Synopsis of the Golden Chamber, Middle Volume: Chapter 12 — Phlegm-Fluid Cough Syndrome and Pulses, and Their Treatment
Overall Paraphrase
This chapter discusses coughing and related illnesses caused by phlegm-fluid (abnormal accumulation of fluids due to metabolic dysfunction in the body, forming pathological fluid retention). The chapter begins with a Q&A format, classifying water-fluid diseases into four types: phlegm-fluid, suspended fluid, spilled fluid, and supporting fluid. The distinctions are:
- Phlegm-fluid: The body was previously robust but now emaciated. Fluids move within the intestines, producing gurgling sounds in the abdomen.
- Suspended fluid: After drinking water, fluid accumulates below the ribs. Coughing or expectoration pulls on the area below the ribs, causing pain.
- Spilled fluid: After drinking water, fluid spills into the four limbs. It should be expelled through sweating, but sweating does not occur. The body feels painful and heavy.
- Supporting fluid: Coughing with qi reversal, requiring the patient to lean on something to breathe. Shortness of breath prevents lying flat, and the body appears swollen.
Water-fluid can also affect the five viscera: When fluid stops at the heart, the epigastric region feels hard with palpitations, shortness of breath, and aversion to drinking water. When fluid stops at the lungs, the patient spits saliva but desires water. When fluid stops at the spleen, there is shortness of breath, fatigue, and bodily heaviness. When fluid stops at the liver, there is fullness and distension below the ribs, with pain on sneezing. When fluid stops at the kidneys, there is palpitation below the heart.
Regarding retained fluid (fluid that lingers for a long time): When retained fluid is below the heart, there is an area on the back the size of a palm that feels cold. When retained fluid is below the ribs, pain radiates to the supraclavicular fossa and worsens with coughing. When retained fluid is in the chest, there is shortness of breath, thirst, and wandering pain in the four limbs and joints. A deep pulse indicates retained fluid. If there is phlegm above the diaphragm, with chest fullness, wheezing, coughing, and phlegm production—attacks accompanied by chills and fever, back pain, lumbar pain, involuntary tearing, bodily tremors, and muscle twitching—there is bound to be latent fluid (fluid hidden deep within, triggered by external contraction).
Excessive drinking of water may suddenly cause wheezing and abdominal fullness. Eating little but drinking much water causes water to stop below the heart—severe cases lead to palpitations, mild cases to shortness of breath.
Regarding pulse diagnosis: If both cun pulses are wiry, it leans toward cold, commonly seen after severe purging causing deficiency. If one side is wiry, it mostly indicates fluid. In lung fluid, the pulse is not wiry—only suffering from wheezing and shortness of breath. In supporting fluid, there is also wheezing with inability to lie flat, shortness of breath, yet the pulse appears calm.
The general treatment principle is: Phlegm-fluid disorders should be harmonized and dispersed with warm-natured medicinals.
The following formulas, their compositions, and decoction methods are direct records from ancient texts. They are provided solely for understanding classical medical theory and do not constitute any medicinal guidance.
The chapter then presents a series of formulas and syndromes:
- Phlegm-fluid below the heart, with chest and rib support fullness and dizziness—the ancient formula Linggui Zhugan Tang is used: Fuling (Poria) 4 liang, Guizhi (Cassia twig) 3 liang, Baizhu (Atractylodes macrocephala) 3 liang, Gancao (Licorice) 2 liang. Decoct 6 sheng of water down to 3 sheng, take warm in three divided doses. Urination becomes free after the medicine. This embodies warming yang to transform fluid and strengthening the spleen to promote water metabolism.
- Shortness of breath with mild fluid accumulation—should be eliminated through urination. Linggui Zhugan Tang may be used, or Shenqi Wan (Kidney Qi Pill). This illustrates treating the same disease with different approaches: one warms the spleen yang, the other tonifies kidney qi.
- Hidden pulse, desire to purge, comfort after purging, but hardness and fullness below the heart persist—this indicates retained fluid about to be expelled. The ancient formula Gansui Banxia Tang is used: Gansui (Kansui root) 3 large pieces, Banxia (Pinellia) 12 pieces, Shaoyao (Peony) 5 pieces, zhi Gancao (honey-fried Licorice) 1 piece. After decoction, honey is added and taken in one dose. This formula attacks and expels water-fluid, guiding it out according to its tendency. Its action is harsh and potent—for scholarly study only.
