The pattern of internal retention of water-fluid refers to a series of symptoms caused by the abnormal movement and distribution of body fluids, where water stagnates and transforms into fluid retention, accumulating in different parts of the body such as the chest, abdomen, gastrointestinal tract, or limbs. Jingui Yaolue refers to it as "phlegm-fluid retention." This syndrome is often caused by the deficiency of yang qi leading to its inability to circulate, and disturbance of qi transformation resulting in fluid retention. It is commonly seen in internal damage Zabing.

The clinical manifestations of this syndrome mainly include: splashing sound in the stomach, gurgling sounds in the intestines, heavy swelling of the limbs, chest tightness and hypochondriac pain, pain induced by coughing and spitting, shortness of breath, vomiting of frothy saliva, coldness in the back the size of a palm, dizziness and blurred vision, slight puffiness of the face, white greasy tongue coating, and a wiry or deep wiry pulse.

This syndrome is scattered among various disease patterns such as "phlegm-fluid retention," "pleural fluid retention," "thoracic fluid retention," "subcutaneous fluid retention," and "vertigo."

This syndrome should be differentiated from "pattern of water-dampness flooding" and "phlegm pattern."

bubble_chart Differentiation and Treatment

This syndrome varies depending on the location where the fluid retention accumulates, and the affected zang-fu organs also differ, hence the mechanism of disease and clinical manifestations vary.

1. For example, when fluid retention accumulates in the stomach and intestines, it is often due to irregular diet, excessive drinking, or overstrain internal damage, leading to spleen and stomach impairment, weakened middle yang, dysfunction of spleen in transportation, and fluid retention turning into "phlegm-fluid retention." Symptoms include a generally weak constitution with recent weight loss, abdominal distension and fullness with pain, the presence of fluid in the stomach, gurgling sounds in the intestines, dry mouth and tongue, puffy face and eyes, short and yellow urine, dry and hard stools, yellow and greasy tongue coating, and a slippery and rapid pulse. Treatment should focus on dispersing fluid retention, strengthening transportation, and guiding downward, using modified Stephania, Pricklyash Seed, Pepperweed and Rhubarb Pill(Jingui Yaolue).
2. Another example is fluid retention in the chest and flanks, often caused by cold-dampness infiltration, obstruction of Jingmai, liver meridian distribution in the flanks, disharmony of liver collaterals, lung's failure to disperse and descend, and disordered qi movement, leading to "pleural fluid retention." Symptoms include coughing and spitting with pain, pain in the flanks radiating to the supraclavicular fossa, aggravated pain during coughing, turning, and breathing, shortness of breath, white tongue coating, and a deep and wiry pulse. Treatment should focus on expelling fluid retention, using modified Ten Jujubes Decoction(Jingui Yaolue).
3. Another example is fluid retention in the chest and lungs, often due to pre-existing phlegm-fluid retention, prolonged illness, and external pathogen invasion, leading to lung qi's failure to disperse and descend, and fluid retention following qi counterflow, resulting in "thoracic fluid retention." Symptoms include coughing and dyspnea in a semi-reclining position, shortness of breath preventing lying down, swelling appearance, copious white frothy sputum, white and greasy tongue coating, and a wiry and tight pulse. Treatment should focus on warming the lung and resolving fluid retention, using modified Minor Green-Blue Dragon Decoction(Jingui Yaolue).
4. Another example is fluid retention overflowing to the limbs, often due to pre-existing fluid retention and external contraction, leading to obstruction of striae and interstice, resulting in "subcutaneous fluid retention." Symptoms include mild swelling of the limbs, absence of sweating despite the need, body pain and heaviness, and if both exterior cold and internal fluid retention are severe, fever and chills, copious white frothy sputum, and cough and wheezing may also be seen. Treatment should focus on inducing sweating to release the exterior and warming to resolve internal fluid retention, using modified Minor Green-Blue Dragon Decoction;
5. if the fluid retention stagnates and transforms into heat, symptoms such as fever, dysphoria, dry mouth, mixed pale and yellow complexion, and a floating, wiry, and rapid pulse may also be seen. Treatment should focus on inducing sweating to release the exterior, clearing stagnant heat, and resolving fluid retention, using modified Major Blue Dragon Decoction(Jingui Yaolue).
6. Another example is fluid retention below the heart, with weakened spleen yang, fluid retention counterflowing upward, yin mist spreading, and yang qi being constrained and unable to ascend, resulting in "vertigo." Symptoms include dizziness, blurred vision, nausea and vomiting, cough and qi counterflow, phlegm-fluid retention below the heart, fullness in the chest and flanks, white and greasy tongue coating, and a wiry and slippery pulse. Treatment should focus on strengthening the spleen to resolve fluid retention and invigorating middle yang, using modified Poria, Cinnamon Twig, Bighead Atractylodes and Licorice Decoction combined with Alisma Decoction(Jingui Yaolue).

