金匮云。问曰。病患脉数。数为热。当消谷引食。而反吐者。何也。师曰。以发其汗。令阳
微膈气虚。脉乃数。数为客热。不能消谷。胃中虚冷故也。脉弦者。虚也。胃气无余。朝食暮吐。
变为胃反。寒在于上。医反下之。今脉反弦。故名曰虚。
凡脉阳盛则数。阴盛则迟。其人阳气既微。何得脉反数。脉既数。何得胃反冷。此不可不求
其故也。盖脉之数。由于误用辛温发散而遗客热。胃之冷。由于阳气不足而生内寒。医不达权通
变。见其脉数。反以寒剂泻其无辜。致上下之阳俱损。其脉遂从阴而变为弦也。上之阳不足。日
中以前。所食亦不消化。下之阳不足。日暮以后。阳亦不入于阴。而糟粕不输于大小肠。从口入
者。惟有从口出而已。故曰胃气无余。言胃中之阳气。所存无几。所以反胃而朝食暮吐也。
寸口脉微而数。微则无气。无气则营虚。营虚则血不足。血不足则胸中冷。
上条以汗下之故。而致病脉若此。此条以上焦营卫不逮。亦致反胃之证。故不复叙。唯言脉
之阴阳本象。今微而数。微乃失阳之象。数乃失阴之体。奚止客热而已。胸中者。营卫之海。营
卫虚。不统于胸中。故胸中冷矣。夫营卫之气。出入脏腑。健运周身。本生于谷。复消磨其谷。
营卫非谷不充。谷非营卫不化。所以胸中冷者。亦必致胃不纳谷也。虽然。当以正气不足论之。
若以热治寒。不惟反助客热。且复耗其气。损其阴矣。世人治是病。非丁、附则姜、桂。孰知正
气为何如哉。
趺阳脉浮而涩。浮则为虚。涩则伤脾。脾伤则不磨。朝食暮吐。暮食朝吐。宿谷不化。名曰
胃反。脉紧而涩。其病难治。脾气运动。则脉不涩。胃气坚固。则脉不浮。今脉浮是胃气虚不能
腐熟水谷。脉涩是脾血伤不能消磨水谷。所以阳时食入阴时反出。阴时食入阳时反出。盖两虚不
相参合。故莫由转输。下入大小肠也。河间谓趺阳脉紧。内燥盛而中气衰。故为难治。可见浮脉
病成。必变紧脉也。况紧而见涩。明是亡血之象。上脘亡血。膈间干涩。食不得入。
下脘亡血。必并大小肠皆枯。食不得下。故难治也。
呕而脉弱。小便复利。身有微热。见厥者难治。四逆汤主之。
谷入于胃。长气于阳。脉道乃行。今胃不安于谷而成呕。呕则阴气不资于脉。故脉弱。弱则
阳气虚不能充于内外。下焦虚。则小便自利。上焦虚。则浊气上升。逼迫其浮阳于外。外虽假热。
内实真寒。证成厥逆。顷刻决离而不返矣。治之诚难。非四逆汤不能挽回也。
诸呕吐。谷不得下者。小半夏汤主之。
诸呕吐。谷不得下。指暴病呕吐而言。故以半夏、生姜涤除胃中痰饮。水谷自无阻碍矣。
胃反呕吐者。大半夏汤主之。
胃反呕吐。为脾胃气虚而饮积。故用半夏之燥湿。即兼人参以补胃气也。蜜者性滞滋湿。用
之何哉。以胃之上脘燥。故食难入。虽食亦不得下中脘。用之以润胃燥。扬之水者。佐蜜以润上
脘之燥也。
胃反吐而渴。欲欲水者。茯苓泽泻汤主之。
胃反吐。津液竭而渴也。欲饮水以润之。无小便不利而用泽泻。何哉。观外台以此治消渴脉
绝。胃反呕食。则知水虽入而不散于脉。脉之阴体绝矣。泽泻者。不惟利膀胱之溺。亦能引桂、
姜之辛入膀胱。行布水精于五经。故凡渴欲饮水者。多用行水之剂。岂独防其水停而已哉。正欲
行水布散经脉。滋润表里。解其热郁耳。茯苓之淡行其上。泽泻之咸行其下。白术、甘草之甘布
其中。桂、姜之辛开其道。通其气。导其水。以令四布而和营卫也。
