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[Wan] Qi belongs to Yang, Blood belongs to Yin. Yang governs movement, and Yin governs stillness. The blood in the human body must not move recklessly. The Classics state: If the Yang collaterals (Yang Luo) are injured, blood overflows outward; outward overflow results in epistaxis (nosebleed). If the Yin collaterals (Yin Luo) are injured, blood overflows inward; inward overflow results in hematochezia (blood in stool). Currently, the fire of the sores and rashes scorches the interior, forcing blood to move recklessly, and blood moves along with the fire. If Yang collaterals are injured, blood exits from the Upper Jiao, resulting either in epistaxis or hematemesis (vomiting blood). If Yin collaterals are injured, blood exits from the Lower Jiao, resulting either in hematuria (blood in urine) or hematochezia. If both Yin and Yang collaterals are injured, blood exits from both above and below. Among all types of hemorrhage, only those bleeding from the nose may have a rationale for treatment; the rest are fatal syndromes. There are also cases where pockmarks ulcerate and cannot scab or contract, with unceasing bleeding; this is hemorrhage from Yang sores and is also untreatable.

[Zhang] The statement that reckless blood flow exiting from the mouth, large and small intestines, Yang sores, or pockmark toxins refers to cases where bleeding is profuse and does not stop; these are considered untreatable. However, if at the initial onset, one carefully deduces the cause and manages it properly, are there really no survivors? If pockmarks are red and painful, accompanied by irritability, heat, thirst, hematochezia, or epistaxis, first use Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) [for hemorrhage]. Then use Jiajian Dazicao San (Modified Great Arneia Powder) [for grayish-white pockmarks], removing Huangqin (Scutellariae Radix) and adding Mutong (Akebiae Caulis) as the main treatment. Wu treated various hemorrhages using Xijiao Dihuang Tang combined with Zhizi (Gardeniae Fructus), Huangqin, Lianqiao (Coptidis Rhizoma - *Note: Text says Qin/Lian, usually implies Huangqin/Huanglian*, here translated as Huanglian Coptidis Rhizoma based on context of clearing heat), and Baishao Yao (Paeoniae Radix Alba) throughout. There were cases where epistaxis at the onset did not stop but responded to purgatives.

[Xue] A child, after developing pockmarks, suffered either epistaxis or hematochezia. The pockmark scars were irregularly red and white, and the fingers alternated between cold and hot. I stated this was due to deficiency of Yuan Qi (Original Qi) and the erratic coming and going of rootless fire. In the morning, Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) was used; in the evening, Wuyi Yigong San (Five Agents and Sufficient Virtue Powder) was used. After more than twenty doses of each, the child recovered. Later, due to mental exertion, the condition relapsed. The same two formulas were used as the main treatment, assisted by Shiquan Dabu Tang (Ten Complete Tonifying Decoction), leading to recovery.

Xijiao Dihuang Tang: Indicated for pockmarks, rashes, and measles accompanied by epistaxis or hematochezia.
Ingredients: Mudanpi (Moutan Cortex), Xijiao (Rhinoceros Horn - *Note: Substitute with Water Buffalo Horn in modern practice*), Chishao Yao (Red Peony Root), Sheng Dihuang (Raw Rehmannia Root).
If heat is excessive, add Jiu Chao Huanglian (Wine-fried Coptidis Rhizoma). If blood stasis stagnates in the chest, add Cu Zhi Dahuang (Vinegar-processed Rheum Palmatum). If bleeding occurs from the mouth and nose, add Daji (Great Thistle Root) and Maogen (Imperatae Rhizoma). If blood appears in urine, remove Dahuang and add Xiaoji (Small Thistle Root). Decoct in water and take warm.

Er Bao San: Indicated for purple-colored pockmarks, fever, epistaxis, hematuria, thirst, and delirious speech.
Ingredients: Xijiao (Rhinoceros Horn), Dai Mao (Trionycis Carapax).
Grind these two ingredients into juice and administer in one dose; recovery will follow immediately.

