河间曰∶痞与否同，不通泰之义也。其心膈闷而不痛者为痞满，内外皆胀急者为肿胀，二者似同实异。
有中气弱不能营运精微而为痞者，又有饮食痰积不能运化而为痞者，又有湿热太甚，上乘心下而为痞者，有
误下以致内虚入而痞者，皆土邪之为病。东垣曰∶伤寒杂症，下之太过则为痞满，皆
血症也，盖下则亡阴，阴者即脾胃之阴亡也。故胸中之气，因阴虚而下陷于心之分，以致心下痞满，
宜理脾胃兼阴药治之。若全用气药，则痞益甚。此发前人所未发也。
然痞有虚实之殊∶实痞能食而大便闭，黄连、枳实、浓朴苦以泄之；虚痞不能食而大便利，白芍、陈
皮酸以收之。有湿则四肢困重，小便短少，苍术、茯苓、半夏、滑石、泽泻以渗之。郁滞不通，食难消化，
抚芎、浓朴、香附、苍术、枳实以开之。脾胃虚而运转不舒为痞者，人参、甘草、茯苓、白术甘以温之。
饮食过伤痞寒者，青皮、枳实、浓朴、山楂、神曲以消导之。挟痰血成窠囊者，桃仁、红花、香附、大
黄之类。右关多弦迟者，必心下坚满，以肝木克脾土，郁结不得开通，木香顺气丸。如大病后元气未复而
痞者，补中益气汤加陈皮。
李士材曰∶《内经》之论肿胀，五脏六腑靡不有之。详考全经，如脉要论曰∶胃脉实则胀。病形篇曰∶
胃病者，腹 胀。本神篇曰∶脾气实则腹胀，泾溲不利。应象论曰∶浊气在上，则生 胀。此四条皆实胀
也。太阴阳明论曰∶饮食起居失节，入五脏则 满闭塞。师传篇曰∶足太阴之别公孙，虚则鼓胀。此二条
皆虚胀也，经脉篇曰∶胃中寒则胀满。方宜论曰∶脏寒生满病。风论曰∶胃风膈寒不通，失衣则 胀。此
三条皆寒胀也。六元正纪、至真等论，云太阴所至为跗肿，及土郁之发，太阴之初气，太阴之胜复，皆湿
胜之肿胀也。或曰水运太过∶或曰寒胜则浮；或曰太阳司天，太阳胜复；少阳司天，少阳胜复；或曰热胜
则肿，皆火胜之热胀也。或曰
厥阴司天、在泉，厥阴之复；或曰阳明之复，皆水邪侮土，及金气反胜之肿胀也。由是，则五运六气
亦各有肿胀矣。
然经有提其纲者，曰∶诸湿肿满，皆属于脾；又曰∶其本在肾，其末在肺。皆聚水也。又曰∶肾者胃
之关也，关门不利，故聚水而从其类也。可见诸经虽皆有肿胀，无不由于脾、肺、肾者。盖脾土主营运，
肺金主气化，肾水主五液，凡五气所化之液，悉属于肾；五液所行之气，悉属于肺；转输二脏，以制水生金
者，悉属于脾，故肿胀不外此三经也。
但阴阳虚实，不可不辨，大抵阳症必热，热者多实；阴症必寒，寒者多虚。先胀于内，而后肿于外者
为实，先肿于外，而后胀于里者为虚。小便黄赤，大便秘结者为实；小便清白，大便泻泄为虚。滑数有力
为实，弦数微细为虚。色红气粗为实，色悴声短为虚。凡诸实症，或六淫外客，或饮食内伤，阳邪急速，
甚至必暴，每成于数日之间。若是虚症，或情志多劳，酒色过度，日积月累，其来有渐，每成于经月之
后。
然治实颇易，理虚恒难。虚人气胀者，脾虚不能运气也。虚人水胀者，土虚不能制水也。水虽制于脾
，实则统于肾。肾本水脏，
而元阳寓焉。命门火衰，既不能自制阴寒，又不能温养脾土，则阴不从阳，而精化为水，故水肿之症多属
火衰也。
丹溪以为湿热，宜养金以制水，使脾无贼邪之患，滋水以制火，使肺金得清化之权。夫制火固可保金，
独不虑其害土乎？惟属热者宜之。若阳虚者，岂不益其病哉。
更有不明虚实，专守下之则胀已之一法，虽得少宽于一时，真气愈衰，未几而肿胀再作，遂致不救，殊
可叹也。
余于此症，察其实者，直清阳明，反掌收功。苟涉虚者，
温补脾胃，渐次康复。其有不大实亦不大虚者，先以清利见功，继以补中调摄。
又有标实而本虚者，泻之不可，补之无功，极为危险。在病名有鼓胀与蛊胀之殊∶鼓胀者，中空无物
，腹皮绷急，多属于气也；蛊胀者，中实有物，腹形充大，非虫即血也。在
女科有气分、血分之殊∶气分者，心胸坚大，而病发于上，先病水胀，而后经断；血分者，血结胞门，而
病发于下，先因经断，而后水胀。在治法有理肺、理脾之殊；先喘而后胀者，治在肺；先胀而后喘者，治在
脾。此其大略也。
腹胀身热者死。腹胀寒热似疟者死。腹大胀，四未清，脱形，泄甚者为逆。腹胀便血，脉大时绝者死。
唇黑或肿肝伤。缺盆平心伤。脐突脾伤。足心平肾伤。背平肺伤。五伤死。大便滑泄，水肿不消者死。泻后
