沈氏（四二） 三疟住后足肿，旋及大腹胸胁，纳食大减，气急脉细。此分明脾肾两虚，
脾虚
则不能制水，肾寒则膀胱亦不能化，失渗泄之能，以成泛滥之势；治法莫稳于四明加减肾气
丸，并补中益气汤，分早晚而进。但此法久服方有效，又奈汤丸中药品，有力者方能办。今
田家之妇，粒食不缺为幸，焉能办此？坐忍其毙，又非仁人之用心。因推敲一方，以欲退其
肿，必有利水∶欲利其水，必先利气。而不知单利其气，仍如无云而致雨，岂可得耶？然则
何如？须按《内经》气化能出之法，在温而利之也。
椒目（一钱） 丁香（十只） 老姜皮（七分） 橘皮（一钱二分） 苏梗（八分） 通草（七分）
大腹皮（二钱） 泽泻（一钱五分） 车前子（一钱） 茯苓皮（二钱）
五帖皮肤发痒纳增，又五帖皮肤皱揭，顿觉宽松。前方应效虽速，所谓急则治标，非万
全之
法。改用培土利气暖肾，以冀痊愈。前方去通草、车前子，加党参二钱，生冬术二钱，十服
，病去其半。又用异功散，加黄 、苡仁、丁香、椒目、泽泻、老姜皮、大苏梗，十余剂，
而饮食起居如常。
朱女（十四） 上下俱肿，半年来病日加重，不思纳食，寤着谵语，咳呛脉数。此气虚兼
滞，须补养疏通安神。
党参（二钱） 龙眼肉（七枚） 枣仁（二钱） 茯神（一钱五分） 砂仁壳（一钱） 远志（一
钱） 大苏梗（一钱） 橘皮（一钱） 杏仁（二钱五分去皮研） 桑皮（一钱五分蜜水炒）
四服眼鼻分明，踝细大半，夜眠安静能纳，神气通畅。将前方增减药味分两，作丸料。
彼父
以此女为不起，访予延医，一决生死，今得如此速效，感激无尽。盖肿胀虽列一门，其实殊
途。肿易治而胀难治，缘胀关脏腑，肿则重在水，轻在气。若能别其虚实，辨明所兼，应手
取效，亦非难也。欲辨肿胀，但着头足俱浮，大腹不甚坚紧者为肿，独大腹坚紧如鼓，青筋
累累为单胀最重；或头面朝肿，两脚晚肿，惟腹无时不然者，始为胀兼肿也。将肿胀缕析于
此，以俾学人之豁目焉。
王（五岁） 童年身肿，属肺气不舒，膀胱不利。
茯苓皮 橘皮 桑皮 大腹皮 苡仁 杏仁 木通 车前子 姜皮
沈氏（六八） 形衰气弱，流运失时，口糜内热，肢肿不纳，两脉沉细带数，此症难治。
盖人
气应天，目下仲夏，阳气弛张于外，如草木无不生长葱郁，而人岂可抑敛不伸耶？在年壮气
盛，或于冬月为寒邪所逼，即病为伤寒；至春化温，及夏为热。所以可疗者，因其本气充实
，举而升之，补偏救弊，以归天和。此则不然，姑拟一方，冀回万一。
连翘 香豉 薄荷 防风 橘红 杏仁 山栀 人参 老姜皮
服此竟有效，然至秋时方起，欲其久住，难矣哉！
赵（六十） 甲周之年，患水肿。由于气虚少运，膀胱失利，非旦晚可愈，耐性服药，庶
可奏效。
党参 黄 生冬术 大腹皮 苏梗 砂仁壳 橘红 茯苓 泽泻 姜皮
又，前方添归身、白芍、煨木香，减砂仁壳、苏梗，有效，脚肿退，腹胀宽，制丸剂可以
收功。
沈（二十） 疟后面浮脚肿，脉来沉涩，用上下分消法。
苏叶 羌活 防风 茯苓 泽泻 苡仁 橘皮 香附 砂仁壳 姜皮 西河柳
易漏，故频饮频溺，所有精气，随水下注，从膀胱而出，如米泔者精液也，如酒酵者精
气也
。如此日夜发热，岂止 羸？体质薄弱，鲜不免者。前方虽效，然非大补肾阴，终归复萌，
乃去石膏、黄连，又服三十剂，肌肉渐复，目明如旧。
沈氏（第四十二条医案）：三疟（一种间歇性发作的疟疾，三日一发）停止后出现足部肿胀，随即蔓延至大腹和胸胁部位，食欲大幅减退，气促且脉象细弱。这显然是脾肾两虚所致。脾虚则不能制约水湿，肾寒则膀胱也不能气化，失去了渗泄的功能，从而形成水势泛滥的局面；治疗方法以四明加减肾气丸（一种温补肾阳、化气行水的方剂）配合补中益气汤（李东垣方，主治脾胃气虚、中气下陷），分早晚服用最为稳妥。但是这种方法需要长期服用才见效，况且汤剂和丸剂中的药材，财力雄厚的人才能置办。如今田间的农妇，能保住每日粮食不缺已是万幸，哪里有能力置办这些药材？坐视其死亡，又不是仁人志士的本心。于是推敲出一个新方子，想要消退水肿，必须有利尿作用；想要利尿，必须先调理气机。然而不知道单纯利气，就像没有云彩却想下雨一样，怎么可能做到呢？既然如此，该怎么办呢？必须依据《内经》中关于“气化”能使津液排出的原理，采用温阳并利水的方法。
椒目（一钱） 丁香（十只） 老姜皮（七分） 橘皮（一钱二分） 苏梗（八分） 通草（七分）
大腹皮（二钱） 泽泻（一钱五分） 车前子（一钱） 茯苓皮（二钱）
服用五帖后皮肤发痒，食欲增加；再服五帖后皮肤皱缩脱屑，顿觉身体宽松。前方虽然见效快，但这属于“急则治标”，并非万全之法。改用培土（健脾）、利气、暖肾的方法，希望彻底痊愈。前方去掉通草、车前子，加入党参二钱、生冬术（白术的一种炮制规格）二钱，服用十剂，病去了一半。又用异功散（四君子汤加陈皮），加入黄芪、薏苡仁、丁香、椒目、泽泻、老姜皮、大苏梗，十余剂后，饮食起居恢复正常。
朱家女儿（十四岁）：上下全身都肿，半年多来病情日益加重，不想进食，睡眠时说胡话，咳嗽气喘且脉象数。这是气虚兼有气滞，需要补养、疏通并安神。
党参（二钱） 龙眼肉（七枚） 枣仁（酸枣仁，二钱） 茯神（一钱五分） 砂仁壳（一钱） 远志（一钱） 大苏梗（一钱） 橘皮（一钱） 杏仁（二钱五分，去皮研碎） 桑皮（桑白皮，一钱五分，蜜水炒）
