（论一首脉证二十一条方十九首）
问曰。夫饮有四。何谓也。师曰。有痰饮。有悬饮。有溢饮。有支饮。问曰。四饮何以为异。
师曰。其人素盛。今瘦。水走肠间。沥沥有声。谓之痰饮。饮后水流在胁下。咳吐引痛。
谓之悬饮。饮水流行。归于四肢。当汗出而不汗出。身体疼重。谓之溢饮。咳逆倚息。
气短不得卧。其形如肿。谓之支饮。
〔衍义〕水性走下。而高原之水。流入于川。川入于海。塞其川。则洪水泛溢。而人之
饮水亦若是。内经曰。饮入于胃。游溢精气。上输于脾。脾气散精。上归于肺。通调
水道。下输膀胱。水精四布。五经并行。今所饮之水。或因脾土壅塞而不行。或因
肺气涩滞而不通。以致流溢。随处停积。水入肠间者。大肠属金主气。小肠属火。
水与火气相搏。气火皆动。故水入不得流走肠间。沥沥有声。是名痰饮。然肠胃
与肌肤为合。素受水谷之气。长养而肥盛。今为水所病。故肌肉消瘦也。水入胁
下者。属足少阳经。少阳经脉从缺盆下胸中。循胁里。过季胁之部分。其经多气。
属相火。今为水所积。其气不利。从火上逆胸中。遂为咳吐。吊引胁下痛。是名悬
饮。水泛溢于表。表阳也。流入四肢者。四肢为诸阳之本。十二经脉之所起。水至
其处。若不胜其表之阳。则水散当为汗出。今不汗。是阳不胜水。反被阻碍经脉
荣卫之行。故身体疼重。是名溢饮。水流入肠间。宗气不利。阳不得升。阴不得降。
呼吸之息。与水迎逆于其间。遂作咳逆倚息。短气不得卧。荣卫皆不利。故形如肿也。是名支饮。
水在心。心下坚筑。短气。恶水不欲饮。
〔衍义〕心属火。火、阳也。阳主动。肾属水。水、阴也。阴主静。静则坚。今水在心下。水克
火。水守于外。故坚。火内郁不宁。故筑筑然动而短气。水既外停。故恶水不欲饮
也。
水在肺。吐涎沫。欲饮水。
〔衍义〕仲景凡出病候。随其脏气变动而言之。不拘定于何邪也。如吐涎沫。属肺
脏。在肺痿证中者。上焦有热者。肺虚冷者。皆吐涎沫。今水在肺亦然。盖肺主气。
行荣卫。布津液。诸邪伤之。皆足以闭塞气道。故荣卫不行。津液不布。气停液聚。
变成涎沫而吐出之。若咳若渴者。亦肺候也。皆无冷热之分。但邪与气相击则
咳。不击则不咳。津液充其玄府则不渴。燥之则渴。随所变而出其病。亦不止于
是也。而在他证。方后更立加减法。便见仲景之意。
水在脾。少气身重。
〔衍义〕脾居中焦。与胃为表里。受谷化精。输于五脏百骸。脾实则中气强盛。体质
强健。今水在脾而脾病矣。中虚则少气。肌肉不得所养。唯受水气。水阴也。故身重。
水在肝。胁下支满。嚏而痛。
〔衍义〕肝有两叶。布在胁下。经脉亦循于是。与少阳胆为表里。今水客于肝。表里
气停。故支满。嚏者。气喷出也。少阳属火。火郁则有时而发。邪虽发动。不得布散。
惟上冲于鼻额。故作嚏。吊引胁下所结而痛。原病式曰。嚏以鼻痒而作声。鼻为
肺窍。痒为火化。火干阳明。痒为嚏也。
水在肾。心下悸。
〔衍义〕心属火而宅神。畏水者也。今水在肾。肾水愈盛。上乘于心。火气内郁。神灵
不安。故作悸动。筑筑然惧也。
夫心下有留饮。其人背寒冷如掌大。
〔衍义〕心之俞出于背。背、阳也。心有留饮。则火气不行。惟是寒饮注其俞。出于背。
寒冷如掌大。论其俞之处。明其背之非尽寒也。
留饮者。胁下痛引缺盆。咳嗽则辄已。（一作转甚）
〔衍义〕胁下为厥阴之支络。循胸出胁下。足厥阴脉布胁肋。而缺盆是三阳俱入。
然独足少阳从缺盆过季胁。饮留胁下。阻碍厥阴少阳之经络。不得疏通。肝苦急。气不通故痛。
少阳上引缺盆。故咳嗽则气攻冲。其所结者通。而痛辄已。（一作转甚）如上条咳而痛同也。
胸中有留饮。其人短气而渴。四肢历节痛。脉沉者。有留饮。
〔衍义〕胸中者。肺部也。肺主气以朝百脉。治节出焉。饮留胸中。宗气呼吸。惟以布
息。故短气。气不布。则津液不化而膈燥。是以渴也。足厥阴肝脏主筋。束骨而利
关节。其经脉上贯于膈。而胆之经亦下胸中贯膈。夫饮者。即湿也。其湿喜流关
节。从经脉流而入之。作四肢历节痛。留饮。水类也。所以脉亦沉也。
膈上病痰满喘咳吐。发则寒热。背痛腰疼。目泣自出。其人振振身 剧。必伏饮。
〔衍义〕膈上表分也。病痰满喘咳。乃在表之三阳。皆郁而不伸。极则化火。冲动膈
