December 18, 2012

Dr. Hú Xī-Shù’s approach in the treatment of coughs

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Part 1

(Originally published in the online journal 'The Junkyard Daoist'

For the last few years I have been engaged in quite extensive research and study in the unique methods and treatment style of Dr. Hú Xī-Shù.  Although I have never personally studied with him (I was only eight years old when he died), I have always felt a very deep connection to his approaches.  To be a student of the Jīng Fāng current one must become intimate with the classic writings of Zhòng-Jǐng (仲景),  Fāng Yǒu-Zhí (方有执), Xú Líng-Tāi (徐灵胎), and the modern writings of Hú Xī-Shù (胡希恕), Liú Dù-Zhōu (刘渡舟), Fàn Zhōng-Lín (范中林), and Huáng Huáng (黄煌), to name just a few. There are obviously countless physicians of the past and present that have contributed to this fascinating and clinically relevant specialty however; these are the physicians that have exerted the greatest influence on my practice. 
There are currently very few books available on the Jīng Fāng current available in the English language, and it is for this exact reason that my colleague Michael Max and I are in the process of translating a very important clinical text exemplifying the strategies and methods utilized by some of these doctors mentioned above.  It is my hope that this text will assist in raising the level of study in North America, and contribute to the ever-evolving state of Chinese medicine in the west.

The following is the first part of a translation with commentary on the treatment of coughs, taken from Dr. Hú’s ‘Popular Lectures on Cold Damage’ (伤寒论通俗讲话).  It includes his various theories on treatment and includes representative case studies to illustrate these methods.  Part two will follow in the next issue. 


Coughing is mainly caused by the invasion of phlegm and thin-fluids.  Treatment should involve warm transformation, descending counterflow and calming

There are numerous formulas that are able to effectively treat coughs, some may even say that there are ‘thousands upon thousands’ (成千上万).  However, when treating coughs, Dr. Hú would most commonly use the formula Bàn Xià Hòu Pò Tāng (Pinellia and Magnolia Bark Decoction), taken from the Jīn Guì Yào Lüè (Essentials from the Golden Cabinet), where it clearly illustrates an intimate relationship between coughing and phlegm and thin-fluids. Numerous cases of coughing are due to the upward invasion of phlegm and thin-fluids, causing qì to run counterflow and not descend.  The treatment of phlegm and thin-fluids is clearly elucidated in the Jīn Guì Yào Lüè where it states:

“In diseases of phlegm, and thin-fluids, one should harmonize with warm medicinals”.

This is a very important treatment principle in addressing phlegm, thin-fluids, and coughs.  Adhering to these principles when selecting suitable formulas, will increase our clinical effectiveness.



Case Study

Huang, Female, 38 years old                                                                                                              

Initial diagnosis was on Feb 12, 1966:  Patient presented with a cough combined with expectoration of white phlegm, an itchy throat, chest fullness, a dry throat with no desire for fluids and bilateral rib side distension.  She has already taken several packages of herbal formulas to no avail.  Her tongue coating was thick and slimy, and her pulse was slippery-thin.

This pattern belongs to phlegm and thin-fluids harassing the upper (burner), and impaired depurative downbearing of the lungs.  This was treated by warm transformation and downbearing counterflow with Bàn Xià Hòu Pò Tāng with additions and subtractions.

Bàn Xià 4 qián,                      
Hòu Pò 3 qián,                       
Fú Líng 4 qián,                       
Sū Zǐ 3 qián,      
Jú Pí 5 qián,
Xìng Rén 3 qián,          
Jié Gěng 3 qián                       
Shēng Jiāng 3 qián

Results:  After taking only 2 packages of the above herbs, the cough had stopped.   

Bàn Xià Hòu Pò Tāng is originally from the Jīn Guì Yào Lüè in the miscellaneous gynaecological diseases section.  Originally used for “female patients with the sensation of fried meat in the back of the throat”
Dr. Hú believed this formula to be Xiǎo Bàn Xià Jiā Fú Líng Tāng with the additions of Hòu Pò and Sū Yè.  It is used in phlegm-thin fluids qì bind manifesting with chest fullness, throat blockage and cough.  It warms and transforms phlegm and thin-fluids, downbears counterflow, and regulates qì.    The patient above was manifesting with a cough due to phlegm and thin-fluids, therefore the use of this formula offered a quick resolution.
The original formula contains (Zǐ) Sū Yè, but Dr. Hú prefered to use (Zǐ) Sū Zǐ.  If there are obvious exterior signs present, then (Zǐ) Sū Yè may be added, and you may also add either Guì Zhī Tāng or Má Huáng Tāng.  If heat signs are present then Shēng Shí Gāo may be added.  If there is an enduring cough due to cold thin-fluids, without any obvious exterior signs, then combine with Líng Gān Wǔ Wèi Jiāng Xīn Xià Tāng (Poria, Licorice, Schisandra, Ginger, Asarum, and Pinellia Decoction).



