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(Ohematemesis, spitting blood, coughing blood, expectorating blood, blood extravasation, bleeding from the nine orifices)

Miu Zhongchun (Zi: Zhongchun) said: There are three principles for treating hematemesis. First, it is advisable to promote blood circulation rather than merely stop bleeding. When blood does not follow its normal pathways, it is due to rebellious Qi obstructing upwards. Promoting blood circulation allows the blood to return to the meridians, and the bleeding will stop spontaneously; if one forcibly stops the bleeding, blood stasis occurs. Blood stasis leads to fever and loss of appetite, causing the disease to become chronic and stubborn. Second, it is advisable to tonify the Liver rather than attack it. The Classics state: The five Zang organs store essence and Qi without leaking them. The Liver governs the storing of blood. In patients with hematemesis, the Liver has lost its proper function. Nourishing the Liver calms the Liver Qi, allowing blood to have a place to return; attacking the Liver causes Liver deficiency, leading to an inability to store blood, resulting in even more profuse bleeding. Third, it is advisable to direct Qi downward rather than clear fire. Excess Qi generates fire. Directing Qi downward lowers fire; once fire is lowered, Qi no longer rises, and blood follows Qi, preventing the hazard of overflowing from the upper orifices. Lowering fire requires cold and cool agents, but this often damages Stomach Qi. Damaged Stomach Qi impairs the Spleen's ability to control blood, making it even harder for blood to return to the meridians.

Currently, there are two major pitfalls in treating hematemesis. One is the exclusive use of cold and cool herbs, such as Huangqin (Scutellariae Radix), Huanglian (Coptidis Rhizoma), Shanzhi (Gardeniae Fructus), Siwu Tang (Four Substances Decoction), Zhimu (Anemarrhenae Rhizoma), and Huangbai (Phellodendri Cortex). These often damage the Spleen, causing diarrhea, leading to untreatable conditions. The other is the exclusive use of Renshen (Ginseng Radix et Rhizoma). For those with Lung heat, using Renshen harms Lung Qi, worsening cough. There are cases where Renshen cures the condition, but these are cases of Qi deficiency causing wheezing and coughing. Qi belongs to Yang and is not caused by Yin deficiency with blazing fire; such cases are rare, one or two in a hundred.

Liu Mosheng said: Regarding hematemesis, people only know that rebellious Qi causes blood extravasation and rising fire causes blood flooding. They do not realize that within the Zang-Fu organs, there are diaphragmatic membranes that separate and fix the blood, preventing it from permeating and overflowing. The so-called diaphragm is extremely thin and fragile; any injury causes it to rupture, leading to upward bleeding. Thus, "injury to the Yang collaterals causes blood to overflow upwards, while injury to the Yin collaterals causes blood to seep downwards." If an already injured membrane suffers further injury, the vomiting of blood will be severe. Although the diaphragm is injured, blood stasis forms at the site, slowing the flow. However, if sudden Yin fire breaks through the accumulated blood stasis, blood surges like a tide, accompanied by audible gurgling sounds. At this moment, breathing is irregular, the face is red as if drunk, restlessness prevails, and the mind is chaotic. This is the manifestation of Dragon-Lei Fire (Ministerial Fire) raging, and the pulse is rapid and difficult to assess. After a short while, when the fire subsides and clarity returns, the face becomes pale, breathing stabilizes, and bleeding gradually stops. Only then can the pulse be palpated. Medication should be administered at this time, after the stasis has been cleared, followed by gradual regulation and slow tonification. However, one must avoid sudden cloying tonification and must not use herbs that consume Qi. Understanding these principles provides the foundation for treating blood disorders.

Blood vomited by the patient consists of Yin blood and Yang blood. Yang blood moves with Qi, circulating within the vessels, harmonizing the Five Zang organs, and distributing to the Six Fu organs; this is called Ying blood (Nutritive Blood). Yin blood resides in the collaterals, guarding the Zang organs, nourishing Shen (Spirit), and moistening sinews and bones. If the Zang organs are injured by internal or external pathogens, the Yang blood traveling along the meridians reaches the injury site, is blocked by the pathogen, and leaks out of the meridians. Or, the Yin blood residing in the collaterals, due to lingering pathogens causing tearing, enters the intestines and stomach and is excreted.

