经义
岁土太过，饮发中满食减。○土郁之发，为饮发注下。○太阳司天，湿气变物，水饮内蓄，中满不食。
○太阴在泉，民病饮积。○太阴之胜，饮发于中。○太阴所至，为积饮痞隔。○少阴司天，四之气，民病饮发。
○诸病水液，澄澈清冷，皆属于寒。（《素问》）
哲言
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，咳唾引痛，谓之悬饮。○饮水流行，
归于四肢，当汗出而不汗出，身体疼痛，谓之溢饮。○咳逆倚息，短气不得卧，其形如肿，谓之支饮。○夫心下
有留饮，其人背寒冷如掌大。○留饮者，胁下痛引缺盆，咳嗽则转甚。○胸中有留饮，其人短气而渴，四肢历节
痛。○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，必有伏饮。○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。○水在心，心下坚筑，短气，恶水不欲饮；水在肺，
吐涎沫，欲饮水；水在脾，少气身重；水在肝，胁下支满，嚏而痛；水在肾，心下悸。（《金匮》）
按痰饮病者，痰为物化之病，而饮为物不化之病也。饮食入胃，胃中阳盛气足，则俱为正气正血，灌滋
脏腑，敷通营卫矣，何有于痰饮？痰饮者，胃阳不足以腐消，脾气不足以旋运，而痰饮成矣。痰即食物也，入
胃而胃冷不足以消之，斯化为痰；饮即水也，入胃而脾湿不足以输之，斯留为饮。二者虽常相附而居，而
其实所因各异。皆应责之以脾胃虚寒，俾有用之饮食，成为害之痰饮。《内经》言饮而不及于痰，言痰自仲景
始，已有痰病之说列于《伤寒论》中，复合痰饮而言之于《金匮》。细考其文，究以饮为主，而以痰为附论。
可见痰即食物，虽为病而不必荡除，但能腐化水谷，在痰不必专治而自减；饮为水邪，有留伏则最难驱逐，势
必分明辨证，在水必有专治而后安。此二病合论中，又宜存分晰之见，不容混其义焉。（魏荔彤）
饮者，蓄水之名，自外而入；痰者，肠胃之液，自内而生。其初各别，其后同归，故积饮不散，亦能变痰，
是饮为痰之渐，痰为饮之化。若其外出，则饮形清稀，痰形稠浊，又不同也。（《证治汇补》）
水气上逆则呕，停于膈间则痞，上干于头则眩，凌心则悸。（汪 庵）
痰饮总为一证，而因则有二∶痰因于火，有热无寒；饮因于湿，有热有寒，即有温泉无寒火之理也。
○痰饮者，水走肠间，沥沥有声；悬饮者，水流胁下，咳嗽引痛；溢饮者，水流行于四肢，汗不出而身重；支
饮者，咳逆倚息短气，其形如肿。一由胃而下流于肠，一由胃而旁流于胁，一由胃而外出于四肢，一由胃而上
入于胸膈。始先不觉，日积月累，水之精华，转为混浊，于是遂成痰饮。必先团聚于呼吸大气难到之处，故由
肠而胁而四肢，至渐渍于胸膈，其势愈逆矣。痰饮之患，未有不从胃而起者矣。○水所蓄聚之区，皆名留饮。留
者，留而不去也。留饮去而不尽者，皆名伏饮。伏者，伏而不出也。（喻嘉言）
补编
病痰饮者，当以温药和之。○心下有痰饮，胸胁支满，目眩，苓桂术甘汤主之。○夫短气有微饮，当从小
便去之，苓桂术甘汤主之，肾气丸亦主之。○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。○病悬饮者，十枣汤主之。○病溢饮者，当发其汗，大青龙汤主之，小青龙汤
亦主之。○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。○心下有支饮，其人苦冒眩，
泽泻汤主之。○支饮胸满者，浓朴大黄汤主之。○支饮不得息，葶苈大枣泻肺汤主之。○呕家本渴，渴者为欲解，
今反不渴，心下有支饮故也，小半夏汤主之。○腹满，口舌干燥，此肠间有水气，己椒苈黄丸主之。○卒呕吐，
心下痞，膈间有水，眩悸者，半夏加茯苓汤主之。○假令瘦人脐下有悸，吐涎沫而颠眩，此水也，五苓散主之。
○《外台》茯苓饮治水，胸中有停痰宿水，自吐出水后，心胸间虚，气满不能食，消痰气令能食。○咳逆倚息不
得卧，小青龙汤主之。○先渴后呕，为水停心下，此属饮家，小半夏茯苓汤主之。（《金匮》）
按∶“此为留饮欲去故也”句，当在“利反快”之下，必传写之讹。○按∶“支饮胸满”之“胸”字，当
是“腹”字，若是“胸”字，无用承气汤之理，当改之。○按“瘦人”之“瘦”字，当是“病”字。“颠眩”
之“颠”字，当是“巅”字，巅者，头也。文义始属，当改之。（《医宗金鉴》）
《金匮》云∶病痰饮者，当以温药和之。按痰生于胃寒，饮生于脾湿。温药者，补胃阳，燥脾土，兼擅其
长之剂也。言和之，则不专事温补。即有行消之品，亦概其例义于温药之中，方谓之和之，而不可谓之补之、
益之也。盖痰饮之邪，因虚而成，而痰亦实物，必少有开导，总不出"温药和之"四字，其法尽矣。言攻下者
固非，专言温补者，亦不达“和之”二字之理。仲景之言，一字千金，不能易也。（魏荔彤）
《内经》有积饮之说，无痰饮之名。两汉以前，谓之淡饮。仲景始分痰饮、悬饮、溢饮、支饮之义，立
大小青龙、半夏、苓桂术甘、肾气等汤，以及内饮外饮诸法，独超千古。总之痰饮之作，必由元气亏乏及阴盛
阳衰而起，以致津液凝滞，不能输布，留于
胸中。水之清者，悉变为浊，水积阴则为饮，饮凝阳则为痰。若果真元充足，胃强脾健，则饮食不失其度，运
行不停其机，何痰饮之有？故仲景云∶“病痰饮者，当以温药和之”。后人不知痰饮之义，妄用消痰破气，滋
填腻补，大伤脾胃，堆砌助浊，其于仲景治痰饮之法，岂不大相乖谬乎？然痰与饮虽为同类，而实有阴阳之别。
阳盛阴虚，则水气凝而为痰；阴盛阳虚，则水气溢而为饮。然而病变不同，治法有异。如脾、肾阳虚，膀胱气
化不通者，取苓桂术甘汤、茯苓饮、肾气、真武等法，以理阳、通阳及固下益肾、转旋运脾为主。如外寒引动，
宿饮上逆，及膀胱气化不通，饮逆肺气不降者，以小青龙合越婢等法，开太阳膀胱为主。如饮邪伏于经络，及
中虚湿伏成痰者，则有川乌、蜀漆之温经通络，《外台》茯苓饮去甘草，少佐苦辛淡渗理湿。其饮邪上冲膻
中，及悬饮流入胃中而为病者，又有姜、附、南星、菖蒲、旋复、川椒等，驱饮开浊，辛通阳气。（《临证指南》）
痰饮之或留或伏，而用法以治之。由胃而上胸膈心肺之分者，驱其所留之饮还胃，下从肠出，或上从呕出，
其出皆直截痛快，而不至于伏匿，人咸知之。若由胸膈而外出肌肤，其清者或从汗出，其浊者无可出矣，必
还返于胸膈，由胸膈还返于胃，乃可入肠而下出。驱之，必有伏匿肌肤而不胜驱者。若由胸膈而深藏于背，背
为胸之腑，更无出路，尤必还返胸膈，始得趋胃趋肠而顺下。岂但驱之不胜驱，且有挟背间之狂阳壮火，发为
痈毒，结如橘囊者，伏饮之艰于下出，易于酿祸，其谁能辨之？谁能出之耶？○《内经》但曰∶留者攻之耳。
仲景于是析义以尽其变∶无形之气，热结于胃，则用调胃承气攻之；热结于肠，则用大、小承气攻之；有形之
饮，痞结于胸，则用陷胸汤攻之；痞结于胁，则用十枣汤攻之；留结于肠胃之间，则用甘遂半夏汤攻之。（喻嘉言）
痰饮之本，皆水也。水入于胃，游溢精气，上输于脾，此自阳入阴也。脾气散精，上归于肺，此地气上升
也。通调水道，下
输膀胱，是天气下降也。水精四布，五经并行，是水入于经而血乃行也。若阴阳不和，清浊相干，胃气乱于中，
脾气难于升，肺气滞于降，而痰饮作矣。除痰者，降气清火治其标，补阴利水治其本。涤饮者，降气燥湿治其
标，温肾利水治其本。（柯韵伯）
脉候
肝脉软而散，色泽者，当病溢饮。（《素问》）
肺饮不弦，但苦喘短气。○支饮，亦喘不能卧，加短气，其脉平也。○脉浮而细滑，伤饮。○脉沉者有留饮。
