帝曰∶脉之应于寸口，如何而胀？伯曰∶其脉大坚以涩者，胀也。邪盛则大，邪
实则坚，涩者，气血虚而不流利也。洪大之脉阴气必衰，坚强之脉胃气必损，故大坚以
涩病当为胀。是以脾具坤静之德，而有干健之运，故能使心肺之阳降肝肾之阴升，而成
天地之泰，是为平人。今也七情内伤，六淫外感，饮食失节，房劳致虚，脾土之阴受
伤，转运之官失职，胃虽受谷，不能运化，是以心肺之阳不能降，肾肝之阴不能升，而
成天地不交之否，清浊相混，隧道壅塞，郁而为热，热留为湿，湿热相生，遂成胀满，
本无形之气为病，难作有形之症调理，有谓秋夏冬治之稍易，惟春最难者，以其木旺，
而土受克，不能制水也。然轻者俱易，重者俱难，不独春也。名鼓者，以其中空外浮，
取其象而名之也。更名蛊者，以其侵蚀之害，取其义而名之也。治者宜补其脾，又须
养肺金以制木，使脾无贼邪之患，滋肾阴以制火，使肺得清化之令，脾肺肾之气交通
则水谷自然克化，却碱味，断妄想，无有不安，医者急于取效，病者苦于胀满，喜行利
药以求通快，不知觉得一日半日，其胀满病邪愈甚，而元气转伤矣。又有标实而本虚
者，泻之不可，补之无功，极为危险，全在杜微防渐，标本得宜，使脾肾之元阳生发，
而阴邪之凝滞释然矣。
水肿鼓胀，皆因脾虚所致，然水肿轻而鼓胀重，何也？水肿则饮食如常，鼓胀则饮
食不及常也。先头足肿，后腹大者，水也、肿也。先腹大，后四肢肿者，气也、胀也。
治水肿则惟补脾导水而已，治鼓胀则补脾导水，兼以消谷，庶乎可也。虽然鼓胀有气血
寒热四者之殊，多由怒气伤肝，木邪克土，所以脾病而不能运化水谷也。又要养肺金以
制肝木，使脾无贼邪，则运化行而水谷消矣。以此观之，治鼓胀之法，必以补脾制
肝，导水消谷为主，看所挟而兼用药，挟气则散气，挟血则破血，挟寒则温寒，挟热则
清热，自无不愈，其有不可治者，此乃脾虚之极，为真脏病也。真脏病者，由真火不能
生土耳，岂止脾脏而已哉。
人有行房，用力过度，则汗出于肾，《经》言汗出于肾，逢于风，内不得入于脏
腑，外不得越于皮肤，客于玄府。行于皮肤，传于 肿，本之于肾，名曰风水，治宜
滋肾散风，如四物汤加荆防羌柴防己之类。不可作脾虚湿肿，而用参术，及利水之药，
愈使风邪内陷。
火性炎上，水性润下，消渴证不交，而火偏盛也。水气证不交，而水偏盛也。治之
之法，在制其偏而使之相济，敌小火不能化大水，先必泻其水，后补其火，开鬼门是发
汗，泻在表在上之水也，洁净府，谓利小便，泻在里在下之水也。水势既减，然后用
暖药以补元气，此治实治热之次第也。若不明虚实寒热，专守下则胀已之一法，虽得稍
宽于一时，真气愈衰，未几而肿胀再作，遂致不救矣。故涉虚者，温补脾肾，如肾气丸
之类，补中微泻，使其渐次康复，然王道无近功，必以缓取效。古今明医，岂不知克伐
之功速，而旷日持久，亦以中气既衰，恐蹈虚虚之祸耳。中满者，其症悉与鼓胀水肿无
异，何故属之气虚？气虚者，肾中之火气虚也。中满者，中空似鼓，虚满而非实满也。
《经》曰∶诸湿肿满，皆属于脾，又曰∶其本在肾，其末在肺，皆聚水也。诸经虽皆有
肿胀，无不由于脾肺肾者，盖脾土主营运，肺金主气化，肾水主五液，凡五气所化之
液，悉属于肾。五液所行之气，悉属于肺，转输二脏，以制水生金者，悉属于脾，若脾
不能散胃之水精于肺，而病于中，肺不得通胃之水道于膀胱，而病于上，肾不能司胃之
关门时其输泄，而病于下，是以胃土不能制肾水，水逆而上行，传入于肺，故水虽制于
脾，而实主于肾，盖肾本水脏，而无阳生气所由出。若肾中阳虚，则命门火衰，既不能
自制阴寒，又不能温养脾土，阴阳不得其正，则化而为邪也。治者惟知泄水，而不知
益胃，或知益胃，而不知温肾，故多下之，强令水出，不根据天度流转，故胃气愈虚，肾
阳愈损，则发而不能制也。莫若行其所无事，则为上计，何举手便用《内经》？去菀
陈，开鬼门，洁净府，如舟车丸禹功散之类。若真知为水湿之气客于中焦，侵于皮
肤，如水晶之光亮，手按之随起者，以前药一服而退。若久病大病后，或伤寒疟痢后，
女人产后，小儿痘后，与夫元气素弱者，概以前法施之，脾气愈泄愈虚，不可复救矣。
故治肿者，先以脾土为主，须补中益气，或六君子汤温补之，再以金匮肾气丸补土以
母，俾脾强土旺，则能散精于肺，通调水道，下输膀胱，水精四布，五经并行矣。或
者疑谓喘胀水满，又加纯补之剂，恐益胀满，必须补药中，加行气利水之品，此论似
得病情，终非纳气藏源至理。盖肺气既虚，不可复行其气，肾水已衰，不可复利其水，
纯补之剧，初时似觉不快，过时药力得行，则气归者自归，而行者自行，如土之在雨
中，则为泥，得和风暖日，则湿去而阳和自得，万物生长矣。
东垣曰∶中满治法，当开鬼门，洁净府，泻之于内，谓脾胃有病，令上下分消其
湿，下焦如读，气血自然分化，或如大实大满，大小便不利者，从权以寒热药下之，此
以论治有余之症也。至于补肾以治肿，其说难明，盖禹之治水，行其所无事也。若一事
疏凿，则失之矣。今人之治水者，牵牛、大戟，粗工之小智，正禹之所恶也。间有五
苓、五皮者，以为中正，亦转利转虚，肾气愈衰，而愈不能推送矣。故须用补肾，《经》
曰∶肾开窍于二阴，肾气化则二阴通，二阴闭则胃填胀。肾者胃之关，关门不利，故水
聚而从其类也。《经》又曰∶肾主下焦，三焦者，决读之官，水道出焉。膀胱者，州都
之宫，津液藏焉。必待三焦之火化，始能出焉。其三焦之经，在上者，布膻中，散落心
包，在下者，出于委阳，上络膀胱，上佐天道之施化，下佐地道之发生，与手厥阴为表
里，以应诸经之使者也。是故肾虚者，下焦之火虚也。虽小便之清长，必由于肺金之输
化，然膀胱之气旺，始能吸胸中之气以下行，但肾与膀胱为表里，膀胱之失运化，必
由肾气之衰微，故始因火小不能化水，后则水大火不能化矣。《经》曰∶三焦病者，气
满，小腹光坚，不得小便，溢则水留而为胀，仲景金匮肾气丸补而不滞，通而不泄，
诚治肿之神矣。
有一身之间，惟面与足浮肿，早则面甚，晚则脚甚。《经》云，面肿为风，脚肿
为水，乃风热所致也。虽然病后元气未复者，每多见此，盖由真气根本不固，故日中
行坐，则气坠下面，晚脚肿，夜中睡卧，则气升浮，而早面浮，若概作风湿治之，益虚
其虚，故以治不足之法，治有余则可，治有余之法，治不足则不可。
凡有 瘕积块痞块，即是胀病之根，日渐月积，腹大如箕，若抱瓮然，是名单腹
胀，不似水气散于皮肤面目四肢也。缘中州
之地久窒，其四运之轴清者不升，浊者不降，互相结聚，牢不可破，实因脾土之衰
微，而藏气之司失职，盖人之有身，赖中央以运四旁，今中央既竭，焉有精华四达，故
憔悴枯槁，中腹如鼓，昧者猛用劫夺之药，暂消而复肿愈甚，疑其何物邪气若此之盛，
岂知猛药所攻，即以此身之元气，转与此身为难首，实如驱良民为寇也。明乎此则有培
