Classical TCM Approaches to Thirst in Late-Stage Cancer Patients

Clinically, many late-stage cancer patients develop thirst to an almost unbearable degree; in the patients' own words, they want to soak themselves in water. This symptom has long been familiar in the case records of ancient wound physicians. In Wang Kentang's Zhengzhi Zhunsheng (Standards of Pattern and Treatment, the Wounds and Ulcers volume), the section on accompanying patterns of abscesses and sores lists thirst as the very first accompanying pattern. Since Wang's work combines his own clinical experience with the accumulated insights of wound physicians through the ages, I record it below for patients' reference.

<</span>General Principle>[a]: For sores and ulcers with thirst, regardless of whether the lesion is swollen or ulcerated, if the pulse is rapid (author's note: a rapid pulse means more than five beats per respiratory cycle) and feverish with thirst, use Zhuye Huangqi Tang. If the pulse is not rapid, no fever, or the pulse is rapid and forceless with thirst or dry mouth, use Buzhong Yiqi Tang. If the pulse is rapid with constipation, use Qingliang Yin. If the cubit pulse is large and flooding but forceless on pressure with thirst, use modified Bawei Wan (author's note: here the modified Bawei Wan refers to the version created by Xue Lizhai). This pill is especially wonderful for treating dry mouth, a yellow tongue, and incessant drinking.

<</span>Xue> (author's note: Xue Lizhai): For thirst from sores and ulcers, if there is burning pain and fever with normal urination and bowel movement, it is heat in the upper burner—use Zhuye Shigao Tang. If a swollen ulcer comes with fever and dry, difficult stool, it is heat in the internal organs—use Sishun Qingliang Yin. If there is severe burning swelling and pain, it is binding of heat-toxin—use Xianfang Huoming Yin. If there is diffuse swelling with slight pain, it is deficiency and stagnation of qi and blood—use Buzhong Yiqi Tang. If stomach fire has scorched and damaged the fluids, use Zhuye Huangqi Tang. If stomach qi is deficient and fails to generate fluids, use Buzhong Yiqi Tang. If stomach qi is injured and fluids are lost internally, use Qiwei Baizhu San. If thirst arises from drying up of kidney water, or dryness of mouth and tongue, use modified Bawei Wan. Or, when dry mouth and thirst come first, followed by frequent urination and then carbuncle (author's note: this resembles today's diabetes complicated by tumor); or when after a carbuncle heals there is thirst and drinking, or a yellow, dry, hard tongue with frequent urination and recurrence of carbuncle—these are especially ominous signs. If one can foresee the cause and prophylactically take modified Bawei Wan and Buzhong Yiqi Tang to nourish the source of transformation, future trouble may be avoided.

<</span>Dan> (author's note: Zhu Danxi): Thirst from abscesses and sores is due to dual deficiency of qi and blood; use Renshen (ginseng) and Huangqi to supplement qi, Danggui and Shaoyao to nourish blood, or Rendong Wan, or Huangqi Liuyi Tang.

Master Wu says: When thirst from sores is urgent, give Shenxian Zhui Du Wan to draw out and expel the evil toxin; Qutan Tang, Qianjin Lulu Tang, Wuxiang Lianqiao Tang, Liuwei Che'ao San, and Wanjin San may all be selected. If thirst persists after purgation, then use a fluid-generating, qi-supplementing decoction; once fluids are generated and qi and blood are restored, thirst stops of itself. Danxi says: giving purgatives for severe thirst—without clearly indicating the pulse and pattern, how does one know purgation is indicated? Later it is said that if thirst persists after purgation, then supplementing is used—again without clearly stating the pulse and pattern. I fear this means: whenever there is severe thirst, purge; if thirst remains after purging, then supplement. The ancients treated before illness; can such medication be justified? Moreover, thirst belongs to the upper burner. While the sore is still swollen, purgation may perhaps be used; but after ulceration, thirst is mostly due to deficiency of qi and blood—why wait until after purgation to treat the deficiency?

<</span>Jingyao> (author's note: Waike Jingyao, Essentials of External Medicine): Dry mouth differs from thirst; mineral elixirs and heavy-sinking medicines should not be used—their harm is as immediate as turning a hand. Use Sangzhi Jian Wuwei Tang to rescue the drinking. Danxi says: this is a wonderful formula. Yet it does not mention that rich food produces fire, that anger produces fire, or that sexual excess stirs fire; I fear thirst would not easily be removed.

Master Li says: Thirst arising after a carbuncle heals is often fatal; only modified Bawei Wan is most marvelous. Since carbuncles mostly arise from deficiency, if thirst appears after the carbuncle has settled, taking this pill stops the thirst; if there is no thirst after it settles, taking this pill prevents thirst forever. Or, if thirst precedes the carbuncle, taking this pill not only stops the thirst but also prevents the carbuncle. (Author's note: judging by this passage, it seems diabetes may trigger tumors; I have indeed clinically seen patients who developed tumors after diabetes. Given the records of so many physicians, Xue Lizhai's modified Bawei Wan must be quite effective for diabetes.) (Xue Lizhai's related discourses are omitted below, as they have already been cited.)

