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Blood effusion and blood discharge are numerous in manifestation, yet there are cases that do not require forced differentiation. They are now summarized into nine categories, headed by a general discussion, as their formulas are often interchangeable.

**Overview of Etiology** Blood is like water; when water flows underground and all rivers are regulated, there is no fear of blockage or bursting. Blood circulates through the Ying (Nutrient) meridians and Fu-Shu (Stream-Spring) points of the body; if it is not injured externally by the Four Qi (Wind, Cold, Summer-heat, Dampness) nor depressed internally by the Seven Emotions (Joy, Anger, Worry, Thought, Grief, Fear, Fright), it flows naturally and smoothly. If there is even slight disharmony in its regulation, blockage inevitably occurs. Consequently, blood cannot follow the meridians to nourish the hundred vessels; it may become stagnant or scattered, flow downward abnormally, or rush upward and overflow. Thus arise various syndromes such as hematemesis (vomiting blood), epistaxis (nosebleed), bleeding from the bowels and bladder, hematohidrosis (sweating blood), and hemoptysis (coughing up blood). Among the ten types of blood loss, none is more severe than this. Differentiating according to syndromes allows for appropriate treatment. (*San Yin Fang*)

The harm caused by blood manifests as hematemesis and epistaxis when it acts recklessly, and as consumptive disease (Xu Lao) when it is depleted. When blood stasis accumulates in the upper part, the person becomes forgetful; when it accumulates in the lower part, the person becomes manic. Encountering cold causes tendons to lose nourishment and become spasmodic; accompanying heat causes internal toxicity and stasis leading to jaundice. In the urine, it presents as painful dysuria; in the stool, it presents as intestinal wind (blood in stool). In women, regarding the advancement or retardation of menstruation, leukorrhea with bleeding, and metrorrhagia, the diseases are varied. All these are caused by blood. (*Zhi Zhi Fang*)

Humans possess Yin and Yang, and thus have Qi and Blood. Qi is Yang, Blood is Yin. Men are governed by Yang, so Yang prevails over Yin; women are governed by Yin, so Yin prevails over Yang. Diseases of Qi and Blood are the same for both men and women. Everyone knows that a hundred diseases arise from Qi, but who knows that Blood is the womb of a hundred diseases? Blood is like water; when water flows underground and rivers are regulated, there is no fear of obstruction. If human blood vessels stagnate in the meridians, channels, stomach, and intestines, the roots of a hundred diseases arise from here. Alternating chills and fever, jaundice and macules, spontaneous fright and mania, irritability and oppression, vomiting and nausea, sticky phlegm and spontaneous sweating, flushing and consumptive disease, painful dysuria, leukorrhea and metrorrhagia, hematemesis, epistaxis, coughing and spitting, dizziness and syncope, cold extremities, confusion and forgetfulness, masses and pain, difficulty in movement and urinary incontinence—all these syndromes, what else could they be but blood diseases? The classic says, "First remove the blood, then regulate it," which is indeed well-founded. (Ibid.)

Its pathology involves deficiency and stagnation, heat and cold. Blood deficiency leads to Yang excess; Yang excess leads to Fire stirring; Fire stirring carries blood upward, escaping through the orifices to cause syndromes such as hematemesis, vomiting blood, and epistaxis. In blood heat, Yang Qi sinks into the Blood, making the Blood hot; following Qi downward, it causes hematuria, hematochezia, metrorrhagia, and intestinal wind bleeding. Blood cold coagulates between the Zang-Fu organs, causing mass diseases (Jia Ji). Blood stagnation accumulates in the skin, causing toxic abscesses with pus. (*Yuan Li*) (Note: *Yi Yi Shang* also discusses deficiency, stasis, cold, and heat; refer to the overview of syndrome differentiation and treatment.)

Blood is originally Yin Essence and should not move; movement causes disease. Blood manages Ying Qi and Shen Qi and should not be damaged; damage causes disease. Generally, movement is due to Fire; excessive Fire forces blood to act recklessly. Damage is due to Qi; Qi injury means Blood has nowhere to reside. Thus, some injure Fire through the Seven Emotions, some injure Qi through the Seven Emotions; some stir Fire through fatigue and sexual indulgence, some injure Yin through fatigue and sexual indulgence. Or external pathogens remain unresolved, with Heat郁 (stagnating) in the meridians; or indulgence in alcohol without restraint stirs Fire in the Stomach; or Middle Qi deficiency and cold fail to secure and hold, causing sinking and collapse downward; or Yin excess repels Yang, causing Fire to lose its root and overflow upward. These are all causes of moving blood. Thus, reckless movement above appears in the seven orifices; flow downward exits through the two yin openings; or congestion and stasis in the meridians develop into carbuncles, ulcers, and pus-blood; or depression and knotting in the Zang-Fu organs remain as blood masses and blood syndromes; or encountering Wind-Heat causes macules and rashes; or stagnating Yin-Cold causes pain and bi-syndrome. These are all syndromes of blood disease. (*Jing Yue Quan Shu*)

