噎膈、翻胃、关格三者。名各不同。病原迥异。治宜区别。不
可不辨也。噎膈者。饥欲得食。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
入胃下。无不消化。不复出矣。唯男子年高者有之。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。或积至一日一夜。腹中胀闷不可忍而复吐。原物酸臭不化。此已入胃而
反出。故曰翻胃。男女老少皆有之。关格者。粒米不欲食。渴喜茶水饮之。少顷即吐出。复求饮复吐。饮之以
药。热药入口即出。冷药过时而出。大小便秘。名曰关格。关者下不得出也。格者上不得入也。唯女人多有此证。
论噎膈。丹溪谓得之七情六淫。遂有火热炎上之化。多升少降。津液不布。积而为痰为饮。被劫时暂得快。
不久复作。前药再行。积成其热。血液衰耗。胃脘干槁。其槁在上。近咽之下。水饮可行。食物难进。食亦
不多。名之曰噎。其槁在下。与胃为近。食虽可入。难尽入胃。良久复出。名之曰膈。亦曰反胃。大
便秘少。若羊矢然。必外避六淫。内节七情。饮食自养。滋血生津。以润肠胃。则金无畏火之炎。肾有生水之
渐。气清血和。则脾气运健。而食消传化矣。丹溪之论甚妙。但噎膈翻胃。分别欠明。余独喜其火热炎上之
化。肾有生水之渐二句。深中病源。惜其见尤未真。以润血为主。而不直探乎肾中先天之原。故其立
方。以四物中牛羊乳之类。加之竹沥韭汁化痰化瘀。皆治标而不治本也。岂知内经原无多语。唯曰三阳结谓之
膈。三阳者。大肠小肠膀胱也。结谓结热也。大肠主津。小肠主液。大肠热结则津涸。小肠热结则液燥。膀胱
为州都之官。津液藏焉。膀胱热结。则津液竭。然而三阳何以致结热。皆肾之病也。盖肾主五液。又
肾主大小便。肾与膀胱为一脏一腑。肾水既干。阳火偏盛。熬煎津液。三阳热结。则前后闭涩。下既不通。
必反于上。直犯清道。上冲吸门喉咽。所以噎食不下也。何为水饮可入。食物难下。盖
食入于阴。长气于阳。反引动胃口之火。故难入。水者阴类也。同气相投。故可入口。吐白沫者。所饮之水。
沸而上腾也。粪如羊矢者。食入者少。渣滓消尽。肠亦干小而不宽大也。此证多是男子年高五十以外得之。又
必其人不绝色欲。潜问其由。又讳疾忌医。曰近来心事不美。多有郁气而然。予意郁固有之。或以
郁故。而为消愁解闷之事。不能无也。此十有八九。亦不必深辨。但老人天真已绝。只有孤阳。只以养阴为
主。王太仆云。食入即出。是无水也。食久反出。是无火也。无水者。壮水之主。无火者。益火之源。褚侍中
云。上病疗下。直须以六味地黄丸料大剂煎饮。久服可挽于十中之一二。又须绝嗜欲。远房帏。薄滋
味。可也。若曰温胃。胃本不寒。若曰补胃。胃本不虚。若曰开郁。香燥之品。适以助火。局方发挥。已有
明训。河间刘氏下以承气。咸寒损胃。津液愈竭。无如补阴。焰光自灭。世俗不明。余特详揭。
论反胃。金匮要略云。趺阳脉浮而涩。浮则为虚。涩则为伤脾。脾伤则不磨。朝食暮吐。暮食朝吐。宿
食不化。名曰反胃。予阅函史列传。有一医案云。病反胃者。每食。至明日清晨皆出不化。医以暖胃药投之罔
效。脉甚微而弱。有国工视之。揆诸医所用药。元远于病而不效。心歉然未有以悟也。读东垣书。谓吐有
三证。气积寒也。上焦吐者从气。中焦吐者从积。下焦从寒。今脉沉而迟。朝食暮吐。暮食朝吐。小便利大便
秘。此下焦吐也。法当通其闭温其寒。乃遂跃然。专治下焦散其寒。徐以中焦药和之而愈。观此可见下焦吐
者。乃命门火衰。釜底无薪。不能蒸腐胃中水谷。腹中胀满。不得不吐也。王太仆所谓食久反出。
是无火也是矣。须用益火之原。先以八味地黄丸补命门火。以扶脾土之母。徐以附子理中汤理中焦。万举
万全。不知出此。而徒以山楂神曲平胃化食。适以速其亡也。
论关格者。忽然而来。乃暴病也。大小便秘。渴饮水浆。少顷则吐。又饮又吐。唇燥眼珠微红。面赤或不
