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The more intense the fire, this is a condition of blood deficiency with internal fire. Therefore, the method of "tonifying Qi for blood loss" (Xue Tuo Yi Qi) can only be applied to bleeding caused by damage to the Yin collaterals without fire; it is difficult to apply to cases where the Yang collaterals are damaged, blood is lost, fire is vigorous, and the patient suffers from lao zhai gu zheng (tuberculosis with bone-steaming fever), rapid pulse, and internal heat. At these critical junctures, errors have always been common. When considering the damage to the Yin and Yang collaterals of blood, one must distinguish between the presence or absence of fire, and need not be rigidly confined to whether the blood overflows from above or leaks from below. For example, hemoptysis and hematemesis are blood overflowing from above. If the patient has a pale complexion and a deep, slow pulse, this is due to Yang deficiency failing to control the blood; in ancient times, there were cases where treating with stomach-tonifying herbs achieved success. Furthermore, if the Yangming Large Intestine has fire causing intestinal bleeding (chang hong), this is blood leaking from below; in ancient times, herbs such as Huangbai (Phellodendri Cortex) and Huaimi (Sophorae Flos) were used for treatment. In summary, regardless of whether the blood overflows from above or leaks from below, if upon examination it is found that blood loss is accompanied by fire, it is blood damaged by the Yang collaterals, and cooling blood and nourishing blood methods should be used; if blood loss is not accompanied by fire, it is blood damaged by the Yin collaterals, and the method of tonifying Qi for blood loss may be employed. (From *Zheng Yin Mai Zhi*)

In cases of sudden massive hematemesis due to internal injury, blood flows like a gushing spring, flowing from both mouth and nose, and death will occur within moments if not rescued urgently. It is necessary to use one liang of Ren Shen (Ginseng Radix et Rhizoma) ground into powder, mixed with one qian of refined wheat flour, and taken with fresh well water; or use Du Shen Tang (Single Ginseng Decoction) to tonify Qi. Why are no blood-stopping herbs added? Because tangible blood cannot be generated quickly, while intangible Qi must be urgently secured; intangible Qi can naturally generate tangible blood. If true Yin is deficient and deficient Yang floats upward, massive hematemesis also occurs; in this case, Ba Wei Di Huang Tang (Eight-Ingredient Rehmannia Root Decoction) must be used to secure true Yin and guide fire back to its source, and Ren Shen should not be used at this time. Once the fire has returned to its source, Ren Shen can then be used. ○ After any blood loss, high fever inevitably occurs. The ancient formula Dang Gui Bu Xue Tang uses one liang of Huang Qi (Astragali Radix) and six qian of Dang Gui (Angelicae Sinensis Radix). Although named for tonifying blood, Huang Qi is the sovereign herb because vigorous Yang can generate Yin blood. Those who do not understand this principle, seeing high fever and surging pulses in all six positions, may mistakenly use dispersing methods, or mistake the presentation for Bai Hu Tang syndrome and erroneously administer Bai Hu Tang, leading to immediate danger. ○ When treating blood disorders, regulation before and after must follow the principles of the Heart, Spleen, and Liver meridians: the Heart generates blood, the Spleen controls blood, and the Liver stores blood. Gui Pi Tang is a formula for these three meridians. Yuan Zhi (Polygalae Radix) and Suan Zao Ren (Ziziphi Spinosae Semen) tonify the Liver to generate Heart Fire; Fu Shen (Poria Cum Radix) tonifies the Heart to generate Spleen Earth; Ren Shen, Huang Qi, and Gan Cao tonify the Spleen to consolidate Lung Qi; Mu Xiang (Vladimiriae Radix) enters the Spleen first, with the overall aim of returning blood to the Spleen. This is especially suitable for patients injured by anger damaging the Liver or worry damaging the Spleen. (From *Zhao Shi Yi Guan*)