**Blood Overflows When It Gets Hot** The *Nei Jing* states that if Gallbladder Heat shifts to the Brain, it causes nasal congestion and sinusitis (Yuan), transmitting to nosebleed and blindness. Blood overflows when it gets hot and coagulates when it gets cold. The Gallbladder receives Stomach Heat, follows the meridians upward to shift to the Brain. Generally, if the Yang collaterals overflow, blood acts recklessly; in the nose, it is epistaxis; in the sweat pores, it is hematohidrosis. The two are different; this is the fault of heat-jue blood overflow. (*Sheng Ji Zong Lu*) (Note: My late father said: Hematohidrosis, Wang Shi annotates as "filthy blood," seen in *Shuo Wen*. *Sheng Ji Zong Lu* interpreting it as sweat is too loose.)

All Qi belongs to Yang, all Blood belongs to Yin. Yin excess leads to Yang deficiency; Yang excess leads to Yin deficiency. The classic says, "Yang excess causes Yin disease, Yin excess causes Yang disease." Various blood syndromes and epistaxis occur because Yang Qi invades Yin, injuring Yin Qi, causing blood to leave its normal path, exiting from the mouth or nose. If it erupts suddenly with bright red color, accompanied by heart vexation and irritability, desiring to draw out blood, reaching one or two dou, this is Yang pathogen violently entering the Yin division. Blood gets hot and scatters. Human menstrual blood is like the rivers of heaven and earth; when the weather is hot and the earth is warm, the rivers boil and surge. Thus, there are epistaxis and lung abscesses, with syndromes largely similar but slightly different. (*Ji Feng Pu Ji Fang*)

Blood acting recklessly never arises without Heat. Generally, blood gets hot and overflows; when both Blood and Qi are hot, blood follows Qi upward, resulting in hematemesis and epistaxis. (*Ji Sheng Fang*)

Blood closes and becomes astringent when cold, and flows freely when hot. When Ying Qi is deficient and exhausted, and Wind-Cold invade mutually, it is easy to become a syndrome of consumptive disease and amenorrhea. As for bleeding syndromes, they are mostly caused by accumulated Heat. Once the Ying pathway opens, blood becomes uncontrollable. (*Zhi Zhi Fang*)

Blood follows Qi; when Qi is cold and moves slowly, blood becomes astringent and stagnant; when Qi is hot and moves fast, blood boils. Blood belongs to Yin and does not move without Yang, so it coagulates when encountering cold; Qi belongs to Fire and strengthens when scarce, so it burns when encountering heat. (*Yi Biao*)

**Principles of Upward Overflow and Downward Collapse** A question was asked: Human Yang Qi guides Yin Blood, and Yin Blood grounds Yang Qi. Why do Clear and Turbid interfere with each other, disturbing inside and outside, causing blood to leave its meridians, leading to the danger of upward overflow and downward collapse? Blood may be vomited, spat, coughed up, come from the nose, eyes, ears, teeth, tongue, saliva, skin, or bowels/bladder, or accumulate without flowing, each causing different harms. Please reveal the profound principles, categorizing the sources of Zang-Fu and meridians to enlighten beginners. Shi Wen answered: The classic says Blood and Qi are different names for the same substance. Although divided into Yin/Yang and Clear/Turbid, they are all transformed from the essence of food and water. Initially mixed as one, without distinction of Clear and Turbid, driven by Spleen Qi, they rise like mist to the Lung to become Qi. If Qi is not consumed, it returns to the Kidney as Essence. If Essence is not leaked, it returns to the Liver to transform into clear Blood. If Blood is not drained, it returns to the Heart, transformed by Li Fire into True Blood, nourishing the Spleen, governing movement, and sustaining life. Nothing is more precious than this. Although the classic says "upper injection to the Lung transforms into Blood," it essentially does not depart from the transformation of Five Elements Qi, circulating like a ring. What was said above merely summarizes the main aspects of Ying, Wei, Blood, and Qi. Ying and Wei are Essence Qi; Blood is Shen Qi. Qi warms, Blood moistens. Although Qi inherits Yang harmony and Blood inherits Yin substance, Yin contains Yang and Yang contains Yin; they cannot be strictly separated. The most pure and clear, obeying the Sovereign's command, harmonizes the five Zang organs, storing without losing, is the blood that nourishes the Zang. The turbid within the clear, wielding transport power, sprinkles the six Fu organs, full but not clogged, is the infused blood. The clear within the clear, meeting the measure of Ying circulation, flows through the hundred vessels, full but not leaking, is the Ying meridian blood. Their source is one, analyzed into three, each having its jurisdiction. If each guards its territory, Yin and Yang will be balanced and secreted; how could there be upward overflow and downward collapse? Generally, because human constitution has biases, and labor/injury has biases, blood leaks from the place of deficiency or excess. Since constitution is biased, food and water mostly follow the biased Qi transformation; the strong becomes stronger, the weak becomes weaker. Yang excess leads to Yin decline; Yin decline leads to Fire prosperity; Fire prosperity causes blood to overflow upward. Yin excess leads to Yang weakness; Yang weakness leads to Fire decline; Fire decline loses its control, causing collapse downward. The overflowing blood is not solely due to Fire excess; the collapsing blood is not solely due to Yang decline. But if the color is bright purple and thick, it is Fire excess; if the color is dull and pale without luster, it is Yang decline. Investigating the source of collapse, it may be due to rebellious Zang Qi or disordered Fu Qi, both causing disease. Upward overflow must pass through the Lung and Stomach; downward collapse must occur through the large and small intestines, and descend via the Bladder. (*Yi Tong*) (Below distinguishes the colors of blood from the five Zang and stomach/intestines, recorded later.)

