某 舌黄不渴饮。久嗽欲呕吐。前用金匮麦门冬汤养胃小效。自述背寒口吐清痰。暑湿客邪
未尽。虚体。当辅正醒脾却暑。
人参 茯苓 广皮 半夏 姜汁
郭（五八） 知饥能纳。忽有气冲。涎沫上涌。脘中格拒。不堪容物。内经谓肝病吐涎沫。丹溪云。上升之
气。自肝而出。木火上凌。柔金受克。咳呛日加。治以养金制木。使土宫无戕贼之害。滋水制火。
令金脏得清化之权。此皆老年积劳致伤。岂攻病可效。（肝火刑金）
苏子 麦冬 枇杷叶 杏仁 北沙参 桑叶 丹皮 降香 竹沥
曹（四五） 劳倦嗔怒。呕吐身热。得汗热解。而气急不寐不饥。仍是气分未清。先以上焦主治。以肺主
一身气化也。
杏仁 郁金 山栀 香豉 橘红 栝蒌皮
呕吐症。内经与金匮论之详矣。乃后人但以胃火胃寒痰食气滞立论。不思胃司纳食。主
乎通降。其所以不降而上逆呕吐者。皆由于肝气冲逆。阻胃之降而然也。故灵枢经脉
篇云。足厥阴肝所生病者。胸满呕逆。况五行之生克。木动则必犯土。胃病治肝。不过隔一
之治。此理浅近易明。人乃不能察。而好奇之辈。反夸隔二隔三之治。岂不见笑于大方也
哉。试观安胃丸。理中安蛔丸。所用椒梅。及胃虚客气上逆之旋复代赭。此皆胃药乎。抑肝
药乎。于此可省悟矣。今观先生之治法。以泄肝安胃为纲领。用药以苦辛为主。以酸佐之。
如肝犯胃而胃阳不衰有火者。泄肝则用芩连。楝之苦寒。如胃阳衰者。稍减苦寒。用苦辛
酸热。此其大旨也。若肝阴胃汁皆虚。肝风扰胃呕吐者。则以柔剂滋液养胃。熄风镇逆。若
胃阳虚。浊阴上逆者。用辛热通之。微佐苦降。若但中阳虚而肝木不甚亢者。专理胃阳。或
稍佐椒梅。若因呕伤。寒郁化热。劫灼胃津。则用温胆汤加减。若久呕延及肝肾皆虚。冲气
上逆者。用温通柔润之补。下焦主治。若热邪内结。则用泻心法。若肝火冲逆伤肺。则用养
金制木。滋水制火。总之治胃之法。全在温通。虚则必用人参。药味皆属和平。至于治肝
之法。药味错杂。或寒热互用。或苦辛酸咸并投。盖因厥阴有相火内寄治法不得不然耳。
但观仲景乌梅丸法。概可知矣。案辑六十有余。大半皆由肝邪为患。非先生之卓识。安能
畅发此理乎哉。（华岫云）
徐评 所录诸方。属蓄饮者四五。属反胃者二三。反胃自有主治之法。蓄饮亦有成方可用。乃
全不分别。惟以治肝胃之药参错成方。又用人参及姜附者七八。皆与反胃蓄饮相反。则呕吐
一症。此老全未梦见也。患诸病者。亦大不幸矣。
洞庭有一金姓者。患呕吐症数年。其先人与此老甚相契。此老竭力治之年余。皆用此等方。而
病者几殆。因求治于余。余曰蓄饮也。世无知者。为制一方。其病立已。其人因受业于余。即此可
征矣。
某患者，舌苔黄而不口渴饮水。长期咳嗽导致想要呕吐。之前使用金匮麦门冬汤（Jinkui Maidong Tang，源自《金匮要略》的滋养胃阴方剂）养胃，取得微小疗效。自述背部发冷、口吐清稀痰液。这是暑湿外邪尚未清除，且体质虚弱。应当扶助正气、醒脾化湿、祛除暑邪。
人参 茯苓 广皮（陈皮） 半夏 姜汁
郭某（五十八岁），知道饥饿并能进食。忽然有气向上冲逆，涎沫上涌，胃脘部格拒不适，无法容纳食物。《内经》说肝病会吐出涎沫，朱丹溪说，上升之气发自肝脏，木火上行侵犯肺金，导致肺金受克，咳嗽呛逆日益加重。治疗以滋养肺金、制约肝木为主，使脾胃不受侵害；滋补肾水以制约心火，令肺脏获得清肃转化的权力。这都是老年人因长期劳累导致的损伤，岂能通过攻伐病邪的方法见效？（肝火刑金证）
苏子 麦冬 枇杷叶 杏仁 北沙参 桑叶 丹皮 降香 竹沥
曹某（四十五岁），因劳累疲倦和恼怒，出现呕吐、身体发热。出汗后热退，但气急、失眠、没有食欲。这仍然是气分邪热未清。先从上焦肺脏进行治疗，因为肺主一身的气化功能。
杏仁 郁金 山栀 香豉 橘红 栝蒌皮
关于呕吐症，《内经》与《金匮要略》论述得很详细了。然而后人仅仅从胃火、胃寒、痰食、气滞立论，不思考胃的功能是受纳食物，关键在于通降。之所以不降反上逆而呕吐，都是由于肝气冲逆，阻碍了胃气的下降所致。所以《灵枢·经脉篇》说，足厥阴肝经所生的疾病中，包括胸满、呕逆。况且五行生克关系中，木动则必然犯土。胃病治肝，不过是“隔一”的治疗法（指通过中间脏腑间接治疗）。这个道理浅显易懂，人们却不能察觉，而那些好奇的人，反而夸耀“隔二”、“隔三”的治疗法，难道不怕被大方之家耻笑吗？试看安胃丸、理中安蛔丸所用的花椒、乌梅，以及针对胃虚客气上逆的旋复代赭汤，这些究竟是胃药呢，还是肝药呢？从这里可以省悟了。现在看先生（叶天士）的治疗方法，以泄肝安胃为纲领，用药以苦味、辛味为主，酸味为辅佐。如果肝气犯胃而胃阳不衰且有火者，泄肝则用黄芩、黄连、川楝子的苦寒之品；如果胃阳衰者，稍微减少苦寒药，使用苦、辛、酸、热之品。这是大概的宗旨。如果肝阴和胃汁都虚，肝风扰动胃导致呕吐者，则以柔润药剂滋液养胃，熄风镇逆。如果胃阳虚，浊阴上逆者，用辛热药通阳，微加苦降药。如果只是中阳虚而肝木不甚亢盛者，专门调理胃阳，或者稍加花椒、乌梅。如果因呕吐受伤，寒郁化热，劫灼胃津，则用温胆汤加减。如果久呕延及肝肾皆虚，冲气上逆者，用温通柔润的补法，从下焦主治。如果热邪内结，则用泻心法。如果肝火冲逆伤肺，则用养金制木、滋水制火的方法。总之，治胃的方法，全在于温通。虚证必须用人参。药物性质大多平和。至于治肝的方法，药味错杂，或寒热互用，或苦、辛、酸、咸并用。这是因为厥阴肝经内有相火寄居，治疗方法不得不如此。只要看看张仲景的乌梅丸法则，概可知晓了。医案辑录六十多篇，大半都是由肝邪为患。如果不是先生的卓识，怎么能畅发此理呢？（华岫云评）