腹胀而有青筋者死。阴囊及茎肿者死。水肿先起于腹，后散四肢者可治；先起于四肢，后归于腹者死。
中满 赵养葵曰∶中满与鼓胀、水肿无异，然而不同者，中满中空似鼓，虚满而非实满也。大约脾
肾两虚所致，治者惟知泄水，而不知益胃，是以发而不能制也。
若真知为水湿之气客于中焦，侵于皮肤，如水晶之光亮，手按之随起者，《内经》去菀陈 、开鬼门、
洁净府之法，近如舟车丸、禹功散之类，一服而退，何误之有？
若久病大病后，或伤寒疟痢后，女人产后，小儿痘后，与夫元气素弱，概以前法施之，脾气愈泄愈虚，
不可复收矣，故治肿者先以补脾土为主。
或为喘满，而又加纯补，恐益 胀，必加行气利水之品方妙，不知肺气已虚，不可复行其气；肾水
已衰，不可复利其水。纯补之剂，初时似觉不快，过时药力得行，渐有条理
矣。
张仲景金匮肾气丸，能补而不滞，通而不泄，为治肿之神方。以中满之病，原于肾中之火气虚
不能行水，此方以八味为主，以补肾中之火，则三焦有所禀命，而能行水。又火能生土，土实而能制水
矣。如牛膝、车前二味，最为切当。车前利小便而不走气，与茯苓同功，强阴益精；牛膝治老人失
溺，补中续绝，壮阳益精。此方试之甚效，故详着焉。
前所论症，乃治脾肾两虚者。至于纯是脾虚，既以参 四君为主，亦须以八味丸兼补命门火，盖脾土
非命门不能生，虚则补母之义也。
喻嘉言曰∶从来肿病，遍身头面俱肿尚易治，若只单单腹胀肿则难治。遍身俱肿者，脏腑俱各有见症，
故泻肝、泻肺、泻膀胱、泻大小肠之药，间有取效之时。而单单腹胀，则中州之地，久窒其四达之轴，而清
者不升，浊者不降，互相结聚，牢不可破，实因脾气之衰，而泻脾之药尚敢漫用乎？或谓肿为大满大实，必
从乎泻，则病后肿与产后肿，将亦泻之耶？
世人过信刘张之学，以汗、吐、下三法劫除百病，罔顾元气之羸劣。所以凡用劫夺之药，其始非不遽
消，其后攻之不消矣，后再攻之，如铁石矣。不知者见之，方谓何物邪气，若此之甚。自明者观之，不过为猛
药所攻，即以此身之元气，转与此身为难首，实有如驱良民为寇之比。所以赤子盗兵，弄于潢池，禀其然哉。
惟理脾一法，可以行之。故有培养一法，补元气是也。三法俱不言泻，而泻在其中，无余蕴矣。
徐东皋曰∶经云脏寒生满病，胃中寒则胀满，太阴所至为中满。大抵脾湿有余，无阳不能施化，如土
之久于雨水，则
为泥矣。惟风和日暖，湿去阳生，自然生长也，治此宜以辛热药主之。若湿热，饮食有余，脾胃
充实者，可下。如伤寒邪入于里，而或腹满坚实，大便硬结者，三承气下之。若因脾虚为主，少佐辛热，
以行壅滞之气，庶使脾土旺健，胀满营运，经所谓塞因塞用也。
张景岳曰∶肿胀之病，气水二字足以尽之，能辨而知其虚实，无余蕴矣。病在气分，当治气为主；病在
水分，则治水为先。然气水本为同类，故治水者当兼理气，益气化水自化也；治气亦当兼水，以水行气
亦行也。
夫病在气分者，因气之滞，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，悉由气分作胀。而虚实之治，反如冰炭，必详辨之，乃能因机通变。
若病在水分者，以阴胜于阳，而肌肤皆肿，光薄明润，且肿不速，每自下而上，肿有分界。
欲辨水气之异者，须辨阴阳。若病在气分，阳症、阴症皆有之；若病在水分，则为阴症。盖阳旺则
气化，而水即为精；阳衰则气不化，而精即为水。水即身中之血气，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？
然水主于肾，气主于肺，水清于下，而气竭于上，所以下为肿满，上为喘急，标本俱病，危斯亟矣。
此宜速救本原，若作实喘，犹然泄肺，无不败矣。
河间说：痞与“否”字相同，是不通泰的意思。心膈部闷塞但不疼痛的称为痞满，内外都胀急的称为肿胀，这两者看似相同实则不同。
