中满者。其证悉与鼓胀水肿无异。何故属之气虚。请得明言之否。曰气虚者。肾中之火气虚也。中满者。
中空似鼓。虚满而非实满也。大略皆脾肾两虚所致。海藏云。夫水气者。乃胃土不
能制肾水。水逆而上行。传入于肺。故令人肿。治者惟知泄水。
而不知益胃。故多下之强令水出。不根据天度流转。故胃愈虚。食无滋味。则发而不能制也。莫若行其所无事。
则为上计。何今之人。不知此等高论。举手便以为水肿。用内经去宛陈 。开鬼门洁净府之法治之。如舟车
丸禹功散之类。若真知其为水湿之气。客于中焦。侵于皮肤。皮肤中如水晶之光亮。手按之随起者。以前药一服
而退。若久病大病后。或伤寒疟痢后。女人产后。小儿痘后。与夫元气素弱者。概以前法施之。脾气愈泄愈虚。
不可复救矣。故治肿者。先以脾土为主。须补中益气汤。或六君子汤温补之。俾脾土旺。则能散精于肺。通调
水道。下输膀胱。水精四布。五经并行矣。或者疑谓喘胀水满。而又加纯补之剂。恐益胀满。必须补药中。加行
气利水之品方妙。此论似深得病情。终非大方家体。盖肺气既虚。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。
至于补肾以治肿。其说难明。盖禹之治水。行其所无事也。若一事疏凿。则失之矣。今人之治肾水者。牵
牛大戟。粗工之小智。正禹之所恶也。间有用五苓五皮者。以为中正。亦转利转虚。肾气愈衰而愈不能推送矣。
故须用补肾。经曰。肾开窍于二阴。肾气化则二阴通。二阴闭则胃填胀。故曰肾者胃之关。关门不利。故水聚而
从其类也。又曰。肾主下焦。三焦者。决渎之官。水道出焉。膀胱者。州都之官。津液藏焉。必待三焦之火化。
始能出也。其三焦之经。在上者布膻中。散络心包。在下者。出于委阳。上络膀胱。上佐天道之施化。下佐地
道之发生。与手厥阴为表里。以应诸经之使者也。是故肾虚者。下焦之火虚也。宣明五气论云。下焦溢为水。以
水注之。斯气窒而不泻。则溢而为水也。经曰。三焦病者。气满小腹尤坚。不得小便。溢则水留而为胀。惟张仲
景制金匮肾气丸。补而不滞。通而不泄。诚治肿之神方。国朝薛立斋先生。屡用屡效。详载之医案中。余根据其案。亲
试之甚效。故敢详着焉。世有患此者。幸毋诞之乎。
金匮肾气丸 此方藏于金匮玉函
白茯苓（三两） 附子（五钱） 川牛膝（一两） 肉桂（一两） 泽泻（一两） 车前子（一两） 山
茱萸（一两） 山药（一两） 牡丹皮（二两） 熟地（四两）
中满之病。原于肾中之火气虚。不能行水。此方内八味丸为主。以补肾中之火。则三焦有所禀命。浩然
之气。塞乎天地。肾气不虚而能行水矣。内有附子肉桂辛热之品。热则流通。又火能生土。土实而能制水矣。
内加牛膝车前子二味。最为切当。考之本草云。车前子虽利小便。而不走气。与茯苓同功。强阴益精。令人有
子。牛膝治老人失溺。补中续绝。壮阳益精。病患虚损。加而用之。方见金匮要略。故名金匮肾气丸。
前所论证治。乃脾肾两虚者。至于纯是脾虚之证。既以参
四君为主。亦须以八味丸兼补命门火。盖脾土非命门火不能生。虚则补母之义。不可不知。
又有一等纯是阴虚者。其证腹大脐肿腰痛。两足先肿。小水短涩。喘嗽有痰。不得卧。甚至头面皆肿。或
面赤口渴。但其人饮食知味。大便反燥。医见形肿气喘水证标本之疾。杂用利水之药而益甚。殊不知阴虚。三
焦之火旺。与冲脉之属火者。同逆而上。由是水从火溢。上积于肺而嗽。甚则为喘呼不能卧。散聚
于阴络而为跗肿。随五脏之虚者。入而聚之。为五脏之胀。皆相火泛滥其水而生病也。以六味地黄加门冬五味
大剂服之。余亲试有验。故录。
又有一等火郁者。其证口苦胁痛恶寒。目黄面黄呕酸等证。须用逍遥散舒其郁。继以六味、肾气滋其阴。
亦禁用分利。
Zhongman (Middle Jiao Fullness) presents with symptoms identical to Guxiang (Drum-like Distension) and Shuizhong (Edema). Why is it attributed to Qi Deficiency? Allow me to explain clearly. "Qi Deficiency" here refers to the deficiency of Fire-Qi within the Kidney (Mingmen Fire). Zhongman manifests as an abdominal cavity hollow like a drum, representing a false fullness rather than true excess. Generally, it is caused by the simultaneous deficiency of both the Spleen and Kidney.