服用四帖后眼鼻肿胀明显消退，脚踝细了大半，夜间睡眠安静并能进食，神气通畅。将前方增减药味及剂量，制成丸药料。她的父亲认为这个女孩没救了，拜访我请医生来看，决断生死，现在得到如此快速的疗效，感激不尽。大概肿胀虽然列为一门疾病，其实路径不同。肿容易治而胀难治，因为胀与脏腑关系密切，肿主要重在水湿，轻在气机。如果能辨别虚实，辨明兼夹证候，应手取效，也不是难事。想要辨别肿胀，只要头脚都浮肿，大腹不是很坚硬的，就是肿；只有大腹坚硬如鼓，青筋暴露的是单胀，最为严重；或者头面早晨肿，两脚晚上肿，只有腹部始终肿胀的，这才是胀兼肿。在此详细分析肿胀的区别，以便让学习中医的人眼界开阔。
王家孩子（五岁）：童年时期身体肿胀，属于肺气不舒展，膀胱不利。
沈氏（六十八条医案）：形体衰弱，气力虚弱，气血运行失去常态，口腔糜烂伴有内热，四肢肿胀且不思饮食，两脉沉细带数，此症难治。
大概人的气机应合天道，眼下正值仲夏，阳气弛张于体表，如同草木无不生长茂盛，而人难道可以抑制收敛而不伸展吗？对于年轻气盛之人，如果在冬天被寒邪逼迫，就会得伤寒病；到了春天化为温病，夏天则为热病。所以可以治疗的原因，是因为他们本气充实，举起升发之气，纠正偏颇，补救弊端，以回归自然和谐。这里的情况却不是这样，暂且拟定一方，希望挽回万一。
连翘 香豉（淡豆豉） 薄荷 防风 橘红 杏仁 山栀（栀子） 人参 老姜皮
服用此方竟然有效，但要到秋天才能好转，想要长久维持健康，很难啊！
赵氏（六十岁）：甲周之年（指六十岁，干支纪年循环一周），患水肿。由于气虚运化无力，膀胱失利，不是早晚能治愈的，要有耐心服药，或许可以奏效。
党参 黄芪 生冬术 大腹皮 苏梗 砂仁壳 橘红 茯苓 泽泻 姜皮
另外，在前方的基础上添加当归身、白芍、煨木香，减少砂仁壳、苏梗，有效果，脚肿消退，腹胀缓解，制作丸剂可以收功。
沈氏（二十岁）：疟疾后面部浮肿、脚肿，脉象沉涩，使用上下分消法（宣上畅中渗下）。
苏叶 羌活 防风 茯苓 泽泻 苡仁 橘皮 香附 砂仁壳 姜皮 西河柳
易漏（指精气外泄），所以频繁饮水、频繁排尿，所有的精气随着水液下注，从膀胱排出，像米泔水一样的叫精液，像酒酵一样的叫精气。像这样日夜发热，岂止是瘦弱？体质薄弱的人，很少有不发生的。前方虽然有效，但如果不大补肾阴，最终还是会复发，于是去掉石膏、黄连，又服用三十剂，肌肉逐渐恢复，眼睛明亮如旧。
Shen (Case 42): After the cessation of Sanlüe (a type of intermittent malaria occurring every three days), edema appeared in the feet, subsequently spreading to the abdomen and chest/hypochondrium. Appetite decreased significantly, accompanied by shortness of breath and a fine pulse. This is clearly deficiency of both Spleen and Kidney. Spleen deficiency fails to control water metabolism; Kidney cold prevents the Bladder from transforming Qi, leading to a loss of excretory function and resulting in a tendency for water flooding. The most stable treatment method is administering Siming Jiashen Shenqi Wan (Siming Modified Kidney Qi Pill, a formula warming Kidney Yang and promoting Qi transformation to move water) combined with Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction, treating Spleen-Stomach Qi deficiency and sinking of Middle Qi), taken separately in the morning and evening. However, this method requires long-term administration to be effective. Moreover, the herbs in the decoctions and pills are costly, affordable only by those with financial means. For a farmer's wife, merely ensuring sufficient daily grain is fortunate enough; how could she afford such medicines? To sit idle and let her die contradicts the heart of a benevolent person. Therefore, I deliberated on a new prescription: to reduce edema, diuresis is necessary; to promote diuresis, regulating Qi must come first. Yet, simply promoting Qi alone is like trying to rain without clouds—how can it work? So, what should be done? One must follow the principle in *Neijing* that "Qi transformation allows fluids to exit," employing methods to warm and promote diuresis.
