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[Classic Discourse]
When the Yangming governs the climate, if coughing persists and white blood is expectorated, death ensues. ○ Anger causes Qi to rebel; in severe cases, hematemesis occurs. (Su Wen)

[Philosophical Remarks]
In cases of hematemesis, coughing with rebellious Qi, rapid pulse accompanied by fever, and inability to sleep, death ensues. ○ In habitual drinkers who develop coughing, hematemesis invariably follows. This results from excessive drinking. (Jin Gui Yao Lue)

The Heart governs Blood but does not store it; at night, Blood returns to the Liver. The Liver stores Blood but does not govern it; during the day, it obeys the command of the Heart. The Heart is the Sovereign, and the Liver is the Minister. When the Sovereign Fire moves, the Minister Fire follows; when the Minister Fire moves, the Fires of the Six Channels follow. When Fire stirs internally, Blood moves with it; when Fire flares upward, Blood rises with it. (Ming Yi Zhi Zhang)

If a small amount of scattered blood is found in saliva, this is bleeding caused by the flaming up of the Minister Fire from the Kidney. If the blood appears like red threads and is coughed out from phlegm, this is bleeding due to heat injury to the Lung collaterals. If white blood is coughed up, pale red in color and resembling flesh or lung tissue, death is certain. (Zhu Danxi)

Bleeding from the mouth differs depending on whether it originates from the pharynx or the larynx. The upper Jiao has only two openings for intake and output: the pharynx and the larynx. The pharynx is the upper opening of the Stomach, so blood coming from the pharynx must originate from the Stomach. The larynx is the upper opening of the Lungs, so blood coming from the larynx must originate from the Lungs. However, the larynx connects to the Lungs and actually governs the clear pathways of the Five Zang organs; the pharynx connects to the Stomach and actually governs the turbid pathways of the Six Fu organs. People know that bleeding from the Lungs indicates disease in the Five Zang organs, but they do not realize that bleeding from the pharynx often also originates from the Zang organs. The Classics state: "The Five Zang organs all receive Qi from the Stomach." The Stomach is the root of the Five Zang organs. Since the Qi of the Five Zang organs is derived from the Stomach, can diseases of the Five Zang organs fail to affect the Stomach? In current observations of hematemesis, ancients stated that vomiting blood comes from the Stomach, yet how could one know it also originates from the Zang organs? Generally, massive vomiting of bright red blood due to excess Stomach fire is indeed a disease of the Stomach itself, which needs no further explanation. As for anger causing Qi rebellion leading to hematemesis, although the blood emerges from the Stomach, the Qi rebellion lies in the Liver, where Wood pathogen overacts on Earth. Similarly, for hematemesis caused by flaming Desire Fire (Minister Fire), although the blood emerges from the Stomach, the fire originates from the source of Kidney Water, and Yin pathogen overacts on the Stomach. From this, we see that Fire generated by the Five Emotions can all affect the Stomach; thus, blood from the pharynx is not merely a Stomach disease. However, blood coughed up must come from the larynx, and bleeding from the larynx requires examination of the Five Zang organs. Vomited or spat-out blood must come from the pharynx, and bleeding from the pharynx can involve both the Five Zang and Six Fu organs. Moreover, the Stomach is the Sea of Water and Grain, the residence of abundant Qi and Blood, and actually the source of the Chong and Ren vessels' Blood Sea. Therefore, for amenorrhea due to Blood deficiency, one should seek the source of Blood generation, which is the Stomach; for hematemesis, one should seek the source of Blood disturbance, which is the Zang organs. ○ Regarding hemoptysis and sputum-blood, various schools attribute it to the Lungs; regarding spitting blood and salivary blood, they attribute it to the Kidneys. Is this sufficient? One fails to realize that hemoptysis, sputum-blood, spitting blood, and salivary blood are all related to the Kidneys. Why? Because the Kidney meridian ascends from the Kidney, passes through the Liver and diaphragm, enters the Lungs, follows the throat, and flanks the base of the tongue. Its branch leaves the Lungs, connects with the Heart, and pours into the chest. This shows the connection between Lungs and Kidneys; when diseased, both are affected. Furthermore, Blood belongs to the category of Essence, and the Kidney governs the Five Fluids. Thus, in all Blood diseases, although differentiation involves the Five Zang organs, the root cause is always Kidney Water deficiency. Water deficiency leads to Fire excess; Fire excess injures Metal; Metal disease leads to Lung dryness; Lung dryness damages collaterals causing hemoptysis, and fluid depletion forms phlegm. The manifestation (Biao) is in the Lungs, but the root (Ben) is in the Kidneys. To treat Blood without addressing the Kidneys is ultimately ineffective. The Kidney contains both Water and Fire; Water deficiency cannot nourish, and Fire deficiency cannot transform. Those who skillfully observe the subtleties of Water and Fire can see through the internal organs clearly. (Zhang Jingyue)