养一法。补益元气是也。则有招纳一法，脾虚下陷者，升举阳气，肾虚上浮者，纳气归
源是也。则有解散一法，开鬼门洁净府是也。三者具不言泻，而泻在其中矣。
有气血郁而停滞，久之而血痹不行，湿热生虫，腹形充大，中实有物，名之为蛊，
非如鼓胀腹皮绷急，而属于气，中空无物也，亦宜详辨。妇人有水分与血分之殊，心
胸坚大，而病发于上，先病水胀，而后经断，谓之水分，血结胞门，而病发于下，先
因经断，而后水胀，谓之血分，水肿皆起于房劳过度，先自胫肿后腹大，按之随手而起
者，水也。单腹胀乃脾虚之甚，必大剂参术桂附，下元虚寒者，金匮肾气丸料，大剂作
汤，初服必胀闷难当，久则正气旺，而得健运，胀消矣。乃《内经》塞因塞用之法，少
用则滋壅于上，多服则峻补于下，盖中州虚乏壅滞，必赖大补而流通其气。
《经》言∶营气循脉，卫气逆为脉胀，卫气既逆，乃循分肉之间，而为肤胀，故人
身以气为主，失其和则为邪气，得其平则为正气，正气者，即真气也。元气也。一息不
运，则机缄穷，一毫不续，则霄壤判，然气主于肺，肺为诸气之司，生于胃，胃为化源
之所，原于肾，肾为根本之地，故气虚。补虚者，定法也。气无补法者，俗论也。如痞
闷壅塞，似难于补，不知正虚不补，邪由何行？然有补之而不效者，未知补之法也。凡
一切气上，但知求于脾肺，而不求之肾耳。盖肾间动气，为五脏六腑之本，十二经络之
根，呼吸之门，三焦之原，人或房劳不节，或思虑太过，皆能伤肾，故曰∶思之为害甚
于欲，肾既有伤，气无管束，遂多郁滞，肺出气也。肾纳气也。肾虚不能纳气，则气上
而不下，是肺病而实肾病也。子病累及于母，治之者，无徒事于肺，当以补肾为本，
补肾之要，尤在纳气为主，纳气之法，导火归之而已，盖火为气之根也。
《经》曰∶浊气在上，则生 胀，故鼓胀者，虽脾胃病，其原则气由于肾，盖脾为
阴中至阴为不迁之位，天为阳，火也。地为阴，水也。在人则为脾，同阴水之化，若中
气充足，则元阳健运，否则阳气不能运化精微，聚而不改，为胀为满，宜入温补之剂，
长养胃中生发之气，上行清道，浊阴自降，胀满自愈，倘以分消为事，图宽快于一时，
则脾气因分消而愈虚，运化因愈虚而愈难，此治脾胃之论也。而未及于肾，夫肾虽为水
脏，而命门之相火寄焉。命门之火衰，则真阳微而脾土弱，胀满生焉。《经》云∶脏寒
生满病，故欲补土者，尤莫如补肾中之真火，火旺则土强，而胀自愈，至于开鬼门，
洁净府，乃治外感有形之实症，而非治内伤无形之气病也。
水肿者，脾病也。出于肺，而本于肾。三经之寒气为病，而实原于三焦之气不化，
闭而不行，留溢为肿，脾制水者也。土受邪，则水反侮之，肺生水者也。金气病，则
水不能输，然其本更在于肾，肾虽水脏，实元阳生气所由出也。若肾中之阳虚，则命门
火衰，何能温养脾胃，是以阴寒上乘，至阴益困，不能为之健运矣。要知气即火也，阳
也。精即水也，阴也，阳旺则化精而为气，阳衰则不能化，而水即为邪，火衰则不能化
水，水盛则火不能化阴，不从阳而精气皆可化为水也。故水肿之水，实无水也。本于气
之所化，真气旺，则水即为气，真气衰，则气即化水，因脾肺肾真元之气先亏而致之，
盖肾居下焦属水，统摄阴液，为水之本，脾居中焦属土，合肌肉为水之堤防，主化谷生
津，以灌溉诸经，肺居上焦属金，为水之化源，行荣卫而主治节，以通调水道，人或劳
倦房室，以伤其脏，则在肾不能统摄宣通而停蓄矣。在脾不能堤防灌溉而泛滥矣。在肺
不能生化通调而壅闭矣。三焦之气闭塞，决读之官郁遏，水道不通，津液亦闭，血脉不
流，尽化为水，水因气闭，气因水壅，肿病日甚，观此则知得之于脾肺肾三经，更本于
气也、火也，明矣。故《经》曰∶三阴结谓之水，三阴结者，谓脾肺之脉俱寒结也，脾
肺寒结，则气化为水矣。所以金匮肾气，内用桂附，以运动其枢机，则水自下，非若五
苓之专于行水为事也。
凡治肿胀，其阴阳虚实，不可不辨，大抵阳证必热，热者多实，阴证必寒，寒者多
虚，先胀于内，而后肿于外者，为实，先肿于外，而后胀于里者，为虚。小便黄赤，大
便秘结，为实，小便清白，大便溏泄，为虚，滑数有力为实，弦浮微细为虚，色红气
粗为实，色悴声短为虚。凡诸实症，或六淫外客，或饮食内伤，阳邪急速，其至必暴，
每成于数日之间。若是虚证，或情志多劳，或酒色过度，日积月累，其来有渐，每成于
经月之后，然治实颇易，理虚恒难，虚人气胀者，脾虚不能运气也。虚人水肿者，土虚
不能制水也。水虽制于脾，实则统于肾，肾本水脏，而元阳寓焉。命门火衰，既不能自
制阴寒，又不能温养脾土，则阴不从阳，而精化为水，故肾之真阳盛，则水皆内附，而
与肾气同其收藏矣。水肿之症，多属火衰也。丹溪以为湿热，养肺金以制水，使脾无
贼邪之患，滋肾水以制火，使肺得清化之权，夫制火固可保金，独不虑其害土乎？惟
属热者宜之，若阳虚者，岂不益其病哉！
又有妇人内有积聚，似水胀而非水胀。《经》曰∶石瘕生于胞中，寒气客于子门，
子门闭塞，气不得通，恶血当泻不泻，血以留止，日以益大，状如怀子，月事不以时下
者，可导而下，若寒气客于肠外，与卫气相搏，气不得荣，因有所系，癖而内着，息肉
黄帝问道：脉象在寸口部的表现，怎样判断是胀病？岐伯回答说：脉象大而坚实且涩滞的，就是胀病。邪气盛则脉大，邪气实则脉坚，涩脉代表气血虚弱且不流利。洪大的脉象说明阴气必然衰少，坚强有力的脉象说明胃气必然受损，所以脉象大、坚、涩，疾病应当表现为胀满。因此，脾具有坤卦安静柔顺的德行，同时具备乾卦刚健运行的功能，所以能使心肺的阳气下降，肝肾的阴气上升，从而形成天地交泰的和谐状态，这就是健康的人（平人）。如今由于七情内伤，六淫外感，饮食不节制，房事过度导致虚损，使得脾土的阴气受伤，负责转运功能的官职失职，胃虽然受纳食物，但不能运化，于是心肺的阳气不能下降，肾肝的阴气不能上升，形成了天地不交的“否”卦状态，清浊之气相互混杂，经络隧道壅塞阻滞，郁结而化热，热邪停留转化为湿邪，湿热相生，最终形成胀满。这本来是无形之气的病变，难以当作有形的症状来调理。有人说秋季、夏季、冬季治疗比较容易，只有春季最难，这是因为春季木气旺盛，克制脾土，脾土不能制约水湿的缘故。然而轻症都容易治，重症都难治，并不只是春季如此。名叫“鼓”的，是因为其中空外浮，取它的形象来命名。改名为“蛊”的，是因为它有侵蚀危害的特性，取它的含义来命名。治疗者应当补益脾脏，又须滋养肺金以制约肝木，使脾脏没有贼邪侵害的忧患，滋补肾阴以制约相火，使肺脏得到清肃化生的命令，脾、肺、肾三脏之气交通顺畅，那么水谷自然能够消化，戒除碱味食物，断绝妄想，就没有不安稳的。医生急于求效，病人苦于胀满，喜欢使用通利药物以求得通畅爽快，不知道这样过了一两天，胀满的病邪反而更严重，元气更加损伤了。又有标实证而本虚证的，泻下不可行，补益无功效，极为危险，全在于防微杜渐，标本处理得当，使脾肾的元阳生发，而阴邪的凝滞自然解除。
