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Chapter 19 of 27
金匮要略
Overall Interpretation
This chapter specifically discusses the pulse manifestations, treatment principles, and formulas for three categories of disorders: vomiting, hiccup (retching), and diarrhea/dysentery (下利). The entire chapter contains one discourse, twenty-seven articles on pulse patterns and symptoms, and twenty-three formulas.
I. General Principles and Pattern Differentiation Essentials for Vomiting Disorders
When a patient's vomitus contains supportive pus (pus formed from ulcerative lesions within the body), anti-emetic drugs must not be used to forcibly stop the vomiting — once the pus is completely expelled, the vomiting will cease naturally. This embodies the principle of "guiding according to the momentum": vomiting is the body's pathway for expelling harmful substances, and forcibly blocking it is counterproductive to recovery.
When vomiting occurs first, followed by thirst, this indicates that the pathogenic factor is about to depart and the body fluids are temporarily depleted — a sign that the condition is improving. When thirst occurs first, followed by vomiting, this indicates retained fluid (abnormal accumulation of water in the body) stagnating at the epigastrium (the stomach region), and belongs to the category of fluid retention sufferers (those with pre-existing internal fluid stasis). In general vomiting patients, thirst should normally be present; if thirst is now absent, it is because there is branching fluid retention (water retention supporting and stagnating at the epigastrium) in the epigastrium, which belongs to the branching fluid retention disorder.
Someone asks: When a patient has a rapid pulse, a rapid pulse indicates heat, and heat should be able to digest food and increase appetite — yet the patient vomits instead. Why is this? The teacher answers: Because diaphoresis was mistakenly applied, causing slight decline of yang qi and deficiency of qi in the diaphragm region. The rapid pulse appearing at this time is transient heat (false heat, deficient heat floating externally), which cannot digest food. The root cause lies in cold deficiency of the stomach. A wiry pulse indicates deficiency patterns, with exhaustion of stomach qi; food eaten in the morning is vomited in the evening, evolving into gastric reflux (the anti-peristaltic disorder of morning ingestion with evening emesis, and evening ingestion with morning emesis). Cold pathogen was originally in the upper burner, but the physician erroneously applied purgation, causing the pulse to become wiry — hence it is called deficiency.
The Cunkou pulse (radial artery at the wrist) is faint and rapid: Faintness indicates insufficiency of qi; insufficiency of qi leads to nutritive qi deficiency (weakening of the nutritive blood); nutritive qi deficiency leads to insufficiency of blood; insufficiency of blood leads to coldness in the chest.
The Fuyang pulse (dorsalis pedis artery, used by ancients to assess spleen-stomach qi) is floating and rough: Floating indicates deficiency of stomach qi; rough indicates impairment of the spleen; when the spleen is impaired, it cannot grind and digest food, resulting in food eaten in the morning being vomited in the evening, and food eaten in the evening being vomited in the morning — undigested retained food, named gastric reflux. If the pulse is tight and rough, the condition is difficult to treat.
When a patient desires to vomit, purgation must not be applied.
II. Treatment of Hiccup (Retching)
When hiccup is accompanied by abdominal fullness, the patient's urination and defecation should be observed. Whichever passage is not free should be facilitated, and once freed, the hiccup will resolve on its own. This follows the approach of "treating upper disorders through the lower body" — although hiccup is located above the diaphragm, its root may lie in obstruction of the bowel qi.
When vomiting is accompanied by chest fullness, Zhuyu Tang (Dogwood Decoction) is the primary treatment.
Zhuyu Tang Formula: Evodia (Wuzhuyu) one sheng, ginseng three liang, fresh ginger six liang, Chinese dates twelve pieces. These four ingredients, cooked in five sheng of water, reduced to three sheng; take seven ge warm, three times daily.
When there is dry heaving (retching without vomitus), vomiting saliva and froth, accompanied by headache, Zhuyu Tang is also the primary treatment.
When vomiting is accompanied by borborygmus (intestinal gurgling) and epigastric lumpiness (a feeling of blockage and fullness in the stomach region), Banxia Xiexin Tang (Pinellia Draining the Heart Decoction) is the primary treatment.
Banxia Xiexin Tang Formula: Pinellia (washed) half sheng, skullcap three liang, dried ginger three liang, ginseng three liang, coptis one liang, Chinese dates twelve pieces, licorice (honey-fried) three liang. These seven ingredients, cooked in one dou of water, reduced to six sheng; after removing the dregs, decoct again to concentrate to three sheng; take one sheng warm, three times daily.
