谚云。风劳鼓及膈。四证一犯。即难为疗。噫。病则病矣。何遂至于若是耶。余
请以膈申言之。人之身中。由咽至胸为上膈。由胸至心为中膈。由胃至肝
为下膈。上膈者。禀上焦之气而主纳。中膈者。禀中焦之气而主腐熟。下膈
者。禀下焦之气而主出。人之所以有生者。惟此出纳腐熟之司。如天之运
行不息。而地道之生长化收藏。寒燠不失其宜。乃能顺令而布化也。苟或
太早而失之敦阜则云雨不施。而孤阳浊治。水泽为枯矣。苟或太涝而失
之卑监。则沉霾闭塞。而凝阴惨淡。生气索竭矣。故膈之始也。病在上。咽嗌
不利。则食而噎。犯于上焦。地气不升。天气不降。将成亢旱之兆矣。然食犹
能强之而使安也。继犯中焦。虽食而中脘不下。下之而痛。稍久则吐痰水。
胃液不藏。肝火乘之。则味变而酸。脾阴既竭。则纳而不化。天气愈不降。地
气愈不升。乃见痞塞之状矣。则食不能强之而使安也。继犯下焦。朝餐而
夕吐。夕餐而朝吐。火气渐消。孤阴独存。阴阳不相为济。五脏之液既竭。六
腑无以资禀升降。出纳俱废。所云天气地气者安在哉。乃至绝粒而亡矣。
然则络无法以治之耶。曰。初须别其七情之所偏。继须审其气血之所竭。
水火之所胜。唯在补其中气。调其怫郁。开其痰气。热者清之。寒者温之。使
协于平。而又察上中下受病之浅深。而为之斟酌焉。安见其不可疗哉。独
所难者。患疾之人。不知死期将迫。而反复煎熬之。必至髓竭液亡。终不悔
悟。吾且奈之何也。
按噎在咽嗌之所。膈在心胃之间。反则直从下而上矣。越人谓心肺在
膈上。上焦在心下。下膈。胃上口。中焦在胃中脘。下焦在脐下。内经则以
左附上。候肝与鬲。右附上。候脾与胃。则鬲之属心下也明矣。余所以推
而上之。又推而下之。非以其形而言。乃以其用而言也。犹三焦为水谷
之道路。气之所终始。而所云如雾如沤如渎者。不以其用哉。矧内经止
言膈。而不及噎与反。则以膈统上中下。又复何疑。然妙在与肝为配。盖
膈之一症。多由郁怒伤肝而作。郁则为热。日渐煎熬。血液枯竭。心肺之
阳。不得通行。肠胃之阴。不得下停。而膈病之所由作。患者治者。从此求
之。思过半矣。
开郁汤 治膈噎初起有火者。
山栀（炒黑） 陈神曲（炒） 桔梗 香附（醋炒） 川贝母（去心研） 茯苓 广皮（各一钱） 抚芎（五分）
姜一片。荷叶蒂三个。水煎。
远志汤 第二用。
远志肉（甘草制） 茯神 白芍药（洒炒） 熟半夏 广皮（各一钱） 枣仁（一钱半） 人参（二钱） 钩藤（三
钱）
桂圆肉五枚。姜一片。水煎。有热加山栀。寒加炮姜。气加木香。燥加丹参柏子仁。
此中焦药也。若在下焦。以八味消息之。
谚语说：风病、劳病、鼓胀病以及膈噎病，这四种病症一旦染上，就难以治疗。唉，生病确实是件痛苦的事，但为何会严重到这种地步呢？我请允许针对“膈”这一病症详细阐述。
人的身体中，从咽喉到胸部称为上膈，从胸部到心口称为中膈，从胃部到肝脏称为下膈。上膈禀受上焦之气，主要功能是受纳食物；中膈禀受中焦之气，主要功能是腐熟水谷；下膈禀受下焦之气，主要功能是排泄糟粕。人之所以能生存，全靠这些受纳、腐熟和排泄的功能。就像天体运行不息，大地上的生长化收藏有序进行，寒暑调节得当，才能顺应时令而生化万物。如果过早地失去敦厚稳重（指阳气过亢或阴液不足导致的失衡），就会像云雨不施，导致孤阳独治，水泽枯竭。如果过于潮湿而失去卑监之德（指湿气过重或阳气不振），就会阴沉闭塞，导致凝滞的阴气惨淡，生机耗尽。
所以，膈病开始时，病位在上焦，咽喉不利，进食时发生哽噎，这是邪气侵犯上焦，导致地气不升、天气不降，呈现出类似亢旱的征兆。此时，食物尚且可以勉强咽下并安顿。接着邪气侵犯中焦，虽然进食但食物停滞在中脘部不下行，强行吞咽则疼痛。时间久了就会呕吐痰水，胃液不能内藏，肝火乘虚侵袭，导致食物味道变酸。脾阴既然枯竭，则只能摄入而不能消化。此时天气更不下降，地气更不上升，于是出现痞塞的症状。这时，食物已无法勉强咽下并安顿。接着邪气侵犯下焦，早晨吃的饭晚上吐出来，晚上吃的饭第二天早上吐出来。体内的火气逐渐消退，只剩孤阴独存，阴阳无法相互济助。五脏的津液已经枯竭，六腑失去了赖以资生的基础，升降功能丧失，受纳与排泄全部废弛。所谓的天地之气又在哪里呢？最终导致断绝饮食而死亡。
那么，络脉就没有办法治疗了吗？回答说：起初必须辨别七情（喜、怒、忧、思、悲、恐、惊）中哪一种情绪偏盛，接着必须审视气血耗竭的程度，以及水火二气的胜负情况。治疗关键在于补益中气，调理气机的郁结，开通痰浊的气机。有热的予以清热，有寒的予以温散，使身体恢复平衡。同时观察上、中、下三焦受病的深浅程度，从而斟酌用药。怎么能说不可治疗呢？唯独难办的是，患病的人不知道死期将至，反而反复自我煎熬，必然导致骨髓枯竭、津液亡失，始终不肯悔悟，我又能拿他们怎么办呢？
