病派之分，自巢氏始也。病失其本，亦自巢氏始也。何者？老子曰∶少则得，多
则惑。且俗谓噎食一证，在《内经》苦无多语，惟曰∶三阳结，谓之膈。三阳者，谓大肠、
小肠、膀胱也。结，谓结热也。小肠热结则血脉燥；大肠热结则后不圊；膀胱热结则津液涸。三阳既结
则前后闭塞。下既不通，必反上行，此所以噎食不下，纵下而复出也。
谓胃为水谷之海，日受
其新，以易其陈，一日一便，乃常度也。今病噎者，三日、五日，或五、七日不便，是乖其度也
，亦明矣。岂非三阳俱结于下，广肠枯涸，所食之物，为咽所拒。纵入太仓，还出咽嗌。此
阳火不下，推而上行也。故经曰∶少阳所至为呕涌，溢食不下，此理岂不晓然？又《气厥论》云∶
肝移寒于心为狂膈中阳气与寒相搏，故膈食而中不通，此膈阳与寒为之也，非独专于寒
也。《六节脏象》又云∶人迎四盛以上为格阳。王太仆云∶阳盛之极，故膈拒而食不得入。
《正理论》曰∶格则吐逆。故膈亦当为格。
后世强分为五噎，谓气、忧、食、思、劳也。后又分
为十膈五噎。其派既多，其惑滋甚。人之溢食，初未必遽然也。初，或伤酒食，或胃热欲吐。或胃风欲吐，
医氏不察本原，火里烧姜，汤中煮桂，丁香未已，豆蔻继之，荜茇未已，胡椒继之。虽曰和胃
，胃本不寒；虽曰补胃，胃本不虚。设如伤饮止可逐饮；设如伤食，止可逐食。岂可言虚，
便将热补？《素问》无者，于法犹非。素热之人，三阳必结，三阳既结，食必上潮。医氏犹云
∶胃寒不纳。燔针钻肉，炷艾灼肌，苦楚万千。三阳热结，分明一句，到了难从。不过抽薪最
为紧要，扬汤止沸，愈急愈增。岁月弥深，为医所误。人言可下，退阳养阴。张眼吐舌，恐
伤元气。止在冲和，闭塞不通，经无来路，肠宜通畅，是以鸣肠。肠既不通，遂成噎病。
世传五噎宽中散，有姜有桂；十膈散，有附有乌。今予既斥其方，信乎与否，以听后贤。或云
∶忧恚气结，亦可下乎？余曰∶忧恚磐礴，便同火郁，太仓公见此皆下。法废以来，千年不
复。今代刘河间治膈气噎食，用承气三汤，独超近代。今用药者，不明主使，如病风狂嘻嘻
，不及观其效，犹昧本原，既懒问咨，妄兴非毁。今予不恤，姑示后人。用药之时，更详轻
重。假如闭久，慎勿陡攻，纵得攻开，必虑后患，宜先润养，小着汤丸，累累加之，关扃自
透。其或咽噎，上阻涎痰，轻用苦酸，微微涌出，因而治下，药势易行。设或不行，蜜盐下
导，始终勾引，两药相通，结散阳消，饮食自下。莫将巴豆，耗却天真，液燥津枯，留毒不
去。人言此病，曾下夺之，从下夺来，转虚转痞。此为巴豆，非大黄牵牛之过。箕城一酒官
，病呕吐，逾年不愈，皆以胃寒治之，丁香、半夏、青陈、姜附，种种燥热，烧锥燎艾
，莫知其数。或少愈，或复剧，且十年，大便涩燥，小便赤黄。命予视之。予曰∶诸痿喘呕，皆属于上
。王太仆云∶上，谓上焦也。火气炎上之气，谓皆热甚而为呕。以四生丸下三十行，燥粪肠
垢，何啻数升？其人昏困一、二日，频以冰水呷之，渐投凉乳酪、芝麻饮，时时咽之。数日外
，大啜饮食，精神气血如昔。继生三子，至五旬而卒。
病证的分类，是从巢元方开始的。对疾病本质的误解，也是从巢元方开始的。为什么呢？老子说：“少则得，多则惑。”况且世俗所说的“噎食”这一证候，在《黄帝内经》中并没有过多的论述，只说：“三阳结，谓之膈。”所谓三阳，指的是大肠、小肠和膀胱。“结”，是指热邪郁结。小肠热结则血脉干燥；大肠热结则大便不通；膀胱热结则津液枯竭。三阳经的热邪既然郁结，那么前阴和后阴就会闭塞。下部既不通畅，气机必然反向上行，这就是为什么会出现噎食不下，即使勉强咽下也会吐出来的原因。
胃被称为水谷之海，每天接受新的饮食，以替换陈旧的食物，一天排便一次，这是正常的规律。现在患噎病的人，三天、五天，或者五到七天不便秘，这显然是违背了正常规律，这也是很明显的。难道不是三阳经都在下部郁结，导致广肠（直肠）干枯涸竭，所吃的食物被咽喉拒绝？即使进入太仓（胃），也会从咽喉再吐出来。这是因为阳火不能下行，反而推挤着向上运行。所以医经说：“少阳之气到达人体时表现为呕吐涌逆，饮食不下”，这个道理难道不明显吗？另外，《素问·气厥论》说：“肝将寒邪移传于心，会导致狂症和膈证，因为中焦的阳气与寒邪相互搏结，所以出现膈食且中焦不通，这是膈阳与寒邪相争的结果，并不仅仅是因为寒邪。”《素问·六节脏象论》又说：“人迎脉盛大四倍以上为格阳。”王冰注解说：“阳气盛极，所以格拒而食物无法进入。”《素问·至真要大论》的正理论解释曰：“格则表现为吐逆。”所以“膈”也应当写作“格”。
