Hemoptysis

Hemoptysis

The lungs govern qi, and coughing is a disease of qi; therefore, hemoptysis is considered a lung-related condition. The lung qi externally connects with the skin and hair and opens its orifices through the nose. When external symptoms such as nasal congestion occur and the skin and hair are sealed, the lung qi instead becomes internally congested, rushing into the throat and causing a cough. This is also a result of external factors. The lung qi also descends to the bladder and intestines, regulating body fluids and controlling the rhythm of breathing (1). When this regulation proceeds smoothly, the qi flows naturally and breathing becomes peaceful; however, if this regulation fails, the qi reverses and causes a cough—this is an internal cause of coughing. As for external causes of coughing, they are usually due to blockage of the orifices, preventing lung qi from reaching the surface, causing it to rush inward and trigger a cough. In this case, the lung itself is not necessarily damaged. On the other hand, internal causes of coughing arise from the failure of the lung's regulatory function. The lung is a metal organ, light and pure in nature, and constantly bathed in yin fluids that nourish its structure. Therefore, the lung leaves hang down like the heavens descending (2), and the qi flows downward like rain and dew, moistening everything below. As a result, the bladder functions properly, bowel movements are regular, and the qi of all five organs and six viscera is well-moistened and unblocked, which is the benefit of the lung's regulation of qi. If the lung lacks yin fluids and is subjected to fire punishment, it will become lung atrophy. The lung leaves will burn and droop, unable to descend, and the yin fluids will no longer flow downward. Consequently, the lung qi will reverse and cause a cough—this is an internal cause of coughing and a difficult condition to treat.

These two scenarios represent the lung's inherent diseases that directly cause coughing. In addition, there are cases where other organs interfere and also cause coughing. Since the lungs are like a canopy, with all other organs beneath them, the phlegm, dampness, and fire from other organs can all rise and attack the lungs, causing them to cough. Therefore, the "Plain Questions · Chapter on Coughing" clearly distinguishes between different organs and summarizes the situation as "concentrated in the stomach and affecting the lungs (3)." Although the illness originates from other organs, it ultimately affects the lungs, which is why the lungs are primarily responsible for coughing. One must first understand the root cause of coughing before treating hemoptysis. After all, coughing does not always involve blood loss, but blood loss almost always involves coughing. For example, external infections can lead to blood loss, with the infection originating in the skin and hair and eventually affecting the lungs, thus causing a cough. Or, accumulated heat in the stomach can fuel the metal element, causing the qi to rise and trigger a cough. Or, anger in the liver can cause the qi to reverse and lead to a cough—these are real cases of blood loss that inevitably cause coughing. Or, deficiency of yin and excess of fire can make the lungs lose their ability to regulate qi, leading to dryness and coughing. Or, depression in the spleen meridian and deficiency in the heart meridian can also cause coughing. Or, deficiency in the kidney meridian and lack of yang qi can cause the qi to rise and lead to coughing—these are cases of blood loss that inevitably involve coughing. There are also cases of phlegm coughing, which fall somewhere between mild and severe. And there are cases of qi coughing, which are mostly mild but occasionally severe. Some people cough first and then lose blood, while others lose blood first and then cough; some cough briefly and then recover, while others cough persistently—there are countless variations. One must carefully investigate each case to find the appropriate treatment for blood loss and exhaustion.

