《灵枢·上膈篇》帝曰∶气为上膈者，食饮入而还出，余已知之矣。虫为下膈，下膈者，食 时乃出，余
未得其意，愿卒闻之。岐伯曰∶喜怒不适，食饮不节，寒温不时，则寒汁流于肠中，流于肠中则虫寒，虫寒则
积聚，守于下管，则肠胃充廓，卫气不营，邪气居之。人食则虫上食，虫上食则下管虚，下管虚则邪气胜之，
积聚已留，留则痈成，痈成则下管约。其痈在管内者，即而痛深；其痈在外者，则痈外而痛浮，痈上皮热。
马注∶膈者，膈膜也，前齐鸠尾，后齐十一椎，所以遮隔浊气，不使上熏心肺也。然有膈上之病者，乃
气使然，食饮一入，实时还出；有膈下之病者，乃虫使然，食饮周时，始复外出，由于喜怒不适，食饮不节，
寒温不时，以致寒汁流于肠中，则虫因寒聚于下脘，脐上二寸也，虫聚下脘，故肠胃充廓，卫阳之气不得上营，
邪气居之，其虫因食而上，上则下脘虚而邪气胜，积聚而成壅，壅则下脘约，约者闭也。其壅在脘内者，按之
其痛深，壅在脘外者，按之其痛浮，壅之皮上热，以其阻闭在下，故食饮 时乃出也。楠按∶《素问·阴阳
别论》曰∶一阳发病，其传为膈。又曰∶三阳结，谓之隔。盖一阳者，少阳经
也，少阳为枢，枢病而气阻滞不转，故久而传变为膈病也。三阳者，太阳经也，太阳为开，其气由内以达外者，
其经结而不开，则内阻隔而不流通。是皆言阳气郁逆而成膈病，即此条所云气为上膈者也。又云下膈者，以
寒汁流于肠中，积聚结而成痈，当以通阳破瘀为主，治与一阳发病、三阳结之证源不同也。又言卫气不营者，
以卫气起于下焦，营气起于中焦，卫气自下而升，与营气交通，由胸而分行营卫，今下脘积聚而卫不得交营，
则阴阳正气失位，邪僻之气居之，而充廓于肠胃，故饮食 时不化而复出，其与后世名反胃病者相类也。
《灵枢·上膈篇》中，黄帝问道：气滞导致的上膈病，表现为饮食入口后立即吐出，我已经了解了。至于虫积导致的下膈病，下膈病的表现是进食后过一段时间才吐出，我不明白其中的道理，希望能听您详细讲解。岐伯回答说：如果喜怒情绪失调，饮食没有节制，寒热冷暖不适宜，那么寒性的津液就会流注于肠道之中。寒汁流于肠中，会导致寄生虫受寒；寄生虫受寒则停滞积聚，守驻在下脘（胃的下口），致使肠胃胀满扩张，卫气不能正常循行，邪气便占据其间。人进食时，虫子向上觅食，虫子向上则下脘空虚，下脘空虚则邪气亢盛，积聚之物停留不去，久留则形成痈脓，痈脓形成则下脘狭窄闭塞。如果痈在管腔内部，按压时疼痛深沉；如果痈在管腔外部，则体表疼痛浮浅，且痈处皮肤发热。
马莳注释：膈，指的是膈膜，前面与鸠尾穴齐平，后面与第十一椎骨齐平，它的作用是阻隔浊气，不让其向上熏蒸心肺。然而，有位于膈上的疾病，是由气机阻滞引起的，饮食刚入胃，随即吐出；有位于膈下的疾病，是由虫积引起的，饮食经过一个时辰左右，才重新吐出。这是由于喜怒不适、饮食不节、寒温不调，导致寒汁流于肠中，虫子因此因寒而聚集于下脘（即脐上二寸处）。虫子聚集在下脘，所以肠胃胀满，卫阳之气无法上行营卫，邪气占据其中。虫子因食物而上行，上行则下脘虚而邪气胜，积聚而成壅塞，壅塞则下脘闭阻。“约”就是闭塞的意思。如果壅塞在脘内，按压时疼痛深沉；壅塞在脘外，按压时疼痛浮浅；壅塞处的皮肤发热，因为阻塞闭在于下，所以饮食要过一段时间才吐出。
楠按语：《素问·阴阳别论》说：“一阳发病，其传为膈。”又说：“三阳结，谓之隔。”所谓“一阳”，指的是少阳经。少阳主枢机，枢机生病则气机阻滞不能运转，所以久而久之传变为膈病。所谓“三阳”，指的是太阳经。太阳主开泄，其气由内达外，如果经脉结滞而不能开启，则内部阻隔而不流通。这都是指阳气郁逆而形成膈病，也就是本条所说的“气为上膈”。又提到“下膈”，是因为寒汁流于肠中，积聚凝结而成痈，治疗应当以通阳破瘀为主，其病因病机与“一阳发病”、“三阳结”的证候来源不同。另外提到“卫气不营”，是因为卫气起于下焦，营气起于中焦，卫气自下而上升，与营气交通，经由胸部分行营卫。如今下脘有积聚，卫气不能与营气相交，导致阴阳正气失位，邪僻之气占据，并充塞胀满于肠胃，所以饮食经过一段时间后不化而复出，这与后世所称的“反胃病”相似。
In the *Ling Shu: Shang Ge Pian* chapter, the Yellow Emperor asked: "Qi stagnation causing Upper Ge (obstruction above) manifests as food and drink being vomited immediately after ingestion; I already understand this. Regarding Lower Ge (obstruction below) caused by parasites, where food is vomited only after a period of time has passed since eating, I do not grasp the rationale behind it and wish to hear your complete explanation." Qibo replied: "If emotions such as joy and anger are imbalanced, dietary intake lacks moderation, and exposure to cold or heat is irregular, then cold fluids will flow into the intestines. When these cold fluids flow into the intestines, the parasites become cold. When parasites become cold, they accumulate and gather, residing at the Xia Wan (lower opening of the stomach). This causes the intestines and stomach to become distended and expanded, preventing the Wei Qi (Defensive Qi) from circulating normally, allowing pathogenic factors to occupy the space. When a person eats, the parasites move upward to feed. As they move upward, the Xia Wan becomes deficient. When the Xia Wan is deficient, pathogenic factors prevail. The accumulated material remains stagnant; if it stays for too long, an abscess forms. Once the abscess forms, the Xia Wan becomes constricted and obstructed. If the abscess is within the lumen, pressing on it causes deep pain; if the abscess is outside the lumen, the pain on the surface is superficial, and the skin over the abscess feels hot."
