四者，维持一身，以注维字之义。马元台以血脉筋骨四字未妥，因注四维为四肢。汪 庵以王、马二注，俱于
代字无着，因注四维为四时。诸说不一，窃思四维之见素问者屡矣，《气交变大论》曰∶岁土不及，四维有埃
云润泽之化。《五常政大论》曰∶其眚四维。故王注以四维为东南、西南、东北、西北之位，马元台、吴鹤皋
注此二篇之四维，亦俱宗王注四隅方位，而说是四维当作四隅解。四维相代，当作人身之四隅解。盖言肿之起
于前、后、左、右者，自此至彼，一身尽肿，阳气乃坏极而无存矣。四隅尽肿者，即脐突，背平，缺盆平，足
心平之类。丹溪以此二句为衍文，此求其说，而不得从而为之辞，亦不知为不知之义也。（《吴医汇讲》）
病机之切于人身者，水火而已矣。水流湿，火就燥，水柔弱，火猛烈，水泛溢于表里，火游行于三焦，
拯溺救焚，可无具以应之乎？《经》谓二阳结，谓之消。三阴结，谓之水。三阴者，手足太阴脾肺二脏也。胃
为水谷之海，水病莫不本之于胃，《经》乃以属之脾肺者何耶？使足太阴脾足以转输水精于上，手太阴肺足以
通调水道于下，海不扬波矣。惟脾、肺二脏之气，结而不行，后乃胃中之水日蓄，浸灌表里，无所不到也，是
则脾、肺之权，可不伸耶？然其权尤重于肾，肾者胃之关也，肾司开阖，肾气从阳则开，阳太盛则关门大开，
水直下而为消。肾气从阴则阖，阴太盛则关门常阖，水不通而为肿。《经》又以肾本肺标，相输俱受为言，然
则水病以脾肺肾为三纲矣。于中节目，尤难辨晰。《金匮》分五水之名，及五脏表里主病，彻底言之，后世漫
不加察，其治水辄宗霸术，不能行所无事，可谓智乎！然水在心之部，则
郁心火炳明之化；水在肝之部，则郁肝木发生之化；水在肺之部，则孤阳竭于外，其魄独居；水在脾之部，则
阴竭于内，而谷精不布；水在肾之部，不但诸阳退伏，即从阳之阴，亦且退伏，孤阴独居于下而隔绝也。故胃
中之水，惟恐其有火，有火乃属消渴，末传中满之不救。肾中之水，惟恐其无火，无火则真阳灭没，而生气内
绝。其在心之水，遏抑君火，若得脾土健运，子必救母，即在肝在肺在肾之水，脾土一旺，水有所制，犹不敢
于横发。夫水土平成以神禹为师，医门欲平水土，不师仲景而谁师乎？○胃本水谷之海，五脏六腑之大源。脾不
能散胃之水精于肺，而病于中；肺不能通调胃之水道于膀胱，而病于上；肾不能司胃之关门时其输泄，而病于
下，所以胃中积水，浸淫无所底止耳。仲景论水气一门，极其精详，惟恐足太阴脾之健运失职，手太阴肺之治
节不行，足少阴肾之关门不开，并其腑膀胱之气化不行，所用方药，皆不蹈重虚之戒，立于无过之地。海藏集
仲景治肺痈葶苈大枣泻肺汤为例，是欲以泻肺之法，为泻水之法矣。集仲景治伤寒痞连两胁，杂证支饮在胁之
十枣汤为例，是欲以泻胸胁及膀胱，为泻水之法矣。何其敢于操刃，而借口仲景耶？后来依样葫芦，不伤脾，
即泻肺；不泻肺，即泻膀胱，乃致积水滔天，载胥及溺。水病门中，成方百道，求一救肺气之 郁，而伸其治
节之方，无有也。求一救膀胱阻绝，而伸其气化之方，无有也。○凡禽兽之类，有肺者有尿，无肺者无尿，故水
道不利，而成肿满，以清肺为急。此义前人阐发不到，后之以五苓、五皮、八正等方治水者，总之未悟此旨。
至于车水放塘，种种劫夺膀胱之剂，则杀人之事矣。（喻嘉言）
水肿乃脾、肺、肾三脏之病。盖水为至阴，故其本在脾肾，水化于气，故其标在肺，水惟畏土，故其制在
脾。今肺虚，则气不化精而化水；脾虚，则土不制水而反克；肾虚，则水无所主而妄行，水不归经，则逆而上
泛，故传入于脾，则肌肉浮肿，传入于
肺，则气息喘急。分而言之，三脏各有所主，合而言之，则总由阴胜之害，而病本皆归于肾。肾为胃关，关门
不利，故聚水而从其类也。然关门何以不利也？《经》曰∶膀胱者，州都之官，津液藏焉，气化则能出矣。夫
所谓气化者，即肾中之气也，即阴中之火也。阴中无阳，则气不能化，所以水道不通，溢而为肿。故凡治肿者，
必先治水，治水者，必先治气。若气不能化，则水必不利。惟下焦之真气得行，始能传化，惟下焦之真水得位，
始能厘清，求古治法，惟加减肾气汤，诚对证之方也。（张景岳）
人之脏腑，以脾胃为主。盖人之饮食，皆入于胃，而运以脾，犹地之土也。然脾胃能化物与否，实由于水、
火二气，非脾土所能也。火盛则脾胃燥，水盛则脾胃湿，皆不能化物，乃生诸病。水肿之证，盖水盛而火不能
化也，火衰则不能化水，故水入于脾胃，皆渗入血脉骨肉，血亦化水，发为肿胀，皆自然之理也。先导其水，
使水气少减，后补其火，使二气平和，斯病去矣。丹溪谓脾失运化，由肝木侮脾，乃欲清心经之火，使肺金得
令，以制肝木，则脾土全运化之职，水自顺道，乃不为肿，其词迂而不切。（何伯斋）
按刘河间以水肿为湿热，谓在表有热宜汗，在里有热宜下，开鬼门，洁净府，盖言有余之证然也。丹溪以
脾虚不能制水，治当补中行湿利小便，盖言不足之证然也。若夫滋肾制火之说，愚切以为未当。盖补肾之药，
乃阴滞柔润，适足以滋其湿耳。今治此证，但脾虚受湿，为不足所致者，宜燥脾土，兼利小便。若非气郁、饮
食、湿热所致者，禁不得妄下，临时快利，水气复来，而无以治之也。（刘宗浓）
《经》云∶诸水，身半以下肿者，当利小便；身半以上肿者，当发汗。身半以上，天气主之，身半以下，
地气主之。天气主之者，其在皮也，其在皮者，故汗而发之。问曰∶肌肉之外，皮肤之里，首足一身皆肿者，
当作何治？答曰∶亦宜汗之也，与身半
以上同法。肺心以上俱宜汗，中州以下皆宜下，如小便利而渴，则不宜汗，不宜下，以其重亡津液故也。（王好古）
治水之法，行其所无事，随表里寒热上下，因其势而利导之，故宜汗、宜下、宜渗、宜清、宜温、宜燥，
六者之中，变化莫拘。○身有热者可汗，身无热者可利，肌肤痛者可汗，溺赤涩者可利，腰上肿者可汗，腰下
肿者可利，所谓开鬼门，洁净府，上下分消之法也。（《证治汇补》）
开鬼门，麻黄、羌活、防风、柴胡、葱白之属；洁净府，泽泻、木通、通草、防己、葶苈、猪茯苓之属；
去菀陈 ，商陆、大戟、甘遂、芫花、牵牛之属；宣布五阳，桂、附、干、姜、吴茱萸之属；血肿，珀琥、郁
金、刘寄奴、苏木之属。（《张氏医通》）
水病，其人必真火衰微，不能化生脾土。故水无所摄，泛溢于肌肉间，治惟助脾益火。而助脾益火之剂，
最妙是五苓散，肉桂以益火，火暖则水自流；白术以补土，土实则水自障；二苓、泽泻以引水，则水自渗泄，
无不应手而愈。（孙庆曾）
治水，用柴胡、泽泻，一升一降，厘清水道，则水无不下矣。（徐春圃）
肾主水，水有真水，有客水，肾气温，则客水亦摄而归真；肾气寒，则真水亦汛而为客水。客寒必搏之，
真武汤从土中殖火，使真水从温处镇摄，客水自化而归真，何必行导渗之令？（程郊倩）
肺热，则失其下降之令，以致水溢高原，淫于皮肤而为肿。医罕明乎此，实脾导水，皆不能愈。故用麦冬
清肺，开其下降之源。粳米益脾，培乎生金之母，治病必求其本也。（吴鹤皋）
热燥伤肺而为肿者，乃绝水之源也，当清肺除燥，而水自生，栀豉汤加黄芩。若热在下焦，阴消阳气不得
化者，当益其阴，则阳气自化，黄柏、知母是也。（《保命集》）
大病后浮肿，此系脾虚，宜六君子汤。小便不利，间进五苓
散。脾肺虚弱，不能通调水道者，宜补中益气汤。（周慎斋）
有一身之间，惟面与脚浮肿，早则面甚，晚则脚甚。《经》云∶面肿为风，脚肿为水，乃风湿所致也。然
病后元气未复者，每多见此证，盖由本气不固，故日中行坐，则气坠而晚脚肿，夜间睡卧，则气升而早面浮。
若概作风湿治，益虚其虚矣。（冯楚瞻）
凡患水肿须忌盐，毫末不得入口。若无以为味，以醋少许调饮食，不能忌盐，服药无效。（《得效方》）
鼓胀
心胀烦心，肝胀胁痛，脾胀呕哕，肺胀喘嗽，肾胀腰痛，胆胀口苦，胃胀脘痛，大肠胀肠鸣飧泻，小肠胀
少腹引腰痛，膀胱胀小便癃闭，三焦胀气满皮肤。（《医学入门》）
气胀者，七情郁结，胸腹满闷；食胀者，谷食不化，痞满恶心；虫胀者，腹痛能食，喜吃茶叶泥土；积胀
者，痞块有形，心腹坚硬；水胀者，停饮肠鸣，怔忡喘息；瘀胀者，跌仆，产后大便黑色；虚胀者，腹软任按，
食入倒饱。更有单腹胀者，腹大肢瘦，此自胀满既久，气血结聚，不能释散，俗名曰蛊，其病更重。（《证治汇补》）
凡治是病，必须会通圣经诸条之旨，然后能识脏腑之部分形证，邪气之所自来。纵是通腹胀满，卒难究竟
者，亦必有胀甚之部，与病先起处，即可知属何脏腑之气受邪而不行者为先，而后及乎中焦气交之分，于是转
运不前，壅聚通腹胀满也。若脾胃受邪，便先是胃脘心下痞气起，渐积为通腹胀也。腹属脾，属脾者，则饮
食少，属他脏腑者，则饮食如常，此可验也。又须分其表里浅深，胀在皮肤孙络之间者，饮食亦如常。胀在肠
胃肓膜之间者，则饮食减少，其气壅塞于五脏，则气促急不食而病危矣。是故病在表者易治，入腑者难治，入
脏者不治。更要分别寒热逆实，其脏腑之气本盛，被邪气填塞不行者为实；脏腑之气本不足，因邪气所壅者为
虚。实者祛之，虚者补之，寒者热之，热者寒之，结
者散之，留者行之。邪从外入内而盛于中者，先治其外，而后调其内。阴从下逆上而盛于中者，先抑之而后调
其中。阳从上降下而盛于中者，先举之亦调其中，使阴阳各归其部。故《内经》治法，谓平治权衡，去菀陈 ，
开鬼门，洁净府，宣布五阳，巨气乃平，此之谓也。俗工不明其道，专守下之则胀已一法，虽得少宽一时，然
真气因泻而脱，邪气必复聚成胀，遂致不救，可胜叹哉！（《证治准绳》）
鼓证者，中空外急似鼓，故曰鼓。单复胀满，四肢百体，咸无肿形，与通身水肿不类。盖水肿者，邪气
协阳气游行一身，邪气去而为汗、为溺，则正气复而为血、为气矣。鼓证，则邪毒专攻脏腑，阳气滞而不行，
盖肿轻而胀重也。或曰∶鼓证一也，何东垣之论主寒，河间之论主火，丹溪之论主脾虚，道岂二乎？予曰∶皆
是也，其原皆出《内经》，但经文会其全，三子各言其一也。《经》曰∶三阴结，谓之水。又曰∶脏寒生满病。
又曰∶腹满 胀，支鬲 胁。下厥上冒，过在足太阴阳明。初乃寒湿郁遏，久则阳气渐衰，阴气独盛。人身之
