膈症之病形何如。曰。膈之为病。一阳明尽之矣。丹溪以噎膈反胃之病。谓得之六淫七情。
遂有火热炎上之化。多升少降。津液不布。血液衰耗。胃脘干枯。其槁在上。近咽之下。水饮可
行。食物难入。入亦不多。名之曰噎。其槁在下。与胃相近。食虽可入。难尽入胃。入即吐出。
名之曰膈。（饮食之际。气忽阻塞。曰噎。心下隔拒。或食到膈间不得下。曰膈。良久复出者翻
胃。丹溪合而为一。固为未尽。医贯竟以噎膈为上脘干槁不纳食。而以呕吐归之翻胃。则亦不尽
其理。东庄云。噎膈亦有食入而吐者。但不同于翻胃之每食必出。翻胃止吐原物。有食必尽。噎
膈则或食或痰或白沫酸水。或多或少。或初病不
吐。而久之屡作。或吐糟粕。非痰非食非血。若酱汁然者。此上脘下脘枯槁。皆噎膈也。）总缘下
脘与厥阴少阳相逼。七情用事。肝胆先病。病则郁而生热。热则其气熏蒸于胃。久之胃中阴血亦
干。而渐至糟粕不能受。气化之推移。积叠于胃底。于是胃中之气。上逆而为火。中脘为火所盘
踞。竟不思谷矣。其津液不能下行。则小肠下之阑门。亦致枯槁。小肠手太阳也。闭则生火。愈
干则愈热。愈热则愈干。亦不能司其泌别矣。然后膀胱无所禀受。而小便赤浊。大肠无所禀受。
而便若羊矢。（大肠无血故也）成不治之症矣。（从胃脘上下。溯源穷流。阐发靡遗。膈症主此。
思过半矣。）总之胃为气血之海。人见其不思饮食。便为胃气之虚。用参 白术补之。见其食即
呕吐。便为胃中之寒。以姜桂茱萸暖之。 （补之则增其膈。暖之则速其亡。总因不达三阳结三
字之精义耳。）殊不知肠胃之为物。最喜润泽。试以羊豕之肚观之。必是滑腻稠粘。如液如脂。如
膏如泽。在人胃亦如是。所谓阴也。膈症之人。其肠胃必枯槁干燥。绝无滑腻稠粘等象。是胃阴
亡也。阴亡。地气绝也。地气绝。则天气从何处生乎。故多死。（急救胃阴。亦或有得生者。）
膈症与翻胃何以辨之。膈症饥欲得食（可知非不思食也。实不能食耳。前后思食思谷等数思字。俱改
能字为妥。）但噎塞迎逆于咽喉胸膈之间。在胃口之上。未曾入胃。即带痰涎而出。若一入胃。
无不消化。不复出矣。惟男子年高者有之。故曰少无噎膈翻胃者。饮食倍常。尽入于胃矣。但朝
食暮吐。暮食朝吐。或一两时而吐。或积至一日夜而吐。腹中胀闷不可忍。而复吐出。原物酸臭
不化。此已入胃而反出。故曰翻胃。男女老少皆有之。（此辨甚明。）治膈症者。或以为胃虚而
用温补。或以为开郁而用香燥等剂。必至死
而后已。（温补香燥。俱以助火。药与症反。不死何待。）不知此乃关门枯槁。肾水不能上达。
经曰。肾乃胃之关。关门不利。升降息矣。关门。即气交之中。天之枢也。故肾旺。则胃阴充足。
胃阴充足则思食。当用六味饮加归芍养之。（予治荆溪潘尔修之膈。用左归饮去茯苓加生地当
归。两大剂而便润食进。又十剂而两便如常。饮食复旧。盖以左归饮中有甘草。则直走阳明。以
和其中。且当归生地合用。则能清胃火以生其阴。胃阴上济。则贲门宽展。故饮食能进。胃阴下
达。则幽门阑门皆滋润。故二便如常。去茯苓者。恐其分流入坎。不若端顾阳明之速效耳。）
或血燥大肠枯干。有黑屎积叠胃底。则当以熟地五钱。当归白芍桃仁麻仁各三钱。微微润之。如
其形体如常。气血充足。即以前方内加大黄一二钱。以助血药。（东庄云。损庵尝言大黄治膈之妙
。实出至理。但不可施于久病与羸败者耳。如用。竟合四物汤或麻仁润肠丸佳。）大肠一润利。
而胃自开矣。（惯用大黄者。第见其用以败胃耳。而不惯用大黄者。偏能用以开胃。岂非奇绝
。）一开之后。大剂六味左归等类。不数饮之。方有济也。脉必至数均调。其形体则微大而弦。有
一种大便甚利且溏。（与膈症分别处。只在此。）每食必吐。是名翻胃。王太仆云。食入反出。
是无火也。八味丸主之。此验症全在大便。如一干结。便非无火。一味滋润如前法。（东庄云。此症
则王太仆之论为的。壮水之主益火之原二法。随症并用。赵氏分噎膈为无水。反胃为无火。非
也。噎膈但不能食耳。反胃必吐。即出久出。以迟速分也。）
膈症的症状表现是怎样的？回答说：膈症的病机，用阳明经的理论就可以概括了。朱丹溪认为噎膈和反胃的病，是由于六淫（风、寒、暑、湿、燥、火六种外感病邪）和七情（喜、怒、忧、思、悲、恐、惊七种情志变化）引起的。于是产生了火热炎上的病理变化，气机多升少降，津液不能布散，血液衰耗，导致胃脘干枯。如果干枯发生在上部，靠近咽喉的地方，水饮可以下行，但食物难以下咽，即使勉强吃也吃不多，这叫做“噎”。如果干枯发生在下部，靠近胃的地方，食物虽然能进去，但难以全部进入胃中，进去后就会吐出来，这叫做“膈”。（在饮食的时候，气突然阻塞，叫做噎；心下部位隔拒，或者食物到了膈间不能下行，叫做膈；过了很久又吐出来的叫做翻胃。朱丹溪将这三者合为一谈，确实不够详尽；《医贯》竟然把噎膈归结为上脘干枯不纳食，而把呕吐归为翻胃，这也未能穷尽其理。东庄说：噎膈也有进食后呕吐的情况，但与翻胃那种每吃必吐不同。翻胃只吐出原物，且必须吃完才吐；噎膈则有时吐食物，有时吐痰，有时吐白沫酸水，或多或少，有的初病时不吐，时间久了频繁发作，有的吐出糟粕，既不是痰也不是食物也不是血，像酱汁一样。