（按本篇咳嗽诸条。本为悬饮支饮而设。题目中不须有此二字。疑是后人所误添。似宜芟去。）
问曰。夫饮有四。何也。
按 元嵩曰。四饮。云悬。云溢。云支。皆就饮之情状。而命其名。皆是虚字。然则淡饮。不应特用实字。今据水
走肠闲一证考之。淡者。盖是水饮摇动之名。淡。与澹通。灵枢邪气脏腑病形篇。心下澹澹。恐人将捕之。说文云。澹。
水摇也。从水詹声。并可以证焉（宋玉高唐赋。水淡淡而盘纡。注。淡淡。摇动貌。枚乘七发。纷屯澹淡。又湍流溯波。
又澹淡之。注。澹淡。摇荡貌。马融长笛赋。颐淡滂流。注。水摇荡貌。搜神后记。二月中蕨始生。有一甲士。折食一
茎。即觉心中淡淡欲吐。皆淡澹相通之征也。）以其居四饮之首。故取以题篇目。从来注家。不知痰之为淡。又不知其
本水摇之谓。而转为津液为病之总称。故其所解释。皆与经旨不协矣。此说有理。伊芳泽信恬亦有说。其意相同。且曰。
澹。淡。诸书多相通用。而痰用澹字绝少。但医心方。引短剧云。白微
汤。治寒食药发。胸中澹（外台。作痰。）酢干呕烦。又引效验方云。断膈丸。治胸间有澹水。并是淡痰之正字。
此言亦是。（嵩又曰。初月帖。淡闷。与干呕对言。盖虚烦之谓。）
又按悬饮。据巢源。悬字似悬痛之谓。（巢源。又有悬癖候。曰。咳唾则引胁下悬痛。所以谓之悬癖。）然以他三饮
例之。则犹宜从前注。为悬挂之义为稳。又成氏注平脉法。沉潜水蓄。支饮急弦曰。蓄积于内者。谓之水蓄。故脉沉潜。
支散于外者。
谓之支饮。故脉急弦。程氏盖袭此误。
又按篇中支饮。自有二证。其一上迫胸中。其一壅聚心下。其胸中证。多实结宜疏荡。而亦有泛漫宜消导者。
其心下证。多泛漫宜消导。而亦有实结宜疏荡者。学人须熟审经旨。勿敢混看焉。
水在心。
先兄曰。坚者。心下坚实也。筑者。筑筑然悸动也。千金可证。短气者。饮抑往来之气故也。
尤注似迂。
水在肺。
先兄曰。涎沫。即咳而吐痰也。
水在肾。（医碥曰。心。当作脐。）
夫心下有留饮。
按此支饮之类证已。盖初非四饮外。别有留饮伏饮也。
留饮者。胁下痛引缺盆。
按已。亦甚也。辄已。即辄甚。经典中往往有此义。胸中有留饮。
〔沈〕此明支饮甚则变为溢饮矣。盖留饮乃气郁水积。故谓脉沉者。有留饮也。
膈上病痰。满喘咳吐（先兄曰。满喘二字。疑倒置。）
〔魏〕诸症。皆伏饮内寒。逼阳在外之候。
按病痰二字。当作之病为是。此条亦是支饮之类证。其人振振身 剧。即与苓桂术甘汤之身为振振摇。真武汤之身
动。振振欲擗地。其机相同。
夫病患饮水多。必暴喘满。（朱本。亦无喜字。）
〔朱〕此明饮邪有实有虚。而所致异途。脉亦迥殊也。饮水多二句。是言饮之骤致者。食少饮多四句。是言饮之积
渐者。如两手皆见弦脉。夫弦则为减。当以正气虚寒论治。设一手独弦。明是病气有偏着。偏着者为实邪。则又当以攻
邪论治矣。皆大下后虚五字。疑属衍文。（节录）按喘短气。是支饮所有。悸。是痰饮支饮所俱有。又太阳中篇曰。发
汗后饮水多。必喘。又曰。太阳病。小便利者。以饮水多。必心下悸。伤寒例。亦论饮水多为喘。稻叶元熙曰。脉双弦
者寒也二句。是客。脉偏弦者饮也句。是主。主客对举。为以脉断病之法。朱氏谓为衍文者谬。此说为是。
肺饮不弦。
焦循雕菰集。罗浩医经余论序曰。其论金匮。以咳则其脉弦。与弦则卫气不行。如肺饮不弦。肺饮二字句。谓肺饮
之轻者有不弦。但短气而不咳。其弦则卫气不行而咳矣。则重矣。非谓肺饮无弦脉也。
心下有痰饮。
〔程〕心下有痰饮。即支饮也。
病患脉伏。其人欲自利。
按此证。亦是心下支饮。而病邪盘结者。与木防己汤。十枣汤证。其机稍近。而其位不均。
甘遂半夏汤方（宋本外台。芍药一两。又云。三枚。）
按赵氏曰。甘草缓甘遂之性。使不急速。徘徊逐其所留。入蜜。亦此意也。此程氏所本。又按此方四味。都以枚称。
径长之品。恐难以附子乌头之枚例之。岂甘遂芍药。亦以如指大准之乎。考医心方。引短剧方云。人参一枚者。以重二
分为准。此似宜以为率。盖二分。即古秤之十二铢。今之二厘九豪也。但半夏在别例耳。
脉沉而弦者。悬饮内痛。
按内痛。诸家无解。岂胁肋内有痛之谓乎。玉机真藏论。有内痛引肩项文。
十枣汤方
本草。图经。载本方云。病悬饮者。亦主之。胡洽。治水肿及支饮 饮。加大黄。甘草。并前五物。各一两。枣十
枚。同煮如法。一方。又加芒硝一两。汤成下之。（按圣济芫花汤。原于此方。）
医垒元戎曰。胡洽方。治支饮 饮。于十枣汤中。加大黄。甘草。同煎服之。故以相反之剂。欲其上下俱去也。
病溢饮者。当发其汗。
按二汤证治。徐氏以挟热伏寒为辨。恐未必是。盖其别在从病之轻重。分药之紧慢。而二方俱不过用以散表水也。
膈间支饮。其人喘满。（本草。图经。引深师。作其脉沉紧。不愈。作乃愈。复发下。有汗至三日四字。无与字。）
木防己汤方（宋本外台。石膏。鸡子大。十二枚。碎。绵裹。本草引深师。木防己二两。石膏二枚。鸡子大。
绵裹。）
木防己加茯苓芒硝汤方（本草。无茯苓。）
泽泻汤方
圣惠。治心下有水不散。是胸中痰饮。不能下食。宜服此方。
于本方。加半夏。生姜。
和剂。解暑三白散。治冒暑伏热。引饮过多。阴阳气逆。霍乱呕吐。小便不利。脏腑不调。恶心头晕。并皆治之。
于本方。加白茯苓。各等分。每服半两重。水一盏。姜五片。灯心十茎。煎八分服。
支饮胸满者。
按此条证。据尤鉴二说。是支饮而兼胃实者。故有须于承气也。（辑义引鉴。饮满。即支饮讹。）
小半夏汤方〔赵〕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。
外台。文仲。疗香港脚入心。闷绝欲死。
半夏（三两洗切） 生姜（二升半）
上二味。内半夏。煮取一升八合。分四服。极效。
圣惠。治五噎。胸膈咽喉不利。痰逆食少方。
半夏七枚。小者。汤洗去滑。捣细罗为散。都为一服。以浓生姜汤调服之。患年多者。不过三服瘥。
魏氏家藏方。殊胜汤。去痰涎。进饮食。
于本方。加甘草。
防己椒目葶苈大黄丸方
〔徐〕先服一小丸起。尤巧。所谓峻药缓攻也。〔魏〕何云一丸。疑误。临病酌加为妥。
按魏说似是。然赤石脂丸。亦梧子大服一丸。仍两存之。
卒呕吐心下痞。（本草。图经引云。又主呕哕谷不得下。眩悸。小半夏加茯苓汤。）
按此亦心下支饮证也。
小半夏加茯苓汤方
卫生家宝。竹叶汤。治热吐翻胃。及伤寒遍身发热冷吐。
于本方。加竹叶。
叶氏录验方。半夏汤。治肩臂痛（即本方）
假令瘦人脐下有悸。
按此证。即首条所谓痰饮之类已。脐下有悸。与肠间漉漉。稍同其辙。而用五苓散者。亦温药和之之意也。
五苓散方（按小岛尚质曰。泽泻一两一分。当作五分。始合古义。此方。伤寒论一以铢两称。却是后人所改。
此说确。又按外台黄胆。引伤寒论。作泽泻五分。益足以征矣。）
按本证无发汗之理。方后多饮暖水汗出愈一句。盖系于以伤寒论有此文。而此亦附见者。尤氏说似牵会。
朱氏集验方。附子五苓散。治翻胃吐食。
大附子一只。取空。入五苓散在内。炮熟。上为细末。用姜汤下。何元寿方。
附方
外台。茯苓饮。
按此亦支饮证。而与苓桂术甘汤。小半夏汤等证。其机相近者也。
咳家其脉弦。
按据次条。此亦膈间支饮也。又沈氏析此以下九条。题云咳嗽。曰。此与肺胀痈痿之咳嗽不同。而肺胀痈痿。
乃陡起之证。此因饮蓄相搏而咳。所以另立一门也。此说似是。然本篇以咳嗽有因水饮者。而连类及之。非为咳嗽