The laypeople often refer to lower bleeding as Changfeng (Intestinal Wind), unaware that "Wind" is merely one of the Six Evils. If Wind pathogen invades and lodges in the intestinal and gastric meridians, or if external Wood-Wind pathogen attacks the intestines and stomach internally, it may be called Changfeng. But what if the bleeding is not caused by Wind, but by Heat and Fire evils affecting the intestines and stomach, combined with stagnation of Qi due to Cold, Heat, Dryness, or Dampness, along with irregular diet and excessive exertion damaging the Yin collaterals? Can this also be called Changfeng? Generally, blood from Changfeng is clear and bright red, spraying like splashes, which is characteristic of Wind nature, as stated in Suwen: "Long-standing Wind entering the interior leads to Intestinal Wind and undigested stool diarrhea." Initially administer Xieqing Wan (Drain Green Pill) for one or two doses, then Xiaoyao San (Free and Easy Wanderer Powder) with Jiu Zhu Huanglian (Wine-processed Coptidis Rhizoma), Qianghuo (Notopterygii Rhizoma), Fangfeng (Saposhnikoviae Radix), and Wumei (Mume Fructus). For deficient individuals, Renshen Weifeng Tang (Ginseng Stomach Wind Decoction) is most effective. What people do not know is that if blood shoots from the anus like a thread or drips continuously, it is blood from the Five Hemorrhoids (Wu Zhi) and should be treated according to the Hemorrhoid chapter. Blood that is turbid and dark black indicates Zangdu (Visceral Toxin), where toxic vapors accumulate over time before manifesting. Use Xiaowuchen Tang (Minor Black Still Water Decoction) to deliver Heishen San (Black Divine Powder). For cases with excess pulse, constipation, and vigorous pathology, use Zanglian Wan (Visceral Connection Pill). For Changfeng complicated by damp-toxin, where stool resembles bean curd dregs mixed with purple-black stasis, this is dampness brewed from rich wine and heavy flavors, entering the Stomach via the Foot-Yangming Meridian and overflowing downward. For fine pulses indicating Cold, use Shengyang Chushi Fangfeng Tang (Raise Yang Drain Dampness Saposhnikovia Decoction). For rapid pulses indicating Heat, remove Baizhu (Atractylodis Macrocephalae Rhizoma) and Cangzhu (Atractylodis Rhizoma), add Huanglian (Coptidis Rhizoma), Danggui (Angelicae Sinensis Radix), and Gancao (Glycyrrhizae Radix). For Changfeng lower bleeding, use Liuji Nu (Artemisiae Anomfoliae Herba) half liang, Yacha (Sprouted Tea) one liang, and Meihui (Ink Ash) three qian, ground into powder, divided into three doses, taken with Wumei Tang (Mume Decoction); bleeding stops immediately. Afterwards, take Guipi Tang (Restore the Spleen Decoction) frequently for regulation.

For Changfeng lower bleeding, if blood sprays out separately, shooting far and wide like a sieve, accompanied by abdominal pain, this is caused by Yangming Qi rushing with heat-toxin. Use Renshen Baidu San (Ginseng Detoxifying Powder). If ineffective, use Shengyang Chushi Hexue Tang (Raise Yang Drain Dampness Harmonize Blood Decoction). For chronic blood disorders, if purple-black blood is passed due to seasonal heat, this is damp-toxin intestinal disease, involving Yangming and Shaoyang meridian syndromes. Use Shengyang Yishen Tang (Raise Yang Tonify Kidney Decoction). For prolonged lower bleeding with sallow complexion and deficiency of the lower origin, use Sizijunzi Tang (Four Gentlemen Decoction) plus Huangqi (Astragali Radix), Danggui (Angelicae Sinensis Radix), and Shaoyao (Paeoniae Radix). Use Duanhong Wan (Stop Red Pill). For severe deficiency, use Shiquan Dabu Tang (Ten Complete Great Tonifying Decoction) minus Fuling (Poria) plus Fangfeng (Saposhnikoviae Radix). Jiegu said: For lower bleeding, Fangfeng (Saposhnikoviae Radix) is the upper envoy, Huanglian (Coptidis Rhizoma) is the middle envoy, and Diyü (Sanguisorbae Radix) is the lower envoy. Qianjin Fang states: Bleeding appearing before stool is distant blood (Yuanxue), suitable for Huangtu Tang (Yellow Earth Decoction); bleeding appearing after stool is near blood (Jinxue), suitable for Chixiaodou Danggui San (Adzuki Bean and Angelica Powder). (Note: Jingui Yaolüe states stool before bleeding is distant blood and bleeding before stool is near blood, which is a transcription error. Because Cold in the Stomach fails to control blood, losing its transport function, it descends, thus Huangtu Tang is used to warm it. If Heat in the Large Intestine fails to hold blood, causing Ying blood to move too fast and descend, Chixiaodou Danggui San is used to clear it.) Bright purple-red blood indicates Heat injuring Yin collaterals; use fried and powdered Huaihua (Sophorae Flavescentis Flos) taken with rice soup. Huaijiao paste (Fructus Sophorae) is especially good. Pale, thin blood indicates Spleen deficiency; use single herb Baizhu (Atractylodis Macrocephalae Rhizoma) made into pills with rice soup. Dark, dull blood indicates accumulated stasis; use 2 liang of human hair (Luankou) and 4 liang of Honghua (Carthami Flos), calcined in a red-hot jar until ash, discard Honghua ash, keep only hair ash, grind finely, divide into three doses, taken on an empty stomach with decoction of fried black Diyü (Sanguisorbae Radix); effect seen in three days. Although lower bleeding is said to be due to Large Intestine accumulation of Heat, one must distinguish deficiency and excess, avoiding pure cold agents, and must add acrid-dispersing herbs as the main component. For chronic cases, regulate Stomach Qi and add lifting herbs. Therefore, lower gastrointestinal bleeding is often resolved by treating the Stomach, not merely using bitter-cold herbs.