○咳者，其脉弦，为有水。○脉偏弦者，饮也。○脉弦数，有寒饮，冬夏难治。○脉沉而弦者，悬饮内痛。○久
咳，数岁不已，其脉弱者可治，实大数者死。其脉虚者必苦冒，其人本有支饮在胸中故也。（《金匮》）
按∶脉弦数之"数"字，当是"迟"字，始与寒饮理合，当改之。（《医宗金鉴》）
选案
微患饮癖三十年。始因夜坐写文，左向伏几，是以饮食多坠左边，夜饮又向左卧，壮时不觉，三五年后，
觉酒止从左下有声，胁痛食减 杂，每十余日，必呕酸水数升，暑月止右边有汗，左边绝无。遍访名医，间或
中病，月余复作。自揣必有 囊，如水之有科臼，不盈科不行。但清者可行，浊者停滞，无路决之，故积至五
七日，必呕而出。脾土恶湿而水则流湿，莫若燥脾以去湿，崇土以填科臼，乃制苍术丸，服三月而疾除。
（许叔微）
【经典论述】
岁运土气太过，会导致饮邪发作，出现中焦胀满、食欲减退。○土气郁结而发时，表现为饮邪发作和腹泻。○当太阳主司天时，湿气改变万物，导致水饮内停蓄积，中焦胀满而不思饮食。○太阴主在泉时，百姓易患饮邪积聚之病。○太阴之气偏胜时，饮邪发于中焦。○太阴之气所至之时，表现为积饮、痞塞阻隔。○少阴主司天时的第四个节气阶段，百姓易患饮邪发作。○各种疾病中的水液分泌物，如果清澈寒冷，都属于寒证。（出自《素问》）
【哲人言论】
问：饮邪分为四种，具体指什么？答师曰：有痰饮、悬饮、溢饮、支饮这四种。○问：这四种饮邪有何区别？答师曰：
病人平时身体壮盛现在却消瘦，水流在肠间流动，发出沥沥的声音，称为痰饮。○饮水后，水流停留在胁下，咳嗽吐唾沫时牵引疼痛，称为悬饮。○饮水后水液流行，归于四肢，应当出汗却不出汗，身体疼痛，称为溢饮。○咳嗽气逆，倚靠呼吸，气短不能平卧，身形浮肿，称为支饮。○心下有留滞的饮邪，病人的背部有一块手掌大小的地方感觉寒冷。○留饮病，胁下疼痛并牵引至缺盆穴，咳嗽时症状加重。○胸中有留滞的饮邪，病人气短且口渴，四肢关节游走性疼痛。○膈上有痰病，胸闷气喘咳嗽吐痰，发作时伴有寒热，背痛腰疼，眼泪自出，病人身体震颤剧烈，必定是有潜伏的饮邪。○病人饮水过多，必然突然发生喘促胀满，凡是吃得少喝得多，水停在心下，严重的会出现心悸，轻微的会气短。○水邪在心，心下坚硬筑筑跳动，气短，厌恶喝水不想饮；水邪在肺，吐出涎沫，想喝水；水邪在脾，气少身体沉重；水邪在肝，胁下支撑胀满，打喷嚏时疼痛；水邪在肾，心下悸动。（出自《金匮要略》）
按语：痰饮病中，痰是食物消化后的病理产物，而饮是食物未能消化的病理产物。饮食进入胃中，如果胃中阳气旺盛、气机充足，那么饮食就会转化为正气和正血，灌溉滋养脏腑，疏通营卫，哪里会有痰饮呢？产生痰饮的原因，是胃阳不足以腐熟消化，脾气不足以旋转运化，于是痰饮形成了。痰就是食物，进入胃中如果胃冷不足以消化它，就化为痰；饮就是水，进入胃中如果脾湿不足以输布它，就停留成为饮。这两者虽然常常相伴存在，但实际成因各异。都应当归责于脾胃虚寒，使得有用的饮食变成了有害的痰饮。《内经》只谈饮而不谈痰，谈痰是从张仲景开始的，《伤寒论》中已有痰病的说法，又在《金匮要略》中将痰饮合而论之。仔细考证其文义，终究以饮为主，而以痰为附带论述。可见痰即食物，虽然是病邪但不必彻底清除，只要能腐熟水谷，对于痰不必专门治疗而自然会减少；饮是水邪，有留滞潜伏则最难驱逐，必须分明辨证，对于水邪必须有专门的治疗才能安宁。在这两种疾病的合论中，又应该存有分辨清晰的见解，不容混淆它们的含义。（魏荔彤）
饮，是蓄水的名目，从外部侵入；痰，是肠胃的津液，从内部产生。起初各自不同，后来殊途同归，所以积饮不散，也能变成痰，这是饮是痰的渐进，痰是饮的转化。如果向外排出，则饮的形状清稀，痰的形状稠浊，又不相同了。（《证治汇补》）
水气上逆则呕吐，停滞在膈间则痞塞，上犯头部则眩晕，凌迫心脏则心悸。（汪昂）
痰饮总括为一个证候，但成因有两种：痰因于火，只有热没有寒；饮因于湿，有热也有寒，这就是说有温泉却没有寒火的道理。
○痰饮，是水走肠间，沥沥有声；悬饮，是水在胁下，咳嗽牵引疼痛；溢饮，是水流行于四肢，无汗而身体沉重；支饮，是咳逆倚息气短，身形如肿。一种是由胃向下流入肠，一种是由胃向旁流入胁，一种是由胃向外出于四肢，一种是由胃向上入于胸膈。开始并不觉得，日积月累，水的精华转为混浊，于是遂成痰饮。必定先团聚在呼吸大气难以到达的地方，所以由肠到胁到四肢，逐渐浸渍于胸膈，其势越来越逆乱。痰饮的祸患，没有不从胃发起的。○水蓄积聚集的区域，都叫留饮。留，是停留不去的意思。留饮去除不干净的，都叫伏饮。伏，是潜伏不出来的意思。（喻嘉言）
【补编】
患痰饮病的人，应当用温药调和治疗。○心下有痰饮，胸胁支撑胀满，头晕目眩，用苓桂术甘汤主治。○气短有轻微饮邪，应当从小便排除，用苓桂术甘汤主治，肾气丸也主治。○病人脉象沉伏，其人想要自利（腹泻），泻后反而爽快，虽然腹泻，心下继续坚硬胀满，这是因为留饮想要排出的缘故，用甘遂半夏汤主治。○患悬饮病的，用十枣汤主治。○患溢饮病的，应当发汗，用大青龙汤主治，小青龙汤也主治。○膈间的支饮，病人喘满，心下痞硬坚实，面色黑，脉象沉紧，得病几十天了，医生用吐法和下法治疗未愈，用木防己汤主治。体质虚弱的就会痊愈，体质实的三天后复发，再次用药无效者，宜用木防己汤去石膏加茯苓芒硝汤主治。○心下有支饮，病人苦于头昏目眩，用泽泻汤主治。○支饮胸满的，用厚朴大黄汤主治。○支饮呼吸困难，用葶苈大枣泻肺汤主治。○呕吐的病人本来应该口渴，口渴的是将要解除了，现在反而不渴，是因为心下有支饮的缘故，用小半夏汤主治。○腹部胀满，口舌干燥，这是肠间有水气，用己椒苈黄丸主治。○突然呕吐，心下痞塞，膈间有水，眩晕心悸的，用半夏加茯苓汤主治。○假如瘦人脐下有悸动感，吐涎沫且头顶眩晕，这是水邪，用五苓散主治。○《外台秘要》的茯苓饮治疗水邪，胸中有停痰宿水，自己吐出清水后，心胸间空虚，气满不能进食，此方能消痰气使其能进食。○咳逆倚息不能平卧，用小青龙汤主治。○先口渴后呕吐，是水停心下，这属于饮家，用小半夏茯苓汤主治。（出自《金匮要略》）
按语：“此为留饮欲去故也”这句话，应当在“利反快”之下，一定是传抄的错误。○按语：“支饮胸满”的“胸”字，应当是“腹”字，如果是“胸”字，就没有使用承气汤的道理，应当改正。○按语：“瘦人”的“瘦”字，应当是“病”字。“颠眩”的“颠”字，应当是“巅”字，巅是指头。文义才通顺，应当改正。（出自《医宗金鉴》）
《金匮要略》说：患痰饮病的人，应当用温药调和治疗。按语：痰生于胃寒，饮生于脾湿。温药，是既能补胃阳又能燥脾土，兼擅其长的方剂。说“和之”，就不是专门从事温补。即使有行气消导的药物，也是概括在温药的义理之中，这才叫“和之”，而不能称之为“补之”、“益之”。大概痰饮之邪，因虚而成，而痰也是实物，必须稍有开导，总离不开“温药和之”这四个字，其中的法度已经完备了。说要用攻下法固然不对，专门说用温补法，也不懂“和之”二字的道理。仲景的话，一字千金，不可更改。（魏荔彤）
