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I once read Cheng Wuji's *Shanghan Mingli Lun* (Clarification of Principles in Cold Damage). It stated: "Ou (vomiting with sound) is characterized by the presence of sound." This is colloquially referred to as "Yue" (hiccups/choking sound). "Tu" (spitting/vomiting out contents) refers to expelling material from the stomach. Therefore, there is "Gan Ou" (dry heaving), but no "Gan Tu" (dry spitting). Consequently, regarding "Ou", Zhang Zhongjing said, "food intake leads to a desire to vomit"; regarding "Tu", he said, "diet enters the mouth and is immediately vomited." Thus, it can be known that there is a distinction in severity between Ou and Tu. He further stated: "Yue is colloquially called 'Ke Ni' (coughing against)." I harbored private doubts about this. Therefore, I consulted Zhang Zhongjing's *Shanghan Lun* (Treatise on Cold Damage) to verify its correctness and correct his assertions.

In the *Shanghan Lun*, mentions of "Ou," "Tu," "Gan Ou," and "Yue" are numerous, whereas mentions of "Ke Ni" appear only twice. By categorizing and observing these passages together: "Ou" corresponds to Li Dongyuan's description of sound and matter emerging simultaneously. "Tu" corresponds to Li Dongyuan's description of matter emerging without sound. As for "Gan Ou" and "Yue," both involve the emergence of sound without matter. Li Dongyuan subsumed both under "Yue" and did not discuss "Gan Ou" separately. So, what exactly distinguishes "Gan Ou" from "Yue"? It is merely a difference in degree—mild versus severe. Hence, when Zhang Zhongjing discusses "Gan Ou," he uses plain and ordinary language; however, when discussing "Yue," he states: "In Taiyang Wind Strike, after fire therapy induces sweating, prolonged duration leads to delirium; in severe cases, it progresses to Yue." He also says: "In Yangming Wind Strike, if there is no bowel movement, abdominal fullness increases, and Yue occurs, it is incurable." Furthermore: "After massive vomiting or purging leading to extreme deficiency, followed by extreme sweating, Yue results." Although some descriptions seem plain, they differ significantly from those describing "Gan Ou."

I further pondered: Li Dongyuan regarded "Gan Ou" and "Yue" as one entity, while Zhang Zhongjing regarded them as two. Viewing them as one, indeed, both involve the solitary emission of sound. However, viewing them as two, "Gan Ou" is the mild form of "Yue," and "Yue" is the severe form of "Gan Ou." The sound of "Gan Ou" is light, small, and short; the sound of "Yue" is heavy, loud, and long. Although long sounds have degrees of severity, they essentially constitute a single syndrome. Now, Cheng Wuji conflates "Ou" (defined as having sound) with "Gan Ou," failing to distinguish them. He also equates "Yue" with "Ke Ni." Such views I cannot accept.

Zhang Zhongjing named the simultaneous emergence of sound and matter "Ou," the solitary emergence of matter "Tu," and the solitary emergence of sound "Gan Ou." Precisely because "Ou" involves both sound and matter, the case where only sound rings out without matter is termed "Gan" (Dry/Empty); "Gan" implies emptiness. Regarding "Tu," there must be matter; how could it be termed "Gan"? Zhang Zhongjing added the character "Gan" to "Ou" specifically to distinguish the sound-and-matter-emerging "Ou" from others. Cheng Wuji, however, claimed "Ou" possesses only sound, equating it with "Gan Ou." Does this not deviate from Zhang Zhongjing's original intent?

Zhang Zhongjing stated: "For patients with vomiting due to abscess pus, do not treat the vomiting directly; once the pus is exhausted, the condition will resolve itself." If it is described as "vomiting out the pus," how can "Ou" be defined as possessing only sound? Similarly, phrases like "vomiting upon taking medicine," "vomiting upon eating," "vomiting food," and "those craving water must vomit" cannot support the definition of "Ou" as sound-only. Additionally, in the Shaoyin disease section concerning the use of Tongmai Sini Tang, the symptom description includes "Gan Ou," yet the modification instructions later state, "If there is Ou, add Sheng Jiang (Fresh Ginger)." If Zhang Zhongjing truly believed "Ou" meant only sound, he would not have established the term "Gan Ou." The fact that he used both "Ou" and "Gan Ou" clearly demonstrates their distinct meanings.

Moreover, Zhang Zhongjing spoke of "Yu Ou" (desire to vomit) and "Yu Tu" (desire to spit), but never "Yu Gan Ou" or "Yu Yue." The term "Yu" implies a premonition of something about to emerge but not yet emerged. Only tangible objects can be anticipated before emergence; intangible sounds cannot. Tangible objects emerging from the chest and diaphragm can be foreseen even before exiting. Intangible sounds cannot be predicted; one can only know them after they have occurred. "Ou" and "Tu" refer to tangible matter, hence they can be described as "Yu." "Gan Ou" and "Yue" refer to intangible sound, hence they cannot be described as "Yu." Cheng Wuji cited "food intake leads to desire to vomit" and "diet enters mouth and is immediately vomited" to argue for differences in severity between Ou and Tu, implying that "Yu" denotes mildness and "Ji" (immediately) denotes severity. How does he know that the usage of "Yu" versus non-"Yu" was intended to distinguish between tangible and intangible, rather than severity? If his theory were correct, then phrases like "vomiting upon taking medicine," "vomiting upon eating," "warmth in the heart with desire to vomit," and "qi rebellion with desire to vomit"—all found in Zhang Zhongjing's work—would contradict his interpretation. He also cited the colloquial term "Yue" to prove points about "Ou." In fact, "Yue" and "Chi Te" (hiccup/chattering teeth) share identical pronunciation and meaning despite different characters. Using this to prove definitions of "Ou" is tenuous.

