The wisdom of regulating “water” in Zhang Zhongjing’s 《伤寒论 – Treatise on Cold Damage》is vividly illustrated through the prescription Ling Gui Zhu Gan Decoction. The focus is the mechanism of “warming yang and transforming qi” in Ling Gui Zhu Gan Decoction, which is a classic and effective solution for “fluid retention” disorders.
Operation of Bodily Fluids in the Body
Only when the metabolism of bodily fluids is balanced can normal life activities occur. Once imbalanced, it leads to “water” diseases.
When we drink water, how are the bodily fluids metabolized and circulated in the body? Normally, bodily fluids circulate in the form of “qi” (steam or vapor). This means water must transform from a liquid state into a gaseous (qi) state to circulate throughout the body. To transform water into qi, a driving force is needed — that is, fire. Fire in human physiology is yang qi. The warming and transforming actions of yang qi promote the conversion of bodily fluids into qi, similar to boiling water to produce steam — requiring fire. In Chinese medicine, this process is called “qi transformation”.
If there is a deficiency in yang qi, bodily fluids cannot transform into qi and will accumulate somewhere: under the skin causing edema, in the chest or abdomen causing hydrothorax or ascites, or accumulate in organs leading to water disorders of the five organs (five organ water diseases). Therefore, water-related diseases are largely due to a deficiency in yang qi or lack of “fire”. Hence, when treating, warm yang herbs are often added to promote the transformation of water into qi. Just as Zhang Zhongjing stated, “For phlegm and fluid ailments, one should use warm medicine to harmonize” (For phlegm and fluid ailments, warm medicine should harmonize).
Some Disorders Due to Fluid Metabolism Imbalance
When the body’s fluid metabolism becomes chaotic, various signs will appear, including those caused by water, dampness, phlegm, and fluid, leading to issues across all systems.
The proliferation of water, dampness, phlegm, and fluid collectively refers to fluid metabolism disorders. Generally: dampness accumulates into water, water gathers into fluid, fluid accumulates into phlegm. The more liquid form is fluid, and the thicker form is phlegm. Clinically, it can sometimes be difficult to clearly differentiate, resulting in terms like: water-dampness, water-fluid, phlegm-fluid, phlegm-dampness, representing the holistic perspective of Chinese medicine.
Treatment of Water Disorders in 《伤寒论 – Treatise on Cold Damage》
The treatment of water disorders in 《伤寒论 – Treatise on Cold Damage》is clearly stratified into three basic levels: Transforming water (fluid), facilitating water, and expelling water.
- Transforming water: When water and dampness have not yet become severe, the method of warming yang to transform qi is used (using warm yang herbs or aromatic herbs to evaporate water and dampness). This is like a light rain moistening the ground, which evaporates when the sun appears. Formulas like Fu Ling Gan Cao Tang and Ling Gui Gan Zao Tang belong to this category.
- Drying dampness/Permeating dampness: When water accumulation increases (like a small pond), simply warming isn’t fast enough. At this stage, “Drying dampness” (using drying herbs) or “Permeating dampness” (using soil to cover the pond so water is absorbed into the ground) is required. The Spleen is associated with Earth, so tonifying the Spleen essentially equates to enhancing Earth to permeate dampness. Formulas like Ling Gui Zhu Gan Decoction and Li Zhong Decoction belong to this category.
- Facilitating water: If water and dampness are excessive (like a large pond), using soil to cover is labor-intensive. The best method is to clear the water flow (dig drainage). This is the facilitating water method. Formulas like Wu Ling San, Zhen Wu Tang, and Zhu Ling Tang fall into this group.
- Expelling water: If water and dampness are extremely severe, akin to flooding or severe blockage, a strong method to expel the flood is necessary. This is the expelling water method (strong purging, both urination and defecation increase significantly). Special care is needed when using this approach. Formulas like Shi Zao Tang, Da Xian Xiong Tang, and Mu Li Zhe Xie San are in this group.
Ling Gui Zhu Gan Decoction – Composition and Uses
Ling Gui Zhu Gan Decoction comprises four ingredients: Fu Ling, Gui Zhi, Bai Zhu, Gan Cao. This blend incorporates damp-drying, permeating, and facilitating water.