立门也。
夫有支饮家。咳烦胸中痛者。
〔朱〕夫曰有支饮家。则支饮之由来旧矣。乃因循失治。病气变迁。有加无已。始也咳逆。今且壅闭而烦矣。始也
倚息不得卧。今则胸中宗气。为饮邪搏结。有似兼悬饮之痛矣。夫病久邪盛。似可卒死。乃仍迁延至百日。或一岁者。
只以支饮之邪。本实邪也。邪实宜攻。不嫌过峻。主以十枣汤。所谓有病则病当之也。
按赵程意与徐同。沈鉴意与魏同。朱氏所解。或可备一说。仍表出之。又尤氏曰。其甚者。荣卫遏绝。神气乃亡。
为卒死矣。否则延久不愈。至一百日或一岁。则犹有可治。为其邪瘥缓。而正得持也。亦通。久咳数岁。其脉弱者
可治。
〔魏〕又有久咳数岁。饮之留伏也久矣。证之成患也深矣。诊之脉弱者。久病正虚。是其常也。久病而邪亦衰。是
其幸也。可以于补正气。寓逐水饮之法治之。徐徐可收功也。故曰可治。若夫诊其脉。而实而大而数。则正虚而邪方盛。
欲补其正。有妨于邪。欲攻其邪。有害于正。可决其死也。然此亦为治之不如法者言耳。苟能遵奉仲景。以扶阳益气为
本。以温中散寒。清热散邪为斟酌。以导水于二便。宣水于发汗为权宜。何遽致于必死乎。
咳逆倚息不得卧。
按此即首条支饮证也。盖其人上焦素有停饮。今时气所触。相搏犯肺。以为此证。故与小青龙汤。双解表里。然非
敢备诸般表候也。
青龙汤下已。多唾口燥。
按下已者。服毕也。多唾者。青龙之功着。而饮豁之征。犹今之患支饮者。及其欲愈。必吐稠痰。唾。亦稠痰也（宜
参肺痿。及前篇肺中寒条。）口燥者。亦饮去之征。与渴同机。续后三条。俱举药验。此证亦即是已。而咳止息平。义
寓其中矣。此下脉证。非为青龙汤而发。以其饮所在。不特上焦。亦潴于中下。而更或有所挟。今服汤之后。支饮虽散。
他证嗣见者也。寸脉沉。尺脉微者。魏氏曰。寸脉沉者。支饮有窠囊。欲去之而不能尽去也。尺脉微者。正阳虚于
下。而阴寒之气。斯厥逆而上奔也。此解似佳。唯尺脉微。岂为血虚而现乎。手足厥逆者。阳素不盛。今为饮。
遏住所致。与瓜蒂散之厥。其情相近。气从小腹。上冲胸咽者。下焦之水上迸也。手足痹者。其人血虚故也。其面
翕热如醉。复下流阴股者。胃中有热。被饮迫动。或升或降也。小便难者。膀胱不输也。时复冒者。即是心下支饮之故。
而有时失升也。先证。三焦俱有水。加以血虚与胃热。然其所急。特在气冲。故先用桂苓五味甘草汤。以抑逆散饮。此
方。比之苓桂术甘汤。有五味而少术。彼以胃为主。而此犹兼肺。故用五味以利肺气。比之苓桂甘枣汤。彼饮在下。而
此饮在上也。
咳满即止。而更复渴。
〔赵〕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。
按此节。当以至为热药也。为一截看。咳满即止。是姜辛之功着。然药势燥胃。故为渴而下焦之水。亦随发动。
此际更宜苓桂五味甘草汤者。意在言外矣。服之以下。是接上文治其咳满句。言服之咳满即止当发渴。而反不渴者。
为心下有支饮也。渴反止。赵氏注。为反不渴读。程氏亦然。宜从。此支饮。与青龙证不同。所谓冒者。
即前条时复冒之加重者也。复内半夏者。所以驱水饮。止呕逆也。
水去呕止。其人形肿者。
〔尤〕血虚之人。阳气无偶。发之最易厥脱。麻黄不可用矣。杏仁味辛能散。味苦能发。力虽不及与证适宜也。按
水去。即心下之水去。故呕止。是半夏之功着矣。然内水外溢。以为形肿。故治犹遵前法。而表水非麻黄不能驱除。盖
杏仁之与麻黄。其性虽有紧慢之别。而其功用。则稍相均。以其人血虚。故以此易彼耳。其人遂痹
者。前段手足痹也。厥者。亦即前段手足厥逆。倘得麻黄。以亡其阳。则更甚也。血虚者。尺脉微之应也。此无救
逆之法。顾证既至此。则宜别处固阳救液之药。非前方加减之所治矣。
若面热如醉。
按此上四条。如云治其气冲。而承以冲气即低之类。其文上下相应。特此条自为起端。故程氏。尤氏。以为别证。
然其治仍守上方。则知亦接上来矣。面热如醉者。即前段所谓面翕热也。其初胃热未长。故不敢为意。今蓄饮未散。而
胃热增剧。故加大黄以利之。徐氏所谓。虽有姜辛之热。各自为功。而无妨者。实得其理矣。（千金方衍义。引赵氏。
今二注本无考。）
又按以上六条。皆设法备变者也。盖病有证候错杂。或陆续变替。乃不可不就其所急。而为之处疗者。是此诸条之
所以设。而使人知圆机之妙者已。唯所叙诸证。未必一人兼备。亦未必非一人兼备。且所处之药。皆着其功。如更发他
证者。是不必药之所致。要不过假此数端。以示为治之次第也。其初则时气触动。而其次则下焦水逆。次则肺饮复动。
（按：本篇中关于咳嗽的条文，原本是为悬饮和支饮而设立的。题目中不需要有“咳嗽”这两个字。怀疑是后人错误添加的，似乎应该删去。）
问曰：水饮分为四种，为什么呢？
按语：元嵩说：四饮称为悬、溢、支，都是根据水饮的情状来命名，用的都是虚词。那么，“淡饮”就不应特别使用实字。现在根据“水走肠间”这一证候来考证，“淡”大概是指水饮摇动的名称。“淡”与“澹”相通。《灵枢·邪气脏腑病形篇》中说：“心下澹澹，恐人将捕之。”《说文解字》云：“澹，水摇也。从水詹声。”这都可以作为证明。（宋玉《高唐赋》：“水淡淡而盘纡。”注解说：“淡淡，摇动貌。”枚乘《七发》：“纷屯澹淡。”又提到湍流溯波，又说“澹淡之”。注解说：“澹淡，摇荡貌。”马融《长笛赋》：“颐淡滂流。”注解说：“水摇荡貌。”《搜神后记》记载：二月中蕨菜刚生出来时，有一名甲士，折食了一茎蕨菜，立刻觉得心中淡淡欲吐。这些都是“淡”、“澹”相通的证据。）因为“淡饮”居于四饮之首，所以取它来作为篇名。历来注解的医家，不知道“痰”就是“淡”，也不知道它是本于水摇动的意思，反而将其转变为津液为病的总称，所以他们所作的解释，都与经典原意不符。这种说法很有道理。伊芳泽信恬也有类似的论述，意思相同，并且说：“澹”、“淡”在各类书籍中多通用，而“痰”用“澹”字的情况极少。但《医心方》引用《短剧方》说：“白薇汤，治寒食药发，胸中澹（《外台秘要》作‘痰’）酢干呕烦。”又引用《效验方》说：“断膈丸，治胸间有澹水。”这都是“淡痰”的正字用法。这话也是对的。（元嵩又说：《初月帖》中，“淡闷”与“干呕”对举，大概是指虚烦的意思。）
又按：关于悬饮，据《诸病源候论》， “悬”字似乎是“悬痛”的意思。（《诸病源候论》中有“悬癖候”，说：“咳唾则引胁下悬痛，所以谓之悬癖。”）然而参照其他三种饮来看，还是沿用前人的注解，解释为“悬挂”之义更为稳妥。另外，成无己在注释《平脉法》时说：“沉潜水蓄，支饮急弦。”说：“蓄积于内的，叫做水蓄，所以脉象沉潜；散布于外的，叫做支饮，所以脉象急弦。”程氏大概是沿袭了这个错误。
又按：本篇中的支饮，自然有两种证候。一种是上迫胸中，一种是壅聚心下。属于胸中的证候，多属实结，宜用疏荡之法；但也有泛漫者，宜用消导之法。属于心下的证候，多属泛漫，宜用消导之法；但也有实结者，宜用疏荡之法。学习的人必须熟读并审察经典原意，不敢混看。
水在心。
先兄说：坚，是指心下坚实。筑，是指筑筑然悸动。《千金方》可以佐证。短气，是因为水饮抑制了往来之气所致。尤在泾的注解似乎迂腐。
水在肺。
先兄说：涎沫，就是咳嗽而吐出的痰。
水在肾。（《医碥》说：这里的“心”字，应当是“脐”字。）
夫心下有留饮。
