虚实 噎膈之病，有虚有实。实者，或痰或血，附着胃脘，与气相搏，翳膜外裹，或复吐出，膈气暂
宽，旋复如初。虚者，津枯不泽，气少不充，胃脘干瘪，食涩不下。虚者润养，实者疏瀹，不可不辨也。
（《金匮翼》）
证有数等 气噎膈者，深师七气汤主之（方出《千金》，凡十二味）。血噎膈者，韭汁饮主之。痰噎
膈者，栝蒌实丸主之（用蒌仁、枳壳、半夏、桔梗）。火噎膈者，回令丸主之。食噎膈者，食郁越鞠丸主之。
（《医方考》）（宜与治例中《微义》文相参。）
噎分五种∶有气滞者，有血瘀者，有火炎者，有痰凝者，有食积者。虽分五种，总归七情之变。由气郁为
火，火旺血枯，津液成痰，痰壅而食不化也。（《汇补》）
膈有酒膈、气膈、虫膈、劳膈之别。酒膈者，脾胃为酒所伤，精液枯竭。气膈者，恼怒太过，肝木乘脾。
虫膈者，好食煎炒香味，烁散其津液，以致生虫。劳膈者，或饮食不知节，有伤中宫之土，或房事太过，不生
土。（《医学指要》）
酒毒 好酒之徒患此者，必是顽痰。盖酒能发火，火能生痰，痰因火煎，胶结不开，阻塞道路，水饮
下咽，亦觉痛
涩。若以血槁治，投当归、地黄等药，血未必润，反助其痰，病何由愈。若黑瘦之人，真阴素虚，常觉内热，
又不嗜酒，或过服香燥热药者，当以血槁治。（《订补指掌》）
酒客多噎膈，饮热酒者尤多。以热伤津液，咽管干涩（观其口舌干涩可知），食不得入也。（《医碥》）
死血有痰（宜与后行血诸方相参。）凡食下有碍，觉屈曲而下，微作痛，此必有死血有痰然也，宜竹
沥姜汁入药服。（《医统》）（按∶《六要》举此证曰∶用前膏子药润补之，后以代抵当丸下之。盖膏子言韭
汁、牛乳、生姜捣汁和匀。又《原病集》处以润血汤，见滋阴方中。）
一男子壮年，食后必吐出数口，却不尽出，膈上时作声，面色如平人。知其为病，不在脾胃，而在膈间。
问其得病之由，乃因大怒未止，辄啜谷，即其时有此证料之，以怒甚则血菀于上，积在膈间，有碍气之升降，
津液因聚为痰为饮，与气相搏而动，故作声也。用二陈汤加香附、韭汁、莱菔子，服二日，以瓜蒂散酸浆吐之，
再一日又吐，痰中见血一盏，次日复吐，见血一钟，其病即愈。瘀血在膈间，阻碍气道而成，多以代抵当丸
（方附《瘀血》中）作芥子大，取三钱，去枕仰卧，细细咽之，令其搜逐停积，至天明利下恶物，却好将息，
自愈。（《准绳》）但饮热汤，及椒姜辄呃者，即瘀血也。（《医通》）
吐涎沫 每饮食入胃，便吐涎沫，如鸡子白。盖脾为涎，脾虚不能约束津液，故涎沫自出，非人参、
白术、诃子、益智仁不能摄也。（《医通》）
死证 年高者，不治。（《丹溪》）（按∶《正传》曰∶年五十余，则不可治矣。《医统》曰∶以其
气血俱虚故也。余见未满六旬，按法治之而守戒慎者，亦愈；惟不忌浓
味并房劳忧思者，必危。）
粪如羊屎者，断不可治，大肠无血故也。（同上）
气血俱虚者，则口中多出沫，但见沫大出者，必殆。（《钩玄》）（按《统旨》曰∶或口吐红痰。《医统》
曰∶吐痰如蟹沫者，不可治。《景岳》曰∶脾气败也。）
腹中 嘈痛如刀割者，不治。（《医统》）（《景岳》曰∶营虚之极，血竭于中也。）
得此症者，能少纳谷，则不出一年而死。全不纳谷，则不出半年而死。（《源流论》）
治例 治疗之法，调顺阴阳，化痰下气，阴阳平匀，气顺痰下，膈噎之疾，无由作矣。（《济生》）
夫治此疾也，咽嗌闭塞，胸膈痞闷，似属气滞；然有服耗气药过多，中气不运而致者，当补气而自运。大
便燥结如羊矢，似属血热，然服通利药过多，致血液耗竭而愈结者，当补血润血而自行。有因火逆冲上，食不得
入，其脉洪大有力而数者，或痰饮阻滞而脉结涩者，当清痰泄热，其火自降。有因脾胃阳火亦衰，其脉沉细而
微者，当以辛香之药温其气，仍以益阴养胃为之主，非如局方之惟务燥烈也。若夫不守戒忌浓味房劳之人，及
年高无血者，皆不能疗也。（《微义》）
凡膈病初起，郁结太过，血液未枯者，当以沉香、木香、豆蔻等开提之，不可徒用滋补；及久病胃伤，津
液已涸者，当以白蜜、芦根、当归、白芍养之，不可徒事香燥，此先后之序也。（《汇补》）
此证之所以疑难者，方欲健脾理痰，恐燥剂有妨于津液；方欲养血生津，恐润剂有碍于中州。审其阴伤火旺
者，当以养血为亟；脾伤阴盛者，当以温补为先。更有忧恚盘
礴，火郁闭结，神不大衰，脉犹有力，当以仓公、河间之法下之。（《必读》）
噎膈属气血两虚，由于血液衰少而非痰气壅逆所成，忌破气、升、复忌下、消导、燥、苦寒、辛热，宜降、
清热润燥、甘温甘平以益血，略佐辛香以顺气。（《本草经疏》）
至于食入反出，是中焦土寒，下焦火虚，以附子理中汤、香砂六君子汤加干姜、八味地黄丸，间服多效。
若食不得入，必以黄连黄芩人参干姜汤为主，泻心汤亦妙。吴茱萸汤，不论噎膈反胃皆可用，唯以呕而胸满为的
证，干呕、吐涎沫、头痛亦为的证。（《时方妙用》）（按∶陈氏有续论，详论膈噎宜芩连参姜汤、吴茱萸汤之
理，须参。）
治察中上中下之分 患此病者，百无一生，但有中上、中下之分，速死、迟死之异。中上者，上焦中焦不
和也。中下者，下焦中焦不和也。中下不和，其死迟；中上不和，其死速。然治得其宜，速者可迟；治失其宜，
迟者亦速矣。初患此病，医者每用辛香行气之药，谓能宽胸以开胃。讵知不能食者真气虚也，真气既虚，岂可复
行辛散以耗其气乎。既耗其气，元本不甚虚者，犹可苟延；其元本虚者。数月之间，身命便不保矣。又初患此
病，医者有用养血滋阴之药，谓开阑门而使之下，可以不吐。若系中下二焦不相通贯，谷入中脘，下焦不相顺接，
腐化有愆，仍从中院而上逆，逆则吐，此滋润下行之药，投之亦效；愈而复发，复投此药，便不效矣。初因下
焦不得顺接，可以滋润下行，久则阴盛阳虚，下焦生阳之气，不能环复于上，下而不上，则不效矣，不效必至身
命不保矣。其中下二焦，火气衰微，初起或便用参、 、术、姜、桂、附等药服之，亦觉有效。药虽效而病不除，
其后必疑温补之非，转服他药，终归不治。天下岂有
不食谷之人哉，经云得谷者昌，失谷者亡，善夫。（《医学真传》）（按∶《兰台轨范》亦称膈病乃胃口枯槁
之症，百无一治。）
治要滋润禁香热 或曰∶胃脘干槁者，古方果可治乎？将他有要捷之法者，或可补前人之未发者乎？
予曰∶古方用人参以补肺，御米以解毒，竹沥以消痰，干姜以养血，粟米以实胃，蜜水以润燥，姜以去秽，正是
此意。张鸡峰亦曰∶噎当是神思间病，惟内观自养，可以治之。此言深中病情，而施治之法，亦为近理。夫噎病
生于血干，夫血阴气也，阴主静，内外两静，则脏腑之火不起，而金水二气有养，阴血自生，肠胃津润，传化合
宜，何噎之有。因触类而长，曾制一方，治中年妇人，以四物汤，加和白陈皮、留尖桃仁、生甘草、酒红花，浓
煎，入驴尿饮，以防其或生虫也，与数十帖而安。又台州治一匠者，年近三十，勤于任务而有艾妻，且喜酒，其
面白，其脉涩，重则大而无力。令其谢去任务，卧于牛家，取新温牛乳饮之，每顿进一杯，一昼夜可饮五七次，
尽却食物，以渐而至八九次。半月大便润，月余而安。然或口干，盖酒毒未解，间饮甘蔗汁少许。（《局方发挥》）
治膈症者，或以为胃虚而用温补，或以为开郁而用香燥等剂，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。关门即气交之中，天之枢也。故肾旺则胃阴充足，胃阴充足则思食，
