〔Commentary〕

〔Commentary〕

Coughing up blood is called hemoptysis. Since coughing is governed by the Lung, hemoptysis should first be attributed to the Lung. However, the Lung is the "canopy" of the five zang and six fu organs, with all other organs residing beneath it. Phlegm, dampness, and fire can all ascend and attack the Lung, leading to coughing; therefore, hemoptysis is a condition connected to every organ in the body. The author’s view inherits the perspective from "The Plain Questions" that "all five zang and six fu organs can cause coughing, not just the Lung." The author categorizes hemoptysis into real cough,虚 cough, phlegm cough, qi cough, bone-steaming cough, and lung abscess cough, presenting a well-organized and meticulous analysis.

Real Cough: There are five types. The first is external wind-cold invasion, with symptoms such as headache, chills, fever, and hemoptysis. For this type, Zhang Zhongjing and Dong Yuan often used Ma Huang Tang with modifications, while "Medical Classics of the Imperial Academy" recommended Su Zi Jiang Qi Tang with modifications. The author advocates using Xiao Chai Hu Tang with additions of purple perilla, schizonepeta, angelica, and moutan bark, to unblock the triple burner, benefiting both the qi level and the blood level—a step forward compared to the simple qi-benefiting approach of ma huang and su zi. The second type is prolonged external exposure, where old cold enters the Lung, causing recurrent coughing and stirring up fire in various meridians. For cases showing exterior cold and interior heat, Xiao Chai Hu Tang with modifications is appropriate. For cases where fire hides within cold, Qian Jin Mai Men Dong Tang with modifications is suitable. The third type is internal invasion by summer-heat dampness, which triggers hemoptysis, with symptoms such as body heat, thirst, and fullness in the chest and abdomen. Treatment should focus on clearing interior heat, using Ren Shen Xie Fei Tang or Xi Jiao Di Huang Tang. The fourth type is anger-fire in the liver channel rising upward and attacking the Lung, causing coughing. In such cases, Chai Hu Mei Lian San with modifications is recommended. The fifth type is pathogenic heat stirring up water-dampness, which attacks the Lung, resulting in coughing, shortness of breath, and facial swelling. For this type, Zhang Zhongjing used Yue Bi Tang, while Dan Xi used Si Wu Tang with peach kernels and chebulic myrobalan. The author believes Yue Bi Tang is effective for treating external wind-induced lung distension. Although this type of hemoptysis has symptoms similar to lung distension, such as water-dampness attacking the Lung, the underlying pathology is still in the blood level. The author considers Dan Xi’s use of Si Wu Tang to be “truly suited to the condition,” and in terms of its therapeutic significance, it has the effect of “awakening the eyes and ears, shaking the conscience.” Based on personal clinical experience, the author further proposes using Tong Qiao Huo Xue Tang to treat this condition, believing it is more effective than Si Wu Tang in eliminating phlegm and resolving blood stasis.

虚 Cough: There are two types. The first is when, regardless of external or internal injury, fluid loss damages the Lung tissue, making it unable to stay moist and droop properly, leading to scorched and lifted Lung tissue and qi reversal causing coughing. Clinically, this presents as a pattern of yin deficiency and excessive fire. Bao He Tang from "Ten Medicinal Divine Books" is the preferred formula for treating this type of hemoptysis. For patients whose yin deficiency turns to dryness, resulting in lung dryness and fistula, and who have long-term, intractable coughs, Qing Zao Jiu Fei Tang with cooling and moisturizing properties can be used. The second type is Lung meridian deficiency-cold, with symptoms such as thin, clear sputum and cold-related urinary incontinence. The author treats this with Liu Jun Zi Tang with modifications, aiming to nourish the earth to generate metal, which is more appropriate than Gan Cao Gan Jiang Tang from "Jin Gui Yao Lue."

