溲溺不通。匪细故也。小腹急痛。状如复碗。奔迫难禁。期朝不通。便令人呕。名曰关格。又日不通而
毙矣。今人一见此证。除用五苓散之外。束手待毙。若盐熨丹田。蝼蛄田螺罨脐之法。抑末也。
若津液偏渗于肠胃。大便泄泻。而小便不通者。宜五苓分利之。若水停心下。不能下输膀胱者。亦用五
苓渗泄之。若六腑客热。转于下焦而不通者。用益元散以清之。若气迫闭塞。升降不通者。宜升麻以提之。或
探吐之。譬如水注之气。上窍开而下窍通也。
经曰。膀胱者。州都之官。津液藏焉。气化则能出矣。又曰。三焦者决渎之官。水液出焉。可见膀胱但
能藏水。必待三焦之气化。方能出水。有服附子热药太过。消尽肺阴。气所不化。用黄连解毒而通者。有用
茯芩陈皮甘草汤。送下木香沉香末而通
者。此皆气化之验也。以上治法。皆有余之证。谓膀胱中原有水。或为热结。或气闭。有水可通而通之也。至
于不足之证。乃虚劳汗多。五内枯燥。脂腴既去。不能生津。膀胱中原无水积而欲通之。如向乞人而求食。已
穷而益穷矣。故东垣分在气在血而治之。以渴与不渴辨之。如渴而小便不利。此属上焦气分。水生于金。肺热
则是清化之源绝矣。当于肺之分助其秋令。水自生焉。如天令至秋。白露降。须用清金之药。如生脉散之类为
当。又有脾虚者。盖因饮食失节。伤其胃气。陷于下焦。经所谓脾胃一虚。令人九窍不通。用补中益气汤。以
参甘温之品。先调其胃气。以升柴从九原之下而提之。则清升而浊自降矣。清肺者。隔二之治也。补脾者。
隔三之治也。东垣虚则补母之妙用。类如此。此皆滋后天之化源者。如不渴而小便不利。此属下焦血分。下焦
者。肾与膀胱也。乃阴中之阴。阴受热。闭塞其下流。经曰。无阳则阴无以生。无阴则阳无以化。若淡渗之
药。乃阳中之阴。非纯阴之剂。阳何以化。须用滋肾丸。此气味俱阴。乃阴中之阴也。东垣先生治一人目睛突
出。腹胀如鼓。膝以上坚硬。皮肤欲裂。饮食不下。便秘急危者。精思半夜而得之。投之即愈。此是阴虚。阳
无以化也。盖至于真阳真阴虚者。东垣未之论。如有真阴虚者。惟六味地黄以补肾水。滋肾丸又所当禁。
黄柏知母恐其苦寒泄水。又忌淡味渗泄之药。有真阳虚者。须八味丸。褚氏云。阴已萎而思色以降其精。则精
不出而内败。小便道涩如淋。精已耗而复竭之。则大小便道牵痛。愈痛则愈便。愈便则愈痛。戴氏云。有似淋非
淋。便中有如鼻涕之状。此乃精溺俱出。精塞溺道。故欲出不能而痛。宜大菟丝子丸鹿茸丸。戴氏亦得褚氏之
法也。若至于转筋喘急欲死。不问男女孕妇产后。急用八味丸料煎饮。缓则不救。或疑桂附辛热。不敢轻用。
岂知肾气虚寒。水寒水冻之义。得热则流通。舍此更有何物。能直达
膀胱。而使雪消春水来耶。
丹溪治一老人患小便不利。因服分利之药太过。遂致秘塞。点滴不出。予以其胃气下陷。用补中益气汤。
一服而通。因先多用利药。损其肾气。遂致通后。遗尿一夜不止。急补其肾然后已。凡医之治是证者。未有不
用泄利之剂。谁能顾其肾气之虚哉。予特表之。以为世戒。
后若有善法丹溪者。已明知其肺虚矣。乃以补中益气汤。送肾气丸。岂不上下相须。子母相益耶。灵枢
言手太阴之别。名曰列缺。其病虚则欠缺。小便遗数。肺为上焦。通调水道。下输膀胱。肾又上连肺。故将两
藏。是子母也。母虚子亦虚。自然之理。东垣云。小便遗失。肺金虚也。宜安卧养气禁劳役。以黄 人参之类
大补之。不愈当责之肾。经曰。膀胱不约为遗尿。仲景云。下焦竭则遗溺失便。又云。下焦不归。则遗溲。盖
下焦在膀胱上口。主分别清浊溲小便。下焦不归其部。不能约制溲便。故遗溺。大抵天暖衣浓则多汗。天冷衣
薄则多溺。多溺者寒也。至于不禁。虚寒之甚。非八味丸不效。古方如菟丝子丸。鹿茸散。二气丹。俱可选用。
戴氏云。睡着遗尿者。此亦下元冷小便无禁而然。宜大菟丝子丸。猪胞炙碎煎汤下。凡遗尿皆属虚。刘河间
谓热甚。客于肾部。干于足厥阴之经。廷孔郁结。甚而气血不能宣通。则痿痹。神无所用。故津液渗入膀胱。
而旋溺遗失。不能收禁也。即内经淫气遗溺。痹聚在肾。此系热证。不可不知。考之薛按。有因劳发热作渴。
小便自遗。或时闭涩。余作肝火血虚。阴挺不能约制。午前补中益气汤。加山药山茱。午后六味丸。月余悉退。
大抵不禁之病。虚寒多而实热少。倘以虚证误投泻火。顷刻危殆。慎之慎之。
小便不通，并非小毛病。小腹急迫疼痛，形状像倒扣的碗，奔迫难忍，如果一整天不通，就会让人呕吐，这叫做“关格”。又说，如果小便不通就会导致死亡。现在的人一见到这个证候，除了使用五苓散之外，就束手待毙。像用盐熨丹田、蝼蛄和田螺敷脐的方法，都是治标末节的做法。
