【纲】仲景曰。太阳病过经十余日。心下温温欲吐。而胸口痛。大便反溏。腹微满。郁郁微烦。
先其时极吐下者。与调胃承气汤。
【目】朱肱曰。吐有冷热二症。寸口脉数。手心热。烦渴而吐。以有热在胃脘。五苓散主之。
伤寒有表症。渴欲饮水。水入口即吐者。名水逆。由心经受热而小肠不利也。宜五苓散。发汗后。
水浆不得入口为逆。若更发汗。必吐下不止。小半夏加茯苓汤。大半夏加橘皮汤。
柯琴曰。过经十余日。病不在太阳矣。仍曰太阳病者。此太阳坏病也。心下者。胃口也。心下
温温欲吐者。胃口有遗热而胃气不和也。故用本汤微和之。
【纲】仲景曰。伤寒咳逆上气。脉散者死。
【目】张元素曰。咳逆者。火热奔急上行而肺阴不内也。便秘者。大承气汤。便软者。泻心汤。
王好古曰。伤寒咳逆脉散死。仲景之言不虚伪。大抵原因失下生。咳逆喉中阴不内。便软惟宜
用泻心。便硬尤宜大承气。二药神攻作者谁。东垣洁古为良剂。
少阴咳逆者。此失下也。阴消将尽。阳逆上行。使阴不内也。然阴既尽。阳亦将尽也。故为阳
极脉微将尽者。宜泻心汤。如不用泻心。凉膈散去硝黄。清肺散亦可。若脉左浮右沉。实非表也。
里极则反出于表也。何以然。咳逆舌强右脉实者。知少阴里也。饮水过多。心下痞而咳逆者。五苓
散主之。别无恶候是也。恶候生。或兼以舌挛。语言不正。而反昏冒与咽痛者。少阴也。速下之。
宜大承气也。何以脉浮为表。脉浮之实大。沉之损小。是为表也。浮之实大。沉之亦然。即非表也。
邪入已深矣。内热当沉。反浮。阳极复之表也。
王肯堂曰。阴症者。内已伏阴。阴气太甚。肾水擅权。肝气不生。胃火已病。丁火又消。所以
游行相火。寒邪迫而萃集于胸中。亦欲尽也。故令人发热。大渴引饮。病患独觉热。他人按执之。
身体肌肉骨髓血脉俱寒。此火即无根之火也。故用丁香、干姜之类。热药温胃。其火自下。
吴绶曰。咳逆者。气上逆而为吃忒也。方书或以为咳嗽者非。本条言死。谓其形损也。吃忒。
有因胃实失下者。其气皆从胃至胸嗌之间而为吃忒。易老治法。失下胃热内实。便硬者。承气汤。
便软者。泻心汤。胃虚有热。橘皮竹茹汤。有痰饮。半夏生姜汤。或茯苓半夏汤。若胃冷。橘皮干
姜汤。加味理中汤。要略云。其气自脐下直冲于胸嗌间吃忒者。此阴症也。其病不在胃也。且病下
虚。内以伏阴。或误用寒凉。遂致冷极于下。迫其相火上冲。萃集胸中。以为吃忒。亦欲
尽也。若不识此。为水极似火。误用凉药。下咽立败矣。凡治。须用羌活附子散、加味附子汤。急
温其下。真阳一回。火降而吃忒自止也。如冷极吃忒不止者。或兼以硫黄乳香散 法。或灸期门中
脘关元气海。但要取手足温暖。而脉生。阳回阴退则活矣。
陶华曰。咳逆者。俗名吃忒。才发声于喉间则遽止。吃吃然连续连声。然而短促不长。古人谓
即哕者非也。哕与干呕相似。但其声浊恶而长。皆有声而无物。病至于哕则危矣。大抵KT 近于哕。KT
者。但胸间气塞不得下通。哕则恶浊之声达于外矣。经曰。阳脉浮则为气KT 。又曰。脉滑则为哕。
此为医家责虚取实之过也。设若咳逆。脉散无伦。则难治。与伤寒咳而气逆。固不同也。若将吃忒
紊于哕与咳而气逆。则误人多矣。临病必明辨焉。
【纲】张仲景说：太阳病经过传变十余日后，胃脘部感到恶心欲吐，同时胸口疼痛，大便反而稀溏，腹部轻微胀满，心中郁郁不舒且伴有轻微烦躁。如果在发病前曾经被强行使用催吐或泻下法治疗，应给予调胃承气汤。
【目】朱肱说：呕吐分为寒证和热证两种。如果寸口脉数，手心发热，心烦口渴并伴有呕吐，这是因为胃脘有热，主治方剂为五苓散。
伤寒病如果有表证，患者想喝水，但水入口后立即吐出，这称为“水逆”，是由心经受热导致小肠功能不利所致，适宜用五苓散。发汗后，连水浆都无法入口的称为“逆”。如果此时再次发汗，必然导致呕吐和腹泻不止。可用小半夏加茯苓汤、大半夏加橘皮汤治疗。
柯琴说：病程经过十余日，病邪已不在太阳经了。之所以仍称为“太阳病”，这是太阳病的坏病（因误治而变的复杂病证）。心下指的是胃口部位。心下温温欲吐，是胃口有余热且胃气不和的表现，因此使用本方（调胃承气汤）微微调和胃气。
【纲】张仲景说：伤寒病出现咳嗽气逆、上冲之气，脉象散乱无根的，预后不良，主死。
【目】张元素说：咳逆（呃逆），是由于火热之邪奔急上行，导致肺阴不能内守所致。如果大便秘结，用大承气汤；如果大便软，用泻心汤。
