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Capítulo 68 de 81
黄帝内经·灵枢
The Yellow Emperor asked: I already understand the condition of Shang Ge (upper diaphragm obstruction — food is regurgitated immediately after entering the stomach, i.e., vomiting right after eating). But regarding Xia Ge (lower diaphragm obstruction — food is regurgitated after a longer period), the condition caused by worm accumulation — where food enters the stomach and is only vomited after about a full day and night — I have yet to understand its underlying principle. I hope to hear your detailed explanation.
Qi Bo replied: If a person experiences improper joy and anger (emotional dysregulation), unregulated eating and drinking (lack of dietary discipline), and untimely exposure to cold and warmth (inappropriate adaptation to climate), this causes cold-type fluids to flow into the intestinal tract. When cold fluids flow into the intestines, they cause worms (referring in ancient times to intestinal parasites) to become chilled and accumulate in clusters, coiling around the lower passage (the lower opening of the stomach, near the pylorus). The worm accumulation causes blockage, leading to the intestines and stomach becoming distended and engorged, while defensive qi (the qi that protects the body surface and resists external pathogens) can no longer circulate properly, and pathogenic qi takes advantage of the deficiency to take up residence.
When a person eats, the worms smell the food and crawl upward to feed; when the worms feed, the lower passage becomes vacuous; once the lower passage is vacuous, pathogenic qi takes advantage and enters; the accumulation thereby remains and persists; when the accumulation persists over time, it forms an abscess (a lesion where qi and blood stagnate and heat putrefies into pus); once the abscess forms, the lower passage becomes constricted, the channel narrows, and food can no longer pass down smoothly — it is only vomited after a considerable interval.
If the abscess is within the passage (on the inner wall of the intestine), then the pain is deep-seated; if the abscess is outside the passage (on the outer wall of the intestine), the pain is relatively superficial, and the skin above the abscess feels warm.
The Yellow Emperor asked: How should acupuncture be administered for treatment?
Qi Bo said: First, use your fingers to gently press the abscess, observing the pathways of qi and blood circulation and the depth and location of the abscess. First insert the needle superficially at the side of the abscess, then gradually increase the depth inward, repeatedly adjusting the needling, but do not exceed three passes. Determine the depth of needling according to the depth or shallowness of the abscess. After needling, one must also apply fomentation, allowing the heat to penetrate deep into the body; daily let the warmth enter internally, so that pathogenic qi gradually declines and the great abscess will then disperse and rupture. At the same time, one should observe dietary prohibitions (what the ancients called "can jin" — multiple abstinences), to eliminate the internal causative factors. One must also maintain a state of being tranquil and free from striving (inner calm, avoiding overexertion), for only then can qi and blood circulate. Afterward, use salty-flavored substances (salty flavors soften hardness and dissipate masses) for regulation, and the grains of food will be able to digest and pass downward.
📌 Textual Critical Note: The original text of this chapter contains several textual errors in its transmission: "shang zhu" should be "shang ge"; "shi qin bu jie" should be "shi yin bu jie"; "zhu fu" should be "chen fu"; "yi zhi" should be "yi ci"; "tian zeng" should be "tian dan"; "cheng ruo" is suspected to be "xian ruo". The above translation follows the standard collated edition.
The core medical principle of this chapter lies in discussing the etiology, pathogenesis, and acupuncture treatment of xia ge disease, embodying several important ideas from the Nei Jing:
I. The Three-Dimensional View of Etiology Qi Bo categorizes the causes of xia ge into three types: emotional dysregulation (improper joy and anger), dietary indiscretion (unregulated eating and drinking), and external exposure to pathogens (untimely cold and warmth). Together, these three factors give rise to the internal generation of cold-type pathological products (cold fluids), which in turn trigger a chain of pathological changes. This embodies the Nei Jing's consistently emphasized holistic view of "three categories of etiological factors" — internal causes, external causes, and non-internal-non-external causes — intertwined rather than a single factor causing disease.
II. The Chain-like Progression of Pathogenesis This chapter presents a clear chain of pathological development:
Cold fluids flow to intestines → worms chill and accumulate → intestines and stomach become engorged → defensive qi fails to circulate → pathogenic qi takes residence → worms feed upward leaving the lower passage vacuous → pathogenic excess causes accumulation to remain → abscess forms → lower passage becomes constricted → food cannot pass downward
This chain reveals the dialectical relationship between "deficiency" and "pathogenic factors": worms feeding upward cause the lower passage to become vacuous; vacuity allows pathogenic qi to take advantage and enter — this is a concrete development of the Nei Jing's principle that "where pathogenic qi gathers, there must be deficiency of qi." At the same time, from accumulation to abscess formation, it embodies the pathological evolution pattern of qi and blood stagnation over time transforming into heat and forming pus.
III. Interior-Exterior Differentiation of Abscess "If the abscess is within the passage, the pain is deep-seated; if the abscess is external, then the abscess is external and the pain is superficial, with warmth over the abscess's skin" — this is a diagnostic method that distinguishes the location of the abscess by the depth of pain location and whether there is local skin warmth, embodying the diagnostic thinking of "inferring the internal from observing the external." Deep pain indicates the abscess is internal; superficial pain with skin warmth indicates the abscess is external. This approach of inferring internal pathology from external manifestations retains diagnostic significance to this day.
