经云。太阴所至为中满，诸湿肿满。皆属于脾。诸胀腹大。皆属于热。清气在下。则生飧泄。
浊气在上。则生 胀。金匮云。趺阳脉微弦。法当腹满。不满者必便难。两 疼痛。此虚寒从下上
也。当以温药服之。
趺阳以候内因。寸口以候外因。趺阳脾胃之脉而见微弦。为厥阴肝木所侵。侮其阴气。横聚
于腹。法当胀满有加。设不满。阴邪必转攻而上。决无轻散之理。盖阴邪即聚。不温必不散。阴
邪不散。阴窍必不通。故知其便必难。势必逆攻两 而痛。较腹满更进一步也。虚寒之气从下而
上。由腹而 。才见一斑。亟以温药服之。使阴邪从阴窍走散而不至上攻则善矣。
病者腹满。按之不痛为虚。痛者为实。可下之。舌黄未下者。下之黄自去。
腹满时减复如故。此为寒。当与温药。腹满不减。减不足言。当须下之。宜大承气汤。
腹满不减。减不足言。当须下之。宜大承气汤一条。已见伤寒阳明府实证。此腹满时减复如
故。为虚寒。当温之。盖腹满虽因中气虚寒。然下焦之真阳未灭。有时而升。则有时而减。然终
属虚寒。故复如故。而当与温药也。
按之心下满者。此为实也。当下之。宜大柴胡汤。
邪从胸胁而入于阳位。合用大柴胡两解之。与脐腹硬痛承气证不同。
病者痿黄。躁而不渴。胸中寒实而利不止者死。
寸口脉弦者。即胁下拘急而痛。其人啬啬恶寒也。
此论外因之腹满。故脉辨于寸口也。寸口脉弦而胁下拘痛者。其人表气微虚。不能外御其邪。
俾风邪即与水气相合。而为胁下拘痛。表中阳虚故啬啬恶寒也。
夫瘦人绕脐痛。必因风冷。谷气不行。而反下之。其气必冲。不冲者。心下则痞。
瘦人本无痰湿痹着。而绕脐痛者。为肌肉疏薄。风冷得以直入。干于脾土之阴分。土气伤则
不能转运。是以谷气不行。若反下之。徒虚其肠胃。邪气愈逆。因而上冲。经曰。气上冲胸。邪
在大肠故也。不冲者。邪在于胃。客气上逆。则心下痞也。
病腹满。发热十日。脉浮而数。饮食如故。浓朴七物汤主之。
腹满者。邪气入于里也。发热者。阳气达于外也。虽病经十日而脉浮数。邪犹未全入里。况
能食以证胃气之有权。故用小承气合桂枝去芍药汤。两解表里之法。较之桂枝加大黄汤。多枳、朴而少芍药。以枳、
朴专泄壅滞之气。故用之。芍药专收耗散之阴。此腹但满而不痛。与阴血无预。故去之。
腹中寒气。雷鸣切痛。胸胁逆满呕吐。附子粳米汤主之。
腹中寒气奔迫。上攻胸胁。以及于胃。而增呕逆。顷之胃气空虚。邪无所砥。辄入阳位则殆
矣。是以除患之机。所重全在胃气。乘其邪初犯胃。尚自能食。而用附子、粳米之法。温饱其胃。
胃气温饱。则土浓而邪难上越。胸胁逆满之浊阴。得温无敢留恋。必还从下窍而出矣。
痛而闭者。浓朴三物汤主之。
痛而闭塞。无雷鸣呕逆之证者为实。当下之。即用小承气。倍浓朴。而易其名。以其无亢极
之火。故不用承气二字。与理中汤之易名人参汤一义。
东垣曰。经云。诸胀腹大。皆属于热。此八益之邪。有余之证。自外而入。风寒之邪。传入
于里。寒变为热。而作胃实。日晡潮热。大渴引饮。谵语胀满者。承气汤下之。下之则胀已是也。
五脏六腑俱有胀满。更以胀家寒热多少较之。胃中寒则胀满。浊气在上。则生 胀。胃中寒湿菀
遏故也。太阴之厥。则腹满 胀。后不利。不欲食。食则呕。不得卧。按所云寒胀多如此。亦有
膏粱之人。醇酒浓味之湿热不得施化。郁于内而成胀满者。此热胀之谓也。调经篇云。因饮食劳
倦。损伤脾胃。始受热中。末传寒中。皆由脾胃之气。不能运化精微。致水谷聚而不散。遂成胀
满。又有饮食过伤而成 胀飧泄者。经云。清气在下。则生飧泄。浊气在上。则生 胀。此阴阳
反作。病之逆从也。夫饮食不节。起居不时者。阴受之。阴受之则入五脏。入五脏则闭塞不通而
成胀矣。此皆饮食自倍。肠胃乃伤所致。治胀务在调其虚实。适其寒
温。兼寒热补泻之法于战守之间。从少从多。各从其类。可一言而尽也。
张三锡曰。胀满悉属脾虚。运化不及。浊气填塞所致。初起微佐以消化。舒郁为先。势甚而
二便涩滞者。微利之。弱人或稍久。一切病后产后疮疽后。必用参、术、 、芍大补脾气为主。
而佐以消化。浓朴、木香、黄连之类。然王道无近功。必数十帖以渐取效。每见粗工专守下之则
胀已一法。用商陆、牵牛等。一泻即消。三日后复起。然真气因泻而下脱。邪气必复聚而成胀。
遂致不救。可胜道哉。
腹胀诸证。虽属寒者多。属热者少。然世治胀。喜用辛温散气之药。即使湿热作胀。亦必赖
辛温之品以散气。气散则胀满亦宽。但须以去湿热之药为主。而兼辛温为引导则可。然又有火盛
阴虚。热乘血分者。其腹虽胀而不甚大。按之益坚。小便黄赤。大便秘涩。至夜则微热。其脉数
实而细小。不可误作食积湿热治。盖消导则阴愈伤。去湿则津愈涸矣。宜用极苦极寒之药。如当
归龙荟丸。或四物汤加宣胡二连、芦荟。俱用醋制。可一服而效也。有气虚不能裹血。血散作胀。
必其人大便不坚。或时结时溏。溏则稍减。结则渐加。小便清利。甚则浑白如泔。其脉缓大而滞。
气口益甚。慎不可用辛温耗气之药。宜四君子去白术。加木香、泽泻、当归、芍药。以固其气中之
血。有血虚不能敛气。气散作胀。必其人烦热便燥。小便黄数。其脉浮数而弦。人迎尤甚。慎不
可用苦寒伤胃之药。宜四物汤去地黄。加黄 、肉桂、甘草、煨姜以和其血中之气。外因六气成
胀。藿香正气散。内因七情成胀。沉香降气散。忧思过度致伤脾胃。心腹膨胀。喘促烦闷肠鸣。
气走漉漉有声。大小便不利。脉虚而涩。局方七气汤。浊气在上。则生 胀。生姜泻心汤加木香、
浓朴。脾胃不温不能腐熟水谷而胀。附子理中汤。肾脏虚寒不能生化脾土而胀。济生肾气丸。中