这是因为上脘和下脘都枯槁了，都属于噎膈。）总的来说，是因为下脘与厥阴肝经、少阳胆经相互逼迫，七情致病，肝胆先发病。病了就会产生郁结而生热，热邪熏蒸于胃，久而久之胃中的阴血也会干枯，逐渐导致无法容纳糟粕。随着气化功能的推移，积滞堆积在胃底，于是胃中之气上逆化为火，中脘被火邪盘踞，竟然不想吃东西了。其津液不能下行，导致小肠下端的阑门，也变得枯槁。小肠属于手太阳经，闭塞则生火，越干就越热，越热就越干，也不能执行其泌别清浊的功能了。然后膀胱无所禀受，小便赤浊；大肠无所禀受，大便像羊屎一样。（因为大肠无血滋润的缘故）这就成了不治之症了。（从胃脘上下溯源穷流，阐发得没有遗漏。膈症的主治原理在此，思考一下就能明白大半了。）总之，胃是气血的海源。人们看到病人不思饮食，就认为是胃气虚弱，用人参、白术来补益；看到病人进食即呕吐，就认为是胃中有寒，用生姜、肉桂、吴茱萸来温暖。（补益则会加重膈塞，温暖则会加速死亡。总因不明白“三阳结”这三个字的精义罢了。）殊不知肠胃这种器官，最喜欢润泽。试看猪羊的肚肠，一定是滑腻稠粘，像液体、像油脂、像膏脂、像泽润。人的胃也是这样，这就是所谓的“阴”。患膈症的人，其肠胃必然枯槁干燥，完全没有滑腻稠粘等象，这是胃阴亡失。阴亡，就是地气断绝。地气断绝，天气从哪里产生呢？所以大多死亡。（急救胃阴，或许还有生存的可能。）
如何辨别膈症与翻胃？膈症的人饥饿时想要吃东西（可知并非不想吃，而是实在不能吃。前文提到的几次“思食”、“思谷”，都应改为“能”字才妥当），但在咽喉胸膈之间感到噎塞迎逆，在胃口之上，食物未曾进入胃中，就带着痰涎吐出来。如果一旦进入胃中，无不消化，也不会再吐出来。这种情况多见于年高的男子，所以说年少的人没有噎膈和翻胃。如果是翻胃，饮食量加倍，都能完全进入胃中。但是早晨吃的晚上吐，晚上吃的早晨吐，或者过一两个时辰就吐，或者积累到一天一夜才吐，腹中胀闷难受，然后吐出来，吐出的还是原物，酸臭不化。这是已经入胃而又反吐出来，所以叫翻胃。男女老少都有此病。（这种辨析非常清楚。）治疗膈症的人，有的认为是胃虚而用温补法，有的认为是气郁而用香燥类药物，必定等到死才停止。（温补和香燥，都会助长火邪，药性与病症相反，不死还等什么？）不知道这是由于关门枯槁，肾水不能上达。经书说：肾是胃的关隘。关隘不通利，升降之气就停止了。这个“关门”，就是气交之中，天之枢纽。所以肾气旺盛，则胃阴充足；胃阴充足就会想吃东西。应当用六味地黄丸加当归、白芍来滋养。（我曾治疗荆溪潘尔修的膈症，用左归饮去掉茯苓，加入生地、当归，服用两大剂后大便通畅、食欲增进，又服十剂后大小便恢复正常，饮食恢复如常。大概因为左归饮中有甘草，能直走阳明经以调和其中焦，且当归、生地合用，能清胃火以滋生阴液。胃阴上济，则贲门宽展，所以饮食能进；胃阴下达，则幽门、阑门皆滋润，所以二便如常。去掉茯苓，是担心它分流入肾，不如专注顾护阳明经来得速效。）如果是血燥导致大肠枯干，有黑屎积叠在胃底，则应当用熟地黄五钱，当归、白芍、桃仁、麻仁各三钱，微微润燥。如果患者形体如常，气血充足，就在前方中加入大黄一二钱，以辅助血药。（东庄说：损庵曾言大黄治疗膈症的妙处，确实出于至理，但不可用于久病和身体衰弱者。如果使用，最好配合四物汤或麻仁润肠丸。）大肠一旦润滑通畅，胃自然开豁。（习惯用大黄的人，只见它用来败坏胃气；而不习惯用大黄的人，却能用它来开胃，难道不是奇绝吗？）一旦开豁之后，大剂量服用六味地黄丸、左归饮之类，喝上几副，才有疗效。脉象必定至数均匀调和，形体微大而弦。有一种情况是大便非常通利且稀溏。（这与膈症的区别之处，就在于此。）每吃必吐，这叫翻胃。王太仆说：食入反出，是无火的表现，用八味丸主治。这种验证病症的关键全在大便：如果大便干结，就不是无火，一味滋润如前面的方法。（东庄说：此症则王太仆的论述确切。壮水之主、益火之原两种方法，随症并用。赵氏将噎膈分为无水，反胃分为无火，是不对的。噎膈只是不能进食，反胃必定呕吐，即使是久吐或迟吐，也只是以快慢来区分。）
What are the clinical manifestations of Ge Syndrome (Obstruction Syndrome)? The answer is: The pathology of Ge Syndrome can be fully explained by the theory of the Yangming Channel. Zhu Danxi believed that the diseases of Ye Ge (Dysphagia) and Fan Wei (Regurgitation) result from the Six Evils (Wind, Cold, Summerheat, Dampness, Dryness, Fire) and Seven Emotions (Joy, Anger, Worry, Pensiveness, Sorrow, Fear, Fright). This leads