- Floating, thin, and slippery pulse indicates mild injury from water-fluid. Wiry and rapid pulse with cold-fluid is difficult to treat in winter and summer. Deep and wiry pulse suggests suspended fluid with internal pain.
- Suspended fluid disease—the ancient formula Shizao Tang is used: Yuanhua (Genkwa flower), Gansui (Kansui root), Daji (Peking spurge root), equal amounts, pounded and sifted. First decoct 10 large jujubes into a soup, then add the powder. The strong take one qianbi (approximately 1–1.5 g); the weak take half a qian, taken warm in the early morning. If there is no purging, add half a qian the next day. After free purging, congee is used for recuperation. This is a potent water-attacking formula and must never be self-administered today.
- Spilled fluid disease—sweating should be induced. Ancient formulas include Da Qinglong Tang or Xiao Qinglong Tang. Da Qinglong Tang: Mahuang (Ephedra) 6 liang, Guizhi 2 liang, zhi Gancao 2 liang, Xingren (Apricot kernel) 40 pieces, Shengjiang (Fresh ginger) 3 liang, Dazao (Jujube) 12 pieces, Shigao (Gypsum) the size of a chicken egg. Xiao Qinglong Tang: Mahuang 3 liang, Shaoyao 3 liang, Wuweizi (Schisandra) half a sheng, Ganjiang (Dried ginger) 3 liang, zhi Gancao 3 liang, Xixin (Asarum) 3 liang, Guizhi 3 liang, Banxia half a sheng. Both formulas release spilled fluid through the surface—Da Qinglong also clears internal heat, while Xiao Qinglong warms and transforms cold-fluid.
- Supporting fluid above the diaphragm: wheezing and fullness, epigastric rigidity, dark dull facial complexion, deep and tight pulse. Illness lasting dozens of days, not resolved by emetic or purgative methods—the ancient formula Mufangji Tang is used: Mufangji (Fourstamen Stephania root) 3 liang, Shigao 12 pieces, Guizhi 2 liang, Renshen (Ginseng) 4 liang. Those with deficiency recover; those with excess relapse after three days. If the second dose does not cure, switch to Mufangji Tang minus Shigao, plus Fuling and Mangxiao: Mufangji 2 liang, Guizhi 2 liang, Renshen 4 liang, Mangxiao (Mirabilite) 3 he, Fuling 4 liang. This demonstrates the transformation between deficiency and excess in supporting fluid and modifying formulas accordingly.
- Supporting fluid below the heart with pronounced dizziness and vertigo—use Zexie Tang: Zexie (Alisma) 5 liang, Baizhu 2 liang. Promotes water metabolism and strengthens the spleen.
- Supporting fluid with chest fullness—use Houpo Dahuang Tang: Houpo (Magnolia bark) 1 chi-lenth, Dahuang (Rhubarb) 6 liang, Zhishi (Immature bitter orange) 4 pieces. Moves qi and purges downward.
- Supporting fluid causing breathing difficulty—use Tingli Dazao Xiefei Tang (formula found in the Lung Abscess chapter). Drains the lungs and expels fluid.
- Those who vomit should ordinarily be thirsty; thirst indicates the illness is improving. If instead there is no thirst, it is supporting fluid below the heart—the ancient formula Xiao Banxia Tang is used: Banxia 1 sheng, Shengjiang half a jin. Warms the stomach, disperses fluid, and stops vomiting.
- Abdominal fullness, dry mouth and tongue—water qi in the intestines—the ancient formula Jijiao Lihuang Wan is used: Fangji (Stephania tetrandra), Jiaomu (Prickly ash seed), Tinglizi (Tingli seed), Dahuang, 1 liang each. Make honey pills the size of parasol seeds. Resolves water-fluid from both front and back.
- Sudden vomiting, epigastric oppression, fluid above the diaphragm, dizziness, and palpitations—use Xiao Banxia Jia Fuling Tang: Banxia 1 sheng, Shengjiang half a jin, Fuling 3 liang. Harmonizes the stomach, directs counterflow downward, and promotes water metabolism.