《内经》有积饮的说法，没有痰饮的名称。两汉以前，称为淡饮。张仲景才开始区分痰饮、悬饮、溢饮、支饮的含义，创立大小青龙汤、半夏类方、苓桂术甘汤、肾气丸等汤剂，以及内饮外饮等各种治法，独超千古。总之痰饮的产生，必定是由于元气亏乏及阴盛阳衰而起，导致津液凝滞，不能输布，留于胸中。水之清的，全部变为浊，水积在阴则为饮，饮凝滞在阳则为痰。如果真的元真充足，胃强脾健，那么饮食不失其度，运行不停其机，哪里有痰饮呢？所以仲景说：“患痰饮病的人，应当用温药调和治疗。”后人不懂痰饮的意义，妄用消痰破气、滋腻填补的药物，大伤脾胃，堆砌助长浊邪，这与仲景治疗痰饮的方法，岂不是大相径庭吗？然而痰与饮虽为同类，实则阴阳有别。阳盛阴虚，则水气凝结而为痰；阴盛阳虚，则水气溢出而为饮。然而病变不同，治法各异。如脾、肾阳虚，膀胱气化不通的，取用苓桂术甘汤、茯苓饮、肾气丸、真武汤等法，以理阳、通阳及固下益肾、转旋运脾为主。如外寒引动，宿饮上逆，及膀胱气化不通，饮逆肺气不降的，用小青龙汤合越婢汤等法，以开通太阳膀胱经为主。如饮邪伏于经络，及中虚湿伏成痰的，则有川乌、蜀漆的温经通络，《外台》茯苓饮去甘草，少佐苦辛淡渗以理湿。其饮邪上冲膻中，及悬饮流入胃中而为病的，又有姜、附、南星、菖蒲、旋复花、川椒等，驱饮开浊，辛通阳气。（出自《临证指南医案》）
痰饮或留或伏，用法来治疗它。由胃向上到胸膈心肺部位的，驱除所留的饮邪还归于胃，向下从肠排出，或向上从呕吐出，其排出都是直截痛快，不至于伏匿，人们都知道。若由胸膈向外达肌肤，其中清的或许从汗出，其中浊的无处可出，必定还要返回胸膈，由胸膈返回胃，然后才能入肠而下出。驱除它，必定有伏匿在肌肤而无法被驱除的。若由胸膈深藏于背部，背为胸之腑，更没有出路，尤其必须返回胸膈，才能趋向胃趋向肠而顺下。岂只是驱除不胜驱除，而且有挟带背部间的狂阳壮火，发为痈毒，结聚如橘囊的，伏饮难于下出，易于酿成祸患，谁能辨别呢？谁能将其排出呢？○《内经》只说：“留者攻之”。仲景于是分析义理以穷尽其变化：无形之气，热结于胃，则用调胃承气汤攻之；热结于肠，则用大、小承气汤攻之；有形的饮邪，痞结于胸，则用陷胸汤攻之；痞结于胁，则用十枣汤攻之；留结于肠胃之间，则用甘遂半夏汤攻之。（喻嘉言）
痰饮的根本，都是水。水进入胃中，游溢精气，向上输送给脾，这是自阳入阴。脾气散布精微，向上归于肺，这是地气上升。通调水道，向下输送给膀胱，这是天气下降。水精四布，五经并行，是水进入经脉而血乃运行。如果阴阳不和，清浊相干扰，胃气乱于中，脾气难于升，肺气滞于降，于是痰饮产生了。除痰，是降气清火治其标，补阴利水治其本。涤饮，是降气燥湿治其标，温肾利水治其本。（柯韵伯）
【脉候】
肝脉软而散，色泽好的，应当患溢饮病。（出自《素问》）
肺饮脉不弦，只是苦于喘促气短。○支饮，也喘不能卧，加上气短，其脉象平和。○脉浮而细滑，是伤于饮邪。○脉沉的有留饮。○咳嗽的，其脉弦，是有水邪。○脉偏弦的，是饮邪。○脉弦数，有寒饮，冬夏难治。○脉沉而弦的，是悬饮内痛。○久咳，数年不好，其脉弱者可治，实大数的预后不良。其脉虚的必定苦于头昏，其人本来胸中有支饮的缘故。（出自《金匮要略》）
按语：脉弦数的“数”字，应当是“迟”字，才与寒饮的道理相合，应当改正。（出自《医宗金鉴》）
【选案】
轻微患有饮癖病三十年。开始因为夜晚坐着写文章，向左伏在几案上，因此饮食多坠向左边，夜间饮酒又向左卧，年轻时不觉察，三五年后，觉得酒止从左下有声，胁痛食减杂症，每十余日，必呕酸水数升，暑天只有右边有汗，左边绝无。遍访名医，偶尔中病，月余又发作。自己揣测必定有囊袋，如水之有坑洼，不填满坑洼就不流动。但清的可行，浊的停滞，无路决堤，所以积至五七日，必呕出。脾土恶湿而水则流湿，不如燥脾以去湿，崇土以填坑洼，于是制成苍术丸，服用三月而疾病消除。
（许叔微）
[Classical Discourse]
When the annual earth qi is excessive, fluid retention (Yin) may manifest with middle jiao fullness and reduced appetite. ○ When earth qi is stagnant and erupts, it presents as fluid retention and diarrhea. ○ When Taiyang governs the year, dampness alters things, causing water and fluids to accumulate internally, leading to middle jiao fullness and anorexia. ○ When Taiyin governs the lower region, the people suffer from fluid accumulation diseases. ○ When Taiyin qi prevails, fluid retention arises in the middle. ○ When Taiyin qi arrives, it manifests as accumulated fluid retention, epigastric distension, and obstruction. ○ During the fourth qi period when Shaoyin governs the year, the people suffer from fluid retention. ○ All pathological fluids that are clear, cold, and thin belong to Cold patterns. (From *Suwen*)
[Philosophical Discourses]
Question: There are four types of fluid retention; 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 these four types differ? Master said:
If a person was formerly robust but is now emaciated, and water flows between the intestines making a gurgling sound, this is called Tan Yin. ○ After drinking water, if the fluid stays in the hypochondrium and coughing or spitting causes pulling pain, this is called Xuan Yin. ○ If drinking water leads to fluid flowing into the four limbs, sweating should occur but does not, accompanied by body pain, this is called Yi Yin. ○ If there is coughing with air reversal, leaning on something to breathe, shortness of breath, inability to lie flat, and swelling-like appearance, this is called Zhi Yin. ○ If there is retained fluid under the heart, the patient feels cold on the back in an area the size of a palm. ○ In cases