More on the Spleen & Diabetes

reported by
Bob Flaws, Dipl. Ac. & C.H., Lic. Ac., FNAAOM, FRCHM

Keywords: Chinese medicine, diabetes, spleen, treatment based on pattern discrimination

As more and more patients are being diagnosed with diabetes mellitus during routine blood analysis, more and more Chinese doctors are realizing that the traditional teachings on this disease need to be expanded and refined. In premodern China, patients were not diagnosed with wasting and thirsting disease (xiao ke bing), the traditional equivalent of diabetes mellitus, until they were symptomatic, and that meant the symptoms of polydipsia, polyphagia, and polyuria, the so-called three polys. Based on the three polys, most of the traditional Chinese literature on diabetes has focused on yin vacuity and dryness and heat as the main patterns of this condition. However, many patients diagnosed with diabetes do not present a yin vacuity pattern of signs and symptoms. Instead, most patients with type 2 diabetes diagnosed by routine blood and/or urine analysis are overweight and have a history of overeating sugar and sweets, fatty, oily foods, acrid, peppery foods, and drinking too much alcohol. Therefore, more and more Chinese doctors are recognizing and emphasizing the role of the spleen in this disease and especially in its early stages. An example of this is Liang You-ya et al.’s article titled, “The Treatment of Diabetes Mellitus Based on Regulating & Rectifying the Spleen & Stomach’s Axis of Upbearing & Downbearing.” This article appeared in issue #4, 2002 of Xin Zhong Yi (New Chinese Medicine) on pages 5-6. A precis of that article appears below.  

The spleen & stomach’s relationship to the disease mechanisms of diabetes

Unregulated eating and drinking causing damage and detriment to the spleen and stomach resulting in loss of command over the qi mechanism’s upbearing and downbearing is closely related to the production of diabetes. The spleen and stomach are the latter heaven root and the source of engenderment and transformation of the qi and blood. The spleen governs movement and transformation and the upbearing of the clear. The stomach governs receiving and intake and the downbearing of the turbid. Therefore, the spleen and stomach are mutually opposing and mutually productive. The spleen is lodged in the middle burner and is categorized as earth. It is the root of the five viscera. After food and drink enter the stomach, the spleen transports and spreads the finest essence of water and grains, thus constructing and nourishing the five viscera, the four limbs, and the hundreds of bones. Likewise, water and drinks enter the stomach. These ascend and gather in the lungs which frees the flow and regulates the water passageways. These descend and are transported to the bladder. This water essence is also transported to the four limbs and moves in the five channels. Thus it is said, “The spleen makes the stomach move the fluids and humors.” Hence, one can see that, when the spleen and stomach’s upbearing and downbearing are fortified and effulgent, the body’s physiological functions and metabolism are basically sound.

If one overeats sweet, slimy, thick-flavored foods and eats too many rich, fatty meats, this may result in the engenderment of dampness which obstructs the spleen. In that case, spleen earth becomes congested and stagnant, and the food and drink which are taken in are difficult to transform or digest. Rather, they produce dampness, turbidity, accumulation, and stagnation. Thus gradually, step by step, the stomach loses its harmony and downbearing, and this results in the middle burner spleen and stomach’s qi mechanism losing its regulation over upbearing and downbearing. In that case, “The spleen is not able to make the stomach move the fluids and humors.” On the one hand, this causes disturbance in the finest essence’s transformation and engenderment from water and grains and the circulation of qi and blood. On the other, long-standing accumulation, stagnation, and depression of water and grains may transform heat which may burn and damage stomach fluids. Therefore, the stomach becomes hot and dry. It is this dryness and heat which gives rise to the symptoms which are traditionally associated with wasting and thirsting disease.