上之痰吐发。然膈间之伏饮。则留而不出。因其不出。则三阳之气虽动。尚被伏
饮所抑。足太阳经屈而不伸。乃作寒热。腰背疼痛。其经上至目内 。故目泣自
出。足少阳经气。属风火之化。被抑不散。并于阳明。属在肌肉之分。故振振身
而剧也。是条首以痰言。末以饮言。二者有阴阳水火之分。痰从火而上。熬成而
浊。故名曰痰。饮由水湿留积不散而清。故名曰饮。亦是五行水清火浊之义。
夫病患饮水多。必暴喘满。凡食少饮多。水停心下。甚者则悸。微者短气。脉双弦者
寒也。皆大下后里虚。脉偏弦者饮也。
〔衍义〕饮水多留于膈。膈气不行则喘满。食少胃气虚。复多饮。胃土不能运水。水
停心下。心火畏水。甚则神不安。为怔忡惊悸。微者阳独郁。而为短气。夫脉弦者。
为虚为水。若两寸皆弦。则是大下之后。阳气虚寒所致。若偏见弦。则是积水之处也。
肺饮不弦。但苦喘短气。
〔衍义〕脉弦为水为饮。今肺饮而曰不弦。何也。水积则弦。未积则不弦。非谓肺饮
尽不弦也。此言饮水未积。犹得害其阳。虽不为他病。亦适成其苦喘短气也。
支饮亦喘。而不能卧。加短气。其脉平也。
〔行义〕脉平当无病。何以有病而反平也。正与上条不弦意同。明其虽有支饮。而饮尚不留伏。
不停积。以其在上焦。未及胸中。不伤经脉。故脉平。然终碍其阴阳升降。故喘不能卧短气耳。
病痰饮者。当以温药和之。
〔衍义〕痰饮由水停也。得寒则聚。得温则行。况水行从乎气。温药能发越阳气。开腠理。通水道也。
心下有痰饮。胸胁支满。目眩。苓桂术甘汤主之。
苓桂术甘汤方
茯苓（四两） 桂枝 白术（各三两） 甘草（二两）
上四味。以水六升。煮取三升。分温三服。小便则利。
〔衍义〕心胞络循胁出胸下。灵枢曰。胞络是动。则胸胁支满。此痰饮积其处而为病也。
目者心之使。心有痰水。精不上注于目。故眩。本草茯苓能治痰水。伐肾邪。痰、水类也。治水必自小便出之。然
其水淡渗手太阴。引入膀胱。故用为君。桂枝乃手少阴经药。能调阳气。开经络。况痰水得温则行。用之为臣。白术除
风眩燥痰水。除胀满。以佐茯苓。然中满勿食甘。用甘草何也。盖桂枝之辛。得甘则佐其发散。和其热而使不僭也。复
益土以制水。甘草有茯苓。则不支满而反渗泄。本草曰。甘草能下气。除烦满也。
夫短气有微饮。当从小便去之。苓桂术甘汤主之。（方见上）肾气丸亦主之。（方见妇人杂病中）
〔衍义〕微饮而短气。由饮水停蓄。致三焦之气升降呼吸不前也。二方各有所主。
苓桂术甘汤主饮在阳。呼气之短。肾气丸主饮在阴。吸气之短。盖呼者出心肺。
吸者出肾肝。茯苓入手太阴。桂枝入手少阴。皆轻清之剂。治其阳也。地黄入足
少阴。山萸入足厥阴。皆重浊之剂。治其阴也。一证二方。岂无故哉。
病者脉伏。其人欲自利。利反快。虽利。心下续坚满。此为留饮欲去故也。甘遂半夏汤主之。
甘遂半夏汤方
甘遂（大者三枚） 半夏（十二枚） 芍药（五枚） 甘草（如指大一枚炙）
上四味。以水二升。煮取半升。去滓。以蜜半升和药汁。煎取八合。顿服之。
〔衍义〕仲景尝谓天枢开发。胃和脉生。今留饮之堵塞中焦。以致天真不得流通。胃气不得转输。脉隐伏而不显。
留饮必自利。自利而反快者。中焦所塞暂通也。通而复积。续坚满。必更用药尽逐之。然欲直达其积饮。莫若甘遂快利。
用之为君。欲和脾胃。除心下坚。又必以半夏佐之。然芍药停湿。何留饮用之乎。甘草相反甘遂。何一方兼用之。盖芍
药之酸。以其留饮下行。甘遂泄之。本草谓其独去水气也。甘草缓甘遂之性。使不急速。徘徊逐其所留。入蜜亦此意也。
然心下者。脾胃部也。脾胃属土。土由木郁其中而成坚满。非甘草不能补土。非芍药不能
伐木。又可佐半夏和胃消坚也。雷公炮炙法。有甘草汤浸甘遂者矣。
脉浮而细滑。伤饮。
〔衍义〕脉之大小。皆从气血虚实变见者也。伤于饮。则气虚而脉浮。血虚而脉细。
阳火被郁。则微热而脉滑也。
脉弦数。有寒饮。冬夏难治。
〔衍义〕此言其脉邪之不相应也。寒饮反见数脉。数是内经有用热远热。有用寒
远寒之戒。在夏用热药治饮。则数脉愈增。在冬用寒药治热。则寒饮愈盛。皆伐天和。所以在冬夏
难也。在春秋。或可适其寒温而消息之。
脉沉而弦者。悬饮内痛。病悬饮者。十枣汤主之。