水肿和鼓胀，都是因为脾虚所致，但是水肿轻而鼓胀重，为什么呢？水肿则饮食如常，鼓胀则饮食不如常。先头足浮肿，后腹部膨大的，是水病、肿病。先腹部膨大，后四肢浮肿的，是气病、胀病。治疗水肿只需补脾并引导水湿排出即可，治疗鼓胀则需补脾导水，兼以消食化谷，才可以。虽然鼓胀有气、血、寒、热四者的不同，多由怒气伤肝，肝木邪气克制脾土，所以脾病而不能运化水谷。又要滋养肺金以制约肝木，使脾脏没有贼邪侵害，那么运化功能恢复，水谷就能消化了。由此看来，治疗鼓胀的方法，必须以补脾制肝、导水消谷为主，根据所夹杂的病因而兼用药物，夹杂气滞则理气散气，夹杂血瘀则破血化瘀，夹杂寒邪则温散寒邪，夹杂热邪则清热泻火，自无不愈的道理。那些不可治愈的，这是脾虚到了极点，属于真脏病。真脏病，是由于真火不能生脾土造成的，岂止是脾脏的问题呢。
有人行房事用力过度，汗出于肾，《内经》说汗出于肾，若逢风邪侵袭，内不能进入脏腑，外不能透达皮肤，风邪客居在玄府（汗孔），运行于皮肤，传变为浮肿，病本在肾，名叫风水，治疗宜滋肾散风，如四物汤加入荆芥、防风、羌活、柴胡、防己等药。不可当作脾虚湿肿，而用人参、白术及利水药物，那样会使风邪进一步内陷。
火的性质炎上，水的性质润下，消渴证是因为水火不交，而火偏盛。水气证是因为水火不交，而水偏盛。治疗的方法，在于制约其偏颇使之相互济助，小火不能化大水，必须先泻其水，后补其火。“开鬼门”是发汗，泻去在表、在上的水邪；“洁净府”是利小便，泻去在里、在下的水邪。水势既已减退，然后用温暖药物补益元气，这是治疗实证、热证的步骤。如果不明白虚实寒热，专门坚守“下则胀已”这一方法，虽然暂时获得稍许宽松，但真气更加衰弱，不久肿胀再次发作，最终导致无法救治。所以对于涉及虚证的，要温补脾肾，如肾气丸之类的药物，在补益中微微泻浊，使其逐渐康复，然而王道之法没有近功，必须通过缓慢的方式取得疗效。古今名医，难道不知道攻伐之功迅速，而旷日持久，也是因为中气已经衰弱，恐怕陷入虚虚之祸罢了。中满的症状与鼓胀、水肿无异，为什么归属于气虚？气虚，是指肾中的火气虚。中满，是指中空似鼓，是虚满而不是实满。《内经》说：各种湿肿满，都归属于脾；又说：病本在肾，病末在肺，都是水液积聚。各经虽然有肿胀，无不由于脾、肺、肾三脏。大概脾土主营运，肺金主气化，肾水主五液，凡是五气所化的津液，都属于肾。五液所运行的气，都属于肺，转输这两脏，以制水生金的，都属于脾。如果脾不能将胃的水谷精微散布到肺，而病在中焦；肺不能将胃的水道通调到膀胱，而病在上焦；肾不能主管胃的关门按时输泄，而病在下焦，因此胃土不能制约肾水，水逆而上行，传入于肺，所以水虽然受脾制约，但实际上主宰于肾，因为肾本是水脏，却是阳气生气发出的源头。如果肾中阳虚，则命门火衰，既不能自制阴寒，又不能温养脾土，阴阳不得其正，就化而为邪。治疗者只知道泄水，而不知道益胃，或者知道益胃，而不知道温肾，所以多用泻下法，强行令水排出，不顺应天道流转的规律，因此胃气越虚，肾阳越损，则发病而不能制约。不如顺其自然，才是上策，何必一出手就用《内经》中去菀陈莝、开鬼门、洁净府，如舟车丸、禹功散之类的猛药？如果真正知道是水湿之气客居于中焦，侵扰皮肤，像水晶一样光亮，手按下去随即弹起的，用前面的温和药物一服就能消退。如果是久病大病之后，或者伤寒疟疾痢疾之后，女人产后，小儿痘疹之后，以及元气素来虚弱的人，一概用前面的猛药方法施治，脾气越泄越虚，就无法挽救了。所以治疗浮肿，先以脾土为主，须补中益气，或用六君子汤温补，再用金匮肾气丸补土以生金（注：原文“补土以母”疑为笔误或特定语境，通常理解为培土生金或补肾，此处依文意译为补土以助生化之源，俾脾强土旺，则能散精于肺，通调水道，下输膀胱，水精四布，五经并行矣。或者有人怀疑说喘胀水满，又加纯补的药剂，恐怕增加胀满，必须在补药中，加入行气利水的品种，这种说法似乎符合病情，终究不是纳气藏源的至理。因为肺气既然虚弱，不能再行其气，肾水已经衰少，不能再利其水，纯补的药物，初时似乎觉得不快，过时药力得以运行，则气归者自然归位，而行者自行，如同土地在雨中，变成泥浆，得到和风暖日，则湿气去除而阳气调和自然获得，万物生长了。
李东垣说：中满的治疗方法，应当开鬼门，洁净府，从内部泻下，意思是脾胃有病，让上下分消其湿，下焦如渎（沟渠），气血自然分化，或者像大实大满，大小便不利的，权且用寒热药泻下，这是论述治疗有余的病症。至于补肾以治肿，他的说法难以明了，大概是大禹治水，是顺应水性，无所事事（顺其自然）。如果一事疏凿，就失之偏颇了。现在的人治水，用牵牛子、大戟，是粗工的小聪明，正是大禹所厌恶的。间或使用五苓散、五皮饮的，认为它是中正之道，也是越利水越虚，肾气越衰，越不能推送了。所以必须用补肾，《内经》说：肾开窍于二阴，肾气化则二阴通，二阴闭则胃填胀。肾是胃的关口，关门不利，所以水聚而从其类也。《内经》又说：肾主下焦，三焦是决渎之官，水道出焉。膀胱是州都之宫，津液藏焉。必须等待三焦的火化，才能排出。其三焦的经脉，在上的，布散在膻中，散落于心包，在下的，出于委阳穴，上络膀胱，上佐天道之施化，下佐地道之发生，与手厥阴心包经为表里，以应诸经的使者。所以肾虚，是下焦之火虚。虽然小便的清长，必由于肺金的输化，然而膀胱之气旺，始能吸胸中之气以下行，但肾与膀胱为表里，膀胱的失运化，必由肾气的衰微，所以开始因为火小不能化水，后来水大火也不能化了。《内经》说：三焦病，气满，小腹坚硬，不得小便，溢则水留而为胀，仲景的金匮肾气丸补而不滞，通而不泄，确实是治疗浮肿的神方。
有一身之间，只有面与足浮肿，早晨面部浮肿严重，晚上脚部浮肿严重。《内经》说，面肿为风，脚肿为水，是风热所致。虽然病后元气未恢复的人，每多见此，大概由于真气根本不固，所以日中行坐，则气坠下面，晚脚肿，夜中睡卧，则气升浮，而早面浮，如果一概作风湿治疗，更加虚其虚，所以用治不足的方法，治有余则可，治有余的方法，治不足则不可。
凡是有瘕积块痞块，即是胀病的根，日渐月积，腹大如箕，若抱瓮然，这叫单腹胀，不像水气散于皮肤面目四肢。因为中州之地久窒，其四运之轴清者不升，浊者不降，互相结聚，牢不可破，实因脾土之衰微，而藏气之司失职，大概人有身体，依赖中央（脾）以运四旁，今中央既竭，哪有精华四达，所以憔悴枯槁，中腹如鼓，愚昧者猛用劫夺之药，暂消而复肿愈甚，怀疑是何物邪气如此之盛，岂知猛药所攻，即以此身之元气，转与此身为难首，实如驱良民为寇也。明乎此则有培养一法。补益元气是也。则有招纳一法，脾虚下陷者，升举阳气，肾虚上浮者，纳气归源是也。则有解散一法，开鬼门洁净府是也。三者具不言泻，而泻在其中矣。