Zhaomu (Pepper Seed) [1 qian], Dingxiang (Clove) [10 pieces], Laojiangpi (Old Ginger Peel) [7 fen], Jupi (Tangerine Peel) [1.2 qian], Sugeng (Perilla Stem) [8 fen], Tongcao (Tetrapanax Pith) [7 fen], Dafupi (Areca Peel) [2 qian], Zexie (Alisma Rhizome) [1.5 qian], Cheqianzi (Plantago Seed) [1 qian], Fulingpi (Poria Peel) [2 qian].
After five doses, skin itching occurred and appetite increased. After another five doses, skin wrinkled and peeled, bringing immediate relief. Although the previous prescription worked quickly, it represents "treating the acute symptoms" (Ji Ze Zhi Biao), which is not a comprehensive solution. Switched to strengthening Earth (Spleen), promoting Qi, and warming Kidney to hope for a complete cure. Removed Tongcao and Cheqianzi from the previous formula, added Dangshen (Codonopsis Root) [2 qian] and Sheng Dongzhu (Raw Atractylodes Macrocephala Rhizome) [2 qian]. After ten doses, half the illness was gone. Then used Yigong San (Yi Gong Powder, Si Jun Zi Tang plus Chen Pi), adding Huangqi (Astragalus Root), Yiren (Coix Seed), Dingxiang (Clove), Zhaomu (Pepper Seed), Zexie (Alisma Rhizome), Laojiangpi (Old Ginger Peel), and Da Sugeng (Large Perilla Stem). After more than ten doses, diet and daily life returned to normal.
Miss Zhu (14 years old): Edema throughout the upper and lower body, worsening over six months. No desire to eat, delirium during sleep, coughing/wheezing, and a rapid pulse. This is Qi deficiency combined with stagnation, requiring nourishment, unblocking, and calming the Spirit.
Dangshen (Codonopsis Root) [2 qian], Longyanrou (Longan Aril) [7 pieces], Zaoren (Ziziphus Seed) [2 qian], Fushen (Poria with Hostwood) [1.5 qian], Sharenqiao (Amomum Villosum Shell) [1 qian], Yuanzhi (Polygala Root) [1 qian], Da Sugeng (Large Perilla Stem) [1 qian], Jupi (Tangerine Peel) [1 qian], Xingren (Apricot Seed) [2.5 qian, peeled and crushed], Sangpi (Morus Alba Bark) [1.5 qian, stir-fried with honey].
