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Whenever a patient drinks excessive amounts of water, sudden wheezing and chest fullness will inevitably occur. Generally, when food intake is low but fluid intake is high, water stagnates in the epigastrium (region below the heart). In severe cases, palpitations occur; in mild cases, shortness of breath occurs. A double-string-like pulse indicates cold syndrome, often resulting from interior deficiency after drastic purgation. A single-string-like pulse indicates fluid retention.

[Note] In this passage, the sentences "A double-string-like pulse indicates cold..." appearing below "in mild cases, shortness of breath" do not fit the context logically and should be separated into a new paragraph at the end.

[Commentary] When a patient eats little and drinks much, if urination is free, it is Xiao Ke disease (Wasting and Thirsting Syndrome); if urination is difficult, it is Liu Yin disease (Retained Fluid Disease). Liu Yin refers to what is now called Water Retention Disease. If water stagnates in the Upper Jiao (Upper Burner) chest, it obstructs Lung Qi from descending, causing sudden wheezing and chest fullness. If water stagnates in the Middle Jiao (Middle Burner) epigastrium, severe cases invade the Heart, causing restless palpitations; mild cases hinder the Lung, causing shortness of breath. If water stagnates in the Lower Jiao (Lower Burner) lower abdomen, it fails to transport to the Bladder, causing abdominal urgency. Zhang Zhongjing mentions only the Upper and Middle Jiao here, omitting the Lower Jiao, not out of omission, but because it was detailed in the Shang Han Lun (Treatise on Cold Damage).

[Collected Annotations] Cheng Lin stated: Excessive drinking causes water qi to float and stagnate in the chest and diaphragm, leading to sudden wheezing and chest fullness. When one eats little and drinks much, the Spleen and Stomach earth cannot circulate and overflow with essence and qi. Severe cases stagnate in the epigastrium causing palpitations. Mild cases block the chest and diaphragm, causing shortness of breath.

Thirst followed by vomiting indicates water stagnating in the epigastrium; this belongs to the category of Yin Jia (Fluid-Disease Patients), treated with Xiao Ban Xia Fu Ling Tang (Minor Pinellia and Poria Decoction).

[Commentary] Water stagnating in the epigastrium belongs to the Middle Jiao, which governs the Stomach. Therefore, it causes not only palpitations and shortness of breath but also vomiting. Palpitations and shortness of breath occur because water stays outside the stomach, rising from below the diaphragm to invade the chest. Vomiting occurs because water stays inside the stomach, surging upward from the stomach to the mouth. However, only when thirst leads to excessive drinking followed by vomiting does it constitute a vomiting disease of the Yin Jia. Xiao Ban Xia Tang is used to stop vomiting; adding Poria is because the vomiting is caused by excessive water intake, so diuresis is combined.

[Collected Annotations] Wei Litong stated: Water stagnating in the epigastrium blocks righteous qi, preventing the transformation and generation of body fluids, which rise to the chest and throat, causing thirst. Thirst necessitates drinking; once water enters, it exacerbates the surging rebellion, hence thirst precedes vomiting. This belongs to the Yin Jia; one must treat the fluid retention, not the thirst as if it were a Xiao Ke case. Treating fluid retention requires acrid-drying herbs, while treating thirst requires cold-moistening herbs; they are vastly different. How can one treat blindly without distinguishing the syndrome?

You Yi stated: Thirst followed by vomiting implies no prior vomiting disease; due to thirst and excessive drinking, the water fails to descend and rebels upward. Hence, it is said: this belongs to the Yin Jia. Xiao Ban Xia Tang stops vomiting and directs rebellious qi downward; adding Poria removes retained water.

Formula for Xiao Ban Xia Jia Fu Ling Tang (Minor Pinellia and Poria Decoction):
Ban Xia (Pinelliae Rhizoma, 1 sheng)
Sheng Jiang (Zingiberis Recens Rhizoma, 0.5 jin)
Fu Ling (Poria, 3 liang)
Boil these three ingredients in 7 sheng of water to obtain 1.5 sheng. Divide into two warm doses.

