灵枢云。气为上膈者。食饮入而还出。虫为下膈。下膈者食 时乃出。
食饮入而还出。气壅膈上。谓之上膈。然有虚实之分。若实而气壅。则食无所容。虚而气塞。
则食不得化。皆令人食入即出也。至若食 时乃出。虫寒积聚而谓下膈。不过言膈证中有此一证耳。
然有命门火衰不能生土。脾胃虚寒。多致食 时乃出者。岂非下膈之证乎。读者不可专以虫为下
膈而胶执也。
素问云。三阳结谓之膈。
三阳结者。大肠小肠膀胱结热也。小肠结热。则血脉燥。大肠结热。则后不圊。膀胱结热。
则津液涸。三阳俱结。前后秘涩。下既不通。必反上逆。此所以噎食不下。从下而逆于上也。
饮食不下。膈塞不通。邪在胃脘。
不通者。浊气在上。肾肝吸入之阴气。不得下而反在上也。病在于胃。故饮食不下。
膈塞闭绝。上下不通。则暴忧之病也。
此言噎膈皆起于郁结不舒。胃气不能敷布所致。张鸡峰所谓神思间病是也。
薛立斋曰。内膈呕逆。食不得入。是有火也。病久而吐。食入反出。是无火也。若脾胃气虚
而胸膈不利者。六君子加丁、沉二香壮脾土以生元气。若用辛热之剂而呕吐噎膈者。异功散加当
归、川斛益土以抑阴火。胃火内膈而饮食不入者。四君子加酒炒芩、连清火养胃。若脾胃虚寒。
饮食不入。或食入反出者。六君子加木香、炮姜温中补脾。如过服润剂养血有伤于中州者。治法
亦无越此。若内有实积。指迷七气汤。污血在胃者。局方七气汤加桃仁。与干漆同炒。去漆用之。
若误服耗气之药。血无所生。噎膈而大便燥结者。四君子加当归、芍药补脾生血。若火逆冲上。
食不得入者。四君子加山栀、川连清火养血。若痰饮阻滞而食不得入者。六君子加木香、山栀。
补脾化痰。若不慎房劳。不节浓味。不戒气怒者。不治。年高无血亦不治。噎而白沫大出。粪如
羊矢。不治。胸腹嘈痛如刀割者。死期迫矣。
李士材云。噎膈反胃。总是血液枯槁。二证皆名为膈。内经总有三阳结谓之膈一语。洁古分
吐证为三端。上焦吐者。皆从于气。食则暴吐。中焦吐者。皆从于积。或先吐而痛。或先痛而吐。
下焦吐者。皆从于寒。朝食暮吐。暮食朝吐。大抵气血亏损。复因忧思悲恚。则脾胃受伤。血液
渐耗。郁气生痰。痰则塞而不通。气则上而不下。如碍道路。饮食难进。噎塞所由成也。脾胃虚
伤。营运失职。不能熟腐五谷。变化精微。食虽可入。良久复出。反胃所由成也。二者皆膈间受
病。故通名为膈也。噎塞之吐。即洁古之上焦吐。反胃之吐。即下焦吐也。王太仆云。食不得入。
是有火也。食入反出。是无火也。噎膈大都属热。反胃大都属寒。然亦不可拘也。脉大有力。呕
吐酸臭。当作热治。脉小无力。呕吐清水。当作寒医。
色之黄白而枯者为虚寒。红赤而泽者为实热。能合色脉。庶乎无误。此证之所以疑难者。方欲健
脾理痰。恐燥剂有妨于津液。方欲养血生津。恐润剂有碍于中州。审其阴伤火旺者。当以养血为
先。脾伤气虚者。当以温补为主。此皆虚实阴阳之辨。临证之权衡也。冬三月。阴气在外。阳气
内藏。外助阳气。不得发汗。内消阳火。勿令泻泄。此固闭密之大要也。夏三月。阳气在外。阴
气在内。噎病值此时。天助正气而锉其邪气。不治自愈。或不愈者。阴气热盛。正气不升耳。四
君子汤送开关利膈丸。每饮食入胃。便吐涎沫如鸡子白。盖脾为涎。脾虚不能约束津液。故涎沫
自出。非人参、白术、诃子、益智仁不能摄也。古人指噎膈为津液干枯。故水液可行。干物梗塞。
为槁在上焦。愚窃疑之。若果津枯。何以食才下咽。涎随上涌乎。故知膈咽之间。交通之气不得
降者。皆冲脉上行。逆气所作也。惟气逆。故水液不能居润下之常。随气逆从耳。若以津枯而用
润下之剂。岂不反益其邪乎。宜六君子加减。挟寒脉迟细者。加肉桂、附子。挟热脉滑数者。加
枳实、黄连。若噎而声不出者。加五味子、竹茹。喉中有一块。食物不下者。痰气也。加海石、
诃子。膈间作痛。多是瘀血。归尾、桃仁、韭汁、童便。甚者加大黄微利之。千金方治胸中久寒。
呕逆气上。饮食不下。结气不消。用五噎丸。若饮食不得下。手足冷。上气咳逆。用五膈丸。血
槁者。地黄、麦冬煎膏。入藕汁、人乳、童便、芦根汁、桃仁泥和匀。细细呷之。因火逆而噎。
梨汁、藕汁等分熬膏蜜收。不时噙热咽之。有痰。加竹沥。因七气致病。而中挟冷热食积。胃气
不和而噎膈者。诸七气汤选用。食物下咽。屈曲自膈而下。梗塞作微痛。此污血在胃口也。用四
物加韭汁、姜汁、竹沥、童便、驴尿、牛羊乳、蜂蜜煎膏润利之。后以代抵当丸下之。若火盛作
嘈痛者忌姜汁。胃虚欲呕吐者忌韭汁。犯之必转剧。有冷积结滞者。用理中加川乌头、蜀椒、川
连、巴豆霜、皂荚末蜜丸。凉水送下十五丸。暂服五七服。
后以四君子加黄 、橘红、砂仁调理。如大便燥结。不时进开关利膈丸二三十丸以微导之。丹方。
治噎膈吐逆不食。用啄木鸟。去毛熬膏。和骨捣烂。入麝香一钱。蜜收。瓷罐盛好。昼夜不时嗅
之。嗅过即盖。勿令散气。以其性善入木。专泄肝郁。然在初起时。用之辄应。若病久元气槁竭。
虽服峻补。尚难为力。况外治乎。
〔诊〕脉紧而芤。紧则为寒。芤则为虚。虚寒相搏。脉为阴结而迟。其人则噎。然多有至死脉
不变者。以胃中痰饮湿热胶固。脉常和软。然细察之。必兼弦象也。
易思兰治一人膈满。其证胸胁胃脘饱闷。脐下空虚如饥不可忍。腰腿酸疼。坐立战摇。大便
燥结。每日进清粥一二钟。食下即呕酸吐水。服药二年不效。诊之。左右寸关俱沉大有力。两尺
自浮至沉。三候俱紧。按之摇摆之状。此气膈病也。须开导其上。滋补其下。兼而行之。遂与越
鞠去山栀。加连翘、桔梗、木香。侵晨令服八味丸百粒。服至半月。动履如常。
喻嘉言治一妇。病膈二十余日。饮粒全不入口。尺脉已绝不至。询其二便。自病起至今。从