Enduring depressed phlegm and thin-fluids frequently transform into heat, and therefore true cold, and false heat signs need to be clearly distinguished

In clinical practice, numerous patients with coughs are frequently seen.  Quite often they have taken several decoctions yet their symptoms fail to improve, even to the point where some of these patients symptoms intensify.  One of the main reasons for this is the inability to clearly differentiate between cold and heat.  The following case study illustrates this problem.

Case Study

A 63-year-old male presented at the clinic on January 4, 1966 complaining of a cough accompanied by spitting up of yellowish-white sputum that has been going on for the last four months.  This initially started last year in October with symptoms of a productive cough and throat pain, for which he had taken various medicinals that offered no relief and in fact caused some wheezing.  The main formula he was initially prescribed was a modified version of Sāng Xìng Tāng (Mulberry Leaf and Apricot Kernel Decoction). He had also mentioned that in this time he has consumed over one kilo of Chūan Bèi Mǔ (Fritillariae cirrhosae Bulbus). 
Current signs and symptoms:  Cough with copious amounts of yellowish-white sputum, irritability, chest fullness, aversion to cold in the back, dry mouth with a desire to drink, yet after every time he drank water, his abdomen would be uncomfortable.  He had a yellow slimy tongue coat, red tongue tip, and a wiry, slippery, thin pulse. 
Dr. Hú prescribed Xiǎo Qīng Lóng Jiā Shí Gāo Tāng (Minor Blue-Green Decoction plus Gypsum)

Má Huáng3 qián
Guì Zhī 3 qián
Xì Xīn 2 qián
Gān Jiāng 2 qián
Bái Sháo 3 qián
Zhì Gān Cǎo 3 qián
Wǔ Wèi Zǐ 3 qián
Bàn Xià 5 qián
Shēng Shí Gāo 1.5 liǎng

After writing this formula a question was posed to Dr. Hú asking why so many warm natured herbs were used, if heat signs were so obvious?  Dr. Hú replied: 

“This patient has already taken numerous formulas containing heat clearing medicinals, and his symptoms have only gotten worse.  The medicinals were not prescribed according to the presentation.  We can see from his current symptoms that he has an aversion to cold in his back, and abdominal discomfort after drinking water.  This is a pattern of thin-fluids collecting in the interior, and specifically cold thin-fluids.  Now if we were to administer bitter cold medicinals in order to clear heat and transform phlegm, not only would we fail to remove the phlegm, but we would further damage this patients’ yáng qì and the phlegm would in fact get worse.  When there is a substantial amount of phlegm and thin-fluids, that collect and stagnate for long periods of time, they will inevitably transform into heat, which invades the heart and chest causing irritability and chest fullness.  Therefore, by not removing the phlegm and thin-fluids, we would be unable to eliminate the heat, and the cough would fail to subside.  This is a pattern of exterior cold, with thin-fluids collecting internally, accompanied by upper (burner) heat.  Xiǎo Qīng Lóng Jiā Shí Gāo Tāng matches the presentation.  Xiǎo Qīng Lóng Tāng is used to resolve the exterior and eliminate phlegm in order to treat the root.  Shēng Shí Gāo is used to clear upper burner heat to expel the branch. Whether or not we can achieve a positive outcome will be determined after the formula is taken”.

Results:  after taking three packages of the formula, his irritability and chest fullness were reduced, as was the yellow phlegm and dry mouth.  His tongue coating was slightly slimy, so Xì Xīn, and Gān Jiāng were increased to 3 qián, and Shēng Shí Gāo was decreased to 1 liǎng.  This was continued for six more packages in which time his aversion to cold in the back was gone, the spitting up of phlegm was reduced, and no yellow sputum was seen.  Shēng Shí Gāo was removed from the formula and he was given twelve more packages, after which his condition completely resolved. 

November 16, 2012

Xiè Xīn Tāng (Heart Draining Decoction)-泄心汤

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From the ‘Interpretation of the Jīn Gùi Yào Lüè’ by Sòng Jiàn-Píng (2009)

I am currently in the process of translating the second volume of the Jīn Guì Fāng Gē Kuò (金贵方歌括) by Chén Xiū-Yuán. I have been so immersed in it lately, that I feel I’ve been neglecting this site, and figured I should work on something to put up. Because of the intense amount of work and dedication this book requires, I figured it would make more sense to translate something I’ve been using as reference, helping myself and others elucidate the deeper meaning behind the formulas discussed in the text. The following is the small section on Xìe Xīn Tāng, for which I recently worked on. I’ve had a bit of a hard time with the line “heart qi insufficiency” (心气不足), as I’ve read several commentaries, including the Qiān Jīn Fāng, which state that this is a typo, and the actual line should read, 心气不定 (heart qi instability/unsettled). Neither one of these still make immediate sense to me, but I am getting closer to understanding what it means and it’s pathological/physiological implications. Since I am still processing and working with this line, I’ll share my thoughts on a later date. I’d love to get other perspectives in the comments section.