后世强行将其分为五种噎，即气噎、忧噎、食噎、思噎、劳噎。后来又细分为十膈五噎。其分支派别既然繁多，造成的困惑也就更加严重。人们出现的溢食（反流）现象，起初未必是突然发生的。起初，可能是因为饮酒饮食不当，或者是胃热想要呕吐，或者是胃受风邪想要呕吐。医生们不考察根本原因，就在火里烧姜，在汤中煮桂枝，丁香还没停，豆蔻又跟上，荜茇还没停，胡椒又继上。虽然说是为了调和胃气，但胃本来就不寒；虽然说是为了补胃，但胃本来就不虚。假如是伤于饮邪，只应祛除饮邪；假如是伤于食积，只应消导食积。怎么能说是虚证，就立即使用热性药物来补益？《素问》中没有提到的治法，按照医理来说也是错误的。素来有内热的人，三阳经必然郁结，三阳既已郁结，食物必然会上泛。医生们还说：“胃寒不能纳食。”于是用燔针钻肉，用艾炷灼烧肌肉，患者遭受了万千痛苦。对于“三阳热结”这四个字，明明很清楚，却难以听从执行。不过，抽去柴薪才是最为紧要的，扬汤止沸，越急迫情况越严重。岁月越来越深，是因为被医生误治。有人说可以使用泻下法来退阳养阴，但睁眼吐舌，担心会损伤元气。其实只要保持冲和之气，如果闭塞不通，经络没有来路，肠道应该通畅，所以会有肠鸣。肠道既然不通畅，最终形成噎病。
世间流传的五噎宽中散，含有干姜和桂枝；十膈散，含有附子和乌头。现在我既然斥责这些方剂，信还是不信，留给后世的贤者评判。有人说：“忧愤气结，也可以使用泻下法吗？”我说：“忧愤之气郁结磐礴，便如同火郁一样，汉代太仓公见到这种情况都使用泻下法。自从这种法则废弃以来，千年未能恢复。当今刘河间治疗膈气噎食，使用承气汤类的三种方剂，独自超越近代医家。如今用药的人，不明白药物的主要作用，就像病人发疯嘻嘻笑一样，来不及观察疗效，仍然不明根本原因，既然懒得询问咨询，就妄自兴起非议诋毁。我现在不顾这些，姑且展示给后人看。用药的时候，更要详细斟酌轻重。假如闭结时间很久，千万不要猛烈攻伐，纵然攻开了，也必须顾虑后患，应该先滋润养护，少量服用汤剂或丸药，多次叠加使用，关窍自然通透。如果有咽部噎塞，上部阻碍涎痰，轻微使用苦酸药物，微微引起涌吐，然后顺势治疗下部，药势容易通行。假如仍然不行，用蜜盐作为导引药，始终勾引上下，两药相通，郁结消散，阳气消退，饮食自然下行。不要使用巴豆，耗损人体的真气，导致液燥津枯，留毒不去。有人说这个病，曾经使用过泻下夺实的方法，因为从下面夺实而来，反而变得虚弱痞满。这是巴豆的问题，不是大黄、牵牛子的过错。箕城的一位酒官，患病呕吐，超过一年不好，都用胃寒来治疗，使用丁香、半夏、青皮陈皮、干姜附子等种种燥热药物，还有烧锥烙艾，数量不知多少。有时稍微好转，有时病情加重，这样持续十年，大便涩滞干燥，小便赤黄。请我去诊治。我说：“各种痿证、喘证、呕证，都归属于上焦。”王冰注解说：“上，指的是上焦。”火气炎上的气机，说明都是热盛而导致呕吐。我用四生丸让他泻下三十次，排出的燥粪和肠垢，何止几升？那人昏沉困倦了一两天，频繁地喝冰水，逐渐投喂凉乳酪、芝麻饮，时时吞咽。几天之后，大口饮食，精神气血恢复如昔。后来生了三个儿子，直到五十岁去世。
The classification of disease categories originated with Chao Yuanfang. The misunderstanding of the root causes of diseases also originated with Chao Yuanfang. Why? Laozi said, "To have little is to gain; to have much is to be confused." Moreover, the so-called "Yi Shi" (dysphagia with food retention) syndrome in popular belief has very few mentions in the *Huangdi Neijing* (Yellow Emperor's Inner Canon), which only states: "When the Three Yang channels are knotted, it is called Ge (obstruction)." By "Three Yang," we refer to the Large Intestine, Small Intestine, and Bladder. "Knotting" refers to the stagnation of heat. When heat knots in the Small Intestine, the blood vessels become dry; when heat knots in the Large