IV. Interpretation of Wu Ling San Syndrome Text
First, let us review the original text, examining the passages regarding Wu Ling San from the “Shang Han Lun” and “Jin Kui Yao Lue” to summarize and then share my experiences.
(1)
Song edition, Article 71: In cases of Tai Yang disease, after sweating, if there is profuse sweating, dryness in the stomach, restlessness, and inability to sleep, and the patient desires to drink water, give a little to drink, allowing the stomach qi to harmonize for recovery. If the pulse is floating, urination is not smooth, there is slight fever, and thirst, Wu Ling San is indicated. Formula 34. This is Zhu Ling San.
Ingredients: Zhu Ling (Polyporus) 18 grams (peeled), Ze Xie (Alisma) 60 grams, Bai Zhu (White Atractylodes) 30 grams, Fu Ling (Poria) 18 grams, Gui Zhi (Cinnamon Twig) 15 grams (peeled).
Mix the five ingredients into a powder, and take one teaspoon mixed with warm water three times a day. Drink plenty of warm water; sweating will help recovery, and rest as needed.
The formula Wu Ling San states to “drink plenty of warm water; sweating will help recovery, and rest as needed.” This indicates that in Tai Yang disease, sweating is necessary. However, excessive sweating can damage body fluids, leading to symptoms such as “dryness in the stomach, restlessness, and desire for water.” In this case, water should be consumed gradually to harmonize the stomach qi; otherwise, issues with stomach qi may arise, hindering recovery. Although sweating has occurred, if it is excessive and not properly managed, the exterior syndrome remains, resulting in a floating pulse and fever. Additionally, excessive sweating damages body fluids, leading to difficulties in urination and symptoms of thirst. Furthermore, the metabolism of body fluids may also be affected. This can be understood as follows: a cold can have multiple effects on the body, and the symptoms of each cold may vary. Sometimes it affects the nose, sometimes the throat, and sometimes it manifests as gastrointestinal symptoms, which are common and thus often overlooked. However, some individuals may experience disturbances in fluid metabolism during a cold, which is less common but does occur clinically. I will provide an example later. A patient once told me that he experiences discomfort in urination when he has a cold, indicating that external pathogens can affect the metabolism of body fluids. In fact, the pathogenesis of Wu Ling San syndrome may involve several scenarios: first, the exterior syndrome is unresolved; second, body fluids are damaged; and third, the exterior pathogen affects the metabolism of body fluids. It is possible for all three pathologies to coexist in Wu Ling San syndrome.
(2)
Song edition, Article 72: After sweating, if the pulse is floating and rapid, and there is thirst, Wu Ling San is indicated. Formula 35. Use the previous formula 34.
From the symptomatology of Wu Ling San, Song edition 72 only provides the new pulse sign of “floating and rapid.” Aside from this, it does not provide us with more information.
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Song edition, Article 73: In cases of cold damage, if sweating occurs and there is thirst, Wu Ling San is indicated; if there is no thirst, then Fu Ling Gan Cao Tang (Poria and Licorice Decoction) is indicated. Formula 36.
Ingredients: Fu Ling (Poria) 60 grams, Gui Zhi (Cinnamon Twig) 60 grams (peeled), Gan Cao (Licorice) 30 grams (roasted), Sheng Jiang (Fresh Ginger) 90 grams (sliced).
Boil the four ingredients in four liters of water until two liters remain, strain, and divide into three warm doses.
