《洁古家珍》，吐证有三，气、积、寒也。皆从三焦论之，上焦在胃口，上通于
天气，主内而不出。中焦在中脘，上通天气，下通地气，主腐熟水谷。下焦在脐下，
下通于地气，主出而不纳。是故上焦吐者，皆从于气。气者、天之阳也。其脉浮而
洪。其症食已暴吐，渴欲饮水，大便燥结，气上冲胸而发痛。其治当降气和中。中
焦吐者，皆从于积，有阴有阳，食与气相假为积而痛。其脉浮而弦。其证或先痛而
后吐，或先吐而后痛。法当以小毒药去其积，槟榔、木香和其气。下焦吐者，皆从
于寒，地道也，其脉大而迟。其证朝食暮吐，暮食朝吐，小便清利，大便秘而不通。
治法宜毒药通其闭塞，温其寒气，大便渐通，复以中焦药和之，不令大腑秘结而自
愈也。《此事难知》，问呕吐哕，胃所主，各有经乎？答曰∶胃者总司也，内有太阳、
阳明、少阳三经之别，以其气血多少，而为声物有无之不同。即吐属太阳，有物无声，
乃血病也。有食入即吐，食已则吐，食久则吐之别。呕属阳明，有物有声，气血俱
病也。仲景云∶呕多虽有阳明证，不可下，哕属少阳，无物有声，乃气病也。（此以干
呕为哕也。）医家大法∶食刹则吐为之呕，生姜半夏汤。食入则吐为之暴吐，生姜橘皮
汤。食已则吐为之呕吐，橘皮半夏汤。食久则吐为之反胃，水煮金花丸。食再则吐
为之翻胃，易老紫沉丸。旦食不能暮食。则吐、食不下，脉实而滑，半夏生姜大黄汤下
之。洁古论吐分三焦，其说盖本于黄帝，所谓气为上膈，食饮入而远出为下膈，食
时乃反出之。其上焦食已暴吐者，今世谓之呕吐也。中下二焦食久而吐，食再而
吐者，今世谓之膈气反胃也。分呕吐、膈气为二门。赵以德云∶夫阴阳气血，随处
有定分，独脾胃得之，则法天地人而三才之道备。故胃有上、中、下三脘，上脘法
天为阳，下脘法地为阴，中脘法气交之分。阳清而阴浊，故阳所司者气，阴所司者
血。然阳中亦有阴，阴中亦有阳，于是上脘气多血少，则体干道之变化动也。下脘
血多气少，则体坤道之资生静也。中脘气血相半，故运上下动静升降之气行。由是
物之入胃，各从其类聚。水饮者，物之清。谷食者，物之浊。然清中有浊，浊中有
清，故饮之清者，必先上输于司气之肺，而后四布为津为液。清中之浊者，则下输
膀胱为便溺出焉。食之清者，亦必先淫精于司血之心肝，以养筋骨经脉，更化荣卫，
流注百骸。浊中之浊者，则自下脘变糟粕，传送下大肠出焉。若邪在上脘之阳则气
停，气停则水积，故饮之清浊混乱，则为痰、为饮、为涎、为唾、变而成呕。邪在
下脘之阴则血滞，血滞则谷不消，故食之清浊不分，而为噎塞、为痞满、为痛为胀、
变而成吐。邪在中脘之气交者，尽有二脘之病。是故呕从气病，法天之阳，动而有
声，与饮俱出，犹雷震必雨注也。吐从血病，法地之阴，静而无声，与食俱出，象
万物之吐出于地也。气血俱病，法阴阳之气交，则呕吐并作，饮食皆出。然在上脘，
非不吐食也，设阳中之阴亦病，则食入即吐，不得纳于胃也。非若中脘之食已而后
吐，下脘之食久而方出。其下脘，非不呕也，设阴中之阳亦病，则吐与呕齐作，然
呕少于吐，不若上脘之呕多于吐也。
《洁古家珍》指出，呕吐的证候有三种：气、积、寒。这三种情况都从三焦的角度来论述。上焦位于胃口，向上通达天气，主要功能是受纳食物而不排出。中焦位于中脘，向上通达天气，向下通达地气，主要功能是腐熟水谷。下焦位于脐下，向下通达地气，主要功能是排出废物而不受纳。因此，上焦引起的呕吐，都是由气机失调所致。气属于天之阳。其脉象浮而洪大。其症状表现为进食后立即剧烈呕吐，口渴想喝水，大便干燥结滞，气逆冲胸并引发疼痛。治疗应当降气和胃。中焦引起的呕吐，都是由积滞所致，有阴积和阳积之分，食物与气相互搏结形成积滞而疼痛。其脉象浮而弦。其症状表现为或者先疼痛后呕吐，或者先呕吐后疼痛。治法应当用具有毒性的药物去除积滞，用槟榔、木香来调畅气机。下焦引起的呕吐，都是由寒邪所致，属于地道（阴），其脉象大而迟滞。其症状表现为早晨吃的饭晚上吐出来，晚上吃的饭早晨吐出来，小便清长通畅，大便秘结不通。治疗方法适宜用药物通开闭塞，温散寒气，待大便逐渐通畅后，再用调理中焦的药物调和，不让大肠腑气秘结，病自然痊愈。
《此事难知》中提问：呕吐哕（呃逆/干呕），由胃所主，各自有对应的经络吗？回答说：胃是总司消化的器官，内部包含太阳、阳明、少阳三条经络的区别，因为气血多少不同，所以声音和吐出物的有无也不同。其中，吐属于太阳经，有物无声，这是血分病变。又有食入即吐、食已则吐、食久则吐的区别。呕属于阳明经，有物有声，这是气血俱病。张仲景说：“呕多虽有阳明证，不可下。”哕属于少阳经，无物有声，这是气分病变。（这里将干呕称为哕）。医家的常规大法：食物刚吃下就吐出的称为呕，用生姜半夏汤。食物吃进去就吐出的称为暴吐，用生姜橘皮汤。食物吃完就吐出的称为呕吐，用橘皮半夏汤。食物停留很久才吐出的称为反胃，用水煮金花丸。吃两次就吐出的称为翻胃，用易老紫沉丸。早上吃了不能晚上再吃，既吐又吃不进，脉象实而滑，用半夏生姜大黄汤攻下。