有中气虚弱，不能运化输布精微物质而导致痞证的，又有饮食停滞、痰湿积聚，不能运化而导致痞证的，又有湿热过盛，上乘于心下部位而导致痞证的，又有误用攻下法导致内部虚弱、邪气内陷而导致痞证的，这些都是土（脾胃）邪为患的疾病。东垣说：伤寒和杂病，如果攻下太过就会形成痞满，这都属于阴血受损的病症，因为攻下会耗伤阴液，这里的阴就是指脾胃之阴的耗伤。所以胸中的气，因为阴虚而下陷到心之分野，导致心下痞满，应当调理脾胃并配合滋阴药治疗。如果全用理气药，则痞满会更加严重。这是阐发了前人未曾发现的问题。
然而痞证有虚实之分：实痞能进食但大便闭塞，可用黄连、枳实、厚朴等苦味药来泄降；虚痞不能进食但大便通畅，可用白芍、陈皮等酸味药来收敛。有湿邪则四肢困重，小便短少，可用苍术、茯苓、半夏、滑石、泽泻等药来渗利。气机郁滞不通，食物难以消化，可用抚芎（川芎）、厚朴、香附、苍术、枳实等药来开郁。脾胃虚弱而运转不舒导致痞证的，用人参、甘草、茯苓、白术等甘温药来温补。饮食过度损伤导致寒痞的，用青皮、枳实、厚朴、山楂、神曲等药来消导。夹杂痰血形成窠囊的，用桃仁、红花、香附、大黄之类。右关脉多呈弦迟象的，必定心下坚硬胀满，这是由于肝木克制脾土，气机郁结不得开通，可用木香顺气丸。如大病后元气未恢复而出现痞证的，用补中益气汤加陈皮。
李士材说：《内经》关于肿胀的论述，五脏六腑无不涉及。详细考察全书，如《脉要精微论》说：胃脉实则胀。《病形篇》说：胃病表现为腹胀。《本神篇》说：脾气实则腹胀，大小便不利。《应象论》说：浊气在上，则生胀满。这四条都是实胀。《太阴阳明论》说：饮食起居失于节制，邪入五脏则满塞闭塞。《师传篇》说：足太阴之别络公孙穴，虚则出现鼓胀。这两条都是虚胀。《经脉篇》说：胃中寒则胀满。《方宜论》说：脏寒产生满病。《风论》说：胃风膈寒不通，受寒则胀。这三条都是寒胀。《六元正纪大论》、《至真要大论》等篇章说，太阴所至为跗肿，以及土郁发作时，太阴初之气，太阴的胜复之气，都是湿气偏胜导致的肿胀。或者说水运太过；或者说寒胜则浮肿；或者说太阳司天，太阳胜复；少阳司天，少阳胜复；或者说热胜则肿，这都是火气偏胜的热胀。或者说厥阴司天、在泉，厥阴的复气；或者说阳明的复气，这都是水邪侮犯脾土，以及金气反胜导致的肿胀。由此看来，五运六气也各有肿胀。
然而经典中有提纲挈领的说法，说：各种湿邪导致的肿胀满闷，都归属于脾；又说：其根本在肾，其标末在肺，都是水液聚集所致。又说：肾是胃的关口，关门不利，所以水液聚集并随同类相从。可见各经虽然都有肿胀，但没有不源于脾、肺、肾三经的。大概脾土主管运化，肺金主司气化，肾水主管五液，凡是五气所化生的津液，都归属于肾；五液所运行的气，都归属于肺；转输这两脏，以制约水生金的，都归属于脾，所以肿胀不外乎这三经。
但是阴阳虚实，不可不辨别，大体上阳证必然发热，发热的多为实证；阴证必然畏寒，畏寒的多为虚证。先在内腹胀胀，而后在外肢体浮肿的为实证；先在外肢体浮肿，而后在内腹中胀满的为虚证。小便黄赤，大便秘结的为实证；小便清白，大便泄泻的为虚证。脉象滑数有力为实证，脉象弦数微细为虚证。面色红赤、气息粗重为实证，面色憔悴、声音短促为虚证。凡各种实证，或是六淫外邪侵袭，或是饮食内伤，阳邪发病急速，甚至必然暴烈，往往在数日内形成。如果是虚证，或是情志劳倦过度，酒色无度，日积月累，其来势缓慢，往往经过数月之后才形成。
然而治疗实证颇容易，调理虚证恒常困难。虚人气胀的，是脾虚不能运化气机。虚人水胀的，是土虚不能制约水湿。水湿虽然受脾制约，但实际上统属于肾。肾本是水脏，而元阳寓存其中。命门火衰，既不能自制阴寒，又不能温养脾土，则阴不能从阳，精气化为水液，所以水肿的病症多属于火衰。
丹溪认为属湿热，应当养金以制水，使脾没有贼邪的侵害，滋水以制火，使肺金得到清化的权力。抑制火固然可以保金，难道就不担心伤害脾土吗？只有属于热证的才适宜。如果是阳虚者，岂不是加重病情吗？
更有不明白虚实，专门坚守“下之则胀已”这一方法的，虽然暂时得到少许宽舒，但真气更加衰弱，不久肿胀再次发作，最终导致无法救治，实在令人叹息。
我对于这种病症，察其实证的，直接清泻阳明，很快就能见效。如果涉及虚证，温补脾胃，逐渐康复。那些不大实也不大虚的，先用清利之法见效，继之以补中调摄。
