CHAPTER 60 Abdominal Masses
Abdominal masses are called Ji Ju (
). Ji indicates actual abdominal masses which are immovable; if there is an associated pain, its location is fixed. These masses are due to stasis of Blood. I shall call them ‘Blood masses’. Ju indicates abdominal masses which come and go, do not have a fixed location and are movable; if there is an associated pain, it too comes and goes and changes location. Such masses are due to stagnation of Qi. I shall call them ‘Qi masses’. Actual abdominal lumps therefore pertain to the category of abdominal masses and specifically Ji masses, i.e. Blood masses.
Another name for abdominal masses was Zheng Jia (
), Zheng being equivalent to Ji, i.e. actual, fixed masses, and Jia to Ju, i.e. non-substantial masses from stagnation of Qi. Zheng Jia is normally used in referring to abdominal masses that generally occur only in women; but they do occur in men as well, though rarely. Chapter 60 of the Simple Questions says: “Diseases of the Directing Vessel … in women are masses below the waist.”1 In this context, the Simple Questions uses the term Jia-Ju, i.e. non-substantial masses from Qi stagnation.
The term Ji Ju appears in the Classic of Difficulties which clearly distinguishes the two types:
Ji masses pertain to Yin and Ju masses to Yang … When Qi accumulates it gives rise to Ji masses, when it gathers it gives rise to Ju masses. Ji masses arise from the Yin organs and Ju masses from the Fu organs. Ji masses have a fixed location and pain, and have boundaries above and below, and edges to the right and left [i.e. they have clearly defined borders]. Ju masses seem to start from nowhere, without a boundary above and below and with a moving pain.2
The Essential Prescriptions of the Golden Cabinet by Zhang Zhong Jing says:
Ji masses arise from the Yin organs and they cannot be moved; Ju masses arise from the Yang organs, they come and go, the pain has no fixed location, and they are easier to treat.3
The General Treatise on the Aetiology and Symptoms of Diseases (AD 610) says:
Abdominal masses are due to cold and heat not being regulated [i.e. exposure to extremes of weather], irregular diet and stagnation of the Qi of the Yin organs. If they do not move they are called Zheng; if they are movable they are called Jia. ‘Jia’ implies the meaning of ‘false’: this is because these masses can come and go and are not actual masses.4
Since the time of the Tang dynasty, eight types of women’s abdominal masses have been described, i.e. yellow, green, dry, blood, fat, fox, snake and turtle mass.
Aetiology
Emotional strain
Emotional strain is the most common cause of the formation of abdominal masses. Anger, especially when repressed, frustration, resentment, hatred, worry and guilt can all lead to stagnation of Liver-Qi and, in the long run, to stasis of Liver-Blood. The Liver channel plays an important role in the movement of Qi in the lower abdomen and, in women, Liver-Blood plays a paramount role in the circulation of Blood in this area.
Irregular diet
Diet is another important aetiological factor in the formation of abdominal masses. Irregular eating or the excessive consumption of cold and raw foods may lead to the formation of Cold in the lower abdomen. Cold contracts and naturally interferes with the circulation of Qi and, especially, Blood; it may lead to stasis of Blood.
Excessive consumption of greasy foods, on the other hand, impairs the Spleen and may lead to the formation of Dampness and Phlegm, which can settle in the lower abdomen and bring about abdominal masses. There is also a close interaction between Phlegm and stasis of Blood so that one may lead to or aggravate the other.
External pathogenic factors
External pathogenic factors are less important in the aetiology of abdominal masses. The most important pathogenic factor is external Cold which can invade the lower abdomen and impair the circulation of Blood eventually leading to stasis of Blood. Chapter 66 of the Spiritual Axis says: “Ji masses are due to Cold.”5
External Dampness may invade the channels of the legs and then creep up them to settle in the lower abdomen where, in the long run, it transforms into Phlegm and may give rise to abdominal masses.
Pathology
As for pathology, abdominal masses are always characterized by either stagnation of Qi or stasis of Blood, the former being non-substantial and the latter substantial masses. In addition to stagnation, there may also be Phlegm. However, in all cases of abdominal masses there is always an underlying deficiency of Qi. Deficient Qi fails to transport and transform and, leading to stagnation of Qi and Blood, it allows masses to form.