当用六味饮加归、芍养之。（《四明》）
世之病此者，惟痰与火、血枯气郁者为多，《局方》例用五膈宽中散、沉香开膈散之类，皆是辛热耗血助火
之剂。如果阳衰有寒，或郁而内实者，辛而获效。若施之于血枯火热痰饮所致者，乃速死之道，慎之。（《统
旨》）（按∶膈噎
禁香燥热药，其说本出子和，而丹溪亦更辨之，宜并考。）
或云∶嗝咽因气郁，故用辛热以散之，所以不得不用热剂也。予曰∶夫气郁者，气虚而郁者也，非实也。
兹因气虚而郁热，若用辛热耗气，则是虚者益虚，热者益热，其何以为救治之道哉。病之初作，每见悉用辛香燥
热劫之，愈而复作，愈劫愈深，至于危困。（《医统》）
古方治噎膈，多以止吐之剂通用。不思吐，湿证也，宜燥；噎膈，燥证也，宜润。经云三阳结谓之膈，
夫结，热也，热甚则物干。凡噎膈证，不出胃脘干槁四字。夫胃既槁矣，而复以燥药投之，不愈益其燥乎。
（《心悟》）
用下例 假如 久，慎勿陡攻，纵得攻开，必虑后患，宜先润养，小着汤丸，累累加增，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（用黑牵牛、大黄、
朴硝、皂角），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。（《事亲》）（按∶此治验不是噎膈，
其意盖在使人类推耳。）
子和因河间三乙承气之治，谓噎膈之病，惟宜用下，结
散阳消，其疾自愈，夫脘膈之病，岂下可去。虽仲景有大黄甘草，东垣有通幽润肠等法，为便秘呕吐者立，然自
是食入辄吐之治，非所论于食噎不下也。独其所谓慎勿顿攻，宜先润养云云，始终勾引，两药相通者，其言甚
善。盖痰血在脘，不行不愈，而药过病所，反伤真气，非徒无益矣。故以小丸累加，适至病所，无过不及，以平
为期，则治噎之道也，但须审是痰是血而行之耳。（《金匮翼》）
温中利气诸方（温凉调停诸方）膈中之病，名曰膏肓，汤丸经过，针灸不及，所以作丸含之，令气势得
相熏染，有五膈丸方。
麦门冬十分去心，甘草十分炙，椒、远志、附子、炮干姜、人参、桂、细辛各六分，捣筛，以上好蜜丸如
弹丸，以一枚含，稍稍咽其汁，日三丸服之。主短气，心胸满，心下坚，冷气也。此疾有十许方，率皆相类，此
方最胜。（《肘后》）
五噎丸，主胸中久寒，呕逆逆气，食饮不下，结气不消方。
干姜 蜀椒 食茱萸 桂心 人参（各五分） 细辛 白术 茯苓 附子（各四分） 橘皮（六分）
上十味末之，蜜和丸如梧子大，以酒服三丸，日三服。不知，稍加至十丸。（《千金》）
《广济》疗噎，胸胁气满，每食气噎，通气汤方。
半夏（洗） 生姜（各六两） 橘皮 桂心（各三两切）
上四味切，以水八升，煮取二升五合，绞去滓，分温三服，服别相去，如人行六七里服。（《外台》）又
《集验》通气噎汤，于本方去橘皮，加羚羊角。
卢，阴阳逆乱，已成关格（按∶此关格盖是膈症），议
用附子泻心汤，为上热下寒主治。（《临证指南》）
毛，老年形消，不食不便，气冲涌涎，乃关格之症，议用进退黄连汤。
川连 淡干姜 半夏 姜汁 人参 茯苓 附子 生白芍（同上）
毕（五四），夏间诊视，曾说难愈之 。然此病乃积劳伤阳，年岁未老，精神已竭，古称噎膈反胃，都因
阴枯而阳结也。秋分后复诊，两脉生气已索，交早咽燥，昼日溺少，五液告涸，难任刚燥阳药，是病谅非医药
能愈。
大半夏汤，加黄连、姜汁。（同上）（按∶《时方妙用》论大半夏汤之理，当参。）
治饮食喜噎，宜服半夏散方。
半夏（一两） 干姜（一两炮裂锉） 石膏（二两） 人参（一两去芦头） 栝蒌根（一两） 桂心（一两）
甘草（半两炙微赤锉） 吴茱萸（半两汤浸七遍焙干微炒）
上件药捣，粗罗为散，每服三钱，以水一中盏，入生姜半分，枣二枚，小麦、小豆各五十粒，同煎至六分去
滓，不计时候稍热服。（《圣惠》）
治膈气妨闷，不能下食，吐逆烦喘，诃黎勒散方。
诃黎勒皮（一两） 木香（三分） 陈橘皮（一两） 五味子（三分） 半夏（三分） 人参（三分）
桂心（三分） 赤茯苓（三分） 芦根（一两锉） 枳壳（三分）
虚实 噎膈这种病，有虚证和实证两种。实证，或是痰浊、或是瘀血，附着在胃脘部，与气机相互搏结，外面像有一层翳膜包裹着，有时呕吐出来之后，胸膈间的气滞暂时得到舒缓，但很快又恢复原状。虚证，则是津液枯竭不能滋润，元气不足无法充盈，导致胃脘干瘪，食物吞咽困难且涩滞不下。对于虚证应当用滋润滋养的方法治疗，对于实证应当用疏通疏导的方法治疗，这一点不可不加以辨别。（出自《金匮翼》）
证候有多种类型 气噎膈，主要使用深师七气汤来治疗（该方出自《千金方》，共十二味药）。血噎膈，主要使用韭汁饮来治疗。痰噎膈，主要使用栝蒌实丸来治疗（由瓜蒌仁、枳壳、半夏、桔梗组成）。火噎膈，主要使用回令丸来治疗。食噎膈，主要使用食郁越鞠丸来治疗。（出自《医方考》）（应当与治例中引用的《微义》一文参照阅读。）
噎证分为五种：有气滞型的，有血瘀型的，有火炎型的，有痰凝型的，有食积型的。虽然分为五种，但总归是由于七情（喜、怒、忧、思、悲、恐、惊）变化所致。因为气机郁结化为火邪，火旺则耗伤血液导致干枯，津液凝聚成痰，痰浊壅盛导致食物无法消化。（出自《汇补》）
膈证有酒膈、气膈、虫膈、劳膈的区别。酒膈，是因为脾胃被酒所伤，导致精液枯竭。气膈，是因为恼怒过度，肝木之气乘袭脾土。虫膈，是因为喜好食用煎炒香味的食物，烧灼散失体内的津液，以致生出寄生虫。劳膈，是因为饮食不知节制，损伤了中焦脾胃之气；或者是房事过度，导致不能化生脾土之气。（出自《医学指要》）
酒毒 嗜好饮酒的人患此病，必定是顽痰作祟。因为酒能引发火邪，火邪能生痰，痰因火邪煎熬而胶结不散，阻塞道路，即使喝水咽下，也会感到疼痛涩滞。如果用治疗血枯的方法，投用当归、地黄等药物，血液未必能得到滋润，反而助长痰湿，病怎么能痊愈呢？如果是身体黑瘦的人，真阴素来虚弱，常觉得内热，又不嗜酒，或者过服香燥热性药物的人，才应当以血枯论治。（出自《订补指掌》）
经常喝酒的人多患噎膈，饮用热酒的人尤其多。因为热邪损伤津液，导致咽管干涩（看他的口舌干涩就可以知道），所以食物无法咽下。（出自《医碥》）
死血有痰（应当与后文活血化瘀的各种方剂参照阅读）。凡是进食时有阻碍感，感觉食物屈曲下行，微微作痛，这必定是有死血（瘀血）兼有痰浊，适宜在药中加入竹沥和姜汁服用。（出自《医统》）（按：《六要》对此证论述说：先用前面的膏滋药进行润补，然后再用代抵当丸攻下。所谓膏滋药是指韭汁、牛乳、生姜捣碎取汁混合均匀。另外《原病集》开具润血汤，见滋阴方中。）
有一个壮年男子，饭后必吐出几口食物，却吐不干净，胸膈上方时常发出声响，面色看起来和正常人一样。判断他的病不在脾胃，而在膈间。询问他得病的原因，是因为大怒未止时，就强行进食，据此推断，大怒会导致气血上逆郁积，积聚在膈间，阻碍气机的升降，津液因此聚集成痰饮，与气机相互搏动而产生声响。使用二陈汤加入香附、韭汁、莱菔子，服用两天后，再用瓜蒂散配合酸浆水催吐，第二天又吐了一次，痰中带血一盏，次日再次催吐，见血一钟，病随即痊愈。瘀血停留在膈间，阻碍气道而形成此病，多用代抵当丸（方剂附在《瘀血》篇中）制成芥菜籽大小的药丸，每次取三钱，去枕仰卧，细细咽下，让它搜逐停积的瘀血，到早晨排出恶物，然后好好调养，自然痊愈。（出自《准绳》）但如果只喝热汤，以及遇到花椒、生姜就打嗝的，也是瘀血的表现。（出自《医通》）
