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Article 1 Question: The pathogenic factor of fluid retention (Yin) is divided into four types. What are they? Master replied: There is Tan Yin (Phlegm-Fluid), Xuan Yin (Hanging Fluid), Yi Yin (Overflowing Fluid), and Zhi Yin (Supporting Fluid). Again asked: How do these four types of fluid retention differ from each other? Master said: If a person was previously robust but now has become emaciated, it is because water flows into the intestines, producing a gurgling sound; this is called Tan Yin. After drinking, if water flows and stays under the hypochondrium, causing pain when coughing or spitting, it is called Xuan Yin. If after drinking, water flows and accumulates in the four limbs, sweating should occur but does not, leading to body ache and heaviness, it is called Yi Yin. If there is cough with air counterflow, reliance on support for breathing, shortness of breath, inability to lie flat, and the appearance resembles edema, it is called Zhi Yin.

Tan (Phlegm) is transformed from the body fluids of the Zang-Fu organs, akin to law-abiding citizens turning into bandits due to sudden upheaval. The causes triggering this transformation of body fluids generally fall into two categories: Cold and Heat. For instance, if the Lung is affected by Heat, the Metal element (Lung) shows signs of melting, damaging Yin. When Yin is damaged, the throat feels as if something is stuck and cannot be expelled, with slight pain resembling a strained voice. After one or two days, thick yellow phlegm is coughed up. If it gradually becomes thinner and whiter, it indicates recovery; this is the first scenario. If the Lung is affected by mild Cold, Yang Qi is constrained and lung lobes tighten. Extreme constraint leads to eruption, and Cold pathogens transform into Heat along with the movement of Yang Qi. The interaction of Cold and Heat peels away fluids to expel pathogens, resulting in coughing up white, clump-shaped phlegm resembling congee, coated with sticky saliva and clear water. This represents a case where Cold is the root and Heat is the branch, with both factors present simultaneously; this is the second scenario. Initially, there is difficulty in defecation, gradually leading to dryness and constipation. Lower Qi floats and stagnates, Heat exists in the intestines and stomach, steaming upwards, drying the Lung and depleting fluids. Fire irritation causes itching, leading to cough. Large amounts of thick yellow phlegm are coughed up continuously day and night; this is Heat-Phlegm in the Stomach, the third scenario. Bad phlegm formed from deteriorating conditions is excluded here. As for "Tan Yin" mentioned in this chapter, although similar to the sticky saliva caused by Cold, it is actually a different pathology and must be distinguished. Because it is accumulated from drinking water, it is called "Yin"; because like Tan, it can cause cough, it is also called "Tan Yin". Since Tan Yin permeates outside the epigastrium and does not flow into the Small Intestine or Bladder, but hangs under the hypochondrium, it is called Xuan Yin. Because Tan Yin hangs for a long time and the Qi of the meridians becomes deficient, it overflows into the meridians taking advantage of the deficiency, hence called Yi Yin. Because Tan Yin does not permeate to both hypochondria but blocks centrally at the Heart Below (epigastrium), having the meaning of being supported by an object, it is called Zhi Yin. Fluid retained for a long time is called Liu Yin (Retained Fluid); fluid deeply hidden is called Fu Yin (Hidden Fluid). If fluid enters the Zang organs in solid form, it causes sudden death. Its initial symptoms involve only Water Qi attacking the organs, so for the five Zang organs, it is directly called "Water". All these originate from Cold Qi stagnation in the Lung, preventing normal exhalation; they form due to Cold Qi stagnation in the Spleen, failing to distribute properly. This differs from the "Tan" transformed from body fluids mentioned earlier. Therefore, its nature is cold like clear water, sticky like thin glue. Medications should be pungent, sweet, and warm; treatment methods should induce sweating and promote urination; this is the fixed rule. Occasionally, bitter, salty, cold, and moistening drugs may be used, but these are variations for changing conditions. "Su Sheng" refers to abundant flesh. The current emaciation is evident. Generally, those with deficient Yang have abundant flesh; previous robustness implies deficient Yang; current emaciation implies deficiency of Yin fluids in the intestines and stomach, leading to internal wasting. Deficient Yang cannot transport fluid; deficient Yin relies on external water, causing stagnation. Water flowing in the intestines without penetrating downward produces a gurgling sound; thus is Tan Yin defined. In these four sentences, focus on the words "intestines". "Yin Hou" means after Tan Yin formation, not referring to drinking soup or water. If Tan Yin does not move, it will later seep from the intestines to the Stomach, then expand horizontally to the hypochondrium. Because lower support leads to upper floating, central fullness leads to lateral pouring, and the Stomach meridian connects to the hypochondrium, water flows outside the intestines and stomach to the hypochondrium. The hypochondrium is the region of Shaoyang and Jueyin; Liver and Gallbladder Qi tends to rebel, causing cough and spit. The collaterals in the hypochondrium swell with water, causing vibration and pulling pain when coughing/spitting. The water under the hypochondrium has no exit, resembling hanging on a shelf; thus is Xuan Yin defined. In these four sentences, focus on "hypochondrium". "Yin Shui" and "Yin Hou" have the same meaning, stating that water from Xuan Yin, if lingering for a long time, flows from meridians to the four limbs. Water in meridians is moved by Yang Qi and can be resolved through sweat. Now, with deficient Yang, sweating fails to occur; thus, heat in water causes pain, and sinking water causes heaviness; thus is Yi Yin defined. In these five sentences, focus on "four limbs". Regarding cough with air counterflow, relying on sitting/support for breathing, and water accumulating at the Heart Below raising the Diaphragm Qi, making inhalation difficult and causing shortness of breath, leading to inability to lie flat. Additionally, floating water forces Qi to bulge outward, making the shape resemble edema; thus is Zhi Yin defined. In these five sentences, focus on "relying on support for breathing and shortness of breath". Thus, although there are four names for fluid retention, the principle is the same. It starts with Tan Yin and Xuan Yin, ultimately returning to Yi Yin and Zhi Yin. The transmission of these four depends on the deficiency or excess of the chest, hypochondrium, and meridians, determining the extent and speed.