十枣汤方
芫花（熬） 甘遂 大戟（各等分）
上三味捣筛。以水一升五合。先煮肥大枣十枚。取八合去滓。内药末。强人服一
钱匕。羸人服半钱。平旦温服之。不下者。明日更加半钱。得快下后。糜粥自养。
〔衍义〕脉沉病在里也。凡弦者为痛为饮为癖。悬饮结积在内作痛。故脉见沉弦。
此条言病脉而不言药。后出一条。言药而不言病脉。可知悬饮之痛。不止上条。
伤寒中悬饮。亦用是汤。则知十枣汤之治悬饮之证最多也。故将下条粘连上
条。成注谓芫花之辛以散饮。甘遂、大戟之苦以泄水。大枣之甘以益脾而胜水也。
病溢饮者。当发其汗。大青龙汤主之。小青龙汤亦主之。
大青龙汤方
麻黄（六两去节） 桂枝（二两去皮） 甘草（二两炙） 杏仁（四十个去皮尖）
生姜（三两） 大枣（十二枚） 石膏（如鸡子大碎）
上七味。以水九升。先煮麻黄减二升。去上沫。内诸药。煮取三升。去滓。温服一升。
取微似汗。汗多者。温粉粉之。
小青龙汤方
麻黄（去节三两） 芍药（三两） 干姜（三两） 五味子（半升）
甘草（三两炙） 细辛（三两） 桂枝（去皮三两） 半夏（半升汤洗）
上八味。以水一斗。先煮麻黄减二升。去上沫。内诸药。煮取三升。去滓。温服一升。
〔衍义〕伤寒论寒邪伤荣。麻黄汤。风邪伤卫。桂枝汤。风寒两伤荣卫者。大青龙汤。
稍迫心肺证。小青龙汤。今溢饮亦是荣卫两伤治之。何也。出方不出证。又何也。
盖溢饮之证。已见首篇。故不重出。水饮溢出于表。荣卫尽为不利。犹伤寒荣卫
两伤。故必发汗以散水。而后荣卫行。经脉行。则四肢之水亦消矣。
膈间支饮。其人喘满。心下痞坚。面色黧黑。其脉沉紧。得之数十日。医吐下之不愈。
木防己汤主之。虚者即愈。实者三日复发。复与不愈者。宜木防己汤。去石膏。加茯苓芒硝汤主之。
木防己汤方
木防己（三两） 石膏（十二枚鸡子大） 桂枝（二两） 人参（四两）
上四味。以水六升。煮取二升。分温再服。
木防己加茯苓芒硝汤方
木防己（三两） 桂枝（三两） 人参（四两） 芒硝（三合） 茯苓（四两）
上五味。以水六升。煮取二升。去滓。内芒硝。再微煎。分温再服。微利则愈。
〔衍义〕心肺在膈上。肺主气。心主血。今支饮在膈间。气血皆不通利。气为阳主动。
血为阴主静。气不利。则与水同逆于肺而为喘满。血不利。则与水杂揉。结于心
下而为痞坚。肾气上应水饮。肾气之色黑。血凝之色亦黑。故黧黑之色亦见于
面也。脉沉为水。紧为寒。非别有寒邪。即水气之寒也。医虽以吐下之法治。然药
不切于病。故不愈。用木防己者。味辛温。能散留饮结气。又主肺气喘满。所以用
为主治。石膏味辛甘微寒。主心下逆气。清肺定喘。人参味甘温。治喘。破坚积。消
痰饮。补心肺气不足。皆为防己之佐。桂枝味辛热。通血脉。开结气。且支饮得温
则行。又宣导诸药。用之为使。若邪之浅。在气分多而虚者。服之即愈。若邪客之
深。在血分多而实者。则愈后必再发。故石膏是阳中之治气者则去之。加芒硝
味咸寒。阴分药也。治痰实结。赖之去坚消血癖。茯苓伐肾邪。治心下坚满。佐芒硝则行水之力益倍。
心下有支饮。其人苦冒眩。泽泻汤主之。
泽泻汤方
泽泻（五两） 白术（二两）
上二味。以水二升。煮取一升。分温再服。
〔衍义〕明理论。眩为眼黑。冒为昏冒。伤寒之冒眩。以阳虚。中风亦有眩冒。乃风之
旋动也。原病式以昏冒。由气热冲心也。目暗黑。亦火热之气郁。二论曰虚曰风
曰火。各一其说。三者相因。未始相离。风火不由阳虚。则不旋动。阳虚不由风火。
则不冒眩。盖伤寒者以寒覆其阳。阳郁化火。火动风生故也。
(One general discussion, twenty-one pulse and symptom patterns, nineteen prescriptions)
Question: There are four types of fluid retention (Yin). 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 are these four types of fluids distinguished?