Zhang Zhongjing stated: Misapplying sweating to the Shaoyin meridian disturbs the channel blood, resulting in lower exhaustion and upper reversal, which is difficult to treat. One does not realize that "lower exhaustion" refers to the depletion of Yin blood in the lower body, and "upper reversal" refers to the rebellion of Yin Qi in the upper body. Qi and Blood are mutually attached; without Blood, Qi scatters without control; without Qi, Blood coagulates and fails to flow. Thus, when Yin fire moves, Yin Qi must rush upward; as Yin Qi rushes upward, Yin blood must overflow upward. Once blood overflows, the Qi accompanying it scatters in the chest and cannot return to its original position, causing upper reversal. With Yin Qi rebelling upward, Long Lei fire (ministerial fire) responds accordingly; bleeding stops only when blood is exhausted, and reversal stops only when Qi is restored. Zhang Zhongjing judged this as difficult to treat not because it is untreatable, but I elucidate the mechanism: prioritizing the tonification of Yang Qi in the Spleen is the primary principle. Tonifying Spleen Yang has three benefits: First, vigorous Spleen Yang is like clear skies and bright sun, causing Long Lei fire to subside; Second, vigorous Spleen Yang clears obstructive Yin Qi from the chest like empty space free of dust; Third, vigorous Spleen Yang aids digestion and transformation of essences, regenerating the depleted lower blood. Modern formularies wrongly cite chronic cough leading to consumption with blood-streaked sputum as a Yang syndrome, fearing the use of Spleen-tonifying methods and citing increased cough as an example. They fail to consider that even if hemoptysis is accompanied by cough, it is merely a cough caused by rebellious Qi; once Qi descends, the cough ceases, let alone in those who originally had no cough. Ancient formulas treated Long Lei fire using Rou Gui (Cinnamomi Cortex) and Fu Zi (Aconiti Lateralis Radix Praeparata) to guide fire back to its source, but this is applicable temporarily, not chronically, for acute bleeding. Depleted blood may not control the harsh nature of these herbs, and undisturbed blood may be irritated by them. Here, strengthening Earth (Spleen) is paramount; thick Earth prevents turbid Yin from rising, and blood disorders cease naturally. (Yu Jiayan)

Blood loss syndromes have various names, and the origins of the Three Causes (External, Internal, and Neither Internal nor External) must be detailed. External causes are mostly Yang pathogens. Since Yin deficiency exists first, one is easily susceptible to external wind-heat, dryness, and fire. Pathogens of Yin cause disease only in one or two out of ten cases. The treatment generally focuses on the Hand Three Yin meridians, investigating the pathology in the Ying (Nutrient) level of the Heart and Wei (Defensive) level of the Lung. Internal causes involve anger and depression injuring the Liver, physical labor and mental strain depleting the Heart and Spleen, and indulgence in sex damaging the True Yin and True Yang of the Kidney. Treatment should focus on the Foot Three Yin meridians, examining their mutual overcoming and regulating transformations. Neither internal nor external causes include dietary preferences and injuries from straining or falling. Treatment varies by organ and meridian. External causes must have signs of pathogen invasion first; internal causes must have interior symptoms. Generally, to regulate Lung and Wei, use sweet-cool descending herbs like Sha Shen (Glehniae Radix), Mai Dong (Ophiopogonis Radix), Yu Zhu (Polygonati Odorati Rhizoma), and Chuan Hu (Dendrobii Caulis). To treat Heart Ying, use light-clear nourishing herbs like Sheng Di Huang (Rehmanniae Radix), Xuan Shen (Scrophulariae Radix), Dan Shen (Salviae Miltiorrhizae Radix), and Lian Qiao (Forsythiae Fructus). If wind excess dries fluids, add sweet-cold herbs like Lu Gen (Phragmitis Rhizoma) and Zhe Zhi (Saccharum Japonicum Juice); if warmth excess strengthens fire, add bitter-cold herbs like Huang Qin (Scutellariae Radix) and Shi Gao (Gypsum Fibrosum); if summerheat forces the Qi level, assist with Hua Shi (Talcum) and He Ye (Nelumbinis Folium) to open and resolve; if in the Ying level, combine with Jin Yin Hua (Lonicerae Japonicae Flos) and Xi Jiao (Rhinocerotis Cornu) for clearing and aromatic action; in autumn, select pure sweet herbs to clear dryness; in winter, increase clear-tonification to aid storage. These are the general principles for external causes. For Yin pathogen diseases, old formulas include Ma Huang Ren Shen Shao Yao Tang, and Mr. [Author] has Guizhi modification methods. Internal injuries are more complex to treat. If anger moves Liver Yang and blood follows rebellious Qi, use Miao's method "Qi is the commander of Blood," with Su Zi (Perillae Fructus), Yu Jin (Curcumae Radix), Sang Ye (Mori Folium), Dan Pi (Moutan Cortex), and Bei Mu (Fritillariae Bulbus). If stagnation damages Liver Yin over time, and Wood-Fire internally burns the Yang collaterals, use softening Liver and nourishing Yin methods, with E Jiao (Asini Corii Colla), Huang Qin, Sheng Di Huang, Mai Dong, Bai Shao (Paeoniae Radix Alba), and Gan Cao. If fatigue damages Heart and Spleen, and Qi fails to control blood, use sweet-warm fortification methods, such as Bao Yuan Tang and Gui Pi Tang. If indulgence exhausts Kidney Essence, or Yang hyperactivity floats Yin, or Yin injury allows Yang to escape, use methods following Yin or Yang, such as Qing Qian (Plumbum), Liu Wei Di Huang Wan, Rou Gui, Qi Wei Di Huang Wan, plus Tong Bian (Human Urine). If essence is exhausted and the sea is empty, with Qi floating and blood surging, urgently secure True Yuan and greatly tonify essence and blood, using Ren Shen, Gou Qi (Lycii Fructus), Shu Di Huang (Rehmanniae Radix Praeparata), Zi Shi Ying (Fluoritum), and He Che Da Zao (Placentae Humana). These are the general principles for internal causes. Regarding neither internal nor external causes, smoking irritates the Lung, and alcohol heat damages the Stomach, both aiding fire and moving blood. Treatments for upper and middle jiao include Wei Jing Tang, Gan Lu Yin, Mao Gen (Imperatae Rhizoma), and Ou Zhi (Nelumbinis Rhizoma Sanguis). Falls causing blood stasis and overflow should first be guided downward, then supplemented and unblocked. Straining is rooted in labor injury; Yang movement relaxes collaterals causing blood overflow. Treatment differs from deficiency; tonifying Yin and Qi must avoid astringents. Formulas like Dang Gui Jian Zhong Tang and Xuan Fu Hua Tang are chosen for their ability to enter collaterals along meridians. These are the general principles for neither internal nor external causes. However, the organs governing blood are the Heart, Liver, and Spleen; the source of blood generation is the Yangming Stomach. If the Stomach is disharmonious, treat the Stomach first. Ren Zhai said: All blood disorders that persist for a long time often conclude with stomach medicine. There are thin-flavored methods to nourish Stomach Yin, such as Mai Dong Tang, Sha Shen, Bian Dou (Dolichoris Semen), Fu Shen, and Shi Hu (Dendrobii Caulis); there are sweet-warm methods to establish Middle Yang, such as Ren Shen Jian Zhong Tang and Si Jun Zi Tang modifications; there are Yin-nourishing methods that do not hinder the Stomach, preserving sweetness and returning fluids, such as Fu Mai Tang modifications. Other methods like tonifying Earth to generate Metal, calming Liver and benefiting Stomach, tonifying Spleen and soothing Stomach, calming Spirit and regulating Stomach, and Kidney-Stomach interaction, when encountering loss of appetite, lack of hunger, and difficult transport, often show efficacy based on this principle, generating resources continuously. (From *Lin Zheng Zhi Nan*)

