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There is dried blood (stasis blood retained for a long time) within the interior. It is still necessary to use potent medicines to eliminate it. If deficiency has not yet formed, one must certainly not leave pathogenic factors to cause harm. Therefore, excess syndromes absolutely cannot use formulas for tonifying deficiency; whereas for deficiency syndromes, one does not discard all formulas used for excess syndromes, fearing that leaving pathogens will cause harm. In cases of deficiency with excess complications, attack and tonification are used simultaneously, or in a ratio of ten parts tonification to one part attack, depending on the physician's skillful management.

The above discussion roughly covers the treatment principles for hematemesis throughout its course. However, it does not detail concurrent syndromes and transformed syndromes; these are established in separate categories and analyzed item by item. Physicians verifying treatments can derive them through this examination.

In hematemesis (vomiting blood forcefully), blood spurts out of the mouth without sound. In emesis of blood (vomiting blood with effort/noise), there is sound upon expulsion; when severe, the sound resembles a frog's croak; when mild, it manifests as hiccuping, merely indicating unsmooth qi flow. Although both involve blood exiting the mouth, the treatment is no different from hematemesis. The distinction lies in hematemesis being silent while emesis of blood is noisy. Since the syndromes differ slightly, if treatment methods are not detailed, how can they fit precisely like threads entering an eye? Regarding severity, hematemesis is lighter and emesis of blood is heavier. In hematemesis, qi remains relatively smooth; in emesis of blood, qi is more rebellious. From the perspective of zang-fu organs, hematemesis originates in the Stomach, while emesis of blood originates in the Liver. Why is this so? The Qi of Liver Wood governs the dredging and draining of Spleen Earth, and the Shaoyang (Lesser Yang) spring-generating Qi resides within the Stomach, responsible for ascending clear turbidity and descending cloudy turbidity, serving as the pivot for Ying and Wei circulation. Thus, in the *Shanghan Lun* (Treatise on Cold Damage), Shaoyang disease presents with dry retching and incessant vomiting, indicating that the Shaoyang pivot function is impaired: clear Qi is obstructed and fails to ascend, while turbid Qi rebels and fails to descend. In the *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet), cases of vomiting saliva/froth, headache, and chest fullness are treated with Wuzhuyu Tang (Evodia Decoction). Evodia fruit is used to descend the turbid Qi of the Liver; once Liver Qi descends, vomiting stops naturally. This occurs because Liver Wood loses its normal dredging and draining function, invading Earth horizontally, thus forming rebellious vomiting. Using Evodia primarily descends Liver turbid Qi; if Liver Qi does not rebel, vomiting ceases. From this, we can see that all vomiting belongs to the Liver and Gallbladder, and since blood is governed by the Liver, seeing emesis of blood dictates that treatment should focus on regulating the Liver. Various schools state that emesis of blood comes from the Liver but fail to explain the rationale. Therefore, I cite the *Jingui Yaolue* and *Shanghan Lun* to prove this. However, the vomiting in these texts refers to miscellaneous disease vomiting belonging to the Qi level, whereas vomiting due to blood loss specifically belongs to the Blood level, so treatment methods naturally differ.

If dry retching occurs first, followed by emesis of blood, or if dry retching persists after emesis of blood, this is due to rebellious Qi of the Shaoyang channel. Treat with Dachaihu Tang (Major Bupleurum Decoction) plus Puhuang (Cattail Pollen), Danpi (Moutan Bark), Taoren (Peach Seed), and Danggui (Angelica Sinensis). Once emesis of blood stops, administer Xiaochaihu Tang (Minor Bupleurum Decoction) to harmonize Ying and Wei and pivot the exterior and interior. When the Upper Jiao is unobstructed and fluids descend, Stomach Qi becomes harmonious, retching and hiccups cease, blood calms down, and stops surging upward. Since the Liver and Gallbladder are connected, gallbladder disease invariably affects the liver; Danshi Xiaoyao San (Red Peony and Gardenia Rambling Powder) can treat both.