Master said: If a person was previously robust but has now become emaciated, and water flows through the intestines making a gurgling sound, this is called Tan Yin (Phlegm-Fluid). If after drinking water, the fluid accumulates in the hypochondrium, causing pain radiating to the chest when coughing or spitting, this is called Xuan Yin (Hanging Fluid). If drinking water causes the fluid to flow and overflow into the four limbs, sweating should occur but does not, resulting in heavy and painful body, this is called Yi Yin (Overflowing Fluid). If there is coughing with air reversal, needing to lean on something to breathe, shortness of breath, inability to lie flat, and the appearance resembles edema, this is called Zhi Yin (Branching Fluid).
[Commentary] The nature of water is to flow downward, just as water from highlands flows into rivers, and rivers into the sea. If the river channels are blocked, floods will overflow. The situation with humans drinking water is similar. The *Nei Jing* states: "When fluid enters the stomach, its essence and qi float and overflow, moving upward to the spleen. The spleen disperses the essence, sending it upward to the lung. The lung regulates the water passages, directing them downward to the bladder. Water essence is distributed in all directions, flowing through the five meridians." Now, the water consumed may fail to move due to obstruction of the spleen earth, or fail to circulate due to stagnation of lung qi, leading to overflow and accumulation wherever it stops.
When water enters the intestines, the large intestine belongs to Metal and governs Qi, while the small intestine belongs to Fire. Water and fire qi interact; both qi and fire move. Thus, when water enters the intestines, it makes a gurgling sound, which is named Tan Yin (Phlegm-Fluid). However, the intestines and stomach are connected to the skin and muscles. Normally nourished by food and drink, the body becomes robust. Now damaged by water pathogen, the muscles become emaciated.
When water enters the hypochondrium, it relates to the Foot Shaoyang Gallbladder Meridian. This meridian descends from the Clavicle Fossa (Quepen) through the chest, follows the interior of the hypochondrium, and passes the lateral costal region. This meridian is rich in Qi and belongs to Ministerial Fire. Accumulated by water, the Qi becomes obstructed and rebels upward along the fire to the chest, causing coughing, spitting, and pain radiating to the hypochondrium, named Xuan Yin (Hanging Fluid).
When water overflows to the exterior, the exterior is Yang. Entering the four limbs, which are the roots of all Yang meridians and the origin of the twelve meridians, if the water cannot overcome the Yang of the exterior, it should dissipate as sweat. Since no sweat occurs, Yang fails to overcome the water, instead obstructing the circulation of Ying and Wei in the meridians, causing heaviness and pain in the body, named Yi Yin (Overflowing Fluid).
When water flows into the intestines, Zong Qi (Gathering Qi) is obstructed, Yang cannot ascend, and Yin cannot descend. Respiratory Qi meets with water pathogen, causing coughing, air reversal, leaning to breathe, shortness of breath, and inability to lie flat. Ying and Wei are both obstructed, so the form appears swollen, named Zhi Yin (Branching Fluid).
Water in the Heart: Hardness and palpitations below the heart, shortness of breath, aversion to water and unwillingness to drink.
[Commentary] The Heart belongs to Fire, which is Yang and active. The Kidney belongs to Water, which is Yin and quiet. Quietness implies firmness. Now water is below the Heart; Water conquers Fire. Water stays outside, causing firmness. Fire is depressed inside and restless, causing palpitations and shortness of breath. Since water is stopped externally, there is an aversion to water and unwillingness to drink.
Water in the Lung: Spitting of saliva and foam, desire to drink water.
[Commentary] Zhang Zhongjing describes pathological signs according to the changes in Zang organ Qi, not limited to specific pathogens. For instance, spitting saliva and foam belongs to Lung pathology. In Lung萎 (Flaccidity) syndrome, whether due to heat in the Upper Jiao or cold deficiency of the Lung, saliva and foam are spat out. Similarly, when water is in the Lung. The Lung governs Qi, circulates Ying and Wei, and distributes Body Fluids. Various pathogens damaging it can block the airways, stopping Ying and Wei circulation and fluid distribution. Stagnant Qi and accumulated fluids transform into saliva and foam, which are spat out. Cough or thirst are also Lung signs, without distinction of cold or heat. Only when pathogen strikes Qi does cough occur; otherwise, no cough. When fluids fill the Xuancui (pores/secretory openings), there is no thirst; when dry, there is thirst. Pathologies manifest according to transformation, not limited to these. In other syndromes, modification methods listed after formulas reveal Zhongjing's intent.
Water in the Spleen: Shortness of breath, heavy body.
[Commentary] The Spleen resides in the Middle Jiao, paired with the Stomach as Interior-Exterior. It receives grain, transforms essence, and distributes it to the five Zang organs and bones. When Spleen is full, Middle Qi is strong, and physique is robust. Now water is in the Spleen, causing Spleen disease. Middle deficiency leads to shortness of breath; muscles lack nourishment and are affected by water Qi. Water is Yin, hence the heavy body.