反胃系真火式微。胃寒脾弱不能消谷。朝食暮吐。暮食朝吐。或一两时而吐。或积至一日一
夜。腹中胀闷。不可忍而复吐。虽曰脾胃虚寒。然致病之由。必有积滞于内。千金治反胃初起。
用金匮茯苓泽泻汤。去白术换干姜。加人参、橘皮、大黄、青竹茹。得利。去大黄。为胃虚反食。
下喉便吐之主方。若吐出原物。酸臭不化。此饮食入胃。既抵胃之下脘。复返而出也。宜理中汤
为主。甚则加丁、附、川连。若脉数而邪热不杀谷。乃火性上炎。多升少降。应与异功散加沉香、
川连、归、芍、生地。食物之后。冷涎不已。随即反出。或心腹觉疼。藿香安胃散。或六君子加
丁者、藿香。咽喉阻塞。胸膈满闷。暂用香、砂、枳、朴以开其结滞。然破气药过多。中气因而
不运。异功散加香、砂使气旺自能运化。气滞痞塞实痛。平胃散加藿香、砂仁。胃虚中气不运而
噎塞者。四君子加黄 、橘红、砂仁。反胃而渴欲饮水。金匮茯苓泽泻汤。千金去白术、生姜加
半夏。小便不利。桂苓丸加半夏、泽泻、甘草、生姜作汤服。虚人反胃多渴。七味白术散。反胃
食入一日半日。吐出如故。乃胃气虚弱而有痰。不能消化。随气逆上也。二陈加丁香、藿香、鸡
内金。虚。加白术、炮姜。大便燥结。久闭不通。似属血热。不可顿攻。止可清热润燥。小制汤
丸。渐次加之。关扃自透。开关利膈丸。然服通利之剂过多。血液耗竭。转加闭结者。宜用人参
固本丸料煎膏。时时服之。胃反上气。食即吐出。属热者。千金用芦根、茆根等分煎服。不应。
加竹茹、生姜。反胃倦怠无力。垂死者。以人参一二两浓煎。加姜汁顿服。属寒者。加桂附少许。
下焦虚寒。不能生土。食久反出。用附子一枚。切去尖上一片。镂成一孔。入丁香四十九粒。仍
将切下者掩上扎定。捣取生姜自然汁煮熟焙干为末。每用一匙置舌上。徐徐以津唾送下。若烦渴
则频与糜粥。忌油腻生冷。此孙兆秘传。累效。虚甚者。加人参一两驾驭之。郁悒失意人。或孤
寡。初起自当舒郁。逍遥散。久之必兼补养。归脾汤。命门火
衰。不能生土。食久反出。其脉沉迟。八味丸加丁、沉。间进黑锡丹。精衰不能蒸腾于上。咽喉
闭塞。水谷艰进。强食则吐者。六味丸加肉桂、五味。不应。加沉香、砂仁。有阳虚不能统运。
呕逆便秘。用人参、大黄、附子攻之即通。然真气竭者。终不可救。瘀血在膈。阻滞气道而成者。
代抵当丸作芥子大。服二钱。去枕仰卧。细细咽之。但饮热汤及椒、姜辄呃者。即瘀血也。反胃
而胸中嘈杂不宁。或作或止。其人懊 。面上有白点者。作虫积治之。丹方。治噎膈反胃。用
虎酥炙为末。每服二钱。独参汤送下。或猫胞一具。炙脆为末。稍加脑、麝。陈酒服之。虎啖
生人。猫食生鼠。其性则一。故可代用。若胃中寒痰。不能纳食者。狗宝为末。每服五七分至一
钱。陈酒服之。以上三方。轻者一服。重者三服。剧者不过七服。后以理中、四君、八味等调之。
又方。用陈香橼一枚。去瓤。入生姜汁拌生附子末一两。外以姜滓。湿纸裹煨。 透焙燥为末。
每服五七分至一钱。浓煎独参汤服之。此孙兆变法也。反胃初愈。切不可与粥饮。每日与独参
汤。少加炒陈米。不时煎服。旬日后方可小试稀糜。往往即食饭者。多致复病而危。凡反胃而致
大吐白沫如鸡子清者。是肺胃俱虚。矢如羊粪。则大肠血槁。即大补气血。终亦必亡而已。
〔诊〕胃反脉数无力为血虚。脉缓无力为气虚。数而有力为有热。数而滑疾为有痰。紧而滑者。
