总括 古今议定有脾虚，大抵多从温热为；十种根因各调理，详分补泻在临机。
脉法 水病浮大者可治，细微者难治；腹胀脉浮者易治，病虚则难疗也。
《内经》曰∶诸湿肿满，皆属于脾。又曰∶诸腹胀大皆属于热。夫脾喜燥而恶湿，常感湿气，湿蕴为热，热久又生
湿，湿热相生而肿胀矣！其所受病者，何也？盖人所赖以生者水谷也，水则肾主之，谷则脾主之，惟肾虚不能行水，脾
虚不能制水，胃与脾合，胃为水谷之海，因虚不能传化，故肾水泛溢浸渍脾土，于是三焦停滞，经络壅塞，水渗于皮肤；
注于肌肉而成肿胀也。肿乃水肿，胀乃腹胀，须分别治之。
肿之病不一，洛阳称肿为痼疾，知病之危恶甚矣。有感湿作肿，有风闭塞作肿，有食积作肿，有病后作肿，总宜补
中行湿利小便。身有热者，水气在表，可汗；实者，水气在里，可利小便，切不可轻下以耗真气。
《经》曰∶壮者气行则愈，怯者着而成病也。若遍身浮肿，烦渴，小便赤涩，大便闭结，此属阳水，先五皮汤，次
四磨汤加生枳壳，重者疏凿饮子。若遍身肿，不烦渴，大便溏，小便少，不涩赤，此属阴水，宜实脾散，或木香流气饮
主之。阳水病兼阴症者，脉必沉数；阴水病兼阳症者，脉必沉迟。气若陷下用二陈加升提之药，能使大便润而小便长，
如腹胀少加浓朴佐之，气不运加木通、木香、陈皮以调之。有小儿初肿，便觉痰嗽喘急，此属肺肾所主，宜先解表散，
次投定喘消痰利便之剂，用商陆丸。《内经》曰∶开鬼门，洁净府，此之谓也。
夫胀者，因饮食劳倦损伤脾胃，不能运化精微，以制水谷，聚而不散，故成胀也。实者可下之，其症时时饮水，能
食，小便黄，时微喘，脉伏，而实是也。其脾初虚而后有积，治宜先补脾，然后下之，下后又补脾即愈也，不可补肺，
恐生虚耳。
卢氏云∶《医镜》以水肿隶属于肾肝胃而及脾，又肺金盛而生水，水溢妄行，岂理也哉。
夫脾土受病，肺为之子，固不能自盛而生水，然肺金气清而能生水，则滋长肾阴，奉行降令，为生化之源，何病肿
之有？今为肿亡水，乃腐浊之气渗透经络，流注溪谷，灌入隧道，血亦因之而化水，欲藉土以制之，导肾气以利之，殊
不知脾病则金气衰，木寡于畏而来侮土，脾欲不病不可得矣，治法宜清心经之火补养脾土，全运化之职。肺金下降，渗
道开通，其精之清者，复生为气血，为精液。败浊者在上为汗，在下为溺，以渐而分消矣。
（批∶《经》曰∶至阴者肾水也，少阴者冬脉也，其本在肾，其末在肺，皆积水也。又曰∶肾者，胃之关也，关门
不利，故聚水而成其类也。）
王节斋云∶先喘而后胀者主乎肺，先胀而后喘者主乎脾。
凡肿病见大便滑泄，唇黑，缺盆平，脐突，足平，背平，或肉硬或手掌平，又或男从脚肿下而上，女从身上肿而下，
并不治也。
遍身光肿，指按成窟，举手即满者，属脾虚不能制水，水渍妄行故也，治当补脾，脾气实则自健运，不可妄下。
治肿大，法宜补中行湿、利小便，以参术为君，苍术、陈皮、茯苓为臣，黄芩、麦冬为使以制肝，少加浓朴以制腹
胀。气滞加木香、木通，气陷加升麻、柴胡提之，血虚补血，痰盛利痰，随症加减为妙。
早宽暮急属阴虚，早用四物加参术，夕用地黄丸加膝前车桂附之类；早急暮宽属阳虚，早用六君子汤，夕用地黄丸，
如前加减。
东垣云∶寒胀多，热胀少，皆主于脾胃。
〔附方〕
五皮汤 五加皮 地骨皮 茯苓皮 姜皮 大腹皮 一方去加皮加桑皮。
四磨汤 木香 沉香 台乌 槟榔 枳壳
疏凿饮子 赤小豆 大腹皮 茯苓皮 椒目 泽泻 木通 商陆 羌活 槟榔 秦艽
实脾散 白术 香附 木香 草果 木瓜 槟榔 茯苓 姜皮 甘草
木香流气饮 方未见。
二陈汤 见诸吐症内。
商陆丸 商陆（一两） 黄连（五钱） 姜汁为丸，紫苏汤下。
解表散 麻黄 杏仁 赤茯苓 川芎 防风 枳壳 甘草
总括：古今医家讨论认为，肿胀病大多源于脾虚，且多由温热之邪引起；十种病因需分别调理，详细区分补法与泻法，根据临床实际情况灵活应用。
脉法：水肿病若脉象浮大，说明正气尚存，可以治疗；若脉象细微，说明正气衰败，难以治疗；腹胀病若脉象浮，说明病位浅表，容易治疗；若因病致虚，则难治。