气，热则流通，寒则凝结。凝结则胀满生焉。故东垣以辛热散之，苦温泄之，淡渗利之，上下分消，此东垣之
论不可废也。《经》曰∶诸腹胀大，皆属于热。故《原病式》云∶诸腹胀大，鼓之如鼓，气为阳，阳为热，气
盛则如是也。世言脾虚不能制水，似是而实非。夫万物热盛则丰隆，寒盛则敛缩，阳邪猛烈，元气从之，二阳
搏击于中，日新月盛，安得不成鼓也，此河间之论，亦不可废也。《经》曰∶诸湿肿满，皆属于脾。脾具坤静
之德，而有干健之运，苟脾土受伤，转输失职，遂成胀满。人身以脾土为本，脾不健旺，则清气不升，浊气不
降，浊气在上，则生 胀，此鼓证之所由来也。若中无阳邪，宜行大补，所谓气虚不补，气何由行？又清肺金，
滋肾水，制肝养脾，皆至理攸寓，此丹溪之论，又不可废也。虽然，三子之论，固合经旨，抑有说焉。东垣言鼓
证属寒者多，属热者少。予谓鼓
证属热者多，属寒者少。东南之人，湿热为病，十居八、九，西北之地，严寒为病固多，然寒主收敛，未必能
成胀大，此以理论之，知其热多寒少也。河间之论固当，但其中有燥热，有湿热，若不区别，祸如反掌。燥热
为病，则大便闭结，小便短涩，身热腹痛，闷乱不安，一投参、 ，则胀满不数日而成，其为害也速而烈。湿
热为病，大便频溏，小便清少，脉濡体倦，嗜卧减食，其为患也缓而深。故治燥热者，清热之中少加濡润。治
湿热者，渗利之内少加温散。燥者润之，湿者燥之，各求其属，以合中道。丹溪补脾扶脾之论固确，但果饮食
所伤，频仍不已，上无痰气之阻，中无邪热之留，斯可用补？否则，有痰者兼消痰，有火者兼降火，清补兼施，
益莫大焉。此外有七情之伤脾，如怒伤肝，肝克脾，脾气不舒，必胀于胃，名曰胜克。怒乘肺，肺气不伸，必
胀于大肠，名曰乘克。又有劳倦之损脾，有所远行，形气衰少，谷气不盛，热气熏于胸中。又有血积之遏脾，
或注于胸膈，或滞于胃中，或郁于少腹，皆能抑遏，清气不升，浊气不降，俗呼血鼓者是也。鼓证重疾，每见
第四种解释，是维持全身，来阐释“维”字的含义。马元台认为用“血脉筋骨”四个字不妥当，因此将“四维”注释为四肢。汪庵认为王冰和马元台的注释，都未能落实在“代”字上，因此将“四维”注释为四季。各种说法不一，我私下思考，“四维”见于《素问》的情况屡见不鲜，《气交变大论》说：“岁土不及，四维有埃云润泽之化。”《五常政大论》说：“其眚四维。”所以王冰将“四维”注释为东南、西南、东北、西北四个方位，马元台和吴鹤皋在注释这两篇中的“四维”时，也都遵循王冰关于四隅方位的注释，并认为这里的“四维”应当作“四隅”（四方角落）来解释。“四维相代”，应当解释为人身的四隅部位。这是说肿胀从身体前、后、左、右各处发起，由此及彼，全身都肿，阳气于是败坏到极点而完全消失。四隅全部肿胀的表现，就是肚脐突出、背部平坦、锁骨窝（缺盆）平坦、足心平坦这类情况。朱丹溪认为这两句是衍文（多余的文字），这是他在寻求解释却不得要领时，无法顺从而随意附会，也是不知道就是不知道的态度。（出自《吴医汇讲》）
与人体关系最密切的病机，不过是水和火罢了。水向湿处流，火向燥处燃；水性柔弱，火性猛烈。水泛滥于表里之间，火游行于三焦之中，拯救溺水和火灾，难道不需要具备相应的治疗方法来应对吗？《内经》说：“二阳结，谓之消。”“三阴结，谓之水。”所谓三阴，是指手足太阴脾肺两脏。胃是水谷之海，水病没有不以胃为本源的，《内经》却将其归属于脾肺，这是什么原因呢？如果足太阴脾能够充分地将水精转输到上部，手太阴肺能够充分地在下部通调水道，那么胃这个“海”就不会波涛汹涌了。只是因为脾、肺两脏的气机郁结而不能运行，随后胃中的水日渐蓄积，浸灌于表里，无处不到。这样看来，脾、肺的职权，怎能不伸张呢？然而，其职权尤其以肾为重。肾是胃的关口，肾主管开阖：肾气从阳则开，阳气太盛则关门大开，水直下而下利成为消渴证；肾气从阴则阖，阴气太盛则关门常闭，水不通畅而成为水肿证。《内经》又说肾为本、肺为标，二者相互输注共同受病。既然如此，水病就以脾、肺、肾为三大纲领了。其中的细节，尤其难以辨别清晰。《金匮要略》区分了五水的名称，以及五脏表里的主病，彻底地进行了论述。后世之人漫不经心地不加考察，治疗水病往往采用霸道之法，不能做到顺应自然、无所作为的境界，这能算是明智吗？然而，水在心之部，则郁遏心火光明温煦的功能；水在肝之部，则郁遏肝木生发舒展的功能；水在肺之部，则孤阳耗竭于外，肺魄独自居守；水在脾之部，则阴精耗竭于内，而水谷精微不能布散；水在肾之部，不但诸阳退伏潜藏，就连随从阳气的阴气，也一并退伏潜藏，导致孤阴独居于下而被隔绝。所以，胃中的水，只怕它有火，有火就属于消渴证，最终传变为中满胀急而不治。肾中的水，只怕它没有火，没有火则真阳灭没，而生机的内在源泉断绝。至于在心之水，遏抑君火，如果能得到脾土的健运，子必救母，即使在肝、肺、肾的水病，只要脾土旺盛，水有所制约，也不敢肆意横溢。治理水土要效法大禹，医学界想要平治水土，不师法张仲景还能师法谁呢？○胃本是水谷之海，是五脏六腑的大源头。脾不能将胃的水精散布给肺，就会在中焦生病；肺不能将胃的水道通调给膀胱，就会在上焦生病；肾不能掌管胃的关口按时进行输泄，就会在下焦生病，所以胃中积水，浸淫扩散而没有止境。张仲景论述水气病一门，极其精详，只是担心足太阴脾的健运功能失职，手太阴肺的治节功能不行，足少阴肾的关门不开，以及其腑膀胱的气化功能不行。他所用的方药，都不蹈入重复虚损的禁忌，立于没有过失的地位。李东垣收集张仲景治疗肺痈的葶苈大枣泻肺汤作为范例，是想用泻肺的方法作为泻水的方法；收集张仲景治疗伤寒痞气连及两胁、杂病支饮在胁部的十枣汤作为范例，是想用泻胸胁及膀胱的方法作为泻水的方法。为什么敢于贸然动刀，却借口说是张仲景呢？后来的人依样画葫芦，不是伤脾，就是泻肺；不是泻肺，就是泻膀胱，致使积水滔天，大家都随之溺亡。在水病门类中，成百上千的成方，找不到一个能救助肺气郁结，而伸展其治节功能的方子；找不到一个能救助膀胱阻绝，而伸展其气化功能的方子。○凡是禽兽之类，有肺的就有尿，没有肺的就没有尿，所以水道不利而成肿胀满闷，以清肺为紧急。这个道理前人阐发不够，后世用五苓散、五皮散、八正散等方治疗水病的，总之是没有领悟到这个宗旨。至于像车水放塘一样，种种劫夺膀胱的药剂，那就是杀人的行为了。（喻嘉言）
水肿是脾、肺、肾三脏的疾病。因为水是至阴之物，所以它的根本在脾肾；水化为气，所以它的标象在肺；水只畏土，所以它的制约在脾。现在肺虚，则气不能化精而化为水；脾虚，则土不能制水反而被水反克；肾虚，则水无所主而妄行，水不归经，则逆而上泛，所以传入于脾，则肌肉浮肿，传入于肺，则气息喘急。分开来说，三脏各有所主；合起来说，则总由阴胜的危害，而病本都归于肾。肾是胃的关口，关口不利，所以聚水而同类相聚。然而关口为什么不利呢？《内经》说：“膀胱者，州都之官，津液藏焉，气化则能出矣。”所谓气化，就是肾中之气，也就是阴中之火。阴中没有阳，则气不能化，所以水道不通，溢出而为肿。所以凡治疗肿病，必须先治水；治水，必须先治气。如果气不能化，则水必然不利。只有下焦的真气得行，始能传化；只有下焦的真水得位，始能厘清。探求古人的治法，只有加减肾气汤，确实是对症的方子。（张景岳）
人的脏腑，以脾胃为主。因为人的饮食，都进入胃，而由脾来运化，就像地上的土一样。然而脾胃能否消化食物，实际上取决于水、火二气，而不是脾土本身所能决定的。火盛则脾胃燥，水盛则脾胃湿，都不能消化食物，从而产生各种疾病。水肿之证，大概是水盛而火不能化，火衰则不能化水，所以水进入脾胃，都渗入血脉骨肉，血也化为水，发为肿胀，这都是自然的道理。先引导其水，使水气稍微减少，然后补其火，使二气平和，病就好了。朱丹溪说脾失运化，是由于肝木侮脾，于是想要清心经之火，使肺金得令，以制约肝木，那么脾土就能全权行使运化之职，水自然顺道而行，就不为肿了，这种说法迂腐而不切实际。（何伯斋）
按刘河间的观点，以水肿为湿热，认为在表有热宜用汗法，在里有热宜用下法，开鬼门（发汗），洁净府（利小便），这说的是有余的实证。朱丹溪认为脾虚不能制水，治疗应当补中行湿利小便，这说的是不足的虚证。至于滋肾制火的说法，我私下认为是不恰当的。因为补肾的药，多是阴滞柔润之品，恰好足以助长湿气。现在治疗此证，如果是脾虚受湿，因不足所致的，宜燥脾土，兼利小便。如果不是气郁、饮食、湿热所致的，严禁不要妄用下法，临时虽然痛快，但水气复来，就无法治疗了。（刘宗浓）
《内经》说：“诸水，身半以下肿者，当利小便；身半以上肿者，当发汗。”身半以上，由天气主导；身半以下，由地气主导。由天气主导的，病位在皮毛，病在皮毛，所以用汗法发散。问：肌肉之外，皮肤之内，头、足、全身都肿的，应当怎么治疗？答：也适宜用汗法，与身半以上的治法相同。肺、心以上的病位都适宜用汗法，中州以下的病位都适宜用下法。如果小便利且口渴，则不宜用汗法，也不宜用下法，因为会再次亡失津液。（王好古）
治疗水病的方法，是顺应自然，根据表里、寒热、上下，顺着病势而引导它，所以适宜汗法、适宜下法、适宜渗湿、适宜清热、适宜温阳、适宜燥湿，在这六种方法中，变化不拘泥于固定模式。○身上有热的可以用汗法，身上无热的可以用利法，肌肤痛的可以用汗法，小便赤涩的可以用利法，腰部以上肿的可以用汗法，腰部以下肿的可以用利法，这就是开鬼门、洁净府、上下分消的方法。（《证治汇补》）
开鬼门（发汗），用麻黄、羌活、防风、柴胡、葱白这一类；洁净府（利小便），用泽泻、木通、通草、防己、葶苈、猪苓茯苓这一类；去菀陈莝（去除郁积的陈腐之物），用商陆、大戟、甘遂、芫花、牵牛这一类；宣布五阳（宣通五脏之阳气），用肉桂、附子、干姜、吴茱萸这一类；治疗血肿，用琥珀、郁金、刘寄奴、苏木这一类。（《张氏医通》）
水病，其人必定是真火衰微，不能化生脾土。所以水无所摄纳，泛溢于肌肉之间，治疗只宜助脾益火。而助脾益火的药剂，最妙的是五苓散，用肉桂以益火，火暖则水自流；用白术以补土，土实则水自障；用二苓、泽泻以引水，则水自渗泄，没有不随手而愈的。（孙庆曾）