李东垣（洁古）论述呕吐分为三焦，他的说法大概源于黄帝内经，所谓气阻于上膈，饮食进入后很久才吐出为下膈，进食时随即反出为上膈。其中上焦食后即剧烈呕吐的情况，当今世人称之为呕吐。中焦和下焦食物停留很久才吐、吃两次就吐的情况，当今世人称之为膈气或反胃。将呕吐和膈气分为两个门类。赵以德说：阴阳气血，到处都有固定的分配，唯独脾胃得到这种分配，则效法天地人三才之道而完备。所以胃有上、中、下三个脘，上脘效法天为阳，下脘效法地为阴，中脘效法气交之分野。阳清而阴浊，所以阳所主管的是气，阴所主管的是血。然而阳中也有阴，阴中也有阳，于是上脘气多血少，体现天道变化的动态；下脘血多气少，体现地道资生的静态；中脘气血各半，所以运化上下动静升降的气机运行。因此，进入胃的食物，各自依从其类别聚集。水饮，是物之清者；谷食，是物之浊者。然而清中有浊，浊中有清，所以饮水中的清者，必须先上行输送给主管气的肺，然后散布全身成为津液。清中之浊者，则下行输送到膀胱作为大小便排出。食物中的清者，也必须先滋养主管血的心肝，以濡养筋骨经脉，进而化生营卫之气，流注全身百骸。浊中之浊者，则自下脘变为糟粕，传送到大肠排出。如果邪气在上脘之阳，则气停聚，气停则水积聚，导致饮的清浊混乱，从而变成痰、饮、涎、唾，变化而成呕吐。邪气在下脘之阴，则血滞涩，血滞则食物不消化，导致食的清浊不分，从而变成噎塞、痞满、疼痛、胀满，变化而成呕吐。邪气在中脘之气交处，兼有上、下两脘的病证。所以呕源于气病，效法天之阳，动而有声，随饮水一起吐出，就像雷震必伴随雨注一样。吐源于血病，效法地之阴，静而无声，随食物一起吐出，象征万物从地里吐露出来。气血俱病，效法阴阳之气交，则呕吐并作，饮食皆吐出。然而在上脘，并非不吐食物，假如阳中之阴也发病，则食入即吐，食物无法纳入胃中。这不像中脘那样食后才吐，也不像下脘那样食久后才吐出。在下脘，并非不呕，假如阴中之阳也发病，则吐与呕同时发作，然而呕少于吐，不像上脘那样呕多于吐。
According to *Jiegu Jiazhen* (Treasures from the Home of Jiegu), there are three types of vomiting syndromes: Qi (vital energy), Accumulation (food stagnation), and Cold. These are all analyzed through the lens of the Triple Burner (San Jiao). The Upper Burner is located at the gastric opening, connects upward with the Heaven Qi, and is responsible for receiving but not expelling. The Middle Burner is located at Zhongwan (CV12), connects upward with Heaven Qi and downward with Earth Qi, and is responsible for rotting and ripening food and fluids. The Lower Burner is located below the umbilicus, connects downward with Earth Qi, and is responsible for expelling but not receiving. Therefore, vomiting originating from the Upper Burner is caused by Qi dysfunction. Qi belongs to the Yang of Heaven. Its pulse is floating and surging. Symptoms include sudden violent vomiting after eating, thirst with desire to drink water, dry and constipated stool, Qi rushing upward to the chest causing pain. Treatment should focus on descending Qi and harmonizing the middle. Vomiting originating from the Middle Burner is caused by Accumulation, which can be Yin or Yang type, where food and Qi intertwine to form accumulation causing pain. Its pulse is floating and wiry. Symptoms may present as pain followed by vomiting, or vomiting followed by pain. The method is to use slightly toxic drugs to remove the accumulation, and use Areca Seed (Binglang) and Costus Root (Muxiang) to regulate Qi. Vomiting originating from the Lower Burner is caused by Cold, belonging to the Earthly Dao (Yin). Its pulse is large and slow. Symptoms include vomiting in the evening what was eaten in the morning, and vomiting in the morning what was eaten in the evening; clear and profuse urination, and constipation without passage. The treatment method should use drugs to open blockages and warm the cold Qi. Once the stool gradually passes, use Middle Burner formulas to harmonize, preventing severe constipation of the Large Intestine Fu-organ, leading to spontaneous recovery.
