case study

Spleen and Stomach yin

deficiency water swelling
This is a case1 of a 54-year-old woman. Her main complaint
was edema throughout the whole body. It developed in
her lower limbs when she caught a chill after bathing.
Another cause was the great demand of household duties
that led her to over work herself. Gradually the water swelling became worse. When she came to see me, she had
been suffering from this for more than nine months.
n Qin Bo-Wei (1901-1970) was
one of the most influential
scholar-physicians in Chinese
medicine during the 20th century.
n Sharon Weizenbaum has been
practising Chinese medicine for
23 years and has lectured around
the US. In 1998 she founded
White Pine Healing Arts a centre
dedicated to the practice and
teaching of Asian medicine, and
is currently the director. Sharon is
also a Frances Perkins Scholar at
Mt HolyokeCollege where she is
translating her teachers book
on herbal gynecology.
www.whitepinehealingarts.com/
index.htm

36

Vol 41

By Qin Bo-Wei
Translation & commentary
by Sharon Weizenbaum

HE PATIENTS WHOLE BODY had superficial

edema that pitted when pressed. Her hands
tingled, she felt flustered, thirsty and liked to
drink. Her abdomen was swollen and her appetite very strong. Her urination was copious and
clear, bowel movements normal, pulse wiry, big
and rapid. Her tongue was glossy red with cracks
like porcelain. Her complexion was withered yellow and lacked lustre.
Diagnosis and treatment method: In order
to treat the root fluid insufficiency of the Spleen
and Stomach, the method had to be to boost the
Stomach and generate fluids.

Shi Hu
Sha Shen
Tian Hua Fen
Bai Shao
Shan Yao
Huang Qi Pi
Bai Zhu
Sheng Yi Ren
Chi Xiao Dou

12g
12g
12g
12g
24g
10g
10g
15g
30g

(Dendrobii Herba)
(Glehniae Adenophorae Radix)
(Trichosanthis Radix)
(Paeoniae Radix alba)
(Dioscoreae Rhizoma)
(Astragali Cortex)
(Atractylodis macrocephalae)
(Coicis Semen)
(Phaseoli Semen)

After three packets of these herbs, the swelling

gradually decreased. After six packets the tongue
became paler and a coat began to develop.
Discussion: This case of water swelling for more
than nine months is a mix of excess and deficiency. From the complex symptoms Dr Qin grasped
the main pathological condition and firmly established the disease mechanism. He first thought
over Spleen vacuity as the root of why this patient
could not transform dampness. The Nei Jing says:
All damp swelling accumulating belongs to the
Spleen. But, aside from the yellow complexion,
arm tingling and flustered heart being (possible)
manifestations of the Spleen being weak and unable to transform, there was also thirst with the
ability to drink, a very strong appetite and profuse
clear urine. These later symptoms did not conform to a disease mechanism of damp blockage.
With the tongue and pulse, these symptoms show
Spleen and Stomach extreme fluid depletion.
According to the sayings of Hua Xiu-Yun2:

case study

When the Spleen yang is insufficient and the

Stomach has cold damp it is appropriate to warm,
dry, raise up and transform. In this kind of case,
one should carefully obey Dong-Yuans method.
On the other hand, if the Spleen yang is not depleted and the Stomach has dry fire, then one
should follow Ye Tian-Shis method of nourishing the Stomach. Therefore, in this case of water swelling Spleen and Stomach yin deficiency
was the principle mechanism. Dr Qin decided
to boost the Stomach and generate fluids as the
main treatment and good results were achieved.
Translators commentary: This case is interesting to me from both a diagnostic and treatment
point of view. Dr Qin was able to resist the temptation we can all feel when we are faced with complex and seemingly contradictory cases to jump to
a simplistic interpretation. He considered Spleen
yang deficiency as a causative factor in the water
swelling but could see it was more complex than
this. I think many of us would get confused to see
pitting edema, which is always a manifestation of
yang deficiency, with a red peeled, cracked tongue
and a great appetite. He knew definitively that the
yin fluids were depleted in this case because of
the tongue presentation, the strong appetite and
the quenchable thirst.