[Epistaxis and Hematemesis]
[Xue] The "Douzhen Fang" states: When pockmarks are erupting, they should appear slightly, similar in principle to sweating. Although blood and sweat differ, their source is one. Pockmarks arise from foul blood; pathogenic factors knot in the Lung and Stomach, and toxic vapors naturally ascend. If this syndrome appears, do not administer drugs blindly, lest improper treatment cause un-extruded blood stasis to accumulate and already extruded blood to be damaged, generating complications. If there is thirst for cold drinks and heat in hands and feet, this indicates blazing toxic vapors and upward overflow of blood; use Xijiao Dihuang Tang from the "Shengji Zonglu". If epistaxis is caused by Lung Meridian heat-toxin, use Dihuang Qingfei Yin (Rehmannia Lung-Clearing Drink). If hematemesis is caused by Stomach Meridian heat-toxin, also use Xijiao Dihuang Tang from the "Shengji Zonglu". If hematochezia is caused by Intestine-Stomach heat-toxin, use this formula as well. If thirst is for hot drinks and hands/feet are not hot, this is Spleen-Lung Qi deficiency failing to control blood, causing reckless movement; use Wuyi Yigong San. If bleeding is accompanied by thirst, irritability, and a red face, this is blood depletion; use Danggui Buxue Tang (Angelica Tonify Blood Decoction).

A child had epistaxis with a rapid Cun pulse. This indicated Fire in Metal of the Lung. Use Xiebai San (Drain White Powder) to stop bleeding; although limbs became fatigued, recovery followed using Yiqi Tang (Qi-Tonifying Decoction).

A child had red pockmarks, hematemesis, and fever. This indicated Stomach Meridian heat-toxin. First use Xijiao Dihuang Tang from the "Shengji Zonglu"; as symptoms gradually improved, recover with Wuyi Yigong San.

[Wan] Hemorrhage during fever from sores/rashes is generally unfavorable. However, bleeding from the nose indicates Fire punishing the Lung; since the nose is the opening of the Lung, one should drain fire, cool blood, clear the Lung, and use Xuanshen Dihuang Tang mixed with Yujin powder, plus Maogen juice and Jingmo ink juice to drink. If epistaxis stops, it is good; if it continues incessantly, it is untreatable.

Xuanshen Dihuang Tang
Ingredients: Xuanshen (Scrophulariae Radix), Sheng Dihuang (Raw Rehmannia Root), Mudanpi (Moutan Cortex), Zhizi Ren (Gardeniae Fructus) [1.5 qian each], Gancao (Licorice Root), Shengma (Cimicifugae Rhizoma) [0.5 qian each], Baishao Yao (Paeoniae Radix Alba) [1 qian].
Chop finely. Add Ban Chao Puhuang (Stir-fried Typha Pollen) 0.5 qian. Decoct in one cup of water until reduced to 0.7 cup. Remove dregs and take warm.

Zhan Guan San: Indicated for purple pockmarks with fever and unceasing epistaxis.
Ingredients: Sheng Dihuang (Raw Rehmannia Root), Mudanpi (Moutan Cortex), Huangqin (Scutellariae Radix) [0.5 fen each], Shengma (Cimicifugae Rhizoma) [0.3 fen], Ou Jie (Lotus Rhizome Node), Maogen (Imperatae Rhizoma) [1 qian each], Lv Dou (Mung Bean) [49 grains].
Decoct in water and take.

[Hematochezia]
For children with blood in stool, observe the nature of the blood and the timing. If pockmarks are vigorous and stool has been retained for several days, with blood coming out with feces, this is injury to the anal region causing bleeding. If pockmarks have retracted and stool contains pus and blood, this is blood from Dao Ye (retraction/inversion of pockmarks). Apart from these two categories, any hematuria or hematochezia indicates deterioration of Zang-Fu organs and reckless movement of Yin blood, which is a certain death sign.

[Xue] Wenren said: If pockmarks present with blood in stool or black feces, and the patient sleeps without waking, this is an ominous sign indicating excessive internal heat. Treat with Xijiao Dihuang Tang, Baolong Wan (Dragon-Holding Pill), and Xiao Chaihu Tang (Minor Bupleurum Decoction) added with Sheng Dihuang. I opine that if the aforementioned symptoms include alternating chills and fever with thirst, use Xiao Chaihu Tang added with Sheng Dihuang. If fever and fatigue occur, use Wuyi Yigong San added with Danggui (Angelicae Sinensis Radix). If dry mouth and thirst occur, use Renshen Baizhu San (Ginseng and Atractylodes Macrocephala Powder). Generally, thirst with desire to drink and fever indicates Excess Heat; thirst for hot drinks with non-hot extremities indicates Deficiency Heat; cold extremities indicate Deficiency Cold. Physicians must examine carefully.

A child had pockmarks with blood in stool and failure to erupt. My father attributed this to deficiency of Qi and Blood. Use Zicao Kuiban Tang (Arneia Rapid-Eruption Decoction) added with Renshen (Ginseng), Fuling (Poria), Danggui, and Baizhu (Atractylodis Macrocephalae Rhizoma). Bleeding stopped instantly, pockmarks erupted, and recovery followed with Bazhen Tang (Eight Treasures Decoction).

