bubble_chart Concept

Edema refers to generalized swelling of the body, which is pitting upon pressure.

The Neijing refers to edema as "water" or "edema," and categorizes it into "wind edema," "stony edema," "gushing water," and other symptoms and signs; the Jingui Yaolue also refers to it as "water qi," dedicating a specific chapter to its discussion, and further divides it into "wind edema," "skin edema," "typical edema," and "stony edema." During the Yuan Dynasty, Zhu Dan-xi classified it into two major categories: "yang edema" and "yin edema," which have been followed by later generations.

Skin edema should be distinguished between "edema" and "qi swelling." The former involves skin swelling with a watery appearance, which does not rebound upon pressure; the latter involves unchanged skin color, which rebounds immediately upon pressure. This section discusses edema.

Additionally, if the edema is predominantly in the lower limbs, refer to the section on "foot swelling." Gynecological conditions such as "edema in pregnancy" and "postpartum edema" are discussed in separate chapters and are not within the scope of this section.

bubble_chart Pattern Analysis

1. Wind-cold Invading the Lung︰The eyelid swells first, with a rapid onset, followed by swelling in the limbs and the whole body, aversion to wind and cold, or accompanied by fever, joint aching pain, scanty urine, thin white tongue coating, and a floating tight pulse. This is due to external contraction of wind-cold, lung qi becoming depressed and failing in its dispersing and descending functions. When the lung fails to descend, it cannot dredge and regulate the water passage to transport fluids downward to the bladder, leading to impaired distribution and excretion of water, resulting in water-dampness retention, manifesting as dysuria and edema. The presence of wind-cold on the exterior causes marked aversion to cold with mild fever, joint aching pain, and other wind-cold Xieke manifestations in the exterior of the foot taiyang channel, with discomfort in the taiyang channel qi. The pulse is mostly floating and tight; the tongue coating is often thin and white. The treatment should aim to dissipate wind-cold, ventilate the lung, and disinhibit water. Ephedra plus Atractylodes Decoction can be used.
2. Wind-heat Invading the Lung︰Sudden swelling of the eyelids and face, fever with aversion to wind, cough, red and swollen sore throat, scanty urine, slightly red edges and tip of the tongue, thin yellow coating, and floating rapid pulse. This is due to wind-heat attacking the upper body, lung qi failing in purification. The lung is the upper source of water; when lung qi is depressed and loses its purifying function, it cannot dredge and regulate the water passages, leading to edema. In both cases, the location of the disease is in the lung. The lung is located in the upper energizer; when the water passages of the upper energizer are blocked, the swelling is more pronounced in the eyelids and head/face. For differentiation, there are characteristics of wind-heat, such as marked fever with mild aversion to cold, cough, red throat, and scanty dark urine. The pulse is often floating and rapid, and the coating is usually thin and yellow. The treatment principle for both is to release the exterior, but it should focus on pungent-cool to ventilate the lung, clear heat, and promote diuresis. Ephedra, Forsythia and Rice Bean Decoction can be used.
3. Water-Dampness Encumbering the Spleen︰Limb edema, with a slow onset and prolonged course, the swelling often starts from the limbs and is more pronounced in the abdomen and lower extremities, heavy body and fatigue, chest tightness and nausea, bland taste in the mouth, clear and scanty urine, white and greasy tongue coating, deep and slow or deep and tardy pulse. It is mostly caused by inherent spleen qi deficiency, inability to transport and transform water-dampness, dampness accumulation trapping the spleen, or exposure to water and rain, prolonged residence in damp environments, cold-dampness invading internally, lingering in the middle energizer, the spleen being trapped by dampness, leading to dysfunction in transportation and transformation, water-dampness failing to be discharged downward, and overflowing into the skin to cause edema. The spleen governs the four limbs, and when the spleen is trapped by dampness, it leads to edema, with swelling often starting from the limbs; dampness is internal, and clear yang fails to ascend, hence heaviness of the head as if wrapped; dampness is inherently turbid, and internal retention of water-dampness causes heavy body and fatigue, bland taste in the mouth; dampness trapping the middle energizer disrupts the ascending and descending functions, leading to disharmony in stomach descent, resulting in chest tightness and nausea; dampness is a yin pathogen, and internal retention of water-dampness impairs bladder qi transformation, leading to clear and scanty urine. In summary, when diagnosing edema due to water-dampness trapping the spleen, it is essential to grasp the characteristic of heavy dampness. Treatment involves warming and transforming water-dampness and unblocking yang to promote diuresis, with prescriptions such as Stomach Poria Decoction and Five-Peel Decoction.
4. Spleen Yang Deficiency︰The edema is particularly severe below the abdomen and waist, recurrent and unhealed, with pitting upon pressure, accompanied by mental fatigue, cold limbs, reduced appetite, loose stools, scanty and clear urine, a pale tongue with thin white and slippery coating, and a deep slow pulse. It is mostly caused by the failure to treat excess-pattern edema, which over time damages spleen yang, or by overstrain injuring the spleen, leading to spleen deficiency and impaired transportation and transformation, or yang deficiency failing to control water, resulting in edema. The swelling is most pronounced below the abdomen and waist, often recurrent and unhealed, with pitting upon pressure. It is also accompanied by symptoms of spleen yang insufficiency such as cold limbs, fatigue, anorexia, and loose stools. In clinical differentiation, when water-dampness encumbers the spleen, the emphasis is on "dampness," primarily manifesting as an excess pattern with underlying deficiency. In contrast, edema due to spleen yang deficiency emphasizes "yang deficiency," with prominent deficiency manifestations. Treatment should combine warming and activating spleen yang with resolving dampness and promoting diuresis. Spleen-Strengthening Decoction is the main prescription.
5. Kidney Yang Deficiency︰Generalized edema, with swelling typically starting from the waist and feet, more pronounced below the waist, especially severe around the medial malleoli of both feet. Accompanied by soreness, weakness, and heaviness in the waist and knees, cold and damp scrotum, aversion to cold, cold limbs, scanty and clear urine, pale and swollen tongue with thin white coating, deep, thin, and weak pulse. Often manifests as generalized edema. Since the waist is the abode of the kidneys, and the kidneys belong to the lower energizer, deficiency of kidney yang leads to obstruction of the water passage in the lower energizer, hence swelling often begins from the waist and feet, with more severe swelling around the ankles, along with accompanying symptoms such as soreness, weakness, and heaviness in the waist and knees, and cold, damp scrotum. Edema due to spleen yang deficiency is accompanied by reduced appetite, loose stools, cold limbs, and fatigue. Careful differentiation is necessary for accurate diagnosis. Treatment should focus on warming kidney yang and warming yang qi to promote diuresis, primarily using the Life-Relieving Kidney Qi Pill.
6. Deficiency of Both Qi and Blood︰Gradually, facial and limb edema becomes apparent, with a complexion that is pale or shallow yellow, pale lips, dizziness, palpitations, shortness of breath, poor appetite, physical fatigue, and low spirits. The tongue texture is pale with little coating, and the pulse is weak, thin, and feeble. This condition is mostly caused by spleen and stomach qi deficiency, insufficient generation and transformation, or prolonged illness leading to dual deficiency of qi and blood, resulting in the malnutrition of zang-fu organs, which disrupts water metabolism and leads to edema. Wanbing Huichun·Edema states: "Swelling that is worse in the morning and better in the evening indicates blood deficiency, while swelling that is worse in the evening and better in the morning indicates qi deficiency. If swelling is severe both morning and evening, it signifies dual deficiency of qi and blood." This discussion can serve as a reference for pattern identification when emphasizing qi and blood. Treatment primarily focuses on tonifying qi and tonifying blood, often using Returning to Spleen Decoction.

