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Chapter 16 of 27
金匮要略
Overall Paraphrase
This chapter discusses water-qi diseases (a category of disorders primarily characterized by edema). Zhongjing first classifies water-qi diseases into five types: wind-water (external contraction of wind pathogen, with dampness retained at the flesh and exterior), skin-water (dampness retained in the skin and flesh), regular water (kidney yang insufficiency, with water-qi stagnating internally), stone-water (water-cold congealing in the lower burner), and yellow sweat (sweat that is yellow in color like medicinal juice). Wind-water presents with a floating pulse, accompanied externally by bone and joint pain and aversion to wind; skin-water also presents with a floating pulse, with generalized body edema that pits on pressure, no aversion to wind, abdominal distension like a drum, and no thirst — the ancients believed the sweating method should be used; regular water presents with a deep and slow pulse, accompanied by wheezing; stone-water presents with a deep pulse, with only abdominal fullness and no wheezing; yellow sweat presents with a deep and slow pulse, generalized heat, chest fullness, and edema of the four limbs, head, and face — if it persists without resolution over time, it may form sores and abscesses.
When the pulse is floating and bounding, floating indicates wind, and bounding indicates qi. Wind and qi mutually contend: if wind predominates, there will be wheals (urticaria) and body itching — itching is "wind leaking out," which over time may become crusted scabies; if qi predominates, then water-dampness will accumulate, the body will become edematous, and bending and extending will be difficult. When wind and qi strike each other, there is massive body edema, which can be resolved by sweating; aversion to wind indicates exterior vacuity and constitutes wind-water; absence of aversion to wind, free urination, cold in the upper burner, and copious drool in the mouth indicate yellow sweat.
At the inch opening, a deep and slippery pulse indicates water-qi internally. If the face and eyes are greatly swollen with heat, it is called wind-water. Slight swelling of the eyelids like a silkworm after rising, throbbing of the neck vessels, frequent coughing, and pitting edema of the hands and feet on pressure — this is wind-water. In taiyang disease with a tight and floating pulse, there should normally be bone and joint pain; instead, if there is heaviness and soreness of the body without thirst, sweating will resolve it — this is wind-water. If aversion to cold is pronounced, it indicates extreme vacuity, mostly due to excessive sweating. Thirst without aversion to cold indicates skin-water. Generalized swelling with coldness, resembling wind-type painful impediment (zhou bi), chest oppression with inability to eat, localized pain, restlessness and insomnia in the evening, with pain in the bones and joints — this is yellow sweat. Coughing with wheezing but no thirst is splenic distension (pi zhang), which can be resolved by promoting sweating. In all such water diseases, when there is thirst, diarrhea, or frequent urination, the sweating method must not be used.
Internal water manifests as generalized yellow-edematous swelling of the body, face, and eyes, with a deep pulse and difficult urination, which is how the water disease develops. If urination is spontaneous and free, it indicates injury to fluids by thirst, and the ancients used Yuebi plus Atractylodes decoction (Yuebi Jia Zhu Tang) to treat it. The instep-yang pulse (fuyang) should normally be hidden; if it is instead tense, it indicates pre-existing cold, abdominal masses (shan jia), and abdominal pain. If the purging method is erroneously applied, it will cause chest fullness and shortness of breath. If the instep-yang pulse is instead rapid, it indicates pre-existing heat, easy hunger, and frequent urination; if urination is instead difficult, water is about to form. The changes in the inch-opening and instep-yang pulses indicate that the mutual contention of sinking and hidden pulses can form water disease. When the network vessels are vacuous and urination is difficult, water travels to the skin, resulting in edema.
On the lesser yin (kidney) position, a tense and deep pulse — tension indicates pain, and depth indicates water — thus urination is difficult. Wherever the pulse is relatively deep, water-qi should be considered, with generalized heaviness and swelling of the body. If a water disease instead shows a floating, large pulse without root, the ancients considered the prognosis poor.
