Discussion on the Appropriate Use and Avoidance of Medications

Discussion on the Appropriate Use and Avoidance of Medications

Sweating, vomiting, purging, and harmonizing are the four major therapeutic methods for treating miscellaneous diseases; however, when it comes to blood-related conditions, some methods are appropriate while others are not. Excessive sweating in cases of cold damage can deplete body fluids, and vomiting blood not only damages yin and blood but also harms water and fluids, leading to a situation where both water and blood are depleted, leaving the body as dry as a skeleton. Therefore, Zhang Zhongjing strictly forbids inducing sweating in patients with nosebleeds. Since nosebleeds already prohibit sweating, it goes without saying that vomiting and spitting up should also be avoided. When the pulse is hidden and qi is suppressed, blood cannot rise; inducing sweating will cause qi to dissipate. For patients with vomiting blood, qi is the most difficult to contain; if it continues to dissipate, blood will overflow along with the qi and cannot be restrained. Thus, even if there are exterior symptoms, one should only employ harmonizing and dispersing methods, and avoid directly using ma-huang, gui-zhi, qiang-huo, or du-huo. Only if the blood loss is caused by an external pathogen can one proceed with exterior dispersing, but even then, both dispersing and consolidating methods must be used together, so as not to cause excessive sweating and further depletion of yin. It is essential to understand that patients with blood-related conditions should avoid sweating before deciding how to induce sweating. As for vomiting, it is especially prohibited: since qi in patients with blood loss tends to rise against the normal flow, if phlegm or sputum appears and the patient then vomits again, it will only exacerbate the upward movement of qi, causing it to continue rising uncontrollably. In treating such conditions, the priority is to suppress the upward flow of qi (1), ensuring that qi does not surge upward, thereby preventing blood from overflowing. By lowering lung qi, smoothing stomach qi, and nourishing kidney qi, when qi descends, blood also descends, and once the blood stops flowing, qi will naturally stabilize as well. Patients with blood-related conditions should especially avoid disturbing qi; not only should they refrain from vomiting during illness, but even after recovery, if other miscellaneous conditions arise, they should not lightly use emetic drugs, as vomiting often triggers blood-related conditions. Understanding that blood-related conditions prohibit vomiting means knowing that suppressing qi to stop vomiting is itself a method of treating blood-related conditions. Some may ask: since blood-related conditions are often characterized by deficiency, and sweating and vomiting are already contraindicated, shouldn't purging be even more strictly avoided? My answer is: no. The reason blood rises is because qi surges and overflows; therefore, vomiting and sweating are prohibited, and further disturbing qi is even more unacceptable. As for purging, it is precisely intended to curb the surging qi. In most cases of blood-related conditions, qi is excessively fiery and vigorous, and when it surges uncontrollably, purging is the best way to break its momentum. Zhang Zhongjing's emergency purging method for preserving yin is a prime example; clinical practice has proven that this method effectively preserves yin. When qi is too intense in blood-related conditions, the greatest fear is losing yin, and purging is precisely a way to save yin—purging is nothing less than replenishing yin (2). However, purging must be carried out at the right time; if pathogenic factors have lingered for a long time and vital energy is already depleted, or if there is severe diarrhea, then heroic measures are futile, and one can only proceed slowly, using gentle, cooling, and descending methods to avoid violating the principle of purging. As for harmonizing, it is the first-choice method for treating blood-related conditions: externally, it harmonizes lung qi; internally, it harmonizes liver qi, while also paying special attention to spleen and kidney qi. One may replenish yin to harmonize yang, reduce yang to harmonize yin, remove stasis to harmonize blood, drain water to harmonize qi, or combine tonifying and purging, or alternate between cold and warm therapies—there are countless subtle nuances that cannot all be listed here. Beyond these four methods, there is also tonification, which is particularly important for patients with blood-related conditions who suffer from various forms of deficiency and debility (3); indeed, almost every patient talks about tonification. Many texts emphasize tonification, often accounting for eight or nine out of ten cases, yet few realize that tonification for blood-related conditions also has its own indications and contraindications. For example, if pathogenic factors remain unaddressed and tonification is still administered, it is like closing the door to let thieves in; if blood stasis is not cleared and tonification is still given, it is like helping the thief bring disaster. When it comes to tonifying the spleen, three or four out of ten cases are appropriate; when it comes to tonifying the kidneys, five or six out of ten cases are suitable. Tonifying yang is appropriate in two or three out of ten cases, while tonifying yin is suitable in eight or nine out of ten cases. There is an ancient method of tonifying qi to control blood, which is aimed at those whose qi is depleted, not at those whose qi is rebellious. There is also a method of guiding fire back to its origin, which is designed for those whose fire is too cold and spreading, not for those whose yin is deficient and yang is excessive. After all, for patients with blood loss, if the fire has not yet ignited, tonification can help heal them; but if the fire has already flared up, cooling agents are just enough to undermine the vitality of the five zang organs, while warming tonics can harm the true yin of the two kidneys. Only by using sweet and cool herbs to nourish yin while also supporting yang can blood return to its proper place. In general, the appropriate use and avoidance of medications for blood-related conditions are roughly as described above; understanding the main points allows one to read the entire book with confidence.

