其脉大（止）阳为腑 马云。脉见于寸口。其脉大者。以邪气有余也。其脉坚者。以邪气不散也。其
脉涩者。以气血涩滞也。故为胀。然脉大而坚者为阳脉。其胀在六腑。脉涩而坚者为阴脉。其胀在五脏也。张
云。大都洪大之脉。阴气必衰。坚强之脉。胃气必损。故大坚以涩。则病当为胀。一曰脉病在阴。则胀在脏。
脉病在阳。则胀在腑。亦通。
三者皆存焉 甲乙。三、作二是。志云。此病在气而及于脏腑血脉之有形。故三者皆存焉。
郭胸胁 甲乙。郭、作廓。张云。排挤于脏腑之外。以胸胁为郭。而居于皮肤之中。是即胀之所舍。
匣匮之藏禁器 说文。匣、匮也。又匣匮也。载侗六书。故今通以脏之大者为匮。次为匣。小为椟。
简案、禁器、盖禁秘之器。
愿闻其故 马云。此处必阙。乃岐伯言。张志同。
脏腑之郭也 甲乙。郭上有城字。张云。胸腹者。所以保障五内。故为脏腑之郭。
宫城 马云。按黄帝时本纪。记其民不习伪。官不怀私。市不预价。城郭不闭。则此时有宫城矣。张
云。膻中、胸中也。肺覆于上。膈膜障于下。为清虚周密之宫。心主之所居也。故曰宫城。
胃之五窍者 闾里门户也 张云。闾、巷门也。里、邻里也。周礼五家为比。五比为闾。盖二十五家
为闾也。风俗通曰。五家为轨。十轨为里。盖五十家为里也。胃之五窍。为闾里门户者。非言胃有五窍。正以
上自胃脘。下至小肠大肠。皆属于胃。故曰闾里门户。如咽门、贲门、幽门、阑门、魄门、皆胃气之所行也。
故总属胃之五窍。
廉泉、玉英 马云。即玉堂。俱任脉经穴。
营气循脉（止）工在疾泻 甲乙。并脉、作并血脉。循分、作循分肉。三里上有取字。注云。灵枢作营
气循脉为脉胀。卫气并脉循分肉为肤胀。一下、一本作分。下同。楼氏以此三十九字。移下文黄帝曰善。何以
解惑之上。云。原误在病各有形之下。黄帝曰。愿闻之上。有三里而泻之上。当有脱简。甲乙云。凡五脏六腑
之胀。皆取三里。三里者。胀之要
穴也。张云。清者为营。营在脉中。其气精专。未即致胀。浊者为卫。卫行脉外。其气 疾滑利。而行于分肉
之间。故必出卫气之逆。而后病及于营。则为脉胀。是以凡病胀者。皆发于卫气也。卫气逆而并于脉。复循分
肉之间。故为肤胀。三里、足阳明经穴。阳明为五脏六腑之海。而主肌肉。故胀在肌肤者。当以针泻之。一下
三下。谓一次再次三次也。盖邪有远近。故泻有难易耳。
肺胀 金匮要略云。上气喘而躁者。属肺胀。又云。肺胀咳而上气。烦躁而喘。脉浮者。心下有水气。
简案、本节肺胀盖谓肿胀中属肺者。与金匮所论不同。
央央然 张云。困苦貌。
濯濯 张云。肠鸣水声也。马云。按邪气脏腑病形篇。有大肠者诸证。与此同。
气癃 张云。膀胱气闭。小水不通也。
轻轻然 甲乙作壳壳然。
久塞其空 马云。虚则补之。其穴空。皆正气充塞。志云。塞其空者。外无使经脉肤腠疏空。内使脏
腑之神气充足。自无厥逆之患矣。此良工治未病也。张氏医通云。按诸胀统言无问虚实。工在疾泻。次云补虚
泻实。神归其室。二说相左。其义何居。原夫诸胀之因。良由卫气僭逆。故宜疾泻以下其气。气下则胀消矣。
卫为水谷之悍气。常行脉外。不能入于脉。今以僭逆过甚。乃并居营分而入于脉。则为脉胀。卫气并脉循分肉
间。则为肤胀。故昭揭于脏腑诸胀之前。且言凡此诸胀。其道在一。故其治总不越针三里。以疾泻之也。明知
逆顺者。知胃逆之甚与不甚也。针数不失者。随近远之一下三下也。
然后厥气在下 甲乙。后、作而。
乃合为胀 甲乙。合、作舍。
合之于真 三合而得 张云。不得其真。所以生惑。胀虽由于卫气。然有合于血脉之中者。在经脉
也。有合于脏者。在阴分也。有合于腑者。在阳分也。三合既明。得其真矣。志云。元真之气。通会于腠理。
与营卫合并。而充行于形身者也。故营卫二气。合之于真元三合。而得其厥逆之因矣。简案、即上文三者皆存
焉之义。
不下者 张云。胀不退也。
陷于肉肓而中气穴者也 张云。上文云。一下三下者。言针当必陷于肉肓。亦必中于气穴。然后可以
取效也。张注痹论肓膜云。肓者。凡腔腹肉理之间。上下空隙之处。皆谓之肓。不独以胸膈为言。姚氏云。按
金匮玉函曰。腠者。是三焦通会元真之处。理者。是皮肤脏腑之文理也。夫脏腑之文理。乃脏腑募原之肉理。