满腹内坚硬如盘。不能坐卧。大小便涩滞。上气喘促。面色痿黄。通身虚肿者。此寒热错杂。胶
固于中。营卫血气凝滞于内也。分消汤、分消丸。详寒热多少。或加减用之。诸七气选用亦可。
气口脉紧滑。恶心饱闷。口干内热者。是食积。枳实导滞丸。饱食奔走。或跌扑凝血不散。或妇
人血聚而成肿胀。腹上有青紫筋。腹中按之疼。脉来弦涩。当作蓄血治之。怒甚气逆。腹胁胀满。
两手脉弦。青皮、陈皮、木香、山栀、柴胡、枳壳、归尾、桃仁、芍药、薄桂。嗜酒之人。病腹
胀如斗。前后溲便俱有血。用利药转加。其脉数而涩。此得之湿热伤脾阴。不能统血。胃虽受谷。
脾不输运。故成痞胀。当理脾气。祛湿热。兼养血之剂。如枳实、黄连、炮姜、半夏、茯苓、当
归、芍药、阿胶、乌梅、砂仁之类。白芍、乌梅收脾阴。黄连、枳实泻胀满。归、胶补营血。苓、
半去涎饮。砂仁醒脾气也。倘触动平昔所蓄之湿热。胀满逆上喘急者多死。下利不止者亦死。
〔诊〕脉来缓大者属气虚。弦数者为血热。气口紧盛或滑为停滞。濡滑为湿热。弦细为肝邪乘
脾。人迎浮弦为风气内乘。弦细而数为阴邪上逆。若虚大无根。为脾胃气衰。沉细短涩。为肾脏
气绝。
石顽治太史钱宫声媳。去秋疟久大虚。饮食大减。经水不调。季冬略行一度。今春时发寒热。
腹满不食。服宽胀利水药不应。拟进破血通经之剂。邀石顽相商。其脉左寸厥厥动摇。右关与两
尺虽微弦。而重按久按。却滑实流利。惟右寸左关虚濡而数。寻之涩涩少力。此阴中伏阳之象。
洵为胎脉无疑。良由中气虚乏。不能转运其胎。故尔作胀。前医曰。自结 迄今。距十二载。从
来未曾受孕。病后元气大虚。安有怀娠之理。石顽曰。向之不孕。必有其故。今病后余热留于血
室。因而得妊。亦恒有之。细推病机。每粥食到口。辄欲作呕。惟向晚寒热之际。得热饮入胃。其寒
热顿减。岂非胃气虚寒。水精不能四布。留积而为涎液。汪洋心下乎。俗名恶阻是也。其腹满便
难之虚实。尤须明辨。金匮有云。趺阳脉微弦。法当腹满。不满必便难。乃虚寒从下上也。当以
温药服之。况大便之后。每加胀急。以里气下通。浊阴乘机上扰。与得下临时宽快迥殊。其治虽
当安胎为主。但浊阴之气。非藉辛温不能开导其结。遂疏四君子汤。益入归、芍以收营血之散。
稍借肉桂为浊阴之向导。使母气得温中健运之力。胎息无浊阴侵犯之虞。桂不伤胎。庞安常先有
明试。余尝屡验之矣。服后寒热渐止。腹胀渐宽。饮食渐进。胎息亦渐形着而运动于脐上。至仲
夏。因起居不慎。而胎漏下血。前医犹认石瘕而进破积之方。乃明谕脉证。左寸动滑。断属干象。
而与扶脾药得安。后产一子。举家称快。设不审而与通经破血。能保子母双全之庆乎。
飞畴治谢元海。因夏月常饮火酒。致善食易饥。半月后。腹渐胀满。大便艰涩。而食亦日减。
医用削克清火俱不效。左脉细数。右脉涩滞。此始为火助胃强而善食。继为火灼胃液而艰运。艰
运则食滞而胀满。胀满则食减。今宜断食辛烈。乘元气未漓。祛其滞而回其液。日久则费调理也。
因用枳实导滞汤去黄连、白术。加葛根。一服大便通利而滞行。又用健脾理气。三日后以小剂生
脉加葳蕤、煨葛根。不半月而愈。
《黄帝内经》说：太阴湿土之气盛行时，会导致中焦痞满；各种湿气引起的浮肿和胀满，都归属于脾。各种腹部胀大，都归属于热证。清阳之气如果不升反而在下，就会发生完谷不化的泄泻。浊阴之气如果不降反而在上，就会发生腹胀。
《金匮要略》说：趺阳脉（候脾胃之气）微带弦象，按法应当出现腹满。如果不腹满，必定是大便困难，两胁下疼痛。这是虚寒之气从下向上侵犯所致。应当用温性药物来治疗。
趺阳脉用来诊察内因病变，寸口脉用来诊察外因病变。趺阳脉是脾胃的脉象，如果见到微弦之象，说明被厥阴肝木所克制，肝木侮犯脾土阴气，横逆积聚于腹部，按法应当出现严重的胀满。假设没有腹满，说明阴邪必然转而攻冲向上，绝不会有轻散的道理。因为阴邪一旦聚集，不用温药必然不能消散。阴邪不散，阴窍（前后二阴）必然不通畅，所以知道大便一定困难。病势必然逆攻两胁导致疼痛，这比单纯的腹满更进一步了。虚寒之气从下向上，由腹部波及胁肋，只是显露了一小部分迹象，急需服用温药，使阴邪从阴窍走散而不向上攻冲，这样就好了。
病人腹部胀满，按压时不痛的属于虚证，痛的属于实证，可以用攻下法。舌苔黄而未用过攻下药的，用了攻下药后黄苔自然去除。
腹部胀满有时减轻，过后又像原来一样，这是寒证，应当给予温药。腹部胀满持续不减，即使有减轻也不足挂齿，应当必须用攻下法，适宜用大承气汤。
“腹部胀满持续不减，即使有减轻也不足挂齿，应当必须用攻下法，适宜用大承气汤”这一条，已经见于《伤寒论》阳明腑实证中。这里提到的“腹部胀满有时减轻，过后又像原来一样”，属于虚寒证，应当用温法。大概腹部胀满虽然是因为中气虚寒，但是下焦的真阳尚未熄灭，有时能够上升，所以有时胀满会减轻。然而终究属于虚寒，所以胀满又会恢复原状，因此应当给予温药。
按压心下部感到胀满的，这是实证，应当用攻下法，适宜用大柴胡汤。
邪气从胸胁进入阳位，合用大柴胡汤表里双解。这与脐腹硬痛的大承气汤证不同。
病人面色萎黄，烦躁但不口渴，胸中有寒实之邪且腹泻不止的，预后不良，属死证。
寸口脉弦的，即胁下拘急而疼痛，病人怕冷。
这是论述外因引起的腹满，所以在寸口脉上进行辨析。寸口脉弦且胁下拘痛，说明病人表气微弱虚弱，不能在外抵御邪气，致使风邪与水气相合，从而引起胁下拘痛。表中阳气虚故而感到怕冷。
瘦人绕脐疼痛，必定是因为风冷，谷气运行不畅，如果反而用攻下法，正气必然上冲。不上冲的，心下部就会痞塞。
