经义
帝曰∶其有不从毫毛生，而五脏阳已竭也。津液充郭，其魄独居，孤精于内，气耗于外，形不可与衣相
保，此四极急而动中，是气拒于内，而形施于外，治之奈何？岐伯曰∶平治于权衡，去菀陈 ，微动四极，温
衣，缪刺其处，以复其形，开鬼门，洁净
府，精以时服。五阳已布，疏涤五脏，故精自生，形自盛，骨肉相保，巨气乃平。○肾者至阴也，至阴者盛
水也；肺者太阴也，少阴者冬脉也。其本在肾，其标在肺，皆积水也。○肾何以能聚水而生病？肾者胃之关也，
关门不利，故聚水而从其类也。○水病下为浮肿大腹，上为喘呼，不得卧者，标本俱病。○不得卧，卧则喘者，
是水气之客也。○颈脉动，喘疾咳曰水。目里微肿，如卧蚕起之状曰水。○阴阳结斜，多阴少阳曰石水。○三阴
结谓之水。○因于气为肿，四维相代，阳气乃竭。○热胜则肿。○诸湿肿满，皆属于脾。○诸胀腹大，皆属于热。
○浊气在上，则生 胀。○有病心腹满，旦食而不能暮食，名为鼓胀，治之以鸡矢醴，一剂知，二剂已。（《素问》）
肤胀者，寒气客于皮肤之间， 然不坚，腹大身尽肿，皮浓，按其腹 而不起，腹色不变，此其候也。
○鼓胀者，身皆大，大与肤胀等，色苍黄，腹筋起，此其候也。○足太阴虚则鼓胀。○脾气实则腹胀。○心胀者，
烦心短气，卧不安。肺胀者，虚满而喘咳。肝胀者，胁下满而痛引少腹。脾胀者，善哕，四肢烦 ，体重不能
胜衣。肾胀者，腹满引背，央央然腰髀痛。胃胀者，腹满，胃脘痛，鼻闻焦臭，妨于食，大便难。大肠胀者，
肠鸣而痛濯濯，冬日重感于寒，则飧泄不化。小肠胀者，少腹 胀，引腰而痛。膀胱胀者，少腹满而气癃。三
焦胀者，气满于皮肤中，轻轻然不坚。胆胀者，胁下痛胀，口中苦，善太息。（《灵枢》）
哲言
夫胀与肿，内因则各有殊，而外形多相似，其可辨者，如先腹大，后四肢肿者为胀病；先头足肿，后腹
大者是水也。但腹大而四肢竟不肿者为胀病，脐腹四肢悉肿者是水也。（沈金鳌）
凡诸实证，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。（李士材）
问曰∶肿与胀有辨乎？曰∶肿自肿，胀自胀。盖气血流行。脏腑调和，脉络疏通，在外安得作肿？在内安
得作胀？缘其人肾气虚，失开阖之权；肺气虚，失清肃之令；脾气虚，失健运之常；表气虚，外邪易入，于是
在肌肉则肿生，在脏腑则胀生。见于外自知其肿，人亦知其肿也，发于内自知其胀，人不知其胀也。但肿胀多
端，虚实各异，风、寒、湿、热、水、虫、血、食之各种，不悉言之，何以知所适从哉？夫风寒外入之肿，则
为实证，如头面之肿、发颐之肿、牙龈之肿是也。湿热外入之肿多实，而亦有虚证，如疮疡之肿、单腹之肿、
痛痹之肿是也。若气水虫血之肿，则有虚实两证，如目下之肿、周身之肿、手足之肿、腹皮光亮之肿、肾囊肾
茎之肿、腹有青筋之肿是也，治法各以证合脉为尽善也。然胀与肿迥乎不同，肾火衰微，中土虚寒，脾元不运
而胀矣。水不生肝，木郁不达，两胁不和而胀矣。阴火灼金，肺气 郁，喘咳壅塞而胀矣。不特此也，又有湿
热在脾胃而胀，水饮在中脘而胀，瘀血在中焦，及虫积在肠胃而胀，气滞食阻在阳明而胀，大小便不通在少腹
而胀。外风无胀病，而胀病亦不一。大抵肿有形而胀无形，胀者肿之渐，内伤居多；肿者胀之剧，外感无与。
内伤有胀而亦有肿，外感有肿而却无胀。医家务以外肿内胀，确认亲切，则肿自肿，而胀自胀，不有了然胸中
者乎！（《会心录》）
肿胀病在气分者，因气之滞。如气血之逆，饮食之逆，寒热风湿之逆，气虚不能运化之逆，但治节有不行
者，悉由气分，皆能作胀。凡气分之病，其色苍，其内坚，其胀或连胸胁，其痛或及脏腑，或倏而浮肿者，阳
性急速也。或自上及下者，阳本乎上也。或通身尽肿者，气无不至也。有随按而起者，如按气囊也。然此虽皆
气分，而气病各有不同，有气热而胀者，曰诸胀腹大，皆属于热也；有气寒而胀者，曰胃中寒则 胀，曰脏寒
生满病也；有气湿而胀者，曰诸湿肿满，皆属于脾也；有气虚而胀者，元气虚也，曰足太阴虚则鼓胀也；有气
实而胀者，邪气实也，曰肾气
实则胀；曰脾气实则腹胀；曰胃气实则胀也，凡此虽皆胀病，而治之之要，则全在察其虚实。大都阳证多热，
热证多实；阴证多寒，寒证多虚。先胀于内，而后及于外者多实，先肿于外，而渐及于内，或外虽肿而内不胀
者多虚。小便红赤，大便秘结者多实；小便清白，大便稀溏者多虚。脉滑有力者多实，弦浮微细者多虚。形色
红黄，气息粗长者多实；形容憔悴，声音短促者多虚。年青少壮，气道壅塞者多实；中衰积劳，神疲气怯者多
虚。虚实之治，反如冰炭，若误用之，必致害矣。○病在水分者，以阴胜于阳。而肌肤皆肿，此与气证，本有
不同。凡水之为病，其色明润，其皮光薄，其肿不速，每自下而上，按肉如泥，肿有分界。盖阴本于下，而浸
渍有渐，皆水病之证也。观《水胀篇》言寒气之胀，按其腹 而不起；水肿之病，按其腹随手而起，如囊裹
水之状。然以愚见及察之证验，则若与此论相反。盖凡是水证，必按之 而不起，此其水在肉中，如糟如泥，
按而散之，猝不能聚，未必如水囊之比。凡随按随起者，亦惟虚无之气，其速乃然，故辨当若此也。凡欲辨水
气之异者，在欲辨其阴阳耳。若病在气分，则阳证阴证皆有之；若病在水分，则多为阴证。何也？盖水之与气，
虽为同类，但阳旺则气化，而水即为精，阳衰则气不化，而精即为水。故凡病水者，本即身中之血气，但其为
邪为正，总在化与不化耳。水不能化，因气之虚，岂非阴中无阳乎？此水肿之病，所以多属阳虚也。然水主于
肾，气主于肺，水渍于下，而气竭于上，所以下为肿满，上为喘急，标本俱病，危斯极矣。此当速救本原，庶
保万一，倘以虚喘为实邪，而犹然泄肺，无不败矣。（张景岳）
肿本乎水，胀由乎气。肿分阳水、阴水，外来者为有余，即为阳水；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。且胀不必兼肿，而肿则必兼胀，亦有肿胀同时
并至者，病形变幻不一。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
郁兼热者用半夏泻心，苦辛通降；有湿热气郁积者用鸡金散，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，暖下泻浊；有寒湿在于气分，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，清肃上焦之气；有湿下着为痹，则用加味活络，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、神佑、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；更有伤及肾者，则又需加减八味、济生等丸矣。○夏季湿热郁蒸，脾胃气弱，水谷之气
不运，湿着内蕴为热，渐至浮肿腹胀，小水不利。治之非法，水湿久渍，逆行犯肺，必生咳嗽喘促，甚则坐不
得卧，俯不能仰，危期速矣。大凡喘必生胀，胀必生喘，方书以先喘后胀者治在肺，先胀后喘者治在脾。《金
匮》有风水、皮水、石水、正水、黄汗，以分表里之治。河间有三焦分消，子和有磨积逐水，皆有奥义。世俗论
水湿喘胀之证，以开鬼门取汗为表治。分利小便洁净府为里治。又以诸湿肿满，皆属于脾，用健脾燥湿为稳治，
治之不效，技穷束手矣。不知凡病皆本乎阴阳，通表利小便，乃宣经气，利腑气，是阳病治法。暖水脏，温脾
肾，补阳以驱水，是阴病治法。治肺以轻清开上，治脾必佐温通，若阴阳表里乖违，脏真日漓，阴阳不运，亦
必作胀。治以通阳，乃可奏绩，如《局方》禹余粮丸。甚至三焦交阻，必用分消，肠胃窒塞，必用下夺，但不
得与伤寒实热同例，擅投硝、黄、枳、朴，
扰动阴血。若太阴脾脏，饮湿阻气，温补不应，欲用下法，少少甘遂为丸可也。（《临证指南》）
水肿鼓胀，皆因脾虚所致。然水肿轻而鼓胀重者，何也？盖水肿则饮食如常，鼓胀则饮食不及常，治水肿
惟补脾导水而已，治鼓胀则补脾导水，兼以消谷，庶乎可也。（冯楚瞻）
胀满之病，每见用克伐伤损脾肾，证变泄泻喘促而不可救，往往用《金匮》肾气丸，转危为安，妙在桂、
附补脾之母。张三锡加参、术，活人殊众。（薛立斋）
中满之病，原于肾中之火气虚，不能行水，宜八味丸以补肾中之火，则三焦有所禀受，肾气不虚而能行
水矣。若纯是脾虚之证，既以参 四君为主，亦须用八味丸兼补命火。盖脾土非命火不能生，此虚则补母之义
也。又有一等纯是阴虚，三焦冲脉之火，同逆而上，水从火溢，上积于肺而为嗽，甚则为喘呼不得卧，散聚于
阴络而为肿，随五脏之虚，入而聚之则为胀。皆相火泛溢其水而生病也，以六味汤加麦冬、五味，服之有验。（赵养葵）
肿满有寒水侮土者，其肿必先由头面四肢起，然后及于腹中，此证可以补中益气汤，吞《金匮》加减肾
气丸。然当治之于早，不然水势冲决，土崩岸败，无济于事。（《己任编》）
水肿
师曰∶病有风水，有皮水，有正水，有石水，有黄汗。○风水。其脉自浮，外证骨节疼痛，恶风。○皮
水，其脉亦浮，外证浮肿，按之没指，不恶风，真腹如鼓，不渴，当发其汗。○正水，其脉沉迟，外证自喘。
○石水，其脉自沉，外证腹满，不喘。○黄汗，其脉沉迟，身发热，胸满，四肢头面肿，久不愈，必致痈脓。○
心水者，其身重而少气，不得卧，烦而躁，其人阴肿。○肝水者，其腹大，不能自转侧，胁下腹痛，时时津
液微生，小便续通。○肺水者，其身肿，小便难，时时鸭溏。○脾水者，其腹大，四肢苦重，津液不生，但苦
少气，小便难。○肾水者，其腹
大，脐肿，腰痛，不得溺，阴下湿如牛鼻上汗，其足逆冷，而反瘦。○诸有水者，腰以下肿，当利小便；腰以
上肿，当发汗，乃愈。○问曰∶病有血分、水分，何也？师曰∶经水前断，后病水，名曰血分，此病难治。先
病水，后经水断，名曰水分，此病易治。何以故？去其水，其经自下。○风水，脉浮身重，汗出恶风者，防己
黄汤主之。○风水，恶风，一身悉肿，脉浮，不渴，续自汗出，无大热，越婢汤主之。○皮水为病，四肢肿，
水气在皮肤中，四肢聂聂动者，防己茯苓汤主之。○里水，越婢加术汤主之，甘草麻黄汤亦主之。○问曰∶黄
汗之为病，身体肿，发热，汗出而渴，状如风水，汗沾衣，色正黄，如 汁，脉自沉，何从得之？师曰∶以汗
出入水中浴，水从汗孔入得之，宜 芍桂酒汤主之。（《金匮》）
按∶其人阴肿四字，当在肾水条内，错简在此，当移之。○面反瘦之下，当补上条其人阴肿四字。○里水之
“里”字，当是“皮”字。岂有里水，而用麻黄之理？当改之。（《医宗金鉴》）
风肿者，皮粗，麻木不仁，走注疼痛是也。气肿者，皮浓，四肢瘦削，腹胁胀膨是也。血肿者，皮间有血
缕赤痕是也。妇人怀妊，有气遏水道而肿者，饮食无阻，既产自消，所谓子肿是也。（朱丹溪）
皮浓色苍，四肢削瘦，胸腹痞满，自上而下者，多属气。皮薄色嫩，肿有分界，自下而上者，多属水。又
按之不成凹而即起者气也；按之成凹不即起者湿也。（《医学入门》）
按∶水肿有痰阻、食积、血瘀，致清不升，浊不降而成者；有湿热相生，隧道阻塞而成者；有燥热冲激，