又有标实而本虚的，泻之不可，补之无功，极为危险。在病名上有鼓胀与蛊胀的区别：鼓胀，中空无物，腹皮绷急，多属于气病；蛊胀，中实有物，腹形充大，不是虫积就是瘀血。在女科方面有气分、血分的区别：气分者，心胸坚大，病发于上部，先病水胀，而后月经停止；血分者，血结胞门，病发于下部，先因月经停止，而后出现水胀。在治法上有理肺、理脾的区别：先喘而后胀的，治在肺；先胀而后喘的，治在脾。这是大概的情况。
腹胀且身热的死。腹胀伴寒热往来像疟疾一样的死。腹部大胀，四肢清冷，形体脱失，泄泻严重的为逆证。腹胀伴便血，脉大时而断绝的死。嘴唇黑或肿表示肝伤。缺盆平表示心伤。脐突表示脾伤。足心平表示肾伤。背平表示肺伤。这五种损伤致死。大便滑泄，水肿不消的死。泻后腹胀且有青筋暴露的死。阴囊及阴茎肿死的。水肿先起于腹部，后散至四肢的可治；先起于四肢，后归于腹部的死。
赵养葵说：中满与鼓胀、水肿无异，然而不同的地方在于，中满中空似鼓，是虚满而非实满。大约是由脾肾两虚所致，医者只知道泄水，而不知道益胃，所以发作而不能控制。
如果真正知道是水湿之气客居中焦，侵及皮肤，像水晶一样光亮，手按之随即弹起的，《内经》去菀陈莝、开鬼门、洁净府的方法，近世如舟车丸、禹功散之类，一服即退，有什么错误呢？
如果是久病大病后，或伤寒疟痢后，女人产后，小儿痘疹后，以及素来元气虚弱的人，一概使用前法施治，脾气愈泄愈虚，不可恢复了，所以治肿者先以补脾土为主。
或者出现喘满，而又加上纯补，恐怕会增加胀满，必须加入行气利水的药物才妙，但如果不知肺气已虚，不可再行其气；肾水已衰，不可再利其水。纯补的药物，初时似乎觉得不快，过时药力得行，逐渐有条理了。
张仲景的金匮肾气丸，能补而不滞，通而不泄，是治疗水肿的神方。因为中满之病，原于肾中火气虚不能行水，此方以八味药为主，补肾中之火，则三焦有所禀命，而能行水。又火能生土，土实而能制水了。如牛膝、车前二味，最为恰当。车前利小便而不走气，与茯苓同功，强阴益精；牛膝治老人失禁，补中续绝，壮阳益精。此方试用甚效，故详细记载于此。
前所述病症，是治疗脾肾两虚的。至于纯是脾虚，既然以人参、四君子汤为主，也必须以八味丸兼补命门之火，盖脾土非命门不能生，这是虚则补母的道理。
喻嘉言说：从来肿病，遍身头面俱肿尚易治，若只单单腹胀肿则难治。遍身俱肿者，脏腑俱各有见证，所以泻肝、泻肺、泻膀胱、泻大小肠的药，间或有取效的时候。而单单腹胀，则中州之地，久窒其四达之轴，而清者不升，浊者不降，互相结聚，牢不可破，实因脾气之衰，而敢漫用泻脾的药吗？有人说肿为大满大实，必从乎泻，那么病后肿与产后肿，也将用泻法吗？
世人过分相信刘完素、张从正的学说，以汗、吐、下三法劫除百病，不顾元气的羸弱。所以凡用劫夺之药，开始并非不迅速消除，其后攻之不消了，再后攻之，如铁石般坚硬了。不懂的人见了，才问是什么邪气，如此严重。从明白的人看来，不过是猛药所攻，即用此身之元气，转而与此身为难，实在有如驱赶良民成为寇盗相比。所以赤子盗兵，弄于潢池，禀赋使其如此啊。只有理脾一法，可以施行。所以有培养一法，补元气是也。三法都不言泻，而泻在其中，没有剩余的内涵了。
徐东皋说：经文说脏寒生满病，胃中寒则胀满，太阴所至为中满。大体上是脾湿有余，无阳不能施化，如同土地久于雨水，则成为泥沼了。只有风和日暖，湿去阳生，自然生长也，治疗此症宜以辛热药为主。如果是湿热，饮食有余，脾胃充实者，可下。如伤寒邪入于里，而或腹满坚实，大便硬结者，用三承气汤下之。若因脾虚为主，少佐辛热，以行壅滞之气，庶使脾土旺健，胀满营运，经所谓塞因塞用也。
张景岳说：肿胀之病，气水二字足以尽之，能辨而知其虚实，没有剩余的内涵了。病在气分，当治气为主；病在水分，则治水为先。然气水本为同类，故治水者当兼理气，益气化水自化也；治气亦当兼水，以水行气亦行也。
夫病在气分者，因气之滞，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，悉由气分作胀。而虚实之治，反如冰炭，必详辨之，乃能因机通变。
若病在水分者，以阴胜于阳，而肌肤皆肿，光薄明润，且肿不速，每自下而上，肿有分界。
