诸本无篇字。
气为上膈者 甲乙。上膈下更有上膈二字。马云。此言膈证。有上下之分。而尤详下膈之义也。
膈者。膈膜也。前齐鸠尾。后齐十一椎。所以遮隔浊气。不使上熏心肺也。然有为膈上之病者。乃气使然。食
饮一入。实时还出。有为膈下之证者。乃虫使然。食饮周时。始复外出。但帝明于上膈向昧于下膈。张云。
时、周时也。愚按、上膈下膈。即隔食证也。
喜怒不适（止）邪气居之 甲乙二流字俱作留。张云。凡伤胃气。则阳虚而寒。汁流于肠中。虫寒不行。
则聚于下管。而肠胃充满也。卫气、脾气也。脾气不能营运。故邪得聚而居之。
人食则虫上食（止）痈上皮热 甲乙。即而、作沉而。其痈在外。作其痈在脘外者。并是。张云。痈、壅
同。如论疾诊尺篇曰。目窠微痈者。义亦犹此。虫寒闻食。则喜而上求之。上则邪气居之。而乘虚留聚。以致
痈于下脘。要约不行。故食入 时复出也。管之内外。即言下脘也。邪伏于中。故热见于皮肉之上。
微按其痈（止）谷乃下矣 甲乙。伍、作互。咸、作酸。乃下下有鬲字。张云。察其气所必由以刺之也。
先浅刺其旁气所及之处。稍纳其针而渐深之。以泄其流行之邪。然后还刺其所病之正穴。以拔其积聚之本。但
宜至再三而止。不可过也。邪沉者深刺之。邪浮者浅刺之。刺后必熨以火。而日使之热。则气温于内。而邪自
溃散也。三相参为参。五相伍为伍。凡食息起居。必参伍宜否。守其禁以除内之。再伤。又必恬 无为。以养
其气。则正气乃行。而邪气庶乎可散。盖膈证最为难愈。故当切戒如此。咸从水化。可以润下软坚。苦从火化。
可以温胃。故皆能下谷也。简案、甲乙以本篇为邪气聚于下脘。发内痈。次篇以胃脘痈之诊。志注。亦以痈如
字释之。今据其有痈上皮热。及大痈乃溃等语而推之。则似因内痈而膈食者。盖上文所谓上膈者。巢源诸书所
论五膈之属。（病源五膈忧膈恚膈气膈寒膈热膈外台集验五膈忧膈气膈食膈寒膈饮膈）所谓下膈食。 时乃出。
（邪气脏腑病形篇云脾脉急甚为膈中食饮入而还出后沃沫今膈证不必如此盖古该翻胃而谓之膈故虞抟云膈亦曰
反胃岂本此欤再案食已而吐者龚氏回春谓之回食病即本经所谓膈中上膈也）因虫与痈者。五膈等外。别是一种
之膈证也。马张痈读为壅。虽义稍通。其旨趣终未明晰。且张记
治验一则。乃寻常膈证。非本篇所载下膈证自别。志以痈为内痈。然注文亦糊涂。故不可从也。医说引鸡峰方
云。噎膈病乃神意间气也。劝令净观内外。将一切用心力事。委之他人。服药方见效。即本节恬 无为之旨也。
各版本中均无“篇”字。
气逆导致上膈证（指饮食入胃即吐出的病症）。《甲乙经》记载，在“上膈”二字之下还有重复的“上膈”二字。马云认为，这里所说的膈证，有上、下之分，但尤其详细阐述了“下膈”的含义。
所谓“膈”，是指膈膜。其位置前方与鸠尾穴齐平，后方与第十一椎骨齐平。它的作用是遮挡隔绝浊气，防止其上熏心肺。然而，有的病位在膈之上，这是由气机逆乱所致。饮食刚入口，立刻就会吐出；有的病位在膈之下，这是由虫积所致。饮食经过一个时辰（约两小时），之后才会吐出。只是黄帝对“上膈”讲得很明白，而对“下膈”却讲得模糊。张云指出：“时”即“周时”。愚按：上膈和下膈，实际上就是隔食证（吞咽困难或食入即吐的病症）。
因喜怒失调而不适（止）邪气停留于体内。《甲乙经》和《流注》两个版本中的“留”字都写作“流”。张云认为，凡是损伤胃气，就会导致阳虚生寒。津液流注于肠中，虫体因寒冷而不能运行，于是聚集在下脘（胃的下部），导致肠胃充满胀满。卫气，此处指脾气。脾气不能正常营运，所以邪气得以聚集并停留在那里。
人进食时，虫子上行觅食（止）痈肿部位皮肤发热。《甲乙经》中，“即而”作“沉而”。“其痈在外”作“其痈在脘外者”，这两种解释都可以。张云认为，“痈”通“壅”（阻塞）。如《论疾诊尺篇》所说：“目窠微痈者”，意思也与此类似。虫体因寒冷闻到食物气味，便喜欢向上寻求食物。上行则邪气停留其中，乘虚积聚，从而导致在下脘形成痈肿。由于经络之气不得通行，所以食物吃进去后，过一会儿又吐出来。“管之内外”，即指下脘部位。邪气潜伏在体内深处，所以热象表现在皮肉表面。