Water in the Liver: Supportive fullness under the hypochondrium, pain triggered by sneezing.
[Commentary] The Liver has two lobes distributed under the hypochondrium, and its meridian traverses this area, paired with the Shaoyang Gallbladder as Interior-Exterior. Now water pathogen lodges in the Liver, causing stagnation of Interior-Exterior Qi, resulting in supportive fullness. Sneezing is the expulsion of Qi. Shaoyang belongs to Fire; when Fire is depressed, it occasionally erupts. Although the pathogen activates, it cannot disperse, only rushing upward to the nose and forehead, causing sneezing, which pulls on the knot under the hypochondrium causing pain. *Yuan Bing Shi* states: Sneezing occurs due to nasal itching producing sound. The nose is the orifice of the Lung; itching is transformed by Fire. Fire harasses Yangming, causing itching and sneezing.
Water in the Kidney: Palpitations below the heart.
[Commentary] The Heart belongs to Fire and houses the Spirit; it fears Water. Now water is in the Kidney, Kidney Water becomes excessive and attacks upward to the Heart. Fire Qi is internally depressed, the Spirit is unsettled, causing palpitations and fear.
When there is retained fluid (Liu Yin) below the Heart, the person feels cold on the back in an area the size of a palm.
[Commentary] The Back-Shu point of the Heart emerges on the back; the back is Yang. With retained fluid in the Heart, Fire Qi does not circulate. Only cold fluid injects into its Shu point and emerges on the back, causing coldness in an area the size of a palm. Discussing the location of the Shu point clarifies that the entire back is not cold.
In cases of retained fluid, pain in the hypochondrium radiates to the Clavicle Fossa (Quepen); coughing causes the pain to cease (or worsen).
[Commentary] The hypochondrium is the branch collateral of Jueyin. It traverses the chest and exits the hypochondrium. The Foot Jueyin Liver Meridian distributes to the hypochondrium and ribs, while Quepen is where all three Yang meridians enter. However, only the Foot Shaoyang Gallbladder Meridian passes from Quepen to the lateral costal region. Fluid retained in the hypochondrium obstructs the Jueyin and Shaoyang meridians, preventing smooth flow. The Liver suffers from urgency; Qi obstruction causes pain. Shaoyang connects upward to Quepen; thus, coughing drives Qi upward, unblocking the knot, and pain ceases (or worsens). This is consistent with the previous clause where coughing causes pain.
When there is retained fluid in the Chest, the person experiences shortness of breath and thirst, pain in all joints of the four limbs, and a deep pulse; this indicates retained fluid.
[Commentary] The Chest is the location of the Lungs. The Lung governs Qi to direct all vessels, and regulation arises here. Retained fluid in the Chest affects Zong Qi respiration, limiting it to breathing, causing shortness of breath. Qi fails to distribute, so Body Fluids do not transform, leading to dryness at the diaphragm and thirst. The Foot Jueyin Liver governs tendons, binding bones and facilitating joint movement. Its meridian penetrates the diaphragm, and the Gallbladder meridian also descends through the chest and penetrates the diaphragm. Fluid is essentially dampness. Dampness tends to flow into joints, entering via meridians, causing pain in all joints of the four limbs. Retained fluid is a type of water, hence the pulse is also deep.
Phlegm in the Upper Diaphragm causes fullness, wheezing, coughing, and vomiting. Attacks involve chills and fever, back and waist pain, spontaneous tearing, and severe trembling of the body. This is hidden fluid (Fu Yin).
[Commentary] The upper diaphragm is the exterior aspect. Phlegm disease with fullness, wheezing, and coughing involves the three Yang meridians of the exterior, which are depressed and unable to extend. Extremity leads to fire transformation, stirring phlegm in the upper diaphragm to vomit. However, hidden fluid in the diaphragm remains trapped. Because it does not exit, although the three Yang Qi moves, it is suppressed by the hidden fluid. The Foot Taiyang Meridian bends and does not extend, causing chills, fever, and back/waist pain. Its meridian ascends to the inner canthus, causing spontaneous tearing. Foot Shaoyang Qi belongs to wind-fire transformation; suppressed and unable to disperse, it merges with Yangming, affecting the muscle layer, causing severe trembling. This clause begins with phlegm and ends with fluid. They differ in Yin/Yang and Water/Fire. Phlegm rises from fire, is boiled into turbidity, hence named Phlegm. Fluid results from stagnant water-dampness, remaining clear, hence named Fluid. This aligns with the Five Elements principle that water is clear and fire is turbid.
If a patient drinks much water, sudden fullness and wheezing will definitely occur. Generally, eating little and drinking much causes water to stop below the Heart. Severe cases cause palpitations; mild cases cause shortness of breath. A double-wiry pulse indicates Cold, resulting from interior deficiency after severe purgation. A single-sided wiry pulse indicates Fluid retention.