治疗水病，用柴胡、泽泻，一升一降，厘清水道，则水无不下行的。（徐春圃）
肾主水，水有真水，有客水。肾气温，则客水也能摄纳而归入真水；肾气寒，则真水也会泛滥而为客水。客寒必须搏击它，真武汤从土中殖火，使真水从温暖处镇摄，客水自然化解而归入真水，何必下达导渗的命令？（程郊倩）
肺热，则失去其下降的职能，以致水溢出于高原（肺位高），淫溢于皮肤而为肿。医生很少明白这一点，实脾导水，都不能治愈。所以用麦冬清肺，开启其下降之源；用粳米益脾，培补生金之母，治病必须求其根本。（吴鹤皋）
热燥伤肺而为肿的，是断绝了水的源头，应当清肺除燥，而水自然生成，可用栀豉汤加黄芩。如果热在下焦，阴消阳气不得化的，应当益其阴，则阳气自然化，可用黄柏、知母。（《保命集》）
大病后浮肿，这是脾虚所致，宜用六君子汤。小便不利，间或进服五苓散。脾肺虚弱，不能通调水道的，宜用补中益气汤。（周慎斋）
有一身之间，只有面部和脚部浮肿，早晨面部严重，晚上脚部严重。《内经》说：“面肿为风，脚肿为水”，这是风湿所致。然而病后元气未恢复的人，经常多见此证，大概是因为本气不固，所以白天行走坐立，则气坠而晚上脚肿，夜间睡卧，则气升而早上面浮。如果一概当作风湿治疗，更是使其虚弱更甚。（冯楚瞻）
凡是患水肿必须忌盐，丝毫不得入口。如果没有味道，用少许醋调和饮食，如果不能忌盐，服药无效。（《得效方》）
心胀烦心，肝胀胁痛，脾胀呕哕，肺胀喘嗽，肾胀腰痛，胆胀口苦，胃胀脘痛，大肠胀肠鸣飧泻，小肠胀少腹引腰痛，膀胱胀小便癃闭，三焦胀气满皮肤。（《医学入门》）
气胀，是七情郁结，胸腹满闷；食胀，是谷食不化，痞满恶心；虫胀，是腹痛能食，喜欢吃茶叶泥土；积胀，是痞块有形，心腹坚硬；水胀，是停饮肠鸣，怔忡喘息；瘀胀，是跌仆，产后大便黑色；虚胀，是腹软任按，食入倒饱。更有单腹胀者，腹大肢瘦，这是由于胀满日久，气血结聚，不能释散，俗名曰蛊，其病更重。（《证治汇补》）
凡是治疗这个病，必须融会贯通《圣经》（指经典医籍，此处应指《内经》等经典）各条的宗旨，然后才能识别脏腑的部分形证，邪气从哪里来。即使是通体腹胀满，突然难以究底的，也一定有胀得特别严重的部位，以及病最初起始的地方，就可以知道是哪一脏腑之气受邪而不行在先，然后才波及中焦气交之分，于是转运不前，壅聚导致通体腹胀满。如果脾胃受邪，便先是胃脘心下痞气起，逐渐积累为通体腹胀。腹部属脾，属脾的，则饮食少；属其他脏腑的，则饮食如常，这可以验证。又须分辨其表里浅深，胀在皮肤孙络之间的，饮食也如常。胀在肠胃肓膜之间的，则饮食减少，其气壅塞于五脏，则气促急不食而病危了。所以病在表的易治，入腑的难治，入脏的不治。更要分别寒热虚实，其脏腑之气本盛，被邪气填塞不行为实；脏腑之气本不足，因邪气所壅的为虚。实的祛之，虚的补之，寒的热之，热的寒之，结的散之，留的行。邪从外入内而盛于中的，先治其外，而后调其内。阴从下逆上而盛于中的，先抑之而后调其中。阳从上降下而盛于中的，先举之亦调其中，使阴阳各归其部。所以《内经》的治法，谓平治权衡，去菀陈莝，开鬼门，洁净府，宣布五阳，巨气乃平，说的就是这个意思。庸医不明白这个道理，专门坚守“下之则胀已”这一种方法，虽然暂时得到一点宽舒，然而真气因泻而脱失，邪气必复聚成胀，遂致不治，可叹啊！（《证治准绳》）
鼓证，中空外急似鼓，所以叫鼓。单胀或复胀满，四肢百体，都没有肿形，与通身水肿不同。水肿，是邪气协带阳气游行一身，邪气去而为汗、为溺，则正气复而为血、为气。鼓证，则是邪毒专攻脏腑，阳气滞而不行，可以说是肿轻而胀重。有人说：鼓证是一个病，为什么东垣的论点主寒，河间的论点主火，丹溪的论点主脾虚，道理难道有两个吗？我说：都是对的，它们的根源都出自《内经》，只是经文概括了全面，三位先生各自说了一方面。《内经》说：“三阴结，谓之水。”又说：“脏寒生满病。”又说：“腹满 胀，支鬲 胁。下厥上冒，过在足太阴阳明。”起初是寒湿郁遏，久则阳气渐衰，阴气独盛。人身之气，热则流通，寒则凝结。凝结则胀满生焉。所以东垣用辛热散之，苦温泄之，淡渗利之，上下分消，这是东垣的论点不可废除。《内经》说：“诸腹胀大，皆属于热。”所以《原病式》说：“诸腹胀大，鼓之如鼓，气为阳，阳为热，气盛则如是也。”世人说脾虚不能制水，似是而实非。万物热盛则丰隆，寒盛则敛缩，阳邪猛烈，元气从之，二阳搏击于中，日新月盛，怎么能不成鼓呢，这是河间的论点，也不可废除。《内经》说：“诸湿肿满，皆属于脾。”脾具坤静之德，而有干健之运，如果脾土受伤，转输失职，遂成胀满。人身以脾土为本，脾不健旺，则清气不升，浊气不降，浊气在上，则生 胀，这是鼓证的由来。如果中没有阳邪，宜行大补，所谓气虚不补，气何由行？又清肺金，滋肾水，制肝养脾，都是至理所在，这是丹溪的论点，也不可废除。虽然如此，三位先生的论点，固然符合经旨，但我还有话说。东垣说鼓证属寒的多，属热的少。我认为鼓证属热的多，属寒的少。东南之人，湿热为病，十居八九，西北之地，严寒为病固多，然寒主收敛，未必能成胀大，这是从理论推断，知其热多寒少。河间的论点固然恰当，但其中有燥热，有湿热，如果不区别，祸如反掌。燥热为病，则大便闭结，小便短涩，身热腹痛，闷乱不安，一投参、芪，则胀满不数日而成，其为害也速而烈。湿热为病，大便频溏，小便清少，脉濡体倦，嗜卧减食，其为患也缓而深。所以治燥热者，清热之中少加濡润。治湿热者，渗利之内少加温散。燥者润之，湿者燥之，各求其属，以合中道。丹溪补脾扶脾的论点固然确切，但如果真是饮食所伤，频繁不止，上无痰气之阻，中无邪热之留，这才可用补？否则，有痰的兼消痰，有火的兼降火，清补兼施，益处莫大。此外有七情之伤脾，如怒伤肝，肝克脾，脾气不舒，必胀于胃，名叫胜克。怒乘肺，肺气不伸，必胀于大肠，名叫乘克。又有劳倦之损脾，有所远行，形气衰少，谷气不盛，热气熏于胸中。又有血积之遏脾，或注于胸膈，或滞于胃中，或郁于少腹，都能抑遏，清气不升，浊气不降，俗呼血鼓的就是这些。鼓证重疾，经常看见……
Fourth interpretation: This maintains the whole body, elucidating the meaning of "Wei" (support/pillar). Ma Yuantai considered the four characters "blood vessels, sinews, bones, and tendons" inappropriate, thus annotating "Si Wei" (Four Poles) as the four limbs. Wang An believed that both Wang Bing's and Ma Yuantai's annotations failed to adequately address the character "Dai" (substitution/alternation), thus annotating "Si Wei" as the four seasons. Various theories differ. I privately ponder that "Si Wei" appears frequently in the *Suwen* (Basic Questions). The *Qijiao Bian Dalun* (Great Treatise on Changes in Qi Intercourse) states: "When Earth Qi is insufficient in a year, the Si Wei undergo transformations of dust clouds, moisture, and nourishment." The *Wuchang Zheng Dalun* (Great Treatise on the Five Constant Policies) states: "Its disaster affects the Si Wei." Therefore, Wang Bing annotated "Si Wei" as the positions of Southeast, Southwest, Northeast, and Northwest. Ma Yuantai and Wu Hegao, when annotating "Si Wei" in these two treatises, also followed Wang Bing's annotation regarding the four corners (Si Yu) and argued that "Si Wei" here should be interpreted as "Si Yu" (four corners). "Si Wei Xiang Dai" (The Four Poles alternate/substitute) should be interpreted as the four corners of the human body. This means that edema arises from the front, back, left, and right, spreading from one place to another until the whole body is swollen; at this point, Yang Qi is ruined to the extreme and no longer exists. Swelling of all four corners manifests as protruding umbilicus, flat back, flat clavicular fossae (Quepen), flat soles of the feet, etc. Zhu Danxi considered these two sentences to be interpolations (superfluous text); this was an attempt to find an explanation but failing to follow through with proper reasoning, reflecting an attitude of not knowing what one does not know. (From *Wu Yi Hui Jiang*)