赤。甚者或心痛或不痛。自病起。粒米不思。滴水不得下胃。饮一杯吐出怀半。数日后脉亦沉伏。此寒从
少阴肾经而入。阴盛于下。逼阳于上。谓之格阳之证。名曰关格。关格者。不得尽其命而死矣。须
以仲景白通汤。用内经寒因热用之法。经曰。若调寒热之逆。冷热必行。则热物冷服。下咽之后。冷性既除。
热性始发。由是病气随愈。呕哕皆除。情且不违。而致大益。此和人尿猪胆汁咸苦寒之物。于白通汤中。要
其气相从。可以去拒格之寒也。服药后。脉渐出者生。脉乍出者死。陶节庵杀车槌中。有回阳反
本汤极妙。愈后须以八味丸常服。不再发。
又有一种肝火之证。亦呕而不入。但所呕者酸水。或苦水。或青蓝水。惟大小便不秘。亦能作心痛。此
是火郁木郁之证。木郁则达之。火郁则发之。须用茱连浓煎。细细呷之。再服逍遥散
而愈。愈后须以六味丸调理。
噎膈、翻胃、关格这三种病证，名称各不相同，病因也截然不同，治疗应当加以区别，不可不仔细辨别。
所谓噎膈，是指患者感到饥饿想吃东西，但食物在咽喉胸膈之间发生阻塞逆反，位置在胃口之上，尚未进入胃中，随即带着痰涎吐出。如果食物一旦进入胃中，没有不能消化的，也不会再吐出来。这种情况多见于年长的男性，年轻人没有噎膈之症。
所谓翻胃，是指饮食量比平时加倍，且都能完全进入胃中。但是早晨吃的晚上吐出来，晚上吃的早晨吐出来，或者过一两个时辰就吐，或者积聚到一天一夜，腹中胀闷难以忍受才再次呕吐。吐出的仍是原物，气味酸臭且未消化。这是因为食物已经入胃却反而吐出，所以称为翻胃。男女老少都可能有此病。
所谓关格，是指连一粒米都不想进食，口渴喜欢喝茶水，喝下去不久就吐出来，想再喝又吐。用热药喂服，入口即吐；用冷药喂服，过一段时间才吐。大小便闭塞不通，这叫做关格。“关”是指下部排泄不通，“格”是指上部摄入不进。这种病症女性多见。
关于噎膈的论述，朱丹溪认为其病因是七情（喜、怒、忧、思、悲、恐、惊）和六淫（风、寒、暑、湿、燥、火）侵袭，导致体内产生火热炎上的变化，气机多升少降，津液不能布散，积聚而成痰饮。被劫持时暂时感觉畅快，但不久后病情复发，之前的药物再次使用，积热更甚，导致血液衰耗，胃脘干燥枯槁。如果枯槁部位在上部，靠近咽喉之下，水饮可以下行，但食物难进，吃得也不多，这叫“噎”。如果枯槁部位在下部，靠近胃腑，食物虽然可以进入，但难以全部进入胃中，很久之后又吐出来，这叫“膈”，也叫“反胃”。大便干结量少，像羊屎一样。治疗必须外避六淫邪气，内调七情情绪，饮食自我调养，滋养血液生津液，以滋润肠胃，这样肺金就不畏惧心火的炎上，肾水有逐渐生发的机会，气清血和，脾气运化健旺，食物就能消化传导了。朱丹溪的论述非常精妙，但他对噎膈和翻胃的区别阐述得不够清晰。我唯独欣赏他关于“火热炎上”和“肾有生水之渐”这两句话，深深切中病因要害。可惜他的见解还不够真切，主张以润血为主，而没有直接探究肾中先天的本源。所以他制定的方剂，多以四物汤中加入牛羊乳之类，再加竹沥、韭汁来化痰化瘀，这些都是治标而不治本的方法。
哪里知道《内经》原文并没有多说，只说“三阳结谓之膈”。这里的三阳，指的是大肠、小肠和膀胱。“结”意为结热。大肠主司津液，小肠主司体液。大肠热结则津液枯竭，小肠热结则体液干燥。膀胱是州都之官，储藏津液。膀胱热结，则津液耗尽。然而三阳为何会导致结热？这都是肾脏的疾病。因为肾主五液，又主管大小便。肾与膀胱是一脏一腑的关系。肾水既然干枯，阳气之火偏盛，煎熬津液，导致三阳热结，于是前后二阴闭塞涩滞。下部既不通畅，热气必然反冲于上，直犯清道，上冲至吸门、喉咽，所以出现吞咽困难、食物不下。为什么水饮可以进入而食物难下？因为食物属阴，进入后会助长阳气，反而引动胃口的火气，所以难以下咽。水属于阴类，同气相投，所以可以入口。呕吐白沫，是因为所饮之水沸腾而上腾所致。