而肉理之中有脉系。卫气陷于肓膜。而入于脉络。故当取之气穴。王芳侯云。按素问有气府论。气穴论。总属
手足三阴三阳之经脉。而分府与穴者。谓腑者藏也。压遏血气之藏于内也。穴者窟也。气从此而出入者也。
必更其道 张云。三而不下。必未得其所也。故当更穴再刺之。
必审其KT 张云。唇疡曰KT 。盖胀之微甚。必见于唇。故当审之于此。以察其虚实。然KT 字未妥。
必脉字误也。简案、KT 又作HT 。即诊同。难经本义。刘仁木序。KT 、KT 深浅是也。
其脉大，属阳，病在六腑。马云说：脉象显现于寸口部位。脉象大的原因，是由于邪气有余。脉象坚实的原因，是由于邪气郁结不散。脉象涩滞的原因，是由于气血运行不畅。因此形成胀病。然而，脉象大而坚实的属于阳脉，其胀病位于六腑；脉象涩而坚实的属于阴脉，其胀病位于五脏。张云说：大体上洪大的脉象，阴气必然衰少；坚强有力的脉象，胃气必然受损。所以脉象既大又坚且涩，疾病应当表现为胀病。另一种说法是：脉象病变在阴分，则胀病在脏；脉象病变在阳分，则胀病在腑。这种说法也是通顺的。
这三种情况（指脉大、脉坚、脉涩）都存在于这里。《甲乙经》中，“三”字写作“二”。张志聪注说：此病由气机失调进而影响到脏腑和血脉等有形的实体，所以这三种脉象表现都存在。
郭，指胸胁部位。《甲乙经》中，“郭”字写作“廓”。张云说：邪气排挤于脏腑之外，以胸胁作为外廓，而居于皮肤之中，这就是胀病所停留的地方。
匣匮之藏禁器：《说文解字》解释：“匣”即“匮”。又说“匣”和“匮”同义。载侗在《六书》中记载，所以现在通常把较大的脏器称为“匮”，较小的称为“匣”，更小的称为“椟”。简案认为：“禁器”，大概是禁止秘藏的器具。
希望听闻其中的缘故。马云说：此处必定有脱漏，乃是岐伯所言。张志聪意见相同。
这是脏腑的外廓。《甲乙经》中，“郭”字上有“城”字。张云说：胸腹部位，是用来保护五脏六腑的，所以称为脏腑的外廓。
宫城：马云说：按《黄帝本纪》记载，记述当时百姓不习虚伪，官员不怀私心，市场不干预物价，城郭不关闭，那么那时就有宫城了。张云说：膻中，即胸中。肺覆盖在上面，膈膜阻挡在下面，构成了清虚周密的宫殿，是心主居住的地方，所以称为宫城。
胃的五窍，如同闾里的门户：张云说：闾，是巷门；里，是邻里。《周礼》规定五家为比，五比为闾，大概二十五家为闾。《风俗通》说：五家为轨，十轨为里，大概五十家为里。所谓胃的五窍如同闾里的门户，并不是说胃真的有五个孔窍，而是指从上方的胃脘，到下方的小肠、大肠，都属于胃的管辖范围，所以称为闾里门户。如咽门、贲门、幽门、阑门、魄门，都是胃气运行的通道，所以总归属于胃的五窍。
营气循行于脉中……工匠在于迅速泻法：《甲乙经》中，“并脉”写作“并血脉”，“循分”写作“循分肉”。三里穴上方有“取”字。注释说：《灵枢》原文作“营气循脉”为脉胀，“卫气并脉循分肉”为肤胀。“一下”、“一本”作“分”，下同。楼氏认为这三十九字，移到了下文“黄帝曰善，何以解惑”之上，说：原本错误地放在“病各有形”之下，“黄帝曰，愿闻之”之上，有“三里而泻”之上，应当有脱简。《甲乙经》说：凡是五脏六腑的胀病，都取足三里穴。足三里，是治疗胀病的要穴。张云说：清纯之气为营，营气行于脉中，其气精专，不会立即导致胀病；浑浊之气为卫，卫气行于脉外，其气疾滑利，而行于分肉之间。所以必须是卫气逆乱，然后病及于营，才形成脉胀。因此凡是患胀病的人，都发源于卫气。卫气逆乱并与脉并行，又循行于分肉之间，所以形成肤胀。足三里，是足阳明经的穴位。阳明经是五脏六腑的海，并且主司肌肉，所以胀病在肌肤者，应当用针刺泻法。所谓“一下”、“三下”，是指一次、再次、三次施针。大概是因为邪气有远近之分，所以泻法的难易程度不同。
肺胀：《金匮要略》说：气喘而且烦躁的，属于肺胀。又说：肺胀咳嗽且上气，烦躁而喘，脉浮的，心下有停水。简案认为：本节所说的肺胀，大概是指肿胀病中属于肺的部分，与《金匮要略》所论述的不同。
央央然：张云说：困苦的样子。
濯濯：张云说：肠鸣的水声。马云说：按《邪气脏腑病形篇》，有大肠的各种证候，与此相同。
轻轻然：《甲乙经》写作“壳壳然”。