吐涎沫 每当饮食进入胃中，就吐出涎沫，像鸡蛋清一样。这是因为脾主涎，脾虚不能约束津液，所以涎沫自行流出，非用人参、白术、诃子、益智仁等药不能摄纳住。（出自《医通》）
死证 年纪大的人，难以治愈。（出自《丹溪心法》）（按：《正传》说：年龄五十多岁，就不可治了。《医统》说：因为气血都虚弱的原因。我见过未满六十岁的人，按照法则治疗并遵守禁忌谨慎调养，也痊愈了；只有那些不忌口浓味厚腻食物并纵欲、忧虑思虑的人，必定危险。）
大便像羊屎一样干燥的，绝对不可治，这是因为大肠没有血液滋润的缘故。（同上）
气血都虚弱的人，口中会多出泡沫，只要见到泡沫大量涌出的，必定危险。（出自《钩玄》）（按《统旨》说：或者口吐红痰。《医统》说：吐痰像螃蟹泡沫一样的，不可治。《景岳全书》说：这是脾气败坏的表现。）
腹中嘈杂疼痛如刀割一样的，不可治。（出自《医统》）（《景岳全书》说：这是营血极度虚弱，血液在中焦枯竭的表现。）
得了这个病的人，如果能稍微吃进一点谷物，就不会超过一年而死；完全吃不进谷物，就不会超过半年而死。（出自《源流论》）
治例 治疗的方法，在于调顺阴阳，化痰降气。如果阴阳平和均匀，气顺痰消，膈噈的疾病就没有发作的机会了。（出自《济生方》）
治疗这种疾病，咽喉闭塞，胸膈痞闷，似乎属于气滞；但是如果有服用过多耗气药物的情况，导致中气不运转而致病，应当补气使其自然运转。大便干燥坚硬如羊屎，似乎属于血热，但是如果有服用过多通利药物的情况，导致血液耗竭而更加结滞的，应当补血润血使其自行通畅。有的因为火气上逆冲撞，食物无法咽下，脉象洪大有力且数的，或者痰饮阻滞而脉象结涩的，应当清化痰热泄热，火气自然下降。有的因为脾胃阳气衰微，脉象沉细而微弱的，应当用辛香性质的药物温煦其气，仍以益阴养胃为主，不像局方那样一味追求燥烈。至于那些不遵守禁忌、食用浓味厚腻食物及纵欲的人，以及年老无血的人，都是无法治疗的。（出自《微义》）
凡是膈病初起，郁结太过，血液尚未枯竭的，应当用沉香、木香、豆蔻等药开提气机，不可单纯使用滋补药；等到久病胃气受伤，津液已经枯竭的，应当用白蜜、芦根、当归、白芍来滋养，不可单纯使用香燥药，这是治疗的先后顺序。（出自《汇补》）
这个病症之所以疑难，是因为想健脾理痰时，担心燥性药物妨碍津液；想养血生津时，又担心滋润药物碍滞中焦脾胃。仔细审视如果是阴伤火旺的，应当以养血为急务；脾伤阴盛的，应当以温补为先。更有忧愁愤懑盘踞体内，火邪郁闭结聚，神气尚未大衰，脉象还有力的，应当采用仓公、河间的方法攻下。（出自《必读》）
噎膈属于气血两虚，是由于血液衰少而不是痰气壅逆所造成，忌讳破气、升提、攻下、消导、燥性、苦寒、辛热的药物，适宜用降气、清热润燥、甘温甘平的药物来益血，略微佐以辛香药物来顺气。（出自《本草经疏》）
至于食物吃进去又反吐出来，这是中焦土寒，下焦火虚，可以用附子理中汤、香砂六君子汤加干姜，或者八味地黄丸，交替服用多有效。如果食物完全吃不下，必须以黄连黄芩人参干姜汤为主，泻心汤也很好。吴茱萸汤，不论噎膈还是反胃都可以使用，唯独以呕吐且胸满为确切证候，干呕、吐涎沫、头痛也是确切证候。（出自《时方妙用》）（按：陈氏有续论，详细论述膈噎宜用芩连参姜汤、吴茱萸汤的道理，需要参考。）
治疗需察辨中上、中下的区别 患此病的人，百无一活，但有中上、中下的区别，以及速死、迟死的差异。中上者，是上焦和中焦不和。中下者，是下焦和中焦不和。中下不和，死亡较晚；中上不和，死亡较快。然而如果治疗得当，快的可以变慢；治疗失当，慢的也会变快。刚患此病时，医生常用辛香行气的药物，认为能宽胸开胃。哪里知道不能进食是因为真气虚弱，真气既然虚弱，怎么可以再使用辛散药物来耗气呢？既然耗散了气，元气本不很虚的人，还可以勉强延续生命；元气本已虚弱的人，几个月之内性命就不保了。另外刚患此病时，医生有用养血滋阴药物的，认为开通阑门使之下行，可以不呕吐。如果是中下二焦不相贯通，食物进入中脘，下焦不相顺接，腐熟转化出现差错，仍然从中院向上逆行，逆行则呕吐，这种滋润下行的药物，投用也有效；病愈后复发，再投用此药，就不效了。起初因为下焦不得顺接，可以使用滋润下行药，时间久了则阴盛阳虚，下焦生发之阳气不能循环回复于上，只下不上，就不效了，不效必定导致性命不保。其中下二焦，火气衰微，初起或许直接用参、芪、术、姜、桂、附等药服用，也觉得有效。药虽然有效但病根未除，后来必定怀疑温补不对，转而服用其他药物，最终归于不治。天下哪有不吃谷物的人呢？经书说得到谷气昌隆，失去谷气灭亡，说得真好啊。（出自《医学真传》）（按：《兰台轨范》也称膈病是胃口枯槁的病症，百无一治。）
治疗关键在于滋润，禁止使用香燥热药 有人说：胃脘干槁的病，古方果真能治吗？如果有其他简便快捷的方法，或许可以弥补前人的未发之处吧？我说：古方用人参补肺，御米解毒，竹沥消痰，干姜养血，粟米实胃，蜜水润燥，姜去秽，正是这个意思。张鸡峰也说：噎证大概是神志方面的病，只有内观自养，才可以治疗。这话深深切中病情，而施治的方法，也为近于情理。噎病生于血干，血属阴气，阴主静，内外都安静，那么脏腑之火就不会升起，而金水二气得到滋养，阴血自然生成，肠胃津液滋润，传化功能适宜，哪里有噎证呢？由此类推，我曾配制一方，治疗中年妇人，用四物汤，加入和白陈皮、留尖桃仁、生甘草、酒红花，浓煎，加入驴尿饮用，以防其生虫，服用几十帖而安。另外台州治疗一个工匠，年纪近三十，勤于劳作且有艾妻（指妻子早逝或独居等，此处语境略晦，指生活状况），且喜欢喝酒，面色苍白，脉象涩，重按则大而无力。让他辞去工作，住在牛家，取新温的牛乳饮用，每顿喝一杯，一昼夜可喝五七次，完全停止其他食物，逐渐增加到八九次。半个月后大便变润，一个多月后痊愈。然而如果口干，那是酒毒未解，偶尔喝少许甘蔗汁。（出自《局方发挥》）
治疗膈症的人，有的认为是胃虚而用温补，有的认为是开郁而用香燥等剂，必然导致死亡才停止。不知道这是关门枯槁，肾水不能上达。经书说肾是胃的关隘，关隘不利，升降就停止了。关隘即气交之中，天之枢纽。所以肾旺盛则胃阴充足，胃阴充足则思食，应当用六味地黄饮加当归、白芍来滋养。（出自《四明》）
世上患此病的人，多是痰与火、血枯气郁造成的，《局方》通常使用五膈宽中散、沉香开膈散之类，这些都是辛热耗血助火的药剂。如果是确实阳气衰弱有寒，或者郁结而内实的，用辛热药获得疗效。如果施用于血枯火热痰饮所致的病人，乃是加速死亡的道路，务必谨慎。（出自《统旨》）（按：膈噎禁用香燥热药的说法，原本出自张子和，而朱丹溪也进一步辨析过，应当一并考证。）
有人说：膈咽是因为气郁，所以用辛热药来疏散它，所以不得不使用热剂。我说：气郁的人，是气虚而郁结，并非实证。现在因为气虚而郁热，如果使用辛热药耗气，那就是虚者更虚，热者更热，这怎么作为救治之道呢？病刚开始发作时，往往看见全部使用辛香燥热药劫夺正气，病愈后又复发，越劫夺越深，直到危困。（出自《医统》）