如果是津液偏渗于肠胃，导致大便泄泻而小便不通的，适宜用五苓散分利水湿。如果是水饮停聚在心下，不能向下输注到膀胱的，也使用五苓散来渗湿泄浊。如果是六腑有客热，传转到下焦而导致不通的，使用益元散来清热。如果是气机迫塞闭塞，升降不通的，适宜用升麻来提升气机，或者采用探吐的方法。这就好比打开上面的窍道，下面的窍道自然通畅一样。
《内经》说：膀胱是州都之官，津液藏在这里，经过气化作用才能排出。又说：三焦是决渎之官，水液由此而出。由此可见，膀胱只能藏水，必须依赖三焦的气化作用，才能排出尿液。有的因为服用附子等热药太过，耗尽了肺阴，导致气无法气化，使用黄连解毒汤而通利的；有的用茯苓陈皮甘草汤，送服木香沉香末而通利的。这些都是气化作用的验证。以上治疗方法，都属于有余的证候。意思是膀胱中原有水，或者是被热邪结聚，或者是气机闭塞，是有水可以通利而进行通利治疗。至于不足的证候，乃是虚劳汗多，五脏内部枯燥，脂膏腴肉既已去除，不能生津液，膀胱中原没有积水却想要通利它，就像向乞丐乞求食物，已经贫穷反而更加贫穷了。所以李东垣区分在气和在血来治疗，以口渴与不口渴来辨别。如果口渴且小便不利，这属于上焦气分。水生于金（肺），肺热则清化的源头断绝了。应当在肺的方面辅助秋令，水自然能生成。就像天气到了秋天，白露下降，须用清金（清肺）的药物，如生脉散之类才恰当。又有脾虚的情况，大概是因为饮食失节，损伤了胃气，陷于下焦。经书所说脾胃一虚，使人九窍不通，使用补中益气汤，用人参、甘草甘温的药物，先调理胃气，用升麻、柴胡从九原之下提升气机，那么清气上升而浊气自然下降。清肺，是隔二（隔脏）的治疗法。补脾，是隔三（隔两脏）的治疗法。李东垣“虚则补母”的妙用，大抵如此。这些都是滋养后天化源的方法。如果不口渴且小便不利，这属于下焦血分。下焦，就是肾和膀胱。这是阴中之阴。阴受热邪，闭塞了下流的路径。经书说：无阳则阴无以生，无阴则阳无以化。如果淡渗的药物，是阳中之阴，不是纯阴的药剂，阳气如何能化？须用滋肾丸。此药气味俱阴，是阴中之阴。李东垣先生治疗一个人眼睛突出，腹胀如鼓，膝盖以上坚硬，皮肤欲裂，饮食不下，便秘危急的情况，深思半夜而找到方法，投药后立刻痊愈。这是阴虚，阳气无法气化所致。至于真阳真阴虚的情况，李东垣没有论述。如果有真阴虚的，只有六味地黄丸来补肾水，滋肾丸又在禁忌之列。黄柏、知母恐怕其苦寒泄水，又忌用淡味渗泄的药物。有真阳虚的，须用八味丸。褚氏说：阴精已经萎弱还想通过房事泄精，那么精液出不来而在体内败坏，小便道涩滞像淋证一样。精液已经消耗而又再次竭尽，那么大小便通道牵拉疼痛，越痛越想排便，越想排便就越痛。戴氏说：有类似淋证但不是淋证，便中有像鼻涕一样的东西，这是精溺（精液和小便）俱出，精液堵塞溺道，所以想出来却不能出来而疼痛，适宜用大菟丝子丸、鹿茸丸。戴氏也是得到了褚氏的方法。如果到了转筋、喘急快要死的时候，不问男女、孕妇还是产后，急忙用八味丸的药料煎煮饮用，迟缓了就救不回来了。有人怀疑桂枝、附子辛热，不敢轻易使用。哪里知道肾气虚寒，是水寒水冻的道理，得到热药则流通，除了这个还有什么东西，能直达膀胱，而使冰雪消融春水到来呢？
朱丹溪治疗一个老人患小便不利，因为服用分利药物太过，导致秘塞，点滴不出。我认为他是胃气下陷，使用补中益气汤，一服药就通了。因为先前多用利药，损伤了肾气，导致通利之后，遗尿一夜不止，急忙补肾才停止。凡是医生治疗这个证候，没有不用泄利药物的，谁能顾及他肾气的虚弱呢？我特意表彰这一点，作为世人的警戒。
后来如果有人善于效法丹溪，既然明知他肺虚了，还用补中益气汤送服肾气丸，难道不是上下相互需要，子母相互增益吗？《灵枢》说手太阴肺经的别络名叫列缺，它的病虚则欠缺，小便遗尿频数。肺为上焦，通调水道，向下输注到膀胱。肾又向上连接肺，所以将这两脏视为子母关系。母虚子亦虚，是自然的道理。李东垣说：小便遗失，是肺金虚损，应当安卧养气禁止劳累，用人参等大补之药。如果不愈，应当责之于肾。经书说：膀胱不约束则遗尿。张仲景说：下焦衰竭则遗尿失禁。又说：下焦不归位，则遗溲。大概下焦在膀胱上口，主分别清浊和小便。下焦不归其部，不能约束小便，所以遗尿。大体上天暖衣服厚则多汗，天冷衣服薄则多尿。多尿的是寒证。