【Medical Case】
Liu, male, 51 years old. Initial consultation on October 25, 2011.
Main complaint: Back pain worsened for over 10 months.
Medical history: The patient is a bus driver, often disregarding back pain. Since January of this year, back pain has worsened, occurring every night, accompanied by coldness in the back, chills, and requiring an electric blanket for comfort. In summer, he also fears cold but did not need the electric blanket. A week ago, he started using it again. Besides back pain, he feels cold all over, with wandering joint pain. He experiences fatigue and wants to sleep by evening, waking at 4:30 AM with discomfort in the left chest and middle abdomen, but without pain, feeling the need to stretch, which disappears after about fifteen minutes upon getting up. Dizziness occurs every two days, sometimes with a spinning sensation, accompanied by stiffness in the head and neck. He had hematuria diagnosed as prostatitis by Western medicine, currently experiencing difficulty urinating with interruptions. He has had stubborn constipation for ten years, self-reported as related to his job, initially due to holding in bowel movements while driving, which later developed into constipation. Currently, he defecates 1-2 times a month, with hard, dark stools. Previously, he had halitosis, and tests showed positive for HP, which was treated with a triple therapy. His mouth is not dry. On January 28, 2011, a coronary CT showed a superficial myocardial bridge in the middle segment of the left anterior descending artery. Gastroscopy revealed gastric antrum inflammation. He had taken Chinese medicine for three months without effect, during which he used 9g of raw rhubarb for several weeks without improvement in constipation. His complexion is dull, lips are purple, tongue is pale red with a yellow-white greasy coating and teeth marks, pulse is deep, slow, thin, and weak.
Prescription: Gui Zhi (Cinnamon Twig) 30g, Zhu Fu Ling (Poria) 50g, Ze Xie (Alisma) 60g, Sheng Bai Zhu (Raw Atractylodes) 60g, Qiang Huo (Notopterygium) 15g, Du Huo (Angelica Pubescens) 15g, Jing Jie (Schizonepeta) 9g, Fang Feng (Siler) 9g, 7 doses.
November 1, 2011, second consultation: After taking the above formula for one dose, the fear of cold significantly reduced; he had previously worn two wool sweaters but now removed them and no longer needed the electric blanket. Back pain decreased; wandering joint pain resolved; discomfort in the left chest and stomach in the early morning around 4:30 AM disappeared; dizziness greatly reduced, and stiffness in the head and neck resolved; difficulty urinating decreased. The tongue is pale red, with a yellow-white greasy coating, and the pulse is deep, slow, thin, and stronger than before.
Prescription: Same as the initial prescription, adding Bu Guo Zhi (Psoralea) 30g, Guo Sui Bu (Euphorbia) 30g, Dang Gui (Angelica Sinensis) 30g, changing Sheng Bai Zhu to 90g, 7 doses.
November 8, 2011, third consultation: The patient is in good spirits, back pain has basically resolved, fear of cold, wandering pain, and stiffness in the head and neck have all resolved, and dizziness is now rare. Occasionally, there is bloating and pain in the upper abdomen, with some difficulty urinating, and bowel movements are once a week, formed, soft, and not dark. The tongue coating is thin, white, greasy, and the pulse is deep, slow, thin, and stronger than before.
Prescription: Gui Zhi 30g, Zhu Fu Ling (Poria) 50g, Ze Xie 60g, Sheng Bai Zhu 120g, Qiang Du Huo (Notopterygium and Angelica Pubescens) 9g, Dang Gui 30g, Cong Rong (Cistanche) 30g, Bu Guo Zhi 30g, Guo Sui Bu 30g, Rou Gui (Cinnamon) (added later) 3g, 7 doses.
Further treatment continued, mostly adjusting the third prescription. On November 15, he reported bowel movements every three days, and on November 24, he reported daily bowel movements, with all symptoms basically resolved. Occasionally, there were slight relapses, but continued medication resolved them. Later, the patient experienced shortness of breath when climbing stairs and weakness in both knees, which improved with the use of Liu Wei Di Huang Wan (Six Flavor Rehmannia Pill) combined with Xian Ling Pi (Poria) and Ge Jie (Gecko).
