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Edema

Edema is a disorder with demonstrable accumulation of excessive fluid in the subcutaneous tissues, which manifests itself as puffiness of the head, face, eyelids, limbs, abdomen, back and scrotum or even general anasarca. It may be accompanied by hydrothorax or ascites in serious cases.

Edema occurring in various diseases, such as cardiac edema, renal edema, hepatic edema, endocrinous edema, nutritional edema, etc., may be differentiated and treated with the principles mentioned in this section.

Etiology and Pathogenesis

The causes of edema are either exogenous or endogenous in origin. Wind, cold and dampness are the common exogenous causative factors, and immoderate diet and drinking, overstrain and debility are the common endogenous factors. The pathogenesis may be summarized as follows:

A. An affection caused by wind-cold or wind-heat impedes the dispersing function of the lungs, leading to the obstruction of water passages and the accumulation of body fluids. Skin infections with accumulation of wind and dampness-heat in the superficies interfere with the function of spleen and lungs and disturb the fluid metabolism. Prolonged affection caused by dampness-heat may lead to dysfunction of the bladder, and edema ensues.

B. Living in a wet and cold place, wading through water or being drenched by rain may induce dysfunction of spleen, which results in accumulation of dampness and fluid.

C. Immoderate diet and drinking or overstrain impairs the spleen, resulting in the failure of the spleen to distribute the lucid-yang upward and the turbid-yin downward and the accumulation of dampness and fluid. Deficiency of spleen may attenuate the production of qi and blood, thus impeding the fluid metabolism.

D. Congenital insufficiency and sexual indulgence may consume kidney-essence, leading to the failure of kidney-qi in maintaining the normal fluid metabolism and then the accumulation of fluid. Physiologically, the kidneys, spleen and lungs are the organs responsible for the normal fluid metabolism in the body, and pathologically they affect each other. The deficiency of kidney-qi may result in failure of the descending of lung-qi and obstruction of water passages, which may be further aggravated. The deficient spleen-yang fails to control water, leading to the deficiency of kidney-yang, and vice versa. Besides, blood stasis may impair the water passages of the triple jiao and render some cases of edema intractable.

Syndrome Differentiation and Therapeutic Principles

A. Syndrome differentiation

(a) Differentiation between edema and swelling: Edema is usually accompanied by swelling, but the two disorders are different. Edema is an accumulation of fluid which is morphotic, while swelling is an accumulation of qi which is amorphous. Those with thin and lustrous skin which becomes pitted after applying pressure have edema, while those with thick and lusterless skin which does not become pitted after applying pressure show the presence of swelling.

(b) Differentiation between yin edema and yang edema: Edema resulting from an affection caused by exogenous wind and dampness, accumulation of dampness-heat and skin infections usually manifests itself as superficies, heat or sthenia syndrome and is grouped under the category of yang edema; That caused by overstrain, immoderate diet and drinking, debility and sexual indulgence commonly manifests itself as interior cold or asthenia-syndrome and is grouped under the category of yin edema.

(c) Identification of the organs affected: Yang edema usually involves the lungs and spleen, and yin edema affects the spleen and kidneys.

(d) Identification of yin-yang, cold-heat and asthenia-sthenia transformations: In general, yang edema is attributed to sthenia-syndrome and yin edema to a primary asthenia-syndrome with a secondary sthenia-syndrome. A longstanding case of yang edema may develop into yin edema. However, a case of yin edema may reveal sthenia-syndrome when complicated by an affection caused by exogenous evils.

B. Therapeutic principles

The principles applied for relieving edema are as follows: (1) Promoting water excretion by means of diaphoresis, diuresis and elimination of evils; (2) Strengthening healthy qi and activating qi and fluid movement by invigorating the spleen and warming the kidneys; and (3) Lowering turbidness and eliminating blood stasis. For yang edema, the therapy of dispelling evils is chiefly recommended. If yang edema manifested as sthenia-syndrome is changed to asthenia-syndrome, the therapy of supporting healthy qi should be adopted. For yin edema, the chief principle is to support healthy qi and to dispel evils; if the case is complicated by an affection caused by exogenous evil, the therapy of dispelling evils should be employed first. For the cases of edema due to an insufficiency of qi and blood as well as a deficiency of spleen and retention of dampness, the therapy of benefiting the spleen, eliminating dampness and tonifying qi and blood should be applied, and diuretic therapy is not necessary.

Classification and Treatment

A. Yang edema

(a) Edema due to exogenous wind

Manifestations: Edema beginning from the eyelids and rapidly developing to the extremities and whole body with predominant involvement of the head and face, lustrous and thin skin which becomes pitted after applying pressure and dysuria. In the case with predominant wind-heat, the general symptoms are accompanied by fever, aversion to wind, soreness and redness of throat, red tongue and floating, rapid and smooth pulse; in the case with predominant wind-cold, the general symptoms are accompanied by chilliness, fever, dyspneic cough, thin, white tongue coating and floating and smooth or tense pulse.

