经义
三阳结，谓之隔。○二阳发病，其传为隔。○隔则闭绝，上下不通，则暴忧之病也。（《素问》）
气为上隔者，食饮入而还出；虫为下隔者，食 时乃出。（《灵枢》）
哲言
《经》言∶二阳结谓之消；三阳结，谓之隔。此传写之文互误也。《经》言热中、消中矣，未有不兼数
溲者，于胃与大肠何与乎？至于饮食不下，隔塞不通，言之屡矣，未有及小肠、膀胱者，故知隔之为病，于三
阳无与也。小肠、膀胱主液，结则液枯竭，故急攘水谷之气以自救，而液究不生，则数溲矣，是以消当责之三
阳也。胃主纳谷，大肠主出谷；结在胃则不纳，结在大肠则难出。食入即吐者，病在胃之上口也。食入徐吐者，
病在胃之下口也。朝食暮吐者，病在大肠之上口也。且隔噎垂毙，必有大便如羊屎者，是大肠结之明证也，是
以隔当责之二阳也。（《医参》）
此病不在外，不在内，不属冷，不属热，不是实，不是虚，多缘忧思恚怒，动气伤神，动则诸证随见，气
静痰平。手扪之，不得疾之所在；目视之，不知色之所因；耳听之，不知音之所发。故针灸药石，皆不获效，
乃神思间病，惟内观自养可治。（张鸡峰）
噎食一证，在《内经》惟曰三阳结谓之隔。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，则前后闷塞。下既不通，必反上行，此所以
噎食不下，纵下而复出也。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，三五七
日不便，是乖其度也明矣。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。《经》曰∶人迎四盛以上为格阳。王太仆云∶阳盛之极，故格拒而食不得入。《正理论》
云∶格则吐逆。故隔亦当为格。后世强分五噎，又分十隔，其派既多，其惑滋甚。人之溢食，未必遽然，或伤
酒食，或胃热欲吐，或冒风欲吐，医不察本，火里烧姜，汤中煮桂，若曰温胃，胃本不寒，若曰补胃，胃本不虚，设
如伤饮，止可逐饮，伤食，止可逐食，岂可言虚，便将热补？《素问》三阳热结分明一句，到了难从，不过抽
薪，扬汤止沸，愈治愈增，岁月弥深，为医所误。人言可下，退阳养阴，张眼吐舌，恐伤元气，肠宜通畅，肠
既不通，遂成噎病。或云∶忧恚气结，亦可下乎？余曰∶忧恚盘礴，便同大郁，仓公下法，废来千年，今代刘
河间治隔噎，用承气三汤，独超元箸。（《儒门事亲》）
噎隔、反胃二证，丹溪谓其名虽不同，病出一体，然实有不同也。盖反胃者，食犹能入，入而反出；噎隔
者，隔塞不通，食不得下。食入反出者，以阳虚不能化也，可补可温，其治犹易；食不得下者，以气结不能行
也，或开或助，治有两难，此其轻重之有不同也。且反胃多能食，噎隔不能食，故噎隔之病，则病于胸臆上焦，
而反胃之病，则病于中、下二焦，此其见证之有不同也。所以反胃之治，宜益火之原，以助化功；噎隔之治，
宜调养心脾，以舒结气。此其证既不同，延医亦当分类也。○噎隔多有便结不通者，《经》曰三阳结谓之隔。
子和曰∶三阳者，大肠、小肠、膀胱也；结谓热结也。三阳既结，则前后闭涩，下既不通，必反上行，所以噎
食不下，纵下而复出，此阳火不下，推而上行也。愚按∶此说不然。夫结之为义，《内经》原非言热，如曰阴
阳结邪，多阴少阳，曰石水；又曰思则气结，是岂以结为热耶？且热则流通，寒则凝结；凡霜凝冰结，惟寒
冽有之，而热则无也。矧《经》言三阳结者，止言小肠、膀胱，与大肠无涉。盖三阳者太阳也，手太阳小肠、
足太阳膀胱。小肠属火，膀胱属水；火不化则阳气不行，而传导失职；水不化则阴气不行，而清浊不分，此
皆致结之由也。子和不察，遂以三阳之结，尽言为热，岂理也哉！然人之病结者，本非一端∶气能结，血亦
能结，阳能结，阴亦能结，余非曰结必皆寒，而全无热也。但阴结阳结；证自不同。夫阳结者热结也，因火
盛烁阴，所以干结，此惟表邪传里，及阳明实热者乃有之。然热结者，必有烦渴发热等证，洪大滑实等脉，
最易辨也。若下有结闭，而上无热证，此阴结耳。正以命门无火，气不化精，所以凝结于下，而治节不行。
此惟内伤血气，败及真阴者，乃有之也。内伤至此，而犹云为热，岂必使元阳尽去，别有生生之道乎！○噎
隔，古人多认为寒。自河间治用承气，子和以三阳之结，尽论为热。余味此言，不能无惑。盖噎隔由于枯槁，
本非实热，承气尚可用乎？酒食过多者，未必遂成噎隔，而隔病又岂皆素热之人乎？丹溪承二子之说，辟《局
方》之非，所叙病原，固难缕辨，第以此证，而力指为热，能无谬乎？且云燥热之剂，随手得快。夫燥热既能
奏效，岂真火证乎？盖脾土恶湿，故燥之可也；火能生土，故热之亦可也。温燥扶阳，此自脾家正治，而必欲
非之，似属矫矣。又如脾胃清和能受能运之说，此实至理，第余之所谓清和者则不同。盖丹溪所言者，惟恐火之
盛；余之所言者，惟恐阳之衰。请以天人之理证之，夫天人之所同赖者，惟此阳气而已。故《经》曰∶天气清
净，光明者也。又曰∶阳气者，若天与日，失其所，则折寿而不彰，故天运当以日光明。由此言之，阳气胜则
温暖光明，非清和乎？阴气胜，则风霾晦瞑，非不清和乎？且春夏万物之盛，非阳盛之化乎？秋冬万物之衰，
非阳衰之兆乎？人之饮食，朝入口而午化尽，午入胃而暮化尽，此其中焦之热，亦何异大烹之鼎；使朝食而
午不饥，午食而晚不饥，饮食化迟，便是阳亏之候。矧乎全不能行，全不能化者，医且犹云有火，岂必并此化
源，尽行扑灭而后可，亦堪嗟矣！○反胃本属火虚。盖食入于胃，使果胃暖脾强，则无不化，何至复出。诸
家有谓其有痰者，有谓其有热者，不知痰饮之留，正因胃虚，而完谷复出，岂犹有热？观王太仆曰∶内格呕逆，
食不得入，是有火也；病呕而吐，食入反出，是无火也。此言诚尽之矣。然无火之由，有三焦之辨∶寒在上
焦，则多为恶心欲吐，此胃阳虚也；寒在中焦，则食入不化，每至中脘少顷复出，此脾阳虚也；寒在下焦，则
朝食暮吐，暮食朝吐，乃食入幽门，丙火不能传化，故
久而复出，此命阳虚也。使不知病本所在，混行猜摸，而妄祈奏效，所以难也。○凡治噎隔，当以脾肾为主。
盖脾主运化，而脾之大络布于胸膈；肾主津液，而肾之气化，主乎二阴。故上焦之噎隔，其责在脾；下焦之闭
结，其责在肾。治脾者宜从温养，治肾者宜从滋润，舍此二法，他无快捷方式矣。○一用温补以治噎隔，人必疑其
壅滞，而且嫌其迂缓。不知中气败证，此其为甚，使非速救根本，则脾气何由再健。设用补而噎塞愈甚，必
须千方百计，务从元气中酌其所宜，庶可保全。若用补虽未见功，但得无碍，便是相投。且此病最不易治，既
能受补，必须多服，方得渐效，不可性急，致疑以自误也。○治反胃，当辨新久，及所致之因。或酷饮无度，
伤于酒湿；或纵食生冷，败其真阳；或七情忧郁，竭其中气。无非伤损胃气而然。必以扶助正气，健脾养胃为
主。但新病胃气未坏，饮食未消，则当兼去其滞；逆气未调，则当兼解其郁。若病久体弱，则当专用温补，不
可妄行峻利，重伤胃气。○反胃多有便闭者，此其上出，固因下之不通也；然下之不通，又何非上之不化乎？盖
脾胃气虚，然后治节不行，而无以生血，血涸于下，所以闭结不通，此真阴枯槁证也。必使血气渐充，脏腑渐
润，方是救本之治。若徒为目前之计，推之逐之，虽见暂通，而真阴愈竭矣。（张景岳）
噎隔之病，气郁居多，然亦有阴血不足者，以其酒色是耽，胃中之火沸腾，则肺金先受邪矣，金主降令，
火凌于肺，津液成浊，况又下竭肾水，将何摄伏其火以下行耶？《经》曰∶肾开窍于二阴。阴血既亏，则大便
燥结，结则下焦闭，而气反上冲，幽门不通，上冲吸门，肺主出气，肾主纳气，虚则失司乃职，是有阳无阴，
有升无降也。故守真、子和、丹溪，皆以火热为言，戒用刚燥，其意深矣。然用药必假滋润为主，阴血生则大
便润，润则下焦开，开则气降，肾司乃职，而病寻愈矣。噫！用药之法，固为详悉，然人不能铁石其心，痛断
酒色，则虽日饮琼浆，亦莫
能以致其生也。（孙一奎）
论噎隔，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。被劫暂快，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，食物难入，入亦不多，
名之曰噎；其槁在下，与胃相近，食虽可入，良久复出，名之曰隔，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，则脾气健运，
而食消传化矣。此论甚妙，但噎隔、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。惜其见犹未真，惟以润血为主，而不直探先天之原，立方以四物，牛、羊乳之类，加竹沥、韭汁化痰化
瘀，皆治标而不治本也。岂知《内经》原无多语，惟曰三阳结谓之隔。然而三阳何以致结，皆肾之病也。盖肾
