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In the context of Cold Damage (Shanghan) disease, how should one elucidate the manifestation of hiccups (Yue)? Hiccups are commonly referred to as "ke ni" (coughing against the reverse). Qi-ni (a sensation of qi obstruction in the throat, pronounced like 'ye') is similar to hiccups. Qi-ni involves only a sensation of qi stagnation and blockage between the chest and throat, preventing downward flow, yet it produces no sound. In contrast, hiccups are characterized by audible "chi chi" sounds. Hiccups correspond to the Metal element in Five Elements theory; they arise because the Stomach is afflicted by disease. Both hiccups and Qi-ni are disorders of the Stomach, differing only in severity.

If deficiency-cold pathogens contend with each other, and water is administered to induce profuse sweating, the cold water will contend with the pathogenic cold. The patient will then develop Qi-ni, indicating that Stomach qi is deficient and exhausted. Following severe vomiting or purgation in Cold Damage disease, if the patient is extremely deficient and experiences profuse sweating, with external qi being constrained and depressed, administering water to induce further sweating may result in hiccups. This occurs because of coldness within the Stomach. Furthermore, if the Stomach is deficient and cold, unable to accept food, drinking water can trigger hiccups. From these observations, it is evident that both hiccups and Qi-ni are Stomach disorders.

The Classics state: If the foot-yang pulse (Duyang pulse) is floating, it indicates Qi-ni (qi obstruction); if the pulse is slippery, it indicates hiccups. These outcomes are due to medical error, specifically the mistake of treating a deficiency pattern as an excess pattern. Generally, after improper purgation, Stomach qi becomes deficient and rebels upward, leading to hiccups. The Classics also state: In patients with dampness, premature purgation leads to hiccups; attacking heat in a constitutionally deficient patient leads to hiccups; in Yangming disease, if the patient cannot eat and heat is attacked, hiccups will inevitably occur. All such cases result from hiccups caused by Stomach deficiency following purgation.

However, Qi-ni is caused by the contention of cold water and cold pathogens, and can be treated with Xiao Qing Long Tang (Minor Blue Dragon Decoction) with Mahuang removed and Fuzi added. Conversely, hiccups are formed by the congestion and depression of heat, preventing the free flow of qi. Mild cases have indications for harmonizing methods, while severe cases have indications for purging methods. The Classics state: If there is tidal fever accompanied by intermittent hiccups, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is indicated, representing a harmonizing method. If hiccups are accompanied by abdominal fullness, one must examine the anterior and posterior orifices to determine which is obstructed; relieving the obstruction cures the condition, representing a purging method.

When Cold Damage disease progresses to hiccups, the illness has reached its extremity. It is not like mild symptoms such as thirst or irritability. For instance, in Taiyang wind-strike, if fire therapy is used to force sweating, yin and yang become both deficient and exhausted, the body becomes dry and withered, sweat appears only on the head stopping at the neck, there is abdominal fullness and slight panting, dry mouth and rotting throat, or constipation. Over time, delirium may occur, and in severe cases, hiccups appear, indicating the extremity of the disease. If urination ceases, abdominal fullness increases, and hiccups appear, it is untreatable, signifying the exhaustion of true qi. In such cases, even a divine physician would find it impossible to manage this critical state of collapse.