瘦人本来没有痰湿阻滞，而绕脐疼痛的，是因为肌肉疏薄，风冷得以直接侵入，干扰脾土的阴分。脾土之气受伤则不能转运，所以谷气运行不畅。如果反而用攻下法，只会使肠胃更虚，邪气更加逆乱，因而向上冲逆。《内经》说：气上冲胸，是因为邪气在大肠。不上冲的，邪气在胃，客气上逆，就会导致心下部痞塞。
病人腹部胀满，发热十天，脉浮而数，饮食如常，用浓朴七物汤主治。
腹满是邪气入里的表现。发热是阳气达于体外的表现。虽然患病经过十天但脉象仍浮数，说明邪气还没有完全入里。况且能进食证明胃气尚有权衡能力，所以用小承气汤合桂枝去芍药汤，采用表里双解的方法。这比桂枝加大黄汤多了枳实、厚朴，少了芍药。因为枳实、厚朴专门宣泄壅滞的气机，所以使用它们。芍药专门收敛耗散的阴液，此症只是胀满而不痛，与阴血无关，所以去掉它。
腹中有寒气，肠鸣如雷，剧烈疼痛，胸胁气逆胀满，呕吐，用附子粳米汤主治。
腹中寒气奔迫，向上攻冲胸胁及胃，增加呕逆。不久胃气空虚，邪气没有抵挡，就侵入阳位，这就危险了。所以消除祸患的关键，重在保全胃气。趁着邪气刚侵犯胃，病人还能进食，就用附子、粳米的方法，温补温暖胃气。胃气温饱，则脾土厚实而邪气难以向上越出。胸胁逆满的浊阴之气，得到温煦就不敢留恋，必然还会从下窍排出。
腹痛且闭塞，没有肠鸣呕逆症状的属于实证，应当用攻下法。即用小承气汤，加倍厚朴，并更改名称。因为没有亢盛至极的火邪，所以不用“承气”二字。这与理中汤改名人参汤的道理相同。
李东垣说：《内经》说：各种腹部胀大，都归属于热证。这是八益之邪，有余的证候，从外部进入体内。风寒之邪传入里部，寒变为热，造成胃实证。日晡时（下午3-5点）潮热，大渴引饮，谵语胀满的，用承气汤攻下。攻下后胀满即可消除。
五脏六腑都有胀满，再根据胀家寒热的多少来比较。胃中寒则胀满，浊气在上，就会发生腹胀，这是胃中寒湿郁遏的缘故。太阴厥逆，则腹满腹胀，后阴不利，不想吃东西，吃了就吐，不能躺卧。按上述所说，寒胀大多如此。也有吃膏粱厚味、醇酒浓味的人，湿热不得施化，郁结在内而成胀满的，这就是热胀。《调经篇》说：因为饮食劳倦，损伤脾胃，起初受热中，后来传变为寒中，都是因为脾胃之气，不能运化精微，导致水谷聚积不散，遂成胀满。又有饮食过度损伤而成腹胀、完谷不化的泄泻，《内经》说：清气在下，则生飧泄；浊气在上，则生腹胀。这是阴阳反作，病证的逆乱。饮食不节制，起居不定时，阴经受邪。阴经受邪则入五脏，入五脏则闭塞不通而成胀。这些都是因为饮食过量一倍，肠胃乃受伤所致。治疗胀满务必调理虚实，适应寒温，兼用寒热补泻之法在战守之间，从少从多，各从其类，可以一言以蔽之。
张三锡说：胀满都属于脾虚，运化不及，浊气填塞所致。初起轻微佐以消食化积，以舒解郁结为先。病情严重且二便涩滞的，轻微通利。体弱之人或病程稍久，一切病后、产后、疮疽后，必须用人参、白术、茯苓、芍药大补脾气为主，而佐以消食化积，如厚朴、木香、黄连之类。然而王道之治没有近功，必须数十帖才能逐渐见效。常见粗工专门坚守“下之则胀已”这一方法，用商陆、牵牛等药，一泻即消。三日后复发。然而真气因泻而下脱，邪气必重新聚积而成胀，最终导致不治，岂可胜道哉。
腹胀诸证，虽然属寒的多，属热的少。然而世人治疗胀满，喜欢用辛温散气的药。即使是湿热作胀，也必定依赖辛温之品来散气。气散则胀满也会宽缓。但必须以去湿热之药为主，兼用辛温作为引导才可以。然而又有火盛阴虚，热乘血分的，其腹部虽然胀但不甚大，按压更坚硬，小便黄赤，大便秘涩，到了夜间则微热，脉象数实而细小，不可误作食积湿热治疗。因为消导则阴液更伤，去湿则津液更枯竭。适宜用极苦极寒的药，如当归龙荟丸，或四物汤加宣胡连、芦荟，都用醋制，可以一服而效。有气虚不能包裹血液，血散作胀的，必定其人大便不坚，有时干结有时稀溏，稀溏则稍减，干结则渐加，小便清利，严重时浑浊如米泔水，脉象缓大而滞，气口脉尤其明显，千万不可用辛温耗气的药。适宜用四君子汤去白术，加木香、泽泻、当归、芍药，以固护气中之血。有血虚不能收敛气机，气散作胀的，必定其人烦热便燥，小便黄数，脉象浮数而弦，人迎脉尤其明显，千万不可用苦寒伤胃的药。适宜用四物汤去地黄，加黄芪、肉桂、甘草、煨姜以调和血中之气。外因六气成胀，用藿香正气散。内因七情成胀，用沉香降气散。忧思过度致伤脾胃，心腹膨胀，喘促烦闷肠鸣，气走漉漉有声，大小便不利，脉虚而涩，用局方七气汤。浊气在上，则生腹胀，用生姜泻心汤加木香、厚朴。脾胃不温不能腐熟水谷而胀，用附子理中汤。肾脏虚寒不能生化脾土而胀，用济生肾气丸。中满腹内坚硬如盘，不能坐卧，大小便涩滞，上气喘促，面色萎黄，通身虚肿的，这是寒热错杂，胶固于中，营卫血气凝滞于内也，用分消汤、分消丸。详细辨别寒热多少，或加减使用。诸七气汤选用亦可。
气口脉紧滑，恶心饱闷，口干内热的，是食积，用枳实导滞丸。饱食奔走，或跌扑凝血不散，或妇人血聚而成肿胀，腹上有青紫筋，腹中按压疼痛，脉来弦涩，当作蓄血治疗。怒甚气逆，腹胁胀满，两手脉弦，用青皮、陈皮、木香、山栀、柴胡、枳壳、归尾、桃仁、芍药、薄桂。嗜酒之人，病腹胀如斗，前后溲便俱有血，用利药后加重，脉数而涩，这是湿热伤脾阴，不能统血，胃虽受谷，脾不输运，故成痞胀，当理脾气，祛湿热，兼养血之剂，如枳实、黄连、炮姜、半夏、茯苓、当归、芍药、阿胶、乌梅、砂仁之类。白芍、乌梅收脾阴，黄连、枳实泻胀满，归、胶补营血，苓、半去涎饮，砂仁醒脾气也。倘若触动平昔所蓄之湿热，胀满逆上喘急者多死。下利不止者亦死。