主五液，又主二便，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，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，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，肠亦干小而不宽大也。此证多是年高得之，又必其人不绝色欲。盖老人天真已绝，只有孤阳，故宜养阴
为主。王太仆云∶食入既出，是无水也；食久反出，是无火也。无水者壮水之主；无火者益火之原。褚侍中云∶
上病疗下，直须以六味丸料，大剂煎饮，久服可挽一、二。又须绝嗜欲，远房帏，薄滋味可也。（赵养葵）
饮食之际，气或阻塞曰噎。心下隔拒，或食到膈间，不得下行曰隔。良久复出曰翻胃。丹溪合而为一，固
为未尽。《医贯》竟以噎隔为上脘干枯不纳食，而以呕吐归之反胃，则亦不尽其理。噎隔亦有食入而吐者，但
不同于翻胃之每食必出。翻胃只吐原
物，噎隔则或食、或痰、或白沫酸水。初病不吐，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，皆噎隔也。○肠胃最喜润泽，试以羊、豕之肚观之，必是滑腻稠粘，如液如脂，如膏如泽，人
胃亦如是，所谓阴也。隔证之人，其肠胃必枯槁，绝无滑腻稠粘，是胃阴亡也。阴亡地气绝矣，地气绝，则天
气从何处生乎？故多死。○治隔证者，或以为胃虚而用温补，或以为开郁而用香燥，必至死而后已。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。故肾旺则胃阴充足，胃阴充足则思
食，当用六味加归、芍养之；或血燥肠枯，有黑矢积叠胃底，又当以熟地、归、芍、桃仁、麻仁润之。如其气
血未衰，方内加大黄以助药力，大肠润利，胃自开矣。○又有一种便利且溏，每食必吐，是名翻胃。王太仆云∶
食久反出，是无火也；八味丸主之。此验证全在大便，如便干结，即非无火，一味滋润如前法。（《己任编》）
愚按∶隔证病在上焦，而其原实在下焦。饮食下咽，至膈不能直下，随即吐出，乃贲门为病。血液干枯，
胃口收小，初病饮食尚可入，病久浆粥俱难下。盖血液枯槁，津液不润，凝结顽痰，而阻塞胃脘者有之；气结
不行，血滞成瘀，而阻塞胃脘者有之。第贲门之槁，顽痰之聚，瘀血之阻，皆由忧思过度则气结，气结则施
化不行，酒色过度则伤阴，阴伤则精血耗竭，运守失职，而脾中之生意枯；五液无主，而胃中之津液涸，虚阳
上泛，挟冲、任二脉，直上阳明，贲门终日为火燔燎，不槁不已，是以隔塞不通，食不得入矣。虽然，隔证之
食不得入为有火，与反胃之食久复出为无火，迥乎不同。而隔证之火，其根实发乎肾。若肾中水亏，不能摄伏
阳光，而虚火不藏者，治宜壮水之主，从阴引阳，则焰光自敛。若肾中火亏，不能生化元气，而龙火不归者，
治宜益火之原，补阳生阴，则真气上升。如是则血液有生动之机，贲门有滋养之润，胃司受纳，而脾司传化矣。
若刘氏下以咸寒，损
胃尤烈。严氏分为五隔，惑人失从。不若养血益气，以通肠胃，补阴助阳，以救本原，则大便润而小便通，下
既宣通，必无上冲贲门之患也。奈何庸工泥于气结不行，阻碍道路之故，妄投辛香破气、化痰清火之药，谓病
【经文义理】
三阳经气结滞，称为“隔”。○ 二阳经受病，其传变可发展为“隔”。○ “隔”证表现为上下闭塞不通，这是由突然的极度忧思所致的疾病。（出自《素问》）
气逆在上部导致上隔的，饮食进入后随即吐出；虫积在下部导致下隔的，进食很长时间后才吐出。（出自《灵枢》）
【哲人言论】
《内经》说：二阳结滞称为“消”；三阳结滞称为“隔”。这是传抄过程中的文字互误。《内经》提到热中和消中，没有不伴有小便频数的，这与胃和大肠有什么关系呢？至于饮食不下、膈塞不通的说法屡见不鲜，却从未提及小肠和膀胱，因此知道“隔”这种病与三阳经无关。小肠和膀胱主管津液，若发生结滞则津液枯竭，所以机体急于摄取水谷之气来自救，但津液终究无法生成，从而导致小便频数，因此“消”证应归责于三阳经。胃主受纳水谷，大肠主传导糟粕；结滞在胃则不能受纳，结滞在在大肠则难以排出。食入即吐的，病位在胃的上口；食入后缓慢呕吐的，病位在胃的下口；早晨吃晚上吐的，病位在大肠的上口。况且噎隔病危重时，必然有大便像羊屎一样的症状，这是大肠结滞的明证，因此“隔”证应归责于二阳经。（出自《医参》）
这种病不在体表，也不在脏腑内部，不属于寒证，也不属于热证，不是实证，也不是虚证，多是因为忧思愤怒，扰动气机损伤神志。气机动荡时各种症状随之出现，气机平静则痰浊平息。用手触摸，找不到疾病的所在；用眼看，不知道面色变化的原因；用耳听，不知道声音发出的根源。所以针灸药物都难以见效，这是神志方面的疾病，只有内省修养才能治愈。（张鸡峰）
噎食这一证候，在《内经》中只说“三阳结谓之隔”。所谓三阳，是指大肠、小肠、膀胱；“结”指的是热结。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。三阳既已结滞，则前后二阴闷塞不通。下部既然不通，气机必然反向上行，这就是为什么噎食不下，即使咽下去也会再次吐出的原因。胃是水谷之海，每天接受新的食物以代谢陈旧的食物，一天一次排便，这是正常的规律。现在患噎病的人，三五天甚至七天不便秘，这显然违背了正常规律。难道不是三阳经都在下部结滞，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），又返回从咽喉吐出吗？这是因为阳气之火不能下行，反而推向上行。《内经》说：人迎脉盛大四倍以上为格阳。王太仆说：阳气盛极，所以格拒而食物不能进入。《正理论》说：格则呕吐逆乱。所以“隔”也应当写作“格”。后世强行区分五噎、十隔，流派繁多，困惑更深。人的溢食呕吐未必是突然发生的，有的因伤酒食，有的因胃热想吐，有的因受风想吐，医生不考察根本原因，用火姜烧煮，汤中加桂枝，如果说温胃，胃本来不寒；如果说补胃，胃本来不虚。假如是伤饮，只可逐饮；伤食，只可消食，怎么能说是虚证，就用热药补益？《素问》中关于三阳热结的说法非常明确，到了后世却难以遵循，不过是抽薪止沸，越治越严重，岁月加深，这都是被医生误治的结果。有人说可以用泻下法，退阳养阴，睁眼吐舌，恐怕损伤元气。肠道宜通畅，肠道既然不通，就形成了噎病。有人说：忧怒气结，也可以用下法吗？我说：忧怒郁结，就像大郁一样，仓公的下法，废弃千年，如今刘河间治疗噎隔，使用承气三汤，独超元好问之上。（出自《儒门事亲》）
噎隔和反胃两个证候，朱丹溪认为名称虽然不同，但病源出于一体，然而实际上是有区别的。大概反胃是食物还能吃进去，进去后又反出来；噎隔是膈塞不通，食物不能下咽。食物进去又反出来的，是因为阳虚不能消化，可以补益温煦，治疗还比较容易；食物不能下咽的，是因为气结不能运行，或开郁或辅助，治疗有两难之处，这是轻重程度的不同。而且反胃大多能进食，噎隔不能进食，所以噎隔的病，是在胸臆上焦，而反胃的病，是在中、下二焦，这是见证的不同。所以治疗反胃，适宜益火之源，以助化功；治疗噎隔，适宜调养心脾，以舒解结气。既然证候不同，延请医生时也应当分类诊治。○ 噎隔多有便秘不通的情况，《内经》说三阳结谓之隔。张子和说：三阳是指大肠、小肠、膀胱；结是指热结。三阳既已结滞，则前后闭涩，下部不通，必然反向上行，所以噎食不下，即使咽下也会复出，这是阳气之火不下行，反而推向上行。我认为：这种说法不对。“结”的含义，《内经》原本并非指热，如说阴阳结邪，多阴少阳，称为石水；又说思则气结，这难道是把结当作热吗？而且热则流通，寒则凝结；凡是霜凝冰结，只有寒冷才有，而热是没有的。况且《内经》说三阳结，只提到小肠、膀胱，与大肠无关。所谓的三阳是指太阳经，手太阳小肠、足太阳膀胱。小肠属火，膀胱属水；火不化则阳气不行，而传导失职；水不化则阴气不行，而清浊不分，这些都是导致结滞的原因。张子和没有考察清楚，于是把三阳之结全部说成是热，这岂合理哉！然而人得结滞的病，本非一端：气能结，血也能结，阳能结，阴也能结，我并不是说结滞必定都是寒，而没有热。只是阴结和阳结，证候自然不同。所谓阳结是热结，因为火盛灼伤阴液，所以干结，这只有在表邪传入里，以及阳明实热时才存在。然而热结者，必然有烦渴发热等证候，洪大滑实等脉象，最容易辨别。如果下部有结闭，而上部没有热证，这是阴结。正是因为命门无火，气不能化精，所以凝结于下，而治节不行。这只有在内伤气血，败坏真阴时才存在。内伤到了这一步，还说它是热，难道一定要使元阳尽去，才另有一条生生之道吗？○ 噎隔，古人多认为是寒证。自从河间用承气汤治疗，张子和把三阳之结全部论述为热。我品味这些话，不能不感到困惑。大概噎隔是由于枯槁，本非实热，承气汤还能用吗？酒食过多的人，未必立刻形成噎隔，而隔病又难道全是素来有热的人吗？朱丹溪继承二子之说，批判《局方》的错误，所述病因，固然难以一一辨析，只是把这个证候，极力指为热证，能不谬误吗？而且说燥热之剂，随手就能见效。既然燥热能奏效，难道是真正的火证吗？大概脾土厌恶湿气，所以燥湿是可以的；火能生土，所以热也是可以的。