Vomiting is caused by abnormally rising of the stomach-Qi in retrograde fashion and propelling the food in the stomach upward. In a narrower sense, vomiting is the throwing up of food accompanied by sound. Throwing up without sound is called spitting up, and sound without throwing up is called retching.
Etiology and Pathology
The principal causes of vomiting are attack by exogenous pathogenic evils, intemperate diet and internal injury by the passions.
Attack by Exogenous Evil. This is mostly attack by Wind, Cold, Summer Heat, Dampness or another of various turbid factors. Such an attack injures the stomach and causes it to fail in its functions of harmonization and descent, forcing stomach-Qi to ascend abnormally in retrograde fashion. Whatever is in the stomach can follow stomach-Qi in its abnormal movement, and vomiting results. In general, sudden vomiting is mainly due to these exogenous evils attacking the stomach. In summer, it is mostly Summer Heat or Dampness; in autumn and winter, it is mostly Wind or Cold.
Intemperate Diet. An intemperate diet means mainly imbalance between hot and cold foods, overindulgence, or excessive raw, cold, greasy foods or foods that are hard to digest. Any of these can lead to indigestion and food retention, which in turn injures the stomach. When stomach-Qi is unable to descend normally it ascends abnormally and induces vomiting. Intemperate diet can also affect the spleen and the stomach and impair their transportation and transformation functions. The essences from food and drink can no longer be extracted, and Phlegm-Rheum would be formed. When Phlegm and Rheum rise adversely, vomiting can also result.
Internal Injury by Passions. Anxiety, brooding and rage can all constrain liver-Qi movement. When liver-Qi becomes constrained it moves abnormally and injures the stomach, leading to disharmony between the liver and the stomach. stomach-Qi may then ascend abnormally and induce vomiting. Alternately, liver-Qi becomes pent-up, transforms into Fire and forces stomach-Qi to move upwards. Anxiety and brooding also injure the spleen. When spleen functions are impaired, food cannot be readily digested and its essences transported and made available for generating Qi and blood. The stomach then loses its ability to harmonize and descend. This also induces vomiting. Conversely, prolonged vomiting can itself injure Qi and Yin, leading in turn to insufficiency of the spleen and the stomach.
Thus, though vomiting is primarily a symptom of stomach illnesses it also involves the liver and the spleen. An illness with vomiting as the prominent symptom may be of strength or of deficiency. A strength illness is due to an exogenous evil, retained food, accumulated Phlegm-Rheum or liver-Qi attacking the stomach. A deficiency illness is due to deficiency of spleen and stomach Qi and Yin. In general, an illness in the early stages is likely to be of strength. But if prolonged it can easily transform into one of deficiency, or one of mixed strength and deficiency.
In addition to vomiting, these illnesses manifest principally food retention and much sputum and saliva, or a bitter and acid taste in the mouth, or retching. In an illness of strength vomiting tends to be sudden or prompt following eating, though it may also occur without eating. In an illness of deficiency, vomiting tends to be recurrent without pattern, or there is nausea and retching. What is vomited is usually food taken on that day.
If vomiting is due to exogenous Wind and Cold attacking the stomach, the tongue coating is white and the pulse floating and tight.
If it is due to exogenous Wind and Heat, the tongue is red with a thin yellow coating, and the pulse is floating and rapid.
If it is due to food retention, the vomitus contains acid and has a fetid unpleasant odor. The tongue coating is thick and greasy and the pulse slippery.
If it is due to liver-Qi (Fire) attacking the stomach, the vomitus contains bitter and yellow water. The sides of the tongue are red, with a think greasy coating, and the pulse is taut.
If it is due to deficiency of spleen and stomach Qi giving rise to endogenous Cold, the vomitus contains clear water, sputum and saliva. The tongue is pale, with white and moist coating, and the pulse is threadlike and feeble.
If it is due to deficiency of stomach-Yin, the vomitus contains sticky foam. The tongue is red and dehydrated, with scant coating, and the pulse is threadlike and rapid.