Among pathogenic mechanisms, those most pertinent to the human body are Water and Fire. Water flows toward dampness; fire moves toward dryness. Water is soft and weak; fire is fierce and violent. When water overflows in the exterior and interior, and fire travels through the Sanjiao (Triple Burner), is it not necessary to have methods to respond to saving drowning victims and extinguishing fires? The *Classic* says: "When the Two Yangs are knotted, it is called Xiao (Consumption/Polydipsia)." "When the Three Yin are knotted, it is called Shui (Water/Edema)." The Three Yin refers to the Hand and Foot Taiyin Spleen and Lung organs. The Stomach is the Sea of Water and Grain; there is no water disease that does not originate from the Stomach. Why does the *Classic* attribute it to the Spleen and Lung? If the Foot Taiyin Spleen is sufficient to transport water essence upward, and the Hand Taiyin Lung is sufficient to regulate water passages downward, then the Sea would not have turbulent waves. Only because the Qi of the Spleen and Lung is knotted and fails to circulate does the water in the Stomach accumulate day by day, inundating the exterior and interior, reaching everywhere. Thus, can the authority of the Spleen and Lung fail to be extended? However, their authority is even more critical in the Kidney. The Kidney is the gate of the Stomach; the Kidney controls opening and closing. When Kidney Qi follows Yang, it opens; if Yang is too excessive, the gate opens wide, water flows directly down, resulting in Xiao (polyuria/consumption). When Kidney Qi follows Yin, it closes; if Yin is too excessive, the gate remains closed, water cannot pass, resulting in swelling. The *Classic* also states that the Kidney is the root and the Lung is the branch, mutually transmitting and jointly affected. Therefore, water diseases take the Spleen, Lung, and Kidney as the three main principles. The details within are particularly difficult to distinguish clearly. The *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet) distinguishes the names of five types of water and the diseases governed by the interior-exterior relationships of the five Zang organs, discussing them thoroughly. Later generations, without careful observation, often resort to harsh methods for treating water diseases, failing to act naturally without forcing things; can this be considered wise? However, when water is in the Heart region, it stifles the bright transformation of Heart Fire; when water is in the Liver region, it stifles the generating transformation of Liver Wood; when water is in the Lung region, solitary Yang exhausts externally, and the Po (Lung Soul) resides alone; when water is in the Spleen region, Yin essence exhausts internally, and grain essence is not distributed; when water is in the Kidney region, not only do all Yang energies retreat and hide, but even the Yin that follows Yang retreats, leaving solitary Yin isolated below and cut off. Therefore, regarding water in the Stomach, one fears fire; if there is fire, it belongs to Xiao Ke (wasting-thirst syndrome), which eventually transmits to Zhong Man (abdominal fullness) and becomes incurable. Regarding water in the Kidney, one fears the lack of fire; if there is no fire, True Yang is extinguished, and internal life energy is severed. As for water in the Heart, it suppresses Sovereign Fire; if Spleen Earth operates healthily, the child saves the mother. Even for water in the Liver, Lung, or Kidney, once Spleen Earth is robust, water is controlled and dares not overflow recklessly. To level earth and water, one takes Da Yu (the Great Yu) as a model; in medicine, to level earth and water, who else but Zhang Zhongjing should be modeled? ○ The Stomach is originally the Sea of Water and