刘宗浓曰。呃逆有虚有实。有火有痰有水气。不可专作寒论。盖伤寒发汗吐下后。与泻利日
久。及大病后。妇人产后有此证。皆属脾胃大虚。若因痰水停积心下。或因暴怒气逆痰厥。或伤
寒热病失下。则皆属热也。夫水性润下。火性炎上。今其气自下冲上。非火而何。大抵治法。虚
则补之。虚中须分寒热。如因汗吐下后。误服寒凉过多。当温补之。如脾胃阴虚。火逆上冲。当
平补之。挟热者。当凉补之。若实者。如伤寒失下。地道不通。因而呃逆。当寒下之。如痰饮停
蓄。或暴怒气逆痰厥。此等必形气俱实。别无恶候。随其邪之所在。涌之泄之。清之利之。胃虚
木挟相火。直冲清道而上者。异功散加肉桂。甚则加黄柏、附子。送六味丸。吐利后。胃气虚寒
者。理中汤加附子、丁香、柿蒂。吐利后。胃虚热者。橘皮竹茹汤。呃逆呕吐多者。属胃虚有痰。
半夏、茯苓、生姜。兼食结痰积则膈间饱闷。枳、术、半夏、生姜。平人饮热汤及食椒、姜即呃
者。此胃中有寒痰死血也。死血。用韭汁、童便下越曲丸。虚人、用理中汤加蓬术、桃仁。痰。
加茯苓、半夏。盖呃逆皆是寒热错乱。二气相搏使然。故治亦多用寒热相兼之剂。如丁香、柿蒂
并投之类。试观平人冷呃。令其思
想则止。思则脾火气乘。而胃气和矣。呃逆虽多有属火者。然病后久虚发呃。皆属于寒。宜用半
夏一两。生姜一两。水煎热服。或用丁香数十粒。柿蒂十枚。滚水泡服。或理中汤加枳壳、茯苓、
半夏。不应。加箬蒂、丁香。若胃中寒甚。呃逆不已。或复呕吐。丁香煮散。或附子粳米汤加炒
川椒、丁香。暴怒呃逆。神昏吐涎。此肝火逆上。防有血积膈间。若按之痛者。藕汁、麻油。服
少顷。即探吐之。不痛者。陈皮二两。煎汤探吐之。产后呃逆。最为恶候。急灸期门左穴。艾炷
如小豆大。宜服四逆加人参汤、羌活附子散。或桂心五钱。姜汁三合。和水煎服。
石顽曰。呃逆在辨寒热。寒热不辨。用药立毙。凡声之有力而连续者。虽有手足厥逆。大便
必坚。定属火热。下之则愈。万举万全。若胃中无实火。何以激搏其声逆上而冲乎。其声低怯而
不能上达于咽喉。或时郑声虽无厥逆。定属虚寒。苟非丁、附。必无生理。若胃中稍有阳气。何
致音声馁怯不前也。盖胃中有火则有声。无火则无声。误以柿蒂、芦根辈治之。仓扁不能复图矣。
又有始热终寒者。始本热邪。因过用苦寒。寒郁其热。遂至呃逆。急宜连理汤加姜、半主之。五
六日大便不通者。削陈酱姜导之。若真阳素虚人。误用苦寒通其大便。必致热去寒起。多成不救。
复有饮热饮冷而呃。背微恶寒。目睛微黄。手足微冷。大便溏黑者。属瘀血。若饮热则安。饮冷
则呃。虽有背恶寒。手足冷。大便溏等证。此属湿痰。肥人多此。须推瘀血痰饮例治之。
噫气 灵枢云。寒气客于胃。厥逆从下上散。复出于胃。故为噫。保命集云。噫者。胸中气
不交也。仲景云。噫气不除者。旋复代赭石汤主之。则知噫气为中气不治。土不制水。水饮上泛。
故用旋复、半夏以散痰饮。人参、甘草、姜、枣以温胃气。代赭以镇坠逆气而引参力下行也。若
老人噫气。乃胃中虚寒痰逆而然。止宜理中丸温助胃气为主。或加
枳实、香附、砂仁之类助其消化。虽然。真气已衰。即使调理得宜。终不能过五年矣。
诸逆冲上 气逆冲上。火气炎上故也。经云。逆气象阳。凡气逆。必证象阳盛。面赤脉洪。
当以法降其逆乃愈。若以气象阳盛。而用寒药攻之。则不救矣。气上冲咽不得息。喘息有声不得
卧。调中益气汤加吴茱萸。观厥气多少用之。如夏月有此证为大热也。宜以酒炒川连、知、柏。
少加肉桂为末。酒丸服二钱。仍多饮汤。少时以美 压之。使直至下焦。以泻冲脉之逆也。盖逆
者。寒热之气逆而不顺也。当随四时寒热温凉以制之。厥阴气上冲心。咽不得息。治法见伤寒厥
阴病条。戴复庵云。虚炎之证。阴阳不升降。下虚上盛。气促喘急。宜苏子降气汤下黑锡丹。
Liu Zongnong stated: Epigastric regurgitation (E Ni, hiccup or belching with upward rushing sensation) can be classified into deficiency and excess patterns, and involves fire, phlegm, or water qi. It cannot be exclusively treated as a cold pattern. Generally, after the treatment of Cold Damage (Shang Han) via sweating, vomiting, or purging, or following prolonged diarrhea and dysentery, as well as after severe illnesses or postpartum in women, such symptoms belong to extreme deficiency of the Spleen and Stomach. If caused by the accumulation of phlegm and water in the epigastrium (Xin Xia), or due to sudden anger causing Qi rebellion and Phlegm Jue (Phlegm syncope), or due to failure to purge heat pathogens in Cold Damage febrile diseases, these cases belong to heat patterns. Water has the nature of moistening and flowing downward, while Fire has the nature of flaring upward. Now that the Qi rushes from below to above, if not Fire, then what? In general, the treatment principle is: for deficiency, use tonification; within deficiency, one must distinguish between cold and heat. If caused by excessive intake of cold-cooling herbs after sweating, vomiting, or purging, warm tonification should be used. If it is Yin deficiency of the Spleen and Stomach with Fire rebelling upward, mild tonification should be used. If accompanied by heat, cool tonification should be used. For excess patterns, such as epigastric regurgitation caused by failure to purge in Cold Damage leading to blocked bowel movements, cold purgation should be used. For accumulated phlegm-fluids or sudden anger causing Qi rebellion and Phlegm Jue, where both the physical form and Zheng Qi are solid without other critical signs, treatment should follow the location of the pathogen, employing methods such as inducing vomiting, purging, clearing