Li Dongyuan (Haicang) stated: Water-Qi disease occurs because Stomach Earth fails to control Kidney Water, causing water-Qi to reverse and ascend into the Lungs, leading to edema in humans. Practitioners only know how to drain water but fail to tonify Stomach Qi; thus, they often use purgatives to forcibly expel water. This disregards the natural circulation of Heavenly Degrees (physiological rhythms), causing Stomach Qi to become increasingly deficient. With loss of taste for food, the body's defensive capacity cannot be maintained. It is better to act without unnecessary interference ("Xing Qi Suo Wu Shi"), which is the superior strategy.
However, contemporary practitioners do not understand such profound theories. Upon seeing swelling, they immediately diagnose Edema and treat it according to the *Neijing* principles of "removing accumulated stasis," "opening the ghost gate (sweating)," and "cleansing the fu organs." They employ formulas such as Zhouche Wan (Boat Cart Pill) and Yugong San. If one truly recognizes that water-dampness qi has lodged in the Middle Jiao and invaded the skin, presenting with skin that shines like crystal and rebounds immediately upon pressure, these draining medicines would resolve it in one dose. However, for patients after prolonged illness or major disease, or following Cold Damage, malaria, dysentery, postpartum women, children after smallpox, or those with constitutionally weak Yuanqi, applying these draining methods indiscriminately will further deplete Spleen Qi, leading to irreparable deficiency.
Therefore, treating edema must prioritize strengthening Spleen Earth. One must use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) or Liujunzi Tang (Six Gentlemen Decoction) for warm tonification. When Spleen Earth is robust, it can distribute essence to the Lungs, regulate water passages, and transport fluids downward to the Bladder. Water essence then distributes throughout the body, and the five meridians function in parallel.
Some doubt this: "The patient suffers from panting, distension, and water retention; adding purely tonifying agents might worsen the fullness. It is essential to add Qi-moving and diuretic herbs to the tonics." This argument seems to grasp the pathology well but lacks the perspective of a master physician. Since Lung Qi is already deficient, one should not move Qi further; since Kidney Water is already depleted, one should not drain Water further. Purely tonifying formulas may initially feel uncomfortable, but once the medicinal power takes effect, order gradually returns.
Regarding treating edema via Kidney tonification, the theory is difficult to elucidate. Yu the Great controlled floods by following nature's course, avoiding forced dredging. Modern practitioners treating Kidney water disorders use harsh drugs like Qian Niu Zi (Pharbitis Seed) and Da Ji (Euphorbia Root), which represent the petty wisdom of crude physicians—precisely what Yu the Great abhorred. Some use Wuling San (Five-Ingredient Powder with Poria) or Wupi Yin (Five-Peel Decoction), considering them moderate, but this leads to increased deficiency with each urination, further depleting Kidney Qi and impairing its ability to push fluids.
Thus, Kidney tonification is necessary. The Classics state: "The Kidney opens into the two yin orifices." When Kidney Qi transforms, the orifices are patent; when blocked, the Stomach becomes filled and distended. Hence, "The Kidney is the gate of the Stomach." If the gate is unregulated, water accumulates and gathers by kind. Also: "The Kidney governs the Lower Jiao." The Sanjiao (Triple Burner) is the official of irrigation, where water passages originate; the Bladder is the official of the capital, storing fluids. Fluids can only be excreted after undergoing fire transformation by the Sanjiao. The Sanjiao meridian spreads in the chest at Danzhong, connecting to the Pericardium; inferiorly, it emerges at Weiyang, connecting upward to the Bladder. It assists the heavenly way in transformation and the earthly way in generation, standing exterior-interior to the Hand-Jueyin, serving as the messenger to all meridians.