【Analysis】
I believe that fluid disorders can generally be categorized into several types: insufficient fluids; excessive fluids (this is a convenient way to describe it, but in reality, excessive fluids are no longer just fluids), which leads to abnormal fluid metabolism, resulting in water, dampness, phlegm, and retention; and another situation where both insufficient and excessive fluids coexist, which still pertains to abnormal fluid metabolism and distribution, manifested as retention of water, dampness, and phlegm in certain areas while other areas experience fluid deficiency, which can be simply referred to as water stagnation with fluid deficiency.
Insufficient and excessive fluids have clinical manifestations well known to practitioners, so I will not elaborate further. The coexistence of water stagnation and fluid deficiency, while not common, can often be seen in clinical practice and is described in the classics. For example, the symptoms of thirst and difficulty urinating in Wu Ling San syndrome arise due to water retention preventing fluids from ascending, which is caused by abnormal fluid metabolism and distribution. Similar pathological changes observed in clinical practice include: simultaneous thirst and loose stools, constipation and difficulty urinating, and the presence of both thin and greasy tongue coatings.
For those with insufficient fluids, supplementation and moistening are required; for those with excessive fluids, drainage and expulsion are necessary, but more importantly, it is crucial to identify the abnormal links in fluid metabolism for targeted treatment. As for those with both water stagnation and fluid deficiency, should we supplement or drain? This is not the key issue. Restoring normal fluid metabolism and distribution is the fundamental approach to treating the disease. In the case of Wu Ling San syndrome, Zhu Ling (Polyporus), Fu Ling (Poria), and Ze Xie (Alisma) promote diuresis and drain dampness; Bai Zhu (Atractylodes) and Fu Ling strengthen the spleen and assist in transportation; Gui Zhi (Cinnamon Twig) warms the channels and promotes qi transformation, facilitating urination and naturally alleviating thirst without directly treating it.
This patient, being a bus driver, maintains a fixed posture for long periods, leading to stagnation of qi and blood, as evidenced by his dull complexion and purple lips. The obstruction of qi and blood affects the movement of yang qi, hence the main complaint of coldness and pain in the back, with a fear of cold even in summer. In mid-October, he used an electric blanket at night, and the pulse was deep, slow, thin, and weak, indicating obstruction of local yang qi and accompanying deficiency of yang qi. When yang qi is obstructed, fluid metabolism is impaired, leading to water and dampness retention, hence the difficulty urinating, greasy tongue coating, and upward surge of water qi causing dizziness. As for the stubborn constipation, it is another aspect of abnormal fluid metabolism, indicating insufficient fluid distribution in the intestines.
Since the patient is currently on medical leave, the focus of treatment is not on invigorating qi and blood, although qi and blood stagnation is the initiating factor, it may not be the focus of differentiation and treatment. The key in current treatment is to warm and promote yang qi, and to circulate water and dampness. Therefore, a large dose of Wu Ling San was chosen, adding Qiang Huo, Du Huo, Jing Jie, and Fang Feng to dispel wind and eliminate obstruction, and to elevate yang. The medication matched the pathology, hence after taking one dose, the symptoms significantly reduced. Continued medication not only resolved the cold pain in the back but also transformed bowel movements from once every 1-2 months to once every three days, ultimately achieving daily bowel movements and smoothness.
This case has deepened my understanding of Wu Ling San syndrome, as well as the understanding of the relationship between formulas and syndromes.
It is generally believed that the tongue in Wu Ling San syndrome has a slippery coating, yet this patient had a tongue coating that was yellow-white and greasy, with teeth marks. In fact, water, dampness, and phlegm are one entity; a greasy coating not only indicates the presence of dampness and phlegm in the body but can also serve as evidence of water retention; slippery coatings are relatively rare in clinical practice, and if one rigidly adheres to this, there will be few opportunities to use Wu Ling San.
