〔衍义〕风火之动。散乱其阳。则阳虚。湿饮者。亦如伤寒之义。虽然。阳虚风火所致。
然必各治其所主。寒者治寒。湿者治湿。察三者之轻重。以药佐之。此乃支饮之
在心者。阻其阳之升降。郁而不行。上不充于头目。久则化火。火动风生而作眩晕
。故苦冒眩也。利小便以泄去支饮。和其中焦。则阳自升而风火自息矣。泽泻
能开胃关。去伏水。泄支饮。从小便出之。佐以白术和中益气。燥湿息风。药不在品味之多。惟要中病耳。
支饮胸满者。浓朴大黄汤主之。
浓朴大黄汤方
浓朴（一尺） 大黄（六两） 枳实（四枚）
上三味。以水五升。煮取二升。分温再服。
〔衍义〕凡仲景方。多一味。减一药。与分两之更重轻。则易其名。异其治。有如转丸
者。若此三味加芒硝。则谓之大承气。治内热腹实满之甚。无芒硝。则谓之小承
气。治内热之微甚。浓朴多。则谓之浓朴三物汤。治热痛而闭。今三味以大黄多。
名浓朴大黄汤。上三汤皆治实热而用之。此支饮胸满。何亦以是治之。倘胸满
之外。复有热蓄之病。变迁不一。在上在下。通宜利之耶。胸满者下之。然此水饮
也。不有热证。况胸满未为心下实坚。且胸中痞硬。脉浮。气上冲咽喉者。则半表
半里和解之。至有医误下。为心下硬痛。名结胸者。以大陷胸汤下之。不甚痛。犹
不可下。以小陷胸利之。今支饮之胸满。遽用治中焦实热之重剂乎。是必有说。姑阙之。
支饮不得息。葶苈大枣泻肺汤主之。（方见肺痈中）
〔衍义〕支饮留结。气塞胸中。故不得息。葶苈能治结利饮。大枣通肺气补中。此虽
与肺痈异。而方相通者。盖支饮之与气。未尝相离。支饮以津液所聚。气行则液
行。气停则液聚而气亦结。气阳也。结亦化热。所以与肺痈热结者同治。
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。
小半夏汤方
半夏（一升） 生姜（半斤）
上二味。以水七升。煮取一升半。分温再服。
〔衍义〕呕家为有痰饮动中而欲出也。饮去尽而欲解矣。反不渴。是积饮所留。由
气不畅。结聚津液而成耳。半夏之味辛。其性燥。辛可散结。燥可胜湿。用生姜以
制其悍。孙真人云生姜呕家之圣药。呕为气逆不散。故用生姜以散之。
腹满。口舌干燥。此肠间有水气。己椒苈黄丸主之。
己椒苈黄丸方
防己 椒目 葶苈（熬） 大黄（各一两）
上四味。末之。蜜丸如梧子大。先食饮服一丸。日三服。稍增。口中有津液。渴者。加芒硝半两。
〔衍义〕肺与大肠合为表里。肺本通调水道。下输膀胱。今不输膀胱。仅从其合。积
于肠间。水积则金气不宣。 郁成热为腹满。津液遂不上行。以成口燥舌干。用
防己、椒目、葶苈。皆能利水行积聚结气。而葶苈尤能利小肠。然肠胃受水谷之
气。若邪实腹满者。非轻剂所能治。必加芒硝以泻之。
卒呕吐。心下痞。膈间有水。眩悸者。半夏加茯苓汤主之。
小半夏加茯苓汤方
半夏（一升） 生姜（半斤） 茯苓（三两一法四两）
上三味。以水七升。煮取一升五合。分温再服。
〔衍义〕心下痞。膈间有水。眩悸者。阳气必不宣散也。经云以辛散之。半夏、生姜皆
味辛。本草。半夏可治膈上痰。心下坚呕逆者。眩亦上焦阳气虚。不能升发。所以
半夏、生姜并治之。悸则心受水凌。非半夏可独治。必加茯苓去水。下肾逆以安神。神安则悸愈也。
假令瘦人脐下有悸。吐涎沫而癫眩。此水也。五苓散主之。
五苓散方
泽泻（一两一分） 猪苓（三分去皮） 茯苓（五分） 白术（三分） 桂（二分去皮）
上五味为末。白饮服方寸匕。日三服。多饮暖水。汗出愈。
〔衍义〕人瘦有禀形。有因病瘦者。金土水形之人肥。火木形之人瘦。今云瘦人者。
必非病瘦。乃亲形也。朱丹溪云。肥人多虚。瘦人多热。盖肥人由气不充于形。故
虚多。瘦人由气实。故热多。肥人不耐热者。为热复伤气。瘦人不耐寒者。为寒复
伤形。各损其不足故也。巢氏病源。为邪入于阴则癫。瘦人火木之盛。为水邪抑
郁在阴。不得升发。鼓于脐下作悸。及至郁发。转入于阳。与正气相击。在头为眩。
在筋脉为癫。为神昏。肾液上逆。为涎沫吐出。故用五苓治之。茯苓味甘淡。渗泄
水饮内蓄。故为君。猪苓味甘平。用为臣。白术味甘温。脾恶湿。水饮内蓄。则脾气
不治。益脾胜湿。故为佐。泽泻味咸寒为阴。泄泻导溺。必以咸为助。故为使。桂枝辛热。肾恶燥。
水蓄不利。则肾气燥。以辛润之。故亦为使。多饮暖水。令汗出愈者。以辛散水气。外泄得汗而解也。
附方
外台茯苓饮 治心胸中有停痰宿水。自吐出水后。心胸间虚。气满而不能食。消痰气。令能食。
茯苓（三两） 人参（三两） 白术（三两） 枳实（二两） 橘皮（二两半） 生姜（三两）
上六味。以水六升。煮取一升八合。分温三服。如人行八九里进之。
〔衍义〕此由上中二焦气弱。水饮入胃。脾不能转归于肺。肺不能通调水道。以致
停积为痰为水。吐之则下气因而上逆。积于心胸。是谓虚。气满不能食。先当补
益中气。以人参白术下逆气。行停水。以茯苓逐积消气满。以枳实调诸气。开脾
胃。而宣扬推布。发散凝滞。赖陈皮、生姜为使也。
咳家。其脉弦。为有水。十枣汤主之。（方见上）
〔衍义〕脉经以弦为水气。为厥逆。为寒。为饮。风脉亦弦。若咳者。如水气。如厥逆。如寒。如风。皆能致咳。
欲于弦脉而分诸邪。不亦难乎。设或水邪之弦稍异。果何象乎。前条悬饮者沉弦。别论支饮者急弦。二者有沉急之不同。