Masses from stagnation of Qi come and go, are movable on palpation and change location. If there is pain, the pain has no fixed location and is accompanied by a pronounced feeling of distension.
Masses from stasis of Blood are fixed in location, they are not movable on palpation and feel quite hard. If there is pain, it is fixed and stabbing in character.
Masses from Phlegm feel soft on palpation and have a fixed location. There is usually no pain.
Identification of patterns and treatment
The treatment of abdominal masses is always based on moving Qi and Blood. However, there are other factors to take into account depending on the stage of the disease. In the beginning stages of the condition, the pathogenic factor (stagnation of Qi or stasis of Blood) is relatively weak and the body’s Qi relatively strong. In the middle stages, the body’s Qi is weakening and the pathogenic factor becoming more prominent. In the late stages, the pathogenic factor is very prominent and the masses very developed while the body’s Qi is very weak.
Thus, irrespective of the pathogenic factor involved, the principle of treatment must be guided by the stage of the condition:
Also, when moving Qi in Qi masses, the treatment principle is to move Qi primarily and invigorate Blood secondarily. In Blood masses, the treatment principle is to invigorate Blood, eliminate stasis, ‘break’ Blood primarily and move Qi secondarily. Thus, the formulae given below are only a guideline. The approach adopted should be chosen according to the pattern of the disease, but the formulae must be modified in every case according to its stage.
Furthermore, all prescriptions indicated below should be modified with the addition of ‘softening’ herbs, i.e. herbs which soften masses: this is particularly necessary for masses from stasis of Blood or Phlegm. Softening herbs are:
As for the relative application of acupuncture and herbal medicine, especially for Blood masses, the herbal treatment is primary in relation to acupuncture.
Qi masses
Liver-Qi stagnation
Clinical manifestations
Movable abdominal masses which come and go, abdominal distension and pain which come and go with the masses, a feeling of discomfort in the hypochondrium, depression, moodiness, irritability, alternation of constipation and diarrhoea. Tongue: the body colour may be normal or slightly Red on the sides. Pulse: Wiry.
Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-14 Siman, Ren-6 Qihai. Reducing or even method.
Herbal treatment
a Prescription
b Prescription
Explanation
The present formula differs from the previous one in three respects: it is much stronger in its action and better at dissolving masses, it invigorates Blood and it scatters Cold. It is therefore especially indicated when Qi stagnation is associated with Cold and the tongue is Pale and the pulse is Tight.
Women’s Treasure remedy
This remedy pacifies the Liver, moves Qi, eliminates stagnation, tonifies Spleen-Qi, nourishes Liver-Blood and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body with slightly Pale sides.
Liver-Qi stagnation
Movable abdominal masses which come and go, abdominal distension and pain which come and go with the masses, a feeling of discomfort in the hypochondrium, depression, moodiness, irritability, alternation of constipation and diarrhoea. Tongue: the body colour may be normal or slightly Red on the sides. Pulse: Wiry.
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-14 Siman, Ren-6 Qihai. Reducing or even method.
Retention of food and Phlegm
Clinical manifestations
Soft abdominal masses, which may be strip-like in shape, abdominal distension, constipation or diarrhoea, poor appetite, nausea and a feeling of fullness. Tongue: Swollen, with a sticky coating which is thicker on the root. Pulse: Slippery.
Acupuncture
Ren-12 Zhongwan, BL-20 Pishu, Ren-10 Xiawan, Ren-6 Qihai, L.I.-4 Hegu, ST-40 Fenglong, ST-36 Zusanli, BL-21 Weishu, ST-34 Liangqiu, SP-6 Sanyinjiao. Reducing or even method, except on Ren-12 and BL-20 which should be reinforced.
Herbal treatment
a Prescription
Explanation
This formula moves Qi and resolves food retention in the lower abdomen. It is particularly used if there is constipation.
Modifications
b Prescription
c Prescription
Explanation
Soft abdominal masses, which may be strip-like in shape, abdominal distension, constipation or diarrhoea, poor appetite, nausea and a feeling of fullness. Tongue: Swollen, with a sticky coating which is thicker on the root. Pulse: Slippery.
Blood masses
Stagnation of Qi and Blood
Clinical manifestations
Hard and immovable abdominal masses, abdominal distension and pain, late periods. Tongue: Purple. Pulse: Wiry.