按语：这是支饮的类似证候罢了。本来并非在四饮之外，另有留饮和伏饮。
留饮者，胁下痛引缺盆。
按语：“已”字，也是“甚”的意思。“辄已”，即“辄甚”。经典文献中往往有这样的含义。胸中有留饮。
〔沈〕这里说明支饮严重时会变为溢饮。留饮乃是气郁水积，所以说脉沉是有留饮。
膈上病痰，满喘咳吐（先兄说：“满喘”二字，怀疑是倒置。）
〔魏〕各种症状，都是伏饮内寒，逼迫阳气在外的表现。
按语：“病痰”二字，当作“之病”才是正确的。这条也是支饮的类似证候。其人振振身 剧，就与苓桂术甘汤证的“身为振振摇”，真武汤证的“身动，振振欲擗地”，其机理相同。
夫病患饮水多，必暴喘满。（朱本也没有“喜”字。）
〔朱〕这里说明饮邪有实有虚，而导致的途径不同，脉象也迥然不同。“饮水多”两句，是说饮邪骤然形成的；“食少饮多”四句，是说饮邪逐渐积聚的。如果两手都见到弦脉，弦脉主减，应当以正气虚寒来论治。假如只有一只手独见弦脉，明确是病气有偏着，偏着的属于实邪，则又应当以攻邪来论治。那“皆大下后虚”五个字，怀疑是衍文。（节录）按语：喘、短气，是支饮所具有的；悸，是痰饮、支饮所共有的。另外《伤寒论·太阳篇》说：“发汗后饮水多，必喘。”又说：“太阳病，小便利者，以饮水多，必心下悸。”《伤寒例》也论述饮水多为喘。稻叶元熙说：“脉双弦者寒也”两句，是客位；“脉偏弦者饮也”一句，是主位。主客对举，是以脉断病的方法。朱氏认为是衍文是错误的。这种说法是正确的。
肺饮不弦。
焦循《雕菰集》中罗浩《医经余论序》说：他论述《金匮》，认为“咳则其脉弦”与“弦则卫气不行”，以及“肺饮不弦”，“肺饮”二字连读，意思是肺饮轻的有不弦的，只是短气而不咳。如果弦，则是卫气不行而咳，这就重了。并不是说肺饮没有弦脉。
心下有痰饮。
〔程〕心下有痰饮，就是支饮。
病患脉伏，其人欲自利。
按语：这个证候，也是心下支饮，而且病邪盘结。与木防己汤、十枣汤的证候，机理稍近，但部位不均。
甘遂半夏汤方（宋本、《外台秘要》中，芍药一两，又说：三枚。）
按语：赵氏说：甘草缓和甘遂的药性，使其不急速，徘徊逐其所留。加入蜂蜜，也是这个意思。这是程氏所依据的。又按：此方四味药，都用“枚”来计算长度较大的物品，恐怕难以用附子、乌头的“枚”来类比。难道甘遂、芍药，也是以如手指大小为准吗？考证《医心方》引用《短剧方》说：“人参一枚者，以重二分为准。”这似乎可以作为标准。二分，就是古秤的十二铢，现在的二厘九毫左右。但半夏在别例中有所不同。
脉沉而弦者，悬饮内痛。
按语：“内痛”，各家没有解释。难道是胁肋内有痛的意思吗？《素问·玉机真藏论》中有“内痛引肩项”的文句。
十枣汤方
《本草》、《图经》记载本方说：病悬饮者，也主治。胡洽治疗水肿及支饮，加大黄、甘草，并前五物，各一两，枣十枚，同煮如法。一方，又加芒硝一两，汤成后下之。（按：《圣济总录》芫花汤，源于此方。）
《医垒元戎》说：胡洽方，治疗支饮，于十枣汤中，加大黄、甘草，同煎服之。所以用相反的药物，想要它们上下俱去。
病溢饮者，当发其汗。
按语：关于两汤的证治，徐氏以挟热伏寒来辨别，恐怕未必正确。大概区别在于根据病情的轻重，区分药物的紧慢，而两方都不过是用来发散表水的。
膈间支饮，其人喘满。（《本草》、《图经》引用《深师方》，作“其脉沉紧”，“不愈”作“乃愈”，“复发下，有汗至三日”四字，无“与”字。）
木防己汤方（宋本、《外台秘要》中，石膏，鸡子大，十二枚，碎，绵裹。《本草》引用《深师方》，木防己二两，石膏二枚，鸡子大，绵裹。）
木防己加茯苓芒硝汤方（《本草》中没有茯苓。）
泽泻汤方
《太平惠民和剂局方》（圣惠）：治疗心下有水不散，是胸中痰饮，不能下食，宜服此方。
在本方中，加半夏、生姜。
《和剂局方》：解暑三白散，治疗冒暑伏热，引饮过多，阴阳气逆，霍乱呕吐，小便不利，脏腑不调，恶心头晕，都治疗。
在本方中，加白茯苓，各等分。每服半两重，水一盏，姜五片，灯心十茎，煎至八分服。
支饮胸满者。
按语：这条证候，据尤在泾的两个说法，是支饮兼胃实，所以需要用承气汤。（《辑义》引用尤鉴，认为“饮满”即“支饮”之讹。）
小半夏汤方〔赵〕半夏的味道辛，性质燥。辛可散结，燥可胜湿。用生姜来制约它的悍烈。孙真人说：生姜是呕家的圣药。呕吐是气逆不散，所以用生姜来散之。
《外台秘要》、文仲：治疗香港脚入心，闷绝欲死。
半夏（三两，洗切） 生姜（二升半）
以上两味药，放入半夏，煮取一升八合，分四次服用，极有效。
《太平惠民和剂局方》（圣惠）：治疗五噎，胸膈咽喉不利，痰逆食少方。
半夏七枚，小的，汤洗去滑，捣细罗为散，都为一服，以浓生姜汤调服之。患病年数多的，不过三服痊愈。
魏氏家藏方：殊胜汤，去痰涎，进饮食。
在本方中，加甘草。
防己椒目葶苈大黄丸方
〔徐〕先服一小丸开始，尤其巧妙。所谓峻药缓攻。〔魏〕为什么说一丸，怀疑有误。临病酌加为宜。
按语：魏的说法似是。然而赤石脂丸，也是梧子大，服一丸，仍两存之。
卒呕吐心下痞。（《本草》、《图经》引用说：又主呕哕谷不得下，眩悸，小半夏加茯苓汤。）
按语：这也是心下支饮证。
小半夏加茯苓汤方
《卫生家宝》：竹叶汤，治疗热吐翻胃，及伤寒遍身发热冷吐。
在本方中，加竹叶。
叶氏录验方：半夏汤，治疗肩臂痛（即本方）。
假令瘦人脐下有悸。
按语：这个证候，就是首条所说的痰饮之类。脐下有悸，与肠间漉漉，稍微同其辙理。而用五苓散的，也是温药和之的意思。
五苓散方（按小岛尚质说：泽泻一两一分，当作五分，才符合古义。此方，《伤寒论》中以铢两称量，却是后人改的。此说确凿。又按：《外台秘要》黄疸篇，引用《伤寒论》，作泽泻五分，更足以证明。）
按语：本证没有发汗的道理。方后“多饮暖水汗出愈”一句，大概是鉴于《伤寒论》有此文，而此处也附带提及。尤氏的说法似乎牵强附会。
朱氏集验方：附子五苓散，治疗翻胃吐食。
大附子一只，取空，放入五苓散在内，炮熟，上为细末，用姜汤送下。何元寿方。
附方
《外台秘要》：茯苓饮。
按语：这也是支饮证，而与苓桂术甘汤、小半夏汤等证候，机理相近。
咳家其脉弦。
按语：据次条，这也是膈间支饮。另外沈氏将此以下九条，题名为咳嗽，说：这与肺胀、痈痿的咳嗽不同。而肺胀、痈痿，是突然起病的证候，此因饮蓄相搏而咳，所以另立一门。这种说法似是。然而本篇认为咳嗽有因水饮者，而连类及之，并非为咳嗽立门。
夫有支饮家，咳烦胸中痛者。
〔朱〕说“有支饮家”，则支饮由来已久。于是因循失治，病气变迁，有加无已。起初是咳逆，现在已经壅闭而烦了。起初是倚息不得卧，现在是胸中宗气，被饮邪搏结，有点像兼有悬饮的痛了。病久邪盛，似乎可以猝死，然而仍然迁延至百日，或一年，只是因为支饮之邪，本是实邪。邪实宜攻，不嫌过峻。主以十枣汤，所谓有病则病当之。
按语：赵、程的意思与徐相同，沈、鉴的意思与魏相同。朱氏的解释，或许可以备一说，仍表出之。另外尤氏说：严重的，荣卫遏绝，神气乃亡，就会猝死。否则拖延日久不愈，至一百日或一年，则还有可治，因为其邪势较缓，而正气得以支持。也通顺。
久咳数岁，其脉弱者可治。