Key Points of Analysis
Deficiency versus Strength. Vomiting in an illness of strength tends to have a short course and occurs abruptly. The volume is usually large, and the vomitus usually contains much acid or malodorous content. The pulse is usually replete and forceful.
Vomiting in an illness of deficiency, on the other hand, tends to have a prolonged or an intermittent course. The volume is usually small, and the vomitus usually is unbearably acid or foul. The pulse is usually feeble and forceless. Keep in mind, however, that an illness of strength can transform into one of deficiency and vice versa, and that mixed deficiency-strength illnesses are also common.
Quality of Vomitus. Acid, fetid and foul vomitus is typical of vomiting due to food retention. Bitter yellow fluid is typical of vomiting due to Heat in the gallbladder. Acid green fluid is typical of vomiting due to Heat in the liver. Turbid sputum or saliva is typical of vomiting due to the Phlegm-Rheum. Clear fluid is typical of vomiting due to cold or insufficiency of the stomach. Small amounts of sticky foam are typical of deficiency of stomach-Yin.
Exogenous Evils Attacking Stomach
Main Symptoms. Abrupt vomiting. If due to Cold, there are also fever, cold-aversion, headache, absence of sweating, a thin white tongue coating, and a floating and tight pulse. If due to Wind-Heat, there are also fever, wind-intolerance, headache, spontaneous sweating, a red tongue with thin yellow coating, and a floating and rapid pulse. If due to Summer Heat and Dampness, there are also fever, sweating, restlessness, thirst, a red tongue with yellow greasy tongue coating, and a soft and rapid pulse.
Therapeutic Principle. Eliminate the exogeneous pathogenic evil, release the exterior, dissipate the turbid and settle the stomach.
Treatment. For Wind-Cold attacking the stomach, Huoxiang Zheng Qi San. If there is food retention, with chest tightness and abdominal distention, remove baizhu, gancao and dazao, and add shenqu (medicated leaven), maiya (Hordeum), jineijin (Gallus) and other herbs that promote digestion and intestinal motility.
For Wind-Heat attacking the stomach, Yin Qiao San.
For Summer Heat and Dampness causing vomiting, Xin Jia Xiangru Yin (Newly Supplemented Elsholtzia Drink).
Main Symptoms. Vomiting of acid and fetid materials; epigastric and abdominal distention or pain, amelioration after vomiting; eructation; anorexia; and constipation or loose feces. The tongue coating is thick and greasy. The pulse is slippery.
Therapeutic Principle. Promote digestion, relieve food retention, settle the stomach and suppress abnormally risen stomach Qi.
Treatment. Bao He Wan.
If there is strong stomach-Heat, add lugen (Phragmites), huanglian (Coptis) and huangqin (Scutellaria).
If there is strong stomach-Cold, remove lianqiao and add ganjiang (Zingiber) and sharen (Amomum).
If there is much retained food, with abdominal distention and constipation, add dahuang (Rheum palmatum) and zhishi (Citrus aurantium) to unblock the intestines and conduct turbid Qi downward.
If the vomiting is due to unclean foods or drinks, or due to overindulgence, with epigastric pain and nausea without vomiting, first induce vomiting as soon as possible with normal saline (0.9%) solution.
Interior Blockage by Phlegm-Rheum
Main Symptoms. Vomiting of sputum, saliva and clear fluids, chest tightness, epigastric distention and distress, anorexia, dizziness, and palpitation of the heart; or, vomiting accompanied by borborygmus. The tongue coating is white and greasy, and the pulse is slippery.
Therapeutic Principle. Warm the middle-jiao, dissipate Phlegm and Rheum, settle the stomach and suppress the abnormally risen stomach Qi.
Treatment. Er Chen Tang combined with Ling Gui Zhu Gan Tang (Poria-Cinnamomum-Atractylodes-Zingiber Decoction). The combined formula has the following composition: processed banxia (Pinellia) 10 g, fuling (Poria) 12 g, guizhi (Cinnamomum) 10 g, baizhu (Atractylodes) 10 g, chenpi (Citrus tangerina) 10 g, shengjiang (Zingiber) three slices, and gancao (Glycyrrhiza) 6 g.