Treatment principle
Move Qi, invigorate Blood, remove obstructions from the Connecting channels and dissolve masses.
Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Reducing or even method.
Herbal treatment
b Prescription
Women’s Treasure remedy
This remedy pacifies the Liver, moves Qi, eliminates stagnation, invigorates Blood, eliminates stasis and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body with Red or Purple sides.
Stagnation of Qi and Blood
Hard and immovable abdominal masses, abdominal distension and pain, late periods. Tongue: Purple. Pulse: Wiry.
G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Reducing or even method.
Stasis of Blood knotted in the Interior
Clinical manifestations
Hard, immovable and painful masses in the abdomen, dark and withered complexion, dry skin, feeling cold, amenorrhoea, painful periods, late periods. Tongue: Purple. Pulse: Choppy.
This is a condition of severe and chronic stasis of Blood with obvious masses. The dark and withered complexion reflects stasis of Blood and the cold feeling is due not to internal Cold, but to poor circulation of Blood. The skin is dry because stagnant Blood is pooled in the lower abdomen and does not moisten and nourish the skin.
Treatment principle
‘Break’ Blood, eliminate stasis, soften hardness, dissolve masses, regulate Spleen and Stomach.
Acupuncture
G.B.-34 Yanglingquan, Ren-6 Qihai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, ST-29 Guilai, LIV-3 Taichong, SP-6 Sanyinjiao, LIV-8 Ququan, ST-36 Zusanli and BL-20 Pishu. Reducing or even method, except on LIV-8, ST-36 and BL-20 which should be reinforced.
Herbal treatment
a Prescription
b Prescription
Explanation
Modifications
The following variations apply to both the above formulae.
c Prescription
Modifications
Table 60.1 compares and contrasts the above three formulae.
Women’s Treasure remedy
This remedy is a variation of the formula Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill which invigorates Blood, eliminates stasis and dissolves masses. The tongue presentation appropriate to this remedy is a Purple body.
Stasis of Blood knotted in the Interior
Hard, immovable and painful masses in the abdomen, dark and withered complexion, dry skin, feeling cold, amenorrhoea, painful periods, late periods. Tongue: Purple. Pulse: Choppy.
G.B.-34 Yanglingquan, Ren-6 Qihai, SP-4 Gongsun (on the right) and P-6 Neiguan (on the left), SP-10 Xuehai, BL-17 Geshu, ST-29 Guilai, LIV-3 Taichong, SP-6 Sanyinjiao, LIV-8 Ququan, ST-36 Zusanli and BL-20 Pishu. Reducing or even method, except on LIV-8, ST-36 and BL-20 which should be reinforced.
A 45-year-old woman had been suffering from a myoma in the uterus which was about 2 cm in diameter. Her lower abdomen was generally distended and her periods were rather heavy, with dark, clotted blood. Apart from this, she was in good health. Her tongue was Purple on the sides (Plate 11) and her pulse was slightly Firm (i.e. Wiry at the deep level).
Diagnosis
This myoma was due to stasis of Blood of the Liver: this is confirmed by the Purple colour on the sides of her tongue and the dark colour of her menstrual blood.
Treatment principle
The treatment principle followed was to move Liver-Blood and eliminate stasis in the uterus. This patient was treated only with herbs.
A 27-year-old woman had been diagnosed as having a large cyst on one ovary (7.5 cm in diameter), a myoma between the uterus and the ovary, and endometriosis. This caused her some abdominal pain and discomfort. The abdomen felt hard on palpation. Her periods were painful, sometimes heavy and sometimes scanty, sometimes stopping and starting, and the menstrual blood was dark with clots. She had an excessive vaginal discharge, yellow in colour. Her tongue was Pale-Purple, Swollen and with a sticky coating all over which was yellow on the root (Plate 12). Her pulse was Slippery, slightly Firm (Wiry at the deep level), Deep, and Weak on both Rear positions.
Diagnosis
The ovarian cyst and myoma were due to stasis of Blood, but there was also Damp-Heat in the Lower Burner contributing to the stagnation in that area. Underlying these two conditions, there was also a deficiency of the Kidneys.
