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The tendons in the neck are coarse and protruding. Upon palpating the pulse, the Chi position (Cun-Kou pulse at the wrist corresponding to the Kidney) is very chaotic. It was said: "This is due to excessive sexual indulgence last night." The blood was then examined; its color was bright red like the sun. After inquiring about the patient's living conditions again, it was stated: "The Shaoyin meridian connects to the root of the tongue. Shaoyin belongs to the Kidney. Now, the blood of the Kidney is gushing out, and the root of the tongue has become stiff; there is no way to save this case. As a last resort, one dose of pill medicine will be used to stabilize and secure the Yuan Qi (Primordial Qi). If the Qi can turn to the Dantian (Lower Elixir Field), treatment may proceed slowly." Strongly decocted Renshen Tang (Ginseng Decoction) was taken internally, followed by 30 pills of Heixi Dan (Black Tin Pill). There was phlegm-rattling sound in the throat, and the medicine gradually entered the lower abdomen. Soon after, the tongue became soft and the patient could speak, but no voice came out. Urgently, a moistening and purgative formula was administered to follow the previous medication. Thus, Ejiao (Donkey-hide Gelatin), 1 liang, was dissolved and taken hot in three doses, completed within half a day. The body heat gradually subsided, and the neck tendons flattened. Porridge was consumed, and Kidney-tonifying herbs were given, with Qishi (Mineral Salt) added in large amounts. After taking them, the patient recovered.

Yu Zhen commented: Using Renshen Tang to administer Heixi Dan for treating hematemesis (vomiting blood) supplements methods not found in ancient texts. However, following up with Ejiao for great efficacy, and then with Qishi Kidney-tonifying herbs for complete recovery, is perhaps unlikely.

He also treated Gu Meixian, aged over twenty. His physique was obese, and he had a fondness for alcohol. In early summer, he suffered from a hemorrhagic syndrome, losing one or two cups of blood every night. This continued until late summer, with massive blood loss. Yet his complexion was not haggard, his body did not emaciate, his pulse was not surging, and he had no aversion to cold or fever. He only suffered from shortness of breath and panting upon exertion, frequent coughing at night, a sensation of obstruction in the throat, tightness and pressure in the chest, stabbing distension in the back, irritability, and anger. Physicians used Renshen (Ginseng) and Ejiao, following established methods for treating hemorrhage, for over a month, yet the condition worsened. Another physician used Ziyin Gaozi (Nourishing Yin Pastes) to moisten the upper jiao, and Niuxi (Achyranthes Root) and Huangbai (Phellodendron Bark) to guide downward. None were effective. When Jiuni Sanqi (Sanqi Powder prepared with wine) was taken, the bleeding stopped and coughing ceased, but soon the bleeding recurred and coughing increased. Yu Jia Yan said: "This disease is caused by strong liquor damaging the Stomach. The Stomach is a zang-fu organ rich in Qi and Blood. Although internal deficiency gradually develops, external signs are not yet apparent. Investigating the cause, it must have resulted from sexual intercourse while intoxicated and full. Generally, when Body Qi moves, Blood moves. During coitus and ejaculation, the Qi movement resembles the creative forces of Heaven and Earth, causing significant Blood disturbance. Essence is transformed from Blood. The infusion of essence is not limited to the Stomach meridian alone. However, the Blood moved in this specific meridian was blocked by intoxication and overeating, preventing it from connecting continuously with other meridians in their ceaseless circulation. Thus, an apparent excess pattern of blood loss was created. Now it has become a habitual condition. The Stomach meridian runs from head to foot, naturally descending. Due to hematemesis, it reverses and ascends, causing breathing difficulties and panting. The Qi of the Stomach transmits to the Large Intestine, Small Intestine, and Bladder, also naturally descending. Due to repeated vomiting, Qi rebels upward and fails to descend, causing pain and stuffiness in the chest and abdomen. Stomach Qi surges upward, vomiting rebels and breaks through horizontally, causing chaos in the Qi of the chest. Hence the sensation of tightness and pain, even radiating to the back, as the back is the mansion of the chest. The irritability and anger arise because the upper part of the Stomach is the Diaphragm. As stated in the *Neijing*: 'Blood spurts above the diaphragm, Qi spurts below the diaphragm.' This reversal of Qi and Blood causes it. Moreover, the great collateral of the Stomach penetrates the diaphragm and connects to the Lung. The tightness between the diaphragm affects the Lung space; Qi distension and sticky phlegm—aren't these all transmissions from Stomach disease? During the long summer when Earth Qi is prosperous, the pathogen of the mother (Spleen/Stomach) fully transmits to the child (Lung). By the third autumn when Dry Metal rules, the afflictions of coughing, panting, and fullness will surely increase. Lung abscess and Stomach abscess transformations will surely arrive. This year, Shaoyin governs the Heaven Qi, which is Hot. The intense summer heat is the seasonal Heat. Combined with accumulated Heat in the Stomach, they fan the disaster. Without treating the Heat, the bleeding will not stop. One must follow the principle in the *Neijing*: 'When Heat floods and causes blood overflow, treat with Salty-Cold substances.' Use Yuanmingfen (Mirabilite) dissolved in water to decoct Huangbai, and Qishi dissolved in water to decoct Zhimu. Add a little Gancao (Licorice Root) to moderate the bitterness. After four doses, the bleeding stopped. Unfortunately, the family did not complete the course. In mid-August, he indeed developed a lung abscess and died.