**Pulse Diagnosis (Color Diagnosis, Death Syndromes)** Chi pulse slippery and rapid indicates Blood deficiency. Choppy indicates little blood. Pulses showing choppy, soft, and weak indicate blood loss. Pulses have Yin and Yang; if both Duyang and Shaoyin pulses are faint, and the person does not vomit, there must be blood loss below. (*Mai Jing*)

If the pulse is洪数 (Surging-Rapid), it is unfavorable; if微小 (Minute-Small), it is favorable. (*Ji Feng Pu Ji Fang*)

In all syndromes of blood loss, the Kou (Hollow) pulse appears. Depending on its position (upper/lower), verify the exit point. Generally, in blood loss, the pulse should be deep and fine. If floating and large, it will be difficult to treat later. (*Cui Shi Mai Jue*) (Note: Kou pulse in blood loss originates from Zhang Zhongjing. "Pulse should be deep and fine" originates from *Nan Jing · Chapter 17*.)

The classic says: Those presenting with blood, fever, and large pulse are difficult to treat; this is Fire pathogen prevailing. Those with cool body and quiet pulse are easy to treat; this is righteous Qi recovering. (*Dong Yuan Shi Xiao Fang*)

Pulse in blood loss should be deep, fine, harmonious, and slow; not floating, large, or solid-large. (*Hui Chun*)

Generally, in blood loss, the pulse is surging, large, and powerless, i.e., Kou pulse. Since Yin Blood is deficient, Yang has no foundation, floating and scattering outward, hence this image; thus, postpartum patients often show this pulse. Mistaking it for Excess Fire greatly violates [principles]. (*Liu Yao*)

Generally, after illness, coughing and vomiting blood with a large and chaotic pulse indicates injury to the Yang collaterals of the Upper Jiao; lower bleeding and hematuria indicate injury to the Yin collaterals; both are critical. (*Zhun Sheng*)

Mostly, pulses in blood loss should be deep, fine, soft, and weak, or floating/sinking harmonious and slow, or surging/large but not rapid, or floating/sinking slippery and slow, or deficient/faint. Or in sudden vomiting/collapse, all six pulses vanish. This pulse matching the disease is easy to treat. Or if floating/Kou/floating-leather appear, or floating/sinking both choppy, or knotted/short, this pulse indicates deficiency while the disease is heavy; if treated appropriately, many recover. If floating-rapid/surging-rapid appear, or fine-rapid without drumming, or floating-large and scattered, or hurried/intermittent and powerless, or slippery without Stomach Qi, or wiry/tough, or solid-large, or fine-small and forceful/rapid, this disease-pulse reversal indicates untreatable conditions; even with Lu Bian (Lu Qian and Bian Que), hands would be tied. So the classic says: Yang path is solid, Yin path is deficient. Yue Ren (Bian Que) said: Fine indicates deficiency, Tough indicates excess. In blood loss, pulse should be deep and fine; reversing to floating-large and tough is death; deficiency disease showing excess pulse. Blood moistens collaterals, body governs Yin stillness. Before blood loss, collaterals are moist, soft, harmonious, and slow. When intense heat forces blood to overflow externally, True Yin is exhausted, leading to Yin exhaustion and Yang hyperactivity. Fire fills empty houses, showing excess pulse, causing solitary Yang to function alone. How can it survive alone? Also, diagnose by color. After blood loss, if face shows yellow/green/white with spirit, or eyes closed preferring sleep, or limbs warm, diet normal, or dislike loud voice, voice faint not harsh, this is favorable, without other clashing syndromes, easy to treat. If face is green/dark without luster, or malar flush, lips/mouth like vermilion, or alternating sleep/wake, vexation/insomnia, or body very hot, or four limbs cold, or breath short/rough, or shouting/harsh speech, or delirium/mania/coma, or grasping clothes/touching bed, muscle twitching/tendon tremor, or sweating like rain, head sweat only, or whole body cold, skull/fontanelle hot, or eye sockets sunken. Or thirst wanting water, or limbs swollen/full, or umbilical/abdominal colic unceasing, or Stomach Qi failed, vomiting/refusing food—all these are ominous signs, untreatable. (*Xuan Qi Jiu Zheng Lun*)