古方治疗噎膈，多以止吐的药剂通用。没考虑到呕吐，是湿证，宜用燥药；噎膈，是燥证，宜用润药。经书说三阳结谓之膈，所谓结，就是热，热甚则物体干枯。凡是噎膈证，不出“胃脘干槁”四个字。胃既然已经干枯了，如果再投用燥药，不是更加增加它的燥吗？（出自《心悟》）
使用攻下法的例子 假如病程已久，千万不要突然猛烈攻下，纵然攻开了，也必须顾虑后患，应当先滋润滋养，小剂量开始服用汤药或丸药，逐渐增加剂量，关窍自然通透。如果出现咽噎，上部阻碍涎痰，轻微使用苦酸药，微微涌出痰涎，从而治疗下部，药势容易通行，如果不行，用蜜盐导下，始终勾引上下两药相通，结散阳消，饮食自然下行。不要使用巴豆，耗损天真元气，液燥津枯，留下毒素不去。人们说这个病，曾经用攻下法治疗，从攻下而来，转为虚弱痞塞，这是巴豆的过错，不是大黄、牵牛的过错。箕城一位酒官，患病呕吐，一年多不愈。都用胃寒来治疗，丁香、半夏、青皮、陈皮、生姜、附子种种燥热药物，烧锥灸艾，数量不知多少。有时稍好，有时加重，长达十年，大便涩燥，小便赤黄。请我去诊治。我说：各种痿证、喘证、呕吐，都属于上焦。王太仆说：上指上焦。火气炎上的气，都说因为热甚而呕吐。用四生丸（用黑牵牛、大黄、朴硝、皂角），攻下三十次，排出的燥粪肠垢，何止数升。那人昏困了一两天，频繁地啜饮冰水，逐渐投喂凉乳酪、芝麻饮，时时咽下。几天后，大口饮食，精神气血如往昔，后来生了三个儿子，到五十岁去世。（出自《事亲》）（按：这个治疗验案并不是典型的噎膈，其用意大概在于让后人类推。）
张子和因为河间的三乙承气汤治法，说噎膈的病，只适宜用攻下法，结散阳消，病自然痊愈，可是脘膈的病，难道攻下就能去除吗？虽然仲景有大黄甘草汤，东垣有通幽润肠等方法，是为便秘呕吐设立的，但这自然是针对食入辄吐的治疗，不适合讨论食噎不下的情况。唯独他说“慎勿顿攻，宜先润养”等等，“始终勾引，两药相通”的话，非常正确。因为痰血在脘部，不运行不会痊愈，而药力超过病所，反而伤害真气，不仅无益反而有害。所以用小丸药逐渐增加，刚好到达病所，不过分也无不及，以平和为标准，这就是治疗噎证的方法，但必须审察是痰还是血而行之。（出自《金匮翼》）
温中利气诸方（温凉调停诸方）膈中的病，名为膏肓，汤药丸药经过，针灸达不到，所以做成丸药含在嘴里，让药气能够相互熏染，有五膈丸方。
麦门冬十分去心，甘草十分炙，椒、远志、附子、炮干姜、人参、桂、细辛各六分，捣碎筛粉，以上好蜂蜜制成如弹丸大的丸药，含一枚，慢慢咽下其汁液，每天三次服用。主治短气，心胸满闷，心下坚硬，冷气。这种病有十多个方子，大多相似，此方最好。（出自《肘后备急方》）
干姜、蜀椒、食茱萸、桂心、人参（各五分）；细辛、白术、茯苓、附子（各四分）；橘皮（六分）。
以上十味药研末，蜂蜜和丸如梧桐子大，用酒送服三丸，每天三次。无效，逐渐增加到十丸。（出自《千金方》）
以上四味药切碎，用水八升，煮取二升五合，过滤去渣，分三次温服，每次服药间隔，如人行走六七里的时间。（出自《外台秘要》）另外《集验方》通气噎汤，在本方中去掉橘皮，加入羚羊角。
卢某，阴阳逆乱，已成关格（按：此关格大概是膈症），建议用附子泻心汤，作为上热下寒的主治方。（出自《临证指南医案》）
毛某，老年形体消瘦，不食不便，气冲涌涎，乃是关格的病症，建议用进退黄连汤。
毕某（五四），夏间诊视，曾说难愈之症。然而此病乃积劳伤阳，年纪未老，精神已竭，古称噎膈反胃，都因阴枯而阳结也。秋分后复诊，两脉生气已索，交早咽燥，昼日溺少，五液告涸，难任刚燥阳药，这病估计非医药能愈。
大半夏汤，加黄连、姜汁。（同上）（按：《时方妙用》论述大半夏汤的道理，应当参考。）
治疗饮食喜噎，宜服半夏散方。
半夏（一两）、干姜（一两炮裂锉）、石膏（二两）、人参（一两去芦头）、栝蒌根（一两）、桂心（一两）、甘草（半两炙微赤锉）、吴茱萸（半两汤浸七遍焙干微炒）。
以上药材捣碎，粗罗为散，每次服三钱，用水一中盏，加入生姜半分，枣二枚，小麦、小豆各五十粒，同煎至六分，去渣，不计时候稍热服。（出自《太平圣惠方》）
诃黎勒皮（一两）、木香（三分）、陈橘皮（一两）、五味子（三分）、半夏（三分）、人参（三分）、桂心（三分）、赤茯苓（三分）、芦根（一两锉）、枳壳（三分）。
Deficiency and Excess: The disease of Yige (dysphagia and regurgitation) presents with both deficiency and excess patterns. In the excess pattern, phlegm or blood stasis adheres to the epigastrium, struggling with Qi, wrapped externally like a membrane; occasionally, vomiting expels these pathogenic factors, providing temporary relief to the chest Qi, but the condition soon returns to its original state. In the deficiency pattern, body fluids are depleted and fail to moisten, while Qi is insufficient to fill and support, leading to a dry and shriveled epigastrium where food enters with difficulty and feels rough. For deficiency patterns, moistening and nourishing methods should be used; for excess patterns, dredging and unblocking methods should be employed. This distinction must not be overlooked. (From *Jinkui Yi*)
Various Syndromes: For Qi-type Yige, Shenshi Qiqi Tang (Deep Master's Seven-Qi Decoction) is indicated (prescription from *Qianjin Fang*, comprising twelve ingredients). For Blood-type Yige, Jiuzhi Yin (Leek Juice Drink) is indicated. For Phlegm-type Yige, Gualou Shi Wan (Trichosanthes Fruit Pill) is indicated (composed of Trichosanthis Semen, Aurantii Fructus, Pinelliae Rhizoma, Platycodonis Radix). For Fire-type Yige, Huiling Wan is indicated. For Food-type Yige, Shiyu Yueju Wan is indicated. (From *Yifang Kao*) (Refer also to the text in *Weiyi* within the Treatment Examples.)