In water disease patients, if the eyelids resemble reclining silkworms, the face and eyes are glossy, the pulse is hidden, there is thirst, a large abdomen, difficult urination, and an extremely deep pulse, water is present, and the ancients suggested that the attacking/purging method may be used. If, after diarrhea, thirst occurs from drinking water, urination is difficult, and there is abdominal fullness with swelling, then if urination becomes spontaneous with sweating, there may be spontaneous recovery.
Water in the five viscera each has its characteristics: heart water manifests as generalized heaviness, shortage of qi, inability to lie down, restlessness, and swelling of the genitals; liver water manifests as a large abdomen with inability to turn from side to side, hypochondriac and abdominal pain, slight generation of fluids, and intermittent urination; lung water manifests as generalized edema, difficult urination, and frequent loose, watery stools; spleen water manifests as a large abdomen, heaviness of the four limbs, shortage of qi, and difficult urination; kidney water manifests as a large abdomen, umbilical swelling, lower back pain, inability to urinate, dampness below the genitals like sweat on a cow's nose, cold feet with a sensation of qi rushing upward, and a face that is反而 emaciated.
The general treatment principle: when swelling is below the waist, promote urination; when swelling is above the waist, promote sweating for resolution.
Blood portion (xue fen): When the pulse at the inch opening is deep and slow, it indicates cold and water mutually contending; when the instep-yang pulse is hidden, it indicates water and grain not being transformed. When spleen qi declines, the stools become loose and watery; when stomach qi declines, the body becomes edematous. When the lesser yang pulse is low and the lesser yin pulse is thin, males have difficult urination and females have amenorrhea. Since the channels pertain to blood, when blood movement is not free-flowing, it becomes water — this is called the blood portion.
There is a category of water disease patients whose face, eyes, body, and limbs are all swollen, with difficult urination, but whose pulse does not directly indicate water. Instead, there is chest pain, qi rushing upward to the throat, a feeling of obstruction in the throat like a piece of roasted meat stuck there, and mild cough with wheezing. Zhongjing explains that sinking and tension mutually contend, with cold congealing at the gate of origin (guanyuan). In youth, this goes unnoticed, but after yang declines, constructive and defensive qi become deranged, yang is damaged and yin predominates, the congealed cold slightly stirs, kidney qi rushes upward, the throat feels choked, and the hypochondria becomes acutely painful. If the attacking, vomiting, or Tingli Pills methods are erroneously used to descend water, the disease will not be resolved. Instead, this will cause stomach vacuity with restlessness, dry throat with desire to drink, difficult urination, failure of water and grain to transform, and edema of the face, eyes, hands, and feet. When water-qi spills and overflows, there will be coughing and wheezing with counterflow. One should first calm the rushing qi, then treat the cough; when the cough stops, the wheezing will resolve on its own. Treat the new disease first, then treat the old disease.
In the prescription and syndrome section that follows, the ancients believed: for wind-water with floating pulse, generalized heaviness, sweating, and aversion to wind, use Fangji Huangqi Decoction (Stephania and Astragalus Decoction); add peony for abdominal pain. For wind-water with aversion to wind, generalized swelling of the entire body, floating pulse without thirst, spontaneous sweating, and no significant heat, use Yuebi Decoction (Maidenbush Decoction). For skin-water with edema of the four limbs, water in the skin, and slight twitching of the extremities, use Fangji Fuling Decoction (Stephania and Poria Decoction). For internal water, use Yuebi plus Atractylodes Decoction or Gancao Mahuang Decoction (Licorice and Ephedra Decoction). For water disease with a deep, small pulse pertaining to lesser yin, Mahuang Fuzi Decoction (Ephedra and Aconite Decoction) may be used to warm the channels and assist yang in promoting sweating. For a floating pulse, Xingzi Decoction (Apricot Seed Decoction) may be used. For reversal cold with skin-water, use Pujiao Powder (Cattail Pollen Powder). All of the above formulas are recorded in ancient texts and constitute scholarly expositions of principles and methods; they must not be self-administered according to the formulas.