〔魏〕又有久咳数岁，饮之留伏也久矣。证之成患也深矣。诊之脉弱者，久病正虚，是其常也。久病而邪亦衰，是其幸也。可以于补正气，寓逐水饮之法治之。徐徐可收功也。故曰可治。若夫诊其脉，而实而大而数，则正虚而邪方盛，欲补其正，有妨于邪，欲攻其邪，有害于正，可决其死也。然此亦为治之不如法者言耳。苟能遵奉仲景，以扶阳益气为本，以温中散寒，清热散邪为斟酌，以导水于二便，宣水于发汗为权宜，何遽致于必死乎。
咳逆倚息不得卧。
按语：这就是首条支饮证。大概其人上焦素有停饮，今时被时气所触，相搏犯肺，以为此证。所以与小青龙汤，双解表里。然而并非敢备诸般表候。
青龙汤下已，多唾口燥。
按语：“下已”者，服毕也。“多唾”者，青龙之功着，而饮豁之征。犹如今之患支饮者，及其欲愈，必吐稠痰。唾，也是稠痰（宜参肺痿，及前篇肺中寒条）。“口燥”者，也是饮去之征，与渴同机。续后三条，俱举药验。此证亦即是已，而咳止息平，义寓其中矣。此下脉证，非为青龙汤而发，以其饮所在，不特上焦，亦潴于中下，而更或有所挟。今服汤之后，支饮虽散，他证嗣见者也。寸脉沉，尺脉微者，魏氏说：寸脉沉者，支饮有窠囊，欲去之而不能尽去也。尺脉微者，正阳虚于下，而阴寒之气，斯厥逆而上奔也。此解似佳。唯尺脉微，岂为血虚而现乎。手足厥逆者，阳素不盛，今为饮遏住所致。与瓜蒂散之厥，其情相近。气从小腹，上冲胸咽者，下焦之水上迸也。手足痹者，其人血虚故也。其面翕热如醉，复下流阴股者，胃中有热，被饮迫动，或升或降也。小便难者，膀胱不输也。时复冒者，即是心下支饮之故，而有时失升也。先证，三焦俱有水，加以血虚与胃热。然其所急，特在气冲。故先用桂苓五味甘草汤，以抑逆散饮。此方，比之苓桂术甘汤，有五味而少术。彼以胃为主，而此犹兼肺，故用五味以利肺气。比之苓桂甘枣汤，彼饮在下，而此饮在上也。
咳满即止，而更复渴。
〔赵〕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。
按语：此节，当以“至为热药也”为一截看。咳满即止，是姜辛之功着。然药势燥胃，故为渴而下焦之水，亦随发动。此际更宜苓桂五味甘草汤者，意在言外矣。服之以下，是接上文治其咳满句。言服之咳满即止当发渴，而反不渴者，为心下有支饮也。渴反止，赵氏注，为反不渴读。程氏亦然。宜从。此支饮，与青龙证不同。所谓冒者，即前条时复冒之加重者也。复内半夏者，所以驱水饮，止呕逆也。
水去呕止，其人形肿者。
〔尤〕血虚之人，阳气无偶，发之最易厥脱。麻黄不可用矣。杏仁味辛能散，味苦能发，力虽不及与证适宜也。按语：水去，即心下之水去，故呕止，是半夏之功着矣。然内水外溢，以为形肿，故治犹遵前法，而表水非麻黄不能驱除。盖杏仁之与麻黄，其性虽有紧慢之别，而其功用，则稍相均。以其人血虚，故以此易彼耳。其人遂痹者，前段手足痹也。厥者，亦即前段手足厥逆。倘得麻黄，以亡其阳，则更甚也。血虚者，尺脉微之应也。此无救逆之法，顾证既至此，则宜别处固阳救液之药，非前方加减之所治矣。
若面热如醉。
按语：以上四条，如云治其气冲，而承以冲气即低之类，其文上下相应。特此条自为起端，故程氏、尤氏，以为别证。然其治仍守上方，则知亦接上来矣。面热如醉者，即前段所谓面翕热也。其初胃热未长，故不敢为意。今蓄饮未散，而胃热增剧，故加大黄以利之。徐氏所谓，虽有姜辛之热，各自为功，而无妨者，实得其理矣。（《千金方衍义》引用赵氏，今二注本无考。）
又按：以上六条，皆设法备变者也。盖病有证候错杂，或陆续变替，乃不可不就其所急，而为之处疗者。是此诸条之所以设，而使人知圆机之妙者已。唯所叙诸证，未必一人兼备，亦未必非一人兼备。且所处之药，皆着其功。如更发他证者，是不必药之所致。要不过假此数端，以示为治之次第也。其初则时气触动，而其次则下焦水逆，次则肺饮复动。
(Commentary: The clauses regarding cough in this chapter were originally established for Xuan Yin (Hanging Fluid) and Zhi Yin (Pendent Fluid). The term "cough" is not necessary in the title. It is suspected to be an erroneous addition by later generations and should perhaps be deleted.)
Question: Why are there four types of fluid retention?
Commentary: Yuan Song stated that the four types of fluid retention—Xuan, Yi, and Zhi—are named based on their characteristics and states, using abstract terms. Therefore, "Dan Yin" should not specifically use a concrete character. Examining the syndrome of "water flowing through the intestines," "Dan" likely refers to the shaking or undulating nature of fluid retention. "Dan" is interchangeable with "Tan." In *Ling Shu: Pathogenic Factors and Disease Manifestations of the Viscera and Organs*, it says: "The area below the heart feels turbulent (Tan Tan), as if one fears being captured." *Shuo Wen Jie Zi* states: "Tan means water shaking. It consists of the water radical and the phonetic component Zhan." This can serve as evidence. (In Song Yu's *Gao Tang Fu*: "The water ripples and winds around." The commentary notes: "Rippling indicates a shaking appearance." In Mei Cheng's *Qi Fa*: "Chaotic and turbulent." It also mentions turbulent waves flowing upstream, and again "Tan Dan." The commentary notes: "Tan Dan indicates a swaying appearance." In Ma Rong's *Chang Di Fu*: "Yi Dan Pang Liu." The commentary notes: "Water swaying and flowing." In *Sou Shen Hou Ji*: "In mid-February, when ferns begin to sprout, a soldier ate one stem and immediately felt a sensation of nausea in his heart. These are all signs of the interchangeability of 'Dan' and 'Tan'.) Since "Dan Yin" ranks first among the four types of fluid retention, it was chosen to name the chapter. Historically, commentators did not know that "Tan" (Phlegm) was originally "Dan," nor did they understand its origin in the meaning of water shaking. Instead, they transformed it into a general term for diseases caused by body fluids. Consequently, their explanations did not align with the original intent of the classics. This explanation is reasonable. Yi Fangze Xin Tian also had a similar view, stating that "Tan" and "Dan" are often used interchangeably in various texts, but "Tan" rarely uses the character "Tan." However, *Yi Xin Fang* cites *Duan Ju*: "Bai Wei Tang treats cold-food stagnation causing turbulence (in *Wai Tai Mi Yao* written as 'Tan') in the chest, sour belching, dry retching, and irritability." It also cites *Xiao Yan Fang*: "Duan Ge Wan treats Tan water in the chest." These are the correct characters for "Dan Tan." This statement is also valid. (Yuan Song further said: In the *Chu Yue Tie*, "Dan Men" is contrasted with "dry retching," referring to empty irritability.)
Furthermore, regarding Xuan Yin, according to *Zhu Bing Yuan Hou Lun*, the character "Xuan" seems to refer to "hanging pain." (*Zhu Bing Yuan Hou Lun* has a section on "Xuan Pi Syndrome," stating: "Coughing and spitting causes hanging pain in the hypochondrium, hence it is called Xuan Pi.") However, comparing it with the other three types of fluid retention, it is more stable to follow previous commentaries interpreting it as the meaning of "hanging." Additionally, Cheng Wuji, in his commentary on *Ping Mai Fa*, stated: "Sinking and submerged water accumulation; Zhi Yin presents with a rapid and wiry pulse." He explained: "Accumulated internally is called Water Accumulation, hence the pulse is sinking and submerged. Scattered externally is called Zhi Yin, hence the pulse is rapid and wiry." Cheng Shi likely copied this error.
Furthermore, Zhi Yin in this chapter naturally has two syndromes. One presses upward against the chest, and the other accumulates at the epigastrium. Chest syndromes are mostly solid knots suitable for purging and draining, but some are diffuse and suitable for resolving and guiding out. Epigastric syndromes are mostly diffuse and suitable for resolving and guiding out, but some are solid knots suitable for purging and draining. Students must carefully study the classic text and avoid conflating them.
Fluid in the Heart.
My elder brother said: "Jian" (firmness) refers to firmness below the heart. "Zhu" refers to a pounding palpitation. *Qian Jin Fang* confirms this. Shortness of breath is caused by fluid retention suppressing the movement of Qi. You Kaijing's commentary seems pedantic.