Although comparing "Ou" and "Tu," "Tu" is milder than "Ou"; and comparing "Tu" and "Gan Ou," "Gan Ou" is milder than "Tu," each of these three has varying degrees of severity and should not be rigidly fixed. However, comparing "Ou/Tu," "Gan Ou," and "Yue," the severity of "Yue" is certainly incomparable to the other three. Thus, *Tai Su* states: "When wood is decayed, its leaves fall; when disease is deep, the voice becomes Yue." Although "Yue" can range from mild/treatable to severe/incurable, once the disease reaches the stage of "Yue," treatment becomes fundamentally difficult.

Furthermore, "Ke Ni" is colloquially called "Chi Ni" or "Chi Te." However, the term "Ke Ni" appears only in the first chapter of *Shanghan Lun*, "Bian Mai Ping Mai Fa" (Differentiation of Pulse Methods). It is absent from the Six Channels Disease chapters and the chapters on sweating and purging appropriateness. Those chapters contain only "Yue." Later scholars, noting the absence of "Ke Ni" in the Six Chapters and the presence of "Yue," concluded that "Yue" is synonymous with "Ke Ni," calling "Ke Ni" the name for "Yue Ni." Alas, Sun Simiao initiated this view, and Zhu Fengyi and Cheng Wuji echoed it, thereby confusing the terminology of "Yue" and "Ke Ni."

*Jingui Yaolue* states: "The patient feels as if panting but not panting, as if vomiting but not vomiting, as if hiccuping but not hiccuping, feeling thoroughly distressed and helpless in the heart; Sheng Jiang Ban Xia Tang governs this." "For Gan Ou or Yue accompanied by cold extremities, Ju Pi Tang governs this." "For Yue Ni, Ju Pi Zhu Ru Tang governs this." From this, it is evident that Zhang Zhongjing's "Yue Ni" refers only to conditions similar to "Gan Ou," never referring to "Ke Ni." "Ke Ni" and "Yue Ni" are distinct. "Ke Ni" describes a sound that starts and stops abruptly; although it may repeat dozens of times, it is short and abrupt, resembling the "ke" of coughing, hence "Ke Ni." "Yue Ni" describes a sensation of wanting to vomit matter but producing nothing, characterized by a turbid, harsh, long, and forceful sound that continues until qi is exhausted, unlike the mild nature of "Gan Ou," hence "Yue Ni." Both arise from rebellious qi ascending, hence both use the character "Ni" (Rebellion). Sun Simiao erroneously equated "Yue Ni" with "Ke Ni." Why? When discussing cold damage, although he interpreted "Ke Ni" and "Ke Ni Shang Qi" in *Bian Mai Ping Mai Fa* as "Chi Te," how can we be sure it wasn't a disease of coughing with rebellious qi? Therefore, I dare not definitively classify it as "Chi Te."

*Jingui Yaolue* states: "Disease of Ke Ni, cunkou pulse is faint and rapid; this is Lung Abscess." "Ke Ni Shang Qi, frequent expectoration of turbid phlegm, ability only to sit, inability to sleep; Zao Jiao Wan governs this." "Ke Er Shang Qi, water-chicken sound in the throat; She Gan Ma Huang Tang governs this." These three cases all describe diseases of coughing with rebellious qi. How can "Ke Ni" be exclusively defined as "Chi Te"? Contemporary Shanghan practitioners acknowledge "Chi Te" exists, yet it is missing from the Six Channels and Sweating/Purging chapters of *Shanghan Lun*; it must have been lost during transmission. Although "Chi Te" is not mentioned in those specific chapters, one absolutely cannot equate "Yue" with the "Ke Ni" of "Chi Te," nor equate "Yue" with the "Ke Ni" of coughing with rebellious qi.

One might ask: "You argue that the 'Yue Ni' in *Jingui Yaolue* is not the 'Chi Te' disease, yet why did later practitioners cure 'Chi Te' using Ju Pi Zhu Ru Tang?" I reply: "Ju Pi Zhu Ru Tang is a pungent-sweet formula with dispersing, relaxing, harmonizing, and tonifying properties. Although 'Yue Ni' and 'Chi Te' are different diseases, both are caused by the stagnation and disturbance of pathogenic and righteous qi. Therefore, the formula cures both. While 'Yue Ni' and 'Chi Te' can be treated with the same medication, they cannot be viewed as the exact same pathological entity."