Coughing Up Blood When Angry or Tired? Doctor Xue Lizhai’s Two Hematemesis Cases — Soothe the Liver and Drain Fire in the Morning, Boost Qi and Nourish Yin at Night
Patient search terms: spitting blood / coughing up blood / vomiting blood / a few mouthfuls of blood / spitting blood when angry / spitting blood when tired / lumps on both sides of the neck / lymph node tuberculosis / distension and pain in the flanks / afternoon fever / no strength in the body / cannot eat / insomnia and vivid dreams / palpitations
Medical terms: hematemesis (liver fire invading the lungs · qi deficiency failing to hold blood) · scrofula · injury from the seven emotions · deficiency of both qi and blood · yin deficiency
Opening: two women, both spitting blood — but two completely different treatments
Today we look at two gynecology cases from Doctor Xue Lizhai (Xue Ji), the director of the Imperial Medical Academy in the Ming dynasty. By coincidence, both patients spit blood, and their symptoms looked nearly the same — yet Doctor Xue prescribed in two totally different directions: for one, soothe the liver and drain fire; for the other, boost qi and support the upright. The same mouthful of blood — why should the treatments be so far apart? By the end of these two cases, you will understand the weight of that word “pattern differentiation” (bian zheng) in Chinese medicine.
💬 Note from Doctor Luo: Doctor Xue Lizhai was the director of the Imperial Medical Academy in the Ming dynasty, from a family of imperial physicians, and he left more than three thousand recorded cases, with gynecology especially well represented. He had a habit — he would write down the patient’s personality before anything else, and he was not shy about it. Why? Because in the eyes of the ancients, emotion and illness were always linked. Even today we still split medicine into psychology and gastroenterology, but the ancients knew long ago: these two are one and the same thing.
Patient one: a quick-tempered woman with a neck full of lumps
The first woman had a very quick temper. What was her illness? Luo li (scrofula) — what we call lymph node tuberculosis today: strings of beads-like lumps growing along both sides of the neck and under the armpits. On top of that she was spitting blood and running a fever, with distension and pain in both flanks (the sides of the ribcage), and every afternoon it grew especially heavy.
💬 Note from Doctor Luo: Why does scrofula grow where it grows? The lumps of lymph node tuberculosis appear on both sides of the neck and the sides of the body — and those are exactly the pathways of the liver and gallbladder channels. So this illness is mostly tied to liver qi stagnation and binding in the liver and gallbladder. When liver fire stirs, blood surges upward — hence the spitting of blood. The flanks are the liver channel’s home turf, so liver qi stagnation shows up there as distension and pain. Afternoon fever means the suppressed fire is sitting in the yin aspect. Doctor Xue looked and saw: anger injuring the liver — the root was liver fire.
The crucial detail: there is liver fire — so why not just drain it?
There is liver fire, so shouldn’t he simply drain the liver fire? Doctor Xue Lizhai would not do it that way. He saw the other side of the picture — this woman’s qi and blood were both deficient.
💬 Note from Doctor Luo: Remember this: people with quick tempers, whose liver fire blazes up day after day, always have weak spleens and stomachs. This is not a matter of a day or two — it accumulates over years: liver fire bullies the spleen and stomach, the spleen and stomach grow more and more insufficient, the source that transforms qi and blood runs dry, and the upright qi is slowly consumed. So rest assured — there is no such thing as a person who is quick-tempered every single day and still in excellent health. This case record does not mention fatigue or emaciation, but Doctor Xue knew in his heart: inside this body, the shadow of qi-blood deficiency was surely there. So you cannot simply drain fire — you must drain and support at the same time.
The prescription: an augmented Xiao Yao San every morning — soothe the liver, drain fire, and resolve phlegm
How did Doctor Xue Lizhai write the formula? Every morning, he used Xiao Yao San (Free and Easy Powder) plus fried gardenia, phellodendron bark, fritillaria, platycodon, ophiopogon and schisandra.
💬 Note from Doctor Luo: Xiao Yao San is an immortal formula that has been used for a thousand years, and its logic is crystal clear. I call it the “iron triangle for people in a bad mood”. First — soothe the liver: people in a bad mood always have liver qi that is not flowing, so the liver must be soothed. Second — strengthen the spleen: when liver wood runs rampant it attacks spleen earth, and the spleen and stomach are bullied for years, so the spleen must be built up. Third — nourish the blood: when the spleen and stomach are weak, qi and blood cannot be produced, and the person is bound to be blood deficient, so the blood must be nourished. Soothe the liver, strengthen the spleen, nourish the blood — three directions aimed with precision, which is why people still use Xiao Yao San every day. As for the additions: fried gardenia drains heart fire, phellodendron bark clears damp-heat, fritillaria resolves phlegm — lumps like scrofula only dissolve when the phlegm is resolved — ophiopogon nourishes yin, and schisandra is sour and astringent — spitting blood needs to be drawn back and held, and schisandra also tonifies the lungs.
Doctor Luo also took a moment to explain one herb in particular — platycodon root (jie geng):
💬 Note from Doctor Luo: Jie geng is the herb that “carries medicine upward” — it lifts the medicinal action toward the upper body. In modern terms, it opens the passages of the upper burner (the lungs and respiratory tract) and increases permeability — which is why it can expel pus: if there is an abscess in the lungs, it pushes it out; it also soothes the throat and diffuses the lungs. When the passages are open, the medicine penetrates more easily and works faster in the upper body. Adding jie geng to this formula was very clever — it carries the action upward so the medicine takes effect in the head and upper burner.
