The "Ask Dr. Jiang" column is designed to explore corners of Chinese medicine that may not be easily understood by American practitioners or are underrepresented in American clinical health literature.
Dear Dr. Jiang:
Here in Florida, I seem to encounter a lot of patients who suffer from yin deficiency and dampness at the same time. According to the textbooks, the herbs that tonify yin are sweet and cloying and mostly contraindicated for dampness, while the herbs that drain dampness are drying and therefore contraindicated for yin deficiency. So, how do you treat these patients with Chinese herbal medicine?
Dear Swamped Dry:
Dampness and yin deficiency commonly occur together clinically and require a strategy that combines tonifying yin and transforming dampness. This scenario usually occurs because damp or phlegm has transformed into damp heat or phlegm heat, and the resulting fire damages fluids. That's not the only possibility, however. Sometimes there's no evil heat at all, and the dampness alone gives rise to yin deficiency. This is because the turbid dampness is using up all the normal body fluids, causing the body's yin to become depleted. Still another possibility is that yin deficiency occurs first, and the resulting deficiency heat thickens the normal body fluids, creating phlegm. This second scenario is more likely to occur in the upper burner.
Let's look at common treatment strategies for each of the three burners. The ingredients for the formulas below are all listed in Bensky and Barolet's Formulas and Strategies.
Either phlegm by itself or phlegm heat can damage yin if it has been in the upper burner for a long time. Alternatively, Lung yin deficiency can result from Kidney yin deficiency, and the deficiency heat can, over a prolonged period of time, injure lung fluids resulting in the formation of phlegm. The requisite treatment principle is to transform phlegm, clear heat, and nourish yin. Three common formulas that incorporate this strategy are bu fei e jiao tang, mai men dong tang and jin shui liu jin jian.
Incidentally, the last formula has been recorded incorrectly in Formulas and Strategies. According to the classical source text (Jing Yue Quan Shu), you're supposed to use shou di huang, not sheng di huang. The author of this text, Zhang Jing Yue, was so renowned for his use of shou di huang that he was nicknamed "Zhang Shou Di" by his peers.
In the middle burner, yin deficiency often occurs as a result of damp heat damaging yin. If the damp heat causes diarrhea, the damage will be accelerated even farther. The other scenario occurs when a patient with pre-existing yin deficiency develops damp heat as a result of consuming bad food. The treatment in both cases requires that you simultaneously transform damp and tonify yin. There are several formulas that can be used.
One of the best formulas for this twofold problem is zhu ling tang. Although it is most often used to treat damp heat urinary problems, the shang han lun prescribed this formula for diarrhea and insomnia as well. The e jiao tonifies yin and blood and counteracts the drying effects of the other herbs in the formula.
For more severe diarrhea, you can use bai tou weng jia gan cao e jiao tang. This is basically bai tou wen tang with e jia and gan cao added to nourish the blood and yin. It was originally designed for dysentery occurring after labor, but we can borrow it for any damp heat diarrhea complicated by yin and blood deficiency. Another way to treat this pattern is to modify ge gen huang lian huang qin tang by adding Lung-Stomach yin-tonifying herbs such as sha shen, mai men dong and tian hua fen.
Sometimes the yin becomes damaged by diarrhea resulting from cold or cold damp attacking the middle burner. If this happens, the patient will remain sick even after the diarrhea has stopped. You should use si ni jia ren shen tang, which warms the middle burner and tonifies qi and yin.
Ascites or "drum distention" (gu zhang) is a middle burner condition that usually leads to yin deficiency, since the massive accumulation of abdominal water leaches normal yin from the body. The yin deficiency occurs in spite of extreme dampness and even cold. The treatment of ascites is quite complicated, too complicated to go into here; it often involves spleen deficiency, dampness, yin deficiency and blood stasis all occurring simultaneously. If you are looking for herbal treatment strategies for this condition, I recommend that you consult Wu and Fischer's Practical Therapeutics of Traditional Chinese Medicine.
In the lower burner, accumulated dampness easily transforms into heat, which then causes yin deficiency. The other possibility is that dampness and heat sink into the lower burner of a patient that has preexisting yin deficiency. The combined pattern usually manifests as a heat dysuria (re lin), causing frequent urine with a burning or itching sensation. The treatment principle is to leach out damp, clear heat, and tonify yin. Here again, the indicated formula is zhu ling tang.
I need to add a word here about pulse and tongue interpretation, because many of my American students tend to be misguided by these signs, especially when they are facing multipattern conditions like dampness combined with yin deficiency. The fact is, pulses and tongues will often reflect only one pattern or side of the condition, and you have to rely on the other signs and symptoms to get a full picture of the other patterns involved. For example, you could find a fast, thin pulse, which indicates yin deficiency, but at the same time you might find overall symptoms that indicate dampness such as fullness in the abdomen or loose stools. Your end diagnosis requires that you integrate the pulse with these other symptoms.
The tongue is actually a little bit easier to read, since it often reflects more than one pattern. In the case of phlegm heat damaging yin, for example, the tongue will be greasy and yellow, with red peeled patches. But this doesn't always happen. Sometimes you have a greasy tongue coat, but have to rely on symptoms such as night sweats and warm palms and soles to recognize that there is yin deficiency as well as dampness. Once again, you won't know the whole presentation unless you integrate the tongue with all of the other signs and symptoms.
Edited with the assistance of John Pirog, MSOM.
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