This syndrome is often characterized by yin exuberance and yang deficiency, a condition of root deficiency and branch excess. Fluid retention is a yin pathogen, which congeals when encountering cold, and autumn's cold climate often triggers it. It is also prone to occur in individuals with constitutional yang deficiency, excessive water intake, or excessive alcohol consumption, as yang fails to transform qi, and qi fails to transform fluid retention, leading to weakened spleen yang and unresolved fluid retention. Jingui Yaolue refers to "persistent fluid retention" and "recurrent fluid retention," where persistent fluid retention refers to fluid retention that remains unresolved, and recurrent fluid retention refers to fluid retention that lurks and recurs. The "retention" and "lurking" types of fluid retention are named due to the prolonged and deep-seated nature of the pathogen, and they fall within the scope of the aforementioned four types of fluid retention, albeit with a longer course and more entrenched pathogen. This syndrome is closely related to the lungs, spleen, kidneys, and triple energizer due to the disturbance of qi transformation caused by abnormal fluid metabolism and distribution, with spleen-kidney yang deficiency and constrained yang qi being key factors in unresolved fluid retention.

This syndrome is due to insufficient yang qi and weakened defensive functions, making it susceptible to invasions by wind-cold, summerheat dampness, which often leads to concurrent symptoms. If wind-cold invades externally, it may trigger new contraction leading to recurrent fluid retention, not only causing symptoms such as chest and abdominal distension and fullness, heavy body, cough, and panting due to fluid retention internally, but also exterior pattern symptoms like fever and chills, and joint pain due to external binding of wind-cold; if combined with summerheat dampness, symptoms such as nausea and vomiting, thirst without desire to drink, and restlessness may also appear. For the occurrence of concurrent symptoms, treatment must address both expelling pathogens and resolving fluid retention. In the evolution of this syndrome, persistent fluid retention and spleen yang deficiency may manifest as mental fatigue, heavy limbs, anorexia, loose stool, vomiting of clear fluid, fullness below the heart, palpitation, and coldness in the back the size of a palm; if fluid retention persists, spleen deficiency may affect the kidney, leading to kidney yang deficiency, which disturbs qi transformation and fails to warm and evaporate body fluids, presenting as cold limbs, vomiting of clear fluid, pulsations below the navel, shortness of breath, sore waist, dizziness, and difficulty in urination. It may also show fluid pathogens attacking the heart and lungs; if kidney yang is insufficient, cold pathogens congeal internally, yin is exuberant and yang is weak, leading to edema due to yang deficiency forming "cold fluid shooting the lung," with symptoms like cough, panting, inability to lie flat, severe panting upon movement, copious white frothy sputum, cold limbs, facial and limb swelling, and clear urine; if spleen-kidney yang deficiency, internal retention of fluid, yang failing to transform qi, and qi failing to move water, it may result in "water pathogen attacking the heart," with symptoms like palpitation, vertigo, nausea, chest and gastric stuffiness and fullness, lower limb swelling, and difficulty in urination. Jingui Yaolue states: "For those suffering from phlegm-fluid retention, it should be treated with warming medicines," clearly indicating that warming yang and resolving retained fluid are the principles for treating this syndrome. However, clinically, one must avoid excessive warm dryness and uncontrolled diuresis and purging, which may lead to qi consumption and damage to fluids. Caution is essential.

The syndrome of water-dampness flooding and the pattern of internal retention of water-fluid: Both are caused by yin exuberance and yang deficiency, leading to disturbance of qi transformation and abnormal water metabolism, manifesting as pathological changes such as fluid retention, water stagnation, and dampness obstruction, with symptoms like chest oppression and heavy body. However, the syndrome of water-dampness flooding mainly involves water-dampness retention overflowing to the skin, causing systemic edema in the head, face, limbs, chest, and abdomen, with symptoms such as eyelid swelling, limb or whole-body swelling, and scanty urine. The key points for differentiation from the pattern of internal retention of water-fluid are:

1. The syndrome of water-dampness flooding refers to water qi flooding the whole body, while the pattern of internal retention of water-fluid refers to water retention in localized areas.
2. Although both have clinical manifestations of internal water-dampness obstruction, the syndrome of water-dampness flooding mainly presents with edema and difficulty in urination, while the pattern of internal retention of water-fluid mainly involves fluid retention in the chest, flanks, and gastrointestinal tract.