有气血郁而停滞，久之而血痹不行，湿热生虫，腹形充大，中实有物，名之为蛊，非如鼓胀腹皮绷急，而属于气，中空无物也，亦宜详辨。妇人有水分与血分之殊，心胸坚大，而病发于上，先病水胀，而后经断，谓之水分，血结胞门，而病发于下，先因经断，而后水胀，谓之血分，水肿皆起于房劳过度，先自胫肿后腹大，按之随手而起者，水也。单腹胀乃脾虚之甚，必大剂参术桂附，下元虚寒者，金匮肾气丸料，大剂作汤，初服必胀闷难当，久则正气旺，而得健运，胀消矣。乃《内经》塞因塞用之法，少用则滋壅于上，多服则峻补于下，盖中州虚乏壅滞，必赖大补而流通其气。
《内经》说：营气循脉，卫气逆为脉胀，卫气既逆，乃循分肉之间，而为肤胀，故人身以气为主，失其和则为邪气，得其平则为正气，正气者，即真气也。元气也。一息不运，则机缄穷，一毫不续，则霄壤判，然气主于肺，肺为诸气之司，生于胃，胃为化源之所，原于肾，肾为根本之地，故气虚。补虚者，定法也。气无补法者，俗论也。如痞闷壅塞，似难于补，不知正虚不补，邪由何行？然有补之而不效者，未知补之法也。凡一切气上，但知求于脾肺，而不求之肾耳。盖肾间动气，为五脏六腑之本，十二经络之根，呼吸之门，三焦之原，人或房劳不节，或思虑太过，皆能伤肾，故曰：思之为害甚于欲，肾既有伤，气无管束，遂多郁滞，肺出气也。肾纳气也。肾虚不能纳气，则气上而不下，是肺病而实肾病也。子病累及于母，治之者，无徒事于肺，当以补肾为本，补肾之要，尤在纳气为主，纳气之法，导火归之而已，盖火为气之根也。
《内经》说：浊气在上，则生䐜胀，所以鼓胀者，虽脾胃病，其原则气由于肾，盖脾为阴中至阴为不迁之位，天为阳，火也。地为阴，水也。在人则为脾，同阴水之化，若中气充足，则元阳健运，否则阳气不能运化精微，聚而不改，为胀为满，宜入温补之剂，长养胃中生发之气，上行清道，浊阴自降，胀满自愈，倘以分消为事，图宽快于一时，则脾气因分消而愈虚，运化因愈虚而愈难，此治脾胃之论也。而未及于肾，夫肾虽为水脏，而命门之相火寄焉。命门之火衰，则真阳微而脾土弱，胀满生焉。《内经》云：脏寒生满病，故欲补土者，尤莫如补肾中之真火，火旺则土强，而胀自愈，至于开鬼门，洁净府，乃治外感有形之实症，而非治内伤无形之气病也。
水肿者，脾病也。出于肺，而本于肾。三经之寒气为病，而实原于三焦之气不化，闭而不行，留溢为肿，脾制水者也。土受邪，则水反侮之，肺生水者也。金气病，则水不能输，然其本更在于肾，肾虽水脏，实元阳生气所由出也。若肾中之阳虚，则命门火衰，何能温养脾胃，是以阴寒上乘，至阴益困，不能为之健运矣。要知气即火也，阳也。精即水也，阴也，阳旺则化精而为气，阳衰则不能化，而水即为邪，火衰则不能化水，水盛则火不能化阴，不从阳而精气皆可化为水也。故水肿之水，实无水也。本于气之所化，真气旺，则水即为气，真气衰，则气即化水，因脾肺肾真元之气先亏而致之，盖肾居下焦属水，统摄阴液，为水之本，脾居中焦属土，合肌肉为水之堤防，主化谷生津，以灌溉诸经，肺居上焦属金，为水之化源，行荣卫而主治节，以通调水道，人或劳倦房室，以伤其脏，则在肾不能统摄宣通而停蓄矣。在脾不能堤防灌溉而泛滥矣。在肺不能生化通调而壅闭矣。三焦之气闭塞，决渎之官郁遏，水道不通，津液亦闭，血脉不流，尽化为水，水因气闭，气因水壅，肿病日甚，观此则知得之于脾肺肾三经，更本于气也、火也，明矣。故《内经》说：三阴结谓之水，三阴结者，谓脾肺之脉俱寒结也，脾肺寒结，则气化为水矣。所以金匮肾气，内用桂附，以运动其枢机，则水自下，非若五苓之专于行水为事也。
凡治肿胀，其阴阳虚实，不可不辨，大抵阳证必热，热者多实，阴证必寒，寒者多虚，先胀于内，而后肿于外者，为实，先肿于外，而后胀于里者，为虚。小便黄赤，大便秘结，为实，小便清白，大便溏泄，为虚，滑数有力为实，弦浮微细为虚，色红气粗为实，色悴声短为虚。凡诸实症，或六淫外客，或饮食内伤，阳邪急速，其至必暴，每成于数日之间。若是虚证，或情志多劳，或酒色过度，日积月累，其来有渐，每成于经月之后，然治实颇易，理虚恒难，虚人气胀者，脾虚不能运气也。虚人水肿者，土虚不能制水也。水虽制于脾，实则统于肾，肾本水脏，而元阳寓焉。命门火衰，既不能自制阴寒，又不能温养脾土，则阴不从阳，而精化为水，故肾之真阳盛，则水皆内附，而与肾气同其收藏矣。水肿之症，多属火衰也。丹溪以为湿热，养肺金以制水，使脾无贼邪之患，滋肾水以制火，使肺得清化之权，夫制火固可保金，独不虑其害土乎？惟属热者宜之，若阳虚者，岂不益其病哉！
又有妇人内有积聚，似水胀而非水胀。《内经》说：石瘕生于胞中，寒气客于子门，子门闭塞，气不得通，恶血当泻不泻，血以留止，日以益大，状如怀子，月事不以时下者，可导而下，若寒气客于肠外，与卫气相搏，气不得荣，因有所系，癖而内着，息肉
The Yellow Emperor asked: How does the pulse at the cunkou (inch position) manifest to indicate distension? Bole replied: A pulse that is large, firm, and choppy indicates distension. When pathogenic factors are abundant, the pulse becomes large; when pathogens are solid, the pulse becomes firm. A choppy pulse signifies deficiency of qi and blood and lack of smooth flow. A surging and large pulse indicates a decline in yin qi, while a firm and strong pulse indicates damage to stomach qi. Therefore, a large, firm, and choppy pulse suggests that the disease should present as distension. Thus, the spleen possesses the virtue of Kun (earth), which is quiet and yielding, yet has the function of Qian (heaven), which is vigorous and active. It enables the yang qi of the heart and lungs to descend