Treatment principle
This patient’s condition was very complex due to the presence of endometriosis, ovarian cyst and uterine myoma. The ovarian cyst was too large to be dissolved with herbal treatment but she did not want an operation. I therefore agreed to treat her in order first of all to tonify the general body condition, second to treat the endometriosis, and third to attempt to shrink the cyst. The treatment principle was to move Liver-Blood, eliminate stasis in the Uterus, resolve Damp-Heat and tonify the Kidneys. She was treated only with herbs.
Herbal treatment
The formula used was a variation of the two formulae Gui Zhi Fu Ling Wan Ramulus Cinnamomi-Poria Pill and Si Miao San Four Wonderful Powder:
Explanation
The first nine herbs constitute the two root formulae.
This formula was used, with some variations, for about 9 months. After this time, her condition improved insofar as her periods were more regular, not painful and the blood was not clotted. The ovarian cyst also was reduced in size. Afterwards, the prescription was changed, introducing more tonifying herbs such as Bai Zhu Rhizoma Atractylodis macrocephalae and Dang Shen Radix Codonopsis.
Deficiency of Upright Qi and stasis of Blood
Clinical manifestations
Hard and painful masses, sallow complexion, loss of weight, loss of appetite, exhaustion. Tongue: Purple. Pulse: Fine and Choppy.
This is a chronic condition of severe Blood stasis which has led to the formation of masses with an underlying deficiency of the body’s Qi. From the point of view of Western medicine, it could correspond to carcinoma.
Acupuncture
Ren-4 Guanyuan, Ren-6 Qihai, Ren-8 Shenque, BL-23 Shenshu, BL-20 Pishu, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Even method on the last two points and reinforcing method on all the others. Moxa should be used on Ren-4, Ren-6 or Ren-8.
Herbal treatment
Prescription
Explanation
The first eight herbs constitute the Eight Precious Decoction which tonifies Qi and Blood.
Women’s Treasure remedies
The first remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The second remedy is a variation of the formula Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction which invigorates Blood and eliminates stasis. The tongue presentation appropriate to these two remedies is a Bluish-Purple body.
Deficiency of Upright Qi and stasis of Blood
Hard and painful masses, sallow complexion, loss of weight, loss of appetite, exhaustion. Tongue: Purple. Pulse: Fine and Choppy.
Ren-4 Guanyuan, Ren-6 Qihai, Ren-8 Shenque, BL-23 Shenshu, BL-20 Pishu, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Even method on the last two points and reinforcing method on all the others. Moxa should be used on Ren-4, Ren-6 or Ren-8.
Prognosis and prevention
The subject of prognosis in abdominal masses cannot be separated from that of Western diagnosis. In the case of abdominal masses perhaps more than in any other, a Western diagnosis is essential. Although Chinese medicine can be effective in treating masses, we should never treat them blindly without first establishing what they really are.
As explained below, from a Western perspective masses can be due to many different pathologies: enlarged organs, cysts, myomas (‘fibroids’), spastic colon, masses of faeces or malignant tumours. The treatment and prognosis in each of these cases will obviously differ enormously. Furthermore, in addition to the above types of masses, one should add those that are non-substantial, i.e. due to Qi stagnation.
First of all, to make a prognosis from a Chinese perspective, we must differentiate between masses due to Qi and masses due to Blood accumulation: the former are much easier to disperse. Acupuncture can be used to disperse Qi masses but Blood masses are better treated with both acupuncture and herbal medicine.
From a Western perspective, to mention the most common causes of masses, those due to a spasm in the colon or to masses of faeces are the easiest to resolve. Ovarian cysts and uterine myomas can be dispersed only if they are very small (not more than 2 cm in diameter). There are three types of myomas: subserous (on the outside wall of the uterus), interstitial (within the wall of the uterus) and submucous (on the inside of the uterus, see below). The interstitial myomas are the easiest (or better, the least difficult) to disperse, and the subserous ones the most difficult (see Ch. 67).
As for malignant tumours of the abdomen, Chinese herbs must be used in conjunction with Western treatment. The prognosis varies according to the organ involved and the stage of the carcinoma: however, the differentiation and treatment outlined in this chapter do not apply to malignant tumours as their treatment needs a different approach. Of all malignant tumours, lymphomas respond best to treatment with Chinese herbs.
Finally, masses due to enlargement of organs can be dispersed by a combination of both acupuncture and herbs. In all the above cases, treatment will necessarily take a long time and patience is required from both the practitioner and the woman.