Vomiting without spitting blood belongs to the Shaoyang; vomiting accompanied by spitting blood belongs to the Liver channel. Liver Qi is prone to anger, and its fire is most rampant. Observing the *Shanghan Lun*, when Liver Qi insults the Lung, it is called "Zong" (Vertical/Unrestrained); puncture Qimen (LR14). When Liver Qi insults the Spleen, it is called "Heng" (Horizontal/Excessive); also puncture Qimen. These utilize needling to drain the pathogen. Thus, when Liver Qi anger and rebellion cause vomiting, it is especially appropriate to dispel Liver Fire and not let the enemy go unchecked. Following Zhongjing's intent from needling, we now use decoctions: Danggui Luye Wan (Angelica and Aloe Pill) plus Danpi and Puhuang is suitable. For any emesis of blood caused by anger, or Liver Qi rebelling horizontally, presenting with aversion to human voices, desire to die rather than live, urge to kill with a sword, mania, cursing, and ignoring kinship ties, these are ruthless fires of the Liver channel. Only large-dose prescriptions can eradicate them. If one hesitates and delays, allowing the condition to persist until the pathogen remains strong while healthy Qi declines, resulting in deficiency with excess complications, neither attacking nor tonifying works well, yet attacking is unbearable due to weakness. This is like Song Dynasty employing Jia Sidao, nurturing treachery until the nation was near collapse before removing him—too late. If the disease is assessed as milder, simply cool Liver Blood and regulate Stomach Qi, and emesis of blood will stop. Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) plus Chaihu and Zhike, taken until bleeding stops, followed by Xiaoyao San (Rambling Powder) plus Ejiao (Donkey-hide Gelatin), Muli (Oyster Shell), and Xiangfu (Cyperus Rhizome) to conclude treatment.

Those who usually vomit sour or bitter fluids, or frequently vomit sour/bitter fluids after blood loss: Vomiting sour indicates Damp-Heat. Observe that hot soup left overnight in summer turns sour; thus, vomiting sour is Damp-Heat. Vomiting bitter indicates Ministerial Fire. The Gallbladder houses Ministerial Fire, and bile is bitter; thus, the taste of Ministerial Fire can alter Stomach fluids to become bitter. Borrow Zuojin Wan (Left Metal Pill) plus blood-level medicines is appropriate for treating the blood level. These two types of medicines are pungent, bitter, descending, and draining; used as guides among blood-treating herbs, they are particularly effective.

After emesis of blood stops, if Liver/Gallbladder fire is hyperactive, Blood deficiency causes irritability, cheeks are red with thirst, chest/hypochondriac stabbing pain, fever with night sweats, and restless dreams, this is Ministerial Fire blazing internally, potentially developing into bone-stealing consumption (Gu Zheng Lao Zhai). Treat with Chaihu Qinggu San (Bupleurum Clearing Bone Decoction). If accompanied by cough and throat itching, this is disharmony between Liver and Lung Qi. Use Sixian San (Four Reversal Powder) combined with Xiangsu Yin (Perilla Drink), plus Xingren (Apricot Seed), Zhike (Aurantium Fructus), Kuxin Pi (Phellodendron Bark), Zhimu (Anemarrhena Rhizome), Danggui, and Baishao (White Peony Root). If there is a constant sensation of Qi obstruction in the throat, frequent belching and hiccups, this is unsmooth Qi between Liver and Heart. Use Xiangsu Yin plus Chaihu, Bohe (Mint), Shegan (Belamcanda Rhizome), Niubangzi (Arctium Fruit), Tianbeimu (Fritillaria Bulb), Danggui, and Xuanfuhua (Inula Flower). Xiaoyao San is a crucial herb for treating Liver channel disorders; with appropriate modifications, it yields prompt results.

Although vomiting belongs to the Liver and Gallbladder, it always involves the Stomach Fu organ. Stomach Qi rebelling upward was detailed in the Hematemesis section; I supplement this for physicians here. For blood syndromes accompanied by vomiting, treat the blood; once blood stops, vomiting stops naturally. For vomiting accompanied by blood, such as in "Huishi Bing" (Regurgitation Disease) where bloody fluid appears after vomiting, this is Stomach Qi rebellion and Blood exhaustion—a difficult-to-treat syndrome. Banxiaren Tang (Pinellia and Semen Trichosanthis Decoction) and Maimendong Tang (Ophiopogon Decoction) treat it. Yinvu Jian (Jade Woman Decoction) plus Puhuang and Hama Ren (Hemp Seed) is also effective. Siwu Tang (Four Substances Decoction) plus Gancao (Licorice), Cundong (Ophiopogon), Zhike, Fuling (Poria), Oujiang (Lotus Root Juice), Luobojiang (Radish Juice), Shengjiang (Fresh Ginger), and Jingzhuyou (Bamboo Sap) are all clearing, draining, Stomach-regulating, Blood-nourishing, and anti-emetic agents.

This chapter discusses blood, focusing solely on emesis of blood. However, no blood-loss syndrome presents as a single isolated symptom without accompanying others. To detail items, I had to establish separate categories. Regarding formula usage, one must refer to various syndromes and adapt accordingly. If one rigidly adheres to one category to seek treatment, is it not like gluing the tuning pegs of a zither (being inflexible and unable to adapt)?