And at night? Gui Pi Tang washing down Liu Wei Di Huang Wan — the core method of this article
In the morning Xiao Yao San. And at night? Doctor Xue’s method: at night, use Gui Pi Tang (Spleen-Restoring Decoction) to wash down Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill).
💬 Note from Doctor Luo: This is the medication method I want to introduce to you today. For people who are deficient in both qi and blood with a bit of yin deficiency on top — who want the Gui Pi Wan pills to boost qi and blood, but also want Liu Wei Di Huang Wan to nourish yin — how do you take them together? Doctor Xue’s method: use the Gui Pi Tang decoction to wash down the Liu Wei Di Huang Wan. Gui Pi Tang is a decoction, absorbed directly through the spleen and stomach; Liu Wei Di Huang Wan is a water pill that dissolves slowly and works on the middle and lower burner — Gui Pi supplements the spleen (middle burner), Liu Wei Di Huang supplements the liver and kidneys (lower burner). Upper and lower are both covered — in effect, boosting both qi and blood plus nourishing yin at the same time. People today can take the two together this way too: soak the Gui Pi Wan pills in water and use that water to wash down the Liu Wei Di Huang Wan — either works.
And the result? This woman’s symptoms all cleared up. But Doctor Xue knew very well — the illness is cured, yet if the temperament never changes, it will return sooner or later.
Patient two: after losing her son, she spat a few mouthfuls of blood with every exertion
The second woman’s fate was sadder. She was extremely hardworking and worn down, and then she lost her son — her child died. From then on she could not eat, and one day she suddenly vomited a great deal of blood, which stopped on its own. But from that day forward, every time she exerted herself, she would spit a few mouthfuls of blood — as if she had a consumptive illness (tuberculosis) — and she grew weary and listless, with no strength at all in her body.
💬 Note from Doctor Luo: This case is the exact opposite of the first one — the deficiency is glaring. After losing her son she grieved and could not eat. Grief and sorrow injure the lungs, and they injure the spleen too; with the lung qi wounded and the spleen and stomach wounded, the qi grows weaker and weaker. When qi is deficient, it can no longer hold the blood — without the force of qi to grip the blood, a single bout of exertion or strain lets the blood escape. So this illness is not liver fire; it is qi deficiency failing to hold blood. Look at her: pale sallow complexion, weak voice, pale tongue with scalloped edges — while the quick-tempered woman in the first case had a greenish complexion and a forceful voice. One excess, one deficiency — poles apart.
How did Doctor Xue treat her? Bu Zhong Yi Qi Tang (Supplement the Middle and Boost Qi Decoction) before noon, and Gui Pi Tang washing down Rehmannia pills after noon.
💬 Note from Doctor Luo: This is the cycle of supporting the upright: in the morning, Bu Zhong Yi Qi Tang boosts the qi and lifts the yang upward; in the afternoon and evening, Gui Pi Tang boosts qi to hold the blood, supplements qi and blood, and settles the spirit — and with it, Liu Wei Di Huang Wan nourishes the liver and kidneys and replenishes yin. After heavy bleeding, yin blood has been consumed heavily, and this is exactly the formula to slowly rebuild it. Following this approach, the illness resolved.
Two kinds of spitting blood, one truth: both were started by emotion
Set the two cases side by side, and everything is clear:
💬 Note from Doctor Luo: The same spitting of blood — Doctor Xue saw two different patterns in it. The first woman: liver fire — quick-tempered, greenish complexion, forceful voice; Xiao Yao San in the morning to soothe the liver and drain fire, Gui Pi Tang with Liu Wei Di Huang Wan at night to support the upright. The second woman: deficiency — grief over losing her son, pale sallow complexion, weak voice; Bu Zhong Yi Qi Tang before noon to boost qi, Gui Pi Tang with Rehmannia pills after noon to nourish yin. But the two cases share one thing: both were tied to emotion. One was wounded by sorrow; the other was wounding herself with her own anger — different fates, yet the body takes the same damage. Herbal treatment is necessary, but you also have to think it through for yourself: the body is the home of the emotions. If you torment your body with your emotions day after day, even Doctor Xue Lizhai standing beside you and dosing you daily will not guarantee a full recovery.
Bonus: Gui Pi Tang washing down Liu Wei Di Huang Wan — when does this method fit?
Finally, Doctor Luo expanded on this medication method in more detail for your reference:
💬 Note from Doctor Luo: Not everyone suits this combination. The general rule is: take qi-boosting herbs in the morning (Bu Zhong Yi Qi, Xiao Yao), and yin-nourishing herbs at night (Liu Wei Di Huang) — nourishing yin in the afternoon and evening follows the rhythm of nature. If you have insufficient qi and blood — for example insomnia, vivid dreams, half-awake half-asleep states, palpitations (heart racing), puffy eyelids, drooling during sleep, inability to control urination, frequent edema — these are signs that qi is failing to hold blood and failing to hold water, and Gui Pi is the right medicine. If there is also some yin deficiency and you want to keep nourishing yin at night, you can learn from Doctor Xue Lizhai: at night, take Gui Pi Tang and wash down Liu Wei Di Huang Wan — Gui Pi Tang builds the spleen, Liu Wei Di Huang nourishes the liver and kidneys, the middle and lower burners are both covered, qi and blood are boosted together with yin nourishment. It is a remarkably elegant way to take medicine. Keep this idea in mind — you will come to appreciate it more and more.
Compiled from Doctor Luo Dalun’s explanation of Doctor Xue Lizhai’s cases, from Records of the Xue Family Medical Cases (《薛氏医案》) by Xue Ji (Ming dynasty).