- Thin-built individuals with palpitations below the umbilicus, spitting saliva, dizziness and vertigo—water-fluid is the cause—use Wuling San: Zexie 1 liang 1 fen, Zhuling (Polyporus) 3 fen, Fuling 3 fen, Baizhu 3 fen, Guizhi 2 fen. Ground into powder, taken with rice gruel and warm water, aim for slight sweating for recovery. Transforms qi and promotes water metabolism.
- Attached formula from Waitai — Fuling Yin: Treats retained phlegm-water in the chest and heart, with emptiness in the chest and heart after vomiting water, qi fullness with inability to eat. Dissolves phlegm-qi and opens the stomach to promote appetite. Composition: Fuling, Renshen, Baizhu, 3 liang each; Zhishi 2 liang; Jupi (Tangerine peel) 2 liang and a half; Shengjiang 4 liang.
- Chronic cough with wiry pulse indicates water-fluid—the ancient formula Shizao Tang is recommended. Individuals with a supporting-fluid constitution who cough, feel vexed, experience chest pain, and do not die suddenly but linger to one hundred days or even a year—ancient practitioners still considered Shizao Tang. For chronic cough of many years: a weak pulse is treatable; a full, large, and rapid pulse carries a poor prognosis. A deficient pulse necessarily causes dizziness—because there was originally supporting fluid in the chest—and treatment belongs to the fluid category.
- Cough with qi reversal, needing to lean for breath, inability to lie flat—use Xiao Qinglong Tang.
- After taking Xiao Qinglong Tang: if excessive salivation, dry mouth, deep cun pulse, faint chi pulse, cold hands and feet, qi rushing from the lower abdomen up to the chest and throat, numbness of the hands and feet, facial heat as if drunk, then flowing down to the genitals and thighs, difficult urination, and frequent dizziness—the ancient formula Guiling Wuwei Gancao Tang treats the qi surge: Fuling 4 liang, Guizhi 4 liang, zhi Gancao 3 liang, Wuweizi half a sheng.
- After the surging qi settles, if instead there is coughing and chest fullness—use Guiling Wuwei Gancao Tang minus Guizhi, plus Ganjiang and Xixin, to treat cough and fullness: Fuling 4 liang, Gancao 3 liang, Ganjiang 3 liang, Xixin 3 liang, Wuweizi half a sheng.
- After cough and fullness cease, thirst reappears and qi surges again—because Xixin and Ganjiang are warm medicinals. Thirst should occur; if instead there is no thirst, it is supporting fluid. Supporting fluid necessarily causes dizziness, which necessarily leads to vomiting. With vomiting, add Banxia to remove water: Fuling 4 liang, Gancao 3 liang, Xixin 2 liang, Ganjiang 2 liang, Wuweizi half a sheng, Banxia half a sheng.
- After water-fluid is removed and vomiting ceases, but the body becomes edematous—add Xingren. By standard logic, Mahuang should be used, but since the patient has numbness, it is not used. If Mahuang were mistakenly used, it would stir the yang qi and cause cold extremities, because the patient's blood is deficient: Fuling 4 liang, Gancao 3 liang, Wuweizi half a sheng, Ganjiang 3 liang, Xixin 3 liang, Banxia half a sheng, Xingren half a sheng.
- If the face becomes hot as if drunk—stomach heat surging upward to the face—add Dahuang to promote defecation: Fuling 4 liang, Gancao 3 liang, Wuweizi half a sheng, Ganjiang 3 liang, Xixin 3 liang, Banxia half a sheng, Xingren half a sheng, Dahuang 3 liang.
- Thirst followed by vomiting—water stopping below the heart—belongs to the fluid category. Use Xiao Banxia Jia Fuling Tang.
🧠 Deep Understanding
Core Principles 💡
- The substance of the four-fluid classification: Based on the site of fluid retention and clinical manifestations, it reveals the "ever-moving and unsettled" nature of water-fluid disease. The same water pathogen, stopping in different locations, manifests entirely differently, indicating that treatment must identify the precise location of the disease.
