Original case is from Qin Bo-Wei.
A 54 year old female became chilled after taking a bath, which resulted in floating edema in her lower limbs. She then became fatigued due to her household duties and the condition gradually worsened. When I saw her at a group consultation the disease had already been going on for nine months. She presented with whole body pitting floating edema, numbness and tingling in the hands, flusteredness, dry mouth with intake of fluids, a sensation of hunger in her abdomen and was eating more than normal, increased quantity of clear urination, and her bowels were normal. The pulse was wiry, large and rapid and she had a smooth bare red tongue with cracks. Her complexion was sallow yellow and lack luster.
This case is a complex of excess and deficiency symptoms where the primary issue stemmed from Spleen deficiency unable to transform dampness. The Yellow Emperor’s Internal Classic says,
All dampness with swelling and fullness is ascribed to the Spleen.”
However apart from the appearance of the sallow yellow complexion, numbness and tingling in the hands, flusteredness which are from Spleen deficiency and insufficiency of engendering transformation, there was thirst with an intake of fluids, increased appetite, long voidings of clear urine, which are discrepancies in regard to the pattern of damp obstruction. Further contrarian signs were the tongue and pulse, which corresponded to an extreme deficiency of Spleen and Stomach fluids. Therefore, cosiderations where based on what Hua Xiu said,
If there is Spleen yang insufficiency with cold dampness in the stomach it is suitable to warm, dry, ascend, and transport, naturally abiding by Dong Yuan’s method. However, if the Spleen yang is not exhausted and there is dry fire the in Stomach, then one should follow Mr. Ye’s (Ye Tian-Shi) method of nourishing the Stomach yin.”
Therefore the prescription used fundamentally augmented the Stomach and generated fluids.
The prescription was:
- shí hú (Dendrobii Herba)12g
- shä shën (Radix Adenophorae seu Glehniae)12g
- tiän huä fên (Trichosanthis Radix)12g
- bái sháo (Paeoniae Radix alba)12g
- shän yào (Dioscorea Rhizome)24g
- huáng qí pí (Astragali Cortex)9g
- dōng zhú (frostbitten Ovate Atractylodes)9g
- yì yî rén (Coicis Semen)15g
- chì xiâo dòu (Phaseoli Semen)30g
After three packets the floating edema gradually reduced. After six packets, the red tongue became pale and a thin coat developed. This was a rather peculiar case study.
Source: Complete Famous Medical Works of Qin Bo-Wei (2002),Chinese Medicine Ancient Works Publishing House (p. 84).
Translated by: Jason Blalack
Jason’s commentary: This is an elegant example of how to address two seemingly contradictory patterns at the same time. Pitting floating edema is often thought to be caused by yang deficiency. However, there are other causes that one must consider, and this case specifically demonstrates one of those possibilities.
Fundamentally this is a case of lack of Spleen function (hence the Nei Jing quote), precisely Spleen yin deficiency and Spleen qi deficiency, with the inability to transform dampness.
It is easy to see the differences between a yin deficiency pattern and one of the yang deficiency. Less clear is the difference between qi and yang deficiency. Although qi is related to yang from a yin and yang relativity perspective, qi deficiency as a diagnosis (and consequent treatment) is different than yang deficiency. Yang deficiency floating edema uses a warming and transforming method with medicinals such as zhì fù zî (Aconiti Radix lateralis preparata), guì zhï (Cinnamomi Ramulus), gän jiäng (Zingiberis Rhizoma), and jiäo mù (Zanthoxyli Semen). This strategy is inappropriate for this case.
Dr. Qin makes a specific point in addressing this issue by quoting Hua Xiu, which points out the difference in treatment principles between Spleen yang deficiency (with the use of warming medicinals) and dry fire/ yin deficiency heat (with the nourishment of Stomach yin). Therefore the latter principle is the foundation of the formula, coupled with medicinals to augment the Spleen and Stomach, and of course address the dampness. Therefore, this formula is very simple to understand if one understands these treatment principles.
1.shí hú (Dendrobii Herba), shä shën (Radix Adenophorae seu Glehniae), tiän huä fên (Trichosanthis Radix), and bái sháo (Paeoniae Radix alba) nourish fluids and yin.
2. shän yào (Dioscorea Rhizome), huáng qí pí (Astragali Cortex), and dōng zhú (frostbitten Ovate Atractylodes) augment the Spleen and Stomach (qi).
These two core treatment principles address the root deficiency that is leading to the dampness.
3. huáng qí pí (Astragali Cortex), yì yî rén (Coicis Semen), and chì xiâo dòu (Phaseoli Semen) mildly transform and promote the resolution of dampness. These mild medicinals are chosen so as not to damage the yin.
Finally, Dr. Qin, in a discussion following this case, emphasizes how one needs to be flexible and not latch on to a standard treatment strategy for a specific condition. One must evaluate the individual patient in context of their chief complaint. For example, to blindly latch on to a dry dampness or warm and transforming method because one assumes the chief complaint (floating edema) must come from a cold damp or yang deficiency pattern would be a mistake. Instead Dr. Qin understands human physiology enough to know that Spleen yin and qi deficiency is enough to explain the dampness and floating edema.
Therefore not only does Dr. Qin use a treatment strategy that is not commonly discussed for floating edema, but he also combines treatment strategies to fit the individual. This is a perfect example of how TCM is meant to be flexibly practiced. Unfortunately, TCM is often portrayed as being simplistic or “cookbook style” because of the seemingly clear-cut categories that correspond to various diseases. However, Dr. Qin, one of the key architects in designing TCM, clearly demonstrates that this is not how one practices in real life. Such patterns are mere guidelines and not meant for boxes that your patient must be fit into.
Original Chinese: 女，五十四岁。因浴后受凉，下肢发现浮肿;又因家务劳累，逐渐加重。当我会诊时，病已九个月，全身浮肿，按之有坑，手麻，心慌，口干引饮，腹中知饥，食量比平时增加，小便量多色清，大使日行，脉象弦大而数，舌光红有裂纹，面色萎黄不泽。根据以上虚实夹杂症状，首先从脾虚不能化湿考虑，《黄帝内经》所谓 “诸湿肿满，皆属于脾”。但是除了面色萎黄、手麻、心悸为脾虚生化不及的现象外，口渴能饮，腹饥量增，小便清长，均不符合于湿阻。相反地在脉舌方面，表现为脾胃津液极虚。为此，依据华峨云所说:”脾阳不足，胃有寒湿，-脏-腑皆宜于温燥升适者，自当洛遵东垣之法;若脾阳不亏，胃有燥火，则当遵叶氏养胃阴之法。”用了益胃生津为主的方剂，石斜、沙参、花粉、白芍各四钱，山药八钱，黄瓦皮、冬术各三钱，生政仁五钱，赤豆-两。三剂后，浮肿渐退;六剂后，舌红本淡，布生薄苔。这是一个比较特殊的病例。