精要云。有二证。一谓初发。不曾得内托散。伏热在心。一谓气虚。脾气不正。其伏热
在心者。与内托散。气虚者。宜嘉禾散。有寒热。宜正气散。兼与山药丸以补肾。
丹溪曰。诸逆冲上呕哕。皆属于火。托里散性凉。固有降火之理。若嘉禾散徒温暖以助
。山药丸补肾以壮下焦之阴。粗为近理。然治呕须分先后。肿疡时当作毒瓦斯上攻治之。溃疡
后当作阴虚补之。若年老因疽溃后呕不食者。宜参 白术膏佐使药。随时随证加减。亦用独
参汤而愈者。山药丸缓急未易治。○河间谓病疮呕逆。湿气侵于胃也。药中宜倍加白术。海
云。吐者有物无声。乃血病也。哕者无物有声。乃气病也。呕者有声有物。气血俱病也。仲
景曰。呕家虽有阳明证。勿下之。咳逆者。火自下冲上胃口而作声也。病后胃虚所致。阴大
虚也。病而至此多危。善于治者。岂可泛言呕吐无分别耶。
热盛脉数。精要与漏芦汤。单煎大黄汤等。若不甚热。脉缓弱。只投五香连翘汤。
丹溪曰。热盛脉数。若肿疡时脏腑秘而体实者。犹可与也。若溃疡脓血出多。热盛脉数
。去死为近。岂可下乎。缓弱之脉。古人皆以为邪毒已散。五香之飞走升散。其可用乎。
尝见治寒以热。而寒弥甚。治热以寒。而热弥炽。何也。假如心实生热者。当益其肾。
滋。热自除。肾虚生寒者。当补其心。心火降。寒自退。此所谓寒之而热取之阴。热之而寒
者取之阳也。又寒因热用。热因寒用。要在通其理类而已。又闻微者逆之。甚者从之。盖治
寒以热。必凉而行之。治热以寒。必温而行之。此亦欲其调和也。其间有正有权者。盖病有
微有甚。微者逆治。理之正也。甚者从治。理之权也。
《精要》中说：有两种证候。一种是指疮疡初发时，没有及时服用内托散，导致伏热蕴结在心；另一种是指气虚，脾气不健运。对于伏热在心者，给予内托散治疗；对于气虚者，适宜用嘉禾散。伴有寒热症状的，适宜用正气散，同时配合山药丸以补肾。
朱丹溪说：各种冲逆向上的呕吐、呃逆，都属于火邪。托里散药性凉，确实有降火的道理。而嘉禾散只是单纯温补以助阳气，山药丸通过补肾来壮旺下焦之阴，这些说法虽然粗浅但接近事理。然而治疗呕吐必须分清病程阶段。在肿疡（未溃破）时期，应当当作毒瓦斯上攻来治疗；在溃疡（已溃破）之后，应当当作阴虚来补益。如果是老年人因疽疮溃破后出现呕吐、不能进食的情况，适宜用参术白膏作为佐使药，并根据时间和证候随时加减。也有使用独参汤而痊愈的案例。山药丸药力缓和，对于急症不易见效。○刘河间认为患疮疡出现呕吐呃逆，是湿气侵袭胃腑所致，用药中应当加倍使用白术。海云说：吐是有物无声，属于血病；哕（呃逆）是无物有声，属于气病；呕是有声有物，属于气血俱病。张仲景说：呕吐患者即使有阳明证，也不可用攻下法。咳逆（呃逆），是火气自下向上冲撞胃口而发出的声音，多由病后胃虚引起，属于阴气大虚。病情发展到这种地步大多危险，善于治病的人，怎么能笼统地说呕吐没有区别呢？
如果热盛脉数，《精要》推荐漏芦汤，或单煎大黄汤等。如果热势不重，脉象缓弱，只投予五香连翘汤。
朱丹溪说：热盛脉数，如果在肿疡时期，脏腑闭塞且体质壮实者，还可以使用攻下法。如果在溃疡后脓血流出过多，仍然热盛脉数，这就离死亡不远了，怎么还能用攻下法呢？脉象缓弱，古人都认为是邪毒已经消散，五香连翘汤具有升散走窜的特性，这种情况下还能使用吗？
我曾经见到用热药治寒证，但寒邪反而更严重；用寒药治热证，但热邪反而更炽盛。为什么呢？假如心实证产生热邪，应当补益肾水，滋润肾阴，热邪自然消除。肾虚产生寒邪，应当补益心火，心火下降，寒邪自然退去。这就是所说的“用寒药治疗发热，若无效则从阴分论治；用热药治疗寒冷，若无效则从阳分论治”。又有“寒因热用”、“热因寒用”，关键在于通晓其原理类推罢了。又听说轻微的病症用逆治法，严重的病症用从治法。大概用热药治寒证，必须凉服（反佐）；用寒药治热证，必须温服（反佐）。这也是为了调和阴阳。其中既有正治也有权变。因为疾病有轻微和严重之分。轻微的用逆治法，这是常理的正道；严重的用从治法，这是常理的权变。
The *Jingyao* (Essentials) states: There are two types of syndromes. One refers to the initial onset where the *Neituo San* (Internal Support Powder) was not administered, leading to latent heat accumulating in the Heart. The other refers to Qi deficiency with dysfunctional Spleen Qi. For those with latent heat in the Heart, administer *Neituo San*; for those with Qi deficiency, *Jiahe San* (Harmonizing Grain Powder) is appropriate. If accompanied by aversion to cold and fever, *Zhengqi San* (Regulating Qi Powder) is suitable, supplemented with *Shanyao Wan* (Dioscorea Pill) to tonify the Kidney.