Article 2 Water in the Heart: Hardness and palpitations below the Heart, shortness of breath, aversion to water, desire not to drink.
This article, combined with the following two, details Zhi Yin. Because Zhi Yin accumulates at the Heart Below, its Water Qi can attack upward to the Heart and Lung, forming symptoms of Water in Heart and Lung. "Heart Below" refers to the area below the Heart, collectively naming the Epigastrium and its exterior. Fluid accumulation in the Epigastrium causes hardness and pulsation ("Zhu"). Inhalation cannot descend, causing shortness of breath. However, the next article describes Water outside the Epigastrium, a progression of Xuan Yin; fluid retains for a long time, transforms into Heat, and burns externally, causing thirst for water. This article describes Water inside the Epigastrium, elevated by Tan Yin; internal pressure of fluid causes aversion to water and lack of desire to drink.

Article 3 Water in the Lung: Spitting of saliva and foam, desire to drink.
Fluid branches under the Lung, and Water Qi attacks upward, preventing Lung Qi from extending downward and causing rebellion. Thus, saliva and foam rise and are spat out. See notes on the previous article.

Article 4 Water in the Spleen: Shortness of energy (Shao Qi), heavy body.
This details the symptoms of Yi Yin. Any transmission of Tan Yin or Xuan Yin can cause this. Tan Yin transmits internally from the Stomach collateral to the Spleen; Xuan Yin transmits laterally from the hypochondrial collateral to the Spleen. Thus, both can cause Water Qi in the Spleen. When Spleen Earth Yang declines and Water Qi attacks, it cannot transport and distribute, overflowing to the four limbs; this is inevitable. Hence, this describes Yi Yin symptoms. Spleen stagnation prevents Jing-Han (essence and vigorous Qi) from ascending, causing Shao Qi. Spleen dampness and Sun-Water sinking cause body heaviness. Shao Qi refers to insufficient exhalation; Duan Qi refers to shallow inhalation.

Article 5 Water in the Liver: Fullness and support sensation under the hypochondrium, pain upon sneezing.
This details the symptoms of Xuan Yin. The hypochondrium is the pathway of the Liver collateral. Fluid hangs here, attacking the Liver via the collateral. Thus, Water in the Liver. Fluid fills the hypochondrium, feeling like support and bulging; hence "Zhi Man", which is the meaning of Zhi Yin. Sneezing originates from the Lung. The Liver is invaded by Water Evil, its unconquered element (Metal controls Wood). The Lung dislikes dampness and tries to expel it, causing sneezing. However, sneezing requires substantial Qi from below to surge upward, exacerbating the fullness and causing vibrating pain. This is synonymous with pain from coughing/spitting.