而咳脉之弦。岂一字可尽。仲景尝论水蓄之脉曰沉潜。今谓为水。其弦将仿佛有沉潜之象乎。将有沉急之象乎。凡遇是
证是脉。必察色闻声。问所苦。灼然合脉之水象。然后用是方下之。独据脉。恐难凭也。
夫有支饮家。咳烦。胸中痛者。不卒死。至一百日。或一岁。宜十枣汤（方见上）
〔衍义〕心肺在上。主胸中。阳也。支饮乃水类属阴。今支饮上入于阳。动肺则咳。动
心则烦。搏击膈气则痛。若阳虚不禁其阴之所逼者。则荣卫绝而神亡。为之卒
死矣。不卒死犹延岁月。则其阳不甚虚。乃水入于肺。子乘于母所致也。
久咳数岁。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。治属饮家。
〔衍义〕三脉固为支饮之咳。然诸邪之病。皆不越此。内经曰。久病脉弱者生。实大
者死。又脉大则病进。盖弱脉邪气衰。实大邪气盛。久病者正气已虚。邪气亦衰。
虽重可治。若邪盛加之脉数。火复刑金。岂不死乎。其脉虚苦冒者。盖胸中乃发
越阳气之地。支饮停积。阻其阳气。不得升于上。又不得充于下与阴接。惟从支
饮浮泛眩乱。头清道。故苦冒也。治其饮。则阳气行而可愈矣。
咳逆倚息不得卧。小青龙汤主之。（方见上）
青龙汤下已。多唾口燥。寸脉沉。尺脉微。手足厥逆。气从小腹上冲胸咽。手足痹。其
面翕热如醉状。因复下流阴股。小便难。时复冒者。与茯苓桂枝五味甘草汤。治其
气冲。
桂苓五味甘草汤方
茯苓（四两） 桂枝（四两去皮） 甘草（三两炙） 五味子（半升）
上四味。以水八升。煮取三升。去滓。分温三服。
冲气即低。而反更咳。胸满者。用桂苓五味甘草汤去桂。加干姜、细辛以治其咳满。
苓甘五味姜辛汤方
茯苓（四两） 甘草（三两） 细辛（三两） 干姜（三两） 五味（半升）
上五味。以水八升。煮取三升。去滓。温服半升。日三服。
咳满即止。而更复渴。冲气复发者。以细辛、干姜为热药故也。服之当遂渴。而渴反
止者。为支饮也。支饮者。法当冒。冒者必呕。呕者复内半夏。以去其水。
苓甘五味姜辛半夏汤方
茯苓（四两） 甘草（二两） 细辛（二两） 干姜（二两） 五味（半升） 半夏（半升）
上六味。以水八升。煮取三升。去滓。温服半升。日三服。
水去呕止。其人形肿者。加杏仁主之。其证应内麻黄。以其人遂痹故不内之。若逆
而内之者必厥。所以然者。以其人血虚。麻黄发其阳故也。
苓甘五味加姜辛半夏杏仁汤方
茯苓（四两） 甘草（三两） 五味（半升） 干姜（三两）
细辛（三两） 半夏（半升） 杏仁（半升去皮尖）
上七味。以水七升。煮取三升。去滓。温服半升。日三服。
若面热如醉。此为胃热上冲熏其面。加大黄以利之。
苓甘五味加姜辛半杏大黄汤方
茯苓（四两） 甘草（三两） 五味（半升） 干姜（三两）
细辛（三两） 半夏（半升） 杏仁（半升） 大黄（三两）
上八味。以水一斗。煮取三升。去滓。温服半升。日三服。
〔衍义〕此首篇支饮之病也。以饮水。水性寒下。应于肾。肾气上逆入肺。肺为之不
利。肺主行荣卫。肺不利则荣卫受病。犹外感风寒。心中有水证也。故亦用小青
龙汤治。服后未已。为水停未散。故多唾。津液未行。故口燥。水在膈上。则阳气衰。
寸口脉沉。麻黄发阳。则阴血虚。故尺脉微。尺脉微则肾气不得固守于下。冲任
二脉相挟。从小腹冲逆而起矣。夫冲任二脉。与肾之大络。同起肾下。出胞中。主
血海。冲脉上行者至胸。下行者至足少阴。入阴股。下抵足 上。是动则厥逆。任
脉至咽喉。上颐循面。故气冲咽胸。荣卫之行涩。经络时疏不通。手足不仁而痹。
其面翕然如醉状。因复下流阴股。小便难。水在膈间。因火冲逆。阳气不得输上。
故时复冒也。内经曰。诸逆冲上。皆属于火。又曰。冲脉为病。气逆里急。故用桂苓
五味甘草汤。先治冲气与肾燥。桂味辛热。散水寒之逆。开腠理。致津液以润之。
茯苓、甘草行津液。渗蓄水。利小便。伐肾邪。为臣。甘草味甘温。补中土。制肾气之
逆。五味酸平以收肺气。内经曰。肺欲收。急食酸以收之。服此汤。冲气即止。因水
在膈不散。故再变。而更咳胸满。即用前方去桂加干姜、细辛。散其未消之水寒。
通行津液。服汤后咳满即止。三变而更复渴。冲气复发。以细辛、干姜乃热药。服
之当遂渴。反不渴。支饮之水。蓄积胸中故也。支饮在上。阻遏阳气。不布于头目。
故冒。且冲气更逆。必从火炎而呕也。仍用前汤加半夏。去水止呕。服后水去呕
止。四变水散行出表。表气不利。其人形肿。当用麻黄发汗散水。以其人遂痹。且
血虚。麻黄发其阳。逆而内之必厥。故不内。但加杏仁。杏仁微苦温。肾气上逆者。
得之则降下。在表卫气得之。则利于行。故肿可消也。服后五变。因胃有热。循脉
上冲于面。热如醉。加大黄以泄胃热。盖支饮证。其变始终不离小青龙之加减。足为万世法也。
先渴后呕。为水停心下。此属饮家。小半夏茯苓汤主之。（方见上）
〔补注〕云渴未有不饮水者。渴饮水。则渴为水解。而水亦为渴消矣。乃复作呕者
何哉为水不为渴消。而且不得下归于胃。下趋膀胱。致停于心下也。虽然。就下
性也。水又何以停。因上脘本有痰饮。阻抑上升之津。故先为渴。然后知先能为
上阻者。亦即后能下阻者也。心下去上未远。为清华之位。岂得容水少刻。势必
呕出。故仍以小半夏茯苓汤主之也。