Zhu Danxi stated: All rebellious upward movements, including vomiting and hiccups, belong to Fire. *Tuoli San* (Support Interior Powder) has a cool nature and indeed possesses the principle of descending Fire. However, *Jiahe San* merely provides warmth to assist Yang, and *Shanyao Wan* tonifies the Kidney to strengthen the Yin of the Lower Jiao; these explanations are crude but close to reason. Nevertheless, treating vomiting requires distinguishing between stages. During the ulceration stage (before rupture), it should be treated as toxic vapors attacking upwards; after the ulcer has ruptured, it should be treated as Yin deficiency requiring supplementation. For elderly patients who experience vomiting and inability to eat after the rupture of a carbuncle, *Shenzhu Baigu Gao* (Ginseng and Atractylodes Paste) should be used as an adjunctive medicine, adjusted according to time and syndrome. There are also cases cured using *Dushen Tang* (Single Ginseng Decoction). *Shanyao Wan* acts slowly and is not easy to use for acute conditions. Liu Hejian believed that vomiting and hiccups in sores are caused by dampness invading the Stomach, suggesting doubling the dosage of *Baizhu* (Atractylodis Rhizoma) in the prescription. Haiyun stated: Vomiting with material but no sound indicates a Blood disease; hiccupping without material but with sound indicates a Qi disease; vomiting with both sound and material indicates a disease affecting both Qi and Blood. Zhang Zhongjing said: Even if a patient with vomiting presents with Yangming syndrome, purgatives should not be used. Hiccups (Ke Ni) are sounds produced by Fire rushing upward from below to strike the stomach opening, often resulting from post-illness Stomach deficiency and severe Yin deficiency. Conditions reaching this stage are often critical; skilled practitioners certainly do not speak generally of vomiting without distinction.
If heat is abundant and the pulse is rapid, *Jingyao* recommends *Lulu Tang* (Phlomis Decoction) or decocting *Dahuang* (Rhei Radix et Rhizoma) alone. If the heat is not severe and the pulse is slow and weak, only *Wuxiang Liaoqiao Tang* (Five-Aromatic Forsythia Decoction) should be administered.
Zhu Danxi stated: In cases of abundant heat and rapid pulse, if during the pre-ulceration stage the internal organs are blocked and the constitution is strong, purgatives may still be used. However, if after ulceration there is excessive loss of pus and blood, yet heat remains abundant and the pulse rapid, death is near; how can purgatives be used? A slow and weak pulse is considered by ancients as a sign that pathogenic toxins have dissipated; since *Wuxiang* formulas have ascending and dispersing properties, can they still be used?
I have observed treating cold with heat, yet the cold becomes more severe; treating heat with cold, yet the heat becomes more intense. Why? If excess Heat arises from the Heart, one should benefit the Kidney water to nourish Yin, and the heat will naturally subside. If Cold arises from Kidney deficiency, one should tonify the Heart fire; as Heart fire descends, the cold will naturally recede. This is what is meant by "treating heat with cold medicines, if ineffective, treat from the Yin"; and "treating cold with hot medicines, if ineffective, treat from the Yang." There are also principles of "using heat due to cold" and "using cold due to heat," which rely on understanding the underlying logic. It is also heard that mild diseases are treated oppositely (Ni Zhi), while severe diseases are treated similarly (Cong Zhi). Generally, when using hot medicines to treat cold, they must be taken cool (counter-assistance); when using cold medicines to treat heat, they must be taken warm (counter-assistance). This is intended to harmonize. Among these, there are standard treatments (Zheng) and flexible adaptations (Quan). Since diseases vary in severity, mild cases are treated oppositely, which is the orthodox principle; severe cases are treated similarly, which is the adaptive principle.