Tuoli Xiaodu San, modified: Thirst from drinking cold things is heat-toxin. Add Chixiaodou (rice bean) and Zhimu (Anemarrhena); if no effect, temporarily use Zhuye Huangqi Tang. Thirst from ravenous eating is stomach fire; add Shigao (gypsum), Shanzhi (Gardenia), and Tianhuafen (Trichosanthes root); if no effect, temporarily use Zhuye Shigao Tang. Thirst from poor appetite and bodily fatigue is stomach qi deficiency; remove Baizhi, Lianqiao, and Jinyinhua, and add Renshen and Baizhu. If no effect, temporarily use Shiquan Dabu Tang plus Wuweizi (Schisandra) and Maimendong (Ophiopogon). Dry mouth and tongue are kidney qi deficiency; remove the three herbs and add Shudihuang (processed rehmannia), Shanzhuyu (Cornus), and Shanyao (Dioscorea). If no effect, combine with Liuwei Dihuang Wan. If still no effect, assist with Buzhong Yiqi Tang. Spontaneous sweating with internal heat and dry mouth is stomach qi deficiency; remove the three and add Renshen, Huangqi, Danggui, and Baizhu. If no effect, temporarily use Liujunzi Tang. Night sweats with internal heat and dry mouth are yin-blood deficiency; remove the three and add Shudihuang, Maimendong, and Wuweizi. If no effect, temporarily use Danggui Liuhuang Tang.

Author's note: Tuoli Xiaodu San is a formula from Xue Lizhai's Jiaozhu Furen Liangfang (Annotated Good Prescriptions for Women), used for abscesses and sores: Renshen 1 qian, Huangqi (stir-fried) 1 qian, Danggui (wine-washed) 1 qian, Chuanxiong 1 qian, Shaoyao (stir-fried) 1 qian, Baizhu (stir-fried) 1 qian, Chenpi 1 qian, Fuling 1 qian, Jinyinhua 7 fen, Lianqiao 7 fen, Baizhi 7 fen, Gancao 5 fen. In Xue Lizhai's time 1 qian was about 4 g today.

Zhuye Huangqi Tang From Shenmi. Treats great thirst from abscesses and sores, with fever or diarrhea, or urination like stranguria.

Shengdihuang (raw rehmannia) and Huangqi, each 2 qian; Danggui (moistened with wine), Danzhuye (lophatherum), Chuanxiong, Zhi Gancao (honey-fried licorice), Chao Huangqin (stir-fried scutellaria), Chao Baishao (stir-fried white peony), Renshen, Tianhuafen, Duan Shigao (calcined gypsum), each 1 qian; Maimendong (heart removed) 2 qian.

Two cups of water, three slices of ginger, boil to eight-tenths; take at a distance from meals. (Author's note: taken one hour after meals.)

Xue says: The foregoing pattern is one of the seven evil signs (author's note: in TCM external medicine, the seven poor prognostic signs in tumor patients); treated with this formula the effect is very swift. There are also cases where the left pulse is floating and large with fever or thirst—disperse the exterior pathogen; where the right pulse is deep and replete with fever or thirst—discharge the internal pathogen. If after ulceration there is thirst, or urination like stranguria, with a large but forceless pulse, it belongs to qi-blood deficiency; strongly supplement qi and blood. Some, after ulceration, have persistent fever or thirst, and are then judged a hopeless defeat pattern. But if there is a pre-existing stomach fire, or residual heat-toxin in the stomach channel with the stomach pulse still rapid, the above decoction should still be taken; if, after taking it, the pulse instead becomes large, fever worsens, and thirst returns, this is a defeat pattern—because genuine qi is deficient while pathogen qi is replete. Nowadays, ulcer patients fear Shigao and Huangqin because they are cold in nature and often refuse them; but if the stomach pulse has not settled, no other drug can rescue them. If treatment is delayed over time, qi and blood are scorched, pus and blood grow ever more profuse, qi and blood ever more deficient, and the case turns to defeat. In treating such cases, one may set aside the pattern and follow the pulse. Generally, among sore and ulcer patterns, seeing one or two of the seven evil signs is very fearful; when deficiency is complicated by evil signs, it is untreatable; when repletion patterns show no evil signs, they resolve of themselves.

Tuoli Huangqi Tang Indications same as above.

Chao Huangqi (stir-fried astragalus) 6 qian; Zhi Gancao and Tianhuafen, each 1 qian.

Two cups of water, boil to eight-tenths; take frequently. Adding Renshen 1 qian is especially marvelous.

Xue says: I use this formula for thirst due to qi deficiency, with great effect. If both qi and blood are deficient, or thirst follows heavy discharge of pus and blood, or fever accompanies it, use Tuoli Yangrong Tang.

Tuoli Yangrong Tang

Renshen, Zhi Huangqi, Jiu Danggui (wine-fried tangkuei), Chao Baishao, Shudihuang, Maimendong, Chuanxiong, Baizhu, each 1 qian; Wuweizi (finely ground), Zhi Gancao, each 5 fen.

