Edema is the abnormal retention and accumulation of water in the body as a result of failure of the lung, the spleen and the kidney in their functions of transforming, transporting and distributing fluids. The excess water then overflows into the interstitial tissues in the muscles and the skin. Clinically, it is seen as puffy swelling in the head, face, eyelids, extremities, the trunk, or even the entire body.
The causes of the dysfunction of the lung, the spleen and the kidney that can lead to edema include attack by exogenous disease-causing pathogens, improper diet and internal injury by over-exhaustion. Based on the nature of these causative factors.
Etiology and Pathology
The formation of edema is the manifestation of dysfunction of Qi transformation throughout the body. This dysfunction may be due to attack by exogenous pathogenic evils or to internal injury. The principal abnormality is in the zang organs, the lung, the spleen and the kidney; but the process also involves the fu organs, the urinary bladder and the sanjiao.
Among the zang viscera, the kidney is the root and the lung is the appearance, while the spleen controls water movement. If there is impairment of the dispersion function of the lung, the transportation function of the spleen and the gate-controlling function of the kidney, then the sanjiao loses its ability to regulate water and gall bladder-Qi its activity. This failure impairs the proper circulation of water, so that it overflows its normal channels into the skin and muscles and produces edema.
Yang Edema
Wind Invasion to the Lung. This impairs the lung’s ability to ventilate. The lung is the upper source of water, and it governs dispersion and descending. When exogenous Wind lodges in the lung, its dispersion and descending are impaired. As a result, water movement also becomes impaired. The interaction between exogenous Wind and the retained water leads to the overflow of water into the superficies, giving rise to edema.
Dampness Infiltrating the Spleen. Dampness infiltrating the spleen can trap spleen-Qi. The spleen prefers to be dry. Living in a humid place, wading in water or getting drenched by rain can all conduce to Dampness attacking the middle-jiao. Overindulgence in raw and cold foods can also conduce to attack by Dampness. When Dampness traps spleen-Qi, the spleen is unable to transport and transform water. Water then overflows its normal pathways into the superficies and gives rise to edema.
Internalization of Dampness Toxin. The superficies is the exterior region governed by the visceral organs of the lung and the spleen. When lesions of the superficies, such as abscesses and carbuncles, are inadequately treated to eradicate their poisons the poisons can transmit to the interior and attack the lung and the spleen. This attack can impair the spleen’s ability to transform and transport water and the lung’s ability to regulate the water pathways. Water can then overflow into the superficies and give rise to edema.
Dampness-Heat Accumulation. Accumulation and gelling of Dampness can trap sanjiao-Qi and transform into endogenous Heat. Dampness and Heat in the sanjiao prevents the ascending of the clear and the descending of the turbid. Obstruction of sanjiao-Qi movement induces blockage of water passage, leading to water overflowing its normal pathways and giving rise to edema.
Yin Edema
Spleen-Yang Deficiency. This may result from overindulgence in improper diets or excessive physical fatigue. In either case, the spleen and the stomach are injured and their ability to transport and transform water impaired. The retained water has nowhere to go but to overflow into the superficies, giving rise to edema.
Kidney-Yang Deficiency. The kidney governs water metabolism and is in charge of the discharge and retention of fluid. Overindulgence in sexual activity, multiple pregnancies, and protracted illness improperly or inadequately treated can all consume kidney-Qi. Failure of the kidney in Qi transformation and water circulation results in water retention, hence to water overflowing into the superficies and giving rise to edema.
Clinical Manifestation
When edema first develops it tends to affect the eyelids. From the eyelids it spreads to the rest of the face and to the distal extremities. It then progresses to the trunk. Sometimes, edema can begin in the feet and progress up the legs and eventually the entire body.
In mild cases, edema may be limited to the eyelids, the face and the distal lower extremities. In severe cases, the entire body may be affected. The abdomen may be markedly distended (ascites), and the chest may become tight with palpitation of the heart and orthopnea. In even more severe cases, there may be anuria, nausea, vomiting, fetid halitosis, epistaxis and gingival bleeding. There may even be critical symptoms such as headache, convulsion, delirium or coma.