Intestine, defecation is obstructed; when heat knots in the Bladder, body fluids are depleted. Once the Three Yang channels are knotted, both the anterior and posterior orifices become blocked. Since the lower part is not unblocked, the Qi must reverse and move upward. This is why dysphagia occurs where food cannot go down, and even if forced down, it comes back up.
The Stomach is regarded as the Sea of Water and Grain, receiving new intake daily to replace the old. Defecating once a day is the normal standard. Now, patients suffering from Yi disease may go three, five, or even five to seven days without defecation. This clearly deviates from the normal standard. Is it not because the Three Yang channels are all knotted at the lower level, causing the Changchang (rectum) to become dry and withered, so that ingested food is rejected by the throat? Even if it enters the Taicang (Stomach), it returns out through the pharynx. This is because Yang Fire does not descend but is pushed upward. Thus, the classics state: "Where Shaoyang reaches, there is vomiting and surging, overflow, and inability to ingest food." Is this principle not obvious? Furthermore, the *Qi Jue Lun* (Treatise on Qi Reversal) says: "When Liver transfers cold to the Heart, it results in Kuang (mania) and Ge (obstruction). The Yang Qi in the middle jiao contends with the cold, causing obstruction of food and blockage in the middle. This is caused by the contention between Ge Yang and cold, not solely by cold." The *Liu Jie Zang Xiang* (Six Sections of Viscera Manifestations) also states: "When the Renying pulse is four times fuller than normal, it is called Ge Yang." Wang Bing (Wang Taipu) commented: "Extreme excess of Yang leads to rejection, preventing food from entering." The *Zheng Li Lun* (Theory of Regular Principles) states: "Ge manifests as vomiting and reversal." Therefore, "Ge" should also be written as "Ge" (rejection).