Yie (choking sensation) is divided into five types: those caused by Qi stagnation, blood stasis, flaming fire, phlegm coagulation, and food accumulation. Although categorized into five types, they all stem from alterations due to the Seven Emotions (Joy, Anger, Worry, Pensiveness, Sorrow, Fear, Fright). Qi stagnation transforms into fire; excessive fire dries up the blood; body fluids condense into phlegm; phlegm obstruction prevents food digestion. (From *Huibu*)
Ge (obstruction) is distinguished into Wine-Ge, Qi-Ge, Worm-Ge, and Labor-Ge. Wine-Ge results from damage to the Spleen and Stomach by alcohol, leading to exhaustion of essence and fluids. Qi-Ge results from excessive anger, causing Liver Wood to overact upon Spleen Earth. Worm-Ge arises from a preference for fried and aromatic foods, which scorch and dissipate body fluids, leading to the generation of parasites. Labor-Ge is caused by undisciplined diet damaging the Middle Jiao Earth, or excessive sexual activity failing to generate Spleen Earth Qi. (From *Yixue Zhiyao*)
Alcohol Toxicity: Those addicted to alcohol who suffer from this disease invariably have stubborn phlegm. Alcohol generates fire; fire generates phlegm; phlegm is scorched by fire into a sticky mass that obstructs pathways, causing pain and roughness even when water is swallowed. If treated as blood dryness using herbs like Danggui (Angelicae Sinensis Radix) and Dihuang (Rehmanniae Radix), the blood may not be moistened, but the phlegm will instead be aggravated, and the disease cannot heal. However, if the patient is thin and dark-complexioned, with inherent True Yin deficiency, frequent internal heat, no fondness for alcohol, or a history of overusing aromatic-dry-hot medicines, then it should be treated as blood dryness. (From *Dingbu Zhizhang*)
Frequent drinkers often develop Yige, especially those who drink hot wine. Heat damages body fluids, causing dryness and roughness in the pharyngeal tube (evident from dry mouth and tongue), preventing food intake. (From *Yique*)
Dead Blood with Phlegm (Refer to subsequent blood-invigorating formulas). Whenever there is an obstruction during swallowing, a sensation of twisting descent, and slight pain, this indicates the presence of dead blood (blood stasis) and phlegm. It is appropriate to add Zhuli (Bambusa Textilis Caulis Infusum) and Jiangzhi (Zingiberis Rhizoma Expressum) to the decoction. (From *Yitong*) (Note: *Liuyao* states: Use previous paste medicines for moistening and tonifying, followed by Daididang Wan for purgation. The paste refers to mixed leek juice, cow milk, and ginger juice. Additionally, *Yuanbing Ji* prescribes Runxue Tang, found in the Yin-Nourishing section.)