Patients prone to vomiting should naturally feel thirsty; thirst indicates the condition is resolving. If there is no thirst now, it is due to Zhi Yin (Branching Fluid) in the epigastrium, treated with Xiao Ban Xia Tang.

[Commentary] For Yin Jia patients, thirst arises because water stagnation hinders qi transformation and fluid generation. For vomiting-prone patients, thirst arises because vomiting dries the stomach and damages body fluids; thus, they should naturally be thirsty. If vomiting is followed by thirst, giving small amounts of water harmonizes the stomach and generates fluids, indicating resolution. If there is no thirst after vomiting, it is because Zhi Yin has existed in the epigastrium. Only Xiao Ban Xia Tang is used to stop vomiting, without adding Poria, because there is no thirst or new fluid retention, and since body fluids are already damaged by vomiting, further diuresis would deplete them again.

[Collected Annotations] Li [Name missing] stated: This specifically addresses treating vomiting. Thirst in vomiting patients indicates resolution, as stomach qi recovers and fluids generate. If Zhi Yin exists in the epigastrium, there is no dryness and thus no thirst; vomiting occurs due to overflowing fluids. Ban Xia and Sheng Jiang warm and harmonize stomach qi and disperse rebellious qi with their acridity, making them holy medicines for vomiting.

Formula for Xiao Ban Xia Tang (Minor Pinellia Decoction):
Ban Xia (Pinelliae Rhizoma, 1 sheng)
Sheng Jiang (Zingiberis Recens Rhizoma, 0.5 jin)
Boil these two ingredients in 7 sheng of water to obtain 1.5 sheng. Divide into two warm doses.

[Collected Exegesis] Shen Mingzong stated: This is the formula for vomiting caused by Zhi Yin overflowing above the diaphragm. Vomiting always damages fluids, so thirst should occur. Thus, "vomiting patients should be thirsty"; if thirsty, the illness departs via vomiting, termed "desire for resolution." If Zhi Yin exists in the epigastrium, stagnation in the chest/diaphragm causes dryness, leading to vomiting without thirst. One must treat the fluid: Sheng Jiang disperses pathogens, Ban Xia clears fluids, and vomiting stops.

Sudden vomiting, epigastric stuffiness, water between the diaphragm, vertigo, and palpitations are treated with Ban Xia Jia Fu Ling Tang (Pinellia Decoction with Added Poria).

[Commentary] Sudden vomiting, even without thirst, accompanied by epigastric stuffiness, indicates water coagulation between the diaphragm. Vertigo results from water blocking Yang Qi from ascending; palpitations result from water Qi invading the Heart. Even without thirst or new fluid retention, the abundance of chronic fluid retention is evident. One need not worry about body fluids but must add Poria to promote urination, thereby opening obstructions and clearing blockages.

[Collected Annotations] Zhao Liang stated: Epigastric stuffiness and water between the diaphragm; vertigo and palpitations indicate Yang Qi cannot disperse freely. The Classics state: "Disperse with Acrid." Ban Xia and Sheng Jiang are acrid; Ben Cao records Ban Xia treats phlegm above the diaphragm. Epigastric hardness, vomiting, rebellious Qi, and vertigo indicate Upper Jiao Yang Qi deficiency failing to ascend, treated by both Ban Xia and Sheng Jiang. Palpitations involve the Heart being invaded by water, which Ban Xia alone cannot treat; Poria must be added to remove water, direct Kidney rebellious Qi downward, and calm the Spirit, curing palpitations.

You Yi stated: Fluid Qi rebelling in the Stomach causes vomiting; stagnating in Qi mechanisms causes epigastric stuffiness; invading the Heart causes palpitations; obscuring Yang causes vertigo. Ban Xia and Sheng Jiang stop vomiting and direct Qi downward; adding Poria removes water.

Formula for Ban Xia Jia Fu Ling Tang (See above).

If a thin person experiences palpitations below the umbilicus, spits saliva/foam, and suffers from vertigo, this is Water Pathogen, treated with Wu Ling San (Five-Ingredient Powder with Poria).

