肩背痛而寒，少气不足以息，溺色变。宜补中益气汤以补肺气。冬脉者肾也，冬脉不及，则令人 中清，脊中
痛，小便变。宜地黄丸以助肾气。此虚证也。（《证治准绳》）
凡小便，人但见其黄，便谓是火，不知人逢劳倦，小水即黄；焦思多虑，小水亦黄；泻痢不期，小水亦黄；
酒色伤阴，小水亦黄。使非有淋痛热证相兼，不可因黄便谓之火，余见逼枯汁毙人者多矣。《经》曰∶中气不
足，溲便为之变。义可知也。（张景岳）
脉候
便血则芤，数则赤黄，实脉癃闭，热在膀胱。（《脉诀》）
选案
王善夫病小便不通，渐成中满，腹坚如石，腿裂出水，夜不得睡，不能饮食。请予延医，归而至旦不寐，
因记《素问》云∶无阳则阴无以生，无阴则阳无以化。又云∶膀胱者，州都之官，津液藏焉，气化则能出。
凡病癃秘，是无阴则阳无以化也。此因膏粱积热，损伤肾水，火又逆上而为呕哕，关格之证悉具，死在旦夕矣。
遂处大苦寒之剂，黄柏、知母各一两，桂一钱为引，服药须臾，前阴如刀刺火烧，溺如瀑泉，肿胀遂消。此证
一在上焦气分而渴，一在下焦血分而不渴，二者之殊，至易辨耳。（李东垣）
马参政父年八旬，初患小便短涩，因服药分利太过，遂致闭塞，涓滴不出。予以饮食伤其胃气，陷于下焦，
乃用补中益气汤，一服小便即通。因先多服利药，损其肾气，遂致通后遗尿不止，复用八味丸补其肾气乃已。（朱丹溪）
姚公懋之室患遗尿，医谓肾虚，用补肾之剂，三年未效。予
与补中益气汤加山药、山萸、桑螵蛸，四剂全愈。（程华仲）
叶茂卿乃郎出痘，未大成浆，其壳甚薄；两月后，尚有着肉不脱者；一夕腹痛，大叫而绝。余取梨汁入温
汤灌之，少苏；遂以黄芩二两煎汤加梨汁与服，痛止。令制膏子药频服，不听。其后忽肚大无伦，一夕痛叫，
小肠突出脐外五寸，交纽各二寸半，如竹节壶顶状；茎物绞折长八、九寸，明亮如灯笼，外证从来不经闻见。
余以知之素审，仍为治之，以黄芩、阿胶二味，日进十余剂，三日后始得小水，五日后水道清利，脐收肿缩而
愈。夫人一身之气，全关于肺，肺清则气行，肺浊则气壅。肺主皮毛，痘不成浆，肺热而津不行也。壳着于肉，
名曰甲错；甲错者，多生肺痈；痈者壅也，岂非肺气壅而然与？腹痛叫绝者，壅之甚也，壅甚则并水道亦闭，
是以其气横行于脐中，而小肠且为突出。至于外肾弛长，尤其剩事矣。吾用黄芩、阿胶清肺之热，润肺之燥，
治其源也。气行而壅自通，源澄斯流清矣。缘病已造极中之极，惟单味多用，可以下行，取效捷耳。（喻嘉言）
一妇少腹肿大如瓜，小便秘而不通，此转胞病也。以补中益气汤冲入韭菜汁一小杯，服讫，令患者横卧床
上，选力妇以患者两膝弯架于肩上，将下体虚空，提起摇摆数四，俾尿胞倒上，徐徐放下，去衣不及，小便射
出，热如汤，黑如墨，顷刻盈盆，腹肿立消。后遇数人，皆以此法治愈。
一人小便不通十日，服五苓、八正等方，俱不效；仰卧于床，腹大如箕，胀痛难当，诊脉迟而有力。此
冷闭也，由于风寒冷气，结塞下焦，留于膀胱故耳。治用姜、附、槟榔、牛膝、枳实、青皮、乌药、赤苓、车
前子，药进片时，腹内喧响，溲如涌泉，腹消而起。
附方
敷脐方 治小便不通，腹胀如鼓。用大螺一枚，盐半匕，捣敷脐下一寸三分，以帛缚之即通。
熨脐方 用葱三斤，切碎炒热，布包熨小肚，小便立通。分作二包替换。○又炒盐半斤，囊盛熨脐下亦通。
熏洗法 治气闭小便不通，胀急危殆。用皂角、葱头、王不留行各数两，煎汤一盆，令病者坐浸其中，熏
洗下体，热气内达，壅滞自通。妇人用葱数茎塞阴中，外加熏洗，其通尤速。
又法 治败精干血，溺孔结垢，阻塞水道，小便胀急不通。令病患仰卧，用翎筒插入马口，以水银一、二
钱灌入，以手轻轻导之，诸塞皆通。水银仍随溺出，毫无伤碍。
又法 用猪胞一个，胞底穿一小孔，以翎筒安孔内，根底用线系紧，筒口细杖子堵定，上用蜡封；胞口人
气吹满，扎定；再用手捻住筒根，揭去蜡封，将翎筒插马口内，解开根头，捻气透入，小便即出。
肩背疼痛且伴有恶寒，气短不足以呼吸，尿液颜色改变。适宜使用补中益气汤来补益肺气。（《证治准绳》）
冬季的脉象对应肾脏，如果冬季脉象不及（虚弱），会导致人体内部清冷，脊柱中间疼痛，小便异常。适宜使用地黄丸来辅助肾气。这属于虚证。
凡是小便，人们只看到黄色，就认为是火邪，却不知道人遇到劳累疲倦时，小便就会变黄；思虑过度焦灼时，小便也会变黄；腹泻痢疾不期而至时，小便也会变黄；酒色损伤阴液时，小便也会变黄。如果不是伴有淋证、疼痛、发热等热证同时出现，不能因为小便黄就断定是火邪，我见过因误判而逼迫枯涸之汁导致人死亡的情况很多了。《黄帝内经》说：中气不足，大小便就会发生异常。其中的道理可以推知了。（张景岳）
【脉候】
大便出血则脉象芤（中空如葱管），脉数则小便赤黄，脉实则为癃闭（排尿困难或尿潴留），病热在膀胱。（《脉诀》）
【选案】
王善夫患小便不通，逐渐发展成腹部胀满坚硬如石，腿部皮肤裂开流出水液，夜间无法入睡，不能进食。请我延请医生诊治，我回家直到天亮都无法入睡，于是想起《素问》中说：没有阳气则阴精无法生成，没有阴精则阳气无法化生。又说：膀胱是州都之官，津液藏于其中，经过气化作用才能排出。凡是癃秘的病证，都是因为没有阴精则阳气无法化生。这是因为长期食用肥甘厚味积滞成热，损伤了肾水，火热之气逆上导致呕吐呃逆，关格（上下不通的危重证候）的症状全部具备，死亡就在旦夕之间了。于是开具大苦寒的药物，黄柏、知母各一两，桂枝一钱作为引经药，服药不久，前阴感觉像刀刺火烧一样，尿液像瀑布泉水般涌出，肿胀随即消退。这个病症，一个在上焦气分表现为口渴，一个在下焦血分表现为不渴，两者的区别，非常容易辨别。（李东垣）
马参政的父亲八十岁，起初患小便短少涩滞，因为服用利尿药物太过，导致完全闭塞，一滴也排不出。我认为这是饮食损伤了胃气，气陷于下焦，于是使用补中益气汤，服一次后小便即通。因为之前多服用了利水药物，损伤了肾气，导致通利之后遗尿不止，再次使用八味丸补益肾气才停止。（朱丹溪）
姚公懋之的妻子患遗尿症，医生认为是肾虚，使用补肾的药物，三年未见效。我给予补中益气汤加入山药、山茱萸、桑螵蛸，四剂药后完全痊愈。（程华仲）