长久闭塞其空虚之处：马云说：虚证应当补益，其穴位空虚，都要使正气充塞充实。张志聪注说：闭塞其空虚，是指外部不让经脉腠理疏泄空虚，内部使脏腑的神气充足，自然就没有厥逆的祸患了。这是高明医生治未病的方法。《张氏医通》说：按各种胀病统而言之，不问虚实，工匠在于迅速泻法；接着又说补虚泻实，神气回归其室。两种说法相左，其中的道理何在？推究各种胀病的成因，确实是由于卫气僭越逆乱，所以应当迅速泻法以降其气。气降则胀消。卫气是水谷产生的悍气，常行于脉外，不能进入脉中。现在因为僭逆过于严重，于是并入营分而进入脉中，就形成脉胀。卫气并入脉中循行于分肉间，就形成肤胀。所以在讲述脏腑诸胀之前，特别指出凡此诸胀，其道一致，所以治疗总不离针刺足三里，用迅速泻法。所谓明知逆顺，是知道胃气逆乱的严重程度；针刺次数不失，是随着邪气远近决定一下或三下。
然后厥气在下：《甲乙经》中，“后”字写作“而”。
于是合而为胀：《甲乙经》中，“合”字写作“舍”。
合之于真，三合而得：张云说：不得其真，所以产生疑惑。胀病虽然由于卫气，但有合于血脉之中的，在经脉；有合于脏的，在阴分；有合于腑的，在阳分。三合既然明了，就得到了真相。张志聪注说：元真之气，通会于腠理，与营卫合并，而充盛运行于形体周身。所以营卫二气，合之于真元，通过三合，而得到厥逆的原因。简案认为：即上文“三者皆存焉”的意思。
陷入肉肓而中气穴者也：张云说：上文说“一下三下”，意思是针刺应当必然陷入肉肓，也必然中于气穴，然后才能取效。张氏注《痹论》关于肓膜说：肓，凡是腔腹肉理之间，上下空隙之处，都称为肓，不仅仅指胸膈。姚氏说：按《金匮玉函》说：腠，是三焦通会元真的地方；理，是皮肤脏腑的纹理。脏腑的纹理，乃脏腑募原的肉理，而肉理中有脉系。卫气陷入肓膜，而入于脉络，所以应当取之于气穴。王芳侯说：按《素问》有《气府论》、《气穴论》，总属于手足三阴三阳的经脉，而区分府与穴，是说府是藏纳之处，压遏血气于内；穴是窟窿，气从此出入。
必须更换其道：张云说：刺三次而不退，一定是没有找到正确的穴位。所以应当更换穴位再刺。
必须审察其KT：张云说：唇上的疮疡称为KT。大概胀病的轻重，必然表现在嘴唇上，所以应当在此处审察，以观察其虚实。然而“KT”字不妥，可能是“脉”字误写。简案认为：“KT”又作“HT”，即诊视之意。《难经本义》刘仁木序中提到：“KT、KT深浅是也。”
Its pulse is large, belonging to Yang, and the disease is in the Six Fu organs. Ma Yun states: The pulse manifests at the Cun Kou position. A large pulse indicates an excess of pathogenic factors. A firm pulse indicates that pathogenic factors are stagnant and not dispersing. A choppy (se) pulse indicates stagnation of Qi and Blood circulation. Thus, distension disorders arise. However, a pulse that is both large and firm belongs to Yang pulses, indicating distension located in the Six Fu organs; a pulse that is choppy and firm belongs to Yin pulses, indicating distension located in the Five Zang organs. Zhang Yun states: Generally, a surging and large pulse implies a deficiency of Yin Qi; a strong and rigid pulse implies damage