Key Points of Analysis
Yang Edema versus Yin Edema. Yang edema develops mainly when exogenous pathogenic evil invades the body and causes visceral organ dysfunction. Yang edema generally begins high in the body and progresses downward to affect the entire body. The skin overlying Yang edema tends to be stretched and lustrous, and the edema is non-pitting (the skin depressed by pressure rebounds promptly upon release of pressure). There may be such accompanying symptoms of Heat or strength, such as restlessness, fever, thirst, scanty dark urine or constipation.
Yin edema develops mainly when improper diet, excessive fatigue, sexual overindulgence or protracted illness injures genuine Qi, causing spleen and kidney dysfunction. Yin edema tends to develop insidiously and has a prolonged and fluctuating course. It generally begins low in the body and progresses upward to affect the entire body. The skin overlying Yin edema tends to be loose, and the edema is pitting (pressure leaves a depression which persists for minutes). There may be accompanying symptoms of Cold or deficiency, such as oliguria, loose feces, lassitude and weakness without thirst.
Lingering Yang edema can turn into Yin edema if genuine Qi is depleted or water retention is severe. Yin edema can manifest some features of Yang edema if there is superimposed invasion by exogenous pathogen or a sudden increase in swelling. Thus, Yang edema and Yin edema may be intermingled.
Regional Correlation. The location of edema and the associated symptoms are useful for identifying the main visceral organ that is diseased.
If edema is in the eyelids and face and there are chills and fever, cough and panting respiration, the disease is in the lung.
If edema is the face and limbs and there is palpitation of the heart, the disease is in the heart.
If edema affects the entire body (anasarca) and there are heaviness in the limbs, fullness in the abdomen and anorexia, the disease is in the spleen.
If edema is mainly below the waist and there are aching weakness in the waist and knees and cold limbs, the disease is in the kidney.
If edema affects the entire body (anasarca) with subcostal and abdominal distention (ascites), so that it is difficult to move or turn over, the disease is closely related to a pathological condition of the liver.
Herbal Treatment
Yang-edema
Wind Invasion to the Lung
Main Symptoms. Rapid onset edema of the eyelids, followed over time by edema of the limbs and the entire body; chills and fever; joint and limb aches; and difficulty with urination. If Wind is joined by Heat, there are sore throat, a red tongue and a floating, slippery and rapid pulse. If Wind is joined by Cold, there are cold-intolerance, cough, a thin white tongue coating and a floating and slippery or deep and tight pulse.
Therapeutic Principle. Dispel Wind, cool Heat, unblock the lung and mobilize water.
Treatment. Yue Bi Jia Zhu Tang (Yue Maid Decoction with Atractylodes). It has the following composition: mahuang (Ephedra) 6g, shigao (gypsum) 15 g, baizhu (Atractylodes) 12 g, shengjiang (Zingiber) 4 g, dazao (Ziziphus) 6 g, and raw gancao (Glycyrrhiza) 4 g.
If there is Heat as well as Wind, add lianqiao (Forsythia), banlangen (Isatis), fresh baimaogen (Imperata) and herbs with similar actions to unblock the lung and cool Heat.
If there is Cold as well as Wind, remove shigao and add zisu leaf (Perilla), guizhi (Cinnamomum) and fangfeng (Saposhnikovia) to release the exterior.
If Defensive-Yang is deficient, with much sweating and wind-aversion, use instead Fangji Huangqi Tang (Stephania-Astragalus Decoction) to invigorate the Defensive Level and mobilize water.
Dampness Infiltrating the Spleen
Main Symptoms. Pitting edema over the entire body; oliguria; chest tightness with dysphoria; and heaviness of the body. The tongue coating is white and greasy, and the pulse deep and even. The onset is gradual and the course prolonged.
Therapeutic Principle. Strengthen the spleen, eliminate Dampness, stimulate Yang and promote diuresis.