Fluid in the Lung.
My elder brother said: Saliva and foam refer to coughing up phlegm.
Fluid in the Kidney. (*Yi Bian* states: The character "Heart" here should be "Umbilicus".)
Where there is retained fluid in the epigastrium.
Commentary: This is a similar syndrome to Zhi Yin. Originally, there were no separate Retained Fluid (Liu Yin) and Hidden Fluid (Fu Yin) outside the four types of fluid retention.
Retained fluid manifests as pain under the ribs radiating to the clavicle.
Commentary: The character "Yi" also means "severe." "Zhe Yi" means "becomes severe." Classical texts often have this meaning. Where there is retained fluid in the chest.
[Shen] This clarifies that severe Zhi Yin transforms into Yi Yin (Overflowing Fluid). Retained fluid is Qi stagnation and water accumulation, hence a sinking pulse indicates retained fluid.
Pathogenic phlegm above the diaphragm, fullness, wheezing, coughing, and vomiting (My elder brother said: The characters "Man Chuan" [fullness and wheezing] are suspected to be inverted.)
[Wei] All these symptoms are manifestations of hidden fluid retention with internal cold forcing Yang Qi outward.
Commentary: "Bing Tan" should be read as "Zhi Bing" (disease of...). This clause is also a similar syndrome to Zhi Yin. The patient experiences violent trembling of the body, which shares the same mechanism as the "trembling of the body" in Ling Gui Zhu Gan Tang syndrome and the "trembling, wanting to fall to the ground" in Zhen Wu Tang syndrome.
If a patient drinks much water, they will definitely experience sudden wheezing and fullness. (Zhu's edition also lacks the character "Xi".)
[Zhu] This clarifies that pathogenic fluid retention has both excess and deficiency patterns, leading to different pathways and distinct pulses. The phrase "drinks much water" refers to fluid retention arising suddenly. The phrases "eats little, drinks much" refer to fluid retention accumulating gradually. If both wrists show a wiry pulse, since wiry indicates reduction, it should be treated as deficiency-cold of the healthy Qi. If only one wrist shows a wiry pulse, it clearly indicates pathological Qi has a bias; biased excess pathogens require treatment by attacking the pathogen. The five characters "all after severe purgation are deficient" are suspected to be interpolations. (Excerpt) Commentary: Wheezing and shortness of breath are present in Zhi Yin. Palpitations are common in Tan Yin and Zhi Yin. Furthermore, in the *Tai Yang Chapter* of *Shang Han Lun*: "After sweating, if the patient drinks much water, they will definitely wheeze." It also says: "In Tai Yang disease, if urination is clear and frequent, due to drinking much water, there will definitely be palpitations below the heart." *Shang Han Li* also discusses wheezing due to drinking much water. Inaba Motohiro stated: "Double wiry pulse indicates cold" are the secondary points; "Single wiry pulse indicates fluid retention" is the primary point. Primary and secondary contrasts constitute the method of diagnosing disease via pulse. Zhu's claim that it is an interpolation is incorrect. This explanation is correct.
Lung fluid retention does not present with a wiry pulse.
Jiao Xiong's *Diao Gu Ji*, in Luo Hao's preface to *Yi Jing Yu Lun*, stated: In discussing *Jin Gui*, he argues that "cough implies a wiry pulse" and "wiry pulse implies Wei Qi cannot circulate," along with "lung fluid retention does not present with a wiry pulse." Reading "lung fluid retention" as a phrase, it means mild lung fluid retention may not present with a wiry pulse, manifesting only as shortness of breath without cough. If wiry, then Wei Qi cannot circulate, causing cough, which is severe. It does not mean lung fluid retention never presents with a wiry pulse.
There is phlegm-fluid retention in the epigastrium.
[Cheng] Phlegm-fluid retention in the epigastrium is Zhi Yin.
The patient's pulse is deep and hidden, and they desire spontaneous diarrhea.
Commentary: This syndrome is also epigastric Zhi Yin, with pathogenic factors knotted. Its mechanism is slightly close to Mu Fang Ji Tang and Shi Zao Tang, but the location is uneven.
Gan Sui Ban Xia Tang Formula (Song Edition and *Wai Tai Mi Yao*: Bai Shao 1 liang, also says: 3 pieces.)
Commentary: Zhao Shi stated: Gan Cao (Licorice Root) moderates the nature of Gan Sui (Kansui Root), preventing it from acting too rapidly, allowing it to linger and chase away the retained fluid. Adding honey serves the same purpose. This is what Cheng Shi based his interpretation on. Furthermore, the four ingredients in this formula are measured by "pieces" (long items). It is difficult to apply the standard for Fu Zi (Aconite) and Wu Tou (Aconite) pieces to them. Could Gan Sui and Bai Shao also be standardized as finger-sized? Consulting *Yi Xin Fang* citing *Duan Ju Fang*: "One piece of Ren Shen (Ginseng) is standardized to weigh 2 fen." This seems like a suitable standard. 2 fen is 12 zhu in ancient weights, approximately 0.29 liang today. However, Ban Xia (Pinellia Tuber) follows a different example.
A sinking and wiry pulse indicates internal pain from Xuan Yin.
Commentary: "Nei Tong" (internal pain) has no explanation among various commentators. Does it mean pain inside the costal region? *Su Wen: Yu Ji Zhen Cang Lun* contains the phrase "internal pain radiating to the shoulder and neck."
Shi Zao Tang Formula
*Ben Cao* and *Tu Jing* record this formula: For patients with Xuan Yin, it also treats it. Hu Qia treats edema and Zhi Yin by adding Da Huang (Rhubarb Root and Rhizome) and Gan Cao (Licorice Root), along with the previous five herbs, each 1 liang, and 10 dates, boiled together as directed. Another prescription adds Mang Xiao (Mirabilite) 1 liang, taken after the decoction is ready. (Note: *Sheng Ji Zong Lu* Yuan Hua Tang originates from this formula.)
*Yi Lei Yuan Rong* stated: Hu Qia's formula for treating Zhi Yin adds Da Huang and Gan Cao to Shi Zao Tang, boiling and taking them together. Thus, using contrary agents aims to expel pathogens from both upper and lower regions.
For Yi Yin (Overflowing Fluid) syndrome, sweating should be induced.
Commentary: Regarding the treatment of the two formulas, Xu Shi distinguished them by heat-clinging-with-cold-retention, which is likely incorrect. The distinction lies in the severity of the disease determining the urgency of the medication, and both formulas are merely used to disperse superficial water.
Zhi Yin between the diaphragm, the patient experiences wheezing and fullness. (*Ben Cao* and *Tu Jing* cite *Shen Shi Fang*: "their pulse is deep and tight"; "not cured" becomes "then cured"; "relapse after purgation, sweating for three days" four characters, lacking the character "Yu".)
Mu Fang Ji Tang Formula (Song Edition and *Wai Tai Mi Yao*: Shi Gao (Gypsum Fibrosum), size of a chicken egg, 12 pieces, crushed, wrapped in silk. *Ben Cao* cites *Shen Shi Fang*: Mu Fang Ji (Stephania Root) 2 liang, Shi Gao 2 pieces, size of a chicken egg, wrapped in silk.)
Mu Fang Ji Jia Fu Ling Mang Xiao Tang Formula (*Ben Cao* lacks Fu Ling (Poria)).
