12. Syndrome of Spleen-Yang deficiency
Manifestations
Main symptoms
Cramping pain in the epigastria or abdomen, which is often worse after taking cold food and drinks, poor appetite, abdominal distension.
Secondary symptoms
Diarrhea, poor appetite and feeling full easily, cold limbs, heaviness of the body, tired and reluctant to move.
Tongue
Pale, dull in color with a white and moist coating.
Pulse
Deep, slow and weak, especially in the second position on the right side.
Associated disorders in western medicine
Chronic digestive diseases, anemia, edema, nephritis, hypotension, hypothyroidism, hypoadrenalism, poor nutrition or consuming a low calorie diet.
Analysis of the syndrome
Spleen-Yang is very important in promoting digestion and water metabolism. It is considered as the key control in the body as the ascending of the Spleen-Qi and descending of the Stomach-Qi directly influence how the Qi, water and food essence move and change in the body. Spleen-Yang warms and stimulates the Qi movement and water metabolism, and promotes the process of Qi and blood generation in the body, which provides a foundation for life after birth of each individual.
Spleen-Yang can be weakened by improper food, eating habits and medicines, or by chronic diseases. In addition, Kidney-Yang deficiency may directly cause Spleen-Yang deficiency.
• When Spleen-Yang is too weak, it may generate internal cold and make the Qi and blood circulation slow down; thus cramping pain in the abdomen and cold limbs may present.
• When the Spleen-Yang is weak and is not able to transform and transport food and drink, diarrhea may occur.
• If the Yang is too weak to transform water into body fluids, water and dampness may accumulate in the Middle-Jiao and in muscles. Patients may feel tired, heavy of body and reluctant to move.
• If the Yang fails to stimulate the Stomach-Qi, patients will lose appetite and develop distension in the stomach and abdomen.
• Spleen-Yang deficiency is manifested as a pale and dull color of the tongue with a white, moist coating and a slow, deep and weak pulse, particularly in the second position on the right side.
Treatment principle: Tonify the Spleen-Yang and warm the Middle-Jiao
Herb selection principles and formula composition strategies
• First, sweet and warm herbs that enter the Spleen meridian, are able to warm the Spleen-Yang and tonify the Spleen-Qi are selected.
• Second, pungent and warm herbs that can scatter the cold in the Middle-Jiao, thereby spreading the warmth in the body and accelerating the water metabolism, are often used.
• Third, warm and pungent or warm and bitter herbs are selected to promote Qi movement and spread fluid.
CAUTIONS
1. Protect the Stomach:
Herbs that cause irritation of the Stomach should be avoided. In conditions where the herbs are really necessary, they should be taken after meals.
2. Protect the Spleen:
Cloying and heavy herbs can place an extra burden on the Spleen and should be used with caution. They should be used with herbs that regulate the Qi in the Middle-Jiao or herbs that promote digestion.
Structure of the formula and selection of herbs
Chief: Tonify the Spleen-Yang
Ren Shen ( Ginseng radix) and Huang Qi ( Astragali radix)
Ren Shen and Huang Qi are two strong herbs that tonify the Qi. Both are sweet and slightly warm, and enter the Spleen and Lung meridians. They may effectively tonify the Qi and gently strengthen the Yang and the Middle-Jiao. They are often selected as chief in formulas. Together with herbs that are pungent and warm, which stimulate the Yang of the Spleen and disperse the cold, they can generate the Yang of the Spleen and treat the symptoms that are caused by cold and weakness of the Spleen.
Moreover, Huang Qi, and especially raw Huang Qi, can ascend the Qi in the Middle-Jiao, strengthen the muscles and treat tiredness. As it enters the Lung meridian, it can strengthen the Lung-Qi so as to accelerate the water metabolism, and therefore can treat water accumulation in the body, such as edema.
Zhi Gan Cao ( Glycyrrhizae radix preparata) and Yi Tang ( Maltose)
Zhi Gan Cao and Yi Tang are able to tonify the Spleen-Qi. Compared with tonifying herbs such as Huang Qi and Ren Shen, their tonifying strength is mild. However, they have special usage in tonifying the Spleen.
Zhi Gan Cao and Yi Tang are sweet and neutral in nature, and enter the Spleen meridian. According to the concept that the combination of sweetness, warmth and pungency develops the ability to tonify the Yang, they are often used in combination with pungent-warm herbs in order to tonify the Yang in a gentle and steady way.
Moreover, in cases of Spleen-Yang deficiency, they are suitable for selection in chronic disorders where the Yang and Yin, as well as the Qi and blood, are all deficient. With the combination of warm and cold herbs, they can tonify the Yang and Yin effectively in a balanced way. Furthermore, they can reduce the side effects of the hot or cold herbs that may injure the Yin, the blood, the Yang and the Qi in the process of tonifying the Spleen.
The moderate tonifying action is an important characteristic of these two sweet substances. As sweetness may slow speed, release tension and alleviate the two or more conflicted aspects in a pathological development, Gan Cao and Yi Tang can reduce the cramping pain in the stomach and abdomen and relieve diarrhea and vomiting.