If Phlegm gels and transforms into Heat, the middle-jiao may become blocked and the stomach’s functions may be impaired. This produces such symptoms as a bitter taste, nausea and vomiting, a red tongue with yellow greasy coating, and a slippery and rapid pulse. In this case, use Wen Dan Tang instead to cool Heat, settle the stomach, dissipate Phlegm and stop vomiting.
Liver-Qi Attacking Stomach
Main Symptoms. Vomiting, acid regurgitation, frequent eructation; chest and subcostal distention and pain; restlessness and discomfort. Vomiting and acid regurgitation are aggravated by emotional distress. The sides of the tongue are red, with thin and greasy coating. The pulse is taut.
Therapeutic Principle. Unblock the liver, regulate Qi, settle the stomach and suppress the abnormally risen stomach Qi.
Treatment. In the early stages, Banxia Houpo Tang.
If stagnant Qi gives rise to Heat, with chest tightness, dysphoria and vomiting of acid fluids, use Si Ni San combined with Zuo Jin Wan to unblock the liver, regulate Qi, cool Heat and stop vomiting.
For constipation and blockage of visceral Qi, add dahuang (Rheum palmatum) and zhishi (Citrus aurantium).
If Fire injures stomach Yin, producing dry mouth and throat, burning in the stomach and a red tongue with little coating, add nanshashen (Adenophora tetraphylla, axilliflora orpereskiaefolia) and shihu (Dendrobium chrysanthum).
Deficiency-Cold in Spleen and Stomach
Main Symptoms. Intermittent nausea following even slightly excessive intake; poor appetite; indigestion; chest and epigastric tightness; dry mouth without desire to drink; a pale and lusterless complexion; lassitude and weakness; preference for warmth with cold-aversion (cold limbs if severe); and loose feces. The tongue is pale, with thin white coating, and the pulse is threadlike and feeble.
Therapeutic Principle. Warm the middle-jiao, strengthen the spleen, settle the stomach and suppress the abnormally risen stomach Qi.
Treatment. Li Zhong Wan or Liu Jun Zi Tang as the basic formula.
For vomiting of sputum, saliva and clear fluids, add guizhi (Cinnamomum) and wuzhuyu (Evodia) to warm the middle-jiao and suppress the abnormally risen Qi.
For vomiting of clear fluids accompanied by coldness in the epigastrium and the limbs, in addition to guizhi and wuzhuyu add processed fuzi (Aconitum), rougui (Cinnamomum) and other herbs that warm Yang of the middle-jiao and disperse Cold.
Deficiency of Stomach-Yin
Main Symptoms. Repeated vomiting of small amounts, or frequent nausea and retching; dry mouth and throat; hunger without appetite; and epigastric distress. The tongue is red and dry, with little coating. The pulse is threadlike and rapid.
Therapeutic Principle. Nourish Yin, moisten dryness, suppress abnormally risen Qi and stop vomiting.
Treatment. Maimendong Tang (Ophiopogon Decoction). It has the following composition: maimendong (Ophiopogon) 10 g, renshen (Panax) 10 g, processed banxia (Pinellia) 10 g, jingmi (Oryza sativa) 9 g, dazao (Ziziphus) three pieces, and gancao (Glycyrrhiza) 6 g.
If Yin is severely injured, use smaller amounts of banxia to avoid Yin injury through warming Dryness, but add shihu (Dendrobium chrysanthum), tian-huafen (Trichosanthes) and yuzhu (Polygonatum) to generate fluids and nourish the stomach.
If vomiting is frequent, add zhuru (Phyllostachys nigra), chenpi (Citrus tangerina) and pipaye (Eriobotrya japonica) to settle the stomach.
For constipation, add huomaren (Cannabis sativa) and baimi (mel) to moisten the intestines and lower visceral Qi.