When dry heaving is accompanied by diarrhea, Huangqin Jia Banxia Shengjiang Tang (Skullcap Plus Pinellia and Fresh Ginger Decoction) is the primary treatment.
Huangqin Jia Banxia Shengjiang Tang Formula: Skullcap three liang, licorice (honey-fried) two liang, peony two liang, pinellia half sheng, fresh ginger three liang, Chinese dates twelve pieces. These six ingredients, cooked in one dou of water, reduced to three sheng; strain, take one sheng warm, twice during the day and once at night.
For all types of vomiting where food cannot be swallowed, Xiao Banxia Tang (Minor Pinellia Decoction) is the primary treatment.
When vomiting is located above the diaphragm, and after vomiting the patient desires water, this is a sign of impending recovery — water should be given immediately (in small amounts, frequently sipped). If the desire for water is pronounced, Zhuling San (Polyporus Powder) is the primary treatment.
Zhuling San Formula: Polyporus (Zhuling), Poria (Fuling), and White Atractylodes (Baizhu), equal parts each. These three ingredients are ground into a powder; take one fangcunbi (approximately one gram) with water, three times daily.
When vomiting is accompanied by a weak pulse, urination is instead free-flowing, there is mild heat in the body, and cold extremities (reversal of the four limbs) appear, the condition is difficult to treat — Sini Tang (Four Adverse Decoction) is the primary treatment.
Sini Tang Formula: Prepared aconite (raw use) one piece, dried ginger one and a half liang, licorice (honey-fried) two liang. These three ingredients, cooked in three sheng of water, reduced to one sheng and two ge; strain, divide into two warm doses. For those of robust constitution, one large aconite piece and three liang of dried ginger may be used.
When vomiting is accompanied by fever, Xiao Chaihu Tang (Minor Bupleurum Decoction) is the primary treatment.
Xiao Chaihu Tang Formula: Bupleurum half jin, skullcap three liang, ginseng three liang, licorice three liang, pinellia half jin, fresh ginger three liang, Chinese dates twelve pieces. These seven ingredients, cooked in one dou and two sheng of water, reduced to six sheng; after removing dregs, decoct again to concentrate to three sheng; take one sheng warm, three times daily.
For vomiting due to gastric reflux, Da Banxia Tang (Major Pinellia Decoction) is the primary treatment.
Da Banxia Tang Formula: Pinellia (washed) two sheng, ginseng three liang, white honey one sheng. These three ingredients, with one dou and two sheng of water, are repeatedly stirred and aerated with the honey two hundred and forty times, then cooked to yield two and a half sheng; take one sheng warm, the remainder divided into two doses.
When the patient vomits immediately after eating, Dahuang Gancao Tang (Rhubarb and Licorice Decoction) is the primary treatment.
Dahuang Gancao Tang Formula: Rhubarb four liang, licorice one liang. These two ingredients, cooked in three sheng of water, reduced to one sheng; divided into two warm doses.
For gastric reflux with vomiting, thirst, and desire for water, Fuling Zexie Tang (Poria and Alisma Decoction) is the primary treatment.
Fuling Zexie Tang Formula: Poria half jin, alisma four liang, licorice two liang, cinnamon twig two liang, white atractylodes three liang, fresh ginger four liang. These six ingredients, cooked in one dou of water, reduced to three sheng; add alisma and cook again to yield two and a half sheng; take eight ge warm, three times daily.
After vomiting, if the patient is thirsty and drinks greedily, Wenge Tang (Clam Shell Decoction) is the primary treatment. It also treats mild external wind pathogen invasion with tight pulse and headache.
Wenge Tang Formula: Clam shell five liang, ephedra three liang, licorice three liang, fresh ginger three liang, gypsum five liang, apricot kernels fifty pieces, Chinese dates twelve pieces. These seven ingredients, cooked in six sheng of water, reduced to two sheng; take one sheng warm — recovery follows upon sweating.
For dry heaving, retching, and spitting of saliva and froth, Banxia Ganjiang San (Pinellia and Dried Ginger Powder) is the primary treatment.