欲辨水气之异者，须辨阴阳。若病在气分，阳症、阴症皆有之；若病在水分，则为阴症。盖阳旺则气化，而水即为精；阳衰则气不化，而精即为水。水即身中之血气，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？
然水主于肾，气主于肺，水清于下，而气竭于上，所以下为肿满，上为喘急，标本俱病，危斯亟矣。
此宜速救本原，若作实喘，犹然泄肺，无不败矣。
Hejian stated: "Pi" (fullness and obstruction) is synonymous with "Pi" (blockage), meaning a state of non-communication and lack of smooth flow. When there is stuffiness in the heart and diaphragm without pain, it is called Pi Man (fullness and obstruction); when both internal and external areas are swollen and tense, it is called Zhong Zhang (swelling). Although these two conditions appear similar, they are fundamentally different.
There are cases where weak Middle Qi fails to transport and transform essential nutrients, leading to Pi; there are cases where food retention and phlegm accumulation fail to be transformed, leading to Pi; there are cases where damp-heat is excessive and rises to affect the epigastrium, leading to Pi; and there are cases where improper use of purgatives leads to internal deficiency and pathogenic invasion, resulting in Pi. All these are diseases caused by the evil of Earth (Spleen/Stomach).
Dongyuan stated: In Shanghan (Cold Damage) and miscellaneous diseases, excessive purgation leads to Pi Man, which belongs to blood/Yin injury. Purgation destroys Yin, and here "Yin" refers to the Yin of the Spleen and Stomach. Consequently, Qi in the chest sinks into the region of the Heart due to Yin deficiency, causing fullness and obstruction in the epigastrium. Treatment should regulate the Spleen and Stomach while incorporating Yin-nourishing herbs. If only Qi-regulating herbs are used, the fullness will worsen. This elucidates insights previously unexplored.