In *Cishi Nan Zhi* (Difficulties in This Matter), it is asked: Do vomiting, retching, and hiccups, which are governed by the Stomach, each have their own meridians? The answer is: The Stomach is the general manager of digestion. Internally, it distinguishes between the Taiyang, Yangming, and Shaoyang meridians. Due to differences in the quantity of Qi and Blood, there are variations in the presence of sound and expelled matter. Specifically, "Tu" (expulsion/vomiting without sound) belongs to the Taiyang meridian, involves matter but no sound, and is a disease of the Blood level. It is further distinguished into immediate expulsion upon eating, expulsion after eating, and delayed expulsion. "Ou" (retching/vomiting with sound) belongs to the Yangming meridian, involves both matter and sound, and indicates disease of both Qi and Blood. Zhang Zhongjing stated: "If there is much retching, even if there are Yangming symptoms, purgation is contraindicated." "Yue" (hiccups/dry heaves) belongs to the Shaoyang meridian, involves sound but no matter, and is a disease of the Qi level. (Here, dry heaves are referred to as Yue.) The general principle of medical practice is: Vomiting immediately after swallowing food is called Ou, treated with Shengjiang Banxia Tang (Fresh Ginger and Pinellia Decoction). Vomiting immediately after food enters is called Baotu (Sudden Vomiting), treated with Shengjiang Chuanpi Tang (Fresh Ginger and Tangerina Peel Decoction). Vomiting immediately after finishing a meal is called Outu, treated with Chuanpi Banxia Tang (Tangerina Peel and Pinellia Decoction). Vomiting after food has stayed for a long time is called Fanwei (Reverse Stomach), treated with Shuizhu Jinhua Wan (Water-Boiled Golden Flower Pill). Vomiting after eating twice is called Fange, treated with Yilao Zichen Wan (Yilao's Purple Sinking Pill). If one cannot eat again in the evening after eating in the morning, accompanied by vomiting and inability to ingest food, with a solid and slippery pulse, treat with Banxia Shengjiang Dahuang Tang (Pinellia, Fresh Ginger, and Rhubarb Decoction) to purge.