Ma Shi commented: "The 'Ge' refers to the diaphragm membrane, which aligns anteriorly with the Jiutui point (CV15) and posteriorly with the eleventh thoracic vertebra. Its function is to block turbid Qi, preventing it from ascending to harass the Heart and Lungs. However, diseases located above the diaphragm are caused by Qi stagnation, where food and drink enter and are immediately regurgitated. Diseases located below the diaphragm are caused by parasite accumulation, where food and drink remain for about one shichen (two hours) before being expelled. This results from emotional imbalance, irregular diet, and improper temperature regulation, leading to cold fluids flowing into the intestines. Consequently, parasites gather in the Xia Wan due to cold (located two cun above the umbilicus). Because parasites gather at the Xia Wan, the intestines and stomach become distended, and Wei Yang Qi cannot ascend to nourish, allowing pathogenic factors to reside. The parasites move upward due to food intake; upon moving up, the Xia Wan becomes deficient, allowing pathogenic factors to prevail. Accumulation leads to obstruction, and obstruction leads to constriction ('Yue' means closure). If the obstruction is inside the stomach tube, pressing causes deep pain; if outside, pressing causes superficial pain; the skin over the obstruction is hot because the blockage is lower down, so food and drink take time to pass through.
Nan's analysis states: The *Su Wen: Yin Yang Bie Lun* says: 'When Yi Yang (the first Yang channel) is affected, its transmission leads to Ge.' It also says: 'San Yang (the three Yang channels) becoming knotted is called Ge.' 'Yi Yang' refers to the Shaoyang channel. Shaoyang governs the pivot mechanism; when the pivot is diseased, Qi stagnates and fails to rotate, eventually transmitting into a Ge disease. 'San Yang' refers to the Taiyang channel. Taiyang governs opening and releasing; its Qi moves from interior to exterior. If the channel is knotted and cannot open, internal obstruction occurs without circulation. These all refer to Yang Qi depression and rebellion causing Ge disease, which corresponds to the 'Qi causing Upper Ge' mentioned in this text. Regarding 'Lower Ge,' it arises because cold fluids flow into the intestines, accumulating and knotting to form an abscess. Treatment should primarily focus on unblocking Yang and breaking blood stasis. Its etiology differs from that of 'Yi Yang onset' and 'San Yang knotting.' Furthermore, regarding 'Wei Qi failing to circulate,' Wei Qi originates in the Lower Jiao, while Ying Qi (Nutritive Qi) originates in the Middle Jiao. Wei Qi ascends from below and communicates with Ying Qi, distributing Ying and Wei via the chest. Now, due to accumulation in the Xia Wan, Wei Qi cannot interact with Ying Qi, causing the upright Qi of Yin and Yang to lose their proper position, allowing abnormal pathogenic Qi to occupy and distend the intestines and stomach. Thus, food and drink remain undigested and are regurgitated after a delay, resembling what later generations termed Fan Wei disease (regurgitation)."