In terms of clinical reality, what we are talking about here is overeating sweets, fats, oils, and meats resulting in obesity. In terms of Chinese medicine, the spleen is vacuous and damp while the stomach may be hot and dry. If the stomach is hot, it is, at least in part, because of stagnation and accumulation transforming heat. Other symptoms of spleen vacuity noted by Liang et al. include a sallow yellow facial complexion, lassitude of the spirit, fatigue, lack of strength in the limbs, if severe, lower extremity edema, numbness and insensitivity, irregular defecation (constipation and/or diarrhea). All of these symptoms are due to the spleen and stomach’s loss of command over upbearing and downbearing with dampness and turbidity collecting and stagnating.

The spleen & stomach’s relationship to the complications of diabetes

Not only are the spleen and stomach at the root of the causation of diabetes mellitus, loss of the spleen and stomach’s governance of the upbearing and downbearing is closely associated with many of the pathological complications of this disease. For instance, lower extremity sores and ulcers, so-called diabetic foot, are mostly due to spleen-stomach damp heat accumulating and stagnating and brewing internally. Diabetic gastric paresis manifesting as postprandial abdominal distention, nausea, vomiting, constipation, and/or diarrhea is categorized as stomach glomus in Chinese medicine, and this is mostly due to spleen-stomach vacuity weakness with loss of command over upbearing and downbearing. Therefore, water dampness accumulates, stagnates, and obstructs the middle burner. Other conditions common in diabetes related to spleen vacuity and, therefore, dampness which Liang et al. do not mention are fatigue and lack of strength, poor wound healing, a lack of defensive qi leading to opportunistic infections, palpebral xanthomatosis, and diabetic bullae.

The pattern discrimination treatment of diabetes vis á vis the spleen & stomach’s upbearing & downbearing

Based on the preceding theory, Liang et al.identify six patterns of diabetes mellitus all involving the spleen and stomach.

1. Spleen vacuity with phlegm dampness (and turbidity) obstructing internally

This pattern is mostly due to overeating fatty, sweet, thick-flavored foods and drinking too much alcohol. Food accumulates and is not transformed. This brews dampness and engenders turbidity which accumulate and stagnate, encumber and obstruct the middle burner. If this condition endures, it eventually causes detriment and damage to the spleen qi, and spleen vacuity fails to move. Hence the finest essence of water and grains is not able to be spread and dispersed. Instead, phlegm dampness becomes exuberant internally.

The signs and symptoms of this pattern are bodily obesity, a dry mouth, polydipsia, hunger but poor digestion, possible abdominal distention and even vomiting after eating, lassitude of the spirit, fatigue, bodily heaviness, dizziness, vertigo, frequent urination, loose stools, a pale, fat tongue with teeth-marks on its edges and thick, slimy, possibly turbid fur, and a slippery, bowstring or slippery, fine pulse. In this case, the treatment principles are to fortify the spleen and boost the stomach, dispel phlegm and transform dampness, and the medicinals Liang et al. suggest using are: Radix Panacis Ginseng (Ren Shen), Sclerotium Poriae Cocos (Fu Ling), Rhizoma Atractylodis Macrocephalae (Bai Zhu), Rhizoma Pinelliae Ternatae (Ban Xia), Radix Bupleuri (Chai Hu), Fructus Citri Aurantii (Zhi Ke), Herba Agastachis Seu Pogostemi (Huo Xiang), Radix Puerariae (Ge Gen), Fructus Schisandrae Chinensis (Wu Wei Zi), Radix Auklandiae Lappae (Mu Xiang), and mix-fried Radix Glycyrrhizae (Gan Cao).