Though the mechanism for how water might

accumulate when yin deficiency is the primary
disease factor is not articulated by Qin or the
writer, perhaps it might be helpful to the reader
to give some explanation. One clue is in the intake: the swelling began after the patient caught
a chill. Cold easily damages the yang qis ability
to transform fluids. We can know for sure that
this patients yang is deficient because of the pitting edema.
Another clue as to how Dr Qin reconciles these
apparently contradictory disease factors can be
found in the formula he wrote. We might expect
Dr Qin to simply enrich the yin with sweet greasy
medicinals and drain dampness with bitter cold
damp draining medicinals.
On the surface that would make sense. But Dr
Qin knew that sweet greasy herbs to enrich the
yin might make the dampness worse and bitter
cold damp draining medicinals could damaged
the yin and yang of the Kidneys. In this case,
the urine was already copious so any herbs that
greatly increase urination would have to be used
with great care.
Dr Qin used a clever method. The first two
herbs are sweet and cool but are also slightly
bitter and so are not excessively cloying. Both
enter the Stomach and generate fluids. Sha Shen

Tian Hua Fen and Shan Yao

have something in common.
They are both chalky.
This means they have the
capacity to increase the
absorptive capacity of the
organs they enter.

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The Lantern

37

feature

38

Vol 41

case study

(Glehniae Adenophorae Radix) has the added

benefit of calming the spirit.
Sha Shen (Glehniae Adenophorai Radix) can make
the Lung metal qi descend clearly, which suppresses Liver wood in order to quiet the ethereal
soul. When both the ethereal soul and the corporeal soul are quieted and settled, fright and
fear will naturally transform.3
Shi Hu (Dendrobii Herba) enters the Stomach
and Kidneys to clear heat and enrich fluids. Tian
Hua Fen (Trichosanthis Radix) and Shan Yao (Dioscoreae Rhizoma) have something in common.
They are both chalky.4 This means they have the
capacity to increase the absorptive capacity of
the organs they enter. Tian Hua Fen (Trichosanthis Radix) increases the absorptive capacity of
the Stomach. It moistens by helping the Stomach absorb fluids into a physiological form. Yin
deficiency is often characterised by an inability
to absorb fluids. This can lead to contradictory
symptoms of dampness and yin deficiency. Shan
Yao (Dioscoreae Rhizoma) increases the absorptive capacity of the Kidneys so this patients urination can be decreased allowing her fluids to be
absorbed and made into Kidney yin. Urine can
be checked without blocking the pathway for the
dampness to leave. When the Kidney qi is able to
absorb well, this does not constrain dampness.5
We do not often think this way as doctors of Chinese medicine but I have found this perspective
invaluable in my clinical practice. It is interesting
that in spite of yin deficiency and frequent urination, Dr Qin did not use Shan Zhu Yu (Corni
Fructus) and Shu Di Huang (Rehmanniae Radix
preparata).
In my opinion, and some may disagree with
me, when there is an accumulation of dampness
along with yin deficiency, we can and should help
the body convert the pathological water back into
the physiological dynamic. We do this by increasing the healthy absorptive functions of the Spleen
and Kidneys. This in turn is done by using chalky
herbs. This is what Qin Bo-Wei did here.
Huang Qi Pi (Astragali Cortex) tonifies the
Spleen qi and as the bark of the plant, it drains
dampness and travels more in the superficial aspects of the body.
Usually when a patient has pitting edema we
use hot herbs along with damp draining herbs to
supplement the yang in order to transform dampness. Most often herbs such as Fu Zi (Aconiti Carmichaeli Praeparata Radix) or Gui Zhi (Cinnamomi Cassiae Ramulus) are used in combination
with damp draining herbs.
In this case though, because the yin was so damaged, Dr Qin used the gently warm properties of
Bai Zhu (Atractylodis macrocephalae Rhizoma)
to supplement yang.