As for prevention, any patient who is prone to abdominal masses or has been cured of one should follow certain precautions: first of all, avoid the excessive consumption of cold energy foods, and especially cold drinks, as these tend to lead to stasis in the lower abdomen (an important recommendation especially in countries such as the USA where people tend to consume large quantities of iced drinks). During the menstrual period and after childbirth, women should carefully avoid exposure to cold or dampness (e.g. wearing a wet swimming suit on a windy beach, sitting on damp grass, etc.). Women who practise meditation concentrating the breath in the lower abdomen should do so in a standing rather than sitting position: this practice in a sitting position tends to increase or cause stagnation in the lower abdomen in women. Moderate exercise is vital to keep Qi moving in the lower abdomen. Even just brisk walking in the open air (although not in a city centre!) is an effective exercise. Tai Ji Quan is an excellent exercise to remove or prevent stagnation in the lower abdomen, and it is particularly suited to those over 40.
Finally, women should take care not to catch cold after sexual activity and also to avoid sex during the periods: both these activities lead to stasis of Blood in the lower abdomen.
Western view
Masses which are sufficiently large or sufficiently close to the abdominal wall cause increased resistance to palpation. Obviously, only Blood masses may correspond to actual abdominal masses from the point of view of Western medicine. Qi masses, by their very nature, are not actual, physical masses.
From a Western diagnostic perspective, it is very important to establish whether a mass is in the abdominal wall or the abdominal cavity. This distinction can be easily made with a simple test. With the patient supine, ask her to raise the head in order to tense the abdominal muscles. If the mass is in the abdominal cavity, it will be shielded by the tensed muscles and will cease to be palpable. If the mass is in the abdominal wall, it will still be felt through the tensed abdominal muscles.
Myoma
A myoma is a solid, well-defined benign growth in the myometrium. Myomas are by far the most common tumours of the uterus: it is estimated that 20% of all women over 35 years harbour them.6 Often called fibroids, this is a misnomer as they are composed of smooth muscle tissue. Myomas vary in size ranging from microscopic to enormous proportions. They may be single or, more frequently, multiple. There are different types of myomas (Fig. 60.1):
Small myomas are often symptomless. When they reach a certain size they become palpable and, if large, the mass can be seen bulging from the abdomen. Excessive uterine bleeding is a common consequence of myomas: this is due to expansion of the endometrium from pressure of the myoma with consequent increased amount of endometrial tissue.
Myomas do not usually cause pain; however, if there is torsion of their pedicle they may cause dysmenorrhoea. Large myomas may press on the bladder and cause urinary symptoms such as bladder irritability, increased frequency or dysuria. Myomas are discussed in Chapter 67.
Ovarian cysts
Ovarian cysts may be physiological (called functional): they occur when an enlarged follicle fails to rupture. A functional ovarian cyst resolves by itself and requires no treatment.
Neoplastic cysts are new growths not arising from normal physiological processes. There are very many types of neoplastic cysts and their classification is extremely complex. The reader is therefore referred to one of the gynecology textbooks mentioned in the bibliography.
Polycystic ovary disease
Polycystic ovary disease is characterized by the presence of numerous small cystic follicles varying in size but seldom exceeding 0.5 cm in diameter. There is failure of the ovarian enzyme systems which are necessary for the normal production of oestrogens. The patient is usually obese and complains of amenorrhoea, infertility and hirsutism (excessive body hair growth). Polycystic ovary syndrome is discussed in Chapter 66.
Endometriosis
Endometriosis does not usually cause an abdominal mass, but it can do so when there is a build up of scar tissue and displacement of the uterus. Endometriosis is discussed in Chapter 65.
Carcinoma of the cervix
Carcinoma of the cervix causes an abdominal mass only when it is invasive and it has grown beyond the limits of the cervix. The earliest sign of cervical carcinoma is vaginal bleeding, at first irregular and brought on by coitus, micturition or defaecation. Later, the bleeding may become continuous. When the growth ulcerates and becomes infected, a think, blood-stained discharge appears, later becoming offensive. The median age of onset of invasive cervical cancer is 45 years.