Phlegm-Cough: Divided into two types—excessive heat and deficiency-cold. For the former, because blood deficiency cannot carry qi, "excess qi is fire," and water and fluids are scorched into phlegm, with phlegm and fire combining to cause hemoptysis. While using Xie Fei Wan to treat this condition has the advantage of striking at the root, "Ten Medicinal Divine Books" recommends alternating between Xiaohua Wan and Taiping Wan—one to attack the pathogen, the other to support the body—achieving a balance of attack and support, which is a good method for eliminating the problem and restoring peace, representing an improvement over previous formulas. For the latter,

The nose is the orifice of the Lung. The root of the nose connects to the Taiyang meridian, while the nostrils are flanked by the Yangming meridian, and internally connect to the Lung, governing respiration. It serves as the gateway through which the pure and empty energy communicates with heaven and earth, so it should be kept open rather than blocked, breathing rather than panting, exhaling rather than bleeding. Why then does nosebleed occur? According to "Jin Gui," if heat injures the yang collateral vessels, nosebleeds occur; if heat injures the yin collateral vessels, rectal bleeding occurs. The yin collateral vessels refer to the network of vessels inside the body, near the intestines and stomach, thus mainly causing rectal bleeding. The yang collateral vessels refer to the network of vessels outside the body, in the muscles and skin, where blood flows upward along the yang meridians, eventually reaching the nose and causing nosebleeds. However, the yang collateral vessels are part of the Taiyang and Yangming meridian networks. Since Taiyang and Yangming run throughout the body, blood from the yang collateral vessels, when injured by Taiyang, travels up the meridians from the back to the nose, causing nosebleeds—this is what Zhang Zhongjing meant by "Taiyang activation in spring and summer." When injured by Yangming, the blood travels up from the chest to the nose, which is what Zhang Zhongjing meant by "Yangming activation in autumn and winter." We will discuss these two scenarios separately.

Taiyang governs opening, and in spring and summer, yang energy should naturally develop. If it becomes blocked, pathogenic factors accumulate and cause nosebleeds, with symptoms such as nasal congestion, headache, and confusion from chills and fever. This may happen either because of pre-existing accumulated heat that should be released in spring and summer, or because of wind, epidemic, or summer heat that triggers the condition. There are also cases where people catch a cold and fail to sweat, leaving pathogenic factors with no way out, so they escape through the blood, resulting in nosebleeds—this is called "red sweat," indicating that the pathogen wants to self-heal, a fact doctors must be aware of. However, even considering red sweat, we can see that if Taiyang energy cannot be released through the skin, it will manifest as red sweat, meaning that if Taiyang heat cannot be discharged externally, it will inevitably force itself out through the nose as a nosebleed. The skin is the Lung's partner, and Taiyang energy governs the skin externally while connecting to the Lung internally; the nose is also the Lung's orifice. Therefore, to treat Taiyang nosebleeds, one must primarily treat the Lung. Looking at "Shang Han Lun," which uses Ma Xing Li Fei to treat Taiyang, we can see that treating the Lung is equivalent to treating Taiyang. The treatment should focus on clearing Lung fire and promoting Lung qi; when Lung qi is clear, Taiyang energy will naturally become clear, and nosebleeds will cease. For external wind-cold, when the skin is cold and dry without sweating, use Ma Huang, Ren Shen, and Shaoyao Tang. If Lung fire is severe, with dizziness, pain, shortness of breath, and a slippery, large, rapid pulse, use Ren Shen Xie Fei Tang with schizonepeta, kudzu, pu huang, maogen, shengdi, and tongbian. For long-term nosebleeds and blood deficiency, use Dan Xi Zhi Niu San with added mahuahua, huangqin, schizonepeta, and apricot kernel. All of these prescriptions add musk and coptis to cases with nasal congestion, since wind-cold mixed conditions often involve external cold blocking the nose, and this situation is especially common in cases with internal fire blockage. Using qianghuo would only make the nose more blocked, so coptis and musk are used to open the blockage, and once the nosebleeds stop, it is advisable to continue taking the original Zhi Niu San formula and Liu Wei Di Huang Tang to consolidate the results. There are also cases where kidney meridian deficiency-fire floats upward, affecting the Du meridian and causing nosebleeds, with symptoms such as lower back pain, neck and spine pain, dizziness, and cold feet. This happens because kidney meridian deficiency-fire rises upward, so it is advisable to use Zhi Niu San with additions of cuibu, niuxi, xuduan, kudzu, lu jiaojian, tongbian, and yuan shen to treat it. Since the Du meridian is closely related to Taiyang, treating Taiyang also treats the Du meridian. Similarly, the Chong meridian is closely related to Yangming, so treating Yangming also treats the Chong meridian. Taiyang is a meridian with relatively little blood, while the Du meridian is the master of vital energy, and its blood must never be damaged. After the nosebleeds stop, it is advisable to use Di Huang Tang with tian dong, a jiao, xue yu, and wu wei to replenish it.