A young man vomited several mouthfuls after every meal, though not completely emptying. There was occasional noise above the diaphragm, yet his complexion appeared normal. I determined the pathology lay not in the Spleen and Stomach, but in the diaphragm region. Inquiry revealed the onset followed intense anger followed immediately by eating. Anger causes blood to pool upward and accumulate in the diaphragm, obstructing the ascending and descending of Qi. Body fluids thus gather into phlegm and fluid retention, struggling with Qi to produce noise. I prescribed Erchen Tang plus Xiangfu (Cyperi Rhizoma), Jiuzhi (Leek Juice), and Laifuzi (Raphani Semen). After two days, I induced vomiting using Gouti San (Melon Sepal Powder) with sour plum juice. On the second day of vomiting, one cup of bloody sputum was expelled; on the next day, another cup. The disease then resolved. Blood stasis in the diaphragm obstructs the Qi pathway. Daididang Wan (see *Yuxue* chapter) is typically used, formed into mustard-seed-sized pills. Take 3 qian, lie supine without a pillow, and swallow slowly to search out and eliminate accumulated stasis. By morning, foul matter is evacuated via bowels. With proper recuperation, self-healing occurs. (From *Zhunsheng*) However, if only drinking hot soup or encountering pepper/ginger triggers hiccups, this also indicates blood stasis. (From *Yitong*)
Spitting Saliva Foam: Every time food enters the stomach, saliva foam is spat out, resembling egg whites. The Spleen governs saliva; Spleen deficiency fails to constrain body fluids, causing spontaneous leakage of saliva foam. Only Renshen (Ginseng Radix), Baizhu (Atractylodis Macrocephalae Rhizoma), Hezi (Chebulae Fructus), and Yizhiren (Alpiniae Oxyphyllae Semen) can secure it. (From *Yitong*)
Incurable Signs: In elderly patients, it is incurable. (From *Danxi*) (Note: *Zhengchuan* states: Over fifty years old, it is untreatable. *Yitong* states: Because both Qi and Blood are deficient. I have seen patients under sixty cured by following treatment rules and observing taboos; however, those who ignore dietary restrictions and engage in sexual exertion or worry/pensiveness face grave danger.)
Stool resembling sheep dung is absolutely incurable, due to lack of blood in the Large Intestine. (Same source)
When both Qi and Blood are deficient, excessive foam appears in the mouth. If large amounts of foam are observed, death is imminent. (From *Gouxuan*) (Note: *Tongzhi* mentions spitting red phlegm. *Yitong* states spitting phlegm like crab foam is incurable. *Jingyue Quanshu* attributes this to failure of Spleen Qi.)
Abdominal嘈杂 (burning/discomfort) and pain like knife-cutting is incurable. (From *Yitong*) (*Jingyue Quanshu* states: Extreme deficiency of Ying Blood, depletion of blood in the middle.)
Patients with this syndrome who can eat a little grain will not survive beyond one year; those who cannot eat at all will not survive beyond six months. (From *Yuanliu Lun*)
Treatment Principles: The therapeutic method involves regulating Yin and Yang, resolving phlegm, and directing Qi downward. When Yin and Yang are balanced and Qi flows smoothly with phlegm resolved, Yige cannot arise. (From *Jisheng Fang*)
Treating this disease: Throat closure and chest fullness seem to indicate Qi stagnation; however, if caused by excessive use of Qi-consuming medicines leading to non-movement of Middle Qi, tonification of Qi is required to restore movement. Dry stool resembling sheep dung seems to indicate Blood Heat; however, if caused by excessive purgatives depleting blood and worsening constipation, nourishing and moistening Blood is required to restore flow. If food cannot enter due to rebellious Fire rushing upward, with a surging, forceful, and rapid pulse, or if blocked by phlegm-fluids with a knotted and choppy pulse, clearing phlegm and draining heat is necessary to subdue the Fire. If Spleen and Stomach Yang Fire is also declining, with a deep, fine, and faint pulse, aromatic-warm medicines should warm the Qi, primarily focusing on nourishing Yin and the Stomach, rather than relying solely on drying-hot formulas as in the Bureau Formulas. Those who disregard taboos regarding rich foods and sexual activity, and the elderly lacking Blood, are beyond cure. (From *Weiyi*)
At the initial stage of Ge disease, with excessive constraint but unexhausted Blood, lifting agents like Chenxiang (Aquilariae Lignum), Muxiang (Vladimiriae Radix), and Doukou (Amomi Fructus Rotundus) should be used; do not rely solely on tonification. In chronic stages with Stomach injury and exhausted fluids, Bai Mi (Honey), Lugeng (Phragmitis Rhizoma), Danggui (Angelicae Sinensis Radix), and Baishao (Paeoniae Radix Alba) should be used to nourish; do not rely solely on aromatic-drying agents. This is the sequence of early and late treatment. (From *Huibu*)
The difficulty of this syndrome lies in the dilemma: wishing to strengthen the Spleen and resolve phlegm, one fears drying agents will harm fluids; wishing to nourish Blood and generate fluids, one fears moistening agents will obstruct the Middle Jiao. If Yin injury and Fire flourishing are identified, nourishing Blood is urgent. If Spleen injury with Yin abundance is identified, warming and tonifying come first. In cases of pent-up sorrow and anger with constrained Fire, where Spirit is not significantly depleted and the pulse remains forceful, purgative methods akin to those of Cang Gong and He Jian should be employed. (From *Bidu*)
Yige belongs to dual deficiency of Qi and Blood, resulting from diminished Blood rather than phlegm-Qi rebellion. Avoid breaking Qi, ascending, purging, digesting, drying, bitter-cold, and pungent-hot agents. Favor descending, clearing heat, moistening dryness, sweet-warm, and sweet-neutral agents to benefit Blood, slightly assisting with aromatic agents to smooth Qi. (From *Bencao Jing Shuluo*)
For regurgitation of ingested food, indicating Cold in the Middle Jiao Earth and deficiency of Fire in the Lower Jiao, Fuzi Lizhong Tang, Xiangsha Liujunzi Tang plus Ganjiang, or Bawei Dihuang Wan, taken alternately, are often effective. For inability to ingest food, Huanglian Huangqin Renshen Ganjiang Tang is primary; Xiexin Tang is also excellent. Wuzhuyu Tang is applicable to both Yige and Fanwei, specifically indicated for vomiting with chest fullness, dry retching with saliva foaming, and headache. (From *Shifang Miaoyong*) (Note: Mr. Chen has a continuation discussing the rationale for Qinlian Shenjiang Tang and Wuzhuyu Tang in Yige; refer to it.)
