Library

The *Jingui Yaolue* states: Someone asked, "If a patient has a rapid pulse (Shu Mai), which indicates heat, they should have an increased appetite and digest food easily. However, if they vomit instead, what is the reason?" The master replied, "This is due to excessive sweating, which has caused yang qi to become weak and qi in the diaphragm to be deficient, resulting in a rapid pulse. This 'rapidness' represents a transient or 'guest' heat (Ke Re) that cannot digest food; the root cause is deficiency-cold in the stomach. If the pulse is wiry (Xian Mai), it also indicates deficiency, meaning there is no surplus of stomach qi. Food eaten in the morning is vomited in the evening, evolving into 'Wei Fan' (Gastric Reflux). Cold pathogen is located in the upper jiao, but the physician mistakenly used purgatives. Now the pulse has become wiry, hence it is named deficiency."

Generally, a pulse is rapid when yang is excess and slow when yin is excess. Since the patient's yang qi is already weak, why is the pulse rapid? Since the pulse is rapid, why is the stomach cold? The cause must be investigated. The rapidity of the pulse stems from the misuse of acrid-warm dispersing agents, leaving behind guest heat. The coldness of the stomach stems from insufficient yang qi generating internal cold. Physicians who do not understand flexibility and adaptation, seeing a rapid pulse, mistakenly use cold-natured herbs to purge the innocent, damaging both upper and lower yang. Consequently, the pulse transforms from yin characteristics to wiry. Deficiency of upper yang means food consumed before noon is not digested. Deficiency of lower yang means yang cannot enter yin after dusk, causing waste products to fail to transport to the large and small intestines. What enters the mouth must exit the mouth. Thus, it is said that 'stomach qi is exhausted,' meaning very little stomach yang remains, leading to gastric reflux and vomiting in the evening what was eaten in the morning.

At the Cun Kou position, if the pulse is faint (Wei) and rapid, 'faint' indicates lack of qi. Lack of qi leads to Ying blood deficiency. Ying blood deficiency leads to blood insufficiency. Blood insufficiency leads to coldness in the chest.

The previous paragraph discussed how erroneous sweating and purging methods led to such pathological pulses. This paragraph discusses how failure of Ying and Wei qi to reach the upper jiao also causes gastric reflux. Therefore, it does not re-narrate the details but only discusses the fundamental yin-yang images of the pulse. A faint and rapid pulse here: 'faint' is the image of lost yang, and 'rapid' is the image of lost yin substance. It is not merely guest heat. The chest is the sea of Ying and Wei qi. When Ying and Wei are deficient, they cannot govern within the chest, resulting in chest coldness. Ying and Wei qi enter and exit the zang-fu organs and move throughout the body. They originate from grain and consume grain. Ying and Wei cannot be filled without grain, and grain cannot be transformed without Ying and Wei. Therefore, chest coldness inevitably leads to the stomach's inability to accept food. Although so, treatment should focus on the insufficiency of righteous qi. If one treats this cold with heat [Note: Context implies treating the apparent heat or using inappropriate heat], it will not only aggravate the guest heat but also consume qi and damage yin. People treating this disease often use Ding (Clove) and Fu (Aconite) or Jiang (Ginger) and Gui (Cinnamon). Who understands the importance of righteous qi?

At the Yu Yang position, if the pulse is floating (Fu) and choppy (Se), 'floating' indicates deficiency, and 'choppy' indicates spleen injury. Spleen injury leads to failure to grind food. Morning food is vomited in the evening, evening food in the morning, undigested food remains, named 'Wei Fan'. If the pulse is tight (Jin) and choppy, the disease is difficult to treat. When spleen qi moves normally, the pulse is not choppy. When stomach qi is solid, the pulse is not floating. Now, floating pulse indicates stomach qi deficiency failing to rot and ripen water and grain. Choppy pulse indicates spleen blood injury failing to digest water and grain. Thus, food eaten during yang hours exits during yin hours, and food eaten during yin hours exits during yang hours. Because two deficiencies do not interact, transport fails, and food cannot descend into the large and small intestines. He Jian stated that a tight Yu Yang pulse indicates intense internal dryness and decline of middle qi, making it difficult to treat. Thus, a floating pulse pathology will inevitably transform into a tight pulse. Moreover, a tight pulse combined with choppy clearly indicates blood loss. Blood loss in the upper wan (upper orifice) causes dryness and astringency in the diaphragm, preventing food entry. Blood loss in the lower wan causes withering of the large and small intestines, preventing food descent, hence difficult to treat.

