bubble_chart Concept

Expectoration of blood refers to bleeding from the lungs or the respiratory tract (trachea), which is expelled through coughing, often accompanied by phlegm and blood, or blood streaks in the phlegm. If there is little phlegm but a significant amount of blood, or if there is massive bleeding, it is referred to as hemoptysis.

The term "expectoration of blood" originates from Neijing. Danxi Xinfa refers to it as "hemoptysis." The "Zhengzhi Yaojue" also calls it "coughing blood." Later, some attempted to distinguish between expectoration of blood, coughing blood, and hemoptysis, but this distinction holds little clinical significance. What should be clarified, however, is that in various medical texts throughout history, expectoration of blood has sometimes been referred to as hematemesis. For example, in the "Jingui: Palpitation Due to Fright, Vomiting Blood, Nosebleeds, Lower Bleeding, Chest Fullness, Static Blood, Abnormal Pulse Patterns, and Treatment" chapter, it states: "Those with vexing coughs will inevitably experience hematemesis." In the "Cold-Damage Disease Treatise," it is broadly referred to as "loss of blood." As a result, later generations sometimes conflated hematemesis and expectoration of blood, collectively calling them hematemesis. Although blood is expelled from the mouth in both cases, the location of the disease differs, and the terms and concepts must be strictly distinguished.

bubble_chart Pattern Analysis

1. External Contraction︰Sudden coughing with bloody sputum, aversion to cold with fever, itchy throat, dizziness, headache, chest pain; or dry nose, dry mouth, thin yellow tongue coating, floating and rapid pulse; or thin white tongue coating, floating and tight pulse. This syndrome is often caused by constitutional lung yin deficiency with internal accumulation of deficient heat. If affected by wind-heat, summerheat, or autumn dryness pathogens that fail to be cleared, the combined internal and external heat may scorch the lung collaterals, leading to hemoptysis. Alternatively, if there is pre-existing lung excess heat and external contraction of wind-cold, the externally constrained wind-cold may depress yang qi, causing the internally depressed yang to combine with lung heat and intensify it into fire, which can also scorch the lung collaterals and result in hemoptysis—this is also called "cold enveloping fire syndrome." External contraction of wind-heat hemoptysis must present with fever and thirst, while external contraction of wind-cold hemoptysis will definitely show headache and aversion to cold, making the two easily distinguishable. For external contraction of wind-heat hemoptysis, Mulberry Leaf and Apricot Kernel Decoction is prescribed; for external contraction of wind-cold hemoptysis, Ephedra Ginseng Peony Decoction is used.
2. Lung Heat Exuberance︰The sputum is yellowish with leukorrhea and blood, hemoptysis is profuse with bright red blood, accompanied by dry mouth and thirst, dry and sore throat, often with fever, chest and hypochondriac pain, irritability and susceptibility to anger, constipation, dark urine, red tongue with yellow coating, and wiry, slippery, rapid pulse. This is mostly due to the failure to disperse and resolve the external contraction of the six excesses, leading to stagnation transforming into heat, fire, or dryness; or due to pent-up anger damaging the liver, liver depression transforming into fire, and wood fire tormenting metal; or due to the accumulation of heat in the stomach from alcohol or rich, fried foods, which rises to fumigate the lungs. All these factors can lead to excessive lung heat, heat damaging the lung collaterals, and fire carrying blood upward, resulting in coughing up blood-streaked sputum. The treatment focuses on clearing the lungs and draining fire, supplemented by stopping bleeding, with White-Draining Powder combined with Ten-Ash Powder as the main prescriptions.
3. Blood Stasis Obstructing the Lung Collaterals︰Coughing up blood-stained sputum or hematemesis, palpitation, coughing and dyspnea in a semi-reclining position, inability to lie flat, chest tightness with stabbing pain, cyanotic lips, dull complexion, dark orbits, purple-dark tongue texture or with ecchymosis, deep wiry and choppy pulse or wiry slow with intermittent beats. This syndrome is often caused by prolonged hemoptysis, vessel injury with blood overflow, and blood stasis retained in the lungs; or by recurrent fluid retention obstructing the lungs, leading to qi stagnation and blood stasis in the lungs. When blood stasis obstructs the lung collaterals, the collaterals are injured, and blood is coughed up with phlegm, often appearing as frothy blood-streaked sputum. The distinguishing feature of this syndrome compared to other types is the presence of static blood symptoms, such as cyanotic lips, dull complexion, dark orbits, tongue purpura, and wiry-choppy pulse. The treatment involves using the Six Gentlemen Metal and Water Decoction combined with blood-invigorating and hemostatic herbs.
4. Spleen-Lung Qi Deficiency︰Hemoptysis persists for a long time with scanty and dull-colored blood, cough with white sputum, pale complexion, aversion to cold, mental fatigue and limb weakness, palpitation with shortness of breath, faint voice and reluctance to speak, poor appetite with no taste, loose stools, pale tongue with thin white coating, deep and thin or hollow pulse. It belongs to the deficiency pattern, which is the failure of qi to control blood. It should be treated by tonifying both the spleen and lung, and tonifying qi to control blood. Ginseng, Poria and White Atractylodes Powder is the main prescription.
5. Yin Deficiency︰Dry cough with scant sputum or sticky sputum that is difficult to expectorate, hemoptysis with bright red blood, more blood and less sputum, recurrent hemoptysis. Flushed cheeks in the afternoon, low-grade fever with irritability, feverish feeling in palms and soles, dry throat with desire to drink, night sweat and lack of strength, or seminal emission and dreamfulness, or heat in the groin area, pain in the waist and spine, red tongue texture with scant or no coating, thin and rapid pulse, weak pulse at both chi positions. Mostly caused by constitutional yin deficiency, or after Rebing, excessive indulgence in alcohol and sex, leading to kidney yin depletion. When kidney yin is depleted, fire flares up and scorches the metal (lung), resulting in lung dryness and collateral damage, hence hemoptysis occurs. The manifestation is in the lung, but the root is in the kidney. The syndrome can be differentiated into lung yin deficiency and kidney yin deficiency, both falling under the category of internal damage deficiency syndromes. When lung yin deficiency is predominant, symptoms include only cough, shortness of breath, dry throat, afternoon tidal fever, vexing heat in the chest, palms and soles, and night sweat. If accompanied by kidney yin deficiency, there may also be seminal emission, dreamfulness, and pain in the waist and spine. In cases of severe kidney yin deficiency, heat in the groin area may occur, and night sweat is particularly pronounced on the inner thighs. Treatment focuses on nourishing yin and reducing fire, with Lily Bulb Metal-Securing Decoction as the primary remedy.