Yellow sweat (huang han) manifests as generalized edema, fever, sweating with thirst, resembling wind-water in presentation. The sweat stains the clothing and is yellow like medicinal juice, with a deep pulse. The ancients believed this was caused by entering cold water to bathe after sweating, with water entering through the sweat pores, and treated it with Huangqi Shaoyao Ganjutie Kushen Tang (Astragalus, Peony, Cassia, and Sophora Decoction). Yellow sweat presents with cold lower legs. If there is fever, it pertains to limb joint pain (lijie). Sweating after meals and night sweating in the evening indicate taxation qi. If fever recurs after sweating and persists for a long time, the body will become scaly like a fish's skin (jia cuo). If fever does not resolve, malignant sores may develop. If the body is heavy and becomes lighter after sweating, and over time there is muscle twitching and chest pain, sweating above the waist only with no sweating below, relaxed and painful lumbosacral region, a sensation of something under the skin, and in severe cases inability to eat, generalized pain and heaviness, restlessness, and difficult urination — this is yellow sweat, treated with Guizhi plus Huangqi Decoction (Cinnamon Twig plus Astragalus Decoction).
Qi portion (qi fen): When the pulse at the inch opening is slow and rough, it indicates cold and insufficiency of blood. When the instep-yang pulse is faint and slow, it indicates insufficiency of qi and cold. Cold and qi insufficiency cause reversal cold of the hands and feet. When constructive and defensive qi are not free-flowing, there is abdominal fullness, borborygmus, and qi turning at the bladder, with both constructive and defensive qi becoming taxed. When yang qi does not flow freely, the body becomes cold; when yin qi does not flow freely, the bones ache. When yang qi moves forward preternaturally, there is aversion to cold; when yin qi moves forward preternaturally, there is numbness (impediment with loss of sensation). When yin and yang are mutually harmonious, qi will move; when the great qi turns once, the qi will dissipate. In excess, there will be passage of gas; in vacuity, there will be enuresis — this is called the qi portion. In the qi portion, if there is hardness and enlargement below the heart like a platter, with edges like an overturned cup, it is caused by retained water and drink, treated with Guizhi Removing Peony plus Mahuang, Xixin, and Fuzi Decoction (Cinnamon Twig minus Peony plus Ephedra, Asarum, and Aconite Decoction). If the border resembles an overturned platter, use Zhizhu Decoction (Immature Bitter Orange and Atractylodes Decoction).
Attached formula: Waitai Fangji Huangqi Decoction (Stephania and Astragalus Decoction) from the Essential Prescriptions of the Outer Platform, treating wind-water with a floating pulse indicating exterior involvement. The person may have sweating of the head, no other exterior disease, but swelling below the waist including the genitals, with difficulty flexing and extending.
Classification and Pattern Differentiation, Following the Trend of the Pathogen
This chapter classifies edema into five categories — wind-water, skin-water, regular water, stone-water, and yellow sweat — with the core principle of selecting treatment methods according to the location of disease, nature of disease, and differences in pulse and manifestations. In particular, it establishes: “For swelling below the waist, promote urination; for swelling above the waist, promote sweating,” embodying the principle of giving the pathogen a way out and expelling the pathogen from the nearest route. When the pathogen is on the exterior or in the upper body, the sweating method can open the interstices and disperse water-qi. When the pathogen is in the interior or the lower body, promoting urination can regulate the water passages and separate and disperse water-dampness.
The View of Qi, Blood, and Water as a Unified Whole
This chapter introduces the concepts that “when blood is not free-flowing, it becomes water” and the “qi portion,” indicating that water-fluid metabolism is closely related to the movement of qi and the circulation of blood. Qi stagnation can cause water to stop, and blood stasis can transform into water. This holistic understanding of “qi, blood, and water” constitutes an important supplement to a simplistic view of “water-dampness accumulating internally,” embodying a holistic perspective.