至于不禁，是虚寒得很严重，非八味丸无效。古方如菟丝子丸、鹿茸散、二气丹，都可以选用。戴氏说：睡着时遗尿，这也是下元寒冷小便无禁摄造成的，适宜用大菟丝子丸，猪胞炙碎煎汤送服。凡遗尿都属虚证。刘河间认为热甚，客居于肾部，干扰足厥阴肝经，廷孔郁结，严重时气血不能宣通，则痿痹，神无所用，所以津液渗入膀胱，随即溺尿遗失，不能收禁。即《内经》所说淫气遗溺，痹聚在肾，这是热证，不可不知道。考证薛己的医案，有因劳累发热作渴，小便自遗，或有时闭涩，我认为是肝火血虚，阴挺（指前阴下垂或松弛，此处指约束无力）不能约束。午前用补中益气汤，加山药、山茱萸，午后用六味丸，月余全部消退。大体上不禁的病，虚寒多而实热少。倘若将虚证误投泻火药，顷刻间就会危殆。谨慎啊，谨慎啊。
Urination obstruction is no trivial matter. The lower abdomen feels urgent and painful, shaped like an inverted bowl, with a sense of urgency that is hard to restrain. If urination does not occur for a day, it may cause vomiting; this condition is named Guan Ge (Obstruction and Reversal). It is also said that death will result if urination remains blocked. Nowadays, upon seeing this syndrome, people only resort to Wu Ling San (Five-Ingredient Powder with Poria) and then wait helplessly for death. Methods such as warming the Dantian (Conception Vessel 4) with salt or applying earthworms and snails to the umbilicus are merely treating the branch.
If body fluids leak excessively into the intestines and stomach, causing diarrhea while urination is blocked, it is appropriate to use Wu Ling San (Five-Ingredient Powder with Poria) to separate and drain dampness. If water stagnates in the epigastrium and cannot descend to the Bladder, Wu Ling San (Five-Ingredient Powder with Poria) should also be used to seep out and drain turbidity. If there is exogenous heat in the Six Fu Organs transferring to the Lower Jiao (Lower Burner) causing blockage, Yi Yuan San (Benefit Origin Powder) should be used to clear the heat. If Qi compression causes blockage and impedes ascending and descending movements, Sheng Ma (Cimicifugae Rhizoma) should be used to lift the Qi, or emesis can be induced by tickling the throat. This is like opening the upper orifice so that the lower orifice becomes patent.