温燥扶阳，这是脾家的正治法，却一定要反对它，似乎有些矫枉过正。又如脾胃清和能受能运的说法，这确实是至理，但我所说的清和则不同。大概朱丹溪所说的是，唯恐火之盛；我所说的是，唯恐阳之衰。请用天人之理来证明，天地人所共同依赖的，唯有此阳气而已。所以《内经》说：天气清净，光明者也。又说：阳气者，若天与日，失其所，则折寿而不彰，所以天运当以日光明。由此而言，阳气胜则温暖光明，不是清和吗？阴气胜，则风霾晦瞑，不是不清和吗？况且春夏万物之盛，不是阳盛的变化吗？秋冬万物之衰，不是阳衰的征兆吗？人的饮食，早上入口中午化尽，中午入胃晚上化尽，这其中的中焦之热，又何异于大烹之鼎；假如早晨吃中午不饿，中午吃晚上不饿，饮食消化迟缓，便是阳亏的征候。更何况完全不能行，完全不能化的，医生还说有火，难道一定要把这化源全部扑灭才可以吗？这也太令人叹息了！○ 反胃本属火虚。大概食物进入胃中，如果果真是胃暖脾强，则无不消化，怎么会反出来呢？各家有说是痰的，有说是热的，不知道痰饮的停留，正因为胃虚，而完谷复出，难道还有热吗？看王太仆说：内格呕逆，食不得入，是有火也；病呕而吐，食入反出，是无火也。这话确实说尽了。然而无火的原因，有三焦的辨别：寒在上焦，则多为恶心欲吐，这是胃阳虚；寒在中焦，则食入不化，每至中脘片刻后复出，这是脾阳虚；寒在下焦，则朝食暮吐，暮食朝吐，乃食物进入幽门，丙火不能传化，所以久而复出，这是命门阳虚。如果不了解病的根本所在，胡乱猜测，妄求奏效，所以难治。○ 凡治疗噎隔，应当以脾肾为主。大概脾主运化，而脾的大络布于胸膈；肾主津液，而肾的气化，主宰二阴。所以上焦的噎隔，责任在脾；下焦的闭结，责任在肾。治脾适宜从温养入手，治肾适宜从滋润入手，舍去这两种方法，没有其他快捷途径了。○ 用温补来治疗噎隔，人们一定怀疑其壅滞，而且嫌弃其迂缓。不知道中气败坏的证候，这是最严重的，如果不是速救根本，脾气如何能再强健。假如用补药而噎塞更甚，必须千方百计，务必从元气中斟酌适宜的用法，才可以保全。如果用补药虽然未见功效，但只要不碍事，就是相投。而且此病最不容易治，既然能受补，必须多服，才能逐渐见效，不可性急，以致怀疑自己而耽误病情。○ 治疗反胃，应当辨别新久，以及所致的原因。或是酗酒无度，伤于酒湿；或是纵食生冷，败坏真阳；或是七情忧郁，耗竭中气。无非是伤损胃气所致。必须以扶助正气，健脾养胃为主。但是新病胃气未坏，饮食未消，则应当兼去其滞；逆气未调，则应当兼解其郁。如果病久体弱，则应当专用温补，不可妄行峻利，重伤胃气。○ 反胃多有便秘的情况，这是因为上出固因下之不通；然而下之不通，又何尝不是上之不化呢？大概脾胃气虚，然后治节不行，而无以生血，血枯于下，所以闭结不通，这是真阴枯槁的证候。必须使血气渐充，脏腑渐润，才是救本的治疗。如果徒为目前之计，推之逐之，虽然见到暂时通畅，而真阴更加枯竭了。（张景岳）
噎隔的病，气郁居多，然而也有阴血不足的，因为其沉溺于酒色，胃中之火沸腾，则肺金先受邪了，肺金主降令，火凌犯于肺，津液变成浊，何况又下竭肾水，将用什么摄伏其火以下行呢？《内经》说：肾开窍于二阴。阴血既已亏损，则大便燥结，结则下焦闭，而气反上冲，幽门不通，上冲吸门，肺主出气，肾主纳气，虚则失司乃职，是有阳无阴，有升无降也。所以守真、子和、丹溪，都以火热为言，戒用刚燥，其意深远。然而用药必须假借滋润为主，阴血生则大便润，润则下焦开，开则气降，肾司乃职，而病寻愈矣。唉！用药的方法，固然详细，然而人不能铁石其心，痛断酒色，则虽日饮琼浆，也不能使其生存。（孙一奎）
论噎隔，朱丹溪认为得之于七情六淫，遂有火热炎上之变化，多升少降，津液不布，积而为痰为饮。被劫持暂快，不久复发，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，食物难入，入亦不多，名之曰噎；其槁在下，与胃相近，食虽可入，良久复出，名之曰隔，亦曰反胃，大便秘少，若羊矢然。必须外避六淫，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，则脾气健运，而食消传化矣。此论甚妙，但噎隔、翻胃，分别欠明。我唯独喜欢他“火热炎上之化，肾有生水之渐”两句，深中病源。可惜其见解仍未真切，只以润血为主，而不直探先天之原，立方以四物汤，牛、羊乳之类，加竹沥、韭汁化痰化瘀，都是治标而不治本。哪里知道《内经》原本没有多语，只说三阳结谓之隔。然而三阳何以致结，都是肾的病啊。大概肾主五液，又主二便，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，所以噎食不下也。何为水饮可入，食物难下？大概食物进入阴分，长气于阳，引动胃口之火，故难入；水是阴类，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，肠亦干小而不宽大也。此证多是年高得之，又必其人不绝色欲。大概老人天真已绝，只有孤阳，故宜养阴为主。王太仆说：食入既出，是无水也；食久反出，是无火也。无水者壮水之主；无火者益火之原。褚侍中说：上病疗下，直须以六味丸料，大剂煎饮，久服可挽一、二。又须绝嗜欲，远房帏，薄滋味可也。（赵养葵）
饮食之际，气或阻塞曰噎。心下隔拒，或食到膈间，不得下行曰隔。良久复出曰翻胃。丹溪合而为一，固为未尽。《医贯》竟以噎隔为上脘干枯不纳食，而以呕吐归之反胃，则亦不尽其理。噎隔亦有食入而吐者，但不同于翻胃之每食必出。翻胃只吐原物，噎隔则或食、或痰、或白沫酸水。初病不吐，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，皆噎隔也。○ 肠胃最喜欢润泽，试以羊、猪的肚子观察，必定是滑腻稠粘，如液如脂，如膏如泽，人胃也是如此，所谓阴也。隔证之人，其肠胃必定枯槁，绝无滑腻稠粘，是胃阴亡也。阴亡地气绝矣，地气绝，则天气从何处生乎？所以多死。○ 治疗隔证者，有人以为是胃虚而用温补，有人以为是开郁而用香燥，必至死而后已。不知道这是关门枯槁，肾水不能上达。《内经》说：肾乃胃之关。关门不利，升降息矣。所以肾旺则胃阴充足，胃阴充足则思食，当用六味丸加当归、芍药养之；或者血燥肠枯，有黑矢积叠胃底，又当以熟地、归、芍、桃仁、麻仁润之。如其气血未衰，方内加大黄以助药力，大肠润利，胃自开矣。○ 又有一种便利且溏，每食必吐，是名翻胃。王太仆说：食久反出，是无火也；八味丸主之。此验证全在大便，如便干结，即非无火，一味滋润如前法。（《己任编》）
我认为：隔证病在上焦，而其原实在下焦。饮食下咽，至膈不能直下，随即吐出，乃贲门为病。血液干枯，胃口收小，初病饮食尚可入，病久浆粥俱难下。大概血液枯槁，津液不润，凝结顽痰，而阻塞胃脘者有之；气结不行，血滞成瘀，而阻塞胃脘者有之。第贲门之槁，顽痰之聚，瘀血之阻，皆由忧思过度则气结，气结则施化不行，酒色过度则伤阴，阴伤则精血耗竭，运守失职，而脾中之生意枯；五液无主，而胃中之津液涸，虚阳上泛，挟冲、任二脉，直上阳明，贲门终日为火燔燎，不槁不已，是以隔塞不通，食不得入矣。虽然，隔证之食不得入为有火，与反胃之食久复出为无火，迥乎不同。而隔证之火，其根实发乎肾。若肾中水亏，不能摄伏阳光，而虚火不藏者，治宜壮水之主，从阴引阳，则焰光自敛。若肾中火亏，不能生化元气，而龙火不归者，治宜益火之原，补阳生阴，则真气上升。如是则血液有生动之机，贲门有滋养之润，胃司受纳，而脾司传化矣。若刘氏下以咸寒，损胃尤烈。严氏分为五隔，惑人失从。不若养血益气，以通肠胃，补阴助阳，以救本原，则大便润而小便通，下既宣通，必无上冲贲门之患也。奈何庸工泥于气结不行，阻碍道路之故，妄投辛香破气、化痰清火之药，谓病……
[Scriptural Meaning]
When the Qi of the Three Yang meridians is knotted (stagnant), it is called "Ge" (Obstruction). ○ When disease occurs in the Two Yang meridians, its transmission can develop into "Ge". ○ The "Ge" syndrome manifests as blockage and lack of communication between the upper and lower parts; this is a disease caused by sudden extreme worry and sorrow. (From *Su Wen*)
Qi rebellion in the upper part causing Upper Ge results in food and drink being vomited out immediately after ingestion; insect accumulation in the lower part causing Lower Ge results in food being vomited out only after a long time. (From *Ling Shu*)
