【纲】仲景曰。伤寒一日。太阳受之。脉若静者。为不传。颇欲吐。若躁烦。脉急数者。为传
也。
【目】庞安常曰。颇欲吐。就受寒之一日已见。是将来呕逆之机。已伏于此。
【纲】仲景曰。少阴症。饮食入口则吐。心中温温欲吐。复不能吐。始得之。手足寒。脉弦迟
者。此胸中实。不可下也。当吐之。若膈上有寒饮。干呕者。不可吐也。当温之。宜四逆汤。
【目】韩祗和曰。此本少阴肾脏之病。但曰脉弦。弦犹带少阳之象。曰胸中实。胸中者阳明之
分。况实则必有宿滞。故不尽从少阴温治之法。亦不可从阳明攻下之法。而用吐法也。
朱肱曰。曾经汗下。关脉迟。胃中虚冷而吐者。干姜黄芩黄连人参汤。寒多不饮水而吐者。理中
汤去术加生姜。吐利。手足逆冷。烦躁甚者。吴茱萸汤。若伤寒解后。虚羸少气。气逆欲吐者。竹
叶石膏汤。
【纲】仲景曰。阳明中风。脉弦浮大而短气。腹部满。胁下及心痛。久按之。气不通。鼻干不
得汗。嗜卧。一身及面目悉黄。小便难。有潮热。时时哕。耳前后肿。刺之小瘥。外不解。病过十
日。脉弦浮者。与小柴胡汤。脉但浮。无余症者。与麻黄汤。若不尿腹满。加哕者。不治。
【目】朱肱曰。伤寒咳逆。此症极恶。仲景经中不载。孙真人云。咳逆寻遍方论。无此名称。
穷其状。咳逆者。哕逆之名。盖古人以咳逆为哕耳。大抵咳逆者。古人所谓哕是也。 者。今人
所谓干呕是也。扁鹊中藏经。治伤寒咳逆。丁香散。
丁香、柿蒂各一分。甘草、良姜各半钱。沸汤点作一服。乘热猛吃。极效。
三因有竹茹汤等方。亦有丁香散。竹茹汤、治阳症也。本事方治伤寒后咳逆。豆蔻汤。治阴症。
丁香、茴香、肉豆蔻等药。若阳症不可用。凡咳逆。多有先热而后吃生冷。或凉药。多相激而成。
盖阴阳二气相搏也。
成无己曰。KT 则但胸喉间气塞滞不得下通。然而无声也。哕则吃吃有声。二者相近。皆胃之疾。
但有轻重耳。虚寒相搏。及饮冷水。令汗大出。水得寒气。冷必先搏。其人即KT 。言胃气虚弱也。
伤寒大吐下后。极虚。复发汗出者。其人外气怫郁。复与之水以发其汗。因得哕。即是观之。皆胃
疾可知矣。然KT 为水寒相搏。宜小青龙去麻黄加附子。哕则热气壅郁。气不得通而成。轻者。但和解。
如潮热。时时哕。与小柴胡是也。重者。必攻下。如哕而腹满。视其前后。知何部不利。利之则
愈。是也。伤寒有此。病已极矣。非若渴烦等轻缓之候也。
鳌按。时时哕。内不解也。至腹部满加哕。比时时哕更加甚矣。
【纲】仲景曰。阳明病不能食。攻其热必哕。所以然者。胃中虚冷故也。以其人本虚。故攻其
热必哕。
若胃中虚冷不能食者。饮水必哕。
【目】成无己曰。观此。哕为胃疾可知矣。大抵妄下后。胃则虚。气因逆。所以成哕。
魏荔彤曰。阳明病至不能食。即有手足 然汗出等症之假热。便不可误为胃实之热而攻之。致
胃阳愈陷而脱。寒邪愈盛而冲。盖必作哕症。谷气将绝也。仲师再明为胃中虚冷之故。以其人本属
胃冷而虚。并非胃热之实。欲医于能食不能食。辨胃之寒热也。且胃中之虚冷。不惟决于能食不能
食。且决于能饮不能饮。若胃中真实虚冷。固不能食矣。且饮水必哕可与以阴寒攻破之剂乎。此虽
有表症。且不治表而治里。虽有阳明假热之症。宁容不治真寒而治假热乎。所宜明辨而慎出之者也。
【纲】仲景曰。伤寒大吐大下之。极虚。复极汗者。以其人外气怫郁。复与之水以发其汗。因
得哕。所以然者。胃中虚冷故也。
