张元素曰。阳黄者。大小便赤涩身热。是脾土与心火相搏。为阳病。法当先利小便。后下大便。阴黄者。清便自调。
面目及身黄。四肢冷。是脾虚不能制肾水。宜益黄散。下使君子丸。
少阴肾水。太阴肺金。金本生水。水融两阴。肾邪相传。膀胱是侵。逆于脾土。反被水沉。脾虚失制。随水所淫。
脾既受克。不能生心。水激心火。与肺相临。肺又受害。化原失凭。以致水溢。肾邪纵横。脾易受湿。水乃与并。脾主
四肢。流走 。渗于脉络。皮肤是寻。血亦化水。停积日深。乃作水肿。腹饱筋青。手足面目。悉属水停。或气喘逆。
或口呻吟。或发烦渴。或寒热乘。或小便秘。溺出如针。胸满胁胀。减食失音。背平脐凸。命乃将倾。须洁净府。亦开
鬼门。去菀陈 。内经是箴。当须识此。急早治惩。根由症状。仔细详明。嗟嗟水肿。病岂寻恒。时俗谬妄。河白是称。
遍考方书。古无此名。
曾氏曰。原肿病之由。标本之疾。肾主元气。天一之水生焉。肺主冲化。地四之金属焉。肾为本而肺为标。皆至阴
以积水。其为病也。肾者。胃之关键。关键不利。则枢机不转。水乃不行。渗于脉络皮肤。而为浮肿。当推究内外所因
为治。儿大者。凭脉以明虚实。古方有十种论症。短气不得卧。为心水。两胁紧痛。为肝水。大便鸭溏。为肺水。
四肢苦重。为脾水。腰痛足冷。为肾水。口苦咽干。为胆水。乍虚乍实。为大肠水。腹急肢瘦。为膀胱水。小便闭
涩。为胃水。少腹急满。为小肠水。然脉浮为风为虚。沉伏为水病。沉则脉络虚。伏则小便难。即为正水。脾脉虚大。
多作脾肿。因循不治。乃成水肿。盖脾属土。喜燥而恶湿。常感湿气。湿又喜伤脾。血化为水。土败不能制水。则停蓄
不行。留滞皮肤。故作浮肿。初得病时。见眼胞早晨浮突。午后稍消。急以羌活散疏解。次醒脾散。及间投南星腹皮散。
其脾冷困。则燥以草果、缩砂之类。然此症夏秋冬治之颇易。惟春不然。盖四时之水。无如春水泛溢。兼肝木旺而脾土
受克。不能受水。所以难疗。须徐徐调理取效。若脾热而困。入投燥热药。虽不能生土。亦可胜水。奈杀之太过。土不
胜火。则热愈盛而不食。发热烦渴。又进燥剂。由此面目转浮。致脾败。手足背肿。脐凸。皆脾之外候。有未经发表。
递用下药。一泻肿消。乃曰泻之力。不知脾愈泻而愈虚。不旬月。其肿如初。此世人但知泻肿为最。不求十补而一泻之
论。法当随四时用药解表。通利小便。春以七宝丹加麻黄、桂枝、赤苓、姜、葱。夏以五苓散加麻黄、苡仁、车前子、
姜、葱。秋以清肺饮加羌活、细辛、商陆。姜、葱。冬以冲和饮加白术、生川乌、赤小豆、
姜、葱。次投滋润救脾导水汤剂渗泄之。乃为良法。更以香陆胃苓丸顿服。自安。
有国中便觉痰嗽气喘。小水不通。正属肺肾所主。先服解表散。次投三白散。凡得此病。非一朝夕之故。不可求速
效。以致虚脱。如愈后。再感外风。满面虚浮。用排风散和解。仍服救脾汤剂。免致反复。刘氏曰。治肿非易。补养尤
难。忌食物切须详审。有久不消者。下浚川丸即效。
史演山曰。肿胀二症。此由虚中有积。久患失治。日渐传变。症候多端。随轻重。察盛衰。审表里以主治。先固其
本。后治其标。斯无患矣。受湿肿。食毒瓦斯肿。伤寒虚气入腹肿。泻痢虚气入腹肿。此四种所患病不相同。皆由虚得之。
受湿。谓脾胃受湿冷。久不克化。气浮。四肢头面皆肿。食毒瓦斯肿。由脾胃伤冷积。毒瓦斯停留胃脘。致气入腹。蛊胀肿
急。伤寒由下之太早。乘虚入腹作肿。泻痢久。脾气亦虚。是以致肿。以上宜平调胃气。补脏充实。方可去肿。先服
四味理中汤减半干姜加白术、桑皮。伤寒虚肿。加枳实。作喘加淡豉。泻痢虚胀。宜正气调胃。胃气既壮。救生丹利之。
肿即退。再用观音散调补脏腑。即平复矣。
王履曰。气虚肿。亦名气蛊。血虚肿。亦名血蛊。小儿所患肿胀一门。最为要急。前人少有究竟。然肿胀之作。皆