轻轻按压痈肿部位（止）谷物才能下行。《甲乙经》中，“伍”作“互”，“咸”作“酸”，“乃下”下有“鬲”字。张云认为，这是观察气机运行的必经之路来进行针刺治疗。先在旁边气机所及之处浅刺，稍微深入针具以逐渐泄去流行的邪气，然后再刺病变的正穴，以拔除积聚的根本。但只宜进行两三次即可停止，不可过度。邪气深沉的深刺，邪气浮浅的浅刺。针刺后必须用火熨法热敷，使每日保持温热，这样体内阳气温暖，邪气自然溃散。三数相参称为“参”，五数相伍称为“伍”。凡饮食呼吸起居，必须参伍斟酌是否适宜，遵守禁忌以防再次内伤。若已受伤，又必须清静无为，以养护正气，那么正气就能运行，邪气或许可以消散。大概膈证是最难治愈的，所以应当如此严格戒慎。“咸”味从水化，可以润下软坚；“苦”味从火化，可以温胃。所以都能帮助谷物下行。简案：《甲乙经》认为本篇讲的是邪气聚于下脘，引发内痈。次篇讲的是胃脘痈的诊断。志氏注释也将“痈”字照原义解释。现在根据文中提到“痈上皮热”以及“大痈乃溃”等语句来推断，这似乎是因内痈而导致膈食症。上文所说的“上膈”，属于巢元方等书中论述的五膈范畴（病源五膈：忧膈、恚膈、气膈、寒膈、热膈；外台集验五膈：忧膈、气膈、食膈、寒膈、饮膈）。所谓“下膈”，是食后一个时辰才吐出（《邪气脏腑病形篇》说脾脉急甚为膈中，食饮入而还出，后沃沫，现在的膈证不必如此，大概是古代统称翻胃为膈，所以虞抟说膈也叫反胃，难道本于此吗？再案：食毕即吐者，龚氏《回春》称为回食病，即本经所说的膈中上膈）。因虫积和内痈导致的，是在五膈之外，另外的一种膈证。马莳和张介宾将“痈”读为“壅”，虽然意思稍通，但最终旨趣并不明晰。而且张介宾记录的一个治验案例，是普通的膈证，并非本篇所载的下膈证，二者自是不同的。志氏将“痈”理解为内痈，但他的注文也含糊不清，所以不可采纳。《医说》引用鸡峰方的说法：“噎膈病乃是神意间的气机问题。”劝患者清净观照内外，将一切用心费力的事情委托给他人，服药才见效，这正是本节“恬淡无为”的宗旨。
None of the versions contains the character "Pian" (Chapter).
Qi rising causing Shang Ge syndrome (a condition where food is vomited immediately after ingestion). The *Jia Yi Jing* records that below the characters "Shang Ge," the characters "Shang Ge" are repeated. Ma Yun states that this refers to Ge syndrome, which has upper and lower distinctions, but particularly elaborates on the meaning of Xia Ge (Lower Ge).
The term "Ge" refers to the diaphragm membrane. Its anterior aspect aligns with the Jiutui point, and its posterior aspect aligns with the eleventh thoracic vertebra. Its function is to shield and isolate turbid Qi, preventing it from steaming upward to affect the Heart and Lungs. However, some diseases occur above the Ge, caused by rebellious Qi. Food and drink enter and are immediately expelled. Other conditions occur below the Ge, caused by intestinal parasites. Food and drink remain for a Zhou Shi (a traditional time unit, approx. two hours) before being expelled. The Yellow Emperor explained Shang Ge clearly but was obscure regarding Xia Ge. Zhang Yun notes: "Shi" means "Zhou Shi." This commentator observes that Shang Ge and Xia Ge essentially refer to Ge Shi syndrome (dysphagia or regurgitation).