to a pathological transformation of fire and heat flaring upward, where Qi ascends more than it descends, body fluids fail to distribute, blood becomes depleted, and the stomach cavity dries up. If the dryness occurs in the upper part, near the throat, liquids may pass through, but food is difficult to swallow; even if swallowed, only a small amount enters. This is called "Ye" (Choking). If the dryness occurs in the lower part, near the stomach, food may enter but cannot fully pass into the stomach; what enters is vomited out. This is called "Ge" (Obstruction). (When Qi suddenly blocks during eating, it is called Ye; when there is rejection below the heart, or food reaches the diaphragm area and cannot descend, it is called Ge; vomiting after a long delay is called Fan Wei. Zhu Danxi combined these three into one category, which was indeed incomplete. *Yi Guan* [The Canon of Medicine] attributed Ye Ge solely to dryness in the upper Jiaowei preventing food intake, and regurgitation to Fan Wei, which also fails to capture the full logic. Dongzhuang stated: Ge Syndrome can also involve vomiting after eating, but it differs from Fan Wei, where every meal is vomited. Fan Wei only vomits the original food, and only after the meal is finished. Ge Syndrome may vomit food, phlegm, white foam, or sour water, in varying amounts. Some do not vomit initially but vomit frequently over time; some vomit residue that is neither phlegm, food, nor blood, resembling sauce. This is because both the upper and lower Jiaowei are withered, constituting Ge Syndrome.) In general, this is due to the lower Jiaowei being pressured by the Jueyin Liver Channel and Shaoyang Gallbladder Channel. Pathogenic factors related to emotions cause the Liver and Gallbladder to fall ill first. Illness leads to stagnation generating heat; heat steams the stomach. Over time, the Yin-blood in the stomach dries up, gradually rendering it unable to accept waste. With the shift of Qi transformation, accumulation piles up at the bottom of the stomach. Consequently, Qi in the stomach rebels upward transforming