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(Shuddering, nausea)

The emission of sound without vomitus is called *yue* (shuddering/dry heaving). (Pronounced yuě. It refers to dry heaving. Additionally, in the *Neijing*, *yue* is interpreted as hiccups, which has a different meaning.) The emission of sound with vomitus is called *ou* (vomiting), and the emission of soundless vomitus is called *tu* (regurgitation/spitting out). These diseases are located in the Stomach. Zhao Yi-de, however, considered that having sound but no vomitus (or only water) is *ou*, having vomitus but no sound is *tu*, and having both vomitus and sound is *ou tu*. He proposed that the Stomach is divided into three chambers: the Upper Chamber models Heaven, belongs to Clear Yang, is associated with the Qi level, and governs movement; the Lower Chamber models Earth, belongs to Turbid Yin, is associated with the Blood level, and governs stillness. Although Yang contains Yin and Yin contains Yang, the Upper Chamber ultimately has more Qi and less Blood, the Lower Chamber ultimately has more Blood and less Qi, and the Middle Chamber has an equal balance of Qi and Blood. When food and drink enter the Stomach, they also separate Clear from Turbid. Water and drinks belong to the Clear aspect of substances, while grains and foods belong to the Turbid aspect. Within the Clear, there is Turbid; thus, the Clearer part of the Clear ascends to the Lung and spreads to become Body Fluids. The Turbider part of the Clear descends to the Bladder and exits as urine and feces. Within the Turbid, there is Clear; thus, the Turbider part of the Turbid becomes dregs and exits via the Large Intestine. The Clearer part of the Turbid permeates into the blood vessels to become essence. If pathogenic factors invade the Yang region of the Upper Chamber, Qi stagnation and fluid accumulation occur. The clear and turbid nature of fluids becomes chaotic, forming phlegm-fluids, saliva, and sputum. This obstructs the chest, causing discomfort, prevents Clear Qi from ascending, and agitates to cause vomiting. Therefore, *ou* (vomiting with sound) is a disease of Qi. It models the Yang of Heaven, moves with sound, and exits together with water, similar to thunder shaking and rain pouring. If pathogenic factors invade the Yin region of the Lower Chamber, Blood stasis occurs and food stagnates. *Tu* (regurgitation without sound) models the Yin of Earth, is still and silent, and food is expelled from the mouth, similar to things emerging from the earth. If pathogenic factors are in the Middle Chamber, both *ou* and *tu* occur simultaneously, and all ingested food and drink are expelled. (Jiegu stated: Vomiting from the Middle Jiao belongs to accumulation, formed by the interaction of food and Qi creating stagnation. One may experience pain before vomiting or vomiting before pain, which reflects the mixing of clear and turbid—Qi is clear, food is turbid. He also stated: Vomiting from the Lower Jiao belongs to Cold; morning eating and evening vomiting belongs to the nature of Yin. Dongyuan also stated: The Shaoyang channel has abundant Qi and scarce Blood, manifesting as sound without vomitus; the Yangming channel has abundant Qi and abundant Blood, manifesting as sound with vomitus; the Taiyang channel has abundant Blood and scarce Qi, manifesting as vomitus without sound. All these align with this concept. However, the distinction of abundant or scarce Qi and Blood is not divided by the three chambers of the Stomach, but by the three channels. Do not be rigid about this.) Nevertheless, the Upper Chamber does not fail to expel food. If the Yin within Yang also becomes diseased (e.g., if there is phlegm-blood stagnation in the Upper Chamber, which is a tangible substance and thus belongs to Yin), then food will be vomited immediately upon entry and cannot enter the Stomach (see below), unlike the Middle Chamber where food is vomited after digestion, or the Lower Chamber where food is vomited after a long retention. The Lower Chamber does not fail to produce *ou*. If the Yang within Yin also becomes diseased (e.g., if Fire from the Thunder Dragon rushes upward), then *tu* and *ou* will occur together, but *ou* will be less than *tu*, unlike the Upper Chamber where *ou* exceeds *tu*. When water and grain enter the Stomach, if the Spleen Qi fails to transport and Clear/Turbid are not separated, downward flow into the Large Intestine causes diarrhea, while upward congestion causes vomiting. Thus, vomiting and diarrhea are counterparts, making their logic clear. Water flows downward, Fire flares upward. Knowing that vomiting arises from Fire transformation and is mostly Heat-related, one can know that diarrhea