Yangming governs closing (2). In autumn and winter, yin energy should naturally contract. If dry fire damages its network of vessels, heat rises and escapes, losing its ability to control closure, forcing blood upward along the meridians and out through the nose. Symptoms include thirst, shortness of breath, dry nasal passages, and dizziness from heat, possibly caused by alcohol or the influence of the six qi. In any case, it is Yangming dryness combined with pathogenic factors that leads to nosebleeds. Since Yangming's inherent energy is already dry, once illness enters this meridian, it invariably turns dry. Treatment methods always focus on balancing dryness, using Xie Xin Tang with shengdi, hua fen, zhi ke, bai shao, and gan cao. Alternatively, use Xi Jiao Di Huang Tang with huangqin and shengma to detoxify heat. After the nosebleeds stop, use Yu Nu Jian with pu huang to nourish and calm down, followed by gan

Drink plenty of dew to nourish the body, and consume pear jelly, lotus root juice, radish juice, white honey, etc., all of which are suitable for the condition.

Although the two approaches differ, the nose is ultimately the orifice of the Lung meridian, and blood belongs to the Liver meridian, so anyone who suffers from nosebleeds (3) will inevitably have yellow eyes. Zhang Zhongjing said: "If the eyes are yellow, the nosebleeds haven't stopped; if the eyes are clear, the nosebleeds have stopped." (4) Since the Liver opens the orifices to the eyes, and blood disturbs the Liver meridian, the eyes turn yellow, so treatment should focus on harmonizing the Liver. And since blood affects the Lung orifice, it should also be harmonized with the Lung. For now, regardless of spring or autumn, the main focus should be on harmonizing the Liver and Lung, using Di Huang Tang to treat it. After the nosebleeds stop, take Di Gu Pi San to nourish the body. Not only should blood be treated by harmonizing the Liver and Lung, but all forms of vomiting and spitting should also be treated by harmonizing the Liver and Lung. The Liver governs blood, while the Lung governs qi; treating blood requires balancing qi. What else could one do without harmonizing the Liver and Lung?

Furthermore, if nosebleeds persist for a long time, too much blood is lost, heat decreases along with the blood, and qi also disappears with the blood—this is like a knife wound: if blood keeps flowing, qi will disappear too, and when blood is completely gone, death follows. In such cases, use Du Shen Tang to save the patient. If the limbs are cold and breathing is labored, add fu zi to guide qi back to its roots. If the person's face and nose are dark and purplish (5), it indicates that blood is severely affecting the Lung, and if left untreated, it could be fatal. Use San Su Yin to treat this condition. Such critical cases should be treated with San Su Yin, and this is the proper way to provide relief. Whether it works or not, we cannot guarantee it.

According to the principle, medicines work faster for diseases in the intestines and stomach, and slower for diseases in the meridians. Nosebleeds are a disease in the meridians, so using external treatments can also achieve quick results. For example, use Shi Hui San to plug the nose and swallow it—this is very reliable; or grind human fingernails into powder and blow it into the nose to stop the bleeding; or use wall spider nests (6) to plug the nose, utilizing their network to maintain it. Dragon bone blown into the nose can solidify the blood hole and prevent nosebleeds. White alum blown into the nose has a dispersing effect that cuts off the blood flow. Apply vinegar and soil to the scrotum, since the scrotum belongs to the Liver, and the Liver governs blood. Applying something to the scrotum to restrain Liver qi will naturally stop the Liver blood flow, addressing the upper problem by tackling the lower one—this is a very reasonable approach. Drop eel blood into the nose. Put turtle blood in the nose. Soak the feet in warm water to draw the heat downward. Tie up the patient's middle finger. Stick wet paper on the top of the head and iron it to dry, using the ironing method to generate heat. Some of these methods may work, others may not, but we record them all for reference.

