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Vomiting (Ou) refers to retching with sound but no matter expelled; spitting (Tu) refers to the expulsion of food. Vomiting can be caused by either cold or heat, whereas spitting is generally due to stomach cold. When vomiting is accompanied by fever, irritability, and oppression, it is caused by pathogenic heat.

When vomiting is accompanied by acid regurgitation, a sensation of cold in the throat, and excessive salivation, it is caused by pathogenic cold. Generally, when exterior pathogens in Shanghan (Cold Damage) are about to transmit inward, the reversal of interior Qi leads to vomiting. Therefore, pathogens located at the half-exterior half-interior level often present with vomiting; if the pathogen remains entirely in the exterior, this symptom does not occur. For pathogens at the half-exterior half-interior level, harmonization and dispersal are indicated; for reversed Qi, descending is indicated; for phlegm, resolving phlegm is indicated; for heat, clearing heat is indicated; for cold, warming is indicated. The *Qianjin Fang* states: "Patients with vomiting should take fresh ginger frequently; this is the sacred medicine for vomiting." However, even if a patient with vomiting presents with Yangming syndrome patterns, purgation must not be used. This is because the Qi is reversed upward and the pathogen has not yet entered the fu organs, so it is fundamentally not a stomach excess pattern. Attacking the lower body when Qi is reversed upward will cause deficiency in the lower jiao, allowing the reversed Qi to exploit this weakness, leading to severe danger. If the pulse is faint and weak, the situation is even more critical.

After the transmission through the three yang meridians in Shanghan is complete, the three yin meridians should be affected. If the patient can eat and does not vomit, it indicates that the pathogen has not entered the yin level. Thus, we know that vomiting results from the pathogen transmitting to the interior. Observing the treatment principles of Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction), it states: "No vomiting and no thirst indicate no heat in the interior." Observing the treatment principles of Shizao Tang (Ten Jujube Decoction), it states: "Dry retching, shortness of breath, sweating, and absence of aversion to cold indicate that the exterior is resolved but the interior is disharmonious." From these, we can deduce that vomiting generally indicates an interior pattern; only when accompanied by irritability and thirst does it indicate internal heat.

Zhang Zhongjing's *Shanghan Lun* states: "Those who wish to vomit after eating belong to the Yangming stage, treated with Wuzhuyu Tang (Evodia Decoction). If symptoms worsen after taking the decoction, the pathology belongs to the upper jiao." It also states: "In Shaoyin disease, characterized by vomiting and diarrhea, cold limbs, and extreme irritability, Wuzhuyu Tang (Evodia Decoction) is indicated."

The *Shanghan Lun* states: "If a patient has a rapid pulse, which indicates heat, they should digest food well and desire drinking water. If they instead vomit, it is because excessive sweating has depleted Yang Qi, causing Qi deficiency in the diaphragm, resulting in a rapid pulse. This rapid pulse represents 'guest heat' (false heat), which cannot digest food; vomiting occurs because of cold deficiency in the stomach." Li Dongyuan stated: "Pathogenic heat fails to transform grain; thus, when pathogenic heat resides in the stomach, appetite is lost."

The *Shanghan Lun* states: "In Yangming disease, if the patient cannot eat, attacking the heat will inevitably lead to hiccups (Yue). This is because of cold deficiency in the stomach. Since the person is inherently deficient, attacking the heat will cause hiccups. If cold deficiency in the stomach prevents eating, drinking water will also induce hiccups. If there is cold-fluid retention above the diaphragm causing dry retching, emesis should not be induced; urgent warming is required, suitable for Sini Tang (Four Reversal Decoction)."

The *Shanghan Lun* states: "In Shanghan, if hiccups occur with abdominal fullness, examine the anterior and posterior orifices to determine which is obstructed; unblocking the obstruction will cure the condition." Various methods for treating hiccups are detailed in the chapter on Hiccups (E Ni).