〔诊〕脉来缓大的属气虚。弦数的为血热。气口紧盛或滑为停滞。濡滑为湿热。弦细为肝邪乘脾。人迎浮弦为风气内乘。弦细而数为阴邪上逆。若虚大无根，为脾胃气衰。沉细短涩，为肾脏气绝。
石顽治疗太史钱宫声的儿媳。去年秋天疟疾日久身体大虚，饮食大减，月经不调，季冬时节仅行经一次。今年春天时常发寒热，腹部胀满不进食，服用宽胀利水药无效。打算进用破血通经的药剂，邀请石顽商量。其脉左寸厥厥动摇，右关与两尺虽微弦，但重按久按，却滑实流利，只有右寸左关虚濡而数，寻之涩涩少力。这是阴中伏阳的征象，确实是胎脉无疑。大概是由于中气虚乏，不能转运其胎，所以产生胀满。前医说：自结婚至今，距十二载，从来未曾受孕，病后元气大虚，哪有怀孕的道理。石顽说：之前的不孕，必有其原因。现在病后余热留于血室，因而得妊，也是常有的事。仔细推究病机，每粥食到口，辄欲作呕，惟向晚寒热之际，得热饮入胃，其寒热顿减，难道不是胃气虚寒，水精不能四布，留积而为涎液，汪洋心下吗？俗名恶阻是也。其腹满便难的虚实，尤其需要明辨。《金匮要略》说：趺阳脉微弦，按法应当腹满，不满必便难，乃虚寒从下上也，应当用温药服用。何况大便之后，每加胀急，因为里气下通，浊阴乘机上扰，与得下临时宽快截然不同。其治疗虽然应当安胎为主，但浊阴之气，非藉辛温不能开导其结，于是开具四君子汤，加入当归、芍药以收敛营血的散失，稍微借用肉桂作为浊阴的向导，使母气得温中健运之力，胎息无浊阴侵犯之虞。桂不伤胎，庞安常先有明试，我尝屡验之矣。服药后寒热渐止，腹胀渐宽，饮食渐进，胎息亦渐形着而运动于脐上。至仲夏，因起居不慎，而胎漏下血。前医仍然认为是石瘕而进用破积的方子，于是明确谕示脉证，左寸动滑，断属妊娠之象，而与扶脾药得安。后来产下一子，举家称快。如果不审察而用通经破血，能保子母双全之庆乎？
飞畴治疗谢元海。因为夏天常饮火酒，导致善食易饥。半月后，腹部渐渐胀满，大便艰涩，而食欲也日渐减少。医生用削克清火的方法都不见效。左脉细数，右脉涩滞，这是开始为火助胃强而善食，接着为火灼胃液而艰运。艰运则食滞而胀满，胀满则食减。现在应当断绝辛辣食物，趁着元气未漓，祛除滞气而恢复津液，日久则费调理也。于是用枳实导滞汤去黄连、白术，加葛根。一服大便通利而滞行。又用健脾理气，三日后用小剂生脉散加葳蕤、煨葛根，不半月而愈。
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: When the dampness of Taiyin (Taiyin Wet Earth) prevails, it leads to fullness in the middle jiao; various swellings and distensions caused by dampness all belong to the Spleen. Various abdominal enlargements all belong to Heat syndromes. If Clear Yang fails to ascend and remains below, it generates stool with undigested food (Sun Xie). If Turbid Yin fails to descend and remains above, it generates abdominal distension.
The *Jingui Yaolue* (Essential Prescriptions from the Golden Cabinet) states: A FuYang pulse (palpated at the dorsalis pedis artery, reflecting Stomach and Spleen Qi) that is slightly wiry indicates that abdominal distension should occur according to the method. If there is no distension, there must be difficulty in defecation and pain in both hypochondriac regions. This is due to deficiency-cold invading from below upwards. It should be treated with warm herbs.