However, Pi differs in excess and deficiency: Excess Pi presents with ability to eat but constipation; bitter herbs like Huanglian (Coptis Rhizome), Zhishi (Immature Bitter Orange), and Houpo (Magnolia Bark) are used to drain. Deficiency Pi presents with inability to eat but free stool; sour herbs like Baishao (White Peony Root) and Chenpi (Aged Tangerine Peel) are used to astringe. With Dampness, limbs feel heavy and urine is scant; herbs like Cangzhu (Atractylodes Rhizome), Fuling (Poria), Banxia (Pinellia Tuber), Huashi (Talcum), and Zexie (Alisma Rhizome) are used to leach out dampness. With stagnation and indigestion, herbs like Fuxiong (Ligusticum Chuanxiong Rhizome), Houpo, Xiangfu (Cyperus Rhizome), Cangzhu, and Zhishi are used to open stagnation. For Pi due to Spleen/Stomach deficiency and poor transformation, Ganwen (sweet-warm) herbs like Renshen (Ginseng Root), Gancao (Licorice Root), Fuling, and Baizhu (Atractylodes Macrocephala Rhizome) are used to warm and tonify. For Cold Pi due to dietary overindulgence, Qingpi (Green Tangerine Peel), Zhishi, Houpo, Shanzha (Hawthorn Fruit), and Shenqu (Medicated Leaven) are used to digest and guide out food. For Phlegm-Blood forming nodules, Taoren (Peach Kernel), Honghua (Safflower), Xiangfu, and Dahuang (Rhubarb Root) are used. If the Right Guan pulse is wiry and slow, indicating hardness and fullness in the epigastrium due to Liver Wood overacting on Spleen Earth and stagnant Qi, Muxiang Shunqi Wan (Costus Root Qi-Circulating Pill) is indicated. For Pi following severe illness with unrecovered Yuan Qi (Original Qi), Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with added Chenpi is used.
Li Shicai stated: The *Neijing* discusses swelling involving all five Zang and six Fu organs. Detailed examination reveals: *Mai Yao Jing Wei Lun* states, "Stomach pulse excess leads to distension." *Bing Xing Pian* states, "Stomach disease manifests as abdominal distension." *Ben Shen Pian* states, "Spleen excess leads to abdominal distension and difficult urination/defecation." *Ying Xiang Lun* states, "Turbid Qi remaining above generates distension." These four points describe Excess Distension. *Tai Yang Yang Ming Lun* states, "Irregular diet and lifestyle, entering the five Zang, causes fullness and blockage." *Shi Chuan Pian* states, "Deficiency in the collateral Sunqiong of Foot Taiyin leads to Drum Distension." These two points describe Deficiency Distension. *Jing Mai Pian* states, "Cold in the Stomach leads to fullness and distension." *Fang Yi Lun* states, "Organ cold generates fullness diseases." *Feng Lun* states, "Stomach wind with diaphragmatic cold and obstruction leads to distension upon exposure to cold." These three points describe Cold Distension. *Liu Yuan Zheng Ji Da Lun* and *Zhi Zhen Yao Da Lun* state that arrival of Taiyin causes edema, and during Earth Depression or Taiyin's initial Qi/victory-reversal, it is swelling due to Dampness excess. Some attribute it to Water Transport excess; some to Cold excess causing floating; some to Taiyang ruling heaven/victory-reversal or Shaoyang ruling heaven/victory-reversal; some to Heat excess causing swelling. These are Heat Distension due to Fire excess. Some attribute it to Jueyin ruling heaven/in泉 or Yangming reversal, representing Water Evil insulting Earth or Metal Qi counter-excess, causing swelling. Thus, the Five Movements and Six Qi also each have their own types of swelling.
However, the classics provide a general principle: "All dampness-induced swelling and fullness belong to the Spleen"; also, "The root is in the Kidney, the branch is in the Lung," referring to water accumulation. Also, "The Kidney is the gate of the Stomach; if the gate is not functional, water accumulates and follows its kind." Thus, although all meridians can present with swelling, none do not originate from the Spleen, Lung, and Kidney. The Spleen Earth manages transport and transformation; the Lung Metal manages Qi transformation; the Kidney Water manages the five fluids. All fluids transformed by the five Qi belong to the Kidney; all Qi transported by the five fluids belongs to the Lung; the transmission between these two organs, controlling Water generating Metal, belongs to the Spleen. Therefore, swelling does not exceed these three meridians.