〔Note〕

(1) Suppress the upper: For pathological mechanisms involving upward movement of qi, it must be brought down to achieve therapeutic effect. This concept originates from "Su Wen · Zhi Zhen Yao Da Lun," where the original phrase is "suppress the high."

(2) Not merely: Meaning "no different from."

(3) Deficiency and debility: A general term for various diseases caused by deficiencies in the five zang organs, also known as "lao qie."

〔Commentary〕The author believes that sweating, vomiting, purging, and harmonizing are the four major methods for treating miscellaneous diseases. However, when it comes to treating blood-related conditions, sweating and vomiting should be strictly avoided. He says: "When the pulse is hidden and qi is suppressed, blood cannot rise; inducing sweating will cause qi to dissipate." He also adds: "For patients with blood loss, qi tends to rise against the normal flow. If phlegm or sputum appears and the patient then vomits again, it will only exacerbate the upward movement of qi, causing it to continue rising uncontrollably." This shows that both sweating and vomiting can cause qi to rise, thereby worsening the symptoms of blood-related conditions. As for purging, some people believe that since blood-related conditions are often characterized by deficiency, and sweating and vomiting are already contraindicated, purging may not be very appropriate. However, the author argues that purging is an important method for treating blood-related conditions. He says: "In most cases of blood-related conditions, qi is excessively fiery and vigorous, and when it surges uncontrollably, purging is precisely the best way to curb its momentum." This indicates that when suffering from blood-related conditions, especially hemoptysis or hematemesis, qi surges upward, making purging highly appropriate. Zhang Zhongjing created the emergency purging method for preserving yin, and clinical practice has proven that this method can indeed preserve yin. In blood-related conditions, qi and fire are often overly abundant, and the greatest fear is losing yin. Using purging can both calm the surging qi and preserve the yin that is about to be depleted, so employing this method to treat blood-related conditions often yields the expected results. However, if the patient has been ill for a long time and is severely deficient, or if there is severe diarrhea, then this method is not very suitable, and one can only use gentle, cooling, and descending methods to slow things down. As for harmonizing and tonifying, traditional physicians have always considered them the major methods for treating blood-related conditions, but the author believes that harmonizing is the first-choice method. In harmonizing, if there are exterior symptoms, one harmonizes lung qi; if there are interior symptoms, one harmonizes liver qi, while also regulating the qi of the spleen and kidneys. In addition, there are various forms of harmonizing, such as replenishing yin to harmonize yang, reducing yang to harmonize yin, removing stasis to harmonize blood, draining water to harmonize qi, or combining tonifying and purging, or alternating between cold and warm therapies. Regarding tonifying, the author says: "Patients with blood-related conditions often suffer from various forms of deficiency and debility, so almost everyone talks about tonifying." However, if pathogenic factors remain unaddressed and tonification is still administered, it is like closing the door to let thieves in; if blood stasis is not cleared and tonification is still given, it is like helping the thief bring disaster. According to the author's clinical experience, tonifying yin is most appropriate for blood-related conditions, followed by tonifying the kidneys, and then tonifying the spleen and yang. In addition, he also explains two methods: tonifying qi to control blood and guiding fire back to its origin. The former is designed for those whose qi is depleted, i.e., for situations where qi does not govern blood, while the latter is designed for those whose fire is too cold and spreading, referring to situations where qi is deficient and fire is excessive. In such cases, cooling agents can undermine the vitality of the five zang organs, while warming tonics can harm the true yin of the two kidneys. Only by using sweet and cool herbs to nourish yin while also supporting yang can fire be guided back to its origin. In summary, in this article, the author discusses methods for treating blood-related conditions, offering insightful and concise arguments that serve as a comprehensive guide to treatment for such conditions.