秘结不通而成者，证属有余。有服寒凉伤饮食，中气虚衰而成者；有大病后，正气衰惫而成者；有小便不利，
水液妄行，脾莫能制而成者，证属不足。宜分别治之。（《医方集解》）
肾气壮，则水还于肾；肾气虚，则水散于皮。（华元化）
《经》云∶热胜则肿者，盖四肢为诸阳之本，阳结于外，不得行于阴，则邪热郁于四肢，故为肿也。况
邪在六腑，则阳脉不和，阳脉不和，则气留之，以其气留，故而为肿。（《圣济总录》）
《内经》四维相代，阳气乃竭二句。按王太仆注，四维为血肉筋骨。吴鹤皋注，四维为血脉筋骨。以是
【经文原义】
黄帝问道：有的病不是从毫毛开始，而是五脏的阳气已经衰竭。津液充满胸腹，阴精独存于内，精气枯竭于内，阳气耗散于外，形体消瘦以至于衣服都穿不下了。四肢拘急并伴有内脏症状，这是气机阻滞于内，而形体衰败于外。治疗该怎么办？岐伯回答说：应当权衡阴阳虚实进行平治，去除体内郁积的陈腐之物，轻微活动四肢，注意保暖，用缪刺法针刺患处，以恢复形体。开启汗孔（发汗），通利膀胱（利尿），使精气按时输布。五脏阳气得以布散，疏通涤荡五脏，那么精气自然生成，形体自然强盛，骨肉相互保全，大气的运行也就平和了。○肾属于至阴，至阴的脏腑容易积聚水湿；肺属于太阴，少阴经是冬季的主脉。水肿病的根本在肾，标象在肺，都是由于水湿停聚所致。○为什么肾脏能积聚水湿而致病？因为肾是胃的关口，如果关门不利，水湿就会聚集并按照同类相求的道理泛滥。○水病在下表现为浮肿和大腹，在上表现为喘息呼叫、不能平卧，这是标本俱病。○不能平卧，一躺下就喘息的，是水气侵袭所致。○颈部人迎脉搏动，气喘且咳嗽严重的，称为水病。眼睑内侧微微肿胀，像卧蚕起来的样子，称为水病。○阴阳之气结滞偏斜，阴多阳少的，称为石水。○三阴经气结滞，称为水病。○因气机阻滞导致肿胀，四时之气交替失常，阳气就会衰竭。○热邪亢盛会导致肿胀。○各种湿邪导致的肿胀和腹满，都归属于脾。○各种胀满和腹部膨大，都归属于热。○浊气停留在上部，就会产生胀满。○有心腹胀满，早上能吃晚上不能吃的病，名叫鼓胀，用鸡矢醴治疗，服一剂见效，服两剂痊愈。（出自《素问》）
肤胀，是由于寒气客居在皮肤之间，腹部胀大但按之不坚硬，全身都肿，皮肤增厚，按压腹部凹陷不起，腹部颜色不变，这就是它的征候。○鼓胀，身体都肿大，大小与肤胀相等，肤色苍黄，腹部青筋暴露，这就是它的征候。○足太阴脾经虚弱会导致鼓胀。○脾气实盛会腹胀。○心胀，表现为心烦短气，睡眠不安。肺胀，表现为虚满且喘咳。肝胀，表现为胁下胀满疼痛并牵引少腹。脾胀，表现为频繁呃逆，四肢烦扰沉重，身体沉重得连衣服都穿不动。肾胀，表现为腹部胀满牵引背部，腰部和大腿根部酸痛。胃胀，表现为腹部胀满，胃脘疼痛，鼻子闻到焦臭味，妨碍进食，大便困难。大肠胀，表现为肠鸣且腹痛如濯濯声，如果在冬天再次感受寒邪，就会导致完谷不化的泄泻。小肠胀，表现为小腹胀满，牵引腰部疼痛。膀胱胀，表现为小腹胀满且小便不通。三焦胀，表现为气充满在皮肤之中，轻轻然但不坚硬。胆胀，表现为胁下疼痛胀满，口苦，喜欢叹气。（出自《灵枢》）
【哲人言论】
关于胀和肿，内在病因各有不同，但外形大多相似。可以辨别的是：先腹部大，后四肢肿的，是胀病；先头脚肿，后腹部大的，是水病。但如果腹部大而四肢完全不肿的，是胀病；脐腹四肢全部肿胀的，是水病。（沈金鳌）
凡是实证，或者是六淫外邪侵袭，或者是饮食内伤，阳邪来势急速，发病必然突然，往往在几天之内形成。如果是虚证，或者是情志劳倦过度，或者是酒色无度，日积月累，发病缓慢，往往在几个月之后才形成。（李士材）
有人问：肿和胀有区别吗？回答说：肿就是肿，胀就是胀。气血流行，脏腑调和，脉络疏通，在外怎么会发生肿？在内怎么会发生胀？这是因为此人肾气虚弱，失去了开阖的权力；肺气虚弱，失去了清肃的职能；脾气虚弱，失去了健运的常态；表气虚弱，外邪容易侵入。于是在肌肉层面产生肿，在脏腑层面产生胀。表现在外面，自己知道是肿，别人也知道是肿；发作在里面，自己知道是胀，别人却不知道是胀。但是肿胀表现多种多样，虚实各不相同，风、寒、湿、热、水、虫、血、食等各种原因，如果不详细论述，怎么知道该遵循哪种治法呢？风寒外侵引起的肿，属于实证，比如头面部的肿、发颐（腮腺炎类）的肿、牙龈的肿等。湿热外侵引起的肿多属实证，但也有虚证，比如疮疡的肿、单腹（单腹胀）的肿、痛痹的肿等。至于气、水、虫、血引起的肿，则有虚实两种证型，比如眼下肿、周身肿、手足肿、腹皮光亮的肿、肾囊阴茎的肿、腹部有青筋的肿等，治疗方法都要根据证候结合脉象来确定才是完善的。然而胀与肿截然不同，肾火衰微，中土虚寒，脾元不运化而导致胀。水不生肝，木气郁结不达，两胁不和而导致胀。阴火灼伤肺金，肺气郁闭，喘咳壅塞而导致胀。不仅如此，还有湿热在脾胃导致胀，水饮在中脘导致胀，瘀血在中焦导致胀，虫积在肠胃导致胀，气滞食阻在阳明导致胀，大小便不通在少腹导致胀。外风没有胀病，但胀病也不止一种。大抵来说，肿是有形的，胀是无形的；胀是肿的初期，多由内伤引起；肿是胀的严重阶段，外感病很少涉及。内伤病既有胀也有肿，外感病有肿却没有胀。医生如果能明确区分外肿和内胀，确认得非常清楚，那么肿就是肿，胀就是胀，心中不就豁然开朗了吗！（《会心录》）
肿胀病在气分的，是因为气机阻滞。比如气血逆乱，饮食停滞，寒热风湿干扰，气虚不能运化等逆乱情况，只要治节功能不行，都源于气分，都能导致胀。凡是气分的病，面色发苍，内部坚实，胀满有时牵连胸胁，疼痛有时波及脏腑，或者突然浮肿的，是阳性病，来势急速。或者从上往下发展的，是因为阳本乎上。或者全身都肿的，是因为气无所不至。有的按下去立刻弹起来的，像按气囊一样。虽然这些都属气分，但气病各有不同：有气热而胀的，即“诸胀腹大，皆属于热”；有气寒而胀的，即“胃中寒则胀”，“脏寒生满病”；有气湿而胀的，即“诸湿肿满，皆属于脾”；有气虚而胀的，是元气虚，即“足太阴虚则鼓胀”；有气实而胀的，是邪气实，即“肾气实则胀”，“脾气实则腹胀”，“胃气实则胀”。凡此种种虽都是胀病，但治疗的关键，全在于辨别虚实。大体上阳证多热，热证多实；阴证多寒，寒证多虚。先在内部胀，然后波及外部的多属实证；先在外部肿，然后逐渐波及内部，或者外部虽肿但内部不胀的多属虚证。小便红赤，大便秘结的多属实证；小便清白，大便稀溏的多属虚证。脉滑有力的多属实证，脉弦浮微细的多属虚证。形色红黄，气息粗长的多属实证；形容憔悴，声音短促的多属虚证。年轻力壮，气道壅塞的多属实证；中年衰退，积劳成疾，神疲气怯的多属虚证。虚实的治疗，截然相反如冰炭，如果误用，必定造成危害。○病在水分的，是因为阴胜于阳。肌肤全都肿胀，这与气证本来不同。凡是水病，肤色明润，皮肤光薄，肿胀发展不快，往往自下而上，按压肌肉像泥一样，肿胀有分界。因为阴本乎下，浸渍是渐进的，这都是水病的证候。看《水胀篇》说寒气之胀，按压腹部凹陷不起；水肿之病，按压腹部随手而起，像囊裹水的样子。然而依我的见解及临床观察验证，却与此论相反。凡是水证，必须按压凹陷不起，这是因为水在肉中，像糟粕像泥土，按下去散开，短时间内不能聚拢，未必像水囊那样。凡是随按随起的，也只是虚无之气，速度才这么快，所以辨别应当如此。凡是想要辨别水气不同的，关键在于辨别阴阳。如果病在气分，那么阳证阴证都有；如果病在水分，则多为阴证。为什么呢？水和气虽然是同类，但阳气旺盛则气化正常，水就变成了精微物质；阳气衰弱则气化不行，精微物质就变成了水湿。所以凡是患水病的，原本就是体内的血气，但其成为邪气还是正气，全在于气化与否。水不能气化，是因为气虚，难道不是阴中没有阳吗？这就是水肿病多属于阳虚的原因。然而水主于肾，气主于肺，水湿浸渍于下，而肺气竭绝于上，所以下部肿满，上部喘息急促，标本俱病，危险到了极点。这应当迅速救补本源，或许能保住一线生机，如果把虚喘当作实邪，仍然使用泻肺的方法，没有不失败的。（张景岳）
肿的根本在于水，胀的根本在于气。肿分为阳水和阴水，外来邪气导致的为有余，即为阳水；内部产生的为不足，即为阴水。至于胀病的成因更多，胀的部位各异，或因湿、因郁、因寒、因热、因气、因血、因痰、因积、因虫，都可以导致胀。无论是在脏腑、脉络、皮肤，还是在身体的上下表里，都能产生胀。甚至起初因寒，久郁化为热，或者起初是热中，最后传变为寒中。而且胀不一定兼有肿，但肿则必然兼有胀，也有肿胀同时并发的，病情变幻不一。有湿在下方的，用分利法；有湿在上中下三焦的，用分消法；有湿邪着里者，用五苓散通达膀胱；有湿郁兼热者，用半夏泻心汤，苦辛通降；有湿热气郁积者，用鸡金散，消导与利水并行；有气血郁积，夹杂湿热邪气，久留不散者，用小温中丸清理相火，健运中州；有湿热与水寒之气交横，气喘尿少，全身肿胀者，用禹余粮丸，崇土制水，暖下泻浊；有寒湿在气分，则用干姜、附子；有寒湿入血分，则用桂枝、附子；有湿邪向上甚而为热，则用麻黄、杏仁、石膏、薏苡仁，清肃上焦之气；有湿邪向下着而为痹，则用加味活络丹，宣通下焦之郁。有用薤白、瓜蒌的，是为了滑润气机的痹结于腹胁；有用制何首乌、当归尾的，是为了搜逐经络隧道中凝涩的血沫；有用玉壶丸、控涎丹、神佑丸、神芎丸的，是根据痰饮水积的轻重来驱除它们。这些都是病邪未损伤脏气，仅仅在腑的上下、膜的表里。如果有胃阳虚的，人参、茯苓必须进用；脾阳衰的，白术、附子必须投用；更有伤及肾脏的，则需要加减八味丸、济生肾气丸等。○夏季湿热郁蒸，脾胃气弱，水谷之气不运化，湿邪内蕴化为热，逐渐导致浮肿腹胀，小便不利。治疗不当，水湿久渍，逆行犯肺，必然产生咳嗽喘促，甚至坐不得卧，俯不能仰，危期速至。大凡喘必生胀，胀必生喘，方书认为先喘后胀的病在肺，先胀后喘的病在脾。《金匮要略》有风水、皮水、石水、正水、黄汗，以此区分表里治法。河间刘完素有三焦分消法，张子和有磨积逐水法，都有深奥的意义。世俗论述水湿喘胀之证，认为开鬼门取汗是表治，分利小便洁净府是里治。又认为诸湿肿满皆属于脾，用健脾燥湿是稳妥治法，但治疗无效，技穷束手。不知道凡是病都本乎阴阳，通表利小便，是宣通经气，利通腑气，这是阳病治法。暖水脏，温脾肾，补阳以驱水，这是阴病治法。治肺用轻清开上，治脾必佐温通，如果阴阳表里乖违，脏真日渐流失，阴阳不运，也必然作胀。治疗以通阳，才能奏效，比如《局方》禹余粮丸。甚至三焦交阻，必须用分消法，肠胃窒塞，必须用下夺法，但不能与伤寒实热同例，擅自投用硝石、大黄、枳实、厚朴，扰动阴血。如果是太阴脾脏，饮湿阻气，温补不应，想用下法，少量甘遂做成丸药服用也可以。（《临证指南》）
水肿和鼓胀，都是因为脾虚所致。但是水肿轻而鼓胀重的，为什么呢？因为水肿患者饮食如常，鼓胀患者饮食不及平常。治疗水肿只需补脾导水即可，治疗鼓胀则要补脾导水，兼以消谷，才可以。（冯楚瞻）
胀满的病，常常见到使用克伐药物损伤脾肾，导致证候变为泄泻喘促而无法救治。往往使用《金匮要略》的肾气丸，转危为安，妙在桂枝、附子补脾之母（火生土）。张三锡加入人参、白术，救人无数。（薛立斋）