由荣卫不顺。脏腑怯弱。壅滞三焦。流注百脉。表里俱虚。邪正相乱。以致四肢浮盛。肚腹膨满。多由食毒得之。饮食
得之。症伤得之。饥饱得之。积久不化。故成斯病。病由虚得。或妄乱通下。因虚致虚。根不得去。疾加益甚。是谓坏
症危症。先投荣卫饮子。次服分气饮子以散滞。斯病去矣。
叶桂曰。夏季湿热郁蒸。脾胃气弱。水谷之气不运。湿着内蕴为热。渐至浮肿腹胀。小水不利。治之非法。水湿久
积。逆行犯肺。必生咳嗽喘促。甚则坐不得卧。俯不能仰。危期速矣。大凡喘必生胀。胀必生喘。方书以先喘后胀者治
在肺。先胀后喘者治在脾。亦定论也。金匮有风水、皮水、石水、正水、黄汗。以分表里之治。河间有三焦分消。子和
有磨积逐水。皆有奥义。学人不可不潜心体认。难以概述。阅近代世俗论水湿喘胀之症。以内经开鬼门取汗为表治。分
利小便洁净府为里治。经旨病能篇。谓诸湿肿满。皆属于脾。以健脾燥湿为稳治。治之不效。技穷束手矣。不知凡病皆
本乎阴阳。通表利小便。乃宣经气利腑气。是阳病治法。暖水脏。温脾肾。补后方以驱水。是阴病治法。治肺以轻开上。
治脾必佐温通。若阴阳表里乖违。脏真日漓。阴阳不运。亦必作胀。治以通阳。乃可奏绩。如局方禹余粮丸。甚至三焦
交阻。必用分消。肠胃窒塞。必用下夺。然不得与伤寒实热同例。擅投硝、黄、枳、朴。扰动阴血。若太阴脾脏饮湿阻
气。温之补之不应。欲用下法。少少甘遂为丸可也。其治实症。选用方法。备采葶苈大枣汤、牡蛎泽泻散、甘遂半夏汤、
子和桂苓汤、中满分消饮、五子五皮汤、茯苓防己汤、小青龙汤、木防己汤、泻白散、五苓散、控涎丹、禹功丸、大顺
散、越婢汤。徐姓小儿。单胀数月。服肥儿丸、万安丸、磨积丹、绿矾丸、鸡肫药。俱不效。余谓气分不效。宜治血络。
所谓络瘀则胀也。用归须、桃仁、延胡、山甲、蜣螂、 虫、灵脂、山楂之类为丸。十日全愈。
Zhang Yuansu stated: In Yang Jaundice (Yang Huang, jaundice characterized by heat signs), the urine and stool are red and scanty with difficulty in passing, accompanied by fever. This is caused by the struggle between Spleen Earth and Heart Fire, constituting a Yang disease. The treatment principle should be to first promote urination, then purge the bowels. In Yin Jaundice (Yin Huang, jaundice characterized by cold deficiency signs), the urine and stool are normal and harmonious. The face, eyes, and body turn yellow, and the four limbs are cold. This is due to Spleen Deficiency failing to control Kidney Water. It is appropriate to use Yihuang San (Yellow-Boosting Powder) and administer Shijunzi Wan (Quisqualis Pill).