Later generations arbitrarily divided it into Five Types of Yi: Qi Yi (Qi-type), You Yi (Sorrow-type), Shi Yi (Food-type), Si Yi (Thought-type), and Lao Yi (Exhaustion-type). Later, it was further subdivided into Ten Types of Ge and Five Types of Yi. With so many branches, the confusion became even more profound. The phenomenon of regurgitation in people did not necessarily occur suddenly at first. Initially, it might be due to injury from alcohol or food, or stomach heat wanting to vomit, or stomach wind wanting to vomit. Physicians, failing to investigate the root cause, would roast ginger in fire and boil Cinnamon Twig (Guizhi) in decoctions. After Dingxiang (Clove) came Doukou (Cardamom); after Bibai (Long Pepper) came Hujiao (Pepper). Although they claimed to harmonize the Stomach, the Stomach was originally not cold; although they claimed to tonify the Stomach, the Stomach was originally not deficient. If injured by fluid retention, one should only dispel the fluid; if injured by food stagnation, one should only resolve the food. How can one speak of deficiency and immediately use hot tonics? Methods not found in the *Suwen* are contrary to medical principles. In individuals with inherent heat, the Three Yang channels must knot; once knotted, food will inevitably reflux. Yet physicians still claim: "Cold Stomach fails to receive." They use burning needles piercing flesh and moxa burning muscle, inflicting countless sufferings. The phrase "Three Yang Heat Knotting" is clear, yet difficult to follow. The most crucial method is removing the firewood (addressing the root); stirring boiling water to stop boiling only makes it worse. As years passed, errors accumulated due to medical mismanagement. Some argue for purgation to withdraw Yang and nourish Yin, fearing damage to Yuan Qi. However, maintaining harmony is key. If blocked, meridians have no path, intestines should be patent, hence borborygmus. If intestines are blocked, Yi disease forms.
The widely circulated Wuzhe Kuanzhong San contains Ginger and Cinnamon Twig; Shige San contains Aconite and Aconitum. Since I have criticized these formulas, let future sages judge their validity. Someone asks: "Can purgation be used for Qi knotting due to sorrow?" I reply: "Sorrowful Qi stagnation is similar to Fire Depression. Tai Cang Gong treated such cases with purgation. Since this method was abandoned, it has not been restored for a millennium. Today, Liu Hejian treats Ge Qi and Yi Shi using Chengqi Decoction variants, surpassing modern practitioners. Current prescribers do not understand the primary agents. Like a madman laughing, they fail to observe efficacy and remain ignorant of the root. Lazy to consult, they rashly criticize. I disregard this and show this to posterity. When prescribing, carefully consider severity. If obstruction is long-standing, do not attack abruptly. Even if opened, worry about sequelae. First, moisten and nourish. Use small doses of decoctions or pills repeatedly until the gates open naturally. If there is throat blockage with saliva and phlegm above, mildly use bitter and sour substances to induce slight vomiting, then treat the lower part, allowing medicinal force to flow easily. If still ineffective, use honey and salt as guides, connecting upper and lower. The knot disperses, Yang dissipates, and food descends naturally. Do not use Croton Seed (Badou) to deplete True Essence, leading to dry fluids and retained toxins. People say this disease resulted from previous purgative depletion, causing weakness and fullness. This is Badou's fault, not Dahuang or Niuxi's. An official in Jicheng suffered vomiting for over a year, treated as Cold Stomach with Clove, Pinellia, Tangerine Peel, Ginger, and Aconite—various drying and heating herbs, plus burning cones and moxa. Condition fluctuated for ten years, with dry stool and dark yellow urine. I examined him. I said: 'All Wei, Chuan, and Ou syndromes belong to the Upper Jiao.' Wang Bing noted: 'Upper refers to the Upper Jiao.' Flaming fire Qi rises, indicating excessive heat causing vomiting. I administered Sisheng Wan, inducing thirty purgations, expelling dry feces and intestinal filth, several sheng in volume. The patient was dazed for one or two days, frequently sipping ice water, gradually consuming cool yogurt and sesame drink. Days later, he ate heartily, recovering his spirit and Qi/Blood. He later had three sons and died at fifty."