Therapeutic principles: Expel wind, clear away heat, release stagnated lung-qi, and promote water excretion.

Prescription: The Modification of Yuebi Decoction Radix Ephedrae 9 g
Gypsum Fibrosum 30 g
Semen Phaseoli 30 g
Rhizoma Imperatae 30 g
Radix Platycodi 9 g
Radix Glycyrrhizae 6 g
Rhizoma Atractylodis 10 g

Remarks: For cases with redness and swelling of the throat, add Fructus Arctii and Rhizoma Belamcandae to clear away heat, expel superficial evils and ease the throat. For cases with dyspneic and productive cough, add Semen Armeniacae Amarum, Radix Peucedani and Cortex Mori Radicis to release stagnated lung-qi and relieve dyspnea and cough. For cases of edema due to skin infection, add Fructus Forsythiae, Flos Lonicerae and Herba Taraxaci to clear away heat and toxic materials. For cases with sweating and aversion to cold due to deficiency of superficial yang, use the Modified Decoction of Stephaniae Tetrandrae and Astragali consisting of Stephaniae Tetrandrae, Astragali, Atractylodis Macrocephalae and Alismatis to support the superficies and promote the discharge of water.

(b) Edema due to the retention of dampness

Manifestations: General anasarca with pitted edema (especially the lower limbs), an insidious onset and a long course, oliguria, heavy sensation of the body, fatigue, chest distress, abdominal distention, poor appetite, nausea, white, greasy tongue coating and deep and slow pulse.

Therapeutic principles: Activate yang, promote diuresis, strengthen the spleen, and eliminate dampness.

Prescription: The Modification of Five Peels Decoction with the Powder of Five Drugs Containing Poria

Poria 15-30 g
Exocarpium Benincasae 12 g
Exocarpium Zingiberis 10 g
Pericarpium Citri Reticulatae 10 g
Polyporus Umbellatus 10 g
Pericarpium Arecae 10 g
Cortex Mori Radicis 10 g
Rhizoma Alismatis 12 g
Rhizoma Atractylodis Macrocephalae 10 g
Ramulus Cinnamomi 6 g

Remarks: For cases with edema more prominent over the upper half of the body and dyspneic cough, add Herba Ephedrae and Semen Armeniacae Amarum to release the stagnated lung-qi and relieve dyspnea, or add Semen Lepidii seu Descurainiae to purge the lungs, relieve dyspnea and promote diuresis. For cases with fatigue, flat taste in the mouth, epigastric distress, anorexia and thick, white tongue coating, add Rhizoma Atractylodis and Cortex Magnoliae Officinalis to regulate the stomach and eliminate dampness. For cases with profound edema and oliguria, add Pericarpium Lagenariae and Semen Plantaginis to promote diuresis and reduce swelling.

(c) Edema due to the accumulation of dampness-heat

Manifestations: General anasarca, tense and lustrous skin, oliguria or constipation, feverish sensation, thirst, oppressive sensation over the epigastrium and chest, yellow, greasy tongue coating and rapid and deep or smooth pulse.

Therapeutic principles: Clear away dampness-heat.

Prescription: The Modified Decoction for Diuresis

Extra Poria 24 g
Pericarpium Arecae 10 g
Rhizoma Alismatis 15 g
Semen Plantaginis 10 g
Semen Phaseoli 30 g
Semen Zanthoxyli 6 g
Radix Stephaniae Tetrandrae 10 g
Rhizoma seu Radix Notopterygii 10 g
Radix Ledebouriellae 10 g
Semen Arecae 10 g
Radix Phytolaccae 6 g

Remarks: For cases with constipation and abdominal distention, add Semen Lepidii seu Descurainiae and Radix et Rhizoma Rhei to promote water excretion by purgation. For cases with profound edema, noisy breathing, dyspnea and wiry and forceful pulse due to accumulation of water in the chest and failure of lung-qi to stay downward, use the Modified Mixture of Five Peels Decoction, Powder of Five Drugs Containing Poria and Decoction of Lepidii seu Descurainiae and Jujubae for expelling phlegm, which contains Semen Lepidii seu Descurainiae, Fructus Jujubae, Poria, Pericarpium Citri Reticulatae, Pericarpium Arecae, Cortex Mori Radicis, Rhizoma Slismatis, etc.

B. Yin edema

(a) Edema due to deficiency of spleen-yang

Manifestations: Pitted edema more prominent over the lower half of the body, distension and oppression over the abdomen and epigastrium, poor appetite, diarrhea, sallow complexion, cold extremities, spiritlessness, oliguria, pale and corpulent tongue with white, greasy or white, smooth coating and deep and slow or weak pulse.

Therapeutic principles: Warm yang, invigorate spleen, activate qi circulation, and promote diuresis.