The FuYang pulse is used to diagnose internal causes, while the CunKou pulse (radial artery) is used to diagnose external causes. The FuYang pulse reflects the Stomach and Spleen; if a slight wiry appearance is seen, it indicates invasion by Jueyin Liver Wood, which insults the Yin Qi of the Spleen, accumulating horizontally in the abdomen. According to the method, severe distension should ensue. If distension does not occur, it implies that the Yin pathogen has turned to attack upwards, and there is absolutely no possibility of mild dispersion. Once Yin pathogens gather, they will not disperse without warming. If Yin pathogens do not disperse, the Yin orifices (anterior and posterior) will necessarily be obstructed. Therefore, we know defecation must be difficult. The pathological trend will inevitably attack the hypochondrium causing pain, which is a step further than simple abdominal distension. Deficiency-cold Qi moves upwards from below, affecting the hypochondrium from the abdomen; this reveals only a glimpse of the situation. It is urgent to administer warm medicines so that Yin pathogens disperse through the Yin orifices and do not attack upwards, which would be ideal.
If a patient presents with abdominal distension, pressing it yields no pain, indicating a Deficiency syndrome; pain upon pressing indicates an Excess syndrome, which can be treated with purgatives. If the tongue coating is yellow and purgatives have not yet been used, the yellow coating will disappear after purgation.
If abdominal distension decreases intermittently but returns to its previous state, this is a Cold syndrome, and warm medicines should be administered. If abdominal distension persists without relief, and any reduction is negligible, purgation is necessary, preferably using Da Cheng Qi Tang (Major Order the Qi Decoction).
The statement "Abdominal distension persists without relief, and any reduction is negligible, purgation is necessary, preferably using Da Cheng Qi Tang" appears in the discussion of Yangming Fu Organ Excess Syndromes in the *Shanghan Lun*. Here, "abdominal distension decreases intermittently but returns to its previous state" indicates a deficiency-cold syndrome, requiring warming. Although abdominal distension may result from deficiency-cold of the Middle Qi, the True Yang of the Lower Jiao has not extinguished. Occasionally, it rises, causing intermittent reduction in distension. However, it ultimately belongs to deficiency-cold, so the distension returns, necessitating warm medicines.
