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The *Yuan Bing Shi* (Treatise on the Causes of Disease) states: Ji Yin (accumulated fluid retention) and Liu Yin (lingering fluid retention) refer to the accumulation and failure to disperse of fluids in the body. When water encounters dryness, it dissipates; when it encounters dampness, it fails to resolve. Therefore, it is believed that Ji Yin is caused by Earth-dampness leading to Qi stagnation and obstruction.

Zi He (Zhang Congzheng) said: Generally, when people suffer from Tan (phlegm), there are five types: one is Feng Tan (wind-phlegm), two is Re Tan (heat-phlegm), three is Shi Tan (damp-phlegm), four is Jiu Tan (wine-phlegm), and five is Shi Tan (food-phlegm). Roughly speaking, Feng Tan is caused by external cold exposure and drinking cold liquids; Re Tan is caused by excessive fire suppressing Metal (the Lung); Shi Tan is caused by stagnant fluid failing to disperse; Jiu Tan and Shi Tan are caused by overindulgence in diet causing injury.

Commentary: Tan (phlegm) is transformed from accumulated fluid retention, so the *Yuan Bing Shi* lists it under the category of Taiyin Spleen-Dampness. The theory of five types of phlegm proposed by Zi He actually all originate from dampness, differing only in the accompanying pathogenic factors. Wang Yinjun, in his medical texts, discusses five types of phlegm: wind-phlegm, cold-phlegm, heat-phlegm, qi-phlegm, and flavor-phlegm. Flavor-phlegm arises from consuming rich flavors, wine, and strong beverages; qi-phlegm arises from emotional frustration or unfulfilled desires; heat-phlegm arises from consuming spicy, roasted, heavy, and greasy foods; cold-phlegm arises from exposure to cold and chill; wind-phlegm arises from contracting wind pathogens, or from wind-heat stagnation. These are all cases where a person already has a predisposition to phlegm, which is triggered by wind-cold, qi disorders, heat, or dietary flavors, rather than representing five distinct independent types of phlegm. I believe that treatment should address the disease as the root and the accompanying pathogenic factor as the branch.

Wang Yinjun said: Regarding the color of phlegm, clear and white indicates cold, while yellow and turbid indicates heat. However, one must not ignore that initially it may be clear and white, but over time turns yellow and turbid. Clear and thin phlegm tends to accumulate in the upper jiao, while yellow, turbid, thick, and sticky phlegm condenses in the lower jiao. Phlegm that is easily coughed up is clear and white; phlegm that is difficult to expectorate is yellow, turbid, and obstructed. If spitting blood continues for a long time, damp-heat stagnates and condenses above and below, leaving no clear phlegm. In severe cases, blood appears, and as the blood deteriorates, the phlegm turns black. This type of phlegm is called "Guan Ge" (obstruction and regurgitation), unrecognized by patients with atypical diseases. Furthermore, clear phlegm has a faint odor, but over time develops an foul smell, varying in sour, pungent, fishy, musky, scorched, or bitter tastes.

Commentary: Distinguishing clarity and turbidity based on the duration of the phlegm accurately grasps the pathology.

