Hemoptysis

Hemoptysis

Hemoptysis refers to sputum mixed with blood threads. Ancient scholars believed that hemoptysis originated in the heart, as the heart governs blood vessels, and the blood threads in hemoptysis resemble the shape of blood vessels. Others argued that hemoptysis originates in the kidneys, since the kidneys control the five fluids (1), and when the “false fire” (2) rises, the fluids overflow upward and condense into sputum. But if sputum is already produced, why does it still contain blood threads? Because when kidney qi descends, the water in the bladder is released, but now the kidney qi does not transform into bladder qi—it instead carries the bladder’s water upward, turning it into sputum. The bladder is the “room” of the body, and when the bladder’s water boils due to heat, it draws the body’s blood along with it, making it a case of water disease combined with blood disease. For example, women who first develop edema and then experience amenorrhea are said to have “water accumulation,” which is a manifestation of water disease affecting the blood. Similarly, the Shanghan Lun mentions heat accumulating in the bladder, causing blood to flow downward (3). Heat accumulation in the bladder is indeed a water disease, and it can also trigger the blood in the body to flow downward through urine, another manifestation of water disease affecting blood. Based on this, we can conclude that water overflowing into sputum can also stir up the body’s blood. Ancient methods only claimed that hemoptysis originated in the kidneys, but failed to explain the mechanism, leading some incompetent practitioners to mistakenly believe that blood actually comes from the kidneys. In fact, the claim that hemoptysis originates in the kidneys means that kidney qi does not transform into bladder qi, causing the water in the bladder to boil into sputum and stir up the body’s blood. This theory had never been discussed before, but I discovered it through the Shanghan Lun, and after thousands of thoughts, I finally arrived at this conclusion, which should not be kept secret. Physicians who understand this can determine how to treat hemoptysis and also identify the root cause of sputum. Zhang Zhongjing’s Zhuling Tang transforms the water in the bladder while simultaneously nourishing its blood, making it the most legitimate option, with added danpi and puhuang to cleanse the blood. For the origin of sputum and the root of blood, this formula covers both. Alternatively, Dihuang Tang can be used with Xuanfuhua, Wuwei, Tiandong, Cundong, and Puhuang. For severe cases, Dabuyin Wan can be used with Haifen, Niuxi, Yunling, Danpi, and Haji. All these formulas are primarily aimed at treating sputum, and they stem from the belief that the kidneys are the source of hemoptysis, providing a solution. Since the kidneys transform water into bladder qi, draining the bladder is equivalent to draining the kidneys. The bladder and the blood room share the same space, so if the bladder’s water does not overflow, the blood in the blood room will not move either. All these formulas treat the bladder and also the blood room, hence their effectiveness.

Sputum is governed by the kidneys, while blood is governed by the heart. Moreover, water and fire are interdependent—the kidneys affect the heart, and the heart affects the kidneys. When the heart’s fire is too strong, the blood vessels cannot stay calm, resulting in blood threads in the sputum. For those with coughing and sore throat, Daochi Yin with Huanglian, Danpi, Xueyu, Puhuang, Tiandong, Cundong, Jianbei, and Fuling can be used to treat the blood threads, while Digupi San with Fuling, Shegan, Xuanfuhua, and Niuxi can also be used to treat the sputum. All these formulas are based on the idea that hemoptysis originates in the heart. The heart governs blood vessels and resides in the chest, close to the lungs. Lung qi is prone to coughing, which easily stirs up the blood in the heart, so sputum from coughing often contains blood threads, and treating the blood threads requires focusing on the heart. The lungs are the source of water, and when the water is unclear and condenses into sputum, the sputum does not descend but instead stirs up the blood. Treating lung sputum is therefore a quick way to treat hemoptysis. Although the origin of sputum and blood is in the heart and kidneys, it inevitably involves the lungs. Taiping Wan is a lung-clearing agent, while Ziyuan San and Baohuo Tang are also good at clearing lung sputum, offering both cleansing and tonifying effects. In addition, referring to the section on coughing and spitting blood can provide a complete picture of treatment.

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〔Notes〕 (1) Five Fluids: "Plain Questions · Chapter on the Manifestation of the Five Qi": "The heart gives rise to sweat, the lungs to tears, the liver to tears, the spleen to saliva, and the kidneys to saliva; these are known as the five fluids."

(2) Deficient Fire: Refers to internal fire caused by deficiency of true yin.

(3) Heat accumulation in the bladder, with blood flowing out: If a Taiyang pattern remains unresolved, heat transforms and enters the interior, accumulating in the bladder, resulting in symptoms such as acute distension in the lower abdomen, the patient behaving like a madman, and blood flowing out. See Article 106 of the Treatise on Cold Damage.

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〔Commentary〕Hemoptysis refers to blood streaks in sputum. Previous scholars believed that this condition was closely related to the heart and kidney organs. The author inherits this view and further elaborates on it. He cites the passage from the Treatise on Cold Damage about heat accumulation in the bladder leading to blood flowing out, and uses the fact that women first develop swelling and then experience amenorrhea to illustrate how water-related disorders can lead to blood-related disorders. Thus, he argues that "when kidney qi fails to transform into bladder qi, water boils up into phlegm, which in turn stirs up the uterine blood," thereby becoming an important cause of hemoptysis. Regarding the relationship between this condition and the heart, the author points out that the heart and lungs both reside in the chest; when lung qi is reversed, it can stir up heart blood. Throughout the discussion, the author employs methods of analogy and logical reasoning. Although this approach may sometimes seem far-fetched, traditional Chinese medicine has long based its treatment of hemoptysis on the heart and kidney, reflecting thousands of years of clinical practice and thus cannot be ignored. For example, the formula Zhu Ling Tang combined with Dan Pi and Pu Huang, Di Huang Tang combined with Xuan Fu Hua, Wu Wei Zi, Er Dong, and Pu Huang, and Da Bu Yin Wan combined with Hai Ge Fen, Yun Ling, Dan Pi, and Ha Jie all take treating the kidney as the basis for treating hemoptysis. Similarly, the formulas Dao Chi Yin combined with Huang Lian, Dan Pi, Xue Yu, Pu Huang, Er Dong, Bei Mu, and Fu Ling, and Di Gu Pi San combined with Fu Ling, She Gan, Xuan Fu Hua, and Niu Xi all take treating the heart as the basis for treating hemoptysis. These are all important practical summaries by the author. In addition, "the lungs are the upper source of water; when water is not clear and condenses into phlegm, and when phlegm does not descend but stirs up the blood, treating the phlegm in the lungs is also a quick way to treat hemoptysis," which is also a valid argument.

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