of retained fluid, there is pain in the hypochondrium radiating to the Clavicular Fossa (Qie Ren acupoint), worsening with coughing. ○ If there is retained fluid in the chest, the patient suffers from shortness of breath and thirst, with wandering joint pain in the four limbs. ○ If phlegm disease exists above the diaphragm, presenting with fullness, wheezing, coughing, and expectoration, accompanied by chills and fever upon onset, backache, lumbago, spontaneous tearing, and severe tremors of the body, there must be latent fluid retention. ○ If a patient drinks excessively, sudden wheezing and fullness will occur. Generally, if food intake is low but fluid intake is high, water stops under the heart; severely, palpitations occur; mildly, shortness of breath occurs. ○ Water in the Heart causes hardness and pounding under the heart, shortness of breath, aversion to water and unwillingness to drink; Water in the Lung causes expectoration of saliva and foam, desire to drink; Water in the Spleen causes Qi deficiency and heavy body; Water in the Liver causes hypochondriac distension and pain upon sneezing; Water in the Kidney causes palpitations under the heart. (From *Jingui Yaolue*)
Commentary: In Phlegm-Fluid diseases, Tan (Phlegm) is a pathological product of digested food, whereas Yin (Fluid) is a pathological product of undigested food. When food enters the Stomach, if Stomach Yang is vigorous and Qi is sufficient, the food transforms into righteous Qi and Blood, nourishing the Zang-Fu organs and circulating Ying and Wei. How could Tan Yin arise? Tan Yin arises because Stomach Yang is insufficient for rotting and digesting, and Spleen Qi is insufficient for rotation and transportation. Tan is essentially food; if it enters the Stomach and the Stomach is too cold to digest it, it transforms into Tan. Yin is essentially water; if it enters the Stomach and Spleen Dampness prevents its distribution, it remains as Yin. Although these two often coexist, their actual causes differ. Both should be attributed to Deficiency-Cold of the Spleen and Stomach, turning beneficial food into harmful Tan Yin. The *Neijing* discusses Yin but not Tan; discussion of Tan began with Zhang Zhongjing. Tan disease concepts appeared in *Shanghan Lun*, and later Tan and Yin were discussed together in *Jingui Yaolue*. Careful examination reveals that Yin is primary, while Tan is secondary. Thus, Tan is food; although pathogenic, it need not be eradicated completely. If digestion of grains is restored, Tan will decrease without specific treatment. Yin is Water Evil; if retained and latent, it is hardest to expel. Distinct differentiation is required, and specific treatment for Water is necessary for peace. In discussing these two diseases together, one must maintain clear distinctions and not confuse their meanings. (Wei Litong)
Yin refers to accumulated water entering from outside; Tan refers to fluids of the intestines and stomach generated from within. Initially distinct, they eventually converge. Thus, accumulated Yin that does not dissipate can transform into Tan; Yin is the gradual stage of Tan, and Tan is the transformation of Yin. If expelled externally, Yin appears clear and thin, while Tan appears thick and turbid, which is different. (*Zhengzhi Huibu*)
