尝读成无己伤寒明理论。有曰。呕者。有声者也。俗谓之 。吐者。吐出其物也。故有干呕
。而无干吐。是以于呕。则曰食谷欲呕。及吐。则曰饮食入口即吐。则呕吐之有轻重可知矣
。又曰。哕者。俗谓之咳逆是也。余窃疑之。于是即仲景伤寒论。以考其是非。以订其说。
夫伤寒论曰。呕。曰吐。曰干呕。曰哕者至多。曰咳逆者。则二而止也。因类聚而观之。夫
呕者。东垣所谓声物兼出者也。吐者。东垣所谓物出而无声者也。至若干呕与哕。皆声出而
无物也。东垣但以哕该之。而无干呕之论。夫干呕与哕。其所异者。果何在哉。微甚而已矣
。故仲景于干呕。则皆平易言之。于哕。则曰。太阳中风。火劫。发汗后。久则谵语。甚者
至哕。又曰。阳明中风。若不屎。腹满加哕者。不治。又曰。大吐。大下之极虚。复极汗出
者
。因得哕。虽亦间有似平易言者。然比之言干呕。则径庭矣。窃又思之。干呕与哕。东垣视
为一。仲景视为二。由为一而观之。固皆声之独出者也。由为二而观之。则干呕乃哕之微
。哕乃干呕之甚。干呕者。其声轻小而短。哕者。其声重大而长。长者虽有微甚之分。盖
一证也。今成氏乃以呕为有声。与干呕混而无别。又以哕为咳逆。若此者。余未之能从也。
夫仲景以声物兼出而名为呕。以物独出而名为吐。以声独出而名为干呕。惟其呕兼声物。故
无物而声空鸣者。乃谓之干。干犹空也。至于吐。则是必有物矣。其可谓之干乎。仲景于呕
字上加一干字。所以别夫呕为声物兼出者耳。成氏乃以呕为独有声。而同乎干呕。得不有失
仲景措辞之本意欤。仲景曰。呕家有痈脓者。不可治呕。尽脓自愈。夫谓之呕尽脓。其可以
呕为独有声乎。至于曰得汤则呕。得食而呕。饮食呕。贪水者必呕之类。亦不可以呕为独有
声矣。又少阴病。下利。用通脉四逆汤一条。其所叙诸证。既有干呕之文。何下文加减法中
。
又曰。呕者加生姜乎。设仲景果以呕为独有声。则不当又立干呕之名矣。观其既曰呕。又曰
干
呕。则其义之殊别也。讵不着明也哉。且仲景尝言欲呕矣。又言欲吐矣。未尝言欲干呕。欲
哕也。夫欲之为义。将出未出。而预有所觉之辞也。夫将出未出。而预觉者。惟有形之物则
然。无形之声。则不然也。有形之物。将出乎胸膈之间。则虽未出。而亦可以前知。若无形之
声。则不能前知。其将出。必待夫既出。而后可知也。呕与吐。主有形之物言。故可谓之欲
。干呕与哕。主无形之声言。故不可谓之欲。成氏引食谷欲呕。饮食入口即吐二句。而谓呕
吐有轻重。其意盖以呕言欲。而为轻。吐言即。而为重。安知言欲不言欲者。本为有形无形
设。不为轻重置也。果如其说。则得汤则呕。得食而呕。心中温温欲吐。气逆欲吐之语。不
出于仲景乎。又引俗谓之 一句以证呕。夫 与哕。盖字异而音义俱同者也。以之证呕亦疏
矣
。虽然。以呕与吐较之。吐轻于呕。以吐与干呕较之。干呕轻于吐。然三者亦各自有轻重。
不可定拘也。但以呕吐干呕与哕而较。则哕之为重。必非三者之比矣。故太素曰。木陈者。
其叶落。病深者。其声哕。夫哕虽亦有轻而可治。重而不可治者。然病至于哕。则其治也。
终不易矣。且夫咳逆。俗以吃逆与吃忒呼之。然咳逆二字。仅见伤寒论首。辨脉平脉法中。
其
六经病篇。及汗下可否诸篇。皆无所有。其所有者哕也。后人因见六经病篇。及汗下可否诸
篇。但有哕而无咳逆。遂谓哕即咳逆。而曰咳逆者。哕逆之名。吁。斯言也。孙真人倡于前
。朱奉议成无己和于后。由是哕与咳逆之名义紊矣。金匮要略曰。病患胸中似喘不喘。似
呕不呕。似哕不哕。彻心中。愦愦然。无奈者。生姜半夏汤主之。干呕哕。若手足厥者。橘
皮
汤主之。哕逆者。橘皮竹茹汤主之。观此则仲景所谓哕逆但指与干呕同类者言。何尝指咳
逆言乎。咳逆哕逆不同。咳逆言其声之才发而遽止。虽发止相续有至数十声者。然而短促不
长。有若咳嗽之咳然。故曰咳逆。哕逆则言其似欲呕物以出。而无所出。但声之浊恶长而有
力。直至气尽而后止。非如干呕之轻而不甚。故曰哕逆。二者皆由气之逆上而作。故俱以逆