Therefore, Kidney deficiency implies a deficiency of Fire in the Lower Jiao. The *Xuanming Wuqi Lun* states: "Overflow from the Lower Jiao becomes water." If water is added, Qi becomes obstructed and cannot discharge, overflowing into water disease. The Classics also say: "In Sanjiao disease, there is Qi-fullness in the lower abdomen, particularly hard, with inability to urinate. Overflow causes water retention and distension." Only Zhang Zhongjing’s Jin Gui Shen Qi Wan (Kidney Qi Pill from the Golden Cabinet), which tonifies without stagnation and unblocks without leakage, is truly the divine formula for treating edema. Mr. Xue Lizhai of our dynasty used it repeatedly with success, detailing cases in his medical records. I tested it based on his cases with great efficacy, hence recording it in detail. Let those suffering from this condition not dismiss it as absurd.
Jin Gui Shen Qi Wan: Stored in *Jin Gui Yu Han*.
Bai Fu Ling (Poria, 3 liang), Fu Zi (Prepared Aconite Root, 5 qian), Chuan Niu Xi (Cyathula Root, 1 liang), Rou Gui (Cinnamon Bark, 1 liang), Ze Xie (Alisma Rhizome, 1 liang), Che Qian Zi (Plantago Seed, 1 liang), Shan Zhu Yu (Cornus Fruit, 1 liang), Shan Yao (Dioscorea Rhizome, 1 liang), Mu Dan Pi (Moutan Cortex, 2 liang), Shu Di Huang (Rehmannia Root, prepared, 4 liang).
Zhongman originates from deficient Fire-Qi in the Kidney, failing to transform water. This formula uses Ba Wei Wan (Eight-Ingredient Pill) as the main component to tonify Kidney Fire, allowing the Sanjiao to receive orders. Vast Qi fills heaven and earth; with non-deficient Kidney Qi, water transformation resumes. The inclusion of Fu Zi and Rou Gui provides acrid-hot properties that promote circulation; Fire generates Earth, making Earth solid enough to control Water. Adding Niu Xi and Che Qian Zi is most appropriate. According to Materia Medica: Che Qian Zi promotes urination without dispersing Qi, functioning similarly to Poria, strengthening Yin and benefiting essence, aiding fertility. Niu Xi treats elderly urinary incontinence, tonifies the middle, restores severed tendons/bones, strengthens Yang and benefits essence. For patients with deficiency, these are added. Derived from *Jin Gui Yao Lue*, it is named Jin Gui Shen Qi Wan.
The preceding discussion addressed Spleen-Kidney dual deficiency. For pure Spleen deficiency, although Can Si Jun Zi Tang (Ginseng Four-Gentlemen Decoction) is primary, one must concurrently use Ba Wei Wan to tonify Mingmen Fire. Because Spleen Earth cannot generate without Mingmen Fire, the principle of "tonifying the mother when deficient" must be understood.
Another category involves pure Yin deficiency. Symptoms include abdominal enlargement, umbilical protrusion, lower back pain, initial swelling of both feet, short and scanty urine, panting with phlegm, inability to lie flat, even facial swelling, or red face with thirst. However, the patient retains taste for food and stool tends to be dry. Physicians seeing edema, panting, and water signs may mix diuretics, worsening the condition. They fail to realize this is Yin deficiency with hyperactive Fire in the Sanjiao and rebellious Fire in the Chong Mai. Water overflows with fire, accumulating in Lungs causing cough, severe panting, and inability to lie down; scattering into Yin collaterals causing dorsal foot swelling; entering deficient Zang organs causing Zang distensions. All result from Ministerial Fire flooding causing water pathology. Using Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) plus Mai Dong (Ophiopogon Tuber) and Wu Wei Zi (Schisandra Berry) in large doses proved effective in my practice, so I record it.
Another type is Fire Depression. Symptoms include bitter taste, hypochondriac pain, aversion to cold, yellow eyes, yellow face, acid regurgitation. Use Xiaoyao San (Free and Easy Wanderer Powder) to soothe depression, followed by Liu Wei Di Huang Wan and Shen Qi Wan to nourish Yin. Diuretics must strictly be avoided.