中满的病，原于肾中火气虚，不能行水，宜用八味丸以补肾中之火，这样三焦有所禀受，肾气不虚就能行水了。如果是纯脾虚的证候，既然以参苓四君子汤为主，也必须用八味丸兼补命门之火。因为脾土非命门之火不能生化，这是“虚则补母”的道理。又有一类纯是阴虚，三焦冲脉之火一同逆而上行，水从火溢，上积于肺而咳嗽，严重时喘息不能平卧，散聚于阴络而肿胀，随着五脏的虚弱，进入而聚积就成为胀。这都是相火泛溢其水而生病，用六味地黄汤加麦冬、五味子，服用有效。（赵养葵）
肿满有寒水侮土的，其肿必先从头面四肢起，然后波及腹部，此证可以用补中益气汤，吞服《金匮要略》加减肾气丸。但应当早期治疗，不然水势冲决，土崩岸败，就无济于事了。（《己任编》）
【水肿】
老师说：病有风水，有皮水，有正水，有石水，有黄汗。○风水，脉象自浮，外证骨节疼痛，恶风。○皮水，脉象也浮，外证浮肿，按之没指，不恶风，腹部如鼓，不渴，应当发汗。○正水，脉象沉迟，外证自喘。○石水，脉象自沉，外证腹满，不喘。○黄汗，脉象沉迟，身体发热，胸满，四肢头面肿，久不愈，必然导致痈脓。○心水，身体沉重而气短，不能平卧，心烦而躁动，其人外阴肿胀。○肝水，腹部大，不能自行翻身，胁下腹痛，时时津液微生，小便断续通畅。○肺水，身体肿，小便难，时时鸭溏（稀便）。○脾水，腹部大，四肢苦重，津液不生，只苦于气短，小便难。○肾水，腹部大，脐肿，腰痛，不能排尿，外阴潮湿像牛鼻上的汗，双脚逆冷，反而消瘦。○凡是患有水病的，腰以下肿，当利小便；腰以上肿，当发汗，这样才能痊愈。○有人问：病有血分、水分，是什么道理？老师说：月经先停止，后生病水，名叫血分，此病难治。先生病水，后月经停止，名叫水分，此病易治。为什么？去除了水邪，月经自然下行。○风水，脉浮身重，汗出恶风的，防己黄芪汤主治。○风水，恶风，全身悉肿，脉浮，不渴，持续自汗出，无大热的，越婢汤主治。○皮水为病，四肢肿，水气在皮肤中，四肢微微跳动的，防己茯苓汤主治。○里水，越婢加术汤主治，甘草麻黄汤也主治。○有人问：黄汗这个病，身体肿，发热，汗出而渴，状如风水，汗沾衣，颜色正黄，像汁液，脉象自沉，是怎么得的？老师说：因为出汗时进入水中洗澡，水从汗孔进入而得病，宜芍药桂枝酒汤主治。（《金匮要略》）
按语：其中“其人阴肿”四字，应当在肾水条内，此处是错简，应当移过去。○“面反瘦”之下，应当补上条“其人阴肿”四字。○里水的“里”字，应当是“皮”字。哪有里水而用麻黄的道理？应当改正。（《医宗金鉴》）
风肿，皮肤粗糙，麻木不仁，走注疼痛。气肿，皮肤增厚，四肢瘦削，腹胁胀膨。血肿，皮肤间有血丝赤痕。妇人怀孕，有气遏水道而肿的，饮食无阻，生产后自消，所谓子肿。（朱丹溪）
皮肤增厚色苍，四肢削瘦，胸腹痞满，自上而下发展的，多属气。皮肤薄嫩，肿有分界，自下而上发展的，多属水。另外按之不成凹且即起的，是气；按之成凹且不即起的，是湿。（《医学入门》）
按：水肿有因痰阻、食积、血瘀，致清不升，浊不降而成的；有因湿热相生，隧道阻塞而成的；有因燥热冲激，秘结不通而成的，证属有余。有因服寒凉伤饮食，中气虚衰而成的；有大病后，正气衰惫而成的；有小便不利，水液妄行，脾莫能制而成的，证属不足。应当分别治疗。（《医方集解》）
《内经》说：热胜则肿，是因为四肢为诸阳之本，阳结于外，不得行于阴，则邪热郁于四肢，所以为肿。况且邪在六腑，则阳脉不和，阳脉不和，则气留之，以其气留，所以为肿。（《圣济总录》）
[Scriptural Meaning]
The Yellow Emperor asked: There are cases where the disease does not originate from the hair follicles, but rather the Yang Qi of the Five Zang organs has already been exhausted. Body fluids fill the chest and abdomen, Yin essence resides alone within, while Jing (essence) is depleted inside and Qi dissipates outside. The body becomes so emaciated that it cannot even be covered by clothes. This presents with stiffness in the four extremities accompanied by internal symptoms. This indicates that Qi is blocked internally, while the physical form deteriorates externally. How should this be treated? Qibo replied: One should balance the Yin and Yang through weighing and measuring, remove the accumulated stale matter within, gently move the four extremities, keep warm, apply Miao acupuncture at the affected sites to restore the physical form. Open the "Ghost Gates" (sweat pores) to induce sweating, and purify the "Clean House" (bladder) to promote urination, allowing Jing to be distributed in due course. When the Yang Qi of the Five Zang organs is distributed, and the five organs are dredged and cleansed, Jing will naturally generate, the physical form will naturally prosper, bones and flesh will protect each other, and the Great Qi will become peaceful. ○ The Kidney belongs to Supreme Yin; Supreme Yin tends to accumulate water. The Lung belongs to Taiyin, and the Shaoyin meridian is the pulse of winter. The root of edema lies in the Kidney, while its manifestation lies in the Lung; both are caused by water accumulation. ○ Why can the Kidney accumulate water and cause disease? Because the Kidney is the gate of the Stomach. If the gate is not functioning properly, water accumulates and spreads according to the principle of similarity. ○ Water disease manifests below as edema and abdominal distension, and above as wheezing, calling out, and inability to lie flat. This is a condition where both the root and the branch are diseased. ○ Inability to lie flat, with wheezing upon lying down, is caused by the invasion of water Qi. ○ Pulsation in the neck vessels, accompanied by severe wheezing and coughing, is called water disease. Slight swelling in the inner canthus of the eye, resembling a silkworm resting, is called water disease. ○ When Yin and Yang Qi knot and slant, with excessive Yin and deficient Yang, it is called Stone Water. ○ Knotting of the Three Yin meridians is called water disease. ○ Swelling caused by Qi stagnation, with alternating dysfunction of the four seasons, leads to the exhaustion of Yang Qi. ○ Excessive Heat causes swelling. ○ All dampness-induced swelling and fullness belong to the Spleen. ○ All distension and abdominal enlargement belong to Heat. ○ Turbid Qi remaining in the upper jiao produces bloating. ○ A disease characterized by abdominal fullness, where one can eat in the morning but not in the evening, is named Drum Distension (Gu Zhang). It is treated with Ji Shi Li (Chicken Dropping Fermented Liquid); one dose brings improvement, two doses bring cure. (From *Su Wen*)
