Reflections on ‘Studying While Practicing’ – Insight Ninety-One

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Metabolism of Body Fluids in Traditional Chinese Medicine

The Huangdi Neijing (Yellow Emperor’s Inner Canon), Suwen, Chapter on the Differentiation of Meridians states: “When fluids enter the stomach, they circulate and transform into vital energy, ascending to the spleen, where the spleen disperses the essence, which then ascends to the lungs. The lungs regulate the water pathways, descending to the bladder, where the essence of water is distributed. This process aligns with the four seasons and the five organs, balancing yin and yang, and is considered normal.” From this, we understand that after food enters the body, it is absorbed through the stomach’s “circulating vital energy” and the spleen’s “dispersing essence,” allowing the extraction of the fine essence of water and grains, which then “ascends to the lungs” to nourish the five organs and six bowels as well as the limbs. The lungs also govern the regulation of fluids, ensuring that the metabolized water is transported to the bladder for excretion. The normal metabolism of body fluids relies on the transformation, distribution, operation, and excretion by the spleen, lungs, kidneys, liver, sanjiao (triple burner), and bladder. Therefore, we can say that the spleen is responsible for the movement of water, the lungs for the regulation of water, the kidneys for the governance of water, the liver for the dispersal of water, and the sanjiao for the pathways of water. The metabolism of body fluids is a collaborative effort among the five organs, six bowels, and meridians, allowing for the absorption of essence and the excretion of waste.

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Water Retention and Fluid Deficiency are Results of Imbalanced Fluid Metabolism

Water retention occurs due to abnormal distribution and transformation of body fluids, resulting in pathological accumulation of dampness within the body’s tissues and organs, which can lead to various diseases. Fluid deficiency refers to the depletion of body fluids, leading to a lack of nourishment for the internal organs and the skin, resulting in a series of pathological states characterized by dryness. In general, water retention is characterized by “excess water,” while fluid deficiency is characterized by “lack of water.” Both conditions can be systemic or localized. Water retention and fluid deficiency are completely opposite in nature; can they occur simultaneously? The answer is yes. Clinically, we observe cases of water retention, fluid deficiency, and the coexistence of both, similar to how it can be dry in one area while raining in another on Earth. The body’s fluid levels are generally stable; when water retention occurs in one area, fluid deficiency may arise in another.

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Coexistence of Water Retention and Fluid Deficiency is Common in Clinical Practice

In the Shanghan Lun (Treatise on Cold Damage), the 28th section states: “If after taking Guizhi Decoction, the patient still has a stiff neck, fever, no sweating, a feeling of fullness and slight pain in the chest, and difficulty urinating, then Guizhi should be removed and replaced with Fuling Baizhu Decoction.” This follows the 27th section on “Taiyang Disease,” indicating that the initial suspicion was of a Taiyang wind-cold syndrome. The persistence of symptoms after taking Guizhi Decoction confirms this diagnosis. The subsequent use of purgatives suggests a misjudgment of the condition as a Yangming organ syndrome due to the presence of “fullness and slight pain in the chest,” leading to mismanagement. Therefore, the conditions described are not simply Taiyang wind-cold syndrome or Yangming organ syndrome, but rather a combination of water retention and fluid deficiency.

Although the patient exhibits “stiff neck and fever,” resembling Taiyang wind-cold syndrome, the absence of sweating differentiates it from the Guizhi Decoction syndrome. The key part of this section is the latter half: “fullness and slight pain in the chest, and difficulty urinating.” This indicates an internal retention of water and fluid deficiency. The “stiff neck and fever” arise from the stagnation of water retention, which obstructs the clear yang energy, causing pain. Water retention in the chest area leads to “fullness and slight pain in the chest,” while stagnation in the bladder results in difficulty urinating. This condition, characterized by internal water retention and fluid deficiency, was initially treated with Guizhi Decoction to induce sweating, followed by purgatives, which resulted in fluid depletion. This case illustrates the simultaneous presence of internal water retention and fluid deficiency, and Zhang Zhongjing prescribed “Guizhi without cinnamon, adding Fuling and Baizhu Decoction” to address it, using Fuling to drain dampness, Baizhu to dry dampness and strengthen the spleen, and adding Shaoyao and Gancao to nourish yin and generate fluids, while Shengjiang and Dazao both release water vapor and harmonize the spleen and stomach. The removal of cinnamon was due to the absence of sweating. Thus, the formula concludes with “urination improves, then recovery occurs,” rather than recovery through sweating.

There are many formulas that demonstrate the coexistence of water retention and fluid deficiency, such as the classic Zhu Ling Decoction, which treats the syndrome of water-heat intermingling, where water retention, fluid deficiency, and pathogenic heat coexist. It employs Zhu Ling, Fuling, and Ze Xie to drain dampness and promote urination, while Hua Shi clears heat and drains dampness, and E Jiao nourishes yin and moistens dryness. Another example is the Dao Chi San from the Children’s Medicine Manual, which treats urinary pain due to excess heat in the heart transferring to the small intestine, with effects of clearing heat, nourishing yin, and promoting urination. The formula includes Sheng Di Huang, which is sweet and cold, to cool the blood, nourish yin, and reduce fire; Mu Tong, which is bitter and cold, to clear heart fire and guide small intestine heat downward. The combination of these two herbs nourishes yin and restrains fire while promoting urination. The unique feature of Dao Chi San is the combination of sweet and bitter cold herbs, focusing on nourishing yin and promoting urination without harming yin or depleting the stomach.

In my clinical practice, whenever I encounter cases of internal dampness retention, I always remain vigilant for the possibility of concurrent fluid deficiency. If fluid deficiency is present, I treat with both promoting urination and nourishing yin; if fluid deficiency is absent, I still promote urination and eliminate dampness while adding herbs that nourish yin and generate fluids without hindering dampness, such as Shi Hu, Mao Gen, and Lu Gen, to ensure that dampness is eliminated while preserving fluids and expelling pathogens while retaining the upright.

Warm Reminder: This article is intended for academic discussion and exchange, and it is not recommended for patients to use directly, and consultation with a physician is advised before use.