to Stomach Qi. Therefore, if the pulse is large, firm, and choppy, the disease should manifest as distension. Another theory holds: If the pulse pathology is in the Yin aspect, the distension is in the Zang organs; if the pulse pathology is in the Yang aspect, the distension is in the Fu organs. This interpretation is also valid.
These three conditions [referring to large, firm, and choppy pulses] all exist here. The *Jia Yi Jing* writes "two" instead of "three". Zhang Zhicong notes: This disorder originates from Qi dysfunction and extends to the tangible entities of Zang-Fu organs and vessels; thus, these three pulse manifestations coexist.
"Guo" refers to the chest and hypochondrium. In the *Jia Yi Jing*, "Guo" is written as "Kuo". Zhang Yun states: Pathogenic factors crowd outside the Zang-Fu organs, using the chest and hypochondrium as an outer wall, residing within the skin. This is where the distension disorder resides.
"Xie Kui zhi cang jin qi": The *Shuo Wen Jie Zi* explains: "Xie" is synonymous with "Kui". It further states that "Xie" and "Kui" share the same meaning. Zai Tong records in his *Liu Shu*: Hence, it is now commonly accepted that larger viscera are termed "Kui", smaller ones "Xie", and even smaller ones "Du". The commentary suggests: "Jin qi" likely refers to vessels for secure storage or forbidden containers.
"I wish to hear the reason." Ma Yun states: There must be a lacuna here; this was spoken by Qibo. Zhang Zhicong agrees.
"This is the outer wall of the Zang-Fu organs." In the *Jia Yi Jing*, the character "Cheng" precedes "Guo". Zhang Yun states: The chest and abdomen serve to protect the internal Zang organs, hence they are called the outer wall of the Zang-Fu.