Fullness in the epigastrium upon pressing indicates an Excess syndrome, requiring purgation, preferably using Da Chai Hu Tang (Major Bupleurum Decoction).
Pathogens entering the Yang regions from the chest and hypochondrium require Da Chai Hu Tang to resolve both exterior and interior simultaneously. This differs from the Cheng Qi Tang syndromes characterized by hardness and pain around the umbilicus and abdomen.
If a patient presents with sallow complexion, irritability without thirst, cold-excess in the chest, and unceasing diarrhea, the prognosis is fatal.
A wiry pulse at the CunKou position indicates stiffness and pain in the hypochondrium, accompanied by aversion to cold.
This discusses abdominal distension caused by external factors, hence the differentiation via the CunKou pulse. A wiry CunKou pulse with hypochondriac stiffness and pain indicates weak exterior Qi unable to defend against pathogens externally, allowing Wind pathogens to combine with Water-Qi, causing hypochondriac stiffness and pain. The deficiency of Yang Qi in the exterior and interior results in aversion to cold.
Thin individuals suffering from periumbilical pain likely suffer from Wind-Cold obstructing the movement of Grain Qi. If purgatives are incorrectly used, Qi will counterflow upwards. If it does not counterflow, Epigastric Pi (Glomus) will form.
Thin individuals typically lack Phlegm-Dampness obstruction. Periumbilical pain in them occurs because their muscles are thin and sparse, allowing Wind-Cold to penetrate directly and interfere with the Yin aspect of Spleen Earth. Injury to Earth Qi impairs transport and transformation, leading to stagnation of Grain Qi. Incorrect use of purgatives only empties the intestines and stomach, causing pathogens to rebel and rush upwards. As the *Neijing* states: "Qi rushes to the chest" because the pathogen is in the Large Intestine. If it does not rush, the pathogen is in the Stomach; rebellious Guest Qi causes Epigastric Pi.
For abdominal distension with fever for ten days, floating and rapid pulse, and normal appetite, Nong Pu Qi Wu Tang (Cinnamon Twig and Magnolia Bark Seven Substance Decoction) is indicated.
Abdominal distension indicates pathogens entering the interior; fever indicates Yang Qi reaching the exterior. Despite ten days of illness, the floating and rapid pulse suggests pathogens have not fully entered the interior. Furthermore, the ability to eat demonstrates that Stomach Qi still holds authority. Thus, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) combined with Gui Zhi Qu Shao Yao Tang (Cinnamon Twig Decoction minus Peony) is used to resolve both exterior and interior. Compared to Gui Zhi Jia Huang Qi Tang (modified), this formula contains more Zhi Shi (Immature Bitter Orange) and Hou Po (Magnolia Bark) and less Shao Yao (Peony). Zhi Shi and Hou Po specifically drain stagnant Qi, while Shao Yao collects dissipating Yin. Since this case involves distension without pain and does not affect Yin Blood, Shao Yao is removed.
For cold Qi in the abdomen causing borborygmus (rumbling sounds) and cutting pain, rebellious fullness in the chest and hypochondrium, and vomiting, Fu Zi Mi Tang (Aconite and Rice Decoction) is indicated.
Cold Qi in the abdomen surges upward, attacking the chest, hypochondrium, and Stomach, increasing vomiting and regurgitation. Soon, Stomach Qi becomes empty, leaving no resistance for pathogens, which then invade Yang regions, leading to danger. Therefore, the key to eliminating disaster lies in preserving Stomach Qi. While pathogens initially invade the Stomach and the patient can still eat, Fu Zi and Mi (Rice) are used to warm and nourish the Stomach. Warmth and nourishment thicken the Earth element, making it difficult for pathogens to rise. The turbid Yin causing rebellious fullness in the chest and hypochondrium, warmed, will not linger and will exit through the lower orifices.
For pain accompanied by constipation, Nong Pu San Wu Tang (Magnolia Bark Three Substance Decoction) is indicated.
Pain with obstruction, without borborygmus or vomiting, indicates an Excess syndrome requiring purgation. Xiao Cheng Qi Tang is used with doubled Hou Po, and the name is changed. Because there is no extreme Fire, the term "Cheng Qi" is omitted, similar to how Li Zhong Tang is renamed Ren Shen Tang.
Li Dongyuan stated: The *Neijing* says, "Various abdominal enlargements all belong to Heat." This refers to excess syndromes of the Eight Benefits pathogens entering from outside. Wind-Cold pathogens transmit to the interior, transforming from Cold to Heat, creating Stomach Excess. Symptoms include tidal fever at dusk, intense thirst, delirium, and distension; these are treated with Cheng Qi Tang purgatives. After purgation, the distension resolves.