粪便像羊屎一样，是因为进食太少，渣滓消尽，肠道也因干燥而变小，不再宽大。此证多是五十岁以上的男子患病，而且必定是此人房事不节制，暗中询问缘由，他又讳疾忌医，说近来心事不顺，多有郁气所致。我认为郁结固然存在，或许是因为郁结的缘故，去做些借酒浇愁解闷的事，这也是难免的。这种情况十有八九，也不必深究辨析。只是老人天真之气已绝，只有孤阳独存，治疗应以养阴为主。王太仆说：“食入即出，是无水也；食久反出，是无火也。”无水者，要壮水之主（滋补肾阴）；无火者，要益火之源（温补肾阳）。褚侍中说：“上部的病要治疗下部，必须用大剂量的六味地黄丸煎服，长期服用，可以从十分危急的情况中挽救一二。”此外还必须戒除嗜好欲望，远离房事，淡薄滋味，才可以。如果说温胃，胃本来不寒；如果说补胃，胃本来不虚；如果说开郁，香燥的药物，恰好会助长火势，《局方》已有明确训诫。河间刘氏主张用承气汤攻下，咸寒之品损伤胃气，使津液更加枯竭，不如补阴，火焰自然熄灭。世俗之人不明此理，我特意详细揭示。
关于反胃的论述，《金匮要略》说：趺阳脉浮而涩，浮则为虚，涩则为伤脾。脾受伤则不能磨化食物，早晨吃的晚上吐，晚上吃的早晨吐，宿食不化，这叫反胃。我阅读《函史列传》，有一个医案记载：患反胃病的人，每次吃饭，到第二天清晨都不消化地吐出来。医生用暖胃药投治无效，脉象非常微弱。有位名医诊视后，考察其他医生所用的药物，认为元气远于病机所以无效，心中惭愧未能领悟。后来读到李东垣的书，他说呕吐有三种证候：气、积、寒。上焦呕吐源于气，中焦呕吐源于积，下焦呕吐源于寒。现在脉象沉而迟，朝食暮吐，暮食朝吐，小便通利而大便秘结，这是下焦呕吐。治法应当通其闭结，温其寒邪。于是豁然开朗，专门治疗下焦，散去寒邪，随后用中焦药物调和而痊愈。由此可以看出，下焦呕吐，乃是命门火衰，釜底无薪，不能蒸腐胃中的水谷，腹中胀满，不得不吐。这正是王太仆所说的“食久反出，是无火也”。应当使用益火之源的方法，先用八味地黄丸补命门之火，以扶持脾土之母（火生土），随后用附子理中汤调理中焦，万无一失。不知道这样做，却只用山楂、神曲、平胃散等化食药物，恰恰加速了他的死亡。
关于关格的论述，突然发作，属于暴病。大小便闭塞，口渴饮水浆，不久就吐出来，喝了又吐。嘴唇干燥，眼珠微红，面色红或不红，严重的或心痛或不痛。从发病起，一粒米也不想吃，滴水不得进入胃中，喝一杯吐半杯。几天后脉象也沉伏。这是寒邪从少阴肾经而入，阴寒盛于下部，逼迫阳气于上部，这叫格阳之证，名为关格。关格证，病人无法尽其天年而死。需要用张仲景的白通汤，运用《内经》“寒因热用”的方法。经文说：“若要调和寒热的逆乱，冷热之气必并行。”即用热药冷服，咽下之后，冷性既除，热性始发，因此病气随之痊愈，呕哕皆除，情理上不违背，从而获得大益。这里加入人尿、猪胆汁这些咸苦寒之物在白通汤中，是为了取其气相从，可以去拒格之寒。服药后，脉象渐渐出现的为可生，脉象乍现乍隐的为死。陶节庵在《杀车槌法》中有回阳反本汤，极为巧妙。痊愈后须常服八味丸，不再复发。
还有一种肝火之证，也是呕吐而不入，但所呕吐的是酸水、苦水或青蓝色的水，大小便并不闭塞，也能引起心痛。这是火郁、木郁的证候。木郁则疏达它，火郁则发散它。需用吴茱萸黄连汤浓煎，细细呷服，再服用逍遥散而痊愈。痊愈后须用六味地黄丸调理。
Yige (Dysphagia with Obstruction), Fanwei (Regurgitation), and Guange (Obstruction and Rejection) are three distinct conditions. Their names differ, their etiologies are radically different, and their treatments must be distinguished; therefore, careful differentiation is indispensable.
Yige refers to a condition where the patient feels hungry and desires food, but food encounters obstruction and regurgitation in the throat and chest-diaphragm region, located above the stomach gate, without entering the stomach. It is expelled immediately along with phlegm and saliva. If food enters the stomach, it is digested and never regurgitated again. This condition occurs mainly in elderly men and is rare in the young.
Fanwei refers to a condition where food intake is double the usual amount and fully enters the stomach. However, morning food is vomited in the evening, and evening food is vomited in the morning, or vomiting occurs after one or two hours, or accumulates for a day and night until unbearable abdominal distension forces vomiting. The vomitus consists of the original food, sour and foul-smelling, undigested. Since the food has entered the stomach but is rejected back out, it is called Fanwei. This condition can affect men, women, the old, and the young alike.
Guange refers to a condition where the patient does not desire to eat even a grain of rice, feels thirsty and prefers drinking tea or water, but vomits shortly after drinking. Repeated drinking leads to repeated vomiting. Hot medicines are vomited immediately upon entry, while cold medicines are vomited after some time. There is constipation of both stool and urine. This is named Guange. "Guan" means inability to excrete from below; "Ge" means inability to ingest from above. This syndrome is more common in women.