Prescription: The Modified Decoction for Invigorating Spleen-Qi

Poria 30 g
Rhizoma Atractylodis Macrocephalae 10 g
Rhizoma Atractylodis 10 g
Rhizoma Zingiberis (dried) 10 g
Radix Aucklandiae 10 g
Cortex Magnoliae Officinalis 10 g
Fructus Tsaoko 10 g
Pericarpium Arecae 10 g
Fructus Chaenomelis 10 g
Ramulus Cinnamomi 6-10 g
Rhizoma Alismatis 10 g

Remarks: For cases with shortness of breath and mental fatigue due to qi deficiency, add Radix Codonopsis Pilosulae, Rhizoma Dioscoreae and Semen Dolichoris to benefit qi and strengthen the spleen. For cases with excessive dampness, add more Ramulus Cinnamomi and Alismatis to activate bladder-qi and promote diuresis. For cases with chest distress, abdominal distention, nausea and thick, greasy tongue coating, add Herba Agastachis and Herba Eupatorii to eliminate dampness, regulate the stomach and keep qi downwards.

(b) Edema due to declination of kidney-qi

Manifestations: Longstanding edema which becomes pitted after applying pressure and more prominent over the lower half of the body, oliguria or polyuria, lumbar pain and heaviness, cold extremities, aversion to cold, mental fatigue, palpitations, shortness of breath, pale or dimmish complexion, pale and corpulent tongue with white coating and deep and thready or slow pulse.

Therapeutic principles: Warm the kidneys, support yang, and promote diuresis.

Prescription: The Modification of Jisheng Pill for Invigorating Kidney-Qi and Zhenwu Decoction

Radix Rehmanniae Praeparata 10 g
Poria 30 g
Radix Aconiti Lateralis Praeparata 6-10 g
Rhizoma Dioscoreae 10 g
Rhizoma Atractylodis Macrocephalae 10 g
Radix Paeoniae Alba 10 g
Radix Glycyrrhizae Praeparata 6 g
Rhizoma Zingiberis Recens 3 g
Ramulus Cinnamomi 6-12 g
Radix Achyranthis Bidentatae 10 g
Rhizoma Alismatis 10-15 g
Herba Leonuri 30 g

Remarks: For cases with polyuria and discharge of clear urine, add Radix Morindae Officinalis and Fructus Psoraleae, and omit Alismatis to warm the kidneys and strengthen primordial qi. Add Radix Salviae Miltiorrhizae, and increase the dosage of Radix Aconiti Lateralis Praeparata and Ramulus Cinnamomi for cases with palpitations, cyanotic lips, and feeble and rapid or slow and irregular pulse caused by the deficiency of heart-yang, blood stasis and an upward attack of waterevil. For cases with dyspnea, sweating and feeble, floating and rapid pulse caused by failure of the kidneys to manage inspiration and retention of fluid in the lungs, add Radix Ginseng, Cecko, Fructus Schisandrae and Fructus Psoraleae, or add the Pill of Starnum Nigrum to strengthen yang and improve inspiration.

(c) Edema due to deficiency of the spleen and stomach

Manifestations: Sallow complexion, general anasarca, edema more prominent on the head in the morning and on the lower limbs in the afternoon or after overstrain, fatigue, normal or loose stool, polyuria, thin, greasy tongue coating and feeble pulse.

Therapeutic principles: Strengthen the spleen, and eliminate dampness.

Prescription: The Modified Powder of Codonopsis Pilosulae, Poria and Atractylodis Macrocephalae, which contains Radix Codonopsis Pilosulae, Rhizoma Atractylodis Macrocephalae, Poria, Radix Astragali, Radix Angelicae Sinensis, Ramulus Cinnamomi; Pericarpium Citri Reticulatae, Radix Aconiti Lateralis Praeparata and Fructus Psoraleae may also be added. Remarks: Aside from medications, nutritives such as soybeans, chicken, fish, peanuts, etc., should be used to supplement.

Experiential Prescriptions

A. Herba Spirodelae (15 g), Herba Equiseti Hiemalis (10 g) and Semen Phaseoli; prepared as decoction; applicable to yang-edema caused by wind.

B. Stylus Maydis (30-60 g) and Fructus Jujubae (6 pieces); prepared as decoction; applicable to mild cases of edema with oliguria.

C. Pericarpium Lagenariae (3 pieces, dried); prepared as powder; 15 grams three times daily; applicable to cases of edema with oliguria.

D. Radix Astragali (60 g); simmered with a hen; applicable to nutritional edema.

E. Equal amount of Ramulus Cinnamomi, Rhizoma Zingiberis (dried), Radix Codonopsis Pilosulae, Rhizoma Atractylodis Macrocephalae, Sulfur, Radix Paeoniae Alba and Alumen; prepared as powder; put on the umbilicus and covered with a piece of adhesive plaster and changed once weekly; applicable to yin edema due to the deficiency of spleen-yang and declination of kidney-qi.

Copyright 1995 Hopkins Technology

 


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