Phlegm pattern and the pattern of internal retention of water-fluid: Both can be seen in cases of spleen yang deficiency, leading to failure in transporting and transforming water and grain essence, resulting in fluid retention and phlegm accumulation, with symptoms such as coughing up phlegm. However, the disease mechanism of phlegm pattern is more complex than that of the pattern of internal retention of water-fluid. In addition to the aforementioned causes of phlegm, it can also involve dryness-heat scorching fluids to form phlegm, and insufficient qi and blood leading to phlegm production. The clinical manifestations of phlegm pattern are numerous, as phlegm can move with qi movement and reach anywhere, with distinctions such as wind phlegm, heat phlegm, cold phlegm, dry phlegm, and old phlegm. The key points for differentiation from the pattern of internal retention of water-fluid are:

1. It is generally believed that fluids transform into phlegm when influenced by yang, hence the saying "dampness-heat generates phlegm," making phlegm sticky and turbid; fluids transform into retained fluids when influenced by yin, hence the saying "retained fluids are yin pathogens," making retained fluids clear and thin.
2. Phlegm pattern manifests systemically, affecting zang-fu organs and meridians, with phlegm reaching everywhere, such as phlegm in cough, vomiting of phlegm, phlegm sounds in the throat, phlegm confusing the heart orifice, phlegm-heat stirring wind, subcutaneous nodules, phlegm flowing through meridians, etc., while the pattern of internal retention of water-fluid involves localized fluid retention.
3. Although both can present with coughing up phlegm, phlegm pattern also has clinical manifestations of intangible phlegm. Therefore, this should be used for differentiation.

bubble_chart Documentation

1. Suwen-Zhizhenyao Da Lun: "The year's Taiyin terrestrial effect…people suffer from fluid accumulation and heart pain…。"
2. Suwen-Qijiaobian Da Lun: "Excessive year's earth, rain and dampness prevail…fluid accumulation causes fullness in the middle, reduced appetite, inability to lift the limbs, and changes in position."
3. Jingui Yaolue‧Phlegm-fluid retention cough disease pulse and symptom treatment: "A person who was once robust but now thin, with water moving in the intestines, making a dripping sound, is called phlegm-fluid retention. After drinking, water flows under the ribs, causing pain when coughing and spitting, called pleural fluid retention. Water flows and returns to the limbs, should sweat but does not, causing body pain and heaviness, called subcutaneous fluid retention. Coughing and dyspnea in a semi-reclining position, shortness of breath and inability to lie down, with a swollen appearance, is called thoracic fluid retention."
4. Jingui Yaolue Xindian‧Phlegm-fluid retention cough disease pulse and symptom treatment: "Chronic cough disease lasting for several years, thoracic fluid retention soaking the lungs and causing cough, if the fluid retention persists, the cough will not heal.…Although the fluid retention diminishes, the body's resistance cannot defend, enough to obscure the clear yang qi, hence the person must suffer from dizziness. This disease is caused by thoracic fluid retention, removing the fluid will cure the disease, hence it is said to treat the fluid retention."
5. Rumen Shiqin‧Discussion on fluid retention should remove water, warming and tonifying may worsen: "The causes of fluid retention come from five sources: from anger and depression; from exhaustion; from overthinking; from excessive drinking; from catching cold during heat. Although there are many patterns of fluid retention syndrome, they all stem from these."
6. Jingyue Quanshu‧Phlegm-fluid retention: "Phlegm and fluid retention, though said to be of the same category, are actually different. Fluid retention belongs to the category of water fluids, such as vomiting clear water, chest and abdominal distension, acid swallowing, belching, and gurgling sounds, these are all due to the stagnation of food and water, which is called fluid retention. Phlegm is different from fluid retention; fluid retention is clear and thin while phlegm is thick and turbid; fluid retention only stagnates in the intestines and stomach while phlegm can reach everywhere. The stagnation of food and water turning into fluid retention is entirely due to the spleen and stomach; phlegm that can reach everywhere is caused by injuries to any of the five zang-organs. Therefore, in treating these, one must know the distinction and must not overlook the root cause."