Discomfort due to excessive joy or anger causes pathogenic Qi to remain in the body. Both the *Jia Yi Jing* and *Liu Zhu* versions write the character as "Liu" (flow/remain). Zhang Yun argues that damaging Stomach Qi leads to Yang deficiency and cold. Fluids flow into the intestines; because the parasites become cold and immobile, they gather in the Xia Wan (lower stomach), causing fullness in the intestines and stomach. Wei Qi here refers to Spleen Qi. Since Spleen Qi cannot circulate and transport effectively, pathogenic Qi can gather and reside there.
When a person eats, the parasites move upward to feed... heat appears on the skin overlying the abscess. In the *Jia Yi Jing*, "Ji Er" is written as "Chen Er." The phrase "its abscess is external" is interpreted as "the abscess is outside the Wan (stomach area)," both interpretations being acceptable. Zhang Yun states that "Yong" (abscess) is synonymous with "Yong" (obstruction/blockage). As stated in the *Lun Ji Zhen Chi Pian*: "Slight swelling in the eye sockets," the meaning is similar here. Cold parasites, smelling food, prefer to seek it upward. Upward movement allows pathogenic Qi to reside there, accumulating in vacuities, leading to an abscess in the lower Wan. Because the meridians' Qi does not flow smoothly, food enters and is later expelled. "Inside and outside the tube" refers to the lower Wan. Pathogenic Qi hides deep within, so heat manifests on the skin and flesh.
Gently pressing the abscess... grain then descends. In the *Jia Yi Jing*, "Wu" is written as "Hu," "Xian" as "Suan," and the character "Ge" follows "Nai Xia." Zhang Yun suggests this involves observing the pathway of Qi to perform acupuncture. First, shallowly puncture nearby areas where Qi reaches, gradually inserting the needle deeper to drain circulating pathogenic Qi. Then, puncture the primary acupoint of the diseased area to extract the root of the accumulation. However, this should be done only two or three times and must not be excessive. Deep puncture for deep-seated pathogens; shallow puncture for superficial pathogens. After needling, apply moxibustion or hot compresses daily to maintain warmth. This warms the interior Qi, causing pathogenic Qi to disperse naturally. "San" refers to the combination of threes; "Wu" refers to the pairing of fives. Regarding diet, respiration, and daily life, one must carefully consider appropriateness, observe taboos to prevent internal injury, and if injured, practice tranquility and non-action to nourish Zheng Qi (Upright Qi). When Zheng Qi flows, pathogenic Qi may dissipate. Ge syndrome is notoriously difficult to cure; thus, such strict precautions are necessary. "Xian" (Salty) transforms via Water, moistening and softening hardness; "Ku" (Bitter) transforms via Fire, warming the Stomach. Thus, both facilitate the descent of grain. Jian An notes: The *Jia Yi Jing* posits that this chapter discusses pathogenic Qi gathering in the lower Wan, causing internal Yong. The next chapter discusses the diagnosis of Wei Wan Yong. Zhi's commentary also interprets "Yong" literally. Based on mentions of "heat on skin overlying Yong" and "large Yong suppurating," it seems this describes Ge Shi caused by internal Yong. The aforementioned "Shang Ge" belongs to the Five Ge discussed in works like Chao Yuanyang's *Bing Yuan*. The so-called "Xia Ge," where food is expelled after a Zhou Shi (*Xie Qi Zang Fu Bing Xing Pian* states: rapid Spleen pulse indicates Ge Zhong, food/drink enters and returns, followed by frothy saliva; modern Ge syndrome need not be so severe; likely ancient terms for vomiting/regurgitation were collectively called Ge, hence Yu Tun said Ge is also Fan Wei). Parasite-induced and Yong-induced cases are distinct types of Ge syndrome outside the Five Ge. Ma Shi and Zhang Jiebin read "Yong" as "Yong" (blockage); while semantically passable, the intent remains unclear. Furthermore, Zhang's recorded case involves ordinary Ge syndrome, distinct from the Xia Ge described in this chapter. Zhi interprets "Yong" as internal Yong, but his annotation is confused and thus unreliable. *Yi Shuo* cites the *Ji Feng Fang*: "Ye Ge syndrome is a matter of Shen Yi (spiritual intent) and Qi." It advises patients to observe internally and externally calmly, delegating all strenuous mental tasks to others, so that medication becomes effective. This aligns with the principle of "tranquility and non-action" in this section.