Shaoyin Kidney Water and Taiyin Lung Metal: Metal naturally generates Water, and the two Yin aspects merge. If Kidney pathogenic factors transmit, they invade the Bladder, then counterattack Spleen Earth, and are conversely submerged by Water. Spleen Deficiency loses its controlling ability and follows the flooding of Water. Once the Spleen is overcome, it cannot generate Heart Fire; Water agitates Heart Fire, which approaches Lung Qi. The Lung suffers harm, losing its source of transformation, leading to water overflow. Kidney pathogens run rampant, the Spleen easily suffers from Dampness, and Water merges with it. The Spleen governs the four limbs; Water flows and moves, seeping into the collaterals and seeking the skin. Blood also transforms into Water, accumulating over days and months, resulting in Edema (Shuizhong, swelling due to water retention). Abdominal fullness and cyanotic veins, as well as swelling of the hands, feet, face, and eyes, all belong to water stagnation. There may be panting and rebellious Qi, groaning from the mouth, irritability and thirst, alternating chills and fever, constipation of the small intestine, urination feeling like needle pricks, chest fullness and hypochondriac distension, reduced appetite and loss of voice, a flat back and protruding umbilicus, indicating that life is on the verge of collapse. One must employ methods to purify the Fu organs (promote urination) and open the ghost gates (induce sweating). Remove accumulated stale matter; this is the admonition of the *Neijing* (Inner Canon). One must recognize this, treat urgently and early. Investigate the root causes and symptoms carefully. Alas! Edema is not an ordinary disease. Popular misconceptions are absurd; they call "Hebai" a disease name. Examining medical texts, there was no such name in ancient times.
Zeng stated: The origin of edema involves root and branch diseases. The Kidney governs Yuan Qi, generated from Tianyi Water; the Lung governs Chong transformation, formed from Di Si Metal. The Kidney is the root, and the Lung is the branch; both are extreme Yin and prone to accumulating water. Among them, the Kidney is the key of the Stomach. If the key is obstructed, the pivot does not turn, water does not flow, seeps into collaterals and skin, becoming generalized edema. One must investigate internal and external causes for treatment. For older children, determine deficiency or excess via pulse diagnosis. Ancient formulas describe ten types of syndromes: Shortness of breath and inability to lie flat is Heart Water; tight pain in both hypochondria is Liver Water; duck-like loose stools is Lung Water; heaviness in the four limbs is Spleen Water; lower back pain and cold feet is Kidney Water; bitter taste in the mouth and dry throat is Gallbladder Water; alternating deficiency and excess is Large Intestine Water; abdominal urgency and emaciated limbs is Bladder Water; closed and scanty urination is Stomach Water; urgency and fullness in the lower abdomen is Small Intestine Water. However, a floating pulse indicates Wind or Deficiency; a deep and hidden pulse indicates Water disease. Deep pulse implies deficient collaterals; hidden pulse implies difficult urination, which is Zheng Water (True Water). A large and deficient Spleen pulse often presents as Spleen Swelling. If neglected, it becomes Edema. Since the Spleen belongs to Earth, it prefers dryness and dislikes dampness. It often contracts dampness, and Dampness loves to damage the Spleen. Blood transforms into water; when Earth fails to control Water, it stagnates and does not move, remaining in the skin, thus causing edema. At the onset, the eyelids swell in the morning and subside slightly in the afternoon. Immediately use Qianghuo San (Notopterygium Powder) to disperse and resolve, followed by Xingpi San (Spleen-Awakening Powder), and intermittently administer Nanxing Fupi San (Arisaema and Tangerine Peel Powder). If there is Spleen Cold and fatigue, use drying herbs like Caoguo (Black Cardamom) and Suosha (Amomum). However, this condition is relatively easy to treat in Summer, Autumn, and Winter, but difficult in Spring. Among the waters of the four seasons, none is more overflowing than Spring Water. Additionally, Liver Wood is vigorous and overcomes Spleen Earth, so the Spleen cannot accept water, making it hard to treat. Gradual regulation is required for efficacy. If there is Spleen Heat and fatigue, administering drying-hot drugs may overcome water, though it cannot generate Earth. However, excessive killing leads to Earth failing to withstand Fire, causing intense heat, anorexia, fever, irritability, and thirst. Further administration of drying agents causes the face and eyes to become swollen, leading to Spleen failure, swelling of the dorsum of hands and feet, and protruding umbilicus—all external signs of Spleen decline. If exterior syndrome has not been released, and laxatives are used sequentially, the swelling subsides after one purge, claiming credit for the purgative power. But the Spleen becomes more deficient with each purge. Within a month, the swelling returns to its original state. People only know that purging edema is best, ignoring the theory of "tonify ten times, purge once." The method should involve releasing the exterior according to the seasons and promoting urination. In Spring, use Qibao Dan (Seven-Treasure Pill) added with Mahuang (Ephedra), Guizhi (Cinnamon Twig), Chifuling (Red Poria), Shengjiang (Fresh Ginger), and Congbai (Scallion White). In Summer, use Wuling San (Five-Ingredient Powder with Poria) added with Mahuang, Yiren (Coix Seed), Cheqianzi (Plantago Seed), Shengjiang, and Congbai. In Autumn, use Qingfei Yin (Lung-Clearing Decoction) added with Qianghuo (Notopterygium), Xixin (Asarum), Shanglu (Phytolacca), Shengjiang, and Congbai. In Winter, use Chonghe Yin (Harmonizing Decoction) added with Baizhu (Atractylodes Macrocephala), Sheng Chuanwu (Raw Aconitum Carmichaelii), Chixiaodou (Adzuki Bean), Shengjiang, and Congbai. Subsequently, administer Runzai Jiupi Daoshui Tangji (Moisturizing Spleen-Saving and Water-Guiding Decoction) for渗泄 (percolating and draining). This is a good method. Also, take Xianglu Weiling Wan (Fragrant Phytolacca and Coptis Pill) in one dose, and peace will ensue.