For blood overflow and leakage with accumulation and reckless discharge, initially, use blood-moving and stasis-breaking agents to curb their vigor, then differentiate and treat. A question arises: If purgatives are used after blood loss, how can the deficiency bear it? The answer is: Since blood is acting recklessly and has lost its proper pathway, if accumulated stasis is not removed and unblocked, reckless behavior becomes the norm, and how can it be controlled? Moreover, what is removed is old, and what is born is new; why speak of deficiency? Purgatives are used by blood-loss patients only in the initial stage of accumulation and reckless discharge; they are contraindicated for hemorrhagic deficiency patients after significant blood loss. (Hua Bo Ren)

Accumulated blood is distinguished by Upper, Middle, and Lower Jiao. Accumulation in the Upper Jiao causes forgetfulness; Xi Jiao Di Huang Tang is indicated. Accumulation in the Middle Jiao causes chest fullness, yellow skin, rinsing water without swallowing; Tao Ren Cheng Qi Tang is indicated. Accumulation in the Lower Jiao causes mania-like state, black stool, hardness and fullness in the lower abdomen; Di Dang Tang/Wan is indicated. (Wang Haogu)

Regarding blood stasis syndromes, people today only know that sprains cause stasis. They do not know that fire carrying blood upward, causing vomiting or epistaxis, may lead to retention if the patient endures it; or that cold-herbal medicines may cause internal coagulation; or that excessive worry leads to stagnation of Ying blood; or that anger causes blood to rebel upward, unable to descend, failing to return to its vessels, and accumulating in the chest and diaphragm. These are causes of blood stasis. Also, falls and sprains may not be felt immediately but manifest later when Qi declines. Doctors seeing hematemesis may misdiagnose deficiency and use tonics; Qi gains support, the illness temporarily eases, but Qi declines daily, the illness deepens, eventually forming a "nest" (chronic lesion) that is incurable. ○ A question asks: How to verify phlegm combined with blood stasis? I say: You know phlegm combining with stasis, but do you know stasis combining with phlegm? If blood injury occurs first, blood rebellion causes Qi stagnation; Qi stagnation generates phlegm, which gathers with blood, named "stasis combining with phlegm." Pressing the affected area causes fixed pain; symptoms include vomiting, epistaxis, or black stool; pulse is slippery on light pressure and choppy on heavy pressure. Treatment should guide phlegm and break stasis: first use Dao Tan Tang (Cang Zhu, Xiang Fu, Zhi Ke, Bai Jie Zi to open stagnation and guide phlegm); then use Xiong (Chuan Xiong), Gui (Dang Gui), Tao Ren, Hong Hua, Su Mu, Dan Pi, E Zhu to break stasis. If phlegm stagnation exists first, followed by blood stasis gathering with phlegm, named "phlegm combining with stasis." Pain shifts slightly; symptoms include distension or alternating chills/fever; pulse is hollow on light pressure and slippery on heavy pressure. Treatment should break stasis first, then resolve phlegm, or do both simultaneously. Mistaken use of tonics or cold herbs may cause pathogens to stagnate and form nests. Verification of nests: pain prevents turning; or heat/swelling in lung membranes, coughing wheezing with foul sputum. Danxi said: "Phlegm combining with stasis forming nests is incurable." This is exactly what is meant. (Luo Chicheng)

