by Eric Brand

The more things change, the more they stay the same. Let’s look at the treatment of vomiting in pregnancy. This condition that has been known since ancient times and its fundamental treatment has remained fairly consistent throughout the ages. Vomiting in pregnancy was mentioned in the Han dynasty Jin Gui Yao Lue (“Essential Prescriptions of the Golden Coffer”), the Sui dynasty Zhu Bing Yuan Hou Lun (“The Origin and Indicators of Disease”), the Tang dynasty Bei Ji Qian Jin Yao Fang (“A Thousand Gold Pieces Emergency Formulary”), and the Song dynasty Fu Ren Da Quan Liang Fang (“Compendium of Good Remedies for Women”). Many of the medicinals used in early texts remain common in the pattern-based treatments and formulas found in modern Chinese curriculum texts.

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Pathomechanisms

Following pregnancy, Chinese texts say that the “fetal origin begins to congeal; blood accumulates to nourish the fetus and the uterus becomes full.”
– The chong mai connects to the uterus and the yang ming channels.
– Qi congests in the chong mai and ascends counterflow.

The famous Ming dynasty physician Zhang Jing-Yue summarized the pathomechanisms involved with his statement that “vomiting in pregnancy is often due to stomach vacuity and qi stagnation.”

In stomach vacuity, there is loss of harmonious downbearing. Vomiting occurs because chong qi follows to ascend counterflow.
– In patients with constitutional spleen vacuity with phlegm, phlegm-rheum may follow the counterflow qi as well.

Vomiting in pregnancy is a condition that is located in the stomach, but it often involves the liver and the spleen. The principle mechanism involved is counterflow ascent of chong channel qi, along with loss of the stomach’s harmonious downbearing.

Typically, it begins with spleen-stomach vacuity, with stomach qi ascending counterflow. Gradually, the stomach qi is damaged and the spleen’s movement lacks strength. Over time, the following progressions can occur:

Engendering and transformation is insufficient, and liver blood vacuity results.

Liver depression affects the spleen, intensifying the vomiting.

If the condition recurs, it will damage yin and humor, depriving the stomach of moisture. If severe, kidney yin becomes damaged, water fails to moisten wood, and the liver and kidney become diseased. This causes daily and severe vomiting that recurs and does not heal easily.

Empirical Formulas:

Here is an example of a modern empirical formula (Jing Yan Fang), taken from an authoritative Chinese gynecology textbook.

• huò xiāng gěng (藿香梗patchouli stem, Pogostemi Caulis)
• xīn huì pí (新会皮 Xinhui tangerine peel, Citri Pericarpium Xinhuiensis) (this is a subtype of Chen Pi)
• jiāng bàn xià (姜半夏 ginger pinellia, Pinelliae Tuber cum Zingibere Praeparatum)
• zhì gān cǎo (炙甘草 mix-fried licorice, Glycyrrhizae Radix cum Liquido Fricta)
• tiáo qín (条芩 young scutellaria, Scutellariae Radix Nova) [stir-fried]
• xù duàn (续断 dipsacus, Dipsaci Radix) [stir-fried]
• sāng jì shēng (桑寄生 mistletoe, Taxilli Herba)
• zhú rú (竹茹 bamboo shavings, Bumbusae Caulis in Taenia) [ginger-processed]

For patients with poor appetite and poor digestion, dizziness, sore lower back and sloppy stool. The overall formula transforms damp-turbidity, rectifies qi, and arouses the spleen and stomach. Ginger-processed bàn xià and zhú rú are a “sacred” pair to downbear counterflow and relieve vomiting. Stir-fried young huáng qín clears fetal heat and eliminates dampness and heat formation. Xù duàn and sāng jì shēng secure the kidney and quiet the fetus. This formula emphasizes both quieting the fetus and treating the disease.

Ancient texts abound with recipes for vomiting in pregnancy. Consider the similarities between these two prescriptions from Sun Si-Miao and the modern recipe above.

jú pí tāng (橘皮汤 Tangerine Peel Decoction)
• zhú rú (竹茹 bamboo shavings, Bambusae Caulis in Taenia)
• rén shēn (人参 ginseng, Ginseng Radix)
• bái zhú (白朮 white atractylodes, Atractylodis Macrocephalae Rhizoma)
• shēng jiāng (生姜 fresh ginger, Zingiberis Rhizoma Recens)
• hòu pò (厚朴 officinal magnolia bark, Magnoliae Officinalis Cortex)
• chén pí (陈皮 tangerine peel, Citri Reticulatae Pericarpium)

And an unnamed prescription, also from Sun Si-Miao's Qian Jin Fang:
• zhú rú (竹茹 bamboo shavings, Bumbusae Caulis in Taenia)
• bàn xià (半夏 pinellia, Pinelliae Rhizoma)
• shēng jiāng (生姜 fresh ginger, Zingiberis Rhizoma Recens)
• fú líng (茯苓 poria, Poria)
• chén pí (陈皮 tangerine peel, Citri Reticulatae Pericarpium)

Acupressure treatment is used in addition to acupuncture and medicinal therapy. Acupressure emphasizes PC-6 (Nei Guan), with sustained stimulation for up to 15-30 minutes for severe cases. Major points for acupuncture include LV-3 (Tai Chong), ST-36 (Zu San Li), and ST-40 (Feng Long), as well as Ren 12 (Zhong Wan), PC-6 (Nei Guan), and SP-9 (Yin Ling Quan). Additional modern approaches include auricular acupuncture and subcutaneous injection of Vitamin B1 into the point ear shen men.

