景岳曰∶愚按肿胀一证，观《灵枢》胀论之义，则五脏六腑，无不有之。再考
诸篇，如脉要精微论曰∶胃脉实，气有余则胀。邪气脏腑病形篇曰∶胃病者，腹
胀，胃脘当心而痛。本神篇曰∶脾气实，则腹胀，泾溲不利。阴阳应象大论曰∶浊
气在上，则生 胀。此皆实胀也。太阴阳明论曰∶饮食起居失节，入五脏，则 满
闭塞。经别篇曰∶足太阴之别公孙。虚则鼓胀。皆虚胀也。经脉篇曰∶胃中寒，
则胀满。异法方宜论曰∶脏寒生满病。风论曰∶胃风膈塞不通，腹善胀，失衣则
胀。此皆寒胀也。阴阳别论曰∶二阴一阳发病，善胀心满。诊要经终论曰∶手少阴
终者，腹胀闭。足太阴终者，腹胀闭。此心脾受伤之胀也。此外如六元正纪，至真
要大等论，有云太阴所至，为身重 肿。及土郁之发，太阴之初气，太阴之胜复，
皆湿胜之肿胀也。有曰水运之太过，有曰寒胜则浮，有曰太阳之司天，太阳之胜复，
皆寒胜之肿胀也。有曰少阴之司天，少阴之胜复，少阳之司天，少阳之胜复，有曰
热胜则肿，皆火胜之肿胀也。有曰厥阴之司天在泉，厥阴之复，有曰阳明之复，是
皆水邪侮土，及金气反胜之肿胀也。观此，则不惟五脏六腑，即五运六气，亦无不
皆有是病。然至真要大论曰∶诸湿肿满，皆属于脾。水热穴论曰∶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。由此言之，
则诸经虽皆有胀，然无不关于脾、肺、肾三脏。盖脾属土，主运化。肺属金，主气。
肾属水，主五液。凡五气所化之液，悉属于肾。五液所行之气，悉属于肺。转输于
二脏之中，以制水生金者，悉属于脾。所以肿胀之生，无不由此三者。但证有阴阳
虚实，如诸论之所云者，不可不辩。大都阳证多热，热者多实。阴证多寒，寒者多
虚。先胀于内而后及于外者多实，先肿于表而后甚于里者多虚。小便黄赤，大便秘
结者多实；小水清白，大便稀溏者多虚。脉滑数有力者多实，弦浮微细者多虚。形
色红黄，气息粗长者多实；容颜憔悴，音声短促者多虚。凡是实证，必由六淫有余
伤其外，或饮食怒气伤其内，故致气道不行，三焦壅闭。此则多在气分，无处不到，
故不分部位而多通身浮肿。又或气实于中，则为单腹胀急。然阳邪急速，其至必暴，
每成于旬日、数日之间，此惟少壮者多有之。但破其结气，利其壅滞，则病无不愈。
此治实之道也。若是虚证，必由五志积劳，或酒色过度，伤其脾肾，日积月累，其
来有渐。此等病候，多染于中年之外。其形证脉气，必有虚寒之候，显然可察。非
若实证之暴至，而邪热壅结、肝气悍逆之有因也。治实者，本无所难。最难者，在
治虚耳。然虚有在气者，有在水者。在气者，以脾气虚寒，不能运化，所谓气虚中
满者是也。在水者，以脾虚不能制水，则寒水反侮脾土，泛滥为邪。其始也，必从
阴分渐次而升，按肉如泥，肿有分界，所谓水鼓、水胀者是也。然水虽制于脾，而
实主于肾。盖肾本水脏，而元阳生气所由出。若肾中阳虚，则命门火衰。既不能自
制阴寒，又不能温养脾土。阴阳不得其正，则化而为邪。夫气即火也，精即水也。
气之与水，本为同类，但在于化与不化耳。故阳旺，则化而精能为气；阳衰，则不
化而水即为邪。凡火盛水亏则病燥，水盛火亏则病湿。故火不能化，则阴不从阳，
而精气皆化为水。所以水肿之证，多属阳虚，故曰寒胀多，热胀少也。然观丹溪之
治肿胀，云清浊相混，隧道壅塞而为热。热留为湿，湿热相生，遂成胀满。治宜补
其脾，又须养肺金以制木，使脾无贼邪之患。滋肾水以制火，使肺得清化之令。其
说重在湿热，而犹以制火为言，夫制火固可保金，独不虑其不生土乎？若以此法施
于阳实而热者则可；若以治阳虚而气不化者，岂不反助阴邪而益其病哉。故予之治，
此必察其果系实邪，则直清阳明，除之极易。凡属虚劳内损者，多从温补脾肾而愈，
俱得复元。或临证之际，有虚实未明，疑似难决者，则宁先以治不足之法，探治有
余。若果未投而病反加甚，是不宜补也。不妨易辙，自无大害。倘药未及病而病自
甚者，其轻重真假，仍宜详察。若误以治有余之法治不足，而曾经峻攻者，真气复
伤，虽神丹不能疗矣。或从清利，暂见平复，使不大补脾肾，以培根本，虽愈目前，
未有不危亡踵至者。此治虚之道也。夫肿胀之病，多有标实本虚，最为危候。若辨之不明，则祸人非浅。
张景岳说：我考察肿胀这一病证，参考《灵枢·胀论》的含义，可知五脏六腑没有不发生肿胀的。再考证其他篇章，《脉要精微论》说：胃脉实，气有余就会发生胀满。《邪气脏腑病形篇》说：胃病的人，腹部胀满，胃脘部当心而痛。《本神篇》说：脾气实，就会腹胀，大小便不利。《阴阳应象大论》说：浊气在上，就会产生胀满。这些都属于实胀。《太阴阳明论》说：饮食起居失于节制，邪气侵入五脏，就会导致痞满闭塞。《经别篇》说：足太阴脾经的络穴公孙，虚证时会出现鼓胀。这些属于虚胀。《经脉篇》说：胃中有寒，就会胀满。《异法方宜论》说：内脏寒冷会产生满闷的病证。《风论》说：胃受风邪，膈塞不通，腹部容易胀满，受凉后胀满加重。这些都属于寒胀。《阴阳别论》说：二阴一阳发病，容易胀满、心下痞满。《诊要经终论》说：手少阴心经气绝，会出现腹胀闭结；足太阴脾经气绝，也会出现腹胀闭结。这是心脾受伤导致的胀满。此外如《六元正纪大论》、《至真要大论》等篇章，有说太阴湿土所至，会导致身体沉重浮肿。以及土郁发作时，太阴初之气、太阴之胜复，都是湿气偏胜导致的肿胀。有说水运太过，有说寒气偏胜则出现浮肿，有说太阳司天、太阳之胜复，都是寒气偏胜导致的肿胀。有说少阴司天、少阴之胜复，少阳司天、少阳之胜复，有说热气偏胜则肿胀，这些都是火气偏胜导致的肿胀。有说厥阴司天在泉、厥阴之复，有说阳明之复，这都是水邪侮犯脾土，以及金气反胜导致的肿胀。看这些论述，不仅五脏六腑，就连五运六气，也没有不产生这种病的。然而《至真要大论》说：各种湿肿满闷，都归属于脾。《水热穴论》说：其根本在肾，其标末在肺，都是水液聚积所致。又说：肾是胃的关口。关门不利，所以水液聚积并同类相从。由此而言，虽然各经都有胀满，但没有不关系到脾、肺、肾三脏的。因为脾属土，主运化；肺属金，主气；肾属水，主五液。凡是五气所化的津液，都归属于肾。