The original text by Zhang Zhongjing suggests that Wu Ling San syndrome often presents with thirst, yet this patient did not have a dry mouth. I personally believe that the classic symptoms of thirst and difficulty urinating are merely a subtype of Wu Ling San syndrome; while the symptoms of cold pain in the back, difficulty urinating, constipation, dizziness, and greasy tongue coating in this case represent another subtype. From a pathophysiological perspective, the Taiyang disease with exterior pathogens unresolved, internally transmitting to the bladder, and water accumulating in the lower jiao can be considered a subtype of Wu Ling San syndrome; yang qi not moving, with water qi surging upward can also be a subtype; and in this case, the obstruction of yang qi (accompanied by yang qi deficiency) and water stagnation with fluid deficiency is likewise a subtype of Wu Ling San syndrome. If we then combine the pathology with pulse and symptom observations, the clinical operability will be stronger, but due to space limitations, I will leave this work for the readers to complete themselves.
In conclusion, I believe that the relationship between formulas and syndromes cannot be simply understood as “seeing the syndrome and using the corresponding medicine”; behind each formula-syndrome relationship lies a pathology, which is common knowledge. The key is to refine the expression of pathology and pulse symptoms, establishing a subtype system for each formula-syndrome relationship. This requires studying the original texts of Zhang Zhongjing, the writings of later generations of formula experts, and the clinical insights of ordinary practitioners regarding this formula, as well as the practitioner’s own understanding and practice, ultimately requiring correct thinking to express clearly; otherwise, it will still resemble ordinary textbooks or general reference books, making it difficult for readers to grasp the essence.
Finally, regarding the patient’s stubborn constipation, I would like to add two points. First, in the second consultation, Dang Gui (Angelica Sinensis) was added at 30g, and in the third consultation, Rou Cong Rong (Cistanche) was added at 30g. Although these two herbs can moisten the intestines, the key to resolving constipation clearly does not lie here. The patient’s constipation was quite severe, and previous doctors had used 9g of raw rhubarb for several weeks without effect; how could these two herbs alone be sufficient? Second, the case utilized a large dose of Sheng Bai Zhu, increasing from 60g to 120g. Did the patient’s constipation improve due to this? I believe not. The use of large doses of Bai Zhu for constipation is based on the experience of Wei Longxiang, whose medical discussions were published in the early 1980s in the “Journal of Traditional Chinese Medicine”. My experience is limited, and perhaps this was the earliest report; later, reports of cases and clinical studies regarding the use of large doses of Bai Zhu for constipation gradually increased. Some argue that Bai Zhu’s ability to relieve constipation originates from Zhang Zhongjing. In the “Shang Han Lun” (Treatise on Cold Damage), it states: “In cases of cold damage for eight or nine days, with wind and dampness colliding, the body aches and is restless, unable to turn or lie down, without vomiting or thirst, the pulse is floating, weak, and rough; Gui Zhi and Fu Zi Decoction is the main treatment. If the person has hard stools and urination is self-sufficient, remove Gui and use Bai Zhu Decoction as the main treatment.” Some believe this text indicates that Bai Zhu can relieve constipation, but others interpret the annotations to mean that “this is originally one formula with two methods; if the stools are hard and urination is self-sufficient, remove Gui; if the stools are not hard and urination is not self-sufficient, add Gui.” They argue that “hard stools” merely means formed stools and should not be interpreted as constipation. I do not wish to critique the understanding of this text here. My practice indicates that large doses of Bai Zhu can relieve constipation in mild cases, but in stubborn cases, it is often ineffective. Therefore, I believe that while large doses of Bai Zhu may have some benefit in this case, they are certainly not the main reason. Moreover, the patient later switched to Liu Wei Di Huang Wan combined with other herbs without using any laxatives, and still achieved daily bowel movements. This all indicates that without Wu Ling San as the main formula to warm yang qi and circulate water and dampness, even with large doses of Bai Zhu, Dang Gui, and Cong Rong, it would be difficult to expect the constipation to resolve.
Copyright statement: This article is excerpted from “Thinkers of Traditional Chinese Medicine” Volume II. Copyright belongs to the relevant rights holders. If there are any improper uses, please feel free to contact us for negotiation.