Below are pattern-based treatments, as stated in a typical Chinese gynecology text. Note how suitable many of the formulas are to using a “modular” formulation approach of combining common base formulas.

Spleen–Stomach Vacuity

Signs and Symptoms:
• Poor food intake, vomiting of clear water or clear drool
• Dizziness, fatigue, pale tongue with white fur, moderate/slippery pulse

Formulas
• Xiang Sha Liu Jun Zi Tang or
• Empirical Rx:
– Fo Shou, Chen Pi, Huo Xiang, Bi Bo, Sheng Jiang, Huang Qin, Gan Cao
• Xiang Sha Yang Wei Wan (Aucklandia and Amomum Stomach-Nourishing Pill)
– Mu Xiang, Sha Ren, Chen Pi, Fu Ling, Ban Xia, Xiang Fu, Zhi Shi, Bai Dou Kou, Hou Po, Huo Xiang, Gan Cao, Sheng Jiang, Da Zao

Principle acupuncture points: PC 6, St 36; supplementing technique, retain needles 10-15 min

Dietary Therapy
– Paste of sha ren and ginger juice
– Sha ren 9 g, 150 g carp fish, 10 g sheng jiang, 3 stems cong bai, ten pieces of pepper, salt. Boil to make soup.

Qi Gong
– Use friction massage on the lower abdomen with the edge of the hands for 15-20 min, 3X/day

Liver-Stomach Disharmony

• The liver is yin in substance but it uses yang.
• After conception, yin and blood accumulate below, leaving a relative effulgence of liver qi.
• The liver effulgence ascends counterflow and causes counterflow stomach qi.
• Because the liver and gallbladder share an interior-exterior relationship, there may also be vomiting of bitter liquid if bile is discharged.

Signs and Symptoms:
• Nausea, vomiting of sour or bitter liquid, if severe, vomiting of bile
• Emotional depression, fullness in the chest, rib-side pain, belching, sighing
• Pale or red-tipped tongue, slightly yellow fur. Wiry, slippery pulse.

Formula
Ban Xia Hou Po Tang + Zuo Jin Wan
– Ban Xia, Hou Po, Fu Ling, Sheng Jiang, Zi Su Ye, Huang Lian, Wu Zhu Yu

Acupuncture:
• PC 6, St 36, Liver 3, all bilateral. Draining technique, no retention necessary.

Dietary therapy:
– Fresh bamboo shoots 30g, rice 5 g. Boil the bamboo shoots and use this water to make congee. Let cool and sip slowly in small amounts.

Qi Gong:
– While breathing in, direct qi down from the dan tian towards Ki 1, which helps to downbear yang.

Phlegm-Damp Obstruction

Signs and Symptoms
• Nausea and oppression in the stomach duct, vomiting of phlegm-drool
• No thought of food or drink, bland or slimy taste in the mouth. Pale tongue or enlarged tongue with greasy white fur. Slippery or soggy pulse.

Formula:
• Xiao Ban Xia Tang (modified)
– Ban Xia, Sheng Jiang, Fu Ling, Bai Zhu, Sha Ren, Chen Pi

Acupuncture:

• PC 6, St 36, St 40, Sp 4. Even supplementation and draining technique, do not use excessive stimulation.

Dietary Therapy:
– Fu ling congee: powdered fu ling 15g, rice 50 g, boil to make congee, which is eaten hot. If there is no effect, add ban xia and sheng jiang

Qi Gong
– Massage from diaphragm down to large intestine, down towards anus

Dual Vacuity of Qi and Yin

• Retching damages qi, vomiting damages yin. Thus, vomiting over a long period of time damages qi and yin.
• Insufficiency of liver yin causes liver qi or liver fire to stir, intensifying the vomiting.
• Liver is the child of the kidney, so if kidney yin is insufficient, the child (liver) will consume the mother’s (kidney) qi. This will worsen the vomiting.
• Insufficiency of stomach yin deprives the stomach of moisture, which can also produce vomiting.
• All together, there can be severe damage to the fluids, and serious conditions of damage to yin, fluids, qi, and essence.

Signs and Symptoms:
• Recurrent nausea and vomiting, with bitter yellow liquid or blood-streaked liquid
• Dry, lusterless skin, low-grade fever and dry mouth, sunken eyes, scanty urination and dry stool. Red dry tongue, thin, rapid forceless pulse.

Formula:
• Sheng Mai San + Zeng Ye Tang + Zhu Ru, Tian Hua Fen, and Lu Gen

Sources: 中医妇产科学, 人民卫生出版社, 北京, 2001(Chinese Medical Gynecology), 千金方 (Qian Jin Fang, Formulas Worth a Thousand Gold, Sun Si-Miao, Tang dynasty).