**Overview of Syndrome Differentiation and Treatment** Causes of blood disease are four: Deficiency, Stasis, Cold, Heat. Methods of treating blood are five: Tonify, Purge, Break, Cool, Warm. Blood deficiency syndromes: morning cool/evening hot, heat in palms/soles, dry/scaly skin, white lips, irregular menstruation in women, faint/small/powerless pulse. Method: Tonify. Blood heat syndromes: epistaxis/hematemesis, hematochezia/hematuria, afternoon fever, early menstruation in women, faint/small/rapid pulse. Method: Cool. Blood cold syndromes: inability to match Qi, losing operational rhythm, numbness/weakness, dull skin, abdominal mass/pain, late menstruation in women, faint/small/slow pulse. Method: Warm. Blood stasis in Upper Jiao: Upper Jiao heat, vexation, rinsing mouth without swallowing. Method: Cool and Break. Blood stasis in Lower Jiao: manic-like, delirious/thirsty, jaundiced body/eyes, black tongue, lower abdominal fullness/pain, free urination, constipation. Method: Purge. Blood stasis with Cold: no headache, no aversion to cold, body heat/thirst, incoherent speech, seeing ghosts, free urination, black stool. Method: Warm and Promote. (*Yi Yi Shang*)

Generally, stasis is easy to treat; dryness is hard to cure. (*Yi Biao*)

Once stasis is removed, new blood generates, so it is easy to treat. If the Sea of Blood is dry, Yin cannot grow suddenly, so it is hard to treat. (*Yi Ji*)

**Hemoptysis and Hematuria** When blood fills the eyes, vision is clear; fills ears, hearing is acute; fills limbs, movement is strong; fills skin, complexion is white. Stained, it turns black; lost, it turns yellow. External heat makes it red; internal heat steams upward to the throat. Or steams downward to the large intestine as small orifices. Throat has orifices, so hemoptysis kills; intestine has orifices, so hematochezia kills. Hematochezia can still be stopped; hemoptysis is hard to cure. Throat stops nothing; even a hair causes cough. Blood seeping into throat, the more it seeps, the more it coughs; the more it coughs, the more it seeps. Drinking diuretics saves one in a hundred. Taking cold-cooling herbs kills one in a hundred. Although Blood is Yin category, what moves it is Harmonious Yang. (*Chu Shi Yi Shu*)

**Upward/Downward Unfavorable/Favorable** Blood syndromes moving upward, whether spitting, vomiting, or ejecting, are all unfavorable (Ni); if changing to downward movement as foul diarrhea, it is favorable (Shun). Blood moving upward is unfavorable, hard to treat; moving downward is favorable, easy to treat. So Zhongjing said: "In blood accumulation syndrome, if blood is passed, it should heal itself." This intent is the same. If a healthy person suddenly has diarrhea, the disease progresses. Now, if a blood syndrome patient moves upward then reverts to downward foul diarrhea, the pathogen wants to leave; this is known as auspicious. (*Dong Yuan*)

Generally, downward movement is favorable and easy to treat; upward overflow is unfavorable and hard to treat. Treatment should tonify Yin and move Yang, clear heat and regulate Qi; when Qi is smooth, blood returns to meridians. (*Ru Xuan*)