Zi He said: Liu Yin (lingering fluid retention) is a specific syndrome. The ancients distinguished between Si Yin (four fluids) and Wu Yin (five fluids), naming them according to the clinical presentation. I discuss the origins of fluid retention as having five sources: those arising from stagnation, those due to external causes, those due to mental exertion/worry, those due to excessive drinking, and those due to heat injuring cold intake. Although fluid retention syndromes are numerous, their causes do not exceed these categories. Water is a yin substance, but accumulated water generates dampness, retained wine causes dryness/heat, and over time it transforms into phlegm. Fluids in the left hypochondrium resemble Fei Qi (fat mass); in the right hypochondrium, they resemble Xi Ben (breath burden); entering the Lung causes frequent coughing; entering the Large Intestine causes diarrhea; entering the Kidney causes Yong Shui (surging water); affecting the Taiyang channel causes Zhi Yin (fluid retention supporting the chest). All result from rebellious Qi. Thus, if located superiorly, facial edema occurs; inferiorly, abdominal swelling; centrally, distension, fullness, epigastric oppression, and rebellious phlegm. If remaining in the Yang aspect, it eventually transforms into Qi disorders; if remaining in the Yin aspect, it eventually forms physical masses. Currently, practitioners often treat fluid retention as cold accumulation, using warm and hot tonifying agents. Since dampness and water are not removed, Heart Fire increases instead. Moreover, there is no tonification method for lingering fluid retention; tonifying Qi only exacerbates the condition. Do we not know the principle from the *Neijing*: "Those that remain should be attacked"? Even Baizhu (Atractylodis Rhizoma), Renshen (Ginseng Radix et Rhizoma), and Fuling (Poria) can cause obstruction when taken. How much more so burning moxibustion? The resulting oppression is understandable. Previous prescriptions used Wuyin Wan (Five Fluids Pill) containing Fanshi (Alumen), Badou (Crotonis Fructus), and Wutou/Fuzi (Aconiti Lateralis Radix Praeparata). Although these are purgatives, they ultimately share the nature of dryness and heat. Liu Hejian now uses Shizao Tang (Date Decoction) plus Dahuang (Rhei Radix et Rhizoma) and Qianniu (Pharbitidis Semen) to create Sanhua Shenyao Wan (Three Flowers Divine Protection Pill). For newly acquired diseases, taking this clears the Qi flow and removes fluid retention, leading to recovery. Previously, a patient suffered for years without cure. My pulse diagnosis showed minute pulses on the left hand (indicating cold) and slippery, large pulses on the right hand (indicating dryness/heat). Using Guiti San (Melon Pedicle Powder) to induce vomiting expelled several sheng of cold phlegm, with profuse sweating. Subsequently, Daoshui Wan (Water-Guiding Pill) and Yugong San (Yu Gong Powder) were used to remove intestinal dry feces, also several sheng. After half-recovery, phlegm-resolving agents were used to promote urination, descend fire, and open the stomach appetite. Within a month, the patient recovered.

Commentary: This discussion correctly identifies that fluid retention is caused by water-dampness manifesting as various syndromes, and should not be treated with warming tonification. It is detailed and clear. However, relying solely on Sanhua Shenyao Wan is too harsh. (See General Discussion for details.)

Discussion on the errors of the Bureau Formulary using hot medicines to treat Qi disorders, phlegm, fluid retention, vomiting, and dysphagia.

Danzhu (Zhu Danxi) said: At the onset of Qi disorders, the signs are subtle. They may arise from improper diet, external exposure to wind-rain-cold-heat, internal emotional disturbance, or excessive consumption of rich flavors that assist Yang Qi, accumulating as Di Re (diaphragmatic heat). Or, due to robust constitution, tight pores, no sweat, non-flowing body fluids, confusion of clear and turbid Qi, causing Qi disorders. Symptoms include oppression, pain, loss of appetite, belching with putrid odor, acid regurgitation, heartburn, or bloating. Without seeking the root cause, it is assumed to be cold, and acrid-aromatic drying-hot agents are immediately administered. After a few doses, temporary relief brings satisfaction, considering it a miraculous formula. However, rich diets and emotional habits remain unchanged. The old disease is temporarily suppressed by the harsh drugs, allowing turbid fluids to gather easily. Half a month or a month later, previous symptoms recur. Such progression leads from Qi disorder to accumulation, and from accumulation to phlegm. This is the origin of phlegm, fluid retention, and acid regurgitation. Without skilled physicians encountering the situation, erroneous medicines continue. Phlegm combined with blood stasis forms nests/cysts. This is the sequence leading to oppression, pain, vomiting, dysphagia, and regurgitation. Dietary fluids become stagnant, channels become obstructed, bowel movements vary between constipation and loose stools, lower transformation fails, and middle jiao stagnation worsens. Physicians fail to observe this, still insisting on cold patterns, regretting that previous medicines were not hot enough. They wait for long-term use to warm the Spleen and strengthen the Stomach, eliminate accumulation, and move Qi, hoping for sudden resolution. They fail to realize that the Stomach is the Sea of Water and Grain, abundant in Blood and Qi; the Spleen is the organ of digestion, functioning well when Qi is clear and harmonious. Long-term intake of aromatic-hot flavors excessively agitates Blood and Qi. Initially, Stomach fluids coagulate; over time, Spleen Qi dissipates, and transformation slows. Physicians then claim deficiency and accumulated cold cannot be treated with ordinary herbs, prescribing Wutou/Fuzi (Aconite) and cinnabar pills exclusively. Over time, Blood and Qi are exhausted, the Stomach lining becomes dry and shriveled, leading to dysphagia or regurgitation. Zhang Zhongjing discussed six types of fluid retention, differentiating syndromes of the Five Zang organs: those suitable for exterior release should be sweated; those suitable for interior drainage should be purged; stagnant ones guided; stagnated ones dispersed; heat ones cleared; cold ones warmed; mixed heat/cold ones counter-assisted; dampness-involved ones leached with bland agents; deficiency-involved ones tonified and nourished. Treatment methods are complete. Alas, physicians are incompetent, and patients disregard taboos, allowing medicine to aid pathogenic factors, deepening the disease, moving further from health, which is deeply pitiable.