arises from Water transformation and is mostly Cold-related. Furthermore, one can understand that dysuria (scanty, painful urination) occurs because Fire Qi restricts descent. All these principles are clarified. Therefore, when external pathogens invade and cause vomiting, it is due to Stomach Yang being constrained and rushing upward; treatment should employ Acrid-Dispersing methods, and Shengjiang (Fresh Ginger) is essential. When vomiting is caused by internal Heat and Stomach Fire rushing upward (not due to external pathogens), treatment should employ Clearing-Descending methods, and Shigao (Gypsum Fibrosum) is essential. When Phlegm-Dampness stagnates, transforms into Heat, and rebels upward, Chenpi (Citrus Reticulatae Pericarpium), Banxia (Pinelliae Rhizoma), and Fuling (Poria) are essential. When Food Stagnation and Qi Stagnation rebel upward, Zhishi (Aurantii Fructus Immaturus) and Maiya (Hordei Fructus Germinatus) etc. are essential. When Heat binding in the Bowels prevents downward flow and interferes upward, Dahuang (Rhei Radix et Rhizoma) and Huashi (Talcum) etc. are essential. This is the protocol for treating Excess-Heat syndromes. If Stomach Qi is deficient and failing to transport, leading to constrained Heat and vomiting, one must promote and raise Stomach Qi. If Cold prevents transport, suppressing Fire and causing vomiting, one must Warm the Middle and Dispel Cold. If there is Deficient Heat in the Chest, and prolonged fasting leads to vomiting, providing the Yin of the Five Grains to harmonize it will stop it immediately. This is the protocol for treating Deficient-Heat syndromes. Whether vomiting is due to Excess Fire rebellion or Cold constraining Fire leading to rebellion, vomiting fundamentally stems from Fire, though one cannot uniformly treat it with Cold-Cooling herbs. Additionally, stimuli such as probing with feathers/ornaments, rocking from boats/carts, or exposure to foul odors can disturb Stomach Qi and cause vomiting. Disturbance involves movement, which belongs to Yang and is a transformation of Fire. Although this cannot be treated directly with Fire therapy, it can still be described as related to Fire. To claim it is not Fire, or even to call it Cold, because it cannot be treated with Fire therapy, would be false. This theory applies to all diseases, not just vomiting. (Someone asked: The *Shanghan Lun* and *Jinkui Yaolue* explicitly state that vomiting is due to Stomach Cold, why do you attribute it to Fire? I replied: If there were merely Yin-Cold coagulation without Qi rebelling upward, how could vomiting occur? Qi is Fire. Cold is the root; Cold constraining Qi to rebel upward is the branch. Zhang Zhongjing specifically addressed the root.) For Heat-induced vomiting, characterized by preference for cold and aversion to heat, irritability, thirst with desire to drink, and a surging-rapid pulse, use Erchen Tang (see Phlegm-Fluids) added with Huanglian (Coptidis Rhizoma), Chao Zhizi (Gardeniae Fructus stir-fried), Pipaye (Loquat Leaf), Zhuru (Bambusa Textilis Caulis in succo), Genge (Puerariae Radix), and Shengjiang (Zingiberis Rhizoma Recens), taken with Luzhigen juice (Reed Rhizome Juice). For Stomach Heat, characterized by aversion to food and vomiting, vomiting at the smell of food, and vomiting even after taking medicine, use Luzhigen juice alone. For Lower Jiao Excess Heat, characterized by obstruction of urination and defecation, rebellious Qi unable to continue, and uncontrollable violent vomiting, a condition named "Zoubu" (Running Nourishment), use Renshen Tang (Ginseng Decoction). For fever in the body and back, pulling pain in arms and costal regions, oppression in the diaphragm, and vomiting followed by diarrhea after eating (or subsequent diarrhea), a condition named "Louqi" (Leaking Qi), caused by Wind-Heat invading the Upper Jiao and constrained Heat entering the interior, use Maimendong Tang (Ophiopogonis Decoction). For vomiting bitter fluid, indicating Gallbladder Heat and bile leakage, select Zusanli (ST36) and Yanglingquan (GB34). The Classic states: All vomiting and acid regurgitation belong to Heat. Normally, Body Fluids, following ascending Qi, accumulate in the upper Stomach. Due to Damp-Heat failing to disperse, acidity forms. (This is the same principle as wine lees turning sour when heated.) When constrained to the extreme, it surges upward and is vomited. In severe cases, teeth feel sour and numb, preventing speech. This is called "Tu Suan" (Vomiting Acid). Use Pingmu Tang, adding a small amount of Wuzhuyu (Evodiae Fructus) as a counter-agent. If the acid cannot be vomited out but remains lodged in the Stomach, unable to be coughed up or swallowed down, it is called "Tun