When the Heart lacks Blood nourishment, Heat generates. Heat steams the chest, causing Metal (Lung) to fear Heat and lose its descending function. During respiration, Qi remains latent within inches. Fire steams below while Qi rushes above, frying fluids and Jin-Ye into Blood, which rises with Dryness. Coughing, vomiting, and spitting will all contain redness. It is impossible to prevent Blood from drying up and fluids from exhausting. One should stabilize the Qi of the Heart and Lungs, using sweet-cool methods to generate nourishment, ensuring sufficient fluids above to descend and shade Ying-Yin, thereby benefiting Water, like mist and dew irrigating a hot door. ○ Controlling Fire is not solely achieved by supplementing Water; sufficient Blood also extinguishes flames. Blood is Yin. In Yin deficiency, Water deficiency fails to nourish Wood, injuring Ying-Blood. Thus, Yang Fire reigns unchecked; lacking Blood lubrication, it draws upon Kidney Water for self-rescue. However, a drop of water cannot quench raging Fire; instead, it transforms with Fire, rising and frying into Blood. This is why spitting blood is said to originate from the Kidneys. (Cheng Jiaoqian)

Regarding hematemesis, people only know of Qi rebellion causing Blood overflow and Fire rising causing Blood flooding. They do not know that Blood within the Zang-Fu organs is separated by the diaphragm membrane, preventing leakage. The diaphragm membrane is extremely thin and brittle; any injury causes rupture, leading to Blood overflowing upwards. (Liu Mosheng)

[Supplement]
For persistent hematemesis, Bo Ye Tang (Cassia Twig Decoction) is indicated. ○ For heart Qi insufficiency manifesting as hematemesis and epistaxis, Xie Xin Tang (Drain the Heart Decoction) is indicated. (Jin Gui Yao Lue)
Note: The phrase "heart Qi insufficiency" should likely be "heart Qi excess". If it were insufficiency, how could this formula be used? It must be a transcription error. (Yi Zong Jin Jian)

There are three principles for treating hematemesis: Promote Blood circulation rather than stop bleeding. Blood failing to follow meridians is due to Qi rebellion and congestion. Promoting circulation allows Blood to follow meridians, stopping bleeding naturally; forcing cessation causes Blood stasis, leading to fever and anorexia, making the condition chronic. Tonify the Liver rather than attack it. The Classics state: "The Five Zang organs store Essence-Qi and do not drain." The Liver stores Blood; hematemesis indicates Liver dysfunction. Nourishing the Liver pacifies Liver Qi, allowing Blood to return; attacking the Liver causes Liver deficiency and inability to store Blood, worsening hemorrhage. Descend Qi rather than descend Fire. Excess Qi becomes Fire; descending Qi descends Fire. When Fire descends, Qi does not rise, and Blood follows Qi without overflowing from the upper orifices. Descending Fire requires cold-cooling herbs, which damage Stomach Qi. Damaged Stomach Qi impairs Spleen control over Blood, causing further extravasation. (Miao Zhongchun)

The Classics state: "The Middle Jiao extracts juice, transforming it into red, which is called Blood." Also: "Nurtured by the Heart, it transforms into red Blood." This indicates that although Blood is generated by the Heart and stored by the Liver, it is actually produced from the essence of Water and Grain in the Middle Jiao. Physicians seeing Blood syndromes immediately assume Heat and use cooling herbs indiscriminately. In early stages with strong Fire, this may work; but in patients with weak Middle Qi, repeated use inevitably damages Spleen Earth. Once Spleen Earth is damaged, the source of transformation is cut off, and few survive. Blood mixed with phlegm or small amounts of vomited blood indicate collateral injury, which is most dangerous. The Classics state: "Damage to Yang collaterals causes external Blood overflow." If there is no cough, it is treatable; if Blood stops but cough persists, even immortals cannot save them. Rare survivors are usually wealthy individuals trusting skilled physicians, where one or two in ten might live; among the poor, survival is rare. Massive vomiting of several bowls indicates Blood from the Chong and Ren vessels filling the skin and muscles; if appetite is preserved without cough or asthma, it is less dangerous and easier to manage. Some bleed from youth to old age; others experience uncontrollable torrential bleeding and die within days. In summary, small amounts are collateral Blood, deep-seated despite low volume; large amounts are superficial Skin Blood, shallow despite high volume. Vulgar doctors believe large amounts are Stomach Blood and small amounts are Zang Blood, not realizing that Zang means storage and should not be injured. True Zang Blood, if even one mouthful is vomited, leads to death within five days; what treatment remains? Although hematemesis involves Yin injury and requires nourishing Yin and Blood, some cases involve Yang deficiency failing to secure Blood, requiring Ginseng, Poria, [missing character], and Atractylodes to tonify Qi and secure Blood. In extreme Yang deficiency with cold limbs, anorexia, vomiting, and diarrhea, use Ginger, Cinnamon Twig, and Aconite urgently; do not rigidly adhere to the notion that hematemesis is Fire and use only Yin-nourishing herbs. (Wu Renzhai)

