Water Stagnation and Qi Deficiency Syndrome and the Application of Wu Ling San
1. Introduction
Today, I would like to share with you the topic of “Water Stagnation and Qi Deficiency Syndrome and the Application of Wu Ling San”.
Have you heard of the term “Water Stagnation and Qi Deficiency Syndrome”? This term is likely something I coined myself, as a search online would yield few results, most of which are related to my work. The second keyword is Wu Ling San (Five-Ingredient Powder with Poria), which anyone who has studied herbal formulas or the texts “Shang Han Lun” (Treatise on Cold Damage) and “Jin Gui Yao Lue” (Essential Prescriptions from the Golden Cabinet) should be familiar with. However, in practice, not many people actually use Wu Ling San. People often only apply it to conditions like edema, pleural effusion, and ascites. Yet, in our typical TCM outpatient clinics, patients with edema, pleural effusion, or ascites are quite rare. Therefore, if you limit its application to these conditions, the usefulness of Wu Ling San becomes quite small. Since I started university in 1994, I have followed many teachers and copied their formulas, but I rarely saw anyone use Wu Ling San, which is likely the reason. I myself also did not use Wu Ling San for a long time, until the last few years when I learned how to apply this formula. Thus, the transition from not using a good formula to being able to use it can be described as a revolutionary change. When you do not know how to use it, you may have patients in front of you who could benefit, but you do not know how to treat them; however, once you learn to use the formula, you will discover applicable conditions. Because you can now use this formula, some previously considered difficult cases can now be treated.
2. Case Introduction
Today, I will share many cases, some of which have been published, while most have not. The first case is one that has been published in “Thoughts of Traditional Chinese Medicine: Volume 2”. Let us start with this case.
Liu, male, 51 years old. Initial diagnosis on October 25, 2011.
Chief complaint: Back pain worsening for over 10 months.
Medical history: The patient is a bus driver and often experiences back pain, which he did not take seriously. Since January of this year, the back pain has worsened, occurring every night, accompanied by coldness in the back and chills. He finds comfort only when using an electric blanket at night, and even in summer, he feels cold but does not need the electric blanket. A week ago, he started using the electric blanket again. In addition to back pain, he also feels cold all over, with wandering joint pain. He experiences fatigue and wants to sleep at night, but at around 4:30 AM, he feels discomfort in the left chest and middle abdomen, but without pain, just a feeling of wanting to stretch. This discomfort disappears about 15 minutes after getting up. He has dizziness, occurring on average every two days, sometimes accompanied by a spinning sensation and neck stiffness. He has had hematuria in the past, and Western medicine diagnosed him with prostatitis. Currently, he has difficulty urinating, with intermittent flow. He has had stubborn constipation for 10 years, which he attributes to his work nature; initially, he had to hold in his bowel movements while driving, which later developed into constipation. Now, he has a bowel movement only 1-2 times a month, and the stools are dark and hard. He previously had halitosis, and tests showed positive for Helicobacter pylori, which was treated with a triple therapy. He also experiences dry mouth. A coronary CT on January 28, 2011, showed a superficial myocardial bridge in the left anterior descending artery. Gastroscopy revealed gastric antrum inflammation. He had taken Chinese medicine for 3 months without improvement, during which he took 9g of raw rhubarb for several weeks, but constipation did not improve. His complexion is dull, lips are purple, tongue is pale red with tooth marks on the edges, and the coating is yellowish-white and greasy. The pulse is deep, slow, thin, and weak.
Note: Previous physician prescribed 9g of Fu Zi (Aconite) and 9g of raw rhubarb for a period, but it was ineffective.
For this patient, consider his many complaints. Given his sensitivity to cold, one might think to use Fu Zi, which is a common thought. His severe constipation would typically lead a doctor to prescribe raw rhubarb, but he had taken it for a while without effect.
My prescription: Gui Zhi (Cinnamon Twig) 30g, Zhu Ling (Polyporus) 50g, 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.
The formula I prescribed was a modified Wu Ling San, adding some wind-dispelling herbs, and the results were very good. After taking one dose, his sensitivity to cold significantly decreased. At that time, he was wearing two wool sweaters, but he was able to take one off, and he no longer needed the electric blanket at night. His back pain and joint pain improved, and the discomfort at 4 AM also resolved, as did the dizziness; all these symptoms were significantly alleviated.
During the second consultation, I made slight adjustments based on the initial prescription. By the third visit, just two weeks later, his mental state had improved, back pain had mostly disappeared, and he no longer felt cold or had joint pain. Dizziness occurred less frequently, although he sometimes felt bloating in the upper abdomen and had intermittent urination. His bowel movements also improved, now occurring once a week. His tongue coating was better than before, and the pulse was noticeably stronger. Continued treatment was based on the third consultation formula with modifications. He started treatment on October 25, and by November 15, just 20 days later, he was having bowel movements every three days. By November 24, he was having daily bowel movements, and his symptoms had mostly resolved. Later, he experienced shortness of breath and knee weakness, for which I switched to Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) combined with Yin Yang Huo (Epimedium) and He Shou Wu (Fo-Ti), which also resolved.
