略例云阳证咳逆者胃热失下也阴消将尽阳逆上行使阴不内也为之恶候或兼以舌挛语言不
正而
反昏胃与咽痛者少阴也速下之宜大承气汤若阳极脉微将尽者不宜下宜泻心汤养阴退阳而已凉
膈芒硝清肺亦可阴证者内已伏阴阴气太甚肾水檀权肝气不生胃火已病丁火又消所有游行相火
寒邪迫而率集于胸中亦欲尽也故令人发热大渴引饮并去盖覆病患独觉热也他人按之身体皆寒
此火即无根之火也故用丁香干姜之类温胃其火自下咳逆乃止非如阳证以凉膈泻心汤退心火阴
气乃生且阴证咳逆从呕哕而生胃寒呕哕不已阳逆继之也
按咳逆本由阴气已虚阳火暴甚直冲而上出于胃入于肺而作声东垣用凉药者所以泻热降火
也若
夫所谓阴证咳逆者盖以阴气先消阳火亦竭浮于胸中亦欲散也故不宜用寒而反以温药养胃留其
阳气胃气一和阳生则阴长之说也而此略例以阳证为失下用承气泻心二药分便秘便软用之则可
矣以阴证为阴气太甚肾水擅权寒邪迫火而上愚谓肾阴若盛则火自不妄动矣其所谓寒邪者未审
其指受外寒耶内寒耶还只是虚耶姑俟明哲
又案张子和云火欲上行为寒邪所遏寒不胜火故作声此则是上寒遏下热与外寒郁内热之义
同亦与前说不同
难知云夫咳逆证活人断为哕逆其说似是而非盖哕者干呕也若有物直出则为吐也呕物旋出
则为
呕也呕无物出则为哕也咳逆者或水渍于肺而心痞或连续不已而气逆或喜笑过多而气噎或咽饮
而错喉而气抢或急食干物而气塞皆能作咳逆之声连续不绝俗谓之吃忒是也大抵咳逆者不顺之
义吃忒者差错之义二者皆气不得下为火热托之而使上至咽喉中噎而止也人或以纸捻鼻嚏而止
或诈冤盗贼因恐而止或鼻热闻食香调气而止皆抑之骇之而使气下也千金以咳逆上气者为病肺
脉散者死是心火刑于肺金也是以李氏称易老云咳逆者火热奔急上行而肺金不内何其当哉故便
秘者大承气汤下之便软者泻心汤主之朱氏断为胃寒并阳证二法用药治哕虽胜大抵其哕之意止
是气逆上行似咳逆耳即非仲景所谓咳逆之本证也尽哕者出声也哕出其气哕声尽然后吸咳逆者
入声也抑气不出逆声尽然后呼也出入呼吸其大不同兼呕哕者本于胃咳逆者本于肺何其难辨哉
《略例》中说：阳证咳逆，是因为胃热未及时攻下，导致阴液消亡将尽，阳气上逆，使阴气不能内守，这是恶候。如果兼有舌体挛缩、言语不正，反而神志昏蒙，以及胃部和咽喉疼痛的，属于少阴病，应当迅速攻下，适宜用大承气汤。如果是阳极脉微、生机将尽的情况，则不宜攻下，适宜用泻心汤来滋养阴气、退抑阳气。凉膈散加芒硝清肺也是可行的。
阴证咳逆，是因为体内已潜伏阴寒，阴气太盛，肾水擅权（肾水过旺克制心火），肝气无法生发，胃火已经病变，丁火（心火）又消退。游行的相火被寒邪逼迫，聚集于胸中，也想要消散了。所以使人发热、极度口渴、引饮不止，并且掀去盖被，病人独自觉得热，但他人触摸其身体却是寒冷的。这就是无根之火。所以使用丁香、干姜之类温胃的药物，虚火自然下行，咳逆才会停止。这与阳证不同，阳证是用凉膈散、泻心汤退去心火，阴气才能生长。而且阴证咳逆是从呕吐和呃逆产生的，因为胃寒导致呕吐呃逆不止，阳气上逆继之而来。
按语：咳逆本来是由阴气已虚，阳火暴甚，直冲而上，出于胃而入于肺，从而发出声音。东垣（李杲）使用凉药，是为了泻热降火。至于所谓的阴证咳逆，是因为阴气先消，阳火也枯竭，浮于胸中，也想要消散。所以不适宜用寒凉药，反而用温药养胃，以留住阳气。这是“胃气和则阳生，阳生则阴长”的道理。而《略例》认为阳证是失于攻下，用承气汤、泻心汤分别针对便秘和便软的情况使用，这就可以了。但认为阴证是阴气太盛，肾水擅权，寒邪逼迫火势上炎，我认为如果肾阴旺盛，火自然不会妄动。至于所说的寒邪，不清楚是指感受外寒，还是内寒，或者仅仅是虚寒？暂且等待明智者辨析。
又案：张子和说，火欲上行，被寒邪遏制，寒不胜火，所以发出声音。这实际上是上寒遏下热，与外寒郁闭内热的意义相同，但也与前人的说法不同。
难知（朱肱）说：咳逆证，《活人书》判断为哕逆，这种说法似是而非。大概哕就是干呕；如果有物直接吐出，就是吐；呕出的东西随即出来，就是呕；呕而无物吐出，就是哕。咳逆，有的是水渍于肺导致心下痞塞，有的是连续不断导致气逆，有的是喜笑过多导致气噎，有的是咽饮时误入喉间导致气抢，有的是急食干物导致气塞，这些都能产生咳逆之声，连续不绝，俗称为“吃忒”。大抵咳逆是不顺的意思，吃忒是差错的意思，两者都是气不得下行，被火热托举而上至咽喉中噎住而止。有人用纸捻刺激鼻孔打喷嚏来止住，有的假装受冤或盗贼因恐惧而止住，有的因鼻热闻食物香气调理气息而止住，这些都是通过抑制、惊吓使气下行。《千金方》认为咳逆上气是肺病，脉象散乱主死，这是心火刑克肺金。所以李氏称赞易老（张元素）说：“咳逆是火热奔急上行，而肺金不能内守”，这话很恰当。因此，便秘的用大承气汤攻下，便软的用泻心汤主治。朱氏判断为胃寒，并用治疗阳证的两法用药治疗哕，虽然高明，但大抵其哕的意思只是气逆上行，类似咳逆罢了，并不是仲景所说的咳逆的本证。尽哕是出声，哕是出气，哕声结束后才吸气；咳逆是入声，压抑气不出，逆声结束后才呼气。出入呼吸有很大不同。兼有呕吐和哕的，病本在胃；咳逆的病本在肺，怎么容易辨别呢？