Yu Zhen commented: This case's discussion of the disease and prescription formulation is far beyond ordinary reach. Did Xichang truly possess the ability to see through walls like Changsang Yuanhua (Bian Que)? It is merely being well-versed in the *Neijing* and skilled in its application, so that citing classic meanings and verifying them against pathogenesis leads to logical coherence, avoiding forced interpretations. Mr. Shicai said: "Thorough reading awakens the spirit; deep thinking allows communication with spirits." Truly so.

Zhou Shenzhai treated a man surnamed Chen, aged thirty-five. He had a nature fond of alcohol and lust. Suddenly, he suffered from hematemesis, three to five times a day. He had no appetite, eating only one bowl of porridge daily, but drinking several cups of boiling wine. The next morning, after eating porridge again, the previous day's porridge was completely vomited up. After vomiting, abdominal distension occurred, with intermittent pain and sourness. He slept neither day nor night. Drinking several cups of boiling wine provided slight relief. The next day was the same. Approaching July, no physician mentioned this was a Blood-stasis syndrome. All said it was incurable. Zhou examined him; the six pulses were short and rapid. He said: "After vomiting, one should feel relaxed, yet there is distension; drinking boiling wine brings slight relief. This is a Blood-stasis syndrome. Wine is Evil Yang; lust is also Evil Yang. When Evil Yang prevails, Righteous Yang declines. Additionally, anger injures the Liver, so the Liver fails to store Blood; overthinking injures the Spleen, so the Spleen fails to control Blood. Middle Qi is greatly deficient, and Blood does not return to the vessels. There is undoubtedly Blood stasis in the Middle Jiao. Vomiting or purging methods should be used. But since the Spleen and Stomach are greatly deficient, if Yang Qi is not allowed to ascend, how can Yin Cold dissipate?" First, Liujunzi Tang (Six Gentlemen Decoction) was used, with Baizhu (Atractylodes Macrocephala Rhizome) processed using Cangzhu (Atractylodes Rhizome). Dingxiang (Clove) was added to warm the Stomach; Cao Kou (Cardamom Fruit) treated epigastric pain. Over thirty doses were taken. Then, Liangjiang (Alpinia Officinarum Rhizome), 1 liang, and Chentubi (Old Wall Soil), 4 liang, were decocted together. Once the soil melted into slices, Chenpi (Tangerine Peel) without white pith, Caokou, Renshen, Baizhu, Fuling (Poria), Gancao, Hujiao (Pepper), and Dingxiang, each 5 qian, and Xixin (Asarum), 4 qian, were ground into powder. Taken on an empty stomach, delivered with clear salt water or wine, 2 qian per dose. This medicine specifically aims to support Yang. Blood stasis, congealed by Yin Cold, resolves naturally when Yang becomes vigorous. If blood flows downward after taking the medicine, it is auspicious. However, the blood vomited upward, approximately six or seven bowls. Chest oppression and confusion ensued, hands and feet turned cold, and consciousness was lost. Urgently, Renshen, 5 qian, and Paojiang (Prepared Ginger), 8 fen, were decocted. Then calmness returned. Later, chest oppression/confusion and fire rising from below the navel with dizziness occurred. Fuling Buxin Tang (Poria Heart-Nourishing Decoction) was given. One dose brought peace. Later, Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia) plus Renshen and Paojiang led to recovery.