Exogenous Evils Attacking Stomach. The principle is to dispel the evil, release the exterior, dissipate the turbid and settle the stomach. Select the acupoints Hegu (LI-4), Zhongwan (CV-12), Zusanli (ST-36) and Neiguan (PC-6). Apply the reducing method. At Zhongwan, following needling apply moxibustion. If treatment at these acupoints is not effective and the illness worsens, apply acupuncture to the acupoint Jinjinyuye (EX-HN 12). Prick to induce slight bleeding.
Food Retention. The principle is to promote digestion and settle the stomach. Select the acupoints Zhongwan (CV-12), Zusanli (ST-36) and Taibai (SP-3). The following acupoints are held in reserve, to use if necessary: Jianli (CV-11) and Gongsun (SP-4). At these acupoints apply the reducing method.
Interior Blockage by Phlegm-Rheum. The principle is to warm the middle-jiao, dissipate Phlegm-Rheum, settle the stomach and suppress the abnormally risen Qi. Select Zhongwan (CV-12), Neiguan (PC-6), and Zusanli (ST-36). The following acupoints are held in reserve, to use if necessary: Jianli (CV-11), Zhangmen (LR-13), Liangmen (ST-21) and Fenglong (ST-40). Moxibustion is applied after needling.
Liver-Qi Attacking Stomach. The principle is to unblock the liver, relieve stagnation, settle the stomach and suppress the abnormally risen Qi. Select Zhongwan (CV-12), Zusanli (ST-36) and Taichong (LR-3). The following acupoints are held in reserve, to use if necessary: Qimen (LR-14), Zhangmen (LR-13) and Gongsun (SP-4). At these reserve acupoints apply the reducing method.
Deficiency-Cold in Spleen and Stomach. The principle is to strengthen the spleen and settle the stomach. Select Zhongwan (CV-12), Zhangmen (LR-13), Zusanli (ST-36) and Tianshu (ST-25). Apply the reinforcing method and add moxibustion.
Deficiency of Stomach-Yin. The principle is to nourish Yin and settle the stomach. Select Zhongwan (CV-12), Zusanli (ST-36), Sanyinjiao (SP-6) andGongsun (SP-4). Apply the reinforcing method without moxibustion.
The patient was an adult male who had chronic gastritis. For 5 days he had relapse of his condition, with epigastric pain and anorexia. On the day of consultation vomiting worsened, producing thin fluids and saliva. It was accompanied by intermittent nausea, stickiness and bitter taste in the mouth, slightly yellow urine and watery feces. His tongue was dark purple, with white greasy coating covered by yellow. His pulse was small and slippery.
Diagnosis. Chronic deficiency of middle-jiao Yang, with strong Cold in the interior. The relapse was precipitated by intemperate diet causing injury to the middle-jiao, so that Cold and retained food interact and give rise to Heat, and impairment of the stomach functions.
Therapeutic Principle. Warm the middle-jiao, dispel Cold, regulate Qi with acrid herbs, complemented with bitter herbs to drain downward and relieve stagnation.
Treatment and Course. The formula prescribed had the following composition: processed fuzi slices (Aconitum) 5 g, wuzhuyu (Evodia) 2 g, zisu stalk (Perilla) 10 g, processed banxia (Pinellia) 10 g, chenpi (Citrus tangerina) 5 g, baidoukou (Amo-mum cardamomum) 3 g, ginger-treated huanglian (Coptis) 3 g, ganjiang (Zingiber) 3 g, zhishi (Citrus aurantium) 10 g, and binglang with peel (Areca) 10 g.
After 2 days treatment vomiting stopped, but the patient still had retching and eructation, abdominal distention, difficulty with defecation and discomfort relieved by passing gas. Treatment was continued with modified formula: processed fuzi and baidoukou were removed and gualou (Trichosanthes) 12 g added. The patient defecated large amounts of foul brown feces. The tongue coating became normal, and all symptoms resolved except for vague epigastric pain. Treatment was continued to consolidate the therapeutic effect.