肿胀证。大约肿本乎水。胀由乎气。肿分阳水阴水。其有因风因湿因气因热。外来者为有
余。即为阳水。因于大病后。因脾肺虚弱。不能通调水道。因心火克金。肺不能生肾水。以致
小便不利。因肾经阴亏。虚火烁肺金而溺少。误用行气分利之剂。渐至喘急痰盛。小水短
赤。酿成肿证。内发者为不足。即为阴水。若胀病之因更多。所胀之位各异。或因湿因郁因
寒因热因气因血因痰因积因虫。皆可为胀。或在脏在腑。在脉络在皮肤。在身之上下。表
里皆能作胀。更或始因于寒。久郁为热。或始为热中。末传寒中。且也胀不必兼肿。而肿则
必兼胀。亦有肿胀同时并至者。其病形变幻不一。其病机之参伍错综。更难叙述。故案中
诸症。有湿在下者。用分利。有湿在上中下者。用分消。有湿而着里者。用五苓散通达膀胱。
有湿郁热兼者。用半夏泻心法。苦辛通降。有湿热气郁积者。用鸡金散加减。消利并行。有
气血郁积。夹湿热之邪。久留而不散者。用小温中丸。清理相火。健运中州。有湿热与水寒
之气交横。气喘溺少。通身肿胀者。用禹余粮丸。崇土制水。暖下泄浊。有寒湿在乎气分。则
用姜附。有寒湿入于血分。则用桂附。有湿上甚为热。则用麻杏膏苡等味。清肃上焦之气。
有湿下着为痹。则用加味活络等剂。宣通下焦之郁。有藉乎薤白栝蒌者。滑润气机之痹
结于腹胁也。有藉乎制黄归尾者。搜逐血沫之凝涩于经隧也。有藉乎玉壶控涎神保神
芎者。视其或轻或重之痰。饮水积而驱之也。此皆未损夫脏气。而第在腑之上下。膜之表
里者也。若有胃阳虚者。参苓必进。脾阳衰者。术附必投。更有伤及乎肾者。则又需加减八
味济生等丸矣。其他如养阳明之大半夏汤。疏厥阴之逍遥散。盖由证之牵连而及。是又
案中法外之法也已。（姚亦陶）
徐评 胀满之为病。即使正虚。终属邪实。古人慎用补法。又胀必有湿。湿则有热。内经所以指
为热症。今多用温补之药。内虽有通利之品。而臣不胜主。贻误必多。细阅诸案。恐愈者少。而不
治者多也。
胀满必有有形之物。宜缓缓下之。
肿胀病证。大致来说，肿的根源在于水湿，胀的成因在于气机阻滞。肿分为阳水和阴水两类。其中，因风、因湿、因气、因热等外邪侵袭所致者，属于有余之证，即为阳水。若因大病之后，脾肺虚弱，不能通调水道；或因心火克制肺金，导致肺不能生肾水，致使小便不利；或因肾经阴液亏损，虚火灼伤肺金而尿量减少，此时误用行气分利药物，逐渐发展为喘促急促、痰多壅盛、小便短少色赤，酿成肿证，这类内发者为不足之证，即为阴水。
至于胀病的成因更多，发生部位各异。或因湿、因郁、因寒、因热、因气、因血、因痰、因积、因虫，皆可导致胀病。病变可在脏、在腑、在脉络、在皮肤，在身体的上下、表里各处都能引起胀满。此外，有的起初因寒邪，久郁化为热邪；有的起初为热中，最终传变为寒中。而且，胀病不一定兼有肿，但肿病必然兼有胀，也有肿胀同时并发的情况。其病形变幻莫测，病机错综复杂，难以详尽叙述。
因此，医案中各种症状的处理方法如下：湿气在下焦者，采用分利法；湿气在上、中、下三焦者，采用分消法；湿气留着于里者，使用五苓散以通达膀胱气化；湿气郁结兼有热邪者，使用半夏泻心汤法，通过苦辛通降来治疗；湿热之气郁结积聚者，使用鸡金散加减，使消导与利湿并行；气血郁结积聚，夹杂湿热邪气，久留不散者，使用小温中丸，以清理相火，健运中焦脾胃；湿热与水寒之气交杂横逆，出现气喘、尿少、全身肿胀者，使用禹余粮丸，以崇土制水，温暖下焦并泄除浊邪；寒湿停留在气分者，则使用干姜、附子；寒湿侵入血分者，则使用肉桂、附子；湿气偏盛于上焦化为热邪者，则使用麻杏苡甘膏等药物，以清肃上焦肺气；湿气偏盛于下焦导致痹证者，则使用加味活络丹等剂，以宣通下焦气机郁滞；借助薤白、瓜蒌者，是为了滑润并疏通腹胁部气机的痹结；借助制何首乌、当归尾者，是为了搜逐并消除经络隧道中凝涩的血瘀；借助玉壶丸、控涎丹、神保丸、神芎丸者，是根据痰饮的轻重程度，针对饮水积滞而驱除痰饮。这些情况都尚未损伤脏腑真气，仅仅是在六腑的上下、膜原的表里之间。
如果有胃阳虚弱的情况，必须进服人参、茯苓；脾阳衰微的情况，必须投用白术、附子。更有伤及肾脏者，则需要使用加减八味丸或济生肾气丸等方剂。其他如滋养阳明胃气的半夏汤，疏理厥阴肝气的逍遥散，都是由于病症牵连波及而采用的治法，这又是医案中常规治法之外的变通之法。（姚亦陶评）
徐灵胎评注：胀满这种病，即使正气虚弱，终究属于邪气实盛。古人慎用补法。另外，胀病必有湿邪，湿邪蕴久则生热，《内经》因此将其指认为热症。如今多用温补药物，虽然方中含有通利之品，但臣药（辅助药）的力量胜不过主药（温补药），必然造成延误和错误。仔细研读诸医案，恐怕治愈者少，而不治（死亡或恶化）者多。
Swelling and Distension Syndromes. Generally speaking, the root of swelling (Edema) lies in water-dampness, while the cause of distension (Abdominal Distension) lies in Qi stagnation. Swelling is divided into Yang Water and Yin Water. Those caused by external pathogens such as Wind, Dampness, Qi stagnation, or Heat are considered excess syndromes, classified as Yang Water. Conversely, if it arises after a severe illness due to deficiency of Spleen and Lung, leading to an inability to regulate water passages; or due to Heart Fire suppressing Lung Metal, preventing Lung from generating Kidney Water, resulting in difficult urination; or due to Yin deficiency in the Kidney channel, with deficient fire scorching Lung Metal causing scanty urine, and mistakingly using Qi-moving and diuretic agents, gradually progressing to panting, rapid breathing, profuse phlegm, and short, dark urine,酿成 (forming) a swelling syndrome—this internal origin represents a deficiency syndrome, classified as Yin Water.