[Original Text]  
"(When) heart qì is insufficient, with blood ejection and spontaneous external bleeding, Xiè Xīn Tāng masters it". (JGYL 17)

Xiè Xīn Tāng also treats sudden turmoil (cholera) disease

Dà Huáng 2 liǎng
Huáng Lián 1 liǎng
Huáng Qín 1 liǎng

Use 3 shēng of water for the three ingredients above, boil until reduced to one shēng, and take in one single dose.

[Comparisons] Heart qì vacuity: In the Qiān Jīn Fāng it is written as heart qì instability/unsettled) (心气不定)

[Presentation] A treatment for patterns of blood ejection and spontaneous external bleeding due to exuberant heat.

[Explanation] Both blood ejection and spontaneous external bleeding are categorized as exuberant heat patterns. The heart stores the shén, and governs the blood vessels. If heart fire is exuberant, it will cause frenetic movement of the blood, which results in blood ejection and spontaneous external bleeding. If the spirit is harassed there will be vexation and disquietude. Xiè Xīn Tāng is the treatment of choice, which clears heat and discharges fire. Within the formula, Huáng Lián and Huáng Qín clear heat, downbear fire, and discharge heat from the heart channel, so heart blood can quiet down on it’s own. Dà Huáng is bitter, cold, downbearing and discharging. It causes the descent of fire qi so blood can be calmed and stop moving frenetically. When these three medicinals are combined, they directly break heat, downbear fire, and stop bleeding.

[Commentary] Xiè Xīn Tāng and Bǎi Yè Tāng both treat blood ejection, however, Bǎi Yè Tāng mainly treats blood ejection due to central qì vacuity cold. Typical signs seen with this presentation are a somber white facial complexion, lassitude of spirit and fatigue, pale tongue body with a white coating, and a vacuous weak pulse. Xiè Xīn Tāng treats blood ejection due to exuberant heat, which is typically accompanied with heart vexation and disquietude, a red complexion, red tongue body, vexation thirst, constipation, a rapid pulse, etc. The two prescriptions above introduce us to two major methods and treatment principles for the treatment of blood ejection. One to warm yáng and restore qì, and one to discharge fire and clear heat in order to stop bleeding. In regards to Xìe Xīn Tāngs’ treatment of blood heat with frenetic movement, bleeding can manifest in several different ways including, vomiting of blood (hematemesis), external bleeding, blood in the urine (hematuria), blood in the stools (hemafecia), etc. which can all be treated quite effectively.

This is a commonly used formula for treating exuberant heat in the three burners, and is used clinically for the congestion of pathogenic-toxic fire and heat causing disorders in either the upper or lower burners, or the exterior or interior. Examples being, the upward harassment of toxic heat causing a red complexion and tongue, ulcerations of the mouth and tongue, tooth swelling and pain, vexation heat, and oppression in the chest, or toxic heat manifesting on the exterior with skin damage due to swollen and toxic sores.


[Case Example] A sixty-year-old female patient presented on April 20, 1994. She has a history of a duodenal ulcer for many years, and has recently been quite fatigued, with unbearable epigastric pain. This morning after eating breakfast, she immediately felt nauseous and had a desire to vomit. Soon after she vomited approximately 300ml of fresh blood, which contained stasis clots but no food from her digestive tract. She has continued to feel nauseous and has been vomiting blood quite frequently up until the time of her consultation. Her tongue was red, with a thin yellow coating, and she had a wiry-slippery-rapid pulse. The diagnosis was blood ejection. The pattern belonged to heat accumulation in the stomach causing frenetic movement of the blood. Treatment involved clearing the stomach, discharging heat, transforming stasis, and stopping bleeding.

Formula:

Dà Huáng 30g
Huáng Qín 9g
Huáng Lián 9g
Dài Zhě Shí 30g

The medicinals above were to be decocted (and drunk) quickly

After taking the formula, the vomiting of blood stopped, and the epigastric pain decreased. She was continued on two more packages of the formula to clear the remaining pathogens.

(Luó Wèi Dōng: Effective Treatments with Classical Formulas, vol. 4.)

November 3, 2012

Reflections on the patterns and treatment of Liver cancer


The following is an article I translated a couple years ago for a mainland Chinese medical journal, I just found while digging through my hard drive. While I (luckily) don't treat lots of liver cancer, there's still some juicy content in the article, and some great classical reference. Enjoy!