Suan" (Swallowing Acid). When the body surface is exposed to Wind-Cold, internal Heat becomes more constrained, and the sour sensation pierces the heart. If the body surface is warm, pores open, and internal Heat dissipates, or if aromatic-hot decoctions are taken to disperse Body Fluids, temporary relief may occur. (Dongyuan stated: Sour taste has a contracting nature, indicating strong Metal. Cold Water is the child of Metal. The child makes the mother full, so acrid-hot agents are used to treat Cold draining the Lung. His intent was also that when the Taiyang channel is externally attacked by Cold, skin and hair close, trapping Heat inside. Taiyang belongs to Cold Water, skin and hair belong to Lung Metal, hence the discussion in terms of Metal and Water.) However, hot agents should never be overused. Danxi used Huanglian (Coptidis Rhizoma) and Wuzhuyu (Evodiae Fructus), each processed by stir-frying, alternating as assistants according to seasons, with Cangzhu (Atractylodis Rhizoma) and Fuling (Poria) as supports, made into small pills to swallow. Huanglian Tang made into pills is also acceptable. Food retention can also cause acidity, like grain and meat turning sour in containers due to Damp-Heat. Use Shengliao Pingwei San (see Food Retention) added with Maiya (Hordei Fructus Germinatus) and Shenqu (Massa Medicata Fermentata); for Phlegm, use Kaiyu Tang (Open Depression Decoction). Anger causing vomiting and rebellion, chest fullness and diaphragmatic distension, lack of appetite with constant fullness, and vomiting after eating, use Xiaoyao San (see Depression). I once suffered from dry heaving. Taking a little Shengjiang provided slight relief. Mistaking this for Cold, I underwent multiple ineffective treatments for over ten years. Later, I realized it was Stomach Heat and cured myself using Heat-Clearing and Fluid-Nourishing herbs. If it were truly Stomach Cold, one would prefer heat and dislike cold, have a slow pulse and white urine, and Lizhong Tang (see Middle Cold) or Wuzhuyu Tang would naturally be applicable. Previously, someone with Stomach Cold vomiting used Fuzi Lizhong Tang added with Dingxiang (Caryophylli Flos). The medicine was vomited immediately upon reaching the mouth. Later, Ganjiang (Zingiberis Rhizoma) and Baizhu (Atractylodis Macrocephalae Rhizoma) were removed, using only Renshen (Ginseng), Fuzi (Aconiti Lateralis Radix Praeparata), Dingxiang (Caryophylli Flos), Muxiang (Aucklandiae Radix), and Chenxiang (Aquilariae Lignum Resinatum), and the vomiting stopped immediately. This was because Ganjiang and Baizhu were cloying/stagnating. Additionally, some hot medicines must be taken cold; if taken hot, they induce vomiting. This is the method of "Treating Heat with Cold Administration." Luo Qianfu said: For those who do not respond to various hot medicines, Hongdou Wan (Red Bean Pill) is miraculous. For vomiting unresponsive to various drugs, heavy-settling substances should be used to suppress the rebellious Qi. If Phlegm-Qi knots in the throat and diaphragm, preventing porridge and medicine from passing, causing immediate vomiting upon reaching the throat, administer Lingsha Dan (Cinnabar Pill) with Jiangsu Tang (Ginger and Perilla Decoction), and treat further once medicine can be retained. Vomiting pus indicates a gastric abscess (*Weiyuan Yong*). There is no need to treat the vomiting; it will heal spontaneously once the pus is exhausted. Vomiting worms: Worm movement causes nausea and vomiting. Medicine intake causes worm movement, which triggers vomiting. If worms are not expelled but the medicine is, this is not a good strategy. One must add ten stir-fried Chuanjiao (Sichuan Pepper) grains to the medicine, so that worms see the pepper and lie dormant. A feeling of floating unease, inner agitation, wanting to vomit but unable to, is called "Enxin" (Nausea). This is Qi and Phlegm congestion, which cannot be opened without Wayao (Linderae Radix). Use Banxiahua Tang (Pinellia and Pinellia Decoction) or Xiao Banxia Fuling Tang (Minor Pinellia and Poria Decoction) (see Phlegm-Fluids). Zhang Zhongjing said: Those who want to vomit should not be purged, because Qi is surging upward; forcing it downward causes suppression and confusion. He also said: Vomiting immediately after eating (Fire syndrome) can be treated with Dahuang Gancao Tang (Gastrodia and Licorice Decoction) to purge, because since vomiting has already occurred and continues incessantly, with ascent but no descent, it is necessary to guide it downward. After vomiting depletes Body Fluids, thirst inevitably ensues;生津 (generating fluids) is appropriate. Vomiting accompanied by severe pain, with vomitus resembling green vegetable leaves, indicates a fatal prognosis.