[Philosophical Discourse]
The *Classic* states: Knotting in the Two Yang is called "Xiao" (Consumption); knotting in the Three Yang is called "Ge". This is an error in transcription where texts were swapped. The *Classic* mentions Heat Center and Xiao Center, none of which do not involve frequent urination; what does this have to do with the Stomach and Large Intestine? As for the statements about inability to swallow food and blockage, they are mentioned frequently, yet never refer to the Small Intestine or Bladder. Therefore, we know that the disease of "Ge" has nothing to do with the Three Yang meridians. The Small Intestine and Bladder govern fluids; if knotted, fluids dry up, so the body urgently seeks Qi from water and grain to save itself, but fluids ultimately cannot be generated, leading to frequent urination. Thus, "Xiao" should be attributed to the Three Yang meridians. The Stomach receives grain; the Large Intestine discharges grain. If knotting is in the Stomach, reception fails; if in the Large Intestine, discharge is difficult. Vomiting immediately after eating indicates pathology at the upper opening of the Stomach. Slow vomiting after eating indicates pathology at the lower opening of the Stomach. Vomiting in the evening what was eaten in the morning indicates pathology at the upper opening of the Large Intestine. Moreover, when Ge syndrome is critical, there must be stool like sheep dung; this is clear evidence of Large Intestine knotting. Therefore, "Ge" should be attributed to the Two Yang meridians. (From *Yi Can*)
This disease is neither external nor internal, neither cold nor hot, neither excess nor deficiency. It mostly arises from worry, thought, anger, disturbing Qi and damaging Shen (Spirit). When disturbed, various symptoms appear; when Qi is calm, phlegm subsides. Palpation reveals no location of disease; vision shows no cause for complexion changes; hearing reveals no source of voice changes. Thus, acupuncture and herbs are ineffective. This is a disease of the Shen (Spirit/Mind), treatable only through introspection and self-nourishment. (Zhang Jifeng)
Regarding the syndrome of dysphagia/obstruction, the *Nei Jing* only states "Three Yang knotting is called Ge." By "Three Yang," it refers to the Large Intestine, Small Intestine, and Bladder; "Knotting" refers to heat knotting. Heat knotting in the Small Intestine dries blood vessels; heat knotting in the Large Intestine causes constipation; heat knotting in the Bladder depletes fluids. Once the Three Yang are knotted, the front and back orifices become blocked. Since the lower pathway is blocked, Qi must reverse upwards, which is why food cannot go down, and even if swallowed, it comes back up. The Stomach is the Sea of Water and Grain, receiving new food daily to replace the old, with one bowel movement per day being normal. Now, patients with Ge syndrome go three, five, or seven days without a bowel movement, clearly violating normal rules. Is it not because the Three Yang are all knotted below, causing the Changchang (rectum) to dry up, so that ingested food is rejected by the throat, and even if entering the Tai Cang (Stomach), returns from the throat? This is because Yang Fire does not descend but pushes upwards. The *Classic* says: A Renying pulse four times larger than normal indicates Ge Yang. Wang Taipu said: Extreme Yang excess causes rejection so food cannot enter. The *Zheng Li Lun* says: Ge leads to vomiting and reversal. Therefore, "Ge" should also be written as "Ge" (Rejection). Later generations arbitrarily divided it into