Regarding distension, the causes are numerous and locations vary. It can be caused by Dampness, depression/stagnation, Cold, Heat, Qi, Blood, Phlegm, accumulation, or parasites, all capable of causing distension. The pathology may reside in Zang organs, Fu organs, collaterals, or skin, affecting any part of the body, interior or exterior. Furthermore, some cases start with Cold which lingers and transforms into Heat; others start as Heat in the Middle but transmit to Cold in the end. Moreover, distension does not necessarily accompany swelling, but swelling invariably accompanies distension, and there are cases where both occur simultaneously. The clinical manifestations are variable, and the pathogenesis is complex and intricate, making it difficult to describe fully.
Therefore, in the medical records, various symptoms are treated as follows: For dampness located in the Lower Jiao, the method of separation and purgation (diuresis) is used. For dampness affecting Upper, Middle, and Lower Jiaos, the method of simultaneous dispersion is employed. For dampness lingering internally, Wuling San (Five-Ingredient Poria Pill) is used to unblock Bladder Qi transformation. For dampness stagnating with heat, Banxia Xiexin Tang (Pinellia Decoction for Draining the Epigastrium) method is applied, using bitter and acrid flavors to promote descending action. For accumulation of damp-heat and Qi/Blood stagnation, Jijin San (Chicken Gizzard Lining Powder) is modified, combining digestion-promoting and diuretic actions. For Qi and Blood stagnation mixed with damp-heat that persists long-term, Xiaowenzhong Wan (Minor Warm Middle Pill) is used to clear Ministerial Fire and strengthen the Middle Jiao transport. For chaotic interaction of damp-heat and cold-water qi, presenting with panting, scanty urine, and generalized edema, Yuyuliang Wan (Hematite Pill) is prescribed to fortify Earth to control Water, warm the Lower Jiao, and drain turbidity. For cold-damp in the Qi level, Ginger (Shengjiang) and Aconite (Fuzi) are used. For cold-damp entering the Blood level, Cinnamon Twig (Guizhi) and Aconite (Fuzi) are used. For excessive dampness transforming into heat in the Upper Jiao, Mahuang Xinggancao Yiyiren Tang (Ephedra, Apricot Seed, Licorice, and Coix Seed Decoction) etc. are used to clear and descend Upper Jiao Qi. For dampness settling in the Lower Jiao causing Bi syndrome, Jiawei Huoluo Dan (Modified Collateral-Unblocking Pill) etc. are used to ventilate and unblock Lower Jiao stagnation. Use of Xiebai and Gualou (Chinese Leek Bulb and Trichosanthes Fruit) aims to lubricate and resolve Qi obstruction in the abdomen and hypochondrium. Use of Zhidu Huangqi and Dangguiwei (Prepared Polygonum Multiflorum Root and Angelica Sinensis Tail) aims to search out and eliminate blood stasis in the meridians. Use of Yuhu Wan, Kongxian Dan, Shenbao Wan, and Shenyong Wan targets phlegm-fluid retention, driven according to severity. These conditions have not yet damaged Zang organ Qi, remaining merely within the Fu organs' upper/lower aspects or the membrane's interior/exterior.
If Stomach Yang is deficient, Renshen (Ginseng) and Fuling (Poria) must be advanced. If Spleen Yang declines, Baizhu (Atractylodes Macrocephala Rhizome) and Fuzi (Aconite Lateralis Radix Praeparata) must be administered. If Kidney is injured, Jiawei Bawei Wan (Modified Eight-Ingredient Pill) or Jisheng Shenqi Wan (Kidney-Qi Pill for Childbearing) are required. Others, such as Dabanzhong Tang (Major Pinellia Decoction) to nourish Yangming Stomach, or Xiaoyao San (Free and Easy Wanderer Powder) to soothe Jueyin Liver, are treatments derived from connected pathologies, representing methods beyond the standard protocols in these records. (Commentary by Yao Yitao)
Xu Lingtai’s Commentary: Distension and fullness, even when accompanied by righteous Qi deficiency, ultimately belong to excess of pathogenic factors. Ancients were cautious about using tonification. Furthermore, distension inevitably involves Dampness; Dampness generates Heat. Thus, the Neijing classifies it as a Heat syndrome. Nowadays, many use warming and tonifying drugs. Although formulas contain draining/diuretic herbs, the assistant herbs cannot overpower the chief tonifying herbs, leading to frequent errors. Careful review of these cases suggests few recoveries and many deaths or deteriorations.
Distension always involves tangible pathological products (such as accumulations or fluid retention); thus, gentle purgation should be applied slowly.