Article 6 Water in the Kidney: Palpitations below the Heart.
This is a condition separate from the Four Fluids, corresponding to the unmanifested Fu Yin mentioned in Article 11. Zhang Zhongjing listed this among the Zang organs, showing profound intent to prevent disease progression. The Kidney is the Water Organ, like the sea of heaven and earth, resonating with water sources. If Kidney Yang is strong and urination is smooth, True Yin is secure, and external water flows freely; how could there be Hidden Fluid? If Yang Virtue is weak, disaster lies in wait. Without perceiving the subtle early signs, peace is impossible. Disease from the Four Fluids accumulates from top to bottom, progressing gradually like filling basins; symptoms are slow and relatively mild. Disease from Fu Yin erupts from bottom to top, like a tidal wave bursting; symptoms are urgent and severe. "Ji" (palpitation) here is Water Ji, distinct from deficiency-induced palpitations with fluttering and noise. Water Ji involves a sense of dread as if impending disaster, with constant vigilance. Heart and Kidney jointly govern the Hand and Foot Shaoyin meridians, their Qi connecting in the profound depths. Hidden Water in the Kidney causes the Heart Monarch to be unsettled, like the Yellow River threatening to burst while the divine mechanism in Luocheng secretly illuminates, manifesting as muscle twitching. This describes initial symptoms. Regarding established conditions, the Four Fluids also flood from above, peaking at Zhi Yin; Fu Yin also transmits from below, peaking in the four Zang organs.

Article 7 When there is Retained Fluid at the Heart Below, the person experiences coldness on the back, the size of a hand.
Combining this with Articles 8, 9, and 10, excluding Yi Yin (which leads to death if unresolved, lacking signs of long-term retention), the remaining three Fluids, if lingering, are called Liu Yin. This article discusses long-term Zhi Yin. The Heart connection attaches to the back. Retained Zhi Yin at the Heart Below allows Cold-Damp Qi to transfer to the back via the connection, causing coldness on the back corresponding to the hand size. This is the necessary correspondence between internal form/energy and external manifestation.

Article 8 In cases of Retained Fluid, pain under the hypochondrium radiates to the Quepen point, worsening with cough.
This discusses long-term Xuan Yin. Quepen (ST12) is the 12th acupoint of the Foot-Yangming Meridian, located below the neck, between the chest and breast, below Qishe, above Qihu. There are two points, left and right. Pain radiating to Quepen and worsening with cough. See notes on Article 1 (Xuan Yin) and Article 5 (Water in Liver).

Article 9 In cases of Retained Fluid in the Chest, the person experiences shortness of breath and thirst, and pain in the joints of the four limbs.
This also discusses long-term Zhi Yin. Article 7 mentions Retained Fluid at the Heart Below, implying fluid in the Epigastrium. Here, Retained Fluid in the Chest is higher than the Heart Below, pressing against the Lung. Pressing the Lung makes it difficult for Qi to descend, causing shortness of breath. Thirst is detailed in Article 3 (Water in Lung). Pain in the joints of the four limbs: The body regards joints as valleys. Pain indicates fluid is about to overflow externally, preceded by Qi stagnation and dizziness.

Article 10 A deep pulse indicates Retained Fluid.
This summarizes the pulse of Retained Fluid. Water nature tends downward. Fluid retained internally causes heavy, sinking Qi that cannot float. Thus, a deep pulse indicates Retained Fluid. Diagnosis follows specific locations: Deep pulse at Cun position indicates fluid in the Chest (symptoms of Article 9); slightly above Guan position indicates fluid at the Heart Below (symptoms of Article 7); slightly below Cun position, appearing singly on left or right, indicates fluid under the hypochondrium (symptoms of Article 8). Other Zang-Fu are diagnosed by their respective positions, using the Accumulation Pulse rules from Chapter 12 as the standard. A deep pulse should also show slippery and fine qualities.

