Volume Two: Hematemesis

Volume Two: Hematemesis

In healthy individuals, blood flows smoothly through the meridians, permeates the skin, and circulates without obstruction—this is called following the regular pathway, adhering to the natural course of blood circulation. Once this regular flow is disrupted, blood overflows into the gastrointestinal tract and rises against the normal flow of qi, resulting in vomiting. This is because qi in the human body moves within the blood and also outside the blood; upward, it manifests as respiration; downward, as bowel movements; and outward, as sweat through the skin. When qi is harmonious, it leads the blood, and blood follows its guidance; when blood is harmonious, it protects qi, allowing qi to remain tranquil (1). When qi stagnates, blood凝; when qi is deficient, blood脱; when qi is forced, blood走; and when qi continues to move while blood tries to stop, it cannot succeed. Before vomiting occurs, blood deviates from its regular pathway—sometimes it travels from the spine into the diaphragm, and from there into the stomach. In severe cases, the blood rushes out with a popping sound, accompanied by a gurgling noise; in milder cases, there is no sound. Therefore, whenever someone vomits blood, they invariably experience pain in the chest and back, because the blood originates from the spine and is driven by qi, unable to find harmony, thus causing back pain. Alternatively, blood may travel from the flanks into the small intestine, sometimes producing a rumbling sound as it enters the stomach and eventually leads to vomiting. Consequently, patients with blood loss often experience pain in the lower back and flanks. These two pathways are different, and therefore require different treatments. Blood coming from the spine should primarily be treated by addressing the lungs; blood coming from the flanks should primarily be treated by addressing the liver. This is because the lungs are like a canopy, located between the spine and the thoracic diaphragm, and since blood originates from this area, treating the lungs is the most appropriate approach. The liver, on the other hand, is the organ responsible for managing blood, located in the lower flanks, so treating the liver is also appropriate. However, although the lungs and liver are both pathways for blood, the actual act of vomiting is ultimately controlled by the stomach. Any time a person coughs or vomits food, the stomach is to blame. Although blood is not under the stomach's direct control, it is still a form of vomiting, so it is only natural to hold the stomach accountable. Moreover, blood ultimately ends up in the "sea of blood," which is connected to the "river of blood" (2). The pulse of the river of blood is closely linked to the Yangming meridian, and there is no case where the river of blood does not flow upward, yet blood does flow upward. Zhang Zhongjing's treatment of blood focuses on treating the river of blood, because the pulse of the river of blood is closely linked to the Yangming meridian, so treating the Yangming meridian is equivalent to treating the river of blood. The Yangming meridian's qi flows downward in a natural manner, but now it is flowing upward instead, violating its normal downward flow. Therefore, it is urgent to adjust the stomach so that the qi flows downward and the vomiting stops, thereby preventing blood from rushing out uncontrollably. At this point, the root cause of the blood issue is no longer important to investigate; the top priority is to stop the bleeding. After the bleeding stops, any blood that has left the regular pathway but has not yet been expelled is considered stagnant blood. Since it is incompatible with good blood, it may even turn into heat, tuberculosis, tumors, or sharp pains, and over time, unpredictable complications may arise. Therefore, it is imperative to eliminate stagnant blood as soon as possible to prevent future problems. Hence, eliminating stagnant blood is the second priority. After stopping the bleeding and eliminating stagnant blood, there is still concern that blood may surge again, so medication is needed to stabilize it. Thus, calming the blood is the third priority. When evil forces gather, the righteous forces are bound to be weakened. With so much blood lost, it is inevitable that yin will become deficient. Yin is the guardian of yang; when yin is deficient, yang has nowhere to rely on, and over time, yang will follow yin and disappear. Therefore, replenishing yin is the final step to restore balance. These four steps constitute the overall framework for treating blood-related conditions, and within this framework, there are specific items, which will be detailed below.