Grain, the great source of the Five Zang and Six Fu organs. If the Spleen cannot scatter the water essence of the Stomach to the Lung, disease occurs in the Middle Jiao; if the Lung cannot regulate the water passages of the Stomach to the Bladder, disease occurs in the Upper Jiao; if the Kidney cannot manage the gate of the Stomach to control its output and discharge, disease occurs in the Lower Jiao. Thus, water accumulates in the Stomach, infiltrating without limit. Zhang Zhongjing’s discussion on Water Qi is extremely precise and detailed, fearing only that the healthy transportation of the Foot Taiyin Spleen fails, the governance of the Hand Taiyin Lung ceases, the gate of the Foot Shaoyin Kidney does not open, and the Qi transformation of its paired organ, the Bladder, does not function. His prescribed medicines never tread into the taboo of repeated deficiency, standing in a position of no fault. Li Dongyuan collected Zhang Zhongjing’s Tingli Dazao Xiefei Tang (Thladiaplea and Jujube Decoction to Drain the Lung) for lung abscess as an example, intending to use lung-draining methods as water-draining methods. He collected Zhang Zhongjing’s Shizao Tang (Ten Date Pill) for cold damage stagnation extending to both hypochondria and miscellaneous disorders with fluid retention in the hypochondria, intending to use draining of the chest/hypochondria and Bladder as water-draining methods. How daring to wield the blade while using Zhang Zhongjing as an excuse! Later practitioners imitated this blindly; either injuring the Spleen or draining the Lung; either draining the Lung or draining the Bladder, leading to torrents of accumulated water where everyone drowns. In the category of water diseases, among hundreds of established formulas, none can rescue Lung Qi depression and extend its governance function. None can rescue Bladder obstruction and extend its Qi transformation function. ○ For birds and beasts, those with lungs have urine; those without lungs have no urine. Therefore, when water passages are obstructed, causing swelling and fullness, clearing the Lung is urgent. This principle was not sufficiently expounded by predecessors. Those who later used Wuling San (Five-Ingredient Powder with Poria), Wupi San (Five-Rind Powder), or Bazheng San (Eight-Righteousness Powder) to treat water diseases ultimately failed to grasp this essence. As for methods like pumping water out of ponds—various agents that forcibly drain the Bladder—are acts of killing people. (Yu Jiayan)
Edema is a disease of the Spleen, Lung, and Kidney. Since Water is Supreme Yin, its root lies in the Spleen and Kidney. Water transforms into Qi, so its branch manifestation lies in the Lung. Water fears Earth, so its control lies in the Spleen. Now, if the Lung is deficient, Qi cannot transform essence into water [error in logic in original or specific context: usually Lung transforms fluids]; if the Spleen is deficient, Earth cannot control Water and is counter-attacked; if the Kidney is deficient, Water has no master and runs wild. Water does not return to its channels, reversing and flooding upward. Thus, when transmitted to the Spleen, muscles swell; when transmitted to the Lung, breathing becomes rapid and wheezy. Separately, each of the three organs has its specific domain; collectively, it is all due to the harm of Excess Yin, with the root disease returning to the Kidney. The Kidney is the gate of the Stomach; when the gate is obstructed, water gathers and associates with its kind. But why is the gate obstructed? The *Classic* says: "The Bladder is the official of the capital, storing fluids; Qi transformation allows them to exit." What is meant by Qi transformation is the Qi within the Kidney, i.e., the Fire within Yin. Without Yang within Yin, Qi cannot transform, so water passages are blocked, overflowing to cause edema. Therefore, whoever treats edema must first treat water; whoever treats water must first treat Qi. If Qi cannot transform, water will certainly not flow smoothly. Only when the True Qi of the Lower Jiao moves can transmission and transformation occur; only when the True Water of the Lower Jiao assumes its proper position can clarity be restored. Seeking ancient treatment methods, only Jiawei Shenqi Tang (Modified Kidney Qi Pill) is truly the correct formula for the syndrome. (Zhang Jingyue)
