《精要》云，呕逆有二证。一证为初发不曾服内托，散，伏热在心。一证为气虚脾气
不正，其伏热在心者。与内托散三两帖，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。内托散性凉，故有降火之理。若嘉禾散，补力已少，徒温暖以助火耳。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，溃疡后当作阴虚治
之。若年老因疽溃后，呕逆不食者，宜参术膏峻补取效，佐使药随时随证加减。恐用山
药丸，缓急未易得力。河间谓疮疡呕者，湿气侵胃也，药中宜倍加白术。
疮疡作呕，不可泥于毒瓦斯内攻，而概用败毒等药。如热甚 痛，邪气实也，仙方活
命饮解之。作脓 痛，胃气虚也，托里消毒散补之。脓熟胀痛，气血虚也，先用托里散，
后用针以泄之。 痛便秘，热蕴于内也，内疏黄连汤导之。若因寒药伤胃而呕者，托里
健中汤，胃寒少食而呕者，托里益中汤。中虚寒淫而呕者，托里温中汤。肝木乘脾土而
呕者，托里抑青汤。胃脘停痰而呕者，托里消中汤。脾虚自病而呕者，托里益黄汤。郁
结伤脾而呕者，托里越鞠汤。若不详究其源，而妄用攻毒之药，则肿者不能溃，溃者不能
敛矣（薛氏）。丹溪虽云∶肿疡当作毒瓦斯攻心治之，溃疡当作阴虚治之，亦大概之言耳。今之热
毒内攻而呕者寡，脾胃虚寒而呕者多，岂可胶柱而鼓瑟哉？又曰∶欲呕作呕，或外搽内
服寒凉，或痛甚，或感寒邪秽气而呕，皆胃气虚也，托里消毒散，去三味，加藿香，倍
参术。（三味∶连翘、白芷、银花）热盛脉数（《精要》）与漏芦汤，单煮大黄汤等。若不甚热，脉缓弱，
只投五香连翘。多热盛脉数，去死已近，岂汤。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，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？（以上《准绳》。）
疮疡作呕，不问已溃未溃，惟以脉实而数，喜饮冷者，为毒瓦斯内攻，下之。脉弱而
喜温者，为阳气不足，补之。（《大成》）
《外科精要》记载，呕吐逆气有两种证型。一种证型是初发病时未曾服用内托散，导致伏热蕴结在心胸；另一种证型是气虚导致脾气不运化。对于伏热在心者，应给予内托散，连服三帖；对于气虚者，适宜用嘉禾散；若伴有寒热往来症状，适宜用正气散，并兼服山药丸以补肾。朱丹溪说：各种向上冲逆的呕吐、呃逆，都属于火邪。内托散药性凉，所以有降火的作用。至于嘉禾散，其补益之力已经很少，只是徒然通过温暖来助长火势罢了。山药丸补肾以壮旺下焦之阴，大体上还算接近医理。然而治疗呕吐必须分清病程阶段，在肿疡（未溃破的疮疡）时期，应当当作毒瓦斯上攻来治疗；在溃疡（已溃破的疮疡）之后，应当当作阴虚来治疗。如果老年人因疽疮溃破后，出现呕吐逆气、不能进食的情况，适宜用参术膏峻猛补益以求见效，辅助药物随时间和证候变化进行加减。恐怕使用山药丸，在急症中难以迅速见效。刘河间认为疮疡呕吐，是湿气侵犯胃腑所致，用药中应加倍加入白术。
疮疡引起呕吐，不可拘泥于“毒瓦斯内攻”的说法，而一概使用败毒等药物。如热势严重且疼痛，属于邪气实盛，可用仙方活命饮来解毒消散；如成脓期疼痛，属于胃气虚弱，可用托里消毒散来补益；如脓液成熟且胀痛，属于气血虚弱，先用托里散，后用针具刺破排脓；如疼痛伴大便秘结，属于热邪蕴结于内，可用内疏黄连汤导泻通腑。如果是因服用寒凉药物损伤胃气而呕吐，用托里健中汤；胃寒、食欲少而呕吐，用托里益中汤；中焦虚寒湿盛而呕吐，用托里温中汤；肝木乘克脾土而呕吐，用托里抑青汤；胃脘部停聚痰饮而呕吐，用托里消中汤；脾虚自身病变而呕吐，用托里益黄汤；郁结伤脾而呕吐，用托里越鞠汤。如果不详细探究病因根源，而妄用攻毒的药物，那么肿疡就不能溃破，溃破的疮口就不能愈合了（薛己）。丹溪虽然说过：肿疡当作毒瓦斯攻心来治，溃疡当作阴虚来治，但这也只是大概而言。如今热毒内攻导致呕吐的较少，脾胃虚寒导致呕吐的较多，怎么能拘泥固执不知变通呢？又说：想要呕吐或已经呕吐，或者外敷内服寒凉药物，或者疼痛剧烈，或者感受寒邪秽气而呕吐，都是胃气虚弱所致，用托里消毒散，去掉三味药，加入藿香，加倍人参和白术。（这三味药指：连翘、白芷、金银花）。热势旺盛、脉象数疾（《外科精要》），用漏芦汤，单煮大黄汤等。如果热势不很盛，脉象缓弱，只投予五香连翘汤。多热盛脉数，说明死期将近，岂能用汤药救治？丹溪说：热盛脉数，如果在肿疡时期，脏腑秘结而体质壮实的人，还可以用下法。如果在溃疡期脓血流出，还能用下法吗？脉象缓弱，古人都认为是邪毒已散，五香连翘汤中药物飞走升散，那还能用吗？（以上引自《医学入门》/《准绳》）。