叶茂卿的儿子出痘疹，未能大成脓浆，痘壳很薄；两个月后，还有附着在肉上不脱落的；一天晚上腹痛，大叫一声后昏厥。我取梨汁加入温水中灌服，稍苏醒；于是用黄芩二两煎汤加入梨汁让患者服用，疼痛停止。让人制作膏子药频繁服用，患者不听。后来突然肚子大得无与伦比，一天晚上疼痛大叫，小肠突出肚脐外五寸，交纽部分各二寸半，像竹节壶顶的形状；生殖器绞折长八、九寸，明亮如灯笼，这种外部症状从来没见过。我因为了解病情素来透彻，仍然为他治疗，用黄芩、阿胶两味药，每天进服十余剂，三天后才开始有小便，五天后面水道清利，肚脐收缩肿胀消退而痊愈。人一身的气，全关系到肺，肺清则气行，肺浊则气壅滞。肺主皮毛，痘疹不成浆，是肺热而津液不行。痘壳附着在肉上，名叫“甲错”；甲错的人，多生肺痈；痈就是壅滞，难道不是肺气壅滞造成的吗？腹痛叫绝，是壅滞非常严重，壅滞严重则连同水道也闭塞，所以气横行于脐中，小肠甚至突出。至于外生殖器弛长，更是次要的了。我用黄芩、阿胶清除肺热，滋润肺燥，是从源头治疗。气行则壅滞自通，源头清澈则水流清利。因为病情已经发展到极中之极，只有单味药多用，可以下行，取效迅速罢了。（喻嘉言）
一位妇女小腹肿大如瓜，小便闭塞不通，这是转胞病。用补中益气汤冲入韭菜汁一小杯，服完后，让患者横躺在床上，选力气大的妇人将患者的两膝弯架在肩上，使下体虚空，提起摇摆数次，使尿胞倒置向上，徐徐放下，来不及穿衣，小便射出，热如开水，黑如墨汁，顷刻间盈满盆，腹肿立即消除。后来遇到几个人，都用这个方法治愈。
一个人小便不通十天，服用五苓散、八正散等方剂，都不见效；仰卧在床上，肚子大如簸箕，胀痛难忍，诊脉迟而有力。这是冷闭，由于风寒冷气，结塞下焦，留在膀胱的缘故。治疗用干姜、附子、槟榔、牛膝、枳实、青皮、乌药、赤茯苓、车前子，药进片刻，腹内喧响，小便如涌泉般流出，腹胀消去而起。
【附方】
敷脐方：治疗小便不通，腹胀如鼓。用大螺一枚，盐半匕，捣碎敷在脐下一寸三分处，用布帛绑住即可通利。
熨脐方：用葱三斤，切碎炒热，用布包好熨烫小腹部，小便立通。分成两包替换。○又或用炒盐半斤，装在囊中熨烫脐下也能通利。
熏洗法：治疗气闭导致的小便不通，胀急危殆。用皂角、葱头、王不留行各数两，煎一盆汤，让病人坐在其中浸泡，熏洗下体，热气内达，壅滞自然通利。妇人可用葱数茎塞入阴道中，外加熏洗，通利尤其迅速。
又法：治疗败精干血，溺孔结垢，阻塞水道，小便胀急不通。让病患仰卧，用翎毛筒插入尿道口，用水银一两二钱灌入，用手轻轻引导，各种堵塞皆通。水银仍随小便排出，毫无伤害。
又法：用猪膀胱一个，在膀胱底穿一个小孔，将翎毛筒安装在孔内，根部用线系紧，筒口用细木棍堵定，上面用蜡封住；膀胱口吹气充满，扎紧；再用手捏住筒根，揭去蜡封，将翎毛筒插入尿道口，解开根部，捻气透入，小便即出。
Shoulder and back pain accompanied by aversion to cold, shortness of breath with insufficient respiration, and change in urine color. It is appropriate to use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) to tonify Lung Qi. The Winter pulse corresponds to the Kidney; if the Winter pulse is deficient, it causes internal coldness, pain in the spine, and abnormal urination. It is appropriate to use Dihuang Wan (Rehmannia Pill) to assist Kidney Qi. This is a deficiency syndrome. (*Zhengzhi Zhunshen*)
Regarding urination, people often see yellow urine and attribute it to Fire pathogen, not realizing that when one encounters fatigue or overwork, urine becomes yellow; when one is anxious and overthinking, urine also becomes yellow; when diarrhea or dysentery occurs unexpectedly, urine also becomes yellow; when wine and sexual excess damage Yin fluids, urine also becomes yellow. Unless accompanied by symptoms of strangury, pain, and heat, one should not conclude it is Fire merely because the urine is yellow. I have seen many cases where patients died due to being forced into a state of dried-up fluids based on such misjudgments. The *Classic* states: "When Middle Qi is insufficient, urination and defecation become abnormal." The meaning can be inferred from this. (Zhang Jingyue)
[Pulse Diagnosis]
Hematochezia presents with a Kou (scallion-stalk) pulse; rapid pulse indicates red-yellow urine; Excess pulse indicates strangury/urinary retention; Heat is in the Bladder. (*Maijue*)
[Selected Cases]
