（《灵枢·上膈篇》全 附∶膈证治按）
黄帝曰∶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。（此
言膈证有上下之分，而复有因气因虫之异也。因于气则病在上，故食饮一入，实时还出；因于虫则病在下，故食入 时
而复出。 时，周时也。愚按∶上膈下膈，即膈食证也。此在本经，自有正条，奈何后世俱以脉之关格，认为膈证，既
不知有上下之辨，亦不知有虫气之分，其谬甚矣。 音醉。）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，则肠胃充郭，卫气不营，邪气居之。（凡伤胃气，则阳虚而寒汁流于肠中，虫
寒不行，则聚于下管而肠胃充满也。卫气，脾气也。脾气不能营运，故邪得聚而居之。管，脘同。郭，廓同。）人食则虫
上食，虫上食则下管虚，下管虚则邪气胜之，积聚以留，留则痈成，痈成则下管约。（虫寒闻食，则喜而上求之，上则邪
气居之而乘虚留聚，以致痈于下脘，要约不行，故食入 时复出也。痈，壅同。如《论疾诊尺篇》曰目窠微痈者，义亦
犹此。）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。（管之内外，即言下脘也。邪伏于中，故热
见于皮肉之上。）黄帝曰∶刺之奈何？岐伯曰∶微按其痈，视气所行，（察其气所必由以刺之也。）先浅刺其旁，稍内益深，
还而刺之，毋过三行。（先浅刺其旁气所及之处，稍纳其针而渐深之，以泄其流行之邪，然后还刺其所病之正穴，以拔其
积聚之本；但宜至再至三而止，不可过也。）察其沉浮，以为深浅，已刺必熨，令热入中，日使热内，邪气益衰，大痈乃
溃。（邪沉者深刺之，邪浮者浅刺之，刺后必熨以火而日使之热，则气温于内而邪自溃散也。溃音会。）伍以参禁，以除
其内，恬 无为，乃能行气，（三相 为参，五相伍为伍。凡食息起居，必参伍宜否，守其禁以除内之再伤。又必恬 无
为，以养其气，则正气乃行，而邪气庶乎可散。盖膈证最为难愈，故当切戒如此。恬音甜。 音淡。）后以咸苦化，谷乃
下矣。（咸从水化，可以润下软坚，苦从火化，可以温胃，故皆能下谷也。苦味详按，见运气类十七，少阴司天条下。愚
按∶上文云气为上膈者，食饮入而还出。夫气有虚实，实而气壅，则食无所容，虚而气寒，则食不得化，皆令食入即出
也。至若虫为下膈者，虫上食则下脘虚，其寒汁流于肠中，而后致痈滞不行，则亦因阳气之虚于下，故食入周时复出也。
然余尝治一中年之妇患此证者，因怒因劳，皆能举发，发时必在黄昏，既痛且吐，先吐清涎，乃及午食，午食尽，乃及
早食，循次而尽，方得稍息，日日如是，百药不效。乃相延视，则脉弦而大。余曰∶此下膈证也。夫弦为中虚，大为阴
不足。盖其命门气衰，则食至下焦，不能传化，故直至日夕阳衰之时，则逆而还出耳。乃用八味参杞之属，大补阴中之
阳，随手而应。自后随触随发，用辄随效，乃嘱其加意慎重，调至年余始愈。可见下膈一证，有食入周日复出而不止
时者，有不因虫痈而下焦不通者矣。此篇特言虫痈者，盖亦下膈之一证耳，学人当因是而推展之。）
《灵枢·上膈篇》全文（附：膈证治疗按语）
黄帝说：气逆导致上膈，饮食入口后立即吐出，我已经知道了。虫积导致下膈，下膈的症状是食物吃下去很久之后才吐出来，我不明白其中的道理，希望能听您详细讲解。（这里说明膈证有上、下之分，并且病因有因气和因虫的区别。因气致病则病位在上，所以饮食一进入就立刻吐出；因虫致病则病位在下，所以食物吃下去后过一段时间才吐出。“时”指一周的时间。我按语认为：上膈和下膈，就是膈食证。这在《内经》本经中有正条论述，为何后世都将脉象中的“关格”认为是膈证，既不知道有上下的区别，也不知道有虫和气的区分，这种错误太严重了。“音醉”。）
岐伯说：喜怒情绪不适，饮食没有节制，寒暖调节不当，就会导致寒湿汁液流注于肠中。寒湿汁液流注于肠中，虫子受寒，虫子受寒就会积聚停滞，守在下脘，导致肠胃充满胀满，卫气不能正常运行，邪气占据其中。（凡是损伤胃气，就会阳气虚而寒湿汁液流注于肠中，虫子受寒不运行，就会聚集在下脘而使肠胃充满。卫气，这里指脾气。脾气不能营运，所以邪气得以为聚而停留。管，同“脘”。郭，同“廓”。）人进食时虫子向上觅食，虫子向上觅食则下脘空虚，下脘空虚则邪气胜之，积聚停留，停留久了就会形成痈脓，痈脓形成则下脘狭窄闭塞。（虫子闻到食物气味，喜欢向上寻找，向上则邪气占据并乘虚留聚，以致在下脘形成痈脓，约束不通，所以食物吃进去后过一周左右才吐出。痈，同“壅”。如《论疾诊尺篇》说目窠微肿者，意义也与此类似。）如果痈在管内，按压时疼痛深沉；如果痈在管外，则痈肿在外而疼痛浅浮，痈处皮肤发热。（管的内外，即指下脘部位。邪气潜伏在中焦，所以热象见于皮肉之上。）