The *Lue Li* (Brief Examples) states: In Yang syndrome cough-convulsion (Ke Ni, hiccup), it is due to stomach heat that was not purged in time. This leads to the exhaustion of Yin fluids and the reversal of Yang Qi upwards, preventing Yin from being retained internally. This is a malignant sign. If accompanied by tongue contraction, abnormal speech, sudden confusion, and pain in the stomach and throat, it belongs to Shaoyin syndrome. It should be treated with rapid purging, suitable for Da Cheng Qi Tang (Great Order the Qi Decoction). If Yang is at its extreme with faint pulse and life force fading, purging is contraindicated; instead, Xie Xin Tang (Drain the Epigastrium Decoction) should be used to nourish Yin and subdue Yang. Liang Ge San (Cool the Chest Powder) added with Mang Xiao (Mirabilite) to clear Lung heat is also acceptable.
In Yin syndrome cough-convulsion, internal cold has already latent within. Yin Qi is excessive, Kidney Water dominates (excessive Kidney water suppressing Heart Fire), Liver Qi fails to generate, Stomach Fire is diseased, and Ding Fire (Heart Fire) has diminished. The wandering Ministerial Fire is forced by Cold Evil to gather in the chest, also tending to dissipate. Thus, it causes fever, extreme thirst with excessive drinking, and the patient removes covers, feeling hot alone, while others feel cold when touching the body. This is Rootless Fire. Therefore, warming the Stomach with herbs like Ding Xiang (Clove) and Gan Jiang (Dried Ginger) causes the false fire to descend, and cough-convulsion stops. This differs from Yang syndrome, where Liang Ge San and Xie Xin Tang are used to clear Heart Fire so that Yin Qi can grow. Moreover, Yin syndrome cough-convulsion arises from vomiting and hiccups (Yue); because Stomach Cold causes persistent vomiting and hiccups, Yang Qi reverses upwards subsequently.