[Note] The character "thin" (shou) should likely be "diseased" (bing). The character "dian" (epileptic/crazy) in "dian xuan" should be "dian" (vertex/top of head); vertex means head. The context fits this correction. This is a transcription error.

[Commentary] "Ji" refers to a pounding heartbeat sensation. The previous passage mentioned palpitations in the epigastrium due to water stagnation there; this passage mentions palpitations below the umbilicus due to water stagnation below the umbilicus. If Ben Tun (Running Piglet) is impending, it is Yang Deficiency, treated with Fu Ling Gui Zhi Gan Cao Da Zao Tang (Poria, Cinnamon Twig, Licorice, and Jujube Decoction). Here, spitting saliva indicates Water Rebellion in the Stomach, and vertex vertigo indicates Water blocking Yang; thus, it is Excess Water, treated with Wu Ling San.

Formula for Wu Ling San (Five-Ingredient Powder with Poria):
Ze Xie (Alismatis Rhizoma, 1 liang 1 fen)
Zhu Ling (Polypori Umbellati Sclerotium, peeled, 3 fen)
Fu Ling (Poria, 3 fen)
Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 fen)
Gui Zhi (Cinnamomi Ramulus, peeled, 2 fen)
Grind the five ingredients into powder. Take one cun-bi (square inch measure) with rice broth, three times daily. Drink plenty of warm water until sweating occurs for cure.

For shortness of breath with slight fluid retention, elimination via urination is indicated. Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction) is primary; Shen Qi Wan (Kidney Qi Pill) is also applicable.

[Commentary] Water stagnating in the epigastrium causes severe palpitations, treatment established. Mild cases cause shortness of breath, with two treatments: Qi-deficiency shortness of breath is due to insufficient Qi to sustain respiration; slight-fluid shortness of breath is due to water obstruction hindering respiration. Shortness of breath on exhalation indicates obstruction of Heart/Lung Yang; use Ling Gui Zhu Gan Tang to unblock Yang, promoting Bladder pore function. Shortness of breath on inhalation indicates obstruction of Liver/Kidney Yin; use Shen Qi Wan to unblock Yin, opening the urinary gate. Hence, Ling Gui Zhu Gan Tang is primary, and Shen Qi Wan is also applicable.

Formula for Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction):
Fu Ling (Poria, 4 liang)
Gui Zhi (Cinnamomi Ramulus, 3 liang)
Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 liang)
Gan Cao (Glycyrrhizae Radix et Rhizoma, 2 liang)
Boil these four ingredients in 6 sheng of water to obtain 3 sheng. Divide into three warm doses. Urination will follow.

Formula for Shen Qi Wan (Kidney Qi Pill) (See in Women's Miscellaneous Diseases section).

[Collected Exegesis] You Yi stated: Yin is a water disease. Treating water requires eliminating it via urination. Ling, Gui, Zhu, Gan tonify Earth Qi to move water; Shen Qi Wan warms Yang Qi to move water. Though indications differ, both promote urination.

When there is retained fluid (Liu Yin) in the epigastrium, the person feels cold on the back, an area the size of a palm. In Liu Yin, pain under the hypochondrium radiates to the Clavicular Fossa (Que Pen), worsening with coughing. With retained fluid in the chest, the person has shortness of breath and thirst. Limb joint pain with a deep pulse indicates retained fluid.

[Note] In ancient texts, "Deep pulse indicates retained fluid" appears below "limb joint pain," suggesting it should be a separate line to align with pulse theory discussion. "Shortness of breath and thirst" should likely read "shortness of breath and wheezing"; there may be missing text before "limbs." These are transcription errors.

[Commentary] Early-stage retained fluid cured by Xiao Ban Xia Tang plus Poria, Wu Ling San, or Shen Qi Wan represents minor pathogenic factors. If severe and persistent: retained in the Heart blocks Heart Yang, causing back coldness; retained in the hypochondrium hinders Liver Qi, causing hypochondriac pain radiating to the clavicle, worsening with cough; retained in the chest congests Lung Qi, causing shortness of breath and wheezing; retained in the body blocks meridians, causing limb joint pain. By inference, retained in the Spleen causes abdominal swelling and heaviness; retained in the Kidneys causes scrotal, foot, and calf swelling. This is logical.