Yu Zhen commented: This case shows outstanding insight in recognizing the disease and ingenious understanding in medication. It is completely unrelated to standard hematemesis treatments. Because after stopping bleeding, vomiting caused distension, the distension should have been treated. "Evil Yang prevails, Righteous Yang declines" in the case record is a profound truth. People indulge desires relying on alcohol, feeling pleased with apparent yang strength, unaware that they still rely on Mingmen True Yang. Once desires are satisfied and evil Yang subsides, True Yang finally rests. Frequent rising and subsiding of desire fire gradually depletes True Yang. Even if desires arise but are not fulfilled, seemingly sparing True Yang, it is like adding another fire under a bright lamp; as this extra fire grows strong, the lamp's light dims. The logic is understandable. Therefore, those who fall ill frequently after middle age must find blessing in closing the gate (abstaining from sex). Especially finding great blessing in remaining detached and free of desire.

Shi Wen treated the son of Tao Zhenhan, a tooth merchant. Suffering from labor-induced consumption and coughing, blood loss gushed like a spring. Taking Shengdi Juice (Rehmannia Juice) and Mo Zhi (Ink Stick) failed to stop it. A disciple, Zhou Zi, used 2 sheng of hot Tongbian (Child's Urine) to stop it. Shi Wen palpated the pulse: wiry, large, and deficient. Spontaneous sweating, panting, and fatigue. At night, restlessness and agitation. Danggui Buxue Tang (Dongquiang Blood-Nourishing Decoction) was given. After four doses, heat cleared. Occasionally felt stabbing pain in the left hypochondrium, with rattling sounds upon pressing. This was caused by youthful fondness for wine and arrogance, leading to fights. Zeshu Mijian Tang (Plantain, Atractylodes, and Elsholtzia Decoction) plus fresh Lotus Root Juice was administered orally. Dark purple-black blood clumps were passed in stool, clearing over several days. Later, Si Wu Gai Ru San (Four Oyster Shell and Rubus Powder) was given as powder, divided into four doses. Cooked inside the belly of a yellow hen and eaten. Remaining medicine formed honey pills. After finishing the course, bleeding did not recur.

Yu Zhen commented: Spontaneous sweating, panting, fatigue, wiry-large-deficient pulse, without indiscriminately prescribing Dihuang Tang or Shengmai San, is highly commendable. Using Buxue Tang was due to nighttime restlessness. Considering the fight history due to hypochondriac pain implies the person's physique must be robust. Thus, resolving stasis without tonification is most appropriate.

Gao Shizong recorded: The niece of my friend's grandson, Du, married into the Zhang family. After a miscarriage, she suffered coughing and hematemesis. Pulse was rapid and choppy; complexion pale. Fullness in the Stomach and Spleen diarrhea. Physicians used Qi-regulating, Fire-descending, and Hemostatic drugs, worsening the condition. I prescribed Lizhong Tang (Middle-Warming Decoction) plus Muxiang (Aucklandiae Root) and Danggui (Angelica Sinensis). Doubling the dosage of Renshen and Baizhu stopped the bleeding. Subsequently, Guipi Tang (Spleen-Restoring Decoction) and Jiaban Bawei Yinzi (Modified Eight-Flavor Drink) were used, and various symptoms gradually improved. At that time, Gu Feng arrived from Hu Lake. Examining her, he said: "Such severe deficiency has been stabilized to this extent; only the power of Renshen and Baizhu could achieve this. Currently, there is slight coughing and intermittent night fever. Urgent warming and tonification is needed to prevent future issues." Therefore, Jiaban Bawei Wan (Modified Eight-Flavor Pills) were taken in the morning, and Jiaban Guipi Tang in the evening. Shortly after, a quack physician exclaimed: "Blood diseases originate from Fire; how can hot medicines be used?" Consequently, Lung-clearing and Blood-cooling agents were advanced. The patient felt increasing gastric distress and loss of appetite. Forced by external opinion to take them, after more than a month, the disease flared severely. Bleeding surged like a fountain, varying in color from purple to black to bright red. The patient resented this and summoned me again. I examined her and said: "It is ruined. The zang-fu organs are coerced by Cold-Coolling [drugs]. Ying and Wei are damaged, Water and Fire are exhausted. The pulse exits but does not enter; the disease advances but does not retreat. Nothing can be done." Shortly after, she indeed died. Renzhai's *Zhizhi* states: "When Ying Qi is deficient and scattered, Blood flows erratically. This is what is meant by 'When Yang is deficient, Yin must flee.'" Cao's *Bi Yong Fang* states: "If one takes Shengdi, Lotus Root Juice, Zhuru (Bamboo Shavings), etc., life is far away." Thus, misunderstanding the term "Nourishing Yin" in ancient times could kill people. Moreover, quacks do not understand this, grabbing herbs casually, making excuses of "clearing Fire." What kind of Fire is this, that it can be cleared? The ingredients seem stable, but who knows they cut into the intestines and stomach like saws. How terrifying! "Tonifying Qi for Blood Loss" is a rudimentary principle. Not knowing even this, how can one understand where Qi is generated and how Blood is transformed? Is it not difficult? Wielding the knife to cut, fewer than one in a hundred survives. Those with benevolent hearts should pay some attention here.