Skin distension (Fu Zhang) occurs when Cold pathogen lodges between the skin. The abdomen is distended but not hard. The whole body is swollen, the skin is thickened, pressing the abdomen leaves an indentation that does not rise immediately, and the abdominal color remains unchanged. This is its clinical presentation. ○ Drum Distension (Gu Zhang) presents with generalized enlargement equal to that of Skin Distension, with a sallow-yellow complexion and visible subcutaneous veins on the abdomen. This is its clinical presentation. ○ Deficiency of the Foot-Taiyin Spleen meridian leads to Drum Distension. ○ Excess of Spleen Qi leads to abdominal distension. ○ Heart Distension presents with vexation, shortness of breath, and restless sleep. Lung Distension presents with empty fullness, wheezing, and coughing. Liver Distension presents with fullness and pain under the hypochondrium radiating to the lower abdomen. Spleen Distension presents with frequent hiccups, irritability and heaviness in the four limbs, and a body weight so great that one cannot bear clothing. Kidney Distension presents with abdominal fullness radiating to the back, and aching pain in the waist and thighs. Stomach Distension presents with abdominal fullness, epigastric pain, olfactory hallucinations of burnt odor, difficulty eating, and constipation. Large Intestine Distension presents with borborygmus and gurgling pain; if exposed to cold again in winter, it leads to undigested stool diarrhea. Small Intestine Distension presents with lower abdominal distension radiating to the waist and causing pain. Bladder Distension presents with lower abdominal fullness and urinary retention. Sanjiao Distension presents with Qi filling the skin, feeling light but not hard. Gallbladder Distension presents with pain and distension under the hypochondrium, bitter taste in the mouth, and frequent sighing. (From *Ling Shu*)
[Philosophical Discourse]
Regarding Distension (Zhang) and Swelling (Zhong), the internal causes differ, but the external appearances are often similar. They can be distinguished as follows: If the abdomen enlarges first, followed by swelling of the four limbs, it is a Distension disease. If the head and feet swell first, followed by abdominal enlargement, it is Water disease. However, if the abdomen is large but the four limbs do not swell at all, it is a Distension disease. If the umbilicus, abdomen, and four limbs are all swollen, it is Water disease. (Shen Jin'ao)
All excess syndromes, whether caused by the Six Exogenous Pathogens or dietary injury, involve Yang pathogens which are rapid in nature. Their arrival is sudden, often forming within a few days. If it is a deficiency syndrome, whether due to emotional labor or excess in wine and sexual activity, it accumulates day by day and month by month. Its onset is gradual, often forming after several months. (Li Shicai)
Someone asked: Is there a distinction between swelling and distension? I replied: Swelling is swelling, and distension is distension. When Qi and Blood flow freely, the Zang-Fu organs are harmonious, and the collaterals are unobstructed, how can swelling occur externally? How can distension occur internally? This happens because the person's Kidney Qi is deficient, losing the power of opening and closing; Lung Qi is deficient, losing the function of clearing and descending; Spleen Qi is deficient, losing the normal state of transformation and transportation; Exterior Qi is deficient, allowing external pathogens to easily enter. Thus, swelling arises in the muscles, and distension arises in the Zang-Fu organs. Manifesting externally, one knows it is swelling, and others know it is swelling. Occurring internally, one knows it is distension, but others do not know it is distension. However, swelling and distension have many variations, and deficiency/excess patterns differ. Wind, Cold, Dampness, Heat, Water, Parasites, Blood, and Food stagnation—all these various causes must be discussed in detail to know which approach to follow. Swelling caused by external invasion of Wind-Cold is an excess syndrome, such as swelling of the face/head, parotitis (Fayi), or gums. Swelling caused by external invasion of Damp-Heat is mostly excess, but can also be deficiency, such as swelling from sores/ulcers, isolated abdominal swelling (Dan Fu), or swelling from painful obstruction (Tong Bi). As for swelling caused by Qi, Water, Parasites, or Blood, there are both excess and deficiency syndromes, such as swelling under the eyes, generalized swelling, swelling of hands/feet, shiny abdominal skin swelling, scrotal/penile swelling, and swelling with blue veins on the abdomen. Treatment methods