疮疡引起呕吐，不问是否已经溃破，只要脉象实而数，喜欢喝冷水的，就是毒瓦斯内攻，用下法治疗；脉象弱而喜欢温暖的，就是阳气不足，用补法治疗。（《外科大成》）
According to *Waike Jingyao* (Essentials of Surgery), there are two patterns for vomiting and regurgitation. One pattern occurs when the disease is in its initial stage and has not yet been treated with *Neituo San* (Internal Support Powder), leading to latent heat accumulating in the heart region. The other pattern arises from Qi deficiency causing dysfunction of the Spleen's transportation. For those with latent heat in the heart, administer *Neituo San* for three doses; for those with Qi deficiency, *Jiahe San* (Harmonizing Grain Powder) is appropriate; if accompanied by alternating chills and fever, *Zhengqi San* (Regulating Qi Powder) is suitable, combined with *Shanyao Wan* (Dioscorea Pill) to tonify the Kidney. Zhu Danxi stated: "All upward rushing and vomiting or hiccups belong to Fire." *Neituo San* is cool in nature, thus possessing the function of descending Fire. As for *Jiahe San*, its tonifying power is minimal, merely providing warmth which may inadvertently assist Fire. *Shanyao Wan* tonifies the Kidney to strengthen the Yin of the Lower Jiao, which is roughly consistent with medical principles. However, treating vomiting requires distinguishing between stages: during the ulcerative stage (swelling without rupture), it should be treated as toxic vapors attacking upward; after the ulceration (rupture), it should be treated as Yin deficiency. If an elderly patient suffers from vomiting, regurgitation, and inability to eat after a carbuncle ruptures, *Shenzhu Gao* (Ginseng and Atractylodes Paste) should be used for vigorous tonification to achieve effect, with adjuvant herbs adjusted according to time and syndrome. It is feared that *Shanyao Wan* would not act quickly enough in urgent cases. Liu Hejian believed that vomiting in sores and ulcers is caused by dampness invading the Stomach, so Bai Zhu (Atractylodis Rhizoma) should be doubled in the prescription.