言之。孙真人乃以哕逆当咳逆。何邪。彼言伤寒者。虽以辨脉平脉法之咳逆。与咳逆上气。
视为吃忒。然安知其不为咳而气逆之病乎。故今不敢定其必为吃忒也。金匮要略曰。病咳逆
。寸口脉微而数。此为肺痈。咳逆上气。时时唾浊。但坐。不得眠。皂荚丸主之。咳而上气
。喉中水鸡声。射干麻黄汤主之。此三条者。皆是咳而气逆之病。岂可以咳逆。专为吃忒哉
。今伤寒家本有吃忒。而论中六经病篇。及汗下可否诸篇。却无者。必亡逸于散落之余耳。
虽吃忒为六经病篇。及汗下可否诸篇所不言。决不可以哕。为吃忒之咳逆。亦不可以哕。为
咳而气逆之咳逆也。或曰。吾子以要略所谓哕逆。非吃忒病。何后人治吃忒者。用橘皮竹茹
汤而愈乎。余曰。橘皮竹茹汤辛甘之剂也。有散。有缓。有和。有补。其哕逆吃忒病虽不同
。而为邪正之气怫郁扰乱所致则一。故用焉而皆愈。虽然哕逆吃忒。以一药同治。则可，以
一体同视。则不可。
我曾阅读成无己的《伤寒明理论》，其中说道：“呕，是有声音的。”俗称为“哕”。“吐”，是吐出胃中内容物。所以有“干呕”，而没有“干吐”。因此，对于呕，仲景说“食谷欲呕”；对于吐，仲景说“饮食入口即吐”。由此可见，呕吐二者有轻重之分。他又说：“哕，俗称咳逆。”我对此暗自怀疑。于是我便依据张仲景的《伤寒论》来考证其是非，以订正他的说法。
《伤寒论》中提到“呕”、“吐”、“干呕”、“哕”的情况非常多，而提到“咳逆”的只有两处罢了。我将这些条文分类聚集起来观察。所谓“呕”，是东垣所说的声与物同时出来的情况。“吐”，是东垣所说的只有物出来而没有声音的情况。至于“干呕”和“哕”，都是只有声音出来而没有东西吐出。李东垣只用“哕”来概括这两种情况，而没有单独论述“干呕”。那么，“干呕”和“哕”的区别究竟在哪里呢？不过是程度轻微与严重而已。所以张仲景在提到“干呕”时，用语都很平常平易；而在提到“哕”时，则说：“太阳中风，用火劫发汗后，时间久了会出现谵语，严重的甚至出现哕。”又说：“阳明中风，如果不排便，腹部胀满且出现哕的，属于不治之症。”还说：“大吐、大下之后导致极度虚弱，又极度出汗的，因而导致哕。”虽然也有看似平常的描述，但比起描述“干呕”来，差别就大了。
我又进一步思考：李东垣将“干呕”与“哕”视为一种，而张仲景将其视为两种。从视为一种的角度看，固然是都只有声音独自发出；但从视为两种的角度看，则“干呕”是“哕”的轻症，“哕”是“干呕”的重症。“干呕”的声音轻小且短促，“哕”的声音沉重且长。虽然长声也有轻重之分，但本质上是一个证候。现在成无己却把“呕”解释为只有声音，从而与“干呕”混淆而无区别；又把“哕”解释为“咳逆”。像这样的观点，我不能遵从。
张仲景将声与物同时出来命名为“呕”，将只有物出来命名为“吐”，将只有声音出来命名为“干呕”。正因为“呕”兼有声和物，所以没有东西只有声音空鸣的，才称之为“干”，“干”就是空的意思。至于“吐”，那必定是有物的，怎么能称之为“干”呢？张仲景在“呕”字上加一个“干”字，正是为了区分那种声物同时出的“呕”。成无己却认为“呕”只有声音，而与“干呕”相同，这难道不是违背了张仲景用词的本意吗？
张仲景说：“患有痈脓的呕吐者，不可治疗呕吐，待脓排尽自然痊愈。”既然说是“呕尽脓”，怎么能说“呕”只有声音呢？至于说“得汤则呕”、“得食而呕”、“饮食呕”、“贪水者必呕”等语句，也不能说“呕”只有声音。另外，《伤寒论》少阴病篇下利用通脉四逆汤的一条条文中，叙述的症状里既有“干呕”的文字，为什么在下文的加减法中又说“呕者加生姜”呢？如果张仲景果真认为“呕”只有声音，就不应当再设立“干呕”的名称了。看他既说“呕”，又说“干呕”，其中的意义区别，难道不明显吗？