徐大椿评语：所记录的各方，属于蓄饮证的占四五成，属于反胃证的占二三成。反胃自有主治之法，蓄饮也有成方可用，竟然完全不分别，只用治肝胃的药参差错杂组成方剂，又使用人参及姜附的占七八成，这些都与反胃、蓄饮的治疗原则相反。那么对于呕吐这一症状，这位老先生完全未曾梦见（意指未得要领）。患各种病的患者，也太不幸了。
洞庭有一位姓金的人，患呕吐症数年。他的祖先与这位老先生非常投契。这位老先生竭力治疗了一年多，都用这类方子，而病人几乎危殆。于是来求治于我。我说这是蓄饮证，世上无人知晓。为他制定一方，病立刻就好了。那人因此拜我为师，由此就可以证明了。
A patient presented with a yellow tongue coating but no desire to drink. Chronic cough led to nausea and vomiting. Previously, Jinkui Maidong Tang (Cistanche and Ophiopogon Decoction from *Jin Gui Yao Lue*, used to nourish stomach yin) was used to nourish the stomach, yielding slight effect. The patient reported coldness in the back and expectoration of clear phlegm. This indicates that summerheat-damp pathogenic factors have not yet been cleared, combined with a deficient constitution. Treatment should support healthy qi, awaken the spleen, and dispel summerheat.
*Ren Shen* (Ginseng Radix), *Fu Ling* (Poria), Guang Pi (Tangerine Peel), *Ban Xia* (Pinellia Rhizoma), Ginger Juice.
Mr. Guo (58 years old) felt hungry and could eat. Suddenly, there was a sensation of qi rushing upward, with saliva and foam surging up, and rejection in the epigastrium, making it impossible to retain food. *Nei Jing* states that liver disease causes vomiting of saliva and foam. Zhu Danxi said that ascending qi originates from the liver; when wood fire ascends and insults metal, metal is constrained. Coughing and wheezing worsened daily. Treatment focused on nourishing metal to control wood, preventing damage to the earth palace (spleen/stomach); nourishing water to control fire, allowing the lung organ to regain its power of clearing and transforming. These are all injuries caused by chronic fatigue in the elderly. How could attacking the pathogen be effective? (Liver Fire Insulting Metal Syndrome)
*Suzi* (Perilla Fructus), *Mai Dong* (Ophiopogon Tuber), *Pipa Ye* (Loquat Leaf), *Xing Ren* (Apricot Seed), *Bei Sha Shen* (Glehnia Root), *Sang Ye* (Mulberry Leaf), *Dan Pi* (Moutan Cortex), *Xiang Xiang* (Aquilaria Wood), Bamboo Sap.