When sores and ulcers cause vomiting, one must not rigidly adhere to the concept of "toxic vapors attacking inward" and indiscriminately use detoxifying drugs. If heat is severe and painful, indicating excess pathogenic factors, *Xianfang Huoming Yin* (Immortal Formula Preserving Life Decoction) can resolve it. If pain occurs during suppuration, indicating Stomach Qi deficiency, *Tuoli Xiaodu San* (Support Interior and Detoxify Powder) can tonify it. If pus is mature with distending pain, indicating Qi and Blood deficiency, first use *Tuoli San* (Support Interior Powder), then puncture with a needle to drain it. If pain is accompanied by constipation, indicating heat accumulation internally, *Nishu Huanglian Tang* (Draining Internal Coptis Decoction) can guide out the stagnation. If vomiting results from cold-natured drugs injuring the Stomach, use *Tuoli Jianzhong Tang* (Support Interior and Strengthen Middle Decoction); if due to Stomach cold with poor appetite, use *Tuoli Yizhong Tang* (Support Interior and Benefit Middle Decoction); if due to middle Jiao deficiency with cold-damp excess, use *Tuoli Wenzhong Tang* (Support Interior and Warm Middle Decoction); if due to Liver Wood overacting on Spleen Earth, use *Tuoli Yiqing Tang* (Support Interior and Suppress Green Decoction); if due to phlegm retention in the epigastrium, use *Tuili Xiaozhong Tang* (Support Interior and Eliminate Middle Phlegm Decoction); if due to Spleen deficiency itself, use *Tuoli Yihuang Tang* (Support Interior and Benefit Yellow Decoction); if due to constraint injuring the Spleen, use *Tuoli Yueju Tang* (Support Interior and Resolve Depression Decoction). If the root cause is not investigated in detail and toxic-purging drugs are used recklessly, swelling will not suppurate, and open ulcers will not heal (Xue Ji). Although Danxi stated that ulcers should be treated as toxic vapors attacking the Heart, and post-ulceration as Yin deficiency, this is only a general statement. Nowadays, vomiting due to internal attack of heat-toxin is rare, while vomiting due to Spleen and Stomach deficiency-cold is common; how can one stick rigidly to old theories? Furthermore, he said: Vomiting triggered by desire, or caused by external application/internal administration of cold-cooling drugs, or severe pain, or exposure to cold pathogens and foul odors, all indicate Stomach Qi deficiency. Use *Tuoli Xiaodu San*, removing three herbs, adding Huoxiang (Agastache Herba), and doubling Renshen (Ginseng Radix et Rhizoma) and Baizhu (Atractylodis Rhizoma). (The three removed herbs are: Lianqiao (Forsythiae Fructum), Baizhi (Angelicae Dahuricae Radix), and Yinhua (Lonicerae Japonicae Flos)). For excessive heat and rapid pulse (*Waike Jingyao*), use *Loulu Tang* (Euphorbiae Humifusae Decoction) or decoct Dahuang (Rhei Radix et Rhizoma) alone. If heat is not severe and the pulse is slow and weak, only administer *Wuxiang Lianqiao* (Five-Aromatic Forsythia formula). Excessive heat with rapid pulse indicates imminent death; how can decoctions help? Danxi said: With excessive heat and rapid pulse, if it is during the swelling stage and the viscera are constipated with a strong constitution, purgation may still be applicable. But if pus and blood have flowed during the ulcer stage, can purgation still be used? A slow and weak pulse was considered by ancients as dispersion of evil toxins; since *Wuxiang* formulas contain aromatic and ascending-dispersing herbs, can they still be used? (Above quoted from *Zhunsheng*).
For vomiting caused by sores and ulcers, regardless of whether they have ruptured or not, if the pulse is excess and rapid, and the patient prefers cold drinks, it is toxic vapors attacking inward, and purgation should be used. If the pulse is weak and the patient prefers warmth, it is insufficiency of Yang Qi, and tonification should be used (*Waike Dacheng*).