按语：噎病位于咽喉部位，膈病位于心胃之间，反胃则是食物直接从下往上吐出。扁鹊（越人）认为心肺在膈之上，上焦在心之下，下膈是胃的上口，中焦在胃的中脘，下焦在脐下。《黄帝内经》则以左手关前寸口脉候肝与膈，右手关前寸口脉候脾与胃，由此可见膈归属于心下部位。我之所以向上推导又向下推导，不是从形体结构来说，而是从功能作用来说的。这就好比三焦是水谷运行的道路，气机始发的地方，所说的如雾、如沤、如渎，不也是从功能角度而言吗？况且《内经》只提到“膈”，而没有单独提及“噎”与“反”，是以“膈”统摄上、中、下三焦，这又有什么可怀疑的呢？然而，其精妙之处在于与肝相配属。大概膈这一病症，多由郁怒伤肝所致。郁结则生热，日渐煎熬，导致血液枯竭，心肺的阳气不得通行，肠胃的阴液不得下行停留，这就是膈病产生的原因。患者和治疗者若能从此处探求，便已掌握了大半的道理。
开郁汤：治疗膈噎初起伴有火热症状者。
山栀（炒黑）、陈神曲（炒）、桔梗、香附（醋炒）、川贝母（去心研碎）、茯苓、广皮（各一钱）、抚芎（五分）。加生姜一片，荷叶蒂三个，水煎服。
远志汤：第二方使用。
远志肉（甘草制）、茯神、白芍药（酒炒）、熟半夏、广皮（各一钱）、枣仁（一钱半）、人参（二钱）、钩藤（三钱）。加桂圆肉五枚，生姜一片，水煎服。若有热象加山栀，寒象加炮姜，气滞加木香，燥象加丹参、柏子仁。此方为中焦用药。若病在下焦，可用八味丸酌情调治。
As the proverb says: Wind disease, Lao disease (consumptive disease), Gu distension (abdominal distension with fluid accumulation), and Ge syndrome (obstruction of the esophagus/stomach). Once any of these four conditions occurs, it is difficult to treat. Alas, illness is indeed painful, but why does it reach such a dire state? I shall elaborate on "Ge" syndrome.
In the human body, from the pharynx to the chest is called Upper Ge; from the chest to the heart region is Middle Ge; from the stomach to the liver is Lower Ge. Upper Ge inherits the Qi of the Upper Jiao (Upper Burner) and governs reception. Middle Ge inherits the Qi of the Middle Jiao and governs the decomposition and ripening of food. Lower Ge inherits the Qi of the Lower Jiao and governs excretion. The reason humans can survive lies in these functions of reception, digestion, and excretion. It is like the ceaseless movement of the heavens and the growth, transformation, storage, and collection on earth. Only when cold and heat are appropriately regulated can one follow the seasonal commands to distribute vitality. If there is premature loss leading to excessive dryness and elevation, clouds and rain will not be distributed, resulting in solitary Yang dominating and water sources drying up. If there is excessive dampness leading to low and oppressive stagnation, heavy miasma will block, causing stagnant Yin to become bleak, and vital energy will be exhausted.