【衍义】风邪与火邪的扰动，会散乱人体的阳气，从而导致阳虚。湿饮的病机，也如同伤寒病的道理一样。虽然如此，既然是阳虚由风火引起，但必须分别治疗其主导因素。寒证就治寒，湿证就治湿，观察这三者（风、火、湿/寒）的轻重程度，以药物辅助调理。这就是支饮留结在心部，阻碍了阳气的升降，导致气机郁滞而不能运行。上部不能充养头目，日久则化生火热，火热扰动而生风，从而引发眩晕。所以会出现头部昏沉眩冒的症状。通过利小便来泄去支饮，调和其中焦脾胃，那么阳气自然上升，风火自然平息。泽泻能够开通胃关，去除潜伏的水饮，泄除支饮，使其从小便排出。佐以白术来调和中焦、益气、燥湿息风。用药不在于味数众多，关键在于能切中病机。
浓朴大黄汤方
浓朴（一尺） 大黄（六两） 枳实（四枚）
以上三味药，用水五升，煮取二升，分两次温服。
【衍义】凡是张仲景的方剂，多一味或少一味，或者剂量轻重不同，就会改变名称，治疗方法也不同。例如转丸之类。像这三味药如果加上芒硝，就叫做大承气汤，治疗内热腹实胀满严重的病症；如果没有芒硝，就叫小承气汤，治疗内热轻重的病症；如果浓朴用量多，就叫浓朴三物汤，治疗热痛且便秘的病症。现在这三味药中大黄用量多，名叫浓朴大黄汤。上述三个方子都是治疗实热证的。这里支饮导致的胸满，为什么也用这个方子治疗呢？如果在胸满之外，还有热邪蓄积的病症，变化不一，无论在上在下，都适宜通利吗？胸满应当用下法。然而这是水饮之邪，如果没有热证，况且胸满还未达到心下坚硬的程度，如果出现胸中痞塞硬满、脉浮、气上冲咽喉等症状，则属于半表半里证，应当和解。如果有医生误用下法，导致心下硬痛，称为结胸，就用大陷胸汤攻下；疼痛不严重的，尚且不可用下法，而用小陷胸汤清热化痰开结。现在支饮的胸满，难道要突然使用治疗中焦实热的重剂吗？这一定有说法，暂时存疑。
对于支饮导致呼吸困难的，用葶苈大枣泻肺汤主治。（方剂见肺痈篇中）
【衍义】支饮留结，气机阻塞于胸中，所以呼吸困难。葶苈子能治疗结聚、利水饮，大枣能通肺气、补中气。这虽然与肺痈不同，但方剂原理相通。因为支饮与气机未曾分离，支饮是由津液聚集而成，气行则津液行，气停则津液聚而气亦结。气属阳，结聚也会化热，所以与肺痈的热结证采用相同的治疗方法。
呕吐的病人本来应该口渴，口渴说明病将要解除。现在反而不渴，是因为心下有支饮的缘故。用小半夏汤主治。
小半夏汤方
半夏（一升） 生姜（半斤）
以上两味药，用水七升，煮取一升半，分两次温服。
【衍义】呕吐病人是因为有痰饮动于中焦而欲排出。如果饮邪去尽，病就要解除了。反而不渴，是积留的饮邪所致，由于气机不畅，凝结津液而成。半夏味辛，性燥，辛能散结，燥能胜湿。用生姜来制约半夏的悍烈之气。孙思邈说生姜是治疗呕吐的圣药。呕吐是气逆不散，所以用生姜来发散它。
己椒苈黄丸方
防己 椒目 葶苈子（炒） 大黄（各一两）
以上四味药，研成细末，蜜炼为丸，如梧桐子大。饭前用温水送服一丸，每日三次，逐渐增加剂量。如果口中出现津液，说明有效；如果口渴，加芒硝半两。
【衍义】肺与大肠相表里。肺本应通调水道，向下输送到膀胱。现在不输注到膀胱，仅与其相合的大肠有关，积聚在肠间。水积则金气（肺气）不宣发，郁结成为热邪导致腹满，津液遂不能上行，形成口燥舌干。使用防己、椒目、葶苈子，都能利水、行积聚、结气，而葶苈子尤其能利小肠。然而肠胃受纳水谷之气，如果是邪实腹满，非轻剂所能治愈，必须加芒硝来泻下。
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。
小半夏加茯苓汤方
半夏（一升） 生姜（半斤） 茯苓（三两，一方为四两）
以上三味药，用水七升，煮取一升五合，分两次温服。
【衍义】心下痞塞，膈间有水，眩晕心悸，这是因为阳气必然不能宣散。《内经》说用辛味药发散。半夏、生姜都味辛。《本草》记载，半夏可治疗膈上痰、心下坚、呕吐逆气。眩晕也是上焦阳气虚，不能升发，所以半夏、生姜共同治疗。心悸则是心受到水的凌犯，不是半夏能单独治疗的，必须加茯苓去水，降肾逆以安神。神安则心悸痊愈。
假设瘦人脐下有悸动感，吐涎沫并发生癫眩，这是水饮作祟，用五苓散主治。
五苓散方
泽泻（一两一分） 猪苓（三分，去皮） 茯苓（五分） 白术（三分） 桂枝（二分，去皮）
以上五味药研成粉末，用米汤送服方寸匕，每日三次，多喝暖水，出汗后痊愈。
【衍义】人的消瘦有先天禀赋形成的，也有因病致瘦的。金、土、水形的人肥胖，火、木形的人消瘦。现在说瘦人，必定不是因病致瘦，而是先天形体。朱丹溪说：肥人多虚，瘦人多热。大概肥人是因为气不能充实于形体，所以虚多；瘦人是因为气实，所以热多。肥人不耐热，是因为热又伤气；瘦人不耐寒，是因为寒又伤形。各自损伤了其不足的部分。巢元方的《诸病源候论》认为，邪入于阴则发癫。瘦人火木之气旺盛，被水邪抑制郁结在阴分，不得升发，鼓动于脐下产生悸动。等到郁结发作，转入阳分，与正气相搏击，在头部则为眩晕，在筋脉则为癫疾，表现为神志昏迷。肾液上逆，吐出涎沫。所以用五苓散治疗。茯苓味甘淡，渗泄体内蓄积的水饮，所以作为君药。猪苓味甘平，作为臣药。白术味甘温，脾恶湿，水饮内蓄，则脾气不治，益脾胜湿，所以作为佐药。泽泻味咸寒属阴，泄泻导溺，必须以咸味为助，所以作为使药。桂枝辛热，肾恶燥，水蓄不利，则肾气燥，用辛味滋润它，所以也作为使药。多喝暖水，令汗出而愈，是因为辛味发散水气，从体表排泄，得汗而解。