A typical case of coughing: External wind-cold invasion, initially presenting with headache, chills, and fever. Zhang Zhongjing said that if coughing is accompanied by wheezing and loud sounds, and in severe cases even spitting blood, Ma Huang Tang should be used. Li Dongyuan followed his idea and used Ma Huang, Ren Shen, and Shao Yao Tang. It can be seen that many cases of coughing with blood are caused by external factors. Ancient remedies used Ma Huang, which is a powerful agent against disease and mainly targets the qi system, with relatively little effect on the blood system. It should be noted that coughing is indeed a disease of the qi system, but if it does not affect the blood system, why would it lead to blood loss? Therefore, it is necessary to consider both the qi and the blood systems. "Medical Classics" uses Su Zi Jiang Qi Tang, while I use Xiao Chai Hu Tang combined with Zi Su, Jing Jie, Dang Gui, Bai Shao, Dan Pi, and Xing Ren, treating both the qi and the blood systems simultaneously, which is the best way to harmonize the exterior and cleanse the interior. For those with heavy fire and constipation, add Jiu Jun; for those with chills and no sweat, add Ma Huang; for those with pain and distension in the chest, waist, and back, if there is blood stasis, add Tao Ren and Hong Hua. Xiao Chai Hu is good at unblocking the three jiao, regulating the lungs and the liver, and harmonizing the defensive qi and vital qi. With appropriate adjustments, it is suitable for both the blood and the qi systems. For those with blood-related conditions and accompanying exterior symptoms, this formula is particularly appropriate. Puming Zi Zhi Sou San can also be used, but its medicinal power is too weak to treat serious illnesses, such as mild coughing with a small amount of blood. In such cases, this lighter formula should be used for adjustment, as it is neither too strong nor too weak. For those who want to stop bleeding, add Pu Huang and Ou Jie; for those who want to clear fire, add Ku Qin and Cun Dong; for those who want to reduce phlegm, add Jian Bei and Fu Ling; for those who want to lower qi, add Xing Ren and Zhi Ke; for those who want to replenish blood, add Dang Gui and Sheng Di. All of the above formulas and their adjustments are specifically designed for new cases of hemoptysis. For those with long-term external invasions, where old cold has entered the lungs and prolonged coughing and wheezing have led to blood loss, the cough is actually caused by the cold reversing the fire and attacking the lung metal, and the lung qi also stimulates the blood vessels in the chest and back, causing blood to be expelled along with the cough. Although the illness originates from the cold, it is actually caused by the cold stimulating the fire. Therefore, the treatment should focus on warming the cold and stimulating the fire, clearing the fire and dispersing the cold, covering all aspects. Use Qian Jin Mai Men Dong Tang and Xiao Chai Hu combined with Su Zi and Dong Hua. For those with cold encasing fire, it is appropriate to use Xiao Chai Hu Tang with adjustments to clear the stagnant fire. For those with fire hidden in the cold, it is appropriate to use Qian Jin Mai Men Dong Tang to search for the old cold, and replace Ma Huang with Xi Xin, adding Hei Jiang and Wu Wei Zi, especially to remove the cold from the lungs. However, blood-related conditions often avoid harshness, preferring softer approaches such as Ku Qin, Cun Dong, Yu Zhu, and Gua Shuang to soften the fire. By removing the fire hidden in the cold, one can better adjust the treatment. Nevertheless, when the cold resides in the lungs, it will eventually transform into fire. Once it becomes fire, it should be treated specifically as fire, while still warming the cold—this is like carrying firewood to put out a fire. The above discussion concerns external wind-cold invasions turning into hemoptysis, which is the most common scenario. Misdiagnosis by doctors often leads to tuberculosis, so caution is required. In addition, there are also internal

When the lung metal is clean and moist, the fire naturally subsides, phlegm is eliminated, qi is regulated, and coughing stops. For those with blood deficiency, add Sheng Di; for those with excessive fire, add Xi Jiao; for those with abundant phlegm, add Bei Mu; for those with blood, add Pu Huang. The above two formulas provide detailed treatment for virtual fire in the lung meridian. Many people with blood loss suffer from yin deficiency and excessive fire, and following the above treatment methods, eight or nine out of ten cases are successful. However, there are also one or two cases where the lung meridian is excessively cold. The "Inner Canon" states: "Cold and cold drinks harm the lungs; the lungs dislike cold, and often produce excessive saliva and qi." Zhang Zhongjing treated this with Gan Cao Gan Jiang Tang. However, the "Golden Chamber" mentions frequent urination and bedwetting, which is caused by the inability to control the lower part of the body. Therefore, there is clear evidence of cold-induced urinary problems, and Gan Cao Gan Jiang is used to warm the body. Moreover, the pulse will be deep, slow, and weak, and the phlegm will be thin and diffuse, unlike the treatment with Qing Zao and Bao He, which are aimed at clearing dryness and maintaining balance. Therefore, warming medicine is preferred. I suggest using Liu Jun Zi as the main formula, adding Dang Gui, Bai Shao, Pao Jiang, and Wu Wei Zi, which are suitable for both stopping coughing and stopping bleeding. For those with cold in the spleen meridian and phlegm causing coughing, this formula is also appropriate. If the spleen meridian has excessive fire and produces phlegm with blood, then Xiao Yao San combined with Cun Dong, Ou Jie, and Pu Huang is suitable. If the liver meridian has excessive fire and produces phlegm with blood, then Xiao Yao San combined with Dan Pi, Shan Zhi, and Wu Wei Zi is also suitable. As for the kidney meridian, if it has excessive fire and produces phlegm with blood, please refer to the section on spitting blood and hemoptysis. For those with liver and kidney deficiency, detailed treatment is provided in the section on hemoptysis, including measures to suppress the qi and detailed instructions for six volumes on coughing.