Spleen yang deficiency and kidney yang deficiency both belong to the yang deficiency pattern, with a prolonged course of illness. The swelling is more pronounced below the waist, and the tongue and pulse manifestations are quite similar. Clinically, they often occur together, with the swelling from kidney yang deficiency being more severe than that from spleen yang deficiency.

The differentiation between dual deficiency of qi and blood and spleen yang deficiency swelling: the former is characterized by prominent qi deficiency symptoms (such as shortness of breath) and blood deficiency symptoms (such as pale or slightly yellow complexion, pale lips, palpitations, dizziness, etc.), without the presence of yang deficiency symptoms (such as cold limbs, loose stools, etc.), and the swelling is not as severe as in yang deficiency swelling.

The symptom of swelling is mainly attributed to the dysfunction of water metabolism. In the process of water metabolism in the human body, the diffusion and descent of lung qi, the ascending and descending transportation of spleen qi, the steaming and transformation of kidney yang, the qi transformation of the bladder, and the water metabolism function of the triple energizer pathways play important roles. If the diffusion and descent of lung qi are abnormal, leading to blocked water passages, swelling above the waist is seen; if the transportation and transformation of spleen qi are abnormal, and the qi transformation function of the kidneys is impaired, leading to blocked water passages in the lower energizer, water retention below the waist is seen. Generally, if the onset is rapid, with swelling more pronounced in the upper body, and belongs to the heat pattern or excess pattern, it is called yang edema; if the onset is slow, with a long course, swelling more pronounced in the lower body, and belongs to the cold pattern or deficiency pattern, it is called yin edema. The "Synopsis of Prescriptions of the Golden Chamber" states: "Generalized swelling, thirst, scanty and red urine, and frequent constipation belong to yang edema; generalized swelling, no thirst, normal or loose stools, and scanty but not red urine belong to yin edema." However, in reality, deficiency and excess often coexist, and differentiation can be made based on the characteristics of the symptoms during clinical diagnosis.

bubble_chart Documentation

1. Jingui Yaolue．"On Abnormal Pulse Syndromes and Treatments of Water Qi": "Diseases include wind edema, skin edema, typical edema, stony edema, and yellow sweat. Wind edema is characterized by a floating pulse, external symptoms of joint pain, and aversion to wind; skin edema also shows a floating pulse, external symptoms of swelling that leaves an indentation when pressed, no aversion to wind, a distended abdomen like a drum, no thirst, and should be treated by inducing sweating. Typical edema is characterized by a deep and slow pulse, external symptoms of spontaneous panting; stony edema shows a deep pulse, external symptoms of abdominal distension and fullness without panting. Yellow sweat is characterized by a deep and slow pulse, body fever, chest fullness, swelling of the limbs, head, and face, and if it does not heal for a long time, it will inevitably lead to abscesses and pus."
2. Danxi Xinfa．"On Edema": "Generally, edema that starts in the abdomen and then spreads to the limbs can be treated. Edema that starts in the limbs and then returns to the abdomen cannot be treated. Efflux diarrhea, along with black lips, flat clavicular fossa, umbilical hernia, flat feet, flat back, or hardened flesh, or flat palms, or in men swelling starting from the feet and moving upwards, and in women swelling starting from the body and moving downwards, are all untreatable." (Note: "Untreatable" should be understood as difficult to treat.)