Water Qi reversing upward causes vomiting; stopping in the diaphragm causes epigastric fullness; affecting the head causes dizziness; harassing the Heart causes palpitations. (Wang Ang)
Tan Yin is generally one syndrome, but has two causes: Tan is caused by Fire, having Heat but no Cold; Yin is caused by Dampness, having both Heat and Cold. This explains why there are hot springs but no cold fires.
○ Tan Yin: water flows in intestines with gurgling sounds; Xuan Yin: water in hypochondrium with coughing and pulling pain; Yi Yin: water flows in four limbs, no sweat, heavy body; Zhi Yin: coughing, air reversal, shortness of breath, swelling-like form. One flows downward from Stomach to Intestines; one flows sideways from Stomach to Hypochondrium; one flows outward from Stomach to Four Limbs; one flows upward from Stomach to Chest and Diaphragm. Initially unnoticed, day by day and month by month, the essence of water turns turbid, forming Tan Yin. It first gathers where respiratory Qi cannot reach easily. Thus, from Intestines to Hypochondrium to Limbs, gradually infiltrating the Chest and Diaphragm, the condition becomes more rebellious. The trouble of Tan Yin always originates from the Stomach. ○ Areas where water accumulates are all called Retained Fluid (Liu Yin). "Retained" means staying and not leaving. Retained fluid that is not fully eliminated is called Latent Fluid (Fu Yin). "Latent" means hiding and not emerging. (Yu Jiayan)
[Supplement]
Patients with Tan Yin should be treated with Warm Medicines to harmonize. ○ If there is Tan Yin under the heart, with hypochondriac distension and dizziness, Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractodes, and Licorice Decoction) is indicated. ○ For shortness of breath due to mild fluid retention, promote urination; Ling Gui Zhu Gan Tang is indicated, and Shen Qi Wan (Kidney Qi Pill) is also indicated. ○ If the patient's pulse is deep and hidden, desiring diarrhea, which brings relief, yet epigastric hardness/fullness persists despite diarrhea, this indicates Retained Fluid attempting to exit; Gan Sui Ban Xia Tang (Kansui and Pinellia Decoction) is indicated. ○ For Xuan Yin, Shi Zao Tang (Ten Jujube Decoction) is indicated. ○ For Yi Yin, induce sweating; Da Qing Long Tang (Major Green Dragon Decoction) is indicated, and Xiao Qing Long Tang (Minor Green Dragon Decoction) is also indicated. ○ For Zhi Yin in the diaphragm, presenting with wheezing and fullness, hard epigastric fullness, dark complexion, and deep-tight pulse, lasting dozens of days, unresponsive to emetic and purgative treatments, Mu Fang Ji Tang (Stephania Decoction) is indicated. If the constitution is deficient, recovery occurs; if solid, recurrence happens in three days; if subsequent treatment fails, Mu Fang Ji Tang minus Shigao (Gypsum) plus Fuling (Poria) and Mangxiao (Mirabilite) is indicated. ○ For Zhi Yin under the heart causing severe dizziness, Ze Xie