【目】成无己曰。胃虚得水。虚寒相搏。故哕也。吴茱萸汤、理中汤。活人用橘皮干姜汤、半夏
生姜汤、羌活附子汤。
陶华曰。哕者。即干呕之甚者也。其声浊恶而长。亦是有声而无物。病至于哕。则难治。盖因
胃气本虚。汗下太过。或复饮水。水寒相搏。虚逆而成。又有热气壅郁。上下气不通而哕者。轻则
和解疏利。甚则温散。若不尿腹满而哕。与咳逆脉散无伦者。虽神医不能措手矣。
【纲】仲景曰。伤寒哕而腹满。视其前后。知何部不利。利之则愈。
【目】王肯堂曰。仲景无方。活人。前部宜猪苓汤。后部宜调胃承气汤。
鳌按。前数条。由胃冷之故。此条。由胃热之故。
【纲】张仲景说：伤寒发病第一天，邪气侵犯太阳经。如果脉象平静（指脉象未变，无躁动之象），说明病邪没有传变。如果病人频频想吐，或者出现烦躁不安、脉搏急促快速的情况，说明病邪已经发生传变。
【目】庞安常说：“频频想吐”这一症状，在受寒的第一天就已经出现，这是将来发生呕吐呃逆的先机，病机已经潜伏在此处。
【纲】张仲景说：少阴病证，饮食入口即吐，心中感觉温热不适想要呕吐，却又吐不出来。刚得病时，手脚发凉，脉象弦而迟缓的，这是胸中有实邪阻滞，不可使用泻下法，应当使用涌吐法。如果是膈上有寒饮停留，导致干呕的，不可使用涌吐法，应当使用温阳化饮法，适宜用四逆汤。
【目】韩祗和说：这本来是少阴肾脏的病，但提到脉象“弦”，弦脉还带有少阳经的特征；提到“胸中实”，胸中属于阳明经的分野。况且实证必然有宿食停滞，所以不能单纯从少阴经温补治法考虑，也不能从阳明经攻下治法考虑，而应采用涌吐法。
朱肱说：曾经经过发汗或泻下治疗，关脉迟，因胃中虚冷而呕吐的，用干姜黄芩黄连人参汤。寒多且不饮水而呕吐的，用理中汤去掉白术加生姜。伴有呕吐腹泻、手足逆冷、烦躁严重的，用吴茱萸汤。如果是伤寒病愈后，身体虚弱消瘦、气息短少、气逆想要呕吐的，用竹叶石膏汤。
【纲】张仲景说：阳明中风，脉象弦、浮、大且短气，腹部胀满，胁下及心口疼痛，长时间按压后，气机不通畅，鼻干不得汗出，嗜睡，全身及面目都发黄，小便困难，有潮热，时常呃逆，耳前耳后肿胀。针刺后稍微好转，但表证仍未解除。病程超过十天，脉象仍见弦浮的，给予小柴胡汤。如果脉象仅见浮，没有其他症状的，给予麻黄汤。如果不排尿且腹部胀满，加上呃逆的，属于不治之症。
【目】朱肱说：伤寒引起的咳逆，这个症状非常凶险，张仲景的《伤寒论》中没有记载。孙思邈说：咳逆遍寻方论，没有这个名称。推究其状貌，咳逆就是哕逆的名称，大概古人把咳逆称为哕。这里的“啰”（注：原文此处可能有误或通假，结合上下文指干呕类症状），是今人所说的干呕。《扁鹊中藏经》治疗伤寒咳逆，用丁香散。丁香、柿蒂各一分，甘草、良姜各半钱，用沸水冲泡作为一服，趁热猛喝，效果极佳。
《三因极一病证方论》中有竹茹汤等方剂，也有丁香散。竹茹汤治疗阳证。《本事方》治疗伤寒后的咳逆，用豆蔻汤，治疗阴证。药物包括丁香、茴香、肉豆蔻等。如果是阳证不可使用。凡是咳逆，大多先发热然后吃生冷食物，或服用凉药，多因相互激荡而成，大概是阴阳二气相搏的结果。
