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This is a counter-flow syndrome. Individuals who vomit will inevitably feel thirsty. However, if the water they drink cannot be transported and descend due to deficiency-cold in the diaphragm, it can be confirmed that there is fluid retention in the diaphragm. "Xuan" (dizziness) refers to vertigo, which is a response to fluid lifting and Qi floating. "Ji" (palpitations) refers to startled palpitations, which is a response to fluid invading Heart Fire; this is the same as the subcardiac palpitations mentioned in Clause 6, but it is not deficiency-type palpitations. Shengjiang (Dried Ginger) and Banxia (Pinellia Rhizome) warm the diaphragm and direct rebellious Qi downward, thus achieving the effect of stopping vomiting and opening痞 (stagnation). Fuling (Poria) promotes diuresis to remove fluid, thus achieving the effect of settling latent Qi and calming the Spirit. This elucidates the previous Clause 28. Generally, vomiting without thirst is caused by pre-existing cold-fluid leading to vomiting; sudden vomiting accompanied by stagnation is caused by pre-existing cold-vomiting leading to fluid accumulation. Although the symptoms are inverted and different, both ultimately result in Zhi Yin (Branching Fluid), so both are primarily treated with this decoction, with specific modifications.

Clause 31: Suppose a thin person experiences palpitations below the umbilicus, spits saliva and foam, and suffers from dian xuan (vertigo of the vertex). This is due to fluid. Wuling San (Five-Ingredient Powder with Poria) is the primary treatment.

Wuling San Formula: Fuling (Poria), Zhuling (Polyporus), Zexie (Alisma), Baizhu (Atractylodes Macrocephala Rhizome), Guizhi (Cinnamon Twig).
The above five herbs are powdered. Take one cun-bi (a measure of volume) mixed with rice water, three times daily. Drink plenty of warm water; recovery occurs with sweating.

Palpitations below the umbilicus differ from the startled palpitations mentioned above and other deficiency-type palpitations elsewhere. It likely refers to a jumping sensation on either side of the umbilicus, like a finger snapping. This is because Qi in the chest and diaphragm is deficient above, causing Qi in the lower abdomen to rush upward to respond, resulting in this movement. The presentation is similar to Ben Tun (Running Piglet). "Dian" should be read as "Dian" (vertex). Dian xuan refers to vertigo at the vertex. It is generally understood that thin people often have excess Yang and insufficient Yin. If Yang were in excess, there would be no palpitations below the umbilicus or vertigo at the vertex. If Yin were insufficient, fluids would not float upward to produce saliva and foam. Now, since there are palpitations below the umbilicus, we know there is Qi deficiency in the chest and diaphragm attracting upward reversal. Since there is spitting of saliva/foam and vertex vertigo, we know there is pathogenic excess in the intestines lifting Qi upward. Upper deficiency leading to lower palpitations indicates an inability to transport fluid; lower excess leading to foaming and vertigo indicates accumulated fluid. Thus, it is said to be fluid pathology.

The rationale of Wuling San is detailed in the *Shanghan Lun*. Using it for this clause has profound implications. Removing fluid is treating the root. By draining the Bladder to remove fluid, the lower abdomen does not attack the chest and diaphragm with its excess; this addresses the first aspect of treating umbilical palpitations. With fluid removed and no fluid Qi shooting upward, saliva and foam will descend; this is the second aspect. With fluid removed and floating/distending Qi settling downward, vertex vertigo can be eliminated; this is the third aspect. Furthermore, Fuling, Baizhu, and Guizhi can replenish the clear Qi in the upper jiao to resist the upward attack from below; this is the fourth aspect. Drinking warm water to induce sweat prevents intestinal fluid from overflowing into collaterals and helps dissipate unsettled floating Qi; this is the fifth aspect. Zhang Zhongjing's diagnostic methods and formula principles are subtle and exquisite, generally as described.

Clause 32: In chronic cough, a wiry pulse indicates the presence of fluid. Shizao Tang (Ten-Date Decoction) is the primary treatment.

This describes Xuan Yin (Hanging Fluid) that has not yet forced the Lung, but causes cough due to fluid Qi shooting upward. Its pulse, symptoms, and treatment are as follows. A wiry pulse indicates Yang deficiency and external contraction. Yang deficiency leads to an inability to transport fluid, so a wiry pulse governs fluid. In chronic cough, seeing this pulse indicates the cough is due to Xuan Yin in the hypochondrium with water Qi shooting upward, hence "presence of fluid." Shizao Tang treats Xuan Yin, as detailed in Clause 22 and *Shanghan Lun* notes; thus, using it here is appropriate.

Clause 33: For patients with Zhi Yin (Branching Fluid) suffering from cough, irritability, and chest pain, if they do not die suddenly, after one hundred days or one year, Shizao Tang is suitable.