Reflections on the patterns and treatment of Liver cancer
Dr. Su San-Leng

Translated by Eran Even

Summary: 
In regards to the analysis and grouping of liver cancer signs and symptoms, we attach great importance to spleen deficiency patterns according to the manifestation and to the developmental process of the patients’ individual physical factors. While the basic overall objective of treatment is in the regulation of spleen deficiency following a holistic ideology, we must also take into account the various disease mechanisms and simultaneous accompanying symptoms. By adhering to these factors and to the spirit of Chinese medical pattern differentiation we are able to achieve positive results and outcomes.

Keywords: 
Liver cancer, spleen deficiency, holistic ideology, treatment based on pattern identification.     


Introduction:
Liver cancer is a very harmful condition, which is generally difficult to treat.  The prognosis for most cases is quite poor [1] [2], usually requiring more diverse treatments.  There are several pieces of literature in existence which discuss the treatment of liver cancer, with discussions about disease aetiology and pathology, yet most are focused in the wrong direction.  From the perspective of the symptoms at the onset of the condition, in reality particular importance should be focused on the pattern of spleen deficiency [3]. In conforming to the science and study of organ manifestations, and treatments according to pattern identification, we are able to treat the whole disease and obtain relatively high clinical effectiveness [4]. 
However, there is certainly no doubt that liver cancer is a growing concern amongst cancers.  The intent of this article is to simply illustrate the usage of the theory of treatments based on pattern identification according to the theories of organ physiology and pathology as the starting point, so as to draft proper and effective treatment guidelines.  With that being said, in regards to treatment according to pattern identification, [liver cancer] does not fall within the theory of organ manifestations, but instead we should expound on the idea of the [spleen organ] being the core of this clinical reality. 


Examining the past:
(1)  Disease mechanism and disease location:
From our document analysis, we can see the commonly seen mechanisms involved in liver cancer are; qi stagnation, blood stasis, congealing of phlegm, damp turbidity, toxic heat, and deficiency damage. [5]. Although these patterns can offer an explanation as to the progression and state of the patients’ condition, they are all however, established and known to be based on the premise of liver cancer and are simply used as a method of classification.  In reality, according to the initial clinical manifestation of the patient, they are almost always based on the organ manifestation signs and symptoms of the spleen and stomach, even to the point where, prior to the emerging of any concrete patterns, we see various symptoms of the digestive system.  Therefore, if we eliminate preconceived thoughts and ideas, we are able to see that the disease mechanism and location of liver cancer is in fact related to the spleen and stomach, and by this we would be able to determine our treatment [6].  Even within the developmental process of the late stages of the disease, the signs and symptoms of the spleen and stomach are still inevitably linked.  Moreover, with a spleen deficiency pattern, there can be simultaneous patterns such as, blood stasis, qi stagnation, congealed phlegm, damp turbidity, toxic heat, etc. In other words, the presence of cancer (in liver cancer) is always anatomically found in the liver, however, the nature and occurrence of the condition is found in the spleen according to the study of traditional Chinese medical organ manifestations.



   (2) Treatment Methods: 
According to traditional methods, most treatments involve some element of clearing heat, resolving toxicity, invigorating blood, transforming stasis, softening hardness, scattering binds, attacking toxins with toxins, etc, in order to disperse and eliminate tumors [7], but in reality the results are usually unsatisfactory. 
The clearing heat and resolving toxicity method is utilized in cancer therapy when the cause of the cancer is heat or fire, so therefore, the treatment principle is to eliminate and drive out pathogenic heat. However, treatment efficacy must be assessed.  It is quite common in folk medicine to use secret recipes to treat liver cancer consisting of bitter cold medicinals which if used for extended periods of time can damage stomach qi, creating digestive dysfunctions and invariably decreasing immunity. 
The method of invigorating blood and transforming stasis is considered in cases of liver tumors accompanied by cirrhosis [8] [9] [10].  It is of common belief that  a definite relationship between liver cirrhosis and blood stasis exists [11].   Due to this reason, blood invigorating medicinals are commonly used as part of a treatment plan to transform stasis and eliminate tumors.  However simply using blood invigorating, stasis transforming medicinals in order to disperse tumors bears very little significance, and in addition there exist varying levels of controversy surrounding these medicinals. 
The method of softening hardness and scattering binds is also commonly used, based on the belief that tumors are simply congealed phlegm nodules, and so therefore medicinals are used to transform phlegm and soften hardness.  However, these types of medicinals are more suitable for certain types of abnormal glandular dysfunctions (resembling tumors), as it is not easy to disperse hyperplastic growths or solid tumors. 
It is believed that cancer is caused by the amassment of toxic pathogenic factors of a stubborn nature, and therefore another method used is the administration of toxins to treat toxins. Using general herbs to achieve this function is quite difficult, so we must therefore use toxic medicinals in order to conquer these toxins.  When using these types of medicinals we must take two issues into consideration.   The first is that many of these toxic substances are harmful to the organisms’ cells and tissues, so it is imperative that we find strong and distinctive medicinals specific to cancer cells, otherwise we run the risk of damaging the right qi.   The second issue is that we must be certain that the dosage administered is adequate in order to be effective, but must question whether or not there is the possibility of damage to the body due to accumulation (of the toxic medicinal) after reaching the desired dose.