Phlegm-fluid disease above the diaphragm causes fullness, wheezing, coughing, and expectoration. Attacks feature chills and fever, back pain, waist pain, spontaneous tearing, and severe body tremors, indicating Fu Yin (Hidden Fluid).

[Commentary] Injury from fluid that remains and does not depart is Liu Yin (Retained Fluid); that which hides and is hard to attack is Fu Yin (Hidden Fluid). Fu Yin refers to fluid lingering above the diaphragm, latent and unreleased, with periodic attacks. Similar to modern asthma triggered by autumn cold or spring wind, attacks cause wheezing, chest fullness, coughing, profuse sputum, chills/fever, back/waist pain, tearing upon severe coughing, and body tremors, known colloquially as "howling asthma."

[Collected Annotations] Cheng Lin stated: Phlegm-fluid in the diaphragm causes wheezing, coughing, and expectoration; manifesting externally causes chills/fever, back/waist pain; severe coughing lifts lung lobes and causes tearing; severe wheezing shakes shoulders and causes body tremors. Such severity indicates Hidden Fluid.

A floating, fine, and slippery pulse indicates injury from fluid.

[Commentary] A fluid disease presenting with a floating, fine, and slippery pulse indicates early-stage Phlegm-Fluid where water pathogen has not yet penetrated deeply.

[Collected Annotations] Li [Name missing] stated: Fluid pulses should be deep; a floating pulse indicates water in the Lung.

A deep pulse indicates retained fluid.

[Note] This passage originally followed "limb joint pain" but is placed here.

[Commentary] A fluid disease presenting with a deep pulse indicates Liu Yin (Retained Fluid), signifying the water pathogen is penetrating deeply.

[Collected Annotations] Cheng Lin stated: Deep pulses generally indicate water; thus, a deep pulse signifies water-fluid.

Li [Name missing] stated: The Classics say: "Deep and submerged indicates water accumulation."

If the patient has a hidden (Fu) pulse, desires spontaneous diarrhea, feels relief after defecation, yet continues to have epigastric hardness/fullness despite diarrhea, this indicates the retained fluid is attempting to exit. Treat with Gan Sui Ban Xia Tang (Kansui and Pinellia Decoction).

[Note] The sentence "this indicates the retained fluid is attempting to exit" should follow "feels relief after defecation"; this is a transcription error.

[Commentary] A fluid disease presenting with a hidden pulse indicates Fu Yin (Hidden Fluid), signifying deep water pathogen. In fluid diseases, if spontaneous diarrhea brings relief, it indicates the retained fluid is trying to exit and resolve. However, if diarrhea brings no relief and epigastric hardness persists, the retained fluid is knotted and reluctant to leave; it requires attack with Gan Sui Ban Xia Tang. Licorice is added counter-intuitively to stimulate action, ensuring breakthrough against stubborn water knots. Since spontaneous diarrhea occurs, Peony is added to restrain, preventing excessive depletion after the pathogen is overcome.

Formula for Gan Sui Ban Xia Tang (Kansui and Pinellia Decoction):
Gan Sui (Kansui Radix, 3 large pieces)
Ban Xia (Pinelliae Rhizoma, boiled in 1 sheng water to 0.5 sheng, strained, 12 pieces)
Shao Yao (Paeoniae Radix Alba, 5 pieces)
Gan Cao (Glycyrrhizae Radix et Rhizoma, roasted, size of a finger, 1 piece)
Boil these four ingredients in 2 sheng of water to obtain 0.5 sheng. Strain. Mix with 0.5 sheng of honey and decoct to 0.8 sheng. Take all at once.

