Cheng Guopeng on the Treatment of Edema Disease

Doctor zhou
The Qing-dynasty famous physician Cheng Guopeng (courtesy name Zhongling), in his work Yixue Xinwu (Medical Mind Awakening), has a chapter titled Shuizhong Xinwu (Mind Awakening on Edema), which specifically discusses the treatment of edema disease and is of considerable reference value.
Cheng Guopeng divided edema into several types. He said: Edema disease has divisions of exterior and interior, cold and heat, and kidney and stomach. Generally, when the limbs are swollen but the abdomen is not, it is exterior. When the limbs are swollen and the abdomen is also swollen, it is interior. When there is vexing thirst and dry mouth, red urine and bound stool, and the patient likes cold food and drink, this belongs to Yangming heat. When there is no vexing thirst, the stool is normal, and the patient likes hot food and drink, this is yin-water, i.e. cold. When wheezing comes first and then swelling, it is water accumulated in the kidney channel. When swelling comes first and then wheezing, or there is only swelling without wheezing, it is water stored in the stomach channel.
That is, he held that edema has divisions of exterior/interior, cold/heat, and kidney/stomach; he mainly distinguished it into two types, water accumulated in the kidney channel and water stored in the stomach channel, and listed the clinical manifestations of each type.
Exterior-pattern edema: the limbs are swollen, the abdomen is not. Interior-pattern edema: the limbs are swollen and the abdomen is also swollen, roughly equivalent to late-stage ascites today. Vexing thirst, dry mouth and tongue, dark urine, bound stool, liking cold drinks and cold food belong to edema caused by Yangming heat pattern. No dry mouth or tongue, normal stool, liking hot drinks and hot food belong to edema caused by yin-cold pattern. When the patient first has wheezing and then swelling appears, this is water accumulated in the kidney channel. When swelling appears first and then wheezing, or there is only swelling without wheezing, this is caused by water stored in the stomach channel.
For the above different types of edema, Cheng Guopeng gave corresponding treatment recommendations.
To treat water stored in the stomach channel, one may use Wupi Yin (Five-Peel Decoction): Dafupi (Areca peel, washed in black soybean juice), Fulingpi (Poria peel), Chenpi (Tangerine peel), Sangbaipi (Mori bark), each one qian five fen (4.5 g), and Shengjiangpi (Ginger peel) eight fen (2.4 g), decocted in water.
The symptoms caused by water stored in the stomach channel are further divided into edema above the waist and edema below the waist. For edema above the waist, while using Wupi Yin, one should also promote sweating, adding Zisu (Perilla), Qinjiao (Gentianae macrophyllae), Jingjie (Schizonepeta) and Fangfeng (Saposhnikovia). For edema below the waist, one should also promote urination; on the basis of Wupi Yin, add Chixiaodou (Red Phaseolus), Chifuling (Red Poria), Zexie (Alisma), Cheqianzi (Plantago seed), Bixie (Dioscorea hypoglauca) and Fangji (Stephania).
If the stool is not moving, then while using Wupi Yin one should also combine purgatives, adding Dahuang (Rhubarb) and Tinglizi (Descurainia seed). If the patient abdominal belly is bloated, add Buguzhi (Psoralea), Houpo (Magnolia bark), Chenpi, Maiya (Barley sprout) and Shanzha (Hawthorn), herbs that move qi and resolve food stagnation.
For qi-deficiency patients, add qi-tonifying and spleen-fortifying herbs Renshen (Ginseng), Baizhu (White Atractylodes) and Fuling (Poria). For yin-cold pattern patients, add Fuzi (Aconite), Ganjiang (Dried Ginger) and Rougui (Cinnamon bark). For heat-pattern edema, add Lianqiao (Forsythia), Huangbai (Phellodendron) and Huangqin (Scutellaria). For edema with abundant phlegm, add Fabanxia (processed Pinellia) and Shengjiang (Fresh Ginger).
After stomach-channel edema is treated and the swelling subsides, one should no longer use Wupi Yin, but switch to Lizhong Tang (Center-Rectifying Decoction) to fortify the spleen and solidify the stomach, or use Jinkui Shenqi Wan to warm the vital gate, or use Liuwei Dihuang Wan plus Niuxi (Achyranthes) and Cheqianzi (Plantago seed) to nourish kidney water and clear remaining heat.