Mr. Cao (45 years old), due to labor, fatigue, and anger, experienced vomiting and fever. After sweating, the fever resolved, but he had rapid breathing, insomnia, and lack of appetite. This still indicates that pathogenic heat in the qi level has not been cleared. Treatment should first focus on the upper jiao, as the lung governs the qi transformation of the whole body.
*Xing Ren* (Apricot Seed), *Yu Jin* (Curcuma Aromatica Rhizome), *Zhi Zi* (Gardenia Fruit), *Xiang Chi* (Fermented Soybean), Ju Hong (Tangerine Peel), *Gua Lou Pi* (Trichosanthes Peel).
Regarding vomiting, *Nei Jing* and *Jin Gui Yao Lue* discussed it in detail. However, later authors only formulated theories based on stomach fire, stomach cold, phlegm-food retention, and qi stagnation. They failed to consider that the stomach's function is to receive food, relying primarily on descending and unblocking. The reason for failure to descend and instead rising reversely to cause vomiting is all due to rebellious qi from the liver obstructing the stomach's descent. Thus, *Ling Shu: Jing Mai* chapter states: "The diseases generated by the Foot-Jueyin Liver meridian include chest fullness and vomiting/reversal." Moreover, according to the generation and restriction of the Five Elements, when wood moves, it inevitably attacks earth. Treating stomach disease via the liver is merely a treatment separated by one organ (indirect treatment). This principle is shallow and easy to understand, yet people fail to perceive it. Those seeking novelty instead boast of treatments separated by two or three organs. Would they not be laughed at by experts? Consider An Wei Wan (Stomach-Calming Pill) and Li Zhong An Hui Wan (Regulate Middle and Calm Roundworms Pill), which use Zanthoxylum and Mume fruit; and Xuan Fu Dai Zhe Tang (Inula and Hematite Decoction) for stomach deficiency with rebellious guest qi. Are these stomach medicines or liver medicines? One can realize this here. Now, observing Mr.'s treatment method, the guideline is to drain the liver and calm the stomach. Medicines are primarily bitter and acrid, assisted by sour. If liver qi invades the stomach and stomach yang is not deficient but has fire, draining the liver uses bitter-cold herbs like Huang Qin (Scutellaria Root), Huang Lian (Coptis Rhizoma), and Chuan Lian Zi (Toosendan Fruit). If stomach yang is deficient, slightly reduce bitter-cold herbs and use bitter, acrid, sour, and hot herbs. This is the general principle. If both liver yin and stomach fluid are deficient, and liver wind disturbs the stomach causing vomiting, then use soft agents to nourish fluids and calm the stomach, extinguish wind, and suppress reversal. If stomach yang is deficient and turbid yin rises reversely, use acrid-hot herbs to unblock, slightly assisting with bitter-descending herbs. If only middle yang is deficient and liver wood is not very hyperactive, specifically regulate stomach yang, or slightly assist with Zanthoxylum and Mume fruit. If injury from vomiting leads to cold stagnation transforming into heat, scorching stomach fluids, then modify Wen Dan Tang (Warm the Gallbladder Decoction). If prolonged vomiting extends to deficiency of both liver and kidney, with chong qi rising reversely, use warm-unblocking and soft-moistening tonification, treating from the lower jiao. If pathogenic heat binds internally, use the Xie Xin method (Drain the Epigastrium method). If liver fire rebels and injures the lung, use methods to nourish metal to control wood and nourish water to control fire. In short, the method of treating the stomach lies entirely in warming and unblocking. For deficiency, Ren Shen (Ginseng Radix) must be used. The medicinal properties are generally mild and peaceful. As for treating the liver, the medicinal ingredients are mixed; sometimes cold and hot are used together, or bitter, acrid, sour, and salty are administered simultaneously. This is because the Jueyin Liver meridian houses ministerial fire internally, so the treatment method must be so. Just observing Zhang Zhongjing's Wu Mei Wan (Mume Pill) rule, one can generally understand. Over sixty case records were compiled, more than half caused by liver pathogenic factors. Without Mr.'s profound insight, how could this principle be fully expounded? (Commented by Hua Xiuyun)
Xu's Commentary: Among the recorded prescriptions, four or five parts belong to Phlegm-Fluid Retention (Chu Yin), and two or three parts belong to Fan Wei (Regurgitation/Vomiting after eating). Fan Wei has its own specific treatment methods, and Chu Yin also has established formulas available. Yet, no distinction is made. Only liver-and-stomach-calming medicines are mixed and matched to form prescriptions. Seven or eight out of ten use Ren Shen (Ginseng Radix) along with Jiang (Zingiberis Rhizoma) and Fu Zi (Aconiti Lateralis Preparata Radix). All these contradict the treatment principles for Fan Wei and Chu Yin. Therefore, regarding the symptom of vomiting, this old master has never even dreamed of understanding it. Patients suffering from various diseases are extremely unfortunate.
There was a man surnamed Jin in Dongting who suffered from vomiting for several years. His ancestors were very close friends with this old master. The old master treated him diligently for over a year using such prescriptions, but the patient nearly died. He then sought treatment from me. I said, "This is Phlegm-Fluid Retention. No one in the world understands it." I prescribed a formula, and the illness was cured immediately. That person subsequently became my student. This serves as evidence.