2. Spleen vacuity & qi stagnation

In this case, the spleen is typically habitually or systemically vacuous. On top of this, emotional depression or anger may damage the liver, and wood may fail to course earth. (This may also be referred to as a liver-spleen disharmony.) Hence the finest essence is not spread, resulting in this disease. One of the characteristics of this pattern is that its clinical symptoms are not marked. (In other words, one does not see the three polys.) However, blood glucose and urine glucose are abnormal. The clinical symptoms that are apparent are emotional depression, tension, agitation, irritability, fatigue, lack of strength, chest and rib-side distention and fullness, a tendency to sighing, postprandial ductal and abdominal distention and fullness, recurrent belching, unregulated defecation, possible alternating constipation and diarrhea, a pale tongue with white fur, and a bowstring, fine or deep, bowstring pulse. For this pattern, the treatment principles are to fortify the spleen and course the liver, move the qi and abduct stagnation. The formula Liang et al. suggest using is Si Jun Zi Tang (Four Gentlemen Decoction) plus Xiao Yao San (Rambling Powder) with additions and subtractions.

3. Spleen vacuity with phlegm & stasis

This pattern is due to habitual spleen vacuity with internal exuberance of phlegm dampness. If this lasts for a long time, it causes exhaustion and consumption of the body’s strength which leads, in turn, to the movement and transportation of the qi and blood becoming uneasy. Thus blood stasis is engendered internally, and phlegm and stasis mutually bind. This pattern is mostly seen in those with a long disease course. Its clinical signs and symptoms include habitual bodily obesity but a loss of weight after the disease is diagnosed, oral thirst but no polydipsia, stomach duct glomus and fullness, lassitude of the spirit, fatigue, lack of strength in the four limbs or lower extremity edema, if severe, numbness of the feet and ulcerous sores, frequent urination, a fat, pale, but dark tongue with teeth-marks on its edges and turbid, slimy fur, and a fine, slippery pulse. The treatment principles for this pattern are to fortify the spleen and transform phlegm, quicken the blood and transform stasis using the formula from pattern #1 above plus Tao Hong Si Wu Tang (Persica & Carthamus Four Materials Decoction) with additions and subtractions.

4. Spleen yin vacuity with dryness & heat depression & binding

This pattern is mostly caused by addiction to fried, grilled foods and alcohol which, over time, results in the accumulation of heat which transforms dryness. If dryness and heat become depressed and bound in the middle burner, fluids and humors will not move and there may be the onset of wasting and thirsting. The clinical manifestations of this pattern are rapid hungering, oral thirst with polydipsia, a lusterless facial complexion, marked loss of weight, frequent, short, reddish urination, dry, bound stools, a red, fat, tender tongue with thin, dry, yellow fur, and a fine pulse. The treatment principles are to supplement the spleen and nourish yin, moisten dryness and scatter binding. The formula Liang et al. suggest using is Huang Qi Tang (Astragalus Decoction) plus Qing Liang Yin Zi (Clearing & Cooling Drink) with additions and subtractions: mix-fried Radix Astragali Membranacei (Huang Qi), uncooked Radix Rehmanniae (Sheng Di), Radix Dioscoreae Oppositae (Shan Yao), Sclerotium Poriae Cocos (Fu Ling), Radix Trichosanthis Kirlowii (Tian Hua Fen), Tuber Ophiopogonis Japonici (Mai Men Dong), Fructus Schisandrae Chinensis (Wu Wei Zi), Radix Bupleuri (Chai Hu), Semen Pruni Persicae (Tao Ren), Semen Pruni Armeniacae (Xing Ren), Radix Angelicae Sinensis (Dang Gui), Rhizoma Cimicifugae (Sheng Ma), Gypsum Fibrosum (Shi Gao), Radix Gentianae Scabrae (Long Dan Cao), Radix Scutellariae Baicalensis (Huang Qin), Rhizoma Anemarrhenae Aspheloidis (Zhi Mu), and mix-fried Radix Glycyrrhizae (Gan Cao).

(Personally, I prefer to call this pattern a liver-spleen disharmony with qi and yin vacuity, dryness, and heat.)