Yu Zhen commented: Hematemesis is currently very common. Some occur due to causes, others without. External pathogens of the Six Evils disturbing Blood are lighter. Internal causes of alcohol, lust, worry, and anger disturbing Blood are heavier. And non-internal/external causes like overwork, lifting heavy objects, enduring hunger, and walking fast all cause blood loss. However, one can still seek the cause and treat accordingly. If none of these apply, and hematemesis occurs without reason, this is the most severe. The *Neijing* says: "Earth resides in the Great Void, held up by Great Qi." If Great Qi leaks occasionally, earthquakes and mountain collapses occur, and waters become turbulent, overflowing or drying up. The human body is the same. If Great Qi is thick, it suffices to contain and secure. Even if the Three Causes are violated, other diseases form, not hematemesis. If Great Qi is weak, it cannot support. Like a thin dike leaking water easily, or a collapsed dike bursting. People only adhere to the theory of "Heat forcing Blood to run wild," which is wrong. Observe this case and reflect sharply. However, Renshen, Huangqi (Astragalus), and Baizhu are sometimes effective, sometimes not. Great Qi is formless, different from Ying Qi, Wei Qi, Zong Qi, and Zhong Qi. It cannot be supplemented by herbs or animal products. I have seen people devouring meat and rice, only to die shortly after a sudden burst of blood. I have also seen people taking Ginseng daily, yet still dying from frequent bleeding. These are malignant diseases. Only cultivating character and regulating life can possibly reverse them. The *Neijing* says: "Tranquil and empty, True Qi follows. Spirit remains within, how can disease arise?" This is the formless Great Medicine. In my youth, I opened the apertures too early, violating Chu Shi's warning. At fourteen or fifteen, I suffered from nocturnal emissions and spitting blood. At twenty-four, it worsened. Coughing phlegm always contained blood. More than ten nocturnal emissions a month. Then coughing, night fever, throat itching, fire rising, malarial flush, and back pain. I considered myself doomed. At that time, I had elderly parents with white hair above, and no infants below. Worried by illness and fearing death, the suffering was indescribable. I wanted to dispel the fear of death but had no way. Seeing my emaciation, my parents ordered my wife to sleep in a separate room. I also re-read *Xianyu Yinyuan*. Viewing life and body as worn-out shoes, the fear of death melted like ice. Lustful dreams never occurred again. From then on, I was peaceful and content, naturally free of annoyance and impatience. I quit smoking and alcohol, fearing women like scorpions. After two years, all illnesses healed. After three years, children were born. Dare I not share this with the world? I hope those suffering from this disease will try it.