Commentary: This discussion attributes the causes of vomiting, oppression, belching, acid regurgitation, dysphagia, and regurgitation to initial Qi disorders mismanaged with drying-hot medicines forming phlegm/fluid retention. Thus, it is listed under the Phlegm-Fluid Retention section. Detailed descriptions of these syndromes should be cross-referenced here.

Respectfully noted: Regarding phlegm diseases, Zhang Zhongjing’s discussion of Four Fluids and Six Syndromes, covering internal and external Three Causes, is appropriate. The Four Fluids describe syndromes manifesting due to phlegm; the Three Causes discuss injuries leading to phlegm formation. Only Wang Yinjun argued that all human diseases originate from phlegm, revealing insights previously unexplored, demonstrating profound understanding of phlegm pathology. His Guantan Wan (Phlegm-Expelling Pill) treats all such diseases simply, but compared to Zhang Zhongjing’s differentiation of exterior-interior and internal-external causes requiring sweating, purging, warming, or draining, it is less precise. Moreover, it ignores differences in deficiency/excess and cold/heat. The origins of phlegm disease include: generated by heat; generating heat; caused by wind-cold-damp-heat; caused by fright; caused by Qi disorders; caused by alcohol; caused by food stagnation; caused by Spleen deficiency failing to transform. Heat-phlegm often causes irritability; wind-phlegm often causes paralysis and strange syndromes; cold-phlegm often causes bone bi; damp-phlegm often causes fatigue and weakness; fright-phlegm often causes heart pain and epilepsy; fluid-phlegm often causes hypochondriac and arm pain; food-stagnation phlegm often causes masses and oppression. The manifestations are numerous and hard to name. Wang Yinjun’s discussion is quite detailed. Students should examine the clinical presentation and pulse/syndromes to identify the accompanying pathogen and treat according to exterior-interior, upper-lower, deficiency-excess. As for Zi He’s assertion that fluid retention requires no tonification and must be removed via vomiting, sweating, and purging, leading to frequent cures, and his critique of hot medicines treating phlegm, these are incisive. However, cases involving cold or deficiency must also be considered. Long-standing phlegm congeals and blocks; resembling cold stagnation, if warm guiding medicines are not used, rejection reactions may occur. Furthermore, in cases of external wind-cold binding and internal phlegm-Qi stagnation, without warm dispersal, how can stagnation be opened? Also, in individuals with deficient Blood and Qi, phlegm lodging in the middle jiao blocks the clear pathways, causing various limb and body syndromes. Pathologically, phlegm stagnation should be guided out, but tonification must accompany this, making it difficult to strictly adhere to Zi He’s three methods. Generally, chronic prolonged illnesses that do not lead to sudden death are often due to food stagnation and fluid retention. Why? Because Stomach Qi relies on phlegm accumulation for nourishment; even with little food intake, Stomach Qi does not suddenly collapse. Conversely, using overly harsh purgatives for phlegm damages Spleen Qi further, impairing fluid transport, causing phlegm to regenerate and increase. The method should be to tonify the Spleen and Stomach and clear the middle jiao, allowing phlegm to naturally drain downward. This is treating the root. The world calls this the "King's Way" of medicine.

Discussion on phlegm syndromes resembling evil spirits (see Tonifying Deficiency section).