Commentary: Cough-convulsion originally stems from deficient Yin Qi and violent excess of Yang Fire rushing upwards, originating from the Stomach and entering the Lung, producing sound. Dong Yuan (Li Gao) used cooling medicines to purge heat and descend fire. As for the so-called Yin syndrome cough-convulsion, it is because Yin Qi has first exhausted, and Yang Fire is also depleted, floating in the chest and tending to dissipate. Therefore, cold medicines are unsuitable; instead, warm medicines are used to nourish the Stomach and retain Yang Qi. This aligns with the principle that "when Stomach Qi harmonizes, Yang generates, and when Yang generates, Yin grows." However, the *Lue Li* considers Yang syndrome as resulting from missed purgation, using Cheng Qi Tang or Xie Xin Tang depending on constipation or soft stool, which is acceptable. But regarding Yin syndrome as excessive Yin Qi with Kidney Water dominating and Cold Evil forcing Fire upward, I argue that if Kidney Yin were abundant, Fire would not move recklessly. Regarding the mentioned Cold Evil, it is unclear whether it refers to external Cold, internal Cold, or merely deficiency Cold. I leave this for wiser scholars to clarify.
Another case: Zhang Zi He stated that Fire desires to ascend but is obstructed by Cold Evil; since Cold cannot overcome Fire, sound is produced. This implies upper Cold obstructing lower Heat, similar to the meaning of external Cold郁 (stagnating) internal Heat, yet differing from previous explanations.
Nan Zhi (Zhu Gong) said: Regarding cough-convulsion, the *Huo Ren Shu* judges it as Yue (hiccup/dry heave). This view is plausible but incorrect. Generally, Yue refers to dry heaving; if material is expelled directly, it is Vomiting (Tu); if material comes out immediately after retching, it is Ou (vomiting); if there is retching without expulsion, it is Yue. Cough-convulsion may result from water dampness affecting the Lung causing epigastric fullness, continuous non-stop episodes causing Qi reversal, excessive laughter causing Qi obstruction, swallowing drinks incorrectly causing Qi snatching, or eating dry food quickly causing Qi blockage. All these can produce continuous cough-convulsion sounds, commonly called "Chi Te" (hiccups). Broadly, cough-convulsion means disorderliness, and Chi Te means error; both involve Qi failing to descend, pushed up by Heat/Fire to the throat where it stops. Some stop it by inducing sneezing with paper twists, some by feigning injustice or fear of thieves, some by smelling food fragrance to regulate Qi. These methods work by suppressing or startling the Qi to make it descend. The *Qian Jin Fang* states that cough-convulsion with ascending Qi is a Lung disease; a scattered pulse indicates death, representing Heart Fire punishing Lung Metal. Thus, Li praised Yi Lao (Zhang Yuansu) saying: "Cough-convulsion is Fire/Heat rushing upward urgently, while Lung Metal fails to contain it," which is accurate. Therefore, for constipation, Da Cheng Qi Tang is used to purge; for soft stool, Xie Xin Tang is the main prescription. Zhu judged it as Stomach Cold and used two methods for Yang syndrome to treat Yue. Although effective, the essence of Yue is merely Qi reversing upward, resembling cough-convulsion, but it is not the primary syndrome of cough-convulsion as described by Zhong Jing. Full Yue produces sound; Yue expels Qi, and inhalation follows after the sound ends. Cough-convulsion involves inhalation; Qi is suppressed and does not exit, and exhalation follows after the reverse sound ends. The difference between exiting and entering breath is significant. Cases combined with vomiting and Yue originate from the Stomach; cough-convulsion originates from the Lung. How difficult is it to distinguish them?