must be determined by combining syndrome differentiation with pulse diagnosis. However, Distension and Swelling are fundamentally different. Decline of Kidney Fire and deficiency-cold of the Middle Earth (Spleen/Stomach) lead to distension due to failure of Spleen Yuan to transform. Water failing to nourish the Liver, leading to Wood stagnation and disharmony of the hypochondrium, leads to distension. Yin Fire burning Metal, causing Lung Qi stagnation, wheezing, coughing, and congestion, leads to distension. Not only that, there is also distension due to Damp-Heat in the Spleen/Stomach, fluid retention in the Middle Jiao, blood stasis in the Middle Jiao, parasite accumulation in the intestines/stomach, Qi stagnation and food obstruction in the Yangming, and blockage of urination/defecation in the lower abdomen causing distension. External Wind does not cause distension diseases, but distension diseases are not uniform. Generally speaking, Swelling has form, while Distension is formless; Distension is the beginning of Swelling, mostly caused by internal injury; Swelling is the severity of Distension, rarely associated with external contraction. Internal injuries present with both distension and swelling; external contractions present with swelling but no distension. If physicians can clearly distinguish external swelling from internal distension, confirming them accurately, then swelling will be recognized as swelling, and distension as distension, bringing clarity to the mind! (*Huixin Lu*)
Swelling and distension involving the Qi level are due to Qi stagnation. Such as reversal of Qi and Blood, dietary reversal, interference of Cold/Heat/Wind/Dampness, and reversal due to Qi deficiency failing to transform. As long as the regulatory function fails, all stem from the Qi level and can cause distension. For diseases of the Qi level, the complexion is sallow, the interior is firm, distension may extend to the chest and hypochondrium, pain may affect the Zang-Fu, or sudden edema may occur; this is Yang nature, rapid in movement. Or developing from top to bottom, because Yang originates from above. Or generalized swelling throughout the body, because Qi reaches everywhere. Some rebound immediately upon pressure, like pressing an air bag. Although all these belong to the Qi level, Qi diseases vary: There is distension due to Qi Heat, i.e., "All distension and abdominal enlargement belong to Heat." There is distension due to Qi Cold, i.e., "Cold in the Stomach causes distension," "Cold in the Zang generates fullness diseases." There is distension due to Qi Dampness, i.e., "All dampness-induced swelling and fullness belong to the Spleen." There is distension due to Qi Deficiency, which is Yuan Qi deficiency, i.e., "Deficiency of Foot-Taiyin leads to Drum Distension." There is distension due to Qi Excess, which is Pathogenic Excess, i.e., "Excess of Kidney Qi causes distension," "Excess of Spleen Qi causes abdominal distension," "Excess of Stomach Qi causes distension." Although all these are distension diseases, the key to treatment lies entirely in distinguishing deficiency and excess. Generally, Yang syndromes are mostly Heat, and Heat syndromes are mostly Excess; Yin syndromes are mostly Cold, and Cold syndromes are mostly Deficiency. Distension starting internally and then affecting the exterior is mostly Excess; swelling starting externally and gradually affecting the interior, or external swelling without internal distension, is mostly Deficiency. Red urine and constipation indicate Excess; clear urine and loose stools indicate Deficiency. Slippery and forceful pulses indicate Excess; wiry, floating, faint, and fine pulses indicate Deficiency. Red-yellow complexion and coarse breathing indicate Excess; emaciated appearance and short voice indicate Deficiency. Youth and vigor with obstructed Qi pathways indicate Excess; middle-age decline with chronic fatigue, mental fatigue, and timid Qi indicate Deficiency. The treatments for deficiency and excess are as opposite as ice and charcoal; misuse will surely cause harm. ○ Diseases in the Water level are due to Yin surpassing Yang. The skin and muscles are all swollen. This is fundamentally different from Qi syndromes. For Water diseases, the complexion is bright and moist, the skin is thin and glossy, the swelling develops slowly, usually rising from below, pressing the flesh feels like mud, and the swelling has distinct boundaries. Because Yin originates from below, and infiltration is gradual, these are all signs of Water