3. Case Reflection
In this case, consider that if a doctor who favors Fu Zi were to assume that 9g was ineffective, they might increase the dosage to 30g, then to 60g, 90g, or even 300g or 500g. Have you seen teachers in clinical practice use large doses of Fu Zi? (Students: Yes.) What is the maximum dose you have seen? (Students: 60g.) I wrote a book published in 2006 titled “Critical Illnesses and Difficult Diseases Relied on Fu Zi,” which collected experiences from many modern famous doctors using Fu Zi. Indeed, many doctors use large doses of Fu Zi, and I have also used over 200g in the past. For example, I treated another patient with chronic diarrhea using Fu Zi, increasing the dose from 9g to 90g, but it was ineffective. I do not wish to belittle others; I have been in the same situation. However, later, when I added 15g of Ma Huang (Ephedra) and reduced the dose of Fu Zi, the chronic diarrhea patient improved. Why was that? I will briefly mention this patient’s situation. She experienced diarrhea whenever her abdomen felt cold, which is not unusual, but her case was quite severe; for instance, she would have diarrhea just by entering our classroom, as the floor is cement, and even without the air conditioning, she would have diarrhea. With the air conditioning on, it was even worse. She felt cold on the cement or tiled floors, and even in the kitchen, she would feel cold and have diarrhea. In summer, she wore short sleeves but also needed a down vest and carried a cotton cushion. For this patient, the common thought would be to warm the Yang, but why did increasing the dose of Fu Zi not work? I later discovered her pulse was very deep, indicating a hidden pulse. So, when I used Ma Huang to release the exterior, her diarrhea significantly improved.
This shows that if we can recognize the syndrome, we can prescribe an appropriate formula; if we cannot recognize the syndrome, even if it is right in front of you, you will not recognize it. Where does the problem lie? I believe it lies in our lack of recognition. We know too little and master too little.
The Huogong school was very popular ten years ago and attracted a lot of attention, becoming quite famous. Why? Because there are too many people in the TCM community who do not read. For those who do not read, having one more method is certainly good. While having one more method is indeed an improvement, it is just one more method; there are still many more methods to learn. We in TCM should be eclectic. If you learn a little and think it is the ultimate, that is stagnation and a narrow view. Some people think I am also from the Huogong school; why? Because I wrote a book, “Critical Illnesses and Difficult Diseases Relied on Fu Zi,” which I compiled during my university years in 2000-2001, when people were not yet aware of the Huogong school. However, I was too young at that time, and no one was willing to help me publish it, so it was not until 2006, when the Huogong school was popular, that it was published. In the postscript of that book, I stated that I am actually an eclectic practitioner. In fact, practicing TCM should be about being eclectic; you are building a large structure and need to place various methods in their corresponding positions. All methods are effective, but they are suitable for different people.
Returning to our case, this patient benefited from Wu Ling San; why use Wu Ling San? You will find out shortly. What I want to emphasize is that we need to think while reading; we need to think while studying and also when not studying, because some things are not in the books, or they may not be mentioned in the texts. For example, the key symptoms of Wu Ling San in “Shang Han Lun” are mild fever, thirst, and difficulty urinating. But in reality, patients often present with dry mouth, which is not mentioned in the texts. Therefore, in addition to thinking while studying, it is also important to think in clinical practice; this is crucial for progress in TCM; otherwise, we will only be learning ancient knowledge forever.
The recognition of syndromes involves understanding both the common syndromes related to pathogenesis, such as Heart Yin Deficiency Syndrome and Heart Fire Excess Syndrome, as well as learning about formula syndromes, such as Wu Ling San syndrome, Gui Zhi Tang syndrome, and Ma Huang Tang syndrome. Recognition of syndromes also includes recognizing formula syndromes. Water retention is a syndrome of pathogenesis; from this perspective, water retention may equal edema, pleural effusion, and ascites. However, from the perspective of Wu Ling San syndrome, water retention does not necessarily equal edema, pleural effusion, and ascites. Therefore, Wu Ling San should not be simply understood as a diuretic formula; it should not be simply understood as a formula for treating edema, pleural effusion, and ascites. In fact, the examples I will discuss later, such as fever and coldness in the back, include some symptoms that are already mentioned in the texts “Shang Han Lun” and “Jin Gui Yao Lue,” while others are not mentioned in these texts. For instance, if a patient has urinary incontinence, would you still prescribe Wu Ling San if they already have urinary incontinence? If a patient has frequent nighttime urination, would you still want to promote urination? If a patient has cracked lips, would you still use Wu Ling San? In fact, it is not that simple. I will discuss these medical cases shortly.
(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 Press, 2021 edition, pages 38-73)
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Also, the Song of Returning to Kuaiji and its Preface
Li He
During the Liang dynasty, Yu Jianwu once composed a palace body rhyme to respond to the prince. When the national power declined, Jianwu first secretly fled to Kuaiji, and later returned home. I believe there must be some remaining writings, but now I cannot find them, so I composed the Song of Returning to Kuaiji to supplement the sadness.
Wild pepper flour on the wall, damp fireflies fill the palace.
The city tower should teach people, autumn quilt dreams of the bronze chariot.
Wu frost dots the returning temples, the body is soft with the evening reeds.
Gazing at the golden fish, the captive minister guards the humble.