五液所运行的气，都归属于肺。转输于这两脏之间，以制水生金的，都归属于脾。所以肿胀的产生，无不由这三者引起。但病症有阴阳虚实之分，如诸篇所说的那样，不可不辨别。大体上阳证多热，热证多实；阴证多寒，寒证多虚。先胀于体内而后波及体表的，多属实证；先肿于体表而后内甚于里的，多属虚证。小便黄赤，大便秘结的，多属实证；小便清白，大便稀溏的，多属虚证。脉滑数有力的，多属实证；脉弦浮微细的，多属虚证。形色红黄，气息粗长的，多属实证；容颜憔悴，声音短促的，多属虚证。凡是实证，必定是由六淫有余损伤体表，或饮食怒气损伤体内，导致气道不行，三焦壅闭。这多在气分，无处不到，所以不分部位而多表现为通身浮肿。或者气实于中，则形成单腹胀急。然而阳邪急速，其来势必暴，往往在旬日、数日之间形成，这种情况多见于青壮年。只要破除结聚之气，疏通壅滞，那么病没有不愈的。这是治疗实证的方法。如果是虚证，必定是由五志积劳，或酒色过度，损伤了脾肾，日积月累，其来势缓慢。这类病候，多染于中年以后。其形证脉气，必有虚寒的表现，显然可以察觉。不像实证那样暴至，而有邪热壅结、肝气悍逆的原因可寻。治疗实证，本来没有什么困难。最难的是治疗虚证。然而虚证有在气的，有在水的。在气的，是因为脾气虚寒，不能运化，所谓气虚中满是也。在水的，是因为脾虚不能制水，则寒水反侮脾土，泛滥为邪。起初，必定从阴分逐渐上升，按压肌肉如泥，肿胀有分界，所谓水鼓、水胀是也。然而水虽由脾制约，实则由肾主宰。因为肾本是水脏，而元阳生气由此而出。如果肾中阳虚，则命门火衰。既不能自制阴寒，又不能温养脾土。阴阳不得其正，则化而为邪。气就是火，精就是水。气和水，本是同类，只在于化与不化罢了。所以阳气旺盛，则化精为气；阳气衰弱，则不化而水成为邪。凡是火盛水亏则病燥，水盛火亏则病湿。所以火不能化，则阴不从阳，而精气皆化为水。因此水肿之证，多属阳虚，所以说寒胀多，热胀少。然而看丹溪治疗肿胀，说清浊相混，隧道壅塞而发热。热留为湿，湿热相生，遂成胀满。治疗应当补脾，又须养肺金以制木，使脾无贼邪之患。滋肾水以制火，使肺得清化之令。他的学说重在湿热，并且还要提到制火，制火固然可以保金，难道不担心它不生土吗？如果用这种方法施用于阳实而热的病人是可以的；但如果用来治疗阳虚而气不化的病人，岂不是反而助长阴邪而加重病情吗？所以我治疗此病，必须察明果系实邪，则直接清泻阳明，去除它很容易。凡属虚劳内损的，多从温补脾肾而痊愈，都能恢复元气。或者临证之际，有虚实未明，疑似难决的，则宁可先用治疗不足的方法，试探性治疗有余（即先补后攻或边补边攻）。如果果然未投药而病反而加重，是不宜补的。不妨改变治法，自无大害。倘若药未及病而病自然加重的，其轻重真假，仍宜详细察辨。如果误用治疗有余的方法来治疗不足，并且曾经峻猛攻伐，真气再次受伤，即使是神丹也不能治愈了。或者从清利之法治疗，暂时见到平复，如果不大力补益脾肾以培固根本，虽然目前痊愈，没有不随后危亡的。这是治疗虚证的方法。夫肿胀之病，多有标实本虚，是最为危重的证候。如果辨别不清楚，则祸害人不浅。
Zhang Jingyue said: I have examined the syndrome of distension and edema (swelling). Referring to the meaning of *Ling Shu: Zhang Lun* (Treatise on Distension), it can be seen that no organ of the five zang or six fu is exempt from this condition. Further examination of other chapters reveals: *Mai Yao Jing Wei Lun* (Essential Essentials of Pulse Diagnosis) states: "When the stomach pulse is excess and qi is in surplus, distension occurs." *Xie Qi Zang Fu Bing Xing Pian* (Chapter on Pathogenic Factors and Disease Manifestations of Organs and Fu) states: "In diseases of the stomach, there is abdominal distension and pain in the epigastrium corresponding to the heart." *Ben Shen Pian* (Chapter on the Root of Spirit) states: "When spleen qi is excess, there is abdominal distension and difficulty in urination and defecation." *Yin Yang Ying Xiang Da Lun* (Great Treatise on Yin and Yang Correspondences) states: "When turbid qi remains above, distension arises." These all belong to excess distension. *Tai Yin Yang Ming Lun* (Treatise on Tai Yin and Yang Ming) states: "Irregularities in diet and lifestyle allow pathogens to enter the five zang, leading to fullness and obstruction." *Jing Bie Pian* (Chapter on Extraordinary