and the yin qi of the liver and kidneys to ascend, thereby achieving the harmonious state of Taiji (Heaven and Earth interacting), which characterizes a healthy person (Ping Ren). Currently, internal injury from the seven emotions, external contraction of the six climatic factors, irregular diet, and excessive sexual activity leading to deficiency, all injure the yin of the spleen earth. The official responsible for transportation and transformation loses its duty. Although the stomach receives food, it cannot transform and transport it. Consequently, the yang qi of the heart and lungs cannot descend, and the yin qi of the liver and kidneys cannot ascend, resulting in the state of Pi (Heaven and Earth not interacting). Clear and turbid qi mix together, meridians and collaterals become obstructed, stagnation generates heat, and lingering heat transforms into dampness. Dampness and heat generate each other, eventually forming distension and fullness. This is originally a disease of formless qi, making it difficult to treat as if it were a tangible symptom. Some say that treatment in autumn, summer, and winter is relatively easy, but spring is the most difficult, because wood qi is prosperous in spring, overcoming spleen earth, preventing it from controlling water. However, mild cases are all easy to treat, and severe cases are all difficult, not just in spring. Named "Drum" (Gu), it is so called because it is hollow inside and floating outside, taking its image as its name. Renamed "Gu" (Worm/Insect), it is named for its erosive harm, taking its meaning as its name. Treatment should tonify the spleen, and also nourish lung metal to control liver wood, ensuring the spleen suffers no invasion from hostile pathogens. Nourish kidney yin to control ministerial fire, allowing the lungs to receive the command of clear transformation. When the qi of the spleen, lungs, and kidneys communicates smoothly, food and drink will naturally be digested. Avoid alkaline flavors, cut off delusions, and there will be no unrest. Physicians eager for quick results, and patients suffering from distension and fullness, often prefer using purgative or diuretic drugs to seek relief. They do not realize that after one or two days, the pathogenic factor of distension becomes more severe, and the primordial qi is further damaged. There are also cases where the branch manifestation is excess but the root is deficiency. Purging is contraindicated, and tonification is ineffective, making the condition extremely dangerous. Success depends entirely on preventing subtle changes before they occur, handling both root and branch appropriately, allowing the primordial yang of the spleen and kidneys to arise, so that the stagnation of yin pathogens is naturally resolved.