附方
外台茯苓饮 治疗心胸中有停痰宿水，自吐出水后，心胸间空虚，气满而不能进食，消痰气，令能进食。
茯苓（三两） 人参（三两） 白术（三两） 枳实（二两） 橘皮（二两半） 生姜（三两）
以上六味药，用水六升，煮取一升八合，分三次温服。如人行走八九里的时间进服一次。
【衍义】这是由于上中二焦气弱，水饮进入胃中，脾不能转归于肺，肺不能通调水道，以致停积为痰为水。吐之后则下气因而上逆，积聚于心胸，这叫虚。气满不能食，先当补益中气，用人参、白术降逆气、行停水，用茯苓逐积消气满，用枳实调诸气、开脾胃、宣扬推布、发散凝滞，依靠陈皮、生姜作为使药。
【衍义】《脉经》认为弦脉主水气、厥逆、寒、饮。风脉也呈弦象。如果咳嗽，如水气、厥逆、寒、风等皆能致咳。想要从弦脉中分辨各种邪气，不是很困难吗？假设水邪之弦稍有不同的样子，究竟是什么样呢？前条悬饮者脉沉弦，别论支饮者脉急弦，二者有沉急的不同。而咳嗽脉之弦，岂是一个字可以概括的？张仲景曾论述水蓄之脉曰沉潜。现在说是水，其弦脉将仿佛有沉潜之象吗？还是有沉急之象呢？凡遇到这种证候和脉象，必须察色闻声，问所苦，确然符合脉之水象，然后用此方攻下。仅凭脉象，恐怕难以凭借。
凡是患有支饮的人，咳嗽心烦，胸中痛的，如果不猝死，延续到一百天或一年，宜用十枣汤。（方剂见上文）
【衍义】心肺在上，主胸中，属阳。支饮乃水类，属阴。现在支饮上入于阳，动肺则咳，动心则烦，搏击膈气则痛。如果阳虚不能禁受阴邪的逼迫，则营卫断绝而神亡，为之猝死。如果不猝死而延续岁月，则其阳不甚虚，是水入于肺，子乘于母所致。
久咳数年，脉弱者可以治疗，脉实大数者死。脉虚者，一定苦于头目昏冒。其人本来胸中有支饮的缘故。治疗归属于饮家范畴。
【衍义】这三种脉象固然是支饮咳嗽的表现，然而各种邪气的病，都不超出这些范围。《内经》说：久病脉弱者生，实大者死。又说脉大则病进。大概弱脉表示邪气衰，实大表示邪气盛。久病者正气已虚，邪气亦衰，虽重也可治。如果邪盛加之脉数，火复刑金（火克金），岂不死乎？脉虚苦冒者，盖胸中是发越阳气之地，支饮停积，阻遏阳气，不得升于上，又不得充于下与阴接，惟随支饮浮泛眩乱，头部清窍受阻，所以苦于昏冒。治疗其饮，则阳气行而可愈。
咳嗽气逆，倚靠呼吸，不能平卧，用小青龙汤主治。（方剂见上文）
服用青龙汤后，出现多唾、口燥，寸脉沉，尺脉微，手足厥冷，气从小腹上冲胸咽，手足麻木，面色红赤如醉状，随后又流注于阴股，小便难，时常昏冒的，给予茯苓桂枝五味甘草汤，治疗其气冲。
桂苓五味甘草汤方
茯苓（四两） 桂枝（四两，去皮） 甘草（三两，炙） 五味子（半升）
以上四味药，用水八升，煮取三升，去滓，分三次温服。
气冲即降低，但反而更咳嗽、胸满的，用桂苓五味甘草汤去掉桂枝，加干姜、细辛以治疗其咳满。
苓甘五味姜辛汤方
茯苓（四两） 甘草（三两） 细辛（三两） 干姜（三两） 五味子（半升）
以上五味药，用水八升，煮取三升，去滓，温服半升，每日三次。
咳满即止，但更复现口渴，气冲复发的，是因为细辛、干姜为热药的原因。服用后应当随即口渴，但如果口渴反而停止的，是因为有支饮。支饮患者，法当昏冒，昏冒者必呕吐，呕吐者再加入半夏，以去除水饮。
苓甘五味姜辛半夏汤方
茯苓（四两） 甘草（二两） 细辛（二两） 干姜（二两） 五味子（半升） 半夏（半升）
以上六味药，用水八升，煮取三升，去滓，温服半升，每日三次。
水去呕止，但身体浮肿的，加杏仁主治。其证应当加入麻黄，但因为其人已有痹症，所以不加入。如果逆而加入，必定导致厥逆。之所以这样，是因为其人血虚，麻黄发散其阳气故也。
苓甘五味加姜辛半夏杏仁汤方
茯苓（四两） 甘草（三两） 五味子（半升） 干姜（三两）
细辛（三两） 半夏（半升） 杏仁（半升，去皮尖）
以上七味药，用水七升，煮取三升，去滓，温服半升，每日三次。
苓甘五味加姜辛半杏大黄汤方
茯苓（四两） 甘草（三两） 五味子（半升） 干姜（三两）
细辛（三两） 半夏（半升） 杏仁（半升） 大黄（三两）
以上八味药，用水一斗，煮取三升，去滓，温服半升，每日三次。
【衍义】这是首篇所述的支饮病。因为饮水，水性寒下，应于肾。肾气上逆入肺，肺为之不利。肺主行营卫，肺不利则营卫受病，犹同外感风寒，心中有水证。所以也用小青龙汤治疗。服药后未已，是因为水停未散，所以多唾。津液未行，所以口燥。水在膈上，则阳气衰。寸口脉沉。麻黄发阳，则阴血虚，故尺脉微。尺脉微则肾气不得固守于下，冲任二脉相挟，从小腹冲逆而起。夫冲任二脉，与肾之大络，同起肾下，出胞中，主血海。冲脉上行者至胸，下行者至足少阴，入阴股，下抵足上，是动则厥逆。任脉至咽喉，上颐循面，故气冲咽胸。营卫之行涩，经络时疏不通，手足不仁而痹。其面翕然如醉状，因复下流阴股，小便难。水在膈间，因火冲逆，阳气不得输上，故时复冒也。《内经》说：诸逆冲上，皆属于火。又说：冲脉为病，气逆里急。故用桂苓五味甘草汤，先治冲气与肾燥。桂枝味辛热，散水寒之逆，开腠理，致津液以润之。茯苓、甘草行津液，渗蓄水，利小便，伐肾邪，为臣药。甘草味甘温，补中土，制肾气之逆。五味子酸平以收肺气，《内经》说：肺欲收，急食酸以收之。服此汤，冲气即止。因水在膈不散，故再变，而更咳胸满。即用前方去桂枝加干姜、细辛，散其未消之水寒，通行津液。服汤后咳满即止。三变而更复渴，冲气复发，以细辛、干姜乃热药，服之当遂渴，反不渴，是支饮之水，蓄积胸中故也。支饮在上，阻遏阳气，不布于头目，故冒。且冲气更逆，必从火炎而呕也。仍用前汤加半夏，去水止呕。服后水去呕止，四变水散行出表，表气不利，其人形肿。当用麻黄发汗散水，以其人遂痹，且血虚，麻黄发其阳，逆而内之必厥，故不内。但加杏仁。杏仁微苦温，肾气上逆者，得之则降下；在表卫气得之，则利于行，故肿可消也。服后五变，因胃有热，循脉上冲于面，热如醉，加大黄以泄胃热。盖支饮证，其变始终不离小青龙之加减，足为万世法也。
