose. Only Xi Jiao can descend into Kidney Water and ascend via the Kidney meridian. Di Huang (Rehmannia Root) is a Yin-nourishing agent, making them a matched pair. Current formularies state that if Xi Jiao is unavailable, Sheng Ma (Cimicifuga Rhizome) can substitute. But Xi Jiao and Sheng Ma differ completely in odor, shape, and nature. How can they substitute? I say: There is another explanation. The Ren and Chong meridians attach to the Stomach Meridian of Foot-Yangming, which also enters the nose. If Fire stagnates in Yangming and cannot vent, epistaxis results. Thus, Sheng Ma can substitute. Sheng Ma is a Yangming herb; it should not substitute for non-Yangming epistaxis. Epistaxis can also result from Yin deficiency and Fire decline, where blood drips drop by drop without forming a stream. In such cases, strong Fire-tonifying agents are needed, and Xi Jiao should not be used generally.

For cold damage lasting five or six days, with sweating only on the head, no sweat on the body, stopping at the neck, free urination, and thirst for drinks, this is a Blood stasis syndrome. Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) and Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction) are appropriate. Based on upper/middle/lower deficiency or excess, use Xi Jiao Di Huang Tang for the upper, Tao Ren Cheng Qi Tang for the middle, and Di Dang Tang/Wan (Breakthrough Decoction/Pill) for the lower.

Blood flowing from gum fissures or gums is called dental epistaxis, involving the Yangming and Shaoyin meridians. The Kidney governs bones; teeth are the markers of bones. Gums belong to Stomach Earth. Upper teeth are static and belong to Earth; lower teeth move and belong to Water. Yangming disease presents with foul breath intolerable to others, rotting gum flesh, unbearable pain, and gushing blood, but teeth remain firm. Such patients love alcohol or consume excessive roasted/fatty/sweet foods, resulting from pampering. Internal treatment uses Qing Wei Tang (Clear Stomach Decoction); external application uses Shi Gao San (Gypsum Powder). Severe cases use Tiao Wei Cheng Qi Tang (Regulate the Waist Magnolia Bark Decoction) to pass black stools and heal. For chest deficiency heat, Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) plus Mu Dan Pi (Moutan Cortex) and Huang Lian (Coptis Rhizome) works. Shaoyin disease presents with no foul breath, but loose or falling teeth, bleeding from fissures or painless bleeding. This is Fire exploiting Water deficiency. An Shen Wan (Calming the Kidney Pill) heals it. I often treat Water deficiency with Fire using Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) plus Gu Sui Bu (Drynaria Rhizome), and without Fire using Ba Wei Di Huang Wan (Eight-Ingredient Pill with Rehmannia) plus Gu Sui Bu (Drynaria Rhizome), achieving immediate results. Externally, Xiong Shu Gu San (Male Rat Bone Powder) is applied to stabilize loose teeth. Toothache radiating to the brain indicates Shaoyin cold damage, treated with Ma Huang Fu Zi Xi Xin Tang (Ephedra, Aconite, and Asarum Decoction). Pediatric rickets with bleeding, foul breath, and rotting flesh is treated with Lu Hui Wan (Aloe Pill).

Anger injuring the Liver causing hematemesis/epistaxis presents with blue lips/face and wiry pulses. Chai Hu Zhi Zi Qing Gan San (Bupleurum and Gardenia Liver-Clearing Powder) is required.

Stagnation injuring the Spleen requires Gui Pi Tang (Restore the Spleen Decoction) plus Mu Dan Pi (Moutan Cortex) and Zhi Zi (Gardenia Fruit). Expanding on this, many people suffer blood disorders due to stagnation. All stagnation involves the Liver. Wood contains Fire; severe stagnation prevents Fire from dispersing and Blood from storing, causing reckless movement. 'Stagnation' includes not only anger but also sorrow. Anger and sorrow are aspects of it. If one inherently has Yin deficiency and Fire, and is affected by Wind-Cold-Damp-Heat, closing the skin pores creates stagnation. Stagnation prevents Fire from venting, and Blood moves recklessly with Fire. Stagnation in meridians causes nasal bleeding; stagnation in the stomach cavity causes vomiting. Stagnation syndromes always present with choppy pulses and aversion to wind/cold. Ignorant practitioners mistake this for deficiency and use warming tonification, which is wrong. One must observe dull complexion, desire to vomit, bitter taste, or sour taste. If these signs exist, the primary treatment must be to disperse stagnation. 'For Wood stagnation, extend it; for Fire stagnation, vent it.' Xiao Yao San (Wandering Free Powder) is the precise formula, added with Mu Dan Pi (Moutan Cortex), Zhu Yu (Evodia Fruit), and Huang Lian (Coptis Rhizome), yielding immediate results. After bleeding stops, if Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) is not used to nourish Yin, recurrence is certain the next day. I discussed this in detail in *Treatise on Five Stagnations*.