王好古说：伤寒病出现咳逆且脉象散乱的会死亡，张仲景的话并非虚言。大体上是因为失于攻下所致。咳逆时喉中阴气不能内守，大便软者适宜用泻心汤，大便硬者尤其适宜用大承气汤。这两味药神效的作者是谁？东垣李杲（号洁古）认为是良剂。
少阴病出现的咳逆，也是由于失于攻下。阴液消亡将尽，阳气逆乱上行，使得阴气不能内守。然而阴既已尽，阳也将要耗尽。所以对于阳气极盛、脉微欲绝的情况，适宜用泻心汤。如果不使用泻心汤，可用凉膈散去芒硝、大黄，或者清肺散也可以。如果脉象左浮右沉，实际上并不是表证。里证极重时反而会反映在表。为什么这样呢？咳逆伴舌强、右脉实的，可知病在少阴里证。饮水过多，导致心下痞塞而出现咳逆的，主治方剂为五苓散，前提是别无其他危重征候。如果出现危重征候，或者兼见舌体挛缩、言语不正、反而昏冒及咽痛，则属于少阴病危象，需急速攻下，适宜用大承气汤。为什么说脉浮为表？脉浮取时实大，沉取时损小，这才是表证。如果浮取实大，沉取也同样实大，那就不是表证。邪气已经深入，内热应当沉伏，反而浮越，这是阳极复返于表的现象。
王肯堂说：阴症，是指体内已潜伏阴寒，阴气太盛，肾水擅权，肝气不生，胃火已病，丁火（心火）又消。所以游行相火，寒邪逼迫而聚集于胸中，这也是阳气欲尽的表现。因此让人发热，大渴引饮，病人自己觉得热，但他人触摸其身体肌肉骨髓血脉时却是寒冷的。这就是无根之火。因此使用丁香、干姜等热性药物温胃，火势自然下行。
吴绶说：咳逆，就是气机上逆导致的打嗝（吃忒）。有些医书将其认为是咳嗽，这是错误的。本条提到“死”，是指形体受损严重。打嗝，有的因为胃实失于攻下，其气都从胃至胸咽之间而上逆导致打嗝。易老（张元素）的治疗法则：失下导致胃热内实，大便硬的，用承气汤；大便软的，用泻心汤。胃虚有热的，用橘皮竹茹汤；有痰饮的，用半夏生姜汤或茯苓半夏汤。如果是胃冷，用橘皮干姜汤或加味理中汤。《金匮要略》说：气自脐下直冲于胸咽间打嗝的，这是阴症。病位不在胃，而是下焦虚，内部潜伏阴寒，或者误用寒凉药物，导致冷极于下，逼迫相火上冲，聚集于胸中，这也是阳气欲尽的表现。如果不认识这一点，把水极似火（真寒假热）误用凉药，服药后立即败亡。凡是治疗，须用羌活附子散、加味附子汤，急温下焦。真阳回归，火降而打嗝自然停止。如果冷极导致打嗝不止，或者兼用硫黄乳香散的方法，或者灸期门、中脘、关元、气海穴，只要取得手足温暖，脉搏恢复，阳气回归阴气退却就能存活。
陶华说：咳逆，俗称打嗝。刚在喉间发出声音就立刻停止，吃吃然连续发声，但是短促不长。古人说它就是哕（干呕/呃逆重症），这是不对的。哕与干呕相似，但其声音浊恶而长，皆有声而无物排出。病至于哕则危险了。大体上咳逆近于哕，但咳逆只是胸间气塞不得下通，哕则是恶浊之声达于外。经文说：阳脉浮则为气噫（嗳气/气逆）。又说：脉滑则为哕。这是医生责备虚证而错误地采取实证治法的过错。如果咳逆，脉象散乱无伦次，则难治，这与伤寒咳嗽而气逆是不同的。如果把打嗝混淆于哕与咳嗽气逆，就会误导很多人。临病时必须明辨清楚。
[General Principle] Zhang Zhongjing stated: In Taiyang disease, after more than ten days have passed since the onset (or transmission), there is a sensation of nausea in the epigastrium, accompanied by chest pain. The stool is conversely loose, with slight abdominal fullness, and a feeling of depression and mild irritability. If emetic or purgative treatments were forcibly applied prior to this stage, Tiaowei Chengqi Tang (Stomach-Regulating Decoction) should be administered.