Differentiating Upper/Middle vs. Middle/Lower Treatment: Patients with this disease rarely survive, but distinctions exist between Upper-Middle and Middle-Lower involvement, and fast versus slow mortality. Upper-Middle involves disharmony of Upper and Middle Jiaos; Middle-Lower involves disharmony of Middle and Lower Jiaos. Middle-Lower disharmony leads to slower death; Upper-Middle to faster death. Proper treatment can slow fast mortality; improper treatment can accelerate slow mortality. Initially, physicians often use aromatic Qi-moving drugs to open the chest and stimulate appetite. However, inability to eat stems from deficiency of True Qi. Once True Qi is deficient, how can pungent-dispersing drugs be used to further consume Qi? Consuming Qi allows those with mild root deficiency to linger, but those with severe root deficiency lose their lives within months. Alternatively, some physicians initially use Blood-nourishing and Yin-moistening drugs to open the "Lanmen" gate and promote downward movement to prevent vomiting. If the Middle and Lower Jiaos are disconnected, food entering the Middle Jiao fails to connect with the Lower Jiao for proper transformation, reversing upward and causing vomiting. Such moistening-downward drugs may work initially; upon recurrence, they cease to work. Initially, Lower Jiao disconnection responds to moistening-downward drugs. Over time, Yin becomes abundant and Yang deficient; the generating Yang Qi of the Lower Jiao cannot circulate upward. Downward-only movement fails, leading to death. In Middle-Lower disharmony with weak Fire, using Renshen, Huangqi, Baizhu, Ganjiang, Guizhi, Fuzi early on may show effect. But if the disease persists despite efficacy, suspicion of warming-tonification errors arises, leading to switching treatments and ultimate failure. As the Classic says, "Those who obtain Grain prosper; those who lose Grain perish." (From *Yixue Zhenzhuan*) (Note: *Lantai Guidfan* also calls Ge disease a withering of the stomach gate, incurable.)
Treatment Requires Moistening, Prohibiting Aromatic-Heat: Some ask: Can ancient formulas treat gastric withering? Are there quicker methods to supplement predecessors? I reply: Ancient formulas use Renshen to tonify Lung, Yumi (Oryza Sativa Var. Glutinosa) to detoxify, Zhuli to resolve phlegm, Ganjiang to nourish Blood, Sumi (Panicum miliaceum) to solidify Stomach, honey-water to moisten dryness, and Ginger to remove filth. This aligns with the principle. Zhang Jifeng also stated: Yie is a disorder of the Spirit/Mind; only introspection and self-nurturing can cure it. This deeply hits the pathology, and the treatment approach is reasonable. Yie arises from Blood dryness. Blood is Yin; Yin is quiet. Inner and outer quietude prevents organ Fire from rising, nourishing Metal and Water, generating Yin-Blood, moistening intestines/stomach, and ensuring proper transmission. Thus, no Yie. Applying this logic, I formulated a prescription for a middle-aged woman: Siwu Tang plus Chenpi (Citri Reticulatae Pericarpium), Taoren (Persicae Semen), Sheng Gancao (Raw Glycyrrhizae Radix et Rhizoma), and Honghua (Carthami Flos) decocted strongly, drunk with Donkey Urine to prevent worm generation. Dozens of doses brought peace. Also, a craftsman in Taizhou, nearly thirty, diligent, widowed, fond of wine, pale, with a choppy pulse (large and powerless when heavy). Advised him to quit work, stay with cattle, drink fresh warm cow milk, one cup per sitting, 5-7 times daily, stopping other foods, gradually increasing to 8-9 times. Bowels softened in half a month; recovered in a month. If thirsty, due to unresolved alcohol toxicity, drink small amounts of Sugarcane Juice. (From *Jufang Fahui*)
Treating Ge syndrome, some use warming-tonification for Stomach deficiency, others use aromatic-drying for opening constraint, leading inevitably to death. They do not realize this is withering of the "Gate," where Kidney Water cannot ascend. The Classic states the Kidney is the Gate of the Stomach; if the gate is blocked, ascent and descent cease. The gate is the pivot of Qi interaction, the hub of Heaven. When Kidney is robust, Stomach Yin is sufficient; sufficient Stomach Yin induces appetite. Use Liuwei Yin plus Danggui and Baishao to nourish. (From *Siming*)
Most cases involve Phlegm-Fire, Blood dryness, and Qi constraint. *Jufang* typically uses Wuge Kuanzhong San or Chenxiang Kaige San, which are pungent-hot, consuming Blood and aiding Fire. Effective only for true Yang deficiency with Cold or internal constraint with excess. For Blood dryness, Fire, Phlegm, or Fluids, such treatments are paths to quick death. Be cautious. (From *Tongzhi*) (Note: The prohibition of aromatic-dry-hot drugs for Yige originates from Zhang Zihe, further analyzed by Danxi; consult both.)
Some argue: Yie is due to Qi constraint, so pungent-hot dispersants are necessary. I say: Qi constraint is due to Qi deficiency, not excess. Here, Qi deficiency leads to constrained Heat. Using pungent-hot drugs consumes Qi, making deficiency worse and Heat hotter. How can this save the patient? Early in the disease, physicians often use pungent-aromatic-dry-hot drugs to劫 (rob/crush) the pathogen. The disease recurs, gets deeper with each robbery, until critical. (From *Yitong*)
Ancient formulas generally used anti-emetics for Yige. They failed to consider that vomiting is a Damp syndrome requiring drying; Yige is a Dry syndrome requiring moistening. The Classic says: Conjunction of the Three Yang is called Ge. Conjunction implies Heat; extreme Heat causes dryness. All Yige syndromes boil down to "dryness and withering of the epigastrium." If the Stomach is already withered, adding drying drugs only increases dryness. (From *Xinwu*)
Use of Purgatives Example: If the disease has persisted long, do not attack suddenly. Even if opened, worry about aftermath. First, moisten and nourish. Start with small doses of decoctions or pills, gradually increasing until the gate opens naturally. If choking with upper obstruction of saliva/phlegm, mildly use bitter-sour agents to induce slight vomiting, facilitating downward treatment. If ineffective, use honey-salt to guide downward. Connect upper and lower agents to scatter knots and dissipate Yang, allowing food to descend. Do not use Badou (Crotonis Fructus) to consume Tianzhen (innate vitality); liquid dryness and fluid depletion leave toxins behind. People say this disease worsened by purgation became deficient and obstructed; this is Badou's fault, not Dahuang (Rhei Radix et Rhizoma) or Qianniu (Pharbitidis Semen). An official in Jicheng suffered vomiting for over a year, treated as Stomach Cold with Dingxiang (Caryophylli Flos), Banxia (Pinelliae Rhizoma), Qingpi (Citri Reticulatae Pericarpium Viride), Chenpi, Shengjiang, Fuzi, and moxibustion. Symptoms fluctuated for ten years, with dry stool and yellow urine. I diagnosed: All Wei, Chuan, and Ou belong to the Upper Jiao. Wang Taiabu said: Upper refers to Upper Jiao. Fire Qi flaring upward causes vomiting due to extreme Heat. Used Sisheng Wan (Hei Qianniu, Dahuang, Poxiao, Zaorao) to purge thirty times, evacuating liters of dry feces. Patient was confused for one-two days, drank ice water frequently, then cool yogurt and sesame drink. Days later, ate heartily, spirit and Qi restored, fathered three sons, died at fifty. (From *Shiqin*) (Note: This case is not typical Yige, intended for analogy.)