Wang Shanfu suffered from urinary retention, which gradually developed into abdominal fullness, with the abdomen hard as stone, skin cracking on the legs leaking fluid, inability to sleep at night, and inability to eat. He invited me to consult. Returning home, I could not sleep until dawn, recalling the *Suwen*: "Without Yang, Yin cannot be generated; without Yin, Yang cannot be transformed." It also states: "The Bladder is the official of the capital, storing fluids; only through Qi transformation can they be excreted." All cases of strangury and retention stem from the lack of Yin preventing the transformation of Yang. This case was caused by accumulated heat from rich foods damaging Kidney Water, with Fire rebelling upward causing vomiting and hiccups, presenting all signs of Guan-Ge (obstruction of upper and lower jiao), with death imminent. Therefore, I prescribed strong bitter-cold herbs: Huangbai (Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma), each 1 liang, with Guizhi (Cinnamomi Ramulus) 1 qian as a guiding herb. Shortly after taking the medicine, the external genitalia felt like knife-stabbing and burning, and urine gushed out like a waterfall, with swelling subsiding immediately. In this condition, one aspect involves thirst due to Qi-level pathology in the Upper Jiao, while the other involves no thirst due to Blood-level pathology in the Lower Jiao; the distinction between the two is very easy to identify. (Li Dongyuan)
The father of Councilor Ma, aged eighty, initially suffered from scanty and obstructed urination. Due to excessive use of diuretic medicines, he became completely blocked, unable to pass even a drop. I reasoned that dietary injury had damaged Stomach Qi, causing it to sink into the Lower Jiao. Thus, I used Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). After one dose, urination resumed. However, because he had previously taken too many diuretics, damaging Kidney Qi, he experienced continuous enuresis after urination resumed. I then used Ba Wei Wan (Eight-Ingredient Pill with Rehmannia) to tonify Kidney Qi, which resolved the issue. (Zhu Danxi)
The wife of Yao Gongmaozhi suffered from enuresis. Physicians attributed it to Kidney deficiency and used Kidney-tonifying formulas for three years without effect. I administered Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) added with Shanyao (Dioscoreae Rhizoma), Shanzhuyu (Corni Fructus), and Sangpiaoxiao (Mantis Egg Case). After four doses, she was completely cured. (Cheng Huazhong)
Ye Maoqing's son contracted smallpox but failed to form proper pustules; the crusts were very thin. Two months later, some crusts remained adherent to the flesh. One night, he suffered abdominal pain, cried out loudly, and fainted. I took Pear Juice mixed with warm water and administered it; he slightly revived. Then, I decocted Huangqin (Scutellariae Radix) 2 liang, added Pear Juice, and gave it to him, stopping the pain. I instructed making