Song edition, Article 73 differentiates between Wu Ling San and Fu Ling Gan Cao Tang, presenting a challenging passage in the “Shang Han Lun.” The text is simple; we can only infer from the formulas. In terms of symptoms, the only difference between the two is thirst and no thirst. Modern commentators generally believe that whether it is Wu Ling San syndrome or Fu Ling Gan Cao Tang syndrome, both indicate a disturbance in the metabolism of body fluids, with Wu Ling San syndrome being more severe, leading to thirst; while the lighter condition does not yet cause thirst. This is the difference between Wu Ling San syndrome and Fu Ling Gan Cao Tang syndrome. What do you think of this explanation? I believe it is incorrect. Why? Because if that were the case, it would imply that there is no essential difference between the two, only a difference in severity. If it were merely a difference in severity, it would be simple: one could increase the dosage of the lighter formula or decrease the dosage of the heavier formula, as they would not differ in essence. This is the first point. Secondly, consider that Wu Ling San is a powder, taken in small amounts; while Fu Ling Gan Cao Tang, although it contains only four ingredients, is a decoction and thus has a larger volume. How could it be that Wu Ling San syndrome is more severe while Fu Ling Gan Cao Tang syndrome is lighter? This presents a problem. Therefore, I believe this explanation is incorrect.
From a clinical perspective, as I mentioned earlier, Wu Ling San syndrome often does not present with dry mouth. Based on my interactions with patients, the vast majority do not report dry mouth. Everyone has studied TCM diagnostics, which includes asking about dry mouth. The pathogenesis of dry mouth may be due to yin deficiency, internal heat, or insufficient body fluids. I would like to ask everyone, when you ask a patient if their mouth is dry, if they say it is not dry, would you continue to ask further? If you think further questioning is necessary, please raise your hand.
(A student raises their hand)
Teacher: Please share your thoughts.
Student A: I would continue to ask how much water they drink.
Teacher: So you would ask how much water they drink in a day, correct?
Student A: Yes.
Teacher: If they say they drink eight cups of water a day, what do you think?
Student A: That would be a lot of water.
Teacher: Is drinking eight cups of water a day normal?
Student A: No, it’s not normal; they shouldn’t need that much water.
Teacher: If they say they drink five cups of water a day, do you think that’s normal? Would you continue to ask further?
Student A: Yes, I would ask if it’s warm or cold.
Teacher: The temperature of the water is another matter; we are just discussing the quantity of water.
Student A: I would consider the size of the cup and how they feel about their water intake. (pauses)
Teacher: Please sit down, thank you! This student has made a good point, considering the issue comprehensively, but it’s still not enough. I haven’t checked the TCM diagnostic texts, but I recall that if a patient reports no dry mouth, it is generally considered normal. However, this is not necessarily the case. Consider a patient who believes they are normal; if their mouth is dry, they drink water, and if it’s not dry, they don’t drink. When you ask them if their mouth is dry, they will likely say it is not, as they believe they are normal. Another patient may have a dry mouth and not drink water all day; when you ask them if their mouth is dry, they also say it is not. Thus, you receive the same information: both say their mouth is not dry, but the actual situations are completely different. As a doctor, your knowledge differs from that of the patient. What information you seek and how the patient responds may not match. They only see their own situation and may not realize that others are different. Because they experience it daily, they take it for granted and believe it is normal. About ten years ago, I learned during a consultation that some patients reported not drinking water all day despite having a dry mouth. This caught my attention, and I realized that such individuals exist. This is not something found in textbooks; it is an opportunity for learning from patients. Since then, I have made it a point to ask further when encountering such situations in clinical practice.
To ask further, you need to design your questions, as the information you receive may still be misleading. As the previous student mentioned, if one person says they drink eight cups of water a day and another person also says the same, we can assume that drinking eight cups is normal. However, are their symptoms the same? They may not be. One person might say, “My daughter tells me to drink eight cups of water,” so they do it every day; another person might naturally drink when thirsty and not drink when not thirsty, yet they also end up drinking eight cups. Are they the same? Clearly not. One person may not be thirsty but drinks eight cups because they were told to, while another drinks based on their own needs. You need to rule out such situations.
Therefore, you must ask further: do they drink eight cups of water because they are thirsty, or because someone told them to? Of course, the size of the cups is also important, as the previous student mentioned, and I won’t elaborate further.