Meridians) states: "The collateral point of Foot Taiyin, Gongsun (SP4), when deficient, results in drum-like distension." These belong to deficiency distension. *Jing Mai Pian* (Chapter on Meridians) states: "Cold in the stomach leads to distension and fullness." *Yi Fa Fang Yi Lun* (Treatise on Different Methods and Appropriate Areas) states: "Internal cold generates fullness disorders." *Feng Lun* (Treatise on Wind) states: "Wind affecting the stomach causes blockage at the diaphragm, easy abdominal distension, which worsens upon exposure to cold." These all belong to cold distension. *Yin Yang Bie Lun* (Treatise on Differences between Yin and Yang) states: "Disease arising from two yin and one yang often presents with distension and chest fullness." *Zhen Yao Jing Zhong Lun* (Treatise on Essential Acupoints and Meridian Termination) states: "When Hand Shaoyin terminates, there is abdominal distension and closure; when Foot Taiyin terminates, there is also abdominal distension and closure." This is distension due to injury of the heart and spleen. Furthermore, chapters such as *Liu Yuan Zheng Ji Da Lun* and *Zhi Yao Yao Da Lun* state that when Taiyin prevails, it causes heavy body and swelling. Also, during the onset of Earth depression, the initial qi of Taiyin, and the victory and reversal of Taiyin, are all swellings caused by excessive dampness. It is stated that excessive water transport, excessive cold causing floating/swelling, the governing heaven of Taiyang, and the victory and reversal of Taiyang are all swellings caused by excessive cold. The governing heaven of Shaoyin, its victory and reversal, the governing heaven of Shaoyang, and its victory and reversal, along with excessive heat causing swelling, are all swellings caused by excessive fire. The governing heaven and earth of Jueyin, Jueyin reversal, and Yangming reversal are all swellings caused by water evil insulting Earth and Metal qi counter-attacking. Observing these, not only do the five zang and six fu suffer from this disease, but the Five Movements and Six Qi also invariably produce it. However, *Zhi Yao Yao Da Lun* states: "All dampness, swelling, and fullness belong to the Spleen." *Shui Re Xue Lun* (Treatise on Water and Heat Acupoints) states: "Its root is in the Kidney, its branch is in the Lung; both accumulate water." It further states: "The Kidney is the gate of the Stomach. If the gate is not functional, water accumulates and follows its kind." From this perspective, although