Article 11 Phlegm disease above the Diaphragm presents with fullness, wheezing, cough, and vomiting. Upon onset, chills and fever, back and waist pain, spontaneous tearing, and violent trembling occur. There must be Hidden Fluid.
This elucidates the symptoms of Water in the Kidney and palpitations below the Heart from Article 6. Fu Yin refers to latent, unmanifested fluid. It is about to manifest but not fully so, being more severe than mere palpitations in Article 6. "Must be Hidden Fluid" reflects Zhang Zhongjing's prophetic insight, often unnoticed by others. "Phlegm disease above the Diaphragm" means chronic phlegm pathology above the Diaphragm. "Wheezing, fullness, cough, vomiting" results from this pathological phlegm causing chest fullness, wheezing, coughing, and vomiting. These two phrases are the main symptoms, serving as diagnostic keys for expert physicians. "Onset" means exacerbation at certain times. The word "Onset"贯穿 (runs through) the following five symptoms. "Mu Qi" means tears. "Zhen Zhen Shen Yun Ju" indicates Yang deficiency with upward rushing. See *Shanghan Lun* and other notes. Chills, fever, etc., occurring simultaneously resemble Yang deficiency with external Cold invasion. However, since the patient has chronic phlegm-Qi above the Diaphragm triggering fullness, wheezing, cough, and vomiting, it is known not to be an acute illness but caused by Hidden Fluid in the Kidney. Although fluid hides below, its Cold-Damp Qi attacks upward through emptiness. The Lung dislikes dampness and cold. Thus, Cold-Damp Phlegm above the Diaphragm rises with Damp Qi (causing fullness/wheezing) and Cold Qi (causing cough/vomiting). Occasional exacerbation occurs because Lung Cold-Damp persists on Bing/Ding days (Fire) and Wu/Ji days (Earth), while Hidden Fluid dominates on Ren/Gui days (Water). Chills/Fever: Cold is the fundamental nature of fluid; rising fluid causes chills. Rising Cold repels slight Yang outward, causing both chills and fever. Back: The mansion of the Chest. Chest fullness and cough make Qi penetrate the back, causing pain. Waist: The mansion of the Kidney. Slight Yang in the Kidney is forced outward by Cold-Fluid, causing waist pain. Tears, though Liver fluid, are released spontaneously because Cold-Fluid presses upward and cannot control them. Cold Qi floats upward, forcing all Yang to retreat, causing trembling and shaking. Can Ling Gui Zhu Gan Tang (Article 18) and Shen Qi Wan alleviate this? Ling Gui Zhu Gan Tang removes Hidden Fluid; Shen Qi Wan tonifies Kidney Yang to prevent recurrence. Disciple asks: Article 6 note states this is a condition outside the Four Fluids, i.e., Fu Yin. Articles 2-6 clearly list the transmission of Four Fluids to the five Zang organs. Why is "Water in Kidney" considered outside the Four Fluids? One. Article 6 says "Water in Kidney" without mentioning "Fu Yin"; Article 11 mentions "Fu Yin" without "Kidney". How do we know Kidney Water is Fu Yin? Two. Four Fluids transmit via specific paths, from intestines/stomach to chest/hypochondrium/meridians, entering via mouth. If Kidney Water is Fu Yin and outside the Four Fluids, yet enters via mouth, how is it outside? From what path does this fluid enter and hide in the Kidney? Three. Tan Yin transmission has names like Xuan, Yi, Zhi, Liu, and symptoms in chest, epigastrium, hypochondrium, limbs. Zhang Zhongjing does not detail Fu Yin transmission, yet you say it is urgent and severe. Is merely hiding until becoming ill like this article considered severe, or are there other changes? Four. Please explain. Answer: This question is essential. Water in Heart, Lung, Liver, Spleen are severe conditions transmitted into Zang organs after the Four Fluids. Only Water in Kidney is a mild condition before the Four Fluids, i.e., Wei Yin (Micro Fluid) in Article 18. Since Kidney is the Water Organ, slight weakness in Kidney Yang summons Water to hide as fluid, hence "outside the Four Fluids". Anything latent and unseen is called Fu. Not only Heart, Lung, Liver, Spleen, but also Upper/Middle Jiao Fu organs cannot harbor Fu Yin. It's not that there is no fluid; if there were, external symptoms would be obvious, so it couldn't be called "hidden". Only Kidney and Bladder, one Zang one Fu, resembling rivers/seas, can hide fluid for extended periods. Thus, Water in Kidney is Fu Yin. Four Fluids enter via mouth; does Fu Yin not enter via mouth? Yes. But Four Fluid disease arises from failure of Upper/Middle Jiao Yang to distribute, causing gradual accumulation and rising. Fu Yin disease occurs when Upper/Middle are healthy, but Kidney Qi is cold and deficient, and Fu transformation stops with Cold. Bladder collaters connect to Kidney, allowing Cold-Water Qi to enter via Fu collaters and hide in Kidney. Tan Yin progression to Yi/Zhi is already severe; transmission to Kidney leads to death. Source comes from the Sea, and overflow floods the Sea, symbolizing land subsidence. Fu Yin progression generally has three outcomes: 1. Latent and unmanifested, flaring during Winter/Water periods (Ren/Gui months/days) like this article. 2. Fluid hides in the abyss, Cold Qi harasses the Upper Void, contracting Lung Qi, preventing distribution, causing water accumulation in intestines, transforming into Tan Yin. I call this the mild condition before Four Fluids, source from the Sea. 3. Fu Yin attacks upward, trapping Spleen/Lung Yang, preventing transportation, stopping urination. Fluid surges from above, daily swelling, cyanosis of skin/muscle, leading to death. This matches the "tidal wave burst" noted in Article 6, urgent and severe.