未一通。一味痰沫上涌。 待尽。诊得上部有脉。下部无脉。是吐则未必死也。但得天气下降。
则地道自通。然妇人尺脉全无。莫可验其受孕。万一伤之。呼吸立断。用六君子加旋复花。煎调
赤石脂末。服下呕即稍定。三日后渐渐不呕。又三日后粥饮渐加。举家欣快。但病者全不大便。
刻刻以通利为嘱。曰。脏气久结。食饮入胃不多。积之既久。自然通透。若以归、地润肠。恐滞
膈而作呕。硝、黄通肠。恐伤胎而殒命。姑弗其请。坚持三五日。气下肠通。腹中之孕。果渐形
着。而病全瘳矣。
又治一人患膈气。粒米不入。始吐清水。次吐绿水。次吐黑水。次吐臭水。呼吸将绝。一昼
夜先服理中汤六剂。不令其绝。来早转方。一剂而安。金匮有云。噫气不除者。旋复代赭石汤主
之。吾于此病分别用之者有二道。一者以黑水为胃底之水。此水且出。则胃中之津久已不存。不
敢用半夏以燥其胃也。一者以将绝之气止存一系。以代赭坠之。恐其立断。必先以理中分理阴阳。
使气易于降下。然后代赭得以建奇奏绩。乃用旋复花一味煎汤。调代赭石末二匙与之。才入口。
即觉其转入丹田矣。但困倦之极。服补药二十剂。将息二月而愈。
李士材治张孟端夫人。忧愤交乘。食下辄噎。胸中隐隐痛。阳脉滑而阴脉搏。痰血互凝之象。
以二陈汤加归尾、桃仁。郁金、五灵脂。四剂未效。因思人参与五灵脂同用。善于浚血。即以前
剂入人参三钱。倍用五灵脂。再剂血从大便而出。十剂噎止。弥月而愈。
又治金元之之内患噎。胸腹奇痛。经阻。医认瘀血。察其脉细为气衰。沉为寒痼。况自下及
上。处处皆痛。明非血矣。用参、 、白术、木香、姜、桂。煎成。和醇酒进之。甫入口便快。
服理中汤半月而痛止。
石顽治朱彦真酒膈。呕逆不食。每日惟痛饮热酒一二觥。少顷即作酸呕出。膈间大痛。杂治
经年不效。良由平昔好饮热酒所致。此即丹溪所谓好饮热酒。死血留胃口之候。授以人参散。方
用人参一两。煎成。加麝香半分。冰片三厘。三剂便能进食。盖麝片善散胃口之痰与瘀血耳。十
剂后改服柏子仁汤。半月而安。二方出自云岐。人多未知。每以予为尚异。何可为之辨耶。
又治沈 蕃。平昔大便燥结。近患噎膈。不能安谷者月余。虽素禀丰腴。近来面色皎白。大
非往昔。时方谷雨。正此
证危殆之际。始求治于石顽。诊得六脉沉涩。按久则衰。幸举指即应。为疏六君子汤。下一味狗
宝作散调服。甫十剂而呕止食进。再十剂而谷肉渐安。更十剂起居如故。惟是大便尚觉艰难。乃
以六味丸去泽泻。加归、芍、首乌作汤。服至月余。便溺自如。秋深更服八味丸三月而康。大抵
噎膈之人。体肥痰逆者可治。枯 津衰者多不可治。同时有同道王公峻患此。禀气病气。与沈相
类。误信方士。专力委之而致不起。顾人月亦患此证。自谓脉急不当用参。日服仙人对坐草而毙。
郭孝闻八月间噎食艰进。六脉弦劲搏指。延至来春三月告殂。然瘦人间有可疗者。昔秦伯源噎膈
呕逆。而形神枯槁。神志郁抑。且不能胜汤药之费。予门人邹恒友。令其用啄木鸟入麝熬膏。时
嗅其气以通其结。内服逍遥散加香、砂以散其郁。不数剂所患顿除。厥后海货行陈君用噎膈。亦
用此法而愈。两君至今色力尚强。又一农人。噎膈不食。时呕清涎如赤豆沙水。此属血淤于内可
知。庸师不审。误用消克破气药。而致绝粒不食。殆所必至。其邻叟怜其贫 。乃述其病苦。求
救于予。遥拟一方。用桂苓饮加当归、桃仁、丹皮、牛膝。用熬枯黑糖。和 虫浆调服。下溏黑
如污泥者甚多。当知农人戮力受伤。血郁于内而致呕逆。但当攻其积血。呕逆自已。孰谓治病不
求其本。而可轻议其药哉。
《灵枢》说：气滞在上部导致上膈，表现为饮食进入后随即吐出；虫积在下部导致下膈，表现为食物停留一段时间后才会吐出。
饮食进入后随即吐出，是因为气机壅塞在膈上，这称为上膈。然而其中有虚证和实证的区分。如果是实证而气机壅塞，那么食物就无法容纳；如果是虚证而气机阻滞，那么食物就无法消化。这两种情况都会导致食物吃下去就吐出来。至于那种食物停留一段时间后才吐出的情况，古人说是因为寒邪积聚成虫而称为下膈，但这不过是指膈证中的一种情况罢了。
然而，如果有命门火衰不能温煦脾土，导致脾胃虚寒，也常常出现食物停留一段时间后才吐出的情况，这难道不是下膈的证候吗？读者不可仅仅执着于“虫”是导致下膈的原因而拘泥固执。
所谓三阳经气机郁结，是指大肠、小肠和膀胱有热结。小肠有热结，则血脉干燥；大肠有热结，则大便不通；膀胱有热结，则津液枯竭。如果三阳经都发生郁结，前后二便都会秘涩不通。下部既然不通，气机必然反而向上逆乱，这就是为什么会出现噎食不下、从下往上逆行的原因。
所谓不通，是因为浊气停留在上部，肾和肝吸入的阴气，不能下行反而停滞在上部。病变部位在胃，所以饮食无法下行。
膈塞闭塞，上下不通，这是由突然的严重忧怒引起的疾病。
这段话是说噎膈都起因于情志抑郁不舒，导致胃气不能正常布散，也就是张鸡峰所说的“神思间病”。
薛立斋说：内膈伴有呕吐逆气，食物无法进入，这是有火（热）的表现。患病日久且呕吐，食物吃进去又反吐出来，这是无火（寒）的表现。如果是脾胃气虚而导致胸膈不利，用六君子汤加丁香、沉香两味香药，以壮脾土而生发元气。如果使用辛热药物却导致呕吐噎膈的，用异功散加当归、川石斛，以益土抑阴火。如果是胃火内盛导致膈塞而饮食不入的，用四君子汤加酒炒黄芩、黄连，以清火养胃。如果是脾胃虚寒，饮食不入，或者食物吃进去又反吐出来的，用六君子汤加木香、炮姜，以温中补脾。如果因为过服润燥养血药物而损伤了中焦脾胃的，治疗方法也不超出上述范围。如果体内有实性积滞，用指迷七气汤。如果有瘀血在胃，用局方七气汤加桃仁，与干漆同炒，去掉干漆后使用。如果误服耗气药物，导致血液无所生化，出现噎膈且大便燥结的，用四君子汤加当归、芍药，以补脾生血。如果是火气上逆冲撞，导致食物无法进入的，用四君子汤加山栀、黄连，以清火养血。如果是痰饮阻滞导致食物无法进入的，用六君子汤加木香、山栀，以补脾化痰。如果不慎房事劳损，不节制浓腻厚味的饮食，不戒除愤怒情绪，属于不治之症。年老且阴血枯竭的，也不治。如果噎膈时大量吐出白沫，粪便像羊屎一样干结，属于不治之症。如果胸腹嘈杂疼痛如刀割一般，死期迫近了。
