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