Banxia Ganjiang San Formula: Pinellia and dried ginger, equal parts each. These two ingredients are pounded into a powder; take one fangcunbi, decocted in one and a half sheng of fermented millet water (jiangshui) until seven ge remain; take in a single dose.
When the patient experiences sensations in the chest resembling wheezing without true wheezing, resembling retching without true retching, resembling hiccup without true hiccup — an overall state of severe vexation and helplessness in the chest and diaphragm — Shengjiang Banxia Tang (Fresh Ginger and Pinellia Decoction) is the primary treatment.
Shengjiang Banxia Tang Formula: Pinellia half sheng, fresh ginger juice one sheng. These two ingredients: first cook the pinellia in three sheng of water to obtain two sheng; add the ginger juice, cook again to yield one and a half sheng; take while slightly cool, divided into four doses — three during the day and once at night. Discontinue once symptoms resolve.
For dry heaving and hiccup accompanied by cold extremities of the hands and feet, Jupi Tang (Tangerine Peel Decoction) is the primary treatment.
Jupi Tang Formula: Tangerine peel four liang, fresh ginger half jin. These two ingredients, cooked in seven sheng of water, reduced to three sheng; take one sheng warm — recovery follows upon swallowing.
For unremitting hiccup, Jupi Zhuru Tang (Tangerine Peel and Bamboo Shavings Decoction) is the primary treatment.
Jupi Zhuru Tang Formula: Tangerine peel two sheng, bamboo shavings two sheng, Chinese dates thirty pieces, fresh ginger half jin, licorice five liang, ginseng one liang. These six ingredients, cooked in one dou of water, reduced to three sheng; take one sheng warm, three times daily.
III. Pattern Differentiation and Treatment of Diarrhea/Dysentery (下利)
When the qi of the six bowels is exhausted externally, the manifestations are cold hands and feet, upward counterflow of qi, and cramping of the feet. When the qi of the five viscera is exhausted internally, the manifestation is unremitting diarrhea, and in severe cases, numbness and loss of sensation in the hands and feet.
When diarrhea is accompanied by a deep and wiry pulse, there is tenesmus (anal heaviness and sensation of incomplete defecation). A large pulse indicates that the diarrhea has not yet ceased. A faint, weak, and rapid pulse is a sign of impending spontaneous resolution — even with fever present, the prognosis is acceptable and death will not occur.
In diarrhea with cold extremities and absence of pulse palpable, if after moxibustion treatment the extremities remain cold, and if the pulse does not return but instead slight wheezing appears, this is a fatal sign (critical condition). When the Shaoyin pulse is weaker than the Fuyang pulse, this is favorable (stomach qi remains — vitality persists).
Diarrhea with mild fever, thirst, and a weak pulse will resolve spontaneously.
Diarrhea with a rapid pulse, mild heat, and sweating will resolve spontaneously. If the pulse is tight, the pathogenic factor has not yet resolved.
Diarrhea with a rapid pulse and thirst will resolve spontaneously. If it does not improve, then passage of pus and blood in the stool is certain, because internal heat is present.
Diarrhea with a paradoxical wiry pulse, fever, and sweating of the body will resolve spontaneously.
Diarrhea accompanied by the passage of gas (flatulence) indicates that urination should be facilitated (using diuresis to firm the stool).
In diarrhea where the Cunkou pulse is paradoxically floating and rapid, while the Chi pulse is rough, passage of pus and blood in the stool is certain.
In diarrhea of undigested food (presence of undigested food particles in the stool), diaphoresis must not be used to attack the exterior — erroneous sweating will inevitably produce abdominal distension.
In diarrhea with a deep and slow pulse, mildly flushed face, mild fever, and passage of undigested food, the patient will necessarily experience oppression and dizziness (a sensation of veiling and lightheadedness) followed by sweating and resolution. Such patients inevitably have mild cold extremities — the reason is yang floating to the face (deficient yang floating upward) and lower deficiency (yang deficiency of the lower burner).
When the pulse disappears after diarrhea with cold extremities — if the pulse returns and the extremities become warm within one day and night, the patient will survive; if the pulse does not return, death ensues.
In diarrhea with abdominal distension and body pain, one should first warm the interior, then attack the exterior. For warming the interior, Sini Tang is appropriate; for attacking the exterior, Guizhi Tang (Cinnamon Twig Decoction) is appropriate.