李士材说：噎膈和反胃，总是因为血液枯槁。这两种证候都名为膈。《内经》中总共只有“三阳结谓之膈”这一句话。洁古将呕吐证分为三类：上焦呕吐，都源于气机失调，进食后立即剧烈呕吐；中焦呕吐，都源于积滞，有时先呕吐后疼痛，有时先疼痛后呕吐；下焦呕吐，都源于寒邪，早晨吃的晚上吐，晚上吃的早晨吐。大抵而言，气血亏损，再加上因忧思悲愤，导致脾胃受伤，血液逐渐消耗，郁结之气产生痰饮，痰饮阻塞而不通，气机上逆而不能下降，就像道路上有障碍一样，导致饮食难进，这就是噎塞形成的原因。脾胃虚损，运化功能失职，不能熟腐五谷，变化精微，食物虽然可以进入，但很久之后又会复出，这就是反胃形成的原因。这两种情况都是膈间受病，所以通称为膈。噎塞的呕吐，就是洁古所说的上焦吐；反胃的呕吐，就是下焦吐。王太仆说：食物无法进入，是有火；食物进入后又反吐出来，是无火。噎膈大多属热，反胃大多属寒。然而也不可拘泥于此。如果脉象大而有力，呕吐物酸臭，应当按热证治疗；如果脉象细小无力，呕吐清水，应当按寒证治疗。面色黄白而干枯的是虚寒，红赤而有光泽的是实热。能够结合面色和脉象来判断，才大概不会出错。这个病症之所以疑难，是因为想要健脾理痰，担心燥湿药会妨碍津液；想要养血生津，又担心滋润药会阻碍中焦脾胃。仔细审察如果是阴伤火旺的，应当以养血为先；如果是脾伤气虚的，应当以温补为主。这都是虚实阴阳的辨别，是临证时的权衡标准。冬季三个月，阴气在外，阳气内藏，外部助长阳气，不得发汗；内部消减阳火，不要让它泻泄。这是固密闭藏的大要。夏季三个月，阳气在外，阴气在内，噎病正值此时，天助正气而削弱邪气，不治也能自愈。如果不能自愈，是因为阴气热盛，正气不能上升。可以用四君子汤送服开关利膈丸。如果每次饮食入胃，就吐出像鸡蛋清一样的涎沫，这是因为脾主涎，脾虚不能约束津液，所以涎沫自行流出，非人参、白术、诃子、益智仁不能摄纳。古人指噎膈为津液干枯，所以水液可行，干硬食物梗塞，称为“槁在上焦”。我私下对此表示怀疑。如果真的津液干枯，为什么食物刚咽下，涎液就会随之涌上呢？因此知道膈咽之间，交通的气机不能下降，都是因为冲脉上行，逆气作祟。正因为气逆，所以水液不能居留在其正常的润下位置，而是随着气逆而上行。如果用润下的药物治疗津枯，岂不是反而助长邪气吗？适宜用六君子汤加减。兼有寒邪、脉象迟细的，加肉桂、附子；兼有热邪、脉象滑数的，加枳实、黄连。如果噎膈且声音出不来的，加五味子、竹茹。喉中感觉有一块东西，食物下不去的，是痰气所致，加海浮石、诃子。膈间疼痛，多是瘀血，用归尾、桃仁、韭菜汁、童便。严重的加大黄轻微通便。千金方治疗胸中久寒，呕吐逆气上冲，饮食不下，结气不消，用五噎丸。如果饮食无法下行，手足冰冷，上气咳嗽逆乱的，用五膈丸。血液干枯的，用地黄、麦冬煎膏，加入藕汁、人乳、童便、芦根汁、桃仁泥混合均匀，细细含服。因火逆而噎的，用梨汁、藕汁各等分熬膏，用蜂蜜收存，不时含服热咽。有痰的，加竹沥。因七情致病，且中挟冷热食积，胃气不和而致噎膈的，选用各种七气汤。食物咽下后，曲折地从膈下经过，梗塞并伴有轻微疼痛，这是瘀血在胃口，用四物汤加韭菜汁、姜汁、竹沥、童便、驴尿、牛羊乳、蜂蜜煎膏润利。随后用代抵当丸攻下。如果火盛导致嘈杂疼痛的，忌用姜汁。胃虚想呕吐的，忌用韭汁，触犯这些必定病情加重。有冷积结滞的，用理中汤加川乌头、蜀椒、黄连、巴豆霜、皂荚末，制成蜜丸，凉水送服十五丸，暂时服用五到七次。随后用四君子汤加黄芪、橘红、砂仁调理。如果大便燥结，不时进服开关利膈丸二三十丸以轻微导滞。丹方：治疗噎膈呕吐逆气不进食，用啄木鸟，去毛熬膏，和骨头捣烂，加入麝香一钱，用蜂蜜收存，装在瓷罐里密封保存。昼夜不时闻其气味，闻过后立即盖好，不要让香气散失。因为啄木鸟的性质善于入木，专门疏泄肝郁。然而在疾病初起时使用，往往有效。如果病久元气枯竭，即使服用峻补的药物，尚且难以奏效，何况是外治法呢？
〔诊法〕脉象紧而芤，紧脉主寒，芤脉主虚。虚寒相搏，脉象呈现阴结而迟缓，病人就会噎膈。然而多有直到死亡脉象都不改变的，因为胃中痰饮湿热胶固，脉象常显得和软，但仔细察看，必然兼有弦象。
易思兰治疗一个人患膈满证，症状是胸胁胃脘饱闷，脐下空虚像饥饿得无法忍受，腰腿酸痛，坐立摇晃不稳，大便燥结，每天只喝一两碗清粥，食物吃下去就呕吐酸水，服药两年无效。诊脉发现左右寸关脉都沉大有力，两尺脉从浮到沉，三部脉都紧，按压时有摇摆的感觉。这是气膈病。必须开通疏导上部，滋补下部，同时进行。于是给予越鞠丸去掉山栀，加连翘、桔梗、木香。清晨令其服用八味丸一百粒。服用半个月后，行动如常。