[Collected Exegesis] Cheng Lin stated: Retained pathogens are moved using Kansui to drain fluid; knotted pathogens are dispersed using Pinellia to scatter phlegm-fluid. Kansui acts directly; to prevent excessive fluid-draining, Licorice and White Honey moderate with sweetness, and Peony restrains with sourness. Although Licorice and Kansui are contrary, they assist each other. This is the method of restraint via sour-astringency and sweet-slowing. The Ling Shu states: "Regulating a formula is like tying a bag." This is what is meant!

You Yi stated: Licorice and Kansui are contrary, yet used together to ensure a single battle eliminates all retained fluid, achieving synergy through mutual stimulation. Peony and White Honey not only calm the center but also mitigate drug toxicity.

Question: There are four types of Yin (Fluid), what are they? Master said: There is Tan Yin (Phlegm-Fluid), Xuan Yin (Hanging Fluid), Yi Yin (Overflowing Fluid), and Zhi Yin (Branching Fluid). Question: How do the four fluids differ? Master said: If a person who was formerly plump is now thin, with water moving between intestines making gurgling sounds, it is called Tan Yin; if fluid flows under the hypochondrium after drinking, causing pain upon coughing/spitting, it is called Xuan Yin; if drinking water flows to the limbs, sweat should occur but does not, causing body ache and heaviness, it is called Yi Yin; if coughing/rebellious Qi requires leaning to breathe, shortness of breath prevents lying down, and the form resembles edema, it is called Zhi Yin.

[Commentary] Question: Fluid disease includes not only Liu Yin and Fu Yin, why does the world speak of four types? Answer: Liu Yin and Fu Yin describe the new/old and shallow/deep nature of fluid disease. The current four types—Tan, Xuan, Yi, Zhi—describe the clinical manifestations. These four types essentially follow the logic of Liu/Fu Yin but are divided based on the location of water flow. Named by their characteristics, hence four types. Tan Yin: water moves through intestines without draining, essence stays in diaphragm without transporting; heated by Yang becomes phlegm, condensed by Yin becomes fluid. Sounds occur wherever present: gurgling in throat (upper) or intestines (lower). This corresponds to chronic cough/phlegm/wheezing worsening in autumn/winter and improving in spring/summer. Xuan Yin: fluid flows under hypochondrium, hanging without ascending/descending, knotted and unresolved, causing pain upon coughing/spitting. Corresponds to hypochondriac fluid accumulation/pain. Yi Yin: fluid flows to limbs, sweat should occur but doesn't, blocking exterior meridians, causing body ache/heaviness. Corresponds to Feng Shui/Water Edema. Zhi Yin: fluid stops in chest, coughing/rebellious Qi hinders breathing, shortness of breath prevents lying down, resembling edema. Corresponds to fluid retention with wheezing/fullness preventing supine position.

[Collected Annotations] Zhao Liang stated: Water flows downward; highland water flows to rivers, rivers to sea. Blocking rivers causes flooding. Human water intake is similar. Nei Jing states: Water enters Stomach, circulates essence, uploads to Spleen, Spleen scatters essence to Lung, Lung regulates water passages, downloads to Bladder, fluids distribute everywhere, Five Meridians run parallel. Current drinking water, if Spleen Qi fails to scatter upward or Lung Qi fails to conduct downward, flows and accumulates randomly, causing disease.

Cheng Lin stated: Nei Jing says: When Earth Depression manifests, fluid arises within. Due to its flowing nature, treatments vary (sweating, purging, warming, promoting urination).

Li [Name missing] stated: There are four fluids, yet this chapter names only Tan Yin. Essentially, water accumulating in Yin becomes fluid; fluid condensing in Yang becomes phlegm. Separately, there are four; collectively, all are Tan Yin.

You Yi stated: Formerly plump, now thin, indicates fluids transformed into phlegm-fluid, no longer nourishing the body externally, but flowing downward to intestines. Overflowing drinking water indicates excess water and rebellious Qi. Flowing to hypochondrium is Xuan Yin; returning to limbs is Yi Yin. "Xuan" hangs in one place; "Yi" overflows to four sides. Knotted偏 (偏) upward attaching to Heart/Lung is Zhi Yin. Zhi Yin is like river branches or tree limbs, near organs but not central. Coughing/rebellious Qi preventing supine position indicates pressure on Lung.