[Commentary] Excess water retained in the diaphragm blocks diaphragmatic Qi, causing wheezing and fullness. Eating little means Stomach Qi is deficient; combined with excess drinking, Spleen Earth cannot transport water, causing it to stop below the Heart. Heart Fire fears Water; severely, the Spirit is unsettled, causing palpitations. Mildly, Yang is solely depressed, causing shortness of breath. A wiry pulse indicates deficiency or water. If both Cun positions are wiry, it results from Yang deficiency and cold after severe purgation. If only one side is wiry, it indicates water accumulation.
Lung fluid retention does not present a wiry pulse, but rather suffering from wheezing and shortness of breath.
[Commentary] A wiry pulse indicates water/fluid. Why does Lung fluid retention say "not wiry"? Water accumulation causes wiriness; non-accumulation does not. This does not mean all Lung fluid retentions are non-wiry. It refers to water not yet accumulated. Although it hasn't caused other diseases, it damages Yang, resulting in wheezing and shortness of breath.
Zhi Yin (Branching Fluid) also causes wheezing, inability to lie flat, and shortness of breath, but the pulse is normal.
[Commentary] A normal pulse implies no disease. Why is there disease yet the pulse is normal? This aligns with the previous "non-wiry" meaning. It clarifies that although Zhi Yin exists, the fluid is not yet deeply retained or accumulated. Being in the Upper Jiao and not reaching the Chest, it does not damage the meridians, hence the pulse is normal. However, it ultimately hinders the ascent and descent of Yin and Yang, causing wheezing, inability to lie flat, and shortness of breath.
Patients with Tan Yin (Phlegm-Fluid) should be treated with warm herbs to harmonize.
[Commentary] Tan Yin results from water stagnation. It gathers with cold and moves with warmth. Moreover, water movement follows Qi. Warm herbs can vent Yang Qi, open interstices, and unblock water passages.
With Tan Yin below the Heart, supporting fullness in the chest and hypochondrium, and dizziness, Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) is the primary treatment.
Ling Gui Zhu Gan Tang Formula
Fuling (Poria, 4 liang) Guizhi (Cinnamon Twig, 3 liang) Baizhu (Atractylodes Macrocephala, 3 liang) Gancao (Licorice, 2 liang)
The above four ingredients are decocted in six sheng of water to obtain three sheng. Divide into three warm doses. Urination will increase, and the condition will resolve.
[Commentary] The Pericardium Collateral traverses the hypochondrium and emerges below the chest. *Ling Shu* states: When the Pericardium Collateral is disturbed, there is supporting fullness in the chest and hypochondrium. This is pathology caused by Tan Yin accumulation there. The eyes are the messengers of the Heart. With phlegm-water in the Heart, essence does not ascend to the eyes, causing dizziness. Materia Medica records that Fuling treats phlegm-water and suppresses Kidney pathogens. Phlegm and water are similar. Treating water requires excretion via urine. Fuling is light and penetrating, entering the Hand Taiyin Lung Meridian and guiding to the Bladder, hence used as Sovereign herb. Guizhi is a herb for the Hand Shaoyin Heart Meridian, regulating Yang Qi and opening meridians. Since phlegm-water moves with warmth, it is used as Minister. Baizhu eliminates wind-induced dizziness, dry phlegm-water, and distension/fullness, assisting Fuling. However, fullness in the middle prohibits sweet taste; why use Gancao? The acridity of Guizhi, combined with sweetness, aids dispersion and moderates heat to prevent rebellion. It also benefits Earth to control Water. Gancao combined with Fuling prevents fullness and promotes drainage. Materia Medica states: Gancao directs Qi downward and eliminates irritability and fullness.
For shortness of breath due to slight fluid retention, elimination via urine is appropriate. Ling Gui Zhu Gan Tang is the primary treatment. (Formula seen above) Shen Qi Wan (Kidney Qi Pill) is also indicated. (Formula seen in Women's Miscellaneous Diseases chapter)
[Commentary] Slight fluid retention causing shortness of breath results from water accumulation hindering the ascent, descent, and respiration of Qi in the Three Jiao. The two formulas have different indications. Ling Gui Zhu Gan Tang treats fluid in Yang, specifically shortness of breath during exhalation. Shen Qi Wan treats fluid in Yin, specifically shortness of breath during inhalation. Exhalation originates from Heart and Lung; inhalation from Kidney and Liver. Fuling enters Hand Taiyin, Guizhi enters Hand Shaoyin; both are light and clear agents treating Yang. Dihuang enters Foot Shaoyin, Shanzhuyu enters Foot Jueyin; both are heavy and turbid agents treating Yin. One syndrome, two formulas, surely not without reason.
If the patient's pulse is hidden (Fu), and they desire spontaneous diarrhea, which brings relief, yet the abdomen continues to feel hard and full despite the diarrhea, this is due to retained fluid attempting to exit. Gansui Banxia Tang (Kansui and Pinellia Decoction) is the primary treatment.
Gansui Banxia Tang Formula
Gansui (Kansui Root, 3 large pieces) Banxia (Pinellia Tuber, 12 pieces) Shaoyao (Peony Root, 5 pieces) Gancao (Licorice, 1 piece the size of a finger, roasted)
The above four ingredients are decocted in two sheng of water to obtain half a sheng. Strain. Mix with half a sheng of honey and decoct the medicine juice to obtain eight he. Take in one dose.