先渴后呕，为水停心下，此属饮家，用小半夏茯苓汤主治。（方剂见上文）
【补注】说口渴没有不喝水的。渴而饮水，则渴为水解，而水亦为渴消矣。乃复作呕者何哉？因为水不为渴消，而且不得下归于胃，下趋膀胱，致停于心下也。虽然，水就下性也。水又何以停？因上脘本有痰饮，阻抑上升之津，故先为渴。然后知先能为上阻者，亦即后能下阻者也。心下去上未远，为清华之位，岂得容水少刻？势必呕出。故仍以小半夏茯苓汤主之也。
[Commentary] The movement of wind and fire scatters and disrupts the body's Yang Qi, leading to Yang deficiency. The pathology of dampness and fluid retention is similar to that of cold damage (Shanghan). Although this is the case, since Yang deficiency is caused by wind and fire, one must treat their respective dominant factors. Treat cold with cold-resolving methods, treat dampness with dampness-dispelling methods, and observe the severity of these three factors (wind, fire, damp/cold) to assist with appropriate herbs. This describes Branch Fluid (Zhi Yin) retained in the Heart region, obstructing the ascending and descending of Yang Qi, causing stagnation and failure to circulate. The upper part fails to nourish the head and eyes; over time, it transforms into fire. Fire agitation generates wind, resulting in vertigo. Thus, there is a sensation of heavy dizziness and confusion (Ku Mao). Promoting urination drains the Branch Fluid, harmonizing the Middle Jiao allows Yang Qi to rise naturally and wind-fire to subside. Alisma Rhizoma (Zexie) opens the stomach gate, removes latent water, and drains Branch Fluid via urination. It is assisted by Atractylodes Macrocephala Rhizome (Baizhu) to harmonize the Middle Jiao, boost Qi, dry dampness, and extinguish wind. The number of herbs is not important; what matters is hitting the target of the disease.
For patients with Branch Fluid causing chest fullness, Nongpu Dahuang Tang (Magnolia Bark and Rhubarb Decoction) is indicated.
Nongpu Dahuang Tang Formula
Magnolia Bark (1 chi), Rhubarb (6 liang), Immature Bitter Orange (4 pieces)
Boil the above three ingredients in 5 sheng of water to obtain 2 sheng. Divide into two warm doses.