- "Warm medicinals to harmonize" as the general guideline: Phlegm-fluid belongs to yin pathogens, easily damaging yang qi. It coagulates when cold and moves when warmed. Warm-natured medicinals can invigorate yang qi, transform qi, and move water—hence they constitute the principal treatment method. However, "harmonize" does not mean drastic supplementation but rather moderation, avoiding excessive warmth that damages yin or excessive dryness that harms fluids.
- Guiding according to tendency: Based on the location and momentum of the disease, give the pathogen the nearest route of exit—spilled fluid in the exterior is treated by sweating; mild fluid below is treated by promoting urination; suspended and retained fluid may be attacked and expelled; supporting fluid in the chest and diaphragm is treated by moving qi and resolving fluid or draining the lungs. This is the therapeutic logic running through the entire chapter.
- Dynamic syndrome differentiation: The series of modifications after Xiao Qinglong Tang best exemplifies "observe the pulse and syndrome, know what error was committed, and treat accordingly." The changes in qi surge, cough, thirst, vomiting, edema, and facial heat are matched by adjustments in the formula, demonstrating that phlegm-fluid disorders constantly transform among cold, heat, deficiency, and excess—one formula cannot be used throughout.
- Integrating pulse and syndrome: The wiry, deep, hidden, weak, full, large, and rapid pulses are used to judge the depth of fluid retention, the state of vital qi, and prognosis—reflecting the distinctive features of ancient empirical medicine.
Modern Perspective 🌟
- The four fluids may correspond to certain modern clinical presentations: suspended fluid resembles pleural effusion, supporting fluid resembles cardiogenic pulmonary edema or asthma, spilled fluid resembles systemic or limb edema, and phlegm-fluid resembles gastrointestinal fluid accumulation or chronic digestive disorders. However, TCM uses syndrome classification, which is not identical to modern disease diagnosis.
- Formulas that warm yang and promote water metabolism—such as Linggui Zhugan Tang, Zexie Tang, and Wuling San—may involve mechanisms in modern research such as regulating aquaporins, improving circulation, and anti-inflammatory effects, but more high-quality evidence is needed, and they cannot replace modern diagnosis and treatment.
- Harsh water-expelling medicinals like Gansui, Yuanhua, and Daji have明确 toxicity and strong irritant effects. Modern clinical use is extremely rare and requires strict control. Ancient records reflect historical usage—they must not be self-tried.
- Ancient prognostic statements such as "a weak pulse is treatable; a full, large, and rapid pulse indicates death" were summaries of observational experience at the time. Today, judgment should combine imaging, laboratory, and other modern modalities—pulse diagnosis alone cannot determine prognosis.
- "Warm medicinals to harmonize" emphasizes restoring the body's own water metabolism and carries value in holistic regulation, but for specific illnesses, standard medical consultation remains essential.
Health Insights ⚡
- Moderation in eating and drinking: Do not overdrink water, especially for those with weak spleen and stomach—avoid large one-time intake of fluids and cold beverages to reduce the risk of fluid stagnation.
- Nurture the spleen and stomach: Maintain regular meals, avoid excessive hunger or fullness, reduce raw, cold, and greasy foods, and avoid prolonged residence in damp environments.
- Timely treatment of external contractions: Do not delay treatment of colds, coughs, or wheezing to avoid repeated attacks leading to latent fluid.
- If persistent cough, wheezing, inability to lie flat, chest and rib pain, obvious edema, or urinary abnormalities occur, seek medical attention promptly—do not self-prescribe ancient formulas.
📚 Related Knowledge
- Related concepts: Water-qi disease, water metabolism of the lungs, spleen, and kidneys, Triple Burner qi transformation, phlegm-fluid-dampness sharing a common origin with divergent pathways, surging of qi upward, supporting fluid and heart yang, retained fluid and latent fluid.
- Further reading: Synopsis of the Golden Chamber, Chapter on Water-Qi Disease and Pulses and Treatment; Treatise on Febrile Diseases (Shanghan Lun), passages concerning Linggui Zhugan Tang, Shizao Tang, Wuling San; Jingyue Quanshu, Section on Phlegm-Fluid; Linzheng Zhinan Yian, Section on Phlegm-Fluid.
This content is based on classical Chinese medical texts and is provided solely for cultural and classical study. It does not constitute any medical diagnosis, medication guidance, or treatment recommendation. Please seek timely medical care if unwell.