Therefore, at the beginning of Ge syndrome, the pathology is in the Upper Jiao. If the throat is obstructed, eating causes choking. This indicates pathogenic factors invading the Upper Jiao, where Earth Qi fails to ascend and Heaven Qi fails to descend, presenting signs akin to severe drought. At this stage, food can still be forced down to settle. Subsequently, if the Middle Jiao is invaded, although food is eaten, it remains stuck in the middle epigastrium without descending; forcing it down causes pain. After some time, phlegm and water are vomited. Stomach fluids fail to be stored, Liver Fire takes advantage of this weakness, causing the taste to turn sour. Since Spleen Yin is exhausted, intake occurs without digestion. Heaven Qi descends even less, and Earth Qi ascends even less, resulting in a sensation of fullness and obstruction. At this point, food can no longer be forced down to settle. Finally, if the Lower Jiao is invaded, morning meals are vomited in the evening, and evening meals are vomited in the morning. Fire Qi gradually diminishes, leaving solitary Yin. Yin and Yang fail to mutually support each other. Fluids of the Five Zang organs are exhausted, and the Six Fu organs lose their source for ascending and descending. Both reception and excretion cease. Where then are the Heaven and Earth Qi? Ultimately, death occurs due to the cessation of food intake.
Is there truly no way to treat this via the collaterals? The answer is: Initially, one must distinguish which of the Seven Emotions (Joy, Anger, Worry, Thought, Sadness, Fear, Fright) is predominant. Subsequently, one must examine the extent of Qi and Blood exhaustion, and the dominance of Water and Fire. The key lies in tonifying Middle Qi, regulating Qi stagnation, and opening Phlegm obstruction. Heat is cleared; Cold is warmed, bringing the body into balance. Furthermore, observe the depth of pathology in the Upper, Middle, and Lower Jiao, and adjust treatment accordingly. How can one say it is untreatable? The only difficulty lies in the patients themselves, who do not realize that death is imminent, instead repeatedly tormenting themselves, inevitably leading to exhaustion of marrow and fluids, yet never repenting. What can be done about them?
Note: "Ye" (choking) is located in the pharynx. "Ge" (obstruction) is between the heart and stomach. "Fan" (regurgitation/vomiting upwards) involves food moving directly from below upwards. Yue Ren (Bian Que) stated that the Heart and Lung are above the diaphragm, the Upper Jiao is below the heart, the Lower Ge is the upper orifice of the stomach, the Middle Jiao is at the Zhongwan point of the stomach, and the Lower Jiao is below the umbilicus. The *Neijing* states that the left Cun position corresponds to the Liver and Diaphragm, while the right Cun position corresponds to the Spleen and Stomach. Thus, it is clear that the Diaphragm belongs to the area below the heart. My reasoning upward and downward is not based on anatomical form, but on functional utility. Just as the Three Jiao are the pathways for water and grain, and the starting and ending points of Qi, the descriptions of "like mist," "like foam," and "like drainage" are also based on function. Moreover, the *Neijing* mentions only "Ge" and does not separately discuss "Ye" and "Fan," using "Ge" to encompass the Upper, Middle, and Lower Jiao. Is there any doubt about this? However, its subtlety lies in its association with the Liver. Generally, Ge syndrome often arises from Liver injury due to depression and anger. Depression generates Heat, which gradually consumes and dries up Blood. Yang Qi of the Heart and Lung cannot circulate freely, and Yin fluids of the Intestines and Stomach cannot descend and settle. This is the origin of Ge syndrome. If patients and practitioners seek the cause from this perspective, they will have grasped more than half of the solution.
Kaiyu Decoction (Open Stagnation Decoction): Treats early-stage Ge syndrome with Fire symptoms.
Gardeniae Fructus (Stir-baked until black), Shenqu (Fermented Wheat Mass, stir-baked), Platycodonis Radix (Jiegeng), Cyperi Rhizoma (Xiangfu, vinegar-fried), Fritillariae Thunbergii Bulbus (Chuanbeimu, heart removed and ground), Poria (Fuling), Citri Reticulatae Pericarpium (Guangpi) (each 1 qian), Ligusticum Chuanxiong Rhizoma (Fuxiong) (0.5 qian). Add one slice of Ginger and three lotus leaf stalk bases. Decoct in water.
Yuanzhi Decoction: For second-line use.
Polygalae Radix (Yuanzhi, processed with Licorice), Poria Cum Radix (Fushen), Paeoniae Radix Alba (Baishao, stir-fried with wine), Pinelliae Rhizoma Preparatum (Shubanxia), Citri Reticulatae Pericarpium (Guangpi) (each 1 qian), Ziziphi Spinosae Semen (Zaoren) (1.5 qian), Ginseng Radix et Rhizoma (Renshen) (2 qian), Uncariae Ramulus cum Uncis (Gouteng) (3 qian). Add five flesh fruits of Longan Arillus and one slice of Ginger. Decoct in water. Add Gardeniae Fructus if Heat is present; add Zingiberis Rhizoma Preparatum (Paojiang) if Cold is present; add Aucklandiae Radix (Muxiang) if Qi stagnation is present; add Salviae Miltiorrhizae Radix (Danshen) and Biota Seed (Baiziren) if Dryness is present. This formula treats the Middle Jiao. If the pathology is in the Lower Jiao, adjust according to Bawei Wan (Eight-Ingredient Pill).