Its nature is very warm, so that taking it strengthens

the Spleen and digestion it is most important
medicinal for tonifying the Spleen organ. Each
organ has both yin and yang. Bai Zhu (Atractylodis macrocephalae Rhizoma) supplements the
yang, so it tonifies the qi.6
Since Bai Zhu (Atractylodis macrocephalae Rhizoma) is drying, how can the Divine Husbandmans Classic of the Materia Medica say that
it generates fluids? It is because the Spleen is
averse to dampness. Once Spleen dampness prevails, the qi is unable to transform: from where
might fluids be generated? Thus it is said: the
Bladder is the dwelling of the yin fluids and
yang fluids, from which they exit [by virtue of]
qi transformation. [This function of qi transformation] explains the present usage of Bai Zhu
(Atractylodis macrocephalae Rhizoma) to dry
dampness and allow qi to circulate, so that the
fluids following qi transformation, might be generated.7
Bai Zhu (Atractylodis macrocephalae Rhizoma)
combined with Yi Yi Ren (Coicis Semen) warms
the yang of the Spleen to transform and drain
dampness. The choice of Yi Yi Ren (Coicis Semen)
is interesting as well. Yi Yi Ren (Coicis Semen)
we mostly know as an herb to leach dampness
through urination.
However, it has a special characteristic that
makes it perfect for this patient. It strengthens the
Spleen while draining damp. Yi Yi Ren (Coicis Semen) is also chalky and it therefore, in my mind,
strengthens the absorptive capacity of the Spleen.
This is how it is able to also stop diarrhea and
why it does not damage the yin.
Its harmonious nature allows it to tonify without
being cloying, and to leach out dampness without harming the yin.8
In addition, Yi Yi Ren (Coicis Semen) eliminates
pathogenic dampness from the flesh, which is
where this patients dampness is lodged.
Chi Xiao Dou (Phaseoli Semen), like all beans,
also has a chalky quality and so, while leaching
dampness, it will also not injure the yin.
Thus, in conclusion, a case such as this can be
very instructive on a number of points, such as:
how to warm the yang in extremely yin deficient
patients; how to drain dampness while protecting both yin and yang; how to help pathological
fluids be absorbed back into physiological dynamics; and importantly, how to determine the
level and place of the dampness, in this case in the
flesh, and use the correct herbs for that location,
in this case Huang Qi Pi (Astragali Cortex) and Yi
Yi Ren (Coicis Semen).

Endnotes
1. Zhong Guo Xian Dai Ming Zhong Yi
Yi An Jing Hua, (Essential Traditional
Chinese Medical Case Studies from
Famous Modern Doctors), Volume 3;
Beijing Science and Technology Press,
1990; pg 1647.
2. Hua Xiu-Yun was a chief disciple
of Ye Gui, and was the man who organized Yes case histories to create
the Lin Zheng Zhi Nan Yi An (A Case
Record Compass of Clinical Patterns)
the prime source for the study of Ye
Tian-Shis clinical art.
3. Zhang Xi-Chun (1918-1934) Essays
on Medicine Esteeming the Chinese
and Respecting the Western, In D. Bensky, S. Clavey & E. Stoger (Eds.) Materia Medica third ed. Seattle Eastland
Press
4. This idea that chalky herbs increase
the absorptive capacity of the Spleen
or Kidney or both is my own observation. When I made this connection,
many case studies made more sense
to me. I have used this concept in the
clinic for years and have only grown
more certain that these herbs work in
this way. Other examples are Duan Mu
Li (Ostreae Concha Calcined), Duan
Long Gu (Fossilia Ossis Mastodi), Ge
Gen (Peurariae Radix) etc.
5. The analogy I use is land that passes the perk test. When land is able to
absorb water, then water is also able to
flow away in a controlled way. When
land cannot absorb because there is
rock or clay under a thin layer of soil,
then there is both dryness and pockets of stagnant swamp area. Water
and possibly sewage seeps away and
into streams and groundwater. That
is why one is not allowed to build on
land that does not perk. Our bodies
are the same. When our Kidneys or
Spleen are unable to absorb, physiological fluids leak out of the body or
into surrounding tissues.
6. Huang Gong-Xiu (1773) Seeking
Accuracy in Materia Medica In D. Bensky, S. Clavey & E. Stoger (Eds.) Materia Medica third ed. Seattle Eastland
Press
7. Chen Jia-Mo, (1525) Hidden Aspects of Materia Medica In D. Bensky,
S. Clavey & E. Stoger (Eds.) Materia
Medica third ed. Seattle Eastland
Press
8. D. Bensky, S. Clavey & E. Stoger
(Eds.) Materia Medica third ed. Seattle
Eastland Press, 1993.

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