The Classics state: "The Bladder is the official of the metropolis, where fluids are stored; only through Qi transformation can they be discharged." It also states: "The San Jiao (Triple Burner) is the official of irrigation, from which water fluids exit." From this, we can see that the Bladder can only store water; it requires the Qi transformation of the San Jiao (Triple Burner) to discharge urine. Some cases involve excessive consumption of Lung Yin due to overuse of hot herbs like Fuzi (Aconiti Lateralis Radix Praeparata), leading to failure of Qi transformation; these are treated with Huanglian Jiedu Tang (Coptis Decoction to Relieve Toxicity) to restore patency. Others are treated with Fuling Chenpi Gancao Tang (Poria, Tangerine Peel, and Licorice Decoction) administered with powdered Muxiang (Aucklandiae Radix) and Chenxiang (Aquilariae Lignum Resinatum) to achieve urination. These are all demonstrations of Qi transformation. The above treatments apply to Excess syndromes, meaning there is water originally in the Bladder, either bound by Heat or blocked by Qi stagnation; thus, treatment involves promoting the flow of existing water.
In contrast, Deficiency syndromes arise from chronic exhaustion and excessive sweating, leading to dryness within the Five Zang Organs. Once the essence and fat are depleted, body fluids cannot be generated. If one attempts to promote urination when there is no water accumulation in the Bladder, it is like begging food from a beggar who is already impoverished—adding to the poverty. Therefore, Li Dongyuan distinguished treatment based on whether the pathology lies in Qi or Blood, differentiating by thirst or lack thereof. If there is thirst accompanied by difficult urination, this belongs to the Qi aspect of the Upper Jiao (Upper Burner). Water is generated by Metal (Lung); Lung Heat cuts off the source of clear transformation. Treatment should support the Autumn function (Metal) at the Lung level, allowing water to generate naturally, akin to white dew falling in autumn. Clearing Metal (clearing the Lung) herbs, such as Shengmai San (Generate Pulse Powder), are appropriate.
Another scenario involves Spleen Deficiency, often caused by irregular diet damaging Stomach Qi, causing it to sink into the Lower Jiao. As the Classics state, when the Spleen and Stomach are deficient, the nine orifices become blocked. Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) should be used, containing sweet-warm herbs like Renshen (Ginseng Radix et Rhizoma) and Gancao (Glycyrrhizae Radix et Rhizoma) to first regulate Stomach Qi. Shengma (Cimicifugae Rhizoma) and Chaihu (Bupleuri Radix) lift the Qi from the depths, causing clear Yang to ascend and turbid Yin to descend naturally. Clearing the Lung is a treatment separated by two organs (indirectly treating the mother organ via the child's path? Note: In TCM theory, Lung is Metal, Kidney is Water. Metal generates Water. Here "Ge Er" refers to treating the organ that generates the affected organ indirectly or via a specific pathway logic described by Dongyuan). Supplementing the Spleen is a treatment separated by three organs. This illustrates Li Dongyuan’s ingenious application of "Deficiency tonifies the Mother." These methods all nourish the source of post-heaven transformation.
If there is no thirst but urination is difficult, this belongs to the Blood aspect of the Lower Jiao (Kidney and Bladder), which is Yin within Yin. If Yin is affected by Heat, the downward flow is blocked. The Classics say: "Without Yang, Yin cannot be generated; without Yin, Yang cannot transform." Diuretic herbs are "Yin within Yang," not pure Yin agents, so how can Yang transform? Zi Shen Wan (Nourish Kidney Pill) should be used. This formula has flavors and properties that are purely Yin, representing Yin within Yin.
Mr. Li Dongyuan once treated a patient with protruding eyes, abdominal distension like a drum, hardness above the knees, skin feeling ready to burst, inability to eat, and severe constipation. After deep contemplation until midnight, he found a remedy that cured the patient immediately. This was due to Yin Deficiency preventing Yang transformation. However, Li Dongyuan did not discuss True Yang and True Yin Deficiency. For True Yin Deficiency, Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia) is used to tonify Kidney Water, while Zi Shen Wan (Nourish Kidney Pill) is contraindicated. Huangbai (Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma) are avoided because their bitter-cold nature may drain water; bland diuretics are also contraindicated. For True Yang Deficiency, Bawei Wan (Eight-Ingredient Pill) is required.
