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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.)