Ze Xie Tang Formula
*Sheng Hui*: Treats water stagnating below the heart, which is phlegm-fluid retention in the chest preventing food intake. This formula is suitable.
Add Ban Xia (Pinellia Tuber) and Sheng Jiang (Fresh Ginger Rhizome) to this formula.
*He Ji Ju Fang*: Jie Shu San Bai San treats summerheat invasion with latent heat, excessive drinking, reversal of Yin and Yang Qi, cholera-like vomiting, difficulty urinating, disharmony of the viscera and bowels, nausea, dizziness, etc.
Add Bai Fu Ling (Poria with Hostwood) to this formula, equal parts. Take half a liang per dose, with one cup of water, 5 slices of ginger, and 10 stems of Deng Xin Cao (Juncus Effusus Pith), decoct to 8/10 strength and take.
Zhi Yin with chest fullness.
Commentary: According to You Jian's two interpretations, this is Zhi Yin combined with stomach excess, hence requiring Cheng Qi Tang. (*Ji Yi* cites You Jian, suggesting "Yin Man" is a corruption of "Zhi Yin".)
Xiao Ban Xia Tang Formula [Zhao]: Ban Xia is pungent and drying. Pungency disperses knots, dryness overcomes dampness. Sheng Jiang controls its harshness. Sun Simiao said: Sheng Jiang is the holy medicine for vomiting. Vomiting is due to rebellious Qi failing to disperse, so Sheng Jiang is used to disperse it.
*Wai Tai Mi Ya*, Wen Zhong: Treats Hong Kong foot entering the heart, suffocating and near death.
Ban Xia (3 liang, washed and sliced) Sheng Jiang (2 sheng 5 dou)
Combine the two ingredients, add Ban Xia, boil to obtain 1 sheng 8 he, divide into four doses. Extremely effective.
*Sheng Hui*: Treats Five Stagnations, obstruction in the chest, diaphragm, throat, rebellious phlegm, and poor appetite.
7 small Ban Xia pieces, wash in hot water to remove slipperiness, grind finely into powder. Mix as one dose, take with strong Sheng Jiang soup. For chronic cases, no more than three doses result in recovery.
Wei Shi Jia Cang Fang: Shu Sheng Tang, eliminates phlegm-saliva, promotes appetite.
Add Gan Cao (Licorice Root) to this formula.
Fang Ji Jiao Mu Ting Li Da Huang Wan Formula
[Xu]: Start with one small pill. Very clever. This is known as using harsh drugs gently. [Wei]: Why say one pill? Suspected error. Adjust according to the condition.
Commentary: Wei's view seems plausible. However, Chi Shi Zhi Wan is also walnut-sized, taking one pill. Both views are preserved.
Sudden vomiting and epigastric stuffiness. (*Ben Cao* and *Tu Jing* cite: Also treats hiccups, inability to swallow grain, dizziness, palpitations, Xiao Ban Xia Jia Fu Ling Tang.)
Commentary: This is also an epigastric Zhi Yin syndrome.
Xiao Ban Xia Jia Fu Ling Tang Formula
*Wei Sheng Jia Bao*: Zhu Ye Tang treats hot vomiting, reverse flow of food, and cold vomiting with generalized fever in Shang Han.
Add Zhu Ye (Bamboo Leaf) to this formula.
Ye Shi Lu Yan Fang: Ban Xia Tang treats shoulder and arm pain (this is this formula).
Suppose a thin person has palpitations below the umbilicus.
Commentary: This syndrome is the same category as the first clause of Tan Yin. Palpitations below the umbilicus are somewhat similar to gurgling in the intestines. Using Wu Ling San (Five-Ingredient Powder with Poria) follows the principle of harmonizing with warm medicines.
Wu Ling San Formula (Commentary: Xiao Jiao Shosei stated: Ze Xie 1 liang 1 fen should be 5 fen to conform to ancient principles. This formula in *Shang Han Lun* uses zhu and liang, which were changed by later generations. This view is accurate. Furthermore, *Wai Tai Mi Yao* Jaundice section cites *Shang Han Lun* as Ze Xie 5 fen, further confirming this.)
Commentary: This syndrome has no rationale for inducing sweating. The post-formula instruction "drink plenty of warm water until sweat appears and it cures" is likely because *Shang Han Lun* has this text, and this is attached accordingly. You Shi's explanation seems far-fetched.
Zhu Shi Ji Yan Fang: Fu Zi Wu Ling San treats reverse flow of food and vomiting.
One large Fu Zi (Prepared Aconite Lateral Root), hollowed out, filled with Wu Ling San inside, roasted until cooked, ground into fine powder. Take with ginger soup. He Yuanshou Formula.
Attached Formulas
*Wai Tai Mi Yao*: Fu Ling Yin.
Commentary: This is also a Zhi Yin syndrome, with mechanisms similar to Ling Gui Zhu Gan Tang and Xiao Ban Xia Tang.
Patients with chronic cough have a wiry pulse.
Commentary: Based on the next clause, this is also inter-diaphragmatic Zhi Yin. Additionally, Shen Shi grouped the following nine clauses under the title "Cough," stating: This differs from the cough of Fei Zhang (Lung Distension) and Yong Fei (Lung Abscess/Atrophy). Fei Zhang and Yong Fei are acute conditions, whereas this cough arises from fluid retention clashing. Hence, it is established as a separate section. This view is plausible. However, this chapter includes cough due to water-fluid retention and mentions it by association; it does not establish a separate section for cough.
For those who have a history of Zhi Yin, experiencing cough, irritability, and chest pain.
[Zhu] Saying "those who have a history of Zhi Yin" implies the condition has existed for a long time. Due to neglect and improper treatment, the pathology changes, worsening continuously. Initially, there was rebellious cough; now there is congestion and irritability. Initially, there was orthopnea; now the Zong Qi in the chest is bound by pathogenic fluid, resembling the pain of concurrent Xuan Yin. With long-standing disease and abundant pathogens, sudden death might seem possible, yet it persists for 100 days or a year. This is because Zhi Yin pathogens are essentially excess pathogens. Excess pathogens require attack, not fearing overly harsh methods. The main treatment is Shi Zao Tang, meaning "when there is disease, the disease bears the brunt."
Commentary: Zhao and Cheng's intentions align with Xu's; Shen and Jian's intentions align with Wei's. Zhu's explanation can be prepared as one perspective and is presented here. Additionally, You Shi stated: In severe cases, Ying and Wei are obstructed, Shen Qi perishes, leading to sudden death. Otherwise, if prolonged without cure, reaching 100 days or a year, it is still treatable because the pathogen is slow-acting, allowing the healthy Qi to sustain itself. This is also coherent.
Chronic cough for several years, if the pulse is weak, is treatable.
[Wei] There are also cases of chronic cough for several years where fluid retention has been hidden for a long time, and the syndrome has become deeply entrenched. If the diagnosed pulse is weak, it is normal for long-term disease to involve deficiency of healthy Qi. It is fortunate that with long-term disease, the pathogen also declines. Treatment can focus on tonifying healthy Qi while incorporating methods to expel water-fluid retention. Gradually, success can be achieved. Hence, it is said to be treatable. However, if the diagnosed pulse is excess, large, and rapid, then healthy Qi is deficient while the pathogen is flourishing. Tonifying healthy Qi would hinder the pathogen; attacking the pathogen would harm healthy Qi. Death can be predicted. But this applies only to improper treatment. If one follows Zhang Zhongjing, taking support of Yang and tonification of Qi as the foundation,酌情 using warming of the middle and dispersal of cold, clearing heat and dispersing pathogens, guiding water out through the two excretions, and promoting sweating as temporary measures, how could it inevitably lead to death?