Excessive drinking injuring the Stomach causing hematemesis post-vomiting is treated with Ge Hua Jie Cheng Tang (Kudzu Flower Relieving Intoxication Decoction) plus Mu Dan Pi (Moutan Cortex) and doubled Huang Lian (Coptis Rhizome) to drain downward and upward. When the wine disease heals, the bleeding stops. Overconsumption of roasted/spicy/hot foods causing upper Jiao heat congestion, chest/abdominal fullness/pain, and purple-black bloody clots is treated with Tao Ren Cheng Qi Tang (Peach Kernel and Magnolia Bark Decoction) to guide out via bowels. This is the method of removing firewood from under the cauldron.

These two cases, though internal injury, are treated as excess syndromes using the above methods.

Women with fever, menstruation just starting or ending, delirium lighter by day and heavier by night, seeing ghosts, and frequent/incontinent urination, are diagnosed with Heat Entering the Blood Chamber. Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Hong Hua (Safflower), Sheng Di Huang (Rehmannia Root), Mu Dan Pi (Moutan Cortex), Guan Gui (Cinnamon Twig), and Gui Wei (Cinnamon Twig tip) for breaking blood stasis is required. See Shanghan Section.

Falls from horses/carts, bruises, fractures, blood loss, stasis accumulation, swelling, pain, and fever are first treated with Tao Ren (Peach Kernel), Da Huang (Rhubarb Root), Chuan Xiong (Ligusticum Rhizome), Dang Gui (Angelica Root), Chi Shao (Red Peony Root), Mu Dan Pi (Moutan Cortex), and Hong Hua (Safflower) to break stasis and reduce sharpness. Then, differentiate and treat with harmonizing blood and detoxifying herbs. Zhang Zi He used Tong Jing San (Unblock Meridians Powder) and Shen Yun Wan (Divine Elixir Pill) to purge dozens of times, removing disease like sweeping, preventing disability. He also used this for beating injuries with swelling, pain, fever, and near-death state; after ten-plus purges, swelling receded and fever vanished. Truly not empty talk.

Postpartum lochia未尽 (not fully discharged) causing Elizabeth pillow pain requires Tao Ren (Peach Kernel), Hong Hua (Safflower), Dang Gui (Angelica Root), Chuan Xiong (Ligusticum Rhizome), Chi Shao (Red Peony Root), and Mu Dan Pi (Moutan Cortex) to move and break blood, plus Jiang (Ginger) and Gui (Cinnamon) for warmth to move stasis. For deficiency pain without stasis, separate warming tonification is needed; do not indiscriminately use blood-breaking agents. Discussing current flaws: Hematemesis and epistaxis are either Yin deficiency or Yang deficiency, as I detailed. Now, seeing blood disorders, people assume Yin deficiency/blood deficiency, asking what else but Si Wu Tang (Four Substances Decoction)? Assuming Fire agitation is heat, asking what else but Huang Qin (Scutellaria Root), Huang Lian (Coptis Rhizome), Zhi Zi (Gardenia Fruit), and Huang Bai (Phellodendron Bark)? Assuming cough is Fire, asking what else but Zi Wan (Aster Root), Bai Bu (Stemona Root), Zhi Mu (Anemarrhena Rhizome), and Bei Mu (Fritillaria Bulb)? Zhu Dan Xi and Dai Yuan Li gave clear instructions; how can one deviate? Who knows that Yin deficiency syndromes mostly present with upper heat and lower cold? Initially, cooling herbs bring relief to the upper Jiao, and doctors/patients think this is the way. Soon, appetite decreases. They assume indigestion and add Shen Qu (Massa Fermentata) and Shan Zha (Hawthorn Fruit). Longer still, heat intensifies, phlegm-cough increases, irritability worsens. They assume insufficient dosage and increase cooling herbs, leading to diarrhea and abdominal distension. Then, Zhi Ke (Aurantii Fructus) and Da Fu Pi (Areca Pericarpium) for widening the middle and moving Qi are added. At this point, if not dead, when will one die? Thus, coughing/vomiting blood with intermittent fever does not necessarily become consumption (Zhai). Continuing Si Wu Tang (Four Substances Decoction), Huang Bai (Phellodendron Bark), and Zhi Mu (Anemarrhena Rhizome) creates consumption. Chest fullness/distension and depression do not necessarily become abdominal distension. Continuing Shan Zha (Hawthorn Fruit) and Shen Qu (Massa Fermentata) creates abdominal distension. Facial edema and scanty/difficult urination do not necessarily become edema (Shui). Continuing diuretic herbs create edema. Qi stagnation and chest blockage do not necessarily become dysphagia (Ye). Continuing Qing Pi (Aurantii Fructus Immaturus) and Zhi Ke (Aurantii Fructus) creating relief forms dysphagia. Once formed, medicine cannot cure, and danger approaches. Then they say the disease violates protocols, and even correct medicines are helpless.