Five Dysphagias and Ten Obstructions, creating many schools and deepening confusion. Overflowing food/vomiting does not happen suddenly; it may be due to alcohol/food injury, stomach heat wanting to vomit, or wind exposure wanting to vomit. Doctors failing to investigate the root cause use roasted ginger and cinnamon, claiming to warm the Stomach, but the Stomach is not originally cold; claiming to tonify the Stomach, but it is not originally deficient. If injured by drinks, dispel the drink; if injured by food, resolve the food. How can one call it deficiency and use hot tonics? The statement in *Su Wen* about Three Yang heat knotting is clear, but later practitioners find it hard to follow, merely drawing wood to stop fire or stirring boiling water to stop boiling, making treatment worse over years. This is medical error. Some say purgatives can be used to retreat Yang and nourish Yin, opening eyes and sticking out tongues, fearing damage to Yuan Qi. The intestines should be unobstructed; since they are not, Ge syndrome forms. Someone asks: Can purgatives be used for Qi knotting from worry/anger? I say: Worry/anger stagnation is like major depression. Cang Gong's purgative method has been abandoned for a millennium. Today, Liu Hejian treats Ge/Dysphagia using Chengqi Decoctions, surpassing Yuan Haowen. (From *Ru Men Shi Qin*)
Danxi stated that although Dysphagia (Ye) and Ge (Obstruction) and Fanwei (Reverse Stomach) have different names, they originate from the same source, yet there are real differences. Fanwei allows food entry but it comes back out; Ye/Ge involves blockage preventing entry. Food entering then reversing out is due to Yang deficiency failing to transform; it can be tonified and warmed, making treatment easier. Food unable to enter is due to Qi knotting failing to move; it requires opening or assisting, making treatment difficult. This is the difference in severity. Also, Fanwei patients often eat, while Ye/Ge patients cannot; thus Ye/Ge affects the Chest/Upper Jiao, while Fanwei affects the Middle/Lower Jiao. This is the difference in manifestations. Therefore, treating Fanwei requires benefiting the Source of Fire to aid transformation; treating Ye/Ge requires nourishing Heart and Spleen to soothe Qi knotting. Since syndromes differ, doctors should classify them. ○ Ye/Ge often involves constipation. The *Classic* says Three Yang knotting is Ge. Zihe said: Three Yang refers to Large Intestine, Small Intestine, Bladder; knotting means heat knotting. Once knotted, front/back are blocked, lower不通 leads to upward reversal, causing dysphagia/vomiting. I argue: This view is incorrect. The meaning of "Knotting" in the *Nei Jing* is not originally heat, e.g., Yin/Yang knotting with more Yin less Yang is Stone Water; thinking causes Qi knotting. Is knotting heat? Heat flows; cold knots. Frost/ice only happens in cold, not heat. Moreover, the *Classic*'s mention of Three Yang knotting only refers to Small Intestine and Bladder, unrelated to Large Intestine. The so-called Three Yang here refers to Taiyang: Hand Taiyang Small Intestine and Foot Taiyang Bladder. Small Intestine belongs to Fire, Bladder to Water. If Fire doesn't transform, Yang Qi doesn't move, and transportation fails; if Water doesn't transform, Yin Qi doesn't move, and clear/turbid don't separate. These cause knotting. Zihe failed to observe this, attributing all Three Yang knotting to heat, which is unreasonable. However, knotting diseases are not one-sided: Qi can knot, Blood can knot, Yang can knot, Yin can knot. I don't say knotting is always cold, nor that there is no heat. But Yin knotting and Yang knotting differ. Yang knotting is heat knotting, caused by Fire