Tang (Alisma Decoction) is indicated. ○ For Zhi Yin with chest fullness, Hou Po Da Huang Tang (Magnolia Bark and Rhubarb Decoction) is indicated. ○ For Zhi Yin causing breathing difficulty, Ting Li Da Zao Xie Fei Tang (Descurainia Seed and Jujube Decoction to Drain the Lung) is indicated. ○ Vomiting patients usually feel thirsty; thirst indicates resolution. If currently not thirsty, it is due to Zhi Yin under the heart; Xiao Ban Xia Tang (Minor Pinellia Decoction) is indicated. ○ Abdominal fullness with dry mouth and tongue indicates water Qi in the intestines; Ji Jiao Li Huang Wan (Areca Seed, Descurainia, and Rhubarb Pill) is indicated. ○ Sudden vomiting with epigastric fullness, water in the diaphragm, dizziness, and palpitations; Ban Xia Jia Fu Ling Tang (Pinellia with Added Poria Decoction) is indicated. ○ If a thin person has palpitations below the umbilicus, expectorates saliva/foam, and experiences vertigo, this is Water; Wu Ling San (Five-Ingredient Powder with Poria) is indicated. ○ *Waitai Mi Yao*'s Fuling Yin (Poria Drink) treats water, phlegm, and old fluid in the chest. After self-vomiting clear fluid, if the chest feels empty, Qi is full, and appetite is lost, this formula eliminates phlegm-Qi to restore appetite. ○ For coughing, air reversal, and inability to lie flat, Xiao Qing Long Tang is indicated. ○ Thirst followed by vomiting indicates water stopping under the heart; this belongs to Fluid Disease families; Xiao Ban Xia Fu Ling Tang (Minor Pinellia and Poria Decoction) is indicated. (From *Jingui Yaolue*)
Commentary: The phrase "this is because Retained Fluid attempts to exit" should follow "diarrhea brings relief"; it is likely a transcription error. ○ Commentary: The character "Chest" (Xiong) in "Zhi Yin Chest Fullness" should be "Abdomen" (Fu); if it were "Chest," using Chengqi Decoctions would be illogical; it should be corrected. ○ Commentary: The character "Thin" (Shou) in "Thin Person" should be "Sick" (Bing). The character "Dian" (颠) in "Dian Xuan" should be "Dian" (巅), meaning head. The text makes sense only after correction. (From *Yizong Jinjian*)
*Jingui Yaolue* states: Patients with Tan Yin should be treated with Warm Medicines to harmonize. Commentary: Tan arises from Stomach Cold; Yin arises from Spleen Dampness. Warm medicines are formulas that supplement Stomach Yang and dry Spleen Earth, excelling in both. "Harmonizing" implies not solely focusing on warming and tonifying. Even if there are moving and resolving agents, they fall under the principle of Warm Medicines. This is "harmonizing," not merely "tonifying" or "benefiting." Since Tan Yin pathogens arise from deficiency, and Tan is a tangible substance, slight guidance is needed. The method lies entirely within "Warm Medicines to Harmonize." Advocating purgation is incorrect; advocating only warming and tonifying misunderstands "harmonizing." Zhongjing's words are precious; they cannot be changed. (Wei Litong)