Looking to the future

(1)  The importance of strengthening the spleen
In the early stages of liver cancer, symptoms are generally not perceived, and once these symptoms develop they are usually associated with the centre (spleen and stomach organs).  In the later stages of the condition, the  commonly seen symptoms include epigastric fullness and focal distention, torpid intake, nausea, vomiting, abnormal bowel movements, weight loss, fatigue, swelling in the upper right abdomen, pain, splenomegaly, heat effusion, ascites, jaundice, etc.  Nearly all of these symptoms are related to a spleen deficiency pattern.  Li Dong-Yuan of the earth supplementation school declared:  
“In cold deficiency and weakness of the spleen and stomach, there is inability to transport and transform the essence of food and grain, which will gather and give rise to distention and fullness.  If there is an abundance of dampness, distention and fullness will also be present with non transformed food.  In spleen diseases there will be fatigue and somnolence, loss of use of the limbs, and sloppy diarrhea.  If food damage affects the Tai-Yin or Jue-Yin (channels), there may be vomiting, or focal distention and fullness, and perhaps even dysentery or intestinal aggregation”.  

Essentially a pattern of spleen deficiency losing the ability to transport and transform will give rise to the aforementioned symptoms. 

According to his famous treatise, Li (Dong-Yuan’s) discussion of swellings and lumps in the abdominal cavity is considerably similar to the description of liver cancer.   
“When the spleen is diseased, there should be stirring qi around the umbilicus, which is firm and painful on palpation.  This stirring qi is solid and fixed, hard as if an accumulation, with vague pain or, in the extreme, even great pain.  Presence of this stirring qi leads to the disease of spleen deficiency”.

  In the Classic of Difficulties (Nan Jing) it is said;  
“Accumulations in the spleen are named focal distention.  They are present in the epigastrium; the abdomen is large resembling an inverted bowl, and the condition endures without recovery. The four limbs are unable to receive, jaundice develops, and foods and drinks fail to build the skin and flesh”. 

  It is written in the Comprehensive Recording of Divine Assistance from the Zhenghe Era (Sheng Ji Zong Lu):   
“Accumulated qi in the abdomen failing to recover over an extended period, which is firm when pressed, and immobile, is called a concretion.  This is caused by cold and dampness, and/or unseasonal foods and drinks causing spleen deficiency weakness. If foods and drinks are not reduced, (the abdomen) will feel firm like a bowl when pressed and the condition will seem endless. This will cause the body to become thin and the abdomen large. Death will most certainly ensue, if this is not eliminated”.   

Regarding abdominal water (ascites), our predecessors also believed that the cause was a spleen earth deficiency.  In the 4th century text, ‘Emergency Formulas to Keep Up One’s Sleeve’ it is written:  

“Water diseases are the result of deficiency and damage following a major disease such as the aftermath of diarrhea or dysentery.  Fluids are unable to be dispersed, the triple burner is diseased and urination is inhibited, gradually producing amassment and finally spreading throughout all the channels and collaterals”.   

The fever associated with liver cancer can be due to various factors, such as the general feverishness associated with cancer, fever due to an infection, or the result of a deficiency of the body, which are similar to Li Dong-Yuan’s description of restrained and obstructed spleen yang.   
“Heat in the four limbs, heat of the muscles, sinew impediment heat, heat in the bone marrow, drowsiness, and heat in the hands which feel like being burnt with fire.  In most cases, this is caused by blood deficiency.  Or it may be caused by restrained and obstructed yang qi within spleen earth due to stomach deficiency and eating too many chilled foods.  This will result in the effusion of depressed fire”. 

Hua Tuo’s ‘Central Treasury Classic’ says:  
“In diseases of the spleen, blood and qi will be unsettled.  With this unsettling, there will be unceasing alternation of cold and heat, which resembles malaria”. 

Currently, the formula Artemisia Yinchenhao Decoction (Yin Chen Hao Tang) is used to treat jaundice associated with liver cancer, as most physicians ascribe this to damp heat in the liver and gall bladder.  In reality, this goes against (Zhang) Zhong-Jing’s original intention.  Zhong-Jing said:  

“In Yang brightness disease there is heat effusion and sweating.  This is (due to) straying heat which is unable to cause yellowing.  If there is only sweating from the head, and not from the body, stopping at the neck, along with inhibited urination and thirst with intake of fluids, this indicates stasis heat in the interior which will cause yellowing and therefore, Yin Chen Hao Tang governs” [12].   