寒饮上逆。小弱而涩。血虚胃反。寸紧尺涩。其人胸满。不能食而吐。吐止者为下之。故不能食。
设言未止者。此为胃反。故脉微涩。滑伯仁治一妇反胃。每隔夜食。至明晚皆吐出不消。其脉沉
而弱。他医以暖胃药罔效。滑迟疑未决。一日读东垣书。谓反胃有三。气积寒也。上焦吐者从于
气。中焦吐者从于积。下焦吐者从于寒。脉沉而迟。朝食暮吐。暮食朝吐。小溲利。大便秘。为
下焦吐也。法当通其秘。温其寒。复以中焦药和之。滑得此说。遂以萸、茴、丁、桂、半夏。二十余剂而
安。所谓寒淫所胜。平以辛热也。
石顽治汤伯干子。年及三旬。患呕吐经年。每食后半日许。吐出原物。全不秽腐。大便二三
日一行。仍不燥结。渴不喜饮。小便时白时黄。屡用六君子、附子理中、六味丸。皆罔效。日滨
于危。逮后延余诊之。其两关尺弦细而沉。两寸皆涩而大。此肾脏真阳大亏。不能温养脾土之故。
遂以崔氏八味丸与之。或谓附子已经服过二枚。六味亦曾服过。恐八味亦未能克效也。余曰不然。
此证本属肾虚。反以姜、附、白术伐其肾水。转耗真阴。至于六味。虽曰补肾。而阴药性滞。无
阳则阴无以生。必于水中补火。斯为合法。服之。不终剂而愈。
《金匮要略》中说：有人问，病人脉象数，数脉主热，应当食欲旺盛、消化食物并容易饥饿进食，但却反而呕吐，这是什么原因呢？医生回答说，这是因为发汗过度，导致阳气微弱、膈间气虚，脉象才表现为数。这里的“数”是客热（外来的或暂时的热邪），不能消化食物，根本原因是胃中虚冷。如果脉象弦，也是虚证的表现，说明胃气已无余存。早晨吃进去的食物，晚上吐出来，演变为胃反病。寒邪位于上焦，医生反而使用攻下法，现在脉象反而变弦，所以称为虚证。
大凡脉象阳盛则数，阴盛则迟。既然病人的阳气已经微弱，为什么脉象反而数？脉象既然数，为什么胃反而冷？这是不可不探究其原因的。大概脉象数的原因，是由于误用辛温发散药物而遗留了客热；胃冷的原因，是由于阳气不足而生内寒。医生不懂权变通融的道理，见到脉数，反而用寒凉药剂泻其无辜的邪气，导致上下两部的阳气都受损，脉象于是从阴脉转变为弦脉。上部的阳气不足，中午以前，所吃的食物也不能消化；下部的阳气不足，傍晚以后，阳气也不能入于阴分，导致糟粕不能输送到大小肠。从口进入的食物，只能从口吐出罢了。所以说“胃气无余”，是指胃中的阳气所剩无几，因此出现反胃、朝食暮吐的症状。
寸口脉微而数，微脉表示无气，无气则营血虚，营血虚则血液不足，血液不足则胸中寒冷。
上一条论述是因为汗法和下法误治，导致致病脉象如此。这一条是因为上焦营卫之气不能到达，也导致反胃的证候，所以不再详细叙述，只谈论脉象的阴阳本象。现在的脉象微而数，微是失去阳气的表现，数是失去阴体的表现，哪里仅仅是客热而已呢？胸中是营卫之海，营卫虚弱，不能在胸中统摄，所以胸中寒冷。营卫之气，出入脏腑，健运周身，本来由水谷化生，又消耗水谷。营卫没有水谷就不能充盈，水谷没有营卫就不能消化。所以胸中寒冷，也必然导致胃不能纳食。虽然如此，应当从正气不足来论治。如果用热药治疗寒证（注：此处原文逻辑似有矛盾，结合下文“若以热治寒...且复耗其气”，实指误将真寒假热当作实热，或用寒药治寒，或指误治导致的热象被误认为真热而用寒药，但根据后文“世人治是病非丁附则姜桂”，此处语境更倾向于批评世医见数脉即用寒药，或者指若将这种因虚产生的“热”当作实热去治，会助长客热并耗气伤阴。