[Commentary] In Zhang Zhongjing's formulas, adding or removing one herb, or changing the dosage weight, alters the name and treatment indication. For example, if Magnolia Bark, Rhubarb, and Immature Bitter Orange are combined with Mirabilite (Mangxiao), it becomes Da Chengqi Tang (Major Order the Qi Decoction), treating severe internal heat and abdominal fullness/stagnation. Without Mirabilite, it is Xiao Chengqi Tang (Minor Order the Qi Decoction), treating mild-to-moderate internal heat. If Magnolia Bark is used in larger quantities, it is called Nongpu Sanyu Tang (Magnolia Bark Three-Ingredient Decoction), treating painful constipation due to heat. Here, with Rhubarb in greater quantity, it is named Nongpu Dahuang Tang. All three decoctions treat excess heat syndromes. Why is this formula used for Branch Fluid-induced chest fullness? If there are additional symptoms of heat accumulation varying in location, should purgatives be used universally? Chest fullness generally requires purgation. However, this is fluid retention. Without heat signs, and given that chest fullness has not reached the hardness of the epigastrium, if there are symptoms of chest oppression, floating pulse, and Qi rushing up to the throat, it is a half-exterior/half-interior syndrome requiring harmonization. If a physician mistakenly uses purgation, causing epigastric hardness and pain (Jie Xiong / Knotting Chest), Da Xiannu Tang (Major Trap the Chest Decoction) is used. If pain is mild, even less suitable for purgation, Xiao Xiannu Tang (Minor Trap the Chest Decoction) is used. Would one suddenly use a heavy purgative for middle-jiao excess heat for Branch Fluid chest fullness? There must be an explanation; this remains open for now.
For Branch Fluid causing difficulty breathing, Tingli Dazao Xiefei Tang (Descurainia Seed and Jujube Decoction Draining the Lung) is indicated. (Formula seen in Lung Abscess chapter)
[Commentary] Branch Fluid stagnates, blocking Qi in the chest, causing dyspnea. Descurainia Seed (Tinglizi) treats stagnation and promotes diuresis; Jujube (Dazao) unblocks Lung Qi and tonifies the center. Although different from Lung Abscess, the principle is similar because Branch Fluid and Qi are inseparable. Branch Fluid is gathered Jin Ye (Body Fluids); when Qi moves, fluids move; when Qi stops, fluids gather and Qi knots. Qi is Yang; knotting generates heat. Thus, it is treated similarly to the heat-knotting of Lung Abscess.
Patients who vomit usually feel thirsty; thirst indicates resolution. Now, the patient feels no thirst because there is Branch Fluid in the Heart area (epigastrium). Banxia Shengjiang Tang (Pinellia and Ginger Decoction) is indicated.
Banxia Shengjiang Tang Formula
Pinellia Tuber (1 sheng), Fresh Ginger (0.5 jin)
Boil the above two ingredients in 7 sheng of water to obtain 1.5 sheng. Divide into two warm doses.
[Commentary] Vomiting occurs because phlegm-fluid agitates the interior and seeks to exit. Once the fluid is gone, resolution follows. The absence of thirst indicates retained accumulated fluid due to poor Qi circulation condensing fluids. Pinellia is pungent and drying; pungency disperses knots, dryness overcomes dampness. Fresh Ginger controls Pinellia's harshness. Sun Simiao stated Ginger is the holy medicine for vomiting. Vomiting is rebellious Qi failing to disperse; thus, Ginger is used to scatter it.
Abdominal fullness and dry mouth/tongue indicate water Qi in the intestines. Jifeng Lihuang Wan (Stephania, Lepidium, Descurainia, and Rhubarb Pill) is indicated.
Jifeng Lihuang Wan Formula
Stephania Root (Fangji), Lepidium Seed (Juemiu), Descurainia Seed (Tinglizi, roasted), Rhubarb (Da Huang) - each 1 liang
Grind the above four ingredients into powder, mix with honey to form pills the size of wutong seeds. Take one pill before meals with water, three times daily, gradually increasing the dose. If saliva appears in the mouth, it is effective. If thirsty, add 0.5 liang of Mirabilite.
[Commentary] Lung and Large Intestine are exterior-interior pairs. Lung normally regulates water passages, directing them to the Bladder. Now, instead of draining to the Bladder, it relates only to its pair, accumulating in the intestines. Water accumulation prevents Metal Qi (Lung Qi) from disseminating, transforming into heat causing abdominal fullness. Fluids fail to ascend, causing dry mouth and tongue. Stephania, Lepidium, and Descurainia promote diuresis and move stagnant Qi. Descurainia specifically benefits the Small Intestine. However, for excess patterns with abdominal fullness, light agents are insufficient; Mirabilite must be added to purge.
Sudden vomiting, epigastric stuffiness, water between the diaphragm, dizziness, and palpitations are treated with Banxia Jiafuling Tang (Pinellia plus Poria Decoction).
Xiao Banxia Jiafuling Tang Formula
Pinellia Tuber (1 sheng), Fresh Ginger (0.5 jin), Poria (3 liang, alternative text says 4 liang)
Boil the above three ingredients in 7 sheng of water to obtain 1.5 sheng. Divide into two warm doses.
[Commentary] Epigastric stuffiness, water between the diaphragm, dizziness, and palpitations indicate Yang Qi fails to disseminate. The Classic states to use pungent herbs to disperse. Pinellia and Ginger are pungent. Materia Medica records Pinellia treats phlegm above the diaphragm, epigastric hardness, and vomiting/rebellion. Dizziness is also due to deficient Upper Jiao Yang failing to ascend. Both herbs address this. Palpitations result from Water insulting the Heart, which Pinellia alone cannot treat; Poria must be added to drain water and calm the Spirit by lowering Kidney rebellion. Calmed Spirit resolves palpitations.
Assuming a thin person experiences palpitations below the umbilicus, spits saliva foam, and suffers epilepsy-like vertigo, this is Water. Wuling San (Five-Ingredient Powder with Poria) is indicated.
Wuling San Formula
Alisma Rhizoma (Zexie, 1.1 liang), Polyporus (3 fen, peeled), Poria (5 fen), Atractylodes Macrocephala Rhizome (Baizhu, 3 fen), Cinnamon Twig (Guizhi, 2 fen, peeled)
Grind the above five ingredients into powder. Take one cun-bi with rice water, three times daily. Drink plenty of warm water; recovery follows sweating.