This illustrates that in the treatment of jaundice, the use of Yin Chen Hao Tang in reality treats diseases of the spleen and stomach earth and not of liver and gallbladder wood. 
It can be seen from a great deal of the quotes mentioned above, and although they cannot cover the whole story, a pattern of spleen deficiency is a solid explanation of the majority of cases seen with this condition.  According to this explanation following the principles of strengthening the spleen is often the correct strategy to use. 


(2) Whole treatment supplementation     
Holistic ideology is one of the characteristics of Traditional Chinese medicine [13].  Although liver cancer is a liver disease, it is not seen as completely independent from the other organs.  Although the treatment of malignant tumors is difficult, by understanding the basic elements of the condition such as the bodies’ yin and yang, cold and heat, deficiency and excess factors we see how these imbalances can create specific conditions.  Therefore, by looking at the manifestations of the various viscera and bowels and treating according to pattern identification, we are able to devise a treatment strategy, harmonize the body and bring about equilibrium to the whole system.  This is the same basic strategy that is applied to the clinical treatment of tumors.
Due to the refractory nature of this condition, we must employ other treatment methods, and this is the part that needs to be further explored and investigated in depth.  However, considering the holistic ideology present in Chinese medicine, we must adapt a comprehensive treatment rationale which conforms to this ideology.    Under the premise of spleen deficiency, every patient will have individual physical characteristics, and the disease may develop in a different matter with various outcomes.   There may be accompanying patterns such as qi stagnation, blood stasis, congealing of phlegm, damp turbidity, toxic heat, and insufficiency of yin fluids.  In the later stages these fluids may be completely damaged similar to a pattern of spleen and kidney dual deficiency.  When treating, we must not overlook harmonization, and from experience we know that treating the whole is of utmost importance.   




Conclusion:
  According to this paper and to various clinical reports, we see that there are numerous methods used to treat liver cancer.  However, many of these treatment effects are rather undesirable.  Paying particular attention to the onset, location and mechanism of the condition we find that although the symptoms are namely in the liver according to anatomical study, the clinical manifestations and symptoms are found in the spleen.  With regards to the traditional Chinese medical theory of treatment based on pattern identification, in reality it is the spleen that should be the main focus, and because the condition is usually in a chronic state, one must attach great importance to treating the deficiency.  With that being said, the core of treatment should be on spleen deficiency and addressed throughout the entire course of therapy, remaining mindful of any simultaneous patterns the patient may be presenting with.  By adhering to this comprehensive treatment strategy, we may be able to acquire excellent treatment outcomes.


References:

[1] Liao Ji-Ding. Clinical Oncology. He Ji Publishing.  (2003); p. 499
[2] Yu Ren-Cun, Jiang Ting-Liang, Yu Er-Xin.  Tumor Research. Zhi Yin Publishing House, Republic of China, (1983); p. 386.
[3] Tang Jian-You, Yu Ye-Qin. The Origin, Development, and Characteristics of Liver Cancer. Shang Hai Science and Technology Press, (1999); p. 374-375
[4] ibid: p. 375
[5] Zhang Chi-Zhi, Zhou Zhen-Xiang, Wang Ru-Feng.  The Essentials of Patterns and Treatments of Tumor Diseases. Science and Technology Documents Publishing, (1999); p.146-147.
[6] Xu Yi-Yu, Yu Er-Xin, Unique Experiences in the Treatment of Late Stage Liver Cancer. Shang Hai Journal of Traditional Chinese Medicine, (1996) (1); 10
[7] Gao Jin.  Foundations and Research Methods in Oncology. People’s Medical Publishing House, (1999); p. 447-449.
[8] Su Wu-Xiong.  Cancer.  Shui Niu Publishing, Republic of China, (1980); 192.
[9] Tang (1999):  p. 123
[10] Liao (2003): p. 491
[11] Wang Bai-Xiang. Study of Chinese Medical Liver & Gallbladder disorders. Chinese Medicine Science and Technology Press. (1993): p. 615
[12] Li Pei-Sheng. Selected Readings on Cold Damage.  Zhi Yin Publishing House, Republic of China, (1991): p. 178.
[13] Wang Xin-Hua.  Foundational Theory in Chinese Medicine.  People’s Medical Publishing House.  (2001): p. 12-15   




  

October 9, 2012

September 24, 2012

Tài Yáng flow charts

Digging through some of my papers over the weekend, I found an old chart I have, which gives a breakdown of the patterns found in the Shāng Hán Lún (伤寒论), with corresponding formulas, in a neat little flow chart format.  I decided to translate it this morning as I think it's pretty cool.  I've started with the Tài Yáng section, and will finish up the rest in the next few days.  Enjoy!