[Commentary] Zhu Gong stated: Vomiting presents as either cold or heat syndromes. If the Cun position pulse is rapid, the palms are hot, and there is irritability, thirst, and vomiting, this indicates heat in the stomach region; Wuling San (Five-Ingredient Poria Powder) is the primary formula.
In Shanghan disease, if exterior symptoms exist, and the patient desires water but vomits immediately upon ingestion, this is termed "Water Reversal" (Shui Ni). It results from heat in the Heart meridian causing dysfunction of the Small Intestine. Wuling San is appropriate. After sweating therapy, if even liquids cannot be retained, it is termed "Reversal." If sweating is applied again, incessant vomiting and diarrhea will ensue. Xiaobanxia Jia Fuling Tang (Minor Pinellia Decoction plus Poria) or Dabanxia Jia Chupi Tang (Major Pinellia Decoction plus Tangerine Peel) may be used.
Ke Qin stated: After more than ten days, the pathogen is no longer in the Taiyang meridian. Referring to it still as "Taiyang disease" indicates a "Huabing" (complicated disease due to mismanagement) of Taiyang. "Xin Xia" refers to the gastric opening. The sensation of nausea in the epigastrium indicates residual heat at the gastric opening and disharmony of Stomach Qi. Therefore, this decoction (Tiaowei Chengqi Tang) is used to gently harmonize the Stomach.
[General Principle] Zhang Zhongjing stated: In Shanghan disease, if coughing and rebellious Qi occur alongside a scattered pulse, the prognosis is fatal.
[Commentary] Zhang Yuansu stated: Ke Ni (hiccup/rebellious Qi) occurs when fire-heat rushes upward urgently, preventing Lung Yin from being contained internally. If constipation is present, Dachengqi Tang (Major Order the Qi Decoction) is indicated; if the stool is soft, Xiexin Tang (Drain the Epigastrium Decoction) is indicated.
Wang Haogu stated: In Shanghan disease, hiccup accompanied by a scattered pulse leads to death; Zhang Zhongjing's words are not false. Generally, this arises from failure to purge earlier. During hiccup, Yin fails to remain internal. Soft stools suit Xiexin Tang; hard stools particularly suit Dachengqi Tang. Who authored these effective remedies? Li Dongyuan (Jiegu) considered them excellent prescriptions.
Hiccup in Shaoyin disease also stems from failure to purge. Yin fluids are nearly exhausted, Yang rebels upward, preventing Yin from remaining internal. However, once Yin is exhausted, Yang will also soon exhaust. Thus, for conditions where Yang is extreme and the pulse is faint and near exhaustion, Xiexin Tang is suitable. If Xiexin Tang is not used, Liangge San (Cool the Chest Powder) without Mangxiao (Natrii Sulfas) and Huanglian (Coptidis Rhizoma) or Qingfei San (Lung-Clearing Powder) may be used. If the pulse is floating on the left and sunken on the right, it is not actually an exterior syndrome. Extreme interior excess can manifest superficially. Why? Hiccup with tongue stiffness and a solid Right pulse indicates Shaoyin interior syndrome. Excessive drinking leading to epigastric stuffiness and hiccup is treated with Wuling San, provided no other ominous signs exist. If ominous signs arise, such as tongue contraction, abnormal speech, dizziness, or sore throat, it belongs to critical Shaoyin syndrome; rapid purging is required, and Dachengqi Tang is suitable. Why is a floating pulse considered exterior? If the pulse is large and solid on superficial palpation but diminished on deep palpation, it is exterior. If it is large and solid on both superficial and deep palpation, it is not exterior. The pathogen has entered deeply. Internal heat should sink; if it floats instead, it indicates Yang extremity returning to the exterior.
