My Clinical Experience Using Zhuling Decoction to Resolve Edema in Cancer Patients

Zhuling Tang (Polyporus Decoction) is a classic famous formula from the Shanghan Lun. The Shanghan Lun mentions it in three original passages:

If the pulse is floating with fever, thirst with desire to drink, and difficult urination, Zhuling Tang governs. (223)

In Yangming disease, if sweating is profuse and there is thirst, Zhuling Tang may not be given, because profuse sweating dries the stomach and Zhuling Tang would further promote urination. (224)

In Shaoyin disease, with diarrhea for six or seven days, cough and vomiting with thirst, and vexation and inability to sleep, Zhuling Tang governs. (319)

Of these three, passages 223 and 319 are the indications of Zhuling Tang, and passage 224 is its contraindication. Later generations summarized Zhuling Tang's indication as the pattern of Shaoyin yin deficiency with binding of water and heat.

I believe that to use Zhuling Tang well one must firmly grasp two points: first, the binding of water and heat; second, the internal retention of fluid. For patients with fluid insufficiency and profuse sweating, Zhuling Tang is not only contraindicated—no diuretic at all should be used.

Zhuling Tang consists of five herbs: E Jiao (Ass-hide gelatin), Zhu Ling (Polyporus), Fu Ling (Poria), Ze Xie (Alismatis Rhizoma), and Hua Shi (Talcum). In the Shanghan Lun the dose of each is one liang. Here one liang is a Han-dynasty liang, about 15 g today. Clinically I also mostly use 10-15 g; for large doses I go up to 30-60 g.

E Jiao nourishes yin and supplements blood; Zhu Ling, Fu Ling, Ze Xie, and Hua Shi are all diuretics. So the logic of Zhuling Tang is easy to understand: on the one hand it nourishes yin and clears heat, and on the other it promotes diuresis and reduces swelling. It suits patients with yin-deficiency internal heat combined with internal fluid retention.

Internal fluid retention has various presentations: retained fluid in the upper jiao causes cough, wheezing, and vomiting; retained fluid in the small intestine causes loose diarrhea; retained fluid in the kidney and bladder causes difficult urination; retained fluid in the upper or lower limbs causes edema of the upper or lower limbs. Thus any patient with the above symptoms plus yin-deficiency internal heat may be treated with Zhuling Tang. Only those with profuse sweating cannot use it, because profuse sweating already consumes the body's fluids; adding a diuretic would make the fluid insufficiency even worse.

Zhuling Tang may be widely used for pyelonephritis, kidney stones, chyluria, asthma, cough, and other conditions of the water-heat binding with fluid retention pattern. It may also be used for edema in cancer patients caused by pleural effusion, ascites, pelvic effusion, or lymphatic obstruction, but the pattern differentiation must be precise.

I treated a lymphoma patient who recently developed edema. I first used modified Huangqi Fangji Tang and Guizhi Jia Gegen Fuling Tang without effect. I used Huangqi Fangji Tang because this patient had also developed edema two years earlier, which I had resolved with Huangqi Fangji Tang. I used Guizhi Jia Gegen Fuling Tang because the patient had stiffness of the neck and upper back; after taking it, the neck and back were no longer stiff, but the edema was not resolved.

Since the edema was not resolved, I worried that further delay would affect the patient's quality of life, and I urged him to combine Chinese and Western medicine and undergo chemotherapy. But the patient himself was hesitant, wanting to continue TCM treatment; moreover, because of COVID-19, hospital chemotherapy also required queuing. So I found another way for him. He added two new reports: first, the edema was milder in the morning and worse at night; second, the stool was loose. Based on these two points, I felt the patient fit the Zhuling Tang indication.

I therefore decided to try Zhuling Tang combined with Er Cao Dan. I prescribed: E Jiao 12 g (melted separately), Fu Ling 30 g, Zhu Ling 30 g, Ze Xie 30 g, Hua Shi 30 g (wrapped for decoction), Han Lian Cao (Ecliptae Herba) 30 g, Che Qian Cao (Plantaginis Herba) 30 g. I also instructed him to take Zhi Bai Dihuang Wan, Xi Huang Wan, and the anticancer medicine prepared according to my multi-target anticancer approach with large compound TCM formulas (the detailed medication rationale is in the linked article). After taking the medicine, the effect was immediate: urination increased and the edema rapidly resolved.

This shows that once TCM finds the right treatment approach, the onset of action can be very fast.