If hair follicles on the feet bleed like threads and flow incessantly, death ensues. Urgently soak the feet in three sheng of hot vinegar; take one liang of Ren Shen, three liang of Dang Gui, and one slice of Chuan Shan Jia (Manis Squama) fried and powdered, mixed with Shen Gui Tang. This condition results from unrestrained alcohol and sex; it is not recorded in formularies, but this formula is miraculous. Bleeding from the umbilicus is also a rare syndrome; Liu Wei Tang (Six-Ingredient Rehmannia Pill) plus Gu Sui Bu (Drynariae Rhizoma) cures it. Tooth bleeding is also treated with this formula. The umbilicus and teeth are locations of the Kidney meridian; bleeding here is Kidney fire escaping outward. Liu Wei Tang nourishes Water, extinguishing fire; Gu Sui Bu specifically repairs bone leaks. ○ Tongue bleeding like a spring indicates extreme Heart fire failing to store blood. Use Liu Wei Tang plus Huai Hua (Sophorae Flos). ○ Bleeding from seven orifices indicates Kidney meridian deficiency heat. Use Liu Wei Tang plus Mai Dong, Wu Wei Zi (Schisandrae Fructus), and Gu Sui Bu. (From *Shi Shi Mi Lu*)

Pulse Signs

Resting with a vigorous pulse is called blood depletion. (From *Su Wen*)

Patients with pale faces, no chills/fever, and a deep, wiry pulse have epistaxis; floating and weak, disappearing on pressure, indicates lower bleeding; irritability and cough indicate hematemesis. (From *Jin Gui Yao Lue*)

Ruo and Ruo pulses indicate blood loss; Kou pulse indicates hemorrhage; Se pulse indicates scant blood; Lao pulse indicates accumulated blood. Deep, weak, slippery, and small pulses indicate survival; solid, large, wiry, and firm pulses indicate death. Wiry and thin pulses at Guan and Chi positions, like touching a blade, indicate death. (From *Zheng Hui Bu*)

In all bleeding cases, body heat and large pulse are difficult to treat; cool body and quiet pulse are easy to treat. (Li Dongyuan)

Selected Cases

Mr. Liu Yuan loved roasted foods, was emotionally distressed, and drank strong liquor, damaging the Spleen and Stomach, igniting fire in Earth. Initially, he had night sweats and palpitations, affecting the Pericardium. Later, Water dried up and Metal weakened, causing red sweat from pores, staining clothes red, a strange syndrome. I said: This is Spleen/Stomach Yin blood transforming with Pericardium fire fluid, circulating with Qi to the interstices, similar to hematemesis. Prescribed Modified Qing Xin Lian Zi Yin; stopped in one dose, cured in three. ○ Li Kanghou indulged in sex/sound, suffered vertigo for days, suddenly bled from hair follicles incessantly. Doctors suspected a strange syndrome and left. I said: This is Kidney Water exhaustion, uncontrolled ministerial fire, stirring five-Zang deficient fire, flaming to the vertex. Not strange at all. Prescribed Liu Wei Tang plus Che Qian, Niu Xi, Xu Yu Tan; stopped in one dose. ○ A woman suppressed anger, vomited dryly, forced blood from her mouth, growing bowl-sized from morning to noon, filling her mouth, blocking breathing. Doctors were helpless. I ordered decocting concentrated Huang Lian juice, cooling it in a well, applying it. After a meal, half reduced. Added Hai Shi, decocted together, applied slowly and swallowed gradually, resolved completely. This is violent Heart fire agitation. Easily cured with Xiao Yao San plus Dan Pi, Zhu Yu, fried Huang Lian. (Cheng Huazhong)

A woman’s calf itched; scratching caused a thread of fresh blood to shoot four to five chi away, filling jars and bowls, fainting. I said: This is Blood Arrow. Ordered dense application of Bai Cao Shuang, binding with cloth, and administering Bu Zhong Yi Qi Tang plus Huang Lian, Sheng Di Huang, Bai Shao. Consciousness returned, bleeding stopped, cured in two doses. (Zhou Yuzai)