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[General Summary]
Ancient and modern physicians discuss that edema and distension diseases mostly stem from Spleen deficiency (Spleen Xu), and are largely caused by warm-heat pathogens; the ten root causes require separate regulation, and detailed differentiation between tonification and purging methods must be applied according to clinical circumstances.

[Pulse Diagnosis]
In water diseases (edema), if the pulse is floating and large, it is treatable; if fine and minute, it is difficult to treat. In abdominal distension, if the pulse is floating, it is easy to treat; if the condition is deficient, it is difficult to cure.

The *Neijing* states: "All dampness-induced swelling and fullness belong to the Spleen." It also states: "All abdominal distension and enlargement belong to heat." The Spleen prefers dryness and dislikes dampness. Often affected by dampness, dampness stagnates and transforms into heat; prolonged heat generates more dampness. Damp-heat generate each other, leading to swelling and distension! What is the pathogen involved? Generally, humans rely on water and grain for life. Water is governed by the Kidney, and grain by the Spleen. Only when the Kidney is deficient can it not move water, and when the Spleen is deficient can it not control water. The Stomach and Spleen are exterior-interior related; the Stomach is the sea of water and grain. Due to deficiency, it cannot transmit and transform, so Kidney water overflows and infiltrates Spleen earth. Consequently, the Triple Burner stagnates, meridians become obstructed, water seeps into the skin, and pours into the muscles, resulting in swelling and distension. Swelling refers to water edema, and distension refers to abdominal distension; they must be treated separately.

Swelling diseases vary. In Luoyang, swelling is called a stubborn disease, indicating the severity and malignancy of the illness. There is swelling caused by dampness invasion, swelling caused by wind obstruction, swelling caused by food retention, and swelling occurring after illness. Generally, one should employ methods to tonify the middle, resolve dampness, and promote urination. If the body has fever, the water qi is in the exterior, and sweating can be used; for excess patterns, where water qi is in the interior, promoting urination can be used. One must never lightly use purgatives to consume the true qi.

The *Classic* says: "Those who are strong recover as qi moves; those who are weak develop disease as pathogens adhere." If there is generalized edema, irritability and thirst, red and scanty urine, and constipation, this belongs to Yang Water. Use Wupi Tang (Five-Skin Decoction) first, followed Simo Tang (Four-Massage Decoction) with raw Zhiqiao (Immature Bitter Orange), and for severe cases, Shuzao Yinzi (Drainage Decoction). If there is generalized edema without irritability or thirst, loose stools, scanty urine that is not astringent or red, this belongs to Yin Water. Shipi San (Solidify the Spleen Powder) or Muxiang Liqi Yin (Aucklandia Qi-Regulating Decoction) should be used. For Yang Water with Yin symptoms, the pulse will be deep and rapid; for Yin Water with Yang symptoms, the pulse will be deep and slow. If qi sinks, use Erchen Tang (Two-Cured Decoction) with lifting herbs to moisten the bowels and increase urination. If abdominal distension occurs, add Houpo (Magnolia Bark); if qi does not move, add Mutong (Akebia Stem), Muxiang (Costus Root), and Chenpi (Tangerine Peel) to regulate. If a child initially swells and feels phlegm, coughing, and wheezing, this is governed by the Lung and Kidney. First, release the exterior and scatter pathogens, then administer asthma-calming, phlegm-resolving, and diuretic agents, such as Shanglu Wan (Phytolacca Pill). The *Neijing* says: "Open the ghost gate (sweat pores), cleanse the clean mansion (bladder)." This refers to these methods.

As for distension, it is caused by dietary irregularities and fatigue damaging the Spleen and Stomach, preventing the transformation of refined essences and the control of water and grain, leading to accumulation and lack of dispersion, thus forming distension. Excess patterns can be purged. Symptoms include frequent desire to drink, ability to eat, yellow urine, occasional mild wheezing, and a hidden pulse. If the Spleen was initially deficient but later developed accumulation, treatment should first tonify the Spleen, then purge, and finally tonify the Spleen again for recovery. Do not tonify the Lung, lest it create deficiency.

Mr. Lu said: The *Yijing* subordinates edema to the Kidney, Liver, and Stomach, involving the Spleen, and claims that excessive Lung Metal generates water, causing water to overflow and act recklessly. Is this logical?

When Spleen Earth is diseased, the Lung, being its child, certainly cannot flourish independently to generate water. However, Lung Metal, with clear qi, can generate water, thereby nourishing Kidney Yin, executing descending functions, and serving as the source of generation and transformation. How could swelling occur? Now, due to swelling, fluids are lost, and turbid qi penetrates the meridians, flows into the valleys, and pours into the tunnels. Blood also transforms into water. Attempting to use Earth to control it and guide Kidney qi to promote urination ignores the fact that Spleen disease leads to declining Metal qi. Wood, lacking restraint, attacks Earth. Thus, the Spleen inevitably becomes diseased. Treatment should clear Heart Fire, tonify Spleen Earth, and restore its transforming and transporting functions. Lung Metal descends, permeation channels open, and the clear essence regenerates into blood, qi, and fluids. The turbid败败 parts become sweat above and urine below, gradually dissipating.