Rebellious cough, orthopnea, inability to lie down.
Commentary: This is the Zhi Yin syndrome from the first clause. Generally, the patient has pre-existing stagnant fluid in the Upper Jiao. Now, triggered by seasonal pathogens, they clash and invade the Lung, causing this syndrome. Hence, Xiao Qing Long Tang is used to simultaneously resolve the exterior and interior. However, it does not prepare for all possible exterior symptoms.
After taking Qing Long Tang, there is excessive salivation and dry mouth.
Commentary: "Xia Yi" means after taking the medicine. "Duo Tuo" (excessive saliva) indicates the efficacy of Qing Long Tang and the resolution of fluid retention. Similar to modern patients with Zhi Yin who, upon nearing recovery, spit thick phlegm. Saliva is also thick phlegm (refer to Fei Fei [Lung Atrophy] and the preceding clause on Cold in the Lung). "Kou Zao" (dry mouth) is also a sign of fluid resolution, sharing the same mechanism as thirst. The following three clauses all demonstrate drug effects. This syndrome is also considered resolved, with cessation of cough and normalization of breathing implied. The subsequent pulse and syndrome descriptions are not solely for Qing Long Tang. Since the fluid retention is not only in the Upper Jiao but also accumulates in the Middle and Lower Jiao, and may have accompanying factors, after taking the decoction, although Zhi Yin dissipates, other syndromes subsequently appear. A deep pulse in the Cun position and a faint pulse in the Chi position: Wei Shi stated: A deep Cun pulse indicates Zhi Yin has formed a nest/cavity, attempting to expel it but unable to completely remove it. A faint Chi pulse indicates deficiency of Healthy Yang in the lower part, causing Yin-Cold Qi to rebel and rush upward. This explanation is good. However, does a faint Chi pulse indicate blood deficiency? Cold hands and feet indicate that Yang was never robust, now obstructed by fluid retention. This is similar to the cold extremities in Gua Di San. Qi rushing from the lower abdomen to the chest and throat is the surging of water from the Lower Jiao. Numbness of hands and feet is due to blood deficiency in the person. Facial flushing like drunkenness, followed by downward flow to the inner thighs, indicates heat in the Stomach, stirred by fluid retention, rising or falling. Difficulty urinating indicates failure of the Bladder to transport. Occasional dizziness is due to epigastric Zhi Yin and occasional loss of ascending function. Previously, there was water in all three Jiaos, compounded by blood deficiency and Stomach heat. However, the urgent issue is the Qi rush. Hence, Gui Ling Wu Wei Gan Cao Tang is used first to suppress rebellion and dissipate fluid retention. Compared to Ling Gui Zhu Gan Tang, this formula has Wu Wei Zi (Schisandra Fruit) but lacks Bai Zhu (Atractylodes Macrocephala Rhizome). The latter focuses on the Stomach, while this one also involves the Lung, hence Wu Wei Zi is used to benefit Lung Qi. Compared to Ling Gui Gan Zao Tang, the latter has fluid in the lower part, while this one has fluid in the upper part.
When cough and fullness cease, but thirst recurs.
[Zhao] After taking the medicine, cough and fullness cease. After three transformations, thirst recurs. The Chong Qi rebels again. Because Xi Xin (Asarum) and Gan Jiang (Dried Ginger Rhizome) are hot drugs, taking them should lead to thirst. Conversely, not feeling thirsty is because water-fluid retention is accumulated in the chest.
Commentary: This section should be viewed as a segment ending with "due to the hot nature of the drugs." Cessation of cough and fullness demonstrates the efficacy of Jiang and Xin. However, the drug's nature dries the Stomach, causing thirst, and water from the Lower Jiao is also activated. At this juncture, Ling Gui Wu Wei Gan Cao Tang is more appropriate, implying this intention. Following "taking it..." connects to the previous sentence treating cough and fullness. It states that after taking it, cough and fullness cease and thirst should occur, but if not, it is due to Zhi Yin in the epigastrium. Zhao's annotation reads "Ke Fan Zhi" as "fan bu ke" (contrary to not feeling thirsty). Cheng Shi agrees. This should be followed. This Zhi Yin differs from the Qing Long syndrome. The mentioned "Mao" (dizziness) is an exacerbation of the "occasional Mao" in the previous clause. Re-adding Ban Xia is to drive out water-fluid retention and stop rebellious vomiting.
When water leaves and vomiting stops, but the body becomes swollen.
[You] In people with blood deficiency, Yang Qi has no companion, making collapse most likely during treatment. Ma Huang (Ephedra Stem) cannot be used. Xing Ren (Apricot Seed) is pungent and dispersing, bitter and releasing. Although its strength is insufficient to match the syndrome... Commentary: "Water leaves" means water in the epigastrium has left, hence vomiting stops, demonstrating the efficacy of Ban Xia. However, internal water overflowing externally causes body swelling. Thus, treatment still follows the previous method, and superficial water cannot be驱除 (expelled) without Ma Huang. Although Xing Ren and Ma Huang differ in intensity, their functions are somewhat comparable. Because the patient has blood deficiency, one replaces the other. The subsequent numbness refers to the numbness of hands and feet in the previous section. Cold extremities also refer to the cold hands and feet in the previous section. If Ma Huang were used, it would cause loss of Yang, making it worse. Blood deficiency corresponds to the faint Chi pulse. There is no method to rescue rebellion here. Given the syndrome has reached this stage, one should seek other medicines to consolidate Yang and save fluids, which are not treatable by modifications of the previous formula.
If the face is hot like drunkenness.
Commentary: The above four clauses, such as treating Qi rush followed by "when Qi rush subsides," correspond in text. However, this clause starts independently, so Cheng Shi and You Shi considered it a separate syndrome. Yet, since the treatment still adheres to the above formula, it is known to continue from the previous section. "Face hot like drunkenness" is the "facial flushing" mentioned earlier. Initially, Stomach heat was not significant, so it was ignored. Now, with retained fluid not yet dissipated and Stomach heat worsening, Da Huang (Rhubarb Root and Rhizome) is added to drain it. Xu Shi stated that although there is heat from Jiang and Xin, they perform their respective functions without hindrance, which truly captures the principle. (*Qian Jin Fang Yan Yi* cites Zhao Shi, but current editions lack this note.)
Furthermore, the above six clauses are all methods prepared for variations. Diseases have complex or sequentially changing syndromes, requiring immediate treatment based on urgency. This is why these clauses are set, showing students the subtlety of flexible thinking. The described syndromes may not necessarily coexist in one person, nor may they not. Moreover, the prescribed drugs all achieve their effects. If other syndromes develop, it is not necessarily due to the drugs. It merely uses these examples to demonstrate the sequence of treatment. Initially, seasonal pathogens trigger it; subsequently, Lower Jiao water rebels; then, Lung fluid reactivates.