First, stop the bleeding: This method focuses solely on the Yangming meridian. The Yangming meridian's qi flows downward in a natural manner, so when it flows upward instead, it is due to the qi being too strong. Although hematemesis is a condition of deficiency, it is a deficiency of blood rather than qi. Moreover, at the beginning of the bleeding, pathogenic factors are at their strongest, so although the body is weak, the pathogenic factors are strong. Think about it: blood in the human body is normally hidden, but now it has completely reversed its usual pattern, creating a situation akin to overturning heaven and earth. It is not as if real evil forces are fighting against it—so why would blood suddenly start to flow out? If we do not eliminate the pathogenic factors, we will only further weaken the righteous forces, making the weak even weaker and the strong even stronger. Furthermore, when blood enters the stomach, the stomach becomes full, even though it is not like a case of cold damage where the stomach is filled with hard stool. Still, the accumulation of blood in the stomach is a tangible phenomenon. Therefore, it is imperative to quickly eliminate the excess, to strike at the root of the problem (4), so that we can lower the qi and stop the upward flow. Zhang Zhongjing's Xinxin Tang is the main remedy for this purpose. For patients with heavy bleeding, add Tongbian and Maogen; for those with shortness of breath and fullness, add Xingren and Houpu; for those with blood deficiency, add Shengdi and Danggui; for those whose qi has escaped with the blood and cannot return to its roots, add Renshen, Danggui, Wuwei, and Fupian; for those with alternating cold and heat, add Chaihu and Shengjiang, or add Ganjiang and Aiyè to counteract the effects. Adjust according to the specific condition, but always keep the core idea of Xinxin Tang in mind, so as to fully embody the teachings of the sage and achieve great efficacy. After all, qi originates in the kidneys; when water is deficient, qi becomes hot. Fire originates in the heart; when blood is deficient, fire becomes intense. When fire and qi clash, qi becomes strong, and strong qi drives blood to behave erratically. At this point, replenishing kidney water to balance qi is just empty talk; replenishing heart blood to match fire is also inadequate. Therefore, only purging fire can quell the chaos and restore peace, eliminating the pathogenic factors to preserve the righteous forces. Although the name is Xinxin Tang, it is actually a stomach-purging formula. When the stomach qi descends, the heart fire is somewhat calmed, and the heat in the stomach also does not build up, so qi flows smoothly and blood does not flow upward. Moreover, the single ingredient rhubarb can both clear out old impurities and create new ones, affecting both yang and yin—not just the qi in the stomach, but also the qi in the meridians, skin, and body. Whenever qi clashes with blood, causing disharmony, rhubarb's nature can reach everywhere. Because its medicinal potency is so strong, it can overcome and control the conflict, forcing the conflicting qi to submit. It not only rapidly lowers the qi but also leaves no residual pathogenic factors behind, which is something many people today dare not do, unfortunately. However, there are also mild cases where using a sledgehammer to crack a nut is unnecessary. Ge Kejiu's (5) Shi Hui San can also be effective, based on the principle of "stop when red meets black." The magic lies in rhubarb's ability to lower qi and thereby lower blood. In most cases of hematemesis, six or seven out of ten patients are genuine cases, and the above two formulas work immediately. However, there are also cases of deficiency and cold, which account for one or two out of ten patients with hematemesis, and doctors should definitely be aware of this. In cases of deficiency, too much blood is lost, leading to shortness of breath, fainting, and a lack of sustained energy. The six pulses are thin, weak, and scattered, similar to a knife wound where both blood and qi are exhausted, putting the patient in a critical condition. Only Shenpi Tang can rescue the qi, preventing it from escaping, so that blood does not rush out. In cases of cold, yang fails to control yin, causing yin blood to overflow. The patient will invariably feel cold hands and feet, loose stools and urinary incontinence, with thin, slow, and sticky pulses, pale complexion, and pale lips. Sometimes there is internal cold and external heat, revealing the true nature of cold and heat deficiency. Gancao Ganjiang Tang is the main remedy, balancing yang and yin, so that the cold recedes and yin blood can protect itself. However, blood is essentially yin juice, so dry agents (6) are strictly forbidden. Nevertheless, there are also cases where yang fails to control yin, requiring ginger and fupian. For those with cold above and heat below, using Qin, Lian, ginger, and fupian together is also acceptable. All these methods, when applied appropriately, can effectively cure the condition. For patients whose condition has been worsened by incompetent treatment and whose bleeding still does not stop, the situation has dragged on for a long time, with numerous complications, but even using the above methods, it is still impossible to completely stop the bleeding. If the problem is stagnant blood that refuses to move, then Xuefu Zhuyu Tang is the main remedy. For those with excessive fire, add Huangqin and Huanglian; for those with excessive phlegm, add Yunling and Guashuang; for those with coughing and reverse flow, add Xingren, Wuwei, and Cundong; for those with night sweats and body heat, add Qinghao, Dong Sangye, Huangbo, and Muli; for those with shortness of breath, add Xingren and Suzi; for those with body pain, chest and abdominal fullness, and constipation, add rhubarb. If you want more details, refer to the sections on phlegm, stasis, and heat, which cover all aspects of treatment. There is also the matter of identifying the root cause of the disease and taking targeted measures to stop the bleeding, which is a method that should never be neglected. For those who consume alcohol and heavily fried foods, their pulses are fast and slippery, with dry mouth and chest discomfort, and difficulty with bowel movements. They