喻嘉言治疗一位妇人，患膈证二十多天，米粒饮食完全无法入口，尺脉已经绝迹摸不到。询问其二便情况，从发病到现在，从未通畅一次，只是一味地痰沫上涌，生命垂危。诊脉发现上部有脉，下部无脉，这说明呕吐不一定致死。只要天气（肺气）下降，地道（肠道）自然通畅。然而妇人尺脉全无，无法验证是否受孕。万一伤了胎儿，呼吸立刻就会断绝。于是用六君子汤加旋复花，煎好后调服赤石脂末。服下后呕吐稍微安定，三天后渐渐不再呕吐，又过了三天粥饮逐渐增加，全家欣喜快乐。但病人依然不大便，时刻嘱咐要通利。我说：脏气久结，饮食入胃不多，积滞久了，自然会通透。如果用当归、地黄润肠，恐怕会阻滞膈气而引发呕吐；用芒硝、大黄通肠，恐怕会伤害胎儿而丧命。姑且不理他们的请求，坚持三五天。结果气下肠通，腹中的胎儿果然逐渐显现，而病完全痊愈了。
又治疗一个人患膈气，粒米不入，开始吐清水，接着吐绿水，然后吐黑水，最后吐臭水，呼吸即将断绝。第一天夜里先服用理中汤六剂，不让其气息断绝，第二天早上转换方剂，一剂就安定了。《金匮要略》说：嗳气不止的，用旋复代赭石汤主治。我在这个病案中分别使用的方法有两个道理：一是认为黑水是胃底的水，这种水都能吐出来，说明胃中的津液早已不存在，不敢用半夏来燥湿伤胃；二是认为将绝的气息仅存一线，如果用代赭石重坠之，恐怕气息立刻断绝。必须先以理中汤分理阴阳，使气容易降下，然后代赭石才能建立奇功。于是只用旋复花一味煎汤，调服代赭石末两匙给他。刚入口，就觉得气转入丹田了。只是极度困倦，服用补药二十剂，调养两个月才痊愈。
李士材治疗张孟端的夫人，忧愤交加，食物吃下就噎住，胸中隐隐作痛，阳脉滑而阴脉搏动，这是痰血互凝的迹象。先用二陈汤加归尾、桃仁、郁金、五灵脂，服用四剂未见效。想到人参和五灵脂同用，善于疏通瘀血，就在前方中加入人参三钱，加倍使用五灵脂。再服两剂，瘀血从大便排出，十剂后噎止，一个月后痊愈。
又治疗金元之的内患噎膈，胸腹奇痛，月经阻断。医生认为是瘀血，但我察其脉细为气衰，沉为寒痼，况且疼痛自下而上，处处皆痛，明显不是血瘀。用人参、黄芪、白术、木香、生姜、肉桂，煎成后，兑入醇酒服用。刚入口就觉得舒畅，服用理中汤半个月后疼痛停止。
石顽治疗朱彦真的酒膈，呕吐逆气不进食，每天只痛饮热酒一二杯，不久就作酸呕吐出，膈间剧烈疼痛，杂治多年无效。这完全是因为平时喜欢喝热酒所致，这就是丹溪所说的好饮热酒，导致死血留驻胃口的征候。传授给他人参散，方中用人参一两，煎成后，加麝香半分、冰片三厘，三剂就能进食。因为麝香、冰片善于消散胃口中的痰与瘀血。十剂后改服柏子仁汤，半个月后安宁。这两个方子出自云岐，人们大多不知道，常认为我崇尚奇异，这怎么能为他们辩解呢？
又治疗沈蕃，平时大便燥结，最近患噎膈，不能进食谷物一个多月。虽然素来体格丰腴，近来面色皎白，大不如往昔。当时正值谷雨时节，正是此证危殆之际，才开始求治于石顽。诊得六脉沉涩，按之久则衰弱，幸好举指即应。于是开具六君子汤，下一味狗宝研粉调服。刚十剂就呕止食进，再十剂谷物肉类逐渐安稳，更十剂起居如故。只是大便仍觉艰难，于是用六味丸去掉泽泻，加当归、芍药、首乌作汤剂，服用一个多月，大小便自如。深秋再服用八味丸三个月而康复。大抵噎膈之人，身体肥胖痰逆者可治，枯瘦津液衰竭者多不可治。同时有一位同道王公峻患此病，禀赋和病气与沈蕃相似，误信方士，专力依赖偏方而导致不起。顾人月也患此证，自认为脉急不当用人参，每日服用仙人对坐草而死。郭孝闻八月间噎食艰进，六脉弦劲搏指，延至来年三月去世。然而瘦人中也有可疗者，昔日秦伯源患噎膈呕逆，形神枯槁，神志抑郁，且不能承担汤药费用，我的门人邹恒友，让他用啄木鸟入麝香熬膏，时时闻其气味以通其结，内服逍遥散加香附、砂仁以散其郁，不数剂所患顿除。后来海货行陈君患噎膈，也用此法而愈。两位先生至今神色体力尚强。又一农人，噎膈不食，时常呕吐清涎如赤豆沙水，这属于血淤于内可知。庸医不审，误用消克破气药，而导致绝粒不食，这几乎是必然的结果。他的邻居老翁怜悯其贫穷，于是陈述其病苦，向我求救。我远程拟定一方，用桂苓饮加当归、桃仁、丹皮、牛膝，用熬枯的黑糖，和土鳖虫浆调服。排出稀溏黑色如污泥的东西很多。应当知道农人劳作受伤，血郁于内而致呕逆，只要攻逐其积血，呕逆自然停止。谁说治病不求其本，就可以轻率议论药物呢？
The *Ling Shu* (Spiritual Pivot) states: When Qi stagnation occurs in the upper part, it leads to Shang Ge (Upper Obstruction), characterized by food and drink being vomited immediately after ingestion. When虫 (parasites/worms) accumulate in the lower part, it leads to Xia Ge (Lower Obstruction), characterized by food being vomited only after a period of time has passed.