Edema and Drum Distension are both caused by spleen deficiency. However, edema is mild, while Drum Distension is severe. Why? In edema, appetite remains normal; in Drum Distension, appetite is less than normal. If swelling starts in the head and feet and later the abdomen enlarges, it is water disease/edema. If the abdomen enlarges first and later the limbs swell, it is qi disease/distension. To treat edema, one need only tonify the spleen and guide out water. To treat Drum Distension, one must tonify the spleen, guide out water, and simultaneously promote digestion of grains, which may succeed. Although Drum Distension differs in terms of qi, blood, cold, and heat, it mostly arises from anger injuring the liver, where wood pathogen overcomes earth, causing spleen disease and inability to transform and transport water and grain. One must again nourish lung metal to control liver wood, so the spleen has no hostile pathogens, allowing transformation to proceed and water/grain to digest. From this perspective, the method for treating Drum Distension must focus on tonifying the spleen, controlling the liver, guiding out water, and promoting digestion. Depending on accompanying factors, add appropriate herbs: if accompanied by qi stagnation, disperse qi; if by blood stasis, break blood; if by cold, warm against cold; if by heat, clear heat. There will surely be no case that does not heal. Those that cannot be treated are due to extreme spleen deficiency, constituting a Zang-Fu organ collapse disease (Zhen Zang Bing). Zhen Zang Bing occurs because true fire cannot generate spleen earth; it is not merely a spleen issue.
When a person engages in sexual intercourse with excessive effort, sweat comes from the kidneys. The Classic states that sweat comes from the kidneys. If exposed to wind, it cannot enter internally to the zang-fu organs nor exit externally to the skin, but lodges in the xuanku (pores). Moving through the skin, it transmits to swelling, originating in the kidney, named Feng Shui (Wind Water). Treatment should nourish the kidney and scatter wind, such as Si Wu Tang added with Jing Jie, Fang Feng, Qiang Huo, Chai Hu, and Fang Ji. Do not treat it as spleen deficiency with dampness-induced swelling using Ren Shen and Bai Zhu, nor use diuretics, as this would cause the wind pathogen to sink deeper internally.
Fire nature flares upward; water nature moistens downward. Xiao Ke (Wasting-Thirst) syndrome occurs because water and fire do not interact, and fire is predominant. Shui Qi (Water Qi) syndrome occurs because water and fire do not interact, and water is predominant. The treatment method lies in restraining the excess to allow mutual assistance. Small fire cannot transform large water; one must first drain the water, then tonify the fire. "Kai Gui Men" (Open the Ghost Gate) refers to inducing sweating to drain water located in the exterior and upper body. "Jie Jing Fu" (Cleanse the Pure Mansion) refers to promoting urination to drain water located in the interior and lower body. Once the water momentum is reduced, then use warm medicines to tonify primordial qi. This is the sequence for treating excess and heat syndromes. If one does not understand deficiency/excess and cold/heat, and solely adheres to the method "purging resolves distension," although temporary relief may be gained, the true qi will further decline, and swelling will recur shortly thereafter, leading to untreatable conditions. Therefore, for cases involving deficiency, warm and tonify the spleen and kidneys, such as with Shen Qi Wan. Tonify slightly while draining to allow gradual recovery. However, the King's Way (Wang Dao) yields no immediate results; efficacy must be sought gradually. Did ancient and modern wise physicians not know that attacking/draining works quickly? Yet they persisted in slow methods because the middle qi was already depleted, fearing the disaster of "deficiency inducing deficiency." Zhong Man (Middle Fullness) symptoms are identical to Drum Distension and Edema. Why is it attributed to qi deficiency? Qi deficiency here refers to deficiency of fire qi in the kidney. Zhong Man means hollow inside like a drum, a false fullness rather than true fullness. The Classic says: All dampness, swelling, and fullness belong to the spleen. It also says: The root is in the kidney, the branch is in the lungs; all are accumulations of water. Although all meridians can have swelling, none do not originate from the spleen, lungs, and kidneys. Spleen earth manages transportation; Lung metal manages qi transformation; Kidney water manages the five fluids. All fluids transformed by the five qi belong to the kidney. All qi moving the five fluids belongs to the lungs. The transmission between these two zang organs, controlling water to generate metal, belongs to the spleen. If the spleen cannot scatter stomach water essence to the lungs, disease arises in the middle; if the lungs cannot regulate stomach water pathways to the bladder, disease arises in the upper; if the kidneys cannot manage the stomach's gate to time its excretion, disease arises in the lower. Thus, stomach earth cannot control kidney water; water rebels and moves upward, transmitting to the lungs. Although water is controlled by the spleen, it is actually governed by the kidney, for the kidney is fundamentally a water organ, yet it is the source from which yang qi emerges. If kidney yang is deficient, Mingmen fire declines. It cannot control yin-cold internally, nor warm and nourish spleen earth. Yin and yang lose their proper balance and transform into pathogens. Treaters who only know how to drain water without knowing how to benefit the stomach, or who benefit the stomach without warming the kidney, often use purgatives to force water out, ignoring the natural cycle of heaven and earth. This causes stomach qi to become more deficient and kidney yang more damaged, leading to outbreaks that cannot be controlled. It is better to act according to natural processes, which is the best strategy. Why immediately apply methods from the Neijing such as removing accumulation, opening the ghost gate, and cleansing the pure mansion, using formulas like Zhou Che Wan or Yu Gong San? If one truly knows that water-dampness qi has invaded the middle jiao and skin, appearing bright like crystal and rebounding immediately upon pressure, one dose of the aforementioned gentle medicine will resolve it. However, for chronic illness, post-major illness, post-typhoid/malaria/dysentery, postpartum women, post-smallpox children, or those with constitutionally weak primordial qi, applying these aggressive methods generally will cause spleen qi to leak and become more deficient, becoming irrecoverable. Therefore, when treating swelling, prioritize spleen earth. Tonify the middle and boost qi, or use Liu Jun Zi Tang to warm and tonify. Then use Jin Gui Shen Qi Wan to tonify earth to support the mother (kidney), so that spleen strength and earth prosperity allow scattering essence to the lungs, regulating water pathways, and transporting down to the bladder. Water essence distributes everywhere, and the five meridians circulate together. Some doubt that adding purely tonifying agents to wheezing, distension, and water-fullness might increase fullness, suggesting adding qi-moving and diuretic herbs to tonics. This view seems to fit the condition but is not the profound truth of gathering qi and returning to the source. Since lung qi is deficient, it cannot be further moved; since kidney water is depleted, it cannot be further drained. Purely tonifying agents may initially feel uncomfortable, but once the medicinal power acts, qi returns to its place and flows naturally. Like soil in rain turning to mud, when warmed by gentle winds and sun, moisture leaves and yang harmony is restored, allowing all things to grow.