Article 12 Patients who drink excessively will suddenly experience wheezing and fullness. Generally, those with poor appetite and high fluid intake retain water at the Heart Below. Severe cases have palpitations; mild cases have shortness of breath.
This is binge drinking. Different from retained fluid in Xuan/Zhi Yin. This is upper-level binge drinking, different from Fu Yin and Wei Yin (Article 18). First two sentences: Patient has Heat in Chest/Diaphragm and drinks much. Water cannot penetrate quickly, stopping at Heart Below. Water presses Lung Qi causing wheezing; water floats in Chest causing fullness. Though not fully formed Four Fluids, the pathology is temporarily similar to Zhi Yin. Last four sentences: Regardless of being a patient, anyone with deficient Stomach/poor appetite and Heat in Diaphragm/excessive drinking can suffer this. Palpitations and shortness of breath are detailed elsewhere. The implication is that even if it is binge drinking, if not treated with Zhu Ling Tang or Wu Ling San to stop thirst and remove fluid, it will gradually develop into Four Fluid conditions.

Article 13 Bilateral wiry pulses indicate Cold, usually due to interior deficiency after severe purgation. Unilateral wiry pulse indicates Fluid.
These three articles summarize Four Fluid pulses. This article likely refers to Xuan Yin. Wiry pulse indicates Yang deficiency and Qi reduction. Fluid retention is caused by Yang Qi failing to exhale and penetrate downward, so Fluid pulse is always wiry. However, bilateral wiry pulses suggest interior Yang deficiency, indicating Middle Cold due to severe purgation causing interior deficiency and Qi collapse. Do not mistake this for Fluid pulse. Only unilateral wiry pulse indicates Xuan Yin in the left/right hypochondrium. However, according to Accumulation Pulse rules, bilateral wiry suggests fluid in the center. Zhi Yin in Chest/Epigastrium may also show bilateral wiry pulses. Differentiate by symptoms. Fluid diseases have wheezing, thirst, shortness of breath; post-purgation interior deficiency lacks these. Article 10 says Retained Fluid pulse is deep; this article says Xuan Yin pulse is wiry. Are Fluid pulses deep and wiry together? My experience suggests: Early Fluid disease often shows wiry pulse; late/chronic Fluid disease often shows deep pulse. Zhang Zhongjing distinguishes them intentionally.

Article 14 Lung Fluid is not wiry; the patient suffers mainly from wheezing and shortness of breath.
Lung Fluid refers to Zhi Yin floating to Chest/Diaphragm, injuring the Lung. Wiry pulse indicates Qi reduction. Water accumulation in Chest/Diaphragm prevents Qi from descending, gathering above the fluid. Thus, the wiry pulse of Qi reduction is absent. Wheezing and shortness of breath are detailed elsewhere. Saying Fluid pulse is wiry, but Lung Fluid specifically may not be wiry, do not be misled by this. Rely on external symptoms, similar to Stomach having retained food showing slippery pulse.

Article 15 Zhi Yin also causes wheezing, inability to lie flat, plus shortness of breath, but the pulse is level/normal.
Zhi Yin, referring to Zhi Yin at the Heart Below. Same Zhi Yin has high and low positions. High ones press the Lung, called Lung Fluid. Low ones are at Heart Below, far from Lung, called Zhi Yin generally. Fluid accumulation in Epigastrium makes Qi descent difficult, causing wheezing. Inability to lie flat is because lying horizontal causes fluid to press the Lung. Shortness of breath is a symptom of Lung Fluid. If fluid is at Heart Below, pulse is still wiry. If fluid rises slightly causing shortness of breath, Qi gathers in the Lung. Qi gathering makes the pulse level rather than wiry/reduced.

Article 16 Tan Yin disease should be treated with warm herbs to harmonize.