disease. Observing the *Water Distension Chapter*, it says that distension from Cold Qi shows indentation upon pressing that does not rise; whereas Edema shows immediate rebound upon pressing, like a bag wrapping water. However, based on my observations and clinical verification, this contradicts that theory. In fact, for all Water syndromes, pressing causes indentation that does not rise immediately. This is because the water is in the flesh, like dregs or mud; pressing disperses it, and it cannot gather quickly, unlike a water bag. Cases that rebound immediately upon pressing are due to void Qi, which moves fast. Therefore, differentiation must be done thus. To distinguish differences in Water Qi, one must differentiate Yin and Yang. If the disease is in the Qi level, both Yang and Yin syndromes exist; if in the Water level, it is mostly Yin syndromes. Why? Although Water and Qi are of the same category, when Yang is vigorous, Qi transforms, and Water becomes Essence; when Yang declines, Qi fails to transform, and Essence becomes Water. Therefore, all Water diseases originate from the body's own Qi and Blood, but whether they become pathogenic or healthy depends on transformation. Failure of Water transformation is due to Qi deficiency; is this not Yin lacking Yang? This is why Edema diseases mostly belong to Yang Deficiency. However, Water is governed by the Kidney, and Qi by the Lung. Water soaking below while Qi exhausts above results in lower swelling/fullness and upper wheezing/urgency, affecting both root and branch, which is extremely critical. One must urgently rescue the origin to preserve life. If one mistakes deficiency wheezing for excess pathogen and still uses Lung-draining methods, failure is inevitable. (Zhang Jingyue)
Swelling stems from Water, and Distension stems from Qi. Swelling is divided into Yang Water and Yin Water. External origin implies surplus, hence Yang Water; internal origin implies insufficiency, hence Yin Water. The causes of Distension are more numerous, and the locations of distension vary. It can be caused by Dampness, Stagnation, Cold, Heat, Qi, Blood, Phlegm, Accumulation, or Parasites, all capable of causing distension. Whether in Zang-Fu, collaterals, skin, or anywhere in the body's upper/lower or interior/exterior, distension can occur. Furthermore, it may start as Cold and become Heat due to long-term stagnation, or start as Heat in the interior and transmit to Cold in the interior. Distension need not accompany swelling, but swelling must accompany distension. There are also cases where swelling and distension occur simultaneously, with变幻 (changing) manifestations. For Dampness below, use separation and drainage; for Dampness in Upper/Middle/Lower Jiao, use separation and elimination; for Dampness adhering to the interior, use Wu Ling San to unblock the Bladder; for Damp-Stagnation with Heat, use Ban Xia Xie Xin Tang for bitter-pungent descending; for Damp-Heat Qi-Blood stagnation accumulating, use Ji Jin San for simultaneous digestion and diuresis; for Qi-Blood stagnation with lingering Damp-Heat, use Xiao Wen Zhong Wan to clear Minister Fire and strengthen the Middle Jiao; for intermingled Damp-Heat and Cold-Water Qi with wheezing and oliguria and generalized swelling, use Yu Yu Liang Wan to fortify Earth to control Water, warm the Lower Jiao, and drain turbidity; for Cold-Damp in the Qi level, use Ginger and Aconite; for Cold-Damp entering the Blood level, use Cinnamon and Aconite; for Dampness rising excessively causing Heat, use Ephedra, Apricot Kernel, Gypsum, and Coix Seed to clear and肃ify the Upper Jiao; for Dampness sinking causing Bi syndrome, use Modified Huo Luo Dan to vent the Lower Jiao stagnation. Use Scallion White and Trichosanthes Fruit to lubricate Qi obstruction in the abdomen/hypochondrium; use Processed Polygonum Multiflorum and Angelica Sinensis Tail to search out and expel coagulated blood in the meridians; use Yu Hu Wan, Kong Xian Dan, Shen You Wan, and Shen Xiong Wan to drive out Phlegm-Fluid-Accumulation according to severity. These are conditions where Zang Qi is not yet damaged, located only in the Fu organs' upper/lower or membranes' exterior/interior. If Stomach Yang is deficient, Ginseng and Poria must be advanced; if Spleen Yang declines, Atractylodes and Aconite must be administered; if the Kidney is injured, Jia Jian Ba Wei Wan or Jisheng Wan are needed. ○ In summer, Damp-Heat steams and郁蒸s, Spleen-Stomach Qi weakens, Grain-Water Qi fails to transform, Dampness accumulates internally turning to Heat, gradually