Xiao Hui Xiang ( Foeniculi fructus)
Xiao Hui Xiang is pungent and warm, and enters the Spleen and Stomach meridians. It can warm the Middle-Jiao and expel cold and dampness. It is used to treat abdominal pain, distension, poor appetite, vomiting and diarrhea due to the internal cold. It is an aromatic herb and can disperse cold and promote Qi movement, thereby alleviating pain and improving appetite.
In conditions of Spleen-Yang deficiency, this herb is often used with herbs that are sweet and warm, or sweet and neutral, to tonify the Spleen-Qi and strengthen the function of the Yang.
Gan Jiang ( Zingiberis rhizoma)
Gan Jiang, the dry ginger, is very pungent and primarily enters the Spleen meridian. It disperses cold, dries dampness and treats abdominal pain with a cold sensation and a cramping nature. It can also treat diarrhea and poor appetite due to Yang deficiency of the Spleen. Combined with herbs that tonify the Spleen-Qi, it can improve the function of the Spleen-Yang.
Deputy: Tonify the Spleen-Qi and dry dampness
Bai Zhu ( Atractylodis macrocephalae rhizoma) and Cang Zhu ( Atractylodis rhizoma)
Bai Zhu is sweet and warm, and enters the Spleen and Stomach meridians. It can tonify the Spleen-Qi. It is also bitter in taste and can dry dampness in the Middle-Jiao. It can treat poor appetite, fullness in the stomach, distension in the abdomen, diarrhea and heaviness of the limbs due to Qi deficiency with dampness accumulation in the Middle-Jiao.
Cang Zhu is pungent, bitter and warm, and enters the Spleen and Stomach meridians. This herb has no function in tonifying the Spleen, but it can effectively dry dampness, thereby relieving diarrhea, heaviness and stiffness of the body.
Assistant: Stimulate the water metabolism, eliminate the accumulated water and regulate the Qi in the Middle-Jiao
Gui Zhi ( Cinnamomi cassiae ramulus)
Gui Zhi enters the Heart meridian and is hot and pungent in nature. The young twigs have an aromatic smell that gives this herb a thin-pungent property, which makes it move quickly and lightly.
In the condition of Spleen-Yang deficiency, Gui Zhi can be used to stimulate water metabolism and accelerate water transforming into Qi, thereby relieving edema and difficult urination due to Yang deficiency. In addition, it can particularly warm the blood, stimulate the Heart and promote blood circulation, and can treat cold hands and feet, cramp of the muscles and pain due to cold in the blood.
Sheng Jiang ( Zingiberis rhizoma recens)
Sheng Jiang, the fresh ginger, is pungent and slightly warm. It enters the Stomach meridian, is able to disperse damp-cold there and to direct the Stomach-Qi downwards. It can be selected in the formula when cold invades the Stomach and disturbs the descending of the Qi. The manifestations are vomiting and stomach cramp. In addition, it can stimulate the Yang of the Spleen and Stomach, scatter the cold and water accumulation in the Stomach, and thus promote digestion and improve appetite. For this reason, Sheng Jiang can also be used in the condition of Spleen-Yang deficiency.
Fu Ling ( Poria)
Fu Ling is sweet, bland and neutral, and enters the Heart, Spleen, Stomach, Lung and Kidney meridians. It is able to drain out dampness by promoting urination. It can also tonify the Spleen and calm the mind. Because it is sweet and bland, it drains out dampness without the side effect of injuring the Yin and Yang of the body. In the condition of Spleen-Yang deficiency, it is often used as an assistant for treating accumulation of water and dampness in the Middle-Jiao. The manifestations are heaviness of the body, distension of the abdomen and difficult urination.
Chen Pi ( Citri reticulatae pericarpium)
Chen Pi is pungent, bitter and slightly warm. It enters the Stomach and Spleen meridians and is effective in regulating the Qi of these organs. Its aromatic smell can stimulate the Spleen, transform the dampness and soothe the Stomach-Qi. It is often used for distension and pain in the abdomen, reduced appetite, fullness of the stomach, nausea and vomiting.
In the condition of Spleen-Yang deficiency, Chen Pi can be used as an assistant to regulate the Qi that is disturbed in the Middle-Jiao and improve the transportation and transformation of food and drinks in the body.
Common accompanying symptoms and treatment
• Food accumulation: add Jiao Mai Ya (deep-fried Hordei fructus germinatus), Jiao Shen Qu (deep-fried Massa medicata fermentata) and Jiao Shan Zha (deep-fried Crataegi fructus) to promote food digestion.
• Nausea and vomiting of clear water due to accumulation of cold and fluid in the Stomach: add Ban Xia ( Pinelliae rhizoma) with Sheng Jiang ( Zingiberis rhizoma recens) to disperse the cold and fluid accumulation. In a severe case, Wu Zhu Yu ( Evodiae fructus) may be applied to warm the Stomach and reduce the cold in the Stomach.