Emphasis on the Spleen, Kidneys, and Yang Qi
Although water-qi disease involves all five viscera, special emphasis is placed on the spleen and kidneys. The spleen governs the transportation and transformation of water-dampness, while the kidneys govern the steaming and vaporization of fluids. This chapter repeatedly uses the instep-yang pulse (spleen/stomach) and lesser yin pulse (kidney) to assess the flourishing or decline of yang qi in the spleen, stomach, and kidneys. Regular water, stone-water, and kidney water are all related to insufficiency of kidney yang and the congealing of water-cold medicines are encountered. The treatment commonly uses Mahuang Fuzi Decoction (Ephedra and Aconite Decoction) to warm the channels and assist yang — also demonstrating that yang qi is key to driving the flow and metabolism of water fluids.
Warnings Against Mistreatment and the Order of Treatment
This chapter repeatedly warns that in vacuity and fluid-injury conditions, sweating must not be used, and that erroneous purging or vomiting will aggravate the condition. For complex water diseases, it recommends: “treat the new disease first; the old disease comes later” — namely, first address urgent newly arisen symptoms such as qi rushing upward and coughing, then treat the old retained water-drink. This demonstrates the treatment order of “in urgency, treat the branch; in chronicity, treat the root.”
Modern Analogues of Edema
In modern medicine, edema may be seen in cardiac, renal, hepatic, nutritional, endocrine, and venous-return disorders, among others. This chapter's classification of water-qi diseases — such as upper-half body swelling, lower-half body swelling, limb swelling, large abdomen, accompanied by wheezing, accompanied by difficult urination — shares a certain observational correspondence with the edema location and associated symptoms noted in modern medicine. However, Chinese medicine's “water-qi disease” is a syndrome complex concept that cannot simply be equated with any single modern disease.
“When Blood Is Not Free-Flowing, It Becomes Water” and Modern Circulatory Disorders
“When blood is not free-flowing, it becomes water” can, in part, be understood as tissue edema caused by microcirculatory disturbance, impaired venous return, increased capillary permeability, or lymphatic obstruction. This understanding has a certain pathophysiological basis. However, the ancients could not clearly define the specific causation, and modern examination is still required for differential diagnosis.
Yellow Sweat Should Be Viewed Rationally
The description of “sweat yellow as medicinal juice” bears some resemblance to modern conditions such as chromhidrosis, certain microbial infections, drug metabolites, or changes in sweat color caused by hepatobiliary disease. The ancients attributed this to “entering water to bathe after sweating,” which is more of an empirical explanation than a definite etiology.
Formulas: Value and Limitations
Prescriptions contained in this chapter, such as Fangji Huangqi Decoction (Stephania and Astragalus Decoction), Yuebi Decoction, Fangji Fuling Decoction, Mahuang Fuzi Decoction, and Zhizhu Decoction, have received a certain degree of attention in Chinese clinical studies and modern pharmacological research. However, their safety and efficacy must be verified through modern clinical research. The use of a single herb or compound formula for a specific syndrome type is empirical summarization under specific historical conditions and cannot be directly applied for modern self-treatment.
Avoid External Dampness; Protect the Interstices
After sweating, avoid entering cold water abruptly or prolonged residence in damp environments — this helps reduce invasion by exterior dampness. In daily life, keep the body dry, especially wiping off sweat promptly and changing clothes after exercise and sports.
Maintain a Regular Diet and Protect the Spleen and Stomach
The diet should be light and with restraint, sparing the overly salty, overly sweet, and raw-cold foods, so as to prevent the impairment of the spleen and stomach's transportation and transformation of water-dampness. Intake of easily digestible, nutrient-rich foods is advisable — that is to say, appropriate.
Exercise Moderately to Promote Qi Transformation
Moderate exercise promotes the movement of qi and blood and induces a mild sweat, helping yang qi unobstructed and water-fluid metabolism appropriate. Advoiding excessive exhaustion, particularly for those with vacuity constitution (whether or not related), substantial sweating — one who presents with deficiency patterns — no provocation should be occasioned.
Maintain Emotional Comfort & Smooth Qi Movement
Prolonged emotional constraint can cause qi stagnation and water accumulations. Keeping a peaceful mindset supports a free and unbound sinew-qi milieu externally and encourages healthy circulation effectively — this being positively conducive no water conflagration outcomes.
Value Bodily Signals, Pursue Timely Medical, Insight
Regarding pronounced this classic sympt