- Fu Ling: Tasteless and mildly balanced, it permeates dampness and facilitates urination to eliminate excess water, also tonifying the Spleen and calming the heart.
- Gui Zhi: Pungent and sweet with a warm nature, it warms yang to transform qi, opens appetite, strengthens the Spleen, and dilates blood vessels to “transform” excess water.
- Bai Zhu: Bitter and warm, it tonifies and benefits Spleen qi, dries dampness, and works with Fu Ling to absorb residual water fluids.
- Gan Cao: It nourishes Spleen qi on one hand, and harmonizes the other ingredients on the other.
Ling Gui Zhu Gan Decoction Treats Dizziness
Zhang Zhongjing uses it to treat internal fluid retention syndrome due to Spleen deficiency. The Spleen is “the source of qi and blood” and “the acquired root.” When the Spleen is deficient it fails to transport and transform fluids, causing water which turns to phlegm and dampness resulting in illness.
In 《伤寒论 – Treatise on Cold Damage》, Spleen deficiency with water retention can lead to: “the region under the heart is irritated and full, qi rushes up to the chest, standing causes dizziness… the body trembles unsteadily” (the area below the heart is bloated, qi surges to the chest, standing causes dizziness… the body trembles unsteadily). Ling Gui Zhu Gan Decoction is a “trump card” for treating dizziness caused by mid-focus fluid dampness invading the head.
Ling Gui Zhu Gan Decoction Treats “Water-Heart Disease”
The renowned master Liu Douzhou used this formula marvelously to treat heart diseases due to water rising to the heart, coining the term “water-heart disease”.
- Observing color: Dark facial color (water color). In severe cases, black spots may appear on the cheeks, nose, lips (water spots).
- Tongue diagnosis: Pale and swollen tongue, with a slick and wet coating.
- Pulse diagnosis: Wiry, deep or knotted pulse.
- Differential diagnosis: Symptoms of water qi surging upward (qi surging from below the heart to the throat); chest pain and fullness; palpitations; shortness of breath.
Ling Gui Zhu Gan Decoction for Water Qi and Phlegm-Fluid
With their flowing nature, water qi and phlegm-fluid cause diverse diseases in the cardiovascular, digestive, respiratory, and sensory systems.
- “Strange” heart diseases: A coronary artery disease patient frequently spat white foam from the throat up to 1 meter, accompanied by nausea and hand tremors. Liu Lao diagnosed water qi rising to the heart, using Ling Gui Zhu Gan Decoction combined with Ze Xie, Ban Xia, and fresh ginger, cured in 14 doses.
- Digestive: Bloating, loss of appetite, nausea, immediate bowel urge after eating. This formula strongly nourishes central qi, helping boost immunity.
- Respiratory: Coughing or wheezing due to phlegm-fluid, with copious phlegm. This formula treats the underlying cause of phlegm by strengthening the Spleen.
- Sensory: Used for papilledema (can be combined with Ren Shen, Ju Hua, Gou Qi Zi, Che Qian Zi), increased intraocular pressure, allergic rhinitis, postnasal drip (combined with Li Zhong Tang).
Modifications to Ling Gui Zhu Gan Decoction
Clinical modifications can be made according to symptoms:
- Excessive phlegm with slippery pulse: Combine with Er Chen Tang.
- Severe dizziness: Add Ze Xie.
- Facial flushing: Add Bai Wei.
- High blood pressure: Add Hong Hua, Xi Xian Cao, Yi Mu Cao, Niu Xi.
- Knotted or large pulse: Remove Bai Zhu and add Wu Wei Zi.
- Cold damp-induced cough: Remove Bai Zhu and add Yi Yi Ren.
- Palpitations or fearfulness: Add Long Gu, Mu Li.
With its ability to strengthen the Spleen and harmonize the center, Ling Gui Zhu Gan Decoction is the optimal solution for disorders caused by water qi and phlegm-fluid. The flexible application of transforming-facilitating-expelling water levels helps achieve high clinical efficacy.