*Neijing* mentions Accumulated Fluid but not the name Tan Yin. Before the Han dynasties, it was called Dan Yin. Zhang Zhongjing first distinguished the meanings of Tan Yin, Xuan Yin, Yi Yin, and Zhi Yin, establishing formulas like Da/Xiao Qing Long Tang, Ban Xia variations, Ling Gui Zhu Gan Tang, and Shen Qi Wan, along with methods for internal and external fluid retention, surpassing antiquity. In summary, Tan Yin arises from Yuan Qi deficiency and Yin excess/Yang decline, causing Jin Ye (Body Fluids) to stagnate and fail to distribute, remaining in the chest. Clear water turns turbid; water accumulating in Yin becomes Yin; Yin condensing in Yang becomes Tan. If Yuan Qi is sufficient, Stomach strong, and Spleen healthy, diet is regulated, and movement is continuous; how could Tan Yin exist? Hence Zhongjing said: "Patients with Tan Yin should be treated with Warm Medicines to harmonize." Later generations, misunderstanding Tan Yin, recklessly used phlegm-resolving and Qi-breaking drugs, or cloying tonics, damaging Spleen and Stomach and aiding turbidity, greatly deviating from Zhongjing's methods. However, although Tan and Yin are similar, they have Yin-Yang differences. Yang excess and Yin deficiency cause Water Qi to condense into Tan; Yin excess and Yang deficiency cause Water Qi to overflow into Yin. Pathologies differ, so treatments vary. For Spleen/Kidney Yang deficiency and Bladder Qi transformation failure, use Ling Gui Zhu Gan Tang, Fuling Yin, Shen Qi Wan, or Zhen Wu Tang to regulate, unblock, and tonify Lower Jiao/Spleen. For external Cold triggering old Yin reversal and Bladder Qi failure with Yin rebelling against Lung Qi descending, use Xiao Qing Long Tang combined with Yue Bi Tang to open Taiyang/Bladder. For Yin lurking in collaterals or Middle Deficiency with Dampness transforming into Tan, use Chuan Wu (Aconite) and Shu Qi (Escallonia) for warming collaterals, or *Waitai* Fuling Yin minus Gancao with bitter/acrid/diuretic herbs for Dampness. For Yin rushing to Danzhong or Xuan Yin flowing into Stomach, use Ginger, Aconite, Nanxing (Arisaema), Changpu (Acorus), Xuanshu (Inula), Chuanjiao (Sichuan Pepper) to drive out Yin, open turbidity, and unblock Yang with Acrid warmth. (From *Linzheng Zhinan Yitan*)
Tan Yin, whether retained or latent, is treated accordingly. If located from Stomach up to Chest/Diaphragm/Lung/Heart, drive the retained Yin back to Stomach, exiting down via Intestines or up via vomiting. These exits are direct and effective, avoiding latency, which everyone knows. If moving from Chest/Diaphragm outward to Skin/Muscle, the clear part may exit via sweat, but the turbid part has no exit, must return to Chest/Diaphragm, then to Stomach, then to Intestines to exit down. Driving it out may fail against those latent in skin/muscle. If hiding deeply in the Back (the Fu organ of the Chest), there is no exit; it must return to Chest/Diaphragm to move toward Stomach/Intestines downwards. Not only is driving difficult, but it may carry fierce Yang/Fire from the Back, causing abscesses/toxins nodulating like orange sacs. Latent Yin is hard to discharge downward and prone to disaster; who can distinguish it? Who can expel it? ○ *Neijing* only says: "Retain, attack it." Zhongjing analyzed meanings to exhaust variations: Formless Qi, Heat binding in Stomach, use Tiao Wei Cheng Qi Tang to attack; Heat binding in Intestines, use Da/Xiao Cheng Qi Tang to attack; Tangible Yin, Epistaxis binding in Chest, use Xian Xiong Tang to attack; Epistaxis binding in Hypochondrium, use Shi Zao Tang to attack; Retention binding between Intestines/Stomach, use Gan Sui Ban Xia Tang to attack. (Yu Jiayan)