If the patient can answer clearly, that’s ideal. However, I have also encountered situations where some patients are confused and lack education, making it difficult for them to understand your questions and respond clearly. In such cases, you must design your questions to clarify. You can create scenarios, for example, asking: “You came to see me today, and let’s say you drank water at home, and now you’ve been here for several hours without water; is your mouth dry now?” This is just an example. By using such scenarios, you can gradually uncover the truth.
As doctors, we are like detectives; the consultation process reflects a doctor’s diagnostic thinking. Reading medical cases and copying formulas from teachers is different: medical cases are flat and organized, while copying formulas reveals the details of the consultation process and provides insight into a doctor’s thought process, which is also very important.
(4)
Song edition, Article 74: In cases of wind stroke with fever, if there is no resolution after six or seven days and there is restlessness, with both exterior and interior symptoms, and thirst with a desire to drink water, if water is ingested and vomited, this is called water counterflow, and Wu Ling San is indicated. Formula 37. Use the previous formula 34.
In the Kang Ping edition, the phrase “with both exterior and interior symptoms” is a note, and the phrase “called water counterflow” is also a note. In the Song edition, both have become part of the original text, but fortunately, these notes do not affect reading. Here, the symptomatology of Wu Ling San adds “vomiting upon drinking water.”
(5)
Song edition, Article 141: If the disease is in the yang, it should be resolved by sweating; if cold water is used instead, the heat will be suppressed and the restlessness will increase, leading to the appearance of goosebumps. If there is a desire to drink water but no thirst, administer Wen Ge San; if not, give Wu Ling San. If there is a cold accumulation in the chest without heat symptoms, give San Wu Xiao Xian Xiong Tang. Use the previous formula six. Bai San may also be taken. One version states to use San Wu Xiao Bai San.
This article also presents several challenging points, including San Wu Xiao Xian Xiong Tang, Bai San, and San Wu Xiao Bai San. Additionally, there is Wen Ge San; we will not delve into that as it does not relate to Wu Ling San. The first part states, “If the disease is in the yang,” the patient still has exterior symptoms, and sweating should be used for treatment. However, “if cold water is used instead,” the heat is suppressed by cold water, leading to increased restlessness and goosebumps. Here, we encounter a challenging issue: the phrase “desire to drink water but no thirst” is unclear. I am not sure if everyone understands this; I certainly do not. What does “desire to drink water but no thirst” mean? Could it be that someone told them to drink eight cups of water? I wrote a new book titled “Shang Han Lun Qiu Zhen,” where I honestly state that I do not understand this phrase. In fact, it may also be incorrect. The subsequent text states, “if not, give Wu Ling San.” What does this symptom mean? I do not know. It does not provide us with new symptom information.
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Song edition, Article 156: If the condition is below the heart, it leads to fullness below the heart. If treated with Xie Xin Tang, the fullness does not resolve. If the patient is thirsty, has a dry mouth, and has difficulty urinating, Wu Ling San is indicated. Nineteen. One version states: “endure for one day to recover.” Use the previous formula seven.
“If the condition is below the heart, it leads to fullness below the heart,” this fullness is due to the downward method, and Xie Xin Tang should be used. On the surface, it seems that Xie Xin Tang should be used, but “if the fullness does not resolve, and the patient is thirsty, has a dry mouth, and has difficulty urinating, Wu Ling San is indicated.” This indicates that the fullness syndrome simultaneously presents with thirst, dry mouth, and difficulty urinating, which adds a new symptom of “fullness.”
(7)
Song edition, Article 244: In cases of Tai Yang disease, if the pulse is weak and floating, and the patient has fever and sweating, with a return of chills, and no vomiting, but has fullness below the heart, this indicates a need for downward treatment. If the patient does not have chills and is thirsty, this indicates a transition to Yang Ming. If urination is frequent, constipation is likely, and if the patient does not change clothes for ten days, they will not suffer. If thirsty, give Wu Ling San. Formula 30.