**Examining Color** Blood originating from Lung, due to Dragon/Lei hyperactivity or cough/rebellion, must overflow upward, often mixed with phlegm foam and pink-red. Originating from Pericardium, also overflows upward, color must be true red, like lacquer luster. If clotting upon vomiting, non-sticky to touch, it is guarding organ blood; seeing this means death. Originating from Spleen, either overflowing from Stomach region or collapsing from Small Intestine, must be bright purple thick, but less lustrous than Pericardium blood. Originating from Liver, either vomiting upward or collapsing downward, blood must be blue-purple thick, possibly with blood threads or clots. Originating from Kidney, either from cough/rebellion or spitting, or mixed in thin phlegm like pearls. Though little blood, color not bright, harm is most severe. Occasionally from essence orifice; if Qi transformation injured, exits from Bladder urethra. All relate to Zang Qi. Originating from Stomach, mostly mixed with fluid/phlegm, vomiting forms plates/cups, spreading everywhere. Because abundant Qi/Blood, medicine power reaches easily, not as severe as Zang blood, but as root of five Zang, cannot be ignored. (*Yi Tong*) (Note: This theory is slightly too subtle, perhaps not absolute; recorded for future study. Also discussed in hematemesis, mutually developing, refer. Also, bright color is heat, stasis is cold; since various schools have stated this, see subsequent articles.)

**Fever** All blood loss with severe fever is difficult to treat; only one or two in ten recover. (*Yao Jue*)

Yang excess body heat with much thirst; Yin excess body cool without thirst. However, Blood is Yin; body cool is easy to heal. (*Ru Men*)

No tidal fever is mild; tidal fever is severe. (*Yi Biao*)

No fever, no panting: curable (Blood loss, Yin deficiency, heat retained inside, no external heat manifestation, this is normal. No panting means although Blood is diseased, Qi has not floated, so treatable). Fever, unable to lie down: critical failure (Blood loss body heat, Yang has no attachment, floating/scattering outside form layers. Unable to lie down means Qi root has detached, so critical). (*Yi Ji*)

After blood loss, great heat, great thirst, fever, syndrome resembles Bai Hu Tang, except pulse is deficient-large not becoming solid. Mistaken use of cooling herbs causes death. Dang Gui Bu Xue Tang is primary formula: Huang Qi one liang, Dang Gui two qian. (*Zhun Sheng*)

After all blood loss, great fever often occurs, named Blood Deficiency Fever. Ancient formula Dang Gui Bu Xue Tang: Chuan Huang Qi one liang, Dang Gui six qian. Named tonifying blood but using Huang Qi as sovereign; Yang prosperity generates Yin blood. Like Dan Xi used for postpartum fever: Shen, Qi, Gui, Xiong, Hei Jiang to assist. Questioned: Dried Ginger is pungent-hot, why use it? Answer: Ginger is pungent, can guide blood herbs into Qi branch to generate new blood (charred enters blood, cooked warms middle). Understand spiritually. (*Yi Guan*)

**Dizziness** Blood deficiency dizziness sudden collapse: cannot moxa, cannot startle/cry/move. Movement leads to death by vacuity. Must use Dang Gui, Chuan Xiong, Bai Shao, Shu Di Huang, Huang Qi, Ren Shen, Bai Zhu, Fu Ling, Chen Pi, Jing Jie Sui, Gan Cao each seven fen, Jujube two pieces, Wu Mei one piece, decoct together. (*Jin Kui Yi*)

Dizziness and fever after blood loss often occur; this is deficiency Fire flaming upward and disturbing externally. Do not mistake for external contraction and use Wind herbs. (*Yi Tong*)

**Treatment Divided into Eight Methods** Treatment divided into eight methods: One is Descending Qi, due to upper excess/lower deficiency, Qi rising not descending, blood following Qi upward, escaping upper orifices. Method: Su Zi, Chen Xiang etc. to smooth Qi; Qi descends, blood returns to meridians. Two is Breaking Stasis, due to upper chest heat/stagnant stasis, purple-black clots, chest fullness/pain. Method: Shu Da Huang, Tao Ren, Dan Pi, Zhi Shi etc. to guide downward, turning unfavorable to favorable. Three is Warming Middle, due to cold clothes/food penetrating Blood branch, blood getting cold coagulating, not returning to meridians acting recklessly, blood dark/black, sallow color, cool body. Method: Pao Jiang, Rou Gui etc. to warm middle and harmonize Qi; Qi harmonious, blood returns to meridians. Four is Warming Dispersing, if cold clothes/contracting cold, dark color/orifice heat, body/head pain. Method: Jiang, Gui, Xiong, Su etc. to warm middle disperse cold; cold gone, blood returns to meridians. Five is Tonifying Qi, due to person's True Qi always deficient, spirit tired, Yin/Yang not interacting...