黄帝说：如何针刺治疗？岐伯说：轻轻按压痈处，观察气血运行的情况，（观察气血必然经过的路径以进行针刺。）先在旁边浅刺，稍微深入一些，来回多次针刺，不要超过三次。（先在旁边气血所及之处浅刺，稍纳针而逐渐加深，以泄出流行的邪气，然后回刺病变的正穴，以拔除积聚的根本；但适宜至多两到三次就停止，不可过度。）观察邪气的浮沉，以此决定针刺的深浅，刺完后必须用熨法，使热量进入体内，每天让热气内入，邪气日益衰减，大痈自然溃破。（邪气沉伏的深刺，邪气浮浅的浅刺，刺后必须用火熨，并每天使其温热，则体内气温而邪气自然溃散。“溃”音会。）配合五行相克禁忌，以消除体内的病邪，心境恬淡无为，才能行气通畅，（三相互参为参，五相互伍为伍。凡饮食起居，必参考适宜与否，遵守禁忌以消除内部再次受伤。又必须恬淡无为，以养护正气，则正气乃行，而邪气或许可以消散。因为膈证最为难治愈，所以应当切实戒除这些禁忌。“恬”音甜。“澹”音淡。）随后用咸味和苦味的药物化解，谷物就能下行矣。（咸味从水化，可以润下软坚；苦味从火化，可以温胃，所以都能帮助谷物下行。苦味的详细分析见运气类十七，少阴司天条下。我按语认为：上文说气逆导致上膈，饮食入口立即吐出。气有虚实，实则气机壅塞，食物无处容纳；虚则气寒，食物无法消化，都导致食入即出。至于虫积导致下膈，虫子向上觅食则下脘空虚，寒湿汁液流注肠中，而后导致痈滞不行，这也是因为下焦阳气虚弱，所以食物吃进去一周左右才吐出。然而我曾经治疗一位中年妇女患此证，因愤怒和劳累都会诱发，发作时间一定在黄昏，既疼痛又呕吐，先吐出清涎，然后是中午吃的食物，中午食物吐尽，然后是早上吃的食物，依次吐完，才能稍微休息，日日如此，百药无效。于是请我去看，脉象弦而大。我说：这是下膈证。弦脉主中虚，大脉主阴不足。大概是因为命门气衰，食物到达下焦，不能传化，所以直到日落夕阳衰微之时，气逆而上吐出。于是使用八味丸加人参、枸杞之类的方剂，大补阴中之阳，随手见效。此后每次触发都发作，用药随即有效，于是嘱咐她加意慎重，调养了一年多才痊愈。可见下膈这一证候，有食物吃进去一周左右才吐出且不止一次的，也有不因虫痈而是下焦不通导致的。这篇专门讲虫痈，大概也是下膈的一种证候罢了，学习的人应当由此推展理解。）
The full text of *Ling Shu: Shang Ge Pian* (Appendix: Notes on the Treatment of Ge Syndrome)
Huangdi said: Qi reversal causing Upper Ge, where food and drink are ingested and immediately regurgitated, I already understand this. Parasites causing Lower Ge, where Lower Ge is characterized by food being regurgitated only after a period of time has passed since ingestion; I do not yet grasp the rationale behind this and wish to hear it explained thoroughly. (This passage indicates that Ge syndrome is divided into upper and lower types, with etiologies differing between Qi stagnation and parasitic accumulation. When caused by Qi, the pathology is located superiorly, so food and drink are regurgitated immediately upon entry; when caused by parasites, the pathology is located inferiorly, so food is regurgitated after a duration. "Shi" refers to a cycle or period. My commentary notes: Upper Ge and Lower Ge refer to the syndrome of dysphagia and vomiting (Ge Shi). This has its own primary discussion in the *Nei Jing*. Why did later generations mistake the pulse pattern of Guan-Ge for Ge syndrome? They failed to distinguish between upper and lower locations and between Qi and parasitic causes, which is a significant error. "Zui" is the pronunciation.)