5. Stomach yin vacuity with dryness & heat internally binding

This pattern is due to habitual stomach yin insufficiency or enduring disease in which heat damages yin. It may also be due to overeating acrid, peppery, dry, and hot foods which also consume and exhaust stomach yin. thus there is wasting and thirsting. The clinical symptoms of this pattern are vexatious thirst with polydipsia, rapid hungering, a dry mouth and chapped lips, emaciation, vexatious heat in the four limbs, frequent, short, reddish urination, dry, bound stools, a crimson red tongue with thin, dry, yellow fur, and a rapid, replete (I would say surging) pulse. The treatment principles for this pattern are to clear heat and moisten dryness, nourish yin and harmonize the stomach and the formula to use is Ren Shen Bai Hu Tang (Ginseng White Tiger Decoction) plus Tiao Wei Cheng Qi Tang (Regulate the Stomach & Order the Qi Decoction) with additions and subtractions: Radix Panacis Ginseng (Ren Shen), uncooked Gypsum Fibrosum (Shi Gao), Herba Lophatheri Gracilis (Dan Zhu Ye), Rhizoma Anemarrhenae Aspheloidis (Zhi Mu), Radix Et Rhizoma Rhei (Da Huang), uncooked Radix Rehmanniae (Sheng Di), Tuber Ophiopogonis Japonici (Mai Men Dong), Radix Scrophulariae Ningpoensis (Xuan Shen), Radix Trichosanthis Kirlowii (Tian Hua Fen), and Radix Glycyrrhizae (Gan Cao).

6. Stomach yin vacuity with stasis & heat internally binding

This pattern is typically an evolution from the preceding pattern. Because of long-term fluid desiccation and blood dryness, stasis and heat bind internally. Its clinical symptoms include emaciation, a dry mouth with poilydipsia which does not remit the thirst, hunger but no desire to eat, clamoring stomach or insidious pain, a dry throat, frequent urination, dry bound stools like sheep droppings, numbness and insensitivity of the extremities, possible ulcers and sores, stasis blackness (i.e., diabetic dermopathy), a dark red, tender tongue with scanty fluids and possible static spots or macules, and a fine, rapid pulse. The treatment principles for this pattern are to nourish yin and engender fluids, quicken the blood and transform stasis. The formula Liang et al. suggest using is Huo Xue Run Zao Sheng Jin Yin Jia Jian (Quicken the Blood, Moisten Dryness & Engender Fluids Drink with Additions & Subtractions): Tuber Asparagi Cochinensis (Tian Men Dong), Tuber Ophiopogonis Japonici (Tian Men Dong), Fructus Schisandrae Chinensis (Wu Wei Zi), Semen Trichosanthis Kirlowii (Gua Lou Ren), Semen Cannabis Sativae (Huo Ma Ren), Radix Angelicae Sinensis (Dang Gui), cooked Radix Rehmanniae (Shu Di), uncooked Radix Rehmanniae (Sheng Di), Radix Trichosanthis Kirlowii (Tian Hua Fen), and Radix Glycyrrhizae (Gan Cao).

Conclusion:

When Western practitioners of Chinese medicine look at most Chinese textbook descriptions of diabetes mellitus, they are often perplexed that their patients do not fit any of the pattern presented in such books. That is because Chinese typically diagnosed diabetes much later in its course than we do here in the contemporary West. As the Chinese make more and more use of routine blood and urine analysis, they too are “catching” patients with diabetes much earlier than did premodern doctors such as Zhu Dan-xi and Zhang Jing-yue. Therefore, there is a shift in emphasis going on in modern Chinese medicine regarding the pattern discrimination treatment of this disease, thus bringing this disease’s Chinese medical treatment more into line with Western clinical experience. Liang et al.’s article summarized above is an example of this new line of thought in contemporary Chinese medicine.

Copyright © Blue Poppy Press, 2002. All rights reserved.

For more information on the Chinese medical treatment of diabetes and its complications, see Bob Flaws, Lynn Kuchinski & Robert Casañas’s The Treatment of Diabetes Mellitus with Chinese Medicine available from Blue Poppy Press in late Spring-early Summer, 2002.