Examples of classical formulas
Li Zhong Wan (Regulate the Middle Pill) 
Source: Shang Han Lun 
Composition
Gan Jiang ( Zingiberis rhizoma) 5 g
Ren Shen ( Ginseng radix) 6 g
Bai Zhu ( Atractylodis macrocephalae rhizoma) 9 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Analysis of the formula
This formula is able to warm the Middle-Jiao, strengthen the Spleen-Yang and treat internal cold due to Spleen-Yang deficiency.
• The chief herbs are Gan Jiang and Ren Shen. Gan Jiang can effectively and quickly warm the Middle-Jiao and Ren Shen can strongly tonify the Spleen-Qi. They strengthen each other’s function, spread the Yang and scatter the coldness in the body.
• Bai Zhu, as deputy, can tonify the Spleen-Qi and enhance the ability of Ren Shen. In addition, it can dry the dampness that has developed from the Yang deficiency in the Middle-Jiao and enhance the ability of Gan Jiang to spread the Yang.
• Zhi Gan Cao serves as assistant as well as envoy. It is able to tonify the Spleen, and harmonize and moderate the actions of the herbs in this formula.
Commentary on strategies
In this formula, each herb has a specific function and they cooperate in order to construct the Yang of the Middle-Jiao. It is in pill form and is made with honey, which assists Yang generation in the Middle-Jiao in a steady and sufficient way. It is particularly useful in a chronic condition of Spleen-Yang deficiency.
Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) 
Source: Shang Han Lun 
Composition
Yi Tang ( Maltose) 30 g
Gui Zhi ( Cinnamomi cassiae ramulus) 9 g
Bai Shao Yao ( Paeoniae radix lactiflora) 9 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Sheng Jiang ( Zingiberis rhizoma recens) 10 g
Da Zao ( Jujubae fructus) 4 pieces
Analysis of the formula
This formula primarily treats Spleen-Qi and Yang deficiency. In fact, it treats a chronic syndrome of deficiency of the Middle-Jiao, where the Yin and blood are also deficient due to long-term Yang and Qi deficiency. The Yang and Qi deficiency are manifested as intermittent, spasmodic abdominal pain that responds favorably to local application of warmth and pressure, reduced appetite, and cold and sore extremities. The Qi and blood deficiency are manifested as a lusterless complexion, palpitations, a pale tongue and a thready pulse. The Yin deficiency shows in low-grade fever, dry mouth, dry throat and irritability.
Since Qi, blood, Yin and Yang are all deficient in the Middle-Jiao in different degrees, they bring a dilemma in treatment: if tonifying the Yang by using pungent and hot herbs, the Yin and blood would be injured; if nourishing the Yin and blood by using cold and sour herbs, the Yang and Qi could be injured too. The formula Xiao Jian Zhong Tang demonstrates important strategies so that all the aspects may be tonified in a balanced and sufficient way.
• A large amount of Yi Tang is applied as the chief ingredient. Since it is sweet and neutral and enters the Spleen meridian, it can directly tonify the Spleen without harming the Yin or the Yang. Its nourishing nature makes it perfect for smoothing the muscles, and thus it can relieve cramping pain.
• When Yi Tang and pungent-sweet-hot Gui Zhi are used together, they can tonify the Spleen-Yang and stimulate its function. As the pungent and hot nature of Gui Zhi is modified by the large amount of Yi Tang, this herb will not injure the Yin and blood. Gui Zhi is considered as one of the deputies.
• When Yi Tang and the sour-bitter-cold Bai Shao Yao are used together, they can generate the Yin of the body and therefore treat blood and Yin deficiency. As the cold nature of Bai Shao Yao is minimized by the large amount of Yi Tang, the Yang and Qi will not be injured. Bai Shao Yao is considered as another deputy in the formula.
• The pungent and hot Sheng Jiang stimulates the Yang and assists Gui Zhi to warm the Middle-Jiao. It also soothes the Stomach-Qi, disperses cold and water accumulation and improves digestion.
• The sweet-warm Da Zao can tonify the blood and Spleen-Qi, and serves as assistant to Bai Shao Yao. It enhances the function of Bai Shao Yao to tonify the blood and Yin.
• Zhi Gan Cao serves as assistant as well as envoy. On the one hand, as assistant to the chief, it can tonify the Spleen and ease the muscles; on the other hand, as envoy, it moderates the action of the other herbs in the formula.
Commentary on strategies
This formula demonstrates important strategies so that all the aspects may be tonified in a balanced and sufficient way. These can be found from several distinct characteristics of this formula.
• First, the sweet herbs are used to tonify the Spleen directly.
• Second, the herbal combinations of sweet and warm, and sweet and cold are applied to generate the Yang and Yin respectively.
• Third, the combinations of herbs and ratios of dosages are arranged in a thoughtful way to avoid a dilemma in treatment. This is seen particularly in the use of sweet herbs as the center of balance. In this way, the Yin, Yang, Qi and blood are generated gradually, steadily and sufficiently.