成无己说：噫（打嗝）只是胸喉间气塞滞涩不得下行，然而没有声音。哕（呃逆）则吃吃有声。两者相近，都是胃的疾病，只是轻重不同罢了。虚寒相搏，以及饮用冷水，令大汗出，水遇到寒气，冷气必然相搏，病人就会噫，这是说胃气虚弱。伤寒经过大吐大下之后，极度虚弱，又再次发汗出，病人外表气机怫郁，再给水以发汗，因此导致哕。由此看来，都是胃的疾病可知了。然而噫是因为水寒相搏，适宜用小青龙汤去掉麻黄加附子。哕则是热气壅滞郁结，气不得通畅而成。轻的，只需和解，如潮热、时时哕，用小柴胡汤就是此类。重的，必须攻下，如哕而且腹部胀满，观察前后二便，知道哪一部不利，通利它就好了。伤寒出现这种情况，病已经很严重了，不像口渴烦躁等轻缓的症状那样。
沈金鳌按语：时时哕，是内里病邪未解。到了腹部胀满加上哕，比时时哕更加严重了。
【纲】张仲景说：阳明病不能进食，如果攻伐其热，必定会导致哕。之所以这样，是因为胃中虚冷的缘故。因为这个人本来体质虚弱，所以攻伐其热必定导致哕。
【目】成无己说：看这里，哕是胃的疾病可知了。大致是误用攻下后，胃气虚弱，气机上逆，所以形成哕。
魏荔彤说：阳明病到了不能进食的地步，即使有手足濈然汗出等假热的症状，也不可误认为是胃实的热证而攻下，否则会导致胃阳进一步陷入脱失，寒邪更加旺盛冲逆，必然会出现哕症，谷气即将断绝。张仲景再次明确说明是胃中虚冷的缘故，因为这个人本来属于胃冷而虚，并不是胃热的实证。想要通过医生判断能食与不能食，来辨别胃的寒热。而且胃中的虚冷，不仅取决于能食与否，也取决于能饮与否。如果胃中真实虚冷，固然不能进食，而且喝水必哕，怎么可以用阴寒攻破的药剂呢？这里虽然有表证，也不治表而治里；虽然有阳明假热的症状，岂容不治真寒而治假热呢？这是应该明辨并谨慎处方的。
【纲】张仲景说：伤寒经过大吐大下，极度虚弱，又极度发汗。因为病人外表气机怫郁，再给水以发汗，因此导致哕。之所以这样，是因为胃中虚冷的缘故。
【目】成无己说：胃虚得到水，虚寒相搏，所以发生哕。吴茱萸汤、理中汤，《活人书》用橘皮干姜汤、半夏生姜汤、羌活附子汤。
陶华说：哕，就是严重的干呕。其声音浊恶而长，也是有声而无物。病发展到哕的程度，就难治了。大概是因为胃气本虚，汗下太过，或者又饮水，水寒相搏，虚逆而成。又有热气壅滞郁结，上下气不通而哕的。轻的，和解疏利；重的，温散。如果不排尿、腹部胀满而哕，以及咳逆脉象散乱无伦次的，即使是神医也无法下手了。
【纲】张仲景说：伤寒哕而且腹部胀满，观察前后二便，知道哪一部不利，通利它就好了。
[General Principle] Zhang Zhongjing said: In the first day of Shanghan (Cold Damage), the Taiyang channel is affected. If the pulse remains quiet (indicating no change or agitation), it means the pathogen has not transmitted. If the patient frequently desires to vomit, or presents with restlessness and irritability, along with a rapid and hurried pulse, it indicates that the disease has transmitted.