In humans, the Zang-Fu organs prioritize the Spleen and Stomach. Human food enters the Stomach and is transported by the Spleen, just as earth covers the ground. However, whether the Spleen and Stomach can digest food actually depends on the Qi of Water and Fire, not merely on Spleen Earth itself. Excessive Fire makes the Spleen and Stomach dry; Excessive Water makes them damp; neither can digest food, leading to various diseases. Edema is essentially Water Excess where Fire cannot transform it. If Fire is deficient, it cannot transform Water, so Water entering the Spleen and Stomach infiltrates blood vessels, flesh, and bones, transforming blood into water, causing swelling. This is natural law. First, guide the water to reduce its Qi slightly; then tonify Fire to balance the two Qi, and the disease will depart. Danxi stated that Spleen loss of transportation is due to Liver Wood insulting the Spleen, and thus sought to clear Heart Fire so that Lung Metal could take command to control Liver Wood, allowing Spleen Earth to fully perform its transportation function, letting water flow smoothly without swelling. His words were roundabout and impractical. (He Bozhai)
According to Liu Hejian, edema is caused by Damp-Heat. He stated that Heat in the Exterior warrants sweating, and Heat in the Interior warrants purging: Kai Guimen (Open Ghost Gates/sweating), Jing Jianfu (Clean Pure House/diuresis). This describes excess syndromes. Danxi attributed edema to Spleen Deficiency failing to control Water, advocating tonifying the Middle, drying Dampness, and promoting urination. This describes deficiency syndromes. As for the theory of nourishing the Kidney to control Fire, I personally consider it inappropriate. Kidney-tonifying herbs are typically Yin-stagnant, soft, and moistening, which merely aids Dampness. Currently, for this syndrome, if it is Spleen Deficiency receiving Dampness due to insufficiency, one should dry Spleen Earth and promote urination. If it is not caused by Qi Stagnation, Food Retention, or Damp-Heat, one must strictly avoid reckless purgation. Temporary relief may occur, but Water Qi will return, becoming untreatable. (Liu Zongnong)
The *Classic* says: "For all water diseases, if swelling is below the waist, promote urination; if swelling is above the waist, induce sweating." Above the waist is governed by Heaven Qi; below the waist is governed by Earth Qi. Governed by Heaven Qi implies involvement of the skin; since it involves the skin, sweat it to release it. Question: If swelling affects the entire body, inside the muscle and outside the skin, head to foot, how should it be treated? Answer: Sweating is also appropriate, following the same method as swelling above the waist. Diseases above the Lung and Heart warrant sweating; those below the Central Region warrant purging. If urination is free and thirst is present, neither sweating nor purging is suitable, as this would further deplete Body Fluids. (Wang Haogu)
The method of treating water is to act naturally, following the Exterior/Interior, Cold/Heat, Upper/Lower, and guiding according to the trend. Thus, sweating, purging, seeping, clearing, warming, and drying are all applicable. Among these six, changes are不拘泥 (not rigid). ○ If the body has heat, sweating is appropriate; if no heat, diuresis is appropriate. If skin/muscles hurt, sweating is appropriate; if urine is red and scanty, diuresis is appropriate. If swelling is above the waist, sweating is appropriate; if below the waist, diuresis is appropriate. This is the method of Kai Guimen, Jing Jianfu, and upper-lower dispersion. (*Zhengzhi Huibu*)
Kai Guimen (Opening Ghost Gates/Sweating): Ephedrae Herba (Mahuang), Notopterygii Rhizoma et Radix (Qianghuo), Saposhnikoviae Radix (Fangfeng), Bupleuri Radix (Chaihu), Allii Fistulosi Bulbus (Congbai), etc.