Guizhi Tang Formula: Cinnamon twig (peeled) three liang, peony three liang, licorice (honey-fried) two liang, fresh ginger three liang, Chinese dates twelve pieces. These five ingredients, chopped, cooked in seven sheng of water over a low fire, reduced to three sheng; strain, take one sheng at moderate temperature. Shortly after taking, drink one sheng of hot thin congee to boost the medicinal power, and cover with bedding to keep warm for about two hours, so that a light sweat all over the body is achieved — do not allow profuse sweating like flowing water. If recovery follows one dose, discontinue the remainder.
In diarrhea where the three pulse positions (Cun, Guan, Chi) are all calm but palpation reveals hardness below the heart, purgation should be applied promptly — Da Chengqi Tang (Major Purgative Decoction) is appropriate.
In diarrhea with a delayed and slippery pulse, this belongs to the excess pattern — once the accumulated stagnation is eliminated, the diarrhea will cease; purgation should be applied urgently — Da Chengqi Tang is appropriate.
In diarrhea with a paradoxically slippery pulse, it indicates retained stagnation that should be expelled — recovery follows purgation — Da Chengqi Tang is appropriate.
When diarrhea has resolved but recurs at the same season in which it occurred in previous years, it is because the disease root has not been completely eliminated — purgation should be applied — Da Chengqi Tang is appropriate.
When diarrhea is accompanied by delirium (confusion and nonsensical speech), it indicates dry stools (hard, desiccated feces) in the intestines — Xiao Chengqi Tang (Minor Purgative Decoction) is the primary treatment.
Xiao Chengqi Tang Formula: Rhubarb four liang, magnolia bark (honey-fried) two liang, immature bitter orange (large, honey-fried) three pieces. These three ingredients, cooked in four sheng of water, reduced to one sheng and two ge; strain, divide into two warm doses. Discontinue once the bowels move freely.
When diarrhea involves the passage of pus and blood, Taohua Tang (Peach Blossom Decoction) is the primary treatment.
Taohua Tang Formula: Halloysite (red) one jin (half used whole in decoction, half sifted as powder to be taken separately), dried ginger one liang, japonica rice one sheng. These three ingredients, cooked in seven sheng of water until the rice is done; strain, take seven ge warm, with one fangcunbi of the halloysite powder stirred in, three times daily. If recovery follows the first dose, do not take the remainder.
For heat-type diarrhea with tenesmus, Baitouweng Tang (Anemone Decoction) is the primary treatment.
Baitouweng Tang Formula: Anemone (Baitouweng) two liang, coptis three liang, phellodendron three liang, ash bark (Qinpi) three liang. These four ingredients, cooked in seven sheng of water, reduced to two sheng; strain, take one sheng warm. If not cured, take again.
After diarrhea, when the vexation becomes more severe but palpation reveals the area below the heart to be soft, this is deficient vexation (formless heat disturbing the mind, not a formed pathogen) — Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment.
Zhizi Chi Tang Formula: Gardenia fourteen pieces, fermented soybean four ge (wrapped in silk cloth). These two ingredients, cooked in four sheng of water — first boil the gardenia to obtain two and a half sheng, then add the soybean and cook to yield one and a half sheng; strain, divide into two doses. Take one warm dose; stop after vomiting occurs.
For diarrhea with undigested food, true cold internally and false heat externally, with sweating and cold extremities, Tongmai Sini Tang (Vessel-Unblocking Four Adverse Decoction) is the primary treatment.
Tongmai Sini Tang Formula: Aconite (large piece, raw use) one piece, dried ginger three liang (four liang for robust constitutions), licorice (honey-fried) two liang. These three ingredients, cooked in three sheng of water, reduced to one sheng and two ge; strain, divide into two warm doses.
When diarrhea is complicated by lung abscess, Zishen Tang (Salvia Decoction) is the primary treatment.
Zishen Tang Formula: Salvia (Zishen) half jin, licorice three liang. These two ingredients, cooked in five sheng of water — first boil the salvia to obtain two sheng, then add the licorice and cook to yield one and a half sheng; divide into three warm doses. (Suspected not to be Zhang Zhongjing's original formula.)
For qi diarrhea (diarrhea accompanied by the passage of gas, qi escaping with the bowel movement), Helizishuo San (Chebula Powder) is the primary treatment.
Helizishuo San Formula: Chebula fruit ten pieces (roasted in ash). This single ingredient is ground into powder, mixed with congee broth, and taken in a single dose. (Suspected not to be Zhang Zhongjing's original formula.)