into fire, occupying the Middle Jiaowei, leading to a loss of appetite for grain. Body fluids fail to descend, causing the Lamen (Gate) at the lower end of the Small Intestine to become withered. The Small Intestine belongs to the Hand-Taiyang channel; obstruction generates fire. The drier it gets, the hotter it becomes; the hotter it gets, the drier it becomes. It can no longer perform its function of separating the clear from the turbid. Subsequently, the Bladder receives nothing, resulting in dark and turbid urine; the Large Intestine receives nothing, resulting in stool like sheep droppings (due to lack of blood nourishment in the Large Intestine). This becomes an incurable condition. (Tracing the source and flow from the upper and lower stomach reveals all details without omission. The main principles for treating Ge Syndrome are here; understanding this covers more than half the knowledge.) In summary, the Stomach is the sea of Qi and Blood. People see the patient has no desire to eat and assume it is Stomach-Qi deficiency, using Ginseng (*Ren Shen*) and Atractylodes Macrocephala Rhizome (*Bai Zhu*) to tonify. Seeing immediate vomiting after eating, they assume it is Cold in the Stomach, using Ginger (*Sheng Jiang*), Cinnamon Twig (*Rou Gui*), and Evodia Fruit (*Zhu Yu*) to warm. (Tonifying increases the obstruction; warming accelerates death. This is entirely due to failing to understand the profound meaning of "Three Yang Knotting".) Little do they know that the intestines and stomach, as organs, prefer moisture and lubrication. Observe the bellies of sheep and pigs; they are slippery, viscous, fluid-like, oily, pasty, and moist. The human stomach is the same; this is referred to as "Yin". Patients with Ge Syndrome have intestines and stomachs that are inevitably withered and dry, lacking any slippery or viscous qualities. This indicates the loss of Stomach Yin. Loss of Yin means the extinction of Earth Qi. If Earth Qi is extinct, from where can Heaven Qi arise? Therefore, most patients die. (Urgently rescuing Stomach Yin may offer a chance of survival.)