Endometrial carcinoma
The peak incidence of endometrial carcinoma is at 61 years and 75% of cases occur after the menopause. Various risk factors have been identified, all of which relate to excessive exposure of the endometrium to oestrogen; these include obesity, late menopause, polycystic ovary syndrome, oestrogen-secreting ovarian tumours and exogenous oestrogen administration (as in the contraceptive pill and hormone replacement therapy).
An abdominal mass (usually with pain) is a late symptom of endometrial carcinoma. In the initial stages, the most common sign is vaginal bleeding usually occurring after the menopause. At first the bleeding is slight and intermittent; later it may become continuous and heavy. In pre-menopausal women, there is irregular inter-menstrual bleeding. In the early stages there may be a watery discharge which may later become offensive.
Appendix I: ovarian cysts
Ovarian cysts fall under the category of ‘Abdominal Masses’ (zheng jia 
). The oldest description of a pathology resembling ovarian cysts is in Chapter 57 of the Spiritual Axis which describes an abdominal mass called ‘Intestines Deep Mass’ (chang tan 
):
External Cold engages in a fight with the Defensive Qi, Qi cannot flourish and accumulations develop inside forming a nodule: a perverse Qi rises and decayed flesh forms. In the beginning the lump is the size of an egg; gradually it increases in size until it becomes the same size as the abdomen of a woman at full term’s pregnancy. After some years, the lump feels hard on pressure but it is moveable; it fluctuates with the menstrual periods.7
Aetiology and pathology
The aetiology of ovarian cysts is often attributed to invasion of external pathogenic factors suffered during the period or soon after childbirth, both times when the genital system is in a vulnerable state and prone to be invaded by such pathogens.
This cause of disease is usually combined with emotional stress leading to stagnation of Qi and Blood and with dietary irregularity (excessive consumption of sugar and greasy foods) leading to Spleen-Qi deficiency and Phlegm.
The pathology of ovarian cysts is always characterized by a combination of Phlegm, Dampness and stasis of Blood.
Thus, the principle of treatment is to resolve Phlegm and Dampness, invigorate Blood, eliminate stasis, soften hardness and dissolve.
The dosages and approach to treatment should be adapted according to whether the woman has periods or not. If the woman suffers from amenorrhoea, most Chinese doctors recommend using a rather vigorous approach with fairly large doses. If the woman has periods, one should distinguish whether these are heavy or scanty. If the periods are heavy, in addition to the treatment principles mentioned above, one should tonify Qi, consolidate the Directing and Penetrating Vessels and cool Blood; if the periods are scanty, one should tonify Qi and nourish Blood.
Herbal treatment
a Prescription
Explanation
Please note that the dosages given are those used by Dr Shen Zhong Li: I would personally recommend reducing by at least half if not more. I should also add that Huang Yao Zi is slightly toxic and should be used only for a few weeks at a time with breaks of a 4–5 weeks in between; furthermore, it should not be used if the patient has a history of liver disease such as hepatitis A, B or C or liver cirrhosis.
Modifications
Dr Shen Zhong Li specifically advises against using insects (such as Di Bie Chong Eupolyphaga or Shui Zhi Hirudo) to ‘break’ Blood as they are too powerful and may injure the body’s Qi and Blood.
b Prescription
Explanation
The above dosages are from the original formula by Dr Yao. I would personally reduce them by at least half.
This formula differs from the previous one in so far as it also strongly tonifies Qi with a high dose of Huang Qi: this is used according to the principle that ‘tonifying the Upright Qi automatically expels pathogenic factors’.
Modifications
Dr Yao suggests giving this prescription for 1 month and then checking the results with an ultrasound scan: if necessary, continue for another month.
c Prescription
Explanation
The first five herbs constitute the formula Gui Zhi Fu Ling Wan which invigorates Blood, eliminates stasis and dissolves masses.
As was the case for the previous two prescriptions, the dosages of this prescription are those indicated by Dr Wang Hui Lan: I would personally reduce them by at least half.
The emphasis of this formula is invigorating Blood and moving Qi.
Table 60.2 illustrates the differences between the above three formulae.
Appendix II: cervical dysplasia
Cervical dysplasia is characterized by three abnormalities: a disorderly maturation or a lack of differentiation of the squamous epithelial cells; nuclear abnormalities; and increased mitotic activity. This condition’s incidence is in direct correlation with the age of onset of sexual intercourse and the number of sexual partners, i.e. the younger the age of regular intercourse and the higher the number of partners, the higher the risk of developing cervical dysplasia. The relationship between cervical squamous pre-cancer and sexual intercourse is beyond doubt as the condition is virtually unknown in celibate women.