[Commentary] Thinness can be constitutional or pathological. Earth/Metal/Water types are fat; Fire/Wood types are thin. "Thin person" here refers to constitution, not illness. Zhu Danxi said: Fat people have much deficiency; thin people have much heat. Fat people lack Qi filling the form, hence deficiency; thin people have excess Qi, hence heat. Fat people tolerate heat poorly because heat injures Qi; thin people tolerate cold poorly because cold injures the form. Each damages their deficiency. Chao Yuanfang's *Source of Diseases* states evil entering Yin causes epilepsy. Thin people have strong Fire/Wood, suppressed by Water Evil in Yin, unable to ascend, stirring palpitations below the umbilicus. When released, it turns to Yang, striking Righteous Qi: vertigo in the head, epilepsy/coma in sinews/vessels. Kidney fluids rebel upward as saliva foam. Thus, Wuling San is used. Poria is sweet/bland, leaching internal water, serving as Sovereign. Polyporus is sweet/neutral, serving as Minister. Atractylodes is sweet/warm; Spleen dislikes dampness; water accumulation disorders Spleen Qi; Atractylodes tonifies Spleen and overcomes dampness, serving as Assistant. Alisma is salty/cold/Yin, promoting urination; salt assists, serving as Envoy. Cinnamon Twig is pungent/hot; Kidney dislikes dryness; water retention causes Kidney dryness; pungency moistens, serving as Envoy. Drinking warm water induces sweat to dissipate water Qi externally.
Supplementary Formula
Waitai Fuling Yin (Poria Drink from External Cabinet) treats retained phlegm and old water in the heart/chest. After vomiting out water, the chest feels empty, Qi is full preventing eating. It resolves phlegm/Qi to restore appetite.
Poria (3 liang), Ginseng Radix (Renshen, 3 liang), Atractylodes Macrocephala Rhizome (Baizhu, 3 liang), Immature Bitter Orange (Zhishi, 2 liang), Tangerina Peel (Chenpi, 2.5 liang), Fresh Ginger (3 liang)
Boil the above six ingredients in 6 sheng of water to obtain 1.8 sheng. Divide into three warm doses. Take after walking for about eight or nine li.
[Commentary] This results from weak Qi in Upper and Middle Jiao. Water enters Stomach, Spleen fails to transport to Lung, Lung fails to regulate water passages, accumulating as phlegm/water. Vomiting causes Lower Qi to rebel upward, accumulating in chest (deficiency). Full Qi prevents eating. First tonify Middle Qi with Ginseng and Atractylodes to descend rebellious Qi and move stagnant water. Poria eliminates accumulation and fullness. Immature Bitter Orange regulates Qi, opens Spleen/Stomach, and disperses stagnation. Tangerina Peel and Ginger serve as Envoys.
Coughing patients with a wiry (Xian) pulse have water. Shizao Tang (Ten Jujubes Decoction) is indicated. (Formula seen above)
[Commentary] *Mai Jing* states wiry pulse indicates water Qi, reversal-cold, cold, and fluid retention. Wind pulse is also wiry. Cough can be caused by water, reversal-cold, cold, or wind. Differentiating pathogens solely by wiry pulse is difficult. Assuming water-wiry pulse differs slightly, what is its appearance? Previous text stated Hanging Fluid (Xuan Yin) has deep-wiry pulse; Branch Fluid has urgent-wiry pulse. They differ in deep vs. urgent. How can cough-wiry pulse be summarized in one word? Zhongjing described water retention pulse as deep/submerged. Is the wiry pulse here resembling deep/submerged or deep/urgent? One must observe complexion, listen to voice, ask about suffering, and confirm water signs in the pulse before using this purgative. Relying solely on pulse is unreliable.
For chronic Branch Fluid patients with cough, irritability, and chest pain, if they do not die suddenly but survive for 100 days or a year, Shizao Tang is indicated. (Formula seen above)
[Commentary] Heart and Lung are superior, governing the chest, belonging to Yang. Branch Fluid is Water, belonging to Yin. When Branch Fluid enters Yang, disturbing Lung causes cough; disturbing Heart causes irritability; striking Diaphragm Qi causes pain. If Yang deficiency cannot withstand Yin pressure, Ying and Wei cut off, Spirit perishes, leading to sudden death. Surviving for years implies Yang is not severely deficient; this is Water entering Lung, Child affecting Mother (Kidney/Lung relationship).
Long-term coughing for years: Weak pulse is treatable; Excess, large, rapid pulse indicates death. Deficient pulse causes severe dizziness. This is due to pre-existing Branch Fluid in the chest. Treatment belongs to Fluid Syndromes.
[Commentary] These three pulses characterize Branch Fluid cough, but all pathogenic diseases fall within these categories. *Neijing* states: Long illness with weak pulse lives; excess/large pulse dies. Large pulse means disease progresses. Weak pulse indicates declining pathogen; excess/large indicates strong pathogen. In long illness, both Righteous Qi and Pathogen decline; even severe cases are treatable. If strong pathogen adds rapid pulse, Fire insults Metal (Lung), leading to death. Deficient pulse with dizziness: Chest is where Yang Qi ascends. Branch Fluid blocks Yang, preventing ascent and connection with Yin below. It floats chaotically, clouding clear orifices, causing dizziness. Treating the fluid allows Yang to circulate and resolve.
Cough with rebellious Qi, inability to lie flat, treated with Xiao Qinglong Tang (Minor Green Dragon Decoction). (Formula seen above)
After taking Qinglong Tang, if symptoms include excessive salivation, dry mouth, deep Cun pulse, faint Chi pulse, cold limbs, Qi rushing from lower abdomen to chest/throat, numbness of limbs, facial flushing like drunkenness, flowing down to inner thighs, difficult urination, and intermittent dizziness, give Guiling Wuli Gancao Tang (Poria, Cinnamon, Schisandra, and Licorice Decoction) to treat the Qi rush.
Guiling Wuli Gancao Tang Formula
Poria (4 liang), Cinnamon Twig (4 liang, peeled), Licorice Root (3 liang, honey-fried), Schisandra Berry (Wuweizi, 0.5 sheng)
Boil the above four ingredients in 8 sheng of water to obtain 3 sheng. Strain, divide into three warm doses.
If the Qi rush subsides but cough and chest fullness worsen, use Guiling Wuli Gancao Tang minus Cinnamon Twig, adding Dried Ginger (Ganjiang) and Asarum (Xixin) to treat cough and fullness.