Blood in phlegm mostly relates to the Spleen Meridian; treatment depends on whether blood or phlegm appears first. If blood appears before phlegm-cough, it is Minister Fire flaming up, frying fluids into phlegm; treatment prioritizes descending Fire. Using phlegm-resolving herbs here causes uncontrolled bleeding. If phlegm-cough precedes blood, it is extreme heat generating phlegm carrying Blood upward; treatment prioritizes resolving phlegm. Using hemostatics here causes phlegm stagnation. (Zheng Hui Hui Bu)

Excess Qi becomes Fire; Blood follows Qi upward. Supplementing Water lowers Fire naturally; smoothing Qi prevents Blood rebellion. E-Jiao (Donkey-Hide Gelatin), Achyranthes Root, and Moutan Bark supplement Water; Perilla Seed, Tangerine Peel, and Agarwood smooth Qi. Child's urine guides Blood downward to the lower orifices and promotes Blood circulation; Lotus Root Juice ensures Blood flow without stagnation and has astringent properties. (Yuan Bing Shi)

After hematemesis, recovery should be achieved with Stomach-tonifying formulas. This saying is excellent. I use Shen Ling Bai Zhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder), decocting and discarding the first decoction, taking the second and third decoctions, or making pills discarding the first decoction, which is very effective. (Zhou Shenzhai)

[Pulse Diagnosis]
A Lung pulse that is firm and long indicates disease with spitting blood. ○ A Heart pulse that is slightly choppy indicates Blood overflow. ○ An insufficient Autumn pulse causes wheezing, shortness of breath, coughing, and hemoptysis. (Su Wen)

[Selected Cases]
Zhang Zhiyuan loved raw and cold foods and contracted Cold pathogens. Self-medicating with dispersants, he suddenly vomited blood. Further use of cooling herbs brought him to the brink of death. His pulse was slight and slow, body cool, face pale, and blood black and foul-smelling. This was Stomach Qi failure to transport and transform, with Yang deficiency allowing Yin Blood to escape. Mu Xiang Li Zhong Tang (Costus Root and Center-Regulating Decoction) cured him instantly. ○ Wang Zhouyi suffered recurrent blood loss annually, responding well to Li Zhong Tang previously, but recently it failed. I reasoned: Taking Li Zhong Tang for blood syndromes addresses Yang deficiency with Yin escaping via the turbid pathway from the Stomach. This case involved Kidney Yin failing to hold, combined with Liver Qi rushing to the Lungs. The Lungs could not receive Qi, invading the clear pathway causing cough and rebellion. Prescribed Rehmannia Root, Moutan Cortex, Angelica Sinensis Tail, Chinese Yam, Poria, Ophiopogon Tuber, Schisandra Berry, and Alisma Rhizome, with a little Bupleurum Root. He stabilized immediately. (Cheng Huazhong)

Huang Zhanhou had a history of blood loss. One morning, he suddenly vomited a basin-full of blood, with Qi surging in the throat, drifting consciousness, high fever like steaming, and stiff neck tendons. His Chi pulse was chaotic. This resulted from sexual exhaustion and lack of self-care. The blood was bright red like the sun. I said: The Shaoyin meridian connects to the tongue root. Shaoyin refers to the Kidney. Now Kidney Blood is gushing out, and the tongue root is stiff; no cure exists. Desperately, I gave one dose of pills to anchor Yuan Qi. If Qi returned to the Dantian, recovery might be possible. I decocted Ginseng Soup and administered thirty Black Tin Pills (Hei Xi Dan). Sound was heard in the throat as it descended. Soon, his tongue softened, and he could speak. Urgently following with moistening purgatives, I gave one liang of E-Jiao (Donkey-Hide Gelatin), dissolved and taken in three doses over half a day. Fever subsided, neck tendons relaxed. He consumed congee and Kidney-tonifying herbs with Autumn Stone (Qiu Shi) and recovered. (Yu Jiayan)