Food and drink being vomited immediately after ingestion is due to Qi obstruction in the diaphragm region, which is called Shang Ge (Upper Obstruction). However, there is a distinction between excess and deficiency patterns. If it is an excess pattern with Qi obstruction, food cannot be retained; if it is a deficiency pattern with Qi blockage, food cannot be digested. Both conditions result in immediate vomiting after eating. As for the condition where food is vomited after staying for a while, it was traditionally attributed to cold accumulation forming虫 (parasites), termed Xia Ge (Lower Obstruction). This merely refers to one type among various types of Ge syndromes.
However, if Mingmen Fire (Fire of the Gate of Life) declines and fails to warm the Spleen Earth, leading to Spleen-Stomach Deficiency Cold, food may also be vomited after a delay. Is this not also a manifestation of Xia Ge (Lower Obstruction)? Readers should not rigidly adhere to the notion that only虫 (parasites) cause Xia Ge (Lower Obstruction).
The *Su Wen* (Basic Questions) states: Obstruction of the Three Yang meridians is called Ge (Obstruction).
The obstruction of the Three Yang meridians refers to heat accumulation in the Large Intestine, Small Intestine, and Bladder. Heat accumulation in the Small Intestine causes dryness of the blood vessels; heat accumulation in the Large Intestine leads to constipation; heat accumulation in the Bladder results in the depletion of body fluids. If all Three Yang meridians are obstructed, both anterior and posterior orifices become blocked. Since the lower pathway is blocked, Qi must rebel upwards, causing dysphagia and food refusal due to upward rebellion from below.
Inability to swallow food and diaphragmatic obstruction indicate that the pathogenic factor is located in the Epigastrium (Stomach).
The term "obstruction" refers to turbid Qi stagnating in the upper jiao, preventing the Yin Qi inhaled by the Kidney and Liver from descending, causing it to remain in the upper jiao instead. The pathology lies in the Stomach, hence the inability to ingest food.
Diaphragmatic closure and blockage of both upper and lower pathways constitute a disease caused by sudden severe emotional depression.
This passage indicates that Dysphagia and Obstruction (Ye Ge) arise from emotional depression failing to flow freely, causing Stomach Qi to fail in its distribution. This is what Zhang Jifeng referred to as "disease arising from mental contemplation."