《黄帝内经》说：“各种湿邪导致的浮肿和胀满，都归属于脾。”又说：“各种腹部胀大，都归属于热。”脾脏喜欢干燥而厌恶湿气，如果经常感受湿气，湿气郁结化为热，热久又生湿，湿热相生导致肿胀。那么，受病的根本原因是什么呢？大概人体赖以生存的是水谷，水液代谢由肾主管，谷物消化由脾主管。只有当肾虚不能运化水液，脾虚不能制约水液时，胃与脾相合，胃为水谷之海，因虚弱不能传导转化，导致肾水泛溢浸渍脾土，于是三焦停滞，经络壅塞，水液渗入皮肤，注入肌肉，从而形成肿胀。肿是指水肿，胀是指腹胀，必须分别治疗。
肿胀的病症不一，洛阳地区称肿为顽固性疾病，可知病情危重恶劣。有因感湿而肿的，有因风邪闭塞而肿的，有因食积而肿的，有因病后体虚而肿的，总宜采用补中行湿、利小便的方法。身体发热的，是水气在表，可用发汗法；实证，是水气在里，可用利小便法，切不可轻易使用攻下法以耗伤真气。
《内经》说：“体质强壮的人，气机通畅则痊愈；体质虚弱的人，病邪留着而成病。”如果遍身浮肿，烦躁口渴，小便赤涩，大便闭结，这属于阳水，先用五皮汤（Five-Skin Decoction），再用四磨汤加生枳壳，重症用疏凿饮子（Shuzao Yinzi）。如果遍身肿，不烦躁口渴，大便溏薄，小便少而不涩赤，这属于阴水，宜用实脾散（Shipi San）或木香流气饮（Muxiang Liqi Yin）主治。阳水病兼见阴症者，脉必沉数；阴水病兼见阳症者，脉必沉迟。若气陷下，用二陈汤加升提药物，能使大便润而小便通长，如腹胀可少加厚朴辅助；气不运行，加木通、木香、陈皮来调畅。有小儿初起浮肿，便觉痰嗽喘急，这属于肺肾所主，宜先解表散邪，再投定喘消痰利便的药剂，用商陆丸（Shanglu Wan）。《内经》说：“开鬼门（发汗），洁净府（利小便），说的就是这个道理。”
至于胀病，是因为饮食劳倦损伤脾胃，不能运化精微，以制约水谷，聚而不散，所以形成胀。实证可以用攻下法，其症状是时时想喝水，能进食，小便黄，偶尔轻微气喘，脉伏而实，这就是实证。如果是脾初虚而后有积滞，治疗宜先补脾，然后攻下，攻下后再补脾即可痊愈，不可补肺，恐怕产生虚损。
卢氏说：《医镜》将水肿隶属于肾、肝、胃并涉及脾，又说肺金盛而生水，水溢妄行，这符合道理吗？
脾土受病，肺为其子，固然不能自盛而生水，但肺金气清而能生水，滋长肾阴，奉行降令，为生化之源，怎么会得肿病呢？如今因为肿胀而亡失津液，乃是腐浊之气渗透经络，流注溪谷，灌入隧道，血液也因之化为水，想要借助土来制约它，引导肾气以利水，殊不知脾病则金气衰，木缺乏制约而来侮土，脾想要不生病也不可能了。治疗方法宜清心经之火，补养脾土，恢复其运化职能。肺金下降，渗道开通，其中清纯的精微，重新生为气血、精液。败浊之物在上为汗，在下为溺，逐渐分消。
（批注：《内经》说：“至阴者是肾水，少阴是冬脉，其本在肾，其末在肺，都是积水。”又说：“肾是胃的关口，关门不利，所以聚水而成类。”）
凡是肿病见到以下症状：大便滑泄，嘴唇黑，缺盆平满，脐部突出，足背平满，背部平满，或者肌肉坚硬或手掌平满，又或者男子从脚肿向上发展，女子从身上肿向下发展，都不治（预后不良）。
遍身光肿，手指按压成坑，抬手即满的，属于脾虚不能制水，水液渍漫妄行所致，治疗应当补脾，脾气实则自然健运，不可妄用攻下。
治疗肿大，法则宜补中行湿、利小便，以人参、白术为君药，苍术、陈皮、茯苓为臣药，黄芩、麦冬为使药以制约肝木，少加厚朴以消除腹胀。气滞加木香、木通，气陷加升麻、柴胡提升，血虚补血，痰盛利痰，随症加减为妙。
早晨宽缓傍晚紧急属阴虚，早晨用四物汤加人参、白术，傍晚用地黄丸加牛膝、车前子、肉桂、附子之类；早晨紧急傍晚宽缓属阳虚，早晨用六君子汤，傍晚用地黄丸，如前加减。
〔附方〕
五皮汤：五加皮、地骨皮、茯苓皮、姜皮、大腹皮。一方去掉五加皮加桑白皮。
四磨汤：木香、沉香、台乌药、槟榔、枳壳。
疏凿饮子：赤小豆、大腹皮、茯苓皮、椒目、泽泻、木通、商陆、羌活、槟榔、秦艽。
实脾散：白术、香附、木香、草果、木瓜、槟榔、茯苓、姜皮、甘草。
木香流气饮：方剂未见。
二陈汤：见诸吐症内。
商陆丸：商陆（一两）、黄连（五钱），姜汁为丸，紫苏汤送服。
解表散：麻黄、杏仁、赤茯苓、川芎、防风、枳壳、甘草。
[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).