To treat water accumulated in the kidney channel with difficult urination, abdominal distension and limb swelling, or phlegm wheezing and urgent breath, one may use Jinkui Shenqi Wan. The Jinkui Shenqi Wan Cheng Guopeng used is not the one in Zhang Zhongjing Jingui Yaolue, but the Jinkui Shenqi Wan from the Jisheng Fang, also called Jisheng Shenqi Wan; the Japanese call this formula Ni che Shenqi Wan. This formula, on the basis of Zhang Zhongjing Jinkui Shenqi Wan, adds Niuxi and Cheqianzi, giving a better diuretic effect.
The formula Cheng Guopeng gave is: Great Shudi (Prepared Rehmannia) eight liang, Shanyao (Dioscorea) eight liang, Shanzhuyu (Cornus), Mudanpi (Moutan bark), Zexie (Alisma), Cheqianzi (Plantago seed), Niuxi (Achyranthes), each two liang, Fuling (Poria) six liang, Rougui (Cinnamon bark) one liang, Fuzi (Aconite) one liang (double for severe deficiency-cold). Crush all the above; separately take five liang of Wujiapi (Acanthopanax bark), boil in a large bowl of water, strain off the dregs, mix with the herbs, add refined honey, and form into pills the size of a parasol tree seed; each morning take four qian (12 g) with boiled water.
On the basis of Jisheng Shenqi Wan, this formula further adds Wujiapi, which has the actions of dispelling wind and dampness, supplementing the liver and kidney, strengthening sinews and bones, and promoting diuresis to reduce swelling. Shenqi Wan is the representative formula for supplementing the liver and kidney and promoting diuresis to reduce swelling; this formula, on the basis of Shenqi Wan, adds the diuretic Cheqianzi, the downward-guiding Niuxi, and Wujiapi which both supplements liver and kidney and promotes diuresis to reduce swelling; therefore its power to supplement liver and kidney and promote diuresis to reduce swelling is greater than that of Jinkui Shenqi Wan.
This formula has some effect on emphysema and on pleural and abdominal effusion caused by cancer; the Japanese Ministry of Health and Welfare recommends using Ni che Shenqi Wan after cancer patients develop thoracic and abdominal effusion. For many years I have used the patent medicine Jinkui Shenqi Wan (the version containing Niuxi and Cheqianzi) to treat pleural and abdominal effusion of the pattern of liver-kidney deficiency, with some effect.
Cheng Guopeng used Jinkui Shenqi Wan to treat edema patients, and also made modifications according to the patient specific condition. He said: The preceding condition (water accumulated in the kidney channel) belongs to yin deficiency; from this formula remove Gui (Rougui) and Fu (Fuzi), and add Wenha (clam shell) and Muli (Oyster shell), each two liang. For severe damp-heat, add Huangbai five qian, and do not use Wujiapi, replacing it with a decoction of eight liang of Bixie.
In fact, besides summarizing the above treatment experience, Cheng Guopeng also gave a treatment method for another kind of edema, this one caused by blood stasis. So at the end of Shuizhong Xinwu, he also gave a formula called Tongjing Wan.
Tongjing Wan formula: Dangguiwei (Angelica tail), Chishao (Red Peony), Shengdi (Raw Rehmannia), Chuanxiong (Ligusticum), Niuxi (Achyranthes), Wulingzhi (Troghopterus excrement), each one liang; Honghua (Safflower) and Taoren (Peach kernel), each five qian; Xiangfu (Cyperus) two liang; Hupo (Amber) seven qian five fen. Crush all the above; take two liang of Sumuxie (sappan wood shavings), boil in wine, mix in sugar, boil until dissolved, mix with the herbs and form into pills the size of a parasol tree seed. Take three qian each time; ordinary people take with wine. The weak take with Lizhong Tang; for blood cold, add five qian of Rougui to Lizhong Tang.
The herbs used in Tongjing Wan are basically all blood-activating and stasis-resolving herbs, so the edema disease it treats should also be caused by blood stasis, mostly what is today called liver ascites.

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