Distension can occur in all five Zang and six Fu organs. Differentiate based on the degree of Cold or Heat. Cold in the Stomach causes distension; Turbid Yin remaining above causes abdominal distension due to stagnation of Cold-Damp in the Stomach. Jueyin collapse of Taiyin causes abdominal distension, difficulty in bowel movements, anorexia, vomiting after eating, and inability to lie down. As described, Cold distension often presents thus. However, individuals consuming rich foods and alcohol may develop distension due to Damp-Heat failing to transform and stagnating internally; this is called Heat distension. The *Tiao Jing Pian* states: Due to dietary irregularities and overwork damaging the Spleen and Stomach, one initially suffers Heat Zhong, later transmitting to Cold Zhong. All result from Spleen and Stomach Qi failing to transform essence and grains, causing water and food to accumulate and form distension. Overeating also causes abdominal distension and Sun Xie. The *Neijing* states: "Clear Qi below generates Sun Xie; Turbid Qi above generates abdominal distension." This is the reversal of Yin and Yang, representing inverted pathology. Irregular diet and起居 (daily routine) damage Yin. Damage to Yin enters the Five Zang, causing blockage and distension. All these result from doubling food intake and injuring the intestines and stomach. Treatment of distension must regulate Deficiency and Excess, adapt to Cold and Heat, and employ methods of Cold/Heat and Tonification/Purging flexibly.
Zhang Sanxi stated: Distension all belongs to Spleen Deficiency, failure of transformation, and filling by Turbid Qi. In early stages, mildly assist with digestion and prioritize relieving depression. If severe with obstructed urination and defecation, mildly promote drainage. For weak patients, long-term cases, or post-illness/postpartum/post-ulcer states, primarily tonify Spleen Qi with large doses of Ren Shen (Ginseng), Bai Zhu (Atractylodes), Fu Ling (Poria), and Bai Shao (White Peony), assisted by digestive herbs like Hou Po, Mu Xiang, and Huang Lian. However, the "Kingly Way" (gentle tonification) takes time; dozens of prescriptions may be needed for gradual effect. Crude practitioners often stick to the rule "purge to resolve distension," using Lu Shang (Mercurial Root) and Qian Niu (Morning Glory Seed) for immediate relief. Distension recurs after three days. True Qi escapes downward due to purging, and pathogens reaccumulate, leading to untreatable conditions.
Although most abdominal distension cases are Cold, few are Heat. Yet, physicians often prefer acrid-warm Qi-dispersing herbs. Even for Damp-Heat distension, acrid-warm herbs are relied upon to disperse Qi. Dispersed Qi alleviates distension. However, herbs removing Damp-Heat should be primary, with acrid-warm herbs as guides. For Fire-Excess with Yin Deficiency, where Heat invades the Blood level, the abdomen is distended but not greatly enlarged; pressing makes it harder. Urine is yellow-red, stools are dry, with slight fever at night. Pulse is rapid, solid, yet fine. Do not mistake this for Food Stagnation or Damp-Heat. Digestion harms Yin further; drying Dampness depletes fluids. Use extremely bitter and cold herbs like Dang Gui Long Hui Wan (Angelica Dragon Gallbladder Pill) or Si Wu Tang (Four Substances Decoction) plus Xuan Hu Lian (Scutellaria and Coptis prepared with vinegar) and Lu Hui (Aloe), all vinegar-processed, effective in one dose.
For Qi Deficiency failing to contain Blood, causing Blood dispersion and distension, stools are not hard, alternating between loose and formed. Loose stools reduce distension slightly; formed stools increase it. Urine is clear. Severe cases have urine turbid like rice wash. Pulse is slow, large, and sluggish, especially at Qi Kou. Do not use acrid-warm Qi-consuming herbs. Use Si Jun Zi Tang (Four Gentlemen Decoction) minus Bai Zhu, plus Mu Xiang, Ze Xie, Dang Gui, and Bai Shao to secure Blood within Qi.
For Blood Deficiency failing to gather Qi, causing Qi dispersion and distension, patients are irritable with dry stools and frequent yellow urine. Pulse is floating, rapid, and wiry, especially at Ren Ying. Do not use bitter-cold Stomach-injuring herbs. Use Si Wu Tang minus Di Huang, plus Huang Qi (Astragalus), Rou Gui (Cinnamon Bark), Gan Cao (Licorice), and Wei Jiang (Baked Ginger) to harmonize Qi within Blood.
External Six Qi causing distension: Huo Xiang Zheng Qi San (Agarwood and Evodia Powder - *Note: Text says Huo Xiang Zheng Qi San*). Internal Seven Emotions causing distension: Chen Xiang Jiang Qi San (Aquilaria Descending Qi Powder). Excessive worry/sorrow damaging Spleen/Stomach, causing heart/abdominal distension, panting, irritability, borborygmus, obstructed urination/defecation, deficient and choppy pulse: Ju Fang Qi Qi Tang (Formulary Seven Qi Decoction). Turbid Yin above causing distension: Sheng Jiang Xie Xin Tang (Fresh Ginger Draining Heart Decoction) plus Mu Xiang and Hou Po. Spleen/Stomach cold failing to ripen food causing distension: Fu Zi Li Zhong Tang (Aconite Regulate Middle Decoction). Kidney deficiency-cold failing to generate Spleen Earth causing distension: Ji Sheng Shen Qi Wan (Life-Saving Kidney Qi Pill). Central fullness with hardness like a plate, inability to sit/lie, obstructed urination/defecation, panting, sallow complexion, generalized edema: Cold-Heat complex, stuck in the center,凝滞 (stagnant) Ying/Wei and Blood/Qi. Use Fen Xiao Tang/Wan (Separate and Eliminate Decoction/Pill). Adjust based on Cold/Heat degrees. Qi Qi Tangs may also be selected.