Li Dongyuan's (Jiegu's) discussion on dividing vomiting by the Triple Burner is likely based on the *Huangdi Neijing*. It states that Qi obstruction in the Upper Diaphragm causes food and drink to emerge from far away later (Lower Diaphragm), while food emerging immediately upon eating is the Upper Diaphragm. The case of sudden violent vomiting after eating in the Upper Burner is currently termed "Outu" (Vomiting). The cases of prolonged retention and vomiting in the Middle and Lower Burners, or vomiting after eating twice, are currently termed "Geqi" (Diaphragmatic Qi) or "Fanwei" (Reverse Stomach). Thus, Otu and Geqi are divided into two categories. Zhao Yi-de stated: Yin-Yang, Qi, and Blood have fixed distributions everywhere. Only the Spleen and Stomach embody this distribution, completing the principles of Heaven, Earth, and Man (Three Powers). Therefore, the Stomach has Upper, Middle, and Lower Guan (orifices/chambers). The Upper Guan corresponds to Heaven (Yang), the Lower Guan corresponds to Earth (Yin), and the Middle Guan corresponds to the intersection of Qi. Yang is clear and Yin is turbid; thus, Yang governs Qi, and Yin governs Blood. However, within Yang there is Yin, and within Yin there is Yang. Consequently, the Upper Guan has more Qi and less Blood, reflecting the dynamic changes of the Heavenly Dao. The Lower Guan has more Blood and less Qi, reflecting the static nourishment of the Earthly Dao. The Middle Guan has equal parts Qi and Blood, thus transporting the ascending, descending, moving, and still Qi of the upper and lower regions. Therefore, substances entering the stomach gather according to their nature. Water and drinks are the clear aspect of substances; grains and food are the turbid aspect. Yet, within clarity lies turbidity, and within turbidity lies clarity. Thus, the clear part of drinks must first ascend to the Lung, which governs Qi, and then distribute throughout the body to become Jin-Ye (body fluids). The turbid part of the clear flows downward to the Bladder and exits as urine and feces. The clear part of food must first nourish the Heart and Liver, which govern Blood, to support sinews, bones, and vessels, and further transform into Ying and Wei (Nutritive and Defensive Qi), flowing into the hundred bones. The turbid part of the turbid becomes dregs in the Lower Guan, transmits to the Large Intestine, and exits. If pathogenic factors affect the Yang of the Upper Guan, Qi stagnates; Qi stagnation leads to fluid accumulation. Thus, the clarity and turbidity of drinks mix, transforming into Phlegm, Fluids, Saliva, and Spittle, changing into vomiting. If pathogenic factors affect the Yin of the Lower Guan, Blood stasis occurs; Blood stasis prevents food digestion. Thus, the clarity and turbidity of food are not separated, transforming into Dysphagia, Fullness, Pain, and Distension, changing into vomiting. Pathogenic factors at the Qi intersection of the Middle Guan involve diseases of both the Upper and Lower Guan. Therefore, vomiting arises from Qi disease, corresponding to the Yang of Heaven, moving with sound, exiting with fluids, like thunder bringing rain. Expulsion arises from Blood disease, corresponding to the Yin of Earth, still without sound, exiting with food, symbolizing things emerging from the earth. When both Qi and Blood are diseased, corresponding to the intersection of Yin-Yang Qi, both vomiting and expulsion occur, and food and drink are expelled. However, in the Upper Guan, although food is not vomited, if the Yin within Yang is also diseased, food is expelled immediately upon entry and cannot enter the Stomach. This differs from the Middle Guan, where vomiting occurs after eating, and the Lower Guan, where vomiting occurs after a long delay. In the Lower Guan, although retching does not occur, if the Yang within Yin is also diseased, expulsion and retching occur simultaneously, though retching is less than expulsion, unlike the Upper Guan where retching exceeds expulsion.