[Detailed Commentary] Pang Anchang stated: The symptom of "frequently desiring to vomit" appearing on the first day of cold invasion is the precursor mechanism for future vomiting and hiccups; the pathological basis is already latent here.
[General Principle] Zhang Zhongjing said: In Shaoyin syndrome, if food and drink are vomited immediately upon entering the mouth, and there is a warm discomfort in the heart region with a desire to vomit but inability to do so, accompanied by cold hands and feet at the onset, and a string-taut (Xian) and slow (Chi) pulse, this indicates excess pathogenic factors in the chest. Purging (downward draining) is contraindicated; instead, emesis (inducing vomiting) should be used. However, if there is cold fluid retention above the diaphragm causing dry heaving, emesis is contraindicated; warming methods should be employed, preferably using Sini Tang (Four Reversal Decoction).
[Detailed Commentary] Han Zhihe stated: This originates from a disease of the Shaoyin Kidney. However, the mention of a "string-taut" pulse carries characteristics of the Shaoyang channel. The term "excess in the chest" relates to the Yangming area. Since excess implies retained food stagnation, treatment cannot solely follow Shaoyin warming methods nor Yangming purging methods, but rather should utilize emesis.
Zhu Gong stated: For patients who have undergone sweating or purging therapies, presenting with a slow Guan pulse and vomiting due to deficiency-cold in the stomach, Ganjiang Huangqin Huanglian Renshen Tang (Ginger, Coptis, Pinellia, and Ginseng Decoction) is indicated. For those with excessive cold, no desire for water, and vomiting, Lizhong Tang (Regulate the Middle Decoction) with Bai Zhu removed and Sheng Jiang added is suitable. For cases with vomiting, diarrhea, cold extremities, and severe restlessness, Wuzhuyu Tang (Evodia Decoction) is used. For post-Shanghan recovery presenting with emaciation, shortness of breath, and rebellious Qi causing a desire to vomit, Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) is appropriate.
[General Principle] Zhang Zhongjing said: In Yangming Wind-Strike, the pulse is string-taut, floating, and large, accompanied by shortness of breath, abdominal fullness, pain in the hypochondrium and heart region, obstruction of Qi upon prolonged pressure, dry nose without sweat, lethargy, jaundice affecting the whole body and face, difficulty in urination, tidal fever, frequent hiccups, and swelling around the ears. After acupuncture provides slight relief, if the exterior syndrome remains unresolved and the disease persists beyond ten days, with a string-taut and floating pulse, Xiaochaihu Tang (Minor Bupleurum Decoction) should be given. If the pulse is merely floating without other symptoms, Mahuang Tang (Ephedra Decoction) is indicated. If there is anuria, abdominal fullness, and hiccups, the condition is incurable.
[Detailed Commentary] Zhu Gong stated: Coughing reversal (Ke Ni) in Shanghan is a very ominous symptom, yet it is not recorded in Zhang Zhongjing's classic. Sun Simiao noted that searching through medical texts reveals no such name. Investigating its manifestation, "Ke Ni" refers to Hui Ni (hiccups/rebellious Qi); essentially, ancients referred to hiccups as Ke Ni. The character "Luo" (referring to dry heaving in context) corresponds to modern "dry heaving." The *Qingbi Zhongzang Jing* treats Shanghan Ke Ni with Dingxiang San (Clove Powder): Clove and Persimmon Calyx each 1 fen, Licorice and Galangal each 0.5 qian, brewed in boiling water as one dose, taken hot while drinking vigorously, which is highly effective.
The *San Yin Fang* includes Zhuru Tang and Dingxiang San. Zhuru Tang treats Yang syndromes. The *Ben Shi Fang* treats post-Shanghan Ke Ni with Doukou Tang for Yin syndromes, using herbs like Clove, Fennel, and Nutmeg. These are contraindicated for Yang syndromes. Generally, Ke Ni often follows fever and consumption of cold/raw foods or cooling medicines, caused by mutual agitation of Yin and Yang Qi.