Xue Lizhai stated: Internal Ge accompanied by vomiting and rebellion, where food cannot enter, indicates the presence of Fire (Heat). Long-standing illness with vomiting, where food enters and then comes back out, indicates the absence of Fire (Cold). For cases of Spleen-Stomach Qi Deficiency causing chest and diaphragmatic discomfort, use Liu Jun Zi Tang (Six Gentlemen Decoction) plus Ding Xiang (Clove) and Chen Xiang (Aquilaria Wood) to strengthen Spleen Earth and generate Original Qi. If pungent-hot medicines induce vomiting and Ge, use Yi Gong San (Extraordinary Power Powder) plus Dang Gui (Angelica Sinensis) and Chuan Hu Shi (Dendrobium nobile) to tonify Earth and suppress Yin Fire. For internal Stomach Fire causing obstruction and inability to eat, use Si Jun Zi Tang (Four Gentlemen Decoction) plus Jiu Chao Huang Qin (Scutellaria Root wine-fried) and Lian Zi (Coptis Rhizome) to clear Fire and nourish the Stomach. For Spleen-Stomach Deficiency Cold causing inability to eat or regurgitation of ingested food, use Liu Jun Zi Tang (Six Gentlemen Decoction) plus Mu Xiang (Aucklandia Root) and Pao Jiang (Prepared Ginger) to warm the Middle and tonify the Spleen. If excessive use of moistening and blood-nourishing medicines damages the Middle Jiao, the treatment principles do not exceed those mentioned above. For internal excess accumulation, use Zhi Mi Qi Qi Tang (Point-Guiding Seven Qi Decoction). For blood stasis in the Stomach, use Ju Fang Qi Qi Tang (Bureau Formula Seven Qi Decoction) plus Tao Ren (Peach Seed), stir-fried together with Gan Xi (Drywood Resin), discarding the resin before use. If qi-consuming medicines were mistakenly taken, leading to lack of blood generation, resulting in Ge and dry stool, use Si Jun Zi Tang (Four Gentlemen Decoction) plus Dang Gui (Angelica Sinensis) and Shao Yao (Peony Root) to tonify the Spleen and generate blood. For Fire rebelling upwards preventing food intake, use Si Jun Zi Tang (Four Gentlemen Decoction) plus Shan Zhi (Gardenia Fruit) and Chuan Lian Zi (Melia Toosendan Fruit/Coptis - Note: Text says Chuan Lian, likely Coptis or related bitter cold herb, here interpreted as clearing fire) to clear Fire and nourish blood. For Phlegm-Fluid obstruction preventing food intake, use Liu Jun Zi Tang (Six Gentlemen Decoction) plus Mu Xiang (Aucklandia Root) and Shan Zhi (Gardenia Fruit) to tonify the Spleen and transform Phlegm. Cases involving reckless sexual activity, indulgence in rich/greasy foods, and uncontrolled anger are incurable. Elderly patients with depleted blood are also incurable. Patients vomiting large amounts of white foam with sheep-dung-like dry stools are incurable. Those experiencing burning pain in the chest and abdomen like knife cuts are near death.
Li Shicai stated: Dysphagia (Ye) and Regurgitation (Fan Wei) are always due to blood exhaustion. Both syndromes are named Ge (Obstruction). The *Nei Jing* mentions only "Obstruction of the Three Yang is called Ge." Jie Gu divided vomiting into three categories: Upper Jiao vomiting stems from Qi disorders, characterized by sudden violent vomiting after eating; Middle Jiao vomiting stems from accumulations, sometimes vomiting precedes pain, sometimes pain precedes vomiting; Lower Jiao vomiting stems from Cold, characterized by morning food vomited in the evening, or evening food vomited in the morning. Generally, Qi and Blood deficiency, combined with worry, thought, sadness, and resentment, injures the Spleen and Stomach, gradually consuming blood. Depressed Qi generates Phlegm, which blocks passage, while Qi rebels upwards and does not descend, obstructing the pathway like a barrier, making food intake difficult, thus forming Dysphagia. Spleen-Stomach deficiency impairs transportation and transformation, failing to properly digest grains and extract essences. Although food can enter, it is regurgitated after a long time, forming Regurgitation. Both involve pathology in the Diaphragm area, hence collectively called Ge. Vomiting in Dysphagia corresponds to Jie Gu's Upper Jiao vomiting; vomiting in Regurgitation corresponds to Lower Jiao vomiting. Wang Tai Pu stated: Inability to ingest food indicates Fire; regurgitation of ingested food indicates absence of Fire. Dysphagia mostly belongs to Heat; Regurgitation mostly belongs to Cold. However, one should not be dogmatic. A large, forceful pulse with sour-smelling vomit suggests Heat treatment; a small, weak pulse with clear water vomiting suggests Cold treatment. Yellowish-white and dry complexion indicates Deficiency-Cold; reddish and lustrous complexion indicates Excess-Heat. Combining complexion and pulse analysis ensures accuracy. The difficulty in treating this syndrome lies in the dilemma: wanting to tonify the Spleen and resolve Phlegm, yet fearing drying agents will damage fluids; wanting to nourish blood and generate fluids, yet fearing moistening agents will hinder the Middle Jiao. For Yin injury with hyperactive Fire, prioritize nourishing blood; for Spleen injury with Qi deficiency, prioritize warming and tonifying. These are distinctions of Excess/Deficiency and Yin/Yang, serving as clinical weighing scales. During winter months, Yin is external and Yang is internal; assist external Yang without sweating; reduce internal Yang Fire without purging. This is key to conservation. During summer months, Yang is external and Yin is internal. If Dysphagia occurs at this time, heavenly Yang assists healthy Qi to defeat pathogenic Qi, potentially healing spontaneously. If not, it is due to excessive Yin-Heat preventing healthy Qi from rising. Use Si Jun Zi Tang (Four Gentlemen Decoction) to deliver Kai Guan Li Ge Wan (Open Passages and Benefit Diaphragm Pill). If every meal triggers vomiting of saliva resembling egg whites, it is because the Spleen governs saliva, and Spleen deficiency fails to control fluids. Only Ren Shen (Ginseng), Bai Zhu (Atractylodes Macrocephala), He Zi (Chebula Fruit), and Yi Zhi Ren (Alpinia Oxyphylla) can secure it. Ancients attributed Dysphagia to fluid exhaustion, allowing