This states that long-standing Zhi Yin must seep laterally from the Middle Jiao to become Xuan Yin, so the treatment follows the Xuan Yin protocol. Zhi Yin accumulates from the intestines to the Stomach, then to the epigastrium, and finally seeps outward to the chest, forming a supportive structure, hence called Zhi Yin. When Zhi Yin lingers and becomes a chronic condition, its Qi shoots upward to the Lung, causing cough; if fluid transforms into heat, it causes irritability. Additionally, fullness in the collateral vessels of the chest often leads to sudden death due to high-rising fluid Qi cutting off vital energy. If they do not die suddenly and survive for a hundred days or a year, it means the Zhi Yin has seeped laterally into the hypochondrium to become Xuan Yin. Thus, the momentum of Zhi Yin wanes mid-course, preventing death. Treating according to this mechanism following the Xuan Yin protocol makes Shizao Tang the precise remedy.

Clause 34: Chronic cough lasting several years: a weak pulse is treatable; a solid, large, and rapid pulse indicates death. A deficient pulse implies severe dizziness (Mao). This is because the patient originally had Zhi Yin in the chest. Treatment belongs to the category of treating fluid retention.

Cough vibrates all meridians. Therefore, labor cough, heat cough, and cold cough often lead to death if prolonged, rarely lasting several years. Only cough caused by cold-fluid Qi shooting upward may persist. This is due to fluctuations in Yang Qi in the chest and the balancing influence of Fire/Earth months/days. Here, "pulse" refers to the Right Cun position. A weak pulse means although Lung and Chest Yang Qi are slight, the fluid is not high, allowing Qi to expand freely, like a bag with little content appearing soft. Treating with Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction) to remove fluid and fill the chest is relatively easy, hence "treatable." If the pulse body is internally hard and solid, externally bulging and large, and rapid and urgent, seeing any one indicates death, let alone all three. Fluid lifting narrows the Qi boundary, blocking the inner chambers of Yin Essence (Solid); exhausting the Qi to the extreme edge (Large); and shortening the Earth boundary making Qi movement urgent (Rapid). This is likened to the Song Dynasty fleeing south, crowding people into a small area, increasing taxes, and becoming poor—a state of solid, large, and rapid national pulse. Generals like Zhang, Han, Liu, and Yue tried to save the nation but could only prolong the dynasty briefly before collapse, akin to Zhang Zhongjing's meaning of "death, untreatable." Below "deficient pulse," elaborating on the treatability of a weak pulse: "Weak" refers to faint pulsation; "Deficient" refers to emptiness within, as weak pulses are often deficient. See Clause 25 note for "Mao" (dizziness). Reiterating pulse/symptoms confirms fluid evidence without confusion. "Treatment belongs to fluid family" means Xuan Yin and Zhi Yin have specific protocols; one need not treat cough directly, as removing fluid will stop the cough.

Clause 35: Cough with rebellious Qi, leaning on support to breathe, unable to lie flat. Xiao Qing Long Tang (Minor Green Dragon Decoction) is the primary treatment. After taking Xiao Qing Long Tang, if symptoms include excessive salivation, dry mouth, deep Cun pulse, shallow Chi pulse, cold limbs, Qi rushing from the lower abdomen to the chest and throat, numbness in hands/feet, facial flushing like drunkenness, subsequent flow to the inner thighs, difficult urination, and intermittent dizziness, use Fuling Guizhi Wuwei Gancao Tang (Poria, Cinnamon Twig, Schisandra, and Licorice Decoction) to treat the Chong Qi (Rushing Qi). Once Chong Qi subsides, if cough and chest fullness worsen, use Guiling Wuwei Gancao Tang minus Guizhi, plus Ganjiang (Dried Ginger) and Xixin (Asarum) to treat cough and fullness. If cough/fullness stops but thirst recurs and Chong Qi relapses, it is due to the heating nature of Xixin and Ganjiang. Normally, taking these should cause thirst; if thirst stops instead, it indicates Zhi Yin. Zhi Yin typically causes dizziness and vomiting. Add Banxia to remove fluid. Use Fuling Guizhi Wuwei Gancao Tang minus Gancao and Guizhi, plus Ganjiang, Xixin, and Banxia. If fluid is removed and vomiting stops but edema appears, add Xingren (Apricot Kernel). Although Mahuang (Ephedra) should be added for edema, it is omitted due to existing numbness. Adding it against indications would cause Jue (cold extremities/reversal) because the patient has Blood deficiency, and Mahuang disperses Yang. If facial flushing like drunkenness is due to Stomach Heat rushing up, add Dahuang (Rhubarb) to drain it.

Xiao Qing Long Tang Formula: Mahuang (Ephedra), Baishao (White Peony Root), Wuweizi (Schisandra Berry), Ganjiang (Dried Ginger), Gancao (Licorice Root), Guizhi (Cinnamon Twig), Banxia (Pinellia Rhizome), Xixin (Asarum).
Boil the eight ingredients in ten dou of water. First boil Mahuang to reduce by two sheng, skim the foam. Add remaining herbs, boil to three sheng, strain. Warm take one sheng. Modifications: If mild diarrhea, remove Mahuang, add Yuanhua (Genkwa Flower). If thirsty, remove Banxia, add Gualougen (Trichosanthes Root). If choking, remove Mahuang, add Fu Zi (Aconite). If difficult urination/lower abdominal fullness, remove Mahuang, add Fuling. If wheezing, remove Mahuang, add Xingren.