Master Chu stated: "If Jing (Essence) is already withered but one seeks sexual gratification to release essence, the essence will not exit but rot internally, causing the urinary channel to feel obstructed like strangury. If Jing is already exhausted and further depleted, the channels for stool and urine will pull and hurt; the more it hurts, the more one desires to defecate/urinate, and the more one tries, the more it hurts." Master Dai added: "There are cases resembling strangury but not being strangury, where mucus-like substances appear in the urine. This is because both Jing and urine are expelled; Jing blocks the urinary channel, making it difficult to pass and painful. Da Tusizi Wan (Large Dodder Seed Pill) and Lurong Wan (Deer Antler Pill) are appropriate." Master Dai also mastered Master Chu's methods.
If the condition progresses to muscle twitching, panting, and impending death, regardless of gender, pregnancy, or postpartum status, Bawei Wan (Eight-Ingredient Pill) decoction must be administered urgently; delay means death. Some doubt the use of Guizhi (Cinnamomi Ramulus) and Fuzi (Aconiti Lateralis Radix Praeparata) due to their acrid-hot nature. However, consider the principle of Kidney Qi deficiency and cold: water freezes in cold and flows with heat. What other substance can reach the Bladder directly and melt the snow like spring water arrives?
Zhu Danxi treated an elderly man with difficult urination. Due to excessive use of diuretic drugs, he became completely blocked with no drops passing. Zhu diagnosed Stomach Qi sinking and prescribed Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction), which resolved the blockage after one dose. However, because previous diuretics had damaged Kidney Qi, the patient experienced enuresis (involuntary urination) all night after urination resumed. Urgent Kidney tonification stopped it. Physicians treating this condition rarely avoid draining/diuretic agents; few consider the underlying Kidney Qi deficiency. I highlight this as a warning for future generations.
Later practitioners who emulate Danxi might recognize Lung Deficiency and administer Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) alongside Shenqi Wan (Kidney Qi Pill). Is this not mutual support between upper and lower, and mutual benefit between Child and Mother? The *Ling Shu* states: "The collateral of Hand Taiyin [Lung] is named Lieque (LU 7). Its disease manifests as deficiency and lack, with enuresis and frequent urination." The Lung is the Upper Jiao, regulating water passages and transmitting downwards to the Bladder. The Kidney connects upward to the Lung; thus, these two Zang organs form a Mother-Child relationship. If the Mother is deficient, the Child is also deficient—a natural law. Li Dongyuan said: "Enuresis is due to Lung Metal Deficiency. One should rest, conserve Qi, avoid labor, and strongly tonify with Ren Shen (Ginseng Radix et Rhizoma). If ineffective, blame the Kidney." The Classics state: "If the Bladder fails to constrain, enuresis occurs." Zhang Zhongjing said: "When the Lower Jiao exhausts, enuresis and incontinence result." He also said: "When the Lower Jiao fails to return to its position, leakage of urine occurs." The Lower Jiao, located above the bladder opening, distinguishes clear from turbid and controls urination. If it fails to reside in its proper place, it cannot constrain urine, leading to enuresis. Generally, warm weather and thick clothing cause sweating; cold weather and thin clothing cause increased urination. Increased urination indicates Cold. Enuresis indicates extreme Deficiency-Cold, requiring Bawei Wan (Eight-Ingredient Pill) for efficacy. Ancient formulas like Tusizi Wan (Dodder Seed Pill), Lurong San (Deer Antler Powder), and Erqi Dan (Two-Qi Elixir) are also selectable options.
Master Dai said: "Nocturnal enuresis during sleep is caused by coldness in the Lower Yuan (Lower Source) leading to loss of urinary control. Da Tusizi Wan (Large Dodder Seed Pill) administered with decoction of roasted pig bladder is appropriate." All enuresis belongs to Deficiency. Liu Hejian argued that extreme Heat lodging in the Kidney region interferes with the Foot Jueyin [Liver] meridian, causing congestion in the urethral orifice. When Qi and Blood cannot circulate freely, flaccidity and numbness occur, rendering the Spirit useless, so fluids seep into the Bladder and are lost involuntarily. This corresponds to the *Nei Jing* statement: "Pathogenic factors causing enuresis indicate Bi Syndrome gathering in the Kidney." This is a Heat syndrome, which must be known.
Reviewing Xue Ji's medical records: A case involved fever and thirst due to overwork, with spontaneous enuresis or occasional retention. I diagnosed Liver Fire and Blood Deficiency, where the Yin structures failed to constrain. Morning administration of Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) with Shanyao (Dioscoreae Rhizoma) and Shanzhuyu (Corni Fructus), and afternoon administration of Liuwei Wan (Six-Ingredient Pill), resolved symptoms within a month. Generally, enuresis is mostly Deficiency-Cold rather than Excess-Heat. Mistakenly prescribing fire-draining herbs for a Deficiency syndrome can lead to critical danger instantly. Be cautious, be cautious.