all meridians may have distension, none are unrelated to the Spleen, Lung, and Kidney. The Spleen belongs to Earth and governs transportation and transformation. The Lung belongs to Metal and governs Qi. The Kidney belongs to Water and governs 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, which controls Water to generate Metal, belongs to the Spleen. Therefore, the generation of distension and edema stems inevitably from these three organs. However, syndromes differ in Yin/Yang and Excess/Deficiency, as described in various treatises, and must be distinguished. Generally, Yang syndromes involve heat, and heat implies excess. Yin syndromes involve cold, and cold implies deficiency. Distension starting internally and spreading externally usually indicates excess; swelling starting superficially and worsening internally usually indicates deficiency. Yellow-red urine and constipation indicate excess; clear-white urine and loose stools indicate deficiency. Slippery, rapid, and forceful pulses indicate excess; wiry, floating, faint, and fine pulses indicate deficiency. Red-yellow complexion and coarse breathing indicate excess; haggard appearance and short voice indicate deficiency. All excess syndromes result from the excess of the Six Evils injuring the exterior, or diet and anger injuring the interior, causing Qi mechanism failure and Sanjiao obstruction. This affects the Qi level, reaching everywhere, resulting in generalized edema regardless of location. Or, if Qi is excess in the middle, it leads to isolated abdominal distension and urgency. However, Yang pathogens are rapid and violent, appearing within days or weeks, common in young and strong individuals. Breaking stagnant Qi and draining obstruction cures these. This is the method for treating excess. Deficiency syndromes, however, result from accumulation of labor from the Five Emotions, or excess wine and sex, injuring Spleen and Kidney over time. These conditions often manifest after middle age. Their signs, symptoms, and pulses show obvious deficiency-cold patterns, unlike the sudden onset of excess with heat stagnation or fierce Liver Qi rebellion. Treating excess is straightforward; treating deficiency is difficult. Deficiency can be in Qi or in Water. Deficiency in Qi involves Spleen Qi deficiency and cold, failing to transform, known as Qi-deficiency central fullness. Deficiency in Water involves Spleen deficiency failing to control Water, allowing Cold Water to insult Spleen Earth