Two cups of water, three slices of ginger, two jujubes, boil to eight-tenths; take away from meals.

Huangqi Liuyi Tang Taken lifelong, it prevents abscesses and sores; truly an essential formula for treating thirst and supplementing deficiency.

Mian Huangqi (astragalus) 6 liang, moistened with dilute salt water, steamed over rice, and baked dry. Gancao 1 liang, half raw and half honey-fried.

Each time, coarsely crush 1 liang; two cups of water, boil to eight-tenths, take away from meals. Or make into fine powder; take 2 qian each time in warm water in the morning and at noon; adding Renshen is especially marvelous.

Qiwei Baizhu San Treats stomach qi deficiency, or dry mouth and thirst from punitive treatment, vomiting and diarrhea, and poor appetite.

Baizhu, Fuling (peel removed), Renshen, each 7 qian; Zhi Gancao 1.5 liang; Muxiang (costus) 2.5 qian; Huoxiang leaves 0.5 liang; Gegen (kudzu root) 1 liang.

Grind into fine powder; take 3-5 qian each time in warm water.

Zhuye Shigao Tang Treats abscesses and sores with exuberant stomach fire, swelling pain, and thirst.

Danzhuye, Shigao, Jiegeng (Platycodon), Mutong (Akebia), Bohe (mint), Zhi Gancao.

Boil with ginger in water and take.

Xuanshen San Treats abscesses and sores turned to pus and water, inability to eat, vexation, dry mouth and troublesome thirst, much drinking, and emaciated limbs.

Xuanshen (Scrophularia), Huanglian (Coptis, root hairs removed), Tuguagen (Trichosanthes kirilowii root), Maimendong (heart removed), Chishao (red peony), Baixianpi (Dictamnus root bark), each 1 liang; Shengma (Cimicifuga) 7.5 qian; Huomaren (hemp seed), Chuanpuxiao (Mirabilitum), Shudahuang (prepared rhubarb), each 1.5 liang.

Coarsely chop. Take 3 qian each time in one cup of water; add a fen of Shengdihuang, finely cut, and boil together to six-tenths; strain; take warm at any time.

Gegen San Treats swelling and abscess with exuberant heat, dry mouth and troublesome thirst, or occasional dry retching.

Gegen, Huangqi, Shengma, Maimendong (heart removed), Tianhuafen, Chishao, Zhiren (Gardenia seed), Shengdihuang, each 1 liang; Huangqin 7.5 qian; Sheng Gancao 0.5 liang.

Coarsely chop. Take 4 qian each time in one cup of water, boil to six-tenths, strain; take warm at any time.

Gange Yin Treats thirst from back abscess.

Huangqin and Puxiao (Glauber's salt), each 1.25 liang; Gange (dried kudzu root) 1 liang (author's note: in Ming-Qing times 1 liang = 16 qian).

Coarsely chop and scatter. Take 3 qian each time; use loquat leaves (the white down on the back removed and washed clean) and boil together; take at any time.

Rendong Wan Treats prevention of carbuncle after thirst disease has healed.

First put Rendong grass (author's note: the honeysuckle vine is Rendong grass) into a bottle, then add ash-free wine, simmer gently over a slow fire overnight, take out and sun-dry; add a little Gancao and grind all into powder; then use the leftover soaking wine to mix into a paste and form pills the size of wutzi seeds. Take sixty to seventy pills each time with warm wine. It also treats the five hemorrhoids and various goiters.

Sangzhi Fang Greatly treats thirst. Take tender mulberry branches, finely chop one sheng and stir-fry; boil in three sheng of water down to one sheng; take five or seven doses daily; more is even better.

Wuweizi Tang Treats withering and exhaustion of kidney water with dry mouth and tongue.

Chao Huangqi 3 liang; Renshen 2 liang; Wuweizi and Maidong, each 1 liang; Zhi Gancao 5 qian.

Finely chop. Take 5 qian each time, boil in water; take day and night, five to seven doses.

Xue says: This formula is a compound of Liuyi Tang and Shengmai San, an excellent formula for nourishing the source of transformation. If kidney water is already dried up with deficiency fire flaring upward causing dry mouth and thirst, it must be assisted with modified Bawei Wan.

Modified Bawei (Dihuang) Wan

Shudihuang, Shanyao, Shanzhuyu meat, Wuweizi, each 4 liang; Mudanpi (Moutan bark), Bai Fuling, Zexie (Alisma; washed in wine, steamed, baked dry), each 3 liang; Rougui (cinnamon bark) 2 liang.

Grind each separately into powder, add rehmannia and mix well, add refined honey and form pills the size of wutzi seeds. Take seventy to eighty pills each time on an empty stomach before meals with warm water.

Master Li says: A nobleman fell ill with carbuncle; before it settled, thirst set in and he drank several sheng a day. I used modified Bawei Wan; the other physicians all laughed, saying, if this drug can stop thirst, we shall no longer practice medicine! They persisted with Mugua, Wumei, Baiyaojian, and the like, and the thirst only worsened. Forced to do otherwise, I used this pill; in three days the thirst stopped. With prolonged taking, qi and blood grew stronger and appetite doubled.