liquids but blocking solids, termed "Withering in the Upper Jiao." I doubt this. If fluids were truly exhausted, why would saliva surge upon swallowing? Thus, the failure of communicating Qi in the esophagus to descend is due to the Chong Mai (Penetrating Vessel) ascending and rebellious Qi acting up. Due to Qi rebellion, fluids cannot stay in their normal downward-moistening position but rise with the Qi. Using downward-moistening agents for fluid exhaustion would only exacerbate the pathogen. Use Liu Jun Zi Tang (Six Gentlemen Decoction) with modifications: add Rou Gui (Cinnamon Bark) and Fu Zi (Aconite Root) for Cold with slow/thready pulse; add Zhi Shi (Immature Bitter Orange) and Huang Lian (Coptis Rhizome) for Heat with slippery/rapid pulse. For Dysphagia with voice loss, add Wu Wei Zi (Schisandra Berry) and Zhu Ru (Bamboo Shavings). For a lump in the throat preventing food descent, it is Phlegm-Qi; add Hai Shi (Halloysitum) and He Zi (Chebula Fruit). Pain in the diaphragm is often blood stasis; use Gui Wei (Angelica Sinensis Tail), Tao Ren (Peach Seed), Jiu Cai Zhi (Leek Juice), and Tong Bian (Child's Urine). Severe cases add Da Huang (Rhubarb Root) for mild purgation. Qian Jin Fang treats chronic chest cold, vomiting, rebellion, food refusal, and stuck Qi with Wu Ye Wan (Five Obstructions Pill). For inability to eat, cold extremities, and cough/rebellion, use Wu Ge Wan (Five Obstructions Pill). For blood exhaustion, decoct Di Huang (Rehmannia Root) and Mai Dong (Ophiopogon Tuber) into paste, mix with Ou Zhi (Lotus Root Juice), Ren Ru (Human Milk), Tong Bian (Child's Urine), Lu Gen Zhi (Reed Rhizome Juice), and Tao Ren Ni (Peach Paste), sip slowly. For Fire-rebellion Dysphagia, boil equal parts Li Zhi (Pear Juice) and Ou Zhi (Lotus Root Juice) into paste with Honey, hold hot in mouth and swallow. Add Zhu Li (Bamboo Juice) for Phlegm. For Dysphagia due to Seven Emotions mixed with cold/heat food retention and Stomach disharmony, select appropriate Qi Qi Tang formulas. If food passes down curving through the diaphragm with slight pain, it is blood stasis in the stomach opening; use Si Wu Tang (Four Substances Decoction) plus Leek Juice, Ginger Juice, Bamboo Juice, Child's Urine, Donkey Urine, Cow/Sheep Milk, and Honey paste for lubrication, followed by Dai Di Dang Wan (Substitute Ying-Such Pill) to purge. Avoid Ginger Juice if Fire causes burning pain; avoid Leek Juice if Stomach deficiency causes nausea, as doing so worsens symptoms. For cold accumulation, use Li Zhong Tang (Regulate the Middle Decoction) plus Chuan Wu Tou (Sichuan Aconite), Shu Jiao (Sichuan Pepper), Huang Lian (Coptis), Ba Dou Shuang (Croton Seed Frost), and Zao Jiao Mo (Gleditsia Spine Powder) made into honey pills, taken with cool water (15 pills), temporarily 5-7 doses. Then regulate with Si Jun Zi Tang plus Huang Qi (Astragalus), Ju Hong (Tangerina Peel), and Sha Ren (Amomum Fruit). For dry stool, occasionally take 20-30 Kai Guan Li Ge Wan pills for mild guidance. Dan Formula: For Dysphagia with vomiting and refusal to eat, use Woodpecker, remove feathers, decoct into paste, mix with crushed bones, add 1 qian She Xiang (Musk), preserve in honey in a porcelain jar. Smell intermittently day and night, covering immediately to prevent volatilization. Its nature penetrates wood, specifically resolving Liver Depression. Effective in early stages. For late-stage Qi/Blood exhaustion, even strong tonics fail, let alone external treatments.
[Diagnosis] Tight and hollow (Kou) pulse: Tight indicates Cold, Hollow indicates Deficiency. Deficiency and Cold combine, creating Yin obstruction with a slow pulse, leading to Dysphagia. Often, the pulse remains unchanged until death because Phlegm-Fluid and Damp-Heat are firmly fixed in the Stomach, making the pulse appear soft, though careful inspection reveals a Wiry (Xian) quality.
Yi Silan treated a patient with Diaphragmatic Fullness: Chest, hypochondrium, and epigastrium felt full and stifling; umbilical area felt empty like unbearable hunger; waist and legs were sore and painful; sitting or standing caused trembling; stool was dry; only consumed 1-2 bowls of thin rice porridge daily, vomiting acid water immediately after eating; two years of medication failed. Pulse: Cun and Guan on both sides were deep, large, and forceful; Chi pulses from floating to deep were tight in all three positions; pressing revealed a swaying sensation. This is Qi Ge (Qi Obstruction). Must open and guide the upper, tonify the lower, simultaneously. Prescribed Yue Ju Wan (Resolve Frustration Pill) minus Shan Zhi (Gardenia), plus Lian Qiao (Forsythia), Jie Geng (Platycodon), and Mu Xiang (Aucklandia). Administer Ba Wei Wan (Eight-Treasure Pill) 100 pills in the morning. After half a month, movement returned to normal.
Yu Jiayan treated a woman with Ge syndrome for over 20 days, unable to ingest any grain or liquid, Chi pulse absent. Inquiry revealed no bowel or bladder movement since onset, only constant phlegm spitting, life hanging by a thread. Diagnosis: Pulse present in upper jiao, absent in lower jiao. Vomiting does not necessarily mean death. If Heaven Qi (Lung Qi) descends, Earth Path (Intestines) will naturally open. However, absent Chi pulse in women makes pregnancy verification impossible. Risk of harming fetus could lead to immediate death. Prescribed Liu Jun Zi Tang (Six Gentlemen Decoction) plus Xuan Fu Hua (Inula Flower), decocted with Chi Shi Zhi (Red Halloysite) powder. Vomiting subsided after first dose, stopped gradually after three days, diet increased after six days. Family rejoiced. Patient still had no bowel movement, urgently requesting purgation. I said: Organ Qi has been bound for a long time, little food enters, accumulation takes time to clear. Using Dang Gui/Di Huang to moisten intestines might obstruct Diaphragm and cause vomiting; using Xiao/Huang (Mirabilite/Rhubarb) to purge might harm fetus and cause miscarriage. Ignored requests, persisted for 3-5 days. Qi descended, intestines opened, fetus became visible, disease cured completely.