Water in the Heart: epigastric hardness/pounding, shortness of breath, aversion to water/no desire to drink. Water in the Lung: spitting saliva/foam, desire to drink. Water in the Spleen: lack of Qi, body heaviness. Water in the Liver: hypochondriac fullness/supporting distension, pain upon sneezing. Water in the Kidney: epigastric palpitations.

[Note] "Epigastric palpitations" should likely read "Umbilical palpitations"; this is a transcription error.

[Commentary] The four fluids may stay in diaphragm, intestines, hypochondrium, limbs, or chest, but this does not exhaust all water pathologies. Thus, it elaborates: Water in Heart causes epigastric hardness, shortness of breath, palpitations, no desire to drink. Water in Lung causes spitting saliva/foam, thirst/desire to drink. Water in Spleen causes Qi deficiency and body heaviness. Water in Liver causes hypochondriac fullness and pain upon sneezing. Water in Kidney causes umbilical palpitations. Physicians applying this analogically will understand water diseases thoroughly.

Zhi Yin with chest fullness is treated with Hou Po Da Huang Tang (Magnolia Bark and Rhubarb Decoction).

[Note] "Chest fullness" should likely read "Abdominal fullness"; if chest, there is no rationale for using Chengqi Decoction. This is a transcription error.

[Commentary] Zhi Yin with chest fullness involves Lung pathogen, suitable for Mu Fang Ji Tang or Ting Li Da Zao Tang. Zhi Yin with abdominal fullness involves Stomach pathogen, thus treated with Hou Po Da Huang Tang, which is Xiao Cheng Qi Tang (Minor Order the Qi Decoction).

[Collected Annotations] You Yi stated: Suspect "chest fullness" should be "abdominal fullness." Zhi Yin often causes chest fullness; why use purging here? Hou Po Da Huang is identical to Xiao Cheng Qi Tang. Unless there is abdominal pain and constipation, do not test lightly.

Formula for Hou Po Da Huang Tang (Magnolia Bark and Rhubarb Decoction):
Hou Po (Magnoliae Officinalis Cortex, 1 chi)
Da Huang (Rhei Radix et Rhizoma, 6 liang)
Zhi Shi (Immature Bitter Orange, 4 pieces)
Boil these three ingredients in 5 sheng of water to obtain 2 sheng. Divide into two warm doses.

Phlegm-fluid in the epigastrium, chest/hypochondriac supporting fullness, and vertigo are treated with Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction).

[Commentary] This elaborates on symptoms and treatment following the previous passage. Phlegm-fluid in epigastrium means fluid water flows in the diaphragm, causing chest/hypochondriac supporting fullness. This fullness blocks Yang Qi from ascending to head/eyes, causing vertigo. Ling Gui Zhu Gan Tang is used to promote urination and unblock Yang Qi.

[Collected Annotations] Li [Name missing] stated: Chest/hypochondriac supporting fullness indicates phlegm-fluid stagnation in the middle; vertigo indicates blocked Yang Qi failing to ascend. Poria leaches dampness to drain fluid; Cinnamon Twig guides to move Yang Qi; Atractylodes removes dampness and strengthens Spleen; Licorice harmonizes middle and boosts Qi. Together, they tonify Earth to control Water.

Formula for Ling Gui Zhu Gan Tang (See above).

Abdominal fullness, dry mouth/tongue, indicates water qi in the intestines, treated with Fang Ji Ding Jun Li Huang Wan (Stephania, Zanthoxylum, Lepidium, and Rhubarb Pill).

[Commentary] This further details symptoms to distinguish treatment. Phlegm-fluid in epigastrium with gurgling throat sounds, or water qi in intestines with gurgling intestinal sounds, uses Ling Gui Zhu Gan Tang (the method of warming and harmonizing). If abdominal fullness adds, water has become solidified; dry mouth/tongue indicates water fails to transform. Thus, Fang Ji, Jiao Mu, Ting Li, and Da Huang attack water knots from front and back. Once water knots open, abdominal fullness resolves. Water