[Commentary] Zhongjing once said that when Tian Shu opens, Stomach harmonizes, and pulse generates. Now, retained fluid blocks the Middle Jiao, preventing Tian Zhen (innate Qi) from circulating and Stomach Qi from transforming. The pulse hides and does not appear. Retained fluid must cause spontaneous diarrhea. Relief after spontaneous diarrhea indicates temporary unblocking of the Middle Jiao obstruction. Re-accumulation leads to continued hardness and fullness; medication must be used to thoroughly expel it. To reach the retained fluid directly, nothing is faster than Gansui's rapid purgation, so it is used as Sovereign. To harmonize Spleen and Stomach and eliminate subcardiac hardness, Banxia assists. However, Shaoyao retains dampness; why use it for retained fluid? Gancao opposes Gansui; why use them together? The sourness of Shaoyao directs retained fluid downward, while Gansui drains it. Materia Medica says it alone removes water Qi. Gancao moderates Gansui's nature, preventing rapid action, allowing it to linger and pursue the retained fluid. Honey serves the same purpose. The subcardiac area is the Spleen-Stomach region, belonging to Earth. Earth becomes hard and full due to Wood depression within. Only Gancao can tonify Earth; only Shaoyao can subdue Wood. They also assist Banxia in harmonizing Stomach and eliminating hardness. Leigong Processing Method mentions soaking Gansui in Gancao decoction.
A floating, fine, and slippery pulse indicates injury by fluid retention.
[Commentary] Pulse magnitude varies with Qi/Blood and Deficiency/Excess. Injury by fluid causes Qi deficiency and floating pulse; Blood deficiency causes fine pulse. Depressed Yang-Fire causes slight heat and slippery pulse.
A wiry and rapid pulse with cold fluid retention is difficult to treat in winter and summer.
[Commentary] This describes mismatched pulse and pathogen. Cold fluid presenting with a rapid pulse warns against using heat far from heat and cold far from cold (*Nei Jing*). Using hot herbs for fluid in summer increases the rapid pulse; using cold herbs for heat in winter exacerbates cold fluid. Both harm Harmonious Heaven. Hence difficulty in winter and summer. In spring and autumn, one might adjust for cold and warmth.
A deep and wiry pulse indicates internal pain from Xuan Yin (Hanging Fluid). For patients with Xuan Yin, Shizao Tang (Ten Jujube Decoction) is the primary treatment.
Shizao Tang Formula
Yuanhua (Genkwa Flower, roasted) Gansui (Kansui Root) Daji (Euphorbia Root, equal parts)
The above three ingredients are pounded and sifted. Use one sheng five he of water. First decoct ten large jujubes until reduced to eight he, then strain. Add the powder. Strong persons take one qianbi; weak persons take half a qianbi. Take warm on an empty stomach in the morning. If no effect, increase by half a qianbi the next day. After rapid purgation, nourish with millet porridge.
[Commentary] Deep pulse indicates interior disease. Wiry pulse indicates pain, fluid, or mass. Xuan Yin accumulation internally causes pain, hence deep and wiry pulse. This clause discusses pulse but not formula; the next discusses formula but not pulse. This shows Xuan Yin pain is not limited to the previous clause. Even in Shanghan (Cold Damage) with Xuan Yin, this decoction is used, indicating Shizao Tang treats many Xuan Yin syndromes. Thus, linking the next clause to this one. Cheng Zhu notes: Yuanhua's acridity disperses fluid; Gansui and Daji's bitter cold drain water; Jujube's sweetness benefits Spleen to overcome water.
For patients with Yi Yin (Overflowing Fluid), sweating should be induced. Da Qing Long Tang (Major Blue-Green Dragon Decoction) is the primary treatment. Xiao Qing Long Tang (Minor Blue-Green Dragon Decoction) is also indicated.
Da Qing Long Tang Formula
Mahuang (Ephedra Stem, 6 liang, nodes removed) Guizhi (Cinnamon Twig, 2 liang, bark removed) Gancao (Licorice, 2 liang, roasted) Xingren (Apricot Seed, 40, husks and tips removed)
Shengjiang (Fresh Ginger, 3 liang) Dazao (Jujube, 12 pieces) Shigao (Gypsum, size of a chicken egg, crushed)
The above seven ingredients are decocted in nine sheng of water. First boil Mahuang to reduce by two sheng, remove the scum. Add other herbs. Decoct to obtain three sheng. Strain. Take one sheng warm. Induce slight sweating. If sweating is excessive, dust with warm powder.
Xiao Qing Long Tang Formula
Mahuang (Ephedra Stem, 3 liang, nodes removed) Shaoyao (Peony Root, 3 liang) Ganjiang (Dried Ginger, 3 liang) Wuweizi (Schisandra Berry, half sheng)
Gancao (Licorice, 3 liang, roasted) Xixin (Asarum, 3 liang) Guizhi (Cinnamon Twig, 3 liang, bark removed) Banxia (Pinellia Tuber, half sheng, washed in boiling water)
The above eight ingredients are decocted in one dou of water. First boil Mahuang to reduce by two sheng, remove the scum. Add other herbs. Decoct to obtain three sheng. Strain. Take one sheng warm.