"Gong Cheng" (Palace City): Ma Yun states: According to the *Annals of the Yellow Emperor*, it is recorded that people did not practice hypocrisy, officials harbored no selfishness, markets did not interfere with prices, and city walls were not closed; thus, there was a 'Gong Cheng' at that time. Zhang Yun states: Dan Zhong, which is the chest center. The lungs cover above, and the diaphragm blocks below, forming a clear, empty, and complete palace, which is the residence of the Heart Master. Hence, it is called Gong Cheng.
"The five apertures of the stomach are like the gates of neighborhoods": Zhang Yun states: Lu refers to alley gates; Li refers to neighborhoods. The *Rites of Zhou* stipulates that five families form a Bi, and five Bis form a Lu, comprising twenty-five families. The *Feng Su Tong* states: Five families form a Gui, and ten Guis form a Li, comprising fifty families. The phrase "the five apertures of the stomach are like neighborhood gates" does not mean the stomach literally has five holes. Rather, it signifies that from the upper stomach (Wei Wan) down to the small and large intestines, all belong to the jurisdiction of the stomach, hence termed neighborhood gates. Such as the pharyngeal gate, cardiac gate, pyloric gate, ileocecal gate, and anal gate, are all pathways for Stomach Qi, so they are collectively attributed to the five apertures of the stomach.
Lian Quan and Yu Ying: Ma Yun states: These are actually the Yu Tang acupoint, both belonging to the Ren Mai (Conception Vessel).
Ying Qi circulates within the vessels... The practitioner's skill lies in rapid sedation: In the *Jia Yi Jing*, "Bing Mai" is written as "Bing Xue Mai", and "Xun Fen" as "Xun Fen Rou". Above the San Li point, there is the character "Qu". The annotation states: The *Ling Shu* text reads "Ying Qi circulates in the vessels" as Mai Distension, and "Wei Qi merges with vessels and circulates in muscle spaces" as Fu Distension. "One strike" and "one manuscript" read "Fen", same below. Lou Shi argues that these thirty-nine characters were misplaced above "The Yellow Emperor said: Excellent, how to resolve confusion?" He claims they originally erroneously appeared under "Each disease has its form," between "The Yellow Emperor said: I wish to hear," and above "San Li and sedation," implying missing bamboo slips. The *Jia Yi Jing* states: For all distensions of the Five Zang and Six Fu organs, one should select San Li. San Li is the essential acupoint for treating distension. Zhang Yun states: Pure essence becomes Ying Qi, circulating within the vessels; its Qi is refined and concentrated, not immediately causing distension. Turbid essence becomes Wei Qi, circulating outside the vessels; its Qi is swift, slippery, and smooth, moving between muscle spaces. Therefore, only when Wei Qi becomes rebellious does the pathology affect Ying, resulting in Mai Distension. Thus, all distension disorders originate from Wei Qi. When Wei Qi rebels and merges with the vessels, then circulates through muscle spaces, it results in Fu Distension. San Li is an acupoint of the Foot-Yangming Meridian. The Yangming meridian is the sea of the Five Zang and Six Fu organs and governs the muscles. Therefore, for distension in the skin and muscles, needle sedation should be used. "One strike" and "three strikes" refer to performing the needling once, twice, and three times. This is because pathogens vary in depth/distance, affecting the difficulty of sedation.
Fei Distension: The *Jin Gui Yao Lue* states: Wheezing accompanied by agitation belongs to Fei Distension. It also states: Fei Distension involves coughing and rebellious Qi, irritability, and wheezing; if the pulse is floating, there is water retention in the epigastrium. The commentary notes: The Fei Distension mentioned in this section likely refers to distension disorders specifically involving the Lung, which differs from the discussion in the *Jin Gui*.
Yang Yang Ran: Zhang Yun states: A look of distress or hardship.
Zhuo Zhuo: Zhang Yun states: The sound of water gurgling in the intestines. Ma Yun states: Referring to the chapter on Pathogenic Factors and Zang-Fu Diseases, there are various syndromes of the Large Intestine identical to this.
Qi Long: Zhang Yun states: Closure of Qi in the Bladder, resulting in inability to urinate.
Qing Qing Ran: The *Jia Yi Jing* writes "Ke Ke Ran".