(Parenthetical Note: The *Classic* says: "The Supreme Yin is Kidney Water, Shaoyin is the Winter Pulse. Its root is in the Kidney, its branch in the Lung; both involve water accumulation." It also says: "The Kidney is the gate of the Stomach. If the gate is not unobstructed, water accumulates.")

Wang Jiezhai said: Wheezing preceding distension indicates the Lung as the primary site; distension preceding wheezing indicates the Spleen as the primary site.

For any swelling disease, if the following signs appear: slippery diarrhea, black lips, flat clavicular fossae, protruding umbilicus, flat dorsum of feet, flat back, hard flesh, or flat palms; or if men swell from feet upward, and women swell from body downward, these are untreatable (prognosis is poor).

Generalized shiny edema where finger pressure leaves a pit that fills immediately upon lifting belongs to Spleen deficiency failing to control water, causing water to soak and act recklessly. Treatment should tonify the Spleen; when Spleen qi is solid, transportation naturally improves. Do not recklessly use purgatives.

For treating large swelling, the method should be tonifying the middle, resolving dampness, and promoting urination. Ren Shen (Ginseng) and Bai Zhu (Atractylodes Macrocephala) serve as Sovereign herbs, Cang Zhu (Atractylodes Lancea), Chenpi (Tangerine Peel), and Fu Ling (Poria) as Minister herbs, Huang Qin (Scutellaria) and Mai Dong (Ophiopogon) as Envoy herbs to restrain the Liver, with a small amount of Houpo (Magnolia Bark) to relieve abdominal distension. Add Mu Xiang (Aucklandia) and Mu Tong (Akebia) for qi stagnation; add Sheng Ma (Cimicifuga) and Chai Hu (Bupleurum) for qi sinking; tonify blood for blood deficiency; resolve phlegm for abundant phlegm. Adjust according to symptoms for best results.

Morning relief and evening urgency indicate Yin deficiency. Use Siwu Tang (Four Substances Decoction) with Ren Shen and Bai Zhu in the morning, and Dihuang Wan (Rehmannia Pill) with Niu Xi (Achyranthes), Che Qian Zi (Plantago Seed), Rou Gui (Cinnamon Bark), and Fu Zi (Aconite) in the evening. Morning urgency and evening relief indicate Yang deficiency. Use Liu Junzi Tang (Six Gentlemen Decoction) in the morning, and Dihuang Wan in the evening, adjusting as before.

Li Dongyuan said: Cold distension is common, hot distension is rare; both are governed by the Spleen and Stomach.

[Attached Formulas]
Wupi Tang (Five-Skin Decoction): Wujiapi (Acanthopanacis Cortex), Digupi (Lycii Cortex), Fulingpi (Poria with Hostwood Skin), Jiangpi (Zingiberis Rhizoma Cum Scaly Skin), Dafupi (Arecae Pericarpium). One formula removes Wujiapi and adds Sangbai Pi (Morus Alba Root Bark).
Simo Tang (Four-Massage Decoction): Muxiang (Aucklandiae Radix), Chenxiang (Aquilariae Lignum Resinatum), Taiwu (Pinelliae Rhizoma Preparatum - note: likely referring to Wuyu/Aucklandia here contextually or specific variety), Binglang (Arecae Semen), Zhike (Aurantii Fructus Immaturus).
Shuzao Yinzi (Drainage Decoction): Chixiaodou (Phaseoli Semen Rubrum), Dafupi (Arecae Pericarpium), Fulingpi (Poria with Hostwood Skin), Jiaomu (Zanthoxyli Semen), Zexie (Alismatis Rhizoma), Mutong (Akebiae Caulis), Shanglu (Phytolaccae Radix), Qianghuo (Notopterygii Rhizoma et Radix), Binglang (Arecae Semen), Qinjiao (Gentianae Macrophyllae Radix).
Shipi San (Solidify the Spleen Powder): Baizhu (Atractylodis Macrocephalae Rhizoma), Xiangfu (Cyperi Rhizoma), Muxiang (Aucklandiae Radix), Caoguo (Tsao-ko Fruit), Mugua (Chaenomelis Fructus), Binglang (Arecae Semen), Fuling (Poria), Jiangpi (Zingiberis Rhizoma Cum Scaly Skin), Gancao (Glycyrrhizae Radix et Rhizoma).
Muxiang Liqi Yin (Aucklandia Qi-Regulating Decoction): Formula not seen.
Erchen Tang (Two-Cured Decoction): See under various vomiting syndromes.
Shanglu Wan (Phytolacca Pill): Shanglu (Phytolaccae Radix, 1 liang), Huanglian (Coptidis Rhizoma, 5 qian). Made into pills with Ginger Juice, taken with Perilla Decoction.
Jiebiao San (Exterior-Release Powder): Mahuang (Ephedrae Herba), Xingren (Armeniacae Semen Amarum), Chi Fuling (Poria with Red Hostwood), Chuanxiong (Ligustici Chuanxiong Rhizoma), Fangfeng (Saposhnikoviae Radix), Zhike (Aurantii Fructus Immaturus), Gancao (Glycyrrhizae Radix et Rhizoma).