Vomiting with a weak pulse, frequent urination, slight fever, and appearance of cold limbs indicate a difficult-to-treat condition, managed with Si Ni Tang (Frigid Extremities Decoction).

Grain enters the stomach and nourishes yang, allowing the pulse vessels to flow. Now, the stomach is unsettled by grain, causing vomiting. Vomiting prevents yin qi from nourishing the pulse, resulting in a weak pulse. Weakness indicates yang qi deficiency failing to fill the interior and exterior. Lower jiao deficiency leads to spontaneous urination. Upper jiao deficiency allows turbid qi to rise, forcing floating yang to the exterior. Although there is false heat externally, there is true cold internally. The syndrome forms Jue Ni (cold limbs/reversal), and yin-yang separation occurs instantly. Treatment is indeed difficult; only Si Ni Tang can reverse it.

For various types of vomiting where food cannot go down, Xiao Ban Xia Tang (Minor Pinellia Decoction) is indicated.

"Various vomiting, food cannot go down" refers to acute vomiting. Therefore, Ban Xia (Pinellia Rhizome) and Sheng Jiang (Fresh Ginger) are used to wash away phlegm-fluids in the stomach, removing obstacles to water and grain.

For gastric reflux vomiting, Da Ban Xia Tang (Major Pinellia Decoction) is indicated.

Gastric reflux vomiting is due to spleen-stomach qi deficiency and fluid accumulation. Ban Xia dries dampness, and Ren Shen (Ginseng Root) supplements stomach qi. Why use Honey (Feng Mi)? Its nature is cloying and promotes dampness. It is used because the upper wan of the stomach is dry, making food hard to swallow and pass to the middle wan. Honey moistens stomach dryness, just as stirring water requires honey to moisten the upper wan.

For gastric reflux vomiting accompanied by thirst and desire for water, Fu Ling Ze Xie Tang (Poria and Alisma Decoction) is indicated.

Gastric reflux vomiting depletes fluids, causing thirst. One desires water to moisten, yet Ze Xie (Alisma Rhizome) is used even without difficulty in urination. Observing that *Waitai Miyao* uses this for Xiao Ke (Wasting-Thirst) with absent pulse and gastric reflux vomiting, we know that although water enters, it does not disperse into the vessels, indicating the yin aspect of the vessel is exhausted. Ze Xie not only promotes bladder urination but also guides the acridity of Gui Zhi (Cinnamon Twig) and Sheng Jiang into the bladder, distributing water essence to the five meridians. Thus, for those thirsty and desiring water, diuretic agents are often used, not just to prevent water retention, but to distribute water through meridians, moisten interior and exterior, and resolve heat stagnation. Fu Ling's bland nature acts upward, Ze Xie's salty nature acts downward, Bai Zhu (Atractylodes Macrocephala Rhizome) and Gan Cao (Licorice Root)'s sweet nature spreads in the middle, Gui Zhi and Sheng Jiang's acrid nature opens the pathway, circulating qi and guiding water to harmonize Ying and Wei.