However, Yin/Yang and Excess/Deficiency must be distinguished. Generally, Yang syndromes involve heat, and heat often indicates excess; Yin syndromes involve cold, and cold often indicates deficiency. Swelling starting internally then externally indicates excess; swelling starting externally then internally indicates deficiency. Yellow/red urine and constipation indicate excess; clear/white urine and diarrhea indicate deficiency. Slippery, rapid, and forceful pulses indicate excess; wiry, rapid, faint, and fine pulses indicate deficiency. Red complexion and coarse breathing indicate excess; sallow complexion and short voice indicate deficiency. All excess syndromes, whether from Six Evils invading externally or dietary injury internally, involve rapid Yang pathogens, often manifesting violently within days. Deficiency syndromes, whether from emotional labor, excessive alcohol/sex, accumulate gradually over months.
Treating excess is relatively easy; treating deficiency is consistently difficult. Deficiency Qi distension is due to Spleen deficiency failing to move Qi. Deficiency Water swelling is due to Earth deficiency failing to control Water. Although Water is controlled by the Spleen, it is ultimately governed by the Kidney. The Kidney is a Water organ but houses Original Yang. Decline of Mingmen Fire (Gate of Life Fire) means it cannot control internal Cold nor warm the Spleen Earth, so Yin does not follow Yang, and essence transforms into water. Thus, edema often belongs to Fire decline.
Danxi believed it was Damp-Heat, advocating nourishing Metal to control Water (protecting Spleen from thief evils) and nourishing Water to control Fire (allowing Lung Metal to clear and transform). While controlling Fire protects Metal, does one not worry about harming Earth? This is only suitable for Heat syndromes. For Yang deficiency, would this not worsen the condition?
Some, unaware of excess/deficiency, strictly adhere to "purgation cures distension." Though providing temporary relief, Yuan Qi further declines, and swelling returns shortly after, leading to untreatable conditions, which is lamentable.
For my approach: For excess, directly clear Yangming for quick results. For deficiency, warm and tonify Spleen/Stomach for gradual recovery. For mixed mild excess/deficiency, start with clearing/drainage, then tonify middle and regulate.
For superficial excess with root deficiency, purging is contraindicated, tonifying is ineffective, making it highly dangerous. Regarding nomenclature: Gu Zhang (Drum Distension) has an empty center, tight skin, mostly Qi-related; Gu Zhang (Insect Distension) has solid contents, enlarged abdomen, either parasites or Blood stasis. In Gynecology: Qi aspect involves upper body firmness, starting with water swelling then amenorrhea; Blood aspect involves blood binding at the uterus, starting with amenorrhea then water swelling. Regarding treatment: Regulate Lung vs. Regulate Spleen. Wheezing first then distension treats the Lung; distension first then wheezing treats the Spleen. This is the general overview.
Abdominal distension with body heat: death. Abdominal distension with chills/fever resembling malaria: death. Large abdominal distension, cold extremities, emaciation, severe diarrhea: adverse prognosis. Abdominal distension with bloody stool, large pulse intermittently absent: death. Black/swollen lips: Liver injury. Flat clavicular fossa: Heart injury. Protruding umbilicus: Spleen injury. Flat soles: Kidney injury. Flat back: Lung injury. These five injuries lead to death. Loose stools with unresolved edema: death. Abdominal distension with visible veins after diarrhea: death. Scrotal/penile swelling: death. Edema starting in abdomen then spreading to limbs: treatable. Edema starting in limbs then returning to abdomen: death.
Zhao Yangkui stated: Zhong Man (Middle Fullness) is similar to Drum Distension and edema, but differs as Zhong Man is hollow like a drum, being false fullness rather than true fullness. It is generally caused by Spleen/Kidney dual deficiency. Physicians only know to drain water but not benefit the Stomach, so it recurs uncontrollably.
If truly knowing it is Water-Damp Qi lodging in the Middle Jiao, invading skin, shining like crystal, rebounding instantly upon pressure, the *Neijing* methods of removing accumulation, opening pores (sweating), and cleansing the bladder (diuresis), using formulas like Zhouche Wan or Yugong San, can resolve it in one dose. What error is there?
However, for chronic/severe illness post-phase, post-Shanghan/malaria/dysentery, post-partum women, post-smallpox children, or those with inherent weak Yuan Qi, applying these methods exhausts Spleen Qi irreparably. Thus, treating swelling prioritizes tonifying Spleen Earth.