The difference between lung heat congestion and external contraction wind heat expectoration of blood is that the former does not have exterior pattern such as aversion to cold with fever, itchy throat, and floating pulse. Those with predominant lung heat only have accompanying symptoms such as dry and sore throat, dry mouth and thirst, yellow phlegm, and coughing. If there is irritability, frequent anger, chest and rib pain, bitter taste in the mouth, and dry throat, it indicates internal liver fire.

The heat from yin deficiency with effulgent fire is a deficiency fire, which is different from the excess fire of lung heat congestion. Deficiency fire is caused by internal damage to true yin. Once true yin is injured, it loses its foundation, and deficiency fire arises, manifesting only as low-grade fever, feverish feeling in palms and soles, and often fever in the afternoon. This is different from the high heat, thirst, and constipation seen in excess fire. Excess fire presents with a red tongue with yellow coating, while deficiency fire presents with a red tongue without coating. Excess fire has a wiry and rapid pulse with strength, while deficiency fire has a thin and rapid pulse without strength, especially with weak pulses at both chi positions, which is characteristic of kidney fire.

Both spleen lung qi deficiency and yin deficiency with effulgent fire expectoration of blood belong to deficiency pattern, but the latter involves deficiency fire scorching the lung collaterals. Expectoration of blood without fire results in a small amount of dark-colored blood, while expectoration of blood with fire results in a large amount of bright red blood. Both conditions are treated with tonifying methods, nourishing yin and reducing fire, and calming the collaterals to stop bleeding.

bubble_chart Documentation

1. Lingshu-Jingmai: "The kidney meridian of foot Shaoyin,... when it is in motion, it causes illness such as hunger without appetite, a face as dark as lacquered wood. Coughing and spitting then result in blood, and there is gasping and panting."
2. Six Essentials of Medicine: "Expectoration of blood, unless it is due to extreme rest and desire to cease, should not be treated. This is true for all diseases, but this one especially requires caution."