Long-term sealing of its emptiness: Ma Yun states: For deficiency patterns, tonification is indicated. The acupoints are empty; one must ensure righteous Qi fills them. Zhang Zhicong notes: Sealing the emptiness means preventing the exterior meridians and cuticle from becoming loose and empty, while ensuring the Shen Qi of the Zang-Fu organs is abundant internally, thereby avoiding rebellion. This is the method of the superior physician treating disease before it arises. The *Zhang Shi Yi Tong* states: Regarding all distensions generally, regardless of deficiency or excess, the practitioner's skill lies in rapid sedation; subsequently, it mentions tonifying deficiency and sedating excess, returning Shen to its chamber. These two statements seem contradictory. What is the rationale? Investigating the cause of distensions, it stems from the rebellion of Wei Qi; thus, rapid sedation is appropriate to descend the Qi. Once Qi descends, distension subsides. Wei Qi is the fierce Qi derived from food and fluids, usually circulating outside the vessels and unable to enter them. Now, due to excessive rebellion, it merges into the Ying level and enters the vessels, causing Mai Distension. Wei Qi merging with vessels and circulating in muscle spaces causes Fu Distension. Therefore, before discussing Zang-Fu distensions, it emphasizes that the principle for all these distensions is consistent: treatment generally involves needling San Li with rapid sedation. Knowing reversal and normalcy means understanding the severity of Stomach Qi rebellion. Not missing the number of needles means adjusting the frequency (one or three strikes) based on the distance/depth of the pathogen.
Then Rebellious Qi is below: In the *Jia Yi Jing*, "Hou" is written as "Er".
Thus combining to form distension: In the *Jia Yi Jing*, "He" is written as "She".
Merging with the True, obtaining the Three Mergers: Zhang Yun states: Failing to grasp the truth leads to confusion. Although distension arises from Wei Qi, it can merge with blood vessels (in the meridians), merge with Zang organs (in the Yin aspect), or merge with Fu organs (in the Yang aspect). Once these three mergers are clarified, the truth is obtained. Zhang Zhicong notes: Yuan Zhen Qi communicates through the cou li, merges with Ying and Wei, and circulates throughout the body. Thus, Ying and Wei Qi, merged with Yuan Zhen through the three mergers, reveal the cause of rebellion. The commentary notes: This aligns with the meaning of "these three exist" mentioned earlier.
Not descending: Zhang Yun states: Distension does not recede.
Sinking into the muscular fat and hitting the Qi acupoints: Zhang Yun states: The previous text mentions "one to three strikes," meaning the needle must sink into the muscular fat (Huang) and accurately hit the Qi acupoints to be effective. Zhang's annotation on Huang membrane in the *Bi Lun* states: Huang refers to any hollow space between cavities and muscle textures, above and below, not just the diaphragm. Yao Shi states: According to the *Jin Gui Yu Han*, Cou is where the San Jiao communicates Yuan Zhen; Li is the texture of skin and Zang-Fu organs. The texture of Zang-Fu organs is the muscle texture of the Zang-Fu Mu Yuan, within which lie vessel systems. Wei Qi sinking into the Huang membrane enters the vessel network, so one should select Qi acupoints. Wang Fanghou states: The *Su Wen* contains chapters on Qi Fu and Qi Acupoints, covering all Hand and Foot Yin and Yang meridians. Distinguishing Fu and Acupoints: Fu refers to storage, containing and suppressing Blood and Qi internally; Acupoints refer to caves, where Qi enters and exits.
Must change the approach: Zhang Yun states: If three strikes do not reduce the condition, the correct point has not been found. Therefore, one must change the acupoint and needle again.
Must examine its KT: Zhang Yun states: Sores on the lips are called KT. Likely, the severity of distension manifests on the lips, so examination here reveals deficiency or excess. However, the character "KT" is inappropriate and may be a typo for "Mai" (pulse). The commentary notes: "KT" is also written as "HT", referring to diagnosis/palpation. Liu Renmu's preface to the *Ben Yi of Nan Jing* mentions: "KT, KT depth is also so."