This article in the Kang Ping edition is a near-original text. The terms “weak and floating” are notes in the Kang Ping edition, and the phrase “this indicates a transition to Yang Ming” is also a note. Removing these, it states that the patient has Tai Yang disease with a weak and floating pulse; “fever and sweating, return of chills, slight vomiting, but fullness below the heart indicates that the patient has Tai Yang wind.” Therefore, the pulse is weak and floating, with fever, sweating, and chills, but the doctor mistakenly treated it with downward methods, leading to fullness below the heart. The subsequent section states that if the downward method is not mistakenly applied, the patient may later develop “no chills and thirst.” The next part states, “if urination is frequent, constipation is likely, and if the patient does not change clothes for ten days, they will not suffer… if thirsty, give Wu Ling San.” This thirst is not indicative of Yang Ming disease. With the phrase “this indicates a transition to Yang Ming,” it suggests a different understanding, indicating Yang Ming disease. Based on the Kang Ping edition, removing these phrases, it connects to “no chills and thirst,” “frequent urination,” and “constipation,” which is Wu Ling San syndrome. Is this patient like the bus driver? Frequent urination also indicates difficulty in urination. Constipation is severe, and if 9 grams of Da Huang (Rhubarb) has no effect, I forgot whether the previous doctor prescribed any laxatives. The medications I prescribed, if they had a laxative effect, would be at most Sheng Bai Zhu (Fresh White Atractylodes), and later there was also Dang Gui (Angelica Sinensis). However, consider that Dang Gui and Bai Zhu do not have the same laxative effect as Da Huang. If 9 grams of Da Huang does not work, but my medications do, it indicates that the essence of the issue is not due to the use of laxatives, but rather that the patient exhibits symptoms of disturbed fluid metabolism while also appearing to have insufficient fluids in certain areas. This means that the disturbance in fluid metabolism is actually a case of uneven distribution of body fluids. Returning to the topic of my lecture today, titled “Water Stagnation and Fluid Deficiency,” it indicates that in some areas, it seems that there is an excess of fluids, while in others, there appears to be a deficiency, indicating uneven distribution, but in essence, it is the same: a disturbance in fluid metabolism.
(8)
Song edition, Article 386: In cases of cholera, with headache, fever, and body aches, if there is a lot of heat and a desire to drink water, Wu Ling San is indicated; if there is more cold and no desire to drink water, Li Zhong Wan (Regulating the Middle Pill) is indicated. Two.
The term “cholera” in the Kang Ping edition is “vomiting and diarrhea,” meaning: “vomiting and diarrhea, headache, fever, and body aches, if there is a lot of heat and a desire to drink water, Wu Ling San is indicated; if there is more cold and no desire to drink water, Li Zhong Wan is indicated.” Thus, “vomiting and diarrhea” is also a symptom of Wu Ling San. Here, you can see one case is “more heat with a desire to drink water,” while the other is “more cold with no desire to drink water.” Generally, it is understood that Wu Ling San should also be a warming formula, but here it states “more heat with a desire to drink water,” indicating that sometimes it is not as we previously understood. In clinical practice, we find that some patients do not fit this pattern; although they feel hot, they can still use Wu Ling San. Sometimes, the application of formulas and understanding of the patient’s pathogenesis cannot be simply interpreted based on their aversion to cold or heat, as this passage illustrates. You can experiment with this in your clinical practice.
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In the “Jin Kui Yao Lue, Chapter on Phlegm, Cough, and Pulse Diagnosis and Treatment, Section 12”: If a thin person has palpitations below the navel, vomits saliva, and feels dizzy, this is due to water, and Wu Ling San is indicated.
The “Jin Kui Yao Lue” here adds two symptoms: “palpitations” and “vomiting saliva and feeling dizzy,” both of which are symptoms of Wu Ling San syndrome.
(This article is excerpted from “Half a Day of Clinical Practice, Half a Day of Reading 2” by Xing Bin, published by China Traditional Chinese Medicine Publishing House, 2021, pages 38-73)
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