IV. The Hierarchical View of Acupuncture "Gently press the abscess and observe where qi travels" — first palpation for localization; "first shallowly needle its side, then gradually go deeper" — the needling hierarchy of entering shallow, then progressively deeper; "do not exceed three passes" — the therapeutic principle of stopping at the right point, avoiding over-treatment; "observe its depth or shallowness to determine the depth" — the individualized treatment concept of flexibility according to the person and the condition. Together, these constitute the Nei Jing's ideas of safe and precise acupuncture.
V. The Holistic Treatment View of Post-Needling Care After acupuncture, treatment does not end; three additional measures are needed: fomentation (heat entering internally to support the decline of pathogenic qi), dietary prohibitions (to eliminate internal causes), and tranquility without striving (regulating emotions to allow qi to circulate). This embodies the Nei Jing's concept of "combining treatment with recuperation" — therapeutic intervention is merely a catalyst; recovery ultimately depends on the body's own healthy qi being restored, and the restoration of healthy qi requires the cooperation of diet and emotional regulation.
On "Worm Accumulation" and Xia Ge What the ancients called "worms," from a modern medical perspective, primarily refers to intestinal parasites (such as roundworms). Large accumulations of roundworms in the intestine can indeed cause intestinal obstruction, presenting with abdominal pain, distension, and vomiting — showing considerable consistency with the symptoms described in this chapter, such as "intestines and stomach engorged" and "food entering and then being regurgitated, or being vomited only after about a day." The fact that ancients, over two thousand years ago, could associate food being regurgitated after ingestion with intestinal parasites reflects keen clinical observational ability.
On the "Abscess" What "when the abscess forms, the lower passage becomes constricted" describes may, in modern pathological terms, correspond to localized inflammatory masses or ulcers in the intestine, causing luminal narrowing or obstruction, thereby impeding food passage. Although the ancients used the concept of "abscess" as a broad categorization of this kind of local pathology involving qi and blood stagnation with heat putrefaction into pus, their directional grasp of the pathological process of inflammation and suppuration is reasonable.
On "Cold Fluids Flowing into the Intestines" The interpretation of "cold fluids" cannot be simplistically equated with "liquid" in the modern anatomical sense. Understood from the perspective of traditional Chinese medical pathogenesis, this refers to metabolic disturbance of fluids due to yang deficiency and cold congelation — the fluids cannot be properly distributed and instead accumulate and stagnate in the intestines. Although modern medicine has no concept of "cold fluids," phenomena such as abnormal intestinal secretion, edema, and exudation are indeed present in many digestive system diseases. The ancients' description is an abstract generalization of pathological phenomena within the theoretical framework of yin-yang and cold-heat.
Historical Limitations It should be noted that attributing the cause of disease to the single chain of "worms chilling and then accumulating" oversimplifies the complex etiology of intestinal obstruction, pyloric obstruction, and similar conditions. The causes of xia ge in modern medicine include tumors, ulcer scars, hernias, adhesions, parasites, and many other possibilities — by no means only "worm accumulation." Furthermore, the specific technique of needling "not exceeding three passes" described in this chapter, due to differences between ancient and modern needle instruments and anatomical knowledge, cannot be evaluated for actual efficacy using modern standards, and should not be directly applied clinically.
Although this chapter discusses the disease of xia ge, the general principles of life regulation contained within it still offer inspiration for ordinary people:
Regulate Emotions ⚡: Excess in joy and anger disrupts qi movement and affects digestive function. Maintaining emotional stability in daily life — not being prone to sudden anger, excessive joy, or excessive worry — helps maintain the normal functioning of the gastrointestinal tract. This resonates with the modern medical "brain-gut axis" theory — that emotional states significantly affect the digestive system.
Moderation in Diet ⚡: Unregulated eating and drinking is one of the causes explicitly identified in this chapter. In daily life, one should eat at regular times and in moderate amounts, avoiding overeating, avoiding excessive cold and raw foods, chewing slowly, and allowing the digestive system to work regularly.
Guard Against Cold in Daily Life ⚡: Untimely exposure to cold and warmth can allow cold pathogens to invade internally. Particularly during seasonal transitions and cold periods, it is important to keep the abdomen warm and avoid cold beverages directly irritating the gastrointestinal tract — common-sense care.
Cultivate a Tranquil Spirit ⚡: This chapter particularly emphasizes that "tranquility and freedom from striving enable qi to circulate." Maintaining inner calm and avoiding overexertion helps harmonize the movement of qi throughout the body and maintains normal digestive function. The fast pace of modern life makes it all the more necessary to consciously set aside time for relaxation and rest.
Warmth for the Spleen and Stomach ⚡: The fomentation method in this chapter reflects the ancients' emphasis on "warming and unblocking." For ordinary people, practice of adequately warm diets and avoiding large amounts of cold beverages over long periods is a stomach-friendly habit (not directed at any particular disease).
Associated Concepts:
Further Reading:
This content is based on classical Chinese medicine texts and is provided solely for the study of traditional culture and classical literature. It does not constitute any medical diagnosis, prescription, or treatment recommendation. Please consult a qualified healthcare provider for any health concerns.