Some feel phlegm, cough, panting, and complete lack of urination; this correctly belongs to the governance of Lung and Kidney. First take Jiebiao San (Exterior-Resolving Powder), then administer Sanbai San (Three-Whites Powder). Any illness obtained is not due to a single day or night; do not seek rapid effects, leading to deficiency collapse. If, after recovery, external Wind is contracted again, causing facial puffiness, use Paifeng San (Wind-Expelling Powder) to harmonize, and continue taking Jiupi Tangji (Spleen-Saving Decoction) to prevent recurrence. Liu stated: Treating swelling is not easy; tonification is even more difficult. Foods to avoid must be carefully examined. For those who do not subside for a long time, Junchuan Wan (River-Dredging Pill) is effective.
Shi Yanshan stated: The two syndromes of swelling and distension arise from deficiency with accumulation. Long-term neglect leads to gradual progression and diverse symptoms. Observe severity, assess excess and deficiency, examine interior and exterior to guide treatment. First secure the root, then treat the branch, and there will be no disaster. Receiving Dampness swelling, Food-Toxic Gas swelling, Cold Damage Qi entering the abdomen causing swelling, and Dysentery Qi entering the abdomen causing swelling—these four diseases differ but all arise from deficiency. "Receiving Dampness" refers to Spleen and Stomach contracting cold-dampness, failing to digest for a long time, causing Qi to float, leading to swelling of the four limbs, head, and face. "Food-Toxic Gas swelling" results from Spleen and Stomach injury by cold accumulation, toxic gas staying in the stomach cavity, causing Qi to enter the abdomen, leading to urgent gu-distension swelling. Cold Damage swelling occurs because purgation was too early, allowing pathogens to enter the abdomen vacuously and cause swelling. Long-term dysentery makes Spleen Qi deficient, thus causing swelling. Above cases should be treated by balancing Stomach Qi and tonifying Zang organs to fill them up, then swelling can recede. First take Siwei Lizhong Tang (Four-Ingredient Lizhong Decoction) with half dosage of Ganjiang (Dried Ginger), adding Baizhu and Sangpi (Mulberry Bark). For Cold Damage deficiency swelling, add Zhishi (Immature Bitter Orange); for panting, add Danshi (Light Fermented Soybean). For dysentery deficiency distension, regulate Stomach Qi with Zhengqi; once Stomach Qi is strong, use Jiusheng Dan (Life-Saving Pill) to drain, and swelling will recede. Then use Guanyin San (Guanyin Powder) to regulate and tonify Zang organs, and recovery will occur.
Wang Lü stated: Qi deficiency swelling is also called Qi Gu; Blood deficiency swelling is also called Blood Gu. The category of swelling in pediatrics is most critical, yet predecessors rarely explored it thoroughly. However, swelling arises from unsmooth Ying and Wei, weak Zang and Fu, obstruction of the Triple Burner, flowing through the hundred vessels, deficiency in both interior and exterior, confusion of pathogenic and righteous Qi, leading to floating and fullness of the four limbs and distension of the abdomen. It mostly results from food toxicity, dietary issues, trauma, irregular eating, and long-term indigestion. The disease stems from deficiency; if indiscriminate purgation is used, deficiency leads to further deficiency, the root is not removed, and the disease worsens, termed a ruined or critical syndrome. First administer Yingwei Yinzi (Ying-Wei Decoction), then Fenqi Yinzi (Qi-Separating Decoction) to dissipate stagnation, and the disease will depart.