Treatment. Combined Wu Pi Yin (Five-Peels Drink) and Wei Ling Tang (Stomach Fuling Decoction). The combined composition is as follows: chenpi (Citrus tangerina) 10 g, cangzhu (Atractylodes) 10 g, houpo (Magnolia) 6g, dafupi (Areca catechu) 10 g, zhuling (Polyporus) 15 g, fuling peel (Poria) 30 g, sangbaipi (Morus) 10 g, zexie (Alisma) 15 g, baizhu (Atractylodes) 10 g, guizhi (Cinnamomum) 6g, shengjiang (Zingiber) 6g, dazao (Ziziphus) 6g, and gancao (Glycyrrhiza) 6g.
If edema is very severe and causes wheezing, add mahuang (Ephedra), xingren (Prunus armeniaca) and tinglizi (Lepidium) to purge evils from the lung, mobilize water and relieve wheezing.
Internalization of Dampness Toxin
Main Symptoms. Edema beginning in the eyelids and progressing to the entire body; difficulty with urination; skin abscesses and carbuncles that may fester; windaversion and fever. The tongue is red, with thin yellow coating, and the pulse is floating, slippery and rapid.
Therapeutic Principle. Unblock the lung, detoxify poisons, eliminate Dampness and reduce swelling.
Treatment. Combination of Mahuang Lianqiao Chixiaodou Tang (Ephedra-Forsythia-Phaseolus Decoction) and Wu Wei Xiao Du Yin (Five-Ingredients Detoxification Drink).
For carbuncles and abscesses that have ruptured with erosion, add kushen (Sophora) and tufuling (Smilax glabra).
If there is much Wind with pruritus, add baixianpi (Dictamnus dasycarpus) and difuzi (Kochia scoparia).
If there is Heat in blood producing local inflammation in the skin, add mu-danpi (Paeonia suffruticosa), chishaoyao (Paeonia lactiflora) and dahuang (Rheum palmatum).
Dampness-Heat Accumulation
Main Symptoms. Anasarca with stretched and lustrous skin; epigastric and abdominal fullness; dysphoria, thirst; dark urine; and constipation. The tongue coating is yellow and greasy, and the pulse is slippery and rapid or deep and rapid.
Therapeutic Principle. Eliminate Heat and Dampness.
Treatment. Shu Zao Yin Zi (“Excavating” Drink). It has the following composition: Qianghuo (Notopterygium) 10 g, Qinjiao (Gentiana) 10 g, dafupi (Areca catechu) 15 g, fuling peel (Poria) 30 g, shengjiang peel (Zingiber) 10 g, zexie (Al-isma) 10 g, mutong (Akebia quinata) 6g, huajiao seed (Zanthoxylum bungeanum) 6g, chixiaodou (Phaseolus calcaratus) 30 g, andbinglang (Areca) 10 g.
If abdominal distention and constipation fail to respond to this formula, add fangji (Stephania), tinglizi (Lepidium) and dahuang (Rheum palmatum) to enhance purgation.
If Dampness and Heat have injured Yin, use Zhuling Tang (Polyporus Decoction) to nourish Yin and promote diuresis.
Yin-edema
Spleen-Yang Deficiency
Main Symptoms. Anasarca, with pitting edema most prominent below the waist; epigastric and abdominal distention; poor appetite; loose feces; lusterless complexion; lassitude; cold limbs; and oliguria. The tongue is pale, with white and greasy or white and smooth coating. The pulse is deep and even.
Therapeutic Principle. Warm and invigorate spleen-Yang, promote diuresis and eliminate Dampness.
Treatment. Shi Pi Yin (Spleen-Strengthening Drink). It has the following composition: processed fuzi (Aconitum) 6 g, ganjiang (Zingiber) 6g, caoguo (Amo-mum tsao-ko) 10 g, fuling (Poria) 30 g, baizhu (Atractylodes) 10 g, fried gancao (Glycyrrhiza) 6g, shengjiang (Zingiber) 6g, dazao (Ziziphus) 6g, dafupi (Areca catechu) 12 g, muxiang (Aucklandia) 10 g, houpo (Magnolia) 10 g, and mugua (Chaenomeles) 10 g.