blazing Yin, leading to dryness; this occurs only when exterior pathogens transmit inward or in Yangming Excess Heat. Heat knotting must have irritability/thirst/fever and surging/slippery/excess pulses, easy to distinguish. If there is lower blockage but no upper heat signs, this is Yin knotting. It is due to Mingmen lacking Fire, Qi failing to transform Essence, causing knotting below and failure of regulation. This occurs only in internal injury depleting True Yin. At this stage, calling it heat implies destroying Yuan Yang to find life, which is absurd. ○ Ancient people considered Ye/Ge as Cold. Since Hejian used Chengqi Tang and Zihe attributed Three Yang knotting to Heat, I am confused. Ye/Ge stems from withering/dryness, not Excess Heat; can Chengqi Tang be used? Those who overeat/drink don't necessarily get Ye/Ge, nor are all Ge patients inherently hot. Danxi followed these two, criticizing Ju Fang, describing etiology hard to refute fully, but insisting on Heat seems erroneous. If drying-hot agents work instantly, is it truly a Fire syndrome? Spleen Earth dislikes dampness, so drying is okay; Fire generates Earth, so heating is okay. Warming-drying supporting Yang is correct for Spleen, opposing it seems excessive. Regarding Danxi's theory of Spleen/Stomach clarity/harmony enabling reception/transformation, this is true, but my clarity/harmony differs. Danxi feared Fire excess; I fear Yang deficiency. Consider Heaven/Humanity: both rely on Yang Qi. *Classic*: Heavenly Qi is clear and bright. Yang Qi is like Heaven and Sun; losing it shortens life. Thus, Heaven moves by Sun's brightness. Yang abundance brings warmth/light (clear/harmonious); Yin abundance brings wind/fog/darkness (unclear/unharmonious). Spring/Summer growth is Yang abundance; Autumn/Winter decline is Yang deficiency. Food eaten morning is digested noon; noon food digested night. This middle Jiao heat is like a cooking pot. If morning meal doesn't hunger at noon, or noon meal doesn't hunger at night, slow digestion indicates Yang deficiency. If completely unable to move/digest, doctors still say there is Fire? Must we extinguish this source of transformation? Sigh! ○ Fanwei belongs to Fire Deficiency. If food enters the Stomach and the Stomach is warm/Spleen strong, everything transforms; why come back out? Some say Phlegm, some say Heat. Phlegm/fluid retention exists because Stomach is weak; undigested food coming out implies no Heat. Wang Taipu said: Internal Ge with vomiting/reversal, food cannot enter, is Fire; vomiting/reversal after entry, food comes back out, is No Fire. This is accurate. However, "No Fire" has Three Jiao distinctions: Cold in Upper Jiao causes nausea/wanting to vomit (Stomach Yang Def); Cold in Middle Jiao causes undigested food returning after a while (Spleen Yang Def); Cold in Lower Jiao causes morning/evening vomiting (Mingmen Yang Def). Not knowing the root makes treatment hard. ○ Treating Ye/Ge should focus on Spleen and Kidney. Spleen governs transformation, its large Luo vessels distribute to chest/diaphragm; Kidney governs fluids, its Qi transformation governs the two yin orifices. Upper Jiao Ge responsibility lies with Spleen; Lower Jiao blockage responsibility lies with Kidney. Treating Spleen requires warming/nourishing; treating Kidney requires moistening/nourishing. Without these two methods, there are no shortcuts. ○ Using warm-tonics for Ye/Ge raises suspicion of stagnation and slowness. But mid-Qi collapse is severe; without saving the root, how can Spleen Qi recover? If tonification worsens blockage, one must try every method to suit Yuan Qi. If tonification doesn't fail, it matches. This disease is hard to cure; if it accepts