People with nosebleeds should not sweat, as sweating will cause the forehead to sink. Zhang Zhongjing has explicitly forbidden this, and based on this example, we can conclude that all blood-related conditions should avoid sweating. Doctors should be cautious about this.

Although different from other conditions involving coughing and vomiting, since they all involve blood, it is advisable to consult each category to ensure comprehensive treatment without missing anything.

〔Note〕 (1) Nosebleed: Bleeding from the nose. (2) Closing: To close. (3) People prone to nosebleeds: Those who frequently suffer from nosebleeds. (4) Yellow eyes mean nosebleeds haven’t stopped; clear eyes mean nosebleeds have stopped: This comes from "Jin Gui Yao Lue · Chapter on Palpitations, Vomiting, and Nosebleeds." The original text reads: "If the eyes are yellow, the nosebleeds haven’t stopped. Once the yellow fades, the eyes become clear, indicating that the nosebleeds have stopped." (5) Dark: Meaning very dark. (6) Wall spider nest: A nest of egg-laying insects, shaped like a silkworm cocoon. These insects are spider-like, flat, dark brown, with eight long legs, and build their nests on walls, about the size of a coin, hence the name "wall spider nest."

〔Commentary〕"Jin Gui Yao Lue" records that "from spring to summer, nosebleeds are caused by Taiyang, and from autumn to winter, they are caused by Yangming." Based on this statement, the author divides nosebleeds into two categories. The first belongs to Taiyang, because Taiyang governs opening and symbolizes the vigorous rise of yang energy in spring and summer. If pathogenic factors block the skin, Taiyang energy cannot be released, resulting in red sweat (nosebleeds). Such nosebleeds are often accompanied by exterior symptoms, so treatment should focus on clearing Lung fire and promoting Lung qi. For exterior symptoms caused by wind-cold, use Ma Huang, Ren Shen, and Shaoyao Tang; for severe Lung fire and rapid pulse, use Ren Shen Xie Fei Tang with modifications; for long-term nosebleeds and blood deficiency, use Dan Xi Zhi Niu San. For all these cases, if there is nasal congestion, add musk and coptis, and emphasize avoiding warming herbs like qianghuo. This distinguishes blood-related conditions from purely exterior ones, and the author warns people not to overlook this distinction. After the nosebleeds stop, take the original Zhi Niu San formula with added Liu Wei Di Huang Tang to consolidate the results. For cases where kidney meridian deficiency-fire disturbs the Du meridian, with symptoms such as lower back pain, neck and spine pain, and cold feet, add niuxi, chuan duan, gu sui bu, lu jiaojian, tong bian, and yuan shen to the Zhi Niu San formula. The second category belongs to Yangming, because Yangming governs closing and symbolizes the contraction of yin energy in autumn and winter. If dry heat accumulates internally and yin energy cannot be contained, blood will rush outward and cause nosebleeds. The author believes that "Yangming's inherent energy is already dry, and patients in this meridian inevitably become dry," so treatment should focus on clearing heart fire and nourishing yin with products like Yu Nu Jian and Gan Lu Yin, with modifications. After the fire subsides, use Gan Lu Yin to balance things out. In addition, the author also bases his argument on the passage in "Jin Gui Yao Lue" that "if the eyes are yellow, the nosebleeds haven’t stopped. Once the yellow fades, the eyes become clear, indicating that the nosebleeds have stopped," suggesting that, from the perspective of the organs, nosebleeds should be attributed more to the Liver, since the Lung opens the orifice to the nose, and also more to the Lung. When too much blood is lost and qi disappears along with the blood, use Du Shen Tang to urgently restore yang energy. There are also some external remedies that can be used as clinical references. In summary, the author divides nosebleeds into two categories—those associated with exterior symptoms and those associated with interior heat—which are common types of nosebleeds in clinical practice. However, there is also a type of nosebleed caused by qi deficiency that cannot control the blood, which is also quite common in clinical settings, but the author did not discuss it, which is a minor shortcoming. Furthermore, the author is overly rigid in his use of meridian nomenclature, which makes his reasoning somewhat forced.