Treated another man with Ge Qi, unable to eat rice, vomiting clear water, then green water, then black water, then foul water, breathing nearly ceased. First night, gave Li Zhong Tang (Regulate the Middle Decoction) 6 doses to sustain life. Next morning, changed formula, one dose brought peace. *Jin Gui* states: Persistent belching is treated with Xuan Fu Dai Zhe Shi Tang (Inula and Hematite Decoction). My rationale for separate use: 1) Black water is bottom-stomach water; its ejection implies Stomach fluids are gone; dare not use Ban Xia (Pinellia) to dry Stomach. 2) Vital Qi is barely hanging by a thread; heavy sinking agent Dai Zhe Shi (Hematite) might sever it instantly. Must first use Li Zhong Tang to balance Yin/Yang, facilitating Qi descent, then Dai Zhe Shi can work wonders. Used only Xuan Fu Hua decoction mixed with 2 spoons of Dai Zhe Shi powder. Upon entry, Qi felt transferred to Dan Tian. Extreme fatigue followed; 20 doses of tonics, recuperated over two months.
Li Shicai treated Mrs. Zhang Menduan: Overwhelmed by grief and indignation, food stuck immediately after swallowing, dull chest pain. Yang pulse slippery, Yin pulse wiry/forceful, indicating Phlegm-Blood congealment. Used Er Chen Tang (Two Aged Herbs Decoction) plus Gui Wei (Angelica Tail), Tao Ren (Peach Seed), Yu Jin (Curcuma Aromatica), and Wu Ling Zhi (Trogopterus Dung). Four doses ineffective. Realized Ren Shen (Ginseng) and Wu Ling Zhi together promote blood circulation. Added 3 qian Ren Shen, doubled Wu Ling Zhi. Two more doses, blood expelled via stool. Ten doses stopped Dysphagia, cured in one month.
Treated Jin Yuanzhi's internal Dysphagia: Strange chest/abdominal pain, amenorrhea. Doctor diagnosed blood stasis. I observed fine pulse (Qi deficiency), deep pulse (Cold stubbornness). Pain from bottom to top everywhere clearly not blood stasis. Used Ren Shen, Huang Qi, Bai Zhu, Mu Xiang, Sheng Jiang, Rou Gui, decocted with mellow wine. Felt relief upon entry. Li Zhong Tang for half a month stopped pain.
Shi Wan treated Zhu Yanzhen's Alcohol Ge: Vomiting/rebellion, refusal to eat, drinking 1-2 cups hot wine daily, soon vomiting acid, severe diaphragmatic pain, years of failed treatments. Caused by habitual hot wine drinking, leading to dead blood retention in stomach opening (per Danxi). Prescribed Ren Shen San (Ginseng Powder): 1 liang Ren Shen, decocted, added She Xiang (Musk) 0.5 fen, Bing Pian (Borneol) 0.3 li. Three doses allowed eating. Musk/Borneol disperses Phlegm and blood stasis in stomach opening. After ten doses, switched to Bai Zi Ren Tang (Biota Seed Decoction), peaceful in half a month. Formulas from Yunqi, unknown to many who think I seek novelty.
Treated Shen Fan: Chronic dry stool, recent Dysphagia, unable to eat grains for over a month. Once robust, now pale white, very different from past. Grain Rain season, critical time for this disease. Six pulses deep and choppy, weakening with pressure, but responsive on light touch. Prescribed Liu Jun Zi Tang (Six Gentlemen Decoction) with Gou Bao (Dog Gallstone) powder. Ten doses stopped vomiting, improved appetite. Ten more doses stabilized diet. Ten more doses restored routine. Stool still difficult: Liu Wei Wan (Six-Ingredient Pill) minus Ze Xie, plus Dang Gui, Shao Yao, Shou Wu, decocted. One month, normal urination/defecation. Late autumn, Ba Wei Wan (Eight-Treasure Pill) for three months, fully recovered. Generally, obese Dysphagia patients with Phlegm rebellion are treatable; emaciated patients with fluid exhaustion are mostly incurable. Contemporary Wang Gongjun had similar constitution/disease, believed in quacks, relied solely on them, died. Gu Renyue had same disease, thought rapid pulse contraindicated Ginseng, took Xian Ren Dui Zuo Cao daily, died. Guo Xiaowen had difficult swallowing in August, wiry/tight pulses, died next March. However, some thin patients are treatable. Formerly, Qin Boyuan had Dysphagia/vomiting, emaciated, depressed, poor, couldn't afford herbs. My student Zou Hengyou used Woodpecker + Musk paste, smelled intermittently to open knots, internally Xiao Yao San (Free and Easy Wanderer Powder) plus Xiang Fu, Sha Ren to dissipate depression. Few doses cured. Later, Chen Jun (seafood merchant) cured similarly. Both still vigorous. Another farmer, Dysphagia/refusal to eat, vomiting clear saliva like red bean water, indicating internal blood stasis. Quack doctors mistakenly used breaking/pushing Qi medicines, causing total food refusal. Neighbor pitied him, asked me. Remote prescription: Gui Ling Yin plus Dang Gui, Tao Ren, Dan Pi, Niu Xi, cooked with charred brown sugar, mixed with Tu Bie Chong (Ground Beetle) paste. Passed much black sludge-like loose stool. Farmer injured by labor, blood stagnation caused vomiting. Treating the blood stasis stops vomiting. Who says treating disease without seeking root can lightly discuss medicine?