*修正理解*：原文“若以热治寒”在此处语境略显突兀，结合上下文“奚止客热而已...胸中冷矣...若以热治寒...且复耗其气”，通常“以热治寒”是正确的治法，但这里可能是指如果仅仅针对表面的“数/热”表象，而不顾根本的“虚/寒”，或者是指如果错误地判断病机。再细读：“此条以上焦营卫不逮...故胸中冷矣...若以热治寒，不惟反助客热，且复耗其气，损其阴矣。” 这句话在中医逻辑中较难解释，因为胸中冷理应热治。查阅张璐《张氏医通》原意，此处可能是在讨论一种复杂的病机，即虽然有寒，但若单纯用大热之药，可能会因为阴虚或客热的存在而产生副作用，或者原文意指“若以（治）热（之法）治（此）寒”。但看后文“世人治是病，非丁、附则姜、桂”，说明当时医生多用温热药。那么前文“若以热治寒...”可能是指如果误判了“数脉”为实热而用寒药？不对，原文写的是“若以热治寒”。让我们重新审视：前文说“脉既数...何得胃反冷...盖脉之数由于误用辛温...遗客热...胃之冷由于阳气不足...医不达权...见其脉数，反以寒剂泻其无辜”。这一段明确说了医生见数脉用了寒剂。那么下一段“若以热治寒...”可能是指另一种情况，或者是对前文的补充？不，看段落结构，“上条...此条...故不复叙...唯言脉之阴阳本象...今微而数...奚止客热而已...胸中冷矣...夫营卫...所以胸中冷者...亦必致胃不纳谷也。虽然，当以正气不足论之。若以热治寒，不惟反助客热，且复耗其气，损其阴矣。” 这里可能存在文本传抄错误或特殊的辩证逻辑。通常“胸中冷”需温补。如果“以热治寒”会导致“助客热、耗气损阴”，那说明这个“寒”不是单纯的寒，或者这个“热”药不对症。但紧接着说“世人治是病，非丁、附则姜、桂。孰知正气为何如哉！”这是在批评世人滥用温热药。因此，前一句“若以热治寒...”极有可能是指“若以（治）热（证的方法，即寒药）治（此）寒（证）”？或者是原文有误，应为“若以寒治热”？鉴于后文批评世人用姜桂，前文批评医生用寒剂，这里逻辑较为混乱。但在翻译时，我将忠实于原文字面意思，并结合语境稍作理顺：既然根本是正气不足，如果简单地用热药去治这个寒（可能指如果不顾阴虚或客热背景，盲目投以大热之品），不仅会助长客热，还会耗气伤阴。世人治疗这个病，不是用丁香、附子，就是用干姜、肉桂，谁懂得正气的重要性呢？
趺阳脉浮而涩，浮脉表示虚，涩脉表示脾受伤。脾受伤则不能磨化食物，早晨吃晚上吐，晚上吃早上吐，宿食不化，称为胃反。脉象紧而涩，病情难治。脾气运动正常，脉就不涩；胃气坚固，脉就不浮。现在脉浮，是胃气虚不能腐熟水谷；脉涩，是脾血伤不能消磨水谷。所以在阳气旺盛的时候（阳时）吃进去的食物，在阴气旺盛的时候（阴时）反而出；在阴时吃进去的食物，在阳时反而出。这是因为两个方面的虚弱不能相互参合，所以无法转输下行进入大小肠。刘河间认为趺阳脉紧，是内燥盛而中气衰，所以难治。可见浮脉的病成之后，必定会变成紧脉。况且紧脉兼见涩脉，明显是亡血的表现。上脘亡血，膈间干涩，食物不能进入；下脘亡血，必然连同大小肠都干枯，食物不能下行，所以难治。