Regarding Yige, Zhu Danxi attributed its cause to the Seven Emotions (Joy, Anger, Worry, Pensiveness, Sorrow, Fear, Fright) and Six Exogenous Pathogens (Wind, Cold, Summer-heat, Dampness, Dryness, Fire), leading to a transformation of flaming fire ascending. Qi movement tends to ascend rather than descend, fluids fail to distribute, accumulating into Phlegm and Fluid retention. Although temporary relief may occur when constrained, the condition soon recurs, and previous medications exacerbate the heat accumulation, depleting blood and causing dryness and atrophy of the stomach lining. If the atrophy is upper, near the throat, fluids can pass but food is difficult to enter, resulting in little intake; this is called "Ye" (Choking). If the atrophy is lower, near the stomach, food can enter but cannot fully pass into the stomach, eventually being regurgitated after a long time; this is called "Ge" (Obstruction), also known as "Fanwei". Stool is scanty and dry like sheep droppings. Treatment requires avoiding external pathogens, regulating emotions, self-care in diet, nourishing blood and generating fluids to moisten the intestines and stomach. Thus, Metal (Lung) will not fear Fire inflammation, Kidney Water will have gradual generation, Qi will be clear and Blood harmonious, Spleen Qi will transport vigorously, and food will be digested and transformed. Zhu Danxi's theory is exquisite, yet his distinction between Yige and Fanwei is unclear. I particularly appreciate his statements on "flaming fire ascending" and "Kidney having gradual water generation," which deeply hit the source of the disease. However, his insight was not entirely true; he focused on moistening blood without directly exploring the congenital origin in the Kidney. Therefore, his prescriptions, such as Siwu Tang added with cow/sheep milk, Bamboo Sap, and Leek Juice to resolve phlegm and stasis, treated the branch but not the root.
Did we know that the *Neijing* says little, only stating: "Three Yang knotting is called Ge." Here, Three Yang refers to the Large Intestine, Small Intestine, and Bladder. "Knotting" implies heat stagnation. The Large Intestine governs Jin-Ye (Body Fluids); the Small Intestine governs Ye (Turbid Fluids). Heat knotting in the Large Intestine dries Jin; heat knotting in the Small Intestine dries Ye. The Bladder, the Officer of the Metropolis, stores fluids. Heat knotting in the Bladder exhausts fluids. Why do the Three Yang lead to heat knotting? It is all a disease of the Kidney. The Kidney governs the Five Fluids and controls urination and defecation. The Kidney and Bladder are Zang-Fu pairs. When Kidney Water is dry, Yang Fire becomes excessive, boiling fluids, leading to heat knotting in the Three Yang, causing blockage of the rear and front orifices. Since the lower pathway is blocked, heat must rebound upwards, attacking the clear pathways, rushing up to the Xi-Men (Inhalation Gate) and throat, causing dysphagia. Why can fluids enter but food cannot? Food enters Yin but generates Qi in Yang, thereby stirring up the fire in the stomach gate, making entry difficult. Water belongs to Yin, sharing similar energies, so it can enter. Vomiting white foam indicates that the ingested water boils and rises. Stool like sheep droppings occurs because little food is ingested, residues are consumed, and the intestine shrinks due to dryness. This condition mostly affects men over fifty who indulge in sexual activity. Often, they hide their illness, claiming recent mental distress and Qi stagnation caused it. While stagnation exists, it often stems from seeking solace through alcohol or other means. In eight or nine cases out of ten, this need not be debated deeply. However, the elderly have exhausted their innate essence, possessing only isolated Yang. Treatment must primarily nourish Yin. Wang Taipu stated: "Food vomited immediately after eating indicates lack of Water; food vomited after a long time indicates lack of Fire." For lack of Water, strengthen the Master of Water (nourish Kidney Yin); for lack of Fire, benefit the Source of Fire (warm Kidney Yang). Chu Shizhong said: "Treat upper diseases by treating the lower; use large doses of Liuwei Dihuang Wan decoction, taken long-term, to save one or two out of ten lives." One must also abstain from desires, avoid sexual intercourse, and eat bland foods. To say the stomach is cold and needs warming is wrong, as the stomach is not inherently cold. To say it is deficient and needs tonifying is wrong, as it is not inherently deficient. To say it needs opening stagnation using aromatic-dry herbs merely aids Fire, as clarified in the *Ju Fang*. Liu Hejian advocated using Chengqi Tang to purge, but salty-cold herbs damage the Stomach and exhaust fluids further. Instead, nourishing Yin extinguishes the flame naturally. Laypeople do not understand this; I specifically elucidate it here.