heat, or promoting urination. If Stomach deficiency leads to Liver Wood carrying Ministerial Fire rushing directly up the clear pathways, Yichong San (Extraordinary Power Powder) with Rou Gui (Cinnamon Bark) should be used. For severe cases, add Huang Bo (Phellodendron Bark) and Fu Zi (Aconite Root), taken with Liuwei Wan (Six-Ingredient Rehmannia Pill). After vomiting and diarrhea, if the Stomach Qi is deficient and cold, Lizhong Tang (Regulate the Middle Decoction) with Fu Zi, Ding Xiang (Clove), and Shi Di (Persimmon Calyx) should be used. After vomiting and diarrhea, if there is Stomach deficiency with heat, Jupi Zhuru Tang (Tangerine Peel and Bamboo Shavings Decoction) should be used. For frequent epigastric regurgitation and vomiting belonging to Stomach deficiency with phlegm, Ban Xia (Pinellia Tuber), Fu Ling (Poria), and Sheng Jiang (Fresh Ginger) may be used. If accompanied by food stagnation and phlegm accumulation causing fullness and oppression in the chest and diaphragm, Zhi Shi (Immature Bitter Orange), Bai Zhu (Atractylodes Rhizome), Ban Xia, and Sheng Jiang should be used. For healthy individuals who experience epigastric regurgitation after drinking hot soup or eating pepper and ginger, this indicates cold-phlegm and dead blood (old blood stasis) in the Stomach. For dead blood, use Chive Juice and Tong Bian (Child's Urine) to deliver Yueju Wan (Yueju Pill). For deficient persons, use Lizhong Tang with Peng Zhu (Curcuma Zedoaria) and Tao Ren (Peach Seed). For phlegm, add Fu Ling and Ban Xia. Generally, epigastric regurgitation results from the disorder of cold and heat, where Yin and Yang Qi clash. Therefore, treatments often combine cold and heat herbs, such as using Ding Xiang and Shi Di together. Observe that normal people experiencing cold-induced epigastric regurgitation can stop it by thinking, because thought engages Spleen Fire Qi, harmonizing Stomach Qi. Although many cases of epigastric regurgitation belong to fire, those occurring after severe illness and prolonged deficiency belong to cold. Use Ban Xia (1 liang) and Sheng Jiang (1 liang), decocted in water and taken hot; or use dozens of Ding Xiang grains and ten Shi Di pieces, soaked in boiling water; or Lizhong Tang with Zhi Qiao (Aurantium Fructus), Fu Ling, and Ban Xia. If ineffective, add Ruo Di (Bamboo Leaf Sheath) and Ding Xiang. If Stomach cold is severe and epigastric regurgitation persists, or vomiting recurs, use Ding Xiang San (Clove Powder) or Fuzi Jingmi Tang (Aconite and Rice Decoction) with fried Chuan Jiao (Sichuan Pepper) and Ding Xiang. For epigastric regurgitation due to sudden anger, with unconsciousness and salivation, this is Liver Fire rebelling upward; guard against blood stasis in the diaphragm. If tender to pressure, use Lotus Root Juice and Sesame Oil, take for a moment, then induce vomiting. If not tender, use 2 liang of Chen Pi (Tangerine Peel) decocted in water to induce vomiting. Postpartum epigastric regurgitation is a dire prognosis. Moxibustion should be applied urgently to the left Qimen (Liv 14) acupoint with moxa cones the size of a small bean. Si Ni Jia Renshen Tang (Frigid Extremities Decoction plus Ginseng) or Qiang Huo Fu Zi San (Notopterygium and Aconite Powder) should be administered, or Gui Xin (Cinnamon Heart) 5 qian mixed with 3 he of Ginger Juice, decocted in water.