Lingan Wuli Jiangxin Tang Formula
Poria (4 liang), Licorice Root (3 liang), Asarum (3 liang), Dried Ginger (3 liang), Schisandra Berry (0.5 sheng)
Boil the above five ingredients in 8 sheng of water to obtain 3 sheng. Strain, take 0.5 sheng warm, three times daily.
If cough and fullness stop but thirst returns and Qi rush recurs, it is because Asarum and Dried Ginger are hot herbs. Taking them should cause thirst. If thirst stops instead, it is due to Branch Fluid. Branch Fluid patients typically experience dizziness; dizzy patients often vomit. Add Pinellia (Banxia) to remove water.
Lingan Wuli Jiangxin Banxia Tang Formula
Poria (4 liang), Licorice Root (2 liang), Asarum (2 liang), Dried Ginger (2 liang), Schisandra Berry (0.5 sheng), Pinellia Tuber (0.5 sheng)
Boil the above six ingredients in 8 sheng of water to obtain 3 sheng. Strain, take 0.5 sheng warm, three times daily.
If water is gone and vomiting stops but edema occurs, add Apricot Kernel (Xingren). The pattern suggests adding Ephedra (Mahuang), but due to existing numbness, it is omitted. Adding it would cause厥 (Jue/Cold extremities/reversal) because the patient has Blood deficiency, and Ephedra disperses Yang.
Lingan Wuli Jiangxin Banxia Xingren Tang Formula
Poria (4 liang), Licorice Root (3 liang), Schisandra Berry (0.5 sheng), Dried Ginger (3 liang), Asarum (3 liang), Pinellia Tuber (0.5 sheng), Apricot Kernel (0.5 sheng, skin and tip removed)
Boil the above seven ingredients in 7 sheng of water to obtain 3 sheng. Strain, take 0.5 sheng warm, three times daily.
If facial flushing like drunkenness occurs, this is Stomach Heat rushing up to face. Add Rhubarb (Dahuang) to drain it.
Lingan Wuli Jiangxin Banxia Xingren Dahuang Tang Formula
Poria (4 liang), Licorice Root (3 liang), Schisandra Berry (0.5 sheng), Dried Ginger (3 liang), Asarum (3 liang), Pinellia Tuber (0.5 sheng), Apricot Kernel (0.5 sheng), Rhubarb (3 liang)
Boil the above eight ingredients in 1 dou of water to obtain 3 sheng. Strain, take 0.5 sheng warm, three times daily.
[Commentary] This discusses the initial Branch Fluid syndrome. Drinking water, whose nature is cold and sinking, corresponds to Kidney. Kidney Qi rebels upward into Lung, causing Lung dysfunction. Lung governs Ying and Wei; Lung dysfunction affects Ying and Wei, similar to external wind-cold with internal water. Thus, Xiao Qinglong Tang is used. Post-medication symptoms persist because water remains stagnant (saliva). Fluids not circulating cause dry mouth. Water above diaphragm depletes Yang; Cun pulse is deep. Ephedra disperses Yang, injuring Yin Blood, so Chi pulse is faint. Faint Chi pulse means Kidney Qi fails to secure below; Chong and Ren meridians join, rushing from lower abdomen. Chong/Ren originate below Kidney, exit Uterus, govern Blood Sea. Chong goes up to chest, down to Shaoyin, into inner thigh, to foot; disturbance causes reversal-cold. Ren goes to throat, face; thus Qi rushes to chest/throat. Ying/Wei flow is sluggish, meridians sparse/block, causing limb numbness. Facial flushing like drunkenness flows down to thighs, difficult urination. Water between diaphragm, stirred by Fire rebellion, Yang fails to transmit upward, causing intermittent dizziness. *Neijing*: All rebellious upward movements belong to Fire. Chong disease: Qi rebellion and urgency. Thus, Guiling Wuli Gancao Tang treats Chong Qi and Kidney dryness first. Cinnamon is pungent/hot, disperses cold-water rebellion, opens pores, generates fluids. Poria and Licorice move fluids, leach water, benefit urination, attack Kidney evil (Minister). Licorice tonifies Earth, controls Kidney rebellion. Schisandra is sour/neutral, astringes Lung Qi (*Neijing*: Lung desires constriction, eat sour to constrain it). After this, Qi rush stops. Because water remains in diaphragm, condition changes again to cough/fullness. Use previous formula minus Cinnamon, add Dried Ginger and Asarum to scatter remaining cold-water and move fluids. Cough/fullness stop. Third change: thirst returns, Qi rush recurs. Asarum/Ginger are hot; should cause thirst. No thirst means Branch Fluid accumulates in chest. Upper Branch Fluid blocks Yang from reaching head/eyes, causing dizziness. Rebellious Qi follows Fire to cause vomiting. Add Pinellia to previous formula to drain water and stop vomiting. Fourth change: water gone, vomiting stopped, water disperses to exterior, exterior Qi blocked, causing edema. Should use Ephedra to sweat and scatter water. But patient has numbness and Blood deficiency; Ephedra disperses Yang, causing Jue if used. Thus, omit Ephedra, add Apricot Kernel. Apricot Kernel is bitter/warm, descends rebellious Kidney Qi, facilitates Exterior Wei Qi, resolving edema. Fifth change: Stomach Heat rushes up face, causing flushing. Add Rhubarb to drain Stomach Heat. Branch Fluid variations always revolve around modifications of Xiao Qinglong Tang, serving as a model for eternity.
Thirst followed by vomiting indicates water retention in the Heart area (epigastrium), belonging to Fluid Syndromes. Xiao Banxia Fuling Tang (Pinellia and Poria Decoction) is indicated. (Formula seen above)
[Supplementary Note] Thirst invariably leads to drinking. Drinking resolves thirst, and water is consumed. Why does vomiting recur? Because water is not resolved by thirst, nor does it descend to Stomach or Bladder, but stops in the epigastrium. Although water flows downward, why does it stop? Because phlegm-fluid in the upper Stomach obstructs ascending fluids, causing initial thirst. The same obstruction that blocked upwards later blocks downwards. The epigastrium is close to the upper burner, a pure/clear zone, intolerant of water stagnation. Water must be vomited out. Thus, Xiao Banxia Fuling Tang is used.