tonics, long-term use is needed for gradual effect. Do not be impatient and doubt yourself. ○ Treating Fanwei requires distinguishing new/old and causes. Alcohol injury damages Yang; raw/cold food damages True Yang; emotional depression exhausts Mid-Qi. All damage Stomach Qi. Primary treatment is supporting Righteous Qi, strengthening Spleen/Stomach. New cases with intact Stomach Qi require resolving stagnation/depression. Old cases with weak constitution require pure warm-tonification, avoiding harsh purgatives. ○ Fanwei often has constipation because upper exit depends on lower passage. Lower blockage is due to upper failure to transform. Spleen/Stomach Qi deficiency leads to failed regulation and blood generation failure; blood dries below causing constipation, a True Yin withering syndrome. Treatment must replenish Qi/Blood and moisten organs. Purging temporarily clears but depletes True Yin further. (Zhang Jingyue)
Ye/Ge is mostly Qi depression, but can be Yin/Blood deficiency due to indulgence in alcohol/sex. Stomach Fire boils, injuring Lung Metal first. Lung governs descending; Fire insults Lung, turning fluids turbid. With Kidney Water exhausted below, how can Fire be controlled to descend? *Classic*: Kidney opens to two yin. Yin/Blood deficiency causes dry stool; knotting blocks Lower Jiao, Qi rushes up.幽门 (Pylorus) blocked, Qi hits Ximen (Aeropharynx). Lung governs exhalation, Kidney inhalation. Deficiency loses function, resulting in Yang without Yin, ascending without descending. Souzhen, Zihe, Danxi spoke of Fire/Heat, warning against rigid-drying herbs, implying deep meaning. Medication must prioritize moistening. Generating Yin/Blood moistens stool, opening Lower Jiao, allowing Qi to descend, restoring Kidney function, curing disease. Alas! Even with detailed medication, if one cannot cut off alcohol/sex, drinking nectar won't save life. (Sun Yikui)
Danxi attributes Ye/Ge to Seven Emotions/Six Evils, causing Fire/Heat flaring up, rising more than descending, fluids not distributing, accumulating into Phlegm/Fluids. Temporary relief follows, but recurrence builds heat, depleting Blood, causing Stomach lining to wither. Withering above near throat allows fluids but not food (Dysphagia); withering below near Stomach allows food but delayed vomiting (Ge/Fanwei), with scant sheep-dung-like stool. Prevention requires avoiding Six Evils, regulating Seven Emotions, dietary self-care, nourishing Blood/fluids to moisten intestines. Then Metal fears no Fire, Kidney generates Water, Qi/Blood harmonize, Spleen transforms food. This is profound, but distinction between Ye/Ge and Fanwei is unclear. I like "Fire flaring up, Kidney generating water" as hitting the source. But focusing only on moistening Blood ignores the Primordial Origin. Formulas like Siwu Tang, milk, bamboo juice treat symptoms, not root. *Nei Jing* says "Three Yang knotting is Ge." Why do Three Yang knot? It is a Kidney disease. Kidney governs five fluids and two bowels, paired with Bladder. Dry Kidney Water leads to Yang Fire excess, boiling fluids, causing Three Yang heat knotting, blocking front/back. Lower blockage forces reversal up to clear pathways/Ximen, causing dysphagia. Why fluids enter but food doesn't? Food enters Yin, generates Yang, stimulating Stomach Fire, making entry hard; Water is Yin, matching Qi, so it enters. White foam is boiled water rising. Sheep-dung stool is due to little food intake and dry/shrunken intestines. This disease affects elderly who don't abstain from sex. Elderly have lost Tianzhen, possessing only isolated Yang, so nourishing Yin is primary. Wang Taipu: Food entering then exiting is No Water; food staying then exiting is No Fire. No Water requires strengthening Water Master; No Fire requires benefiting Fire Source. Chu Shizhong: Treat upper disease via lower, use Liuwei Wan decoction in large doses long-term. Abstain from desires, avoid bedchamber, light diet. (Zhao Yangkui)