况且张仲景曾说要“欲呕”，也曾说要“欲吐”，从未说过要“欲干呕”或“欲哕”。“欲”这个字的含义，是指将要出来但尚未出来，预先有所感觉的词句。将要出来但尚未出来而能预先察觉的，只有有形的物体才会这样，无形的声音则不然。有形的物体，将从胸膈之间出来，即使未出，也可以预先知道。若是无形的声音，则不能预先知道，必须等到它已经发出了，才可以知道。“呕”与“吐”是针对有形之物而言的，所以可以称之为“欲”；“干呕”与“哕”是针对无形之声而言的，所以不能称之为“欲”。成无己引用“食谷欲呕”、“饮食入口即吐”两句，来说明呕吐有轻重之分，他的意思大概是认为说“欲”的“呕”较轻，说“即”的“吐”较重。怎么知道说“欲”不说“欲”（指哕），原本是为了区分有形和无形，而不是为了区分轻重呢？果然像他所说的那样，那么“得汤则呕”、“得食而呕”、“心中温温欲吐”、“气逆欲吐”这些话语，不都是出自张仲景吗？他又引用俗语称“哕”一句来证明“呕”。其实“哕”与“吃忒”（呃逆），只是字形不同，音义却是相同的。用这个来证明“呕”，也很牵强。
虽然如此，拿“呕”与“吐”比较，“吐”比“呕”轻；拿“吐”与“干呕”比较，“干呕”比“吐”轻。但这三者各自也有轻重，不可拘泥固定。但如果将“呕吐”、“干呕”与“哕”进行比较，那么“哕”的严重程度，肯定不是前三者能比的。所以《太素》说：“树木枯朽，叶子就会掉落；病情深重，声音就会变成哕。”虽然“哕”也有轻而可治、重而难治的区别，但病发展到出现“哕”的程度，治疗终究不容易。
况且“咳逆”，俗称为“吃逆”或“吃忒”。然而“咳逆”二字，仅在《伤寒论》首篇《辨脉平脉法》中出现。在六经病篇及汗下可否诸篇中，都没有这个词。那些篇章中有的只是“哕”。后人因为看到六经病篇及汗下可否诸篇中，只有“哕”而没有“咳逆”，于是就说“哕”就是“咳逆”，并说“咳逆”是“哕逆”的名字。唉，这种说法，孙思邈在前面倡导，朱奉议和成无己在后面附和，从此“哕”与“咳逆”的名义就混乱了。
《金匮要略》说：“病人胸中似喘不喘，似呕不呕，似哕不哕，彻心中愦愦然无奈，生姜半夏汤主之。”“干呕哕，若手足厥者，橘皮汤主之。”“哕逆者，橘皮竹茹汤主之。”看这里，张仲景所说的“哕逆”只是指与“干呕”同类的病症，何曾指“咳逆”呢？“咳逆”与“哕逆”不同。“咳逆”是说声音刚发出就立刻停止，虽然发止相续多达几十声，但是短促不长，好像咳嗽的“咳”一样，所以叫“咳逆”。“哕逆”则是说似乎想要呕吐东西出来，却什么也没出来，只有声音浊恶、长而有力，直到气竭才停止，不像“干呕”那样轻微而不严重，所以叫“哕逆”。这两者都是因为气逆上冲而发作，所以都用“逆”字来称呼。孙思邈却把“哕逆”当作“咳逆”，这是为什么呢？他说伤寒病时，虽然把《辨脉平脉法》中的“咳逆”与“咳逆上气”看作“吃忒”，但怎么知道那不是因咳嗽而导致的气逆病呢？所以我现在不敢断定它一定是“吃忒”。
《金匮要略》说：“病咳逆，寸口脉微而数，此为肺痈。”“咳逆上气，时时唾浊，但坐不得眠，皂荚丸主之。”“咳而上气，喉中水鸡声，射干麻黄汤主之。”这三条，都是咳嗽而气逆的病，怎么能把“咳逆”专门当作“吃忒”呢？现在的伤寒家本就有“吃忒”病，但在《伤寒论》六经病篇及汗下可否诸篇中却没有提到，一定是散佚遗漏了。虽然“吃忒”没有被六经病篇及汗下可否诸篇提及，但也绝不能把“哕”当作“吃忒”的“咳逆”，也不能把“哕”当作咳嗽气逆的“咳逆”。
有人问：“您认为《金匮要略》所说的‘哕逆’不是‘吃忒’病，为什么后人治疗‘吃忒’用橘皮竹茹汤而痊愈了呢？”我说：“橘皮竹茹汤是辛甘的药剂，具有散、缓、和、补的作用。‘哕逆’与‘吃忒’的病虽然不同，但都是由邪正之气怫郁扰乱所致，所以用这个方子都能治愈。虽然‘哕逆’与‘吃忒’可以用同一个药共同治疗，但把它们看作同一种病体，却是不可以的。”
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."