The root of Tan Yin is Water. Water enters Stomach, overflows with essence, transports upward to Spleen; this is Yang entering Yin. Spleen Qi scatters essence, returns upward to Lung; this is Earth Qi ascending. Unblocking Water pathways, transporting downward to Bladder; this is Heaven Qi descending. Water essence distributes four ways, Five Meridians run together; water enters meridians, Blood flows. If Yin-Yang disharmony, Clear/Turbid interfere, Stomach Qi chaos in Middle, Spleen Qi hard to ascend, Lung Qi滞 in descending, then Tan Yin forms. Removing Tan: Descend Qi, Clear Fire to treat Branch; Tonify Yin, Promote Urination to treat Root. Purging Yin: Descend Qi, Dry Dampness to treat Branch; Warm Kidney, Promote Urination to treat Root. (Ke Yunbo)
[Pulse Diagnosis]
Liver Pulse soft and scattered, with lustrous color, indicates Yi Yin disease. (From *Suwen*)
Lung Yin pulse is not wiry, but suffers from wheezing and shortness of breath. ○ Zhi Yin also wheezes, cannot lie flat, adds shortness of breath, pulse is normal. ○ Pulse floating, fine, and slippery indicates injury by Fluid. ○ Pulse deep indicates Retained Fluid. ○ Coughing with wiry pulse indicates Water. ○ Wiry pulse on one side indicates Fluid. ○ Wiry-rapid pulse indicates Cold Fluid, difficult to treat in Winter/Summer. ○ Deep-wiry pulse indicates Xuan Yin internal pain. ○ Chronic cough for years, weak pulse is treatable, Excess-Large-Rapid pulse indicates death. Weak pulse causes severe dizziness; originally due to Zhi Yin in Chest. (From *Jingui Yaolue*)
Commentary: The character "Rapid" (Shu) in "Wiry-Rapid Pulse" should be "Slow" (Chi) to align with Cold Fluid theory; correct it. (From *Yizong Jinjian*)
[Selected Cases]
Mildly suffered from Yin Pi (Fluid Mass) for thirty years. Initially, because sitting at night writing, leaning left on desk, food mostly fell to the left side; night drinking also sleeping on left. Young, did not notice. Three to five years later, felt wine stop with sound from lower left, hypochondriac pain, reduced appetite mixed with other symptoms. Every ten-plus days, vomited several sheng of sour water. Summer months, only right side sweated, left side absolutely no sweat. Visited many famous doctors, occasionally hit the mark, relapsed after a month. Self-reflection: must have a sac/pouch, like water needing basins; does not flow unless basin is filled. Clear parts flow, turbid parts stagnate, no outlet to drain, so accumulating 5-7 days, must vomit out. Spleen Earth dislikes Dampness, Water flows Dampness. Better to Dry Spleen to remove Dampness, Build Earth to fill basins. Thus made Cang Zhu Wan (Atractodes Pill), taken for three months, disease eliminated.
(Hu Shumi)