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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 teacher s book on herbal gynecology www whitepinehealingarts com index htm 36 Vol 4 1 By Qin Bo Wei Translation commentary by Sharon Weizenbaum T HE PATIENT S 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 Yuan s method On the other hand if the Spleen yang is not depleted and the Stomach has dry fire then one should follow Ye Tian Shi s 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 Translator s 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 qi s ability to transform fluids We can know for sure that this patient s 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 ORIENTAL MEDICINE PAEDIATRICS April May 2007 Sydney Adelaide Melbourne Brisbane The most comprehensive 2 day course on paediatrics currently available by Professor and practitioner D r S oma G lick D O M L Ac Cert C Hom USA includes Sho ni shin Acupuncture Moxibustion Chinese Herbal Formulas Acute Homeopathic Remedies Dietary lifestyle recommendations Specific diagnosis treatment strategies Practical experience Art of Health for information 1800 089 770 info artofhealth com au The Lantern 37

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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 patient s 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 Husbandman s 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 patient s 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 Ye s 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 Shi s 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 The Lantern 39