Zihehe, influenced by Hejian's San-Yi Chengqi treatment, claimed Yige requires purgation to scatter knots and dissipate Yang. However, epigastric/diaphragmatic diseases cannot be cured merely by purging. Although Zhongjing had Dahuang Gancao Tang and Dongyuan had Tongyou and Runchang methods for constipation/vomiting, these address immediate regurgitation, not Yige with inability to pass food. His advice "do not attack suddenly, first moisten/nourish" and "connect upper/lower agents" is excellent. Phlegm/blood in the epigastrium must move to heal; medicine exceeding the disease site harms True Qi. Thus, small pills gradually increased to reach the site precisely, balancing excess and deficit, is the way to treat Yige, provided one distinguishes Phlegm from Blood. (From *Jinkui Yi*)
Warming Middle and Benefiting Qi Formulas (Warm/Cool Balanced Formulas): Diseases of the Diaphragm are named Gaohuang (vital areas beyond reach of decoctions/pills/acupuncture). Therefore, pills are held in the mouth to allow vaporized qi to permeate. Five Ge Pills follow.
Maimendong (Ophiopogonis Radix) 10 parts, descored; Gancao (Glycyrrhizae Radix et Rhizoma) 10 parts, roasted; Jiao (Zanthoxyli Fructus), Yuanzhi (Polygalae Radix), Fuzi (Aconiti Lateralis Radix Praeparata), Paoganjiang (Zingiberis Rhizoma Praeparatum), Renshen (Ginseng Radix), Guizhi (Cinnamomi Ramulus), Xixin (Asari Radix et Rhizoma) each 6 parts. Pound and sieve. Make pills with premium honey the size of a bullet. Hold one pill in the mouth, slowly swallowing the juice. Take three pills daily. Indicated for shortness of breath, chest fullness, hardness below the heart, and cold Qi. Among many similar formulas, this is superior. (From *Zhouhou*)
Five Yie Pills: Indicated for chronic cold in the chest, retching/rebellious Qi, inability to eat/drink, and unconsumed constrained Qi.
Ganjiang (Zingiberis Rhizoma), Shujiao (Zanthoxyli Fructus), Shizhuyu (Torreyaefolia Fructus), Guixin (Cinnamomi Cortex), Renshen (each 5 parts); Xixin (Asari Radix et Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Fuling (Poria), Fuzi (Aconiti Lateralis Radix Praeparata) (each 4 parts); Ju pi (Citri Reticulatae Pericarpium) (6 parts).
Ten ingredients powdered, mixed with honey into pills the size of梧子 (Chinese parasol tree seeds). Take three pills with wine, three times daily. If ineffective, increase to ten pills. (From *Qianjin*)
Guangji Formula for Yie: Chest/hypochondriac fullness, choking Qi with each meal. Tongqi Tang.
Banxia (Pinelliae Rhizoma, washed), Shengjiang (Zingiberis Rhizoma Recens) (each 6 liang); Ju pi (Citri Reticulatae Pericarpium), Guixin (Cinnamomi Cortex) (each 3 liang, sliced).
Four ingredients sliced. Boil in 8 sheng water to 2.5 sheng. Strain. Divide into three warm doses. Take intervals equivalent to walking 6-7 li. (From *Waitai*) Also, *Jiyan* Tongqi Yie Tang removes Ju pi and adds Lingyangjiao (Saigae Tataricae Cornu).
Lu: Yin-Yang reversal,已形成 Guan Ge (Obstruction-Rebellion - likely Ge syndrome). Propose Fuzi Xiexin Tang for Upper Heat and Lower Cold. (From *Linzheng Zhinan*)
Mao: Elderly, emaciated, anorexic, constipated, Qi rushing with saliva foam. Guan Ge syndrome. Propose Jintui Huanglian Tang.
Chuanlian (Coptidis Rhizoma), Dan Ganjiang (Zingiberis Rhizoma Praeparatum), Banxia (Pinelliae Rhizoma), Jiangzhi (Zingiberis Rhizoma Expressum), Renshen (Ginseng Radix), Fuling (Poria), Fuzi (Aconiti Lateralis Radix Praeparata), Sheng Baishao (Paeoniae Radix Alba) (Same source).
Bi (54 years old): Diagnosed in summer, deemed incurable. This disease results from accumulated fatigue damaging Yang. Though young in age, Spirit is exhausted. Ancient texts attribute Yige/Fanwei to Yin dryness and Yang knotting. Autumn equinox follow-up: Vital Qi in pulses exhausted, early throat dryness, scant daytime urination, exhaustion of Five Fluids. Cannot tolerate harsh-dry Yang drugs. Disease likely incurable by medicine.
Dabansha Tang (Half-Ginger Half-Semen Persicae Decoction), plus Huanglian (Coptidis Rhizoma), Jiangzhi. (Same source) (Note: Refer to *Shifang Miaoyong* for rationale of Dabansha Tang.)
Prescription for Dysphagia with Preference for Eating: Banxia San.
Banxia (Pinelliae Rhizoma) (1 liang), Ganjiang (Zingiberis Rhizoma Praeparatum) (1 liang, roasted/crushed), Shigao (Gypsum Fibrosum) (2 liang), Renshen (Ginseng Radix) (1 liang, descored), Gualougen (Trichosanthis Radix) (1 liang), Guixin (Cinnamomi Cortex) (1 liang), Gancao (Glycyrrhizae Radix et Rhizoma) (0.5 liang, roasted/red/crushed), Wuzhuyu (Evodiae Fructus) (0.5 liang, soaked/washed seven times/dried/lightly roasted).
Pound ingredients, sift coarsely. Take 3 qian per dose. Add 1 zhong lamp of water, 0.5 fen Shengjiang (Zingiberis Rhizoma Recens), 2 dates, 50 grains Xiaomai (Tritici Semen), 50 grains Xiaodou (Phaseoli Semen). Decoct to 0.6 portion. Strain. Take warm, anytime. (From *Shenghui*)
Prescription for Ge Qi Obstruction, Inability to Eat, Vomiting/Irritability/Panting: Helile San.
Helile Pi (Terminalia Chebulae Pericarpium) (1 liang), Muxiang (Vladimiriae Radix) (3 fen), Chen Ju pi (Citri Reticulatae Pericarpium) (1 liang), Wuweizi (Schisandrae Chinensis Fructus) (3 fen), Banxia (Pinelliae Rhizoma) (3 fen), Renshen (Ginseng Radix) (3 fen), Guixin (Cinnamomi Cortex) (3 fen), Chi Fuling (Poria with Red Heart) (3 fen), Lugeng (Phragmitis Rhizoma) (1 liang, crushed), Zhike (Aurantii Fructus) (3 fen).