a paste medicine for frequent intake, but he did not comply. Later, his abdomen suddenly became enormously distended. One night, he cried out in pain, and his small intestine protruded five cun outside the umbilicus, with the twisted portion measuring two and a half cun each, resembling the top of a bamboo-joint pot; the penis was twisted, eight or nine cun long, bright as a lantern. Such external manifestations had never been seen before. Since I knew the disease thoroughly, I continued treatment using Huangqin (Scutellariae Radix) and Ejiao (Asini Corii Colla), administering more than ten doses daily. After three days, he began to pass small amounts of urine; after five days, the urinary tract cleared, the umbilicus retracted, swelling subsided, and he recovered. The Qi of the whole body is entirely related to the Lung; if the Lung is clear, Qi flows; if the Lung is turbid, Qi stagnates. The Lung governs skin and hair. Failure of smallpox to form pus indicates Lung Heat and failure of Jin-Ye (Body Fluids) to circulate. Crusts adhering to flesh are called "Jiacuo" (criss-cross scaling); those with Jiacuo often develop Feiyong (Lung Abscess); Yong means obstruction. Is this not caused by Lung Qi obstruction? Severe abdominal pain and crying indicate severe obstruction; severe obstruction closes the urinary pathway as well, causing Qi to rush horizontally through the umbilicus, leading to intestinal protrusion. Flaccidity and elongation of the external genitals are merely secondary effects. I used Huangqin (Scutellariae Radix) and Ejiao (Asini Corii Colla) to clear Lung Heat and moisten Lung dryness, treating the root cause. When Qi flows, obstruction clears; when the source is pure, the flow is clear. Because the disease had reached an extreme degree, only single herbs in large doses could descend effectively and produce rapid results. (Yu Jiayan)
A woman had a lower abdomen swollen like a melon, with complete urinary retention. This was Zhuantong (Bladder Displacement) disease. I used Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) mixed with a small cup of Chive Juice. After ingestion, the patient lay horizontally on the bed. A strong woman placed the patient's bent knees on her shoulders, suspending the lower body empty, lifted and swung the patient several times to invert the bladder upwards, then slowly lowered her. Before clothes could be put on, urine shot out, hot as boiling water and black as ink, filling the basin instantly, and abdominal swelling disappeared immediately. Subsequently, several similar cases were cured using this method.