leading to edema and abdominal distension with difficult urination. Improper treatment allows Water-Dampness to soak for long, reverse attack the Lung, causing cough and wheezing, potentially progressing to orthopnea and inability to bend/extend, indicating imminent danger. Generally, wheezing generates distension, and distension generates wheezing. Formulas state that wheezing preceding distension treats the Lung, while distension preceding wheezing treats the Spleen. *Jin Gui Yao Lue* distinguishes Wind Water, Skin Water, Stone Water, Correct Water, and Yellow Sweat to differentiate exterior/interior treatments. Hejian Liu Wan Su proposed Triple Burner separation; Zihe Zhang proposed grinding accumulation and draining water; both have profound meanings. Secular discussions on Water-Dampness Wheezing-Distension claim opening Ghost Gates (sweating) is exterior treatment, and separating/draining urine (purifying Clean House) is interior treatment. Also claiming "All dampness swelling/fullness belongs to Spleen," using Spleen-fortifying and Damp-drying as a stable treatment, often yields no effect, leaving physicians helpless. They do not know that all diseases stem from Yin-Yang. Unblocking exterior and promoting urination vents Meridian Qi and Fu Qi, which is the treatment for Yang diseases. Warming the Water Organ, warming Spleen/Kidney, tonifying Yang to drive Water, is the treatment for Yin diseases. Treating the Lung requires light/clear agents to open the upper; treating the Spleen must assist with warming/unblocking. If Yin-Yang and Interior-Exterior are discordant, and Zhen Qi daily depletes, Yin-Yang fails to transport, leading to distension. Treatment with Yang-unblocking can achieve results, such as Yu Yu Liang Wan from *Ju Fang*. Even with Triple Burner obstruction, separation is necessary; with intestinal blockage, purgation is necessary. But do not equate this with Excess-Heat in Cold Damage; arbitrarily administering Nitre, Rhubarb, Immature Bitter Orange, and Magnolia Bark disturbs Yin Blood. If it is Taiyin Spleen organ with Fluid-Damp obstructing Qi, and warming/tonifying fails, attempting purgation, small doses of Kansui pills may be used. (*Lin Zheng Zhi Nan*)
Edema and Drum Distension are both caused by Spleen Deficiency. But why is Edema mild while Drum Distension is severe? Because Edema patients eat normally, whereas Drum Distension patients eat less than usual. Treating Edema requires only Spleen-tonifying and Water-guiding. Treating Drum Distension requires Spleen-tonifying, Water-guiding, plus Grain-digesting, to be effective. (Feng Chuzhan)
In treating Distension-Fullness, clinicians often use attacking drugs that damage Spleen and Kidney, leading to irreversible diarrhea and wheezing. Often, using *Jin Gui* Shen Qi Wan turns danger to safety. The妙 (wonder) lies in Cinnamon Twig and Aconite tonifying the Mother of the Spleen (Fire generates Earth). Zhang Sanxi added Ginseng and Atractylodes, saving many lives. (Xue Lizhai)
Middle Fullness originates from deficiency of Fire-Qi in the Kidney, failing to move Water. Use Ba Wei Wan to tonify Kidney Fire, so the Sanjiao receives endowment, Kidney Qi becomes sufficient, and Water moves. If it is purely Spleen Deficiency, although using Shen Ling Si Jun Tang as the main formula, one must also use Ba Wei Wan to tonify Mingmen Fire together. Because Spleen Earth cannot be generated without Mingmen Fire, this is the meaning of "Tonifying the Mother when Deficient." Another type is pure Yin Deficiency, where Fire of the Sanjiao and Chong Mai rebels upward, Water overflows from Fire, accumulates in the Lung causing cough, or severe wheezing/orthopnea, scatters in Yin Collaterals causing swelling, and enters/pools according to Zang deficiency causing distension. All are diseases caused by Minister Fire overflowing Water. Use Liu Wei Tang plus Ophiopogon and Schisandra, which is effective. (Zhao Yangkui)
Swelling-Fullness due to Cold Water insulting Earth starts with swelling of the head, face, and four limbs, then affects the abdomen. This syndrome can be treated with Bu Zhong Yi Qi Tang, swallowing *Jin Gui* Jia Jian Shen Qi Wan. However, treat it early; otherwise, Water forces breach, Earth collapses, and it is useless. (*Ji Ren Bian*)
[Edema]