Dai Fu'an said: Bright red color indicates Heat; dark, pale color indicates Cold. Cold blood results from Cold in the intestines and stomach disrupting Ying blood transport, descending abnormally; treat with Siwu Tang (Four Substances Decoction) plus Paojiang (Processed Ginger) and Zhigancao (Honey-fried Licorice). Hot blood results from Heat-toxin accumulating in the intestines and stomach, or from excessive alcohol consumption and eating fried/roasted foods; treat with Siwu Tang plus Qianggen (Rubiae Radix), Huaihua (Sophorae Flavescentis Flos), Jiu Huanglian (Wine-processed Coptidis Rhizoma), and Chaohei Shanzhi (Stir-fried Black Gardeniae Fructus). If bleeding is caused by cold drinks or raw/cold foods congealing the blood, abdominal pain and dull-pale color occur; treat with Fuzi Lizhong Tang (Aconite Regulate the Middle Decoction) with doubled Paojiang (Processed Ginger) and Jiu Lian (Wine-processed Coptidis Rhizoma). Yin-constriction hematochezia refers to Jueyin Liver blood constricting internally, unable to be transported by Yang Qi, seeping into the intestines and descending; this is not internal Yin-Cold constriction. Treat with Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with doubled Huangqi (Astragali Radix) and Paojiang (Processed Ginger). For the above two syndromes, various schools adopt Baogjian Pingwei Diyü Tang (Treasure Mirror Calm Stomach Sanguisorba Decoction) and Jieyin Dan (Bind Yin Pill). I dare to correct those who fail to discern their validity.

For internal injury with blood stasis, presenting with acute pain in the chest, hypochondrium, and lower abdomen, use Taoren Chengqi Tang (Peach Kernel Downward-Pursuing Decoction) or Dai Didang Tang (Iron Mortar Replacing Dandang Decoction), selecting based on pain location. Dahuang (Rhei Radix et Rhizoma) should be soaked in Tongbian (Child Urine) and processed with Jiuzhi (Leek Juice). For deficient individuals, add a small amount (2-3 fen) of Guizhi (Cinnamomi Ramulus) and Fuzi (Aconiti Lateralis Radix Praeparata). If stasis is dark and not fresh, long-term treatment requires warming-blood herbs to achieve efficacy. For blood depletion with dry stool and passage of bright-purple blood, this is due to Large Intestine dryness. Use single herb Huaijiao Gao (Sophora Fruit Paste) to cool and moisten. Another prescription: Mix real sesame oil with rotten flowers, eat on an empty stomach; cured in three days. For Changfeng hematochezia, use single herb Hanlian Hua (Ecliptae Herba), decoct strongly with Congbai (Scallion White), rinse mouth and swallow; effective in one dose. Another prescription for Changfeng hematochezia: Liuji Nu (Artemisiae Anomfoliae Herba) half liang, Songluo Cha (Songluo Tea) one qian, Wumei Rou (Mume Flesh) one piece, decoct and take; effective. For poisoning by Gu (worms) causing organ failure, passing blood like chicken liver or rotting meat, with severe heart-abdominal colic, treat with Maligen Mo (Marli Root Powder), taken with water using a square-inch spoon, expelled via vomiting.

Li Shicai treated a man suffering from Changfeng lower bleeding. Having used Siwu Tang, Huangqin, Huanglian, and Huaihua for a long time without success, with recurrent episodes and sallow complexion, his pulse was floating and moderate only in the Spleen position. This indicated Earth deficiency with concurrent Wind-Dampness. He prescribed Cangzhu (Atractylodis Rhizoma) 3 qian, Fuling (Poria), Renshen (Ginseng Radix et Rhizoma), Huangqi (Astragali Radix), Shengma (Cimicifugae Rhizoma), Chaihu (Bupleuri Radix), and Fangfeng (Saposhnikoviae Radix) each 1 qian. After four doses, bleeding stopped. Switched to Shiquan Dabu Tang (Ten Complete Great Tonifying Decoction) for regulation, resulting in recovery.

Shiwan treated Wu Xing Han Jin Du Chunjie Jin Xuan, who suffered from abdominal pain, diarrhea, and lower bleeding. After using Xianglian Wan (Fragrant Coptis Pill), food intake became difficult, lower abdomen felt tight and knotted, urinary retention occurred, yet there was no desire for hot drinks. The complexion was sallow, and he passed blood more than fifty times day and night. Upon consultation, the Qi Kou pulse was deep, fine, and tight. The blood passed was dark and turbid like amaranth juice. Prescribed Lizhong Tang (Regulate the Middle Decoction) with Rougui (Cinnamomi Cortex) 2 qian. After one dose, urination resumed, and the lower abdomen relaxed. After two doses, bleeding decreased and appetite improved. After four doses, diarrhea reduced to three or four times daily, with slight white pus in the stool. Prescribed Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with Paojiang (Processed Ginger). After four doses, he recovered.