should use Baihu Tang with Yincheng, fried Zhizhi, rhubarb, and lotus root joints to treat the condition. For those who catch an external pathogen, they first experience headache, chills, and fever, with floating and tight pulses, indicating that the cold has invaded the blood, blocking the exterior and pushing the interior upward, resulting in hematemesis. Ma Huang Ren Shen Shaoyao Tang is the remedy for this. If the pulse is floating and fast, it indicates a wind attack, with yang as the pathogenic factor, so Xiao Chaihu Tang with Jingjie, Fangfeng, Danggui, Bai Shao, Danpi, Puhuang, Zhimu, Shigao, and Xingren is the appropriate remedy. If it is an epidemic, the external symptoms are similar to those of a cold, but internally there is latent heat attacking, with white coating on the tongue, aversion to heat, short and reddish urine, murky and dirty stools, restlessness in the heart, and slippery, fast pulses. In this case, Shengjiang San with Taoren, Danpi, flower pollen, Shengdi, Wei Ren, Shigao, Xingren, and Gancao is the appropriate remedy, and Xijiao Di Huang Tang is also effective. If it is due to summer heat, the heart feels hot and restless, as summer is a combination of dampness and heat, so the focus should be on clearing heat and draining dampness. Shengjiang Qinghua Tang with Fangji, Mutong, and Wei Ren is the appropriate remedy, and for mild cases, rhubarb can be omitted. If the qi is rebellious and the blood boils, resulting in hematemesis, Danzhi Xiaoyao San with Qingpi, Muli, Puhuang, and Dancao is the appropriate remedy. For those whose qi and fire are too intense, use Danggui Aloe Pill to calm the chaotic situation. For those who suffer from fatigue, exhaustion, uneven diet, and stress, with mental confusion, poor appetite, and shortness of breath, and who experience hematemesis due to emotional distress, use Gui Pi Tang as the main remedy. For those with cold in the middle and heat in the south, add roasted ginger; for those with heat in the north, add Chaihu and Shan Zhi. For those who suffer from falls, injuries, and strenuous physical labor, resulting in blood loss, the appropriate method is to replenish qi to make up for the lost energy, and to remove stasis to treat the injury. Siwu Tang with Huangqi, Renshen, Xuduan, Taoren, Honghua, Chenjiu, and Tongbian is the appropriate remedy. For those who indulge in excessive sexual desire, with yin deficiency and yang excess, the symptom is nocturnal fever, night sweats, dreams of intercourse, tinnitus, insomnia, and six pulses that are thin, fast, and tightly coiled. In this case, Di Huang Tang with Puhuang, Lotus Root Joints, Ajiao, and Wuwei is the appropriate remedy. The method of stopping bleeding is outlined above, but if you want to refine it and make it perfect, you must thoroughly study the entire book, otherwise you won't be able to grasp every detail. In summary, blood is a substance that flows when hot,凝 when cold, stops when it sees black, and also stops when it encounters cold. Therefore, some people use warming medicines to stop bleeding, such as ginger and artemisia. Others use cool water to stop bleeding, either by using running water or well water, taking advantage of the fact that cold makes blood凝. Herbs like Huangqin and Lian also have the property of stopping bleeding by cooling. Some use hundred-herb frost, Beijing ink, or Shi Hui San to stop bleeding, taking advantage of the fact that seeing black means stopping. Black represents water, red represents fire, and water controls fire, so water can stop fire. This seventh method of using water and fire colors to fight each other and achieve success shows that we can understand the nature of water and fire, and use this knowledge to choose the right medicines. No blood-related condition is truly difficult to treat. There are also those who use salt to stop bleeding, such as Tongbian, Matong, and dust-laden water, which is consistent with the principle in the "Inner Canon" that salt can drive blood. Tongbian is particularly effective in restoring spiritual vitality, controlling fire pathogens to nourish kidney water, and has great benefits. Therefore, many doctors say that anyone who takes Tongbian will surely live, while anyone who doesn't take Tongbian will surely die. I personally drink a bowl of Tongbian every morning, called Huilong Tang. There are many essays praising the wonders of Huilong Tang, and all patients should take it. Although there are many methods for stopping bleeding, the most important one is still lowering qi. Therefore, ingredients like agarwood, sandalwood, Xingren, Su Zi, Xuanfu, Zhike, Banxia, Jianbei, Houpu, and Xiangfu should all be used as appropriate. Rhubarb, as both a qi medicine and a blood medicine, is particularly effective in stopping bleeding without leaving stasis. Once you understand these methods, you've already mastered more than half of the techniques for stopping bleeding. After all, stopping bleeding does not only mean preventing blood from overflowing into the stomach and thus avoiding vomiting. During a major hemorrhage, blood flows through the meridians and eventually reaches the stomach, so whether it overflows into the stomach or not, it is still just waste, with no significant harm. Only the blood that has not yet overflowed but is still moving within the meridians—if it were to overflow, it could never return, so it must be stopped urgently, so that it can still return to the meridians and follow the original path to become harmonious blood. Stopping bleeding means preventing blood that has not yet overflowed from doing so, thereby preserving a portion of the blood and saving a portion of life, rather than simply stopping the dead blood that has already entered the stomach. Nowadays, medical professionals often talk about stopping bleeding, but they forget that at the beginning of the bleeding, the blood has not yet been stored, so where exactly is the stasis? If they try to remove the stasis first, they will end up eliminating all the blood that has already moved within the meridians, making the blood even drier and the illness even worse, so how can they avoid further damage? Only by stopping the bleeding first can the blood return to its original path and avoid rushing out uncontrollably, so stopping bleeding is the first priority.