Qibo said: Inappropriate emotions such as anger and joy, unregulated diet, and irregular exposure to cold and warmth cause cold fluids to flow into the intestines. When cold fluids flow into the intestines, the parasites become cold; when parasites become cold, they accumulate and stagnate, residing in the Lower Wan (lower epigastrium), causing distension and fullness of the stomach and intestines, preventing the Wei Qi (Defensive Qi) from circulating normally, allowing pathogenic factors to occupy the space. (Any damage to Stomach Qi leads to Yang deficiency and the flow of cold fluids into the intestines. When parasites become cold and cease moving, they gather in the Lower Wan, filling the stomach and intestines. Here, Wei Qi refers to Pi Qi (Spleen Qi). Since Spleen Qi cannot circulate and nourish, pathogenic factors can accumulate and reside. "Guan" is synonymous with "Wan". "Guo" is synonymous with "Kuo".) When a person eats, the parasites move upward to feed. When parasites move upward, the Lower Wan becomes deficient. When the Lower Wan is deficient, pathogenic factors prevail, leading to accumulation and stagnation. Prolonged stagnation results in the formation of an abscess (Yong). Once the abscess forms, the Lower Wan becomes constricted and obstructed. (Parasites, smelling food, prefer to seek it upward. Upward movement allows pathogenic factors to occupy the space and accumulate due to deficiency, leading to an abscess in the Lower Wan. The constriction prevents passage, hence food is regurgitated after a cycle. "Yong" is synonymous with "Yong" (obstruction/blockage). As stated in *Lun Ji Zhen Chi Pian*, slight swelling of the eye sockets implies a similar meaning.) If the abscess is inside the lumen, pressure elicits deep pain; if the abscess is outside the lumen, the swelling is external and the pain is superficial, accompanied by heat on the skin overlying the abscess. (Internal and external of the lumen refer to the Lower Wan. Pathogens hidden within manifest heat on the surface muscles and skin.)
Huangdi asked: How should acupuncture be applied? Qibo replied: Gently press the abscess area to observe the course of Qi circulation. (Observe the pathways where Qi must travel to guide needling.) First, needle shallowly around the periphery, then gradually deepen the insertion. Repeat the needling but do not exceed three passes. (First, needle shallowly at the periphery where Qi reaches, slightly inserting the needle and gradually deepening it to drain circulating pathogens. Then, return to needle the primary acupoint of the disease to extract the root of the accumulation; however, limit this to two or three times and stop, avoiding excess.) Observe the depth of the pathogen (floating or sinking) to determine needle depth. After needling, apply moxibustion or warming therapy (Wen) to introduce heat into the interior. Daily application of internal heat will cause the pathogenic factor to decline further, leading to the rupture of the large abscess. (Deeply needle sinking pathogens, shallowly needle floating pathogens. After needling, apply fire warming daily to maintain internal warmth, causing the pathogen to disperse spontaneously. "Kui" is pronounced "Hui".) Combine these methods with the Five Elements prohibitions to eliminate internal pathogens. Maintain a state of tranquility and non-action (Dan) to allow Qi to flow freely. (Three elements interrelating form "Can"; five elements interweaving form "Wu". Regarding diet, rest, and daily life, one must assess appropriateness and observe prohibitions to prevent internal re-injury. Furthermore, one must remain tranquil and inactive to nourish Zheng Qi (Upright Qi), allowing it to circulate so that pathogenic factors may dissipate. Since Ge syndrome is particularly difficult to cure, such precautions are essential. "Tian" is pronounced "Tian". "Dan" is pronounced "Dan".) Subsequently, use salty and bitter flavors to resolve the condition, allowing grain to descend. (Salty flavor transforms via Water, moistening the lower body and softening hardness; bitter flavor transforms via Fire, warming the Stomach. Thus, both facilitate the descent of grain. Detailed analysis of bitter flavor is found in the Luck Category, Section 17, under the heading of Shaoyin ruling Heaven. My commentary notes: The earlier text mentioned Qi reversal causing Upper Ge, where food is regurgitated immediately. Qi can be Excess or Deficient. Excess Qi causes obstruction, leaving no room for food; Deficient Qi causes cold, preventing digestion. Both lead to immediate regurgitation. Regarding Lower Ge caused by parasites, parasite feeding empties the Lower Wan, cold fluids flow into the intestines, and subsequent stagnation/abscess formation is due to Yang deficiency in the Lower Jiao. Hence, food is regurgitated after a cycle. However, I once treated a middle-aged woman with this syndrome. Anger and fatigue triggered attacks, always occurring at dusk. She experienced pain and vomiting, first clearing clear saliva, then midday food, then morning food, sequentially emptying before finding relief. This persisted daily despite various medicines. Upon examination, her pulse was Wiry (Xian) and Large (Da). I diagnosed this as Lower Ge. Wiry indicates Middle Deficiency; Large indicates Yin insufficiency. Her Mingmen Qi was declining, so food reaching the Lower Jiao could not be transformed and transmitted. Consequently, during the time of sunset when Yang declines, the Qi reversed and was vomited up. I prescribed Ba Wei Dan (Eight-Ingredient Pill) supplemented with Ren Shen (Ginseng) and Gou Qi Zi (Goji Berry) to strongly tonify Yang within Yin. The response was immediate. For subsequent episodes, each treatment was effective. I advised her to be extremely cautious and regulate her lifestyle. She recovered after more than a year of regulation. This demonstrates that Lower Ge includes cases where food is regurgitated after a week or more, and cases not caused by parasites or abscesses but by Lower Jiao obstruction. This chapter specifically discusses parasitic abscesses, which are merely one type of Lower Ge. Students should extrapolate from this understanding.)