How to differentiate Ge Syndrome from Fan Wei? Patients with Ge Syndrome feel hungry and want to eat (indicating it is not a lack of desire to eat, but an inability to eat. The previous mentions of "thinking of food" should be interpreted as "able to think of food"). However, they feel choking and reversal in the throat and chest-diaphragm region, above the stomach opening. Before food enters the stomach, it comes back up mixed with phlegm and saliva. If it does enter the stomach, it is digested and never vomited again. This condition mostly affects elderly men, hence it is said that young people do not suffer from Ye Ge or Fan Wei. In contrast, with Fan Wei, dietary intake doubles, and everything enters the stomach. However, morning meals are vomited in the evening, and evening meals in the morning, or vomited after one or two hours, or accumulated for a day and night before vomiting. The abdomen becomes unbearably distended and uncomfortable, then the original food, sour and undigested, is vomited out. This is food that has entered the stomach and is rejected, hence called Fan Wei. It affects men, women, old, and young alike. (This differentiation is very clear.) Those treating Ge Syndrome often attribute it to Stomach deficiency and use warming and tonifying methods, or attribute it to Qi stagnation and use aromatic and drying agents, leading inevitably to death. (Warming and tonifying, as well as aromatic and drying herbs, all assist fire. The treatment contradicts the syndrome; why would one expect survival?) They do not realize this is due to the "gate" being withered, and Kidney Water failing to ascend. The Classics state: The Kidney is the gate of the Stomach. If the gate is obstructed, the ascending and descending of Qi cease. This "gate" refers to the pivot of Qi interaction, the hub of Heaven. Thus, when Kidney Qi is robust, Stomach Yin is sufficient; when Stomach Yin is sufficient, appetite returns. One should use Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill) plus Angelica Sinensis Radix (*Dang Gui*) and White Peony Root (*Bai Shao*) to nourish. (I once treated Pan Xiuxiu from Jingxi for Ge Syndrome using Zuogui Yin [Left Restoring Decoction] minus Poria (*Fu Ling*), adding Rehmannia Glutinosa Radix Preparata (*Shu Di Huang*) and Dang Gui. After two large doses, bowel movements became smooth and appetite improved; after ten doses, bowel and urinary functions returned to normal, and diet recovered. This is likely because Zuogui Yin contains Licorice Root (*Gan Cao*), which travels directly to the Yangming channel to harmonize the middle jiao. Moreover, Dang Gui and Shu Di Huang together clear Stomach fire and generate Yin. When Stomach Yin ascends, the贲门 (cardia) relaxes, allowing food intake; when Stomach Yin descends, the pylorus and Lamen are moistened, ensuring normal excretion. Fu Ling was removed to prevent its draining effect into the Kan [Water/Kidney], as focusing on Yangming yields faster results.) If blood dryness causes Large Intestine withering, with black feces accumulating at the stomach bottom, one should use 5 qian of Prepared Rehmannia Root (*Shu Di Huang*), and 3 qian each of Angelica Sinensis Radix (*Dang Gui*), White Peony Root (*Bai Shao*), Peach Kernel (*Tao Ren*), and Hemp Seed (*Ma Ren*) to gently moisten. If the patient's physique is normal and Qi and Blood are sufficient, add 1-2 qian of Rhubarb (*Da Huang*) to the above formula to assist the blood-nourishing herbs. (Dongzhuang said: Sun An mentioned the miracle of Da Huang in treating Ge Syndrome is truly reasonable, but it must not be used for chronic illness or debilitated patients. If used, it is best combined with Siwu Tang [Four-Substance Decoction] or Mahuang Run Chang Wan [Hemp Seed Intestine-Moistening Pill].) Once the Large Intestine is moistened and unblocked, the Stomach naturally opens. (Those accustomed to using Da Huang only see it damaging the Stomach; those unaccustomed to it use it to open the Stomach. Is this not extraordinary?) After opening, administering large doses of Liuwei Dihuang Wan, Zuogui Yin, etc., for several servings will yield results. The pulse must be regular and balanced, and the physique slightly large and wiry. There is a type where bowel movements are very frequent and loose (this is the key distinction from Ge Syndrome). Vomiting after every meal is named Fan Wei. Wang Taipu said: Food entering and then coming back out indicates a lack of Fire; Bayi Wan (Eight-Ingredient Pill) is the primary treatment. Verifying this syndrome depends entirely on the stool: if the stool is dry and hard, it is not a lack of Fire; one should simply use moistening methods as described above. (Dongzhuang said: For this syndrome, Wang Taipu's argument is accurate. The methods of strengthening the master of Water and benefiting the origin of Fire should be used according to the syndrome. Zhao divided Ye Ge into lack of Water and Fan Wei into lack of Fire, which is incorrect. Ye Ge involves inability to eat; Fan Wei involves inevitable vomiting. They are distinguished only by the speed of ejection.)