[Commentary] In *Shanghan Lun*, Cold Evil injuring Ying uses Mahuang Tang; Wind Evil invading Wei uses Guizhi Tang; Wind-Cold injuring both Ying and Wei uses Da Qing Long Tang. Slightly pressing on Heart and Lung uses Xiao Qing Long Tang. Now Yi Yin also injures both Ying and Wei; why treat it this way? The formula is given without symptoms because Yi Yin symptoms were already presented in the first section. Water overflowing to the exterior disrupts Ying and Wei completely, similar to Ying-Wei injury in Cold Damage. Therefore, sweating is necessary to scatter water, allowing Ying and Wei to circulate and meridians to function, thereby resolving water in the four limbs.
Branching Fluid in the Interscapular Region causes wheezing and fullness, epigastric hardness and fullness, dark complexion, and a deep, tight pulse. Acquired over dozens of days, unsuccessful treatment with vomiting and purging methods. Fangji Tang (Stephania Decoction) is the primary treatment. If the pattern is deficiency, recovery occurs immediately. If solid, relapse occurs in three days. If recurrence fails to respond to repeated administration, Fangji Tang minus Shigao plus Fuling and Muxiao Tang (Stephania minus Gypsum plus Poria and Mirabilite Decoction) is indicated.
Fangji Tang Formula
Mufangji (Stephania Tetrandra, 3 liang) Shigao (Gypsum, 12 pieces size of chicken egg) Guizhi (Cinnamon Twig, 2 liang) Renshen (Ginseng, 4 liang)
The above four ingredients are decocted in six sheng of water to obtain two sheng. Divide into two warm doses.
Fangji Plus Fuling and Muxiao Tang Formula
Mufangji (Stephania Tetrandra, 3 liang) Guizhi (Cinnamon Twig, 3 liang) Renshen (Ginseng, 4 liang) Muxiao (Mirabilite, 3 he) Fuling (Poria, 4 liang)
The above five ingredients are decocted in six sheng of water to obtain two sheng. Strain. Add Muxiao. Simmer slightly. Divide into two warm doses. Slight purgation indicates recovery.
[Commentary] Heart and Lung are above the diaphragm; Lung governs Qi, Heart governs Blood. Branching Fluid in the interscapular region obstructs both Qi and Blood. Qi is Yang and active; Blood is Yin and static. Qi obstruction causes rebellion with water to the Lung, leading to wheezing and fullness. Blood obstruction mixes with water, knotting in the epigastrium causing hardness and fullness. Kidney Qi corresponds to water; Kidney color is black. Blood coagulation color is also black; hence the dark complexion appears on the face. Deep pulse indicates water; tight indicates cold. There is no separate cold pathogen, only cold from water Qi. Although doctors used vomiting and purging, the medicine did not match the disease, hence failure. Mufangji is acrid and warm, dispersing retained fluid and Qi knots, and treating Lung wheezing/fullness, hence used as Sovereign. Shigao is acrid, sweet, and slightly cold, treating rebellious Qi below the Heart, clearing Lung, and calming wheezing. Renshen is sweet and warm, treating wheezing, breaking hard accumulations, dissolving phlegm-fluid, and tonifying Heart-Lung Qi deficiency, serving as Assistant to Fangji. Guizhi is acrid and hot, unblocking blood vessels, opening Qi knots, and since branching fluid moves with warmth, it guides other herbs, serving as Envoy. If pathogen is shallow, mostly in Qi level and deficiency, recovery occurs upon ingestion. If pathogen is deep, mostly in Blood level and solid, relapse occurs after recovery. Thus, Shigao, which treats Qi in Yang, is removed. Muxiao is salty and cold, a Yin-level agent, treating phlegm-solid knots, relying on it to eliminate hardness and blood stasis. Fuling suppresses Kidney pathogen and treats epigastric hardness/fullness; assisting Muxiao doubles the water-draining power.
With Branching Fluid below the Heart, the person suffers from dizziness and vertigo. Zexie Tang (Alisma Decoction) is the primary treatment.
Zexie Tang Formula
Zexie (Alisma Rhizome, 5 liang) Baizhu (Atractylodes Macrocephala, 2 liang)
The above two ingredients are decocted in two sheng of water to obtain one sheng. Divide into two warm doses.
[Commentary] *Ming Li Lun* states: Xuan (vertigo/dizziness) is black vision; Mao (dizziness/heaviness) is mental clouding. In Cold Damage, Mao-Xuan is due to Yang deficiency. In Wind Stroke, there is also Xuan-Mao, caused by wind rotation. *Yuan Bing Shi* attributes Mao to Qi-Heat rushing to the Heart. Dark/black eyes are also due to Fire-Heat Qi depression. These theories cite deficiency, wind, and fire, each offering a perspective. The three are interrelated and inseparable. Wind and Fire do not rotate without Yang deficiency; Yang deficiency does not cause Mao-Xuan without Wind and Fire. In Cold Damage, cold covers Yang; Yang depression transforms into Fire; Fire agitation generates Wind.