Wang Kentang stated: Yin syndrome involves latent Yin cold within. Excessive Yin allows Kidney Water to dominate, Liver Qi fails to generate, Stomach Fire is diseased, and Ding Fire (Heart Fire) diminishes. Thus, Ministerial Fire wanders, and cold pathogen forces accumulation in the chest. This also signifies the exhaustion of Yang. Hence, fever, intense thirst, and a subjective feeling of heat occur, yet others feel coldness in the patient's muscles, bones, marrow, and vessels upon touch. This is "Rootless Fire." Therefore, warming herbs like Dingxiang (Caryophylli Flos) and Ganjiang (Zingiberis Rhizoma) are used to warm the Stomach, causing the fire to descend.
Wu Shou stated: Ke Ni refers to Qi rebelling upward, causing hiccups (Chi Te). Some medical texts mistakenly identify this as coughing. The mention of "death" in this context refers to severe physical depletion. Hiccups can result from Stomach excess due to failure to purge; the Qi rises from the Stomach through the chest and throat. Zhang Yuansu's treatment principle: For failure to purge resulting in internal Stomach heat and excess, with hard stools, use Chengqi Tang; with soft stools, use Xiexin Tang. For Stomach deficiency with heat, use Chupi Zhuru Tang (Tangerine Peel and Bamboo Shave Decoction); for phlegm-fluids, use Banxia Shengjiang Tang (Pinellia and Fresh Ginger Decoction) or Fuling Banxia Tang (Poria and Pinellia Decoction). For Stomach cold, use Chupi Ganjiang Tang (Tangerine Peel and Dried Ginger Decoction) or Jiawei Lizhong Tang (Modified Center-Regulating Decoction). *Jingui Yaolue* states: Qi rushing straight from below the navel to the chest and throat causing hiccups indicates Yin syndrome. The pathology is not in the Stomach but in lower deficiency with latent Yin, or caused by erroneous use of cold medicines leading to extreme cold below, forcing Ministerial Fire upward to accumulate in the chest, signifying Yang exhaustion. Failure to recognize this, and mistaking "water extreme resembling fire" (true cold/false heat) for heat, using cooling medicines will cause immediate collapse. Treatment requires Qianghuo Fuzi San (Notopterygium and Aconite Powder) or Jiawei Fuzi Tang (Modified Aconite Decoction) to urgently warm the lower Jiao. Once True Yang returns, the fire descends, and hiccups stop. For persistent hiccups due to extreme cold, methods involving Liuhuang Xurong San (Sulfur and Frankincense Powder) or moxibustion at Qimen, Zhongwan, Guanyuan, and Qihai acupoints may be used. The goal is to restore warmth to the limbs and regenerate the pulse; when Yang returns and Yin retreats, survival is possible.
Tao Hua stated: Ke Ni is commonly known as hiccups. It stops abruptly after sound emerges from the throat, producing continuous short sounds ("chi chi"), but they are short and not prolonged. Ancients incorrectly equated this with Yue (dry heaving/severe hiccup). Yue resembles gan ou (dry retching), but its sound is turbid, foul, and long, with sound but no matter expelled. Disease reaching Yue is critical. Generally, Ke Ni is close to Yue, but Ke Ni is merely Qi blockage in the chest failing to descend, whereas Yue emits foul sounds externally. The Classics state: Floating Yang pulse indicates Qi Yi (belching/rebellious Qi). Also: Slippery pulse indicates Yue. These errors stem from physicians wrongly treating deficiency as excess. If Ke Ni presents with a chaotic, scattered pulse, it is difficult to treat and differs from Shanghan cough with rebellious Qi. Confusing hiccups with Yue or cough with rebellious Qi leads to many errors. Clinicians must distinguish them clearly.