Fuling Guizhi Wuwei Gancao Tang Formula: Guizhi, Fuling, Wuweizi, Gancao.
Boil four ingredients in eight sheng of water to three sheng, strain. Divide into three warm doses.

Guiling Wuwei Gancao Tang minus Guizhi plus Ganjiang Xixin Formula: Fuling, Wuweizi, Gancao, Ganjiang, Xixin.
Boil five ingredients in eight sheng of water to three sheng, strain. Warm take half sheng, three times daily.

Guiling Wuwei Gancao Tang minus Gancao minus Guizhi plus Ganjiang Xixin Banxia Formula: Fuling, Wuweizi, Ganjiang, Xixin, Banxia.
Boil five ingredients in eight sheng of water to three sheng, strain. Warm take half sheng, three times daily.

Lingan Wuwei Jiangxin Banxia Tang plus Xingren Formula: Fuling, Gancao, Wuweizi, Ganjiang, Xixin, Banxia, Xingren.
Boil seven ingredients in ten dou of water to three sheng, strain. Warm take half sheng, three times daily.

Lingan Wuwei Jiangxin Banxia Xingren Tang plus Dahuang Formula: Fuling, Gancao, Wuweizi, Ganjiang, Xixin, Banxia, Xingren, Dahuang.
Boil eight ingredients in ten dou of water to three sheng, strain. Warm take half sheng, three times daily.

Cough with rebellious Qi, leaning to breathe, unable to lie flat is detailed previously. This symptom indicates fluid branching in the chest and diaphragm, filling the lung tubes. Xiao Qing Long Tang releases the exterior and promotes diuresis to resolve fluid, hence it is used. After taking it, symptoms cease. Mild sweating removes fluid via sweat, calming Lung Qi; diuresis removes fluid via urine, expanding Chest Yang. From "excessive salivation" to "intermittent dizziness" (twelve sentences), it describes complex variations after the main symptoms cease. There are roughly four types of variations:
1. Sweating empties the Diaphragm, causing lower Qi to rush up as Chong Qi, leading to upward surging and excessive salivation.
2. Phlegm-fluid patients have deficient Yang. Sweating/diuresis further depletes Yang, allowing Kidney Yin turbidity to invade Lung/Chest, causing cough and fullness. Deep Cun/Shallow Chi pulse and cold/numb limbs reflect this.
3. Pre-existing Stomach stagnation combined with sweating (Heart fluid) emptying the upper Jiao allows Stomach Heat to flare, causing dry mouth and flushed face.
4. Residual fluid remains, accumulating again as Zhi Yin due to upper Jiao emptiness, flowing to inner thighs, causing difficult urination and dizziness.
Zhang Zhongjing arranges these complexities meticulously. If variations appear singly, treat singly. If combined, treat Chong Qi first, as it represents upper deficiency and lower excess, potentially gathering more fluid. Fuling Guizhi Wuwei Gancao Tang uses Guizhi and Gancao to fill the upper emptiness and lift/support, while Wuweizi astringes and Fuling drains downward to suppress Chong Qi. Once Chong Qi settles, latent cold Qi rises, causing cough and fullness (Cold opposes Lung's warmth; Cold is unsuitable for Chest Yang). Remove Guizhi, add Ganjiang and Xixin, double Gancao. This shifts focus to warming the lower Jiao to transform upper cold. Wuweizi anchors downward, while Ganjiang/Xixin send warm Qi down to meet it, assisted by Gancao to float warm Qi upward to resolve cough/fullness. If thirst recurs after stopping cough/fullness, it indicates Zhi Yin returning due to heat drugs floating fluid. Zhi Yin causes dizziness and vomiting; add Banxia to descend and remove fluid. Remove Gancao/Guizhi to ensure downward action without lingering in the chest. This formula uses draining/astringent herbs to warm the lower Jiao and remove fluid, differing from the previous formula's use of Gancao to warm the middle. Zhang Zhongjing's mastery is miraculous. If edema persists after vomiting stops, add Xingren to benefit the Lung. Numbness with deep/shallow pulses and cold limbs contraindicates Mahuang due to Blood deficiency; using it would cause Jue. Facial flushing with dry mouth indicates Stomach Heat; add Dahuang to drain. This clause resembles a clinical case record preserved as a method.

Clause 36: Thirst followed by vomiting indicates water retention under the Heart (Stomach). This belongs to the fluid family. Xiaobanxia Fuling Tang (Minor Pinellia and Poria Decoction) is the primary treatment.

Thirst implies drinking much; vomiting implies rebellion and failure to transport. Thus, water is retained under the Heart. Saying "belongs to fluid family" means one need not treat vomiting directly; removing fluid will stop vomiting. Banxia removes fluid and directs rebellious Qi downward to stop vomiting; adding Fuling promotes diuresis. Who else but this combination could handle it?