Gastric reflux belongs to the decline of True Fire (Ming Men Fire), with cold stomach and weak spleen failing to digest food. Morning food is vomited in the evening, evening food in the morning, or vomited after one or two hours, or accumulated for a day and night. Abdominal distension and fullness are unbearable before vomiting. Although it is spleen-stomach deficiency-cold, the cause must involve internal stagnation. *Qianjin Fang* treats early-stage gastric reflux using *Jingui* Fu Ling Ze Xie Tang, replacing Bai Zhu with Gan Jiang (Dried Ginger), adding Ren Shen, Ju Pi (Tangerine Peel), Da Huang (Rhubarb Root), and Qing Zhu Ru (Green Bamboo Shavings). After obtaining loose stools, remove Da Huang. This becomes the main formula for stomach deficiency with immediate vomiting upon swallowing. If the vomitus is the original food, sour and foul without digestion, it means food reached the lower wan of the stomach and returned. Li Zhong Tang (Regulate the Middle Decoction) is primary; add Ding, Fu Zi (Prepared Aconite Root), and Huang Lian (Coptis Rhizome) for severe cases. If the pulse is rapid and pathogenic heat fails to digest food, it is fire flaring upward, rising more than descending. Use Yi Gong San (Yi Gong Powder) plus Chen Xiang (Agarwood), Huang Lian, Dang Gui (Angelica Sinensis Root), Bai Shao (White Peony Root), and Sheng Di Huang (Rehmannia Root). After eating, if cold saliva continues and is immediately vomited, or if heart/abdomen hurts, use Huo Xiang An Wei San (Patchouli Stomach-Calming Powder). Or Liu Jun Zi Tang (Six Gentlemen Decoction) plus Ding, Huo Xiang. For throat obstruction and chest/diaphragm fullness, temporarily use Xiang Fu (Cyperus Rhizome), Sha Ren (Cardamom Seed), Zhi Shi (Immature Bitter Orange), and Hou Po (Magnolia Bark) to open stagnation. However, too many qi-breaking drugs impair middle qi transport. Yi Gong San plus Xiang Fu and Sha Ren makes qi vigorous enough to transform. For qi stagnation, fullness, and solid pain, Ping Wei San (Peaceful Stomach Powder) plus Huo Xiang and Sha Ren. For stomach deficiency with middle qi failure causing dysphagia, Si Jun Zi Tang (Four Gentlemen Decoction) plus Huang Qi (Astragalus Root), Ju Hong (Red Tangerine Peel), and Sha Ren. For gastric reflux with thirst and desire for water, use *Jingui* Fu Ling Ze Xie Tang; *Qianjin* version removes Bai Zhu and Sheng Jiang, adds Ban Xia. For difficulty in urination, Gui Ling Wan (Cinnamon and Poria Pill) plus Ban Xia, Ze Xie, Gan Cao, and Sheng Jiang decocted as soup. For deficient patients with gastric reflux and much thirst, Qi Wei Bai Zhu San (Seven-Ingredient Atractylodes Powder). For gastric reflux where food eaten a day or half-day later is vomited unchanged, it is stomach qi deficiency with phlegm failing to digest, rising with rebellious qi. Er Chen Tang (Two-Cured Decoction) plus Ding, Huo Xiang, and Ji Nei Jin (Chicken Gizzard Membrane). For deficiency, add Bai Zhu and Pao Jiang (Roasted Ginger). For dry stool constipation lasting long, seemingly blood-heat, do not purge abruptly. Only clear heat and moisten dryness with Xiao Zhi Tang/Wan (Small-Scale Decoction/Pill), gradually increasing dosage until the obstruction clears, or use Kai Guan Li Ge Wan (Open Lock and Benefit Diaphragm Pill). However, excessive use of purgatives exhausts blood, worsening constipation. In such cases, use Ren Shen Gu Ben Wan Material decocted as paste, taken frequently. For gastric reflux with rebellious qi and immediate vomiting upon eating, belonging to heat, *Qianjin* uses Lu Gen (Reed Rhizome) and Mao Gen (Imperata Rhizome) equal parts decocted. If ineffective, add Zhu Ru (Bamboo Shavings) and Sheng Jiang. For gastric reflux with fatigue and weakness, near death, decoct 1-2 liang of Ren Shen thickly, add Jiang Zhi (Ginger Juice), and take in one dose. For cold type, add small amounts of Gui Zhi and Fu Zi. For lower jiao deficiency-cold failing to generate earth (spleen), with food vomited after a long time, use one Fu Zi slice with a hole carved in it, insert 49 Ding grains, replace the slice, tie securely, boil in fresh ginger juice, dry, and powder. Take one spoon on the tongue, swallow slowly with saliva. If烦渴 (irritable thirst), give millet gruel frequently. Avoid greasy, raw, and cold foods. This is Sun Zhao's secret prescription, effective repeatedly. For severe deficiency, add 1 liang of Ren Shen to control it. For depressed/unhappy people, or widows/widowers, start by soothing depression with Xiao Yao San (Free and Easy Wanderer Powder). Later, supplement with Gui Pi Tang (Restore the Spleen Decoction). For Ming Men fire decline failing to generate earth, with late vomiting and deep-slow pulse, Ba Wei Wan (Eight-Ingredient Pill) plus Ding and Chen Xiang. Intermittently administer Hei Xi Dan (Black Tin Pill). For essence decline failing to vaporize upward, causing throat closure and difficulty swallowing, forcing vomiting upon forced eating, Liu Wei Wan (Six-Ingredient Pill) plus Rou Gui (Cinnamon Bark) and Wu Wei Zi (Schisandra Berry). If ineffective, add Chen Xiang and Sha Ren. For yang deficiency failing to govern transport, with vomiting, reversal, and constipation, use Ren Shen, Da Huang, and Fu Zi to purge, which will unblock. However, if true qi is exhausted, it is ultimately incurable. For stasis blood in the diaphragm blocking airways, Dai Di Dang Wan (Substitute Di Dang Pill) made mustard-seed sized, take 2 qian. Lie supine without pillow, swallow slowly. If drinking hot soup or pepper/ginger causes hiccups, it is stasis blood. For gastric reflux with chest clatter and restlessness, intermittent, with mental vexation and white spots on the face, treat as parasite accumulation. Dan Formula for Ye Ge (Dysphagia) and Fan Wei: Roast Hu Su (Tiger Placenta?), powder, take 2 qian, send down with Du Shen Tang (Single Ginseng Decoction). Or roast one Cat Placenta, powder, add slight Bing Pian (Borneol) and She Xiang (Musk), take with aged wine. Tigers eat living humans, cats eat living mice; their natures are similar, so they can substitute. For cold-phlegm in stomach failing to accept food, use Gou Bao (Dog Gallstone) powder, 5-7 fen to 1 qian, with aged wine. The above three formulas: mild cases one dose, heavy three doses, severe not exceeding seven doses. Afterwards, regulate with Li Zhong, Si Jun Zi, Ba Wei, etc.