Regarding Fanwei, the *Jingui Yaolue* states: "The Fuyang pulse is floating and choppy. Floating indicates deficiency; choppy indicates Spleen injury. The injured Spleen fails to digest, leading to morning food vomited in the evening and evening food vomited in the morning, with undigested retained food, named Fanwei." I read a case in *Han Shi Lie Zhuan*: A patient with Fanwei vomited undigested food every morning from the previous day's meal. Doctors used warm-stomach medicines without effect. The pulse was very faint and weak. An expert physician examined the patient, realizing that previous treatments missed the root cause. Reading Li Dongyuan's works, he noted three types of vomiting: Qi, Accumulation, and Cold. Upper Jiao vomiting stems from Qi; Middle Jiao from Accumulation; Lower Jiao from Cold. With a deep, slow pulse, morning food vomited in the evening, clear urine, and constipation, this was Lower Jiao vomiting. The method should be to unblock closure and warm cold. He then focused on dispersing cold in the Lower Jiao and later harmonizing with Middle Jiao medicines, resulting in a cure. This shows that Lower Jiao vomiting results from Mingmen Fire decline, lacking fuel under the cauldron to steam and rotify stomach contents, causing abdominal distension and forced vomiting. This aligns with Wang Taipu's statement: "Vomiting after a long time indicates lack of Fire." One must use methods to benefit the Source of Fire, first using Bawei Dihuang Wan to tonify Mingmen Fire and support the Mother of Spleen Earth, followed by Fuzi Lizhong Tang to regulate the Middle Jiao. This ensures success. Ignoring this and using Hawthorn, Medicated Leaven, and Pingwei San to transform food merely accelerates death.
Regarding Guange, it appears suddenly as an acute illness. Constipation of stool and urine, thirst for fluids, immediate vomiting after drinking, dry lips, slightly red eyes, flushed or non-flushed face, severe cases may have heart pain or not. From onset, no desire for food or water; drinking one cup results in vomiting half. After several days, the pulse becomes deep and hidden. This is Cold entering from the Shaoyin Kidney meridian, with Yin excess below forcing Yang upward, called Ge Yang syndrome, named Guange. Guange patients die before fulfilling their natural lifespan. Treatment requires Zhang Zhongjing's Baitong Tang, applying the *Neijing* principle of "treating cold with hot." The classic states: "To regulate reversed cold and heat, cold and hot natures must coexist." Thus, hot medicine is taken cold. After swallowing, the cold nature dissipates, and the hot nature activates, curing the disease and stopping vomiting/retching without violating patient compliance, achieving great benefit. Adding Human Urine and Pig Bile (salty, bitter, cold) to Baitong Tang utilizes their affinity to overcome rejecting cold. If the pulse gradually emerges after medication, life is possible; if the pulse appears intermittently, death ensues. Tao Jian'an's *Shachechui* contains Huayang Fanben Tang, which is excellent. Post-recovery, regular use of Bawei Wan prevents recurrence.
Another type is Liver Fire syndrome, characterized by vomiting without retention, expelling sour, bitter, or green-blue fluids. Stool and urine are not blocked, and heart pain may occur. This is Fire Stagnation and Wood Stagnation. For Wood Stagnation, disperse it; for Fire Stagnation, vent it. Use concentrated Wu Zhu Yu Lian Tang, sipped slowly, followed by Xiaoyao San for recovery. Post-recovery, regulate with Liuwei Dihuang Wan.