Bao Xianshu, in his twenties, tasted blood every morning while washing his face, vomiting three mouthfuls. This persisted into the afternoon. Physicians were baffled. Pulse was slippery and rapid, especially at the Cun positions. I said: The head and face are the meeting of all Yang. Yin deficiency leads to Yang hyperactivity; Yang hyperactivity causes Blood to leave meridians, leaking down the throat during washing. Treatment should nourish Yin and cool Blood. With four substances (Si Wu Tang) plus Moutan Cortex and Safflower as the sovereign to generate and cool Blood, Phellodendron Bark as minister to nourish Kidney, Ophiopogon Tuber as assistant to clear Lungs, Schizonepeta Spike and Lygodium Spore as envoys to clear the head/face, and a little child's urine to descend Fire. After ten doses, bleeding halved. Others suggested removing Safflower, Moutan, and child's urine; bleeding recurred. Reinstating the original ingredients cured him. (Yu Wuting)

A man, constitutionally strong, near seventy, suddenly vomited blood. Pulse was wiry and strong. Given clearing-heat and calming-Liver herbs, bleeding stopped. A month later, chest discomfort returned, with a few mouthfuls of blood, stopped by medication. One night, he vomited a piece of liver weighing about one qian, followed by five or six pieces the size of chess pieces. He became lethargic, refused food, and died days later. ○ A woman with chronic cough and hemoptysis, internal heat, and fatigue for months, had a wiry, rapid, and deficient pulse. I said: This is Fire excess scorching Metal. In summer Fire season, given Fire-draining and Metal-protecting herbs, waiting for Autumn Metal season for hope. She took Ginseng, Ophiopogon, Moutan, Poria, Aster Tataricus, and Lily Bulb. One day, she vomited two pieces of lung, resembling cooked pig lung, with dull chest pain. The previous herbs failed, and she died. (Yi Tang San Ji)

Ni Xiaolian, over forty, had chronic spleen injury from overthinking, with occasional vomiting triggered by labor. I used Li Yin Jian (Nourish Yin Decoction) combined with Wen Wei Yin (Warm Stomach Infusion), curing him instantly. At the end of summer, mental labor caused vomiting and diarrhea with palm-sized blood clots, purple or red, alarming in volume. Doctors attributed this to Fire arising from Heart and Spleen due to labor, compounded by summer heat (two Fires combining). Prescribed Rhinoceros Horn (now prohibited, substitute with Buffalo Horn), Rehmannia Root, child's urine, Coptis Rhizome, and Anemarrhena Rhizome. After two doses, vomiting worsened, pulse became tight and rapid, condition critical. His son begged for consultation. Given large doses of Ginseng, Prepared Rehmannia Root, Dried Ginger, and Honey-fried Licorice Root. Initially no effect; second dose reduced nausea. Added two qian each of Aconite Root and Roasted Ginger, one liang each of Ginseng and Prepared Rehmannia, four qian Atractylodes Macrocephala Rhizome, one qian Honey-fried Licorice, and two qian Poria. Administered at dusk, he slept deeply. Taken again at midnight, vomiting and bleeding stopped. Large doses of warming and tonifying herbs led to full recovery. Colleagues were initially shocked by my prescription but convinced after recovery, stating: "Without you, he would have died from cold-cooling herbs." Child's urine induces vomiting; Rhinoceros Horn, Anemarrhena, and Coptis damage Spleen. In a season of two Fires, the syndrome was not two Fires, but Spleen injury from labor with Yang deficiency failing to control Blood. Using cold-cooling herbs would have destroyed the Spleen. Several subsequent cases with identical symptoms were saved by this method, hence recorded. (Zhang Jingyue)

[Attached Formulas]
Bu Mo Wan (Repair Membrane Pill) Treats gastric membrane damage after hematemesis ceases. Equal parts of Bletilla Striata Ash, Silk Cotton Ash, and Fish Swim Bladder Ash, ground to powder, formed into pills with honey.
Zhi Shi Xue Fang (Formula for Treating Blood Loss) Use two qian of a woman's topknot hair, washed and air-dried, placed in a clay bottle, sealed with mud, pierced with needles, calcined, cooled, and ground to powder. Take two qian per dose, mixed with Lotus Root Juice, Ink Stick Juice, and child's urine, stewed and taken.