During eating, Qi obstruction is Dysphagia (Ye). Blockage below heart or food stuck in diaphragm not descending is Ge. Delayed vomiting is Fanwei. Danxi combined them, incomplete. *Yi Guan* defined Ge as upper Stomach dryness refusing food, attributing vomiting to Fanwei, also incomplete. Ye/Ge can also vomit after eating, but unlike Fanwei which always vomits. Fanwei vomits original food; Ye/Ge vomits food/phlegm/white foam/sour water. Early stage no vomiting; later frequent vomiting of dregs, not phlegm/food/blood, like sauce. This is upper/lower Stomach withering, both Ge. ○ Intestines/Stomach love moisture. Sheep/pig bellies are slippery/sticky like fat/grease; human Stomach is similar, representing Yin. Ge patients have withered intestines/Stomach, lacking slipperiness, indicating Stomach Yin death. Yin death means Earth Qi ends; if Earth Qi ends, where does Heaven Qi generate? Hence often fatal. ○ Treating Ge: some use warm-tonics for Stomach Def, some use aromatic-drying for depression, leading to death. This is actually Gate Withering, Kidney Water cannot reach up. *Classic*: Kidney is Stomach's Gate. Gate dysfunction stops ascent/descent. Healthy Kidney ensures Stomach Yin sufficiency, prompting appetite. Use Liuwei Wan plus Danggui/Shaoyao. Or dry Blood/intestine with black stool at Stomach bottom, use Shudi/Danggui/Shaoyao/Taoren/Huomaren to moisten. If Qi/Blood not weak, add Dahuang to assist. Moist Large Intestine opens Stomach. ○ Another type has loose stools, always vomiting after eating, named Fanwei. Wang Taipu: Food stays then exits is No Fire; Bawei Wan treats it. Verification depends on stool. If dry, not No Fire; use moistening method. (Ji Ren Bian)
I argue: Ge disease is in Upper Jiao, but root is in Lower Jiao. Food swallowed reaches diaphragm, cannot go straight down, vomited immediately. This is Jianmen (cardia) pathology. Blood dryness shrinks Stomach mouth. Early stage food enters; late stage even gruel difficult. Blood withering, fluids not moistening, congealing stubborn phlegm blocking Stomach; Qi knotting, Blood stasis blocking Stomach. Jianmen withering, phlegm accumulation, Blood stasis obstruction are caused by excessive worry/Qi knotting (blocking transformation) and excessive sex/alcohol damaging Yin (depleting Essence/Blood, failing transport/storage, killing Spleen vitality). Five fluids lack master, Stomach fluids dry. Deficient Yang floats up, carrying Chong/Ren meridians to Yangming. Jianmen burns all day until withered, causing blockage/inability to eat. Although Ge inability to eat is Fire, and Fanwei delayed vomiting is No Fire, they differ greatly. Ge Fire root is Kidney. If Kidney Water deficient failing to control Sunlight/Deficient Fire, treat by strengthening Water Master, guiding Yang from Yin, flames subside. If Kidney Fire deficient failing to generate Yuan Qi/Dragon Fire not returning, treat by benefiting Fire Source, tonifying Yang generating Yin, True Qi rises. Then Blood moves, Jianmen nourished, Stomach receives, Spleen transforms. Liu氏 using salty-cold purges severely damages Stomach. Yan氏 dividing into Five Ges confuses people. Better to nourish Blood/support Qi to unblock intestines, tonify Yin/assist Yang to save root. Then stool moist, urine clear, lower unblocked, no risk of rushing Jianmen. Alas, mediocre doctors stick to Qi knotting/blockage, wrongly using acrid-aromatic Qi-breaking/phlegm-resolving/fire-clearing herbs, saying disease...