The Master said: Diseases include Wind Water, Skin Water, Correct Water, Stone Water, and Yellow Sweat. ○ Wind Water: Pulse is floating; exterior signs include bone/joint pain and aversion to wind. ○ Skin Water: Pulse is also floating; exterior signs include edema, pitting upon pressure, no aversion to wind, drum-like abdomen, no thirst; should induce sweating. ○ Correct Water: Pulse is deep and slow; exterior sign is spontaneous wheezing. ○ Stone Water: Pulse is self-deep; exterior sign is abdominal fullness, no wheezing. ○ Yellow Sweat: Pulse is deep and slow, body fever, chest fullness, swelling of four limbs/head/face; if prolonged, leads to abscess/pus. ○ Heart Water: Body heavy, shortness of breath, inability to lie flat, vexation/restlessness, genital swelling. ○ Liver Water: Abdominal enlargement, inability to turn over independently, hypogastric pain, occasional slight saliva production, intermittent urination. ○ Lung Water: Body swelling, difficult urination, frequent loose stools. ○ Spleen Water: Abdominal enlargement, heavy limbs, lack of saliva generation, shortness of breath, difficult urination. ○ Kidney Water: Abdominal enlargement, umbilical swelling, lower back pain, inability to urinate, genital moisture like sweat on a cow's nose, cold feet, yet emaciation. ○ For all Water diseases: Swelling below the waist requires promoting urination; swelling above the waist requires inducing sweating, then recovery. ○ Question: What are Blood Level and Water Level diseases? Master said: Menstruation stops first, then Water disease occurs, named Blood Level; this is difficult to treat. Water disease occurs first, then menstruation stops, named Water Level; this is easy to treat. Why? Remove the Water, and menstruation returns naturally. ○ Wind Water, pulse floating, body heavy, sweating, aversion to wind: Fang Ji Huang Qi Tang governs. ○ Wind Water, aversion to wind, whole body swelling, pulse floating, no thirst, continuous spontaneous sweating, no high fever: Yue Bi Tang governs. ○ Skin Water disease, four limbs swelling, Water Qi in skin, four limbs twitching: Fang Ji Fu Ling Tang governs. ○ Interior Water: Yue Bi Jia Zhu Tang governs; Gan Cao Ma Huang Tang also governs. ○ Question: Yellow Sweat disease, body swelling, fever, sweating with thirst, resembling Wind Water, sweat stains clothes yellow like juice, pulse self-deep. How is it acquired? Master said: Bathing in water while sweating, Water enters through sweat pores. Yi Shao Yao Gui Zhi Jiu Tang governs. (*Jin Gui Yao Lue*)
Commentary: The phrase "person's genital swelling" should be in the Kidney Water section; this is a misplaced slip, should be moved. ○ Below "face appears emaciated," the phrase "person's genital swelling" from the previous section should be added. ○ The character "Interior" in Interior Water should be "Skin." How could Interior Water use Ephedra? Should be corrected. (*Yi Zong Jin Jian*)
Wind Swelling: Rough skin, numbness/anesthesia, migrating pain. Qi Swelling: Thick skin, emaciated limbs, distended abdomen/hypochondrium. Blood Swelling: Red streaks/blood threads in the skin. Pregnant women may have Qi blocking Water channels causing swelling, with normal diet, resolving after delivery; this is called Zi Zhong (Fetal Swelling). (Zhu Danxi)
Thick skin, sallow color, emaciated limbs, chest/abdominal stuffiness, developing from top to bottom: Mostly Qi. Thin/tender skin, distinct swelling boundaries, developing from bottom to top: Mostly Water. Also, non-pitting and immediate rebound: Qi; pitting and slow rebound: Dampness. (*Yi Xue Ru Men*)
Commentary: Edema can be formed by Phlegm obstruction, Food accumulation, Blood stasis, causing Clear not ascending, Turbid not descending—these are Excess syndromes. Can be formed by Cold/Cooling drugs injuring diet, Middle Qi deficiency—these are Deficiency syndromes. Can be formed post-major illness with exhausted Zheng Qi—Deficiency. Can be formed by difficult urination, chaotic Water fluids, Spleen unable to control—Deficiency. Should be treated separately. (*Yi Fang Ji Jie*)
When Kidney Qi is strong, Water returns to the Kidney; when Kidney Qi is weak, Water scatters into the skin. (Hua Yuanhua)
*Classic* says: "Heat excess causes swelling." The four limbs are the root of all Yang. Yang knots externally, cannot enter Yin, so Evil Heat stagnates in the four limbs, causing swelling. Moreover, if Evil is in the Six Fu organs, Yang meridians are disharmonious; Yang meridian disharmony causes Qi stagnation; due to Qi stagnation, swelling occurs. (*Sheng Ji Zong Lu*)
Regarding the two sentences from *Nei Jing*: "Four dimensions alternate, Yang Qi is exhausted." Wang Bing (Wu Taipu)注释: Four dimensions refer to Flesh, Blood, Sinew, Bone. Wu Hegao注释: Four dimensions refer to Blood Vessels, Sinew, Bone. Taking this as...