A phlegm cough (11): When there is substantial phlegm and heat in the lungs, and the qi reverses, leading to hemoptysis, it is better to address the root cause rather than just quell the symptoms. Use Xie Fei Wan to treat the problem at its source. In fact, hemoptysis is always related to phlegm; the body's qi transports blood, and the blood carries qi. If there is too little blood, the qi cannot carry enough, leading to internal heat. When heat accumulates, water and body fluids are scorched, boiling into phlegm. Therefore, when fire is strong, phlegm is abundant; when phlegm is abundant, the circulation of qi is obstructed, qi builds up, and heat increases. At this point, trying to supplement the deficiency only strengthens the evil, while trying to eliminate the evil only makes the deficiency worse. Only by combining both approaches can one achieve a balanced treatment. First, use "Ten Medicinal Gods Book" digestive pills, and at bedtime, mix honey with the pills to attack the root cause—then swallow Taiping Wan to replenish the deficiency. Combining attack and replenishment is a clever way to eliminate evil and bring peace. If doctors only focus on replenishing, they may miss many opportunities. If patients are hesitant to use digestive pills, they can use Er Chen Tang to initially break down the problem. Er Chen lowers qi and promotes water metabolism, making it a good tool for eliminating phlegm. If one wants to also promote lung qi, add Xing Ren, Su Zi, and Sang Pi. For those whose coughing prevents them from sleeping, it is due to water and drink (12) flooding the lungs, preventing the lung leaves from descending. Add Ting Li and Da Zao; for those with severe fire, add Gua Wei Shuang, Huang Qin, and Lao Lian; for those with mild fire, add Cun Dong and Zhi Mu; for those dealing with cold, add Chai Hu, Jing Jie, and Fang Feng; for those dealing with blood, add Dang Gui, Bai Shao, Dan Pi, and Tao Ren. All of the above are treatments for eliminating solid phlegm. There is also virtual phlegm, which occurs when the spleen meridian is deficient in yin, dry qi produces phlegm, which sticks to the throat, causing hoarseness, coughing, and fever, with a thin, rapid pulse. In such cases, it is not advisable to try to drain the phlegm, as it may further damage the body fluids. Instead, it is better to moisturize the body to generate more fluids, which will loosen the phlegm. Use Bao He Tang, Qing Zao Rescue Lung Tang, and Zi Yuan San to maintain moisture. If there are phlegm nodules or qi nodules stuck in the throat, making it difficult to swallow, it is a plum pit syndrome, caused by heart fire congealing phlegm. In such cases, use Hua Tan Wan combined with Niubang Zi to dissolve the phlegm. Xiang Su Yin combined with Ju Jing, Zhi Ke, Jian Bei, Yun Ling, Xuan Fu, and Gan Cao can also be used to treat this condition. There are also cases where stomach pain causes diaphragmatic movement, with symptoms such as chest and flank discomfort, coughing, wheezing, and hiccups. People with blood loss often experience these symptoms, so it is appropriate to use Meng Shi Gun Tan Wan to treat them. If the stomach has qi deficiency and phlegm, use Xuan Fu Dai Zhe Shi Tang, which also treats blood issues by adding Dang Gui, Bai Shao, and Su Mu, and treats fire issues by adding Cun Dong and Ku Qin. Hiccups are discussed in detail in six volumes, but here we focus on phlegm coughing, which has not been fully covered. Phlegm coughing is also related to liver qi reversing and invading the lung meridian, causing phlegm to accumulate and obstruct the qi, leading to coughing. Symptoms include bitter taste in the mouth, headache, red cheeks, anger, pain in both flanks, and it is appropriate to use Wen Dan Tang combined with Qing Pi, Bai Jie, Chai Hu, and Shan Zhi. If liver fire is rampant and rebellious, add Ginger Yellow and Big Yellow; if the liver meridian has excessive fire and produces phlegm, use Dan Zhi Xiao Yao San combined with Long Gu, Mu Li, A Jiao, and Bei Mu. The root of phlegm-related diseases lies in the lungs, but the origin is in the kidneys. The kidneys' water rises and flows, creating phlegm. Phlegm attacks the lungs and causes coughing, so treating phlegm should focus on the kidneys. The kidney meridian's yang deficiency cannot control water, and when water rises and triggers heart fire, causing palpitations and coughing, and when yang floats upward, causing sore throat and facial heat, it is appropriate to use Zhen Wu Tang combined with Xi Xin, Gan Jiang, and Wu Wei Zi to cool the water and calm the fire. However, this is only legislation for phlegm-related diseases. People with blood loss often have yin deficiency and yang excess, and tend to avoid these kinds of medications, because the kidney yang cannot transform water, leading to shortness of breath, coughing, and phlegm rising. Therefore, only kidney yang pills that transform yin into yang, warming but not overly hot, are suitable. This formula has been treasured since the Song and Yuan dynasties. It is said that people with blood loss and exhaustion have hot upper bodies and cold lower bodies, with yang floating outside and yin isolated inside. Only this formula can draw yang into yin, using medicine in a miraculous way. For those with kidney yang deficiency, this formula is truly precious; for those with kidney yin deficiency, however, this formula is not suitable. People with blood loss often have hot upper bodies and cold lower bodies, with yang floating outside and yin isolated inside. The reason why yang does not stay is actually due to yin deficiency, not yang deficiency. If one takes this formula, yin does not emerge while yang becomes even stronger, which is called "using yang to generate yin," but in reality, it is using yang to promote yin. If the upper body is hot and the lower body is cold, with yang floating outside and yin isolated inside, the pulse will be very weak, bowel movements will be loose, hands and feet will be cold, and one will crave water, even drinking one and urinating two—this formula is the most effective. If it is purely yin deficiency, this formula is not suitable, because it aims to use yang to generate yin, but only a small amount of gui fu can be used as a counterbalance. For example, when using zhi bo to nourish the kidneys, both zhi bo and gui fu are used, but zhi bo is only five parts, while gui fu is only five percent, so it is used to draw yin from yang. Can one really use too much gui fu to help yang fight yin? If the kidneys are deficient in yin and fire rises, condensing into phlegm, then it is appropriate to use Zhu Ling Tang. Di Huang Tang combined with Mai Dong, Wu Wei Zi, Xuan Fu, A Jiao, Xing Ren, Ha Jie, and Niu Xi is also in line with Zhu Ling Tang's intention, and the nourishing effect is even greater. Please refer to the section on hemoptysis for more details.