Li Dongyuan said: For treating Zhong Man, one should open the ghost gate, cleanse the pure mansion, and purge from within. This means when spleen and stomach are diseased, allow dampness to dissipate from above and below. The lower jiao is like a ditch, and qi and blood naturally differentiate. Or, in cases of great excess and fullness with difficulty in urination and defecation, temporarily use cold and hot purgatives. This discusses treating excess syndromes. As for tonifying the kidney to treat swelling, his explanation is hard to clarify. It is akin to Yu the Great controlling water by doing nothing (following nature). If one tries to dredge every detail, one errs. Those today who treat water using Niu Bang Zi (Pipiza) and Da Ji (Euphorbia) display the petty wisdom of crude practitioners, which Yu the Great detested. Occasionally, Wu Ling San or Wu Pi Yin are used as moderate approaches, but they lead to more draining and more deficiency, further depleting kidney qi and reducing its ability to push forward. Thus, one must use kidney tonification. The Classic says: The kidney opens into the two orifices. When kidney qi transforms, the two orifices open; when closed, the stomach becomes full and distended. The kidney is the gate of the stomach. If the gate is not functional, water gathers according to its kind. The Classic also says: The kidney governs the lower jiao. The San Jiao is the official of drainage, from which water passages emerge. The Bladder is the palace of the capital, storing fluids. Only after the fire transformation of the San Jiao can they be discharged. The San Jiao meridian, in the upper, spreads in the Danzhong, dispersing around the Pericardium. In the lower, it emerges at Weiyang, connecting upwards to the Bladder. It assists the heavenly dao in transformation and the earthly dao in generation. It forms an exterior-interior relationship with the Hand Jueyin, acting as the messenger responding to all meridians. Thus, kidney deficiency is deficiency of fire in the lower jiao. Although clear and long urination depends on lung metal transformation, bladder qi must be vigorous to absorb chest qi and draw it downward. Since kidney and bladder are exterior-interior, bladder failure in transformation must stem from kidney qi decline. Initially, small fire cannot transform water; later, even large fire cannot transform the accumulated water. The Classic says: In San Jiao disease, there is qi fullness, hardness in the lower abdomen, and inability to urinate. Overflow leads to water retention and distension. Zhang Zhongjing's Jin Gui Shen Qi Wan tonifies without stagnation and unblocks without leaking; it is indeed a divine formula for treating swelling.
In some cases, only the face and feet swell. Morning brings severe facial swelling; evening brings severe foot swelling. The Classic says: Facial swelling is due to wind; foot swelling is due to water. This is caused by wind-heat. However, in people whose primordial qi has not recovered after illness, this is often seen. It is due to the instability of true qi and root. During the day, sitting or walking causes qi to sink to the lower part, leading to evening foot swelling. At night, sleeping causes qi to float upward, leading to morning facial swelling. If treated generally as wind-dampness, it further damages deficiency. Thus, using methods for deficiency to treat excess is acceptable, but using methods for excess to treat deficiency is not.
Any masses, nodules, or痞块 (pi blocks) are the root of distension diseases. Day by day, month by month, the abdomen enlarges like a basket or a jar, known as Dan Chu Zhang (Single Abdominal Distension). This differs from water qi scattered on the skin, face, eyes, and limbs. Because the central region (middle jiao) has been blocked for a long time, the axis of the four movements fails: clear qi does not ascend, turbid qi does not descend. They knot together, firmly unbreakable. This is truly due to the decline of spleen earth and the failure of the zang-fu officials. The human body relies on the center to move the four peripheries. Now that the center is exhausted, how can essence reach everywhere? Thus, emaciation and withering occur, with the middle abdomen like a drum. Ignorant practitioners fiercely use plundering drugs. Temporary reduction is followed by worse swelling. They wonder what evil qi is so powerful. They do not realize that the fierce drugs attack the body's own primordial qi, turning it against itself, like driving good citizens to become bandits. Understanding this, there is a method of cultivation: tonifying primordial qi. There is a method of recruitment: for spleen deficiency with sinking, raise yang qi; for kidney deficiency with floating, gather qi and return to the source. There is a method of dispersion: open the ghost gate and cleanse the pure mansion. These three methods do not explicitly mention purging, yet purging is included within them.
When qi and blood stagnate and stop, over time blood bi (obstruction) prevents flow, damp-heat generates worms, the abdomen becomes large and filled, with solid matter inside. This is named Gu (Worm/Insect). It is not like Drum Distension where the abdominal skin is tight and it belongs to qi, being hollow inside. Careful differentiation is required. Women have differences between Water Component and Blood Component. If the chest and heart are hard and large, disease originates above, starting with water distension and then amenorrhea, it is called Water Component. If blood knots in the uterus gate, disease originates below, starting with amenorrhea and then water distension, it is called Blood Component. Edema all arises from excessive sexual fatigue. Swelling starts in the shins and later the abdomen enlarges; pressing it rebounds immediately—it is water. Single abdominal distension is extreme spleen deficiency. It requires large doses of Ren Shen, Bai Zhu, Gui Zhi, and Fu Zi. For lower yuan deficiency-cold, use Jin Gui Shen Qi Wan ingredients in large doses as a decoction. Initial intake may cause unbearable distension and stuffiness, but over time, righteous qi becomes prosperous, transportation improves, and distension subsides. This is the Neijing method of "treating blockage with blockage" (Sei Yin Sei Yong). Small doses cause stagnation above; large doses provide harsh tonification below. Since the middle region is deficient and stagnant, it relies on major tonification to circulate qi.
The Classic says: Ying Qi follows the vessels; Wei Qi reversing causes Mai Zhang (Vessel Distension). Once Wei Qi reverses, it follows between the muscle intervals, causing Fu Zhang (Skin Distension). Thus, the human body is primarily governed by qi. Loss of harmony makes it pathogenic qi; gaining balance makes it righteous qi. Righteous qi is True Qi and Yuan Qi. If breath does not move for a moment, the mechanism ends; if continuity breaks for an instant, heaven and earth are separated. Qi is mainly governed by the lungs; the lungs are the director of all qi. Qi is born in the stomach; the stomach is the source of transformation. Qi originates in the kidney; the kidney is the place of foundation. Therefore, qi deficiency... Tonifying deficiency is a fixed method. Saying "qi has no tonification method" is a vulgar theory. Although bloating and obstruction seem difficult to tonify, one does not know that if righteous deficiency is not tonified, how can pathogens move? However, some find tonification ineffective because they do not know the method of tonification. Regarding all upward-rising qi, people only seek treatment in the spleen and lungs, not in the kidney. The moving qi in the kidney cavity is the root of the five zang and six fu organs, the root of the twelve meridians, the door of respiration, and the origin of the San Jiao. People who are immoderate in sexual activity or overthink all injure the kidney. Thus it is said: Harm from thinking is greater than harm from desire. Once the kidney is injured, qi has no restraint and becomes stagnant. The lungs exhale qi; the kidneys inhale qi. If kidney deficiency cannot inhale qi, qi rises and does not descend. This is lung disease but actually kidney disease. Child disease affecting the mother: Treaters should not merely attend to the lungs but should make tonifying the kidney the foundation. The key to tonifying the kidney especially lies in inhaling qi. The method of inhaling qi is guiding fire back to its source, for fire is the root of qi.