September 10, 2012

A Case of Guì Zhī Fù Zǐ Tāng (Cinnamon Twig and Aconite Accessory Root Decoction)


 The following is a case taken from 'Five Steps to Shang Han Treatment Based on Pattern Identification' (方证相对:伤寒辨证论治五步), which my colleague Michael Max and I are currently translating, and should be available sometime within the next year.  Periodically, I will post random tidbits from the text in order to wet readers appetites, and for readers to get a feel for the overall text.  To read another case from the book, click here

 



Case by the Fire spirit currents’ Fàn Zhōng-Lín (范中林)


A sixty-year old female Yǒng Níng native farmer from Wēn jiāng county in Sì Chūan province presented at the clinic.

Step 1: Chinese Medical Diagnosis:

This patient already had a history of rheumatic pain, and in August of 1974 she had come in for her initial consultation. She complained of an uncomfortable feeling in her body, a fear of cold, dizziness, and body pain. When she had come in, she was stooped over, and mentioned that she easily suffered from severe, acute pain in her lower back, with great difficulty stretching out. This was accompanied by continuous cold sweats emanating from her head, after which she would proceed to lay in bed without rising. At this point Dr. Fán was sought out for treatment.



Step 2: List of Disease Mechanisms

· Lumbar pain which felt as if it had been cut, with great difficulty turning sides, ‘old’ feeling of the body with a fear of cold, feverishness, and numbness in the extremities. She had a green-blue dark facial complexion, dark lips, a slightly red tongue body, with a slippery, greasy coating. Her arms felt slightly cold on palpation, and her pulse was floating and deficient: This is a Tài Yáng pattern with the mutual contending of wind and dampness, and deficiency of defensive yáng.

 
Step 3: Comprehensive Analysis

This is a pattern of Tài Yáng wind-dampness. In order to treat, one should warm the channels, scatter cold, dispel wind, and eliminate dampness.



Step 4: Formulas According to Pattern

In this case guì zhī fù zǐ tāng (Cinnamon Twig and Aconite Accessory Root Decoction) masters it.



In clause 174 of the Shāng hán lùn (傷寒論 Discussion of Cold Damage) it is written:

“In cold damage that has lasted for eight or nine days, where wind and dampness mix with each other, there will be irritable pain in the body, an inability to turn sides, absence of vomiting, or thirst, and a pulse which is floating, deficient and rough. guì zhī fù zǐ tāng (Cinnamon Twig and Aconite Accessory Root Decoction) masters it”.

The case above is essentially identical to this clause, and therefore the original formula was used in treatment, and only the dosages of the medicinals were altered.



Step 5: Medicinals According to Pattern

The dosage of guì zhī (Cinnamomi Ramulus) was increased in order to discharge and scatter exterior wind-cold, free the yáng, and transform qì.

Combined with shēng jiāng (Zingiberis Rhizoma recens), wind pathogens are expelled from the skin and body hair.

The dosage of fù zǐ (Aconiti Radix lateralis preparata) was increased in order to warm the channels, drive out cold, stop pain, assist kidney yáng, and secure the foundation of defensive yáng.

The assistants zhì gān cǎo (Glycyrrhizae Radix preparata), and hóng zǎo (Jujubae Fructus), boost the centre, and harmonize the nutritive and defensive qì, therefore the three medicinals above can eliminate and battle to promote natural resolution.

Formula:

guì zhī (Cinnamomi Ramulus) 15g
fù zǐ (Aconiti Radix lateralis preparata) 60g (cooked separately for thirty minutes)
shēng jiāng (Zingiberis Rhizoma recens) 30g
zhì gān cǎo (Glycyrrhizae Radix preparata) 10g
hóng zǎo (Jujubae Fructus) 30g

Four packages were prescribed.

After taking the four packages, all of her symptoms had basically reduced, and after another four, her condition had completely resolved. Afterwards, she was able to walk and work as per usual. On inquiry in June of 1979, the patient said that since recovering five years ago, she has never had a relapse of the condition.

July 23, 2012

Professor Chén Rùi-Chūn’s experience in the usage of Wǔ Líng Sǎn (Five-Ingredient Powder with Poria) (陈瑞春教授应用五苓散经验)


The following is a small excerpt of my most recent article/translation, which will be published in the Lantern's September issue.   



Article by: Zhèng Yàn-Huá, Jiāng Xī University of Traditional Chinese Medicine
Translated by:  Eran Even


 Professor Chén Ruì-Chūn (1936-2008), originally from Tóng Gǔ county in Jiāng Xī province, was a very well known classical formulas (jīng fāng 经方) specialist, whose impressive career as a clinician, scholar, and clinical advisor spanned well over fifty years.   