Another formula: Take one aged Xiang Yuan (Citron), remove pulp, mix with 1 liang of raw Fu Zi powder soaked in ginger juice. Wrap in ginger residue and wet paper, bake thoroughly, dry, and powder. Take 5-7 fen to 1 qian, with thick Du Shen Tang. This is Sun Zhao's modified method. After initial recovery from gastric reflux, absolutely avoid porridge/drinks. Give Du Shen Tang daily with a little fried old rice, decocted occasionally. After ten days, try thin gruel. Those who eat rice immediately often relapse and become critical. For gastric reflux causing massive vomiting of white foam like egg whites, lung and stomach are both deficient. Stool like sheep dung indicates large intestine blood exhaustion. Even with major tonification of qi and blood, death is inevitable.

[Diagnosis] Gastric reflux with rapid but forceless pulse indicates blood deficiency. Slow but forceless pulse indicates qi deficiency. Rapid and forceful pulse indicates heat. Rapid and slippery-fast pulse indicates phlegm. Tight and slippery pulse indicates cold-fluid rebellion. Small, weak, and choppy pulse indicates blood deficiency gastric reflux. Tight at Cun and choppy at Chi positions indicate chest fullness, inability to eat, and vomiting. If vomiting stops, it was due to erroneous purging, hence inability to eat. If vomiting does not stop, it is gastric reflux, hence faint and choppy pulse.

Slai Bo Ren treated a woman with gastric reflux, eating every other night, vomiting undigested food the next evening. Pulse was deep and weak. Other doctors' warming stomach medicines failed. Slai hesitated. One day he read Dong Yuan's book, stating gastric reflux has three types: Qi, Accumulation, Cold. Upper jiao vomiting stems from Qi; middle jiao from Accumulation; lower jiao from Cold. Deep-slow pulse, morning food evening vomit, evening food morning vomit, frequent urination, constipation, indicates lower jiao vomiting. Method: Unblock constipation, warm cold, then harmonize with middle jiao medicine. Slai used Yu (Cornel Fruit), Hui Xiang (Fennel Seed), Ding, Gui Zhi, Ban Xia. Over twenty doses, she recovered. As stated: "When cold dominates, soothe with acrid-hot."

Shi Wan treated Tang Bokan's son, nearly thirty, suffering from vomiting for years. Half an hour after eating, he vomited the original food, completely undigested. Bowel movements every 2-3 days, not dry. Thirsty but not desiring drink. Urine sometimes white, sometimes yellow. Liu Jun Zi Tang, Fu Zi Li Zhong Tang, Liu Wei Wan all failed. Condition became critical. I diagnosed: Guan and Chi pulses on both sides were wiry, fine, and deep. Cun pulses on both sides were choppy and large. This is great deficiency of Kidney True Yang, failing to warm and nourish Spleen Earth. I prescribed Cui Shi Ba Wei Wan (Cui Shi's Eight-Ingredient Pill). Some said: "You already gave two Fu Zi and Liu Wei Wan, perhaps Ba Wei Wan won't work either." I said: "No. This case is fundamentally Kidney deficiency. Using Jiang, Fu, Bai Zhu previously attacked Kidney Water, consuming True Yin. Liu Wei Wan, though tonifying kidney, has cloying yin herbs. Without Yang, Yin cannot be generated. One must 'tonify fire within water,' which is the correct method." He recovered before finishing the course.