The Classic says: Turbid qi in the upper generates Chang Zhang (Distension). Thus, although Drum Distension is a spleen-stomach disease, its principle of qi originates in the kidney. Spleen is the most yin among yin, occupying a fixed position. Heaven is yang, fire. Earth is yin, water. In humans, this corresponds to the spleen, transforming like yin water. If middle qi is sufficient, primordial yang operates vigorously. Otherwise, yang qi cannot transform fine essences, which accumulate and change not, causing distension and fullness. Warm and tonifying agents should be entered to nurture the generating qi of the stomach, ascending through the clear pathways, so turbid yin naturally descends, and distension/fullness heals themselves. If one focuses on separating and eliminating to seek temporary relief, spleen qi becomes more deficient due to separation, and transformation becomes harder due to deficiency. This is the argument for treating spleen and stomach, but it does not reach the kidney. Although the kidney is a water organ, the ministerial fire of Mingmen resides there. If Mingmen fire declines, true yang becomes weak and spleen earth becomes weak, generating distension and fullness. The Classic says: Cold in the zang generates fullness diseases. Therefore, to tonify earth, nothing is better than tonifying the true fire in the kidney. Fire prosperous means earth strong, and distension heals itself. As for opening the ghost gate and cleansing the pure mansion, these treat external contraction tangible excess syndromes, not internal injury formless qi diseases.
Edema is a spleen disease. It emerges from the lungs and originates in the kidneys. Cold qi of the three meridians causes disease, but essentially it stems from the non-transformation of San Jiao qi. Closed and not moving, it stays and overflows as swelling. The spleen controls water. If earth is attacked by pathogens, water rebels against it. The lungs generate water. If metal qi is diseased, water cannot be transported. However, the root lies even more in the kidney. Although the kidney is a water organ, it is actually the source from which primordial yang qi emerges. If kidney yang is deficient, Mingmen fire declines. How can it warm and nourish spleen and stomach? Thus yin-cold attacks upward, supreme yin becomes further distressed, and cannot perform vigorous transformation. Know that qi is fire, yang. Essence is water, yin. When yang is prosperous, it transforms essence into qi. When yang declines, it cannot transform, and water becomes pathogen. When fire declines, it cannot transform water. When water is abundant, fire cannot transform yin. Not following yang, both essence and qi can transform into water. Thus, the water in edema is essentially no water. It originates from the transformation of qi. When true qi is prosperous, water becomes qi; when true qi declines, qi transforms into water. This is caused by the prior depletion of true yuan qi of the spleen, lungs, and kidneys. The kidney resides in the lower jiao, belongs to water, controls yin fluids, and is the root of water. The spleen resides in the middle jiao, belongs to earth, combines with muscles as the dam of water, governs transforming grains and generating fluids to irrigate the meridians. The lungs reside in the upper jiao, belong to metal, are the source of water transformation, circulate Ying and Wei, govern regulation, and regulate water pathways. If people injure their zang organs through fatigue or sexual excess, the kidney cannot control and disseminate, leading to stagnation. The spleen cannot act as a dam and irrigate, leading to flooding. The lungs cannot generate, transform, and regulate, leading to blockage. San Jiao qi closes, the official of drainage is suppressed, water passages do not flow, body fluids close, blood vessels do not flow, all transforming into water. Water is closed by qi; qi is congested by water. Swelling worsens daily. Observing this, we know it derives from the spleen, lungs, and kidneys, and fundamentally from qi and fire. Thus the Classic says: Contraction of the three yin is called water. Contraction of the three yin means cold contraction of the spleen and lung pulses. Spleen and lung cold contraction causes qi to transform into water. Therefore, Jin Gui Shen Qi Wan uses Gui Zhi and Fu Zi internally to move the pivot, so water goes down naturally, unlike Wu Ling San which specializes in moving water.
In all treatments of swelling and distension, yin/excess and deficiency must not fail to be distinguished. Generally, yang syndromes must be hot; heat usually indicates excess. Yin syndromes must be cold; cold usually indicates deficiency. Distension inside first, then swelling outside, is excess. Swelling outside first, then distension inside, is deficiency. Yellow-red urine and constipation indicate excess. Clear-white urine and loose stools indicate deficiency. Slippery, rapid, and forceful pulse indicates excess. Wiry, floating, faint, and fine pulse indicates deficiency. Red color and coarse breath indicate excess. Sallow complexion and short voice indicate deficiency. All excess syndromes, whether from six excess pathogens externally or dietary injury internally, involve rapid yang pathogens arriving violently, often forming within days. If deficiency syndromes, whether from emotional labor or excessive alcohol/sex, accumulate day by day and month by month, arriving gradually, they often form after months. Treating excess is quite easy; managing deficiency is always difficult. Qi distension in deficient people is due to spleen deficiency failing to move qi. Edema in deficient people is due to earth deficiency failing to control water. Although water is controlled by the spleen, it is actually governed by the kidney. The kidney is fundamentally a water organ, housing primordial yang. Mingmen fire decline means it cannot control yin-cold internally, nor warm spleen earth. Yin does not follow yang, and essence transforms into water. Thus, when the true yang of the kidney is prosperous, water attaches internally and stores with kidney qi. Edema syndromes mostly belong to fire decline. Dan Xi believed it was damp-heat. He suggested nourishing lung metal to control water, so the spleen has no hostile threat; nourishing kidney water to control fire, so the lungs gain the power of clear transformation. Controlling fire certainly protects metal, but does one not worry about harming earth? This is suitable only for heat syndromes. For yang deficiency, would it not worsen the disease?
Furthermore, women may have internal accumulations that resemble water distension but are not. The Classic says: Shi Xia (Stone Mass) arises in the uterus. Cold qi lodges in the Zi Men (cervical opening). Zi Men closes, qi cannot pass, evil blood should discharge but does not, blood stays and stops, growing larger day by day, resembling pregnancy, with menstruation not occurring on time. It can be guided and discharged. If cold qi lodges outside the intestines, contending with Wei Qi, qi cannot nourish, binding internally, forming癖 (Pi) and attaching inside, polyps...