Cheng Wuji stated: Yi (belching) involves Qi stagnation in the chest and throat without sound. Hui (hiccups) produces audible sounds. Both are gastric disorders differing only in severity. Yi results from the struggle between deficiency-cold and water intake after profuse sweating; it indicates weak Stomach Qi. Hui occurs after severe Shanghan purging/vomiting leading to extreme weakness, followed by sweating and re-administration of water to induce sweat, causing external Qi oppression and subsequent hiccups. Thus, both are gastric issues. Yi due to water-cold struggle may use Xiao Qinglong Tang minus Mahuang plus Fuzi. Hui due to heat stagnation requires different approaches: mild cases use harmonization (e.g., Xiaochaihu Tang for tidal fever and hiccups); severe cases with abdominal fullness require purging based on urinary or fecal obstruction. This indicates critical illness, unlike mild thirst or irritability.
Shen Jin'ao commented: Frequent hiccups indicate internal unresolved pathology. Abdominal fullness with hiccups is more severe than frequent hiccups alone.
[General Principle] Zhang Zhongjing said: In Yangming disease, if the patient cannot eat, attacking the heat will inevitably cause hiccups. This is because of deficiency-cold in the Stomach. Due to the person's inherent deficiency, attacking heat leads to hiccups.
If the Stomach is deficiency-cold and unable to eat, drinking water will inevitably cause hiccups.
[Detailed Commentary] Cheng Wuji stated: From this, we know hiccups are a gastric disorder. Generally, improper purging leads to Stomach deficiency and rebellious Qi, causing hiccups.
Wei Litong stated: When Yangming disease progresses to inability to eat, even if there are false-heat signs like sweaty extremities, one must not mistake it for Stomach excess-heat and purge it. Doing so would cause further collapse of Stomach Yang and intensify Cold Evil, leading to hiccups and exhaustion of Grain Qi. Zhang Zhongjing clarifies this is due to Stomach deficiency-cold, not excess-heat. The ability to eat or not helps distinguish Stomach cold from heat. Furthermore, the ability to drink water distinguishes true deficiency-cold (where drinking causes hiccups) from other conditions. One should not use cold/purgative agents here. Even with exterior symptoms, treat the interior; despite false-heat signs, treat true cold, not false heat. This requires careful differentiation.
[General Principle] Zhang Zhongjing said: After severe Shanghan vomiting and purging, leading to extreme weakness, followed by profuse sweating, if the patient has external Qi oppression and is given water to induce sweat, hiccups result. This is due to deficiency-cold in the Stomach.
[Detailed Commentary] Cheng Wuji stated: Stomach deficiency combined with water intake leads to deficiency-cold struggle, causing hiccups. Indications include Wuzhuyu Tang, Lizhong Tang, Ju Pi Gan Jiang Tang, Ban Xia Sheng Jiang Tang, and Qiang Huo Fu Zi Tang (from *Huoren Shu*).
Tao Hua stated: Hui is severe dry heaving, characterized by loud, foul, prolonged sounds without expulsion. It is difficult to treat as it stems from original Stomach Qi deficiency, excessive sweating/purging, or water-cold struggle causing rebellious Qi. Alternatively, heat stagnation blocking upper and lower Qi flow can cause hiccups. Mild cases require harmonization and疏导 (unblocking); severe cases require warming and dispersing. Anuria, abdominal fullness with hiccups, or scattered pulses with coughing-reversal are incurable even for divine physicians.
[General Principle] Zhang Zhongjing said: In Shanghan, if hiccups are accompanied by abdominal fullness, examine the anterior (urinary) and posterior (fecal) orifices. Identify which is obstructed and unblock it to cure.
[Detailed Commentary] Wang Kentang stated: Zhang Zhongjing provided no formula. *Huoren Shu* suggests Zhuling Tang for anterior obstruction (urinary) and Tiaowei Chengqi Tang for posterior obstruction (fecal).
Shen Jin'ao commented: The previous clauses attribute hiccups to Stomach cold. This clause attributes them to Stomach heat.