The exposed area of columnar epithelium on the ectocervix is called the transformation zone because, over many years, the columnar cells are replaced by squamous epithelium by a process of metaplasia. The risk of developing cervical cancer or pre-cancer is increased if the transformation zone is exposed to a sexually transmitted carcinogen at a time of maximum cellular activity during adolescence. This fact is in complete agreement with the Chinese view that sexual activity at an early age is very detrimental to the Directing and Penetrating Vessels because the Uterus and these vessels are in a vulnerable state at such an age.
Cervical dysplasia in its various stages, carcinoma in situ and invasive carcinoma of the cervix are now recognized as a continuum of the same disease. There are three stages of severity of cervical intra-epithelial neoplasia (CIN):
Figure 60.2 illustrates the normal cervical epithelium together with its changes in stages CIN 1, 2 and 3.
Figure 60.2 Cervical epithelial changes in CIN.
(Reproduced with permission from Govan, McKay Hart and Callander 1993 Gynaecology Illustrated, 4th edn, Churchill Livingstone, Edinburgh, pp 208–209.)
After these three, the next stage would be invasive carcinoma which has a very poor prognosis: its main sign is vaginal bleeding brought on by coitus, micturition or defaecation. The bleeding later becomes continuous, and when the growth ulcerates there is a blood-stained discharge.
The staging of invasive cervical carcinoma is as follows:
Although the above terminology stresses the continuing nature of the process leading from CIN 1 to carcinoma, in cervical dysplasia this is not an inexorable progression from one stage to the next: for example, it is quite possible for cases of CIN 1 to revert to normal. Furthermore, many cases of CIN, regardless of the grade, never progress to the next stage.
From a Chinese perspective, whether a case of CIN progresses through the various stages or remains stationary (or even reverts to normal) depends on the state of that person’s Upright Qi. Cancer and Upright Qi are like the two sides of a pair of scales: when one goes up, the other goes down. Thus, anything that makes the body’s Qi go up (with treatment and healthy lifestyle) will make cancer reverse or stay stationary.
CIN is diagnosed through the Papanicolaou (Pap) smear, while colposcopy allows the accurate localization of the abnormal epithelium. Treatment may consist in any of the following procedures:
Whichever treatment is adopted, the aim is to destroy the transformation zone entirely to a depth of 6 mm. Cone biopsy involves the excision of a cylinder of tissue from the cervix so that the entire transformation zone is excised: this procedure is both diagnostic and therapeutic.
From the point of view of Chinese medicine, this condition would have been diagnosed in the old times only at its invasive stage, i.e. when it manifests with vaginal bleeding and, later, a blood-stained, offensive discharge, by which time the carcinoma is already quite advanced and probably not treatable with Chinese medicine. Thus, to treat cervical dysplasia we must obviously rely on a Western diagnosis with the Pap smear test.
As for its aetiology, this has already been mentioned above: it is often due to onset of regular sexual intercourse at too early an age which injures the Directing and Penetrating Vessels. Adolescence is a very vulnerable time in the life of a girl and any cause of disease at this age has serious consequences. In fact, other causes of disease may play a contributory role. Invasion of external Dampness easily invades the gynecological system in women and may form the basis for the development of dysplasia or cancer. Emotional problems at puberty time also have a very deep influence on a girl’s life: they may cause stagnation of Qi in the Liver which easily affects the genital system in women. After some time, Qi stagnation may turn into Blood stasis and cause masses.
Thus, the pathology is characterized first and foremost by a deficiency of the Upright Qi and a weakness of the Directing and Penetrating Vessels; in addition, there may be stagnation of Qi, stasis of Blood or Damp-Heat.
Treatment
As for the treatment, there are no specific formulae for CIN in its three stages: it is sufficient simply to identify the main patterns and treat the woman accordingly. There will always be an underlying deficiency that may involve the Liver and/or Kidneys: this may be a deficiency of Qi, Yang, Blood or Yin. In addition, there may be pathogenic factors and particularly Dampness and/or Liver-Qi stagnation. If deficiency predominates, one should tonify Qi, Yang, Blood or Yin primarily and modify the formula with herbs to resolve Dampness or move Qi according to the case. If Fullness predominates, one should start with a formula that resolves Dampness or moves Liver-Qi and modify it with the addition of tonic herbs.