Ye Tianshi stated: In summer, damp-heat stagnates and steams, Spleen and Stomach Qi is weak, the Qi of water and grain does not transform, dampness adheres internally generating heat, gradually leading to edema, abdominal distension, and difficult urination. Improper treatment causes water-dampness to accumulate for a long time, reverse and attack the Lung, inevitably causing cough and panting, severe cases unable to sit or lie down, danger imminent. Generally, panting generates distension, and distension generates panting. Medical books state that panting preceding distension is treated in the Lung, and distension preceding panting is treated in the Spleen, which is a definitive conclusion. *Jinkui Yaolue* mentions Fengshui (Wind Water), Pishui (Skin Water), Shishui (Stone Water), Zhengshui (True Water), and Huanghan (Yellow Sweat) to distinguish interior-exterior treatments. Hejian proposed Triple Burner differentiation and separation; Heizi advocated grinding accumulation and driving out water; all have profound meanings. Students must study them earnestly; they are difficult to summarize. Reading modern popular discussions on water-dampness, panting, and distension, using *Neijing*'s "open ghost gates" to induce sweat as exterior treatment, and "purify Fu organs" by separating and draining urine as interior treatment. The *Neijing* chapter "Bingneng" states "All dampness, swelling, and fullness belong to the Spleen," advocating strengthening the Spleen and drying dampness as a stable treatment. If ineffective, skills are exhausted. They do not know that all diseases are rooted in Yin-Yang. Releasing the exterior and promoting urination promotes Jing Qi and Fu Qi, which is the treatment for Yang diseases. Warming the Water Organ (Kidney), warming Spleen and Kidney, and tonifying posterior to drive out water is the treatment for Yin diseases. Treating the Lung requires light opening of the upper; treating the Spleen must assist with warming and unblocking. If Yin-Yang and interior-exterior are discordant, Zhen Qi daily depletes, Yin-Yang does not circulate, swelling will occur. Treatment by unblocking Yang can achieve results. Such as Ju Fang Yuyuliang Wan (Hematite Pill), even if Triple Burner blocks intersect, separation and drainage must be used; if intestines and stomach are blocked, purgation must be used. However, this cannot be equated with Cold Damage excess-heat; arbitrarily administering Xiaoshi (Mirabilite), Huanglian (Coptis), Zhishi, and Houpo disturbs Yin blood. If Taiyin Spleen organ has fluid-dampness blocking Qi, and warming/tonifying fails, if purgation is desired, a small amount of Gansui (Kansui Root) made into pills is acceptable. For treating excess syndromes, selected methods include Tingli Dazao Tang (Descurainia Seed and Jujube Decoction), Muzhi Zexie San (Oyster Shell and Alisma Powder), Gansui Banxia Tang (Kansui and Pinellia Decoction), Hezi Guiling Tang (Hezi's Guiling Decoction), Zhongman Fenxiao Yin (Middle-Fullness Separation Decoction), Wuzi Wupi Tang (Five-Seeds Five-Skins Decoction), Fuling Fangji Tang (Poria and Stephania Decoction), Xiao Qinglong Tang (Minor Green Dragon Decoction), Mufangji Tang (Stephania Decoction), Xiebai San (Drain-Lung Powder), Wuling San (Five-Poria Powder), Kongyan Dan (Saliva-Control Pill), Yugong Wan (Yu-Gong Pill), Dashun San (Great-Shun Powder), Yebi Tang (Wild Cat Decoction). Child surnamed Xu had isolated abdominal distension for months; took Fei'er Wan (Child-Nourishing Pill), Wan'an Wan (Ten-Thousand-Peace Pill), Moji Dan (Accumulation-Grinding Pill), Lvfan Wan (Green Vitriol Pill), Jizhen Yao (Chicken Gizzard Medicine), all ineffective. I said if Qi-b层面 treatment fails, treat Blood collaterals, as "collateral stasis causes distension." Use Guixu (Angelica Sinensis Thorns), Taoren (Peach Kernel), Yanhusuo (Corydalis), Shan Jia (Pangolin Scales), Changlang (Darkling Beetle), Mengchong (Blue Bottle Fly Larva), Lingzhi (Lignus), Shanzha (Hawthorn) made into pills, cured completely in ten days.