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。）
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.)