In order to truly understand the clinical application of Wǔ Líng Sǎn  (Five-Ingredient Powder with Poria), Dr. Chén would often emphasize that one must begin from the perspective of the patho-mechanism, and not be limited by just the Shāng Hán Lùn’s (傷寒論 Discussion of Cold Damage) concept of water amassment. This would provide more varied opportunities to use this formula. 
I was fortunate enough to have had the opportunity to study with Dr. Chén, and observe his extensive use of this formula.  The following are just a few examples illustrating these ideas.    




In the Shāng Hán Lùn (傷寒論 Discussion of Cold Damage), Wǔ Líng Sǎn  (Five-Ingredient Powder with Poria) appears in eight different lines (71, 72, 73, 74, 141, 156, 244, and 386), and with the exception of line 386 where it is indicated in the treatment of sudden turmoil disease, the remaining lines are all mainly associated with tài yáng water amassment patterns, with symptoms of thirst, and difficult urination, accompanied by either the presence or absence of exterior signs.  Excerpts from the following lines illustrate the major signs and symptoms associated with this formula:

Line 71: “If the pulse is floating, urination is inhibited, and there is slight heat with dispersion thirst, Wǔ Líng Sǎn masters it”

Line 72: “Irritability and thirst”

Line 73: “There is sweating and thirst”

Line 74: “There is an exterior and interior pattern present, with thirst and a desire to drink water, and vomiting immediately following the ingestion of fluids”

Line 141: “A desire to drink water”

Line 156: “Thirst with a dry mouth, irritability, and difficult urination”

In regards to clinical practice, Dr. Chén would emphasize the need for a comprehensive analysis of Wǔ Líng Sǎn ’s (Five-Ingredient Powder with Poria) patho-mechanism, and as students, would require us to delve into deep study in order to comprehend the main points or ‘gist’ of the original text in the Shāng Hán Lùn (傷寒論 Discussion of Cold Damage). 
He felt that the essential patho-mechanism involved with Wǔ Líng Sǎn  (Five-Ingredient Powder with Poria) is the inability of qì to transform water.  With the loss of qì transformation causing the non-distribution of water and fluids, we see thirst, and with the accumulation and stagnation of these fluids, we see difficult urination.  In addition, the inability of qì to transform water can also manifest with copious urination.  Therefore, in order to increase one’s flexibility in clinic, and successfully treat numerous conditions, one must grasp the basic mechanism of “qì being unable to transform water” when using Wǔ Líng Sǎn  (Five-Ingredient Powder with Poria). 


1.    Copious Urination

Copious urination is a commonly seen symptom in clinic in both the young and the elderly, usually manifesting as frequent urination.  In children, copious urination is commonly due to pre-heaven insufficiency, with inhibited Bladder qì transformation and a lack of water transformation.  In the elderly, where qì, blood, yīn and yáng may all be deficient, Bladder qì may be inhibited manifesting as frequent urination, and even in some cases as incontinence and enuresis.  Dr. Chén thought that when these kinds of patients were treated from the perspective of a Kidney qì deficiency with Kidney supplementing, urine astringing medicinals, the results were typically less than satisfactory.  This is because copious urination (especially night time urination), and frequent urination are not just simply due to Kidney deficiency, or qì deficiency, but more directly caused by the decline of the transformative function of the Bladder.  Therefore, in treatment one should warm the Kidneys and transform qì, adding a small amount of assistant medicinals to support the Kidney function of absorption and intake.  Dr. Chén would commonly use Wǔ Líng Sǎn  (Five-Ingredient Powder with Poria) with the addition of medicinals such as Sāng Piāo Xiāo (Mantidis Ootheca) and Yì Zhì Rén (Alpiniae oxyphyllae Fructus), in order to obtain satisfactory results.  

Case:  A seventy-three year old female patient presented at the clinic on January 8, 2002.  She was seeking treatment with Chinese medicine following breast cancer surgery.  She complained of frequent nighttime urination, occurring five-six times a night, which was significantly affecting her sleep.  Her appetite was normal, as were her bowel movements, with one movement per day.  She was in generally good health, with no other major complaints.  She was given a modified version of Wǔ Líng Sǎn  (Five-Ingredient Powder with Poria). 

Guì Zhī 10g (Cinnamomi Ramulus)
Fú Líng 15g (Poria)
Zhū Líng 10g (Polyporus)
Zé Xiè 10g (Alismatis Rhizoma)
Bái Zhú 10g (Atractylodis macrocephalae Rhizoma)
Sāng Piāo Xiāo 10g (Mantidis Ootheca)
Qiàn Shí 20g (Euryales Semen)
Yì Zhì Rén 10g (Alpiniae oxyphyllae Fructus)

After taking five packages of the above formula, urination decreased to two-three times per night.  After another five packages, it decreased to once or twice a night, which greatly improved her sleep and overall spirit.  Afterwards, she was given a formula to boost qì, strengthen the Spleen, and regulate the Spleen and Stomach.