Jing Jianfu (Cleaning the Pure House/Diuresis): Alismatis Rhizoma (Zexie), Akebiae Caulis (Mutong), Tinosporae Caulis (Tongcao), Stephaniae Tetrandrae Radix (Fangji), Thladiapiae Fructus (Tingli), Polyporus (Fuling), Poria (Fuling), etc.
Qu Wan Chen Cuo (Removing Accumulated Decay): Phytolaccae Radix (Shanglu), Euphorbiae Pekinensis Radix (Daji), Kansui Radix (Gansui), Genkwa Flos (Yuanhua), Pharbitidis Semen (Qianniu), etc.
Xuan Bu Wu Yang (Announcing and Distributing the Five Yangs): Cinnamomi Ramulus (Guizhi), Aconiti Lateralis Radix Praeparata (Fuzi), Zingiberis Rhizoma (Ganjiang), Evodiae Fructus (Wuzhuyu), etc.
Blood Swelling: Succinum (Hupo), Curcumae Longae Rhizoma (Yujin), Linderae Radix (Liujinu), Sappan Lignum (Sumu), etc. (*Zhangshi Yitong*)
In water diseases, the patient invariably has diminished True Fire, unable to generate Spleen Earth. Thus, Water has no containment and overflows between muscles. Treatment solely assists the Spleen and benefits Fire. Among agents that assist the Spleen and benefit Fire, Wuling San (Five-Ingredient Powder with Poria) is exquisite. Rougui (Cinnamon Bark) benefits Fire; when Fire is warm, Water flows freely. Baizhu (Atractylodis Macrocephalae Rhizoma) tonifies Earth; when Earth is solid, Water is contained. Erling (Polyporus and Poria) and Zexie (Alismatis Rhizoma) guide Water; thus Water seeps and drains spontaneously, healing instantly. (Sun Qingzeng)
To treat water, use Chaihu (Bupleuri Radix) and Zexie (Alismatis Rhizoma); one ascends, one descends, clarifying the water passages, so Water inevitably flows down. (Xu Chunpu)
The Kidney governs Water. There is True Water and Guest Water. When Kidney Qi is warm, Guest Water is also contained and returns to True Water; when Kidney Qi is cold, True Water floods and becomes Guest Water. Guest Cold must be combated. Zhenwu Tang (True Warrior Decoction) plants Fire within Earth, causing True Water to be suppressed and controlled from warmth; Guest Water naturally transforms and returns to True. Why issue orders for drainage and seepage? (Cheng Jiaoqian)
Lung Heat causes the loss of its descending function, leading to Water overflowing from the High Plain (Lung), invading the skin, and causing edema. Physicians rarely understand this; strengthening the Spleen and guiding Water cannot cure it. Therefore, use Maidong (Ophiopogonis Tuber) to clear the Lung and open the source of descent. Use Jingmi (Oryza Sativa Germ) to benefit the Spleen and cultivate the Mother of Metal. Treating disease requires seeking its root. (Wu Hegao)
When Heat-Dryness injures the Lung causing edema, the source of Water is cut off. One should clear the Lung and remove Dryness, so Water generates naturally; use Zhichi Tang (Gardenia and Fermented Soybean Decoction) plus Huangqin (Scutellariae Radix). If Heat is in the Lower Jiao, consuming Yin and preventing Yang from transforming, one should tonify Yin so Yang transforms naturally; use Huangbai (Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma). (*Baoming Ji*)
Post-major illness edema is due to Spleen Deficiency; use Liujunzi Tang (Six-Gentleman Decoction). If urination is difficult, occasionally administer Wuling San (Five-Ingredient Powder with Poria). If Spleen and Lung are weak and cannot regulate water passages, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). (Zhou Shenzhai)
In some cases, only the face and feet swell: severe facial swelling in the morning, severe foot swelling in the evening. The *Classic* says: "Facial swelling is Wind; foot swelling is Water," caused by Wind-Damp. However, after illness, when Yuan Qi has not recovered, this syndrome is common. It is due to unstable Root Qi. During the day, walking and sitting cause Qi to sink, leading to evening foot swelling; at night, sleeping causes Qi to rise, leading to morning facial floating. If treated generally as Wind-Damp, it further weakens the weakness. (Feng Chuzhan)
All patients with edema must avoid salt; not a trace should enter the mouth. If flavor is needed, use a little vinegar to season food. If salt cannot be avoided, medication will be ineffective. (*Defang Fang*)
Distension Drum (Gu Zhang)
Heart Distension: vexation; Liver Distension: hypochondriac pain; Spleen Distension: vomiting and hiccups; Lung Distension: wheezing and coughing; Kidney Distension: lower back pain; Gallbladder Distension: bitter taste; Stomach Distension: epigastric pain; Large Intestine Distension: borborygmus and undigested stool diarrhea; Small Intestine Distension: lower abdomen pain radiating to the lower back; Bladder Distension: urinary retention; Sanjiao Distension: abdominal fullness and skin distension. (*Yixue Rumen*)
Qi Distension: Seven Emotions knotting, chest and abdominal fullness; Food Distension: undigested grains, stagnation, nausea; Parasite Distension: abdominal pain with appetite, craving tea leaves and soil; Accumulation Distension: palpable masses, hard heart and abdomen; Water Distension: retained fluids with borborygmus, palpitations and wheezing; Blood Stasis Distension: history of trauma or postpartum, black stools; Deficiency Distension: soft abdomen, feeling full immediately after eating. Furthermore, Single Abdominal Distension features a large abdomen with thin limbs. This results from long-standing distension where Qi and Blood knot and cannot disperse, commonly known as Gu (蛊 -蛊毒/Gu Poison), which is more severe. (*Zhengzhi Huibu*)