Appended Formulas
Qianjin Yi Xiao Chengqi Tang: Treats constipation, hiccup, and frequent delirium. (Formula seen above.)
Waitai Huangqin Tang: Treats dry heaving with diarrhea.
Skullcap three liang, ginseng three liang, dried ginger three liang, cinnamon twig one liang, Chinese dates twelve pieces, pinellia half sheng. These six ingredients, cooked in seven sheng of water, reduced to three sheng; take warm, divided into three doses.
The core academic thinking of this chapter can be summarized at the following levels:
I. The Principle of "Guiding According to Momentum" in Treating Vomiting
The opening statement — "when there is supportive pus accompanying vomiting, do not treat the vomiting; once the pus is fully expelled, recovery follows spontaneously" — establishes that vomiting is not merely a symptom requiring suppression, but may represent the body's self-protective response for expelling pathogenic factors. This thinking runs throughout the chapter: accumulation above is treated by emesis, accumulation below by purgation, retained fluids by resolving the fluids, deficiency-cold by warming and supplementation — consistently following the principle of "examining the disease mechanism and treating in accordance with its momentum."
II. The Significance of Discussing Vomiting, Hiccup, and Diarrhea Together
Although the three manifestations differ, the core location of disease lies in the middle burner and spleen-stomach, and the core disease mechanism is none other than loss of normal ascending-descending function: when stomach qi that should descend instead ascends counterflowing, vomiting and hiccup result; when spleen qi that should ascend instead sinks, diarrhea results. Zhang Zhongjing's placement of them in the same chapter reflects the holistic view of the spleen and stomach as the pivot of ascending and descending — in treating vomiting and hiccup, consider downbearing the stomach qi; in treating diarrhea, consider elevating the spleen qi; while fluid retention, mixed cold-heat patterns, and intermingled deficiency-excess mechanisms often simultaneously affect both directions of ascent and descent.
III. Refined Pulse Diagnosis Distinguishing Cold-Heat and Deficiency-Excess
The precision in pulse assessment throughout this chapter is extraordinary. The same "rapid pulse" in cold deficiency of the stomach indicates transient heat (false heat), entirely different from genuine heat that promotes digestion and hunger. Likewise, in diarrhea the same finding — a deep and wiry pulse — indicates tenesmus, a large pulse indicates predominant pathogen without cessation, and a faint-weak-rapid pulse indicates spontaneous resolution of the condition. This ability for "same pulse, different interpretations" arises from the diagnostic method of correlating pulse and symptoms — pulse findings must never be assessed in isolation; full-body symptoms must be integrated to determine the disease mechanism.
IV. The "Treating Excessive Discharge with Purgation" Approach to Diarrhea
Diarrhea is itself a manifestation of discharge, yet this chapter employs Da Chengqi Tang, Xiao Chengqi Tang, and other purging formulations to treat diarrhea in multiple instances, embodying the paradoxical therapeutic principle known as "treating excessive discharge with purging." When undigested food, dry stools, accumulations, or other stagnated pathogens are present in the body, diarrhea represents precisely the body's attempt to expel these pathogens — under such circumstances, far from halting the diarrhea, one should assist the purgative process, and only once the pathogenic accumulation is fully eliminated will the diarrhea resolve naturally. Once again, this echoes the opening principle of "do not treat the vomiting" — symptoms are not the enemy; the disease mechanism is.
V. Distinguishing the Order of Exterior-Interior Treatment and the Critical Sign of "Dai Yang"
"The patient has diarrhea, abdominal distension and fullness, and body pain: first warm the interior, then attack the exterior" establishes the treatment sequence when both exterior and interior are affected: when interior deficiency-cold is urgent, first rescue the interior, and only after the interior qi has recovered should the exterior be treated; otherwise, yang qi may desert outwardly, and the patient's life would hang by a thread. "Facial Dai Yang" (diarrhea with undigested food and a slightly red complexion) is a critical manifestation of yin exuberance repelling yang. This chapter explicitly states that this is "due to lower deficiency," providing a classic paradigm for later generations to identify true cold with false heat.
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This content is based on classical Chinese medicine texts and is provided solely for the study and research of traditional culture. It does not constitute any medical diagnosis, medication, or treatment advice; if you feel unwell, please seek medical attention promptly.