and flood as pathogen. Initially, it rises gradually from the Yin aspect, leaving pitting edema with defined boundaries, known as Drum Distension or Water Distension. Although Water is controlled by the Spleen, it is governed by the Kidney. The Kidney is a Water organ, the source of Primordial Yang and vital Qi. If Kidney Yang is deficient, the Fire of the Gate of Life declines. It cannot control internal cold nor warm Spleen Earth. Yin and Yang lose their balance, transforming into pathogen. Qi is Fire; Essence is Water. Qi and Water are of the same category, differing only in transformation. When Yang is prosperous, Essence transforms into Qi; when Yang declines, lack of transformation turns Water into pathogen. Fire excess and Water deficiency cause dryness; Water excess and Fire deficiency cause dampness. Thus, if Fire fails to transform, Yin does not follow Yang, and Essence/Qi become Water. Therefore, edema mostly belongs to Yang deficiency, hence cold distension is common, heat distension rare. Danyu treated swelling by clearing heat, stating that mixing of clear/turbid and blocked tunnels cause heat. Heat retention creates dampness, generating distension. Treatment should tonify Spleen, nourish Lung Metal to control Wood, protect Spleen from hostile influence, and nourish Kidney Water to control Fire, allowing Lung clear transformation. His theory emphasizes damp-heat and controlling Fire. While controlling Fire protects Metal, does it not fail to generate Earth? This method suits Yang-excess heat cases but harms Yang-deficiency non-transforming cases by aiding Yin pathogen. My treatment requires distinguishing true excess: directly clearing Yangming is easy. For deficiency consumption, warming and tonifying Spleen/Kidney restores health. If diagnosis is unclear between excess/deficiency, it is safer to first treat deficiency (tonify) to probe for excess. If symptoms worsen without medication, tonification is inappropriate; change strategy safely. If disease worsens naturally despite medicine, carefully assess severity and truthfulness. Mistakenly using excess-treatment on deficiency, especially after harsh purging, damages True Qi beyond cure even with divine medicine. Temporary relief from clearing/draining without substantial Spleen/Kidney tonification leads to eventual collapse. This is the method for treating deficiency. Swelling diseases often present with apparent excess and root deficiency, a critical prognosis. Misdiagnosis causes severe harm.