Treating this disease requires integrating the principles of various classic texts to identify the location and symptoms of the Zang-Fu organs and the origin of pathogenic factors. Even if general abdominal distension is sudden and difficult to resolve, there must be a part where distension is most severe and the initial site of onset. This reveals which Zang-Fu organ's Qi was first affected and stagnant, subsequently involving the intersection of Qi in the Middle Jiao, leading to failed transportation and general abdominal distension. If the Spleen and Stomach are affected, it begins with stagnation in the epigastrium/xiacheng, gradually accumulating into general distension. The abdomen belongs to the Spleen; if it belongs to the Spleen, appetite decreases; if it belongs to other organs, appetite remains normal. This can verify the diagnosis. One must also distinguish superficial vs. deep, exterior vs. interior. Distension in the skin and collateral vessels allows normal diet. Distension in the intestines, stomach, and membranes reduces diet. Qi congested in the Five Zang organs causes rapid breathing, anorexia, and critical illness. Thus, diseases in the Exterior are easy to treat; those entering the Fu organs are difficult; those entering the Zang organs are incurable. One must distinguish Cold/Heat and Deficiency/Excess. If Zang-Fu Qi is originally strong but blocked by pathogens, it is Excess; if Zang-Fu Qi is originally deficient but congested by pathogens, it is Deficiency. Expel the Excess; Tonify the Deficiency. Warm the Cold; Cool the Heat. Scatter the Knots; Move the Retention. If pathogens enter from the Exterior and become excessive in the Middle, treat the Exterior first, then regulate the Interior. If Yin reverses from Below and becomes excessive in the Middle, suppress it first, then regulate the Middle. If Yang descends from Above and becomes excessive in the Middle, lift it first, then regulate the Middle, so Yin and Yang return to their respective regions. Thus, the *Neijing* treatment method states: Balance and weigh, remove accumulated decay, open ghost gates, clean the pure house, announce the five Yangs, and the Great Qi will be balanced. This is what is meant. Ignorant physicians do not understand this way, adhering solely to "purging resolves distension." Although temporary relief occurs, True Qi escapes due to purging, and pathogens re-aggregate into distension, leading to death. How lamentable! (*Zhengzhi Zhunsheng*)
Gu Syndrome (Drum Syndrome) is hollow inside and tense outside, resembling a drum, hence the name. Single or multiple distensions affect the limbs and body without swelling forms, unlike generalized edema. In edema, pathogens travel with Yang Qi throughout the body; when pathogens leave as sweat or urine, Righteous Qi returns as Blood and Qi. In Gu Syndrome, pathogenic toxins attack the Zang-Fu exclusively, and Yang Qi stagnates and fails to move; thus, swelling is light, but distension is heavy. Some ask: Gu Syndrome is one disease; why does Dongyuan argue for Cold, Hejian for Fire, and Danxi for Spleen Deficiency? Is the Dao divided? I say: All are correct. Their origins lie in the *Neijing*. The Classic covers the whole; the three masters each covered one aspect. The *Classic* says: "Three Yin knotted is Water." Also: "Cold in Zang generates fullness diseases." Also: "Abdominal fullness and distension, supporting the diaphragm and hypochondria. Reversal from below and covering from above, the fault lies in Foot Taiyin and Yangming." Initially, Cold-Damp stagnates; over time, Yang Qi declines, and Yin Qi dominates alone. Human Qi flows when hot; it coagulates when cold. Coagulation generates distension. Thus, Dongyuan uses Acrid-Warm to disperse, Bitter-Warm to drain, and Bland-Leaching to promote urination, dispersing upper and lower. Dongyuan’s theory cannot be discarded. The *Classic* says: "All abdominal distensions and enlargements belong to Heat." Thus, *Yuanbing Shi* says: "All abdominal distensions and enlargements, drum-like when beaten. Qi is Yang; Yang is Heat. Excess Qi presents thus." The world says Spleen Deficiency fails to control Water; this seems plausible but is false. When Heat is excessive in all things, they flourish; when Cold is excessive, they contract. Yang Pathogens are fierce; Original Qi follows them. Two Yangs battle in the middle, growing daily and monthly; how can this not become a drum? Hejian’s theory cannot be discarded. The *Classic* says: "All Dampness, swelling, and fullness belong to the Spleen." The Spleen possesses the virtue of Kun (Stillness) and the movement of Qian (Strength). If Spleen Earth is injured and transportation fails, distension ensues. The human body relies on Spleen Earth as the root. If Spleen is not robust, Clear Qi does not ascend, Turbid Qi does not descend. Turbid Qi staying above generates distension. This is the origin of Gu Syndrome. If there is no Yang Pathogen in the Middle, major tonification is suitable. As the saying goes: If Qi Deficiency is not tonified, how can Qi move? Also, clearing Lung Metal, nourishing Kidney Water, controlling Liver, and supporting Spleen are profound truths. Danxi’s theory cannot be discarded. Although the three masters' theories align with the Classic, there is more to say. Dongyuan stated Gu Syndrome is mostly Cold, rarely Heat. I argue Gu Syndrome is mostly Heat, rarely Cold. In the Southeast, Damp-Heat diseases account for 80-90%. In the Northwest, Severe Cold diseases are many, but Cold governs contraction and may not necessarily cause enlargement. Theoretically, Heat is more common than Cold. Hejian’s theory is appropriate, but it includes Dry-Heat and Damp-Heat. If not distinguished, disaster is swift. Dry-Heat disease: constipation, scanty dark urine, fever, abdominal pain, restlessness. Administering Renshen (Ginseng) and Huangqi (Astragalus) causes distension to develop in days; harm is fast and fierce. Damp-Heat disease: frequent loose stools, clear/scanty urine, soggy pulse, fatigue, lethargy, reduced appetite; harm is slow and deep. Therefore, treating Dry-Heat: add moistening agents to heat-clearing methods. Treating Damp-Heat: add warming-dispersing agents to leeching-promoting methods. Dryness: Moisten it. Dampness: Dry it. Seek their belonging to meet the Mean. Danxi’s theory of tonifying/supporting the Spleen is accurate, but if injury is due to food, frequent and unceasing, with no phlegm-Qi obstruction above and no Evil-Heat retention in the Middle, then tonification can be used? Otherwise, if there is phlegm, eliminate phlegm; if there is Fire, descend Fire. Clearing and tonifying together brings great benefit. Additionally, Seven Emotions injuring the Spleen: Anger injures Liver; Liver insults Spleen; Spleen Qi is not smooth, distending in the Stomach, named Sheng Ke (Overcoming). Anger attacks Lung; Lung Qi does not extend, distending in the Large Intestine, named Cheng Ke (Assaulting). Also, Fatigue damaging the Spleen: traveling far, form and Qi decline, Grain Qi is insufficient, Heat steams the chest. Also, Blood Stasis suppressing the Spleen: flowing to the chest/diaphragm, stagnating in the Stomach, or knotting in the lower abdomen, all suppressing Clear Qi ascent and Turbid Qi descent, commonly called Blood Drum. Gu Syndrome is a serious disease, often seen...