Shi Wan stated: The key to treating epigastric regurgitation lies in distinguishing cold from heat. Failure to do so will lead to immediate death upon medication administration. If the sound is forceful and continuous, even if accompanied by cold extremities, the stool must be hard, indicating a definite heat pattern; purgation will cure it successfully. How else could the lack of excess fire in the Stomach agitate and propel the sound upward? If the sound is low, timid, and fails to reach the throat, or if occasional Zheng Sheng (delirious speech) occurs without cold extremities, it definitely belongs to deficiency-cold. Without Ding Xiang and Fu Zi, there is no hope. If there were any Yang Qi in the Stomach, why would the voice be weak and hesitant? Generally, fire in the Stomach produces sound; absence of fire means absence of sound. Mistakenly treating with Shi Di or Lu Gen (Reed Rhizome) renders even Cang Gong and Bian Que powerless. There are also cases starting as heat and ending as cold, where initial heat pathogens are suppressed by excessive bitter-cold herbs, leading to epigastric regurgitation. Lianli Tang (Coix and Pinellia Decoction) with Sheng Jiang and Ban Xia is urgent. For constipation lasting five to six days, guide with sliced aged soy sauce ginger. For persons with inherent True Yang deficiency, mistaken purgation with bitter-cold herbs will cause heat to depart and cold to arise, often resulting in untreatable conditions. Another scenario involves epigastric regurgitation triggered by drinking hot or cold liquids, with slight aversion to cold on the back, slightly yellow eyes, slightly cold hands and feet, and loose black stools, indicating Blood Stasis. Comfort with hot drinks and regurgitation with cold drinks, despite back aversion to cold and cold extremities, points to Damp-Phlegm, common in obese individuals; treat according to Blood Stasis and Phlegm-Fluid patterns.
Belching (Yi Qi): The Ling Shu states: When cold pathogens lodge in the Stomach, rebellious Qi scatters upward and exits through the Stomach, causing belching. The Baoming Ji states: Belching is the lack of interaction between Qi in the chest. Zhang Zhongjing stated: For persistent belching, Xuanfu Daizhe Shi Tang (Inula and Hematite Decoction) is indicated. This shows belching results from dysfunction of Middle Qi, Earth failing to control Water, leading to water-fluids rising. Thus, Xuan Fu Hua (Inula Flower) and Ban Xia are used to dissipate phlegm-fluids, Ren Shen (Ginseng), Gan Cao (Licorice), Sheng Jiang, and Da Zao (Jujube) to warm Stomach Qi, and Dai Zhe Shi (Hematite) to anchor rebellious Qi and guide the power of Ginseng downward. For elderly patients with belching due to Stomach deficiency-cold and rebellious phlegm-Qi, Lizhong Wan (Regulate the Middle Pill) should be the main treatment to warm and assist Stomach Qi, possibly adding Zhi Shi, Xiang Fu (Cyperus Rhizome), or Sha Ren (Amomum Fruit) to aid digestion. However, since True Qi is already depleted, even with proper regulation, life expectancy rarely exceeds five years.
Various Rebellious Qi Rushing Upward: Rebellious Qi rushing upward is due to the flaring nature of Fire Qi. Classics state: Rebellious Qi mimics Yang excess. Any Qi rebellion manifests with Yang excess signs, such as red face and surging pulse. Treatment should lower the rebellion to achieve cure. Mistaking this apparent Yang excess for true Yang excess and attacking with cold herbs will be fatal. For Qi rushing to the throat causing breathing difficulty, noisy wheezing, and inability to lie down, Tiaozhong Yiqi Tang (Regulate Middle and Boost Qi Decoction) with Wu Zhu Yu (Evodia Fruit) should be used, adjusted based on the degree of Jue Qi. In summer, this presentation indicates intense heat; use wine-fried Huang Lian (Coptis Rhizome), Zhi Mu (Anemarrhena Rhizome), and Huang Bo, with a little Rou Gui, made into pills taken with wine, followed by abundant fluid intake and pleasant food to drive the medicine to the Lower Jiao to drain the Chong Mai (Penetrating Vessel) rebellion. "Rebellion" refers to the disorder of cold and heat Qi. Treatment must adapt to seasonal cold, heat, warmth, and coolness. When Jue Yin Qi rushes to the Heart causing throat obstruction, see the Cold Damage Jue Yin Disease section. Dai Fu'an stated: For deficiency-fire syndromes with dysfunctional Yin-Yang ascending-descending, Lower Deficiency and Upper Excess, causing shortness of breath and急促 wheezing, Su Zi Jiang Qi Tang (Perilla Seed Descending Qi Decoction) with Hei Xi Dan (Black Tin Pill) should be used.