呕吐而脉弱，小便反而通畅，身体有轻微发热，出现四肢厥冷的，属于难治之证，用四逆汤主治。
谷物进入胃中，滋养阳气，脉道才能运行。现在胃不安于谷物而成为呕吐，呕吐则阴气不能资助脉道，所以脉弱。脉弱则阳气虚，不能充养内外。下焦虚，则小便自利；上焦虚，则浊气上升，逼迫浮阳于体表。外表虽有假热，内里实际上是真寒。证候形成厥逆，顷刻之间阴阳决离而不能返回。治疗确实很难，不用四逆汤不能挽回。
各种呕吐，食物不能下咽，指的是急性发作的呕吐，所以用半夏、生姜涤除胃中的痰饮，水谷自然就没有阻碍了。
胃反呕吐，是因为脾胃气虚而痰饮积聚，所以用半夏燥湿，同时加入人参来补胃气。蜂蜜性质滞腻滋湿，为什么要用它呢？因为胃的上脘干燥，所以食物难以下咽，即使吃进去了也不能到达中脘。使用蜂蜜是为了滋润胃燥，正如扬之水需要佐使蜂蜜来润上脘之燥一样。
胃反呕吐，津液枯竭而口渴。想喝水来滋润它，但没有小便不利却用泽泻，为什么呢？观察《外台秘要》用此方治疗消渴脉绝、胃反呕食的情况，就知道水虽然进入体内但不能散布于脉中，脉的阴体已经衰竭。泽泻不仅能利膀胱的小便，也能引导桂枝、生姜的辛味进入膀胱，布散水精于五经。所以凡是口渴想喝水的人，多用行水之剂，难道只是为了防止水停吗？正是为了行水布散经脉，滋润表里，解除热郁。茯苓的淡味行于上，泽泻的咸味行于下，白术、甘草的甘味布于中，桂枝、生姜的辛味开其道，通行气机，引导水液，使其四布调和营卫。
反胃属于真火式微，胃寒脾弱不能消化食物，早晨吃晚上吐，晚上吃早上吐，或者一两个时辰就吐，或者积存到一天一夜才吐，腹中胀闷，难以忍受而复吐。虽然说是脾胃虚寒，但致病的原因，一定是有积滞在内。《千金方》治疗反胃初起，用《金匮》茯苓泽泻汤，去掉白术换成干姜，加入人参、橘皮、大黄、青竹茹。服用后得利，去掉大黄，作为胃虚反食、下喉即吐的主方。如果吐出的是原物，酸臭不化，这是饮食进入胃中，抵达到胃的下脘后，又返出来。宜用理中汤为主，严重时加丁香、附子、黄连。如果脉数且邪热不能杀谷（消化食物），这是火性上炎，多升少降，应与异功散加沉香、黄连、当归、白芍、生地。食物之后，冷涎不止，随即反出，或者心腹疼痛，用藿香安胃散。或者六君子汤加丁香、藿香。咽喉阻塞，胸膈满闷，暂时用香附、砂仁、枳实、厚朴来开通结滞。然而破气药过多，中气因而不能运化，可用异功散加香附、砂仁，使气旺自能运化。气滞痞塞实痛，用平胃散加藿香、砂仁。胃虚中气不运而噎塞的，用四君子汤加黄芪、橘红、砂仁。反胃而渴欲饮水，用《金匮》茯苓泽泻汤，《千金方》中去掉白术、生姜加半夏。小便不利，用桂苓丸加半夏、泽泻、甘草、生姜煎汤服。虚人反胃多渴，用七味白术散。反胃食入一日半日，吐出如故，是胃气虚弱而有痰，不能消化，随气逆上也。用二陈汤加丁香、藿香、鸡内金。虚者，加白术、炮姜。大便燥结，久闭不通，似乎属血热，不可顿然攻下，只可清热润燥，用小制汤丸，逐渐增加剂量，关扃自然通透，或用开关利膈丸。然而服用通利之剂过多，血液耗竭，反而加重闭结的，宜用人参固本丸料煎膏，时时服用。胃反上气，食入即吐，属热证的，《千金方》用芦根、茅根等分煎服，无效，加竹茹、生姜。反胃倦怠无力，垂死的，用人参一二两浓煎，加姜汁顿服。属寒证的，加少许桂枝、附子。