A qi cough: No phlegm, no blood, but the qi is choked and causes a cough. This is due to true yin deficiency in people with blood loss, resulting in the lung qi not being contained and the kidney qi not being absorbed. The condition is very serious and difficult to treat. If it is determined that the lung qi is not contained, the person cannot lie on their back; if they do, the qi reverses and causes a cough, which in turn stirs up the heart, or if the lung leaves are uneven, the person lies on one side, and when they turn over, the cough does not stop. In such cases, it is appropriate to use Qing Zao Rescue Lung Tang combined with Bai He, Wu Wei Zi, Amber, and Stalactite to stabilize and contain the lung qi. When the lung qi is well maintained, it can cover and contain the qi, and the qi will not cough. If it is determined that the kidney qi is not absorbed, the person has shortness of breath, the fire rises, both cheeks turn red, and the throat is uncomfortable. Zhang Zhongjing said that if the number of blood vessels decreases and there is fever and cough, it should not be treated. This indicates that yang does not attach to yin and qi does not return to its original state—a serious condition. Six Wei Wan combined with Cheng Xiang,

Wu Wei Zi, Mai Dong, and Magnetic Stone are used to nourish and contain the qi, so that the qi is attracted back to the kidneys, and the kidney water grows, while also sealing the qi, so that the qi will not reverse and cough. Alternatively, use Kidney Qi Pills combined with Mai Dong, Wu Wei Zi, and Niu Xi, using Gui Fu to attract the qi back to its original state. Chen Xiuyuan said that when the lungs and kidneys do not communicate and both heaven and earth are deficient, use Two Plus Dragon Bone Soup combined with A Jiao, Mai Dong, and Wu Wei Zi. According to me, both Kidney Qi Pills and Two Plus Dragon Bone Soup are treatments for yang deficiency in the lungs and yin deficiency in the kidneys, with hot upper bodies and cold lower bodies. If both the lungs and kidneys have yang deficiency and the qi cannot be sustained, leading to exhaustion and difficulty breathing, then it is appropriate to use Bao Yuan Tang combined with Wu Wei Zi. The above two methods are not quite suitable. If both the lungs and kidneys have yin deficiency, then none of the three methods are appropriate. People with blood loss often have qi coughing and reversing. Qi is generated in the kidneys and governed by the lungs. When the lung yin is sufficient, the airways are moist and unblocked; when the kidney yin is sufficient, the qi roots are stored and contained. Only when the lung yin is insufficient does the qi become dry and cough; only when the kidney yin is insufficient does the qi float and cough. This is a case of lung and kidney yin not communicating, and the treatment should refer to Mai Di Huang Tang and San Cai Tang to nourish the yin of both organs. To absorb lung qi, add Bai He, Wu Wei Zi, and Stalactite; to absorb kidney qi, add stone, Cheng Xiang, and Wu Wei Zi. In addition, there are also methods for dealing with qi reversing, which will be explained in detail in the sections on hemoptysis and six volumes on coughing.