A child had pockmarks with blood in stool, red urine, pockmarks colored like ochre, fever, desire for cold drinks, and difficulty in urination and defecation. My father attributed this to Excess Heat in the Heart and Small Intestine. Use Bazheng San (Eight Correctives Powder), followed by Jiedu Fangfeng Tang (Detoxification and Saposhnikovia Decoction) and drinking Celery Juice, leading to recovery.

A child had hematochezia as pockmarks were nearly healing, with pale face, aversion to cold, and inability to pass stool despite urge. I attributed this to deficiency of Yuan Qi sinking downward. Use Yiqi Tang. The family did not believe this and administered blood-cooling agents, resulting in vomiting, diarrhea, abdominal pain, and death.

A child had hematochezia as pockmarks were nearly healing, with pale face, aversion to cold, cold hands and feet, and a deep, fine pulse almost imperceptible. I attributed this to deficiency and cold of Yang Qi, proposing Renshen, Jiang (Ginger), and Gui (Cinnamon Bark). The family refused. The next day, the child died with blue-black hands and feet. Regrettable.

A child had blood in stool for three to four days after pockmark eruption, a few drops daily, failing to erupt by the eighth day. Imperial Physician Qian Chunlin attributed this to deficiency and cold of Spleen Qi. Use Muxiang San (Costus Powder) for two doses, adding Dingxiang (Caryophylli Flos) 11 grains and Renshen 5 qian. The next day, pockmarks erupted with pus, bleeding stopped, and recovery occurred after twenty-plus days.

[Hematuria]
[Yuan] Hematuria occurring two to three days after pockmark eruption is named "Qin Sha Hong" (Soaking Sand Red). This is because fierce toxins gather in the Heart, the Heart loses its mastery, and blood rushes recklessly following the toxin. The Heart connects to the Small Intestine, pouring into the Bladder, causing hematuria. Urine may resemble black bean juice or Sa Mu (Sappan Wood) water. Cases with pain are easier to treat; those without pain are difficult.

Main Formula
Ingredients: Mutong (Akebiae Caulis), Sheng Dihuang (Raw Rehmannia Root), Huangqi (Astragali Radix), Chishao Yao (Red Peony Root), Xijiao (Rhinoceros Horn), Diyu (Sanguisorbae Radix), Shengma (Cimicifugae Rhizoma), Zicao (Arnebiae Radix et Rhizoma), Cheqian Ye (Plantaginis Leaf) [use heavily], Dengcao (Junci Medulla).
Decoct in water. If painful, add Gancao Shao (Licorice Root Tip), Huashi (Talcum), and Zhizi (Gardeniae Fructus).

In my treatment of this pockmark type, the key lies in clearing the Heart and resolving toxicity, ensuring Yin blood returns to the Ying (Nutritive) level. The use of Shengma and Huangqi requires careful observation before administration; one must not rigidly adhere to a formula to harm people. If urine resembles black bean juice, toxins have rushed to the Heart and Ying Yuan (Source) has separated; eight or nine out of ten will die. If accompanied by dysuria, with blood clots remaining like cotton threads an inch long, crying when attempting to urinate due to unbearable pain, urgently use Chao Zhizi powder (Stir-fried Gardeniae Fructus) mixed with Qinglongxu Cao juice (Equisetum Hiemale Juice) to take, followed by Mutong Tang. This may work.

[Skin Rupture and Bleeding]
[Xue] Wenren said: Constipation, hematuria resembling blood, carbuncle/toxin formation, and ruptured pockmarks on the body indicate blazing internal fire due to failure to resolve and promote drainage. Urgently treat with Xijiao Dihuang Tang, Xiao Chaihu Tang added with Sheng Dihuang, or Sishun Yin. I opine that if Heart-Spleen heat is excessive, use Xijiao Dihuang Tang. If Heart-Liver heat is excessive, use Xiao Chaihu Tang added with Sheng Dihuang. If constipation exists, first use Sishun Yin, then Xijiao Tang. If severe redness and pain with obstruction of both bowels and urine occur, urgently use Huoming Yin (Life-Saving Drink) added with Xiaoshi (Mirabilite) and Dahuang. If redness, pain, aversion to cold, and fever occur, use Huoming Yin added with Mahuang (Ephedrae Herba). If caused by the nursing mother's anger/fire, use Jiawei Xiaoyao San (Modified Free and Easy Wanderer Powder) and Jiawei Guipi Tang (Modified Restore the Spleen Decoction).