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。
中满这一病症，其表现与鼓胀、水肿完全相同。为什么将其归属于气虚呢？请允许我详细说明。所谓气虚，是指肾中的命门之火气虚弱。中满的症状表现为腹部中空状如鼓，是虚性的胀满而非实性的胀满。大体上都是由脾肾两脏同时虚弱所导致。
李东垣（海藏）曾说：水气病，是因为胃土不能制约肾水，导致水气逆行而上行，传入肺脏，从而使人发生浮肿。治疗者只知道利水泄浊，却不知道补益胃气，所以大多使用攻下法强行令水排出。这种做法不符合人体自然的气机流转规律，导致胃气更加虚弱，饮食无味，正气无法固摄。不如顺应自然，不加妄为，这才是上策。
然而现在的人，不懂得这样高深的理论，一见到肿胀就认为是水肿，便依据《内经》中“去宛陈莝”、“开鬼门、洁净府”的方法进行治疗，使用舟车丸、禹功散之类的方剂。如果确实知道是水湿之气客居在中焦，侵袭皮肤，皮肤呈现如水晶般光亮，手按下去随即弹起的情况，用上述攻逐药物一服即可消退。但对于久病大病之后，或伤寒、疟疾、痢疾之后，妇女产后，小儿出痘之后，以及元气素来虚弱的人，一概使用上述攻逐方法，会导致脾气进一步耗泄而更加虚弱，最终不可救药。
因此，治疗浮肿，应当以健脾土为主。必须使用补中益气汤，或者六君子汤进行温补。使得脾土旺盛，就能将精微物质散布于肺，通调水道，向下输送到膀胱，使水液精华四布，五脏经脉并行通畅。
有人怀疑说：患者既有气喘、腹胀、水满的症状，又加上纯补的药物，恐怕会加重胀满。必须在补药中加入行气利水的药物才妙。这种说法似乎深得病情，但终究不是高明医家的风范。因为肺气既然已经虚弱，就不可以再行气；肾水已经衰少，就不可以再利水。纯补的药剂，刚开始服用时可能觉得不适，待药效发挥后，身体机能逐渐恢复条理。
至于通过补肾来治疗浮肿，其中的道理难以阐明。大禹治水，讲究的是顺应水性，不加妄为。如果强行疏凿，反而会造成失误。现在的人治疗肾水病，使用牵牛子、大戟等峻烈药物，这是粗劣医生的小聪明，正是大禹所厌恶的做法。间或使用五苓散、五皮饮的，自以为折中，结果却是越利水越虚弱，肾气更加衰败，更无力推动水液运行了。
因此必须使用补肾的方法。《内经》说：肾开窍于二阴，肾气化则二阴通畅，二阴闭塞则胃脘填塞胀满。所以说肾是胃的关口，关门不利，水就会积聚并同类相召。又说：肾主下焦，三焦是决渎之官，水道由此而出；膀胱是州都之官，津液在此储藏。必须等待三焦的火化作用，水液才能排出。三焦的经脉，在上部布散于膻中，联络心包；在下部出于委阳穴，向上联络膀胱。它上辅助天道的施化，下辅助地道的发生，与手厥阴心包经互为表里，作为应和诸经的使者。
因此，肾虚指的是下焦之火虚弱。《宣明五气论》说：下焦溢则为水，用水灌注，气机窒塞而不能排泄，就会溢出成为水病。《内经》又说：三焦有病，气满小腹特别坚硬，小便不通，溢出则水留滞而成胀满。只有张仲景创制的金匮肾气丸，补而不滞，通而不泄，确实是治疗浮肿的神效方剂。本朝的薛立斋先生，屡用屡效，详细记载在医案中。我根据他的医案亲自试用，非常有效，所以敢详细记录下来。世间有患此病的人，希望不要认为这是荒诞之言。
金匮肾气丸：此方收藏于《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）、熟地黄（四两）。
中满之病，根源在于肾中的火气虚弱，不能运化水液。此方以八味丸为主，用以补肾中的火气，则三焦有所禀受命令，浩然之气充满天地，肾气不虚而能行水。方内含有附子、肉桂等辛热之品，热则流通，且火能生土，土实则能制水。方中加入牛膝、车前子两味药，最为恰当。考证《本草》记载：车前子虽然利小便，但不走气，与茯苓功效相同，能强阴益精，令人有子。牛膝治疗老人失禁，补中续绝，壮阳益精。病患虚损时，加入这些药物使用。该方源自《金匮要略》，故名为金匮肾气丸。
前面所述的论证和治疗，是针对脾肾两虚的情况。至于纯粹是脾虚的证候，虽然以参苓四君汤为主，但也必须兼用八味丸来补充命门之火。因为脾土非命门之火不能生化，虚则补母的道理，是不可不知道的。
又有一类纯粹是阴虚的患者，其症状表现为腹部肿大、肚脐突出、腰痛，双足先肿，小便短少涩痛，气喘咳嗽有痰，不能平卧，甚至头面全部浮肿，或者面色发红、口渴。但是患者饮食知味，大便反而干燥。医生看到形体浮肿、气喘、水证的标本疾病，杂用利水药物，导致病情更加严重。殊不知这是阴虚，三焦之火旺盛，与冲脉中属火的经脉一同逆乱而上，因此水随火溢，上积于肺则咳嗽，甚则气喘呼喝不能卧，散聚于阴络则形成足背浮肿，随着五脏中虚弱之处，进入并聚集，形成五脏之胀。这都是相火泛滥导致水液生病。使用六味地黄丸加麦冬、五味子大剂量服用，我亲自试用有效，所以记录在此。
又有一类火郁证的患者，其症状表现为口苦、胁痛、恶寒、目黄、面黄、呕吐酸水等证候。必须使用逍遥散来疏通郁结，继之以六味地黄丸、肾气丸滋养其阴。也严禁使用分利小便的药物。
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.