After four doses, swelling around eyes and nose clearly subsided, ankles reduced by half, night sleep became quiet with ability to eat, and Spirit/Qi flow smoothed. Adjusted the ingredients and dosages of the previous formula to prepare pill material. Her father believed she would not survive, visited me to consult a physician for a prognosis of life or death. Now seeing such rapid efficacy, he is endlessly grateful. Generally, although Swelling and Distension are listed as one category, their paths differ. Edema (Zhong) is easier to treat than Distension (Zhang). Distension relates closely to Zang-Fu organs, whereas edema focuses primarily on Water and secondarily on Qi. If one can distinguish deficiency/excess and identify concurrent patterns, achieving quick results is not difficult. To differentiate: if head and feet are both floating/swollen, but the abdomen is not very firm/tight, it is Edema. If only the abdomen is firm/tight like a drum, with prominent veins, it is Dan Zhang (Single Distension), the most severe type. If face/head swells in the morning, feet swell in the evening, but the abdomen is always swollen, it is Distension complicated by Edema. Analyzing these distinctions here aims to clarify vision for students of medicine.
Wang (5 years old): Childhood body swelling, attributed to Lung Qi not dispersing freely and Bladder dysfunction.
Fulingpi (Poria Peel), Jupi (Tangerine Peel), Sangpi (Morus Alba Bark), Dafupi (Areca Peel), Yiren (Coix Seed), Xingren (Apricot Seed), Mutong (Akebia Stem), Cheqianzi (Plantago Seed), Jiangpi (Ginger Peel).
Shen (Case 68): Frail physique, weak Qi, disrupted circulation, mouth ulcers with internal heat, limb swelling, anorexia, deep/fine pulses with rapid quality. This condition is difficult to treat.
Human Qi corresponds to Heaven. Currently mid-summer, Yang Qi expands outward, just as all plants grow lushly. How can humans suppress and contract instead of extending? For young people with robust Qi, if forced by Cold pathogens in winter, they may contract Shanghan (Cold Damage); in spring it transforms into Wenbing (Warm Disease), and in summer into Heat. Treatable cases succeed because the root Qi is substantial; lifting and raising it corrects imbalance and restores harmony with Nature. This case is different. Tentatively prescribing a formula hoping for a slight recovery.
Lianqiao (Forsythia Fruit), Xiangchi (Fermented Soybean), Bohe (Mint), Fangfeng (Saposhnikovia Root), Juhong (Red Tangerine Peel), Xingren (Apricot Seed), Shanzhi (Gardenia Fruit), Renshen (Ginseng Root), Laojiangpi (Old Ginger Peel).
This prescription proved effective, but improvement would not occur until autumn. Maintaining long-term health would be extremely difficult!
Zhao (60 years old): At the age of sixty (completion of a sexagenary cycle), suffered from Edema. Due to Qi deficiency and poor transport, Bladder failed to discharge properly. Not curable in a day or two; patience in taking medicine is required for efficacy.
Dangshen (Codonopsis Root), Huangqi (Astragalus Root), Sheng Dongzhu (Raw Atractylodes Macrocephala Rhizome), Dafupi (Areca Peel), Sugeng (Perilla Stem), Sharenqiao (Amomum Villosum Shell), Juhong (Red Tangerine Peel), Fuling (Poria), Zexie (Alisma Rhizome), Jiangpi (Ginger Peel).
Additionally, added Guishen (Angelica Sinensis Root Body) and Baishao (White Peony Root), Wei Muxiang (Stir-baked Costus Root) to the previous formula; reduced Sharenqiao and Sugeng. Effective: foot edema receded, abdominal distension eased. Prepared as pills to conclude treatment.
Shen (20 years old): Post-malaria facial and foot edema, deep/choppy pulse. Used Upper-Lower Separating Drainage Method.
Suye (Perilla Leaf), Qianghuo (Notopterygium Rhizome), Fangfeng (Saposhnikovia Root), Fuling (Poria), Zexie (Alisma Rhizome), Yiren (Coix Seed), Jupi (Tangerine Peel), Xiangfu (Cyperus Rhizome), Sharenqiao (Amomum Villosum Shell), Jiangpi (Ginger Peel), Xihe Liu (Salix Caprea Catkin).
Prone to leakage (essence escaping), causing frequent drinking and urination. All essence follows water downward, exiting via Bladder. What looks like rice wash water is Jingye (Essence Fluid); what resembles wine lees is Jingqi (Essence Qi). With fever day and night, how can one avoid emaciation? Those with weak constitutions rarely escape this. Although the previous formula worked, without strongly tonifying Kidney Yin, relapse is inevitable. Thus, removed Shigao (Gypsum Fibrosum) and Huanglian (Coptis Rhizome). After thirty more doses, muscles gradually recovered, eyesight cleared as before.