下焦虚寒，不能生土（脾），食久反出，用附子一枚，切去尖上一片，镂成一孔，放入丁香四十九粒，仍将切下的部分掩上扎定，捣取生姜自然汁煮熟焙干为末。每用一匙放在舌上，徐徐用津唾送下。如果烦渴，则频繁给予糜粥，忌油腻生冷。这是孙兆的秘传，屡试有效。虚甚者，加人参一两驾驭之。忧郁失意的人，或是孤寡之人，初起应当舒郁，用逍遥散。久之必兼补养，用归脾汤。命门火衰，不能生土，食久反出，脉象沉迟，用八味丸加丁香、沉香。间歇进服黑锡丹。精衰不能蒸腾于上，咽喉闭塞，水谷艰进，强食则吐的，用六味丸加肉桂、五味子。无效，加沉香、砂仁。有阳虚不能统运，呕逆便秘的，用人参、大黄、附子攻之即通。然而真气竭者，终究不可救。瘀血在膈，阻滞气道而成的，用代抵当丸做成芥子大，服二钱。去枕仰卧，细细咽下。只要喝热汤及椒、姜就打嗝的，就是瘀血。反胃而胸中嘈杂不宁，或作或止，其人心中懊恼，面上有白点的，按虫积治疗。丹方治疗噎膈反胃，用虎酥炙为末，每服二钱，独参汤送下。或者用猫胞一个，炙脆为末，稍加冰片、麝香，陈酒服之。虎吃活人，猫吃活鼠，其性相同，所以可以代替使用。如果胃中寒痰，不能纳食的，用狗宝为末，每服五七分至一钱，陈酒服之。以上三方，轻者一服，重者三服，剧者不超过七服。后用理中汤、四君子汤、八味丸等调理。
又一方，用陈香橼一枚，去瓤，入生姜汁拌生附子末一两，外面用姜滓，湿纸包裹煨透焙干为末。每服五七分至一钱，浓煎独参汤服之。这是孙兆的变法。反胃初愈，切不可给粥饮，每日给独参汤，少加炒陈米，不时煎服，十日后才可以小试稀糜。往往立即吃饭的，多导致复发而危重。凡是反胃而导致大吐白沫如鸡蛋清的，是肺胃俱虚；大便如羊粪，是大肠血枯，即使大补气血，最终也必亡而已。
〔诊法〕胃反脉数无力为血虚，脉缓无力为气虚，数而有力为有热，数而滑疾为有痰，紧而滑者为寒饮上逆，小弱而涩者为血虚胃反，寸紧尺涩者，其人胸满，不能食而吐，吐止的是因为被误下，所以不能食。如果说吐未止的，此为胃反，所以脉微涩。
滑伯仁治疗一位妇女反胃，每隔一晚进食，到第二天晚上都将未消化的食物吐出。其脉沉而弱。其他医生用暖胃药无效。滑伯仁迟疑未决。一天读李东垣的书，说反胃有三：气、积、寒。上焦吐者从于气，中焦吐者从于积，下焦吐者从于寒。脉沉而迟，朝食暮吐，暮食朝吐，小便利，大便秘，为下焦吐。治法应当通其秘，温其寒，再用中焦药调和。滑伯仁得到这个说法，于是用山茱萸、茴香、丁香、桂枝、半夏，二十多剂而痊愈。所谓寒淫所胜，平以辛热。
石顽治疗汤伯干的儿子，年近三十，患呕吐经年，每次进食后半日左右，吐出原物，完全不腐败，大便二三日一行，仍不燥结，口渴但不喜欢喝水，小便时而白时而黄，屡次用六君子汤、附子理中汤、六味丸，都无效，日渐濒危。后来请我诊治，其两关尺脉弦细而沉，两寸脉皆涩而大。这是肾脏真阳大亏，不能温养脾土的缘故。于是用崔氏八味丸给他。有人说附子已经服过两枚，六味丸也曾服过，恐怕八味丸也不能见效。我说不是这样，这个证候本属肾虚，反而用姜、附、白术伐其肾水，转而耗伤真阴。至于六味丸，虽然说是补肾，但阴药性质滞腻，无阳则阴无以生，必须于水中补火，这才是合法。服药，不到一疗程就好了。
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.