Qi Kou pulse tight and slippery, nausea, fullness, dry mouth, internal heat: Food Stagnation. Use Zhi Shi Dao Zhi Wan (Immature Bitter Orange Directing Stasis Pill). After overeating/rushing or trauma with blood stasis, or women with blood accumulation causing swelling, bluish-purple veins on abdomen, tenderness on pressure, wiry-choppy pulse: Treat as Blood Stasis. Anger causing Qi rebellion, hypochondriac distension, wiry pulses in both hands: Qing Pi, Chen Pi, Mu Xiang, Shan Zhi, Chai Hu, Zhi Ke, Gui Wei, Tao Ren, Bai Shao, Bo Gui. Alcoholics with distension like a bowl, hematuria/hematochezia, worsening with purgatives, rapid-choppy pulse: Damp-Heat injuring Spleen Yin, failing to control Blood. Stomach receives food, Spleen fails to transport, causing Pi-Zhang. Regulate Spleen Qi, remove Damp-Heat, nourish Blood. Use Zhi Shi, Huang Lian, Pao Jiang, Ban Xia, Fu Ling, Dang Gui, Bai Shao, E Jiao, Wu Mei, Sha Ren. Bai Shao/Wu Mei collect Spleen Yin; Huang Lian/Zhi Shi drain distension; Gui/E Jiao nourish Ying-Blood; Fu Ling/Ban Xia remove Phlegm-Fluid; Sha Ren awakens Spleen Qi. If previously accumulated Damp-Heat is triggered, causing rebellious distension and panting, death is likely. Unceasing diarrhea also leads to death.
[Diagnosis] Slow-large pulse indicates Qi Deficiency. Wiry-rapid indicates Blood Heat. Tight-full or slippery Qi Kou indicates Stagnation. Soft-slippery indicates Damp-Heat. Wiry-fine indicates Liver Pathogen attacking Spleen. Floating-wiry Ren Ying indicates Wind Qi invading internally. Wiry-fine-rapid indicates Yin Pathogen rebelling upwards. Empty-large rootless pulse indicates Spleen/Stomach Qi decline. Deep-fine-short-choppy pulse indicates Kidney Qi exhaustion.
Shi Wen treated the daughter-in-law of Grand Secretary Qian Gongsheng. Last autumn, prolonged malaria caused severe deficiency, reduced diet, and irregular menstruation. Only one period occurred in late winter. This spring, intermittent chills and fever developed, with abdominal distension and anorexia. Abdominal distension-promoting and diuretic drugs failed. Shi Wen proposed blood-breaking and menstruation-inducing agents. Upon consultation, the left Cun pulse was erratic and shaking. Right Guan and both Chi pulses were slightly wiry but slippery, solid, and smooth upon deep/long palpation. Right Cun and Left Guan were deficient, soft, rapid, and searching revealed sluggish force. This indicated Hidden Yang within Yin, undoubtedly a fetal pulse. Likely due to deficient Middle Qi failing to transport the fetus, causing distension. Previous physicians argued pregnancy was impossible after twelve years of infertility and post-illness Qi deficiency. Shi Wen reasoned that residual heat from illness remained in the Blood Chamber, conceiving is common. Analyzing symptoms: nausea upon eating porridge, relief of chills/fever with hot drinks in evening, indicates Stomach Qi deficiency-cold, failure of Water-Essence to distribute, accumulating as saliva/fluid in the epigastrium (commonly known as Morning Sickness/E Zu). Differentiating deficiency/cold vs. excess/heat for distension/constipation is crucial. *Jingui* states: "FuYang pulse wiry... distension... if no distension, constipation... deficiency-cold from below... treat with warm meds." Post-defecation distension worsens because lower Qi opening allows Turbid Yin to rise, distinct from temporary relief after defecation. Treatment prioritizes calming the fetus. However, Turbid Yin requires acrid-warm herbs to open knots. Shi Wen prescribed Si Jun Zi Tang, adding Dang Gui and Bai Shao to gather dispersed Ying-Blood, with a little Rou Gui as a guide for Turbid Yin, strengthening Mother Qi to protect Fetus. Cinnamon does not harm the fetus, as proven by Pang Anchang and verified by Shi Wen. After medication, chills/fever stopped, distension eased, diet improved, and fetal movement became apparent above the umbilicus. In mid-summer, careless living caused threatened miscarriage bleeding. Previous physicians diagnosed Shi Jia (Uterine Fibroids/Mass) and prescribed blood-breaking formulas. Shi Wen clarified the pulse (left Cun moving/sliding indicates pregnancy) and continued Spleen-tonifying herbs. The patient delivered a healthy son. Had Shi Wen used blood-breaking agents, mother and child might not have survived.
Fei Chou treated Xie Yuanhai. Summer consumption of strong liquor led to excessive hunger and appetite. Half a month later, abdominal distension developed, stools became difficult, and appetite decreased. Doctors' attempts at draining and clearing fire failed. Left pulse fine-rapid, right pulse sluggish. Initially, Fire strengthened Stomach Qi (excessive eating); subsequently, Fire scorched Stomach fluids (difficult transport). Transport difficulty caused food stagnation and distension, reducing appetite. Advice: Avoid spicy foods. While Yuan Qi is intact, remove stagnation and restore fluids. Use Zhi Shi Dao Zhi Tang minus Huang Lian and Bai Zhu, add Ge Gen (Kudzu). One dose relieved constipation and stagnation. Then strengthen Spleen and regulate Qi. After three days, use small dose of Sheng Mai San plus Rui Zhu (Polygonatum) and Wei Ge Gen. Recovered in half a month.