If there is shortness of breath with a weak voice, add renshen (Panax) and huangqi (Astragalus).
If there is oliguria, add guizhi (Cinnamomum) and zexie (Alisma) to mobilize Qi and water.
Kidney-Yang Deficiency
Main Symptoms. Persistent pitting anasarca, especially prominent below the waist; palpitation of the heart; tachypnea; lumbar aches; cold-aversion; lassitude; either oliguria or polyuria; and a pallid or gray complexion. The tongue is pale and plump, with white coating. The pulse is deep, slow, threadlike and feeble.
Therapeutic Principle. Warm the kidney, invigorate Yang, promote Qi transformation and mobilize water.
Treatment. Combined Ji Sheng Shen Qi Wan (Life-Promoting kidney-Qi Decoction) and Zhen Wu Tang. The combined composition is as follows: processed fuzi (Aconitum) 9 g, rougui (Cinnamomum) 6 g, cheqianzi (Plantago) 10 g, fuling (Poria) 30 g, zexie (Alisma) 12 g, baizhu (Atractylodes) 10 g, baishaoyao (Paeonia) 10 g, andniuxi (Achyranthes) 10 g.
For palpitation of the heart and cyanosis of the lips, increase the amount of fuzi and add guizhi (Cinnamomum) and danshen (Salvia) to warm Yang and remove blood stasis.
For dyspnea, add gejie (Gekko gecko) and wuweizi (Schisandra), or use Hei Xi Dan.
For lassitude, somnolence, nausea and halitosis smelling like urine, add dahuang (Rheum palmatum), huanglian (Coptis) and wuzhuyu (Evodia).
Acupuncture Treatment
Yang-edema
Select the acupoints Feishu (BL-13), Lieque (LU-7), Shuifen (CV-9), Sanjiaoshu (BL-22) and Yinlingquan (SP-9). Use filiform needles and apply the reducing method.
Yin-edema
Select the acupoints Pishu (BL-20), Shenshu (BL-23), Shuifen (CV-9) and Sanyin-jiao (SP-6). Use filiform needles and apply the reinforcing method. Warming-needle moxibustion may also be applied.
Case Study
The patient was a 26-year old male who had edema developing over 5 years. At the outset he had intermittent chest tightness with palpitations of the heart. He began to notice edema of the feet, which gradually extended upward. At the time of admission he had nausea, vomiting, palpitation of the heart, shortness of breath with orthopnea, marked oliguria, watery feces, cyanotic lips, and crimson cheeks as though rouged.
Examination revealed extensive and marked edema from the feet to the waist. The abdomen was markedly distended. The tongue coating was white, smooth and greasy. The pulse was threadlike, rapid and taut.
Diagnosis. Edema due to Yang deficiency, with Qi stagnation and blood stasis.
Treatment and Course. Augmented Zhen Wu Tang was prescribed. The expanded composition was as follows: processed fuzi slices (Aconitum) 6 g, shengjiang (Zingiber) 6g, fried baizhu (Atractylodes) 9g, baishaoyao (Paeonia) 9g, fuling (Poria) 15 g, sharen (Amomum villosum) 2g, andmuxiang (Aucklandia) 2g.
After four doses, the quantity of urine increased and edema in the lower limbs essentially disappeared except in the feet. Abdominal distention, nausea and vomiting improved, but the cheeks were still crimson. He had recurrent episodes of restlessness and dysphoria, and a cough that produced blood-streaked sputum. His pulse remained threadlike and rapid, and was somewhat taut.
Diagnosis. Protracted illness with restless dysphoria; floating Yang not pulled back; and Liver-Fire attacking the lung.
He was treated with the same formula without muxiang and in combination with Dai Ge San (Indigo and Concha Powder). After two doses, cough stopped and the patient began to recover.