Yu Zhen further commented: Miu Zhongchun's Three Principles for Treating Hematemesis are revered as clear instructions by the world. Their meaning has not been carefully expounded. The first principle states: "It is suitable to move Blood, not to stop Blood." This is correct. However, among Blood-moving herbs, only Dahuang (Rhubarb) applies, as Blood moving downward is smooth. One must also consider whether the Blood syndrome is new or old, and the amount of blood lost, to decide usage. Purging is suitable at the beginning of reckless flow, but not after massive depletion. The current text does not specify which herb moves Blood, only stating "moving Blood makes it follow the collaterals." This has led to recent deaths from taking too much Shan Yang Xue (Mountain Goat Blood). Who knows if this sentence is misleading? Regarding surging blood, it must be stopped. Ancient formulas like Huarui Shi San (Flower Coral Stone Powder), Shihui San (Ten Ashes Powder), Tongbian, and Mo Zhi all aim to stop it. After stopping, resolving or tonifying can be discussed later. Letting it vomit without thinking how to stop it, how can one seek survival? Specifically, the method of stopping blood values clear differentiation of Deficiency/Excess and Cold/Heat, so that tonifying/draining and warming/cooling are handled steadily. The text says: "Stopping it causes Blood congealing; congealing causes fever and food aversion, making the disease chronic." Consider that modern hematemesis patients often have fever and food aversion; is it ever due to Blood congealing? If it is Blood congealing, Zhang Zhongjing's Dahuang Zhechong Wan (Rhubarb and Ground Beetle Pill) could still save it. The worry is endless Blood loss; Yin deficiency leads to disease, Yin exhaustion leads to death, leaving no remedy. The second principle: "Suitable to tonify Liver, not to attack Liver." The annotation says: "Nourishing the Liver calms Liver Qi, allowing Blood to return to its source. Attacking it makes Liver deficient, unable to store Blood, causing more bleeding." This explanation is clever. However, one must look at the pulse. Liver Yin certainly needs nourishing, but Liver Yang also needs controlling. If encountering Wood-Fire hyperactivity with Blood rebelling with Qi, Yi Qing Wan (Suppress Green Pill), Longdan Xiegan Tang (Gentian Liver-Draining Decoction), Vine-processed Dahuang, Taoren (Peach Kernel), Zhike (Bitter Orange), Qingqian (Blue Lead), and Tieshui (Iron Rust Water)—were these ever forbidden? Mastering the way, attacking is also tonifying. Failing to master the way, and merely regarding Shudi (Prepared Rehmannia), Danggui, Yurou (Cornus), and Gouqi (Goji Berry) as Liver-tonifying herbs, is erroneous. The final principle: "Suitable to descend Qi." Qi has Deficiency/Excess and Cold/Heat. In Blood syndromes, Qi is mostly Deficient, rarely Excess; mostly Hot, rarely Cold. Only for those who are strong and prone to anger, with Excess Liver Qi causing hematemesis, suppressing and clearing the Liver, descending Qi and descending Fire are suitable. Others: If Lung Qi is deficient and fails to descend, use Shengmai San or Guanyin Yingmeng San. If Middle Qi is deficient and fails to descend, use Sijunzi Tang or Shenju Jian. If Kidney Yang is deficient and fails to grasp Qi, leading to failure to descend, use Bawei Wan or Heixi Dan. If Kidney Yin is deficient and fails to grasp Qi, leading to failure to descend, use Dubuyin Wan or Santian Fengsui Dan. One must seek the reason for failure to descend and treat accordingly; this is descending. How can one rely on Jiu Zhi (Leek Juice), Suzi (Perilla Seed), or Fan Jiangxiang (Sandalwood) as Qi-descending herbs? Regarding the phrase "Not suitable to descend Fire," cunning physicians use it as an excuse, claiming that taking Shengdi and Maidong for hematemesis inevitably leads to consumption. They then sell fake Ejiao to replace these two. Not knowing that seeing a Blood syndrome and generally using Shengdi and Maidong deserves criticism. But discarding these two items is throwing the baby out with the bathwater. Moreover, in my experience, nine out of ten people with upper orifice bleeding fit Danxi's description of "Yang Excess, Yin Deficiency, ascending without descending." Only one or two in a hundred fit Renzhai's "Yang Deficiency, Yin Flees" or Cao's Gancao Ganjiang Tang (Licorice and Ginger Decoction), or Zhao's Jiangxue Danshu's Guifu (Cinnamon and Aconite). For those deficient with Fire, clear and tonify together. For those deficient without Fire, tonify Qi and Blood together. Whether to descend Fire or not depends on the case; there is no fixed method. If taking bitter-cold drugs inevitably leads to death, then Zhang Zhongjing's Xiexin Tang (Drain the Epigastrium Decoction) in the *Jinkui Yaolue* would be the chief culprit, wouldn't it?