Acupuncture
Acupuncture is effective in treating cervical dysplasia and the main points would be:
Moxa can be used if there is deficiency of Qi, Yang or Blood.
Herbal treatment
Normally, to treat benign or malignant tumours, one needs to use some herbs that ‘break’ Blood, some that dissolve masses, some that resolve Phlegm and some that resolve Toxic-Heat, according to the case. However, in the case of CIN 1 and CIN 2, there is no tumour but only cell changes that may later give rise to a tumour: thus, in these cases, there is no need to resolve Phlegm, ‘break’ Blood, dissolve masses or resolve Toxic-Heat. In such cases, I would simply add one or two anti-cancer herbs to one of the following formulae:
To each of these formulae I would add one herb with an anti-cancer effect such as Bai Hua She Cao Herba Hedyotis diffusae or Ban Zhi Lian Herba Scutellariae barbatae (6 g).
The Journal of Traditional Chinese Medicine reports the treatment of 30 cases of CIN 2 and 3 with a follow up over 10 years.11 The formula used was the following:
Prescription
Modifications
As can be seen from an analysis of the ingredients, this formula resolves Toxic-Heat and ‘breaks’ Blood and, as such, it is probably better for CIN 3 rather than CIN 2.
External use
Prescription
Explanation
Boil the herbs in about 1 pint of water for 30 minutes, strain, let cool until lukewarm and use as a vaginal douche by the means of a small rubber pump.
Both acupuncture and herbal medicine, singly or in combination, give good results in cervical dysplasia, usually within 6 months of treatment.
1979 The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen 
), People’s Health Publishing House, Beijing, p. 320. First published c. 100 BC..
Nanjing College of Traditional Chinese Medicine 1979 A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi 
), People’s Health Publishing House, Beijing, p. 122. First published c. 100 BC..
He Ren 1979 A Popular Guide to the Essential Prescriptions of the Golden Cabinet (Jin Gui Yao Lue Tong Su Jiang Hua 
), Shanghai Science Publishing House, Shanghai, p. 83. The Essential Prescriptions of the Golden Cabinet itself was written by Zhang Zhong Jing and first published c. AD 220..
Chao Yuan Fang AD 610 General Treatise on the Aetiology and Symptomatology of Diseases (Zhu Bing Yuan Hou Zong Lun), cited in Zhang Bo Yu 1986 Chinese Internal Medicine (Zhong Yi Nei Ke Xue 
), Shanghai Science and Technology Press, Shanghai, p. 187..
1981 Spiritual Axis (Ling Shu Jing 
), People’s Health Publishing House, Beijing, first published c. 100 BC, p. 122..
Jones H W, Seegar Jones G 1980 Gynaecology, Williams and Wilkins, Baltimore, p. 245..
Huang Tao Qiang 1989 The Experience of Dr Shen Zhong Li in Treating Ovarian Cysts (Shen Zhong Li Zhi Liao Luan Chao Nang Zhong de Jing Yan), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi 
) 30(6): 15..
Yao Shi An 1996 What Should One Pay Attention to when Treating Ovarian Cysts with Chinese Medicine? (Zhong Yi Zhi Liao Luan Chao Nang Zhong Ying Zhu Yi Shen Me?), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi) 37(2): 119..
Wang Hui Lan 1994 Clinical Observation on Augmented Gui Zhi Fu Ling Wan in the Treatment of Ovarian Cysts (Gui Zhi Fu Ling Wan Jia Wei Zhi Liao Luan Chao Nang Zhong Lin Chuang Guan Cha), Journal of Traditional Chinese Medicine (Zhong Yi Za Zhi) 35(6): 355..
Tian Jing Feng 1989 The Treatment with Chinese Herbs of 30 Cases of Cervical Dysplasia at stage CIN 2 and 3 – Ten Years Observation of Results (Zhong Yi Yao Zhi Liao II, III Qi Gong Jing Ai 30 Li – 10 Nian Liao Xiao Guan Cha), Journal of Chinese Medicine (Zhong Yi Za Zhi) 30(9): 30..