If accompanied by wheezing/fullness, adding pure tonification may worsen distension; adding Qi-moving and diuretic herbs is better. But if Lung Qi is already deficient, moving Qi is contraindicated; if Kidney Water is already depleted, draining Water is contraindicated. Pure tonics may initially feel uncomfortable, but as药效 takes effect, order is restored.
Zhang Zhongjing's Jin Gui Shen Qi Wan (Kidney Qi Pill from the Golden Cabinet) tonifies without stagnation and unblocks without leakage, a divine formula for swelling. Zhong Man originates from deficient Fire Qi in the Kidney failing to move Water. This formula uses eight ingredients to tonify Kidney Fire, empowering the Triple Burner to move Water. Fire generates Earth; solid Earth controls Water. Achyrhantes Root (Niuxi) and Plantago Seed (Cheqianzi) are particularly apt. Cheqianzi promotes urination without depleting Qi, functioning like Fuling, strengthening Yin and benefiting essence; Niuxi treats elderly incontinence, supplements the middle, reconnects severances, strengthens Yang and benefits essence. This formula is highly effective, hence detailed here.
The previous discussion addressed Spleen/Kidney dual deficiency. For pure Spleen deficiency, using Renshen and Sijunzi Tang (Four Gentlemen Decoction) as main, one must also use Shenqi Wan to tonify Mingmen Fire, as Spleen Earth cannot generate without Mingmen, following the principle of tonifying the mother in deficiency.
Yu Jiayan stated: Generalized swelling of face/body is easier to treat; isolated abdominal distension/swelling is difficult. Generalized swelling shows symptoms in various organs, so draining Liver/Lung/Bladder/Intestines may occasionally work. Isolated abdominal distension blocks the central pivot, preventing clear rising and turbid descending, causing stubborn aggregation due to Spleen Qi decline. Dare one casually use Spleen-draining herbs? Some say swelling is great fullness/excess requiring purging; should post-illness or post-partum swelling be purged?
People overly trust Liu Wansu and Zhang Congzheng, using sweating/vomiting/purging to eradicate diseases, ignoring frail Yuan Qi. Purging drugs may reduce swelling initially, but later become ineffective, then resistant as iron. Laypeople wonder at the severity of the pathogen; experts see it as damage by harsh drugs, turning the body's own Qi against itself, like driving good people to banditry. Only regulating the Spleen works. Thus, cultivation (tonifying Yuan Qi) is key. The three methods imply purging within tonification, leaving no room for improvement.
Xu Donggao stated: Classics say organ cold generates fullness, stomach cold causes distension, Taiyin arrival causes middle fullness. Generally, Spleen Dampness excess without Yang cannot transform, like soil becoming mud after rain. Only warm sun and breeze remove dampness and generate Yang for growth. Treatment requires acrid-hot herbs. For Damp-Heat with dietary excess and solid Spleen/Stomach, purging is possible. For Shanghan entering interior with hard abdomen and constipation, Chengqi Decoctions purge. For Spleen deficiency as main cause, add slight acrid-hot herbs to move stagnant Qi, strengthening Spleen Earth for transport, fulfilling the classic "treating obstruction with obstruction" principle.
Zhang Jingyue stated: Swelling is fully described by "Qi" and "Water"; distinguishing excess/deficiency covers all aspects. Qi-biased disease treats Qi primarily; Water-biased disease treats Water primarily. Since Qi and Water are related, treating Water requires managing Qi (tonifying Qi transforms Water); treating Qi requires managing Water (moving Water moves Qi).
Qi-biased disease arises from Qi stagnation, Qi/Blood rebellion, dietary rebellion, Cold/Heat/Damp/Wind rebellion, or Qi deficiency failing to transform. Any failure in regulation causes Qi-biased distension. Excess/Deficiency treatments are opposite as ice and charcoal; careful distinction is needed for adaptive therapy.
Water-biased disease involves Yin exceeding Yang, causing generalized, shiny, slow-rising swelling from below with distinct boundaries. To distinguish Water/Qi, differentiate Yin/Yang. Qi-biased includes both Yang/Yin syndromes; Water-biased is exclusively Yin syndrome. Strong Yang transforms Qi, turning water into essence; weak Yang fails to transform Qi, turning essence into water. Water is blood/Qi in the body; whether pathogenic or normal depends on transformation. Failure to transform water due to Qi deficiency implies Yin lacking Yang.
Water is governed by Kidney, Qi by Lung. Clear water below, exhausted Qi above leads to lower swelling/fullness and upper wheezing, affecting root and branch, critically urgent. One must quickly save the root. Treating as excess wheezing and draining the Lung will inevitably fail.