A man suffered from urinary retention for ten days. Treatments with Wuling San (Five-Ling Powder) and Bazheng San (Eight-Right Powder) were ineffective. He lay supine on the bed, abdomen distended like a winnowing basket, unbearable distension and pain. Pulse was slow but forceful. This was Cold Obstruction, caused by Wind-Cold pathogenic qi blocking the Lower Jiao and remaining in the Bladder. Treatment used Jiang (Zingiberis Rhizoma), Fuzi (Aconiti Lateralis Radix Praeparata), Binglang (Arecae Semen), Niuxi (Achyranthis Bidentatae Radix), Zhishi (Aurantii Fructus Immaturus), Qingpi (Citri Reticulatae Pericarpium Viride), Wuyao (Linderae Radix), Chifuling (Poria cum Pini Radix), and Cheqianzi (Plantaginis Semen). Shortly after administration, rumbling occurred in the abdomen, and urine gushed out like a spring, with abdominal distension resolving and the patient rising.
[Supplementary Formulas]
Umbilical Application Formula: Treats urinary retention and drum-like abdominal distension. Use one large snail and half a spoonful of salt, pound into a paste, apply to 1.3 cun below the umbilicus, and bind with cloth to achieve patency.
Umbilical Moxibustion/Ironing Formula: Use three jin of scallions, chop finely, stir-fry until hot, wrap in cloth, and iron the lower abdomen. Urination will resume immediately. Divide into two packs for rotation. ○ Alternatively, use half a jin of stir-fried salt, place in a bag, and iron the area below the umbilicus to achieve patency.
Fumigation and Washing Method: Treats Qi-blockage causing urinary retention, distension, urgency, and critical danger. Use several liang each of Zaogiao (Gleditsiae Sinensis Fructus Spina), Congtou (Allii Fistulosi Bulbus), and Wangbulexing (Vaccariae Semen). Decoct in a basin of water. Let the patient sit and soak, fumigating and washing the lower body. Internal penetration of heat resolves obstruction naturally. For women, insert several stalks of scallion into the vagina, plus external fumigation and washing, for faster results.
Another Method: Treats residual semen and dried blood, crust formation in the urethral meatus, blocking the urinary pathway, causing distension, urgency, and retention. Have the patient lie supine. Insert a feather quill tube into the urethral meatus. Inject one or two qian of Mercury. Gently guide with hand to clear all obstructions. Mercury exits with urine, causing no harm.
Another Method: Use one pig bladder. Pierce a small hole in the base. Attach a feather quill tube to the hole. Tie the root tightly with thread. Plug the tube mouth with a thin stick. Seal the top with wax. Inflate the bladder mouth with air and tie it shut. Hold the tube root with hand. Remove wax seal. Insert feather quill tube into the urethral meatus. Untie the root. Squeeze air into the bladder. Urine will flow out immediately.